Abstract book - ESPRAS

Croatian Medical Association
Croatian Society of Plastic, Reconstructive and Aesthetic Surgery
University Hospital Dubrava, Zagreb, Croatia
Department 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, Croatia
15th-20th October, 2004.

Naslovna strana – reklama ROZISTEP

5th CROATIAN CONGRESS FOR PLASTIC, RECONSTRUCTIVE AND
AESTHETIC SURGERY
ESPRAS appointed Congress for 2004.
Dubrovnik-Cavtat, Croatia
15th-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.
Croatian Medical Association
organized by
Croatian Society of Plastic,
Reconstructive and Aesthetic Surgery
University Hospital Dubrava, Zagreb, Croatia
Department for Plastic, Reconstructive
and Aesthetic Surgery
Local co-organizer
County Hospital Dubrovnik
Under the auspicies of
Dubrovnik – Neretva County

ORGANIZING COMMITTEE
CONGRESS PRESIDENT
Zdenko Stanec
President of the Croatian Society of Plastic, Reconstructive and Aesthetic
Surgery (CSPRAS)
VICE PRESIDENTS
Marko Margaritoni
Zdravko Roje
GENERAL SECRETARIES
Sanda Stanec
Rado Žic
TREASURER
Rudolf Milanović
ORGANISING COMMITTEE
Zdenko Stanec, Marko Margaritoni, Zdravko Roje, Rado Žic, Sanda Stanec,
Rudolf Milanović, Srećko Budi, Franjo Rudman, Krešimir Martić, Zlatko Vlajčić, Marina
Mamić-Pavelić
SCIENTIFIC COMMITTEE
Josip Unušić, Mišo Virag, Neven Olivari, Milomir Ninković, Radojko Ivrlač,
Vedran Uglešić, Mario Zambelli, Sanda Stanec, Rado Žic, Ivo Džepina
HONORARY COMMITTEE
Ivan 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 Surgery
University Hospital Dubrava
Avenija Gojka Šuška 6, 10000 Zagreb, Croatia
Tel.: +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 HOTEL
20210 Cavtat, Croatia
Salon 5
Tel: +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.
Craniosynostosis
A 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 Syndromes
Rarely 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.
Hypertelorism
The 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.
Hypotelorism
This 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 Microsomia
This 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 Clefts
These 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 Surgery
These 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 features
Notched posterior nasal spine
Bifid uvula
Lucent midline strip
Occult SMCP
No Intraoral signs
Small midline defect on endoscopy
?Musculus uvulae absence
Clinical situation is more complex
Spectrum of severity
Key is abnormal levator insertions
Examination important

Lateral videofluoroscopy most useful
Presentation is at various stages
Neonatal examination
Feeding difficulties
Failure to thrive
Glue Ear
Speech 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 options
Correction 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. UVspectrum
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 used
The 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.Meyer ii 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
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
function.
Kleinert vi 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
There are as many different standards for evaluating functional recovery
after replantation (for sensation, motor outcomes, assessment to cold
intolerance and all the indicators of complications) as there are reporting
surgeons vii .
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. Leung viii and Frykman ix 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

eview 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
rejection x .
REFERENCES
1 Mc Carthy: Replantation and revascularization of the upper extremity. Plastic
Surgery, Vol.7, The hand, Part 1, May & Littler 1990, p.4356.
1 Meyer VE, Chen Z-W, Beasley RW: Basic technical considerations in
reattachment surgery. Orthop Clin North Am 12:871, 1981.
1
Chow JA et al: Forearm replantation — Long term functional results. Ann
Plast Surg 10:15, 1983.
1 Russell RC et al: The late functional results of upper limb revascularization
and replantation. J Hand Surg 9A:623, 1984.
1 Urbaniak JR: Replantation of amputated parts: Technique, results, and
indications. In: AAOS Symposium on Microsurgery. St Louis, CV Mosby,
1979, pp 64-82.
1 Kleinert H, Jablon M, Tsai T: An overview of replantation and results of 347
replants in 245 patients. J Trauma 20:390, 1980.
1 Tamai S: Twenty years' experience of limb replantation: Review of 293 upper
extremity replants. J Hand Surg, 7:549, 1982.
1
Leung PC: Thumb reconstruction using second-toe transfer. Hand Clin
1(2):285, 1985.
1 Frykman GK et al: Functional evaluation of the hand and foot after one-stage
toe-to-hand transfer. J Hand Surg 11A:9, 1986.
1 Lee WP, Mathes DW: Hand transplantation: pertinent data and future
outlook. J Hand Surg 24A(5):906, 1999.