Achieving predictability in augmentation mastopexy.

BACKGROUND: Augmentation mastopexy remains a procedure wrought with high rates of complications and revisions given the diametrically opposing forces in this combined procedure. Thus, many surgeons remain cautious and err on a staged procedure. This article provides a dependable, predictable, and straightforward approach to a challenging operation. The technique centers on five key points, including precise preoperative markings, 8-cm vertical limbs with a broad pedicle base, limited undermining of thick skin flaps, small subpectoral implants, and movement of the nipple no more than 4 cm. METHODS: Eighty-three patients who underwent augmentation mastopexy performed by a single surgeon (R.J.R) were included in a retrospective chart review following institutional review board approval. Information regarding demographics, implant contracture, degree of breast ptosis, and standard breast measurements was recorded. Operative data and postoperative complications were documented. RESULTS: At a mean follow-up of 38 months, major complications included 16 revisions and one readmission for superficial thrombophlebitis. The majority of revisions were for scar revision or implant size change. Minor complications included two hematomas, one seroma, three T-point skin sloughs, and two minor infections. There were no instances of major flap loss or nipple loss. CONCLUSIONS: The technique described provides a safe and conservative surgical approach for one-stage augmentation mastopexy resulting in the avoidance of major pitfalls and irreversible complications of flap or nipple loss while achieving the desired results of the patient and surgeon. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Predictors of failed primary abdominal closure in the trauma patient with an open abdomen.

BACKGROUND: We sought to characterize risk factors for failed closure after damage-control laparotomy and to examine the impact of two broad categories of open abdomen-management technique on rates of fascial approximation. METHODS: We retrospectively reviewed (January 2006-December 2008) all trauma patients with an open abdomen after damage-control laparotomy. Patients with definitive abdominal closure before discharge were classified as successful closure (SC) and those discharged with a planned ventral hernia were classified as failed closure (FC). Univariate stepwise logistical analyses were conducted to identify covariates related to resuscitation volumes and injury severity that were associated with FC. Surgical techniques were dichotomized as fascial based or vacuum based and compared with chi square. RESULTS: Sixty-two subjects met final eligibility (SC 44, FC 18). SC and FC were similar, with the exception of, respectively, initial base excess (-8.0 ± 4.2 vs -11.4 ± 4.9; P = 0.009), injury severity score (ISS; 29.0 ± 15.2 vs 20.6 ± 12.1; P = 0.04), and frequency of penetrating injury (47.7% vs 77.8%; P = 0.03). Stepwise regression showed significant associations between failed closure and increasing Penetrating Abdominal Trauma Index (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.01-1.11), worsening base excess on arrival (OR 0.79, 95% CI 0.66-0.93), and lower ISS (OR 0.94, 95% CI 0.89-1.00). Fascial-based versus vacuum-based management techniques had no effect on closure rates. CONCLUSIONS: Volume of blood transfused, crystalloid given, and open abdomen management technique were not related to closure rates; however, worsened base excess on arrival, penetrating trauma, higher Penetrating Abdominal Trauma Index, and a lower ISS were associated with FC. The latter was true despite an association also being found between FC and lower ISS scores, reflecting the propensity of ISS to underestimate injury burden after penetrating injury.

A 20-year experience with secondary rhytidectomy: a review of technique, longevity, and outcomes.

BACKGROUND: The increasingly more common secondary rhytidectomy patient presents with recurrent soft-tissue descent and stigmata of primary face lift, which can require techniques unique to secondary rhytidectomy. The senior author's (R.J.R.) experience with secondary rhytidectomy is reviewed, focusing on surgical technique, longevity, and outcomes. METHODS: Data collected after chart review of a 20-year study period included face-lift technique; duration between primary, secondary, and tertiary face lifts; concurrent procedures; and complications (i.e., hematoma, seroma, nerve injury, skin slough, infection, and need for revision). Surgical technique focuses on the "five Rs" of secondary rhytidectomy: (1) resect skin/scar, (2) release of abnormal superficial musculoaponeurotic system (SMAS) vectors, (3) refill by means of fat grafting, (4) reshape with SMASectomy or SMAS-stacking plication, and (5) redrape skin. The longevity of primary and secondary procedures was compared. RESULTS: A total of 811 face lifts were performed during the study period; 60 were secondary procedures. Ten secondary patients went on to have a tertiary face lift. Average duration between primary and secondary face lift was 9.0 years, and that between secondary and tertiary procedures was 7.5 years, showing no difference in longevity (p = 0.2). Complications included one each of seroma, skin slough, and temporary marginal mandibular nerve injury (2 percent). Necessary revisions included one neck, one earlobe, and one preauricular scar. CONCLUSIONS: Secondary rhytidectomy has complications similar to those of a primary procedure, and most patients have a second operation a decade later. Adherence to the five Rs of secondary rhytidectomy will enable the plastic surgeon to safely restore youth and correct stigmata of primary face lift.

The role of biologic mesh in abdominal wall reconstruction: a systematic review of the current literature.

BACKGROUND: Biologic mesh in the form of allograft or xenograft products have been used in complicated abdominal hernia repair, but few comparative studies exist. METHODS: A systematic review of original incisional hernia studies was conducted to include 2 primary end points: hernia recurrence and surgical site occurrence. Analysis of variance and a Satterthwaite t test compared the devices. RESULTS: Twenty-nine studies were included in this analysis, which included 1,257 patients. The total number of studies and the total subjects for each device include the following: Permacol (Tissue Science Laboratories, Hampshire, UK) (4/64), Surgisis (Cook Medical, Bloomington, IN) (3/87), and Alloderm (LifeCell, Corp, Branchburg, NJ) (23/1,106). Device-specific recurrence rates and surgical site occurrence rates, respectively, were as follows: Alloderm (20.8%, 31.4%), Permacol (10.9%, 25%), and Surgisis (8.0%, 40.2%). A Satterthwaite t test comparison revealed significantly higher numbers of hernia recurrence (P = .006) and surgical site occurrence (P = .04) when comparing Alloderm with Permacol. CONCLUSIONS: Biologic mesh does play a beneficial role in abdominal wall reconstruction although allograft acellular dermal matrix does have a higher recurrence rate as compared with xenograft products, which limits its current role in hernia repair.