Hans Anderl

Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention.

This prospective study reveals that the incidence of seroma formation after harvesting the latissimus dorsi muscle by scalpel is reasonably moderate. This incidence is lower when the resulting skin flaps are tacked to the underlying structures with resorbable sutures. In contrast, electrocautery dissection shows a significantly much higher rate of seroma formation, probably because of thermal injury of the wide fascial wound layers or the subcutaneous fat tissue. Fifty-eight patients were distributed among three groups. Within each group a specific way of latissimus dorsi muscle harvesting and donor site treatment was accomplished. The group of scalpel dissection and skin flap fixation to the underlying layers with additional tacking sutures shows the lowest rate of seroma formation (9.1%, N = 2) due to the avoidance of shearing effects. A clearly higher incidence is present in the group of scalpel dissection without tacking sutures (38.1%, N = 8), whereas seromas most frequently result after electrocautery dissection without skin flap fixation (80.0%, N = 12).

Internal mammary vessels: anatomical and clinical considerations

This study was designed to investigate the anatomy of the internal mammary (thoracic) artery (IMA) and comitant vein(s) (IMV) relevant to their use in microsurgery. We dissected the internal mammary (thoracic) vessels bilaterally in 86 cadavers from the clavicle down to the 6th rib. At the level of the 4th rib, the distance between the sternum and the IMA was large enough [range 10.0-23.6 mm] and the diameter of the IMA [range 0.99-2.55 mm] and comitant vein(s) [range 0.64-4.45 mm] wide enough for both end-to-end and/or end-to-side anastomosis. These results were in close agreement with supplementary measurements obtained by Doppler ultrasound in 34 healthy female volunteers. Based on all these findings we suggest that the internal mammary vessels are suitable recipient vessels for free tissue transfers in the thoracic region, especially for breast reconstruction with the free transverse rectus abdominis myocutaneous (TRAM) flap.

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

&NA; 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.

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.

Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction

In breast reconstruction with a free flap following mastectomy, the recipient vessels most widely used are in the axillary system, which limits flap movement and flexibility in breast shaping. In addition, scarring and fibrosis can make dissection of the vessels difficult. We have performed 22 breast reconstructions using a free transverse rectus abdominis myocutaneous (TRAM) flap anastomosed to the internal mammary (thoracic) vessels. There has been no flap failure. The surgical techniques and the advantages and limitations of the internal mammary system are presented and the internal mammary vessels compared with the axillary vessels as a recipient vascular system.

Primary simultaneous lip and nose repair in the unilateral cleft lip and palate.

Background: “Do not touch the nose in primary repair of the unilateral cleft lip and palate!” In the past, this dogmatic attitude caused functional and aesthetic (psychological) problems for the child until secondary corrections during adolescence were performed. In the 1950s, surgeons started to correct at least a few features of the nasal deformity and to develop radically corrective measures. Since 1970, a new and very comprehensive concept of correction has been used at the authors’ department of plastic and reconstructive surgery. Methods: Methods of primary nasal repair by various surgeons are presented chronologically. The main features of the authors’ strategy are special incision lines, extensive mobilization of all dislocated structures, straightening of the deviated septum, correction of the deformed ala and nasal tip, induction of bone growth in hypoplastic areas under the alar base and along the piriform aperture, and a special suture technique of the orbicularis muscle to form a better philtrum. Results: Improvement of the aesthetic and functional results can be achieved with this type of nasal repair. Since 1970, approximately 500 patients have been operated on with this method at the authors’ hospital and elsewhere, with 80 percent showing satisfactory results and 20 percent revealing deficiencies. Severe nasal deformities, which were common when no primary repair was applied, were not observed. This observation period provides evidence that no growth retardation occurs. Conclusions: Because of the good results of this method and the lack of growth retardation, this approach is to be recommended. It also benefits children in underdeveloped countries, where frequent surgery is not possible.

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

&NA; 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. (Plast. Reconstr. Surg. 100: 402, 1997.)

Restoration of voluntary emptying of the bladder by transplantation of innervated free skeletal muscle.

BACKGROUND On the basis of studies with animals and experience with functioning muscle transfer in plastic surgery, we have developed a surgical technique to restore detrusor function for patients with bladder acontractility in whom there is no treatment alternative. METHODS Three patients (aged 26 years, 28 years, and 68 years) with bladder acontractility as a result of spinal-cord injury (two patients) and chronic overdistension (one patient), who required catheterisation for bladder emptying for 5 years, 2 years, and 2 years, respectively, took part in our study. The patients were treated with microneurovascular free transfer of autologous latissimus dorsi muscle to the bladder to restore detrusor function. Follow-up included clinical and urodynamic evaluation, colour doppler sonography, intravenous urography, and flow-mode computerised tomography. FINDINGS The three patients voluntarily emptied their bladders at 16 weeks, 16 weeks, and 30 weeks after surgery, respectively. There was no need for further catheterisation throughout the follow-up period. On urodynamic assessment at 12 months after the operation bladder capacity was found to be 600 mL, 600 mL, and 650 mL, residual urinary volume 0 mL, 50 mL, 90 mL, and maximum flow rate 26 mL/s, 25 mL/s, and 18 mL/s, respectively. Activity at the transplanted latissimus dorsi was confirmed by ultrasonography and flow-mode computerised tomography. INTERPRETATION Microneurovascular free transfer of latissimus dorsi muscle to functionally restore a deficient detrusor muscle has proved to be successful for the three patients in our study. This technique may also be an option to restore the function of other smooth-muscle organs.

Free Flap Closure of Recurrent Palatal Fistula in the Cleft Lip and Palate Patient

Recurrent palatal fistulas present a particularly vexing problem for the cleft surgeon. In this setting, the cycle of repair followed by breakdown results in increasing scar formation with associated soft tissue contracture and a resultant increase in fistula size. This pernicious cycle of events renders random local tissue transfers obsolete. As such, the cleft surgeon must look to tongue flaps or local axial pattern flaps as a means of bringing well-vascularized, pliable tissue into the defect. Although this approach has been the standard of care for the last few decades, we believe that the modern-day success rates of free tissue transfers (95%) make them a viable, one-stage means of closing these defects. In this report we present our clinical experience with recurrent palatal fistulas and highlight the effective use of the dorsalis pedis-first dorsal metatarsal artery free flap as a means of repair.

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

&NA; 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. (Plast. Reconstr. Surg. 102: 1939, 1998.)