[Phalloplasty in female-to-male transsexuals: experience from 259 cases]. / Phallusbildung beim Frau-zu-Mann Transsexuellen: Erfahrung in 259 Fällen.

BACKGROUND: The free radial forearm flap is state of the art for a phalloplasty in female-to-male transsexuals. Alternatives are the free fibula flap or the pedicled groin flap. METHOD: In a retrospective study, 269 phalloplasties performed between 1993 and 2009 were analysed for success rates and complications. The operative technique for the radial forearm flap in 2 designs and the groin flap penile reconstruction are described. RESULTS: Indications for penile reconstruction were transsexualism in 96.3%. We used 135 radial forearm flaps, 119 groin flap reconstructions, 2 fibula, one scapula and 2 pedicled randomised flaps. Of the radial forearm flaps, 10 flaps had a thrombosis (3 arterial, 4 venous, 3 combined) on postoperative day 0, 1 (n=5), 4, 4, 5 and 24. Six revisions were successful; 4 flaps failed (3%). 12 flaps (9%) showed a partial or superficial necrosis which required an operative revision. CONCLUSION: The radial forearm flap can be performed in various designs. If the patient wishes a glans plasty the Gottlieb design is favoured. In obese patients with a short forearm the Chang design is recommended as it provides a sufficient pedicle length for anastomosis without a venous interpositional graft. The radial forearm flap has a high success rate, but late thromboses and partial necrosis are particular problems. Surgically, we recommend a trapezoid design, a skin graft if there is any sign of tension, a subfascial dissection and sufficient subcutaneous veins for drainage of the ulnar urethra. The groin flap penile reconstruction is a rare alternative for patients who wish a larger bulk, refuse to accept a stigmatising scar on the forearm and whose priority is not voiding while standing.

[Microsurgical reconstruction of the pelvic floor after pelvic exenteration. Reduced morbidity and improved quality of life by an interdisciplinary concept]. / Mikrochirurgische Beckenbodenrekonstruktion nach Exenteratio pelvis. Verminderte Morbidität und verbesserte Lebensqualität durch ein interdisziplinäres Konzept.

BACKGROUND: Pelvic exenteration for advanced or recurrent rectal cancer often results in complex defects associated with high complication rates and morbidity for the patients. The goal of therapy is therefore restoration of functional stability and adequate soft tissue coverage, thus enhancing the quality of life with limited life expectancy by an interdisciplinary approach. PATIENTS AND METHODS: We report on eight patients treated by combined interdisciplinary pelvic exenteration with resection of the sacrum and subsequent coverage of the pelvic floor defect with free latissimus dorsi muscle flaps. All patients were treated in two stages according to a pre-established therapeutic algorithm. First, an abdominal and transsacral pelvic exenenteration was performed with an ileostomy and ileum conduit system and the pelvic floor was closed with vicryl meshes. The open wound was optimized by vacuum-assisted closure (VAC) therapy before reconstruction of the pelvic floor was undertaken 10-12 days later with free latissimus dorsi musculocutaneous flaps either anastomosed to the lower or upper gluteal vessels or to an AV-loop using the saphenous vein as connection to the groin vessels. RESULTS: In all cases a sufficient and stable reconstruction of the pelvic floor could be achieved and no flap loss occurred. In three patients a minor wound dehiscence occurred, which could be closed by secondary suture. The time span between the free flap transfer and stable wound closure was 19-28 days. Later complications such as fistula formation and chronic wound infections were not observed. The survival of the patients ranged from 10-36 months. CONCLUSION: The present two-stage concept of pelvic floor reconstruction with free latissimus dorsi muscle flaps for wound closure after pelvic exenteration improves postoperative morbidity and mortality and increases the quality of life of the affected patients. A shortened period of open wound therapy brings additional economic benefits. Because of its anatomical features the free latissimus dorsi flap can be regarded as the method of choice of microsurgical reconstruction within an interdisciplinary concept after pelvic exenteration.

[Gillies and McLaughlin's dynamic muscle support in irreversible facial palsy]. / Dynamische Muskelersatzplastik nach Gillies und McLaughlin bei irreversibler Fazialisparese.

The goals in surgical treatment of unilateral long-standing facial paralysis are individual concepts restoring mimetic function, aesthetic facial symmetry at rest and protection of the eye by complete eyelid closure. Facial reanimation with free neuromuscular flaps is the actual standard treatment. The reanimation of the paralysed eyelid is still a major problem. Gillies described in 1934 his technique using the transposition of the temporal muscle with two strips of its own fascia performing a dynamic support of the upper and lower eyelid. McLaughlin was using the temporal muscle in combination with fascia lata for the reanimation of the oral muscle sling (1953). There are still some indications for these procedures. The long-term follow-up of 93 patients with Gillies procedure and 180 patients with McLaughlin's muscle support gives a sound base for decision making in facial reanimation.

[Current treatment of hamate hook fractures]. / Aktuelle Behandlung der Hamulus ossis hamati-Fraktur.

PURPOSE: Hamate hook fractures can be treated conservatively or surgically, whereby fragment and fracture position, age of the fracture, associated injuries, and individual needs of the patient all influence the choice of the therapeutic procedure. Acute non-displaced fractures are frequently treated conservatively, while displaced fractures and nonunions undergo surgical treatment. We report our experience in diagnostic and therapeutic management of 14 hamate hook fractures. CLINICAL MATERIAL AND METHOD: During a three-year period, 14 patients (eleven men and three women) 21 to 73 years old (42.0 +/- 17.9 years) with fractures at the base of the hamate hook were treated at three hand surgery units. The retrospective study of all patients included a chart review, postoperative radiological imaging after one year, and clinical examinations with grip strength measurements after 18 to 34 months (27.8 +/- 4.9 months). In six patients (43 %), the acute fracture was immobilized in a lower arm cast for six weeks, while eight patients (57 %) were operated primarily. In five cases (36 %) excision of the fragment and in three cases (21 %) open reduction and internal fixation using a screw were performed. Of six patients treated conservatively, five developed nonunion after two to five months (3.0 +/- 1.2 months) with persistent pain and underwent secondary surgery. One patient was asymptomatic despite a nonunion and declined surgical treatment. In three cases the fragment was excised, while two patients underwent open reduction and internal fixation with a screw. RESULTS: All patients operated primarily were free of complaints three months after surgery. The success rate of surgical treatment (8/8) was therefore significantly higher than that after conservative treatment (1/6). CONCLUSION: Compared to conservative treatment of acute non-displaced hamate hook fractures, which is associated with a high risk of developing symptomatic nonunion, primary surgical treatment reliably yields a good clinical outcome. Here, results after fragment excision and open reduction and internal fixation are comparable.

[The free gracilis perforator flap for autologous breast reconstruction]. / Der freie Grazilis-Perforator-Lappen zur autologen Brustrekonstruktion.

The free gracilis perforator flap is an alternative possibility for autologous breast reconstruction, if previous abdominal operations preclude this donor site, or if there is atypical distribution of fat tissue. The perforator flap is based on the main pedicle of the gracilis muscle. The muscle itself and its innervation can be completely preserved, if the angiosome of this vascular pedicle offers sufficient tissue. In skinny patients however it may be necessary to include the neighbouring angiosome of the second gracilis pedicle by means of the intramuscular anastomosis between both pedicles. In such a case a thin muscle strip with the joining vessel must be included in the flap. The bulk of the gracilis muscle and its motor nerve can, however, still be preserved. Breast reconstruction with this technique was successfully performed on six patients (two bilateral). It is a good alternative to a reconstruction with gluteal, or anteromedial, or lateral thigh perforator flaps.

[Myosonographic evaluation of rectus abdominis muscle function after DIEP flap breast reconstruction]. / Myosonographische Funktionsprüfung des M. rectus abdominis nach DIEP-Lappenplastik zur autologen Brustrekonstruktion.

Donor-site morbidity following autologous breast reconstruction is a well-known disadvantage of free or pedicled TRAM flaps. Bulging and weakness of the abdominal wall and sometimes even hernias occur. Due to recent technical advances in microsurgery, there are different possibilities for breast reconstruction like the deep inferior epigastric perforator (DIEP) flap which is harvested without rectus muscle. First studies describe good aesthetic results without the complication of hernias and disadvantage of abdominal wall weakness. Myosonography is a new method to test the dynamic rectus muscle function and evaluate the donor-site morbidity after DIEP flap breast reconstruction. This study aims to analyze the value of myosonographic measurements to evaluate the donor-site morbidity following perforator flap elevation of the abdominal wall. Between November 2000 and August 2001, 34 patients at the Markus Hospital in Frankfurt/Main, Germany received breast reconstruction with a DIEP flap. Myosonographic examinations pre- and postoperatively were performed. Furthermore, clinical testing of rectus muscle function with the Janda score in combination with a questionnaire about impairment in daily activities and subjective opinion about discomfort took place. Two months postoperatively, myosonography showed almost identical rectus muscle function at the side of the vessel preparation compared to the contralateral side. Good aesthetic results were also achieved. The absolute muscle thickness at maximum contraction and the difference of muscle thickness between relaxation and contraction were almost identical on both sides. Myosonography is a non-invasive and inexpensive method to test rectus muscle function providing exact and reliable data. Results of this study confirm the hypothesis of lower donor-site morbidity caused by DIEP flaps compared to free or pedicled TRAM flaps. The DIEP flap method for autologous breast reconstruction is highly accepted by patients because of good aesthetic results combined with the lowest possible donor-site morbidity. After more than 180 DIEP flaps with good aesthetic results without abdominal wall hernias this method has become the "gold standard" for autologous breast reconstruction in our department.

Continuous quality management of breast hypertrophy by the German Association of Plastic Surgeons: a preliminary report.

In 1998, the German Association of Plastic Surgeons started a new quality assurance program based on a standardized questionnaire to examine the tracer diagnosis "breast hypertrophy." The authors present the results of a pilot study evaluating 799 patients (mean age, 38 years). Breast reduction was performed as an inpatient procedure in 99% of patients. Mean weight reduction was 1,135 g (range, 140-3,870 g). The inverted-T scar technique was used in 45% of patients, the vertical scar technique in 52% of patients, and other techniques were restricted to 2% of patients. The selection of technique was based on the choice of the surgeon. The overall incidence of complications was 21.5%, and included predominantly wound dehiscence, without marked differences between the two techniques. Less than 10 years after the introduction of a new technique for breast reduction with reduced length of scar, it is now used as often as traditional methods.

[Facial reconstruction with microsurgical tissue transfer]. / Gesichtsrekonstruktionen mit mikrochirurgischem Gewebstransfer.

Although regional flaps are the first choice for face reconstructions, large defects require tissue transfer from other parts of the body. Pedicled musculocutaneous flaps or free flaps are then the choice. Retrospective analysis of our cases of 42 pedicled and 58 free flaps between 1990 and 1999 showed a lower complication rate for free flaps. Moreover, free flaps offer the possibility of choosing from a variety of flap types, including thin fasciocutaneous perforator flaps, bulky musculocutaneous flaps and composite flaps with vascularized bone. Complex reconstructions of the face may require chimera and prefabricated flaps. Our choice then is the scapular region, where the subscapular vessels can carry independent tissue blocks of skin, bone and muscle. We demonstrate the reconstruction of the nose, palate and alveolar crest of the maxilla with such a prefabricated chimera flap.

Planar hexacoordinate carbon: a viable possibility.

The viability of molecules with planar hexacoordinate carbon atoms is demonstrated by density-functional theory (DFT) calculations for CB6(2-), a CB6H2 isomer, and three C3B4 minima. All of these species have six pi electrons and are aromatic. Although other C3B4 isomers are lower in energy, the activation barriers for the rearrangements of the three planar carbon C3B4 minima into more stable isomers are appreciable, and experimental observation should be possible. High-level ab initio calculations confirm the DFT results. The planar hexacoordination in these species does not violate the octet rule because six partial bonds to the central carbons are involved.

The resection of gastrocnemius muscles in aesthetically disturbing calf hypertrophy.

In some patients, oversized calves lead to mental distress and avoidance of certain social activities. They hide their legs in pants and seek medical advice. If the thickness of the subcutaneous fat is normal and cannot be diminished by liposuction, the oversized calves are caused by pure muscle hypertrophy. Using the gastrocnemius for muscle flaps in covering knee defects does not impair the function of the patient's leg; therefore, resection of the total gastrocnemius muscle for aesthetic calf reduction was performed in 15 consecutive patients without any lasting impairment with stability or sports activities. The patient was placed in a prone position, and the muscles were bluntly freed and pulled through two incisions of 5-cm length in the hollow of the knee and above the Achilles tendon. The resected muscles weighed between 410 and 810 g each. In two patients, the sural nerve was stretched or cut during the operation. The consequent numbness of the lateral ankle and sole persisted for 9 and 13 months, respectively. All 15 patients were satisfied with the results; none complained of lack of stability or insecurity in walking; and all became active in sports or changed their dress habits.

[A new method of microvascular anastomosis: clips with a soluble stent]. / Eine neue Methode der mikrovaskulären Anastomose: Clips mit einem auflösbaren Stent.

In this study, we investigated a new method of microvascular anastomosis using titanium clips combined with a soluble intraluminal stent. This method was used to perform anastomoses of the common carotid artery in five NZW rabbits and the abdominal aorta in five rabbits. Five rabbits ears were isolated on their central vascular pedicles. The central ear artery was transected and anastomosed using the stent/clip technique. In five carotid arteries, a conventional sutured anastomosis was performed. All anastomoses were patent at POD 1, 7 and 21. The average time to perform stent/clip anastomoses was significantly (p < 0.001) shorter than conventional sutured anastomoses (2.5 min vs. 9 min). There was no observable side effect from the stent material and no evidence of peripheral emboli. The stent/clip technique is an easy, fast and safe method of microvascular anastomosis.

Assembly of A- and B-type lamins studied in vivo with the baculovirus system.

We have expressed an A-type lamin (Xenopus lamin A), a probable A-type lamin (Drosophila lamin C), two B-type lamins (Xenopus lamin LI, Drosophila lamin Dmo), and two mutants of Xenopus lamin A in Sf9 cells. All proteins were synthesized at high levels resulting in formation of paracrystals with an axial repeat of 18.5-20.0 nm by A-type lamins; in contrast B-type lamins assembled into aggregates with a fibrillar ultrastructure. Of the four wild-type proteins analyzed only lamin Dmo was found in the nuclear compartment of Sf9 cells in association with the lamina whereas the three other lamins assembled into polymers localized in the cytoplasm as well as the nucleoplasm. The Xenopus lamin A mutant lacking the complete carboxy-terminal tail assembled in the cytoplasm into long filament bundles consisting of fibrils of less than 6 nm diameter. In vitro the non-helical amino-terminal head domain of lamins is required for the formation of 'head-to-tail' polymers. A lamin A mutant lacking this domain could be efficiently extracted from Sf9 cells with physiological buffers containing Triton X-100, demonstrating the importance of this domain for lamin assembly in vivo.

The tuberous breast deformity: classification and treatment.

To date there are many descriptive terms for the tuberous breast deformity but there is no widely accepted nomenclature. A retrospective study was undertaken of 68 tuberous breasts and the operative corrections performed. The deformities were classified into four types. Type I (hypoplasia of the lower medial quadrant), type II (hypoplasia of the lower medial and lateral quadrants, sufficient skin in the subareolar region), type III (hypoplasia of the lower medial and lateral quadrants, deficiency of skin in the subareolar region) and type IV (severe breast constriction, minimal breast base). Areolar prolapse, usually regarded as a major symptom, was only found in 30 (44%) deformed breasts. Postoperative review of 51 breasts in 31 patients showed that type I cases treated by reduction mammaplasty of adequately sized breasts or augmentation of hypoplastic breasts had excellent results. These procedures with additional spreading of the breast tissue in type II deformities give good results. Severe cases (types III and IV) treated by augmentation and tissue spreading procedures have an unsatisfactory shape and have a 'second crease' deformity. For types III and IV, additional skin in the subareolar region by tissue expansion or flap procedures is necessary. There is no one method to correct 'the' tuberous breast but there are many procedures which should be used according to the type of deformity. The classification developed could end the confusion in nomenclature.

Effect of cortisone on capsular contracture in double-lumen breast implants: ten years' experience.

Two groups of patients are compared with respect to capsular contracture after insertion of silicone breast prostheses. Six hundred seventy four women received single-lumen gel prostheses and 700 received double-lumen prostheses with cortisone. The addition of 12.5 mg of prednisolone to double-lumen prostheses diminished capsular contracture (Baker II to IV) dramatically; in patients with simple augmentation from 19% to 4.9%, in patients with subcutaneous mastectomy from 54% to 14.9%, and in patients with breast reconstruction from 64% to 24.4%. The use of double-lumen implants has three distinct advantages: (1) There is no bleeding and therefore no contact of the body with the silicone gel. (2) There is no danger of ruptured implants, even if the outer shell shows leakage. (3) If prednisolone is administered, capsular contracture is prevented to a significant degree.

[Siliconoma and rheumatic symptoms--a familial and a questionable complication of silicone implantation]. / Silikonome und rheumatische Symptomatik--eine bekannte und eine fragliche Komplikation von Silikonimplantaten.

Ruptured silicone-gel filled implants after breast augmentation or reconstruction may cause siliconomas. These lesions frequently develop years later and should be surgically excised. Since the use of modern double lumen implants they do not occur anymore. The possibility of a correlation between silicone implants and the incidence of rheumatologic disorders is critically evaluated by case reports from the world literature. Up to now, no statistically significant cumulation of these disorders in women with silicone implants can be observed.

[Progress in the use of tissue expanders for defect closure of the body surface--experimental principles]. / Fortschritte in der Verwendung von Expandern zum Defektverschluss der Körperoberfläche--experimentelle Grundlagen.

The principle of soft tissue expansion has been applied in widespread techniques in the field of plastic and reconstructive surgery since Radovan (1976) presented a method in which silicone expanders were subcutaneously implanted. Many experimental and clinical reports have been published since then, dealing particularly with the histomorphology, vascularization, and pathophysiology of expanded skin as well as with surgical techniques. Our own study intends to identify the effects of tissue expanders on the biomechanical, biochemical, and morphological qualities of expanded skin, and to determine the influence of pharmacological therapy during expansion.

Reduction of capsular formation around silicone breast implants by D-penicillamine in rats.

In a controlled study in 109 female rats we evaluated the effect of soluble D-Penicillamine in doses of 10 mg/ml or 100 mg/ml on capsular formation around semipermeable 2 cm3 mini-prostheses. This was compared with methylprednisolone 1 mg/ml or 10 mg/ml, and a group given saline served as controls. The drugs were injected into the lumen. Capsular wet weight and capsular tensile strength were measured after a period of 40 days. Rats given D-Penicillamine showed a significant, dose-dependent, reduction in wet weight and tensile strength compared with the saline group. There was no significant difference between the groups given D-Penicillamine and those given steroids. Topical treatment with diffused D-Penicillamine can significantly reduce the amount of capsular formation around silicone implants. This drug, which is highly specific for the systemic treatment of fibrotic diseases, should be evaluated further to use in reducing capsular formation.

Efficacy, tolerability and pharmacokinetics of teicoplanin in patients undergoing breast surgery.

In a prospective open trial, 21 female patients undergoing breast surgery received a single intravenous bolus injection of teicoplanin, 400 mg, 30 minutes before the operation. During surgery, (1 hour after teicoplanin administration), samples of breast and fat tissue and serum were collected; 24 hours and 48 hours after dosing, samples of wound exudate were taken. Teicoplanin concentrations were determined using the RASA method. Teicoplanin levels were lowest in fat tissue. Teicoplanin levels in wound exudate were found to be satisfactorily high. However, teicoplanin levels in fat and breast tissue and in wound exudate exceeded the MIC90 for various staphylococcus strains, such as S. aureus and S. epidermidis. No local or systemic adverse reactions were observed during the trial. Teicoplanin was well tolerated. Preliminary results from this trial, therefore, indicate that teicoplanin may be a suitable antibiotic for use in the prophylaxis of infection in breast surgery.