Daniel J. Gould

Decrease in Seroma Rate After Adopting Progressive Tension Sutures Without Drains: A Single Surgery Center Experience of 451 Abdominoplasties Over 7 Years.

BACKGROUND Abdominoplasty is a common aesthetic procedure in the United States. Pollock and Pollock described their progressive tension technique in 2000 and published a series of 597 patients in 2012 of their experience. The reported seroma rate in the literature ranges from 2% to 26% with drains and 0.1% to 4% with progressive tension sutures (PTS) without drains. OBJECTIVES Given these data, we decided to use PTS and forego drains in abdominoplasty. Here we present our experience with the transition. METHODS This is a retrospective chart review of 451 abdominoplasties performed at our outpatient surgery center over a 7-year period (2009-2015). We gathered data on patient demographics, concomitant liposuction, and complications and length of follow up. RESULTS Five main differences were examined in PTS vs traditional abdominoplasty using drains groups. These included rate of seroma, wound complication, scar revision, hematoma, and follow up. We found a decreased rate of seroma in the PTS group, 2% vs 9%. Wound complications were similar. Scar revision was slightly higher in the PTS group at 17% vs 10% in traditional abdominoplasty, this association had a P value of .048. The rates of hematoma were similar (0% vs 1%). The mean follow up was 6 months in PTS and 9 months in traditional abdominoplasty. Addition of liposuction did not increase the rate of seroma. CONCLUSIONS PTS without drains significantly decreased the seroma rate in our practice. Our experience adds to the mounting evidence that surgeons should consider using the PTS technique and abandon the use of drains in abdominoplasty. A well powered, multicenter, randomized controlled study is needed in order to definitively lay this question to rest. LEVEL OF EVIDENCE 4 Therapeutic.

Social Media Return on Investment: How Much is it Worth to My Practice?

Background Plastic surgeons are rapidly integrating social media into their practices and recent articles on the subject have exploded in the literature. Although social media is being evaluated as a tool, few have actually been able to quantify the impact of social media on a practice. Objectives To quantify the return on investment for social media in a plastic surgery practice. Methods The ideal method for this type of study is a new practice, without preexisting clients and with a broad approach to marketing to examine the effects of multiple marketing tools. In this study, we profile a start-up plastic surgery practice in Beverly Hills, Los Angeles. Results In this study, we report practice demographics as well as one year of income, broken down by the referral source for each patient. The dollar amount returned was reported for several social media resources and other internet-based marketing tools. Conclusions Social media has a relatively high return on investment, and to date this is the first study to transparently quantify the value of social media in plastic surgery.

Supermicrosurgery: History, Applications, Training and the Future

Supermicrosurgery, a technique of dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm, has revolutionized the fields of lymphedema treatment and soft tissue reconstruction. The technique offers several distinct benefits to microsurgeons, including the ability to manipulate small vessels that were previously inaccessible, and to minimize donor-site morbidity by dissecting short pedicles in a suprafascial plane. Thus, supermicrosurgery has become increasingly popular in recent years, and its applications have greatly expanded since it was first introduced 20 years ago. While supermicrosurgery was originally developed for procedures involving salvage of the digit tip, the technique is now routinely used in a wide variety of microsurgical cases, including lymphovenous anastomoses, vascularized lymph node transfers and perforator-to-perforator anastomoses. With continued experimentation, standardization of supermicrosurgical training, and high quality studies focusing on the outcomes of these novel procedures, supermicrosurgery can become a routine and valuable component of every microsurgeon’s practice.

Our Surgical Experience: Open Versus Endoscopic Carpal Tunnel Surgery

Carpal tunnel release is one of the most common hand operations in the United States and every year approximately 500,000 patients undergo surgical release. In this article, we examine the argument for endoscopic carpal tunnel release versus open carpal tunnel release, as well as some of the literature on anatomical variants in the median nerve at the wrist. We further describe the experience of several surgeons in a large academic practice. The goals of this article are to describe key anatomic findings and to present several cases that have persuaded us to favor offering patients open carpal tunnel release.

Superior Pedicle Technique of Reduction Mammaplasty: A Stepwise Approach

Numerous surgical options for breast reduction have been described, but in the current healthcare environment, efficiency is of the utmost importance. In this Featured Operative Technique, the authors describe an efficient, reproducible, and simple method for minimal to moderate reduction mammaplasty that utilizes a superior pedicle. The surgical maneuvers were developed and conveyed to the senior author (W.G.S.) by Dr John Bostwick. This approach preserves superior and medial breast fullness while providing appropriate resection of the breast parenchyma to ameliorate symptoms and produce a smaller, lifted breast with a more youthful appearance. The surgical technique maintains a reliable blood supply to the nipple-areola complex (NAC) from the internal mammary artery and its perforators, and involves minimal transposition of the NAC. The authors reviewed the charts of 62 consecutive patients who underwent this procedure and found the complication rate to be 11.3%. Complications included 1 hematoma, 1 standing cone deformity, 3 soft-tissue infections, 8 incisional breakdowns, and 1 unilateral necrosis of the NAC.

Seroma Rates Are Not Increased When Combining Liposuction With Progressive Tension Suture Abdominoplasty: A Retrospective Cohort Study of 619 Patients

Background Several studies have demonstrated that progressive tension sutures (PTS) reduce seroma. Many fear that adding liposuction to abdominoplasty will increase seroma rates and avoid drainless abdominoplasty when performing concomitant liposuction. Objectives We sought to identify whether liposuction increases seroma in PTS and non-PTS abdominoplasty. Methods In this retrospective study, 619 patients underwent abdominoplasty between 2009 and 2017, of which 299 patients had drainless abdominoplasty with PTS and 320 had drain-based abdominoplasty. We compared complications among PTS patients with and without liposuction and among drain-based abdominoplasty patients with and without liposuction. Results Demographics were similar between PTS and drain patients and between liposuction and nonliposuction PTS. Mean liposuction volume with PTS was 1592 ± 1048 mL. Seroma in the PTS group was found to be 2.6%, which is consistent with previous data. PTS without liposuction had a rate of seroma of 6.67% compared to a rate of 2.2% with liposuction; these rates were not significantly different (P = 0.20). A total of 207 patients had drain-based abdominoplasty with liposuction, and 113 had it without liposuction. Seroma with liposuction was 9.17% and without liposuction was 6.19%, although these differences were not significant (P = 0.52). PTS lipoabdominoplasty had less seroma compared with drain-based lipoabdominoplasty (P = 0.01). Conclusions Liposuction was performed in 80% of the patients, and patients with lipoabdominoplasty were not at a higher risk of seroma, in the drain group or the PTS group. More patients may allow validation that liposuction may actually be protective with PTS. Regardless, there is no increase in seroma with the addition of liposuction to PTS drainless abdominoplasty. Level of Evidence 3

Insta-grated Plastic Surgery Residencies: The Rise of Social Media Use by Trainees and Responsible Guidelines for Use

Background Ethical guidelines for appropriate use of social media are beginning to be delineated. As social media becomes ingrained in plastic surgery culture, education of residents on appropriate use of social media is increasingly important. Recently, plastic surgery residency programs have begun to utilize social media. Objectives This study characterized the trends and content of plastic surgery residency-associated Instagram accounts. Methods Active individual residency program Instagram accounts were identified for integrated plastic surgery programs. Metrics for each account were retrieved on September 16, 2017, including date of first post, number of posts, and followers. Individual posts were analyzed for content of post. Results Fourteen of 67 (21%) integrated plastic surgery programs were found to have active Instagram accounts. There has been an exponential growth of programs adopting Instagram since August 2015. A total of 806 posts were created. Thirty-two (3.97%) posts had intraoperative photos and only one (0.12%) showed a patient image. There were 4466 followers of plastic surgery residency programs. A linear correlation was found between number of posts and number of followers, while there was no correlation of number of followers and time since account start. Conclusions Instagram use by plastic surgery integrated programs continues to grow exponentially, and programs are appropriately using the platform. Active use of the resident social media results in increased influence. Resident use of social media has many benefits. We propose social media guidelines for plastic surgery trainees and advocate for continued appropriate use and autoregulation by plastic surgery trainees.

Spinning out of control: a 19-year-old female with spinning-related exertional thigh compartment syndrome

Thigh compartment syndrome (TCS) is a rare condition caused by high pressures within the fascial compartments of the thigh, impeding capillary flow and leading to decreased perfusion, tissue hypoxia, and necrosis. TCS is most frequently associated with trauma and anticoagulation but has also rarely been associated with exercise-related injury. We present the case of a 19-year-old female who reported painful swelling in her thighs and darkening of her urine after participating in a spinning class. On physical examination, the patient was found to have tight, painful thigh compartments with extreme tenderness on passive motion. Labs revealed a marked elevation of creatine kinase and leukocytosis. The patient was diagnosed with TCS and underwent emergent decompression fasciotomy and aggressive IV fluids for protection against myoglobinuria. Due to high clinical suspicion, prompt diagnosis, and early surgery, the patient experienced excellent recovery without functional deficits.

Vectra 3d Imaging for Quantitative Volumetric Analysis of the Upper Limb: A Feasibility Study for Tracking Outcomes of Lymphedema Treatment

Background: Secondary lymphedema of the upper limb is a common sequela following lymphadenectomy during oncologic surgery. The gold standard for evaluating treatment outcomes in upper limb lymphedema is limb volume measurement. However, current techniques lack sensitivity to localized changes. In this study, the Vectra 3D imaging system was used to accurately and precisely obtain volume measurements of the upper limb in patients with lymphedema. Methods: A feasibility study was performed in 11 patients with lymphedema and 22 upper extremities; 24 arms were evaluated in total. Three-dimensional images were taken of the upper extremities, and Vectra 3D software was used to calculate the volume of the hand, forearm, and upper arm. These measurements were compared to traditional circumference (tape) and water displacement measurements. Results: The 24 arm volumes ranged from 1517 to 4050 cc. The Vectra 3D provided precise and accurate volume measurements (average SD ± 1.0 percent of total volume). Measurements of the forearm and upper arm correlated with circumference measurements (R2 = 0.991) and were in good agreement, with the mean difference between measurement techniques being 2.8 ± 2.0 percent. Three-dimensional measurements of hand, forearm, and upper arm correlated with water measurements (R2 = 0.990) and had a mean difference between measurement techniques of 2.6 ± 2.1 percent. Conclusions: The Vectra 3D system provides precise and accurate data comparable to those of the most commonly used technique to estimate limb volume (tape measurement) and gold-standard water volume measurement. Three-dimensional imaging also offers several advantages, including time efficiency and obtaining localized measurements with high spatial resolution. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Correction of the Inverted Nipple

Nipple inversion is common, occurring in 2–10% of the female population. It can be congenital or acquired, and patients report difficulty breastfeeding and interference with their sexuality when seeking treatment. This deformity can cause significant psychological trauma, and though surgical repair has been developed over the years, little data exists regarding recurrence rates, complications, and the demographics of patients seeking this type of surgery. In this chapter, we demonstrate an integrated approach to the correction of nipple inversion that minimizes ductal disruption. This approach is ideal, as it does not interfere with future breastfeeding, it provides a long-term robust repair, and it is relatively easy to administer in an outpatient setting. The correction of nipple inversion involves blunt dissection and vertical spreading parallel to the lactiferous ducts. The majority of the time lactiferous ducts are preserved, although sometimes selective division of only those ducts that restrict nipple projection is performed. Traction stenting helps ensure eversion and protects the repair. Our technique produces excellent results with a recurrence rate of 12.6%. In our experience, this technique has proven effective and safe for the treatment of inverted nipples.