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OBJECTIVE: Pregnancy induced gigantomastia is a rare condition (1:100.000 pregnancies) of unknown etiology. Regarding this condition we would like to discuss the possibilities of antenatal treatment, management during pregnancy and treatment after delivery. RESULTS: In our histological and immunological investigations we did not find any facts that will point out any specific etiology of this condition. The pregnancy induced gigantomastia could not be influenced by any conservative management or medical treatment. CONCLUSION: Therefore we would recommend plastic reconstructive surgery from medical as well as cosmetic point of view.

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The arterial quality of a skin flap largely depends on the vascular connections to the surrounding tissue. We can differentiate three typical vascular structures underneath the body's surface: large supporting vessels running parallel to the body's surface, transporting vessels (perforators) with a segmental vascularization and leading to horizontal (reticular) nets of distribution. These structures can be found at the subcutaneous plane, all septofascial planes, and the vascular pattern of the muscles. All three structures can provide sufficient blood to partially separated and mobilized skin areas (flaps). Each skin flap can be classified by the type of enclosed tissue (subcutis, fascia, muscle) and the type of blood supply (axial, segmental, reticular). The quality of blood flow within a skin flap is not disturbed by separation and mobilization if the vascular continuity to the supporting horizontal vessels stays intact. This is the case in socalled axial pattern flaps (the supporting vessel is elevated with the flap) and in segmental pattern flaps (here continuity stays intact with the supporting vessel in deeper layers). In contrast, reticular pattern flaps are characterized by a decreased quality of blood flow (sensible to pressure and tension) because they lack a direct connection to the supporting vessels. Most skin flaps show a complex organization of their vascular structure: they either have a parallel support by several structures (improved quality of blood circulation) or they contain several structures in sequence within their longitudinal axis (decreased quality of blood circulation). This structural analysis does not take into account the hemodynamic conditions and their influence on the quality of blood circulation which are predisposed by the width and the amount of vessels.

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The female breast can be reduced by a number of operative techniques. Their goal is to transform different deformities into a so-called ideal form. The ideal form is obtained by small changes such as fixing the nipple's position in relation to predetermined anatomical marks. Under certain conditions we have to deviate from the ideal form. In these cases the operative method used is not determined by the deformity but by the desired form. Reduction mammoplasty techniques are just variations of a single method whose principles still need to be defined.

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Studies done on the skin's blood circulation have also resulted in the development of new, more complex flaps. This complexity has made a standardized classification of flaps no longer possible. As a result of this, we have tried to analyze the inner system of flaps. This analysis has made a connection between the construction and the vascular structure of the flaps evident. Based on the fundamental construction and basic vascular structure, we are able to divide the flaps into three elementary types. All the complex flaps are composed of these three elementary types. This composition takes place in the form of a parallel connection or in the form of a sequential connection of the elementary types or both. To ensure the adequate blood supply of a flap, it is necessary to maintain the continuity of the elementary vascular patterns.

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Thermic lesions of the neck, the shoulder, and the thoracic wall in young children are characterized by identical etiology, pathology, and prognosis. Scald injuries from hot liquids cause deep second-degree up to superficial third-degree burns. In these injuries the subcutaneously located mammary gland is not affected. Therefore, the severe deformities that may occur in puberty are only defects of the soft tissue coverage and not of the mammary glands. Radical scar excision and skin grafting is the therapy of choice. Z-plasty and local flaps may correct these burn defects only partially because the loss of tissue is compensated only by a new distribution of the adjacent skin areas.

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Because of high infection rats and because of possible deformities after radical débridement there is still some restraint in primary wound closure in facial bite injuries. Today the sophistication of facial reconstructive surgery provides the possibility even with injuries with significant skin defects to gain primary healing with satisfactory results from a cosmetic point of view as well as from a functional one.

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Beside the importance of its prehensile function the human hand plays an essential role in the conveyance of expression. Manual gestures support the mimic and confirm the spoken word. Based on the psychofunctional connection between mimic and gesture the hand becomes an outlet for psychogenic disorders. The resultant projection of emotional processes into motor disorders has been a matter of conjecture etiologically. Psychogenic manifestation in isolated motor disorders of the hand is considered to be either a functional nervous disorder or a focal dystonia. In comparison to the conversion phenomena reported up until now, in which flexor muscle units of the hand are involved with increased muscular activity (spasm), the cases presented here are characterized by a functional motor disorder manifested as an isolated paralysis of a selective extensor muscle unit (M. extensor pollicis longus) of the hand. After a multidisciplinary approach including clinical morphology, neurology, EMG and psychiatry the final diagnosis of a psychogenic paralysis of the hand is made using direct electro-stimulation of the neuromuscular unit with a needle electrode under simultaneous elimination of the psychic influence (general anesthesia without muscular relaxation). Through such confirmed motor inactivity the psychic genesis of the clinically existing paralysis is proven. Through immediate introduction of a multimodal therapy including physical and psychiatric treatment psychogenic paralyses of the hand can be restored totally.

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In severely burned patients water and electrolyte imbalance is the most obvious disturbance during the shock period but problems also occur because of large protein losses and absorption of toxic products from the damaged skin. These factors may impair brain function and this may be further affected by the action of drugs used for therapy. Brain function was assessed in 12 burned patients by EEG recordings. The EEG records showed no changes specific to burned patients. Changes were seen similar to those seen in patients under intensive care for other surgical conditions and seemed to be related to the level of consciousness and to the drug therapy.

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The authors report a modified positioning of patients for long-term handsurgical operations under regional anaesthesia. After equalizing the level of hand- and operating table, the operating table is tilted 10-15 degrees towards the hand-table. The upper limb is abducted only 30-40 degrees and then rotated outwards. This guarantees a comfortable positioning of the patients for a longer period of time.

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In a case report, replantation of a subtotally amputated forearm at the elbow region is described. The elbow joint was reconstructed. At the end of the operation a huge soft tissue defect remained leaving the vein grafts unprotected. Using a latissimus dorsi myocutaneous island flap, the soft tissue defect was covered and the function of the biceps muscle restored.

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Mammography using X-ray with low penetration allows a sharp picture with very good contrast of the trabecular medulla and the diaphyseal cortex in the hand skeleton. Because of the higher X-ray dosage the technique should be used only in the following indications: 1. Fractures and fissures in the joints. 2. Evaluation of osseous consolidation in doubtful cases. 3. Distinction between recent and old changes.

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The value of a combined skin and muscle pedicle as opposed to the purely muscular pedicle is discussed using the example of the myocutaneous island skin flap of the M. latissimus dorsi in the neck-, shoulder-, and upper arm region. There is an indication scheme for the choice of flap pedicle depending on the tension and kinking of the flap or possible previous damage of the muscle pedicle.

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On a patient with traumatic loss of all of the fingers a light but satisfactory grip was obtained by the construction of an opposition post with sensation. This was achieved by a tubed abdominal pedicle flap containing iliac bone graft. A neurovascular cross-finger flap was transfered from the uninjured hand in such a way that an anastomosis to a branch of the nerve of the injured hand was possible, allowing for the development a satisfactory sensation.

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This work describes the results of 75 flexor tendon repairs with all injuries involving the flexor tendons of the fingers either in the palm or in "no-man's land". Of these 75 cases, primary repair was performed in half the cases with flexor tendon grafts. Comparisons were made between these two varying methods of treatment, bearing in mind the nature and circumstances of the injury. In the group of primary tendon repairs, 60% of the patients showed good to very good results; in the grafted group, only 42% showed equally good results. From this study it is felt that primary tendon repair, when technically feasible, is the prefered procedure within the palm or the digits. Associated nerve and bone injuries were not found to be a contraindication to such an approach.

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