Reduction Mammaplasty: What Cup Size Will I Be?

BACKGROUND: Predicting cup size after reduction mammaplasty is a challenge well recognized by plastic surgeons. This study presents a method whereby the weight of tissue to be excised can be predicted on the basis of the initial and desired cup size. METHODS: Breast density was calculated from resection specimens. Cup volumes of a specific range of bra style were then measured by filling the bra cups with modeling clay on a mannequin and the volume measured via water displacement. These data were then correlated to breast tissue volume and weight. RESULTS: The average breast tissue density calculated was 0.98 g/ml (SD = 0.05). Bra cup volume measurements showed a steady progression according to both cup and band sizes. A table was constructed to predict the weight of tissue required for excision to achieve the desired change in cup size. CONCLUSION: These results can assist plastic surgeons in predicting the amount of breast tissue to excise to achieve a given cup size. A secondary use of these results is a breast volume guide for implant planning.

Safety and Efficacy Concerns of Autologous Fat Grafting for Velopharyngeal Insufficiency.

OBJECTIVE: Autologous fat grafting of the velopharynx has been well described for the treatment of velopharyngeal insufficiency (VPI), with most studies purporting it as a technique with low morbidity useful in the treatment of mild VPI. Prompted by 3 cases of obstructive sleep apnea (OSA) following fat grafting of the velopharynx, we undertook a review of the outcomes of this procedure at our unit. DESIGN: Retrospective case series. PARTICIPANTS: All patients who underwent autologous fat grafting for VPI at the Royal Children's Hospital Melbourne. MAIN OUTCOME MEASURES: Preoperative nasendoscopy findings, perceptual speech assessment results, and rates of revisional surgery and complications. RESULTS: Twenty-eight patients were included in the study. Three patients (11%) developed severe OSA requiring removal of the grafted fat. In a subanalysis of cleft patients, there was a reported improvement in hypernasality in 63% though only 25% had complete resolution of their hypernasality. Patients who had an improvement in speech were more likely to have a velopharyngeal gap of less than 0.5 cm2 on preoperative nasendoscopy. All 3 patients who developed OSA had syndromes associated with hypotonia. CONCLUSIONS: This study raises serious concerns over the safety and efficacy of fat grafting for VPI. Overall, there was a relatively high complication rate with generally poor speech results in our series of patients. Stringent criteria should be used to select candidates for fat grafting, namely, a velopharyngeal gap less than 0.5 cm2 and the absence of a syndrome associated with hypotonia.

Submucous cleft palate: an often-missed diagnosis.

This study aimed to investigate the age at diagnosis, palatal characteristics, and symptoms of submucous cleft palate (SMCP) and to compare the speech outcomes between 3 operative techniques for primary repair of SMCP.It was a retrospective review of 92 patients diagnosed with SMCP between 1994 and 2008, where patients were treated with 1 of 3 surgical procedures: double opposing z-palatoplasty, radical intravelar veloplasty, or pharyngeal flap.The need for a second procedure was considered a primary outcome measure, with operative failure defined by the need for a secondary operation. Postoperative speech was evaluated perceptually using the Great Ormond Street Speech Assessment.We found that SMCP was diagnosed at a mean age of 3.6 years. At diagnosis, 8% were asymptomatic, 67% had abnormal speech, 49% had recurrent otitis media with effusions, and 47% had hearing loss. Ear, nose, and throat surgery was performed on 37% without the diagnosis of SMCP being made. Subjective impression of a short palate was a predictor for secondary surgery (P < 0.02). Age at repair did not affect velopharyngeal insufficiency outcome; however, repair after 18 months of age led to a higher likelihood of developing articulatory speech errors resulting in the need for more speech therapy.In conclusion, the triad of features of SMCP is well recognized, but our study reveals that a high percentage is seen by physicians who have failed to make the diagnosis despite signs and symptoms being evident. Surgical correction is successful regardless of technique and age, but earlier recognition to prevent speech impairment should be sought.

Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma.

BACKGROUND: The timing of soft tissue reconstruction for severe open lower limb trauma is critical to its successful outcome, particularly in the setting of exposed metalware and pre-existing wound infection. The use of negative pressure wound therapy (NPWT) may allow a delay in soft tissue coverage without adverse effects. This study evaluated the impact of delayed free-flap reconstruction, prolonged metalware exposure, pre-flap wound infection, and the efficacy of NPWT on the success of soft tissue coverage after open lower limb injury. METHODS: Retrospective review of all free-flap reconstructions for lower limb trauma undertaken at a tertiary trauma centre between June 2002 and July 2009. RESULTS: 103 patients underwent 105 free-flap reconstructions. Compared with patients who were reconstructed within 3 days of injury, the cohort with delayed reconstruction beyond 7 days had significantly increased rates of pre-flap wound infection, flap re-operation, deep metal infection and osteomyelitis. Pre-flap wound infection independently predicted adverse surgical outcomes. In the setting of exposed metalware, free-flap transfer beyond one day significantly increased the flap failure rate. These patients required more surgical procedures and a longer hospital stay. The use of NPWT significantly lowered the rate of flap re-operations and venous thrombosis, but did not allow a delay in reconstruction beyond 7 days from injury without a concomitant rise in skeletal and flap complications. CONCLUSIONS: Following open lower limb trauma, soft tissue coverage within 3 days of injury and immediately following fracture fixation with exposed metalware minimises pre-flap wound infection and optimises surgical outcomes. NPWT provides effective temporary wound coverage, but does not allow a delay in definitive free-flap reconstruction.

Lawn mower injuries in children: a 30-year experience.

BACKGROUND: Lawn mowers cause severe injuries that are particularly devastating to children. This study analyses the patterns and trends in lawn mower injuries involving children referred to Victoria's principal children's hospital. METHODS: A retrospective review of the patient medical records at the Royal Children's Hospital (Melbourne) Victoria, Australia was carried out. The series included all patients admitted for lawn mower injury during the 30-year period spanning 1975-2004. RESULTS: Lawn mower injuries treated at Royal Children's Hospital were severe and included partially amputated limbs. Overall, admissions for lawn mower injury generally decreased over time from n = 26 in the 1975-1979 interval to n = 14 in the 2000-2004 interval. However, the frequency of admission for injuries caused by ride-on mowers contradicted the overall trend and generally increased over time from n = 5 in the 1975-1979 interval to n = 11 in the 2000-2004 interval. This is of particular concern. Ride-on lawn mowers caused significantly more severe injuries requiring longer periods of admission and more operations during admission in comparison to standard mowers. Rural location at the time of injury was a risk factor associated with requiring longer periods of admission and more operations during admission. Children injured while operating mowers were generally older than children injured as bystanders. CONCLUSION: Lawn mower injuries are a significant cause of morbidity. These injuries are particularly devastating to children. The tragedy is keenly felt in the realization that these devastating injuries to children could all be prevented. Strategic preventative measures should be developed through partnership between the medical profession, the media, industry specialists and the wider community.

Air bag-associated burn.

Burns due to the deployment of air bags have been occasionally described in recent years. Most reports are about injuries in the USA. However, there have been few reports of this type of injury in Australia. This case report details such an injury that took place in a road traffic accident in Melbourne, Australia.

Outpatient cleft lip repair.

The emphasis on cost reduction and increased efficiency in health care delivery has prompted an increase in outpatient (ambulatory) surgical procedures. A retrospective review of the perioperative management of patients undergoing cleft lip repair at two urban tertiary pediatric hospitals was performed to assess the safety of outpatient cleft lip repair. The hospital database at Childrens Hospital Los Angeles was searched to find all patients who had been operated on for cleft lip repair during calendar years 1999 and 2000. Two groups were identified from Childrens Hospital Los Angeles: the outpatient cleft lip repair group (patients discharged the same day as the operation; n = 91) and the inpatient cleft lip repair group (n = 14). A data set was acquired from the Royal Children's Hospital in Melbourne, Australia, using the same criteria, for fiscal years 1998 to 2000 (n = 50). All patients from Royal Children's Hospital had operations as inpatients. Parameters considered for each group were age, sex, race, ethnicity, length of hospital stay, preexisting medical conditions or diagnoses, complications, and readmissions or presentation to the emergency department within 4 weeks of operation. The Childrens Hospital Los Angeles outpatient group had three readmissions that were considered to be complications of the operation. The Childrens Hospital Los Angeles inpatient group had one readmission attributable to a complication. The Royal Children's Hospital group also had one readmission for a complication. There was no significant difference in the complication rate of the Childrens Hospital Los Angeles outpatient group and the Royal Children's Hospital group (p > 0.05). There was also no significant difference in the complication rate of both of the Childrens Hospital Los Angeles groups compared with the Royal Children's Hospital group (p > 0.05). This study indicates that cleft lip repair performed in an outpatient setting may be a safe alternative to the inpatient operation. Certain preexisting medical conditions, however, may dictate the need for inpatient hospitalization after repair.