Croatian Medical AssociationCroatian Society of Plastic, Reconstructive and Aesthetic Surgery University Hospital Dubrava, Zagreb, Croatia Department for Plastic, Reconstructive and Aesthetic Surgery Abstract book 5th CROATIAN CONGRESS FOR PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY ESPRAS appointed Congress for 2004. Editors: Sanda Stanec, Zlatko Vlajčić, Krešimir Martić, Franjo Rudman ml. Dubrovnik-Cavtat, Croatia 15th-20th October, 2004.
5th CROATIAN CONGRESS FOR PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY ESPRAS appointed Congress for 2004. Dubrovnik-Cavtat, Croatia 15th-20th October, 2004 Abstract bookOrganizer : Croatian Society of Plastic, Reconstructive and Aesthetic Surgery, Croatian Medical AssociationPublisher : Croatian Society of P lastic, Reconstructive and Aesthetic Surgery and Znanje d.d., Zagreb, CroatiaEditors: Sanda Stanec, MD, PhD, Editor-in-Chief Zlatko Vlajčić, MD, Associate Editor Krešimir Martić, MD, Associate Editor Franjo Rudman ml., MD, Associate EditorPrinted by: Znanje d.d., Zagreb, Croatia All rights reserved. No part of this publication may be reproduced, or transmitted in any form or by any means without prior written permission from the publisher.
5th CROATIAN CONGRESS FOR PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY ESPRAS appointed Congress for 2004. organized byCroatian Medical AssociationCroatian Society of Plastic,Reconstructive and Aesthetic SurgeryUniversity Hospital Dubrava, Zagreb, CroatiaDepartment for Plastic, Reconstructiveand Aesthetic SurgeryLocal co-organizerCounty Hospital DubrovnikUnder the auspicies ofDubrovnik – Neretva Countylogo
ORGANIZING COMMITTEE CONGRESS PRESIDENT Zdenko Stanec President of the Croatian Society of Plastic, Reconstructive and Aesthetic Surgery (CSPRAS) VICE PRESIDENTS Marko Margaritoni Zdravko Roje GENERAL SECRETARIES Sanda Stanec Rado Žic TREASURER Rudolf Milanović ORGANISING COMMITTEE Zdenko Stanec, Marko Margaritoni, Zdravko Roje, Rado Žic, Sanda Stanec,Rudolf Milanović, Srećko Budi, Franjo Rudman, Krešimir Martić, Zlatko Vlajčić, Marina Mamić-Pavelić SCIENTIFIC COMMITTEE Josip Unušić, Mišo Virag, Neven Olivari, Milomir Ninković, Radojko Ivrlač, Vedran Uglešić, Mario Zambelli, Sanda Stanec, Rado Žic, Ivo Džepina HONORARY COMMITTEE Ivan Prpić, Đorđe Montani, Ivo Padovan PAST CONGRESES ORGANIZED BY CSPRAS 1st Croatian Congress for Plastic, Reconstructive and Aesthetic Surgery, with international participation, Dubrovnik, 19. - 23. rujan 1998.
2nd Croatian Congress for Plastic, Reconstructive and Aesthetic Surgery, withinternational participation, Opatija , 4. - 8. rujan 1999.3rd Croatian Congress for Plastic, Reconstructive and Aesthetic Surgery, withinternational participation, Split, 20.-24. rujan, 2000.4th Croatian Congress for Plastic, Reconstructive and Aesthetic Surgery, withinternational participation, Zagreb, 25. – 28. rujan 2002.PAST ESPRAS APPOINTED MEETINGS1st European Appointed National Meeting: September, 3- 6, 1998, Istambul,Turkey2nd European Appointed National Meeting: September, 2 – 4, 1999, St.Gallen,Switzerland3rd European Appointed National Meeting: July, 5 – 7, 2000, Birmingham, UK4th European Appointed National Meeting: October 1 – 5, 2003, Athens, GreeceCONGRESS SECRETARIAT:Department for Plastic, Reconstructive and Aesthetic SurgeryUniversity Hospital DubravaAvenija Gojka Šuška 6, 10000 Zagreb, CroatiaTel.: +385 1 290 2569/ Fax.:+385 1 290 2451/ E-mail: email@example.comFrom October 11, for all necessary informations regardingCongress, please contact the Congress Office:CROATIA HOTEL20210 Cavtat, CroatiaSalon 5Tel: +385/(0)20/ 475-896 / Tel: 1896 (for calls from the hotel)Congress web site: www.kbd.hr/plastkirCONTENTSLectures 1
SESSION A :Head and Neck Reconstructive SurgerySESSION B :Head and Neck Aesthetic SurgerySESSION C :Breast Reconstructive SurgerySESSION D :Breast Aesthetic SurgerySESSION E :Body ContouringSESSION F :Upper Extremity ReconstructionsSESSION G :MicrosurgerySESSION H :Lower Extremity ReconstructionsSESSION I :MiscellaneousScientific PostersSponsors & ExhibitorsList of Participants
L1. Craniofacial deformity Prof. Ian T. Jackson Institute for Craniofacial and Reconstructive Surgery Southfield, USA Craniofacial deformity can be relatively minor or it can be devastating. It can be congenitalor it may result from trauma or tumor. Craniosynostosis A single suture involvement can be treated at any time; multiple suture involvement isassociated with raised intracranial pressure and suture release with skull fragmentrepositioning should be performed. Any suture may be affected. Measurement of headsize is important in decision- making. Postural skull deformity should be diagnosedcorrectly, and in most cases surgical treatment is not required. Molding helmets areemployed if the deformity does not self-correct. Crouzon and Apert Syndromes Rarely is early treatment necessary, but with the advent of distraction osteogenesisthere is a move towards earlier correction. The long-term follow-up of thistreatment is not, as yet, available - it may only be an Aevent in time@ andfurther distractions may be necessary. The surgical management consists offrontosupraorbital advancement as required, with midface an advancement at theLeFort III level.
HypertelorismThe basic mechanism is that of a midline cleft and the severity is variable. Severe casesrequire early treatment to bring the orbits into their correct position and hopefully establishbinocular vision. Secondary procedures are frequent, e.g. further osteotomies, nasalreconstruction, and palatal procedures. Facial bipartition is frequently indicated, this givesvery stable and satisfactory correction. If there is a frontal encephalocele, this is resected andrepaired at the same time as the bony correction.HypotelorismThis is a rare condition, however if it occurs orbital osteotomies are performed. The orbitsare moved laterally and the midline defect is bone grafted.Hemifacial MicrosomiaThis occurs with varying severity, in the most severe cases all levels of the face are involved- skull, orbit, maxilla, mandible and soft tissue. The bony problems are dealt with byosteotomies and/or bone grafts. The soft tissue is augmented with free tissue transfer.Distraction osteogenesis will be used when indicated.Facial CleftsThese can involve specific cases or multiple facial regions. The minor clefts are treated in arelatively standard fashion by excision, local flaps, and suture, the more severe cases mayneed the addition of bone grafts, osteotomies or free tissue transfers, as indicated.Team Approach in Craniofacial SurgeryThese complex anomalies require a multi-specialist approach with an experienced anddedicated team - a plastic surgeon experienced in the craniofacial area, neurosurgeon,maxillofacial surgeon, orthodontist, prosthedontist, pediatrician, social worker, experiencednursing staff, and a good anesthetic team. L2. New techniques in breast reduction Prof. Phillip Blondeel Universitair Ziekenhuis, Gent, Belgium L3. Emergency free flap reconstruction of lower leg trauma Prof. Zoran Arnež Department for Plastic, Reconstructive Surgery and Burns, Clinical Center, Ljubljana, Slovenia L4. Extended composite facelift Prof. Edgar Biemer Abteilung fur Plastische und Wiederherstellungschirurgie Klinikum rechts der Isar, Munchen, Germany L5. Perspectives in corset platysmaplasty Prof. Richard C. Sadove The Sadove Clinic, Tel Aviv, Israel L6. Breast augmentation: possibilities and impossibilities
Prof. Rolf R. Olbrisch Klinik fur Plastische Chirurgie Diakonie-Krankenhaus, Dusseldorf, Germany L7. Submucous cleft palate, methods of repair, our philosophy Prof. John Boorman Guy’s Hospital, London & Queen Victoria Hospital, East Grinstead, UK Classic SMCP - Triad of features Notched posterior nasal spine Bifid uvula Lucent midline strip Occult SMCP No Intraoral signs Small midline defect on endoscopy ?Musculus uvulae absence Clinical situation is more complex Spectrum of severity Key is abnormal levator insertions Examination important Lateral videofluoroscopy most useful Presentation is at various stages Neonatal examination Feeding difficulties Failure to thrive Glue Ear Speech problems – Velopharyngeal insufficiency May be part of Velocardiofacial Syndrome (22q11 deletion) Not all SMCP need treatment ~50% will speak normally Treat when there is evidence of palatal dysfunction (feeding/speech) Surgical options Correction of muscle abnormality (Sommerlad / Furlow etc.) Pharyngoplasty if that failsL8. Radical sternectomy and primary musculocutaneousflap reconstruction to control sternal osteitis Prof. Andrej Banic Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital Inselspital, Berne, Switzerland
Objective: Sternal osteitis after median sternotomy causes considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach. Methods: Sternectomy consisted of the resection of the entire sternum including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any re-stabilization of the thoracic wall. 13 patients received a vertical rectus abdominis musculocutaneous (VRAM) flap, 14 patients a pedicled latissimus dorsi musculocutaneous (pLDM) flap and 12 patients a free LDM flap (total of 40 flaps in 39 patients out of 66 patients who required surgical revision due to sternal osteitis out of 6078 sternotomy patients). Results: Two patients died within 30 days postoperatively (early mortality 5.1%), however, not due to sternal infection, which was cured without any recurrence in all patients. 17 patients (44%) required secondary, mostly minor operations due to local complications. Despite some paradoxical chest movements, the patient satisfaction was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3). The short- and long-term complication rates were similar in all three groups. Conclusion: We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection even in the most severe cases, thus reducing infection-related mortality. The tradeoff was a substantial rate of local complications, which, however, did not cause any relevant morbidity.L9. Malignant melanoma. Contemporary diagnostic procedures,treatment, and perspectives for the future Prof. Krzysztof Drzewiecki Department of Plastic Surgery, Rigshospitalet University Hospital Copenhagen, Denmark Cutaneous Malignant Melanoma (CMM) comprises 3% of all malignancies. The incidence rate has tripled during the last 40 years. Middle-aged persons are most often hit by this tumour. Females are slightly overrepresented. UV- spectrum of sunlight is the most important external ethiological factor. Constitutional predisposing factors are freckled persons, who are sensitive to sunshine, persons with many naevi and congenital naevi. 4-10% of patients with CMM report about other single cases of CMM in their families. However, in less than 1% of the melanoma cases a gene defect can be detected. Dermatoscopy and SIA-scopy enhance the probability of a correct clinical diagnosis, provided the doctor is accustomed with this method. Clinical examination, sentinel node procedure, and microscopy are necessary to classify a CMM correctly – before the treatment. The American Joint Committee on Cancer (AJCC) has a staging system based on a TNM assessment, which should be used The standard treatment of CMM is surgery for primary lesion, surgery for secondary regional lymph node deposits and surgery when ever technically possible for distant metastases. Hypertherm Regional Perfusion treatment for regional metastases on the extremities is widely accepted. X-ray treatment is used for CMM metastases that are not accessible for surgery. Chemotherapy, biological modifiers and vaccines should only be used as part of a clinically
controlled study, because they are experimental treatments. Interferons and vaccines are used in a clinical experimental setting as an adjuvant therapy following surgery in suitable patients.L10. Functional free flaps reconstruction Prof. Milomir Ninković Department of Plastic, Reconstructive and Hand Surgery, Burn Centre, Technical University - Hospital Bogenhausen, Munchen, Germany The transfer of a free microvascular flap is a well-established method in the reconstructive surgery. It provides tissue with a rich blood supply, which improves healing process, its resistance to infections, and quality of reconstruction. The technique settles freedom in flap design for optimal contour in accordance with size and shape of the defect. The timing of free tissue transfer after upper extremities injury seems to be a very important issue. The free flap closure can be divided according to time of reconstruction into three categories: primary free flap closure (within 24h), delayed primary free flap closure (2-7 days, and secondary free flap closure (after one week). Many factors besides timing of closure and the success of flap survival alone influence the functional outcome of the upper extremity reconstruction. For instance severity of injury, particular the nerve and muscle damaged, as well as length of bone loss etc. In this presentation all factors which influence the final result of upper extremity are discussed and principles of treatment are defined.L11. R e p l a n t a t i o n Prof. Aurelio Portincasa Plastic and Reconstrucive Surgery Department University of Foggia, Foggia (Italy) Definitions: Replantation: if a part is completely amputated, i.e. cut off without any attaching structures (vessels, nerves, tendons, bone) whatsoever, it will be replanted Revascularization: if a part has been deprived of its main blood supply, but there are connecting structures remaining, such as tendon or nerve, the part has been incompletely amputated and will be revascularized i. Currently the ultimate success of a replantation attempt is judged by functional as well as cosmetic parameters.Meyer ii state that patients with amputations proximal to the wrist joint but close to it are good candidates for replantation, as evidenced by Chen Grade I or II recovery in 80%.In general, upper extremities amputated proximal to the midforearm should not be replanted if the warm ischemia time exceeds 6 hours. The following are universal contraindications to replantation: - concomitant life-threatening injury - multiple segmental injuries in the amputated part - severe crushing or avulsion of the tissues
- extreme contamination - inhibiting systemic illness (small vessel disease, diabetes mellitus, etc) - prior surgery or trauma to the amputated part precluding replantationReturn of function in forearm replantations depends largely on two factors:(a) the degree of nerve regeneration, and(b) the hand rehabilitation programiii. The most frequent complications in upper limb replantation and revascularization are: infection (30%); inadequate debridement; nonunion and intrinsic muscle function weak or absent. Excellent or good results are noted in patients with clean, guillotine-type distal amputations or incomplete proximal amputations with intact nerves. Fair and poor results are associated with crush or avulsion injuries. The potential for functional recovery is directly proportional to the amount of viable tissue remainingiv v. In the hand, all other criteria being favorable few surgeons would argue against replantation in the following circumstances: - multiple finger amputations - thumb amputations - complete amputations of the hand at the palm or wrist - all amputations in children Replantation is still controversial in the following clinical situations: - loss of a single digit other than the thumb, especially the index and digitorum superficialis (FDS) tendon insertion - single-digit amputations distal to the FDS insertion - ring finger avulsion injuries Other contraindications to replantation have been listed above. As regard the level of amputation, scapulothoracic amputation with brachial plexus root avulsions represented the only real absolute contra-indication to replantation. Amputations through the arm to the wrist have the potential for recovery of useful functions, and should be attempted in selected cases after careful evaluation. The same evaluation and case selection is recommended for single digit and distal digital amputations. There is general agreement on the absolute indication for replantation of the thumb, mid-palm, wrist, and forearm level in children so long as the part is not severely crushed. Microsurgical repair of the tiny vessels of infants makes the operation technically difficult; on the other hand, functional return after replantation of digits in small children is often quite good. In the elderly, useful functional recovery cannot be expected with any reliability, thus any attempt at replantation in elderly patients should be carefully weighed against the potential systemic insult from the anesthesia and operation.Clean, minimally crushed amputations yield the best results after replantation. Avulsion injuries, severely contaminated wounds, and amputations with multiple levels of injury are poor choices for replantation. Microsurgical repair in cases where the entire finger has been degloved does not result in good f u n c t i o n . Kleinert vi believes that 12 hours or more of warm ischemia is a relative contraindication to digital replantation. Prompt cooling of the amputated digit to 4°C prolongs the acceptable ischemic period to over 24 hours, with a good chance of complete survival and full functional return. Regarding the patient selection, his/her occupation, economic and social status, nationality, mental health and cooperativeness must all be taken into account when deciding whether to attempt replantation or n o t .
When performing a replantation, one must be particularly careful to placethe anastomoses outside the zone of injury and to incorporate onlyundamaged vessel ends. Excessive shortening of replanted parts results inmuscle-tendon imbalance and dysfunction. The operative sequence varies according to the clinical situation andsurgeons preference. A common approach involves the following steps: - preoperative patient evaluation and preparation - identification of structures in amputated part - identification of structures in the amputation stump - bone shortening (minimal) and bony fixation - muscle-tendon unit repair - nerve repair - arterial repair (with or without recirculation) - venous repair - skin closure or soft tissue coverage There are as many different standards for evaluating functional recoveryafter replantation (for sensation, motor outcomes, assessment to coldintolerance and all the indicators of complications) as there are reportingsurgeonsvii. For failed replants or for extremities that cannot be replanted at the time ofinjury, function can be partially restored by toe-to-finger or toe-to-thumbtransplant. Leungviii and Frykmanix describe the technique and functionalresults of these transfers. Transplantation of composite tissue allografts, such as a hand, offersimmense potential in reconstructive surgery. Thus far, six human handtransplants have been performed with various degrees of success. Areview of current replantation literature suggests that the prospect forsignificant functional return following a hand transplant is quite good solong as here is judicious patient selection and prevention of allograftrejectionx.REFERENCES Mc Carthy: Replantation and revascularization of the upper extremity. PlasticSurgery, Vol.7, The hand, Part 1, May & Littler 1990, p.4356. Meyer VE, Chen Z-W, Beasley RW: Basic technical considerations inreattachment surgery. Orthop Clin North Am 12:871, 1981. Chow JA et al: Forearm replantation — Long term functional results. AnnPlast Surg 10:15, 1983. Russell RC et al: The late functional results of upper limb revascularizationand replantation. J Hand Surg 9A:623, 1984. Urbaniak JR: Replantation of amputated parts: Technique, results, andindications. In: AAOS Symposium on Microsurgery. St Louis, CV Mosby,1979, pp 64-82.Kleinert H, Jablon M, Tsai T: An overview of replantation and results of 347replants in 245 patients. J Trauma 20:390, 1980. Tamai S: Twenty years experience of limb replantation: Review of 293 upperextremity replants. J Hand Surg, 7:549, 1982.
Leung PC: Thumb reconstruction using second-toe transfer. Hand Clin1(2):285, 1985. Frykman GK et al: Functional evaluation of the hand and foot after one-stagetoe-to-hand transfer. J Hand Surg 11A:9, 1986. Lee WP, Mathes DW: Hand transplantation: pertinent data and future outlook.J Hand Surg 24A(5):906, 1999. SESSION A : Head and Neck Reconstructive Surgery
A1. Vascular anomalies in the head and neck Berenguer B., P. Rodríguez, B. González, J., Enríquez de Salamanca Division of Plastic Surgery,Children`s Hospital “Niño Jesús”, Madrid, Spain Introduction Despite their high frequency, vascular anomalies continue to generate great confusion. On the one hand vascular lesions may look very similar, but have a completely different prognosis and treatment needs; on the other hand, persisting old descriptive terminology impairs precise communication in the literature. Daunting facial anatomy, gross disfigurement and social stress are significant issues that deserve special attention in the head and neck area. This study reviews the most recent advances in the management of vascular anomalies according to the Biologic Classification1, internationally accepted in Rome in 1996. Materials and Methods Between June 1999 and January 2004, 270 patients with vascular anomalies in the head and neck were seen in our Vascular Anomalies Unit (173 hemangiomas, 67 vascular malformations and 30 other vascular lesions). Capillary malformations were treated with pulsed dye laser. Surgical indication was limited to those with significant ectasia or tissue hypertrophy, most commonly seen in the lips. Venous malformations were percutaneously sclerosed with abslolute alcohol2, often followed by surgical excision and reconstruction. Disfiguring lymphatic malformations were mainly excised. Tedious dissections were required around cranial nerves. Isolated macrocystic malformations were sclerosed with OK 432 (Picibanil). In this group diffuse malformations often invaded the bone, requiring orbital or mandibular
remodelling. Arteriovenous malformations were the most severe. In the quiescent stage, conservative treatment was recommended; growing or endangering lesions were embolized followed by wide excision and reconstruction. For the hemangiomas the first-line treatment was pharmacological. Surgery was indicated in 3 situations: -complications in the proliferative phase (ulcers, visual obstruction, air way obstruction), - functional, aesthetic or psycologic problems during the involuting phase and - functional or aesthetic sequelae after complete involution. Specific problems were addressed according to the nature and exact location of the lesion. The aesthetic subunit approach was stressed in facial surgery. Results Results of treatment of vascular malformations were rated as good to excellent, by the parents and 3 independent raters. The main complication was reexpansion of residual or neoformed vessels (32%). No recurrences were observed in the hemangioma group. Results were graded excellent. The most frequent complication was hematoma (12%). Conclusion Patients with vascular anomalies of the head and neck suffer functional problems as well as distressing aesthetic deformities. Correct evaluation, near follow-up and precise treatment planning allow to obtain optimal results in most lesions 3,4. Interdisciplinary vascular Anomalies Teams offer the best therapeutic frame for these complex lesions5. References 1.Mulliken, J.B., and Glowacki, J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast. Reconstr. Surg. 69:412, 1982. 2. Berenguer B, Burrows PE, Zurakowski D and Mulliken JB. Craniofacial venous malformations: complications and outcome. Plast. Reconstr. Surg. 1999;104:1-11, discussion 12-15. 3. Berenguer B, Enríquez de Salamanca J, González Meli B, Rodríguez Urcelay P, Zambrano A, Perez Higueras A. Large involuted facial hemangioma treated with syringe liposuction. Plast. Reconstr. Surg. 2003;111:314-8. 4. Berenguer B, Mulliken JB, Enjolras O et al. Rapidly involuting congenital hemangioma: clinical and histopathologic features. Pediatr Dev Pathol. 2003; 6:495-510. 5. Berenguer Fröhner B, Enríquez de Salamanca Celada J, González Meli B, Rodríguez Urcelay P. Not all vascular birthmarks are angiomas. An Esp Pediatr.2002,56:127-38.A2. Management of bilateral cleft lip and nasal deformity – state of the art Gonzalez B. Division of Plastic Surgery,Children`s Hospital “Niño Jesús”, Madrid, Spain Surgical management of bilateral cleft lip and nose constitutes a challenge to every surgeon dealing with these patients. These clefts deformities are often
wide and are associated with premaxillary rotation and/or protusion and severe nasal impairment. Furthermore, its incidence is much lower than the unilateral cases and therefore there is shorter experience in its management. This presentation reviews the current state of the art, with special references to the therapeutic principles, the protocol of the “Cleft Unit” of the Children’s Hospital “Niño Jesús” and the aspects that are still under discussion. The facial deformity in bilateral cleft lip presents several aspects that must be taken into account: - Severe loss of lip tissue. - Prolabium often small, short and wide, and lacking of orbicular muscle fibers. - Premaxilla protruded and rotated. - Severe nasal deformity: alar cartilages are flat and rotated caudally, subluxed respect to its anatomic position, and the columela is short or absent. Thus, this is an extremely complex malformation for which several techniques have been developed. Currently, regardless of the protocols and surgical techniques, the basic principles of treatment are: - Single stage primary cheiloplasty. - Primary reconstruction of the orbicularis oris muscle. - Use of the prolabium for lip reconstruction and not for the nose. - Primary correction of nasal deformity at the same time as lip repair. However, important controversial issues still remain: - Previous lip adhesion. - Presurgical orthopedics. - Nasal aproach . - Primary gingivoperiostioplasty and/or primary alveolar bone graft. At the Hospital “Niño Jesus” we follow the present protocol of treatment: - We do not perform active presurgical orthopedics. Passive obturators and/or external compression bands are used to reduce premaxillary protusion. - Single stage primary cheilorhinoplasty at age two-three months. - Primary gingivoperiostioplasty only when maxillary segments are in favorable position. We never do a wide dissection. Our surgical techniques have evolved over time as a result of enhanced technical skills and continuous analysis of the results achieved, including the comparison with those of other centers. Individual surgical techniques may not stand the test of time, and the principles on which they are based advance slowly. Today we still see patients – children and adolescents- with severe sequelae, some of which are the result of previous surgical treatments and often are impossible to correct. The development of multidisciplinary clefts units, in which a large number of cases are treated, offers the best care standards for these patients.A3. Cleft lip and palate treatment – the way we do it Knežević P., Uglešić V., Jokić D., Ožegović I., Kovačić J. Department for Maxillofacial and Oral Surgery, Department for Otolaryngology, University Hospital Dubrava, Zagreb, Croatia The treatment for cleft lip and palate is still in some way controversial, especially the timing of performing the procedure and also the technique. At our Clinic, Millard technique with a little modification for cleft lip was introduced more than twenty years ago. For the cleft palate, we actually use
Langebeck technique in two acts. In the cooperation with our colleagues from Ludwig Maximillian University, Munich, last year we slightly changed the schedule of operation and introduced some new techniques in the procedure. With wide clefts, we operate on three months old babies, always performing lip adhesion with soft palate palatoplasty as a first act. Lip adhesion is followed by cheiloplasty, and later hard palate palatoplasty is done. In our opinion, this is optimal for cleft muscle reconstruction, which is the most important in the treatment of clefts. Although the final results are visible only at the age of adolescence, after the process of growing up is finished, with this article we wanted to present our first results.A4. Nasal deformities in unilateral clefts of the lip Bagatin M., Bagatin T., Bagatin D. Policlinic for Maxillofacial, General and Plastic Surgery “BAGATIN”, Zagreb, Croatia Introduction: Clefts of the lip are followed with different nasal deformities. In unilateral clefts we primary find shorter columella, lower or more-less flat nasal wing, lower or lateraly displaced alar base and lower or unformed floor of the nostril. Material and Methods: In this trial we included patients with unilateral clefts operated from 1990 to 2004. Authors analyse most common deformities of nose in unilateral clefts before and after cheiloplasty and they try to explain their origin, prevention and correction. Also patients with secondary nasal deformities are analysed and old and new secondary corrections of nasal deformities are presented. Results: After cheiloplasty authors most often found lower and wider nostrils, less often lower or lateraly displaced alar base, asymmetrical tip of the nose and flat alar wing. Results of secondary corrections of nasal deformities show better results after new than old secondary procedures. Conclusion: These deformities of nose after surgical correction are connected with different relationship of nasal structures, loss of tissue, deformities of growth and are reflection of primary deformation, selected surgical procedure, surgeon´s point of view, patient´s reaction to procedure. Authors modification of nasal muscle reconstruction give satisfactory result in primary and secondary procedures.A5. Nose and lip hemangioma-merits of CO ₂ laser Costagliola M., Polyclinique du Parc, Toulouse, France Angioma of the nose (cyrano nose or pinocchio nose) considerably spoils the appearance of an other wise normal child. It is an hemangioma ie a capillary malformation present a birth. Sometimes hemangioma involves nose and upper lip : it is a Tapir angioma. Superficial capillary hemangiomas or strawberry angiomas are immature and usually resolve with time. Because they go through several stages and there is the possibility that they will virtually disappear, they have been called
“phasic angiomas”. Deeper sub cutaneus hemangiomas have a fibrous component (hamartomatous tissue) and will not disappear without treatment. The CO2 laser is excellent because it is strongly absorbed by the tissues and therefore does not penetrate deeply (wave length = 10.6 microns). So it is the treatment of choice for hemangioma of the nose because of these two modes : focalised for excision and defocalised for cocagulation and vaporization. An elliptical excision is performed in one piece. It is kept as small as possible and the nasal alae are spared. There is no bleeding, no edema and healing is good. CO2 laser may not be revolutionary but it gives a good technological aid in plastic surgery treatment in this particular indication which is hemangioma of the face and the nose.A6. Aesthetic reconstruction of the badly burnt face Parkhouse N., London, UKA7. Free jejunum transfer for esophagus reconstruction Biemer E., Munchen, GermanyA8. Head and neck reconstruction with perforator flaps Masià J. Clinica Planas, Sant Pau University Hospital, Barcelona, Spain Introduction The evolution of reconstructive techniques has resulted in the development of procedures that restore form and a sense of wholeness with minimal morbidity and high reconstruction specificity. In recent years, advances in perforator flaps have provided familiarity of the technique required for safe dissection, and in turn this has popularised the use of this flaps for a wide variety of indications. Many perforator flaps have been described for head and neck reconstruction: anterolateral thigh flap, deep circumflex iliac perforator flaps, toracodorsal perforator flap, peroneal perforator flap, abdominal perforator flaps, submental perforator flap … Nevertheless, ALTF has became the workhorse flap for soft tissue reconstruction. Objective We reviewed our indications and results of head and neck reconstruction with perforators flaps in the last 4 years. Materials and methods Retrospective study, between 2001 and 2004, we have been using two kinds of perforator flaps for soft tissue defects: - ALTF: 26 cases. - Taylor extended DIEP flap: 20 cases. The soft tissue defects were intraoral reconstruction in 30 patients, midfacial in 10 cases and temporal area reconstruction in 6 patients.
Results We have had 3 cases of total failure due to a neck haematoma with no early re-exploration. Conclusion The more complex nature of this kind of surgery, which include a longer learning curve and an increased operating time, is highly compensate for the quality of the reconstruction and the minimal morbidity of the donor site. The ALTF is an excellent flap for soft tissue covering of the face, neck and intraoral regions. It gives a large amount of skin with an adjustable thickness (ultrathin, thin, bulky). The vascular pattern allows the use of a more versatile design with double skin paddles based on multiple perforators. The flap may be used according to the chimaeric flap principle to reconstruct complex 3-dimensional defects, including muscle (vatus lateralis, rectus femoris) or/and fascia lata. Its pedicle is quite long and has a suitable vessel diameter. Other advantages are the possible innervation and the flow-through flap concept. The extended DIEP can provide a larger amount of tissue and the pedicle can be longer but, on the other hand, it is thicker and the indications for intraoral defects are reduced. Therefore, we use it as a second option or in cases where we need to cover a large defect or when we need an extremely long pedicle to reach the contralateral side of the neck or a thoracic vessel. Both types have a lower donor site morbidity and allow two teams to work simultaneously.A9. Challanges in microvascular reconstruction of the head and neck Milenović A., Uglešić V., Knežević P., Virag M., Lukšić I. Department for Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia Aim of this presentation is to define the differences between microvascular reconstruction of the head and neck and rest of the body. Subject The reconstruction of the head and neck defects, on one hand has been revolutionized by the development of microvascular soft tissue transfer but on the other hand has been created numerous challenges for the microsurgeon. Filling a defect was a microsurgical philosophy twenty years ago. Advances in microsurgical transplantation have improved reconstruction and today in the head and neck region we can reconstruct different tissues such as skin, mucosa, muscle, bone and teeth. We present various types of flaps and their usage in reconstruction of complex defects. Reconstruction of maxilla and orbit after maxillectomy with combination of flaps supplied with subscapular artery, differences between various types of mandibular reconstruction and implanto-protetic rehabilitation will be presented.
A10. Free flaps for head and neck reconstruction :experience of 148 clinical cases Costa H. Cirurgia Plástica Centro Hospitalar , Porto, Portugal The authors present their experience in head and neck reconstructions with 148 consective free flaps. The patients were 102 males and 46 females whose ages ranged from 8 to 81 years with a mean age of 48 years. Aetiology of the lesions was Traumatic in 12 cases, Tumours in 120 cases, Congenital in 7 cases, Iatrogenic in 5 cases and Infections in 4 cases. The defects were located in different anatomical regions of the head and neck such as scalp, orbit, nose, soft-tissue of face, intraoral region and mandible. The reconstructions were accomplished by different free tissue transfers such as: omentum, jejunum, fasciocutaneous dorsalis pedis, fasciocutaneous and osteo-fasciocutaneous radial forearm flaps, scapular flaps, muscle and myocutaneous flaps (gracilis, inferior rectus abdominis and latissimus dorsi), myo-osseous flaps (deep circumflex iliac crest and anterior serratus) and myo-osseous and osteofasciocutaneous fibular flaps. Flap survival was 95% (138 revascularizations, 7 total necrosis and 3 marginal necrosis). An analysis is made of surgical times, selection and survival rate of the free flaps and the morphofunctional quality of the reconstructions. Free flaps are considered a first choise technique for head and neck reconstruction when the size and location of the defect prevents the use of local flaps.A11. Radial forearm flap- still a good choice in head and neck reconstruction Knežević P., Uglešić V., Butorac L., Milić M., Glamuzina R. Department for Maxillofacial and Oral Surgery, Department for anaestesiology and intensive care, Department for traumatology, University Hospital Dubrava, Zagreb, Croatia The radial forearm flap was developed as a free flap technique in the 1981. Soutar first used the radial forearm flap for intraoral reconstruction in the 1982. Several large series can now testify to the safety and reliability of the radial forearm flap in head and neck reconstruction. An extension of the technique to include a segment of underlying radius has proved useful in reconstruction facial bones, particularly the mandible. A further variation of this donor site uses the deep fascia, together with subcutaneous fat for facial augmentation. In our work we would like to present the cases where the forearm flap was excellent and reliable choice in head and neck reconstruction. We have used it for intraoral reconstruction (hemiglosectomy, retromolar, soft palate and sublingual region), for the partial and full defects of facial skin and for mandible reconstruction as segmental part of bone or as on lay flap in the marginal mandibulotomy. When we have used osteofaciocutaneous flap for the donor site we always put external fixator on the radius. Except losing the small areas of split skin graft we havent any other complications with donor region. The versatility of the donor tissues of the forearm makes this still the most useful donor area for head and neck reconstruction and its excellent
vascularity can be used to great advantage in a variety of instances in head and neck surgery.A12. Lower lip, chin and facial reconstruction using theextended Karapandžic flap Zubčić V., Uglešić V., Knežević P., Zupičić B., Zubčić Z. Department of Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia Introduction Large, full-thickness lip and chin defects after head and neck surgery maintain to be challange f or reconstruction. Lower lip defects of less than 2/3 of the width of the lip can be reconstructed effectively with local flaps. Karapandzic modification of the fan flap was first described in 1974. for near-total lower lip defects. We used modification of the Karapandzic flap for complex lip, chin and facial defects. Modified incisions are placed lateral to the nasolabial sulcus within the RSTL. Blood supply of the extended flap may be simply explained as a random-pattern flap or flap with the reverse flow from the angular artery. Patients and Methods This procedure was used in eight patients in combination with other local flaps and free flaps. Five patients had an intraoral cancer with the extension to the lower lip and chin. Two patients had a skin cancer of the face and oral commissure. One pateint had a lower lip cancer. Simultaneous neck dissection was performed in seven cases. Radial forearm free flaps were used in three patient and free fibula flaps in two patients for intraoral lining and mandibular reconstruction. Pectoralis major myocutaneous flap was used for intraoral lining in one case. In one patient extended Karapandzic flap was performed in combination with Abbe flap and folded radial forearm free flap. Results The wound healing was uneventful in all cases. Free flap survival was 100 percent. Seven patients were discharged without feeding tubes and remaining patient could have only a soft diet. Oral competence was excellent in all cases. The aesthetic appearance was acceptable to almost all patients. Conclusion The goals of reconstruction are to restore oral lining, external cheek and chin, oral competence and function. This modified technique can fulfil all requested goals of a good dynamic reconstruction.A13. Reconstruction of the anterior cranial base Aljinović- Ratković N., Virag M. Department of Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia The defect of the anterior cranial base can develop in severe craniofacial fractures but also during the removal of the tumors of the naso-orbito-
ethmoidal region. There are two main principles of covering these defects : 1. soft cover only (usually pericranial flap), 2. bone reconstruction (calvaria grafts) + soft cover (pericranial flap) which demands more skill in bone surgery. In this presentation we shall review our experience in combined (bone+soft) reconstruction of cranial base defects in 11 patients. In 10 of them the reconstruction was performed immediately ( in 3 after tumor removal and in 7 during fracture treatment) and in one patient as the secondary reconstruction of traumatic defect of cranial base with brain herniation.A14. Cysts and benign tumors of the jaws: Kocaeli experience and a brief summary Agir H., Ozkeskin B., Sen C., Ustundag E., Cek D. Plastic and Reconstructive Surgery Department, Kocaeli Faculty of Medicine, Kocaeli University, Kocaeli, Turkey Introduction: Cysts and benign tumors of the jaws are among the pathologies encountered relatively rare during daily practice and these lesions are well known with their confusing differential diagnosis and challenging reconstructions particularly in advanced or recurrent cases. Material and Methods: We evaluated our patients treated with the diagnosis of jaw cysts or benign tumors between 2002 and 2004 retrospectively according to their age, sex, complaint, etiology, panorex radiographs, anatomical localization, surgical treatment and histopathological diagnosis. Results: Nineteen patients (11 males, 8 females) with an age ranging from 7 to 69 years were included into the study group. In six cases, lesion was located in the maxilla while in thirteen cases pathology was in the mandible. 78.9% of the cases were seen due to their mass and/or tooth related problems. In 46.15% of the mandible cases, the cyst was localized in the parasymphysis-corpus region whereas all of the lesions in the maxilla were located in the anterior maxilla-paranasal area. As a surgical treatment of choice, curettage and cyst wall burring were applied in fourteen cases, enucleation was done in three cases and mandibular resection was performed in two cases. In five cases, autogenous bone grafts were used to fill up the cavities. In two patients, free fibula reconstruction was performed successfully. Review of the histopathological results revealed five radicular cysts, three dentigerous cysts, two keratocysts and two ameloblastomas. Conclusion: In differential diagnosis of the jaw cysts and tumors, panoramic mandibular radiography and CT scanning play a major role. We believe that vigorous burring or excision of the cyst wall should be added to enucleation or curettage in cases which recurrence is likely. Besides, immediate bone grafting can be used for a more stable and cosmetic healing.A15. From birth to maturity: a group of patients who have completed their protocol management Schnitt DE., Agir H., David DJ. Plastic and Reconstructive Surgery Department, Kocaeli Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
The optimal management of the cleft lip and palate patient from birth to completion of treatment presents a formidable challenge to the plastic surgeon and the associated health care system. The multidisciplinary team approach for the management of these patients is widely accepted. However, a paucity of literature exists discussing specific protocol management, interventions, and the long-term outcomes of patients who have completed a strict treatment protocol with a consistent multidisciplinary team. The aim of this study was to present the details of the specific management protocol at the Australian Craniofacial Unit for cleft lip and palate patients and to present a group of patients who have completed this specific protocol and discuss the details of their long-term care. During a 28-year period from 1974 to 2002, the records of 337 patients treated for unilateral cleft lip and palate were evaluated. Of these 337 patients, 22 have completed the same specific protocol management. The same surgeon (David, the senior author) has been responsible for performing all operative interventions and for overseeing the care of each of the 22 patients, ensuring that the treatment protocol has been executed appropriately and without deviation. The interventions and outcomes were analyzed on the basis of speech, hearing, nasal airway, occlusion, psychosocial adjustment, and appearance. Speech results were assessed as normal speech, mild abnormality, or severe abnormality by objective measures, and intervention for velopharyngeal insufficiency was noted. Seventeen patients were rated as having normal speech. Four patients were rated as having mild speech abnormality, one patient was rated as having severe speech abnormality, and seven patients required surgery for velopharyngeal insufficiency. Hearing results were measured objectively, and good hearing results were obtained in 18 cases. Five patients required tympanoplasty. All patients required alveolar bone grafting. The high Le Fort I osteotomy was performed in six cases. Bimaxillary surgery was performed in one case. Of all the patients assessed from birth to maturity, 13 required between three and five surgical interventions, and nine required six operations or more. Further details and photographs of preoperative and postoperative examples will be provided.A16. Reconstruction of the posttraumatic deformities of theface Aljinović- Ratković N. Department of Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia Posttraumatic deformities of the face are the most frequent facial deformities. Most of them are the result of skeletal deformity due to an improper initial treatment. In those patients deformity of the face is usually associated with functional impairment (double vision, malocclusion, nasal obstruction, etc.). Out of 3130 surgical procedures performed in traumatized patients in the Department of Maxillofacial and Oral Surgery in Zagreb in a nine years period, 2172 (69.4%) were initial treatment of trauma and 958 (30.6%) were secondary surgery. Various reconstructive procedures were performed in 432 (44.2%) . The majority of the deformities were orbital and naso-orbital disfigurement. Bone grafting by use of free grafts was the most frequent bony reconstruction, followed by osteotomies and reosteosynthesis. Between corrective procedures for soft tissue deformity, the most frequent were eyelid, nose and lips reconstruction. Sixty four patients underwent more than
five secondary corrections. The most challenging reconstructions shall be reviewed in presentation and discussed.A17. Basocellular carcinoma medial angle of eye – surgical treatment Mujkanović N., Rifatbegović A., Pašić A., Burgić M. Plastic and Reconstructive Surgery, UKC Tuzla, Tuzla, Bosnia and Herzegovina Basocellular carcinoma in relation with other tumors of skin is very frequent ( 80 -90%). In relations with periorbital region distribution of basocellular carcinoma is different. Palpebra inferior 48,9-72,1%. Medial angle of eye 9,62-27,6% and rest of location is lateral angle and palpebra superior. This tumor do local destruction and invasion, but metastasis are very rare 0,0028-0,1%, on other hand basocellular carcinoma has a tendency for endo and perineural metastasis. Relation between male and female are 3:2. Risk for BCK is 40% for male and 30% female, 19,6% on 100 000 citizens for male, and 13,3% for female. In this article we would like to present surgical treatment of tumors on medial angle of eye and reconstruction of defect with medial frontal-glabelar flap.A18. Midface distraction – preliminary report Uglešić V., Jokić D., Knežević P. Department of Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia Midface distraction is a choice of treatment for selective group of patient with maxillary micro and retrognatism. Treatment of the patient with maxillary micrognatism after surgery for cleft lip and palate will be presented. Orthodontic treatment, preoperative planning, selection of the distractor, surgery, course of distraction and its complications and postoperative results will be discussed.
B1. Geometric and volumetric aspects of facialrejuvenation Wolfensberger C. Plastic and Reconstructive Surgery FMH, Zurich, Switzerland With a short historical rewiew about evolution of facial rejuvenation surgery over the last three decades the autor is focussing on naturally looking results of facelifting surgery avoiding the so called ""surgical look",paying attention to geomtric aspects as :hairline,position of ear lobe,hight of upper lip (labial ledge) hight of forehead and brow position,as well as avoiding the "lateral sweep deformity" coming from overtightening the SMAS in the cheek area.Furthermore is is shown with typical case presentations,that facial rejuvenation surgery of our days has turned from skin tightening to repositioning and balancing volumes (volumetric aspects),from aggressive to subtle changes that last,from maximal to minimal access surgery and .last but not least - from complicated to simple with the conclusion that (sometimes)less is more ! The subperiosteal endoscopically assisted midface advancement and the Feldman-Corset-Platysmaplasty as state of the art techniques are included in this presentation.
B2. Periorbital surgery Richter DF. Department of Plastic Surgery Dreifaltigkeits-Krankenhaus, Wesseling, Germany The increasing experience in the periorbita surgery and the recent findings in the anatomy of the orbital septum and associated ligaments results in an extension of the operative spectrum that can be performed by the upper and lower lid blepharoplasty. The most common and traditional approach to upper blepharoplasty has remained essentially unchanged and has not considered, to the same degree as in the lower periorbita, the actual changes that occur with age or more accurate surgical approaches toward rejuvenation These improved surgical techniques of the upper periorbita have been mostly limited to advances in brow lifting. But lateral extension of upper blepharoplasty incision allows the vertical myectomy of the lateral orbicularis oculi muscle for a lasting treatment of Crows feet wrinkles what are common complaints in patients looking for facial rejuvenation. The same approach allows the surgeon to resect the corrugator supercilii muscle, with or without concomitant blepharoplasty, and is suitable for patients who have significant corrugator hyperactivity and deep frown lines without eyebrow or forehead ptosis. The resultant depression is eliminated with fat tranplantation removed during the blepharoplasty, or fat or dermis from other sites should the aesthetic plan not include eyelid surgery. Conventional lower blepharoplasty techniques that remove lower eyelid fat can create a concave contour deformity of the lower eyelids that causes the "operated" appearance. Effective repositioning of the malar fat pad was found to be reliably obtained by release of the lateral orbital thickening and the orbital retaining ligaments. Suspension of the malar soft tissue is in a cephalad direction after release of these structures recreates a youthful facial architecture. It is a procedure that can correct postoperative problems caused by excess orbital fat removal, lower eyelid retraction, and contour problems resulting from malar augmentation. The knowledge of the anatomy of the periorbita and improved surgical techniques allows the surgeon a direct approach to the origin of the problem utilizing either the lower or upper lid blepharoplasty approach.B3. Arcus marginal release in lower blepharoplasties Berrino P. Department of Plastic Surgery, Genova, ItalyB4. Lower eyelid blepharoplasty with TC septal suturing Sadove RC. The Sadove Clinic, Tel Aviv, Israel
B5. Botulinum toxin a treatment of dysthiroidophtalmopathy Stiglmayer N., Juri J., Tojagić M. Department of Ophthalmology, School of Medicine, University of Zagreb, Zagreb, Croatia Introduction Author the clinical use of botulinum toxin-A in the management of patients with dysthyroid eye disease. Treatment of Graves ophtalmophaty does not always provide favorable results. Glucocorticoids, orbital raditherapy and surgery are methods of choice but with a lot of effects. The aim of the study was to evaluate the use of botulinum toxine A reversible chemodenervation as the treatment of ophtalmopathy with „crowding syndrom“ due to extraocular muscle contraction, lidretraction and motility disturbance with diplopia. The injection technique, discussion of mechanism and complication are described Materials and methodes In 62 patients with „active“ phase of dysthyrpid eye disease, 75 patients with diplopia due to motility disturbance and 93 patients with lidretraction only are treated with the injection of botulinum toxin A. A group of patients with “crowding sy“ were treated with retrobulbar injectionon protectionof inferior rectus muscle ( Botox 25-30j/0,25 ml) and in motility disturbances in projection of most affected ( inferior rectus muscle or into medialis rectus muscle or if necessary both, 5j+25j Botox ). Lidretraction was treated with botulinum toxin injection ( Botox 5-10j ) into levator muscle. The effectiveness and acceptability of the treatment was assessed clinically. Results In all patients injections were tolerated well and congestion of the eye was diminished. In 72 patients ocular motility was improved and the angle of deviation was reduced.Retraction diminshed in all patients and in 2,8% ( 3 patients ) were ptosis as side effect. Follow up was for mean of 9 months. Duration of benefit vary from 2 – 4 months with relaps of motility reductionand lidretraction. Conclusion It seems that there is a place for the use of botulinum toxin in dysthyroid opthalmopathy as well as in “acute“ phase to reduce congestion and motility desturbances og in single symptom as retraction. Ther majority of these patients is employed and need binocular function in everyday professional activities as well as for driving. Lidretraction reduced protection of the eye on one side and gives very disfiguring ( frightened and angry ) appearance. Patients with thyroid faces differ from their former appeasrance and all of them in this study reported a beneficial effect from botulinum toxin A treatment.B6. Orthognatic surgery – functional or aesthetic surgery Uglešić V., Jokić D., Knežević P., Gašparović S.* Department of Maxillofacial and Oral Surgery, Department for anaestesiology and intensive care, University Hospital Dubrava, Zagreb, Croatia Orthognatic surgery can be a function and aesthetic operation. Patients, orthodontist and our indication for the surgery will be presented.
Preoperative planning, course of therapy, results and complications for genioplasty, mandibular advancement and setback, maxillary advancement and bimaxillary operations will be discussed.B7. New approach to facial harmony - diagnosis and treatment in orthognatic surgery Costa H. Cirurgia Plástica Centro Hospitalar, Porto, Portugal Individualized Geometric Analysis of Facial Harmony (IGAFH), represents a new proposal of description and diagnosis of craniofacial structures, registered on lateral head film, in an attempt to overcome the multiple random and systematic errors and distortions, usually attributed to conventional cephalometric methods, and that very often cause discrepancy between clinical and cephalometric diagnosis and, very frequently, erroneous treatment planning. Criticism has centred around the use of statistical standards as a means of diagnosis and treatment goals; the intra and inter-individual variability of intracranial planes; the geometric distortion of angular and linear measurements; the overestimating of hard structures evaluation; the discrepancy between soft and subjacent hard structures, etc, To avoid the distortion of the cephalometric conventional methods, none of the above elements should be used in craniofacial diagnosing, since distortion begins when you start measuring and comparing these values to statistical standards. This innovating method is based upon the ancient philosophical concept of harmony proposed by Aristotle and on the artistic concept of proportion by Leonard da Vinci; where measurements be substituted by proportional analysis and statistical patterns can be replaced by the use of the basic structures of the patient, which is, in this way, becomes his own sample. This fact allows, for the first time, the individualization of craniofacial diagnosis, where the ideal of facial harmony can be established on a personal basis. This issue is of paramount importance to achieve facial harmony, by those who have the responsibility of changing craniofacial structures and facial expression, such as orthodontists and both maxilofacial and plastic surgeons. With this very simple method, where proportion becomes more important than measurements, the above-mentioned professionals can find a very realistic and objective way to plan facial intervention, and avoid subjective evaluation, which very often leads to poor treatment results in consequence of distortion caused by evaluation of dismorphic faces.B8. How I handle my facelift patient Olbrisch RR. Klinik fur Plastische Chirurgie Diakonie-Krankenhaus, Dusseldorf, Germany
B9. Male face lift Glumičić S., Budinščak I. Polyclinic ‘’Glumičić Medical Group’’, Zagreb, Croatia Increasing number of male patients throughout the last few years in our practice and their common wish for rejuvenation procedures, mainly FACE LIFT and BLEPHAROPLASTY, has influenced us to analyze the best surgical technique and difference in approach to MALE FACE LIFT in comparison with face lift in female patients. Due to different thickness of the skin, facial hair growth as well as stronger facial muscle structure, the incision for a face lift as well as technique it self varies comparing to the same surgical procedure in female patients. The author will show the preoperative planning, the placement of incision, depending on numerous factors, and the surgical approach it self. Also we will analyze and show the early and late postoperative result in male face lift, with a goal of achieving most natural and yet youthful appearance of man’s face.B10. Tip surgery – open rhinoplasty approach Uglešić V., Knežević P., Milić M. Department of Maxillofacial and Oral Surgery, Department for anaestesiology and intensive care, University Hospital Dubrava, Zagreb, Croatia Tip of the nose surgery is the most creative but in the same time the most demanding part of the rhinoplasty and the approach is still matter of controversy. The aim of the presentation is to show open approach to the tip surgery and the manoeuvres that can improve projection, rotation, shape and definition of the tip of the nose. Special care will be paid to the cartilage grafting and suturing of the alar cartilages. Pros and cons of the open rhinoplasty approach to the tip surgery will be discussed.B11. Relation between functional and aesthetic nasalsurgery Dobrović M. Private ENT Office, Zagreb, Croatia Many surgeons condsidere cosmetic rhynoplasty to be one of the most challenging facial plastic surgery procedures. What distinguishes the art of rhinoplasty form other facial plastic procedures is teh paramount importance that the nose plays in both form and fuction. Preoperative endonasal assesment and causes of functional nasal disorders are discussed. The rhinoplasty surgen must be cognisant of the vital function of the nose at all times that he may either correct a preexisting functional impairement or avoid the potential pitfall of creating one.
B12. Comparision of cartilage scoring and cartilage sparing otoplasty – a study of 203 cases Mandal A., Bahia H., Stewart K. Department of Plastic & Reconstructive Surgery The Royal Hospital of Sick Children, Edinburgh, UK Introduction The Edinburgh experience of different methods of otoplasty techniques in 203 patients (406 ears) over a 5 year period are reviewed.. Material and Methods The patients were divided into 3 groups – group A ( cartilage scoring), group B (cartilage sparing in the fashion of posterior suturing ) and group C ( posterior suturing refined with posterior fascial flap). Demographic details, operation technique, operation time, grade of the surgeon, suture materials, early and late complications, recurrence and revision rates, patients’ and doctors’ comments at the follow-up clinic were retrieved from the case notes. The pre and the post-operative photographs were assessed by a blinded lay observer and a doctor and scored on a visual analogue scale. Median follow-up was 9 months . Results The recurrence rate was 11.0%, 8.0% and 4.8 % in group A,B and C respectively ( p=0.0214). Complications were commoner in group A (8.8%) and group B ( 7.9%) compared to group C (1.2%) ( p= 0.0208). The cosmetic result was judged best in group C ( correlation coefficients > 0.86). Conclusion In our experience, cartilage sparing otoplasty refined with the posterior fascial flap results in significantly improved aesthetic and functional outcomes.B13. Lip contouring and wrinkle filling in programmedsteps by using autologic fat cells Busching K., Crnogorac V., Brockmann A., Hebebrand D., 1 Clinic for Plastic Surgery,Reconstructive and Hand surgery 2 Clinic for Internal Medcine, Diakoniekrankenhaus, Rotenburg, Germany Introduction The use of alloplastic, xenoplastic or autologic fillers are well known for lip contouring and other fillings in aesthetic face surgery. There are controverse opinions about the use of different synthetic fillers. We want to demonstrate our experience for lip contouring and recontouring with fat cell transplantation. Material and method In the period of 2002 to 2004 we performed the contouring and recontouring of lips and wrinkles in 17 patients. In the operation theater we evacuated the fat cells by liposuction usually in tumescent anaesthesia. The main donor region was the abdominal wall. The portion of fat cells were filled in an injector and applicated whith a big dissection needle. All injections were done by local anaesthesia. Every patient got pre operative and post operative
photodocumentation. The first clinical examination and second photodocumentation was taken after four weeks. We got no mesurement forverifying the effect. Every case was examined and discribed by the therapist.Differences could not even be measured without established standards ofphotodocumentation.Every patient underwent at least three steps of augmentation. Theinterruption of each treatment followed 5 to 10 weeks. The control periodfollowed 3 to 22 month (mean: 16 month).ResultsThe terapy concept showed in every case a nearly successfull effect. Aftereach procedure we noticed sufficient results whithout permanent effect forreason of swelling and haematoma. Only 10 to 20 % of the initial volumeremained after four weeks as permanent. After final treatment 30 to 60 %remained as permanent. Nearly every lip contouring succeeded at least afterthree repititions.ConclusionFat cell replantation is a common and good possibility to augment wrinklesand to conture lip volume. A completely satisfaction will be reached ifpatients are sufficiently informed about the treatment concept and technicalexpense. SESSION C :
C1. Breast reconstruction with autologous tissue – TRAMflap or DIEP flap Elberg JJ. Plastic Surgery and Burn Unit, Rigshospitalet, Copenhagen, Denmark. Since Hartramph described the pedicle TRAM flap for breast reconstruction, the lower abdominal skin and subcutaneous tissue has been the most popular
donor site for autologous tissue breast reconstruction. In an effort to reduce donor site morbidity and optimise flap viability and breast design, the microsurgical free TRAM flap became increasingly popular throughout the nineties. The development of the perforator flap concept pushed this process even further with the introduction of the DIEP flap. However Kroll questioned the superiority of the DIEP flap due to increased frequency of marginal skin necrosis and liponecrosis, which stressed the importance of peroperative evaluation of flap perfusion before breast design. The perforator flap concept has in many ways influenced the dissection of traditional flaps, which has led to limited tissue damage also in these flaps. The distribution, size and course through the muscle of perforators in the DIEP flad is subject to significant variability. Thus, some DIEP flaps can be dissected very easily, while others can be very time consuming, technically demanding with a potential risk of severe tissue damage. Based on these considerations it has been our policy to perform a DIEP flap if the flap can be based on one or two perforators in a row and in all other situations to perform a muscle sparing TRAM flap with great emphasis on leaving the motor nerve supply undamaged.C2. Predesigning the free TRAM or DIEP flap Boorman J. Guy’s Hospital, London & Queen Victoria Hospital, East Grinstead, UK Method most applicable for Delayed > Immediate Skin required > Skin sparing Unilateral> Bilateral Free > Pedicled We are trying to create a breast shape Donor site is flat Breast is a rounded cone + gravity Closing wedge principle Creates a cone from a flat surface Measure opposite breast preoperatively Transpose mastectomy scar Mark meridian Measure from medial and lateral to meridian 1 To upper extent of breast
2 along scar 3 to nipple 4 along inframammary crease Create template Transpose to infraumbilical area with skin under tension Can be orientated either way up Surgical details Deepithelialise portion for upper breast Ipsilateral or contralateral DIE vessels TRAM or DIEP depending on tissue volume needed Close wedge before transfer to check viability Internal Mammary or Subscapular axis for anastomosesC3. DIEP and SIEA for breast reconstruction: Theimportance of the superficial inferior epigastric vessels Masià J. Clinica Planas, Sant Pau University Hospital, Barcelona, Spain Introduction The evolution of the reconstructive techniques has resulted in the development of procedures that restore form and a sense of wholeness with minimum morbidity and maximum reconstruction specificity. Following a physiologic and a logical approach if the breast is made of mammary glands and ductus suspended in fat, breast reconstruction should be done by fat and skin alone without muscle sacrifice. The abdominal perforator flaps (DIEP and SIEA) has become the gold standard for breast reconstruction, they combine an excellent tissue quality, a minimal donor site morbidity and, aesthetically, an acceptable abdominal scar. Objective We reviewed our results of breast reconstruction performed during the last 5 years utilizing abdominal perforators flaps. The emphasis of the review was to stress the importance of an accurate dissection of the superficial inferior epigastric vessels as the key to have the possibility of doing a SIEA flap or as the best lifeline in DIEP venous problems. Materials and methods Retrospective study of 145 DIEP and 6 SIEA flaps for breast reconstruction during the last 5 years, we have grouped in: - 30 first cases: DIEP learning curve. - 70 next cases: DIEP technique consolidation. - 51 last cases: Preoperative multidetector CT perforator planning and the SIAE use introduction. Result Comparing the three groups we have found a significative reduction of complications. First 30 70 next 51 last DIEPFs DIEPFs DIEPFs/SIE AFs
TRAM 0% 1.4% (1) 0% conversion Total failure 3.3% (1) 4.2% (3) 1.9% (1) Partial necrosis 10% (3) 2.8% (2) 0% >20% Partial necrosis 16.6% 11,4% (8) 3.9% (2) < 20% (5) Operating time 10.5 h 8h 6.5 h Conclusion The more complex nature of this kind of surgery, longer learning curve, increased operating time, is highly compensate for the quality of the reconstruction (permanent and natural). The superficial epigastric vessels are the key to the technical optimisation of the DIEP flaps reducing the venous drainage problems. Another important advance has been the use of the preoperative multidetector CT mapping, which allows us to be sure that we have chosen the dominant perforator of the flap. Nevertheless, in our experience, the SIEA flaps, despite having the minimal donor site morbidity, are not always the first option for breast reconstruction because blood supplied skin area is less predictable. The shorter length of the SIEA pedicle can present problems in right placement of the flap and in shaping the breast.C4. Six year experience of early-stage breast cancertreatment with skin and nipple sparing mastectomy andimmediate breast reconstruction Stanec S., Stanec Z., Žic R., Budi S., Milanović R., Vlajčić Z., Rudman F., Martić K. Department for Plastic Surgery, University Hospital Dubrava, Zagreb, Croatia Skin sparing mastectomy, described by Toth and Lappert 1991., has been advocated as an oncologically safe approach for the management of patients with early-staged breast cancer that minimizes deformity and improves cosmetic result by preservation of the skin envelope of the breast. Verheyden 1998. described the nipple sparing total mastectomy for treating the premalignant lesions of the breast. Based on experiences of these and other authors, in past six years we have been treating the patients with T1 and T2 breast cancers with skin and nipple sparing mastectomy and immediate reconstruction, mostly using DIEP or latissimus dorsi flaps. We will present our strategy in early breast cancer treatment and discuss the results and follow up of 43 patients treated with skin and nipple sparing mastectomy and immediate breast reconstruction.C5. Our experince in the brest reconstruction with DIEPflap, the learning curve explored
Bušić V., Das Gupta R., Begic A. Telemark Public Hospital Skien, Skien, Norway The deep inferior epigastric perforator (DIEP) flap has been developed as the principle tool for secondary breast reconstruction in our department. This paper details our experience in learning and improving the technique with the help of an experienced outside team of surgeons. In our first 65 DIEP flap breast reconstructions our total flap loss rate was reduced from 9.5% to 0%, partial flap loss rate from 31% to 0%, and fat necrosis rate from 16.6% to 4.3%. We illustrate how departments can benefit from a staged approach to this complex reconstruction technique. Keywords: Deep inferior epigastric flap; breast reconstruction.C6. Omega and inverted omega incision : a concept ofuniform incision in breast surgery Vlajčić Z., Žic R., Stanec S:, Stanec Z. Department for Plastic Surgery, University Hospital Dubrava, Zagreb, Croatia In the history of breast surgery, we have seen a lot of changes in orientation, position, and localization of breast incisions. Most of the biopsy incisions have been made with no consideration of future mastectomy or reconstruction because a wide ellipse of skin removed during the mastectomy included the biopsy site. The primary surgical treatment was in the competence of the oncologic or general surgeon. Reconstruction was not an integral part of breast carcinoma therapy and was considered as a secondary, unimportant treatment to be preformed by a plastic surgeon at a later date if desired by the patient. Wide acceptance of conservative breast operations, skin-sparing mastectomy, and reconstruction as an integral part of breast cancer therapy necessitates new consideration about the initial incisions used for breast biopsy. We consider the omega incision not only as a type of incision but also as a concept that can be used for all breast surgery, including biopsy, lumpectomy, skin-sparing mastectomy, and reconstruction.
REKLAMA BELUPOD1. Breast Reduction Portincasa A., Foggia, Italy
D2. Treatment of moderate breast asymmetry by scarless tissue ressection (Case Report) Eder E. Koln, Germany A significant breast assimetry can rarely be corrected only by means of simple augmentation. The additional scar related procederes are in most cases inevitable.In a case of 25 years old woman with apparent assimetry and ptosis I reduced conically the exsses tissue thrugh periareolar incission. A 310 Mc Ghan HP implant was implanted.After closing the resected fat-glandular tissue edges subcutaneously,a radical underminig of excess skin in medial and lateral direction was performed.After 6 weeks skin adapted completely .Both breast have symetric and satisfactory appearance.D3. Vertical scar mammoplasty Mijatović D., Džepina I., Unušić J., Bulić K. Department of Plastic and Reconstructive Surgery, University Hospital “Zagreb” Zagreb, Croatia In the time between 1996 and 2003 we preformed 52 breast reductions using vertical scar mammaplasty. Indications were breast hypertrophy and breast assimetry. Major advantages af theis method is absence of medial and lateral scarms whiched in our patients group were contur deformity in the lower breast pole, problems with wound heeling, NAC position.D4. Breast reduction – comparison of different techniques Stanec Z., Stanec S., Žic R., Rudman F., Martić K. Department for Plastic Surgery, University Hospital Dubrava, Zagreb, Croatia As with numerous other procedures in plastic surgery, there are a multitude of techniques described for the correction of mammary hyperplasia. The simple fact that so many techniques remain popular is a good indication that there is no one perfect technique that is applicable to every patient, and the plastic surgeon should have a few in his/her repertoire. As our understanding of both breast function and neurovascular supply has improved, increasingly reliable tissue survival is possible, and the main goal in reduction mammaplasty today is focused to minimizing the scars and to bettering the aesthetic appearance and the durability of the resultant breast shape. We will present our own experience with different methods of breast reduction, depending on the patient,s individual characteristics and demands. From our point of view, the advantages and drawbacks of different techniques will be underlined and disscussed.
D5. Inverted nipple – surgical correction (Olivari)experience after 76 operations Olivari N., Department of Plastic Surgery Dreifaltigkeits-Krankenhaus, Wesseling, Germany Inverted nipple is a congenital malformation (0, 5% of female population). Problems are nursing of child (often impossible), hygienic problems, sometimes with infection and aesthetic problems. There are many methods for correction of inverted nipple, with large scars and high percentage of recurrences. All traditional methods are based on the principle to try save the duct. This is in the most cases impossible. For the new method we need only small incision (3 – 4 mm) laterally of the nipple. All ducts and all fibrotic connections should be completely cut. Following this suture with 5.0 Vicryl is preformed inside under mild tension. There is no need for skin suture. Operation can mostly be done under local anaesthesia. In 44 patients were preformed 76 nipple corrections. Average follow up was 23 months with average 34 years old patients. From 76 operated nipples there was no recurrence. In 4 patients were reported that they were able to nurse after operationD6. Asymmetry of the breast as a plastic- reconstructiveproblem Margaritoni M., Bukvić N., Bekić M., Selmani R., Kostopeč P. Department of Surgery, Division of Plastic and Breast surgery, County Hospital Dubrovnik Dubrovnik, Croatia The cause of the breast asymmetry differs from congenital to acquisitive, which is mainly a consequence of breast cancer treatment. The indications for surgical correction could be functional or aesthetic either it is partial or total breast reconstruction. Surgical techniques include use of autologoues tissues or breast implants as well as both techniques. Intervention could be performed on single or both breasts. Additional techniques could be performed to correct the size and shape of the breast and improve final results of the plastic-reconstructive treatment. The authors represent their own results in last few years.D7. Illusions and disillusions in breast surgery : thedifficulty of the art Echinard C. Humani Terra International , Marseille, France
Breast surgery is linked to one of the most symbolic and mythical organ of the women. It can be an easy surgery, or in some cases a difficult task. It can give very enthousiastic results, but can also lead to the worst catastrophies. this review aims at considering historical and philosophical aspects of breast surgery. It wishes to show that breast surgery is not necessarily a holiday party but must be considered with a great deal of honesty, meticulosity and art. It also recalls through different examples how difficult secondary breast surgery can be. Itll stress these difficult problems in breast reconstruction as well as in breast reconstruction or augmentation.D8. Treatment of gynaecomasty Zambelli M. Polyclinic for Plastic Surgery, Rijeka, CroatiaD9. Capsule contraction and infection Olivari N. Department of Plastic Surgery Dreifaltigkeits-Krankenhaus, Wesseling, Germany Certain publication indicate a connection between capsular contraction and bacterial infection ( Courtiss et al., 1979; Burkhardt, 1981). We attempted to clasify this question on 88 patients (106 breasts) of our clinic, with major capsular contraction: - 106 capsule biopsy were sent to histological and bacteriological examination - 106 intracapsular swabs were sent to bacteriological examination - 44 removed implants were sent to bacteriological examination It seems that coagulase-negative staphyloccocus (CNS) is involved in the ethiology of capsular fibrosis. 62% of breasts were infected with CNS. Clinicaly consequence: Extreme aseptic procedure is required during breast augmentation. The implantation pocket and the inlay should be washed with the antibiotics. Redon drainage should be mandatory at least for 24 hours.D10. Special problems in breast augmentation Berrino P. Department of Plastic Surgery, Genova, ItalyD11. Augmentation and mastopexy - guidelines Richter DF. Department of Plastic Surgery Dreifaltigkeits-Krankenhaus, Wesseling, Germany The challenge of these procedures, besides the operation, is to balance between the patients demands of becoming a beautiful breast with the least scars.
According to our own patients and our collected experience we can give precise recommandations for different treatment strategies. In the first place the grade of ptosis and the ammount of the wished volume have to be analyzed.Some very important maesurepoints as well as the kind of ptosis are meaningful for the concept.The following parameters have prooved to be necassary: the distance of the nipple and the jugular fossa, the nipple diameter, the distance of nipple and sternum, and the length of the submammary fold.Depending on the outcome of our examination we can vary our different techniques starting from an "inside lift" with an implant only,to all the different methods as the circumvertical technique, the I- technique and the inverted T-technique. The implant location subpectoral or above the muscle also have to be evaluated.Through our experience we now tend to generously decide towards the more demanding procedure.We rather have more scars for a better result.D12. Hydrodissection, safer and easier way for subpectoral breast augmentation . Eder E. Department of Plastic Surgery, Koln, Germany The best aproach for subpectoral augmentation is doubtless the transaxillary one. If not endoscopically performed,the entire procedure remains a closed one ,without visual control of the operative field.Risk of an uncontrolled bleeding,and inadequat pocket creation is greater as with other techniques.The ifiltrating pump (Medicon LS I 10) and the corresponding infiltration cannula used usually for tumescent lipossuction technique is a usefull device to infiltrate the saline solution combined with adrenaline and Xylonest, in the sub pectoral layer under pressure as to undermine the pectoralis muscle.After 20 min. the entire subpectoral region is anemised through the vasoconstrictive action of adrenalin.A relatively easy and gentle aadditional instrumental preparation is necessary to create a perfect pocket.Since november 2002 until september 2004 I performed 32 subpectoral augmentation using this technique.All patients received antibiotic prophilaction and Methocarbamol as adjunct therapy for post OP pain manegement. No complications were reported.D13. 24 hours free pain breast augmentation. The «nontouch» subfascial technique Keramidas E., Athens Centre for Plastic Surgery, London, UK Purpose The purpose of this prospective study was to determine whether the “non- touch” technique for breast augmentation, popularised by Dr Tebbets can
predict a 24 hours return of the patient in normal activities without post- operative pain. Method and Material Between September 2003 to May 2004, 70 patients underwent bilateral breast augmentation ,60 subfascial and 10 submuscular. The mean age was 25 years old. Surgical Technique 1) All dissection is performed under direct vision, using only the monopolar foot-switching electrocautery , 2) Strictly no blunt dissection 3) Minimal bleeding; less than 10 ml at the end of the procedure, 4) No touching of the muscle or periosteum of the ribs, 5) No drainage in situ, 7) Minimal dressing ( Mepore). The evaluation of the patients included: a) Ability to raise theirs arms above their shoulder the first hours after the operation with no effort or pain. b) Haematoma, bruising or echymosis, infection, c) Post-operative pain for the first 5 days, using the visual analog score d) The time they started normal activities (walking, shopping, lifting light objects). Results 68 (97%) patients were able to raise theirs arms easily 3 to 4 hours after the operation. No haematoma and no infection were observed and only 3 (4%) patients presented mild bruising. The mean pain score was 2.4 for the first 2 days (range 0-5) and dropped to 0.8 the next three days. 65 (93%) of the patients were able to start normal activities the next day with no pain. All patients were extremely pleased by their early recovery. Conclusions The “non-touch” technique could predict, in 93% of the cases, a 24 hours free pain breast augmentation with minimal to none complications.D14. Surgical options vs. patients demands related to the shape and size of the breasts in augmentation mammoplasty procedures Karabeg R., Karabeg A., Lacević S. Clinic for Plastic and Reconstructive Surgery ,University Clinical Center, Sarajevo, Bosnia and Herzegovina Introduction The shape and the size of the prosthesis used in augmentation, together with the approach, depend on the patients wishes and actual possibilities regarding the chest cavity size, breasts symmetry, breast size and patients age. Commonly, patients wishes are not coordinated with their bodys proportions and, therefore, not possible to achieve. Aim of work To clarify some critera in achieving optimal aesthetic results. Material and methods We have analyzed 107 cases surgically treated at the Clinic for Plastic and Reconstructive Surgery and private clinic. Depending on the breasts shape, we have performed the axillar, areolar or inframammary approach. Axillar approach was most commonly used in younger patients with breast hypotrophy without ptosis. Periareolar approach was performed in patients with bigger areolas. In cases where silicone prosthesis were used or if the
areolar diameter was smaller, we have used prosthesis filled with a salinesolution and with a valve. Inframammary approach was employed in patients with slight or moderateptosis in order to keep the surgical incision hidden in the inframammary fold.If the patient asked both for the correction of the prosthesis andaugmentation, we have first performed augmentation which, by itself,partially corrects the ptosis and, after that, we carefully peformed the pexis inthe same act.In slim patients with narrow chest cavity, we have used the anatomical or thetear drop shape with a high profile if the patient wanted bigger breats withemphasized projection.In asymmetry of the breasts we have used impalnts of different size in orderto achieve the symmetry.Results and conclusionIn 101 cases we have achieved very good results. In 2 cases, the patientswere subjectivelt dissatisfied with the size of the breasts, 2 patients were notsatisified with the symmetry achieved and 2 patients were not satisfied withtheir shape.We should try to coordinate patients wishes with objective parameters suchas: the size of the chest cavity, constitution, age, pre-operative size and shapeof the breasts. If the actual circumstances (constitution, age) allow, we souldtry to fullfil patients wishes in total and, at the same time, present our ownaesthetic criteria which may be partially or completely accepted or rejected.Key words: augmentation mammoplasty, patients demands, surgical options
E1. Predetermined «Fleur-de-lys” design for aesthetic abdominoplasty Costagliola M. Polyclinique du Parc, Touluse University, Toulouse, France The authors present a predetermined design of cutaneous resection for abdominoplasty without relocation of the umbilicus and associated liposuction. The design is characterized by two lateral tips, pointing upward, and a central dome, thus resembling a “fleur de lys”. The upper and lower edges of the cutaneous incision are of the same length, which prevents puckers and allows optimal evolution of the scar. The median cutaneous resection removes the horizontal base of the triangular area of pubic hair, producing a lower final scar and giving the mons pubis a more youthfull appearance. The abdominal skin and the oblique scars, placed in the natural folds, are easily concealed even under brief attire. Unlike individual resection techniques which require practice and experience, this technique is perfectly codified and can be carried out by less experience surgeons. The indications of the technique are detailed.E2. Abdominoplasty complications: comprehensiveapproach for the treatment of chronic seroma with pseudobursa Roje Z., Roje Ž., Utrobičić I., Brajčić D. Division of Plasti Surgery and Burns Department of Surgery University Hospital «Split», Split, Croatia Abdominoplasty is a large surgical operation, often followed by a great number of lolcal and general complications. Some studies indicate that the risk of severe complications, including mortality, ranges from 1 in 617 to 1 in 2320 cases. Seroma is a serious consequence that follows each type of abdominal contour surgery, from suction-assisted lipoplasty alone to standard and limited abdominoplasty. A case of a 46 years old women is presented, who was subject to the standard abdominoplasti with liposuction in the same act. In the course of the postoperative follow up examination the forming of seroma and pseudobursa was revealed. The pseudobursa was evacuated multiple times under the ultrasound control. During ona act of seroma evacuation, even 2010 ml of seroma were evacuated. Because of the prolonged forming of seroma, the pseudobursa was growing, what created the effect of a tumor in the front abdominal wall. In the course of the second operation – miniabdominoplasty with neo umbilicoplasty, the peseudobursa was completely excided. And the material was sent to the PH analysis. Space obliterating sutures were set up in more lines to decrease the dead space and to withhold the movement between the abdominal flap and the musculoaponeurotic layer, what is suggested by Saltz and Matarasso. Suction