G. Wechselberger

Definite surgical treatment of complicated recurrent pilonidal disease with a modified fasciocutaneous V-Y advancement flap

BACKGROUND Different methods for managing pilonidal disease have been described in the literature. Recurrence impairs the success of all forms of therapy, but the lowest rates have been reported for reconstructions involving local flaps. Nevertheless, treatment of pilonidal disease with a fasciocutaneous V-Y flap is not a well-established procedure. We have modified the surgical technique and used it selectively for complicated recurrent cases. Our experience with this method is analyzed, and its validity is evaluated. METHODS Twenty-four patients with recurrent pilonidal sinus undergoing radical excision and reconstruction with our modified fasciocutaneous V-Y advancement flap between 1986 and 1993 were studied retrospectively. RESULTS Except for two minor transient wound dehiscences, in all cases primary healing was achieved. Furthermore, an excellent functional result and acceptable scar pattern were obtained in all twenty-four patients, with a mean follow-up of 4.5 years. Neither evidence of recurrence nor impairment of daily life activity was noted. CONCLUSIONS Treatment of complicated recurrent pilonidal sinus with the described technique offers a safe but demanding method for definite reconstruction, and we support a more common application.

Microsurgical repair of the sural nerve after nerve biopsy to avoid associated sensory morbidity: a preliminary report.

OBJECTIVEThe purpose of this article is to report our preliminary results regarding microsurgical repair of the sural nerve after nerve biopsy, in an attempt to reduce the well-described sensory morbidity and neuroma formation. METHODSThree patients with a suspected diagnosis of peripheral neuropathy underwent sural nerve biopsies to establish definitive diagnoses. A 10-mm segment of the sural nerve was resected with local anesthesia. After harvesting of the specimen, the proximal and distal nerve stumps were carefully mobilized and united with epineural suture techniques, under a surgical microscope. Sensory evaluations (assessing the presence of hypesthesia/dysesthesia or pain) of the lateral aspect of the foot, in regions designated Areas 1, 2, and 3, were performed before and 6 and 12 months after the biopsies. A visual analog scale was used for pain estimation. RESULTSThe biopsy material was sufficient for histopathological examinations in all cases, leading to conclusive diagnoses (vasculitis in two cases and amyloidosis in one case). The early post-biopsy hypesthesia, which was present for 4 to 8 weeks, improved to preoperative levels as early as 6 months after the nerve repair. Sensory evaluations performed at 6- and 12-month follow-up times demonstrated that none of the patients complained of pain at the biopsy site or distally in the area innervated by the sural nerve. Ultrasonography performed at the 12-month follow-up examination revealed normal sural nerve morphological features, with no neuroma formation, comparable to findings for the contralateral site. CONCLUSIONMicrosurgical repair of the sural nerve after biopsy can eliminate or reduce sensory disturbances such as paraesthesia, hypesthesia, and dysesthesia distal to the biopsy site, in the distribution of the sensory innervation of the sural nerve, and can prevent painful neuroma formation. To our knowledge, this article is the first in the literature to report on microsurgical repair of the sural nerve after nerve biopsy. Decreased side effects suggest that this technique can become a standard procedure after sural nerve biopsy, which is commonly required to establish the diagnosis of various diseases, such as peripheral nerve pathological conditions, vasculitis, and amyloidosis. More cases should be analyzed, however, to explore the usefulness of the technique and the reliability of sural nerve biopsy samples in attempts to obtain conclusive diagnoses.

Chronisch rezidivierende, lokal destruierende Silikonome nach Brustaugmentation durch flüssiges Silikonöl

Abstract. At the beginning of the sixties the injection of liquid silicon oil was frequently used for breast augmentation. It was thought to be safe, simple and effective. But as complications such as local silconomas, inflammatory reactions, induration, foreign body extrusion and foreign body migration were published this procedure was not used anymore. We report about a 45-year-old female patient who suffered from late complications, chronic recurrent local destructive siliconomas, which have not been described in the literature yet. Because of the destruction forced by the primary siliconimplant a bilateral subcutaneous mastectomy had to be performed and siliconomas were excised at regions different from the original injection site. Several breast reconstructions have been performed but this tissue has also been destroyed by the recurrent and aggressive siliconomas. As there can be a long period of latency before the aforementioned complications of liquid silicon injections can occur, we recommend careful follow-up for these patients.Zusammenfassung. Anfang der 60 er Jahre war die Augmentation der Brust durch Injektion von flüssigem Silikon eine sicher geglaubte Methode, welche ob des simplen Eingriffs und des raschen Erfolgs allzu oft unkritisch angewandt wurde. Als Komplikationen, welche diese Methode in Verruf brachten, wurden lokale Silikonome, entzündliche Infiltrationen und Indurationen, Fremdkörperextrusionen, sowie Fremdkörpermigrationen beschrieben. In der vorliegenden Arbeit wird über den Jahrzehnte langen Krankheitsverlauf einer 45 jährigen Patientin mit einer in der Literatur noch nicht erwähnten Spätkomplikation, der chronisch rezidivierenden, lokal destruierenden Form eines Silikonoms, berichtet. Die lokal destruierende Wirkung des flüssigen Silikons und der sekundären Silikonome erforderte eine beidseitige subcutane Mastektomie, sowie zahlreiche Silikonomexstirpationen auch außerhalb der ursprünglichen Applikationsstelle. Mehrfache plastisch-chirurgische Brustrekonstruktionen wurden durch den ungewöhnlich aggressiven und rezidivierenden Verlauf der Silikonome zerstört. Aufgrund der möglichen jahrelangen Latenz Silikon-assoziierter Komplikationen empfehlen wir eine konsequente Nachuntersuchung für betroffene Patienten aus den frühen Tagen der flüssigen Silikoninjektion.

Freie Lappenplastiken zur Rekonstruktion komplexer Defekte am Handrücken: Ästhetische und funktionelle Aspekte

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.

Coverage of pressure sores with free flaps

AbstractIntroduction. 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 6×6 cm and 25×30 cm. Two combined myocutaneous scapulalatissimus 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.ZusammenfassungEinleitung. Die Deckung von Dekubitalulzera mit instabiler Narbenbildung in der Umgebung ist eine in der Literatur immer wieder abgehandelte Problemstellung. Die lokale und regionale Übertragung von Gewebe kann beim komplexen Dekubitalulkus nicht immer zu einer dauerhaften Beseitigung des Gewebedefizits führen. Besonders bei Auftreten von Rezidiven besteht die Gefahr, dass das Ersatzgewebe aus der Umgebung selbst vernarbt oder durch verschiedenste lokale Gewebeverschiebungen aufgebraucht ist. Eine gute Alternative bietet hierfür die freie Lappenplastik, bei der selbst größere Druckulzera mit gut durchblutetem Gewebe gedeckt werden können. Methoden. Es wurden an unserer Klinik bei 5 Patienten wegen persistierendem, nicht heilenden Dekubitalulkus insgesamt 6 mikrochirurgische Lappenplastiken durchgeführt. Das Alter der Patienten lag zwischen 41 und 63 Jahren. Die zu deckende Defektgröße war zwischen 6×6 cm und 25×30 cm. Es wurden 2 kombinierte myokutane Skapula- Latissimus-dorsi-, zwei myokutane Latissimus-dorsi-, ein anteromedialer Oberschenkel- und ein myokutaner Rectus-femoris-Lappen zur Defektdeckung verwendet. Ergebnisse. Die durchschnittliche Nachuntersuchungszeit betrug 29 Monate. Nach 12 Monaten zeigte sich bei 4 von 5 Patienten der transferierte Lappen gut eingeheilt ohne Hinweis auf ein Rezidiv. Bei einem Patienten kam es zum Lappenverlust, welcher in weiterer Folge erfolgreich durch eine Spalthauttransplantation behandelt werden konnte. Schlussfolgerung.Wir konnten in einer Serie von 5 Patienten mit 6 freien Lappenplastiken zeigen, dass der mikrochirurgische Gewebetransfer bei der Therapie des Dekubitalulkus eine gute Alternative zu den herkömmlichen lokalen Verfahren darstellt. Auch bei älteren und polymorbiden Patienten kann dieses Verfahren durchaus in Erwägung gezogen werden.

Dekubitalulkusdeckung durch mikrochirurgische Lappenplastiken

AbstractIntroduction. 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 6×6 cm and 25×30 cm. Two combined myocutaneous scapulalatissimus 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.ZusammenfassungEinleitung. Die Deckung von Dekubitalulzera mit instabiler Narbenbildung in der Umgebung ist eine in der Literatur immer wieder abgehandelte Problemstellung. Die lokale und regionale Übertragung von Gewebe kann beim komplexen Dekubitalulkus nicht immer zu einer dauerhaften Beseitigung des Gewebedefizits führen. Besonders bei Auftreten von Rezidiven besteht die Gefahr, dass das Ersatzgewebe aus der Umgebung selbst vernarbt oder durch verschiedenste lokale Gewebeverschiebungen aufgebraucht ist. Eine gute Alternative bietet hierfür die freie Lappenplastik, bei der selbst größere Druckulzera mit gut durchblutetem Gewebe gedeckt werden können. Methoden. Es wurden an unserer Klinik bei 5 Patienten wegen persistierendem, nicht heilenden Dekubitalulkus insgesamt 6 mikrochirurgische Lappenplastiken durchgeführt. Das Alter der Patienten lag zwischen 41 und 63 Jahren. Die zu deckende Defektgröße war zwischen 6×6 cm und 25×30 cm. Es wurden 2 kombinierte myokutane Skapula- Latissimus-dorsi-, zwei myokutane Latissimus-dorsi-, ein anteromedialer Oberschenkel- und ein myokutaner Rectus-femoris-Lappen zur Defektdeckung verwendet. Ergebnisse. Die durchschnittliche Nachuntersuchungszeit betrug 29 Monate. Nach 12 Monaten zeigte sich bei 4 von 5 Patienten der transferierte Lappen gut eingeheilt ohne Hinweis auf ein Rezidiv. Bei einem Patienten kam es zum Lappenverlust, welcher in weiterer Folge erfolgreich durch eine Spalthauttransplantation behandelt werden konnte. Schlussfolgerung.Wir konnten in einer Serie von 5 Patienten mit 6 freien Lappenplastiken zeigen, dass der mikrochirurgische Gewebetransfer bei der Therapie des Dekubitalulkus eine gute Alternative zu den herkömmlichen lokalen Verfahren darstellt. Auch bei älteren und polymorbiden Patienten kann dieses Verfahren durchaus in Erwägung gezogen werden.

Ohrmuschelverletzungen : Klassifizierung und Therapiekonzept

ZusammenfassungDie detailgetreue und nach ästhetischen Gesichtspunkten korrekte Versorgung von Ohrmuschelverletzungen bis hin zur Amputation stellt eine anspruchsvolle Aufgabe für den erstbehandelnden Chirurgen dar. Versäumnisse bei Primärbehandlungen führen zu erschwerten Bedingungen bei der Rekonstruktion, die ästhetischen Resultate sind in der Regel dann nicht zufriedenstellend.Vorgestellt und vorgeschlagen wird eine Klassifikation nach Art der Ohrverletzung. Das differenzierte Behandlungskonzept trägt den verschiedenen Belangen Rechnung. Falldarstellungen werden zu verschiedenen Methoden gezeigt und mit der vorhandenen Literatur verglichen und diskutiert.AbstractThe treatment of traumatic defects of the auricle concerning the exact reconstruction of details and aesthetic aspects is exacting for the surgeon. To face the expectations towards best trauma care, the different locations and extent of auricular injuries should be included in the different therapeutic strategies. The insufficient treatment results in mostly difficult secondary conditions.We present a classification for ear traumas, which considers size and location of defects. Depending on this, different techniques and methods of reconstruction are recommended. Advantages and disadvantages are pointed out and discussed with several examples and with the present literature.

Defektdeckung durch freie Lappenplastiken am Fußrücken

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.

Closure of defects on the dorsum of the foot with free flaps. Functional and aesthetic aspects

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.

Defektdeckung durch freie Lappenplastiken am Fußrücken@@@Closure of defects on the dorsum of the foot with free flaps: Funktionelle und ästhetische Aspekte@@@Functional and aesthetic aspects

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.