Results after free flap reconstruction in the extremities are often impaired by missing color match of the transferred flap and the recipient site. But pre-existing color match is the precondition for satisfying aesthetic results. To obtain suitable free flap donor sites in terms of color for extremity reconstruction and to understand frequent color mismatch, we performed a colorimetric study including 60 healthy volunteers. Ten free flap donor sites were compared with ten recipient sites in the extremities. The results of our study showed that lower extremity sites are markedly lighter than upper extremity sites with the exception of the palmar forearm. We encountered an excellent color match of the radial forearm flap to the back of the hand (4.10 ± 1.91) and the palm of the hand (5.62 ± 2.21), and significantly relevant color match to the palmar aspect of the forearm (2.52 ± 1.23). Additionally, the lateral arm flap showed a remarkable color match to the dorsal aspect of the forearm (3.13 ± 2.06). Furthermore we encountered significantly relevant color match of the fibula flap to the anterior aspect of the lower leg (2.01 ± 1.08) and excellent color match of the anterolateral thigh flap (ALT) to the palmar aspect of the forearm (3.66 ± 2.10). No further significantly relevant color differences between the other donor sites and recipient regions were found. Colorimetric measurements are a helpful tool in reconstructive surgery to compare skin color of different anatomic sites.

BACKGROUND:Acute compartment syndrome (CS) of the paravertebral muscles without external trauma is rarely reported in literature. Not all of clinical symptoms for CS are applicable to the paravertebral region.CASE PRESENTATION:A 30-year-old amateur rugby player was suffering from increasing back pain following exertional training specially targeting back muscles. He presented with hardly treatable pain of the lumbar spine, dysaesthesia of the left paravertebral lumbar region as well as elevated muscle enzymes. Magnetic resonance imaging (MRI) showed an edema of the paravertebral muscles. Compartment pressure measurement revealed increased values of 47 mmHg on the left side. Seventy-two hours after onset of back pain a fasciotomy of the superficial thoracolumbar fascia was performed. Immediately postoperatively the clinical condition improved and enzyme levels significantly decreased. The patient started with light training exercises 3 weeks after the operation.CONCLUSIONS:We present a rare case of an exercise-induced compartment syndrome of the paravertebral muscles and set it in the context of existing literature comparing various treatment options and outcomes. Where there is evidence of paravertebral compartment syndrome we recommend immediate fasciotomy to prevent rhabdomyolysis and further consequential diseases.

Sir: We read with great interest the article “Simplifying Circumferential Body Contouring: The Central Body Lift Evolution” by Rohrich et al.1 The authors present the evolution of their technique and experience with the central body lift procedure in a greater than 12-year period and emphasize the key operative elements and strict safety guidelines that afford optimal results with minimal morbidity. We would hereby like to introduce a novel technique to facilitate the preoperative planning and marking concerning the body lift procedure in massive weight loss patients. Preoperative markings are set in standing position,2,3 and this sometimes implicates difficulties for the surgeon, especially in drawing straight vertical and horizontal lines, which later on will be the position of the horizontal scar on the typical position of the abdomen and the back. Scar placement is crucial and the result of a precise marking technique. In the massive weight loss patient, excess skin may make identification of the anatomical landmarks (which are often used for orientation to achieve symmetry) difficult.4 Kalbermatten et al.5 in 2009 suggested body taping to visualize the optimal position for skin incision. This technique makes preoperative marking objectively reproducible. The authors also postulated demands for a sufficient marking technique, which are all fulfilled by our new method too: minimal expenditure of time, congruence of marked and later resected area, and finally cost efficiency. In this Viewpoint, we present a new simple method of reproducibly defining the incision lines for body lift procedures with an available laser marking device (Fig. 1).Fig. 1: Laser device placed opposite the standing patient (Stanley XP180 Cross Line and Laser Plumb; Stanley Deutschland–HDL Industrievertretung GmbH).The patient is placed standing with hanging arms to avoid a tightening effect on the lateral trunk. The laser marking light lines (horizontal and vertical light) are turned on and the vertical light line is placed exactly on the anal cleft. The designated scar line is generally defined by placing the horizontal laser light approximately 2 cm below the upper impression of the underwear’s elastic strap. After marking of a median line, further vertical lines are drawn at a distance of 5 cm (2 inches) as far as the spina iliaca anterior superior by turning the patient. For defining the resection margins, skin is moved upward and downward using the tip of the index finger at each vertical line. Immediately before skin slips of the fingertip, a skin mark is set at the place where the vertical line and laser light intersect. This maneuver is started medially and continued to the lateral side as far as resection is planned. To complete the drawing of the inferior and superior incision line, these points are connected (Fig. 2).Fig. 2: Laser marking light lines (horizontal and vertical light) placed on the back of the patient.The use of this simple instrument allows placement of reproducible skin markings, pays respect to varying tissue mobility, and reduces time needed for preoperative skin marking. As a sighting device, the laser marking device gives the surgeon a secure instrument with which to draw precise lines that finally will result in a more precise positioning of the scar and thus a better postoperative outcome for the massive weight loss patient. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No funding was received for this work. Lorenz Larcher, M.D. Hospital of St. John of God (Barmherzige Brüder) Salzburg (A) Department of Plastic, Aesthetic, and Reconstructive Surgery Academic Teaching Hospital Paracelsus Medical University Salzburg Karl Schwaiger Paracelsus Medical University Salzburg Florian Ensat, M.D. Gottfried Wechselberger, M.D., M.Sc. Heinrich M. Schubert, M.D. Hospital of St. John of God (Barmherzige Brüder) Salzburg (A) Department of Plastic, Aesthetic, and Reconstructive Surgery Academic Teaching Hospital Paracelsus Medical University Salzburg Salzburg, Austria

We report venous thrombosis of a free flap after intravenous application of desmopressin in a 76-year-old woman suffering from a recurrent basalioma. The tumor infiltrated the right hemiface and tumor resection resulted in loss of the entire nose and upper lip and a soft tissue defect over the right orbit, right frontal bone, and right nasopharynx. The defect was reconstructed with a free vascularized iliac bone graft with a skin island based on a perforating vessel originating from the ascending branch of the deep circumflex iliac artery. The flap vessels were anastomosed to the facial artery and vein. The patient’s postoperative course was uneventful in the first 4 days after surgery. On day 5 after free flap transfer, 4 lg Minirin (desmopressin) were administered intravenously because of idiopathic diabetes insipidus. Within 1 hour, the skin island clinically showed signs of venous congestion. Lab tests were performed immediately without any conspicuous result. Immediate revision of the pedicle was performed revealing a long-segment thrombosis of the venous pedicle. Thrombectomy was done and the patient was treated with low molecular heparin and acetylsalicylic acid. Further healing was uneventful and stable soft tissue coverage could be achieved. Desmopressin is the synthetic equivalent to human vasopressin. Clinical applications include the treatment of not only diabetes insipidus and nocturnal enuresis but also coagulation disorders as von Willebrand disease type and mild hemophilia A. Besides its antidiuretic action, desmopressin increases the level of von Willebrand factor and factor VIII and leads to a release of tissue plasminogen activator into the plasma shortening the prolonged activated partial thromboplastin time and the bleeding time. To the best of our knowledge, there is no information about the influence of desmopressin on free flap surgery in the literature. Kon et al. analyzed the patency of saphenous vein grafts in rats. Intimal thickening was assessed by light and scanning electron microscopy. There was no significant difference concerning the rate of thrombosis between the group treated with desmopressin and the control group. However, the rats received desmopressin 30 min before transplantation and not afterwards so it is difficult to compare with our case. Furthermore, they received 1 pg per kilogram, whereas the woman in our report (56 kg) received 4 lg (0.071 lg per kg). Palaia et al. used desmopressin in facelift patients to reduce microhematomas. One preoperative dose of 0.3 lg per kg was administered 15 min before onset of surgery. The authors report no complication directly related to desmopressin, no thrombotic events happened. Keck et al. analyzed the influence of desmopressin on microcirculation in experimental pancreas transplantation in rats. Donors were treated preoperatively with different amounts of desmopressin. In their study, the rate of pancreas thrombosis increased in proportion to the dose of administered desmopressin. In the group treated with <6 lg the rate of thrombosis was 13.6% versus 30% in the group treated with >6 lg. *Correspondence to: Dr. Florian Ensat, M.D., Department of Plastic and Reconstructive Surgery, Hospital of the Barmherzigen Brüder Salzburg, Kajetanerplatz 1, 5020 Salzburg, Austria. E-mail: florian.ensat@gmx.at Received 10 April 2012; Revised 15 June 2012; Accepted 6 August 2012 Published online 13 September 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.22044

A 79-year-old woman was admitted complaining of progressive weakness and numbness of the right hand. The patient was otherwise healthy. The patient's history was unremarkable. Clinical and electrophysiological examination revealed a compression of the ulnar nerve in the ulnar sulcus and in Guyon's canal. Ultrasound evaluation showed a suspicious tumour proximal to the elbow close to the ulnar nerve. The ulnar sulcus was then released and an epineural and perineural lesion 3-4 cm proximal to the sulcus was excised under microscope. The histopathology confirmed the lesion as non-caseating sarcoid granulomas. The patient showed no other signs of systemic sarcoidosis, as neuropathy was the only symptom and the condition improved postoperatively. Sensory deficits and paraesthesia resolved fully. The extension of the minor finger remained slightly inferior compared with the not affected side. Sarcoid neuropathy is a rare neurological complication of sarcoidosis and has to be included in differential diagnosis of nerve conduction impairments.

BACKGROUND:Among many aspects, wound healing depends on early restoration of venous blood flow across wound margins. The type of surgical occlusion of vein stumps during operations was assumed to have an influence on the early postoperative reunion of vein stumps and thereby on wound healing. Currently, there are different methods of vein stump occlusion available: ligation (e.g., Vicryl), closure using metal clips (e.g., LigaClip), coagulation using manually controlled bipolar forceps, and the use of a computer-controlled bipolar system (e.g., BiClamp). The aim of this study was to surgically and histologically compare the healing process, including new vessel formation after vein occlusion using one of the methods listed.METHODS:In a rat model (n = 50), both jugular and femoral veins were prepared, occluded twice with one of the methods mentioned above (i.e., 400 occlusions), and finally cut in-between. Groups of 10 animals were reoperated and evaluated surgically and histologically after 5 days, 10 days, 15 days, 30 days, and 90 days.RESULTS:Occlusion methods using Vicryl, LigaClip, or bipolar forceps allow highly reliable vessel occlusion. Surgical evaluation showed higher occurrence of vessels in between the vein stumps after usage of Vicryl and LigaClip when compared with electrothermic occlusion methods (p = 0.017). Histologic examination showed different courses of the inflammatory reaction and varying capillary counts. Bipolar occlusion methods do cause less vessel occurrence, less inflammatory reaction, and less histologic capillary formation.CONCLUSION:If a reconnection of the venous flow is desirable, the use of Vicryl and LigaClip might be superior to using electrothermic occlusion methods. In contrast, electrothermic methods cause less new vessel formation as well as less inflammatory reaction.

Native skin-flap necrosis following skin-sparing mastectomy (SSM) is treated by raising a capsular flap, formed as a consecutive physiological reaction around breast implant. Using this highly vascularised thin tissue layer as an implant coverage withdraws pressure from the defect and allocates a good background for wound healing.

ObjectiveCoverage of soft-tissue defects of various sizes by an easy-to-do and reliable free muscle/myocutaneous flap.IndicationsSoft-tissue defects of a size up to 10 x 22 cm. Functional muscle transfer, e. g., biceps muscle replacement.ContraindicationsPoor soft-tissue conditions or lesions on both thighs. No recipient vessels. Inadequate personnel and/or technical resources.Surgical TechniqueApproach via a longitudinal medial incision or via the thigh flexion fold. The flap can be designed with or without a skin island. After mobilization from its tendinous part up to its origin, the vascular pedicle is prepared until its origin from the deep femoral artery. After harvesting, transfer is performed by anastomosing and shaping, eventually followed by split-thickness skin grafting.Postoperative ManagementClinical controls and measurement of partial oxygen concentration until day 10. Immobilization for 10 days, if the recipient site is close to a joint. Thrombosis prophylaxis.ResultsDuring the past 10 years, 254 free gracilis flaps were transplanted. Total flap loss rate was 4.3%, whereas reoperation due to hematoma or partial flap loss was necessary in 13.0%.

1. Mori H, Hata Y. Modified C-V flap in nipple reconstruction. J Plast Reconstr Aesthet Surg 2008;61:1109e10. 2. Alfano C, Tenna S, Caggiati A, et al. Nipple reconstruction by local flaps: A long-term comparative study between star and skate techniques. Acta Chir Plast 2004;46:127e31. 3. Schoeller T, Schubert HM, Pulzl P, et al. Nipple reconstruction usinga modified arrow flap technique. Breast2006 Dec;15:762e8. 4. Thomas SV, Gellis MB, Pool R. Nipple reconstruction with a new local tissue flap. Plast Reconstr Surg 1996;97:1053e6.

Deckung von Weichteildefekten unterschiedlichster Form und Größe durch eine zuverlässige freie Muskel- oder Muskel-Haut-Transplantation.

In avalanche accidents, the significance of major trauma as a cause of morbidity and mortality is controversial. The aim of this retrospective study is to determine the severity and pattern of injury in avalanche victims admitted to the University Hospital of Innsbruck between 1996 and 2005. A total of 49 significant injuries were found in 105 avalanche victims; the most frequent were of the extremities (n = 20), the chest (n = 18), and the spine (n = 7). In contrast, cerebral (n = 2), abdominal visceral (n = 1), and pelvic trauma (n = 1) were rare. The severity of injury was minor or moderate in most patients, with only 9 (8.6%) being severely or critically injured. Of 105 (34.3%) avalanche victims, 36 died. Autopsy was performed in 30 of 36 nonsurvivors. The cause of death in the remaining 6 victims was concluded from clinical, radiological, and electrophysiological findings. Trauma was responsible for deaths of only 2 avalanche victims (5.6%); both had cervical spine fractures with dislocation leading to death. One death was due to hypothermia, whereas the remaining 33 fatalities (91.7%) were due to asphyxia. The incidence of life-threatening or lethal trauma was well below 10%. Asphyxia is by far the most important reason for death. Deaths from trauma were solely due to isolated cervical injuries, demonstrating that the cervical spine may be a region at particular risk in avalanche victims.

Objective-Experimental data indicate that when using a sit harness alone, any major fall during rock climbing may cause life-threatening thoraco-lumbar hyperextension trauma or "head down position" during suspension. To clarify the actual influence of the type of harness on the pattern and severity of injury, accidents involving a major fall in a climbing harness were analyzed retrospectively.Methods.-Individuals with a height of fall equal to or exceeding 5 m were identified through a search of accident and emergency records for the period from 2000 to 2004. Data concerning the circumstances of the fall and the patterns of injury were obtained from personal interviews, flight and accident reports, as well as hospital medical records.Results.-Of a total of 113 climbers identified, 73 (64.6%) used a sit harness alone, whereas 40 (35.4%) used a body harness. Fractures and dislocations of the extremities, the shoulder, and the pelvic region were the most common injuries, while the most severe injuries occurred in the head and neck region. Although most falls were associated with mild or moderate injuries, 13 (11.5%) climbers sustained severe or critical multisystem trauma. Falls on more difficult routes were associated with less severe injury. The type of harness used did not influence the pattern or severity of injury. In particular, no evidence was found for the existence of a thoraco-lumbar hyperextension trauma.Conclusions.-The type of harness does not influence the pattern or severity of injury, and the forces transferred via the harness do not cause a specific harness-induced pathology. We did not find any evidence that hyperextension trauma of the thoraco-lumbar region is an important mechanism of injury in climbers using a sit harness alone. Rock contact during the fall, and not the force transferred through the harness, is the major cause of significant injury in climbing accidents.

Background: Optimal prehospital and clinical management of patients with severe pelvic trauma is controversial. Prospective evaluations of different treatment strategies have not been performed and treatment is currently not evidence-based. The purpose of the present study was to develop a porcine model of reproducible severe pelvic trauma for subsequent laboratory trials.Methods: The study was performed on 13 juvenile porcine cadavers. Pelvic fractures were created by applying a pure anterior-posterior compression load to the pelvic ring using a servohydraulic material testing machine. Fracture patterns were classified according to the Young-Burgess classification and the Tile classification using postfracture CT scans including 3D-reconstructions.Results: Disruptions of the posterior pelvic ring segment were unilateral in 12 cases and bilateral in one case transforaminal vertical sacrum fractures. Injuries of the anterior ring segment were obturator ring fractures bilateral, ipsitaterat or contralateraL to the injury of.the posterior ring segment. According to the Tile classification this resulted in 12 type C1 and 1 type C3 fractures. In the Young classification all injuries were classified as type APC III. In six cases transverse process fractures were found ipsitaterat to the posterior ring disruption. Initial force drops indicating bony or ligamentous injuries occurred at mean forces of 4030 +/- 269 N (range, 3617-4374 N).Conclusion: The present model was able to create reproducible unstable pelvic fractures and can be used for controlled laboratory trials to study the management of patients with pelvic fractures. (c) 2007 Elsevier Ltd. All rights reserved.

The interrupted suture technique is most commonly used for microsurgical venous anastomosis. Needle-stitch trauma and intraluminal suture, however, potentially cause vascular wall damage, thrombosis, intimal hyperplasia or even stenosis. Therefore, the present study aimed to show the feasibility and reliability of a modified cuff technique (bipolar anastomosis technique (BAT)) for venous end-to-end anastomosis in a new chicken throat vascular model. In ex vivo experiments, freshly resected chicken jugular veins (N = 96) were used to find ideal BAT time to current settings for venous end-to-end anastomosis. Thereafter, the left jugular vein of chickens (N = 40) was dissected in vivo and subsequently anastomosed using BAT. The quality of anastomosis was evaluated by Doppler sonography immediately, at two hours and at two, six, 12, 16, and 29 weeks after surgery. Additional histological examination took place at two hours (N = 8) and at two (N = 6), six (N = 6), 12 (N = 6), 16 (N = 6) and 29 (N = 6) weeks after surgery. Immediately after surgery (N = 40) and at two hours (N = 38) venous anastomoses were found to be patent in Doppler sonography. Anastomotic rupture caused death in two animals within one hour after surgery. Thrombotic occlusion was found in one animal at six weeks after surgery. In the remaining animals (N = 37) only minimal stenosis which decreased to almost normal levels was sonographically found. The average time needed for anastomosis using BAT was less than two minutes. BAT allows fast venous end-to-end anastomosis in a chicken throat vascular model.

Background: In reconstructive surgery microsurgical repair of dissected nerves can be done end-to-end or by using a nerve graft. Guidelines to support an objective decision, whether tension associated with direct suture is acceptable or grafting is needed, do not exist. All experimental data found concerned the clinical outcome when a certain length defect was treated in various animal models. The aim of this study was to show the feasibility of a new instrument for measuring the tension needed to coapt nerve stumps before beginning nerve suture.Methods: A tension spring balance was modified in a way that the thread of the first suture is used to measure the force applied to the two nerve stumps by the suture before knotting. Immediately after measuring, the suture can be completed by knotting. Twenty-four rat sciatic nerves were dissected, segments of various length were resected, and tension needed for approximation was measured. These ex vivo data were combined with clinical outcome data of previous animal trials.Results: Data obtained showed that tension measured increased almost proportionally to the size of the gap created. The average additional time needed to measure the tension using the Tyrolean Tensiometer was 11 (+/- 4) seconds.Conclusions: None of the methods described before allow intraoperative tension measurement at a time when changes in strategy are still possible. The Tyrolean Tensiometer allows fast and reliable measurement of the tension acting on the first suture and might hereby be useful in predicting final operative outcome.