Abstract: The utilization of complementary and alternative medicine has increased tremendously in the last two decades. Herbal products, homeopathic medicines, and dietary supplements are extremely popular and are available without a prescription (which likely contributes to their popularity). Despite their "natural" characteristics, these remedies have the potential to cause bleeding in patients who undergo surgery. The high use of these supplements among cosmetic surgery patients, coupled with increasing reports of hematomas associated with herbal and homeopathic medicines, prompted the authors to conduct a comprehensive review focused on bleeding risks of such products in an effort to raise awareness among plastic surgeons. This review focuses on 19 herbs, three herbal formulas, two herbal teas, and several other supplements that can cause bleeding perioperatively and postoperatively. In addition to being aware of such adverse effects, plastic surgeons must adequately screen all patients and educate them on the possible dangers associated with these treatments.
Abstract: Plastic surgeons have been performing operations to improve the aesthetic aspect of the breast for centuries. Throughout ancient times, great controversy produced many theories of how breast cancer occurred and the best treatment. Because of beliefs that closure of mastectomy sites could conceal tumor recurrence, breast reconstruction did not gain wide acceptance until the mid-1900s. Today, plastic surgeons have a variety of techniques to reconstruct the breast. The first autologous muscle flap for breast reconstruction was the latissimus dorsi myocutaneous flap, described in 1896 by Iginio Tansini. The introduction of Carl Hartrampf's transverse rectus abdominis myocutaneous flap and Robert J. Allen's deep inferior epigastric perforator flap have also provided excellent reconstructive options. With regard to augmentation, Vincenz Czerny attempted to enhance a woman's breast in 1895 with implantation of a lumbar lipoma. Soon after, surgeons used paraffin injections and polyvinylic alcohol sponge implantation, which yielded disastrous results. In 1961, Thomas Cronin and Frank Gerow promoted the first silicone implant, paving the way for today's silicone and saline prototypes. Although reduction mammaplasty techniques had originated centuries earlier than mastopexy methods, the advancements of both have largely paralleled one another. In 1949, the Wise pattern was introduced to preoperatively plan safer and predictable outcomes in breast reductions. Efforts to minimize scars were achieved with Claude Lassus' introduction and Madeleine Lejour's subsequent modification of the vertical scar mammaplasty. In hopes of fostering an understanding of current post-mastectomy procedures and instilling passion for innovating future techniques, we provide a near-complete, surgically focused historical account of the primary contributors to breast reconstruction.
Abstract: The Centers for Medicare and Medicaid Services has a list of 10 hospital-acquired conditions for which hospitals and physicians will not be reimbursed because it deems such conditions are preventable and should be considered "never events." To evaluate the validity of this premise, the authors conducted a real-life analysis of the incidence and categories of never events occurring in a breast reconstruction cohort of a multisurgeon plastic surgery practice. Cost analysis of estimated revenue loss and risk factors associated with the development of never events are enumerated.
Abstract: Various techniques for obtaining expedient aesthetic coverage of soft tissue defects with limited donor site morbidity have been developed, including the use of a dermal regeneration template (DRT) as the first step in a two-stage surgical approach. Use of DRT in reconstruction has increased as a result of reports suggesting improved cosmetic results and reduced scarring compared to split-thickness skin grafts (STSG), but this approach requires a return to the operating room. To evaluate outcomes of a single-stage procedure, a prospective evaluation of patients with complicated soft tissue defects measuring <200 cm2 was conducted. Following trauma or resection of a tumor, 20 patients underwent single-stage reconstruction with surgical debridement and application of a single-layered DRT and a meshed STSG. Negative pressure wound therapy (NPWT) was applied as a bolster with continuous -125 mm Hg pressure for 5 days. After 5 days, traditional dressings were applied and patients were followed until healed with a minimum follow-up of 5 months to a maximum follow-up of 19 months. Participants included 20 patients (14 men, six women; average age 60 years old [range: 27-92 years]; average wound size 104.5 cm2 [range: 40.0-180.0 cm2]). Wounds were located on the lower extremities (10 patients), upper extremities (seven patients), and trunk (three patients). Average graft take was 98.3% with an average take time of 5.6 days (SD 0.50). No significant differences in graft take rates between male and female patients, smokers and nonsmokers, and patients with and without diabetes mellitus were observed. Wound location also did not affect graft take rates. No wound breakdown, adverse events, or re-operation occurred during follow-up. In this case series, single-stage reconstruction using DRT, STSG, and NPWT was used with good outcomes and second-stage reconstruction surgery was avoided. Prospective, randomized, controlled clinical studies to compare the various surgical and wound care approaches to closing these tissue defects are warranted.
Abstract: Soft tissue deficits associated with exposed tendon and absent paratenon pose difficult reconstructive problems due to tendon adhesions, poor range of motion, poor cosmesis, and donor site morbidity. Integra Bilayer Matrix Wound Dressing (Integra Lifesciences Corp Plainsboro, NJ) is a skin substitute widely used in reconstructive surgery, including the incidental coverage of tendons. However, Integra's post-operative functionality of the tendons has not been well documented. We report the results of using Integra for soft tissue reconstruction overlying tendons with loss of paratenon in upper and lower extremity soft tissue defects.
Abstract: In May 2011, an international panel of wound care experts from multiple disciplines convened to develop this document to summarise the evolution of negative pressure wound therapy (NPWT) technology devices over the past 15 years, specifically concentrating on the V.A.C.(®) Therapy (KCI USA, Inc., San Antonio, TX) family of products. The aim of this document, which will be comprised of six articles, is to describe appropriate use of current technology options across a variety of wound types. The articles will include literature reviews, initiation criteria, treatment outcomes, technical pearls and clinical cases that will show the enhanced outcomes and potential economic value of the various NPWT technologies in use today.
Abstract: Skin grafting is a technique used for transplanting human skin (i.e. epidermal and some dermal layers) from a harvest site to a recipient site. However, advancements in bioengineered matrices have also introduced alternatives to skin grafts. The method used to secure the graft, whether skin or biomatrix, is critical in reducing graft failure. During the past several years, negative pressure wound therapy using reticulated open-cell foam (NPWT/ROCF; V.A.C.® Therapy, KCI USA, Inc., San Antonio, TX) has become a well-established method for bolstering grafts to recipient beds and is being used more frequently over biomatrices to help improve graft outcomes. This review will combine expert opinion with scientific evidence for the use of NPWT/ROCF over grafts.
Abstract: Pressure ulcers (PrUs) are a challenging health concern for both the clinician and the patient. The exact incidence and prevalence of PrUs varies widely among specific clinical populations, from 0.4% to 38% in acute care, from 2.2% to 24% in long-term care and from 0% to 17% in home care. The economic impact of these wounds is impressive with an estimated cost of $11 to $17.2 billion annually in the USA. Guidelines from the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel have provided recommendations for the prevention and treatment of PrUs. Negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF; V.A.C.® Therapy, KCI USA, Inc. San Antonio, TX) has been successfully used for managing PrUs. This review combines expert opinion with scientific evidence to describe the use of NPWT/ROCF in patients with PrUs.
Abstract: Many months after the devastating earthquake in January 2010, wounds remain a major disease burden in Haiti. Since January 2010, through the efforts of corporations, nonprofit charitable organizations, and medical professionals, advanced wound care techniques, including negative-pressure wound therapy (NPWT), have been introduced into the wound care regimens of various hospitals in Haiti. In June 2010, the authors completed their second volunteer trip at a Haitian hospital specializing in orthopedic wounds. The medical team was composed of a plastic surgeon, orthopedic surgeon, anesthesiologist, medical assistant, scrub technician, and registered nurse (specializing in plastic surgery and orthopedics). The authors' team supplied NPWT devices, reticulated open-cell foam dressings, and canisters donated by Kinetic Concepts, Inc, San Antonio, Texas, for use at the hospital. This report describes the medical challenges in postearthquake Haiti (including limb salvage and infection), benefits of adjunctive use of NPWT/reticulated open-cell foam, and current wound care status in a Haitian orthopedic hospital. The future role of NPWT in Haiti and during mass catastrophe in a least-developed country is also discussed.
Abstract: Studies of facial aging up to the present have largely been observational and subjective. This study applies state-of-the-art facial imaging and three-dimensional computer modelling to measure changes in the aging female face. The markers of facial aging discussed here go beyond descriptive accounts by individual practitioners and are presented as quantitative measurements of the volume change in the aging periorbital region.
Abstract: "Social media" describes interactive communication through Web-based technologies. It has become an everyday part of modern life, yet there is a lack of research regarding its impact on plastic surgery practice.
Abstract: BACKGROUND: The use of acellular dermal matrix (ADM) has gained acceptance in breast and abdominal wall reconstructions. Despite its extensive use, there is currently a wide variation of reported outcomes in the literature. This study definitively elucidates the outcome rates associated with ADM use in breast and abdominal wall surgeries and identifies risk factors predisposing to the development of complications. METHODS: A literature search was conducted using the Medline database (PubMed, US National Library of Medicine) and the Cochrane Library. A total of 464 articles were identified, of which 53 were eligible for meta-analysis. The endpoints of interest were the incidences of seroma, cellulitis, infection, wound dehiscence, implant failure, and hernia. The effects of various risk factors such as smoking, radiation, chemotherapy, and diabetes on the development of complications were also evaluated. RESULTS: A majority of the studies were retrospective (68.6%) with a mean follow-up of 16.8 months (SD ± 10.1 months) in the breast group and 14.2 months (SD ± 7.8 months) in the abdominal wall reconstructive group. The overall risks and complications were as follows: cellulitis, 5.1%; implant failure, 5.9%; seroma formation, 8%; wound dehiscence, 8.1%; wound infection, 16.1%; hernia, 27.6%; and abdominal bulging, 28.1%. Complication rates were further stratified separately for the breast and abdominal cohorts, and the data were reported. This provides additional information on the associated abdominal wall morbidity in patients undergoing autologous breast reconstruction in which mesh reinforcement was considered as closure of the abdominal wall donor site. Radiation resulted in a significant increase in the rates of cellulitis (P = 0.021), and chemotherapy was associated with a higher incidence of seroma (P = 0.014). CONCLUSION: This study evaluates the overall complication rates associated with ADM use by conducting a meta-analysis of published data. This will offer physicians a single comprehensive source of information during informed consent discussions as well as an awareness of the risk factors predictive of complications.
Abstract: Cosmetic surgery, historically the purview of plastic surgeons, has in recent years seen an influx of practitioners from other fields of training. Many of these new providers are savvy in marketing and public relations and are beginning to control a surprisingly large amount of cosmetic patient care.
Abstract: Lip augmentations are commonly performed procedures in the United States, with annual numbers surpassing 100 000. While lips contribute to facial beauty, the relative influence of this feature to whole facial appeal has not yet been established. What is also of increasing interest is the consideration of ethnic differences in the evaluation of beauty. However, most current anthropometric measurements refer to Caucasians, and their use in the treatment of Asian American patients would be inappropriate.
Abstract: The aesthetic market is a growing business, as evidenced by the American Society for Aesthetic Plastic Surgery (ASAPS) reporting an increase of 147% in the number of cosmetic procedures performed by members since 1997. This market is consumer-oriented, relying heavily on advertising for survival amid the increasing provider competition.
Abstract: In recent years, there has been a significant increase in the number of non-plastic surgeons performing cosmetic procedures. This has the potential to have an impact on the plastic surgery practitioner by increasing competition and bringing into question the assurance of patient safety. In this study, a demographic analysis was performed of providers of invasive and minimally invasive cosmetic treatments in the Southern California region.
Abstract: Economic tools have been used in the past to predict the trends in plastic surgery procedures. Since 1992, U.S. cosmetic surgery volumes have increased overall, but the exact relationship between economic downturns and procedural volumes remains elusive. If an economic predicting role can be established from plastic surgery indicators, this could prove to be a very powerful tool.
Abstract: This retrospective case series describes our experiences and outcomes using the vacuum-assisted closure (VAC) Therapy System for the management of difficult acute and chronic wounds in paediatric patients.
Abstract: Over the last decade Vacuum Assisted Closure((R)) (KCI Licensing, Inc., San Antonio, TX) has been established as an effective wound care modality for managing complex acute and chronic wounds. The therapy has been widely adopted by many institutions to treat a variety of wound types. Increasingly, the therapy is being used to manage infected and critically colonized, difficult-to-treat wounds. This growing interest coupled with practitioner uncertainty in using the therapy in the presence of infection prompted the convening of an interprofessional expert advisory panel to determine appropriate use of the different modalities of negative pressure wound therapy (NPWT) as delivered by V.A.C.((R)) Therapy and V.A.C. Instill((R)) with either GranuFoam() or GranuFoam Silver() Dressings. The panel reviewed infected wound treatment methods within the context of evidence-based medicine coupled with experiential insight using V.A.C.((R)) Therapy Systems to manage a variety of infected wounds. The primary objectives of the panel were 1) to exchange state-of-practice evidence, 2) to review and evaluate the strength of existing data, and 3) to develop practice recommendations based on published evidence and clinical experience regarding use of the V.A.C.((R)) Therapy Systems in infected wounds. These recommendations are meant to identify which infected wounds will benefit from the most appropriate V.A.C.((R)) Therapy System modality and provide an infected wound treatment algorithm that may lead to a better understanding of optimal treatment strategies.
Abstract: Usage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grown exponentially in the past decade. Hundreds of studies have been published regarding outcomes and methods of therapy used for adult wounds. This treatment is increasingly being used to manage difficult-to-treat paediatric wounds arising from congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children, although relatively few studies have been aimed at this population. Given the anatomical and physiological differences between adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use of NPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure (V.A.C. Therapy, KCI Licensing, Inc., San Antonio, TX) for the treatment of paediatric wounds. The primary objectives of the expert advisory panel were to exchange state-of-practice information on paediatric wound care, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of the existing data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposed paediatrics-specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisions could be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequency and use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriate wound care at the time of publication. They are the result of consensus reached by expert advisory panel members based on their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds. Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panel may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the collaborating medical team, including the surgeon and wound care specialist based on available resources, individual patient circumstances and experience with the V.A.C. Therapy System.
Abstract: This data review reports the results of 15 patients who were treated with Vacuum-Assisted Closure (VAC) negative pressure therapy system in addition to the timed, intermittent delivery of an instilled topical solution for management of their complex, infected wounds. Prospective data for 15 patients treated with negative pressure wound therapy (NPWT)-instillation was recorded and analysed. Primary endpoints were compared to a retrospective control group of 15 patients treated with our institution's standard moist wound-care therapy. Culture-specific systemic antibiotics were prescribed as per specific patient need in both groups. All data were checked for normality of distribution and equality of variance and appropriate parametric and non parametric analyses were conducted. Compared with the standard moist wound-care therapy control group, patients in the NPWT-instillation group required fewer days of treatment (36.5 +/- 13.1 versus 9.9 +/- 4.3 days, P < 0.001), cleared of clinical infection earlier (25.9 +/- 6.6 versus 6.0 +/- 1.5 days, P < 0.001), had wounds close earlier (29.6 +/- 6.5 versus 13.2 +/- 6.8 days, P < 0.001) and had fewer in-hospital stay days (39.2 +/- 12.1 versus 14.7 +/- 9.2 days, P < 0.001). In this pilot study, NPWT instillation showed a significant decrease in the mean time to bioburden reduction, wound closure and hospital discharge compared with traditional wet-to-moist wound care. Outcomes from this study analysis suggest that the use of NPWT instillation may reduce cost and decrease inpatient care requirements for these complex, infected wounds.
Abstract: Abdominoplasty is associated with a 1.1 percent risk of deep venous thrombosis. This has been attributed to rectus plication causing intraabdominal hypertension, known to effect decreased venous return, venous stasis, and thus thrombosis. The authors conducted a pilot study to determine which components of the abdominoplasty procedure (i.e., general anesthesia, flexion of the bed, plication, and/or binder placement) may elevate intraabdominal pressures and whether this was clinically relevant.
Abstract: Women with chronic, cyclical abdominal wall pain after gynecologic surgery may present in the plastic surgeon's office requesting body contouring. We present one such case in which an abdominal wall endometrioma was found. Resection of the endometrioma with the abdominal panniculus resulted in symptomatic cure for the patient. Plastic surgeons should be aware of the association of endometriosis with chronic pelvic/abdominal pain. Furthermore, suspicion of abdominal wall endometrioma should be entertained when patients present with chronic intermittent or cyclical abdominal wall pain after surgery of the pelvis or abdomen, especially after gynecologic or obstetric procedures.
Abstract: Artificial dermis has been used successfully for coverage of full-thickness wounds with a well-vascularized surgical bed. However, the use of artificial dermis in the reconstruction of partial- and full-thickness scalp defects has not been well documented.
Abstract: Pressure ulcers are a serious health issue, leading to clinical, financial, and emotional challenges. Numerous treatment modalities are available to promote wound healing, yet clinicians may be unsure how to incorporate these treatment options into an overall plan of care for the patient with a pressure ulcer. A consensus panel of experienced wound care clinicians convened in July 2004 to review the mechanisms of action and research basis for one such treatment modality: negative pressure wound therapy. After answering key questions about this modality, they developed an algorithm to assist the clinician in making decisions about using negative pressure wound therapy appropriately in patients with Stage III and Stage IV pressure ulcers.
Abstract: Clinical reports of full-thickness skin necrosis have raised concern about the thermal and dermal ischemic effects of ultrasound-assisted liposuction. The purpose of this study was to evaluate skin perfusion in patients treated with ultrasound-assisted liposuction or suction-assisted liposuction. Patients (n = 75) were studied prospectively in the perioperative period surrounding their suction-assisted liposuction (31 patients) or ultrasound-assisted liposuction (64 patients). The laser Doppler flowmeter was used to monitor skin perfusion in the treated regions preoperatively, intraoperatively, and postoperatively at a series of time intervals. The effects of the anesthetic, wetting solution, and type of liposuction (suction-assisted liposuction or ultrasound-assisted liposuction) on skin perfusion were measured. Anesthetic induction significantly increased measured skin perfusion. Wetting solution infusion significantly decreased skin perfusion (-57.4 percent +/- 2.0) by 15 minutes postinfusion. Skin perfusion in the ultrasound-assisted liposuction group was significantly greater than that of the suction-assisted liposuction patients at 1 hour, 1 day, and 1 week postoperatively; however, by 2 to 5 weeks, no difference in skin perfusion was noted and skin perfusion had returned to preoperative levels in both groups. Although skin perfusion in the suction-assisted liposuction group was significantly lower than in the ultrasound-assisted liposuction group in the early postoperative period, no differences in skin perfusion between the groups were noted beyond 1 week postoperatively, suggesting that neither technique impairs perfusion.
