[Cost analysis of conservative versus operative therapy of macromastia]. / Kostenanalyse der konservativen versus operativen therapie der makromastie.

Macromastia causes back and neck pain, scaphodynia, intertrigo of the inframammary crease up to dysaesthesia. Typical complaints of patients with macromastia are physical burden, psychological irritation and aesthetic deformity, often resulting in social isolation. Despite the demonstrable success of reduction mammaplasty to eliminate not only the symptoms of macromastia but the cause of the ailment, conservative therapy is still favoured by insurance companies and bearing of costs for surgical therapy therefore is rejected. Expenses of conservative treatment as well as costs related to appeal and lawsuits against insurance decisions exceed the case-based lump sum of reduction mammaplasty manifold. Conservative treatments do not eliminate the causes of the illness. Therefore the rejection of a medically indicated reduction mammaplasty has to be regarded as unfavourable and economically inefficient.

Unveiling the molecular basis of intrinsic skin aging(1).

The process of skin aging is a combination of an extrinsic and intrinsic aspect, and knowing the molecular changes underlying both is a prerequisite to being able to effectively counter it. However, despite its importance for a deeper understanding of skin aging as a whole, the process of intrinsic skin aging in particular has barely been investigated. In this study, the molecular changes of intrinsic skin aging were analyzed by applying 'Serial Analysis of Gene Expression' (SAGE(TM)) to skin biopsies of young and aged donors. The analysis resulted in several hundred differentially expressed genes with varying statistical significance. Of these, several genes were identified that either have never been described in skin aging before (e.g. APP) or have no identified function, e.g. EST sequences. This is the first time that intrinsic skin aging has been analyzed in such a comprehensive manner, offering a new and partially unexpected set of target genes that have to be analyzed in more detail in terms of their contribution to the skin aging process.

Prilocaine plasma levels and methemoglobinemia in patients undergoing tumescent liposuction involving less than 2,000 ml.

BACKGROUND: As a reaction to reported adverse outcomes after lidocaine infiltration in tumescent liposuction, prilocaine has gained increasing popularity. Previous studies investigating large-volume liposuction procedures found maximum prilocaine levels and methemoglobinemia up to 12 h postoperatively, suggesting that liposuction should be performed as a hospital procedure only. The aim of this study was to determine prilocaine plasma levels and methemoglobinemia in patients after low- to average-volume liposuction for the purpose of defining the required postoperative surveillance period. METHODS: In 25 patients undergoing liposuction involving less than 2,000 ml prilocaine levels and methemoglobinemia were measured over 4 h postoperatively. Liposuction was conducted after the tumescent technique using a 0.05% hypotonic prilocaine solution with epinephrine. RESULTS: The average prilocaine dose was 6.8 + 0.8 mg/kg, with a maximum dose of 15 mg/kg. The peak prilocaine plasma level of 0.34 mug/ml occurred 3 h after the infiltration. The mean methemoglobinemia at this time point was 0.65%. Only one patient demonstrated a slightly elevated methemoglobin level of 1.4%, but lacked any clinical signs of methemoglobinemia. The prilocaine recovery in the aspirate averaged 36 +/- 4%, indicating that a large amount is removed by suctioning. CONCLUSIONS: The patients did not experience high plasma levels of prilocaine or methemoglobinemia undergoing liposuction involving less than 2,000 ml using a 0.05% hypotonic prilocaine solution. The authors therefore conclude that this procedure can be performed safely with a monitoring period of 12 h.

[Pyoderma gangrenosum: a rare cause of unexpected wound healing delay]. / Pyoderma gangraenosum--seltene Ursache einer unerwarteten Wundheilungsstörung.

Pyoderma gangrenosum represents a rare but severe disturbance of wound healing following operative interventions. A case report of pyoderma gangrenosum after breast surgery is presented and the aetiology and the various options regarding investigations and treatment are discussed considering the current literature.

PVP breast implants after two years: initial results of a prospective study.

A prospective study of a new mammary prosthesis with PVP-based gel as filling material was carried out. Scheduled follow-ups were planned at 3, 6, 12, and 24 months post-implantation to assess all complications, Baker scores, and the patient's, and the physician's global assessment of each implant. PVP-filled implants were used in 95 breasts for augmentation (60%) or reconstruction (40%). Sixty-nine percent of all patients underwent a primary procedure, 19% had a history of severe capsular fibrosis. During follow-up, a hematoma was observed in 2% and a seroma in 5%. Leakage occurred in 3% (one iatrogenic and two cases of unknown reason), a Baker 3 in 6% (12 months). No volume increase of the implants occurred. The probability that a patient would be complication-free at 24 months was 0.86. Physician's and patient's satisfaction rating after 12 months remained high without any time effect (physician very good/good 63%, patient 75%). According to our current experiences, the PVP-filled implants are a remarkable alternative with an improved viscosity and enhanced x-ray transmission, compared to saline filled implants.

Evolving concepts in breast reconstruction with latissimus dorsi flaps: results and follow-up of 121 consecutive patients.

Breast reconstruction using autologous tissue is increasingly gaining in interest. A review of results obtained from a series of consecutive patients undergoing breast reconstruction with the latissimus dorsi flap (LDF) was carried out to evaluate the effects of the authors' refinements to the procedure. Data collected during the perioperative course and a minimum follow-up of 12 months in 121 patients (mean age, 47 years; 50% with previous radiotherapy) who underwent treatment from 1994 to 1998 were analyzed retrospectively. In addition, a structured interview was conducted to evaluate patient satisfaction. Eighteen different surgeons in one teaching hospital were involved in the operative procedures. No patient was referred to the intensive care unit. An additional implant was used in 25% of patients. With the exception of the occurrence of seroma, the complication rate was low (seroma, 60%; bleeding, 4%; hematoma, 5%; minor wound dehiscence, 3%; wound infection, 2%). No flap was lost. Donor site morbidity was extremely low; 90% of patients had no complaints. The result of surgery was rated as excellent or good by 59% of patients, 89% would undergo this type of breast reconstruction again, and 91% would recommend it to other women. Refinements that improved the technique substantially included incision lines exclusively in the bra line, improved flap volume resulting from the harvest of an extended fat pad, and quilting sutures to reduce the formation of seroma. In the current study, endoscopic muscle harvest did not represent an improvement in procedure. The technique of breast reconstruction with the LDF has been improved substantially during the past few years, and provides the plastic surgeon with an excellent, safe, and consistently successful method for breast reconstruction.

Continuous quality management of breast hypertrophy by the German Association of Plastic Surgeons: a preliminary report.

In 1998, the German Association of Plastic Surgeons started a new quality assurance program based on a standardized questionnaire to examine the tracer diagnosis "breast hypertrophy." The authors present the results of a pilot study evaluating 799 patients (mean age, 38 years). Breast reduction was performed as an inpatient procedure in 99% of patients. Mean weight reduction was 1,135 g (range, 140-3,870 g). The inverted-T scar technique was used in 45% of patients, the vertical scar technique in 52% of patients, and other techniques were restricted to 2% of patients. The selection of technique was based on the choice of the surgeon. The overall incidence of complications was 21.5%, and included predominantly wound dehiscence, without marked differences between the two techniques. Less than 10 years after the introduction of a new technique for breast reduction with reduced length of scar, it is now used as often as traditional methods.

[Quality assurance in plastic surgery--initial experiences with "breast reduction" tracer diagnosis]. / Qualitätssicherung in der Plastischen Chirurgie--Erste Erfahrungen mit der Tracerdiagnose "Mammareduktion".

Quality assurance has to be an integral part of medical work as it is required by actual health laws. "Tracers" have been used in different parts of medicine as a reliable method. In 1997 we started to establish an internal program for a quality assurance with five different tracers (breast augmentation, breast reduction, oncological and reconstructive breast surgery, liposuction). The outcome is prospectively documented using an operation-specific documentation form. Every three months, the results are discussed in a surgical audit. The overall complication rate after mamma reduction (n = 81) was reduced about 40% to 21% (mean reduction weight 1.7 kg). Therefore, these measurements could promptly improve the quality of treatment of our patients.

[Standard technique of breast reduction surgery with vertical scar]. / Eine Standardtechnik zur Brustreduktion mit vertikaler Narbe.

In 1991, we started to use a new surgical technique for breast reduction with a single vertical scar incision as developed by Marchac, Lassus, and Lejour. The operative procedure wsa changed step-by-step according to the following significant modifications: Simultaneous liposuction is carried out only in the presence of extensive axillary fatty tissue. The undermining of the glandular tissue is limited to the extension of glandular resection. The number of glandular sutures is significantly reduced. A central fixating suture to the pectoral fascia is performed only in the presence of extreme ptosis. The positioning of the nipple-areola complex represents the final step of the reduction procedure after the resection of the glandular tissue. Based on our experience with more than 800 breast reductions, this technique is considered to be a safe standard procedure for nearly all breast sizes.

Successful surgery of multiple recurrent basal cell carcinomas guided by photodynamic diagnosis.

We describe a 56-year-old Caucasian man with history of multiple regressed basal cell carcinomas. During the last 20 years approximately 200 histologically proven basal cell carcinomas preferentially localized on the face were surgically treated. Several large skin grafts were necessary to cover the extensive tissue defects on the face and scalp. Although all excised tissues were histologically proven to be basal cell carcinomas with tumor-free margins, new tumors developed in proximity to the skin graft margins. The dissemination of the new tumors made it difficult to perform additional invasive operation procedures without influencing the cosmetic result. Thus, we used photodynamic diagnosis to improve detection and demarcation of the neoplastic tissues. This procedure facilitated surgical planning and enabled primary in toto excisions. Surgical trauma and a number of interventions were thus minimized with the consequence of improved cosmetic and functional results.

[Subcutaneous mastectomy]. / Zur Problematik der subcutanen Mastektomie.

The subcutaneous mastectomy (SM) which cannot be standardized is the possible treatment in a given indication especially to reduce the risk of cancer to a large extent-though only through experienced hands. Any re-operation often resulting from the complications of reconstructions through silicon prostheses can be more extensive than mamma-carcinoma therapy itself. The patient as well as the surgeon must be aware that the aesthetic result of the therapy is not the primary reason for the operation but the prevention or therapy of a life-threatening disease. With this perspective in mind the high rate of complications with SM is an acceptable risk and may ensure a high degree of permanent tumor removal.

[Physiologic and pathologic patterns of reaction to silicone breast implants]. / Physiologische und pathologische Reaktionsmuster auf Silikonprothesen der Mamma.

Local morphological reaction patterns on breast implants can be of high significance as possible starting point for controversely discussed systemic immune response triggered by silicon or silicone. Therefore, the collagenous capsules of 149 explanted mammoplasty prostheses were examined macroscopically, under a scanning electron microscope and light-microscopically using antibodies to the macrophage antigen CD68, vimentin, muscle actin, and the proliferation antigen MIB1, and were then correlated with anamnestic data (implanted type of prosthesis, indication for im- or explantation). According to our examinations, the in-vivo durability of the prostheses' shells is considerably decreasing with the expansion of their surfaces. Regardless of the type of the prostheses' surface regularly a chronic-proliferating inflammation pattern could be identified in the periprosthetic capsulectomy specimens starting with a synovial metaplasia of proliferating CD-68-negative and vimentin-positive mesenchymal cells in the area surrounding the implants and ending by its transformation into a stage of dense hyaline collagenous fibrous tissue after an advanced implantation period (> 2 years). By this, the texturing of the prosthesis surface modifies only the course, but not the quality of the chronically fibrosing inflammation. Bleeding of prosthesis as well as the incorporation of the polyurethane-foam coating of different prosthesis types into the periprosthetic breast capsule lead to a significant lymphoplasmacytic infiltration, partly with participation of local vessels as defined in a "silicone vasculitis". Morphological signs of an at least local immune response are detectable in 8.3% of the examined fibrotic capsules even without a morphologically identifiable foreign-body embedding. They can be possibly referred to- as well as the complete absence of hyaline collagenous fibrous tissue in 30% of the cases-a yet not causally clarified, inter-individually different susceptibility of the implant bearers. Only the systematic registration of the above-mentioned morphological reaction patterns in a "prosthesis-passport" together with the additional clinical observation of the patients can ensure in future the realistic estimation of potential health risks caused by silicone breast implants.

[Guidelines and quality assurance in plastic breast surgery]. / Leitlinien und Qualitätssicherung in der Plastischen Brustchirurgie.

Guidelines in Plastic Breast Surgery refer to breast-reduction, breast-augmentation, correction of an asymmetry and reconstruction of an amputated breast. Because of the broad variety of the initial findings and treatment strategies and the patients specific interests only short and therefore rough guidelines can be given, and these are of little use for surgeons and economists.

[Manifestation, therapy and follow-up of locoregional breast carcinoma recurrence]. / Manifestation, Therapie und Verlauf des locoregionären Mammakarzinomrezidives.

Between 1992 and 1995, 45 cases of recurrent breast cancers out of 483 breast tumors were treated mainly by local tumor resection. There was no difference in survival time, considering time and number of recurrent events with or without breast reconstruction. Recurrent tumors were detected mainly by the patients themselves.

[The treatment of type-1 diabetics with insulin-induced lipohypertrophy by liposuction]. / Behandlung einer Typ-I-Diabetikerin mit insulin-induzierter Lipohypertrophie durch Fettgewebssaugung.

Extensive areas of lipohypertrophy at the insulin injection sites on both thighs, upper arms and buttocks had developed in a 22-year-old woman with type 1 diabetes. Tissue biopsy showed fat cells of normal size, while the stromal cells in primary culture from the lipohypertrophy tissue demonstrated a greater degree of new fat-cell formation than normal fat tissue, i.e. there was fat-cell hyperplasia. Although the patient avoided these sites for insulin injection during the subsequent 18 months, the amount of excessive fat tissue did not decrease. As the very obvious fat pads distressed the patient, local liposuction was applied without complication at the six affected sites, removing a total of 2,000 ml of fat.-Liposuction is a low-risk curative procedure for removing extensive insulin-induced lipohypertrophic tissue and quickly achieves a cosmetically satisfactory result.

[Progress in the use of tissue expanders for defect closure of the body surface--clinical aspects]. / Fortschritte in der Verwendung von Expandern zum Defektverschluss der Körperoberfläche--klinisch.

The time-honored principle of tissue expansion has only gained clinical relevance in the past 10 years. Its advantages are that sound tissue of equal texture, color, and quality adjacent to a defect or scarred area can be transposed to treat defects without producing further scars. Especially in the hair covered part of the head, but also in reconstruction of the female breast after mastectomy, in large scars from burns, or in large pigmented nevi, tissue expansion has to be reliable. Only when used in extremities does a higher rate of complication demand a certain restriction.

Running Y-V plasty.

Problems in treating burn sequelae include scar tissue contraction, which may develop after wound infections, after secondary wound healing by granulations, and also after split-skin transplants. Development of scar cords near or even over joints can ultimately lead to deformities of the body and limbs because of restriction of mobility. Compression bandages have the goal of counteracting these problems, but are not always effective. An attempt must be made to resect the scar cords and to cover the defect with skin transplants or to change the line of the scar cord with Z plasties. However, the altered blood flow in the nodularly twisted collagen fiber structure of the hypertrophic scar frequently causes the tips of transposed skin flaps (as, for example, in Z plasties) to become necrotic. This situation is avoided by application of Y-V plasties, in which the skin for transposition is not detached from its substratum (in contrast to the Z plasty) but is displaced by sliding it on its substratum. For this purpose, the tension of the scar cord is eliminated over the entire length by several transverse Y-shaped incisions situated in parallel. If the tongues of the upper part slide into the stem of the Y and finally from a V, the scar cord can be lengthened without raising the dermis from it substratum and endangering its blood flow. Because of good results, Y-V plasty has entirely replaced Z plasty in the correction of contracted burn scars at my hospital.

[Treatment of radiation sequelae after breast cancer]. / Behandlung von Strahlenfolgen nach Mammakarzinom.

Defects of the chest wall after radiation for carcinoma of the breast cannot be closed by means of simple split-skin graft or compound flaps because of the decreased blood supply. Only transposition flaps will survive because of their own vascularisation. Musculocutaneous flaps, the latissimus island flap or the vertical or transverse rectus abdominis-flap, which also can be used for the reconstruction of a bid pendolous breast, are the safest.