Clinical results of TRAM flap delay by selective embolization of the deep inferior epigastric arteries.

Preoperative selective embolization of the deep inferior epigastric arteries constitutes a new technique in TRAM flap delay. Whereas surgical ligation of these vessels has proved to be an effective delay procedure in experimental and clinical settings, it requires an additional operative step under general anesthesia. Despite the introduction of the free TRAM leading to improved flap perfusion, this microsurgical technique is not always available because of the requirements of specialized equipment and staff, longer operating hours, and subsequently higher expenses. The search for a minimally invasive, easy, and inexpensive technique to improve perfusion of the pedicled TRAM flap led us to selective embolization of the deep inferior epigastric arteries by an angiographic procedure. After 4 years of experience with this technique, we now present the first clinical results. Breast reconstruction by a delayed pedicled TRAM flap was performed in 40 patients with a mean age of 48.4 years (range, 31 to 66 years). The mean interval between embolization and surgery was 3.6 months. Postoperative data concerning flap survival and complications were available for all patients. Embolization of the deep inferior epigastric arteries was performed bilaterally in 35 patients (87.5 percent) and unilaterally in 5 patients (12.5 percent). Radiotherapy had been applied in 21 patients (52.5 percent) before surgery. Postoperative flap complications consisted of partial necrosis in three (7.5 percent), fat necrosis in one (2.5 percent), impaired wound healing in five (12.5 percent), and postoperative bleeding in two patients (5 percent). Abdominal wound healing complications occurred in six patients (15 percent), abdominal wall weakness in eight (20 percent), and hernia formation in four (10 percent). Surgical corrections were performed at the breast (TRAM flap) in 22 patients (55 percent) and at the abdomen (donor site) in 9 (22.5 percent). Preoperative selective embolization of the deep inferior epigastric arteries constitutes an alternative delay procedure for the pedicled TRAM flap. It is superior to the conventional procedure without delay, offers several advantages compared with surgical ligation of these vessels, and represents an alternative to the free TRAM flap in selected cases.

[Catheter ablation of the inferior epigastric artery. An conservative method for conditioning the pedicled TRAM flap]. / Katheterembolisation der Arteria epigastrica inferior. Ein schonendes Verfahren zur Konditionierung des gestielten TRAM-Lappens.

The pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is a recognized, reliable method of autogenous tissue breast reconstruction after mastectomy. However, the blood supply to the distal part of the flap is often precarious after ligation of the the main feeder, the inferior epigastric artery (AEI), at time of the operation. We describe our clinical experience with a new technique to augment the superior blood stream (superior epigastric artery, AES) by selective embolization of the inferior epigastric artery some weeks prior to plastic surgery. One hundred and eleven embolization procedures were performed until now. Technique of crossover and ipsilateral epigastric spiral embolization is described, requiring minimal time and material as an in- or outpatient procedure. The anatomical situation of the m. rectus abdominis blood supply is discussed as well as possible complications of the procedure.

[Clinical results and color-coded duplex ultrasound findings 4 years after conditioned TRAM flap-plasty]. / Klinische Resultate und FKDS-Befunde vier Jahre nach konditionierter TRAM-Lappenplastik.

Presented is a new technique in preoperative conditioning of the pedicled TRAM-flap employing an interventional-radiologic procedure, selective embolization of the deep inferior epigastric artery (DIEA). During a four year period in 40 patients with a mean age of 48.4 (31-66) years breast reconstruction was performed by a superiorly pedicled TRAM-flap following preoperative conditioning. 30 of 40 patients were eligible for follow-up one to five years postoperatively. The mean interval between embolization and surgery amounted to 3.6 months. In 25 of 30 cases embolization of the DIEA was performed bilaterally, in 5 of 30 cases unilaterally. 14 of 30 patients underwent preoperative radiotherapy for breast cancer. Applying CCDS the peak flow values were determined in the superior epigastric arteries (TRAM/contralateral side). Pre-embolization values (54.9 cm/s/55.8 cm/s), post-embolization values (57.2 cm/s/57.9 cm/s) and late postoperative values (61.0 cm/s/61.6 cm/s) proved a statistically significant effect of selective embolization on peak flow without relevant difference between TRAM and contralateral side (p < 0.05). Postoperative flap complications consisted of partial necrosis in 2 of 30, fat necrosis in 1 of 30, impaired would healing in 5 of 30 and postoperative bleeding in 2 of 30 cases. Abdominal would healing complications occurred in 5 of 30 cases, abdominal wall weakness was found in 8 of 30 and hernia formation in 4 of 30 cases. Corrective surgery was performed at the breast (TRAM-flap) in 22 of 30 and at the abdomen (donor site) in 9 of 30 cases. Patient acceptance concerning selective embolization and TRAM-flap surgery was very high. 29 of 30 patients confirmed that they would again choose this type of breast reconstruction. The pedicled TRAM-flap following preoperative conditioning by selective embolization of the DIEA constitutes a safe and reliable method of breast reconstruction with autogenous tissue. It is superior to the pedicled TRAM-flap without delay and offers definite advantages compared to alternative techniques of enhanced flap vascularization.

[Indications for arterialization of tissue]. / Indikationen für die Arterialisation von Gewebe.

Data from 69 arterialized venous flaps and transplants were reviewed and showed on overall complication rate of 18.6%. Possible hemodynamic mechanisms include, among others, the opening of macro- and microvenous interconnecting pathways with in the perivenous areolar tissue and pressure-induced insufficiency of venouf valves. The use of arterialized venous flaps increases the plastic surgeon's armamentarium if standard local or distant flap procedures are not possible, and the use of a vein to provide arterial inflow into an amputated body part presents a suitable alternative if arteries are not available and venous congestion is controlled.

The V flap: a combination of V-Y advancement and two Limberg transposition flaps.

Two annoying problems are encountered in surgical correction of greater defects by flap plasty: the widely undermined cavity seen when using transposition flaps to cover large wound cavities and the necessity to cut away healthy skin because of dog ears or a Burrow's triangle. The V flap is a method of shifting and transposing of the skin surrounding the defect to avoid these troublesome disadvantages. With the exception of cases where a myocutaneous island flap is indicated, this simple V-flap technique yields excellent surgical results.

[Hidradenitis suppurativa--treatment with myocutaneous island flap or the traditional method]. / Hidradenitis suppurativa--Behandlung mit myokutanem Insellappen oder herkömmlicher Methode.

Inflammations of the apocrine sweat glands are characterized by painful, nodose and often superficially phlogistic infiltrates with a tendency towards abscess-formation and fistulation. These foci of inflammation are situated particularly in the armpit as well as the anal and genital region. The failure of conservative therapy--e.g., application of antibacterial ointments, red light, short-wave therapy or irradiation--is followed by a surgical intervention which involves excising the abscess cavity and leaving the wound open for secondary closure by granulation. The resultant scar is an impairment both functionally and cosmetically, particularly in the axilla; and, in many cases, a new focus of inflammation eventually develops in the immediate vicinity. For multiple occurrence of sudoriparous abscesses in the axilla with undermining of the surrounding cutaneous soft tissue mantle and fistulation, we therefore suggest the following therapeutic concept as an alternative to conventional methods: radical removal of the focus of inflammation far into the healthy tissue with concomitant excision of all sweat glands in the affected area and coverage of the resultant defect with a partial myocutaneous island flap from the latissimus dorsi muscle.

Treatment and prevention of amputation neuromas in hand surgery.

We tried to solve the problem of postamputation neuroma formation by a new operative procedure: the technique of centro-central nerve union with autologous transplantation. The results found in animal experiments corresponded with our clinical experience. Although we carried out this procedure in hand surgery only, we feel there is no reason for not recommending this operation as a routine procedure in all amputations.

[The ultrastructure of ganglia and newly formed tendon sheaths]. / Zur Ultrastruktur von Ganglien und neugebildeten Sehnenscheiden.

Comparative electron microscopic examination of ganglions (from the tendon sheaths and joint capsules of the hand) as well as that of newly formed tendon sheaths (after resection of digital flexors and their tendon sheaths) indicate that both are the result of an adaptive effect of the mesenchyma which enables the formation of a new synovial organ in the presence of an adequate stimulus.