Hisham Seify

Validating three-dimensional imaging of the breast.

The potential to extrapolate accurate data from 3-dimensional (3D) images of the breast is enormous and will greatly improve our ability to qualitatively determine differences in shape, size, and contour. The validity of these calculated measurements is important and needs to be determined before any meaningful data can be evaluated. Part I:Premastectomy 3D images (3dMD patient) were obtained on 19 breasts (14 patients). The volume of the mastectomy specimen was determined intraoperatively using water displacement. Two independent raters then calculated breast volumes using the 3D images and software, and these were compared with the intraoperative volume. Inter- and intrarater reliability was determined. Part II: Surface measurements (nipple to notch) were then evaluated on 20 breasts (10 patients) by comparing the 3D image determined distance to the known measurements. Part I:The average breast volume was 500 mL, compared with 489 mL for rater 1 and 490 mL for rater 2. The relative difference between the measured volume and the calculated volume for rater 1 and rater 2 was about −2%, with a standard deviation of ± 13% to 16%. The coefficient of reproducibility for each reader was excellent, at 0.80 for rater 1 and 0.92 for rater 2. The level of agreement between the readers was also high at 0.975. Part II: The average nipple to notch measurement for each patient was 27.1 cm, compared the calculated average of 25.1 cm for rater 1 and 26.1 cm for rater 2. The mean relative difference between the measured and calculated distances for raters 1 and 2 was about −6%, with a standard deviation of ± 6% to 7%. The level of agreement between readers was high, at 0.975. The ability to objectively determine breast volume and surface measurements using 3D imaging technology is now available with consistent and reproducible accuracy. Measurements are typically underestimated, with more variability when calculating volumes. Although inherent subjectivity will always exist when evaluating breast measurements, 3D technology provides invaluable information, particularly in the longitudinal evaluation of results.

The role of muscle flaps in wound salvage after vascular graft infections: the Emory experience.

Background: The incidence of prosthetic graft infection is 1 to 6 percent, and the mortality rate of infected aortoiliac or aortofemoral bypass is 25 to 75 percent. The goal of this study was to report the use of muscle flaps in the management of patients presenting with infected vascular grafts. Methods: A total of 22 patients required 26 muscle flaps to cover 24 infected vascular grafts. Muscle flaps were used for local wound control in all patients regardless of the fate of the graft. The vascular surgeons elected for graft salvage in eight of the 24 grafts. All of the muscle flaps survived. Results: The average time interval between the bypass and infection was 371 days. One-month follow-up revealed an 88 percent salvage rate, but this decreased to 50 percent during the mean follow-up of 23 months. None of the patients originally managed with a salvaged graft lost a limb, and overall, 14 of 22 limbs in this series remained viable (64.0 percent). The mortality rate during the index hospitalization was 9 percent. In this series, suprainguinal grafts had a higher mortality rate. In addition, infection occurring more than 1 month postoperatively, culture-positive Pseudomonas and methicillin-resistant species, and exposure of the arterial-graft anastomosis were poor prognostic indicators of graft preservation. Conclusions: Management of infected vascular grafts remains a challenging problem. Muscle flap coverage should have a high priority, as the chance of a good outcome is highly favorable in early infections.

Improvement of TRAM flap viability using human VEGF-induced angiogenesis: a comparative study of delay techniques.

Despite the success with transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, ischemia-related complications, including fat necrosis and partial flap loss, continue to occur in 5 to 28 percent of reported series. The associated vascular problems of the TRAM flap stimulated several authors to study the effect of surgical delay, aiming to improve the viability of the flap. The present study investigated the potential effect of human vascular endothelial growth factor (hVEGF) in the induction of angiogenesis in the TRAM flap model and compared its effect with the surgical delay model. The rat model was used to demonstrate the effect of VEGF angiogenesis. Thirty male Sprague-Dawley rats were individually assigned to one of six groups (n = 5 in each group). One control group and five delay groups were established. A variety of flap delay techniques were used to increase the viable surface area of the flap. The flap mean viable surface area for the control group was 50 percent. The surgical delay group (group 2) had a mean viability of 83 percent. The group with the highest percentage of viable flap surface area was group 3, in which both surgical delay and intramuscular injection of VEGF were used (96.6 percent mean flap viability). The mean viable flap surface area in groups 4 (surgical delay and intraarterial VEGF), 5 (intramuscular VEGF), and 6 (intraarterial VEGF) were 90.6 percent, 87 percent, 90.6 percent, respectively. Statistically significant differences were obtained in all groups in comparison to the control group (p < 0.05). No significant differences were seen among the five treatment groups, however. The findings reported in the present study indicate that the use of VEGF to improve the viability of the TRAM flap proved to be beneficial and statistically significant in comparison to the control group.

Transblepharoplasty ptosis repair: three-step technique.

Background: The ability to predict postoperative lid levels in ptosis surgery has been refined over the years, but there is no completely predictable formula with which to predict the final tension in the upper lid that determines the final upper lid level. A significant percentage of patients continue to require postoperative surgical revision. The authors studied the effectiveness of a technique for the quantitation of aponeurotic repair that is not a measured resection procedure, does not require voluntary patient cooperation, and can be performed under general anesthesia. Methods: The surgical technique involves reapproximation of specific anatomical landmarks, adjustment of upper lid level by eyelid gapping, and adjustment of upper lid tension with a spring-back test. Consecutive patient charts were reviewed retrospectively for age, sex, clinical examination, levator function, and outcomes, including revision rate and patient satisfaction. A total of 144 procedures were performed for 80 patients (64 bilateral and 16 unilateral). The series was reported for a 3-year period (2002 through 2005). The mean age was 62 years (range, 40 to 85 years). The average follow-up was 18 months. All patients had acquired adult ptosis with levator dehiscence and good levator function. Results: The criterion for surgical revision was a greater than 1-mm asymmetry between the eyelids or patient dissatisfaction. Twelve patients (15 percent) were considered to be slightly asymmetric postoperatively, but only two (2.5 percent) exceeded the criterion and required surgical revision in the early postoperative period (<1 year). Conclusion: Tarso levator surgery can be performed under general anesthesia using a three-step technique to correct ptosis with a superior predictability.

Salvage of infected spinal hardware with paraspinous muscle flaps : Anatomic considerations with clinical correlation

Purpose:Infected spinal stabilization devices represent a significant reconstructive challenge by threatening spinal stability and increasing the risk of neurologic complications. This study provides an anatomic and clinical investigation of posterior midline trunk reconstruction using paraspinous muscle flaps as the primary method of repair. Methods:We retrospectively analyzed a series of 25 consecutive patients (mean age, 57.2 years; range, 32–78 years) with complex spinal wounds, reconstructed with paraspinous muscle flaps, at a single university healthcare system. To help define the versatility of these muscle flaps, we also performed cadaveric dissections with lead oxide injections in 10 specimens, with an emphasis on regional blood supply, flap width, and arc of rotation. Results:From 1994 to 2000, we successfully reconstructed 25 patients with complex spinal wounds, using 49 paraspinous muscle flaps as the primary method of reconstruction. Hardware present in 22 patients was replaced or retained in 17 cases. Long-term spinal fusion with preservation of neurologic status was observed in all patients, with no cases of dehiscence or reinfection. Wound complications included cerebrospinal fluid leak (1), skin necrosis (1), sinus tracts (3), and seroma (2). Mean length of stay was 24 days (range, 8–57 days). One postoperative death occurred. Paraspinous dissections and injections confirmed a segmental type IV blood supply with medial and lateral perforators, arising from intercostal vessels superiorly and lumbar and sacral vessels inferiorly. Flap width was 8 cm at the sacral base, 5 cm at the level of the inferior scapular angle, and 2.5 cm at the first thoracic vertebra. Conclusions:Paraspinous muscle flaps can be used as the primary reconstructive option to cover and preserve spinal hardware, control local infection, and enable long-term spinal stabilization. Cadaveric dissections confirmed the usefulness of paraspinous flaps, which can be based upon lateral or medial perforators and can be safely mobilized to reliably reconstruct complex spinal wounds.

Effect of vascular endothelial growth factor-induced angiogenesis on TRAM flap harvesting after abdominoplasty.

In this study, the effect of intramuscular injection of human vascular endothelial growth factor (hVEGF) on neovascularization following abdominoplasty was investigated. Twenty-four Sprague-Dawley rats were divided into four groups (n = 6). Two control groups and two experimental groups were established. Abdominoplasty was performed in all rats, with division of all the perforator vessels. In the control groups, normal saline was injected into the rectus abdominis muscle, and in the experimental groups, 100 microg of VEGF and normal saline were injected into the rectus muscle. A transverse rectus abdominis musculocutaneous (TRAM) flap was harvested on day 20 and day 40 in both the control and experimental groups. The range of viability of the TRAM flap was, respectively, 0 to 20 percent (mean, 6.7 percent) and 0 to 25 percent (mean, 14.2 percent) in both short-term and long-term control groups (no VEGF injected). The study (VEGF) group demonstrated a viability of 50 to 80 percent (mean, 70 percent) for the short-term group and 50 to 85 percent (mean, 72.5 percent) in the long-term group. No wound infection was documented, and there were no deaths during the study period. There was no statistically significant difference between the short-term and long-term divisions of the groups (p < 0.01); however, significant differences were observed between the control and experimental groups (p < 0.01). The authors concluded that VEGF injection after abdominoplasty improved the percentage of TRAM flap viability. This method of delay/revascularization could be used for the difficult problem of flap viability following abdominoplasty and for high-risk patients.

Single-stage muscle flap reconstruction of the postpneumonectomy empyema space: the Emory experience.

Background: Postsurgical chronic empyema continues to present a complicated treatment scenario for thoracic and reconstructive surgeons. Muscle flaps are an important option in the management of complex thoracic wounds. This study was designed to report the Emory experience with muscle flaps for the management of complex postsurgical empyema. The authors also present their treatment algorithm for managing empyema thoracis. Methods: The authors retrospectively reviewed the charts of 55 patients requiring different treatment modalities, including muscle flap transposition. Patients were divided into four groups according to the initial thoracic procedure: group A, no surgical resection; group B, postpneumonectomy; group C, postlobectomy; and group D, prophylactic postpneumonectomy or postlobectomy. The study included 42 men (76.4 percent) and 13 women with a mean age of 62 years (range, 39 to 77 years). Results: Fifty-one muscle flap procedures were performed in 42 patients (serratus anterior flaps, 16 patients and 23 flaps; latissimus dorsi flaps, 16 patients and 18 flaps; pectoralis major muscle flaps, intercostal muscle flaps, and rectus abdominis flaps, three patients each: omental flap, one patient). The mean number of ribs resected before flap intervention, usually during the open window thoracostomy, was three. The average time from initial thoracic operation to flap intervention was 4 months. Average time from flap intervention to discharge was 12.5 days. Average hospital stay was 26.6 days. The 51 muscle flaps represented an average of 1.2 procedures per patient. Conclusion: Because of the excellent blood supply of extrathoracic muscle flaps and their ability to reach any place in the pleural cavity, they represent an ideal tissue with which to fill the contaminated pleural space.

The 3-hour muscle-sparing free TRAM flap: safe and effective treatment review of 111 consecutive free TRAM flaps in a private practice setting.

Background: The muscle-sparing free transverse rectus abdominis muscle (TRAM) flap is a reliable technique that provides great versatility, with potentially decreased donor-site morbidity. However, because of the inherent nature of microvascular techniques, it is still regarded as a time-consuming and technically difficult procedure. The goal of this retrospective study was to document the validity of this technique in the private practice setting. Methods: Data were reviewed retrospectively and included patient demographics, total operative time, choice of recipient vessels, outcome, and perioperative morbidities. Results: One hundred one consecutive patients underwent 111 muscle-sparing free TRAM flap procedures for breast reconstruction (immediate, 89 patients; delayed, 12 patients).The internal mammary artery was used in 75 cases and the thoracodorsal artery was used in 36 cases. Average operative time was 185 minutes (3 hours 5 minutes). Average blood loss was 195 cc. There was no total flap loss. Revision of the microvascular anastomosis was performed in four patients, with flap salvage in all of them. Thirteen patients (13 percent) required primary mesh for abdominal wall closure. Fourteen (14 percent) had fat necrosis. Two patients had hematoma that required surgical evacuation. Abdominal wall weakness was detected in two patients (2 percent) and required mesh repair. Conclusions: The technical difficulties associated with the free TRAM flap have been ameliorated using a well-designed surgical plan and consistent technique performed by a team familiar with the procedure to achieve an acceptable average 3-hour operating time, with minimal complications. The authors advocate the muscle-sparing free TRAM flap as the operation of choice for unilateral breast reconstruction using autogenous tissue. The technique is expeditious and relatively safe.

Endoscopic harvest of four muscle flaps: Safe and effective techniques

The recent explosion of endoscopic techniques in plastic surgery has led to the successful harvest of a number of useful muscle flaps. The gracilis, rectus femoris, external oblique, and gastrocnemius muscles can all be harvested safely and reproducibly using endoscopic techniques. The aim of this study was to identify a safe and effective technique for endoscopic muscle flap harvest. Harvesting the gracilis muscle as a free flap and the gastrocnemius as a pedicle flap lends themselves best to the use of endoscopic techniques.

Endoscopic-Assisted Face Lift: Review of 200 Cases

The use of endoscopic techniques in facial esthetic surgery has gained increasing popularity in the last decade. Endoscopic forehead rejuvenation became a reliable technique and an attractive option for both the surgeon and the patient. The use of the endoscope in face and neck lift surgery did not gain the same popularity, as explained by the relative few indications for this technique. In this study, we retrospectively review a series of 200 patients who underwent endoscopic-assisted face-lifts alone or in combination with other esthetic procedures. We divided the patients into 4 groups according to the type of incisions and the surgical approach used in each of them. We also reviewed the current status of using the endoscope in face and neck lift surgery. The technique described in this study uses limited access incisions (limited postauricular, submental, and temporal scalp) to reposition the ptotic facial elements, while avoiding the preauricular and postauricular scarring when indicated. Under endoscopic visualization, the composite face-lift flap elevates the malar fat pad above the zygomaticus muscle to the nasolabial fold. The lower-lid orbicularis oculi muscle is incorporated and lifted with composite flap through the lower blepharoplasty incision. The jowl area is contoured by tangential excision and tightening of the lateral platysma. Pretunneling and hydrodissection defines the plane of dissection and helps to reduce the bleeding during facial and cervical flap elevation. In this study, endoscopic techniques were applicable in selected patients undergoing facial rejuvenation with goals of decreased scarring. Indications for using the technique include young patients (eg, less than 50 years) with a relatively small amount of skin excess or older patients with thick skin and minimal skin redundancy. The technique is particularly attractive to the male patient, by avoiding the preauricular incision and the disruption of the beard line. Patients with excess skin underwent the standard cervicofacial incision. In this group the endoscope was used as a tool for better magnification and illumination.