Complex mincer hand injury in a 4-year-old girl: successful revascularization.

We report on a four-year-old girl who suffered a complex mincer injury to the left hand, resulting in a partial amputation of her hand. To salvage the injured hand, revascularization was performed. The indication, advantages and outcome of the procedure are discussed.

[Closure of defects on the dorsum of the foot with free flaps. Functional and aesthetic aspects]. / Defektdeckung durch freie Lappenplastiken am Fussrücken. Funktionelle und ästhetische Aspekte.

BACKGROUND: Large complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow. PATIENTS AND METHODS: Evaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results. RESULTS: On average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients. CONCLUSION: Free muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.

Free functional rectus femoris muscle transfer for restoration of knee extension and defect coverage after trauma.

In March of 2000 and May of 2002, two patients underwent restoration of knee extension with a free neurovascular rectus femoris flap. The female patient was 10 years and the male patient 19 years old. Both patients sustained a complex trauma of the thigh with fracture of the femur and posttraumatic loss of quadriceps femoris muscles. Follow up of the patients was 51 and 27 months. After 8 months reinnervation were detected by Electromyography (EMG) in both patients and contraction became visible 2 months later. The female patient obtained a good and the male patient a very good functional result. Both patients were able to walk unaided. The authors concluded that free functional rectus femoris transfer can obtain excellent results in treating knee extension and soft-tissue defect due to trauma and loss of the quadriceps femoris muscles.

[Eyebrow injuries. Classification and therapy concept]. / Augenbrauenverletzungen. Klassifizierung und Therapiekonzept.

The aim of primary treatment for eyebrow injuries should be preservation of the original eyebrow under any circumstances. Debridement should be kept to a minimum even when the wound is severe. The treatment of total or partial loss of an eyebrow concerning the exact reconstruction of details and aesthetic aspects is a challenge for the surgeon. The therapy option depends on the type of eyebrow selected for reconstruction. We present a classification for eyebrow injuries, which considers type and size of defects. Based on this, different techniques and methods of reconstruction are recommended. Advantages and disadvantages are discussed and illustrated by several examples.

[Free tissue transplantation for defect coverage of the dorsum of the hand: aesthetic and functional aspects]. / Freie Lappenplastiken zur Rekonstruktion komplexer Defekte am Handrücken: Asthetische und funktionelle Aspekte1.

BACKGROUND: Complex and large soft-tissue defects of the dorsum of the hand, which cannot be covered with skin grafts or local flaps have to be reconstructed by means of free tissue transplantation. The purpose of this study was to present our experience with free fasciocutaneous flaps and muscle flaps with split-thickness skin graft for defect coverage of the dorsum of the hand in eight patients. PATIENTS AND METHOD: Evaluation of eight patients who underwent coverage of the dorsum of the hand with free flaps during 1997 to 2001 is presented. Other treatment options are discussed. RESULTS: Average age of the patients was 57 years and average follow-up was 25 months. For defect coverage we used a later alarm flap in four cases, a gracilis muscle flap with split-thickness skin graft in three cases and a latissimus dorsi flap with split-thickness skin graft in one case. In five patients we performed an extensor tendon reconstruction. Three of those cases achieved a good, one a fair and one case had a bad functional result. In one patient we had a partial flap loss. Muscle flaps with skin graft revealed better esthetic results than fasciocutaneous flaps. CONCLUSION: Microvascular free-tissue transplantation has expanded our options, giving us the opportunity for more refinement in hand reconstruction and improving the standards for a successful outcome.

[Endoscopically-assisted latissimus dorsi muscle harvest in a young child]. / Endoskopisch-assistierte Hebung der M. latissimus dorsi-Lappenplastik beim Kleinkind.

Free tissue transplantation is nowadays regarded as an established method in reconstructive surgery - even in infants. Adequate diameters of vessels for microsurgical anastomosis have been shown in numerous studies. Especially the latissimus dorsi muscle seems to be ideal as a standard flap in this age group. The main disadvantage of this muscle flap lies in its donor-site morbidity with the risk of scar contracture and limitation of shoulder movement. A possible solution to this problem is the endoscopically-assisted harvest of this muscle. A three-year old boy sustained a subtotal amputation of his right heel with consecutive necrosis of soft-tissue. After debridement, a latissimus dorsi-muscle flap was transplanted to cover the defect. The flap was harvested endoscopically-assisted through a single, 2 cm long incision in the left axilla. Healing of the flap was uneventful. At 30 months follow-up the patient showed stable conditions at the right heel without limitations of movement and a hardly visible scar in the left axilla without any noticable growing impairment. Free microvascular muscle-flaps are the treatment of choice in infants with extensive traumatic defects. With the use of minimally invasive operation techniques it is possible to significantly reduce donor-site morbidity and increase therapeutic success even in the youngest patients.

[Reconstruction of the index metacarpophalangeal joint with an osteochondral metatarsal head graft]. / Rekonstruktion des Zeigefingergrundgelenks durch Transplantation des II. Mittelfusskopfes.

We report on a 19-year-old male patient with partial destruction of the index metacarpophalangeal joint due to traumatic middle hand amputation. Six months after replantation the metacarpophalangeal joint defect was reconstructed with an osteochondral metatarsal head graft from the second metatarsophalangeal joint. At a follow-up period of four years the patient achieved full metacarpophalangeal extension, with 40 degrees of flexion and grip strength equal to 90 % of the contralateral index finger. Magnetic resonance imaging showed enhancement of contrast medium as a sign for vitality of the transplant.

[Coverage of pressure sores with free flaps]. / Dekubitalulkusdeckung durch mikrochirurgische Lappenplastiken.

INTRODUCTION: The coverage of recurrent pressure sores with unstable scar in the surrounding tissue is still an unsolved problem in the literature. Local and regional transfer of tissue often does not meet the requirements of the tissue deficit. Especially in recurrent pressure sores, the adjacent skin has already been consumed due to multiple surgeries. As a good alternative, the microsurgical transfer of flaps offers viable tissue to cover even large pressure sores. METHODS: We performed a total of six free flaps in five patients who suffered from intractable pressure sores in the hip region. The age of the patients was between 41 and 63 years. The defect size varied between 6 x 6 cm and 25 x 30 cm. Two combined myocutaneous scapula-latissimus dorsi, two myocutaneous latissimus dorsi, one anteromedial thigh, and one rectus femoris flap were used to cover the defects. RESULTS: The average follow-up time was 29 months. Flaps provided stable coverage in four of five patients at 12-month follow-up. There was one subtotal flap necrosis that was subsequently treated with split-thickness skin grafting. CONCLUSION: In this series of five patients with six free flaps, we were able to show that the microsurgical transfer of tissue is a valuable option in the treatment of difficult pressure sores. Even in older and debilitated patients, this method is a good alternative to conventional local flaps.

An analysis of breast sensation following inferior pedicle mammaplasty and the effect of the volume of resected tissue.

The aim of our study was to evaluate if the amount of resected breast tissue has an influence on breast sensitivity after inferior pedicle mammaplasty. In the prospective study, 15 patients (30 breasts) were divided into two groups: group I (less than 400 g resection) and group II (more than 400 g resection). Preoperatively and six months postoperatively a touch test (Semmes-Weinstein monofilaments) and temperature (warm and cold) tests were performed. The study showed that all patients had increased touch sensitivity six months after inferior pedicle mammaplasty regardless of the amount of resection. In group I an average of 65% and in group II an average of 83% retained sensitivity for temperature postoperatively. These results suggests that this mammaplasty technique preserves intercostal nerves within the inferior pedicle and reliefs chronic nerve traction injury and improves thereby breast sensibility.

Silicone implant correction of pectus excavatum.

Between May 1989 and December 2000 in 24 adult patients with pectus excavatum, a subcutaneous implantation of silicone prostheses was performed. Of the 24 patients, 20 were followed. During follow-up the authors encountered seroma complications in 13 patients and postoperative hematoma in 4 patients. The patients stayed in the hospital 5 days on average, and showed excellent aesthetic results in 80% (N = 16), good results in 10% (N = 2), and fair results in 10% (N = 2). Patient satisfaction was also taken into consideration. A follow-up survey questioned whether patients were satisfied with the cosmetic outcome. On a scale of 1 to 5 points, with 1 point being the highest level of satisfaction, 85% of patients used ratings of 1 and 2 to express satisfaction levels. Silicone implant correction of pectus excavatum in adult patients without any impairment of cardiopulmonary function has value. The major advantages are the minimally invasive operation, the short hospital stay, good aesthetic results, and high patient satisfaction

Small free vascularized iliac crest bone grafts in reconstruction of the scaphoid bone: a retrospective study in 60 cases.

Carpal instability may result in progressive degenerative arthritis of the wrist. The surgical goal of the reconstruction of scaphoid nonunion is to achieve bone union and to restore the scaphoid. Many procedures are described to treat scaphoid nonunion for different indications. This retrospective study reports on the anatomical fundamentals, the operative procedure, and the results of 60 patients (21 with recalcitrant scaphoid nonunion that lasted longer than 4 years, 26 with an avascular pole fragment, and 13 with scaphoid nonunion after previous surgery) who were treated by a small free vascularized iliac crest bone graft. All 60 patients have routinely been followed up clinically and with magnetic resonance imaging. Union was achieved in 91.7 percent by improvement of stability and the compromised vascularity of the scaphoid. The bone flap loss rate and persisting nonunion was 8.3 percent, leading to progressive arthritis and carpal collapse. Complaints concerning discomforts caused by the scar were heard from 40.1 percent of the patients, and 31.7 percent complained of discomforts caused by the bony deformity. Bone deformations on the donor site were detected radiologically in 63.3 percent of the patients. In 31.7 percent, an impairment of the lateral femoral cutaneous nerve was noted. Reconstruction of the scaphoid by means of implantation of a vascularized iliac bone graft proved efficient to treat avascular recalcitrant scaphoid nonunion and pseudarthrosis with avascular proximal pole fragments.

A new contralateral split-breast flap for breast reconstruction and its salvage after complication: an alternative for select patients.

Different approaches to breast reconstruction have been described and nowadays nearly optimized. One major aim in further developments is to reduce donor site morbidity as low as possible. Theoretically, the lowest donor site morbidity could be achieved by using tissue that would be normally discarded during an operation necessary for a different reason. The authors present a new method of breast reconstruction in a mastectomy patient who needed a reduction mammaplasty on the remaining side in addition to the reconstruction. A single-stage split-breast flap from the reduced contralateral side pedicled on its internal mammary perforators was used, thus lowering donor site morbidity by using otherwise discarded tissue. The technical details, patient selection, advantages, possible pitfalls, management of complications, and the risk factors for contralateral malignancy are discussed.

Gracilis muscle flap with a tissue-engineered lining for experimental bladder wall reconstruction.

OBJECTIVE: To assess a pedicled gracilis muscle flap pre-laminated with autologous, in vitro-expanded urothelial cells to reconstruct an entire supratrigonal bladder-wall defect in rats. MATERIALS AND METHODS: A gracilis muscle flap was harvested from 36 male Wistar rats, transposed into the abdomen and wrapped around a silicon-block space holder. Urothelial cells were harvested and expanded ex vivo. Cells were then suspended in fibrin glue and seeded into the gracilis muscle pocket. One week later this pre-laminated flap was transposed into a surgically created supratrigonal bladder-wall defect. All animals underwent such a pre-laminated gracilis flap bladder reconstruction and were categorized into three experimental groups. All surviving animals with urothelial-culture pre-laminated gracilis flap bladder reconstruction were killed 12 weeks (group 1) later. Control rats had gracilis flaps with no cell seeding and treated only with fibrin glue (group 2) or a standard culture medium (group 3) before reconstruction. RESULTS: Specimens stained with haematoxylin and eosin, and a specific immunohistochemical staining (AE1 and AE3-anti-cytokeratin monoclonal antibody stain) showed a continuous, multilayered functioning urothelial lining along the transposed pre-laminated gracilis flap in group 1. All animals in group 1 with an intact urothelial lining on the gracilis muscle survived, in contrast to most animals in groups 2 and 3, where eight and all 12 animals died, respectively. The surviving four animals in group 2 had no detectable urothelial lining. CONCLUSION Successful urinary reconstruction requires a contractile neo-reservoir resistant to resorption over time and a stable, protective urothelial lining. A gracilis muscle flap can be seeded with autologous cultured urothelial cells suspended in fibrin glue. This pre-laminated flap can be safely transposed on its pedicle and be successfully integrated into the remaining bladder wall, with a urothelial lining and the potential to contract. Further studies in larger animals, with a urodynamic assessment, are warranted to determine if this type of bladder-wall replacement technique is suitable for urinary reconstruction in humans.

Transplantation of tracheal epithelial cells onto a prefabricated capsule pouch with fibrin glue as a delivery vehicle.

OBJECTIVE: The purpose of this study was to investigate whether in vitro cultured tracheal epithelial cells can be transplanted onto a prefabricated capsule surface in vivo for possible use in tracheal reconstruction. METHODS: Tracheal epithelial cells from 12 donor inbred rats were harvested for culture and expansion. In 16 recipient inbred rats, 2 sterile cylinders made of silicone rubber were implanted in each rat bilaterally in the folds of both the left and right anterior rectus sheath by wrapping the sheaths around the cylinders to induce a capsule formation. Ten days later, the cell cultures were divided and suspended in 1 of 2 delivery vehicles (standard culture medium or fibrin glue) and implanted onto the capsule surface. To compare the 2 delivery vehicles, we used fibrin glue on one side and the standard culture medium on the other. RESULTS: After 2 (group 1, n = 8) and 4 (group 2, n = 8) weeks, histologic findings, immunohistochemical staining, and electron microscopy demonstrated the capsule to be covered with a tracheal neoepithelium in group 1 and additional ciliated cells and secretory cells in a confluent layer in group 2 but only on the side with fibrin glue as the delivery vehicle. No viable epithelial cells were identified on the side with the standard culture medium in either group. CONCLUSION: We conclude that cultured epithelial cells can be successfully transplanted onto a prefabricated capsule surface with fibrin glue, which will differentiate into morphologic, nearly normal epithelium, showing potential for tracheal reconstruction.

Surgical technique and clinical application of the transverse gracilismyocutaneous free flap.

The unreliability of the distal skin component of the gracilis myocutaneous free flap has been frequently reported. To improve the reliability of the skin we orientated the cutaneous paddle in a transverse direction in the proximal third of the gracilis muscle, as first described by Yousif et al in 1993. Their anatomical studies showed that cutaneous branches of the dominant proximal pedicle have a pronounced tendency to travel in a transverse direction, supplying the skin anteriorly over the adductor longus and sartorius muscles and extending beyond the posterior margin of the gracilis muscle. We adopted this transverse design and transferred myocutaneous gracilis flaps measuring up to 17 x 9 cm. The transverse gracilis myocutaneous flap was dissected in the subfascial plane to include the peri-gracilis fascia, which preserved the fascial vascular network and thus optimised skin-paddle perfusion. Ten transverse gracilis myocutaneous free flaps were performed over 3 years. Skin paddles ranged in size from 10 x 7 cm (70 cm(2)) to 17 x 9 cm (153 cm(2)) with a mean of 113.4 cm(2). Five defects were located in the head and neck region, three in the lower leg, one in the thigh and one in the thorax. Patients were followed for an average of 16.6 months (range: 6--46 months). Minor complications (donor-site wound dehiscence and flap-wound-edge separation) occurred in four patients;however, all 10 flaps survived and healed with complete cutaneous survival.