Efficacy of Combined in-vivo Electroporation-Mediated Gene Transfer of VEGF, HGF, and IL-10 on Skin Flap Survival, Monitored by Label-Free Optical Imaging: A Feasibility Study

Preventing surgical flaps necrosis remains challenging. Laser Doppler imaging and ultrasound can monitor blood flow in flap regions, but they do not directly measure the cellular response to ischemia. The study aimed to investigate the efficacy of synergistic in-vivo electroporation-mediated gene transfer of interleukin 10 (IL-10) with either hepatocyte growth factor (HGF) or vascular endothelial growth factor (VEGF) on the survival of a modified McFarlane flap, and to evaluate the effect of the treatment on cell metabolism, using label-free fluorescence lifetime imaging. Fifteen male Wistar rats (290–320 g) were randomly divided in three groups: group-A (control group) underwent surgery and received no gene transfer. Group-B received electroporation mediated hIL-10 gene delivery 24 h before and VEGF gene delivery 24 h after surgery. Group-C received electroporation mediated hIL-10 gene delivery 24 h before and hHGF gene delivery 24 h after surgery. The animals were assessed clinically and histologically. In addition, label-free fluorescence lifetime imaging was performed on the flap. Synergistic electroporation mediated gene delivery significantly decreased flap necrosis (P = 0.0079) and increased mean vessel density (P = 0.0079) in treatment groups B and C compared to control group-A. NADH fluorescence lifetime analysis indicated an increase in oxidative phosphorylation in the epidermis of the group-B (P = 0.039) relative to controls. These findings suggested synergistic in-vivo electroporation-mediated gene transfer as a promising therapeutic approach to enhance viability and vascularity of skin flap. Furthermore, the study showed that combinational gene therapy promoted an increase in tissue perfusion and a relative increase in oxidative metabolism within the epithelium.

Correlation of Vascular Endothelial Growth Factor subtypes and their receptors with melanoma progression: A next-generation Tissue Microarray (ngTMA) automated analysis

INTRODUCTION

Finding new markers to assess prognosis of melanoma without the necessity to perform a surgical interventions is an important goal in melanoma research. The current study aimed to assess the correlation of clinical course and prognosis of primary and metastatic melanoma with expression of VEGF family and their receptors.

METHODS

A ngTMA block was made from the randomly selected paraffin tissue blocks of the patients with melanocytic nevi, primary and metastatic melanoma. Then sections cut from ngTMA-block were immunohistochemically stained with proper antibodies. Expression of these proteins was investigated using automated image analysis and compared among the study groups.

RESULTS

We analyzed the tissue of 238 patients with following diagnoses: 101 (42.4%) with a diagnosis of nevus, 86 (36.1%) Malignant melanoma and 51 (21.4%) metastasis. Median follow-up time for the malignant lesions was 5.71 years. Among the tested antigen, VEGF-C (p = 0.016), VEGF-R2 (p<0.001) and VEGF-R3 (p = 0.002) were significantly higher expressed in the metastatic tissues. When these scores were assessed in multiple regression models, the only independent factor linked to patient's diagnosis was VEGF-R2 (p<0.001). In addition, groups of highly correlated variables (VEGF-C and VEGF-R3, VEGF-A and VEGF-R1) were found to form separate sub-clusters. On the other side, high values of VEGF-C were associated with both overall and disease-free survival with a statically significant HR of 2.76 (95% CI: 1.27, 5.98; p = 0.01) and 2.82 (95%CI: 1.62, 4.91; p<0.001), respectively.

CONCLUSIONS

This study shows that VEGF-C and VEGF-R2 might represent new prognostic marker in MM. However, further prospective studies are warranted to test their real efficacy as a prognostic marker.

Laser doppler imaging as additional monitoring after digital replanting: A prospective study

BACKGROUND

Despite various exisiting monitoring methods, there is still a need for new technologies to improve the quality of post-operative evaluation of digital replantation. The purpose of the study is using a laser Doppler imaging device (Easy-LDI) as an additional tool to assess perfusion. In this method, the changes in the frequency of the laser ligth provide information regarding perfusion of the monitored tissue.

PATIENTS AND METHODS

This study included seven patients (10 fingers; age of patients: 21-57 years) who suffered from a total (n = 6) or subtotal amputation (n = 4) due to accidents. In addition to hourly standard monitoring with clinical evaluation and skin thermometry, revascularized fingers were hourly monitored with Easy LDI for 48 h.

RESULTS

LDI measurement values ranged between 0.8 and 223 (mean 90.62 ± 21.42) arbitrary perfusion units (APU). The mean LDI values before and after revascularization were 7.1 ± 2.85 and 65.30 ± 30.83 APU, respectively. For the successful revascularized fingers (8 of 10 fingers) values from 19 to 223 APU (mean 98.52 ± 15.48) were demonstrated. All of the replants survived, but due to venous occlusion two digits required revision 12 and 35 h after revascularization, respectively. In the two cases, Easy-LDI also showed a constant and slow decline of the perfusion values. Furthermore, Pearson normalized correlation coefficient showed a positive significant correlation between temperatures of the replants and LDI-values (P < .001, r = +0.392) and a negative significant correlation between Δtemperature and LDI-values (P < .001, r = -0.474).

CONCLUSION

The LDI-device might be a promising additional monitoring technique in detection of perfusion disturbance in monitoring digital replantations.

Efficacy of In Vivo Electroporation-Mediated IL-10 Gene Delivery on Survival of Skin Flaps

Despite advances in understanding the underlying mechanisms of flap necrosis and improvement in surgical techniques, skin flap necrosis after reconstructive surgery remains a crucial issue. We investigated the efficacy of electroporation-mediated IL-10 gene transfer to random skin flap with an aim to accelerate wound healing and improve skin flap survival. Nine male Wistar rats (300-330 g) were divided in two groups (a) control group (n = 5), only surgery no gene transfer, and (b) experimental group, received electroporation-mediated IL-10 gene transfer 24 h before the surgery as prophylaxis (n = 4). Random skin flap (McFarlane) was performed in both groups. Planimetry, Laser Doppler imaging, and immunohistochemistry were used to evaluate the effect of IL-10 gene transfer between study groups at day 7. Electroporation-mediated IL-10 gene transfer decreased percentage of flap necrosis (p value = 0.0159) and increased cutaneous perfusion compared to the control group (p value = 0.0159). In addition, Spearman's rank correlation showed a significant negative correlation between percentage of flap necrosis and Laser Index (p value = 0.0083, r -0.83, respectively). Furthermore, significantly higher mean CD31⁺ vessel density was detected in the experimental group compared to the control group (p value = 0.0159). Additionally, semi-quantitative image analysis showed lower inflammatory cell count in experimental group compared to control group (p value = 0.0317). In vivo electroporation-mediated IL-10 gene transfer reduced necrosis, enhanced survival and vascularity in the ischemic skin flap.

Prognostic value of sentinel lymph node biopsy in melanomas of different Breslow's thickness

BACKGROUND

Although sentinel lymph node biopsy (SLNB) is the most sensitive and accurate investigative modality for establishing regional node status in patients with melanoma, its role and benefit in melanoma of different Breslow's thickness is still controversial.

OBJECTIVE

The current study aimed mainly to evaluate the effects of SLNB results on important outcome parameters in primary melanomas with different Breslow's thicknesses.

METHODS

In a retrospective cohort (1990 to 2014), all cases of single, primary localised cutaneous melanoma tumours were evaluated. Data collected consisted of tumour location, tumour type, ulceration, Breslow's thickness and SLNB result. In addition, locoregional recurrence, distant metastases, disease-free and overall survival were used as the important parameters to compare outcome among the various groups in the current study.

RESULTS

A total of 1111 patients (527 female, 584 male; mean age 64.33 ± 15.44 years) were considered in the analyses in this study, with mean follow-up of 22 77.3 days. The multivariate Cox analysis showed that age, ulceration, Breslow's depth and SLNB result significantly decreased disease-free survival. This analysis also demonstrated that age, gender, ulceration, Breslow's depth and SLNB result significantly affected overall survival. Furthermore, the Kaplan-Meier method showed that the patients with negative SLNB had longer disease-free survival than the patients with positive SLNB in thin, intermediate and thick melanomas (p <0.001, p <0.001 and p = 0.008, respectively). Additionally, in the patients with intermediate melanomas significant better overall survival outcome was observed in those with negative SLNB (p <0.001). Despite worse mean overall survival of the patients with thin or thick melanomas and positive SLNB compared with the patients with negative SLNB, this difference was not statistically significant (p = 0.077 and p = 0.13, respectively).

CONCLUSION

Sentinel lymph node biopsy of melanomas provides important prognostic information and the outcome provides additional information for the management and treatment of the patient.

Evaluation of Medical Students' Attitudes and Performance of Basic Surgery Skills in a Training Program Using Fresh Human skin, Excised During Body Contouring Surgeries

BACKGROUND

Learning surgical skills in the operating room may be a challenge for medical students. Therefore, more approaches using simulation to enable students to develop their practical skills are required.

OBJECTIVES

We hypothesized that (1) there would be a need for additional surgical training for medical students in the pre-final year, and (2) our basic surgery skills training program using fresh human skin would improve medical students' surgical skills.

DESIGN

We conducted a preliminary survey of medical students to clarify the need for further training in basic surgery procedures. A new approach using simulation to teach surgical skills on human skin was set up. The procedural skills of 15 randomly selected students were assessed in the operating room before and after participation in the simulation, using Objective Structured Assessment of Technical Skills. Furthermore, subjective assessment was performed based on students' self-evaluation. The data were analyzed using SPSS, version 21 (SPSS, Inc., Chicago, IL).

SETTING

The study took place at the Inselspital, Bern University Hospital.

PARTICIPANTS

A total of 186 pre-final-year medical students were enrolled into the preliminary survey; 15 randomly selected medical students participated in the basic surgical skills training course on the fresh human skin operating room.

RESULTS

The preliminary survey revealed the need for a surgical skills curriculum. The simulation approach we developed showed significant (p < 0.001) improvement for all 12 surgical skills, with mean cumulative precourse and postcourse values of 31.25 ± 5.013 and 45.38 ± 3.557, respectively. The self-evaluation contained positive feedback as well.

CONCLUSION

Simulation of surgery using human tissue samples could help medical students become more proficient in handling surgical instruments before stepping into a real surgical situation. We suggest further studies evaluating our proposed teaching method and the possibility of integrating this simulation approach into the medical school curriculum.

A retrospective study of 1- versus 2-cm excision margins for cutaneous malignant melanomas thicker than 2 mm

BACKGROUND

Most guidelines recommend at least 2-cm excision margin for melanomas thicker than 2 mm.

OBJECTIVE

We evaluated whether 1- or 2-cm excision margins for melanoma (>2 mm) result in different outcomes.

METHODS

This is a retrospective cohort study on patients with melanomas (>2 mm) who underwent tumor excision with 1-cm (228 patients) or 2-cm (97 patients) margins to investigate presence of local recurrences, locoregional and distant metastases, and disease-free and overall survival.

RESULTS

In all, 325 patients with mean age of 61.84 years and Breslow thickness of 4.36 mm were considered for the study with a median follow-up of 1852 days (1995-2012). There was no significant difference in the frequency of locoregional and distant metastasis between the 2 groups (P = .311 and .571). The survival analysis showed no differences for disease-free (P = .800; hazard ratio 0.948; 95% confidence interval 0.627-1.433) and overall (P = .951; hazard ratio 1.018; 95% confidence interval 0.575-1.803) survival.

LIMITATIONS

The study was not prospectively randomized.

CONCLUSIONS

Our study did not show any significant differences in important outcome parameters such as local or distant metastases and overall survival. A prospective study testing 1- versus 2-cm excision margin is warranted.

High expression of FOXP3 in primary melanoma is associated with tumour progression

BACKGROUND

The antitumour immune response plays an important role in the prognosis of melanoma. High numbers of circulating regulatory T cells have been associated with rapid disease progression.

OBJECTIVES

To assess the influence of forkhead box protein (FOXP)3, CD1a and langerin expression on the prognosis of primary melanoma.

METHODS

We analysed 185 primary melanomas by immunohistochemical staining for expression of the regulatory T-cell marker FOXP3 and the dendritic cell markers langerin and CD1a, and correlated marker expression with clinical outcome.

RESULTS

Disease-free survival and overall survival were significantly longer in patients expressing low levels of FOXP3 in the primary melanoma, whereas they were associated with high expression of CD1a. The negative prognostic value of FOXP3 expression was independent of the Breslow tumour thickness. Langerin expression did not correlate with the clinical outcome.

CONCLUSIONS

High expression of FOXP3 in the primary melanoma may be used as an additional independent prognostic marker for early tumour progression in patients with melanoma.

Estrogen induces nitric oxide production via nitric oxide synthase activation in endothelial cells

INTRODUCTION

17β-estradiol (E2) has been found to induce vasodilation in the cardiovascular system and at physiological levels, resulting in prevention of cerebral vasospasm following subarachnoid hemorrhage (SAH) in animal models. The goal of this study was to analyze the cellular mechanism of nitric oxide (NO) production and its relation to E2, in vitro in brain and peripheral endothelial cells.

METHODS

Human umbilical endothelial cells (HUVEC) and brain endothelial cells (bEnd.3) were treated with estradiol (E2, 0.1, 10, 100, and 1,000 nM), and supernatant was collected at 0, 5, 15, 30, 60, and 120 min for nitric oxide metabolome (nitrite, NO₂) measurements. Cells were also treated with E2 in the presence of 1400W, a potent eNOS inhibitor, and ICI, an antagonist of estradiol receptors (ERs). Effects of E2 on eNOS protein expression were assessed with Western blot analysis.

RESULTS

E2 significantly increased NO2 levels irrespective of its concentration in both cell lines by 35 % and 42 % (p < 0.05). The addition of an E2 antagonist, ICI (10 μM), prevented the E2-induced increases in NO2 levels (11 % p > 0.05). The combination of E2 (10 nM) and a NOS inhibitor (1400W, 5 μM) inhibited NO2 increases in addition (4 %, p > 0.05). E2 induced increases in eNOS protein levels and phosphorylated eNOS (eNOS(p)).

CONCLUSIONS

This study indicates that E2 induces NO level increases in cerebral and peripheral endothelial cells in vitro via eNOS activation and through E2 receptor-mediated mechanisms. Further in vivo studies are warranted to evaluate the therapeutic value of estrogen for the treatment of SAH-induced vasospasm.

[The risk-reducing mastectomy: unnecessary hysteria or life-saving prophylaxis?]

The prophylactic (risk-reducing) mastectomy is a world-wide recognized method for specifically treating the increased breast cancer risk in patients showing a BRCA1 and/or BRCA2 mutation as well as other patient groups at increased breast cancer risk. This option should be offered to all patients having the pertinent risk profile. Breast reconstruction is an integral part of the risk-reducing mastectomy procedure and all possible methods of breast reconstruction, especially autologous tissue reconstruction should be offered to all patients having a medical indication and desiring this surgical treatment. These patients are best managed in certified Breast Care Centres where the different medical and surgical specialists can address interdisciplinary all aspects of genetic counselling, preoperative counselling, mastectomy and reconstructive techniques as well as the necessary postoperative surveillance.

Ankle dorsiflexion arthrodesis to salvage Chopart's amputation with anterior skin insufficiency

BACKGROUND

In Chopart-level amputations the heel often deviates into equinus and varus when, due to the lack of healthy anterior soft tissue, rebalancing tendon transfers to the talar head are not possible. Consequently, anterior and lateral wound dehiscence and ulceration may occur requiring higher-level amputation to achieve wound closure, with considerable loss of function for the patients.

METHODS

Twenty-four consecutive patients (15 diabetes, 6 trauma, and 3 tumor) had Chopart's amputation and simultaneous or delayed additional ankle dorsiflexion arthrodesis to allow for tension-free wound closure or soft tissue reconstruction, or to treat secondary recurrent ulcerations. Percutaneous Achilles tendon lengthening and subtalar arthrodesis were added as needed. Wound healing problems, time to fusion and full weight-bearing in the prosthesis, complications in the prosthesis, and the ambulatory status were assessed. Satisfaction and function were evaluated by the AmpuPro score and the validated Prosthesis Evaluation Questionnaire scale.

RESULTS

Five patients had successful soft tissue healing and fusions but died of their underlying disease 2 to 46 months after the operation. Two diabetic patients required a transtibial amputation. The other 17 patients were followed for 27 months (range, 13-63). The average age of the 4 women and 13 men was 53.9 years (range, 16-87). Postoperative complications included minor wound healing problems in 8 patients, wound breakdown requiring revision in 4, phantom pain in 3, residual equinus in 1, and adjacent scar carcinoma in 1 patient. The time to full weight-bearing in the prosthesis ranged from 6 to 24 weeks (mean 10). The mean AmpuPro score was 107 points (of 120), and the mean Prosthesis Evaluation Questionnaire scale was 147 points (of 200). No complications occurred with the prosthesis. Twelve patients lost 1 to 2 mobility classes (mean 0.9). The arthrodeses all healed within 2.5 months (range, 1.5 to 5 months).

CONCLUSION

Adding an ankle arthrodesis to a Chopart's amputation either immediately or in a delayed fashion to treat anterior soft tissue complications was a successful salvage in most patients at this amputation level. It enabled the patients to preserve the advantages of a full-length limb with terminal weight-bearing.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

[Surgical therapy for reconstruction of body shape and contour following massive weight reduction]

The consequences of massive weight loss through bariatric procedures as well as diet are overall positive. However, the sequelae of massive weight loss present themselves as soft tissue redundancies in the areas of the lower abdomen, upper thigh, upper arm and breast as well as face and neck. This condition presents significant mechanical, physical and social day-to-day limitations for the quality of life of these patients. Surgical techniques are indicated for the reconstruction of the body shape and therapy of the above named problems and the coexistent psychosocial component. These surgical techniques involve dermolipectomies in different body areas and can lead to significant improvement. In view of the worldwide increase of adipositas and the increasing need for bariatric surgery, a parallel increase in demand for such reconstructive post-bariatric interventions can be foreseen. Early and precise information is crucial for the patients before engaging in weight reduction, as is the coverage of the costs of the resulting secondary reconstructive body contouring interventions by the insurance companies.

Topical application of 17β-estradiol (E2) improves skin flap survival through activation of endothelial nitric oxide synthase in rats

This study investigates the influence of 17β-estradiol (E2) on nitric oxide (NO) production in endothelial cell cultures and the effect of topical E2 on the survival of skin flap transplants in a rat model. Human umbilical vein endothelial cells were treated with three different E2 concentrations and nitrite (NO2) concentrations, as well as endothelial nitric oxide synthase (eNOS) protein expressions were analyzed. In vivo, random-pattern skin flaps were raised in female Wistar rats 14 days following ovariectomy and treated with placebo ointment (group 1), E2 as gel (group 2), and E2 via plaster (group 3). Flap perfusion, survival, and NO2 levels were measured on postoperative day 7. In vitro, E2 treatment increased NO2 concentration in cell supernatant and eNOS expression in cell lysates (p < 0.05). In vivo, E2 treated (gel and plaster groups) demonstrated significantly increased skin flap survival compared to the placebo group (p < 0.05). E2 plaster-treated animals exhibited higher NO2 blood levels than placebo (p < 0.05) paralleling the in vitro observations. E2 increases NO production in endothelial cells via eNOS activation. Topical E2 application can significantly increase survival of ischemically challenged skin flaps in a rat model and may augment wound healing in other ischemic situations via activation of NO production.

The role of androgens on hypoxia-inducible factor (HIF)-1α-induced angiogenesis and on the survival of ischemically challenged skin flaps in a rat model

BACKGROUND

Effects of androgens on angiogenesis are controversial. Hypoxia-inducible factor (HIF)-1α promotes expression of vascular endothelial growth factor (VEGF) that stimulates angiogenesis.

PURPOSE

This study investigates whether androgens stabilize HIF-1α in endothelial cells, and androgen depletion decreases VEGF concentrations and skin flap survival.

MATERIALS AND METHODS

Male human umbilical vein endothelial cells (HUVECs) were exposed to dihydrotestosterone (DHT) and HIF-1α expression was measured. In male Wistar rats, standardized proximally based random pattern dorsal skin flaps (3 × 9 cm) were raised 4 weeks after orchiectomy and sham operation, respectively (n = 10, each). Flap VEGF concentrations (immunohistochemistry), perfusion (Laser Doppler), and viability (digital planimetry) were measured.

RESULTS

DHT induced HIF-1α expression in HUVECs. Androgen depletion induced decreased VEGF expression (P = 0.003), flap perfusion (P < 0.05), and survival (44.4% ± 5.2%) compared to controls (35.5% ± 4.5%; P = 0.003).

CONCLUSION

In vitro, androgens may stimulate HIF-1α under normoxic conditions. In rats, androgen depletion decrease VEGF expression and flap survival.

Effective wound closure with a new two-component wound closure device (Prineo™) in excisional body-contouring surgery: experience in over 200 procedures

BACKGROUND

In excisional body-contouring surgery the surgeon is often confronted with time-consuming closure of long wounds. Recently, a new combination of a self-adhering mesh together with a liquid 2-octyl cyanoacrylate adhesive (Prineo™; Ethicon, Inc., Somerville, NJ, USA) has been introduced to replace intracutaneous running suture.

METHODS

An observational study was undertaken to evaluate the efficacy of the new wound closure device in excisional body-contouring procedures between January 2008 and November 2010. Wound characteristics were recorded in a prospectively maintained database.

RESULTS

During the study period, 224 procedures in 180 patients were undertaken. Twenty-seven patients had two subsequent operations and four patients had three subsequent operations. Application of the new device was easy and safe and patient satisfaction with the results was generally high. However, intense local allergic reactions were seen in 4 patients (1.8%), which necessitated early removal and topical corticosteroid treatment.

CONCLUSIONS

Prineo™ enables the surgeon to perform a quick and smooth skin closure, especially in long incisions frequently encountered in excisional body-contouring surgery. The application is fast and easy if basic guidelines are respected. Operating time is saved by eliminating the need for time-consuming intracutaneous running sutures. Removal is easy and painless for the patient. However, there is a potential for local allergic adverse effects of which the surgeon must be aware.

Giulio Cesare Aranzio (Arantius) (1530-89) in the pageant of anatomy and surgery

Giulio Cesare Aranzio in Italian (Julius Caesar Arantius in Latin) has not received full acclaim for his achievements in the field of anatomy and surgery that remain unknown to most physicians. His anatomical books Observationes Anatomicas, and De Humano Foetu Opusculum and surgical books De Tumoribus Secundum Locos Affectos and Hippocratis librum de vulneribus capitis commentarius brevis printed in Latin and additional existing literature on Aranzio from medical history books and journals were analysed extensively. Aranzio became Professor of Anatomy and Surgery at the University of Bologna in 1556. He established anatomy as a distinguished branch of medicine for the first time in medical history. Aranzio combined anatomy with a description of pathological processes. He discovered the 'Nodules of Aranzio' in the semilunar valves of the heart. He gave the first description of the superior levator palpebral and the coracobrachialis muscles. Aranzio wrote on surgical techniques for a wide spectrum of conditions that range from hydrocephalus, nasal polyp, goitre and tumours to phimosis, ascites, haemorrhoids, anal abscess and fistulae, and much more. Aranzio had an extensive knowledge in surgery and anatomy based in part on the ancient Greek and his contemporaries in the 16th century but essentially on his personal experience and practice.

Unilateral hypoplastic breast in a male-to-female transsexual with Poland syndrome after gender reassignment--reconstructive considerations

Gender reassignment procedures are performed more frequently nowadays due to a multidisciplinary approach and improved techniques and selection process. Many male-to-female patients require bilateral breast augmentation as part of the transformation following the gender reassignment if they fail to develop female breast features after hormonal treatment. We report on a very rare incidence of male-to-female gender reassignment in a patient with Poland syndrome. A male-to-female transsexual on hormonal therapy for gender reassignment developed one normal female-shaped breast whereas the other breast remained hypoplastic. As a male, he was not aware of his chest wall deformity but it became a major issue after successful gender reassignment surgery. Our experience with the specific reconstructive considerations and recommendations regarding our surgical approach to this complex reconstructive problem are discussed.

Dynamic repair of scapholunate dissociation with dorsal extensor carpi radialis longus tenodesis

This study investigates the results of a technique using an extensor carpi radialis longus (ECRL) tenodesis for symptomatic scapholunate instability. Symptomatic scapholunate instability has been corrected so far either by limited wrist fusion or by various techniques of soft tissue repair. Limited wrist fusion greatly reduces wrist motion and increases the probability of osteoarthritis in the remaining mobile wrist segments. On the other hand, most types of soft tissue repair are technically difficult to perform and have disappointing results due to the inherent laxity. The presented dynamic approach was used in 20 wrists of 19 patients with static scapholunate instability. Preoperative evaluation included in all patients clinical examination, radiologic evaluation, and arthroscopy for establishing the diagnosis of static scapholunate instability. The technique involves the fixation of the ECRL tendon on the dorsal aspect of the scaphoid by means of a cancellous screw and a special washer. Dynamic ECRL tenodesis of the scaphoid is a safe and simple procedure that enhances the extension forces on the scaphoid in all wrist positions. The results of this preliminary report in 20 wrists showed dynamic ECRL tenodesis to be an effective treatment option for treating symptomatic static scapholunate instability.

Interrelation of peri-operative morbidity and ASA class assignment in patients undergoing gynaecological surgery

OBJECTIVE

The aim of this study was to estimate intra- and post-operative risk using the American Society of Anaesthesiologists (ASA) classification which is an important predictor of an intervention and of the entire operating programme.

STUDY DESIGN

In this retrospective study, 4435 consecutive patients undergoing elective and emergency surgery at the Gynaecological Clinic of the University Hospital of Zurich were included. The ASA classification for pre-operative risk assessment was determined by an anaesthesiologist after a thorough physical examination. We observed several pre-, intra- and post-operative parameters, such as age, body-mass-index, duration of anaesthesia, duration of surgery, blood loss, duration of post-operative stay, complicated post-operative course, morbidity and mortality. The investigation of different risk factors was achieved by a multiple linear regression model for log-transformed duration of hospitalisation.

RESULTS

Age and obesity were responsible for a higher ASA classification. ASA grade correlates with the duration of anaesthesia and the duration of the surgery itself. There was a significant difference in blood loss between ASA grades I (113+/-195 ml) and III (222+/-470 ml) and between classes II (176+/-432 ml) and III. The duration of post-operative hospitalisation could also be correlated with ASA class. ASA class I=1.7+/-3.0 days, ASA class II=3.6+/-4.3 days, ASA class III=6.8+/-8.2 days, and ASA class IV=6.2+/-3.9 days. The mean post-operative in-hospital stay was 2.5+/-4.0 days without complications, and 8.7+/-6.7 days with post-operative complications. Multiple linear regression model showed that not only the ASA classification contained an important information for the duration of hospitalisation. Parameters such as age, class of diagnosis, post-operative complications, etc. also have an influence on the duration of hospitalisation.

CONCLUSION

This study shows that the ASA classification can be used as a good and early available predictor for the planning of an intervention in gynaecological surgery. The ASA classification helps the surgeon to assess the peri-operative risk profile of which important information can be derived for the planning of the operation programme.

Versatility of the Abductor Hallucis Muscle as a Conjoined or Distally-Based Flap

Soft tissue coverage of the medial ankle and foot remains a difficult, challenging, and often frustrating problem to patients as well as surgeons. To our knowledge, the abductor hallucis muscle flap is not frequently used and only a few well documented cases were found in literature. The purpose of this paper is to report and to present the long-term results of a series of four patients who underwent reconstruction of foot and ankle defects with the abductor hallucis muscle flap. In two cases, the abductor hallucis muscle flap was transposed in combination with a medialis pedis flap to cover a medial ankle defect, whereas in another case it was combined with a medial plantar flap. In this latter case, the muscle flap served to fill up a calcaneal dead space after osteomyelitis debridement, whereas the cutaneous flap was used to replace debrided skin at the heel. The abductor hallucis flap was used as a distally-based turnover flap to cover a large forefoot defect in a fourth case. Follow-up period ranged between 18 and 64 months (mean 43.3). In the early postoperative period, two flaps healed completely In two patients marginal flap necrosis occurred which was subsequently skin grafted. No donor-site complication occurred in any of the patients. In all cases, protective sensation of the skin was satisfactory as early as 6 months. In two cases mild hyperkeratosis at the skin graft border to the sole skin (non-weight bearing area of medial plantar and medialis pedis flap donor site) was present, but probably related to poor foot care. All patients were fully mobile as early as 3 months after treatment. In the long-term follow-up (43.3 months), all flaps provided with durable coverage. Functional gait deficit due to consumtion of the abductor hallucis muscle was not apparent. Our long-term results demonstrated that the abductor hallucis muscle flap is a versatile, and reliable flap suitable for the reconstruction of foot and ankle defects. Utilizing the abductor hallucis muscle as a pedicled flap (distally or proximally-based) with or without conjoined regional fasciocutaneous flaps offers a successful and durable alternative to microsurgical tree flaps for small to moderate defects over the calcaneus region, medial ankle, medial foot, and forefoot with exposed bone, tendon, or joint.

Sciatic nerve enlargement in the Klippel–Trenaunay–Weber syndrome

The case of a 35-year-old woman with Klippel-Trenaunay-Weber syndrome (KTWS) showing clinical symptoms of a peroneal nerve lesion is presented. An immense nerve enlargement along most of the sciatic, peroneal and tibial nerve was found to be due to a lipoma arising from the epi- and perineurium. Treatment consisted of extensive microsurgical neurolysis and excision of the tumor resulting in decompression of the affected nerves. Although rare, a perineural lipoma should be kept in mind in patients with KTWS showing neurological abnormalities.

Secondary Breast Reconstruction with Deepithelialized Free Flaps from the Lower Abdomen for Intractable Capsular Contracture and Maintenance of Breast Volume

Although surgical techniques and the quality of mammary prostheses have been improved significantly in recent years, capsular contracture attendant on prosthetic mammary reconstruction remains a major flaw. Although rarely, some patients are confronted with recurrent and intractable capsular contractures with resultant breast deformity, even after multiple attempts at capsulectomies and implant exchange. Patients with recurrent capsular contracture often do not want replacement with a new prosthesis, but desire the maintenance of their breast volume with a safe alternative. In an attempt to maintain breast volume and to improve the aesthetic appearance, secondary breast reconstruction using bilateral deepithelialized free flaps from the lower abdomen was performed in a series of seven patients. Three bilateral muscle-sparing TRAM flaps, two bilateral DIEP flaps, one bilateral SIEA flap, one unilateral SIEA flap, and one unilateral DIEP flap (a total number of 14 flaps) were used following implant removal, total capsulectomy, and prophylactic subcutaneous mastectomy. The early postoperative course was uneventful, and all flaps survived completely with no complications. There were no donor-site problems, except in one patient (case 5), who had partial skin necrosis of the abdominal flap. The long-term results (mean follow-up: 4.8 years) demonstrated an aesthetically satisfactory appearance of the breasts, with no major donor-site problems. Several advantages, as well as drawbacks, are highlighted with this technique.

Adenovirus-mediated transforming growth factor-β ameliorates ischemic necrosis of epigastric skin flaps in a rat model1, 2

BACKGROUND

Gene therapy has been recently introduced as a novel approach to treat ischemic tissues by using the angiogenic potential of certain growth factors. We investigated the effect of adenovirus-mediated gene therapy with transforming growth factor-beta (TGF-beta) delivered into the subdermal space to treat ischemically challenged epigastric skin flaps in a rat model.

MATERIAL AND METHODS

A pilot study was conducted in a group of 5 animals pretreated with Ad-GFP and expression of green fluorescent protein in the skin flap sections was demonstrated under fluorescence microscopy at 2, 4, and 7 days after the treatment, indicating a successful transfection of the skin flaps following subdermal gene therapy. Next, 30 male Sprague Dawley rats were divided into 3 groups of 10 rats each. An epigastric skin flap model, based solely on the right inferior epigastric vessels, was used as the model in this study. Rats received subdermal injections of adenovirus encoding TGF-beta (Ad-TGF-beta) or green fluorescent protein (Ad-GFP) as treatment control. The third group (n = 10) received saline and served as a control group. A flap measuring 8 x 8 cm was outlined on the abdominal skin extending from the xiphoid process proximally and the pubic region distally, to the anterior axillary lines bilaterally. Just prior to flap elevation, the injections were given subdermally in the left upper corner of the flap. The flap was then sutured back to its bed. Flap viability was evaluated seven days after the initial operation. Digital images of the epigastric flaps were taken and areas of necrotic zones relative to total flap surface area were measured and expressed as percentages by using a software program.

RESULTS

There was a significant increase in mean percent surviving area between the Ad-TGF-beta group and the two other control groups (P < 0.05). (Ad-TGF-beta: 90.3 +/- 4.0% versus Ad-GFP: 82.2 +/- 8.7% and saline group: 82.6 +/- 4.3%.)

CONCLUSIONS

In this study, the authors were able to demonstrate that adenovirus-mediated gene therapy using TGF-beta ameliorated ischemic necrosis in an epigastric skin flap model, as confirmed by significant reduction in the necrotic zones of the flap. The results of this study raise the possibility of using adenovirus-mediated TGF-beta gene therapy to promote perfusion in random portion of skin flaps, especially in high-risk patients.

Pediatric cranio-facial surgery. First-year's experience with a gun applying bioabsorbable tacks

AIM

In 2001 a prototype of a gun to apply bioabsorbable tacks in cranio-facial surgery has been developed.

METHODS

From May 2001 to May 2002 this device has been used in the University Hospital of Innsbruck (Austria) for different cranioplasty procedures, in 34 children, showing its reliability for cranio-facial bone fixation. The children were affected by isolated craniosynostosis or by syndromical synostosis (Apert, Crouzon) and in a case of benign tumor of the parietal skull vault. The range of age, at the time of surgery, was between 3 months and 204 months of age. Bone segments were fixed using self-reinforced polylactide plates and tacks.

RESULTS

Firm fixation was obtained intra-operatively and the operative time was reduced about 25-30 minutes as compared to use of plates and screws. This device has just one limitation in its own spring force: sometimes the bone thinner than 1 mm has been broken applying the tacks.

CONCLUSION

After the first-year's experience it is possible to confirm that this device reduces, in selected cases, operative time, blood loss, risk of infection and, as a result, the costs.

Microsurgical Repair of the Sural Nerve after Nerve Biopsy to Avoid Associated Sensory Morbidity: A Preliminary Report

OBJECTIVE

The purpose of this article is to report our preliminary results regarding microsurgical repair of the sural nerve after nerve biopsy, in an attempt to reduce the well-described sensory morbidity and neuroma formation.

METHODS

Three patients with a suspected diagnosis of peripheral neuropathy underwent sural nerve biopsies to establish definitive diagnoses. A 10-mm segment of the sural nerve was resected with local anesthesia. After harvesting of the specimen, the proximal and distal nerve stumps were carefully mobilized and united with epineural suture techniques, under a surgical microscope. Sensory evaluations (assessing the presence of hypesthesia/dysesthesia or pain) of the lateral aspect of the foot, in regions designated Areas 1, 2, and 3, were performed before and 6 and 12 months after the biopsies. A visual analog scale was used for pain estimation.

RESULTS

The biopsy material was sufficient for histopathological examinations in all cases, leading to conclusive diagnoses (vasculitis in two cases and amyloidosis in one case). The early post-biopsy hypesthesia, which was present for 4 to 8 weeks, improved to preoperative levels as early as 6 months after the nerve repair. Sensory evaluations performed at 6- and 12-month follow-up times demonstrated that none of the patients complained of pain at the biopsy site or distally in the area innervated by the sural nerve. Ultrasonography performed at the 12-month follow-up examination revealed normal sural nerve morphological features, with no neuroma formation, comparable to findings for the contralateral site.

CONCLUSION

Microsurgical repair of the sural nerve after biopsy can eliminate or reduce sensory disturbances such as paraesthesia, hypesthesia, and dysesthesia distal to the biopsy site, in the distribution of the sensory innervation of the sural nerve, and can prevent painful neuroma formation. To our knowledge, this article is the first in the literature to report on microsurgical repair of the sural nerve after nerve biopsy. Decreased side effects suggest that this technique can become a standard procedure after sural nerve biopsy, which is commonly required to establish the diagnosis of various diseases, such as peripheral nerve pathological conditions, vasculitis, and amyloidosis. More cases should be analyzed, however, to explore the usefulness of the technique and the reliability of sural nerve biopsy samples in attempts to obtain conclusive diagnoses.

Free anteromedial thigh flap: Clinical application and review of literature

The anteromedial thigh (AMT) flap is reviewed in terms of its vascular anatomy and previous clinical reports in the literature. Our own series of 5 patients treated with this flap for defects in the head and neck region and lower extremity is presented. Although several authors controversially discussed vasculature, we constantly found the pedicle as an emerging septocutaneous perforator at a point where the medial border of the rectus femoris muscle is crossed by the sartorius muscle. In all 5 patients, the AMT flap provided stable coverage with no flap loss. Based on our findings, we conclude that the anteromedial thigh flap offers all the advantages of fasciocutaneous flaps. Therefore, we recommend this flap as an alternative for defects requiring coverages of thin to moderate skin thickness. However, it should be remembered that variations in vascular anatomy are possible.

Distally Based Abductor Hallucis Muscle Flap: Anatomic Basis and Clinical Application

Although rarely used, the abductor hallucis muscle has its indications in coverage of small defects at the medial aspect of the hindfoot as a proximally based muscle flap. The authors describe a 69-year-old female patient in whom the abductor hallucis muscle was used as a distally based flap to reconstruct a defect in the forefoot. An anatomic study was undertaken on two cadaveric feet to explore the practicality of the distally based abductor hallucis muscle flap before it was applied clinically. The distally based abductor muscle flap receives its blood supply from minor and major pedicles in a retrograde fashion from both the dorsal arterial network and the deep plantar system, through communicating branches with the medial plantar artery distally. Transposition of the distally based hallucis flap is only advisable in individuals who have no vascular compromise in the lower leg and foot. To the authors' knowledge, this modification has not yet been described in the available literature.

Carl Nicoladoni and his contributions to scoliosis

Carl Nicoladoni (1847-1902) studied medicine in Vienna and became Privatdozent in surgery in 1876. He accepted a chair as a Professor of Surgery at the university clinics of Innsbruck (1881) and Graz (1895). Nicoladoni has made significant contributions in the progress of surgery and performed a variety of operations in several surgical disciplines. However, his principal contributions are in the field of orthopedic surgery, in particular his excellent and detailed studies on scoliosis, based on thorough anatomic and kinetic investigation. His commitment to the research of scoliosis resulted in three books and three bigger treatises, all of which were printed in German. His earliest book was printed in 1882 and was on the torsion of the scoliotic spine, Die Torsion der Skoliotischen Wirbelsäule. Three bigger treatises on scoliosis entitled Die Architektur der Sskoliotischen Wirbelsäule (The Architecture of the Scoliotic Spine, 1889), Die Architektur der Kindlichen Skoliose (The Architecture of Juvenile Scoliosis, 1894), and Die Skoliose des Lendensegmentes (The Scoliosis of Lumbar Segments, 1894) were published in an anthology called Denkschriften der Kaiserlichen Akademie der Wissenschaften, a series of publications from the imperial academy of science. Two versions of his epical work, Anatomie und Mechanismus der Skoliose (Anatomy and Mechanism of Scoliosis) were printed. A larger edition printed in 1904 was part of the Bibliotheca Medica, a monumental series of various clinical books published around the beginning of the past century. The second version, a shortened one, with the same title was included in an anthology called Deutsche Chirurgie (German Surgery) and published in 1909. The purpose of this historical article is to discuss Nicoladoni's achievements in the field of scoliosis based on a detailed analysis of his books.

Practical use of digital cameras for microphotography through the operating microscope

A practical use of personal digital cameras for taking digital photographs in the microsurgical field through an operating microscope is described. This inexpensive and practical method for acquiring microscopic images at the desired magnification combines the advantages of the digital camera and the operating microscope.

[Coverage of pressure sores with free flaps]

INTRODUCTION

The coverage of recurrent pressure sores with unstable scar in the surrounding tissue is still an unsolved problem in the literature. Local and regional transfer of tissue often does not meet the requirements of the tissue deficit. Especially in recurrent pressure sores, the adjacent skin has already been consumed due to multiple surgeries. As a good alternative, the microsurgical transfer of flaps offers viable tissue to cover even large pressure sores.

METHODS

We performed a total of six free flaps in five patients who suffered from intractable pressure sores in the hip region. The age of the patients was between 41 and 63 years. The defect size varied between 6 x 6 cm and 25 x 30 cm. Two combined myocutaneous scapula-latissimus dorsi, two myocutaneous latissimus dorsi, one anteromedial thigh, and one rectus femoris flap were used to cover the defects.

RESULTS

The average follow-up time was 29 months. Flaps provided stable coverage in four of five patients at 12-month follow-up. There was one subtotal flap necrosis that was subsequently treated with split-thickness skin grafting.

CONCLUSION

In this series of five patients with six free flaps, we were able to show that the microsurgical transfer of tissue is a valuable option in the treatment of difficult pressure sores. Even in older and debilitated patients, this method is a good alternative to conventional local flaps.

Composite skin grafts for basal cell carcinoma defects of the nose

Basal cell carcinoma is the most frequent cutaneous cancer of the nose and is characterized by its local spreading and exceptionally rare tendency to metastasize. Since a significant advantage has been seen in surgery compared to other treatments, surgical excision ensuring the highest chance of cure is frequently employed. Excision defects of the nose may be covered with either local flap or a full-thickness skin graft. In resurfacing such defects following excision of basal cell carcinomas, we favor the technique of composite-skin grafting which involves the harvesting of composite-skin graft including the epidermis, dermis and superficial layers of subcutaneous tissue to obtain the required thickness in the recipient site. This technique was used for defects remaining after the excision of basal cell carcinomas in a series of 15 patients. The areas involved were lateral nasal region (5 cases), nasal tip (4 cases), dorsum (3 cases), alar lobule (2 cases), and soft triangle (1 case). The mean follow-up was 14.2 months. The color, texture and thickness of the composite-skin graft harvested from the preauricular site and the neck compare favorably with the skin of the nose region. Satisfactory results, both clinically and in patient appreciation, have been obtained in both the reconstruction site and the appearance of the donor site in all patients.

Ultrasonography for depiction of brachial plexus injury

Recent development of ultrasonographic equipment has allowed improved spatial resolution for visualizing normal and pathologic conditions of peripheral nerves. Regarding the brachial plexus, only ultrasonographic studies that have described the normal appearance have been reported. To the best of our knowledge, no case report regarding the ultrasonographic description of a brachial plexus lesion has been published. We report the ultrasonographic findings of a brachial plexus injury after extirpation of a suspected enlarged supraclavicular lymph node.