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Excess skin after weight loss is perceived as a major problem for the majority of the bariatric patients, between 68 and 90% desire additional reconstructive surgery. However, only about 20% of the patients actually have the possibility to undergo these procedures. Reliable and valid patient-reported outcome instruments, PROM, are required in order to consider the patients' perspective of excess skin when discussing reconstructive surgery. The aim of this study was to present the updated version of Sahlgrenska Excess Skin Questionnaire, SESQ and to report on the validation process. The material for the process to evaluate internal consistency and known group validity was based on four different studies conducted at the Department of Plastic Surgery at Sahlgrenska University Hospital, Sweden. Internal consistency was high in all four groups examined; the normal population, the obese patients, the post-bariatric patients and the post-abdominoplasty patients. Values for Cronbach's alpha were0.86 in all groups, and the highest value was seen in the obese patients (0.92). Furthermore, regarding known group validity, there were strong significant differences between the answers from the normal population in comparison with most of the other studies. In conclusion, patients thought that the questions in SESQ were easy to understand, that they covered all appropriate aspects of excess skin and the patients did not think that SESQ overlooked any questions or aspects concerning excess skin. SESQ is a valid questionnaire addressing excess skin in post-bariatric patients. The updated version of the SESQ is both accurate and user-friendly.

The majority of post-bariatric patients suffer from excess skin after weight loss, impairing physical, psychosocial and mental health. The abdomen is the most common location for excess skin, and abdominoplasty is the most commonly required reconstructive procedure. Abdominoplasty removes excess abdominal skin and attenuates related symptoms, but knowledge regarding mental health-related effects is scarce. Here, we aimed to evaluate the symptoms and severity of depression before and after abdominoplasty in post-bariatric patients and to analyse the relationships between depressive symptoms, quality of life (QoL) and experience of excess skin. We enrolled 110 former obese patients undergoing abdominoplasty. Three questionnaires evaluating the symptoms of depression (Beck Depression Inventory (BDI-II)), experience of excess skin (Sahlgrenska Excess Skin Questionnaire (SESQ)) and QoL (36-item Short-Form Health Survey (SF-36)) were completed preoperatively and 1 year postoperatively. After abdominoplasty, symptoms of depression (BDI sum score) significantly decreased (5.8 vs. 3.0

Abstract Background Bariatric surgery is an effective weight loss method for patients with obesity. One side effect of bariatric surgery is uncomfortable excess skin. Much remains to be learned about physical measurements and patients’ subjective perceptions of it. Here, we investigated the pre- to post-bariatric changes in patients’ perception and physical measurements of the skin on the arms and thighs, in order to find possible subgroups especially affected by post-operative excess skin and to identify predicting factors. Methods One hundred forty-seven patients eligible for bariatric surgery completed the Sahlgrenska Excess Skin Questionnaire (SESQ) and underwent measurements of their skin before and 18 months after the procedure. Results Although most physical measurements decreased post-operatively, many patients reported increased discomfort. We identified one subgroup particularly prone to report excess skin on the arms post-operatively: women with high discomfort from excess skin on the arms and high body mass index (BMI), pre-operatively. Ptosis of the excess skin seems to be a feasible measurement for predicting post-operative discomfort. For every centimetre of ptosis pre-operatively, patients had 1.37- and 1.31-fold higher odds of achieving a score for post-operative discomfort from excess skin on the upper arms and thighs, respectively, of ≥ 6 (on a 0–10 scale). Conclusions We identified a subgroup especially affected by discomforting excess skin on arms and thighs after weight loss. Furthermore, we suggest a pre-operative pro-operative ptosis measuring to predict post-operative discomfort level. The result of this study further increases the knowledge of excess skin and should be useful in further improving patient education. Level of Evidence: Level III, risk / prognostic study.

BODY-Q is self-administered questionnaire that evaluates appearance, function and symptoms related to bariatric- and body contouring surgery. The purpose of this article was to describe the translation process of a Swedish version of BODY-Q and to evaluate its criterion validity to the Swedish questionnaire Sahlgrenska Excess Skin Questionnaire, SESQ. Materials and methods BODY-Q was translated according to International Society for Pharmacoeconomics and Outcome Research's guidelines. The test of validity was made between parts which were comparable to SESQ. Both questionnaires were responded by 30 subjects who were suffering from excess skin after massive weight loss following bariatric surgery or dieting. Results The correlation between the two questionnaires varied. The parts of BODY-Q evaluating excess skin on the whole body and parts of the body had higher correlations (rs 0.328-0.766) than the parts evaluating side effects of excess skin and body-image (rs 0.103-0.574). Conclusion The Swedish version of BODY-Q has a good criterion validity and can be recommended in the healthcare for patients with excess skin after massive weight loss and for evaluation of the outcomes from reconstructive surgical procedures.

Specialty training in plastic, reconstructive and aesthetic surgery is a prerequisite for safe and effective provision of care. The aim of this study was to assess and portray similarities and differences in the continuing education and specialization in plastic surgery in Europe.A detailed questionnaire was designed and distributed utilizing an online survey administration software. Questions addressed core items regarding continuing education and specialization in plastic surgery in Europe. Participants were addressed directly via the European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS). All participants had detailed knowledge of the organization and management of plastic surgical training in their respective country.The survey was completed by 29 participants from 23 European countries. During specialization, plastic surgeons in Europe are trained in advanced tissue transfer and repair and aesthetic principles in all parts of the human body and within several subspecialties. Moreover, rotations in intensive as well as emergency care are compulsory in most European countries. Board certification is only provided for surgeons who have had multiple years of training regulated by a national board, who provide evidence of individually performed operative procedures in several anatomical regions and subspecialties, and who pass a final oral and/or written examination.Board certified plastic surgeons meet the highest degree of qualification, are trained in all parts of the body and in the management of complications. The standard of continuing education and qualification of European plastic surgeons is high, providing an excellent level of plastic surgical care throughout Europe.Die Facharzt-Weiterbildung für Plastische und Ästhetische Chirurgie ist eine Grundvoraussetzung für sichere und effektive Patientenversorgung. Ziel der vorliegenden Studie war die Darstellung von Gemeinsamkeiten und Unterschieden in der Weiterbildung für Plastische Chirurgie innerhalb von Europa.Ein internetbasierter Fragebogen wurde mit Hilfe eines kostenlosen Formularerstellungstools erstellt und verteilt. Die Fragen betrafen Kernpunkte der Weiterbildung für Plastische Chirurgie in Europa. Die Teilnehmer wurden direkt über das European Leadership Forum (ELF) der European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) kontaktiert. Alle Teilnehmer hatten weitreichende Kenntnisse über die Organisation und Struktur der plastisch-chirurgischen Weiterbildung in ihrem jeweiligen Land.29 Teilnehmer*innen aus 23 europäischen Ländern nahmen an der Umfrage teil. Die Weiterbildung für Plastische Chirurgie beinhaltet grundlegende Prinzipien und Techniken zur Wiederherstellung von Form und Funktion innerhalb der verschiedenen Säulen der Plastischen Chirurgie, sowie in allen Körperregionen. In den meisten europäischen Ländern ist eine Rotation in der Intensiv- und Notfallmedizin und die Behandlung kritisch kranker Patienten obligatorisch. Voraussetzung für die Facharztbezeichnung ist die mehrjährige, national organisierte Weiterbildung, der Nachweis einer festgelegten Anzahl selbstständig durchgeführter Operationen, sowie die mündliche und/oder schriftliche Abschlussprüfung.Fachärzte für Plastische und Ästhetische Chirurgie sind hochqualifiziert und auch im Umgang mit Komplikationen geschult. Der Standard der Weiterbildung der europäischen Plastischen Chirurgen ist hoch, so dass innerhalb Europas eine hohe Qualität plastisch-chirurgischer Versorgung gewährleistet ist.

Health-related quality of life (HRQoL) is one of the core outcomes for breast reconstruction. The aim of this study was to evaluate whether the method of delayed breast reconstruction affects long-term HRQoL.Participants were divided into 2 arms depending on previous radiotherapy, and subsequently randomized between 2 methods of breast reconstruction: a latissimus dorsi flap or a deep inferior epigastric artery perforator flap in the radiated arm and a thoracodorsal flap and implant or an expander in the non-radiated arm. Validated HRQoL instruments were used: BREAST-Q to evaluate breast specific HRQoL and satisfaction, RAND-36 and EQ-5D to evaluate generic HRQoL, and BDI-21 to measure symptoms of depression and anxiety.During the recruitment period (2009-2015), 233 patients were randomized. After opt-outs and exclusions, the remaining 107 participants comprise the study sample. Postoperative HrQoL was measured on average 7to 8years post-operatively. Response rates varied between 60 and 82 per cent. The BREAST-Q scores were higher after the reconstruction than before for the great majority of domains in both arms; albeit statistically significant only between the 2 methods for physical well-being chest in the radiated arm. Most participants in both arms had minimal or mild depression both before and after the operation.No distinct differences in long-term HrQoL could be seen for different methods There was a clear improvement in HrQoL compared to pre-reconstruction in all groups, but the effect of specific reconstructive methods on scores could not be reliably demonstrated.

Background Even though meshes and matrices are widely used in breast reconstruction, there is little high‐quality scientific evidence for their risks and benefits. The aim of this study was to compare first‐year surgical complication rates in implant‐based immediate breast reconstruction with a biological mesh with that of a synthetic mesh, in the same patient. Methods This study is a clinical, randomized, prospective trial. Patients operated on with bilateral mastectomy and immediate breast reconstruction were randomized to biological mesh on one side and synthetic mesh on the other side. Results A total of 48 breasts were randomized. As the synthetically and the biologically reconstructed breasts that were compared belonged to the same woman, systemic factors were exactly the same in the two groups. The most common complication was seroma formation with a frequency of 38% in the biological group and 3.8% in the synthetical group (p = .011). A higher frequency of total implant loss could be seen in the biologic mesh group (8.5% vs. 2%), albeit not statistically significant (p = .083). Conclusions In the same patient, a synthetic mesh seems to yield a lower risk for serious complications, such as implant loss, than a biological mesh.

The present article provides an overview of the current and expected effects of plastic surgery in Europe. It presents the experience of departments for plastic and reconstructive surgery, as evaluated by interviews with members of the Executive Committee (ExCo) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS). The objective of this overview is to summmarise current information in our area of work and to make this accessible to a broad group of readers. As our knowledge is rapidly increasing during the current pandemic, it is evident that we can only provide a snapshot and this will inevitably be incomplete.Der vorliegende Beitrag bietet einen Überblick über die aktuellen und bevorstehenden Auswirkungen von COVID-19 auf die Plastische Chirurgie in Europa und enthält die Erfahrungen der Abteilungen für Plastische Chirurgie, die durch Interviews von Mitgliedern des Exekutivkomitees (ExCo) der European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) bewertet wurde. Ziel ist es, aktuelle Informationen in unserem Bereich zusammenzufassen und einer breiteren Leserschaft zugänglich zu machen. Insbesondere bei der raschen Entwicklung des Wissens in der aktuellen Pandemie kann natürlich nur eine Momentaufnahme angeboten werden, und es kann kein Anspruch auf Vollständigkeit erhoben werden.

Objectives Meshes/matrices are commonly used in immediate breast reconstruction. There are few studies comparing biological and synthetic meshes and it is unknown what type of mesh gives the best long-term results. The aim of this study was to compare long-term health-related quality of life (HrQoL) and patient satisfaction in implant-based immediate breast reconstruction with a biological mesh (Surgisis®) with that of patients reconstructed with a synthetic mesh (TIGR ® Matrix Surgical Mesh). Material and methods Both cohorts were prospectively included and consecutively operated. Clinical data was collected. HrQoL was evaluated with EuroQoL-5 dimension – 3 levels questionnaire (EQ-5D-3L) and the Hospital Anxiety and Depression Scale (HADS) and the Breast-Q. Results and conclusion Seventy-one patients were operated on in the biological group and 49 in the synthetic group. The response rates were 75 and 84 per cent, respectively. Mean follow-up time was 74 months and 23 months, respectively. There were no statistical differences in satisfaction and quality of life between the two groups. Complications and radiation seem to lead to a lower satisfaction. Our findings could indicate that biological and synthetic meshes give an equal long-term result as regards patients’ perceived quality of life.

Objective: To compare in-depth speech results in Scandcleft Trial 1 as well as reference data from peers without cleft palate (CP). Design: A prospective randomized clinical trial. Setting: A Danish and a Swedish CP center. Participants: 143 of 148 randomized 5-year-olds with unilateral cleft lip and palate. All received lip and velum closure at 4 months, and hard palate closure at 12 months (arm A) or 36 months (arm B). Main Outcome Measures: A composite measure based on velopharyngeal competence (VPC) or velopharyngeal incompetence (VPI), an overall assessment of VPC from connected speech (VPC-Rate), Percentage of Consonants Correct (PCC-score), and consonant errors. Speech therapy visits, average hearing thresholds, and secondary pharyngeal surgeries documented burden of treatment. Results: Across the trial, 61.5% demonstrated VPC and 38.5% VPI. Twenty-two percent of participants achieved age appropriate PCC-scores. There were no statistically significant differences between arms or centers for these measures. In the Danish center, arm B: achieved lower PCC-scores ( P = .01); obtained PCC-scores without s-errors below 79% ( P = .002); produced ≥3 active oral cleft speech characteristics ( P = .004) than arm A. In both centers, arm B attended more speech visits. Conclusions: At age 5, differences between centers and treatment arms were not statistically significant for VPC/VPI, but consonant proficiency differed between treatment arms in the Danish center. Poor speech outcomes were seen for both treatment arms. Variations between centers were observed. As the Swedish center had few participants, intercenter comparisons should be interpreted with caution.

BACKGROUND: Acute normovolemic hemodilution (ANH) has been proposed as a microsurgical technique to improve blood flow in free flaps. OBJECTIVE: Here, we present the first systematic review of clinical and experimental studies on the effect of ANH. METHODS: We performed a systematic literature search of PubMed, Medline, the Cochrane Library, Google Scholar, and ClinicalTrials.gov using search strategies and a review process in agreement with the PRISMA statement and the Cochrane Handbook for systematic reviews of interventions. PICO criteria were defined before bibliometric processing of the retrieved articles, which were analyzed with the SYRCLE RoB tool for risk of bias and the GRADE scale for level of evidence. RESULTS: We retrieved 74 articles from the literature search, and after processing according to PICO criteria, only four articles remained, all of which were experimental. The rating for risk of bias was uncertain according to SYRCLE RoB results, and the level of evidence was low according to GRADE evaluation. CONCLUSIONS: There is no clinical evidence for the effect of ANH on microcirculation in free flaps, and experimental studies provide weak evidence supporting the use of hemodilution in reconstructive microsurgery.

Background There is little high-quality scientific evidence identifying the best and safest methods for delayed breast reconstruction, with most previous studies retrospective in nature. The primary aim was to compare early complication rates for two different breast-reconstructive methods in radiated and non-radiated patients, using a validated scale. The secondary aim was to identify predictors for complications. Materials and methods This study represents a clinical, randomized, prospective trial ( ClinicalTrials.Gov identifier: NCT03963427), where the patients were divided into two study arms: non-radiated and radiated. In the non-radiated arm, patients were randomized to a one-stage lateral thoracodorsal flap with an implant or two-stage expander reconstruction. In the radiated arm, patients were randomized to a latissimus dorsi reconstruction combined with an implant or deep inferior epigastric artery perforator (DIEP) reconstruction. All adverse events were classified according to Clavien–Dindo and summarization of overall morbidity was performed by calculating the Comprehensive Complication Index score. The study was conducted from 2008 to 2020. Results The complication frequencies were similar for the two surgical methods within each arm. In the non-radiated arm, risk factors for any complication were any comorbidities, and in the radiated arm, factors were a high body mass index and a contralateral operation. Conclusions The usage of the Clavien-Dindo scale in reconstructive surgery is feasible, but further validation is needed. In non-radiated patients, the frequencies of short-term complications were similar for lateral thoracodorsal flap and expander reconstruction, whereas in radiated patients, they were similar for DIEP and latissimus dorsi. The complication profile of the methods varied.

Aim: This study aimed to test initial validity, reliability, and feasibility of the Mother-to-Infant Bonding Scale in a sample of Swedish mothers. Methods: A translation was performed through 11 steps using a forward–backward bilingual technique. For criterion validity, the Swedish translation of the Mother-to-Infant Bonding Scale (S-MIBS) was compared with the Postpartum Bonding Questionnaire, sub-scale 1 (PBQ1) and 2 (PBQ2) and Edinburgh Postnatal Depression Scale (EPDS) in a sample of 63 Swedish mothers. Internal consistency was calculated with Cronbach’s alpha. For feasibility testing, the mothers were asked to grade their experience of S-MIBS and PBQ on a four-point scale. Results: The results show a correlation between S-MIBS and PBQ1 ( r=0.80, p

The majority of postbariatric patients experience major problems from excess skin, with most desiring abdominoplasty.To present visual assessments and objective measurements of excess abdominal skin; analyze relationships between patient-reported outcomes, objective measurements of excess skin, and visual assessments; and discuss criteria for reconstructive abdominal surgery in public healthcare.An academic hospital in Sweden.This is a secondary analysis of a prospective, longitudinal study that included 200 obese patients undergoing bariatric surgery, with 147 of these patients participating in follow-up 18-months postsurgery. Patients rated their symptoms related to excess skin and quality of life (QoL) according to the Sahlgrenska Excess Skin Questionnaire and EuroQol-5 D before and after bariatric surgery. Abdominal ptosis was measured at different anatomic locations.Waist circumference and ptosis were significantly reduced at all anatomic locations after weight loss, and abdominal ptosis was significantly larger laterally than at the midline (P.001). The majority of patients had a ptosis ≥3 cm following bariatric surgery and had significantly more symptoms related to excess skin relative to those reported preoperation (P.05). Additionally, the number of patients experiencing discomfort from excess skin increased along with increased ptosis size, but the correlation between ptosis size and QoL was low. Reconstructive abdominal surgery was requested by 70% of patients, all having significantly larger ptosis and significantly more symptoms than those not desiring surgery.Criteria for abdominal reconstruction should be based on both patient-reported symptoms and objective measures to ensure more patient-centered care than is possible only using objective measurements.

Introduction: There is limited knowledge about self-image in relation to excess skin after bariatric surgery. The aim of this study was therefore to explore self-image after massive weight loss and its relationship to gender, weight loss, discomfort regarding excess skin and health-related quality of life. Methods: Eighteen months after obesity surgery, 131 patients filled in questionnaires about self-image (Som jag ser mig sjalv), excess skin (Sahlgrenska Excess Skin Questionnaire, SESQ) and quality of life (EQ-5D and SF-36). In addition, maximal ptosis was measured on their abdomen, arms and thighs. Results: There were no differences in self-image or quality of life between the genders. Participants who scored low discomfort on SESQ had a significantly better overall self-image, in all subscales, compared to those with high discomfort scores (p

In recent years, it has become increasingly popular to use matrices, such as acellular dermal matrices, in implant-based breast reconstruction. To lower the cost and to avoid implanting biological material, the use of synthetic meshes has been proposed. This is the first study examining TIGR® Mesh in a larger series of immediate breast reconstruction. The aims of the study were to examine complications and predictors for complications. All consecutive patients operated on with breast reconstruction with TIGR® Matrix Surgical Mesh and tissue expanders (TEs) or permanent implant between March 2015 and September 2016 in our department were prospectively included. Exclusion criteria were ongoing smoking, BMI (kg/m2) > 30, planned postoperative radiation, and inability to leave informed consent. Fifteen breasts (23%) were affected by complications within 30 d: four (6.2%) major complications and eleven (17%) minor complications. The major complications included two implant losses and one pulmonary embolism (PE). Predictors for a complication were age over 51 years, BMI over 24.5 kg/m2, large resection weight, and the need for a wise pattern excision of skin. Four minor surgical complications occurred after 30 d (minimum follow-up 17 months). There were no implant losses. In addition, minor aesthetic corrections, such as dog-ear resection, were performed in 10 breasts. In conclusion, breast reconstruction with a TE in combination with TIGR® Matrix Surgical Mesh can be performed with a low complication rate. (Less)

Immediate breast reconstruction (IBR) combined with post-mastectomy radiotherapy (PMRT) is associated with an increased risk for complications. Here, we analyse whether IBR combined with PMRT is ethically acceptable. We employ normative analysis following reflective equilibrium and the principles of Beauchamp and Childress: non-maleficence, beneficence, autonomy, and justice. From the perspective of beneficence and non-maleficence, we can choose either IBR or PMRT according to documented risks and complications, delayed autologous breast reconstruction with corresponding benefits but less risk for complications, or even no reconstruction, which for some women, might be equally beneficial. In such a situation, given the level of severity associated with lacking a breast after mastectomy, IBR violates the principles of beneficence and non-maleficence. To deny an IBR in the context of PMRT does not violate the principle of autonomy as it is normally interpreted in the healthcare system, not even when patient-centred care is taken into consideration. Moreover, there is a risk that the decision of the patient will be affected by heuristics, optimism bias, and surgeon bias. IBR in the context of PMRT could be in conflict with the principle of justice, as it could lead to displacement of care for other patient groups. Furthermore, an acceptable level of cost effectiveness should be low, given that living without a breast is a condition of moderate severity. In conclusion, given the current knowledgebase and established ethical norms within the healthcare system, we find strong ethical reasons not to offer IBR when PMRT is expected.

INTRODUCTION: Breast hypertrophy is a condition associated with physical, psychological, and psychosocial problems. The primary aims of this study were to determine the impact of breast hypertrophy and the effects of breast reduction, performed on the basis of well-described inclusion criteria, on general and breast-related health, using both general and diagnosis-specific validated questionnaires. We used a prospective, longitudinal paired study design. A secondary aim was to analyze the relationship between preoperative breast volume, body mass index, sternal notch-to-nipple distance and the weight of resected tissue on the one hand and improvements in health on the other.METHODS: Three hundred forty-eight consecutive patients undergoing breast reduction were included and the Short-Form 36 (SF-36), Breast-Related Symptoms Questionnaire (BRSQ), Modified Breast Evaluation Questionnaire (mBEQ) and BREAST-Q were distributed preoperatively and 1 year postoperatively.RESULTS: A total of 284 (83%) patients answered the questionnaires either preoperatively or postoperatively, or both, and 159 (46%) patients answered both. The breast hypertrophy patients had significantly lower scores preoperatively than the matched normal population when it came to all dimensions of the SF-36 and mBEQ. The preoperative scores for both the BRSQ and BREAST-Q were low.After breast reduction, there were significant improvements in all dimensions of the BRSQ, mBEQ, and Breast-Q and in several dimensions of the SF-36.CONCLUSIONS: Breast reduction reduces or removes disease-associated pain. It improves or normalizes perceived health and psychosocial self-esteem in slightly obese women or women of normal weight with preoperative breast volumes around 1000 mL. Women with higher preoperative breast volumes and longer sternal notch-to-nipple distances appear to be more satisfied with the cosmetic result postoperatively.

Background Weight loss after obesity and pregnancy is associated with excess abdominal skin and weakness of the abdominal wall, which is assumed to cause low back pain and reduce lung function. Today, abdominoplasty is the only known method to treat excess skin, and plication is used to improve aesthetics and function alone or in addition to surgery. There is lack of evidence concerning the surgery's effect on trunk muscles, lung function, and physical function. The aim was to evaluate the effect on trunk muscle endurance, lung function and self-rated physical function after abdominoplasty with and without muscle plication. Aim To evaluate the effect on trunk muscle endurance, lung function, and self-rated physical function after abdominoplasty with and without muscle plication. Methods A series of 125 people were randomised to abdominoplasty with or without rectus abdominis muscle plication. Trunk muscle endurance, lung function, and self-rated physical function (disability rating index) were measured before and 1 year after surgery. Results There were no significant differences in any of the measured variables between the groups either before or after surgery. A significant decrease (p = .02) in back muscle endurance was seen after abdominoplasty without muscle plication. A significant positive effect (p = .04) in one of the activities (running) assessed by DRI was reported after abdominoplasty with muscle plication. Conclusions No significant differences in trunk muscle endurance, lung function, or self-rated physical function were found after abdominoplasty with vs without plication. As the primary indication for surgery was excess skin and not diastasis of the rectus abdominis muscles, there is a need for future trials before conclusions can be drawn of effect of abdominoplasty and plication.

Background The authors prospectively evaluated the effect of isolated abdominoplasty with or without rectus fascia plication on the physical, functional, and psychosocial dimensions of health-related quality of life in post-bariatric surgery patients. They also evaluated whether the objectively measured amount of abdominal excess skin affects the discomfort of excess abdominal skin and changes in health-related quality of life after abdominoplasty. Methods Ninety-four post-bariatric surgery patients answered questionnaires regarding their experience of excess skin and health-related quality of life before and 1 year after isolated abdominoplasty. An objective assessment of the amount of abdominal excess skin was also performed. All study participants were assigned randomly to either undergo or not undergo rectus fascia plication. Results Significant improvements were reported at the follow-up concerning physical, functional, and psychosocial dimensions of health-related quality of life. A significant decrease was observed for the general health subscale of the 36-Item Short-Form Health Survey for the nonplicated group (p = 0.039). No significant differences were observed between the plicated and nonplicated groups. A significant low correlation was identified between the change in the Short-Form physical function subscale after abdominoplasty and measured amount of excess abdominal skin (rs = 0.26, p = 0.033) or resection weight (rs = 0.20, p = 0.10). Conclusions Isolated abdominoplasty in post-bariatric surgery patients seems to improve both physical and psychosocial dimensions of health-related quality of life. However, rectus fascia plication does not appear to influence health-related quality of life. In addition, the correlation between the objectively measured amount of abdominal excess skin and improvements in health-related quality of life after abdominoplasty in post-bariatric surgery patients appears to be low.

An inferior dermal flap ("sling") can be used to cover an implant with two layers of tissue following Wise pattern skin-reducing mastectomies. Here, we performed a systematic review of the risks and benefits of this technique, specifically regarding complications, patient-reported outcomes, and aesthetic outcomes. PubMed and other relevant databases were searched using specific key words, with inclusion criteria comprising studies of dermal sling use involving ≥ 5 patients and performance according to the PICO framework. A meta-analysis was performed using a random-effects model involving a binomial distribution with logit-link function. For each study, the 95% confidence interval (CI) was obtained based on exact limits from a binomial distribution, and heterogeneity testing was performed using a chi-squared test. A total of 428 abstracts were retrieved, with 24 studies meeting the inclusion criteria and including a total of 879 patients and 1184 reconstructed breasts. The mean complication rate was 21.6% (95% CI: 16.9-27.2%), with the most common complication involving wound-healing problems (mean, 11.4%; 95% CI: 8.5-15.2%), and the frequency of implant loss ( 3 months) varied from 0% to 14% (mean, 2.2%; 95% CI: 1.1-4.4%). Seven articles reported patient-reported outcomes, and four reported aesthetic outcomes, with the quality of evidence classified as low for complications and very low for patient-reported outcomes and aesthetic outcomes. Our findings showed that although implant-based reconstruction with a dermal sling is widely used, there is little scientific evidence supporting the method.

Background Excess skin is well known after massive weight loss but, there is missing knowledge from various groups. Objectives To describe and compare excess skin in a reference population during obesity, after obesity surgery, and after reconstructive abdominoplasty. Setting University hospital, Sweden. Methods The following 6 groups were included: the reference population, obese adults before obesity surgery, obese adults after obesity surgery, adolescents after obesity surgery, super-obese adults after obesity surgery, and adults after abdominoplasty. All groups filled in the Sahlgrenska Excess Skin Questionnaire (SESQ). Some groups also underwent measurements of ptosis/excess skin on 4 body parts. Results All groups scored significantly higher experience of and discomfort from excess skin compared with the reference population. SESQ scores were significantly higher for obese adults (10.5 ± 8.5) and even higher for adults and adolescents (12.3 ± 8.1 versus 14.4 ± 7.7) after obesity surgery compared with the reference population (1.5 ± 3.5). Abdominoplasty resulted in significantly reduced scores (2.9 ± 5.2). Those undergoing obesity surgery and weight loss had significantly less excess skin measured on arms, breasts, and abdomen compared with before surgery, except for the upper arms on the adolescents. Excess skin increased on inner thighs in both age groups after weight loss. Correlations between objectively measured ptosis/excess skin and the patients’ experience of and discomfort were .16 to .71, and the highest correlations were found among adolescents. Conclusion Excess skin is not a problem for the vast majority of the normal population but is linked to obesity and massive weight loss. The SESQ score illustrates major problems related to excess skin both for obese adults and after obesity surgery for adults and for adolescents, who have problems similar to or worse than adults. Abdominoplasty markedly decreases symptoms.

Among surgical procedures for constructing a neovagina, positive outcomes are reported in literature for bowel vaginoplasty for male-to-female transgenders and patients with vaginal aplasia. This systematic review shows outcomes of bowel vaginoplasty procedures, and rates the quality of evidence of the included studies. A search of the literature was performed in PubMed, Medline, Cochrane Library and SveMed+, in accordance with the PRISMA statement, between January 2016 and February 2018. The PICOS (patients, intervention, comparator, outcomes and study design) approach was used as inclusion criteria. Among 251 analyzed studies only 34 met inclusion criteria. Quality of evidence and methodology were rated according to GRADE and MINORS, respectively. Data from the included studies were extracted based on study characteristics, participants? specifics, type of intervention/treatment and type of outcome measures into data extraction forms. All studies were non-randomized with a high risk of bias and very low quality of evidence according to GRADE. Vaginal reconstruction with isolated bowel segments provides a self-lubricating neovagina with low rates of failure and revision, and without routine dilatation need. Furthermore, the use of laparoscopic techniques offers a better postoperative cosmetic appearance of the abdomen and a shorter hospital stay. Vaginoplasty using bowel segment is a safe and effective procedure that obtains excellent long-term results as reported by the included studies. Despite that further researches are needed improving methodology with larger populations, retrospective qualitative studies and report of outcome measurements using standardized evaluation tools as the Female Sexual Function Index.

In recent years, it has become increasingly popular to use matrices, such as acellular dermal matrices, in implant-based breast reconstruction. To lower the cost and to avoid implanting biological material, the use of synthetic meshes has been proposed. This is the first study examining TIGR

The usefulness of patient-reported outcome measures is emphasized along with the development of patient-centered care. When implementing patient-reported outcome measures, evidence of the instrument's validity, reliability, and responsiveness in the target population is necessary to secure accurate reporting of the patient's experience. The aim of this study was to identify the literature in which structured patient-reported outcome measures have been used to evaluate the results of gender confirmation surgery, and to systematically evaluate the validity of these instruments.A systematic review of the current literature was performed to identify structured patient-reported outcome measures used to evaluate the outcome of gender confirmation surgery. The identified instruments' validity in the transgender population was assessed for adherence to international guidelines for development and validation of health outcomes instruments.A total of 110 instruments were identified: 64 ad hoc; six generic; 24 evaluating psychiatric, social, or psychosocial aspects; nine evaluating function but only valid in other patient groups; five ad hoc with some formal development/validation; and two specific for gender dysphoria.There is a lack of patient-reported outcome measures that are valid for the transgender population and concurrently sensitive enough to evaluate gender confirmation surgery without the influence of other gender confirming interventions. Basing research on instruments without confirmed validity decreases the validity of the study itself; thus, previous research using patient-reported outcome measures to evaluate gender confirmation surgery can be considered to have a low level of evidence. To obtain valid patient-reported outcome measures, specific for evaluating the results of gender confirmation surgery, development of new instruments or adaptation of existing instruments is needed.

Background: There is a lack of published, validated questionnaires for evaluating psychosocial morbidity in patients with breast hypertrophy undergoing breast reduction surgery. Aim: To validate the breast evaluation questionnaire (BEQ), originally developed for the assessment of breast augmentation patients, for the assessment of psychosocial morbidity in patients with breast hypertrophy undergoing breast reduction surgery. Study design: Validation study Subjects: Women with macromastia Methods: The validation of the BEQ, adapted to breast reduction, was performed in several steps. Content validity, reliability, construct validity and responsiveness were assessed. Results: The original version was adjusted according to the results for content validity and resulted in item reduction and a modified BEQ (mBEQ) that was then assessed for reliability, construct validity and responsiveness. Internal and external validation was performed for the modified BEQ. Convergent validity was tested against Breast-Q (reduction) and discriminate validity was tested against the SF-36. Known-groups validation revealed significant differences between the normal population and patients undergoing breast reduction surgery. The BEQ showed good reliability by test–re-test analysis and high responsiveness. Conclusion: The modified BEQ may be reliable, valid and responsive instrument for assessing women who undergo breast reduction.

An ability to reliably assess excess skin after massive weight loss using well-described and transferrable methods is important. The aim of this trial was to evaluate inter-rater reliability of ptosis and circumference measurements in patients with excess skin after bariatric surgery.Twenty-five postbariatric patients were included in the study, and their excess skin was measured 18 months after surgery. A protocol was designed to measure excess skin in a standardised way. To evaluate the inter-rater reliability in the measuring protocol, all patients were measured twice, by a specialist nurse and a specialist physiotherapist.All circumference measurements on different body parts had an ICC0.9, indicating high reliability. Furthermore, all breast and abdominal ptosis measurements had high reliability. In contrast, visual evaluation of abdominal ptosis had poor reliability. Measurements of ptoses on different body parts had an ICC0.6. There were no systematic differences between the results of the two testers, except for measurements of the buttocks and maximal knee circumference.The measuring protocol presented in this study has high reliability and, therefore, represents a useful instrument to provide a consistent and objective assessment of excess skin in the postbariatric patient.

Breast reconstruction is a common standard procedure in many centres after breast cancer surgery. The aim of the present study was to investigate and compare the incidence of various complications in different reconstruction methods.Six hundred and eighty-five patients were retrospectively classified into five groups: (1) Deep inferior epigastric perforator flap (DIEP), (2) latissimus dorsi flap (LD), (3) lateral thoracodorsal flap (LTDF), (4) expander with secondary implant (EXP), and (5) direct implant (DI). Demographic and perioperative data, the incidence of complications, and follow-up data were collected.There was a significant difference between groups regarding overall early complications (p 0.001). The DIEP group had the highest incidence of overall complications (50.0%) (p 0.05). DIEP also had the highest incidence of fat necrosis (18.3%), skin necrosis (22.1%), and incidence of reoperation for complications (26.9%) compared to the other reconstruction methods. In the entire group of patients, the overall incidence of late complications (occurring30 days after surgery) that needed surgical corrections was 54.7%. The incidence of late complications was 46.2% for DIEP, 66.4% for LD, 74.8% for LTDF, 44.9% for EXP, and 62.9% for DI. The DIEP group had higher incidences of late local complications (fat necrosis, skin necrosis, haematoma, seroma, and wound rupture combined), and scars requiring treatment than the other reconstruction methods.Meticulous registration of incidence of different complications in five different breast reconstruction methods revealed high complication rates with all methods. The differences in incidence of complications were related to the operation method used. Based on these results, careful individual planning of a breast reconstruction is mandatory.

Postoperative infection after breast reduction surgery is a common complication, with the most commonly involved pathogen being Staphylococcus aureus. Previous studies of antibiotic prophylaxis in breast reduction surgery have been inconclusive. The aim of the present study was to clarify the role of prophylactic antibiotics in breast reduction surgery.In total, 325 women were randomized to antibiotic prophylaxis [with 2 g of cloxacillin intravenously (IV) or 600 mg of clindamycin IV] (intervention group) or no antibiotic prophylaxis (control group). Follow-up was conducted at 1 and 2 weeks postoperatively. Patients with signs of infections or other complications were followed up until resolution. Patients who received antibiotic treatment within 30 days from surgery (cloxacillin 750 mg or clindamycin 300 mg orally) were considered having an infection and this was the main outcome variable. All postoperative infections were also judged according to a graded scale.In the intervention group, 26 (16.0%) patients were treated with antibiotic; and in the control group, 32 (19.6%) patients were treated with antibiotics. No difference was found between the groups (relative risk, 0.82; 95% confidence interval, 0.51-1.31; P = 0.49). Twenty-two (14%) patients in the intervention group were classified to have a possible infection according to the scale compared to 27 (17%) in the control group. No statistical difference was found (relative risk, 0.81; 95% confidence interval, 0.48-1.37; P = 0.54).Prophylactic cloxacillin as a single-dose IV in breast reduction surgery does not reduce the incidence of postoperative infections.

Background Complications after breast reconstructive surgery are common, and they can be caused by a wide range of factors. The aim of the present study was to identify independent perioperative risk factors for postoperative complications after breast reconstruction. Methods A retrospective study was performed of 623 consecutive breast cancer patients who had undergone deep inferior epigastric perforator (DIEP) flap, latissimus dorsi (LD) flap, lateral thoracodorsal flap (LTDF), or tissue expander with secondary implant (EXP). Data on demography, perioperative parameters, and complications were collected. Logistic regression models adjusted to the reconstruction method and to confounding demographic factors were used for statistical analysis. Results Increased blood loss for each 10-ml step increased the risk for overall early complications (p = 0.017), early seroma (p = 0.037), early resurgery (p = 0.010), late local overall complications (p = 0.024), and late fat necrosis (p = 0.031). Longer duration of surgery for each 10-minute step increased the risk of overall early complications (p = 0.019), but, in the univariate model, there was an increased risk for nine different types of complications (p = 0.004-0.029). There was no association between the experience of the surgeon performing the procedure and the frequency of complications. Conclusions Duration of surgery and blood loss during surgery are independent risk factors for postoperative complications, and should be minimised. Further research is needed to establish the association between the experience of the surgeon and the occurrence of complications.

Introduction No surgical technique is reported to be the best option for gender-affirmation surgery (GAS) of the genitalia in transmen. Although patients’ preferences are central when choosing a surgical technique, no studies have evaluated this factor. Aim To investigate transmen’s priorities and preferences regarding GAS of the genitalia. Methods From November 2015 to March 2016, 54 transmen with the diagnosis of gender dysphoria who were referred to Sahlgrenska University Hospital for discussion of therapeutic steps (surgery and hormonal treatments) were asked to complete a questionnaire on different attributes achievable with GAS, such as sexual and urinary function and appearance. Forty-seven patients (87%) completed the questionnaire. Age ranged from 18 to 52 years (mean = 26 years, SD = 7.4 years). At the time of interview, no patient had undergone GAS of the genitalia. Main Outcome Measures Answers to completed questionnaires. Results Seventy-six percent of patients identified themselves as male, and 24% wrote other terms such as “mostly male,” “inter-gender” and “non-binary.” Gender identity had a significant impact on patients’ preferences for two questions: the importance of vaginal removal and the importance of having a penis that would be passable in places such as male dressing rooms. These items were more important to patients identifying themselves as male. The most important attributes requested were preserved orgasm ability and tactile sensation. The least important attribute was removal of the vagina, followed by having a penis of human material, minimal scarring, and size. The ability to urinate while standing was considered a high priority by some and a low priority by others. All answers ranged from “unimportant” to “imperative.” Conclusion This series of patients demonstrates a considerable heterogeneity among transmen in their gender identity and preferences regarding GAS of the genitalia, which supports the need for several techniques. Patients must be accurately informed on the different techniques and their specific benefits and limitations to make an informed choice.

A staged protocol for isolated cleft palate (CPO), comprising the early repair of the soft palate at 6 months and delayed repair of the eventual cleft in the hard palate until 4 years, designed to improve maxillary growth, was introduced. CPO is frequently associated with additional congenital conditions. The study evaluates this surgical protocol for clefts in the soft palate (CPS) and for clefts in the hard and soft palate (CPH), with or without additional malformation, regarding primary and secondary surgical interventions needed for cleft closure and for correction of velopharyngeal insufficiency until 10 years of age. Of 94 consecutive children with CPO, divided into four groups with (+) or without (−) additional malformations (CPS + or CPS − and CPH + or CPH−), hard palate repair was required in 53%, performed with small local flaps in 21% and with bilateral mucoperiosteal flaps in 32%. The total incidence of soft palate re-repair was 2% and the fistula repair of the hard palate was 5%. The total incidence of secondary velopharyngeal surgery was 17% until 10 years, varying from 0% for CPS − and 15% for CPH−, to 28% for CPS + and 30% for CPH+. The described staged protocol for repair of CPO is found to be safe in terms of perioperative surgical results, with comparatively low need for secondary interventions. Furthermore, the study indicates that the presence of a cleft in the hard palate and/or additional conditions have a negative impact on the development of the velopharyngeal function.

Background There is a lack of knowledge about the patient’s experience of excess skin after bariatric surgery in patients with body mass index, (BMI)>50 kg/m2. The objective of this study was to evaluate experience of excess skin after laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or laparoscopic Roux-en-Y gastric bypass (LRYGB) and explore possible gender differences. Another aim was to analyze possible correlation between the reported experiences of excess skin with changes in weight, BMI, and hip and waist circumference after surgery. Methods One and/or 2 years after gastric bypass or duodenal switch surgery 57 patients responded to a specific questionnaire. The questionnaire included questions about the amount of excess skin and how much discomfort it caused. Furthermore, the patients were measured concerning weight and waist and hip circumference. Results One year after surgery, a majority of the patients experienced excess skin scored as>2 (“a lot of” or “very much”). The patients in the BPD/DS group experienced significantly more excess skin compared to patients in the LRYGB group. Women experienced more excess skin and discomfort on several body parts than men. The correlations between changes in BMI and the reported experience and discomfort of excess skin were low. There was a low to moderate correlation between changes in waist and hip circumference measures and the experience of excess skin on stomach and buttocks. Conclusion Weight loss after LRYGB and BPD/DS in super-obese patients is associated with substantial discomfort from excess skin. Women reported more discomfort and experienced more excess skin than men. There was a low correlation between experience of excess skin and changes in weight, BMI, and circumference measures.

BACKGROUND: It is controversial whether breast reconstruction with a microvascular free flap should be done without restrictions in patients who have not had radiotherapy. Many regard it as too expensive, but some consider it better and more economically advantageous than an implant reconstruction. METHODS: Databases of publications were searched to find out under what conditions is it suitable to offer a deep inferior epigastric perforator (DIEP) or a transverse rectus abdominis myocutaneous flap to normalize the body's appearance in a woman whose breast(s) had been removed for cancer or to prevent the development of breast cancer. The effect of breast reconstruction with DIEP flaps was analyzed, taking account of the following factors: general satisfaction (quality of life), aesthetic satisfaction (cosmesis), and morbidity. To find out which factors were of potential importance, we recorded age, hypertension, whether scars from previous abdominal surgery were present, microcirculation, whether the patient was overweight or obese, and costs of the procedure. RESULTS: Patients planning to have DIEP flaps should be willing to stop smoking at least 4 weeks before and after the procedure and have a body mass index of less than 30 kg/m to avoid a higher risk of complications. Because of the paucity of papers, it is difficult to recommend one approach over the other when considering general satisfaction, aesthetic satisfaction, and health economics. However, economical long-term outcome is highly dependent on the initial costs of each procedure and the cumulative costs of complications for each reconstruction method. CONCLUSIONS: The scientific foundation of assessment of methods of techniques of breast reconstruction is weak. Therefore, it is important that future studies should present more comparable series, highlight the long-term effects in high-quality studies, to provide the patients with optimal results without undue risks and to avoid financial burdens on society.

The principle of osseointegration is accepted and used in reconstructive surgery. This study presents the first series of five patients where titanium implants have been implanted into the pubic bones of female-to-male (FTM) transsexual patients, in order to attach a "bone-anchored" penile epithesis. Following patient selection based on patients' wishes, pubic bones of 10 FTM transsexuals were analysed by CT-scan and a virtual planning was made. A surgical plan was also developed. To date, five FTM transsexuals have undergone the two-stage surgery. During stage-1, two titanium implants ("fixtures") are implanted onto the pubic bone. Four weeks postop, a new CT scan is performed to analyze osseointegration and the final implant position. During stage-2, the soft tissue of the pubic area is reduced; abutments are inserted and passed through the skin. A few weeks after stage 2 surgery, a penile epithesis is connected to the skin-penetrating titanium implants. Two out of 10 patients who received preoperative CT scan presented with smaller pubic bones, not able to accommodate the fixtures as chosen originally. Preoperative virtual planning is crucial for the selection of the appropriate implants size. The stage-1 and stage-2 surgery occurred uneventfully in all five patients. One patient presented with a wound infection 1 week after stage-2 surgery. Postoperative CT scan demonstrates implant osseointegration in all cases. This experimental clinical study demonstrates that titanium osseointegration is feasible onto the pubic bone. This new approach for penile reconstruction constitutes another alternative for both transsexual patients and cases following genital development disorders, post-trauma and surgery.

The subcutaneous mastectomy is an important step in the treatment of female-to-male transsexual patients. At the Sahlgrenska University Hospital, a two-step procedure was used for mastectomies through 2002-2011. With this procedure, all patients were operated on with a concentric circular incision in the first session of surgery, followed by a second session 7-12 months later. From July 2011, a new approach was adopted, which consists of treating patients according to the algorithm and methods described by Monstrey et al. The aim of this study is to evaluate these two different approaches and determine if similar results, possibly with fewer surgeries and overall lower complication rate, can be achieved by using multiple techniques and a decision-making algorithm as compared to the two-step approach where only a concentric circular technique was used. All female-to-male transsexuals who had mastectomy at Sahlgrenska between 2002-2012 were included in the study. These were divided in two groups: those who were treated according to the single-step, algorithm based, approach (16 patients, 32 mastectomies), and those who were treated with the two-step, concentric circular approach (14 patients, 28 mastectomies). Within the single-step, algorithm based, group the following techniques were used: 6% transareolar technique, 6% semicircular, 13% free nipple graft, 31% extended concentric circular, and 44% concentric circular. Data including type of surgical technique used, complications, and number of surgeries were collected and compared. Complications (e.g., haematoma, nipple necrosis, seroma, wound dehiscence, and infection) occurred in 50% of the patients following the first surgery in the two-step, concentric-circular approach group, for a total of 71.43% of patients with complications following either the first- or the second-step surgery; complications occurred only in 25% of the patients in the one-step, algorithm-based group. The mean number of surgeries per breast was 2.5 for the two-step concentric circular approach, and 1.25 for the single step, algorithm-based approach; particularly, when the concentric circular technique was chosen for the single step, algorithm-based approach, only two of the patients required revision surgery to improve the cosmetic outcome. This study shows that the number of complications and the total number of surgeries performed to satisfy patients were lower after Monstrey's algorithm for mastectomies was implemented as routine practice at the Sahlgrenska University Hospital.

This study was done to analyze the problems of post-bariatric patients with excess skin and to determine their interest in body contouring surgery. The self-administered Sahlgrenska Excess Skin Questionnaire (SESQ) was used together with a study-specific questionnaire. The patients who were operated with bariatric surgery at Sahlgrenska University Hospital between 1999 and 2008 were identified and sent the SESQ and a study-specific questionnaire. The response rate was 65 % (23 % men). The most common problem in both men and women was the feeling of having an unattractive body (91 and 67 %, respectively). The most frequently reported sites of excess skin were the upper arms in women (91 %) and the abdomen in men (78 %). In both women and men, excess skin on the abdomen was reported to cause the most discomfort (median 7 and 3, respectively, on a scale from 0 to 10). Women reported significantly more problems, discomfort, and amount of excess skin (p

Little is known about excess skin in the normal population. The aim of this study was, therefore, to analyse the prevalence, impairments, and discomfort of excess skin in a cross-section of the Swedish population.From the population registry of the Swedish Tax Agency, 1408 subjects living in Västra Götaland County from 18-59 years of age were randomly selected with an equal distribution of the sexes. Additionally, age was equally distributed, although twice as many subjects under 40 years of age were sent the questionnaire due to an expected low response rate for younger people. All subjects were asked to fill out the Sahlgrenska Excess Skin Questionnaire (SESQ), which included questions concerning the amount of and discomfort due to excess skin.No excess skin was reported by 78% of responders, including 71% of women and 87% of men. The responders who reported any excess skin were significantly older, had a higher body mass index (BMI) and reported larger differences between their maximum and current BMI. The most common reported site of excess skin was the abdomen in both women and men (26% and 8%, respectively), and this was reported to cause the most discomfort (median 4 and 2, respectively, on a scale from 0-10). Women graded psychosocial symptoms significantly higher than men, but there were no significant differences in other symptoms.The results indicate that Swedish adults, regardless of sex, do not suffer from excess skin and may be considered as reference values.

It is well known that the risk of complications after abdominal contouring surgery is high. Sparse data in published reports exist, suggesting that complication rates are higher in postbariatric patients compared with patients who have lost weight by dieting. The aim of this study was to analyse the incidence of complications after abdominoplasty in postbariatric patients compared with in patients who have not had weight loss surgery. The aim was also to identify predictive factors associated with the development of postoperative complications. This study retrospectively analysed 190 consecutive patients operated on with abdominoplasty due to abdominal tissue excess from January 2006 to December 2008 at Sahlgrenska University Hospital. Variables analysed were sex, age, max body mass index (BMI), delta BMI (max BMI minus preoperative BMI), preoperative BMI, method of weight reduction, resection weight, and complications. The early complication rates were significantly higher in postbariatric patients (48%) than in patients who had not had weight loss surgery (29%). Resection weight was significantly higher for patients with early local complications compared with patients without early local complications. Max BMI, delta BMI, or preoperative BMI had no influence on the incidence of complications. In conclusion, this study confirms in a fairly large sample that the complication rate after abdominoplasty seems to be higher in postbariatric patients compared with patients who have not had weight loss surgery. However, no predictive factors could be identified explaining these differences. Further studies need to be conducted to identify predictive factors for the occurrence of complications after abdominal contouring surgery.

Abdominoplasty is a well-established operation to remove abdominal tissue excess. The patients' benefits and risks of this surgical treatment are, however, incompletely studied. The aim of this study was to evaluate the quality of evidence of benefits and risks for patients having abdominoplasty from massive weight loss or childbirth. Outcome measures were quality-of-life, respiratory function, back pain, and complication rates. PubMed, Cochrane Database of Systematic Reviews, CRD, CINDAHL, AMED, PsycInfo and different Health technology Assessment organizations (SBU, Kunnskapssenteret, Sundhetsstyrelsen) were searched for articles published until October 2011. Inclusion criteria were studies written in English or Scandinavian language including at least 30 patients with a control group and a case series of at least 100 patients. Review articles and case studies were excluded. The scientific level of evidence was evaluated using the GRADE-system. One small controlled study on abdominoplasty was found indicating a positive effect on quality-of-life. No controlled studies evaluating the other outcomes respiratory function and back pain were found. One prospective study reported minor complications averaging to 25%. Fourteen retrospective studies reported the same pattern. The major complication venous thromboembolism was found in 2%-8% in three series. It is concluded that the quality of evidence of positive health effects for patients having abdominoplasty is very low concerning all studied outcomes.

The World Professional Association for Transgender Health (WPATH) currently publishes the Standards of Care (SOC), to provide clinical guidelines for health care of transsexual, transgender and gender non-conforming persons in order to maximize health and well-being by revealing gender dysphoria. An updated version (7th version, 2011) of the WPATH SOC is currently available. Differences between the 6th and the 7th versions of the SOC are shown; the SOC relevant to penile reconstruction in female-to-male (FtM) persons are emphasized, and we analyze how the 2011 WPATH SOC is influencing the daily practice of physicians involved in performing a penile reconstruction procedure for these patients. Depending by an individual’s goals and expectations, the most appropriate surgical technique should be performed: the clinic performing penile reconstruction should be able to offer the whole range of techniques, such as: metoidioplasty, pedicle and free flaps phalloplasty procedures. The goals that physicians and health care institutions should achieve in the next years, in order to improve the care of female-to-male persons, consist in: informing in details the individuals applying for penile reconstruction about all the implications; referring specific individuals to centers capable to deliver a particular surgical technique; implementing the surgery with the most updated refinements.

To evaluate current reviews and assess scientific validity of the recent literature on penile reconstruction after trauma, penile reconstruction in gender reassignment surgery, concealed penis, and aphallia.Technical advances in penile reconstruction have been highlighted. The few long-term follow-up studies available confirm the difficulty of such surgery, in terms of complications and the limits of the final achievable outcomes. The surgery necessitates several steps and a high number of revisions. Scientific progress in penile reconstruction seems slow, with a lack of controlled studies, high rate of loss to follow-up (especially in sex reassignment surgery) and a lack of validated assessment measures. However, a few recent studies are making the problems clearer, especially in patient selection and the avoidance of raising false expectations in patients.

Background Excess skin is a well-known side effect of massive weight loss after bariatric surgery. However, there is a lack of longitudinal follow-ups. Objectives The primary aims of this study were to investigate the development and amount of excess skin after laparoscopic Roux-en-Y gastric bypass and to relate objective results to subjective experiences. Setting University hospital. Methods From 2009 to 2012, 200 patients were included and assessed with respect to excess skin before and 18 months after bariatric surgery. Patients were measured according to a standardized protocol and completed a questionnaire regarding their subjective experience of excess skin. Results A follow-up visit was completed in 149 patients (78%). All ptosis measurements decreased after weight reduction except for ptosis on the thighs. When comparing objective measurements with patients’ subjective experience and discomfort from excess skin, we found little or low correlation in most body parts (r s .03–.67). The prediction analysis indicated that, for every centimeter of ptosis on the abdomen preoperatively, there was a 2-fold greater probability of having a postoperative ptosis on the abdomen of>3 cm (OR = 2.32, 1.76–3.07). Conclusion The objective measurement of excess skin provides unique information in postbariatric patients’ body habitus. Although the measured excess skin decreased compared with preoperative measurements, patients seem to become more aware of and disturbed and discomforted by it after the weight loss. Importantly, the objectively assessed measurements of excess skin correlated fairly with the perceived discomfort.

Objective: To evaluate the dental arch relationships for a consecutive series from Goteborg, Sweden, who had delayed hard palate closure. Design: Retrospective study. Setting: Sahlgrenska University Hospital, Goteborg, Sweden. Patients: The dental study models of 104 consecutive unilateral cleft lip and palate subjects. The study cohort was born between 1979 and 1994. Longitudinal records were available at ages 5 (n = 94), 10 (n = 97), 16 (n = 59), and 19 years (n = 46). Five assessors rated models according to the GOSLON Yardstick on two separate occasions each. Interventions: These patients had been operated upon according to the Goteborg protocol of delayed hard palate closure (at age 8 years). Results: 85% of subjects were rated in groups 1 and 2 (excellent or very good outcome), 12% were rated in group 3 (satisfactory), and 3% were assigned to group 4 (poor). No patients presented in Group 5 (very poor). Weighted kappa statistics for double determination of Yardstick allocation for five assessors demonstrated values between .65 and .90 for interrater agreement (good/very good) and between .70 and .90 for intrarater agreement (very good). Conclusions: Delayed hard palate closure as practiced in Goteborg since 1979 has produced the best GOSLON Yardstick ratings in a consecutive series of patients ever recorded worldwide, since the Yardstick was first used in 1983. However, it is noteworthy that a new protocol has been introduced in Goteborg since 1994, in which hard palate closure is done at 3 years due to concerns regarding speech.

ObjectiveTo describe articulation and speech symptoms related to velopharyngeal impairment in children born with an isolated cleft palate.DesignBlind assessment of speech at 3, 5, 7, and 10 years of age was performed. Two subgroups were formed based on the results at age 5 years, the no-VPI group and the VPI group, and they were compared with controls.SettingA university hospital.PatientsTwenty-six children born with isolated cleft palate. Seventeen children served as controls.InterventionsSoft palate closure at 7 months and hard palate closure at a mean age of 3 years and 11 months if the cleft extended into the hard palate.Main Outcome MeasuresPerceptual assessments of four variables related to velopharyngeal function and of articulation errors were performed at all ages. Phonetic transcriptions of target speech sounds were obtained at 5, 7, and 10 years and nasalance scores were obtained at age 10 years.ResultsThe no-VPI group continued to have no or minor difficulties. The VPI group improved but continued to have moderate velopharyngeal impairment. Both groups differed significantly from the controls at age 10 years. Persistent velopharyngeal impairment, as well as glottal misarticulation, were mostly found in children with the cleft as a part of a syndrome or together with multiple malformations.ConclusionSmall changes in velopharyngeal impairment were found across ages. Improvement seemed to be related to surgical intervention, and persistent problems seemed to be related to the presence of additional multiple malformations or syndromes.

The purpose of this study was to investigate the effects of velopharyngeal flap surgery on speech and its relation with the activity in the lateral pharyngeal walls. Videofluoroscopic recordings made before and after operation were used in this retrospective study, which comprised 28 patients who had pharyngeal flap surgery between 5:5 and 14:3 (mean 8:6) years:months of age at the Sahlgrenska University Hospital, Göteborg, Sweden. Twenty-four patients had different types of clefts and four had velopharyngeal impairment (VPI) without a cleft palate. Eleven had additional malformations. Speech and activity in the lateral pharyngeal walls were perceptually preoperatively and postoperatively. The study confirmed that patients with VPI can be helped by a velopharyngeal flap operation. There seemed to be a relation with the activity in the lateral pharyngeal wall and speech. The later the postoperative assessment, the better the speech, but the age at operation did not affect the result. The impact of additional anomalies and syndromes should be investigated further.

Skeletal muscle viability is crucially dependent on the tissue levels of its high energy phosphates. In this study we investigated the effect of the preservation medium Perfadex and illumination with Singlet Oxygen Energy (SOE). Singlet oxygen can be produced photochemically by energy transfer from an excited photosensitizer. The energy emitted from singlet oxygen upon relaxation to its triplet state is captured as photons at 634 nm and is here referred to as SOE. Rat hind limb rectus femoris muscles were preserved for five hours at 22 degrees C in Perfadex, saline, SOE illuminated Perfadex or SOE illuminated saline. Extracts of the muscles were analysed by 31P NMR. Data were analysed using two-way analysis of variance and are given as mean values micromol/g dry weight) +/- SEM. The ATP concentration was higher (p = 0.006) in saline groups (4.52) compared with Perfadex groups (2.82). There was no statistically significant difference in PCr between the saline groups (1.25) and Perfadex groups (0.82). However, there were higher (p = 0.003) ATP in the SOE illuminated groups (4.61) compared with the non-illuminated groups (2.73). The PCr was also higher (p < 0.0001) in the SOE illuminated groups (1.89) compared with the non-illuminated groups (0.18). In conclusion, Perfadex in this experimental model was incapable of preserving the high energy phosphates in skeletal muscle during 5 hours of ischemia. Illumination with SOE at 634 nm improved the preservation potential, in terms of a positive effect on the energy status of the muscle cell.