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Fifty-four patients were studied a mean of five years after their breasts had been reconstructed between 1984 and 1990 using the lateral thoracodorsal (LTD) flap in combination with either a thin shell, non-low-bleed (n = 35) or a thick shell, low bleed (n = 19) silicone gel implant. The rate of capsular contracture (Baker III-IV) was 11% in the first group and 10% in the second according to a modified Baker classification. Open capsulotomy was common in both groups of patients (15/35 in the first group and 13/19 in the second). Investigation by applanation tonometry of the capsular contracture agreed with the modified Baker classification. The cosmetic results were evaluated clinically and from photographs. Best scores were recorded for scars and ptosis in both evaluations. There were no significant differences between the general cosmetic results in the two groups. The patients graded their estimations of the final outcome of their breast reconstruction on a 10-point visual analogue scale (VAS); the mean for the first group was 8.7 and for the second 9.2. None of the patients regretted her operation and they would all recommend the procedure to another patient.

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The basic techniques of plastic surgery are of great practical importance in achieving the best possible results when reconstructing skin and subcutaneous tissue. Knowledge of the anatomy of the skin and the normal healing process is also essential. These fundamental principles of skin surgery include appropriate methods of infiltration anesthesia. Detailed descriptions of the technique of skin incision, excision of skin lesions and control of bleeding are given. Techniques of skin suture are described, and recommendations for optimal timing of suture removal and treatment of scar tissue are provided.

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The basic techniques of plastic surgery are of great practical importance in achieving the best possible results when reconstructing skin and subcutaneous tissue. Knowledge of the anatomy of the skin and the normal healing process is also essential. These fundamental principles of skin surgery include appropriate methods of infiltration anesthesia. Detailed descriptions of the technique of skin incision, excision of skin lesions and control of bleeding are given. Techniques of skin suture are described, and recommendations for optimal timing of suture removal and treatment of scar tissue are provided.

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In a retrospective study the results of breast reconstruction with 146 lateral thoracodorsal flaps operated on during the period 1991-94 at the Departments of Plastic Surgery at the Sahlgrenska University Hospital in Göteborg and the Stockholm Söder Hospital were evaluated. The median age of the 135 patients was 51 years (range 37-74). About two thirds of the patients were also operated on on the opposite side at the same time; and this was done more often in Stockholm, which partly explains the longer operating time in Stockholm. Perioperative bleeding (median 100 ml, range 25-400) was similar in both groups. Median postoperative bleeding, which was measured only in Stockholm, was 300 ml (range 30-1000). Seromas were seen only in Göteborg where postoperative drains were rarely used. The rate of early complications (infection and partial necrosis) were higher in Stockholm where more flaps were raised in irradiated tissue. We conclude that the results were similar in the two centres, and the thoracodorsal flap gives good results. The incidence of early morbidity could be reduced by excluding patients who had been irradiated, by inserting drains, and by giving antibiotic prophylaxis.

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A follow up study that compared the results from two plastic surgical centres comprised 95 patients after breast reconstruction with the lateral thoracodorsal (LTD) flap combined with either a smooth or textured saline-filled implant. It was conducted a median of 39 months (range 15-67) after the reconstruction. We investigated the size of the reconstructed breast and LTD flap, symmetry of the breasts, orientation of the mastectomy scar, and the rate of capsular contracture, which were similar in the two centres. However, according to the modified Baker classification and applanation tonometry reconstructions with smooth-surfaced implants and drainage of the implant pocket resulted in softer breasts (p = 0.03). The LTD flap technique in breast reconstruction was a good choice, particularly for women who required a minor breast reconstruction, and the technique can be recommended for suitable patients.

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A modified S-flap method for nipple reconstruction with two local opposing skin flaps, was used for a series of 21 women with a mean age of 50 years (range 30-64). Four patients had bilateral breast reconstructions, so the total number of reconstructed nipple areola complexes (NAC) was 25. The patients were examined 29-46 months (mean 36) after the reconstruction with particular reference paid to projection, size, sensation, and colour of the nipples. The patients also answered a questionnaire about their assessment of the final result. The mean projection of the nipples was 3.9 mm (range 0-9). Five patients had various degrees of necrosis of the skin flaps. One third of the women had some sensation in their reconstructed nipples. Two thirds of the nipples were pale. The patients estimated the final result as 8.2 (range 1-10) on a visual analogue scale.

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Peptide growth factors were mapped immunohistochemically for assessment of their presumed relation to the cells in capsules enveloping gel-filled, smooth-surfaced silicone mammary implants (12 capsules from 11 women). The implant capsules were dominated by fibroblast-like cells, but there were as well macrophages, inflammatory cells, and vascular cells. These cells expressed immunoreactivity for TGF-beta, IGF-II, IGF-I, and, to a lesser extent, PDGFB, NGF, and TNF-alpha. The numerous spindle-shaped cells in the contracted capsules displayed several distinct cytoplasmic actin bundles and fulfilled ultrastructural criteria for myofibroblasts. In contrast, myofibroblasts were recognized in low frequencies in the noncontracted capsules. Mature skin scar tissue did not show any peptide growth factor immunoreactivity, and myofibroblasts were absent. It is postulated that the low-grade chronic inflammatory foreign-body reaction, aggravated by mechanical stress and possible leakage of irritants, stimulates capsule cells to form peptide growth factors, reflecting that extended healing processes prevail in both noncontracted and contracted capsules. We propose that the local enrichment of peptide growth factors, beneficial for acute wound healing, in the chronically irritated tissue around implants provides trophic support for the contractile cells in the implant capsules.

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A simple, reproducible method for measuring the volume of pressure sores is described. The sore is covered with a transparent film which follows the previous skin as much as possible. An isotonic solution is injected through the film; the amount of fluid required to fill the sore represents the sore volume.

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Ninety-four consecutive patients (19 who underwent mastopexy, and 75 who underwent reduction mammaplasty) were reviewed. They had all been operated on using a sliding manoeuvre for transfer of the nipple-areola complex on its underlying parenchyma, which has been in use for reduction mammaplasty in our unit since 1978. This makes it possible to slide the nipple-areola complex on the glandular tissue by making incisions in the de-epithelialised dermal zone on both sides of the areola, and leaving a dermal bridge above. The technique increases the mobility of the nipple-areola complex without jeopardising the blood supply, and is a combination of horizontal and superior pedicle techniques. The patients had been followed up for three to six months, except for five who had been followed up for five to six years. Minor early complications occurred in two patients. The sliding nipple technique is applicable to most types of mammary ptosis and hypertrophy, except those with a sclerotic and stiff parenchyma.

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The present study was undertaken to investigate whether vascular cells show insulin-like growth factor I (IGF-I; somatomedin C) immunoreactivity under normal conditions and/or during angiogenesis in humans and animals, as the trophic peptide IGF-I is considered important for cell growth and differentiation. In adult animals normal blood vessels, i.e., arteries, veins, and capillaries, did not show any IGF-I immunoreactivity. In newborn animals every vascular cell showed IGF-I immunoreactivity; the frequency and intensity thereafter decreased and eventually vanished as the animals approached maturity. Injury of a tissue or organ rapidly induced extensive blood vessel formation and such new blood vessels transiently expressed IGF-I immunoreactivity. Endothelial cells in budding capillaries showed distinct cytoplasmic IGF-I immunoreactivity, as did endothelial cells, smooth muscle cells, and fibroblast in newly formed arteries and veins. In biopsies of human tissue, transient IGF-I immunoreactivity was evident in vascular cells during angiogenesis after injury, as it also was in granulation tissue, skin wounds, and scar capsules around implants. Increased IGF-I immunoreactivity was further demonstrated in vascular cells in biopsies from patients with other changes involving blood vessel formation, e.g., nasal polyps, and in specimens from patients with arteritis, tendonitis, synovitis, Wegener's granulomatosis, idiopathic midline destructive disease, neurofibromatosis (von Recklinghausen's disease), and muscular dystrophy. It is concluded that during angiogenesis, obviously irrespective of inducing factors and mechanisms, vascular wall cells transiently show IGF-I immunoreactivity.

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Early postoperative manipulation of breast implants in patients who underwent breast reconstruction utilizing a lateral thoracodorsal flap is described. This manipulation did not reduce the rate of firm capsular contracture after the reconstruction with the flap, but only postponed its development. Open capsulotomies, however, yielded stationary soft breasts to a statistically significant extent. The patient's acceptance of the reconstructed breast as a natural part of her own body was high. It was not influenced by the occurrence of firm capsular contracture.

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The distribution of somatomedin C (Sm-C; insulin-like growth factor I; IGF-I) immunoreactivity was examined in biopsies from three patients having the diagnosis neurofibromatosis established on clinical and histopathological criteria. All biopsies showed increased Sm-C immunoreactivity limited to areas with neurofibromas. Schwann cells, adjacent spindle-shaped fibroblast-like cells and newly formed blood vessels were positive. In addition, Sm-C immunoreactivity could be demonstrated in cells in the buccal epithelium. There was faint or no Sm-C immunoreactivity in biopsies from normal tissue of the patients and in specimens from control subjects. We propose that an abnormally increased local production of Sm-C, most likely by Schwann cells, forms a link in the chain of pathogenic events resulting in the disease neurofibromatosis.

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A fasciocutaneous transposition flap, the lateral thoracodorsal flap, has been used in 114 cases of breast reconstruction. This flap is raised from the lateral and dorsal aspects of the thoracic wall at the level of the submammary crease, and the size may be varied from 12 to 22 cm in length and 6 to 12 cm in width. The lateral thoracodorsal flap is used with an implant and forms the lateral part of the reconstructed breast. A natural ptotic breast shape is achieved in a single-stage procedure. Complications such as partial necrosis and infection have occurred in 3.5 and 2.5 percent of cases, respectively. The procedure is simple and has at our unit largely replaced the use of the latissimus dorsi musculocutaneous flap in extensive postmastectomy defects. In less disfiguring defects, the lateral thoracodorsal flap has taken the place of direct implantation because the reconstructed breast obtains a more pleasing shape by augmentation of the lower lateral pole.

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The case of an 18-year-old female with absence of the right breast, sternocostal part of the major pectoral muscle and total absence of the minor pectoral muscle and the latissimus dorsi muscle, is presented. She also had decreased sweating capacity and absence of terminal hairs in the central part of her right axilla. Histological examination of skin specimens from this area of the axilla demonstrated hypoplasia of the apocrine sweat glands, but normal eccrine sweat glands, indicating an apocrine dependent axillary sweating function. The breast was constructed using a direct subcutaneous prosthesis implant, giving a final result that was good in regard to shape and softness. This provides grounds for reconsidering the use of the latissimus dorsi muscle flap in breast constructions in Poland's syndrome.

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Although observation in clinical settings of communication augmentation system use by severely physically handicapped nonspeaking persons is important, monitoring of such use in natural settings can yield valuable information about the system, communication frequency, and unique communication needs of the individual. This study was designed to evaluate the use of communication partners as data recorders. For nonspeaking, severely physically handicapped subjects were observed in the home, school or treatment settings by a trained observer and a minimally trained communication partner. Issues of partner training and length of time required to obtain a representative sample of communication arose as a result of this study. More work in the areas of automated data collection systems or use of communication partners as data collectors is required before claiming that accurate communication interactions can be recorded in natural settings.

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