Breast reconstruction with flaps from the lower abdomen

Zusammenfassung: GRUNDLAGEN: Die Abdominalregion ist eine vielseitige Quelle für mehrere Gewebe, welche als Lappen zur Wiederherstellung der weiblichen Brust geeignet sind. Diese beinhalten den gestielten und freien Transverse Rectus Abdominis Myocutaneous Lappen (TRAM), den Deep Inferior Epigastric Perforator Lappen (DIEAP) und den Superficial Inferior Epigastric Lappen (SIEA). METHODIK: Diese Übersicht stellt Geschichte und Technik der Wiederherstellung der Brust mittels Lappen vom Abdomen dar. Alle relevanten Studien und Erfahrungen wurden berücksichtigt. ERGEBNISSE: Der Entscheidungsprozess zur Lappenwahl ist komplex und abhängig von einer Reihe von Faktoren, wobei Lappen mit niedrigerer Hebemorbidität deutliche Vorteile zeigen und ein postoperativ verbessertes ästhetisches Resultat der Hebestelle die Patientenakzeptanz deutlich erhöhen kann. SCHLUSSFOLGERUNGEN: In dieser Übersicht werden Anatomie und präoperative Planung in dieser Spenderregion, Fragen zur intraoperativen Entscheidungsfindung sowie Resultate und Patientenzufriedenheit behandel

Effizienter Erwerb chirurgischer Basistechniken durch "blended learning"

Zusammenfasssung: Hintergrund: Große Studierendenzahlen und heterogene Dozierende erschweren einheitliche Kursgestaltungen und die objektive Standardisierung von Prüfungen im chirurgischen Fertigkeitstraining. Diese Arbeit zeigt die Vorteile des Einsatzes neuer Medien im "Blended-learning-Konzept" für das Fertigkeitstraining im Studiengang Humanmedizin der Universität Basel. Material und Methoden: Der studentische chirurgische "Nahtkurs" wurde nach einem Blended-learning-Konzept mit multimedialer CD, Präsenzveranstaltung und SkillsLab restrukturiert. Die Lernziele des Kurses wurden am Ende der Studienjahre anhand von Posten mit Checklisten im OSCE ("objective structured clinical examination") überprüft. Die studentische Kursbeurteilung sowie die Prüfungsergebnisse vor und nach Einführung des "blended learning" wurden miteinander verglichen. Ergebnisse: Sowohl die Beurteilungen der eingesetzten Lehrmittel, des subjektiven Übungserfolges und des prospektiven Nutzens für das Wahlstudienjahr (Praktisches Jahr) als auch die Gesamtkursbeurteilung waren nach Einführung des Blended-learning-Konzeptes signifikant höher als im alten Kursformat. Auch der Anteil an bestandenen Prüfungen war mit einem Zuwachs von 10% signifikant im Vergleich zum alten Kurs erhöht. Schlussfolgerung: "Blended learning” kann sowohl Wahrnehmung und Leistung als auch die Effizienz des Fertigkeitstrainings und der Betreuungszeit verbessern. Dadurch werden indirekt Ressourcen gespart. Chirurgische Verfahren können klar und übersichtlich vermittelt werde

One-stage versus two-stage lymph node dissection after investigation of sentinel lymph node in cutaneous melanoma: a comparison of complications, costs, hospitalization times, and operation times

The aim of the study was to evaluate whether complication rate, costs, operation times, and hospitalization times differed in two different patient groups: in group 1, frozen section analysis of the sentinel lymph node and lymph node dissection were carried out in the same operation. In group 2, normal investigation of the sentinel lymph node and lymph node dissection were done in a second operation. One hundred thirty-five patients with cutaneous melanoma were included. Hospitalization times, costs, complication rates, and operation times of two-stage and one-stage lymph node dissection of the draining area after detection of metastases in the sentinel lymph node were retrospectively compared. Lymph node metastasis in the sentinel lymph node was found in 23 patients. In 11 patients, removal of the sentinel lymph node and dissection of the lymph node basin was performed in the same operation. In 12 patients, a two-stage procedure was the treatment of choice. Operation times were not different in the two groups (p=0.87) while two-stage operation patients were hospitalized significantly longer (14.2±9.7 vs 23.9±24days; p=0.01) and costs were significantly higher (7,836.90±2,397.95 Swiss francs vs 5,279.40±1,994.90 Swiss francs). In addition, more complications were found in the two-stage grou

Sonication of Removed Breast Implants for Improved Detection of Subclinical Infection

Background: Capsular fibrosis is a severe complication after breast implantation with an uncertain etiology. Microbial colonization of the prosthesis is hypothesized as a possible reason for the low-grade infection and subsequent capsular fibrosis. Current diagnostic tests consist of intraoperative swabs and tissue biopsies. Sonication of removed implants may improve the diagnosis of implant infection by detachment of biofilms from the implant surface. Methods: Breast implants removed from patients with Baker grades 3 and 4 capsular contracture were analyzed by sonication, and the resulting sonication fluid was quantitatively cultured. Results: This study investigated 22 breast implants (6 implants with Baker 3 and 16 implants with Baker 4 capsular fibrosis) from 13 patients. The mean age of the patients was 49years (range, 31-76years). The mean implant indwelling time was 10.4years (range, 3months to 30years). Of the 22 implants, 12 were used for breast reconstruction and 10 for aesthetic procedures. The implants were located subglandularly (n=12), submuscularly (n=6), and subcutaneously (n=4). Coagulase-negative staphylococci, Propionibacterium acnes, or both were detected in the sonication fluid cultures of nine implants (41%), eight of which grew significant numbers of microorganisms (>100 colonies/ml of sonication fluid). Conclusions: Sonication detected bacteria in 41% of removed breast implants. The identified bacteria belonged to normal skin flora. Further investigation is needed to determine any causal relation between biofilms and capsular fibrosi

Optimizing the parameters for hydro-jet dissection in fatty tissue — A morphological Ex Vivo analysis

Summary: Background: The advantage of water-jet dissection is the preservation of vessels and nerves. Especially in liver surgery, blood loss can be significantly decreased. The use of water-jet dissectors in other fields of surgery is currently under investigation. The preparation of vessels in fatty tissue is of special interest for plastic surgeons. The optimal technical parameters were investigated. Methods: Abdominal fat tissue of fresh cadavers was cut under standardized conditions with different parameters of the water-jet dissector. Results: One single pass at a cutting pressure between 20 and 60 Bar makes an incision of 8 mm. Deeper cuts can be achieved by repeated application on the same cut. Five passes at 40 Bar results in a depth of 1.7 cm without vessel damage. If the applied pressure is 50 or 60 Bar, up to 7% damaged vessels can be found. The water-jet dissection leads to a water uptake of the cut tissue. Conclusions: The optimal pressure for water-jet dissection of fatty tissue lies between 30 and 40 Bar. The effect of the mechanical irritation of the vessels has to be investigatedin vivo before using the water-jet dissector for preparation of blood vessels in humans, e.g. for flap dissectio

Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy

Objective: Besides other factors, the choice of reconstructive method for full thickness thoracic wall defects depends on the morbidity of preceding surgical procedures. The pedicled latissimus dorsi flap is a reliable and safe option for reconstruction of the thorax. A posterolateral thoracotomy, however, results in division of the muscle. Both parts of the muscle can be employed to close full thickness defects of the chest wall. The proximal part can be pedicled on the thoracodorsal vessels or the serratus branch; the distal part can be pedicled on paravertebral or intercostal perforators. This retrospective study was undertaken to evaluate the reconstructive potential of both parts of the latissimus dorsi in thoracic wall reconstruction after posterolateral thoracotomy. Methods: Between 1987 and 1999, 36 consecutive patients underwent reconstruction of full-thickness thoracic wall defects with latissimus dorsi-flaps after posterolateral thoracotomies. The defects resulted from infection and open window thoracostomy (n=31), trauma (n=3) and resection of tumours (n=2). The patients' average age was 57 years (range 22-76 years). Twenty-five patients were male, 11 were female. In 31 cases the split latissimus dorsi alone was employed; in five cases additional flaps had to be used due to the size of the defects, additional intrathoracic problems or neighbouring defects. Results: In 34 cases defect closure could be achieved without major complications. Empyema recurred in the pleural cavity in one case and one patient died of septicaemia. The 15 patients who had required a respirator in the preoperative phase could be extubated 4.8 days (average) after thoracic wall reconstruction. Postoperative hospital stay averaged 16 days. Conclusions: Different methods are available for reconstruction of full thickness defects of the thoracic wall. After posterolateral thoracotomy in the surgical treatment of empyema, oncologic surgery and traumatology, the latissimus dorsi muscle still retains some reconstructive potential. Advantages are low additional donor site morbidity and anatomical reliability. As it is located near the site of the defect, there is no need for additional surgical sites or intraoperative repositioning. In our service, the split latissimus dorsi muscle flap has proven to be a valuable and reliable option in thoracic wall reconstructio

Hemiface rhytidectomy.

In the current study, skin flaps raised in the subcutaneous plane were applied for 22 patients who underwent reconstruction for unilateral upper facial skin defects after skin tumor surgery. The defect was reconstructed with flaps designed via procedures similar to classic rhytidectomy techniques using periauricular and temporal skin incisions. Objective assessment of the aesthetic result was possible by comparison with the healthy contralateral side of the face. Immediate postoperative evaluation confirmed facial asymmetry due to unilateral skin tension. High patient acceptance of the procedure, uneventful flap healing, and good aesthetic results were achieved, with almost complete restoration of facial symmetry 1 year postoperatively. In conclusion, unilateral rhytidectomy without plication or resection of the subcutaneous musculoaponeurotic system (SMAS) is an ideal application of aesthetic surgical techniques for the reconstruction of unilateral skin defects

Harmonising evidence-based medicine teaching: a study of the outcomes of e-learning in five European countries

BACKGROUND: We developed and evaluated the outcomes of an e-learning course for evidence based medicine (EBM) training in postgraduate medical education in different languages and settings across five European countries. METHODS: We measured changes in knowledge and attitudes with well-developed assessment tools before and after administration of the course. The course consisted of five e-learning modules covering acquisition (formulating a question and search of the literature), appraisal, application and implementation of findings from systematic reviews of therapeutic interventions, each with interactive audio-visual learning materials of 15 to 20 minutes duration. The modules were prepared in English, Spanish, German and Hungarian. The course was delivered to 101 students from different specialties in Germany (psychiatrists), Hungary (mixture of specialties), Spain (general medical practitioners), Switzerland (obstetricians-gynaecologists) and the UK (obstetricians-gynaecologists). We analysed changes in scores across modules and countries. RESULTS: On average across all countries, knowledge scores significantly improved from pre- to post-course for all five modules (p < 0.001). The improvements in scores were on average 1.87 points (14% of total score) for module 1, 1.81 points (26% of total score) for module 2, 1.9 points (11% of total score) for module 3, 1.9 points (12% of total score) for module 4 and 1.14 points (14% of total score) for module 5. In the country specific analysis, knowledge gain was not significant for module 4 in Spain, Switzerland and the UK, for module 3 in Spain and Switzerland and for module 2 in Spain. Compared to pre-course assessment, after completing the course participants felt more confident that they can assess research evidence and that the healthcare system in their country should have its own programme of research about clinical effectiveness. CONCLUSION: E-learning in EBM can be harmonised for effective teaching and learning in different languages, educational settings and clinical specialties, paving the way for development of an international e-EBM course

Two novel human cytomegalovirus NK cell evasion functions target MICA for lysosomal degradation

NKG2D plays a major role in controlling immune responses through the regulation of natural killer (NK) cells, αβ and γδ T-cell function. This activating receptor recognizes eight distinct ligands (the MHC Class I polypeptide-related sequences (MIC) A andB, and UL16-binding proteins (ULBP)1–6) induced by cellular stress to promote recognition cells perturbed by malignant transformation or microbial infection. Studies into human cytomegalovirus (HCMV) have aided both the identification and characterization of NKG2D ligands (NKG2DLs). HCMV immediate early (IE) gene up regulates NKGDLs, and we now describe the differential activation of ULBP2 and MICA/B by IE1 and IE2 respectively. Despite activation by IE functions, HCMV effectively suppressed cell surface expression of NKGDLs through both the early and late phases of infection. The immune evasion functions UL16, UL142, and microRNA(miR)-UL112 are known to target NKG2DLs. While infection with a UL16 deletion mutant caused the expected increase in MICB and ULBP2 cell surface expression, deletion of UL142 did not have a similar impact on its target, MICA. We therefore performed a systematic screen of the viral genome to search of addition functions that targeted MICA. US18 and US20 were identified as novel NK cell evasion functions capable of acting independently to promote MICA degradation by lysosomal degradation. The most dramatic effect on MICA expression was achieved when US18 and US20 acted in concert. US18 and US20 are the first members of the US12 gene family to have been assigned a function. The US12 family has 10 members encoded sequentially through US12–US21; a genetic arrangement, which is suggestive of an ‘accordion’ expansion of an ancestral gene in response to a selective pressure. This expansion must have be an ancient event as the whole family is conserved across simian cytomegaloviruses from old world monkeys. The evolutionary benefit bestowed by the combinatorial effect of US18 and US20 on MICA may have contributed to sustaining the US12 gene family