Kant Y. Lin

Wound complications of abdominoplasty in obese patients

The records of 90 patients who underwent an abdominoplasty at the University of Virginia Health Sciences Center were analyzed to determine the effect of obesity on the incidence of complications after this surgery. The study patients were divided into three groups-obese, borderline, and nonobese-based on the degree to which their preoperative weights varied from their ideal body weight. A history of previous bariatric surgery was also analyzed to determine what impact that might have on subsequent abdominoplasty. Results showed that 80% of obese patients had complications compared with the borderline and nonobese patients, who had complication rates of 33% and 32.5% respectively (p = 0.001). Previous gastric bypass surgery had no significant effect on the incidence of postabdominoplasty complications. Based on these findings the authors conclude that obesity at the time of abdominoplasty has a profound influence on the wound complication rate following surgery, regardless of any previous weight reduction surgery.

The effect of rigid fixation on the survival of onlay bone grafts: an experimental study.

Much attention has recently been focused on rigid fixation as a method of improving fracture healing. Whether such fixation, when applied to onlay grafting, improves graft take and volume is unknown. To examine this question, we compared survival of both endochondral and membranous grafts fixed rigidly and nonrigidly in areas of low motion (snout) and high motion (femur) in a rabbit model. Gross morphology, histologic analysis, and graft volume kinetics were evaluated. Findings demonstrate that in areas of high motion, the application of rigid fixation improves graft survival, whereas in a low-motion region, no differences in graft volume retention as a function of fixation were observed. Histologically, no differences with the method of fixation employed were seen, and similar revascularization patterns were noted. By kinetic analysis, rigid fixation appears to exert its most profound effect early in the postgraft period. Membranous bone grafts remain superior to endochondral grafts under all circumstances. From these studies, we conclude that rigid fixation is the method of choice in all circumstances where onlay bone grafts may be exposed to motion, shear, and torsional forces.

An Outcome Study of Breast Reconstruction: Presurgical Identification of Risk Factors for Complications

Background: Breast reconstruction following mastectomy has been shown to have a salutary effect on the overall psychological well-being of women being treated for breast cancer. Unfortunately, however, not every patient is an ideal candidate for reconstruction. Complications stemming from reconstructive surgery can cause significant morbidity, the most important of which may be the delay of subsequent adjuvant antineoplastic therapies, and therefore may not be in the best interests of the patient.Methods: A retrospective study was performed on a consecutive series of 123 breast reconstructions in 98 patients, performed by one of two plastic surgeons, in a university setting over a 5-year period, for all surgical outcomes. Specifically, wound-healing complications, infections, and reoperations leading to the potential delay of subsequent chemotherapy or radiotherapy were recorded, and possible risk factors leading to these were sought.Results: Three presurgical risk factors were found to have a statistically significant influence on the development of complications following breast reconstruction. These were: (1) increasing obesity, defined by the body mass index, (2) an active or recent (<5 year) history of cigarette smoking, and (3) a history of previous radiation exposure. Odds ratios were used to describe the magnitude of the effect of each factor for the development of complications. An ordinal regression analysis was used to create a nomogram based on this information that can be used to calculate any individual patient’s presurgical risk for developing major complications following breast reconstruction, based on the presence of these factors.Conclusions: It is possible, based on the presence of specific presurgical risk factors, to predict the probability of developing major complications following breast reconstruction. This information can be useful to the referring physician and plastic surgeon alike in determining which patients are the best candidates for breast reconstruction and which type of reconstruction would be best suited for each individual patient.

Sagittal synostosis : quantitative assessment of presenting deformity and surgical results based on CT scans

We reviewed our experience with nine consecutive patients with untreated isolated nonsyndromic sagittal synostosis. Using a method of 14 clinically relevant measurements taken from preoperative and postoperative CT scan images of these patients, we documented their presenting skeletal dysmorphology and the results of surgical correction at least 1 year after operation. Significant preoperative findings included an elongated cranial vault length that averaged 103 percent of normal and a narrowed cranial vault width both anteriorly at 92 percent and posteriorly at 86 percent of normal. Results of surgical correction, as documented by CT scan measurements, included normalization of the cranial length to 100 percent and of the anterior width to 101 percent of normal and improvement (but undercorrection) of the posterior width to 94 percent of normal. Quantitative measurement of CT scan images confirmed clinically observed findings in these patients before suture release and reconstruction and proved useful in assessing the surgical results achieved.

The surgical management of orbitofacial dermoids in the pediatric patient

Orbitofacial dermoids in the pediatric population represent a diverse group of lesions. Because of their variability in both clinical presentation and contiguous structure involvement, a thorough understanding of their surgical-pathologic anatomy is imperative. In this retrospective review of 84 lesions in 84 patients, we noted segregation of the lesions into three distinct subgroups: brow region dermoids, orbital region dermoids, and nasoglabellar dermoids. Further, we identified physical characteristics within each subgroup that appeared to direct diagnostic workup and subsequent surgical intervention. From this experience, a treatment algorithm was developed that gives the practitioner more precision in the management of these lesions.

An experimental study on the effect of rigid fixation on the developing craniofacial skeleton

Rigid fixation of the craniofacial skeleton has proven of great value in adult orthognathic and traumatic reconstructive surgical procedures. This technique has gained increased acceptance in the surgical treatment of infants and young children with congenital malformations, despite the fact that its effects on subsequent craniofacial growth are unknown. To examine this question, an experimental model using 25 young kittens was developed to compare rigid fixation with conventional wire fixation, with and without osteotomy. Our findings demonstrate a regional restriction of growth in the developing craniofacial skeleton when both wire and plate and screw fixation are utilized in concert with osteotomy. Further, a compensatory growth was observed in individual animals when plate fixation was utilized that was not seen in the wire-treated group. This suggests that there is a dynamic growth interaction between restriction and compensation in this setting.

Comparison study of two types of expander-based breast reconstruction: acellular dermal matrix-assisted versus total submuscular placement.

AbstractRecent reported complications have called some authors to express concern regarding the increased popularity of acellular dermal matrix (ADM)-based breast reconstruction, and its role as an alternative to traditional total submuscular approaches. To address this issue, we compared tissue expansion properties, complication rates, and patient satisfaction for both operative techniques at the same institution. A retrospective review was completed on 75 patients and 100 tissue expander/implant-based breast reconstructions at a single academic institution from 2007 to 2010. Of these cases, 31 patients were reconstructed with ADM and 44 with a submuscular coverage technique. Total complications including seroma, hematoma, infection, skin necrosis, and explantation did not significantly differ between groups (n = 13 for ADM vs. 17 for submuscular, P = 0.814). Consistent with prior reports, ADM-based reconstructions were associated with significantly increased intraoperative fill volumes and lower total number of sessions to achieve final volume. Submuscular reconstructions required a significantly higher tissue expander fill volume. Eight patients in the submuscular group required surgical revision of the breast and inframammary fold, compared with 4 in the ADM group; however, this difference was not significant. Patient satisfaction was equivalent between the 2 groups; however, it was higher in patients with bilateral reconstruction and lower among those who had received adjuvant radiation therapy. Satisfaction with nipple reconstruction was inversely proportional to time elapsed from the procedure to survey conduction. This is the first study to perform a head-to-head comparison on the basis of patient satisfaction, the results of which may be useful in preoperative planning and counseling.

Implant-based, two-stage breast reconstruction in the setting of radiation injury: an outcome study.

Background: More women with breast cancer who either have already had radiation therapy or will be getting radiation therapy as part of their treatment protocol are now seeking implant-based breast reconstruction. The literature on the success of this type of reconstruction in the setting of radiation injury is mixed. Methods: A single reconstructive surgeons experience over a 10-year period with implant-based, two-stage breast reconstruction was retrospectively examined. A total of 267 breasts in 194 patients were included in the study and divided into three groups. Reconstruction was performed for breasts that had no radiation exposure (n = 218), radiation exposure before mastectomy/reconstruction (n = 32), or radiation exposure after mastectomy and first-stage reconstruction but before completion of the second stage of reconstruction (n = 17). Age, follow-up time, history (of diabetes, smoking, and chemotherapy), body mass index, and expander volume were recorded. Logistical regression analysis was performed for major reoperative complications following the reconstruction. Results: Radiation exposure before reconstruction resulted in a 43.8 percent complication rate, during reconstruction had a 41.2 percent complication rate, and no radiation exposure had a 13.8 percent complication rate. The most common complication in both radiation groups was wound dehiscence, but there were also a significant number of patients who had failure of expansion. In addition, smoking significantly influenced the occurrence of complications. Conclusions: Radiation therapy for the treatment of breast cancer significantly increased the incidence of major, reoperative complications in implant-based, two-stage breast reconstruction. Despite this high rate, however, in the present study, 80 percent of patients with major complications went on to complete their breast reconstructions with either implants or autogenous tissue. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Dura mater secretes soluble heparin-binding factors required for cranial suture morphogenesis

SummaryCranial sutures play a critical role in calvarial morphogenesis, serving as bone growth centers during skull enlargement. Defective suture morphogenesis, resulting in premature osseous obliteration of sutures and their failure to function appropriately, causes severe craniofacial anomalies. Previously published data demonstrated osseous obliteration of coronal suturesin vitro in the absence of dura mater and the rescue of sutures from osseous obliteration in rudiments cocultured with dura mater on the opposite sides of 0.45-μm polycarbonate filters. With thisin vitro culture system, experiments were designed to examine the nature of the soluble signal secreted by dura mater, required for maintaining intact sutures. The signal remained active in conditioned medium produced from dura mater, which was capable of rescuing coronal sutures from osseous obliteration in calvaria cultured without dura mater. When conditioned medium was segregated into heparin-binding and non-heparin-binding fractions, the signal capable of maintaining intact coronal sutures cosegregated with the heparin-binding component and remained functional in the absence of the non-heparin-binding component of conditioned medium. Evidence indicates that soluble, heparin-binding factors secreted by the dura mater act as osteoinhibitory signals at the suture site.

REVOLUTIONARY ADVANCES IN THE MANAGEMENT OF TRAUMATIC WOUNDS IN THE EMERGENCY DEPARTMENT DURING THE LAST 40 YEARS: PART I

BACKGROUND AND OBJECTIVES This report provides an overview of advances in wound repair devised by our research team during the last four decades. This collective review is presented in two parts. DISCUSSION The following components are included in Part I: 1) search and treat life-threatening trauma; 2) conduct a thorough history; 3) examine the wound using aseptic technique; 4) anesthetize the wound before cleansing; 5) hair removal, skin disinfection, hemostasis, surgical debridement, and mechanical cleansing; 6) antibiotics, drains, and open wound management. CONCLUSION On the basis of these comprehensive research studies, we have noted a marked reduction in the incidence of wound infection in traumatic wounds.