Handchirurgie Mikrochirurgie Plastische Chirurgie最新文献

Lymphatic drainage through the internal mammary lymph nodes (IMLN) is a key pathway for breast cancer metastasis, although IMLN metastasis is rare following primary treatment. In earlier years, treatment protocols primarily addressed axillary lymph node metastasis.We present five cases where IMLN metastases were discovered incidentally during autologous free-flap breast reconstruction. These cases highlight implications for both the reconstructive plastic surgeon and subsequent adjuvant therapy.From a plastic-reconstructive perspective, we recommend performing routine biopsies on any incidentally identified IMLN during autologous breast reconstruction. Positive findings may upstage the patient's disease and influence further treatment planning. However, we do not recommend actively searching for or extending dissections to harvest IMLN specimens. Only in the presence of a suspicious perinodal tumour mass do we perform an intraoperative frozen-section analysis, with reconstruction paused if malignancy is confirmed. After complete staging and discussion in a multidisciplinary conference, we proceed with tumour resection according to oncological standards if curative resection is deemed feasible. Reconstruction can then be performed during the same procedure. For locoregional recurrence of breast cancer, treatment continues to be a multimodal approach involving surgery, radiation, and systemic therapy to ensure local control and optimise long-term survival. In primary treatment, current national and international guidelines now recommend locoregional irradiation of the internal mammary chain for high-risk cases, which may further reduce the incidence of incidental IMLN metastasis findings in the future.

Introduction:   The entrance of Generation Z (born 1997-2012) into professional life, including the practice of medicine, marks a transformational shift in priorities and values. This generation, shaped by digital immersion and a strong focus on work-life balance, is redefining the landscape of Plastic Surgery. Their preferences for inclusivity, innovation, and structured working hours challenge traditional models of mentorship, patient care, and surgical training. The aim of this survey was to explore the impact of Generation Z on the field of Plastic Surgery through insights offered by leaders of major Plastic Surgery societies in Europe and the United States, who together provide a comprehensive perspective on generational change and its implications for clinical practice, education, and healthcare systems in Plastic Surgery.

Methods:   In October 2024 eight leaders of national Plastic Surgery societies and associations were invited to complete a structured questionnaire with five open-ended questions. They provided detailed responses on challenges, opportunities, and structural changes needed to address Generation Z's influence.

Results:   Key findings highlight a generational shift in the approach to professional life, with an emphasis on digital innovation, work-life balance, and the interaction with social media. Respondents noted an increased interest in aesthetic over reconstructive surgery and a preference for private practice among younger surgeons, raising concerns about workforce shortages in public healthcare. Advances in digital learning and simulation-based training were identified as opportunities to facilitate medical education. However, the ethical challenges of misinformation on social media and a decline in hierarchical mentorship were emphasized as critical concerns. Despite generational tensions, the integration of Generation Z's strengths in technology and advocacy for systemic reform holds promise for addressing burnout and enhancing healthcare delivery.

Conclusion:   The arrival of Generation Z in Plastic Surgery represents a possible pivotal moment to reimagine traditional models of surgical education, patient care, and professional priorities. Collaboration between generations and proactive adaptation to these changes is an imperative to ensure a dynamic, inclusive, and sustainable future for the specialty.

The reconstruction of full-thickness soft tissue injuries on the distal lower extremity depends on the defect size, the patient's risk profile and comorbidities. A pedicled sural flap or a free ALT flap are standard procedures for restoring the tissue. To compare the skin and scar quality of the two reconstructive options, subjective patient perception and satisfaction as well as the objective skin properties were examined using the Patient and Observer Scar Assessment Scale (POSAS), Cuto-, Mexa-, and Tewameter.This retrospective study included 40 patients who received a pedicled sural flap or a free ALT flap for tissue reconstruction on the distal lower extremity between 2013 and 2018. A subjective assessment of skin quality was conducted using the POSAS and a visual analogue scale to determine patients' perception and satisfaction with the surgical results. Skin quality was analysed using a Cuto-, Mexa-, and Tewameter in the flap area, the area surrounding the flap, the healthy contralateral side, the donor site, and the corresponding contralateral side of the donor site.The examination of the subjectively perceived skin and scar quality showed a significantly higher level of satisfaction among patients with ALT flaps than among patients with sural flaps. The POSAS evaluation showed better skin quality at the ALT donor site compared with the sural donor site. The melanin and erythema values recorded by the Mexameter revealed a positive correlation with the POSAS data. In an intra-individual skin comparison, the objective measurements demonstrated that both flaps exhibit reduced elasticity, while both donor sites show increased elasticity compared with the healthy contralateral side. In addition, an increased erythema value was found at the flaps and donor sites compared with the healthy opposite side.The instrument-based measurement methods exhibited objective differences in the skin properties of the examined skin areas. A correlation analysis between subjective perception and objective measurement data demonstrated that visual properties, such as melanin content and erythema, showed a stronger correlation with subjective perception than mechanical properties. Overall, patients with an ALT flap were more satisfied than patients with a sural flap, which can be attributed to a lower morbidity of the donor site.

Uninterrupted blood flow through microsurgically anastomosed vessels is crucial for the postoperative success of reconstructive microsurgery. Contrary to the highly standardized anastomosis techniques, the pivotal partner discipline of evidence-based microsurgical haemostaseology and haemorrheology is still in its infancy. Prospective clinical studies yielding evidence-based recommendations are notably lacking. Currently, perioperative management in microsurgery is based solely on site-specific empirical experience. The collective aim of these diverse efforts is the preoperative identification of increased coagulation (hypercoagulability) or clotting activities (thrombophilia) and the development of relevant anticoagulation strategies. During the 43rd Annual Meeting of the German-Speaking Working Group for Microsurgery (DAM) in November 2022 in Frankfurt, experts in microsurgery, haemostaseology, and anaesthesia deliberated on the fundamentals of coagulation and physiology. Also, alongside a literature review, consensus recommendations for the perioperative management of hypercoagulopathies were established. Subsequently, methodologies were assessed within the panel, criteria for decision-making were gathered, and, ultimately, a consensus recommendation by DAM regarding a perioperative algorithm was devised, which is detailed in this position paper.

Background: In 2016, a new method was described to treat the painful impingement syndrome of the DRUJ: decompression corrective osteotomy of the distal radius. Clinical symptoms are based on a positive compression test; pain occurs with weight-bearing on the forearm. This phenomenon is seen in conjunction with a deformed sigmoid notch together with ulna minus-variance, which leads to increased tension in the distal oblique bundle of the interosseous membrane. The etiology of the condition can be either congenital, post-traumatic, or iatrogenic. Through the proposed osteotomy, decompression in the DRUJ is achieved. This study summarises the results of these surgical procedures performed in our hand centre exclusively in cases of congenital origin.

Patients und methods: Remodelling of the DRUJ is achieved through the shortening of the distal radius together with closed wedge osteotomy. Relief of the interosseous membrane is accomplished by ulnar translation of the radial shaft. This study only included patients with congenital incongruency in the DRUJ. The results were evaluated using a visual analogue scale (VAS) and the Krimmer Wrist Score and by measuring the preoperative and postoperative range of motion as well as grip strength.

Results: Within 11 years, 45 procedures were performed with our method on 38 patients, of which 17 were treated on the right side, 14 on the left side, and 7 bilaterally. In cases of bilateral incongruency, only the symptomatic side was treated. The statistical evaluation showed a significant reduction of pain on the VAS from 7.2 to 2 (p<0.001). No significant changes were seen in the range of motion (p=0.812). The Krimmer Wrist Score showed good to excellent results in almost 90% of cases.

Conclusion: If the indication criteria are met, contraindications are avoided and the osteotomy is correctly performed, this technique leads to an improvement of patients' functionality and quality of life. From a preventive viewpoint, the influence on the progression of the degenerative changes is yet to be demonstrated in further studies. At any rate, this is a safe procedure, which leaves the path open for other possible options.

We present the case of a 24-year-old man who sustained a scaphoid fracture in the presence of congenital scaphotrapezial and lunotriquetral coalitions. As the fracture progressed to a nonunion, a screw osteosynthesis was performed. The altered biomechanics caused by the two coalitions necessitated a dorso-proximal surgical approach, and two screws were implanted to prevent rotational instability. The scaphoid fracture healed entirely.

The treatment of lesions of the superficial radial nerve remains a challenge for surgeons and patients. For patients, such lesions are associated with a high level of suffering due to electrifying pain at the level of the injury as well as sensory dysfunction. Our data collected over a treatment period of 6 years are intended to give an overview of surgical methods, temporal progression and the corresponding outcomes.We retrospectively analysed 17 cases of patients undergoing surgery after a lesion of the superficial branch of the radial nerve between 4/2017 an 12/2022. Sixteen patients were surveyed using standardised measures with regard to regeneration, pain relief and post-surgical satisfaction. The average latency between the causal event and the surgical procedure was 13.4 months (3-60 M). Neurolysis was carried out in 4 of 16 cases in the presence of macroscopically visible cicatricial changes without the occurrence of morphological changes in the nerve and with preserved continuity. Reconstruction through suturing was performed in 12 cases, 4 being performed without and 8 with neuroprotection. In 2 of the latter, neuroprotection was achieved with a neurotube, while 6 were treated by means of wrapping veins.The performed interventions all led to a reduction of pain. Regardless of the time interval between the lesion of the superficial radial nerve and surgery, the procedure led to a relief from discomfort related to previous symptoms of pain, hypesthesia and Tinel sign. Although the reconstruction of the nerve did not lead to complete remission, the patients were satisfied with the results. In most cases, some hypesthesia remained. Neuroprotection through a vein graft led to better pain relief than treatment without a vein graft.Although symptoms remained, pain relief was crucial for the patients. After lesions of the superficial branch of the radial nerve, surgical treatment aiming to preserve or restore the continuity of the injured nerve branch should be considered as a promising option.

This study aimed to evaluate the advantages and disadvantages of early versus delayed single-stage surgery in patients with hand enchondromas who developed pathological fractures, focusing on local tumor control and hand function, to determine the optimal timing for surgery. Delayed surgical curettage may offer advantages regarding both local tumor control and hand function outcomes.Thirty-five patients who developed pathological fractures due to solitary hand enchondromas and underwent surgical treatment between 2015 and 2021 were analysed. Patients were divided into two groups based on the timing of surgery. Patients who underwent surgical treatment immediately after a pathological fracture were assigned to the early-surgery group, and those who underwent surgical treatment after waiting for fracture union were assigned to the late-surgery group. Demographic data, lesion characteristics, and fixation methods were analysed. Parameters affecting outcome measurements were analysed, including visual pain scale, fracture healing time, recurrence, ROM, time to return to daily activities, and secondary surgical procedures.The study included 35 patients, of whom 24 were female, with a median age of 33 years. Fifteen patients were included in the early-surgery group and 20 in the late-surgery group, with a follow-up period of 36.3 and 38.9 months, respectively. The duration of surgery, time to fracture union, and total physical therapy duration during treatment were lower in the late-surgery group (p<0.05). At the final follow-up, the mean loss of ROM was 17.6˚ in the early-surgery group and 3.3˚ in the late-surgery group (p=0.00). The rate of secondary surgery was higher in the early-surgery group (p=0.040).In patients with hand enchondromas presenting with pathological fractures, early surgery resulted in higher complication rates, poorer functional outcomes, and an increased need for secondary surgeries.

Since their introduction by Mennen and Wiese in 1993, semi-occlusive film dressings (SOFD) have been increasingly used in various clinical contexts, including the treatment of Allen type IV fingertip injuries, fingertip necrosis, and cases involving embedded foreign material.This study aimed to investigate whether and, if so, how the outcomes of Allen type III and IV fingertip injuries and fingertip necrosis differ from those of Allen types I and II. In addition, it aimed to investigate if the presence of embedded foreign material under a film dressing increases the risk of complications.A total of 50 patients with 44 fingertip injuries and 13 fingertip necroses were treated with an SOFD in combination with surgical intervention. In 22 out of 50 patients, foreign material was present under the film dressings. During follow-up, cold sensitivity, pain at rest and during activity, the usage of the injured finger in daily life, patient satisfaction with the aesthetic outcome, sensitivity, sweat secretion, papillary ridges, nail deformity, and mobility were assessed. The fingertips were examined for nail growth abnormalities. The results of the Allen type I-IV fingertip injuries and fingertip necrosis were compared with each other and related to findings from the uninjured fingers of the opposite hand. Clinical outcomes showed that SOFD led to good fingertip regeneration at any amputation level and in cases of fingertip necrosis. However, nail deformities increased with shorter lengths of the distal phalanx. Patients with necrosis were less satisfied with the aesthetic outcome compared to those receiving primary treatment after amputation injury. The presence of foreign material under the film dressings did not influence the healing process, and no infections were observed.SOFDs demonstrate good outcomes in Allen type III and IV fingertip injuries as well as in fingertip necrosis, comparable to those of Allen type I and II. However, it is essential to inform patients about potential risks such as nail deformities and compromised aesthetic appearance. Surgical interventions involving foreign material under an SOFD do not affect the healing of fingertip injuries, thus allowing for an expanded range of indications for SOFDs.