Gynecomastia Management: An Evolution and Refinement in Technique at UT Southwestern Medical Center.

Gynecomastia is a benign proliferation of male breast glandular tissue. Gynecomastia can affect men at any stage of life. Traditional treatment options involved excisional surgeries with periareolar or T-shaped scars, which can leave more visible scars on the chest. The technique presented represents a technique used by the senior author, which relies on ultrasonic liposuction and pull-through technique to remove breast tissue. A retrospective chart review was performed, including all patients who were treated, from 2000 to 2013 by the senior author, for gynecomastia. A deidentified database was created to record patient characteristics, including age, height, weight, ptosis, stage of gynecomastia, and gynecomastia classification. Surgical approaches, complications, and revisions were also recorded. Our experience includes 75 patients with all grades of gynecomastia from 2000 to 2013. These cases span the evolution of our technique to include direct pull-through excision with ultrasound-assisted liposuction. The distribution of the grades I, II, III, and IV ptosis was 30.6%, 36 %, 22.6%, and 10.6% respectively. There were no complications in this series. Only one patient with grade III ptosis required revision surgery. This technique provides a safe and aesthetically pleasing way to treat gynecomastia with a low need for revision.

Lateral Abdominal Wall Defects: The Importance of Anatomy and Technique for a Successful Repair.

Flank and lateral abdominal wall defects can be an extremely challenging phenomenon for surgeons to undertake. Their rarity and specific idiosyncrasies in regard to embryologic and anatomical characteristics must be taken into consideration when formulating an operative plan. We will discuss these cardinal points including technical recommendations by notable experts in the field to gain a better understanding in the diagnosis and treatment of this infrequent but morbid occurrence.

An Evidence-Based Model for the Successful Treatment of Flank and Lateral Abdominal Wall Hernias.

BACKGROUND: Lateral abdominal wall defects are a significant contributor to patient morbidity and mortality in the United States. Reconstruction involving flank hernias and bulges is relatively scarce in the literature despite its serious consequences. The authors aim to identify an objective approach for the evaluation and successful repair of defects of the lateral abdominal wall. METHODS: A retrospective analysis was carried out on patients presenting for open repair of a lateral wall defect performed by a single surgeon. Over a 5-year period, there were 29 consecutive patients with a mean follow-up period of 21.2 months. Patient demographics including body mass index, number of hernia defects, number of previous repairs/abdominal operations, defect size, operative time, blood loss, and complications (e.g., recurrence/bulge, seroma, hematoma, wound infection, persistent pain, skin breakdown, and fascial dehiscence) were collected. RESULTS: Patients who underwent flank hernia repairs using an inlay/underlay nonbridged technique with the use of acellular dermal matrix had low recurrence and overall complication rates. Only one patient (3.4 percent) had a recurrence at follow-up, and another patient (3.4 percent) had developed a bulge. CONCLUSIONS: The authors' data indicate successful results when their technique is applied. Proper patient selection is essential, along with a thorough understanding of anatomy and techniques for successful reconstruction. The authors recommend using an inlay (preferred) or underlay repair with acellular dermal matrix to reinforce the surrounding musculofascial closure. This technique, in conjunction with the authors' holistic abdominal wall reconstruction protocol, has optimized outcomes and identified a successful multidisciplinary strategy for the reconstruction of lateral wall defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Changing role of hyaluronidase in plastic surgery.

SUMMARY: Soft-tissue augmentation has become an increasingly popular option for facial rejuvenation. Hyaluronic acid fillers are part of the most rapidly expanding segment of this market, largely because of their safe drug profile and temporary nature. Despite their good safety profile, they can and do have complications ranging from superficial placement, uneven placement, granulomatous reactions, and skin necrosis. This article reviews the on- and off-label uses of hyaluronidase and presents several clinical algorithms detailing the effective and safe use of hyaluronidase to manage complications secondary to hyaluronic acid fillers.

Clostridium difficile enteritis: A report of two cases and systematic literature review.

Clostridium difficile (C. difficile) is the most common cause of healthcare associated infectious diarrhea. In the last decade, the incidence of C. difficile infection has increased dramatically. The virulence of C. difficile has also increased recently with toxigenic strains developing. C. difficile is generally a disease of the colon and presents with abdominal pain and diarrhea due to colitis. However, C. difficile enteritis has been reported rarely. The initial reports suggested mortality rates as high as 66%. The incidence of C. difficile enteritis appears to be increasing in parallel to the increase in colonic infections. We present two cases of patients who had otherwise uneventful abdominal surgery but subsequently developed C. difficile enteritis. Our literature review demonstrates 81 prior cases of C. difficile enteritis described in case reports. The mortality of the disease remains high at approximately 25%. Early recognition and intervention may reduce the high mortality associated with this disease process.

Latissimus dorsi donor-site morbidity: the combination of quilting and fibrin sealant reduce length of drain placement and seroma rate.

Seroma formation has been shown to be a multifactorial process in part due to dead space and the formation of raw surfaces, which produce large quantities of serous exudate. The purpose of this study is to evaluate the effect of quilting/progressive tension sutures (to reduce dead space) and fibrin sealant (to seal the raw surface) in combination on the seroma rate and length of drain placement in patients undergoing latissimus dorsi breast reconstruction. A retrospective review of 43 patients undergoing latissimus dorsi flap breast reconstruction was performed. The patients were divided into 2 groups: quilting sutures alone versus those with quilting sutures and fibrin sealant. Data regarding age, body mass index, smoking history, timing of reconstruction, type of breast surgery, radiation history, complications, length of drain placement, use of fibrin glue, and use of quilting/progressive tension sutures were collected for each patient. Results were analyzed statistically using unpaired t tests (P < 0.05). The quilting group included 19 patients with 24 donor sites. The mean drain placement duration was 21.5 days (range, 9-69 days). One patient in 19 developed a seroma, which was treated and resolved with aspiration. The seroma rate for the quilting only group was 5%. The quilting and sealant group included 23 patients with 26 donor sites. The quilting and sealant group had a mean duration of drain placement of 13.9 days (range, 6-38 days). This was a statistically reduced length of drainage (P = 0.04) compared with quilting only. The quilting and sealant group had 1 patient in 23 develop a seroma with a rate of 4% which compared with quilting only was not statistically significant (P = 0.4). The combination of quilting sutures and fibrin sealant directed at the 2 main mechanisms of seroma formation, (dead space and serous exudate, respectively) can decrease the duration of postoperative drain placement and does maintain low seroma rates.

Aesthetic subunit of the breast: an analysis of women's preference and clinical implications.

Patient satisfaction in breast surgery is dependent on achieving a balance among all aesthetic subunits. The purpose of this study is to identify which subunit of the breast women consider important and correlate this clinically to improve patient satisfaction following breast surgery. A total of 313 subjects (ages, 20-80) were surveyed using a 25-point survey instrument collected via a telemedicine form. The data was analyzed to determine clinical significance. Of the subjects, 63% selected the upper inner quadrant as the most important subunit. Furthermore, 66% of the subjects indicated defects located in this region would lead them to seek operative intervention and this was consistent for all subgroups. Based on these results, defects in the upper inner quadrant of the breast are more likely to cause patient dissatisfaction. Patient outcomes following surgery can be enhanced by restoring volume and minimizing scars in this upper medial subunit of the breast.

The use of non-invasive instruments in characterizing human facial and abdominal skin.

BACKGROUND AND OBJECTIVE: The skin is highly variable. This variation, although helpful for function, causes inconsistencies when assessed using subjective scales. The purpose of this study is to measure differences in skin on the face and abdomen using non-invasive, objective devices as a method to eliminate subjective error and help reduce intra- and inter-observer variability in clinical analysis. STUDY DESIGN/MATERIALS AND METHODS: Eighty-eight subjects between the ages of 18 and 61 were enrolled in this study. These subjects varied in age, ethnicity, and Fitzpatrick score. Facial analysis was performed by clinical evaluation and utilizing non-invasive objective devices which included the DermaScan C 20 MHz HFUS (Cyberderm, Broomall, PA), Tru Vu (Johnson and Johnson), BTC 2000 (SRLI Technologies, Nashville, TN), Derma Unit SSC3 (CK Electronic, Köln, Germany), and the Chromometer. RESULTS: Non-invasive devices were shown to be consistent and accurate through repeated measurement at each of the anatomical points with error rates of less than 5%. Chromometer measurements were able to categorize patients into Fitzpatrick level. DermaScan measurements demonstrated decreasing skin thicknesses associated with increasing age, smoking, and female gender. Derma Unit SSC 3 showed gender and sun exposure related differences in sebum concentration, pH, and moisture content. The Derma Unit SSC 3 sebum concentration also showed correlation with Tru Vu readings for clogged pores and bacterial activity. CONCLUSION: The skin assessment scales that are in use today are often prone to variability and inaccuracy due to their subjectivity. Use of the described objective non-invasive facial analysis method provides an accurate, objective analysis of human skin which can be used to measure changes pre- and post-operatively, or even screen patients prior to procedure to identify non-responders or those prone to adverse events. Utilization of these devices introduces a foundation on which a strong evidence-based approach to aesthetic medicine can be built.

The effect of postoperative enoxaparin on risk for reoperative hematoma.

BACKGROUND: The risk of postoperative bleeding is the chief concern expressed by plastic surgeons who do not use pharmacologic prophylaxis against venous thromboembolism. The Plastic Surgery Foundation-funded Venous Thromboembolism Prevention Study examined whether receipt of postoperative enoxaparin prophylaxis changed 60-day reoperative hematoma rates. METHODS: In 2009, the study's network sites uniformly adopted a "best practice" clinical protocol to provide postoperative enoxaparin to adult plastic surgery patients at risk for perioperative venous thromboembolism. Historical control patients (2006 to 2008) received no chemoprophylaxis for 60 days after surgery. Retrospective chart review identified demographic and surgery-specific risk factors that potentially contributed to bleeding risk. The primary study outcome was 60-day reoperative hematoma. Stratified analyses examined reoperative hematoma in the overall population and among high-risk patients. Multivariable logistic regression controlled for identified confounders. RESULTS: Complete data were available for 3681 patients (2114 controls and 1567 enoxaparin patients). Overall, postoperative enoxaparin did not change the reoperative hematoma rate when compared with controls (3.38 percent versus 2.65 percent, p = 0.169). Similar results were seen in subgroup analyses for breast reconstruction (5.25 percent versus 4.21 percent, p = 0.737), breast reduction (7.04 percent versus 8.29 percent, p = 0.194), and nonbreast plastic surgery (2.20 percent versus 1.46 percent, p = 0.465). In the regression model, independent predictors of reoperative hematoma included breast surgery, microsurgical procedure, and post-bariatric surgery body contouring. Receipt of postoperative enoxaparin was not an independent predictor (odds ratio, 1.16; 95 percent CI, 0.77 to 1.76). CONCLUSION: Postoperative enoxaparin does not produce a clinically relevant or statistically significant increase in observed rates of reoperative hematoma. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk: II.

Postoperative enoxaparin prevents symptomatic venous thromboembolism in high-risk plastic surgery patients.

BACKGROUND: Venous thromboembolism is a major patient safety issue. The Plastic Surgery Foundation-sponsored Venous Thromboembolism Prevention Study examined whether postoperative enoxaparin prevents symptomatic venous thromboembolism in adult plastic surgery patients. METHODS: In 2009, four sites uniformly adopted a clinical protocol. Patients with a Caprini score of 3 or higher received postoperative enoxaparin prophylaxis for the duration of inpatient stay. Venous Thromboembolism Prevention Study historical control patients had an operation between 2006 and 2008 but received no chemoprophylaxis for 60 days after surgery. The primary study outcome was symptomatic 60-day venous thromboembolism. RESULTS: Three thousand three hundred thirty-four patients (1876 controls and 1458 enoxaparin patients) were included. Notable risk reduction was present in patients with a Caprini score greater than 8 (8.54 percent versus 4.07 percent; p=0.182) and a Caprini score of 7 to 8 (2.55 percent versus 1.15 percent; p=0.230) who received postoperative enoxaparin. Logistic regression was limited to highest risk patients (Caprini score≥7) and demonstrated that length of stay greater than or equal to 4 days (adjusted odds ratio, 4.63; p=0.007) and Caprini score greater than 8 (odds ratio, 2.71; p=0.027) were independent predictors of venous thromboembolism. When controlling for length of stay and Caprini score, receipt of postoperative enoxaparin was protective against venous thromboembolism (odds ratio, 0.39; p=0.042). CONCLUSIONS: In high-risk plastic surgery patients, postoperative enoxaparin prophylaxis is protective against 60-day venous thromboembolism when controlling for baseline risk and length of stay. Hospitalization for 4 or more days is an independent risk factor for venous thromboembolism. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The low transverse extended latissimus dorsi flap based on fat compartments of the back for breast reconstruction: anatomical study and clinical results.

BACKGROUND: Despite many modifications to the extended latissimus dorsi flap, its use in autologous breast reconstruction remains limited because of insufficient volume and donor-site morbidity. Through a detailed analysis of the deposition of back fat, this study describes a low transverse extended latissimus dorsi flap harvest technique that increases flap volumes and improves donor-site aesthetics. METHODS: Eight fresh cadaver hemibacks were used to identify the anatomical location of the fat compartments. Correlation between the fat compartments and the fat folds was made using photographic analysis of 216 patients. Retrospective case note review was conducted of all patients who had a low transverse extended latissimus dorsi flap performed by the senior author (M.S.-C.). RESULTS: Cadaveric dissection and photographic analysis confirmed the presence of the four distinct fat compartments in the back. The lower compartments 3 and 4 were the most frequently identified and the largest, with mean values of 367 cm and 271 cm, respectively. The clinical series comprised eight high-body mass index patients who underwent 12 pure autologous breast reconstructions using the low transverse skin paddle harvest technique. Donor-site complications included partial dehiscence (n=2) and minor infection (n=3). There were no instances of seroma, and fat necrosis (<5 percent) occurred in one breast. CONCLUSIONS: The low transverse skin paddle extended latissimus dorsi flap is reliable and provides sufficient volume for purely autologous breast reconstruction with low donor-site morbidity and improved body contouring for a select group of patients. The authors' initial experience with high-body mass index patients shows promising results with this flap in a challenging group.

The extended transverse musculocutaneous gracilis flap: vascular anatomy and clinical implications.

BACKGROUND: The transverse musculocutaneous gracilis (TMG) flap has been used in autologous breast reconstruction, but disadvantages include a small flap volume; therefore, it is only used in small-to-moderate breast reconstructions. We investigated the vascular territory of this flap and the possibility of extending its dimensions. METHODS: Ten circumferential thigh adipocutaneous flaps attached to the gracilis muscle were harvested from adult cadavers. The following parameters were recorded: diameter and length of pedicles, distance of pedicles from pubis, and number and locations of cutaneous perforators. The major pedicles were injected with contrast and subjected to 3-dimensional computed tomography scanning. Images were viewed using both General Electrics and TeraRecon systems, and the vascular territories were measured. Flaps were then incised to include only tissue that was perfused with contrast, and measured for weight and volume. RESULTS: The major pedicle had a mean length of 6.7 cm, diameter of 2.2 mm, and distance from pubis of 8.6 cm. There was a mean of 4.3 cutaneous perforators associated with this flap. Three-dimensional images from contrast injection of the major pedicle showed a cutaneous vascular territory that extended more posteriorly than anteriorly, and had a vertical component. Tissue perfused with contrast had a mean weight of 573 g and volume of 617 mL. Two clinical cases were included to show applications of the extended TMG flap. CONCLUSION: The dimensions of a TMG flap can be increased horizontally (superoposterior thigh) as well as vertically. The vertical portion can be harvested either by undermining the skin inferior to the lower transverse skin incision or by raising a trilobed skin paddle to harvest even more tissue from the medial thigh.

An intra-individual quantitative assessment of acute laser injury patterns in facial versus abdominal skin.

INTRODUCTION: Clinical laser settings have traditionally been calibrated on abdominal skin to predict and anticipate patterns of injuries in facial skin. This experimental approach has limitations as facial skin and abdominal skin have differences that may influence the depth of laser injury. OBJECTIVE: The primary objective of this study is to analyze the acute pattern of laser injury in abdominal skin and facial skin samples from the same subject and detail the anatomical and biophysical properties that can influence the laser tissue interaction. The secondary objective is to develop a conversion factor that will allow the prediction laser column depths in facial skin based upon laser column depths in abdominal skin. METHODS: Fifteen healthy subjects were consented and screened. Two 2 mm spots on the face and abdomen were identified and measured and treated with a fractional CO(2) laser (Lumenis Ltd, Yokneum, Israel), with an energy setting of 15 mj, 300 Hz at a density of 10. Treatment areas were biopsied and analyzed histologically using hematoxylin and eosin and TUNEL staining. RESULTS: Facial skin and abdominal skin have several significant anatomical and biophysical differences (concentration of pilosebaceous units, sebum concentration, and moisture content). Facial tissue demonstrated divergence of laser energy around pilosebaceous units and lateral spread of laser energy along blood vessels. These differences cause attenuation (28%) of the laser energy and result in column depths that are significantly (P < 0.003) shorter in facial tissues (mean depth 415 µm) in comparison to abdominal tissues (mean depth 582 µm). CONCLUSION: The variations in anatomic, biophysical, and biomechanical properties in facial skin cause an attenuation of the laser column depths in facial skin when compared to abdominal skin. A correction factor of 28% is required to predict the depth of laser columns in facial skin based on laser column depths observed in abdominal skin.

Etiology, prevention, and treatment of dermal filler complications.

The availability of dermal fillers for multiple cosmetic indications has led to a dramatic increase in their application. Although fillers are generally regarded as safe tools for soft tissue augmentation, complications can occur. Therefore, to describe and review the complications associated with the currently-available dermal filling agents, the authors conducted a literature review in peer-reviewed journals and present the reported complication rates. They also describe current strategies to avoid, diagnose, and manage complications if they do occur.

Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients.

BACKGROUND: The Venous Thromboembolism Prevention Study (VTEPS) Network is a consortium of 5 tertiary referral centers established to examine venous thromboembolism (VTE) in plastic surgery patients. We report our midterm analyses of the study's control group to evaluate the incidence of VTE in patients who receive no chemoprophylaxis, and validate the Caprini Risk Assessment Model (RAM) in plastic surgery patients. STUDY DESIGN: Medical record review was performed at VTEPS centers for all eligible plastic surgery patients between March 2006 and June 2009. Inclusion criteria were Caprini score ≥3, surgery under general anesthesia, and postoperative hospital admission. Patients who received chemoprophylaxis were excluded. Dependent variables included symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) within the first 60 postoperative days and time to DVT or PE. RESULTS: We identified 1,126 historic control patients. The overall VTE incidence was 1.69%. Approximately 1 in 9 (11.3%) patients with Caprini score >8 had a VTE event. Patients with Caprini score >8 were significantly more likely to develop VTE when compared with patients with Caprini score of 3 to 4 (odds ratio [OR] 20.9, p < 0.001), 5 to 6 (OR 9.9, p < 0.001), or 7 to 8 (OR 4.6, p = 0.015). Among patients with Caprini score 7 to 8 or Caprini score >8, VTE risk was not limited to the immediate postoperative period (postoperative days 1-14). In these high-risk patients, more than 50% of VTE events were diagnosed in the late (days 15-60) postoperative period. CONCLUSIONS: The Caprini RAM effectively risk-stratifies plastic and reconstructive surgery patients for VTE risk. Among patients with Caprini score >8, 11.3% have a postoperative VTE when chemoprophylaxis is not provided. In higher risk patients, there was no evidence that VTE risk is limited to the immediate postoperative period.

The single dominant medial row perforator DIEP flap in breast reconstruction: three-dimensional perforasome and clinical results.

BACKGROUND: Successful outcomes with the deep inferior epigastric artery perforator (DIEP) flap are heavily dependent on identifying the largest perforators. The purpose of this study was to describe the vascular anatomy (location, size, zones of perfusion, and variations) of the single most dominant deep inferior epigastric artery perforator and to report a clinical series based on this flap. METHODS: Eleven abdominal flaps were harvested from fresh adult cadavers, and measurements were combined with clinical measurements from 16 patients. Details such as perforator size, location, type, and zones of perfusion were documented for all flaps and clinical outcomes for all patients. RESULTS: A total of 36 flaps were dissected with an average perforator location within a 3-cm radius of the umbilicus and an average perforator size greater than 1.8 mm. Computed tomographic scans of the cadaver abdominal flaps demonstrated consistent perfusion in zones I and II and half of zones III and IV. Clinical results showed partial flap necrosis in one patient and fat necrosis of less than 5 percent in three patients, all of which occurred in the distal portion of zone III. The deep inferior epigastric artery medial row perforators near the umbilicus were found to be the largest perforators in the entire deep inferior epigastric artery system and abdomen. CONCLUSIONS: The single dominant medial row perforator has a maximal vascularity in zones I and II, and less in zones III an IV. The authors recommend that half of zone III and all of zone IV be discarded to avoid the risks of partial flap loss and fat necrosis.

Perforasomes of the DIEP flap: vascular anatomy of the lateral versus medial row perforators and clinical implications.

BACKGROUND: Regarding the perfusion of a deep inferior epigastric perforator (DIEP) flap, the classic Hartrampf zones II and III were demonstrated by Holm et al. to be reversed using fluorescent perfusion techniques, implying that blood flow from the pedicle travels to the ipsilateral side before crossing the midline. The authors' hypothesis is that the zones of perfusion and the vascular anatomy differ greatly between lateral row and medial row perforators. METHODS: Three-dimensional and four-dimensional computed tomographic angiography was utilized to reappraise the zones of vascularity. Thirty-six DIEP flaps were simulated for this study (14 lateral row perforators versus 22 medial row perforators). Individual perforators were injected with contrast and each flap was subjected to dynamic computed tomography scanning. Images were viewed using TeraRecon software, allowing analysis of branching patterns and perfusion flow. RESULTS: The mean vascular territory for a medial perforator DIEP flap injected with contrast was 296 cm, compared with 196 cm for a lateral perforator DIEP flap. Zone II perfusion was greater in a medial perforator compared with a lateral perforator. Zone III had greater perfusion in a lateral perforator compared with a medial perforator. The authors found that medial perforators conform to the Hartrampf zones of perfusion and lateral perforators follow the Holm theory of perfusion (zones II and III should be reversed for lateral perforator DIEP flaps). Injection of a lateral row-based perforator flap gave a vascular territory that rarely crossed the midline. CONCLUSION: Medial and lateral row perforators offer distinct and stereotypical zones of perfusion that have a significant effect on flap design and harvesting.

The dorsal metacarpal artery perforator flap: a case report utilizing a quaba flap harvested from a previously skin-grafted area for dorsal 5th digit coverage.

Burns to the hand are common in burn victims. These burns often leave complex wounds that require local flaps for coverage. Local flaps are often excluded because they lie within the zone of thermal injury. The purpose of this case report is to report the successful use of a Quaba flap harvested from a previously burned and skin-grafted area. The patient's medical record including pre-operative, intra-operative, and post-operative photographs were reviewed and utilized as sources of data. The patient tolerated the procedure well and was able to return to his previous hand therapy regimen without adverse event and with an acceptable cosmetic result. The Quaba flap can be a safe and effective option for local hand coverage even in previously burned and skin-grafted areas.