Amir H. Taghinia

Incidence of Hematoma Complication with Heparin Venous Thrombosis Prophylaxis after Tram Flap Breast Reconstruction

Background: Randomized controlled studies provide ample evidence that heparin is effective in reducing the risk of thromboembolic complications. Nevertheless, plastic surgeons are often reluctant to use heparin chemoprophylaxis for fear of postoperative bleeding. The authors investigated whether heparin chemoprophylaxis was associated with postoperative hematoma that required evacuation in patients who underwent transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Methods: A multicenter retrospective review of consecutive TRAM flap cases identified 679 patients, 392 in the heparin-treated group and 287 in the control group. The post hoc sample sizes were adequate to detect a 5 percent difference in hematoma rate with 89 percent power at an alpha level of 5 percent (p < 0.05). Outcome measures of reoperative hematoma, deep vein thrombosis, and pulmonary embolism were recorded. Results: Reoperative hematoma occurred in 0.5 percent of patients in the heparin-treated group and 1.0 percent of patients in the control group; this difference was not statistically significant (p = 0.66). Thromboembolic events were detected at a low rate (0.8 percent in the heparin-treated group versus 1.4 percent in the untreated group; p = 0.46). Conclusions: The use of heparin for venous thrombotic prophylaxis did not increase the risk of reoperative hematoma after breast reconstruction with abdominal tissue. The authors propose a risk assessment that balances a statistical hematoma rate of 0.5 to 5 percent (clinically observed rate, 0.5 percent) with use of heparin prophylaxis against a rare (clinically observed rate, 1.4 percent) but morbid occurrence of thromboembolic complications when chemoprophylaxis is omitted.

Fascial flap reconstruction of the hand: a single surgeon's 30-year experience.

Background: The reconstruction of complex hand wounds is challenging due to the requirements for thin and pliable coverage with a reliable vascular supply, potential for sensibility, and provision of a gliding surface. Fascial flaps represent an excellent option for the reconstruction of these complicated defects. Methods: A retrospective review of fascial flap reconstructive procedures to the hand undertaken by a single microsurgeon was performed for operations occurring between 1979 and 2009. Both pedicled and free tissue transfer procedures were included in both pediatric and adult patients. Data were culled from a combination of patient charts, hospital records, radiographic studies, and clinical photographs. Results: Sixty fascial flap reconstructive procedures to the hand were analyzed in 60 patients from the defined 30-year period. The most common pathological process necessitating reconstruction was acute trauma (n = 32, 53 percent). Most of the soft-tissue injuries included in the study sample were located on the dorsal hand and wrist (n = 27, 45 percent). The most commonly utilized reconstructive modality was the temporoparietal fascial flap (n = 35, 58 percent). Most reconstructions were completed as free tissue transfers (n = 46, 77 percent). Perioperative complications were relatively minor; no flap losses were recorded. All cases studied demonstrated excellent long-term coverage with no evidence of underlying tendon adhesion or contracture. Conclusion: Fascial flaps represent an excellent option for coverage of soft-tissue defects of the hand that are not amenable to reconstruction with skin grafting alone, particularly for localized defects with denuded tendons or exposed joints.

Fibro-adipose vascular anomaly: clinical-radiologic-pathologic features of a newly delineated disorder of the extremity.

Background: The diagnosis and management of vascular anomalies of the extremities can be challenging as these disorders are uncommon and may clinically overlap. The aim of this paper is to describe the clinical, radiologic, and histopathologic features of fibro-adipose vascular anomaly (FAVA), a previously unrecognized disorder of the limb. Methods: The clinical, imaging, operative, and histopathologic data from patients with a unique intramuscular lesion of the extremities comprising dense fibrofatty tissue and slow-flow vascular malformations were retrospectively reviewed. Results: Sixteen patients diagnosed with FAVA of the extremity (3 male and 13 female individuals) met the clinical, radiologic, and histopathologic inclusion criteria. The age at presentation ranged from the time of birth to 28 years. The locations of the lesions were: calf (n=10), forearm/wrist (n=3), and thigh (n=3). Fourteen patients presented with severe pain. Seven of the patients with calf lesions had limited ankle dorsiflexion. On imaging, the complex intramuscular lesions replaced muscle fibers with fibrofatty overgrowth and phlebectasia (dilation of the veins). The extrafascial component comprised fatty overgrowth, phlebectasia, and an occasional lymphatic malformation. The histopathologic features comprised dense fibrous tissue, fat, and lymphoplasmacytic aggregates within atrophied skeletal muscle. Adipose tissue also infiltrated skeletal muscle at the periphery of the lesion. There were large, irregular, and sometimes excessively muscularized venous channels and smaller, clustered channels. Other findings include organizing thrombi, a lymphatic component, and dense fibrous tissue–encircled nerves. Conclusions: The constellation of clinical, radiologic, and histopathologic features constitutes a distinct entity comprising fibrofatty infiltration of muscle, unusual phlebectasia with pain, and contracture of the affected extremity. The clinical and radiologic findings permit the diagnosis of FAVA with major therapeutic implications. Level of Evidence: Level III.

The subcutaneous cervicofacial flap revisited.

The cervicofacial flap has been the reconstruction of choice for midface soft tissue defects for over 30 years. Deep plane dissection has been advocated to decrease complication rates and improve results. However, the subcutaneous approach is still widely used. Over a 20-year period, we reviewed all patients who underwent subcutaneous cervicofacial flaps for cheek defects to analyze complications and results. Thirty-two patients (mean age, 71 years) underwent 32 subcutaneous cervicofacial flaps for cheek reconstruction after Mohs micrographic excision of skin cancer. The mean defect size was 7.2 × 5.8 cm. Mean follow-up was 32 months. Only 3 of 32 patients (9%) had minor flap tip or edge necrosis, all managed without further surgery. One patient (3%) had minor long-term ectropion with upward gaze and 31 of 32 patients were happy with their results. The subcutaneous rotation-advancement cervicofacial flap remains an excellent choice for cheek reconstruction with comparable tip necrosis rates and likely lower ectropion rates when compared with the deep plane technique.

Dexmedetomidine in Aesthetic Facial Surgery : Improving Anesthetic Safety and Efficacy

Background: Dexmedetomidine is an &agr;2-agonist anesthetic with several properties that are advantageous in aesthetic facial surgery. By attenuating sympathetic nervous system activity, it induces sedation and analgesia while lowering blood pressure and preventing pain-induced hemodynamic fluctuations. It spares the respiratory drive and decreases the need for supplemental oxygen, thus reducing the fire risk of electrocautery. It decreases narcotic use, thereby further improving respiratory safety and decreasing postoperative nausea and vomiting. This retrospective study evaluated the safety and efficacy of dexmedetomidine in rhytidectomy. Methods: Records were reviewed for 155 consecutive face lifts performed under sedation by one surgeon over 3.5 years. Intraoperative and postoperative parameters and outcomes were compared for 78 patients sedated with dexmedetomidine (dexmedetomidine group) and 77 sedated without dexmedetomidine (no-dexmedetomidine group). Results: Intraoperatively, the dexmedetomidine group had lower mean systolic and diastolic blood pressures and heart rate (p < 0.001). Fewer dexmedetomidine group patients had oxygen desaturation below 92 percent (p < 0.05) and fewer required antihypertensives (p < 0.01), although more required vasopressors (p < 0.01). The dexmedetomidine patients needed less midazolam (p < 0.01) and fentanyl (p < 0.001). Postoperatively, the dexmedetomidine group again had lower mean systolic and diastolic blood pressures and heart rate (p < 0.001). In addition, fewer patients in this group needed postoperative antiemetics (p < 0.05). Immediate postoperative hematomas occurred in two patients in the dexmedetomidine group and one patient in the no-dexmedetomidine group. Conclusions: Dexmedetomidine lowered blood pressure, decreased the frequency of oxygen desaturations, and reduced narcotic, anxiolytic, and antiemetic use. When compared with conventional sedation, dexmedetomidine appears to improve anesthetic safety and efficacy for rhytidectomy patients.

Complex nasal reconstruction.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the goals of nasal reconstruction as they apply to extensive, complex defects that may also involve the adjacent lip or cheeks. 2. Understand the advantages and disadvantages of different options for reconstruction of lining, skeletal support, and skin cover. 3. Discuss current advances in complex nasal reconstruction, including microvascular reconstruction of lining and the three-stage forehead flap. 4. Understand the concepts of laminated and prelaminated flaps and their application in complex nasal defects. Summary: In this article, the authors review methods of reconstructing complex, multilayered nasal defects that may involve surrounding central facial structures. Different means of lining, skeletal support, and skin cover reconstruction are discussed. Emphasis is placed on newer, state-of-the art techniques and reinforcing basic principles.

Reconstruction of the upper aerodigestive tract with the submental artery flap.

Background: The submental artery flap has rekindled interest in using cervical flaps for reconstruction of head and neck defects. In this article, the authors present their experience with this flap for defects of the upper aerodigestive tract. Methods: This is a retrospective study of 21 patients who underwent upper aerodigestive tract reconstruction with submental artery flaps from 1997 to 2005. The flap was used primarily to reconstruct defects after tumor extirpation, severe infections, and burns. In one case, the flap was used to close an esophagocutaneous fistula. Nine patients had irradiation. Three patients had flap prelamination before transfer. Results: The flaps in all 12 patients who had not undergone irradiation survived. With the exception of a small fistula in one patient and transient marginal mandibular nerve palsy in another, none of these patients experienced any major complications. In contrast, six of the nine patients who had been irradiated experienced major complications. These included total flap loss in one, partial flap losses in two, and scar contractures in another three. The difference in major complication rates between these two groups was statistically significant (0 percent versus 67 percent, p < 0.01). Conclusions: In nonirradiated tissues, the submental artery flap is an excellent choice for reconstruction of moderate-sized defects of the upper aerodigestive tract because of its reliability and versatility and the ease with which it can be applied.

Randomized controlled trials in plastic surgery: a 20-year review of reporting standards, methodologic quality, and impact.

Background: Randomized controlled trials in plastic surgery have not been analyzed comprehensively. We analyzed plastic surgical randomized controlled trials with respect to reporting standards, methodologic quality, and impact on the specialty. Methods: Randomized controlled trials published from 1986 to 2006 in three major plastic surgery journals were scored for quality and impact using the Consolidated Standards of Reporting Trials checklist, the Jadad criteria, citation numbers, and other parameters. The associations between the quality scores and multiple independent parameters, including trial impact, were explored. The relative impact of randomized controlled trials in plastic surgery was compared with that in other specialties. Results: A total of 163 randomized controlled trials were evaluated. The average Consolidated Standards of Reporting Trials and Jadad scores were 49 percent and 2.3, respectively. There were deficiencies in the reporting of parameters that influence bias and statistical significance. Randomized controlled trials with high impact or high methodologic quality had higher reporting scores. However, the quality and impact scores did not correlate with the number of participants, subject category, country of origin, or year or journal of publication. Nonsurgical trials had significantly higher quality and impact than surgical trials. Randomized controlled trials in plastic surgery had relatively lower impact as compared with randomized controlled trials in other specialties. Conclusions: The reporting and methodologic standards of randomized controlled trials in plastic surgery need improvement. Standards could be improved if well-accepted reporting and methodologic criteria are considered when designing and evaluating randomized controlled trials. Instituting higher standards may improve the impact of randomized controlled trials and make them more influential in plastic surgery.

Overgrowth conditions: a diagnostic and therapeutic conundrum.

Over the past five decades, one of the major problems in the treatment of overgrowth syndromes of the hand has been classification. Currently, a number of specific conditions with known natural histories have been delineated and reviewed. Treatment is highly individualized. Amputation is still recommended for grotesque deformities of the upper limb. Early aggressive surgery, when indicated, will improve contour, function, and appearance. Specific therapeutic techniques include radical debulking, microvascular neurolysis, vascular reconstruction, epiphysiodesis, and, in some cases, thumb or digit replacement. Long-term outcomes remain in the good-to-fair range and are dependent upon the condition, reconstructive techniques employed, age of patient, and the severity of deformity.

Abductor Digiti Minimi Myocutaneous Flap for Opponensplasty in Congenital Hypoplastic Thumbs

Background: Although abductor digiti minimi transfer is a common form of opponensplasty for congenital hypoplastic thumbs, the inclusion of hypothenar skin with this flap—to create a myocutaneous flap—is not well-described. Methods: From a series of over 600 index pollicizations and hypoplastic thumb reconstructions performed from 1977 to 2007, 14 patients with congenital thumb hypoplasia are presented who had abductor digiti minimi myocutaneous flap transfer to improve thumb opposition. The primary indications for transfer were inadequate thumb opposition and aplastic palmar and thenar soft tissues. Follow-up ranged from 1 to 22 years. Results: All 14 transfers survived and were successful in improving thumb opposition. Key pinch strengths averaged 40 percent of normal. The inclusion of the skin paddle eliminated routing the muscle through tight palmar soft tissues while improving thenar bulk and appearance. Conclusion: In select cases of congenital thumb hypoplasia, opponensplasty using the abductor digiti minimi myocutaneous flap is more advantageous than the traditional muscle transfer.