Moritz Billner

Background: The free latissimus dorsi (LD) muscle flap remains a workhorse for large soft-tissue defects. Its pedicle, however, must be followed proximally into the axilla—into the immediate vicinity of the lymphatics that drain the arm—and whether this compromises upper-extremity drainage has never been settled. The few studies that examined lymphoedema after LD surgery relied on questionnaires and were confined to breast reconstruction, where axillary clearance and irradiation offer a sufficient explanation for anything they found; the harvest itself has never been isolated. Methods: We identified every patient who underwent free LD muscle flap reconstruction for defect coverage at our institution between September 2017 and December 2022 and examined those who attended a standardized cross-sectional follow-up. None had undergone axillary lymph node dissection, sentinel node biopsy, or axillary irradiation, and none had received cervical or supraclavicular irradiation ipsilateral to the donor side. A single examiner measured upper-arm and forearm circumference bilaterally, 10 cm proximal and 10 cm distal to the medial epicondyle. Patients whose flap had been transferred to an upper limb were excluded, because in them the tape measures the flap rather than the donor site. The contralateral limb served as the intra-individual control. The primary endpoint was the mean side difference in upper-arm circumference with its 95% confidence interval. Results: Forty-one patients (25 women, 16 men; mean age 54.4 ± 16.5 years; mean follow-up 14.4 ± 12.0 months, range 3–48) were included. Upper-arm circumference averaged 27.88 ± 3.26 cm on the donor side and 27.77 ± 3.65 cm contralaterally—a difference of +0.11 cm (95% CI −0.28 to +0.50; p = 0.57). Forearm values were 23.82 ± 2.89 cm and 23.94 ± 3.07 cm (−0.12 cm; 95% CI −0.47 to +0.23; p = 0.49). Two of 41 patients (4.9%; exact 95% CI 0.6–16.5%) crossed the conventional 2 cm threshold at the upper arm—and exactly as many crossed it in the opposite direction, with the donor limb the smaller of the two. Side difference bore no relation to time since surgery. Conclusions: Free LD muscle flap harvest showed no detectable difference in arm circumference at two standardized levels in patients who had never undergone axillary lymphadenectomy. The upper-arm mean difference is compatible with no more than a 0.5 cm increase, and threshold crossings occurred equally often in both directions. Circumference is a coarse surrogate that cannot detect subclinical (International Society of Lymphology [ISL] stage 0) lymphoedema; within that limit, these data give no support for avoiding the flap on lymphatic grounds.

Zusammenfassung: Die autologe Brustrekonstruktion mittels Deep Inferior Epigastric Perforator(DIEP)-Lappenplastik gilt aufgrund der Schonung der Rektusmuskulatur, natürlicher Ästhetik und hoher Patientinnenzufriedenheit als etabliertes Standardverfahren. Gleichzeitig ist sie ressourcenintensiv. Fallbezogene gesundheitsökonomische Daten zur Wirtschaftlichkeit im deutschen DRG-System sind bislang begrenzt. Retrospektive monozentrische Fallkostenanalyse von 18 Patientinnen, die 2023 eine einseitige DIEP-Lappenplastik ohne perioperative Komplikationen und ohne DRG-relevante Nebendiagnosen erhielten. Erfasst wurden direkt zuordenbare medizinische Kosten der präoperativen, perioperativen und nachstationären Phase. Die Erlösanalyse erfolgte anhand der aG-DRG J01Z unter separater Berücksichtigung des Pflegeentgelts. Ergänzend wurden fünf Experteninterviews qualitativ ausgewertet. Die mittleren direkten Gesamtkosten betrugen 9829,07 € pro Patientin. Der größte Kostenanteil entfiel auf die perioperative Phase, insbesondere auf den Operationsabschnitt mit 5792,27 €. Dem mittleren DRG-Erlös von 14 017,05 € stand bei Betrachtung direkter Kosten ein positiver Deckungsbeitrag von 4192,65 € gegenüber. Unter Annahme indirekter Kosten von bis zu 50% stiegen die Gesamtkosten auf 14 738,94 €, wodurch bei alleiniger DRG-Vergütung ein Defizit von 721,89 € resultierte. Erst durch das zusätzliche Pflegeentgelt von 1606,85 € ergab sich ein geringer positiver Gesamtsaldo von 884,97 € pro Fall. Die einseitige DIEP-Lappenplastik kann unter den genannten Bedingungen im Sinne eines selektionierten Best-Case-Szenarios im deutschen DRG-System knapp kostendeckend sein. Die wirtschaftliche Tragfähigkeit bleibt jedoch fragil und wird wesentlich durch indirekte Kosten, Pflegeentgelt, Prozessstandardisierung und strukturelle Vorhalteleistungen beeinflusst. Künftige Vergütungsmodelle sollten Prozesskomplexität, Zentrumsstrukturen und patientenbezogene Langzeitergebnisse stärker berücksichtigen.

Background: Early detection of severe infections in burn patients is difficult due to confounding sterile inflammation. Previous research has shown that Pancreatic Stone Protein (PSP) is less affected by trauma and surgery. Therefore, this study investigated whether longitudinal PSP trends can distinguish sterile post-burn inflammation from clinically relevant infections and indicate response to antimicrobial therapy. Methods: This prospective pilot cohort study included 10 consecutive adult patients with moderate to severe burn injuries admitted to a specialized burn intensive care unit. PSP levels were measured using bedside testing (abioSCOPE^®) daily over a 14-day observation period. Clinical parameters, burn severity as assessed by the Abbreviated Burn Severity Index (ABSI), and the occurrence of severe infectious complications, including pneumonia and bacteremia, were systematically recorded. PSP measurements were not used to guide clinical decision-making. Results: Patients who developed severe infectious complications (pneumonia and/or bacteremia; mean ABSI 8.5) showed a consistent and characteristic increase in PSP levels (>350 ng/mL) over time, with elevations preceding the clinical diagnosis of infection (24–120 h). In contrast, patients without pneumonia or bacteremia (mean ABSI 6) exhibited low and stable PSP (<150 ng/mL) concentrations throughout the observation period, despite the presence of burn-related injury and the expected sterile inflammatory response. Conclusions: In this exploratory cohort study distinct PSP trajectory patterns, with persistently low levels in non-infected patients and rising levels preceding clinically diagnosed infection in several cases, were observed. These preliminary findings suggest that longitudinal PSP monitoring may provide potential utility for infection surveillance in burn ICU patients. However, due to the exploratory design and very limited sample size, the findings should be interpreted cautiously and require validation in larger prospective multicenter studies before conclusions regarding clinical decision-making or patient outcomes can be drawn.

Background/Objectives: Free gracilis (GM) and latissimus dorsi muscle (LDM) flaps are reliable options for complex defect coverage, but long-term sensory outcomes remain underexplored. Sensory impairment, especially the loss of protective cutaneous sensation, increases the risk of injury, thermal damage, and ulceration in reconstructed areas. This study aimed to systematically assess multidimensional sensory recovery after free muscle flap (FMF) reconstruction. Methods: In a prospective single-center study, 94 patients (49 GM, 45 LDM) underwent standardized sensory testing following FMF transfer. Five modalities were evaluated: pressure detection (Semmes-Weinstein monofilaments), vibration perception, two-point discrimination (2PD), sharp–dull differentiation, and temperature differentiation. Measurements were compared to contralateral healthy skin (CHS). Subgroup analyses were performed by anatomical region (head, trunk, extremities). Results: All sensory modalities were significantly impaired in FMF compared to CHS (p < 0.0001). Mean pressure thresholds were markedly higher in FMF (248.8 g) versus CHS (46.8 g). Vibration perception scores were reduced (FMF 3.97 vs. CHS 5.31), and 2PD was significantly poorer (11.6 cm vs. 4.7 cm). Sharp–dull and thermal discrimination were largely absent in FMF (positivity rates < 20%), with 58.5% of patients demonstrating only deep pressure sensation (≥300 g). No significant differences were found between GM and LDM in most modalities, except for worse 2PD in GM. Subgroup analyses confirmed uniform deficits across all anatomical regions. Conclusions: FMFs without neurotization result in profound, persistent sensory deficits, particularly the loss of protective sensation. Clinically, fascio-cutaneous flaps with nerve coaptation should be considered in functionally critical regions. Future strategies should focus on neurotization techniques to enhance sensory recovery.

Zusammenfassung: Dieser Fallbericht beschreibt den Verlauf einer nekrotisierenden Fasziitis als schwerwiegende Komplikation nach einer ambulanten Liposuktion. Die Patientin benötigte neben einer prolongierten intensivmedizinischen Behandlung umfangreiche chirurgische Eingriffe, einschließlich radikalen Debridements, Vakuum-Therapie (NPWT) und multipler Lappenplastiken, um die ausgedehnten Gewebedefekte zu decken. Der Fall hebt die Risiken hervor, die mit ästhetischen Eingriffen verbunden sind und unterstreicht die Bedeutung diese Eingriffe nur durch erfahrene, qualifizierte Fachärzte durchführen zu lassen. Zudem zeigt dieser Fall eindrucksvoll die Wichtigkeit einer frühzeitigen Diagnosestellung sowie eines interdisziplinären Managements.

Background/Objectives: Enzymatic debridement with NexoBrid^® is an effective alternative to surgical debridement in burn care, but its potential systemic effects remain unclear. In the context of personalized burn care, understanding individual patient responses to topical agents is essential to optimize outcomes and minimize risks. This study aimed to characterize laboratory and clinical parameter changes following NexoBrid^® application in patients with small burn injuries (≤10% TBSA). Methods: We retrospectively analyzed 75 burn patients treated with NexoBrid^® to evaluate changes in systemic inflammatory markers, coagulation parameters, and clinical parameters before and after enzymatic debridement. Results: Statistically significant increases in body temperature (p = 0.018), decreases in hemoglobin (p < 0.001), and increases in C-reactive protein (CRP) levels (p < 0.001) were observed, suggesting mild systemic inflammatory changes. However, leukocyte counts did not change significantly (p = 0.927), and body temperature remained within the normothermic range, indicating that these changes were not clinically significant. A significant decrease in the prothrombin time ratio (% of normal; p = 0.002) was also observed, suggesting potential impacts on coagulation. Importantly, while body temperature was slightly higher in patients with a higher degree of BSA exposure within the ≤10% TBSA cohort (p = 0.036), the extent of NexoBrid^® application did not correlate with other inflammatory markers. Conclusions: These findings suggest that measurable systemic changes can occur following NexoBrid^® application in small burns, particularly affecting inflammatory and coagulation parameters. These observations contribute to the understanding of treatment-related responses and may help inform clinical decision-making.

Background and Objectives: Toxic epidermal necrolysis (TEN) and Stevens–Johnson syndrome (SJS) are rare yet life-threatening dermatologic conditions characterized by severe skin and mucous membrane involvement. Accurate prognostic systems are crucial for clinical management to assess disease severity and predict outcomes. The primary objective of this study was to assess the epidemiological characteristics and clinical outcomes of patients with Stevens–Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap over a 17-year period at a specialized burn center. The secondary objectives were to evaluate the performance of existing prognostic scoring systems (SCORTEN, Re-SCORTEN, and ABCD-10) in predicting mortality and to propose a novel classification tree model to improve mortality prediction. Materials and Methods: A 17-year retrospective study at a burn center included 68 patients with SJS, SJS/TEN overlap, or TEN. Demographic, clinical, laboratory data, and prognostic scores (SCORTEN, Re-SCORTEN, ABCD-10) were collected and analyzed for associations with mortality. A classification tree was created to detect unknown determinants of SJS/TEN mortality. Results: The drug most frequently associated with the occurrence of SJS/TEN was metamizole. The mortality rate was 51%. Affected body surface area, platelet count, and serum blood urea nitrogen differed significantly between survivors and non-survivors. Regarding the scoring systems, only the Re-SCORTEN showed reliable differentiation for these groups. A classification tree model achieved an accuracy of 89% in predicting the mortality risk. In the ROC curve analysis, the AUC values were 0.88 for the classification tree, 0.66 for Re-SCORTEN, 0.61 for SCORTEN, and 0.56 for ABCD-10. Conclusions: This study explores mortality predictors in SJS/TEN via a classification tree model, highlighting potential factors for further investigation. While cautioning against immediate clinical application due to data constraints, the findings underscore the need for larger studies to validate and refine prediction models in this context.

Background: For years, surgical debridement with autografting has been considered the standard of care in the treatment of severe burns of the hand. However, in recent years, enzymatic debridement has increasingly been reported as a good alternative, especially for burns of the hand, as it selectively preserves viable tissue. In this study, we aim to evaluate the long-term function of the hand after enzymatic debridement in deep dermal burns. Methods: A retrospective chart review was conducted as well as measurements of subjective and objective outcome measures through physical examination and Disabilities of the Arm, Shoulder, and Hand (DASH), Patient and Observer Scar Assessment Scale (POSAS), and Vancouver Scar Scale (VSS) scores. Results: A total of 32 enzymatically debrided hands of 24 patients were included with a mean age of 42.4 ± 16.8 years and a mean follow-up of 31 months. Postoperatively, 19 of these could be managed conservatively using skin substitutes such as “Suprathel”, 13 had to undergo subsequent autografting. The mean DASH score for the entire study population was eight with a mean value of four in the conservatively managed group and fourteen in the autografted group. The mean Patient, Observer POSAS, and VSS values were nineteen, thirteen, and two. A total of 30 cases showed an effortless complete fist closure, and, also in 30 cases, patients attested to be satisfied with the esthetic appearance of the hand on being asked. Conclusions: The descriptive analysis of these results in our study population suggests that the enzymatic debridement of deep burns of the hand, especially combined with subsequent conservative management with skin substitutes, was associated with low long-term hand disability scores at a follow-up of two years.