Quality of life, patient satisfaction and cosmetic outcome after breast reconstruction using DIEP flap or expandable breast implant.

In a cross-sectional postal survey, we compared patient-reported outcomes in patients undergoing breast reconstruction with the deep inferior epigastric perforator (DIEP) flap or an expandable breast implant (EBI). We included 34 consecutive patients who had breast reconstruction with DIEP flap and 30 patients with EBI. Outcomes were assessed using the Short Form 36 (SF-36) quality of life questionnaire, two study-specific patient satisfaction questionnaires and a visual analogue scale (VAS) on cosmetic result. There were no significant differences in SF-36 subscale scores between the two groups. On the study-specific questionnaire, more patients in the DIEP group were satisfied with the appearance of their breast (P<0.0005) and reported an improved social relationship (P=0.02), and fewer patients were sad about their body image (P=0.01) after reconstruction than in the EBI group. On the other study-specific items, satisfaction was similar in the two groups. On all five VAS items, DIEP patients reported better cosmetic results than EBI patients. We conclude that patient satisfaction and cosmetic outcome were better after breast reconstruction with the DIEP flap compared with EBI, while there was no difference in health-related quality of life.

[Hemangioma and vascular malformations. Diagnosis and treatment]. / Hemangiomer og vaskulaere malformasjoner. Diagnose og behandling.

The authors discuss the dilemmas associated with diagnosis and treatment of haemangiomas and vascular malformations. The complexity of these conditions too often sends the patients wandering from one specialist to another in search of an optimal therapeutic approach. We have established a multidisciplinary team to facilitate interspecialty communication on diagnosis, natural history, and therapy.

Preoperative bacterial colonization and its influence on postoperative wound infections in plastic surgery.

During two separate periods a total of 654 patients were included in a clinical study relating preoperative bacterial colonization to occurrence of postoperative wound infection in plastic surgery. During the second period one half of the patients were randomized to receive prophylactic azithromycin. Bacteriological samples were collected from the nasal vestibulum during both periods, and additionally from the surgical field during the second period. All patients had preoperative chlorhexidine bathing. The bacteriological findings were categorized as either normal flora or potentially pathogenic bacteria, and as either having no growth. Surgical wounds were divided into four contamination classes. Postoperative follow-up was 30 days, and assessment of wound infection was based on a graded scale. We did not find any statistically significant relation between preoperative bacterial colonization and postoperative wound infection, regardless of place of sample collection, method of bacterial classification, class of contamination or use of prophylactic azithromycin.

A prospective, double-blind, placebo-controlled trial of a single dose of azithromycin on postoperative wound infections in plastic surgery.

Over a 9-month period from September of 1991 to May of 1992, 339 patients were included in a randomized, double-blind, placebo-controlled study using azithromycin as the prophylactic agent to determine whether it effects a clinically meaningful reduction in postoperative surgical infections in plastic surgery. Azithromycin was given as prophylaxis in 171 patients and placebo in 168 patients. The study medication was a single oral dose taken at 8 P.M. the day before surgery. The patients were followed up for a minimum of 4 weeks after surgery. The patients who received wound infection prophylaxis had 5.1 percent infections compared with 20.5 percent in the placebo group (p = 0.00009). Eighty percent of all wound infections were first seen after discharge, explaining why plastic surgeons might overlook their infectious complications. There was a significant reduction in postoperative complications (p = 0.04) and in the additional use of antibiotics postoperatively (p = 0.007) in the prophylaxis group. Subgroup analysis showed a significant reduction in surgical infections in breast surgery (p < 0.05) and reconstructive surgery with flaps (p < 0.05). No effect of the prophylactic regime was demonstrated in patients undergoing secondary surgery for cleft lip and palate disease.

A prospective, randomized surveillance study of postoperative wound infections after plastic surgery: a study of incidence and surveillance methods.

In a postoperative wound infection study in plastic surgery, 315 patients were randomized to either outpatient wound control after 30 days (group I) or self-control by questionnaire (group II). We present a new definition of wound infection based on physiologic wound healing. The surveillance of postoperative wound infection showed follow-up rates of 95 and 68 percent and infection rates of 16.3 and 17.1 percent for groups I and II, respectively. Of the 43 patients (16.7 percent) with postoperative wound infections, 31 (72 percent) were diagnosed after leaving the hospital, and only 12 (28 percent) were diagnosed during hospital stay. The monthly wound infection rate declined from 23.5 percent when the registration started to 12.2 percent at the end of the surveillance. The wound infection rate nearly tripled when duration of surgery was more than 120 minutes compared with less than 60 minutes. Postoperative wound infection was significantly related to preoperative contamination class, with an increase from 10.2 percent wound infections in class "clean" to 37.5 percent in class "dirty." We conclude that postoperative wound infection also crops up in the plastic surgical department, and this situation has not, to date, been documented sufficiently. A simple questionnaire gives a useful survey of postoperative wound infections. An active follow-up for at least 30 days is essential to register the rate of surgical infections.

Aesthetic treatment of progressive hemifacial atrophy (Romberg's disease): use of a pedicled platysma muscle flap.

Several methods have been described for anesthetic correction of Romberg's disease. We have used the platysma muscle flap as the only procedure in four cases of severe to moderate disease. The platysma flap was transected at the clavicular level, turned at the mandibular margin, and spread subcutaneously on the affected side from the nasolabial fold up to the orbital margin and laterally to the anterior part of the ear. The flap masked the atrophy relatively well, and no complications were seen during or after the procedure. The procedure can be combined with orthognathic surgery if required.

Syringe-assisted microliposuction for cervical rejuvenation. A five year experience.

During a five year period, 71 patients (age range 24-72 years) underwent syringe-assisted liposuction of the neck as the only operation for facial rejuvenation. The patients were seen after one week and three months, and 66 patients were re-examined 5-58 months (mean 31) postoperatively. There were no complications except for slight skin laxity (n = 10), transient hypoaesthesia, and temporary subcutaneous scarring (nodules). In some patients improvement occurred more than 12 months post-operatively. The patients evaluated the result according to a four grade scale; very satisfied (n = 41), satisfied (n = 21), less satisfied (n = 4), and dissatisfied (n = 1). All patients except one would recommend the procedure to other patients with similar problems. We conclude that syringe-assisted liposuction of the neck is a simple, safe, and rewarding procedure even in many elderly patients.

[Excision of tumors in the face]. / Eksisjon av tumorer i ansiktet.

Excision of tumours in the face is a surgical challenge. Most general practitioners and surgeons are reluctant to undertake such procedures. In our opinion there are no reason why small tumours and lesions in the face, which can be excised by a fusiform excision, should not be handled by most doctors. The aim of this article is to remind doctors of well known general principles, so as to obtain a cosmetically good result after surgery.

Surgical treatment of gynaecomastia. Five years' experience with liposuction.

Since liposuction became part of our surgical regimen in 1988, we have operated on 67 patients for gynaecomastia during the five year period 1988-1992. Sixty two of the patients were seen at an extra follow up 4-59 months (means 29 months) postoperatively. Compared to studies that did not include liposuction as part of the operation, we found a lower incidence of postoperative complications and a higher degree of patient satisfaction. Preoperative distinction between adipose and glandular tissue is difficult, and we therefore consider that liposuction should be used during the first part of the operation in nearly all cases of gynaecomastia. Regardless the amount of fat, tunnelling and suction are beneficial, because they help to refine the peripheral contour and define the glandular tissue. Liposuction seems to help the skin to contract, and skin resections are rarely indicated.

Neurocutaneous melanosis. Case report and a brief review.

Neurocutaneous melanosis is a rare congenital syndrome characterised by large or numerous congenital pigmented naevi and excessive proliferation of melanin-containing cells in the leptomeninges. The process is diffuse or multifocal, and has a tendency to infiltrate the neural tissue and the cerebrospinal cord; remote metastases may occur. There is usually histological evidence of malignancy (cellular pleomorphism and mitotic activity). Involvement of the basal cisterns is apt to cause internal hydrocephalus, and the prognosis is grave even when there is no histological evidence of malignancy. We present the case history and necropsy findings of a baby boy with neurocutaneous melanosis, followed by a brief review.

Treatment of large congenital naevi. A review and report of six cases.

To minimize the significant risk of early malignancy, and to obtain acceptable cosmetic results we have treated five infants with large congenital naevi by full-thickness resection of the thickest part and superficial excision of the remaining parts of the naevus. The treatment was followed by rapid healing with little pigmented skin and minimal scarring. One patient treated at the age of six years showed a less favourable cosmetic result. Our experience confirms that the major part of the potentially malignant tissue can be removed and a greatly improved appearance achieved by early surgery. Additional surgery is usually necessary and should be completed before school age to prevent permanent psychological and social effects. Large congenital naevi are rare and difficult to treat. Their treatment should be centralised to regional hospitals that serve large populations.

Lip and nose morphology in patients with unilateral cleft lip and palate from four Scandinavian centres.

Sixty patients with unilateral cleft lip and palate were compared for lip and nose appearance. All patients were photographed from an anteroposterior and a basal view at 7-10 years of age. The photographic registration method was tested for validity and accuracy. Although the four groups of 15 patients each were treated according to different protocols, many similarities were found with shorter lip heights at the cleft side and inclination of the rima oris. Asymmetry of nose and retropositioning at the cleft side naris were generally seen. Significantly straighter noses were demonstrated in the group treated with a two-stage lip nose operation combined with nose plugs, and the two groups where vomer flaps were used showed the greatest deviation of the nose.

[Reduction mammaplasty in breast hypertrophy]. / Reduksjonsplastikk av hypertrophia mammae.

Between January 1984 and November 1990 a total of 292 patients underwent reduction mammaplasty for hypertrophic breasts. Of these patients, 233 had a superomedial pedicle (Orlando's method) and 36 an inferior pedicle (Robbins' method). 23 had various other operations. The patients operated on by Orlando's and Robbins' method were compared retrospectively. It was found that Robbins' method was superior in younger women, owing to increased sensitivity of the nipple-areola complex, and lactation. In the physicians' opinion, wide scars developed in 32% of the patients. In our opinion closing the wound with intracutaneous suture might improve the quality of the scar. Of the patients assessed, 98% were satisfied with the physical outcome of the operation and 86% with the cosmetic outcome. The operative technique of the two methods is described.

[Are silicone breast prostheses dangerous?]. / Er silikonfylte mammaproteser helsefarlige?

Since 1964 silicone breast prostheses have been implanted in 5 million women for breast reconstruction after cancer operations, to correct congenital deformities and for cosmetic reasons. There is no evidence in the literature of a correlation between silicone implants and breast cancer. Some authors claim that silicone implants reduce the reliability of mammography. Autoimmune diseases in patients with silicone mammary implants are reported in less than 40 cases. Most of these are localized or systemic scleroderma. An association with silicone implants has been suggested, but this suggestion has not been confirmed by scientific data.

[Treatment of large congenital pigmented nevi]. / Behandling av store medfødte pigmentnaevi.

Large congenital nevi present a difficult therapeutic problem, since the surgeon must seek to achieve two objectives: To minimize the risk of malignancy; To obtain an acceptable cosmetic result. The first objective calls for early and radical excision of all pigmented areas; this may be impossible because of the operative risk, and the risk of leaving the patient with a deformity or disfiguring scars. The cosmetic indication may justify less aggressive surgery. Relatively new experience indicates that removal of the superficial layers of the nevus shortly after birth is followed by healing with non-pigmented or much less pigmented skin. By combining the removal of the superficial layers of skin with full-thickness resections and reconstructive plastic surgery, it is possible in most cases to achieve a favourable cosmetic result and, at the same time, reduce risk of early malignancy. Wherever possible, the surgical treatment should be completed before the age of five or six years in order to prevent long-lasting psychologic and social effects of the nevus deformity.

Reduction mammaplasty. A comparative study of the Orlando and Robbins methods in 292 patients.

Between January 1984 and November 1990 a total of 292 patients underwent reduction mammaplasty for hypertrophic breasts. Of these 233 had a superomedial pedicle (Orlando's method) and 36 an inferior pedicle (Robbins' method). Twenty-three had various other operations. Those operated on by Orlando's and Robbins' methods were compared retrospectively, and it was found that Robbins' method was superior in younger women because of increased sensitivity, particularly of the nipple-areola complex, and better lactation. In the physician's opinion ugly scars developed in 32% of the patients (n = 287). In our opinion wound closure with a subcuticular suture might improve the quality of the scar. Of the 287 patients assessed, 281 (98%) were satisfied with the physical, and 248 (86%) with the cosmetic, outcome of the operation.

Clinical results in 87 patients treated for asymmetrical breasts. A follow-up study.

A retrospective study was made of 87 patients operated on between 1984 and 1990 for asymmetrical breasts. Thirty-two patients had 36 implants (13 also had breast reduction or mastopexy of the contralateral breast). Capsular contraction, Baker grade II-IV, was found in a third of the implants. The remaining 54 patients underwent reduction mammaplasty or mastopexy alone. 90% of the patients were satisfied with the result. There was no significant difference in the overall satisfaction between the patients who did or did not have implants. We nevertheless think that mammary implants should be avoided whenever possible in the correction of breast asymmetry. Even though there is no difference in patients' satisfaction, it is our experience that those with implants have more frequent follow-up consultations and are subject to more postoperative procedures than those corrected without implants.

Craniofacial and occlusal characteristics in unilateral cleft lip and palate patients from four Scandinavian centres.

Craniofacial morphology and dental occlusion were studied at early school age in 15 consecutive patients with unilateral cleft lip and palate from each of four Scandinavian cleft centres. Treatment differed mainly in the techniques of palatal repair. Push-back closure of the palate particularly impaired maxillary development, which resulted in an increased incidence of crossbite and reduced intercanine distance when compared with patients who had been operated on by the von Langenbeck method or in whom the anterior palate had not yet been closed.