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Nerve fibers are attracted by sutureless end-to-side nerve coaptation into the recipient nerve. Opening a window in the epineurium enhances axon attraction and myelination. The authors analyze the features of nerve repair by end-to-side coaptation. They highlight the known mechanisms of axon sprouting and different hypotheses of start up signals (presence or absence of an epineurial window, role of Schwann cells, signaling from the distal trunk). The clinical literature is also presented and differences between experimental and clinical applications are pointed out. The authors propose their point of view and perspectives deriving from recent experimental and clinical experiences., Competing Interests: Conflicts of interest: None declared.

Background: In previous studies, our research group already evaluated the impact of aesthetic surgery on "quality of life" (QoL). This study evaluates QoL factors and perceptions of well-being after otoplasty as a single indication., Methods: Eighty-one patients who underwent otoplasty were divided into three age groups: Youth 1 (Y1) = 8-12 years (n = 17), Youth 1 (Y2) = 13-17 years (n = 13), and Adult ≥18 years (n = 51). For competitive analysis, 2 groups of tests were used: a standardized self-assessment test on life satisfaction (FLZ(M)), the Glasgow Benefit Inventory (GBI), the standardized Rosenberg Self-Esteem Scale (RSES), the standardized Freiburg Personality Inventory (FPI-R), the Patient Health Questionnaire 4 (PHQ-4), and a self-developed and indication-specific questionnaire for "Adult" group. The tools for the groups Y1 and Y2 were: PHQ-4, KINDL(R), the Glasgow Child Benefit Inventory (GCBI), and a self-developed and indication-specific questionnaire either., Results: Our data bared numerous significant improvements on patients' QoL. In the items "friends" (P = 0.036) and "freedom of anxiety" (P = 0.034) of the FLZ(M), important improvements were found. In section "satisfaction with appearance" (body image), the items "hair" (P = 0.003) and "ear" (P = 0.034) were to point out. The RSES (P = 0.001) and the FPI-R (P = 0.035) data indicated a well-balanced emotional stability. The results of the GBI/GCBI (P = 0.000/P = 0.000) showed a higher QoL of postsurgery patients. The data of the KINDL questionnaire provided increasing values in the modules "friends" (P = 0.033) and "total score" (P = 0.040) for boys of the ages 8 to 12. For all age groups, there was a less affinity to depression (PHQ-4) and a high satisfaction with the aesthetical result (indication-specific questionnaire)., Conclusions: This study showed higher QoL in all age groups by using standardized tools in comparison with the norm data. The knowledge of postoperative psychologic benefits, such as "satisfaction with appearance" (body image) and "different areas of life," self-confidence, and self-esteem as well as lower level of depression support meaningfulness of otoplasty., Level of Evidence: Therapeutic, III: Retrospective cohort or comparative study.

Purpose: The diagnostic use of computer tomography angiography (CTA) to identify perforating blood vessels for abdominal free-flap breast reconstruction was extended to estimate the three-dimensional (3D) preoperative flap volume and to compare it with the real intraoperative flap weights in order to (1) evaluate the accuracy of CTA-based 3D flap volume prediction, and (2) to analyze abdominal tissue estimation for required breast volume reconstruction., Methods: Preoperative CTA was performed in 54 patients undergoing unilateral breast reconstruction with a free, deep, inferior epigastric artery perforator flap. 3D flap volumes ([Formula: see text]) based on CTA data were calculated and compared with the actual intraoperative flap weight (g). In addition, a breast volume to flap volume ratio was calculated to analyze whether the estimated 3D abdominal flap volume would match that of the breast to be removed., Results: 40 CTA data sets (74.1 %) fulfilled the technical requirements for a reliable determination of flap volume. 3D CTA flap volume prediction showed no relevant differences to the actual flap weight (p = 0.44) and high correlations (r = 0.998, [Formula: see text]), allowing a prediction accuracy within 0.29 [Formula: see text] 3.0 % (range: from [Formula: see text]8.77 to 5.67 %) of the real flap weight. Significantly larger flap volumes were harvested compared with the actually required breast volumes ([Formula: see text]), leading to an average of 21 % of the remnant flap tissue potentially being discarded., Conclusions: CTA-based 3D flap volume prediction provides accurate preoperative guidelines concerning the needed amount of abdominal tissue that can be harvested to achieve acceptable symmetry.

Prediction of resection weight (RW) in reduction mammaplasty is helpful in achieving breast symmetry and in fulfilling the stringent reimbursement requirements of health insurance companies. Current breast volume estimations are largely based on surgeon's experience, which are partially unreliable and often cumbersome to obtain. Therefore, this study aims to develop a formula to predict RW based on 3D surface imaging. A total of 68 breasts were treated with bilateral T-scar, and 40 breasts were treated with bilateral or unilateral vertical-scar reduction mammaplasty. Linear distances and volume measurements were assessed 3-dimensionally preoperatively and 6 months postoperatively. Significant correlations between the RW and the calculated preoperative breast volume (ρ = 0.804) and the sternal notch to nipple distance (ρ = 0.839) were found in both techniques (P < .001). Regression equations with the RW were performed to derive prediction formulas. Surgeons may benefit from the formulas in terms of improvement in preoperative planning, dealing with insurance coverage questions, and optimizing patient consultation.

One major objective of all types of breast reduction procedures is to achieve a long-lasting, stable and aesthetically pleasing three-dimensional (3-D) breast shape, but current surgical outcome evaluation is limited. This study compares the extent of soft-tissue oedema and breast tissue migration related to 3-D breast morphology changes after inverted T-scar and vertical-scar breast reduction over 12 months. 3-D breast surface scans of patients undergoing inverted T-scar (n=52 breasts) and vertical-scar (n=44 breasts) reduction mammaplasty were obtained preoperatively and 2-3 days, 1 week, 1 month, 3 months, 6 months, 9 months and 12 months postoperatively. 3-D images were analysed at each time point comparing distances, 3-D breast contour deviations (%), breast surface (cm2) and volume (cc) measurements including volumetric distribution between the upper portion (UP) and the lower portion (LP) of the breast (%). Total postoperative breast volume decreased by 11.7% (T-scar) and by 7.8% (vertical-scar) during the first 3 months (both p<0.001) without relevant changes in the following months, indicating that soft-tissue oedema is resolved after 3 months. The T-scar (vertical-scar) group showed a preoperative UP to LP volumetric distribution of 43:57% (45:55%) versus 86:14% (91:9%) immediately after surgery. Breast tissue significantly redistributes (both p=0.001) from the UP to the LP during the first postoperative year by 16.5% (T-scar) and 21% (vertical-scar), resulting in a final UP to LP ratio of 70:30% for both techniques, without further breast contour deviations (both p>0.05) after 6 months (T-scar) and 9 months (vertical-scar). Breast morphological changes after reduction mammaplasty are completed after a period of 3-6 months in the T-scar group and 6-9 months in the vertical-scar group., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Three-dimensional (3-D) surface imaging has gained clinical acceptance, especially in the field of cranio-maxillo-facial and plastic, reconstructive, and aesthetic surgery. Six scanners based on different scanning principles (Minolta Vivid 910®, Polhemus FastSCAN™, GFM PRIMOS®, GFM TopoCAM®, Steinbichler Comet® Vario Zoom 250, 3dMD DSP 400®) were used to measure five sheep skulls of different sizes. In three areas with varying anatomical complexity (areas, 1 = high; 2 = moderate; 3 = low), 56 distances between 20 landmarks are defined on each skull. Manual measurement (MM), coordinate machine measurements (CMM) and computer tomography (CT) measurements were used to define a reference method for further precision and accuracy evaluation of different 3-D scanning systems. MM showed high correlation to CMM and CT measurements (both r = 0.987; p < 0.001) and served as the reference method. TopoCAM®, Comet® and Vivid 910® showed highest measurement precision over all areas of complexity; Vivid 910®, the Comet® and the DSP 400® demonstrated highest accuracy over all areas with Vivid 910® being most accurate in areas 1 and 3, and the DSP 400® most accurate in area 2. In accordance to the measured distance length, most 3-D devices present higher measurement precision and accuracy for large distances and lower degrees of precision and accuracy for short distances. In general, higher degrees of complexity are associated with lower 3-D assessment accuracy, suggesting that for optimal results, different types of scanners should be applied to specific clinical applications and medical problems according to their special construction designs and characteristics.

Introduction: The aim of this study was to investigate the intraoperative findings, postoperative complications, donor site morbidity and patients' Quality of Life in order to evaluate the usefulness of the free osteofasciocutaneous fibula flap in the reconstruction or construction of a mandibula, neophallus, lower leg or forearm., Materials and Methods: 104 patients were treated with free osteofasciocutaneous fibula flaps in our clinic. 23 for mandible reconstruction, 66 for neophallus reconstruction, 9 for lower leg reconstruction and 6 for forearm reconstruction. These patients were asked to answer a questionnaire and to be present for a clinical and a radiological examination in our department. In addition, their previous records were evaluated retrospectively., Results: The dimension of the surface of the skin island was 178.6 cm(2) (72-352 cm(2)) in average and the average length of the fibular bony part was 15.4 cm (10-23 cm). The most frequent and severe complication was skin island edge necrosis (n=7); no total flap necrosis was found. Donor-site morbidity was low, since no joint instability could be reported. Quality of Life was improved according to the standardised FLZ(M) questionnaire., Conclusion: Advantages of free osteofasciocutaneous fibula flaps were the wide cortical bone and the relative constant anatomy, the long pedicle, flat, uniform and sufficient large and pliable skin island, as well as the good blood circulation also by massive modelling of the skin and bone part. The skin island could be harvested large enough in order to reconstruct extended soft-tissue defects in the face and the extremities as well as to construct neophallus in its normal size without any restrictions. The lower leg donor-site morbidity was moderate and can be readily covered with a sock in patients' everyday life common activities. Finally, in our hands, the utilisation of the free osteofasciocutaneous fibula flap is the best possible therapy for these difficult composite reconstructions., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To conduct objective quantitative and qualitative evaluations of the long-term result in endoscopic forehead-lift., Methods: Medical charts of 143 patients who underwent endoscopic forehead-lift between 1994 and 2007 were reviewed for postoperative complications and the duration of complaints. Patients received a questionnaire to evaluate satisfaction and social restriction after surgery. Objective photographic preoperative and postoperative eyebrow-to-eye distances in a relaxed position and during muscle contractions were obtained., Results: A total of 98 patients (69% response; mean follow-up, 38 months) showed high satisfaction (score, 7.1 of 10). In a relaxed position, mean midpupil-to-eyebrow elevation was 5.6 mm after surgery, with significant eyebrow symmetry between the left and right eyes (P < .05), and showed significant influence of time (P = .005) on persisting eyebrow elevation, with a decrease of almost 1 mm per year. Measurements during muscle contraction showed no relevant differences., Conclusion: Endoscopic forehead-lift enables long-lasting results with highly satisfied patients.

Background: Currently, postoperative outcome analysis in breast augmentation is essentially subjective, and objective evaluation of treatment efficacy is lacking. This study evaluates the influence of anatomic and round implant parameters on breast contour changes after subpectoral breast augmentation using three-dimensional (3D) surface imaging., Methods: 3D surface breast scans of 17 patients (34 breasts) undergoing subpectoral breast augmentation with round implants and of ten patients (20 breasts) receiving anatomic implants via an axillary approach under endoscopic assistance or a submammary fold incision were obtained before and 6 months postoperatively. 3D linear distance, breast volume, and surface measurement were correlated with the implanted round and anatomic implant parameters, and the resulting breast shape changes were evaluated., Results: Total breast volume changed in correlation with the implant size (2.4% difference; r=0.894; p<0.001). Implant volume and type influence the nipple-to-inframammary fold distance (N-IMF). Every inserted 100 ml implant volume enlarges the N-IMF distance by 0.8 cm (anatomic>round; p=0.01). Postoperatively, the IMF dropped by an average of 1.3 cm for round implants and by 1.1 cm for anatomic implants, without relevant differences between the applied surgical incision and the selected implants (p>0.05). Breast projection increased significantly more with anatomic implants (2.4 cm) than with round implants (1.7 cm) (p=0.01). The breast projection increase was 22% less than expected for round implants and 25% less than expected for anatomic implants based on the manufacturer implant parameters (p<0.01), without essential differences regarding the surgical incision., Conclusions: 3D breast shape changes induced by round and anatomic implants after subpectoral augmentation mammaplasty are objectively documented including breast projection, volume, and N-IMF distance changes. 3D surface imaging may have a potential clinical contribution to objective surgical outcome research., Level of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Background: In a previous prospective study, the authors evaluated the quality of life in patients undergoing aesthetic surgery. In this survey, the authors split up the operative indication and analyzed quality of life, self-esteem, and emotional stability after abdominoplasty alone., Methods: Sixty-three patients participated in the study. The testing instrument consisted of a self-developed questionnaire to collect demographic and socioeconomic data and a postoperative complication questionnaire developed especially for abdominoplasties. In addition, a standardized self-assessment test on satisfaction and quality of life (Questions on Life Satisfaction), the Rosenberg Self -Esteem Questionnaire, and the Freiburg Personality Inventory were used., Results: Significantly increasing values in some items of the standardized self-assessment test on satisfaction and quality of life were found: sum scores of the General Life Satisfaction showed a significant improvement (p = 0.004) and the scores of the items housing/living conditions (p = 0.000) and family life/children (p = 0.000). Within the Satisfaction with Health module, a significant improvement in the items mobility (p = 0.02) and independence from assistance (p = 0.01) was found. Values in the module Satisfaction with Appearance (Body Image) increased regarding satisfaction with the abdomen (p = 0.001). Over 84 percent were very satisfied with the aesthetic result, 93.4 percent would undergo the same treatment again, and 88.9 percent would further recommend the operation. Data revealed that participants' self-esteem was very high and their emotional stability was very well balanced., Conclusions: This study demonstrates that abdominoplasty increases most aspects of quality of life, particularly family life, living conditions, mobility, and independency from assistance. Also, patient self-esteem and emotional stability ratings are very high postoperatively.

This study develops an objective breast symmetry evaluation using 3-D surface imaging (Konica-Minolta V910(®) scanner) by superimposing the mirrored left breast over the right and objectively determining the mean 3-D contour difference between the 2 breast surfaces. 3 observers analyzed the evaluation protocol precision using 2 dummy models (n = 60), 10 test subjects (n = 300), clinically tested it on 30 patients (n = 900) and compared it to established 2-D measurements on 23 breast reconstructive patients using the BCCT.core software (n = 690). Mean 3-D evaluation precision, expressed as the coefficient of variation (VC), was 3.54 ± 0.18 for all human subjects without significant intra- and inter-observer differences (p > 0.05). The 3-D breast symmetry evaluation is observer independent, significantly more precise (p < 0.001) than the BCCT.core software (VC = 6.92 ± 0.88) and may play a part in an objective surgical outcome analysis after incorporation into clinical practice., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

In this report we highlight the use of PET scan in plastic and reconstructive surgery. PET scanning is a very important tool in plastic surgery oncology (melanoma, soft-tissue sarcomas and bone sarcomas, head and neck cancer, peripheral nerve sheath tumors of the extremities and breast cancer after breast esthetic surgery), as diagnosis, staging, treatment planning and follow-up of cancer patients is based on imaging. PET scanning seems also to be useful as a flap monitoring system as well as an infection's imaging tool, for example in the management of diabetic foot ulcer. PET also contributes to the understanding of pathophysiology of keloids which remain a therapeutic challenge.

This study explores the quality of life in 118 patients following severe and major hand injury with a Hand Injury Severity Score >50. Each patient answered five different validated outcome measures (DASH (Disability of the Arm, Shoulder, and Hand), FLZ(M) ('Fragen zur Lebenszufriedenheit'), HADS (Hospital Anxiety and Depression Score), BDDE-SR (Body Dysmorphic Disorder Examination-Self Report) and FBeK ('Fragebogen zur Beurteilung des eigenen Körpers'), which were incorporated into a single questionnaire. Each of these questionnaires covered one or more of the established quality-of-life domains. Patients with pain and pressure sensations were significantly less satisfied in life, showed lower levels of health satisfaction, had higher levels of anxiety and depression and showed higher body dysmorphic disorder levels (all p < 0.001). General life satisfaction in this hand-injury study group is highly dependent on the patients` satisfaction with their health and appearance as well as self-confidence. The quality-of-life outcomes improve with time, and despite evidence of continued impairment in the injured hand, the majority of patients had a normal quality of life., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Conventional nerve conduits lack cellular and extracellular guidance structures critical for bridging larger defects. In this study, an exogenous matrix for axonal regeneration was provided by pretreated muscle tissue. In 24 rats, 14-mm sciatic nerve segments were resected and surgically reconstructed using one of the following methods: autograft (AG); bovine type I collagen conduit; (MDM) collagen tube filled with modified denatured autologous muscle tissue. For 8 weeks, functional regeneration was evaluated by footprint and video gait analysis. Evaluation was complemented by electrophysiology, as well as qualitative and quantitative structural assessment of nerves and target muscles. Group AG was superior both structurally and functionally, showing higher axon counts, a more normal gait pattern, and less severe muscle atrophy. Fiber quality (fiber size and myelin thickness) was highest in group MDM, possibly related to the myelin-producing effect of muscular laminin. However, axon count was lowest in this group, and ultrastructural analysis of the denatured muscle tissue showed areas of incomplete denaturation that had acted as a mechanical barrier for regenerating axons. In light of these results, the often advocated use of muscular exogenous matrix for peripheral nerve reconstruction is reviewed in the literature, and its clinical application is critically discussed. In conclusion, combined muscle tubes may have a positive influence on nerve fiber maturation. However, muscle pretreatment is not without risks, and denaturation processes need to be further refined., (Copyright © 2011 Wiley Periodicals, Inc.)

Background: Changes in breast-morphology occur after all types of breast surgery, but a systematic and objective surgical result assessment is currently lacking. Three-dimensional (3-D) surface imaging offers the ability to quantitatively evaluate breast contour, shape, surface and volume changes after surgery. This study evaluates 3-D breast contour and volume changes after breast augmentation over time., Methods: 3-D surface imaging of 14 subpectoral breast-augmentation patients (n = 28 breasts) were accomplished over six time periods (preoperative (OP), post-OP 1: 2-3 days; post-OP 2: 1 week; post-OP 3: 1 month; post-OP 4: 3 months; and post-OP 5: 6 months after surgery) and linear-distance measurement, breast volume and surface changes were analysed. 3-D breast-contour- and volume variations are expressed in percentage changes over time., Results: All breast measurements changed significantly between pre-OP and post-OP 1 (Friedmann test, p = 0.001-0.025). First significant postoperative changes over time compared with post-OP 1 for breast volume, surface, sternal notch to nipple and nipple to inframammary-fold-distance measurements are quantifiable after 1 month (post hoc Wilcoxon test, p = 0.001 for all) with further relevant breast volume (post hoc Wilcoxon test, p = 0.041) and surface changes (post hoc Wilcoxon test, p = 0.037) between months 1 and 3 after surgery. The inframammary fold dropped by 1.4 cm after 6 months and final breast volume ± 0.5% is reached between months 1 and 3 after surgery. Valuable reductions in breast contour and volume by nearly 85% are also reached after 1 month (Wilcoxon test, p = 0.001) and changed to 98% after 3 months and 100% after 6 months., Conclusions: Breast morphological changes following subpectoral breast augmentation are completed after 3 months. 3-D surface imaging may play a part in comparing different breast-augmentation techniques., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: In the last decades, several surgical approaches have been used to improve the appearance and quality of life of female Poland syndrome patients. The aim of this study was to analyze the women's quality of life and long-term outcome after breast reconstruction., Methods: Forty-nine women with Poland syndrome who were treated surgically between 1974 and 2007 received standardized questionnaires to evaluate their quality of life and satisfaction after surgical treatment., Results: Patient response was 65%, with 32 completed questionnaires by 16 women who had pedicled latissimus dorsi myocutaneous (LDM) flaps, 12 with tissue expander or silicone implants, and 4 who had free transverse rectus abdominis myocutaneous (TRAM) flaps. Of these patients, 16 were satisfied or highly satisfied with their postoperative appearance (13 with LDM, 2 with prosthesis, and 1 with TRAM), 16 patients would recommend the same surgery to others under similar circumstances (10 with LDM, 5 with prosthesis, and 1 with TRAM), and 18 patients would choose the same method again (14 with LDM, 3 with prosthesis, and 1 with TRAM)., Conclusions: In our study, we found that satisfactory outcome in breast reconstruction was achieved particularly when using the LDM flap, which remains the only method that recreates the anterior axillary fold. Future studies on reconstruction methods with autogenous tissue (e.g., TRAM, deep inferior epigastric perforator [DIEP] flap) are needed, however, to analyze quality of life and long-term outcome in patients with Poland syndrome.

Background/aim: Our aim was to evaluate the impact of in vitro cultured amnion cells, injected and/or seeded in different scaffolds, on in vivo fetal membrane repair., Materials and Methods: Amnion cells, isolated from allogeneic fetal membranes, were cultured on three different scaffolds for 14 to 21 days. In 33 mid-gestational rabbits, fetoscopic access sites were randomly allocated to four closure study groups: conventional collagen plug, as well as collagen plug, collagen foil, and fibrin glue as scaffolds for the cultured amnion cells. All membrane access sites were sealed with fibrin glue, and the myometrium closed with sutures. Fetal survival, amnion membrane integrity, and the presence of amniotic fluid were evaluated one week later., Results: Cultures showed good survival in the collagen scaffolds. The use of collagen plug as a scaffold for the in vitro cultured amnion cells improved the integrity of fetal membranes to 80%, better than that of any other study group., Conclusion: Despite the need for additional studies, the present data suggest that amnion cells can be a practical and important source of cells for the engineering of constructs for sealing of the fetal membrane.

Background: Herein, we present our latest protocol of following three operative stages for complete phalloplasty, applied in 37 female-to-male transsexuals: first, mastectomy, ovariohysterectomy, urethral lengthening, vaginectomy, colpocleisis, and neourethra prelamination; second, neophallus creation with free sensate osteofasciocutaneous fibula (n = 31) or radial forearm (n = 6) flap; and third, urethral connection, neoscrotum formation, and testicle prosthesis implantation., Results: Occasionally, wound healing disturbance and slight asymmetry of the breasts was observed, as well as colpocleisis revision needed. Partial flap necrosis took place in 6 patients, while 12 presented urethral stricture and 6 a fistula. Despite inferior neophallus sensibility, patients whose neophallus was created using fibula flap experienced better sexual intercourse. However, overall patients' satisfaction was superior., Conclusions: The applied protocol demonstrates the effectiveness of such a multistage and interdisciplinary approach for female-to-male transsexuals, offering an essential improvement of their quality of life, concerning their successful integration into the reassigned gender position in the society.

To date, the dominant blood supply to the head of the fibula and to the growth plate is known to be the anterior tibial artery. The peroneal artery had been used before, among other donor pedicles, for microvascular transfers of this epiphyseal region. This study presents the long-term results of this now obsolete pedicle and compares them to other reports in the literature. Follow-up was performed in 1996 and in 2003 with six patients who underwent wrist reconstruction in the 1980s. Procedures were performed following one resection of a malignant synovialoma, two traumatic hand amputations, and three radial aplasias. Evaluation was performed with functional and radiographic examinations. Three cases that were examined in 2003 are presented in detail. The study shows that if growth plates are closed at the time of procedure or the transplanted fibula is long enough to ensure anastomotic flow between metaphyseal and epiphyseal vessels, results are good. If any of these two conditions is not fulfilled, vascular supply to the epiphysis is insufficient. Long bone deviation or bone necrosis will result. These results confirm clinically current knowledge about the epiphyseal and metaphyseal blood supply to the fibula.

Differences in breast volume and contour are subjectively estimated by surgeons. 3D surface imaging using 3D scanners provides objective breast volume quantification, but precision and accuracy of the method requires verification. Breast volumes of five test individuals were assessed using a 3D surface scanner. Magnetic resonance imaging (MRI) reference volumes were obtained to verify and compare the 3D scan measurements. The anatomical thorax wall curvature was segmented using MRI data and compared to the interpolated curvature of the posterior breast volume delimitation of 3D scan data. MRI showed higher measurement precision, mean deviation (expressed as percentage of volume) of 1.10+/-0.34% compared to 1.63+/-0.53% for the 3D scanner. Mean MRI [right (left) breasts: 638 (629)+/-143 (138) cc] and 3D scan [right (left) breasts: 493 (497)+/-112 (116) cc] breast volumes significantly correlated [right (left) breasts: r=0.982 (0.977), p=0.003 (0.004)]. The posterior thorax wall of the 3D scan model showed high agreement with the MRI thorax wall curvature [mean positive (negative) deviation: 0.33 (-0.17)+/-0.37 cm]. High correspondence and correlation of 3D scan data with MRI-based verifications support 3D surface imaging as sufficiently precise and accurate for breast volume measurements.

The final outcome of severe hand injuries is not solely determined by the residual functional impairment, but is also a function of non-functional criteria, including the sequelae of the accompanying psychological trauma. This paper reviews the literature with respect to the psychological impact of severe hand injuries, including the special impact of amputations, adaptation processes, adaptation stages, prognostic criteria and aesthetic issues influencing the final individual outcome, including present recommendations for promoting a positive outcome. Motivated and psychologically stable people are reported to do well irrespective of the severity of a hand injury. In patients who find it difficult to cope mentally, successful treatment strategies have been proposed. Their implementation is in a constant state of evolution and includes not only improved surgical techniques and advanced pharmacological pain management but also early psychotherapeutic input and involvement of patients in decision making for treatment.

Objective: To investigate the influence of several magnetic resonance imaging (MRI) sequences on amniotic fluid temperature and intrauterine sound pressure., Material and Methods: Temperature and sound pressure measurements during MRI (1.5 T) in pregnant ewes were done. Linear levels and third octave band spectra were compared., Results: No significant changes in the temperature of amniotic fluid were observed. Intrauterine summation levels reached peak levels up to 103.0 dB(A) before starting the MRI sequence and levels up to 116.0 dB(A) during a real-time sequence. Evaluating the octave band spectra, peak levels did not exceed 100.0 dB(L)., Conclusions: Our delimited data revealed no harm for the fetus by an increase in amniotic fluid temperature or hazards for the fetal auditory system by different MRI sequences., (Copyright 2008 S. Karger AG, Basel.)

The severe functional deficits in patients suffering from traumatic peripheral nerve damage underline the necessity of an optimal therapy. The development of microsurgical techniques in the sixties contributed significantly to the progress in nerve repair. Since then, no major clinical innovation has become established. However, with an increased understanding of cellular and molecular mechanisms underlying nerve regeneration, various tubulization concepts have been developed which yield possible alternatives to direct suturing and to autologous nerve grafting in cases of short nerve defects. The vast knowledge gathered in the field of nerve regeneration needs to be further exploited in order to develop alternative therapeutic strategies to nerve autografting, which can result in donor-site defects and often lead to inappropriate results. Considering the encouraging results from preclinical studies, innovative nerve repair strategies are likely to improve the outcome of reconstructive surgical interventions. This paper outlines, in addition to the fundamentals of nerve regeneration, the current treatment options for defects of peripheral nerves. This article also reviews the developments in the use of alternative nerve guides and demonstrates new perspectives in the field of peripheral nerve reconstruction.

Quantification of the complex breast region can be helpful in breast surgery, which is shaped by subjective influences. However, there is no generally recognized method for breast volume calculation. Three-dimensional (3D) body surface imaging represents a new alternative for breast volume computation. The aim of this work was to compare breast volume calculation with 3D scanning and three classic methods, focusing on relative advantages, disadvantages, and reproducibility. Repeated breast volume calculations of both breasts in six patients (n=12) were performed using a 3D laser scanner, nuclear magnetic resonance imaging (MRI), thermoplastic castings, and anthropomorphic measurements. Mean volumes (cc) and mean measurement deviations were calculated, and regression analyses were performed. MRI showed the highest measurement precision, with a mean deviation (expressed as a percentage of mean breast volume) of 1.56+/-0.52% compared with 2.27+/-0.99% for the 3D scanner, 7.97+/-3.53% for thermoplastic castings, and 6.26+/-1.56% for the anthropomorphic measurements. Breast volume calculations using MRI showed the best agreement with 3D scanning measurement (r=0.990), followed by anthropomorphic measurement (r=0.947), and thermoplastic castings (r=0.727). Compared with three classical methods of breast volume calculation, 3D scanning provides acceptable accuracy for breast volume measurements, better spatial interpretation of the anatomical area to be operated on (due to lack of chest deformation), non-invasiveness, and good patient tolerance. After this preliminary study and further development, we believe that 3D body surface scanning could provide better preoperative planning and postoperative control in everyday clinical practice.

Background: The objective of this study was the prospective evaluation of quality of life in patients undergoing aesthetic plastic surgery procedures. We examined pre- and postoperative changes in quality of life, and performed a comparison of our data with a representative random sample., Method: 228 patients agreed to participate in the present study. Measurements were taken preoperatively as well as 3 and 6 months postoperatively. One hundred and thirty two patients completed the three months postoperative evaluation (T1), 82 answered the 6 months follow-up evaluation (T2). The testing instrument included a standardised self-assessment test on satisfaction and quality of life (FLZ(M)), consisting of three modules: satisfaction with general life, health and appearance. Further, a postoperative complication questionnaire was used in order to evaluate the satisfaction with the surgical outcome and to estimate postoperative complications and side effects., Results: Significantly increasing values in two aspects of quality of life were found: health and appearance. Whereas the positive influence on health is persistent, there is a diminishing influence of appearance 6 months postoperatively. Although higher values for some of the individual items of the FLZ(M) modules of the norm data were found in comparison to our study group, a general preoperative lower level of quality of life of the aesthetic surgery patients could not be confirmed. Over 84% were satisfied or very satisfied with the aesthetic result. 85% would undergo the same treatment again and 94% of the patients would further recommend their operation. More than half of the study group did not report a decrease in physical fitness or reduced social contacts in the direct postoperative period., Conclusion: Our study reveals that aesthetic plastic surgery increases most aspects of quality of life, especially regarding body satisfaction and health. It is very well tolerated by the patients and is therefore a recommended option.

In this experimental study on 96 CD rats, microvascular end-to-end anastomoses created via suture or alternatively by means of a VCS-Clip-Application-System, were compared. The aorta abdominalis of the animals, with a diameter of 1.5 +/- 0.2 mm, was experimentally dissected, and the free ends of the vessel then anastomosed. The results were evaluated using sonography, microangiography, histologic examination, and vascular imprints. Postoperative examination was carried out after 1, 3, 7, 14, or 30 days. Major advantages of the VCS-Clip technique over suturing were that it was easy to learn, significantly faster to perform (execution of anastomosis 10.9 +/- 2.6 min versus 19.4 +/- 5.0 min), and produced significantly more favorable histologic results in terms of less inflammatory response, foreign body reaction, necrosis of the tunica media, hyperplasia of the intima, and thrombosis of the vessel lumen. The main disadvantage of the clip technique was a significantly higher rate of stenoses (15.8 +/- 6.0 versus 4.1 +/- 6.6 percent).

Facial hemi atrophy is seen after trauma, Parry-Romberg syndrome and on other rare occasions. Since the aesthetic deficit is very obvious and irritating, facial reconstruction is often requested by these patients. In most cases the only option for sufficient reconstruction is free flap reconstruction, which represents the standard treatment. Recently in plastic surgery, various new techniques have been developed with the potential for multiple applications. Lipofilling has been presented primarily for the correction of cosmetic lesions or the reconstruction of minor soft tissue defects, but even reconstruction of larger soft tissue deficits is possible. The concept of using 3-D technology in facial reconstruction has multiple advantages. Primarily, the ideal final aesthetic outcome can be simulated by virtual reconstruction. Mathematic calculations deliver exact numbers in volume deficits, enabling precise planning of soft tissue substitution especially in lipofilling, ideally avoiding unnecessary corrections. Since autologous soft tissue reconstruction represents a dynamic process with periods of swelling as well as atrophy, quality control is required for achieving optimal results. Use of 3-D scanning has the advantage of reliable visualisation in soft tissue reconstruction without the limitations of harmful side effects. We present the history of a female suffering from the posttraumatic consequences of head injuries related to a car accident and the successful correction of her hemi facial atrophy by autologous lipofilling. Technical details and the potential of 3-D scanning in plastic surgery are discussed.

Precise and objective calculation of breast volume is helpful to evaluate the aesthetic result of breast surgery, but traditional methods are unsatisfactory. Three-dimensional (3D) scanning of the body surface allows reproducible and objective assessment of the complex breast region but requires further investigation before clinical application. The main goal of this study was to investigate the precision and accuracy of breast volume measurement using 3D body scanning. Five independent observers standardized the 3D scanning method using 2 dummy models (n = 200) and examined its applicability with 6 test subjects and 10 clinical patients (n = 2220). Breast volume measurements obtained with the 3D-scanner technology were compared with reference measurements obtained from test subjects through nuclear magnetic resonance imaging. The mean deviation of the breast volume measurements of 1 test subject by all observers, expressed as percentage of volume, was 2.86 +/- 0.98, significantly higher than the deviation for the dummy models, 1.65 +/- 0.42 (P < 0.001). With respect to all clinical patients, the mean measurement precision obtained preoperatively was less precise than that obtained postoperatively (3.31 +/- 1.02 versus 1.66 +/- 0.49, respectively). Interobserver differences in measurement precision were not statistically significant. The mean breast volumes obtained by nuclear magnetic resonance imaging (441.42 +/- 137.05 mL) and 3D scanning (452.51 +/- 141.88 mL) significantly correlated (r = 0.995, P < 0.001). Breast volume measurement with 3D surface imaging represents a sufficiently precise and accurate method to guarantee objective and exact recording.

Breast cancer remains to be one of the most malignant diseases in the female population. It affects an essential part of female self-consciousness, and therefore causes a wide range of psychological traumas. The incidence in Europe and North America varies between 70 up to 100 new cases in 100.000 inhabitants per year. According to contemporary literature, mastectomy remains one of the most effective methods in the laborious effort to treat and overcome cancer. In this report the history of breast reconstruction is presented. The established methods which are taken into consideration after mastectomy and their clinical outcome are portrayed. The authors propose the free TRAM and DIEP flap as the methods of first choice after mastectomy, which offer most reliable transfer and low morbidity. In the recent past, increasing interest is observed for the SIEA flap. The free S-GAP flap is proposed for patients who are not candidates for a TRAM, DIEP or SIEA flap. Moreover, the pedicled Latissimus Dorsi flap remains still as a reliable, versatile alternative, particularly in case of contraindications for the above mentioned free flaps or when complications occurred.

Background: Nowadays, the array of methods for reconstruction of the female breast following mastectomy is vast. In this study, we investigate and compare quality of life after breast reconstruction and satisfaction with the results of two commonly used techniques (autologous tissue vs. expander/implant)., Methods: Ninety-one consecutive patients who underwent breast reconstruction at a German clinic between 1996 and 2001 were included in the study. Patient satisfaction and quality of life were assessed retrospectively using self-evaluation questionnaires., Results: Patients were generally more satisfied with the outcome of the operation when autologous tissue was used. This was significant in the following areas: breast size, form, definition of the lower breast fold, softness of the breast, and symmetry of the breasts. In both groups the quality of life following breast reconstruction at least 2 years after the operation was equal to that of healthy women of the same age group., Conclusion: Although patients were more satisfied with the results of autologous breast reconstruction, procedure choice did not affect quality of life.

Three-dimensional (3-D) recording of the surface of the human body or anatomical areas has gained importance in many medical specialties. Thus, it is important to determine scanner precision and accuracy in defined medical applications and to establish standards for the recording procedure. Here we evaluated the precision and accuracy of 3-D assessment of the facial area with the Minolta Vivid 910 3D Laser Scanner. We also investigated the influence of factors related to the recording procedure and the processing of scanner data on final results. These factors include lighting, alignment of scanner and object, the examiner, and the software used to convert measurements into virtual images. To assess scanner accuracy, we compared scanner data to those obtained by manual measurements on a dummy. Less than 7% of all results with the scanner method were outside a range of error of 2 mm when compared to corresponding reference measurements. Accuracy, thus, proved to be good enough to satisfy requirements for numerous clinical applications. Moreover, the experiments completed with the dummy yielded valuable information for optimizing recording parameters for best results. Thus, under defined conditions, precision and accuracy of surface models of the human face recorded with the Minolta Vivid 910 3D Scanner presumably can also be enhanced. Future studies will involve verification of our findings using test persons. The current findings indicate that the Minolta Vivid 910 3D Scanner might be used with benefit in medicine when recording the 3-D surface structures of the face.

Background: More and more frequently, the registration of life satisfaction is being used to evaluate different medical treatments. So far, there have been only few such surveys on transsexuals (TS). Therefore, the aim of this study was to evaluate the general and the health-related life satisfaction of transsexuals after gender transformation operations., Patients and Methods: Forty patients took part in this German cross-sectional study. The Questions on Life Satisfaction Module (FLZ) and free questions on different aspects of the new gender identity were used as measuring instruments., Results: Of the TS studied, 85-95% were "very satisfied" or "satisfied" with the results of their gender transformation operation in respect to gender identity. The TS were significantly less satisfied (P>0.001) in overall "general life satisfaction" than the general population. In overall FLZ scores for "health-related life satisfaction", no differences were seen., Conclusion: These data indicate a discrepancy between subjective satisfaction with new gender identity and current life situation, and they identify problems with life satisfaction.

The anatomic conditions of the female breast require imaging the breast region 3-dimensionally in a normal standing position for quality assurance and for surgery planning or surgery simulation. The goal of this work was to optimize the imaging technology for the mammary region with a 3-dimensional (3D) laser scanner, to evaluate the precision and accuracy of the method, and to allow optimum data reproducibility. Avoiding the influence of biotic factors, such as mobility, we tested the most favorable imaging technology on dummy models for scanner-related factors such as the scanner position in comparison with the torso and the number of scanners and single shots. The influence of different factors of the breast region, such as different breast shapes or premarking of anatomic landmarks, was also first investigated on dummies. The findings from the dummy models were then compared with investigations on test persons, and the accuracy of measurements on the virtual models was compared with a coincidence analysis of the manually measured values. The best precision and accuracy of breast region measurements were achieved when landmarks were marked before taking the shots and when shots at 30 degrees left and 30 degrees right, relative to the sagittal line, were taken with 2 connected scanners mounted with a +10-degree upward angle. However, the precision of the measurements on test persons was significantly lower than those measured on dummies. Our findings show that the correct settings for 3D imaging of the breast region with a laser scanner can achieve an acceptable degree of accuracy and reproducibility.

Soft tissue defects after knee arthroplasty are a severe problem, which can even result in a loss of the prosthesis or the limb. Well-planned strategies are necessary for sufficient soft tissue reconstruction, resulting in optimal functional and aesthetic results. This report provides information on the classification of the tissue defects and the appropriate options for surgical reconstruction. Besides the basic therapy principles of immobilisation, débridement, planned lavages and antibiotic therapy, defect-dependent surgical techniques of reconstructive surgery are implemented. These include skin transplantation, local fasciocutaneous flaps, local pedicled muscle flaps and free flaps. For best results, interdisciplinary treatment by orthopaedic surgeons, plastic surgeons, microbiologists and physiotherapists is mandatory.

Three-dimensional recording of the surface of the human body or of certain anatomical areas has gained an ever increasing importance in recent years. When recording living surfaces, such as the human face, not only has a varying degree of surface complexity to be accounted for, but also a variety of other factors, such as motion artefacts. It is of importance to establish standards for the recording procedure, which will optimise results and allow for better comparison and validation. In the study presented here, the faces of five male test persons were scanned in different experimental settings using non-contact 3D digitisers, type Minolta Vivid 910). Among others, the influence of the number of scanners used, the angle of recording, the head position of the test person, the impact of the examiner and of examination time on accuracy and precision of the virtual face models generated from the scanner data with specialised software were investigated. Computed data derived from the virtual models were compared to corresponding reference measurements carried out manually between defined landmarks on the test persons' faces. We describe experimental conditions that were of benefit in optimising the quality of scanner recording and the reliability of three-dimensional surface imaging. However, almost 50% of distances between landmarks derived from the virtual models deviated more than 2mm from the reference of manual measurements on the volunteers' faces.

Objective: To evaluate maxillary growth following in utero repair of surgically created cleft lip and alveolar (CLA)-like defects by means of three-dimensional (3D) computer tomographic (CT) cephalometric analysis in the mid-gestational sheep model., Methods: In 12 sheep fetuses a unilateral CLA-like defect was created in utero (untreated control group: 4 fetuses). Four different bone grafts were used for the alveolar defect closure. After euthanasia, CT scans of the skulls of the fetuses, 3D reconstructions, and a 3D-CT cephalometric analysis were performed., Results: The comparisons between the operated and nonoperated skull sides as well as of the maxillary asymmetry among the experimental groups revealed no statistically significant differences of the 12 variables used., Conclusions: None of the surgical approaches used for the in utero correction of CLA-like defects seem to affect significantly postsurgical maxillary growth; however, when bone graft healing takes place, a tendency for almost normal maxillary growth can be observed.

In this study we aimed to set up an in vitro culture of the rabbit amnion in order to support in vivo fetal membrane healing capacity following fetoscopy. Fetal membranes were collected from a mid-gestational rabbit, and cultured on collagen support material for 14 days. 34 rabbits at 22-23 days gestational age (GA) underwent fetoscopy. The entry site was randomly allocated to 4 closure technique study groups: group I, human amnion membrane (n = 23); group II, collagen foil (n = 16); group III, collagen plug (n = 19), and group IV, collagen plug with cultured amnion cells (n = 19). In all groups membrane access sites were additionally sealed with fibrin sealant, and the myometrium was closed with sutures. Fetal survival, amnion membrane integrity, and the presence of amniotic fluid were evaluated at 30 days GA. Cultures showed good survival in the collagen support material. Increased cellularity, survival and proliferations were observed. The amnion at the access site resealed in 58-64% of cases in groups II-IV, but none of the tested techniques was significantly better than the other. Histological examination indirectly revealed the anatomic repair of the membranes, since no entrapment of the membranes could be demonstrated in the myometrial wound.

Aim: To develop a 3D CT cephalometric analysis for maxillary growth evaluation of sheep fetuses operated in utero, and to evaluate the reliability of this analysis by comparing it with a direct cephalometric analysis on dry skulls., Material and Methods: Five skulls of operated sheep fetuses were used, which after preparation were CT scanned and a 3D reconstruction was performed. A cephalometric analysis was performed directly on the dry skulls as well as on the reconstructed 3D CT images. In total, 56 linear distances were measured. In order to access the error of the method, the procedure was repeated after a 2 week interval., Results: The comparison between the direct cephalometric and the 3D CT analysis revealed that only 5 variables were significantly different. The evaluation of the error of method revealed that 7 variables of the direct cephalometric analysis and none of the 3D CT analysis differed significantly., Conclusions: According to the results of this study, it can be concluded that a cephalometric analysis on 3D CT reconstructed images of the skulls includes fewer identification errors and seems to be an accurate and reliable method that could be regarded at least as equivalent to conventional cephalometry.

Now-a-days, high-resolution ultrasound allows an accurate and relatively early diagnosis of congenital malformations. In a limited number of such conditions foetal surgery may be lifesaving. However, premature labour has been the major drawback for open foetal surgery. Recently, improvement of video-endoscopic technology has boosted the development of operative techniques for feto-endoscopic surgery, which has been demonstrated to be less invasive than the open approach. Main clinical application of fetoscopic procedures today is the treatment of feto-foetal transfusion syndrome. Although still in development, feto-endoscopic surgery seems to offer new hope for surgical foetal therapy not only in cases of life threatening conditions. Experimental intrauterine correction of cleft lip and palate (CLP) has been lately performed using the feto-endoscopic approach. This procedure offers two major advantages: first, scarless foetal wound healing and bone healing without callus formation, which would also allow a better/normal maxillary growth, and second, significant decrease of foetal and maternal morbidity. Herein, we report the current status of experimental and clinical foetal surgery and propose possible directions for continuing research to make intrauterine procedures safer. Furthermore, we discuss current knowledge and new perspectives of experimental foetal cleft lip and palate repair, which in the future may lead to such excellent results in the operative treatment of clefts, that less or no secondary corrections and therapies, such as orthodontic, dental, logopedic, etc. would be needed. Only if these conditions can be fulfilled, will we be able to improve substantially our therapy for the human foetus with a cleft lip and palate. In spite of all efforts, however, it must be considered that it may not ever be possible to find the optimal treatment method for this or other craniofacial malformations.

In severe facial burn injuries with extensive destruction of anatomical structures, cosmetic and functional outcome of treatment are frequently not satisfactory. Although operative therapy is being continuously refined, the variety and proximity of structures in the facial region is considered a major challenge in reconstructive surgery. We present the case of a 16-year-old patient with a severe facial burn injury. In planning the reconstructive procedures, we used a multimodal approach employing data from computerized tomography imaging, as well as from surface laser scanning, which provided three-dimensional visualization of facial soft tissues. Amount and pattern of structural loss could thus be determined more precisely and studied more vividly than by inspection of two-dimensional imaging alone. Anatomical features to be reconstructed could be projected onto the skin area of the prelaminated vertical rectus abdominis muscle (VRAM) flap that has been chosen to cover the defect. Prior to surgery, correction of the defects was simulated and the results of the virtual procedure superimposed on a three-dimensional head model of the patient. Tissue elasticity and thickness of the flap, however, could not be ascertained in advance, indicating the limitations of the method.

In the study presented, the long-term outcome and satisfaction of 34 patients who underwent simultaneous bilateral breast reconstruction with a free transverse rectus abdominis muscle (TRAM) flap between 1988 and 2001 were assessed. Flap complications affected 13 of 68 flaps (19.1%). Anastomosis revision was needed in 6 cases (8.8%), the salvage rate being 50%. The rates of total and partial flap loss were 4.4% and 1.5%, respectively. Bilateral flap loss did not occur. Four patients developed donor site complications (11.7%), with wound healing problems being the most common (5.8%). Most patients were satisfied with their decision to have had breast reconstruction with free TRAM, 91% would choose the same operation again, and 91% would recommend this procedure to other patients. Of the operated patients, 20.8% felt an improvement in their sexual life; more patients, however, reported an improvement concerning their social life (37.5%) and life in general (50%).

Aim: The success of intrauterine surgery in treating non-life-threatening malformations such as myelomeningocoele, has also renewed strong interest in using this technique for treating craniofacial malformations. Nevertheless, the only experimental cleft-like defect models known, are those concerning wound healing of soft tissues., Material and Methods: Attempts were made to repair artificial cleft-like defects including transplantation of 11 autogenous foetal bone grafts from the iliac crest or ulna, and were randomly assigned to three study groups, using the mid-gestational sheep model. In a 4th study group, lyophilized collagen, a bone-regenerating bioresorbable implant material, was used to fill the alveolar defect., Results: In all groups, there was a slight degree of asymmetry and thinning of the lip. Radiological studies demonstrated a variable degree of abnormality of the maxilla, ranging from none to a mild deviation. Three-dimensional computer tomography, two-dimensional maximal intensity projection findings, and histological analysis confirmed bony healing of the alveolar cleft-like defect., Discussion/conclusion: Intrauterine autogenous foetal bone transplantation for the repair of cleft-like defects in the sheep is feasible. This is a reliable and valuable model toward a possible clinical application for intrauterine treatment of clefts.

The characteristic of fetal wound healing is scarless wound repair in early gestation. During the last two decades, intensive research efforts have focused on unraveling the molecular regulations underlying the phenomenon of scarless wound healing. Better understanding of synthesis and degradation will enable us to develop important therapeutic options for the prevention and reduction of scarring. The aim of this article is to present an overview, discuss the most important research works of the last two decades on the field of fetal wound healing, and report current therapeutic developments for the modulation of adult wound repair. Recent experimental results using these new therapeutic approaches are very promising and present great possibilities and chances for future surgery.

INDICATION FOR FETAL SURGERY: The widespread use of high-resolution ultrasound in prenatal diagnosis allows nowadays an accurate and early diagnosis of congenital malformations. Some of these can be corrected surgically. In certain cases intrauterine surgery could present functional and aesthetic advantages or be even lifesaving. Due to the extreme sensitiveness of the fetal patient and the fetal membranes, only some defined anomalies currently meet the criteria for intrauterine surgery. However, the list can change in the future since prenatal diagnosis, technical advances, and knowledge of pathophysiology improve constantly., Endoscopic Intrauterine Surgery: Additionally, the recent development of endoscopic intrauterine surgery represents a new and more careful possibility for intrauterine surgery. Endoscopic procedures could avoid the disadvantages of open intrauterine surgery and thus make fetal operations safer, in life-threatening as well as in non-life-threatening malformations such as cleft lip and palate (CLP). The main advantages of these procedures are (1) scarless wound healing and bone healing without callus formation that leave to expect normal growth of the midface and (2) lower fetal and maternal morbidity., Discussion: Based on the results achieved until now, it can be stated that at present the intrauterine operation of CLP on humans cannot be recommended. The high morbidity and mortality risk for mother and fetus cannot be counterbalanced by the unsatisfactory results of a prenatal operation., Conclusion: In this study first results of an experimental investigation with the new endoscopic techniques are presented, whereby the possibilities for optimization and quality improvement of the intrauterine surgical procedures are analyzed in detail.

Since 1993, a total of 41 free osteofasciocutaneous fibular flaps with an extended skin island (average dimensions, 16.9 cm long [range, 12-22 cm] x 10.7 cm wide [range, -16 cm], or 180.8 cm [range, 112-352 cm ]) have been used in by the authors in various clinical applications. To evaluate donor site morbidity, the 41 patients involved were asked to answer a questionnaire and to present themselves for clinical and radiological examination. The subjective findings reported by these patients, and the examinations, showed that donor site morbidity was moderate. Apart from some occurrence of mild edema and pain, as well as modest motor weakness of the great toe, and deficiency of distal nervous segments, only 7 patients were found to have a slightly positive anterior drawer of the talus (anterior subluxation of the talus), but no instability. In conclusion, donor site morbidity after harvest of osteofasciocutaneous fibular flaps for different clinical indications, where extended skin islands were needed, is moderate.