The Effect of Obesity, Bariatric Surgery, and Operative Time on Abdominal Body Contouring Outcomes.

BACKGROUND: Abdominal body contouring procedures are associated with the highest rates of complications among all aesthetic procedures. Patient selection and optimization of surgical variables are crucial in reducing morbidity and complications. OBJECTIVES: The purpose of this single-institution study was to assess complication rates, and to evaluate BMI, operative time, and history of bariatric surgery as individual risk factors in abdominal body contouring surgery. METHODS: A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential lower body lift, fleur-de-lis panniculectomy (FDL), and circumferential FDL between August 2014 and February 2020. Endpoints were the incidence of venous thromboembolism, bleeding events, seroma, infection, wound complications, and reoperations. Univariate statistical analysis and multivariate logistic regressions were performed. Covariates in the multivariate logistic regression were BMI, procedure time, and history of bariatric surgery. RESULTS: A total of 632 patients were included in the study. Univariate analysis revealed that longer procedure time was associated with infection (P = 0.0008), seroma (P = 0.002), necrosis/dehiscence (P = 0.01), and reoperation (P = 0.002). These associations persisted following multivariate analyses. There was a trend toward history of bariatric surgery being associated with minor reoperation (P = 0.054). No significant increase in the incidence of major reoperation was found in association with overweight or obese patient habitus, history of bariatric surgery, or prolonged procedure time. BMI was not found to be an individual risk factor for morbidity in this patient population. CONCLUSIONS: In abdominal body contouring surgery, surgery lasting longer than 6 hours is associated with higher incidence of seroma and infectious complications, as well as higher rates of minor reoperation.

Safety of Rivaroxaban for Postoperative Venous Thromboembolism Prophylaxis Following Abdominal Body Contouring Surgery: 600 Patients.

BACKGROUND: Reducing the incidence of venous thromboembolism (VTE) following abdominal body contouring surgery remains a top priority for patient safety. There is a lack of consensus regarding the optimal chemoprophylactic agent for postoperative VTE prophylaxis, and the role of oral anticoagulants warrants further investigation. OBJECTIVES: The aim of this multisurgeon, single-institution study was to determine the safety and efficacy of a 7-day postoperative rivaroxaban regimen for VTE prophylaxis in abdominal body contouring surgery. METHODS: A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential body lift, fleur-de-lis panniculectomy, or circumferential fleur-de-lis panniculectomy at our surgical center from August 2014 to November 2019. A 7-day postoperative course of once-daily 10 mg rivaroxaban, starting on postoperative day 1, was administered to every patient unless there was a contraindication. The 2 primary endpoints were the incidence of VTE and bleeding events. RESULTS: A total of 600 patients were included in the study. There were no deaths. There were 4 (0.7%) incidents of VTE events: 2 (0.3%) patients suffered pulmonary embolus and 2 (0.3%) patients suffered a lower-extremity deep venous thrombosis. A total of 13 (2.2%) patients suffered complications related to bleeding. Of these, operative intervention for control and evacuation was required in 7 (1.2%) patients. CONCLUSIONS: A 7-day postoperative course of once-daily rivaroxaban for VTE risk reduction in abdominal body contouring surgery is associated with a low incidence of VTE events and a low risk of bleeding complications.

Avulsion Fat Graft Gluteoplasty: Technique Overview.

BACKGROUND: The popularity of gluteoplasty has grown significantly in recent years, and there are a variety of techniques described to address gluteal aesthetic deformities. The aim of this study was to describe the avulsion fat graft gluteoplasty technique. METHODS: A review of all consecutive patients undergone avulsion fat graft gluteoplasty from February 2018 to March 2019 was performed. Data included demographics, operative details, and clinical outcomes. RESULTS: A total of 7 patients with a minimum of 6 months follow-up were analyzed and included in the study. The avulsion fat graft gluteoplasty technique is described in a step-by-step fashion and illustrated by preoperative, postoperative, and intraoperative photographs, as well as video. The average total weight of the avulsed specimen was 372 g (range, 176-596 g) per patient. The average total volume of fat grafting was 593 mL (range, 344-900 mL) per patient. CONCLUSIONS: The avulsion fat graft gluteoplasty is a powerful technique with consistent results and low-risk profile. It provides durable lift and augmentation and produces a predictable and aesthetic scar.

Four-Position Four-Entry Site Circumferential Arm Liposuction: Technique Overview and Experience.

BACKGROUND: In attempting to overcome the challenges associated with arm contouring, arm liposuction has been an area of focus in recent years. In appropriately selected patients, circumferential liposuction is the procedure of choice. The objective of this study is to describe our experience with the four-position four-entry site circumferential arm liposuction technique. METHODS: All consecutive circumferential liposuction procedures that took place at our ambulatory surgical facility from January 2015 to November 2019 were retrospectively reviewed. The four-position four-entry site circumferential arm liposuction technique is described, and photographs as well as videos are presented. RESULTS: A total of 35 patients underwent circumferential bilateral arm liposuction via the four-position four-entry site technique. All patients were female, and their average age was 43 years. The average BMI was 28.4 kg/m2, and the average follow-up was 481 days. The average volume of lipoaspirate was 1,514 ml per patient, and the average volume of aspirated fat was 1,052 ml per patient. There was no incident of infection, seroma, bleeding event or venous thromboembolism. CONCLUSIONS: For the right candidate, the four-entry site four-position circumferential arm liposuction is an efficient and reproducible technique, which produces predictable and pleasing results. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Multicenter, Prospective, Randomized, Contralateral Study of Tissue Liquefaction Liposuction vs Suction-Assisted Liposuction.

BACKGROUND: Tissue liquefaction liposuction (TLL) deploys a novel energy source utilizing a stream of warmed, low-pressurized, and pulsed saline to extract fat tissue. OBJECTIVES: Compare TLL to suction-assisted liposuction (SAL) to determine which device is more efficient for surgeons and provides better recovery for patients. METHODS: Thirty-one adult female patients were followed prospectively in a contralateral study design comparing differences in bruising, swelling, tenderness, and incision appearance ratings between TLL and SAL procedures. Surgical efficiency and appearance of the lipoaspirate were also compared. RESULTS: All 31 patients successfully completed the study. For TLL and SAL procedures, the average volumes of infusion (1.242 vs 1.276 L) and aspirated supernatant fat (704 vs 649 mL) were statistically similar. TLL median fat extraction rate was faster than SAL (35.6 vs 25 mL/min; P < 0.0001), and stroke rate was reduced in TLL vs SAL procedures (48 vs 120 strokes/min; P < 0.0001), and both were statistically significant. The mean total scores for bruising, swelling, treatment site tenderness, and incision appearance were lower, indicating improved patient recovery on the TLL side. CONCLUSIONS: TLL and SAL techniques produced comparable volume of fat aspirate. TLL demonstrated a 42% faster fat extraction rate and a 68% reduction in arm movements needed to complete the procedure compared to SAL, both of these differences are statistically significant. The TLL side was noted to have reduced bruising and swelling and improved incision site appearance with less tenderness compared to the SAL side.

Rivaroxaban for Venous Thromboembolism Prophylaxis in Abdominoplasty: A Multicenter Experience.

BACKGROUND: Abdominoplasty, a commonly performed aesthetic procedure, is considered to have an increased risk of venous thromboembolism (VTE) events. At present, routine VTE chemoprophylaxis following abdominoplasty remains controversial. OBJECTIVES: This study evaluates the authors' experience with rivaroxaban, an oral Factor Xa inhibitor, for VTE prophylaxis in abdominoplasty patients. METHODS: A retrospective case series was conducted. All patients who underwent abdominoplasty and received rivaroxaban were included. The prophylactic dose was 10 mg daily for 7 days, beginning 12 hours postoperatively. Patient demographics, comorbidities, and type of surgery were recorded. The primary outcome measured was hematologic complication, including VTE, hematoma requiring operative evacuation, and need for blood transfusion. RESULTS: From September 2012 until July 2014, 132 patients (122 women and 10 men) underwent abdominoplasty surgery and received rivaroxaban postoperatively. Mean patient age was 43.7 years, and mean body mass index was 27.1. One hundred twenty-five patients also underwent abdominal muscle plication. Eleven patients underwent a fleur de lis vertical skin resection component. One hundred patients underwent concomitant abdominal liposuction, while 79 patients also had back liposuction. Only 1 patient had a symptomatic VTE event. Three patients had a hematoma requiring operative evacuation, and all went on to heal without sequelae. Two patients received a blood transfusion for anemia during their course of rivaroxaban. CONCLUSIONS: Oral rivaroxaban administration for chemoprophylaxis in abdominoplasty patients is safe, with low rates of symptomatic VTE and hematoma formation. The authors continue routine use of the medication for patients at increased risk for VTE events. LEVEL OF EVIDENCE 4: Risk.

Does Implant Insertion with a Funnel Decrease Capsular Contracture? A Preliminary Report.

BACKGROUND: Capsular contracture remains a common and dreaded complication of breast augmentation. The etiology of capsular contracture is believed to be multi-factorial, and its causes may include biofilm formation due to implant/pocket contamination with skin flora. It has been shown that insertion funnel use reduces skin contact and potential contamination by 27-fold in a cadaver model. After incorporating the funnel into our surgical protocols, we anecdotally believed we were experiencing fewer capsular contractures in our augmentation practices. OBJECTIVES: The purpose of this study was to test the hypothesis that capsular contracture related reoperation rates decreased after insertion funnel adoption using data from multiple practices. METHODS: At seven participating centers, we retrospectively reviewed the surgical records from March 2006 to December 2012 for female patients who had undergone primary breast augmentation with silicone gel implants. Group 1 consisted of consecutive augmentations done without the insertion funnel, and Group 2 consisted of consecutive augmentations done with the insertion funnel. The primary outcome variable was development of grade III or IV capsular contracture that led to reoperation within 12 months. RESULTS: A total of 1177 breast augmentations met inclusion criteria for Group 1 and 1620 breast augmentations for Group 2. The rate of reoperation due to capsular contracture was higher without use of the insertion funnel (1.49%), compared to Group 2 with funnel use (0.68%), a 54% reduction (P = 0.004). CONCLUSIONS: The insertion funnel group experienced a statistically significant reduction in the incidence of reoperations performed due to capsular contracture within 12 months of primary breast augmentation.

Sientra high-strength cohesive textured round implant technique: roundtable discussion.

UNLABELLED: : A panel of board-certified plastic surgeons chaired by Dr Grant Stevens convened to discuss their respective experiences with the Sientra High-Strength Cohesive (HSC) Textured Round silicone gel breast implants. The authors have implanted a combined total of approximately 2100 patients. Surgical pearls, complication avoidance, and practice integration tips are among the topics reviewed. The surgeons also present challenging cases and describe how the HSC textured implants helped them achieve a successful outcome. LEVEL OF EVIDENCE: 5 Therapeutic.

Expansion of Renuvion Application to Areas Beyond the Submental Region: Review and Experience.

Background: Minimally invasive and consistent skin redraping following liposuction remains an elusive goal. With the application of Renuvion (Apyx Medical, Clearwater, FL), helium induced cold atmospheric plasma provides coagulation, collagen contraction, and subsequent skin tightening, making this elusive goal attainable. Objectives: The objective of this study is to evaluate energy settings, and the safety profile of Renuvion in an effort to achieve optimal cosmesis through the improvement of skin laxity. Methods: A retrospective review at a single site evaluated cases of Renuvion between March 2020 and May 2022. Energy settings, use of concomitant VASER (Solta Medical, Bothwell, WA) liposuction frequency, and adverse events were analyzed. Results: In total, 180 patients were evaluated, of whom 135 (75%) underwent concomitant VASER liposuction. Renuvion was used on the abdomen (47.8%), thighs (45.6%), arms (27.2%), submental region (25%), hip rolls (21.2%), and back (19.4%). Among the entire cohort, there were a total of 24 (13.3%) complications. The complications consisted of 3 (12.5%) hematomas, 1 (4.2%) burn, 6 (25%) persistent skin laxity with 2 returned operating room (OR) treatments, 4 (16.7%) seromas, 9 (37.5%) postoperative lymphedema that self-resolved, and 1 (4.2%) self-limited neuralgia. There were no complications that required an immediate return to the OR. Conclusions: Renuvion utilization with or without VASER has a relatively high complication rate-with minor complications as the most common-relatively safe barring proper patient selection, which can be mitigated with proper patient selection.

Successful treatment of Parry-Romberg syndrome with autologous fat grafting: 14-year follow-up and review.

Parry first described the syndrome of progressive facial atrophy in 1825, followed by Romberg in 1846. The clinical hallmark of the syndrome is atrophy of the facial soft tissues, including fat and muscle as well as underlying bone. Clinicians have classically reserved treatment until the end of the disease process, after the "burn out" stage. Various treatment modalities have been attempted with differing results. In this study, we present a case of Parry-Romberg syndrome treated with autologous fat grafting. This case report reviews the history of the disease, examines the safety and clinical outcomes of fat grafting as a treatment modality, and challenges the classic timing of that treatment. Additionally, long-term follow-up with photos and histological analysis of specimens are included.

Surgical treatment for scaphocephaly and a calcified cephalohematoma.

Craniosynostosis is the premature fusion of 1 or more of the cranial sutures, with sagittal synostosis being the most common nonsyndromic single suture synostosis. The pathogenesis of craniosynostosis has been extensively studied and is likely multi-factorial. A complex interaction between the dura and overlying suture via multiple growth factors seems to play the most important role. There have been 3 published studies with patients presenting with scaphocephaly and a cephalohematoma, which raises the question of how the 2 conditions may be related. Cephalohematomas can be seen after trauma and a number of other causative factors but usually resorb over time without sequela. In a small percentage of cases, the hematoma persists and calcifies, leading to significant asymmetry and deformity of the skull. Once it reaches this point, surgical intervention may be required to correct the resulting skull deformity. We present a child with scaphocephaly and a cephalohematoma who underwent surgical correction with resection of the cephalohematoma and sagittal suturectomy with spring-assisted surgery.

Maximizing Aesthetics and Patient Selection Utilizing Natrelle Inspira Line Implants in Aesthetic Breast Surgery.

Aesthetic breast augmentation has recently experienced a significant boom in options available to achieve an ideal outcome. Evolving prosthetic device technology has now brought an array of implant gels, implant shells, and fill ratios to customize shape, composition/fill, and feel of the augmented breast. With the vast portfolio of currently available implants, surgeons now have a greater ability to produce tailored and desired outcomes. The Natrelle Inspira line of breast implants by Allergan Medical is a comprehensive portfolio of implants starting with the Responsive series with the softest gel, the SoftTouch series, and the fully Cohesive series. These options allow surgeons to help tailor and create the breast that patients desire.

Avulsion Thighplasty: Technique Overview and 6-Year Experience.

UNLABELLED: When choosing a thigh lift operation, the surgeon also chooses which complications he/she will be managing, and the most dreaded after conventional thigh lifting are those of lymphatic origin such as lymphocele or lymphedema. The authors describe avulsion thighplasty, a technique that spares lymphatics by using aggressive liposuction beneath the planned resection area, and thus minimizes lymphatic complications. The technique is outlined and complications are detailed over a 6-year period with long-term follow-up. The risk of major complications is found to be low and the procedure is found to be safe. Patients must be counseled that the risk of minor complications, such as small wound dehiscence or need for a later scar revision, is substantial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Avulsion brachioplasty: technique overview and 5-year experience.

BACKGROUND: Popularity of arm-contouring procedures, once coveted by the massive weight loss population, has grown among society at large. The technique has evolved with the goal of producing a predictable and thin scar in a location that is acceptable for interpersonal interaction. METHODS: All consecutive brachioplasty patients from May of 2008 to May of 2013 were reviewed retrospectively at a private surgery center. Data collected included age, body mass index, amount of fat removed by liposuction, weight of resected tissue, hematoma or seroma, wound dehiscence, revision procedures, and length of follow-up. RESULTS: The authors reviewed 44 consecutive brachioplasties over 5 years. Average age was 53 years and body mass index was 26. Average amount of liposuctioned fat was 342 ml per arm using 867 ml of tumescent and an average skin specimen weight of 90 g. The follow-up period averaged 446 days. Fourteen patients had wound dehiscence requiring dressing changes. There were no return trips to the operating room for serious concerns such as bleeding or infection. One patient had a seroma. Nine patients underwent scar revision within 1 year. Overall complication rate was 50 percent. Overall revision rate was 21 percent. CONCLUSIONS: Brachioplasty is a rewarding procedure with consistent results and low risk of major complications. The potential for minor complications is substantial, and patients should receive preoperative counseling regarding this risk. In the authors' 5-year study of consecutive patients, 50 percent of patients needed dressing changes for small-wound dehiscence or scar revision within 1 year. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Double myelomeningocele: case report and review.

The presence of a myelomeningocele at multiple levels along the spinal column is a rare event. There are only a few cases of double myelomeningocele reported in the world's literature. Large myelomeningoceles present surgical closure challenges due to the size and location of these defects. We report the case of a newborn female who had two myelomeningoceles with one at the thoracic level and the other at the lumbar level. Surgical closure must provide durable and stable coverage for the spinal cord. Stable coverage was provided for this patient using bilateral paraspinous myofascial turnover flaps. This unusual case report as well as a review of the literature is presented.

The trend of using computed tomography in the detection of acute thoracic aortic and branch vessel injury after blunt thoracic trauma: single-center experience over 13 years.

BACKGROUND: The purpose of this study was to review the trend of using chest computed tomography (CT) and aortography in evaluating patients with blunt thoracic trauma. METHODS: A total of 85 patients who had blunt aortic injury diagnosed by chest CT, aortography, or both were included in this study. RESULTS: Aortography was the dominant modality before 1998, and the use of chest CT has increased to 50% of patients with aortic injuries as of 2001. Isolated aortic, branch vessel, or combined injuries were found in 71 (84%), 11 (13%), and 3 (4%) patients, respectively. All 14 patients with branch vessel injuries were diagnosed by aortography. Ninety-eight percent of patients with aortography were true-positives, and 20% of patients with chest CT had indirect signs of aortic injury. CONCLUSION: Our institution has increased the use of chest CT to evaluate blunt thoracic trauma. Patients with indirect signs of aortic injuries shown on chest CT require further evaluation. In our experience, angiography remains the optimal diagnostic modality for evaluating aortic branch vessel injuries.

Complex blunt aortic injury or repair: beneficial effects of cardiopulmonary bypass use.

OBJECTIVE: To compare the outcomes and associated morbidity in patients with blunt aortic injury (BAI) repaired using cardiopulmonary bypass versus no bypass. Special consideration is given to the influence of bypass in the outcome of complex injuries or repair circumstances. SUMMARY BACKGROUND DATA: There are conflicting data concerning the utility of bypass techniques in the operative management of BAI, and controversy over the subject persists. During the last decade, surgeons at the authors' institution have undergone a change in philosophy concerning management of these injuries and began almost exclusively using cardiopulmonary bypass for the repair in 1996. This project explores the effects of this change in the management of BAI. METHODS: The records of all patients with BAI admitted to a level 1 trauma center over a period of 12 years were reviewed for demographics, injury characteristics, operative technique, and outcome. The bypass group was compared to the no bypass group with respect to morbidity and mortality. Those with a complex injury or repair (CI/R) were examined as a subgroup. CI/R was defined as the presence of an injury with extension proximal to the subclavian artery, involvement of branch vessels, or requirement of maneuvers interfering with anastomosis construction, such as cardiac massage. RESULTS: From January 1, 1990, to December 31, 2001, 91 patients were admitted to Wake Forest University Baptist Medical Center with BAI. Sixty-five of these underwent operative repair. Sixty (32 no bypass, 28 bypass) survived to the immediate postoperative period. Injury Severity Score was similar (33 no bypass, 31 bypass, P =.48), as was admission base deficit (-9.2 m Eq/L no bypass vs. -7.0 mEq/L B, P =.13). Paraplegia occurred in four (12%) of the no bypass group as opposed to 0 of the bypass group (P =.05). No patient in the bypass group experienced complications related to heparinization, and two (7%) experienced bypass-related complications (cerebral edema, femoral vein laceration). Mean clamp time for the entire group was 27 minutes. Examination of the 10 patients with CI/R who survived the operating room showed markedly longer clamp times (59 minutes vs. 22 minutes, P <.0001) and a higher rate of paraplegia/paresis (30% vs. 2%, P =.01) as compared to those without CI/R. Logistic regression demonstrated a significant relationship between increasing clamp time and the CI/R classification (P =.007). All three (100%) of the CI/R patients repaired via clamp-and-sew technique developed paraplegia, while none of the seven CI/R patients repaired on bypass developed neurologic changes (P =.008). CONCLUSIONS: With the use of cardiopulmonary bypass in the repair of BAI, the incidence of paraplegia/paresis has fallen. While patients with typical injuries and uncomplicated repair can expect good results with either technique, cardiopulmonary bypass provides significant advantages in the repair of those with CI/R. With the use of bypass, no CI/R patient developed paraplegia, while all CI/R patients experienced paraplegia before bypass use. Although others have reported the importance of clamp time, in this series clamp time appeared largely to be a surrogate variable for complexity of injury.