[Clinical experiences using the Versajet system in burns: indications and applications]. / Klinische Erfahrungen mit dem Versajet-System in der Verbrennungsbehandlung - Indikationen und Anwendungen.

Early debridement and early skin grafting are the "Gold standard" in the surgical treatment of burns. There are different debridement methods available. Concerning the treatment of burns, surgical-sharp debridement, laser ablation and hydrosurgery system are used. While in full thickness burns the sharp debridement is advisable, the Versajet shows its benefits in the treatment of partial thickness burns. Especially for debridement of difficult to treat areas - face, neck, lips, fingers, interdigital spaces, convex and concave areas the Versajet System shows its benefits. With the Versajet System, tissue excision is precise; moreover it helps to avoid the damage of viable tissue and its vascular supply.

Extended reverse dorsal metacarpal artery flap: clinical experience and donor site morbidity.

Extended reverse dorsal metacarpal artery (RDMA) flaps use the skin from the dorsum of the hand to cover defects of the long fingers up to the distal phalanx. The authors present a series of 12 patients who underwent closure of defects of the long fingers with these flaps. As relevant literature is scarce, special emphasis was put on donor site morbidity. Active and passive total range of motion (TRM) and pinch grip strength of the finger neighbouring the reconstructed one were evaluated and compared to the corresponding finger of the contralateral hand. The donor site was furthermore evaluated for cosmetic appearance and pain. There was no statistically significant difference for active and passive TRM. The difference for pinch grip reached statistical significance (p=0.04). Subjective evaluation of pain and cosmetic appearance by the patients revealed a mean pain value of 1.25 on a visual analogue scale (0=no pain, 10=maximal imaginable pain) and a mean estimation of cosmetic appearance of 8 (visual analogue scale, 0=worst cosmetic result, 10=best cosmetic result). In conclusion, compared to other flaps, the extended RDMA flap is a fast, secure and single-stage procedure for defect coverage on the long fingers with low donor site morbidity.

Surgical management of extensive gnathophyma.

Rhinophyma is an uncommon disease of the nose characterized by irregular skin thickening and nodular deformation. The extensive growth causing 'whisky nose' is due to hyperplasia of the sebaceous glands and the surrounding connective tissue. Other facial regions may concomitantly be affected. We present a case of extensive gnathophyma accompanying minor lesions of the nose. Surgical treatment led to an excellent cosmetic result.

[Severing of the tibial nerve with stripping of the lesser saphenous vein--a rare complication of surgery for varicosity]. / Durchtrennung des Nervus tibialis beim Stripping der Vena saphena parva. Seltene Komplikation nach Varizenchirurgie.

Neurological complications are rare with surgery for varicosities and usually involve the saphenous, peroneal, or sural nerve. When the saphenous vein is stripped in the popliteal region, there is danger of tibial nerve injury due to the topographic situation. We report a serious complication involving an iatrogenic extended lesion of the tibial nerve in the popliteal fossa that occurred in the course of a crossectomy and exeresis of the lesser saphenous vein. The complicated microsurgical reconstruction of this complex nerve injury is described, and the causes and errors leading to it are analyzed.

Donor site morbidity in cross-finger flaps.

As relevant literature is scarce, this study was undertaken to assess the donor site morbidity of cross-finger flaps. It included 23 patients who had undergone reconstruction of a finger defect with a cross-finger flap. Any additional trauma to the donor finger was an exclusion criterion. Split thickness skin grafts were employed for donor site closure in 13 cases, full thickness skin grafts were used in 10 cases. Follow-up time averaged 83 months. Active and passive total range of motion of the donor finger and maximal pinch grip strength in kilopascals were measured. Both parameters were compared to the corresponding finger of the other hand. The donor site scar was evaluated for instability and pain in the donor finger was determined subjectively with a visual analogue scale. Cold intolerance and the cosmetic appearance of the donor site were also assessed. Active total range of motion of the donor fingers averaged 156 degrees . Average active total range of motion of the contralateral control fingers was 173.6 degrees . There was a significant difference between the donor fingers and the control fingers (p = 0.03) but not between split thickness and full thickness grafted donor sites (p = 0.91). Grip strength was significantly impaired in the donor fingers (p = 0.03), but there was no significant difference between split thickness and full thickness grafted donor sites. Subjective cosmetic evaluation by the patients revealed significantly better results for full thickness grafted donor sites. Donor finger pain averaged 2.4 with a range of 0-8. Five of the 13 patients with split thickness grafted donor sites and two of the 10 patients with full thickness grafted donor sites mentioned cold intolerance. In conclusion, the cross-finger flap is a secure and valuable option. There is, however, significant donor site morbidity. Our results suggest that alternative solutions should also be considered and if a cross-finger flap is employed, donor sites should be closed with full thickness grafts.

[The impact of the VAC-treatment for locally advanced malignancy of the scalp]. / Stellenwert der V.A.C.(R)-Therapie beim fortgeschrittenen Kopfhautmalignom.

Locally advanced cutaneous malignancy of the scalp is a disease that requires an aggressive approach to resection and reconstruction. In cases where the pericranium is intact a split-thickness skin graft is a simple treatment, since direct closure often fails because due to the lack of elasticity of the scalp. If there is a loss of periosteum or a skull defect local or free flaps are necessary for sufficient coverage. Increasing geriatric and polymorbid patients with impaired wound healing require surgical treatment, considering pros and cons for general anaesthesia. A simple method of both, combining radicality of tumor resection with outer table bone and skin grafting as a two stage procedure, while minimizing perioperative risk using local anaesthesia and analgo-sedation, using the vacuum assisted closure device, is presented.

Defects on the dorsum of the hand--the posterior interosseous flap and its alternatives.

There are conditions that preclude the use of the posterior interosseous flap for reconstruction of the dorsum of the hand. Based on a series of 34 cases, these conditions are outlined and alternative solutions discussed. The posterior interosseous flap was employed for closure in 30 cases. In four cases different methods were used due to severe trauma to the wrist and distal forearm with potential impairment of the pedicle, a complex defect requiring a composite flap and an anatomical variation. Thin free flaps were employed alternatively. All flaps survived but there was marginal flap necrosis in two posterior interosseous flaps. The posterior interosseous flap proved its usefulness and reliability in reconstruction of the hand in this series. In four cases, free lateral arm and temporoparietal fascial flaps were employed. Flaps based on the main vessels of the forearm were not used due to their significant donor site morbidity.

Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy.

OBJECTIVE: Besides other factors, the choice of reconstructive method for full thickness thoracic wall defects depends on the morbidity of preceding surgical procedures. The pedicled latissimus dorsi flap is a reliable and safe option for reconstruction of the thorax. A posterolateral thoracotomy, however, results in division of the muscle. Both parts of the muscle can be employed to close full thickness defects of the chest wall. The proximal part can be pedicled on the thoracodorsal vessels or the serratus branch; the distal part can be pedicled on paravertebral or intercostal perforators. This retrospective study was undertaken to evaluate the reconstructive potential of both parts of the latissimus dorsi in thoracic wall reconstruction after posterolateral thoracotomy. METHODS: Between 1987 and 1999, 36 consecutive patients underwent reconstruction of full-thickness thoracic wall defects with latissimus dorsi-flaps after posterolateral thoracotomies. The defects resulted from infection and open window thoracostomy (n=31), trauma (n=3) and resection of tumours (n=2). The patients' average age was 57 years (range 22-76 years). Twenty-five patients were male, 11 were female. In 31 cases the split latissimus dorsi alone was employed; in five cases additional flaps had to be used due to the size of the defects, additional intrathoracic problems or neighbouring defects. RESULTS: In 34 cases defect closure could be achieved without major complications. Empyema recurred in the pleural cavity in one case and one patient died of septicaemia. The 15 patients who had required a respirator in the preoperative phase could be extubated 4.8 days (average) after thoracic wall reconstruction. Postoperative hospital stay averaged 16 days. CONCLUSIONS: Different methods are available for reconstruction of full thickness defects of the thoracic wall. After posterolateral thoracotomy in the surgical treatment of empyema, oncologic surgery and traumatology, the latissimus dorsi muscle still retains some reconstructive potential. Advantages are low additional donor site morbidity and anatomical reliability. As it is located near the site of the defect, there is no need for additional surgical sites or intraoperative repositioning. In our service, the split latissimus dorsi muscle flap has proven to be a valuable and reliable option in thoracic wall reconstruction.

Hand surgery and the internet: results of a worldwide survey.

The opportunities offered by the Internet are employed increasingly in medicine. To obtain data on the extent to which the Internet is used by hand surgeons, survey forms were sent to 1043 participants of the Congress of the IFSSH in Vancouver in 1998. Ninety-four per cent of the respondents use the Internet. Most of the participants use the World Wide Web for literature searches, information on events and to read scientific articles. E-mail is used for general and scientific communication with colleagues and also for transmission of patient-related data. Perceived apprehensions include secure transmission of sensitive data, slow data transmission, and the lack of structure and of an authority to control the contents of the Internet. Virtual congresses and a newsgroup on hand surgery seem to be worthwhile future goals. Some problems pointed out in this survey have already been solved, at least partially, and possible solutions for the rest are discussed.

[Presentation of plastic surgery on the internet: experiences with the home page of a department]. / Präsentation der Plastischen Chirurgie im Internet: Erfahrungen mit der Homepage einer Abteilung.

Plastic surgeons are increasingly taking advantage of information opportunities offered by the internet. Between October 1998 and March 1999, 87 individuals returned by e-mail a feed-back form included in the homepage of the Division of Plastic Surgery, Department of Surgery, Karl-Franzens University School of Medicine, Graz, Austria. Most of the responses originated from Austria or other European countries; 10% were from overseas. The most frequent reason for visiting our homepage was to gain information on scientific activities in our department (43 visitors), followed by interest in plastic surgical procedures on the part of patients or referring physicians (35 visitors). Other reasons were interest in educational matters, positions, and general interest in plastic surgery. Our results show that physicians, medical students, and laypersons are increasingly inclined to seek information on plastic surgery via the internet. This in turn should encourage plastic surgery services to present themselves in the World Wide Web.

Salvage of an ischaemic lower limb and a free flap with an arterial Y-graft. Case report.

A defect of the lower limb was treated with a scapular free flap. An end-to-side anastomosis was made to the posterior tibial artery, which was the single perfusing artery of the foot. When it thrombosed, the problem was solved successfully with an arterial Y-graft.

Wrap-around arterialized venous flap for salvage of an avulsed finger.

The case of an avulsed finger with extensive soft-tissue trauma is presented. The digit was salvaged using an arterialized wrap-around flow-through venous flap from the forearm.

Expanded polytetrafluoroethylene threads for lip augmentation induce foreign body granulomatous reaction.

Especially in cases of facial aesthetic surgery, the demands of the patients are high. The formation of a visible and painful nodule will cause not only discomfort but also dissatisfaction. When alloplastic materials are used for facial and lip augmentation, the possibility of migration, allergic reaction, and formation of a foreign body granuloma is always present. Although e-PTFE is the most bioinert alloplastic material available, the authors could show the formation of a foreign body granuloma. When using e-PTFE threads for facial augmentation, the surgeon should keep in mind and inform the patients that the threads can induce a foreign body granulomatous reaction.

[The lower trapezius muscle island flap. Anatomic principles and clinical relevance]. / Der untere M. trapezius-Insellappen. Anatomische Grundlagen und klinische Relevanz.

Up to now, there is no uniform anatomic description neither of the branches of the subclavian artery nor of the pedicle of the lower myocutaneous trapezius flap. A dissection study was carried out on 140 necks in 70 cadavers. Variations of the subclavian artery and its branches, vessel diameter at different levels, the course of the pedicle under the levator scapulae muscle, the arc of rotation of the island flap, and the variations of the segmental intercostal branches to the lower part of the trapezius muscle were examined. Results of this study enable us to suggest a new nomenclature for the branches of the subclavian artery, a proper pedicle definition, and a technique for safe flap elevation. The lower trapezius island flap is a thin and pliable myocutaneous flap with a constant pedicle which ensures safe flap elevation. This flap has the potential for a wider acceptance due to minor donor site morbidity, large arc of rotation, and an ample range of clinical applications in the head and neck area as an island flap as well as a free flap.

[Reconstruction of nose defects by combined multiple flap-plasties and stabilization with cartilage transplants]. / Die Rekonstruktionen von Nasendefekten durch Kombination mehrerer Lappenplastiken und Stabilisierung mit Knorpeltransplantaten.

In the reconstruction of nasal defects, the method of choice involves flaps from the immediate surroundings (nose, cheek, forehead), because of their superior skin colour and texture match. In defects involving all layers of the nose, the inner lining and the nasal skeleton must also be reconstructed. These procedures are often performed in several steps, with incision and elevation of flaps, implantation of cartilage and skin-grafting of the donor site (prefabricating). By using one flap to replace the missing skin and a second flap for inner lining, a stabilizing cartilage graft can be inserted primarily. Using this "sandwich-technique", subtotal nose reconstructions can be performed in a single stage as well. Between 1986 and 1996, 23 patients underwent nasal reconstructions using local flaps. Our reconstructive concept is demonstrated by means of several clinical cases.

[The posterior interosseous flap--review and personal experience]. / Der Interossea posterior-Lappen--Ubersichtsarbeit und eigene Erfahrungen.

The posterior interosseous flap was first introduced by Zancolli and Angrigiani (1985) and short time later by Penteado and Masquelet (1986). The flap is used for soft tissue reconstruction in the hand but has not gained wide acceptance due to tedious pedicle dissection and venous problems. In 1993, Angrigiani et al. published a simplified modification in the elevation of the flap. They included a constant fasciocutaneous perforating vessel in the flap to enhance the viability. We applied the modified elevation technique in twelve patients. Our experience, indications, and complications will be discussed. In contrast to Angrigiani's statement, our flaps still show a temporary mild to moderate venous congestion similar to the flaps raised in the original technique.

[Plastic surgery in the tension field of surgery]. / Die plastische Chirurgie im Spannungsfeld der Chirurgie.

The 70th birthday of Professor Kraft-Kinz, who holds the Chair of Surgery at the University of Graz, is a suitable occasion to review the development of several surgical disciplines into independent specialist fields. Plastic surgery is one such monospecialty which has been in existence as a separate entity for the past 7 years. Important personalities and events in surgery are traced back to the 18th century and described from an Austrian perspective, with particular reference to the University of Graz. The process of achieving independence since 1988, in conjunction with the application of new techniques, in particular microsurgery, has led to enormous expansion of this specialty, both regarding quantity and quality of practice. Hence, the initial divergence has changed to an overlapping convergence of the specialties and the current interdisciplinary cooperation is of great benefit to all the individual subspecialist fields. This is illustrated by means of case reports representing two distinct areas of exemplary interdisciplinary interaction in surgical management.

Surgical treatment of dermatofibrosarcoma protuberans. A retrospective study of 20 cases with review of literature.

The clinicopathological features and results of surgical treatment of 20 patients with dermatofibrosarcoma protuberans (DFSP) were reviewed. All patients have been observed until the present time or death. The primary treatment usually consisted of marginal, wide or radical excision. Re-excision because of recurrence was performed in six of the 20 patients who were treated primarily only by marginal excision. Following re-excision two patients have remained disease-free until the present, the other four of these six patients had a second recurrence. Three of these four patients with a second relapse were successfully treated by excision. Although six patients out of 20 had 13 recurrences at the site of primary therapy, no patient developed lymph node or distant metastases. To date, none of the remaining 14 patients has had recurrence, all having been treated by excision of from 1 to 5 cm, the mean follow-up time was 8.75 years. Based on our data, the high recurrence rate after marginal surgical treatment implies an initial radical resection.