[Prophylactic mastectomy in hereditary breast cancer--ethical considerations]

Bilateral prophylactic mastectomy lowers the risk of developing breast cancer in high-risk patients and hereditary breast cancer by more than 95%. Therefore, in selected cases bilateral prophylactic mastectomy represents an effective procedure for breast cancer prevention and, when combined with modern plastic-surgical techniques of breast reconstruction, can achieve good to excellent cosmetic results and high patient satisfaction. Diligent decision making including an accurate determination of the individual risk profile is mandatory. In case of ethical conflicts that may arise in this context, a clinical ethics consultation can be a helpful tool in establishing a sustainable consensus between patient and treating physician.

[Six treatment principles of the basle pressure sore concept]

The treatment of pressure sores has gained importance due to the increase of geriatric patients and general life expectancy as well as improved therapeutic options in patients with spinal cord injuries. The aetiology of pressure sores is multifactorial. Risk factors such as immobility, malnutrition, and other co-morbidities have to be considered. Therapy of pressure sores is time- and cost-consuming and recurrence rates are high. Successful treatment is based on the interdisciplinary cooperation between conservative and surgical disciplines, nursing, as well as on continuous patient education. The Basle pressure sore concept consists of six principles. Over a total treatment period of approximately three months usually two operative interventions are performed. For effective relief of pressure (1st principle) patients are placed on low-airloss beds. Operative debridement of pressure sores is performed early and systemic or local infection is treated (2nd principle). The wound is then conditioned with moist dressings or VAC (3rd principle). Simultaneously concomitant malnutrition is quantified clinically and chemically and treated by oral or, if necessary, parenteral nutrition. Other risk factors are optimised as well as possible (4th principle). Hereby optimal conditions for plastic-surgical coverage are provided (5th principle). Postoperatively a standardised concept of pressure relief and mobilisation is adhered to (6th principle). This multimodal treatment concept is well established at the University Hospital of Basle for many years. Combined with an effective prevention, the rate of pressure sores could be significantly reduced, wounds could be healed, and the number of recurrences diminished. In a two-year period between January 2004 and December 2005 the Basle plastic surgery team treated 170 pressure sores in 142 patients according to this concept in the Swiss paraplegic centre in Nottwil. In 2006, 78 % of these patients (111 patients) were followed up and recurrence rates of 23 % (26 pressure sores) were found. The Basle pressure sore concept is well established for an interdisciplinary and structured treatment of geriatric and paraplegic patients with pressure sores and provides a reliable basis for effective treatment for this complex disease.

[Current concepts and trends in post-bariatric plastic surgery]

The epidemic-like increase of obesity in all western countries is associated with a growing incidence of morbid obesity. Here, efficient and lasting weight loss is mostly obtained by surgical interventions today performed in a reliable and safe manner. In that way comorbidities associated with obesity can be reduced or abolished. Treating the sequelae of bariatric surgery, with frequent massive weight loss and generalized skin excess, is challenging for the plastic surgeon. The goal is to restore a normal body contour as a prerequisite for complete psychosocial integration of the patients, who are often stigmatized by their outward appearance not only before but also after the weight loss. The present work provides an overview of current concepts and trends in post-bariatric plastic surgery.

[The infragluteal perforator flap]

PURPOSE

Pressure sores of the ischial tuberosities are mostly covered with fascio- or myocutaneous flaps of the posterior thigh. In doing so, vascular territories of adjacent flaps are violated, which are not available any more in case of ulcer recurrences. In consideration of the high recurrence rates of pressure sores in paraplegics, we developed an infragluteal perforator flap that spares adjacent vascular territories.

PATIENTS/MATERIAL AND METHOD

Infragluteal perforator flaps were dissected in five fresh human cadavers to investigate the anatomic relations of the cutaneous branches of the inferior gluteal artery and the inferior clunial nerves and to define the anatomic landmarks for clinical application of an innervated flap. In six paraplegic patients with primary (5/6) and secondary (1/6) pressure sores of the ischial tuberosity, infragluteal perforator flaps were used for wound coverage. The donor defect was closed primarily and postoperative care and patient mobilisation followed a standardised protocol.

RESULTS

In eleven infragluteal perforator flaps that were dissected in cadavers and patients, we found one or two cutaneous branches of the descending branch of the inferior gluteal artery at the lower border of the gluteus maximus muscle that supplied the infragluteal skin. Infragluteal perforator flaps could be harvested on these perforator vessels and transferred to the ischial defects without tension due to the excellent mobility of the skin island. The descending branch of the inferior gluteal artery could be spared in all cases for future flaps. In one patient with multiple recurrences of an ischial pressure sore flap necrosis occurred due to venous congestion. The other five infragluteal perforator flaps healed without complications.

CONCLUSION

The infragluteal perforator flap is suitable for the closure of pressure sores of the ischial tuberosities and can be used as a sensitised flap by inclusion of the inferior clunial nerves. Compared to traditional pedicled flaps of the posterior thigh, the infragluteal perforator flap reduces donor site morbidity and spares the vascular territories of adjacent flaps for future recurrent ulcers.

Aktuelle Behandlung der Hamulus ossis hamati-Fraktur

PURPOSE

Hamate hook fractures can be treated conservatively or surgically, whereby fragment and fracture position, age of the fracture, associated injuries, and individual needs of the patient all influence the choice of the therapeutic procedure. Acute non-displaced fractures are frequently treated conservatively, while displaced fractures and nonunions undergo surgical treatment. We report our experience in diagnostic and therapeutic management of 14 hamate hook fractures. CLINICAL MATERIAL AND METHOD: During a three-year period, 14 patients (eleven men and three women) 21 to 73 years old (42.0 +/- 17.9 years) with fractures at the base of the hamate hook were treated at three hand surgery units. The retrospective study of all patients included a chart review, postoperative radiological imaging after one year, and clinical examinations with grip strength measurements after 18 to 34 months (27.8 +/- 4.9 months). In six patients (43 %), the acute fracture was immobilized in a lower arm cast for six weeks, while eight patients (57 %) were operated primarily. In five cases (36 %) excision of the fragment and in three cases (21 %) open reduction and internal fixation using a screw were performed. Of six patients treated conservatively, five developed nonunion after two to five months (3.0 +/- 1.2 months) with persistent pain and underwent secondary surgery. One patient was asymptomatic despite a nonunion and declined surgical treatment. In three cases the fragment was excised, while two patients underwent open reduction and internal fixation with a screw.

RESULTS

All patients operated primarily were free of complaints three months after surgery. The success rate of surgical treatment (8/8) was therefore significantly higher than that after conservative treatment (1/6).

CONCLUSION

Compared to conservative treatment of acute non-displaced hamate hook fractures, which is associated with a high risk of developing symptomatic nonunion, primary surgical treatment reliably yields a good clinical outcome. Here, results after fragment excision and open reduction and internal fixation are comparable.

[Myosonographic evaluation of rectus abdominis muscle function after DIEP flap breast reconstruction]

Donor-site morbidity following autologous breast reconstruction is a well-known disadvantage of free or pedicled TRAM flaps. Bulging and weakness of the abdominal wall and sometimes even hernias occur. Due to recent technical advances in microsurgery, there are different possibilities for breast reconstruction like the deep inferior epigastric perforator (DIEP) flap which is harvested without rectus muscle. First studies describe good aesthetic results without the complication of hernias and disadvantage of abdominal wall weakness. Myosonography is a new method to test the dynamic rectus muscle function and evaluate the donor-site morbidity after DIEP flap breast reconstruction. This study aims to analyze the value of myosonographic measurements to evaluate the donor-site morbidity following perforator flap elevation of the abdominal wall. Between November 2000 and August 2001, 34 patients at the Markus Hospital in Frankfurt/Main, Germany received breast reconstruction with a DIEP flap. Myosonographic examinations pre- and postoperatively were performed. Furthermore, clinical testing of rectus muscle function with the Janda score in combination with a questionnaire about impairment in daily activities and subjective opinion about discomfort took place. Two months postoperatively, myosonography showed almost identical rectus muscle function at the side of the vessel preparation compared to the contralateral side. Good aesthetic results were also achieved. The absolute muscle thickness at maximum contraction and the difference of muscle thickness between relaxation and contraction were almost identical on both sides. Myosonography is a non-invasive and inexpensive method to test rectus muscle function providing exact and reliable data. Results of this study confirm the hypothesis of lower donor-site morbidity caused by DIEP flaps compared to free or pedicled TRAM flaps. The DIEP flap method for autologous breast reconstruction is highly accepted by patients because of good aesthetic results combined with the lowest possible donor-site morbidity. After more than 180 DIEP flaps with good aesthetic results without abdominal wall hernias this method has become the "gold standard" for autologous breast reconstruction in our department.

[Imaging and therapy of hamulus-ossis-hamati fracture]

The relatively rare fractures of the hamate bone are the most common osseous injuries of the distal carpal row, whereby fractures of both the body and the hook of the hamate occur. We present a hamulus ossis hamate fracture that was caused by direct trauma in a high-level game of underwater rugby. Although this was diagnosed by conventional x-ray, the precise position of the fracture was clearly imaged using thin-layer CT, while additional multiplanar MRT revealed further sequelae of the trauma. A CT follow-up after 10 weeks of conservative therapy did not show any osseous consolidation, which indicated the need for surgical revision with extirpation of the hamulus.

[Clinical results and color-coded duplex ultrasound findings 4 years after conditioned TRAM flap-plasty]

Presented is a new technique in preoperative conditioning of the pedicled TRAM-flap employing an interventional-radiologic procedure, selective embolization of the deep inferior epigastric artery (DIEA). During a four year period in 40 patients with a mean age of 48.4 (31-66) years breast reconstruction was performed by a superiorly pedicled TRAM-flap following preoperative conditioning. 30 of 40 patients were eligible for follow-up one to five years postoperatively. The mean interval between embolization and surgery amounted to 3.6 months. In 25 of 30 cases embolization of the DIEA was performed bilaterally, in 5 of 30 cases unilaterally. 14 of 30 patients underwent preoperative radiotherapy for breast cancer. Applying CCDS the peak flow values were determined in the superior epigastric arteries (TRAM/contralateral side). Pre-embolization values (54.9 cm/s/55.8 cm/s), post-embolization values (57.2 cm/s/57.9 cm/s) and late postoperative values (61.0 cm/s/61.6 cm/s) proved a statistically significant effect of selective embolization on peak flow without relevant difference between TRAM and contralateral side (p < 0.05). Postoperative flap complications consisted of partial necrosis in 2 of 30, fat necrosis in 1 of 30, impaired would healing in 5 of 30 and postoperative bleeding in 2 of 30 cases. Abdominal would healing complications occurred in 5 of 30 cases, abdominal wall weakness was found in 8 of 30 and hernia formation in 4 of 30 cases. Corrective surgery was performed at the breast (TRAM-flap) in 22 of 30 and at the abdomen (donor site) in 9 of 30 cases. Patient acceptance concerning selective embolization and TRAM-flap surgery was very high. 29 of 30 patients confirmed that they would again choose this type of breast reconstruction. The pedicled TRAM-flap following preoperative conditioning by selective embolization of the DIEA constitutes a safe and reliable method of breast reconstruction with autogenous tissue. It is superior to the pedicled TRAM-flap without delay and offers definite advantages compared to alternative techniques of enhanced flap vascularization.

Clinical results of TRAM flap delay by selective embolization of the deep inferior epigastric arteries

Preoperative selective embolization of the deep inferior epigastric arteries constitutes a new technique in TRAM flap delay. Whereas surgical ligation of these vessels has proved to be an effective delay procedure in experimental and clinical settings, it requires an additional operative step under general anesthesia. Despite the introduction of the free TRAM leading to improved flap perfusion, this microsurgical technique is not always available because of the requirements of specialized equipment and staff, longer operating hours, and subsequently higher expenses. The search for a minimally invasive, easy, and inexpensive technique to improve perfusion of the pedicled TRAM flap led us to selective embolization of the deep inferior epigastric arteries by an angiographic procedure. After 4 years of experience with this technique, we now present the first clinical results. Breast reconstruction by a delayed pedicled TRAM flap was performed in 40 patients with a mean age of 48.4 years (range, 31 to 66 years). The mean interval between embolization and surgery was 3.6 months. Postoperative data concerning flap survival and complications were available for all patients. Embolization of the deep inferior epigastric arteries was performed bilaterally in 35 patients (87.5 percent) and unilaterally in 5 patients (12.5 percent). Radiotherapy had been applied in 21 patients (52.5 percent) before surgery. Postoperative flap complications consisted of partial necrosis in three (7.5 percent), fat necrosis in one (2.5 percent), impaired wound healing in five (12.5 percent), and postoperative bleeding in two patients (5 percent). Abdominal wound healing complications occurred in six patients (15 percent), abdominal wall weakness in eight (20 percent), and hernia formation in four (10 percent). Surgical corrections were performed at the breast (TRAM flap) in 22 patients (55 percent) and at the abdomen (donor site) in 9 (22.5 percent). Preoperative selective embolization of the deep inferior epigastric arteries constitutes an alternative delay procedure for the pedicled TRAM flap. It is superior to the conventional procedure without delay, offers several advantages compared with surgical ligation of these vessels, and represents an alternative to the free TRAM flap in selected cases.