Anterior spreader flap technique: A new minimally invasive method for stabilising and widening the nasal valve.

BACKGROUND: The 'anterior spreader flap' is a new minimally invasive technique, for the treatment of nasal valve insufficiency or stenosis. The aim of this study was to present our experience with a series of patients with nasal valve dysfunction corrected by the minimally invasive spreader flap technique. METHODOLOGY: We performed a retrospective review of our patients with nasal valve malfunction who underwent the anterior spreader flap between June 2010 and June 2013. The patients had to judge their symptoms of nasal obstruction pre- and 12 months post-operatively by the Nasal Obstruction and Septoplasty Effectiveness (NOSE) quality-of-life assessment scale. The difference between the pre- and post-operative evaluations of each group and between the groups was calculated, and it was statistically analysed. RESULTS: Forty-three patients were treated. In seven patients, the anterior spreader flap was performed as a single procedure (group F), in 15 patients the anterior spreader flap was combined with a septoplasty and a turbinoplasty (group FST), in 10 patients with a turbinoplasty (group FT) and in 11 with a septoplasty (group FS). All patients reported significant post-operative improvement in nasal breathing (p < 0.05). The mean improvement (diffNOSE) of all patients was 54.2 points. The 'FS' group and the 'FST' group showed best post-operative results, but there were no significant differences between the groups (p > 0.8). CONCLUSIONS: The anterior spreader flap is an effective and safe method for minimally invasive improvement of nasal breathing in patients with nasal valve dysfunction.

Assessment of long-term donor-site morbidity after harvesting the latissimus dorsi flap for neonatal myelomeningocele repair.

BACKGROUND AND AIM: The latissimus dorsi flap (LDF) has been employed very successfully over decades to cover large soft-tissue defects. Its donor-site morbidity has been extensively investigated in adults - but not in children - and is considered to be nonrestrictive. The aim of this long-term study was to assess donor-site morbidity with the modified Constant score more than 8 years after coverage of large myelomeningocele (MMC) defects with a reverse latissimus dorsi flap. METHODS: Within the first days after birth, the reverse latissimus dorsi muscle flap was used uni- or bilaterally in three neonates to cover a large MMC defect. Bilateral shoulder function was tested more than 8 years postoperatively according to the modified Constant score. RESULTS: The mean age at follow-up was 11.7 years. None of the patients experienced any pain or shoulder restrictions during normal daily activities. They all managed to position both of their arms comfortably above the head. Forward flexion was normal in all patients as was abduction and external rotation. Dorsal extension was minimally reduced on the operated side. Internal rotation was symmetric in all patients; the extent of active movement varied from excellent to poor. CONCLUSIONS: Our long-term data suggest that there is no specific and significant impairment of shoulder function after using the distally pedicled reverse LDF for neonatal MMC repair.

[Photography in Hand Surgery. Basic knowledge and standards]. / Fotografie in der Handchirurgie. Grundlegende Kenntnisse und Standards.

Photo documentation plays an important role in hand surgery. Pre- and postoperative documentation, planning of interventions, patient information as well as publications and presentations all require high quality images. Last but not least an accurate documentation is necessary for legal reasons. We present basic knowledge of equipment, photo and processing methods and illustrate imaging techniques and photographic standards for professional work flows in daily hand surgery.

[A case of nerve angiomatosis associated with neurofibromatosis type I]. / Ein Fall Neuroangiomatose bei Neurofibromatose Typ I.

We present the case of a patient suffering from Neurofibromatosis type I (NF-1) with acute, very painful neuropathy of the right lower extremity. The preoperative electro neuro- physiological study showed an impaired function of the peroneal nerve. The MRI revealed an extended diffuse plexiform tumour of the sciatic nerve and at thigh level. Biopsies showed marked diffuse angiomatosis within the sciatic nerve.To our knowledge, this is the first description of an intraneural vascular malformation in NF-1.Treatment of such an entity is a challenge and must be individually defined.

Painful nodules and cords in Dupuytren disease.

PURPOSE: The etiology of Dupuytren disease is unclear. Pain is seldom described in the literature. Patients are more often disturbed by impaired extension of the fingers. We recently treated a series of patients who had had painful nodules for more than 1 year, and we therefore decided to investigate them for a possible anatomical correlate. METHODS: Biopsies were taken during surgery from patients with Dupuytren disease and stained to enable detection of neuronal tissue. RESULTS: We treated 17 fingers in 10 patients. Intraoperatively, 10 showed tiny nerve branches passing into or crossing the fibrous bands or nodules. Of 13 biopsies, 6 showed nerve fibers embedded in fibrous tissue, 3 showed perineural or intraneural fibrosis or both, and 3 showed true neuromas. Enlarged Pacinian corpuscles were isolated from 1 sample. All patients were pain free after surgery. CONCLUSIONS: Although Dupuytren disease is generally considered painless, we treated a series of early stage patients with painful disease. Intraoperative inspection and histological examination of tissue samples showed that nerve tissue was involved in all cases. The pain might have been due to local nerve compression by the fibromatosis or the Dupuytren disease itself. We, therefore, suggest that the indication for surgery in Dupuytren disease be extended to painful nodules for more than 1 year, even in the early stages of the disease in the absence of functional deficits, with assessment of tissue samples for histological changes in nerves.

Focal neuromyotonia: do I love you?

We present a rare case of focal neuromyotonia in a 73-year-old woman with a follow up of 5 years. The clinical picture showed a fixed contraction of the 3rd and 4th finger of the left hand. Similar to other published cases, our patient suffered from COPD and was treated with beta-2-sympathomimetics. This clinical picture shows a rare but rather salient differential diagnosis of Dupuytren's contracture. EMG of the affected muscles may yield a diagnosis and prevent the patient from a long and ineffective treatment "odyssey".

[42-year-old man with painless swelling of the ring finger]. / 42-jähriger Mann mit schmerzloser Schwellung am Kleinfinger.

A 42 years old man presented with a painless increasing swelling in the region of the proximal phalanx and metacarpal bone of the ring finger persistent since five months. Plain X-rays revealed increased soft tissue density. The possibilities of differential diagnostic of tumors in the region were discussed because essential for the correct procedure. Histology revealed a bizarre periostal osteochromatic proliferation (Nora lesion). This rare lesion must be distinguished from an periostic osteosarcoma.

Lyell syndrome revisited: analysis of 18 cases of severe bullous skin disease in a burns unit.

Over the last few years, understanding of the pathophysiology of toxic epidermal necrolysis (TEN), or Lyell's disease, has substantially increased. However, differentiation of severe bullous skin disease remains a challenge for the clinician, and one that is often complicated by late patient referral. We performed a retrospective analysis of all patients with severe bullous skin disease, admitted between 1997 and 2002 to the Burn Centre, which is an integrated part of the Division for Plastic, Hand- and Reconstructive Surgery at the University Hospital of Zurich, Switzerland. We present an overview of our strategies and of the diagnostic and therapeutic difficulties encountered. The final diagnoses of the 18 patients referred to the unit were as follows: eight cases of TEN, one case of staphylococcal scalded-skin syndrome (SSSS), two cases of generalised drug eruption, one case of acute generalised exanthematic pustulosis and one case of febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta (PLEVA). In two cases, the diagnosis remained unclear. In three cases, paraneoplastic origins were suspected but not demonstrated. The overall mortality rate was 33% (six of 18 patients). Remarkably, all patients with histologically confirmed TEN survived. Six of these patients were successfully treated with intravenous immunoglobulins (IVIG). The most common single causative drug inducing TEN (four cases out of eight) was Phenytoin. Establishing an accurate diagnosis-based on a skin biopsy, harvested at an early stage-is more important than ever, because more specific and effective therapeutic modalities are available. As these potentially life-threatening bullous skin disorders are rare, we recommend, that care be provided by an experienced interdisciplinary team, comprising a dermatologist, or dermatopathologist, an intensive care specialist and a plastic surgeon.

Baseline staging in cutaneous malignant melanoma.

BACKGROUND: Baseline staging in patients with primary cutaneous malignant melanoma (MM) is routine, but the diagnostic accuracy and the impact on clinical outcome are still unclear. OBJECTIVES: To evaluate the sensitivity and specificity of baseline staging in the early detection of regional lymph node metastases or distant metastases in patients with MM. METHODS: One hundred consecutive patients with MM of Breslow's tumour thickness over 1.0 mm were enrolled. All patients had an extensive baseline staging including physical examination, ultrasound (US) of the abdomen and regional lymph nodes, chest X-ray, whole-body positron emission tomography (PET) and sentinel lymph node biopsy. The sensitivity and specificity of detection of macroscopic or microscopic metastases in the regional lymph nodes or at distant sites were calculated for each method. RESULTS: Sentinel lymph node biopsy was positive in 26 patients. US detected two of 26 histologically tumour-positive sentinel nodes (sensitivity 8%, specificity 88%) and PET two of 26 (sensitivity 8%; specificity 100%). There were three lymph node metastases with a diameter > 4 mm. All of them were found suspect at physical examination. Two of them were detectable with US, two with PET, and all were identified with either US or PET. Nine patients had suspect findings at distant sites, which were all false positive on further investigation (specificity of the combined staging procedures 91%). At 18 (6-37) months' follow-up, five of 26 (19%) patients with a positive sentinel node and four of 74 (5%) of patients with a negative sentinel node had recurrent or progressive disease. CONCLUSIONS: The combination of physical examination and lymph node US detects the great majority of patients with macroscopic lymph node metastasis (approximately 3% of patients at baseline). Only 10% of patients who have a histologically tumour-positive sentinel node are macroscopically detectable. Altogether, approximately 25% of patients have a positive sentinel node biopsy, among 90% microscopic. The value of whole body staging at baseline remains limited, since distant metastases can hardly ever be detected. The survival benefit of baseline staging and surveillance in patients with cutaneous MM remains to be established by comparative prospective trials.

Laparoscopic technique for secondary vaginoplasty in male to female transsexuals using a modified vascularized pedicled sigmoid.

Between 1995 and 2002, 53 primary sex reassignments in male to female transsexuals were performed at our division. The objective of this procedure is to mimic the female external and part of the internal genitalia both esthetically and functionally. In 11 of the 53 patients, a secondary vaginal lengthening had to be performed due to a short neovagina. This was achieved using a pedicled sigmoid segment, with an open approach in the first 2 patients and using a laparoscopic method in the following 9. This paper focuses on the laparoscopic technique, its benefits and potential complications. Where a primary vaginoplasty, combining inversion of the penile and scrotal skin flaps, yields unsatisfactory functional results, a secondary vaginoplasty using the pedicled sigmoid represents an elegant means to achieve functional improvement. Furthermore, we report a modified surgical approach to the conventional sigmoid transition.

[Breast implant and desmoid tumor: is there an etiological relation?]. / Mammaimplantat und Desmoidtumoren: Besteht ein Zusammenhang?

Desmoid tumor of the breast is a rare lesion. So far only 8 cases in which the tumor origin was linked to a breast implant have been published. Whether there is an etiological relation to the silicone implant or if it is pure coincidence is not evident at this time. We present the case of a 24-year-old female with congenital asymmetric breasts who underwent breast augmentation in our division on the left side and 15 months later had a breast reduction on the other side. Nine years after the first operation we found a suspicious lesion on the side of the breast implant. The histological result of the excisional biopsy showed an aggressive fibromatosis "arising from" the capsule around the silicon implant. We discuss the possible association of breast implant and desmoid tumor of the breast and evaluate the diagnostic and therapeutic options for desmoid tumors of the breast.

[Necrotising fasciitis caused by streptococcal toxic shock syndrome]. / Nekrotisierende Fasziitis - durch Streptokokken induziertes Toxisches Schock-Syndrom.

Between 1994 and 1997, sixteen patients suffering from necrotising soft tissue infection were treated at the burn centre of the Division of Reconstructive Surgery, University of Zurich. The case of a 47 year old man is presented: He suffered from a necrotising fasciitis caused by Streptococcal induced Toxic Shock Syndrome (STSS). This example emphasizes the necessity of early diagnosis, priority of surgical intervention, and the antibiotic strategy. Necrotising fasciitis is a serious disease, caused by a variety of bacteria, which shows a high mortality rate, and its frequency was increasing over the last years.

[Methods, indications and validation of intraoperative nerve conductivity testing]. / Methode, Indikationen und kritische Wertung der intraoperativen Nervenfunktionsdiagnostik*

During nerve surgery, electrodiagnostic methods are applied to assess the availability and viability of nerve fibers and to adjust operative measures accordingly. The validity of this procedure is verified by histology and by the outcome of the operation. This paper explains the techniques of intraoperative nerve action potential (NAP) and somatosensory evoked potential (SEP) recording, how to interpret the electrodiagnostic results, and describes both the special features and the limitations of the methods. We found reliable results of neurography, detecting the presence or absence of spontaneous nerve regeneration across a lesion in continuity months before the reinnervation reached its final target. Based on our results, we suggest that NAP recording of the exposed nerve can widely prevent unnecessary nerve or fascicle resection. Besides this important indication, the nerve function evaluation was successfully used in nerve surgery whenever the quality of the nerve parenchyma was crucial to the operative management. Further indications such as evaluating brachial plexus lesions and the condition of nerve roots, judging the proximal coaptation site in nerve reconstruction, tracing the site of a nerve lesion and identifying the pathophysiology of nerve malfunction are exemplified. Intraoperative nerve conductivity testing should not be considered as a replacement of but rather as a complement to preoperative clinical, electrophysiological and imaging evaluations and a thorough intraoperative morphological examination.

Efficient gene expression in skin wound sites following local plasmid injection.

Transfection of the skin by local gene delivery, as well as widespread transfection of systemic tissues following intravenous injection of cationic liposome/DNA complexes have been reported. Here, we show that surgically wounded mouse skin can be transfected either by local injection of DNA alone or by intravenous injection of optimized cationic liposome/DNA complexes; however, direct cutaneous injection produces much higher levels of gene expression in the skin, which is targeted to dermal and subdermal layers. High levels of chloramphenicol acetyltransferase activity were present from 3 h to 2 wk following direct injection of a gene expression plasmid into wounded skin and were maintained at detectable levels up to 8 wk after injection. Expression of transferred chloramphenicol acetyltransferase as well as beta-GAL genes was localized to fibroblasts, macrophages, and adipocytes as determined by histochemistry and immunohistochemistry. Further- more, local injection of a human granulocyte- colony-stimulating factor gene expression plasmid produced high levels of the biologically relevant human granulocyte-colony-stimulating factor protein in wounded mouse skin. This efficient and simple method of site-specific gene transfer into wounds may lead to the development of cutaneous gene therapy directed against disorders of abnormal cutaneous wound healing.

Functional and morphometric evaluation of end-to-side neurorrhaphy for muscle reinnervation.

This study was undertaken to quantify the effect of motor collateral sprouting in an end-to-side repair model allowing end organ contact. Besides documentation of the functional outcome of muscle reinnervation by end-to-side neurorrhaphy, this experimental work was performed to determine possible downgrading effects to the donor nerve at end organ level. In 24 female New Zealand White rabbits, the motor nerve branch to the rectus femoris muscle of the right hindlimb was dissected, cut, and sutured end-to-side to the motor branch to the vastus medialis muscle after creating an epineural window. The 24 rabbits were divided into two groups of 12 each, with the second group receiving additional crush injury of the vastus branch. After a period of 8 months, maximum tetanic tension in the reinnervated rectus femoris and the vastus medialis muscles was determined. The contralateral healthy side served as control. The reinnervated rectus femoris muscle showed an average maximum tetanic force of 24.9 N (control 26.2 N, p = 0.7827), and the donor- vastus medialis muscle 11.0 N (control 7.3 N, p = 0.0223). There were no statistically significant differences between the two experimental groups (p = 0.9914). The average number of regenerated myelinated nerve fibers in the rectus femoris motor branch was 1,185 +/- 342 (control, 806 +/- 166), and the mean diameter was 4.6 +/- 0.6 microm (control, 9.4 +/- 1.0 microm). In the motor branch to the vastus medialis muscle, the mean fiber number proximal to the coaptation site was 1227 (+/-441), and decreased distal to the coaptation site to 795 (+/-270). The average difference of axon counts in the donor nerve proximal to distal regarding the repair site was 483.7 +/- 264.2. In the contralateral motor branch to the vastus medialis muscle, 540 (+/- 175) myelinated nerve fibers were counted. In nearly all cross-section specimens of the motor branch to the vastus medialis muscle, altered nerve fibers could be identified in one fascicle distal and proximal to the repair site. The results show a relevant functional reinnervation by end-to-side neurorrhaphy without functional impairment of the donor muscle. It seems to be evident that most axons in the attached segment were derived from collateral sprouts. Nonetheless, the present study confirms that end-to-side neurorrhaphy is a reliable method of reconstruction for damaged nerves, which should be applied clinically in a more extended manner.

Artificial skin, split-thickness autograft and cultured autologous keratinocytes combined to treat a severe burn injury of 93% of TBSA.

Despite refinements in burn shock resuscitation, improvements in surgical techniques, advances in intensive care medicine and the presence of very expert surgeons, the treatement of patients with severe burns exceeding 60% TBSA remains a big challenge. A major problem in the treatment of severe burn injuries is the lack of autologous skin. In selected cases cultured epidermal autograft (CEA) may be used. However, they are available only 2-3 weeks after biopsy, thus requiring a temporary wound closure after necrosectomy. A new option is Integra(TM), an artificial skin consisting of a bilayer membrane system. The three-dimensional porous matrix from bovine tendon collagen and a glycosaminoglycan layer is covered by a silicon sheet. The latter prevents fluid loss from the wounds and serves as a barrier against germ invasion. After adequate vascularisation of the dermal template, the silicon layer is removed and replaced by a thin autograft. We present a 26-year old male who sustained a 93% TBSA burn injury (60% full-thickness burn, 33% partial-thickness burn). He was treated with artificial skin, split-thickness autograft and CEA in combination. The clinical history and the follow-up of approx. 1 year are presented and the results discussed. We consider the survival of this patient being a result of the therapeutic progress of the recent decades.