O. Frerichs

The Transverse Myocutaneous Gracilis Muscle Flap: A Fast and Reliable Method for Breast Reconstruction

Background: Autologous breast reconstruction is predominantly performed using free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps. However, some patients are not suitable candidates for flaps from the lower abdomen. The transverse skin island of the gracilis muscle presents an additional option, as it includes tissue from the posterior upper thigh/lower buttock and thus delivers the amount of tissue necessary for breast reconstruction. Methods: In 2007, the authors’ unit performed 73 free flaps for breast reconstruction subsequent to carcinoma, implant-related capsular fibrosis, and breast asymmetry. The transverse myocutaneous gracilis flap was used 32 times. The ventral margin was the greater saphenous vein, and the posterior margin was the midline of the inferior gluteal fold. The skin island could be harvested to a width of up to 30 cm and a height of up to 10 cm. The donor site was closed primarily. Results: Thirty-two flaps were performed in 20 patients. Mean follow-up was 6 months. Mean operating time was 220 minutes for unilateral and 325 minutes for bilateral cases. All flaps and donor sites healed uneventfully. An initially described “tight feeling” at the thigh ceased after 2 to 3 weeks. Persistent hypesthesia of the dorsal thigh was not noted. A major asymmetry of the thigh in unilateral transplantations was not apparent. After 6 months, all flaps were soft. Conclusions: The transverse myocutaneous gracilis flap is a safe, fast flap for reconstruction after benign and malignant breast disease. It combines a constant vascular pedicle with soft subcutaneous tissue that has breast-like characteristics.

Regeneration of peripheral nerves after clenbuterol treatment in a rat model.

Clenbuterol is known to act as a neuroprotective substance in the central nervous system, and also reduces muscle atrophy after denervation. The aim of this study was to evaluate its influence on peripheral nerve regeneration. The rat sciatic nerve model was used in four groups (n = 8 per group). After complete nerve transection and microsurgical coaptation, two groups received a daily oral dose of 100 μg/kg clenbuterol and two served as controls. Regeneration was assessed clinically, histologically, and morphometrically after 4 and 6 weeks. The weight ratios of calf muscles were calculated. Histological examination showed significantly increased axon counts in the clenbuterol group and a better degree of myelination. Muscle weight ratios of the clenbuterol group were significantly increased after 6 weeks, and the animals showed improved function of the hindlimb. Thus, therapy with 100 μg/kg clenbuterol daily after coaptation of a sciatic nerve showed a positive influence on clinical, histological, and morphometrical parameters in the rat model. The underlying mechanism remains unclear.

Stellenwert der CT-Angiografie der Bauchwand für die Planung und Operation von DIEP-, TRAM- und SIEA-Lappenplastiken

Muscle sparing TRAM flaps and DIEA perforator flaps are standard procedures for breast reconstruction. Recently CT-angiography has been established to evaluate perforator vessels pre-operatively. CT-angiography was introduced to our department in July 2009. In a retrospective analysis data of the last 20 patients (altogether 22 flaps) before CT-angiography introduction and the following 20 (also 22 flaps) patients after introduction of CT-angiography were analysed with regard to the ratio of TRAM to DIEP flaps, and the time required to raise the flaps. The same surgeon raised all flaps. As different surgeons performed dissection of the recipient site, anastomoses, and insertion of flaps, and patients received primary (with sentinel or complete lymphadenctomy) or secondary reconstructions, only the time required harvesting the flap was compared. Thus other influences on raising the flap were eliminated. DIEP flaps were harvested with one single perforator. If perfusion or was considered not to be safe via one single perforator a muscle sparing TRAM flap (ms2) was raised. Angiography was performed using a 64-slice multi-detector CT scanner. CT-angiography did not lead to an increased rate of DIEP flaps in relation to ms2-TRAM flaps. Harvesting time of all flap types with CT-angiography on average was 121 min, without CT-angiography 135 min. This was not significantly different. However, separate analysis of DIEP flaps and ms2-TRAM flaps revealed a significant advantage of CT-angiography based harvesting of DIEP flaps of 26 min: with CT-angiography 101 min vs. 127 min without CT-angiography (p<0.028). There were no significant differences for ms2-TRAM flaps. All scans showed course and branching, diameter and size of the inferior epigastric artery. If evident the superficial inferior epigastric artery (SIEA) was marked. Dosage was 292 mGy-606 mGy×cm dependent on body weight. CTDI was 6.8-14.7 mGy. CT-angiography is a reproducible and observer independent procedure that reliably demonstrates the inferior epigastric artery and its perforating branches. Sensitivity is considered to be 99,6%. Additionally the superficial inferior epigastric artery can be evaluated. In our patients the ratio of ms2-TRAM flaps to DIEP flaps was not affected by introducing CT-angiography. However, DIEP flap harvesting was significantly accelerated. Harvesting of ms2-TRAM flaps was not affected. It remains to be seen whether the observed time advantage is really essential for this operation. Preoperative imaging of the perforators allows establishing a detailed, observable and comprehensible operation strategy, which particularly facilitates surgical training and learning of perforator dissection.

Die Artefaktkrankheit in der plastischen Chirurgie

Summary. The therapy of factitious disorders is a challenge for the treating surgeon. Only a clear understanding of the underlying causes and a good doctor-patient relationship make a successful outcome possible. Discussion about a confrontation of the patient with the diagnosis and the best made of treatment is still in progress. Early diagnosis and the cooperation between surgeons and psychiatrists are the most important parts of dealing with factitious disorders. This article gives an overview of symptoms and therapies. Six case reports demonstrate possibilities of the disorders appearance.Zusammenfassung. Die Therapie der Artefaktkrankheit ist eine Herausforderung für den behandelnden Chirurgen. Nur ein Verständnis der zugrundeliegenden Ursachen und eine gute Arzt-Patient-Beziehung ermöglichen einen Therapieerfolg. Umstritten bleibt, ob der Patient mit der Diagnose konfrontiert werden sollte und welche Therapie die günstigste ist. Entscheidend sind die frühzeitige Diagnose und die interdisziplinäre Zusammenarbeit mit Psychiatern/Psychosomatikern. Der Artikel gibt einen Überblick über Symptomatik und Therapiemöglichkeiten und schildert anhand von sechs Falldarstellungen mögliche Krankheitsbilder.

Die Therapie der Thoraxwandosteomyelitis

Abstract.Introduction: Chronic osteomyelitis of the chest wall requires radical debridement and defect coverage with well-perfused tissue. The implantation of synthetic material is still under discussion because of the risk of infection. Methods: A retrospective study was conducted on the complications and functional and aesthetic results of 26 patients with chest wall osteomyelitis after radiation or sternotomy treated by radical debridement and neurovascular pedicled latissimus dorsi muscle. Results: The functional results were excellent with a low complication rate. The muscle showed electric activity synchronous with inspiration and clinically a stabilization of the thoracic defect. Discussion: Maintained muscular activity may play an essential role for stabilizing thoracic defects of up to four ribs or the sternum; implantation of synthetic material is not necessary.Zusammenfassung.Einleitung: Chronische Osteomyelitiden der Thoraxwand erfordern ein radikales Débridement und eine Defektdeckung durch gut durchblutetes Gewebe. Der Einsatz von Fremdmaterialien ist aufgrund der Infektionsgefahr umstritten. Methoden: Retrospektive Evaluation des Krankheitsverlaufs von 26 Patienten mit Sternum- oder Rippenosteomyelitis nach Radiatio oder Sternotomie bezüglich Komplikationen und ästhetischem und funktionellem Ergebnis nach radikalem Débridement und Deckung durch einen neurovasculär gestielten M. latissimus dorsi. Ergebnisse: Bei geringer Komplikationsrate bestand in allen Fällen ein gutes funktionelles Ergebnis. Der Muskel zeigte im EMG eine elektrische Aktivität bei Inspiration und klinisch eine Stabilisierung des Thoraxdefekts. Schlußfolgerung: Durch die erhaltene Aktivität des gestielten Muskels kann ein gutes funktionelles Ergebnis bei Defekten bis zu 4 Rippen oder dem Sternum ohne Einsatz von Fremdmaterialien erreicht werden.