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Biomedical subjects

Norbert Pallua

Publications and source records attributed to Norbert Pallua.

32 records · Page 2Linked to original sources
PubMed2003

Radical resection of giant congenital melanocytic nevus and reconstruction with meek-graft covered integra dermal template.

BACKGROUND: Giant congenital melanocytic nevi represent a surgical challenge, particularly in cases in which the size of the nevus exceeds certain extend and malignant transformations have to be considered. OBJECTIVE: To discuss through case report considerable surgical options when extensive giant congenital melanocytic nevi with malignant transformation are encountered. METHODS: We present an unusual case of a giant congenital melanocytic nevi of the entire back of a 44-year-old patient. To achieve radical resection with direct appropriate wound closure and acceptable outcome, the integument of the entire back was excised and covered with Integra, followed by split-thickness skin grafting after stable integration of the matrix. RESULTS: The approach resulted in a complete excision of the tumor and acceptable cosmetic and excellent biomechanical outcome. CONCLUSION: The introduced practice demonstrates a useful alternative to established methods, particularly if tumor excision in large areas and subsequent wound closure might be achieved in one procedure.

Adult↗
PubMed2003

Pathogenic role of interleukin-6 in the development of sepsis. Part I: Study in a standardized contact burn murine model.

OBJECTIVE: To establish a representative model for the evaluation of interleukin (IL)-6 and IL-6 receptor for pathogenicity and lethality in the postburn period. DESIGN: Ten-week-old C 57 BL/6J mice received a 20% body surface area contact burn and/or lipopolysaccharide (LPS) 48 hrs later. Standardized burns were created with a metal stamp of 150 degrees C of defined pressure and surface area (2.4525 Newton/0.00166 m2) over a period of 11 secs. The depth of dermal injury was verified histologically. The following groups were formed: I: no burn, no LPS (n = 35); II: burn, no LPS (n = 140); III, no burn, LPS (n = 56); and IV, burn, LPS (n = 80), to study the effect of burn alone, sepsis alone, or the combination. Lethal LPS dose (LD100) was determined by application of LPS in increasing doses (200, 300, 400, and 500 microg, n = 32) after burns. MEASUREMENTS: Concentrations of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma), and leukocytes, platelets and organ pathology were evaluated. SETTING: Research laboratory. RESULTS: Burn and LPS showed an additive effect on the release of IL-6 but not of TNF-alpha and IFN-gamma. Leukocyte and platelet numbers decreased significantly (group IV) compared with the other groups (I-III). The maximal levels of IL-6 in group IV were reached earlier than those of TNF-alpha. The contact burn model has a mortality rate of 30%, which is close to clinical outcome. We found the model of contact burn superior to scald or flame burn models. A dose of 400-microg LPS was found to be the lethal LPS dose (LD100). CONCLUSIONS: Our data suggest that preexisting burn injury increases the response to endotoxin. TNF-alpha is not involved in priming. IL-6 on the other hand is a very representative parameter for priming. Because TNF-alpha was obviously not the causative factor, it was concluded that the application of anti-IL-6-mAb should be of great value. Therefore, a therapeutic application was designed, see part II.

Animals↗
PubMed2003

Pathogenic role of interleukin-6 in the development of sepsis. Part II: Significance of anti-interleukin-6 and anti-soluble interleukin-6 receptor-alpha antibodies in a standardized murine contact burn model.

OBJECTIVE: The in vivo effects of anti-interleukin-6 (anti-IL-6) and anti-interleukin-6-alpha receptor (anti-IL-6R) monoclonal antibodies on immune response and survival rate of a burn with subsequent infection were assessed. SUBJECTS: Ten-week-old C 57 BL/6J mice received a standardized contact burn; 48 hrs later endotoxin (LPS) was injected intraperitoneally to induce systemic inflammation. Ten different groups were studied. Groups I-IV sustained a burn and/or a LPS-stimulus but did not receive any anti-cytokines and served as controls. Treatment groups V-X sustained the same injuries but also received anti-IL-6 and anti-IL-6R intravenously either before or after the LPS stimulus. In a further part of the study, a lethal dose of LPS was injected (LPS-LD(100) group) followed by an injection of anti-IL-6 antibody and/or anti-IL-6R antibody. MEASUREMENTS: Serum concentrations of IL-6, tumor necrosis factor (TNF)-alpha, interferon (IFN)-gamma, and white blood cell and platelet counts were determined, and the survival rate over a 2-wk period was assessed. RESULTS: Treatment with anti-IL-6 slightly decreased the inflammatory response when it was given before or after LPS application. The inflammatory response was not decreased after treatment with anti-IL-6R. In the groups that received a combination of anti-IL-6 and anti-IL-6R, there was a significant reduction of the inflammatory response. This was more pronounced when the anti-cytokines were applied after LPS application. A significant reduction in mortality could be shown with both antibodies in the treatment groups and the groups that had received a lethal dose of LPS (LPS-LD(100) group). CONCLUSIONS: IL-6 has a low inflammatory potential, and IL-6R has no inflammatory potential by itself. In contrast, the IL-6/IL-6R complexes have a higher inflammatory potential. Mortality could be reduced by each antibody alone as well as by the combination, supporting the hypothesis that the inflammatory and lethal potentials of IL-6 are not identical. The study suggests that the use of antibodies against IL-6 or IL-6R is effective in the prevention of systemic inflammation in a murine burn model.

Animals↗
PubMed2003

Expression of basic fibroblast growth factor and transforming growth factor-Beta 1 in patients with fasciocutaneous and muscle flaps.

Angiogenesis involves multiple sequential mechanisms stimulating the growth of host endothelium. It occurs in surgical flaps at the interface with the reconstructed wound bed. In this study, concentrations of basic fibroblast growth factor (bFGF) and transforming growth factor-beta 1 (TGF-beta ) were analyzed in sera and wound fluids of 30 patients who underwent surgical treatment with muscle (n = 15) and fasciocutaneous flaps (n = 15). At 12 hours after operation, bFGF levels in wound fluids of patients with muscle flaps were significantly (p < 0.05) higher than in patients with fasciocutaneous flaps. At 24 and 36 hours after surgical treatment, there was no significant difference between them. Each group showed a significant decrease in bFGF levels after 24 and 36 hours. In sera, bFGF was not detectable. The two different groups presented no remarkable difference in TGF-beta concentrations in wound fluids. A correlation between angiogenic factors in sera and wound fluids could not be observed. The results show that angiogenesis is initially more activated in the wound bed of muscle flaps. This might be of great consequence to the healing process and might explain the curative effect of muscle flaps on bradytrophic tissue.

Adult↗
PubMed2003

"I" becomes "L": modification of vertical mammaplasty.

The problems of the vertical mammaplasty by Lejour (i.e., gathering the skin envelope in one vertical suture, frequent secondary healing problems, and later sagging of the inferior glandular part in the case of large and very large breasts) are well known. A simple modification of the Lejour technique, that is, adding a lateral inframammary scar to shorten the vertical scar length, is presented. The modified L technique was used in 45 patients (90 breasts) between October of 1999 and August of 2001. With an average follow-up of 13 months, the jugular notch-to-nipple distance was 21 cm, the vertical scar length was 8.4 cm, the lateral inframammary scar length was 11 cm, and the average resection weight was 625 g per breast (range, 200 g to 2080 g). Even among patients who had very large glandular bases and resection weights it was possible to achieve a breast base reduction, modeling the glandular corpus to a harmonic, well-projecting, and youthful shape. Slight wound-healing problems with spontaneous cicatrization within 2 weeks occurred in six patients. In two patients who exhibited gigantomastia up to 2080 g per breast, partial mamilla necrosis occurred on one side. Ninety-one percent of the patients reported being "very satisfied" with the outcome, and 9 percent reporting being "satisfied." The authors' modification of the vertical mammaplasty to an L-shaped scar technique enables the surgeon to apply the principles of the Lejour technique for higher resection weights and diminishes wound-healing problems, and it is still a scar-minimizing technique that results in a scar-free cleavage. It is easy to learn and an ideal standard technique for a teaching hospital.

Adult↗
PubMed2003

Matrix metalloproteinases and tissue inhibitors of metalloproteinases in sera and tissue of patients with Dupuytren's disease.

Dupuytren's contracture is a fibroproliferative disorder characterized by progressive deposition of mature collagen fibers. In other fibrotic diseases affecting organs such as the liver, lung, heart, and skin, matrix metalloproteinases (MMPs) and their natural inhibitors, the tissue inhibitors of metalloproteinases (TIMPs), play an important role. In this study, serum concentrations of MMP-1, MMP-2, MMP-9, TIMP-1, and TIMP-2 were determined in 22 patients (five women and 17 men; average age, 67 +/- 11 years) with Dupuytren's disease using an enzyme-linked immunosorbent assay. Tissue samples were obtained for standard histological and immunohistochemical analyses. Sera and samples of palmar fascia from 20 patients (13 women and seven men; average age, 60 +/- 15 years) who had undergone hand surgery for carpal tunnel syndrome were used as the control group. Statistical analysis was performed using the Mann-Whitney test. Patients with Dupuytren's contracture presented with a TIMP-1 concentration of 437 +/- 160 ng/ml, a significantly higher TIMP-1 concentration than that seen in the control patients, who had a concentration of 321 +/- 70 ng/ml (p < 0.05). Patients with a proliferative active disease (n = 14) had a significantly higher TIMP-1 concentration (525 +/- 136 ng/ml) than patients (n = 8) with a contracture in the late involutional and residual phase (286 +/- 41 ng/ml; p < 0.05). There were no significant differences in the TIMP-2, MMP-1, MMP-2, and MMP-9 serum concentrations between patients with palmar fibromatosis and the control group. Patients with Dupuytren's disease had a significantly lower MMP-to-TIMP ratio (1.1 +/- 0.3; p < 0.05) than the control group (1.5 +/- 0.35). Patients with an active palmar fibromatosis presented a significantly (p < 0.05) reduced ratio (1 +/- 0.2) compared with those in later phases (1.4 +/- 0.3). TIMP-1 and TIMP-2 could be detected in tissue of patients with Dupuytren's contracture, with an accumulation in proliferative areas. MMPs could be detected locally in Dupuytren's tissue in a few patients, with less positive staining than for TIMPs. In the control group, there was just little or no staining for TIMPs and MMPs. The data indicate that the physiological balance between MMPs and their natural inhibitors is disturbed in patients with a proliferative active Dupuytren's disease. The decrease in the systemic MMP-to-TIMP ratio can cause increased synthesis and deposition of collagen, leading to palmar fibromatosis.

Aged↗
PubMed2002

Refinements in nerve to muscle neurotization.

A modified surgical technique is introduced, enabling restoration of muscle function with direct muscular neurotization. Reliable clinical outcomes result from this technique. We report on a series of 10 patients in whom the supplying motor nerve had been lost at the level of the neuromuscular junction as the result of trauma or tumor resection. Our modification of the operative technique ensures a wide distribution of nerve fibers throughout the remaining muscle tissue and produces a mean motor recovery of M4 after a period of 1 to 2 years.

Adult↗
PubMed2002

MRSA-retrospective analysis of an outbreak in the burn centre Aachen.

The growing interest in methicillin-resistant Staphylococcus aureus (MRSA) has been caused by its increased appearance in hospital and community populations. In our burn centre, an outbreak of MRSA was noticed during an 8-month period. We were able to isolate MRSA in eight patients. DNA analysis by pulsed-field gel electrophoresis (PFGE) demonstrated the development of five different strains during this period. Only two patients developed an infection caused by MRSA colonisation. The infections were proven by positive blood culture or catheter colonisation. One patient developed a clinical vancomycin-resistant sepsis which was treated successfully with the additional application of Quinupristin/Dalfopristin. THIS ANALYSIS SHOWS THAT: (1) the development of MRSA in a burn unit is often created in a single patient by long-term antibiotic therapy and not a result of cross-infection, (2) manifest MRSA infection seldom occurs even in colonised burn patients, and (3) a clinically vancomycin-resistant MRSA infection in burn patients can be treated sufficiently with Quinupristin/Dalfopristin.

Burn Units↗
PubMed2002

Serum concentration of amino-terminal propeptide of type III procollagen (PIIINP) as a prognostic marker for skin fibrosis after scar correction in burned patients.

The amino-terminal propeptide of procollagen type III (PIIINP) has been proposed as a marker for fibrogenesis in patients with different fibroproliferative disorders, e.g. liver and lung fibrosis. In this study, serum concentrations of PIIINP were measured by ELISA as a marker for excessive cicatrization in burned patients before and after scar correction. All patients were followed 6 months to determine a new fibrotic reaction during the wound healing process using the Burn Scar Index and to correlate pre- and post-operative concentrations of PIIINP in their sera with the risk to develop a new severe tissue fibrosis leading to pathological scar formation. Furthermore, PIIINP was determined in the excised scar tissue by immunohistochemistry. The study included 38 patients. Nineteen patients (8 female, 11 male, average age 48.3+/-18.9 years) had hypertrophic scars after major burn injury (TBSA, 21+/-12%; Burn Scar Index, 10.4+/-3.7 points) and underwent scar correction. Nineteen patients (12 female, 7 male, average age 42.3+/-25.5 years) who underwent elective plastic-surgical operations served as the control group. Blood samples were drawn immediately before operation, at the 1st, 3rd, 7th, and 14th post-operative days, as well as 1st, 3rd, and 6th months after operation.Pre-operatively, PIIINP was significantly elevated (P<0.05) in burned patients who underwent scar correction. There was a significant increase (P<0.05) of PIIINP in burned patients from 9.8+/-3.7ng/ml pre-operatively to 13.9+/-4.2ng/ml at the 7th post-operation day. Up to 3 months after operation, the 6 months after scar correction concentration remained at a significantly elevated level compared to pre-operative values. The burned patients had a Burn Scar Index of 7.8+/-3.6 points. Pre-operative PIIINP serum concentrations correlated with the Burn Scar Index (r(2)=0.7 and 0.68; P<0.05). Scar tissue stained intensively positive for PIIINP. There was a significant correlation between pre-operative serum values and degree of immunostaining (r(2)=0.45; P<0.05). The increased concentration of PIIINP seen in our burned patients' sera might serve as a marker for the extent of skin fibrosis and for the risk of developing new severe fibrotic reactions after scar correction.

Adult↗
PubMed2002

Sensory reconstruction of the fingertip using the bilaterally innervated sensory cross-finger flap.

The authors present a series of 15 patients with large soft-tissue defects of the fingertips as a prospective, nonrandomized study. In all cases, reconstruction was achieved using a bilaterally innervated sensory cross-finger flap. This sensory fasciocutaneous flap relies on the dorsal branch of the proper digital nerves, which branch off at the level of the head of the proximal phalanx; sensory supply to the dorsal skin of the middle phalanx is thus ensured. The reconstructive procedure consists of two steps. First, the contralateral dorsal branch of the proper digital nerve is elevated with the flap at proximal interphalangeal joint level. Microsurgical coaptation is performed to the proximal nerve stump of the injured fingertip. After 3 weeks, when the pedicle is dissected, the second nerve is dissected and coapted. Clinical results were evaluated after 12 months. Because the regenerative distance is only 1.5 to 2.5 cm, good sensory regeneration should be expected. In nine of 16 flaps, sensory quality of S2+ (Highet) was present in the flap after 3 weeks. After 12 months, two-point discrimination was present in all patients, the values ranging between 2 and 6 mm (for two-point discrimination), with an average of 3.6 mm. The rate of complications was low. With acceptable additional operative action, a good functional result can be achieved. The indications of this method are discussed in comparison with other methods of fingertip reconstruction.

Adolescent↗
PubMed2002

The free latissimus dorsi flap revisited: a primary option for coverage of wide recurrent lumbosacral defects.

In comparison with other regions of the trunk, defects located in the lumbosacral region are infrequent. However, these particular lesions sometimes present difficulties in reconstruction, arising from the quality of the surrounding tissue and the width of the defects. In this area, the skin adheres strongly to subcutaneous tissue and is difficult to mobilize. Attempts to perform local or regional flaps for covering defects of this area often end in necrosis of the flaps, with subsequent risk of infection and unstable wounds. The consequence is larger defects and the need for a wide, tension-free coverage, which can be performed after a wide debridement. The authors report on 10 patients presenting with wide, recurrent (and in some cases, infected) defects of the lumbosacral region, after already having undergone several reconstructive local or regional operations. In all cases, the authors harvested a free latissimus dorsi flap, lengthening the pedicle by means of an arteriovenous suralis loop connected to the thoracodorsal vessels (lumbar defect) or the femoral vessels (sacral defect). The procedure, already described in the past by others, has been revisited by the authors' group and used as the technique of choice in selected cases, that is, in the presence of wide, recurrent, and infected lesions; radiation; and scarring injuries. The authors thus obtained stable coverage with well-vascularized tissue and were able to save the patients any further operations. The authors suggest, therefore, that this procedure can be used in cases of wide and recurrent defects where other conventional procedures have failed. Advantages, disadvantages, and technical features of the method used are discussed in this article.

Back↗
PubMedDate not supplied

Patients with epilepsy: a high-risk population prone to severe burns as a consequence of seizures while showering.

We document the severe burns sustained by three patients with epilepsy who suffered seizures while showering. On the basis of the circumstances of these accidents, we suggest preventative measures to help other patients with epilepsy avoid similar burn injuries. Patient data collected from January 1987 to May 2004 by the Burn Unit of the Department of Plastic Surgery, University of Aachen, Germany, were reviewed. Three patients with epileptic disorders were found who suffered severe burn injuries caused by seizures that occurred while showering. Scald location and depth was assessed. Three patients (two women, one man) sustained extensive scald injuries after epileptic seizures while showering. Burn extent ranged from 20% to 35% TBSA. Scalds primarily affected the trunk, legs, arms, and buttocks. Two of the three patients used showers with levers for controlling water temperature. Safety devices for limiting water temperature were absent. All patients used shower cubicles. Patients with epilepsy may sustain serious burns, typically affecting the trunk, legs, arms, and buttocks, when a seizure occurs while showering. We suggest that individuals with epilepsy use showers designed with pirouetting taps, rather than levers, to regulate water temperature. Pirouetting taps are less likely to be shifted out of position during a seizure. We also recommend that epileptic patients have safety devices installed in their water heaters that limit maximum water temperature. Such safety devices prevent scald injury. And, finally, we suggest that people with comparable disorders generally avoid using shower cubicles. Instead, showers with curtains should be used, which may allow occupants to escape from dangerously hot shower water more easily.

Accident Prevention↗
PubMedDate not supplied

Accidental burns during surgery.

The purpose of this report is to increase awareness of intraoperative burns during standard procedures, to discuss their possible causes and warning signs and to provide recommendations for prevention and procedures to follow after their occurrence. A total of 19 patients associated with intraoperative burn accidents were treated surgically and analyzed after a mean follow-up of 5 +/- 3.5 months. Review included retrospective patient chart analysis, clinical examination, and technical device and equipment testing. A total of 15 patients recently underwent cardiac surgery, and 4 pediatric patients recovered after standard surgical procedures. A total of 15 patients had superficial and 4 presented with deep dermal or full-thickness burns. The average injured TBSA was 2.1 +/- 1% (range, 0.5-4%). Delay between primary surgery and consultation of plastic surgeons was 4.5 +/- 3.4 days. A total of 44% required surgery, including débridment, skin grafting or musculocutaneous gluteus maximus flaps, and the remaining patients were treated conservatively. Successful durable soft-tissue coverage of the burn region was achieved in 18 patients, and 1 patient died after a course of pneumonia. Technical analysis demonstrated one malfunctioning electrosurgical device, one incorrect positioned neutral electrode, three incidents occurred after moisture under the negative electrode, eight burns occurred during surgery while fluid or blood created alternate current pathways, five accidents were chemical burns after skin preparation with Betadine solution, and in one case, the cause was not clear. The surgical team should pay more attention to the probability of burns during surgery. Early patient examination and immediate involvement of plastic and burn surgeons may prevent further complications or ease handling after the occurrence.

Adult↗