Daniel N. Driscoll

Mastopexy techniques after massive weight loss: an algorithmic approach and review of the literature.

Mastopexy after massive weight loss (MWL) poses unique challenges that may not be successfully addressed with traditional mastopexy procedures. Several novel techniques have been proposed to improve esthetic outcomes; however, little data exists to guide the plastic surgeon on choice of technique for individual patients. A literature review revealed 10 articles with specific emphasis on mastopexy techniques in MWL patients. These articles focused on ways to improve shape, projection, and long-term results, using autologous tissue alone or combined with breast implants. Key concepts include increasing volume of the breast by utilizing excess axillary tissue (lateral thoracic/spiral/intercostal artery perforator flap), modification of existing superomedial pedicle techniques to maximize breast volume, and increasing breast parenchymal support with suture fixation and dermal suspension. This article offers an algorithmic approach to treat breast ptosis in the MWL patient based on breast volume, axillary tissue, desired scar location, and preferred surgical technique.

Nasal reconstruction after severe facial burns using a local turndown flap.

Reconstruction of the nose after severe burn injury is a challenging problem. There are usually associated facial burns, which limits the availability of local flaps. Reconstruction with unburned distant tissue is often not appropriate because of the resulting mismatch in color and texture. Successful nasal reconstruction can be accomplished in this group of challenging patients using a simple, inferiorly based flap from the nasal dorsum with subsequent skin grafting to the resulting defect. We have used an inferiorly based nasal turndown flap to reconstruct severe nasal deformities after burn injury in 28 patients. The flap tissue consists of the dorsal surface of the nose, which is usually made up of skin graft and scar. The flap base is the scar transition zone between the dorsum of the nose and the lining mucosa. This is turned over to provide nasal length, projection, and to stimulate alar lobules. The resulting defect on the dorsum of the nose is then skin grafted. If further length or refinement is required, the procedure may be repeated. The records of all patients who underwent this procedure were reviewed for demographics, age at burn, percentage of total body surface area burned (%TBSA), availability of the forehead, number of procedures, and complications. Twenty-eight patients underwent nasal reconstruction in our series using this local turndown flap. Most of these patients had severe burns, with an average %TBSA of 46%. The procedure was initially applied to patients with devastating injuries and %TBSA of 80%–95%, with extremely limited donor sites. As the success of the procedure was established, less severely burned patients were included in the series, thereby lowering the mean %TBSA. All patients had partial or complete destruction of their forehead donor site. All patients presented for multiple hospitalizations, with an average of 17 hospital admissions. Using this local turndown flap, adequate nasal length and projection could be achieved. There were few complications. All of the flaps survived, although there were 2 cases of necrosis of the distal edge of the flaps (0.7%). This resulted in decreased length and projection but this problem was successfully addressed with additional staged procedures. Contraction of local scar tissue created bulk and support, eliminating the need for distant tissue transfer or cartilage grafting. Twelve of the 28 patients required repeat turndown flaps to achieve sufficient nasal length and projection. These results were durable over a follow-up period of up to several decades. A simple, multistaged dorsal nasal flap can be used to reconstruct severe nasal deformities after facial burn injury. This can obviate the need for distant tissue transfer. Even in patients with subtotal nasal amputation and complete absence of cartilaginous support, the opportunistic use of scar tissue can restore nasal tip projection and alar lobule architecture without cartilage grafting. The resulting nasal reconstruction blends well into the surrounding facial appearance. This simple technique has been remarkably successful in this selected group of patients with challenging nasal deformities.

Combining Scalp Tissue Expansion With Porous Polyethylene Total Ear Reconstruction in Burned Patients

Burned ear reconstruction remains one of the most difficult areas of plastic surgery. A superior result is needed to justify the donor site morbidity when reconstructing with a costochondral graft. Recently, more studies have evaluated porous polyethylene ear reconstruction in microtia and in burns. A total loss of the pinna from burns is rare and often associated with significant alopecia. Tissue expansion is an excellent means of reconstructing burned scalp alopecia. Deeply burned skin is often so densely scarred that a costochondral graft would produce a nondescript scarred mass with little resemblance to the native ear. This mini series overview describes 3 cases of porous polyethylene and total ear reconstructions done in conjunction with tissue expansion reconstruction for burn alopecia. This method can be used as a very efficient combination of procedures in a severely burned patient without the additional morbidity of costochondral grafting.This is the first description of this combination of procedures. At the initial procedure, a large tissue expander is placed beneath the hair-bearing scalp in a subgaleal plane. At the time of tissue expander removal and alopecia resection, a temporoparietal fascia flap is elevated. The incisions for alopecia resection allow easy dissection behind the external auditory meatus. The porous polyethylene construct is then placed posteriorly and wrapped with the temporoparietal fascial flap. The hairline is reconstructed simultaneously. The technique described makes full use of the temporoparietal fascial flap that may, otherwise, be resected or injured with the alopecia resection. It also allows alopecia reconstruction and accomplishes 2 reconstructive goals at once with little or no donor site morbidity.

Packing and temporary closure in a liver injury

As a component of a staged laparotomy for trauma, perihepatic packing can be lifesaving in the patient with exsanguinating liver injury who, due to hypothermia and coagulopathy, is unable to tolerate a more extensive procedure. However, if intra-abdominal pressure increases, the manoeuvre has been reported to compromise cardiopulmonary stability. Patients who suffer the adverse consequences of intra-abdominal hypertension are commonly managed with a loose temporary closure, frequently using an artificial material to bridge the skin defect across the incision. A case is reported where these two seemingly contradictory options were combined to achieve a successful outcome.

Dermabrasion and Thin Epidermal Grafting for Treatment of Large and Small Areas of Postburn Leukoderma: A Case Series and Review of the Literature

Deep burn injuries can have serious aesthetic consequences as it often results in scar tissue and pigmentary changes of the skin. The focus of this article is to report our experience and results using dermabrasion and thin split-thickness skin grafting as a technique for restoring skin pigmentation after burn injuries. Patient records were obtained from a pediatric burn hospital medical record database from 1990 to 2007. Both charts and photographs were retrospectively reviewed. The treatment was evaluated for body region treated, surface area involved, effectiveness of treatment, and number of treatments required. Indications for the procedure included longstanding depigmentation, defined as greater than 1 year, and a patient wiling to have a donor site. The areas of vitiligo were marked and dermabraded with a mechanical dermabrader. Thin epidermal grafts with a thickness of 6 thousands of an inch were harvested with an air-powered dermatome. The grafts were affixed to the dermabraded bed and dressed open or with nonstick gauze for areas of the face and wrapped for areas in the extremities. Eleven patients underwent 16 procedures. The average size of the graft per procedure was 87 cm2 (4–500 cm2). All results were consistent and long-lasting at follow-up. Postburn leukoderma of long duration is well treated by dermabrasion and thin split-thickness skin grafting. This study is unique in describing grafting on multiple occasions and for larger areas than previously described, with two patients undergoing grafting more than 200 cm2.

Burn Ear Reconstruction Using Porous Polyethylene Implants and Tissue Expansion.

Reconstruction of the external ear after a burn is particularly challenging. The nature of the injury poses many problems including excessive scar tissue, poor blood supply, and the lack of adequate and appropriate materials for a framework. The use of costochondral grafts often leads to marginal outcomes which do not justify the morbidity. Children under the age of 10 years commonly have insufficient cartilage for a graft. Medpor® (Stryker, Kalamazoo, MI) offers minimal morbidity and a very effective result. In this series, the authors describe the experience using Medpor® and scalp tissue expansion to reconstruct severely burned ears. A total of 16 pediatric patients underwent 18 reconstructions, with two patients receiving bilateral procedures. All patients received Medpor® implants. Thirteen patients were tissue expanded under the subgaleal plane before reconstruction, for concomitant scalp alopecia reconstruction. Eleven temporoparietal fascial flaps were performed. In the remaining patients, coverage of the implant was achieved by local advancement flaps. Only two patients had complications, with exposure of the construct after several years. In these two cases, the implants were removed. The experience has shown porous polyethylene reconstruction to be very efficient, with low morbidity and good cosmetic outcomes. Medpor® is an excellent option for the reconstruction of both fully and partially burned ears as you may implant only the helical rim, base, or both pieces. The best results were achieved after tissue expansion and the use of the alopecic skin overlying a temporoparietal fascial flap. This has become the preferred method.

Ultrasound-Guided Regional Anesthesia for Pediatric Burn Reconstructive Surgery: A Prospective Study.

Pediatric patients face multiple reconstructive surgeries to reestablish function and aesthetics postburn injury. Often, the site of the harvested graft for these reconstructions is reported to be the most painful part of the procedure and a common reason for deferring these reconstructive procedures. This study in pediatric burn patients undergoing reconstructive procedures examined the analgesia response to local anesthetic infiltration versus either a single ultrasound-guided regional nerve block of the lateral femoral cutaneous nerve (LFCN) or a fascia iliaca compartment block with catheter placement and continuous infusion. Nineteen patients were randomized to one of three groups (infiltration, single-shot nerve block, or compartment block with catheter) and received intraoperative analgesia intervention. Postoperatively, visual analog scale pain scores were recorded—for pain at the donor site—every 4 hours while awake—for 48 hours. This nonparametric data was analyzed using a two-way ANOVA, Friedman’s test, and Kruskal–Wallis test, with significance determined at P < 0.05. The analysis demonstrated that the patients in the regional anesthesia groups were significantly more comfortable over the 48 hour hospital course than the patients in the control group. The patients receiving a single-shot block of the LFCN were more comfortable on postoperative day (POD) 0 while the catheter patients were more comfortable on POD 1 and POD 2. There was not a statistically significant difference in opioid requirements in any group. Regional anesthetic block of the LFCN, with or without catheter placement, provides an improved postoperative experience for the pediatric patient undergoing reconstructive surgery with lateral/anterolateral skin graft versus local anesthesia infiltration of donor site. For optimal comfort throughout the postoperative period, an ultrasound-guided block with continuous catheter may be beneficial.

Global health: burn outreach program.

The objective of this article is to outline the elements of an international burn care outreach program in a resource-constrained country. The program has grown from a collaborative effort with Ukrainian physicians and healthcare officials. With this collaboration, a multipronged approach has been developed to address the gaps in burn care as discovered by years of interaction with the medical community in Ukraine. Contact was initiated with the burn unit of a single municipal hospital in Lviv, Ukraine. Patients with burn injuries were screened and selected patients were comanaged over a 3-year period by American and Ukrainian physicians. This comanagement included repeated evaluation both by telemedicine conferencing as well as annual trips with physicians from Boston, Massachusetts, traveling to Ukraine to assess patients in an outreach clinic and perform surgical procedures. In our first trip in 2011 we assessed 22 patients and operated on 5. In 2012, 38 patients were evaluated and 12 had combined surgical intervention. In our 2013 trip, 63 patients were evaluated and we operated on 22 of these patients. Multiple clinical research projects related to burn prevention and improving perioperative care have been initiated, presented at national meetings, and submitted for publication in peer-reviewed journals. Our outreach program in Lviv, Ukraine, strives to improve overall burn care by a multilayered approach. These elements can serve as a possible template for additional international burn outreach plans as they can be customized for both large and small interventions.

Targeting burn prevention in Ukraine: evaluation of base knowledge in burn prevention and first aid treatment.

Burn prevention has been identified by the World Health Organization (WHO) as a topic in need of further investigation and education throughout the world, with an increased need in low-income countries. It has been noted that implementing educational programs for prevention in high income countries has aided in lowering the rate of burn injuries. The purpose of this study is to evaluate the current education level of knowledge of prevention and first aid treatment of scald burns. A prevention campaign will target these educational needs as a part of an outreach program to improve burn care in Ukraine. The research team evaluated the current health structure in Ukraine and how it could benefit from the increased knowledge of burn prevention and first aid. A test was designed to assess the baseline level of knowledge with regard to first aid and scald prevention in parents, pregnant woman, and healthcare and daycare providers. A total of 14,456 tests were sent to pediatric clinics, obstetrician clinics, and daycare facilities to test respondents. A total of 6,120 completed tests were returned. Doctors presented with the highest level of knowledge averaging 77.0% on prevention and 67.5% on first aid while daycare workers presented the largest gap in knowledge at 65.0% in prevention and 54.3% in first aid. Interest in further educational materials was reported by 92% of respondents. The results of this study clearly show a lack of knowledge in first aid and prevention of scald burn injury in all the populations tested.

Use of telemedicine to improve burn care in Ukraine.

Global burn injuries have been described as the “forgotten public health crises” by the World Health Organization. Nearly 11 million people a year suffer burns severe enough to require medical attention; more people are burned each year than are infected with human immunodeficiency virus/acquired immunodeficiency syndrome and tuberculosis combined. Telemedicine has the potential to link experts in specialized fields, such as burn care, to regions of the world that have limited or no access to such specialized care. A multilevel telemedicine program was developed between Massachusetts General Hospital/Shriners Hospital in Boston, Massachusetts, and City Hospital #8 in Lviv, Ukraine. The program should lead to a sustainable improvement in the care of burn victims in Ukraine. The authors helped establish a Learning Center at City Hospital #8 in Lviv, Ukraine, through which they were able to consult from Shriners Hospital in Boston, on a total of 14 acute burn patients in Ukraine. This article discusses two case reports with the use of telemedicine and how it has allowed the authors to provide not only acute care consultation on an international scale, but also to arrange for direct expert examination and international transport to their specialized burn center in the United States. The authors have established a program through doctors from Massachusetts General Hospital/Shriner’s Hospital in Boston, which works with a hospital in Ukraine and has provided acute consultation, as well as patient transportation to the United States for treatment and direct assessment.