Search

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

High-voltage burn injuries are rare in the pediatric age group, but can lead to devastating, severe sequelae. We present the cases of two young girls who suffered high-voltage burn injuries due to direct contact with overhead power lines. Both patients came from difficult psychosocial backgrounds. The injuries resulted in severe long-term consequences and functional deficits., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Since the introduction of the minimally invasive technique for repair of pectus excavatum (MIRPE), increasing numbers of patients are presenting for surgery. However, controversy remains regarding cardiopulmonary outcomes of surgical repair. Therefore, the aim of our prospective study was to investigate cardiopulmonary function, at rest and during exercise before surgery, first after MIRPE and then after pectus bar removal., Methods: Forty-seven patients were enrolled in a prospective, open-label, single-arm, single-centre clinical trial (Impact of Surgical Treatments of Thoracic Deformation on Cardiopulmonary Function) [NCT02163265] between July 2013 and November 2019. All patients underwent a modified MIRPE technique for surgical correction of pectus excavatum (PE), called Minor Open Videoendoscopically Assisted Repair of Pectus Excavatum. The patients underwent pre- and postoperative chest X-ray, three-dimensional volume-rendering computer tomography thorax imaging, cardiopulmonary function tests at rest and during stepwise cycle spiroergometry (sitting and supine position) and Doppler echocardiography. Daily physical activity questionnaires were also completed., Results: The study was completed by 19 patients (15 males, 4 females), aged 13.9-19.6 years at the time of surgery. The surgical patient follow-up was 5.7 ± 7.9 months after pectus bar removal. No significant differences in cardiopulmonary and exercise parameters were seen after placement of the intrathoracic bar, or after pectus bar removal, compared to presurgery., Conclusions: Our findings indicate that surgical correction of PE does not impair cardiopulmonary function at rest or during exercise. Therefore, no adverse effects on exercise performance should be expected from surgical treatment of PE via the modified MIRPE technique., Clinical Trial Registration Number: clinicaltrials.gov [ClinicalTrials.gov number, NCT02163265]., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: The frequency of sternochondroplasty in cases of pectus carinatum (PC) has increased due to greater surgeon experience and modified surgical techniques. PC deformity does not usually cause cardiopulmonary malfunction or impairment. However, whether cardiopulmonary function changes after surgical repair remains a matter of controversy. The aim of our prospective study was to determine if surgery changes preoperative cardiopulmonary function., Methods: Nineteen patients (16 males, 3 females) were enrolled in a prospective, open-label, single-arm, single-centre clinical trial (Impact of Surgical Treatments of Thoracic Deformation on Cardiopulmonary Function) (NCT02163265) between July 2013 and January 2017. All patients underwent PC repair via a modified Ravitch procedure and wore a lightweight, patient-controlled chest brace for 8 weeks postoperatively (the Innsbruck protocol). The average follow-up surgical examination was 8.3 months after surgery. In all enrolled patients, before surgery and not before 6 months postoperatively chest X-ray, 3-dimensional volume-rendered computed tomography thorax imaging, cardiopulmonary function tests with stepwise cycle spiroergometry (sitting and supine position) and Doppler echocardiography were performed; questionnaires about daily physical activity were also completed., Results: Fourteen patients (aged 16.3 ± 2.6 years at study entry) completed the study. Changes in submaximal and peak power output were not detected during sitting, or when in the supine position. Also, no clinically relevant postoperative changes in spirometry or echocardiography were noted., Conclusions: Our findings confirm that surgical correction of PC does not impair cardiopulmonary function at rest or during physical exercise., Clinical Registration Number: clinicaltrials.gov NCT02163265., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Pectus excavatum is less common in females than in males, and it often aggravates a coexistent breast asymmetry. We conducted a study comparing female patients' versus medical professionals' evaluation of pectus excavatum repair to assess differences in aesthetic outcome ratings. Moreover, we evaluated the influence of surgical correction on patients' self-perception., Methods: Of 30 female patients who were initially screened, 18 patients (mean age, 20 years) who underwent bar removal after surgical correction of pectus excavatum deformity participated in the survey (60%). They completed a questionnaire rating their appearance before and after surgery and responded to a psychological questionnaire about the changes that they had experienced. The mean interval between pectus bar removal and evaluation was 28 months. Standardized preoperative and postoperative patient photographs were evaluated using the same questionnaire by a panel of medical professionals and students (n=24) and the results were compared., Results: Patients rated their preoperative deformity as more severe than the other evaluators, revealing the significant impact of the deformity on patients' self-perception. Postoperatively, patient and professional evaluations were much better than before and were very similar. The psychological evaluation showed a clear improvement in well-being. The ratings of the medical professionals were not influenced by their degree of medical education., Conclusions: Surgical correction of pectus excavatum in female patients positively influences body perception and psychological well-being. It should therefore not be considered as a merely aesthetic correction, but as an important procedure to restore a patient's self-perception.

Surgical procedures for pectus excavatum (PE) repair, such as minimally invasive repair of pectus excavatum or similar interventions (modified open videoendoscopically assisted repair of pectus excavatum), for remodeling the anterior thoracic wall may finally not always achieve sufficiently pleasing aesthetic results. Particularly in the asymmetric and polymorphic cases, remnant deformities may still be present after any sophisticated remodeling attempt. On the other hand, some cases despite optimal surgical management develop mild recurrences with partial concavity or rib cartilage distortion shortly after pectus-bar removal. Secondary treatment options then may include open access surgery, resection, or reshaping of deformed and prominent costal cartilage. Residual concave areas can be filled by autologous tissue, such as cartilage chips, liposhifting, or implantation of customized alloplastics. To provide the best options for a variety of primary or secondary postsurgical expressions of anterior wall deformities, any physician dealing with PE corrections should be familiar with various shaping and complementary reconstructive techniques or at least should have knowledge of such. However, among treating surgeons, there is an awareness that no single method can be applied for every kind of funnel chest deformity. Careful selection of appropriate techniques, either as a single approach for the ordinary deformities or in conjunction with ancillary procedures for the intricate cases, should be mandatory, based on the heterogeneity of symptoms, severity, expectations, and surgical and technical resources. A variety of such ancillary reconstructive procedures for PE repair are explained and illustrated herewith., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Creating an aesthetically appealing result using thoracoplasty, especially when correcting extensive deformities, but only causing low morbidity, is challenging. The frequency of thoracoplasties in cases of pectus carinatum (PC) has increased due to improved experience and modified surgical techniques, resulting in low morbidity and low complication rates. The indications for surgical treatment are still controversial and, in most cases, remain aesthetic or psychological rather than physiological. However, whether cardiopulmonary function changes after surgical repair remains a matter of controversy. We sought to investigate and shed light on published knowledge regarding this question., Methods: We searched MEDLINE and PubMed databases, using various defined search phrases and inclusion criteria, to identify articles on pre- and postoperative cardiopulmonary evaluation and outcomes., Results: Six studies met the inclusion criteria: 5 studies evaluated patients with PC for cardiopulmonary outcomes after chest wall surgery and 1 did so following conservative compression treatment. In these studies, surgical and conservative correction of PC did not reduce absolute lung volumes and spirometric measurements and consequently had no pathogenic effect on cardiopulmonary function., Conclusions: The results of this systematic review suggest that surgical correction of PC has no symptomatic pathogenic effect on cardiopulmonary function. The results, however, revealed both heterogeneity in the examinations used and inconsistent methods within each study. Further prospective trials with a stronger methodological design are necessary to objectively confirm that surgical correction of PC does not impair cardiopulmonary function., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: For the correction of pectus excavatum (PE) deformities in adolescents, adults, and generally in asymmetric cases, a semi-open approach called the MOVARPE (minor open videoendoscopically assisted repair of pectus excavatum) technique is used, consisting of standard pectus bar implantation hybridized with auxiliary sternum osteotomy and multiple chondrotomies. In this study, we report our experiences, discuss pros and cons, and provide technical refinements., Methods: Between September 2005 and March 2015, 61 patients were selected to undergo the MOVARPE instead of the standard MIRPE (minimally invasive repair of pectus excavatum) procedure because of age or specific morphologic characteristics of PE. Patient age ranged from 14 to 45 years (mean 23.4 years)., Results: Auxiliary incisions for skeletal relaxation enabled symmetric remodeling and, in most cases, circumvented the need for a second pectus bar. The bars were left in position for a mean of 19.3 months (range: 12 to 35 months). There were no major complications. Minor complications such as pleural effusion, temporary pneumothorax, and mild recurrence of the deformity after bar removal were seen at rates similar to those for standard techniques. In the current study reporting outcomes of the previously described MOVARPE procedure, the authors saw no evidence of a possible disadvantage in the overall concept or execution of the procedure for the suggested indication., Conclusion: From this experience, we can state that, as an alternative to the MIRPE technique, MOVARPE is a method that offers high efficacy, particularly for rigid and complex pectus excavatum deformities at or beyond puberty.

Minimally invasive repair of pectus excavatum (MIRPE) or similar procedures for pectus excavatum (PE) repair, nowadays no longer performed by one single speciality, may not always achieve sufficient aesthetic results, particularly in the infrapectoral or infraxiphoidal region. Reasons for this include the diaphragm inhibiting correct positioning of the bars, as well as asymmetric deformities which may still be present after remodelling attempts. Furthermore, some cases develop a mild recurrence or partial concavity once the correction bar is removed. However, any secondary re-do MIRPE procedure remains risky because of adhesions between the pleura, lung, pericardium, thoracic wall as residuals from the primary intervention. Treatment options as secondary correction for these deformities may include open access surgery, resection or reshaping of deformed costal cartilage. Moreover, augmentation of a residual concave area can be achieved by autologous transplantation of resected over-abundant cartilage, as well as by liposhifting or implantation of customized alloplastics. A physician dealing with PE corrections should be familiar with various shaping and complementary reconstructive techniques in order to provide the best options for a variety of expressions of anterior wall deformities. Among treating surgeons, there is an awareness that no single method can be applied for every kind of funnel chest deformity. An appropriate technique, either as a single approach for the ordinary deformities or in conjunction with ancillary procedures for the intricate cases, should be selected carefully based on the heterogeneity of symptoms, severity, expectations and surgical skill in addition to the available equipment. Out of a variety of such ancillary procedures available and based on experience within general plastic reconstructive surgery, some techniques for PE repair are explained and illustrated here with their advantages and disadvantages., Competing Interests: The author has no conflicts of interest to declare.

Background: Various methods of corrective thoracoplasty for pectus carinatum deformity have been described, but to date no studies describe a review of complications and how to manage them. Complications are dependent not only on the technique used and the patient's age, but also on the experience of the treating surgeon. The authors present their 15 years' experience with surgical correction of pectus carinatum and the complications that have occurred. A literature review regarding complications with pectus carinatum surgery is performed., Methods: A retrospective review of 95 patients (mean age, 19 years) was performed. One hundred four surgical procedures for repair of pectus carinatum were performed from July of 2000 to July of 2015 using a modified Ravitch technique, bioabsorbable material, postoperative bracing, and in some cases a diced rib cartilage graft technique. Intraoperative and postoperative complications were evaluated., Results: The mean patient follow-up was 13.6 months (range, 4 months to 9.75 years). Intraoperative complications were pleura lesion and laceration of the internal mammary vein. Postoperative complications were recurrent mild protrusion, persistent protrusion of one or two costal cartilages, minor wound healing delay, skin ulcer, hypertrophic scar, transient intercostal dysesthesia, marginal pneumothorax, seroma, meningitis, and epidural hematoma., Conclusions: In our reported series of pectus carinatum repair, increasing experience and progressively less extensive techniques have resulted in fewer complications, low morbidity, and early return to activity. Complications were observed in the early period of application, predominantly because of a lack of experience, and usually subsided with increasing numbers of patients and frequency of surgery., Clinical Question/level of Evidence: Therapeutic, IV.

Bar displacement remains the most common complication of the minimally invasive repair of pectus excavatum (MIRPE). To date, no studies show results from 12 years' experience using a bar fixation technique with only absorbable sutures. Our aim is to show how to stabilize the bar using a modified approach for bar fixation. A retrospective review of 68 patients, who underwent MIRPE or the minor open videoendoscopic assisted repair of pectus excavatum, was performed. To stabilize the pectus bar, both wings of the pectus bar were tied to the ribs in 52 patients with circumcostal absorbable sutures using a Deschamps needle under endoscopic survey and in 16 patients with lateral stabilizers. The stability of pectus bar after the operation was assessed by lateral chest X-ray films and classified as being perfect, incomplete, or poor. No complications were observed in the perioperative period with the circumcostal suture technique. Lateral chest X-rays showed an excellent position of the pectus bar in 50 patients, incomplete position in 1, and poor position in another patient. Our technique seems to be effective in preventing bar displacement following pectus excavatum repair. It does not add any significant cost or time to the operation, and it is fairly simple to perform.

Background: The minimally invasive repair of pectus excavatum (MIRPE) procedure as a standard procedure in children is rarely described in adolescents, adults, or in patients with asymmetric deformities. For these challenging cases, the authors have adopted a semiopen approach (minor open videoendoscopically assisted repair of pectus excavatum, or MOVARPE) with additional skin incisions and osteochondrotomies. This descriptive application study was set to assess whether both procedures are effective and safe in adolescents and adults, to determine whether they have similar complication and recurrence rates, and to analyze the overall outcome in nonpediatric patients., Methods: A retrospective review of 69 patients (45 male and 24 female patients; mean age, 20.8 years) who underwent either technique from August of 2002 to June of 2012 was performed. Intraoperative and postoperative complications, clinical outcome, and patient satisfaction were evaluated., Results: The mean patient follow-up after bar removal in 55 patients was 27.3 months (p = 0.624). In the MIRPE group, two bar dislocations, one rupture of the internal mammary artery, and one case of pneumonia were observed. Mild recurrence of deformity after bar removal was present in four cases. Satisfaction outcomes were excellent in 70 percent in the MOVARPE group and 55.1 percent in the MIRPE group (p = 0.0182)., Conclusion: The MOVARPE technique is a hybridized, semiopen modification of the MIRPE procedure that seems to be advantageous, particularly in adolescents, adults, and those with asymmetric pectus excavatum deformities, for overcoming resistant skeletal rigidity with low complication rates, high patient satisfaction, and superior aesthetic results., Clinical Question/ Level of Evidence: Therapeutic, III.

Background: Within the entity of craniofacial malformations premature craniosynostoses represent the majority of cases. They originate from disturbances in the ossification process, resulting in an osseous closure of cranial sutures ahead of time. Depending on severity and number of the affected sutures, a local or general growth inhibition of the skull follows. In the rare instance of accessory bones along these affected sutures, they may interfere with diagnostics and therapy., Patient: This clinical report describes the case of a seven-month-old male infant with multiple craniosynostoses, an extraordinary large accessory median calvarial bone, two foramina parietalia permagna and a submucosal cleft palate. Chromosomal and genetic analysis did not reveal potential mutations., Results: The osseous abnormalities were diagnosed and displayed by three-dimensional computed tomography. The sequential surgical treatment consisted of occipital remodelling at seven months of age and frontoorbital advancement at fourteen months., Conclusion: This rare anatomical variation of the cranial bones - superimposed by multiple premature craniosynostoses - demonstrates the necessity of accurately conducted preoperative diagnostics for appropriate surgical planning. Knowledge, and precise medical examination of potential anatomical variations facilitate the planning and secure performance of surgery as well as its outcome., (Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Coverage of skin or soft tissue defects of various sizes by transplantation of spit thickness skin grafts., Indications: Skin or soft tissue defects of any size or location as long as there is a good blood supply to the wound bed., Contraindications: Wound bed providing poor blood supply (e.g., tendon or bone), vessels or nerve without soft tissue coverage, any kind of implant material which is not covered by vital soft tissue. Relative contraindications include defect position at the flexion side of joints or other mechanically stressed locations (e.g., heel, neck) and local infection., Surgical Technique: By meticulous debridement of the recipient site and coagulation of venous bleedings, the recipient site is prepared for skin grafting. Thereafter, the split thickness skin graft is harvested and, if necessary, modified by the meshing procedure. Then, the skin graft is placed in the defect and fixated at the wound margins. To promote healing, a special compression dressing is used to cover the split thickness skin graft. In case of uneventful wound healing, this dressing should be left in place for 5 days., Postoperative Management: After removal of the compression dressing, daily changes are done using double layers of fatty gauze, alternated with periods without dressing. In the case of uneventful healing, the skin transplant can be covered starting in week 2 with a thin film of cream ointment., Results: Split thickness skin grafting is a routine maneuver in reconstructive surgery and allows predictable, good results. Partial skin graft losses are mostly due to a combination of inadequate debridement and local infection. If the operation in done technically correct, total graft losses are rare.

Background: Adults are increasingly seeking surgical correction of pectus excavatum deformity, and the alternative custom-made silicone implant is not always desired or suitable. The paramount concern of female patients is the apparent strabism of their breasts. In some cases, the standard minimally invasive reconstruction of pectus excavatum procedure or a modified approach with a semiopen technique can help remodel the anterior thoracic wall and simultaneously reposition the female breasts to a desired and aesthetically acceptable position., Methods: Between November of 2000 and March of 2011, 35 female adolescent and adult patients underwent surgical funnel chest repair with different approaches. In seven of these patients, a pectus bar was implanted using minimally invasive reconstruction of pectus excavatum, whereas 15 underwent a combined semiopen approach. The pectus bar was removed after a period of 14 to 39 months (mean, 31 months) in the minimally invasive reconstruction group and 12 to 25 months (mean, 13.5 months) in the other group. Preoperative and postoperative photographs were examined, and the results were assessed by independent surgeons., Results: During the follow-up period of 1 month to 3.9 years (mean, 12 months), no major complications occurred. The aesthetic appearance of the anterior thoracic wall was distinctly improved, and breast strabism and breast tissue projection were eliminated., Conclusions: Pectus bar implantation appears to be an excellent method for the correction of breast malposition in female adults with a funnel chest deformity. Although invasive, it allows permanent remodeling of the anterior thoracic wall and the décolleté, and a repositioning of the female breast to achieve a natural appearance., Clinical Question/level of Evidence: Therapeutic, IV.

Extensive defect coverage of the palm and anatomical reconstruction of its unique functional capacity remains difficult. In manual laborers, reconstruction of sensation, range of motion, grip strength but also mechanical stability is required. Sensate musculo-/fasciocutaneous flaps bear disadvantages of tissue mobility with shifting/bulkiness under stress. Thin muscle and fascial flaps show adherence but preclude sensory nerve coaptation. The purpose of this review is to present our algorithm for reliable selection of the most appropriate procedure based on defect analysis. Defect analysis focusing on units of tactile gnosis provides information to weigh needs for sensation or soft tissue stability. We distinguish radial unit (r)-thenar, ulnar unit (u)-hypothenar and unit (c)-central plus distal palm. Individual parameters need similar consideration to choose adequate treatment. Unit (r) and unit (u) are regions of secondary touch demanding protective sensation. Restoration of sensation using neurovascular, fasciocutaneous flaps is recommended. In unit (c), tactile gnosis is of less, mechanical resistance of greater value. Reconstruction of soft tissue resistance is suggested first in this unit. In laborers, free fascial- or muscle flaps with plantar instep skin grafts may achieve near to anatomical reconstruction with minimal sensation. Combined defects involving unit (c) require correlation with individual parameters for optimal flap selection. Defect coverage of the palm should not consist of merely providing sensate vascularized tissue. The most appropriate procedure should be derived from careful defect analysis to achieve near to anatomical reconstruction. In laborers, defect related demands need close correlation with sensation and mechanical stability to be expected., (Copyright © 2011 Wiley Periodicals, Inc.)

Pectus excavatum deformity is the most frequent congenital anomaly of the thoracic wall. If the invasive surgical procedures of thoracoplasty are not indicated or the patient refuses them, alternative treatment options should be considered. In such cases, local or distant transposition of autologous tissue could be appropriate. This report presents a selected case of funnel chest deformity and concomitant unilateral breast hyperplasia. Both deformities were corrected simultaneously using a pedicled internal mammary artery perforator (IMAP) flap dissected from the hyperplastic breast. This is a safe, reliable, low-morbidity, one-stage option for adult women that uses an easy-to-harvest flap for simultaneous correction of mild funnel chest deformity and concomitant breast hyperplasia with a single resulting scar.

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., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Various methods of corrective thoracoplasty for congenital anterior chest wall deformities have been described. To date, no studies have described the use of diced cartilage as a surgical procedure in thoracoplasty. The authors present their experience with 23 patients for whom diced cartilage grafts were used as an innovative approach for thoracoplasty., Methods: A retrospective review of 23 patients was performed. From January of 2004 to September of 2010, 18 patients underwent repair of pectus excavatum, three patients underwent repair of pectus arcuatum, and two patients underwent repair of pectus carinatum using diced rib cartilage grafts. Intraoperative and postoperative complications, patient satisfaction, and clinical outcome were evaluated. Preoperative and postoperative photographs were examined, and the results were assessed by independent surgeons., Results: The mean patient follow-up was 18.1 months. No major complications were observed in the perioperative period. Postoperative complications were mild recurrence of deformity (n = 2). No graft extrusion, infection, or contour irregularities occurred. The patients rated their cosmetic results as very good. All 25 of the wrapped diced cartilage grafts appear to have survived completely, with only one partial graft absorption. One patient had palpable diced cartilage., Conclusions: The diced cartilage graft technique is a novel and safe procedure in thoracoplastic refinement procedures with clear advantages, including limited surgical trauma, autogenous material, easy preparation, absence of significant donor-site morbidity, absence of additional costs, high patient satisfaction, and good aesthetic results. The authors advocate using this technique for augmentation and contouring of minor anterior wall deformities in selected patients., Clinical Question/level of Evidence: : Therapeutic, IV.(Figure is included in full-text article.).

Objective: We reviewed further clinical experience with our approach for pectus carinatum repair: modified surgical approach of pectoralis muscle split technique, bioabsorbable plates with screws, and postoperative compressive brace., Methods: From April 2000 to February 2010, 55 patients underwent pectus carinatum repair at our department with modifications of conventional Ravitch repair. There were 14 female and 41 male patients, mean age of 19.3 years at the onset of treatment. Postoperative treatment involved fitting of a lightweight, patient-controlled chest brace., Results: Average follow-up was 13.7 months. Patient satisfaction was excellent for 40 patients (72.7%) and good for the remaining 15 (27.3%); aesthetic appearance was excellent for 37 patients (67.3%) and good for the remaining 18 (32.7%). Postoperative evaluation was objective measurement with a thorax caliper and clinical examination. No major perioperative complications were observed. Postoperative complications were mild recurrence of deformity (n = 3) and persistent, mild, single costal cartilage protrusion (n = 2). No patient had palpable plates or screws, and there was no material breakdown., Conclusions: The combination of muscle split technique and absorbable osteosynthesis represents an alternative in pectus carinatum repair. The pectoralis muscle split technique allows early patient mobilization and rehabilitation. Bioabsorbable plates get completely absorbed, avoiding second operation, and chest brace provides postoperative immobilization of the anterior thoracic wall during healing and avoids development of hypertrophic scars. Our combined approach to the correction of pectus carinatum deformities yields predominantly excellent esthetic results, with low morbidity, low costs, and less invasiveness, leading to high patient satisfaction., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Aims: To study the incidence of perinatal complications in children diagnosed with premature craniosynostosis and their mothers., Methods: Questionnaires were sent to all women (n=220) who delivered a child diagnosed either pre- or postnatally with craniosynostosis and treated at the University Hospital of Innsbruck, Austria between January 1, 1990 and October 10, 2007. The incidence of various complications in the group of children with craniosynostosis was compared with data from the Birth Registry of Tyrol, which served as a comparison population in this study (n=57,317)., Results: A total of 46.4% of the questionnaires were returned (n=102). Children diagnosed with craniosynostosis showed a significantly higher rate of fetal malpresentations at birth [P<0.001; OR 2.38 (CI 1.53-3.70)] compared to the general population. In particular, the rate of abnormal cephalic [P<0.001; OR 3.42 (CI 2.03-5.76)] and breech presentations [P=0.01; OR 2.39 (CI 1.27-4.49)] was significantly increased. In 10% of all neonates the Apgar score (P=0.001) as well as the pH-value (P<0.001) was found to be at least one category lower than in the comparison population., Conclusions: Children diagnosed with craniosynostosis have a significantly higher rate of numerous birth complications compared to the overall births documented at the Birth Registry of Tyrol.

Apert syndrome is characterized by craniosynostosis, midfacial hypoplasia and symmetric cutaneous and bony syndactyly of the limbs. The skull is usually hyperacrobrachycephalic, whereas frank cloverleafing, as a clinically obvious trilobed skull deformity, is rarely seen in these patients. We report a rare case of Apert syndrome with cloverleaf skull deformity, prenatally diagnosed at 26weeks' gestation in which the sonographic features of a characteristic trilobed skull, abnormal biparietal diameter and head circumference, as well as malformations of the upper and lower extremities led to the diagnosis, confirmed by prenatal fibroblast growth factor receptor type 2 mutation analysis and fetal magnetic resonance imaging. The genetic evaluation revealed a p.P253R mutation in fibroblast growth factor receptor type 2 consisting in a transversion C>G at nucleotide 758. We discuss the relevant prenatal morphologic and genetic findings of this patient and review previously published cases. Our report demonstrates the feasibility of the prenatal diagnosis of Apert syndrome with cloverleaf skull using ultrasound, fetal magnetic resonance imaging and mutation analysis, and also highlights the importance of the biparietal diameter as an early predictor of growth restriction in severe craniosynostosis cases., (Copyright 2009 S. Karger AG, Basel.)

Chest wall deformities such as pectus excavatum, pectus carinatum, and cleft sternum can be isolated malformations or dysmorphic features of genetic associations, monogenic disorders, and various numeric and structural chromosomal aberrations. In contrast to the most important syndromes such as Marfan syndrome or Noonan syndrome that can be associated with a chest wall deformity and for which the causative genes are known, etiology of isolated chest wall deformities is still a matter of research. Therefore, an interdisciplinary approach, particularly in patients with additional symptoms is strongly recommended to choose the best therapeutic approach for each patient and its family.

Background: The standard approach for correction of pectus carinatum deformity includes elevation of the pectoralis major and rectus abdominis muscle from the sternum and adjacent ribs. A postoperative restriction of shoulder activity for several weeks is necessary to allow stable healing of the elevated muscles. To reduce postoperative immobilization, we present a modified approach to the parasternal ribs using a pectoralis muscle split technique., Methods: At each level of rib cartilage resection, the pectoralis muscle is split along the direction of its fibers instead of elevating the entire muscle as performed with the standard technique. From July 2000 to May 2007, we successfully used this technique in 33 patients with pectus carinatum deformity., Results: After the muscle split approach, patients returned to full unrestricted shoulder activity as early as 3 weeks postoperatively, compared to 6 weeks in patients treated with muscle flap elevation. Postoperative pain was reduced and the patients were discharged earlier from the hospital than following the conventional approach., Conclusions: The muscle split technique is a modified surgical approach to the parasternal ribs in patients with pectus carinatum deformity. It helps to maintain pectoralis muscle vascularization and function and can reduce postoperative pain, hospitalization, and rehabilitation period.

Occasionally during the minimally invasive repair of pectus excavatum(MIRPE), the conventional flat dissector is not rigid enough to elevate the anterior thoracic wall for bar implantation and its sharp edges may cause vessel or other tissue damage. Asa result of experiencing such complications in four cases, a new highly rigid dissector with a round cross-section was developed and its advantages are presented in a consecutive series of 21 cases.

In reconstructive microsurgery, it is occasionally advantageous to use long recipient or donor vessels for optimal flap inset. These long vessels are prone to kinking or torsion along their longitudinal axis from vessel distension during blood inflow and rising blood pressure. More often than arteries, the veins can also be compressed by overlying tissue sutured under tension or by developing edema. Reanastomosis can no longer be feasible or desirable for several reasons, and the elongated vessels may have to be shifted to a curved course. To avoid detrimental kinking or torsion, fibrin glue can be administered along this new vessel course in order to ensure stabilization. In 20 such cases, we successfully avoided complications when the danger of kinking, torsion, or vein compression was evident after successful anastomosis. On the basis of this experience, we recommend the use of fibrin glue in microsurgical procedures, especially for vessels in intricate geometrical locations., ((c) 2008 Wiley-Liss, Inc.)

The external anal sphincter (EAS) is a skeletal muscle capable of voluntary contraction to prevent accidental defecation. Current reconstructive options for a severely damaged EAS using local muscle flaps are not always adequate for functional repair. The present preliminary experimental model was designed to assess the feasibility of a neuromicrovascular latissimus dorsi muscle transfer for functional external spincter muscle reconstruction. In nine mongrel dogs, the anal sphincter muscles were totally resected, leaving a mucosal canal in place. A segmental latissimus dorsi muscle was shaped around the anal canal in a circular fashion, with coaptation to the pudendal nerve, and vessel anastomosis at the ischiorectal fossa. Functional evaluation was performed using electromyogram, sphincter manometry, video documentation, and histologic examination with standard and immunohistochemical staining. After 8 months, the remaining three eligible dogs were continent. Muscle function was verified by means of electromyogram, sphincter manometry, and a video record. Histologic and immunohistochemical examination confirmed the functional results, showing only minor zones of fatty and fibrous degeneration. Transplantation of a segmental latissimus dorsi muscle with vascular anastomosis and coaptation to the pudendal nerve has proved to be successful in restoring (voluntary) anal continence experimentally in dogs. Its feasibility for perfect orientation as a neosphincter seems to be superior to any pedicled muscle flap. However, these preliminary results deserve further investigation prior to considering application in humans.

Background: Reconstruction or complete cover of extended but polygonal defects is limited by the size of transplantable tissue. One of the largest composite tissue components to be transplanted is the myocutaneous latissimus dorsi flap. Under certain circumstances even this large-scale flap is not sufficient for complete defect cover. Based on experiences with the thoracodorsal artery perforator (TAP) flap, the skin island adjacent to the latissimus muscle may be raised, pedicled on the perforator vessels penetrating the underlying muscle. Thus this island may easily be transposed or rotated to enable additional defect cover., Methods: This method was applied in eight patients for defect cover at the extremities, thorax or for hypopharynx reconstruction. The exact location of perforator vessels may be determined pre- or intraoperatively with a hand Doppler so that skin flap transposition can already be planned before surgery., Results: All of the skin flaps transposed or rotated healed without complications. It may even be assumed that utilizing this method helped to avoid further complications like scar contractures, because tension-free wound closure was feasible., Conclusions: The combined latissimus dorsi- thoracodorsal artery perforator-transpositional free flap is capable of covering very extensive polygonal as well as defects over joints in order to prevent scar contractions.

The ultimate usefulness of replanted fingers is related to the adequacy of nerve, tendon and bone repair. Thirty-eight patients with successful replantation of the thumb, a single finger or after multiple digital amputations were followed up clinically. The subjective disability after finger replantation was evaluated by means of the DASH score, and the presence of cold intolerance was assessed. The subjective outcome of the achieved replantation reached an overall DASH score of 12.3. Patients after thumb replantation reached a score of 10.0, after a single finger replantation DASH 11.2 and after multiple finger amputations and replantation of at least one finger, DASH 16.1. Cold intolerance was subjectively found in 86.7% of all hands with replanted fingers without a correlation to the patients DASH scores. The patient's evaluation of their limb function after replanted digits by means of the DASH score, when combined with an objective external assessment, represents a valuable comparative tool.

Soft tissue coverage of the medial ankle and foot remains a difficult, challenging, and often frustrating problem to patients as well as surgeons. To our knowledge, the abductor hallucis muscle flap is not frequently used and only a few well documented cases were found in literature. The purpose of this paper is to report and to present the long-term results of a series of four patients who underwent reconstruction of foot and ankle defects with the abductor hallucis muscle flap. In two cases, the abductor hallucis muscle flap was transposed in combination with a medialis pedis flap to cover a medial ankle defect, whereas in another case it was combined with a medial plantar flap. In this latter case, the muscle flap served to fill up a calcaneal dead space after osteomyelitis debridement, whereas the cutaneous flap was used to replace debrided skin at the heel. The abductor hallucis flap was used as a distally-based turnover flap to cover a large forefoot defect in a fourth case. Follow-up period ranged between 18 and 64 months (mean 43.3). In the early postoperative period, two flaps healed completely In two patients marginal flap necrosis occurred which was subsequently skin grafted. No donor-site complication occurred in any of the patients. In all cases, protective sensation of the skin was satisfactory as early as 6 months. In two cases mild hyperkeratosis at the skin graft border to the sole skin (non-weight bearing area of medial plantar and medialis pedis flap donor site) was present, but probably related to poor foot care. All patients were fully mobile as early as 3 months after treatment. In the long-term follow-up (43.3 months), all flaps provided with durable coverage. Functional gait deficit due to consumtion of the abductor hallucis muscle was not apparent. Our long-term results demonstrated that the abductor hallucis muscle flap is a versatile, and reliable flap suitable for the reconstruction of foot and ankle defects. Utilizing the abductor hallucis muscle as a pedicled flap (distally or proximally-based) with or without conjoined regional fasciocutaneous flaps offers a successful and durable alternative to microsurgical tree flaps for small to moderate defects over the calcaneus region, medial ankle, medial foot, and forefoot with exposed bone, tendon, or joint.

Large skull defects lead to progressive depression deformities, with resulting neurological deficits. Thus, cranioplasty with various materials is considered the first choice in therapy to restore cerebral function. A 31-year-old female presented with a massive left-sided hemispheric substance defect involving bone and brain tissue. Computed tomography showed a substantial convex defect involving the absence of calvarial bone as well as more than half of the left hemisphere of the brain, with a profound midline shift and a compression of the ventricular system. There was a severe problem due to multiple deep-skin ulcerations at the depression margin, prone to skin perforation with a probability of intracranial infection. In a first step, a free myocutaneous latissimus dorsi flap was transplanted for volume replacement of the hemispheric brain defect, and 4 months later, artificial bone substitute was implanted in order to prevent progressive vault depression deformity. Healing was uneventful, and the patient showed definite neurological improvement postoperatively. Free tissue transfer can be a valuable option in addition to cranioplasty in the treatment of large bony defects of the skull. Besides providing stable coverage for the reconstructed bone or its substitute, it can also serve as a volume replacement., (Copyright 2005 Wiley-Liss, Inc.)

Recurrent palatal fistulae present a particularly vexing problem for patients with cleft lips and palates and their surgeons. When primary closure fails, conventional wisdom and the standard of care suggest local flap techniques for defect closure. For the large majority of patients, this approach is successful. There is, however, a small subset of patients who undergo multiple surgical procedures in unsuccessful attempts to close recalcitrant fistulae, particularly at the anterior, densely scarred, hard palate. In this setting, repair calls for the introduction of well-vascularized pliable tissue to close the defect and to avoid hampering further palatal growth. Local muscle flaps and oral axial pattern flaps have been advocated and used successfully. However, those approaches have their own drawbacks, such as multiple surgical interventions, patient compliance, and intraoral scarring. In an effort to avoid the problems associated with local flaps, distant microvascular tissue transfers were investigated. During a 6-year period, six free-tissue transfers were performed as a primary means of treating recalcitrant palatal fistulae. Three dorsalis pedis flaps and three osseous angular scapular flaps were used. The conditions of all patients improved, with five patients achieving complete long-term closure of the palatal defect. This experience indicates that modern microvascular techniques have reached a level of success commensurate with that of other flap techniques; therefore, it is concluded that free-tissue transfer should be considered as a primary means of addressing these difficult cleft problems.

Even if a surgical procedure is performed for reconstructive and functional reasons, a plastic surgeon must be responsible for the visible result of the work and for the social reintegration of the patient; therefore, the aesthetic appearance of a microsurgically reconstructed lower leg must be considered. Based on the experience of 124 free-tissue transfers to the lower leg performed in 112 patients between January 1994 and March 2001 (110 [88.7 percent] were transferred successfully), three cases are presented. Considerations concerning flap selection and technical refinements in designing and tailoring microvascular flaps to improve the quality of reconstruction, also according to the aesthetic appearance, are discussed.

We report on a case of an emergency free flap cover of a pharyngeal defect which was made necessary by aggressive digestive salivatory and radiation effects 3 weeks after neck-dissection and laser ablation of an epidermoid left tonsil carcinoma. Life threatening intraoral bleeding resulted from the erosion of branches of the external carotid artery. After management of the bleeding, massive blood transfusions and restoration of the patient's general condition, a sandwich patch cover of the transmural pharyngeal defect was achieved using a microvascular lateral arm flap. This aimed at preventing further digestive effects and bacterial colonisation of the neurovascular structures at the carotid triangle. Unfortunately, due to external mechanical forces, the flap became avascular and thus necrotic at the eighth postoperative day; however, until the successful replacement by a myocutaneous latissimus dorsi flap it remained water-tight and fulfilled its sealing task.

Although rarely used, the abductor hallucis muscle has its indications in coverage of small defects at the medial aspect of the hindfoot as a proximally based muscle flap. The authors describe a 69-year-old female patient in whom the abductor hallucis muscle was used as a distally based flap to reconstruct a defect in the forefoot. An anatomic study was undertaken on two cadaveric feet to explore the practicality of the distally based abductor hallucis muscle flap before it was applied clinically. The distally based abductor muscle flap receives its blood supply from minor and major pedicles in a retrograde fashion from both the dorsal arterial network and the deep plantar system, through communicating branches with the medial plantar artery distally. Transposition of the distally based hallucis flap is only advisable in individuals who have no vascular compromise in the lower leg and foot. To the authors' knowledge, this modification has not yet been described in the available literature.

Allthough there has been dramatic progress in limb salvage in recent decades, management of nonhealing wounds in diabetic patients continues to present a dilemma for the reconstructive surgeon. However, the acceptance of free-flap resurfacing of diabetic foot ulcers has increased in recent years. This study reviews 10 microvascular free muscle flaps in nine patients over a mean follow-up period of 44 months. Five patients had evidence of peripheral vascular disease. There was one flap loss, and nine flaps were transferred successfully. No perioperative mortality was encountered. The operations required a long, costly hospitalization (average hospital stay was 40 days). Seven of eight patients whose flaps survived had complications related to the free-flap recipient site. These seven patients underwent 20 secondary surgical procedures due to arterial and venous thrombosis, partial necrosis of the skin grafts, minor local infections, and gangrene or necrosis of the remaining toes. In three patients, progressive ischemic necrosis of the remaining toes, with total survival of the flap, was attributed to a microvascular steal phenomenon. However, all eight patients whose flaps survived subsequently ambulated on their flaps. The study demonstrates that microvascular surgery may result in functional lower-extremity salvage in diabetic patients with foot wounds that are not treatable by local flaps or skin grafts, and are destined for amputation.