Instep split skin grafts on muscle flaps to reconstruct pressure exposed soft tissue parts at the lower extremity.

BACKGROUND: Reconstructed mechanically stressed zones of the lower extremity frequently suffer from problems such as hyperkeratotic edges or chronic ulcerations in the transition zone between conventional thigh skin grafts and normal skin. Defect coverage with skin grafts harvested from the instep region and placed on muscle flaps is not yet an established alternative. METHODS: This is a retrospective study of a series of 12 clinical applications of soft tissue reconstruction at mechanically exposed zones of the lower extremity. Locally transposed or transplanted muscle flaps were covered with meshed instep skin instead of meshed thigh skin for the purpose to gain a superior stable skin surface and transition zones adjacent to normal skin. RESULTS: There is no ulceration found at follow-up from 6 to 72 months. Only one case presented with delayed graft take. Different thicknesses of the corneal layers of the healed instep versus thigh skin grafts were verified histologically. Instep skin grafts showed substantial durability as well as advantageous aesthetic appearance with respect to texture and coloring. All donor sites healed without notable scars or sensitivity disorders. CONCLUSIONS: The instep split skin graft is particularly well suited for defect coverage of muscle flaps transposed or transplanted to mechanically stressed zones of the foot or lower leg. The paramount advantage of transplanted instep skin as compared to thigh skin is given by the feasibility to create a durable graft with a thick horny layer and a stable transition zone at its periphery that is bordering normal skin.

Surgical vein occlusion--comparison of four different methods in a rat model.

BACKGROUND: Among many aspects, wound healing depends on early restoration of venous blood flow across wound margins. The type of surgical occlusion of vein stumps during operations was assumed to have an influence on the early postoperative reunion of vein stumps and thereby on wound healing. Currently, there are different methods of vein stump occlusion available: ligation (e.g., Vicryl), closure using metal clips (e.g., LigaClip), coagulation using manually controlled bipolar forceps, and the use of a computer-controlled bipolar system (e.g., BiClamp). The aim of this study was to surgically and histologically compare the healing process, including new vessel formation after vein occlusion using one of the methods listed. METHODS: In a rat model (n = 50), both jugular and femoral veins were prepared, occluded twice with one of the methods mentioned above (i.e., 400 occlusions), and finally cut in-between. Groups of 10 animals were reoperated and evaluated surgically and histologically after 5 days, 10 days, 15 days, 30 days, and 90 days. RESULTS: Occlusion methods using Vicryl, LigaClip, or bipolar forceps allow highly reliable vessel occlusion. Surgical evaluation showed higher occurrence of vessels in between the vein stumps after usage of Vicryl and LigaClip when compared with electrothermic occlusion methods (p = 0.017). Histologic examination showed different courses of the inflammatory reaction and varying capillary counts. Bipolar occlusion methods do cause less vessel occurrence, less inflammatory reaction, and less histologic capillary formation. CONCLUSION: If a reconnection of the venous flow is desirable, the use of Vicryl and LigaClip might be superior to using electrothermic occlusion methods. In contrast, electrothermic methods cause less new vessel formation as well as less inflammatory reaction.

[Versatility of the free gracilis muscle flap for coverage of soft-tissue defects]. / Der freie Musculus-gracilis-Lappen zur Weichteildefektdeckung.

OBJECTIVE: Coverage of soft-tissue defects of various sizes by an easy-to-do and reliable free muscle/myocutaneous flap. INDICATIONS: Soft-tissue defects of a size up to 10 x 22 cm. Functional muscle transfer, e.g., biceps muscle replacement. CONTRAINDICATIONS: Poor soft-tissue conditions or lesions on both thighs. No recipient vessels. Inadequate personnel and/or technical resources. SURGICAL TECHNIQUE: Approach via a longitudinal medial incision or via the thigh flexion fold. The flap can be designed with or without a skin island. After mobilization from its tendinous part up to its origin, the vascular pedicle is prepared until its origin from the deep femoral artery. After harvesting, transfer is performed by anastomosing and shaping, eventually followed by split-thickness skin grafting. POSTOPERATIVE MANAGEMENT: Clinical controls and measurement of partial oxygen concentration until day 10. Immobilization for 10 days, if the recipient site is close to a joint. Thrombosis prophylaxis. RESULTS: During the past 10 years, 254 free gracilis flaps were transplanted. Total flap loss rate was 4.3%, whereas reoperation due to hematoma or partial flap loss was necessary in 13.0%.

Pattern and severity of injury in avalanche victims.

In avalanche accidents, the significance of major trauma as a cause of morbidity and mortality is controversial. The aim of this retrospective study is to determine the severity and pattern of injury in avalanche victims admitted to the University Hospital of Innsbruck between 1996 and 2005. A total of 49 significant injuries were found in 105 avalanche victims; the most frequent were of the extremities (n = 20), the chest (n = 18), and the spine (n = 7). In contrast, cerebral (n = 2), abdominal visceral (n = 1), and pelvic trauma (n = 1) were rare. The severity of injury was minor or moderate in most patients, with only 9 (8.6%) being severely or critically injured. Of 105 (34.3%) avalanche victims, 36 died. Autopsy was performed in 30 of 36 nonsurvivors. The cause of death in the remaining 6 victims was concluded from clinical, radiological, and electrophysiological findings. Trauma was responsible for deaths of only 2 avalanche victims (5.6%); both had cervical spine fractures with dislocation leading to death. One death was due to hypothermia, whereas the remaining 33 fatalities (91.7%) were due to asphyxia. The incidence of life-threatening or lethal trauma was well below 10%. Asphyxia is by far the most important reason for death. Deaths from trauma were solely due to isolated cervical injuries, demonstrating that the cervical spine may be a region at particular risk in avalanche victims.

Tyrolean tensiometer: a new instrument for easy intraoperative tension measurement before vascular anastomosis.

BACKGROUND AND AIM: In reconstructive surgery microsurgical repair of dissected arteries sometimes has to be done under longitudinal tension. Guidelines to support an objective decision on whether tension associated with direct suture is acceptable or whether grafting is needed, do not exist. All experimental data found concerned the clinical outcome of a certain length defect treated in various animal models. The aim of this study was to show the feasibility of a new instrument for measuring the tension required to adapt arterial stumps, thereby allowing surgical outcome to be assessed before beginning anastomosis. MATERIAL AND METHODS: A modified tension spring balance was used to measure the force applied to the arterial stumps before knotting. Twenty-four rat femoral arteries were dissected, segments of up to 9mm were resected, and the tension needed for approximation was measured. These ex-vivo data were combined with clinical outcome data of previous animal trials. RESULTS: The tension measured increased proportionally to the size of the arterial gap created. The correlation between tension and arterial gap was found to be almost linear. The average additional time required for tension measurement using the Tyrolean Tensiometer was 13 (+/-6) s. DISCUSSION: High anastomotic tension may cause critical or even poor clinical outcome. None of the tension measurement methods described so far allow intraoperative measurement at a time when changes in strategy are still possible. The Tyrolean Tensiometer for the first time allows fast and reliable measurement of the tension acting on the first suture of an anastomosis.

Tyrolean tensiometer: A new instrument for easy intraoperative tension measurement before nerve coaptation.

BACKGROUND: In reconstructive surgery microsurgical repair of dissected nerves can be done end-to-end or by using a nerve graft. Guidelines to support an objective decision, whether tension associated with direct suture is acceptable or grafting is needed, do not exist. All experimental data found concerned the clinical outcome when a certain length defect was treated in various animal models. The aim of this study was to show the feasibility of a new instrument for measuring the tension needed to coapt nerve stumps before beginning nerve suture. METHODS: A tension spring balance was modified in a way that the thread of the first suture is used to measure the force applied to the two nerve stumps by the suture before knotting. Immediately after measuring, the suture can be completed by knotting. Twenty-four rat sciatic nerves were dissected, segments of various length were resected, and tension needed for approximation was measured. These ex vivo data were combined with clinical outcome data of previous animal trials. RESULTS: Data obtained showed that tension measured increased almost proportionally to the size of the gap created. The average additional time needed to measure the tension using the Tyrolean Tensiometer was 11 (+/-4) seconds. CONCLUSIONS: None of the methods described before allow intraoperative tension measurement at a time when changes in strategy are still possible. The Tyrolean Tensiometer allows fast and reliable measurement of the tension acting on the first suture and might hereby be useful in predicting final operative outcome.

Bipolar anastomosis technique (BAT) enables "fast-to-do", high-quality venous end-to-end anastomosis in a new vascular model.

The interrupted suture technique is most commonly used for microsurgical venous anastomosis. Needle-stitch trauma and intraluminal suture, however, potentially cause vascular wall damage, thrombosis, intimal hyperplasia or even stenosis. Therefore, the present study aimed to show the feasibility and reliability of a modified cuff technique (bipolar anastomosis technique (BAT)) for venous end-to-end anastomosis in a new chicken throat vascular model. In ex vivo experiments, freshly resected chicken jugular veins (N = 96) were used to find ideal BAT time to current settings for venous end-to-end anastomosis. Thereafter, the left jugular vein of chickens (N = 40) was dissected in vivo and subsequently anastomosed using BAT. The quality of anastomosis was evaluated by Doppler sonography immediately, at two hours and at two, six, 12, 16, and 29 weeks after surgery. Additional histological examination took place at two hours (N = 8) and at two (N = 6), six (N = 6), 12 (N = 6), 16 (N = 6) and 29 (N = 6) weeks after surgery. Immediately after surgery (N = 40) and at two hours (N = 38) venous anastomoses were found to be patent in Doppler sonography. Anastomotic rupture caused death in two animals within one hour after surgery. Thrombotic occlusion was found in one animal at six weeks after surgery. In the remaining animals (N = 37) only minimal stenosis which decreased to almost normal levels was sonographically found. The average time needed for anastomosis using BAT was less than two minutes. BAT allows fast venous end-to-end anastomosis in a chicken throat vascular model.

Nipple reconstruction using a modified arrow flap technique.

Nipple reconstruction is the perfection of breast reconstruction. Although many reconstruction techniques are available, all come with the risk of projection loss. Most of the commonly used local flap techniques give reliable immediate results, but are associated with a loss in projection of 50 to almost 70% over the first three postoperative years. We herein present a modification of the nipple reconstruction technique as presented by Thomas et al. in 1996. By forming a deepithelialized area when closing the skin donor site, a firm foundation plate for the new nipple is created. The authors observed that this solid foundation plate, as well as the separation of the nipple cavity of the subcutaneous fat, results in less nipple projection loss.

Peroneal nerve lesion after sural nerve graft harvest: an unusual complication--case report.

After harvesting of the sural nerve, the patient developed a partial palsy of the common peroneal nerve due to a lesion of the peroneal nerve and a neuroma of the sural nerve stump. Motor function recovered after performing neurolysis of the common peroneal nerve and mobilization of the neuroma. The sural nerve, in this case originating from the common peroneal nerve, was harvested using a nerve stripper and four small skin incisions. Direct lesion by the forced use of the nerve-stripping instrument followed by the formation of a neuroma close to the peroneal nerve are the suspected reasons for motor dysfunction. Although many authors report using a nerve stripper as a safe, less invasive method to gain nerve material for transplantation, we recommend lengthening the skin incision so as to be aware of anatomical variations and to refrain from pulling the nerve distally to avoid the described complications.

Bipolar anastomosis technique with removable instruments: an easy, fast, and reliable technique for vascular anastomosis.

The interrupted suture technique is most commonly used for microsurgical vascular anastomosis. For several reasons (e.g., exposure of suture material to blood, time needed), many attempts have been made to find other solutions. This article describes a new means of performing a microsurgical vascular anastomosis. The aim of this study was to show the feasibility and possible advantages of this new technique. The basic components at work here are a modified cuff and electrically generated heat used to unite the vessel walls. In this way, both endothelial layers are adapted without manipulating the inside of the vessel or leaving behind foreign matter. Various energy/coagulation time settings were used to perform arterial anastomoses (n = 42) in an isogeneic abdominal aorta interposition model in the rat. The quality of anastomosis was evaluated at days 1, 10, 21, and 120. Immediately after the welding process all anastomoses (n = 42) were patent. No stenosis was found at any observation time. Anastomosis time ranged from 3 to 18 minutes (average, 11 minutes). This new technique permits a vascular anastomosis to be performed easily and reliably with a high patency rate. With this technique, the authors are convinced that a skilled surgeon can create a high-quality anastomosis in a fraction of the time needed to sew an anastomosis.

Acceptance of telemedicine and new media: a survey of Austrian medical students.

Telemedicine and new media (e.g. the Internet, tele-teaching and tele-learning) are increasingly being used in medicine. We surveyed the awareness and acceptance of these developments on the part of medical students (n =750) at the University of Innsbruck. A 16-item questionnaire was handed out in randomly chosen medical classes and collected immediately after completion, which resulted in a response rate of 99.9%. Nearly all of the students used the Internet regularly (68%) or at least sometimes (30%). Telemedicine was already known to most of the students, mainly from articles in magazines and newspapers (41%), but the great majority of them (95%) reported that they did not know about the telemedicine lectures offered by the University of Innsbruck. Most students (75%) thought that they would benefit from tele-teaching or tele-learning. The survey suggested that medical schools should offer more special lectures, as well as undergraduate or postgraduate qualifications in telemedicine. The marketing of such opportunities needs to be improved.