Massive Localized Abdominal Lymphedema Treatment Challenges.

Massive localized lymphedema of the abdomen is a rare condition resulting from a neglected lower abdominal pannus associated with significant disability and morbidity. Compared to other surgical procedures, postbariatric surgery is usually considered a financial drain. In the United Kingdom, this requires National Health Service approval and delays may lead to sequelae that adversely impact on patients' quality of life with increased morbidity. We present a wheelchair-bound patient whose body mass index increased from 53 to 82, while awaiting funding approval increasing her anesthetic and surgical risks. A multidisciplinary approach is mandatory for preoperative, intraoperative, and postoperative care for these patients including anesthetic input and high dependency unit care. Managing this patient was a significant anesthetic and surgical challenge with 47-kg resected tissue. The planning and perioperative measures to minimize morbidity are discussed.

A prospective randomized trial of the efficacy of marginal quilting sutures and fibrin sealant in reducing the incidence of seromas in the extended latissimus dorsi donor site.

BACKGROUND: The extended latissimus dorsi is a workhorse flap and plays an important role in breast reconstruction. Unfortunately, seromas at the flap donor site are a frustrating problem complicating many procedures. The purpose of this study was to evaluate the efficacy of a combination of fibrin sealant (Quixil; Johnson & Johnson, Langhorne, Pa.) and limited quilting sutures at reducing seroma formation. METHODS: This was a prospective, double-blinded, clinical trial under a single surgeon. Twenty-six patients were enrolled in the study, and all were followed up for a period of 6 months. The patients were randomized to receive either quilting sutures only (group 1) or a combination of Quixil sealant and marginal quilting sutures (group 2). RESULTS: The incidence of seroma was 23.1 percent in group 1 and 7.7 percent in group 2 (odds ratio, 0.28; relative risk, 0.33). The mean total volume aspirated was significantly higher in group 1 (196.7 ml compared with 30 ml, p = 0.01). The average number of aspirations was 2.7 in group 1 compared with one in group 2. There was a significant reduction in inpatient stay for group 2 by 2 days (p = 0.01). Operative time was shortened by an average of 25 minutes. CONCLUSIONS: The combination of fibrin sealant and marginal quilting sutures significantly reduces total drainage, hospital stay, and seroma formation. In the authors' opinion, the benefits of seroma prevention outweigh the extra costs associated with this product. The potential, albeit small, risk of virus transmission and allergic reaction, however, needs to be taken into consideration, as with any blood transfusion product.

Two stage study of wound microorganisms affecting burns and plastic surgery inpatients.

This study was designed to identify wound microorganisms and the reasons for differing prevalence between the wards, burns unit and intensive care unit (ICU) in a regional centre for burns and plastic surgery. Antibiotic sensitivities of the 10 most prevalent microorganisms cultured from inpatient wound swabs were also investigated. Inpatient wound swab data were collected retrospectively using notes and departmental database information between January and June 2007. Data were analyzed using chi-squared tests and P-values. Eight hundred five positive wound swabs from 204 swab positive inpatients were analyzed. Stage 1 of this study demonstrated 917 positive swab episodes and 30 varieties of organism. The five most prevalent organisms cultured were Staphylococcus (23.9%), Acinetobacter (21.2%), Methicillin Resistant Staphylococcus aureus (MRSA) (20.8%), Pseudomonas (9.7%) and Enterococcus (5.2%). Stage 2 revealed that Acinetobacter baumanni (ABAU) was significantly more prevalent in military over civilian inpatients (P < .001) and that military inpatients had a significantly greater proportion of ABAU over civilian inpatients within the first 24 hours after admission (P < .001). ABAU episodes were significantly higher on the ICU over the burns unit and on the wards (P < .001). MRSA was significantly more prevalent in military inpatients (P < .001); however, no significant difference was observed within the first 24 hours after admission (P = .440). MRSA was more prevalent on the ICU over the burns unit (P = .023). Pseudomonas aeruginosa (PAER) was significantly more prevalent in military inpatients over civilian inpatients (P < .001), and on the ICU over the burns unit and wards (P = .018). Stage 1 generated a comprehensive, up to date cross section of bacterial flora, with corresponding percentage antibiotic sensitivities, in a regional burns and plastic surgery centre. This will give clinicians a snapshot of organisms affecting inpatient wounds in advance of culture and sensitivity results. Stage 2 demonstrated that ABAU, MRSA, and PAER were significantly more prevalent in the ICU setting. Furthermore, military inpatient wounds grew more ABAU, MRSA, and PAER than civilians, probably due to the longer inpatient stay, dirty nature of wounds, site and complex mechanism of injury. Finally, this study suggests that ABAU was brought into the unit by military patients.

Orbital exenteration for advanced periorbital skin cancers: 20 years experience.

PURPOSE: Orbital exenteration is a disfiguring procedure that results in a significant deformity which poses a reconstructive challenge, especially in elderly patients with significant comorbidities. We reviewed our experience of orbital exenteration. METHODS: A retrospective analysis was conducted identifying all patients undergoing orbital exenteration over a 20-year period. Patient demographics, tumour characteristics and reconstructive techniques used were recorded. RESULTS: Thirty-two patients were treated by orbital exenteration. The majority of these were for basal cell carcinomas (53%). Most patients (62.5%) were ASA grade II or more. Reconstructive techniques included split skin grafting (63%), forehead (25%), scalp (6%) and cervicofacial (6%) flaps. Following reconstruction of the exenterated orbit, 29 patients had a prosthesis. Twenty-six of these rated their final result with their definitive prosthesis as good. CONCLUSIONS: Though there are various options available for reconstruction after orbital exenteration, a split skin graft and orbital prosthesis provide a simple solution for a very difficult problem of advanced periorbital skin cancer in the elderly population with significant comorbidities. The final outcome is comparable to that of more complex flap reconstruction with comparable satisfaction rates.

Reconstruction after conservative treatment for breast cancer: cosmetic sequelae classification revisited.

Patients with suboptimal results following breast conservative therapy are presenting more frequently to plastic surgeons as a difficult management problem. A three-type "cosmetic sequelae classification" is proposed to evaluate and manage these patients. From February of 1991 to November of 2001, 85 patients were treated for cosmetic sequelae of breast conservative therapy at the Institut Curie. The patients were followed up prospectively for 6 to 132 months (median, 33 months). They were assessed with regard to age, site and stage of tumor, type of initial breast conservative therapy undertaken, corrective operative procedures performed, complications, and cosmetic results. Forty-eight patients (56.5 percent) had type 1 cosmetic sequelae, 33 patients (38.8 percent) had type 2, and four patients (4.7 percent) had type 3. Type 1 was managed by contralateral symmetrizing procedures. Type 2 was the most difficult to manage by means of various procedures. Type 3 required mastectomy and immediate breast reconstruction. Type 1 had 97.6 percent good results compared with 82.7 percent for type 2. Three of the four type 3 patients had good results. This article reaffirms the validity of the cosmetic sequelae classification as a simple, practical guide for breast reconstructive surgeons. It discusses the various choices of reconstructive procedures available, the importance of preventing these cosmetic sequelae, and the role of the plastic surgeon in the planning of conservative treatment of breast cancers.