Thomas R. Stevenson

Abdominoplasty, liposuction of the flanks, and obesity: analyzing risk factors for seroma formation.

Background: The purpose of this study was to determine whether seroma formation following abdominoplasty is associated with simultaneous liposuction of the flanks and to stratify the risk of developing seromas according to body mass index. Methods: A retrospective review was conducted of 118 consecutive patients who underwent abdominoplasty with or without flank liposuction from 1992 to 2002. Patients in the abdominoplasty with flank liposuction category were further substratified according to the use of conventional versus ultrasound-assisted liposuction. Data regarding patient age, body mass index, and the occurrence of seromas were collected and analyzed. Results: Fifteen of the 39 patients who underwent abdominoplasty alone (38 percent) developed seromas. This was comparable to the 23 of 79 patients (29 percent) who developed seromas after abdominoplasty combined with flank liposuction (p = not significant). Eight of 19 patients (42 percent) who had liposuction performed with ultrasound assistance developed seromas, compared with 15 of 60 patients (25 percent) who underwent conventional liposuction without ultrasound (p = not significant). When stratified according to body mass index, overweight or obese patients were more likely to develop seromas than patients of normal weight, whether liposuction was performed in the same setting or not [seromas in seven of 37 (19 percent) of normal weight patients versus 31 of 81 (38 percent) of overweight and obese patients, p < 0.05]. Conclusions: Liposuction of the flanks in concert with abdominoplasty does not appear to increase the risk of seroma formation. Patients who are overweight or obese present a statistically significantly higher risk for developing seromas postoperatively than patients of normal weight.

Transantral endoscopic orbital floor exploration: A cadaver and clinical study

&NA; A cadaver and clinical study was performed to determine the value of transantral endoscopy in diagnosis and treatment of orbital floor fractures. Six fresh cadaver heads were dissected using a 30 degree, 4‐mm endoscope through a 1 cm2 antrotomy. In the cadaver, the orbital floor and the course of the infraorbital nerve were easily identified. The infraorbital nerve serves as a reference point for evaluation of fracture size; three zones of the floor are described that are oriented relative to the infraorbital nerve. In the clinical study, nine patients with orbital floor fracture initially underwent endoscopy at the time of fracture repair: three patients had comminuted zygomatico‐orbital fractures, five had monofragmented tetrapod fractures, and one had an isolated orbital blowout fracture. Endoscopic dissection of the orbital fractures revealed seven fractures with an area >2 cm2 and two fractures with an area of <2 cm2. The isolated orbital floor blowout fracture had entrapped periorbital tissue, which was completely reduced endoscopically. A separate patient with a <2 cm2 displaced fracture also had stable endoscopic reduction. In the remaining seven patients, the endoscopic technique assisted with the floor reconstruction by identifying the precise fracture configuration as well as identifying the stable posterior ledge of the orbital floor fracture. There have been no complications in any of our patients to date. We conclude: (1) Transantral orbital floor exploration allows precise determination of orbital floor fracture size, location, and the presence of entrapped periorbita. The information obtained through endoscopic techniques may be used to select patients who would not benefit from lid approaches to the orbital floor and may possibly eliminate nontherapeutic exploration. (2) Transantral endoscopic orbital floor exploration assists in the reduction of complex orbital floor fractures and allows precise identification of the posterior shelf for implant placement. (3) Transantral endoscopic techniques can completely reduce entrapped periorbital tissue caught in a trapdoor type of fracture. (Plast. Reconstr. Surg. 100: 575, 1997.)

The gluteus maximus musculocutaneous island flap; refinements in design and application

The gluteus maximus island musculocutaneous flap has been described using a variety of designs. We employ an island whose long axis is directed toward the pressure sore, minimizing tension in wound closure. Skin overlying the greater trochanter is avoided. Previously undermined skin can be included in the flap. Fifty patients with ischial or sacral pressure sores have been managed by this technique. Superficial dehiscence occurred in 13 percent of patients, and deep dehiscence occurred in 10 percent. The dehiscence closed spontaneously in all but one patient. Forty-nine of the 50 patients experienced complete wound healing at the pressure sore site. The patients have been observed for an average of 20 months (range 3 to 38 months), with one recurrent pressure sore seen at 28 months postoperatively. The gluteus maximus musculocutaneous island flap has proven to be both reliable in healing and durable over the observed interval.

The posterior thigh fasciocutaneous flap: Vascular anatomy and clinical application

Ten adult cadavers were used to accurately detail the vascular anatomy of posterior thigh skin. Fourteen posterior thigh specimens were dissected after blue latex injection of the internal and external iliac arteries. Six posterior thigh specimens underwent selective dye injection of individual profunda perforating arteries and the inferior gluteal artery. The findings reveal an extensive fascial plexus nourished primarily by fasciocutaneous branches of the first and second profunda perforating arteries and secondarily by a terminal fasciocutaneous branch of the inferior gluteal artery. From 1989 to 1992, 24 posterior thigh fasciocutaneous flaps were performed in 24 patients. There were 5 early postoperative complications (21 percent). All but one patient went on to satisfactory healing and stable wound coverage. Three posterior thigh fasciocutaneous flaps were used successfully despite ligation of their inferior gluteal artery blood supply in a previous surgical procedure. These anatomic and clinical findings confirm the reliability of a posterior thigh fasciocutaneous flap based primarily on the first and second profunda perforating arteries. The posterior thigh fasciocutaneous flap can survive in the absence of a patent inferior gluteal artery. Knowledge of the vascular anatomy extends the clinical applicability of the posterior thigh fasciocutaneous flap to patients who might otherwise be excluded because of prior injury or operative procedure.

Management of foot injuries with free-muscle flaps.

Transfer of a free-muscle graft with application of a split-thickness skin graft is one of many techniques available for reconstruction of the massive foot injury. The durability of such a reconstruction has been questioned. We have treated nine patients suffering from foot injuries with extensive soft-tissue loss. Each patient underwent reconstruction using a free-muscle transfer covered by a split-thickness skin graft. A mean follow-up of 33 months (range 17 to 48 months) is reported for these nine patients. Each patient is ambulatory. One patient developed an ulcer on the plantar surface, which was treated successfully by flap revision and skin grafting. We feel this technique provides a durable reconstruction for significant soft-tissue loss of the foot.

MOC-PS(SM) CME article: lower extremity reconstruction.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the evaluation of a patient with a lower extremity wound. 2. Determine when an attempt at wound salvage is likely to be successful. 3. Select an appropriate technique for wound management. 4. Anticipate and identify wound complications. SUMMARY Successful management of a patients wound at or distal to the knee includes accurate site assessment, meticulous debridement, planning, and execution of a reasonable operative procedure. Outlining a reconstructive plan requires consideration of alternatives from basic to most complex, then selection of the simplest technique likely to achieve wound closure with minimal donor-site morbidity. Healing by secondary intention, with or without vacuum-assisted closure, demands few surgical resources. A skin graft may close a well-vascularized wound. A local skin, fasciocutaneus, or muscle flap can provide vascularized tissue to an otherwise ischemic area. A plastic surgeon may use free tissue transfer in the more difficult anatomic regions, particularly for defects of the distal one-third of the lower leg. Other issues demand consideration when treating a patient with a lower extremity wound. Anesthetic options range from none in the case of secondary intention healing, through prolonged general anesthesia in the circumstance of free tissue transfer. Early recognition of a complication makes successful treatment of that problem more rapid and more likely to be successful. Accurate CPT coding ensures appropriate reimbursement for the reconstructive surgeon and fairness to the payer. Finally, some wounds are so extensive and patients so ill from related or unrelated pathologic processes that attempts at reconstruction are ill advised. These patients are better served by early amputation and prompt rehabilitation.

Sternal osteomyelitis: treatment with rectus abdominis muscle

Sternal osteomyelitis complicates recovery in a small number of patients following median sternotomy. Techniques for operative treatment have in common the wide debridement of devitalised tissue and administration of culture-specific antibiotics. The resultant wound can be managed by delayed primary closure or transposition of well-vascularised adjacent tissue. Omentum, pectoralis major muscle and rectus abdominis muscle are suitable for transposition either alone or in combination. Our series is composed of ten patients who underwent rectus abdominis muscle transfer for the treatment of sternal osteomyelitis. The rectus abdominis obliterates dead space in the lower third of the wound, a difficult area to reach with the pectoralis major muscle. Five patients had one rectus abdominis muscle alone transposed, avoiding the aesthetic and functional deficits of pectoralis major transposition and the risks of omental transfer. Wound healing occurred in every case with a minimum of postoperative complications.

Pneumothorax as a complication of breast augmentation.

Background: Pneumothorax is a recognized complication of breast augmentation which, until now, was thought to be rare. The authors hypothesize that it is more common than generally appreciated. Methods: A fax survey was sent to 363 members of the California Society of Plastic Surgeons in 2001, questioning their experience with this complication. Results: The survey response rate was 50 percent, revealing that one in three members of the California Society of Plastic Surgeons had at least one patient who experienced a pneumothorax, and one in 10 had experienced two or more complications of pneumothorax while performing breast augmentation. Sixty-two members reported a total of 83 separate pneumothoraces in their career. No local or hypodermic needle injections were used in 24 percent of these patients. Fifty-five percent of patients were hospitalized, with 71 percent of the cases paid for by insurance companies. Treatment consisted of observation and repeated chest radiograph in 33 percent, needle aspiration alone in 16 percent, and chest tube insertion in 47 percent. Conclusions: The cause is difficult to determine, but causes suspected by respondents included intraoperative laceration of the pleura (43 percent), needle puncture at the time of local injection (37 percent), ruptured pulmonary blebs during or after the procedure (16 percent), and high anesthetic ventilation pressures (3 percent). The authors believe the complication of pneumothorax is more common than generally appreciated and is not necessarily caused by negligence. The authors now include this complication in their consent form and recommend keeping an intracatheter, pigtail catheter, or Heimlich valve in surgical facilities for treatment of a possible tension pneumothorax.

Three-dimensional reconstruction of the below-knee amputation stump : use of the combined scapular/parascapular flap

The technique of combined scapular/parascapular reconstruction of the below-knee stump wound allows three-dimensional contouring of fasciocutaneous tissue into a conical shape. The flap can supply durable cover to the circumference of the stump with good functional results. This technique should be considered for reconstruction of extensive circumferential defects of the below-knee stump.

TRAM flap breast reconstruction and contralateral reduction or mastopexy

The quality of a breast reconstruction is gauged by the symmetry achieved when the reconstructed and opposite breasts are compared. In order to produce a symmetrical appearance, it is often necessary to revise the contralateral, previously unoperated breast. A procedure on the opposite breast can be performed at the same time as breast reconstruction or can be delayed for several months. The purpose of this study was to compare the simultaneous TRAM flap and contralateral breast reduction/mastopexy with the TRAM flap alone according to selected parameters. Our results suggest that performing the combined procedure is safe and yields a satisfactory aesthetic result.