Bill G. Kortesis

The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures.

Objectives: To evaluate the utility of negative-pressure wound therapy (NPWT) in the setting of high-energy open tibial shaft fractures. Design, Setting, and Patients/Participants: This was a retrospective consecutive series in a level 1 university-based trauma center. Forty-nine consecutive patients presenting to a level 1 trauma center between 1996 and 2004 with 50 grade/type III open tibial shaft fractures were assessed. Intervention: The open wounds associated with each fracture were each treated with NPWT before definitive wound closure or coverage. Main Outcome Measurements: Infection rate, need for amputation after attempted definitive coverage, problems with bony healing requiring surgical intervention, reoperation rate after definitive coverage, and the type of definitive coverage required. Results: The overall infection rate for all grade/type III open fractures was 15 of 50 fractures (30%), with 11 of 50 (22%) requiring repeated surgery for infection. The infection rate was 12.5% for grade/type IIIA open fractures, 45.8% for grade/type IIIB, and 50% for grade/type IIIC. Twenty-four of 50 fractures (48%) required subsequent surgery to facilitate fracture healing. Five fractures required amputation after attempted coverage. Seven of 24 fractures initially classified as grade/type IIIA and 10 of 24 fractures initially classified as grade/type IIIB ultimately required free tissue transfer or rotational muscle flap coverage. Conclusions: Infection and nonunion rates with the use of NPWT for temporary coverage of wounds associated with grade/type III open tibial shaft fractures are similar to those of historical controls, but this technique may be beneficial in decreasing the need for free tissue transfer or rotational muscle flap coverage.

Surgical management of foramina parietalia permagna.

Enlarged parietal foramina are rare congenital skull defects identified on physical examination and confirmed radiographically. They are round or oval defects situated on each parietal bone approximately 1 cm from the midline and 2 to 3 cm superior to the lambdoid suture. Although small parietal foramina are common variants in up to 60% to 70% of normal skulls, large parietal foramina ranging from 5 mm to multiple centimeters are less common, with a prevalence of 1:15,000 to 1:25,000. We present a case series of four patients with large persistent parietal foramina managed surgically for the correction of this deformity. Two infants were treated with autologous calvarial bone grafts, and two were treated with a mesh plating system and hydroxyapatite. No patient developed any perioperative complications. No perioperative or delayed infections occurred in our patient population. The mean postoperative follow-up was 36 months. One patient required a second procedure with methylmethacrylate because of late bone graft failure, whereas the others were successfully treated by the initial procedure. Foramina parietalia permagna, otherwise known as fenestrae parietals symmetricae, enlarged parietal foramina, giant parietal foramina, or Catlin marks, are a rare clinical entity. A spontaneous decrease in the size of these defects with growth of the infant has been reported, but this closure is usually incomplete. Surgical intervention of persistent large foramina protects the child against potential injury to the underlying brain. We advocate cranioplasty for active young children and those at risk for injury (i.e., seizure disorder) to decrease the risk for potential intracranial injury.

Does Implant Insertion with a Funnel Decrease Capsular Contracture? A Preliminary Report

BACKGROUND Capsular contracture remains a common and dreaded complication of breast augmentation. The etiology of capsular contracture is believed to be multi-factorial, and its causes may include biofilm formation due to implant/pocket contamination with skin flora. It has been shown that insertion funnel use reduces skin contact and potential contamination by 27-fold in a cadaver model. After incorporating the funnel into our surgical protocols, we anecdotally believed we were experiencing fewer capsular contractures in our augmentation practices. OBJECTIVES The purpose of this study was to test the hypothesis that capsular contracture related reoperation rates decreased after insertion funnel adoption using data from multiple practices. METHODS At seven participating centers, we retrospectively reviewed the surgical records from March 2006 to December 2012 for female patients who had undergone primary breast augmentation with silicone gel implants. Group 1 consisted of consecutive augmentations done without the insertion funnel, and Group 2 consisted of consecutive augmentations done with the insertion funnel. The primary outcome variable was development of grade III or IV capsular contracture that led to reoperation within 12 months. RESULTS A total of 1177 breast augmentations met inclusion criteria for Group 1 and 1620 breast augmentations for Group 2. The rate of reoperation due to capsular contracture was higher without use of the insertion funnel (1.49%), compared to Group 2 with funnel use (0.68%), a 54% reduction (P = 0.004). CONCLUSIONS The insertion funnel group experienced a statistically significant reduction in the incidence of reoperations performed due to capsular contracture within 12 months of primary breast augmentation.

Double myelomeningocele: case report and review

The presence of a myelomeningocele at multiple levels along the spinal column is a rare event. There are only a few cases of double myelomeningocele reported in the worlds literature. Large myelomeningoceles present surgical closure challenges due to the size and location of these defects. We report the case of a newborn female who had two myelomeningoceles with one at the thoracic level and the other at the lumbar level. Surgical closure must provide durable and stable coverage for the spinal cord. Stable coverage was provided for this patient using bilateral paraspinous myofascial turnover flaps. This unusual case report as well as a review of the literature is presented.

Avulsion brachioplasty: technique overview and 5-year experience.

Background: Popularity of arm-contouring procedures, once coveted by the massive weight loss population, has grown among society at large. The technique has evolved with the goal of producing a predictable and thin scar in a location that is acceptable for interpersonal interaction. Methods: All consecutive brachioplasty patients from May of 2008 to May of 2013 were reviewed retrospectively at a private surgery center. Data collected included age, body mass index, amount of fat removed by liposuction, weight of resected tissue, hematoma or seroma, wound dehiscence, revision procedures, and length of follow-up. Results: The authors reviewed 44 consecutive brachioplasties over 5 years. Average age was 53 years and body mass index was 26. Average amount of liposuctioned fat was 342 ml per arm using 867 ml of tumescent and an average skin specimen weight of 90 g. The follow-up period averaged 446 days. Fourteen patients had wound dehiscence requiring dressing changes. There were no return trips to the operating room for serious concerns such as bleeding or infection. One patient had a seroma. Nine patients underwent scar revision within 1 year. Overall complication rate was 50 percent. Overall revision rate was 21 percent. Conclusions: Brachioplasty is a rewarding procedure with consistent results and low risk of major complications. The potential for minor complications is substantial, and patients should receive preoperative counseling regarding this risk. In the authors’ 5-year study of consecutive patients, 50 percent of patients needed dressing changes for small-wound dehiscence or scar revision within 1 year. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Avulsion Thighplasty: Technique Overview and 6-Year Experience.

Summary: When choosing a thigh lift operation, the surgeon also chooses which complications he/she will be managing, and the most dreaded after conventional thigh lifting are those of lymphatic origin such as lymphocele or lymphedema. The authors describe avulsion thighplasty, a technique that spares lymphatics by using aggressive liposuction beneath the planned resection area, and thus minimizes lymphatic complications. The technique is outlined and complications are detailed over a 6-year period with long-term follow-up. The risk of major complications is found to be low and the procedure is found to be safe. Patients must be counseled that the risk of minor complications, such as small wound dehiscence or need for a later scar revision, is substantial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Surgical treatment for scaphocephaly and a calcified cephalohematoma

Craniosynostosis is the premature fusion of 1 or more of the cranial sutures, with sagittal synostosis being the most common nonsyndromic single suture synostosis. The pathogenesis of craniosynostosis has been extensively studied and is likely multi-factoral. A complex interaction between the dura and overlying suture via multiple growth factors seems to play the most important role. There have been 3 published studies with patients presenting with scaphocephaly and a cephalohematoma, which raises the question of how the 2 conditions may be related. Cephalohematomas can be seen after trauma and a number of other causative factors but usually resorb over time without sequela. In a small percentage of cases, the hematoma persists and calcifies, leading to significant asymmetry and deformity of the skull. Once it reaches this point, surgical intervention may be required to correct the resulting skull deformity. We present a child with scaphocephaly and a cephalohematoma who underwent surgical correction with resection of the cephalohematoma and sagittal suturectomy with spring-assisted surgery.

A Multicenter, Prospective, Randomized, Contralateral Study of Tissue Liquefaction Liposuction vs Suction-Assisted Liposuction

Background Tissue liquefaction liposuction (TLL) deploys a novel energy source utilizing a stream of warmed, low-pressurized, and pulsed saline to extract fat tissue. Objectives Compare TLL to suction-assisted liposuction (SAL) to determine which device is more efficient for surgeons and provides better recovery for patients. Methods Thirty-one adult female patients were followed prospectively in a contralateral study design comparing differences in bruising, swelling, tenderness, and incision appearance ratings between TLL and SAL procedures. Surgical efficiency and appearance of the lipoaspirate were also compared. Results All 31 patients successfully completed the study. For TLL and SAL procedures, the average volumes of infusion (1.242 vs 1.276 L) and aspirated supernatant fat (704 vs 649 mL) were statistically similar. TLL median fat extraction rate was faster than SAL (35.6 vs 25 mL/min; P < 0.0001), and stroke rate was reduced in TLL vs SAL procedures (48 vs 120 strokes/min; P < 0.0001), and both were statistically significant. The mean total scores for bruising, swelling, treatment site tenderness, and incision appearance were lower, indicating improved patient recovery on the TLL side. Conclusions TLL and SAL techniques produced comparable volume of fat aspirate. TLL demonstrated a 42% faster fat extraction rate and a 68% reduction in arm movements needed to complete the procedure compared to SAL, both of these differences are statistically significant. The TLL side was noted to have reduced bruising and swelling and improved incision site appearance with less tenderness compared to the SAL side. Level of Evidence 2

Labiaplasty: Current Trends of ASAPS Members

Labiaplasty continues to increase in frequency among the American Society for Aesthetic Plastic Surgery (ASAPS) members. From 2015 to 2016, labiaplasty increased by 23% according to the 2016 Cosmetic Surgery National Data Bank Statistics by ASAPS.1 During this time, more than 35% of all plastic surgeons offered labiaplasty as a part of their practice.1 As with many procedures, multiple variables exist when planning and performing labiaplasty. The primary reason for presentation ranges from unacceptable appearance to discomfort in clothing and often leads a surgeon towards a more or less aggressive technique.2 The tools for patient education vary from verbal discussion, drawings, before and after patient photographs, or labiaplasty origami.3 Labiaplasty origami is a simple and effective hands-on 3D reference for central wedge labiaplasty and clitoral hood reduction.3 We aim to evaluate the ASAPS membership to identify the current trends for labiaplasty. An online questionnaire was distributed to all active ASAPS members (n = 1628). The survey was composed of 12 questions regarding surgeon demographics, preferred labiaplasty technique, and self-reported outcomes (Appendix A).

The hybrid approach in modern gluteoplasty and a proposed decision-making algorithm

The gluteal region is an important aesthetic symbol of the body and represents a major component of sexual attraction. Buttocks descent and atrophy are common presenting complaints for patients seeking elective improvement of their body. Gluteal surgery has a recent history of technique evolution, with various reported methods and refinements, including autologous tissue and alloplastic materials. It has been gaining popularity, and an exponential growth in buttocks procedures has been recorded in the recent years. Modern comprehensive gluteal rejuvenation must address both gluteal atrophy and ptosis. Gluteal implants can give a rounded and enhanced appearance to the buttocks while lifting in the form of excisional techniques can address the ptosis. These techniques may be applied together in one surgical procedure or performed in a staged sequence. This report describes the combination of lifting and enhancement techniques to achieve improvement in the gluteal region. An algorithm, to assist with decision making, based on the gluteal deformity encountered, is also proposed. Two separate clinical examples are described, a patient with gluteal implants with synchronous buttocks lift and a patient with pursestring gluteoplasty followed by gluteal implants at a later time.Level of Evidence: Level V, therapeutic study.