[Individual perforator flaps of the upper extremity]. / Individuelle Perforans-Lappenplastiken an der oberen Extremität.

Perforator flaps allow an individual flap design on the basis of a preoperative ultrasound examination. Aim of the present study is a preliminary evaluation of results and technical pitfalls of this new technique in the use for flap coverage on the dorsum of the hand and the elbow region. Since 1999, seven individually designed pedicled perforator flaps were prepared on the upper extremity. In four cases, defects on the dorsum of the hand and in a further three defects in the elbow region were treated. In the latter cases the flaps were harvested in a mainly epifascial plane, without dissecting the perforating vessels down to their origin. Five flaps were based on perforating vessels of the interosseous arteries, a further two from the lateral collateral humeral artery. Three out of four pedicled perforator flaps used on the dorsum of the hand healed completely. One flap was lost because of venous insufficiency due to the lack of wrist immobilisation. In the elbow region, two out of three defects were successfully covered with an individual perforator flap. One flap was lost due to venous insufficiency, a further needed an additional split-skin graft with a partial flap loss. The main advantage of the presented technique remains the possibility of individual flap design. However, the donor-site defect is almost negligible since in most cases a primary closure of the donor site was possible. The main arteries remained untouched leaving the blood supply to the hand unchanged. Nevertheless, the mainly epifascial harvest of the perforating vessels in the elbow region has the disadvantage of a short pedicle together with a high degree of torsion which leads to an increased risk of flap loss due to venous insufficiency.

[The superior gluteal artery perforator flap (S-GAP-Flap)]. / Der "Superior Gluteal Artery Perforator Flap" (S-GAP-Flap).

Superior gluteal artery perforator flap for breast reconstruction with autologous tissue (S-GAP-flap): With the introduction of perforator flaps for breast reconstruction with autologous tissue the gluteal region became again investigated as a possible donor site. With the S-GAP-flap breast reconstruction from the gluteal region is possible utilising skin and fat without muscle sacrifice. 52 S-GAP-flaps for autologous breast reconstruction with a flap loss rate of 7.7 % were performed at the Department of Plastic and Hand surgery, Behandlungszentrum Vogtareuth, Germany from 1997 till 2002. Although there is an obvious learning curve also with this free tissue transfer, the S-GAP-flap is a reliable alternative in autologous breast reconstruction, when tissue from the lower abdomen is not available.

Clinical classification of free-flap perfusion complications.

Free-tissue transfer is a standard procedure in hand and other plastic and reconstructive surgery. The aim of the present article was to present a new clinical classification of disturbances of the circulation, and to assess the results of treating the specific complication at each of the stages described. Within a period of 29 months, 194 free microvascular flaps were prepared and evaluated in a prospective study. Postoperative monitoring was carried out from a purely clinical point of view. A distinction was made between arterial and venous circulatory disturbances and, in both cases, four stages were characterized, according to the time required for recapillarization, the color of the transfer, and bleeding on puncture. Complications occurred in 69 cases (36 percent), including intraoperative revisions during a first operation. The ratio of arterial to venous insufficiency was 33:35. In the presence of arterial disturbances of the circulation, the proportion of losses increased in progressive stages to 41 percent. With venous disturbances, losses which occurred in stages 1 and 2 were predominantly partial. In 164 cases (85 percent), the flaps remained undamaged. In 15 cases (8 percent), there was partial loss of the transfer and, in a further 13 cases (6 percent), there was complete loss. The authors' results confirmed that the presented clinical classification is, indeed, a measurement of the severity of circulatory impairment. Despite the relatively high complication rate, the use of various methods of treatment finally led, in the overwhelming majority of cases, to a positive result.

A phase II trial of intraluminal irrigation with recombinant human tissue factor pathway inhibitor to prevent thrombosis in free flap surgery.

A multicenter, multinational, blinded, randomized, parallel-group, phase II study was conducted to investigate the use of recombinant human tissue factor pathway inhibitor (rhTFPI; SC-59735) as an antithrombotic additive to the intraluminal irrigating solution during microvascular anastomosis in free flap reconstructive surgery. A total of 622 patients undergoing free flap reconstruction were randomly assigned to three groups. For each group, a different intraluminal irrigating solution was administered at completion of the microvascular arterial and venous anastomoses and before blood flow to the flap was reestablished: rhTFPI at a concentration of 0.05 or 0.15 mg/ml (low-dose or high-dose group, respectively) or heparin at a concentration of 100 U/ml (current-standard-of-practice group). There were no other differences in treatment among the groups. Patient characteristics, risk factors, and surgical techniques used were similar among all three groups. Flap failure was lower (2 percent) in the low-dose rhTFPI group than in the high-dose rhTFPI (6 percent) and heparin (5 percent) groups, but this difference was not statistically significant (p = 0.069). There were no significant differences in the rate of intraoperative revisions of vessel anastomoses (11 percent, 12 percent, and 13 percent) or postoperative thrombosis (8 percent, 8 percent, and 7 percent) among the low-dose rhTFPI, high-dose rhTFPI, and heparin groups, respectively. The rate of postoperative wound hematoma was significantly lower in the low-dose rhTFPI group (3 percent) than in the high-dose rhTFPI (8 percent) and heparin (9 percent) groups (p = 0.040). There were no differences in blood chemistry or coagulation values among the three study groups. Other than hematomas, there were no differences in the incidence or severity of adverse reactions among the three groups. It is concluded that use of rhTFPI as an intraluminal irrigant during free flap reconstruction is safe, well tolerated, and as efficacious as use of heparin for preventing thrombotic complications during and after the operation. Furthermore, the lower dose of rhTFPI (0.05 mg/ml) may reduce the occurrence of postoperative hematoma and help prevent flap failure.

[Treatment and outcome of complications after free flap-plasty]. / Behandlung und Ergebnisse von Komplikationen nach freien Lappenplastiken.

Free tissue transplantation is a routine procedure in reconstructive surgery. Although a lot of free flap techniques have been described, the postoperative management of complications has gained only little interest. Nevertheless, complications of perfusion after free tissue transplantation are not rare and require a systematic approach. The aim of this study is to classify perfusion failures with a simple grading system prospectively on a large clinical series and to evaluate the results of treatment to improve management. In the past ten months, 70 consecutive free flaps have been performed. By the end of the operation, the operating surgeon gave a prognosis concerning the probability of a possible perfusion complication. Postoperative monitoring was done exclusively by clinical examination (colour, time for recapillarisation and bleeding after puncture). According to these parameters, arterial and venous insufficiencies have been classified into four grades. After recording type, time and treatment of a postoperative complication, the result of treatment was rated subjectively and a cause was noted when possible. The final result was classified either as total flap loss, partial flap loss or successful tissue transplantation. A total of 28 (40%) complications, which were treated with an average of 2.1 options, were recorded. The ratio between arterial and venous failure was 15:13. In 21 cases surgical intervention became necessary (intraoperative n = 12, postoperative n = 9). The arising complication was diagnosed correctly in nine cases by the operating surgeon. In ten cases, the cause of the complication remained unclear. In 18 cases, the complication was treated successfully without any flap loss. In six cases partial flap loss was observed and in four cases a total flap loss had to be accepted. Our results confirm that only few objective criteria for treatment options with perfusion failures after free tissue transplantation exist. Nevertheless, the presented classification is a useful tool for standardized evaluation of the results. The various salvage techniques result in positive outcomes for most of the patients.

The value of preoperative Doppler sonography for planning free perforator flaps.

The individual perforating vessels have a high degree of anatomical variation, therefore it is desirable to conduct a careful examination of them before undertaking a perforator flap operation. Because locating the vessels beforehand makes performing the operative procedure much easier, the aim of the present study was to assess the value of using simple acoustic Doppler sonography to plan a perforator flap operation. The vessel examinations were carried out before taking 46 free microvascular flaps from either the lower abdominal wall or the buttock for reconstructive breast surgery. The perforating vessels located were marked, and their position relative to the umbilicus or the most cranial point of the rima ani recorded using a coordinate system. In 40 patients, a perforator flap operation (deep inferior epigastric perforator flap, n = 32; superior gluteal artery perforator flap, n = 8) was actually carried out; in six of these patients, a myocutaneous flap was used because of the insufficient availability of perforating vessels. Before the operation, perforating vessels were marked for each patient, with an average of 7.3 for the deep inferior epigastric perforator flap and 6.5 for the superior gluteal artery perforator flap. Out of 286 vessels marked for later perforator flaps, 162 were identified during the operation. A preoperatively marked vessel was used in 37 of 40 patients. In the remaining patients, a vessel was used that had not been previously marked. The vertical and horizontal distance between the perforating vessels identified during the operation and the preoperative marks averaged 0.8 cm. The results show preoperative Doppler sonography to be useful for locating the position of individual perforating vessels, making it much easier to find them during the operation.

[Perforator flap-plasty and applications to hand surgery]. / Uber die Perforans-Lappenplastik und ihre Anwendung in der Handchirurgie.

In contrast to the classical fasciocutaneous and musculocutaneous flaps, perforator flaps are supplied only by a single perforating branch. The aim of this paper is to present the surgical technique and to discuss the use of perforator flaps in hand surgery. Our previous studies have demonstrated the reliability of a preoperative Doppler for planning perforator flaps in reconstructive surgery of the breast: With 286 preoperatively localized perforating branches, a total of 162 were confirmed in intraoperative dissection. In 37 out of these 46 perforator flaps (80%), a preoperatively localized perforating branch could be used. Based on these results, the individual design of perforator flaps harvested on the forearm for defects on the dorsum of the hand is possible. In a preoperative Doppler exam, a perforating branch, i.e. of the posterior interosseous artery, can be localized. The intraoperative confirmation of the perforating branch allows the successful defect coverage with a distally pedicled flap without taking fascia or septum. In our experience, this possibility of planning an individually designed perforator flap is the major advantage for applications of the perforator flap technique in hand surgery. This is especially true in cases where the harvest of a fasciocutaneous flap is unreliable or impossible due to anatomic variations. On the other hand, the dissection of the pedicle is technically demanding and the individual distribution of the perforating branches requires a high degree of flexibility. However, we do consider this new technique to be a further extension in the armamentarium for soft-tissue coverage of the hand.

[Pedicled versus free TRAM flap for breast reconstruction]. / Gestielter versus freier TRAM-Lappen zur Mammarekonstruktion.

In breast reconstruction, the free TRAM-flap offers many advantages over the pedicled TRAM-flap. Due to its superior perfusion, the free flap rarely develops necrosis. Shaping of the flap is easier due to the lack of the thick muscle pedicle. Because the rectus muscle is spared, there is minimal donor site morbidity. However, the necessary microvascular anastomoses reduced the acceptance of the free TRAM-flap. During a 13-months period, 51 breast reconstructions were performed in 41 patients, 31 unilateral and ten bilateral. 45 flaps served for delayed reconstruction and six flaps for immediate reconstruction. The operations were performed by two teams working simultaneously. The average operating time was 3.9 hours for unilateral and 6.9 hours for bilateral delayed reconstruction. For immediate reconstruction, 6.2 and 6.3 hours were required for uni- and bilateral procedures, respectively. In 38 flaps, the thoracodorsal vessels served as recipient vessels; 13 flaps were anastomosed to the internal mammary artery and vein. Postoperative complications were observed in 13 patients. Three vessel anastomoses had to be revised. In one flap, a partial necrosis occurred; in two flaps hematoma evacuation was necessary. Two patients suffered from fat necroses at the abdomen and one umbilicus was lost. Skin irritations and seromas at the abdomen occurred in five patients. Pulmonary embolism was diagnosed in one patient three weeks postoperatively. Abdominal hernias or bulging in the epigastric area were not observed up to 15 months after reconstruction. These results reveal a low complication rate for breast reconstruction with the free TRAM-flap. The advantages of this technique as compared to the pedicled technique are discussed.

Differentiation between arterial and venous vessel occlusion by simultaneous measurement with laser Doppler flowmetry and photoplethysmography.

In abdominal cutaneous island flaps of rats (n = 16), either the artery or the vein was clamped, while flap perfusion was simultaneously monitored with laser Doppler flowmetry (LDF) and photoplethysmography (PPG) to identify the occluded vessel responsible for insufficient perfusion. The LDF signal decreased promptly after arterial clamping. After venous clamping, only a slow decrease was noted. The LDF amplitude differed statistically significantly between arterial and venous clamping only up to 90 sec after onset but not thereafter, allowing no further distinction between the two types of vessel occlusion. Power spectral analysis of the LDF signal did not show clear differences in frequency ranges between arterial and venous occlusion. In contrast, PPG measurements demonstrated significant differences between both perfusion disorders throughout the entire observation period. These results suggest that dependable differentiation between prolonged arterial and venous vessel occlusion is not possible based on the amplitude or power spectral analysis of the LDF signal alone. PPG may be reliably used to differentiate between arterial and venous perfusion disorders.

[Breast reconstruction with the deep inferior epigastric perforator vein flap]. / Brustrekonstruktion mit dem Vasa epigastrica inferior-Perforanslappen.

Aside from existing advantages for reconstruction of an amputated breast with a free versus a pedicled TRAM-flap, small parts of the rectus abdominis muscle still must be sacrificed to secure blood perfusion of the flap. The deep inferior epigastric perforator flap (DIEP-flap) was recently introduced to overcome this disadvantage in autogenous breast reconstruction. Morbidity of the donor site should be minimized, since this technique avoids fascia or muscle defects. Eight patients underwent ten autogenous breast reconstructions with a DIEP-flap. Four flaps were performed for immediate and six flaps for delayed reconstructions. The internal thoracic artery and vein were used as recipient vessels in seven cases, the thoracodorsal vessels were utilized in three cases. The average operating time was 4.5 hours for unilateral and 6.9 hours for bilateral reconstructions. Two flaps developed total flap necrosis. One was due to a technical error during dissection, another flap developed an arterial thrombosis on postoperative day 5. The remaining flaps healed without problems. Subjectively, patients had far less complaints about the donor site in the lower abdomen compared to a free TRAM-flap, suggesting a lower morbidity in this area with the DIEP-flap.

The deep inferior epigastric artery perforator flap.

This article describes the surgical technique of an autogenous breast reconstruction deep inferior epigastric artery (DIEA) perforator flap and presents clinical cases. Advantages of this technique in regard to donor site morbidity are discussed.

[Reconstruction of the female breast with free transverse lower abdominal flap as perforator flap]. / Wiederherstellung der weiblichen Brust mit dem freien queren Unterbauchlappen als Perforator-flap (DIEP-flap).

The DIEP flap was introduced to autogenous breast reconstruction to avoid defects in the abdominal rectus muscle as created in pedicled and free TRAM flaps. This flap has the same soft tissue dimension as the other transverse abdominal flaps. In addition it has the advantages of free TRAM flaps, i.e. good perfusion and excellent aesthetic qualities and offers the possibility to reduce donor site morbidity.

Increase of immunologically relevant parameters in correlation with Baker classification in breast implant recipients.

A variety of studies have suggested a possible immune reaction to silicone implants, although an increased frequency of rheumatic disorders among implant recipients could not be established. Several immunologically relevant humoral parameters were investigated in 239 breast implant recipients. The following parameters were determined: immunoglobulin G and M, complement C3 and C4, rheumatoid factor, C-reactive protein, antinuclear antibodies, antimitochondrial antibodies, and antithyroglobulin and antimicrosomal antibodies of the thyroid gland. Levels of complement C3 were elevated in 42.5% of the patients. No difference could be observed between silicone gel-filled and saline-filled implant recipients. Complement C4 was increased in 21.3% of the patients and a parallel relationship was observed between elevated C4 and C3 levels (p < 0.0015). In 28% of the patients, the antithyroglobulin titer was elevated > 200 U/ml. No difference was found between silicone gel-filled and saline-filled implant recipients. Elevation of antimicrosomal antibodies existed in 14.3% of the patients and was correlated significantly with antithyroglobulin antibodies (p < 0.0347). In accordance with the classification developed by Baker, we observed a significant correlation between capsule fibrosis types Baker I and II, and elevated C3 values (p < 0.0004) in silicone gel-filled but not in saline-filled implant recipients. Additionally, a correlation was found between increased antithyroglobulin titers (< 200 U/ml) and capsule fibrosis types Baker I and II (p < 0.0001) in this group. In the study presented here, an increase of several humoral parameters could be demonstrated in breast implant recipients, although we failed to correlate these findings with any clinical symptoms.

[The face-neck lift]. / Die Gesichts-Halsspannung.

Today rejuvenation of the face is performed using different anatomical structures. Stretching the skin solely is obsolete. Repositioning of the superficial muscle aponeurotic systems (SMAS) to preserve a natural look and to avoid an unnatural facial expression is the primary goal. The operative procedure will be described in detail.

[Donor site morbidity in free rectus abdominis muscle flaps]. / Die Spendermorbidität beim freien Musculus rectus abdominis-Lappen.

To evaluate donor-site morbidity, we used a questionnaire, which was answered by 196 patients. 152 patients underwent a medical examination. The follow-up ranged from six month to ten years. The results of this retrospective study are presented. In 16,8%, we found hernia of the abdominal wall at the donor-site and relaxation was noticed in 32% of the cases. Painful symptoms of different degrees were reported by 50% of the patients.

Free TRAM. Results and abdominal wall function.

This article reports on 151 breast reconstructions that have been performed in 139 patients using the free TRAM flap. The critical steps of that procedure are evaluated and the muscle-sparing technique used in harvesting the flap as well as the necessity of an accurate donor site closure are emphasized. The results confirm that the free TRAM flap breast reconstruction provides the patient with a reliable, long-lasting good result with respect to the shape and volume of the new breast mound with a justifiable complication rate.

The extended pectoralis major myocutaneous flap: uses and indications.

The vascular territory of the pectoralis major muscle and overlying skin was studied by selective intraarterial dye injections in fresh cadavers. The area of skin overlying the anterior chest and abdominal wall beyond the limits of the pectoralis major muscle that can be elevated as an extended myocutaneous flap was determined. The cadaver injections were evaluated to determine the size and shape of the skin island used to reconstruct defects of the head, neck, and upper trunk with an extended skin paddle off the pectoralis major muscle. Pectoralis muscle flaps with variously shaped skin paddles, some extending beyond the limits of the muscle, were used in 27 patients to cover large soft-tissue defects of the upper thorax, face, and floor of the mouth and as a skin tube to reconstruct the cervical esophagus. The size of the skin paddle ranged from 5 x 7 cm to 26 x 16 cm. All flaps survived completely, and there were no major donor-site complications.

Replantation surgery.

From 1975 to 1988, replantation operations of fingers or hands were performed in 2,040 patients at the Division of Plastic and Reconstructive Surgery, Technical University Munich, Germany. The meticulous repair of blood vessels is still the most important step for a successful replantation. The liberal use of vein grafts very often makes replantations possible even in avulsion and crush injuries. The best functional results are achieved in replantations of distal finger parts, because an intact proximal interphalangeal joint and tendon apparatus guarantees almost a full range of motion. Age alone is not an exclusionary factor for replantation. Even 70 or 80 year old patients can achieve a satisfying functional result after replantation. Replantation as a matter of course is indicated in every amputation. Nevertheless, the extent of tissue damage, patient age and general health condition as well as the patient's wishes regarding a replantation have to be considered before performing a replantation. In addition, only continuous, long-term physical therapy be specialized physical therapists and the continuous postoperative attention of the surgeon ensure a satisfying result.

Technique for liposuction fat reimplantation and long-term volume evaluation by magnetic resonance imaging.

Injection with one's own fat tissue remains controversial due to a lack of objective data pertaining to postoperative volume control. Facial defects in a total of 53 patients were repaired using autogenous fat tissue. The fatty tissue was obtained from the lower abdomen, buttocks, or inner portion of the upper thigh and then suspended before injection in a solution of 250 ml Ringer's solution, 50 ml distilled water, and 0.7 ml hyaluronidase. The fatty tissue was collected by a filter integrated within the suction system and subsequently prepared, as follows: (1) Cell detritus, blood constituents, and local anesthetic were flushed away by using a physiological Ringer's solution. (2) The defects were filled by using a finely calibrated, locked injection, whereby the desired amount of fatty tissue could be accurately instilled. (3) Injection was carefully performed directly under the cutis through a large lumen cannula and under close observation to avoid the injection of any fatty tissue intracutaneously. Before the procedure, the augmented areas had been evaluated by using magnetic resonance imaging (in T1-weighted images). Postoperatively, the sites were once again documented for volume at control intervals of 6 days, and 3, 6, 9, and 12 months. The volumes were computer-calculated integrally from the sum of the area of all the layers according to the following formula:v = (d + g).E(ai). Despite the use of hyaluronidase as well as an atraumatic liposuction technique, microscopic examination revealed 40% of the aspirated cells to have defective cell membranes. Without hyaluronidase, this figure rose to 50%. One-year follow-up in 10 patients showed that through the break-down of these damaged cells, a particularly high volume loss of 49% was documentable at 3 months after the procedure. Further follow-up at 6 months showed that average volume decline had risen to a total of 55%, whereas, at 9 months as well as 12 months, no further loss could be detected. Autogenous fat transplantation after liposuction is a procedure only suitable for the repair of small, soft-tissue defects, especially of the face. The individual deposits should not be any larger than 1 ml, whereby intact fat cells are guaranteed sufficient diffusion up to the point of neovascularization. It is essential that the fatty tissue injection be exactly administered subcutaneously. Together with basic clinical observation, magnetic resonance imaging provides an objective evaluation of volume loss with an average error of only 5%.

The transverse rectus abdominis musculocutaneous free flap: a reliable alternative for delayed autologous tissue breast reconstruction.

The use of the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap has been established world-wide for breast reconstruction. Until now, application of a TRAM free flap, however, has only taken place in special circumstances. The advantages of a TRAM free flap (such as better and more vigorous perfusion than with a pedicled TRAM flap and greater freedom in reconstruction, as well as a lower incidence of weakening within the abdominal wall) are so conclusive that it has become our preferred procedure for breast reconstruction. Twenty-five patients have successfully undergone this procedure at our division. In 6 patients, the arterial or venous microanastomosis, or both, required revision without experiencing, however, total flap loss. Partial flap loss occurred in only 1 patient. All patients (including those having undergone revision) were satisfied with their reconstructed breast form. This satisfaction can be directly attributed to the fact that with this procedure, a desired breast form and volume can almost always be achieved.