ABSTRACT
INTRODUCTION: Diastasis recti represents a midline contour abnormality of the anterior abdominal wall that is secondary to attenuation of the linea alba. Severe diastasis recti is defined as attenuation of the linea alba as well as the linea semilunaris. Treatment options are variable and include conditioning exercises and surgical repair with or without mesh. This manuscript will review the indications and technique of onlay mesh for correction of severe diastasis recti. METHODS: Abdominoplasty with diastasis repair has been performed in 63 women from January 2010 to January 2020. Of these, 4 had repair for severe diastasis that included plication and onlay mesh. The mesh was polypropylene in 3 patients and silk in 1 patient. Indications for onlay mesh included severe diastasis as a means of further reinforcing the strength of the anterior rectus sheath. RESULTS: Of the 4 patients, all tolerated the operation well without morbidity. Natural contour was established in all. There were no infections, seromas, delayed healing or mesh removals. All drains were removed by 7 days. CONCLUSION: The use of an onlay mesh has demonstrated success and should be considered in select patients for the surgical management of severe diastasis.
Subject(s)
Abdominal Wall , Abdominoplasty , Abdominal Wall/surgery , Female , Herniorrhaphy , Humans , Rectus Abdominis/surgery , Surgical MeshABSTRACT
The options for breast reconstruction following mastectomy have greatly expanded. Current techniques include pedicle flaps and free tissue transfers. With the advent of perforator flaps, additional options have become available that have the advantage of reduced donor site morbidity. The purpose of this manuscript is to review the most common methods of breast reconstruction using autologous tissues.
Subject(s)
Breast Neoplasms/surgery , Mammaplasty/methods , Mastectomy/methods , Microsurgery/methods , Surgical Flaps/blood supply , Breast Neoplasms/pathology , Esthetics , Female , Follow-Up Studies , Humans , Tissue and Organ Harvesting/methodsABSTRACT
Pyoderma gangrenosum (PG) is a systemic disease with cutaneous manifestations consisting of necrotizing ulceration. The etiology of PG is controversial, and optimal management strategies have not been established. Current management is primarily medical to control the systemic inflammatory process, with occasional surgical intervention at the ulcer site. Based on the current literature and on the authors' clinical experience, the optimal outcome depends on early diagnoses and a combination of medical and surgical therapy. Initial management is directed toward medical control of the inflammatory process and local wound care. Surgical strategies involve recipient site preparation via local wound care and serial allograft followed by autologous skin graft or muscle flap coverage when necessary. Long-term wound stabilization is obtained only through control of the systemic and local inflammatory process.
Subject(s)
Anti-Inflammatory Agents/therapeutic use , Prednisone/therapeutic use , Pyoderma Gangrenosum/drug therapy , Pyoderma Gangrenosum/surgery , Skin Transplantation , Surgical Flaps , Aged , Female , Humans , Male , Middle Aged , Transplantation, AutologousABSTRACT
Soft-tissue defects of the head and neck are often reconstructed with fasciocutaneous free flaps. The radial forearm flap is used most commonly, however the lateral arm flap may be the flap of choice in certain situations. Advantages include flap elevation with simultaneous tumor ablation, avoidance of intraoperative patient position changes, and primary closure of the donor site. After extirpative procedures of the head and neck region, 4 patients were reconstructed with the lateral arm flap. Flap survival was 100%, a vein graft to supplement the short pedicle length was necessary in 1 patient, all donor sites were closed primarily, and secondary procedures to reduce flap bulk were necessary in 2 patients. The lateral arm flap is an excellent alternative to the radial forearm flap and should be included in the armamentarium of the reconstructive head and neck surgeon.
Subject(s)
Head and Neck Neoplasms/surgery , Plastic Surgery Procedures/methods , Surgical Flaps , Adult , Aged , Arm , Female , Humans , Male , Middle AgedABSTRACT
Temporomandibular joint dysfunction after tumor extirpation of the hemimandible is a frequent sequela after condylar head reconstruction. Condylar head resection is often performed because of oncological and vascular considerations. Recent studies have demonstrated that malignancies of the mandibular ramus and body rarely involve the condylar head, and that the vascularity and supportive structures of the condylar head are sufficient to maintain viability and function. This study demonstrates that temporomandibular joint function is preserved after hemimandibulectomy without resection of the condylar head. Fixation of a vascularized fibular flap to the condylar head is performed in situ. Condylar viability and growth is maintained with painless incisal opening. The condylar head is a growth center for the mandible in the pediatric population. Its preservation in these patients will avoid the long-term problems associated with growth center loss such as malocclusion and concomitant maxillary deformity.
Subject(s)
Bone Transplantation , Mandible/surgery , Mandibular Neoplasms/surgery , Osteotomy , Plastic Surgery Procedures/methods , Surgical Flaps/blood supply , Temporomandibular Joint Disorders/etiology , Aged , Ameloblastoma/surgery , Child , Fibula , Humans , Male , Mandibular Condyle/surgery , Mandibular Neoplasms/secondary , Osteotomy/adverse effects , Postoperative Complications , Temporomandibular Joint Disorders/prevention & control , Thyroid Neoplasms/pathologyABSTRACT
This report of 2 patients demonstrates that bilateral breast reconstruction with the latissimus dorsi musculocutaneous flap is facilitated by simultaneous elevation of the flaps in the prone position and simultaneous insetting of the flaps in the supine position. Operative time, blood loss, and position changes are minimized using this technique.
Subject(s)
Mammaplasty/methods , Posture , Surgical Flaps , Breast Neoplasms/surgery , Female , Humans , Middle Aged , Prone Position , Supine PositionABSTRACT
The management of intractable knee pain secondary to neuromata continues to be optimized. Forty-three patients with intractable knee pain were studied prospectively. Consideration for this procedure requires pain of at least a 1-year duration, failure of conservative management, pain localization at a Tinel's point, and at least a 5-point reduction of pain on a visual analog scale after nerve blockade with 1% lidocaine. Thirty patients met the criteria for the procedure and 25 patients underwent the procedure. Mean patient age was 50.3 years and mean duration of pain was 6.6 years. Pain etiology included total knee replacement in 10 patients and trauma in 15 patients. Mean number of prior operations on the knee was 5.1. Sixty-two nerves were excised in the 25 patients, including the infrapatellar branch of the saphenous nerve (N = 24), the tibiofibular branch of the peroneal nerve (N = 5), the medial retinacular nerve (N = 12), the lateral retinacular nerve (N = 8), the medial cutaneous nerve (N = 6), the anterior cutaneous nerve (N = 3), and the lateral femoral cutaneous nerve (N = 4). Complete pain relief was obtained in 11 patients (44%). Partial pain relief was reported in 10 patients (40%). No pain relief was reported in 4 patients (16%). Follow-up ranged from 1 to 4 years. Selective denervation for neuromatous knee pain is beneficial in select patients. Patient satisfaction was 84% (21 of 25 patients) after the procedure. No patient was made worse.
Subject(s)
Knee/innervation , Neuroma/surgery , Pain, Intractable/surgery , Peripheral Nervous System Neoplasms/surgery , Adult , Aged , Aged, 80 and over , Arthroplasty, Replacement, Knee , Denervation , Female , Humans , Knee Injuries/surgery , Male , Middle Aged , Pain Measurement , Patient Selection , Postoperative Complications/surgery , Reoperation , Treatment OutcomeABSTRACT
Complete excision of a giant neurofibroma can be technically difficult. Thorough preoperative planning with magnetic resonance imaging, computed tomography, and arteriography are indicated to define the extent of the mass and to facilitate operative planning. By following the treatment guidelines discussed in this case report, the authors feel that these tumors can be excised safely with minimal morbidity.
Subject(s)
Neurofibroma, Plexiform/surgery , Skin Neoplasms/surgery , Adult , Back , Humans , Male , Neurofibroma, Plexiform/blood supply , Skin Neoplasms/blood supplyABSTRACT
The management of intractable onychomycosis involving multiple fingernails continues to be optimized. Failure of pharmacological treatment necessitates operative intervention. Current surgical procedures are complex and have frequent donor site complications. This report describes a safe, simple, and effective surgical treatment that eradicates the disease, results in low morbidity, and yields high patient satisfaction.
Subject(s)
Onychomycosis/surgery , Adult , Female , Hand Dermatoses/surgery , Humans , Skin TransplantationABSTRACT
This case report illustrates a method of correction for severe hypertrophy of the frontal bone. Accurate preoperative assessment including physical examination, photographs, and radiological studies are necessary. The anterior table of the frontal bone is removed, recontoured, and stabilized to the adjacent bone while maintaining the integrity of the frontal sinus mucosa. Hydroxyapatite cement is used to resurface and contour the frontal bone. This method is demonstrated to be safe and well tolerated, and should be considered as the procedure of choice for this condition.
Subject(s)
Durapatite/therapeutic use , Frontal Bone/surgery , Osteotomy/methods , Adult , Biocompatible Materials , Humans , Hypertrophy/surgery , Male , Tomography, X-Ray ComputedABSTRACT
Current options in reduction mammaplasty for severe mammary hypertrophy include amputation with free-nipple graft as well as the inferior pedicle and bipedicle techniques. Complications of these procedures include nipple-areola necrosis, insensitivity, and hypopigmentation. The purpose of this study was to determine whether medial pedicle reduction mammaplasty can minimize these complications. Twenty-three patients with severe mammary hypertrophy were studied. The medial pedicle successfully transposed the nipple-areola complex in 44 of 45 breasts (98 percent). Mean change in nipple position was 17.1 cm, and mean weight of tissue removed was 1604 g per breast. Nipple-areola sensation was retained in 43 of 44 breasts (98 percent) using a medial pedicle. Hypopigmentation was not observed, and central breast projection was restored in all patients. This study has demonstrated that medial pedicle reduction mammaplasty is a safe and reliable technique and should be given primary consideration in cases of severe mammary hypertrophy.
Subject(s)
Mammaplasty/methods , Adolescent , Adult , Breast/pathology , Female , Humans , Hypertrophy , Middle AgedSubject(s)
Adenocarcinoma/radiotherapy , Fistula/etiology , Hip Joint/pathology , Joint Diseases/etiology , Rectal Fistula/etiology , Rectal Neoplasms/radiotherapy , Abscess/etiology , Abscess/microbiology , Adenocarcinoma/surgery , Aged , Follow-Up Studies , Hip Joint/microbiology , Humans , Joint Capsule/microbiology , Joint Capsule/pathology , Male , Postoperative Complications , Radiation Injuries/etiology , Radiotherapy, Adjuvant , Rectal Neoplasms/surgery , RecurrenceABSTRACT
This study describes the treatment protocol for and the outcome of the management of complex wounds around total knee replacements. An analysis of 28 patients (29 knees) with complex defects who had surgery between January 1, 1986, and July 30, 1996, was performed. A specific management protocol was applied to each knee on the basis of the size and depth of the wound, the presence of infection, and the quality of soft tissue. Primary treatment included local wound care, debridement, and skin grafting or coverage with a fasciocutaneous flap, pedicled muscle flap, or free muscle transfer. Postoperatively, knees were evaluated using the Knee Society objective score. Successful salvage of the lower extremity was obtained in 28 knees (97 percent) and of the knee prosthesis in 24 of 29 knees (83 percent). Secondary plastic surgery procedures were necessary in five knees (17 percent), and secondary orthopedic procedures were necessary in four knees (14 percent). Successful salvage of total knee arthroplasty in the presence of a complex wound requires early identification of infection, aggressive irrigation and debridement, and early appropriate soft-tissue coverage. The use of our proposed algorithm will facilitate management of these complex wounds.
Subject(s)
Arthroplasty, Replacement, Knee , Surgical Wound Dehiscence/surgery , Surgical Wound Infection/surgery , Adult , Aged , Aged, 80 and over , Algorithms , Debridement , Female , Follow-Up Studies , Humans , Male , Middle Aged , Reoperation , Skin Transplantation , Surgical Flaps , Treatment OutcomeABSTRACT
This article outlines the indications and technique of selective denervation for chronic knee pain secondary to neuromata from prior surgery or trauma and describes the results obtained in a series of patients who underwent selective denervation for neuromatous knee. Of the 13 patients in this series, 3 (23%) rated their outcome as excellent, 7 (54%) rated the outcome as good, and 3 (23%) rated the outcome as poor; no patient rated the outcome as worse. Several case reports are included to illustrate the procedure. This technique should be considered an option in select patients with neuromatous knee pain.
Subject(s)
Denervation/methods , Knee Joint/innervation , Knee Joint/surgery , Pain, Postoperative/surgery , Adult , Aged , Arthroplasty, Replacement, Knee/adverse effects , Humans , Male , Middle Aged , Nerve Block/methods , Neuroma/complications , Pain Measurement , Pain, Postoperative/diagnosis , Pain, Postoperative/etiologyABSTRACT
Injury to the dorsal sensory nerve of the penis following penile prosthesis insertion is extremely rare. The authors report on a patient with insensitivity involving the right penile shaft and glans secondary to entrapment and fibrosis of the dorsal cutaneous nerve of the penis, following penile prosthesis insertion. Following resection of a 2-cm segment of fibrosed nerve, penile sensation was successfully restored using an autogenous vein graft conduit between the proximal and distal nerve segments.
Subject(s)
Penis/innervation , Veins/transplantation , Humans , Male , Middle Aged , Nerve Compression Syndromes/etiology , Nerve Compression Syndromes/surgery , Penile Prosthesis/adverse effects , Penis/blood supply , Peripheral Nerve Injuries , Peripheral Nerves/surgery , Sensation , Transplantation, AutologousABSTRACT
The management options for complex soft tissue defects about the knee are varied. Limb threatening conditions such as exposure of joint prosthesis or bone requires stable coverage to avoid amputation. A study was conducted to review the authors' management protocol and experience with complex defects about the knee. A retrospective analysis from 1986 to 1996 of 35 patients with complex defects about the knee was performed. Treatment options were based on the nature, size, location, and depth of the wound. A specific management protocol was applied for each patient. Treatments included local wound care, debridement and skin graft, fasciocutaneous flap, pedicled muscle flap, and free muscle transfer. Postoperatively, patients were evaluated using Knee Society objective and functional scores and other instruments to measure outcome. Successful salvage of the lower extremity was obtained in 34 (97%) patients. Salvage of the total knee prosthesis was obtained in 24 of 29 (83%) patients. Secondary plastic surgery procedures were necessary in eight (23%) patients. Secondary orthopaedic procedures were necessary in five (15%) patients. No patient required an amputation.
Subject(s)
Connective Tissue/surgery , Knee/surgery , Postoperative Complications/surgery , Surgical Flaps , Adult , Aged , Aged, 80 and over , Algorithms , Arthritis, Rheumatoid/surgery , Arthroplasty, Replacement, Knee , Connective Tissue/physiopathology , Female , Humans , Male , Middle Aged , Osteoarthritis/surgery , Surgical Wound Dehiscence/surgery , Treatment Outcome , Wound Healing/physiologyABSTRACT
We report on four patients with partial and full thickness burns following autogenous tissue breast reconstruction. Three burns were confined to the flap and one burn involved the flap and rim of adjacent skin. Heat sources included a heating pad (n = 3) and sunlight through a bathing suit (n = 1). The injuries occurred from 6 days to 4 years following the reconstruction. The burns were the result of impaired thermoregulatory capacity of transplanted tissue. All wounds healed with local wound care or debridement and skin grafting.
Subject(s)
Breast/injuries , Burns/etiology , Hot Temperature/adverse effects , Mammaplasty/adverse effects , Adult , Body Temperature Regulation , Female , Humans , Mastectomy, Modified Radical , Middle Aged , Surgical Flaps/physiologyABSTRACT
BACKGROUND: Injuries to the ilioinguinal, iliohypogastric, and genitofemoral nerves can result in pain in the inguinal region. STUDY DESIGN: A retrospective analysis of 13 patients with such injuries is reported, with emphasis on the cause of the injury, diagnosis, and the outcome of operative management. RESULTS: The causes of the injuries included appendectomy, inguinal herniorrhaphy, inguinal lymph node dissection, orchiectomy, total abdominal hysterectomy, abdominoplasty, iliac crest bone graft, and femoral catheter placement. Diagnosis of the injury was based on patient history and physical examination. CONCLUSIONS: The outcome of operative management was graded as excellent (n = 10) and good (n = 3). Patient satisfaction was high postoperatively; all were able to return to their normal activity level.
Subject(s)
Groin/innervation , Iatrogenic Disease , Postoperative Complications , Adult , Aged , Female , Groin/surgery , Humans , Male , Middle Aged , Peripheral Nerve Injuries , Peripheral Nerves/surgery , Retrospective StudiesABSTRACT
Entrapment of the lateral femoral cutaneous (LFC) nerve as a source of anterolateral thigh dysesthesias has been recognized for 100 years. Despite this historic recognition, its diagnosis today is often delayed, and definitive treatment of refractory cases by surgical decompression rarely reported. This study describes 26 LFC entrapments in 23 patients whose etiologies include iliac crest bone graft harvesting, seat belt injury associated with motor vehicle accident, and diabetes. Twenty-two of the 23 patients (25 of the 26 entrapments) achieved good to excellent outcomes following surgical decompression of the LFC nerve.