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Defects at the dorsum or tip of the nose are a special challenge for plastic surgeons. Considering the tough skin, primary closure is normally not possible. As full-thickness skin grafts are not satisfactory, we strive for defect-coverage using adjacent skin. One possibility is the bilobed flap which can be used all over the body. Indications, special planning, and technique as well as several variations of the bilobed flap in the nasal region are discussed.

The extensor apparatus of the fingers is a complex structure. The diagram of the extensor apparatus as seen in figure 1 is in reality not so clearly structured. Closed lesions are the mallet finger, where either an avulsion of the bony insertion of the tendon occurs or where a fracture of the base of the distal phalanx with dislocation of a bone-fragment together with the tendon insertion has happened. Other closed lesions are the closed Boutonnière deformity and the avulsion of a lumbrical muscle. The mallet finger is mostly treated conservatively with a prefabricated splint holding the DIP-joint in extension or with a temporary arthrodesis with a Kirschner-wire blocking the DIP-joint in extended position. If bigger pieces of bone are extruded from the base of the terminal phalanx this fragment must be fixed operatively. Today, very fine screws are often used. Also in these cases, a temporary arthrodesis may be helpful. This treatment lasts for 7 weeks. Afterwards for another two weeks the DIP-joint should be immobilised with a Stack-splint during the night. In the Boutonnière deformity the PIP-joint is in flexion and the DIP-joint in hyperextension. The reason is a lesion of the central extensor tendon over the PIP-joint with anterior dislocation of the lateral bands of the interosseus tendon. In early cases by stretching the finger passively the lateral band will be repositioned. In these cases, a conservative treatment with a splint holding the PIP-joint in extension may be successful. This can be combined with revision and suturing of the ruptured part.(ABSTRACT TRUNCATED AT 250 WORDS)

For the reconstruction of the nostril a nasolabial flap is recommended. According to the method of Pers (1967), the upper part of the flap is used for lining and the lower part for the outside coverage of the defect. In order to avoid lateral traction on the nostril, the author recommends that a small triangular flap with an inferior pedicle is left between the nasolabial flap and the nostril. For total reconstruction of the nose, a frontal flap with a primary cantilever bone graft as described by Millard (1966) is suggested. We advise to take one half of forehead skin. This gives a less obvious donor site and enough length in the diagonal direction for the dorsum of the nose and the columella. For the leprotic nose it is emphasized that no skin loss is present, there is only a loss of lining and support. In all advanced cases a large septal defect is encountered. The reliable postnasal inlay of Gillies is mentioned but the draw back to this method is that the care of the postnasal prosthesis may be difficult for leprosy patients with disabled hands. Secondary bone grafting after this procedure has a high failure rate because of infection. For these reasons the reconstruction of lining by two nasolabial flaps according to Farina (1957) is described. The author has regularly used this method with a primary cantilever graft. A modification is again suggested. A small triangular skin flap is raised with the ala, thus avoiding lateral traction on the nostrils after closure of the donor site.

Microsurgery will in the future play a definite role in the treatment of hand injuries not only for nerves but also for small vessels. With this in mind, it is shown how in a comparatively small team a microsurgical service for emergencies can be organized. Essential is the possibility to learn and train on small animals in a microsurgical laboratory. It is advocated to have a laboratory technician in charge of the laboratory who is specially trained in microsurgery and acts as a permanently available teacher. It is shown how continuity of the team capacity can be improved. This is done by combining the experience of a hand surgeon, who for one reason or another has only limited skill in microsurgery, with younger members who are well-trained in this field. Occasionally the laboratory technician may be incorporated, which is acceptable because he only performs vessel anastomoses.

1st. With the aid of an abdominal or an inguinal flap it is possible to reconstruct a finger with sensibility by transporting islands of palmar skin with the corresponding nerve to any amputation stump of the hand. At least three operations are necessary. Parts of bones, joints and tendons may be included in the transported part from the hand. 2nd. These digits are rather bulky. Mobility depends on the preserved joints. 3rd. This method should only be used for thumb reconstruction or to achieve a simple two digit grip. 4th. In children growth of transported bones remains undisturbed.

Assuming that in nerve suture all proximal nerve fiber ends are connected to distal nerve fiber ends the mathematical probability of useful connections in a mixed nerve is evaluated. A connection between two motor fiber ends or between two sensory fiber ends is regarded as useful, whereas a connection between one motor end one sensory end is useless. It can be demonstrated, therefore, that the number of fiber ends, i. e. sensory or motor, which pre-dominate have the better chance for useful connections.

The purpose of this paper is to show a case in which we felt at the end, that the chosen procedure did not fulfill our expectations and in which an alternative procedure would have been preferable. In a 47 year old woman a deep, healed soft tissue defect between the left trochanter and the iliac crest was built up with a free latissimus dorsi musculocutaneous flap. The original plan was to suture the vessels to the gluteal vessels and the nerve to the gluteal nerve. The muscle would have been placed in such a way that the muscle fibres would run from the iliac crest to the trochanter to replace the lost gluteal muscle. This plan was proved on a cadaver dissection. In reality, however, the local vessels were not suitable in size. The flap vessels had to be attached directly to the femoral vessels in the groin area. The flap had, therefore, to be orientated in a different way. The final result gave an insufficient correction of the contour with no functional correction. It was felt in retrospect that contour correction without functional correction would probably have been better performed with an inferior rectus femoris musculocutaneous free flap.

In cases of digital replantation distal to the DIP-joint the sequence of steps in the operation procedure has to be changed, compared with replantation in more proximally situated amputations: the arterial microanastomosis has to be carried out before skeletal fixation. In a few case reports the success of this method but also the failure and an alternative method (double neurovascular VY-plasty) are described.

Equipment and organization of an experimental microsurgical laboratory in a plastic and reconstructive surgery unit of a large size central hospital (Kantonsspital Aarau, Switzerland) are described. A specially trained technician supervises the laboratory and demonstrates technical details of microsurgical sutures to beginners. In addition to clinical work such regular laboratory training is important for all residents.

In order to investigate late results in cases with mamma-augmentations, we have controlled cases which have been operated between 1970 and 1980. From a total number of 70 cases 34 have appeared for control. In spite of the problems of capsular contracture the interest for mamma-augmentation has rather increased during this period of time. We have mainly used 3 types of implants: 1. gelfilled silicon prosthesis, 2. inflatable prosthesis, 3. gelfilled prosthesis with polyurethan coating (Aeshly). In most of the inflatable prosthesis (5) spontaneous perforations occurred so that they had to be exchanged. In 41 cases a simple augmentation was performed. Out of these 16 have been controlled. In 4 cases an augmentation was combined with mastopexy. All of these appeared for control. 13 out of 17 cases of subcutaneous mastectomy with augmentation mammaplasty were controlled. In all cases of subcutaneous mastectomy the prosthesis were placed retropectoral. In 18 cases the prostheses were exchanged either because of leakage or when the prosthesis was injured during a capsulotomy. In 2 cases the prosthesis was removed, in 1 case because of problems with the skin and in another case because of repeated severe capsular contracture even after two capsulotomies. The classification of Baker was used to express the severity of capsular contracture. Prosthesis which was placed retropectorally showed significantly less problems with capsular contracture than prosthesis which was placed subglandular.(ABSTRACT TRUNCATED AT 250 WORDS)

Free fascial and septo-fascial flaps may be used to reconstruct gliding structures for nerves and tendons in combination with skin grafts to cover exposed bones, joints, tendons and nerves, and as filling material for contour correction. The advantages are the minimal disfigurement of the donor site, the very thin soft tissue cover created, and the possibility of avoiding adhesions. Possibilities of the use for reconstruction of gliding structures are shown. In a special case the superiority compared to simple tenolysis is demonstrated. Such flaps include the gliding tissue between latissimus dorsi and serratus anterior based on the thoracodorsal artery, the galea flap on the superficial temporal and the forearm septo-fascial flap on the radial.

Five cases of severe open nasal injuries are presented. A description is given of the early treatment and the results. In the first two cases a major part of the nose and upper lip were avulsed and remained attached by a lateral pedicle. Lining, support and skin were carefully repaired and defects of the nasal mucosa replaced by buccal mucosa. Both cases were treated in co-operation with the ophthalmologist and neurosurgeon. In the third case, a large defect of the nasal skin was replaced by an island flap of midline frontal skin. In the fourth case, a perforating wound of the nose, the nasal floor, and orbit was treated by a complete reconstruction of all the involved structures. The fifth case was an avulsion of the nose with a cranial pedicle in the region of the glabella. There was also a craniofacial injury with fractures into the frontal and ethmoidal sinuses and the medial wall of the orbits. With neurosurgical assistance the nose was reconstructed. The early results were favourable in all five cases.