Al Aly

Body Contouring After Massive Weight Loss

The increase in the number of bariatric surgery procedures over the last decade has led to a large number of massive-weight-loss patients seeking improvement in their resultant body contour deformities caused by the process of weight gain and subsequent loss. In this chapter, the reader will become familiar with the typical presentation of the massive-weight-loss patient to the plastic surgeon and the most common body-contouring procedures utilized to improve their deformities.

Electrosurgery-induced endotracheal tube ignition during tracheotomy.

Electrosurgery was the most common source of ignition for operating room fires prior to the advent of lasers. When combined with volatile anesthetic mixtures, electrosurgery has caused ignition of plastic, rubber, paper, enteric gases, and combustible preparation solutions. We report on an intubated patient whose polyvinyl chloride endotracheal tube ignited during a tracheotomy performed with an electrosurgical unit. The oxygen-rich environment, the polyvinyl chloride tube, and the heat generated by the electrosurgical unit combined to produce a fire. Since otolaryngologists are called upon often to perform tracheotomies on intubated patients, it is imperative that they understand the factors involved in the development of such a fire. This case is presented with an explanation of why this type of fire occurs. A brief review of the literature is included. Different kinds of electrosurgical units, precautions as to their use, and the management of electrosurgery-induced endotracheal tube fires are also discussed.

Brachioplasty in the patient with massive weight loss.

In performing brachioplasty, the authors have created a double-ellipse marking technique to avoid overresecting and leave adequate skin for closure. After resecting, they prevent the interference of soft-tissue swelling during wound closure by immediately closing each segment with temporary staples. Their technique is ideal for patients with massive weight loss.

ENDOSCOPIC PLASTIC SURGERY

This article discusses three of the most popular endoscopic procedures in plastic surgery. Brow lift, transaxillary breast augmentation, and abdominoplasty are all cosmetic procedures with a high demand on inconspicuous scars; however, many investigators are working on reconstructive endoscopically assisted procedures. The treatment of many facial fractures involving the upper third of the facial skeleton usually requires long bicoronal incisions similar to the incisions used in the traditional brow lift. Attempts are under way to use endoscopically assisted minimal-access techniques to reduce and fixate these fractures. Many flaps used in plastic surgery require long scars for harvest, as in the case of the latissimus dorsi muscle flap. A relatively long incision on the back is needed to gain access to the muscle so that it can be elevated from structures superficial and deep to it. Although it is unpopular, investigators have reported harvesting latissimus dorsi muscle flaps through fairly small incisions with the assistance of balloon dissectors and endoscopes. In the field of hand surgery, carpal tunnel release surgery has had more than one method proposed to transect the carpal ligament using endoscopes and special instrumentation. Although some reported series claim excellent results, many hand surgeons are reluctant to use endoscopes because of associated complications and a high recurrence rate of carpal tunnel syndrome. Plastic surgery has special demands that emphasize aesthetics in cosmetic and reconstructive procedures. Although the lack of natural optical cavities has slowed the incorporation of endoscopic surgery in the specialty, surgically created cavities are used to allow for minimal access incisions. The future of plastic surgery will include an ever-increasing number of endoscopically assisted procedures. Cosmetic and reconstructive procedures will benefit from this new technology.

An evaluation of epidural analgesia following circumferential belt lipectomy.

Background: Belt lipectomy combines traditional abdominoplasty with a circumferential excision of skin and fat, with resultant buttock and lateral thigh lifts. Because of the extensive nature of the procedure, postoperative pain management can be difficult. Epidural analgesia has been shown to be efficacious in treating postoperative pain. This study compares the postoperative use of epidural analgesia with more traditional pain management regimens in a large series of belt lipectomy patients. Methods: Charts of 62 belt lipectomy patients were examined retrospectively. Postoperative pain control regimen, pain scores, total amount of opioids administered, and side effects encountered were recorded. Twenty-seven patients had traditional pain control regimens, opioids on demand, and pain control pumps. Thirty-five patients received epidural analgesia as their primary mode of postoperative pain control. Results: Pain scores and total nonepidural opioids used were lower in the epidural analgesia group on postoperative days 0 and 1 compared with the nonepidural group. The two groups converged on postoperative days 2 through 5, sharing similar pain scores and opioid use after discontinuation of epidural analgesia. The incidence of side effects was similar in the two groups, with the exception of pruritus, which was much more prominent in the epidural group. Eight of the 35 epidural patients (23 percent) experienced transient and minor complications associated with epidural therapy; several resolved spontaneously, whereas the balance resolved with cessation or modification of the epidural infusion. Conclusions: Epidural analgesia is more effective than traditional pain control methods in reducing immediate postoperative pain in belt lipectomy patients. On the basis of these findings, epidural analgesia should also be considered for postoperative pain management in other truncal procedures.

Detection of haptenated proteins in organotypic human skin explant cultures exposed to dapsone

Bioactivation of parent drug to reactive metabolite(s) followed by protein haptenation has been suggested to be a critical step in the elicitation of cutaneous drug reactions. Although liver is believed to be the primary organ of drug bioactivation quantitatively, other organs including skin may also metabolize drugs. Cultured human epidermal keratinocytes and dermal fibroblasts have been shown to be capable of bioactivating sulfonamides and sulfones, giving rise to haptenated proteins. It is, however, unclear whether metabolic events in these isolated cells reflect bioactivation in vivo. Hence, split-thickness human skin explants were exposed to dapsone (DDS) or its arylhydroxylamine metabolite (dapsone hydroxylamine, D-NOH) and probed for protein haptenation. DDS and D-NOH were applied either epicutaneously or mixed in the medium (to mimic its entry into skin from the systemic circulation). DDS-protein adducts were readily detected in skin explants exposed to either DDS or D-NOH. Adducts were detected mainly in the upper epidermal region in response to epicutaneous application, whereas adducts were formed all over the explants when DDS/D-NOH were mixed in the culture medium. In addition, adducts were visible in HLA-DR+ cells, indicating their presence in the dendritic cell population in the skin. Our results demonstrate the ability of intact human skin to bioactivate DDS leading to protein haptenation.

Quantitative Analysis of Aesthetic Results: Introducing a New Paradigm

When perusing a plastic surgery journal or attending a plastic surgery meeting, it is evident that the results shown in any given aesthetic presentation are considered by some to be excellent, whereas others deem the same results to be average or less than optimal. This disparity occurs when the interpretation of posttreatment results is based solely on subjective opinion. Certainly, the task of quantifying the results of aesthetic surgery (rather than just subjectively assessing their quality) is immense, but it is essential for aesthetic surgery to follow the trend toward evidenced-based medicine (EBM) that is becoming ingrained in the fabric of the medical profession as a whole. In fact, the quantification of aesthetic surgery results has more far-reaching ramifications than simply determining objective measures by which results can be judged. Objectively assessing the results of our cosmetic surgeries has the potential to change the way surgery is performed. As we all learn more about the philosophies behind EBM (eg, in the Editorial1 by Dr. Felmont Eaves and Dr. Andrea Pusic in this month’s issue, on page 117), it is helpful to also find support among colleagues who have begun implementing it in their own practices. To that end, we would like to share with you the ways in which adding quantitative outcomes assessment, which is the cornerstone of EBM, has changed some of our own clinical approaches. Rigorous research has been conducted and published on how to quantify (instead of merely qualify) patient satisfaction outcomes.2-4 However, as Millard5 taught us, patient satisfaction or dissatisfaction with surgical results should never dissuade us from critically evaluating the results themselves objectively. Thus, it is necessary for us, as plastic surgeons, to adopt a two-pronged approach to the critical evaluation of our surgical results: we must understand our patients’ …

Body contouring following massive weight loss

Obesity is a global disease with epidemic proportions. Bariatric surgery or modified lifestyles go a long way in mitigating the vast weight gain. Patients following these interventions usually undergo massive weight loss. This results in redundant tissues in various parts of the body. Loose skin causes increased morbidity and psychological trauma. This demands various body contouring procedures that are usually excisional. These procedures are complex and part of a painstaking process that needs a committed patient and an industrious plastic surgeon. As complications in these patients can be quite frequent, both the patient and the surgeon need to be aware and willing to deal with them.

Discussion: Liposuction of the arm concurrent with brachioplasty in the massive weight loss patient: is it safe?

I their article “Liposuction of the Arm Concurrent with Brachioplasty in the Massive Weight Loss Patient: Is It Safe?” the authors report that “Liposuction can be performed safely and effectively outside the region of excision at the time of brachioplasty without necessitating prior debulking or staged arm contouring procedures.”1 I have been asked to discuss this article because I do not combine liposuction with brachioplasty. Although I have tried adding liposuction to my brachioplasties, I have not been satisfied when I have done so. As a starting point, I would like to delineate the different ways that liposuction can be combined with a brachioplasty excisional procedure:

Discussion: prospective outcome study of 360 patients treated with liposuction, lipoabdominoplasty, and abdominoplasty.

E medicine is becoming the standard for the entire medical profession, and plastic surgery is no exception. However, plastic surgery is a difficult specialty in which to objectively evaluate results. Most plastic surgery investigators, especially in aesthetic surgery, will report results that are judged subjectively and retrospectively. The reason for this difficulty is rooted in a variety of issues, most importantly the lack of yardsticks with which to compare the final results. In the arena of measuring patient outcomes, most studies are retrospective/subjective impressions of how patients felt about different aspects of their surgical experience. Dr. Swanson is to be congratulated for conducting this study. He has certainly attempted to buck this longstanding trend by prospectively deciding on what needs to be evaluated in his patients’ experiences and then quantifying the information. I believe some of the information contained in this article is quite valuable. His methodology, although not without some weaknesses that he pointed out in his Discussion section, can serve as a model for others in determining outcomes data. Certainly, everyone would agree that evidencebased medicine is the ideal way to practice medicine. However, it is my impression that, like most “buzz” words or phrases, evidence-based medicine has misconceptions associated with it that we as plastic surgeons should be aware of and guard against. As I mentioned above, Dr. Swanson’s article is an excellent article with a lot of very valuable information, but I would like to use it to demonstrate how what appears to be evidence-based information is not always as reliable as one might assume, whereas in other situations it can be. With the introduction of evidence-based medicine to the plastic surgery community and to the editorial processes of our most prominent scientific journals, there is an impression that articles with higher levels of evidence contain superior information compared with lower level articles and that the information is more likely to be objective. I would like to use some of the information in this article to demonstrate the potential pitfalls of these impressions. To start with, this study would qualify as a level II study according to American Society of Plastic Surgeons guidelines, which means that it is a prospective study that compares two or more groups. Figure 1 in the article shows that the pain scores for liposuction alone were found to be significantly lower at 6.1 than the other two abdominoplasty groups, which averaged 7.5 each. The scale used for this part of the study is a subjective 10-point pain scale. Although this scale is often used in pain studies, we all know that pain is a very subjective parameter, and a mere difference of 1.4 units is not significant enough clinically despite the statistical significance in this study. Thus, although the conclusion that liposuction patients experienced less pain is based on a quantitative analysis, the data collected are subjective in nature. In contrast, the amount of time taken off of work, 5.7 days for liposuction and 16 days for the abdominoplasty groups, is much more helpful to the clinician because it is based on an objective measure that demonstrates a very large difference. Another example is the pain score comparisons between female and male patients. Female patients reported an average pain score of 6.57, whereas male patients reported an average of 4.63, which is less than a 2-point difference on the previously mentioned subjective scale. Again, the averages are determined quantitatively, but the orig-