J. Holle

Nerve and vessel supplying ligamentous suspension of the mammary gland.

&NA; Anatomical findings from 28 breast specimens of female corpses have shown a thin horizontal fibrous septum, originating from the pectoral fascia along the level of the fifth rib, heading toward the nipple. This fibrous septum lies in between a cranial and a caudal vascular network, and being mesentery‐like, it is responsible for the supply of the nipple areola complex. The cranial vascular sheet is supplied by the thoracoacromial artery and a branch of the lateral thoracic artery, whereas the caudal sheet is supplied by perforating branches from anastomoses of intercostal arteries. The fibrous septum is also a guiding structure for the main supplying nerve of the nipple. At its borders the septum curves upward into a vertical medial and lateral ligament, which attach the breast to the sternum and the lateral edge of pectoralis minor. These ligaments also contain a regular nerve and vascular supply. In their total, the fibrous septum and its ligaments form a sling of dense connective tissue that acts as a brassierelike suspensory system. These two structures, the fibrous sling and the vascular and nervous membranes attached to it, are consistent anatomical findings, which have not been described before. Their knowledge could be of value and relevance in clinical application. (Plast. Reconstr. Surg. 101: 1486, 1998.)

The sensitivity of the nipple-areola complex: an anatomic study.

Although preservation of the sensitivity of the nipple and areola is an important goal in breast surgery, only scant and contradictory information about the course and distribution of the supplying nerves is found in the literature. The existing controversy might be due to the difficulty in dissecting the thin nerves and to frequent anatomic variations that bias the results if only a small number of cadavers are dissected. We dissected 28 female cadavers and found that the nipple and areola were always innervated by the lateral and anterior cutaneous branches of the 3rd, 4th, and 5th intercostal nerves. The most constant innervation pattern was by the 4th lateral cutaneous branch (79 percent) and by the 3rd and 4th anterior cutaneous branches (57 percent). The anterior cutaneous branches took a superficial course within the subcutaneous tissue and terminated at the medial areolar border in all dissected breasts. The lateral cutaneous branches took a deep course within the pectoral fascia and reached the nipple from its posterior surface in 93 percent of the dissected breasts. In 7 percent of the dissected breasts, the lateral cutaneous branches took a superficial course within the subcutaneous fat and reached the nipple from the lateral side. These findings suggest that the nerves innervating the nipple and areola are best protected if resections at the base of the breast and skin incisions at the medial areolar border are avoided. (Plast. Reconstr. Surg. 105: 905, 2000.)

Technology and long-term application of an epineural electrode

An epineural electrode (ENE) was developed to achieve a controllable, progressive muscle contraction and reduce muscle fatigue during functional electrostimulation. In vitro studies of annular (torus-shaped) electrodes have been carried out to select adequate electrode materials and electrode diameters. We investigated the long-term stability of ENEs using different intensities of current (range: 0.8-1.2 mA) in sheep and rat experiments. Depending upon size and material, ENE tolerates anodic and cathodic impulses of up to 1 msec and 8 mA (peak current). ENEs were used during clinical application in four paraplegic patients (16 channel implants) for stimulation of lower extremities, and in nine quadruplegic patients (eight channel implants) for diaphragm pacing, for a total observation time of 37 patient years. The low rate of clinical complications, including no corrosion of the electrodes or significant loss of nerve fibers, seems related to the small dimensions of the electrode (less than 1 mm2).

The lumbrical muscle flap: Anatomic study and clinical application†

This article describes the anatomy and clinical application of the lumbrical muscle flap. Anatomic and radiologic studies were performed in 20 fresh human cadaver hands injected with latex-lead-oxide solution. Only the 2 radial lumbrical muscles were found suitable for flap transposition. The vascular supply of the first and second lumbrical muscles is from branches originating in the superficial palmar arch and from the common palmar digital artery, respectively. The dominant branches invariably enter the muscle bellies at the junction of their proximal and middle thirds. Pedicled on these vessels, the lumbrical muscles can be transposed to reach the entire palm, up to the wrist flexion crease. The clinical use of the first and second lumbrical muscle flaps in 2 patients demonstrated the value of these flaps for coverage of the median nerve and its palmar branches.

Scarpa's Fascia Flap: Anatomic Studies and Clinical Application

Fascia and fascia-subcutaneous flaps are thin, pliable, and well-vascularized tissue with aesthetic and functional advantages, particularly for the extremities and in the head and neck region. Although various donor sites have been used for these flaps, there is an occurrence of unsatisfactory donor-site defects that are often complicated by conspicuous, widened scars or alopecia. In addition, flap elevation is sometimes prolonged because of the demanding operative procedures as well as the impossibility of a two-team approach. In this anatomic and clinical study we present a new fascial flap that results in a minimal donor-site defect and a short and easy operative procedure. Scarpas fascia, which can be used as both a free and a pedicled flap, is a well-defined single membranous sheet within the subcutaneous tissue layer at the lower abdominal wall. We studied its distribution, structure, and vascular supply in 27 fresh cadaver specimens. In addition, computed tomographic (CT) and ultrasound studies were performed in 13 healthy volunteers and in 3 cadavers before and after injection of diluted contrast material in the superficial epigastric artery. Finally, histologic examinations were done with hematoxylin and eosin or with reticulum and elastin. Our studies showed that Scarpas fascia provides a thin, pliable, and well-vascularized flap pedicled on the superficial epigastric artery. After successful application of the Scarpas fascia flap as a free flap in 3 patients and as a pedicled option in 1 patient, we can recommend this flap as a valuable tool for the reconstructive surgeon.

External oblique abdominal muscle: A new look on its blood supply and innervation

Numerous reports have discussed the use of the external oblique abdominal muscle as a pedicled or a free flap for defect coverage. A detailed description of the supplying vessels and nerves is a prerequisite for successful tissue transfer but so far is not available in the literature.

Reconstruction of the maxilla with prefabricated scapular flaps in noma patients.

Background: Noma (cancrum oris) is a devastating gangrenous disease that leads to severe tissue destruction in the face and is associated with a high rate of mortality. When untreated, it results in disfiguring midface defects and severe scarring. Ideal reconstruction of complex maxillofacial defects requires the restitution of bone, dental implants, soft tissue, and the thin and durable lining of the oral and paranasal cavities. Prefabricated composite grafts from the scapula are used to restore the maxilla in patients with this disease. Methods: A new concept of osteosynthesis involving titanium plates connected to dental implants, achieving greater mechanical stability of the reconstructed bony framework, is described. Nine complex midface defects were reconstructed with dermis-prelaminated scapular flaps. A bone flap from the lateral margin of the scapula was taken and osseointegrated implants were inserted. The bone flap was then prelaminated with dermis and covered with a Gore-Tex sheath to prevent adhesion. Two to 3 months later, the composite flap was transferred to the midface. Results: Restoration of a maxilla with pneumatized paranasal cavities and a keratinized attached epithelium covering the alveolus and hard palate was successfully performed in all noma patients. The reconstructed “masticatory gingiva” and osseointegrated dental implants enabled patients to exercise oral functions shortly after surgery. Conclusion: Long-term observation of selected noma patients showed restoration of oral function and stability of the maxilla after several years.

The vertically based deep fascia turnover flap of the leg: anatomic studies and clinical applications.

&NA; Although fasciocutaneous turnover flaps are a simple and fast method for covering soft‐tissue defects of the lower leg, many reconstructive surgeons have their doubts about them. They revolve around the lack of criteria for safely designing these random‐pattern flaps and around the risk of donor site problems. A vertically based deep fascia turnover flap with a paratibial or parafibular pedicle is presented. Anatomic studies of 36 injected lower limbs showed the deep fascia to be supplied by a mean of 61 vessels. As musculofascial, septofascial, and periosteofascial branches, these contribute to a richly anastomosing vascular network within the deep fascia. Along the deep transverse septum at the medial tibial border, the anterior and posterior peroneal septa, and between the anterior tibial and extensor muscles, the fascia is supplied by segmental vessels in a clearly defined arrangement. Pedicled on these vessels, the deep fascia is a useful candidate tissue for transversely oriented turnover flaps. These are particularly well suited for covering pretibial or prefibular soft‐tissue defects. Unlike adipofascial turnover flaps, the transversely oriented deep fascia turnover flap keeps its subcutaneous layer with its intact vascular plexus so that the overlying skin is adequately perfused even in patients with sizable flaps or an extremely thin skin. Clinical experience with the vertically based paratibial or parafibular deep fascia turnover flap in six patients confirmed its usefulness for covering small to mediumsized soft tissue defects of the lower leg. (Plast. Reconstr. Surg. 100: 1746, 1997.)

Long-term results of nervous tissue alterations caused by epineurial electrode application: an experimental study in rat sciatic nerve.

In order to evaluate the long‐term effects of epineurial electrode application for functional electrical stimulation (FES) the left sciatic nerve of seven rats was exposed. Four ring‐shaped stainless steel wire electrodes were sutured to the epineurium of each nerve in the same manner as performed clinically for carrousel stimulation in man. The nerves were reexposed 1 year after implantation and the stimulation threshold to obtain a tetanic contraction in the lower limb was determined for each electrode. Afterwards the animals were sacrificed. The electrodes were excised and cross sections of the sciatic nerve directly at the site of the electrodes, 2‐mm proximal and 2‐mm distal to them were harvested for hisfologic and planimetric assessment of nerve lesions. The area of damaged neural tissue was expressed as a percentage of the total cross‐sectional area within the perineural sheath. The sciatic nerves of the right side served as controls. The values for the stimulation thresholds ranged between 0.1 and 1.0 mA (mean 0.43 mA). By morphometric examination five of seven nerves were seen altered, the altered areas captured between 1% and 4.8% of the total cross‐sectional area of the nerves within the perineural sheath. Besides two specimens, all altered nerve segments exhibited distinct signs of nerve fiber regeneration. The clinical implications of the results for long‐term electrical stimulation, such as phrenic pacing, are discussed.

Multi-channel indirect stimulation reduces muscle fatigue

Isometric contraction forces were registered in sheep rectus femoris muscles at two different types of simulation through the femoral nerve. Conventional single-channel nerve stimulation (two electrodes) on one leg was compared with multichannel stimulation (four electrodes with rotating activity) on the contralateral leg. Fatigue indices were evaluated according to R.E. Burke et al. (1973), with stimulation parameters modified for the larger dimensions in sheep. Fatigue indices were calculated after 2, 4, 10, 20, 40, and 60 min. After 2 min, submaximal multichannel stimulation resulted in at least 14% less muscle fatigue compared to single-channel stimulation. Accordingly, after prolonged stimulation up to 60 min, higher contraction forces were recorded at multichannel stimulation. The fatigue indices were 0.43 for single-channel and 0.66 for multichannel stimulation. The data clearly indicate that multichannel stimulation results in 23% less muscle fatigue. The experimental results demonstrate the advantages of multichannel stimulation in patients.<<ETX>>