Worldwide, the prevalence of obesity has tripled since 1980. This article gives an overview on the current status of the prevalence of obesity and overweight as well as on the impact of obesity on bariatric surgery and body-contouring surgery.

Background: Lower body lift procedures are in high demand following the increase of massive weight loss patients. As surgical complication rates in this patient group are generally high, patients need to be prepared for risk factors and complications in lower body lift surgery. The aim of this study was to identify the complications and possible risk factors of a lower body lift as concrete data for this procedure are limited.Methods: A prospective study on 50 consecutive patients who underwent a lower body lift procedure was performed. Measures included co-morbidities and complications. Risk factors assessed included patient age, gender, highest lifetime body mass index (BMI) (BMI max), current BMI, excess weight loss (EWL), type of weight loss and nicotine consumption.Results: There were 50 patients (44 females, six males) with a mean age of 41 +/- 10.8 years and a mean EWL of 86.4 +/- 15.6%. Mean BMI max was 49.5 +/- 10.5 kg m(-2), current BMI was 27.8 +/- 4.0 kg m(-2). A total of 35 (70%) patients developed at least one complication. Five patients (10%) suffered a major complication that necessitated surgical revision. Wound dehiscence occurred in 30 patients (60%), followed by seroma in 17 patients (34%). A surgical complication was directly related to BMI max (p=0.02) and age of the patient at the time of surgery (p=0.03).Conclusions: The overall complication rate following a lower body lift was 70%, which is comparable with that known for high-risk patient groups. The most important risk factors are BMI max and age of the patient (Clinical trial registration number (ISRCTN): NCT01551862). (C) 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Four-corner arthrodesis is an accepted surgical option for treatment of scapholunate advanced collapse, scaphoid non-union advanced collapse and midcarpal instability. A preferred source of bone graft for performing four-corner arthrodesis is the iliac crest. An alternative and more convenient donor site is the distal radius. The aim of this study was to investigate whether the union rate after four-corner arthrodesis is influenced by the source of bone graft, that is, iliac crest or distal radius. In a retrospective analysis, charts and radiographs of 180 patients were identified. In 109 patients, iliac crest bone grafts were used, whereas 71 patients received distal radius bone grafts. In the iliac crest bone graft group, 101 out of 109 patients obtained a solid radiographic union of the arthrodesis at an average of 10 weeks after surgery, and non-union in eight patients (7.3%). In the distal radius bone graft group, X-rays of 66 patients showed bone union after an average of 10 weeks after surgery as well and five patients with non-union (7.0%) respectively. There was no statistical difference in bone union. Our data show that distal radius bone graft compares equally to iliac crest bone graft in performing four-corner arthrodesis. The advantages of the distal radius bone graft include a minor surgical exposure and the avoidance of using a distant anatomic site with associated donor-site morbidity.

Introduction: General principle in the treatment of severe burns is early wound closure. A good take of split-thickness-skin-grafts is essential for fast wound healing and thereby for the outcome of the patient. The aim of the study was to evaluate the impact of V.A.C. therapy (R) in the field of acute burn surgery. Patients and Methods: All patients of the Vienna burn centre who were treated with V.A.C.(R) between 2004 and 2006, were evaluated concerning burn surface area, burn degree and outcome. Results: 28 out of 29 patients, suffering from deep dermal and full thickness burns, were discharged with complete wound closure, only one patient died. Conclusion: In our opinion, split-thickness skin-fixation by using V.A.C. therapy (R) is suitable for moist and irregular wound surfaces, for areas exposed to movements and especially for the treatment of older patients with co-morbidities.

INTRODUCTION:General principle in the treatment of severe burns is early wound closure. A good take of split-thickness-skin-grafts is essential for fast wound healing and thereby for the outcome of the patient. The aim of the study was to evaluate the impact of V.A.C. therapy in the field of acute burn surgery.PATIENTS AND METHODS:All patients of the Vienna burn centre who were treated with V.A.C. between 2004 and 2006, were evaluated concerning burn surface area, burn degree and outcome.RESULTS:28 out of 29 patients, suffering from deep dermal and full thickness burns, were discharged with complete wound closure, only one patient died.CONCLUSION:In our opinion, split-thickness skin-fixation by using V.A.C. therapy is suitable for moist and irregular wound surfaces, for areas exposed to movements and especially for the treatment of older patients with co-morbidities.

Introduction: Breast cancer is the most common disease in women, and up to one third develops lymph oedema of the arm following mastectomy, standard axiliary node dissection and postoperative irradiation. Limb reductions have been reported utilising various conservative therapies such as manual lymph drainage and pressure therapy. In failure of conservative therapy H. Brorosn described encouraging results with liposuction. Liposuction removes the hypertrophied adipose tissue and is a precondition to achieve complete reduction. Methods: In our patient we used the power assisted liposuction to remove the hypertrophied adipose tissue. 15 minimal incisions and cannulas with a diameter of 4 and 3mm were used. Liposuction was executed circumferentially, step-by-step, from hand to shoulder. The incisions where left open to drain. We used the dry method. The arm was held in raised position during the hospital day. Two days postoperatively measurements where taken for custom-made compression garment. Result: In our patient the aspirate volume was 2000ml. The wound healing was uneventful and the liposuction in combination with controlled compression therapy produced a consistent and stable reduction of the chronic arm lymph oedema. The difference of the upper limb circumference from 5cm to 11cm has been achieved. Conclusion: The power assisted liposuction combined with controlled compression therapy is a useful, well working therapy in reduction of arm lymph oedema. Also in older patients it is a very good treatment because of less trauma and the time of surgery.

BACKGROUND: Breast cancer, mastectomy and treatment in oncology injure body and self. In this field study we investigate concerns, needs, anxieties and decision-making processes of patients after they are diagnosed with breast cancer. Six patients, who underwent immediate breast reconstruction and six with secondary plastic surgeries after mastectomy, tell their stories. They share their experiences and histories with me, a sociologist and communication scientist, who accompanies them during surgical treatment and beyond. With the documentation of subjective breast reconstruction narratives we aim at deepening an understanding of socio-cultural, political and symbolic meanings of female body tissue. METHODS: The crucial aim of this ethnographic long-term project is the exploration of emotional, social, cultural and gender specific aspects, which determine the life quality of breast reconstruction patients – including these categories into therapeutic concepts. RESULTS: Surgical reshaping of the body's integrity requires the inclusion of psychosocial and cultural factors, which are defined by each single individual woman herself. With the help of this research data indications and therapeutic conceptions can be individually improved. CONCLUSIONS: A mutual translation and mediation process is inspired. Surgeons strengthen their understanding of the patients' voices and languages. Treated women plunge into the imaginary worlds of their plastic and reconstructive surgeons.

BACKGROUND: It has only been during the last decade that immediate breast reconstruction has become accepted as an integrated part of the treatment concept of breast cancer in Austria. The involvement of the plastic surgeon in the planning of treatment at the time of the diagnosis of breast cancer is still far from standard. The aim of this review article is to make it more widely known that immediate breast reconstruction is a choice for the majority of women undergoing complete breast removal or greater disfiguring resections of the breast gland and does not have any negative influence on the oncological late outcome. METHODS: On the basis of a review of the international literature and our own prospective studies on breast reconstruction, the actual indications and contraindications for immediate reconstruction are outlined. Having analysed patients of the Division of Plastic and Reconstructive Surgery at the Department of Surgery at the Medical University of Vienna for the last 15 years, the evolution of immediate breast reconstruction and of the methods applied is described. Special attention is paid to the biology and the course of the tumour disease, to the possible interference with adjuvant therapies, to the influence of age, and to the selection of the operative technique depending the individual situation. RESULTS: All major studies of local recurrence rate and survival rate after immediate breast reconstruction have ruled out any negative effect on the oncological course. Therefore information on the possibility of immediate breast reconstruction has to be passed on to every breast cancer patient at the time of diagnosis. This information has to include the whole range of techniques offered by plastic surgeons for breast preserving surgery, from the local glandular mammaplasty, the reduction mammaplasty for tumor resections in bigger breasts, the partial reconstruction with a myocutaneous latissimus dorsi flap to the reconstruction with a breast implant. In the case of a mastectomy, usually as skin-sparing mastectomy, again the whole spectrum of reconstructive approaches has to be discussed with the patient from the very beginning: the Deep Inferior Epigastric Perforator Flap (DIEP – flap), the Transverse Rectus Abdominis Myocutaneous Flap (TRAM – flap), and the extended latissimus dorsi myocutaneous flap for autologous breast reconstruction, or with the involvement of a breast implant. The immediate breast reconstruction with autologous tissue has become the procedure of first choice, because the disadvantages of the use of implants in the case of necessary postoperative irradiation therapy can be avoided. CONCLUSIONS: Information on all reconstructive possibilities should be passed on by the plastic surgeon to the patient needing a resection of the whole or a greater part of the breast because of breast cancer at the time of diagnosis so as not to miss the chance of immediate reconstruction if preferred by the patient.

Introduction: Although breast reconstruction has become more and more accepted immediately or secondary to breast cancer surgery over the last few years, objective multi-centre follow up studies have to exclude any negative late effect of breast reconstruction on the oncological run of the breast cancer disease. Further on the optimal techniques of reconstruction for the different kind of defects and for the different individual anatomical situations have to be evaluated together with the effect on the psychosocial situation of the patient. Methods: A questionnaire on breast reconstruction has been developed and applied to all patients at the Section of Plastic and Reconstructive Surgery at the Medical University of Vienna during the last 10 years. As a consequence of this experience together with field studies of a sociologist and communication scientist in some of our patients this questionnaire was re-evaluated and adapted to these results. Results: This presented multi-centre study will be started in autumn 2007 with all plastic surgeons performing breast reconstructions. At the beginning of 2008 a parallel study is planned to be started to investigate the communication on breast reconstruction, the integration of reconstruction in an over-all concept of breast cancer treatment, and the patients supply with immediate or secondary breast reconstruction in Austria. Conclusion: A consequent follow-up study of patients with breast cancer and breast reconstruction is necessary to find further proof for the actual concepts on immediate or secondary breast reconstruction.

Traditionally acute scaphoid fractures were treated by immobilization. As a consequence we have to deal with a high number of scaphoid non-unions or SNAC wrists. A study of 30 patients with scaphoid non-union showed that only 30% (9 patients) have not seen a doctor, while the majority of the patients (70%, 21 patients) were treated by a physician after trauma. In 15 (71.4%) of these 21 patients a missed diagnosis and in 6 (28.6%) a failed conservative treatment of the scaphoid fracture were the reasons for scaphoid non-union. Therefore, improvements in the diagnosis and therapy of scaphoid fractures are urgently needed. Herbert's classification of scaphoid fractures provides the underlying rationale for treatment according to the fracture type seen on X-ray. Differentiation between stable and unstable fractures sometimes is difficult from conventional X-rays. In these cases we recommend a CT bone scan in the long axis of the scaphoid. According to the CT scan we modified Herbert's classification: undisplaced waist fractures are classified as stable and can be treated conservatively or can be stabilized percutaneously using minimally invasive procedures. Comminuted or displaced fractures are classified as unstable and need operative treatment because of the increased risk of scaphoid non-union after plaster immobilization. Fractures of the proximal pole of the scaphoid should be treated operatively by internal fixation, even if they are not displaced, because of the reduced perfusion. We recommend a CT scan of the scaphoid, if there is any doubt about the diagnosis or the stability of the scaphoid fracture. In any case, a CT scan has to be ordered to justify a conservative treatment.

PURPOSE:Midcarpal fusion is a reliable treatment for posttraumatic carpal collapse in the short or midlong term. The long-term results remain, however, unclear. The objective of this study was to assess the long-term clinical outcome but also the incidence of an arthrosis of the radiolunate joint or an ulnar translocation after excision of the scaphoid.METHOD AND MATERIAL:37 patients after midcarpal fusion were reexamined after an average follow-up of 97 months clinically and radiologically.RESULTS:The average range of motion from extension to flexion was 62 degrees, the average grip strength changed from 69 % of the opposite side before surgery to 80 % after surgery. Pain in the verbal analogue scale improved from 2.7 preoperatively to 1.7 postoperatively. The Krimmer wrist score was 72, whereas 28 patients (76 %) reached a good or excellent result. The mean DASH score was 24 points. At the X-rays, ten patients (27 %) showed an arthrosis of the radiolunate joint and/or an ulnar translocation. Differences in clinical results between the groups with or without X-ray pathology were not statistically significant. From 107 patients with a midcarpal fusion in the time of interest, seven (6.5 %) had to be converted into wrist arthrodesis because of ongoing pain.CONCLUSION:Also in the long-term the motion-sparing midcarpal fusion offers a functional advantage over wrist arthrodesis.

Little data is available about the long-term functional outcome and quality of life after ray amputation or amputation at the level of the proximal phalanx of the index finger. The purpose of this study was to evaluate the functional outcome and postoperative quality of life after ray amputation or amputation through the proximal phalanx to create a database which is helpful in the decision whether to amputate a digital ray or to preserve a stump.58 patients with amputation of the second ray and 12 patients with amputation through the proximal phalanx of the index finger between 1987 and 1996 were included in the study and examined with respect to hand strength, sensibility, range of motion, pain, and aesthetic result of the hand. Subjective functional outcome was evaluated using the DASH-questionnaire. The majority of patients were male (78 % with ray amputation/83 % with amputation through the proximal phalanx). In 55 %/58 % the operation was performed on the dominant hand. Average age was 45 years and average follow-up was 44.2 months after ray resection and 22.1 months after amputation through the proximal phalanx. Patients lost an average of 10.7 weeks of work after ray amputation and 8.1 weeks after digital amputation. There was no significant loss of grip strength after ray amputation (29 % to 34 % loss of grip strength, 32 % loss of pinch grip) compared with patients after amputation through the proximal phalanx (21 % to 28 % loss of grip strength, 17 % to 35 % loss of pinch grip). DASH-score was 31.3 after ray amputation and 21.7 after digital amputation. Patients with amputation through the proximal phalanx reached a significantly better result in part B of the DASH-questionnaire. 65.5 % of the patients after ray amputation and 91.7 % after digital amputation complained of postoperative pain in the operated hand. Decreased sensibility was found in 55.2 % after ray resection and in 33.3 % after digital amputation. All patients after amputation through the proximal phalanx but only 82.8 % after ray amputation showed a free range of motion of the operated hand. The aesthetic appearance of the operated hand was rated higher after ray amputation. The results show that there is no significant loss of strength after ray amputation compared to amputation through the proximal phalanx as mentioned in the literature. Patients with amputation through the proximal phalanx demonstrate a better functional outcome, while the aesthetic appearance was rated higher after ray amputation. A significant difference was only found in part B of the DASH-questionnaire. This should be considered when the indication for ray amputation is pending.

Transfer of the extensor indicis proprius is the gold standard for reconstruction of the extensor pollicis longus tendon to restore thumb extension. Twenty patients were included to a prospective randomized trial to assess whether an early dynamic motion protocol yields a better outcome than immobilization. Evaluation included postoperative range of motion, grip strength, duration of treatment, and time off work. Ten patients of each group had the thumb immobilized in an extension thumb spica cast for 3 weeks after surgery or underwent an early dynamic motion protocol. Follow-up examinations were performed 3, 4, 6, and 8 weeks after surgery. At 3 weeks total range of motion of the interphalangeal joint was almost twice as good (59°) in the dynamic motion group compared with immobilized patients (31°). At 6 weeks no significant differences between the groups were found. A similar pattern for grip strength and pinch grip was found after 3 weeks, when patients undergoing the motion protocol had significantly better results than the immobilized group. Although the dynamic motion group still had better results after 4 weeks, hand function was similar in both groups after 6 and 8 weeks. Patients with early dynamic motion recovered their hand function more rapidly than immobilized patients, shortening total rehabilitation time and making dynamic motion treatment highly cost-effective. (J Hand Surg 2001;26A:1111–1115. Copyright © 2001 by the American Society for Surgery of the Hand.)

Reconstruction of the abdominal wall is of importance in many clinical situations, but may require the entire spectrum of plastic and reconstructive surgery. Indications for particular procedures depend on the clinical situation and the patient's individual profile. One has to differentiate between life-saving primary measures and secondary corrections to improve form or function. The article outlines current actual concepts of plastic surgical defect reconstruction with wich the general/visceral surgeon should be acquainted, in order to integrate these concepts into a multi-disciplinary approach in pertinent clinical situations.

Es wurden insgesamt 87 Patienten mit Amputation eines Fingerstrahls und 19 Patienten mit Grundgliedamputation eines Langfingers nachuntersucht. Verglichen wurde Kraft und Ästhetik der operierten Hand sowie die postoperative subjektive Zufriedenheit der Patienten in Bezug auf Funktion und Symptomatik der operierten Hand anhand des DASH-Fragebogens. Dabei zeigten Patienten mit Grundgliedamputation bei den Kraftmessungen und beim DASH-Fragebogen überwiegend bessere Ergebnisse, während die Ästhetik der operierten Hand von Patienten mit Strahlamputation besser bewertet wurde. Ein signifikanter Unterschied bestand dabei nur in Teilbereichen des DASH-Fragebogen. Bei der Entscheidung über die Höhe der Amputation sollten nicht nur die Funktion der Hand, sondern auch die subjektive Zufriedenheit, Ästhetik, Geschlecht und Beruf des Patienten einen Einfluß haben.

There are no clear definitions of serious or complex hand injuries in the literature. Multistructural injuries involving a vital risk to the affected part of the body part are usually classified as complex. The quality of the reconstruction, based on sound management principles, determines the aesthetic and functional outcome for the patient. The strategies basically consist of: Careful radical dbridement, thorough analysis of the defect and evaluation of lost functions, injury classification, Patient oriented reconstructive procedures, careful and realistic explanation of perspectives and risks to the patient. Following these principles will most likely achieve the planned objectives of treatment, such as, best possible restoration of form and function, cost-effective therapy, and early professional and social reintegration. Algorithmic approaches are an important aid in the clinical approach to these kinds of problems, making it possible to reach clear reproducible decisions that are amenable to standardization. Despite all individual decisions necessary to achieve optimal care, this standard theoretical framework will be able to improve the quality of care.

In der Literatur findet sich keine klare Definition für schwere oder komplexe Handverletzungen. Im internationalen Konsens werden multistrukturelle Verletzungen mit Gefährdung des betroffenen Körperteils als komplex eingestuft. Die Qualität der Rekonstruktion und der Weiterbehandlung bestimmen das ästhetische und funktionelle Endergebnis für den Patienten. Eine optimale Lösung basiert jedoch immer auf einer sinnvollen strategischen Planung, die aus folgenden Schritten bestehen sollte: Ein sorgfältiges radikales Débridement; eine gründliche Analyse des resezierenden Defekts und der daraus entstehenden Funktionsausfälle; einer wann immer möglichen einzeitigen Rekonstruktion bei gleichzeitiger vorausschauender Planung für eventuelle Sekundäreingriffe; einer sorgfältigen Patientenaufklärung, die realistisch die Perspektiven und möglichen Risiken des operativen Eingriffs darstellt. Mit Einhaltung dieser strategischen Grundsätze lassen sich die Therapieziele – Erhaltung der Extremität, bestmögliche Wiederherstellung von Form und Funktion, frühe berufliche und soziale Reintegration und die Vermeidung von Spätfolgen – am ehesten realisieren. Eine wichtige Hilfe in der klinischen Situation kann die algorithmische Problemlösung darstellen, die klare, standardisierbare nachvollziehbare Entscheidungen vorgibt. Ohne die Flexibilität des Chirurgen einzuschränken, ist so doch ein theoretisches Standardgerüst der Versorgungsstrategie gegeben, mit dem grundsätzlich die Versorgungsqualität verbessert werden kann.

Zusammenfassung. Die Wiederherstellung der ventralen Bauchwand hat in vielen klinischen Situationen einen signifikanten Einfluss auf Prognose und Verlauf der Grundkrankheit. Die Indikation für das jeweils optimale Verfahren richtet sich nach der klinischen Situation und dem individuellen Patientenprofil, wobei das ganze Spektrum der Plastischen Chirurgie zum Einsatz kommen kann. Dabei ist zu unterscheiden zwischen primären Maßnahmen bei vital bedrohlichen Situationen und sekundären Maßnahmen zur Funktions- oder Konturkorrektur. Der Beitrag soll die aktuelle Konzepte der plastisch-chirurgischen Defektdeckung erläutern, die dem Allgemein/Visceralchirurg geläufig sein sollten, um im Bedarfsfall interdisziplinäre Behandlungsoptionen in das therapeutische Konzept integrieren zu können.