Thomas J. Gampper

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.

vascular Anomalies: Hemangiomas

Mulliken and Glowacki categorized vascular anomalies as either hemangiomas or malformations, with the former being the most common tumor of infancy. Despite distinct clinical, radiologic, and histologic findings, the two major types of vascular lesions are often confused. This complicates both patient care and interpretation of the medical literature. A thorough understanding of the presentation, natural history, treatment, and complications of vascular tumors (hemangiomas) and vascular malformations is essential to their proper management. A comprehensive review outlining the diagnosis and treatment of hemangiomas in presented.

Hyperbaric oxygen for the management of radionecrosis of bone and cartilage

Objectives: To review the use of hyperbaric oxygen in the management of radionecrosis of the head and neck. Study Design: A retrospective analysis of patients utilizing chart review and telephone interviews. All patients diagnosed with osteoradionecrosis and chondroradionecrosis of the head and neck and treated with hyperbaric oxygen at the University of Virginia are included. Methods: Demographics, pretreatment data, and precipitating events were recorded. Outcomes were evaluated using a grading scale of symptomatology and physical examination as determined by the patient and physician. Results: Sixteen patients with osteoradionecrosis and five with chondroradionecrosis were reviewed. All patients showed clinical improvement with decreased pain following HBO therapy. None of the patients with chondroradionecrosis required laryngectomies, and two of the four who were tracheotomy dependent were successfully decannulated. The patient and physician grading scores demonstrated moderate to significant improvement in both groups following therapy. Conclusion: The successful use of hyperbaric oxygen for the management of radionecrosis of the head and neck is supported. The unusual prevalence of chondroradionecrosis may be an early reflection of changes in treatment protocols for patients with head and neck cancer. Key Words: Hyperbaric oxygen, osteoradionecrosis, chondroradionecrosis.

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.

Outcomes in threadlift for facial rejuvenation.

The search for less invasive surgical techniques to address the effects of facial aging led to the development of barbed polypropylene sutures for facial suspension. Theoretical advantages of these “threadlifts” included limited scarring, rapid recovery, relative safety, and reduced cost when compared with a standard rhytidectomy. The goal of this study was to evaluate the outcomes of patients undergoing threadlifts to determine the actual complication rates, the durability of results, and the rates of reoperative surgery. A single surgeons initial 2-year experience with 72 patients undergoing threadlifts was retrospectively reviewed. Preoperative patient demographical and clinical data, operative information, and postoperative outcomes data were compiled and evaluated. A total of 72 thread lifts were performed by 1 surgeon over a 24-month period. Of these patients, 76% underwent threadlift alone, whereas concomitant procedures were performed in 24% of patients. Minor complications were common and usually self-limited. Forty-two percent of patients underwent a secondary procedure after primary threadlift, an average of 8.4 months after the original surgery. Thirty-one percent of patients required revisional surgery for cosmetic reasons an average of 8.7 months after their threadlift. Eleven percent of the patients ultimately required removal of palpable threads. Threadlift is a safe procedure associated with minor complications. Rates of revisional surgery for cosmesis are high after threadlift. Time to revisional surgery for cosmesis is short. Results achieved by threadlift are subtle and short-lived. Threadlift is not a minimally invasive replacement of surgical rhytidectomy. Patients should understand the limitations of this technique and its high rates of revisional surgery.

Special Considerations in the Management of Pediatric Upper Extremity and Hand Burns

Pediatric patients account for approximately one third of all burn patients in the United States, with upper extremity or hand involvement in most admitted burn patients. Specialized management and care of pediatric burn patients optimizes functional outcomes. Common mechanisms of injury are discussed. Acute and long-term care aspects of pediatric upper extremity and hand burns require unique considerations. Diagnosis, treatment, and management of upper extremity and hand burns are discussed in detail with respect to the pediatric population.

Evaluation of clinically applicable exsanguination treatments to alleviate venous congestion in an animal skin flap model

This study compares the effectiveness of alleviating venous congestion with mechanically‐made outlets or leech therapy in promoting skin flap survival. Free flaps of abdominal skin (3 × 6 cm) were raised on Sprague‐Dawley rats and subjected to ischemic events, simulating venous congestion. Animals received 1) no treatment; 2) two treatments involving two 18‐gauge needle‐puncture outlets; or 3) two sessions of leech therapy. Flap perfusion was monitored with a scanning laser Doppler flowmeter. Photographic images of flaps at 7 days were assessed for areas of normal tissue (n = 15), and laser Doppler flowmeter data consisted of control (n = 6), outlet (n = 6), and leech (n = 7). Both the needle‐puncture outlet (40.0%± 9.24%) and leech treated (34.6%± 7.34%) groups had a significantly greater surviving skin area than untreated control flaps (8.0%± 5.0%), with 2 of 15 flaps receiving mechanical outlets exhibiting > 90% surviving area. After 7 days, laser Doppler flowmeter data showed greater mean perfusion in the outlet (71.7%± 16.8%) and leech (92.6%± 17.2%) treated groups, compared to controls (15.2%± 10.2%). There was a significant increase in perfusion in the outlet (13.3%± 6.2%) and leech (9.1%± 1.1%) treated groups from the end of secondary ischemia to day 7 (p < 0.05) compared to controls. The results suggest that two spatially separated outlets are as effective as one leech in increasing the area of surviving skin in venous congested flaps.

Applications of hyperbaric oxygen in otolaryngology head and neck surgery : Facial cutaneous flaps

Hyperbaric oxygen therapy is of significant benefit in the setting of an ischemic flap of the head and neck. Mechanistically, hyperbaric oxygen decreases local tissue edema and improves oxygen delivery to compromised tissues. Both capillary and fibroblast in-growth occur at a greater rate with hyperbaric oxygen therapy, and there is an increase in the tensile strength of the wound. Additional indications in the head and neck include traumatic composite amputations, necrotizing soft-tissue infections, and osteoradionecrosis of the facial skeleton.

Resident Participation in International Surgical Missions is Predictive of Future Volunteerism in Practice

Background Interest in global health and international mission trips among medical student and resident trainees is growing rapidly. How these electives and international mission experiences affect future practice is still being elucidated. No study has identified if participation in international surgical missions during residency is a predictor of participation in international surgical missions in practice after training completion. Methods All trainees of our plastic surgery residency program from 1990 to 2011, during the implementation of optional annual international surgical missions, were surveyed to determine if the graduate had gone on a mission as a resident and as a plastic surgeon. Data were compared between graduates who participated in missions as residents and graduates who did not, from 1990 to 2011 and 1990 to 2007. Results Of Plastic Surgery graduates from 1990 to 2011 who participated in international missions as residents, 60% participated in missions when in practice, versus 5.9% of graduates participating in missions in practice but not residency (P<0.0001). When excluding last 5 years, graduates participating in international missions in practice after doing so as residents increases to 85.7%, versus 7.41% who participate in practice but not residency P<0.002. Conclusions Results reveal plastic surgeons who participate in international surgical missions as residents participate in international surgical missions in practice at higher rates than graduates who did not participate in missions during residency. International missions have significant intrinsic value both to trainee and international communities served, and this opportunity should be readily and easily accessible to all plastic surgery residents nationwide.

Correction of posterior sagittal craniosynostosis.

Craniosynostosis involving the posterior sagittal suture results in a characteristic skull deformity known as bathrocephaly. Surgical correction of this deformity using the reverse pi procedure has yielded inconsistent results. We present a new method for expanding the transverse posterior skull while simultaneously reducing the longitudinal dimension. An absorbable microplate-reinforced bone strut is used as a framework on which the remainder of the skull is reconfigured; its stability prevents relapse. The posterior skull squeeze is produced using absorbable mesh plates. Use of rigid fixation is limited to absorbable hardware in the growing craniofacial skeleton.