This report elucidates the continued and relatively rare problem of congenital symmastia and its surgical repair without concomitant bilateral breast reduction. This case highlights the use of suction-assisted lipectomy techniques to address the excess fat in the presternal web and a periareolar approach for access to the intermammary space. The periareolar incision allows for the use of a concealed approach and the avoidance of a central scar that could result in hypertrophy or keloid formation, especially in this patient who is more prone to hypertrophic scarring. Furthermore, plication of the central web dermis to the sternal periosteum in a more superior position serves to not only correct the symmastia but also redrape the excess skin and restore the blunted inframammary folds.
Surgical management of lymphedema of the lower extremity is indicated in select patients when conservative measures have failed. The excisional approach has traditionally consisted of a staged excision procedure or total excision of diseased tissue. Based on an improved knowledge of vascular anatomy and understanding of perforator flap surgery, radical reduction of lymphedema with preservation of perforators (RRPP) applies an excisional approach and microsurgical principles to the radical reduction of lymphedema.Fifteen patients underwent RRPP during the period of June 1993 to February 2002 and were included in this study. Medial and lateral skin flaps were raised through incisions on the anterior and posterior leg, preserving a 4-cm skin bridge in the central portion of the incisions. The skin flaps were reduced to 5 mm in thickness, except in the vicinity of the lateral and medial septae, which contain perforators from the posterior tibial and peroneal arteries.At an average follow-up period of 13 months, a statistically significant reduction in lymphedema was achieved (P < 0.05). The average percentage in reduction above the knee was 51%, below the knee 66%, at the ankle 44%, and at the level of the foot 41%. The average overall lymphedema reduction for the patients was 52%. There were no cases of wound breakdown or skin flap necrosis. Complications consisted of cellulitis in 3 patients and seroma and hematoma in 1 patient.Based on angiosome principles and application of perforator principles to the surgical reduction of lymphedema, effective, long-lasting, and cosmetically appealing results are achieved in a single-stage procedure.
Venous malformations are a subset of low-flow vascular malformations. These are usually present at birth and grow commensurate with the child. The treatment of low-flow vascular malformations has been studied extensively. Many interventions have been devised to benefit this patient population in regard to the pain, ulcerations, infections, cosmetic concerns, and overall bulk associated with these malformations. Treatment can begin with compression garments. Another treatment is sclerotherapy. This can be done as a stand-alone treatment or as an adjunct to surgical excision. Percutaneous sclerosis of venous malformations has an efficacy of between 74 and 90% in relieving symptoms. We present a case of percutaneous sclerotherapy with Sotradecol and ethanol into an extensive lower extremity venous malformation in the setting of orthopedic megaprosthesis. We feel that this led to extensive soft tissue necrosis and infection of the limb and created a precipitous situation.
We report a pseudoaneurysm of the medial plantar artery that developed after percutaneous pinning for a Lisfranc fracture-dislocation in a 68-year-old male. Postembolization ultrasound and arteriography demonstrated successful ablation of the pseudoaneurysm following intra-arterial thrombin injection. Postoperative pulse volume recording and photoplethysmograph of the digits revealed excellent perfusion following ablation. (J Am Podiatr Med Assoc 99(1): 58–60, 2009)
Several authors have cited renal disease as a risk factor for free flap failure. The authors performed a retrospective analysis of all patients who underwent free tissue transfer with concomitant renal disease, including acute renal failure, end-stage renal disease, chronic renal insufficiency, and functional kidney transplants, to determine what effect renal disease has on flap survival and overall reconstructive outcome. More than 1053 free flaps were examined. Renal disease was identified in 32 patients who underwent 33 free tissue transfers. Average patient age was 57 years (range, 36 to 80 years). Twelve patients (38 percent) were on chronic dialysis (end-stage renal disease), 18 patients (56 percent) had chronic renal insufficiency, and three patients (9 percent) had the diagnosis of acute renal failure at the time of surgery. Three patients in the chronic renal insufficiency group had a functioning renal transplant. Average follow-up was 16 months. Immediate postoperative complications occurred in 14 patients (42 percent of the 33 flaps). Overall perioperative mortality was 3 percent. Within the first 30 days there were two cases (6 percent) of primary flap failure; an additional four legs were lost as the result of complications related to their bypass grafts. There were no primary flap failures after 30 days; however, within the first year after surgery an additional seven limbs were lost as the result of progressive ischemia or infection, and an additional three patients died. This resulted in a 52 percent incidence of major morbidity or mortality during the first year and a 55 percent reconstructive success rate in survivors at 1 year. No significant difference was seen in postoperative morbidity or mortality when comparing the end-stage renal disease group to the chronic renal insufficiency group; however, patients with renal disease and diabetes tended to have poorer outcomes. Renal disease, especially renal disease associated with diabetes and peripheral vascular disease, can be a strong indicator of possible reconstructive failure. The surgeon and patient should be aware of the medical and surgical complications associated with this procedure at the outset.
OBJECT A systematic review of the available evidence on the prophylactic and therapeutic use of flaps for the coverage of complex spinal soft-tissue defects was performed to determine if the use of flaps reduces postoperative complications and improves patient outcomes. METHODS A PubMed database search was performed to identify English-language articles published between 1990 and 2014 that contained the following phrases to describe postoperative wounds (“wound,” “complex back wound,” “postoperative wound,” “spine surgery”) and intervention (“flap closure,” “flap coverage,” “soft tissue reconstruction,” “muscle flap”). RESULTS In total, 532 articles were reviewed with 17 articles meeting the inclusion criteria of this study. The risk factors from the pooled analysis of 262 patients for the development of postoperative complex back wounds that necessitated muscle flap coverage included the involvement of instrumentation (77.6%), a previous history of radiotherapy (33.2%), smoking (20.6%), and diabetes mellitus (17.2%). In patients with instrumentation, prophylactic coverage of the wound with a well-vascularized flap was shown to result in a lower incidence of wound complications. One study showed a statistically significant decrease in complications compared with patients where prophylactic coverage was not performed (20% vs 45%). The indications for flap coverage after onset of wound complications included hardware exposure, wound infection, dehiscence, seroma, and hematoma. Flap coverage was shown to decrease the number of surgical debridements needed and also salvage hardware, with the rate of hardware removal after flap coverage ranging from 0% to 41.9% in 4 studies. CONCLUSIONS Prophylactic coverage with flaps in high-risk patients undergoing spine surgery reduces complications, while therapeutic coverage following wound complications allows the salvage of hardware in the majority of patients.
Gender Affirmation Surgery (GAS) is a super specialized subset within the field of plastic and reconstructive surgery (PRS) that is ever evolving and of increasing interest to the PRS community. It is a multifaceted process which, in addition to surgical therapy, involves mental health therapy and hormonal therapy. One rapidly emerging interest within GAS is the role that gender affirming hormone therapy (GAHT) plays in enhancing surgical outcomes. GAHT has been used adjunctively with GAS as a comprehensive therapy to ameliorate gender dysphoria. This literature review will examine the positive effects of GAHT on the surgical outcomes on GAS, as well as other important considerations prior to surgery. As such, the primary objective of this literature review is to evaluate and assess the current evidence concerning the efficacy and safety of GAHT, as it relates to Gender Affirmation Surgery procedures.
Our goal in trans man phalloplasty is to decrease the patient’s level of gender incongruence, obviate the use of an external prosthesis, be able to orgasm, and give the patient the ability to urinate standing (if desired), while also attempting to decrease urinary complications. The decision to undergo urethral lengthening is considered early in this surgical process. However, urethral complications are among the most common problems we see in phalloplasty, and surgical techniques have evolved to decrease these complications. We have developed an advanced two-stage mucosa-only prelaminated neourethra phalloplasty technique to address these issues. Our surgical technique is detailed in addition to providing patient demographics, co-morbidities, flap complications, and urinary sequelae. We also discuss the perineal urethroplasty in patients opting for no urethral lengthening in phalloplasty. All options should be given and risks considered in trans men undergoing soft tissue phalloplasty, and these will be discussed in detail.
