J. Joris Hage

A prospective assessment of surgical risk factors in 400 cases of skin-sparing mastectomy and immediate breast reconstruction with implants to establish selection criteria.

Background: Although attempts have been made to identify the risk factors leading to complications after combined skin-sparing mastectomy and immediate prosthetic breast reconstruction, hardly any criteria are available to preoperatively distinguish patients in whom such an eventful postoperative course may be expected. Therefore, the authors wanted to establish which factors increase the risk of surgical complications to such a level as to adjust their indications for immediate breast reconstruction after skin-sparing mastectomy. Methods: The authors prospectively studied the clinical relevance of six patient-related and nine procedure-related characteristics as potential risk factors for a complicated surgical outcome in 400 combined procedures in 309 patients by univariate and multivariate logistic regression analysis. Risk factors that proved significantly correlated with loss of implant by both analyses were accepted as clinical selection criteria that distinguish potential candidates with an unacceptably high risk of such loss. Results: Mild complications occurred significantly more often in patients who were older than the mean age of 43 years and in breasts that were more than average sized or operated on by a fellow in oncologic surgery. Implants were lost significantly more often in patients who were obese or smoked and in breasts that were more than average sized. Conclusions: The clinically relevant increase of risk of implant loss should lead to reluctance to perform combined skin-sparing mastectomy and immediate prosthetic breast reconstruction in obese patients who smoke (32 percent loss) and in those with more than average sized breasts (27 percent loss).

Plastic Surgery Classics: characteristics of 50 top-cited articles in four Plastic Surgery Journals since 1946.

Background: Citation of published articles by peers provides an indication of the relevance of the scientific work. Still, it is unknown what kinds of plastic surgery articles are cited most often. The authors set out to identify the characteristics of the 50 top-cited articles as published in four international, peer-reviewed, PubMed-indexed general plastic surgery journals. Methods: The 50 most-cited articles were identified in each of the following journals: Plastic and Reconstructive Surgery, the British Journal of Plastic Surgery, the Annals of Plastic Surgery, and the Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery. These 200 articles were ranked after their citation index, defined as the mean number of times they were cited per year during the first 16 years after publication. The top-50 articles thus ranked were analyzed for citation and journal distribution, geographic and institutional origin, surgical and anatomical subject, and level of evidence. Results: Forty-one of the 50 top-cited articles (82 percent) were published in Plastic and Reconstructive Surgery and 35 articles (70 percent) originated from institutions within the United States. Most of the articles dealt with the reconstruction of acquired defects (45 percent) and with basic or experimental research (41 percent). Research that offered means for clinical improvement, rather than a high level of evidence or the results of multi-institutional collaboration, was most often cited. Conclusion: An article featuring a clinical or nonclinical innovation, observation, or discovery that leads to clinical improvement has the best potential to become a “classic.”

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. (Plast. Reconstr. Surg. 107: 734, 2001.)

Novel insights into pathological changes in muscular arteries of radiotherapy patients.

BACKGROUND AND PURPOSE Vascular disease is increased after radiotherapy and is an important determinant of late treatment-induced morbidity and excess mortality. This study evaluates the nature of underlying pathologic changes occurring in medium-sized muscular arteries following irradiation. MATERIALS AND METHODS Biopsies of irradiated medium-sized arteries and unirradiated control arteries were taken from 147 patients undergoing reconstructive surgery with a vascularised free flap following treatment for head and neck (H&N) or breast cancer (BC). Relative intimal thickening was derived from the ratio of the thickness of the intima to the thickness of the media (IMR) on histological sections. Proteoglycan, collagen and inflammatory cell content were also scored. RESULTS Intimal thickness was significantly increased in irradiated vessels: in the H&N group the IMR was 1.5-fold greater without correction for the control artery (p=0.018); in the BC group the IMR increased 1.4-fold after correction for the control artery (p=0.056) at a mean of 4 years following irradiation. There was an increase in the proteoglycan content of the intima of the irradiated IMA vessels, from 65% to 73% (p=0.024). Inflammatory cell content was increased in the intima of the irradiated H&N vessels (p=0.014). CONCLUSIONS Radiation-induced vascular pathology differs quantitatively and qualitatively from age-related atherosclerosis.

Clinical anthropometry and canons of the face in historical perspective

Measurements of the human face as part of the body have been performed since the Greek era, and many aspects of ancient measurements can be found in modern clinical anthropometry. A historical appraisal of the use of facial measurements is presented. The influence on modern facial anthropometry of Greek proportion sciences, the golden proportion, canons of important Renaissance artists, physical anthropology, and cephalometry are discussed. The main difference between human measurements in classic times and modern anthropometry is the denial of realistic sizes and proportions in former times. Human forms and canons were depicted in a way the artist or scientist preferred, rather than how they objectively were. For reconstructive and cosmetic surgery, realistic sizes and proportions are assessed using anthropometric techniques and used as guidelines to correct deformities or disproportions.

Honey-medicated dressing: transformation of an ancient remedy into modern therapy.

Honey has been applied for medicinal purposes since ancient times. Its antibacterial effects have been established during the past few decades. Still, modern medical practitioners hesitate to apply honey for local treatment of wounds. This may be explained by the expected messiness of such local application. Moreover, secondary infectious disease may be caused by contamination of honey with microorganisms. Hence, if honey is to be applied for medicinal purposes, it has to meet certain criteria. The authors evaluated the use and safety of a honey-medicated dressing that was developed to meet these criteria in a feasibility (phase II) study featuring 60 patients with chronic (n = 21), complicated surgical (n = 23), or acute traumatic (n = 16) wounds. In all but 1 patient, it was found easy to apply, helpful in cleaning the wounds, and without side effects. Based on these results, the authors advise to subject this dressing to a randomized, double blind, phase III study.

Skin-sparing mastectomy and immediate breast reconstruction by use of implants: an assessment of risk factors for complications and cancer control in 120 patients.

Background: Combined skin-sparing mastectomy and immediate reconstruction by use of an implant is increasingly accepted as a therapy for patients with breast cancer or a hereditary risk of breast cancer. Because little and contradictory evidence regarding possible risk factors for postoperative complications is available, the authors retrospectively assessed 13 such factors. They also evaluated the oncological safety of the procedure. Methods: From July of 1996 through June of 2000, 174 skin-sparing mastectomies were combined with immediate breast reconstruction in 120 patients. The authors assessed the influence of five patient-related and eight breast-related characteristics on the incidence of a complicated postoperative course by univariate and multivariate analyses. Oncological safety was evaluated by observed recurrent disease and 5-year survival. Results: Severe complications were observed in 17 patients of the 120 patients (14 percent), or 19 of the 174 breasts (11 percent). The patient-related characteristics of age and being operated on unilaterally significantly increased the risk of complications. Resident plastic surgeons and previous breast-conserving therapy including radiotherapy significantly increased the risk of implant loss. The local relapse rate among patients operated on for cancer was 0.02. The actuarial 5-year survival rate among patients who underwent curative mastectomies was 0.96. Conclusions: Combined skin-sparing mastectomy and immediate reconstruction by use of an implant is oncologically safe, but the risk of postoperative complications cannot be neglected. The authors’ observations may offer guidance for adapting indication and treatment strategies for patients with breast cancer or increased hereditary risk of such cancer.

Short-term and long-term histologic effects of castration and estrogen treatment on breast tissue of 14 male-to-female transsexuals in comparison with two chemically castrated men.

The histologic changes induced in the mammary gland of male-to-female transsexuals have not yet been reported in the literature. We studied the histologic changes induced by chemical and surgical castration and estrogen therapy in the breasts of 14 such patients, with particular reference to acinar and lobular formation. To objectify the influence of cross-sex treatment, the histologic findings were compared with those in two men treated hormonally for prostate cancer. The slight increase in the plasma estrogen-to-androgen ratio seen in idiopathic gynecomastia usually does not induce acinar and lobular formation in the male breast. In men treated with nonprogestative antiandrogens for prostate cancer, only moderate acinar and lobular formation occurs. Only in male-to-female transsexuals in whom progestative chemical castration is combined with feminizing estrogen therapy will full acinar and lobular formation occur with hormonally stimulated nuclei and pseudolactational changes. Hence, combined progestative antiandrogens and estrogens are necessary for genetically male breast tissue to mimic the natural histology of the female breast. Orchidectomy does not contribute to this. Apocrine metaplasia may occur in breasts of male-to-female transsexuals, but so far, only four cases of breast cancer in male-to-female transsexuals have been documented.

Metaidoioplasty : an alternative phalloplasty technique in transsexuals

&NA; The various techniques for phalloplasty in female‐to‐male transsexuals produce results that are more or less acceptable, both aesthetically and functionally. However, all these techniques will lead to extensive scarring of the donor area. Metaidoioplasty uses the clitoris, overdeveloped by hormonal treatment, to construct a microphallus in a way comparable to the correction of chordae and lengthening of urethra in male pseudohermaphrodites and in cases of severe hypospadias. It will not leave any scars outside the genital area. My experience in 32 female‐to‐male transsexuals is presented. At best, metaidoioplasty will provide a small phallus hardly, if at all, capable of sexual penetration. Still, I consider it to be a method of choice in cases where the clitoris seems large enough to provide a phallus that will satisfy the patient. (Plast. Reronstr. Surg. 97: 161, 1996.)

Long-term outcome of metaidoioplasty in 70 female-to-male transsexuals.

In 1996, metaidoioplasty was introduced as an alternative to phalloplasty in female-to-male transsexuals. To assess the long-term outcome in 70 consecutive patients (mean follow-up 8 years), we established the characteristics of postoperative events and additional surgical procedures. Metaidoioplasty and primary or secondary scrotoplasty was uneventful in 8 patients. In the other patients, postoperative events included immediate postoperative complications (n = 23), urethral fistulas (n = 26) or strictures (n = 25), or loss (n = 22) or dislocation (n = 34) of testicular prostheses. An average of 2.6 surgical procedures per patient was needed to complete genital confirmation and cope with all events. Additional phalloplasty was performed or scheduled in 17 patients. We conclude that genital reassignment by metaidoioplasty cannot usually be completed in 1 step and that phalloplasty is feasible subsequent to metaidoioplasty. We still consider metaidoioplasty to be a method of choice in selected patients.