Publications by authors named "Nick Spindler"

22 Publications

  • Page 1 of 1

Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study.

BMC Surg 2021 Apr 30;21(1):222. Epub 2021 Apr 30.

Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany.

Objectives: Free flap surgery is an essential procedure in soft tissue reconstruction. Complications due to vascular compromise often require revision surgery or flap removal. We present hyperspectral imaging (HSI) as a new tool in flap monitoring to improve sensitivity compared to established monitoring tools.

Methods: We performed a prospective observational cohort study including 22 patients. Flap perfusion was assessed by standard clinical parameters, Doppler ultrasound, and HSI on t0 (0 h), t1 (16-28 h postoperatively), and t2 (39-77 h postoperatively). HSI records light spectra from 500 to 1000 nm and provides information on tissue morphology, composition, and physiology. These parameters contain tissue oxygenation (StO2), near-infrared perfusion- (NIR PI), tissue hemoglobin- (THI), and tissue water index (TWI).

Results: Total flap loss was seen in n = 4 and partial loss in n = 2 cases. Every patient with StO2 or NIR PI below 40 at t1 had to be revised. No single patient with StO2 or NIR PI above 40 at t1 had to be revised. Significant differences between feasable (StO2 = 49; NIR PI = 45; THI = 16; TWI = 56) and flaps with revision surgery [StO2 = 28 (p < 0.001); NIR PI = 26 (p = 0.002); THI = 56 (p = 0.002); TWI = 47 (p = 0.045)] were present in all HSI parameters at t1 and even more significant at t2 (p < 0.0001).

Conclusion: HSI provides valuable data in free flap monitoring. The technique seems to be superior to the gold standard of flap monitoring. StO2 and NIR PI deliver the most valuable data and 40 could be used as a future threshold in surgical decision making. Clinical Trial Register This study is registered at the German Clinical Trials Register (DRKS) under the registration number DRKS00020926.
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http://dx.doi.org/10.1186/s12893-021-01232-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086299PMC
April 2021

Quality of Life After Bilateral Risk-Reducing Mastectomy and Simultaneous Reconstruction Using Pre-Pectoral Silicone Implants.

Patient Prefer Adherence 2021 13;15:741-750. Epub 2021 Apr 13.

Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.

Purpose: Bilateral risk-reducing mastectomy (BRRM) can reduce the risk of developing breast cancer by up to 95% in women with increased exposure. Although survival is increased, mastectomies can adversely affect a patient physically, psychologically, and psychosexually. High health-related quality of life (HRQoL) is often achieved after simultaneous breast reconstruction (BR) following BRRM; however, data on the pre- and postoperative results of HRQoL are lacking. Therefore, we investigated the quality of life, esthetic outcome, and patient well-being after BRRM and simultaneous implant-based BR.

Patients And Methods: Of the 35 patients who underwent skin-sparing or nipple-sparing mastectomy between May 2012 and December 2017 at a university hospital, only 22 completed the evaluation. Baseline data and data on previous operations and operation techniques were retrieved from the patient's charts. BREAST-Q and short form-36 health survey (SF-36) questionnaires were used to evaluate patient satisfaction and HRQoL.

Results: SF-36 analysis showed a significantly higher score for pain (p=0.043) in our population than in the general female population. Comparing the pre- and postoperative BREAST-Q results, a significant decrease in the physical well-being of the chest (p=0.0179) and a slight improvement in breast satisfaction were observed (p=0.3266). All patients were well-satisfied with the postoperative outcome, reconstruction, and perioperative surgeon care.

Conclusion: Bilateral mastectomy with simultaneous BR using pre-pectoral implants is associated with an HRQoL similar to that of the healthy population. Although bilateral mastectomy may have an immense effect on the psychological, physical, and social aspects, immediate BR preserves the outer appearance and improves self-esteem.
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http://dx.doi.org/10.2147/PPA.S303208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053496PMC
April 2021

[Implementation of the wide awake local anesthesia no tourniquet (WALANT) type of anesthesia in hand surgery].

Orthopade 2021 May 13;50(5):415-424. Epub 2021 Apr 13.

Bereich für Plastische, Ästhetische und Spezielle Handchirurgie, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstr. 20, Haus 4, 04103, Leipzig, Deutschland.

Wide awake local anesthesia no tourniquet (WALANT) refers to an anesthesia technique with low bleeding and complication rates, which enables interventions on the hand in an awake patient without the use of a tourniquet. Bleeding control is achieved through addition of vasoconstrictors to the infiltration solution. Since the motor function of the extremity is not affected, it offers the additional possibility of intraoperative active function testing. The WALANT procedure constitutes an established, effective, easily learnt and resource-sparing technique. The spectrum of surgical possibilities with WALANT is wide and covers nearly all elective and many emergency procedures. Due to multiple advantages in contrast to other regional and general anesthesia procedures, WALANT features an increasing spectrum of surgical applications and practitioners. It is therefore of interest for hand surgeons working both in hospitals and private practices.
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http://dx.doi.org/10.1007/s00132-021-04098-5DOI Listing
May 2021

Free Flap Reconstruction of the Extremities in Patients Who are ≥65 Years Old: A Single-Center Retrospective 1-to-1 Matched Analysis.

Clin Interv Aging 2021 18;16:497-503. Epub 2021 Mar 18.

Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.

Purpose: Demographic changes are leading to population aging, and free flap reconstructions for various indications are expected to become increasingly common among older patients. Therefore, this study evaluated free flap reconstruction of the extremities in older patients and compared the outcomes to those from younger patients who underwent similar procedures during the same period.

Patients And Methods: This single-center retrospective study used a case-control design to compare older and younger patients who underwent free flap reconstruction of soft tissue defects in the extremities. One-to-one matching was performed for older patients (≥65 years) and younger patients (≤64 years) according to indication, flap recipient site, and flap type. The parameters of interest were clinico-demographic characteristics, flap type, defect location, indication for free flap reconstruction, number of venous anastomoses, and postoperative complications (flap loss, infection, and wound healing disorders).

Results: The study included 48 older patients and 133 younger patients, with a mean follow-up of 12 months after discharge. The free flap reconstruction was performed at a mean interval of 19.8±22.8 days (range: 0-88 days). The 1:1 matching created 38 pairs of patients, which revealed no significant differences in the rates of flap necrosis and flap failure.

Conclusion: This study failed to detect a significant age-related difference in the flap necrosis rate after free flap reconstruction of extremity defects. Therefore, with careful perioperative management and patient selection, microsurgical free flap reconstruction is a feasible option for older patients.
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http://dx.doi.org/10.2147/CIA.S300558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987263PMC
March 2021

[Surgical flap according to Littler (neurovascular island flap)].

Oper Orthop Traumatol 2020 Dec 6;32(6):486-493. Epub 2020 Nov 6.

Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Bereich für Plastische, Ästhetische und Spezielle Handchirurgie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.

Objective: Defect coverage of medium-sized soft tissue defects on the ulnar side of the thumb and radial side of the index finger. By using the Littler flap, both, the lost soft tissue coverage and sensitivity, which is necessary for an exact grip to the long fingers, can be simultaneously restored.

Indications: Medium-sized soft tissue defect of the ulnar tip of the thumb, exposed bones and parts of the tendons, extensive soft tissue defects with sensory deficit.

Contraindications: Limiting accompanying injuries of the hand.

Surgical Technique: All-layer incision of the flap at ulnar 3rd digit with proximal exploration of the nerve and vascular bundle. Tracing the bundle to the exit from the palmar arch. After subcutaneous tunneling, shift of the flap into the defect.

Postoperative Management: Immobilization of the thumb in adduction for 7 days in a dorsal plaster splint, followed by free exercise.

Results: Reliable defect coverage with low donor-site morbidity and immediate restoration of sensibility in the ulnar tip of the thump. However, microsurgical dissection, especially of the nerve, is challenging.
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http://dx.doi.org/10.1007/s00064-020-00683-7DOI Listing
December 2020

Secreted Factors from Adipose Tissue Reprogram Tumor Lipid Metabolism and Induce Motility by Modulating PPARα/ANGPTL4 and FAK.

Mol Cancer Res 2020 12 28;18(12):1849-1862. Epub 2020 Aug 28.

Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany.

Recent studies indicate that adipose tissue in obesity promotes breast cancer progression by secreting protumorigenic chemokines, growth factors, and fatty acids. However, the detailed mechanisms by which hypertrophic adipose tissue influences breast cancer cells are still not well understood. Here we show that co-culture with adipose tissue from high-fat diet induced obese C57BL/6 mice alters transcriptome profiles in triple-negative breast cancer (TNBC) cells, leading to upregulation of genes involved in inflammation and lipid metabolism, such as , and . Similar results were obtained by treating TNBC cells with adipose tissue conditioned media (ACM) generated from fat tissue of obese female patients. Many of the upregulated genes were activated by PPAR nuclear receptors, as shown by pathway analyses and gene expression experiments using PPAR agonists and antagonists. Metabolic analysis revealed that TNBC cells cultivated with ACM had significantly higher levels of β-oxidation. Furthermore, ACM-treated TNBC cells displayed a pronounced aggressive cell phenotype, with enhanced wound healing, proliferation, and invasion capabilities. ACM-induced invasion was dependent on the PPAR-target and activated FAK signaling, as shown by depletion and FAK inhibition. Together, our data suggest that factors released by adipose tissue change PPAR-regulated gene expression and lipid metabolism and induce a more aggressive TNBC cell phenotype. These effects are, at least in parts, mediated by fatty acids provided by the adipose tissue. IMPLICATIONS: Adipose tissue provides factors for increased progression of TNBC cells, identifying PPAR- and FAK-signaling as potential novel targets for treatment of TNBC, especially in obese women.
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http://dx.doi.org/10.1158/1541-7786.MCR-19-1223DOI Listing
December 2020

Examination of ex-vivo viability of human adipose tissue slice culture.

PLoS One 2020 26;15(5):e0233152. Epub 2020 May 26.

Institute of Anatomy, University Leipzig, Leipzig, Germany.

Obesity is associated with significantly higher mortality rates, and excess adipose tissue is involved in respective pathologies. Here we established a human adipose tissue slice cultures (HATSC) model ex vivo. HATSC match the in vivo cell composition of human adipose tissue with, among others, mature adipocytes, mesenchymal stem cells as well as stroma tissue and immune cells. This is a new method, optimized for live imaging, to study adipose tissue and cell-based mechanisms of obesity in particular. HATSC survival was tested by means of conventional and immunofluorescence histological techniques, functional analyses and live imaging. Surgery-derived tissue was cut with a tissue chopper in 500 μm sections and transferred onto membranes building an air-liquid interface. HATSC were cultured in six-well plates filled with Dulbecco's Modified Eagle's Medium (DMEM), insulin, transferrin, and selenium, both with and without serum. After 0, 1, 7 and 14 days in vitro, slices were fixated and analyzed by morphology and Perilipin A for tissue viability. Immunofluorescent staining against IBA1, CD68 and Ki67 was performed to determine macrophage survival and proliferation. These experiments showed preservation of adipose tissue as well as survival and proliferation of monocytes and stroma tissue for at least 14 days in vitro even in the absence of serum. The physiological capabilities of adipocytes were functionally tested by insulin stimulation and measurement of Phospho-Akt on day 7 and 14 in vitro. Viability was further confirmed by live imaging using Calcein-AM (viable cells) and propidium iodide (apoptosis/necrosis). In conclusion, HATSC have been successfully established by preserving the monovacuolar form of adipocytes and surrounding macrophages and connective tissue. This model allows further analysis of mature human adipose tissue biology ex vivo.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233152PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7250419PMC
August 2020

Clinical and Microbiological Analysis of Deep Sternal Wound Infections in Fifty-Two Consecutive Patients.

Surg Infect (Larchmt) 2020 May 6;21(4):370-377. Epub 2019 Dec 6.

Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany.

Mediastinitis after cardiac surgery can lead to devastating consequences such as deep sternal wound infections (DSWI). and other coagulase-negative staphylococci belong to the physiological skin flora and therefore generally are not considered pathogenic agents. Thus, local resistance patterns of these bacterial species often recovered from wound specimens generally are ignored while choosing antibiotics for peri-operative prophylaxis in cardiac surgery as well as in the selection of empiric antibiotic therapy of DSWI. During the period May 2012-May 2013, 52 patients suffering from DSWI were treated at our institution. For every patient, deep tissue samples were obtained during surgical debridement procedures and submitted to microbiologic analysis. The frequency of and the time to occurrence of a DSWI was recorded, and baseline data, previous operative interventions, complications, and the technique used for soft tissue reconstruction, as well as the microbiologic results and individual risk factors, were documented. There were 32 male patients (62%) and 20 female. The patients' age at the time of revision was a mean of 67 ± 11.5 years (range 35-83 years). There was bacterial growth in 31 cases (60%), the predominant species being (20 patients; 65%). Extended antibiotic therapy was indispensable to controlling the infection. The local resistance patterns of antibiotics should have a greater influence on the standardized prophylaxis or empirical therapy of DSWI and need to be discussed specifically for this high-risk population. Because of its multi-resistance spectrum, must be classified as a potential pathogen. In the cases reported here, extended antibiotic therapy was necessary to support wound healing and thus good patient outcomes.
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http://dx.doi.org/10.1089/sur.2018.300DOI Listing
May 2020

Deep sternal wound infection - latissimus dorsi flap is a reliable option for reconstruction of the thoracic wall.

BMC Surg 2019 Nov 21;19(1):173. Epub 2019 Nov 21.

Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.

Background: At present, data describing patients' long-term outcomes, quality of life, and survival after deep sternal wound infection are rarely available. The purpose of our study was to evaluate functional outcome and patient well-being after debridement and reconstruction of the sternal defect using a pedicled latissimus dorsi flap following deep sternal wound infection (DSWI).

Methods: This retrospective analysis reviewed 106 cases of DSWI after open-heart surgery treated between May 1, 2012, and May 31, 2015. The parameters of interest were demographic and medical data, including comorbidity and mortality. Follow-up consisted of physical examination of the patients using a specific shoulder assessment, including strength tests and measurements of pulmonary function.

Results: The population consisted of 69 (65%) male and 37 (35%) female patients. Their average age at the time of plastic surgery was 69 years (range: 35-85). The 30-day mortality was 20% (n = 21); after one-year, mortality was 47% (n = 50), and at follow-up, it was 54% (n = 58). Heart surgery was elective in 45 cases (42%), urgent in 31 cases (29%) and for emergency reasons in 30 cases (28%). The preoperative European System for Cardiac Operative Risk Evaluation (EuroSCORE) averaged 16.3 (range: 0.88-76.76). On the dynamometer assessment, a value of 181 Newton (N) (±97) could be achieved on the donor side, in contrast to 205 N (±91) on the contralateral side. The inspiratory vital capacity of the lung was reduced to an average of 70.58% (range: 26-118), and the forced expiratory volume in 1 s was decreased to an average of 69.85% (range: 38.2-118).

Conclusions: Given that only small adverse effects in shoulder function, strength, and pulmonary function were observed, the latissimus dorsi flap appears to be a safe and reliable option for the reconstruction of the sternal region after DSWI.
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http://dx.doi.org/10.1186/s12893-019-0631-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868737PMC
November 2019

Single cell study of adipose tissue mediated lipid droplet formation and biochemical alterations in breast cancer cells.

Analyst 2019 Sep;144(18):5558-5570

Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Germany.

Obesity is a known risk factor for breast cancer and a negative prognostic factor for cancer recurrence and survival. Several studies demonstrated that aggressive breast tumor cells contain higher numbers of intracellular lipid droplets (LDs). Here we applied simultaneous visualization, identification and quantification of the lipid accumulation in lipid droplets (LDs) of aggressive, human triple-negative MDA-MB-231 breast cancer cells treated with adipose tissue-conditioned medium (ACM) derived from overweight and obese patients. In addition to Oil Red O and AdipoRed fluorescent staining, label-free confocal Raman microspectroscopy (CRM) has been applied. CRM enables imaging of cell compartments as well as quantification and monitoring of specific biomolecules and metabolic processes on a single cell level. Interestingly, breast cancer cells incubated with ACM showed a significantly higher number of intracellular LDs. Cultivation of breast tumor cells with ACM of obese patients induced the formation of LDs with a 20-fold higher lipid concentration than cultivation with basal medium. This is in line with the significantly higher levels of NEFAs (non-esterified fatty acids) detected in the ACM obtained from obese patient compared to ACM obtained from overweight patients or basal medium. Further, by principal component analysis, we identified a significant increase in unsaturation, esterification and lipid to protein ratio in LDs in breast cancer cells incubated with ACM. CRM analyses might function as a valuable diagnostic tool to identify metabolic alterations in biological samples which in turn could provide more detailed insights in the pathogenesis of breast cancer in association with obesity.
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http://dx.doi.org/10.1039/c9an00816kDOI Listing
September 2019

Standardized Musculocutaneous Flap for the Coverage of Deep Sternal Wounds After Cardiac Surgery.

Ann Thorac Surg 2019 03 26;107(3):802-808. Epub 2018 Oct 26.

Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.

Background: Deep sternal wound infection remains a serious complication after cardiac surgery, leading to increased morbidity, mortality, and cost. The goal of our study was to develop a standardized, reproducible method to safely cover deep sternal wounds and ensure improved healing rates.

Methods: The study was developed as a retrospective cohort study. We included 58 patients who received standardized latissimus dorsi flap coverage of a sternum defect wound after poststernotomy mediastinitis at our institution between September 2015 and June 2017.

Results: The average age of the cohort was 66.75 years, and 51.72% of patients were men. The mean hospital stay was 26.83 days. Eight patients (14.75%) died during the hospital stay due to sepsis or heart failure. The average flap size was 137.13 cm. The mean operative time was 155 minutes. Seventy-four percent of patients developed a seroma at the donor site, which was treated conservatively with compression garments and taps, and 7% of patients developed a wound dehiscence of the donor site, which was treated conservatively with dressings. The mean follow-up time was 15 weeks. All 50 surviving patients showed complete wound healing on follow-up.

Conclusions: The latissimus dorsi pedicled flap is a safe, reproducible technique for coverage of deep sternal wounds, with few relevant perioperative complications. By setting definite parameters for the flap dissection and by ensuring a reliable blood supply, our method enables the coverage of these complex wounds by an interdisciplinary team in any cardiovascular surgical setting.
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http://dx.doi.org/10.1016/j.athoracsur.2018.09.017DOI Listing
March 2019

A Novel Technique for the Standardized Application of Shock Waves in Experimental Research: The Diver Box.

Ultrasound Med Biol 2018 07 23;44(7):1563-1568. Epub 2018 Apr 23.

Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, St. Rochus Hospital Castrop-Rauxel, Katholische St. Lukas Gesellschaft, Castrop-Rauxel, Germany. Electronic address:

The Diver Box is designed to prevent impedance differences, energy loss or damage to neighboring structures caused by the use of shock waves with application gels. The Diver Box is an acrylic glass container filled with tempered water and includes a coupling membrane to prevent the impedance jump from air to water and to avoid the continuous propagation of shock waves into the tissue, maintaining wave dynamics. Different modes of extracorporeal shock waves can be applied to a mouse skin wound without energy loss and protected from harmful phase-reversed waves. Macroscopic changes were seen in only 5% to 12% of tested specimens. Hazardous phase reversal, back reflection and mechanical tissue damage can be avoided by use of the Diver Box, ensuring standardized extracorporeal shock wave application.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2018.03.006DOI Listing
July 2018

Qualitative and Quantitative Analysis of Cardiac Progenitor Cells in Cases of Myocarditis and Cardiomyopathy.

Front Genet 2018 6;9:72. Epub 2018 Mar 6.

Applied Stem Cell Biology and Cell Technology, Biomedical and Biotechnological Center, University of Leipzig, Leipzig, Germany.

We aimed to identify and quantify CD117 and CD90 endogenous cardiac progenitor cells (CPC) in human healthy and diseased hearts. We hypothesize that these cells perform a locally acting, contributing function in overcoming medical conditions of the heart by endogenous means. Human myocardium biopsies were obtained from 23 patients with the following diagnoses: Dilatative cardiomyopathy (DCM), ischemic cardiomyopathy (ICM), myocarditis, and controls from healthy cardiac patients. High-resolution scanning microscopy of the whole slide enabled a computer-based immunohistochemical quantification of CD117 and CD90. Those signals were evaluated by Definiens Tissue Phenomics® Technology. Co-localization of CD117 and CD90 was determined by analyzing comparable serial sections. CD117/CD90 cardiac cells were detected in all biopsies. The highest expression of CD90 was revealed in the myocarditis group. CD117 was significantly higher in all patient groups, compared to healthy specimens ( < 0.05). The highest co-expression was found in the myocarditis group (6.75 ± 3.25 CD90CD117 cells/mm) followed by ICM (4 ± 1.89 cells/mm), DCM (1.67 ± 0.58 cells/mm), and healthy specimens (1 ± 0.43 cells/mm). We conclude that the human heart comprises a fraction of local CD117 and CD90 cells. We hypothesize that these cells are part of local endogenous progenitor cells due to the co-expression of CD90 and CD117. With novel digital image analysis technologies, a quantification of the CD117 and CD90 signals is available. Our experiments reveal an increase of CD117 and CD90 in patients with myocarditis.
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http://dx.doi.org/10.3389/fgene.2018.00072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845648PMC
March 2018

[Pedicled Omentum Flaps in the Management of Deep Sternal Wound Infections].

Zentralbl Chir 2018 Apr 6;143(2):138-141. Epub 2017 Nov 6.

Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Deutschland.

Aim: Coverage of a deep sternal wound infection with a greater omentum flap. Due to a persistent infection caused by an infected aortic prosthesis, the primarily performed reconstruction with a latissimus dorsi flap had to be revised, and an alternative solution had to be found.

Indication: A deep sternal wound infection is a rare but devastating complication following median sternotomy. If the commonly used muscle flap is not sufficient and artificial material is still present in the wound, for instant drivelines or a vascular prosthesis, the greater omentum flap is a useful option due to its immunologic capacity.

Method: After an exploration of the persisting infected deep sternal wound, a radical debridement is performed followed by a jet lavage. The soft tissue from the greater omentum is prepared via median laparotomy and transferred through a tunnel created in the diaphragm. Then it is pulled into the wound cavity and can be used for tension-free sheathing of the aortic prosthesis. The previously used muscle flap can additionally be used for superficial soft tissue coverage.

Conclusion: Due to its immunologic competence, the greater omentum flap is a good treatment alternative to the commonly used muscle flaps in defects with infected artificial material.
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http://dx.doi.org/10.1055/s-0043-111724DOI Listing
April 2018

Double-Pedicled Free Deep Inferior Epigastric Perforator Flap for the Coverage of Thigh Soft-Tissue Defect.

Plast Reconstr Surg Glob Open 2017 Aug 28;5(8):e1372. Epub 2017 Aug 28.

Department for Plastic, Aesthetic and special Handsurgery, University Clinic Leipzig, Germany.

Soft-tissue defects caused by radiation injury are a challenging task for the reconstructive surgeon, due to the extent of the soft-tissue damage and the associated injuries of the local blood vessels and bone tissue. We present the application of the versatile deep inferior epigastric perforator (DIEP) flap for the coverage of an extended lateral thigh soft-tissue defect after the surgical resection of an undifferentiated pleomorphic high-grade sarcoma, neoadjuvant chemotherapy, and adjuvant chemo- and radiotherapy. A double-pedicled free DIEP flap (756 cm) was harvested and anastomosed to the transverse branch of the lateral femoral circumflex artery and a lateral branch of the popliteal artery (P1). The flap survived completely without serious complications, and the patient was able to walk with crutches 3 months postoperatively. This is the first case report of a free bipedicled DIEP flap for the coverage of a thigh defect in a male patient.
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http://dx.doi.org/10.1097/GOX.0000000000001372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5585425PMC
August 2017

Omentum flap as a salvage procedure in deep sternal wound infection.

Ther Clin Risk Manag 2017 23;13:1077-1083. Epub 2017 Aug 23.

Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig.

Introduction: Deep sternal wound infections (DSWIs) are rare but devastating complication after median sternotomy following cardiac surgery. Especially in the presence of artificial material or inadequate preliminary muscle flaps, the pedicled omentum flap is due to its immunological properties, the predetermined flap in salvage procedures.

Methods: We treated 14 patients suffering a mediastinitis and open thorax using a pedicled omentoplasty as a salvage procedure because of persisting DSWIs. Omentoplasty was performed in combination with a split skin graft and the wound was closed by a vacuum-assisted therapy for 7 days. The patients' sex and comorbid risk factors supporting DSWIs as well as the postoperative complications were recorded.

Results: Retrospective analysis of 14 patients (10 males and four females) after a follow-up time of 24 months was performed. The average age was 75 years (range: 67-83). Heart surgery took place electively in eight cases, in three cases urgently and three for emergency reasons. The preoperative Euro Score was 16 (range 3.51-42.58). We had no flap loss in any patients. The skin graft showed a full take in all patients. Two patients needed revision of an abdominal wound dehiscence after laparotomy and one patient developed hernia in the late outcome.

Discussion: The greater omentum flap has, over many years, become an ideal partner in the coverage and treatment of DSWIs. Especially due to its immunologic capacity and amorphous structure, it has the ability to fill up cavities and cover infected artificial material so residual infections can be controlled.
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http://dx.doi.org/10.2147/TCRM.S134869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574694PMC
August 2017

Anatomic study of the vascular perfusion of the sternum and its clinical relevance in deep sternal wound infection.

GMS Interdiscip Plast Reconstr Surg DGPW 2017 6;6:Doc09. Epub 2017 Jun 6.

Institute of Anatomy, University of Leipzig, Leipzig, Germany.

Deep sternal wound infections (DSWI) are a rare but devastating complication after median sternotomy. Minor perfusion in bone and soft tissue, especially after recruiting the internal mammary artery for bypass supports the development of wound infection and nonunion of the sternal bone. The aim of the study was the macroscopic and radiological presentation of the vascular system supplying the sternum, in particular the compensating blood supply routes in the event that the internal mammary artery is no longer available after use as a bypass vessel. This anatomic study was carried out on the anterior chest wall of 7 specimens. The thorax plates of 7 specimens were analyzed macroscopically after microsurgical preparation. Different anatomic preparations were produced using different contrast or form-giving substances. Radiological analysis and three-dimensional reconstructions were performed to show alternative, collateral sternal vessel perfusion under estimation of the loss of the internal thoracic artery due to a bypass. The length of the ITA (internal thoracic artery), measured from the beginning of the first rib to the division into the superior epigastric artery and musculophrenic artery, was an average of 16.3 cm. On average, 18.5 branches were delivered from each artery, 10 medially to the sternum supply, and 8 to the intercostal muscle. Our analysis gives an overview of the macroanatomic vessel system supplying the sternal bone, describing especially a common trunk deriving from the ITA and supplying multiple branches and playing an important role in building a collateral circulation of the sternum. For better evaluation, in vivo CT analysis with contrast media should be performed in patients prior to the operation and directly after the use of the double ITA to demonstrate the change in perfusion of the sternum. In the future, preconditioning of the sternum by coiling the deriving branches could become an option, although patient selection has to be improved and further analysis of the topic performed.
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http://dx.doi.org/10.3205/iprs000111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461580PMC
June 2017

A new in vivo model using a dorsal skinfold chamber to investigate microcirculation and angiogenesis in diabetic wounds.

GMS Interdiscip Plast Reconstr Surg DGPW 2016 18;5:Doc09. Epub 2016 Feb 18.

Department of Plastic, Esthetic and Special Hand Surgery, University Hospital Leipzig, Germany.

Introduction: Diabetes mellitus describes a dysregulation of glucose metabolism due to improper insulin secretion, reduced insulin efficacy or both. It is a well-known fact that diabetic patients are likely to suffer from impaired wound healing, as diabetes strongly affects tissue angiogenesis. Until now, no satisfying in vivo murine model has been established to analyze the dynamics of angiogenesis during diabetic wound healing. To help understand the pathophysiology of diabetes and its effect on angiogenesis, a novel in vivo murine model was established using the skinfold chamber in mice.

Materials And Methods: Mutant diabetic mice (db; BKS.Cg-m+/+Lepr (db) /J), wildtype mice (dock7Lepr (db) +/+m) and laboratory BALB/c mice were examined. They were kept in single cages with access to laboratory chow with an 12/12 hour day/night circle. Lesions of the panniculus muscle (Ø 2 mm) were created in the center of the transparent window chamber and the subsequent muscular wound healing was then observed for a period of 22 days. Important analytic parameters included vessel diameter, red blood cell velocity, vascular permeability, and leakage of muscle capillaries and post capillary venules. The key parameters were functional capillary density (FCD) and angiogenesis positive area (APA).

Results: We established a model which allows high resolution in vivo imaging of functional angiogenesis in diabetic wounds. As expected, db mice showed impaired wound closure (day 22) compared to wounds of BALB/c or WT mice (day 15). FCD was lower in diabetic mice compared to WT and BALB/c during the entire observation period. The dynamics of angiogenesis also decreased in db mice, as reflected by the lowest APA levels. Significant variations in the skin buildup were observed, with the greatest skin depth in db mice. Furthermore, in db mice, the dermis:subcutaneous ratio was highly shifted towards the subcutaneous layers as opposed to WT or BALB/c mice.

Conclusion: Using this new in vivo model of the skinfold chamber, it was possible to analyze and quantify microangiopathical changes which are essential for a better understanding of the pathophysiology of disturbed wound healing. Research in microcirculation is important to display perfusion in wounds versus healthy tissue. Using our model, we were able to compare wound healing in diabetic and healthy mice. We were also able to objectively analyze perfusion in wound edges and compare microcirculatory parameters. This model may be well suited to augment different therapeutic options.
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http://dx.doi.org/10.3205/iprs000088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4764794PMC
March 2016

Fibrin glue as a protective tool for microanastomoses in limb reconstructive surgery.

GMS Interdiscip Plast Reconstr Surg DGPW 2015 15;4:Doc14. Epub 2015 Dec 15.

Department of Plastic, Esthetic and Special Hand Surgery, University Hospital Leipzig, Germany.

Aim: Fibrin glue becomes a more and more routinely used tool for stabilization of microanastomoses and nerve repair. This paper summarizes the technical properties and advantages of its use in a wide variety of microsurgical contexts, and includes an exemplary limb reconstructive case.

Patients And Methods: A total of 131 patients who had undergone elective and emergency microsurgery mainly of the limbs were retrospectively analyzed, as was the use of free flaps.

Results: The use of fibrin glue allows for proper positioning of anastomoses and repaired nerves. No torsion of the pedicle could be seen. The flap survival rated >94%. The fibrin glue could stay in place in >99%. In the rare case of revision, the fibrin glue could easily be removed without damaging the region of the microanastomosis.

Conclusion: Fibrin glue should not be used to repair insufficient, i.e., leaking anastomoses, but it does protect the site of anastomosis from tissue and fluid pressure. It prevents the pedickle from torsion and its use facilitates relocation of the microanastomoses in cases of revision surgery.
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http://dx.doi.org/10.3205/iprs000073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709928PMC
January 2016

A double-barrelled fibula graft restoring pelvic stability after late posterior ring instability related to a surgical treated osteitis pubis: a case report.

Arch Orthop Trauma Surg 2016 Jan 27;136(1):47-53. Epub 2015 Oct 27.

Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.

Background: Osteitis pubis or symphysitis pubis is a rare occurring non-infectious inflammation of the symphysis, the adjacent pubic bones and surrounding tissue. The therapy might be conservative or surgical by a resection of the symphysis and involved parts of the pubic bone. Nevertheless, this resection might lead to an anterior instability impairing the posterior arch and the sacroiliac joints in the aftermath.

Case Presentation: Here, we report about a 50-year-old women suffering from osteitis pubis treated by wedge resection of the symphysis and parts of the pubic bone. To maintain stability and for local antibiotic treatment a cement spacer was implemented. By clinical inconspicuous findings and the patient's desire, no further surgery was performed. However, 2 years after surgery the spacer dislocated and the patient complained about pain in the posterior arch due to an impaired mobility. Reconstruction surgery was planned including the bridging of the accrued space with a vascularized double-barrelled fibula graft, plate osteosynthesis and rectus abdominis flap coverage. The performed surgery led to pain relief and increased mobility.

Conclusion: The present case highlights the possible complication of surgical treated osteitis pubis leading to anterior arch instability affecting the posterior arch and thus impairing pelvic ring stability and patient mobility. Furthermore, we describe an opportunity to treat this complication or other etiologies contributing to anterior pelvic ring stability with large bone defects using a vascularized double-barrelled fibula graft to restore pelvic stability.
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http://dx.doi.org/10.1007/s00402-015-2355-yDOI Listing
January 2016

Free anterolateral thigh flaps for upper extremity soft tissue reconstruction.

GMS Interdiscip Plast Reconstr Surg DGPW 2015 5;4:Doc05. Epub 2015 Feb 5.

Abteilung für Plastische, Ästhetische und Spezielle Handchirurgie, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinik Leipzig, Deutschland.

Introduction: Limb-threatening wounds of the upper extremity pose a challenge to the micro vascular surgeon. The aim of this study is to analyze the outcome of free anterolateral thigh flaps for upper extremity soft tissue reconstruction.

Methods: A retrospective review of patients undergoing this procedure from 2005 to 2012 was performed. Case note analysis was performed to determine demographic and perioperative factors, and complications and outcomes.

Results: Thirty-two patients with a mean age of 53 years (9-84 yrs) underwent upper extremity reconstruction with an anterolateral thigh (ALT) flap. There were 24 (75%) males and 8 (25%) females. The etiology of the soft tissue defects was: infection (44.6%); post-tumor ablation (40%); and trauma (15.6%). The defect site was most commonly in the forearm (53.1%), followed by the elbow (12.5 %), arm (12.5%) and hand (21.9%). The mean timing of free flap transfer was 6.8 days after admission to our institution (minimum 1 days, maximum 9 days). Mean operative time of surgery was 4 h 39 min (minimum 3 h 2 min, maximum 6 h 20 min). The mean hospitalization was 24.8 days (minimum 5, maximum 85). The ALT success rate was at 92.3%. Partial flap necrosis was documented in five cases (15.6%). Complete flap loss occurred in two post-traumatic cases who both lost their limbs.

Discussion: This flap, in the hands of experienced surgeons, provides reliable coverage of upper extremity defects.
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http://dx.doi.org/10.3205/iprs000064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4604768PMC
October 2015

C-type natriuretic peptide slows down wound healing but promotes angiogenesis in SKH1-hr hairless mice.

Int Wound J 2013 Aug 14;10(4):425-30. Epub 2012 Jun 14.

Clinic for Vascular an Endovascular Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.

C-type natriuretic peptide (CNP) is known to increase growth rate of endothelial cells in vitro. In addition, gene transfer of CNP into ischaemic muscle was shown to induce angiogenesis. So far, no study has addressed the effect of CNP on dermal wound healing. The ear wound model in mice was used in this study. The first group was treated with dsRed-CNP plasmid, whereas the second group was transfected with the empty dsRed-sine plasmid, lacking sequence coding for CNP. The third group was sham operated and treated with saline to serve as second control. Wound size was measured on days 0, 1, 3, 5, 7, 9, 11 and 14. On days 7 and 14 capillary density was analysed. Wound closure rate was significantly reduced in mice treated with CNP [dsRed-CNP 73·3 ± 3·2% versus dsRed-sine 94·5 ± 2·4% versus saline 92·1 ± 2·4%, n = 8 per group, analysis of variance (ANOVA) P < 0·001] at day 7 postop. Capillary density was found to be significantly higher in CNP-treated mice (dsRed-CNP 18·7 ± 3·9 versus dsRed-sine 12·3 ± 2·7 versus control 10·1 ± 4·7, CD31(+) capillaries per microscope field, ANOVA P = 0·018) at day 14 postoperative. CNP significantly reduces wound closure rate in hairless mice but promotes the development of new blood vessels. A possible explanation is the dual effect of CNP, inhibiting growth of fibromyoblasts but stimulating growth of endothelial cells. Thus, CNP may serve as a therapeutic approach to diseases caused by hyperfibrosis.
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http://dx.doi.org/10.1111/j.1742-481X.2012.01001.xDOI Listing
August 2013