The Multiple Rhomboid Vector Suture-Our Experience of Two Years with a Modified Suspension Approach for SMAS Plication Facelifts

Purse string sutures in superficial musculoaponeurotic system (SMAS) plication facelifts may cause technique-related problems, such as soft tissue deformities, dimpling, and bulkiness inside and between the independent sutures. Therefore, the authors have developed a new approach named the multiple rhomboid vector (MRV) suture. A total of 103 patients (89 female, 14 male patients; median age: 57 years) received a primary rhytidectomy with the MRV SMAS plication suture in our clinic (2015-2017). Intraoperative time to perform the suture per side was recorded. Postoperative complications and dimpling and bulkiness of subcutaneous tissues were judged by three independent surgeons from 1 (= none) to 4 (= extreme) after 1 week, 1, 3, 6, and 12 months. A standardized survey, the FACE-Q questionnaire, was performed to evaluate postoperative patient satisfaction. Mean time to perform the suture was 5:14 minutes per side (minimum: 3:20 minutes, maximum: 5:53 minutes; standard deviation: 0:51 minutes). During the follow-up period, four complications were detected (two cases of temporary neurapraxia of the marginal branch of the mandibular nerve {n = 2 [1.9%]} and two cases of retroauricular hematoma {n = 2 [1.9%]}). Postoperative dimpling or bulkiness of subcutaneous tissues was judged as absent. Overall patient satisfaction rate, after the surgery was performed, was measured as "very high." The MRV suture offers a combined horizontal and vertical suspension approach, which effectively addresses the different vectors of age-related facial soft tissue descent with complication rates equal to other surgical lifting techniques. Apart from that, it may help reduce the possibility of contour irregularities, whereby it must be noted that a thorough preoperative assessment together with the patient and surgical planning is crucial to ensure realistic expectations of the surgical outcome.

The role of structured reporting and structured operation planning in functional endoscopic sinus surgery

Computed tomography (CT) scans represent the gold standard in the planning of functional endoscopic sinus surgeries (FESS). Yet, radiologists and otolaryngologists have different perspectives on these scans. In general, residents often struggle with aspects involved in both reporting and operation planning. The aim of this study was to compare the completeness of structured reports (SR) of preoperative CT images and structured operation planning (SOP) to conventional reports (CR) and conventional operation planning (COP) to potentially improve future treatment decisions on an individual level. In total, 30 preoperative CT scans obtained for surgical planning of patients scheduled for FESS were evaluated using SR and CR by radiology residents. Subsequently, otolaryngology residents performed a COP using free texts and a SOP using a specific template. All radiology reports and operation plannings were evaluated by two experienced FESS surgeons regarding their completeness for surgical planning. User satisfaction of otolaryngology residents was assessed by using visual analogue scales. Overall radiology report completeness was significantly higher using SRs regarding surgically important structures compared to CRs (84.4 vs. 22.0%, p<0.001). SOPs produced significantly higher completeness ratings (97% vs. 39.4%, p<0.001) regarding pathologies and anatomical variances. Moreover, time efficiency was not significantly impaired by implementation of SR (148 s vs. 160 s, p = 0.61) and user satisfaction was significantly higher for SOP (VAS 8.1 vs. 4.1, p<0.001). Implementation of SR and SOP results in a significantly increased completeness of radiology reports and operation planning for FESS. Consequently, the combination of both facilitates surgical planning and may decrease potential risks during FESS.

Treatment of Scaphoid Nonunion: Radiologic Outcome of 286 Patients in 10 Years

Background: We analyzed the radiologic outcome of different treatment options for scaphoid nonunion. The results were compared with literature, and a treatment algorithm was proposed. Methods: On the basis of a retrospective case-control study, 286 patients suffering from scaphoid nonunion were treated over a 10-year period. Patients were grouped depending on the location of the nonunion: proximal (n = 126), middle (n = 130), or distal (n = 30) third. In the presence of an avascular proximal fragment or after prior unsuccessful operation, interposition of a vascularized pedicled bone graft from the distal radius was performed (n = 82). Scaphoid healing was detected by conventional radiography and computed tomography. Results: Excellent healing rates of 96.3% were obtained for middle and distal third scaphoid nonunions by conventional iliac crest bone grafting (n = 137). Furthermore, we achieved healing rates of 91.3% for persistent nonunions using a palmar vascularized bone graft from the distal radius after prior unsuccessful operation (n = 23). When using a dorsal vascularized bone graft from the distal radius, scaphoid consolidation was reached in 81.1% for avascular proximal fragments (n = 59). Conclusions: Applying a sophisticated treatment algorithm, the prognosis of scaphoid nonunion is very good.

HPV vaccination as preventive approach for recurrent respiratory papillomatosis - a 22-year retrospective clinical analysis

BACKGROUND

Recurrent respiratory papillomatosis (RRP) is a rare, benign disease of the aerodigestive tract, especially the larynx, caused by infection with the human papillomavirus (HPV) types 6 or 11. Current management focuses on surgical debulking with microdebrider of papillomatous lesions with or without concurrent adjuvant therapy, e.g. Cidofovir®. This retrospective study evaluates the results of patients treated at a department of the university clinic between 1990 and 2012 and compares the results of the conventional treatment with a new treatment approach using adjuvant vaccination with Gardasil®.

METHODS

A retrospective Kaplan Maier analysis of n = 24 patients diagnosed and treated with RPR was performed. The records were reviewed for gender, age at the time of first manifestation of disease and time to recurrence.

RESULTS

Only n = 2 (15.4%) of the n = 13 vaccinated patients developed a recurrence of the disease after a mean time of 54.9 months (SD: 9.5 months). All patients who were not vaccinated (n = 11; 100%) developed a relapse after a mean time of 12.3 months (SD: 9.72 months).

CONCLUSION

We propose that adjuvant HPV vaccination with Gardasil® might have a preventive effect in RRP by occluding new papilloma formation.

Removal of Polyacrylamide Gel (Aquamid®) from the Lip as a Solution for Late-Onset Complications: Our 8-Year Experience

BACKGROUND

The polyacrylamide hydrogel Aquamid^® has been used as a permanent filler to enhance facial soft tissue volume and correct wrinkles since 2001. Various long-term studies have proved the safety of the product. Nonetheless, if complications such as migration occur, they can be difficult to treat.

METHODS

Eleven patients suffering from late-onset complications after taking Aquamid^® injections in the lips underwent product removal and subsequent labial reconstruction between 2009 and 2017. The reconstruction was performed using a modified bikini reduction technique combined, in eight cases, with immediate autologous fat grafting.

RESULTS

In all the patients, general fibrosis and a diffused distribution of the product within all three layers of the lips resulted in the need for labial reconstruction. Migration, as far as in the mucosa and perioral skin, accounted for macroscopically visible yellowish accumulations. In ten out of eleven cases, an individually modified bikini reduction technique, with or without any combination of autologous fat grafting, led to an esthetically satisfying result. One patient developed a severe upper lip necrosis.

CONCLUSION

Contradictory to several previous studies attesting to the lack of migration after Aquamid^® application to the lips, capsule formation around the product is impaired, allowing for migration even years after the injection. Product aspiration is not possible in these cases, thus necessitating complex lip reconstruction. Bikini reduction and fat grafting are valuable tools for labial reconstruction. Product residuals within the mucosa have to be accepted. Special care has to be taken while treating smokers.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Recurrent 8-Year Ongoing Unilateral Breast Seroma Formation after PIP Implant Removal-A Case Report and Review of the Literature

Late seroma formation is a rare complication after implant-based breast enlargement surgery and even less frequent after implant removal. This case report presents a case of painful recurrent seroma formation after the removal of a ruptured Poly Implants Prothèse implant.

A 52-year-old patient presented herself in our clinic with a clinical history of recurrent unilateral seroma of the right breast over a period of 8 years after the initial unilateral implant removal. Removal of the remaining implant and complete bilateral capsulectomy was performed. Intraoperative findings revealed a macroscopically thickened capsule with signs of chronic inflammation on the affected side. The clinical history and the macroscopic appearance of the capsule demanded histopathological exclusion of a possible anaplastic large cell lymphoma.

Histopathological and microbiological analysis of the capsule and encapsulated material revealed no signs of malignancy or infection. Immediate soft tissue reconstruction of the breast was successfully performed using autologous fat transfer. An aesthetically satisfying result regarding symmetry and volume was achieved, and no further seroma formation was observed within a 6-month follow-up period.

Level of evidence:  V, Case Report.

Patient-rated long-term results after complete denervation of the wrist

The aim of this study was to examine the long-term results after the denervation of the wrist. Between 1977 and 2001, we treated 375 patients in our clinic. The mean age was 43.5 years; 81% were male and 19% female. The long-term results were assessed by a questionnaire assessing pain on a visual analog scale and patient satisfaction and by the DASH questionnaire. After a mean follow-up of 12.23 years, we found an overall pain reduction of 52.1%. In 67.7% of the patients, we found a relief of pain: of these, 44% are free of pain until today and 56% were temporarily asymptomatic. Patients with a painful osteoarthritic condition without dynamic instability and good range of motion are ideal candidates to benefit from the denervation. The complete denervation of the wrist is an effective treatment option in patients with painful wrist conditions to reduce pain and improve the overall function.

Histological case-control study of peeling-induced skin changes by different peeling agents in surgically subcutaneous undermined skin flaps in facelift patients

A histological evaluation of peeling-induced skin changes in subcutaneous undermined preauricular facial skin flaps of nine patients was performed. There were three treatment groups: Trichloroacetic acid (TCA) 25%, TCA 40% and phenol/croton oil; one group served as control. Two independent evaluators determined the epidermal and dermal thickness and the depth of necrosis (micrometre). The percentual tissue damage due to the peeling was calculated, and a one-sample t-test for statistical significance was performed. On the basis of the histomorphological changes, peeling depth was classified as superficial, superficial-partial, deep-partial and full thickness chemical burn. The histological results revealed a progression of wound depth for different peeling agents without full thickness necrosis. TCA peels of up to 40% can be safely applied on subcutaneous undermined facial skin flaps without impairing the vascular patency, producing a predictable chemical burn, whereas deep peels such as phenol/croton oil peels should not be applied on subcutaneous undermined skin so as to not produce skin slough or necrosis by impairing vascular patency.

Usability Tests in Medicine: A Cost-Benefit Analysis for Hospitals Before Acquiring Medical Devices for Theatre

PURPOSE

The use of active medical devices in clinical routine should be as safe and efficient as possible. Usability tests (UTs) help improve these aspects of medical devices during their development, but UTs can be of use for hospitals even after a product has been launched. The present pilot study examines the costs and possible benefits of UT for hospitals before buying new medical devices for theatre.

METHODS

Two active medical devices with different complexity were tested in a standardized UT and a cost-benefit analysis was carried out assuming a different device bought at the same price with a higher usability could increase the efficiency of task solving and due to that save valuable theatre time.

RESULTS

The cost of the UT amounted up to €19.400. Hospitals could benefit from UTs before buying new devices for theatre by reducing time-consuming operator errors and thereby increase productivity and patient safety. The possible benefits amounted from €23.300 to €1.570.000 (median = €797.000).

CONCLUSION

Not only hospitals could benefit economically from investing in a UT before deciding to buy a medical device, but especially patients would profit from a higher usability by reducing possible operator errors and increase safety and performance of use.

[Analysis of Diagnosis Related Groups and their Impact on Health Care in Post Massive Weight Loss Surgery]

BACKGROUND

Diagnosis Related Groups (DRG) were introduced in Germany as a medico-economic classification system in 2004. In this analysis, we looked at restorative surgery after massive weight loss, focusing on reimbursement of this fee-per-case system in comparison to costs to deduce possible effects on health care over time.

MATERIAL AND METHODS

First we analysed the algorithms for the relevant DRGs including data about length of stay and reimbursement. Furthermore, we integrated cost data from German reference hospitals of the last 5 years as well as single-centre data from a university hospital.

RESULTS

Due to a diagnosis-related algorithm, coding will constantly lead to DRG K07Z. In 2016, a new diagnosis code specific to massive weight loss was introduced, which now leads to DRG J10B. As a result, reimbursement is reduced by more than half. In the cost matrix, staff, general ward, operation theatre and anaesthesia were identified as the main cost drivers. As expected, there was a statistically significant correlation between general ward costs and time of stay in hospital as well as operation theatre costs and incision-suture time. Considering the cost data of the reference hospitals, there was an average excess of EUR 781 per case whereas our own cost data revealed a deficit of EUR 1 700 to 2 700 per case. This is mainly due to the fact that approximately one third of our patient cohort underwent highly elaborate circular body lifts.

CONCLUSION

It has to be questioned whether a newly introduced main diagnosis code can be applied as such without any underlying cost data having been collected in previous years. Given unchanged treatment measures, the main cost drivers identified by us remain the same, which means that there is no rationale for a drop in revenue. In addition to providing incentives for an efficient use of resources and quality optimisation, this system should offer medical service providers a sustainable and realistic possibility to break even.

[Decompression of Peripheral Nerves in the Treatment of Diabetic Polyneuropathy]

Polyneuropathy causing ulceration and amputation as a long-term consequence of diabetes mellitus is analysed for its pathophysiology, socioeconomic and medical relevance. Outcomes of decompression of peripheral nerves on the lower extremity regarding sensation, pain, development, and recurrence of ulceration, and amputation is evaluated by a systematic literature review in pubmed, medline and embase. Decompression of peripheral nerves in diabetic peripheral neuropathy seems to be a good treatment option for restoring sensation, decreasing pain, as well as for avoiding the development and recurrence of ulceration and amputation.

[Economic profit of different injuries in a centre for hand surgery - replantation vs. amputation]

INTRODUCTION

The Institute for Reimbursements in Hospital (InEK) annually provides an updated DRG system to ensure the medical service providers with a cost-covering remunera-tion. However, the underlying cost data are often opaque and disclosure of the basis of calculation does not take place. On the basis of cost and revenue data from our clinic between 2010 and 2012, a profit statement for amputations and replantation of one or more fingers was employed and compared with the nationwide data of the calculation clinics.

MATERIALS AND METHODS

Inpatient days, the revenue and the costs incurred in our clinic based on the cost matrix of InEK costing manual [4] were determined for amputation (DRG X05B), replantation of one (DRG X07B) and several fingers (DRG X07A). The profit was calculated as the difference between revenues and costs. Further-more, a comparison of our data with the nationwide data of InEK was applied.

RESULTS

For each of the 3 DRGs the actual costs in our clinic were higher than the costs generated by InEK. Only amputation appeared profitable, while all limb-preserving interventions were associated with losses for our hospital. There was a clear discrepancy between the data of cost of InEK GmbH to the data of our clinic.

CONCLUSION

In order not to create any monetary disincentives at the expense of quality of care of individual patients, a cost-covering patient care for all case groups mentioned above should be ensured. The general distrust in the InEK's data that results from such a discrepancy in the cost data can only be rebutted by increasing transparency and disclosure of the calculation basis.

Severe posttraumatic radiocarpal cartilage damage: first report of autologous chondrocyte implantation

STUDY DESIGN

Case report.

CLINICAL QUESTION

Traumatic articular cartilage defects predispose to secondary osteoarthritis accompanied by impairment or complete loss of function in the corresponding joint. On this account, the timely and correct diagnosis as well as the selection of an appropriate therapy for reconstruction of articular cartilage defects is important.

METHODS

A 22-year-old healthy male patient with history of traumatic intra-articular distal radius fracture is presented with in the course detectable 4° cartilage damage in the fovea scaphoidea and into the fovea lunata. For the first time, autologous chondrocyte implantation by the use of an in situ polymerizable albumin-hyaluronic acid gel was performed to restore the articular cartilage.

RESULTS

The assessment 6 months after autologous chondrocyte implantation using the standard DASH questionnaire for upper extremity pointed out an improvement in the patient outcome (DASH score pre-operative: 10.8 and 6 months post-operative: 7.5). The clinical examination also showed an improvement in the range of movement of the wrist without pain. The radiological control investigation (MRI- examination) of the wrist 6 months after implantation also revealed a good integration of the implant.

CONCLUSION

The case presented here demonstrates the first use of autologous chondrocyte implantation for cartilage reconstruction using an in situ polymerizable albumin-hyaluronic acid gel after traumatic cartilage lesion with 4° cartilage damage of the wrist in a 22-year-old non-smoking, active and healthy man. Initial results are promising in terms of mobility, pain and patient outcome. However, further clinical studies have to be performed with larger number of cases.

[Trial provision in clinical routine. Definition of terms and investigation of normal practice]

BACKGROUND

It has become common for hospitals to borrow medical devices from manufacturers to test and try them during the daily routine before purchasing which today is known as trial provision. This study aims at offering a precise definition of trial provisions and a description of the way of proceeding.

METHODS

A total of 60 medical practitioners in 5 German hospitals were surveyed (surgeons n = 40, 66.7 %, radiologists n = 12, 20 % and anesthesiologists n = 8, 13.3 %). Manufacturers and distributors of medical devices (n = 10) and hospital administration executives (n = 8) were also interviewed.

RESULTS

Trial provisions are a promotional marketing tool for manufacturers of medical devices. By lending the device over a specific period for testing before purchasing, hospitals can gain experience in the usage and handling of devices on which a purchase decision can be made. The survey revealed that there are basically three procedural methods which can, however, differ even within one hospital.

CONCLUSION

Trial provisions influence purchasing decisions in clinics. If implemented incorrectly trial provisions may compromise physical integrity, safety and health of patients and can thus lead to judicial and legal consequences for hospitals and medical staff.

[Development of length of stay and reimbursement in elective hand surgery after the introduction of DRGs in Germany]

BACKGROUND

Since its introduction in Germany, the DRG (Diagnosis-Related Groups) system is often fraught with negative connotations. Frequent points of criticism are a deterioration of patient care by decreasing length of stay (LOS) in hospital and a decline in reimbursement. The following investigation analyzes and compares the development of length of stay and reimbursement in hand surgery based on the 3 most common elective procedures.

MATERIAL AND METHODS

The main diagnoses scaphoid nonunion (PSA), Dupuytren's contracture (DK) and rhizarthrosis (RIA) were evaluated for number of cases, length of stay, reimbursement per day and total reimbursement in 2000 as well as 2010 based on the data of our clinic. Patients covered by the Employers' Liability Insurance were not included. Only inpatient cases were considered.

RESULTS

In PSA and RIA an increase in the number of cases is reported (PSA: +11 cases; RIA: +26 cases) and a decrease in DK ( - 7 cases). The sum of the total hospital days declined despite rising case numbers predominantly between 65 (RIA) and 260 days (DK). The average LOS decreased by 3.1 days at DK (48.4%) to 4.1 days at PSA (52.6%). Average revenues per day in 2000 amounted to 379 €, which corresponds to 442 € adjusted for inflation in 2010. Average revenue per day in 2010 was 755 € (RIA), 797 € (PSA) and 876 € (DK). Revenue per case in 2010 were only higher than in 2000, when 5 (RIA) or 6 hospital days (DK and PSA) were not exceeded.

CONCLUSION

With declining revenue per case, the average income per day increased by a reduction in hospital days. A positive or at least equivalent revenue situation can thus only be achieved by a distinct concentration of labor and reduction of hospital days under the DRG-system.

Dermal perfusion of common donor sites free flaps in chronic smokers and nonsmokers

OBJECTIVE

The smoking behavior of the patient influences the indication of plastic surgeon in his reconstruction procedure on the assumption that smoking may increase the complication risks. In the present study, we evaluate the particular aspect of topographic differences in dermal perfusion in chronic smokers and nonsmokers.

METHODS

The perfusion parameter of 8 common donor sites for free flap transplantation were investigated in 152 smoking and nonsmoking subjects (n = 152; women: n = 78, 51%; men: n = 74, 49%; smokers: n = 38, 25%; nonsmokers: n = 114, 75%) using the O2C device (LAE Medizintechnik Giessen GmbH, Gießen, Germany). Oxygen saturation (%), relative hemoglobin concentration (AU [arbitrary unit]), Velocity (AU) and Flow (AU) were monitored noninvasively and compared.

RESULTS

All monitored regions did not show any significant differences in parameters oxygen saturation (smokers = 40%, nonsmokers = 44.5%), relative hemoglobin concentration (smokers = 60 AU, nonsmokers = 60 AU), flow (smokers = 19.5 AU, nonsmokers = 16.5 AU) and velocity (smokers = 10 AU, nonsmokers = 10 AU) between chronic smoking and nonsmoking subjects (P < .05). Also, a distinction between smokers and nonsmokers as a function of gender (women: n = 78, 51%; men: n = 74, 49%) showed no significant differences in all 4 parameters.

CONCLUSIONS

Varied statements regarding surgical complications in chronic and acute smokers were described in the literature. This raises the question of how far restricting the indication of reconstruction procedure for smoking patients due to higher complications is justified. In our study, there is no significant drop of dermal perfusion parameters after chronic tobacco consumption. Nonetheless, the unfavorable effects of smoking in general to human body and health remain undoubted.