Early one-stage repair of complete unilateral cleft lip and palate.

BACKGROUND: The purpose of this prospective study was to evaluate craniofacial morphology in children with complete unilateral cleft lip and palate treated at the Brussels cleft center after a 1-stage complete closure at 3 months and compare the results with a series of children operated on at 3 and 6 months of age according to the Malek surgical protocol. METHODS: A series of 72 consecutive patients who were operated on for nonsyndromic complete unilateral cleft lip and palate were included in this study at approximately the age of 10 years. Thirty-four were treated according to the Malek surgical treatment protocol: the soft palate was closed at a mean (SD) age of 3.04 (0.20) months, followed by simultaneous repair of the lip and hard palate at 6.15 (0.67) months. Thirty-eight underwent 1-stage all-in-one (AIO) closure of the lip and hard and soft palates at 2.98 (0.16) months. Craniofacial morphology was evaluated by means of a digital cephalometric analysis. Cephalometric data were compared with a noncleft control group (n = 40) matched according to age. The same 2 series of children were followed up until 15 years of age, and the results were again compared. RESULTS: Statistical analysis (analysis of variance with post hoc Tukey test) showed in both groups who were operated on a decreased anteroposterior growth compared with the children without cleft at 10 years but the AIO group only was not different from the group without cleft. The maxillary (MxPI/SN) plane was significantly (P = 0.002) increased in the Malek cleft group compared with the AIO group with cleft. At 15 years of age, a difference was not observed anymore between the 2 groups for the anteroposterior growth or for the maxillary plane inclination. CONCLUSIONS: One-stage AIO closure based on the Malek surgical principles provided good anteroposterior midfacial morphology and resulted in less opening of the maxillary plane to the anterior cranial base.

Reconstructive options after cancer surgery of the breast.

Breast cancer is now treated either by conservative therapy or by mastectomy. In the first case, no reconstruction is usually necessary, although some patients require additional surgery for asymmetry, distortion or even severe damage, by surgery or radiotherapy, of the treated breast. In these cases, reconstructive surgery should be performed very carefully, taking full account of the risk of operating in irradiated tissues. Minor procedures are usually adequate, but major surgery, reconstruction with abdominal flap, is sometimes the only solution to solve difficult postradiotherapy disasters. When a mastectomy is the choice of the patient and the surgeon, immediate reconstruction is now performed more often than before, as expansive prostheses are now available, allowing immediate implantation without endangering the skin flaps. In most cases of mastectomy, however, reconstruction is performed as a secondary procedure, in two stages if possible (volume and symmetry after the first, areola after the second). Most of the reconstructions are done by simple implantation of a prosthesis. When local conditions require a flap, the latissimus dorsi musculocutaneous has been the best choice for years, but the lower rectus flap is now taking over, as it gives the advantage of reconstructing a breast with autologous tissue.

Analysis of long-term results of 326 breast reconstructions.

It has been the experience of many surgeons that results following breast reconstruction change with time. To evaluate long-term results, the 350 breast reconstructions performed in the authors' department from January 1977 to April 1986 were reviewed. The results of the 326 cases in which there were sufficient data are presented here, and some late results are shown.

Vertical mammaplasty and liposuction of the breast.

Since 1989, I have used vertical mammaplasty without a submammary scar for all breast reductions. This technique uses adjustable markings, an upper pedicle for the areola, and a central breast reduction with limited skin undermining. The shape of the breast is created by suturing the gland and does not rely on the skin. A personal series of 100 consecutive patients (192 breasts) operated on from 1990 through 1992 is reviewed. Mastopexy was performed in 39 breasts. Among the 153 breasts that required reduction, liposuction was attempted as a complementary procedure before the surgical reduction in the 120 fattest breasts. Between 100 and 1000 cc of fat (mean 300 cc) could be suctioned in 86 breasts. This figure represents 50 percent of the large breasts in patients under 50 years of age and 100 percent of the breasts in patients older than 50 years. In these cases, liposuction made modeling of the gland easier and produced breasts with more useful and stable components. When liposuction was performed, surgical resection was adjusted to obtain the desired breast volume. The amount excised ranged from 120 to 1600 gm per breast (mean 480 gm). There were few complications, none of which required early reoperation. These complications were related to the weight of the breasts and not to the patient's obesity or to the liposuction procedure. In 10 percent of the patients, mostly those with very large and ptotic breasts, some skin redundancy was excised at the lower extremity of the scar after several months to improve the final result. This series proves that vertical mammaplasty can be used in all cases of breast reduction, producing consistently good, stable results with limited scars. The adjunctive use of liposuction in fatty breasts can be considered safe and efficient.

Evaluation of fat in breast tissue removed by vertical mammaplasty.

Breast liposuction, performed immediately prior to surgical reduction, has proven to be an efficient adjuvant method to reduce large breasts, even in young patients. Experience has shown, however, that liposuction is difficult or impossible in breasts in which fat is intimately mixed with glandular tissue. Clinical examination gives no information about the breast content. In order to evaluate the fat content of the breast, 33 unselected specimens removed during breast reductions (20 with liposuction and 13 without liposuction) were subjected to melting in a microwave oven. The fat separated from the residue could be weighed. This confirmed that pure glandular breasts are uncommon and that breast fat varies largely from one patient to another, with extremes of 2 and 78 percent and a mean value of 48 percent. Breast fat increases with age, with the body mass, and with the total volume of the breast. Clinical implications of these new data deserve investigation.

Vertical mammaplasty: early complications after 250 personal consecutive cases.

No surgeon likes to face complications. It takes effort to treat them personally and more effort to note, count, analyze, and demonstrate them. The author carefully followed 250 personal consecutive patients (476 breasts) who underwent vertical mammaplasties between 1990 and 1998; studying the complications and their relationship with the types of breasts and patients was very instructive. The main observations from this study follow. The most frequent benign complication was seroma (5 percent of breasts), which usually required one or two aspirations after surgery. Hematomas occurred in six patients (1.2 percent of breasts), who had all had mastopexies. Hematomas required immediate surgical evacuation. The major complication of breast reduction, i.e., areola necrosis, was rare (only two partial necroses occurred), but it left deformities that were difficult to correct. Infection without tissue necrosis was rare (two cases), and healing complications happened in only 5.4 percent of all cases. Healing complications were directly related to the size and fat content of the breasts. None occurred in mastopexy cases. For reductions, delayed skin healing was observed in 5 percent of cases and delayed breast tissue healing in 3 percent of cases. More healing complications occurred after liposuction of the breast, which was performed in the more fatty breasts. Delayed healing of skin and breast tissue was bothersome because healing was slow, but it left only a moderate deformity. In cases of delayed healing, frequent dressings, rinsing the wound with antiseptic solutions, giving antibiotics if needed, and refraining from early surgical intervention are the keys to success. Good personal contact with the patient, especially if healing is slow, is the best way of helping her and avoiding aggressive attitudes. In conclusion, this survey revealed few complications; however, it does show that the risk of delayed and slow healing is greater in larger breasts. In obese patients, a simpler operation may be indicated, such as liposuction with skin reduction alone or a free nipple graft, as long as the patient is not motivated to obtain the best possible result.

Vertical mammaplasty: update and appraisal of late results.

Vertical mammaplasty was evaluated after 10 years of experience and the study of 250 personal consecutive cases, and a few minor technical modifications are presented. In the beginning, the main advantage of the technique seemed to be the reduced amount of scarring, as this technique avoids submammary scars. With more experience, the major advantages seem to be its adaptability to breasts of various sizes and shapes and its good, consistent, and stable results. Liposuction is useful and reliable, but it cannot be applied to all fatty breasts because fat is sometimes intimately mixed with parenchyma and cannot be reached by a blunt cannula. Vertical mammaplasty raises many questions among surgeons. The most frequent were collected and answered in this report.

Abdominal wall function after rectus abdominis transfer.

The abdominal wall function of 57 patients who have undergone TRAM flap breast reconstructions using the whole rectus muscle, on one side (33 patients) or both (24 patients), was evaluated 6 months to 2 years after surgery. The defect was repaired with a Teflon mesh buried in the rectus sheath. There was a perfect tolerance to the mesh, and no hernia or bulging of the abdominal wall developed. Patients had less back pain after (10 patients) than before (18 patients) the operation and found their sit-up and sport possibilities about the same as before. Detailed assessment of the abdominal muscles by the physiotherapist showed, however, a decreased function, more evident in bilateral cases. CT scans demonstrated a medialization of the lateral muscles, leaving only a small medial portion of the abdominal wall devoid of muscles. On the whole, no problem of clinical significance was encountered, and patients showed a high degree of satisfaction with the operation.

Innervation of the rectus abdominis muscle: implications for rectus flaps.

The usefulness of leaving lateral strips of the rectus abdominis muscle in place during a transverse rectus abdominis musculocutaneous (TRAM) flap procedure is questioned. Since textbooks do not agree on the course of the intercostal nerves in the rectus fascia and no precise description is given of the exact site of penetration of the nerves in the rectus muscle, six fresh cadavers were dissected. It has been observed that the nerves enter the deep face of the muscle in its middle portion. Lateral parts of the muscle are consequently denervated during a transverse rectus abdominis musculocutaneous flap, which preserves them. This has been confirmed by CT scan of the abdominal wall in 10 patients 2 to 37 months after a transverse rectus abdominis musculocutaneous flap. In these patients, a progressive fibrosis and disappearance of the remaining muscle could be demonstrated. It is concluded that a partial taking of the rectus abdominis muscle does not preserve its muscular function.

Incidence of calcifications in the breast after surgical reduction and liposuction.

Liposuction of the breast in combination with vertical mammaplasty was applied to 250 breasts among 386 reductions of large breasts performed in 2 years (1989 to 1991). To evaluate the possible damage to the breast caused by this combined procedure, especially in terms of the occurrence of the postoperative development of calcifications, a comparative study of preoperative and postoperative mammograms was undertaken in 60 randomly selected cases (120 breasts), 34 with and 26 without liposuction. Altogether, 13 calcifications (11 percent) were discovered during the 6- to 30-month follow-up, representing the lowest rate reported in the literature. Deep intraparenchymal calcifications were more frequent after liposuction; most (5 of 7) were macrocalcifications. None could be confused with malignant calcifications because they were more scattered, more regular, and less numerous. Attempts to evaluate the fat content of breasts via preoperative mammography failed to prove this examination a useful way to predict the viability of breast liposuction.

Correction of supernumerary nostrils.

Two rare cases of hypoplastic heminose associated with a supernumerary nostril are presented. In both cases a patent nasal cavity was present on the hypoplastic side. The hypoplastic heminose was reconstructed with the skin and the lining of the second nostril.

[Selected reconstructive technics in the surgery of cancers of the face]. / Techniques de reconstruction sélectionnées dans la chirurgie des cancers de la face.

The technique of facial reconstruction used by the plastic team at the Cancer Center of the University of Brussels are presented. Free grafts are seldom performed because they often lead to disfigurement. An appropriate evaluation of the margins of resection is obtained during the operation by multiple frozen sections, and reconstruction is achieved by local flaps when possible. It is considered that a normal appearance is of extreme importance for old patients suffering from facial cancer, and that the aim of surgery is not only complete eradication of the lesion but also careful reconstruction of the removed structures by simple and safe procedures. The selected techniques are presented for each region of the face.

Progress in esthetic surgery.

Esthetic surgery is now widely accepted by the public and produces results that look more natural than in its early years. Rhinoplasties tend to be undetectable, remodeling of the face includes bone work when useful and treats the soft tissues at the right levels, breast reductions leave minimal scarring, abdominoplasty and liposuction are better adapted to individual deformities. However, so many new techniques are presented that it is sometimes difficult to have a clear opinion about their value before they are widely diffused by the media, and it is mandatory to be careful before proposing a new procedure to our patients.

[Reconstruction of skin defects of the cheek with a large island flap (author's transl)]. / Correction des pertes de substance de la joue par un vaste lambeau en îlot

An island skin flap sliding on its own subcutaneous tissue is described to replace large cheek wound defects after tumor resection in elderly patients. The simplicity of the method and the uniformly good results in 25 cases have led the author to prefer this flap to all other types of local flaps.

[Surgical treatment of some "historical" x-ray dermatites (author's transl)]. / Traitement chirurgical de quelques radiodermites "historiques".

Six cases are presented: two degenerated and four necrotic X-ray dermatitis. Four patients had received X-ray therapy for benign lesions. All suffered long standing X-ray dermatitis lasting up to 60 years. The princip of treatment is a complete excision of the diseased skin and the covering of the defect with flaps. Such severe cases which need a complex treatment, must be handled with caution. X-ray therapy is a powerful but dangerous tool; its dangers are often known late; it should be reserved for severe conditions.

Reconstruction of the nipple-areolar complex after radical mastectomy.

Reconstruction of the nipple areolar complex should be done as a second stage procedure about three months after volume replacement. Symmetry in position, size, and color is of utmost importance for the overall aspect of a breast reconstruction. One piece full thickness grafts from the opposite areola and nipple give the best results. When the remaining areola is too small to provide a full thickness graft, shaving of its surface may be used but often leads to later depigmentation. In these cases inguinal or perineal full thickness skin grafts seem preferable. Projection of the nipple remains a difficult goal. Experience of the authors with 74 nipple areolar reconstructions is discussed.

[Psychological implications of esthetic surgery. Apropos of a study of 68 cases]. / Implications psychologiques de la chirurgie esthétique. A propos dune étude de 68 cas

The candidate to cosmetic surgery is not, contrary to a too common idea, a frivolous creature trying to become more beautiful. He is generally a person with a physical disgrace that induces a frustrating sense of inferiority. The role of the surgeon is to help by removal of the disgrace. The operative indication is thus only psychologic and in some extreme cases, difficult to establish, because the surgeon is badly prepared to this role. A study was performed to understand better the motives and psychologic results of cosmetic operations. Sixty-eight candidates were chosen by the surgeon who considered their disgrace operable. All accepted a psychologic analysis. Following this they were divided into 3 groups: "adapted" (39), "worried" (21) and "perturbated" (8), according to the increasing importance of their emotional disturbances. None of these patients was really psychotic. In the great majority of cases (83%), the interviews with the psychologist disclosed parental difficulties during childhood, followed by a sensation of frustration and of insecurity. Of the 64 operated patients, 62 were reviewed by the psychologist. Fifty-four (87%) were satisfied with the result, among which 45 felt improvement in their psychologic state. Eight were disappointed. Among these, 7 had been classified as "worried" or "distressed". Only 2 patients had reasons to be dissappointed, the others focussed a depressive tendency on a minor and temporary unperfection. Cosmetic surgery thus produces the best psychologic results in "adapted" patients, but is also justified in "worried" or "distressed" patients as the majority will benefit from the operation. In these a careful psychologic contact with the surgeon is mandatory to diminish the postoperative emotional disturbances.

[Recent advances in breast reconstruction]. / Apports récents en reconstruction mammaire.

In ten years, breast reconstruction has become a routine procedure. It is now well established that it does not influence breast cancer. Techniques have been refined, and even use the excess of skin and fat of the lower abdomen to reconstruct a breast without a prosthesis. The indications of reconstruction remain mainly psychological, and it is difficult to predict which patients will be candidates for a reconstructive procedure after their mastectomy. Immediate reconstruction is more often proposed since expansion prostheses are used. It should however be reserved to highly selected cases. An unusual type of reconstruction is now becoming more common, after conservative treatment of breast cancer. It is asked by patients who are disappointed by the aspect of their breast after partial mastectomy and irradiation. Reconstructive surgery is specially difficult in these cases, and may induce more complications than usual reconstruction. It is therefore important that surgeons keep such procedures for cases in which they have good chances to leave a breast with satisfactory volume, consistency and aspect.

Management of the remaining breast in breast reconstruction.

Prophylactic subcutaneous mastectomy is performed only in high risk patients. In other cases, the breast is adapted if needed by conventional techniques. These are slightly modified to obtain a less conical shape of the breast and preserve the whole surface of the areola. In the majority of the cases the nipple-areolar complex will be used at a second stage as donor site for the reconstructed breast.

Breast reconstruction at the tumor center of the University of Brussels. A three year report.

In 80 cases, breast reconstruction was performed as a secondary procedure at least one year after mastectomy for cancer. The prerequisite was absence of local recurrence and distant metastasis, good general condition and careful information on the result to be expected. In the majority of the cases reconstruction was accomplished in two stages: volume replacement with a prosthetic implant was followed after 3 months, by nipple-areolar reconstruction-usually from the opposite side. Capsulotomy or replacement of the prosthesis in case of asymmetry could be performed at this time. If necessary, skin replacement was done as a first procedure by means of a thoraco-epigastric or a latissimus dorsi myocutaneous flap. Aesthetic results are improving with experience and the positive psychological response of the patients is an encouragement to proceed in helping also patients with a rather poor prognosis.