Prevention of Seroma After Abdominoplasty

Background: Seroma is one of the most troubling complications after abdominoplasty; incidence rates of up to 25% have been reported. If it is correct that shearing forces between the two separated abdominal layers play a key role in the development of seroma, postoperative immobilization of the patient until the layers are sufficiently adhered may be a solution to the problem. Objectives: The authors examine the association between length of immobilization and the development of seroma. Methods: This retrospective study included 60 patients; half were immobilized for 24 hours (group 1) and the other half were immobilized for at least 48 hours (group 2). For thromboembolism prophylaxis, all patients received low molecular weight heparin and compression stockings. Postoperative follow-up for detection of seroma continued for at least three months. Results: Mobilization after 24 hours led to a seroma rate of 13%, whereas immobilization of at least 48 hours decreased the seroma rate to 0%. Conclusions: For abdominoplasty patients with a low or moderate thromboembolic risk, the data suggest that immobilization for at least 48 hours with chemical and mechanical thromboembolism prophylaxis significantly reduces the risk of serom

The Transareolar Incision for Breast Augmentation Revisited

Of the various possible incisions for breast augmentation, the transareolar access has gained only limited popularity. The potential side effects of this incision are said to be altered nipple sensation, impaired lactation, an increased rate of infections with capsular fibrosis, well visible scar formation with hypopigmentation, and the need for an additional access in case a breast ptosis correction should prove necessary at a later date. The purpose of this retrospective study was to judge advantages and limitations of transareolar breast augmentation, and to verify whether the reluctant attitude toward this surgical approach is justified. A sample of 18 patients with a transareolar, retropectoral breast augmentation was selected for a retrospective evaluation. The suitability of the technique in general was examined together with early postoperative complications, sensory changes, and late complications on the basis of an evaluation system for cosmetic surgical results. The study showed that only women with an areolar diameter of 3.5cm or more without pronounced breast ptosis were suitable for the transareolar access. No early infections were noted. The rate of capsular fibrosis was 11%. Two years after breast augmentation, 16 women (89%) judged their breast sensation to be normal, but objective assessment showed that mean pressure and vibration sensation were moderately compromised in all parts of the breast. The scars were of good quality, with very little hypopigmentation. With appropriate patient selection, respecting the advantages and limitations, the transareolar incision has its definite place among the different incisions for breast augmentatio

Der Body Mass Index als Entscheidungsgrundlage für medizinisch indizierte Brustreduktionen

Summary: PURPOSE: Breast reduction is a highly emotional theme and bears conflicting interest groups: (1) women who are suffering from symptomatic macromastia and therefore would wish to have their breast reduction paid by the insurers, irrespective of the amount of resection weight, (2) the insurance companies, who are ready to cover only really medically indicated operations and due to a lack of objective parameters often apply the very strict, arbitrary criterium for a minimum resection weight of 500g per breast, and (3) the surgeons, who try to provide a fair, scientific basis for the differentiation between cosmetic and reconstructive indications for breast reductions for the sake of both the patients and the insurance parties. Concerned about such a generalizing rule, we undertook a retrospective review of our patients' charts with both cosmetic and reconstructive indications to judge the available, more-level minimum resection weight standards and see wether they were appropriate to use, or to provide an objective and measurable guideline for a scaled amount of breast reduction beyond the 500 g-resection-rule, adapted to the individual woman's body proportions. METHODS: 136 women could be included in the study. The resection weight was recorded and correlated to various parameters of the body proportions such as weight, height, the body mass index (BMI) and the body surface. The results were compared to the available minimum resection weight rules. RESULTS: The resection weight ranged from 55 to 1530g (mean, 450g ± 266g; median, 406g). Overweight was present in 36% of all patients, whereas obesity was present in 7.5 % of women. The mean BMI was 25.1 kg/m2. Of the twenty-four patients (18%), who were classified a priori as having a cosmetic indication, 4 (18%) had more than 500g breast tissue resected bilaterally. On the other hand, in 55% of reconstructive patients less than the predicted 500g of breast tissue had been resected. From all examined parameters the BMI had the highest correlation to the resected mean breast tissue (r = 0.64, p ≤ 0.001). DISCUSSION: Our retrospective review thus showed that with an arbitrary 500g breast resection-rule all women beyond the mean values for weight and height were clearly put at a disadvantage. Also not completely solving this problem are the already available, more objective guidelines for graded minimum resection weight recommendations which have relied on the body weight or the body surface area, parameters that both had a much lower correlation to the resected breast tissue in the patient group than the BMI. We therefore suggest using the BMI as the basis for a graded, more-level weight resection standard for reconstructive breast reductions. This algorithm is related solely to objectifying data and thus avoids biases from empirically derived data or hardly quantifiable breast (or obesity) related pain syndromes, and respects all the different body builds of wome

A body mass index related scale for reconstructive breast reduction

Breast reduction is a highly emotional topic, involving three conflicting interests: (a) women suffering from symptomatic macromastia, (b) health insurance companies, and (c) surgeons. Many insurance companies, including those in Austria, cover (if at all) only breast reductions with a minimum resection weight of 500g per breast, irrespective of the physical build of the woman involved. We retrospectively reviewed 136 patients' charts from both cosmetic and reconstructive breast reduction operations and compared the breast resection weight to various parameters of body proportions such as height, weight, body mass index (BMI), and body surface area to determine the parameter best correlated to the weight of breast tissue resected. From this we developed a graded scale for guiding future operations irrespective of a woman's body build. The resection weight ranged from 55 to 1530g (mean 450±266, median 406); mean BMI was 25.1. The arbitrary 500g breast resection rule discriminates against women of nonaverage weight or height: of 24 patients (18%) with a cosmetic indication 4 had more than 500g breast tissue resected bilaterally, while in 62 reconstructive patients (46%) less than the arbitrary 500g breast tissue was resected. The parameter best correlated to the mean weight of breast tissue resected (sum of both breasts) was BMI. We therefore suggest using the BMI as the basis for a graded weight resection guideline for reconstructive breast reductions. The BMI-based scale treats equally women of all types of body build. In women with a BMI greater than 30 (classified as adiposity) we recommend that breast reduction be postponed, and a general body weight reduction program be undertaken for the sake of a higher impact on general well-bein

The Cartilage-Sparing Versus the Cartilage-Cutting Technique: A Retrospective Quality Control Comparison of the Francesconi and Converse Otoplasties

From a total of 281 patients with protruding ears who underwent a bilateral otoplasty between 1990 and 2001, a group of 28 (10%) was selected for a retrospective quality control study. The goal was to compare two methods of otoplasty, the Francesconi, a cartilage-sparing technique, and the Converse, a cartilage-cutting technique, in terms of objectively measurable and subjectively discernable differences in results. Objective parameters included measurement of the three cephaloauricular distances and the conchoscapal angle. An independent plastic surgeon performed the evaluation by means of a systematic evaluation system for rating cosmetic surgical procedures and a 5-point visual analog scale for rating satisfaction. The patients' subjective rate of satisfaction also was investigated using the 5-point scale. The mean medial and inferior cephaloauricular distances were significantly smaller in the Francesconi group. The concoscaphal angle was 90°, or less in all the patients of the Francesconi group, but more than 90° in eight patients (57%) of the Converse group (p = 0.041). Accordingly, the independent surgeon found adequate correction of protrusion in 86% of the Francesconi group and 50% of the Converse group (p = 0.050). His satisfaction rate was significantly in favor of the Francesconi technique (p = 0.006). Not unexpectedly, the patients' satisfaction rate was comparably high in both groups, and there was no statistical difference between them. In conclusion, the quality control led to a clear preference of the Francesconi over the Converse otoplasty. In addition, the assessment of the postoperative results with the systematic evaluation system offered an excellent information base by which to judge the results of otoplasty. Consequent use of this evaluation system will lead to progress in the surgical procedur

Multiple bilateral asymmetrical deficiency of trunk muscles

Trunk muscles are an important source for pedicled and free flaps in reconstructive surgery. Unilateral deficiencies of trunk muscles are well known, either isolated or as part of Poland's syndrome. Bilateral muscular deficiencies and a "bilateral Poland anomaly” have also been sporadically reported, but this is rare. We report on an 82-year-old male cadaver with clinically obscure, asymmetric bilateral deficiencies of the majority of trunk muscles. There was a history of acute poliomyelitis in childhood. Histological examination of representative muscle samples of the trunk showed extensive muscle atrophy with fat and connective tissue replacement. This was compatible with the prior diagnosis of poliomyelitis. However, representative sections of the spinal cord failed to reveal the antecedent poliomyelitis. The possibility of subclinical bilateral deficiencies of trunk muscles has to be taken into account in patients with a history of poliomyelitis when planning reconstructions in cases of regional pedicled muscle transfers or free microvascular tissue transfers in reconstructive surger

Fibrin versus polyethylene glycol sealant: an experimental study in rabbits

Fibrin glue has been applied universally in general surgery as an adhesive, hemostatic, or embolizing agent. In reconstructive surgery, fibrin has been used mainly for nerve and microvascular repair or as a substitute for sutures in skin closure and skin grafting. Another area of increasing use is in face-lift surgery, where the goal is to improve hemostasis on the raw surfaces and to discourage the occurrence of major hematomas. However, as most components of the fibrin glue are derived from human or bovine plasma, they may cause allergic reactions and transmit infectious agents such as hepatitis or AIDS virus, or prions such as the Creutzfeldt-Jakob disease agent. With these risks in mind, we tested polyethylene glycol (PEG) sealant, a recently introduced and purely synthetic vascular sealant, as an alternative to fibrin glue. A 2 × 2cm subcutaneous pocket was created on the dorsal thighs of ten New Zealand White rabbits by an incision medial to the sciatic vein. The pockets were randomly filled with either 0.2ml of thawed fibrin glue or PEG sealant. After the operation, the thighs were inspected macroscopically for hematoma, seroma, or granuloma formation. Eleven weeks later, the animals were killed, and the fibrin and polyethylene glycol-filled pockets were harvested en bloc with the overlying skin and processed for histological examination. A swelling, viewed macroscopically, was visible at the experimental site in three thighs of the fibrin group, but in none of the PEG group. Only two specimens of the fibrin group and five specimens of the PEG group showed no signs of inflammation. All other specimens revealed signs of chronic or granulomatous inflammation, with no significant difference between the groups. This experimental study showed that 11weeks after application of either fibrin or PEG sealant, signs of chronic or even granulomatous inflammation were detectable in 2/3 of the specimens in the fibrin group and in approximately 50% of the specimens in the PEG group. Beyond the comparable potential of both sealants to induce inflammatory tissue reactions, PEG sealant has some notable advantages as it is purely synthetic and therefore carries no risk of transmission of viral pathogens or prions. The combination of this safety profile, the ease of application, and the consistently good reported hemostatic results obtained with PEG sealant makes it an interesting alternative to fibrin glue in plastic surger

The effect of superior pedicle breast reductions on breast sensation

The aim of this study was to assess nipple, areola and breast skin sensation after breast reductions with two different superior pedicle techniques: a short, vertical scar technique compared to a long, inverted-T scar technique. Thirty-six women with a vertical technique (group I) and ten women with an inverted-T technique (group II) with a resection weight of ≤500g per breast completed their 1-year follow-up. The four modalities used to evaluate sensation were pressure with Semmes-Weinstein filaments, vibration with a vibrometer, and temperature and pain perception on a qualitative basis. The evaluation revealed that 1-year after breast reduction, the sensation was either reduced, unaltered, or improved in both groups. In the nipple, the mean sensation was markedly reduced throughout all qualities in both groups with the exception of pain, which was enhanced. In the areola, the mean sensation was also reduced in all qualities in both groups. In the quadrants of the skin, mean sensation was improved in terms of pressure and vibration in group I (8.3% normal pressure values preoperatively vs. 70% normal pressure values postoperatively) but reduced in the lower quadrant of the skin in group II with the inverted-T scar. This reduction of pressure was also significant (p = 0.04) in comparison with group I. Apart from this difference between the two groups, this study showed that in breast reductions with a superior pedicle technique, the long-scar technique did not lead to a greater reduction of sensation in the nipple and areola than the short-scar techniqu