John D. Renucci

Outcomes of traditional cosmetic abdominoplasty in a community setting: a retrospective analysis of 1008 patients.

Background: Abdominoplasty is one of the most commonly performed cosmetic operative procedures. Few large studies have examined outcomes of cosmetic abdominoplasty in a community setting. The authors explored postoperative outcome and the preoperative and intraoperative factors that may contribute to these complications. Methods: A retrospective review of consecutive patients undergoing abdominoplasty over an 11-year period was performed. Baseline patient demographics, intraoperative technique, and postoperative outcomes were recorded. Preoperative and intraoperative characteristics were analyzed to determine characteristics that predispose patients to complications and undesirable outcomes. Results: The 1008 study patients underwent either a full or modified abdominoplasty with a total complication rate of 32.6 percent. The most common complication was seroma (15.4 percent). Liposuction of the abdominal flap was performed in 469 patients (46.5 percent) and liposuction of the flanks was performed in 555 patients (55.1 percent). Chi-square analysis followed by logistic regression revealed that liposuction of the flanks and abdomen was independently associated with seroma formation in addition to major and minor complications (p < 0.05). Conclusions: Seroma formation following abdominoplasty is the most common complication. Concomitant liposuction of the flanks and abdomen with the addition of aggressive undermining leads to higher seroma rates. This association is likely multifactorial and may be secondary to increased resorptive demands placed on the abdominal lymphatics in the setting of greater dead space and larger fluid shifts as a result of liposuction. To reduce seroma rates, surgeons should avoid aggressive liposuction and undermining, particularly in high-risk patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Brachioplasty outcomes: a review of a multipractice cohort.

Background: Upper arm deformities secondary to massive weight loss or senile elastosis have led to an increased demand for aesthetic contouring procedures such as brachioplasty. Methods: The records of all patients who underwent a brachioplasty procedure from a multipractice medical center were reviewed. Outcomes measured included patient demographics, operative interventions, and postoperative course. Results: Ninety-six patients were analyzed. Fifty-three patients (55.2 percent) underwent a concomitant procedure, with 53.1 percent undergoing arm liposuction at the time of brachioplasty. Major and minor complications rates were 17.7 percent and 44.8 percent, respectively. Common complications included hypertrophic scarring (24.0 percent) and infection (14.6 percent). The total revision rate was 22.9 percent, with residual contour deformity (40.9 percent of revisions) and hypertrophic scarring (36.4 percent of revisions) representing the most common causes for revision. Patients who underwent a previous bariatric procedure were at an increased risk of developing a major complication (p = 0.02). Concomitant upper arm liposuction and concomitant procedures were not associated with a significantly increased complication rate. Conclusions: Brachioplasty, despite being an effective treatment for contour irregularities of the upper arm, is associated with significant revision and complication rates. Post–bariatric surgery patients should be informed of the potential for increased complications. Additional procedures performed at the time of brachioplasty do not significantly increase complications. Liposuction of the upper arm can be performed safely in conjunction with brachioplasty.

Cosmetic Rhinoplasty: Revision Rates Revisited

BACKGROUND Cosmetic rhinoplasty has great potential to change a patients appearance. It also carries the very real risk of patient dissatisfaction and request for revision. Although there have been many published patient series studying various aspects of rhinoplasty, questions remain regarding revision rates, as well as risk factors for complications, dissatisfaction, and revision. OBJECTIVES The authors investigate the rate of cosmetic rhinoplasty revision at a plastic surgery group practice and identify risk factors for revision. METHODS Medical records were retrospectively reviewed for all patients who presented to a single multisurgeon practice for primary rhinoplasty, septorhinoplasty, and revision rhinoplasty between 1998 and 2008. Patient demographics, preoperative complaints, preoperative physical examination findings, detailed operative data, and postoperative outcomes were abstracted from the charts. Complication rates, revision rates, and postoperative patient satisfaction were calculated and analyzed for identifiable risk factors. RESULTS Of 369 consecutive cosmetic rhinoplasties performed during the study period, 279 (72.7%) were conducted with an open approach. The overall complication, dissatisfaction, and revision rates were 7.9%, 15.4%, and 9.8%, respectively. Postoperatively, most patients (87%) were identified by their surgeons as having had successful anatomical correction of their nasal deformity. History of previous nasal operation or facial fracture, lack of anatomical correction, and occurrence of postoperative complications were associated with both revision and dissatisfaction (P < .05). Failure to address the nasal tip at the time of primary rhinoplasty was associated with a higher level of dissatisfaction. CONCLUSIONS Cosmetic rhinoplasty is one of the most challenging procedures in plastic surgery; however, these data indicate that a high level of patient satisfaction is attainable within a plastic surgery group practice if certain factors are considered. Specifically, surgeons should be aware of risk factors that are potentially associated with dissatisfaction and revision. LEVEL OF EVIDENCE 4.

Outcomes of Fractional CO2 Laser Application in Aesthetic Surgery: A Retrospective Review

BACKGROUND Despite the effectiveness of ablative CO(2) laser resurfacing for facial rejuvenation, its application has been limited owing to an undesirable side-effect profile, including prolonged hyperemia and potential pigmentary changes. However, newer fractional CO(2) laser technology has reduced the recovery time and led to decreases in postprocedural hypo- and hyperpigmentation. OBJECTIVES The authors investigate the application and outcomes of ablative fractional technology in a private cosmetic surgery practice. METHODS In this retrospective cohort study, the charts of patients who received fractional CO(2) laser resurfacing between March 2007 and May 2008 were reviewed. Data regarding patient demographics, pretreatment regimens, detailed operative data, and posttreatment findings were obtained. The length of hyperemia (less than five weeks, five to eight weeks, and more than eight weeks), complication rates, and revision rates were analyzed. A satisfaction survey was also sent to all patients. RESULTS Throughout the 19-month study period, 97 patients received 101 treatments with an average follow-up of 4.5 months. Full-face laser resurfacing was performed in 81.1% of patients, with 64.3% receiving their treatment under local anesthesia without sedation. Length of hyperemia was less than five weeks in 93%, five to eight weeks in 5.9%, and more than eight weeks in 0.9% of patients. Hyperpigmentation (9.9%), milia (6.9%), acne breakout (5.9%), and transient ectropion (0.9%) were less common. Patient satisfaction surveys revealed that a majority of patients were satisfied with their results. CONCLUSIONS New fractional CO(2) laser skin resurfacing is associated with shorter periods of hyperemia, resulting in shorter recovery time in comparison with older ablative technology. The side-effect profile is minor and infrequent. This new technology provides significant clinical improvement with high patient satisfaction.

Vertical Reduction Mammaplasty Utilizing the Superomedial Pedicle: Is It Really for Everyone?

BACKGROUND Classically, the vertical-style reduction mammaplasty utilizing a superomedial pedicle has been limited to smaller reductions secondary to concerns for poor wound healing and nipple necrosis. OBJECTIVES The authors reviewed a large cohort of patients who underwent a vertical-style superomedial pedicle reduction mammaplasty in an attempt to demonstrate its safety and efficacy in treating symptomatic macromastia. METHODS A retrospective review was performed of 290 patients (558 breasts) who underwent a vertical-style superomedial pedicle reduction mammaplasty. All procedures were conducted by one of 4 plastic surgeons over 6 years (JDR, MAA, DLV, DRA). RESULTS The average resection weight was 551.7 g (range, 176-1827 g), with 4.6% of resections greater than 1000 g. A majority of patients (55.2%) concomitantly underwent liposuction of the breast. The total complication rate was 22.7%, with superficial dehiscence (8.8%) and hypertrophic scarring (8.8%) comprising the majority. Nipple sensory changes occurred in 1.6% of breasts, with no episodes of nipple necrosis. The revision rate was 2.2%. Patients with complications had significantly higher resection volumes and nipple-to-fold distances (P = .014 and .010, respectively). CONCLUSIONS The vertical-style superomedial pedicle reduction mammaplasty is safe and effective for a wide range of symptomatic macromastia. The nipple-areola complex can be safely transposed, even in patients with larger degrees of macromastia, with no episodes of nipple necrosis. The adjunctive use of liposuction should be considered safe. Last, revision rates were low, correlating with a high level of patient satisfaction.

Prophylactic sternal plating with pectoralis advancement flaps after sternotomy in patients with a history of chest irradiation

Deep sternal infections secondary to bony instability and malunion, can result in mediastinitis. Previous authors have described the use of prophylactic rigid plate fixation in high-risk patients. The purpose of our study is to review the use of prophylactic sternal platting with pectoralis advancement flaps in high-risk patients with a history of chest irradiation. Fourteen patients (July 2003-September 2008) with a history of chest irradiation who underwent a median sternotomy followed by prophylactic rigid plate fixation of the sternum were reviewed. Breast cancer was the most common etiology of chest irradiation (n=11, 78%). The average EuroSCORE was 24.06% with 72% of patients having a preoperative New York Heart Association (NYHA) class≥III. There were no episodes of sternal non-union, mediastinitis or death. Follow-up was 100% with a 0% 30-day and a 7.1% one-year mortality rate (non-cardiac). A comparison between mean preoperative left ventricular ejection fraction (LVEF) (49.6%) and postoperative LVEF (59.7%) was statistically significant (P<0.0001). All living patients currently maintain a NYHA class I/II. Prophylactic rigid plate fixation and pectoralis flap coverage decreases the risk of developing sternal dehiscence and postoperative wound complications and should therefore be considered in high-risk patients with a history of chest irradiation.

Reduction of post-surgical scarring with the use of ablative fractional CO2 lasers: A pilot study using a porcine model.

Wound healing inevitably leads to scarring, which leads to functional and cosmetic defects. It is the goal of this study to investigate the immediate use of ablative fractional CO2 lasers to reduce post‐operative scarring secondary to surgical wounds.