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The correct positioning of nipple-areolar complexes (NAC) during gender-affirming mastectomies remains a particular challenge. Recently, a Dutch two-step algorithm was proposed predicting the most ideal NAC-position derived from a large cisgender male cohort. We aimed to externally validate this algorithm in a Belgian cohort. The Belgian validation cohort consisted of cisgender men. Based on patient-specific anthropometry, the algorithm predicts nipple-nipple distance (NN) and sternal-notch-to-nipple distance (SNN). Predictions were externally validated using the performance measures: R2-value, means squared error (MSE) and mean absolute percentage error (MAPE). Additionally, data were collected from a Belgian and Dutch cohort of transgender men having undergone mastectomy with free nipple grafts. The observed and predicted NN and SNN were compared and the inter-center variability was assessed. A total of 51 Belgian cisgender and 25 transgender men were included, as well as 150 Dutch cisgender and 96 transgender men. Respectively, the performance measures (R2-value, MSE and MAPE) for NN were 0.315, 2.35 (95%CI:0–6.9), 4.9% (95%CI:3.8–6.1) and 0.423, 1.51 (95%CI:0–4.02), 4.73%(95%CI:3.7–5.7) for SNN. When applying the algorithm to both transgender cohorts, the predicted SNN was larger in both Dutch (17.1measured(±1.7) vs. 18.7predicted(±1.4), p= measured(±1.8) vs. 18.4predicted(±1.5), p= measured(±2.6) vs. 21.2predicted(±1.6), p = 0.025) and too short in the Dutch cohort (19.8measured(±1.8) vs. 20.7predicted(±1.9), p = 0.001). Both models performed well in external validation. This indicates that this two-step algorithm provides a reproducible and accurate clinical tool in determining the most ideal patient-tailored NAC-position in transgender men seeking gender-affirming chest surgery.

La Asociacion Profesional Mundial para la Salud Transgenero1 (WPATH) es una asociacion internacional profesional multidisciplinaria cuya mision es promover la atencion basada en la evidencia, la ed...

Summary Introduction Options for breast reconstructions enclose autologous tissue transfers or implants. Fat grafting is gaining more interest in this specific field of breast surgery. This study concentrates on the technique and aesthetic results of breast reconstruction with fat grafts combined with implants, in women who have undergone total mastectomy. Methods Breast reconstructions (n = 23) was performed using a protocol of intratissular expansion with serial deflation-lipofilling. In order to achieve the best aesthetic outcome, an additional small implant was placed. A retrospective data analysis was performed. In all patients a tissue expander was placed at the time of mastectomy or after removal of a previous breast reconstruction. The mean of lipoaspirate material for the reconstruction was 333 mL (range 120–715 mL). To create an adequate volume of the reconstructed breast, a supplementary small implant was placed, with a mean volume of 222 mL (range 125–375 mL). The mean follow-up was 33 months (range 19–50 months). Results A MRI analysis was performed in eight patients at least 9 months after the last lipofilling procedure, demonstrating a mean of 171 mL (range 64–538 mL) of transferred fat, a mean fat survival of 53% and a volume ratio of fat graft/implant of 0.97 (range 0,3–3,8). Conclusion This composite technique of using autologous fat tissue and implants shows aesthetic pleasant results and must be considered as a valid alternative in a subset of patients. Further investigations to optimize the fat graft take must be encouraged.

Full-thickness defects of the nasal ala can be challenging to reconstruct. The original texture, color and shape of this specific aesthetic unit requires careful planning of the surgical approach and technique in order to minimize donor-site morbidity and repetitive procedures. We describe the use of the chondrocutaneous composite auricular graft to -reconstruct a full-thickness defect of the ala of the nose with a successful and aesthetically pleasing outcome.

Transseksualiteit heeft weinig te maken met seksualiteit en is ook geen seksuele afwijking, maar heeft te maken met de genderidentiteit. Psychotherapeutische behandeling is echter vrijwel nooit succesvol, waar een geslachtsaanpassende behandeling wel positieve resultaten geeft. Men kiest daarom tegenwoordig steeds voor deze zogeheten gender reassignment. Die bestaat uit een eerste fase van psychologisch-psychiatrische begeleiding en diagnostiek, vervolgens een fase van hormonale behandeling en real life experience, en tenslotte de geslachtsaanpassende chirurgie. Deze bijdrage gaat dieper in op de vagino-clitoroplastiek bij man-vrouwtransseksuelen en op de nazorg en laattijdige follow-up bij deze patienten.

Objectives To apply a phalloplasty technique used in female-to-male transsexual surgery in male patients with penile insufficiency. Methods Seven male patients (aged 15 to 42 years) were treated with phalloplasty (6 with radial forearm free flap and one with anterolateral thigh flap) between March 2004 and April 2006 (follow-up, 9 to 34 months). All patients suffered psychologically from their condition, with low self-esteem and sexual and relational dysfunction. They were evaluated by a sexologist-psychiatrist before and after surgery. Erectile implant surgery is offered approximately 1 year after the phallic reconstruction. Results There were no complications concerning the flap. Two complications were reported in the early postoperative period. Two patients developed urinary complications (stricture and/or fistula). Patient satisfaction after surgery was high in 6 cases and moderate in 1 case. Psychological evaluation confirms this, especially on the self-esteem level. Four patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed. Conclusions This success has convinced us that phalloplasty is a valuable treatment for penile insufficiency. It has good results in terms of patient self-esteem and sexual well-being. This technique opens new horizons for the treatment of penile agenesis, micropenis, crippled penis, shrivelled penis, some disorders of sexual development, traumatic amputations, and cloacal exstrophy.

AimThe Belgian medical world has acknowledged the diagnosis of transsexualism and accepted Sex Reassignment Surgery (SRS) as one of the steps in the treatment of choice since 1985. This prevalence and demographic study analyses data on all Belgian individuals who have undergone SRS since that year.MethodsAll (188) plastic surgeons as well as all gender teams (Antwerp, Bruges, Ghent, and Liège) in Belgium were sent demographic questionnaires to be completed for each of their transsexual patients.ResultsThe results show an overall prevalence of 1:12,900 for male-to-female and 1:33,800 for female-to-male transsexuals in Belgium. In Wallonia (the French-speaking region of Belgium) the prevalence is significantly lower than in Flanders (the Dutch-speaking region) and in Brussels (the bilingual capital region). In the total Belgian population the male/female sex ratio is 2.43:1, again with a substantial difference between Wallonia on the one hand and Flanders on the other.Discussion and ConclusionWhile in Flanders and in Brussels the prevalence is comparable to that in other Western European countries, in Wallonia it is markedly lower. Transsexualism in Wallonia appears to be socially less acceptable: persons suffering from gender dysphoria in that part of Belgium encounter more problems accessing gender clinics and receiving treatment.

Perforator flaps are widely used in our unit for breast reconstruction. They provide ample tissue with minimal donor site morbidity together with long lasting aesthetic results. Increasing number of patients may have liposuction procedure which may jeopardise areas such as the abdomen and the buttock which are the donor sites for perforator-free flaps in breast reconstruction. Therefore, liposuction has been considered as a relative contraindication of raising perforator flaps. Six patients who had previous liposuction of the donor sites underwent autologous breast reconstruction with perforator-free flaps. Colour Duplex imaging was obtained in all cases preoperatively in order to evaluate the blood supply to the flap and to map the perforators. There were five deep inferior epigastric artery flaps (DIEP) and one superior gluteal artery perforator (SGAP) flap used. Total flap survival was obtained in all cases. Postoperative course was uneventful. Our results showed that raising perforator flaps after liposuction of the donor sites is possible. Preoperative radiological evaluation of the perforators is mandatory for such difficult cases.

The objective was to compare the outcome of a combined total hysterectomy-vaginectomy-phalloplasty procedure vs. a vaginectomy-phalloplasty procedure in female-to-male (FTM) gender dysphoric individuals, and to report on a large series of vaginectomies in young women. This was a retrospective study and the setting was the Gender Team at Ghent University Hospital. One hundred and five consecutive cases of vaginectomy-phalloplasty with (one-stage) or without (two-stage) total hysterectomy between 1993 and 2003 were included in the study. Patient files of 69 one-stage and of 36 two-stage procedures were reviewed and analysed. Operation time, the need for transfusions, complications, repeated surgery and hospitalisation time were the main outcome measures. Patients were equally distributed over the study period of 10 years. Comparing the two groups, there was a greater need for transfusion in the group of patients undergoing the one-stage procedure. There was no difference in operation time, rate of major complications or hospitalisation time. One-stage sex reassignment surgery (SRS) in FTM transsexual individuals is associated with more blood loss. However, there is no difference in operative and postoperative complications. Vaginectomy seems to be a safe and relatively simple procedure in FTM transsexual patients.

Transsexualism implies that an anatomically normal individual feels that he or she is actually a member of the opposite sex. Treatment usually includes real-life experience along with hormone therapy and sex reassignment surgery. Voice modification surgery may be necessary, as pass ability in general is still in a large extent dependent on the aspects of voice in transsexual people. Often male-to-female patients report being addressed in telephone conversations as their genetic gender, which is experienced as a disability. The purpose of this study was to evaluate the impact of voice on the quality of life in transsexuals. In order to detect the disability caused by a voice disorder, the validated assessment method the Voice Handicap Inventory (VHI) was used. An additional question about the way patients were addressed in a telephone conversation was added. As part of a study describing general health in transsexual persons, done at the Ghent University Hospital Belgium, a total of 48 patients we...

Background To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. Aims The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. Method From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects' initial assessment or treatment. Results On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.

The deep inferior epigastric perforator (DIEP) flap gained widespread popularity as a free flap in breast reconstruction. It is also a versatile and reliable supply of a large amount of skin and soft-tissue, which can be used in other types of reconstruction. We present 25 consecutive cases (28 DIEP flaps) performed in our service during the past 5 years for different indications in lower extremity aesthetic and functional reconstruction, both as pedicled or free flaps. The amount of tissue provided, its reliable vascular supply and long and adequately sized pedicles, together with its limited donor-site morbidity make it a useful alternative free flap.

A technique is described for autologous breast augmentation based on perforator flaps of the lateral chest wall. Raising these flaps as perforator flaps implies minimal donor site morbidity; however, the price to pay is a scar underneath the armpit extending from the lateral end of the inframammary fold onto the back. This scar can be relatively well hidden underneath the arm and in the brassiere. Indications depend on the aversion of the patient against prostheses and the extent of available tissue versus the desired augmentation. As typical indications, we would consider the occasional developmental asymmetry, autologous augmentation after contralateral breast reconstruction, or contour surgery in the bariatric patient.

The pyramidalis muscle is introduced as a new small muscle free flap, with description of its anatomy, the surgical technique and the clinical results in five different cases in which this flap was used to treat small recalcitrant wounds in the foot/ankle region. The pyramidalis muscle can be an alternative option in selective cases to reduce donor site morbidity as compared with more traditional free flaps.

Recent investigations have reported contradictory results on the influence of low-power lasers and polarized light on wound healing. Different biologic effects have been observed after light irradiation but the real benefits of phototherapy in the healing of wounds in patients are still controversial. This article reports on a randomized, prospective single blind study that was set up to evaluate the effect of polarized light (wave length 400–2000 nm, degree of polarization >95%, power density 40 mW/cm2, light energy 2.4 J/cm2) on the healing of standardized wounds. Twenty pairs of identical donor areas of split thickness skin grafts, taken on a similar location on each of the 20 patients, were treated according to an identical wound care protocol. The only difference was that one side was treated with polarized light and the other side without. The healing of these paired wounds was evaluated in a standardized manner and on a daily basis by two independent and blinded observers. The parameters assessed were: the degree of epithelialization, the quality of the granulation tissue, the degree of inflammation, the degree of infection, the aspect of the early scar tissue, blister formation, and the subjective feeling of the patient. Every parameter was scored on a 1–5 scale, with score 1 for the worst and score 5 for the best outcome. Long-term follow-up was performed after 1 month, 3 months, 6 months and 1 year. For all variables, except for infection and blister formation which was not seen in either group, highly significantly better scores were obtained in the donor sites treated with polarized light. Inter-observer agreement was acceptable to very good in all outcome variables. The results of this study demonstrated that polarized light had a beneficial effect on the healing of these standardized wounds, resulting in a faster epithelialization and an improved quality of early scar tissue formation.

The transverse rectus abdominis myocutaneous (TRAM) flap has been the gold standard for breast reconstruction in the last decade. The free deep inferior epigastric perforator (DIEP) flap and the superior gluteal artery perforator (S-GAP) flap are both refinements or “upgrades” of the conventional myocutaneous lower abdominal and gluteal flaps. The harvested skin and fat paddles are similar but none of the underlying muscle is sacrificed. The preservation of the continuity of the muscle fibers, the muscle's motor innervation, and the vascularization by collateral blood vessels ensures normal function of the muscle, only split during surgery, and the muscles that interact with it. The free DIEP and S-GAP flap have comparable complication rates to the free TRAM flap, making these flaps safe and reliable techniques. Although still a very low risk is involved, especially total flap loss, free perforator flap surgery for breast reconstruction is the surgical technique in which the least perioperative and postoperative complications are involved and this offers the patient the best long-term aesthetic result. Additionally, by sparing the donor site muscle and restoring sensation, the normal breast anatomy is imitated in the best possible way; except for a donor site scar, no other damage is caused to the body. The free DIEP flap is the first choice for breast reconstruction because of the inherent characteristics of the lower abdominal wall.

Old age, diabetes and atherosclerotic disease all have been considered to be relative contraindications for microsurgery. As such, gangrenous lesions of the lower limb traditionally resulted in staged amputations. A more aggressive approach, combining revascularization and free tissue transfer, allowed us to limit the level of amputation and to start early ambulation and rehabilitation, without the need for major orthotic help. Performing the vascular procedure, debridement, and free tissue transfer in one single intervention greatly reduces the number of operative procedures without substantial increase in operative time. Twenty consecutive patients underwent a combined free flap and revascularization procedure, two patients died perioperatively. One free flap was lost and needed replacement. All surviving patients were ambulating postoperatively.

Expansion of the forehead skin has been advocated in nasal reconstruction because it provides a flap that is longer and thinner, while allowing easy primary closure of the donor area. With appropriate changes in technique, the same excellent, or even better results in nasal reconstruction can be obtained without the need for tissue expansion. With this technique, a two-stage nasal reconstruction is performed with almost no need for secondary revisions. It eliminates the disadvantages of tissue expansion such as time loss, physical disfigurement, discomfort, extra operation and costs.

A new type of V- or W-shaped intralesional incision for tissue expander insertion is presented. The experience with 50 of these incisions in 36 consecutive patients in the period 1990-93 without any complication has proved the safety of this approach and the advantages of V- or W-shaped incisions over tangential or radial incisions.

Purpose Nonarteritic anterior ischemic optic neuropathy (NAION) is a common, visually disabling disease. It is usually due to a hypotensive perfusion insufficiency leading to infarction of the optic nerve. Only very rarely, NAION has a thromboembolic etiology. A transgender patient with a sequential bilateral NAION related to excessive use of transdermal estrogen is described. Methods A 44 year-old male to female transgender patient developed acute painless visual loss in the right eye (RE) followed by the left eye (LE) 2 months later. She underwent a full ophthalmic exam and an extensive etiological work-up. Results Visual acuity (VA) dropped to perception of light in the RE and, 2 months later, to 3/10 in the left eye. Fundoscopy showed a swollen disc in both eyes in the acute phase, which evolved into pallor later. CT-brain revealed old ischemic areas unrelated to VA loss. A diagnosis of bilateral sequential NAION was made. Predisposing risk factors, though both well controlled, were diabetes and arterial hypertension. Thrombophilia screening and cardiac work-up were negative. When estrogen levels of 60 times the normal value were measured, the patient admitted to overdose with transdermal estrogen to enhance her female characteristics. Such high estrogen levels are very thrombogenic. It is highly likely that it caused the cerebrovascular accidents and also triggered the bilateral sequential NAION. Conclusion NAION only rarely has a thromboembolic etiology. However, careful history taking is warranted to exclude modifiable risk factors in the poorly treatable NAION to prevent affection of the second eye and/or the central nervous system.

Segmental loss of the Achilles tendon with overlying soft tissue and skin defect remains a complex reconstructive challenge. Successful reconstruction combines tendon repair with coverage of the defect by soft tissue flaps, creating an entity that meets up to three predetermined goals: (1) approaching preinjury functionality, (2) resisting shearing forces, and (3) achieving an esthetic result. From June 2009 to June 2011, our center submitted six patients to a one-stage procedure correcting the Achilles tendon using a composite free anterolateral thigh (ALT) flap with vascularized fascia lata. The flap sizes ranged from 5 to 8 cm in width and 16 to 20 cm in length and all flaps included vascularized fascia lata which was rolled to serve as an Achilles tendon. After reconstruction our patients showed good functional results, these patients could walk, climb stairs, and tiptoe again without support. Moreover, normal footwear could be worn. A free composite ALT flap with vascularized fascia lata is a reliable option for coverage of Achilles tendon and overlying soft tissue defects, even in elderly patients.

Data on the necessity of performing screening mammographies in transsexual women are lacking. The main objective of this study was to assess the possibility to perform mammography and breast sonography in transsexual women. Fifty Dutch-speaking transsexual women were interviewed about the following: attitude towards mammography and breast sonography, importance attributed to and satisfaction with breast appearance, opinion about the necessity of breast check-up, expectations regarding discomfort during the exams and knowledge about the breast surgery. A fasting blood sample, clinical breast exam, mammography and breast sonography were performed. At mammography the following parameters were noted: density, technical quality, location of the prostheses, presence of any abnormalities and painfulness. At sonography the following parameters were recorded: density, presence of cysts, visualisation of retro-areolar ducts or any abnormalities. Twenty-three percent of patients are not aware of the type of breast implants and 79% do not know their position to the pectoral muscles. Patient satisfaction with the appearance of their breasts was rather high (7.94 on a scale of 0-10). Mean expected and experienced pain from mammography was low (4.37 and 2.00 respectively). There was no statistically significant difference in expected pain between those who already had mammography and those who did not. There was a significant positive correlation between the expected and the experienced pain. Mammography and breast sonography were technically feasible and no gross anomalies were detected. Since both exams were judged as nearly painless, 98% of transsexual women intended to come back if they would be invited. Since breast cancer risk in transsexual women is largely unknown and breast exams are very well accepted, breast screening habits in this population should not differ from those of biological women.

The objective of this paper was to report on a large series of laparoscopic hysterectomy in female-to-male (FTM) transsexual patients. A retrospective study was carried out by the gender team of Ghent University Hospital, Ghent, Belgium. The patient files of 83 consecutive cases of laparoscopic hysterectomy between April 2003 and August 2007 were reviewed and analyzed. The average operating time for the laparoscopic hysterectomy was 64 (30–150) min. The estimated blood loss for the laparoscopic hysterectomy averaged 86 (25–600) ml. We encountered two bladder perforations, which were immediately repaired, and one hematoma of the vaginal dome, which necessitated a second intervention. The serious complication rate of our series is 3.6%. Sex reassignment surgery (SRS) has proven to be the most effective treatment for patients with gender dysphoria. In FTM transsexual individuals, hysterectomy is an essential part of SRS. Since 2003, we have performed laparoscopic hysterectomy in conjunction with a subcutaneous mastectomy as a first step in SRS in FTM transsexual patients, thus, facilitating the transition for the patient and improving the operative planning for the different surgical teams. Laparoscopic hysterectomy has undoubtedly proven to be superior to abdominal hysterectomy regarding postoperative pain and recuperation, while it is as safe as the vaginal or abdominal route. We think that laparoscopic hysterectomy is the most appropriate method for hysterectomy in FTM transsexual patients.

The indication for microvascular free tissue transfer is usually exposure of vital structures, bone defect, or loss of function. Radical debridement and control of infection is a prerequisite for any kind of reconstructive procedure. This is especially true for untidy wounds in industrial or agricultural settings; in these, one should not hesitate to debride any tissue which is not obviously viable. Aggressive surgical debridement should be performed before flap coverage. Some organisms, however, fail to be eradicated by mechanical debridement as they are particularly pathogenic or embedded in the tissues. Perforator flaps are currently recommended for soft tissue coverage of the upper limb, for their pliability and the low morbidity of the donor site. A case of traumatic deglovement injury of an upper arm is presented. After free flap coverage, it was complicated by a rare and highly pathogenic fungal infection. Successful soft tissue reconstruction obtained with a chimeric free flap was compromised by an expanding fungal infection ultimately leading to limb amputation.

Objectives. Severe penile inadequacy in adolescents is rare. Phallic reconstruction to treat this devastating condition is a major challenge to the reconstructive surgeon. Phallic reconstruction using the free radial forearm flap (RFF) or the pedicled anterolateral thigh flap (ALTF) has been routinely used in female-to-male transsexuals. Recently we started to use these techniques in the treatment of severe penile inadequacy.Methods. Eleven males (age 15 to 42 years) were treated with a phallic reconstruction. The RFF is our method of choice; the ALTF is an alternative when a free flap is contraindicated or less desired by the patient. The RFF was used in 7 patients, the ALTF in 4 patients. Mean followup was 25 months (range: 4–49 months). Aesthetic and functional results were evaluated.Results. There were no complications related to the flap. Aesthetic results were judged as “good” in 9 patients and “moderate” in 2 patients. Sensitivity in the RFF was superior compared to the ALTF. Four patients developed urinary complications (stricture and/or fistula). Six patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed due to infection or erosion.Conclusion. In case of severe penile inadequacy due to whatever condition, a phalloplasty is the preferred treatment nowadays. The free radial forearm flap is still the method of choice. The anterolateral thigh flap can be a good alternative, especially when free flaps are contraindicated, but sensitivity is markedly inferior in these flaps.

Epithelioid sarcoma (ES) of the penis is a rare tumour. We present a case of ES of the penis in a 16-yr-old boy, for which penectomy and immediate reconstruction with a free forearm phalloplasty, including a urethral reconstruction, was performed. Because total penectomy is a dramatic life event for any patient, the option of immediate penile reconstruction is presented. It can help to prevent major psychological problems after this kind of surgery.

Background Raising perforator flaps is said to be a tedious procedure. The benefits, however, are great. In adults, perforator flaps have proved their usefulness and reliability in various clinical situations. In children, donor sites for free flaps are particularly scarce because of the need for a long and reliable vascular pedicle of sufficient size. There is also the need to minimize donor-site morbidity from aesthetic, functional, and psychological perspectives. Methods The authors present a series of 23 consecutive free perforator flaps performed by the first author in 20 children; ages at the time of operation ranged from premature (born at 28 weeks) to 16 years (mean age, 7 years 5 months). Three children presented with upper limb defects; the remaining 17 children sustained major soft-tissue defects of the lower limb. All the lesions necessitated extensive coverage with a free flap. Flaps used in this series included nine deep inferior epigastric artery perforator flaps, seven thoracodorsal artery perforator flaps, and seven compound ("chimera") thoracodorsal artery perforator flaps. Results All flaps but one were successful. With a follow-up of up to 7 years, the results in this series compare favorably with those of perforator flaps in adults or pediatric free flaps in the literature. Conclusions In children, as in adults, perforator flaps are a valuable alternative to the traditional muscle or myocutaneous free flap. Because of the added advantage of reducing donor-site morbidity, perforator flaps have become the authors' preferred option in reconstructive cases in children.

Nine cases of massive soft-tissue loss of the foot were reconstructed by means of a compound (chimera) thoracodorsal artery perforator (TAP) flap, which reconstituted the different functional units (dorsum, heel, instep, weight-bearing surface). In each case, the flap consisted of a skin component isolated on its perforator in combination with a portion of latissimus dorsi muscle and/or serratus fascia, all pedicled on the thoracodorsal vessels. The pedicle length allows up to 4-6 cm of independent mobility of the skin island. The mobility of the various flap components allows the various functional units of the foot to be reconstructed without relying on multiple flaps or anastomoses. The pedicle length was sufficient to be able to perform the anastomosis out of the zone of injury. In some cases the skin island was harvested along with intercostal nerve branches, this gave us the potential to develop a sensate flap. The indications and advantages of this reconstructive method are discussed.

Objective: The success of cleft palate surgery is specifically determined by the subsequent speech characteristics. There are several types of surgical techniques to repair the palate. The surgeon chooses his or her own technique according to the principles (s)he have established based on experience. The main purpose of this study is to determine and to compare the long-term speech outcome (18 years after surgery) regarding overall intelligibility, articulation, resonance, and voice after one-stage Wardill–Kilner palatoplasty or two-stage Furlow palatoplasty. The authors hypothesized that a decreased overall intelligibility, more compensatory articulation disorders, higher nasalance values and more nasality disorders would occur in the two-stage Furlow palatoplasty. Moreover, an increased risk for dysphonic symptoms, caused by the more intensive vocal tract activities, were expected in subjects with higher nasalance scores. An additional objective of this study was to compare the speech and voice characteristics with the age related normative data. Significant differences between the resonance and voice characteristics of the two techniques of palatoplasty and the normative data were hypothesized. Methods: Objective as well as subjective assessment techniques were used. The evaluation of the articulation included a phonetic inventory and a relational analysis in which the consonant and vowel productions were compared with target productions and analyzed for error types at the segmental level. The speech samples were perceptually judged for intelligibility and nasality. The Nasometer was used for the objective measurement of the nasalance values. The assessment of the voice included a perceptual evaluation and a determination of the Dysphonia Severity Index. Results: The subjects who received a two-stage Furlow palatoplasty showed statistically more hypernasality and higher nasalance scores in comparison with the one-stage Wardill–Kilner palatoplasty. No major differences regarding articulation and voice characteristics were found. As expected, significant differences were found between the speech intelligibility and resonance characteristics in subjects who received a palatoplasty and the normative data. Conclusion: Since the subjects who received a one-stage Wardill–Kilner palatoplasty had a significantly better speech outcome it was decided in the craniofacial team of the University Hospital of Ghent that a two-stage palatoplasty would no longer be performed.

Preoperative chemotherapy (PCT) can be used in large primary breast cancer to facilitate breast conservative surgery (BCS). Cosmetic results of BCS are influenced by the size of the residual tumour, relative to the size of the breast. After mastectomy, immediate breast reconstruction (IBR) with autologous tissue provides excellent cosmetic outcome and has proven to be safe in breast cancer patients. Besides improving overall and disease free survival, Quality of Life (QoL), body image and cosmetic outcome are also important issues after treatment for breast cancer. In this study, Health-Related-Quality of Life (HRQL) and body image were evaluated, in patients treated with PCT, followed by BCS, or skin-sparing mastectomy (SSM) and perforator-flap breast reconstruction. Additionally, clinical observers assessed cosmetic outcome. All participants were evaluated by the Medical Outcomes Study (MOS) 36-item Short Form Health Status Survey (SF-36, 36 items) and a study-specific questionnaire. An external panel evaluated standardised photographs of the breasts. For all patients, norm-based scores of physical and mental health state are comparable with the general population, except for vitality (VT) score, which is somewhat lower. No significant differences can be observed between both groups. The majority of the patients were satisfied with the appearance of their breasts. The cosmetic results, assessed by the clinical team, were significantly better for patients having IBR, compared to BCS. The mean score was 7.5/10 for IBR, versus 6.0/10 for BCS (p

Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition flaps and musculocutaneous flaps. These flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the perforator principle to the traditional musculocutaneous flap creates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, well-vascularized tissue can be transferred on one perforator without sacrificing important underlying muscles. The arc of rotation is also larger than in traditional flaps. The authors present an anatomic overview of three types of pedicled perforator flaps: the superior gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator flap. They also report 4 patients in whom a pedicled perforator flap was used to reconstruct a large lumbosacral defect.

Improved shock therapy has extended the limits of survival in patients with massive burns, and nowadays skin coverage has become the major problem in burn management. The use of mesh skin grafts is still the simplest technique to expand the amount of available donor skin. However, very wide-mesh skin grafts take a very long time to heal, often resulting in unaesthetic scar formation. On the other hand, allogeneic cultured keratinocytes have been reported as a natural source of growth factors and thus could be useful to improve wound healing of these wide-mesh grafts. A clinical study was performed to compare the use of cryopreserved allogeneic cultured keratinocytes vs. the traditional cadaveric skin as a double layer over widely expanded autogenous skin grafts. This procedure was performed in 18 pairs of full-thickness burn wounds (with similar depth and location) in 11 severely burned patients. Early clinical evaluation was made at 2, 3, and 4 to 5 weeks. Parameters such as epithelialization, granulation tissue formation, infection, and scar formation were evaluated. Biopsies were taken to compare the histological characteristics of the epidermis, the epidermal-dermal junction, and the dermis. Late evaluations were performed at 6 and 12 months regarding color, softness, thickness, and subjective feeling of the scar tissue. Aside from a faster (p < 0.05) epithelialization in the keratinocyte group at 2 weeks, there were no statistically different results in any of the early evaluated parameters, neither clinically nor histologically. At long-term follow-up, clinical results and scar characteristics were not significantly different in the two compared groups. It is concluded from the results of this study that, during the early phase, epithelialization was faster with allogeneic cultured keratinocytes compared with cadaveric skin. However, taking into account the substantial difference in costs, the described use of cryopreserved allogeneic cultured keratinocytes as a double layer on meshed autogenous split-thickness skin grafts can hardly be advocated.

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12-30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed preoperatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

A patient with Buerger's disease is described in whom reconstruction of a gangrenous forefoot with a free flap has been successfully performed. In order to limit the amputation level, a more aggressive approach toward reconstruction in young patients seems appropriate. To our knowledge, this is the first described case of free flap reconstruction of a gangrenous defect in a Buerger patient.

Despite aggressive approaches to revascularization of the lower extremity, many ischemic lesions still result in amputation. Causes of lower extremity amputation include nonreconstructible peripheral occlusive disease, failed arterial reconstructions and/or infected gangrenous lesions extending into underlying tendon or bone, even after successful revascularization.

Conventional tissue expansion with rectangular or round expanders often results in considerable dog-ear formation and, after resection, in lengthening of the final scar. The resulting scar is, always much longer than the maximal diameter of the skin lesion. These disadvantages are partially avoided by the use of croissant-shaped expanders. Taking the idea of the croissant-shaped expander and thinking further in terms of differential expansion, a new expander has been designed. It consists of a ring-shaped expander that is placed under the normal skin around the lesion. When the appropriate expansion is reached, the skin lesion is excised and the defect is closed with a running subcuticular suture, pulling as much skin as possible centripetally. The resulting scar is shorter than the maximal diameter of the skin lesion. The new expander has been tested in two patients in regions that are reputed for poor scar quality (the back and the upper arm). The results are encouraging.

Purpose Cloacal exstrophy is considered one of the most serious congenital anomalies. Boys present with insufficient penile development and formerly female gender reassignment was considered the treatment of choice. Recently bad outcome was reported in female assigned patients, so male gender assignment is preferred (1-2). In male gender assignment subsequent phalloplasty will be necessary. Due to former surgery in the pelvic region the gold standard phalloplasty using free tissue transfer is not preferred. We therefore offered a pedicled tissue transfer (anterolateral tigh flap ALT) to 2 boys with cloacal exstrophy and raised as boys. Material and Methods Two boys, age 17 and 18 years were seen after multiple reconstructions for cloacal exstrophy. They both had an augmented bladder with closed bladder neck and continent vesicostomy. In both boys a phalloplasty was done using an ALT flap. No urethral reconstruction was done as it was uneccesary. The urethra was left open at the base of the phallus for eventual sperm evacuation. Results Both procedures were uneventfull and in both patients a satisfactory result could be obtained. Both boys expressed their extreme hapiness with the result. Erectile devices will be implanted after 1 year. Conclusions With male gender assignment as gold standard approach to boys with cloacal exstrophy, we present the ALT flap as the method of choice for penile reconstruction.

Revascularisation of a critically ischaemic extremity by means of a free flap occurs through the development of vascular connections at the free flap-surrounding tissue interface. Three clinical cases are presented showing that in the particular situation of free tissue reconstruction of an ischaemic limb, vascular connections develop which are able at least partially to supply the free flap after occlusion of its arterial pedicle. One other case demonstrates similar vascular connections by angiography.

Since its original description more than 25 years ago, the radial forearm flap is universally considered as the golden standard for phallic reconstruction in female-to-male (FTM) transsexuals. Despite a supposedly worldwide use by many major gender teams, there is a relative paucity in the literature of large series of radial forearm phalloplasties. Moreover, although considered as an easy and reliable flap, the radial forearm has been reported to present more problems in penile reconstruction than when used in other areas (e.g. head and neck). In most publications, the reported complication rates are excessively high, and have discouraged surgeons as well as patients to continue with this kind of surgery. This article presents a review of 81 consecutive radial forearm phalloplasty procedures, performed by the same surgical team between 1992 and 2000. A detailed description is given of the immediate postoperative results, in addition to the findings on long-term follow-up. We specifically report on our experience and our current approach with: the operative sequence, preparation and position of the patient, choice and design of the flap, reconstruction of the fixed part of the urethra and vaginectomy, the recipient vessels and nerves, recommendations for re-exploration, handling of urinary tract complications, reconstruction of the scrotum, implantation of the penile stiffener and later follow-up. Special emphasis is put on the different refinements in technique, which have been made over this 8-year period to improve phalloplasty results both functionally and cosmetically.

A transsexual patient has the constant and persistent conviction that he or she belongs to the opposite sex, thus creating a deeply seated gender identity conflict. With psychotherapy being unsuccessful, it has been proven that in carefully selected patients, gender reassignment or adjusting the body to the mind (both with hormones and surgery) is the best way to normalize their lives. Optimal treatment of these patients requires the multidisciplinary approach of a gender team with the input of several specialties. Such a team consists of a nucleus of physicians who sees the patient more frequently: the psychiatrist, the endocrinologist, the plastic surgeon, the gynecologist and the urologist and a more peripheral group that sees the patients more incidentally: the psychologist, the otorhinolaryngologist, the dermatologist, the speech therapist, the lawyer, the nurse and the social worker. Between 1987 and 1999, a total of 71 male-to-female (MTF) and 54 female-to-male transsexuals have undergone gender confirming surgery in our hospital. This article gives a review and an update on the different surgical procedures as well as on the outcome in our patient population. The results in this series of patients clearly demonstrate that a close cooperation of the different surgical specialties, within our multidisciplinary gender team, is the key to success in treating transsexual patients.

A microsurgical pseudoaneurysm is a very rare complication after free flap surgery. The authors report a case of a free thoracodorsal artery perforator flap transferred to a degloving wound on the dorsum of the foot and ankle. The patient developed pedicle thrombosis caused by a septic pseudoaneurysm, which was treated by conservative means. Sufficient vascularization developed within 15 days after surgery and the flap survived completely. This is in sharp contrast to other reported cases of pseudoaneurysm formation, all of which were treated surgically and resulted in flap failure, except in one case. A critical review of the literature is presented and the factors influencing flap survival are discussed.