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Die demografische Entwicklung zeigt einen uberproportionalen Anstieg der Patienten uber 80 Jahre mit einerseits erhohtem, sturzbedingten Verletzungsrisiko (mind. 1 Sturz pro Jahr bei 50%) und andererseits vermehrten Komorbiditaten einschlieslich der sog. geriatrischen Syndromen ( I ntellektueller Abbau, I nstabilitat, I mmobilitat und I nkontinenz) 1 . Die Behandlung dieser posttraumatischen Weichteilschaden bei geriatrischen und multimorbiden Patienten, insbesondere an der unteren Extremitat, gehort zu den zukunftigen medizinischen Herausforderungen.

Hintergrund: Die Weichteilarchitektur der Hohlhand ist einzigartig. Deckung ausgedehnter Weichteildefekte mit Rekonstruktion ihrer funktionellen Eigenschaften ist eine Herausforderung. Anatomische Wiederherstellung mit Geweben anderer Korperregionen ist fast unmoglich. Beim manuell Tatigen ist neben Bewegungsumfang und Sensibilitat auch Stabilitat und Widerstandsfahigkeit der Weichteile gegenuber mechanischer Beanspruchung gefordert. Sensible fasziokutane Lappenplastiken sind durch geringe Adharenz, hohe Schichtdicke zweischneidig. Empfehlungen zur Selektion des Therapieverfahrens sind sparlich. Material und Methode: Detaillierte Defektanalyse (anatomische, taktil-gnostische Einheiten der Hohlhand, individuelle Parameter) liefert wichtige Informationen zur Selektion der Lappenplastik. Unterschieden wurden 4 Einheiten: Thenar (T), Hypothenar (H) und zentrale Hohlhand (Z). Einheit (Z) wird gemeinsam von Einheit zentrale (c’) und distale (d’) Hohlhand gebildet. Einheiten (T) und (H) sind sekundare Greifflachen und erfordern protektive Sensibilitat durch Deckung mittels sensibler fasziokutaner Lappenplastik. Einheit (Z) hat geringere taktil-gnostische Bedeutung. Rekonstruktion der Weichteilstabilitat dieser Einheit ist beim manuell Tatigen wesentlich. Bei einem 21-jahrigen Schlosser wurde ein Defekt (9×13 cm) der dominanten Hohlhand (Gefas-, Nerv-, Sehnenbeteiligung) nach Defektanalyse, Beteiligung (Z), partiell (T) und (H), mittels freier M. grazilis Muskel-Lappenplastik und dickem plantaren Spalthauttransplantat (Starke 0,5 mm) gedeckt. Ergebnisse: 29 Monate postoperativ zeigten sich anatomische Weichteilverhaltnisse (Vancouver scar scale: 1), hohe mechanische Stabilitat, seitengleiche Handfunktion (DASH score: 4). Semmes-Weinstein-Monofilament Test lieferte positive Druckempfindung. Berufliche Wiedereingliederung nach 5 Monaten. Schlussfolgerung: Deckung von ausgedehnten Hohlhanddefekten erfordert die Entscheidung fur Sensibilitat oder Weichteilstabilitat. Bei Voraussetzungen wie: mechanische Beanspruchung, Beteiligung von Einheit (Z) werden Weichteilstabilitat und Widerstandsfahigkeit erstrangig. Defektanalyse ermoglicht zuverlassige Wahl des idealen Therapieverfahrens. Beim manuell Tatigen konnen durch Defektdeckung mittels Muskel-Lappenplastik und plantarem Spalthauttransplantat Gleiches mit Gleichem ersetzt und alle Therapieanforderungen erfullt werden. Background: Skin and soft-tissue architecture of the palm are unique. Coverage of extensive soft-tissue defects restoring the functional capacity of the palm remains a challenging task. Anatomic restoration with skin from another area is hardly possible. In manual labourers, reconstruction of mechanical soft-tissue stability is required in addition to sensation, range of motion and grip strength. Sensate fasciocutaneous flaps bear disadvantages of tissue mobility, shifting and bulkiness. Published criteria for defect-related flap selection are sparse. Material and Methods: Defect analysis (anatomy, units of tactile gnosis, individual parameters) provides information to weigh needs for sensation or tissue stability, influencing selection of most appropriate procedures. We distinguished 4 units: hypothenar (H), thenar (T) and central palm (Z). (Z) consists of a central palmar unit (c’) and the distal palm (d’). Individual parameters (age, profession, dominant hand, psychosocial aspects) were also considered. Units (T) and (H), regions of secondary touch, demand protective sensation by applying sensate fasciocutaneous flaps. In labourers tactile gnosis in (Z) is of less, tissue stability of greater value. An extensive palmar defect (9×13 cm, affecting unit (Z), partially affecting units (T) and (H), of the dominant hand) with combined vessel, nerve, tendon injuries (male labourer, 21 years) was covered after defect analysis with a free gracilis muscle flap and a glabrous intermediate (0.5 mm) thickness skin graft from the instep region. Results: 29 months postoperatively anatomic conditions of palmar soft tissue (Vancouver scar scale: 1), high mechanical soft-tissue stability including normal hand function were evident. Semmes Weinstein testing showed positive pressure sensation. Professional reintegration after 5 months was possible. Conclusion: Defect coverage of the palm must not consist of merely providing sensate vascularised tissue. The most appropriate procedure can be derived from careful defect analysis focusing on the affection of units of tactile gnosis to achieve near to anatomic reconstruction. In labourers, patient- and defect-related demands need close correlation with the value of the selected flaps regarding the sensation and mechanical stability to be expected. In selected cases (mechanical irritation, affection of unit (Z), younger age) by combining microvascular muscle flaps with plantar intermediate thickness skin grafts promising functional results with early professional reintegration can be achieved by reconstructing like with like.

Background While free TRAM or DIEP flaps are still the most common techniques for autologous breast reconstruction, there are also other flaps which are suitable for patients who are not candidates for a TRAM/DIEP flap. In addition to the S-GAP or I-GAP, the transverse myocutaneous gracilis (TMG) flap is an excellent alternative. The tissue utilised is taken from the medial thigh and inferior gluteal area. PATIENTS AND OPERATIONS: We have performed 37 TMG flap operations on 23 patients since 2007. The indications were breast cancer, asymmetry of the breasts and capsular fibrosis. The average age of our patients was 47 years. Incisions are similar to those of a transverse thigh lift. The flap is nourished by perforators from the gracilis and its proximal dominant pedicle. The landmark ventrally is the greater saphenous vein and midpoint of the inferior gluteal fold on the dorsal side. Its size can go up to 30 x 10 cm. Recipient vessels are the internal thoracic vessels. The donor site is closed primarily. All of our patients are immobilised for 2 days and were instructed to avoid sitting for 2 weeks. Results 12 patients were reconstructed after breast cancer, 8 patients had a capsular fibrosis and 3 patients had an asymmetry. The follow-up period was 8 months. Mean operating time for unilateral reconstruction is 220 minutes, for bilateral reconstruction 325 minutes. The weight of the flaps varied from 220 to 440 grams. It takes approximately 30 minutes to harvest the flap. There was no flap loss. Some of the patients described a tight feeling on the thighs for 3 weeks. They described a hypaesthesia on the dorsal thighs. There was one delayed wound healing caused by haematoma. Conclusion In our department, the TMG has become the most preferred flap for breast reconstruction besides the TRAM/DIEP. Especially slim patients with small breasts or a history of surgery on the abdominal wall are ideal candidates. The tissue from the medial thigh is very similar to the breast tissue. The constant vascular anatomy makes it easy to harvest the flap. The resulting scar is well hidden in the patients' underwear.

BACKGROUND Complex and large soft-tissue defects of the dorsum of the hand, which cannot be covered with skin grafts or local flaps have to be reconstructed by means of free tissue transplantation. The purpose of this study was to present our experience with free fasciocutaneous flaps and muscle flaps with split-thickness skin graft for defect coverage of the dorsum of the hand in eight patients. PATIENTS AND METHOD Evaluation of eight patients who underwent coverage of the dorsum of the hand with free flaps during 1997 to 2001 is presented. Other treatment options are discussed. RESULTS Average age of the patients was 57 years and average follow-up was 25 months. For defect coverage we used a later alarm flap in four cases, a gracilis muscle flap with split-thickness skin graft in three cases and a latissimus dorsi flap with split-thickness skin graft in one case. In five patients we performed an extensor tendon reconstruction. Three of those cases achieved a good, one a fair and one case had a bad functional result. In one patient we had a partial flap loss. Muscle flaps with skin graft revealed better esthetic results than fasciocutaneous flaps. CONCLUSION Microvascular free-tissue transplantation has expanded our options, giving us the opportunity for more refinement in hand reconstruction and improving the standards for a successful outcome.