Current State of Surgical Lighting.

Surgical performance in the operating room (OR) is supported by effective illumination, which mitigates the inherent environmental, operational, and visual challenges associated with surgery. Three critical components are essential to optimize operating light as illumination: (1) centering on the surgeon's immediate field, (2) illuminating a wide or narrow field with high-intensity light, and (3) penetrating into a cavity or under a flap. Furthermore, optimal surgical illumination reduces shadow, glare, and artifact in visualization of the surgical site. However, achieving these principles is more complex than at first glance, requiring a detailed examination of the variables that comprise surgical illumination. In brief, efficacious surgical illumination combines sufficient ambient light with the ability to apply focused light at specific operative stages and angles. But, brighter is not always merely better; rather, a nuanced approach, cognizant of the challenges inherent in the OR theater, can provide for a thoughtful exploration of how surgical illumination can be utilized to the best of its ability, ensuring a safe and smooth surgery for all.

Post-Bariatric Body Contouring.

BACKGROUND: The "epidemic" of obesity has recently been accompanied by a new "epidemic" of massive weight loss. The demand for post-bariatric contouring is rising and, as such, it is extremely important for plastic surgeons to be well versed in the treatment of these patients. Unfortunately, the problem is not solely surgical. OBJECTIVES: The aim of this article is to understand the nutritional and psychological complications that can occur in patients following massive weight loss, to understand the anatomic deformities in massive weight loss as a means to correct those deformities surgically, and to understand the complications from post-bariatric contouring procedures in an effort to avoid them. METHODS: This article discusses the nutritional and psychological considerations in the massive weight loss patient, anatomical considerations in this patient group, and the surgical techniques designed to address these anatomic concerns. Important pertinent studies are reviewed and discussed. RESULTS: Anatomical changes are encountered in each region of the body: there are surgical options available to correct them, although potential complications are associated with these surgical procedures. These surgical options are reviewed as well as the risk and benefits associated with them. CONCLUSIONS: There are many problems that need to be addressed in the massive weight loss patient prior to embarking on surgical treatment. Additionally, surgery on massive weight loss patients has unique considerations that distinguish these operations from those performed on the non-bariatric population.

Identification of incidental hepatic malignancy as photopenic defect on 99mTc-sestamibi myocardial perfusion imaging.

A 63-year-old male patient undergoing cardiac SPECT examination was incidentally found to have a large, photopenic (tracer-deficient) region in the right lobe of the liver. Follow-up abdominal CT scan demonstrated a corresponding large (7.8 cm × 6.9 cm), hypodense hepatic lesion. Subsequent CT-guided biopsy revealed metastatic carcinoma of uncertain primary source.

Evidence-based use of pulsed electromagnetic field therapy in clinical plastic surgery.

BACKGROUND: The initial development of pulsed electromagnetic field (PEMF) therapy and its evolution over the last century for use in clinical surgery has been slow, primarily because of lack of scientifically-derived, evidence-based knowledge of the mechanism of action. OBJECTIVE: Our objective was to review the major scientific breakthroughs and current understanding of the mechanism of action of PEMF therapy, providing clinicians with a sound basis for optimal use. METHODS: A literature review was conducted, including mechanism of action and biologic and clinical studies of PEMF. Using case illustrations, a holistic exposition on the clinical use of PEMF in plastic surgery was performed. RESULTS: PEMF therapy has been used successfully in the management of postsurgical pain and edema, the treatment of chronic wounds, and in facilitating vasodilatation and angiogenesis. Using scientific support, the authors present the currently accepted mechanism of action of PEMF therapy. CONCLUSIONS: This review shows that plastic surgeons have at hand a powerful tool with no known side effects for the adjunctive, noninvasive, nonpharmacologic management of postoperative pain and edema. Given the recent rapid advances in development of portable and economical PEMF devices, what has been of most significance to the plastic surgeon is the laboratory and clinical confirmation of decreased pain and swelling following injury or surgery.

Dorsal augmentation rhinoplasty with irradiated homograft costal cartilage.

Augmentation of the nasal framework requires a working knowledge of nasal and facial anatomy, as well as the principles of facial proportion and balance. Dorsal augmentation rhinoplasty is a valuable means of improving nasal appearance in patients with a low and/or concave nasal dorsum, obtuse nasofrontal angle, and low radix. It frequently is combined with other techniques, including columellar strut grafting, nasal tip grafting, and tip suturing, as dorsal deficiencies are often associated with poor tip projection and support and a shortened columella. Our experience with dorsal augmentation rhinoplasty, including the use of irradiated homograft costal cartilage for grafting in 56 surgeries, is described. A high level of patient satisfaction with a low percentage of complications has been seen.

Single-stage maxillary and nasal floor reconstruction with the double-paddle rectus abdominis musculocutaneous free flap.

Palatal integrity is essential for useful speech, deglutition, good oral hygiene, and prevention of nasal regurgitation. Maxillary defects after tumor extirpation, therefore, can have serious functional and cosmetic implications. Given the often disappointing results obtained with local and regional pedicled flaps for maxillary reconstruction, a variety of microvascular free flaps have been utilized in recent years, including the rectus abdominis, fibular, radial forearm, and latissimus dorsi flaps. Experience with these techniques has been documented in a limited number of case reports. We describe our single-stage approach to maxillary and nasal floor reconstruction with the double skin-paddle rectus abdominis musculocutaneous free flap. A series of five patients is presented; six of these immediate free flap reconstructions were performed for defects resulting from tumor resection. A vertical rectus abdominis musculocutaneous free flap was used in all cases, designing two separate skin paddles to accommodate the measured maxillary and nasal floor deficiencies. Anastomoses of the deep inferior epigastric artery and vena comitans were performed end-to-end to the facial artery and vein, respectively. In addition, orbital floor reconstruction with calvarial bone grafts or titanium mesh was performed in all five patients. Separation of the oral and nasal cavities was maintained postoperatively. No intraoperative complications, perioperative mortalities, flap losses, instances of skin paddle necrosis, hematomas, or oronasal fistulae were observed. One patient required bedside drainage of a surgical site abscess that resolved without adverse sequelae. Over the past 4 years, the double skin-paddle rectus abdominis musculocutaneous free flap has provided reliable results at our institution for single-stage reconstruction of maxillary and nasal floor defects. This reconstructive technique should be considered a viable method that can alleviate the functional and cosmetic debility associated with these defects.

Mid-body contouring in the post-bariatric surgery patient.

BACKGROUND: Obesity has become an increasingly important health care problem. It is estimated that almost 20 percent of the adult U.S. population is obese, including approximately 5 percent of the population considered morbidly obese. Recent advances in bariatric surgery have improved the safety and efficacy of weight-loss operations. As a consequence of the above factors, there has been a 150 percent increase in the number of gastric bypass and vertical banding gastroplasty procedures performed over the past 3 years. Post-bariatric surgery care has become an integral part in the care of these patients, with plastic surgeons playing an important role. METHODS: The senior author (B.S.) has developed unique variations of the circumferential and near-circumferential abdominoplasty operations to fulfill the needs of these patients. Seventy-five consecutive mid-body lift procedures have been performed over the past 5 years. The basic operation involves circumferential incisions, anterior flap undermining, and simultaneous flap thinning, without resorting to the need for an anterior midline incision. RESULTS: A dramatic improvement in appearance results from the anterior resection and the lateral thigh and buttock lifts that this procedure affords. More recently, the lower back roll has been removed as well. A cohesive operative sequence that includes optimized patient preparation and positioning, tailoring of flaps for improved contour with avoidance of unnecessary midline scars, a strong superficial fascial system closure, and coordination with the entire operating room team has been developed. CONCLUSION: The procedure is associated with a low complication rate, a dramatically shortened operative time, and high patient satisfaction.

Palmar arch revascularization for arterial occlusion of the distal upper extremity.

During a period of nine years, 10 patients, ages 42 to 66 years (55 +/- 7, mean +/- SD) underwent upper extremity bypass for ischemic changes to the hand not responsive to conservative management. Patients were referred from the vascular department at the authors' institution. Preoperative angiograms were performed and attempts at angioplasty or intravenous attempts to dissolve clots were carried out (with tissue plasminogen activator-tPA) when appropriate. Patients with persistent upper extremity ischemia and an obvious occlusion with reconstitution in the hand were candidates for upper extremity bypass to the palmar arch. All patients had upper extremity bypasses performed with reverse saphenous vein grafts. The proximal anastomoses (end-to-side) were performed by either the vascular or plastic surgery team, while all distal anastomoses (end-to-side) were performed by plastic surgery team microscopic magnification to the deep or superficial palmar arch. Postoperative follow-up ranged from 3 months to 3 years. The bypass graft to the hand resulted in improved pain and resolution of tissue ischemia in all cases. Patients with preoperative ulcers were completely healed by 3 months. The results are in accordance with previous studies demonstrating that improved blood flow afforded by the procedure can improve the healing of recalcitrant ulcers and mitigate the symptoms of ischemic changes. In addition, end-to-side anastomosis to the palmar arch offers significant advantages, in that the continuity of the arch is maintained with all possible outflow vessels, and the problems associated with size discrepancy in the anastomosed vessels are eliminated.

Superolateral pedicle for breast surgery: an operation for all reasons.

BACKGROUND: The evolution of procedures for reduction of breast volume and improvement of breast shape has been ongoing, based on the rich blood supply that has allowed a plethora of pedicle types. With particular consideration of the primary pattern of sensory innervation to the nipple-areola complex previously described, the authors have used the superolateral dermoparenchymal pedicle as a basis for surgery on a variety of presenting breast shapes. METHODS: This has been proven to be a versatile and effective technique for a wide array of breast morphologies with differing patterns of skin excision. The operative technique involves superior rotation of a superolaterally based dermoparenchymal pedicle, resulting in a "periwinkle" effect that provides desirable superior pole fullness and increased projection to the breast. RESULTS: More than 1500 breast procedures have been performed by the senior author (Strauch) during the past 15 years using the superolateral pedicle. Experience has demonstrated that the operation is safe, with total nipple-areola complex loss observed in only four cases. Long-term follow-up to 15 years has shown that the results are maintained well with time. CONCLUSIONS: The superolateral dermoparenchymal pedicle has fulfilled the goals of successful breast surgery. It is a safe and effective technique that has provided long-lasting results for patients. The design of the procedure can be adapted to a variety of skin excision patterns and breast morphologies.

Sural nerve harvest: anatomy and technique.

A minimally-invasive technique of sural nerve harvesting using an initial blunt tip harvesting device, combined with a recessed sharp cutting mechanism for final severance of the nerve, has been developed. Important surgical landmarks have been established, based on a review of the anatomy of the sural nerve. Harvesting is begun through a small incision at the level of the lateral malleolus, thereby identifying the nerve and inserting the nerve-harvesting device. An additional small incision, if needed, is placed at the junction of the middle and distal thirds of the lower leg, a landmark at which an anastomosis between the medial and lateral sural cutaneous nerves is seen in at least 74 percent of patients. When this anastomosis is palpated, the lateral sural cutaneous nerve is visualized and divided, and the dissection of the medial sural cutaneous nerve proceeds in a proximal direction. At the distal end below the popliteal fossa, the cutting mechanism is safely deployed, transecting the nerve. This combination of a limited incision approach with the blunt harvester and sharp, protected division provides 30 to 35 cm of sural nerve graft in the great majority of patients, while reducing the complications often associated with open techniques and minimally-invasive techniques that rely on sharp or blunt instrumentation.

Basal cell nevus syndrome: guidelines for early detection.

Basal cell nevus syndrome is an autosomal dominant condition with complete penetrance and variable expressivity. It is characterized by five major components, including multiple nevoid basal cell carcinomas, jaw cysts, congenital skeletal abnormalities, ectopic calcifications, and plantar or palmar pits. Other features include a host of benign tumors, ocular defects, and cleft lip and palate. Guidelines for diagnosis include a family history, careful oral and skin examinations, chest and skull radiographs, panoramic radiographs of the jaw, magnetic resonance imaging of the brain, and pelvic ultrasonography in women.