Klaus Exner

Investigation of TRAM flap oxygenation and perfusion by near-infrared reflection spectroscopy and color-coded duplex sonography.

Near-infrared reflection spectroscopy, used experimentally for investigation of tissue hemoglobin content and oxygenation in various flaps, was tested in the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, chosen as a simple clinical model because of its well-known vascular anatomy and clinical relevance. The study intended to answer the following questions: Does the near-infrared reflection spectroscopy system used in this study measure tissue hemoglobin content and oxygenation in the superficial skin layers only, as proposed by the manufacturer? Is near-infrared reflection spectroscopy able to detect differences of tissue hemoglobin content and oxygenation in distinct zones of the TRAM flap skin before, early, and late after surgery? Does tissue hemoglobin content and oxygenation correspond to blood flow in the supplying superior epigastric artery and to clinical signs of TRAM flap perfusion and viability? In 11 patients, tissue hemoglobin content and oxygenation in the lower abdomen/TRAM flap, mastectomy skin flap, and contralateral breast were measured by a new near-infrared reflection spectroscopy system preoperatively, early postoperatively, and late postoperatively. Simultaneously, systolic peak flow in the ipsilateral superior epigastric artery was obtained by color-coded duplex sonography. Routine clinical monitoring was performed throughout the early postoperative period. Tissue hemoglobin content and oxygenation in the lower abdomen, mastectomy skin flap, and contralateral breast were similar before surgery but varied considerably between different patients. There were no significant differences among preoperative, early postoperative, and late postoperative values of tissue hemoglobin content and oxygenation in the mastectomy skin flap and contralateral breast. However, near-infrared reflection spectroscopy measurements of the TRAM flap revealed significant differences between preoperative and early postoperative values of tissue hemoglobin content and oxygenation and among zones I, II, and III early after surgery. Tissue hemoglobin content in the TRAM flap skin increased and oxygenation decreased early after surgery. Near-infrared reflection spectroscopy values corresponded to clinical signs of venous congestion predominantly in zone III. Late postoperative return of hemoglobin content and oxygenation in the TRAM flap toward preoperative values can be attributed to improved venous return by reversed flow across regurgitant valves and development of collateral circulation. Finally, there was a significant increase of systolic peak flow in the ipsilateral superior epigastric artery early after surgery. This could be related to the opening of small-caliber choke arteries between the superior and deep inferior epigastric arteries following ligation of the dominant deep inferior epigastric artery and TRAM flap transfer to the chest. Systolic peak flow returned to preoperative values late after surgery. The near-infrared reflection spectroscopy system used in this study appeared to measure hemoglobin content and oxygenation in the superficial skin layers only. Near-infrared reflection spectroscopy was able to detect differences of tissue hemoglobin content and oxygenation in the TRAM flap between preoperative and postoperative measurements and between distinct zones of the TRAM flap early postoperatively. Postoperative changes in near-infrared reflection spectroscopy values corresponded to clinical observations and blood flow in the superior epigastric artery measured by color-coded duplex sonography. Further experience is needed before near-infrared reflection spectroscopy can be advocated for routine clinical flap monitoring.

The resection of gastrocnemius muscles in aesthetically disturbing calf hypertrophy.

In some patients, oversized calves lead to mental distress and avoidance of certain social activities. They hide their legs in pants and seek medical advice. If the thickness of the subcutaneous fat is normal and cannot be diminished by liposuction, the oversized calves are caused by pure muscle hypertrophy. Using the gastrocnemius for muscle flaps in covering knee defects does not impair the function of the patients leg; therefore, resection of the total gastrocnemius muscle for aesthetic calf reduction was performed in 15 consecutive patients without any lasting impairment with stability or sports activities. The patient was placed in a prone position, and the muscles were bluntly freed and pulled through two incisions of 5-cm length in the hollow of the knee and above the Achilles tendon. The resected muscles weighed between 410 and 810 g each. In two patients, the sural nerve was stretched or cut during the operation. The consequent numbness of the lateral ankle and sole persisted for 9 and 13 months, respectively. All 15 patients were satisfied with the results; none complained of lack of stability or insecurity in walking; and all became active in sports or changed their dress habits.

Effect of cortisone on capsular contracture in double-lumen breast implants: Ten years' experience

Two groups of patients are compared with respect to capsular contracture after insertion of silicone breast prostheses. Six hundred seventy four women received single-lumen gel prostheses and 700 received double-lumen prostheses with cortisone. The addition of 12.5 mg of prednisolone to double-lumen prostheses diminished capsular contracture (Baker II to IV) dramatically; in patients with simple augmentation from 19% to 4.9%, in patients with subcutaneous mastectomy from 54% to 14.9%, and in patients with breast reconstruction from 64% to 24.4%. The use of double-lumen implants has three distinct advantages: (l) There is no bleeding and therefore no contact of the body with the silicone gel. (2) There is no danger of ruptured implants, even if the outer shell shows leakage. (3) if prednisolone is administered, capsular contracture is prevented to a significant degree.

The free gracilis perforator flap: anatomical study and clinical refinements of a new perforator flap.

Background: The free gracilis perforator flap is a fascioadipocutaneous flap on the medial thigh, based on perforators of the main pedicle of the gracilis myocutaneous flap. Methods: An anatomical study was performed using 43 cadaver dissections. The vascular anatomy of the gracilis perforator flap with regard to myocutaneous and septocutaneous perforators was assessed. Clinical application was demonstrated in 14 cases. Results: Musculocutaneous perforators of the gracilis muscle pedicle were present in all dissections and were 0.5 mm or more in 93 percent. Septocutaneous perforators were found in 84 percent of the dissections, and perforators of 0.5 mm or more were found in 63 percent. Most musculocutaneous perforators were found in the anterior quarter of the muscle where the pedicle enters the gracilis muscle. A constant intramuscular anastomosis between the main and second vascular pedicles of the gracilis was demonstrated that allowed design of an extended gracilis perforator flap. Conclusions: Successful clinical application in 14 cases confirmed vascular reliability. The gracilis perforator flap is a pliable, thin flap from the medial thigh that can be as large as 18 × 15 cm. The donor site is inconspicuous, and a functional gracilis muscle is preserved. By including a constant intramuscular anastomosis, it is possible to extend the territory of the free flap distally up to a length of 27 cm. Indications include reconstruction of cutaneous defects such as unstable scars or contractures. The medial thigh adipose tissue correlates well with the body mass index and thus can be used for breast reconstruction as a second choice if an abdominal perforator flap is not available.

Hyperplasia of the subcutaneous adipose tissue is the primary histopathologic abnormality in lipedematous scalp

A 51-year-old white woman presented with thickening of the scalp located at the vertex and left lateral occiput without hair abnormalities or alopecia. Skin biopsies of the thickened scalp showed thickening of the subcutaneous tissue with proliferation of mature subcutaneous fat cells but no signs of inflammation or hair abnormalities. During 2.5 years of follow-up, scalp thickening progressed over the entire hair-bearing scalp and persisted without signs of further progression at 3.5 year follow-up. Lipedematous scalp is an extremely rare diagnosis. It is defined by a thickening of the subcutaneous layer of the scalp and can be distinguished from lipedematous alopecia, in which subcutaneous thickening is associated with diffuse alopecia and shortening of scalp hairs. A total of seven cases of lipedematous alopecia and two cases of lipedematous scalp have been reported. We report the third case of lipedematous scalp in a 51-year-old white woman associated with early symptoms of meningitis. Additional features described in the literature include pruritus, pain, and paresthesia of the scalp as well as associated medical problems such as hyperelasticity of skin and laxity of joints, renal failure, and diabetes mellitus. This sporadic disorder is predominantly located at the vertex and occiput. The etiology and pathogenesis of lipedematous scalp and alopecia remain unclear. The treatment is symptomatic.

Dermal suspension flap in vertical-scar reduction mammaplasty.

&NA; Reduction mammaplasty has the following goals: appropriate reduction of breast size, symmetric and youthful breast shape, minimal and inconspicuous scars, and stable, long‐term results. Although the first two parameters can be obtained by various reduction techniques, verticalscar mammaplasty eliminates the horizontal inframammary scar, thereby reducing total scar length. Dermal flaps have been described in various types of reduction mammaplasty. The refinement of the authors’ method is the incorporation of a superiorly pedicled dermal flap for better and longer‐lasting support in vertical‐scar reduction mammaplasty. A total of 73 vertical breast reductions in 38 patients were performed with this technique from May of 1996 to November of 1999. Vertical‐scar reduction mammaplasty with a dermal suspension flap combines minimal scars with an internal support for long‐term stability of the breast shape. (Plast. Reconstr. Surg. 109: 2289, 2002.)

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.

Problem-adapted application of vacuum occlusion dressings: case report and clinical experience

Abstract Vacuum-assisted closure (VAC), a technique using subatmospheric pressure dressings, has been widely used for treatment of various chronic and complicated wounds. In addition to the advantages of an occlusive dressing therapy, the VAC therapy has proved effective in evacuating wound fluid, increasing tissue oxygen tension, decreasing bacterial contamination, and stimulating granulation tissue formation. This leads to more rapid re-epithelialization of wounds compared to conventional dressings. A two-phase VAC technique to provide enhanced coverage of an ischemic ulcer of the lower leg in a diabetic patient is presented. The refined VAC therapy scheme is described in detail and the results in a further 19 patients with complicated wounds of the lower leg and feet are reported.

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.

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