plastische, reconstructieve en esthetische chirurgie - UZ Leuven

PLASTISCHE,RECONSTRUCTIEVE ENESTHETISCHECHIRURGIEBOL L., HIERNER R., VEEKMANN L., VAN DENKERCKHOVE E., GEYSKENS J., VANDERMEERSCH E.:Behandeling van de handen bij epidermolysis bullosa.Tijdschrift voor Geneeskunde, 2005; 61: 929-938.Dystrofische Epidermolysis Bullosa is een zeldzameziekte van de huid en mucosa die wordt gekenmerktdoor het ontstaan van blaren na minimale traumata.Wondheling gaat gepaard met littekenvorming. Vanwegehet continue gebruik gedurende het dagelijks leven zijnmet name de handen blootgesteld aan traumata.Repetitieve episodes van blaarvorming, ulceratie enlittekenvorming leiden tot ernstige deformiteiten metfunctionele beperkingen als gevolg. Het uiteindelijkeresultaat is de ‘cocon-hand’, waarbij er een volledigfunctieverlies optreedt met ernstige gevolgen voor denormale psychomotorische ontwikkeling van het kind.Tot op heden bestaat er geen curatieve therapie.Wanneer handmisvormingen met functionelebeperkingen optreden, is een chirurgische reconstructiegeïndiceerd. Doorgaans worden de resterendehuiddefecten na het vrijzetten van de vingers bedekt metautologe huidgreffen, doch er zijn ook alternatievemethoden. Bovendien wordt chirurgie bemoeilijkt doortechnische en anesthesiologische problemen. Alvorenstot een operatie te komen, dient men zich eerstvoldoende vertrouwd te maken met de problematiekeigen aan deze ziekte.Postoperatief bestaat de zorg voornamelijk uit preventievan recidieven door middel van een perfecte wondzorg,intensieve fysiotherapie en splinting. Omdat hetziekteproces na chirurgie echter onverminderd doorgaat,is het belangrijk de ouders en het kind duidelijk te makendat herhaalde ingrepen in de toekomst waarschijnlijkzijn.DELAERE P., HIERNER R., VRANCKX J., HERMANS R.:Tracheal stenosis treated with vascularized mucosa andshort term stenting. The Laryngoscope, 2005. 115(6): 1132-1134.Segmental tracheal resection with end-to-endanastomosis is the treatment of choice for a stenosisencompassing less than 50% of the tracheal length. Theadvantage of a tracheal resection is that no graft is

necessary and that there is no need for prolongedendotracheal intubation. Augmentation of the tracheallumen by inserting local, regional, or distant tissue isnecessary when a tracheal resection is not possible as,for example, in long-segment stenosis or in cases ofrestenosis after tracheal resection. Trachealreconstruction by using repair tissue is a second choicesolution because the optimal repair tissue is notavailable. The most frequently used reconstructivetissues consist of cartilage grafts, pericardium, andmuscle flaps (used as a carrier for skin, periosteum, orbone). Results obtained with these reconstructive tissuesare not constant because they all lack one or morerequirements for optimal tracheal repair. Experimentalevaluation showed that optimal laryngotracheal repairshould resemble the native tracheal tissue as closely aspossible and be composed of a cartilaginous support, aninternal lining consisting of respiratory mucosa, and areliable blood supply. These tissue characteristics maybe found in revascularized tracheal allo- and autografts.Tracheal allo- and autotransplants are, however, notavailable when dealing with tracheal restenosis or longsegmentstenosis.In previous animal experiments, we looked forautologous tissue matching the optimal tissue as closelyas possible. Composite tissue consisting of vascularizedfascia (blood supply), buccal mucosa (internal lining),and elastic cartilage (support) was found to closelymatch vascularized tracheal transplants. Flapprefabrication was, however, a requirement to allow forhealing of the cartilage component because barecartilage underwent necrosis when directly exposed tothe airway lumen. Composite tissue consisting ofvascularized fascia and mucosa could be used in a onestageprocedure. Vascularized mucosa can repair airwaydefects with primary healing of the reconstructed site.Expansion of the airway lumen will be less pronouncedbecause the cartilaginous supportive component is notavailable. Although support is not available, vascularizedfascia lined with buccal mucosa can succeed in solvingdifficult to treat airway stenosis. It is used here incombination with short-term airway stenting and isillustrated in a case of restenosis after segmentalresection.DELAERE P., VANDER POORTEN V., VRANCKX J.,HIERNER R.: Laryngeal repair after resection of advancedcancer: an optimal reconstructive protocol. Eur. Arch.Otorhinolaryngol., 2005; 262(11): 910-916.Tracheal autotransplantation allows for reconstruction ofextended hemilaryngectomy defects after resection oflaryngeal cancer. With this technique, optimal functionalresults were obtained after a learning curve of more than50 patients. The objective of this paper is to present thefinal reconstructive concept with the typical indications.

Unilateral glottic cancer and lateralizedchondrosarcomas of the cricoid cartilage are resectedwith a hemilaryngectomy including one-half of the cricoidcartilage. After tumor resection, a radial forearm flap witha skin paddle and a fascial paddle are taken. The skinpaddle restores the laryngeal defect temporarily, and thefascial paddle wraps the upper 4 cm of cervical trachea.A 'tracheostomy' is preserved in the area between thereconstructed larynx and the fascia-wrapped trachea.The radial forearm vessels are sutured to the neckvessels. After 4 months, the skin island of the radialforearm flap is removed from the defect and therevascularized, fascial enwrapped trachea istransplanted to the laryngeal defect. The trachealcontinuity is re-established with preservation of atracheostoma. The tracheotomy can be closed after 6weeks. Two case reports are presented: a unilateral T3glottic cancer and a chondrosarcoma of the cricoidcartilage. The two patients showed normal oral feeding 1week after the operation. Hand-free speaking waspossible after closure of the tracheostomy. Trachealautotransplantation after vascular induction of thetrachea with the radial forearm flap leads to optimalrepair of extended hemilaryngectomy defects.HIERNER R.: Operative treatment of pressure sores: howand when? J. Wound Healing, 2005; 10: 110-123.Pressure sores still presents a challenging problem ofdiagnosis and choice of treatment. Nowadays defectclosure alone is not sufficient to fulfil the criteria ofsuccessful defect reconstruction, which are as follows: 1)complete wound closure, 2) persistent wound closure, 3)functional reconstruction allowing early mobilization, 4)acceptable length of time for rehabilitation (and return tonormal life), and to a lesser degree 5) acceptableesthetic result. Successful treatment requires a globaltherapy concept based upon: 1) basic (plastic) surgicalprinciples, 2) defect-related factors, 3)- therapy relatedfactors, and 4) patient-related factors. The global therapyconcept is delivered by a multidisciplinary therapy-team(surgeon, nurse staff, physiotherapist, occupationaltherapist, social service...).HIERNER R., BECKER M., BERGER A.: Indications andresults of operative treatment in birth-related brachialplexus injuries. Handchir. Mikrochir. Plast. Chir., 2005; 37:323-331.Introduction: A review of the literature reveals that underconventional treatment alone or in combination withsecondary muscle/tendon transfer about 4 to 43% ofcases show incomplete recovery with severe functionaland/or aesthetic impairment. If those patients underwentearly microsurgical brachial plexus revision aregeneration without any significant functional and/or

aesthetic impairment could be achieved in 80 - 90% ofcases. Moreover microsurgical reconstruction of thebrachial plexus does increase the possibilities ofsecondary muscle/tendon transfers.Material and method: Our concept is based on ourexperience with more than 1700 presenting a brachialplexus lesions between 1981 and 2000 treated in ourinstitution. Patient selection is done according astandardized algorithme which is presented. There were418 obstetrical brachial plexus lesions. 189 could betreated conservatively. In 225 cases an operativetreatment was necessary. 104 cases underwent earlyrevision of the brachial plexus and secondary tendontransfer was done in 121 patients.Results: Personal results and an analysis of the literaturereveal that in C5/C6 lesions good shoulder function canbe achieved in 60-80%, especially if the accessory nerveis routinely used. Good elbow function can be expectedin over 90%. In C5/C6/C7 lesions there are only slightlyinferior results. In both groups there is a significantfunctional improvement by secondary tendon transfer atthe age of 2 - 3 years. In rare C5 - Th1 lesions thefunctional results depend on the number and quality ofthe remaining roots.Summary: Provided good patient selection, severeobstetrical brachial plexus injuries should be scheduledfor early microsurgical revision. There is no need to waitfor a frustrating spontaneous recovery.HIERNER R., BERGER A.: Ergebnisse der nervalenWiederherstellung der Ellenbogenbeugung nach Läsiondes Plexus brachialis. Handchir., Mikrochir., Plast. Chir.,2005, 37; A1-A12.Einleitung: Die Wiederherstellung der aktivenEllenbogenbeugung ist eins derHauptrekonstruktionsziele bei der Therapie vonLäsionen des Plexus brachialis. Die intraplexuelle„anatomische“ Reinnervation stellt die Therapie der 1.Wahl dar. Für die extraplexuelle Neurotisation des N.musculocutaneous stehen mehrere Axonspender zurVerfügung: N. XI, N. phrenicus, N. ulnaris, Nn.intercostales, N. pectoralis lateralis, kontralaterale C7-Wurzel.Material und Methode: Bei 100 Patienten mit einerNeurotisation des N. Musculocutaneus und einemNachbehandlunbgszeitraum von mehr als 3 Jahrenwurden aktive Ellenbogenbewegung (Neutral-0-Methode), die Kraft der Ellenbogenbeugung (MRC-Klassifikation) und die Geschwindigkeit der funktionellenReinnervation gemessen. Bei 50 Patienten erfolgte eineintraplexuelle Neurotisation von den Wurzeln C5und/oder C6, bei den restlichen 50 eine extraplexuelleNeurotisation von verschiedenen Axonspendern aus. Bei12 Patienten erfolgte eine spino-humerale Neurotisation(1/2 N. XI + Nerventransplantat), bei 3 Patienten erfolgteeine direkte Neurotisation des anterolateralen anteils desTruncus superior mit den N. phrenicus, bei 10 Patienten

erfolgte ein direkter Intercostalistransfer mit 3Interkostalnerven, bei 20 Patienten eineIntercostaltransfer mit 3 Interkostalnerven +Nerventransplantat, bei 3 Patienten erfolgte eine direkteNeurotisation des motorischen Anteils des N. MC mithilfeeines Faszikels des N. ulnaris (Oberlin-Transfer) und bei2 Patienten wurde ein contralateraler C7-Transfer(kompletter dorsaler anteil + vask. N. ulnaris)durchgeführt.Ergebnisse: Nach intraplexueller Neurotisation konnteeine funktionelle aktive Ellenbogenbeugung (> 90°, M3+) bei 45 von 50 Patienten erreicht werden. DieErgebnisse nach extraplexueller Neurotisation könnenwie folgt dargestellt werden: Spino-humeraleNeurotisation 9/12, phrenico-humerale Neurotisation 2/3,direkter Interkostalistransfer 7/10, Interkostalistransfer +Nerventransplantat 14/20, Oberlin-Transfer 3/3,kontralateraler C7-Transfer 3/3. Die Reinnervation nachOberlin-Transfer zeigte bereits nach 4 Monaten klinischsichtbare Muskelkontraktionen.Diskussion: Erst durch die aktive Ellenbogenbeugungsind bimanuelle Tätigkeiten möglich. Im Rahmen derVersorgung von Plexus brachialis-Läsionen mit einen„integrativen Therapie-Konzept“ sollte dieWiederherstelung der aktiven Ellenbogenbeugung auchbei kompletten Läsionen möglich sein. Eineausreichende Anzahl von Axonen, sowie eine guteMuskelfunktion vorausgesetzt, kann mit einer nervalenWiederherstellung der aktiven Ellenbogenbeugung in 60- 90% der Fälle gerechnet werden. Wenn immer möglichsollte eine „anatomische“ intraplexuelle Neurotisationdurchgeführt werden. Für die extraplexuelleNeurotisation haben sich in letzer Zeit vor allem der N.ulnaris und der N. phrenicus bewährt. Wegen desgeringen Spenderdefektes und der schnellerenReinnervation sollte der „Oberlin-Transfer“ - wennmöglich - bevorzugt eingesetzt werden.HIERNER R., BERGER A.: Long-term results after total andsubtotal macroamputation at the upper extremity. Eur. J.Plast. Surg., 2005: 119-130.Using our personal series of 65 patients operatedbetween 1981 and 1993 (upper arm: n = 18, proximaland middle forearm: n = 32, distal forearm and wristlevel: n = 15) and the results of an extensive literaturereview the following criterias were evaluated; 1) survivalrate, 2) possible individual motor and sensory functionsof the extremity, 3) global upper extremity functionjudged according to Chen`s classification, and 4)socioeconomic aspects, and 5) number and nature oflocal and/or systemic complication and subjectivejudgment by the patient. The survival rate of upper limbreplantation, which only means perfect restoration ofviability is about 76 to 92,3%. With the amputation levelgoing distally there is an increase of individual motor andsensory functions of the "functional chain upperextremity". Taking grade I and II results together a

„functional extremity“ can be reconstructed at the upperarm level in 22 to 34%, proximal forearm level 30 to 41%and distal forearm level 56 to 80%. All patients neededat least 2 secondary operative procedures. 5 of 65patients were reamputated because of postoperativecomplications. As the functional results after replantationare at least equal (proximal level) or even far superior(distal level), some protective sensibility at the hand canbe expected even at the most proximal levels, and themissing psychological impairment caused by missingbody integrity, reconstruction should be carried out ifpossible, reasonable with regard to the expectedfunction, estimated of low risk for the patient anddesired. The higher cost and amount of operationsneeded, as well as the longer postoperative care andlonger time of disability after replantation are justified bya significant increase in life quality.HIERNER R., BETZ A., POHLEMANN T., BERGER A.: Longtermresults after lower leg replantation – does the resultjustify the risks and efforts? Eur. J. Trauma, 2005; 4: 389-398.Although subtotal and total lower leg amputation havebeen successfully replanted in the past, nowadays thereis a common opinion that "these replantations do notjustify their efforts, and therefore the patients shouldundergo primary amputation". In order to clarify thishypothesis we carried out a retrospective clinical study ofour personal cases operated on between 1981 – 1998and an extensive literature research. The followingcriteria were evaluated 1) survival rate, 2) individualmotor and sensory functions and global lower extremityfunction judged according to the classification of CHEN,3) socioeconomic aspects (operation time, number ofoperations per patient, time of hospitalization, return tonormal life), 4) number and nature of local and/orsystemic complications and 5) subjective judgment bythe patient.All replanted lower legs in our series survived. UsingCHEN`s classification the functional results can be givenas follows: Stage I 64,2%, Stage II 28,5% (thus a"functional extremity" could be reconstructed in 92,7%),stage III 7,1% and stage IV 0%. Social reintegration wasachieved within 8 to 10 months after replantation. 4 to 7secondary operations were carried out in every patient inorder to improve the result. Total duration of therapy took28 to 48 months. There were no secondary reamputation.Using our personal algorithm, on the one hand there is asignificant decrease in replantation frequency (30% of alltransferred cases in our replantation centre). However,on the other hand those cases replanted show betterfunctional and aesthetic results and a significant lowerreplantation risk. Our results as well as those of otherlarge series show that lower leg replantation is stillworthwhile in a well selected patient group, contrary towhat is believed by an increasing number of orthopaedic

and trauma surgeons.HIERNER R., DEGREEF H.: Indikationen und Ergebnisseder Hauttransplantation bei chronischen Wunden: Das“dermato-plastische Therapiekonzept”. Medireport, 2005,29.Einleitung: Die Hauttransplantation stellt bei chronischenUnterschenkelwunden oft die noch einzig möglicheTherapie dar. Im Kontext der Therapie chronischerWunden kann die Hauttransplantation als unterstützendeMassnahme der Epithelialisierung des Wundgrundesangesehen werden. Wundschluss bedeutetInfektionsprophylaxe und verminderter Verlust vonKörperflüssigkeit. Für den klinischen Gebrauch hat sichdie Einteilung der Hauttransplantate in Abhängigkeit vonder Transplantatdicke (Spalthaut/Vollhaut), Geometrie(Punch, Mesh, Sheat), Art (Eigen = autolog/Fremd =allogen und heterogen), Natur (biologisch/artifiziell) undTransplantationstechnik bewährt.Material und Methode: In einer retrospektiven klinischenStudie wurden 50 Patienten der interdisziplinärendermato-plastischen Sprechstunde mitHauttransplantation bei Ulcus cruris nachuntersucht. Eshandelte sich um 36 Frauen und 14 Männer. Im Altervon 47 – 92 Jahren. Untersuchungskriterien waren: 1)Art und Anzahl von operativen Eingriffen, 2)Wundheilung, 3) Art und Anzahl von Komplikationen, 4)Erneutes Auftreten eines Ulcus cruris imOperationsgebiet und 5) subjektivePatientenzufriedenheit.Ergebnisse: Insgesamt wurden 117 operative Eingriffedurchgeführt (69 Wundbettkonditionierung, 56 autologeHauttransplantationen, 2 Unterschenkelamputationen).Bei 30 Patienten konnte eine primäre, bei 14 Patienteneine subtotale und bei 4 Patienten eine partielleWundheilung erzielt werden. Bei 4 Patienten trat imSpendergebiet eine behandlungsbedürftige Infektion auf.Im Empfängergebiet kam es bei 2 Patienten zu einerNachblutung und bei 6 Patienten zu einer Infektion.Nach kompletter Abheilung des Ulcus trat ein Rezidiv imOperationsgebiet nach einem Jahr bei 11 und nach 2Jahren bei 26 Patienten auf. Die subjektivePatientenzufriedenheit wurde von 18 Patienten mit sehrgut, 17 mit gut, 11 mit befriedigend und 4 mit schlechtangegeben.Schlussfolgerungen: Autologe und allogeneHauttransplantate können erfolgreich bei derBehandlung chronischer Wunden imUnterschenkelbereich eingesetzt werden. Erfolgt dieBehandlung im Rahmen einer interdisziplinärenVersorgung, können Komplikationen bei derTransplantatennahme und fixierung, sowie derWundbettkonditionierung, Nachbehandlung undPrävention deutlich verringert werden. Im Rahmen derWundbettkonditionierung hat sich die allogenenHauttransplantation als Indikator für die Qualität desWundbettes bewährt. Die autologe Hauttransplantation

stellt eine palliative, nicht kurative Therapiemassnahmedar. Das Risiko eines „Wundrezidivs“ ist abhängig vonder Behandlung der Ulcusursache und dem Einsatzmöglicher weiterer symptomatischer Therapien (z.B.Kompressionstherapie…).HIERNER R., DEGREEF H., VRANCKX J.J., GARMYN M.,MASSAGE P., VAN BRUSSEL M.: Skin grafting and woundhealing – the “dermato-plastic team approach”. Clin.Dermatol., 2005; 23: 343-352.Autologous skin grafts are successfully used to closerecalcitrant chronic wounds especially at the lower leg. Ifwound care is done in a dermato-plastic team approachusing the „integrated concept“, difficulties associatedwith harvesting the skin graft, as well as the complexitiesassociated with inducing closure at the donor and therecipient site can be minimized.In the context of wound healing, skin transplantation canbe regarded as 1) a supportive procedure forepithelialization of the wound surface and 2) mechanicalstability of the wound ground. By placing skin grafts on asurface, central parts are covered much faster withkeratinocytes. Skin (wound) closure is the ultimate goal,as wound closure means infection resistance.Depending on the thickness of the skin graft, differentamount of dermis are transplanted with the overlyingkeratinocytes. The dermal component determines themechanical (resistance to pressure and shear forces,graft shrinkage), functional (sensibility) and aestheticproperties of the graft. Generally speaking, the thickerthe graft the better the mechanical, functional andaesthetic and properties however, the worse its neoandrevascularization.Skin grafts do entirely depend on the re- andneovascularization coming from the wound bed. If thewound bed is seen as a recipient site for tissue graftLEXER`s classification turned out to be of extremevalue. Three grades can be distinguished „good woundconditions“, „moderate wound conditions“, and„insufficient wound conditions“. Given “good woundconditions” skin grafting is feasible. However skinclosure alone might not be sufficient to fulfil the criteria ofsuccessful defect reconstruction. In case of „moderate“or „insufficient wound conditions“ wound bedpreparation is necessary. If wound bed preparation issuccessful and “good wound conditions” can beachieved, skin grafting is possible. If, however thisattempt is unsuccessful and “moderate” or “inadequatewound conditions” are persisting, other methods ofdefect reconstruction such as, local flap transfer, distantflap transfer, free (microvascular) flaps and ultimatelyamputation must be considered.HIERNER R., MATTHEUS H., VAN DEN KERCKHOVE E.:Recommendation for a standardised differential

diagnostic, therapy, and documentation of post-traumaticbrachial plexus lesions. Zeitschrift für Physiotherapeuten,2005; 57: 1668-1675.A review of the literature on therapy of posttraumaticlesions of the brachial plexus there is a largediscrepancy regarding the outcome after surgicalreconstruction of the brachial plexus lesions in adults.One reason for the large discrepancy of the givenoutcomes, besides of the variety of the injury pattern, isdue to the deficient standardized evaluation anddocumentation.Aims of the here presented scheme for clinicalexamination and documentation are internationalcomparability with the meaning of a “common language”and standardized recording and documentation ofimportant findings concerning the therapeuticalprocedure.The “PLEXUS EVALUATION SYSTEM” (PES) wasdeveloped in order to optimize the treatment and tocreate an internationally comparable documentation oftherapeutical relevant findings.

HIERNER R., PEETERS W., REYNDERS P.: Simultaneousfree flap transfer in total knee arthroplasty in case ofinsufficiënt soft tissue prior to prosthetic implantation:indications and results. In: Proceedings of the 3rd congressof the world society for reconstructive microsurgery. Eds.: G.Loda, Monduzzi Editore, Milano, 2005: 35-46.Background: The purpose of this paper is to show ourpersonal experience with simultaneous free flap transferin total knee arthroplasty in case of insufficient softtissue prior to prosthetic implantation.Material and Methods: In retrospective clinical study 11patients who underwent simultaneous flap surgery in thecontext of total knee arthroplasty because of insufficientsoft tissue prior to implantation are reviewed. In 10patients a free myo-cutaneous latissimus dorsi flap andin 1 patient a pedicled medial gastrocnemius muscle flapin combination with a split thickness skin graft werecarried out. In a retrospective clinical study, thefollowing criteria were examined: 1) etiology of softtissue defect, 2) number of previous operations, 3) statusof the knee extensor mechanism judged as complete,partial, missing, 4) primary wound healing, 5)complications and 6) active range of motion.Result: Primary wound healing could be achieved in 6patients with a free myocutaneous latissimus dorsi flapand in the only patient with a pedicled medialgastrocnemius muscle flap. After free latissimus dorsitransfer skin breakdown of the recipient site occurred in4 patients. Secondary skin grafting was carried out in 3patients and a fascio-cutaneous flap in the remaining.Average active range of motion prior to combinedsurgery was for extension/flexion 0-7-27°. One year aftersurgery the average active ROM was 0-7-82°.Conclusions: A free flap transfer is indicated for defectswhich cannot be covered by a pedicled medialgastrocnemius flap. Free latissimus dorsi transfer makesprosthesis implantation possible, avoids a postoperativeknee stiffness because of soft tissue and/or scarconstriction, shows a low rate of severe complications inpatients with high risk of wound healing problems, andlead to an adequate, painless global knee function.Moreover, transfer of well vascularized tissue willimprove trophicity at the knee region, and makes futureoperations at this region possible.HIERNER R., VAN DEN KERCKHOVE E.: Ergebnisse derulno-dorsalen Lappenplastik nach interfaszikulärerNeurolyse des N. medianus im Handgelenksbereich.Handchir., Mikrochir., Plast. Chir., 2004.Einleitung: Mehrfache Revisionseingriffe aufgrundpersistierender Beschwerden am N. Medianus führen zueiner zunehmenden Fibrosierung des Gewebes um denNerven – Lager – und im Nerven selbst. Trotz technischeinwandfrei durchgeführter mikrochirurgischer Operationkann vor allemdie überempfindlichkeit im palmarenHandgelenksbereich oft nicht ausreichend beseitigtwerden.

Material und Methode: Im Zeitraum von 1995 – 2002haben wir bei 5 Patienten mit rezidivierendenKompressionsbeschwerden des N. Medianus imHandgelenksbereich eine interfaszikuläremikrochirurgische Neurolyse in Kombination mit einergestielten ulno-dorsalen Fett-Faszienlappenplastik nachBECKER/GILBERT durchgeführt. Es handelt sich um 4Frauen und einen Mann im Alter von 36 – 55 Jahren. Beiallen Patienten wurden vor dieser Operation mindestens4 (4 – 7) Eingriffe durchgeführt. Untersuchungskriteriender retrospektiven Studie waren 1) Schmerzen(Analogskala 0 – 10), 2) Sensibilität (2PDs°, 3) aktiveund passive Gelenkbeweglichkeit (Neutral-à-Methode),4) Grob- und Pinchgriff im Seitenvergleich (JAMAR,PINCHMETER° und 5) subjektive Bewertung desSpenderdefektes am Unterarm durch den Patienten(sehr gut, akzeptabel, schlecht). DerNachuntersuchungszeitraum betrug mindesten 18Monate.Ergebnisse: Bei allen Patienten konnte eine deutlicheVerminderung der Schmerzen von durchschnittlich 7/10(starke Dauerschmerzen und zusätzlicheSchmerzmedikation) auf 4/10 (intermittierende mässigeSchmerzen, keine zusätzliche Schmerzmedikation)erreicht werden. Eine Veränderung der Sensibilität undder aktiven und passiven Gelenkbeweglichkeit nach derOperation konnte nicht gefunden werden.Postoperationem kalm es zu einer Verbesserung derKraft für den Grobgriff von durchschnittlich 14 kg auf 20kg. Der Spenderdefekt am Unterarm wurde von allenPatienten als akzeptabel bezeichnet.Schlussfolgerungen: Durch die Kombination dermikrochirurgischen interfaszikulären Neurolyse mit derulno-dorsalen Lappenplastik wird erreicht: 1) einedeutlich bessere Vaskularisation im Nervenlager, 2) eineVerbesserung der Vaskularisation in neurolysiertenNerven, 3) eine zusätzliche „Abpolsterung“ desneurolysierten Nervens. Dies führt zu einer deutlicheErgebnisverbesserung, aber nicht zu einer völligenBeschwerdefreiheit der Patienten.PETRIE N.C., VRANCKX J.J., HOELLER D., YAO F.,ERIKSSON E.: Gene delivery of PDGF for wound healingtherapy. J. Tissue Viability, 2005. 15(4): 16-21.Gene therapy is an approach to modifying host cells toexpress a therapeutic protein by transfer of geneticmaterial through a variety of techniques. Early studies ofcandidate disease states amenable to such therapyfocused on congenital conditions involving thepermanent mutation of a gene. However, gene therapytechniques may also be of benefit in temporaryconditions, such as impaired healing, where the shortageor lack of a specific protein contributes to the aetiology ofthe problem.Platelet-derived growth factor (PDGF) is one of the firstcytokines released in response to injury and is thereforean obvious candidate for development as a therapeutic

agent. Advances in cloning technology have enabledexpression of a recombinant PDGF, which hassubsequently been applied as an exogenous treatment ina number of animal models. Despite the inefficiency ofexogenous growth factor delivery, these studiesdemonstrated proof of concept that PDGF was able toinfluence wound healing favouraby and provided aplatform from which to launch strategies to deliver PDGFmore efficiently by gene therapy.VERHELLE N., VRANCKX J., VAN DEN HOF B., HEYMANSO.: Bone exposure in the leg: is a free muscle flapmandatory? Plast. Reconstr. Surg., 2005; 116(1): 170-177.Background: In lower leg defects with bone, hardware, orarticular exposure, a free tissue transfer is often the onlyvaluable option. However, in well-selected clinical cases,pedicled flaps are still indicated because they provide analternative for the more demanding and riskymicrosurgical procedure. The medial adipose-fascial flapof the leg represents an ideal local regional fascial flap.Methods: Twenty-two medial adipose-fascial flaps(performed in 21 patients) were reviewed retrospectivelyand compared with a series of 22 free gracilis flaps (22patients) selected out of 150 muscular free flaps forlower leg reconstruction. All patients with defects largerthan 40 cm, peripheral vascular disease, deep defects,and osteomyelitis were excluded in order to obtain thesame surgical indications in which the local medialadipose-fascial flap could have been used.Results: The overall surgical results were comparable,but more medical complications, a longer operative time,and a longer hospital stay were seen in the free musclegroup. Moreover, patients reconstructed with a medialadipose-fascial flap appeared to be more satisfied withthe aesthetic result of their reconstruction.Conclusions Muscle coverage is not mandatory to coverbone in the lower leg. The medial adipose-fascial flapcan provide a good alternative for free flap coverage.This flap seems to have fewer medical complications,requires a shorter operative time and hospital stay, andcan provide better aesthetic results than a free muscleflap.VRANCKX J.J., YAO F., PETRIE N., AUGUSTINOVA H.,HOELLER D., VISOVATTI S., SLAMA J., ERIKSSON E.: Invivo gene delivery of Ad-VEGF121 to full-thicknesswounds in aged pigs results in high levels of VEGFexpression but not in accelerated healing. Wound RepairRegen., 2005; 13(1): 51-60.We have previously reported that endogenous vascularendothelial growth factor (VEGF) concentration in olderpig wounds peaked later and at one-fourth the level ofyoung pigs. These data suggested that VEGF might playa major role in the healing of full-thickness wounds in the

aged pig. By in vivo gene transfer using themicroseeding technique, we treated full-thicknesswounds with different doses of VEGF-expressingadenoviral vector (Ad-VEGF) varying from 1 x 10(7) to2.7 x 10(11) particles per wound (ppw). We found thatthe VEGF expression in wound fluid followed a doseresponsepattern. However, when wounds weremicroseeded with the highest concentration of Ad-VEGF(2.7 x 10(11) ppw), diminished healing rates were found.We then determined the minimal functionalconcentrations of Ad-VEGF. We used five aged Yucatanminipigs, all retired breeders, to analyze the role of overexpressionof 1 x 10(8) and 1 x 10(9) ppw of Ad-VEGF(n= 78) in terms of healing of full-thickness wounds, all2.5 x 2.5 x 1 cm in size (n= 158). The Ad-VEGF solutionswere delivered to the wound floor and borders by in vivomicroseeding. Control wounds (n= 80) weremicroseeded with Ad-Lac-Z (n= 25), treated with saline(n= 49) or treated dry (n= 6). All wounds except for thedry-treated ones were covered with a wound chamberand a wet environment was created by injecting 2.5 mlsaline into the chamber. Peak VEGF expression (2300-4000 pg/ml) was detected on days 2 or 3 post genedelivery. This level of VEGF expression was not seen inthe saline (n= 49) or Ad-null (n= 25) control groups. TheVEGF expression in wounds treated with 1 x 10(8) and 3x 10(8) ppw (n= 39) exhibited a slower onset with a peakconcentration of 400-920 pg/ml on days 5-7. Althoughhigh levels of VEGF expression were achieved in thelocal wound environment, we could not show asignificant increase in neovascularization as comparedto saline-treated wounds. No significant differences wereobserved in the rate of reepithelialization and woundcontraction among groups of full-thickness woundstreated with Ad-VEGF, Ad-null mutant, or saline in theaged "wet wound healing" pig model. These resultsindicate that increased levels of VEGF in woundsproduced by in vivo gene transfer have little effect on thehealing of full-thickness wounds in the aged pig model.Moreover, significantly higher levels of VEGF expressionby Ad-VEGF could lead to impaired wound healing.