Wounds and tissue defects of the hand and foot often lead to severe functional impairment of the affected extremity. Next to general principles of wound healing, special functional and anatomic considerations must be taken into account in the treatment of wounds in these anatomical regions to achieve a satisfactory reconstructive result. In this article, we outline the concept of wound healing and focus on the special aspects to be considered in wounds of the hand and foot. An overview of different treatment and dressing techniques is given with special emphasis on the reconstruction of damaged structures by plastic surgical means.

Zusammenfassung Hintergrund Das Facelift ist mittlerweile der vierthaufigste asthetische Eingriff beim Mann. Die Gesichtsalterung verlauft bei Mannern und Frauen sehr unterschiedlich. Somit werden individuelle Techniken angewendet, da ein einheitliches Konzept fur die operative Gesichtsstraffung beim Mann bisher fehlt. Ziel der Studie ist es, ein genderspezifisches, speziell fur Manner entwickeltes Facelift-Konzept zu evaluieren. Material und Methoden Frauen und Manner (je n=10) wurden einem dreidimensionalen Gesichtsscan und einer anschlie ss enden Simulation eines V-formigen Liftvektors (Standardlift) und einem neuen Facelift-Konzept speziell fur Manner in doppelter T-Form (Male Lift) unterzogen. In einer Online-Umfrage mit 262Teilnehmern wurden sowohl die simulierten als auch die unveranderten Bilder prasentiert und die Attribute Mannlichkeit, Weiblichkeit, Attraktivitat und Jugendlichkeit abgefragt. Statistische Modelle wurden verwendet, um entsprechende Attribute der Straffungen sowie weitere Faktoren zu identifizieren und Unterschiede der Simulationen zu ermitteln. Ergebnisse Verjungende Veranderungen im Gesicht sind generell mit einer deutlichen Verbesserung der Attribute Jugendlichkeit und Attraktivitat im Vergleich zu unveranderten Kontrollgesichtern verbunden. Wie erwartet fuhrt ein Male Lift zur Maskulinisierung, wahrend ein Standardlift zur Feminisierung fuhrt; unabhangig vom Geschlecht der Probanden. Das Male Lift zeigte hohere Werte fur das Attribut Attraktivitat bei mannlichen, ebenso wie das Standardlift bei weiblichen Probanden. Das fur Frauen entwickelte und somit fur Frauen auch besser geeignete Standardlift ist mit einer deutlich hoheren Wahrscheinlichkeit fur das Attribut Jugendlichkeit verbunden, wahrend dies beim neu eingefuhrten Male Lift-Konzept nicht so stark ausgepragt beurteilt wird. Schlussfolgerung Das neue Facelift-Konzept fur mannliche Patienten ist signifikant mit den Merkmalen Mannlichkeit und Attraktivitat verbunden, wahrend das fur Frauen geeignete Standardlift mit deutlich hoheren Bewertungen der Attribute Weiblichkeit und Jugendlichkeit einhergeht. Die Ergebnisse der SIMALIFT-Studie sind der erste Beweis fur die Notwendigkeit einer differenzierteren, geschlechtsspezifischen Herangehensweise an ein Facelift. Abstract Background Facelift is now the fourth most common aesthetic procedure in men. Facial ageing is very different in men and women. Therefore, individual techniques are used since a uniform concept for the surgical facelift in men does not exist. This study aims to evaluate a gender-specific facelift concept especially developed for men. Material and methods Women and men (n=10 each) were subjected to a three-dimensional face scan and a subsequent simulation of a V-shaped lift vector (standard lift) and a new facelift concept especially for men in a double T shape (male lift). In an online survey with 262 participants, the simulated as well as the unchanged images were presented and the attributes masculinity, femininity, attractiveness and youthfulness were queried. Statistical models were used to identify attributes of lifting as well as other factors and differences between the simulations. Results Facelift changes are generally associated with a significant improvement in the attributes of youthfulness and attractiveness compared with unchanged control faces. As expected, a male lift leads to masculinisation, while a standard lift leads to feminisation, regardless of the sex of the subjects. The male lift led to higher values for the attribute attractiveness in male subjects, as did the standard lift in female subjects. The standard lift developed for women is indeed more suitable for women and is associated with a significantly higher probability for the attribute youthfulness, whereas this is not the case in the newly introduced male lift concept. Conclusion The new facelift concept for male patients is significantly associated with masculinity and attractiveness, while the standard lift suitable for women is associated with significantly higher evaluations of femininity and youthfulness. The results of the SIMALIFT study are the first evidence of the need for a more differentiated, gender-specific approach to facelifting.

BACKGROUNDAlthough the etiology of capsular contracture after breast augmentation has not yet been definitively clarified, the literature contains numerous reports placing the blame on a foreign body reaction. We have developed a procedure for covalently activating a silicone surface with an anti-Fas antibody, which might suppress the foreign body reaction on the silicone surface.OBJECTIVESThe authors evaluate whether surrounding tissue might be influenced by anti-Fas antibody coating on silicone disks in comparison to untreated silicone disks in an in vivo model.METHODSDuring this study, 4-mm anti-Fas-coated silicone disks were implanted subcutaneously in the paravertebral region of mice (C57/BL6). Silicone disks passing the activation coating process without anti-Fas antibody incubation were defined as the control group. Twelve weeks after implantation, the disks were removed and the surrounding tissue examined.RESULTSThe tissue surrounding the silicone disks in the experimental group showed significantly increased levels of collagen type 3, elevated levels of matrix metalloproteinase 9, markedly decreased levels of transforming growth factor β2, and a reduced CD68 expression in the pericapsular tissue.CONCLUSIONSThe first in vivo data reveal that the tissue surrounding a silicone surface can be influenced by the vectored binding of an anti-Fas antibody.

The most common implanted material in the human body consists of silicone.Breast augmentation and breast reconstruction using silicone-based implants are procedures frequently performed by reconstructive and aesthetic surgeons.A main complication of this procedure continues to be the development of capsular contracture (CC), displaying the result of a fibrotic foreign body reaction after the implantation of silicone.For many years, experimental and clinical trials have attempted to analyze the problem of its etiology, treatment, and prophylaxis.Different theories of CC formation are known; however, the reason why different individuals develop CC in days or a month, or only after years, is unknown.Therefore, we hypothesize that CC formation, might primarily be induced by immunological mechanisms along with other reasons.This article attempts to review CC formation, with special attention paid to immunological and inflammatory reasons, as well as actual prophylactic strategies.In this context, the word "biocompatibility" has been frequently used to describe the overall biological innocuousness of silicone in the respective studies, although without clear-cut definitions of this important feature.We have therefore developed a new five-point scale with distinct key points of biocompatibility.Hence, this article might provide the basis for ongoing discussion in this field to reduce singlepublication definitions as well as increase the understanding of biocompatibility.

In the daily clinical routine, numerous synthetic medical devices are implanted in the human body, either temporarily or permanently. The synthetic material most often implanted is polydimethylsiloxane (silicone). Numerous studies have demonstrated that silicone is encompassed in a connective tissue capsule by the body, preventing integration into the surrounding tissue. This can result in complications. The aim of our study was to develop a simple procedure to functionalize the silicone surface, thereby positively affecting the material's biocompatibility. By combining a silanization with the use of ester activation, a reactive amino group is generated, which can bind any free carboxyl group. Directional crosslinking of a near-infrared-conjugated fluorophore antibody to the activated silicone surface could be demonstrated on a dose-dependent basis. The redox reaction at a silicone surface coated with an HRP-conjugated antibody caused by the addition of NBT/BCIP could be shown. Covering the silicone discs with an anti-FAS-antibody coating followed by a coincubation with FAS-sensitive T-cells allowed highly significant detection of caspase-3. In summary, our crosslinking procedure enables the stable binding of proteins without the loss of biological function. Through this process, silicones could be endowed with new functions which could improve their biocompatibility.

Otfrid Foerster (1873-1941) became a self-taught neurosurgeon during and after WW I, playing a critical role in the development of peripheral nerve reconstruction. Although best known for describing dermatomes, he published over 300 articles on the nervous system. Confronted by thousands of nerve injuries during WW I, as well as poor results and disinterest from his surgical colleagues, Foerster began performing neurolysis and tension-free nerve repairs himself under emergency conditions. He pioneered grafting motor nerve defects by expendable cutaneous nerves (e.g., sural) and performed intraplexal neurotizations and various nerve transfers, such as the pectoral, subscapular, long thoracic, and thoracodorsal nerves in brachial plexus injuries. Foerster championed rehabilitation, recognizing the potential of electrostimulation and physiotherapy to influence cortical reorganization (brain plasticity) and improve recovery after nerve injury. Foerster died from tuberculosis in 1941, leaving a rich reconstructive peripheral nerve legacy; his innovative and visionary spirit serves as a role model.

BACKGROUND:Saddle-nose deformity is a well-recognized stigma of patients affected by Wegener granulomatosis (WG). However, plastic surgical repair is seldom performed. In this study, the authors aimed to evaluate their own patients exclusively reconstructed by costal cartilage L-strut of the nose for this specific deformity.METHODS:During a 5-year-period, four women with an average age of 33 years underwent reconstructive rhinoplasty of their saddle-nose deformity caused by WG, which in every case was in remission regarding the nose at the time of surgery. Restoration of the nasal framework was performed by an L-shaped rib cartilage graft.RESULTS:The external form and function of the newly reconstructed nose was preserved during an average follow-up period of 42 months for all the patients. No resorption of the rib cartilage graft was observed. A review of the literature found a total of 22 nasal reconstructions for patients affected by WG.CONCLUSION:According to this patient series and a review of the literature, external nasal reconstruction for patients affected by WG appears to be safe and effective if the disease is in remission before any operation. Despite concern that high-dose immune suppression therapy may increase the risk of failure in primary nasal dorsal repair, this could not be observed in the patients of this series, all of whom were receiving immunosuppressive medication. Therefore, nasal reconstruction to improve the physical appearance and thus the psychological well-being of these chronically ill patients seems to be justified.

A postoperative defect of the surrounding soft tissue is one main risk factor for implant exposure and infection following total knee arthroplasty (TKR). The main factors that promote infection, tissue ischemia, and hypoxia are strongly associated with arterial insufficiency and the prevalence of impaired peripheral perfusion. We hypothesized that vascular malperfusion is the predisposing reason for soft tissue complications following TKR necessitating plastic reconstructive surgery.

The aim of this study was to evaluate the relevant conditions for safe free flap transfers. The authors retrospectively studied the data from 150 patients who received free flaps at a single institution. Many parameters were analyzed to reveal if there was a correlation with respect to surgical or medical complications. Regarding safety of free tissue transfer, we found a worse prognosis in flaps where a revision of the microanastomosis had to be performed. Platelet count and leukocyte count had an impact on the prognosis. Patients older than 60 years did not have an increased rate of surgical complications. Apart from active osteomyelitis, the presence of comorbid conditions did not significantly impair the outcome of flap transfer, although smoking and diabetes correlated with minor surgical complications like wound breakdown or hematoma, respectively. Besides one case of lethal heart failure of an octogenarian patient, no severe medical complications occurred in this series of patients. Microvascular free tissue transfer is not significantly impaired by age and most comorbidities. Osteomyelitis as well as elevated leukocytes and lowered platelets may increase the complication rate and worsen the surgical prognosis. Smoking and diabetes might prolong the hospital course of the patients.

Background. Cancer development relies on a variety of mechanisms that facilitate tumor growth despite the presence of a functioning immune system, employing different mechanisms to escape immune rejection. Tumors may eliminate tumor-infiltrating lymphocytes and suppress anti-tumor immune responses, a process called "tumor counterattack," based on activation-induced cell death via the FAS/FAS-ligand system. To overcome this tumor-cell survival strategy, we examined the hypothesis that the sensitivity of FAS mediated apoptosis of Jurkat-T-cells can be suppressed by FLIP transfection of Jurkat-T-cells.Materials and Methods. Jurkat-T-cells were transfected with the FLICE-inhibitory protein FLIP in order to bestow them with a resistance to FAS-receptor-mediated apoptosis. FLIP-transfected and non-transfected Jurkat-T-cells were grown in coincubation with SW620 cells and the rates of apoptosis measured via FACS-analysis of Annexin-V.Results. First, the tumor-counterattack described in the literature was confirmed. About 20% of Jurkat-T-Cells underwent apoptosis in coculture with SW620 cells. After coincubation of SW620 cells with FLIP transfected Jurkat-T-cells the apoptotic rate was significant reduced at levels below 4%.Conclusion. Transfection of Jurkat-T-cells with FLIP reduces the sensitivity of Jurkat-T-cells to FAS-mediated apoptosis and may lead to an improved capability to antagonize the inherent tumor survival strategy of SW620 cells. (C) 2012 Elsevier Inc. All rights reserved.

aClinica de Cirugia Plastica, Reparadora y de la Mano, Facultad de Medicina de Hannover, Alemania. bClinica de Cirugia de la Mano, Sahlgrenska Universitetsjukhuset, Gotemburgo, Suecia. Resumen Objetivo Restablecimiento de la flexion activa del codo contra su propio peso (grado de fuerza ≥ M3) y mejora de la capacidad funcional de toda la extremidad superior por transposicion bipolar del musculo dorsal ancho intacto.

Wiederherstellung der aktiven Ellbogenbeugung gegen Eigenschwere (Kraftgrad ≥M3) und Verbesserung der Gebrauchsfähigkeit der gesamten oberen Extremität durch bipolare Transposition des intakten Musculus latissimus dorsi.

Objective Reconstruction of active elbow flexion against gravity (strength grade >= M3) by transfer of the latissimus dorsi muscle in order to improve the functionality of the upper extremity Indications Irreparable lesions of the musculocutaneous nerve (C5/6). Failure of regeneration after peripheral nerve reconstruction for the musculocutaneous nerve (neurolysis, suture, nerve grafting). Brachial plexus injury (lesions to the upper part, C5/6). Loss of biceps function due to trauma, ischemia, poliomyelitis or tumor. Contraindications Possible recovery of biceps function by rein nervation,spontaneously or after nerve reconstruction. Weakness of the latissimus dorsi muscle (strength grade < M4). Insufficient passive range of motion of the elbow joint (osteoarthritis, contracture). Lack of motivation, reliability, and cooperation of the patient in postoperative rehabilitation program. Surgical Technique The intact latissimus dorsi muscle is transferred with its origin and insertion ventrally and sutured with its thoracic aponeurosis into the insertion of the biceps tendon in order to act as an elbow flexor. Postoperative Management Following postoperative immobilization in an upper-arm Gilchrist bandage at 100 degrees flexion and supination (or neutral position, but not pronation) of the forearm for 6 weeks, passive motion exercises of the elbow are started. Active flexion and extension exercises begin at 8-10 weeks postoperatively. To prevent the deleterious effect of muscle and tendon elongation, an orthosis is used during the night to keep the elbow flexed at 90 degrees for 6 months. Results According to the authors' experience and the results reported in the literature, bipolar latissimus dorsi muscle transfer is a reliable method to restore functional elbow flexion regarding range of motion (> 90 degrees elbow flexion) and strength (at least antigravity strength, >= M3) with acceptable donor morbidity and complication rate.

To the Editor: It is with interest that I read the article by Kreymerman et al, published in the April issue of Annals. The authors do a good job of discussing some aspects of methods used to evaluate implant rupture. As the authors pointed out, comprehensive clinical and radiologic assessment for patients with implants frequently becomes complicated. Thus, a management algorithm is useful to help determine which imaging modality is appropriate and, particularly, when to use magnetic resonance imaging (MRI). Nonetheless, I must point out that there is another side to this equation that is not examined in the present article: costs and technical limitations related to MRI accuracy. MRI is generally accepted as the technique of choice for evaluating implant integrity, with a sensitivity of 70% to 94% and a specificity of 85% to 100%, depending on the applied MRI protocol and on the diagnostic criteria used for the definition of implant status. In recent years, there has been a resurgence of interest in the implant imaging techniques, as well as the lack of logic of the US Food and Drug Administration recommendation for post–silicone implant MRI study. This article again illustrates the value of the MRI to evaluate implant integrity and an algorithm to consider when evaluating these patients. In my experience, frequently implant rupture is asymptomatic because the free silicone remains within the capsule. Therefore, the identification of rupture is based on the use of imaging techniques and MRI has the potential to address questions raised or unanswered with traditional imaging methods. However, implant integrity depend on multiple technical factors and implant factors (ie, capsule contracture, implant position, implant type). In addition, individual investigative imaging methods are diverse, causing difficulty in protocol development for the radiologist. Thus, MRI can present some limitations and as with any other test, there is an inherent false-negative and false-positive rate. It has been suggested that detection of an extracapsular rupture or silicone leakage is relatively easy on silicone-specific MRI images, however in my experience, detection of an intracapsular rupture can be challenging. An intracapsular rupture can be a total collapse of the inner capsule, creating a “lumen within a lumen” appearance, or it can be a focal collapse with multiple intraluminal linear hypointense structures within the silicone-filled lumen (linguine sign) or a focal silicone collection in radial folds (“keyhole” sign). In some situations, a false-negative rupture diagnose can be observed. In these cases, the envelope adherence to the fibrous capsule justified the linguine sign absence and the homogeneous high signal intensity inside the ruptured implant. As described by Berg et al, the term “rupture without collapse” can explain the envelope adherence to the capsule phenomenon and the gel homogeneity that are found in some ruptured implants. Another potential and “cost” problem is related to the false-positive cases. In some situations, the presence of atypical radial folds simulated a “linguine” appearance of a ruptured wavy elastomer. According to some authors, the presence of complex radial folds is one of the principal reasons of false-positive on MRI mimicking the total collapse of the implant shell. In addition, the “linguine sign” can be detected in bleeding implants. In this last situation, the false-positives are due to the presence of atypical folds that mimicked ruptured wavy elastomer. To resolve this problem is important to use orthogonal planes with lesser slice thickness, or volumetric acquisition with volumetric reformatting. In the last 5 years, 7 patients with positive MRI presented without a history or physical examination suggesting a rupture. Based only on the MRI result, all implants were removed and none were ruptured, resulting in unnecessary expense and risk. In conclusion, awareness of potential pitfalls is important if MRI is to maximize its potential in breast imaging. Some pitfalls that may arise in relation to MRI of the breast can readily be avoided by attention to technique and care with interpretation of imaging. On the other hand, screening of asymptomatic breast augmentation patients, and in particular with MRI, remains controversial, and sound scientific studies in this area are scarce. Again, I congratulate the authors on their results.

Background: Controversy remains regarding timing in the management of complex traumatic lower extremity defects. Many authors recommend a definitive bony and soft tissue reconstruction within a critical period of 72 h, yet in many patients this may be impossible due to concomitant injuries or delayed referral. However, little data are available on the results of delayed flap reconstruction of complex traumatic extremity defects, especially using new technologies of wound coverage such as vacuum-assisted closure (VAC (R)) therapy which may reduce the disadvantages of conventional open wound therapy prior to a subsequent flap reconstruction.Methods: We retrospectively analysed the soft tissue reconstructions in 43 open extremity fractures during a 4-year period with special regard to complications, overall flap loss and wound infection.Results: A total of 29 mate and 13 female patients with 33 open fractures of the tower and 10 of the upper extremity were included. All patients had been referred from a trauma centre at a mean interval of 19 days (range 1-96 days) after the trauma event with temporary VAC (R) of their wounds after initial fracture fixation and initial debridement of necrotic tissue. Flap reconstruction was thus only possible later than 72 h and definitive wound closure was achieved at a mean time of 28 days (range 3-106 days). Overall, three pedicled flaps were lost and one of 38 microsurgical free flaps (2.6%) underwent necrosis, the cause of which was unrelated to treatment delay.Conclusions: According to this study, the flap reconstructions performed beyond the frequently quoted critical interval yielded similar results to those of immediate reconstruction within the first 3 days, as reported in the literature.This strategy is in accordance with the principles of 'Damage Control Orthopaedics (DCO)' and may reduce the importance of emergency reconstructions, especially in poly-traumatised patients. (C) 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

BACKGROUND:Arteriovenous loops are an indispensable tool in free flap surgery when appropriate recipient vessels are missing. In this study, the authors analyzed whether the outcome differs when flaps were transferred simultaneously or subsequently after construction of arteriovenous loops. METHODS:Twenty-seven patients requiring free tissue transfer received arteriovenous loops by pedicled or free vein grafts because of inadequate local recipient vessels. In head and neck reconstruction, pedicled brachiocephalic or free saphenous vein grafts were anastomosed to cervical or axillary vessels. Pedicled major saphenous vein grafts were used in the pelvic area whereas, in lower leg and foot reconstruction, free saphenous or brachiocephalic veins were used. Flaps were transferred simultaneously (n = 10) or 4 to 17 days later (n = 17). RESULTS:Thrombosis required revision in staged transfer (n = 3 patients) or in simultaneous flap transfer (n = 2). No free flap was lost. Fisher's exact test did not indicate a significant difference between a simultaneous or staged flap transfer. CONCLUSIONS:Temporary arteriovenous loops provide adequate recipient vessels and flow to supply microvascular free flap tissue transfer in areas lacking recipient vessels and in which no other reconstructive options exists. No statistical differences in complications and overall outcome were found between immediate or secondary free tissue transfer. Meticulous monitoring of microvascular perfusion, however, is mandatory in both approaches and early intervention is necessary to ensure successful tissue transfer.