Lennart Blomqvist

Reduction mammaplasty provides long-term improvement in health status and quality of life.

The objective of this study was to assess health status and quality of life in macromastia patients undergoing reduction mammaplasty. From January of 1997 to June of 1997, the Department of Reconstructive Plastic Surgery, at Stockholm Söder Hospital/Karolinska Hospital, conducted a prospective questionnaire study with preoperative and postoperative (6 and 12 months) assessments in 49 women who were 20 years or older. The questionnaire included four parts: Part I assessed pain (scale 1 to 10) in the neck, shoulders, back, breast, bra strap indention, and head. Part II assessed effects of breast size and weight on body posture, sleep, choice of clothing, sexual relations, and working capacity (scale 1 to 10). Part III assessed preoperative expectations for the operation in comparison with postoperative result (scale 1 to 6). Part IV included SF-36, an international health-related quality-of-life questionnaire, which has been standardized for Swedish women. As a result, reduction mammaplasty (mean resection weight, 1052 g) provided significant reduction of pain in all locations (p < 0.001). The improvements continued up to 12 months postoperatively. The patients’ main subjective problems related to the size and weight of the breast were body posture and choice of clothing. The patients scored significant improvements of all subjective problems (p < 0.001), except sleep. The patients’ expectations were met to a high extent. In some areas such as intimate situations, femininity, and social contacts, the results exceeded the preoperative expectations. Preoperatively, the mammaplasty patients scored significantly lower (p < 0.05 to p < 0.001, depending on area) in SF-36, i.e., the patients had lower quality of life compared with women in the same age group. Reduction mammaplasty resulted in significantly improved quality of life; furthermore, the results were similar after 6 and 12 months, indicating long-term improvement. In fact, after 1 year, there was no statistically significant difference between the patients who had been operated on and the age-matched women, i.e., the women were normalized in health-related quality of life as judged by the SF-36.

A prospective randomised study (named SVEA) of three methods of delayed breast reconstruction. Study design, patients' preoperative problems and expectations.

A randomised study named SVEA to compare three methods for delayed breast reconstruction was initiated in 1994. The methods were: the lateral thoracodorsal flap, the latissimus dorsi flap, and the pedicled transverse rectus abdominis muscle flap. In the present paper we describe the study design, primary endpoints, and inclusion and exclusion criteria. Results from preoperative questionnaires about problems after mastectomy and expectations of the reconstruction are presented. The preoperative questionnaires, completed before randomisation, included a health related quality of life questionnaire, the SF-36, and a questionnaire concerning the impact of breast loss and expectations of the reconstruction. A total of 87 patients have been randomised in SVEA and 30 patients have been followed up outside the randomised study, comprising a reference group. The results from preoperative questionnaires, completed by 106 of the total 117 women, showed that they encountered many problems after mastectomy, primarily about feeling mutilated and being bothered socially. They held high expectations on the breast reconstruction in these areas. The women in the present study did not differ from Swedish women in general regarding health related quality of life, with two exceptions: the study sample scored lower on physical functioning and mental health.

Reduction Mammaplasty: Analysis of Patients' Weight, Resection Weights, and Late Complications

The medical records of 291 patients who had undergone reduction mammaplasty were analysed. A total of 216 (74%) of the women were overweight and 67 (23%) to such a degree that according to our policy they should not have been candidates for operation. Most of the patients were young-199 (68%) were less than 40 years old and 110 (38%) were less than 25 years old. Total bilateral resection weights in many younger women were quite low. Of the 199 patients less than 40 years old 64 (32%) had less than 500 g total bilateral resection weight whereas 85 (92%) of the women 40 years old or more had resections of more than 500 g. Late complications were few-the rate of infection was similar in all weight groups. Fat and nipple necrosis-although rare-were more likely to occur in the obese and in patients over 30 years old.

Clinical experience with the lateral thoracodorsal flap in breast reconstruction.

The lateral thoracodorsal flap is a local fasciocutaneous flap used for breast reconstruction. From 1986 to 1994 the authors used this flap in 157 breast reconstructions in 152 patients. The patients who had been treated with postmastectomy radiotherapy (N = 40) had significantly more (p < 0.01) early complications, such as necrosis and infection. Irradiated patients also required more operations due to secondary complications, such as capsular contracture (p < 0.05). A patient questionnaire (response rate, 91%) was sent to 121 patients and showed that, although a majority of patients felt the reconstructed breast was less sensitive to touch and harder than the contralateral breast, they still regarded the reconstructed breast as a natural part of themselves. More than 90% of patients did not regret the reconstruction and 80% would recommend it to a friend.

The inflammatory reaction in elective flap surgery

&NA; The inflammatory response in three different flap procedures was investigated by measuring the preoperative and postoperative levels of C‐reactive protein, leukocyte count, and body temperature. Patients scheduled for delayed breast reconstruction were operated on with the lateral thoracodorsal flap, the latissimus dorsi flap, or the pedicled TRAM flap. All patients received 2 gm of intravenous cloxacillin for antibiotic prophylaxis and 1 gm of paracetamol four times a day as basic treatment for postoperative pain. Within each treatment group, significant postoperative changes in C‐reactive protein levels, leukocyte count, and body temperature were noted when compared with preoperative values. The highest C‐reactive protein level (130 mg/ml) was found in the TRAM group on the third postoperative day. The kinetic pattern of C‐reactive protein was similar for the latissimus dorsi flap and lateral thoracodorsal flap procedures, but the maximum C‐reactive protein levels were significantly lower, 74 and 44 mg/ml respectively. Small (0.5 to 0.9°C) but significant differences in body temperature were also noted on the second and third postoperative day. The TRAM flap group had the highest, the latissimus dorsi flap group intermediate, and the lateral thoracodorsal flap group the lowest value. The postoperative C‐reactive protein levels seem to reflect the extent of the surgical trauma. (Plast. Reconstr. Surg. 101: 1524, 1998.)

THE LATERAL THORACODORSAL FLAP IN BREAST RECONSTRUCTION: A COMPARISON BETWEEN TWO PLASTIC SURGICAL CENTRES

In a retrospective study the results of breast reconstruction with 146 lateral thoracodorsal flaps operated on during the period 1991-94 at the Departments of Plastic Surgery at the Sahlgrenska University Hospital in Göteborg and the Stockholm Söder Hospital were evaluated. The median age of the 135 patients was 51 years (range 37-74). About two thirds of the patients were also operated on on the opposite side at the same time; and this was done more often in Stockholm, which partly explains the longer operating time in Stockholm. Perioperative bleeding (median 100 ml, range 25-400) was similar in both groups. Median postoperative bleeding, which was measured only in Stockholm, was 300 ml (range 30-1000). Seromas were seen only in Göteborg where postoperative drains were rarely used. The rate of early complications (infection and partial necrosis) were higher in Stockholm where more flaps were raised in irradiated tissue. We conclude that the results were similar in the two centres, and the thoracodorsal flap gives good results. The incidence of early morbidity could be reduced by excluding patients who had been irradiated, by inserting drains, and by giving antibiotic prophylaxis.In a retrospective study the results of breast reconstruction with 146 lateral thoracodorsal flaps operated on during the period 1991-94 at the Departments of Plastic Surgery at the Sahlgrenska University Hospital in Göteborg and the Stockholm Söder Hospital were evaluated. The median age of the 135 patients was 51 years (range 37-74). About two thirds of the patients were also operated on on the opposite side at the same time; and this was done more often in Stockholm, which partly explains the longer operating time in Stockholm. Perioperative bleeding (median 100 ml, range 25-400) was similar in both groups. Median postoperative bleeding, which was measured only in Stockholm, was 300 ml (range 30-1000). Seromas were seen only in Göteborg where postoperative drains were rarely used. The rate of early complications (infection and partial necrosis) were higher in Stockholm where more flaps were raised in irradiated tissue. We conclude that the results were similar in the two centres, and the thoracodorsal flap gives good results. The incidence of early morbidity could be reduced by excluding patients who had been irradiated, by inserting drains, and by giving antibiotic prophylaxis.

REDUCTION MAMMAPLASTY WITH ADRENALINE INFILTRATION: EFFECTS ON PERIOPERATIVE BLEEDING

We present a retrospective comparison of two groups of patients who underwent reduction mammaplasty with (n = 200) and without (n = 44) infiltration of a combination of a local anaesthetic and adrenaline. The vasoconstrictive effect of adrenaline reduced the intraoperative bleeding from 0.5 ml to 0.1 ml/g resected tissue. Postoperative bleeding was also reduced. Drains were omitted in 104 of the patients who had received adrenaline. In spite of this, these patients had no increases in the rates of infection, haematoma formation, or need for reoperation compared with the group that had been given drains. The practical implication is that after local infiltration of a vasoconstrictor agent post-operative drains can be omitted, at least in the Strömbeck reduction mammaplasty procedure.

Clinical follow up of the lateral thoracodorsal flap in breast reconstruction: comparative evaluation from two plastic surgical centres.

A follow up study that compared the results from two plastic surgical centres comprised 95 patients after breast reconstruction with the lateral thoracodorsal (LTD) flap combined with either a smooth or textured saline-filled implant. It was conducted a median of 39 months (range 15-67) after the reconstruction. We investigated the size of the reconstructed breast and LTD flap, symmetry of the breasts, orientation of the mastectomy scar, and the rate of capsular contracture, which were similar in the two centres. However, according to the modified Baker classification and applanation tonometry reconstructions with smooth-surfaced implants and drainage of the implant pocket resulted in softer breasts (p = 0.03). The LTD flap technique in breast reconstruction was a good choice, particularly for women who required a minor breast reconstruction, and the technique can be recommended for suitable patients.A follow up study that compared the results from two plastic surgical centres comprised 95 patients after breast reconstruction with the lateral thoracodorsal (LTD) flap combined with either a smooth or textured saline-filled implant. It was conducted a median of 39 months (range 15-67) after the reconstruction. We investigated the size of the reconstructed breast and LTD flap, symmetry of the breasts, orientation of the mastectomy scar, and the rate of capsular contracture, which were similar in the two centres. However, according to the modified Baker classification and applanation tonometry reconstructions with smooth-surfaced implants and drainage of the implant pocket resulted in softer breasts (p = 0.03). The LTD flap technique in breast reconstruction was a good choice, particularly for women who required a minor breast reconstruction, and the technique can be recommended for suitable patients.

Toxic Shock Syndrome After Burn Injuries in Children

Toxic shock syndrome is a life-threatening exotoxin mediated disease caused by Staphylococcus aureus, which was originally described as affecting menstruating women, but has lately been reported after surgical procedures and burns. The high mortality emphasises the importance of early diagnosis. In most cases there is a prodromal period with fever (> 38.9 degrees C), myalgia, headache, and vomiting before the onset of hypotension and multiorgan failure. We present two cases in children with minor burns, and review current recommendations for treatment.

Hamartoma of the Breast: Surgical Treatment and Reconstruction: Case Report

Hamartoma of the breast is a rare and usually benign tumour with a variable growth pattern. Slowly increasing breast asymmetry is the most common clinical finding. Smaller hamartomas are often diagnosed on mammography. Simple enucleation and secondary expansion of the breast tissue are often sufficient to restore breast symmetry but sometimes, as in the two cases presented, reconstruction is necessary.