[Interdisciplinary position paper "Perioperative pain management"]. / Interdisziplinäres Positionspapier "Perioperatives Schmerzmanagement".

Despite many positive developments, postoperative pain and its treatment is still not always given the necessary attention. Severe pain after surgical procedures affects a significant proportion of patients. This very fact is not only detrimental to the immediate recovery process, but can also form the basis for the development of chronic pain conditions.An adequate and effective management of perioperative pain requires appropriate organizational structures. This multidisciplinary paper which was initiated by the Austrian Society for Anaesthesiology and Intensive Care and the Austrian Pain Society and developed together with numerous specialist and professional societies dealing with the subject aims at supporting the organization of perioperative pain management structures and to make best use of proven concepts. Additional recommendations describe specific interventions for selected types of intervention.

[Peri-areolar approach in pronounced gynecomastia with focus-plasty and liposuction]. / Der periareoläre Zugang bei ausgeprägter Gynäkomastie mit Focusplastik und Fettabsaugung.

INTRODUCTION: The treatment of gigantic gynecomastia has usually been accompanied by ugly scars. METHODS: Because of our experiences in 38 patients with gynecomastia grade III, we suggest a surgical technique that not only involves a simple mastectomy and liposuction, but also a mere periareoler incision and, if necessary, repeated focusplasty and liposuction. Excessive skin can be repaired with a so-called focusplasty. RESULTS: In young patients this can successfully be achieved in one operation. CONCLUSIONS: Because skin has a minimized ability to retract in older patients, repeat operative sessions are necessary.

Suture granulomas: sonography enables a correct preoperative diagnosis.

The purpose of this study was to examine if suture granulomas display distinct sonographic signs and if these signs enable an accurate preoperative diagnosis. In a retrospective and prospective study, the sonographic findings of 22 consecutive suture granulomas were investigated and correlated with subsequent operative results. The sonographic appearance of various surgical sutures in a water bath was also investigated. Sonography was performed with commercially available 5- to 13-MHz linear transducers. The sonographic findings of the suture granulomas included hypoechoic lesions in all cases and hyperechoic double or single lines within the hypoechoic lesions in 20 of 22 cases. Sonography enabled the correct preoperative diagnosis for the investigating radiologists in 20 cases. The sonographic appearance of sutures in a water bath was that of hyperechoic double or single lines. The sonographic signs of suture granulomas (hyperechoic double or single lines within hypoechoic lesions) indicate the correct preoperative diagnosis in a high percentage of cases.

Anatomical study of the perforating vessels of the lower leg.

Difficulty of soft tissue defects of the lower leg demands the development of new methods to treat such defects. The aim of this study is the examination of perforators and the various ways of blood supply to the skin in the lower leg. Provided with certain regularity, we would be able to cure soft-tissue defects also in the difficult zone of the distal segment and on the dorsum of the foot not harming vessels and not affecting mobility of muscles. Subcutaneous island-flaps supplied by perforating vessels could replace free flaps. By saving the crural fascia of 10 lower legs we flayed layers of skin and fat, marked the perforating vessels with pins, and photographed and documented them. Specimens were divided into a proximal, an intermediate and a distal segment, each of them subdivided into a medial, lateral and dorsal section. The perforators, which can be classified as septocutaneous and musculocutaneous vessels, followed a reproducible pattern all over the lower leg. All vessels were sufficient in number as well as in size. Additionally these perforators can easily be identified by colour-coded sonography. The knowledge that perforators in the lower leg occur regularly enables the development of a new operative approach in therapy of soft-tissue defects in this region with the advantage, that the vessels used can be selected preoperatively.

[Effect of transplant length on functional and morphologic outcome of nerve transplantation--an experimental study]. / Der Einfluss der Transplantatlänge auf das funktionelle und morphologische Ergebnis der Nerventransplantation--Eine experimentelle Studie.

BACKGROUND: The present study was done in order to clarify whether the sometimes poor results after the use of long grafts for nerve reconstruction are due to the length of the graft itself or due to the concomitant big defect in the soft tissues necessitating the use of long grafts. METHODS: In 22 rabbits, the saphenous nerve was used as a nerve graft. Animals were separated into three groups with different lengths of the grafts, namely 3 cm (group 1), 5 cm (group 2) and 7 cm (group 3). In one hindlimb, the proximal end of the graft was coapted to the motor nerve branch of vastus medialis. In a second step, the distal end of the graft was coapted to the nerve branch of rectus femoris. After a total period of 15 months the maximum tetanic tensions in the reinnervated rectus femoris and in the contralateral untreated muscle were determined. Biopsies of the graft and the motor branch distal to the graft were taken in order to count the number of regenerated myelinated nerve fibers. RESULTS: The average maximum tetanic tension in the rectus femoris muscle reinnervated by the 3 cm long graft was 27.2 N; in group 2 the force amounted to 20.4 N. In group 3, the maximum force was 17.6 N, which meant an average loss of 29% compared to the contralateral untreated muscle. In accordance with the functional results, the mean number of regenerated myelinated fibres in the rectus femoris motor branch decreased from 1683 in group 1 to 1136 in group 3. CONCLUSIONS: The results show that the length of the graft influences the results after nerve grafting to a certain extent, but a combination of other factors like concomitant soft tissue injury and destroyed target organs may also be responsible for some of the poor results after the clinical use of long nerve grafts.

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.

[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.

The impact of a muscle target organ on nerve grafts with different lengths--a histomorphological analysis.

The present study was done in order to evaluate the influence of a target muscle on the regenerative processes in long nerve grafts. In 21 rabbits the saphenous nerve was used as a nerve graft and coapted to the cut motor nerve of vastus medialis. The animals were separated into three groups with different graft lengths, namely 3, 5, and 7 cm. In a second stage the distal end of the graft (Graft.dist.) was coapted to the motor branch of rectus femoris. Cross sections of the normal vastus nerve and the Graft.dist. before and 7 months after the connection to rectus femoris were analyzed histomorphometrically. Before coaptation to the target organ mean fiber number in the Graft.dist. of the 3-cm-long grafts was 3380 and decreased to 2413 in the 7-cm-long grafts. Seven months after coaptation the results showed a statistically significant decrease of fibers in the Graft.dist. of group two and three and a distinct decrease of the fibers in group one. Summarizing, in a two-stage nerve grafting procedure the reinnervation of the muscle target organ leads to a down-regulation of fibers in the distal end of short and long nerve grafts.

Mucosal prelaminated flaps for physiological reconstruction of intraoral defects after tumour resection.

In order to provide vascularised mucosa for reconstruction of intraoral defects after radical tumour resection, 5 distal radial forearm flaps and 1 fibula flap were prelaminated. Prelamination was performed by fixing small, full thickness mucosa pieces onto the fascia and covering the mucosa with an alloplastic sheet as large as the future flap. The alloplastic material was a silicone sheet (n = 2), a Gore-tex sheet (n = 3) or a titanium sheet (n = 1). The mucosa and the alloplastic material were covered by the skin and subcutaneous tissue which had been elevated to expose the fascia. With the silicone and titanium sheets, the mucosa spread on the fascia and the final flaps were thin, pliable, mucus-producing and larger than the original mucosa pieces. With the Gore-tex sheets, extension of the mucosa was prevented by adhesions and the area of mucosa on the final flap was the same size as the original graft. The six prelaminated flaps were harvested after 8-10 weeks. During this time the patients had radiotherapy and chemotherapy. Preserving the skin and subcutaneous tissue reduced donor site morbidity. Six patients had intraoral defects successfully reconstructed with mucus-producing prelaminated flaps.

The influence of the graft length on the functional and morphological result after nerve grafting: an experimental study in rabbits.

Clinical experience shows that the results after the use of long nerve grafts for reconstruction are sometimes poor. Nevertheless several authors have stressed that the concomitant big defect in the soft tissues necessitating the use of long grafts is the reason for some of the failures. In 22 rabbits the saphenous nerve was used as a nerve graft. Animals were separated into 3 groups with different lengths of the grafts, namely 3 cm (group 1), 5 cm (group 2) and 7 cm (group 3). In the left hindlimb the proximal end of the graft was coapted to the cut motor nerve branch of vastus medialis. In a second stage the distal end of the graft was coapted to the nerve branch of rectus femoris. After a total period of 15 months the maximum tetanic tension in the reinnervated rectus femoris and in the contralateral unoperated muscle was determined. Biopsies of the graft and the motor branch distal to the graft were taken in order to count the number of regenerated myelinated nerve fibers. The average maximum tetanic tension in the rectus femoris muscle reinnervated by the 3 cm long graft was 27.2 N, in group 2 the force was 20.5 N. In group 3 the maximum force was 17.6 N, which meant an average loss of 29% compared to the contralateral unoperated muscle. The mean number of regenerated myelinated fibres distal to the graft in the rectus femoris motor branch was 1683 in group 1 and decreased to 1137 in group 3. The results show that the length of the graft influences the results after nerve grafting to a certain extent, but a combination of other factors like concomitant soft tissue injury and destroyed target organs may also be responsible for some of the poor results after the clinical use of long nerve grafts.

Donor-site morbidity of the gracilis flap.

To determine whether there is a specific donor-site morbidity inherent in the elevation of the gracilis flap, we retrospectively examined 42 patients who underwent elevation of their gracilis muscles. We found, on dynamometric measurement, that the adduction strength of the hip joint was decreased by 11 percent when the gracilis muscle was elevated. This decrease in strength was not noticed by the patients. We also found an area of hypesthesia corresponding to the cutaneous territory of the obturator nerve in 40.5 percent of the patients. In addition, many patients were dissatisfied with the aesthetic appearance of the donor site, and a contour deformity of the thigh was present when a myocutaneous flap was elevated. Therefore, we conclude that the gracilis flap has a low but definite rate of donor-site morbidity. The advantages of the flap outweigh by far, however, the sequelae at the donor site.

[Functional and esthetic assessment of donor site defects following transfer of the gracilis muscle]. / Funktionelle und ästhetische Beurteilung der Hebedefekte nach Entnahme des Musculus gracilis.

In order to determine donor-site morbidity after elevation of the gracilis flap, 53 patients from four different departments were examined. The patients filled out a questionnaire about their complaints. 36 patients underwent dynamometric measurements. The adduction strength of the hip-joint was decreased by 11% after elevation of the gracilis muscle. This decrease in strength was not noticed by the patients. 53% of the patients complained about hypesthesia or dysesthesia corresponding to the cutaneous territory of the obturator nerve. The contour of the thigh was adversely affected after elevation of a musculocutaneous flap. The gracilis flap has a low but definite donor-site morbidity, especially concerning the esthetic aspect.

Surgical treatment of developmental asymmetry of the breast. Long term results.

To evaluate our operative techniques for the treatment of breast asymmetry, 30 patients were interviewed and examined three to 16 years after correction of developmental asymmetry. Breast symmetry was assessed by linear measurements and by subjective evaluation. The most satisfactory long term results were found in the patients who had undergone bilateral reduction mammaplasty or unilateral reduction mammaplasty combined with a contralateral mastopexy. In some cases longer lasting symmetry could be achieved by operating on both breasts using similar techniques. Long term results were not significantly better in those patients who had been operated after reaching the age of 18 years, compared with those of patients operated on at the age of 17 years or younger. To avoid psychological consequences therefore it is not always justifiable to delay operation until the breasts have matured.