The effect of ultrasound-assisted liposuction and conventional liposuction on the perforator vessels in the lower abdominal wall.

Scientific reports of clinical in vivo research into the effects and side-effects of ultrasonic-assisted liposuction (UAL) are scarce. Advocates of UAL claim that the damage to vascular and nervous structures is limited and even less than with conventional and/or tumescent liposuction (CL). The effect of tumescent infiltration alone and combined with either CL or UAL was assessed by performing injection studies of the panniculus adiposus of the lower abdominal wall of 20 fresh cadavers and five abdominoplasty specimens. Besides the control and infiltration groups (n=5 in each), there was an additional group of ten cadaver flaps and five abdominoplasty flaps that underwent infiltration followed by UAL in the right half of the flap and infiltration followed by CL in the left half of the flap. Radiographs of these flaps were shown to a blinded panel of ten plastic surgeons, who were asked to evaluate and compare the damage on the basis of the number and magnitude of contrast-medium extravasations in the flap. Vascular damage to the perforating vessels was seen even after infiltration alone, although it was very limited. A variable amount of damage (ranging from little to extensive) was observed in the CL and UAL groups. Statistical analysis of the judgments of the observers could not show that either technique was less damaging than the other. UAL is, therefore, probably more beneficial to the surgeon than to the patient. The financial investment in the device is justified for surgeons with large liposuction practices, mainly, and probably solely, because of the reduced physical strain for the surgeon.

Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps.

A series of 240 deep inferior epigastric perforator (DIEP) flaps and 271 free transverse rectus abdominis myocutaneous (TRAM) flaps from two institutions was reviewed to determine the incidence of diffuse venous insufficiency that threatened flap survival and required a microvascular anastomosis to drain the superficial inferior epigastric vein. This problem occurred in five DIEP flaps and did not occur in any of the free TRAM flaps. In each of these cases, the presence of a superficial inferior epigastric vein that was larger than usual was noted. It is therefore suggested that if an unusually large superficial inferior epigastric vein is noted when a DIEP flap is elevated, the vein should be preserved for possible use in flap salvage. Anatomical studies with Microfil injections of the superficial venous system of the DIEP or TRAM flap were also performed in 15 cadaver and 3 abdominoplasty specimens to help determine why venous circulation (and flap survival) in zone IV of the flaps is so variable. Large lateral branches crossing the midline were found in only 18 percent of cases, whereas 45 percent had indirect connections through a deeper network of smaller veins and 36 percent had no demonstrable crossing branches at all. This absence of crossing branches in many patients may explain why survival of the zone IV portion of such flaps is so variable and unpredictable.

A simple mathematical formula for custom-made croissant tissue expanders.

The popularity of croissant-type tissue expanders has increased steadily during the past 5 years. Croissant-shaped expansion offers the advantage of creating a tailored skin flap that is advanced easily into an elliptical skin defect without the formation of dog-ears or without the need for backcuts in the expanded flap. Because the majority of lesions can be considered elliptical in shape, surgical removal is performed easily with an adapted croissant expander. We present a simple mathematical formula for calculating the exact dimensions of the required croissant expander. A good clinical result was obtained using this formula to design large custom-made croissant tissue expanders in a patient with a giant nevus.

A universal incision for tissue expander insertion.

A new type of V- or W-shaped intralesional incision for tissue expander insertion is presented. The experience with 50 of these incisions in 36 consecutive patients in the period 1990-93 without any complication has proved the safety of this approach and the advantages of V- or W-shaped incisions over tangential or radial incisions.

Scar-length reduction by ring-shaped expansion.

Conventional tissue expansion with rectangular or round expanders often results in considerable dog-ear formation and, after resection, in lengthening of the final scar. The resulting scar is, always much longer than the maximal diameter of the skin lesion. These disadvantages are partially avoided by the use of croissant-shaped expanders. Taking the idea of the croissant-shaped expander and thinking further in terms of differential expansion, a new expander has been designed. It consists of a ring-shaped expander that is placed under the normal skin around the lesion. When the appropriate expansion is reached, the skin lesion is excised and the defect is closed with a running subcuticular suture, pulling as much skin as possible centripetally. The resulting scar is shorter than the maximal diameter of the skin lesion. The new expander has been tested in two patients in regions that are reputed for poor scar quality (the back and the upper arm). The results are encouraging.