A comparison of the donor-site morbidity after using the prelaminated fasciomucosal flap and the fasciocutaneous radial forearm flap for intraoral reconstruction.

Since 1996 we have performed mucosal prelamination of the distal radial forearm flap for functional reconstruction of defects of the intraoral lining. This study was undertaken to demonstrate that the prelaminated fasciomucosal radial forearm flap can provide physiological oropharyngeal reconstruction with mucus-producing tissue, while avoiding the donor-site complications of the fasciocutaneous radial forearm flap. We examined the donor hand at least 6 months postoperatively in 20 patients after using a prelaminated fasciomucosal radial forearm flap and in 15 patients after harvesting a classical fasciocutaneous radial forearm flap. The evaluation of hand function included range of motion, grip power, pinch power, sensibility and vascular analysis in both hands. The patients were asked about cold intolerance, pain and any restrictions in daily life, and the cosmetic appearance of the donor hand was noted. In the prelaminated-flap group (n 20), two patients had decreased wrist extension, and one of these patients also had reduced strength and mild hypaesthesia in the donor hand. In the classical-fasciocutaneous-flap group (n 15), six patients had decreased wrist extension, five patients had reduced strength and four patients had diminished sensibility in the donor hand. Painful neuromas were found only after fasciocutaneous flaps (three cases). Subjective assessment revealed restricted hand function in one patient in the prelaminated-flap group, and in five patients who had undergone fasciocutaneous flap transfer. The results of this study show that using the prelaminated fasciomucosal radial forearm flap minimises the donor-site morbidity. Furthermore, we were able to improve the cosmetic appearance of this very exposed region.

The influence of the donor nerve on the function and morphology of a mimic muscle after cross innervation: an experimental study in rabbits.

In the present study we used the scutuloauricularis muscle in the rabbit to investigate the functional and morphometric alterations in the mimic-muscle system after cross-reinnervation. The scutuloauricularis muscle is the first experimental model that allows functional assessment of a mimic muscle by force measurements. A total of 36 rabbits were separated into three groups. In group 1 the scutuloauricularis nerve was cut and re-sutured to itself to achieve self-reinnervation; in group 2 the buccal nerve was used to cross-reinnervate the fast scutuloauricularis muscle and in group 3 the slow buccinator muscle was cross-reinnervated by the scutuloauricularis nerve. After a period of 6 months the maximal tetanic tensions of the reinnervated scutuloauricularis muscles were determined and histomorphometric examinations of muscle and nerve biopsies were carried out. Force measurements showed no loss of muscle force after self- and cross-reinnervation. The normal scutuloauricularis muscle contained 33%, and the buccinator muscle 46%, slow type I fibres. After self-reinnervation of the scutuloauricularis muscle the fibre-type composition remained unchanged. After cross-reinnervation we saw a significant fast-to-slow transformation of the scutuloauricularis muscle and a significant slow-to-fast transformation of the buccinator muscle. The number of myelinated nerve fibres in the scutuloauricularis nerve increased after cross-reinnervation from 1531 to 4077 (group 2) and to 3813 (group 3). The number of nerve fibres in the buccal nerve (3209) was unchanged after cross-reinnervation. The results of the present study might be relevant in the treatment of irreversible facial palsy by functional muscle transplantation and cross-face nerve grafting. The facial nerve branch used for cross-reinnervation seems to determine the functional outcome.

[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.

[Contour defects after breast preserving therapy of breast carcinoma. Primary and secondary possibilities of correction]. / Konturdefekte bei brusterhaltender Therapie des Mammakarzinoms. Primäre und sekundäre Möglichkeiten der Korrektur.

BACKGROUND: Breast conserving treatment is increasing for primary treatment of breast carcinoma because of the importance of the cosmetic outcome. PATIENTS AND METHOD: We examined 195 patients after breast conserving therapy which was performed between 1983 and 1992. For evaluation of the cosmetic result symmetry, contour of the breast and location of the areola were examined. Radiation effect on breast tissue was evaluated by the Lent score. 72% of the patients had been treated with quadrantectomy and 28% with lumpectomy. RESULTS: Deformities of the contour were visible in 59% of the patients depending on the primary location of the tumor. Lumpectomy from medial quadrants caused poor results. Dislocation of the areola of more than 2 cm was detected in 32% of the patients. The dislocation depended on the primary kind of incision and resulted in 89% of the patients after a radial incision and only in 11% after curvilinear incisions. Telangiectasias were absent in 84% of the patients, the others showed telangiectasias Grade 1 to 3. In 48% of the patients no signs of fibrosis could be detected, in 49% fibrosis Grade 1 to 2 was found. 68% of the patients estimated the cosmetic result as very good or good. Only 10% of the patients estimated the result as fair or bad. The examiner estimated the results as good or very good in 28%. Examples of operative procedures for primary and secondary correction are demonstrated. CONCLUSIONS: Our results showed an adverse effect of long radial incisions. For lumpectomy and axillary node dissection separate incisions should be used. Correction of contour deformities should be done primarily in breast conserving procedures. This is possible by using modified reduction mammaplasties, local flaps of the breast tissue or switching a latissimus dorsi muscle flap. For secondary correction of defects after breast conserving treatment a latissimus dorsi muscle can be used as well as z-plasty for scar contracture.

Neuromucosal prelaminated flaps for reconstruction of intraoral lining defects after radical tumor resection.

To reconstruct intraoral lining defects after radical tumor resection by reinnervated vascularized mucosa, eight distal radial forearm flaps and two fibula flaps were prelaminated. Prelamination was performed by exposing the vascularized fascia, onto which the split distal end of a sural graft was fixed. The fascia and the sural nerve graft were covered by device-meshed mucosa or small full-thickness mucosa pieces. These structures again were covered by a Silastic sheet as large as the future flap, and the wound was closed by the elevated skin and subcutaneous tissue. Coverage by a Silastic sheet enabled mucosal spreading on the fascia, and the final flaps were thin, mucus-producing, and larger than the originally inserted mucosa. The 10 neuromucosal prelaminated flaps were harvested together with the inserted sural nerve graft after 8 to 10 weeks. During this time, the patient underwent radiotherapy and chemotherapy. Donor sites were closed directly by the preserved skin and subcutaneous tissue. Intraoral defects were reconstructed successfully by eight neuromucosal prelaminated distal radial forearm flaps and two neuromucosal prelaminated fibula flaps. The sural nerve grafts, inserted between the fascia and the mucosa, were coaptated eight times with the lingual nerve and two times with the inferior alveolar nerve. Intended reinnervation of the mucosa could already be proved clinically and histologically in the first two patients after 11 and 9 months. Preservation of skin and subcutaneous tissue considerably lowered donor-site morbidity. Neuromucosal prelamination enables reconstruction of intraoral lining defects by reinnervated mucus-producing tissue. Reconstruction of other mucosa-lined structures by this method seems feasible. Avoidance of skin islands for reconstruction lowers donor-site morbidity.

[Actinic brachial plexus lesion]. / Aktinische Plexus brachialis-Läsion.

Radiation-induced brachial plexus lesions are progressive and irreversible complications. Until now, there is no way to successful prevention and treatment of this problem. In our series, relief of pain could be achieved by neurolysis in some cases, but there was no recovery of sensory and motor function. In order to improve the vascularity and nerve tissue regeneration, we performed muscle or gliding tissue flaps after neurolysis in our department. Since 1975, 25 patients who developed radiation-induced plexopathy were treated in our department. We followed 18 patients to evaluate the benefits of our surgical intervention. None of the patients had improvement of their sensory or motor impairment. Relief of severe pain was achieved in 83% either by neurolysis only with or without muscle or gliding tissue flap. In some cases, paresis worsened postoperatively. We also observed a return of severe pain after the operation.

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.

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.

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.

Long term results of inflatable mammary implants.

In this retrospective study, the long term results of 167 inflatable mammary implants in 77 patients who underwent either breast reconstruction or augmentation between 1972 and 1990 were evaluated. All inflatable implants were manufactured by Heyer-Schulte/Mentor company, and were equipped with a posterior leaf valve (style 1800). The mean follow-up was 9 years (SD = 4.3). Complete deflation was found in 23.9% of the implants (22.2% deflation rate from 1972 to 1984 and 25.5% from 1985 to 1992). The incidence of this complication was significantly higher in patients who underwent previous open (p = 0.012) or closed (p = 0.038) capsulotomy. Severe contracture of the implant fibrous capsule (BAC 3 and 4) was found in 37.6% of the patients. Its incidence increased significantly when the postoperative blood loss (assessed by the volume of blood collected by suction drainage) exceeded 250 cc (p = 0.025). Neither the site of the implant (submuscular/subglandular) nor the indication for surgery (reconstruction/augmentation) influenced the rate of severe capsular contracture significantly in this retrospective study.