An external validation of a novel predictive algorithm for male nipple areolar positioning: an improvement to current practice through a multicenter endeavor.

The correct positioning of nipple-areolar complexes (NAC) during gender-affirming mastectomies remains a particular challenge. Recently, a Dutch two-step algorithm was proposed predicting the most ideal NAC-position derived from a large cisgender male cohort. We aimed to externally validate this algorithm in a Belgian cohort. The Belgian validation cohort consisted of cisgender men. Based on patient-specific anthropometry, the algorithm predicts nipple-nipple distance (NN) and sternal-notch-to-nipple distance (SNN). Predictions were externally validated using the performance measures: R2-value, means squared error (MSE) and mean absolute percentage error (MAPE). Additionally, data were collected from a Belgian and Dutch cohort of transgender men having undergone mastectomy with free nipple grafts. The observed and predicted NN and SNN were compared and the inter-center variability was assessed. A total of 51 Belgian cisgender and 25 transgender men were included, as well as 150 Dutch cisgender and 96 transgender men. Respectively, the performance measures (R2-value, MSE and MAPE) for NN were 0.315, 2.35 (95%CI:0-6.9), 4.9% (95%CI:3.8-6.1) and 0.423, 1.51 (95%CI:0-4.02), 4.73%(95%CI:3.7-5.7) for SNN. When applying the algorithm to both transgender cohorts, the predicted SNN was larger in both Dutch (17.1measured(±1.7) vs. 18.7predicted(±1.4), p= <0.001) and Belgian (16.2measured(±1.8) vs. 18.4predicted(±1.5), p= <0.001) cohorts, whereas NN was too long in the Belgian (22.0measured(±2.6) vs. 21.2predicted(±1.6), p = 0.025) and too short in the Dutch cohort (19.8measured(±1.8) vs. 20.7predicted(±1.9), p = 0.001). Both models performed well in external validation. This indicates that this two-step algorithm provides a reproducible and accurate clinical tool in determining the most ideal patient-tailored NAC-position in transgender men seeking gender-affirming chest surgery.

Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata.

Segmental loss of the Achilles tendon with overlying soft tissue and skin defect remains a complex reconstructive challenge. Successful reconstruction combines tendon repair with coverage of the defect by soft tissue flaps, creating an entity that meets up to three predetermined goals: (1) approaching preinjury functionality, (2) resisting shearing forces, and (3) achieving an esthetic result. From June 2009 to June 2011, our center submitted six patients to a one-stage procedure correcting the Achilles tendon using a composite free anterolateral thigh (ALT) flap with vascularized fascia lata. The flap sizes ranged from 5 to 8 cm in width and 16 to 20 cm in length and all flaps included vascularized fascia lata which was rolled to serve as an Achilles tendon. After reconstruction our patients showed good functional results, these patients could walk, climb stairs, and tiptoe again without support. Moreover, normal footwear could be worn. A free composite ALT flap with vascularized fascia lata is a reliable option for coverage of Achilles tendon and overlying soft tissue defects, even in elderly patients.

Phalloplasty: a valuable treatment for males with penile insufficiency.

OBJECTIVES: To apply a phalloplasty technique used in female-to-male transsexual surgery in male patients with penile insufficiency. METHODS: Seven male patients (aged 15 to 42 years) were treated with phalloplasty (6 with radial forearm free flap and one with anterolateral thigh flap) between March 2004 and April 2006 (follow-up, 9 to 34 months). All patients suffered psychologically from their condition, with low self-esteem and sexual and relational dysfunction. They were evaluated by a sexologist-psychiatrist before and after surgery. Erectile implant surgery is offered approximately 1 year after the phallic reconstruction. RESULTS: There were no complications concerning the flap. Two complications were reported in the early postoperative period. Two patients developed urinary complications (stricture and/or fistula). Patient satisfaction after surgery was high in 6 cases and moderate in 1 case. Psychological evaluation confirms this, especially on the self-esteem level. Four patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed. CONCLUSIONS: This success has convinced us that phalloplasty is a valuable treatment for penile insufficiency. It has good results in terms of patient self-esteem and sexual well-being. This technique opens new horizons for the treatment of penile agenesis, micropenis, crippled penis, shrivelled penis, some disorders of sexual development, traumatic amputations, and cloacal exstrophy.

One-stage penectomy and phalloplasty for epithelioid sarcoma of the penis in an adolescent.

Epithelioid sarcoma (ES) of the penis is a rare tumour. We present a case of ES of the penis in a 16-yr-old boy, for which penectomy and immediate reconstruction with a free forearm phalloplasty, including a urethral reconstruction, was performed. Because total penectomy is a dramatic life event for any patient, the option of immediate penile reconstruction is presented. It can help to prevent major psychological problems after this kind of surgery.

Free perforator flaps in children.

BACKGROUND: Raising perforator flaps is said to be a tedious procedure. The benefits, however, are great. In adults, perforator flaps have proved their usefulness and reliability in various clinical situations. In children, donor sites for free flaps are particularly scarce because of the need for a long and reliable vascular pedicle of sufficient size. There is also the need to minimize donor-site morbidity from aesthetic, functional, and psychological perspectives. METHODS: The authors present a series of 23 consecutive free perforator flaps performed by the first author in 20 children; ages at the time of operation ranged from premature (born at 28 weeks) to 16 years (mean age, 7 years 5 months). Three children presented with upper limb defects; the remaining 17 children sustained major soft-tissue defects of the lower limb. All the lesions necessitated extensive coverage with a free flap. Flaps used in this series included nine deep inferior epigastric artery perforator flaps, seven thoracodorsal artery perforator flaps, and seven compound ("chimera") thoracodorsal artery perforator flaps. RESULTS: All flaps but one were successful. With a follow-up of up to 7 years, the results in this series compare favorably with those of perforator flaps in adults or pediatric free flaps in the literature. CONCLUSIONS: In children, as in adults, perforator flaps are a valuable alternative to the traditional muscle or myocutaneous free flap. Because of the added advantage of reducing donor-site morbidity, perforator flaps have become the authors' preferred option in reconstructive cases in children.

The versatile DIEP flap: its use in lower extremity reconstruction.

The deep inferior epigastric perforator (DIEP) flap gained widespread popularity as a free flap in breast reconstruction. It is also a versatile and reliable supply of a large amount of skin and soft-tissue, which can be used in other types of reconstruction. We present 25 consecutive cases (28 DIEP flaps) performed in our service during the past 5 years for different indications in lower extremity aesthetic and functional reconstruction, both as pedicled or free flaps. The amount of tissue provided, its reliable vascular supply and long and adequately sized pedicles, together with its limited donor-site morbidity make it a useful alternative free flap.

Autologous breast augmentation by pedicled perforator flaps.

A technique is described for autologous breast augmentation based on perforator flaps of the lateral chest wall. Raising these flaps as perforator flaps implies minimal donor site morbidity; however, the price to pay is a scar underneath the armpit extending from the lateral end of the inframammary fold onto the back. This scar can be relatively well hidden underneath the arm and in the brassiere. Indications depend on the aversion of the patient against prostheses and the extent of available tissue versus the desired augmentation. As typical indications, we would consider the occasional developmental asymmetry, autologous augmentation after contralateral breast reconstruction, or contour surgery in the bariatric patient.

The long-term speech outcome in Flemish young adults after two different types of palatoplasty.

OBJECTIVE: The success of cleft palate surgery is specifically determined by the subsequent speech characteristics. There are several types of surgical techniques to repair the palate. The surgeon chooses his or her own technique according to the principles (s)he have established based on experience. The main purpose of this study is to determine and to compare the long-term speech outcome (18 years after surgery) regarding overall intelligibility, articulation, resonance, and voice after one-stage Wardill-Kilner palatoplasty or two-stage Furlow palatoplasty. The authors hypothesized that a decreased overall intelligibility, more compensatory articulation disorders, higher nasalance values and more nasality disorders would occur in the two-stage Furlow palatoplasty. Moreover, an increased risk for dysphonic symptoms, caused by the more intensive vocal tract activities, were expected in subjects with higher nasalance scores. An additional objective of this study was to compare the speech and voice characteristics with the age related normative data. Significant differences between the resonance and voice characteristics of the two techniques of palatoplasty and the normative data were hypothesized. METHODS: Objective as well as subjective assessment techniques were used. The evaluation of the articulation included a phonetic inventory and a relational analysis in which the consonant and vowel productions were compared with target productions and analyzed for error types at the segmental level. The speech samples were perceptually judged for intelligibility and nasality. The Nasometer was used for the objective measurement of the nasalance values. The assessment of the voice included a perceptual evaluation and a determination of the Dysphonia Severity Index. RESULTS: The subjects who received a two-stage Furlow palatoplasty showed statistically more hypernasality and higher nasalance scores in comparison with the one-stage Wardill-Kilner palatoplasty. No major differences regarding articulation and voice characteristics were found. As expected, significant differences were found between the speech intelligibility and resonance characteristics in subjects who received a palatoplasty and the normative data. CONCLUSION: Since the subjects who received a one-stage Wardill-Kilner palatoplasty had a significantly better speech outcome it was decided in the craniofacial team of the University Hospital of Ghent that a two-stage palatoplasty would no longer be performed.

Better cosmetic results and comparable quality of life after skin-sparing mastectomy and immediate autologous breast reconstruction compared to breast conservative treatment.

Preoperative chemotherapy (PCT) can be used in large primary breast cancer to facilitate breast conservative surgery (BCS). Cosmetic results of BCS are influenced by the size of the residual tumour, relative to the size of the breast. After mastectomy, immediate breast reconstruction (IBR) with autologous tissue provides excellent cosmetic outcome and has proven to be safe in breast cancer patients. Besides improving overall and disease free survival, Quality of Life (QoL), body image and cosmetic outcome are also important issues after treatment for breast cancer. In this study, Health-Related-Quality of Life (HRQL) and body image were evaluated, in patients treated with PCT, followed by BCS, or skin-sparing mastectomy (SSM) and perforator-flap breast reconstruction. Additionally, clinical observers assessed cosmetic outcome. All participants were evaluated by the Medical Outcomes Study (MOS) 36-item Short Form Health Status Survey (SF-36, 36 items) and a study-specific questionnaire. An external panel evaluated standardised photographs of the breasts. For all patients, norm-based scores of physical and mental health state are comparable with the general population, except for vitality (VT) score, which is somewhat lower. No significant differences can be observed between both groups. The majority of the patients were satisfied with the appearance of their breasts. The cosmetic results, assessed by the clinical team, were significantly better for patients having IBR, compared to BCS. The mean score was 7.5/10 for IBR, versus 6.0/10 for BCS (p<0.0001).Breast conserving treatment or mastectomy with reconstruction may yield comparable results of QoL, but cosmetic outcome is better after SSM and perforator-flap reconstruction. Patients must be offered both options, and clinicians should stress that both are equally effective.