Search

Objective: To measure velopharyngeal closure with magnetic resonance imaging (MRI) and to evaluate speech when treating velopharyngeal insufficiency (VPI) with autologous fat transplantation to the velopharynx., Patients: Nine patients were recruited. Six patients had undergone cleft palate repair and subsequently developed VPI. Three were noncleft patients of which one had developed VPI after nasopharyngeal cancer treatment; another patient had developed VPI after combined adenotonsillectomy, and a third patient had VPI of unknown etiology., Main Outcome Measure: Preoperative and 1-year postoperative MRIs were obtained during vocal rest and during phonation. Data measured were the velopharyngeal distance in the sagittal plane and the velopharyngeal gap area in the axial plane. Preoperative and 1-year postoperative audio recordings were blinded for scoring independently by three senior speech therapists., Results: When comparing preoperative and 1-year postoperative MRI during phonation we found a significant reduction of the median velopharyngeal distance from 4 to 0 mm (p = .011), and a significant reduction of the median velopharyngeal gap area from 42 to 34 mm(2) (p = .038). Nasal turbulence improved significantly (p = .011). Hypernasality/hyponasality and audible nasal emission did not change significantly., Conclusions: Autologous fat transplantation to the velopharynx resulted in a significant reduction of the velopharyngeal distance and the velopharyngeal gap area during phonation, as measured by MRI. This was in accordance with a significant improvement in nasal turbulence. However, hypernasality and audible nasal emission did not change significantly and could not be correlated to the MRI findings.

Objective: To describe Norwegian individuals born with cleft of the secondary palate (CP) in relation to cleft severity, Pierre Robin sequence, associated anomalies, syndromes, and hypodontia and to present estimated longitudinal prevalences., Patients: Nine hundred ninety-four individuals with CP born between 1960 and 2002 referred to the Oslo Cleft Team (OCT)., Method: Data were collected retrospectively from the archives of the OCT., Results: Among all CP, 7.6% had recognized syndromes, 30.5% had associated anomalies, and in 61.9%, CP was the only malformation. Pierre Robin sequence was recorded in 11.7%. Female predominance was observed both in general and in each cleft severity subgroup. Of 610 individuals with CP, only 25.1% were diagnosed with a submucous cleft palate, 45.9% had a cleft of the soft palate only, and in 29%, the cleft extended into the hard palate. Among 309 individuals over the age of 10 years with CP only, hypodontia was found in 28.5%, and in individuals with Pierre Robin sequence, hypodontia was found in 44.1%. During the period 1965 to 1999, the estimated prevalence of individuals with CP in the OCT uptake area was found to be 0.59 per 1000 live births. The estimated prevalence increased slightly over time, both overall and within the cleft severity subgroups., Conclusion: A large proportion of a Norwegian population with CP had syndrome or additional anomalies. The estimated prevalence of CP in this population increased slightly during the observation period.

Our aim was to identify factors associated with the incidence of pharyngoplasty in patients with clefts of the secondary palate (CP). We studied 351 children born between 1968 and 1999 with CP alone, who had their primary operation at the Department of Plastic Surgery, Rikshospitalet University Hospital, Oslo, Norway. Data were collected retrospectively from the archives of the Oslo Cleft Team. During the study period 1968-2007, 68 children (19%) had a pharyngoplasty to improve their speech. Mean follow up time from the primary operation was 16 years (range 2-37). The estimated incidence of pharyngoplasty at 5, 7, 10, and 15 years after the primary operation was 9%, 12%, 14%, and 15%, respectively. Thirty-one (46%) of the pharyngoplasties were done more than seven years after the primary palatal repair. Children with total clefts of the secondary palate had a pharyngoplasty more often than children with clefts of the soft palate alone (7 years incidence: 11 (42%) compared with 22 (10%), p<0.001). Sex, age at time of primary operation, and surgeon's experience were not significantly associated with the necessity for pharyngoplasty. Our study suggested that the necessity for pharyngoplasty is related to the severity of clefts, and duration of observation.

In a cross-sectional postal survey, we compared patient-reported outcomes in patients undergoing breast reconstruction with the deep inferior epigastric perforator (DIEP) flap or an expandable breast implant (EBI). We included 34 consecutive patients who had breast reconstruction with DIEP flap and 30 patients with EBI. Outcomes were assessed using the Short Form 36 (SF-36) quality of life questionnaire, two study-specific patient satisfaction questionnaires and a visual analogue scale (VAS) on cosmetic result. There were no significant differences in SF-36 subscale scores between the two groups. On the study-specific questionnaire, more patients in the DIEP group were satisfied with the appearance of their breast (P<0.0005) and reported an improved social relationship (P=0.02), and fewer patients were sad about their body image (P=0.01) after reconstruction than in the EBI group. On the other study-specific items, satisfaction was similar in the two groups. On all five VAS items, DIEP patients reported better cosmetic results than EBI patients. We conclude that patient satisfaction and cosmetic outcome were better after breast reconstruction with the DIEP flap compared with EBI, while there was no difference in health-related quality of life.

Objective: To estimate the relative risk of recurrence of oral cleft in first degree relatives in relation to cleft morphology., Design: Population based cohort study., Setting: Data from the medical birth registry of Norway linked with clinical data on virtually all cleft patients treated in Norway over a 35 year period., Participants: 2.1 million children born in Norway between 1967 and 2001, 4138 of whom were treated for an oral cleft., Main Outcome Measure: Relative risk of recurrence of isolated clefts from parent to child and between full siblings, for anatomic subgroups of clefts., Results: Among first degree relatives, the relative risk of recurrence of cleft was 32 (95% confidence interval 24.6 to 40.3) for any cleft lip and 56 (37.2 to 84.8) for cleft palate only (P difference=0.02). The risk of clefts among children of affected mothers and affected fathers was similar. Risks of recurrence were also similar for parent-offspring and sibling-sibling pairs. The "crossover" risk between any cleft lip and cleft palate only was 3.0 (1.3 to 6.7). The severity of the primary case was unrelated to the risk of recurrence., Conclusions: The stronger family recurrence of cleft palate only suggests a larger genetic component for cleft palate only than for any cleft lip. The weaker risk of crossover between the two types of cleft indicates relatively distinct causes. The similarity of mother-offspring, father-offspring, and sibling-sibling risks is consistent with genetic risk that works chiefly through fetal genes. Anatomical severity does not affect the recurrence risk in first degree relatives, which argues against a multifactorial threshold model of causation.

Our aim was to assess whether severity of cleft, age at the time of repair, and the operating surgeon's experience contributed to the development of fistulas in patients with clefts of the secondary palate. We studied 814 children born between 1960 and 1999 with clefts of the secondary palate who had had their primary operation at the Department of Plastic Surgery, Rikshospitalet University Hospital, Oslo, Norway. Data were collected retrospectively from the archives of the Oslo Cleft Team. Palatal fistulas developed in 36 patients (4%), among whom 17 patients required correction (2% of the total). The incidence of fistulas was not related to sex. Patients with clefts of the hard and soft palate developed fistulas more often than patients with clefts of the soft palate only (8% compared with 1%, p<0.001). Patients with submucous cleft palates developed fistulas significantly more often than patients with clefts of the soft palate only (5% compared with 1%, p=0.02). Among patients with clefts of the hard and soft palate, the incidence of fistulas increased significantly with increasing age at the time of palatal closure (p=0.005). The incidence decreased significantly the more experienced the operating surgeon was for treating clefts of the hard and soft palate (p<0.001) but not for submucous clefts. Among patients with clefts of the hard and soft palate who had the palate closed at 14 months of age or later, the incidence of fistulas decreased from 21% when the operating surgeon had little experience to 0 when the surgeon had much experience. The incidence of fistulas was related to severity of cleft, age at palatal closure, and the operating surgeon's experience.

Objective: To explore the role of folic acid supplements, dietary folates, and multivitamins in the prevention of facial clefts., Design: National population based case-control study., Setting: Infants born 1996-2001 in Norway., Participants: 377 infants with cleft lip with or without cleft palate; 196 infants with cleft palate alone; 763 controls., Main Outcome Measures: Association of facial clefts with maternal intake of folic acid supplements, multivitamins, and folates in diet., Results: Folic acid supplementation during early pregnancy (> or =400 microg/day) was associated with a reduced risk of isolated cleft lip with or without cleft palate after adjustment for multivitamins, smoking, and other potential confounding factors (adjusted odds ratio 0.61, 95% confidence interval 0.39 to 0.96). Independent of supplements, diets rich in fruits, vegetables, and other high folate containing foods reduced the risk somewhat (adjusted odds ratio 0.75, 0.50 to 1.11). The lowest risk of cleft lip was among women with folate rich diets who also took folic acid supplements and multivitamins (0.36, 0.17 to 0.77). Folic acid provided no protection against cleft palate alone (1.07, 0.56 to 2.03)., Conclusions: Folic acid supplements during early pregnancy seem to reduce the risk of isolated cleft lip (with or without cleft palate) by about a third. Other vitamins and dietary factors may provide additional benefit.

The prevalence of duplications and deletions of the 22q11.2 (DiGeorge syndrome) region was studied among babies born in Norway with open cleft palate without cleft lip (cleft palate only, CPO). During a 5-year period (1996-2001), there were 245 live births with CPO that were referred for surgery. DNA was available from 174 cases with overt cleft palate. DNA copy number was analyzed with the multiplex ligation-dependent probe amplification (MLPA) technique, and an unambiguous result was obtained in 169 (97%) of the samples. We found no 22q11.2 duplications, and one known, and two previously undiagnosed cases with 22q11.2 deletions. All three del22q11-syndrome cases also had heart malformations, which represent one-third of the 10 babies with heart malformations in our study population. The prevalence of del22q11-syndrome among babies with cleft palate with or without additional malformations was 1 of 57 (1.8%). Because the prevalence of CPO in the 35 22q11.2 duplication cases published was 20%, we also investigated if dup22q11-testing was warranted in this group. However, no 22q11.2 duplications were found, indicating that the duplication cases ascertained so far might not be representative of the dup22q11-group as a whole. We conclude that neither del22q11 nor dup22q11 testing is warranted in babies with overt cleft palate as the only finding., ((c) 2006 Wiley-Liss, Inc)

Background: Epidemiological surveillance and research on birth defects require accurate diagnosis and adequate registration. In this regard, the performance of national birth registries is not well described., Methods: We linked clinical data from all 3,616 cleft cases treated in Norway between 1967 and 1998 with data from the Medical Birth Registry of Norway, and calculated the proportion of clinically verified cases reported to the Registry, stratified by severity., Results: The cleft type most completely ascertained was cleft lip and palate (CLP), of which 94% were reported. Ascertainment was less complete for cleft lip alone (83% recorded), and cleft palate only (CPO) (57% recorded). For each of the three types of clefts, completeness of reporting depended on severity of the cleft. For example, 71% of cases with severe CPO were reported, while only 11% of cases with mild CPO were reported., Conclusions: Ascertainment was strongly related to cleft type and severity. To the degree that severity of birth defects may be related to their cause, these patterns of registration have implications for surveillance of birth defects as well as the conduct of etiologic studies. The large proportion of cleft palate cases unrecorded at birth suggests that clinical examination of the newborn palate is often inadequate.

The epidemiology of cleft palate with multiple defects is often thought to be different from that of cleft palate alone, but there are few empirical data on this question. We explored this in a population-based data set created by combining data from two sources: the 1.8 million live births recorded from 1967 to 1998 in the Norwegian Birth Registry, and the two Norwegian surgical centers that repair cleft palate. Accompanying defects were identified from either source. Stratified analysis and logistic regression were used to assess relative risks by covariates. Of 1,431 babies with cleft palate, 31 % had another birth defect recorded by one or both sources. Prevalence of isolated cleft palate was steady over time, while cleft palate with other defects increased substantially. Girls had a higher risk of isolated cleft palate (relative risk 1.4; 95% confidence interval, 1.2-1.6) but not of cleft palate accompanied by other defects (1.1; 0.88-1.3). Older parents and parents who were first cousins had no increased risk of isolated cleft palate, but were twice as likely as others to have a baby with cleft palate accompanied by other defects. Risk factors differ between cases of cleft palate with and without accompanying defects.

Objective: The aim of this trial was to compare the relative effectiveness (efficacy and morbidity) of two surgical procedures for correcting velopharyngeal insufficiency (VPI)., Design: This was an international multicenter randomized trial to study the outcome of two surgical procedures (flap and sphincter pharyngoplasty) for speech, incidence of sleep apnea, and surgical complications., Method: Ninety-seven patients 3 to 25 years old with repaired cleft palate and previously identified VPI were enrolled from five centers in the United States, Norway, and the U.K. Data were collected at presurgery, 3 months postsurgery, and 12 months postsurgery for subsequent analysis blind to the procedure. Main outcome measures included perceptual speech parameters, sleep apnea, nasalance measures, endoscopic features, and surgical complications., Results: Groups for both surgical procedures achieved a high level of clinical improvement. At 3 months postsurgery, elimination of hypernasal resonance was achieved in twice as many patients after the flap procedure. This reached significance. However, at 12 months postsurgery, no statistically significant difference in outcomes remained between the two procedures for resonance, nasalance, endoscopic outcomes, or surgical complications. Flap and sphincter pharyngoplasty rarely resulted in clinically significant sleep apnea, and no difference was detected between the two procedures in the long-term incidence of sleep apnea., Conclusions: Despite strongly held views in the literature concerning the relative effectiveness and safety of flap and sphincter pharyngoplasty, no significant differences were detected 1 year postoperatively.

Cleft lip defects are usually regarded as a single entity, with the assumption that an accompanying cleft palate represents the more severe form. The authors linked data from the Medical Birth Registry of Norway with medical records from two centralized centers to provide a population-based data set. They assessed the distribution of cleft lip only and cleft lip with cleft palate by covariate. Among 1.8 million Norwegian livebirths between 1967 and 1998, there were 1,572 cases of cleft lip with cleft palate and 1,122 cases with cleft lip only. Seventeen percent of those with cleft lip and palate had another defect compared with 9% of those with cleft lip only. For boys, the risk was greater for cleft lip and palate than for cleft lip only (odds ratio=2.4 vs. 1.8, p<0.001 for difference). The risk of cleft lip only, but not of cleft lip and palate, was increased for twins (odds ratio=1.6 vs. 1.1, p=0.11) and infants whose parents were first cousins (odds ratio=2.7 vs. 0.7, p=0.07). Although cleft lip with cleft palate may simply represent a more severe form of the defect, epidemiologic assessments of cleft lip should, when possible, include separate analyses of these two groups.

The aim of this study was to estimate the clinical condition and amount of remaining grafted bone 20 years after final repair of unilateral cleft lip and palate. Eighteen consecutive patients had computed tomograms (CT) and clinical examination 20 years or more after secondary bone grafting which had been done at ages of 7-11 years. The images were obtained with a spiral CT with 1 mm collimation, and reconstructed as three-dimensional volumes with reformatted cut planes. The area of grafted bone was measured in a plane perpendicular to the curved axis of the alveolar arch and compared with the area corresponding section through the non-cleft side. The clinical examination showed satisfactory results in all. CT indicated a mean cross sectional area of 97 mm2 on the cleft side compared with 157 mm2 on the non-cleft side. The bone mass was significantly less on the grafted cleft side (p < 0.001), but the functional results were satisfactory.

We selected 262 case-parent triads from a population-based study of orofacial clefts in Norway, and examined variants of developmental genes TGFA, TGFB3, and MSX1 in the etiology of orofacial clefts. One hundred seventy-four triads of cleft lip cases (CL+/-P) and 88 triads of cleft palate only cases (CPO) were analyzed. There was little evidence for an association of any of these genes with CL+/-P. The strongest association was a 1.7-fold risk with two copies of the TGFB3-CA variant (95% CI=0.9-3.0). Among CPO cases, there was a 3-fold risk with two copies of the TGFA TaqI A2 allele, and no increase with one copy. Assuming this to be a recessive effect, we estimated a 3.2-fold risk among babies homozygous for the variant (95% CI=1.1-9.2). Furthermore, there was strong evidence of gene-gene interaction. While there was only a weak association of the MSX1-CA variant with CPO, the risk was 9.7-fold (95% CI=2.9-32) among children homozygous for both the MSX1-CA A4 allele and the TGFA A2 allele. No association of CPO with the TGFA variant was seen among the other MSX1-CA genotypes. In conclusion, no strong associations were found between CL+/-P and variants at these three genes. There was a possible recessive effect of the TGFA TaqI variant on the risk of CPO, with a 3-fold risk among children homozygous for the variant. The effect of this TGFA genotype was even stronger among children homozygous for the MSX1-CA A4 allele, raising the possibility of interaction between these two genes., (Copyright 2003 Wiley-Liss, Inc.)

The authors discuss the dilemmas associated with diagnosis and treatment of haemangiomas and vascular malformations. The complexity of these conditions too often sends the patients wandering from one specialist to another in search of an optimal therapeutic approach. We have established a multidisciplinary team to facilitate interspecialty communication on diagnosis, natural history, and therapy.

During two separate periods a total of 654 patients were included in a clinical study relating preoperative bacterial colonization to occurrence of postoperative wound infection in plastic surgery. During the second period one half of the patients were randomized to receive prophylactic azithromycin. Bacteriological samples were collected from the nasal vestibulum during both periods, and additionally from the surgical field during the second period. All patients had preoperative chlorhexidine bathing. The bacteriological findings were categorized as either normal flora or potentially pathogenic bacteria, and as either having no growth. Surgical wounds were divided into four contamination classes. Postoperative follow-up was 30 days, and assessment of wound infection was based on a graded scale. We did not find any statistically significant relation between preoperative bacterial colonization and postoperative wound infection, regardless of place of sample collection, method of bacterial classification, class of contamination or use of prophylactic azithromycin.

Over a 9-month period from September of 1991 to May of 1992, 339 patients were included in a randomized, double-blind, placebo-controlled study using azithromycin as the prophylactic agent to determine whether it effects a clinically meaningful reduction in postoperative surgical infections in plastic surgery. Azithromycin was given as prophylaxis in 171 patients and placebo in 168 patients. The study medication was a single oral dose taken at 8 P.M. the day before surgery. The patients were followed up for a minimum of 4 weeks after surgery. The patients who received wound infection prophylaxis had 5.1 percent infections compared with 20.5 percent in the placebo group (p = 0.00009). Eighty percent of all wound infections were first seen after discharge, explaining why plastic surgeons might overlook their infectious complications. There was a significant reduction in postoperative complications (p = 0.04) and in the additional use of antibiotics postoperatively (p = 0.007) in the prophylaxis group. Subgroup analysis showed a significant reduction in surgical infections in breast surgery (p < 0.05) and reconstructive surgery with flaps (p < 0.05). No effect of the prophylactic regime was demonstrated in patients undergoing secondary surgery for cleft lip and palate disease.

In a postoperative wound infection study in plastic surgery, 315 patients were randomized to either outpatient wound control after 30 days (group I) or self-control by questionnaire (group II). We present a new definition of wound infection based on physiologic wound healing. The surveillance of postoperative wound infection showed follow-up rates of 95 and 68 percent and infection rates of 16.3 and 17.1 percent for groups I and II, respectively. Of the 43 patients (16.7 percent) with postoperative wound infections, 31 (72 percent) were diagnosed after leaving the hospital, and only 12 (28 percent) were diagnosed during hospital stay. The monthly wound infection rate declined from 23.5 percent when the registration started to 12.2 percent at the end of the surveillance. The wound infection rate nearly tripled when duration of surgery was more than 120 minutes compared with less than 60 minutes. Postoperative wound infection was significantly related to preoperative contamination class, with an increase from 10.2 percent wound infections in class "clean" to 37.5 percent in class "dirty." We conclude that postoperative wound infection also crops up in the plastic surgical department, and this situation has not, to date, been documented sufficiently. A simple questionnaire gives a useful survey of postoperative wound infections. An active follow-up for at least 30 days is essential to register the rate of surgical infections.

Several methods have been described for anesthetic correction of Romberg's disease. We have used the platysma muscle flap as the only procedure in four cases of severe to moderate disease. The platysma flap was transected at the clavicular level, turned at the mandibular margin, and spread subcutaneously on the affected side from the nasolabial fold up to the orbital margin and laterally to the anterior part of the ear. The flap masked the atrophy relatively well, and no complications were seen during or after the procedure. The procedure can be combined with orthognathic surgery if required.

During a five year period, 71 patients (age range 24-72 years) underwent syringe-assisted liposuction of the neck as the only operation for facial rejuvenation. The patients were seen after one week and three months, and 66 patients were re-examined 5-58 months (mean 31) postoperatively. There were no complications except for slight skin laxity (n = 10), transient hypoaesthesia, and temporary subcutaneous scarring (nodules). In some patients improvement occurred more than 12 months post-operatively. The patients evaluated the result according to a four grade scale; very satisfied (n = 41), satisfied (n = 21), less satisfied (n = 4), and dissatisfied (n = 1). All patients except one would recommend the procedure to other patients with similar problems. We conclude that syringe-assisted liposuction of the neck is a simple, safe, and rewarding procedure even in many elderly patients.

Excision of tumours in the face is a surgical challenge. Most general practitioners and surgeons are reluctant to undertake such procedures. In our opinion there are no reason why small tumours and lesions in the face, which can be excised by a fusiform excision, should not be handled by most doctors. The aim of this article is to remind doctors of well known general principles, so as to obtain a cosmetically good result after surgery.

Since liposuction became part of our surgical regimen in 1988, we have operated on 67 patients for gynaecomastia during the five year period 1988-1992. Sixty two of the patients were seen at an extra follow up 4-59 months (means 29 months) postoperatively. Compared to studies that did not include liposuction as part of the operation, we found a lower incidence of postoperative complications and a higher degree of patient satisfaction. Preoperative distinction between adipose and glandular tissue is difficult, and we therefore consider that liposuction should be used during the first part of the operation in nearly all cases of gynaecomastia. Regardless the amount of fat, tunnelling and suction are beneficial, because they help to refine the peripheral contour and define the glandular tissue. Liposuction seems to help the skin to contract, and skin resections are rarely indicated.

Neurocutaneous melanosis is a rare congenital syndrome characterised by large or numerous congenital pigmented naevi and excessive proliferation of melanin-containing cells in the leptomeninges. The process is diffuse or multifocal, and has a tendency to infiltrate the neural tissue and the cerebrospinal cord; remote metastases may occur. There is usually histological evidence of malignancy (cellular pleomorphism and mitotic activity). Involvement of the basal cisterns is apt to cause internal hydrocephalus, and the prognosis is grave even when there is no histological evidence of malignancy. We present the case history and necropsy findings of a baby boy with neurocutaneous melanosis, followed by a brief review.

To minimize the significant risk of early malignancy, and to obtain acceptable cosmetic results we have treated five infants with large congenital naevi by full-thickness resection of the thickest part and superficial excision of the remaining parts of the naevus. The treatment was followed by rapid healing with little pigmented skin and minimal scarring. One patient treated at the age of six years showed a less favourable cosmetic result. Our experience confirms that the major part of the potentially malignant tissue can be removed and a greatly improved appearance achieved by early surgery. Additional surgery is usually necessary and should be completed before school age to prevent permanent psychological and social effects. Large congenital naevi are rare and difficult to treat. Their treatment should be centralised to regional hospitals that serve large populations.

Sixty patients with unilateral cleft lip and palate were compared for lip and nose appearance. All patients were photographed from an anteroposterior and a basal view at 7-10 years of age. The photographic registration method was tested for validity and accuracy. Although the four groups of 15 patients each were treated according to different protocols, many similarities were found with shorter lip heights at the cleft side and inclination of the rima oris. Asymmetry of nose and retropositioning at the cleft side naris were generally seen. Significantly straighter noses were demonstrated in the group treated with a two-stage lip nose operation combined with nose plugs, and the two groups where vomer flaps were used showed the greatest deviation of the nose.

Since 1964 silicone breast prostheses have been implanted in 5 million women for breast reconstruction after cancer operations, to correct congenital deformities and for cosmetic reasons. There is no evidence in the literature of a correlation between silicone implants and breast cancer. Some authors claim that silicone implants reduce the reliability of mammography. Autoimmune diseases in patients with silicone mammary implants are reported in less than 40 cases. Most of these are localized or systemic scleroderma. An association with silicone implants has been suggested, but this suggestion has not been confirmed by scientific data.

Between January 1984 and November 1990 a total of 292 patients underwent reduction mammaplasty for hypertrophic breasts. Of these patients, 233 had a superomedial pedicle (Orlando's method) and 36 an inferior pedicle (Robbins' method). 23 had various other operations. The patients operated on by Orlando's and Robbins' method were compared retrospectively. It was found that Robbins' method was superior in younger women, owing to increased sensitivity of the nipple-areola complex, and lactation. In the physicians' opinion, wide scars developed in 32% of the patients. In our opinion closing the wound with intracutaneous suture might improve the quality of the scar. Of the patients assessed, 98% were satisfied with the physical outcome of the operation and 86% with the cosmetic outcome. The operative technique of the two methods is described.

Large congenital nevi present a difficult therapeutic problem, since the surgeon must seek to achieve two objectives: To minimize the risk of malignancy; To obtain an acceptable cosmetic result. The first objective calls for early and radical excision of all pigmented areas; this may be impossible because of the operative risk, and the risk of leaving the patient with a deformity or disfiguring scars. The cosmetic indication may justify less aggressive surgery. Relatively new experience indicates that removal of the superficial layers of the nevus shortly after birth is followed by healing with non-pigmented or much less pigmented skin. By combining the removal of the superficial layers of skin with full-thickness resections and reconstructive plastic surgery, it is possible in most cases to achieve a favourable cosmetic result and, at the same time, reduce risk of early malignancy. Wherever possible, the surgical treatment should be completed before the age of five or six years in order to prevent long-lasting psychologic and social effects of the nevus deformity.

Between January 1984 and November 1990 a total of 292 patients underwent reduction mammaplasty for hypertrophic breasts. Of these 233 had a superomedial pedicle (Orlando's method) and 36 an inferior pedicle (Robbins' method). Twenty-three had various other operations. Those operated on by Orlando's and Robbins' methods were compared retrospectively, and it was found that Robbins' method was superior in younger women because of increased sensitivity, particularly of the nipple-areola complex, and better lactation. In the physician's opinion ugly scars developed in 32% of the patients (n = 287). In our opinion wound closure with a subcuticular suture might improve the quality of the scar. Of the 287 patients assessed, 281 (98%) were satisfied with the physical, and 248 (86%) with the cosmetic, outcome of the operation.

A retrospective study was made of 87 patients operated on between 1984 and 1990 for asymmetrical breasts. Thirty-two patients had 36 implants (13 also had breast reduction or mastopexy of the contralateral breast). Capsular contraction, Baker grade II-IV, was found in a third of the implants. The remaining 54 patients underwent reduction mammaplasty or mastopexy alone. 90% of the patients were satisfied with the result. There was no significant difference in the overall satisfaction between the patients who did or did not have implants. We nevertheless think that mammary implants should be avoided whenever possible in the correction of breast asymmetry. Even though there is no difference in patients' satisfaction, it is our experience that those with implants have more frequent follow-up consultations and are subject to more postoperative procedures than those corrected without implants.

Craniofacial morphology and dental occlusion were studied at early school age in 15 consecutive patients with unilateral cleft lip and palate from each of four Scandinavian cleft centres. Treatment differed mainly in the techniques of palatal repair. Push-back closure of the palate particularly impaired maxillary development, which resulted in an increased incidence of crossbite and reduced intercanine distance when compared with patients who had been operated on by the von Langenbeck method or in whom the anterior palate had not yet been closed.

A case is reported in which a fat deposit in a patient who had had a continent urostomy fashioned by Kock's technique, caused skin problems and made catheterisation Kock's technique, caused skin problems and made catheterisation difficult. The condition was successfully treated with liposuction around the stoma.

Since its introduction in 1975 liposuction has become an increasingly popular technique and, in the United States today, is the most commonly performed procedure in cosmetic surgery. However, this technique is also useful in the treatment of a number of other conditions such as gynecomastia and lipomas/lipomatosis, and as an adjuvant procedure to surgical procedures such as reduction mammoplasty, abdominoplasty, and defattening of flaps. The article describes the technique and its indications and possible complications.

The accuracy and sensitivity of radiographic assessments of reactive processes in dental tissues were evaluated by comparison of radiographs and histologic sections. Experimental lesions inflicted on the roots of 10 monkey incisors had been observed by means of serially obtained radiographs over a period of 315 to 370 days. The material was used for evaluation of radiographic assessment of ankylosis. For comparative purposes, assessment of the experimental lesion penetrating to the pulp and periapical radiolucency was added. True and falsely positive or negative recordings formed the basis for calculation of the accuracy and sensitivity of the radiographic assessment. The sensitivity, or the observers' ability to detect the actual changes, was high for pulp penetration, intermediate for inflammation, and low for ankylosis.

Differences in effects on central haemodynamics, organ blood flow, and serum corticosterone were studied in 11 rats anaesthetized with midazolam/fentanyl/fluanisone (MFF) and 11 other rats anaesthetized with sodium pentobarbital. Compared with pentobarbital, MFF reduced aortic blood pressure by 25%, increased heart rate by 20%, and increased cardiac output by 80%. Unlike most tissues, MFF produced a fivefold increase in blood flow to skeletal muscle, and decreased adrenal blood flow compared to pentobarbital anaesthesia. Initial serum corticosterone levels were lower in rats given MFF anaesthesia, indicating better stress protection. This study also indicates that MFF anaesthesia is preferable to pentobarbital because tissue perfusion generally was better preserved.

Early changes in the morphology of the gastric mucosa after the skin had been burned were studied using a standardised model in rats. A full thickness burn was inflicted by exposing about 20% of the total body surface area to hot water (99 degrees C) for 10 s. Intragastric acidity was kept at pH 1.0 or pH 7.4 in six experimental groups of eight rats. Rats were subjected to burns with the stomach irrigated at pH 1.0 or pH 7.4. Parallel groups received fluid replacement with a solution of human albumin, and two uninjured groups served as controls. Lesions of the gastric mucosa were measured by planimetry of photographs, and light microscopy was used for histological examination. At an intragastric pH of 1.0, the burned rats developed mucosal erosions covering an average of 13% of the total glandular mucosa; the remaining groups had only minimal mucosal lesions. Erosions of the gastric mucosa after the skin had been burned could be prevented in two ways--either by establishing an alkaline (pH 7.4) milieu in the gastric lumen, or by replacing sufficient fluid to maintain aortic blood pressure at the pre-experiment level. Fluid replacement prevented mucosal erosions even if the intragastric pH was kept at 1.0. Thus both luminal acidity and local tissue blood flow are possible mechanisms for gastric epithelial damage following burns of the skin.

A report is given of 47 patients with submucous cleft palate operated on during the period 1965 to 1974. The average age of the patients when referred for surgery was high (10.8 years). Eleven patients, or nearly one out of four, had tonsillectomy and/or adenoidectomy performed before the correct diagnosis was made. Sixteen of the patients had a history of recurrent middle ear disease, and 18 patients had another congenital anomaly, the most frequent one being a cleft of the primary palate. Nineteen patients were operated upon with a von Langenbeck palatorraphy, and 28 with a von Langenbeck procedure + a superiorly based pharyngeal flap. Three of the patients were operated on twice. The result with regard to velopharyngeal function was recorded as good in 34 cases, fair in 10, and poor in 3 cases. The results were better in patients operated upon under the age of 7 years. The operative procedures now recommended are: A von Langenbeck (or push-back) closure of the palate combined with a levator sling reconstruction and a superiorly based pharyngeal flap. The possibility for an optimal result is best when the operation is performed at an early age, i.e. as soon as a diagnosis of SMCP and velopharyngeal incompetence has been made. For this reason it is important that better information about the symptoms and signs of SMCP is given to doctors, dentists and speech therapists, who refer these patients to the cleft palate clinic.

A total of 14 teeth were transplanted to simulated alveolar clefts in 5 monkeys. Autogenous cancellous bone was grafted to the cleft together with the tooth in ten instances. Healing processes were observed 216 or 271 days postoperatively. Another group of four teeth were transplanted in the cleft areas 133 days after bone grafting. These teeth were observed for 138 days before sacrifice. Radiological and histological findings support previous reports on adverse effects to dental tissues when placed in direct contact with fresh transplanted bone. Root resorption and ankylosis occurred to a large extent. Establishment of a normal periodontal membrane could, however, be observed when the tooth was transplanted to an area grafted 4 months previously. An interval before tooth transplantation allowing the cancellous graft to organize and bone to remodel seems to be indicated.

Trophic ulceration of the nose is a rare complication occurring in patients with trigeminal anaesthesia. The etiology is not clear, but self-inflicted injuries to an anaesthetic region are considered to play an important part. The authors' experience with three cases indicates that substitution with skin from the affected area of the face will not give a lasting result. It seems probable that only skin with an intact nerve supply can provide a permanent replacement for skin lost in the dystrophic process. This means that a local flap innervated from a non-affected part of the face would offer the best possibility of a permanent cover for these defects.

About 800 patients are admitted annually to Norwegian hospitals for burn injuries. Among these, about 5% (40) patients have extensive burns, and 80-110 have special burns (skinburns combined with inhalation injuries, burns of the hands and burns of the face). The National Burn Center at Haukeland Hospital was opened in October 1984. In our experience decreased mortality, reduced disability and quicker rehabilitation are achieved when extensive and special burns are treated in specialized burn units.

Patients with spontaneous pneumothorax, who were treated in this department during the period 1950-59, were reviewed in 1963. Since the treatment of this group of patients has changed radically towards a greater surgical activity in the form of suction drainage and thoracotomy, the patients from the next decade, comprising 229 episodes in 202 patients, have now been reviewed to evaluate the results of this attitude. The conclusion from the earlier review, that recidivating pneumothorax should be operated upon, is further supported, and in quite a few patients (9%) thoracotomy had to be performed to control the first attack. Pleural rubbing, as an additional procedure to resection of bullae, seems as safe as partial pleurectomy in prevention of relapse. There were few serious operative complications. A rather protracted suction drainage has been practised in this series. One consequence of the experiences from the present review is that this time has been shortened.

A combined surgical/orthodontic procedure to eliminate the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment is described. The operations have been carried out on 378 patients: 240 males and 138 females. Seventy-two patients had bilateral clefts, making a total of 450 grafted clefts. The optimal age for this secondary bone grafting has been found to be 9 to 11 years. In 292 of the cases, the canine had reached its final position in the arch, which allowed a four-group semiquantitative assessment of the newly obtained interdental septum on dental radiographs. The best results have been achieved in cases where the bone graft was carried out prior to the eruption of the canine. In this group, a normal (category I) interdental septal height was achieved in 64 percent and a slightly lower (category II) interdental septum in 32 percent. Interdental septa classified as type I and II are considered to be acceptable. The cleft space was closed in 90 percent of the cases. No significant difference between unilateral and bilateral cases was found. When the same procedure was carried out after eruption of the canine, the results were less favorable.