Die Zeitschrift „Handchirurgie · Mikrochirurgie · Plastische Chirurgie“ (HaMiPla) ist das offizielle wissenschaftliche Organ der Vereinigung der Deutschen Plastischen Chirurgen (VDPC) ebenso wie das der Deutschsprachigen Arbeitsgemeinschaft für Handchirurgie, der Deutschen und Österreichischen Gesellschaften für Handchirurgie und der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße. Mit dem jetzt vorliegenden Heft wird die Funktion des Herausgebers für den Bereich Plastische Chirurgie neu besetzt mit Riccardo Giunta aus München. Er übernimmt damit die Aufgabe von Wolfgang Schneider aus Magdeburg, der die Zeitschrift in den vergangenen Jahren als Herausgeber - gemeinsam mit Ulrich Lanz aus Bad Neustadt an der Saale - erfolgreich unterstützt hat und dieses Jahr sein Amt auf eigenen Wunsch in andere Hände übergeben möchte. Herr Schneider wird unserer Zeitschrift aber weiterhin in seiner nun neuen Aufgabe als wissenschaftlicher Beirat verbunden bleiben und unser neues Herausgeberteam unterstützen. Der Bereich Handchirurgie wird weiterhin von Ulrich Lanz als Herausgeber betreut und vertreten.

Background: Management of soft tissue defects of the hand is one of the most challenging issues in hand surgery.

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.

Die neue Operationstechnik der Perforans-Lappenplastik wurde ursprünglich als Weiterentwicklung der muskulokutanen Lappenplastiken mit dem Ziel der Reduzierung des Hebedefektes von Koshima und Mitarb. (1992[5], 1993[4]) beschrieben. Der eigentliche Durchbruch dieser Technik und ihre weltweite Verbreitung gelangen allerdings erst durch die großen Fallzahlen, die in der Rekonstruktion der weiblichen Brust mit der A. epigastrica inferior-Perforans-Lappenplastik (DIEP Flap) erzielt wurden (Allen und Mitarb. 1995[1], Feller und Galla 1998[3], Blondeel 1999[2]).

Der präparatorische Aufwand von Perforans-Lappenplastiken, bei welchen im Gegensatz zu den muskulokutanen Lappenplastiken die Muskulatur intakt und innerviert bleibt, ist erhöht. Häufig kommt es zu postoperativen Durchblutungsstörungen. Ziel der Studie war es festzustellen, ob Risikofaktoren von Seiten der Patienten das Auftreten einer Durchblutungsstörung bei Perforans-Lappenplastiken beeinflussen. Bei 74 Epigastrica inferior-Perforans-Lappenplastiken (DIEP) und 43 Transverse M. rectus abdominis-Lappen-plastiken (TRAM) wurden Gruppen für die Risikofaktoren Alter (>55 Jahre), Übergewicht (BMI>26) und Nikotinabusus gebildet und jede Art einer Durchblutungsstörung prospektiv analysiert. Die statistische Analyse ergab weder bei den muskulokutanen (TRAM) noch bei den Perforans-Lappenplastiken (DIEP) einen signifikanten Unterschied an Durchblutungsstörungen weder bei Patienten mit noch ohne Risikofaktoren. Nikotinkonsum, Übergewicht und erhöhtes Alter sollten daher keine Kontraindikationen für freie Perforans-Lappenplastiken darstellen.

Intra- und postoperative Durchblutungsstörungen sind mit bis zu 40% der Fälle keine Seltenheit und verlangen schnelles und konsequentes Handeln. Ziel der vorliegenden Studie ist es, prospektiv die Ergebnisse, die Verlustraten sowie das Ergebnis einzelner Behandlungsmaßnahmen zu evaluieren. Von Januar 1998 bis Mai 2000 wurden 208 freie Lappenplastiken durchgeführt. Der überwiegende Anteil wurde zur Rekonstruktion der weiblichen Brust angewandt (70%). 28 (13%) dienten der Wiederherstellung der oberen Extre-mität und 30 (14%) zur Defektdeckung an der unteren Extremität. Im Gesamtkollektiv muß-ten 7,2% Totalverluste und 9% Teilverluste hingenommen werden. Die häufigste Maßnahme war die Neuanlage der arteriellen Anastomose (n=21). Bei Patienten bei denen eine Revisionsoperation nötig war (n=32) mußte in 25% der Fälle ein Totalverlust hingenommen werden. Bei Zweit- (40%) und Drittrevisionen (67%) entsprechend höher.

Free-tissue transfer is a standard procedure in hand and other plastic and reconstructive surgery. The aim of the present article was to present a new clinical classification of disturbances of the circulation, and to assess the results of treating the specific complication at each of the stages described.Within a period of 29 months, 194 free microvascular flaps were prepared and evaluated in a prospective study. Postoperative monitoring was carried out from a purely clinical point of view. A distinction was made between arterial and venous circulatory disturbances and, in both cases, four stages were characterized, according to the time required for recapillarization, the color of the transfer, and bleeding on puncture. Complications occurred in 69 cases (36 percent), including intraoperative revisions during a first operation. The ratio of arterial to venous insufficiency was 33:35. In the presence of arterial disturbances of the circulation, the proportion of losses increased in progressive stages to 41 percent. With venous disturbances, losses which occurred in stages 1 and 2 were predominantly partial. In 164 cases (85 percent), the flaps remained undamaged. In 15 cases (8 percent), there was partial loss of the transfer and, in a further 13 cases (6 percent), there was complete loss.The authors' results confirmed that the presented clinical classification is, indeed, a measurement of the severity of circulatory impairment. Despite the relatively high complication rate, the use of various methods of treatment finally led, in the overwhelming majority of cases, to a positive result.

The individual perforating vessels have a high degree of anatomical variation, therefore it is desirable to conduct a careful examination of them before undertaking a perforator flap operation. Because locating the vessels beforehand makes performing the operative procedure much easier, the aim of the present study was to assess the value of using simple acoustic Doppler sonography to plan a perforator flap operation. The vessel examinations were carried out before taking 46 free microvascular flaps from either the lower abdominal wall or the buttock for reconstructive breast surgery. The perforating vessels located were marked, and their position relative to the umbilicus or the most cranial point of the rima ani recorded using a coordinate system. In 40 patients, a perforator flap operation (deep inferior epigastric perforator flap, n = 32; superior gluteal artery perforator flap, n = 8) was actually carried out; in six of these patients, a myocutaneous flap was used because of the insufficient availability of perforating vessels. Before the operation, perforating vessels were marked for each patient, with an average of 7.3 for the deep inferior epigastric perforator flap and 6.5 for the superior gluteal artery perforator flap. Out of 286 vessels marked for later perforator flaps, 162 were identified during the operation. A preoperatively marked vessel was used in 37 of 40 patients. In the remaining patients, a vessel was used that had not been previously marked. The vertical and horizontal distance between the perforating vessels identified during the operation and the preoperative marks averaged 0.8 cm. The results show preoperative Doppler sonography to be useful for locating the position of individual perforating vessels, making it much easier to find them during the operation.

Free tissue transplantation is a routine procedure in reconstructive surgery. Although a lot of free flap techniques have been described, the postoperative management of complications has gained only little interest. Nevertheless, complications of perfusion after free tissue transplantation are not rare and require a systematic approach. The aim of this study is to classify perfusion failures with a simple grading system prospectively on a large clinical series and to evaluate the results of treatment to improve management. In the past ten months, 70 consecutive free flaps have been performed. By the end of the operation, the operating surgeon gave a prognosis concerning the probability of a possible perfusion complication. Postoperative monitoring was done exclusively by clinical examination (colour, time for recapillarisation and bleeding after puncture). According to these parameters, arterial and venous insufficiencies have been classified into four grades. After recording type, time and treatment of a postoperative complication, the result of treatment was rated subjectively and a cause was noted when possible. The final result was classified either as total flap loss, partial flap loss or successful tissue transplantation. A total of 28 (40%) complications, which were treated with an average of 2.1 options, were recorded. The ratio between arterial and venous failure was 15:13. In 21 cases surgical intervention became necessary (intraoperative n = 12, postoperative n = 9). The arising complication was diagnosed correctly in nine cases by the operating surgeon. In ten cases, the cause of the complication remained unclear. In 18 cases, the complication was treated successfully without any flap loss. In six cases partial flap loss was observed and in four cases a total flap loss had to be accepted. Our results confirm that only few objective criteria for treatment options with perfusion failures after free tissue transplantation exist. Nevertheless, the presented classification is a useful tool for standardized evaluation of the results. The various salvage techniques result in positive outcomes for most of the patients.

In contrast to the classical fasciocutaneous and musculocutaneous flaps, perforator flaps are supplied only by a single perforating branch. The aim of this paper is to present the surgical technique and to discuss the use of perforator flaps in hand surgery. Our previous studies have demonstrated the reliability of a preoperative Doppler for planning perforator flaps in reconstructive surgery of the breast: With 286 preoperatively localized perforating branches, a total of 162 were confirmed in intraoperative dissection. In 37 out of these 46 perforator flaps (80%), a preoperatively localized perforating branch could be used. Based on these results, the individual design of perforator flaps harvested on the forearm for defects on the dorsum of the hand is possible. In a preoperative Doppler exam, a perforating branch, i.e. of the posterior interosseous artery, can be localized. The intraoperative confirmation of the perforating branch allows the successful defect coverage with a distally pedicled flap without taking fascia or septum. In our experience, this possibility of planning an individually designed perforator flap is the major advantage for applications of the perforator flap technique in hand surgery. This is especially true in cases where the harvest of a fasciocutaneous flap is unreliable or impossible due to anatomic variations. On the other hand, the dissection of the pedicle is technically demanding and the individual distribution of the perforating branches requires a high degree of flexibility. However, we do consider this new technique to be a further extension in the armamentarium for soft-tissue coverage of the hand.

In our study, we present the data of eleven patients suffering from scarring of the median nerve, predominantly after open decompression of the carpal tunnel. Dysaesthesia in the palmar region and loss of grip strength prevented performing normal daily activities. All patients except one were relieved of the palmar discomfort and experienced an increase of grip strength allowing their return to work. The hypothenar fat flap has been shown to be a reliable source of local tissue to cover the median nerve. The sprouting of nerve fibers to the skin is prevented as well as median nerve readherence. We believe that the hypothenar fat flap provides sufficient regenerative conditions and coverage of the median nerve within the carpal tunnel in the surgical treatment of abundant scarring.

Because of the loss of mobility, scarring of the median nerve in the carpal tunnel can lead to chronic pain syndrome of the wrist joint, with reduced sensation, muscular dystrophy and severe limitation of the use of the hand. This syndrome most often appears following open carpal tunnel release. Nine patients with scarring of the median nerve in the carpal tunnel were treated with a hypothenar fat-pad flap. Eight of them showed a significant reduction in pain, with improved sensation, trophism and strength. The procedure is suitable as a salvage procedure for restoring a sliding pathway and for cushioning the median nerve in the presence of recurrent lesions in the carpal tunnel.