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Background: Alopecia is defined as partial or complete hair loss. The most common form is androgenetic alopecia, which occurs in both men and women. Despite the nonsurgical options available for treatment, the only permanent solution is hair transplantation. Hair loss has been shown to have significant psychological consequences associated with loss of self-confidence, poor self-image and difficulties in social functioning. We aim to examine the effect of hair transplantation on quality of life and psychosocial functioning., Methods: Forty-eight patients with androgenetic alopecia were enrolled in this two-center prospective study and underwent hair transplantation by the Follicular Unit Extraction method. Different questionnaires were used to assess their quality of life and other psychosocial parameters before and after hair transplantation., Results: According to SF-36 Physical and Mental Health Score patients showed significant improvement in life quality after hair transplantation. Diener's Life Satisfaction Scale (DASS-21) revealed increased life satisfaction after the procedure. Stress and anxiety DASS-21 subscales showed significantly reduced results; while, the DASS-21 depression scale and MSPSS were not significantly changed., Conclusion: Taken together, quality of life and psychosocial functioning increased after hair transplantation. Structured abstract is required. Please provide.I insert name of paragraphs within abstract as follows: background, methods, results, conclusion Level of Evidence II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 ., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: The European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) comprises 40 national societies across Europe. In addition to ESPRAS, there are 8 different European Plastic Surgery societies representing Plastic Surgeons in Europe. The 4 th European Leadership Forum (ELF) of ESPRAS, held under the motto "Stronger together in Europe" in Munich in 2023, aimed to collect and disseminate information regarding the national member societies of ESPRAS and European societies for Plastic Surgeons. The purpose was to identify synergies and redundancies and promote improved cooperation and exchange to enhance coordinated decision-making at the European level., Material and Methods: An online survey was conducted regarding the organisational structures, objectives and challenges of national and European societies for Plastic Surgeons in Europe. This survey was distributed to official representatives (Presidents, Vice Presidents and General Secretaries) and delegates of national and European societies at the ELF meeting. Missing information was completed using data obtained from the official websites of the respective European societies. Preliminary results were discussed during the 4 th ELF meeting in Munich in March 2023., Results: The ESPRAS survey included 22 national and 9 European Plastic Surgery societies representing more than 7000 Plastic Surgeons in Europe. Most national societies consist of less than 500 full members (median 182 members (interquartile range (IQR) 54-400); n=22). European societies, which covered the full spectrum or subspecialities, differed in membership types and congress cycles, with some requiring applications by individuals and others including national societies. The main purposes of the societies include research, representation against other disciplines, specialisation and education as well as more individual goals like patient care and policy regulation., Conclusion: This ESPRAS survey offers key insights into the structures, requirements and challenges of national and European societies for Plastic Surgeons, highlighting the relevance of ongoing close exchange between the societies to foster professional advancement and reduce redundancies. Future efforts of the ELF will continue to further explore strategies for enhancing collaboration and harmonisation within the European Plastic Surgery landscape., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Introduction: Non-melanoma skin cancer (NMSC) is becoming ever more prevalent among older adults. However, older adults with NMSC are often underrepresented in clinical trials and guidelines on effective management is still unclear. The International Society of Geriatric Oncology (SIOG) created a multi-disciplinary task force to explore the potential in developing practical guidelines for the treatment of older patients with basal cell carcinoma (BCC) and skin (cutaneous) squamous cell carcinoma (cSCC)., Materials and Methods: A systematic literature search to identify relevant and up-to-date literature on treatment of NMSC in older adults was conducted on various databases including MEDLINE, Embase, CINAHL, Cochrane, and PubMed. The resulting papers were discussed by an expert panel, leading to a consensus recommendation., Results: A total of 154 articles were identified for the expert panel to utilise in generating consensus recommendations. A major focus on geriatric assessment and management options including surgery, radiotherapy, systemic therapy, clinical monitoring, and medical/medicophysical therapy were reviewed for recommendations., Discussion: Patient age should not be the sole deciding factor in the management of patients with NMSC. Assessment from a multidisciplinary team (MDT) is crucial, and the decision-making process should consider the patient's lifestyle, needs, and expectations. A comprehensive geriatric assessment should also be considered. Patients should feel empowered to advocate for themselves and have their views considered a part of the MDT discussion., Competing Interests: Declaration of Competing Interest Marthe Verhaert reports that her research institution has received speaker's fees through her from Pfizer, MSD, and Roche. Sandrine Aspeslagh reports being a member of an Advisory Board or Board of Directors for MSD, Sanofi, Roche, BMS, Pfizer, Ipsen, and Galapagos., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Specialty training in plastic, reconstructive and aesthetic surgery is a prerequisite for safe and effective provision of care. The aim of this study was to assess and portray similarities and differences in the continuing education and specialization in plastic surgery in Europe., Material and Methods: A detailed questionnaire was designed and distributed utilizing an online survey administration software. Questions addressed core items regarding continuing education and specialization in plastic surgery in Europe. Participants were addressed directly via the European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS). All participants had detailed knowledge of the organization and management of plastic surgical training in their respective country., Results: The survey was completed by 29 participants from 23 European countries. During specialization, plastic surgeons in Europe are trained in advanced tissue transfer and repair and aesthetic principles in all parts of the human body and within several subspecialties. Moreover, rotations in intensive as well as emergency care are compulsory in most European countries. Board certification is only provided for surgeons who have had multiple years of training regulated by a national board, who provide evidence of individually performed operative procedures in several anatomical regions and subspecialties, and who pass a final oral and/or written examination., Conclusion: Board certified plastic surgeons meet the highest degree of qualification, are trained in all parts of the body and in the management of complications. The standard of continuing education and qualification of European plastic surgeons is high, providing an excellent level of plastic surgical care throughout Europe., Hintergrund: Die Facharzt-Weiterbildung für Plastische und Ästhetische Chirurgie ist eine Grundvoraussetzung für sichere und effektive Patientenversorgung. Ziel der vorliegenden Studie war die Darstellung von Gemeinsamkeiten und Unterschieden in der Weiterbildung für Plastische Chirurgie innerhalb von Europa., Materialien Und Methoden: Ein internetbasierter Fragebogen wurde mit Hilfe eines kostenlosen Formularerstellungstools erstellt und verteilt. Die Fragen betrafen Kernpunkte der Weiterbildung für Plastische Chirurgie in Europa. Die Teilnehmer wurden direkt über das European Leadership Forum (ELF) der European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) kontaktiert. Alle Teilnehmer hatten weitreichende Kenntnisse über die Organisation und Struktur der plastisch-chirurgischen Weiterbildung in ihrem jeweiligen Land., Ergebnisse: 29 Teilnehmer*innen aus 23 europäischen Ländern nahmen an der Umfrage teil. Die Weiterbildung für Plastische Chirurgie beinhaltet grundlegende Prinzipien und Techniken zur Wiederherstellung von Form und Funktion innerhalb der verschiedenen Säulen der Plastischen Chirurgie, sowie in allen Körperregionen. In den meisten europäischen Ländern ist eine Rotation in der Intensiv- und Notfallmedizin und die Behandlung kritisch kranker Patienten obligatorisch. Voraussetzung für die Facharztbezeichnung ist die mehrjährige, national organisierte Weiterbildung, der Nachweis einer festgelegten Anzahl selbstständig durchgeführter Operationen, sowie die mündliche und/oder schriftliche Abschlussprüfung., Schlussfolgerung: Fachärzte für Plastische und Ästhetische Chirurgie sind hochqualifiziert und auch im Umgang mit Komplikationen geschult. Der Standard der Weiterbildung der europäischen Plastischen Chirurgen ist hoch, so dass innerhalb Europas eine hohe Qualität plastisch-chirurgischer Versorgung gewährleistet ist., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background:  The European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) previously identified the need for harmonisation of breast reconstruction standards in Europe, in order to strengthen the role of plastic surgeons. This study aims to survey the status, current trends and potential regional differences in the practice of breast reconstruction in Europe, with emphasis on equity and access., Materials and Methods:  A largescale web-based questionnaire was sent to consultant plastic and reconstructive surgeons, who are experienced in breast reconstruction and with understanding of the national situation in their country. Suitable participants were identified via the Executive Committee (ExCo) of ESPRAS and national delegates of ESPRAS. The results were evaluated and related to evidence-based literature., Results:  A total of 33 participants from 29 European countries participated in this study. Overall, the incidence of breast reconstruction was reported to be relatively low across Europe, comparable to other large geographic regions, such as North America. Equity of provision and access to breast reconstruction was distributed evenly within Europe, with geographic regions potentially affecting the type of reconstruction offered. Standard practices with regard to radiotherapy differed between countries and a clear demand for European guidelines on breast reconstruction was reported., Conclusion:  This study identified distinct lack of consistency in international practice patterns across European countries and a strong demand for consistent European guidance. Large-scale and multi-centre European clinical trials are required to further elucidate the presented areas of interest and to define European standard operating procedures., Competing Interests: The authors declare that there is no conflict of interest., (Thieme. All rights reserved.)

Background:  The Executive Committee (ExCo) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) organized a first ESPRAS European Leadership Forum (ELF) to facilitate international exchange and to provide a platform for international leaders and delegates of national societies of Plastic Surgery to discuss common challenges. The presented manuscript presents key findings in a first effort of international harmonization and cooperation., Materials and Methods:  Members of the executive (presidents, vice-presidents, secretary generals) and national delegates of Plastic Surgery national societies discussed hot topics in Plastic Surgery via the Zoom virtual conferencing system (Zoom Video Communications, Inc.). Attending participants responded to a virtual question & answer session with questions being displayed throughout the webinar., Results:  The challenges associated with Aesthetic Surgery performed by doctors who are not board-certified Plastic Surgeons and Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) were perceived as major hot topics within most national societies. Both topics were discussed vividly. Education in plastic surgery and a European fellowship program for young Plastic Surgeons was favored by a large majority of participants. The implementation of European registries for free flaps, implants and for breast reconstruction were supported by the majority of respondents., Conclusion:  The ESPRAS ELF provides a platform to propel international exchange and alliance, communication, education, research and future projects. A further virtual webinar with the topic "Strategies for Strengthening and Defending Plastic Surgery against Others" was suggested to be conducted in spring 2021., Competing Interests: The authors declare that there is no conflict of interest., (Thieme. All rights reserved.)

The aim of this paper is to summarize the results of a consensus process and a European webinar of the two societies, European Association of Societies of Aesthetic Surgery (EASAPS) and the European Society of Plastic, Reconstructive and Aesthetic Societies (ESPRAS) on what is considered safe practice based on the scientific knowledge we have today. This review of the current situations gives considerations which have to be taken into account when getting back to work in plastic surgery with COVID-19 in Europe. At all times, one should be familiar the local and regional infection rates in the community, with particular emphasis on the emergence of second and third waves of the pandemic. Due to the fast-evolving nature of the COVID-19 pandemic the recommendations aim to be rather considerations than fixed guidelines and might need to be revised in near future., Competing Interests: None of the other authors listed have any commercial associations or financial disclosures that might pose or create a conflict of interest with the methods applied or the results presented in this article., (© Georg Thieme Verlag KG Stuttgart · New York.)

The present article provides an overview of the current and expected effects of plastic surgery in Europe. It presents the experience of departments for plastic and reconstructive surgery, as evaluated by interviews with members of the Executive Committee (ExCo) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS). The objective of this overview is to summmarise current information in our area of work and to make this accessible to a broad group of readers. As our knowledge is rapidly increasing during the current pandemic, it is evident that we can only provide a snapshot and this will inevitably be incomplete., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

"Direct to implant," "one-stage," or "immediate" breast reconstruction procedures have become extremely popular in the last decade. The additional task of covering the lower pole of the prosthetic implant for stability can be achieved by one of two principal methods: either the use of acellular dermal matrix (ADM) or alternatively by the use of autologous dermis (inferiorly based dermal flap). In 2013, we published a modification of the inferior pedicle technique for reduction mammaplasty with the principal goal of making a strong, durable, and internalized ``dermal cage'' fixed to the chest wall to support the remaining breast tissue and to prevent the long-term descent of the breast tissue through the effects of gravity. At that time, we started to use the same technique in breast reconstruction for selected cases who required skin or nipple-sparing mastectomy with reduction of the skin envelope, not just to cover the lateroinferior pole of breast implants as an alternative to ADM but primarily for functional support and suspension with fixation of the implant on the chest wall, shaping the reconstructed breast with the aim of preventing lateral displacement. In this article, we present the method and rationale of our "dermal cage" technique explaining differences between previously published modifications by other authors of the inferior dermal pedicle., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: In reconstruction of post-traumatic craniofacial defects Palacos R-40 is mostly used by neurosurgeons and by maxillofacial surgeons after tumor removal with consequently noticeable irregularities on the shape of the cranial region and face. We harvested customized adipodermal (AD) graft in low inguinal region and use it as an inlay autologous graft for surface irregularities correction with a 100% survival and without noticeable reduction of the graft volume., Material and Methods: Between 2009 and 2015, an adipodermal gaft was used in 5 cases of craniofacial post-traumatic defects, 3 of which were due to Palacos R-40 cranial reconstruction and 2 connected to maxillofacial tumor removal and post-traumatic reconstruction., Results: There were no complications and a satisfactory aesthetic result was achieved in all cases., Conclusion: The inguinal inlay autologous AD graft is, due to our best knowledge, an original single-stage procedure for those typical cranial grove-like defects correction. It gives a wide option of different shapes with relatively easy to proceed and predictable result., Competing Interests: • Conflict of interest: None declared.

Focal myositis is a rare, mostly benign disease (pseudotumor) of skeletal muscle, histopathologically characterized by interstitial myositis and tumorous enlargement of a single muscle. The etiology of focal myositis remains unknown; however, localized myopathy has been postulated to be caused by denervation lesions. This case report describes a patient that presented with clinical, laboratory, electromyoneurography, and magnetic resonance imaging features of focal myositis complicated with intervertebral disk protrusion in the lumbosacral spine affected with radicular distress. In most cases, focal myositic lesions show spontaneous regression, relapses are rare, and long-term prognosis is good. There is a wide spectrum of therapeutic options, from no therapy at all through nonsteroidal antirheumatics and glucocorticoids to radiotherapy, surgical excision, and immunosuppressants. In the patient presented, treatment with glucocorticoids, methotrexate, and surgical excision failed to produce satisfactory results. Clinical improvement, pain relief, and reduction in lower leg volume were only achieved by local infiltration of botulinum A toxin.

Background: Sinus pericranii is a rare asymptomatic communication between the intracranial and extracranial venous drainage pathways. The venous flow in this condition circulates through abnormal dilated veins in both directions., Patient/methods: We describe an unusual location of an accessory sinus pericranii that involved the left frontal bone along with the superior orbital rim and the upper eyelid, with special focus on therapy., Results: The patient did not have any complication during the first and second surgery. Final outcome was excellent. The patient did not show any evidence of disease recurrence 1 year after the surgery., Conclusion: We propose a multidisciplinary approach in the treatment of such lesions with a two-step surgery. Excision of the sinus pericranii is possible if the sinus pericranii is not a major venous outflow channel of the brain, which can be evaluated by angiography., (Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: In spite of more recent techniques for breast reduction, the inferior pedicle technique has proven to be enduring and still a very popular option in the plastic surgeon's armamentarium despite certain shortcomings. This technique is especially important for treating large breasts with a long sternal notch-to-nipple distance. The modifications we describe in this article overcome some of the main drawbacks of the standard inferior pedicle technique and make the procedure particularly effective when used on appropriately selected patients. This is achieved principally by the creation of a strong, durable, and internalized "dermal cage" that remains fixed to the chest wall in the upper part, as well as on both sides, to support the majority of the remaining breast tissue. This serves several purposes, including narrowing the breast thereby giving good projection and reduction of the N-IMF length of the inferior pedicle. Through suspension and fixation of the inferior pedicle to the chest wall, one can mitigate the effects of gravity on the inferior pedicle. The benefits of this include reduced tension on the T junction, thereby reducing the incidence of wound dehiscence in the immediate postoperative period, while reduction of tension on the nipple-areola complex reduces "bottoming" out over the long term. This process has been the main shortcoming of the inferior pedicle technique to date. The technique was used on 26 patients over a 7-year period with a mean long-term follow-up of 41 months. The results demonstrate the short- and long-term effectiveness of our own particular combination of modifications to previously described techniques and modifications of the inferior pedicle breast reduction., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Introduction: The precise vascular anatomy of posterior lower leg skin is not well understood. Despite being a potential donor site for sural artery perforator flaps, this region is rarely used and underestimated. The aim of this study was to provide exact preoperative planning for medial and lateral sural artery perforator flap harvest., Methods: An anatomical study on 16 cadaveric lower legs was performed to determine the number and location of all medial and lateral sural artery perforators in relation to five fixed points (medial and lateral maleolus, calcaneus, medial and lateral condyle). A Duplex study on 32 lower legs determined the number and location of dominant medial and lateral sural artery perforators in relation to same anatomical points. Results of the two studies were correlated., Results: A total of 234 perforators were found in the anatomical (134) and Duplex studies (100). A dominant lateral sural artery perforator was found in 9.4% of all lateral perforators in 31% of dissected legs. A dominant medial sural artery perforator was found in 37% of all medial perforators in 94% of legs. The difference in the number of dominant medial and lateral perforators was significant (p < 0.001) in the anatomical study, while no significant difference was found in the Duplex study (p = 0.920)., Conclusion: The anatomical study showed relative unreliability of sural region regarding number of dominant perforators. Therefore, harvest of medial and particularly lateral sural artery perforator flap is unsafe without preoperative perforator mapping. No significant difference in location of dominant perforators was found between Duplex and anatomical studies. Duplex proved reliable for planning of sural artery perforator flaps due to high precision in detecting location of dominant perforators., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Proven benefits of early active mobilisation for intra-synovial flexor tendon repairs have inducted new criteria for a 'perfect suture'. This study has examined different variations of modified Kessler's suture, which could fulfil the new criteria. A total of 93 swine extensor tendons were transected, repaired and tested using a dynamometer with constant rate of extension. The first part of study tested clinically the most used modified Kessler suture, a variation of double modified Kessler suture and intact tendons as a control group. Further variations in the second part of study were due to type of suture, location and number of the knots and type of peripheral suture. According to the results, the tested version of double modified Kessler suture with crossed peripheral suture was the strongest one among all tested variations. The ultimate force for the authors preferred modification of the double modified Kessler (DMK) is significantly higher than modified Kessler suture. The version of DMK with crossed peripheral suture is the strongest one among all tested variations. The lowest strength manifests variation with two knots between tendon ends. The variations with interlocked and outsided knot or monofilament tread are not statistically significant regarding ultimate force. The frequency of suture failure events (suture pull out or tendon and/or suture rupture) is equal respecting braided or monofilament suture. The preferred modification of the double modified Kessler (DMK) suture with crossed peripheral suture is the strongest one among all tested variations and could achieve, concerning range of force, early active mobilisation. Further variations due to the type of thread and location, type and number of the knots did not show statistical significance.

Breast cancer is the most common malignancy in women. Early diagnosis and more effective treatment of invasive breast cancer resulted in significant mortality reduction, improvement of survival and the quality of life of the patients. The management od non-invasive breast cancer, on the contrary, is still controversial and the problem of overdiagnosis and overtreatment of patients come to evidence. In the following text a multidisciplinary team of experts brings the first consensus guidelines aimed to standardize and optimize the criteria and management in diagnosis, treatment and monitoring of non-invasive breast cancer patients in the Republic of Croatia.

The objective of this study was to determine precise localization and external diameter of the lower abdominal wall perforators as well as to investigate some vascularity differences between the same parts of perfusion zones II and III according to Hartrampf perfusion zones. The study was performed on 10 fresh cadavers (20 hemiabdomens) using the gelatin injection technique. All perforators were identified, and their localization and diameter were noted. Measurements were made at the level of the fascia. We noted localization and diameter of arteries on cross-sectional planes of either part of the flap. The median sum of the external diameter of all arteries in zone I was 17.01 mm. The median sum of the external diameter of all arteries in the medial 1/3 part of zone III was 4.17 mm, and in the medial 1/3 part of zone II, it was 0.96 mm. The median sum of the external diameter of all arteries in the intermediary 1/3 part of zone III was 2.16 mm, whereas in the intermediary 1/3 part of zone II, it was 0.81 mm. Significant differences were recorded between proximal and middle horizontal regions of zones II and III and between medial vertical part of zone III and medial vertical part of zone II. Anastomoses between zones I and II are considerably smaller compared with anastomoses between zones I and III. The best vascularized parts of the lower abdominal wall were perfusion zone I, then the inner 2/3 of zone III and medial 1/3 of zone II., (Copyright © 2011 Wiley Periodicals, Inc.)

An apocrine hidradenoma is a benign adnexal neoplasm, usually covered by intact skin, but may show superficial ulceration and serous discharge. This feature is raising the possibility of malignancy as it was in our case of macroscopically suspicious tumour. We described cytomorphologic features of cutaneous nodule that might be a lead to the cytologic diagnosis of hidradenoma, but primary or secondary malignant tumour has been ruled out first.

Purpose: Radiofrequency ablation (RFA) is a promising minimal invasive modality to treat small breast cancer (BCA). In most studies cancers were surgically excised shortly after RFA. We present six patients inoperable when diagnosed with BCA, and performed RFA instead of surgery., Materials and Methods: Ultrasound-guided bipolar RFA was performed under local anesthesia in six women aged 63 - 85 years. They had core-biopsy proven T 1 - 2N0 M0, grade I or II, 1.0 - 2.7 cm sized invasive ductal cancers, with positive estrogen receptor status. Four tumors measured > 2 cm, and three 1.0 - 1.2 cm in diameter. Patients were at high-risk for general anesthesia and surgery because of severely impaired cardiac function, advanced age, or associated diseases (acute myeloid leukaemia (AML), diabetes, hypertension, depression) and/or refused surgery., Results: Six tumors in five patients were completely ablated, without recurrence during follow-up (range: 9 - 49 months). One superficially located cancer was partially ablated; the patient died two months later from myocardial infarction. The Patient with AML and BCA had an infection of the treated breast after 4 months and postponed mastectomy to an AML remission status. There were no signs of malignancy in histopathology; the patient finally died of leukemia 42 months after RFA. The remaining four patients are well, without complications., Conclusion: Ultrasound-guided percutaneous RFA under local anesthesia is an effective alternative to surgery for BCA < 3 cm in patients with a high-risk for surgery., (Georg Thieme Verlag KG Stuttgart . New York.)

Penile and scrotal lymphedema causes significant functional, cosmetic and psychological problems. We present two patients with penoscrotal lymphedema successfully treated with wide radical excision of the lymphedematous tissue and reconstruction with skin flaps and split thickness grafts. No complications occurred postoperatively. Good cosmetic results and functionality are preserved 8 and 15 years after the surgery, with no recurrences.

The treatment of sternal wound infection still carries a high mortality. Treatment preferences range from more conservative treatments that do not include flaps, to more aggressive reconstructions using different types of flaps, and these could be resolved and standardised using a proper classification with a treatment algorithm. We propose modification of the existing classification, with different proposals for treatment, stressing the importance of the radicality of debridement, and report our results in 31 patients, 24 of whom were well satisfied. Eleven were left with some pain in the chest wall, and eight each with some muscular weakness and less than adequate cosmesis. We would also like to recommend the omental flap as the first choice for selected cases. With our selective approach we have achieved good functional and aesthetic results with satisfied patients.

Recently, skin-sparing mastectomy (SSM) with nipple-areola complex (NAC) preservation has been promoted as an oncologically safe procedure in practice for selected patients. The criteria of selection have not been yet defined precisely. The focus of this study was to investigate predictive factors of NAC-base neoplastic involvement to define the indications for NAC preservation. A prospective clinical study was conducted of 108 randomly selected female patients with invasive breast cancer. Analyzed markers of NAC involvement were tumor-nipple distance (TND), tumor size, localization, histologic type, grade, lymphovascular invasion (LVI), site, and axillary lymph-node status. The definitive histologic findings of the NAC base were compared with analyzed markers and the frozen section results. NAC base was positive in 23.15% patients at definitive histology with false-negative results in 4.63% patients at intraoperative frozen section. Significant differences were found in TND, tumor size, axillary lymph-node status, and LVI. There were no significant differences in tumor grade and site and not enough cases for statistical evaluation in histologic type and localization. Clinical indications for NAC preservation, according to this study, include tumors < or =2.5 cm, TND >4 cm, negative axillary lymph node status, and no LVI. Considering the possibility of pre- or intraoperative measurement, tumor size, and TND evaluation will result in the lowest possible mistakes in NAC preservation. Frozen section analyses of the NAC base, because of the "false-negative" possibility, could be deemed as a relative prognostic factor until definitive histologic findings. The presence of an extensive intraductal component (EIC) in the "borderline" cases of these criteria could be an additional argument for NAC removal.

Hyperkeratosis of the nipple and areola is a rare, sporadic, benign condition characterized by verrucosus thickening and brownish discoloration of the nipple and areola. Approximately 50 cases of hyperkeratosis of the nipple and areola have been reported in the literature. Dermatologists treated most of them conservatively. We have described the case of healthy 19-year-old girl with bilateral nevoid hyperkeratosis of the areola and our treatment by surgical removal of the areola and reconstruction with a skin graft. As far as we know, this is the first report of this kind of treatment. The final result is esthetically excellent and without recurrence during 12 months' follow-up.

During the Homeland War in Croatia, many civilians suffered from war wounds of the extremities. Explosive war wounds create composite and devastating injuries mainly by high-energy transfer to the tissue. We present an early reconstruction of explosive heel wound with an iliac osteocutaneous free flap with late follow-up result.

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.

Arthroscopic knee surgery has been well accepted worldwide and has become an important part of orthopaedic surgery. The use of arthroscopy has reduced the duration of hospitalization, overall costs, and time required for the patient to return to sports activities or work. However, because of the closed nature of the procedure and proximity of neurovascular structures to instruments, substantial risk of injuries exists. Significant anatomic variability in the nerve course has not been reported in previous literature as a cause of a knee arthroscopy complication. We present a case of complete transection of an unusually located common peroneal nerve during a knee arthroscopy for lateral meniscal repair in a 22-year-old football player.

The deep inferior epigastric perforator flap is accepted worldwide as a reliable and relatively safe technique for autologous breast reconstruction. Preserving the continuity of the rectus muscle, it reduces donor site morbidity, allowing less postoperative pain, a faster recovery, and a reduced hospital stay. Nevertheless, the more complex nature of this type of surgery leads to increased operating time and a demand for more tedious microsurgical dissection. The authors present a modification of the deep inferior epigastric perforator flap harvesting technique that allows a more safe, simple, and faster elevation of the flap. They have used it successfully for breast reconstruction in 3 patients.

Radiation-induced osteosarcoma is a rare complication of radiation therapy for breast cancer. The authors present a 60-year-old patient in whom osteosarcoma of the chest wall developed 5 years after modified radical mastectomy and radiation therapy for breast cancer. One year after resection of the chest osteosarcoma, metastasis to the contralateral axillary lymph nodes developed and these were removed. Radiation-induced osteosarcoma is difficult to treat and has a poor prognosis, thus early diagnosis is necessary for optimal treatment.

In the Department of Plastic Surgery of "Dubrava" University Hospital from 1993 to 1999 four patients were treated for radiation induced sarcoma. All of the patients were formerly operated for breast cancer and irradiated postoperatively. The mean time span between radiotherapy and development of sarcoma was 4.75 years. Four patients were treated with wide excision and immediate reconstruction with local flaps. One of the patients had fibrosarcoma, two patients had lymphangiosarcoma, and one patient had osteosarcoma. Two patients died within two years. Radiation induced sarcomas are therapy resistant, and the review of literature did not show large controlled investigations which would offer the most optimal treatment. Most frequently a rapid progression of the disease is seen.

In a prospective study on 35 wounded persons we examined the effects of ozone on how well split-thickness skin grafts took in war wounds. Each of the 35 wounded persons hat at least two similar gunshot wounds, one on the lower leg or forearm and the other on the upper leg or upper arm. During the first 10 days all wounds were treated with 10% NaCl water solution dressings until the moment when healthy granulations were observed. Thereafter, the defects were covered with split-thickness skin grafts according to Thiersch. For technical reasons we treated grafts on the lower leg and forearm with ozone following the usual scheme. Grafts on the upper leg or upper arm were treated in the conventional way and they served as a control group. The results obtained in the group followed up are presented by percentage of graft takes after 10 days and accordingly compared with the results obtained in the control group. There was a higher percentage of takes in ozone-treated split-thickness skin grafts. More than 74.3% of the split-thickness skin grafts treated with ozone had a take of more than 75% of the covered surface as apposed to only 40% of the grafts treated with the conventional method. The results in these two groups were compared with a chi square matched pair test. Difference in take of the skin grafts in these two groups was statistically significant at P < 0.01.

The effects of reconstituted basement membrane (Matrigel) on in vivo survival and growth of several murine tumors were studied. Survival of tumor cells was enhanced in all experiments which resulted in increased incidence and/or in increased tumor mass. While basement membrane enhanced the in vivo growth of B16F6 melanoma cells, survival of these mice was prolonged. Basement membrane increased the incidence but reduced the growth of Ehrlich ascites tumor. Walker-256 hypercalcemic breast carcinosarcoma growth was enhanced and glandular-like structures were observed when grown on Matrigel. The results indicate that the enhanced survival of tumor cells in the presence of basement membrane is not unequivocally linked with increased malignancy.