An In-Depth Analysis of 1370 Consecutive Abdominoplasties: Fascial Plication Increases Risk of Venous Thromboembolism, and Scoring for Plication Improves the Caprini Risk Assessment Model.

BACKGROUND: Venous thromboembolism (VTE) is the most dangerous complication of abdominoplasty. One relatively undefined risk factor is plication, which in theory increases VTE risk. OBJECTIVES: To assess the thromboembolic risk of plication. METHODS: A retrospective review of 1370 consecutive abdominoplasties by one surgeon was undertaken. Two groups were considered, plicated (n= 1089) and non-plicated (n = 281), and VTE rates were compared between these groups. RESULTS: There were 25/1089 cases of VTE (2.3%) in plicated patients and 1/281 case of VTE (0.36%) in non-plicated patients, which was statistically significant (Fisher's exact test, p=0.028) despite the non-plicated group being a higher risk population. Case-Control matching yielded 225 pairs which differed statistically only by the presence or absence of plication; there were 12/225(5.3%) VTE events in the plicated group and 0/225 in the non-plicated group (McNemar's test, p=0.0015). Logistic regression demonstrated increased VTE risk with increasing age (OR 1.08, p<0.001), BMI (OR 1.34, p=0.002), Caprini score (OR 2.17, p<0.001), and especially plication (OR 16.76, p=0.008). Adding two points for plication to Caprini scores offered better risk stratification at a level of 7, with an improved combination of sensitivity/specificity (0.31/0.98 vs 0.69/0.96) and a 27% improvement over the 2005 Caprini RAM in the area under a Receiver Operating Characteristic (ROC) curve (0.826 vs 0.651, Z-value -3.596, p = 0.003). CONCLUSIONS: Plication was shown to be a powerful risk factor for the development of VTE in abdominoplasty. Abdominal wall plication should be considered in risk assessment, and scoring for plication may improve the performance of the Caprini RAM.

Corrigendum to: A Case Report of Capsular Contracture Immediately Following COVID-19 Vaccination.

[This corrects the article DOI: 10.1093/asjof/ojab021.].

A Case Report of Capsular Contracture Immediately Following COVID-19 Vaccination.

Capsular contracture is fundamentally an immunological/inflammatory response to the implant, treating it as a foreign body in need of exclusion from the immune system. The capsule surrounding the implant is populated by a rich variety of immunologically active cells such as macrophages, T lymphocytes, and myofibroblasts. Vaccination in general and the COVID-19 vaccine in particular result in specific and nonspecific activation of the immune system, including those immune cells in proximity to the implant. This phenomenon has been previously demonstrated in delayed inflammatory reactions to previously implanted hyaluronic acid fillers following COVID-19 vaccination. This report is what is believed to be the first case of the rapid development of severe ipsilateral capsular contracture in the immediate aftermath of the second dose of the BNT162b2 (Pfizer) vaccine.

Abdominoplasty in the Massive Weight Loss Patient: Are Aesthetic Goals and Safety Mutually Exclusive?

BACKGROUND: The goals of abdominoplasty in massive weight loss (MWL) patients are often functional, with a greater emphasis on safety than on aesthetic rejuvenation. As important as functional improvements and safety are, however, there may be room for increasing the aesthetic potential of abdominoplasties in these patients. OBJECTIVES: To determine the safety of the pursuit of aesthetic goals for abdominoplasty in MWL patients. METHODS: This is a retrospective study examining 910 consecutive female patients consisting of 3 groups: postpartum (n = 718), dietary MWL (n = 65), and bariatric MWL (n = 127). All patients were approached with a well-defined set of aesthetic goals which were pursued as needed and as feasible. RESULTS: The utilization of aesthetic abdominoplasty components was similar in all groups, supporting the assertion that the groups were subjected to a similar aesthetic emphasis. Logistic regression showed that a history of bariatric MWL was an independent risk factor for multiple complications (odds ratio 2.738, P = 0.014) and that elevated body mass index (BMI), smoking, diabetes, and age were likewise independent risk factors for complications. Propensity score-matched case-control pairs showed that bariatric MWL patients were more likely than dietary MWL patients to experience multiple complications (9.52% vs 0%, P = 0.031). CONCLUSIONS: Bariatric MWL patients but not dietary weight loss patients seem to have a higher risk than postpartum patients. Other comorbidities (elevated BMI, smoking, diabetes, and age) seem to be more important predictors of complications than MWL status. Select MWL patients can likely be approached with an emphasis on aesthetic goals, without increasing risks as compared with the postpartum population.

The Pedicled Robertson Mammaplasty: Minimization of Complications in Obese Patients With Extreme Macromastia.

BACKGROUND: Breast reduction for extreme macromastia in obese patients is a potentially high-risk endeavor. Free nipple grafting as well as a variety of pedicled techniques have been advocated for large reductions in obese patients, but the number of different approaches suggests that no single method is ideal. This paper suggests the Robertson Mammaplasty, an inferior pedicle technique characterized by a curvilinear skin extension onto the pedicle, as a potentially favorable approach to this clinical situation. OBJECTIVES: The author sought to determine the safety of the Pedicled Robertson Mammaplasty for extreme macromastia in obese patients. METHODS: The records of a single surgeon's practice over a 15-year period were retrospectively reviewed. Inclusion criteria were a Robertson Mammaplasty performed with a >3000-g total resection and a patient weight at least 20% above ideal body weight. Records were reviewed for patient characteristics, operative times, and complications. RESULTS: The review yielded 34 bilateral reduction patients that met inclusion criteria. The mean resection weight was 1859.2 g per breast, the mean body mass index was 36.4 kg/m2, and the mean sternal notch-to-nipple distance was 41.4 cm. Mean operative time was 122 minutes. There were no cases of nipple necrosis and no major complications that required reoperation under general anesthesia. A total 26.4% of patients had minor complications that required either local wound care or small office procedures, and 4.4% received small revisions under local anesthesia. CONCLUSIONS: The Pedicled Robertson Mammaplasty is a fast and safe operation that yields good aesthetic results and a relative minimum of complications in the high-risk group of obese patients with extreme macromastia.

Sub-Scarpa's Lipectomy in Abdominoplasty: An Analysis of Risks and Rewards in 723 Consecutive Patients.

BACKGROUND: During the course of performing abdominoplasties, a plastic surgeon will encounter a certain body habitus characterized by a thick, tethered, and excessively redundant upper skin flap. Often these patients also demonstrate diffuse and substantial fascial laxity. One approach to this problem involves direct thinning and release of the flap by resection of the sub-Scarpa's fat pad. In theory, this resection should be safe from a flap perfusion standpoint. However, the safety of the sub-Scarpa's resection has not been completely documented. OBJECTIVES: The author sought to assess the safety and efficacy of sub-Scarpa's lipectomy in abdominoplasty. METHODS: A total 723 patients were retrospectively examined and divided into 2 groups: those with (Group B) and those without (Group A) a sub-Scarpa's lipectomy component to the abdominoplasty. Because of differences in the baseline characteristics between the 2 groups, data analysis was performed with a logistic regression model and with propensity score matching. RESULTS: The sub-Scarpa's lipectomy technique allowed for substantial thinning of the flap: the average weight of the resected fat pad was 411 g. Wide undermining allowed for substantial fascial correction, and excellent results were obtainable even in challenging cases. The sub-Scarpa's lipectomy group did not demonstrate an increase in either minor (<5 cm2) or major (>5 cm2) flap necrosis. However, there was a statistically significant increase in fat necrosis and seroma formation in Group B compared with Group A. In both groups, an increasing body mass index was a risk factor for fat necrosis and major flap necrosis. CONCLUSIONS: The implementation of a sub-Scarpa's lipectomy during abdominoplasty is a useful technique to consider for selected abdominoplasty candidates. The risks of minor and major flap loss do not seem to be increased compared to the standard abdominoplasty, but the risks of fat necrosis and seroma formation may be greater.

Surface area measurement of the female breast: phase I. Validation of a novel optical technique.

BACKGROUND: Breast shape is largely determined by the volume of tissue and surface area of the skin envelope. Values for breast surface area have never been published in the literature. The investigators have developed an inexpensive, noninvasive optical method to objectively measure breast volume and surface area, and its accuracy is determined. METHODS: An optical grid is projected onto the breast, and two images are captured to create a computerized three-dimensional model from which volume, surface area, and maximum vertical projection are calculated. RESULTS: To assess accuracy, simple geometric shapes (n = 22) were analyzed, and the actual volume, surface area, and maximum vertical projection were compared with the imaged values using least-squares linear regression. There was excellent correlation in all three parameters (r > 0.995, p < 10). The mean differences in volume, surface area, and maximum vertical projection were 28 +/- 28 ml (mean +/- SD), 2 +/- 9 cm, and 0.4 +/- 0.5 cm, respectively. Female breasts (n = 14) were then analyzed, and the actual volume and surface area were measured using plaster casts. Based on least-squares linear regression, there was excellent correlation between the imaged values and actual values (r > 0.992, p < 10), and the mean differences in volume and surface area were 32 +/- 22 ml and 3 +/- 11 cm, respectively. CONCLUSIONS: For the first time, an optical method has been demonstrated to measure volume and surface area with accuracy. When the method is applied to the breast, measurement errors are small and clinically insignificant. The ability to facilitate quantitative breast surgery will be investigated in future phases of this experiment.

Arterial coupling for microvascular free tissue transfer in head and neck reconstruction.

OBJECTIVE: To demonstrate the efficacy of arterial coupling. DESIGN: We report our experience in head and neck reconstruction with the Unilink Microvascular Anastomotic System (Synovis MCA, Birmingham, Ala). Data were collected in a consecutive series of 49 patients undergoing composite resection of head and neck tumors followed by free tissue transfer. SETTING: All patient care took place at Yale-New Haven Hospital, New Haven, Conn, a university-based tertiary care facility. PATIENTS: Forty-nine consecutive patients aged 43 to 85 years underwent a total of 50 microvascular free tissue transfers using the Unilink coupling device. There were 18 women and 31 men, and the following 3 types of flaps were performed: radial forearm (n = 36), fibula (n = 12), and rectus abdominus (n = 2). INTERVENTIONS: The Unilink coupling device was used in this case series. Each arterial and venous anastomosis was performed with the coupling device. Free tissue transfers were monitored clinically and outcomes were recorded. MAIN OUTCOME MEASURES: Flap survival and thrombosis of the arterial anastomoses were determined, as was median length of stay. RESULTS: There were no flap failures in the series. Of the 50 coupled arterial anastomoses, the predominant coupler size used was 2.5 mm in diameter. Reconstructions included 36 radial forearm, 12 fibular osteocutaneous, and 2 rectus abdominus myocutaneous free flaps. One intraoperative arterial thrombosis occurred, requiring hand-sewn anastomosis, and another pulled away from the intact coupler in a steroid-dependent patient. There were no complications related to technical performance of the coupling device. The median length of stay was 14 days. CONCLUSION: While hand-sewn anastomoses in free tissue transfer remain the preferred technique for many microsurgeons, use of the coupler is a viable alternative to sutured anastomoses.

TRAM Revisions and Contralateral Mammaplasties: The Role of "Mirror Image" Skin Patterns.

Symmetry is the sine qua non of breast reconstruction. A symmetrical result offers peace of mind, a healthy body image, and improved self-esteem to the patient and presents a sometimes elusive goal to the plastic surgeon. When symmetry comes with modest effort we are pleased, but more often the effort is prolonged through several operations over a period of time. This article addresses the management of both the reconstructed breast mound(s) as well as the contralateral breast at different stages of the reconstruction process. By approaching the reconstructed breast mound(s) and a remaining native breast as similar soft tissue structures with similar soft tissue envelopes, it may be possible to maximize the symmetry of the final result.

Use of the operating microscope and loupes for head and neck free microvascular tissue transfer: a retrospective comparison.

OBJECTIVE: To analyze whether less cumbersome loupes are as equally efficacious as the microscope for magnification for free tissue transfers in head and neck reconstruction. DESIGN: A 7-year retrospective review of 151 consecutive microvascular free tissue transfers compares the operating microscope with loupe magnification. SETTING: A tertiary care medical center. PATIENTS: A total of 151 consecutive patients undergoing microvascular reconstructions. INTERVENTION: Microvascular reconstruction of ablative head and neck cancer defects using either microscopic or loupe-provided magnification. MAIN OUTCOME MEASURES: Medical records were reviewed for demographic data, preoperative radiation status, type of defect and flap, length of procedure, complications, and length of stay. RESULTS: Two teams shared the reconstructions, with all microvascular anastomoses created or directly supervised by one of us (D.A.R.). One team used the operating microscope for magnification (84 cases), while the other used loupes (67 cases). Complication rates were statistically similar for the 2 techniques, the length of procedure tended to be shorter in the loupe group, and the length of stay was statistically similar in both groups. CONCLUSIONS: A review of the literature validates the usefulness of loupe magnification in free tissue transfer surgery. To our knowledge, this is the largest number of head and neck reconstruction cases presented comparing these techniques. Loupes offer the surgeon comfort and easy access to and uncomplicated visualization of the operating field. Furthermore, loupes may decrease operating time and help avoid complicated equipment. Therefore, loupe magnification should be considered in head and neck reconstruction without the fear of increased morbidity.