Preoperative MRI to Improve Aesthetic Outcomes in Secondary Mastopexy Augmentation: A Step-by-Step Approach.

Background: Secondary mastopexy augmentation is challenging because of compromised blood supply to the nipple areola complex (NAC). The operating surgeon often relies on clinical judgment and may perform a more conservative elevation of the NAC to minimize the risk of nipple necrosis. Despite this, the danger of necrosis persists. In our experience, MRI with contrast has enhanced preoperative planning in both cosmetic and reconstructive cases. Objectives: The goals of this article are to describe our use of preoperative MRI in identifying the blood supply to the NAC, evaluating dermo glandular thickness, decreasing surgical complications, and improving outcomes in secondary mastopexy augmentation. Methods: A consecutive series of secondary mastopexy augmentation procedures performed in 2021 were reviewed. In each case, preoperative maximum intensity projection (MIP) and/or high-resolution T1-weighted contrast enhanced MRI imaging was reviewed to elucidate the blood supply to the NAC and quantify the dermo glandular thickness. The imaging was used to formulate the operative plan. Preoperative and postoperative photographs were compared. Results: Eight cases were performed, four of which were selected to demonstrate our method using breast MRI with contrast in step-by-step approach. Patient satisfaction was high. The NAC survived in all cases. Conclusions: Surgeons can utilize preoperative breast MRI for strategic operative planning when performing secondary mastopexy augmentation. Visualization of the blood supply to the NAC and dermo glandular flap thickness are vitally important when performing a more aggressive lift of the breast.

Autologous mastectomy reconstruction: Communication among the breast surgery team to maximize aesthetic and oncologic outcome.

Mastectomy breast reconstruction with autologous tissue is challenging. Oncologic and aesthetic goals face previous surgical scars, radiation, chemotherapy, or other comorbidities. We describe a simple approach for autologous mastectomy reconstruction so that breast and plastic and reconstructive surgeons can maximize aesthetic outcomes and minimize wound complications. A retrospective chart review was done on patients who underwent mastectomy and autologous reconstruction. The surgical flight plans were reviewed to delineate an approach, and pre- and postoperative photographs were examined to create a step-by-step process. The most encountered mastectomy and autologous flap reconstruction scenarios were categorized to create a step-by-step process. Successful autologous mastectomy reconstruction to optimize aesthetic outcome and minimize complications requires team communication. Creation of a surgical flight plan using information from the physical examination, MRI and adjunctive imaging, and preoperative photographs is imperative. Thoughtful incision choice and exposure approach are paramount.

Facial reanimation by staged, split masseter muscle transfer.

BACKGROUND: Facial paralysis of the lower face presents severe functional and aesthetic disturbance to patients. The gamut of facial paralysis correction is diverse and must be tailored to the patient. When nerve repair or free functional muscle transfer is unavailable, regional muscle transfer has become a staple in surgical management of facial paralysis. Previous masseter transfers relied on orbicularis oris attachment, which may be atrophic, adhered, or lengthened. Using fascia lata grafts, we describe the senior author's method of staged, split masseter transfer as a reliable method for reanimating the lower third of the face in appropriate candidates. METHODS: The staged, split masseter muscle transfer is a 3-part repair. The first stage places a hemioral fascia lata graft to act as an anchor reinforcement. The second stage transfers the split masseter muscle, suturing to the fascia lata reinforced oral commissure. The third stage, a reefing procedure, is performed 6 to 10 months later under local anesthesia to reinforce attachments. RESULTS: Six patients underwent the staged, split masseter muscle transfer. Mean age was 43 (15-67) years. Mean time to surgery from onset of deficit was 174 months (3 months to 65 years). All patients had significant improvement over preoperative symptoms. Symmetry was restored in repose. On movement, commissure excursion went from 0 to 6.67 mm in the superolateral vector. Of the 6 patients, 5 required an average of 1.5 outpatient revisions to achieve satisfactory results on average of 4.67 (4-127) months after the final stage. CONCLUSIONS: The staged, split masseter transfer is useful for restoring subtle reanimation in patients presenting with facial paralysis. The staged, split masseter transfer provides bulk and restores both static and dynamic function. We present a case series demonstrating excellent long-term functional results.

Approaching revisional surgery in augmentation and mastopexy/augmentation patients.

BACKGROUND: Breast augmentation and mastopexy augmentation procedures are becoming more common. The young plastic and reconstructive surgeon is often challenged revisional surgery operations in these patients. These cases are challenging, require significant operative time, and can be associated with a high revision rate. It is important for the young surgeon to have an approach to deal with these common and difficult scenarios. METHODS: A retrospective chart review was conducted on all patients who underwent a revision augmentation or revision mastopexy augmentation procedure between 2008 and 2010 by the authors. The most commonly encountered mitigating circumstances in the revision augmentation or revision mastopexy augmentation populations were identified and an algorithm was created on how to address these difficult problems. RESULTS: Between July 1, 2008 and July 1, 2010, 264 patients underwent revision augmentation or revision mastopexy augmentation procedures. The most commonly encountered patient scenarios were recurrence of ptosis, recurrent capsular contracture, implant malposition, rippling, and desiring a reduction in implant size. We encountered many mitigating circumstances that complicated the revisions. We devised a stepwise algorithmic approach to address these problems based on the following factors: (1) blood supply to the nipple-areola complex, (2) need to change implant plane, (3) patient desire to reduce or increase in breast implant volume, (4) need for total en bloc capsulectomy or capsulorrhaphy, (5) incision approach used to perform the capsulectomy, and (6) patient-related factors that need to be medically optimized or treated before, during, and after surgery. By adhering to these steps, outcomes can be accomplished more reliably and safely. CONCLUSION: Specialized preoperative planning is necessary to consistently deliver safe and aesthetic revision augmentation and revision mastopexy augmentation results. It is important for the operative surgeon to carefully consider the potential adverse effect of implants and prior mastopexy or reduction incisions and patterns on the blood supply to the nipple-areola complex. With educated planning, successful results can be achieved in most cases, and the risk of serious complications can be minimized.

Reconstruction of an entire metacarpal and metacarpophalangeal joint using a fibular osteocutaneous free flap and silicone arthroplasty.

Radical resection of the entire ring finger metacarpal for a giant cell tumor resulted in a bony defect extending from the distal surface of the hamate to the proximal surface of the proximal phalanx. We reconstructed the metacarpal with a custom-contoured free fibular osteocutaneous flap and maintained motion at the new fibulophalangeal joint using a silicone arthroplasty. At 4.5 years postoperatively, the patient has shown no signs of recurrence of the giant cell tumor. The silicone arthroplasty has maintained 15° to 85° of motion at the new joint. Because of its similar shape to a metacarpal and because it allows faster bony healing compared with a nonvascularized fibular bone graft, a free vascularized fibular bone graft is an ideal candidate for reconstruction of extensive defects of the metacarpals, and placement of a silicone spacer in its distal medullary cavity can preserve motion at the new metacarpophalangeal joint.

Lateral breast flap with superomedial pedicle breast lift.

BACKGROUND: Single-stage, durable aesthetic contouring of the volume-depleted and ptotic breast remains a challenge for plastic and reconstructive surgeons. These challenges are often even more difficult in the patient who has undergone massive weight loss (MWL). OBJECTIVES: The authors describe their technique of reshaping the breasts of MWL patients with laterally-based breast flaps during a superomedial pedicle breast lift. METHODS: A total of 20 patients were treated in a private clinic by one of the authors between April 2006 and January 2010 were included in this study. Each patient underwent breast reshaping with mastopexy, lateral breast autoaugmentation, and implant insertion. A laterally-based breast flap was developed to augment the involuted and ptotic breast and was dissected in conjunction with the superomedial pedicle breast lift to maintain the implant position, prevent bottoming out, and provide tissue coverage between the skin and breast implant in the advent of wound breakdown. RESULTS: Mean follow-up for this patient series was 19.5 months (range, two to 47). The average patient age was 41 years (range, 21 to 56), and the majority of patients had Grade 2 ptosis (14 out of 20). The average volume of the implants in this study was 350 cc (range, 275 to 600). There were no instances of seroma or wound infection. Five patients had minor instances of wound breakdown, but none required surgical revision. One patient developed early capsular contracture and required revision. That same patient developed a small hematoma. Patient self-evaluation revealed a high level of satisfaction; all 20 patients reported being happy with their results. CONCLUSIONS: The laterally-based breast flap, in combination with the superomedial pedicle mastopexy, is a powerful tool for use in the postbariatric or postpartum patient in whom the majority of the breast parenchyma is needed to fill the skin envelope. This flap serves to improve overall breast shape by providing added tissue along the deficient inferior pole, relieving some of the unaesthetic lateral chest wall excess and providing an additional layer of support inferiorly along the fold.

Successful salvage of venous thrombosis of a free flap by creation of a venocutaneous fistula.

This report describes the creation of a venocutaneous fistula to salvage a free fibular osteocutaneous flap compromised by extensive venous thrombosis. This technique has previously been described for salvage of digital replants, but this is the first report of a venocutaneous fistula being used to salvage a free flap. A 21-year-old woman underwent a 9-cm resection of the distal left tibia for an aneurysmal bone cyst. A contralateral right fibular osteocutaneous free flap was used for reconstruction. On postoperative day 2, the skin paddle showed evidence of venous congestion. Reexploration demonstrated extensive thrombosis throughout the entire venous system of the flap. The venae comitantes were transected as far back as possible and brought to the surface of the skin through two small stab wounds to allow venous egress. After a short course of heparin and dextran, the skin flap healed uneventfully and both osteosynthesis sites consolidated. A venocutaneous fistula provides a path of relatively low resistance for venous outflow, improving the arterial inflow-venous outflow balance for a short time until neovascularization and collateral venous channels develop. The venocutaneous fistula technique may be considered for salvage of free flaps compromised by extensive venous thrombosis.

Temporalis fascia for lip augmentation.

BACKGROUND: The pervasiveness of the desire for beautiful lips persists today, with women in the United States spending almost 2.9 billion dollars annually on cosmetics and lip products. The lips occupy the central feature of the lower third of the face and are of paramount importance to facial beauty. Various surgical approaches and methods are used in lip augmentation. METHODS: We reviewed the charts of 7 patients who underwent temporalis fascia lip augmentation to evaluate the temporalis fascia as a safe and effective means for lip augmentation. RESULTS: The average follow-up was 5 years (range, 4-6 years). All patients who underwent lip augmentation were female. The average age of the patients was 47 years old with a range of 36 to 67 years. All patients were very satisfied with the results of their surgical lip augmentation postoperatively and no patients required any revision operations. CONCLUSION: Temporalis fascia is a safe method of lip augmentation and is durable and long lasting. Lip augmentation with temporalis fascia can easily be performed in conjunction with other procedures.

Functional limb salvage following muscle rigor in a pediatric patient.

Acute limb-threatening ischemia is a vascular surgical emergency. Traditionally, 4 to 6 hours are usually available from the onset of acute ischemia to successfully revascularize before irreversible damage occurs. The presence of ischemic rigor traditionally represents irreparable local damage to muscle in the adult population and is an indication for limb amputation. Although the literature is scarce on this topic, few authors have reported superior limb salvage rates in pediatric patients despite the presence of severely impaired arterial perfusion. We present a case of a 10-year-old girl with rigor of the left lower extremity, who underwent surgical reperfusion for acute ischemia approximately 14 hours after the initiation of symptoms. The patient presented with an insensate and paralyzed limb. Pulsatile flow was restored to her lower extremity. She regained protective sensation and suffered no significant sequelae of systemic reperfusion syndrome.

Difficulties with subpectoral augmentation mammaplasty and its correction: the role of subglandular site change in revision aesthetic breast surgery.

BACKGROUND: Difficulties that arise with subpectoral breast implant placement include the following: malpositioning of the implant; improper superior contouring; and unnatural movement with chest muscle contraction. Correction of these deformities is easily achieved by removal of the subpectoral implant, resuspension of the pectoralis major muscle to the chest wall, and reaugmentation with a new implant in the subglandular plane. This study defines a correction modality for the adverse results of subpectoral implant placement in augmentation mammaplasty. METHODS: Pectoralis major resuspension was performed in 36 patients undergoing revision aesthetic breast surgery from 1995 to 2006. All patients had previously placed subpectoral breast implants performed elsewhere with unwanted movement, malposition, and/or capsular contracture. All patients underwent explantation of the breast implant, modified capsulectomy, pectoralis major resuspension, and reaugmentation of the breast in the subglandular position. In cases of symmastia, medial capsulodesis and sternal bolster sutures were used. Patients were evaluated for resolution of symptoms, satisfaction, and complications. RESULTS: Malposition (62 percent), capsular contracture (53 percent), and symmastia (10 percent) were the most common indications for revision, but 100 percent of patients were dissatisfied with abnormal breast movement. The average follow-up time was 20 months. The silicone implants were commonly used, with an average volume change decrease of 27 cc. Unwanted implant movement was eliminated completely (100 percent), symmastia was corrected (100 percent), and capsular contraction was significantly decreased in each respective group. Patient satisfaction with this procedure was high, with a low complication rate. CONCLUSIONS: Pectoralis major resuspension can be performed successfully in aesthetic breast surgery. It can be applied safely to correct problems of unwanted implant movement, symmastia implant malposition, and capsular contraction. The use of silicone gel implants in a novel tissue plane may be beneficial in this diverse, reoperative patient population.

Nasopharyngeal encephalocele: report of transcranial and transpalatal repair with a 25-year follow-up.

BACKGROUND: : Encephaloceles are an extension or protrusion of any intracranial matter through a cranial bone defect. The sphenoethmoidal encephalocele is often fatal. For those who survive long enough, expeditious repair is critical. We report a case that was repaired successfully via a combined transcranial and transpalatal approach, and because of successful repair, the patient underwent multiple secondary reconstructions resulting in a 25-year follow-up. CLINICAL REPORT: : A 3960-g, term male infant from a normal gestation was delivered via cesarean delivery for breech position. Initial examination revealed a 2 x 3-cm gray intraoral nasopharyngeal mass with smooth mucosal covering extruding through a midline palatal cleft. At 4 weeks of life, extradural and intradural exploration of the encephalocele was performed via a bifrontal craniotomy. At 15 months of age, the patient underwent median cleft lip repair. At 6 years of age, hypertelorism was corrected by wedge resection of the frontal and nasal bones and medial mobilization of the orbits. Follow-up was continued until 25 years of age, which revealed excellent maintenance of correction. CONCLUSION: : Sphenoethmoidal encephalocele is a rare sporadic congenital cranial floor defect associated with typical facial and cerebral anomalies. Encephaloceles extending into the nasopharynx may cause airway obstruction and feeding difficulty and present a potential pathway for central nervous system infection. Repair of the encephalocele should then be performed as soon as possible. Care of patients with nasopharyngeal encephaloceles requires a lifetime of reconstructive surgery. Care of these patients can be rewarding to both families and surgeons.

Three tenets for staged correction of Kleeblattschädel or cloverleaf skull deformity.

BACKGROUND: Patients with cloverleaf skull deformity are known to have high morbidity and poor outcome. Physical anomalies include a misshapen, trilobar skull, with a high "bossed" forehead, a bulging temporal region, and a flat posterior skull from multiple cranial suture fusion. METHODS: Patients with cloverleaf skull deformity treated at the University of California, Los Angeles from 1990 to 2006 (n = 14) underwent early cranial vault remodeling (group 1) or staged correction with ventriculoperitoneal shunt (neonate), fronto-orbital advancement (3 to 6 months), and posterior vault remodeling (1 year) (group 2). Morbidity, necessary revisions, and neurologic (developmental testing) and aesthetic (Whitaker score) outcomes were assessed at follow-up. RESULTS: Diagnoses included Apert syndrome, Crouzon syndrome, Pfeiffer syndrome, Saethre-Chotzen syndrome, and nonsyndromic. Early cranial vault remodeling patients had more complications than staged correction patients [pneumonia, meningitis, and excessive bleeding (each 66 percent versus 9 percent); wound infection (66 percent versus 18 percent); and seizure (100 percent versus 0 percent)]. Early cranial vault remodeling patients had prolonged intensive care unit and hospital stays compared with staged correction patients (13 versus 2 days and 27 versus 5 days, respectively). The Whitaker score showed acceptable results at 18 months in group 2 (1.4, no revisions necessary) but not in group 1 (2.8, minor to major bony recontouring). Developmental tests showed that all early cranial vault remodeling patients had lower scores in both preschool tests and global evaluations compared with normative data (mean preschool receptive scores, 95 versus 85; mean preschool expressive scores, 94 versus 87). CONCLUSION: Staged correction of cloverleaf skull provided acceptable neurologic and aesthetic outcomes in the authors' series of patients.

Risk factors for abdominal donor-site morbidity in free flap breast reconstruction.

BACKGROUND: The lower abdomen is the most popular donor site for autologous tissue breast reconstruction. Several studies have reported abdominal morbidity following pedicled and free flap reconstructions using this donor site, yet few studies have compared the various types of free flaps and investigated specific operative and patient-related factors that are associated with higher rates of abdominal complications. METHODS: The authors conducted a retrospective review of all free flap breast reconstructions performed at University of California Los Angeles Medical Center between July of 2002 and July of 2005. RESULTS: A total of 279 patients underwent 211 unilateral and 68 bilateral reconstructions, totaling 347 flaps. Eleven percent were free transverse rectus abdominis myocutaneous (TRAM) flaps, 52 percent were muscle-sparing free TRAM flaps, and 37 percent were deep inferior epigastric perforator (DIEP) flaps. Mean follow-up was 29.9 months. There were 30 total abdominal complications (10.9 percent of patients), including 17 rectus bulges and five hernias. Free TRAM reconstructions had a significantly higher rate of donor-site complications than did DIEP reconstructions. Bilateral flap harvests and obesity (body mass index >30) were significant risk factors for (1) any donor-site complication and (2) rectus bulge/hernia formation. There was no significant increase in donor-site complications associated with various prior abdominal operations. CONCLUSIONS: Donor-site complications are not uncommon, but paying careful attention to patient comorbidities when selecting an operative approach (bilateral versus unilateral, free TRAM versus DIEP, and so on) can minimize postoperative abdominal complications. Furthermore, the results corroborate the recent literature suggesting there is little functional difference in patients receiving muscle-sparing free TRAM versus DIEP reconstructions.

Pediatric facial fractures: current national incidence, distribution, and health care resource use.

To date, reports on the incidence and distribution of pediatric facial fractures have been inconsistent and have originated only from institutional studies. The need for current national data exists. We examined the Kids' Inpatient Database and the Nationwide Inpatient Sample to obtain national information on facial fracture discharges from 1997 to 2003. Data showed that pediatric patients (age, 0-17 years) make up 14.7% of all facial fractures, with children aged 1 to 4 years comprising only 5.6% of the total and children 15 to 17 years old making up more than half the group. The male-to-female ratio was 2.5. Significantly lengthier hospitalizations were observed with female patients, Medicaid insurance, teaching hospitals, government hospitals, and metropolitan hospitals. Significantly higher charges were associated with patients aged 1 to 4 years, Medicaid insurance, Western US geography, teaching hospitals, metropolitan hospitals, and children's hospitals. During the 6-year period of this study, there was a trend toward (1) increased hospital charges (with stable costs), (2) more patients treated at teaching hospitals, and (3) a convergence in length of stay between hospitals with differing ownerships (with government hospitals having progressively shorter hospitalizations, whereas private for-profit hospitals have progressively lengthier hospitalizations). The incidence of facial fractures in children is small yet significant and has remained stable during the past few decades. Certain patient populations are prone to facial fractures, and various patient and hospital factors are associated with lengthier and more expensive hospitalizations. An understanding of disparities in resource use among various patient, hospital, and geographic settings is critical for physicians and policy makers.

Upper lip augmentation: palmaris longus tendon as an autologous filler.

BACKGROUND: Lip augmentation is used to enhance a thin upper lip or correct lip deficiencies. The palmaris longus tendon, an accessory tendon of the wrist, has been used successfully for upper extremity reconstruction and was used in this case series for upper lip augmentation. METHODS: Patients underwent upper lip augmentation using palmaris longus tendon grafts at the University of California, Los Angeles from 1998 to 2005 (n = 38). Vertical lip height, lateral lip projection, and dynamic smile length were measured preoperatively, at 6 weeks, and at 1-year follow-up, and complications, lip mobility, and physician/patient outcome surveys were recorded. RESULTS: Palmaris graft lip augmentation was performed for cosmetic (n = 21) and reconstructive (n = 17) indications. There were two infections and two graft exposures, with no long-term sequelae. The vertical height of the upper lip had a mean increase of 204 percent and a mean relapse of 9 percent (change from postoperative period to follow-up). Lateral projection of the upper lip showed a mean increase of 180 percent and a relapse rate of 7 percent. Dynamic lip mobility had a mean grade of 4.7 of 5 at 1 year, and the postoperative smile length was close to the preoperative length (mean postoperative length was 96 percent of preoperative length). One patient developed a stiff upper lip and required reoperation and therapy for a good final outcome. CONCLUSION: The authors' case series shows that the palmaris longus tendon provides a reliable option for soft-tissue upper lip augmentation, with improved vertical height and lateral projection and maintenance of lip mobility.

Reduced morbidity and improved healing with bone morphogenic protein-2 in older patients with alveolar cleft defects.

BACKGROUND: In older cleft patients, alveolar bone grafting may be associated with poor wound healing, graft exposure, recurrent fistula, and failure of tooth eruption. A new procedure using a resorbable collagen matrix with bone morphogenetic protein (BMP)-2 was compared with traditional iliac crest bone graft to close alveolar defects in older patients. METHODS: Skeletally mature patients with an alveolar cleft defect undergoing alveolar cleft repair were divided into either group 1 (BMP-2, experimental) or group 2 (traditional iliac graft, control) (n = 21). Bone healing was assessed with intraoral examination and NewTom scans (three-dimensional, Panorex, periapical films). Donor-site morbidity was determined with pain surveys. Overall cost and length of hospital stay were used to examine economic differences. RESULTS: Preoperative and follow-up (1 year) intraoral examinations revealed fewer complications (11 percent versus 50 percent) and better estimated bone graft take in group 1 compared with group 2. Panorex and three-dimensional computed tomographic scans showed enhanced mineralization in group 1 compared with group 2. Volumetric analysis showed group 1 had a larger percentage alveolar defect filled with new bone (95 percent) compared with group 2 (63 percent). Donor-site pain intensity and frequency were significant in group 2 but not group 1. The mean length of stay was greater for group 2 compared with group 1. In addition, the mean overall cost of the procedure was greater in group 2 ($21,800) compared with group 1 ($11,100). CONCLUSIONS: For this select group of late-presenting alveolar cleft patients, the BMP-2 procedure resulted in improved bone healing and reduced morbidity compared with traditional iliac bone grafting.

Bilateral lower extremity gangrene requiring amputation associated with heparin-induced thrombocytopenia: a case report.

Heparin is a common cause of thrombocytopenia in hospitalized patients. Between 10% and 15% of patients receiving therapeutic doses of heparin develop thrombocytopenia. Heparin-induced thrombocytopenia (HIT) can cause severe bleeding and thrombosis owing to intravascular platelet aggregation. HIT must be distinguished from other causes of thrombocytopenia. Importantly, heparin use is often associated with an early fall in the platelet count that usually occurs within the first 4 days of initiation and recovers without cessation of heparin treatment. This nonimmune heparin-associated thrombocytopenia has not been found to be associated with thrombosis and does not necessitate discontinuation of heparin. The authors present a case report of a 70-year-old man who received heparin therapy following aortic tissue valve replacement and aortic root repair with graft and developed bilateral lower extremity arterial clots 6 days postoperatively in the setting of positive heparin antibody titers. Ultimately the patient required bilateral above-knee amputations.

Correction of massive hydrocephalus and brain wound in holoprosencephaly.

Holoprosencephaly is a rare disorder of embryologic development that denotes an incomplete or absent division of the embryonic forebrain (prosencephalon) into distinct lateral cerebral hemispheres. In most cases of holoprosencephaly, the fetus fails to survive to term, and those that do survive have severe functional limitations, including mental retardation. We present a case report of cranial vault remodeling in a 20-month-old female who was born with holoprosencephaly and a severe number 0/14 cleft. The patient developed chronic nonhealing ulcers secondary to hydrocephalus, ventriculoperitoneal shunts, and the underlying architecture of her cranial vault.

Bilateral lower extremity gangrene requiring amputation associated with heparin-induced thrombocytopenia--a case report.

Heparin use, both prophylactically and therapeutically, is prevalent among hospitalized patients. Patients on heparin may develop a thrombocytopenia that is self-limited. Fewer patients develop a heparin-induced thrombocytopenia that can cause severe bleeding and thrombosis owing to intravascular platelet aggregation. The authors present a case report of heparin-induced thrombocytopenia in a patient who underwent aortic arch and aortic valve replacement that resulted in bilateral above-knee amputations. The patient developed limb ischemia related to heparin-associated thrombosis, but had a delay in antibody seroconversion. Early and accurate diagnosis of heparin-induced thrombocytopenia requires a high clinical suspicion and may be present despite the absence of serum antibodies.