Jorge I. de la Torre

Open Repair of Ventral Incisional Hernias

Despite advances in many fields of surgery, incisional hernias still remain a significant problem. There is a lack of general consensus among surgeons regarding optimal treatment. A surgeons approach is often based on tradition rather than clinical evidence. The surgeons treatment plan should be comprehensive, with attention focused not merely on restoration of structural continuity. An understanding of the structural and functional anatomy of the abdominal wall and an appreciation of the importance of restoring dynamic function are necessary for the successful reconstruction of the abdominal wall.

Abdominoplasty with Total Abdominal Liposuction for Patients with Massive Weight Loss

BackgroundMassive weight loss after bariatric surgery is associated with significant skin excess, laxity, and ptosis over the abdomen. Good results have been achieved with abdominoplasty and circumferential lipectomy. However, blood transfusions are sometimes needed, and patients may require long hospital stays. Furthermore, morbidity rates are high. Total abdominal liposuction performed with abdominoplasty allows for the preservation of lymphatic vessels below Scarpa’s fascia and eliminates the need for upper flap undermining. This study aimed to evaluate this technique in patients with anterior abdominal redundancy attributable to massive weight loss after bariatric surgery.MethodsThe charts of 60 patients treated between December 2001 and October 2004 were retrospectively reviewed. All the patients had undergone previous bariatric surgery as well as subsequent total abdominal liposuction and abdominoplasty.ResultsThe average amount of wetting solution used was 3.1 l, and the average total aspirate was 2.5 l. The mean pannus weight was 3,649 g, and the average dimension was 48 × 25 × 6 cm. No patient required a blood transfusion. The median in-hospital stay was 1 day, with 42% of the patients treated as outpatients. The median follow-up period was 3 months. Morbidity was 22%. Factors associated with the development of complications were weight of the pannus, transverse dimension of the pannus, and body mass index. All the patients were satisfied with the results.ConclusionsTotal abdominal liposuction followed by abdominoplasty is adequate treatment for anterior abdominal redundancy for patients with massive weight loss.

Surgical anatomy of the midface as applied to facial rejuvenation.

Distinct anatomic structures provide attachments and support for the soft tissues of the central third of the face. Over time, laxity of these structures and descent of the malar fat pad contribute to the characteristic changes seen in the aging face. Mobilization of the midface soft tissues to allow reelevation of the malar fat pad is an effective method of rejuvenating the midface. A focused anatomic dissection of 8 fresh cadaver heads was performed to evaluate 4 soft-tissue structures that control mobilization of the malar fat pad. Specifically, the orbicularis retaining ligaments, the lateral orbital thickening, prezygomatic space, and zygomatic cutaneous ligaments were evaluated. The anatomic relationship of these structures explains the visible effect of aging in the central third of the face. In addition, it correlates with the outcomes of surgical rejuvenation as demonstrated in clinical cases. Effective repositioning of the malar fat pad was found to be reliably obtained by release of the lateral orbital thickening and the orbital retaining ligaments. Suspension of the malar soft tissue is in a cephalad direction after release of these structures recreates a youthful facial architecture. Motor nerve injury is less likely to occur with this technique than with traditional lateral facelift approaches. The conclusion reached is that ptosis of the malar fat pad can be corrected safely and effectively utilizing either the lower lid blepharoplasty approach or temporal prehairline incision. These findings were consistent with clinical data from facial rejuvenation procedures.

Strategies to enhance transductional efficiency of adenoviral‐based gene transfer to primary human fibroblasts and keratinocytes as a platform in dermal wounds

Genetically modified keratinocytes and fibroblasts are suitable for delivery of therapeutic genes capable of modifying the wound healing process. However, efficient gene delivery is a prerequisite for successful gene therapy of wounds. Whereas adenoviral vectors (Ads) exhibit superior levels of in vivo gene transfer, their transductional efficiency to cells resident within wounds may nonetheless be suboptimal, due to deficiency of the primary adenovirus receptor, coxsackie‐adenovirus receptor (CAR). We explored CAR‐independent transduction to fibroblasts and keratinocytes using a panel of CAR‐independent fiber‐modified Ads to determine enhancement of infectivity. These fiber‐modified adenoviral vectors included Ad 3 knob (Ad5/3), canine Ad serotype 2 knob (Ad5CAV‐2), RGD (Ad5.RGD), polylysine (Ad5.pK7), or both RGD and polylysine (Ad5.RGD.pK7). To evaluate whether transduction efficiencies of the fiber‐modified adenoviral vectors correlated with the expression of their putative receptors on keratinocytes and fibroblasts, we analyzed the mRNA levels of CAR, αυ integrin, syndecan‐1, and glypican‐1 using quantitative polymerase chain reaction. Analysis of luciferase and green fluorescent protein transgene expression showed superior transduction efficiency of Ad5.pK7 in keratinocytes and Ad5.RGD.pK7 in fibroblasts. mRNA expression of αυ integrin, syndecan‐1 and glypican‐1 was significantly higher in primary fibroblasts than CAR. In keratinocytes, syndecan‐1 expression was significantly higher than all the other receptors tested. Significant infectivity enhancement was achieved in keratinocytes and fibroblasts using fiber‐modified adenoviral vectors. These strategies to enhance infectivity may help to achieve higher clinical efficacy of wound gene therapy.

Midface anatomy, aging, and aesthetic analysis.

This article reviews the key anatomic structures in the region of the midface, including important surface and bony landmarks, innervation, blood supply, muscle layers, and fat compartments. It also discusses changes in these structures related to the aging process and aesthetic analysis of the midface to aid with operative planning.

Reconstruction of Knee Defects Using Pedicled Gastrocnemius Muscle Flap with Split-Thickness Skin Grafting: A Single Surgeon's Experience with 21 Patients

&NA; Generally, reconstruction of knee defects with exposed bone, joint, tendon, and/or hardware requires a vascularized muscle flap for coverage. Although there are several surgical options for a knee defect reconstruction, the pedicled gastrocnemius muscle still remains the workhorse flap. Although this flap is commonly used for knee defect reconstruction and the technique is described very well, there is an absence of information in the literature detailing the technique of harvesting and insetting of the gastrocnemius flap step by step with illustrations. The purpose of this article is to describe in detail the technique to reconstruct defects of the knee with pedicled gastrocnemius muscle flap as well as to present demographics and surgical results of 21 patients who had knee reconstruction with a pedicled gastrocnemius muscle flap and split‐thickness skin grafting.

Endoscopic Forehead Lifting

The methods for forehead lifting can be classified as en-doscopic, open, or combined (biplanar) (Fig. 57.1). The procedure is not standardized and there is a wide varia-tion of the techniques (Fig. 57.1) [1–11]. Endoscopic brow lifting is one of the first clinical applications of the endoscope in plastic surgery. There are many advan-tages of endoscopic brow lifting, including avoidance of most of the problems associated with the coronal approach such as increased operative time, long scalp scar, scalp dysesthesia, and alopecia. It is a minimally invasive technique and is simple to perform in expe-rienced hands. It offers fast recovery and can easily be combined with other facial procedures and can be used as a safe secondary procedure.