Retrobulbar T cells from patients with Graves' ophthalmopathy are CD8+ and specifically recognize autologous fibroblasts.

Graves' ophthalmopathy is an autoimmune condition characterized by T cell infiltration of the retrobulbar tissue. Phenotypic and functional analysis of these infiltrating cells may provide insight into the pathogenesis of the disease. IL-2-responsive cells were therefore grown out of the retrobulbar tissue from two patients with severe Graves' ophthalmopathy undergoing orbital decompression surgery, and six T cell lines were established and characterized. They consisted predominantly of CD8 + CD45RO+ cells and secreted IL-4, IFN-gamma, and IL-10 upon activation. When screened for their antigen reactivity, all lines proliferated in response to stimulation with autologous retrobulbar fibroblasts in an HLA class I-restricted manner, but did not recognize autologous peripheral blood mononuclear cells, crude eye muscle extract, allogeneic cells, or purified protein derivate of Mycobacterium tuberculosis. In contrast, PBMC from the same patients responded readily to purified protein derivate of Mycobacterium tuberculosis and allogeneic PBMC, but did not recognize autologous fibroblasts. Interestingly, only one of the six retrobulbar T cell lines displayed cytotoxicity towards its specific target cell population. These results suggest that the retrobulbar fibroblasts are a major T cell target in Graves' ophthalmopathy. Pronounced cytokine production in the absence of target cell cytotoxicity may explain fibroblast proliferation, glycosaminoglycan secretion, and secondary eye muscle enlargement in this condition.

Reconstruction of abdominal wall and mons pubis in females with bladder exstrophy.

We report on 3 patients with bladder exstrophy who had considerable scar deformities of the lower abdomen after primary closure of the bladder and/or urinary diversion. The scar tissue was excised, and augmentation of the abdominal wall and mons veneris was achieved by the use of a pedicled, vascularized groin flap with integrated bone from the iliac crest. This procedure is recommended for patients with faulty closure of the pelvic ring and severe defect of the lower abdominal wall.

[Plexus neuropathy: tumor infiltration or radiation damage]. / Plexusneuropathie: Tumorinfiltration oder Strahlenschaden.

Plexus neuropathies often occur in patients with breast cancer after varying periods following surgery and postoperative radiotherapy. In most cases this has been ascribed to radiation fibrosis. The attempt to arrive at a clinical diagnosis fails because of the similarity of symptoms in both cases namely pain and the absence of motoric and sensory reflexes. But a clear diagnosis is of fundamental importance for further treatment. Only a surgical intervention can verify the diagnosis. In this study, the results of operative findings are presented and compared with a second group of patients who had died of breast cancer having undergone surgery and radiotherapy. The findings brought a surprising fact to light: a considerably high percentage of all patients suffered from large scale tumour infiltration in the plexus. The morphology and histopathology of these lesions are described. Possible explanations are given for the difference in lesion patterns, so that a clinical diagnosis might be derived therefrom.

Cross-face nerve transplant.

The two stage principle is one of the most important features of the procedure. It allows starting the operation at a very early stage (one to six months). The donor area in the periphery is very well supplied, therefore as many facial fascicles as necessary can be sacrificed on the healthy side. We have never noticed any functional disturbances. The nerves leading to the buccinator muscle and those which innervate the lateral pull of the mouth are especially suitable. This weakening of the strong pull of the mouth is of great value for symmetry but unfortunately relapse to the original state is common. The selection of the nerve fascicles on the healthy side must be executed in a deep layer below the muscles because all large branches are located here. The end of the sural grafts should positioned far back on the paralyzed side to enable easy anastomoses at the second stage. A face lift incision on the paralyzed side and tightening of the skin are of additional value and provide some support to the elongated muscles. The combination of cross-face nerve transplant with other substitutional methods in which muscles are used for reinnervation is very promising. In our experience physiotherapy is a very important measure. It should be started after the onset of the palsy and continued until restoration of the face is complete. It is usually applied three times a week with exponential current and at a strength of 20 to 60 milliamperes. Each group of muscles receives a 2 to 3 minutes dosage. It is helpful if the patient can use a stimulation apparatus at home daily for short treatments.

Internal mammary vessels as a recipient site.

In breast reconstruction with a free flap, the selection of suitable recipient vessels remains one of the most critical decisions for the surgeon. Most surgeons use one of the branches of the axillary vascular system, the thoracodorsal vessels. Because of a number of difficulties using this recipient site, the authors investigated the anatomy and availability of the internal mammary vessels for free flap breast reconstruction. This article describes the anatomic considerations, surgical technique, clinical experience, advantages, and limitations of using these vessels. In recent years, free autogenous tissue transfer for breast reconstruction has become increasingly common. The free transverse rectus abdominis myocutaneous (TRAM) flap and the more recently described deep inferior epigastric artery (DIEA) perforator flap are currently the methods of choice for postmastectomy breast reconstruction. For patients who cannot have a TRAM flap, free flaps from other donor sites (superior gluteal flap, inferior gluteal flap, Rubens flap, lateral transverse thigh flap) also have become important options.

Radical treatment of craniofacial anomalies in infancy and the use of miniplates in craniofacial surgery.

The radical treatment of craniofacial anomalies in infancy is indicated for medical, technical, and psychosocial reasons. The major problems around the cranium, the orbits, and the face may be safely corrected by osteotomy, suture resection and disjunction, mobilization, repositioning, and reshaping of the various skeletal segments. This radical approach has been possible through the introduction of miniplate fixation. The plates and screws are removed after 3 to 6 months to take optimal advantage of the great formative power of the growing brain, which expands rapidly within the first 2 years of life. In infants, disjunction is more important than advancement, making this approach a dynamic one in contrast with the static procedures for the adolescents and adults. The complete, one-stage procedures are superior to a delayed or two-stage procedure. Experienced administration of pediatric anaesthesia and intensive care are mandatory.

Maintenance of stump length of both upper extremities after severe electrical burn injury.

A patient with electrical injury to both upper extremities which necessitated amputation above the elbow on both sides is presented. Further débridement on the stumps resulted in extensive exposure of bone with little coverage by skin and granulation tissue. Adequate coverage and maintenance of the length of both stumps was possible with bilateral myocutaneous latissimus dorsi flaps. This enabled the patient to carry out various activities and to wear a prosthesis.

Facial reconstruction using a retroauricular-temporal free flap.

Large and deep soft-tissue defects of the face usually require resurfacing by free-tissue transfer. An appropriate free flap for facial reconstruction may be harvested from the retroauricular and temporal region utilizing two arterial pedicles (superficial temporal artery and posterior auricular artery). This flap provides normal color, texture, and thickness and thus is an optimal anatomic and aesthetic reconstruction with minimal donor-site morbidity.

The instep free flap to resurface palmar defects of the hand.

Large and deep soft-tissue defects of the hand require adequate resurfacing by free or distant pedicle flaps. A free flap of suitable size corresponding to the extended palm defect may be harvested from the instep region without encroaching on the weight-bearing area. Following Gillies's concept that "losses must be replaced in kind," and taking into consideration all possibilities of a free-flap reconstruction of the hand, we can conclude that an innervated fasciocutaneous free instep flap provides normal contour, texture, and color and thus an optimal functional, aesthetic, and anatomic reconstruction of the palm with acceptable donor-site morbidity.

Frontofacial advancement with bony separation in craniofacial dysostosis.

A new technique in craniofacial surgery to separate the cranial and nasal cavities from each other is described. This can be achieved by preserving the complete anterior cranial fossa while simultaneously correcting the forehead, orbit, and face in craniofacial dysostosis. With this procedure, the risk of infection deriving from nasal sinuses and cavities should be minimized.

A new classification for the standardization of nomenclature in free flap wound closure.

A profusion of terms are currently used to describe free flap wound closure. It is important to broadly standardize nomenclature when embarking on a comparison of functional outcomes between institutions. Therefore, a series of 68 "emergency" (within 24 hours) free flaps performed by a single surgeon were reviewed with respect to a total experience of 188 free tissue transfers to formulate a consistent nomenclature applicable to free flap wound closure in general. The nomenclature presented divides free flap closure into three categories: "primary free flap closure" (12 to 24 hours), "delayed primary free flap closure" (2 to 7 days), and "secondary free flap closure" (after 7 days). This system is analogous to the standard terms "primary," "delayed primary," and "secondary wound closure." It is consistent with known biologic and microbiologic principles of wound closure in general and should provide a simple basis for classifying free flap wound closure. Illustrative examples are presented to highlight the classification scheme.

Free innervated latissimus dorsi muscle flap for reconstruction of full-thickness abdominal wall defects.

Full-thickness abdominal wall defects continue to be a challenge for the reconstructive surgeon. The most frequently used reconstructive techniques are transfer of a pedicled, local abdominal flap or a distant flap from the thigh region. The purpose of this paper is to present a new approach to full-thickness abdominal wall reconstruction using an innervated free latissimus dorsi musculocutaneous flap. Four patients with large full-thickness abdominal wall defects underwent reconstruction with a free innervated latissimus dorsi muscle flap. In two patients, staged abdominal wall reconstruction was performed. Primary closure was first obtained with a skin graft. During the subsequent definitive reconstruction (with an innervated free latissimus dorsi muscle flap), this skin graft was not excised. Instead, deep dermabrasion of the skin graft was performed, leaving a residual dermal layer. This layer was then covered with a free innervated latissimus dorsi muscle flap. In these two cases, there was no need for the use of a prosthetic mesh. A single stage reconstruction was performed in the other two cases. After abdominal wall sarcoma resection, Prolene mesh was placed and subsequently covered with a free innervated latissimus dorsi muscle flap. There were no free flap failures. The average time of surgery was 4 hours, 50 minutes. The average hospital stay was 14 days. No significant complications occurred except for one donor site seroma. No hernias have occurred postoperatively. The mean follow-up was 21 months. Postoperatively, electromyographic testing was performed regularly in all patients to document reinnervation of the latissimus dorsi muscle flap. With reinnervation and intensive muscle training, the transplanted latissimus dorsi muscle offers enough contractile capacity and strength to adequately replace the function of the missing abdominal wall muscles. In complicated staged reconstructions, dermabrasion of the temporary skin graft allows for the use of a residual dermal layer as a fascia-like substitute to aid in the restoration of structural integrity. The combination of the dermal layer with an innervated free latissimus dorsi muscle provides a strong, vascularized fascial repair as well as an overlying vascularized soft-tissue coverage. In conclusion, adequate functional dynamic reconstruction of full-thickness abdominal wall defects is possible using an innervated free latissimus dorsi muscle flap. The reinnervated latissimus dorsi muscle is suitable for reconstitution of the missing functional and anatomic components of complex abdominal wall defects.

Functional urinary bladder wall substitute using a free innervated latissimus dorsi muscle flap.

This study was designed to investigate the ability of the latissimus dorsi muscle in situ to evacuate a bladder reservoir and to study the functional, anatomic, and histopathologic results of partial or subtotal bladder reconstruction with an innervated free latissimus dorsi muscle in mongrel dogs. In group I (four dogs), the latissimus dorsi muscle was dissected and tailored in situ. Then the so-formed pedicled latissimus dorsi muscle flap was wrapped around tissue expanders of varying sizes (volumes of 50, 100, and 150 cc, respectively) to form a bladder-like reservoir. Electromyography and intraluminal pressure measurements were done at the time of surgery and 6 months thereafter using a standard electromyograph and a Dantec urodynamic unit. In group II (four dogs), the dome of the bladder wall was removed, with up to 50 percent of the mucosal layer being left intact. The resulting muscular defect was repaired with a free innervated latissimus dorsi muscle flap. The transferred latissimus dorsi muscle was shaped and wrapped around the bladder in a spiral form, with particular attention to the resting tension. The thoracodorsal vessels were anastomosed to the pelvic branches of the hypogastric vessels, and the thoracodorsal nerve was coapted to a pelvic motor nerve that was selected by use of a nerve stimulator. Cystography and urodynamic studies were performed after 3, 6, and 9 months. Electromyography was done after 9 months, before sacrifice of the animals, which was followed by regular histologic and electron microscopic examinations. Stimulation of the thoracodorsal nerve of the reconfigured latissimus dorsi muscle reservoirs in situ after 6 months yielded average intraluminal pressures of 190 cmH2O at maximum capacity and 35 cmH2O at a minimum capacity of 10 to 15 cc. Stimulation of the latissimus dorsi muscle transferred to the bladder resulted in a visible and measurable contraction of the transplanted muscle after 9 months. Urodynamic values preoperatively and postoperatively were basically unchanged. During cystography, the bladder outline was smooth during both filling and voiding. Light and electron microscopic examinations confirmed viable, reinnervated muscle. The reconfigured pedicled latissimus dorsi muscle has the ability to evacuate a bladder-like reservoir after nerve stimulation. A detrusor function of the bladder can be induced through the contractility of a reinnervated free latissimus dorsi muscle that was wrapped around the bladder. An innervated free latissimus dorsi muscle flap does not undergo severe muscle fibrosis, contracture, and atrophy such as occur after transfer of completely or partially denervated, pedicled muscle. This means that a functional bladder reconstruction/augmentation can be achieved by microneurovascular transfer of a latissimus dorsi muscle flap.

Clinical experience and indications of the free serratus fascia flap: a report of 21 cases.

The free "serratus fascia" flap as a free flap was first described by Wintsch and named a free fascia flap of gliding tissue; however, it has not yet been given a distinct name. The particular advantages of this flap consist of an easy access and a low donor-site morbidity without functional deficit. Additionally, it may be designed very variably and molded even three-dimensionally as a tendon wraparound flap or folded to fill up cavities. In our clinic, we used this flap in 21 patients for distinct indications and in 7 patients as a vascular graft in fingers or great toe with a minimal adjacent layer of gliding tissue around the vessels for the treatment of cold intolerance after finger replantation or severe finger or toe trauma. In the other cases, this versatile flap served for the coverage of traumatically exposed tendons or bones at the extremities, covered with a skin graft. Eighteen flaps survived completely, whereas 3 flaps developed partial or superficial necrosis. Only once did a major complication by unintentional sacrification of the long thoracic nerve during flap harvesting occur, resulting in a wing scapula. We recommend this flap for defect cover at sites where a thin vascularized gliding layer for defect cover is needed, especially in distal extremities with exposed tendons or nerves, and present the current indications in discussing our experiences.

Closure of gastroschisis by mesh skin grafts in problem cases.

Closure of gastroschisis can be achieved by primary adaptation of the abdominal wall, by implanting a dura patch or by covering the protruding gut with a silastic pouch. In the Pediatric Surgical Department of the University of Innsbruck this last method was used in 14 of 18 cases during the last 8 years. In three children multiple complications and infection resulted in the necessary removal of the silastic pouch from the still protruding gut. Lacking any other alternative, the defect was covered with mesh skin grafts, which took well and permanently closed the abdominal wall.

Emergency free tissue transfer for severe upper extremity injuries.

29 patients with severe upper extremity injury were treated with 27 emergency free flap and three emergency toe-to-hand transfers, after radical débridement and primary reconstruction of all injured structures. There was no flap failure, and no infections or wound-healing complication were seen. Follow-up ranged from 3 months to 6.6 years with a mean of 3.2 years. 19 patients returned to work (14 to their original jobs), three were retired and another seven had no employment before injury. Operation time ranged from 2 hours 45 minutes to 18 hours 20 minutes with an average of 7 hours 45 minutes, depending upon the size of the defect and mechanism of injury. Long-term follow-up revealed successful functional and aesthetic results, decreased morbidity and invalidity, and reduced rates of free flap failure, post-operative infection, secondary operative procedures, hospital stay and medical expense.

Reconstruction of large palmar defects of the hand using free flaps.

The reconstruction of large palmar defects of the hand remains a difficult problem due to the specific anatomical structures and highly sophisticated function of the palm. The glabrous skin and subcutaneous tissue in the palm are perfectly adapted to serve the prehensile function. The particular aim must be that repairs to this functional structure are similar in texture and colour and are aesthetically acceptable. Restoration of sensibility is desirable. For smaller defects a great variety of local pedicled or island flaps can be applied. However, for larger defects with exposed tendons, nerves or other essential structures, free flaps remain as a reliable alternative. This paper reviews our approach of soft tissue reconstruction in 16 patients with large palmar defects using various kinds of free flaps. The advantages, disadvantages and current indications for free flap resurfacing of the palm are discussed.

[High-dose short-term antibiotic therapy in bacteremia and infection in severely burned patients]. / Hochdosierte antibiotische Kurzzeittherapie der Bakteriämie und Sepsis bei Schwerbrandverletzten.

60 to 70% of all late deaths in patients with severe burns are due to sepsis. Thus, treatment with antibiotics is essential in the overall management of such patients, which in our hospital is carried out according to the following principles: 1. No prophylactic antibiotic treatment. 2. Careful evaluation of the bacterial spectrum of the burns, nasopharyngeal area, anal region, sputum and blood cultures. 3. In case of bacteriaemia we start high-dose combination therapy with two different, specific chemotherapeutic agents, given alternately every 4 to 6 hours. 4. In concordance with the clinical picture antibiotic therapy is discontinued as soon as three subsequent blood cultures remain sterile. Since 1980, 58 patients with severe burns (extent: 20 to 90% of body surface) have been treated according to these principles. Mortality due to sepsis was low, namely 9.5% (2 out of 21 patients presenting with bacteriaemia), so that our method of treatment has proven to be effective.

[Dynamic and functional abdominal wall stabilization, reconstruction of extensive abdominal wall defects]. / Dynamische und funktionelle Bauchdeckenstabilisierung, Wiederherstellung von ausgedehnten Bauchwanddefekten.

The aim of any abdominal wall reconstruction is maximal functional stability and adequate soft tissue coverage. The anatomy, elevation and clinical application of the myofascial tensor fasciae latae transposition flap and of the microvascular musculocutaneous latissimus dorsi free flap are presented. Repairing extensive fascial defects and recurrent hernias with the tensor fasciae latae transposition flap provides strong, dynamic, and functional reconstruction of fascial continuity to prevent a further recurrence. Adequate functional and aesthetic repair of a full-thickness abdominal wall defect can be optimally managed by the innervated microsurgical latissimus dorsi free flap.

[Current reconstructive measures for the covering of defects in the extremities]. / Aktuelle rekonstruktive Verfahren zur Defektdeckung an den Extremitäten.

Large defects of soft tissue and bone in the lower extremity are still a great surgical problem with regard to morbidity and preservation of the leg. Conventional operative procedures such as cross leg or pedical flap are frequently not sufficient to guarantee successful treatment. Local muscle flap, myocutaneous flap and free-tissue transfer with microvascular anastomoses are excellent surgical supplements for better and quicker treatment, as they can generally be performed in one operative step. Strict indication and a specially trained operating team are essential for successful treatment in these more risky procedures. The new techniques and applications are demonstrated on various cases.