Biochemical assessment of cellular damage after adipocyte harvest.

Free fat transplantation for soft tissue augmentation yields variable results, which may be related to the technique of fat harvest. To compare the viability of adipocytes harvested by liposuction (sal) or by excision (exc), fat harvested by both techniques from seven lipectomy patients was analyzed by glycerol-3-phosphate dehydrogenase (G3PDH) enzyme assay. Leakage of this lipogenic enzyme through the plasma membrane is a potential indicator of fat cell damage. Preliminary experiments showed this assay to be sensitive and specific for adipocyte G3PDH activity. Treatment of fat tissue with collagenase H resulted in complete release of the component fat cells for analysis with less loss of G3PDH activity, compared to other collagenase preparations. Each sample was digested and separated into three compartments: mature adipocytes-floating layer (F), acellular supernatant (S), and stromal pellet (P). Samples from each compartment were assayed for G3PDH activity, normalized to DNA content, and represented as a percentage of the whole (F + S + P). Within the subgroups, the fat cell fraction of the liposuction samples (Fsal) showed statistically more activity than the excised samples (Fexc) by paired Student's t test (P = 0.004). The supernatant (representing leaked G3PDH) and pellet fractions of excised samples revealed more G3PDH activity than the same fractions from liposuctioned tissue; the former (Sexc) to a significant degree (P = 0.036). Using this assay, the results indicate that liposuction fat harvest does not result in increased fat cell damage compared to fat harvested by excision.

Abdominal surgery in patients with severe morbid obesity.

At the University of Massachusetts Medical Center, from 1984 to 1992, we performed laparotomy or panniculectomy on 42 individuals weighing from 290 to 600 pounds, each with a height-weight index of over 55. All patients weighted more than 220 percent of ideal body weight. Follow-up ranged 8 to 52 months. All patients underwent panniculectomy except one. Pannus resection was performed by means of a large transverse ellipse. A suprapubic wedge resection often was used to minimize the discrepancy between the lengths of the upper and lower transverse incisions. With severe discrepancy, lateral V-flaps also were utilized to minimize the lateral dog-ear. To facilitate preparation, pannus exsanguination, and surgical resection, 10 to 12 towel clips or 4 to 5 large K-wires or Steinmann pins were passed through the central pannus. These were then suspended by rope from the overhead lighting. A two-team approach appears to have distinct advantages, including minimized blood loss, operative time, pulmonary compromise, and hospital stay. The technical difficulties of manipulating a large pannus were simplified by pannus suspension. Early preoperative involvement of the entire operative team, particularly the plastic surgeon, the anesthesiologist, and the nursing staff, allows for proper evaluation of underlying medical problems and appropriately detailed anesthetic and surgical planning. Surgical management of the abdominal pannus in the morbidity obese patient in this series was performed with apparent clinical efficacy, reasonable safety, and long-term functional improvement.

Improved mammographic imaging using tissue expanders for breast augmentation.

Several studies indicate that mammographic evaluation of the breast is inhibited by both submammary and submuscular implants, regardless of implant composition. Two hundred radiographs were evaluated following subpectoral placement of 25 combination gel/saline and 25 saline-filled tissue expanders. Within 3 months after augmentation, mammograms were performed using the standard and displacement techniques; patients with inflated implants were followed by a repeat displacement study (with the expander deflated). After completion of the mammogram, expanders were reinflated. Our experience demonstrates that better visualization of breast tissue may be accomplished by implant-deflated views in patients with small amounts of breast tissue, tight skin envelopes, or capsular contraction. In each of these circumstances, the displaced view failed to adequately demonstrate glandular tissue. The presence of the inflated implant impairs mammographic visualization in a number of ways, including implant opacity, impaired automatic exposure control, interference with breast compressibility, and implant displacement. These effects are consistently present in small breasts (< an estimated 300 g), in breasts with grade III or IV capsular contracture, and in breasts with minimal skin laxity (i.e., nonptotic breasts). Breast compression was compromised to a greater degree in the presence of grade III and IV capsular contracture; however, deflation of an adjustable implant optimized radiographic interpretation to a high degree. The deflatable saline implant yields a less obscured evaluation of the augmented breast. We suggest that an extended-use deflatable device (i.e., tissue expander) be considered as an option in our search for a safe and reliable implant for augmentation mammoplasty, particularly in patients with small breasts, tight skin envelopes, or a propensity for capsular contracture.

Reduction mammaplasty improves symptoms of macromastia.

The condition macromastia has not been defined and characterized precisely by the medical community. Whether the patient with hypertrophic breasts is a candidate for or can be helped by reduction mammaplasty is unclear to both the medical and the lay community. A prospective study of 39 women undergoing reduction mammaplasty surgery was initiated to answer these questions. Patients rated the severity of their somatic pain symptoms and discomfort before reduction mammaplasty and again after complete recovery. The severity of their symptoms and complaints was numerically graded and analyzed. These data were compared with similar data obtained from 40 "small-breasted" women of similar age. Headache, neck pain, back pain, shoulder pain, and bra strap groove pain were present in 60 to 92 percent of patients, and 97 percent of patients had at least three of these pain symptoms preoperatively. All the patients had reduction of their pain symptomatology postoperative, and 25 percent of the study patients had total elimination of pain symptoms by reduction mammaplasty. The postoperative incidence and severity of pain symptoms and discomfort complaints were statistically equivalent to or less than the levels in the control group.

Technical considerations in pectoralis major transfer for treatment of the paralytic elbow.

Modification of pectoralis major transfer as originally described by Clark in 1946 have not addressed concerns such as diminished strength and excursion of the transfer, along with obligatory supination of the forearm. Postoperative scarring from the long oblique chest incision further compounds the psychological impairment that accompanies brachial plexopathy. One hundred forty-three brachial plexopathies were seen over a five-year period. Seven pectoralis major transfers were done to restore elbow flexion in patients with C5-6 and C5-6-7 cord injuries. Mean age and follow-up were 26 years and 25 months respectively. The modifications of this transfer we use improve strength and range of motion by preserving dual innervation of the muscle, by tubularization of the transfer, and by restoration of the transverse aponeurosis as a fascial pulley. By transfer of the pectoralis insertion to the acromion, further anterior shoulder stability may be obtained. Aesthetics can also be improved by use of selected midline and deltopectoral incisions, along with preservation of the remaining pectoralis major and minor.

Aesthetic results following partial mastectomy and radiation therapy.

This study was undertaken to determine the aesthetic changes inherent in partial mastectomy followed by radiation therapy in the treatment of stage I and stage II breast cancer. A retrospective analysis of breast cancer patients treated according to the National Surgical Adjuvant Breast Project Protocol B-06 was undertaken in 57 patients from 1984 to the present. The size of mastectomy varied between 2 x 1 cm and 15 x 8 cm. Objective aesthetic outcome, as determined by physical and photographic examination, was influenced primarily by surgical technique as opposed to the effects of radiation. These technical factors included orientation of resections, breast size relative to size of resection, location of tumor, and extent and orientation of axillary dissection. Regarding cosmesis, 80 percent of patients treated in this study judged their result to be excellent or good, in comparison to 50 percent excellent or good as judged by the plastic surgeon. Only 10 percent would consider mastectomy with reconstruction for contralateral disease. Asymmetry and contour abnormalities are far more common than noted in the radiation therapy literature. Patients satisfaction with lumpectomy and radiation, however, is very high. This satisfaction is not necessarily based on objective criteria defining aesthetic parameters, but is strongly influenced by retainment of the breast as an original body part.

Autogenous vein graft repair of digital nerve defects in the finger: a retrospective clinical study.

Twenty-two digital nerve repairs were performed in the finger using autogenous vein grafts. Eighty-two percent of the repairs were available for follow-up. Results of sensibility return were assessed using moving two-point discrimination, Semmes-Weinstein monofilaments, and vibratory testing. Two-point discrimination averaged 4.6 mm for 11 acute digital nerve repairs using vein conduits 1 to 3 cm in length. Delayed digital nerve repair with vein conduits yielded poor results. Semmes-Weinstein values demonstrated comparable levels of return of slowly adapting fiber/receptors to the quickly adapting fiber/receptors, as evidenced by moving two-point discrimination tests. Vibratory sensibility was present in all. A review of previous experiences with end-to-end digital neurorrhaphies and digital nerve grafting suggests that repair of 1- to 3-cm gaps in digital nerves with segments of autologous vein grafts appears to give comparable results to nerve grafting. Further laboratory and clinical research is necessary to better define the role of interpositional vein conduits for repair of peripheral nerves.

Management of massive ovarian tumors.

Two patients with massive ovarian tumors, one with a 51 kilogram Stage IC mucinous cystadenocarcinoma and the other with a 34 kilogram mucinous cystadenoma, are presented. Problems associated with resection of massive ovarian tumors, including respiratory failure, intraoperative fluid shifts, adequate exposure, orthostatic hypotension and adynamic intestine, are identified. Guidelines for avoiding these pitfalls by the use of appropriate monitoring, controlled drainage of the cyst and transverse elliptic incision with abdominoplasty are suggested.

Needle localization and surgical management of occult breast lesions.

Screening mammography can locate small breast cancer lesions not detectable on physical examination. In this study, the records of 57 patients undergoing radiographically guided preoperative needle localization were reviewed for the period August 1986 to May 1988. Of the 57 cases, 15.8% were positive for cancer and 84.2% were benign breast lesions. Invasive ductal carcinoma was the pathologic diagnosis in all malignant biopsies, except for one case of carcinoma in situ. All positive lesions had shown as microcalcifications on mammogram. The authors examine the criteria for biopsy and discuss their experience with needle localization of occult breast lesion suspicious of breast cancer.

Non-Caucasian rhinoplasty: a 16-year experience.

Rhinoplasty was performed in 134 non-Caucasians over a 16-year period. The indications and techniques for operative approaches pertinent to achieving facial balance and symmetry in the non-Caucasian are described. Alar flaring is best addressed with alar base resection. Alar base resection does not significantly narrow alar width. Reduction in interalar distance is best performed with interalar reduction. If alar flare and wide interalar distance coexist, one should always consider a secondary or tertiary procedure. Planning a secondary procedure avoids devitalizing tissues and multiple super-imposed incisions and permits minor revisions. A simplified approach to removal of excessive tip fat is discussed. Methods of addressing complications peculiar to non-Caucasian rhinoplasties are described. In order to avoid racial incongruity, one must incorporate an alar narrowing procedure, i.e., interalar reduction or alar sill advancement. The results of this study reemphasize the importance of analyzing the nose with respect to the rest of the face in order to establish guidelines for these often difficult nasal reconstructions.

The posterior calf fascial free flap.

Six posterior calf fascial free flaps were employed to reconstruct defects of the upper and lower extremities. One flap failed due to a constricting dressing. Two flaps sustained partial loss secondary to bleeding and hematoma formation. One flap dehisced at the distal suture line due to mobility of an underlying fracture. All surviving flaps eventually healed and resulted in stable, thin coverage. Donor-site morbidity has been minimal. Shortcomings of this flap model have been defined in the peculiarities of its thinness, diffuse vascular oozing, the extent of the vascular territory, and in postoperative monitoring. These problems are analyzed and recommendations for their resolution are presented. Fascia represents a unique tissue which offers an exciting new dimension in the reconstruction of certain defects--particularly those in which thinness is a desirable option. In the posterior calf model, the inclusion of fat represents an alternative modification that allows the surgeon to tailor the design to a variety of problems where fascia alone is too thin and a cutaneous flap is too thick. This concept may find its greatest application in wounds involving the hand or foot. We believe that this and other fascial flap prototypes may offer an ideal solution for reconstruction of major wounds of the extremities.