Fetal spina bifida repair--current trends and prospects of intrauterine neurosurgery

Myelomeningocele is a common dysraphic defect leading to severe impairment throughout the patient's lifetime. Although surgical closure of this anomaly is usually performed in the early postnatal period, an estimated 330 cases of intrauterine repair have been performed in a few specialized centers worldwide. It was hoped prenatal intervention would improve the prognosis of affected patients, and preliminary findings suggest a reduced incidence of shunt-dependent hydrocephalus, as well as an improvement in hindbrain herniation. However, the expectations for improved neurological outcome have not been fulfilled and not all patients benefit from fetal surgery in the same way. Therefore, a multicenter randomized controlled trial was initiated in the USA to compare intrauterine with conventional postnatal care, in order to establish the procedure-related benefits and risks. The primary study endpoints include the need for shunt at 1 year of age, and fetal and infant mortality. No data from the trial will be published before the final analysis has been completed in 2008, and until then, the number of centers offering intrauterine MMC repair in the USA is limited to 3 in order to prevent the uncontrolled proliferation of new centers offering this procedure. In future, refined, risk-reduced surgical techniques and new treatment options for preterm labor and preterm rupture of the membranes are likely to reduce associated maternal and fetal risks and improve outcome, but further research will be needed.

[Lip, jaw, and palate clefts. Analysis of unilateral cleft lip using 3-D laser topometry]

INVESTIGATION

In most cases it is not sufficient to use photographs and plaster casts to document and analyze the three-dimensional morphology of lip, jaw, and palate clefts. The aim of this study was to evaluate the applicability of surface scanning with a 3-D laser topography scanner in patients with unilateral cleft lip.

PATIENTS AND METHODS

Three-dimensional surface scans of the face were performed pre- and postoperatively in 20 patients (3-35 years of age) with a 3-D laser topography scanner. All patients were suffering from nonoperated, one-sided cleft lip, cleft lip-jaw, or cleft lip-jaw and palate. The digital data sets were metrically analyzed and expressed on the basis of quotients, independent of size factors.

RESULTS

Using this 3-D laser scanner it was possible to acquire good quality three-dimensional data sets. Measurements were in the dimension of millimeters. Based on the data sets it was possible to provide the three-dimensional cleft morphology with reproducible landmarks and analyze the data. The postoperative symmetry of the face was controlled and objectively quantified. It is disadvantageous however that numerous views need to be taken to get the full image of the face and that the scanning process takes about 2 s.

CONCLUSION

The presented 3-D laser scanner renders a precise 3-D surface analysis of the lip and nose region in cleft patients. For lively infants or uncooperative adults, the system is suitable only to a limited extent due to the time-consuming scanning process.

Minimal invasive reconstruction of posttraumatic hemi facial atrophy by 3-D computer-assisted lipofilling

Facial hemi atrophy is seen after trauma, Parry-Romberg syndrome and on other rare occasions. Since the aesthetic deficit is very obvious and irritating, facial reconstruction is often requested by these patients. In most cases the only option for sufficient reconstruction is free flap reconstruction, which represents the standard treatment. Recently in plastic surgery, various new techniques have been developed with the potential for multiple applications. Lipofilling has been presented primarily for the correction of cosmetic lesions or the reconstruction of minor soft tissue defects, but even reconstruction of larger soft tissue deficits is possible. The concept of using 3-D technology in facial reconstruction has multiple advantages. Primarily, the ideal final aesthetic outcome can be simulated by virtual reconstruction. Mathematic calculations deliver exact numbers in volume deficits, enabling precise planning of soft tissue substitution especially in lipofilling, ideally avoiding unnecessary corrections. Since autologous soft tissue reconstruction represents a dynamic process with periods of swelling as well as atrophy, quality control is required for achieving optimal results. Use of 3-D scanning has the advantage of reliable visualisation in soft tissue reconstruction without the limitations of harmful side effects. We present the history of a female suffering from the posttraumatic consequences of head injuries related to a car accident and the successful correction of her hemi facial atrophy by autologous lipofilling. Technical details and the potential of 3-D scanning in plastic surgery are discussed.

Quality of life following aesthetic plastic surgery: a prospective study

BACKGROUND

The objective of this study was the prospective evaluation of quality of life in patients undergoing aesthetic plastic surgery procedures. We examined pre- and postoperative changes in quality of life, and performed a comparison of our data with a representative random sample.

METHOD

228 patients agreed to participate in the present study. Measurements were taken preoperatively as well as 3 and 6 months postoperatively. One hundred and thirty two patients completed the three months postoperative evaluation (T1), 82 answered the 6 months follow-up evaluation (T2). The testing instrument included a standardised self-assessment test on satisfaction and quality of life (FLZ(M)), consisting of three modules: satisfaction with general life, health and appearance. Further, a postoperative complication questionnaire was used in order to evaluate the satisfaction with the surgical outcome and to estimate postoperative complications and side effects.

RESULTS

Significantly increasing values in two aspects of quality of life were found: health and appearance. Whereas the positive influence on health is persistent, there is a diminishing influence of appearance 6 months postoperatively. Although higher values for some of the individual items of the FLZ(M) modules of the norm data were found in comparison to our study group, a general preoperative lower level of quality of life of the aesthetic surgery patients could not be confirmed. Over 84% were satisfied or very satisfied with the aesthetic result. 85% would undergo the same treatment again and 94% of the patients would further recommend their operation. More than half of the study group did not report a decrease in physical fitness or reduced social contacts in the direct postoperative period.

CONCLUSION

Our study reveals that aesthetic plastic surgery increases most aspects of quality of life, especially regarding body satisfaction and health. It is very well tolerated by the patients and is therefore a recommended option.

Surgical Therapy of Peripheral Nerve Lesions: Current Status and New Perspectives

The severe functional deficits in patients suffering from traumatic peripheral nerve damage underline the necessity of an optimal therapy. The development of microsurgical techniques in the sixties contributed significantly to the progress in nerve repair. Since then, no major clinical innovation has become established. However, with an increased understanding of cellular and molecular mechanisms underlying nerve regeneration, various tubulization concepts have been developed which yield possible alternatives to direct suturing and to autologous nerve grafting in cases of short nerve defects. The vast knowledge gathered in the field of nerve regeneration needs to be further exploited in order to develop alternative therapeutic strategies to nerve autografting, which can result in donor-site defects and often lead to inappropriate results. Considering the encouraging results from preclinical studies, innovative nerve repair strategies are likely to improve the outcome of reconstructive surgical interventions. This paper outlines, in addition to the fundamentals of nerve regeneration, the current treatment options for defects of peripheral nerves. This article also reviews the developments in the use of alternative nerve guides and demonstrates new perspectives in the field of peripheral nerve reconstruction.

Comparison of experimental microvascular end-to-end anastomosis via VCS-Clips versus conventional suture technique in an animal model

In this experimental study on 96 CD rats, microvascular end-to-end anastomoses created via suture or alternatively by means of a VCS-Clip-Application-System, were compared. The aorta abdominalis of the animals, with a diameter of 1.5 +/- 0.2 mm, was experimentally dissected, and the free ends of the vessel then anastomosed. The results were evaluated using sonography, microangiography, histologic examination, and vascular imprints. Postoperative examination was carried out after 1, 3, 7, 14, or 30 days. Major advantages of the VCS-Clip technique over suturing were that it was easy to learn, significantly faster to perform (execution of anastomosis 10.9 +/- 2.6 min versus 19.4 +/- 5.0 min), and produced significantly more favorable histologic results in terms of less inflammatory response, foreign body reaction, necrosis of the tunica media, hyperplasia of the intima, and thrombosis of the vessel lumen. The main disadvantage of the clip technique was a significantly higher rate of stenoses (15.8 +/- 6.0 versus 4.1 +/- 6.6 percent).

Establishing the method of chimerism monitoring after allogeneic stem cell transplantation using multiplex polymerase chain reaction amplification of short tandem repeat markers and Amelogenin

We describe the implementation, optimization, sensitivity determination and first clinical results of polymerase chain reaction (PCR) amplification of polymorphic short tandem repeat (STR) markers and Amelogenin locus coupled with fluorescent detection and capillary electrophoresis in chimerism monitoring of patients transplanted at three different transplant centers using a commercially available multiplex microsatellite assay. The chimerism analysis was performed with genomic DNA extracted from unselected peripheral blood leukocytes of one hundred pediatric and adult patients, who underwent allogeneic stem cell transplantation (SCT) from human leukocyte antigen (HLA) matched or one antigen mismatched related or unrelated donors for malignant (70 patients) and non-malignant (30 patients) diseases. Tested were 79 donor recipient pairs for 15 STR systems and identified an informative marker in all but one of them (98,7%), using 6 selected systems out of these fifteen, that appeared highly informative in our patients population. In 21 sex-mismatched donor recipient pairs we used the Amelogenin locus to distinguish the X and Y chromosome. In sixty-three out of these 100 patients chimerism was regularly analyzed from blood samples taken at various time points after SCT with the median follow up of 17 months. Complete chimerism (CC), maintained over the whole follow-up period, was detected in 24 (38, 1%), stable and decreasing mixed chimerism (MC) in 28 (44, 4%) and increasing MC in 11 patients (17, 5%). Patients with CC, stable and decreasing MC showed a significantly better (p 0,005) overall survival rate (0, 81), compared to those with increasing MC (0, 24). These results demonstrate that STR-based chimerism monitoring with sensitivity above 1% and high informativity (98, 7% of donor recipient pairs) is necessary in establishing the origin of engrafted cells after an allogeneic SCT, in detecting graft rejection and that it may contribute in identifying patients with imminent leukemia relapse.

Three-dimensional recording of the human face with a 3D laser scanner

Three-dimensional recording of the surface of the human body or of certain anatomical areas has gained an ever increasing importance in recent years. When recording living surfaces, such as the human face, not only has a varying degree of surface complexity to be accounted for, but also a variety of other factors, such as motion artefacts. It is of importance to establish standards for the recording procedure, which will optimise results and allow for better comparison and validation. In the study presented here, the faces of five male test persons were scanned in different experimental settings using non-contact 3D digitisers, type Minolta Vivid 910). Among others, the influence of the number of scanners used, the angle of recording, the head position of the test person, the impact of the examiner and of examination time on accuracy and precision of the virtual face models generated from the scanner data with specialised software were investigated. Computed data derived from the virtual models were compared to corresponding reference measurements carried out manually between defined landmarks on the test persons' faces. We describe experimental conditions that were of benefit in optimising the quality of scanner recording and the reliability of three-dimensional surface imaging. However, almost 50% of distances between landmarks derived from the virtual models deviated more than 2mm from the reference of manual measurements on the volunteers' faces.

Breast reconstruction with autologous tissue following mastectomy

Breast cancer remains to be one of the most malignant diseases in the female population. It affects an essential part of female self-consciousness, and therefore causes a wide range of psychological traumas. The incidence in Europe and North America varies between 70 up to 100 new cases in 100.000 inhabitants per year. According to contemporary literature, mastectomy remains one of the most effective methods in the laborious effort to treat and overcome cancer. In this report the history of breast reconstruction is presented. The established methods which are taken into consideration after mastectomy and their clinical outcome are portrayed. The authors propose the free TRAM and DIEP flap as the methods of first choice after mastectomy, which offer most reliable transfer and low morbidity. In the recent past, increasing interest is observed for the SIEA flap. The free S-GAP flap is proposed for patients who are not candidates for a TRAM, DIEP or SIEA flap. Moreover, the pedicled Latissimus Dorsi flap remains still as a reliable, versatile alternative, particularly in case of contraindications for the above mentioned free flaps or when complications occurred.

Lebensqualität und Zufriedenheit nach Brustrekonstruktion

BACKGROUND

Nowadays, the array of methods for reconstruction of the female breast following mastectomy is vast. In this study, we investigate and compare quality of life after breast reconstruction and satisfaction with the results of two commonly used techniques (autologous tissue vs. expander/implant).

METHODS

Ninety-one consecutive patients who underwent breast reconstruction at a German clinic between 1996 and 2001 were included in the study. Patient satisfaction and quality of life were assessed retrospectively using self-evaluation questionnaires.

RESULTS

Patients were generally more satisfied with the outcome of the operation when autologous tissue was used. This was significant in the following areas: breast size, form, definition of the lower breast fold, softness of the breast, and symmetry of the breasts. In both groups the quality of life following breast reconstruction at least 2 years after the operation was equal to that of healthy women of the same age group.

CONCLUSION

Although patients were more satisfied with the results of autologous breast reconstruction, procedure choice did not affect quality of life.

Accuracy and precision of the three-dimensional assessment of the facial surface using a 3-D laser scanner

Three-dimensional (3-D) recording of the surface of the human body or anatomical areas has gained importance in many medical specialties. Thus, it is important to determine scanner precision and accuracy in defined medical applications and to establish standards for the recording procedure. Here we evaluated the precision and accuracy of 3-D assessment of the facial area with the Minolta Vivid 910 3D Laser Scanner. We also investigated the influence of factors related to the recording procedure and the processing of scanner data on final results. These factors include lighting, alignment of scanner and object, the examiner, and the software used to convert measurements into virtual images. To assess scanner accuracy, we compared scanner data to those obtained by manual measurements on a dummy. Less than 7% of all results with the scanner method were outside a range of error of 2 mm when compared to corresponding reference measurements. Accuracy, thus, proved to be good enough to satisfy requirements for numerous clinical applications. Moreover, the experiments completed with the dummy yielded valuable information for optimizing recording parameters for best results. Thus, under defined conditions, precision and accuracy of surface models of the human face recorded with the Minolta Vivid 910 3D Scanner presumably can also be enhanced. Future studies will involve verification of our findings using test persons. The current findings indicate that the Minolta Vivid 910 3D Scanner might be used with benefit in medicine when recording the 3-D surface structures of the face.

Lebenszufriedenheit transsexueller Patienten nach geschlechtsangleichenden Operationen

BACKGROUND

More and more frequently, the registration of life satisfaction is being used to evaluate different medical treatments. So far, there have been only few such surveys on transsexuals (TS). Therefore, the aim of this study was to evaluate the general and the health-related life satisfaction of transsexuals after gender transformation operations.

PATIENTS AND METHODS

Forty patients took part in this German cross-sectional study. The Questions on Life Satisfaction Module (FLZ) and free questions on different aspects of the new gender identity were used as measuring instruments.

RESULTS

Of the TS studied, 85-95% were "very satisfied" or "satisfied" with the results of their gender transformation operation in respect to gender identity. The TS were significantly less satisfied (P>0.001) in overall "general life satisfaction" than the general population. In overall FLZ scores for "health-related life satisfaction", no differences were seen.

CONCLUSION

These data indicate a discrepancy between subjective satisfaction with new gender identity and current life situation, and they identify problems with life satisfaction.

Weichteildefekte als Komplikation nach Knieendoprothetik

Soft tissue defects after knee arthroplasty are a severe problem, which can even result in a loss of the prosthesis or the limb. Well-planned strategies are necessary for sufficient soft tissue reconstruction, resulting in optimal functional and aesthetic results. This report provides information on the classification of the tissue defects and the appropriate options for surgical reconstruction. Besides the basic therapy principles of immobilisation, débridement, planned lavages and antibiotic therapy, defect-dependent surgical techniques of reconstructive surgery are implemented. These include skin transplantation, local fasciocutaneous flaps, local pedicled muscle flaps and free flaps. For best results, interdisciplinary treatment by orthopaedic surgeons, plastic surgeons, microbiologists and physiotherapists is mandatory.

Foetal surgery and cleft lip and palate: current status and new perspectives

Now-a-days, high-resolution ultrasound allows an accurate and relatively early diagnosis of congenital malformations. In a limited number of such conditions foetal surgery may be lifesaving. However, premature labour has been the major drawback for open foetal surgery. Recently, improvement of video-endoscopic technology has boosted the development of operative techniques for feto-endoscopic surgery, which has been demonstrated to be less invasive than the open approach. Main clinical application of fetoscopic procedures today is the treatment of feto-foetal transfusion syndrome. Although still in development, feto-endoscopic surgery seems to offer new hope for surgical foetal therapy not only in cases of life threatening conditions. Experimental intrauterine correction of cleft lip and palate (CLP) has been lately performed using the feto-endoscopic approach. This procedure offers two major advantages: first, scarless foetal wound healing and bone healing without callus formation, which would also allow a better/normal maxillary growth, and second, significant decrease of foetal and maternal morbidity. Herein, we report the current status of experimental and clinical foetal surgery and propose possible directions for continuing research to make intrauterine procedures safer. Furthermore, we discuss current knowledge and new perspectives of experimental foetal cleft lip and palate repair, which in the future may lead to such excellent results in the operative treatment of clefts, that less or no secondary corrections and therapies, such as orthodontic, dental, logopedic, etc. would be needed. Only if these conditions can be fulfilled, will we be able to improve substantially our therapy for the human foetus with a cleft lip and palate. In spite of all efforts, however, it must be considered that it may not ever be possible to find the optimal treatment method for this or other craniofacial malformations.

Computer aided surgical reconstruction after complex facial burn injuries – opportunities and limitations

In severe facial burn injuries with extensive destruction of anatomical structures, cosmetic and functional outcome of treatment are frequently not satisfactory. Although operative therapy is being continuously refined, the variety and proximity of structures in the facial region is considered a major challenge in reconstructive surgery. We present the case of a 16-year-old patient with a severe facial burn injury. In planning the reconstructive procedures, we used a multimodal approach employing data from computerized tomography imaging, as well as from surface laser scanning, which provided three-dimensional visualization of facial soft tissues. Amount and pattern of structural loss could thus be determined more precisely and studied more vividly than by inspection of two-dimensional imaging alone. Anatomical features to be reconstructed could be projected onto the skin area of the prelaminated vertical rectus abdominis muscle (VRAM) flap that has been chosen to cover the defect. Prior to surgery, correction of the defects was simulated and the results of the virtual procedure superimposed on a three-dimensional head model of the patient. Tissue elasticity and thickness of the flap, however, could not be ascertained in advance, indicating the limitations of the method.

CTLA-4 and the genetic predisposition to autoimmunity

Due to the wide spectrum of clinical manifestations and their epidemiological dimensions, autoimmune diseases represent an important medical issue. They are the consequence of the loss of immune tolerance to autoantigens, which in turn is a result of the interaction of environmental, as well as genetic factors. The predisposing role of HLA antigens is widely accepted; nonetheless, it does not fully explain the occurrence of autoimmune disorders. In this topical review, we present the current knowledge on the role of some non-HLA genes (ICOS, CD28 and CTLA-4 in particular) in the development of autoimmunity. (Fig. 1, Ref: 106.)

Factor V Leiden in patients with venous thrombosis in Slovak population

Resistance to activated protein C determined by factor V Leiden (FVL) is the most frequent inherited risk factor of venous thrombosis. The purpose of our work was to reveal the frequency of FVL in Slovak patients with venous thromboses, to characterise the nature of venous thromboses in this inherited thrombophilia, and to consider the screening approach to investigation of FVL in patients with venous thromboses. 350 patients with a diagnosis of venous thromboembolic disease from various regions of Slovakia were investigated. FVL, detected by polymerase chain reaction, was found in 128/350 (37%) patients with venous thromboses. 118/128 (92%) patients were heterozygous and 10/128 (8%) were homozygous carriers. In 108/128 (84%) patients with FVL the thromboembolic disease occurred spontaneously. Phlebothrombosis occurred predominantly in the lower limbs--117/128 (91%) patients, atypical localisations were rare. The first thromboembolic event was manifested before 40 years of age in 69% of patients. The family history was positive in 60/128 (47%) FVL carriers with thromboembolic disease. Recurrent thrombosis occurred in 30% of patients with FVL. In agreement with findings in other European countries, the prevalence of FVL was high in Slovak patients with thromboembolic disease. The investigation of FVL seems to be justified in patients before 40 years of age with venous thrombosis of lower limbs, in the absence of triggering factors and with a family history of venous thromboembolic disease.

Fetale Wundheilung

The characteristic of fetal wound healing is scarless wound repair in early gestation. During the last two decades, intensive research efforts have focused on unraveling the molecular regulations underlying the phenomenon of scarless wound healing. Better understanding of synthesis and degradation will enable us to develop important therapeutic options for the prevention and reduction of scarring. The aim of this article is to present an overview, discuss the most important research works of the last two decades on the field of fetal wound healing, and report current therapeutic developments for the modulation of adult wound repair. Recent experimental results using these new therapeutic approaches are very promising and present great possibilities and chances for future surgery.