Histological and clinical findings in different surgical strategies for focal axillary hyperhidrosis.

INTRODUCTION: Although a variety of different surgical strategies for focal axillary hyperhidrosis (FAH) have proven effective, little is known of intraoperative and postoperative histologies of different surgical methods. OBJECTIVE: The objective was to use pre-, intra-, and postoperative histologic findings to evaluate different surgical procedures for FAH in establishing a possible correlation between the interventions and clinical outcome. MATERIAL AND METHODS: A total of 40 patients underwent surgery with 15 undergoing liposuction-curettage (LC), 14 radical skin excision (RSE) with Y-plasty closure, and 11 a skin-sparing technique (SST). Before surgery, density and ratio of eccrine and apocrine sweat glands were evaluated with routine histology. Further biopsies were taken directly after surgery in the RSE and SST groups and 1 year postoperatively in all patients. Additionally, gravimetry was performed, side effects were documented, and patients were asked to evaluate the aesthetic outcome of the surgical method by using an analogue scale. RESULTS: Preoperatively, the mean density of eccrine glands was 11.1/cm(2) compared to 16.9/cm(2) apocrine glands (apocrine/eccrine ratio, 1.6). Biopsy specimen directly after surgery showed remaining sweat glands in 7/15 (46.7%) LC patients and in 4/11 (36.4%) of the SST patients. One year after surgery, sweat gland density was significantly reduced in the LC (79.1%) and the SST (74.9%) groups. In the RSE group, only scar formation was present. Gravimetry showed significantly reduced sweat rates 12 months after surgery in all groups (LC, 66.4%; SST, 62.9%; RSE, 65.3% [p<.05]). Most frequent side effects were hematoma (LC, n=3; SST, n=2; RSE, n=3), subcutaneous fibrotic bridles (LC, n=8; SST, n=3; RSE, n=0), skin erosion (LC, n=3; SST, n=4; RSE, n=0), focal hair loss (LC, n=9; SST, n=11; RSE, n=14), and paresthesia (LC, n=4; SST, n=3; RSE, n=5). CONCLUSION: Histologic distribution and density of sweat glands were comparable to previous studies. All three surgical procedures evaluated are effective in the treatment of FAH. RSE and SST techniques are associated with a higher risk of side effects and cause more extensive scarring. However, one LC patient (n=1; 6.7%) did not respond to treatment.

Outcome of simultaneous and staged microvascular free tissue transfer connected to arteriovenous loops in areas lacking recipient vessels.

BACKGROUND: Arteriovenous loops are an indispensable tool in free flap surgery when appropriate recipient vessels are missing. In this study, the authors analyzed whether the outcome differs when flaps were transferred simultaneously or subsequently after construction of arteriovenous loops. METHODS: Twenty-seven patients requiring free tissue transfer received arteriovenous loops by pedicled or free vein grafts because of inadequate local recipient vessels. In head and neck reconstruction, pedicled brachiocephalic or free saphenous vein grafts were anastomosed to cervical or axillary vessels. Pedicled major saphenous vein grafts were used in the pelvic area whereas, in lower leg and foot reconstruction, free saphenous or brachiocephalic veins were used. Flaps were transferred simultaneously (n = 10) or 4 to 17 days later (n = 17). RESULTS: Thrombosis required revision in staged transfer (n = 3 patients) or in simultaneous flap transfer (n = 2). No free flap was lost. Fisher's exact test did not indicate a significant difference between a simultaneous or staged flap transfer. CONCLUSIONS: Temporary arteriovenous loops provide adequate recipient vessels and flow to supply microvascular free flap tissue transfer in areas lacking recipient vessels and in which no other reconstructive options exists. No statistical differences in complications and overall outcome were found between immediate or secondary free tissue transfer. Meticulous monitoring of microvascular perfusion, however, is mandatory in both approaches and early intervention is necessary to ensure successful tissue transfer.

Combination of surgical excision and custom designed silicon pressure splint therapy for keloids on the helical rim.

Keloids are defined as dermal fibrotic lesions which are considered an aberration of the wound healing process. Their etiology and pathogenesis are poorly understood. Different treatment modalities are described in the literature depending on the morphology and size of the keloid. We report a case of a large ear keloid on the helical rim which was successfully treated with surgery and a custom designed silicon pressure clip.

Significant angiogenic potential is present in the microenvironment of muscle flaps in humans.

The purpose of this study was to determine the presence of growth factors and the quality of angiogenic potential in the wound microenvironment in different types of flaps in humans. The wound exudates from 23 flaps were processed for analysis of transforming growth factor beta1 (TGF-beta1), epidermal growth factor (EGF), interleukin 1alpha (IL-1alpha), platelet-derived growth factor-AB (PDGF-AB), vascular endothelial growth factor (VEGF), and insulin-like growth factor (IGF-1) by enzyme-linked immunosorbent assay (ELISA) or radio immuno assay (RIA). Angiogenic activity of wound fluid from latissimus flaps was determined by thymidine incorporation in porcine microendothelial cells exposed to various concentrations of wound fluid and control media. Angiogenic and matrix growth factors were altered in a linear fashion during the wound-healing process. Regression analysis provided evidence for decreasing levels of PDGF and EGF for latissimus flaps. Also, statistically significant differences of growth factor levels were found for paired comparison of flap types at different times after operation. Growth of in-vitro endothelial cells was stimulated most by 10 percent wound fluid, compared to any of the individual recombinant angiogenic factors or combinations of these factors. The data suggest that vascularized tissue flaps will promote wound healing by providing sufficient sources of growth factors in the wound environment. The particular type of flap, i.e., muscle or fasciocutaneous flap, does not seem to have an impact on growth-factor expression.