Juan Angelats

Prediction of postoperative seroma after latissimus dorsi breast reconstruction

Background: The latissimus dorsi flap has become a first-line option in reconstruction of the breast cancer patient. Donor-site seroma is a commonly described postoperative complication of the latissimus dorsi flap. Methods: A retrospective chart review from 1998 to 2003 of all patients undergoing latissimus dorsi breast reconstruction was performed (n = 50). Age of the patients, timing of breast reconstruction, type of nodal dissection (axillary versus sentinel versus none), and chemotherapy status of the patients were examined. Results: The overall incidence of seroma formation was 47 percent. Those patients who had undergone prior or concurrent nodal dissection at the time of breast reconstruction were found to have a higher incidence of seroma formation than patients who had no nodal dissection (52 percent versus 25 percent ) (p = 0.15). Age also was a risk factor for seroma formation, as 63 percent of patients older than 50 had formed seroma as compared with 39 percent of those younger than age 50 (p = 0.08). Conclusion: The authors conclude that advanced age and the presence of nodal disruption before or concurrent with latissimus dorsi breast reconstruction are predictors of donor-site seroma formation.

Upper and lower lip reconstruction using the step technique

The step technique for lip reconstruction is a simple, flexible, one-stage operation that allows reconstruction of full-thickness defects spanning up to two-thirds of the lower lip and, in our experience, one-half of the upper lip without violating the opposite lip or using distant advancement flaps.Twelve patients, ranging in age from 24 to 86 years, underwent full-thickness lip excisions for squamous cell and deeply invading basal cell carcinomas. Reconstruction was achieved by advancing the remaining lateral lip elements to close the defects in a stepwise fashion without violating the remaining orbicularis oris muscle.All patients had a symmetrical, mobile, oral sphincter with intact commissures, adequate buccal sulcus, no symptomatic microstomia, and normal sensation at the completion of the procedure. There have been no recurrences in a nine-month to four-year follow-up, and satisfactory aesthetic results were achieved.

SURGICAL TREATMENT OF HIDRADENITIS SUPPURATIVA OF THE AXILLA

We review our surgical experience with hidradenitis suppurativa of the axilla at Cook County Hospital during the years 1963 to 1972. The operation for this entity described by Pollock et al has (1) reduced the length of hospitalization, (2) increased the rate of primary healing and reduced the period of secondary healing, (3) allowed a great amount of tissue to be excised, (4) permitted both axillae to be operated on at once (without incapacitating the patient), (5) avoided the need for skin grafting, and (6) has had less morbidity for those patients in whom primary healing is not achieved. We believe the method reported by Pollock et al is now the treatment of choice for this disease.

Assessing the safety and efficacy of combined abdominoplasty and gynecologic surgery.

Background:Combined surgery is an attractive option for both patients and surgeons. Unfortunately, it remains unclear to patients whether plastic surgery can be combined safely and efficaciously with other surgeries, particularly gynecologic surgery. The goal of this study was to determine the safety and efficacy of combined abdominoplasty and gynecologic surgery. Methods:A case-control study of 25 patients undergoing combined abdominoplasty and intra-abdominal gynecologic surgery was performed. These combined patients were compared with control group patients undergoing abdominoplasty alone and gynecologic surgery alone. Demographic data, operative time, estimated blood loss, pre- and postoperative hemoglobin, length of hospitalization, and complications were compared between combined and control groups. Results:Statistically significant reductions were seen in operative time, estimated blood loss, and total days of hospitalization when comparing the combined group to the sum of the control groups. In this study, no major complications, including the need for blood transfusion or pulmonary embolus, were noted in any of the patients. Conclusions:These results demonstrate success in performing abdominoplasty with gynecologic surgery, which may be an acceptable option for patients.

A full nasal skin rotation flap for closure of soft-tissue defects in the lower one-third of the nose.

Large soft-tissue defects in the lower one-third of the nose challenge the reconstructive surgeon both technically and aesthetically. Many procedures have been described previously that close the wound with varying degrees of color and texture match. We present a modified nasal rotation flap that closes large soft-tissue defects of the lower one-third of the nose in a single stage with minimal donor-site morbidity and a pleasing aesthetic result.

Latissimus dorsi myocutaneous flap in Poland syndrome.

We present a new approach to the old problem of congenital chest wall malformation—an approach that is anatomically reliable, physiologically sound, and cosmetically pleasing. The procedure used the patients own tissues, thus avoiding the problems associated with the use of a foreign body, such as a silicone mammary implant. In addition, no loss of muscle mass is seen due to the retention of the normal neurovascular supply to the latissimus dorsi muscle.

Modified autogenous latissimus breast reconstruction and the box top nipple.

During the past 3 years, the authors have been using the modified autogenous latissimus myocutaneous flap (MALF) for breast reconstruction in increasing numbers because of occasional patient and surgeon dissatisfaction with other methods of breast reconstruction. They have found this method to have unprecedented reliability, making it preferable to other forms of reconstruction in many patients. Considering the very low morbidity, the high patient satisfaction, and current economic factors, the authors are strong advocates of this form of reconstruction. A procedural outline proposed by McCraw and coworkers is followed, with some useful modifications. An elliptical transverse skin paddle is centered over the back fat roll. The area of the skin ellipse measures approximately 8 ± 2 cm vertically and 30 ± 5 cm transversely. After making the skin incision, a feathering technique is used in all directions through the fatty layer overlying the latissimus and in the tissue beyond the anteroposterior borders of the latissimus (not beyond 5 cm from the skin incision). By means of feathering, the shape of a breast mound can be created in the allowable tissue supported by the latissimus. A 180-degree rotation of the flap allows dependent venous drainage and more bulk in the inferior outer quadrant, where it is needed. In the current series of 47 modified autogenous latissimus breast reconstructions, seromas were common. Other complications included one wound infection, one ulnar neuropraxia, and one fat necrosis. There were no flap necroses (partial or complete) or hematomas. The rarity of complications supports the use of this technique in selected patients. An innovative new technique for nipple reconstruction is also described. The “box top technique” of nipple reconstruction consists of four deepithelialized local flaps covered with a skin graft from the groin. (Plast. Reconstr. Surg. 106: 763, 2000.)

Biplanar flap reconstruction for pressure ulcers: experience in patients with immobility from chronic spinal cord injuries

BACKGROUND Surgical therapy for advanced-stage pressure ulcers recalcitrant to healing is a widely accepted practice. The present study examined the incidence of wound recurrence after reconstruction with fasciocutaneous versus combined (biplanar) muscle and fasciocutaneous flaps. METHODS A retrospective review identified 90 nonambulatory patients with spinal cord injury who underwent reconstruction for persistent decubitus ulcers from 2002 to 2008. Electronic medical records were surveyed for patient comorbidities and postoperative complications. Statistical methods included the Fisher exact test and the Mann-Whitney U test with a 2-sided P value of less than .05. RESULTS Among 90 patients reviewed, 33% (n = 30) received fasciocutaneous flaps and 66% (n = 60) underwent biplanar reconstruction. Comorbidities were the same between cohorts with the exception of a greater prevalence of diabetes in the biplanar group (27% vs 50%; P < .05). The incidence of recurrence for biplanar flaps (25%) was significantly lower than for fasciocutaneous reconstruction (53%; P < .01). CONCLUSIONS Biplanar flap reconstruction should be considered for chronically immobilized patients at high risk for recurrent decubitus ulceration.