Experience of excess skin and desire for body contouring surgery in post-bariatric patients.

BACKGROUND: This study was done to analyze the problems of post-bariatric patients with excess skin and to determine their interest in body contouring surgery. The self-administered Sahlgrenska Excess Skin Questionnaire (SESQ) was used together with a study-specific questionnaire. METHODS: The patients who were operated with bariatric surgery at Sahlgrenska University Hospital between 1999 and 2008 were identified and sent the SESQ and a study-specific questionnaire. RESULTS: The response rate was 65% (23% men). The most common problem in both men and women was the feeling of having an unattractive body (91 and 67%, respectively). The most frequently reported sites of excess skin were the upper arms in women (91%) and the abdomen in men (78%). In both women and men, excess skin on the abdomen was reported to cause the most discomfort (median 7 and 3, respectively, on a scale from 0 to 10). Women reported significantly more problems, discomfort, and amount of excess skin (p < 0.05) than men. There was a strong correlation between the amount of excess skin and the degree of discomfort for all body parts. Seventeen percent of the responders had been operated with body contouring surgery of one body part and 5% of two or more. Fourteen percent desired body contouring surgery of one body part and 61% of two or more. CONCLUSIONS: Most post-bariatric patients, but women in particular, experience significant problems of excess skin and request body contouring surgery.

The lateral thoracodorsal flap in breast reconstruction: a long-term follow up study.

Fifty-four patients were studied a mean of five years after their breasts had been reconstructed between 1984 and 1990 using the lateral thoracodorsal (LTD) flap in combination with either a thin shell, non-low-bleed (n = 35) or a thick shell, low bleed (n = 19) silicone gel implant. The rate of capsular contracture (Baker III-IV) was 11% in the first group and 10% in the second according to a modified Baker classification. Open capsulotomy was common in both groups of patients (15/35 in the first group and 13/19 in the second). Investigation by applanation tonometry of the capsular contracture agreed with the modified Baker classification. The cosmetic results were evaluated clinically and from photographs. Best scores were recorded for scars and ptosis in both evaluations. There were no significant differences between the general cosmetic results in the two groups. The patients graded their estimations of the final outcome of their breast reconstruction on a 10-point visual analogue scale (VAS); the mean for the first group was 8.7 and for the second 9.2. None of the patients regretted her operation and they would all recommend the procedure to another patient.

Tibia as donor site for alveolar bone grafting in patients with cleft lip and palate: long-term experience.

Tibial bone grafts were studied in 137 patients with clefts of the lip and palate. Twenty-one had clefts of the lip and primary palate and 116 had complete unilateral clefts of the lip and palate. Bone grafting was performed secondarily or late secondarily. Bone was harvested from the proximal part of the tibia distal to the tuberosity through an incision about 15 mm long. The mean follow-up time after bone grafting was 5.5 years (range 2-11). There were no operative, or early or late postoperative complications reported (such as haematoma, fracture, or shortening of the limb). Harvesting time was about 15 minutes. The possibility of operating with two teams makes the total operating time shorter. Bleeding was negligible (less than 15 ml) and the amount of bone obtained was always sufficient. Patients were mobilised the next day and were back to full physical activity by one month. Indications for tibial bone grafting included facilitation of tooth eruption into the graft, giving bony support to the neighbouring teeth, making it possible to insert a titanium fixture, raising the alar base of the nose, and closing an oronasal fistula. Compared with iliac, cranial, mandibular, and costal donor sites, using the tibia took less time, gave less bleeding, made it possible for two teams to operate simultaneously, gave a smaller scar, and there were minimal complications and satisfactory quantity and quality of bone in all cases. The results suggested that the tibia is an excellent choice of graft for residual alveolar clefts in patients with cleft lip and palate.

Effect of hypothermia on the ischemic and reperfused rat skeletal muscle, monitored by in vivo (31)P-magnetic resonance spectroscopy.

The aim of this study was to compare the ischemic and postischemic energetic changes of rat skeletal muscle in response to hypothermia or room temperature, monitored noninvasively and continuously by in vivo (31)P-magnetic resonance spectroscopy ((31)P-MRS). A model of pedicled rat rectus femoris muscle was developed and analyzed by in vivo (31)P-MRS at a magnetic field strength of 2.35 T. Measurements were performed at three time points: before ischemia, after 4 hours of ischemia, and after 1 hour of reperfusion. Three groups were studied: (1) sham-operated rats (n = 6); (2) rats subjected to room temperature (24-26 degrees C, n = 6); and (3) rats subjected to hypothermia (9-12 degrees C, n = 6). Blood perfusion was measured by laser Doppler flowmetry (LDF). In the hypothermic group, phosphocreatine (PCr) recovered to 75% and adenosine triphosphate (ATP) to 86%; in the room temperature group, the recovery was 53% and 51%, respectively (P < 0.05). Skeletal muscle subjected to hypothermia (9-12 degrees C) was found to recover to a higher postischemic energetic level compared with skeletal muscle subjected to room temperature. Hypothermia appears to be a simple and effective method with which to reduce the damage related to ischemia and reperfusion.

[Excision and suture in skin and subcutaneous tissue. Basic techniques of plastic surgery are essential for optimal cosmetic results]. / Excision och suturering i hud och subkutan vävnad. Basal plastikkirurgisk teknik bör tillämpas för optimalt kosmetiskt resultat.

The basic techniques of plastic surgery are of great practical importance in achieving the best possible results when reconstructing skin and subcutaneous tissue. Knowledge of the anatomy of the skin and the normal healing process is also essential. These fundamental principles of skin surgery include appropriate methods of infiltration anesthesia. Detailed descriptions of the technique of skin incision, excision of skin lesions and control of bleeding are given. Techniques of skin suture are described, and recommendations for optimal timing of suture removal and treatment of scar tissue are provided.

Combined bone grafting and delayed closure of the hard palate in patients with unilateral cleft lip and palate: facilitation of lateral incisor eruption and evaluation of indicators for timing of the procedure.

OBJECTIVE: To compare outcomes of bone grafting performed before eruption of the lateral incisor to outcomes of grafting performed before eruption of the canine and to evaluate the long-term results of bone grafting combined with delayed closure of the hard palate during mixed dentition. DESIGN: Seventy consecutive patients (52 men and 18 women) with complete unilateral cleft lip and palate were studied. All patients underwent bone grafting with simultaneous closure of the cleft in the hard palate at the stage of mixed dentition. The velum had been repaired in infancy. Mean age for the bone grafting procedure was 8.4 years. Bone grafting was performed to facilitate eruption of the lateral incisor in 43 (61%) of the patients and to facilitate eruption of the canine in the remaining 27 (39%) patients. Intraoral radiographs were used to evaluate the morphologic characteristics of the cleft and the stage of eruption of the permanent lateral incisor and canine before bone grafting. Mean follow-up time was 4.0 years (range, 1-10.1 years). RESULTS: The mean time for the surgery, which included bone grafting and repair of the residual cleft in the hard palate, was 109 minutes, and the mean amount of bleeding was 121 ml. The rate of dehiscence in the flap covering the alveolar bone graft was 14%, and the rate of total failure of bone grafting was 3%. An oronasal fistula developed in the hard palate of 13% of patients, but the fistula was of sufficient size to serve as an indication for reoperation in only 6%. The postoperative alveolar bony height in the cleft area was more than 75% of the normal height in 94% of patients. Closure of the cleft space in the dental arch was performed or planned to be achieved orthodontically in 91% of patients. When bone grafting was performed to facilitate eruption of the lateral incisor, the cleft space was closed orthodontically in 100% of patients. The optimal indicator for timing of the bone grafting procedure from an orthodontic point of view was when the permanent lateral incisor or the canine close to the cleft was covered by a thin shell of bone (i.e., 7-9 years of age).

[Excision and suture in skin and subcutaneous tissue. Basic techniques of plastic surgery are essential for optimal cosmetic results]. / Excision och suturering i hud och subkutan vävnad. Basal plastikkirurgisk teknik bör tillämpas för optimalt kosmetiskt resultat.

The basic techniques of plastic surgery are of great practical importance in achieving the best possible results when reconstructing skin and subcutaneous tissue. Knowledge of the anatomy of the skin and the normal healing process is also essential. These fundamental principles of skin surgery include appropriate methods of infiltration anesthesia. Detailed descriptions of the technique of skin incision, excision of skin lesions and control of bleeding are given. Techniques of skin suture are described, and recommendations for optimal timing of suture removal and treatment of scar tissue are provided.

Use of titanium dental implants as an integrated part of a CLP protocol.

The problem of edentulousness in the cleft area of patients with cleft lip and palate was formerly resolved with a conventional fixed bridge construction, but this approach did not always prove optimal. Nowadays, in these patients the bridge can be substituted by a crown on an osseointegrated titanium implant fixture. The concept of dental rehabilitation using titanium implants has gradually merged into our routine treatment for patients with cleft lip and palate. In this report we describe our surgical technique using osseointegrated titanium implants and evaluate our result in patients with cleft lip and palate. Sixteen patients with cleft lip and palate, 11 men and five women, were divided into two groups: group 1 consisted of six patients who did not need bone grafting prior to the fixture installation, and group 2 comprised 10 patients who had additional bone grafting three months before the fixture installation. Abutments were applied six months after fixture installation. Dental crowns and fixed bridges were then constructed. All patients were seen on regular follow-up visits. Routine roentgenograms were obtained preoperatively and when the abutments were applied. Photographs were taken at these occasions and also after the prosthodontic work was completed. Of a total of 31 fixtures, all except two were osseointegrated at the time of the abutment connection, and the remaining 29 have all been functional during the observation period, giving a success rate of 93%. In group 1 all fixtures (100%) were osseointegrated. The non-integrated fixtures were found in group 2 giving a success rate of 91% in this group. The mean follow-up time after fixture installation was six years and three months, and the mean observation time with loaded fixtures was five years and six months.

Dynamic cranioplasty for brachycephaly.

In craniofacial surgery, the most common techniques for treatment of brachycephaly have been either to let the forehead float on the brain or to fix it in an advanced position. Since neither of these techniques renders acceptable results with enough consistency, we have developed a different way of addressing the problem. In principle, the design of the operation is to restrict upward and transverse growth of the cranium but to allow anterior and posterior expansion. This is accomplished by producing transverse tension across the skull and letting it expand anteriorly by means of a superiorly hinged fronto-orbital flap and posteriorly by an inferiorly based occipital flap. To prevent upward expansion at the squamosal sutures when still open, these junctions are bridged with miniplates. This surgical technique has brought definite improvement to the results even in some Apert syndrome children. During a 2-year period, we have treated 14 infants with this technique and followed 10 of them with roentgencephalometry, 3 for more than 1 year, and 4 for more than 6 months. The diagnoses were the following: nonsyndromal bicoronal synostosis (4), Apert (7), bicoronal synostosis with midline cleft, Saethre-Chotzen, and Antley-Bixler (1 each). The mean age of surgery was 6.6 months (range 3 to 16 months). There were no major complications.

Bone grafting in the mixed and permanent dentition in cleft lip and palatepatients: long-term results and the role of the surgeon's experience.

This long-term study was a follow-up of 46 patients with complete unilateral cleft lip and palate treated with secondary or late secondary bone grafting. Surgeons with different degrees of experience in this procedure had operated on these patients. Morphology of the clefts prior to the grafting was assessed with regard to width of cleft, stage of eruption of permanent canine, presence or absence of permanent lateral incisor and position of permanent lateral incisor and permanent canine in the dental arch. Outcome of surgery was evaluated with regard to the amount of bleeding, flap dehiscence, alveolar bone height, and space closure in the previous cleft area. Dehiscence rate was 23% (11) and total failure rate 4% (2). Alveolar bony height in 38 patients (81%) was more than 75% of the normal alveolar bone height; in 6 cases (13%) between 50-75% bone height and in 3 subjects (6%) surgery had given less than 50% of the normal bone height. Cleft space was closed by orthodontic means in 49% of patients. Best results were obtained when bone grafting was performed prior to canine eruption. Furthermore, significantly better results regarding alveolar bone height were obtained by the more experienced surgeons.

Blockade of the glucocorticoid receptor with RU 486: effects in vitro and in vivo on human adipose tissue lipoprotein lipase activity.

Cortisol is known to induce lipoprotein lipase (LPL) activity in human adipose tissue in vitro and in vivo such as in Cushing's syndrome. The significance of the glucocorticoid receptor (GR) for this induction was evaluated in the present study. The synthetic steroid molecule RU 486, a potent glucocorticoid antagonist, was used as a tool to block the GR, in vitro and in vivo. In addition to LPL activity, glucose tolerance, blood pressure and plasma lipids, all variables influenced by cortisol, were studied in order to evaluate the peripheral antiglucocorticoid activity of RU 486 in vivo, in man. Addition of both cortisol and RU 486 to incubations of human adipose tissue pieces significantly inhibited the increase in LPL activity that could be induced by cortisol alone (p < 0.01). In a ten-fold molarity excess RU 486 totally abolished cortisol action (p < 0.01). With cortisol and RU 486 in equimolar concentrations the RU 486 blockade was probably incomplete and LPL activity induced (p < 0.05). The results imply that the stimulating effect of cortisol on LPL activity in human adipose tissue is mediated via the GR. Administration of 400 mg RU 486 at 2200 hours on two consecutive days to healthy men caused a significant rise in serum cortisol levels measured at 0800 hours (p < 0.05). The mean LPL activity in the subcutaneous abdominal adipose tissue remained unchanged. The mean level of serum triglycerides decreased significantly (p < 0.01) and there was a negative correlation between change in LPL activity and change in triglyceride levels (r = -0.73, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Growth hormone inhibits lipoprotein lipase activity in human adipose tissue.

The in vitro effects of GH on human adipose tissue lipoprotein lipase (LPL) activity and messenger ribonucleic acid (mRNA) levels were studied using a tissue incubation technique. After preincubation for 3 days, abdominal sc adipose tissue pieces were exposed to cortisol (1000 nmol/L) for 3 days to induce LPL activity. Addition of GH (50 micrograms/L) to the cortisol-containing medium during the last 24 h (day 6) caused a decrease by 84 +/- 4% (P < 0.01) in heparin-releasable LPL activity and by 65 +/- 4% (P < 0.01) in total LPL activity. Moreover, the heparin-releasable fraction was reduced from 42% of the total LPL activity with cortisol alone to 17% when both GH and cortisol were present in the incubation medium during the last 24 h (P < 0.01). The reduction in LPL activity in response to GH was not accompanied by a decrease in the level of LPL mRNA measured by a solution hybridization ribonuclease protection assay. In adipose tissue incubated in the control medium for 6 days, the addition of GH alone during the last 24 h caused an insignificant decrease in heparin-releasable LPL activity. Low control activities limited the scope for further decrease. It is concluded that GH counteracts the potent stimulatory effect of glucocorticoids on LPL activity without affecting LPL mRNA levels. Therefore, the inhibition of LPL activity by GH probably occurs during translation and/or posttranslational processing of the enzyme, and the mechanism may involve a decreased channeling of the lipase to the cell surface.

Purine metabolism during microsurgical transfer of human skeletal muscle.

The effect of ischaemia followed by reperfusion on energy metabolism was studied in human skeletal muscle after microsurgical free transfer. Muscle biopsy specimens from 11 patients treated by free muscle transfer for facial palsy, injury to an extremity, or scalp defect were studied. The biopsy specimens were taken during ischaemia and after one hour of reperfusion, respectively. They were analysed for ATP to uric acid and creatine phosphate by high pressure liquid chromatography. Ischaemia lasting one or two hours affected the energy metabolism of the muscle cell as evidenced by a 50% reduction in creatine phosphate; a 20% reduction in ATP and in the energy charge; a 100% increase in inosine monophosphate, and a 700% increase in hypoxanthine and xanthine. Reperfusion for one hour improved these figures somewhat, and induced the production of uric acid. Skeletal muscle can therefore tolerate ischaemia for up to two hours in the clinical situation without permanent damage to the tissues.

Surgical treatment of cleft palate. 27 years' experience of the Wardill-Kilner technique.

During the period 1958-1985, 230 patients with cleft palate were operated on in the Department of Plastic Surgery, University of Göteborg, Sweden. A modified push-back technique according to Wardill and Kilner was used. The children were operated on at a mean age of 13 months. They were divided into two groups, the first in which the cleft affected the velum only (n = 121) and the other in which it also affected the hard palate (n = 109). Postoperative dehiscences and fistulas occurred in 19 (8%) patients, of which 16 (15%) belonged to the group in which the cleft affected the hard palate. Only three (2%) of the 121 patients with a cleft in the soft palate only developed dehiscences. The total number of patients who had to be reoperated on because of dehiscences were 10 (4%) and palatopharyngeal flaps had to be performed in 25 patients (11%) because of speech problems.

Maxillary dental arch and occlusion in patients with repaired clefts of the secondary palate. Influence of push back palatal surgery.

Maxillary morphology and dental occlusion were studied from infancy to age 10 years in 32 patients born with isolated cleft palate. Wardill-Kilner push back repair of the palate had been done at a mean age of 7.5 months. Measurements obtained from casts of the jaws showed that the average maxillary dimensions before as well as after operation were less than those reported for children without clefts. The mean reduction was similar whether the cleft reached into the hard palate or affected the soft palate only. Preoperative anterior maxillary arch width in particular, and also distance from scar line to selected teeth seemed to influence postoperative development of the maxillary dental arch in individual patients.

Assessment of speech in children after repair of isolated cleft palate.

The speech of 31 consecutive patients with isolated cleft palate was evaluated when they were between 10 and 14 years of age. All the children had Wardill-Kilner push-back repairs at a mean age of 7.9 months. Several speech variables were assessed by two trained listeners. In addition, an overall evaluation of the quality of the patients' speech was made by the listeners and by the patients themselves. The patients had some remaining speech problems, mainly hypernasality which was moderate or severe in 7 (23%). The prevalence of compensatory articulations was low, however (n = 4, 13%), and most patients thought that their own speech was normal or relatively normal.

Androgen treatment of abdominally obese men.

Middle-aged men with abdominal obesity were treated in a double-blind study with moderate doses of transdermal preparations of testosterone (T), dihydrotestosterone (DHT), or placebo. This resulted in moderately elevated T concentrations and marked decreases in follicle stimulating and luteinizing hormones in the group treated with T, while the DHT group showed elevated DHT, markedly lower T values, and less diminution of gonadotropin concentrations. In the group treated with T visceral fat mass decreased (measured by computerized tomography) without significant changes in other depot fat regions. Lean body mass did not change. In the group treated with T, glucose disposal rate, measured with the euglycemic hyperinsulinemic clamp method, was markedly augmented. Plasma triglycerides, cholesterol, and fasting blood glucose concentrations as well as diastolic blood pressure decreased. There were no such changes in the DHT or placebo treatment groups. The men treated with T reported increased well-being and energy. In none of the groups did prostate volume, specific prostate antigen concentration, genito-urinary history, or urinary flow measurement change. It is suggested that supplementation of abdominal obese men with moderate doses of T might have several beneficial effects.

Purine metabolism after in vivo ischemia and reperfusion in rat skeletal muscle.

An in vivo rat hindlimb tourniquet ischemia model was used to study the purine nucleotide metabolism in response to 2, 4, and 6 h of ischemia and to the same ischemia periods followed by 1 h of reperfusion. All purine intermediates from ATP to uric acid were determined in skeletal muscle with a high-performance liquid chromatography (HPLC) system. The major metabolic event during ischemia is to temporarily save the nucleotide pool as inosine-5'-monophosphate (IMP. On restitution of the circulation as the energy state recovers, the IMP is converted back to AMP via the purine nucleotide cycle. Six hours of ischemia is associated with irreversible damage and no recovery fo the adenine nucleotides on reperfusion. Fast-twitch muscles appear to be more susceptible than slow-twitch muscles in response to ischemia and reperfusion. A severalfold increase of intracellular hypoxanthine occurred during ischemia, whereas uric acid formation is observed only after reperfusion. These findings are discussed in relation to the proposed role of xanthine oxidase, as an enzyme generating tissue-injurious oxygen free radicals.

Capsular contracture after breast reconstruction with the lateral thoracodorsal flap.

Early postoperative manipulation of breast implants in patients who underwent breast reconstruction utilizing a lateral thoracodorsal flap is described. This manipulation did not reduce the rate of firm capsular contracture after the reconstruction with the flap, but only postponed its development. Open capsulotomies, however, yielded stationary soft breasts to a statistically significant extent. The patient's acceptance of the reconstructed breast as a natural part of her own body was high. It was not influenced by the occurrence of firm capsular contracture.

Substrate exchange in human limb muscle during exercise at reduced blood flow.

The substrate exchange of the calf muscles during leg exercise was compared in patients with chronically reduced blood flow and in matched controls. The arteriovenous differences of glucose, lactate, pyruvate, free fatty acids, glycerol, acetoacetate, beta-OH-butyrate, oxygen, and carbon dioxide were analyzed at rest, at the end of two exercise periods at various work loads, and after 10 min of recovery. Calf blood flow was measured with an electrocardiogram-triggered, computerized, strain gauge, venous occlusion plethysmograph. The results indicate that there was increased extraction of oxygen and ketone bodies in patients with reduced blood flow during exercise, whereas the glucose extraction tended to be lower than in controls. The leg respiratory quotient was lower in the patients even at the point of claudicating pain, suggesting oxidation of endogenous fat. The simultaneously elevated lactate release can be explained by local hypoxia in some muscle fiber populations. The findings are discussed in relation to the enzymatic adaptations known to occur in the calf muscle tissue of these patients.