应用背阔肌岛状肌皮瓣修复烧伤后乳房畸形

目的 介绍应用背阔肌岛状肌皮瓣修复前胸壁烧伤后所致乳房瘢痕挛缩畸形的临床效果.方法 应用扩张或未扩张的背阔肌岛状肌皮瓣修复烧伤后乳房瘢痕、部分缺损畸形,其中轻、中度烧伤后乳房缺失2例,采用背阔肌岛状肌皮瓣修复重度乳房缺失5例,采用扩张的背阔肌岛状肌皮瓣修复.结果 共治疗7例,术后肌皮瓣完全成活,乳房形态明显改善,无肌皮瓣坏死、背部伤口感染、裂开及肩部功能障碍等并发症发生.供区无明显后遗畸形及功能障碍.结论 背阔肌岛状肌皮瓣血运良好,操作简便易行,是修复烧伤乳房畸形的较好方法.     

Advances in breast reconstruction after mastectomy

Over the past 40 years, surgical reconstruction of the breast following mastectomy has become an important aspect of the cancer patient's rehabilitation process. While the surgical emphasis remains on a cure for the cancer, experience with breast reconstruction has not demonstrated any increased rate of cancer recurrence, even when reconstruction is performed immediately following tumor resection. Advances in surgical technique and biotechnology have made post-mastectomy reconstruction possible. The development of silicone gel and saline-filled implants as well as tissue expanders has revolutionized breast reconstruction. The elucidation of musculocutaneous flaps now provides the surgeon with the ability to transfer adequate quantities of vascularized tissue to reconstruct the surgical defects. The advent of microsurgical techniques has provided an additional reconstructive option, with free tissue transfer allowing the plastic surgeon to move musculocutaneous flaps from remote or distant sites to reconstruct the defect. The option of having the reconstruction immediately following the mastectomy procedure is now available to the patient. When reviewing the anatomy of the breast region, the surgeon must consider the mammary gland, its vascular supply, and its lymphatic system. The surgical techniques involved in reconstruction after mastectomy include the use of breast implants and tissue expansion, as well as reconstruction with autogenous tissues. Reconstruction with autogenous tissues includes the use of latissimus dorsi musculocutaneous flap, transverse rectus abdominus musculocutaneous flap, free flap transfer, as well as nipple-areola reconstruction. Breast reconstruction after mastectomy should be undertaken by a plastic and reconstructive surgeon with considerable training and experience with these diversified procedures.     

Reconstruction following an orbital tumor in children

Tumors of the orbital region which may develop during infancy and childhood have multiple origins and a specific treatment should be applied to each lesion as regards the degree of malignancy, the extent of the tumor and the age of the child. The plastic surgeon is usually called when the surgical treatment or the radiotherapy have been mutilating. It is then necessary to offer the most satisfactory reconstruction to the child, taking into account the possibility of a recurrent disease or the future development of the orbital cavity. The following priorities should be observed: 1) The tumoral resection should be as complete and as curative as possible. 2) The sight of the eye should be saved if possible; 3) The skeletal reconstruction should be performed if possible with autologous bone graft taken from the skull area. 4) The soft tissue reconstruction is performed by a series of plastic surgery methods. The use of the temporal muscle is common. 5) The final esthetic result often depends on the choice and the quality of additional corrections (canthopexy, mucosal graft, correction of enophthalmos, etc). The surgery of orbital tumors is a team work (neurosurgery, ophthalmology, otolaryngology, plastic surgery). The presence of the plastic surgeon during the initial treatment is highly recommendable and often permits an immediate reconstruction.     

胰十二指肠切除术中静脉切除重建的研究现状

胰腺癌是一种恶性肿瘤，可接受治愈性手术的患者较少，静脉切除是获取切缘阴性与扩大手术人群的有效方式。外科医师主要通过术前影像学检查与患者特征决定是否在胰十二指肠切除术(pancreaticoduodenectomy，PD)中同时行相关静脉的切除及重建。切除肿瘤侵犯的静脉重建方式有多种选择，主要由肿瘤与静脉间的关系与手术医师的选择有关。PD合并静脉切除重建后可能会带来切缘阳性增多、并发症发生率升高等新的问题。辅助治疗已经成为胰腺癌的标准治疗方案，新辅助治疗在静脉受侵犯时的作用也受到认可。基因组学与信息化技术可能会为未来的手术及术后综合治疗提供新的诊疗方式。     

Application of microvascular surgery in reconstructive digestive tract surgery]

In our institutes, microvascular surgery has been effectively used in reconstructive digestive tract surgery, including esophageal reconstruction and hepatic arterial reconstruction. Free jejunal transfer combined with a gastric pedicle or microvascularly augmented elongated gastric pedicle has been utilized for total esophageal reconstruction. A microvascularly augmented jejunal pedicle or colonic pedicle has been applied in thoracic esophageal reconstructive cases with gastrectomy. Moreover, microvascular surgery has been performed in the reconstruction of the hepatic arterial system in the surgical treatment of pancreatic or bile duct cancer and living related-donor liver transplantation. Some pitfalls in selection of the recipient vessels and handling the intraperitoneal vessels for microvascular anastomosis are also described. Although microvascular surgery has been carried out by plastic and reconstructive surgeons in a team surgical approach, revisions in the medical educational system to create a new-type of surgeon with practical skills and clinical experience in both digestive tract and microvascular surgery will be required in future.     

Expanded occipito-cervico-pectoral flap for reconstruction of burned cervical contracture

Postburn neck contracture and hypertrophic scarring can cause functional limitation and aesthetic disfigurement. Reconstruction of severe deformities and scar of neck following healing from burns confronts the surgeon with some of the most challenging problems in reconstructive surgery. Through knowledge of available reconstructive technique accurate diagnosis of tissue deficiency and secondary distortion, imaginative planning and definitive, careful execution of ones surgical plan are the bare minimum items for achieving improvement in a burned deformed neck. The aim of this article is to assess the role of expanded occipito-cervico-pectoral (o-c-p) flap for reconstruction in a series of four patients with severe burn scar of neck and involvement of shoulder back but intact anterior aspect of chest. This is an alternative method of reconstruction burn scar of neck area.     

Extremity reconstruction using nonreplantable tissue ("spare parts")

After a severe digital or extremity injury, the replantation surgeon should always seek to make the best use out of what tissue is available for reconstruction. Exercising sound surgical judgment and being creative allow the surgeon to restore function to critical areas of the hand or extremity by the judicious use of available tissues that would otherwise be discarded. The use of "spare parts" should, therefore, always be considered to facilitate digital or extremity reconstruction when routine replantation is not possible or is likely to produce a poor functional result. The surgeon should always try to use available nonreplantable tissue to preserve length, obtain soft tissue coverage, or most importantly improve the function of remaining less injured digits. This article presents several case studies that illustrate the principals of spare parts reconstruction performed at the time of the initial debridement using nonreplantable tissue to provide coverage or improve function.     

Rezidiveingriffe an den Beckenarterien nach alloplastischen Rekonstruktionen

Of all vascular reconstructions at the pelvic level, 5.7% are associated with a lesion to the ureter. These are detected postoperatively in 66% of cases. The injury rate seems to be incomparably higher in redo vascular surgical procedures performed on iliac vessels. We report on three patients in whom ureter injuries were caused in the course of revision operations with alloplastic reconstruction of aortic or iliac vessels. We then present the treatment scheme we have elaborated for use in such cases. When severe adhesions are expected we recommend preoperative implantation of an intraureteric stent, which helps to identify the ureter during preparation. The psoas hitch plasty is used for reconstruction in the case of injuries to the lower third of the ureter. Ureteroureterostomy (end-to-end) is performed in such cases only rarely. The need for close cooperation between vascular surgeon and urologist during planning and surgery is emphasized.     

Die plastisch-chirurgische Sekundärrekonstruktion von Schwerstbrandverletzten

Secondary reconstruction following severe burn trauma has improved markedly over the last few decades using all aspects of modern plastic surgery. In surgical reconstruction of burns, it is essential to design comprehensive, clear-cut, and long-term treatment plans. Good patient compliance and thorough follow-ups are imperative regarding the extent of scar and contracture formation, regularly requiring multiple-step surgery. Each treatment site will have to be evaluated separately, taking into account adequate surgical and conservative measures (the "reconstructive ladder"). Aiming at realistic and satisfactory results, surgery does not suffice alone in treating severely burned patients but also requires a well coordinated and seasoned team of occupational and physical therapists, psychologists, and plastic surgeons.     

Treatment of severe four finger crush avulsion injuries

Polydigital crush avulsion injuries with complete loss of soft tissue, including nerves and vessels, where only bone and tendon structures are preserved need sophisticated treatment. Due to the complexity of the injury amputation should be avoided and the major aim is maintenance of maximum finger length by emergency soft tissue coverage, when replantation is impossible. Later reconstruction of sensation with good mechanical properties must be the ultimate aim. Two cases with a four finger crush avulsion injury are reported from the emergency situation through the subsequent secondary reconstruction to the final result. Soft tissue coverage required the full spectrum of hand surgical procedures ranging from local tissue transfer, to temporary pedicled flaps and microsurgical procedures. Possible treatment options are discussed at each step of the reconstruction. Finally, a treatment concept is presented both to ease the surgical approach for the inexperienced and to provide discussion for the experienced hand surgeon. Received: 15 December 1997 / Accepted: 22 February 1999     

Two surgeons,one patient: The impact of surgeon–surgeon familiarity on patient outcomes following mastectomy with immediate reconstruction

BackgroundMastectomy with immediate reconstruction requires the coordination and expertise of two distinct surgeons. This often results in several different combinations of mastectomy and reconstructive surgeons, but with an unknown impact on patient outcomes. We evaluate the effect of different surgical teams on complication rates following mastectomy and immediate reconstruction.MethodsRetrospective review of consecutive patients that underwent mastectomy with immediate prosthetic reconstruction from 4/1998 to 10/2008 at one institution was performed. Patients of the three highest-volume mastectomy and reconstructive surgeons were stratified by their individual combination of surgeons, resulting in nine different surgical teams. Complications were categorized by end-outcome. Appropriate statistics, including multiple linear regression, were performed.ResultsClinical characteristics were similar among patients (n = 511 patients, 699 breasts) with the same mastectomy surgeon but different reconstructive surgeon. Mean follow-up was 38.4 ± 25.7 months. For each mastectomy surgeon, the choice of reconstructive surgeon did not affect complication rates. Furthermore, the combined complication rates of the three highest-volume teams (n = 384 breasts) were similar to the remaining lower-volume teams (n = 315 breasts). Patient factors, but not the individual surgeon or surgical team, were independent risk factors for complications.DiscussionOur study suggests that among high-volume surgeons, complication rates following mastectomy with immediate reconstruction are not affected by the surgeon–surgeon familiarity. The individual surgeon's expertise, and patient risk factors, may have a greater impact on outcomes than the team's experience with each other. These results validate the efficacy and safety of the surgeon distribution model currently used by many breast surgery practices.     

Weichteilschaden beim Unterschenkelschaftbruch

After a lower leg fracture, adequate assessment of soft tissue damage is absolutely essential if treatment is to be successful. Nonoperative treatment is rarely possible. The more severe soft tissue injury is, the less invasive the techniques that can be used for surgical stabilization. Whether or not it is possible to achieve the objectives of treatment, namely healing of the fracture and of the soft tissue damage, depends on the stability of the bone fixation and the soft tissue reconstruction. Bone and soft tissue are treated simultaneously throughout. When soft tissue injury is particularly severe and extensive, trauma surgeon and plastic reconstructive surgeon should work closely together on the case.     

Autologous blood transfusion in surgical treatment of deep burns and their sequelae]

The experience of the treatment of 74 burned cases by means of autotransfusion is presented. The application of autotransfusion made it possible to rule out donor blood transfusions in surgical treatment of a considerable group of the burned. There are grounds to believe that different variants of this method will be widely practised in specialized medical installations dealing with the treatment of the burned and with reconstructive surgery.     

Mamoplastia de reducción en la cirugía del cáncer de mama

Reduction mammaplasty techniques enable the breast cancer surgeon to provide an integral surgical treatment, thus significantly increasing and improving surgical options. These techniques are used to correct problems after the conservative treatment of type 1 breast cancer and to achieve symmetry between the breasts after mastectomy. They are also the basis of cosmetic reconstruction techniques in conservative oncoplastic surgery.     

Reconstruction of the ear after skin and perichondrium loss

Because no two auricular defects are exactly the same, the choice of a suitable method for ear reconstruction is essential. Location and size of the defect influence the choice of technique needed for reconstruction. The method of reconstruction varies if there is skin loss, skin and perichondrium loss, or full-thickness loss. The skin surrounding the defect should be examined to determined if it is lacerated, burned, or scarred to decide whether or not it can be used in reconstruction. A plan of treatment should be decided and explained fully to the patient. A small area of skin loss can be closed by undermining of the edges and direct closure. If this cannot be performed because the defect is too large, the perichondrium is then examined to decide whether or not it is intact.     

Current status of scapholunate interosseous ligament injuries.

Injuries to the scapholunate complex present the surgeon with both diagnostic and treatment dilemmas. The anatomic features, biomechanical properties, radiographic appearance, and surgical treatment algorithms of this small but structurally and kinematically important joint continue to be refined. A thorough history and physical examination, combined with a radiographic evaluation that can include plain radiographs, tomography, motion studies, arthrography, or MRI, usually will define the nature of the ligament injury. Arthroscopy is considered the gold standard for complete evaluation of scapholunate interosseous ligament injury and often is performed as a first step before repair or reconstruction. Procedures such as carpal fusions or capsulodesis can limit excessive scaphoid motion, promote wrist stability, and potentially prevent arthritis, but advances continue to be made in direct scapholunate interosseous ligament reconstruction. Challenges for the future involve improving noninvasive evaluation, defining the degree of extrinsic ligament injury, and improving direct repair and reconstruction.     

Wie viel gefäßchirurgische Notkompetenz benötigt der moderne Unfallchirurg

Management of combat-related major vascular injuries is a challenge to all surgeons and a vascular specialist will not always be available in a wartime setting; therefore, every surgeon deployed to a war setting must be able to cope with these life and limb-threatening injuries. Data obtained from searching Medline and Google on the localization and treatment of combat-related vascular injuries of the USA strike forces in Afghanistan and Iraq were analyzed and adjusted to the requirements of the German Armed Forces. A total of 5–7% of casualties sustained major vascular injuries. After initial treatment using damage control measures to control the bleeding and restore perfusion definitive repair with vascular reconstruction must be performed in a facility with a higher level of care. Basic vascular surgical techniques which all military surgeons need to know are presented taking the austere conditions of a wartime environment into consideration. Preparation of all surgeons for deployment to a wartime situation must include basic knowledge and skills in vascular surgery including emergency and vascular reconstruction techniques.     

Use of scarred flaps and secondary flaps for reconstructive surgery of extensive burns

We report the usefulness of scar flaps and secondary flaps in the surgical repair of extensively burned patients. Burn scar contractures repaired with scarred axial pattern flaps, scarred musculocutaneous flaps and scarred fasciocutaneous flaps are described. However, it is our contention that their application should be strictly limited. An example of the use of scarred secondary axial pattern and musculocutaneous flaps for reconstruction of a burned ear is shown.     

Efficacy of DynaCT for surgical navigation during complex laparoscopic surgery: an initial experience

Background

Precise understanding of surgical anatomy is required during complex laparoscopic surgery (CLS). The purpose of this study was to present our initial operative experience with CLS facilitated by surgical navigation through DynaCT technology.

Methods

Intraoperative computed tomography (CT) images of two CLS cases were obtained by a C-arm DynaCT system (Artis Zeego, Siemens Healthcare, Erlangen, Germany). Image reconstruction was performed on a workstation to define particular anatomical structures of the target tumor. The reconstructed CT images were repeatedly displayed on a submonitor. The surgeon then compared the CT images with a laparoscopic image of the surgical field, thus providing a virtual map to the surgeon.

Results

Using the near-real-time surgical navigation system, the surgeon could visualize the surgical anatomy and easily perform the CLS. All procedures were performed successfully with a satisfactory diagnostic yield.

Conclusion

This novel technology has great potential for application in CLS because it enables generation of accurate depictions of small target tumors and increases the surgeon’s confidence during the procedure.     

Preoperative Doppler Assessment for Transmetatarsal Amputation

A thorough preoperative vascular evaluation should be performed before the initiation of any lower extremity surgical intervention, but particularly in situations of diabetic foot reconstruction with compromised blood flow. The intended emphasis of this brief report is to provide the foot and ankle surgeon with an appreciation for the clinical vascular anatomy of the transmetatarsal amputation through a handheld Doppler examination.