Risk of Thromboembolism Following Body-Contouring Surgery After Massive Weight Loss.

BACKGROUND: "Postbariatric" patients are at significant risk for increased postoperative complications. This study aimed to define the risk of venous thromboembolism following body-contouring surgery after massive weight loss. METHODS: A retrospective analysis was performed on all patients who had undergone all forms of body-contouring procedures after massive weight loss between January 2005 and August 2012 at St George's Hospital, South West London, United Kingdom. Data were collected on patient demographics, comorbidities, risks factors for thromboembolism, preoperative and postoperative body mass index, and type of surgery. RESULTS: A total of 135 operations were performed on 53 patients (43 females, 10 male), with an average age of 44.8 years (range, 26-56 years). Most had staged procedures including 55 abdominoplasties, 23 brachioplasties, 31 thigh lifts, 14 lower-body lifts, and 12 mastopexies. All patients received venous thromboembolism prophylaxis postoperatively including low-molecular-weight heparin (dalteparin) within an average of 22.5 hours after surgery and the application of intraoperative graduated compression stockings. Patients received dalteparin for an average of 4 days (range, 2-14 days), which correlated to their length of stay. One patient had a deep venous thrombosis 14 days postoperatively and then 2 days later developed a nonfatal pulmonary embolus, giving a venous thromboembolism prevalence of 0.74% (1/135). CONCLUSIONS: The clinically apparent venous thromboembolism prevalence was low among patients undergoing body-contouring procedures after massive weight loss in this study. We provide evidence of a successful algorithm to prevent venous thromboembolism for patients undergoing body-contouring procedures after massive weight loss.

Atrophy of the intrinsic musculature of the hands associated with the use of botulinum toxin-A injections for hyperhidrosis: a case report and review of the literature.

Botulinum toxin type A (BTX-A) has been used therapeutically for the treatment of spastic disorders for many years. More recently, the therapeutic utility of BTX-A in the treatment of hyperhidrosis has been recognised. While studies have reported on the efficacy of BTX-A in managing hyperhidrosis, long term data are required in order for the treatment implications to be fully appreciated. We report on a case of severe atrophy of the intrinsic muscles of the hands in a patient treated with intra-palmar BTX-A (Dysport, Speywood, UK) injections for hyperhidrosis. To our knowledge this has not been described in the literature before.

Long-term results of primary syndactyly correction by the trilobed flap technique.

This paper describes the long term results of a surgical technique used for correction of syndactyly. This technique has been practised by the senior author since 1987 and was published in 1990. The technique involves the use of a dorsal trilobed flap for the reconstruction of the commissure and zig-zag incisions for the fingers. This technique does not require the use of skin grafts. This technique has been used in 62 webs in 44 patients. In this total group, there were 30 patients of primary hand syndactyly with 40 webs. Seventeen patients of primary syndactyly with 25 webs were followed up. The follow-up of these patients ranged from 2 years to 12 years. The long term results reveal a simple, effective technique which does not require the use of skin grafts, and is associated with good functional and far superior cosmetic results.

Intrauterine stab leading to a radial nerve palsy.

Penetrating injuries to the gravid uterus are rare. This report documents a fetus that sustained a complete radial nerve palsy (a hemopneumothorax) after a knife wound (complete nerve transection is suspected). Surgical exploration of the nerve was delayed because of respiratory distress. Six weeks later, when exploration was scheduled to be undertaken, some recovery was noted, and exploration was thus deferred. The injury recovered completely in the absence of formal repair.

Vascular cell tumors of the hand in children.

The diagnosis of vascular cell tumors of the upper limb in children can be extremely difficult. There is considerable variation in their presentation and natural history. In most instances, the correct diagnosis can be achieved after a careful history and examination. Almost invariably, they are benign lesions and, of these, hemangiomas and vascular malformations account for more than 90%. Worrying tumors of the intermediate and malignant grade are rare. Any atypical, rapidly growing tumor with superficial ulceration and bony destruction on radiology should be regarded as malignant. Histologic differentiation of all problematic vascular swellings requires the services of an experienced pediatric vascular pathologist. In the future, specific cellular marker profiles of individual lesions may simplify the diagnosis. Conservative, symptomatic management is the first line of treatment for almost every vascular swelling. Intervention is reserved for swellings complicated by ulceration, uncontrollable rapid growth, coagulopathies, cardiovascular compromise, or the possibility of malignancy. Small lesions may generally be simply excised, whereas larger lesions often remain a problem.

The bilobed flap: a new application in the reconstruction of congenital thumb deviation.

Congenital radial angulation deformity of the thumb in Rubinstein-Taybi syndrome is generally corrected by a wedge osteotomy of the delta phalanx and a redistribution of the overlying skin using a Z-plasty or, rarely, skin grafting. We describe a new application of the bilobed flap in the reconstruction of the thumb and discuss its advantages over traditional methods in providing tension-free skin cover, excellent access to the delta phalanx and aesthetically acceptable scars.

Are children with clefts underweight for age at the time of primary surgery?

Children with clefts, especially those with a cleft palate, have an impaired sucking mechanism and are therefore prone to nutritional problems. This study was undertaken to determine whether children with clefts of the lip and/or palate are underweight for age at the time of primary surgery. Underweight for age was defined as being less than 80 percent of expected weight for age or below the 3rd percentile as plotted on standard percentile charts. The records of all children with clefts seen at the Red Cross Children's Hospital between 1976 and 1996 were reviewed. Of these 740 records, 100 were excluded for inadequate data (47), severe systemic syndrome (27), no operation done (22), or craniofacial cleft (4). The records of 640 children were thus included; 195 (30.5 percent) were underweight for age. By comparison, only 13.7 percent of a similar group of noncleft controls (n = 872) were underweight for age. The difference between these two groups was highly significant (p < 0.01). Factors that influenced weight at the time of primary surgery were type of cleft and age at the time of surgery. Children with cleft palate, whether associated with a cleft lip or not, were found to be more underweight for age than those with an isolated unilateral cleft lip (p = 0.008). Children who had surgery after the age of 1 year were 1.5 times more likely to be underweight for age than children who had surgery under 1 year of age (p < 0.01). Children with isolated cleft palates who were underweight for age had a tendency toward a higher fistula rate (36 percent) than those of normal weight (24 percent) (p = 0.18).

Repair of unilateral cleft lip: a comparison of five techniques.

Repair of unilateral cleft lip is a challenging procedure with no single technique satisfactory for all types of unilateral cleft deformity. This study compares retrospectively five techniques of unilateral cleft lip repair in 72 children (45 boys, 27 girls). Twenty-two children had a Millard rotation-advancement repair, 5 children had a Davies Z-plasty, 22 had a modified Z-plasty, 10 had a Tennison-Randall triangular flap repair, and 13 had a Nakajima-Yoshimura straight-line repair. Assessment was performed clinically by a plastic surgeon not involved in the original surgery. Repairs were assessed objectively by measurement of the vertical length of both the repaired and normal sides of the lip with calipers. Subjective criteria used to evaluate the repair were the symmetry of Cupid's bow, the quality of scar, the alignment of white roll, the evenness of the vermilion, and the lip pout. The mean follow-up period was 5.4 years (range, 9 months-29 years). Sixty-five of the 72 repairs measured (90%) were within two standard deviations (SDs) of normal and thus were considered to be of "acceptable" length. Seven repairs were unacceptably short (>2 SDs) on measurement, six of which included a rotation-advancement repair for a complete cleft lip. Subjective results paralleled the objective results. The outcome following repair of unilateral cleft lip was similar for all five surgical methods assessed except for complete cleft lips repaired by the rotation-advancement technique, which tended to result in an unacceptably short lip as measured on the repaired side.

A review of burns treated over a one-year period at Mpilo Central Hospital, Zimbabwe.

A retrospective study is presented of 297 patients (57% male and 43% female) treated for burns at Mpilo Central Hospital, Bulawayo, Zimbabwe in 1991. Of the patients, 73% were in the paediatric age group, 60% of whom were under 5 years of age. Most burns occurred at home (90%), with the majority occurring in the kitchen (61%). The commonest burning agent was hot water (55%). Open-fire burns accounted for 18% of cases. The surface area of burns ranged from 1% to 80% with a mean of 7%. The majority of patients (84%) had superficial thickness burns. Only 6% of the patients required active resuscitation with intravenous fluids. A total of 159 organisms were isolated on 111 pus swabs. The most commonly isolated organism was Staphylococcus aureus (66%). Seven patients (five children and two adults) died, giving a mortality rate of 2%. Although it is desirable to have a purpose-built burns unit this study shows that satisfactory results can be achieved with limited facilities. In our practice, where 90% of burns occur in the home situation, an active public-education campaign would help to reduce the incidence of burns.

Contractures after burns: some observations from a 3-year review in Zimbabwe.

A retrospective study is presented of 53 consecutive patients (25 men, 28 women) with contractures following burns admitted to Mpilo Central Hospital between August 1988 and August 1991. Of the total, 85% were aged 12 years or less. Most of the patients (75%) came from rural areas and in 67% of cases where the nature of the burning agent was known, the burn resulted from an open fire. The site most commonly affected was the hand (51% of cases). Most of the contractures were released either by cross cutting and split skin grafting, or by using some form of flap. No major complications were encountered apart from a few minor wound infections which settled down on antibiotics and dressings. To reduce the incidence of contractures in our practice it is important to educate the rural community about the dangers of open fires especially to children. Rural health personnel should be encouraged to consider early referral of patients with burns likely to lead to contracture formation.