Pedicled hypothenar perforator flap: Indications and clinical application.

BACKGROUND AND AIM: Soft-tissue defects of the palm and the palmar aspect of the fifth finger are a constant problem in reconstructive hand surgery. We present a possible approach to planning and harvesting pedicled hypothenar perforator flaps for the reconstruction of such defects. METHODS: A hypothenar perforator flap was used to reconstruct a soft-tissue defect on the ulnar aspect of the palm and the palmar aspect of the fifth finger of 17 patients. The defects were located over the proximal phalanx of the fifth finger (n = 9), the palm (n = 5), and across both areas (n = 3). The size of the defects was up to 7.9 cm(2). RESULTS: Eleven of the flaps healed primarily, out of which partial flap necrosis was observed in six. Four of these six flaps required operative revision, including debridement and delayed primary wound closure, while two healed secondarily. After an average of 26.6 days (range 21-45 days), all 17 patients achieved complete functional recovery. Despite the complications described, all the primary defects remained covered. CONCLUSION: The pedicled hypothenar perforator flap is an option for reconstruction of ulnar-sided, soft-tissue defects of the palm and little finger. The flap is thin and the donor-site morbidity is low. Hand surgeons may wish to consider this flap when presented with soft-tissue defects in this area.

Rejection, after a slightly prolonged survival time, of Langerhans cell-free allogeneic cultured epidermis used for wound coverage in humans.

Autologous cultured epidermis (CE) grown from small skin biopsies in vitro has been successfully applied for wound grafting in humans. Since it has been reported recently that allogeneic CE might be tolerated as permanent wound cover, we investigated the properties of CE and its use as autologous and allogeneic grafts. Except for some differences, such as the absence of Langerhans cells and the lack of a stratum corneum, CE resembled its natural analogue. Autologous CE applied for grafting of leg ulcers and various surgical skin defects adhered firmly and permanently to the wound bed within 2 weeks, became regularly stratified, and formed a stratum corneum. Langerhans cells gradually entered the grafts; the dermis contained no inflammatory infiltrate. Allogeneic CE unmatched for MHC and blood group antigens used to partially cover tangentially excised third-degree burns, donor sites of split-thickness skin, and a defect after tumor excision initially survived well like the autografts. However, they were completely rejected after 10-22 (mean, 14.5) days, which is 4-5 days later than reported for split-thickness skin allografts. Clinically, rejection presented as "melting" of the graft. (Immuno)histologically, we found a dense mononuclear dermal infiltrate consisting predominantly of activated T cells, vacuolization, and single-cell necrosis of keratinocytes, as well as HLA-DR expression on keratinocytes, and finally separation and lysis of the epidermis. Limiting dilution analysis in 2 out of 4 allograft recipients revealed a considerable increase of circulating donor-specific cytotoxic T cell precursors during graft rejection. We conclude that grafting of allogeneic CE does not lead to permanent but to slightly prolonged graft survival.

Standardization of the first aid treatment of burn injuries in Vorarlberg, Austria.

It is 6 years since a burn unit was installed at the Landeskrankenhaus Feldkirch in Vorarlberg. Before that time, systematic clinical burn care was unknown in this country. Systematic first aid treatment of burn injuries was not known either. According to the principles of quality management, an obligation was felt not only to standardize the burn treatment in the unit itself, but also to make known the principles of first aid to the whole medical staff in our country. This is why we carried out many public relation activities consisting of several lectures to general practitioners and training for the emergency staff, including the lay personnel. The population were even informed about first aid treatment via radio and TV. In 1994, the degree of success in the public relation efforts was examined. During a period of 10 months, all the burn patients were asked about the quality of their first aid treatment. The questionnaires of 72 patients were evaluated, and it was found that the criteria demanded of first aid treatment were met within a range of 77.6-100 per cent. From these figures, it was concluded that public relation activities have been very successful in establishing the first aid care, they have led to a better quality of burn treatment in general and specifically, to a significant reduction in cost.

Oral premedication for operations on the face under local anesthesia: a placebo-controlled double-blind trial.

Modern strategies for preventing or controlling pain and anxiety demand a premedication for operations using local anesthesia and for those using sedation or general anesthesia. For optimal patient care, the premedication should be given orally and, with respect to the outpatient basis of the operations, should have a short recovery period. Midazolam, one of the most favored premedications for general anesthesia, has been recommended as a premedication for operations using local anesthesia as well. However, midazolam has only sedative-anxiolytic effects and does not reduce pain sensation, which should be mandatory for operations using local anesthesia. A further requirement is the maintenance of stable hemodynamics for the prevention of postoperative hematomas, especially in the face. For these reasons, another premedication meeting all requirements (anxiolysis, analgesia, and stable hemodynamics) was researched. A randomized, double-blind prospective study was performed from March of 1997 to June of 1998. Five groups totalling 150 patients were included in the study; each group contained 30 patients who had operations performed solely on the face. In the first four groups, the effect of midazolam (0.15 mg/kg(-1)), morphine (0.3 mg/kg(-1)), and clonidine (1.5 microg/kg(-1)) administered orally was compared with a placebo. The fifth group was the control group and received no premedication. To evaluate the effects of the premedications, a corresponding questionnaire was completed independently by the patient and surgeon. With regard to the anxiolytic or analgesic properties of the premedication, 61 percent of the patients preferred pain reduction to anxiety control, and 24 percent of patients preferred reduction of anxiety. The remainder insisted on a reduction of both properties (8 percent) or had no preference (7 percent). Reduction of anxiety was largest in the midazolam and the clonidine groups, but the difference was not significant. The least pain during the application of local anesthesia was experienced by the morphine group (37 percent) and the clonidine group (33 percent), in contrast to the midazolam group (60 percent) (p = 0.04). Morphine and clonidine met the requirements of pain reduction equally well. Nevertheless, considering the rate and intensity of adverse effects with respect to hemodynamic compromises, nausea, and emesis, clonidine is even better suited as an oral premedication for operations on the face using local anesthesia.

[The development of malignant tumors in nevus sebaceus--therapeutic consequences]. / Die Entwicklung maligner Tumoren auf dem Boden eines Nävus sebaceus--Therapeutische Konsequenzen.

OBJECTIVE: Nevus sebaceus has been considered a relatively infrequent and unimportant congenital hamartoma for plastic surgeons, unless the lesions are so big that they require a large closure of the defect. As such tumors are primarily of a benign nature and the malformed sebaceus glands are located abnormally high in the dermis, surgeons are tempted not to excise the tumors but to eradicate them by dermabrasion or laser beam therapy. Yet, a nevus sebaceus does not only affect sebaceus glands but includes various other malformations of the affected skin and its appendages. In addition, different malignant tumors may occur in nevus sebaceus, even in children and young adults. MATERIALS AND METHODS: We encountered 4 such malignant tumors out of 18 nevus sebaceus operated from 1989 to 1997. All nevi had been clinically inconspicuous. RESULTS: In three patients, one of them being only fifteen years old, an associated basal cell carcinoma was found. The fourth patient had a mixture of three additional tumours, a cystadenoma, a keratoacanthoma and a basal cell carcinoma besides the sebaceous malformations. CONCLUSION: These findings have two consequences. The first is to continue surgical treatment of nevus sebaceus instead of dermabrasion or dermablation and to have the specimen examined histologically. The second consequence is to excise such tumors as early as possible.

[Follow-up of patients with burn injuries following long-term ventilation]. / Nachuntersuchungen bei Brandverletzten nach Langzeitbeatmung.

Follow-ups were performed five years post burn on 13 severely burned patients after long-term ventilation in order to identify damage to the trachea and lung. The study comprised clinical examination, tracheal X-rays, pulmonary function tests with whole-body plethysmography for thoracic compliance, and spiroergometry. Tracheal stenosis was detected in five patients (38%), two patients had reduced total lung capacity and functional residual capacity was increased. Six patients had high values of pulmonary resistance. The comparison between actual and predicted physical work capacity in the spiroergometry showed a reduction below 85% of normal in five patients, but only one patient had a marked low output (51%). It is remarkable that patients after long-term ventilation, even after inhalation trauma have only minimal impairment of pulmonary function and physical work capacity five years after trauma. The high incidence of tracheal-stenosis after tracheotomy has to be considered as a serious finding.

Quantification of faults resulting from disregard of standardised facial photography.

Medical photography is an important part of documentary procedures in plastic surgery both for quality assurance and for protecting surgeons from possible medico-legal claims filed by patients. Photo documentary standards were established to make photos reliable and to enable comparisons between pre- and post-operative views of a patient, different operative procedures and between results achieved by different surgeons. Despite their obvious importance, especially in the documentation of subtle surgical procedures on the face such as rhinoplasty, photo documentary standards continue to be disregarded. In this article, we analyse and quantify faults caused by even small deviations from photo documentary standards. Photos of 10 healthy, young adults (n = 10) taken in accordance with established standards were compared to photos with the similar types of faults in positioning of the head (±10° deviation from the standard), camera angles (±10° deviation from standard) or mimic expression (slight smile). A computer-assisted facial analysis was performed and the effects of faulty photo documentation on the final result were calculated. The analysis showed, for instance, that a +10° fault in positioning of the head causes a mean shortening of the nasal dorsum by 32.34% (p<0.001) and of the front by 15.33% (p = 0.001), whereas the chin is elongated by 6.82% (p = 0.004). A -10° fault elongates the nasal dorsum by 11.93% (p<0.001) and shortens the upper lip by 22.50% (p = 0.007) and the chin by 13.67% (p = 0.001). Deviations from standardised camera angles lead to similar mistakes, but to a lesser extent. A mistake in mimic expression leads to a shortening of the upper lip by 23.20% (p = 0.006) and also to a clear cheek lift. We show that slight deviations from photo documentary standards result in dramatic faults in the final outcome.

Recurrent cranial fibroblastic neoplasm in a male adolescent: case report and review of the literature.

Paediatric fibroblastic tumours are rare neoplasms, of which cranial fasciitis is the most common. We present a case of a male 7-year-old suffering from a cranial tumour preceded by a mild trauma. The tumour recurred despite radical resection within 8 months. Histologically, neither tumour could be classified as any published pathological entity. Both lesions were described as cellular fibroblastic neoplasms; in addition, the recurrent tumour featured a prominent myxoid matrix. In the 12 months following resection of the second tumour, no further disease recurrence has occurred.

Importance of positive interaction in the initial meeting between plastic surgeons and patients: a survey.

The aesthetic plastic surgery patient represents a particularly sensitive and highly demanding client within the whole patient population. There is no doubt that a kind and understanding response to his problems and needs, which are often rather complex, contributes decisively to the establishment of a basis of confidence and it predominantly determines the further course of any interpersonal relationship with the surgeon. A kind response, i.e., positive interaction, signifies the complete acceptance of the patient, both verbally and nonverbally. The surgeon must be all ears to the requests and concerns and must attentively concern himself with all the patient's physical impairments that have grown into a problem. Positive interaction also means assessment and understanding of the patient's personality, including his self-image, his view of reality, and his present condition in order to choose correctly the suitable level of communication. Finally, positive interaction means the precise analysis of the patient's rational and irrational fears and his conceptions and expectations. There must be discussion of his wishes and the therapeutic and surgical possibilities in order to map out an acceptable path of treatment.

Endoscopic plastic surgery: the endoscopic evaluation of implants after breast augmentation.

There is an ongoing discussion about the possible connection of gel-filled silicone implants for breast augmentation and the development of connective tissue disease. In the absence of any proven link and irrespective of the difficulty to prove such a causality, these discussions lead to great concern for the hundreds of thousands of women who underwent breast augmentation with silicone gel implants. As a consequence there are voices that call for regular checks of the implants with regard to their integrity. All the external methods of judging an implant, including MRI, can--if at all--detect only marked lesions or ruptures. Direct visualization of the implant up to now has been the only safe method. Direct visualization can be carried out by reopening the previous incision or by endoscopic inspection. Endoscopic evaluation needs the dexterity of all endoscopic plastic surgery procedures, but with sufficient training and experience it is a very safe, quick, and highly compliant procedure for the patient and can be combined with endoscopic biopsies and other endoscopic operations such as capsulotomies.

A new technique for the treatment of lacrimal gland prolapse in blepharoplasty.

The lateral temporal fullness of the upper eyelid in patients presenting for a blepharoplasty is sometimes due to a prolapse of the lacrimal gland. The operative procedures that attempt to reposition the migrated lacrimal gland have been either dangerous in that they cause a dry-eye syndrome or unsatisfactory in that they have a high rate of recurrence or other complications. A new and different operative approach to a herniated or prolapsed lacrimal gland deals with an extraglandular concept of repositioning the gland that corresponds to the general principles of hernial surgery.

Diagnosis of breast tumors after breast reduction.

We conducted a retrospective study to evaluate the diagnosability of breast tumors after breast reductions as this is a frequent surgical procedure. The data should shed light on the hypothesis that routine screening methods concerning the diagnosis of breast tumors prove more difficult after breast operations. All women who had undergone breast reduction at our department between January 1989 and December 1994 were examined. During this period we counted 166 patients; the majority of them (n = 144) had undergone a bilateral breast reduction and the rest of them (n = 22) a unilateral breast reduction for various reasons. After the operation, all patients were checked in standardized intervals. Those who developed any kind of breast mass (n = 6) were recorded and examined by ultrasound and mammography, and occasionally by an additional fine-needle biopsy. In case any doubt about the dignity had remained, an excisional biopsy was carried out. In none of our patients was it possible to get a precise diagnosis of an ill-defined mass with ultrasound. With mammography, some of the existing masses, which were really scars, mimicked different kinds of tumors, and once a carcinoma was initially interpreted as scar tissue with oil cysts. The diagnosis of breast masses after breast reductions with routinely used screening methods has proved to be more difficult as breast reductions lead to architectural alterations of the remaining breast parenchyma. Such alterations can and should be documented shortly after the operation so that later occurring tumors are distinguished more easily. Therefore, a basic mammography 3 months after each breast reduction has to be claimed in order to facilitate further breast tumor diagnosis.

Closure of nasal defects after tumor excision with local flaps.

There is a myriad of proposals for nasal defect closure. One of the older concepts, the so-called topographical concept, adheres to the nasal subunit principle without taking into consideration textural details of the nasal skin such as thickness and mobility. In a newer concept, a morphological concept, the texture of the nasal skin is a basic consideration for defect closure. The morphological or textural concept demands defect closures only with local flaps of nearly identical texture located within the "unit" nose. In order to find out how the morphological concept influenced our operative design, we carried out a retrospective study from 1988 to 1995 checking the defect closure of all basal cell carcinoma on the nose. Of 598 basal cell carcinoma operated in the face, 141 were located on the nose. During the first years, free skin grafts and regional flaps dominated our operative design, in recent years the use of local flaps according to the criteria of the morphological concept increased significantly, leading not only to functional but also to more aesthetic results.

Poland's syndrome and vascular malformations.

Unilateral hypoplasia of the breast and the pectoralis muscle with a missing anterior axillary fold as part of Poland's syndrome are of major concern, especially for women. The latissimus dorsi is one of the most suitable flaps for breast and anterior thorax reconstructions but it may be hypoplastic or absent. If so, a free tissue transfer of the contralateral latissimus dorsi muscle is the next possible option for reconstruction. As Poland's syndrome is additionally associated with vascular malformations of the diseased hemithorax such as hypoplastic or missing vessels, a preoperative angiography is mandatory for planned microvascular tissue transfer.