Gertrude M. Beer

The normal width of the linea alba in nulliparous women

The function of the linea alba is to maintain the abdominal muscles at a certain proximity to each other. In the case of long‐lasting increased intra‐abdominal pressure, the linea alba widens. Yet, as the existence of the linea a priori implicates a physiological distance between the two rectus muscles, the question arises as to what the normal width of the linea alba is. To evaluate the normal width of the linea alba, we examined 150 nulliparous women between 20 and 45 years of age with a body mass index < 30 kg m−2 by ultrasound at three reference points: the origin at the xiphoid and 3 cm above and 2 cm below the umbilicus. The examination revealed a broad range of widths at the three reference points. The linea was widest at 3 cm above the umbilicus (−35 mm), followed by the reference point 2 cm below the umbilicus (−31 mm) and the origin at the xiphoid (−31 mm). The mean width was 7 ± 5 mm at the xiphoid and 13 ± 7 mm above and 8 ± 6 mm below the umbilicus. For the definition of the normal width of the linea, the 10th and 90th percentiles were taken. The linea alba can be considered “normal” up to a width of 15 mm at the xiphoid, up to 22 mm at the reference point 3 cm above the umbilicus and up to 16 mm at the reference point 2 cm below the umbilicus in nulliparous women. Clin. Anat. 22:706–711, 2009.

Configuration and localization of the nipple-areola complex in men

&NA; The causes of bilateral absence of the nipple‐areola complex in men are seldom congenital, but attributable rather to destruction as a result of trauma, or after mastectomy in female‐to‐male transsexuals and in male breast cancer, or after the correction of extreme bilateral gynecomastia. Such a bilateral loss becomes a major reconstructive challenge with respect to the configuration and localization of a new nipple‐areola complex. Because there is very little information available in the literature, we carried out a cross‐sectional study on the configuration and localization of the nipple‐areola complex in men. A total of 100 healthy men aged 20 to 36 years were examined under standardized conditions. The first part of the study dealt with the configuration of the nipple‐areola complex (dimensions, round or oval shape). The second part concentrated on the localization of the complex on the thoracic wall with respect to anatomic landmarks and in correlation to various parameters such as weight and height of the body, circumference of the thorax, length of sternum, and position in the intercostal space. Of the 100 subjects examined, 91 had oval and seven had a round nipple‐areola complex. An asymmetry between the right and the left side was found in two cases. The mean ratio of the horizontal/vertical diameter of an oval nipple‐areola complex was 27:20 mm and the mean diameter for a round nipple‐areola complex was 23 mm. The center of the nipple‐areola complex was in the fourth intercostal space in 75 percent and in the fifth intercostal space in 23 percent of the subjects. To localize the nippleareola complex on the thoracic wall de novo, at least two reproducible measurements proved to be necessary, composed of a horizontal line (distance from the midsternal line to the nipple = A) and a vertical line (distance from the sternal notch to the intersection of line A, = B). The closest correlation for the horizontal distance A was given by the circumference of the thorax: A = 2.4 cm + [0.09 × circumference of thorax (cm)], (r = 0.68). The best correlation to calculate the vertical distance B was found using the distance A and the length of the sternum: B = 1.2 cm + [0.28 × length of sternum (cm)] + [0.1 × circumference of thorax (cm)], (R = 0.50). In cases of bilateral absence, we recommend creating an oval nipple‐areola complex in men. The appropriate localization can be calculated by means of two simple equations derived from the circumference of the thorax and the length of the sternum. (Plast. Reconstr. Surg. 108: 1947, 2001.)

Comparison of the Incidence and Predicted Risk of Early Surgical Site Infections After Breast Reduction

In plastic surgery, clean, elective operations such as breast reductions are anticipated to have low risk factors for infections (1.1–2.1%). To further lower or prevent surgical site infections (SSI), the efficiacy of a prophylactic administration of antimicrobacterials remains a current controversial issue in plastic surgery. We report here the findings of a retrospective study in which we examined two groups of patients with breast reductions, one of which received a single-shot antimicrobacterial prophylaxis with cefuroxim preoperatively and the other who were given no antimicrobacterials. The aims were to determine the early SSI incidence of both groups, to classify breast reductions with respect to their inherent SSI risk by two widespread, combined risk scores, i.e., the National Nosocomial Infection Surveillance (NNIS) score and the Study on the Efficiacy of Nosocomial Infection Control (SENIC) score, and to compare the actual SSI incidence to the predicted risk of the scores. In the divisions of plastic surgery at two hospitals, 153 patients (group I) and 136 patients (group II) could be included in the study in the 4-year period April 1997 to December 2001. Excluded were all patients with unilateral breast reduction or breast reconstruction and patients who were followed up less than 30 days postoperatively. The two groups were comparable with respect to demographic and clinical features such as age and risk factors, and there were no detectable significant intergroup differences in the general perioperative data. According to the NNIS and the SENIC scores, all operations were “clean,” and the American Society of Anesthesiologists (ASA) score was <3 in all patients. Although the mean duration of the operation was significantly different in the two groups (190 min in group I, 160 min in group II; p < 0.001, Mann–Whitney test; 75th percentile at and 4 and 3 h, respectively), it was longer than 2 h in both groups. The incidence of early infections was 3.9% in the first group, compared with 3.6% in the second group (p = 1.0, odds ratio = 1.07, 95% CI = 0.32–3.6). All infections were local and superficial; no general symptoms were noticed. Three patients had to be readmitted and two of these were reoperated. The rate of infections for both groups was higher than generally anticipated for this kind of clean operations and higher than predicted by the NNIS score for medium risk (predicted risk of 2.9%). The reason for this discrepancy is that the NNIS score is an inpatient risk score which does not include a postdischarge SSI surveillance. Using the NNIS definition of SSI we would have had an infection rate of 0% in both groups in our study. According to the SENIC score, breast reductions can be classified also as medium risk of SSI with a predicted risk of 3.9%, which showed a nearly perfect correspondence with the actual SSI incidence in both study groups. The reason for this increased, medium risk is the factor “operation time >2 h,” which is obviously an inherent risk factor in breast reductions. Among the multitude of patient and nonpatient SSI risk factors, in healthy women operation time was the only factor which could be clearly identified.

Poland's syndrome and vascular malformations

Unilateral hypoplasia of the breast and the pectoralis muscle with a missing anterior axillary fold as part of Polands syndrome are of major concern, especially for women. The latissimus dorsi is one of the most suitable flaps for breast and anterior thorax reconstructions but it may be hypoplastic or absent. If so, a free tissue transfer of the contralateral latissimus dorsi muscle is the next possible option for reconstruction. As Polands syndrome is additionally associated with vascular malformations of the diseased hemithorax such as hypoplastic or missing vessels, a preoperative angiography is mandatory for planned microvascular tissue transfer.

Prevention of Seroma After Abdominoplasty

BACKGROUND Seroma is one of the most troubling complications after abdominoplasty; incidence rates of up to 25% have been reported. If it is correct that shearing forces between the two separated abdominal layers play a key role in the development of seroma, postoperative immobilization of the patient until the layers are sufficiently adhered may be a solution to the problem. OBJECTIVE The authors examine the association between length of immobilization and the development of seroma. METHODS This retrospective study included 60 patients; half were immobilized for 24 hours (group 1) and the other half were immobilized for at least 48 hours (group 2). For thromboembolism prophylaxis, all patients received low molecular weight heparin and compression stockings. Postoperative follow-up for detection of seroma continued for at least three months. RESULTS Mobilization after 24 hours led to a seroma rate of 13%, whereas immobilization of at least 48 hours decreased the seroma rate to 0%. CONCLUSIONS For abdominoplasty patients with a low or moderate thromboembolic risk, the data suggest that immobilization for at least 48 hours with chemical and mechanical thromboembolism prophylaxis significantly reduces the risk of seroma.

Oral premedication for operations on the face under local anesthesia : a placebo-controlled double-blind trial

Modern strategies for preventing or controlling pain and anxiety demand a premedication for operations using local anesthesia and for those using sedation or general anesthesia. For optimal patient care, the premedication should be given orally and, with respect to the outpatient basis of the operations, should have a short recovery period. Midazolam, one of the most favored premedications for general anesthesia, has been recommended as a premedication for operations using local anesthesia as well. However, midazolam has only sedative‐anxiolytic effects and does not reduce pain sensation, which should be mandatory for operations using local anesthesia. A further requirement is the maintenance of stable hemodynamics for the prevention of postoperative hematomas, especially in the face. For these reasons, another premedication meeting all requirements (anxiolysis, analgesia, and stable hemodynamics) was researched. A randomized, doubleblind prospective study was performed from March of 1997 to June of 1998. Five groups totalling 150 patients were included in the study; each group contained 30 patients who had operations performed solely on the face. In the first four groups, the effect of midazolam (0.15 mg/kg‐1), morphine (0.3 mg/kg‐1), and clonidine (1.5 &mgr;g/kg‐1) administered orally was compared with a placebo. The fifth group was the control group and received no premedication. To evaluate the effects of the premedications, a corresponding questionnaire was completed independently by the patient and surgeon. With regard to the anxiolytic or analgesic properties of the premedication, 61 percent of the patients preferred pain reduction to anxiety control, and 24 percent of patients preferred reduction of anxiety. The remainder insisted on a reduction of both properties (8 percent) or had no preference (7 percent). Reduction of anxiety was largest in the midazolam and the clonidine groups, but the difference was not significant. The least pain during the application of local anesthesia was experienced by the morphine group (37 percent) and the clonidine group (33 percent), in contrast to the midazolam group (60 percent) (p = 0.04). Morphine and clonidine met the requirements of pain reduction equally well. Nevertheless, considering the rate and intensity of adverse effects with respect to hemodynamic compromises, nausea, and emesis, clonidine is even better suited as an oral premedication for operations on the face using local anesthesia. (Plast. Reconstr. Surg. 108: 637, 2001.)

Diagnosis of breast tumors after breast reduction.

We conducted a retrospective study to evaluate the diagnosability of breast tumors after breast reductions as this is a frequent surgical procedure. The data should shed light on the hypothesis that routine screening methods concerning the diagnosis of breast tumors prove more difficult after breast operations. All women who had undergone breast reduction at our department between January 1989 and December 1994 were examined. During this period we counted 166 patients; the majority of them (n = 144) had undergone a bilateral breast reduction and the rest of them (n = 22) a unilateral breast reduction for various reasons. After the operation, all patients were checked in standardized intervals. Those who developed any kind of breast mass (n = 6) were recorded and examined by ultrasound and mammography, and occasionally by an additional fine-needle biopsy. In case any doubt about the dignity had remained, an excisional biopsy was carried out. In none of our patients was it possible to get a precise diagnosis of an ill-defined mass with ultrasound. With mammography, some of the existing masses, which were really scars, mimicked different kinds of tumors, and once a carcinoma was initially interpreted as scar tissue with oil cysts. The diagnosis of breast masses after breast reductions with routinely used screening methods has proved to be more difficult as breast reductions lead to architectural alterations of the remaining breast parenchyma. Such alterations can and should be documented shortly after the operation so that later occurring tumors are distinguished more easily. Therefore, a basic mammography 3 months after each breast reduction has to be claimed in order to facilitate further breast tumor diagnosis.

The toe-spreading reflex of the rabbit revisited-functional evaluation of complete peroneal nerve lesions

Although a variety of electrophysiological and morphological tests are available for studying nerve regeneration in animals, these endpoints do not necessarily correlate with the return of muscle function. Recent efforts have focused on the assessment of function as the endpoint of nerve regeneration. One of the best known of these tests is the sciatic function index in rats. For rabbits, the toe-spreading reflex has been suggested as a valuable index of peroneal function. We examined the reliability and sensitivity of the toe-spreading reflex in a study of nerve regeneration of the peroneal nerve in 10 New Zealand White rabbits. Eleven weeks after the transection and immediate suturing of the peroneal nerve in both hind legs (at two slightly different sites), a toe-spreading reflex could always be elicited on that side where the level of the severed nerve was closer to the dependent muscles. Also on this hind leg the muscle weight of the peroneal target muscles was significantly higher (P = 0.031) than on the contralateral side, which corresponds well to the results of the toe-spreading reflex. The toe-spreading reflex is an excellent and sensitive indicator of the onset of motor recovery in the peroneal nerve-dependent muscles of rabbits. Even small differences in the localization of lesions in both hind legs can be differentiated with this test.

Malignant Tumors Associated with Nevus Sebaceous: Therapeutic Consequences

Abstract. Nevus sebaceous has been considered a relatively infrequent and unimportant congenital hamartoma for plastic surgeons unless the lesions are so big that they require a demanding defect closure. As the dignity of such tumors is primarily benign and the malformed sebaceous glands are localized abnormally high in the dermis, the temptation is appealing not to excise these tumors any more but to eradicate them by laser beam therapy. Yet a nevus sebaceous not only affects sebaceous glands but includes various other malformations of the affected skin and its appendages. In addition, different malignant tumors may occur in nevus sebaceous, even in children and young adults. We encountered 4 such malignant tumors of 18 nevi sebaceous operated on from 1989 to 1997. All nevi had been unsuspicious macroscopically. In three patients, one of them only 15 years old, an associated basal cell carcinoma was found. In the fourth patient there was a mixture of three additional tumors, a cystadenoma, a keratoacanthoma, and a basal cell carcinoma, besides the sebaceous malformations. These findings have two consequences: first, to continue surgical treatment of nevus sebaceous instead of dermabrasion or dermablation and to have the specimen examined histologically and, second, to excise such tumors as early in childhood as possible.

The Cartilage-Sparing Versus the Cartilage-Cutting Technique: A Retrospective Quality Control Comparison of the Francesconi and Converse Otoplasties

From a total of 281 patients with protruding ears who underwent a bilateral otoplasty between 1990 and 2001, a group of 28 (10%) was selected for a retrospective quality control study. The goal was to compare two methods of otoplasty, the Francesconi, a cartilage-sparing technique, and the Converse, a cartilage-cutting technique, in terms of objectively measurable and subjectively discernable differences in results. Objective parameters included measurement of the three cephaloauricular distances and the conchoscapal angle. An independent plastic surgeon performed the evaluation by means of a systematic evaluation system for rating cosmetic surgical procedures and a 5-point visual analog scale for rating satisfaction. The patients’ subjective rate of satisfaction also was investigated using the 5-point scale. The mean medial and inferior cephaloauricular distances were significantly smaller in the Francesconi group. The concoscaphal angle was 90°, or less in all the patients of the Francesconi group, but more than 90° in eight patients (57%) of the Converse group (p = 0.041). Accordingly, the independent surgeon found adequate correction of protrusion in 86% of the Francesconi group and 50% of the Converse group (p = 0.050). His satisfaction rate was significantly in favor of the Francesconi technique (p = 0.006). Not unexpectedly, the patients’ satisfaction rate was comparably high in both groups, and there was no statistical difference between them. In conclusion, the quality control led to a clear preference of the Francesconi over the Converse otoplasty. In addition, the assessment of the postoperative results with the systematic evaluation system offered an excellent information base by which to judge the results of otoplasty. Consequent use of this evaluation system will lead to progress in the surgical procedure.