Wound infections in body contouring mastopexy with breast reduction after laparoscopic adjustable gastric bandings: the role of smoking.

BACKGROUND: We retrospectively reviewed charts of 42 postbariatric patients who underwent mastopexy and breast reduction for body contouring to determine whether a significant relationship existed between cigarette smoking and postoperative wound infections and to determine the relative risk given by cigarettes and a cut-off value to predict infections. METHODS: We excluded patients with ongoing clinical infections, recent bariatric surgery (within 1 year), recent antibiotic courses, or systemic diseases such as arteriosclerosis and diabetes mellitus. RESULTS: All patients underwent bariatric surgery with the laparoscopic adjustable gastric bending technique and mastopexy with breast reduction for body contouring. Postoperative infections were present in 35.7% (n = 15) of patients, and 60% of these (n = 9) were superficial. Furthermore, 66.7% of them occurred in smoker patients, and 41.7% of smokers vs. 27.8% of nonsmokers developed infections. Significant differences between infected vs. infection-free patients were present for the number of pack years (p < 0.001) and the overall estimated cigarettes smoked (p < 0.001). A cut-off value of approximately 6.85 pack years (50,000 overall estimated cigarettes) distinguished between infections vs. infections-free patients, with 25% of false positives and 8% of false negatives. Relative risk conferred by smoking was 3.8. CONCLUSIONS: The incidence of infections in our series of postbariatric patients undergoing mastopexy and breast reduction is 35.7%. A cut-off of 6.85 pack years (50,000 estimated overall cigarettes) was determined and, according to this value, the relative risk conferred by smoking was 3.8.

Vaginal reconstructive surgery for severe pelvic organ prolapses: a 'uterine-sparing' technique using polypropylene prostheses.

OBJECTIVE: The Ulmsten's "Integral Theory" for pelvic floor dysfunctions is based on the need to reinforce fascias and ligaments with prostheses to obtain a reconstitution of the pelvic floor's anatomy. In September 2004 we developed a "uterine-sparing" surgical technique to correct such pathologies and in this paper we present results obtained. Primary outcome was to evaluate the technique's efficacy, secondary outcomes the resolution of stress urinary incontinence, postoperative pain (VAS scale), safety and complications. STUDY DESIGN: This prospective study included patients affected by stage 3 and 4 uterine-vaginal prolapse who wished to conserve their uterus. Those with (1) minor degrees of severity, (2) unfit for surgery, (3) with a clear indication to hysterectomy (i.e. endometrial cancer), (4) with an elevated operative risk (American Society of Anaesthesiologists-ASA score III and IV), (5) previous vaginal surgeries and (6) with moderate/severe defecation problems were excluded. The technique consisted in a sacrospinous colposuspension with polypropylene mesh. The pelvic status was classified according to the international Pelvic Organ Prolapse staging system (POP-Q). Postoperative pain was scored with the VAS Scale. All patients were given the King's Health questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Wexner questionnaire. RESULTS: From September 2004 to November 2006 we treated 80 patients. Polypropylene prostheses (Gynemesh-Soft PS, 10cmx15cm - GyneMesh, Gynecare Ethicon - Somerville, NJ, USA) were used to reconstruct the pubo-cervix or the recto-vaginal fascia. We performed an anterior-central vaginal reconstruction in 35 (43.8%) patients, central-posterior in 25 (31%) and total reconstruction in 20 (25%). The median follow-up was 21 months (range 18-26). The severe pelvic prolapse, evaluated with the POP-Q System, was completely treated in all the patients and no recurrences were observed. The urodynamic examination showed a complete resolution of the stress urinary incontinence in 10 patients (83%). Sexual activities improved in all patients. We recorded three vaginal erosions and one patient complained of a postoperative dyspareunia. CONCLUSIONS: This pilot study suggests that our technique is safe and effective and can efficiently repair the pelvic organs prolapse, without undergoing hysterectomy and with a low rate of vaginal erosions.

[Comparative study among autologous and synthetic slings in the treatment of stress urinary incontinence]. / Studio comparativo tra sling autologhe e sintetiche nel trattamento dell'incontinenza urinaria da sforzo.

AIM: Procedures to correct stress urinary incontinence (SUI) are designed to restore support of the urethrovescical junction and, in cases of intrinsic sphinteric dysfunction, improve the coaptation of the urethra. Voiding dysfunction and urinary retention are frequent complications of both urethropexy and urethral sling. Guatelli et al. reported a 8.5% obstruction rate following autologous sling procedure, while the obstruction rate after polypropylene sling meshes procedures was 3.7%. The aim of this study was to compare the success and bladder outlet obstruction (BOO) rates following sling procedure for SUI with two different mesh materials, synthetic versus autologous. METHODS: A prospective study was carried out between July 1995 and December 1995 at the Department of Urology, University of Campinas Medical Center. RESULTS: The median time between the anti-incontinence procedure and the diagnosis of BOO was nine months (3-96 months). All obstructed patients suffered from refractory urgency/frequency syndrome with varying postvoid residual volume. Our experience showed that autologous pubovaginal slings were statistically more obstructive than synthetic ones. CONCLUSION: Autologous and synthetic slings presented comparable success rates in treating SUI. However, BOO was more frequent among patients who underwent autologous sling procedure.

Devastating methicillin resistant Staphylococcus aureus wound infection following abdominoplasty in a prior bariatric surgery patient.

A 46-year-old female smoker presented 12 months after laparoscopic adjustable gastric banding, with massive weight loss and skin excess of the abdomen and flanks. She underwent abdominoplasty with muscle plication and flanks liposuction, but on the 14th postoperative day this was complicated by a methicillin-resistant Staph. aureus wound infection. Multiple surgical debridements and high doses of intravenous antibiotics were necessary for cure and to avoid further septic complications. Complete wound closure was achieved after 3 months of therapy. Concomitant risk factors for wound infection (obesity, smoking, flap construction) contributed to a rare but potentially fatal wound complication following abdominoplasty. We alert the surgeon to such postoperative infections and the necessity for a non-conservative approach.

Wound infections in post-bariatric patients undergoing body contouring abdominoplasty: the role of smoking.

BACKGROUND: In this prospective study, we followed patients after laparoscopic adjustable gastric banding for morbid obesity who underwent abdominoplasty for body contouring. Our purposes were: 1) to determine if a significant relationship between cigarette smoking and postoperative wound infections existed, 2) the relative risk conferred by cigarettes and 3) a cut-off value for the increased risk. METHODS: Patients scheduled for body contouring abdominoplasty were considered eligible. We excluded those with ongoing clinical infections, recent antibiotic administration, those within 1 year from their bariatric surgery and those with systemic diseases. Smokers were asked to stop smoking at least 4 weeks before surgery. RESULTS: Since November 2004, we recruited 60 patients. Postoperative infections were present in 25% (n=15) of patients and 86.7% of these (n=13) were superficial. All except one occurred in smokers (P = 0.0001): 47% of smokers and 3% of nonsmokers developed infections. Significant differences between infections vs infection-free patients were present for the number of cigarettes smoked per day (P<0.001), years of smoking (P< 0.001), overall estimated cigarettes smoked and the number of pack years (P = 0.001). A cut-off value of approximately 62,000 overall estimated cigarettes (8.5 pack years) distinguished between infections vs infection-free patients (6.2% false positives and 7.1% false negatives). Relative risk conferred by smoking was 14 (95% confidence intervals 13.3-16.7). CONCLUSIONS: The incidence of infections in post-bariatric patients undergoing body contouring abdominoplasties is 25%. The relative risk conferred by smoking was 14 and the cut-off value was 62,000 overall cigarettes (8.5 pack years).

[New view in the mammary asymmetry treatments]. / Nuove prospettive nel trattamento delle asimmetrie mammarie.

AIM: Breast asymmetry is a huge chapter of breast abnormalities. Surgical therapy is the exclusive one. The breast of women can vary in shape, volume and position, thus creating esthetic, social and psychological problems. METHODS: We classified breast asymmetry into 6 categories and then we treated them with different surgical techniques: reduction mammaplasty according to Planas; augmentation mammaplasty with prosthesis; grafts or both; ultimately mamma-prosthesis (association of mastopexy and prosthesis). We obtained satisfactory esthetic results often with one surgery procedure. Rarely we performed 2 or more procedures of symmetry. We treated 77 patients suffering from breast asymmetry. We excluded in this study the giant-mammary asymmetry (anomaly determined by severe and asymmetric mammary hypertrophy). RESULTS: We found a low number of complications at short and long term. These results are likely due to the ability of the surgeon in the appropriated preoperative evaluation of the patients and of their expectancy and correct surgical techniques. CONCLUSIONS: We tried to obtain 3 results: shape and position of the sick breast as same as possible to the contralateral breast and less evident scars located in hidden regions.

Methicillin-resistant superinfection of the wound after body-contouring abdominal surgery.

BACKGROUND: This report presents the case of a patient who underwent abdominal body-contouring surgery, then later experienced a severe deep infection and a methicillin-resistant (MRSA) superinfection. CASE REPORT: A 56-year-old female ex-smoker presented, after massive weight loss, with skin excesses on the abdomen and flanks. She underwent an abdominoplasty with muscle plication and flank liposuction. On postoperative day 14, the woman presented with a deep wound infection, then 1 week later with MRSA superinfection. Since then, two surgical debridements and specific intravenous antibiotics have been necessary for a cure and to avoid septicemic complications. Complete wound closure was achieved only after 3 months of therapy, but a massive retractile and painful scar remained. CONCLUSION: Concomitant risk factors for wound infections (obesity, smoking, flap undermining) determined a rare but potentially fatal wound complication after body-contouring abdominoplasty. This complication was presented to alert plastic and general surgeons to such postoperative infections and to the possibility of a nonconservative approach.

Selective embolization of the superior vesical artery for the treatment of a severe retroperitoneal pelvic haemorrhage following Endo-Stitch sacrospinous colpopexy.

Pelvic haemorrhage is a rare but important complication that may follow sacrospinous fixation of the vaginal vault. When such complication occurs, packing and clipping of the involved artery is often suggested as the first-line treatment, while arterial embolization is considered only after failure of surgery. In this report, we describe the successful super-selective embolization of a variant of the superior vesical artery in a patient who underwent Endo-Stitch sacrospinous colpopexy. Based on our experience, we suggest that when a well-trained radiological staff is available, endovascular embolization is an effective and less invasive option.

Results 1 year after the Reemex system was applied for the treatment of stress urinary incontinence caused by intrinsic sphincter deficiency.

We present 1-year results obtained with Reemex for the cure of intrinsic sphincter deficiencies (ISDs). We recruited all patients with primary cases of stress urinary incontinence (SUI) due to an ISD (Valsalva leak-point pressure less than 60 cm or maximal urethral closure pressure less than 20 cm) who did not receive previous surgery. Thirty-eight patients were operated on. Postoperative pain was 3 (range, 1-5, visual analogue scale) at 24 h from surgery. Immediate regulation (the day after surgery) was necessary in three of 38 patients (7.9%), two for obstructive voiding difficulties and one for incontinence. Late regulation was necessary in three of 38 patients (7.9%), two for obstructive voiding difficulties (after 6 months) and one for incontinence (1 year). Symptoms resolved after the sling adjustment. Our results suggest that sling adjustments resolve postoperative failures and maintain the success rate of the Reemex system even in the midterm.

TVT-O vs TVT: a randomized trial in patients with different degrees of urinary stress incontinence.

TVT-O and TVT were compared in patients stratified according the severity of Stress Urinary Incontinence (SUI). Those patients with intrinsic sphincter deficiencies, overactive bladders, associated prolapses, neurovegetative disorders and recurrent SUI or under rehabilitative/medical therapies were all excluded. There were 208 women included. Operating times were longer, and postoperative pain greater for TVT (p < 0.001). TVT produced longer hospitalizations in severe SUI patients (p < 0.001). After 1 year of follow-up, incontinence was cured in all mild SUI patients with both techniques, in all severe SUI patients when treated with TVT and in 66% of them when treated with TVT-O (p < 0.001). Vaginal perforations occurred during the TVT-O (p = 0.01), bladder perforations during TVT (p = NS), bladder obstructions in mild SUI patients after TVT (p < 0.001). The severity of SUI is an important parameter that influences results after TVT-O and TVT, and could be used to guide surgeons in selecting the most effective intervention.

Postoperative wound infections after breast reductions: the role of smoking and the amount of tissue removed.

BACKGROUND: This prospective study followed patients who underwent breast reductions to determine the influence of smoking and the amount of tissue removed on postoperative wound infections. METHODS: Patients who had received breast reductions were considered eligible for the study. The study excluded postbariatric patients and those with ongoing clinical infections, a recent antibiotic course, or systemic diseases that could impair tissue oxygenation. Smokers were instructed to quit smoking at least 4 weeks before surgery. RESULTS: By March 2004, the study had enrolled 87 patients. Postoperative infections were present in 24 cases (27.9%). Infections included 16 in smokers (37.2%), 8 in nonsmokers (18.2%; p < 0.05), 14 in patients with large resections (>0.85 kg; 70%), and 10 in patients with small resections (14.9%; p < 0.001). Significant differences were found between the patients who experienced infections and those who were infection free in terms of the overall estimated cigarettes smoked (mean, 146,000; range, 29,200-228,125 vs mean, 10,950; range, 9,125-54,750; p < 0.001), the number of pack years (mean, 20; range, 4-31 vs mean, 2; range, 1-8; p < 0.001), and the amount of tissue removed (mean, 0.9 kg; range, 0.5-2 kg vs mean, 0.5 kg; range, 0.2-1.4 kg; p < 0.001). The analysis for all the patients determined an odds ratio of 2.04 for smoking and 4.7 for the amount of tissue removed. CONCLUSIONS: Smoking and the amount of tissue removed are important issues in aesthetic breast surgery that need to be addressed accurately by the plastic surgeon. If future larger studies confirm these data, surgeons could have a simple and easy method for stratifying patients according to their risk for the development of wound infections and for prescribing specific preventive measures.

A retrospective analysis of 3,000 primary aesthetic breast augmentations: postoperative complications and associated factors.

BACKGROUND: A large retrospective analysis was performed on a homogeneous group of patients undergoing primary aesthetic breast augmentations to define complication rates and find associated factors. METHODS: Data were collected from the personal databases of two different surgeons working at the Crown House Hospital, Oldbury, Birmingham, United Kingdom. The period considered was January 1996 to December 2001. All patients who received primary breast augmentation with or without associated mastopexy for cosmetic purposes were recorded. RESULTS: A total of 3,002 women were included in the study. Hematomas were present in 46 patients (1.5%), infections in 33 patients (1.1%), breast asymmetries in 23 patients (0.8%), rippling in 21 patients (0.7%), and capsular contractures in 14 patients (0.5%). The multivariate analysis found that implant placement and the technique used for pocket creation were variables associated with complications (p < 0.05). Capsular contractures carried a progressive cumulative risk and, in our series, appeared 5 years after surgery. No association was found between contractures and hematomas or infections. CONCLUSIONS: The overall incidence of complications in our series was relatively high (4.6%). Surgical placement of prostheses and the technique used for pocket creation were associated with complications. However, few patients required reoperation (1.6%), and the overall satisfaction rate was acceptable (visual analog score, 7).

Infections of breast implants in aesthetic breast augmentations: a single-center review of 3,002 patients.

BACKGROUND: A large retrospective analysis examined primary aesthetic breast augmentations to find specific factors that could favor or counteract the occurrence of infections. METHODS: Data were collected from the personal databases of two different surgeons at the Crown House Hospital, Oldbury, Birmingham, United Kingdom, from January 1999 to December 2004. All the patients who received primary aesthetic breast augmentation with or without associated mastopexy were recorded. RESULTS: A total of 3,002 women were reviewed. Infections were experienced by 33 patients (1.1%). The analysis showed that Mentor prostheses and local antibiotics both were protective against the occurrence of infections (p < 0.05). On the contrary, the use of drains significantly increased the risk fivefold (p < 0.05). CONCLUSIONS: The incidence of infections in aesthetic breast augmentations is 1.1%, and Mentor prostheses, antibiotics in the pocket, and the use of drains seem associated with their occurrence.

Breast asymmetries: a brief review and our experience.

The authors describe their personal experience with the management of mammary asymmetries. A review of their database from January 1998 to January 2005 identified 177 patients with idiopathic breast asymmetries. All these cases had been classified previously into six groups. Bilateral asymmetric hypertrophy and unilateral hypertrophy were treated with reduction mammaplasty. Unilateral hypertrophy with amastia or hypoplasia of the contralateral side was managed with reduction and augmentation mammaplasty. Unilateral amastia or hypoplasia (Poland's syndrome) was treated with a single monopedicle transverse rectus abdominis muscle (TRAM) flap, and asymmetric bilateral hypoplasia was managed with augmentation mammaplasty. Unilateral mammary ptosis was treated with mastopexy and augmentation mammaplasty. The proposed classification, derived from the authors' experience in this field, gives an idea of how they usually treat these patients. It is useful for a first evaluation, but after that, every treatment must always be individualized on a patient-by-patient basis.

Autologous cartilage graft rhinoplasties.

BACKGROUND: The authors report their experience with autologous graft rhinoplasties. METHODS: Data were collected retrospectively, with selection of only autologous grafts from 2,000 rhinoplasties performed at the Plastic and Reconstructive Department of the University of Rome Tor Vergata. RESULTS: A total of 62 patients from January 1995 to January 2005 were selected. Most of the patients were treated with the "open tip" technique, whereas 9.7% had a classic endonasal approach. Follow-up evaluation was performed with outpatient visits at 2 and 6 weeks, then at 3, 6, and 12 months. Good aesthetic results were obtained for 93.5% of the patients, and 83.7% had complete satisfaction. CONCLUSION: Autologuos cartilage graft rhinoplasty is an affordable technique easy to learn that widens possibilities of interventions for nasal pyramid reconstruction.