Alexander F. Mericli

Comparison study of two types of expander-based breast reconstruction: acellular dermal matrix-assisted versus total submuscular placement.

AbstractRecent reported complications have called some authors to express concern regarding the increased popularity of acellular dermal matrix (ADM)-based breast reconstruction, and its role as an alternative to traditional total submuscular approaches. To address this issue, we compared tissue expansion properties, complication rates, and patient satisfaction for both operative techniques at the same institution. A retrospective review was completed on 75 patients and 100 tissue expander/implant-based breast reconstructions at a single academic institution from 2007 to 2010. Of these cases, 31 patients were reconstructed with ADM and 44 with a submuscular coverage technique. Total complications including seroma, hematoma, infection, skin necrosis, and explantation did not significantly differ between groups (n = 13 for ADM vs. 17 for submuscular, P = 0.814). Consistent with prior reports, ADM-based reconstructions were associated with significantly increased intraoperative fill volumes and lower total number of sessions to achieve final volume. Submuscular reconstructions required a significantly higher tissue expander fill volume. Eight patients in the submuscular group required surgical revision of the breast and inframammary fold, compared with 4 in the ADM group; however, this difference was not significant. Patient satisfaction was equivalent between the 2 groups; however, it was higher in patients with bilateral reconstruction and lower among those who had received adjuvant radiation therapy. Satisfaction with nipple reconstruction was inversely proportional to time elapsed from the procedure to survey conduction. This is the first study to perform a head-to-head comparison on the basis of patient satisfaction, the results of which may be useful in preoperative planning and counseling.

Current trends in vaginal labioplasty: a survey of plastic surgeons.

Background:Labioplasty serves to resolve an anatomic variation that results in aesthetic and functional difficulties for many women. To date, little effort has been made to compare the efficacy or prevalence of various techniques, and furthermore, evidence-based practice guidelines have not yet been established for this procedure. The purpose of this study is to elucidate the current armamentarium and practice guidelines for labia minora reduction, as well as to examine self-reported outcomes for this procedure. Methods:A 2009 web-based survey was sent to members of the American Society of Plastic Surgeons via electronic mail. The survey was used to assess surgeon demographics, practice guidelines for labioplasty, and self-reported outcomes measures. Results:A total of 750 surgeons responded to the survey (19.7% response rate), and 51.0% of surgeons currently offered labioplasty. The total number of procedures over the past 24 months for all respondents was 2255. Per surgeon over 24 months, the mean number of procedures was 7.37 (range, 0–300). Surgeons that directly advertised that they performed labioplasty performed a mean of 14.2 procedures over 24 months versus a mean of 5.01 for those who did not (P = 0.001). The mean time suggested to refrain from intercourse was 31.3 days. Redundancy or inadequate resection and wound dehiscence were the 2 most common reasons that caused surgeons to reoperate. Surgeons using plain gut suture material had the highest reported rates of reoperation. The prevalence of each technique was as follows: simple amputation (52.7%), W-SHAPED resection (9.5%), S-shaped resection (8.8%), central v-wedge (36.1%), central wedge with z-plasty (13.9%), and deepithelialization (1.2%). The mean perceived patient satisfaction rate reported by surgeons was greater than 95% for all techniques, and there was no statistically significant difference when comparing perceived patient satisfaction among the techniques (P = 0.337). Conclusions:This study provides data suggesting that labioplasty has been safely and effectively used by many plastic surgeons. However, there is great variation with regard to both techniques and practice guidelines. In establishing these discrepancies among surgeons, we hope to provide the impetus for further academic dialogue and prospective trials.

Evaluating the Role of Postoperative Prophylactic Antibiotics in Primary and Secondary Breast Augmentation: A Retrospective Review

BACKGROUND The use of postoperative prophylactic antibiotics following augmentation mammaplasty remains a controversial topic, with many surgeons opting for extended prophylaxis. OBJECTIVES The authors evaluate the role of postoperative prophylactic antibiotics in both primary and secondary cosmetic breast augmentation. METHODS A five-year retrospective chart review was performed on all patients undergoing cosmetic breast augmentation at a single institution from January 2005 to December 2009. The four attending physicians in this study utilized similar perioperative protocol and implant materials. Patients were divided into two cohorts: those who had received three days of postoperative antibiotics (primarily cephalosporins) and those who had not. End points of particular interest included infection, capsular contracture (CC), and local wound complications. The mean follow-up time was 3.8 years. RESULTS A total of 605 implants were included over the five-year study period. The overall infection rate was 0.66%. For primary augmentation, 493 implants were studied, with 52% of those patients having received postoperative antibiotics. There was no statistically significant reduction in infection, CC, or total complication rate for those receiving postoperative antibiotics. Similarly, 112 implants were studied for secondary augmentation, and again, postoperative antibiotics were not associated with a reduction in complications. CONCLUSIONS The data suggest that there was no reduction in the overall rate of total complications, infection, or CC with postoperative prophylactic antibiotics for either primary or secondary cosmetic breast augmentation. This study provides Level 3 evidence in support of discontinuing prophylactic postoperative antibiotics following cosmetic breast augmentation.

Paraspinous muscle flap reconstruction of complex midline back wounds: Risk factors and postreconstruction complications.

With increasingly complex spine surgeries now being performed on a more comorbid patient population, the reconstruction of midline back wounds from these procedures is becoming a frequent dilemma encountered by plastic surgery. The purpose of this study is to examine the effect of various preoperative risk factors on postoperative wound healing complications after paraspinous muscle flap reconstruction of midline back defects. An Institutional Review Board-approved, 11-year, retrospective, office and hospital chart review was conducted. All adult patients who underwent paraspinous muscle flap reconstruction during the study period were included. There were 92 patients in the study, representing the largest reported series to-date for the paraspinous muscle flap procedure. Mean follow-up was 120 days. Several wound-healing risk factors were present in this patient population: 72% were malnourished, 41% had hypertension, 37% were obese, 34% had a history of smoking, 32% had diabetes, 16% were on chronic steroids, 14% had a history of more than 2 previous spine surgeries, and 9% had a history of radiation to the wound area. Factors significantly (P < 0.05) associated with postreconstruction wound complications included history of traumatic spine injury, prereconstruction hardware removal, a history of more than 2 spine surgeries, hypertension, and lumbar wound location. This patient population possesses multiple comorbidities making complex wound healing difficult. Several specific risk factors are associated with an increased rate of postreconstruction wound complications after paraspinous muscle flaps. The paraspinous muscle flap remains an important tool for spinal wound reconstruction in the reconstructive surgeons armamentarium.

Pediatric craniofacial fractures due to violence: Comparing violent and nonviolent mechanisms of injury

Background:This study examines the epidemiologic data of pediatric craniofacial fractures secondary to violence, comparing these data to craniofacial fractures sustained from all other causes. Methods:A retrospective review was completed on all patients who presented to the emergency department of a major urban childrens hospital from 2000 to 2005 with a craniofacial fracture. Data were compared between patients with fractures due to violent and nonviolent mechanisms. Socioeconomic analysis was performed using Geographic Information System mapping and 2000 US Census data by postal code. Results:One thousand five hundred twenty-eight patients were diagnosed with skull and/or facial fractures. Isolated skull fractures were excluded, leaving 793 patients in the study. Ninety-eight children were injured due to violence, and 695 were injured from a nonviolent cause. Patients with violence-related fractures were more likely to be older, male, and nonwhite and live in a socioeconomically depressed area. A greater number of patients with violence-related injuries sustained nasal and mandible angle fractures, whereas more patients with non-violence-related injuries sustained skull and orbital fractures. Those with violence-related craniofacial fractures had a lower percentage of associated multiorgan system injuries and a lower rate of hospital admissions and intensive care unit admissions. The rate of open reduction and internal fixation for craniofacial fractures was similar in both groups. Conclusions:Patients with violence-related fractures had fewer associated serious injuries and lower morbidity and lived in a more socioeconomically depressed area. The information gained from this descriptive study improves our ability to characterize this population of pediatric patients and to identify the associated constellation of injuries in such fractures.

Reconstruction of complex posterior cervical spine wounds using the paraspinous muscle flap

Background: The paraspinous muscle flap is often overlooked for use in cervical wounds, as surgeons cite the decreased size and mobility of the muscles in the cervical region. The purpose of this article is to introduce the paraspinous muscle flap technique for reconstruction of cervical spine wounds. Methods: An 11-year, single-institution, retrospective chart review was performed on 14 consecutive patients from 1996 to 2007. All patients underwent paraspinous muscle flap surgery to provide soft-tissue coverage of the cervical spine following wound healing complications resulting in exposed hardware or bone. Variables of interest included demographics, comorbidities, and postreconstruction wound healing complications. Results: The overall complication rate after paraspinous muscle flap surgery was low [two of 14 (14 percent)] and consisted of two minor wound infections. There was no postreconstruction seroma, a well-known complication of the trapezius muscle flap, which is often thought of as the first-line option for posterior cervical soft-tissue reconstruction. Conclusion: The paraspinous muscle flap is an expeditious and reliable solution to complex cervical spine wounds. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. Figure. No caption available.

Treatment of postsurgical temporal hollowing with high-density porous polyethylene.

AbstractTemporal hollowing is most frequently an acquired defect and can be caused by a volumetric deficiency of bone, soft tissue, or both. Given high-density porous polyethylene’s ease of use, customizability, long-term strength and resiliency, and successful application in other areas of the craniofacial skeleton, the authors have used it as the first-line material for reconstruction of temporal hollowing. Herein, we present 4 illustrative cases demonstrating this technique and further describe subtypes of the temporal defect with appropriate means of reconstruction. The cases were reviewed for comorbidities, intraoperative details, and the postoperative course. There were no complications, and all patients were pleased with their final result. High-density porous polyethylene is a safe, well-studied, and easily handled biomaterial that is useful for the treatment of temporal hollowing.

The single fascial incision modification of the "open-book" component separation repair: A 15-year experience

PurposeComplex abdominal wall hernias can be challenging for the reconstructive surgeon. The use of autologous tissue is preferable when possible. The authors review their 15-year experience regarding the “open-book” technique of ventral hernia repair. This repair entails a single fascial incision releasing the external oblique and concurrently incorporates the anterior rectus sheath as a turnover flap for abdominal wall reconstruction. This modification allows large defects to be closed with autologous tissue alone in a 2-layer fascial repair in a vest-over-pants fashion in a simple, straightforward surgical approach. MethodsA 15-year, single-surgeon retrospective review was conducted of 35 consecutive select patients who underwent component separation using the open-book variation. Hospital and office-based charts were reviewed. Complications were recorded as either major (hernia recurrence or any complication requiring readmission or reoperation) or minor (treated on an outpatient basis). Individual complications included hernia recurrence, infection, seroma, hematoma, and skin necrosis. ResultsSixty-three percent of the patients in the study had, at minimum, 1 recognized comorbidity before reconstructive surgery. Only 2 (6%) of 35 patients experienced hernia recurrence during the course of the 15 years. The minor complication rate was 8/35 (23%), including infection (5; 14%), skin necrosis (5; 14%), and hematoma (1; 3%). The major complication rate was 5/35 (14%), including hernia recurrence (2; 6%), infection (2; 6%), skin necrosis (2; 6%), and hematoma (1; 3%). Factors associated with a statistically significant increased rate of overall complications included chronic obstructive pulmonary disease (80%; P = 0.03) and hypertension (39%; P = 0.04). The average length of follow-up was 16 (3) months. ConclusionsOur series suggests that with appropriate patient selection, this technique is associated with a low hernia recurrence rate when compared to the published literature. Additionally, the major complication rate is acceptable given these patients’ many comorbidities and complicated surgical history. The presence of chronic obstructive pulmonary disease and/or hypertension was found to be statistically associated with an increased complication rate. The single fascial incision modification of the open-book component separation technique is an effective addition to the reconstructive surgeons’ armamentarium in the management of these patients.

Abdominal contouring in super obese patients: A single-surgeon review of 22 cases

Background:It is generally believed that increasing obesity is a predictor of postoperative complications after abdominal contouring procedures such as abdominoplasty and panniculectomy. The purpose of this study is to review the complication rate for abdominal contouring in the level 3 obesity category (body mass index [BMI], >40 kg/m2) and to examine the safety of this procedure when performed in this select patient population. Methods:Between 2003 and 2008, an institutional review board-approved, single-surgeon, single-institution retrospective review was conducted for all patients presenting for abdominal contouring. In all, 100 patients with precontouring BMI <40 kg/m2 were excluded, resulting in 22 patients who met the criteria for Level 3 obesity category, which are also referred as “super obese.” To date, this is the largest series that has reported pertaining to this category and procedures. Results:In this series, 77% (17/22) had prior bariatric surgery. The mean hospitalization was 2.8 days and mean length of follow-up was 202 days. The major complication rate was 4.5% (1/22). Conclusions:Abdominal contouring can be performed safely, effectively, and with minimal morbidity in the super obese. Only one patient required readmission after developing an infected seroma and all patients progressed to a well-healed wound. BMI >40 kg/m2 should not preclude patients from undergoing this functional and beneficial surgical procedure.

An Algorithmic Anatomical Subunit Approach to Pelvic Wound Reconstruction.

Background: Prior radiation therapy, pelvic dead space, and a dependent location contribute to perineal dehiscence rates as high as 66 percent after primary closure of pelvic wounds. Various regional flaps have been described to reconstruct pelvic defects, but an algorithmic pairing of individual flaps to specific anatomical regions has not been described. Methods: A retrospective review of a prospectively maintained database was performed to identify consecutive pelvic reconstructions from 2010 to 2013 with at least 6 months’ follow-up. Pelvic defects and resulting flaps were described by anatomical subunits involved: anterolateral thigh flap for mons, gracilis flap for labia majora and introitus, vertical rectus abdominis myocutaneous flap for vagina and/or perineal raphe, and gluteus musculocutaneous flap for isolated perianal defects. Results: Twenty-seven women and three men underwent consecutive pelvic reconstruction with a mean age of 60 years (range, 26 to 83 years) and a mean body mass index of 28 kg/m2 (range, 17 to 40 kg/m2). Twenty-one patients (70 percent) had prior radiation therapy. In total, 45 flaps were performed according to the subunit principle. Three patients had a minor dehiscence (<5 cm), one patient had a major dehiscence, and one required reoperation for abscess. There were two partial flap losses necessitating débridement and readvancement of the flap. Twenty-five percent of female patients were sexually active after vaginal reconstruction. Conclusions: The pelvic subunit principle provides an effective algorithm for choosing the ideal pedicled flap for each region involved in acquired pelvic defects. This algorithm is based on individual attributes that make each flap most appropriate for each subunit. Complications were minimal and patient satisfaction with appearance and function was excellent.