should be performed as far dorsally as possible. In this not cause any problems. In a female patient that means way the loop is covered by the neighbouring erector mus loss of most of the sensation in the breast. culature and a further muscle flap is not needed, thus elim The problem of postoperative intercostal neuralgia is inating the possibility of a further functional deficit. So far very well analyzed by the authors, but the indication for we have been successful with one loop and did not have to denervation by forming three or more loops between in involve more than two intercostal nerves. tercostal nerves has to be limited to very selected cases. The functional deficit seems to be the most question The need of involvement of so many dermatomes has to able side effect of the procedure proposed by the authors. be clearly proven preoperatively, and the disadvantages must be investigated more precisely in the future. The ex Preoperative pulmonary function was not compared to the postoperative situation. Therefore, the statement that the perience of the authors, which is limited to five patients denervation of six or more intercostal spaces does not and the insufficient study of long-term effects, leads me cause any reduction of respiratory function cannot be ac to advise that this procedure is not used routinely at the cepted, especially because of the additional use of neigh moment. bouring musculature for coverage and improvement of vascularization of the nerve loops. Even if it has been M. Frey Universitatsk1inik fiir Chirurgie proven that there is no interference with pulmonary func Abteilung fiir Plastische und tion, one has to consider that it may be impossible to com Rekonstruktive Chirurgie pensate for respiratory deficits which occur with aging. Intensivstation fiir Brandverletzte Besides the motor deficit, it is difficult to accept that Wahringer Giirtel 18-20 the loss of sensation in six dermatomes or more does A-1090 Wien, Austria The Invited Commentary by Prof. M. Frey is very critical 5. We did indeed not measure pulmonary capacity before and to the point. We have considered that patients who and after the intervention. Possibly preoperative normal have untreatable post-thoracotomy pain and have gone breathing was impaired due to pain. Certainly pre- and through the complete ladder of pain treatment will accept postoperatively short and long-term follow-up objective any procedures which may help them with pain relief. Our measurements will give accurate information. However, major concern, as underlined by the reviewer, was cer the selective role of denervation is difficult to ascertain tainly the impact of the procedure on pulmonary function. as it is known that pulmonary function decreases with There is no point in replacing one debilitating disease by age. Only a long-term prospective case control study with another. Several comments, however, should be made. sufficient patients will provide answers to this question. This was certainly not the aim of our paper. 1. Postoperatively, none of the patients complained about their pulmonary function during normal daily activities. With respect to the sensory deficit due to the procedure, it In contract, previously their normal daily activities were has to be mentioned that sensory evoked potentials were severely restricted due to pain. For example, one patient always absent preoperatively in the two dermatomes adja returned to manual labor, performing hard construction cent to the thoracotomy and in some patients in even work. He had no complaints during this work activity. more. Problems concerning the loss of nipple sensation 2. Regarding additional muscle slips to cover the loop, the were not mentioned by female patients. However, it is latissimus dorsi was usually selected. Certainly, this mus known that loss of nipple sensation may occur after a nor cle does not influence any respiratory function as is mal breast reduction, which is requested and performed known from its extensive use even with complete transfer for merely aesthetic reasons. of the muscle. Covering the loop by neighboring erector Searching through the literature and examining the so musculature is certainly an alternative, however it is a lutions proposed for this problem, we feel that we ap muscle with a large excursion and therefore not the first proached the problem of post-traumatic neuroma in con choice to bring in contact with regenerating nerves. tinuity properly. The proposed resection of an entire rib 3. Moreover, it is known from the experience of neuroti by Prof. Frey might be very efficient, but can also not zation of the brachial plexus, even in young patients, be considered as non-aggressive. Finally, we do agree, where six or seven intercostal nerves are used, that no dra as mentioned before, that this procedure should be re matic pulmonary dysfunction occurs due to adaptation by stricted to patients in desperate straits. compensatory mechanism. P.J. Guelinckx · N.K. Sinsel · T. Lerut 4. A certain amount of pulmonary capacity loss is well tolerated and not debilitating, as for example after partial UZ Gosthuisberg, Herestraat 49 pneumonectomy. This is in contrast to permanent untreat B-3000 Leuven, Belgium able pain.
European Journal of Plastic Surgery – Springer Journals
Published: Feb 1, 1998
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