Clinical and electroneurographic evaluation of sensory/motor-differentiated nerve repair in the hand.

In 17 patients acetylcholinesterase activity was used to differentiate between sensory and motor fascicles in median and ulnar nerve repair of the hand. Eleven patients received follow-up evaluation 1 to 11 years after surgery, and at that time clinical and electroneurographic examinations were performed to evaluate the techniques. Clinical examination showed that four patients had regained on average 71.9% of hand function after median nerve repair, one patient had regained 83.6% of hand function after ulnar nerve repair, four patients had regained on average 53.3% of hand function after median and ulnar nerve repair, and two patients had regained on average 43.5% of hand function after median and partial ulnar nerve repair. The contribution of the ulnar nerve to reinnervation of the thenar muscles was 68.5%, whereas the median nerve did not contribute to reinnervation of the hypothenar muscles. Distal latencies for the median nerve showed a delay of 36% of the upper limit of normal value, and those for the ulnar nerve revealed a delay of 21.5%. This study demonstrated that sensory/motor-differentiated nerve repair of the median and ulnar nerves is possible and can be proven electroneurographically.

[The long-term changes after the implantation of silicone breast prostheses]. / Langzeitveränderungen nach Implantation von Mammasilikonprothesen.

In a prospective study 60 patients with unilateral or bilateral mammary implants underwent mammography and sonography. Location, form and structure of the implants were evaluated. Additionally capsular fibrosis and its influence on the imaging quality of parenchyma was scored. We found increasing implant deformities and increasing density of the implants with increasing postoperative interval. There was poor statistically significant correlation between the thickness of the periprosthetic capsular and the postoperative interval in prepectoral implants (r = 0.555, p < 0.01); in case of subpectoral implants there was no such correlation. In 88% of the cases imaging quality was scored as adequate by two independent observers, with additional views in all cases. We conclude that sufficient imaging quality for the assessment of parenchyma and of potential implants complications may be obtained by the combination of mammography and sonography.

A new technique to correct facial paralysis.

In two cases of unilateral ficial paralysis, the advanced atrophy of the muscles forced us to try a new technique for dynamin reanimation. To our knowledge, this has not yet been reported in the literaturel. The technique combines a free nerve graft across the face with a free muscle graft or a muscle flap. The result in both our cases was good.

Epithelioid sarcoma.

The first appearance, the 12-year follow-up, and the autopsy of a patient with a strange soft-tissue tumor in the lower leg region are described. Although it was originally taken for a malignant synovial tumor, its peculiar distribution pattern, together with its histologic picture, confirmed the final diagnosis as an epithelioid sarcoma.

The importance of the correct resting tension in muscle transplantation: experimental and clinical aspects.

The influence of a reduction of resting tension by elongation of the tendon on muscle function and morphology is investigated in the rectus femoris muscle of the rabbit. An elongation of the patellar tendon of 5 mm causes a reduction of the twitch tension to 73.5 percent of the contralateral control side and a reduction of the tetanic tension to 78.3 percent 6 months after surgery. The histologic, histochemical, and planimetric changes are similar to those reported by other authors for tenotomy, but they are less marked. The clinical relevance of these experimental results for free muscle transplantation with microneurovascular anastomoses and some technical details are discussed.

Surgical anatomy of the mimic muscle system and the facial nerve: importance for reconstructive and aesthetic surgery.

Mimic muscles are arranged in four layers regarding their origins, and these four layers should be considered when muscle tissue is added or lifted. All mimic muscles are built up by parallel fibers. Mean values of length, width, and thickness of the three lip elevators have been determined. These data might be of importance when dealing with this muscle system, which appears rather different from all other muscles in the human. The individual muscles receive their innervating facial nerve branches from their deeper surface when they belong to the superficial (first, second, or third) layer and from outside when they lie in the deepest (fourth) layer. Nerve branches communicate at least four times before innervating their respective muscles.

Distribution of motor and sensory fibers in the intercostal nerves. Significance in reconstructive surgery.

If the distribution of the types of nerve fibers in the various intercostal nerves is taken into consideration, an intercostal nerve segment can be an acceptable donor nerve graft for sensory and/or motor nerve replacements. We describe the distribution of motor and sensory axons in various segments of the upper and lower intercostal nerves.

Grip reconstruction by double-toe transplantation in cases of a fingerless hand and a handless arm.

In two cases, a grip reconstruction by double toe-to-hand transfer is demonstrated. In the first patient, all fingers of the left hand were amputated at the metacarpophalangeal joint level. The second and third fingers were reconstructed by transplantation of the second toe from the left foot and the third toe from the right foot. Although the distal and the middle phalanx of the transplanted third toe had to be amputated because of mummification 2 weeks after the transplantation and was covered with a groin flap, good function of the newly formed grip can be demonstrated. The second patient is a 21-year-old man with amputation of both hands at the wrist. A grip formation on the right lower arm was performed by transplantation of the second toe of each foot together with the metatarsal bone and a dorsalis pedis flap. Both metatarsal bones were fixed to the ulna and radius with metal plates, and tendons and nerves, together with a vascular supply, were reconstructed. One year after the operation, a follow-up study demonstrates good function of the newly formed "hand." The patient is able to use his two new "fingers" during daily life, mainly to hold small objects. A myoelectric prosthesis has been placed on the patient's left arm, and the patient uses this to hold bigger objects. Restoration of sensation and the range of movement of the newly formed right "hand" are demonstrated and discussed.

An experimental comparison of the different kinds of muscle reinnervation: nerve suture, nerve implantation, and muscular neurotization.

In this experimental study, the changes in histologic pattern and functional recovery of the rectus femoris muscle of the rabbit were investigated 6 months after denervation and immediate microsurgical repair of the nerve supply of the muscle. Three different ways of reinnervation were used: nerve suture, nerve implantation directly into the muscle, and muscular neurotization by the underlying muscle. For evaluation, histochemical methods and tension measurements were used. In the results, nerve suture and nerve implantation were superior to muscular neurotization. Nevertheless, muscular neurotization was successful in all cases and led to positive EMG recordings. The functional recovery in the nerve suture and in the nerve implantation groups was astonishingly high and reached 70 to 80 percent of the tension of the control muscles. The results of this experimental study and their clinical relevance are discussed.

Histochemical mapping and fiber size analysis of mimic muscles.

Fourteen functionally relevant mimic muscles of nine human bodies were analyzed with respect to their muscle fiber sizes and their histochemical fiber type composition. In cryostat sections stained for actomyosin ATPase, type 1 and type 2 fibers were evaluated separately by means of computer-assisted image analysis. The fiber diameters varied between 20.24 and 41.45 microns. According to the proportions of the fiber types, the mimic muscles could be classified into three groups: (1) phasic muscles, with 14 to 15 percent type 1 fibers, (2) intermediate muscles, with 28 to 37 percent type 1 fibers, and (3) tonic muscles, containing 41 to 67 percent type 1 fibers. It is concluded that one has to consider this diversity of mimic muscles when planning the surgical reconstruction of facial paralysis.

Experimental free-muscle transplantation with microneurovascular anastomoses.

In 13 rabbits the rectus femoris muscle was freely transplanted from the left to the right side using microneurovascular anastomoses. About 7 months after surgery the muscle transplants were assessed functionally by force measurements. On the average, the transplanted muscles regained 55 percent of the maximal tetanic tension of unoperated, normal rectus femoris muscles, expressed as force per gram of muscle weight even 68 percent. After functional assessment, the muscles were weighed and then used for histologic, histochemical, planimetric, and biochemical evaluation. H&E-stained cross sections showed a high content of healthy muscle fibers; only some small atrophic and single fat cells were scattered over the cross sections. Good reinnervation over the sutured muscle nerve was confirmed by the type-grouping of muscle fibers in the NADH and myofibrillar ATPase staining. There was an excellent correlation between the functional results and the histologic picture as well as the content of choline acetyltransferase (CAT). A certain parallelism was found between the function of the transplants and the content of hexokinase, but none for the other estimated muscle enzymes, such as malate dehydrogenase (MDH), creatine kinase (CK), and lactic dehydrogenase (LDH). All enzyme levels were lower than in normal muscles. The results of this experimental series underline the utility of muscle transplantation with microneurovascular anastomoses to restore lost muscle function, even in the extremities, when strong forces are needed.

[Scalp avulsion injuries (author's transl)]. / Skalpierungsverletzungen

In a recent scalp avulsion injury, the scalp should always be re-implanted without delay if at all available. Subsequent normal hair growth can hardly be expected, but at least an original skin replacement has been effected. The reconstruction of only a part of the scalp should be performed in such a way that the hairless area is situated in the centre. The surrounding hair will cover this centre part. Rotation flaps in the region of the scalp follow other rules than apply to all other areas of the body. If applied correctly, good results can be achieved because of the excellent blood supply.

[Mammography of non-palpable lesions (spot localisation) (author's transl)]. / Zur radiologischen Erfassung nicht palpabler Mammatumoren.

Modern methods of mammary investigation currently enable the detection of tiny-tumours which are not clinically palpable and referral of these patients to surgery at an early stage. This poses a challenge to the surgeon, who cannot rely on palpation as a guide to accurate extirpation of the tumour, but has to rely wholly on the radiological report. A method was, thus, worked out in this department to provide accurate evaluation of the position of the suspect area of the breast to facilitate operative measures and, furthermore, act as safety measure between the time of tumor biopsy and receipt of the histological report. Preparation radiography proves that the suspect area on mammography is identical with removed specimen. The advantages of this procedure are obvious. The surgeon can rely fully on the radiodiagnostic findings and enlist the radiologist as essential member of the therapeutic team. As a result the operative procedure can be finely gauged by the surgeon and the tumour removed with maximum sparing of healthy breast tissue. This procedure has produced excellent results in 35 patients and can be recommended for application to patients with tiny tumours.

[Iatrogenic tissue damage and its treatment (author's transl)]. / Iatrogen bedingte Gewebeschäden und ihre Behandlung

Modern medicine with its manifold therapeutic possibilites brings many side effects which might result in tissue damage. 8 cases of iatrogenic tissue damage seen over a period of 5 years are presented and discussed. Measures for correction and reconstruction are proposed.

[Reconstruction of the breast after surgery for cancer (author's transl)]. / Mammarekonstruktion nach tumorchirurgischen Eingriffen.

The tendency towards less radical, stage-dependent procedures in the surgical management of breast cancer has opened the way to improvement in the reconstructive measures available. Reconstruction of the female breast can be undertaken with greater or lesser success and facility according to whether the initial procedure was subcutaneous mastectomy, modified radical mastectomy or the Rotter--Halstedt radical operation. The different plastic reconstructive methods developed over the past years are discussed and illustrated by cases treated under our care.

[The effect of anti-inflammatory substances on free muscle transplants in the experimental animal (author's transl)]. / Die Auswirkung entzündungshemmender Substanzen auf das freie Muskeltransplantat im Tierexperiment

The effect of repeated subcutaneous injections of hydrocortisone and phenylbutazone on connective tissue formation was investigated in free rat muscle transplants. The follow-up investigation took place 4 weeks after transplantation of the long extensor muscles of the digits to the vastus lateralis group of the rectus femoris muscle. Connective tissue measurements were performed on the basis of hydroxyproline determinations. It was observed that in the untreated transplant there is twice as much connective tissue (expressed as a percentage) as in the same muscle remaining in situ. Hydrocortisone did not reduce the amount of connective tissue in the transplant. Phenylbutazone reduced the amount of connective tissue by 27%. At the same time the total weight of the transplants treated with hydrocortisone and phynylbutazone was reduced by 15% and 33% respectively. Attention is drawn to the myotoxic properties of hydrocortisone and phenylbutazone. Hence, in spite of the inhibited connective tissue formation there is no improvement in muscle fibre regeneration and their use cannot be recommended.

[Reconstruction of deformities of the external ear]. / Die Rekonstruktion äusserer Ohrmissbildungen.

Microtia is a rare malformation. Reconstruction of microtia is not a routine operation because of its rarity of occurrence and the complex deformity. In this paper the indication for surgical treatment, technique, results and complications are discussed. Two different operation methods were used in our patients. A multiple-stage and a single-stage reconstruction procedure. We used autogenous rib cartilage. Five of the seven treated patients came to the follow-up examination. Reconstruction was performed 2 years ago in two cases and between 4 and 12 years ago in three cases. Our patients were content with the result in so far as they would be prepared to undergo treatment again. Carefully built rib framework is an essential prerequisite for a successful postoperative result. Microtia represents a greater psychological problem than a cosmetically imperfect result after reconstruction.

[Biochemistry of benign-symmetrical lipomatosis (adenolipomatosis Launois-Bensaude, Madelung's disease)]. / Zur Biochemie der benignen-symmetrischen Lipomatose (Adenolipomatose Launois-Bensaude, Madelung'sche Krankheit)

1. Total lipids, total cholesterol, cholesterol esters, phospholipids, triglycerides and free fatty acids as well as the fatty acids profiles of the different lipid classes were determined in serum, lipomatous and normal adipose tissue. Triglycerides were elevated in patient L's serum. The distribution of serum lipoproteins in this patient's serum showed a type IV according to Fredrickson. All other lipid parameters were within the normal range. Palmitoleic acid was increased nearly in all lipid fractions of the patients' sera as well as in the lipids of lipomatous subcutaneous adipose tissue. 2. The lipomatous adipose tissues of the patients showing no histological abnormalities revealed higher levels of cyclic AMP than normal subcutaneous adipose tissue. 3. Serum uric acid was normal (patient E.), between the normal and pathological range (patient L.) and elevated (patient W.). Urinary uric acid excretion was increased in all three patients. 4. 14C-glycine was overincorporated into urinary uric acid in all three patients. 5. Adenine phosphoribosyltransferase activities in the hemolysates were within the normal range. A decrease of hypoxanthine-guanine phosphoribosyltransferase activities could be demonstrated in two patients' (e., w.) erythrocytes. Erythrocyte phosphoribosylpyrophate synthetase activity was slightly increased in patient L.'s and twice the normal value in patient W.'s erythrocytes.

[Gynecomastia: attempt at a classification and surgical results]. / Die Gynäkomastie: Versuch einer Klassifizierung und operative Ergebnisse.

Gynecomastia may appear at any age of life. We divided the cases we treated into three groups depending on the size of the gynecomastia. The patients were surgically corrected and then re-examined in order to find the most suitable incision. We consider a semicircumareolar incision on the inferior areolar margin the best. This kind of incision can also be used in cases of massive gynecomastia and results in almost invisible scars.

[Clinical and electroneurographic results following surgery of carpal tunnel syndrome]. / Klinische und elektroneurographische Ergebnisse nach Operation von Karpaltunnelsyndromen.

The surgical treatment of carpal tunnel syndrome is successful in most cases. Sometimes, however, it is not possible to reach a satisfying result. In order to find out the reasons for failure, we examined 80 surgically treated patients. Clinical and electroneurographical parameters were observed. We could show, that the time of intervention and the age of the patient are responsible for the results. The skin incision has to be planned carefully in order to avoid transection of the palmar cutaneous nerve. In cases of systemic diseases the patient has to be informed preoperatively about the possibility of incomplete recovery.