[Treatment of chronic osteomyelitis of the tarsal bones with free muscle flaps]. / Die Behandlung der chronischen Osteomyelitis der Fusswurzelknochen mittels freier Muskellappen.

Although the value of free muscle flaps in the treatment of chronic osteomyelitis of the lower leg is well documented, only few reports deal with the use of free muscle flaps for treatment of osteomyelitis of the tarsal bones. Four patients with chronic osteomyelitis of the tarsal bones (in three patients several bones were involved) were treated using the following regimen: radical debridement, coverage with a free muscle flap, and systemic antibiotic therapy. In two patients, infection recurred following primary transplantation of the muscle flap. In one of these patients, recurrence was controlled by repeating the same regimen. In the other patient, debridement was repeated and the calcaneus was transposed to obliterate the resultant bone cavity. At follow-up (mean 19 months following last surgical procedure), all four patients showed no evidence of infection and were fully weight-bearing. Chronic osteomyelitis of tarsal bones can be successfully treated by radical debridement and coverage with muscle flaps, even in advanced stages of the disease. The clinical and anatomical peculiarities of this region, however, have to be taken into consideration.

[A comparison of long-term outcome of 6 techniques of breast reduction]. / Ein Vergleich der Langzeitergebnisse von sechs Techniken der Mammareduktionsplastik.

In a retrospective study we examined 192 patients who underwent breast reduction between 1973 and 1993 to compare the long-term results of six various reduction mammaplasty techniques. We investigated patient's satisfaction, the relief of preoperative symptoms as well as the possibility of lactation. The sensitivity of the areola was measured with Semmes-Weinstein monofilaments and the breast contour, the scar formation, and the complication rate were evaluated. 89% of our patients were very satisfied with the cosmetic result. Breast-feeding was possible after all techniques except for free-nipple grafting. The sensitivity of the areola was found to be more decreased after using a superior pedicle technique. Breast ptosis was obtained in 30% of our patients and correlated significantly with postoperative weight loss. Breast ptosis was less frequent after using an inferior pedicle technique. Length and width of the scar, as well as the complication rate correlated with the resection weight.

Morphometric and functional results after CO(2) laser welding of nerve coaptations.

BACKGROUND AND OBJECTIVE: Several reports describe nerve coaptations by laser welding in combination with stay sutures and bonding material. This study was undertaken to obtain functional and morphologic information by using a nerve coaptation technique by epineurial CO(2) laser welding only. STUDY DESIGN/MATERIALS AND METHODS: The sciatic nerves of 24 rats were transected and epineurially coapted with the CO(2) laser at 60 mW or with microsutures as a control. Walking track analysis were carried out to evaluate the functional recovery, and the nerves were harvested for histology after 6 months of regeneration. RESULTS: None of the 24 nerves showed dehiscence of the coaptations, and all showed good nerve fiber regeneration. Better results were obtained for the functional evaluation of the sciatic function index (P < 0.02) and the toe spread index (P < 0.04) from the laser nerve coaptations. Likewise, the morphologic evaluations of the fiber density (P < 0.04) and area fraction (P < 0.002) were better in the laser group. CONCLUSION: CO(2) laser welded nerve coaptations are as successful as their sutured counterparts and may become a promising alternative in clinical practice.

[Soft tissue tumors with difficult to distinguish boundaries. From myxoma to myxofibrosarcoma: a case report]. / Weichteiltumoren mit schwer beurteilbarer Dignität. Vom Myxom zum Myxofibrosarkom: Ein Fallbericht.

Myxofibrosarcoma is a slow-growing subcutaneous tumor found in the older patient. Because of its deceptive macroscopic and histologic appearance, it is often misinterpreted as a benign lesion. We report a case of this tumor in a young woman recurring five times before the final diagnosis was made. Since recurrence may lead to tumor progression and increases the risk of metastasis, accurate diagnosis and radical removal of the lesion are extremely important. Eight benign and malignant myxoid tumors that have to be considered as differential diagnosis are reviewed.

The sensitivity of the nipple-areola complex: an anatomic study.

Although preservation of the sensitivity of the nipple and areola is an important goal in breast surgery, only scant and contradictory information about the course and distribution of the supplying nerves is found in the literature. The existing controversy might be due to the difficulty in dissecting the thin nerves and to frequent anatomic variations that bias the results if only a small number of cadavers are dissected. We dissected 28 female cadavers and found that the nipple and areola were always innervated by the lateral and anterior cutaneous branches of the 3rd, 4th, and 5th intercostal nerves. The most constant innervation pattern was by the 4th lateral cutaneous branch (79 percent) and by the 3rd and 4th anterior cutaneous branches (57 percent). The anterior cutaneous branches took a superficial course within the subcutaneous tissue and terminated at the medial areolar border in all dissected breasts. The lateral cutaneous branches took a deep course within the pectoral fascia and reached the nipple from its posterior surface in 93 percent of the dissected breasts. In 7 percent of the dissected breasts, the lateral cutaneous branches took a superficial course within the subcutaneous fat and reached the nipple from the lateral side. These findings suggest that the nerves innervating the nipple and areola are best protected if resections at the base of the breast and skin incisions at the medial areolar border are avoided.

External oblique abdominal muscle: a new look on its blood supply and innervation.

Numerous reports have discussed the use of the external oblique abdominal muscle as a pedicled or a free flap for defect coverage. A detailed description of the supplying vessels and nerves is a prerequisite for successful tissue transfer but so far is not available in the literature. A study of the arteries and nerves supplying the external oblique abdominal muscle was carried out in 42 cadavers after injection of a mixture of latex and bariumsulfate. In seven fresh cadavers the motor branches were identified with the Karnovsky technique. Three different groups of arteries were identified as the nurturing vessels. The cranial part of the muscle is supplied by two branches of the intercostal arteries. While the lateral branches run on the outer surface of the muscle together with the nerves, the anterior branches enter the muscle from its inner surface. The caudal part of the muscle derives its main blood supply from one or two branches of the deep circumflex iliac artery (94.7%) or the iliolumbar artery (5.3%). The external oblique abdominal muscle is innervated by motor branches of the lateral cutaneous branches of the anterior spinal nerves in a segmental pattern. With the exception of the subcostal nerve the motor branches enter the outer surface of the muscle digitation arising from the rib above. The results show that the cranial half of the external oblique abdominal muscle has a strictly segmental blood and nerve supply while the caudal half of the muscle derives its main blood supply from one artery but still shows a segmental innervation.

Normal cutaneous sensibility of the breast.

A total of 150 healthy women were studied to determine normal values for breast sensibility and to investigate the influence of breast size and ptosis on breast sensation. Cutaneous pressure thresholds were evaluated bilaterally in six areas including the nipple, the areola, and the skin of the breast using the Semmes-Weinstein monofilaments. We found that the skin of the superior quadrant was the most sensitive part of the breast, the areola was less sensitive, and the nipple was the least sensitive part. The cutaneous sensibility of all tested areas decreased significantly with increasing breast size and increasing breast ptosis. The nipple was less sensitive in women who had a previous pregnancy. Age, smoking history, or hormonal contraception had no significant influence on breast sensation. The study shows that the Semmes-Weinstein test is an adequate method for assessing sensation in the breast.

[Nerve coaptation using CO2 milliwatt laser]. / Nervenkoaptation mit dem CO2-Laser im Milliwattbereich.

The technique of laser tissue welding with a low-output CO2 laser has become popular due to the minimal amount of nerve tissue damage caused. The purpose of this study was to ascertain the efficacy of nerve coaptation by laser tissue welding in comparison to micro-sutures. In a first series of 15 rats, peripheral nerves were transsected. 24 nerves were coaptated by laser welding (LW) with different parameters in order to evaluate the optimal laser settings. For comparison, six nerves were coapted (NS) with four 10/0 nylon sutures. Finally, the nerves were removed and the tensile strength of the different coaptations determined. The best results of the laser welds were obtained at laser settings of 40 to 60 mW in the continuous mode resulting in a tensile strength of 9.5 +/- 2.2 g. The tensile strength was 39.3 +/- 7.3 g for the sutured coaptation. In a second series, one sciatic nerve was coapted in thirteen rats by laser welding (LW) (60 mW, cont. mode) and in eleven rats using four 10/0 nylon sutures (NS). After six months, the Sciatic Function Index (SFI) was evaluated and the nerves were harvested for histological examination of transverse and longitudinal sections. All animals showed good regeneration and none of the 24 nerve coaptations showed dehiscence. The SFI was for the NS-group -94 +/- 23 and for the LW-group -77 +/- 20. The mean number of myelinated nerve fibres (NS 10,170 +/- 2512 vs. LW 11,902 +/- 1649) and the fibre diameter (NS 4.30 +/- 0.14 um vs. LW 4.02 +/- 0.59 microns) of the nerves distal to the coaptation were similar in both groups and showed no statistical difference. We conclude that nerve coaptation by CO2-laser welds are as successful as the 10/0 nylon sutures in the animal model. Improvements of welding techniques may in the future reduce nerve damage even further and so yield even better functional results.

[Interdisciplinary status of plastic, esthetic and reconstructive surgery in Austria]. / Interdisziplinäre Stellung der Plastischen, Asthetischen und Wiederherstellungschirurgie in Osterreich.

To evaluate the actual status of interdisciplinary treatment involving plastic surgery in Austria in 1993 and 1994, standardised questionnaires were sent to all Departments of Plastic Surgery and to 129--mainly surgically orientated--medical departments in Vienna. The survey revealed that more than 50 percent of interdisciplinary co-operation took place with the departments of traumatology, general surgery and dermatology. The demand for co-operation with plastic surgeons was especially felt in tumor surgery, peripheral nerve surgery and hand surgery. An additional demand for co-operation represented larger soft tissue defects and congenital anomalies.

Sliding door technique for the repair of midline incisional hernias.

We describe a technique that enables the autologous repair of large midline incisional hernias by restoring the functional musculoaponeurotic support of the abdominal wall. Unlike other methods of hernia repair, the essential step of the sliding door technique is the complete release of the rectus abdominis muscles from the anterior and posterior layers of their sheaths. The released muscles are thus overlapped and sutured together without tension. Another step of the technique is the release of both rectus sheaths by incising the aponeuroses of the external oblique muscles. We report on the use of this technique in 10 patients with midline incisional hernias (mean size of the abdominal musculofascial defect 14 x 11 cm). The patients were examined 14 months to 5.5 years after hernia repair. Two postoperative complications occurred: one marginal skin necrosis and one subcutaneous seroma. Recurrences were not observed. Ultrasound examination showed that the rectus muscles maintained their overlapped position postoperatively. Clinical muscle testing indicated that the strength of the released rectus muscles provides functional support to the reconstructed anterior abdominal wall.

The lumbrical muscle flap: anatomic study and clinical application.

This article describes the anatomy and clinical application of the lumbrical muscle flap. Anatomic and radiologic studies were performed in 20 fresh human cadaver hands injected with latex-lead-oxide solution. Only the 2 radial lumbrical muscles were found suitable for flap transposition. The vascular supply of the first and second lumbrical muscles is from branches originating in the superficial palmar arch and from the common palmar digital artery, respectively. The dominant branches invariably enter the muscle bellies at the junction of their proximal and middle thirds. Pedicled on these vessels, the lumbrical muscles can be transposed to reach the entire palm, up to the wrist flexion crease. The clinical use of the first and second lumbrical muscle flaps in 2 patients demonstrated the value of these flaps for coverage of the median nerve and its palmar branches.

The vertically based deep fascia turnover flap of the leg: anatomic studies and clinical applications.

Although fasciocutaneous turnover flaps are a simple and fast method for covering soft-tissue defects of the lower leg, many reconstructive surgeons have their doubts about them. They revolve around the lack of criteria for safely designing these random-pattern flaps and around the risk of donor site problems. A vertically based deep fascia turnover flap with a paratibial or parafibular pedicle is presented. Anatomic studies of 36 injected lower limbs showed the deep fascia to be supplied by a mean of 61 vessels. As musculofascial, septofascial, and periosteofascial branches, these contribute to a richly anastomosing vascular network within the deep fascia. Along the deep transverse septum at the medial tibial border, the anterior and posterior peroneal septa, and between the anterior tibial and extensor muscles, the fascia is supplied by segmental vessels in a clearly defined arrangement. Pedicled on these vessels, the deep fascia is a useful candidate tissue for transversely oriented turnover flaps. These are particularly well suited for covering pretibial or prefibular soft-tissue defects. Unlike adipofascial turnover flaps, the transversely oriented deep fascia turnover flap keeps its subcutaneous layer with its intact vascular plexus so that the overlying skin is adequately perfused even in patients with sizable flaps or an extremely thin skin. Clinical experience with the vertically based paratibial or parafibular deep fascia turnover flap in six patients confirmed its usefulness for covering small to medium-sized soft tissue defects of the lower leg.

The external oblique muscle free flap.

To date, the external oblique muscle has been considered to have a purely segmental vascular supply and therefore has been used surgically only as a pedicled flap. To better define the vascular anatomy and nerve supply of the muscle, we performed arterial injection studies and dissected the nerves that entered the muscle in 35 human cadavers. We found that in addition to the segmental arteries, one or two large branches of the deep circumflex iliac artery contributed significantly to the blood supply of the external oblique muscle in 33 of the 35 cadavers. We also found that the lateral cutaneous branches of the intercostal nerves entered and supplied the muscle near its origin from the rib in a strictly segmental pattern. These anatomic findings enabled us to transplant the external oblique muscle successfully as a free flap based on the deep circumflex iliac vessels in six patients. The muscle flap is thin, pliable, and can be combined with an iliac bone or an abdominal skin transplant. Its vascular pedicle is long (mean 12 cm) and of adequate diameter for microvascular repair. The donor scar of the flap is inconspicuously situated along the inguinal ligament and the iliac crest. Finally, since the muscle has a multiple nerve supply, it has the potential to provide several functional units at the recipient site when transplanted as a functional free flap.

Scarpa's fascia flap: anatomic studies and clinical application.

Fascia and fascia-subcutaneous flaps are thin, pliable, and well-vascularized tissue with aesthetic and functional advantages, particularly for the extremities and in the head and neck region. Although various donor sites have been used for these flaps, there is an occurrence of unsatisfactory donor-site defects that are often complicated by conspicuous, widened scars or alopecia. In addition, flap elevation is sometimes prolonged because of the demanding operative procedures as well as the impossibility of a two-team approach. In this anatomic and clinical study we present a new fascial flap that results in a minimal donor-site defect and a short and easy operative procedure. Scarpa's fascia, which can be used as both a free and a pedicled flap, is a well-defined single membranous sheet within the subcutaneous tissue layer at the lower abdominal wall. We studied its distribution, structure, and vascular supply in 27 fresh cadaver specimens. In addition, computed tomographic (CT) and ultrasound studies were performed in 13 healthy volunteers and in 3 cadavers before and after injection of diluted contrast material in the superficial epigastric artery. Finally, histologic examinations were done with hematoxylin and eosin or with reticulum and elastin. Our studies showed that Scarpa's fascia provides a thin, pliable, and well-vascularized flap pedicled on the superficial epigastric artery. After successful application of the Scarpa's fascia flap as a free flap in 3 patients and as a pedicled option in 1 patient, we can recommend this flap as a valuable tool for the reconstructive surgeon.

The combined use of a pedicled Scarpa's fascia flap and a groin flap for simultaneous coverage of dorsal and palmar finger defects.

A case is reported in which the dorsal and palmar aspects of the fingers in a severely crushed hand were covered by combining a pedicled Scarpa's fascia flap and a groin flap. Secondary heterotopic finger transposition was additionally performed to restore satisfactory hand function. An acceptable result was obtained.

[Utilization potential of the CO2-laser in dermal changes]. / Einsatzmöglichkeiten des CO2-Lasers bei dermalen Veränderungen.

44 patients with various cutaneous lesions including 18 tattoos, 13 hypertrophic scars or keloids, 4 xanthelasmas, 4 capillary haemangiomas, and 5 other benign cutaneous lesions were treated by CO2-Laser. 28 of these patients were reexamined after a follow-up period of three to four years. Good results were achieved with the CO2-Laser in the treatment of tattoos, xanthelasmas, and haemangiomas. Satisfactory results were obtained in one patient with peri-ungual Koenen-tumors and in two patients with perianal condylomas. Keloids and plantar warts recurred after an initial improvement. The attempts to remove hypertrophic scars did not bring the desired results. In four cases a superficial local wound infection led to a delayed healing process together with an aesthetically unsatisfying final appearance. CO2-Laser treatment brings certain advantages in selected cases where traditional techniques of plastic surgery have a higher complication rate and are additionally a greater burden for the patient. Particularly larger tattoos, multiple xanthelasmas, and capillary haemangiomas are successfully removed with the CO2-Laser, despite the time consuming method for the attending physician.

Effect of the CO2 milliwatt laser on neuroma formation in rats.

BACKGROUND AND OBJECTIVE: The purpose of this study was to determine whether the milliwatt laser can suppress neuroma formation at the end of a divided nerve. STUDY DESIGN/MATERIALS AND METHODS: The peripheral nerves of eight rats were transected with microscissors and the cross-sectional area of their proximal ends was irradiated using the CO2 milliwatt laser. The power ranges used were similar to those applied to weld neural tissue. RESULTS: None of the eight irradiated nerve ends formed a neuromatous bulb and only one of them regenerated into the surrounding tissues. Histologically, these nerve ends did not show the disorganized picture of classic neuromas. On morphometric measurements, they contained less connective tissue than the control nerve ends (P < 0.001) and their nerve fibers were larger in diameter (P < 0.001) and better myelinated (P < 0.001). CONCLUSION: These findings in rats show that the CO2 milliwatt laser has the ability to suppress neuroma formation at the end of a divided nerve.

Endoscopic carpal tunnel release using a single-portal system.

In this prospective clinical study, we present our experience with a new single portal carpal tunnel release kit. The safety and efficacy of this new device was assessed and compared with a consecutive control group treated with conventional open carpal tunnel release. 126 patients were enrolled in this study, 64 of them were treated endoscopically (group 1) and 62 by open release of the carpal ligament (group 2). Follow-ups were conducted at 1, 3, 6, 12 and 24 weeks postoperatively. A serious intraoperative complication in group 1 was a transection injury of a branch of the superficial palmar arch. No intraoperative complications were noted in group 2. Postoperative evaluation revealed significantly less scar tenderness in group 1 at 1 week (P < 0.001), 3 weeks (P < 0.001) and 24 weeks (P < 0.05) compared to group 2. Functional status at 1 week was significantly (P < 0.05) better in group 1 than in group 2 but not at later times. Grip strength at 1 week (P < 0.001), 3 weeks (P < 0.05) and 12 weeks (P < 0.05), and pinch strength at 3 weeks (P < 0.001) were significantly higher in group 1. No significant differences between the groups were obtained regarding postoperative symptom severity. The new device provides a reliable tool for single portal carpal tunnel release, although the risk of inadvertent damage to the neurovascular structures always remains a possibility with the endoscopic carpal tunnel technique.

The extended gracilis muscle flap for reconstruction of the lower leg.

The width of the gracilis muscle was measured before and after removal of the epimysium in 10 fresh cadavers. The average extent of muscle widening achieved by epimysium removal was over 100% (mean 112.6%; standard deviation 11.9%). This extended muscle flap enabled us to cover successfully even large soft tissue defects measuring up to 300 cm2. In 27 consecutive patients, soft tissue defects of the lower leg with exposed bone have been repaired by free tissue transfer of a gracilis muscle flap, covered with split skin grafts. The advantages of the gracilis muscle flap were the low donor site morbidity with almost no recognisable functional loss, the easy surgical access, the thin and flat shape of the muscle, and its adequate size after excision of the epimysium. Reconstruction with a gracilis muscle flap resulted in an inconspicuous, stable, and flat contour of the lower leg. The entire length of the vascular pedicle of the gracilis muscle was easily harvested in our patients by routinely dissecting the pedicle on both sides of the adductor longus muscle.

Donor-site morbidity of the gracilis flap.

To determine whether there is a specific donor-site morbidity inherent in the elevation of the gracilis flap, we retrospectively examined 42 patients who underwent elevation of their gracilis muscles. We found, on dynamometric measurement, that the adduction strength of the hip joint was decreased by 11 percent when the gracilis muscle was elevated. This decrease in strength was not noticed by the patients. We also found an area of hypesthesia corresponding to the cutaneous territory of the obturator nerve in 40.5 percent of the patients. In addition, many patients were dissatisfied with the aesthetic appearance of the donor site, and a contour deformity of the thigh was present when a myocutaneous flap was elevated. Therefore, we conclude that the gracilis flap has a low but definite rate of donor-site morbidity. The advantages of the flap outweigh by far, however, the sequelae at the donor site.