[Correction of body contour in an obese man after large weight loss following a bariatric procedure]. / Correctie van de lichaamscontour bij een obese man die sterk was afgevallen door een bariatrische ingreep.

A 42-year-old man was referred to the plastic surgery outpatient clinic with the request for body contouring surgery after previous bariatric surgery elsewhere. With help of the bariatric interventions he had lost 109 kg and now weighed 227 kg. At this stable weight he had a large surplus of abdominal wall skin with functional hindrance and inflammation due to chafing. After treating his comorbidity we eventually performed an extended abdominal dermolipectomy and excised 32.8 kg of skin surplus. There was some temporary wound dehiscence which was treated conservatively. The patient was very satisfied with the improvement in his body contour.

Colpectomy after vaginoplasty in transsexuals.

BACKGROUND: Penile amputation, vaginoplasty, and clitoroplasty help male-to-female transsexuals accept their bodies and increase psychosocial function. Subsequent colpectomy is unusual. CASES: We report three patients in whom complicated, long-term problems subsequent to vaginoplasty led to total colpectomy in one case of neovaginal overgrowth of condylomata acuminata, and in two cases of colitis in rectosigmoid transplants used for neovaginoplasties. CONCLUSION: Before inversion of penile skin, in cases in which the genital skin has condylomata, the risk of condylomata overgrowth might be anticipated. Rectosigmoid vaginoplasty might result in therapy-resistent colitis, which also could lead to colpectomy.

Evolution of the methods of neovaginoplasty for vaginal aplasia.

The aim of vaginoplasty should be the creation without excessive morbidity of a neovagina that will be satisfying in appearance, function and feeling. The multitude of methods described in the literature indicates the fact that an ideal approach has not yet been found. In this paper the various methods are described and discussed. It is concluded that the non-operative impression technique, the peritoneum pull-through technique and the use of skin grafts are methods of choice. In cases where immediate vaginal reconstruction after oncological surgery is indicated, myocutaneous flaps are preferred. Only in cases in which other methods have failed should recto-sigmoid transplantation be considered.

Abdominoplastic secondary full-thickness skin graft vaginoplasty for male-to-female transsexuals.

When inversion of combined penile and scrotal skin flaps for vaginoplasty in male-to-female transsexuals has become impossible or has not led to functional results, alternative vaginoplasty techniques should be considered. Colocolpopoiesis involves major surgery and often leads to disappointing long-term results. An Abbé-McIndoe vaginoplasty applying split-thickness skin grafts often does not provide favorable results in the scarred area encountered after complications of skin flap inversion surgery. Because thicker skin grafts show less tendency to shrink, the use of a full-thickness skin graft has been advocated for vaginoplasty in females. In this paper, we present our technique of successful secondary vaginoplasty applying full-thickness skin grafts in six male-to-female transsexuals. In patients with sufficient groin and abdominal skin to spare, a miniabdominoplasty allows for acceptable donor site scarring combined with correction of the abdominal skin surplus. In flat-tummied patients, the conventional abdominoplasty will allow for sufficient skin to be harvested to ensure successful secondary vaginoplasty. Abdominoplastic vaginoplasty has been proven to provide a good alternative whenever a laparotomy is not favored or is contraindicated in secondary cases.

History offhand: a golfer's needleholder.

Sir Harold D. Gillies was the father of modern plastic surgery. Apart from being an extraordinary surgeon, he was an innovator of surgical instruments and an outstanding golfer. He adopted Kocher's suture scissors and converted them for needleholding. The authors believe that the surgeon Gillies adapted this needleholder to fit his golfer's hand.

Labial masses following vaginoplasty in male transsexuals: the differential diagnosis.

Following vaginoplasty and vulvoplasty for male-to-female transsexualism, a mass may evolve in one of the major labia in a minority of patients. From April of 1989 to April of 1994, we treated seven patients with such masses. The case reports presented illustrate some of the differential diagnoses of this long-term complication. More often than not, the swelling was caused by infection. The funiculus or even testicular rest in itself also may represent the mass. Intralabial urethral fistula appears to be the second cause of swelling, either with or without inflammation. As an exceptional cause we observed a swelling representing a cyst of prostatic origin. In all, the mass could be excised completely.

Formulation of trichloroacetic acid peeling solution: a bibliometric analysis.

Since the beginning of this century, trichloroacetic acid solutions of various concentrations have been used for chemical exfoliation. These solutions have been prepared by using four different formulas. To prepare a 50% solution, for instance, water may be added to 50 g of trichloroacetic acid crystals until 100 ml of solution is obtained (weight-to-volume solution). Alternatively, 50 g of water may be added to 50 g of trichloroacetic acid crystals (weight-to-weight solution), or 50 g of trichloroacetic acid crystals may be solved in 100 ml of water (weight-plus-volume solution). Finally, a saturated trichloroacetic acid solution (or "100% solution") may be diluted by an equal volume of water (dilution). Depending on the method used, these so-called 50% solutions contain 40 to 71 weight-to-volume percentages of trichloroacetic acid. From a review of 120 publications on trichloroacetic acid peeling that have appeared since 1926, it was concluded that the authors of 87 of these publications (73 percent) did not report their formula for the trichloroacetic acid solution. Any one of the four methods was reported to have been used by the 33 authors who did report their formula. Eight of 10 internationally reputed pharmacopeias were found not to include the formula of a trichloroacetic acid solution. Proper evaluation of results and prevention of complications of trichloroacetic acid chemexfoliation is only feasible if both the concentration and the formula of trichloroacetic acid solution are reported by the author. Practitioners who use a trichloroacetic acid solution need to establish that the concentration of the solution they apply corresponds with that of the solution reported in the literature.

Sparing a testis during vaginoplasty in male-to-female transsexuals: does it benefit our patients?

Testosterone and its metabolite dihydrotestosterone are the libido hormones for the male, vital to sex drive and sexual function. Fear of loss of libido and orgasm is the main reason to retain at least one testis in male-to-female transsexuals during vaginoplasty. We report on four South American transsexual patients in whom we resected a remaining testis to illustrate the superfluity of retaining it. Because there are multiple reasons for castration, we advise that bilateral orchidectomy be performed in the course of sex reassignment surgery for male-to-female transsexuals.

Unfavorable long-term results of rectosigmoid neocolpopoiesis.

We report on unfavorable long-term results after rectosigmoid neocolpopoiesis in 12 patients, as well as on possible prevention and treatment of these results. To prevent neovaginal introitus stenosis, the rectosigmoid mucosa should be sutured to the perineal skin in an exaggerated interdigital fashion. In cases where introitus stenosis has developed, pedicled transposition flaps from perineum or labia or from the gluteal or inguinal plica region have to be used. Similar flaps also may be applied in cases of rectovagina fistulas. Neuromas at the mucosa-perineal junction often are resistant to therapy. So-called diversion colitis may be manifested by mucous discharge, mucosal bleeding, or discomfort. This disorder may be treated successfully by local application of a solution containing short-chain fatty acids. Loperamidehydrochloride (Imodium) administered half an hour before intravaginal penetration may be helpful to weaken or even prevent neovaginal contractions. Because of the possible higher risk of neovaginal adenocarcinoma, long-term follow-up of these patients is indicated.

Sculpturing the neoclitoris in vaginoplasty for male-to-female transsexuals.

One of the goals of vaginoplasty for transsexuals is the construction of an aesthetically appealing female perineum. Cosmetic considerations imply the creation of a clitoris-like structure ventral to the urethral orifice. A review of the scarce references on neoclitoroplasty in the literature on vaginoplasty is given. In our hospital, the neoclitoris is usually sculptured to its final appearance during the actual vaginoplasty, employing a free composite graft of the tip of the penile glans to cover the shortened dorsal neurovascular bundle. From the review of the literature and from our experience one may conclude that our technique presents hardly any complications and leads to acceptable results, both functionally and cosmetically. We consider transpositioning of the glans on its long dorsal neurovascular pedicle a technique with too high a risk.

The devastating outcome of massive subcutaneous injection of highly viscous fluids in male-to-female transsexuals.

Illicit subcutaneous injections of massive quantities of highly viscous fluids are still performed, often by unqualified persons. Fifteen male-to-female transsexuals consulted the authors regarding their devastating long-term outcomes after the injection of up to 8 liters of alleged silicone or mineral oil to feminize their bodies. After a latency period of up to 17 years, these injections led to complications ranging from scarring and deformity to infections. These patients were treated conservatively for inflammation and infection or surgically by resection of the oil-infested areas. In view of the potential dangers, feminization by the injection of high-viscosity fluids should be soundly condemned.

Secondary corrections of the vulva in male-to-female transsexuals.

From December of 1980 to May of 1998, 390 male-to-female transsexuals underwent vaginoplasty by inversion of the penile skin and a triangular perineoscrotal flap. Although minor modifications were made throughout the years, the basic surgical technique remained the same over this 17.5-year period. In 86 of the 390 patients (22 percent), secondary corrections of the vulva were deemed necessary. A total of 130 corrections were performed in these 86 patients. In the same 17.5-year period, the authors performed 26 secondary corrective procedures in 19 patients in whom the initial vaginoplasty had been done elsewhere. Bilateral Z-plasties were performed 69 times to center the labia in instances when the ventral part of the labia majora remained too far apart. This is not advisable, primarily because it will reduce the vascular supply of the penile skin flap. Introital widening by five-flap advancement was performed in 40 cases in which a dorsal skin fold obstructed the introitis. The use of the triangular perineoscrotal flap favors the vaginal and introital width, but its base should be close to the anal ring to prevent such a skin fold. Secondary construction of the labia minora was performed 27 times, and a skin reduction of the labia majora was performed 20 times. So far, the authors have been unable to develop a satisfactory method for primary construction of the labia minora. Because the appearance of the vulva may charge gradually during the first postoperative year, secondary vulvar corrections should not be performed in that period.

Prevalence and distribution of hand fractures.

A retrospective survey of the medical charts of all 36,518 patients attending the Accident and Emergency Department of the VU University Medical Centre, in Amsterdam, from January 1 to December 31, 1996 was performed. Of these, 4303 sustained one or more fractures, and hand fractures accounted for 19% of all fractures. Patients with hand fractures were typically men aged between 15 and 35 years. The right hand was involved as often as the left. Most of the hand fractures involved the metacarpals but, as a group of bones, the combined phalanges were most commonly fractured. The little finger ray was most commonly injured of the hand. We found no seasonal variability in the incidence of hand fractures.

Augmentation mammaplasty in male-to-female trans-sexuals: facts and figures from Amsterdam.

In male-to-female trans-sexuals in whom the hormonal treatment has not resulted in sufficient growth of the breasts, augmentation mammaplasty may be considered. Mammaplasty is performed in two-thirds of our patients who have had vaginoplasties. We present our experience of 201 patients operated on at the Academisch Ziekenhuis Vrije Universiteit in Amsterdam up to 1997. The patients' mean age was 34 years (range 17-76) and the mean follow-up was four years (range 2 weeks to 16 years). In keeping with our protocol, most patients had had oestrogen therapy and a successful real-life experience for a minimum of 1.5 years. The mean size of implants has nearly doubled over the years. Male-to-female trans-sexuals often request large breasts and repeated augmentation mammaplasties were required, mainly in cases where the result of initial augmentation was not outspoken.

[Chondrosarcoma of the bony thoracic wall]. / Chondrosarcoom van de benige thoraxwand.

An 85-year-old man was admitted because of a slowly growing mass in his left flank, which had been present for 16 years. A very large chondrosarcoma was diagnosed, weighing 8.5 kg. After radical resection of the tumour the patient recovered well. No recurrences developed during follow-up.

Current treatment methods for combination antiretroviral therapy-induced lipoatrophy of the face.

Combination antiretroviral therapy (CART) reduces the mortality and morbidity in HIV-infected patients. However, facial lipoatrophy (FLA) is one of the well-known side-effects of this treatment and subsequently imposes major problems for HIV-infected patients. In the last decade, ample experience has been obtained with both local therapeutic options as well as possible systemic treatment options. Soft tissue fillers are a relatively simple and efficient treatment option for FLA. Especially, the biodegradable semi-permanent fillers combine a good effect with durability and an acceptable safety profile. The best way to prevent or restrict the development of FLA remains the exclusion of thymidine analogue nucleoside reverse-transcriptase inhibitors from the CART schedule.