Fleur-de-lis panniculectomy after bariatric surgery: our experience.

BACKGROUND: Plastic surgeons are faced with increasing numbers of patients presenting for insurance-covered skin excision procedures following bariatric surgery. Panniculectomy for symptomatic relief of rashes is commonly performed, but an isolated infraumbilical amputation-type panniculectomy is a highly unaesthetic procedure, leaving many patients deeply dissatisfied. It may be also fraught with complications due to large incisions and potential for dead-space. In these patients, many surgeons avoid the fleur-de-lis panniculectomy, despite the body contour aesthetic advantage, because of increased time, more scarring, and a perceived increase in complications. METHODS: This is a retrospective chart review of 130 consecutive postbariatric surgery patients who had panniculectomy over a 2-year period at our institution. RESULTS: A total of 30 patients underwent a traditional panniculectomy and 100 patients had a fleur-de-lis panniculectomy. Mean weight loss from bariatric surgery to panniculectomy was 58.2 kg, with an average body mass index (BMI) of 30. Fifty-seven patients had additional procedures performed at the time of panniculectomy. Twenty-two patients (17%) had complications, with 5 in the traditional group (17%) and 17 in the fleur-de-lis group (17%) (P = 1.0). Six males (40%) had more complications compared with 18 females (15.7%) (P = 0.034). Patients with BMI <30 had 10 complications compared with patients with BMI ≥30 had 15 complications. CONCLUSIONS: There are many benefits of fleur-de-lis over traditional panniculectomy, even for medical necessity cases. There is limited undermining of tissue which minimizes/eliminates skin necrosis. Our experience with primarily fleur-de-lis panniculectomies shows a complication rate lower than most published data. Fleur-de-lis potentially creates a better symptom correction and cosmetic outcome by resecting maximal skin in both vertical and horizontal directions. These findings must be balanced against a potentially longer operation.

Porcine xenograft biosynthetic wound dressings for the management of postoperative Mohs wounds.

Cadaveric allografts and a large variety of other biologic dressings have been reported as being useful for the postoperative management of Mohs micrographic surgery (MMS) wounds. Although the use of porcine xenografts for the immediate postoperative management of these wounds is known, their use has not been detailed in the dermatology literature. A case series of 15 consecutive Mohs micrographic surgery patients (mean age = 74.9 years, range = 49 to 89 years) with wounds initially managed with porcine xenografts is described. Porcine xenografts were useful in a variety of clinical settings following MMS. These included: (1) wound management when tumor margins were indeterminate pending additional dermatopathology studies and (2) wound management when there are issues such as through and through nasal defects involving the mucosa, large wound depth, exposed cartilage and or bone, or patient medical comorbidities that delay or prevent plans for immediate wound reconstruction. Future controlled studies of biologic dressings are needed to determine which options are best for micrographic surgery wounds. Comparisons should also include the traditional option of second intention healing without biologic dressings.

Adductor magnus perforator flap revisited: an anatomical review and clinical applications.

BACKGROUND: The adductor magnus musculocutaneous perforator flap is a medial thigh flap whose utility is often overshadowed by that of its anatomic neighbor, the gracilis flap. It has a large, reliable pedicle and associated skin paddle. Few reports have been published describing the use of this flap as a local or free tissue transfer. The purpose of this study is to revisit and further characterize the anatomy of this extremely versatile yet underutilized flap. MATERIALS/METHODS: A total of 13 cadavers (n = 26 thighs) were dissected to identify the musculocutaneous perforators that supply the skin of the posteriomedial thigh. The vascular anatomy was studied using multiple modalities. Based on the anatomic data, a local V-Y advancement flap was designed. A total of 8 patients (n = 10 flaps) underwent reconstruction of locoregional defects. RESULTS: Our anatomic studies confirmed the presence of multiple parallel musculocutaneous perforators that travel through the adductor magnus muscle and course obliquely in a posterior-inferior direction. We found that the primary perforator is reliably found approximately 8 cm distal to the groin crease and 2 cm posterior to the posterior border of the gracilis muscle. We discovered that it is consistently accompanied by a separate perforator located 2 cm distally. Minimal dissection into the muscle revealed a Y-configuration of these 2 perforators. This configuration was present in 100% of the cadaveric dissections and is supplied by the first medial branch of the profunda femoris artery. Computed tomography angiograms depicted vascular arborization of the perforators supplying the flap. Clinical experience showed that complete flap survival was achieved in all of the cases. CONCLUSION: The adductor magnus perforator flap is a reliable flap that offers robust blood supply, through a consistent vascular pedicle, to an extensive skin territory. Our anatomic studies revealed the consistent presence of 2 proximal perforators in the medial thigh that are linked by an intramuscular Y-configuration that provides enhanced blood supply to a local V-Y advancement flap design. The location of the skin paddle on the proximal medial thigh allows for minimal donor-site morbidity as it can be closed primarily with a V-Y advancement flap design, obviating the need for skin grafting.

Single-stage forehead flap in nasal reconstruction.

The paramedian forehead flap has become the standard of care for major nasal reconstruction. The classic procedure involves a second-stage operation to divide and inset the external pedicle. We present our experience in a clinical series using single-stage forehead flap reconstruction. Our indications include elderly patients, pediatric patients treated during mission trips, and any patient in whom an external pedicle or two-stage procedure is problematic. From 2008 to 2009, 9 patients underwent a single-stage forehead flap. The majority had defects after excision of skin cancer. Our modification involves removal of radix and proximal nasal skin and fat and deepithelialization of the proximal pedicle to allow inset without excess compression or kinking. This modification avoids the sequelae of an external pedicle, which include bleeding, dressings, the inability to wear eyeglasses, and the patient's reluctance to appear in public. It safely provides acceptable results and avoids a mandatory secondary procedure.

Rare isolated trapezoid fracture: a case report.

Isolated fractures of the trapezoid are rare. Of all of the fractures of the carpus, the most common is the scaphoid, which represents 68.2% of all carpal fractures (Papp, Orthop Clin N Am 38:251-60, 2007). In contrast, trapezoid fractures represent 0.4% of all carpal injuries. Because it is an infrequently fractured carpal bone, there is a wide variety of treatment plans, including rest, immobilization, and surgery (Green and Pederson, Green's Operative Hand Surgery, Elsevier, Philadelphia, 759 pp, 2005). In this report, we describe a patient who presented with an isolated fracture of the trapezoid that was successfully treated with cast immobilization and had a full functional recovery.

Sinoviortesis, inofensiva para el cartílago / Synoviorthesis, harmless to the cartilage

En estudios previos realizados por los autores se ha encontrado el efecto de la oxitetraciclina en el cartílago articular, razón por la cual hemos buscado alternativas terapéuticas a esta sustancia. Realizamos un estudio comparando cuatro sustancias y evaluando su efecto en el cartílago articular. Estas sustancias fueron: cloruro de potasio, oxitetraciclina, etanolamina y metrotexate, las cuales se aplicaron en 20 rodillas de conejos por grupo, tomando un grupo control de igual número. Se encontró una disminución en el espesor del cartílago articular en la oxitetraciclina, pero no así en el de los expuestos a la etanolamina, de manera estadísticamente significativa.

Efecto de la oxitetraciclina sobre el cartílago articular / Oxytetracycline effect on articular cartilage

En general ha existido preocupación acerca de los posibles efectos sistémicos de los agentes utilizados en la sinoviortesis especialmente en pacientes esqueléticamente inmaduros, y acerca de la acción local de esas sustancias en el cartílago articular, sin conocer las consecuencias a corto ni a largo plazo. En este estudio experimental en animales se inyectó en las rodillas de 64 conejos de 3 meses de edad una dosis de oxitetracilina al 2% cada 2 semanas, dividiéndolos en 4 grupos que se sacrificaron respectivamente a las 48 horas, 2 semanas, 4 semanas y 8 semanas de la aplicación, teniendo adicionalmente un grupo de control en cada momento al que no se aplicó sustancia alguna. Se realizaron cortes anatómicos de las rodillas y se cuantificó el espesor del cartílago y la densidad poblacional de condrocitos. Se encontró que no había una disminución significativa en el número de condrocitos pero si una disminución progresiva del espesor del cartílago que llega al 50% a la octava semana.

Increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus in hand infections at an urban medical center.

BACKGROUND: The purpose of this article is to report the increased incidence of community-acquired methicillin-resistant S. aureus in hand infections at an urban medical center. METHODS: The authors performed a retrospective review of all patients with hand infections over a 21-month period, and all patients with culture-positive methicillin-resistant S. aureus were identified. Cases determined to be nosocomial were excluded. The study period was divided into three 7-month periods. RESULTS: A total of 343 hand infections were treated over a 21-month period. Eighty-nine patients (26 percent) with culture positive methicillin-resistant S. aureus were identified; of these, 75 were determined to be community-acquired methicillin-resistant S. aureus patients. Statistical analysis was performed using the Fisher's exact test (p < 0.0001), the chi-square test for equal proportions, the Cochran-Armitage trend test, and two-way analysis of variance. The demographics of the patients were compared using two-way analysis of variance, and patients were found to be similar in all three time periods with respect to mean age and sex. The incidence of community-acquired methicillin-resistant S. aureus increased to 40 percent during the last 7-month period compared with 14 percent during the first two periods. Overall, the incidence of methicillin-resistant S. aureus increased to 47 percent during the last 7 months compared with 16 percent and 17 percent in the first two 7-month periods, respectively. Based on their treatment approach and literature review, the authors have developed an algorithm to treat community-acquired methicillin-resistant S. aureus hand infections. CONCLUSIONS: The authors' findings at Temple University Hospital may help to alert health care providers to take necessary steps to control the spread of methicillin-resistant S. aureus in the community and in the inpatient setting. Cultures should be carefully followed and infections should be treated with appropriate antibiotics.

Efecto de la osteotomía de pelvis tipo Pemberton en el cartílago articular de la cadera / Effect of type Pemberton osteotomy of the pelvis in the articular cartilage of the hip

La osteotomía periacetabular de Pemberton es un procedimiento que modifica la forma y volumen del acetábulo al descender su porción anterolateral, teniendo como fulcro el cartílago triradiado. Este cambio en la conformación del acetábulo produce un pliegue en la superficie del cartílago articular. Este estudio es un modelo experimental en animales, con 20 conejos raza Nueva Zelanda de 3 meses de edad , en los que se realizó la osteotomia pélvica tipo Pemberton, que describe el proceso de reparación y remodelación del cartílago articular. Se encontró la formación de un pliegue en el cartílago después de realizar la osteotomia, el cual se remodela de manera parcial en el curso de 8 semanas. Además se observó durante el proceso reparativo inicialmente una reacción inflamatoria, luego se encuentra una disminución del espesor del cartílago y de la densidad de condrocitos, que se recuperó parcialmente luego de 8 semanas.