Croatian Medical AssociationCroatian Society of Plastic, Reconstructive and Aesthetic Surgery

University Hospital Dubrava, Zagreb, CroatiaDepartment for Plastic, Reconstructive and Aesthetic Surgery

Abstract book

5th CROATIAN CONGRESS FOR PLASTIC, RECONSTRUCTIVE AND AESTHETIC

SURGERY ESPRAS appointed Congress for 2004.

Editors: Sanda Stanec, Zlatko Vlajčić, Krešimir Martić, Franjo Rudman ml.

Dubrovnik-Cavtat, Croatia15th-20th October, 2004.

Naslovna strana – reklama ROZISTEP

5th CROATIAN CONGRESS FOR PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

ESPRAS appointed Congress for 2004.

Dubrovnik-Cavtat, Croatia15th-20th October, 2004

Abstract book

Organizer : Croatian Society of Plastic, Reconstructive and Aesthetic Surgery, Croatian Medical Association

Publisher : Croatian Society of P lastic, Reconstructive and Aesthetic Surgery and Znanje d.d., Zagreb, Croatia

Editors: Sanda Stanec, MD, PhD, Editor-in-Chief Zlatko Vlajčić, MD, Associate Editor Krešimir Martić, MD, Associate Editor Franjo Rudman ml., MD, Associate Editor

Printed by: Znanje d.d., Zagreb, Croatia

All rights reserved. No part of this publication may be reproduced, or transmitted in any form or by any means without prior written permission from the publisher.

5th CROATIAN CONGRESS FOR PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

ESPRAS appointed Congress for 2004.

organized by

Croatian Medical Association

Croatian Society of Plastic, Reconstructive and Aesthetic Surgery

University Hospital Dubrava, Zagreb, Croatia Department for Plastic, Reconstructive and Aesthetic Surgery

Local co-organizerCounty Hospital Dubrovnik

Under the auspicies of Dubrovnik – Neretva County logo

ORGANIZING COMMITTEE

CONGRESS PRESIDENTZdenko Stanec

President of the Croatian Society of Plastic, Reconstructive and Aesthetic Surgery (CSPRAS)

VICE PRESIDENTSMarko Margaritoni

Zdravko Roje

GENERAL SECRETARIESSanda Stanec

Rado Žic

TREASURERRudolf Milanović

ORGANISING COMMITTEEZdenko Stanec, Marko Margaritoni, Zdravko Roje, Rado Žic, Sanda Stanec,

Rudolf Milanović, Srećko Budi, Franjo Rudman, Krešimir Martić, Zlatko Vlajčić, Marina Mamić-Pavelić

SCIENTIFIC COMMITTEEJosip Unušić, Mišo Virag, Neven Olivari, Milomir Ninković, Radojko Ivrlač,

Vedran Uglešić, Mario Zambelli, Sanda Stanec, Rado Žic, Ivo Džepina

HONORARY COMMITTEEIvan Prpić, Đorđe Montani, Ivo Padovan

PAST CONGRESES ORGANIZED BY CSPRAS 1st Croatian Congress for Plastic, Reconstructive and Aesthetic Surgery, with international participation, Dubrovnik, 19. - 23. rujan 1998.

2nd Croatian Congress for Plastic, Reconstructive and Aesthetic Surgery, with international participation, Opatija , 4. - 8. rujan 1999.

3rd Croatian Congress for Plastic, Reconstructive and Aesthetic Surgery, with international participation, Split, 20.-24. rujan, 2000.

4th Croatian Congress for Plastic, Reconstructive and Aesthetic Surgery, with international participation, Zagreb, 25. – 28. rujan 2002.

PAST ESPRAS APPOINTED MEETINGS 1st European Appointed National Meeting: September, 3- 6, 1998, Istambul, Turkey

2nd European Appointed National Meeting: September, 2 – 4, 1999, St.Gallen, Switzerland

3rd European Appointed National Meeting: July, 5 – 7, 2000, Birmingham, UK

4th European Appointed National Meeting: October 1 – 5, 2003, Athens, Greece

CONGRESS SECRETARIAT:Department for Plastic, Reconstructive and Aesthetic SurgeryUniversity Hospital DubravaAvenija Gojka Šuška 6, 10000 Zagreb, CroatiaTel.: +385 1 290 2569/ Fax.:+385 1 290 2451/ E-mail: plkir@kbd.hr

From October 11, for all necessary informations regarding Congress, please contact the Congress Office:

CROATIA HOTEL20210 Cavtat, CroatiaSalon 5Tel: +385/(0)20/ 475-896 / Tel: 1896 (for calls from the hotel) Congress web site: www.kbd.hr/plastkir

CONTENTS

Lectures 1

SESSION A : Head and Neck Reconstructive Surgery

SESSION B : Head and Neck Aesthetic Surgery

SESSION C : Breast Reconstructive Surgery

SESSION D : Breast Aesthetic Surgery

SESSION E : Body Contouring

SESSION F : Upper Extremity Reconstructions

SESSION G : Microsurgery

SESSION H : Lower Extremity Reconstructions

SESSION I : Miscellaneous

Scientific Posters

Sponsors & Exhibitors

List of Participants

LECTURES

REKLAMA FOTONA

L1. Craniofacial deformity Prof. Ian T. Jackson Institute for Craniofacial and Reconstructive Surgery Southfield, USA

Craniofacial deformity can be relatively minor or it can be devastating. It can be congenital or it may result from trauma or tumor.CraniosynostosisA single suture involvement can be treated at any time; multiple suture involvement is associated

with raised intracranial pressure and suture release with skull fragment repositioning should be performed. Any suture may be affected. Measurement of head size is important in decision- making. Postural skull deformity should be diagnosed correctly,

and in most cases surgical treatment is not required. Molding helmets are employed if the deformity does not self-correct.

Crouzon and Apert SyndromesRarely is early treatment necessary, but with the advent of distraction osteogenesis there is a

move towards earlier correction. The long-term follow-up of this treatment is not, as yet, available - it may only be an Aevent in time@ and further distractions may be

necessary. The surgical management consists of frontosupraorbital advancement as required, with midface an advancement at the LeFort III level.

HypertelorismThe basic mechanism is that of a midline cleft and the severity is variable. Severe cases require early treatment to bring the orbits into their correct position and hopefully establish binocular vision. Secondary procedures are frequent, e.g. further osteotomies, nasal reconstruction, and palatal procedures. Facial bipartition is frequently indicated, this gives very stable and satisfactory correction. If there is a frontal encephalocele, this is resected and repaired at the same time as the bony correction.HypotelorismThis is a rare condition, however if it occurs orbital osteotomies are performed. The orbits are moved laterally and the midline defect is bone grafted.Hemifacial MicrosomiaThis occurs with varying severity, in the most severe cases all levels of the face are involved - skull, orbit, maxilla, mandible and soft tissue. The bony problems are dealt with by osteotomies and/or bone grafts. The soft tissue is augmented with free tissue transfer. Distraction osteogenesis will be used when indicated.Facial CleftsThese can involve specific cases or multiple facial regions. The minor clefts are treated in a relatively standard fashion by excision, local flaps, and suture, the more severe cases may need the addition of bone grafts, osteotomies or free tissue transfers, as indicated.

Team Approach in Craniofacial SurgeryThese complex anomalies require a multi-specialist approach with an experienced and dedicated team - a plastic surgeon experienced in the craniofacial area, neurosurgeon, maxillofacial surgeon, orthodontist, prosthedontist, pediatrician, social worker, experienced nursing staff, and a good anesthetic team.

L2. New techniques in breast reduction Prof. Phillip Blondeel Universitair Ziekenhuis, Gent, Belgium

L3. Emergency free flap reconstruction of lower leg trauma Prof. Zoran Arnež

Department for Plastic, Reconstructive Surgery and Burns, Clinical Center, Ljubljana, Slovenia

L4. Extended composite facelift Prof. Edgar Biemer Abteilung fur Plastische und Wiederherstellungschirurgie Klinikum rechts der Isar, Munchen, Germany

L5. Perspectives in corset platysmaplasty Prof. Richard C. Sadove The Sadove Clinic, Tel Aviv, Israel

L6. Breast augmentation: possibilities and impossibilities Prof. Rolf R. Olbrisch Klinik fur Plastische Chirurgie Diakonie-Krankenhaus, Dusseldorf, Germany

L7. Submucous cleft palate, methods of repair, our philosophy Prof. John Boorman Guy’s Hospital, London & Queen Victoria Hospital, East Grinstead, UK

Classic SMCP - Triad of featuresNotched posterior nasal spineBifid uvulaLucent midline strip

Occult SMCP No Intraoral signsSmall midline defect on endoscopy?Musculus uvulae absence

Clinical situation is more complexSpectrum of severityKey is abnormal levator insertionsExamination important

Lateral videofluoroscopy most useful

Presentation is at various stagesNeonatal examinationFeeding difficultiesFailure to thriveGlue EarSpeech problems – Velopharyngeal insufficiency

May be part of Velocardiofacial Syndrome (22q11 deletion)

Not all SMCP need treatment ~50% will speak normally

Treat when there is evidence of palatal dysfunction (feeding/speech)

Surgical optionsCorrection of muscle abnormality (Sommerlad / Furlow etc.)Pharyngoplasty if that fails

L8. Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis Prof. Andrej Banic Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital Inselspital, Berne, Switzerland

Objective: Sternal osteitis after median sternotomy causes considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach.

Methods: Sternectomy consisted of the resection of the entire sternum including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any re-stabilization of the thoracic wall. 13 patients received a vertical rectus abdominis musculocutaneous (VRAM) flap, 14 patients a pedicled latissimus dorsi musculocutaneous (pLDM) flap and 12 patients a free LDM flap (total of 40 flaps in 39 patients out of 66 patients who required surgical revision due to sternal osteitis out of 6'078 sternotomy patients).

Results: Two patients died within 30 days postoperatively (early mortality 5.1%), however, not due to sternal infection, which was cured without any recurrence in all patients. 17 patients (44%) required secondary, mostly minor operations due to local complications. Despite some paradoxical chest movements, the patient satisfaction was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3). The short- and long-term complication rates were similar in all three groups.

Conclusion: We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection even in the most severe cases, thus reducing infection-related mortality. The tradeoff was a substantial rate of local complications, which, however, did not cause any relevant morbidity.

L9. Malignant melanoma. Contemporary diagnostic procedures,treatment, and perspectives for the future Prof. Krzysztof Drzewiecki Department of Plastic Surgery, Rigshospitalet University Hospital Copenhagen, Denmark

Cutaneous Malignant Melanoma (CMM) comprises 3% of all malignancies. The incidence rate has tripled during the last 40 years. Middle-aged persons are most often hit by this tumour. Females are slightly overrepresented. UV-spectrum of sunlight is the most important external ethiological factor. Constitutional predisposing factors are freckled persons, who are sensitive to sunshine, persons with many naevi and congenital naevi. 4-10% of patients with CMM report about other single cases of CMM in their families. However, in less than 1% of the melanoma cases a gene defect can be detected. Dermatoscopy and SIA-scopy enhance the probability of a correct clinical diagnosis, provided the doctor is accustomed with this method. Clinical examination, sentinel node procedure, and microscopy are necessary to classify a CMM correctly – before the treatment. The American Joint Committee on Cancer (AJCC) has a staging system based on a TNM assessment, which should be usedThe standard treatment of CMM is surgery for primary lesion, surgery for secondary regional lymph node deposits and surgery when ever technically possible for distant metastases. Hypertherm Regional Perfusion treatment for regional metastases on the extremities is widely accepted. X-ray treatment is used for CMM metastases that are not accessible for surgery. Chemotherapy, biological modifiers and vaccines should only be used as part of a clinically controlled study, because they are experimental treatments. Interferons and vaccines are used in a clinical experimental setting as an adjuvant therapy following surgery in suitable patients.

L10. Functional free flaps reconstruction Prof. Milomir Ninković Department of Plastic, Reconstructive and Hand Surgery, Burn Centre, Technical University - Hospital Bogenhausen, Munchen, Germany

The transfer of a free microvascular flap is a well-established method in the reconstructive surgery. It provides tissue with a rich blood supply, which improves healing process, its resistance to infections, and quality of reconstruction. The technique settles freedom in flap design for optimal contour in accordance with size and shape of the defect. The timing of free tissue transfer after upper extremities injury seems to be a very important issue. The free flap closure can be divided according to time of reconstruction into three categories: primary free flap closure (within 24h), delayed primary free flap closure (2-7 days, and secondary free flap closure (after one week).Many factors besides timing of closure and the success of flap survival alone influence the functional outcome of the upper extremity reconstruction. For instance severity of injury, particular the nerve and muscle damaged, as well as length of bone loss etc.In this presentation all factors which influence the final result of upper extremity are discussed and principles of treatment are defined.

L11. Replantation Prof. Aurelio Portincasa Plastic and Reconstrucive Surgery Department

University of Foggia, Foggia (Italy) Definitions: Replantation: if a part is completely amputated, i.e. cut off without any

attaching structures (vessels, nerves, tendons, bone) whatsoever, it will be replanted

Revascularization: if a part has been deprived of its main blood supply, but there are connecting structures remaining, such as tendon or nerve, the part has been incompletely amputated and will be revascularized i.

Currently the ultimate success of a replantation attempt is judged by functional as well as cosmetic parameters.Meyerii state that patients with amputations proximal to the wrist joint but close to it are good candidates for replantation, as evidenced by Chen Grade I or II recovery in 80%.In general, upper extremities amputated proximal to the midforearm should not be replanted if the warm ischemia time exceeds 6 hours. The following are universal contraindications to replantation:

- concomitant life-threatening injury - multiple segmental injuries in the amputated part - severe crushing or avulsion of the tissues - extreme contamination

- inhibiting systemic illness (small vessel disease,

diabetes mellitus, etc) - prior surgery or trauma to the amputated part precluding replantation Return of function in forearm replantations depends largely on two factors: (a) the degree of nerve regeneration, and (b) the hand rehabilitation program iii. The most frequent complications in upper limb replantation and

revascularization are: infection (30%); inadequate debridement; nonunion and intrinsic muscle function weak or absent.

Excellent or good results are noted in patients with clean, guillotine-type distal amputations or incomplete proximal amputations with intact nerves.

Fair and poor results are associated with crush or avulsion injuries. The potential for functional recovery is directly proportional to the amount of viable tissue remaining iv v.

In the hand, all other criteria being favorable few surgeons would argue against replantation in the following circumstances:

- multiple finger amputations - thumb amputations - complete amputations of the hand at the palm or wrist - all amputations in children

i

REKLAMA JOHNSON – NASLOVNA STRANA

Zadnja strana jednaka

ii

Replantation is still controversial in the following clinical situations:

- loss of a single digit other than the thumb, especially the index

and digitorum superficialis (FDS) tendon insertion - single-digit amputations distal to the FDS insertion - ring finger avulsion injuries Other contraindications to replantation have been listed above. As regard the level of amputation, scapulothoracic amputation with brachial

plexus root avulsions represented the only real absolute contra-indication to replantation. Amputations through the arm to the wrist have the potential for recovery of useful functions, and should be attempted in selected cases after careful evaluation. The same evaluation and case selection is recommended for single digit and distal digital amputations.

There is general agreement on the absolute indication for replantation of the thumb, mid-palm, wrist, and forearm level in children so long as the part is not severely crushed.

Microsurgical repair of the tiny vessels of infants makes the operation technically difficult; on the other hand, functional return after replantation of digits in small children is often quite good. In the elderly, useful functional recovery cannot be expected with any reliability, thus any attempt at replantation in elderly patients should be carefully weighed against the potential systemic insult from the anesthesia and operation.

Clean, minimally crushed amputations yield the best results after replantation. Avulsion injuries, severely contaminated wounds, and amputations with multiple levels of injury are poor choices for replantation. Microsurgical repair in cases where the entire finger has been degloved does not result in good func t ion .

Kleinertvi believes that 12 hours or more of warm ischemia is a relative contraindication to digital replantation. Prompt cooling of the amputated digit to 4°C prolongs the acceptable ischemic period to over 24 hours, with a good chance of complete survival and full functional return.

Regarding the patient selection, his/her occupation, economic and social status, nationality, mental health and cooperativeness must all be taken into account when deciding whether to attempt replantation or not .

When performing a replantation, one must be particularly careful to place the anastomoses outside the zone of injury and to incorporate only undamaged vessel ends. Excessive shortening of replanted parts results in muscle-tendon imbalance and dysfunction.

The operative sequence varies according to the clinical situation and surgeon's preference. A common approach involves the following steps:

- preoperative patient evaluation and preparation

- identification of structures in amputated part

- identification of structures in the amputation stump

- bone shortening (minimal) and bony fixation - muscle-tendon unit repair - nerve repair - arterial repair (with or without recirculation) - venous repair - skin closure or soft tissue coverage

iii

iv

v

There are as many different standards for evaluat ing functional recovery after replantation (for sensation, motor outcomes, assessment to cold intolerance and all the indicators of complications) as there are reporting surgeonsvii.

For failed replants or for extremities that cannot be replanted at the time of injury, function can be partially restored by toe-to-finger or toe-to-thumb transplant. Leungviii and Frykmanix describe the technique and functional results of these transfers.

Transplantation of composite tissue allografts, such as a hand, offers immense potential in reconstructive surgery. Thus far, six human hand transplants have been performed with various degrees of success. A review of current replantation literature suggests that the prospect for significant functional return following a hand transplant is quite good so long as here is judicious patient selection and prevention of allograft rejectionx.

REFERENCES Mc Carthy: Replantation and revascularization of the upper extremity. Plastic Surgery, Vol.7, The hand, Part 1, May & Littler 1990, p.4356. Meyer VE, Chen Z-W, Beasley RW: Basic technical considerations in reattachment surgery. Orthop Clin North Am 12:871, 1981.

Chow JA et al: Forearm replantation — Long term functional results. Ann Plast Surg 10:15, 1983.

Russell RC et al: The late functional results of upper limb revascularization and replantation. J Hand Surg 9A:623, 1984.

Urbaniak JR: Replantation of amputated parts: Technique, results, and indications. In: AAOS Symposium on Microsurgery. St Louis, CV Mosby, 1979, pp 64-82.

Kleinert H, Jablon M, Tsai T: An overview of replantation and results of 347 replants in 245 patients. J Trauma 20:390, 1980.

Tamai S: Twenty years' experience of limb replantation: Review of 293 upper extremity replants. J Hand Surg, 7:549, 1982.

Leung PC: Thumb reconstruction using second-toe transfer. Hand Clin 1(2):285, 1985.

Frykman GK et al: Functional evaluation of the hand and foot after one-stage toe-to-hand transfer. J Hand Surg 11A:9, 1986.

Lee WP, Mathes DW: Hand transplantation: pertinent data and future outlook. J Hand Surg 24A(5):906, 1999.

SESSION A : Head and Neck

Reconstructive Surgery

A1. Vascular anomalies in the head and neck Berenguer B., P. Rodríguez, B. González, J., Enríquez de Salamanca Division of Plastic Surgery,Children`s Hospital “Niño Jesús”, Madrid, Spain

IntroductionDespite their high frequency, vascular anomalies continue to generate great confusion. On the one hand vascular lesions may look very similar, but have a completely different prognosis and treatment needs; on the other hand, persisting old descriptive terminology impairs precise communication in the literature. Daunting facial anatomy, gross disfigurement and social stress are significant issues that deserve special attention in the head and neck area. This study reviews the most recent advances in the management of vascular anomalies according to the Biologic Classification1, internationally accepted in Rome in 1996.Materials and MethodsBetween June 1999 and January 2004, 270 patients with vascular anomalies in the head and neck were seen in our Vascular Anomalies Unit (173 hemangiomas, 67 vascular malformations and 30 other vascular lesions).Capillary malformations were treated with pulsed dye laser. Surgical indication was limited to those with significant ectasia or tissue hypertrophy, most commonly seen in the lips. Venous malformations were percutaneously sclerosed with abslolute alcohol2, often followed by surgical excision and reconstruction.Disfiguring lymphatic malformations were mainly excised. Tedious dissections were required around cranial nerves. Isolated macrocystic malformations were sclerosed with OK 432 (Picibanil). In this group diffuse malformations often invaded the bone, requiring orbital or mandibular remodelling. Arteriovenous malformations were the most severe. In the quiescent stage, conservative treatment was recommended; growing or endangering lesions were embolized followed by wide excision and reconstruction. For the hemangiomas the first-line treatment was pharmacological. Surgery was indicated in 3 situations: -complications in the proliferative phase (ulcers, visual obstruction, air way obstruction),- functional, aesthetic or psycologic problems during the involuting phase and- functional or aesthetic sequelae after complete involution.Specific problems were addressed according to the nature and exact location of the lesion. The aesthetic subunit approach was stressed in facial surgery.ResultsResults of treatment of vascular malformations were rated as good to excellent, by the parents and 3 independent raters. The main complication was reexpansion of residual or neoformed vessels (32%). No recurrences

were observed in the hemangioma group. Results were graded excellent. The most frequent complication was hematoma (12%).ConclusionPatients with vascular anomalies of the head and neck suffer functional problems as well as distressing aesthetic deformities. Correct evaluation, near follow-up and precise treatment planning allow to obtain optimal results in most lesions 3,4. Interdisciplinary vascular Anomalies Teams offer the best therapeutic frame for these complex lesions5.

References 1.Mulliken, J.B., and Glowacki, J. Hemangiomas and vascular

malformations in infants and children: a classification based on endothelial characteristics. Plast. Reconstr. Surg. 69:412, 1982.

2. Berenguer B, Burrows PE, Zurakowski D and Mulliken JB. Craniofacial venous malformations: complications and outcome. Plast. Reconstr. Surg. 1999;104:1-11, discussion 12-15.

3. Berenguer B, Enríquez de Salamanca J, González Meli B, Rodríguez Urcelay P, Zambrano A, Perez Higueras A. Large involuted facial hemangioma treated with syringe liposuction. Plast. Reconstr. Surg. 2003;111:314-8.

4. Berenguer B, Mulliken JB, Enjolras O et al. Rapidly involuting congenital hemangioma: clinical and histopathologic features. Pediatr Dev Pathol. 2003; 6:495-510.

5. Berenguer Fröhner B, Enríquez de Salamanca Celada J, González Meli B, Rodríguez Urcelay P. Not all vascular birthmarks are angiomas. An Esp Pediatr.2002,56:127-38.

A2. Management of bilateral cleft lip and nasal deformity – state of the art Gonzalez B. Division of Plastic Surgery,Children`s Hospital “Niño Jesús”, Madrid, Spain

Surgical management of bilateral cleft lip and nose constitutes a challenge to every surgeon dealing with these patients.  These clefts deformities are often wide and are associated with premaxillary rotation and/or protusion and severe nasal impairment. Furthermore, its incidence is much lower than the unilateral cases and therefore there is shorter  experience in its management.

This presentation reviews the current state of the art, with special references to the therapeutic principles, the protocol of the “Cleft Unit” of the Children’s Hospital “Niño Jesús” and the aspects that are still under discussion.

The facial deformity in bilateral cleft lip presents several aspects that must be taken into account:- Severe loss of lip tissue.- Prolabium often small, short and wide, and lacking of orbicular muscle fibers.- Premaxilla protruded and rotated.- Severe nasal deformity: alar cartilages are flat and rotated caudally, subluxed respect to its anatomic position, and the columela is short or absent.

Thus, this is an extremely complex malformation for which several techniques have been developed. Currently, regardless of the protocols and

surgical techniques, the basic principles of treatment are:- Single stage primary cheiloplasty.- Primary reconstruction of the orbicularis oris muscle.- Use of the prolabium for lip reconstruction and not for the nose.- Primary correction of nasal deformity at the same time as lip repair.

However, important controversial issues still remain:- Previous lip adhesion.- Presurgical orthopedics.- Nasal aproach .- Primary gingivoperiostioplasty and/or  primary alveolar bone graft.

At the Hospital “Niño Jesus” we follow the present protocol of treatment:- We do not perform active presurgical orthopedics. Passive obturators and/or external compression bands are used to reduce premaxillary protusion.- Single stage primary cheilorhinoplasty at age two-three months.- Primary gingivoperiostioplasty only when maxillary segments are in favorable position. We never do a wide dissection.

Our surgical techniques have evolved over time as a result of enhanced technical skills and continuous analysis of the results achieved, including the comparison with those of other centers.  Individual  surgical techniques may not stand the test of time, and the principles on which they are based advance slowly.  Today we still see patients – children and adolescents- with severe sequelae, some of which are the result of previous surgical treatments and often are impossible to correct.

The development of multidisciplinary clefts units, in which a large number of cases are treated, offers the best care standards for these patients.

A3. Cleft lip and palate treatment – the way we do it Knežević P., Uglešić V., Jokić D., Ožegović I., Kovačić J. Department for Maxillofacial and Oral Surgery, Department for Otolaryngology, University Hospital Dubrava, Zagreb, Croatia

The treatment for cleft lip and palate is still in some way controversial, especially the timing of performing the procedure and also the technique. At our Clinic, Millard technique with a little modification for cleft lip was introduced more than twenty years ago. For the cleft palate, we actually use Langebeck technique in two acts. In the cooperation with our colleagues from Ludwig Maximillian University, Munich, last year we slightly changed the schedule of operation and introduced some new techniques in the procedure. With wide clefts, we operate on three months old babies, always performing lip adhesion with soft palate palatoplasty as a first act. Lip adhesion is followed by cheiloplasty, and later hard palate palatoplasty is done. In our opinion, this is optimal for cleft muscle reconstruction, which is the most important in the treatment of clefts. Although the final results are visible only at the age of adolescence, after the process of growing up is finished, with this article we wanted to present our first results.

A4. Nasal deformities in unilateral clefts of the lip Bagatin M., Bagatin T., Bagatin D. Policlinic for Maxillofacial, General and Plastic

Surgery “BAGATIN”, Zagreb, Croatia

Introduction: Clefts of the lip are followed with different nasal deformities. In unilateral clefts we primary find shorter columella, lower or more-less flat nasal wing, lower or lateraly displaced alar base and lower or unformed floor of the nostril.

Material and Methods: In this trial we included patients with unilateral clefts operated from 1990 to 2004. Authors analyse most common deformities of nose in unilateral clefts before and after cheiloplasty and they try to explain their origin, prevention and correction. Also patients with secondary nasal deformities are analysed and old and new secondary corrections of nasal deformities are presented.

Results: After cheiloplasty authors most often found lower and wider nostrils, less often lower or lateraly displaced alar base, asymmetrical tip of the nose and flat alar wing. Results of secondary corrections of nasal deformities show better results after new than old secondary procedures.

Conclusion: These deformities of nose after surgical correction are connected with different relationship of nasal structures, loss of tissue, deformities of growth and are reflection of primary deformation, selected surgical procedure, surgeon´s point of view, patient´s reaction to procedure. Authors modification of nasal muscle reconstruction give satisfactory result in primary and secondary procedures.

A5. Nose and lip hemangioma-merits of CO₂ laser Costagliola M., Polyclinique du Parc, Toulouse, France

Angioma of the nose (cyrano nose or pinocchio nose) considerably spoils the appearance of an other wise normal child. It is an hemangioma ie a capillary malformation present a birth. Sometimes hemangioma involves nose and upper lip : it is a Tapir angioma.

Superficial capillary hemangiomas or strawberry angiomas are immature and usually resolve with time. Because they go through several stages and there is the possibility that they will virtually disappear, they have been called “phasic angiomas”. Deeper sub cutaneus hemangiomas have a fibrous component (hamartomatous tissue) and will not disappear without treatment.

The CO2 laser is excellent because it is strongly absorbed by the tissues and therefore does not penetrate deeply (wave length = 10.6 microns).

So it is the treatment of choice for hemangioma of the nose because of these two modes : focalised for excision and defocalised for cocagulation and vaporization. An elliptical excision is performed in one piece. It is kept as small as possible and the nasal alae are spared. There is no bleeding, no edema and healing is good.

CO2 laser may not be revolutionary but it gives a good technological aid in plastic surgery treatment in this particular indication which is hemangioma of the face and the nose.

A6. Aesthetic reconstruction of the badly burnt face Parkhouse N., London, UK

A7. Free jejunum transfer for esophagus reconstruction Biemer E., Munchen, Germany

A8. Head and neck reconstruction with perforator flaps Masià J. Clinica Planas, Sant Pau University Hospital, Barcelona, Spain

IntroductionThe evolution of reconstructive techniques has resulted in the development of procedures that restore form and a sense of wholeness with minimal morbidity and high reconstruction specificity. In recent years, advances in perforator flaps have provided familiarity of the technique required for safe dissection, and in turn this has popularised the use of this flaps for a wide variety of indications.Many perforator flaps have been described for head and neck reconstruction: anterolateral thigh flap, deep circumflex iliac perforator flaps, toracodorsal perforator flap, peroneal perforator flap, abdominal perforator flaps, submental perforator flap … Nevertheless, ALTF has became the workhorse flap for soft tissue reconstruction.ObjectiveWe reviewed our indications and results of head and neck reconstruction with perforators flaps in the last 4 years. Materials and methodsRetrospective study, between 2001 and 2004, we have been using two kinds of perforator flaps for soft tissue defects:

- ALTF: 26 cases. - Taylor extended DIEP flap: 20 cases.

The soft tissue defects were intraoral reconstruction in 30 patients, midfacial in 10 cases and temporal area reconstruction in 6 patients. ResultsWe have had 3 cases of total failure due to a neck haematoma with no early re-exploration. ConclusionThe more complex nature of this kind of surgery, which include a longer learning curve and an increased operating time, is highly compensate for the quality of the reconstruction and the minimal morbidity of the donor site.The ALTF is an excellent flap for soft tissue covering of the face, neck and intraoral regions. It gives a large amount of skin with an adjustable thickness (ultrathin, thin, bulky). The vascular pattern allows the use of a more versatile design with double skin paddles based on multiple perforators. The flap may be used according to the chimaeric flap principle to reconstruct complex 3-dimensional defects, including muscle (vatus lateralis, rectus femoris) or/and fascia lata. Its pedicle is quite long and has a suitable vessel diameter. Other advantages are the possible innervation and the flow-through flap concept.The extended DIEP can provide a larger amount of tissue and the pedicle can be longer but, on the other hand, it is thicker and the indications for intraoral defects are reduced. Therefore, we use it as a second option or in cases where we need to cover a large defect or when we need an extremely long pedicle to reach the contralateral side of the neck or a thoracic vessel.

Both types have a lower donor site morbidity and allow two teams to work simultaneously.

A9. Challanges in microvascular reconstruction of the head and neck Milenović A., Uglešić V., Knežević P., Virag M., Lukšić I. Department for Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia

Aim of this presentation is to define the differences between microvascular reconstruction of the head and neck and rest of the body.

Subject The reconstruction of the head and neck defects, on one hand has been

revolutionized by the development of microvascular soft tissue transfer but on the other hand has been created numerous challenges for the microsurgeon.

Filling a defect was a microsurgical philosophy twenty years ago. Advances in microsurgical transplantation have improved reconstruction and today in the head and neck region we can reconstruct different tissues such as skin, mucosa, muscle, bone and teeth. We present various types of flaps and their usage in reconstruction of complex defects.

Reconstruction of maxilla and orbit after maxillectomy with combination of flaps supplied with subscapular artery, differences between various types of mandibular reconstruction and implanto-protetic rehabilitation will be presented.

A10. Free flaps for head and neck reconstruction : experience of 148 clinical cases Costa H. Cirurgia Plástica Centro Hospitalar , Porto, Portugal

The authors present their experience in head and neck reconstructions with 148 consective free flaps. The patients were 102 males and 46 females whose ages ranged from 8 to 81 years with a mean age of 48 years. Aetiology of the lesions was Traumatic in 12 cases, Tumours in 120 cases, Congenital in 7 cases, Iatrogenic in 5 cases and Infections in 4 cases.

The defects were located in different anatomical regions of the head and neck such as scalp, orbit, nose, soft-tissue of face, intraoral region and mandible. The reconstructions were accomplished by different free tissue transfers such as: omentum, jejunum, fasciocutaneous dorsalis pedis, fasciocutaneous and osteo-fasciocutaneous radial forearm flaps, scapular flaps, muscle and myocutaneous flaps (gracilis, inferior rectus abdominis and latissimus dorsi), myo-osseous flaps (deep circumflex iliac crest and anterior serratus) and myo-osseous and osteofasciocutaneous fibular flaps. Flap survival was 95% (138 revascularizations, 7 total necrosis and 3 marginal necrosis).

An analysis is made of surgical times, selection and survival rate of the free flaps and the morphofunctional quality of the reconstructions. Free flaps are

considered a first choise technique for head and neck reconstruction when the size and location of the defect prevents the use of local flaps.

A11. Radial forearm flap- still a good choice in head and neck reconstruction Knežević P., Uglešić V., Butorac L., Milić M., Glamuzina R. Department for Maxillofacial and Oral Surgery, Department for anaestesiology and intensive care, Department for traumatology, University Hospital Dubrava, Zagreb, Croatia The radial forearm flap was developed as a free flap technique in the 1981.

Soutar first used the radial forearm flap for intraoral reconstruction in the 1982. Several large series can now testify to the safety and reliability of the radial forearm flap in head and neck reconstruction. An extension of the technique to include a segment of underlying radius has proved useful in reconstruction facial bones, particularly the mandible. A further variation of this donor site uses the deep fascia, together with subcutaneous fat for facial augmentation.

In our work we would like to present the cases where the forearm flap was excellent and reliable choice in head and neck reconstruction. We have used it for intraoral reconstruction (hemiglosectomy, retromolar, soft palate and sublingual region), for the partial and full defects of facial skin and for mandible reconstruction as segmental part of bone or as on lay flap in the marginal mandibulotomy. When we have used osteofaciocutaneous flap for the donor site we always put external fixator on the radius. Except losing the small areas of split skin graft we haven't any other complications with donor region. The versatility of the donor tissues of the forearm makes this still the most useful donor area for head and neck reconstruction and it's excellent vascularity can be used to great advantage in a variety of instances in head and neck surgery.

A12. Lower lip, chin and facial reconstruction using the extended Karapandžic flap Zubčić V., Uglešić V., Knežević P., Zupičić B., Zubčić Z. Department of Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia

Introduction Large, full-thickness lip and chin defects after head and neck surgery

maintain to be challange f or reconstruction. Lower lip defects of less than 2/3 of the width of the lip can be reconstructed effectively with local flaps. Karapandzic modification of the fan flap was first described in 1974. for near-total lower lip defects.

We used modification of the Karapandzic flap for complex lip, chin and facial defects. Modified incisions are placed lateral to the nasolabial sulcus within the RSTL. Blood supply of the extended flap may be simply explained as a random-pattern flap or flap with the reverse flow from the angular artery.

Patients and Methods This procedure was used in eight patients in combination with other local

flaps and free flaps. Five patients had an intraoral cancer with the extension to the lower lip and chin. Two patients had a skin cancer of the face and oral commissure. One pateint had a lower lip cancer.

Simultaneous neck dissection was performed in seven cases. Radial forearm free flaps were used in three patient and free fibula flaps in two patients for intraoral lining and mandibular reconstruction. Pectoralis major myocutaneous flap was used for intraoral lining in one case. In one patient extended Karapandzic flap was performed in combination with Abbe flap and folded radial forearm free flap.

Results The wound healing was uneventful in all cases. Free flap survival was 100

percent. Seven patients were discharged without feeding tubes and remaining patient could have only a soft diet. Oral competence was excellent in all cases. The aesthetic appearance was acceptable to almost all patients.

Conclusion The goals of reconstruction are to restore oral lining, external cheek and

chin, oral competence and function. This modified technique can fulfil all requested goals of a good dynamic

reconstruction.

A13. Reconstruction of the anterior cranial base Aljinović- Ratković N., Virag M. Department of Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia

The defect of the anterior cranial base can develop in severe craniofacial fractures but also during the removal of the tumors of the naso-orbito-ethmoidal region. There are two main principles of covering these defects : 1. soft cover only (usually pericranial flap), 2. bone reconstruction (calvaria grafts) + soft cover (pericranial flap) which demands more skill in bone surgery. In this presentation we shall review our experience in combined (bone+soft) reconstruction of cranial base defects in 11 patients. In 10 of them the reconstruction was performed immediately ( in 3 after tumor removal and in 7 during fracture treatment) and in one patient as the secondary reconstruction of traumatic defect of cranial base with brain herniation.

A14. Cysts and benign tumors of the jaws: Kocaeli experience and a brief summary Agir H., Ozkeskin B., Sen C., Ustundag E., Cek D. Plastic and Reconstructive Surgery Department, Kocaeli Faculty of Medicine, Kocaeli University, Kocaeli, Turkey

Introduction: Cysts and benign tumors of the jaws are among the pathologies encountered relatively rare during daily practice and these lesions are well known with their confusing differential diagnosis and challenging reconstructions particularly in advanced or recurrent cases.Material and Methods: We evaluated our patients treated with the diagnosis of jaw cysts or benign tumors between 2002 and 2004 retrospectively

according to their age, sex, complaint, etiology, panorex radiographs, anatomical localization, surgical treatment and histopathological diagnosis.Results: Nineteen patients (11 males, 8 females) with an age ranging from 7 to 69 years were included into the study group. In six cases, lesion was located in the maxilla while in thirteen cases pathology was in the mandible. 78.9% of the cases were seen due to their mass and/or tooth related problems. In 46.15% of the mandible cases, the cyst was localized in the parasymphysis-corpus region whereas all of the lesions in the maxilla were located in the anterior maxilla-paranasal area. As a surgical treatment of choice, curettage and cyst wall burring were applied in fourteen cases, enucleation was done in three cases and mandibular resection was performed in two cases. In five cases, autogenous bone grafts were used to fill up the cavities. In two patients, free fibula reconstruction was performed successfully. Review of the histopathological results revealed five radicular cysts, three dentigerous cysts, two keratocysts and two ameloblastomas.Conclusion: In differential diagnosis of the jaw cysts and tumors, panoramic mandibular radiography and CT scanning play a major role. We believe that vigorous burring or excision of the cyst wall should be added to enucleation or curettage in cases which recurrence is likely. Besides, immediate bone grafting can be used for a more stable and cosmetic healing.

A15. From birth to maturity: a group of patients who have completed their protocol management Schnitt DE., Agir H., David DJ. Plastic and Reconstructive Surgery Department, Kocaeli Faculty of Medicine, Kocaeli University, Kocaeli, Turkey

The optimal management of the cleft lip and palate patient from birth to completion of treatment presents a formidable challenge to the plastic surgeon and the associated health care system. The multidisciplinary team approach for the management of these patients is widely accepted. However, a paucity of literature exists discussing specific protocol management, interventions, and the long-term outcomes of patients who have completed a strict treatment protocol with a consistent multidisciplinary team. The aim of this study was to present the details of the specific management protocol at the Australian Craniofacial Unit for cleft lip and palate patients and to present a group of patients who have completed this specific protocol and discuss the details of their long-term care. During a 28-year period from 1974 to 2002, the records of 337 patients treated for unilateral cleft lip and palate were evaluated. Of these 337 patients, 22 have completed the same specific protocol management. The same surgeon (David, the senior author) has been responsible for performing all operative interventions and for overseeing the care of each of the 22 patients, ensuring that the treatment protocol has been executed appropriately and without deviation. The interventions and outcomes were analyzed on the basis of speech, hearing, nasal airway, occlusion, psychosocial adjustment, and appearance. Speech results were assessed as normal speech, mild abnormality, or severe abnormality by objective measures, and intervention for velopharyngeal insufficiency was noted. Seventeen patients were rated as having normal speech. Four patients were rated as having mild speech abnormality, one patient was rated as having severe speech abnormality, and seven patients required surgery for velopharyngeal insufficiency. Hearing results were measured objectively, and good hearing results were obtained in 18 cases. Five patients required

tympanoplasty. All patients required alveolar bone grafting. The high Le Fort I osteotomy was performed in six cases. Bimaxillary surgery was performed in one case. Of all the patients assessed from birth to maturity, 13 required between three and five surgical interventions, and nine required six operations or more. Further details and photographs of preoperative and postoperative examples will be provided.

A16. Reconstruction of the posttraumatic deformities of the face Aljinović- Ratković N. Department of Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia

Posttraumatic deformities of the face are the most frequent facial deformities. Most of them are the result of skeletal deformity due to an improper initial treatment. In those patients deformity of the face is usually associated with functional impairment (double vision, malocclusion, nasal obstruction, etc.).

Out of 3130 surgical procedures performed in traumatized patients in the Department of Maxillofacial and Oral Surgery in Zagreb in a nine years period, 2172 (69.4%) were initial treatment of trauma and 958 (30.6%) were secondary surgery. Various reconstructive procedures were performed in 432 (44.2%) . The majority of the deformities were orbital and naso-orbital disfigurement. Bone grafting by use of free grafts was the most frequent bony reconstruction, followed by osteotomies and reosteosynthesis. Between corrective procedures for soft tissue deformity, the most frequent were eyelid, nose and lips reconstruction. Sixty four patients underwent more than five secondary corrections. The most challenging reconstructions shall be reviewed in presentation and discussed.

A17. Basocellular carcinoma medial angle of eye – surgical treatment Mujkanović N., Rifatbegović A., Pašić A., Burgić M. Plastic and Reconstructive Surgery, UKC Tuzla, Tuzla, Bosnia and Herzegovina

Basocellular carcinoma in relation with other tumors of skin is very frequent ( 80 -90%). In relations with periorbital region distribution of basocellular carcinoma is different. Palpebra inferior 48,9-72,1%. Medial angle of eye 9,62-27,6% and rest of location is lateral angle and palpebra superior. This tumor do local destruction and invasion, but metastasis are very rare 0,0028-0,1%, on other hand basocellular carcinoma has a tendency for endo and perineural metastasis. Relation between male and female are 3:2. Risk for BCK is 40% for male and 30% female, 19,6% on 100 000 citizens for male, and 13,3% for female. In this article we would like to present surgical treatment of tumors on medial angle of eye and reconstruction of defect with medial frontal-glabelar flap.

A18. Midface distraction – preliminary report Uglešić V., Jokić D., Knežević P. Department of Maxillofacial and Oral Surgery, University Hospital Dubrava,

Zagreb, Croatia

Midface distraction is a choice of treatment for selective group of patient with maxillary micro and retrognatism.

Treatment of the patient with maxillary micrognatism after surgery for cleft lip and palate will be presented. Orthodontic treatment, preoperative planning, selection of the distractor, surgery, course of distraction and its complications and postoperative results will be discussed.

SESSION B :Head and Neck Aesthetic

Surgery

REKLAMA HEBE

B1. Geometric and volumetric aspects of facial rejuvenation Wolfensberger C. Plastic and Reconstructive Surgery FMH, Zurich, Switzerland

With a short historical rewiew about evolution of facial rejuvenation surgery over the last three decades the autor is focussing on naturally looking results of facelifting surgery avoiding the so called ""surgical look",paying attention to geomtric aspects as :hairline,position of ear lobe,hight of upper lip (labial ledge) hight of forehead and brow position,as well as avoiding the "lateral sweep deformity" coming from overtightening the SMAS in the cheek area.Furthermore is is shown with typical case presentations,that facial rejuvenation surgery of our days has turned from skin tightening to repositioning and balancing volumes (volumetric aspects),from aggressive to subtle changes that last,from maximal to minimal access surgery and .last but not least - from complicated to simple with the conclusion that (sometimes)less is more !

The subperiosteal endoscopically assisted midface advancement and the Feldman-Corset-Platysmaplasty as state of the art techniques are included in this presentation.

B2. Periorbital surgery Richter DF. Department of Plastic Surgery Dreifaltigkeits-Krankenhaus, Wesseling, Germany

The increasing experience in the periorbita surgery and the recent findings in the anatomy of the orbital septum and associated ligaments results in an extension of the operative spectrum that can be performed by the upper and lower lid blepharoplasty. The most common and traditional approach to upper blepharoplasty has remained essentially unchanged and has not considered, to the same degree as in the lower periorbita, the actual changes that occur with age or more accurate surgical approaches toward rejuvenation These improved surgical techniques of the upper periorbita have been mostly limited to advances in brow lifting. But lateral extension of upper blepharoplasty incision allows the vertical myectomy of the lateral orbicularis oculi muscle for a lasting treatment of Crow's feet wrinkles what are common complaints in patients looking for facial rejuvenation. The same approach allows the surgeon to resect the corrugator supercilii muscle, with or without concomitant blepharoplasty, and is suitable for patients who have significant corrugator hyperactivity and deep frown lines without eyebrow or forehead ptosis. The resultant depression is eliminated with fat tranplantation removed during the blepharoplasty, or fat or dermis from other sites should the aesthetic plan not include eyelid surgery. Conventional lower blepharoplasty techniques that remove lower eyelid fat can create a concave contour deformity of the lower eyelids that causes the "operated" appearance. Effective repositioning of the malar fat pad was

found to be reliably obtained by release of the lateral orbital thickening and the orbital retaining ligaments. Suspension of the malar soft tissue is in a cephalad direction after release of these structures recreates a youthful facial architecture. It is a procedure that can correct postoperative problems caused by excess orbital fat removal, lower eyelid retraction, and contour problems resulting from malar augmentation. The knowledge of the anatomy of the periorbita and improved surgical techniques allows the surgeon a direct approach to the origin of the problem utilizing either the lower or upper lid blepharoplasty approach.

B3. Arcus marginal release in lower blepharoplasties Berrino P . Department of Plastic Surgery, Genova, Italy

B4. Lower eyelid blepharoplasty with TC septal suturing Sadove RC .

The Sadove Clinic, Tel Aviv, Israel

B5. Botulinum toxin a treatment of dysthiroid ophtalmopathy Stiglmayer N., Juri J., Tojagić M. Department of Ophthalmology, School of Medicine, University of Zagreb, Zagreb, Croatia

IntroductionAuthor the clinical use of botulinum toxin-A in the management of patients with dysthyroid eye disease. Treatment of Graves ophtalmophaty does not always provide favorable results. Glucocorticoids, orbital raditherapy and surgery are methods of choice but with a lot of effects. The aim of the study was to evaluate the use of botulinum toxine A reversible chemodenervation as the treatment of ophtalmopathy with „crowding syndrom“ due to extraocular muscle contraction, lidretraction and motility disturbance with diplopia. The injection technique, discussion of mechanism and complication are describedMaterials and methodesIn 62 patients with „active“ phase of dysthyrpid eye disease, 75 patients with diplopia due to motility disturbance and 93 patients with lidretraction only are treated with the injection of botulinum toxin A. A group of patients with “crowding sy“ were treated with retrobulbar injectionon protectionof inferior rectus muscle ( Botox 25-30j/0,25 ml) and in motility disturbances in projection of most affected ( inferior rectus muscle or into medialis rectus muscle or if necessary both, 5j+25j Botox ). Lidretraction was treated with botulinum toxin injection ( Botox 5-10j ) into levator muscle. The effectiveness and acceptability of the treatment was assessed clinically.ResultsIn all patients injections were tolerated well and congestion of the eye was diminished. In 72 patients ocular motility was improved and the angle of deviation was reduced.Retraction diminshed in all patients and in 2,8% ( 3 patients ) were ptosis as side effect.

Follow up was for mean of 9 months. Duration of benefit vary from 2 – 4 months with relaps of motility reductionand lidretraction.ConclusionIt seems that there is a place for the use of botulinum toxin in dysthyroid opthalmopathy as well as in “acute“ phase to reduce congestion and motility desturbances og in single symptom as retraction. Ther majority of these patients is employed and need binocular function in everyday professional activities as well as for driving. Lidretraction reduced protection of the eye on one side and gives very disfiguring ( frightened and angry ) appearance. Patients with thyroid faces differ from their former appeasrance and all of them in this study reported a beneficial effect from botulinum toxin A treatment.

B6. Orthognatic surgery – functional or aesthetic surgery Uglešić V., Jokić D., Knežević P., Gašparović S.* Department of Maxillofacial and Oral Surgery, Department for anaestesiology and intensive care, University Hospital Dubrava, Zagreb, Croatia

Orthognatic surgery can be a function and aesthetic operation. Patients, orthodontist and our indication for the surgery will be presented.

Preoperative planning, course of therapy, results and complications for genioplasty, mandibular advancement and setback, maxillary advancement and bimaxillary operations will be discussed.

B7. New approach to facial harmony - diagnosis and treatment in orthognatic surgery Costa H. Cirurgia Plástica Centro Hospitalar, Porto, Portugal

Individualized Geometric Analysis of Facial Harmony (IGAFH), represents a

new proposal of description and diagnosis of craniofacial structures, registered on lateral head film, in an attempt to overcome the multiple random and systematic errors and distortions, usually attributed to conventional cephalometric methods, and that very often cause discrepancy between clinical and cephalometric diagnosis and, very frequently, erroneous treatment planning.

Criticism has centred around the use of statistical standards as a means of diagnosis and treatment goals; the intra and inter-individual variability of intracranial planes; the geometric distortion of angular and linear measurements; the overestimating of hard structures evaluation; the discrepancy between soft and subjacent hard structures, etc,

To avoid the distortion of the cephalometric conventional methods, none of the above elements should be used in craniofacial diagnosing, since distortion begins when you start measuring and comparing these values to statistical standards.

This innovating method is based upon the ancient philosophical concept of harmony proposed by Aristotle and on the artistic concept of proportion by Leonard da Vinci; where measurements be substituted by proportional analysis and statistical patterns can be replaced by the use of the basic structures of the patient, which is, in this way, becomes his own sample. This

fact allows, for the first time, the individualization of craniofacial diagnosis, where the ideal of facial harmony can be established on a personal basis.

This issue is of paramount importance to achieve facial harmony, by those who have the responsibility of changing craniofacial structures and facial expression, such as orthodontists and both maxilofacial and plastic surgeons. With this very simple method, where proportion becomes more important than measurements, the above-mentioned professionals can find a very realistic and objective way to plan facial intervention, and avoid subjective evaluation, which very often leads to poor treatment results in consequence of distortion caused by evaluation of dismorphic faces.

B8. How I handle my facelift patient Olbrisch RR.

Klinik fur Plastische Chirurgie Diakonie-Krankenhaus, Dusseldorf, Germany

B9. Male face lift Glumičić S., Budinščak I. Polyclinic ‘’Glumičić Medical Group’’, Zagreb, Croatia

Increasing number of male patients throughout the last few years in our practice and their common wish for rejuvenation procedures, mainly FACE LIFT and BLEPHAROPLASTY, has influenced us to analyze the best surgical technique and difference in approach to MALE FACE LIFT in comparison with face lift in female patients. Due to different thickness of the skin, facial hair growth as well as stronger facial muscle structure, the incision for a face lift as well as technique it self varies comparing to the same surgical procedure in female patients. The author will show the preoperative planning, the placement of incision, depending on numerous factors, and the surgical approach it self. Also we will analyze and show the early and late postoperative result in male face lift, with a goal of achieving most natural and yet youthful appearance of man’s face.

B10. Tip surgery – open rhinoplasty approach Uglešić V., Knežević P., Milić M. Department of Maxillofacial and Oral Surgery, Department for anaestesiology and intensive care, University Hospital Dubrava, Zagreb, Croatia

Tip of the nose surgery is the most creative but in the same time the most demanding part of the rhinoplasty and the approach is still matter of controversy.

The aim of the presentation is to show open approach to the tip surgery and the manoeuvres that can improve projection, rotation, shape and definition of the tip of the nose. Special care will be paid to the cartilage grafting and suturing of the alar cartilages.

Pros and cons of the open rhinoplasty approach to the tip surgery will be discussed.

B11. Relation between functional and aesthetic nasal surgery Dobrović M. Private ENT Office, Zagreb, Croatia Many surgeons condsidere cosmetic rhynoplasty to be one of the most

challenging facial plastic surgery procedures. What distinguishes the art of rhinoplasty form other facial plastic procedures is teh paramount importance that the nose plays in both form and fuction. Preoperative endonasal assesment and causes of functional nasal disorders are discussed. The rhinoplasty surgen must be cognisant of the vital function of the nose at all times that he may either correct a preexisting functional impairement or avoid the potential pitfall of creating one.

B12. Comparision of cartilage scoring and cartilage sparing otoplasty – a study of 203 cases Mandal A., Bahia H., Stewart K. Department of Plastic & Reconstructive Surgery The Royal Hospital of Sick Children, Edinburgh, UK

Introduction The Edinburgh experience of different methods of otoplasty techniques in 203 patients (406 ears) over a 5 year period are reviewed.. Material and Methods The patients were divided into 3 groups – group A ( cartilage scoring), group B (cartilage sparing in the fashion of posterior suturing ) and group C ( posterior suturing refined with posterior fascial flap). Demographic details, operation technique, operation time, grade of the surgeon, suture materials, early and late complications, recurrence and revision rates, patients’ and doctors’ comments at the follow-up clinic were retrieved from the case notes. The pre and the post-operative photographs were assessed by a blinded lay observer and a doctor and scored on a visual analogue scale. Median follow-up was 9 months . Results The recurrence rate was 11.0%, 8.0% and 4.8 % in group A,B and C respectively ( p=0.0214). Complications were commoner in group A (8.8%) and group B ( 7.9%) compared to group C (1.2%) ( p= 0.0208). The cosmetic result was judged best in group C ( correlation coefficients > 0.86). Conclusion In our experience, cartilage sparing otoplasty refined with the posterior fascial flap results in significantly improved aesthetic and functional outcomes.

B13. Lip contouring and wrinkle filling in programmed steps by using autologic fat cells Busching K., Crnogorac V., Brockmann A., Hebebrand D., 1 Clinic for Plastic Surgery,Reconstructive and Hand surgery 2 Clinic for Internal Medcine, Diakoniekrankenhaus,

Rotenburg, Germany

IntroductionThe use of alloplastic, xenoplastic or autologic fillers are well known for lip contouring and other fillings in aesthetic face surgery. There are controverse opinions about the use of different synthetic fillers. We want to demonstrate our experience for lip contouring and recontouring with fat cell transplantation.Material and methodIn the period of 2002 to 2004 we performed the contouring and recontouring of lips and wrinkles in 17 patients. In the operation theater we evacuated the fat cells by liposuction usually in tumescent anaesthesia. The main donor region was the abdominal wall. The portion of fat cells were filled in an injector and applicated whith a big dissection needle. All injections were done by local anaesthesia. Every patient got pre operative and post operative photodocumentation. The first clinical examination and second photo documentation was taken after four weeks. We got no mesurement for verifying the effect. Every case was examined and discribed by the therapist. Differences could not even be measured without established standards of photodocumentation.Every patient underwent at least three steps of augmentation. The interruption of each treatment followed 5 to 10 weeks. The control period followed 3 to 22 month (mean: 16 month).ResultsThe terapy concept showed in every case a nearly successfull effect. After each procedure we noticed sufficient results whithout permanent effect for reason of swelling and haematoma. Only 10 to 20 % of the initial volume remained after four weeks as permanent. After final treatment 30 to 60 % remained as permanent. Nearly every lip contouring succeeded at least after three repititions.ConclusionFat cell replantation is a common and good possibility to augment wrinkles and to conture lip volume. A completely satisfaction will be reached if patients are sufficiently informed about the treatment concept and technical expense.

SESSION C : Breast Reconstructive

Surgery

REKLAMA ALERGAN

C1. Breast reconstruction with autologous tissue – TRAM flap or DIEP flap Elberg JJ. Plastic Surgery and Burn Unit, Rigshospitalet, Copenhagen, Denmark. Since Hartramph described the pedicle TRAM flap for breast reconstruction,

the lower abdominal skin and subcutaneous tissue has been the most popular donor site for autologous tissue breast reconstruction. In an effort to reduce donor site morbidity and optimise flap viability and breast design, the microsurgical free TRAM flap became increasingly popular throughout the nineties. The development of the perforator flap concept pushed this process even further with the introduction of the DIEP flap.

However Kroll questioned the superiority of the DIEP flap due to increased frequency of marginal skin necrosis and liponecrosis, which stressed the importance of peroperative evaluation of flap perfusion before breast design. The perforator flap concept has in many ways influenced the dissection of traditional flaps, which has led to limited tissue damage also in these flaps. The distribution, size and course through the muscle of perforators in the DIEP flad is subject to significant variability. Thus, some DIEP flaps can be dissected very easily, while others can be very time consuming, technically demanding with a potential risk of severe tissue damage.

Based on these considerations it has been our policy to perform a DIEP flap if the flap can be based on one or two perforators in a row and in all other situations to perform a muscle sparing TRAM flap with great emphasis on leaving the motor nerve supply undamaged.

C2. Predesigning the free TRAM or DIEP flap Boorman J. Guy’s Hospital, London & Queen Victoria Hospital, East Grinstead, UK

Method most applicable forDelayed > ImmediateSkin required > Skin sparingUnilateral> BilateralFree > Pedicled

We are trying to create a breast shapeDonor site is flatBreast is a rounded cone + gravity

Closing wedge principle Creates a cone from a flat surface

Measure opposite breast preoperatively Transpose mastectomy scarMark meridianMeasure from medial and lateral to meridian

1 To upper extent of breast2 along scar

3 to nipple4 along inframammary crease

Create template Transpose to infraumbilical area with skin under tensionCan be orientated either way up

Surgical detailsDeepithelialise portion for upper breast Ipsilateral or contralateral DIE vesselsTRAM or DIEP depending on tissue volume neededClose wedge before transfer to check viabilityInternal Mammary or Subscapular axis for anastomoses

C3. DIEP and SIEA for breast reconstruction: The importance of the superficial inferior epigastric vessels Masià J. Clinica Planas, Sant Pau University Hospital, Barcelona, Spain

IntroductionThe evolution of the reconstructive techniques has resulted in the development of procedures that restore form and a sense of wholeness with minimum morbidity and maximum reconstruction specificity. Following a physiologic and a logical approach if the breast is made of mammary glands and ductus suspended in fat, breast reconstruction should be done by fat and skin alone without muscle sacrifice. The abdominal perforator flaps (DIEP and SIEA) has become the gold standard for breast reconstruction, they combine an excellent tissue quality, a minimal donor site morbidity and, aesthetically, an acceptable abdominal scar. ObjectiveWe reviewed our results of breast reconstruction performed during the last 5 years utilizing abdominal perforators flaps. The emphasis of the review was to stress the importance of an accurate dissection of the superficial inferior epigastric vessels as the key to have the possibility of doing a SIEA flap or as the best lifeline in DIEP venous problems.Materials and methodsRetrospective study of 145 DIEP and 6 SIEA flaps for breast reconstruction during the last 5 years, we have grouped in:

- 30 first cases: DIEP learning curve. - 70 next cases: DIEP technique consolidation.

- 51 last cases: Preoperative multidetector CT perforator planning and the SIAE use introduction.

ResultComparing the three groups we have found a significative reduction of complications.

First 30 DIEPFs

70 next DIEPFs

51 last DIEPFs/SIEAFs

TRAM conversion

0% 1.4% (1) 0%

Total failure 3.3% (1) 4.2% (3) 1.9% (1)Partial necrosis >20%

10% (3) 2.8% (2) 0%

Partial necrosis < 20%

16.6% (5)

11,4% (8) 3.9% (2)

Operating time 10.5 h 8 h 6.5 h

ConclusionThe more complex nature of this kind of surgery, longer learning curve, increased operating time, is highly compensate for the quality of the reconstruction (permanent and natural). The superficial epigastric vessels are the key to the technical optimisation of the DIEP flaps reducing the venous drainage problems. Another important advance has been the use of the preoperative multidetector CT mapping, which allows us to be sure that we have chosen the dominant perforator of the flap. Nevertheless, in our experience, the SIEA flaps, despite having the minimal donor site morbidity, are not always the first option for breast reconstruction because blood supplied skin area is less predictable. The shorter length of the SIEA pedicle can present problems in right placement of the flap and in shaping the breast.

C4. Six year experience of early-stage breast cancer treatment with skin and nipple sparing mastectomy and immediate breast reconstruction Stanec S., Stanec Z., Žic R., Budi S., Milanović R., Vlajčić Z., Rudman F., Martić K. Department for Plastic Surgery, University Hospital Dubrava, Zagreb, Croatia

Skin sparing mastectomy, described by Toth and Lappert 1991., has been advocated as an oncologically safe approach for the management of patients with early-staged breast cancer that minimizes deformity and improves cosmetic result by preservation of the skin envelope of the breast. Verheyden 1998. described the nipple sparing total mastectomy for treating the premalignant lesions of the breast. Based on experiences of these and other authors, in past six years we have been treating the patients with T1 and T2 breast cancers with skin and nipple sparing mastectomy and immediate reconstruction, mostly using DIEP or latissimus dorsi flaps. We will present our strategy in early breast cancer treatment and discuss the

results and follow up of 43 patients treated with skin and nipple sparing mastectomy and immediate breast reconstruction.

C5. Our experince in the brest reconstruction with DIEP flap, the learning curve explored Bušić V., Das Gupta R., Begic A. Telemark Public Hospital Skien, Skien, Norway

The deep inferior epigastric perforator (DIEP) flap has been developed as the principle tool for secondary breast reconstruction in our department. This paper details our experience in learning and improving the technique with the help of an experienced outside team of surgeons. In our first 65 DIEP flap breast reconstructions our total flap loss rate was reduced from 9.5% to 0%, partial flap loss rate from 31% to 0%, and fat necrosis rate from 16.6% to 4.3%. We illustrate how departments can benefit from a staged approach to this complex reconstruction technique. Keywords: Deep inferior epigastric flap; breast reconstruction.

C6. Omega and inverted omega incision : a concept of uniform incision in breast surgery Vlajčić Z., Žic R., Stanec S:, Stanec Z. Department for Plastic Surgery, University Hospital Dubrava, Zagreb, Croatia

In the history of breast surgery, we have seen a lot of changes in orientation, position, and localization of breast incisions. Most of the biopsy incisions have been made with no consideration of future mastectomy or reconstruction because a wide ellipse of skin removed during the mastectomy included the biopsy site. The primary surgical treatment was in the competence of the oncologic or general surgeon. Reconstruction was not an integral part of breast carcinoma therapy and was considered as a secondary, unimportant treatment to be preformed by a plastic surgeon at a later date if desired by the patient. Wide acceptance of conservative breast operations, skin-sparing mastectomy, and reconstruction as an integral part of breast cancer therapy necessitates new consideration about the initial incisions used for breast biopsy. We consider the omega incision not only as a type of incision but also as a concept that can be used for all breast surgery, including biopsy, lumpectomy, skin-sparing mastectomy, and reconstruction.

SESSION D :Breast Aesthetic Surgery

REKLAMA BELUPO

D1. Breast Reduction Portincasa A., Foggia, Italy

D2. Treatment of moderate breast asymmetry by scarless tissue ressection (Case Report) Eder E. Koln, Germany

A significant breast assimetry can rarely be corrected only by means of simple augmentation. The additional scar related procederes are in most cases inevitable.In a case of 25 years old woman with apparent assimetry and ptosis I reduced conically the exsses tissue thrugh periareolar incission.A 310 Mc Ghan HP implant was implanted.After closing the resected fat-glandular tissue edges subcutaneously,a radical underminig of excess skin in medial and lateral direction was performed.After 6 weeks skin adapted completely .Both breast have symetric and satisfactory appearance.

D3. Vertical scar mammoplasty Mijatović D., Džepina I., Unušić J., Bulić K. Department of Plastic and Reconstructive Surgery, University Hospital “Zagreb” Zagreb, Croatia

In the time between 1996 and 2003 we preformed 52 breast reductions using vertical scar mammaplasty.Indications were breast hypertrophy and breast assimetry.Major advantages af theis method is absence of medial and lateral scarms whiched in our patients group were contur deformity in the lower breast pole, problems with wound heeling, NAC position.

D4. Breast reduction – comparison of different techniques Stanec Z., Stanec S., Žic R., Rudman F., Martić K. Department for Plastic Surgery, University Hospital Dubrava, Zagreb, Croatia As with numerous other procedures in plastic surgery, there are a multitude

of techniques described for the correction of mammary hyperplasia. The simple fact that so many techniques remain popular is a good indication that there is no one perfect technique that is applicable to every patient, and the plastic surgeon should have a few in his/her repertoire. As our understanding of both breast function and neurovascular supply has improved, increasingly reliable tissue survival is possible, and the main goal in reduction mammaplasty today is focused to minimizing the scars and to bettering the

aesthetic appearance and the durability of the resultant breast shape. We will present our own experience with different methods of breast reduction, depending on the patient,s individual characteristics and demands. From our point of view, the advantages and drawbacks of different techniques will be underlined and disscussed.

D5. Inverted nipple – surgical correction (Olivari) experience after 76 operations Olivari N., Department of Plastic Surgery Dreifaltigkeits-Krankenhaus, Wesseling, Germany

Inverted nipple is a congenital malformation (0, 5% of female population). Problems are nursing of child (often impossible), hygienic problems,

sometimes with infection and aesthetic problems. There are many methods for correction of inverted nipple, with large scars and high percentage of recurrences. All traditional methods are based on the principle to try save the duct. This is in the most cases impossible.

For the new method we need only small incision (3 – 4 mm) laterally of the nipple. All ducts and all fibrotic connections should be completely cut.

Following this suture with 5.0 Vicryl is preformed inside under mild tension. There is no need for skin suture. Operation can mostly be done under local anaesthesia. In 44 patients were preformed 76 nipple corrections. Average follow up was 23 months with average 34 years old patients. From 76 operated nipples there was no recurrence. In 4 patients were reported that they were able to nurse after operation

D6. Asymmetry of the breast as a plastic- reconstructive problem Margaritoni M., Bukvić N., Bekić M., Selmani R., Kostopeč P. Department of Surgery, Division of Plastic and Breast surgery, County Hospital Dubrovnik Dubrovnik, Croatia

The cause of the breast asymmetry differs from congenital to acquisitive, which is mainly a consequence of breast cancer treatment.The indications for surgical correction could be functional or aesthetic either it is partial or total breast reconstruction.Surgical techniques include use of autologoues tissues or breast implants as well as both techniques. Intervention could be performed on single or both breasts. Additional techniques could be performed to correct the size and shape of the breast and improve final results of the plastic-reconstructive treatment.The authors represent their own results in last few years.

D7. Illusions and disillusions in breast surgery : the difficulty of the art Echinard C.

Humani Terra International , Marseille, France    Breast surgery is linked to one of the most symbolic and mythical organ of

the women. It can be an easy surgery, or in some cases a difficult task. It can give very enthousiastic results, but can also lead to the worst catastrophies. this review aims at considering historical and philosophical aspects of breast surgery. It wishes to show that breast surgery is not necessarily a holiday party but must be considered with a great deal of honesty, meticulosity and art. It also recalls through different examples how difficult secondary breast surgery can be. It'll stress these difficult problems in breast reconstruction as well as in breast reconstruction or augmentation.

D8. Treatment of gynaecomasty Zambelli M. Polyclinic for Plastic Surgery, Rijeka, Croatia

D9. Capsule contraction and infection Olivari N. Department of Plastic Surgery Dreifaltigkeits-Krankenhaus, Wesseling, Germany

Certain publication indicate a connection between capsular contraction and bacterial infection ( Courtiss et al., 1979; Burkhardt, 1981).

We attempted to clasify this question on 88 patients (106 breasts) of our clinic, with major capsular contraction:- 106 capsule biopsy were sent to histological and bacteriological examination

- 106 intracapsular swabs were sent to bacteriological examination - 44 removed implants were sent to bacteriological examination It seems that coagulase-negative staphyloccocus (CNS) is involved in the

ethiology of capsular fibrosis. 62% of breasts were infected with CNS. Clinicaly consequence: Extreme aseptic procedure is required during breast

augmentation. The implantation pocket and the inlay should be washed with the antibiotics. Redon drainage should be mandatory at least for 24 hours.

D10. Special problems in breast augmentation Berrino P. Department of Plastic Surgery, Genova, Italy

D11. Augmentation and mastopexy - guidelines Richter DF. Department of Plastic Surgery Dreifaltigkeits-Krankenhaus, Wesseling, Germany

The challenge of these procedures, besides the operation, is to balancebetween the patients demands of becoming a beautiful breast with the least scars.

According to our own patients and our collected experience we can giveprecise recommandations for different treatment strategies.In the first place the grade of ptosis and the ammount of the wished volumehave to be analyzed.Some very important maesurepoints as well as the kindof ptosis are meaningful for the concept.The following parameters have prooved to be necassary: the distance of the nipple and the jugular fossa, the nipple diameter, the distance of nipple and sternum, and the length of the submammary fold.Depending on the outcome of our examination we can vary our different techniques starting from an "inside lift" with an implant only,to all the different methods as the circumvertical technique, the I-technique and the inverted T-technique. The implant location subpectoral or above the muscle also have to be evaluated.Through our experience we now tend to generously decide towards the more demanding procedure.We rather have more scars for a better result.

D12. Hydrodissection, safer and easier way for subpectoral breast augmentation. Eder E. Department of Plastic Surgery, Koln, Germany

The best aproach for subpectoral augmentation is doubtless the transaxillary one.If not endoscopically performed,the entire procedure remains a closed one ,without visual control of the operative field.Risk of an uncontrolled bleeding,and inadequat pocket creation is greater as with other techniques.The ifiltrating pump (Medicon LS I 10) and the corresponding infiltration cannulaused usually for tumescent lipossuction technique is a usefull device to infiltrate the saline solution combined with adrenaline and Xylonest, in the sub pectoral layer under pressure as to undermine the pectoralis muscle.After 20 min. the entire subpectoral region is anemised through the vasoconstrictive action of adrenalin.A relatively easy and gentle aadditional instrumental preparation is necessary to create a perfect pocket.Since november 2002 until september 2004 I performed 32 subpectoral augmentation using this technique.All patients received antibiotic prophilaction and Methocarbamol as adjunct therapy for post OP pain manegement.No complications were reported.

D13. 24 hours free pain breast augmentation. The «non touch» subfascial technique Keramidas E., Athens Centre for Plastic Surgery, London, UK

PurposeThe purpose of this prospective study was to determine whether the “non-touch” technique for breast augmentation, popularised by Dr Tebbets can predict a 24 hours return of the patient in normal activities without post-operative pain.Method and Material

Between September 2003 to May 2004, 70 patients underwent bilateral breast augmentation ,60 subfascial and 10 submuscular. The mean age was 25 years old.Surgical Technique1) All dissection is performed under direct vision, using only the monopolar foot-switching electrocautery , 2) Strictly no blunt dissection 3) Minimal bleeding; less than 10 ml at the end of the procedure, 4) No touching of the muscle or periosteum of the ribs, 5) No drainage in situ, 7) Minimal dressing ( Mepore).The evaluation of the patients included: a) Ability to raise theirs arms above their shoulder the first hours after the operation with no effort or pain. b) Haematoma, bruising or echymosis, infection, c) Post-operative pain for the first 5 days, using the visual analog score d) The time they started normal activities (walking, shopping, lifting light objects).Results68 (97%) patients were able to raise theirs arms easily 3 to 4 hours after the operation. No haematoma and no infection were observed and only 3 (4%) patients presented mild bruising. The mean pain score was 2.4 for the first 2 days (range 0-5) and dropped to 0.8 the next three days. 65 (93%) of the patients were able to start normal activities the next day with no pain. All patients were extremely pleased by their early recovery. ConclusionsThe “non-touch” technique could predict, in 93% of the cases, a 24 hours free pain breast augmentation with minimal to none complications.

D14. Surgical options vs. patient's demands related to the shape and size of the breasts in augmentation mammoplasty procedures Karabeg R., Karabeg A., Lacević S. Clinic for Plastic and Reconstructive Surgery ,University Clinical Center, Sarajevo, Bosnia and Herzegovina

IntroductionThe shape and the size of the prosthesis used in augmentation, together with the approach, depend on the patients' wishes and actual possibilities regarding the chest cavity size, breasts' symmetry, breast size and patients' age. Commonly, patients' wishes are not coordinated with their body's proportions and, therefore, not possible to achieve. Aim of workTo clarify some critera in achieving optimal aesthetic results.Material and methodsWe have analyzed 107 cases surgically treated at the Clinic for Plastic and Reconstructive Surgery and private clinic. Depending on the breasts' shape, we have performed the axillar, areolar or inframammary approach. Axillar approach was most commonly used in younger patients with breast hypotrophy without ptosis. Periareolar approach was performed in patients with bigger areolas. In cases where silicone prosthesis were used or if the areolar diameter was smaller, we have used prosthesis filled with a saline solution and with a valve. Inframammary approach was employed in patients with slight or moderate ptosis in order to keep the surgical incision hidden in the inframammary fold. If the patient asked both for the correction of the prosthesis and

augmentation, we have first performed augmentation which, by itself, partially corrects the ptosis and, after that, we carefully peformed the pexis in the same act.In slim patients with narrow chest cavity, we have used the anatomical or the ''tear drop'' shape with a high profile if the patient wanted bigger breats with emphasized projection. In asymmetry of the breasts we have used impalnts of different size in order to achieve the symmetry.Results and conclusionIn 101 cases we have achieved very good results. In 2 cases, the patients were subjectivelt dissatisfied with the size of the breasts, 2 patients were not satisified with the symmetry achieved and 2 patients were not satisfied with their shape. We should try to coordinate patients' wishes with objective parameters such as: the size of the chest cavity, constitution, age, pre-operative size and shape of the breasts. If the actual circumstances (constitution, age) allow, we sould try to fullfil patients' wishes in total and, at the same time, present our own aesthetic criteria which may be partially or completely accepted or rejected.Key words: augmentation mammoplasty, patients' demands, surgical options

SESSION E : Body Contouring

Prazno ili slika

E1. Predetermined «Fleur-de-lys” design for aesthetic abdominoplasty Costagliola M.

Polyclinique du Parc, Touluse University, Toulouse, France

The authors present a predetermined design of cutaneous resection for abdominoplasty without relocation of the umbilicus and associated liposuction. The design is characterized by two lateral tips, pointing upward, and a central dome, thus resembling a “fleur de lys”. The upper and lower edges of the cutaneous incision are of the same length, which prevents puckers and allows optimal evolution of the scar. The median cutaneous resection removes the horizontal base of the triangular area of pubic hair, producing a lower final scar and giving the mons pubis a more youthfull appearance. The abdominal skin and the oblique scars, placed in the natural folds, are easily concealed even under brief attire. Unlike individual resection techniques which require practice and experience, this technique is perfectly codified and can be carried out by less experience surgeons. The indications of the technique are detailed.

E2. Abdominoplasty complications: comprehensive approach for the treatment of chronic seroma with pseudobursa Roje Z., Roje Ž., Utrobičić I., Brajčić D. Division of Plasti Surgery and Burns Department of Surgery University Hospital «Split», Split, Croatia

Abdominoplasty is a large surgical operation, often followed by a great number of lolcal and general complications. Some studies indicate that the risk of severe complications, including mortality, ranges from 1 in 617 to 1 in 2320 cases. Seroma is a serious consequence that follows each type of abdominal contour surgery, from suction-assisted lipoplasty alone to standard and limited abdominoplasty. A case of a 46 years old women is presented, who was subject to the standard abdominoplasti with liposuction in the same act. In the course of the postoperative follow up examination the forming of seroma and pseudobursa was revealed. The pseudobursa was evacuated multiple times under the ultrasound control. During ona act of seroma evacuation, even 2010 ml of seroma were evacuated. Because of the prolonged forming of seroma, the pseudobursa was growing, what created the effect of a tumor in the front abdominal wall. In the course of the second operation – miniabdominoplasty with neo umbilicoplasty, the peseudobursa was completely excided. And the material was sent to the PH analysis. Space obliterating sutures were set up in more lines to decrease the dead space and to withhold the movement between the abdominal flap and the musculoaponeurotic layer, what is suggested by Saltz and Matarasso. Suction drainage lasted for 2 weeks after the second operation with a compressive girdle that was released periodically during the day. The follow up aws done 3 months after the second operation without forming infection, hernia, skin necrosis or any new chronic seroma with neo pseudobursa.Key words:Abdominoplsty complications, local and systemic complications, seroma, pseudobursa formation, surgical excision

E3. Liposuction Zambelli M. Polyclinic for Plastic Surgery, Rijeka, Croatia

E4. Reconstructive surgery of female genitalia. Congenital anomalies and oncological cases. Drzewiecki KT. Rigshospitalet University Hospital, Dept. of Plastic Surgery, Copenhagen, Denmark

Sex differentiation begins at the 5th week of the gestation, and it is completed by the 12th. week, when the external genitalia are fully distinguishable. The differentiation process can be impaired on different levels leading to varying degrees of anomaly and well-known clinical syndromes. Cases as gender ambiguity should be diagnosed as early as possible. A gender evaluation programme has to be followed. Treatment and surgery should preferably begin before the age of 2 years. Minor genital anomaly is usually not detected before puberty and should be treated shortly after the underlying disorder has been diagnosed.In many cases ablative surgery for malignancies in female external genitalia calls for reconstructive procedures. The ano-genital region is very well vascularised from 3 main vessels, therefore many local flaps can be used for reconstruction.chronic wounds such as the EPIBASE® graft, which corresponds to an epidermis sheet composed of cultured autologous keratinocytes. Hard to heal venous leg ulcers and necrotizing angiodermatitis benefit greatly from EPIBASE® treatment

SESSION F : Upper Extremity Reconstructions

SLIKA ILI PRAZNO

F1. Congenital hand deformities Enriquez de Salamanca Celada J. “Niño Jesús” Children’s University Hospital, Madrid, Spain

Introduction Congenital hand malformations still constitute a most exciting surgical field.

The ample variety of deformities demands a system of standardisation, beyond the classical description of operations found in textbooks.

Delivering a malformed newborn poses the mother a devastating psychological impact. A treatment plan with well-defined surgical goals helps overcoming it.

In this lecture I will try to communicate how we deal with such problems in our hospital, summarising the experience of the last fourteen years with over 350 operations performed by the same surgeon.

Material and methods We use the classification adopted by the I.F.S.S.H. But instead of applying

fixed surgical plans to the cases we think about a/ the requisites a hand should fulfil when reconstructed; b/ the functional objectives that have to be obtained; c/ the consideration aesthetics has in this kind of problems.

Results The requisites the hand should fulfil after operation are sensibility, mobility and

stability. In case of conflict between these two last parameters, the mobility is to be sacrificed and the hand is let in a favourable position.

The functional objectives are, in decreasing order of importance: 1/ lateral “key” pinch, the most useful of thumb pinching possibilities in day-life activities; 2/ power grip, 3/ receptivity, the possibility of extending the fingers and thumb and opening the webs; and 4/ “sapiens”, pulp to pulp, pinch.

Aesthetics is a contradictory item. Although not frequently avowed sometimes the surgery performed is not a quest for function but a trial to eliminate the stigmata of malformation. In these cases the objective is to reconstitute the normal, harmonic pattern of the contour using the same principle used by the designers of anthropomorphic characters in cartoons.

Quite on the contrary sometimes when looking for function the aesthetic appearance remains ugly or even worsens after surgery.

Conclusions Congenital hand deformities must be dealt with clear functional and aesthetic

objectives. This way useless procedures are avoided, real possibilities are offered, the expectations become realistic and the transference of the mother is made easier.

F2. Mutilating hand injuries a practical approach to classification Smith GD.*, Peart F.**, Kleinert H.*** *Selly Oak Hospital, Birmingham, U.K. **Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, Kentucky, USA ***University of Louisville School of Medicine, Louisville, Kentucky, USA

Mutilating hand injuries result in loss of all or part of the hand and compromise both the function and aesthetic appearance of the hand. They cover a broad spectrum of injury patterns and mechanisms, involve multiple structures and may require complex reconstruction. Individual description of these injuries is time-consuming and complicated. There is a need for a working classification for mutilating hand injuries which allows rapid communication between clinicians concerning the severity of the injury and helps in assessing the injury, providing a guide to likely treatment and prognosis.

We propose a new classification of mutilating hand injuries, to be applied from the carpus distally. It divides the injury into five main types according to the remaining functional digits and the expected grips they are likely to provide. Each type is divided into two subtypes depending on whether initial repair will require simple methods of closure or complex reconstruction or replantation. This varies depending on the individual circumstances of the patient, surgeon

and environment. We have retrospectively applied this classification to all mutilated hand injuries seen over an eight month period. We will give clinical examples of each type.

F3. Complex hand injuries Teo TC. Queen Victoria Foundation Trust Hospital, East Grinstead, UK

F4. Treatment of posttraumatic contractures of the hand Roje Z ., Roje Ž., Utrobičić I., Brajčić D. Division of Plasti Surgery and Burns Department of Surgery University Hospital «Split», Split, Croatia

Contracture of stiffness is the most common sequel of hand injuries associated with functional disturbance, which usually need additional surgical treatment. Principles of treatment based on diagnosis of the causative pathology.Three major types of posttraumatic contracture and stiffness are fallows:

1. Extension contracture of the MP joint of the finger 2. Flexion and/or extension contracture of PIP joint 3. Adductor contracture of the thumb

Additional two types of ischemic contracture are: 1. Volkman ischemic contracture of the forearm flexors 2. Intrising contracture of the interosseous muscles

Conclusion 1. Prevention is generally more effective than tretment of all types of contractures 2. The prerequisite of appropriate treatment for established contracture is correct diagnosis of the causative pathology 3. Various types of operative releasing procedures are well known and can be apply to solve the problems of the post-traumatic contractures of the hand

F5. Hand injuries on artificial ski slope Keramidas E., Rodopoulou S., Solomos M., Miller G. Plastic Surgery, Northern General Teaching Hospital, Sheffield, UK Introduction Skiing is very popular in United Kingdom with more than 30 artificial ski

slopes spreading all over the country. Our purpose was to find out the spectrum of hand injuries referred to our Unit after skiing in an artificial ski slope.

Materials and Methods From March 2002 to April 2003, 36 patients attended to our Department

following an injury sustained on artificial ski slope. 27 lesions concerned the thumb (16 fractures, 10 injuries to the ulnar collateral ligament of the MCP joint and 1 dislocation of the MCP joint. The rest of the injuries were 3 fractures of the fourth ray, 4 fractures and 2 joints dislocation of the fifth ray. 24 of the patients were operated.

Results Fractures of the fingers and especially of the thumb are the most common

type of injuries on the artificial ski slopes. On the contrary injury to the ulnar collateral ligament of the MCP joint of the thumb is the most common hand injury in snow.

Conclusions This study demonstrates the spectrum of hand injuries occurring in artificial

ski slope. Fractures of the thumb are the most common injuries, something that is not so common in snow skiing injuries. This indicates that the hardness of the artificial slope is traumatic to the hand.

F6. Closed reduction and external fixation of fractures of phalanges. Retrospective analysis of 50 consecutive cases Margić K. Department for Plastic and reconstructive Surgery, County Hospital “dr.Franc Derganc”, Šempeter pri Gorici, Slovenia

In the last four years 50 consecutive closed and unstable fractures of phalanges in adults were treated with closed reduction and external fixation (CREF). Among them 40 were isolated and 10 multiple involving more than one long digit. Fractures of thumb, terminal phalanx and avulsion or slice fractures were excluded. In all cases reduction was done under fluoroscopic control and first 1,4 mm k-wires were applied respecting the fracture configuration; additional wires were added as needed, connecting units were applied and connected with 2,0 k-wire. At the end of the procedure stability and passive mobility of all joints were checked. Controlled active exercises have started as soon as possible. After four weeks hardware were removed; full loading was allowed eight weeks after intervention. Mobility of injured finger was compared with the same finger on the uninjured hand and graded as excellent (full unrestricted mobility), very good (overall deficit of mobility equal or less than 150) and good (overall deficit of mobility equal or less than 300). Outcome results with at least 5 months of follow up were as follows: excellent 15/40, very good 9/40, good 2/40, poor 10/40 (including 3/40 refractures), and unknown 4/40. In multiple fractures as outcome result the mobility of the worst finger was chosen: excellent 5/10, good 2/10, poor 2/10, died form unrelated causes 1/10. The fact that more than 72% of patients with isolated and more than 77% with multiple fractures of phalanges have overall restriction of finger mobility equal or less than 300 confirms that CREF is simple and effective option in the treatment of unstable phalangeal fractures.

F7. Pins and rubber traction system for coplex fractures of the hand Keramidas E. Miller G. Plastic Surgery, Northern General Teaching Hospital, Sheffield, UK

IntroductionWe present the surgical technique and our results of the use of the pins-and-rubbers traction system (Suzuki frame) for repair of complex inraarticular fractures and fracture-dislocations of the fingers.Material and methods

From February 1999 to April 2003 we used the Suzuki frame technique in 20 patients. Six of them had sustained fracture-dislocation of the PIP joint, five had sustained comminuted intraarticular fracture of the same joint, three had complex inrtaarticular fracture of the MCP joint of the thumb and two had intraarticular fracture of the IP joint of the thumb. Four patients were lost in the follow-up. The mean age of the patients studied was 26 years old and the mean follow-up was 20 months.Results The mean range of active motion was 82° (range60-105°) for the PIP joint, 88° for the MCP joint of the thumb and 58° for the IP joint of the thumb. Two pin track infections were successfully treated with antibiotics. Only two patients had poor functional results.ConclusionsThe treatment of complex inraarticular fractures of the fingers is a difficult problem. Using the aforementioned technique we can achieve very good results in these difficult situations. The technique is a simple one using only K-wires and elastic bands, it allows immediate mobilization and it is less bulky than some of the other distraction-mobilization devices described in the literature.

F8. Painful posttraumatic states: ignored and poorly understood problem Margic K., Pirc J. Department for Plastic and reconstructive Surgery, County Hospital “dr.Franc Derganc”, Šempeter pri Gorici, Slovenia

In present retrospective study we have tried to distinguish some subtypes in poorly understood area of posttraumatic painful states. Complex regional pain syndrome (CRPS), being on the top of them is characterized by combination of sensory, motor and autonomic nerve system symptoms. International Association for Study of Pain described continuous pain as the leading criterion in CRPS. The term “continuous pain” is ill defined. It can represent intermittent pain (use-related, work-related) and continuous spontaneous pain with exacerbations during use and work, awakening patients during night etc.

We have analyzed data of 51 consecutive patients fulfilling modified research IASP criteria for diagnosis of CRPS involving upper extremity. Since primary or secondary role of sympathetic nerve system in painful states is still debatable we have used quality of pain and motor impairment as principal criteria for subdivision. Patients with continuous pain, sympathetic disturbances but without motor impairment described by Birklein and al. as exaggerated posttraumatic pain state were excluded. Our analysis suggests few possible subgroups: a.) subgroup with use-related pain and motor impairment but without spontaneous pain; b.) subgroup with diffuse spontaneous pains and numerous painful trigger points, c.) patients in whom after the treatment of fully blown CRPS I evident clinical pathology was found; d.) subgroup where hospitalization and physical therapy were enough for all symptoms to disappear; e.) subgroup with psychiatric, psychologic problems or malingering; f.) fully blown CRPS. Our still developing program of treatment consists of hospitalization, physical therapy, local blockades of painful points, and continuous regional analgesia in refractory cases.

F9. Surgical treatment of carpal tunnel syndrome Mircevska - Zogovska E ., Naceska A., Dzonov B., Mircevski V. Clinic of Plastic and Reconstructive Surgery, Skopje, Macedonia

During the last 10 years, we have observed and treated 39 cases presenting carpal tunnel syndrome.

The cause of compression in case of carpal tunnel syndrome may vary as in our series:

1. Carpal tunnel lipoma: 2 cases 2. Epidermoidal cyst of the skin occupying carpal tunnel: 1 case 3. Neurofibromatosis: 3 cases 4. Hypertrophy of the transversal ligament: 4 cases 5. Tendovaginitis: 15 cases 6. Oedema of the transversal carpal ligament: 9 cases 7. Postoperative fibrosis in cases operated in other centers (transverse carpal ligament incision only): 5 cases Thirty five had surgical excision of the transversal carpal ligament and

only incision has been done in four cases.Our follow up has been from 6 months up to 2 years. We have not seen recurrences.

In conclusion we prefer surgical excision of transversal carpal ligament to avoid surgical pitfalls in case of carpal tunnel small space occupying lesion and to avoid recurrences.

F10. Rehabilitation programm by bilateral hand transplantation Ninković MK., Ninkovic M.M.*, Piza H.**, Gabl M.***, Margreiter R.**** Innsbruck Medical University, Department of Surgery, Unit of Physical Medicine and Rehabilitation, Innsbruck, Austria *Technical University - Hospital Bogenhausen, Department of Plastic, Reconstructive and Hand Surgery, Burn Centre, Munich, Germany ** Innsbruck Medical University, Department of Plastic and Reconstructive Surgery, Innsbruck, Austria *** Innsbruck Medical University, Department of Traumatologie, Innsbruck, Austria **** Innsbruck Medical University, Department of Surgery, Innsbruck, Austria

BackgroundThe previous experimental results with long-term survival of animal limb allograft and positive results of single hand transplantation encouraged us to plan (January 1999) and performed first (March 2000) and a second (February 2003) bilateral hand transplantation.MethodComprehensive pretransplantation evaluations of both recipients (first-47-year, male patient lost both hands in carpal level, second-45 year, male patient with bilateral proximal forearm amputation) and search for adequate donor according to the sex, size, skin colour and texture were done preoperatively. Three surgical teams worked simultaneously and independently. The immunosuppressive therapy was started intraoperative. First day after successful surgery the intensive

programme of rehabilitation was introduced. This protocol was designed based on early protective motion and cognitive therapy after Perfetti.ResultsThere were no intraoperative or early postoperative complications. Sensory and motor recovery increased gradually and cortical reorganisations were shown. Judging from the Tinel sign advancement, nerve recovery appeared to be ahead of schedule as compared with comparable replant patients. Ten months after surgery the first patient was able to return to his job and complete independent in the activities of daily living. The second patient is still in rehabilitation`s program showing adequate motor and sensitivity recovery considering the level of the amputation.ConclusionLimited experience of hand transplantation confirmed importance of adequate patient selection, recipient donor matching, minimal cold-ischemia time, as well as appropriate simultaneous surgery, immunosuppressive therapy and early intensive rehabilitation. These prerequisites can lead to effective and save hand transplantation with very promising functional and aesthetic results.

F11. The musicians hand : the diagnosis and management of upper limb problems in musicians Miller G. Sheffield Teaching Hospitals, Sheffield, UK Dance and music is fundamental in all cultures. Plato wrote…music reduces

to order and harmony any disharmony in the revolutions within us…Given the length of time music and medicine have coexisted (since the beginning of civilization itself!) why is it that only the past three or so decades has seen a interest in medical conditions specific to the performing artist? There are probably three main reasons for this:

1. Increasing numbers of epidemiological studies showing the high incidence and prevalence of medical problems in instrumentalist musicians 2. The development of sports and occupational medicine and the identification of ‘overuse injuries’ – these are analogous to injuries in musicians

3. The creation and development of a completely new medical discipline – performing arts medicine However, musicians are often reluctant patients and nonmusician doctors are

often reluctant to treat them. This problem is exacerbated by insufficient education in the fields of health awareness for musicians and performing arts medicine for doctors.

Even though the hand or the mouth is the major tool of the musician, the entire body (posture, psyche etc.) is important in this discipline. A holistic and therefore multidisciplinary approach is necessary when dealing with performing arts problems. It is crucial that both the physician and the musician understand the importance of allowing the body to perform in a semi automated way for optimal performance.

Moberg's concept of movement being under computer control is a very useful one in this context. Automatic control is indispensable for highly skilled neuromuscular activity of any kind. Trying too hard produces muscular tension (non synergistic co-contractions) which inevitably produces pain, the mechanism been similar to that of a tension headache accumulation.

Evaluation of the musician with an upper limb problem begins with a systematic approach that identifies important generalized abnormalities, such as hypermobility syndrome (Figure 1).

Then a comprehensive clinical examination (from the neck distally) should be performed to rule out postural problems with the neck; spondylosis or thoracic outlet syndrome, mal adaptations, rotator cuff problems osteoarthrosis or other arthropathies affecting the shoulder; tendonosis osteoarthrosis or compression entrapment neuropathies in the elbow region, osteoarthrosis and other arthropathies affecting the wrist; tendonosis, peritendonitis crepitans, stenosing tenovaginitis and restrictive tenosynovitis and compression entrapment neuropathies affecting the wrist and hand; finally compression-entrapment neuropathies, stenosing tenovaginitis and restrictive tenosynovitis, extensor mechanism subluxation, thumb or other instability affecting the hand or digits.

This must be followed by a search for unusual abnormalities, such as anatomical variants (an example is shown in Figure 2) or evidence of dystonia that could possibly account for the patient’s symptoms. Only when this is complete can the specialist consider the possibility of a diagnosis of misuse/overuse syndrome in patients with non-specific multifocal or diffuse pain, a faulty technique or abnormal practice or performing schedules.

In

>95% of problems nonsurgical treatment is indicated and the concept of modifying the player—instrument ‘interface’ is a very useful one in these cases. In one series of 613 patients (Table 1) psychosocial problems accounted for 19% of problems, technical/interface problems in 40% and an unequivocal diagnosis in 41% (only 4% of the total required surgery).

Figure 1. Hypermobility syndrome in a violinist

Figure 2. Anomalous intertendinous connections between flexor pollicis longus and flexor digitorum profundus II in the Linburg-Comstock syndrome

Indications for surgery are usually

different in this group compared to nonmusicians. Surgical planning, surgical technique and the postoperative rehabilitation regime may all have to be modified according to the often highly specific requirements of the musician-patient.

F12. Deliberate self harm. The St Andrew’s experience. Dewing D., Mashadi S., Iwaguwe F. St Andrew’s Department for Plastics and Burns, Chelmsford, Essex, UK

Wrist injuries deliberately inflicted with bladed instruments are increasing on an annual basis. Patients display a range of injuries ranging from the extreme with nerve and vessel damage requiring extensive repairs to simple skin deep cuts.These patients often present with a host of social problems , with an injury pattern that is part of a series of similar events and are poorly compliant regarding follow-up.We look at patterns of injury, socio-behavioural and demographic and make recommendations about how this population might be treated in the future.

Clear diagnosis 257 41%

Symptomatic hypermobility syndrome 17 3

True tenosynovitis 38 6

Rotator cuff/frozen shoulder 39 6

Old injury 68 11

Osteoarthritis 26 4

Thoracic outlet syndrome 14 2

Rheumatoid arthritis 8 1

Low back pain 23 4

Ganglion 13 2

Carpal tunnel syndrome 3 0.5

Tennis elbow 8 1

Technical causes 245 40%

Psychological 115 19%

Table 1. Upper limb problems in musicians n=617 [Winspur & Wynn Parry 2000]

SESSION G :Microsurgery

PRAZNO ILI SLIKA

G1. Polymeric nerve guides in peripheral nerve reconstruction Nicolai J-PA., Meek MF., Bertleff MJOE. Department of Plastic Surgery, University Hospital Groningen Gröningen, Netherlands

Regenerating axons need pathways to reach their original end organ. The best pathway is the (empty) Schwanncell tube. Gaps of only a few milimeters between the proximal nerve stump and the distal Schwanncell tube impete successful regeneration. These gaps are easily filled with fibroblasts, resulting in scar tissue. Suturing the proximal to the distal nerve stump under tension also results in scar tissue that prevents axons to reach distal Schwanncell tube.Gaps are therefore generally bridged by nerve grafts long enough to allow for tensionless suturing.“Can nerve grafts be replaced by artificially manufactured tubes?” is a question that led to the development of nerve guides. Three of these are currently commercially available: Labtician, MedDev and Polyganics. The latter is composed of poly (D L, Lactid acid- -Capro Lacton), PLLA-CL for short. The last of these three was developed, clinically tested and commercialized under the name of Neurolac in Groningen, the Netherlands.Ten years of laboratory testing, e.g. in animal experiments, preceded a multicenter clinical trial. The results of this trial show that gaps up to 20 mm bridged with a Neurolac nerve guide have the same rate of sensory restauration as after primary nerve sutures. It is concluded that the Neurolac PLLA--CL nerve guide can be safely clinically applied, is relatively inexpensive and gives excellent results in nerve regeneration over distances of at least 20 mm.

G2. A novel approach to the dissection of the anterolateral thigh perforator flap Spyriounis PK. Department for Plastic Surgery, Veteran's Hospital, Athens, Greece

The anterolateral thigh perforator flap (ATL-thigh perforator flap) is a well-described and versatile flap with specific advantages. The large skin territory available and the minimum donor site morbidity are some to mention. Although the flap is a <<workhorse>> in the Orient, its use in the Europe and the USA is still limited. The reasons for that are the complicated anatomy as well as the different characteristics of the donor site. The potential to thin the flap in situ solves the second problem. Still though the dissection remains challenging. We describe a new approach that facilitates better pedicle exposure, long pedicle length and large vessel caliber. In our experience the operative time is shorter as well.

Materials and methods The author has used the free ATL-thigh perforator flap in 3 patients utilizing

a novel approach that has not been described before in the literature. All the patients suffered from head and neck malignancies. The

reconstruction was done with the aid of the particular flap. The success rate was 100%.

Results The author introduces a new approach to facilitate dissection and use of the

free ATL-thigh perforator flap. By using this technique we successfully transferred the flap in 3 different occasions without complications.

Conclusion A novel approach to the dissection of the ATL-thigh perforator flap is

presented. By using this approach we gain extra pedicle length, we perform safer dissection and the operating time is shorter as well. Although the patient number is small the advantages of the procedure become obvious enough to allow us to safely introduce the method as our preferred one.

 

G3. The use of IR thermography for evaluation of cutaneous flap survival Drviš P¹, Shejbal D¹, Pegan B¹, Kalogjera L¹, Petrović I² ¹ Department of Otolaryngology - Head and neck surgery, University Hospital “Sestre milosrdnice”, Zagreb, Croatia ² Department of Surgery, University Hospital “Zagreb”, Zagreb, Croatia

IntroductionThere are plenty of recent studies showing the influence of different drugs on the survival of the cutaneous flap. The effects of a topically applied capsaicin, methylprednisolon, mitomycin and gastric pentadecapeptide BPC-157 in improving skin vitality and preventing distal flap necrosis were tested in a random-pattern dorsal skin flap model.Material and MethodsWistar rats were randomized into five groups, four experimental groups and a control group. A standardized full thickness dorsal random-pattern skin flap was raised on each rat and sutured back into place. A gelatin sponge was placed before suturing between the flap and its recipient bed, with 0.9% saline in the control group and with capsaicin, methylprednisolon, mitomycin and pentadecapeptide BPC-157 in the experimental groups. The flap survival was judged one week postoperatively, and the extent of skin flap survival was compared between the experimental groups and control. Vitality of the flap and survival area was measured by infrared thermography. ResultsThe topically applied methylprednisolon and pentadecapeptide BPC-157 resulted in statistically significant decrease in skin flap necrosis, compared with the control group (p< 0.05), topically applied capsaicin and mitomycin did not show statistically significant decrease in skin flap necrosis. The topically applied methylprednisolon and pentadecapeptide BPC-157 was effective in reducing ischemic necrosis in failing random-pattern skin flaps in this rat model. ConclusionsThe results of this study suggest that such a topical drug application might have significant effects in the reduction of ischemic necrosis in the distal parts of skin flaps, and this treatment might also have applications as prophylactic therapy for risky skin flaps. Thermography of the skin is an easy method for estimating the vitality and survival area of the skin flaps.

G4. Use of near infrared spectroscopy for monitoring of flap perfusion Novak E 1 ., Pavlic R1., Podbregar M2. 1Department of hand surgery and burns, plastic and reconstructive surgery 2Department for intensive internal medicine, General and teaching hospital Celje, Celje, Slovenia

Strict evaluation of flap perfusion is essential if one is to prevent, recognize, and treat complications. Several techniques have been suggested to assess flap perfusion in an attempt to predict flap survival (clinical observation,

differential thermometry, vital dye measurements, ultrasound Doppler, color flow ultrasound, implantable optochemical oxygen-sensing electrode device, photopletysmography, electromagnetic flowmetry-etc).The ideal monitoring system should: reflect the condition of the entire flap; be reliable, reproducible, consistent, and sensitive; provide continuous monitoring; be easily interpreted; be affordable; be relatively unaffected by the external environment.Traditionally flap perfusion has been identified through clinical assessment or invasive measurements. Clinical observation remains the gold standard and fulfills many of the criteria of the ideal monitoring system. In some situation clinical observation of flap perfusion is very difficult, sometimes results are not reliable or not easy to interpret.Near infrared spectroscopy uses near infrared light to illuminate tissue. The light is emitted and received by a probe lying on the surface of the tissue. Within the tissue, some light is absorbed by molecules and some is scattered by reflection from the surface of the cells. Differential absorption by oxygenated and deoxygenated hemoglobin affects the amount of light returned to the surface. Analysis of this reflected light provides the percent tissue oxygen saturation (StO2).The InSpectraTM tissue spectrometer, which we use, noninvasively measures StO2 of the arterioles, capillaries and venules in a local tissue bed – flap and provides accurate, reliable information in areas as small as a few centimeters in a matter of seconds, that can be used for continuous monitoring of flap perfusion. We will present our experiences with this technique in monitoring flap perfusion.

G5. Perforator island flaps. Preliminary report Gruden Stanić O. Department for Plastic and reconstructive Surgery, County Hospital “dr.Franc Derganc”, Šempeter pri Gorici, Slovenia

This study was designed to identify the localization and diameter of perforator arteries and veins along principal vessels of the forearm and lower leg. Appropriate vascular pedicles could be used as the base of local perforator island flaps. With ultrasound examination on health voluntaries few pedicles were identified. Their vascular territories were delineated with perfusion studies on cadavers. Some of them seem to be very promising for clinical practice, especially when we need rapid and safe method for covering of exposed underlying structures.

G6. Lymph drainage by jejunum flap microsurgically implanted in soft tissue Stritar A. 1 , Arnež Z. 1, Stanec Z2, Grmek M3, Us J4,. 1Department for Plastic, Reconstructive Surgery and Burns, Clinical Center, Ljubljana, Slovenia 2Department for Plastic, Reconstructive and Aesthetic Surgery, University Hospital “Dubrava”, Zagreb, Croatia 3Department for Nuclear medicine, Clinical Center , Ljubljana, Slovenia 4Institute for Oncology, Ljubljana, Slovenia

Our experimental study was carried on with 13 animals – dogs. At first we fixed a permanent lymph stasis to a back extremity with irradiation and further lymphadenectomy, lymph congestion was proved. Then we proceeded a microsurgical implantation of jejunum flap to a damaged extremity. As a lymphatic regeneration was expected, the reconstruction was proved by histological analysis, RTG – lymphography, colour lymphography and lymphoscintigraphy.Statistical analyses prove good results only in case of a successful flap transplantation.Hyperplasia of lymphatic elements and lymphangiectasies in jejunum wall tissue were determinated with histological analyses. Histostereologic results among samples do not give significant data. However, a comparison with a native jejunum wall shows a greater blood vessels density in implanted samples.Lymphoscintigraphy revealed a suitable drainage from peripheral tissue to the jejunum transplant, through the transplant and further on proximally to abdominal lymph nodes. A drainage to venous blood is excluded.With a colour lymphography a clear density of colour at the edge of the implant was evident.RTG lymphography, either direct or indirect, prove a drainage, so by our conclusion, there is a formation of a new lymph vessels, so distally as proximally.In any case the jejunum should contain mucosis, primary growth of the intestinal autotransplant into the tissue is prevented by a formation of mucocele.The whole research with both experimental models – induction of a lymph stasis and the jejunum transplantation –– results the fact that the jejunum can function as an inner physiological shunt for lymph drainage.

SESSION H : Lower Extremity Reconstructions

PRAZNO ILI SLIKA

H1. Long term results of free flap foot reconstruction D ž epina I ., Mijatović D., Unušić J. Department of Plastic and Reconstructive Surgery, University Hospital “Zagreb” Zagreb, Croatia

Treatment of foot injuries is formidable challenge for reconstructive surgeon. In order to obtain good long results we must restore soft tissue cover, structural integrity and sensation.

At the department of plastic and reconstructive surgery, KBC Rebro in Zagreb we treated 43 patients with complex foot injuries using microvascular free flaps in the period from 1990 to 1993. Injuries were caused by explosions and missile fragments an 87% of the cases while traffic accidents accounted for 11% and farm injuries 2%. Free flaps used for reconstruction were: latissimus dorsi, serratus anterior, rectus abdominis, forearm, scapular, DCA and gracilis. Patients were followed-up for 10-13 years. Outcome of reconstruction was evaluated using Maryland foot score, pedobarography and questionnnaire.52% of all patients had good or excellent results, with the rate of secondary and tertiarry amputation in 5,2%.Free flap reconstruction of complex foot injuries can provide good functional outcome in the long term follow-up.

H2. The versatility of the anterolateral thigh flap for lower limb reconstruction Keramidas E., Miller G. Plastic Surgery, Northern General Teaching Hospital, Sheffield, UK

IntroductionOur purpose was to explore the versatility of the free anterolateral thigh flap for soft tissue defects of the lower limb.Marerial and Methods We use the flap in 6 patients to cover defects at the lower limb. In 3 patients was used as a fasciocutaneous flap in 2 as a cutaneous flap (supra-thin) and in 1 case as a musculucutaneous with part of vastus lateralis muscle. 5 of the flaps were based in a musculucutaneous perforator and one in septocutaneous perforator. 2 of the flaps were used to cover defects at the lower third of the leg, 2 to cover an exposed Achilles tendon , one to cover an exposed knee joint, and one to cover the middle third of the leg .Results All the flaps survived 100%. The mean length of the flap range 10-15cm. The mean pedicle length was 12 cm. Three of the donor areas were closed direct with very good results the rest 2 was closed with a split thickness skin graft. The mean follow-up was 16 months. All patients were satisfied with the results.ConclusionThe anterolateral thigh flap has several advantages:1) two-surgical teams can work simultaneously, 2) long vascular pedicle 12-16cm with diameter of the vessel 2-2,5mm,3) skin with good texture and much especially for lower limb reconstruction,4) minor donor site morbidity especially when it is closed directly,5) there is no scarification of a major vessel,6) large skin paddle,7) can be used as a fasciocutaneous, musculucutaneous, cutaneous, adipofacial as a flow through, chimeric and as a sensate flap. We found this flap very useful and reliable for difficult soft tissue defects of the lower limb.

H3. Using cross tibia transplantation and foot replantation in amputation of both lower extremities Kempny T., Jelen S., Vresky B., Kysely T. Department of Plastic Surgery, University Hospital “Ostrava”

Ostrava, Czech Republic

IntroductionThe authors present the case of 40 years men which was subtotaly amputated both lower extremities by the train.Material and MethodsWe decided to do an tibia replantation from the left calf with the skin like through flow flap and replantation of the right foot, and the artificial legon the left leg.ResultsIn the postoperative time were done repeatedly (4x) superficial necrectomy and two weeks later was done osteosynthesis with fixateur externe to ensure the talocrural joint stability by previous intramedullary osteosynthesis of the right tibia. Three months later injury was the patient able to work.ConclusionsIn this case of our patient, which had the n.tibialis in continuity we did not used the usual crioss calf replantation, but the more complicated right calf reconstruction. The result was a original hallux position and 10 mm two points discrimination in the n.tibialis innervated area after three years. Patient walks by an French crutches and is able to live normal life.

H4. Importance of soft tissue covering in the treatment of chronic osteomyelitis Gavrankapetanović I., Gavrankapetanović F, Bišćević M. Department for orthopedics, Clinical Center “Sarajevo”, Sarajevo, Bosnia and Herzegovina

Introductionin our work we present soft tissue defects after osteomyelitis caused by high cinetic projectils.Patients and methodsThere is 30 patients with verified osteomyelitis and soft tissue defect who were operated on our clinic. Surgical technique were consisted of classical treatment with PMMA gentamicin pearls and soft tissue cowering. We have had an original statistic form and software support. Follow up time were 8 years.ResultsIn group of patients were we have preformed an op0erative procedures ( 30 patients) with debridement and forage, lavage, aplication of PMMA pearls and soft tissue cowering during the 8 years we had only two recidivs, solved by aditional opeartive procedure.Conclusion Suggested operative protocol with omplantation of PMMA gentamicin pearls with soft tissue cowering in excelent methode in definitive chronical myelitis treatment.

H5. The use of ALT flap in lower extremity reconstruction Žic R., Stanec Z., Budi S., Stanec S., Milanović R., Rudman F., Martić K. Department for Plastic, Reconstructive and Aesthetic Surgery, University Hospital «Dubrava», Zagreb, Croatia

Although microsurgical reconstruction of the foot has allowed us to reconstruct foot defects previously requiring amputation the selection of flaps to cover large defects is small. With the use of the anterolateral thigh flap we have gained a large thin flap which is able to cover large dorsal and plantar defects with good contour restoration and early return of ambulation in normal footwear. In addition the donor site, even when covered with a split skin graft, is functionally and cosmetically acceptable to the patients and no functional loss at the donor site is seen. In this paper the authors present their experience with the use of the ALT flap in patients with large defects of the foot.

H6. Lower extremity reconstruction experience in 175 patients Agir H., Sen C., Dinar S., Cek D. Plastic and Reconstructive Surgery Department, Kocaeli Faculty of Medicine, Kocaeli University, Kocaeli, Turkey

IntroductionAcute or chronic wounds of the lower extremity have still been considered as challenging problems of reconstructive surgery despite the major advances in local flap closure and microsurgical transfer.Material and MethodsWe reviewed our patients with lower extremity wounds surgically treated between 2002 and May 2004 in order to see our results and evaluate own management principles. We assessed our outcome according to age, etiology, nature of the defect and its anatomical location, preoperative studies, closure techniques and complications.ResultsThere were 258 patients treated due to their various lower extremity wound problems. Out of this group, 175 cases (89 males, 86 females) were managed with surgical closure methods other than primary repair and secondary healing. Mean age was 30.86±20.9 years. In 61 cases, wound was due to burn injuries and in 50 cases; defect was caused by diabetic foot. In 19 patients, trauma was the cause whereas pressure sore was the reason in 16 patients. In 90 cases, lesion was located distal to the cruris (ankle-foot region). Cruris and thigh regions were involved in 63 and 59 patients respectively. Free flap closure was used in 11 cases of which two failed. In 62 patients, random or axial type local flaps were chosen for closure however 25.8% of them had various types of wound healing problems like infection, detachment, partial or total necrosis. Majority of these patients had diabetes or high tension electric burn injury.ConclusionVascular anatomy and etiopathology behind the defect should be very well known in the reconstructive approach to the lower extremity wounds in order to make a better decision and planning before the closure. Besides, expertise on local flap use and skills in microsurgical technique will definitely lower the complication and amputation rates in difficult cases of lower extremity.

H7. Lymphatic reconstruction as a new concept in lymphoedema

surgical treatment Stritar A., Leskovsek A., Solinc M., Beslic N. Department for Plastic, Reconstructive Surgery and Burns, Clinical Center, Ljubljana, Slovenia

In the last decade some new surgical methods for restoration of lymph flow are described. Some are in experimental research and few are clinically used. They represent a vascular implantation of a healthy, new lymphatic tissue into lymphoedematous limb, what it means an inner incorporated flap, as a conduit for lymph drainage. Reconstruction itself is more complex and demanding, as bridging or shunting operations, where free omentum, free lymph perinodal - node and vascularised lymphatico adipovenous flaps are used.

All the methods must be individually selected to lymphoscintigraphic findings, local tissue conditions, axioms of lymphoedema surgery and general condition and aim of a patient. In general, the results of lymphatic reconstruction operations are still badly evaluated and our experiences and conclusions are positioned. Theoretical considerations are sometimes discordant to practical surgical skills and abilities. We operated 6 patients, as a microsurgical transfer of a lymph node and 2 patients as a bridged omentum major flap, while some patients are recruited for lymphaticoadipovenous transfer, for secondary lymphoedema.Results of a lymph node transfer are not finally completed. Our experiences point out, that surgical release of a scar was in benefit, and healthy lymph nodes must be selected. According to this fact in a case of lymphatic systemic predisposition a donor area must be examined by a lymphoscintigraphic or ultrasound findings.All mentioned operations above also need more ethical and forensic consent.

SESSION I : Miscellaneous

PRAZNO ILI SLIKA

I1. Body dysmorphic disorder Nola I. Private Dermatovenerology Office, Zagreb, Croatia

Dissatisfaction with appearance is very prevalent in our society and it is practically the norm. But, when someone becomes intensely preoccupied with what they believe to be a defect in their appearance, then they may be suffering from a mental condition called Body Dysmorphic Disorder (BDD). BDD is also known as dysmorphophobia, the psychiatric condition that has been described for more than a century. The preoccupation causes emotional distress and social impairment. BDD usually takes a chronic course. People with BDD often have a history of multiple visits to dermatologists and cosmetic surgeons with resulting unsuccessful treatment. So, failure to recognize people with BDD frequently lead to cosmetic medical or cosmetic surgical approach but demonstrate u unrealistic expectations. People with BDD may blame the physician for producing what is perceived as an unacceptable outcome. People with BDD frequently develop major depressive episodes and are at risk for suicide. So, there is a failure to combine cosmetic surgical treatment with psychiatric therapy when treating a person with BDD.

I2. A multimodale therapy in the treatment of the decubital ulcer Crnogorac V 1 ., Wagner D2., Arnold J2., Hebebrand D1., Busching K1., 1 Clinic for Plastic Surgery,Reconstructive and Hand surgery 2 Clinic for Internal Medcine, Diakoniekrankenhaus, Rotenburg, Germany

IntroductionThe origin of the decubitus ulcer is adequately well-known. Therefore we have especially focused our attention on a specific group of patients with significant relapse-endangered and aberrant therapy concepts. Part of this endangered group of patients are particularly those with neurological diseases and malfunctioning of the urinal-rectal system. Despite greatest preventive measures and a multiplicity of industrially manufactured adjuvants it is still possible that the decubitus ulcer originates and subsist in a variety of seriousness.

This clinical trial, taking the well-established therapeutic-treatments into account, is based on the elimination of incontinence problems in order to improve the local dermis state.In addition to the classical surgical decubitus ulcer therapy occurs a temporary or permanent stoma probe according to Hartmann. If malnutrition or promising results exist, we adment our therapy concept with an additive PEG-probe in order to support substitution of the calorific nutrition.Material and MethodsThe theraphy scheme of the decubitus ulcer treatment consists of:1.The minimisation of pressure by means of adequate storage 2. Intense hygienic procedures and skincare3. Disinfection and cleaning of wound-in extensive necrosis surgical debridement 4. In case of indication of surgical debridement preoperative stomaprobe according to Hartmann5. PEG-Probe for the applicaiotn of specific probenutrition6. Cartographic and photographic course record of the woundsituation7. final cover of the soft tissue defect with local flaps8. continuation of intense storagetherapy and education of the nursing staff and patients relativesResultsUp to now 18 patients have been treated with the above-named therapy concept. In this number included are 5 patients with an additional nutrition programme. A definite advancement considering the woundsituation could be observed within 15 patients. Two patients showed no substantial conditioning of the wound.The operative defectcover succeeded with a lasting effect within 17 patients relapseless with typical flaps. One patient has been excluded from clinical study for reason of complience.ConclusionsThe present data proof the benefit of the preoperative anus praeter-probe for local skin and woundsituation.In addition to that it reduces and simplifies the high nursing maintenance for the nursing staff and the patients relatives.The malnutrition in relation to decubitus ulcer has been controversially discussed. Four out of five PEG-patients confirm the impression, that the woundsituation and general situation can be positively influenced.A failure of therapy was only noticed within patients that due to contraindications were not able to receive a anus-praeter-probe.

I3. Self inflicted burns in Afghanistan: the fate of unhappy women Echinard C., Leroy P., Brunel M.J., Azzizi MD., Tessier J.L., Humani Terra International , Marseille, France   

The authors are reporting their experience about self inflicted burns in women during the post taliban period en Afghanistan. 750 burns patients are treated every year in the public hospital. 2/3 of them are women and among them, 250 are suicides by flame. Humani Terra International, a surgical N.G.O. has discovered this problem immediatly after the fall of the taliban two years ago. Surgeons, anaesthesists and nurses of the N.G.O. are going regularly to Herat in order to treat and to set up a modern burn unit in collaboration with Handicap International.

 

I4. Epibase: a new autologous keratinocyte cultures Costagliola M. Polyclinique du Parc, Toulouse, France

Cell therapy is becoming a very interesting solution to replace degenerated or damaged tissues. In January 1998, Genevrier Laboratories inaugurated a new department especially designed for the production of cultured cells as therapeutic agents.Meeting clinician therapeutic needs by providing autologous keratinocytes, fibroblasts and chondrocytes in the near future, represents the primary aim of the Biotechnology department. Concrete cell-based products are already being used for the treatment of burns and cutaneous chronic wounds such as the EPIBASE graft; which corresponds to an epidermis sheet composed of cultured autologous keratinocytes. Hard to heal venous leg ulcers and necrotizing angiodermatitis benefit greatly from EBIPASE treatment.

I5. Future of bioresorbable biomaterials: multifunctionality Ashammakhi N.1,2, Veiranto M.1, Tiainen J.2, Niemelä S-M.2, Törmälä P.1

1 Tampere University of Technology, Institute of Biomaterials, Tampere, Finland. 2 Oulu University Hospital, Department of Surgery, Oulu, Finland

Aim The aim of the study was to characterize properties of multifunctional (MF)

bioabsorbable rods and screws. Material and methods Bioaborbable polymers (PLGA 80/20 or PLDLA 70/30) were used as the

matrix, and bioactive glass (BG) as osteoconductive agent. In MF-1, ciprofloxacin (CF) was included and in MFM-2, for a tissue-reaction modifying agent was used. The self-reinforced (SR) were sterilized using -irradiation. Drug release, mechanical properties, and microstructure were evaluated. In vitro cell models were used. In vivo models included the implantation in rabbits’ cranial bone & rats’ subcutis. Biomechanical (pull out strength) testing was done in cadaver bones.

Results CF was released from the studied screws after 44 wks (P/L/DL)LA) and 23 wks

(PLGA) in vitr. (0.06 – 8.7 µg/ml/d for P(L/DL)LA and 0.6 - 11.6 µg/ml/d for PLGA). Initial shear strength of the studied ciprofloxacin-releasing screws was 152 MPa for P/L/DL)LA & 172 MPa for PLGA. Studied screws retained their mechanical properties for 12 wks (P(L/DL)LA) and 9 wks (PLGA) in vitro at the level that ensures their fixation properties. Histology of MF-1 showed increased giant cells at the implantation site. Pull-out tests indicated that the early version of the MF-1 type of screws have lower values as compared to controls. Inhibition of bacterial growth, attachment and biofilm formation was significantly different than controls. MF-2: Over 60 d, release.

Conclusion SR-P(L/DL)LA and SR-PLGA MF implants with appropriate drug release,

structural, mechanical and biocompatibility properties can be produced. Clinical studies will be started in near future (MF-1).

Acknowledgements: Research funds from the Technology Development Center in Finland (TEKES,

Biowaffle Project 40274/03 and MFM Project 424/31/04), the European Commission (EU Spare Parts Project QLK6-CT-2000-00487), the Academy of

Finland (Project 73948) and the Ministry of Education (Graduate School of Biomaterials and Tissue Engineering) are greatly appreciated.

I6. ESPRAS web site Echinard C. Humani Terra International , Marseille, France   

SCIENTIFIC POSTERS

PRAZNO ILI SLIKA

P 1. Management of burn injuries without a burn unit: Kocaeli experience Agir H., Dinar S., Sen C., Unal C., Cek D. Plastic and Reconstructive Surgery Department, Kocaeli Faculty of Medicine, Kocaeli University, Kocaeli, Turkey

Introduction Every year more than one hundred burn patients need a standard care of a burn unit or center in Kocaeli, central city of a densely populated industrial region of Turkey. However, most of these patients are admitted to general plastic surgery clinics in the city without a burn unit. University hospital is

the largest tertiary referral center in the region, which drains more than 50% of these cases per year, and it does not have any burn unit service at all. We decided to evaluate our results and protocols, besides the particular problems we have encountered and the solutions we have found since 1996 in this highly demanding field of plastic surgery.

Material and Methods We included 108 burn injury patients into our study group who were treated between May 2002 and May 2004. We scrutinized the medical records and studied the cases according to their age, sex, etiology, burn percentage, injury region, surgical treatment, complications and outcome.Results Mean age of the patients was 19.7±19.2 with a male: female ratio of 1.45. In 53.7% of the cases, a scald was the cause and 18.5% of the patients were admitted due to a high-tension electrical burn injury. Head and neck region was mostly affected in children below 5 years age. Least affected body area was genitalia. Following emergency unit admission, fasciotomy was applied in 17 cases. Tracheostomy and escharotomy were done in four and three patients respectively. Ten patients were directly admitted to surgical intensive care unit. As for the surgery, STSG was undertaken in 77 patients whereas local flaps and free flaps were needed in sixteen and eight cases respectively. Amputation rate for the high-tension electrical burn injury was 25%. Mean hospital stay for all of the patients was 37 days while the average number of operation per patient was 3.2. In 4% of the patients, severe burn contractures were developed despite all preventive measures. More than 50% of the pediatric cases with hand burn injury underwent additional surgeries for their scar and joint contractures. Most devastating results were obtained in electrical burn injury group. Mortality rate was 1.8 %. Conclusion Most of the plastic surgeons who work in developing countries and treat burns in their clinics always need to reevaluate and adjust the burn management principles to their own circumstances. In this study, it may be concluded that even severe burn injuries can be managed in general plastic surgery wards with a relatively low mortality and morbidity rate. However, if the complications, hospital stays and the outcomes in functional and cosmetic aspects were taken into consideration in comparison to literature, it would be hardly suggested that burn units were not very essential in burn injury treatment in third world countries.

P 2. Reconstruction of the severely burned face: A case report Aljinović-Ratković N., Uglešić V., Krmpotić M.. Department of Maxillofacial and Oral Surgery, University Hospital “Dubrava”, Zagreb, Croatia

The reconstruction of the severely burned face often demands multiple reconstructive procedures. The authors are presenting a patient with a total defect of the soft tissue of the lower face, partial defect of the upper lip and nose, contractures of the eyelids and submandibular region and total defect of both auricles. The reconstruction was performed in several steps during three years. The radial microvascular flap was used for the reconstruction of the lower face and lower lip, the forehead flap was used for the reconstruction of

the tip of the nose and upper lip. Wolf grafts were used for eyelids. Implants for auricular epitheses were inserted in the both mastoid region.

P 3. Treatment and prophylaxis of post-burn cicatrization with Contratubex Andonovska D., Atanasova E., Marcikik G., Andonovski D., Dzorceva M. Plastic, Reconstructive and Aesthetic surgery and Burns Center, City Surgical Clinic “St.N.Ohridski”, Skopje, Macedonia

IntroductionThis paper present a single-centre experience with Contractubex® gel manufactured by Merz, for the treatment of superficial burns and for prophylactics and treatment of hypertrophic scars and keloid. In the period of 1 year Contractubex ® gel was administered to 100 patients. The patients were divided in two groups on the basis of surgical treatment. The shortest application period of Contractubex ® gel was 3 months and the longest, 6 months. We report very good results in all patients.Material and MethodsDuring a period of April 2003 to April 2004, Contractubex ® was applied to 100 patients in the Department of Burns and Plastic Surgery at the City Surgical Clinic, Skopje, Macedonia. The patients were divided into two groups. We used human foetal membranes also known as amniotic membrane like biological dressing in 73 cases (73%).Surgical escharectomy and skin grafting were performed in only 27 cases (27%). In first group Contractubex ® gel was applied in a layer of 1 mm by simple spreading on the skin. In the second group: the preparation was applied twice daily with light rubbing massage. Patients were observed and results were compared at monthly follow-up examination.ResultsIn both groups, we observed the following scar variables: size, height, softness, elasticity, paraesthesia, itching, skin temperature and type of consequence after epithelialization or autotransplantation. After applying, patients feel less itching; color and consistency and tension of the scar have significant difference than that of scars treated differently.ConclusionsThe preparation Contractubex ® gell by Merz is perfect choice for epithelialized superficial burns and to deeper burns covered by plastic surgery.

P 4. Dilemas about diagnosis and treatment of melanoma in our clinical material Arifi H., Zatriqi V., Buja Z. Berisha A. Department for Plastic Surgery, Clinical Center, Priština, Kosovo

Opste je poznato u svetu sto se tice diagnostike te lecenja malignog melanoma odavno prevazidjeno sto nije slucaj kod nas. Dileme oko diagnostike i ako u posljednjih petljeca usavarsana,nova spoznanja na polju diagnostike kao:ELM,DELM,UZV ne invazivne metode,te invazivnih metoda citoloska punkcija pigmentirane promjene preko identifikaciji i

biopsiju santinel limfnog cfora novije su dostignuca koje kod nas zbog nedostatka tehnickih uvjeta kao i nedovoljnog profesinalizma pogorsavaju prognozu malignog melanoma.Pogorsanje prognozi doprinosi i nemogucnost aplikaciji jedinstvenog protokola lecenja malignog melanoma.Cilj rada: nam je da preko nekoliko klinickih slucajeva da prikazeme koje su najcesce dileme oko diagnostike i lecenja MM na nasem klinickom materjalu.Pitanje koje nama kirurzima muci jeste najvise na polju lecenja, sto se tice kirurskog tipa lecenja ona uklapa u savremene principe dok preostalji dio koje pripada polji onkologiji ono je kompljetno otpustena na volju samog pacienta i obitelja pacienata zbog nedostatka onkoloskog instituta oni su obavezni da ostalji dio lecenja obavljati van zemlje.

  

P 5. A multicenter study on resorbable craniomaxillofacial osteofixation Ashammakhi N. 1,7, Dominique R. 2, Arnaud E2., Marchac D. 2, Ninković M. 3, Donoway D. 4, Jones B. 4, Serlo W. 5, Laurikainen K. 6, Pertti Törmälä1, Timo Waris7

1 Tampere University of Technology, Institute of Biomaterials, Tampere, Finland.2 Hopital Necker-Enfants Malades, Craniofacial Unit, Paris, France 3 University of Innsbruck, Department of Plastic and Reconstructive Surgery, Innsbruck, Austria 4 Great Ormond Street Hospital for Sick Children, Craniofacial Unit, London, UK.5 Oulu University Hospital, Department of Pediatrics, Oulu, Finland 6 Linvatec Ltd., Tampere, Finland7 Oulu University Hospital, Department of Surgery, Oulu, Finland

Bioabsorbable osteofixation devices were developed to avoid problems associated with metals. Bioabsorbable devices are mostly made of the polymers polylactide (PLA), polyglycolide (PGA) and their copolymers (PLGA and P(L/DL)LA). Using the technique of self-reinforcement of bioabsorbable materials, it is possible to manufacture osteofixation devices with ultra high strength. Self-reinforced (SR) polyglycolide-co-polylactide (SR-PLGA) 80/20 was selected to make devices (BiosorbTM PDX) for this study because of its favorable degradation characteristics. The aim of this study was to evaluate the efficacy of using SR-PLGA (BiosorbTM) plates and screws in the fixation of osteotomies in craniomaxillofacial (CMF) surgery. In a prospective study, 165 patients (161 children and 4 adults) were operated on in four EU centers (Paris, Innsbruck, London and Oulu) from May 1 st, 1998 to January 31st, 2002. Indications included correction of dyssynostotic deformities (n=159), reconstruction of bone defects following trauma (n=2), tumor removal (n=2), and treatment of encephalocoele (n=2). Plates used were 0.8, 1 or 1.2 mm thick and screws had an outer (thread) diameter of 1.5 or 2 mm and a length of 4, 6 or 8 mm. Tacks had an outer diameter of 1.5 or 2 mm and a length of 4 or 6 mm. Intraoperatively the devices were easy to handle and apply and provided stable fixation apart from two cases. Postoperative complications occurred in 12 cases (7.3%), comprising infection (n=6), bone resorption (n=4), diabetes insipidus (n=1), delayed skin wound healing/skin slough (n=2), and liquorrhea (n=1). Accordingly, SR-PLGA 80/20 (Biosorb) plates and screws can be used safely and with favorable outcome in corrective cranioplasties, especially in infants and young children.  

Keywords

Bioabsorbable, biosorb, bone, fixation, polylactide, polyglycolide, self-reinforced

Acknowledgements Research funds from The Technology Development Center in Finland

(TEKES, 90220, Biowaffle Project 40274/03 and MFM Project 424/31/04), The European Commission (Biomedicine and Health Programme, European Union Demonstration Project BMH4-98-3892, R&D Project QLRT-2000-00487, EU Spare Parts Project QLK6-CT-2000-00487) and The Academy of Finland (Projects 37726 and 73948) and the Ministry of Education (Graduate School of Biomaterials and Tissue Engineering) are greatly appreciated.

P 6. Uloga radiologa u rekonstrukcijskoj kirurgiji dojke Brnić Z., Zagreb, Croatia

P 7. New method of relocation of NAC in male Budi S. Department for Plastic, Reconstructive and Aesthetic Surgery, University Hospital «Dubrava», Zagreb, Croatia

IntroductionThe cause for bilateral loss is seldom congenital, and usually destruction from trauma, particularly burn injury. Quite a similar problem is the creation of the NAC in female-to-male transsexuals and after correction of extreme bilateral gynaecomastia. As there are only few reports on anatomical approaches to contour a male chest such as the precise localisation of NAC, a prospective study on this question was carried out. Material and method A total of 100 healthy men aged 20-36 years were examined. The study was concentrated on the precise localisation of the NAC on the thoracic cage in relation to various measurements such as weight, height of the body, circumference of the thorax, length of sternum, position in the intercostal space and all the various distances such as the distance between sternal notch and nipples and, between midline of sternum and nipples. ResultsCircumference of the thorax and length of the sternum were estimated as the best predictors of the NAC location. To localize the NAC on the thoracic wall de novo, at least two reproducible measurements proved to be necessary, composed of two lines, in this study, two radius. The upper radius has a stating point in sternal notch, while stating point of another radius is in processus xiphoideus. Intersection point of these two radius is the position of the nipple. Formulas have been calculated for all variables. For the maximal precision tables have been calculated, and the work sheet in Microsoft Excel has also been created. A precision of this method has been proved on a control group (n = 52).ConclusionThe appropriate localization of the NAC in male, in cases of bilateral absence, can be calculated by means of this method derived from the circumference of the thorax and the length of the sternum of the patient.

P 8. Foreign body in the maxillar sinus-Case report Gjorgievska J., Dzokic G., Tudzarova-Gorgova S., Zogovska-Mircevska E. Department of Plastic and Reconstructive Clinical Center Skopje, Med. Faculty “St.Cyril and Methodius”, Skopje, Macedonia

IntroductionForeign bodies are very rare in the maxillary sinus. There is no mention of them in the standard textbooks. An interesting case of piece of branch of a tree left in the maxillary sinus it’s reported for a rarity. Case reportA 61 year old man presented with chronic fistula and secretion in the left infraorbital region. Three months ago he had minor accident by falling down on his face, he felt pain while the foreign body entered in the left infraorbita region. The patient himself took out some peaces of wood. He went twice to an Ophtalmologist , but after 20 days from the fall the wound closed and healed from the outside. Now the patient complains about secretion in the left infraorbital region on the place where he had the wound. He is accepted at our department and operated, we had extracted the foreign body, which was wood long about 8cm with diameter about 1cm. Post operatively the patient had no complications such as infection and secretion from the nose.DiscussionThe infraorbital region and upper part of maxillary sinus are relatively easily penetrated by foreign bodies and objects. However, their incidence is increasing with a rise in the incidence of vehicular accidents and gang wars. The above case demonstrates the potential danger of foreign bodies injuries in the midfacial region with possible serious complications.

P 9. Carpal tunnel syndrome: One day surgery at our hospital Huis M., Šoštar K. Department of Surgery, General Hospital Zabok, Zabok, Croatia

IntroductionCarpal Tunnel Syndrome is a condition caused by compression of the median nerve at the wrist, which can lead to pain and weakness in the hand. The median nerve supplies sensations to the thumb and first two fingers, and also to some of the muscles of the hand.Surgical AnatomyThe carpal tunnel is composed of two walls–the deep wall is the bones of the wrist and the superficial wall is a thick ligament located just under the skin of palm side of the wrist. The tendons which flex the fingers and the median nerve pass through this tunnel. Patient and MethodsA 52 years-old-female came to our hospital with clinical and EMNG signs of the Carpal Tunnel Syndrome; Hoffman–Tinel was positive. According to examination she suffered from problems two years ago. After standard preoperative tests, she underwent Open Carpal Tunnel Release Surgery in Local Anaesthesia and Bloodless Operative Field provided by the tourniquet placed over the upper arm. An Incision, about 4 centimetres was made in the palm, extending from the skin crease to the wrist. The ligament was exposed

and then carefully discised along its length, making the median nerve entirely visible in the tunnel. The nerve was carefully inspected to be sure it is free along its length in the tunnel and not compressed. After the minuciuos hemostasis the wound was closed. Procedure was performed in 10 minutes. The patient was released from hospital 2 hours after the procedure.ResultsControl postoperative examination was next morning. Sutures were removed 10 days after the surgery. 3 weeks later the patient underwent, 1 month, Supervised Hand Physical Therapy Program. 3 months after the surgery control EMNG showed good results; Hoffman – Tinel was negative. Pain, tingling and night time symptoms disappeared.ConclusionsWe believe, according to our results and One–Day–Surgery Program, that the Open Carpal Tunnel Release Surgery in Local Anaesthesia and Bloodless Field provides good treatment for our patients with Carpal Tunnel Syndrome. 

P 10. Analysis of data of reduction mammaplasty in our region Janjić Z., Momčilović D., Jovanović M., Erić M., Nikolić J. Clinic for Plastic and Reconstructive Surgery, University Hospital, Novi Sad, Serbia and Montenegro

Introduction

The goal of this study is to achive clear indications for reduction mammaplasty on regional level. Motivation for this retrospective study is the fact that in our country, as well as in most others, there is not clear separation between “cosmetic” and “medical” mammaplasty.

Material and methods

In this study we have statisticaly analised clinical and outpatient data of patients who had bilateral reduction mammaplasty on The Clinic for Plastic and Reconstructive Surgery, Clinical Centre-Novi Sad, Vojvodina, Serbia and Montenegro. Analisys od objective criteria included: body weight, hight, body mass index (BMI), weight of ressection tissue of braests and body weight after the operation. After that, we created the questionnaire, which was sent by post to the operated patients. The questions were relating to physical and psychological discomfort before and after the breast reduction operation.

Results

Analysis of data included only 19 operated patients from which we received correctly filled questionnaires. We got following regional data: 1. Average age of our patients was 27 years (16 to 50 years old). All examined patients had physical difficulties because of breast hypertrophy, and most of them had neck and back pain (17 patients – 98,47%). Psychological discomfort (incapability for exercises, avoiding of appearance in public) had 15 patients (78,94%). Average value of BMI in our patients was 29,2 (from 26,4 to 33,2). Thirteen patients (68,42%) were overweight and 6 patients were obese. Analysis of body weight after operation showed reduction of weight in 15 patients (78,94%). All the

patients emphasize that they were in better condition after the operation, especially related to physical troubles. Only one patient (5,26%) was dissatisfied with her appearance.

Conclusions

In conclusion we would like to emphasize that BMI is not decisive factor to set indication for “medical” breast reduction, because all our patients, even they with overweight or obesity, improved their haelth condition after operation.

P 11. Melanoma malignum of the trunk Janjić Z., Jovanović M., Pisarev-Šoć M., Nalić B., Popović A. Clinic for Plastic and Reconstructive Surgery, University Hospital, Novi Sad, Serbia and Montenegro

IntroductionAuthors have shown the results of five years retrospective study for patients with melanoma localized of the trunk. It is well known that localizations of tumor on the body influence the surviving rate and that is important prognostic factor. We wanted to show all aspects and differences comparing trunk localization melanoma with other body localizations. Materials and MethodsMaterials for this study include patients treated in the hospital and as outpatients at the Clinic for Plastic and Reconstructive Surgery, Clinical Center Novi Sad, Vovjodina, Serbia and Montenegro. Material was shown tabulary and graphically and was later statistically analyzed. Obtained data were compared with other localizations for same period of time and also with previous data (same authors), comparing five and ten years morbidity and mortality. ResultsResults shows that in the last five years there were 245 operated patients with primary melanoma of the skin and complications (metastasis and local recurrence). The greatest number of operated patients had localization on the trunk (80 patients-32,65%). In total there are moderate female domination (130-53,06% female: 115-46,93% male), while considering only trunk localization there are opposite situation (48-60% male: 32-40% female). Distribution of the patients among age groups shows that the most often involved are population in the sixth and seventh decade of life. Considering only trunk localization the incidence of this disease in this age group is even higher (60% trunk: 49% others). The trunk localization had more superficial spreading melanoma (45 patients-56,25%), while other localizations had almost equal number of nodular and superficial type of melanoma (54 patients- 32,72%). From entire number of 11 patients (4,48%) who were reported with primary tumor and metastasis, 9 (11,25%) of them had melanoma of the trunk. Only two patients with local recurrence that we had in our study had it’s localization on the trunk. Tumor exulceration, as well as greater deepness of skin invasion is also characterization of this region of body. ConclusionsFor all this reasons, comparing to other localizations, it is obvious why melanoma of the trunk gives earlier and numerous complications witch influence the mortality.

P 12. Adrenaline solution in flap surgery Jovanović M., Janjić Z., Jeremić P. Clinic for Plastic and Reconstructive Surgery, University Hospital, Novi Sad, Serbia and Montenegro

IntroductionMany doubts are expressed in medical literature and in clinical practicas to the usage of adrenaline on the tissue with intact or damaged circulation. In this experimental study we tried to clarify some of the dilemmas relating to the indications and optimal dosage and concentration of adrenaline in plastic surgery with minimal risk for possible local complications. On our experimental model we tried to evaluate local influence of adrenaline solution on flap circulation after subcutaneous injections, according to the tested concentrations and time intervals of administration. Material and methodsResearch was carried out on 50 rabbits. We used local retrograde flap on rabbit ear as experimental model for examination of local influence of adrenaline on traumatized tissue. We elaborated the blood stream in flaps (arteriography, fluorescine, metilen blue), measured the surface of distal flap necrosis by computer programme and eventually we evaluated the results of pathohistologic samples of tissue.ResultsLocal activity of adrenaline solution on intact and traumatized tissue was almost the same in both examined concentrations. Infiltration of only one dose of adrenaline solution did not provoke the progrediation of necrosis in both concentrations. We got the significant increase of average percentage of flap necrosis by increasing the time interval between administration of two doses of adrenaline solution. ConclusionsFour times higher concentration of adrenaline solution shows almost the same effects on intact and traumatized tissue (1:50.000 – 1:200.000). Single usage of adrenaline solution in examined concentrations is harmless on flap vitality. Statistically, injection of repeated doses of adrenaline solution in time interval of 35 minutes, will significantly increase the average percentage of flap necrosis (13%). Namely, it will cause irreversible damage of flap tissue.

P 13. Our experience in wound closure with V.A.C. Jurišić D., Pirjavec A. Plastic Surgery Unit, Clinical Hospital Center, Rijeka, Croatia

V.A.C. therapy is new non invasive meted, which acts on the principle of localized and controlled negative pressure, either continuous or intermittent that acts over the inert medication made of medical polyuretan. This material is porous, sterile, can be adapted to the wound size and does not contain any medicaments.Patient preparation- necrectomy,

- shaving of the surrounding skin (if possible), - flush the wound with the saline solution, - dry up the skin around the wound,

- choose appropriate length of the medication, - take care that the tubus is not placed to close to the wound.

Changing the medication - every 48 hours ( if not indicated differently, - every 12 hours if the wound is infected (CFU >150).Changing the container with the exudat - when fluid level reaches 250cc, - once a weak no matter of fluid level.Indications

- ulcus cruris, - decubital wounds, - preparation for surgical procedures (transplantation), - deep combustions, - infected surgical wounds.

Contraindications - fistulae, - osteomielytis - malignant wounds.

Results - the pictures of pre and post therapy status will be shown

P 14. Comparison of transthecal to traditional block for anesthesia of the finger Keramidas E., Rodopuolou S., Tsoutsos D. Miller G., Ioannovich I., Plastic Surgery, Northern General Teaching Hospital, Sheffield, UK

IntroductionChiu in 1990 was the first to desccribe the transthecal (TT) digital block, using the flexor tendon sheath for anesthetic infusion. Our purpose was to compare the TT digital block with the traditional block (TD) with regards, the onset of time to achieve anesthesia and pain during the infiltrationMaterials and MethodsA randomized double blind study was performed in 50 patients to compare the transthecal (TT) to traditional subcutaneous infiltration (TD) techniques of digital block anesthesia. All the patients had sustained injury involving two or four fingers of the hand. Each patient served as his/her own control, having one finger infiltrated with the TT technique and the other with the TD technique. Time to loss of pinprick sensation and pain (at the time of the infiltration and 24 hours postoperatively) was assessed using a visual analogue scale and verbal response score. A total of 104 blocks (52TT and 52TD) were performed.Results

All these blocks were successful. Mean time to achieve anesthesia with TT block was 165 seconds compare with 100 seconds for the TD block. Mean analogue pain score was higher for TT blocks than for TD blocks (3.2+/- 0.19 versus 1.6+/- 0.14). Twenty four hours post operatively 24 patients who had the TT block experienced pain at the injection site of the digit. However, none of the patients who were delivered TD block complained for pain at the digit. The patient’s preferred technique of anesthesia for their finger was the TD block as it causes less pain.Conclusions

Our results confirm the efficacy of the TT block to achieve anesthesia of the finger however because it is more painful procedure it is not recommended.

P 15. Milestones in the formation of fibrous tissue joint construct Länsman S1, Pääkkö P2, Kellomäki M3, Törmälä P3, Ashammakhi N3,4

1 Oulu University Hospital, Department of Ophthalmology, Oulu, Finland.2 University of Oulu and Oulu University Hospital, Department of Pathology, Oulu, Finland3 Tampere University of Technology, Institute of Biomaterials, Tampere, Finland4 Oulu University Hospital, Department of Surgery, Oulu, Finland

BackgroundBioabsorbable synthetic materials can be used to induce fibrous tissue formation and be used to develop small joints. Aims To study the poly-L/D-lactide (PLDLA) 96/4 (96/4, molar ratio of L/D lactide) scaffolds in vivo in the subcutaneous tissue of rats.Material and methods Cylindrical knitted mesh scaffolds were made of PLDLA 96/4 fibers, with each fiber made of 8 PLDLA filaments (15 x 3.5 mm). Three types were evaluated: Dense (weight 30 g), ordinary (25 g) and loose (20 g). Four scaffolds were implanted in the dorsal subcutis of each of the used 32 rats. The implants were retrieved after 3 days, 1, 2, 3, 6, 12, 24 and 52 weeks postoperatively, examined for tissue reaction and fibrous tissue ingrowth. Results Tissue ingrowth reached the innermost part of the implants within 3 wks. Fibrin was the first to fill in the scaffold followed by the cells and at last collagen fibers were found in the structure. The orientation of the collagen fibers inside the implant changed from non-oriented to highly oriented fibers forming septae. Macrophages increased in number over time. The material was not fragmented at 52 wks.Conclusions Upon implantation in rats, fibrous tissue ingrowth proceeds from all sides of the scaffold filling it completely by 3 wks. Collagen fibers get more organized by time. Single PLA fibers were not fragmented by 52 wks.Acknowledgements Research funds from the Technology Development Center in Finland (TEKES, Biowaffle Project 40274/03 and MFM Project 424/31/04), the European Commission (EU Spare Parts Project QLK6-CT-2000-00487), the Academy of Finland (Project 73948) and the Ministry of Education (Graduate School of Biomaterials and Tissue Engineering) are greatly appreciated.

P 16. Evaluation of Plastic Surgery patients in Zagreb Leppee M. Zavod za javno zdravstvo grada Zagreba, Zagreb, Croatia

P 17. Vertical mammoplasty-mastopexy for ptotic breasts-our experiance Marcikik G., Andonovska D., Stevkovska M., Gorceva M., Atanasova E. Department of Plastic and Reconstructive Clinical Center Skopje, Med. Faculty “St.Cyril and Methodius”, Skopje, Macedonia

IntroductionThere are a lot of surgical techniques that describe correction of the ptotic breasts. Vertical mammoplasty gives a good approach and good aesthetic results, without horizontal scars, good neurovascular supply to the nipple areola complex and a good shape of the breast.Material and methodsWe have had 4 women in this last year on the age of 26-55 years. Four vertical mastopexy according to Lajoure technique were performed. Preoperative we did the markings on the skin on the breasts, then during the operation we did the deepithelisation and mastopexy with the suture to the thoracic wall and then with a few sutures we made the shape of the breasts. We use drainage for 5 days.ResultsWe have had satisfactory results for both patients and the operating team. We took out the stitches (5-0, 3-0 Nylon, Prolen) 10-15 postoperative day. We had one seroma, that healed spontaneously. The shape of the breasts is projection and with time the scars are minimal visible.ConclusionVertical mammoplasty is a good solution for ptotic breasts with good sensibility of the nipple areola complex, minimal scars (without horizontal scars), good shape and projection of the breasts. Vertical mammoplasty is a technique that could always be our choice.

P 18. Reconstruction of the areola-nipple complex Margaritoni M., Bukvić N., Kostopeč P., Selmani R. Department of Surgery, Division of Plastic and Breast Surgery, County Hospital Dubrovnik Dubrovnik, Croatia

Reconstruction of the areola-nipple complex is important part of breast reconstructive surgery with notable influence on final cosmetic result. A few different techniques are usually performed trying to improve better shape, volume and pigmentation of areola-nipple complex.The authors represent their own experience in areola-nipple reconstruction.

P 19. Operative treatment of the fractures and pseudoarthrosis of scaphoid – 8th year follow up Matec B., Šurjak Ž., Vlahović T., Malović M., Rabić D. Clinic for Traumatology, Zagreb, Croatia

P 20. Children with cleft lip and palate: inhalation anaesthesia vs. general balanced Milić M., Gašparović S., Butorac Rakvin L., Knežević P., Uglešić V. Department for Anaestesiology and Intensive Care, Department for Maxillofacial and Oral Surgery, University Hospital Dubrava, Zagreb, Croatia

Background and objectiveThe children with cleft lip and palate need special attention from anesthesiologist. Due to position of malformation, difficult ventilation and intubation are very often. Postoperative complications have higher incidence than in other patients. The aim was to compare inhalation anesthesia (sevoflurane) with balanced general anesthesia (midazolam, fentanyl,vecuronium).Materials and methodsIn prospective study we analyzed heart rate, ECG II lead, haemoglobine and haematocrite before, intra and postoperativly in 117 children. They were divided in two groups: I group in 63 children anesthesia were induced with sevoflurane (5-8%) and maintaned with fenatnyl (0,005mg/kg), vecuronium (0,1mg/kg), and midazolam (0,05mg/kg) and in II group 54 children get sevoflurane/oxygen/air mixture supplemented with fentanyl (0,005mg/kg).Results and discussionOne hundred and seventeen children were between 5 days and 3 years of age (mean age 11,4 months). Our patients’ mean body weight were 12,2 kg.The children with body weight more than 5 kg were premedicated with midazolam and atropin intramuscular and induction in both group were with sevoflurane. There were no differences between values of heart rate, haemoglobine and haematocrit in both groups. Six children had difficult intubation.The estimated intraoperative blood loss exceeded 10-20% estimated circulating blood volume in 5 children(I group 3, II group 2).Seventeen children which get sevoflurane for maintaining anaesthesia developed postanaesthesia excitation. So we concluded that balanced general anesthesia would be our choice.

P 21. The usage of Ilizarov's methode in congenital anomalies of lower extremity Nikolayeva N. Odessa State Medical University, Odessa, Ukraine

PurposeTo define opportunities of Ilizarov’s method in the treatment of congenital anomalies of lower extremity.Materials and Methods48 children with congenital anomalies of lower extremity were investigated. In 12 cases occurred congenital hypoplastic femur (in 3 cases accompanied with congenital coxa vara and congenital dislocation of patella), in 6 cases – congenital tibial shortening, 14 – congenital pseudoarthrosis of tibia and fibular, 5 – fibular hemimelia, 3 – tibial

hemimelia, 7 – congenital typical clubfoot (relapses after traditional surgery or postponed diagnostics), 1 – congenital atypical clubfoot. Clinical, X-ray, ultrasound, laboratorial methods of investigation were used.Surgical treatment included liquidation of malformations in Ilizarov’s frame by closed ostheosynthesis (polylocal longitudinal and transversal) in combination with open interventions and following distraction.Results Good results achieved in all cases. The results of usage of Ilizarov’s method showed advantages of such approach – possibility of simultaneous multiplan operations:- in congenital hypoplastic femur – closed compactotomy & following distraction (m.b. corrigative osteotomy & transposition of patella);- in congenital pseudoarthrosis – resection of pathological tissues & Ilizarov’s frame & closed compactotomy & following distraction;- in fibular hemimelia – removal of fibrous fibular rudiment & tendoligamentocapsulotomy & reduction of dislocation in ankle joint & closed tibial compactotomy & following distraction;- in tibial hemimelia – fibular transposition & reduction of dislocation in ankle joint & closed fibular compactotomy & following distraction.- in clubfoot-closed ligamentocapsulotomy & compactotomy & following distraction.ConclusionThe usage of Ilizarov’s method is the best decision in the treatment of such congenita anomalies of extremities as congenital femoral and tibial shortening, hemimelia, pseudoarthrosis, problematic clubfoot. Ilizarov’s method allows to decide plural reconstruclive problems effectively and simultaneously.

P 22. Evaluation of PLDLA scaffolds & mesenchymal stem cells for bone engineering Oudina K1, Potier E1, Arnaud E2, Ellä V3,

Kellomäki M3, Ashammakhi N3,4, Petite H1

1 Université D. Diderot, Faculté de Médecine Lariboisière Saint-Louis, Laboratoire de Recherches Orthopédiques UMR CNRS 7052, Paris, France 2 Hopital Necker-Enfants Malades, France Craniofacial Unit, Paris, France3 Tampere University of Technology, Institute of Biomaterials, Tampere, Finland4 Oulu University Hospital, Department of Surgery, Oulu, Finland

IntroductionThe aim of this study is to assess the influence of fluid flow on MSC loaded onto 12 filaments PLDLA scaffolds and to determine the kinetics of proliferation and differentiation of MSCs when cultured on 4 and 12 filaments PLDLA scaffolds for 40 days in a bioreactor. Methods MSCs were isolated from rat bone marrow and expanded in alpha-MEM + 10 % FBS supplemented with dexamethasone, Ascorbate2-phosphate and -glycerophosphate. Knitted 12 or 4 filament Poly-L,D-lactide (PLDLA, L/D ratio 96/4) scaffolds were used. At passage P3-P5, 12 fil. scaffolds were soaked for 1 h in a MSC cell suspension at 106 cells/ml and then placed in 50 ml cell culture tube. Constructs were then cultured either on a stoval low profile roller at 6 rpm or left still. At day 28, DNA content, ALP

activity and calcium content were determined. 4 and 12 PLDLA filament constructs were prepared as aforementioned and DNA content, ALP activity and calcium content were determined every 3 days from day 0 to day 40 (n=3). Results DNA content (87000 23000 versus 5600013000cells per scaffold), ALP activity (64 20 versus 21 UI), and calcium content per scaffold (289 34 versus 21 6 ng /construct), were significantly higher in dynamic culture when compared to static cultures. No significant differences in DNA content, ALP activity or calcium content between the different scaffolds with different fiber thicknesses. Discussion and Conclusions MSCs proliferation and differentiation was significantly enhanced when fluid flow was applied. A 10 fold increase in calcium content per scaffold was observed when MSCs were cultured in the presence of fluid flow. PLDLA scaffolds were able to support MSC osteogenic differentiation. Acknowledgements This research was supported by grants from the EU [PROJECT N° QLRT-2000-00487 (chondral and osseous tissue engineering “Spare parts”), Spare Parts Project QLK6-CT-2000-00487], the Technology Development Center in Finland (TEKES, Biowaffle Project 40274/03 and MFM Project 424/31/04), the Academy of Finland (Project 73948) and the Ministry of Education (Graduate School of Biomaterials and Tissue Engineering). The authors wish to thank Dr Benoit from the service de pharmacie, Lariboisière for her help in this study.

P 23. TRAM and latissimus flap in palliative breast surgery Pašić A., Rifatbegović A., Mujkanović N., Burgić M. Plastic and Reconstructive susrgery, UKC “Tuzla”, Tuzla, Bosnia and Herzegovina

We can’t say with a sure is increase number of malignanat disease in realy increase or is it result of better diagnostic procedures. Theoreticly, on appearance and number of carcinomas because of early diagnosis we can affect by : preventive measures, mass screening procedures, treatment and new researches. New diagnostic procedures contribute to considerable number of breast cancer diagnosis in women. It’s evident that number is higher from day to day, and frequency has moved to younger ages. Breast cancer is frequently malignant tumor in women. Appearance of breast cancer is unusual before 20.th years of age, but it’s more frequently between 50.th and 70.th years of age. Risk for appearance of breast canacer is 1 : 8, and it mean that one of eight women will become ill during a life. Risk to get a cancer is higher with ages. Although , appearance of breast cancer is possible in any life ages, but this disease is unusual in women before 35 years of age. Approximative, 75% discovery cases of new breast cancers are in women older than 50 years of age. In this work is analised 30 progressive egzulcerative breast cancer and 25 progressive local relaps. At progressive breast cancers pathohistological and immunohistological analysis are done and corresponding therapy. After that patients had been operated and defects had been provide with TRAM and latissimus flap.

P 24. Surgical treatment of tumor recurrences localized at medial angle of eye Rifatbegović A., Mujkanović N., Pašić A., Burgić M. Plastic and Reconstructive susrgery, UKC “Tuzla”, Tuzla, Bosnia and Herzegovina

Morfology medial angle of eyes specifical, and tumors of this region can very often, and very fast infiltreted “ deeper structures “. Relativly often tumors has atendency for intraneural and perineural metastasis. That are the reasons for serious preoperative treatment ( CT scan of orbits and paranasal sinuses ). Operative traetment require redical excision and patohistological verification of resectional borders.After first excision recidiv is in 5,36% after second excision 17 %, and after tird and fourth excision 50 %. In this article we would like to present and analized cases with recidivans tumors, causes, mistakes and definitive results.

P 25. Anterior transfer of tibialis posterior tendon in treatment of peroneal palsies Salihagić S., Fazlić A. Clinic for Plastic and Reconstructive Surgery, Sarajevo, Bosnia and Herzegovina

Introduction Tendon transfer is the shifting of the insertion of a muscle from its normal attachement to another side to replace active muscular action that was lost by paralysis and to restore dynamic muscle balance.Peroneal palsies can be treated with anterior transfer of tibialis posterior tendon with correction of drof foot.This type of transfer can be used for correction of pes equinovarus and varus deformity combined with spastic cerebral palsy.Material and methodsDuring period 1992 - 2001 67 patient have been treated with anterior transfer of tibialis posterior tendon, with ireparabile leasions of peroneal nerve.ResultsWith this type of operation, we established lost dorsiflexion of foot. Optimal timing for operation is 1,5 - 2 years after injury of peroneal nerve.ConclusionThis operation is method of choise in treatment of peroneal palsies.

P 26. Novel method for correction of trigonocephaly in children Serlo W.1, Törmälä P.2, Waris T.3, Ashammakhi N.2,3

1 Oulu University Hospital, Department of Pediatrics, Oulu, Finland. 2 Tampere University of Technology, Institute of Biomaterials, Tampere, Finland 3 Oulu University Hospital, Department of Surgery, Oulu, Finland

We report on the feasibility of applying bioabsorbable tacks using a new tack-shooter to fix bioabsorbable plates applied endocranially for the correction of three cases of trigonocephaly. Tacks do not require tapping or tightening because they are applied using a tack-shooter directly into drill holes in the bone. Hence, the technique saves valuable operative time. A 1.5- to 2.0-cm broad supraorbital bar (bandeau) was raised and reshaped. The corrected shape was maintained using a Biosorb plate (Bionx Implants Ltd, Tampere, Finland), and tacks were applied on the endocranial side of the bar. The plate extended a few centimeters laterally beyond the edge of the supraorbital bar, and it was fixed with Biosorb miniscrews and/or tacks affixed to the temporal bones. Other molded bone pieces were fixed using Biosorb plates, screws, and/or tacks. The technique of using tacks was easy, and it provided secure osteofixation. Cosmetic results were excellent, and no complications were encountered except for palpability of plate edges on the right side of the skull in one case.AcknowledgementsResearch funds from the Technology Development Center in Finland (TEKES, Biowaffle Project 40274/03 and MFM Project 424/31/04), the European Commission (EU Spare Parts Project QLK6-CT-2000-00487), the Academy of Finland (Project 73948) and the Ministry of Education (Graduate School of Biomaterials and Tissue Engineering) are greatly appreciated.

P 27. Adductor tenotomies in children with cerebral palsy Talić A., Gavrankapetanović I., Mahić Z., Biščević M. Department for orthopedic and traumatology, Clinical center Sarajevo, Sarajevo, Bosnia and Herzegovina Aim of work is to point on adductor tenetomy importance in operative

treatment of children with cerebral palsy. Indications for adductor tenotomy at children with cerebral palsy are

established on consiliar meeting for neuromuscular disseases on our Department. Children with cerebral palsy whose hip abduction is less than 20 degrees are candidates for this operation which will allow and better hygiena of patient. Adductor tenotomy is a first phase of treatment protocol in descendent program of treatment. After billateral adductor tenotomy, abdominofemoral plastercast is to aplicate for four weeks and later admition on Department to start with physioterapy.

Results With this operative procedure, we achieve verticalisation of child, solve

contracture of hips and improove a walk at children who have had walking disturbances.

P 28. Follow-up of resorption of PLGA 80/20 screws for 1,5 year in rabbits Tiainen J1, Soini Y2, Törmälä P3, Waris T1, Ashammakhi N1,3 1 Oulu University Hospital, Department of Surgery, Oulu, Finland

2 Oulu University Hospital, Department of Pathology, Oulu, Finland 3 Tampere University of Technology, Institute of Biomaterials, Tampere, Finland

The aim of this study was to assess tissue reactions to bioabsorbable self-reinforced polylactide/polyglycolide (SR-PLGA) 80/20 miniscrews in rabbit cranial bone. One PLGA screw was implanted on one side and one titanium screw on the other side of the sagittal suture (n=21). Three animals were sacrificed after 2, 4, 8, 16, 24, 54 and 72 weeks. In histological examination the numbers of macrophages, giant cells, active osteoblasts and fibrous tissue layers were assessed and degradation of the bioabsorbable screws was evaluated. After two weeks, macrophages were seen near the heads of both screws. After 4 and 8 weeks, the bioabsorbable screws were surrounded by fibrous tissue. Osteoblastic activity and groups of several giant cells were seen. After 24 weeks, a significant change in the morphology of the PLGA screws had occurred. Osteoblastic activity and the amount of giant cells had decreased. After one year, some PLGA biomaterial was still present. PLGA screws had been replaced by adipose tissue, fibrous tissue and “foamy macrophages” which had PLGA particles inside them. After 1½ years, the amount of biomaterial remaining had decreased remarkably. The particles of biomaterial were inside “foamy macrophages”. SR-PLGA 80/20 screws are biocompatible and have no clinically manifested complications when used in cranial bone of rabbits. No contraindications as regards their clinical use in craniofacial surgery was found when studied in cranial bone of rabbit.Keywords Cranial bone, rabbit, SR-PLGA, tissue reaction, titanium AcknowledgementsResearch funds from the Technology Development Center in Finland (TEKES, Biowaffle Project 40274/03 and MFM Project 424/31/04), the European Commission (Project BMH4-98-3892, Project QLRT-2000-00487, EU Spare Parts Project QLK6-CT-2000-00487), the Academy of Finland (Projects 37726 and 73948), and the Ministry of Education (Graduate School of Biomaterials and Tissue Engineering) are greatly appreciated.

P 29. Assessment of guided cranial bone defect regeneration Vesala A-L1, Kallioinen M2, Törmälä P3, Kellomäki M3, Ashammakhi N1,3

1 Oulu University Hospital, Department of Surgery, Oulu, Finland 2 Oulu University Hospital, Department of Pathology, Oulu, Finland 3 Tampere University of Technology, Institute of Biomaterials, Tampere, Finland

The aim was to evaluate the use of self-reinforced poly-L,D-lactide 96/4 (SR-PLA96) sheets for cranial bone tissue engineering in experimental defects in rabbits. Square defects of 10 x 10 mm were created in the right parietal bone. SR-PLA96 implants (15x15 mm) were used to cover these defects in 12 New Zealand White rabbits. Similar defects were created in the left parietal bone, but

no sheets were used (controls). The rabbits were killed after 6, 24, or 48 weeks. Histology and histomorphometry were used to evaluate healing of the defects. Defects covered with SR-PLA96 sheets showed more abundant bone formation than control (non-covered) defects. At 6 weeks, the defects were occupied mainly by fibrous tissue. At 24 weeks, healing with bone formation was more obvious in the covered defects. At 48 weeks, bone completely bridged defects covered with SR-PLA96 sheets, and incomplete bridging was seen in non-covered control defects. Hence, bone tissue engineering in experimental cranial bone defects in rabbits can be achieved using SR-PLA96 sheets to guide bone regeneration.

Key words: Bioabsorbable, guided bone regeneration, polylactide, tissue engineering

Acknowledgements Research funds from the Technology Development Center in Finland (TEKES,

Biowaffle Project 40274/03 and MFM Project 424/31/04), the European Commission (EU Spare Parts Project QLK6-CT-2000-00487), the Academy of Finland (Project 73948) and the Ministry of Education (Graduate School of Biomaterials and Tissue Engineering) are greatly appreciated.

P 30. Fractures of the base of first metacarpal bone. Vlahović T 1 ., Šurjak Ž1, Malović M1., Matec B1., Tadic J1, Rabić D1, Veir Z.2 1Clinic for Traumatology, Zagreb, Croatia 2Department for Surgery, General Hospital “Josip Benčević”, Slavonski Brod, Croatia

Fractures of the base of the firts metacarpal are particularly common. The present excemination was carried out in order to find out a correlation between the clinical outcome and type of fracture, the quality of reduction, the surgical procedure and the extent of osteoarthrosis. Mechanysm of injury is an axially directed force through the partially flexed metacarpal shaft. We had 146 cases of fractures of the base of the first metacarpal bone which we devided into four types: 44% Bennet fractures, 39% extraarticular fractures, 112% Rolando fractures and 5% comminuted fractures. Patients were predominantlly between 20 and 39 years old ( 69% males ). We used conservative and operative treatment methods, depending on fracture type. Most extraarticular fractures can be treated conservativelly with good outcome results depending on achived reduction and fragment stability. Intraarticular fractures present treatment challenges because they tend to displace due to deforming force acting at base of thumb. are particularly common. The present excemination was carried out in order to find out a correlation between the clinical outcome and type of fracture, the quality of reduction, the surgical procedure and the extent of osteoarthrosis. Mechanysm of injury is an axially directed force through the partially flexed metacarpal shaft. We had 146 cases of fractures of the base of the first metacarpal bone which we devided into four types: 44% Bennet fractures, 39% extraarticular fractures, 112% Rolando fractures and 5% comminuted fractures. Patients were predominantlly between 20 and 39 years old ( 69% males ). We used conservative and operative treatment methods, depending on fracture type. Most extraarticular fractures can be treated conservativelly with good outcome results depending on achived reduction and fragment stability. Intraarticular fractures present treatment

challenges because they tend to displace due to deforming force acting at base of thumb.

P 31. Perilunate dislocations – our experience Vlahović T 1 ., Malović M1, Šurjak Ž1,., Matec B1., Veir Z.2, Rabić D1, 1Clinic for Traumatology, Zagreb, Croatia 2Department for Surgery, General Hospital “Josip Benčević”, Slavonski Brod, Croatia

With this poster we would like to present our experiance in treating perilunate injuries. The wrist is a complex of joints between seven bones whose function is to provide motion to and transmit force between the hand distally and the forearm proximally. Most clinically important carpal dislocations and fracture-dislocations result from falls on the palm of the hand resulting in a hyperextension injury to the wrist. We classified perilunate injuries in classification made by Mayfield and co-workers who has made IV stages of perilunate instability. Perilunate dislocations and fracture dislocations are uncommon injuries, constituting about 10% of all carpal injuries. These injuries tend to remain undiagnosed for varying lenghts of time and when discovered treatment varies and is controversial. Periluanr dislocations are very unstabile injuries and and we prefer to be treated with OR IF. OR gives the best oportunity for primary repair of ligaments and fixation to obtain good results. This poster examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner

P 32. Surgical facial wounds. Simple interrupted percutaneous suture (SIPS) versus running intradermal suture (RIS) Vukašin G., Bednar S., Berebrić B., Lazić G. Department for ENT, General Hospital Karlovac, Karlovac, Croatia

The purpose of this study is to compare the esthetics of scars resulting from surgical facial wounds sutured either with simple interrupted percutaneous ( SIPS ) or with running intradermal suture ( RIS ). We admited and followed sixty patients, and managed seventyone surgical wounds from simple excisions and primary closure.Thirtythree wounds were sutured with SIPS and thirtyeight with RIS. All the patients were informed with procedure and signed the consent form. All surgical procedures were performed by the same surgeon and under the same conditions.Evaluation of each scar was made blindly by two independent observers and by the patients the first, the third and the sixth moth after surgery. Judged by independent observers the first month after surgery ( early results ), excellent 90% results were obtained with RIS to just 22% excellent results with SIPS. Three months after surgery the results were improved in the group of patients sutured with SIPS. Excellent results raised to 64%, judged by independent observers.

Finally, six months after surgery esthetic results were fairly very close in both groups of patients sutured either with RIS or SIPS suture.There is advantage in using RIS over SIPS in early days, months, after surgery and practically no advantage six months after surgery in the type of facial wounds described.

P 33. Evaluation of biomechanical properties of bioabsorbable implants Waris E1, Happonen H2, Raatikainen T3, Kaarela O4, Törmälä P5, Santavirta S3, Konttinen YT3, Ashammakhi N4,5

1 University of Helsinki, Biomedicum Helsinki, Institute of Biomedicine/Anatomy,

Helsinki, Finland. 2 Linvatec Biomaterials Ltd., Tampere, Finland 3 Helsinki University Central Hospital, Helsinki, Finland 4 Oulu University Hospital, Department of Surgery, Oulu, Finland 5 Tampere University of Technology, Institute of Biomaterials, Tampere, Finland

Bioabsorbable fixation devices offer a useful option to treat small hand fractures. In a biomechanical study in tranversally osteotomized cadaver metacalpal bones, self-reinforced (SR) poly-L/DL-lactide (P(L/DL)LA) 70/30 and polylactide-polyglycolide (PLGA) 80/20 miniplatings were compared with standard metallic fixation methods. 112 fresh-frozen metacarpals from humans had 3-point bending and torsional loading after transverse osteotomy followed by fixation using seven methods: dorsal and dorsolateral 2.0-mm SR-PLGA plating, dorsal and dorsolateral 2.0-mm SR-P (L/DL)LA plating, dorsal 1.7-mm titanium plating, dorsal 2.3-mm titanium plating, and crossed 1.25-mm Kirschner wires. In apex dorsal and palmar bending, dorsal SR-PLGA and SR-P(L/DL)LA plates provided stability comparable with dorsal titanium 1.7-mm plating. When the bioabsorbable plates were applied dorsolaterally, apex palmar rigidity was increased and apex dorsal rigidity was decreased. Bioabsorbable platings resulted in higher torsional rigidity than 1.7-mm titanium plating. In another biomechanical study in obliquely (radial to ulnar orientation) osteotomized pig metacarpal bones, we compared the stabilities of various bioabsorbable fixation devices with metallic fixation devices. 1.5 mm self-reinforced poly-L-lactide (SR-PLLA) pins provided fixation rigidity comparable with 1.5 mm Kirschner wires in dorsal and palmar apex bending, whereas in lateral apex bending and in torsion the rigidity was equal to that of 1.25 mm Kirschner wires. 2.0 mm SR-P(L/DL)LA screws provided rigidity comparable with that of 1.5 mm Kirschner wires in all testing modes. The bioabsorbable plate considerably enhanced the bending stabilities of the fixation system, but a single interfragmentary screw provided only limited rotational rigidity. The results demonstrate that using ultra-high strength SR implants, adequate fixation stability for hand fracture fixation can be achieved. Accordingly, bioabsorbable miniplating can be used safely in the clinical stabilization of metacarpal and phalangeal fractures.Acknowledgements Research funds from the Technology Development Center in Finland (TEKES, Biowaffle Project 40274/03 and MFM Project 424/31/04), the European Commission (EU Spare Parts Project QLK6-CT-2000-00487), the Academy of Finland (Project 73948) and the Ministry of Education

(Graduate School of Biomaterials and Tissue Engineering) are greatly appreciated.

P 34. Experience with bioresorbable fixation of mandibular fractures Ylikontiola L1, Sundquist K1, Sandor GK2, Tormala P3, Ashammakhi N3,4

1 University of Oulu, Oulu University Hospital, Department of Oral and Maxillofacial Surgery, Oulu, Finland.2 University of Toronto, The Hospital for Sick Children, Toronto, Canada3 Tampere University of Technology, Institute of Biomaterials, Tampere, Finland4 Oulu University Hospital, Department of Surgery, Oulu, Finland

Objective Bioresorbable osteofixation devices are being increasingly used in orthognathic surgery and in cases of trauma to avoid problems associated with conventional metal osteofixation devices. The aim of this clinical study was to assess the reliability and efficacy of bioresorbable self-reinforced poly-L/DL-lactide (SR-P(L/DL)LA 70/30) plates and screws in the fixation of mandibular fractures in adults. Study Design Ten patients (20 to 49 years old) with isolated anterior mandibular parasymphyseal fractures were treated by means of open reduction and internal fixation using SR-P(L/DL)LA 70/30 bioresorbable plates and screws. Results During the minimum of 6 months of follow-up, no problems were encountered except for 1 case where a plate became exposed intraorally and infected. This required debridement and later excision of the exposed part of the plate. Despite this setback the fractured bone healed well. Conclusions SR-P(L/DL)LA 70/30 plates and screws are reliable for internal fixation of anterior mandibular fractures in adults. Proper soft tissue coverage should be ensured to avoid plate exposure. Should implant exposure occur, it might be necessary to excise the exposed part after fracture healing (6-8 weeks postoperatively).

Acknowledgements Research funds from the Technology Development Center in Finland (TEKES, Biowaffle Project 40274/03 and MFM Project 424/31/04), the European Commission (EU Spare Parts Project QLK6-CT-2000-00487), the Academy of Finland (Project 73948) and the Ministry of Education (Graduate School of Biomaterials and Tissue Engineering) are greatly appreciated.

P 35. Ultrasound in aesthetic breast surgery Ignatovski B., Bartoš V., Polyclinic for Surgery, Ginaecology and Plastic Surgery «Arcadia», Daruvar, Croatia

Breasts are the symbol of feminisity, and an organ of the female body which is a subject to numerous diseases ranging from inflammatory processes, through different stages of mastoparhy , to benign and malign tumours.Breasts shaping, as an individual surgery, holds the first place in frequency in aestethicplastic surgery. It is important to have a complete insight of the breasts condition at the moment of performing an aestetic surgery.The importance of ultrasound diagnostics as a procedure in the preparation for surgery and monitoring of patients condition after surgery will be discussed in the paper. It is especially important in the augmentative mammaplastics since we have to monitor two subjects; the brest and the implant.

P 36. News in rhinoplasty (endoscopic and atraumatic approach) Glušac B. Private ENT Office, Makarska, Croatia

Rinokirurške operacije su najstarije, najčešće i ujedno najkontraverznije u estetskoj kirurgiji lica. U zadnjih 10 godina rinoplastikaje doživjela najveće promjene u odnosu na ostalu kirurgiju lica.Današnji moderni cilj rinoplastike bio bi da u jednom aktu riješi funkcijiski i estetski problem pacijenta. Prvi cilj estetske kirurgije nosa bila bi funkcija (sjetimo se da septuma ima oko 10 svojih funkcija i 9 sastavnih dijelova) pa onda estetska korekcija nosa.Danas težimo atraumatskom pristupu tj. minimalnoj invazivnoj krirurgiji, sa maksimalnim efektom, bez ožiljka, postoperacijskih otoka, krvarenja, podljeva, te sa brzim oporavkom.Već 5 godina rabimo endoskopski pristup u rinoplastici pomoću fiberendoskopa, endo mikrokamere, monitora. Kontroliramo tijekom operacije koštano-hrskavičnu grbu, septum te meka tkiva piramide.Zahvaljujući modernoj tehnologiji, preciznim, oštrim instrumentima, te optičkoj kontroli, nemamo više nikakvih komplikacija u smislu ostataka grbe ili otvorenog krova piramide, te dobivamo na vremenu, što je jako bitno za brzi oporavak pacijenta. Prikaz (u u živo) na DVD-u, zatvorena tehnika, 7 minuta, endoskopski pristup.

P 37. Digital photography and patohystological analysis ex tempore Burgić M. Plastic and Reconstructive susrgery, UKC “Tuzla”, Tuzla, Bosnia and Herzegovina

Tumors of perorbital region always require histological analysis of resection borders because we would like to be sure that borders are clean of tumor. If the tumor are infiltrated deeper structures surgical treatment must be in 2-3 acts ( if is retrobulbar tissue or bone are infiltrated ). In this cases surgeon can not to interpreted analysis. Because we took a pictures interoperate with digital camera . We took a pictures of excision zones and layers. On pictures we put the sings on excision zones and adequate landmark and than we send pictures to histological analysis. On this way surgeon has adequate interpretation of analysis and reliable and most quality situation for patient prognosis and good possibility to continue therapy.

P 38. Endoscopically assisted suctioning of lipomas Gverić T., Huljev D., Zdilar B., Simon S., Skok I. General Hospital “Sveti Duh”, Zagreb, Croatia

Within the group of 32 patiens with citologically verified lipoma, 16 had been operated in the classical way, and 16 with endoscopiclly assisted suctioning. After 12 month of monitoring, there was not established any difference as far as recidivism is concerned. Endoscopically assisted suctioning was approved as safe and effective method in removing lipoma on visible locations, which resulted also with minimale scarnes and cosmeticaly great result, shorterpostoperative recovery and shorter absence.

P 39. Necrotizing fasciitis of abdominal wall, V.A.C. As a support method Huljev D., Gverić T., Kučišec-Tepeš N. General Hospital «Sveti Duh» Zagreb, Croatia

Necrotizing fasciitis is an acute surgical condition which demands a prompt andcombined treatment. Early recognition and aggressive surgical debridement, along with a target antibiotic treatment,significantly affect the overall course of treatment and, ultimately, survival. A case of a femal patient with necrotizing fasciitis of the abdominal wall, the course and methods used in the treatment, particulary the microbiological aspect and the use of V.A.C. ( vacum assisted closure) as an auxiliarymethod, are presented in this work.

P 40. V.A.C. As a method for treatment of postoperative hematoma after abdominoplasty, case report Gverić T., Huljev D. General Hospital «Sveti Duh» Zagreb, Croatia

In this work the authors describe the use of a vacuum assisted closure in treatment of postoperative hematoma of abdomen after classical

abdominoplasty. Fully closed treeatment of the hematoma minimizes the possibility of infectons and makes classical bandaging and axpensive dressing unneccessary. V.A.C. was approved axcellent within the aspect of patient confort, quicker recovery and shorter medical treatment.

P 41. Reconstruction of the brachial artery pseudoaneurysms following venipuncture in infants Bulić K., Unušić J., Džepina, Mijatović D. Department of Plastic and Reconstructive Surgery, University Hospital “Zagreb”, Zagreb, Croatia

Advances in invasive diagnostic procedures and increased survival of low birth weight infants have resulted in an increase of pediatric vascular injuries, representing a challenging problem in surgical practice. Only two cases of pseudoaneurysms of the brachial artery following venipuncture in infants have been reported in the literature.We report three cases of brachial artery pseudoaneurysms following venipuncture in infants operated upon in our institution, the age of infants ranging from 43 to 64 days. Infants were operated 25 to 42 days following the injury. While in two infants the arterial continuity following resection was restored with an end-to-end anastomosis, in the third infant, the use of a venous interposition graft was necessary. Duplex US was used in preoperative evaluation and postoperative follow-up of all three infants. The child requiring a more complex reconstructive procedure was also evaluated with helical contrast computed tomography.The key points in managing these injuries are early diagnosis and microvascular reconstruction.

SPONSORS & EXHIBITORS :

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Algoritam

Bauerfeind d.o.o., Zagreb, Croatia Carl Zeiss d.o.o., Zagreb, Croatia Elastic d.o.o., Daruvar, Croatia

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Zepter

LIST OF PARTICIPANS

A) FACULTY

Prof. Zoran Arnež Ljubljana, Slovenia

Prof. Andrej Banić Zurich, Switzerland

Beatriz Berenguer, MDMadrid, Spain

Pietro Berrino, MD Genova, Italy

Prof. Edgar Biemer Munchen, Germany

Prof. Phillip Blondeel Gent, Belgium

Prof. John Boorman London, UK

Srećko Budi, MD, PhD Zagreb, Croatia

Horacio Costa, MD Oporto, Portugal

Prof. Michel CostagliolaToulouse, France

Prof. Kris T. DrzewieckiCopenhagen, Denmark

Christian Echinard, MDMarseille, France

Egon Eder, MDKoln, Germany

Prof. Jens Jorgen ElbergCopenhagen, Dennmark

Javier Enriquez de Salamanca, MDMadrid, Spain

Beatriz Gonzalez, MD Madrid, Spain

Prof. Ian Jackson Southfield, USA

Krešimir Martić, MDZagreb, Croatia

Jaume Masià, MDBarcelona, Spain

Rudolf Milanović, MD, MS Zagreb, Croatia

Gavin Miller, MDSheffield, UK

Roland Ney, MDMontreux, Switzerland

Prof. Jean-Philippe NicolaiGroningen, Netherlands

Prof. Milomir Ninković Munchen, Germany

Prof. Marina Ninković Innsbruck, Austria

Prof. Rolf R. OlbrischDusseldorf, Grmany

Prof. Neven Olivari Wesseling, Germany

Nicholas Parkhouse, MD, MCh, FRCSLondon, UK

Prof. Aurelio Portincasa Foggia, ItalyStefano Piccolo, MDRimini, Italy

Dirk F.Richter MDWesseling, Germany

Franjo Rudman MDZagreb, Croatia

Prof. Richard C. SadoveTel Aviv, Israel

Sanda Stanec MD, PhDZagreb, Croatia

Prof. Zdenko StanecZagreb, Croatia

Tiew C. Teo MDLondon, UK

Christoph Wolfensberger MDZurich, Switzerland

Zlatko Vlajčić MDZagreb, Croatia

Rado Žic MD, PhDZagreb, Croatia

B) AUTHOR INDEX

AAgir H. A14, A15, H6, P1Aljinović Ratković N. A13, A16, P2

Andonovska D. P3, P17Andonovski D. P3Arifi H. P4Arnaud E. P5, P22

Arnež Z. L3, G6, Arnold J. I2Ashammakhi N. I5, P5, P15, P22,

P26, P28, P29, P33, P34

Atanasova E. P3, P17Azzizi M.D. I3

BBagatin D. A4Bagatin M. A4Bagatin T. A4Bahia H. B12Banić A. W1, L8 Bartoš VladoBednar S. P32Begic A. C5Bekić M. D6Berebrić B. P32Berenguer B. A1 Berisha A. P4Berrino P. B3, D10Beslič N. H7 Biemer E. A7, W2, L4, Biščević M. H4, P27Blondeel P. L2, W3,Boorman J. C2, W4, L7Brajčić D. E2, F4, Brnić Z. P6, Brockmann A. B13Brunel M.J. I3Budi S. C4, H5, P7, Budinščak I. B9Buja Z. P4Bukvić N. D6, P18Bulić K. D3, P41Burgić M. A17, P23, P37Busching K. B13Bušić V. C5Butorac L. A11, P20

CCek D. A14, H6, P1Costa H. A10, B7Costagliola M. A5, E1, I4Crnogorac V. B13, I2

DDas Gupta R. C5David D.J. A15Dinar S. H6, P1Dobrović M. B11Dominique R. P5Donoway D. P5Drviš P. G3Drzewiecki K.T. L9, E4Džepina I. D3, H1,P41Dzokic G. P8Dzonov B. F9

Dzorceva M. P3

EEchinard C. D7, I3, I6Eder E. D12, D2Elberg J.J. C1, W5Ella V. P22Enriquez de Salamanca J. F1Erić M. P10

FFazlić A. P25

GGašparović S. B6Gavrankapetanović F. H4Gavrankapetanović I. H4, P27Gjorgievska J. P8, Glamuzina R. A11Glumičić S. B9Glušac B. P36Gonzalez B. A2Gorceva M. P17Grmek M. G6Gruden Stanič O. G5Gverić T. P38, P39, P40

HHapponen H. P33Hebebrand D. B13Huis M. P9Huljev D. P38,P39,P40

IIgnatovski B. P35Ioannovich I. P14

JJackson I. L1, W6Janjić Z. P10, P11, P12Jelen S. H3Jeremić P. P12Jokić D. A3, A18, B6Jones B. P5Jovanović M. P10, P11, P12Juri J. B5Jurišić D. P13

KKaarela O. P33Kallioinen M. P29Kalogjera L. G3Karabeg A. D14Karabeg R. D14Kellomaki M. P15, P22, P29Kempny T. H3Keramidas E. P14, D13, F5, F7, H2, Kleinert H. F2

Knežević P. A3, A9, A11, A12, A18, B6, B10, P20

Konttinen Y.T. P33Kostopeč P. D6, P18Kovačić J. A3Krmpotić M. P2Krpan I. P30Kučišec-Tepeš N. P39Kysely T. H3

LLacević S. D14Lansman S. P15Laurikainen K. P5Lazić G. P32Leppee M. P16Leroy P. I3Leskovšek A. H7Lukšić I. A9

MMahić Z. P27Malović M. P19, P30, P31Mandal A. B12Marchac D. P5Marcikik G. P3, P17Margaritoni M. D6, P18Margić K F6, F8Martić K. C4, D4, H5Masia J. A8, C3Matec B. P19, P30, P31Mijatović D. D3, H1,P41Milanović R. C4, H5Milenović A. A9Milić M. A11, B10, P20Miller G. F5, F7, F11, H2, P14Mircevska-Zogovska E. F9, P8 Mircevski V. F9Momčilović D. P10Mujkanović N. A17, P23, P24

NNaceska A. F9Nalić B. P11Nanković V. W14Ney R. W13Nicolai J-P. W7, W15, G1Niemela S-M. I5Nikolayeva N. P21Nikolić J. P10Ninković Ma. F10Ninković M. W8, L10, P5 Nola I. I1Novak E. G4

OOlbrisch Rolf R. B8, L6, W15Olivari N. D5, D9Oudina K. P22

Ožegović I. A3Ozkeskin B. A14

PPaakko P. P15Parkhouse N. A6Pašić A. A17, P23, P24Pavlic R. G4Peart F. F2Pegan B. G3Petite H. P22Petrović I. G3Piccolo S. W11Pirc J. F8Pirjavec A. P13Pisarev-Šoć M. P11Podbregar M. G4Popović A. P11Portincasa A. W9, D1, L11Potier E. P22

RRaatikainen T. P33Rabić D. P19, P30, P31Richter D.F. B2, D11, W10Rifatbegović A. A17, P23, P24Rodopoulous S. F5, P14Roje Z. E2, F4Roje Ž. E2, F4Rudman F. C4, D4, H5

S, ŠSadove R.C. B4, L5Salihagić S. P25Sandor G.K. P34Santavirta S. P33Schnitt D.E. A15Selmani R. D6, P18Sen C. A14, H6, P1Serlo W. P5, P26Shejbal D. G3Simon S. P38Skok I. P38Smith G.D. F2Soini Y. P28Solomos M. F5Spyriounis P.K. G2Stanec S. C4, C6, D4, H5Stanec Z. C4, C6, D4,

G6, H5Stevkovska M. P17Stewart K. B12Stiglmayer N. B5Stritar A. G6, H7Sundquist K. P34Šolinc M. H7Šoštar K. P9Šurjak Ž. P19, P30, P31

TTalić A. P27Teo T.C. F3, W12Tessier J.L. I3Tiainen J. I5, P28Tojagić M. B5Tormala P. P15, P26, P28,

P29, P33, P34Tsoutsos D. P14Tudzarova-Gorgova S. P8

UUglešić V. A3, A9, A11, A12, A18,

B6, B10, P2, P20Unal C. P1Unušić J. D3, H1, P41Us J. G6Ustundag E. A14Utrobičić I. E2, F4

VVeir Z. P31Veiranto M. I5Vesala A-L. P29

Virag M. A9, A13Vlahović T. P19, P30, P31Vlajčić Z. C4, C6Vresky B. H3Vukašin G. P32

WWagner D. I2Waris E. P33Waris T. P26, P28Wolfensberger C. B1

YYlikontiola L. P34

Z,ŽZambelli M. D8, E3Zatriqi V. P4Zdilar B. P38Zubčić V. A12Zubčić Z. A12Zupičić B. A12Žic R. C4, C6, D4, H5

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