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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.

The European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) previously identified the need for harmonisation of breast reconstruction standards in Europe, in order to strengthen the role of plastic surgeons. This study aims to survey the status, current trends and potential regional differences in the practice of breast reconstruction in Europe, with emphasis on equity and access. A largescale web-based questionnaire was sent to consultant plastic and reconstructive surgeons, who are experienced in breast reconstruction and with understanding of the national situation in their country. Suitable participants were identified via the Executive Committee (ExCo) of ESPRAS and national delegates of ESPRAS. The results were evaluated and related to evidence-based literature. A total of 33 participants from 29 European countries participated in this study. Overall, the incidence of breast reconstruction was reported to be relatively low across Europe, comparable to other large geographic regions, such as North America. Equity of provision and access to breast reconstruction was distributed evenly within Europe, with geographic regions potentially affecting the type of reconstruction offered. Standard practices with regard to radiotherapy differed between countries and a clear demand for European guidelines on breast reconstruction was reported. This study identified distinct lack of consistency in international practice patterns across European countries and a strong demand for consistent European guidance. Large-scale and multi-centre European clinical trials are required to further elucidate the presented areas of interest and to define European standard operating procedures. Im Rahmen des ELF der ESPRAS wurde die Notwendigkeit standardisierter Richtlinien zur Brustrekonstruktion auf europäischer Ebene definiert. Ziel dieser Studie ist es, zunächst einen Überblick über den aktuellen Status, Entwicklungen und mögliche regionale Unterschiede der Brustrekonstruktion in Europa zu geben, wobei ein Schwerpunkt auf dem Angebot, der Verteilung und dem Zugang zur Brustrekonstruktion liegt. Es erfolgte eine internetbasierte Befragung von in der Brustrekonstruktion spezialisierten Plastischen Chirurgen, welche zusätzlich die nationalen Versorgungsstrukturen ihrer jeweiligen Länder überblicken. Geeignete Teilnehmer wurden über das ExCo der ESPRAS und nationale Delegierte von ESPRAS identifiziert. Die Ergebnisse wurden mit aktueller evidenzbasierter Literatur verglichen. 33 Teilnehmer aus 29 europäischen Ländern nahmen an der Studie teil. Im Vergleich zur Gesamtzahl durchgeführter Mastektomien war die Inzidenz der Brustrekonstruktionen in Europa relativ gering, vergleichbar mit anderen großen geografischen Regionen, wie z. B. Nordamerika. Die Verfügbarkeit und der Zugang zur Brustrekonstruktion war innerhalb Europas gleichmäßig verteilt, allerdings kann die geografische Region das Verfahren der Brustrekonstruktion (Eigengewebe vs. Implantat) beeinflussen. Deutliche Differenzen zeigten sich bezüglich Brustrekonstruktionen bei bestrahlten Patientinnen. Die Studie identifizierte ein ausgeprägtes Maß an Inkohärenz in den internationalen Standards zwischen den europäischen Ländern. Es besteht großer Bedarf für kohärente europäische Leitlinien. Europäische, multizentrische klinische Studien sollten initiiert werden, um eine evidenzbasierte Grundlage zu schaffen.

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 Executive Committee (ExCo) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) organized a first ESPRAS European Leadership Forum (ELF) to facilitate international exchange and to provide a platform for international leaders and delegates of national societies of Plastic Surgery to discuss common challenges. The presented manuscript presents key findings in a first effort of international harmonization and cooperation. Members of the executive (presidents, vice-presidents, secretary generals) and national delegates of Plastic Surgery national societies discussed hot topics in Plastic Surgery via the Zoom virtual conferencing system (Zoom Video Communications, Inc.). Attending participants responded to a virtual question answer session with questions being displayed throughout the webinar. The challenges associated with Aesthetic Surgery performed by doctors who are not board-certified Plastic Surgeons and Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) were perceived as major hot topics within most national societies. Both topics were discussed vividly. Education in plastic surgery and a European fellowship program for young Plastic Surgeons was favored by a large majority of participants. The implementation of European registries for free flaps, implants and for breast reconstruction were supported by the majority of respondents. The ESPRAS ELF provides a platform to propel international exchange and alliance, communication, education, research and future projects. A further virtual webinar with the topic "Strategies for Strengthening and Defending Plastic Surgery against Others" was suggested to be conducted in spring 2021. Das Exekutivkomitee (ExCo) der ESPRAS hat im Oktober 2020 das erste ESPRAS European Leadership Forum (ELF) initiiert, um den internationalen Austausch zwischen den verschiedenen nationalen plastisch-chirurgischen Gesellschaften zu fördern und eine Plattform für die Bewältigung gemeinsamer Herausforderung bereitzustellen. Das vorgelegte Manuskript präsentiert die wichtigsten Ergebnisse und Schlussfolgerungen dieses Treffens. Mitglieder des Vorstands (Präsidenten, Vize-Präsidenten, Generalsekretäre) und Delegierte der nationalen Gesellschaften für Plastische Chirurgie diskutierten aktuelle Themen der Plastischen Chirurgie über das virtuelle Konferenzsystem Zoom (Zoom Video Communications, Inc.). Über Zoom erfolgte zudem eine Umfrage zu verschiedenen international relevanten plastisch-chirurgischen Themen. Die Durchführung ästhetischer Eingriffe durch Ärzte ohne Facharztweiterbildung in der Plastischen Chirurgie, sowie das Brustimplantat-assoziierte anaplastische großzellige Lymphom (BIA-ALCL) wurden als die wichtigsten internationalen Herausforderungen der Plastischen Chirurgie erkannt, für deren Bewältigung auf europäischer Ebene ein standardisiertes Vorgehen diskutiert wurde. Weiterhin wurden aktuelle Entwicklungen in der Weiterbildung junger Plastischer Chirurgen eruiert, wobei die Etablierung eines europäischen Fellowship Programms von der Mehrheit der Befragten stark befürwortet wurde. Strategien zur Einführung von europäischen Registern für freie Lappenplastiken, Implantate und für die Brustrekonstruktion wurden erörtert. Das ESPRAS ELF stärkt den internationalen Austausch und die europäische Einheit in der Plastischen Chirurgie. Ein weiteres virtuelles Webinar mit dem Thema „Strategien zur Stärkung und Verteidigung der Plastischen Chirurgie gegenüber anderen“ wurde für das Frühjahr 2021 terminiert.

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.

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.

Introduction. The surgical techniques currently available for penile reconstruction for trans-men with gender dysphoria present with multiple drawbacks and often fail to meet patients’ expectations. Literature reports three cases where penile transplantation has been performed for cis-men, with the last two cases being considered successful. Aim. To determine whether an en bloc surgical dissection can be performed in a male cadaver, in order to include structures necessary for penile transplantation (from a deceased donor male) to a recipient with female genitalia in gender affirmation surgery. Method. The study was conducted in the form of explorative dissections of the genital and pelvic regions of three male cadavers preserved in phenol-ethanol solution. Results. The first two dissections failed to explant adequately all the relevant structures. The third dissection, which was performed along the pubic arch and through the perineum, succeeded in explanting the relevant structures: it, in fact, allowed for identification and adequate transection of urethra, vessels, dorsal nerves, crura of corpora cavernosa, and bulb of corpus spongiosum, in en bloc explantation of male genitalia. Conclusions. It is possible to explant the penis and associated vessels, nerves, and urethra en bloc from a cadaver. This study suggests a surgical technique for en bloc explantation aiming for transplantation of the penis from a cadaveric donor male to a recipient with female genitalia.

Background:. Different health conditions are treated in a Plastic Surgery unit, including those cases whose main goal is to enable patients to feel and integrate better within society and therefore improving quality of life, rather then physical functions. Methods:. We discuss moral principles that can be used as a guide for health professionals to revise and create policies for plastic surgery patients presenting with non–life-threatening conditions. Results:. A specific anatomical feature is not always an indicator of patient’s well-being and quality of life, and therefore it cannot be used as the sole parameter to identify the worst-off and prioritize the provision of health care. A policy should identify who preoperatively are the worst-off and come to some plausible measure of how much they can be expected to benefit from an operation. Policies that do not track these principles in any reliable way can cause discrimination. Conclusions:. A patient-centered operating system and patient’s informed preferences might be implemented in the process of prioritizing health. In circumstances when the effectiveness of a specific treatment is unproven, professionals should not make assumptions based on their own values.

Background: Breast reconstruction is an essential component in the treatment of breast cancer. Postoperative complications after breast reconstruction are common and affect patient satisfaction. Determining independent risk factors using patient characteristics could be advantageous for patient assessment and counseling. Methods: We retrospectively enrolled 623 consecutive patients who underwent reconstruction with a deep inferior epigastric perforator flap (DIEP), latissimus dorsi flap (LD), lateral thoracodorsal flap (LTDF), or tissue expander with a secondary implant (EXP) in this study. Information on demographic and perioperative factors was collected, as well as information on all postoperative complications. Logistic regression was used to analyze associations between possible patient-related risk factors and postoperative complications. Results: Smoking was associated with the highest number of early overall complications [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.25–3.37, P=0.0005], followed by body mass index (BMI) (OR 1.07, 95% CI 1.01–1.13, P=0.017). High BMI was associated with the highest number of late overall postoperative complications (OR 1.06, 95% CI 1.00–1.11, P=0.042), followed by history of radiotherapy (OR 1.66, 95% CI 1.01–2.74, P=0.046). When the risk factors were combined, the risk for postoperative complications rose exponentially. Conclusions: Our results provide evidence that patients should cease smoking and overweight patients should lose weight before undergoing breast reconstruction. Additionally, if the patient has received radiotherapy, the reconstruction method should be carefully chosen. High BMI, history of radiotherapy, and smoking are independent risk factors for many types of both early and late postoperative complications in breast reconstructive surgery. Combining these risk factors multiplies the risk of postoperative complications.

Background and aims: Longstanding uncertainty surrounds the selection of surgical protocols for the closure of unilateral cleft lip and palate, and randomised trials have only rarely been performed. This paper is an introduction to three randomised trials of primary surgery for children born with complete unilateral cleft lip and palate (UCLP). It presents the protocol developed for the trials in CONSORT format, and describes the management structure that was developed to achieve the long-term engagement and commitment required to complete the project. Method: Ten established national or regional cleft centres participated. Lip and soft palate closure at 3–4 months, and hard palate closure at 12 months served as a common method in each trial. Trial 1 compared this with hard palate closure at 36 months. Trial 2 compared it with lip closure at 3–4 months and hard and soft palate closure at 12 months. Trial 3 compared it with lip and hard palate closure at 3–4 months and soft palate closure at 12 months. The primary outcomes were speech and dentofacial development, with a series of perioperative and longer-term secondary outcomes. Results: Recruitment of 448 infants took place over a 9-year period, with 99.8% subsequent retention at 5 years. Conclusion: The series of reports that follow this introductory paper include comparisons at age 5 of surgical outcomes, speech outcomes, measures of dentofacial development and appearance, and parental satisfaction. The outcomes recorded and the numbers analysed for each outcome and time point are described in the series. Trial registration: ISRCTN29932826.

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.

Introduction Gynecomastia and/or mastodynia is a common medical problem in patients receiving antiandrogen (bicalutamide or flutamide) treatment for prostate cancer; up to 70% of these patients result to be affected; furthermore, this can jeopardise patients’ quality of life. Aims To systematically review the quality of evidence of the current literature regarding treatment options for bicalutamide-induced gynecomastia, including efficacy, safety and patients’ quality of life. Methods The PubMed, Medline, Scopus, The Cochrane Library and SveMed+ databases were systematically searched between January 1, 2000 and December 31, 2014. All searches were undertaken between January and February 2015. The search phrase used was:”gynecomastia AND treatment AND prostate cancer”. Two reviewers assessed 762 titles and abstracts identified. The search and review process was done in accordance with the PRISMA statement. The PICOS (patients, intervention, comparator, outcomes and study design) process was used to specify inclusion criteria. Quality of evidence was rated according to GRADE. Main Outcome Measures Primary outcomes were: treatment effects, number of complications and side effects. Secondary outcome was: Quality of Life. Results Eleven studies met the inclusion criteria and are analysed in this review. Five studies reported pharmacological intervention with tamoxifen and/or anastrozole, either as prophylactic or therapeutic treatment. Four studies reported radiotherapy as prophylactic and/or therapeutic treatment. Two studies compared pharmacological treatment to radiotherapy. Most of the studies were randomized with varying risk of bias. According to GRADE, quality of evidence was moderate to high. Conclusions Bicalutamide-induced gynecomastia and/or mastodynia can effectively be managed by oral tamoxifen (10–20 mg daily) or radiotherapy without relevant side effects. Prophylaxis or therapeutic treatment with tamoxifen results to be more effective than radiotherapy.

Cortisol is known to induce lipoprotein lipase (LPL) activity in human adipose tissue in vitro and in vivo such as in Cushing's syndrome. The significance of the glucocorticoid receptor (GR) for this induction was evaluated in the present study. The synthetic steroid molecule RU 486, a potent glucocorticoid antagonist, was used as a tool to block the GR, in vitro and in vivo. In addition to LPL activity, glucose tolerance, blood pressure and plasma lipids, all variables influenced by Cortisol, were studied in order to evaluate the peripheral antiglucocorticoid activity of RU 486 in vivo, in man. Addition of both Cortisol and RU 486 to incubations of human adipose tissue pieces significantly inhibited the increase in LPL activity that could be induced by Cortisol alone (p

Middle-aged men with abdominal obesity were treated in a double-blind study with moderate doses of transdermal preparations of testosterone (T), dihydrotestosterone (DHT), or placebo. This resulted in moderately elevated T concentrations and marked decreases in follicle stimulating and luteinizing hormones in the group treated with T, while the DHT group showed elevated DHT, markedly lower T values, and less diminution of gonadotropin concentrations. In the group treated with T visceral fat mass decreased (measured by computerized tomography) without significant changes in other depot fat regions. Lean body mass did not change. In the group treated with T, glucose disposal rate, measured with the euglycemic hyperinsulinemic clamp method, was markedly augmented. Plasma triglycerides, cholesterol, and fasting blood glucose concentrations as well as diastolic blood pressure decreased. There were no such changes in the DHT or placebo treatment groups. The men treated with T reported increased well-being and energy. In none of the groups did prostate volume, specific prostate antigen concentration, genito-urinary history, or urinary flow measurement change. It is suggested that supplementation of abdominal obese men with moderate doses of T might have several beneficial effects.