Warren A. Ellsworth

Techniques for labia minora reduction: an algorithmic approach.

BackgroundAesthetic reduction of the labia minora has gained popularity, and a number of different techniques have been described. Each procedure has its own set of advantages and disadvantages. However, no algorithm has been defined for pairing the degree of deformity with the optimal surgical procedure.MethodsPatients were stratified into one of four groups based on labial size. The surgeon chose one of three reduction techniques based on the degree of labial hypertrophy and the patient’s aesthetic preferences for labial edge color and contour. Three reduction techniques were used including the edge excision technique, the inferior wedge resection technique, and deepithelialization reduction labioplasty. The success of aesthetic reduction was evaluated, as was symptomatic relief.ResultsThe 12 procedures performed included five deepithelialization techniques, four edge excision techniques, and three inferior wedge resection techniques. As reported, 92% of the patients were “very satisfied” with their aesthetic and functional results. The complications were minimal, with three patients experiencing minor wound healing difficulties that resolved spontaneously. One patient who underwent the edge excision technique was “not satisfied” and complained of overreduction.ConclusionThe authors found all three techniques for labia minora reduction to be useful in different clinical situations. A novel algorithm is described for matching the optimal surgical technique for each patient based on her degree of hypertrophy and aesthetic goals.

Mycobacterium abscessus infection after breast augmentation: a case of contaminated implants?

Infections after breast augmentation are uncommon, occurring in 1-3% of cases. Treatment often requires additional surgeries and may yield a sub-optimal cosmetic result. For this reason, post implant infection remains a serious concern among plastic surgeons. A 48-year-old female presented to our clinic with bilateral breast implant infections 3 months after primary augmentation in China. Cultures grew Mycobacterium abscessus, a previously undescribed infectious aetiology after breast augmentation. The fastidious nature of the organism often results in a negative acid fast stain and initially sterile cultures. For these reasons, clinical signs of infection in the face of sterile cultures should raise suspicion of Mycobacterium infection among clinicians. While the overall incidence of Mycobacterium infection after breast augmentation is low, it remains an important and often overlooked aetiology for patients with a lack of systemic symptoms and initial sterile cultures.

Perioperative considerations for patient safety during cosmetic surgery - preventing complications.

Maintaining patient safety in the operating room is a major concern of surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential, and pressure to avoid these complications in cosmetic surgery is increasing. Traditionally, nursing and anesthesia staff have managed patient positioning and safety issues in the operating room. As the number of office-based procedures in the plastic surgeons practice increases, understanding and implementing patient safety guidelines by the plastic surgeon is of increasing importance.A review of the Joint Commissions Universal Protocol highlights requirements set forth to prevent perioperative complications. In the present paper, the importance of implementing these guidelines into the cosmetic surgery practice is reviewed. Key aspects of patient safety in the operating room are outlined, including patient positioning, ocular protection and other issues essential for minimization of postoperative morbidity. Additionally, as the demand for body contouring surgery in the cosmetic practice continues to increase, special attention to safety considerations specific to the obese and massive weight loss patients is mandatory.After review of the present paper, the reader should be able to introduce the Joint Commissions Universal Protocol into their daily practice. The reader will understand key aspects of patient positioning, airway management and ocular protection in cosmetic surgery. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese, massive weight loss patients and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patients experience and surgical outcome.

Platelet rich plasma enhances tissue incorporation of biologic mesh

BACKGROUND High recurrence rates because of poor tissue incorporation limit the use of acellular dermal matrices (ADMs) in ventral hernia repair (VHR). Platelet rich plasma (PRP) is a growth factor-rich autologous blood product known to enhance tissue repair through cellular proliferation and neovascularization. We sought to study the effect of PRP on a porcine noncross-linked ADM in an in vivo model of VHR. We hypothesized that PRP would enhance ADM-tissue incorporation in a rat model of VHR. METHODS Whole blood was extracted from Lewis rats followed by PRP isolation and characterization. Using a rat model of VHR, a noncross-linked ADM (Strattice) was implanted and activated PRP applied before closure. Rats were sacrificed at 2, 4, and 6 wk. Immunohistochemical staining of CD 31 on endothelial cells was used to quantify neovascularization. Hematoxylin eosin stained tissues were measured to quantify tissue deposition. RESULTS Platelet concentration of PRP was standardized to 1 × 10(6) platelets/μL. Grossly, vessels were more evident in PRP-treated rats. Immunohistochemical analysis demonstrated neovascularization was significantly greater in the PRP-treated ADMs at all time points. This increase in neovascularization correlated with an increased thickness of tissue deposition at 4 and 6 wk. CONCLUSIONS PRP enhanced neovascularization and incorporation in a rat model of VHR. Enhanced neovascularization was associated with earlier and greater tissue deposition on the ADM. This suggests that PRP could be used as an adjunct to VHR in clinical scenarios where poor wound healing is anticipated and enhanced neovascularization and early tissue deposition are desired.

Delayed Aortic Rupture After Aortic Endograft Placement in Patient With Spinal Hardware

Aortic injuries presenting in a delayed fashion after attempted repair of an acute injury are uncommon. We report a case of a patient presenting with an initial aortic injury associated with thoracic spinal hardware placement, which was repaired with an open and endovascular approach, and 5 months later presented with hemoptysis. The cause of hemoptysis was erosion of the descending thoracic aorta between the spinal hardware and the thoracic endograft. The patient underwent descending aorta replacement with a Dacron tube graft, removal of the hardware, and coverage with a pedicled omental flap. This is a unique presentation of erosion of the aorta between the spinal hardware and the earlier placed endovascular stent-graft.

Breast Reconstruction in Women Under 30: A 10-Year Experience

Abstract:  The number of women diagnosed with breast cancer at a young age (≤30 years) continues to rise. As young women present for breast cancer management with greater frequency, an accurate characterization of the differences in cancer treatments and reconstruction techniques is imperative to optimize care. Here, we sought to identify the reconstruction trends in this population of women ≤30 years at time of breast cancer diagnosis. We retrospectively reviewed the charts of women aged ≤30 years who underwent breast reconstruction at The University of Texas M.D. Anderson Cancer Center. We extracted data on the patients’ diagnosis, adjuvant therapy, reconstructive choice, reason for reconstructive choice, and decision for contralateral prophylactic mastectomy (CPM). Over a 10‐year period, 54 patients aged ≤30 years underwent 77 breast reconstructions, including 30 microsurgical autologous tissue reconstructions and 34 tissue expander‐based reconstructions. Donor site limitations, including insufficient abdominal tissue, restricted the number of patients eligible for abdominal based reconstruction despite the patients’ interest in the latter. The rate of CPM was 43%, which was significantly higher than the national average of 8%, further complicating the possibility of total autologous reconstruction. Because of the high rate of bilateral mastectomy and innate donor tissue limitations, young, healthy women who are otherwise ideal candidates for free tissue transfer using the abdominal donor site undergo significantly more tissue expander reconstructions than expected. Implant‐based reconstruction or donor sites other than the abdomen must be considered in this unique population.

Platelet-rich plasma: a biomimetic approach to enhancement of surgical wound healing.

Platelets are small anucleate cytoplasmic cell bodies released by megakaryocytes in response to various physiologic triggers. Traditionally thought to be solely involved in the mechanisms of hemostasis, platelets have gained much attention due to their involvement wound healing, immunomodulation, and antiseptic properties. As the field of surgery continues to evolve so does the need for therapies to aid in treating the increasingly complex patients seen. With over 14 million obstetric, musculoskeletal, and urological and gastrointestinal surgeries performed annually, the healing of surgical wounds continues to be of upmost importance to the surgeon and patient. Platelet-rich plasma, or platelet concentrate, has emerged as a possible adjuvant therapy to aid in the healing of surgical wounds and injuries. In this review, we will discuss the wound healing properties of platelet-rich plasma and various surgical applications.

Does Acellular Dermal Matrix Thickness Affect Complication Rate in Tissue Expander Based Breast Reconstruction

Background. While the benefits of using acellular dermal matrices (ADMs) in breast reconstruction are well described, their use has been associated with additional complications. The purpose of this study was to determine if ADM thickness affects complications in breast reconstruction. Methods. A retrospective chart review was performed including all tissue expander based breast reconstructions with AlloDerm (LifeCell, Branchburg, NJ) over 4 years. We evaluated preoperative characteristics and assessed postoperative complications including seroma, hematoma, infection, skin necrosis, and need for reintervention. We reviewed ADM thickness and time to Jackson-Pratt (JP) drain removal. Results. Fifty-five patients underwent 77 ADM-associated tissue expander based breast reconstructions, with average age of 48.1 years and average BMI of 25.9. Average ADM thickness was 1.21 mm. We found higher complication rates in the thick ADM group. Significant associations were found between smokers and skin necrosis (p < 0.0001) and seroma and prolonged JP drainage (p = 0.0004); radiated reconstructed breasts were more likely to suffer infections (p = 0.0085), and elevated BMI is a significant predictor for increased infection rate (p = 0.0037). Conclusion. We found a trend toward increased complication rates with thicker ADMs. In the future, larger prospective studies evaluating thickness may provide more information.

Three dimensional model for surgical planning in resection of thoracic tumors

Highlights • 3D printed model can be made of thoracic malignancy by taking CT image of the patient and creating a 3D surface rendered imaging and printing it on 3D printer.• 3D printed model can help counsel the patient about the planned operation.• 3D printed model can help in surgical planning of the resection of complex thoracic tumors.

Reduction and Mastopexy Techniques for Optimal Results in Oncoplastic Breast Reconstruction

Breast conservation therapy has emerged as an important option for select cancer patients as survival rates are similar to those after mastectomy. Large tumor size and the effect of radiation create cosmetic deformities in the shape of the breast after lumpectomy alone. Volume loss, nipple displacement, and asymmetry of the contralateral breast are just a few concerns. Reconstruction of lumpectomy defects with local tissue rearrangement in concert with reduction and mastopexy techniques have allowed for outstanding aesthetic results. In patients who have a reasonable tumor- to breast-size ratio, this oncoplastic surgery can successfully treat the patients cancer while often improving upon preoperative breast shape. Specific surgical guidelines in reduction and mastopexy help achieve predictable aesthetic results, despite the effects of radiation, and can allow for a single surgical procedure for cancer removal, reconstruction, and contralateral symmetry in one stage.