Patient Satisfaction Using BREAST-Q and Breast Implant Illness after Breast Reconstruction in Transwomen.

Background: Gender-affirming breast augmentation comprises an increasing portion of breast augmentations performed by plastic surgeons. Satisfaction and breast implant illness (BII) symptoms in this population have not been well studied. This study aimed to evaluate satisfaction and BII symptoms in transwomen who received nontextured implants as part of their breast reconstruction. Methods: We conducted a retrospective review of transwomen who underwent breast augmentation for gender-affirming surgery. We performed telephone survey evaluation using the BREAST-Q questionnaire preoperatively, 6 months and 1 year after breast implant placement. Survey evaluation asking about BII symptoms was also administered at the same time points. Results: Twenty-six patients completed the BREAST-Q survey, which demonstrated significantly improved satisfaction postoperatively at 6 and 12 months when compared with median preoperative scores for psychosocial (P < 0.001; P < 0.001), sexual (P < 0.001; P < 0.001), and overall satisfaction with breasts (P < 0.001; P < 0.001). Physical well-being of the chest decreased at 6 months (P < 0.001) but improved in comparison with 12 months (P < 0.001). Thirty-four patients completed the BII survey, with 18% reporting symptoms at 3 months and 29% at 1 year. Zero patients requested explantation. Conclusions: Transwomen exhibit a significant increase in breast, psychosocial, and sexual well-being after breast augmentation. However, patients experienced a decreased physical well-being, and many report symptoms associated with BII. These results can be used to better counsel these individuals preoperatively and set reasonable postoperative expectations. Further studies investigating long-term satisfaction in larger cohorts are needed.

Sixteen hundred years of increasing tree cover prior to modern deforestation in Southern Amazon and Central Brazilian savannas.

Tropical ecosystems are under increasing pressure from land-use change and deforestation. Changes in tropical forest cover are expected to affect carbon and water cycling with important implications for climatic stability at global scales. A major roadblock for predicting how tropical deforestation affects climate is the lack of baseline conditions (i.e., prior to human disturbance) of forest-savanna dynamics. To address this limitation, we developed a long-term analysis of forest and savanna distribution across the Amazon-Cerrado transition of central Brazil. We used soil organic carbon isotope ratios as a proxy for changes in woody vegetation cover over time in response to fluctuations in precipitation inferred from speleothem oxygen and strontium stable isotope records. Based on stable isotope signatures and radiocarbon activity of organic matter in soil profiles, we quantified the magnitude and direction of changes in forest and savanna ecosystem cover. Using changes in tree cover measured in 83 different locations for forests and savannas, we developed interpolation maps to assess the coherence of regional changes in vegetation. Our analysis reveals a broad pattern of woody vegetation expansion into savannas and densification within forests and savannas for at least the past ~1,600 years. The rates of vegetation change varied significantly among sampling locations possibly due to variation in local environmental factors that constrain primary productivity. The few instances in which tree cover declined (7.7% of all sampled profiles) were associated with savannas under dry conditions. Our results suggest a regional increase in moisture and expansion of woody vegetation prior to modern deforestation, which could help inform conservation and management efforts for climate change mitigation. We discuss the possible mechanisms driving forest expansion and densification of savannas directly (i.e., increasing precipitation) and indirectly (e.g., decreasing disturbance) and suggest future research directions that have the potential to improve climate and ecosystem models.

Vascular Perfusion of the Facial Skin: Implications in Allotransplantation of Facial Aesthetic Subunits.

BACKGROUND: As the field of face transplantation develops, it may be possible to transplant segments of facial skin to replace facial aesthetic subunits in selected cases. The aim of this study was to identify the more reliable vascular pedicles of each facial aesthetic subunit for its use in transplantation METHODS:: Six full facial soft-tissue flaps were harvested, and the external carotid artery was identified and cannulated proximal to the facial artery. Next, radiopaque contrast was injected through the facial artery into three of the facial flaps and through the superficial temporal artery in the other three facial flaps. After vascular injections, three-dimensional computed tomographic arteriographs of the faces were obtained, allowing analysis of the arterial anatomy and perfusion in different facial aesthetic subunits. RESULTS: The chin, lower lip, upper lip, medial cheek, nose, and periorbital units were perfused in all facial flaps where the facial artery was injected and in none of those where the superficial temporal artery was injected. The lateral cheek was perfused in 100 percent of the superficial temporal artery flaps and in 67 percent of the facial artery flaps. The lateral forehead contained contrast in 100 percent of the superficial temporal artery-injected flaps and in none of the facial artery-injected flaps, and the medial foreheads contained contrast in 67 percent of the facial artery-injected flaps and in 67 percent of the superficial temporal artery-injected flaps. CONCLUSION: The majority of the facial subunits can be harvested based on the facial artery pedicle, with the exception of the lateral forehead, which is based on the superficial temporal artery.

Accuracy of Visual Estimates of Partial Flexor Tendon Lacerations.

PURPOSE: To determine whether hand surgeons could accurately and consistently estimate the size of partial flexor tendon lacerations. MATERIALS AND METHODS: Thirty-two partial flexor tendon lacerations were made in the flexor digitorum profundus tendons of a fresh-frozen cadaveric hand. Four hand surgeons and 5 residents estimated the size of the lacerations. Estimates were repeated 3 days later. Magnified images of the laceration cross-section were used to calculate the true size of each laceration. Inter- and intrarater reliability were calculated using the intraclass correlation coefficient. Accuracy was measured with the mean bias error and the mean absolute error. RESULTS: Interrater and intrarater reliabilities were both high. There was a high level of consistency for both surgeons and residents. In terms of accuracy, there was a 3% bias toward underestimation. The mean absolute error was 11%. There was no statistically significant difference between the accuracy of attending hand surgeons and that of residents. Participants were less accurate when estimating lacerations close to a 60% laceration threshold for surgical repair (lacerations in the 50%-70% range). For lacerations within this range, an incorrect management decision would have been made 17% of the time, compared with 7% of the time for lacerations outside that range. CONCLUSIONS: The accuracy and reliability of surgeon estimates of partial flexor tendon laceration size were high for surgeons and residents. Accuracy was lower for lacerations close to the threshold for repair. CLINICAL RELEVANCE: Visual estimation is acceptable for evaluating partial flexor tendon lacerations, but it may be less reliable for lacerations near the threshold for repair. Therefore, surgeons should be cautious when deciding whether or not to repair partial lacerations in the borderline range.

The Profunda Artery Perforator Flap: Investigating the Perforasome Using Three-Dimensional Computed Tomographic Angiography.

BACKGROUND: The profunda artery perforator flap has been emerging as an alternative method of autologous breast reconstruction. This flap uses upper posterior thigh tissue. The profunda artery perforator perforasome is investigated using three-dimensional computed tomographic angiography. METHODS: Ten cadaveric thighs were dissected centered over the profunda artery perforator. The perforator was injected with contrast medium and the flap was then subjected to computed tomographic scanning using a GE Lightspeed 16-slice scanner. The three-dimensional images were viewed, and measurements were obtained using Aquarius software, including horizontal and vertical extensions of the flap and areas of perfusion. Clinical examples are presented. RESULTS: A profunda artery perforator (occasionally two) was consistently found in the upper medial thigh region, posterior to the gracilis muscle. The area of vascularity shown by the spread of contrast extends inferiorly beyond the usual lower border of the profunda artery perforator flap, which is usually 7 cm wide. In injected cadaveric flaps, the mean horizontal dimension was 16.7 cm and the mean vertical dimension was 16.5 cm. The mean area perfused was 8812 cm. CONCLUSIONS: The profunda artery perforator flap is a vascularly sound flap, and is a good option for autologous breast reconstruction. Advantages include a reliable pedicle, no position changes required, and possibly an improved donor-site contour from a thigh lift. It is an excellent alternative to abdominally based free flaps and can also be used in conjunction with other flaps for further volume enhancement.

Influence of using a single facial vein as outflow in full-face transplantation: A three-dimensional computed tomographic study.

BACKGROUND: The aim of this study was to evaluate the contribution of a single unilateral facial vein in the venous outflow of total-face allograft using three-dimensional computed tomographic imaging techniques to further elucidate the mechanisms of venous complications following total-face transplant. METHODS: Full-face soft-tissue flaps were harvested from fresh adult human cadavers. A single facial vein was identified and injected distally to the submandibular gland with a radiopaque contrast (barium sulfate/gelatin mixture) in every specimen. Following vascular injections, three-dimensional computed tomographic venographies of the faces were performed. Images were viewed using TeraRecon Software (Teracon, Inc., San Mateo, CA, USA) allowing analysis of the venous anatomy and perfusion in different facial subunits by observing radiopaque filling venous patterns. RESULTS: Three-dimensional computed tomographic venographies demonstrated a venous network with different degrees of perfusion in subunits of the face in relation to the facial vein injection side: 100% of ipsilateral and contralateral forehead units, 100% of ipsilateral and 75% of contralateral periorbital units, 100% of ipsilateral and 25% of contralateral cheek units, 100% of ipsilateral and 75% of contralateral nose units, 100% of ipsilateral and 75% of contralateral upper lip units, 100% of ipsilateral and 25% of contralateral lower lip units, and 50% of ipsilateral and 25% of contralateral chin units. CONCLUSION: Venographies of the full-face grafts revealed better perfusion in the ipsilateral hemifaces from the facial vein in comparison with the contralateral hemifaces. Reduced perfusion was observed mostly in the contralateral cheek unit and contralateral lower face including the lower lip and chin units.

Mastopexy and reduction mammoplasty pedicles and skin resection patterns.

SUMMARY: Mastopexy and reduction mammoplasty share techniques of pedicle formation and skin excision patterns, with the main difference being the amount of breast tissue resected. Various types of excision patterns and orientation of pedicles were developed throughout the years, each with flares of popularity at different times. This article reviews the multiple techniques of pedicle orientation and skin excision patterns separately and gives the advantages and disadvantages of each.

Lumbar and thoracic perforators: vascular anatomy and clinical implications.

BACKGROUND: Pedicled perforator flaps in the thoracic and lumbar regions allow reconstruction of the posterior trunk. They enable reconstruction of various local defects without microvascular anastomoses and with minimal donor-site morbidity and excellent cosmesis. The authors examined the locations of perforators in the lumbar and thoracic regions. METHODS: Ten cadaver hemithoraces and lumbar regions were freshly harvested and dissected. Intraarterial injections were performed with colored latex, followed by dissection in the suprafascial plane. Perforators with a diameter larger than 0.5 cm were located and measured from the midline and from C7 (thoracic) and coccygeal (lumbar) reference points. The most dominant perforators were injected with radiopaque dye and scanned with high-resolution computed tomography. The patterns were analyzed by the quadrat counting test (based on chi-square statistics) for the null hypothesis of complete spatial randomness. RESULTS: A total of 164 thoracic and 216 lumbar perforators were identified. These were clustered in highest density in two major areas within 10 to 20 cm of the C7 and coccygeal reference points and 10 cm from the midline; this pattern was not a random distribution (p < 0.001). Perforasomes of lumbar perforators in some instances crossed the midline, joining adjacent contralateral lumbar perforators by means of direct and indirect linking vessels. CONCLUSIONS: Lumbar and thoracic pedicled perforator flaps provide useful options for reconstructing complex defects. Use of these flaps is aided by anatomical knowledge of the location of major clusters of perforators.

Proximal peroneal perforator in dual-skin paddle configuration of fibula free flap for composite oral reconstruction.

BACKGROUND: Composite defects of the oral cavity are often the result of trauma or advanced-stage tumor extirpation. The resultant deformity frequently requires a three-dimensional reconstruction of bone and soft-tissue. The fibula free flap is the preferred method of reconstruction, with various modifications focused on providing supplemental soft-tissue coverage. The objective of this study was to ascertain both anatomic and clinical data regarding the proximal peroneal perforator and its contribution to the evolution of the fibula free flap. METHODS: Ten cadaver lower extremities were dissected to isolate the most proximal perforator supplying skin over the proximal lateral lower leg. Data were recorded regarding perforator presence, location, and course. Furthermore, review of clinical cases in which the proximal perforator was used in fibula free flap design was performed for operative data collection. RESULTS: Cadaveric dissections revealed the proximal perforator to be present in 90 percent of specimens. Most commonly, the perforator, originating from the peroneal artery, traveled a short intramuscular course through the soleus muscle prior to supplying the overlying skin. In all clinical cases, the perforator was easily located with Doppler prior to incision, and there were no cases of flap failure or skin paddle loss. Flap inset was found to be optimal in all cases, with no tethering or undue tension. CONCLUSIONS: The proximal peroneal perforator was found to be anatomically reliable and clinically useful in composite oral cavity reconstruction following tumor removal. The gained separation between skin paddles allows for greater versatility in flap design and inset. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Does empiric antibiotic therapy change MRSA [corrected] hand infection outcomes? Cost analysis of a randomized prospective trial in a county hospital.

BACKGROUND: The incidence of community-acquired methicillin-resistant Staphylococcus aureus infections is rising at an alarming pace. Effective treatment has historically involved early débridement and antibiotic administration. This study was designed to prospectively determine the effectiveness of empiric therapy in treating hand infections. METHODS: A prospective randomized trial was conducted at a level I county hospital. Patients with a hand infection received either empiric intravenous vancomycin at admission or intravenous cefazolin. Outcomes were tracked using severity of infection, appropriate clinical response, and length of stay. Cost-effectiveness was calculated using total cost for each patient in both groups. Statistical analyses were performed. RESULTS: Forty-six patients were enrolled in the study. Twenty-four were randomized to cefazolin (52.2 percent) and 22 (47.8 percent) to vancomycin. There was no statistical difference between cost of treatment (p < 0.20) or mean length of stay (p < 0.18) between the groups. Patients randomized to cefazolin had higher mean costs of treatment compared with patients who were randomized to vancomycin (p < 0.05). Patients with more severe infections had more expensive mean costs of treatment (p < 0.0001) and longer mean length of stay (p = 0.0002). Near the end of the study, the incidence of community-acquired methicillin-resistant S. aureus at the authors' county hospital was discovered to be 72 percent, which caused the study to be terminated prematurely by the institutional review board because of the high incidence precluding further randomization. CONCLUSIONS: Appropriate early treatment for methicillin-resistant S. aureus has not been definitively established. No difference in outcome using cefazolin versus vancomycin as a first-line agent was identified.

Obturator nerve anatomy and relevance to one-stage facial reanimation: limitations of a retroperitoneal approach.

BACKGROUND: Single-stage facial reanimation with a partial gracilis muscle coapted to the contralateral facial nerve seems an optimal surgical solution yet has not supplanted the two-stage approach. Insufficient obturator nerve length may limit reach to sizable contralateral facial nerve branches (possibly necessitating interposition nerve grafting), compromise optimal muscle positioning, or risk nerve coaptation under tension. This study evaluates whether retroperitoneal obturator nerve dissection would effectively lengthen the nerve, thus obviating the aforementioned limitations. METHODS: Ten hemifaces and obturator nerves of five cadavers were dissected. Facial measurements included modiolus to contralateral facial nerve branches of sufficient size at the vertical line of the lateral orbital rim. Obturator nerve measurements included gracilis neurovascular hilum to (1) obturator canal entry point (ab), (2) intraobturator canal point where additional adductor branches are inseparable by internal neurolysis (ac), and (3) retroperitoneal point of separation between anterior and posterior obturator branches (ad). Obturator nerve reach for cross-facial nerve coaptation was assessed. RESULTS: Successful coaptation was achieved with obturator nerve dissection to point b approximately 20 percent of the time, to point c 60 to 70 percent of the time, and to retroperitoneal point d 90 to 100 percent of the time CONCLUSIONS: Successful coaptation to large contralateral facial nerve branches is feasible in 90 to 100 percent of cases if the entire anterior obturator branch is harvested. However, the increased risk of retroperitoneal dissection and sacrifice of additional adductor branches decreases the viability of this approach. Obturator canal dissection (point c) provides reach in 60 to 70 percent of cases, but short interposition nerve grafting may prove necessary.

Nerve transfers for facial transplantation: a cadaveric study for motor and sensory restoration.

BACKGROUND: Restoration of facial animation and sensation is highly important for the outcome after facial allotransplantation. The identification of healthy nerves for neurotization is of particular importance for successful nerve regeneration within the allograft. However, because of the severity of the initial injury and resultant scar formation, a lack of healthy nerve stumps in the recipient is a commonly encountered problem. In this study, the authors evaluate the technical feasibility of performing nerve transfers in facial transplantation for both sensory and motor neurotization. METHODS: Fifteen fresh cadaver heads were used in this study. The study was divided into two parts. First, the technical feasibility of nerve transfer from the cervical plexus to the mental nerve and the masseter nerve to the buccal branches of the facial nerve was assessed. Next, the authors performed nerve transfers in simulated face transplants to describe the surgical technique, focusing on sensory restoration of the midface and upper lip by neurotization of the infraorbital nerve, sensory restoration of the lower lip by neurotization of the mental nerve, and smile reanimation by neurotization of the buccal branches of the facial nerve. RESULTS: In all specimens, coaptation of at least one of the branches of the cervical plexus to the mental nerve and between the masseter nerve to the buccal branch of the facial nerve was possible. In simulated face transplant procedures, nerve transfers of the supraorbital nerve to the infraorbital nerve, cervical plexus branches to the mental nerve, and masseter nerve to facial nerve are all technically possible. CONCLUSIONS: Nerve transfers are a technically feasible option that could theoretically be used in face transplantation either as a primary nerve reconstruction when there are no available healthy nerves, or as a secondary procedure for enhancement of functional outcomes.

Subcutaneous fat tissue engineering using autologous adipose-derived stem cells seeded onto a collagen scaffold.

BACKGROUND: This pilot study examined the efficacy of 5-bromo-2-deoxyuridine-labeled autologous adipose-derived stem cells seeded onto collagen scaffolds to augment and/or regenerate the fat-enriched hypodermal tissue in an acute porcine wound model. METHODS: Porcine autologous adipose-derived stem cells were isolated and cultured. At passage 2, the cells were labeled with 5-bromo-2-deoxyuridine, seeded onto a three-dimensional collagen scaffold, and cultured for 10 days. Scaffolds were implanted subcutaneously in adult pigs with two adipose-derived stem cell scaffolds and two control scaffolds. Animals were euthanized at 2, 4, 8, and 12 weeks; all scaffold conditions were explanted for histology and immunohistochemistry analyses. RESULTS: For all time points, adipose-derived stem cell scaffolds had increased connective tissue matrix within the subcutaneous tissue compared with scaffold alone and untreated porcine skin (p < 0.01). The neosynthesized connective tissue was vascularized and composed of small cells within an abundant extracellular matrix organized in layers. 5-Bromo-2-deoxyuridine cells were detectable only up to 4 weeks and mature adipocytes were absent. Levels of collagen types I, III, and VI differed among the experimental groups, with increased extracellular matrix associated with the presence of adipose-derived stem cells. CONCLUSIONS: The authors' data clearly show the efficacy of adipose-derived stem cells for soft-tissue repair and skin aging because it induces a significant increase of the dermis thickness. Moreover, the authors' results demonstrate the interest of their acute wound model and allowed them to show the skin thickness variation over time of the experiment, which is one of the challenges with which clinicians struggle in fat grafting.

The free descending branch muscle-sparing latissimus dorsi flap: vascular anatomy and clinical applications.

BACKGROUND: Increasing focus on reducing morbidity from latissimus dorsi flaps has led to the evolution of muscle-sparing variants and perforator-based flaps. This study aimed to investigate the vascular anatomy of the muscle-sparing variant and to describe its application as a free flap based on the descending branch of the thoracodorsal artery. METHODS: Twelve fresh cadavers underwent anatomical dissection and angiographic injection studies of the thoracodorsal arterial system. The musculocutaneous territories of the descending and transverse branches to the latissimus dorsi muscle were identified and assessed using three-dimensional reconstruction software of computed tomography imaging results. In the clinical study, five patients underwent reconstruction of a variety of defects using the free descending branch muscle-sparing latissimus dorsi flap. RESULTS: Three- and four-dimensional (computed tomography) angiography demonstrated perfusion of the latissimus dorsi muscle by the transverse and descending branches, with overlap of vascular territories via cross-linking vessels. The descending branch supplied a slightly greater cutaneous area overlying the muscle, although differences between both branches were not significant (p = 0.76). In the clinical study, the free muscle-sparing latissimus dorsi flap provided excellent coverage with no flap complications or seroma. CONCLUSIONS: The free muscle-sparing latissimus dorsi flap based on the descending branch of the thoracodorsal artery is a viable reconstructive option. Significant collateral flow between vessels allows for larger flap harvest than would be expected. The flap is technically simple to harvest, provides a large perfusion area, and is a reliable variant of the full latissimus dorsi flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Free tissue transfers and replantation.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the indications and contraindications for free flap reconstruction. 2. Describe the indications, anatomy, harvest technique, and advantages and disadvantages of the workhorse free flaps. 3. Describe the indications and contraindications for extremity replantation. 4. Describe the techniques and management for extremity replantation. SUMMARY: Microsurgical free flap reconstruction uses a multitude of surgical flaps available to meet the needs of the recipient site. These include cutaneous, muscle, bone, fascia, or some combination of these as available options. Furthermore, sophisticated reconstruction has been enhanced by the development of perforator flaps, enabling multicomponent reconstruction to be performed with reduced donor-site morbidity. It is mandatory that proper débridement of the defect be performed before reconstruction, and that the anastomosis is performed without tension or twisting outside of the zone of injury. There are indications for both musculocutaneous and perforator flaps, and selection is dependent on recipient-site characteristics in addition to function and aesthetics of both the recipient and donor sites. Muscle flaps provide well-vascularized pliable tissue and are used for deep space obliteration, whereas fasciocutaneous flaps are used for flatter, more superficial wounds. Microsurgical replantation of an amputated extremity offers a result that is usually superior to any other type of reconstruction. However, replantation of extremities involves more than microsurgery, as repair of bony and tendon injury must be undertaken as well. This article focuses on the indications, technique, and results of free flap reconstruction and replantation.

Dermolipectomy of the lateral thoracic fat compartment in secondary breast reconstruction revision: Anatomical and clinical results.

UNLABELLED: Fullness in the lateral thoracic area following breast reconstruction can be a source of concern for patients. This redundant tissue creates disharmony between the newly reconstructed breast, the lateral mammary fold, and the lateral thoracic compartment. In this article we present the results of our anatomical/histological study, discuss the operative technique and present a clinical series of patients who underwent this procedure. METHODS: Cadaveric Anatomical study: Dye injection studies on 4 hemi-chests to determine if the lateral thoracic fold is a separate anatomic fat compartment. Tissue from the boundaries between identified compartments was also submitted for routine H&E histological analysis. Clinical study: Retrospective case note analysis of all patients undergoing dermolipectomy performed by the senior author. RESULTS: In the analyzed cadavers, a clear line of delineation was found separating the lateral thoracic fold from the breast and adjacent structures, this was confirmed histologically. Forty patients underwent 64 dermolipectomy procedures. The average dimension of the resected specimen was 13.37 cm (range 3.0-25.0 cm) × 5.44  cm (range 1.0-12.0 cm). The mean time of dermolipectomy following initial reconstruction was 15.4 months. As the BMI increased the average resection size increased both in length (p = 0.002) and width (p = 0.006). There were no postoperative complications. CONCLUSION: The lateral thoracic fold is a distinct fat compartment. Dermolipectomy following breast reconstruction is a useful adjunct and should be considered in any patient with excess skin/subcutaneous tissue in the lateral thoracic region. The procedure has a low complication rate and can be performed in conjunction with other post reconstruction refinement procedures.

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.