Reconstruction of the extremity with the dorsal thoracic fascia free flap.

The dorsal thoracic fascia is the anatomic layer that contains the blood supply to the scapular and parascapular fasciocutaneous flaps. The cutaneous vascular territory of the circumflex scapular artery and its parascapular branches is well known. During the past 8 years, the authors have employed the dorsal thoracic fascia free flap for extremity reconstruction in 17 patients (upper extremity, n = 9; lower extremity, n = 8). The indications for using this free flap included primary coverage after trauma (n = 10), resurfacing of "unstable" scar (n = 3), coverage of plantar foot ulceration (n = 3), and coverage of an exposed lower extremity distal arterial bypass graft (n = 1). The large anatomic boundaries of this flap, the consistent vascular anatomy, and the thin yet durable quality of the tissue make this flap an excellent choice for the reconstruction of upper and lower extremity defects.

[The birth stool in texts of classical tradition]. / Der Geburtsstuhl in Texten antiker Tradition.

The author presents a collection of texts from Antiquity and from the Middle Ages to give an idea of the kind and incidence of references to the birth stool in medical and non-medical texts. The medieval texts are derived--at least indirectly--from classical sources, too. The mention of the birth stool is a marginal issue in medical as well as non-medical texts. In German-speaking culture areas, the widespread knowledge of the birth stool cannot be traced back to earlier than the beginning of the 16th century.

[Birth representation with reference to the magical coriander prescription of Codex Vindobonensis 93, fol. 102r, of the Austrian National Library]. / Die Geburtsdarstellung zum magischen Korianderrezept des Codex Vindobonensis 93, fol. 102r, der Osterreichischen Nationalbibliothek.

One of the most impressive manuscript illustrations of the medieval history of midwifery is found in the Codex Vindobonensis 93, fol. 102r (a manuscript from the early 13th century), illustrating a magic prescription of herba coriandrum to accelerate childbirth. The composition of the omnibus manuscript is critically delineated in its historical context. The illustration, being isolated without any obstetrical teaching text, is judged as part of the ancient tradition of teaching by images which has no parallel north of the Alps. The different image traditions are reflected in the historical use and illustration of the midwifery chair, which can be traced back only to the beginning of the 16th century in Central Europe and on the British Isles. The importance of the magic prescription is shown by comparison within the same and other collections used in the Middle Ages and classified in the context of further traditions of magic in midwifery.

[Erroneous interpretations of archaeologic findings in ancient gynecology]. / Irrige Annahmen im archäologischen Befund antiker Gynäkologie.

The author reviews some archaeologic findings, interesting for medical history, in the field of gynaecology. Due to erroneous opinions, they were described a few years ago in an incorrect manner in wide-spread publications.

["From the origin and development of the French disease" to "Major wound treatment". The work and contributions of Theophrastus Bombastus von Hohenheim, called Paracelsus, on the occasion of the 500th anniversary of his birth year]. / "Vom Ursprung und Herkommen der Franzosen" zur "Grossen Wundartzney". Werk und Wirkung des Theophrastus Bombastus von Hohenheim, genannt Paracelsus, aus Anlass des 500. Geburtsjahres.

On the occasion of Paracelsus's 500th anniversary his life and works are critically portrayed and appreciated. The present state of Paracelsian research in different fields of academic science is shown in the congress report 'Neue Wege der Paracelsus-Forschung'.

[Detection of rupture of fetal membranes using a commercially available fibronectin test kit]. / Zum Nachweis des Blasensprungs mit Hilfe eines kommerziell erhältlichen Fibronectin-Nachweistests.

In a clinical examination an attempt was made to confirm the aptitude of a commercially available immunoassay to detect amniotic fluid. Pure amniotic fluid gained by amniocentesis, not mixed with other secretions, was used. On examination using three different batches the sensitivity of this test amounted to 35/55 in all, or 64%. We came to the conclusion that the present test was not sufficiently reliable to prove or disprove the discharge of amniotic fluid. An explanation is needed especially regarding the role played by the forces which occur during contractions and the presence of cervical and vaginal secretions when fetal fibronectin is found to be present. The evidence of fetal fibronectin could possibly become more important as a predictor of imminent labour than as being proof of the admixture of amniotic fluid in cervical and vaginal secretions.

Free flaps in the elderly.

Microsurgical transfer of tissue has become a primary tool of the reconstructive surgeon. The elderly, as a growing segment of our society, are requiring free-tissue transfers in proportion to their numbers. To investigate the potential morbidity of free-tissue transfers in the elderly, we studied consecutive populations of 31 patients above the age of 65 years and 90 patients below the age of 65 years. Complication rates were 65 and 49 percent, respectively. Premorbid medical conditions were present in 87 percent of patients 65 years and older and in 72 percent of those under 65 years. Medically related complications in free-tissue transfers, previously unreported in the literature, were 35 percent in the elderly group and 10 percent in the younger group. Wound-healing complications were seen in equal proportions between groups. The rates of wound and medically related complications observed in the elderly group were nearly double those observed in the younger group; however, after correction for the presence of preexisting medical conditions, no significant differences were seen between the two groups. These observations suggest that age alone is not a variable in risk for free-tissue transfers. Elective microsurgery can be performed in the elderly patient with a high expectation of success.

Vascular resistance considerations in free-tissue transfer.

The closure of complex wounds is facilitated by microvascular free-tissue transfer. The greatest threat to the success of a free-tissue transfer is thrombosis of the microvascular anastomosis. Technical and pharmacologic advances have decreased the thrombogenic effect of abnormalities of a vessel's endothelial lining, and have decreased the coagulation ability of blood. Equally important to patency of the microvascular anastomosis is blood flow, which is inversely proportional to the total resistance provided by the microcirculatory beds downstream. Because different tissues possess different vascular resistances, some flaps may display more favorable hemodynamics than others. This study was designed to characterize vascular resistance, weight, volume, and surface area of the flaps available for transfer, and to identify favorable tissues for reconstruction from the standpoint of outflow resistances. Data were collected on patients undergoing free-tissue transfers and on experimental free-tissue transfers harvested from canines and fresh cadavers. Results show that resistance is highest in fascial flaps, intermediate in composite bone and soft-tissue flaps, and lowest in muscle and musculocutaneous tissues. Resistance is lower in flaps harvested from the trunk, compared with those harvested from the extremities. The rate of microvascular complications increases as resistance within the flap increases. Muscle and musculocutaneous flaps harvested from the trunk have lower complication rates than fascial and fasciocutaneous flaps. Suggestions for choices of flaps are made, based on the inherent resistance in the various free flap tissues.

Tobacco smoking and complications in elective microsurgery.

This study assesses the risk for complications in patients who chronically smoke but who have quit in the perioperative period of an elective free-tissue transfer as compared with patients who do not smoke. A retrospective review identified 104 free-tissue transfers in 93 smokers and 58 transfers in 51 nonsmokers. The demographics, wound etiology, and recipient sites were similar in the two populations. With the exception of a higher incidence of chronic obstructive pulmonary disease (COPD) among smokers, preexisting comorbid factors also were similar. Postoperative medical complications were comparable between populations. When comparing smokers with nonsmokers, we found that anastomotic patency and flap survival were not different (95 versus 94 percent, respectively), that delayed wound healing at the recipient site was different (35 versus 24 percent), and that smokers require an additional procedure to achieve final wound closure more frequently (27 versus 12 percent, p = 0.03). These findings suggest that cigarette smokers are at increased risk for complications, not at the site of the anastomosis in free-tissue transfer, but rather at the flap's interface with the wound or overlying skin graft.

[Image of the uterus in Greek-Roman antiquity and its representation]. / Das Bild des Uterus in der griechisch-römischen Antike und in ihrer Uberlieferung.

The author describes the common ideas of the human uterus in Etruscan and early Roman Italy known from anatomical ex-votos and gems, most of them found in the regions of Etruria and Latium. In contrast, a medical or scientific concept of the human uterus can be found in various manuscript copies from ancient writers, especially in those derived from the Coan school of medicine, from ancient Greek philosophers and in those derived from Soranus of Ephesus, the best-known teaching authority on obstetrics in Roman medicine. Miscellaneous concepts were characteristic of drawings in later manuscript copies of the early middle ages.

[Are Doppler methods suitable for the study of adaptive maternal central circulatory regulation in pregnancy? II. Assessment of time parameters and determination of minute distance, conclusions]. / Sind Dopplermethoden geeignet zur Untersuchung adaptiver mütterlicher zentraler Kreislaufregulation in der Schwangerschaft?Teil II. Erfassung von Zeitparametern und Bestimmung der Minute Distance, Schlussfolgerungen.

Echocardiographic Doppler measurements of blood flow velocity are a noninvasive way of studying maternal central haemodynamics. Part 2 reports on additive and derived physiological parameters using different Doppler ultrasound techniques. This paper shows that quantitative assessment of adaptive maternal central circulatory regulation must be interpreted in respect of methods and machines. Technical requirements to be met by the Doppler equipment to avoid present limitations are discussed as are various aspects involved in such studies.

[Are Doppler methods appropriate for the study of adaptive maternal central circulation regulation in pregnancy?]. / Sind Dopplermethoden geeignet zur Untersuchung adaptiver mütterlicher zentraler Kreislaufregulation in der Schwangerschaft?

Echocardiographic Doppler measurements of blood flow velocity are a noninvasive way of studying maternal central haemodynamics. Part 1 reports on conditions as well as on practical and theoretical problems recognized as contributing significantly to the use and interpretation of Doppler ultrasound techniques in the assessment of adaptive central circulatory regulation in pregnancy. The significance of different techniques is shown by assessments of the peak velocity and the velocity time integral.

Posterior hindfoot reconstruction.

From August 1983 through December 1988, 25 patients with complex wounds involving the posterior hindfoot underwent reconstruction of that region. The present study reviews the use of microsurgical free-tissue reconstruction in this complex anatomic area. A questionnaire was sent to all patients; 60 percent responded, with a mean postoperative period of 2.1 years. Our experience shows that complex wounds involving soft tissue, bone, tendon, and nerve may be successfully reconstructed by the judicious use of free-tissue transfer combined with standard adjunctive techniques. When flap donor tissue is carefully selected, a one-stage reconstruction without the need for contour revision should be possible. Patient satisfaction has been excellent and solidly healed wounds have been maintained.

Limb salvage despite extensive tissue loss. Free tissue transfer combined with distal revascularization.

Extensive lower-extremity tissue loss may preclude limb salvage despite successful arterial reconstruction. We attempted to avoid limb loss in such patients by combining arterial bypass with microvascular free tissue transfer. Fourteen patient (12 diabetic), 33 to 74 years of age, presented with extensive tissue loss in 15 lower extremities, exposing bone or tendon on the heel, ankle, lower part of the leg, or hindfoot. Mean ulcer size was 5 X 8 cm. Four patients had had previous contralateral below-knee amputations. Femorodistal (seven), popliteal-distal (three), or femoropopliteal (four) bypass, or tibial angioplasty (one), was performed to provide sufficient inflow for free tissue transfer. Serratus anterior, scapular, latissimus dorsi, rectus abdominis, gracilis, ulnar, or temporalis free flaps were used. One free flap failed due to venous thrombosis and was corrected with a second flap. Limb salvage was achieved in 14 (93%) of 15 limbs during a mean follow-up of 24 months. The single amputation occurred due to severe foot ischemia in a patient whose femorodistal bypass remained patent only to the viable free flap. The remaining 13 patients (14 limbs) became ambulatory, including those with free flaps to weight-bearing regions.

Preservation of projection after reduction mammaplasty: long-term follow-up of the inferior pedicle technique.

In reduction mammaplasty by the inferior pedicle technique, the dermal-breast pedicle can be manipulated to form a central breast mound and enhance breast projection. When this technique is applied both to macromastia and breast asymmetry, excellent early results are reported. To study the effects of time on breast reduction, 22 patients were followed for an average of 4.7 years. Contour of the breast mound and projection are well preserved. However, evaluation of long-term results reveals a gradual increase in the inframammary fold to inferior areola distance. Since no increase in the midclavicle to nipple distance is observed, inferior migration of the breast parenchyma and superior displacement of the nipple-areola with respect to the breast mound occur after reduction mammaplasty with the inferior pedicle technique.

[Teratoma of the placenta]. / Teratom der Plazenta.

The authors describe an extremely rare case of a teratoma of the placenta. The course of pregnancy was complicated by an EPH-gestosis pattern of signs and symptoms, and the foetus had hydrocephalus and a maxillary cleft combined with generalised hydrops foetalis and hydramnion. The morphological criteria of a placental teratoma are described and the requisite differential diagnostic delineations are drawn.

Effect of intraarterial prostacyclin on survival of skin flaps in the pig: biphasic response.

Previous research has implicated arachidonic acid metabolites in the failure of the distal dying flap. The progressive ischemic necrosis has been postulated to be secondary to excessive thromboxane A2 production, which upsets the normal balance between prostacyclin and thromboxane. We have examined the effect of continuous intraarterial prostacyclin infusion on axial skin flap survival in the pig, in an effort to reestablish homeostasis. We found prostacyclin to have a biphasic effect upon the flap survival. Low-dose locally administered prostacyclin was of benefit in flap salvage; however, the complicated pharmacological effect of the agent is emphasized.