Alexandrina S. Saulis

Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in "separation of parts" hernia repairs.

&NA; Midline ventral hernia repair with bilateral sliding myofascial rectus abdominis flaps, or the “separation of parts” technique, has low hernia recurrence rates. However, this technique, as originally described, creates massively undermined skin and subcutaneous tissue flaps. These undermined skin flaps can suffer marginal skin loss, fat necrosis, and delayed wound healing. The authors propose that preserving the periumbilical rectus abdominis perforators to the abdominal skin flaps will decrease the prevalence of postoperative superficial wound complications. A retrospective review of 66 consecutive, large, midline hernia repairs using a separation of parts technique was undertaken to identify any correlation between the preservation of periumbilical rectus abdominis perforators to the skin flaps and the prevalence of postoperative wound complications. In 25 cases, the standard separation of parts technique was performed with wide undermining of the skin and subcutaneous tissues. In 41 cases, the modified separation of parts technique was performed with maintenance of the periumbilical rectus abdominis perforators to the abdominal skin flaps. Comparison of these two groups revealed no difference in age; sex; body mass index; initial hernia size on physical examination; prevalence of smoking, diabetes, or steroid use; or prevalence of a simultaneous intraabdominal procedure. A statistically significant difference was noted in postoperative wound complications between the two groups (p < 0.05). Of patients who underwent the standard separation of parts technique, five of 25 patients (20 percent) had wound complications as compared with one of 41 patients (2 percent) who underwent the modified separation of parts technique with perforator preservation. The postoperative hernia recurrence (7 percent and 8 percent, respectively) and hematoma (4 percent and 2 percent, respectively) rates were similar in both groups. A trend of increased wound complications was noted when separation of parts was combined with an intraabdominal procedure (18 percent versus 3 percent, p = 0.08). Interestingly, within this group, the modified separation of parts technique with preservation of the periumbilical rectus abdominis perforators demonstrated a trend of fewer wound complications as compared with the standard separation of parts technique (7 percent versus 31 percent, p = 0.15). The authors conclude that preservation of the periumbilical rectus abdominis perforators significantly reduces the prevalence of major postoperative superficial wound complications in separation of parts hernia repairs. Simultaneous intraabdominal procedures with separation of parts hernia repairs seem to increase the prevalence of wound complications. This increased prevalence of wound complications seems to be minimized when the modified separation of parts technique is performed. (Plast. Reconstr. Surg. 109: 2275, 2002.)

A Retrospective Analysis of Patient Satisfaction with Immediate Postmastectomy Breast Reconstruction: Comparison of Three Common Procedures

Background: The authors aimed to quantify overall patient satisfaction with three breast reconstruction techniques and identify factors that have influenced satisfaction. Methods: Two hundred sixty-eight questionnaires were mailed at least 6 months after immediate breast reconstruction to consecutive breast reconstruction patients over a 3-year period. A second questionnaire was sent out 9 months later to the tissue expander/implant group of patients. Results: The initial questionnaire demonstrated that overall satisfaction was significantly greater in the transverse rectus abdominis myocutaneous (TRAM) flap patients as compared with the tissue expander/implant patients (p < 0.05). However, the number of patients willing to repeat the procedure and recommend their procedure to a friend was similar among all three reconstructive techniques. A significantly greater number of tissue expander/implant patients as compared with TRAM flap patients felt they had not received sufficient information to make an educated decision (p < 0.05). This finding correlated with the lower satisfaction rate among the tissue expander/implant patients. The second questionnaire sent only to the tissue expander/implant patients revealed that the majority felt uninformed about the final aesthetic outcome and the frequency and pain associated with the expansion process. Conclusions: All three groups may claim to be satisfied with their own personal choices. Many patients will continue to choose tissue expander/implant reconstruction in an effort to avoid scars and more extensive surgery. Being less satisfied is not wrong or bad, provided it is known. Tissue expander/implant patients should be thoroughly informed in the preoperative setting about the final aesthetic outcomes and the immediate perioperative expansion period, which may involve a considerable amount of patient commitment and discomfort in some women.

Silicone Occlusive Treatment of Hypertrophic Scar in the Rabbit Model

BACKGROUND Hypertrophic scar formation at sites of healed cutaneous injury often produces functional and esthetic deficits. Treatments have been limited in part by a lack of understanding of scar etiology and the lack of animal models of hypertrophic scarring. Silicone dressing is reported to provide positive outcomes with respect to a reduction in scar hypertrophy and an improvement in color differences, although the exact mechanism is unknown. OBJECTIVE We tested the effectiveness of silicone adhesive gel in the reduction of scar hypertrophy in an animal model of scarring. METHODS Silicone adhesive gel was applied to scars in a rabbit ear model of hypertrophic scarring. Scarring in this model, which displays reduced hypertrophy in response to steroid injections and aging similar to that of human beings, was measured by the Scar Elevation Index (SEI), a ratio of the scar height over normal skin, in which readings greater than 1.0 represent a raised scar. RESULTS SEIs were significantly reduced after 4-week applications of silicone gel (1.15 +/- 0.15 vs 1.71 +/- 0.33, respectively; P < .001) versus untreated scars. Nonsilicone control dressings did not alter SEIs in comparison with those found for controls. No histologic differences in scar cellularity, inflammation, or matrix organization were found between treatment groups; however, ultrastructural observation revealed numerous vacuoles in basal cells of control and nonsilicone-treated scars that were not found in unwounded skin or silicone gel-treated scars. The similarity in water vapor transmission rates for silicone gel and a nonsilicone dressing eliminated scar hydration as the sole mechanism of action of the silicone dressings. CONCLUSIONS Our findings with the rabbit model demonstrate the effectiveness of silicone gel for hypertrophic scar treatment and confirm the usefulness of this model for further study of the mechanism of occlusion. (Aesthetic Surg J 2002;22:147-153.).

Radial forearm skin with flexor carpi radialis muscle: A useful composite free flap

Four patients were treated successfully with a simple modification of the standard radial forearm free flap. The flexor carpi radialis was harvested along with the radial artery vascular pedicle and forearm skin, producing a tennis racket-shaped flap. The entire flexor carpi radialis can be transferred based on radial artery perforators that enter the distal half of the muscle. The flexor carpi radialis can extend the versatility of the radial forearm free flap, principally by providing good-quality coverage of the vascular anastomoses.

62 – Models of Wound Healing in Growth Factor Studies

Wounds occur in all living creatures. A wound epitomizes the natural process of breakdown, and an organisms ability to heal a wound is evidence of its complexity and resilience. Human wounds can be categorized into three groups. The acute wound is defined as a discrete injury followed by a relatively rapid healing phase. Examples include surgical incisions or excisions. In contrast, the chronic wound is one that develops either quickly or over a longer period of time, and is characterized by a significant temporal delay in the healing process, usually greater than 2 months. Often the delay in healing is a result of a compromised healing environment. These wounds are then identified as compromised wounds. The majority of chronic wounds are compromised wounds and in most cases research has identified the compromise leading to the chronic wound. Animal models play a critical role in the development of biological therapeutics pertinent to wound healing. They allow testing of a therapys efficacy and safety in a living model prior to its use in humans. It is important that the model and experimental protocol chosen allow for controlled, reproducible, and quantifiable experimentation. Only under these circumstances can the results be considered valid and subsequently applied to human subjects.