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.

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.

Vertical mammaplasty as secondary surgery after other techniques.

Vertical mammaplasty, a technique that avoids submammary scars, has proved to be a reliable method of breast reduction because it is adaptable to most cases and produces beautiful and durable results. What about secondary cases? In the last 14 cases referred for secondary mammaplasty, at 1-19 years after their initial surgery, patients' indications were poor shape (14), visible and improperly located scars (9), excess volume (8), asymmetry of the areolas (5) or the breasts (1), insufficient volume (2), and asymmetry with reconstructed breast (2). The original scars were inverted T (10), periareolar (2), oblique (1) or vertical (1). Their appearance was a concern for nine patients. All patients but one, who had long submammary scars surrounded by heavy stitch marks requiring correction, could benefit from a vertical mammaplasty. This avoided long months of scar redness and visibility along the submammary folds. Good symmetry and shape could be obtained in all cases by adjusting the markings to the needs. Liposuction was a great help to remove volume without endangering the blood supply of the areolas, possibly transforming reductions in simple mastopexies.

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.

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.

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.

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.

[Analysis of 156 breast reconstructions by transverse rectus abdominis muscle flap (TRAM)]. / Analyse de 156 reconstructions mammaires par TRAM.

The myocutaneous rectus abdominis flap described by Hartrampf was used for 156 breast reconstructions between 1982 and 1992. 107 reconstructions were done with one pedicle. 142 were delayed reconstructions. Partial necrosis of the flap occurred in 10% of the cases in bipedicled flaps and 20% in unilateral flaps. No hernia occurred in this series. Cosmetic results are considered satisfactory or very satisfactory in 59% of the cases when evaluated by the medical team and 76.5% when evaluated by the patients. As a conclusion of this study, the TRAM flap is preferred in delayed reconstructions when local and general conditions are suitable, rather than latissimus dorsi flap reconstructions which require an implant.

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.

[Treatment of cleft lip and palate: long-term results]. / Traitement des fentes labio-palatines: résultats à long terme.

Since 1958, 900 children with cleft lip and palate were operated on at the University Hospital Brugmann in Brussels. Until 1981, the children were operated at 6 months for the lip and at 18 months for the palate with two flap palatoplasties. Since 1982, R. Malek's technique and sequence were adopted. The results after 5 years follow-up are analyzed between two groups of 50 and 49 children operated with the two techniques. Growth of the maxillary arch and phonation are well improved in the second group, but no improvement was observed in terms of hearing.

Neonatal treatment of giant naevi.

A technique of curettage of giant congenital naevi in newborns was proposed by Moss in 1987. We used this technique in 6 children during the last 2 years. The long-term aesthetic results appear to be better than those observed after other methods of treatment. Light microscopy of the pigmented skin confirmed the presence of the majority of naevus cells in the upper dermis. For 3 patients, cultures of the curetted cells showed a melanocyte behaviour similar to that seen in malignant melanoma. These observations are limited to in vitro cultures and are not representative of the in vivo evolution as biopsies of the remaining naevus cells at 3 months of age did not show any malignant characteristics.

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.

Late results and current indications of latissimus dorsi breast reconstructions.

One hundred and fifty latissimus dorsi flaps were used in 145 patients out of a series of 483 breast reconstructions performed from 1977 to 1988. There were few immediate complications and a durable, good cosmetic result was obtained in two-thirds of the 103 cases reviewed after at least one year. The main reasons for dissatisfaction with long-term results were capsular contracture (grades III and IV) and upper displacement of the implant. The rate of these late complications was 30%, the same as found in the simpler subpectoral reconstruction. However, prostheses with a thick outer envelope induced only 10% of severe capsular contracture. Reconstructions with autologous tissue are currently replacing latissimus dorsi flap reconstructions unless local or general conditions contraindicate such major surgery or when the patient lacks motivation.