Masculinizing chest-wall surgeries in transgender patients, a retrospective single-center study.

INTRODUCTION: Masculinizing chest-wall contouring surgery is an important surgical intervention for most transmasculine patients; a vast improvement in quality of life for this group of patients has been documented as a result of receiving surgery. The aim of this study was to evaluate the results of such surgeries performed at our university hospital between 2008 and 2020, as well as the current quality of life of the patients. METHODS: All 16 patients operated between 2008 and 2020 were sent a questionnaire consisting of both BREAST-Q and BODY-Q modules, considered fitting for our study purposes, as well as the BECK Depression Index and a short two-question form with space for feedback. Patients were divided into groups called double incision (DI) and periareolar (PA) depending on the surgical technique used. RESULTS: We found an overall complication percentage of 31.3%, with the DI group scoring 33.3% and PA 28.6%, while secondary aesthetic corrections were necessary for 50% of all patients. The questionnaires yielded 6 responses (37.5%). Participants rated on a scale of 1 to 10 their willingness to undergo the operation again if given the choice; the DI group averaged 10/10, and the PA group 9/10, despite the statistically significant complication and correction rates. CONCLUSIONS: Masculinizing chest-wall contouring surgery has significant complication risks. In our study, frequency of complications did not appear to depend on the surgical technique used. Additionally, the complication rates found in our low volume centre seem to be comparable with those reported from bigger units.

Short- and long-term mortality and causes of death after reconstruction of cancers of the head and neck with free flaps.

The use of free flaps to reconstruct cancers of the head and neck is accompanied by appreciable postoperative morbidity and high long-term mortality, but the causes of death and the impact of postoperative complications on survival have not been well studied. We have therefore analysed retrospectively the causes of death and survival of 146 such patients operated on between 2008 and 2016 of whom a total of 62 (43%) had died by the end of 2016. The cause of death was the primary disease in 45 of the 62. The median survival of those who died with the primary cancer as the cause of death did not differ from that of those who died of other causes. In a multivariate Cox model indicators of five-year mortality were male sex, low body mass index (BMI), American Society of Anesthesiologists (ASA) grade more than II, and late medical complications. Neither the size of the tumour nor any operative factors were independent risks for five-year mortality. Ten patients died within six months of operation, all of whom had higher postoperative C-reactive protein concentrations than those who survived for more than six months. The cause of death of most patients who died after free flap operations for head and neck cancer was the primary diagnosis. According to these results, patient-related factors (male sex, ASA grade more than II, low BMI, and low albumin concentration) have an important role in long-term survival, which highlights the importance of careful selection of patients for operative treatment.

Complications and outcome after free flap surgery for cancer of the head and neck.

We retrospectively studied 136 patients who had free flap reconstruction for cancer of the head and neck at a single centre (2008-2015) to evaluate complications, assess factors associated with them, and analyse their impact on outcome. Preoperative and perioperative data, and surgical and medical complications were recorded, and the impact of the complications on duration of hospital stay and survival were assessed. A total of 86 (63%) patients had complications. Compared with those who did not, they had a higher rate of alcohol abuse (21/86, compared with 5/50, p=0.039), longer operations (median (IQR) 565 (458-653 compared with 479 (418-556) minutes, p<0.001), and greater intraoperative loss of blood (725 (400-1150) compared with 525 (300-800) ml, p=0.042). Complications were more common in patients who had fibular flaps and T4 disease (22/86 compared with 4/50, p=0.010; 47/80 compared with 16/47, p=0.015, respectively). Those who had complications also stayed in hospital longer (median (IQR) 9 (7-12) compared with 15 (10-21) days, p<0.001). Cumulative mortality was higher in patients with late complications (those that occurred after the fourth postoperative day) (61% compared with 36%, p=0.004). In conclusion, complications in more than half the patients were related to alcohol abuse, a more complicated intraoperative course, and fibular flaps. Complications were associated with a longer hospital stay, and survival was higher in those who did not have late complications than in those who did.

Recovery of muscle strength after late repair of distal biceps brachii tendon.

BACKGROUND AND AIMS: Ruptures of the distal part of the biceps brachii tendon are rare. The diagnosis is often delayed and only late repair can be considered. In this study, the recovery of muscle strength after late repair of the distal biceps brachii tendon was evaluated. MATERIALS AND METHODS: Sixteen patients with a ruptured distal biceps brachii tendon were analysed. The mean delay from the primary trauma to the operation was 35 weeks. The tendon was anatomically re-attached with bone anchors. In three cases a tendon graft was needed. The operated arms were immobilised postoperatively for four weeks, after which mobilisation was allowed. Maximal static flexion and supination strength was measured after an average follow-up time of 124 weeks by using a computer-based isokinetic dynamometer. RESULTS: Patient satisfaction and overall muscle strength recovery were very good. Compared to the non-operated side, average flexion strength recovery was 90% and corresponding recovery of supination strength 78%. Weakness on supination remained in the cases where a tendon graft was used. One patient needed a re-operation for a re-rupture. There were three cases of transient paresthesia of the cutaneous nerve. All patients resumed their previous work. CONCLUSION: Late anatomical repair of the biceps brachii tendon restores very good flexion and moderate supination strength. This operation should always be considered when the primary diagnosis is delayed.

Rectus abdominis muscle flap with microvascular anastomoses for repair of recurrent sarcoma.

After radical resection of a recurrent leiomyosarcoma, the thoracic wall was stabilized with a Gore-Tex graft. The skin and soft tissue defect was repaired with a large rectus abdominis flap in which the circulation was secured by end-to-end microvascular anastomosis of the inferior epigastric artery to the internal mammary artery, which had to be cut during tumor removal.

Cosmetic results after wire-guided biopsy of benign breast lesions.

BACKGROUND: There are surprisingly few reports about the cosmetic results of wire-guided biopsy of benign breast lesions as opposed to breast-conserving surgery and irradiation of early breast cancer (BCT). STUDY DESIGN: Twenty potential perioperative risk factors for adverse cosmetic results after wire-guided breast biopsy were prospectively evaluated in 101 patients undergoing the first single biopsy after suspicion of a malignant lesion that subsequently proved to be benign. The overall cosmetic result was evaluated by using 6 specific cosmetic indices individually scored 6 months after the breast biopsy. RESULTS: The overall cosmesis was excellent, good, fair, or poor in 48.5%, 26.7%, 12.9%, and 11.9% of cases, respectively. The corresponding figures according to appraisal by the patients were 22.8%, 58.4%, 17.8%, and 1.0%, respectively. Unsatisfactory (fair or poor) overall cosmetic results were related to excisions extending down to the fascia (p = 0.001) and postoperative complications (p = 0.018) in multivariate analysis. Notably, specimen volume had no significant impact on overall cosmesis, as opposed to cosmesis after BCT. CONCLUSIONS: Cosmetic outcomes after wire-guided biopsy of benign breast lesions were excellent or good in at least 75% of cases. Excisions extending down to the pectoralis fascia and complications were associated with poor aesthetic outcomes.

Wire-guided excision of non-palpable breast cancer: determinants and correlations between radiologic and histologic margins and residual disease in re-excisions.

In cases of wire-guided excision of non-palpable breast cancer (WGE), data concerning the determinants and correlations between radiologic and histologic margins and residual cancer in re-excisions are sparse. A total of 21 variables in 66 WGE followed by 49 re-excisions were prospectively analyzed. In multivariate analysis, only large mammographic lesions were clearly related to positive margins in specimen radiography (P<0.05). Multifocality (P<0.001), large pathologic size (P<0.05) and superficial excision (P<0.05) were related to positive histologic margins and multifocality (P=0.001) to residual disease in re-excisions. The sensitivity, specificity and positive predictive values of specimen radiography for predicting histologic margins were 33%, 79% and 53%, and those for predicting residual disease 30%, 80% and 38%, respectively. The ability of histologic margins to predict residual disease was 91%, 58% and 38%, respectively. In WGE, large mammographic lesions carry a significant risk for radiologically incomplete excision, while pathologically large and multifocal tumors may be histologically incompletely excised, especially if the excision does not extend down to the pectoral fascia. The excision sites of multifocal tumors should be re-excised because of the considerable risk of residual disease. The radiologic and histologic margins of the specimen may be misleading.

Assessment of tissue viability in frostbite by 99Tcm-HDP scintigraphy: an experimental study in New Zealand white rabbits.

Since the appearance of superficial tissue is often an unreliable indicator of deep tissue viability in cases of frostbite, radionuclide scintigraphy with 99Tcm-disodium oxidronate (HDP) was used to assess changes in tissue viability after experimental freezing and thawing of the rabbit ear. One shaved ear, left or right, of each of eight New Zealand white rabbits was frozen with a glass bottle (diameter of bottom 2 cm) filled with liquid nitrogen (-180 degrees C) for 5 min under Ketalar-Rompun anesthesia, the other ear serving as a control. Radionuclide scintigraphy was performed by giving a bolus intravenous injection of 130-170 MBq (3.5-4.5 mCi) 99Tcm-HDP. Radionuclide imaging was used to follow the development of the demarcation line. Scintigraphy was performed 2 h after frostbite and then after 24 h, 48 h, 1 week and 3 weeks. The frostbitten area seemed macroscopically to be warm and swollen immediately after the induction of frostbite. Scintigraphy showed the frostbitten area to be much warmer than the surrounding tissue for the first week and it was not until after that the first cold spots appeared in the middle of the frostbitten area. The necrotic and vital tissue could easily be distinguished after 3 weeks.

Poor interobserver reliability of AO classification of fractures of the distal radius. Additional computed tomography is of minor value.

Interobserver reliability of the AO system of classification of fractures of the distal radius was assessed using plain radiographs and CT. Five observers classified 30 Colles'-type fractures using only plain radiographs; two months later they were reclassified using CT in addition. Interobserver reliability was poor in both series when detailed classification was used. By reducing the categories to five, interobserver reliability was slightly improved, but was still poor. When only two AO types were used, the reliability was moderate using plain radiographs and good to excellent with the addition of CT. The use of CT as well as plain radiographs brings interobserver reliability to a good level in assessment of the presence or absence of articular involvement, but is otherwise of minor value in improving the interobserver reliability of the AO system of classification of fractures of the distal radius.

Composite implant of native bovine bone morphogenetic protein (BMP) and biocoral in the treatment of scaphoid nonunions--a preliminary study.

BACKGROUND AND AIMS: Bone morphogenetic protein (BMP) has been shown to induce bone formation and union in long bone defects and nonunions. We report a preliminary study of a composite implant consisting of a biocoral frame, carrier collagen and bovine BMP in the treatment of scaphoid nonunions. MATERIAL AND METHODS: Two proximal and eight waist area scaphoid nonunions were treated using BMP/coral implant combined with either the Matti-Russe procedure (2 cases) or an interpositional bone graft fixed with screws or compression fixation pins (8 cases). In two cases only a one piece BMP/coral implant was used as an interpositional graft and in other cases interpositional autograft was used with granular BMP/coral implant placed between the fragments and the graft. RESULTS AND CONCLUSIONS: Only two wrists resulted in complete union. These preliminary results suggest that composite implant of BMP, as used in the present study, may not solve the problems encountered in the treatment of scaphoid nonunions. Poor vascular conditions in scaphoid may not provide enough mandatory osteogenic cells for BMP to function properly. In avascular conditions coral does not resorb edequately and implants may also work as a sequester between the bone graft and the scaphoid bone and therefore actually inhibit the healing process.

Use of bioabsorbable osteofixation devices in the hand.

Bioabsorbable internal fixation by means of pins, tacks, screws and miniplates offers an alternative to metallic osteofixation for the stabilization of small bone fractures, osteotomies, ligament injuries and fusions in the hand. The advantages of using them include avoidance of metallic-implant-related long-term complications and a secondary removal operation. Currently the most commonly used devices are made of poly L-lactide (PLLA) and copolymers of polylactides (P(L/DL)LA) and polyglycolide (PLGA). In areas of mechanical stress, the use of ultra-high-strength self-reinforced devices is recommended. Biomechanical studies on fresh frozen bones have shown that the fixation rigidity achieved with self-reinforced devices approaches that of metallic osteofixation methods. The reliability of modern implants has been confirmed in several experimental and clinical studies.

Silicone replacement arthroplasty for Kienböck's disease.

Thirty-nine patients with Kienböck's disease underwent silicone replacement arthroplasty between 1979 and 1994. The patients were followed-up from 1 to 18 years (mean, 8 years). Sixteen prostheses (41%) have had to be removed, from 1 to 18 years postoperatively (mean, 5.6 years), 15 of them because of pain and silicone synovitis or cysts. It appears that silicone synovitis with cyst formation is an inevitable problem in the wrist after silicone replacement arthroplasty of the lunate, and this procedure is only a temporary solution for Kienböck's disease.

Effect of perivascular sympathectomy on distal adrenergic innervation in the hands of monkeys.

Perivascular sympathectomy has been thought to cause distal adrenergic denervation. We performed perivascular sympathectomy for a distance of 1 cm. on two common digital arteries in the right hands of two anaesthetised Macaca arctoides monkeys. Four days later, samples were taken for glyoxylic acid-induced fluorescence examination of the operated and opposite control hand. The distal adrenergic nerves were morphologically normal in appearance after the perivascular sympathectomy. The operation should perhaps be called adventitectomy rather than perivascular sympathectomy and its positive effects may be due to the loss of adventitial support for the vasospastic arteries rather than adrenergic denervation.

The formation of the demarcation line at experimental frostbite.

Experiments were carried out to gain a better understanding of the pathogenesis of frostbite and changes at the demarcation line after freezing and thawing and to determine the forming demarcation line as early as possible. These changes were investigated by histochemical techniques, by histofluorescence, by determining noradrenaline content in the tissue and nerve, by scintigraphy and thermography. The experimental animal was New Zealand white rabbit. The frostbite was produced using a small laboratory bottle filled with liquid nitrogen pressing against the shaved skin in the middle of the proximal part of the ear. Enzyme histochemistry was good in demonstrating the demarcation line between irreversibly damaged and healing frostbitten tissue. Especially the reaction to esterase was the clearest, the demarcation line was visible already after one week. The glyoxylic acid-induced fluorescence method was available for showing adrenergic nerves around the vessels and the accumulation of catecholamines in these nerves in the demarcation line. The result of quantitative measurement of catecholamines in the nerve and tissue was similar and the reaction was the most powerful during the first three days. Scintigraphy was better than thermography and necrotic areas in the middle of the frostbitten area became clearly visible after three weeks. It seems that many changes caused by frostbite happen both in tissue and cells. The role of catecholamines in vascular circumstances is important and that's why chemical or surgical sympathectomy could be useful.

Perivascular sympathectomy of the metacarpal artery of the rabbit paw fails to remove distal adrenergic innervation.

Though vasospastic disorders of the hand are commonly treated by perivascular sympathectomy, which is believed to remove distal adrenergic innervation, our earlier experimental studies with rat saphenous vessels and rabbit ear vessels gave the opposite results. We therefore operated on 12 rabbits, carrying out perivascular sympathectomy of a metacarpal artery in the left forepaw, the right paw serving as a control. Six rabbits were killed after one week and the other six after three weeks, and the adrenergic nerves were examined by glyoxylic acid-induced fluorescence. Adrenergic innervation seemed to be normal in the distal vasculature after perivascular sympathectomy, and seemed to be missing only from the site of the operation.

Failure of perivascular sympathectomy to remove adrenergic nerves from peripheral vessels of the rabbit ear skin.

A perivascular sympathectomy was performed at the base of the ear artery in 11 New Zealand white rabbits. Two days later three were killed, and the central nerve was cut in the remaining eight. The contralateral ear served as a control. Specimens were taken from the distal parts of both ears two days later and the glyoxylic acid-induced fluorescence method was used to show the adrenergic nerves. The arteries of the normal, control ear were surrounded by a dense plexus of fluorescent adrenergic nerves, which were abolished by perivascular sympathectomy only in the segment from which the adventitia had been removed. The adrenergic innervation was normal proximal to the site of perivascular sympathectomy, but there was a short segment of the central vessel distally in which it was diminished. No changes in adrenergic innervation were found in the distal third of the rabbit ear.

Microvascular flaps from the lateral arm and radial forearm for the repair of defects of the Achilles tendon region. Case report.

Two patients presented with loss of skin in the Achilles tendon region, which is difficult to repair satisfactorily. They were both treated with microvascular flaps, one of which was taken from the lateral arm, and the other from the radial forearm. Both methods gave good functional results.

The role of polyglycolic acid rods in the regeneration of cartilage from perichondrium in rabbits.

The role of polyglycolic acid (PGA) rods in the regeneration of cartilage from perichondrium was investigated in 12 growing rabbits. The fifth rib cartilage was resected subperichondrially from both sides. A 10 X 1.5 mm self-reinforced polyglycolic acid (SR-PGA) rod was inserted on one side to replace the resected cartilage and the retained perichondrium was sutured around the implant. On the control side the perichondrium was shaped into a tube without an implant. Samples were taken 4, 12, and 20 weeks after operation. Pronounced neocartilage formation was seen on both sides, and had grown to form a tube around the implant. Also new bone formation was seen in 12 and 20 weeks. Foreign body reaction was seen inside the implants in every animal.

Use of self-reinforced polylactide osteosynthesis devices in craniofacial surgery: a long-term follow-up study.

Self-reinforced polylactic acid or polylactide (SR-PLA) is a biodegradable polymer, which is strong enough to fix weight-bearing cortical bone fractures and osteotomies. We report our experience and follow-up of the use of SR-PLA plates in 15 clinical cranioplasties. Two of the cases are described in greater detail. In one of them SR-PLA plates were used in addition to titanium plates, and in the other an SR-PLA plate fixed with mini-titanium screws was used as the only fixation material. In the other patients SR-PLA plates or wire were used in addition to titanium. So far no complications have been observed in these 15 patients. The only small superficial fistula was associated with a titanium plate and titanium screws. The longest follow-up has been over eight years. Recent results show metal-like deformation properties in addition to complete late resorption, making SR-PLA osteosynthesis devices promising for use in craniofacial surgery.

Desmoplastic fibroma of the calcaneus treated with a microvascular bone graft. Case report.

A calcaneal desmoplastic fibroma in a 24-year-old woman had previously been treated with repeated curettage and bone grafting. Because of a larger recurrence a microvascular bone reconstruction was carried out using an osteofascial radial forearm flap. She could walk without pain in one year. It has not recurred during a five-year follow-up period.