Gottfried Lemperle

Reduction of capsular formation around silicone breast implants by D-penicillamine in rats

In a controlled study in 109 female rats we evaluated the effect of soluble D-Penicillamine in doses of 10 mg/ml or 100 mg/ml on capsular formation around semipermeable 2 cm3 mini-prostheses. This was compared with methylprednisolone 1 mg/ml or 10 mg/ml, and a group given saline served as controls. The drugs were injected into the lumen. Capsular wet weight and capsular tensile strength were measured after a period of 40 days. Rats given D-Penicillamine showed a significant, dose-dependent, reduction in wet weight and tensile strength compared with the saline group. There was no significant difference between the groups given D-Penicillamine and those given steroids. Topical treatment with diffused D-Penicillamine can significantly reduce the amount of capsular formation around silicone implants. This drug, which is highly specific for the systemic treatment of fibrotic diseases, should be evaluated further to use in reducing capsular formation.

151. Chirurgische Therapiemöglichkeit bei ausgedehnter Thoraxwandund Rippenmetastasierung

Summary87 extensive tumors of the chest wall were resected in an 8 year period. The defects including subtotal sternectomies and segment resections up to 7 ribs were reconstructed with musculocutaneous flaps without any osteoplasty or implants. The latissimus dorsi flap closes pleural defects safely. The innervated muscle stabilizes the chest wall. The rectus abdominis flap fits defects of greater volume but the blood supply is less reliable. The use of pectoralis major or free microsurgical tissue transfer may be indicated in absence of any other possibility.ZusammenfassungSeit 1978 sind 87 ausgedehnte Thoraxwandtumore reseziert worden. Die Rekonstruktion der Defekte nach subtotaler Sternektomie oder bis zu 7 Rippensegmenten erfolgte mit musculocutanen Lappenplastiken ohne weitere stabilisierende Implantate. Der Latissimus dorsi ermöglicht den exakten Verschluss grosser Pleuradefekte, der innervierte Muskel stabilisiert die Thoraxwand. Der Rectus-abdominis-Lappen eignet sich für den grösseren Volumenersatz. In seltenen Fällen ist der M. pectoralis major oder der freie mikrochirurgische Gewebetransfer anzuwenden.

Simultaneous total upper and lower lip reconstruction during a humanitarian surgical mission to Africa

There are many ways to reconstruct a missing upper or lower lip. Most textbooks and articles describe vertical nasolabial flaps, horizontal frontal flaps, or platysma flaps from the neck (to be used mainly for inner lining) [1, 2] Distant flaps from the upper arm (Tagliacozzi), musculocutaneous latissimus flap (used in noma repair), or free microsurgical flaps from the forearm (Chinese flap) can serve as a large frontal flap to prevent further mutilation of the face. However, this most simple and cosmetically effective reconstruction of an upper lip has not been described before. Two young men were presented to a team of Interplast-Germany operating in Goma. They had been tortured by marauding soldiers in the rain forests North of Goma, in the Democratic Republic of Kongo. When the men denied having gold, the soldiers sequentially amputated their thumb, fingers 2 and 3, and both ears. In raiding their hut, the soldiers then found a few gold nuggets. As punishment, they proceeded to cut off upper and lower lips of both men. When presented to us, the wounds around the missing lips and ears appeared clean; the finger stumps had been closed surgically. Understandably, both men, aged 23 and 30, were severely traumatized and could only be examined with difficulty. The lips of both patients were amputated entirely and almost professionally between cheeks, nose and chin (Figs. 1 and 2). First, a large horizontal frontal flap was discussed but rejected, since a dark black skin graft would have further disfigured the faces. A free forearm flap was out of question because of a lack of surgical loupes. Therefore, we decided on utilizing local flaps, although the remaining skin of the cheeks appeared very tight. Under general anaesthesia, the full-thickness cheeks with the residual mucosa were undermined on the bony level along the maxillary arches back to both mandibular joints. Square flaps were cut between nose and lower lids and pulled together in the midline below the columella. The skin with some facial muscles complete with inner lining could be pulled towards the midline to cover the upper teeth. For the reconstruction of the lower lips, a reverse 4-cm visor flap from under the chin, including the platysma, was designed and pulled over the chin. The donor defect was closed after undermining the neck skin. For the inner lining, two vertical mucosal cheek flaps (2 × 4 cm) with their base in the lower gingival fold could be raised and pulled to the midline. All flaps healed well, but the constant tension on the wounds opened the view to the frontal teeth again in the younger man. Surprisingly, after 3 months, the upper lip of both men was fully sensitive and the lower lip felt pain during squeezing. Slight muscle movement could be detected in all lips. The same Interplast-Germany team operated a second time on the two patients: the older of the two men * Gottfried Lemperle Lemperle8@aol.com

Ein dreijähriges Hilfsprogramm für Plastische Chirurgie in Peshawar (Pakistan) Kontinuierliche Versorgung Schwerverletzter Patienten des afghanischen Krieges: 1528 große Operationen, 5171 kleinere Eingriffe, 15932 untersuchte Patienten

Since 1980 Interplast Germany has sent many plastic surgeons to developing countries. In 1989 a new Interplast Germany program for helping Afghan refugees in Pakistans Peshawar was started. The Federal Republic of Germany financed the first two years; thereafter, the European Community and Help supported the project. Twenty-four teams with 123 nurses, surgeons and anesthesiologists operated on 1,528 patients in two hospitals. In the same period 5,171 smaller operations have been performed and 15,932 patients have been examined. Low expense for the teams, good support by officials, and professional administration have made this project highly effective for 3 years.Since 1980 Interplast Germany has sent many plastic surgeons to developing countries. In 1989 a new Interplast Germany program for helping Afghan refugees in Pakistans Peshawar was started. The Federal Republic of Germany financed the first two years; thereafter, the European Community and Help supported the project. Twenty-four teams with 123 nurses, surgeons and anesthesiologists operated on 1,528 patients in two hospitals. In the same period 5,171 smaller operations have been performed and 15,932 patients have been examined. Low expense for the teams, good support by officials, and professional administration have made this project highly effective for 3 years.ZusammenfassungSeit 1989 hat Interplast Germany mit 24 Teams 1528 Schwerverletzte Patienten des afghanischen Krieges in Peshawar, Pakistan, operiert. 5171 kleinere Operationen wurden ambulant durchgeführt. 15932 Patienten wurden untersucht. Damit ist eine Spezialabteilung in Peshawar, Pakistan, etabliert worden, deren Verdienst es ist, daß über 1500 Schwerverletzte Patienten nahe ihrem Heimatland und nahe ihren Familien operiert werden konnten. Auf der anderen Seite, sind dadurch den potentiellen Gastländern immense Kosten in ihrem Gesundheits-und Sozialwesen erspart geblieben. Die Qualität der Behandlung entspricht dem Standard, wie er in europäischen und anglo-amerikanischen Kliniken auch gewährleistet ist.

Folded breast implant's pointed edge causing thinning of the skin

Sir, Aesthetic breast augmentation can be fraught with postoperative complications, particularly capsular contracture, malrotation, skin surface irregularities, and implant or inframammary fold malposition. However, we found only one report from 1972, 6 years after introduction of silicone breast implants, which describes Bthe folded breast sign^ as a radiological appearance rather than a clinical sign of a pointed Silastic shell [1]. Since we have corrected this late complication with conspicuous skin thinning several times in the past, we present today on two patients, both slim and tall and without any detectable thorax asymmetry. Two smooth-walled, soft, round, and lowprofile implants had been inserted into the sub-mammary space through the trans-axillary approach [2] in both patients 6 and 5 years prior. Both patients showed absolutely soft breast and had never developed a Baker II–IV capsule. One patient, a 24-year old student received 240 cm smoothwalled implants 5 years ago and recognized the pointed edge in the upper outer quadrant of the right breast (Fig. 1a) about 1 year after augmentation. The implant appeared vertically folded, and its protruding tip could be hidden behind the vertical bra strip. When the tip slowly thinned out the covering dermis, the patient asked for treatment. The implant pocket was so wide that a turning maneuver of the implant counter-clockwise from outside was successful. No pointed tip was palpable, and the implant appeared to be unfolded for over 9 months by now (Fig. 1b). The thinned out skin area recovered by itself after the pressure and rubbing from the inside subsided. The other patient, a 36 year-old riding instructor received two smooth-walled implants of 320 cm 6 years ago and developed a palpable and visible pointed implant tip also approximately 1 year later in the inner lower quadrant of her left breast. Under the impression of a capsule contracture as the cause for folding, she had been re-operated in the meantime three times by widening the pocket but leaving the implant. Early reoccurrence of the implant folding created the same pointed tip each time. Within a few weeks, the subcutaneous fat disappeared under pressure and slight rubbing and the implant edge shined through the skin in an area of about 2 cm in diameter (Fig. 2a). Both smooth implants could be moved easily upwards within their normal wide pockets, but the horizontally folded implant could not be kept unfolded by external maneuvers. Breast sonography [3] showed a clear fold with a pointed tip of the shell in front of the lower edge of the sternum. Checking all available implants on aesthetic surgery meetings, folding was possible in all presently available textured or smooth cohesive implants from all manufacturers (Fig. 3a, b). The only implant which could not be folded was Allergan’s cohesive textured high-profile implant Natrelle (Allergan, Irvine, California, USA) CHP-345 with 12 cm in diameter. Consequently, we inserted this implant in both breasts through a new inframammary incision. The thinned out skin area on the left breast was supported with a triangle-shaped capsular-fascial flap of 6 cm in length, raised from the pectoral muscle [4, 5]. An alternative solution would have been subpectoral implantation, which will support the recovery of thinned out skin in the upper but not in lower quadrants. Twelve months after corrective surgery, both breasts looked perfect without any signs of unevenness or skin thinning (Fig. 2b). Both breasts were firmer than before revision but did not bother the happy patient. * Gottfried Lemperle lemperle8@aol.com

254. Die Wiederaufdehnung der kontrakten Orbita durch eine individuell einstellbare dehnungsplatte

SummaryLoss of an eye always presents the same problem after full-thickness transplantation of the orbit: the empty eye socket begins to contract. To stretch the contracted socket back to its former size, we construct an extension plate out of two half-moon-shaped pieces of a cold polimerization (Paladur). In the middle of these two pieces, an extension screw can be moved twice a week. The eye prosthesis and extension plate can be worn together during the whole stretch period. Finally, the stretched eye socked is filled with a special glass in combination with the prosthesis. This procedure results in a good-fitting eye prosthesis that lasts a long time and is the same size as the normal eye.ZusammenfassungDurch den Verlust eines Auges treten nach Vollhauttransplantation der Orbita immer die gleichen Probleme auf; die Augenhöhle beginnt zu schrumpfen. Um die Augenhöhle wieder zu ihrer normalen Grösse aufzudehnen, haben wir eine Dehnungsplatte aus Paladur entwickelt, in deren Mitte eine Dehnungsschraube sitzt, die der Patient selbst zweimal wöchentlich bewegen kann. Die Glasprothese kann während des ganzen Dehnungsvorganges über 2 Monate gleichzeitig auf der Platte getragen werden. Anschliessend wird die aufgedehnte Orbita durch eine Glaskeramik ausgegossen und mit der Glasprothese verbunden. Dieser Vorgang gewährleistet einen guten, dauerhaften Sitz entsprechend den Grössenverhältnissen des gesunden Auges.

252. Sekundäre Orbita- und periorbitale Weichteilrekonstruktion

SummaryFor remodelling the face after fractures in the orbital region with loss of bone, we have been using custom-made silicone implants (18 patients, 1980–1986). Post-traumatic enophthalmos is best treated by placing an implant of silastic over the fractured floor of the orbit (34 patients, 1980–1986). Local flaps are used for repair of the eyelids (6 patients, 1980–1986).ZusammenfassungBei komplizierten periorbitalen Frakturen mit knöchernem Substanzverlust besonders im Bereich der Jochbeinkontur, wurden Silikonimplantate speziell vorgefertigt, um die Gesichtskontur wiederherzustellen (18 Patienten 1980–1986). Der posttraumatische Enophthalmus nach Orbitabodenfraktur und Fettgewebsverlust erfordert die Anhebung des Auges und die Angleichung der Lidachse. Die Methode der Wahl ist der Ausgleich des Niveau-Unterschiedes mit dem Einbringen einer intraorbitalen Silikonscheibe (34 Patienten 1980–1986). Ober- und Unterlider werden aus lokalen Lappen rekonstruiert (6 Patienten 1980–1986).

331. Hautexpander in der Plastischen Chirurgie

SummarySoft tissue expansion makes reconstructioe operations in plastic surgery possible that had not been possible before. In this process the random pattern flap has been reborn. The skin expander, introduced in 1976 by C. Radovan for breast reconstruction, is now used from head to foot. The fact that primary closure of the donor defect is possible is extraordinary. In addition, the skin next to the recipient area corresponds much more closely with regard to colour, texture, hair and sensitivity than any other skin transplant. Within 3 years 132 patients have been treated with 162 skin expanders. The complication rate has dropped from 27% in the 1st year to 14% in the 3rd. However, the question as to whether one can speak of skin growth has not yet been clarified.ZusammenfassungDie Hautexpansion ermöglicht rekonstruktive Eingriffe in der Plastischen Chirurgie, die zuvor so nicht möglich waren. Dabei erlebt der willkürlich gewählte Hautlappen als Vorschiebelappen eine Renaissance. Der Hautexpander, von C. Radovan 1976 auschließlich zum Brustwiederaufbau eingeführt, wurde sofort von Kopf bis Fuß eingesetzt. Herausragend dabei ist der Primärverschluß des Hebedefektes. Außerdem entspricht die Haut in der Nähe des Empfängerareals besser der Farbe, Textur, Behaarung und Sensibilität. In 3 Jahren wurden 137 Patienten mit 162 Expandern behandelt. Größere Komplikationen sanken von 27% im ersten auf 14% im dritten Jahr. Die Frage, ob es sich um eine Hautvermehrung handelt ist bislang ungeklärt.

61. Die operative Korrektur asymmetrischer Entwicklungsstörungen der weiblichen Brust

SummaryCongenital breast anomalies are amastity, athelia, tuberous breast, polythelia and polymastia. Polands Syndrome may show absence of one breast, nipple and pectoral muscle. Scars due to injuries, burns and thoracic surgery may disturb the infantile development of the breast. The corrective mammaplasty includes augmentations with silicone implants, reductions by different techniques, skin flaps and free grafts. For tuberous Breasts we invented a method with a partial deepithelized thoracoepigastric flap. This flap allows improved shaping and augmentation without silicone implants.ZusammenfassungMammaasymmetrien beruhen auf kongenitalen Fehlanlagen, endogenen Fehlentwicklungen oder auch exogenen Faktoren wie beim Trauma oder der Radiatio. Congenitale Anomalien reichen von der Amastie über die Athelie, von der Polythelie zur Polymastie. Beim Poland-Syndrom kann eine Brust und der M. pectoralis fehlen. Erworbene Asymmetrien sind Folgen schwerer Verbrennungen im Kindesalter, Verletzungen oder Narben nach chirurgischen Eingriffen. Die operativen Korrekturen bestehen in Augmentationen mit Silikonimplantaten, Reduktionsplastiken, lokalen Lappenplastiken und freien Hauttransplantaten. Eine eigene Methode zur Korrektur der tubular breast wird vorgestellt.

157. Über die frühe Phase der Wundheilung nach rekonstruktiven Eingriffen an der weiblichen Brust

SummaryThe fluids in wound-suction drainage were analyzed in patients with reconstructive mamma operations. A decrease in exudation and cellular components was found during an observation time of 7 days. Within the first 24 h, however, the concentration of white cells increased to about 14,000/mm3 and subsequently decreased to about 2,000/mm3 at the 3rd day postoperatively. The increase was caused by polymorphonuclear leukocytes. After that, monocytoid cells and lymphocytes were predominant. Complications of wound healing were indicated by different observations.ZusammenfassungBei rekonstruktiven Eingriffen an der weiblichen Brust wurden die Flüssigkeiten aus den Saugdrainagen untersucht. Im Verlauf waren die geförderten Mengen und der Anteil der cellulären Bestandteile rückläufig. Die Konzentration der weißen Blutzellen zeigte jedoch während der ersten 24 h einen Anstieg auf Werte um 14 000/mm3 im Mittel, nachfolgend eine Abnahme auf Werte um 2000/mm3 bis zum 3. Tag post OP. Der Anstieg wurde von Granulocyten verursacht, danach überwogen monocytäre Elemente und Lymphocyten. Abweichungen von diesem Verhalten wiesen auf Wundheilungsstörungen hin.