Increasing the vascular pedicle length in a free flap using a two-stage preliminary ectopic transfer.

The length of the vascular pedicle is critically important in the use and safety of a free flap. A lengthening of the artery and vein, until now, has been achieved through the use of either an autologous vein interposition graft or an arteriovenous loop. In such patients, the risk is nevertheless increased and does so proportionally to the increasing length of the venous interposition. We present a 30-year-old male electrician who had lost his left forearm and most of his right ulna after high-voltage electrical trauma. Lengthening of the vascular pedicle of a free fibula flap was achieved by anastomosis to the thoracodorsal vessels for 4 weeks. After this time, the flap was raised again together with the pedicle of the latissimus dorsi and used safely for reconstruction of the ulnar defect. Postoperative recovery after both operations was uneventful and the aim of reconstruction fully realized. In our opinion, this procedure provides an interesting alternative in patients in whom the length of the vascular pedicle is crucial but the designated flap has only a short pedicle.

[Dupuytren's contracture. When operate? Conservative preliminary treatment?]. / Dupuytrensche Kontraktur. Wann operieren? Konservative Vorbehandlung?

The etiology, symptomatology, clinical findings, course and staging of Dupuytren's contracture are discussed. Surgery is indicated from the second stage onwards; since pain very rarely occurs, it plays no role in establishing the indication for operation. The surgical techniques available are described. Conservative therapy has no influence on the course of the condition, while radiotherapy is inadmissible on account of its side effects. Physical therapy and physiotherapeutic pre-operative measures can improve the results of surgery.

[Fasciocutaneous flap--a simple alternative to the musculocutaneous or free, microvascular flap of the lower extremity?]. / Der fasziokutane Lappen--eine einfache Alternative zum muskulokutanen oder freien, mikrovaskulären Lappen an der unteren Extremität?

Fasciocutaneous flaps demonstrate, in comparison to subcutaneous transposition flaps, far better local hemodynamic circulation and the length to width ratio can be increased to 3:1 or 5:1 so that they provide a simple method of closure in soft tissue defects. Fasciocutaneous flaps can be prepared rapidly and simply, due to the subfascial dissection, so that traumatic soft tissue defects can be closed directly. The donor site is closed with a split skin graft. Free musculocutaneous flaps and regional musculocutaneous island flaps are far more useful in large muscular defects, degloving injuries and osteomyelitis.

[Reconstruction of the cranial vault and soft tissues of the skull after electrotrauma]. / Rekonstruktion der Schädelkalotte und der Weichteile des Schädels nach Elektrotrauma.

Of 550 patients treated in our burn unit 5.1% had electrical injuries. Injuries of the skull and scalp were caused by entry of electrical current. The classic reconstruction of the scalp and skull is performed after sequestration of the necrotic bone, a time-consuming process which frequently has complications. An alternative is to induce regeneration of the vitalized bone by covering it early with a vascular tissue flap. Skeletal scintigraphy has the advantage of allowing early and safe assessment of the vitality of the injured bone and helps to control vitalization.

[Immediate functional reconstruction of the upper extremity after high voltage electric burns]. / Funktionelle Sofortrekonstruktion an der oberen Extremität nach Starkstromverbrennungen.

Large soft tissue defects on the upper arm and the forearm of a 14-year-old boy caused by electrical trauma were repaired with a free latissimus dorsi flap on the left forearm and a neurovascular lat. dorsi island flap to the right upper arm. Both extremities were saved, the defects covered and good functional repair was achieved. The latissimus dorsi flap is a save and easy procedure with a high variability. It is especially suitable for primary repair of large soft tissue defects.

[Direct closure of donor defects of the radial flap by preliminary stretching of the skin with a skin expander]. / Direktverschluss der Hebedefekte des Radialislappens durch Vordehnung der Haut mit einem Haut-Expander.

One of the disadvantages of the radial forearm flap is the donor defect covered by split skin grafts. The use of a tissue expander allows direct closure of smaller donor defects resulting in a cosmetically more acceptable linear scar. The skin expander must be implanted adjacent to the planned radial forearm flap in the epifascial plane for at least six weeks, preferably for two to three months. The operative technique is demonstrated at a typical clinical case and experiences with six further patients reported.

[Possibilities of the covering of scalp defects after injury or tumor resection]. / Möglichkeiten der Defektdeckung am Schädeldach nach Traumen oder ausgedehnten Tumorresektionen.

The coverage of extensive defects of the scalp is sometimes a problem. In some clinical cases the methods of definitive coverage are shown. Microsurgery permits the replantation of a scalp or the coverage of a defect with a free flap. A new technique consists in the use of a tissue expander to stretch the remaining scalp.

[Long-term results following breast augmentation]. / Langzeitergebnisse nach Mammaaugmentationen.

One hundred late results of augmentation mammaplasty for the following conditions are reported: aplasia, hypoplasia, asymmetry and deformities after total and partial mastectomy. Our criteria for assessment were shape, consistency and quality of scars. The objective assessments were compared with the patients subjective assessments. The most unsatisfactory results were in augmentation after subcutaneous mastectomy and the best were in hypoplasias when small implants were used. Two types of implant were compared: gel filled and inflatable. Results were slightly better with gel filled implants. Better results were obtained if the implant was placed subpectorally and postoperative massage was carried out. Special note is made of the high rate of fibrous capsule contraction.

The forearm flap.

We present our experimental and clinical experiences with the free neurovascular forearm flap. The flap is based on the radial artery, one of the great veins of the forearm (cephalic, basilic, or interconnecting vein), and one or two cutaneous forearm nerves (ulnar, median, or lateral). Because of the standard anatomy, the large caliber of blood vessels, the good sensory supply, the quality and quantity of the forearm skin, and the thin layer of subcutaneous fat, the free forearm flap is a technically easy and safe flap for reconstruction of soft-tissue defects, especially those in the head and neck and those areas of the extremities where sensitive skin is desired.

Long-term follow-up results of 97 finger replantations.

From a total number of 664 finger replantations (DII-DV) we were able to carry out a follow-up of 97 postoperative cases using the follo-wing assessment criteria: mobility, sensitivity, type of amputation, mechanism of injury, level and extent of amputation. Subjective criteria were also taken into account. Using the results of the study we have been able to formulate an evaluation as to the absolute indication for operation of fingers DII-DV.

[Primary transpositions of fingers, results (author's transl)]. / Fingertranspositionen bei Replantationen in mikrochirurgischer Technik.

12 cases of finger transposition during replantation using microvascular techniques are reported, all of which were performed in the Department of Plastic and Reconstructive Surgery, Klinikum Rechts der Isar der Technischen Universität München (Head of Department: Prof. Dr. med. Ursula Schmidt-Tintemann). In multiple injuries of the hand, it is sometimes necessary to reconstruct fingers depending on their functional importance, when it is not possible to make a precise anatomical reconstruction owing to the destruction of the various amputated parts. The functional results following finger transposition are comparable to the results following 500 finger replantations in our hospital.

[Finger replantation in children]. / Fingerreplantationen bei Kindern.

The possibility of replantation is discussed for children's amputation injuries. The use of this technique is also indicated for multiple amputations and severe crush injuries. More than half of the replanted fingers healed successfully. Since the existence of the Replantation centre of the Klinikum Rechts der Isar, over 600 operations of separated limbs were performed. The healing rate of totally and subtotally separated limbs of adults was 87%. The attempt was made to replant separated digits of 14 children, aged from 1 to 8 years, with microvascular anastomoses. The grade of injuries and the minimal size of anatomic structures demand a particularly high standard of the operative standard. Replantation was also indicated for badly squashed and contaminated limbs.

Early experiences in organising and running a replantation service.

In the 10 months since the establishment of a 24-hour replantation service, the centre at the Klinikum rechts der Isar of the Technical University of Munich has treated 162 amputation injuries; 132 underwent replantation surgery and 117 of these healed successfully. Surgical technique, medication and postoperative treatment with physiotherapy are described. Special emphasis is placed on the difficulties associated with crush and avulsion injuries; in most of them the only solution is an intermediate vein graft to bridge the defect in the vessels.