Sir: Surgical emphysema may be defined as abnormal air in the body tissues or tissue spaces.1–5 An important diagnostic feature is crepitus on palpation. We describe a simple way of dealing with a life-threatening upper airway obstruction caused by surgical emphysema using liposuction despite the presence of correctly placed intrapleural chest drains or a tracheostomy tube. Both cases were senior citizens who had been admitted with blunt traumatic pneumothoraces complicated by surgical emphysema. Severe airway constriction caused by traumatic surgical emphysema led to emergency intubation and stabilization by the intensive care team in these patients (Fig. 1).Fig. 1.: Representative patient before and after liposuction.Despite having established a definitive airway, mediastinal emphysema and upper tracheal-bronchial obstruction were still life threatening because of significant and progressive surgical emphysema. In both cases, a decision by the plastic surgical and intensive care teams was made to decompress this surgical emphysema by liposuction. This was done by placing a 28-French chest drain tube with extra holes cut along the length of the tube inserted at the level of the fifth intercostal space, midclavicular line, and pushed cephalad until the tip reached the clavicle. It was moved in and out along under the skin in the plane of the subcutaneous fat while connected to suction with a reservoir bottle. There was little resistance to the tubing because of the amount of air in the subcutaneous tissues. This was successful in decompressing the surgical emphysema and there was no need for further small incisions to be made in the skin. The dramatic effect of this procedure after 1 hour was visible in both patients. There was mild bruising along the liposuction track but no hematomas. The anatomy of the deep fascial planes allows free air to enter the subcutaneous tissue from internal sources. In the lungs, any condition causing increased alveolar pressures precipitates alveolar rupture and air in the intraalveolar space tracks along the pulmonary vasculature into the mediastinum. This follows the path of least resistance between the fascial planes investing the trachea, esophagus, and great vessels.3 Traumatic causes include injury to the facial skeleton causing periorbital subcutaneous emphysema or chest injury resulting in a pneumothorax. This may occur by a sucking mechanism, where a small defect in the skin acts as a flap valve allowing air to be sucked into the superficial tissues by the negative pressure created by movement. This may manifest as a rapid development. Iatrogenic injury normally follows surgical procedures during which air is introduced into the soft tissues and spreads along the fascial planes during central venous catheter line placement, esophagoscopy, dental extraction, chest drain insertion, and tracheostomy. Liposuction may provide a simple, effective way of treating life-threatening surgical emphysema even when a definitive airway is in situ. The technique is simple and can be performed in the accident and emergency department, intensive care ward, or operating theater environment with dramatic effect. A procedure commonly associated with aesthetic surgery does have a life-saving application. Mark Sheldo Lloyd, M.R.C.S.(Eng.), M.Sc., M.Phil. Stas Jankowksi, F.R.C.A., F.R.C.P. Intensive Care Unit Epsom and St. Helier NHS Trust Carshalton Sutton, Surrey, United Kingdom ACKNOWLEDGMENTS Permission to use photographs was kindly granted by the wife of the patient. No funding was necessary in the production of this article.
Abstract Background Surgical applications using breast implants are individualized operations to fill and shape the breast. Physical properties beyond shape, size, and surface texture are important considerations during implant selection. Objectives Compare form stability, gel material properties, and shell thickness of textured shaped, textured round, and smooth round breast implants from 4 manufacturers: Allergan, Mentor, Sientra, and Establishment Labs, through bench testing. Methods Using a mandrel height gauge, form stability was measured by retention of dimensions on device movement from a horizontal to vertical supported orientation. Dynamic response of the gel material (gel cohesivity, resistance to gel deformation, energy absorption) was measured using a synchronized target laser following application of graded negative pressure. Shell thickness was measured using digital thickness gauge calipers. Results Form stability, gel material properties, and shell thickness differed across breast implants. Of textured shaped devices, Allergan Natrelle 410 exhibited greater form stability than Mentor MemoryShape and Sientra Shaped implants. Allergan Inspira round implants containing TruForm 3 gel had greater form stability, higher gel cohesivity, greater resistance to gel deformation, and lower energy absorption than those containing TruForm 2 gel and in turn, implants containing TruForm 1 gel. Shell thickness was greater for textured vs smooth devices, and differed across styles. Conclusions Gel cohesivity, resistance to gel deformation, and energy absorption are directly related to form stability, which in turn determines shape retention. These characteristics provide information to aid surgeons choosing an implant based on surgical application, patient tissue characteristics, and desired outcome.
Capsular tissue, the interface that forms between an implanted device and the body's own soft tissues, has recently been shown to develop its own unique blood supply. This capsular tissue with its extensive vascular plexus has not been described previously as an isolated flap. The purpose of our study was to determine whether an isolated flap of capsular tissue would survive as a local pedicle flap and provide enough inherent vascularity to support a skin graft. Isolated expanded and nonexpanded capsular flaps were compared by using 20 expanders (10 expanded and 10 nonexpanded) in two mixed-breed female pigs. Expanded and nonexpanded capsular flaps were elevated 8 weeks following expander placement. These flaps were raised on their capsular bases alone, and skin grafts were placed onto the capsular surfaces. All the expanded capsular flaps and their skin grafts had 100 percent survival. Skin grafts on the nonexpanded flaps survived an average of 28 percent, with graft survival corresponding to flap survival. This study confirms that flaps of isolated expanded capsular tissue survive and provide enough inherent vascularity to support a split-thickness skin graft.
