Wolfgang Mühlbauer Als Plastischer Chirurg der frühen Jahre und langjähriger Weggefährte verdanke ich meiner „Chefin“ die Berufung zur Plastischen Chirurgie, beginnend mit einer stimulierenden Famulatur im Jahre 1960. Sie wurde gefestigt durch eine 4-monatige Tätigkeit als Medizinalassistent und entscheidend geprägt durch die Rückholung von der University of Colorado in Denver, USA, wohin ich zur Facharztausbildung gegangen war, ans neugegründete Universitätsklinikum r.d. Isar 1968. Sie begleitete meinen klinischen, akademischen und berufspolitischen Werdegang bis zur Neugründung 1984 einer eigenen Abteilung am Klinikum Bogenhausen in München vertrauensvoll und fördernd.All die Jahre versuchte ich ihr nicht nur in der Klinik eine Stütze zu sein, sondern auch privat in schwierigen Lebenslagen beizustehen, nicht zu Letzt im Sinne unseres Hypokratischen Eids „unsere Lehrer zu achten, zu ehren bis ans Ende ihres Lebens“.

Squamous cell carcinoma in a Zenker diverticulum is a very rare condition. We report a case of a patient with a Zenker carcinoma, who was primarily functionally inoperable and therefore received neoadjuvant radiochemotherapy before cardiac bypass surgery. After a complicated course with cardiogenic shock and myocardial infarction, a re-evaluation of functional risk analysis and the tumor situation revealed operability. Subsequently, partial hypopharyngectomy and partial cervical esophageal resection with lymphadenectomy was performed. Reconstruction of the gastrointestinal continuity was made by interposition of a free small bowel graft and microvascular anastomosis. The postoperative course showed a small anastomotic leakage of the hypopharyngeal-small bowel anastomosis, which was successfully treated conservatively.

4572 Background: The treatment of cervical squamous cell carcinoma (SCC) is discussed controversial. A limited resection of the cervical esophagus and reconstruction with a free jejenunal graft interposition using a microsurgical technique has been evaluated in our department. Methods: From 1986–2006 94 patients with the initial staging uT2–4, N any cM0 (75 male, 19 female; age 56+9.6, range: 19–74 years) with cervical SCC of the esophagus were treated with limited esophageal resection and reconstructed with a free jejunal autograft in combination after neoadjuvant RCTx within phase II studies. The median follow up is 23 months (0.1–120). Results: Laryngectomie had to be performed in 13 patients (14%). Recurrent nerve palsy on one side was found in 15/77 (19.5%) and on both sides in 13/77 (17%). Complications occurred in 70 (75%) of the patients, 47% of the patients had more than one complication. Reoperations were necessary in 29 patients (31%). The 30-day mortality was 2/94 (2.1%). Median survival is 29.9 months (1-, 3 and 5-year survival rates: 81%, 43%, 41%). 27/94 (29%) patients showed complete tumor regression (ypT0) after RCTx. Prognostic factors are complete tumor regression (p=0.007), ypT-(p=0.006), the R-category (p=0.018), but not the ypN-category (p=0.06). Neither the occurrence of complications (p=0.57) nor reoperation (p=.89) are associated with survival. The complete resection rate was 76 % (71/94). Median survival is 34.3 months, median recurrence free survival is 21.4 months for the R0 resected patients. 30/71 (42%) had a recurrence (locoregional in 27% (19/71), distant metastases in 10% (7/71) and a combination of both in 6% (4/71). Conclusions: Limited resection of the esophagus and reconstruction by a free jejunal graft after neoadjuvant RCTx is highly sophisticated and complex. Despite a high complication and reoperation rate the results are excellent with a low mortality and a good prognosis. This approach seems to be appropriate for cervical SCC in oncological centers with an infrastructure providing interdisciplinary management. Comparable data for cervical SCC of the esophagus without the inclusion of hypopharyx carcinoma do not exist in literature so far. No significant financial relationships to disclose.

Background Vascular endothelial growth factor (VEGF) is a key regulator of angiogenesis. VEGF A also plays an important role in wound healing of the skin by promoting angiogenesis and by stimulating blood vessel growth. Therefore we tested the hypothesis that flap survival could be increased by the preoperative injection of AdVEGF(165).Methods We studied the effect of AdVEGF(165) in an overdimensioned ischemic random-pattem-flap model in the rat (n = 50) with a length-to-width ratio of 4: 1. VEGF cDNA was administered in two concentrations of 5 x 10(8) plaque-forming units (pfU) and 1 x 10(9) pfU using a recombinant adenoviral vector. Recombinant virus was injected subdermally 7, 3 or 0 days prior to flap harvest for the lower concentration and 7 days prior for the higher concentration. Flap survival and necrosis were observed at day 7, the day the animals were sacrificed.Results Adenoviral gene transfer with VEGF(165) 3 and 7 days before flap harvest showed a significantly increased flap survival of 50% together with a significantly reduced necrosis (p < 0.01). Injection using a titer of 1 x 10(9) pfU 7 days prior to surgery increased flap survival even more, though failing to reach statistical significance compared to the lower concentration. VEGF protein concentration in the injected skin was significantly higher than in controls (p < 0.01). Flap perfusion was increased as well, demonstrated by indocyanine green (ICG) fluoroscopy (p < 0.001).Conclusions Our results confirm the important role of VEGF(165) on angiogenesis in ischemic flaps. Indeed by injecting VEGF(165) at 3 to 7 days preoperatively in a concentration of 1 x 10(9) pfU our data show that length-to-width ratio for random-pattern-flaps could be increased from 2: 1 to 3: 1 and therefore may allow a wider range of applications of this simple flap technique. Copyright (c) 2004 John Wiley & Sons, Ltd.

A regular tissue functioning requires the adequate supply of oxygen and nutrient via blood vessels. The sequences of formation and maturation of vessels are initiated and maintained by different growth factors. The VEGF growth factor plays an exceptional role in these mechanisms. The creation of sublethal ischemia as an angiogenic stimulus known as "Delay" is a well established procedure in plastic surgery, although the underlying molecular biological mechanisms still remain unknown. The important role of VEGF and its regulation depending on oxygen pressure suggest a strong connection between this growth factor and the delay phenomenon. The VEGF concentration in skin and underlying muscle was measured in overdimensioned random pattern flaps on 32 male Sprague-Dawley rats after either VEGF gene therapy or circumcision without elevation of the flap and compared to controls. Additional random pattern flaps were raised seven days post gene therapy or delay. The effect on the flap perfusion was measured postoperatively using Indocyanine green Laser Fluoroscopy and the size of the surviving and necrotic areas of the flaps were analysed. The skin of the random pattern flaps showed both in the Delay group and in the VEGF gene therapy group a significantly elevated VEGF concentration compared to the controls. The underlying rectus abdominis muscle showed no significant differences in VEGF concentration between the groups. The flap perfusion postoperatively was significantly increased solely in the VEGF gene therapy group. The analysis of the surviving area of the flaps showed a significant increase over the controls in the gene therapy group. The Delay procedure results in a significantly and locally raised concentration of the VEGF growth factor. The gene therapeutical use of this growth factor allows us to raise flap perfusion and to reduce necrosis. Both VEGF gene therapy and Delay seem to promote similar mechanisms whereas the gene therapy produced superior results in this setting.

Purpose: Studies have shown that it is possible to derive direct knowledge about the actual mechanical conditions of the wrist by analyzing the subchondral mineralization. The aim of the present study was to evaluate the distribution of the subchondral bone mineralization of the distal radioulnar joint (DRUJ) noninvasively in living subjects by using computed tomography (CT) osteoabsorptiometry to gain new information about the long-term loading conditions.Methods: Twenty-two wrist joints were investigated in 11 healthy young subjects by means of CT osteoabsorptiometry. The CT scans of the DRUJ were taken in the axial plane in neutral position of the forearm and in both maximum pronation and supination. The CT datasets of 1.5-mm sections were obtained and then transferred to an image-analyzing system. The subchondral bone plate in each section was isolated, reconstructed in 3 dimensions, and converted into a false color series.Results: The maximum subchondral bone density in the sigmoid notch of the radius was found along the distal border in all wrists. It was located dorsally in 10 wrists, palmarly in 8 wrists, and centrally in 4 wrists. The maximum bone density on the corresponding articular surface of the ulna was found dorsally in 10 cases, centrally in 8 cases, and palmarly in 4 cases. In 13 cases the maximum bone density was found in direct opposition on radius and ulna in neutral position. A statistically significant difference could not be detected in subjects with an ulna minus variance nor in those with a DRUJ angulation greater than 10 degrees.Conclusions: Our results show that in the sigmoid notch the load is transmitted through either the dorsal or palmar parts of the joint. In contrast the maximum bone density on the side of the ulna was found dorsally and centrally. We conclude that the ulna receives the maximum load in neutral position and supination, whereas because of the dorsopalmar translation of the ulnar head the radius may lead the ulna with either its palmar or dorsal borders during pronosupination. The ligamentous apparatus, the shape of the joint, and the ulna variance, however, may influence load transmission. Copyright (c) 2005 by the American Society for Surgery of the Hand.

Eine normale Gewebefunktion ist auf die adäquate Sauerstoff- und Nährstoffversorgung durch Blutgefäße angewiesen. Die Abläufe der Bildung und Reifung von Gefäßen werden initiiert und aufrechterhalten durch unterschiedliche Wachstumsfaktoren. Dem Wachstumsfaktor VEGF kommt in diesen Prozessen eine herausragende Bedeutung zu. Die Erzeugung subletaler Ischämie als Angiogenesereiz ist unter dem Namen „Delay“ ein in der Plastischen Chirurgie etabliertes Verfahren, deren zugrunde liegende molekularbiologische Mechanismen jedoch weitgehend unbekannt sind. Ziel der vorliegenden Arbeit ist die weitere Aufklärung des Zusammenhangs zwischen VEGF und dem Delay-Phänomen, insbesondere im Vergleich zur adenoviralen Gentherapie als potenziell konkurrierendes, nicht-invasives Verfahren. An 32 männlichen Crl:CD(SD)-Ratten wurde die VEGF-Konzentration in Haut und Muskulatur nach subdermaler Injektion von AdCMV.VEGF165 oder reiner Umschneidung (Delay) einer überdimensionierten Lappenplastik vom „Random-pattern“-Typ gemessen und mit Kontrollen verglichen. Weiterhin wurden nach VEGF-Gentherapie oder Delay nach jeweils sieben Tagen die Lappenplastik gehoben und die Auswirkung der Therapie auf die postoperative Durchblutung mittels Indocyaningrün-Laser-Fluoreszenzangiographie und auf die Größe der überlebenden und nekrotischen Lappenfläche untersucht. Im Hautanteil der Lappenplastiken in der VEGF-Gentherapie-Gruppe und der Delay-Gruppe konnten jeweils gegenüber den Kontrollen signifikant erhöhte VEGF-Konzentrationen nachgewiesen werden. In der angrenzenden Muskulatur zeigten sich keine signifikanten Unterschiede zwischen den Gruppen. Bei der Messung der Perfusion unmittelbar postoperativ wies nur die VEGF-Gentherapie-Gruppe einen signifikant erhöhten Perfusionsindex gegenüber den Kontrollen auf. Die Messung der überlebten Lappenfläche ergab für die AdVEGF-Gruppe eine signifikante Erhöhung gegenüber der Kontroll- und der Delay-Gruppe. Das Delay-Verfahren resultiert in einer signifikant und lokalisiert erhöhten Konzentration des Wachstumsfaktors VEGF. Die gentherapeutische Verwendung dieses Wachstumsfaktors alleine ist in der Lage, die Hautdurchblutung zu steigern und die Entstehung von Nekrose zu reduzieren. Bei Gentherapie mit VEGF und Delay scheinen ähnliche Phänomene abzulaufen, wobei die Therapie mit AdVEGF eine deutliche Überlegenheit zeigt.

Prediction of necrosis has a clinical relevance in all fields of plastic surgery. The new application of indocyanine green (ICG) fluoroscopy in plastic surgery allows an objective quantification of skin perfusion and a high topographical resolution. The aim of the present study is to determine threshold values for flap perfusion under well-defined experimental conditions. Twenty random pattern flaps with a length to width ratio of 4:1 (8 x 2 cm(2)) were dissected on the anterior abdominal wall of 20 male Sprague-Dawley rats. ICG fluoroscopy was performed at the end of the operation. The animals were sacrificed at the seventh postoperative day with a reliable necrosis of the distal part of the flaps. Postoperative ICG fluoroscopy then was analysed both in regions that will survive and undergo necrosis. At day 7 a mean area of 5.5 cm(2) (57% of the total flap area) survived and a mean of 3.8 cm(2) (43%) became necrotic. The surviving part of the flap had a mean perfusion index of 62% compared to reference skin. The distal parts of the flap that necrotised showed an average perfusion index of only 19% postoperatively. Differences were statistically highly significant (p<0.001). Indocyanine green fluoroscopy is a useful tool to evaluate perfusion topographically and predict necrosis. From a statistical point of view a perfusion index of less than 25% of the reference skin can be considered as a sign of developing flap necrosis.

Prediction of necrosis in critically perfused skin flaps is difficult and rarely precise. An early detection of insufficiently perfused skin is highly desirable since it may lead to surgical decisions such as operative flap revision or early resection. The application of laser-induced indocyanine green (ICG) fluoroscopy allows an objective quantification of skin perfusion and a high topographical resolution. Aim of the present study is to determine a threshold value for flap perfusion under well-defined experimental conditions and test the validity of the results in the clinical application. Twenty overdimensioned random pattern flaps with a length to width ratio of 4 : 1 (8 x 2 cm) were dissected at the anterior abdominal wall of 20 male Sprague-Dawley rats weighing 365 g on average. ICG fluorescence was performed at the end of the operation by intravenous injection of 1 g ICG/kg bodyweight into a tail vein and digital recording. On the seventh postoperative day, both the necrotic and surviving areas of the flaps were measured and the ICG-fluorescence was analysed in the areas that had undergone necrosis. 41 flaps with areas of critical perfusion (18 skin flaps, 13 muscle flaps, 8 replantations) were analysed in 39 patients. The surviving part of the flap had a mean perfusion index of 62 % compared to reference skin. The distal parts of the flap that necrotized during the experiment showed an average perfusion index of 19 % postoperatively. Differences were statistically significant (p < 0.001). In clinical application, a number of 13 flaps were found to have a perfusion index less than 25 % in a region of critical perfusion. Eleven of these developed a partial necrosis in that region, one flap underwent total necrosis. Indocyanine green fluoroscopy allows a detailed topographical analysis of flap perfusion and the prediction of necrosis. Experimental findings presented a threshold value for the perfusion index of 25 % which could be confirmed in clinical application.

PURPOSE:Based on biomechanical experiments in specimens it is accepted widely that ulnar length determines loading of distal articular surface of the radius with ulna-minus variance increasing and ulna-plus variance decreasing the loading of the lunate compartment. Nevertheless a direct assessment of the actual loading conditions in the living is currently impossible. The aim of the present study is therefore to evaluate subchondral bone mineralization patterns to provide further information about the role of ulnar length in load transmission through the radiocarpal joint. METHODS:Twelve wrists of healthy subjects with an average age of 33 years and an average congenital ulna-minus wrist of -2.8 mm (range, -4 to -1 mm) were examined by means of computed tomography-osteoabsorptiometry. A further 5 wrists in healthy subjects with an average age of 52 years and an average congenital ulna-plus variance of +3.0 mm (range, +2 to +4 mm) were examined with the same technique. Seventeen wrist joints of 9 healthy subjects with ulna-zero variance were examined in the control group. RESULTS:The results show a mainly lunate mineralization pattern in subjects with ulna-minus wrists in 75% of the cases, which is more frequent than in subjects with ulna-zero wrists. The results in ulna-plus variance show a mainly scaphoid mineralization pattern in 100% of cases. The differences in mineralization patterns are statistically significant. CONCLUSIONS:We conclude from these morphologic results in living subjects that ulnar length determines the peak mineralization patterns of the distal articular surface of the radius with a relatively lesser loading of the lunate fossa in ulna-plus variance and a relatively higher loading history in most cases of ulna-minus variance. The hypothesis, however, that ulna-minus variance is always a sign of a relatively higher loading history of the lunate fossa cannot be supported.

Perforator flaps allow an individual flap design on the basis of a preoperative ultrasound examination. Aim of the present study is a preliminary evaluation of results and technical pitfalls of this new technique in the use for flap coverage on the dorsum of the hand and the elbow region. Since 1999, seven individually designed pedicled perforator flaps were prepared on the upper extremity. In four cases, defects on the dorsum of the hand and in a further three defects in the elbow region were treated. In the latter cases the flaps were harvested in a mainly epifascial plane, without dissecting the perforating vessels down to their origin. Five flaps were based on perforating vessels of the interosseous arteries, a further two from the lateral collateral humeral artery. Three out of four pedicled perforator flaps used on the dorsum of the hand healed completely. One flap was lost because of venous insufficiency due to the lack of wrist immobilisation. In the elbow region, two out of three defects were successfully covered with an individual perforator flap. One flap was lost due to venous insufficiency, a further needed an additional split-skin graft with a partial flap loss. The main advantage of the presented technique remains the possibility of individual flap design. However, the donor-site defect is almost negligible since in most cases a primary closure of the donor site was possible. The main arteries remained untouched leaving the blood supply to the hand unchanged. Nevertheless, the mainly epifascial harvest of the perforating vessels in the elbow region has the disadvantage of a short pedicle together with a high degree of torsion which leads to an increased risk of flap loss due to venous insufficiency.

Das Plattenepithelkarzinom des zervikalen Ösophagus (CEC) ist eine seltene Entität und wird meist erst im lokal fortgeschrittenen Stadium diagnostiziert. Beim resektablen CEC gilt die Ösophagolaryngektomie mit permanentem Tracheostoma als Standard. Im Rahmen einer prospektiven Phase-II-Studie evaluierten wir bei Patienten mit lokal fortgeschrittenem CEC (uT3/4NxM0-Kategorien) ein multimodales Therapiekonzept mit neoadjuvanter Radiochemotherapie (RCT) und limitierter cervikaler Ösophagusresektion, Interposition eines freien Dünndarmsegmentes mit mikrovaskulärem Gefäßanschluss und Pharynxerhaltung. Von 3/1986 bis 2/2001 wurden 54 Patienten mit lokal fortgeschrittenem CEC im Rahmen dieses multimodalen Konzepts behandelt. Bei 28 dieser Patienten erreichte der orale Tumorrand den Hypopharynx. Nach RCT konnte bei 44/54 (81.5%) der Patienten eine Laryngektomie vermieden werden. Eine RO-Resektion war bei 70,4% möglich. Die 30-Tage-Letalität betrug 1.9%. Eine reinterventionsbedürftige Interponatsnekrose trat bei 7/54 (13%) Patienten auf. Am Entlassungstag war eine orale Ernährung bei 38/54 Patienten möglich. Die 5-Jahresüberlebensrate für die gesamte Patientengruppe beträgt 28%, die mediane Überlebensdauer 29 Monate. Patienten mit komplettem histopathologischem Ansprechen (n = 13) Überlebten im Median 75.4 Monate verglichen mit 21.7 Monaten bei subtotalem oder nicht-Ansprechen (n = 41; p = 0,033). Die multivariate Analyse ergibt eine unabhängige prognostische Bedeutung für die pT-Kategorie (p = 0,039; rr 2.48; 95% CI 1.046 - 5.905) und den Nodalstatus pN (p = 0,033; rr 2.904; 95% CI 1.301 -6.482). Trotz der topographischen Nachbarbeziehungen zu Hypopharynx und Larynx ist nach RCT bei einem Großteil der Patienten mit lokal fortgeschrittenem CEC eine radikale zervikale Ösophagussegmentresektion mit Erhalt des Larynx möglich, selbst bei dorsaler Infiltration des Hypopharynx. Die Rekonstruktion mittels Jejunumautotransplantation ermöglicht eine zufriedenstellende Schluckfunktion, die, wie auch der Erhalt der Sprache, in einer hohen Lebensqualität resultiert. Im Vergleich zu bisher publizierten Ergebnissen radikalerer Resektionsverfahren scheint das beschriebene Konzept auch einen Überlebensvorteil zu bieten.

Extravasations of chemotherapeutic drugs may lead to large soft-tissue losses in the hand and forearm and necessitating surgical excision with secondary flap coverage. Unfortunately, a delayed referral to a hand and plastic surgical unit with an already established soft-tissue defect is most common. Nevertheless, in our unit the method of choice is early emergency subcutaneous "wash-out", which facilitates dilution and reduction of concentration of the extravasation and therefore reliably avoids the development of soft-tissue defects. The aim of this paper is to present the surgical technique.

Seit wir begonnen haben, myokutane und fasziokutane Lappen frei zu verpflanzen, wussten wir über „Perforatoren“ und „Perforans-Gefäße“ Bescheid; wir arbeiteten mit ihnen. Die ersten freien Lappen, der „Leistenlappen“ und der „Temporallappen“, waren völlig unterschiedlich, weil hier ausschließlich ein subkutaner Plexus die Haut versorgte. Aber mit dem „Dorsalis pedis-Lappen“ und kurze Zeit danach bei dem „Latissimuslappen“ wussten wir, dass die darüberliegende Kutis durch Perforans-Gefäße ernährt wurde, welche entweder durch das Septum oder durch den Muskel und die Faszie zur Haut gelangen und sie ernähren. Bei den später entwickelten Lappen, wo tiefere und zentralere Gefäße als „Ernährer“ gehoben wurden, schlossen wir immer Perforans-Gefäße mit ein, um eine Durchblutung der Hautinsel zu gewährleisten. Aber zu dieser Zeit stellten wir sie nicht dar und schauten auch nicht individuell nach ihnen. Wir schlossen einfach ein langes Stück des Septums oder einen mehr oder minder großen Teil des Muskels und der Faszie mit ein. Aber wir wussten genau, dass sie nur überleben werden durch Perforans-Gefäße.

Ziel der Qualitätssicherung muss die Verbesserung der medizinischen Versorgung sein. Neben Qualitätssicherungsmaßnahmen, die vorwiegend auf klinischen Parametern und ärztlichen Urteilen basieren, gewinnen subjektive Patientenurteile zunehmend an Bedeutung. In der vorliegenden Studie werden Ergebnisse einer Befragung von 420 ambulanten und stationären plastisch-chirurgischen Patienten zu präoperativer Beratung, operativem Eingriff und Nachsorge vorgestellt. Als vordringlichste Schwachstelle zeigte sich im stationären Bereich eine hohe Unzufriedenheit der Patienten bezüglich der Aufenthaltsräume, sanitären Einrichtungen, Zimmerausstattung und ‐größe. Informationen über die Nachbehandlung wurden oft nicht schnell und umfassend ausgetauscht, ebenso kam es häufig zu einer Verzögerung bei einer indizierten physikalisch-medizinischen Anschlusstherapie. Als Konsequenz der Studie gilt es, anhand der aufgezeigten Schwachstellen Verbesserungen herbeizuführen.

In patients with soft tissue sarcoma of the extremity at high risk of local recurrence, the standard treatment consists of limb sparing surgery and postoperative radiotherapy. Adding intraoperative radiotherapy (IORT) map compare favourably to standard treatment with respect to local control and functional outcome. 25 consecutive patients receiving IORT from 1988 - 1997 in our department were evaluated retrospectively. Overall local control rate was 76% at 4 years, with a local control of 94% at 4 years in 21 patients who received IORT and postoperative radiotherapy. 8 of 14 patients alive showed a good functional outcome. Considering a group at high risk for local recurrence (19x T2, 14x G3, 13x recurrent tumors), our data could point towards an improvement in local control compared to historical groups receiving postoperative radiotherapy alone. Confirmation in a randomized study is required.