[Use of the internal mammary artery in reconstructive microsurgery in the thoracic region: anatomical-radiologic study]. / Die Vasa mammaria interna als Empfänger-gefässe in der rekonstruktiven Mikrochirurgie im Thoraxbereich: Anatomisch-radiologische Studie.

In this study, the topographic anatomy and the diameter of the internal mammary (thoracic) vessels was investigated in regard to their potential as a recipient vessel in reconstructive microsurgery in the ventral thoracic region. Particularly for reconstruction of large thoracic wall defects as well as for female breast reconstruction with free tissue transplantation, these vessels seem to be suitable due to their location. We performed an anatomical study on 86 cadavers and a radiological investigation on 50 female patients and volunteers. We found a mean diameter on 50 female patients and volunteers. We found a mean diameter of 1.8 mm of the artery and 2.1 mm of the commitant vein at the level of the fourth rib, one to two centimeters parasternally. We conclude that the internal mammary vessels can serve as recipient vessels in reconstructive microsurgery in the ventral thoracic region at the level of the fourth rib or cranially. Hypothetically, free muscle flaps for the treatment of sternal osteitis, free fasciocutaneous flaps to replace presternal burn scars or appropriate flaps to fill up a funnel chest cavity subcutaneously may be anastomosed to the internal mammary vessels.

Human cutaneous dendritic cells migrate through dermal lymphatic vessels in a skin organ culture model.

The capacity to migrate from peripheral tissues, where antigen is encountered, to lymphoid organs, where the primary immune response is initiated, is crucial to the immunogenic function of dendritic cells (DC). The skin is a suitable tissue to study migration. DC were observed to gather in distinct nonrandom arrays ("cords") in the dermis upon culture of murine whole skin explants. It is assumed that cords represent lymphatic vessels. Using a similar organ culture model with human split-thickness skin explants, we investigated migration pathways in human skin. We made the following observations. 1) Spontaneous emigration of Langerhans cells took place in skin cultured for 1-3 d. Nonrandom distribution patterns of strongly major histocompatibility complex class II-expressing DC (cords) occurred in cultured dermis. A variable, yet high (>50%) percentage of these DC coexpressed the Birbeck granule-associated antigen "Lag." Ultrastructurally, the cells corresponded to mature DC. 2) Electron microscopy proved that the dermal structures harboring the accumulations of DC (i.e., cords) were typical lymph vessels. Moreover, markers for blood endothelia (monoclonal antibody PAL-E, Factor VIII-related antigen) and markers for cords (strong major histocompatibility complex class II expression on nonrandomly arranged, hairy-appearing cells) were expressed in a mutually exclusive pattern. 3) On epidermal sheets we failed to detect gross changes in the levels of expression of adhesion molecules (CD44, CD54/ ICAM-1, E-cadherin) on keratinocytes in the course of the culture period. The reactivity of a part of the DC in the dermal cords with Birbeck granule-specific monoclonal antibody "Lag" suggests that the migratory population is composed of both epidermal Langerhans cells and dermal DC. We conclude that this organ culture model may prove helpful in resolving pathways and mechanisms of DC migration.

[Indications and concepts for plastic surgery therapy in chronic varicose ulcer]. / Indikation und Konzepte zur plastisch-chirurgischen Therapie bei chronisch-venösen Ulcera cruris.

In the treatment of extensive leg ulcers, surgical therapy is superior to conservative methods in many respects. Radical resection of sclerotic tissue around the ulcer and its causing veins is essential, followed by defect cover with mesh-skin grafts. Surgery leads to prompt healing with a shortened hospitalization and therefore decreases costs; it leads to a prompt relief of pain and a low rate of recurrence. Especially in the aged patient the indication for operation must be well-considered and discussed interdisciplinarily. Even though operative technique seems to be simple, it should be reserved for the plastic surgeon experienced in the treatment of these lesions.

Internal mammary vessels: anatomical and clinical considerations.

This study was designed to investigate the anatomy of the internal mammary (thoracic) artery (IMA) and comitant vein(s) (IMV) relevant to their use in microsurgery. We dissected the internal mammary (thoracic) vessels bilaterally in 86 cadavers from the clavicle down to the 6th rib. At the level of the 4th rib, the distance between the sternum and the IMA was large enough [range 10.0-23.6 mm] and the diameter of the IMA [range 0.99-2.55 mm] and comitant vein(s) [range 0.64-4.45 mm] wide enough for both end-to-end and/or end-to-side anastomosis. These results were in close agreement with supplementary measurements obtained by Doppler ultrasound in 34 healthy female volunteers. Based on all these findings we suggest that the internal mammary vessels are suitable recipient vessels for free tissue transfers in the thoracic region, especially for breast reconstruction with the free transverse rectus abdominis myocutaneous (TRAM) flap.

Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction.

In breast reconstruction with a free flap following mastectomy, the recipient vessels most widely used are in the axillary system, which limits flap movement and flexibility in breast shaping. In addition, scarring and fibrosis can make dissection of the vessels difficult. We have performed 22 breast reconstructions using a free transverse rectus abdominis myocutaneous (TRAM) flap anastomosed to the internal mammary (thoracic) vessels. There has been no flap failure. The surgical techniques and the advantages and limitations of the internal mammary system are presented and the internal mammary vessels compared with the axillary vessels as a recipient vascular system.

[Timing of management of severe injuries of the upper extremity by free flap-plasty]. / Zeitpunkt der Versorgung schwerer Verletzungen der oberen Extremität durch freie Lappen.

From October 1986 until December 1993, fifty-five patients with severe injuries to the upper extremity were treated with 59 free flaps. The mean follow-up period was 34 months (8 TO 87 months). The average hospital stay was 19 days (8 to 40 days). Depending on the timing of reconstruction, the patients were divided into three groups: emergency reconstruction (within 24 hours after injury), delayed reconstruction (up to seven days) and late reconstruction (after seven days). In this paper we present our regime of treatment of severe upper extremity injuries using a free flap and discuss the principles of free flap choice.

[Pyoderma gangraenosum: differential diagnosis in ulcus cruris and postoperative exacerbating processes]. / Pyoderma gangraenosum: Differentialdiagnose bei Ulcus cruris und postoperativ exazerbierenden Prozessen.

A case of pyoderma gangrenosum that was initially misdiagnosed as postthrombotic ulcers is described. Surgical debridement triggered postoperative exacerbation. Dermatologic examination was then initiated and the diagnosis pyoderma gangrenosum was established. No underlying illness was detectable. Immunosuppressive therapy stopped disease activity promptly and as previously reported low-dose cyclosporine was also effective in our exceptionally therapy resistant case. Pyoderma gangrenosum should be considered as a rare, but important differential diagnosis of leg ulcers and postoperative progressive exacerbation. Timely diagnosis based on clinical suspicion is pertinent for correct therapy and to avoid iatrogenic deterioration of the disease.