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

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 causes of the nasolabial crease: A histomorphological study

There are two main conflicting theories on how the nasolabial crease is formed: a muscular theory and a fascial theory. The muscular theory states that the nasolabial crease is mainly formed by the musculodermal insertions of the lip elevator muscles. The fascial theory claims that the nasolabial crease is mainly formed by dense fibrous tissue and by the firm fascial attachments to the fascia of the lip elevator muscles. If the muscular theory was true, the musculodermal insertions of the facial muscles could be interrupted directly by intradermal injections of low doses of botulinum toxin. Eight cadavers who presented with bilateral nasolabial creases were enrolled in the study. The nasolabial creases were harvested from 14 facial halves in their entire lengths and breadths with 5-mm medial and lateral rims. The horizontally cut samples were stained with hematoxylin-eosin (H&E) and Elastica van Gieson (EVG). Immunohistochemistry for the smooth muscle marker actin and the skeletal muscle marker desmin was also performed. In each of the nasolabial creases, numerous skeletal muscle fibers were found in the dermis, which confirmed the muscular theory of the cause of the nasolabial crease. In addition, muscle fibers were present in the dermis 4 mm medial and 4 mm lateral to the nasolabial crease, but the amounts were significantly less than the amount located directly in the crease. Botulinum toxin injected intradermally into the nasolabial crease might constitute a new treatment option to minimize or even eradicate the crease and the fold. Clin. Anat.2012. © 2012 Wiley Periodicals, Inc

Incidence of the superficial fascia and its relevance in skin-sparing mastectomy

BACKGROUND: With the move away from classical radical mastectomy to ever more skin-sparing procedures, there has been an ongoing discussion about how much skin and subcutaneous tissue should be resected to perform an adequate mastectomy while leaving viable skin flaps. One of the common recommendations is to dissect just superficial to the superficial layer (SL) of the superficial fascia of the breast. This, in turn, has revived the old, unsolved controversy about the existence or absence of the SL, a fascia that reportedly encloses the mammary gland ventrally. In skin-sparing mastectomies (SSM), which combine tumor resection with immediate breast reconstruction, the ideal would be to create skin flaps that are thin enough to remove all breast tissue but at the same time are thick enough to preserve flap circulation. The feasibility of meeting these two goals simultaneously and the possible role and relevance of the SL as a guide to dissection in SSM was examined in this study. METHODS: Sixty-two breast resection specimens from 31 women who underwent breast reduction were examined histologically to determine whether the SL was present, whether breast tissue could be detected within or beyond this SL, the measured distance between the caudal border of the dermis and the SL or the breast tissue, and whether the thickness of the subcutaneous fat layer was correlated with the patients' physical data, such as body weight or body mass index (BMI). RESULTS: The SL was absent in 44% of resection specimens. When the SL was present, 42% of specimens contained several islands of breast tissue within the SL. No breast tissue was found beyond the SL. The minimal distance between the SL and the dermis varied from 0.2 mm to 4.0 mm; the minimal distance between the breast tissue and the dermis was 0.4 mm. In 50% of specimens, the minimal distance between the dermis and the SL or breast tissue was or = 5 mm was encountered in only 17% of specimens, and a distance of > or = 10 mm was encountered in only 5% of specimens. No significant correlation between the right and left breast was found with any of the parameters examined. A weak negative correlation was seen between the BMI and the mean thickness of the subcutaneous fat (P = 0.049; correlation coefficient [r] = -0.39; Spearman rank correlation). CONCLUSIONS: Histologic evaluation revealed that the SL is not present in all breasts and, thus, cannot serve as a reliable plane of dissection. Furthermore, if the SL is present microscopically, then it often is too thin and delicate to be detectable macroscopically. Finally, even if the SL is present and visible macroscopically, the distance to the overlying skin is so small in the majority of patients that a dissection superficial to the SL would not leave viable skin flaps in skin-sparing mastectomies

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 × 2 cm 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 0.2 ml 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 11 weeks 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 surgery

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

Oral premedication for operations on the face under local anesthesia: a placebo-controlled double-blind trial

Modern strategies for preventing or controlling pain and anxiety demand a premedication for operations using local anesthesia and for those using sedation or general anesthesia. For optimal patient care, the premedication should be given orally and, with respect to the outpatient basis of the operations, should have a short recovery period. Midazolam, one of the most favored premedications for general anesthesia, has been recommended as a premedication for operations using local anesthesia as well. However, midazolam has only sedative-anxiolytic effects and does not reduce pain sensation, which should be mandatory for operations using local anesthesia. A further requirement is the maintenance of stable hemodynamics for the prevention of postoperative hematomas, especially in the face. For these reasons, another premedication meeting all requirements (anxiolysis, analgesia, and stable hemodynamics) was researched. A randomized, double-blind prospective study was performed from March of 1997 to June of 1998. Five groups totalling 150 patients were included in the study; each group contained 30 patients who had operations performed solely on the face. In the first four groups, the effect of midazolam (0.15 mg/kg(-1)), morphine (0.3 mg/kg(-1)), and clonidine (1.5 microg/kg(-1)) administered orally was compared with a placebo. The fifth group was the control group and received no premedication. To evaluate the effects of the premedications, a corresponding questionnaire was completed independently by the patient and surgeon. With regard to the anxiolytic or analgesic properties of the premedication, 61 percent of the patients preferred pain reduction to anxiety control, and 24 percent of patients preferred reduction of anxiety. The remainder insisted on a reduction of both properties (8 percent) or had no preference (7 percent). Reduction of anxiety was largest in the midazolam and the clonidine groups, but the difference was not significant. The least pain during the application of local anesthesia was experienced by the morphine group (37 percent) and the clonidine group (33 percent), in contrast to the midazolam group (60 percent) (p = 0.04). Morphine and clonidine met the requirements of pain reduction equally well. Nevertheless, considering the rate and intensity of adverse effects with respect to hemodynamic compromises, nausea, and emesis, clonidine is even better suited as an oral premedication for operations on the face using local anesthesia

Configuration and localization of the nipple-areola complex in men

The causes of bilateral absence of the nipple-areola complex in men are seldom congenital, but attributable rather to destruction as a result of trauma, or after mastectomy in female-to-male transsexuals and in male breast cancer, or after the correction of extreme bilateral gynecomastia. Such a bilateral loss becomes a major reconstructive challenge with respect to the configuration and localization of a new nipple-areola complex. Because there is very little information available in the literature, we carried out a cross-sectional study on the configuration and localization of the nipple-areola complex in men.A total of 100 healthy men aged 20 to 36 years were examined under standardized conditions. The first part of the study dealt with the configuration of the nipple-areola complex (dimensions, round or oval shape). The second part concentrated on the localization of the complex on the thoracic wall with respect to anatomic landmarks and in correlation to various parameters such as weight and height of the body, circumference of the thorax, length of sternum, and position in the intercostal space. Of the 100 subjects examined, 91 had oval and seven had a round nipple-areola complex. An asymmetry between the right and the left side was found in two cases. The mean ratio of the horizontal/vertical diameter of an oval nipple-areola complex was 27:20 mm and the mean diameter for a round nipple-areola complex was 23 mm. The center of the nipple-areola complex was in the fourth intercostal space in 75 percent and in the fifth intercostal space in 23 percent of the subjects. To localize the nipple-areola complex on the thoracic wall de novo, at least two reproducible measurements proved to be necessary, composed of a horizontal line (distance from the midsternal line to the nipple = A) and a vertical line (distance from the sternal notch to the intersection of line A, = B). The closest correlation for the horizontal distance A was given by the circumference of the thorax: A = 2.4 cm + [0.09 x circumference of thorax (cm)], (r = 0.68). The best correlation to calculate the vertical distance B was found using the distance A and the length of the sternum: B = 1.2 cm + [0.28 x length of sternum (cm)] + [0.1 x circumference of thorax (cm)], (R = 0.50). In cases of bilateral absence, we recommend creating an oval nipple-areola complex in men. The appropriate localization can be calculated by means of two simple equations derived from the circumference of the thorax and the length of the sternum