Daniel A. Hatef

Thromboembolic Risk Assessment and the Efficacy of Enoxaparin Prophylaxis in Excisional Body Contouring Surgery

Background: There is a paucity of evidence within the plastic surgery literature concerning risk stratification and management of patients with respect to thromboembolic disease. A retrospective chart review was conducted to examine whether the Davison-Caprini risk-assessment model could stratify patients undergoing excisional body contouring surgery, allowing prophylaxis to be managed in an evidence-based manner. Methods: Three hundred sixty excisional body contouring patients at the University of Texas Southwestern Medical Center in Dallas, Texas, under the senior authors’ (J.M.K. and R.J.R.) care were reviewed. Patients were stratified into groups according to the risk-assessment model and into groups based on procedure. Patient characteristics were investigated for their effects on thromboembolic risk. Complications of enoxaparin administration were analyzed. The data were analyzed using appropriate statistical procedures. Results: The highest risk patients had a significantly increased rate of venous thromboembolism when compared with lower risk patients. Body mass index greater than 30 and hormone therapy use were associated with a significantly increased venous thromboembolism rate. Enoxaparin administration was associated with a statistically significant decrease in deep venous thrombosis in circumferential abdominoplasty patients. Enoxaparin administration was associated with higher bleeding rates. Conclusions: Low-molecular-weight heparin may affect the incidence of postoperative thrombotic complications in some surgical populations. In this study, patients who scored greater than four risk factors were at significant risk for venous thromboembolism. Enoxaparin significantly decreased deep venous thrombosis risk in patients undergoing circumferential abdominoplasty. This demonstrates the need for a multicenter, prospective, randomized study to examine various thromboembolic therapies and associated possible complications in these patients.

The Anatomy of the Greater Occipital Nerve: Part Ii. Compression Point Topography

Background: Advances in the understanding of migraine trigger points have pointed to entrapment of peripheral nerves in the head and neck as a cause of this debilitating condition. An anatomical study was undertaken to develop a greater understanding of the potential entrapment sites along the course of this nerve. Methods: The posterior neck and scalp of 25 fresh cadaveric heads were dissected. The greater occipital nerve was identified within the subcutaneous tissue above the trapezius and traced both proximal and distal. Its fascial, muscular, and vascular investments were located and accurately measured relative to established bony landmarks. Results: Dissection of the greater occipital nerve revealed six major compression points along its course. The deepest (most proximal) point was between the semispinalis and the obliquus capitis inferior, near the spinous process. The second point was at its entrance into the semispinalis. The previously described “intermediate” point was at the nerves exit from the semispinalis. A fourth point was located at the entrance of the nerve into the trapezius muscle. The fifth point of compression is where the nerve exits the trapezius fascia insertion into the nuchal line. The occipital artery often crosses the nerve, and this frequently occurs in this distal region of the trapezius fascia, which is the final point. Conclusions: There are six compression points along the greater occipital nerve. These can be located using the data from this study, serving as a guide for surgeons interested in treating patients with migraine headaches originating in these areas. Long-term relief from migraine headaches has been demonstrated clinically by using both noninvasive and surgical decompression of these points.

Anatomy of the auriculotemporal nerve: variations in its relationship to the superficial temporal artery and implications for the treatment of migraine headaches.

BACKGROUND Clinical experience with surgical decompression of specific peripheral nerves in the head and neck for the relief of migraine headache symptoms has proven to be effective in most patients. Some patients, however, continue to have residual symptoms after these procedures. In an effort to better understand potential etiologies for failure of treatment, an investigation was performed to determine whether or not vascular-mediated peripheral trigger points exist that have heretofore been undescribed that may be contributing to persistent symptomatology. One such potential trigger point is the superficial temporal arterys interaction with the auriculotemporal nerve. A cadaveric investigation was performed to advance this anatomical understanding of this relationship. METHODS Both sides of 25 fresh cadaveric heads were dissected in the preauricular and temporal regions. The superficial temporal artery and auriculotemporal nerve were identified and dissected both proximally and distally. Their relationship was examined, and a topographical map of their intersections was generated. RESULTS The auriculotemporal nerve and superficial temporal artery run together in the superficial soft tissue in the preauricular and temple regions. A contiguous relationship between the two was found in 17 hemiheads (34.0 percent). CONCLUSIONS There are variations in the relationship between the auriculotemporal nerve and the superficial temporal artery. These variations may serve as an anatomical explanation for this point as a source of migraine headaches in some patients. A topographical map of the relationship between these two structures may serve as a guide for surgeons interested in decompressing the nerve from the artery when indicated.

Procedural risk for venous thromboembolism in abdominal contouring surgery: a systematic review of the literature

Background: To ensure that patients receive appropriate thromboembolic prophylaxis, other specialties have begun using risk stratification models. Because these models do not include plastic surgery patients, research must be directed toward exploring the risk associated with these operations. A systematic review of the literature was performed to address these issues. Methods: A thorough search for all articles discussing abdominal contouring surgery was conducted. Data were collected from this institution through a retrospective chart review and included in the analysis. Procedures were divided into four groups, dependent on what was reported, as follows: abdominoplasty alone, abdominoplasty with an intraabdominal procedure, abdominoplasty with another plastic surgical procedure, and circumferential abdominoplasty. Frequencies of venous thromboembolism were recorded. Chi-square analysis was performed to examine for statistical differences. Results: One hundred fourteen articles were reviewed; 30 articles were included in the analysis. Circumferential abdominoplasty was associated with the highest venous thromboembolism rate (3.40 percent). This was statistically higher than the thromboembolic rate of abdominoplasty (0.35 percent) (p < 0.0001) and abdominoplasty with concomitant plastic surgery (0.79 percent) (p < 0.0001). Abdominoplasty combined with an intraabdominal procedure was associated with the second highest rate of thromboembolism (2.17 percent). This rate was higher than abdominoplasty alone (p < 0.001) and abdominoplasty with concomitant plastic surgery (p = 0.02). Conclusions: Circumferential abdominoplasty and abdominoplasty performed in combination with an intraabdominal procedure were demonstrated to have significantly increased risk for venous thromboembolism. Patients undergoing these procedures should be risk stratified and have perioperative prophylaxis managed accordingly. It is suggested that both of these operations be placed into a higher exposing risk category within the modified Davison-Caprini risk assessment model.

The zygomaticotemporal branch of the trigeminal nerve: Part II. Anatomical variations.

Background: Musculofascial and vascular entrapments of peripheral branches of the trigeminal nerve have been thought to be trigger points for migraine headaches. Surgical decompression of these sites has led to complete resolution in some patients. The zygomaticotemporal branch of the trigeminal nerve has been shown clinically to have sites of entrapment within the temporalis. A cadaveric study was undertaken to elucidate and delineate the location of this nerves foramen and intramuscular course. Methods: The periorbital and temporal regions of 50 fresh cadaveric hemiheads were dissected. The deep temporal fascia and lateral orbital wall were exposed through open dissection. The zygomaticotemporal nerve was located and followed through the temporalis muscle to its exit from the zygomatic bone. The muscular course was documented, and the nerve foramen was measured from anatomical landmarks. Results: In exactly half of all specimens, the nerve had no intramuscular course (n = 25). In the other half, the nerve either had a brief intramuscular course (n = 11) or a long, tortuous route through the muscle (n = 14). The foramen was located at an average of 6.70 mm lateral to the lateral orbital rim and 7.88 mm cranial to the nasion-lateral orbital rim line, on the lateral wall of the zygomatic portion of the orbit. Two branches were sometimes seen. Conclusions: The zygomaticotemporal branch of the trigeminal nerve is a site for migraine genesis; surgical decompression or chemodenervation of the surrounding temporalis can aid in alleviating migraine headache symptoms. Advances in the understanding of the anatomy of this branch of the trigeminal nerve will aid in more effective surgical decompression.

Is primary thinning of the anterolateral thigh flap recommended

Background:Although primary thinning of the anterolateral thigh (ALT) flap has been successful in Asia, clinical and anatomic studies have demonstrated that this may be inadvisable in Western patients. Recent reports have demonstrated successful thinning of the ALT using smaller flaps. A systematic review was attempted, to assess whether ALT size affects the incidence of vascular compromise after primary thinning. Methods:A systematic review was undertaken to examine the relevant literature. Student t-test was used to compare flaps that did and did not have complications. Fisher exact test was used to compare outcomes of flaps measuring less than and greater than 150 cm2. Results:Eleven articles met the inclusion criteria. Eighty-eight ALT flaps were reported, and vascular compromise was seen in 11 (12.5%). The average size of flaps that demonstrated necrosis was 180.73 cm2; those without necrosis averaged 123.19 cm2 (P = 0.06). Flaps >150 cm2 had a significantly increased rate of compromise (25.93% vs. 6.56%; P < 0.05). Conclusions:A systematic literature review confirms that it is inadvisable to primarily thin large ALT flaps in the Western population. When large ALT flaps are required, primary thinning must be avoided to keep linking vessels intact.

Contemporary management of pediatric facial trauma.

Purpose of reviewFacial fracture management is often complex and demanding, particularly within the pediatric population. Although facial fractures in this group are uncommon relative to their adult counterparts, a thorough understanding of issues relevant to pediatric facial fracture management is critical to optimal long-term success. Recent findingsChildren are not ‘small adults’, and the management of facial fractures in this population is unique. Injuries tend to be less severe, and can often be managed with soft diet and restriction of activity. Maxillomandibular fixation should be used only when indicated, as it can result in temporomandibular joint (TMJ) disturbances; to minimize this risk, it should be in place no longer than 7 days. Open reduction and internal fixation is indicated in severe injuries, and the surgeon must be cognizant of developing teeth. Small plates and screws are useful in this patient population. SummaryIn this review of modern management of the pediatric facial trauma patient, several issues germane to pediatric facial fractures are discussed. Thorough ophthalmologic and dental/occlusive examinations must be undertaken. Conservative management is optimal for many injuries, as the pediatric fracture is typically not as severe as those seen in the adult facial skeleton. When wiring the jaw to allow for noninvasive fixation, treatment time must be short in order to avoid TMJ ankylosis. Rigid fixation is indicated in the rare comminuted, displaced fracture; when employed, the surgeon must use small plates and screws, and avoid injury to developing teeth. These are challenging cases, but with appropriate knowledge and understanding, they can be appropriately managed.

Perioperative Steroids for Minimizing Edema and Ecchymosis After Rhinoplasty: A Meta-Analysis

BACKGROUND Minimizing complications after rhinoplasty is a priority for every surgeon performing the procedure. Perioperative steroid administration has been shown to decrease postoperative edema and ecchymosis in a number of prospective randomized trials. OBJECTIVES In an effort to further elucidate the significance of the data and develop an evidence-based algorithm for steroid administration, the authors offer a meta-analysis of the existing literature. METHODS A systematic review of the literature was performed. All articles were reviewed for relevant data, which were extracted, pooled, and compared. Seven prospective randomized trials investigating perioperative steroid use in rhinoplasty have been conducted and reported. Four of these studies had the same method of patient edema and ecchymosis assessment, and their data were compared. RESULTS Based on results from the four relevant studies, perioperative steroid use significantly reduces postoperative edema and ecchymosis of the upper and lower eyelids at one day and seven days postoperatively (P < .0001). Preoperative steroid administration decreases postoperative upper and lower eyelid edema at one day preoperatively, when compared to postoperative administration (P < .05). Extended dosing is superior to one-time dosing (P < .05). CONCLUSIONS Perioperative steroid use decreases postoperative edema and ecchymosis associated with rhinoplasty. Preoperative administration is superior to postoperative, and extended dosing is superior to singular. Based on these results, evidence-based guidelines for perioperative steroid administration can be given.

Prediction of post-operative necrosis after mastectomy: A pilot study utilizing optical diffusion imaging spectroscopy

IntroductionFlap necrosis and epidermolysis occurs in 18-30% of all mastectomies. Complications may be prevented by intra-operative detection of ischemia. Currently, no technique enables quantitative valuation of mastectomy skin perfusion. Optical Diffusion Imaging Spectroscopy (ViOptix T.Ox Tissue Oximeter) measures the ratio of oxyhemoglobin to deoxyhemoglobin over a 1 × 1 cm area to obtain a non-invasive measurement of perfusion (StO2).MethodsThis study evaluates the ability of ViOptix T.Ox Tissue Oximeter to predict mastectomy flap necrosis. StO2 measurements were taken at five points before and at completion of dissection in 10 patients. Data collected included: demographics, tumor size, flap length/thickness, co-morbidities, procedure length, and wound complications.ResultsOne patient experienced mastectomy skin flap necrosis. Five patients underwent immediate reconstruction, including the patient with necrosis. Statistically significant factors contributing to necrosis included reduction in medial flap StO2 (p = 0.0189), reduction in inferior flap StO2 (p = 0.003), and flap length (p = 0.009).ConclusionStO2 reductions may be utilized to identify impaired perfusion in mastectomy skin flaps.

Primary breast augmentation today: a survey of current breast augmentation practice patterns.

A study was undertaken to survey current practice patterns concerning primary breast augmentation. Members of the American Society for Aesthetic Plastic Surgery (ASAPS) were electronically surveyed concerning issues such as incision location, implant size and type, and complications, as well as information about the surgeons, their practices, and where procedures are performed. The survey response rate was 30%. Plastic surgeons from the South and Southwest made up 40% of respondents. Forty-six percent of respondents had more than 20 years of experience in practice. Forty-three percent of primary breast augmentations were performed in outpatient surgery centers. An anesthesiologist was in attendance in 60% of cases. The average operative time--indicated in 80% of responses--ranged from 45 to 90 minutes. Thirty-three percent of responding plastic surgeons used the base diameter to determine implant size and respondents most commonly used a smooth saline implant placed through an inframammary incision in a submuscular pocket. The most frequently reported complication was nipple sensation changes. Although the reintroduction of silicone gel implants was accompanied by expectations of a sharp increase in their use, this survey revealed that among ASAPS members, saline implants currently are used more often than silicone gel implants. However, both saline and silicone gel implants are used frequently, safely, and reliably. This survey represents a snapshot of current practice and future trends in primary breast augmentation will require additional assessment, although increased use of silicone gel breast prostheses over time is expected.