Devin Coon

Body mass and surgical complications in the postbariatric reconstructive patient: analysis of 511 cases.

Objective:To analyze the impact of body mass indices on postbariatric reconstructive surgery complications. Background:An increasing number of patients are presenting after massive weight loss due to bariatric surgery or diet and exercise. Many of these patients have residual obesity, which may compromise outcomes. Methods:449 patients were enrolled in a prospective registry over 6 years. Measures included medical complications and comorbidities. All cases were analyzed together as well as in two subgroups: single procedure cases (Group I) and multiple procedure cases (Group II). Results:449 patients (407 female, 42 male) with a mean age of 44.5 ± 10.3 underwent 511 separate operations. Mean pre-weight loss BMI (Max BMI) was 51.6 ± 9.5 kg/m2, post-weigh loss BMI (Current BMI) was 29.3 ± 5.0 and the ΔBMI was 22.3 ± 7.5. For all cases (n = 511), the presence of a surgical complication was directly related to Max BMI (P = 0.002) and ΔBMI (P = 0.002) but not Current BMI. Group I consisted of 194 single procedure cases. Complications in Group I were related to Max BMI (P = 0.006) and Current BMI (P = 0.02) but not ΔBMI. Max BMI impacted infections (P = 0.003) while Current BMI impacted dehiscence (P = 0.009) and infections (P = 0.03). Group II consisted of 317 cases with only ΔBMI directly related to overall complications (P = 0.01). Conclusions:Body mass indices influence complications in postbariatric reconstructive surgery. Current BMI may impact complications in single-procedure cases, but appears to play less of a role in larger cases. Careful patient selection, assessment of surgical complexity, and recognition of the particular risks increased by residual obesity can help to optimize outcomes in this patient population.

Fractionated stereotactic body radiation therapy in the treatment of primary, recurrent, and metastatic lung tumors: the role of positron emission tomography/computed tomography-based treatment planning.

PURPOSE The aim of this study was to assess the outcomes of patients treated with stereotactic body radiation therapy (SBRT) in patients with primary, recurrent, or metastatic lung lesions, with a focus on positron emission tomography (PET)/computed tomography (CT)-based management. PATIENTS AND METHODS Fifty-one patients with primary stage I non-small-cell lung cancer (NSCLC; n = 26), recurrent lung cancer after definitive treatment (n = 12), or solitary lung metastases (n = 13) were treated with SBRT between 2005 and 2007. Patients were treated with the CyberKnife Robotic Radiosurgery System with Synchrony respiratory tracking. A dose of 60 Gy was delivered in 3 fractions. All patients had CT or PET/CT performed at approximately 3-month intervals after treatment. RESULTS The median follow-up was 12 months. Local control at median follow-up was 85% in patients with stage I NSCLC, 92% in patients with recurrent lung cancer, and 62% in the patients with solitary lung metastasis. Analysis of the 28 patients with pre- and post-treatment PET/CT scans demonstrated that those with stable disease (n = 4) had a mean standardized uptake value (SUV) decrease of 28%, partial responders (n = 11) had a decrease of 48%, and patients with a complete response (n = 11) had a decrease of 94%. Patients with progressive disease (n = 2) had an SUV decrease of only 0.4%. Only 2 patients (7%) who had reduced fluorodeoxyglucose avidity later progressed locally. No correlations were found between pretreatment SUV and tumor response, disease progression, or survival. Overall 1-year survival rates were 81%, 67%, and 85% among the patients with primary NSCLC, recurrent lung cancer, and solitary lung metastases, respectively. CONCLUSION Stereotactic body radiation therapy with CyberKnife is an effective treatment for patients with medically inoperable recurrent or metastatic lung cancer. Positron emission tomography/CT is valuable in staging, planning, and evaluating treatment response and might predict long-term outcome.

Mammographic changes after fat transfer to the breast compared with changes after breast reduction: a blinded study.

Background: One issue in the adoption of autologous fat transfer to the breast is concern over mammographic changes that may obscure cancer detection. The authors compared mammographic changes following fat grafting to the breast with changes seen after breast reduction. Methods: Twenty-seven women who had normal preoperative mammograms were treated with fat grafting to the breast, including admixing of autologous adipose stem cells with the fat graft, for cosmetic augmentation. Repeated mammograms were performed 12 months after surgery. As a control group, postsurgical mammograms from 23 reduction mammaplasty patients were compared. Eight academic breast imaging radiologists reviewed each mammogram in a blinded fashion. Outcomes analysis accounting for individual radiologists tendencies was performed using generalized estimating equations. Results: The average volume of fat injected per patient was 526.5 cc. Fifty mammograms (27 lipotransfer, 23 breast reduction) were assessed. Differences in interpretation among individual radiologists were consistently observed (p < 0.10). Differences in abnormality rates were nonsignificant for oil cysts, benign calcifications, and calcifications warranting biopsy. Scarring (p < 0.001) and masses requiring biopsy (p < 0.001) were more common in the reduction cohort. Breast Imaging Reporting and Data System scores were higher after breast reduction (p < 0.001). Significant differences in the recommended follow-up time were also seen (p < 0.01). Conclusions: Compared with reduction mammaplasty, a widely accepted procedure, fat grafting to the breast produces fewer radiographic abnormalities with a more favorable Breast Imaging Reporting and Data System score and less aggressive follow-up recommendations by breast radiologists. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Preoperative intensity-modulated radiotherapy and chemotherapy for locally advanced vulvar carcinoma

OBJECTIVE Intensity-modulated radiation therapy (IMRT) is a rapidly maturing technology that allows delivery of radiation dose in a more conformal manner by varying the radiation beams spatially or temporally. The purpose of the study was to assess the clinical outcome in patients with locally-advanced vulvar cancers treated using preoperative chemotherapy with IMRT. METHODS Eighteen patients with stage II-IVA cancer were treated with a modified GOG schema using 5-fluorouracil (5-FU) and cisplatin with twice-daily (BID) IMRT during the first and last weeks of treatment. Surgery was planned for 6-8 weeks post-treatment. RESULTS The median follow-up time was 22 months (2-60 months). Fourteen patients had surgery performed with pathological complete response (pCR) in 9 (64%) patients and partial response (pPR) in 5 patients. There were no recurrences in the 9 patients who achieved pCR whereas 3/5 with pPR had local recurrence (p=0.027). Four patients did not have surgery: one patient died a week after treatment while 2 of the remaining 3 patients had local recurrences. Acute desquamative skin reactions in the vulva and perineum were seen in all patients. Three of the 14 patients who had surgery had prolonged wound complications requiring debridement. No patients had radiation-related acute or late toxicity of grade = 3. The 2-year cause specific and overall survivals were 75% and 70% respectively. CONCLUSION Preoperative chemotherapy and IMRT were well tolerated with good clinical response and early clinical outcome. Pathological complete response predicts better outcomes. Prospective clinical trials with sufficient patient numbers and follow-up are needed to determine the true impact of IMRT in these patients.

Brachioplasty and concomitant procedures after massive weight loss: a statistical analysis from a prospective registry.

Background: A growing number of massive weight loss patients are undergoing brachioplasty. The authors analyzed data from a prospective registry of massive weight loss patients who underwent brachioplasty alone or with concomitant operations to identify statistically significant complications. Methods: One hundred one massive weight loss patients underwent brachioplasty. Outcome measures included operative time; time since gastric bypass; need for revision; arm liposuction; and complications such as seroma, dehiscence, hematoma, infection, and nerve injury. Univariate analyses were performed to assess outcome measures. Results: One hundred one patients (97 women and four men; mean age, 45.9 ± 10.1 years; mean body mass index, 29 ± 3.9) with a mean time since gastric bypass of 28.5 months (range, 7 to 252 months) underwent brachioplasty. Ninety-seven patients (96 percent) had concomitant body contouring procedures; 23.8 percent had concomitant arm liposuction; and 36 patients had complications related to their arms, mostly in the form of a seroma, whereas dehiscence, infection, and hematoma were more prevalent with the concomitant procedures. Patients with a greater change in body mass index had a higher chance of wound infection (odds ratio, 1.1; p = 0.028). Longer operative time was associated with increased rates of surgical complications (p = 0.003; odds ratio, 3.8) at the operative site. There was a trend toward increased complications when arm liposuction was combined with brachioplasty (odds ratio, 2.5; p = 0.05). Conclusions: Brachioplasty is a safe and effective method of treating upper arm deformity in the massive weight loss patient. Although patients with greater weight loss are likely to present for longer contouring procedures and are at highest risk for wound-healing complications, these complications occur most frequently in areas other than the arms.

Plastic surgery and smoking: a prospective analysis of incidence, compliance, and complications.

Background: Tobacco use remains a persistent risk factor in elective plastic surgery. Although nicotine is thought to increase complications, which procedures are affected and the reliability of patient-provided histories remain poorly defined. The authors sought to examine nicotine use and its impact on outcomes. Methods: All patients in a single-surgeon practice undergoing surgery with general anesthesia during a 2-year period were enrolled. Preoperative evaluation included a thorough smoking history. All patients had urine samples taken on the day of surgery to assess for nicotine metabolites. Patients were followed for a minimum of 3 months after surgery and monitored for complications. Results: Four hundred fifteen patients were enrolled. Of these, 139 (33.5 percent) stated that they had quit smoking and 39 (9.4 percent) were admitted active smokers. For the 362 patients with urine nicotine analysis available, 54 showed active smoking. Fifteen of these (4.1 percent) had denied current tobacco use. Patients stating that they had quit smoking were more likely to be deceitful than those stating they had never smoked (p < 0.001). Smokers had significantly higher overall complication rates (OR, 3.7; p < 0.001) and tissue necrosis rates (OR, 4.3; p = 0.02) and were likelier to require reoperation (OR, 3.7; p < 0.001). Conclusions: In a large cohort study examining the prevalence and impact of nicotine in the general plastic surgery population, substantial rates of deception regarding smoking status were found. Furthermore, active smoking was strongly correlated with complications. A methodologic approach to the detection and management of patients using tobacco products can help to optimize outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Medial thigh lift in the massive weight loss population: Outcomes and complications

Background: Complication profiles of medial thighplasty in the massive weight loss population are not well described. The authors present their experience with these procedures in the massive weight loss population. Methods: Thighplasty patients from 2003 to 2012 were assessed. Variables included age, sex, body mass index, method of weight loss, comorbidities, and smoking status. Outcomes included seroma, dehiscence, infection, hematoma, edema, and revision. Statistical analysis was performed as appropriate. Results: One hundred six subjects (90 women and 16 men) underwent thighplasty. Fourteen patients underwent horizontal thighplasty, with a complication rate of 43 percent; 24 underwent short-scar thighplasty, with a complication rate of 67 percent; and 68 underwent full-length vertical thighplasty, with a complication rate of 74 percent. Seventy-two subjects (68 percent) had at least one complication. Complications included dehiscence (51 percent), seroma (25 percent), infection (16 percent), and hematoma (6 percent). Overall, 25 patients (23 percent) developed edema, which did not resolve in two patients by 12 months. Hypertension was significantly associated with postoperative seroma (p = 0.02). Age (p = 0.01), hypothyroidism (p = 0.01), and liposuction outside the area of resection (p = 0.025) were associated with postoperative infections. A full-length vertical incision was associated with increased lower extremity edema (p = 0.007). Conclusions: Medial thighplasty has a high rate of minor wound healing problems. Full-length vertical thighplasty is associated with prolonged edema. Concomitant liposuction may also increase complications. Patients should be counseled appropriately about the potential for minor wound healing problems. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Multiple Procedures and Staging in the Massive Weight Loss Population

Background: Unlike traditional plastic surgery patients who present with a specific anatomical complaint, massive weight loss patients often have multiple regions of concern. No single procedure can address the whole-body deformities associated with massive weight loss. The authors sought to quantify their clinical experience to provide evidence-based analysis of procedural combination in body contouring. Methods: Patients were enrolled in an institutional review board–approved prospective clinical database over a 5-year period. Procedure categories included breast, medial thigh lift, buttock and lateral thigh lift, upper back lift, brachioplasty, and abdomen. Analysis of variance was used to analyze differences between procedure combinations. Results: Six hundred nine massive weight loss patients underwent 661 cases involving 1070 procedures. Length of hospital stay increased with the number of procedures performed (p < 0.001). Second-stage cases (n = 60) had similar complication rates and length of hospital stay. Seroma and dehiscence were strongly correlated with the number of procedures (p < 0.001), as were tissue necrosis and infection (p = 0.02), whereas hematoma was unrelated (p = 0.25). Major complications did not increase in multiple-procedure cases. Conclusions: In a large experience at a high-volume center, concomitant procedures were performed safely in carefully selected patients with low major complication rates. Although aggregate minor complication rates were predictably higher than in single-procedure cases, there was no significant increase on a per-procedure basis. Multiple procedures can be combined safely in the body contouring patient, with surgical staging offering a viable alternative for patients who are unable to undergo combined procedures.

Single magnetic resonance imaging vs magnetic resonance imaging/computed tomography planning in cervical cancer brachytherapy.

AIMS To compare differences in dose to the target volume and organs at risk (OARs) for ring and tandem brachytherapy using individualised magnetic resonance imaging (MRI)/computed tomography-based three-dimensional treatment plans for each application vs plans based on a single scan for all fractions. MATERIALS AND METHODS The study was carried out in 10 patients with carcinoma of the uterine cervix, treated with external beam radiotherapy and five fractions of high dose rate brachytherapy. Planning was carried out using MRI for the first fraction and computed tomography for each of the four subsequent fractions. The MRI-based plan was taken as the reference and the single-plan procedure was calculated by using the weights from the reference plan to calculate the dose distribution for each subsequent computed tomography-based plan. The high-risk clinical target volume (HRCTV) and OARs were delineated as per GEC-ESTRO guidelines. Total doses from external beam radiotherapy and brachytherapy were summated and normalised to a 2 Gy fraction size. RESULTS The mean D(90) for the HRCTV was 81.9 Gy when using one plan and 84 Gy when using individual treatment plans. Similarly, the mean D(2 cc) was 75.68 Gy vs 74.99 Gy for the bladder, 55.84 Gy vs 56.56 Gy for the rectum and 64.8 Gy vs 65.5 Gy for the sigmoid. Ring rotation was identified in three patients, resulting in a change in dwell positions, which otherwise could have led to either a high bladder dose or suboptimal coverage of the HRCTV. CONCLUSIONS Our study has shown that a single-plan procedure achieved acceptable dosimetry in most patients. However, the individualised plan improved dosimetry by accounting for variations in applicator geometry and the position of critical organs.

Nutritional assessment of bariatric surgery patients presenting for plastic surgery: a prospective analysis.

Background: Assessment of nutritional status in the growing postbariatric patient population remains controversial. Previous literature suggests that these patients have poor nutrition that may have adverse effects on surgical outcomes. The authors sought to determine the optimal method of nutritional assessment in postbariatric patients. Methods: One hundred patients presenting for body contouring after bariatric surgery were consecutively enrolled in an institutional review board–approved prospective study. A trained nutritionist assessed protein and calorie intake. All patients underwent baseline laboratory assessment. Results: Eighteen percent of subjects had less than the recommended daily protein intake. Hypoalbuminemia was observed in 13.8 percent of subjects, with hypoprealbuminemia in 6.5 percent. Nearly forty percent of all patients had evidence of iron deficiency, with vitamin B12 deficiency present in 14.5 percent. Ten percent of subjects (all women) were confirmed to have iron deficiency anemia. Impaired fasting glucose was seen in 6.2 percent of subjects, whereas 3.6 percent had hemoglobin A1c levels greater than 6.5. Increasing age (odds ratio, 1.07) and greater change in body mass index (odds ratio, 1.11) were predictors of low protein intake. Dumping syndrome led to 13.3 times increased odds of low albumin levels. Conclusions: The results suggest that inadequate nutrition is common among postbariatric patients presenting for body contouring. The lack of correlation between methods of nutritional assessment supports the combination of multiple methods in determining overall nutritional status. The presence of dumping syndrome, a large change in body mass index, and advanced age may help to identify patients with an increased risk of nutritional deficiency.