Circulatory changes after prolonged ischemia in the epigastric flap.

The circulation system seems to have early encounters with pathophysiologic processes during ischemia and reperfusion, such as overproduction of oxygen radicals, nitric oxide depletion, and leukocyte plugging. The aim of this study was to determine the superficial perfusion and vessel distribution of the epigastric flap with a laser Doppler Imaging (LDI) system during ischemia/reperfusion, and to observe the clinical outcomes 7 days after reperfusion in a separate set of animals. An epigastric flap from male Sprague-Dawley rats (320 to 380 g) was used to assess perfusion in sham animals (n=6) or in 12 hr-ischemia animals (12 hr of ischemia and 3 hr of reperfusion, n = 10) with the LDI system. In a separate experiment, flap size, flap failure index, and histologic sections of the flap from sham animals (n=6) and 12-hr ischemia animals (n=6) were evaluated 7 days after reperfusion. Evaluation of the vessel distribution demonstrated a diffuse picture of flap perfusion after clamp release. Moreover, in the distal portion of the flap, circulation stopped immediately, resulting in a significantly decreased perfusion in the 12-hr ischemia animals during reperfusion, when compared with pre-surgical values (100 percent) or sham animals (77 +/- 26.5 vs. 108 +/- 9.6 percent PU). On day 7, the flaps of animals after ischemia and reperfusion showed significant shrinkage, an increase in flap failure index, as well as necrosis, edema, and leukocyte infiltration. Based on the findings, the authors propose that, after prolonged ischemia, the circulation becomes diffuse, and "no-reflow" occurs in the distal portions of the myocutaneous flap during reperfusion. Perfused areas, assessed with the LDI early during reperfusion, might still become necrotic after several days. In the authors' flap model, edema formation and leukocyte infiltration seem to be related more to ischemia reperfusion damage than to thrombus formation.

[Treatment of chronic osteomyelitis of the tarsal bones with free muscle flaps]. / Die Behandlung der chronischen Osteomyelitis der Fusswurzelknochen mittels freier Muskellappen.

Although the value of free muscle flaps in the treatment of chronic osteomyelitis of the lower leg is well documented, only few reports deal with the use of free muscle flaps for treatment of osteomyelitis of the tarsal bones. Four patients with chronic osteomyelitis of the tarsal bones (in three patients several bones were involved) were treated using the following regimen: radical debridement, coverage with a free muscle flap, and systemic antibiotic therapy. In two patients, infection recurred following primary transplantation of the muscle flap. In one of these patients, recurrence was controlled by repeating the same regimen. In the other patient, debridement was repeated and the calcaneus was transposed to obliterate the resultant bone cavity. At follow-up (mean 19 months following last surgical procedure), all four patients showed no evidence of infection and were fully weight-bearing. Chronic osteomyelitis of tarsal bones can be successfully treated by radical debridement and coverage with muscle flaps, even in advanced stages of the disease. The clinical and anatomical peculiarities of this region, however, have to be taken into consideration.

Evaluation of total vs. regional blood perfusion with a laser Doppler imaging system in the rat epigastric flap.

Monitoring systems to measure flap survival are either invasive, touch the surface of the tissue, or have problems in reproducibility. The authors sought to determine the efficacy of a laser Doppler imaging (LDI) system to measure perfusion in a myocutaneous flap, by producing a two-dimensional picture of the flap without touching the surface. They compared total flap perfusion with perfusion in selected areas of interest after flap surgery. The perfusion in the left groin of Sprague-Dawley rats was measured before and after surface rubbing, skin injury, and during different lighting conditions. The perfusion of the epigastric flap before and over a period of 60 min after elevation was measured, and values were compared to pre-surgical values and to sham-operated animals. They determined the differences between single and running-suture techniques after flap surgery, as well as between venous and/or arterial occlusion. Surface rubbing, skin injury, and light influenced the LDI image. After flap elevation, total flap perfusion remained stable, while the distal area (area 8, n = 7) of the flap showed a statistically significant decrease in perfusion (71 +/- 5.9 vs. 92 +/- 9.5 percent perfusion units--PU; p < .05). The proximal areas (1 to 3, n = 7) of the flap had a higher perfusion at 60 min after flap surgery, compared with sham-operated (n = 8) animals (118 +/- 12.5 vs. 97 +/- 10.4 percent PU; p < .05). The running-suture technique was followed by decreased perfusion on the peripheral side of the flap, compared with the single-suture technique (73.7 +/- 9.2 vs. 99.2 +/- 4.9 percent PU; n = 2). The LDI was able to visualize venous and/or arterial occlusion after flap surgery. Under standardized circumstances (light, temperature), the LDI was efficient in measuring regional flap circulation experimentally. While total flap perfusion after flap surgery remained stable, perfusion in the distal flap decreased significantly.

[A comparison of long-term outcome of 6 techniques of breast reduction]. / Ein Vergleich der Langzeitergebnisse von sechs Techniken der Mammareduktionsplastik.

In a retrospective study we examined 192 patients who underwent breast reduction between 1973 and 1993 to compare the long-term results of six various reduction mammaplasty techniques. We investigated patient's satisfaction, the relief of preoperative symptoms as well as the possibility of lactation. The sensitivity of the areola was measured with Semmes-Weinstein monofilaments and the breast contour, the scar formation, and the complication rate were evaluated. 89% of our patients were very satisfied with the cosmetic result. Breast-feeding was possible after all techniques except for free-nipple grafting. The sensitivity of the areola was found to be more decreased after using a superior pedicle technique. Breast ptosis was obtained in 30% of our patients and correlated significantly with postoperative weight loss. Breast ptosis was less frequent after using an inferior pedicle technique. Length and width of the scar, as well as the complication rate correlated with the resection weight.

[Soft tissue tumors with difficult to distinguish boundaries. From myxoma to myxofibrosarcoma: a case report]. / Weichteiltumoren mit schwer beurteilbarer Dignität. Vom Myxom zum Myxofibrosarkom: Ein Fallbericht.

Myxofibrosarcoma is a slow-growing subcutaneous tumor found in the older patient. Because of its deceptive macroscopic and histologic appearance, it is often misinterpreted as a benign lesion. We report a case of this tumor in a young woman recurring five times before the final diagnosis was made. Since recurrence may lead to tumor progression and increases the risk of metastasis, accurate diagnosis and radical removal of the lesion are extremely important. Eight benign and malignant myxoid tumors that have to be considered as differential diagnosis are reviewed.

[Interdisciplinary status of plastic, esthetic and reconstructive surgery in Austria]. / Interdisziplinäre Stellung der Plastischen, Asthetischen und Wiederherstellungschirurgie in Osterreich.

To evaluate the actual status of interdisciplinary treatment involving plastic surgery in Austria in 1993 and 1994, standardised questionnaires were sent to all Departments of Plastic Surgery and to 129--mainly surgically orientated--medical departments in Vienna. The survey revealed that more than 50 percent of interdisciplinary co-operation took place with the departments of traumatology, general surgery and dermatology. The demand for co-operation with plastic surgeons was especially felt in tumor surgery, peripheral nerve surgery and hand surgery. An additional demand for co-operation represented larger soft tissue defects and congenital anomalies.

Sliding door technique for the repair of midline incisional hernias.

We describe a technique that enables the autologous repair of large midline incisional hernias by restoring the functional musculoaponeurotic support of the abdominal wall. Unlike other methods of hernia repair, the essential step of the sliding door technique is the complete release of the rectus abdominis muscles from the anterior and posterior layers of their sheaths. The released muscles are thus overlapped and sutured together without tension. Another step of the technique is the release of both rectus sheaths by incising the aponeuroses of the external oblique muscles. We report on the use of this technique in 10 patients with midline incisional hernias (mean size of the abdominal musculofascial defect 14 x 11 cm). The patients were examined 14 months to 5.5 years after hernia repair. Two postoperative complications occurred: one marginal skin necrosis and one subcutaneous seroma. Recurrences were not observed. Ultrasound examination showed that the rectus muscles maintained their overlapped position postoperatively. Clinical muscle testing indicated that the strength of the released rectus muscles provides functional support to the reconstructed anterior abdominal wall.

The lumbrical muscle flap: anatomic study and clinical application.

This article describes the anatomy and clinical application of the lumbrical muscle flap. Anatomic and radiologic studies were performed in 20 fresh human cadaver hands injected with latex-lead-oxide solution. Only the 2 radial lumbrical muscles were found suitable for flap transposition. The vascular supply of the first and second lumbrical muscles is from branches originating in the superficial palmar arch and from the common palmar digital artery, respectively. The dominant branches invariably enter the muscle bellies at the junction of their proximal and middle thirds. Pedicled on these vessels, the lumbrical muscles can be transposed to reach the entire palm, up to the wrist flexion crease. The clinical use of the first and second lumbrical muscle flaps in 2 patients demonstrated the value of these flaps for coverage of the median nerve and its palmar branches.

The vertically based deep fascia turnover flap of the leg: anatomic studies and clinical applications.

Although fasciocutaneous turnover flaps are a simple and fast method for covering soft-tissue defects of the lower leg, many reconstructive surgeons have their doubts about them. They revolve around the lack of criteria for safely designing these random-pattern flaps and around the risk of donor site problems. A vertically based deep fascia turnover flap with a paratibial or parafibular pedicle is presented. Anatomic studies of 36 injected lower limbs showed the deep fascia to be supplied by a mean of 61 vessels. As musculofascial, septofascial, and periosteofascial branches, these contribute to a richly anastomosing vascular network within the deep fascia. Along the deep transverse septum at the medial tibial border, the anterior and posterior peroneal septa, and between the anterior tibial and extensor muscles, the fascia is supplied by segmental vessels in a clearly defined arrangement. Pedicled on these vessels, the deep fascia is a useful candidate tissue for transversely oriented turnover flaps. These are particularly well suited for covering pretibial or prefibular soft-tissue defects. Unlike adipofascial turnover flaps, the transversely oriented deep fascia turnover flap keeps its subcutaneous layer with its intact vascular plexus so that the overlying skin is adequately perfused even in patients with sizable flaps or an extremely thin skin. Clinical experience with the vertically based paratibial or parafibular deep fascia turnover flap in six patients confirmed its usefulness for covering small to medium-sized soft tissue defects of the lower leg.

The external oblique muscle free flap.

To date, the external oblique muscle has been considered to have a purely segmental vascular supply and therefore has been used surgically only as a pedicled flap. To better define the vascular anatomy and nerve supply of the muscle, we performed arterial injection studies and dissected the nerves that entered the muscle in 35 human cadavers. We found that in addition to the segmental arteries, one or two large branches of the deep circumflex iliac artery contributed significantly to the blood supply of the external oblique muscle in 33 of the 35 cadavers. We also found that the lateral cutaneous branches of the intercostal nerves entered and supplied the muscle near its origin from the rib in a strictly segmental pattern. These anatomic findings enabled us to transplant the external oblique muscle successfully as a free flap based on the deep circumflex iliac vessels in six patients. The muscle flap is thin, pliable, and can be combined with an iliac bone or an abdominal skin transplant. Its vascular pedicle is long (mean 12 cm) and of adequate diameter for microvascular repair. The donor scar of the flap is inconspicuously situated along the inguinal ligament and the iliac crest. Finally, since the muscle has a multiple nerve supply, it has the potential to provide several functional units at the recipient site when transplanted as a functional free flap.

Scarpa's fascia flap: anatomic studies and clinical application.

Fascia and fascia-subcutaneous flaps are thin, pliable, and well-vascularized tissue with aesthetic and functional advantages, particularly for the extremities and in the head and neck region. Although various donor sites have been used for these flaps, there is an occurrence of unsatisfactory donor-site defects that are often complicated by conspicuous, widened scars or alopecia. In addition, flap elevation is sometimes prolonged because of the demanding operative procedures as well as the impossibility of a two-team approach. In this anatomic and clinical study we present a new fascial flap that results in a minimal donor-site defect and a short and easy operative procedure. Scarpa's fascia, which can be used as both a free and a pedicled flap, is a well-defined single membranous sheet within the subcutaneous tissue layer at the lower abdominal wall. We studied its distribution, structure, and vascular supply in 27 fresh cadaver specimens. In addition, computed tomographic (CT) and ultrasound studies were performed in 13 healthy volunteers and in 3 cadavers before and after injection of diluted contrast material in the superficial epigastric artery. Finally, histologic examinations were done with hematoxylin and eosin or with reticulum and elastin. Our studies showed that Scarpa's fascia provides a thin, pliable, and well-vascularized flap pedicled on the superficial epigastric artery. After successful application of the Scarpa's fascia flap as a free flap in 3 patients and as a pedicled option in 1 patient, we can recommend this flap as a valuable tool for the reconstructive surgeon.

The combined use of a pedicled Scarpa's fascia flap and a groin flap for simultaneous coverage of dorsal and palmar finger defects.

A case is reported in which the dorsal and palmar aspects of the fingers in a severely crushed hand were covered by combining a pedicled Scarpa's fascia flap and a groin flap. Secondary heterotopic finger transposition was additionally performed to restore satisfactory hand function. An acceptable result was obtained.

Endoscopic carpal tunnel release using a single-portal system.

In this prospective clinical study, we present our experience with a new single portal carpal tunnel release kit. The safety and efficacy of this new device was assessed and compared with a consecutive control group treated with conventional open carpal tunnel release. 126 patients were enrolled in this study, 64 of them were treated endoscopically (group 1) and 62 by open release of the carpal ligament (group 2). Follow-ups were conducted at 1, 3, 6, 12 and 24 weeks postoperatively. A serious intraoperative complication in group 1 was a transection injury of a branch of the superficial palmar arch. No intraoperative complications were noted in group 2. Postoperative evaluation revealed significantly less scar tenderness in group 1 at 1 week (P < 0.001), 3 weeks (P < 0.001) and 24 weeks (P < 0.05) compared to group 2. Functional status at 1 week was significantly (P < 0.05) better in group 1 than in group 2 but not at later times. Grip strength at 1 week (P < 0.001), 3 weeks (P < 0.05) and 12 weeks (P < 0.05), and pinch strength at 3 weeks (P < 0.001) were significantly higher in group 1. No significant differences between the groups were obtained regarding postoperative symptom severity. The new device provides a reliable tool for single portal carpal tunnel release, although the risk of inadvertent damage to the neurovascular structures always remains a possibility with the endoscopic carpal tunnel technique.

The extended gracilis muscle flap for reconstruction of the lower leg.

The width of the gracilis muscle was measured before and after removal of the epimysium in 10 fresh cadavers. The average extent of muscle widening achieved by epimysium removal was over 100% (mean 112.6%; standard deviation 11.9%). This extended muscle flap enabled us to cover successfully even large soft tissue defects measuring up to 300 cm2. In 27 consecutive patients, soft tissue defects of the lower leg with exposed bone have been repaired by free tissue transfer of a gracilis muscle flap, covered with split skin grafts. The advantages of the gracilis muscle flap were the low donor site morbidity with almost no recognisable functional loss, the easy surgical access, the thin and flat shape of the muscle, and its adequate size after excision of the epimysium. Reconstruction with a gracilis muscle flap resulted in an inconspicuous, stable, and flat contour of the lower leg. The entire length of the vascular pedicle of the gracilis muscle was easily harvested in our patients by routinely dissecting the pedicle on both sides of the adductor longus muscle.

Donor-site morbidity of the gracilis flap.

To determine whether there is a specific donor-site morbidity inherent in the elevation of the gracilis flap, we retrospectively examined 42 patients who underwent elevation of their gracilis muscles. We found, on dynamometric measurement, that the adduction strength of the hip joint was decreased by 11 percent when the gracilis muscle was elevated. This decrease in strength was not noticed by the patients. We also found an area of hypesthesia corresponding to the cutaneous territory of the obturator nerve in 40.5 percent of the patients. In addition, many patients were dissatisfied with the aesthetic appearance of the donor site, and a contour deformity of the thigh was present when a myocutaneous flap was elevated. Therefore, we conclude that the gracilis flap has a low but definite rate of donor-site morbidity. The advantages of the flap outweigh by far, however, the sequelae at the donor site.

Long term results of inflatable mammary implants.

In this retrospective study, the long term results of 167 inflatable mammary implants in 77 patients who underwent either breast reconstruction or augmentation between 1972 and 1990 were evaluated. All inflatable implants were manufactured by Heyer-Schulte/Mentor company, and were equipped with a posterior leaf valve (style 1800). The mean follow-up was 9 years (SD = 4.3). Complete deflation was found in 23.9% of the implants (22.2% deflation rate from 1972 to 1984 and 25.5% from 1985 to 1992). The incidence of this complication was significantly higher in patients who underwent previous open (p = 0.012) or closed (p = 0.038) capsulotomy. Severe contracture of the implant fibrous capsule (BAC 3 and 4) was found in 37.6% of the patients. Its incidence increased significantly when the postoperative blood loss (assessed by the volume of blood collected by suction drainage) exceeded 250 cc (p = 0.025). Neither the site of the implant (submuscular/subglandular) nor the indication for surgery (reconstruction/augmentation) influenced the rate of severe capsular contracture significantly in this retrospective study.

Bridging of peripheral nerve defects with exogenous laminin-fibrin matrix in silicone tubes in a rat model.

Fibrin matrix (FM) is a biological substance involved in the comprehensive wound healing process, and has been used in local applications as a carrier of nerve growth factor (NGF) to achieve an effective local neurotrophic concentration by slow release of the factor. In the present experiment, an exogenous fibrin matrix enriched with laminin (LM) and tubulized by a silicone conduit was used to improve the bridging effect of a peripheral nerve defect in a rat model. A 10 mm nerve defect was bridged with a 14 mm silicone conduit which was prefilled either with 25 µl fibrin matrix enriched without or with laminin (0.1 µg/ml), serving as groups FM and LM-FM, or with the same amount of saline solution for control (CTR group) (n = 10). After 12 weeks, the nerve conduction velocity and the distal latency were calculated from the electromyographic recordings. In addition, morphological semi-quantitative evaluations in longitudinal and transversal sections were carried out by immuno-histochemical staining with a monoclonal antibody against neurofilament. An improvement in nerve conduction velocity and distal latency, and a better orientation of the regenerated nerve fibers in the gap area were achieved in the LM-FM group than in the CTR and FM groups. These results indicate that the bridging of peripheral nerve defect in a rat model may be improved by the use of exogenous fibrin matrix enriched with laminin (as a filling material) in a silicone conduit.

A noninvasive functional evaluation following peripheral nerve repair with electromyography in a rat model.

A new bipolar surface electrode array was designed and constructed for a noninvasive "closed" functional evaluation with electromyography following sciatic nerve transection in a rat model. This "closed" method was compared with a conventional one-shot "open" measurement. Nerve conduction velocity and distal latency were calculated. Data obtained from the recordings from different animals as well as from the same animal at different points in time yielded excellent reproducibilities. There is no difference in the mean values whether nerve conduction velocity and distal latency are obtained by "closed" or "open" measurements. Correlation was significant (p < 0.01; rNCV = 0.77, rDL = 0.63) between these two methods. The results lead to the conclusion that the noninvasive functional evaluation with the parameters of nerve conduction velocity and distal latency introduced in the present study could be employed as a reliable method for serial functional evaluations following nerve transection in a long-term study in a rat model.