Orientador: Cesar Cabello dos Santos / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-11T14:18:12Z (GMT). No. of bitstreams: 1 Sbalchiero_JulianoCarlos_M.pdf: 1658503 bytes, checksum: e364486f66af09b9d6927c7700999eb1 (MD5) Previous issue date: 2008 / Resumo: Introdução: O Retalho Miocutâneo Transverso do Músculo Reto Abdominal (TRAM) Pediculado é uma técnica muito utilizada em reconstrução de mama, entretanto em situações em que é necessária a utilização das áreas II e IV do retalho as alternativas são os retalhos bipediculados de maior morbidade ou livres de maior complexidade. O TRAM turbinado com anastomose dos vasos epigástricos inferiores profundos na perfurante contralateral pode ser uma alternativa nestes casos. Objetivos: Apresentamos uma série de pacientes submetidas à reconstrução mamária tardia unilateral, com TRAM pediculado preservando a musculatura turbinada na perfurante contralateral e avaliado quanto aos resultados, tempo cirúrgico e complicações relacionadas à mama reconstruída e à área doadora.abdominal. Sujeitos e métodos: Durante o período de março de 2005 a abril de 2006, 22 pacientes foram selecionadas para reconstrução mamária tardia unilateral no Serviço de Cirurgia Plástica e Microcirurgia do Instituto Nacional de Câncer no Rio de Janeiro, Hospital do Câncer Unidade I, por apresentarem os seguintes critérios: 1. Grave seqüela produzida pela mastectomia com extensiva perda cutânea associada a alterações tróficas produzidas pela radioterapia 2. Necessidade de utilização das áreas II e IV do retalho abdominal para obtenção de simetria com a mama contralateral. Resultados: A técnica proposta foi realizada em 17 pacientes. A média de tempo de seguimento foi de 11 meses (9 a 18 meses). A média da idade foi de 47,7 (35 a 68 anos) anos e a média do Índice de Massa Corporal foi de 27,31% (18,75% a 31,7%). A porção lateral do músculo reto abdominal do lado pediculado foi preservada em 12 pacientes. Em todos os casos foram incluídas no retalho as áreas II e IV. A média do tempo cirúrgico foi de 7 horas e 15 minutos (de 5 horas e 20 minutos a 9 horas). A média do tempo de hospitalização foi de 8 dias (6 a 10dias). Foram observadas 4 complicações na área doadora abdominal em 3 pacientes, sendo um abaulamento contralateral; duas deiscências de sutura e uma epidermólise das bordas do retalho abdominal e da cicatriz umbilical. Na mama reconstruída foram observadas 3 perdas parciais de 10% em 2 casos e 30% em um caso; e duas liponecroses associadas a perdas parciais. Ocorreu um caso de TVP com embolia pulmonar de evolução favorável. Conclusões: O TRAM turbinado com anastomose microcirúrgica na perfurante contralateral demonstrou ser uma alternativa viável para reconstrução mamária, atingindo resultados satisfatórios na maioria das pacientes e com uma morbidade e tempo cirúrgico aceitáveis / Abstract: Background: The Transverse Rectus Abdominis Miocutaneous (TRAM) Flap is a technique widely used in breast reconstruction, however in situations where it required the use of flap areas II and IV the alternatives are bipedicle flaps or free flaps of greater morbidity and complexity. The turbocharged TRAM anastomosing the deep inferior epigastric artery and vein with contralateral perforators can be an alternative in these cases. Objective: We present a series of patients undergoing unilateral delayed breast reconstruction with TRAM preserving the muscle turbocharged on contralateral perforator vessels and evaluated on the results, operative time and surgical complications related to the reconstructed breast and abdominal donor site. Patients and methods: During the period March 2005 to April 2006, 22 patients were selected for unilateral delayed breast reconstruction at the Plastic Surgery and Microsurgery Department of the Instituto Nacional de Câncer in Rio de Janeiro, Brazil, Hospital de Câncer I, for present the following criteria: 1. Severe sequelae produced by mastectomy with extensive skin loss associated with trophic skin changes produced by radiotherapy. 2. Need to use the areas II and IV of the abdominal flap for obtaining symmetry with the contralateral breast. Results: The proposed technique was performed on 17 patients. Follow-up ranged from 9 to 18 months (average 11 months). The average patients age was 47.7 years (35 to 68 years) and the average Body Mass Index (BMI) was 27.31% (18.75% to 31.7%). The lateral portion of the rectus muscle was preserved in 12 patients. In all cases were included in the flap areas II and IV. The average surgical time was 7 hs and 15 min (5hs and 20 minutes to 9 hs). The average period of hospitalization was 8 days (6 to 10 days). There were 4 abdominal donor site complications in 3 patients: One abdominal bulging; two minor suture deiscences and a epidermolysis on the flap edge and umbilical scar. In the reconstructed breast were 3 partial loss of 10% in 2 cases and 30% in one case, and two minor fat necrosis associated with partial losses. There was a case of DVT with pulmonary embolism, with good outcome. Conclusions: The turbocharged TRAM with microsurgical anastomosis in contralateral perforators proved to be an effective alternative to breast reconstruction achieving satisfactory results in the majority of patients and with an acceptable morbidity and surgical time / Mestrado / Ciencias Biomedicas / Mestre em Tocoginecologia

INTRODUÇÃO: O retalho ântero-lateral da coxa é baseado em vasos perfurantes do ramo descendente da artéria circunflexa lateral femoral. Este retalho tem características muito interessantes para a cirurgia reparadora, como a pequena espessura, pedículo longo e excelente área doadora. No entanto, existem muitas controvérsias na literatura quanto aos vasos perfurantes e ao trajeto do pedículo deste retalho. Neste trabalho procurou-se estabelecer alguns parâmetros anatômicos e esclarecer estas controvérsias. MÉTODO: Estudaram-se 100 coxas de 50 cadáveres quanto aos seguintes aspectos: 1- Número e localização de perfurantes encontrados, 2- Trajeto do pedículo perfurante, 3- Trajetória intramuscular, 4- Comprimento do trajeto intramuscular, 5- Comprimento total do pedículo, 6- Diâmetro dos vasos e 7- Espessura do retalho. RESULTADOS: 1- Encontraram-se de 0 a 4 perfurantes por coxa estudada, todas em um raio de até 6cm do ponto médio entre a espinha ilíaca ântero-superior e a borda lateral da patela. 2- Os vasos perfurantes tinham trajeto músculo-cutâneo em 75,76% das coxas e septo-cutâneo em 24,24%. 3- Dos pedículos perfurantes com trajeto músculo-cutâneo, 86,67% possuíam trajetória indireta contra 13,33% com trajetória direta. 4- O comprimento médio do trajeto intramuscular dos pedículos foi de 3,67 ± 2,01 cm. 5- O comprimento médio do pedículo total foi de 11,31 ± 3,12 cm. 6- O diâmetro médio da artéria na origem do ramo descendente da artéria circunflexa femoral foi de 2,21 ± 0,85 mm e para as veias no mesmo local de 2,66 ± 1,33 mm e 2,10 ± 1,11 mm. 7- A espessura da tela subcutânea foi de 8,98 ±6,23 mm e da pele de 1,60 ± 0,76 mm. CONCLUSÕES: 1- Existiu uma pequena possibilidade de não haver pedículos perfurantes. 2- Quando presentes, os pedículos perfurantes do ramo descendente da artéria circunflexa lateral femoral eram encontrados em numero de 1 a 4, sempre em um raio de 6 cm a partir do ponto médio entre a espinha ilíaca ântero-superior e a borda lateral da patela. 3- Os trajetos dos pedículos perfurantes eram predominantemente músculo-cutâneos. 4- A trajetória intramuscular encontrada foi predominantemente indireta. 5- O comprimento do trajeto intramuscular correspondeu a 31,69% do comprimento total do pedículo. 6- O comprimento total do pedículo se mostrou adequado tanto para transferências locais como à distancia por técnicas microcirúrgicas. 7- Os diâmetros dos vasos, tanto da artéria quanto das veias, se mostraram adequados para a realização de anastomoses microcirúrgicas. 8- A espessura do retalho encontrada foi significantemente maior nas coxas de indivíduos femininos, mas tanto nos homens quanto nas mulheres a espessura foi relativamente fina. / INTRODUCTION: The anterolateral thigh flap is based on the perforator vessels of the descending branch of the lateral circumflex femoral artery. This flap has very interesting characteristics for the reconstructive surgery, like the small thickness, long pedicle and excellent donor site. On the other hand, there are many controversial data on the literature about the perforator vessels and the pedicle course of this flap. The aims of this study are to establish some anatomical parameters and clear some controversies. METHOD: A hundred thighs of 50 cadavers were studied for: 1- The number and location of the perforator vessels. 2- The course of the perforator pedicles. 3- The intramuscular course. 4- The length of the intramuscular course. 5- The total length of the vascular pedicle. 6- The diameter of the vessels. and 7- The thickness of the flap. RESULTS: 1- There were found from 0 to 4 perforators per thigh, all in a 6cm radius from the mid point between the anterosuperior iliac spine and the lateral border of the patella. 2- The pedicles was musculocutaneous in 75,76% of the thighs and septocutaneous in 24,24%. 3- Among the musculocutaneous pedicles, 86,67% had a direct intramuscular course, and 13,33% had indirect course. 4- The mean length of the intramuscular course was 3,67 ± 2,01 cm. 5- The mean total pedicle length was 11,31 ± 3,12 cm. 6-The mean artery diameter on the origin of the descending branch of the lateral circumflex femoral artery was 2,21 ± 0,85 mm and the mean vein diameter on the same spot was 2,66 ±1,33 mm and 2,10 ± 1,11 mm. 7- The mean subcutaneous fat tissue thickness was 8,98 ± 6,23 mm and the mean skin thickness was e 1,60 ± 0,76 mm. CONCLUSIONS: 1- There was a possibility of finding no perforators of the descending branch of the lateral circumflex femoral artery. 2- When present, the perforators pedicles were found in numbers between 1 to 4, always in a 6cm radius from the mid point between the anterosuperior iliac spine and the lateral border of the patella. 3- The perforators pedicles courses were predominantly musculocutaneous. 4- The intramuscular courses were mainly indirect. 5- The intramuscular length was responsible for 31,69% of the total length of the vascular pedicle. 6- The total length of the pedicle was adequate for either local or microsurgical transfers. 7- The arterial and venous diameters were adequate for microsurgical anastomosis. 8- The female cadavers had significantly thicker flaps, but both in the male and the female cadavers the flap was considerably thin.

Para avaliar a eficiência da técnica do retalho em fechadura associada à pigmentação por tatuagem na reconstrução do complexo aréolo-papilar, foram estudadas 22 pacientes mastectomizadas que haviam sido submetidas à reparação mamária. Realizada a restauração dos complexos com a técnica proposta, medidas das projeções das papilas foram feitas em vários períodos até 18 meses de pós-operatório. A qualidade das pigmentações foi mensurada com notas de 0 a 3, dadas pelas pacientes e pelo cirurgião. Verificou-se uma perda da projeção da papila a aproximadamente 41,50% da projeção inicial. A média das notas atribuídas às tatuagens pelas pacientes e pelo cirurgião foram respectivamente de 1,72 e 1,44 (correspondendo à perda de tonalidade dos complexos) / In order to evaluate the efficiency of nipple areola complex reconstruction using the keyhole flap technique plus tattoo pigmentation, 22 patients who were submitted to mastectomy and breast repair were studied. After the restoration of the complexes with the proposed technique, nipples projection were measured during several periods until the 18th month after surgery and the tattoo quality was evaluated using grades from 0 to 3, which were given by the patients and by the surgeon. A loss of nipple projection to 41,50% of the initial projection was observed. The averages of the grades attributed respectively by the patients and the surgeon to the tattoos were 1,72 and 1,44 (corresponding to the loss of shade of the complexes)

Instituto Dr. Josà Frota / A meta da presente pesquisa foi apresentar tÃcnicas cirÃrgicas associadas ou isoladas, na tentativa de, utilizando cirurgias menos traumÃticas e mais eficientes, proporcionar resultados menos estigmatizantes e deformantes para dar aos portadores da neurofibromatose tipo 1 (NF1) uma qualidade de vida mais digna e melhor integraÃÃo social. Estudou-se neste trabalho 30 pacientes portadores de NF1 por um perÃodo de seis anos, durante os quais se comparou a eficiÃncia de diversas tÃcnicas cirÃrgicas em lesÃes localizadas em vÃrias regiÃes anatÃmicas do corpo e cujas ressecÃÃes atingiram dimensÃes que variaram entre 3 e 51cm. A utilizaÃÃo do tratamento cirÃrgico mostrou ser a maneira mais simples, eficaz e rÃpida para a soluÃÃo de afecÃÃo tÃo traumÃtica para os pacientes. Mesmo quando da utilizaÃÃo de retalhos cutÃneos com comprometimento residual da pele o seguimento operatÃrio mostrou que a doenÃa nÃo evoluiu e nÃo houve qualquer sinal de malignizaÃÃo. Das opÃÃes mais empregadas foram os retalhos cutÃneos loco-regionais, as que melhores resultados proporcionaram, quer do ponto de vista funcional como estÃtico, e os que causaram menor nÃmero de seqÃelas. Vinte e um pacientes se beneficiaram de excisÃes e reparaÃÃes com retalhos e os demais com procedimentos mais simples, o que lhes permitiu uma melhor qualidade de vida e melhor aceitaÃÃo social. Os retalhos cutÃneos loco-regionais foram aqueles que possibilitaram o reparo das maiores Ãreas cruentas e a ressecÃÃo dos mais volumosos tumores, com uma mÃdia de 16,4 x 8,1 cm e um peso mÃdio de 373 g. O âSâ itÃlico com uma mÃdia de 8,5 x 5,5 cm e 135 g e a âZâ plÃstia com 8,5 x 4,8 cm e 82,8 g mostraram-se eficazes para a reparaÃÃo de lesÃes de mÃdio porte onde aparecem como uma das opÃÃes para reparaÃÃo imediata das ressecÃÃes da NF1.ExcisÃo e Sutura com 4,9 x 2,8 cm e 33,8 g e pequenos enxertos de pele estÃo indicados nas lesÃes de dimensÃes menores e de localizaÃÃes especiais, como a face e nariz. NÃo foram detectadas malignizaÃÃes nas 52 peÃas encaminhadas ao laboratÃrio de histopatologia.

The objective of this work is to adopt and further expand the type design of the SONG motor glider. The study will result in the basic aerodynamic calculation and the design of lateral control system including structural strength inspection of selected parts. Subsequently, the proposal will allow for further calculation to be made (of flight mechanics, wings strength or fuselage and empennage firmness) and for more specific constructional design of individual components of the glider.

INTRODUCTION: Transverse rectus abdominus muscle flaps (TRAM) can result in significant abdominal wall donor-site morbidity. We present our experience with bilateral pedicle TRAM breast reconstruction using a double-layered polypropylene mesh fold over technique to repair the rectus fascia. METHODS: A retrospective study was performed that included patients with bilateral pedicle TRAM breast reconstruction and abdominal reconstruction using a double-layered polypropylene mesh fold over technique. RESULTS: Thirty-five patients met the study criteria with a mean age of 49 years old and mean follow-up of 7.4 years. There were no instances of abdominal hernia and only 2 cases (5.7%) of abdominal bulge. Other abdominal complications included partial umbilical necrosis (14.3%), seroma (11.4%), partial wound dehiscence (8.6%), abdominal weakness (5.7%), abdominal laxity (2.9%), and hematoma (2.9%). CONCLUSIONS: The TRAM flap is a reliable option for bilateral autologous breast reconstruction. Using the double mesh repair of the abdominal wall can reduce instances of an abdominal bulge and hernia.

INTRODUCTION: Transverse rectus abdominus muscle flaps (TRAM) can result in significant abdominal wall donor-site morbidity. We present our experience with bilateral pedicle TRAM breast reconstruction using a double-layered polypropylene mesh fold over technique to repair the rectus fascia. METHODS: A retrospective study was performed that included patients with bilateral pedicle TRAM breast reconstruction and abdominal reconstruction using a double-layered polypropylene mesh fold over technique. RESULTS: Thirty-five patients met the study criteria with a mean age of 49 years old and mean follow-up of 7.4 years. There were no instances of abdominal hernia and only 2 cases (5.7%) of abdominal bulge. Other abdominal complications included partial umbilical necrosis (14.3%), seroma (11.4%), partial wound dehiscence (8.6%), abdominal weakness (5.7%), abdominal laxity (2.9%), and hematoma (2.9%). CONCLUSIONS: The TRAM flap is a reliable option for bilateral autologous breast reconstruction. Using the double mesh repair of the abdominal wall can reduce instances of an abdominal bulge and hernia.

Using a general, unsteady, nonlinear vortex lattice method, the aerodynamic loads have been found on a 75° delta wing with and without leading edge vortex flaps. The flap had an area approximately 26 percent of the wing area with a constant chord of 6.7 percent of the wing mean aerodynamic chord and was deflected at 30°. Results for lift, drag, axial force, and pitching moment coefficients are compared with experimental data and show very good agreement. Individual pressure difference coefficients along the wing and flap are also presented and compared with experimental data. Overall, the method shows the leading edge vortex flap to be very effective in reducing drag while maintaining lift comparable to that of the plain wing. / Master of Science

Im Rahmen dieser Arbeit wurde der Einfluss von passiven und elastischen Rückstromklappen, die auch als Flaps bezeichnet werden, auf einen Tragflügel mit NACA0020 Profil untersucht. Mithilfe einer Kraftwaage erfolgte zunächst die Erfassung der Auswirkungen auf das aerodynamische Verhalten des Tragflügels vor und nach der Strömungsablösung. Für ein detailliertes Verständnis wurde zusätzlich die Umströmung mit der Rauchdrahttechnik visualisiert und die Flapkinematik mit der Stereo Vision Technik aufgenommen. Es konnte festgestellt werden, dass die Vorderkantenflaps mit der geringsten Biegesteifigkeit die Gleitzahl des Tragflügels vor allem in abgelöster Strömung erhöhen. Die festgestellte Auftriebssteigerung resultiert aus der langsamen Aufstellbewegung und beschleunigten Anlegebewegung der Flaps, die eine einhergehende Reduzierung der turbulenten Ablösung verursachen. Die Ergebnisse der Arbeit liefern zahlreiche Erkenntnisse, die eine Übertragung des festgestellten Effekts auf andere technische Anwendungen erleichtern.:Abbildungsverzeichnis....................................................................... VII Tabellenverzeichnis............................................................................ XII Symbol- & Abkürzungsverzeichnis..................................................XVI 1 Einleitung......................................................................................... 1 2 Stand der Forschung........................................................................ 4 2.1 Wesentliche Aspekte von Profilumströmungen ................................. 4 2.2 Zusammenfassung essenzieller Aspekte von Tragflügeln mit Flaps ......7 3 Numerische Untersuchung der Profilumströmung....................... 13 3.1 Numerische Modell ......................................................................13 3.1.1 Grundgleichungen und Turbulenzmodell ..............................13 3.1.2 Randbedingungen und Diskretisierungsschema .....................16 3.2 Ergebnisse für das NACA0018 Profil .............................................18 3.3 Ergebnisse für das NACA0020 Profil .............................................19 3.4 Schlussfolgerung aus den Simulationen ..........................................22 4 Kraftmessungen an einem NACA0020 Tragflügel ....................... 23 4.1 Versuchsvorbereitung ...................................................................23 4.1.1 Windkanal ........................................................................23 4.1.2 Tragflügel und Funktionsweise der Kraftwaage .....................25 4.2 Messunsicherheit und Validierung .................................................27 4.3 Position der Flaps auf dem Tragflügel............................................ 31 4.3.1 Flapgeometrie und Flappositionen....................................... 31 4.3.2 Polardiagramme für variierende Flapposition........................34 4.4 Faserverstärkte Silikonflaps...........................................................36 4.4.1 Verwendeten Materialien ....................................................36 4.4.2 Polardiagramm für faserverstärkte Silikonflaps .....................38 4.5 Flapgeometrie .............................................................................40 4.5.1 Untersuchte Flapformen .....................................................40 4.5.2 Polardiagramm der untersuchten Flapformen ....................... 41 4.6 Wirkung der Flaps bei instationären Anströmung...........................43 4.6.1 Versuchsdurchführung ........................................................43 4.6.2 Ergebnisse der instationären Untersuchung...........................45 4.7 Schlussfolgerung der Auftriebs- und Widerstandsuntersuchungen .....47 5 Strömungsvisualisierung mithilfe der Rauchdrahttechnik........... 49 5.1 Experimenteller Aufbau ...............................................................49 5.2 Vorgehensweise bei der Auswertung...............................................50 5.3 Ergebnisse der Visualisierung........................................................ 51 6 Flapkantenkinematik..................................................................... 58 6.1 Versuchsaufbau und Versuchsdurchführung ....................................58 6.2 Bildauswertung ........................................................................... 61 6.3 Ergebnisse ..................................................................................62 6.3.1 VK Konfiguration - ohne Faserverstärkung...........................62 6.3.2 Bewegungsausführung des Vorderkantenflaps der VK-HK Konfiguration - ohne Faserverstärkung.......................................69 6.3.3 Bewegungsausführung des Vorderkantenflaps der VK-HK Konfiguration - mit Faserverstärkung ........................................75 6.3.4 Auswertung und Interpretation ...........................................82 7 Zusammenfassung.......................................................................... 87 8 Ausblick.......................................................................................... 89 Anhang ................................................................................................ 97 A Anhang 1....................................................................................97 B Anhang 2....................................................................................98 C Anhang 3....................................................................................99 / In the following study the effects of elastic and passive flaps were investigated on an airfoil with a NACA0020 profile. At first the aerodynamic performance of different configurations was measured with a force balance. In order to detect its effects before and after stall the angle of attack was varied during the experiments. For the configurations with increased aerodynamic performance additional experiments were carried out. The smoke wire visualization and stereo vision technique allowed a detailled insight in the flow around the NACA0020 profile and the flap movement. The results show that elastic flaps at the leading and trailing edge of the airfoil improve notably the airfoil performance in deep stall. Furthermore, the highest increase of the lift-to-drag ratio was achieved for the configuration with lowest bending stiffness. It was observed that the highest reduction of the turbulent separation region is caused by the flap movement. The increase of lift-to-drag ratio results from a slow upward and a fast downward motion of the elastic flap. The study delivers helpful information for transfer of the observed effect to other technical applications.:Abbildungsverzeichnis....................................................................... VII Tabellenverzeichnis............................................................................ XII Symbol- & Abkürzungsverzeichnis..................................................XVI 1 Einleitung......................................................................................... 1 2 Stand der Forschung........................................................................ 4 2.1 Wesentliche Aspekte von Profilumströmungen ................................. 4 2.2 Zusammenfassung essenzieller Aspekte von Tragflügeln mit Flaps ......7 3 Numerische Untersuchung der Profilumströmung....................... 13 3.1 Numerische Modell ......................................................................13 3.1.1 Grundgleichungen und Turbulenzmodell ..............................13 3.1.2 Randbedingungen und Diskretisierungsschema .....................16 3.2 Ergebnisse für das NACA0018 Profil .............................................18 3.3 Ergebnisse für das NACA0020 Profil .............................................19 3.4 Schlussfolgerung aus den Simulationen ..........................................22 4 Kraftmessungen an einem NACA0020 Tragflügel ....................... 23 4.1 Versuchsvorbereitung ...................................................................23 4.1.1 Windkanal ........................................................................23 4.1.2 Tragflügel und Funktionsweise der Kraftwaage .....................25 4.2 Messunsicherheit und Validierung .................................................27 4.3 Position der Flaps auf dem Tragflügel............................................ 31 4.3.1 Flapgeometrie und Flappositionen....................................... 31 4.3.2 Polardiagramme für variierende Flapposition........................34 4.4 Faserverstärkte Silikonflaps...........................................................36 4.4.1 Verwendeten Materialien ....................................................36 4.4.2 Polardiagramm für faserverstärkte Silikonflaps .....................38 4.5 Flapgeometrie .............................................................................40 4.5.1 Untersuchte Flapformen .....................................................40 4.5.2 Polardiagramm der untersuchten Flapformen ....................... 41 4.6 Wirkung der Flaps bei instationären Anströmung...........................43 4.6.1 Versuchsdurchführung ........................................................43 4.6.2 Ergebnisse der instationären Untersuchung...........................45 4.7 Schlussfolgerung der Auftriebs- und Widerstandsuntersuchungen .....47 5 Strömungsvisualisierung mithilfe der Rauchdrahttechnik........... 49 5.1 Experimenteller Aufbau ...............................................................49 5.2 Vorgehensweise bei der Auswertung...............................................50 5.3 Ergebnisse der Visualisierung........................................................ 51 6 Flapkantenkinematik..................................................................... 58 6.1 Versuchsaufbau und Versuchsdurchführung ....................................58 6.2 Bildauswertung ........................................................................... 61 6.3 Ergebnisse ..................................................................................62 6.3.1 VK Konfiguration - ohne Faserverstärkung...........................62 6.3.2 Bewegungsausführung des Vorderkantenflaps der VK-HK Konfiguration - ohne Faserverstärkung.......................................69 6.3.3 Bewegungsausführung des Vorderkantenflaps der VK-HK Konfiguration - mit Faserverstärkung ........................................75 6.3.4 Auswertung und Interpretation ...........................................82 7 Zusammenfassung.......................................................................... 87 8 Ausblick.......................................................................................... 89 Anhang ................................................................................................ 97 A Anhang 1....................................................................................97 B Anhang 2....................................................................................98 C Anhang 3....................................................................................99

Das Ziel dieser Studie liegt darin, die Vor- und Nachteile der Heparinapplikation nach mikrovaskulär-anastomosierten Transplantaten in der Mund-, Kiefer- und Gesichtschirurgie zu verifizieren und damit einen Nutzen für den klinischen Alltag abzuleiten. In der Zeit von Anfang Februar 2012 bis Ende Februar 2015 erfolgten in der Abteilung für Mund- Kiefer- und Gesichtschirurgie und Plastische Operationen im Klinikum Bremen Mitte 100 mikrovaskulär-anastomosierte Transplan-tationen. Bei 95 % der Fälle wurde die aPTT durch Heparin im Sinne einer Antikoagulation verlängert. Bei 79 % der 100 Fälle konnte ein Verbleiben des Lappens verzeichnet werden. Eine antikoagulative Therapie galt bei mikrovaskulären Transplantaten bisher als ein etabliertes Verfahren zur Vermeidung einer venösen Thrombose des Gefäßstieles. Aufgrund der Kontrollierbarkeit und Steuerbarkeit von hochmolekularem Heparin ist Heparin zur Zeit als das Mittel der Wahl anzusehen in der postoperativen antikoagulativen Therapie bei der mikrovaskulären Lappenchirurgie. Eine antikoagulative Therapie mit Heparin erfordert Aufmerksamkeit und eine intensive Betreuung. Durch die Applikation von Heparin wird das Risiko von Komplikationen erhöht, z.B. eine Heparin-induzierte Thrombozytopenie oder die Gefahr von Blutungen. Inwieweit eine hämostasehemmende / antikoagulative Therapie sinnvoll ist, ist fraglich. Ein signifikanter Unterschied wurde in der eigenen Untersuchung und auch in der neusten Literatur nicht verzeichnet. Die Einflussfaktoren auf das Lappenüberleben scheinen multifaktoriell zu sein. Die Indikationsstellung zur Operation muss gut überlegt sein, um den Erfolg der Operation und das Überleben der Patienten nicht zu gefährden. Patienten, bei denen eine Endothelalteration zu vermuten ist, die zum Beispiel eine vorausgegangene Kombinationsbehandlung mit Strahlentherapie und Chemobehandlung erhalten haben, zeigen ein deutlich höheres Risiko für den Erfolg der Operation im Hinblick auf das Lappenüberleben. Weitere prospektive randomisierte Studien sind erforderlich, um zu beweisen, dass und inwieweit eine hämostasehemmende Therapie einen Einfluss auf das Überleben der Transplantate hat.