Early Ambulation After Microsurgical Reconstruction of the Lower Extremity.

Successful outcomes after microsurgical reconstruction of the lower extremity include timely return to ambulation. Some combination of physical examination, ViOptix tissue oxygen saturation monitoring, and the implantable venous Doppler have shown promise in increasing sensitivity of current flap monitoring. We have incorporated this system into our postoperative monitoring protocol in an effort to initiate earlier dependency protocols. A prospective analysis of 36 anterolateral thigh free flap and radial forearm flaps for lower extremity reconstruction was performed. Indications for reconstruction were acute and chronic wounds, as well as oncologic resection. Twenty-three patients were able to ambulate and 3 were able to dangle their leg on the first postoperative day. One flap showed early mottling that improved immediately after elevation. After reelevation and return to baseline, the dependency protocol was successfully implemented on postoperative day 3. All flaps went on to successful healing. Physical examination, implantable venous Doppler, and ViOptix can be used reliably as an adjunct to increase the sensitivity of detecting poorly performing flaps during the postoperative progression of dependency.

Screw fixation of dermal regeneration template for scalp reconstruction.

Despite many advances in reconstructive techniques, the full-thickness scalp defect remains a difficult problem for the reconstructive surgeon. Patient and disease-specific factors occasionally make reconstruction with a dermal regeneration template (DRT) an attractive option when other methods are less advised. Although the applicability of dermal regeneration templates has been well elucidated, the method of DRT immobilization has not been standardized. Given the difficulty of adherence and subsequent infiltration of host cells into the DRT from the underlying bone due to seroma, hematoma, or shearing forces, we propose a screw and bolster system for DRT immobilization. We present a series of 13 patients with full-thickness scalp loss who underwent reconstruction with DRT and a subsequent split-thickness skin graft. All 13 patients were treated with the screw-bolster method of DRT fixation before a vacuum-assisted closure dressing. The average surface area of the defect was 96 cm. The mean time interval between the application of DRT and skin graft was 28 days. At a mean of 9-month follow-up, all patients achieved a well-vascularized neodermis, and progressed to complete, stable wound healing following application of a split-thickness skin graft. We propose that a screw-bolster system of fixation is a safe and effective method of immobilizing DRT in full-thickness scalp defects.

A comparison of face lift techniques in eight consecutive sets of identical twins.

BACKGROUND: Selecting the "correct" face lift technique has always been a difficult decision for the plastic surgeon. A technique that provides optimal aesthetics for one patient may not provide the same result for another. The complexity of comparing these different results on patients with different facial features further confounds one's ability to decide on a given technique. Even identical twins are often treated more appropriately with a different technique from one twin to the other because the character and severity of facial aging may differ between them. By comparing different superficial musculoaponeurotic system techniques on "less different" people (identical twins), perhaps the ideal technique may be determined. METHODS: Between November of 1997 and April of 1999, eight sets of twins underwent face lift surgery by the senior author (D.E.A.), using one of four techniques. The charts and photographs of the eight consecutive pairs of twins (16 patients) were reviewed retrospectively. RESULTS: No one face lift technique performed in this study produced a superior result as compared with another when performed on the appropriate patient. CONCLUSION: There exists no face lift technique suitable for every patient. As the current literature suggests, there is no one "best" face lift technique of those studied.

Reevaluating resumption of oral intake after abdominoplasty.

BACKGROUND: Traditional postoperative management of patients undergoing abdominoplasty has involved withholding food until patients demonstrate evidence of bowel activity. No literature exists to support this practice, however, and with the expanding trend toward ambulatory abdominoplasty, early feeding may obviate, at least partially, the need for postoperative hospital admission for intravenous hydration, thereby allowing for faster discharge. OBJECTIVE: We sought to investigate whether early feeding of patients contributed to an increased incidence of postoperative nausea and vomiting (PONV), as well as impacted the return of bowel sounds or the usage of antiemetic medications. METHODS: Hospital records of the authors' patients who underwent full abdominoplasty with adjunctive suction-assisted lipoplasty were examined. The senior author (A.M.) held patients nil per os (NPO) until bowel sounds were auscultated (group I), whereas the other authors (S.S.J., M.J.O.) began a regimen of feeding immediately after surgery (group II). RESULTS: No significant differences in age, gender, or body mass index were present. Operative time was significantly shorter in group I. The incidence of PONV, use of antiemetic medications, and presence of audible bowel sounds on postoperative day 1 did not vary significantly between groups. None of the patients with inaudible bowel sounds in either group experienced PONV. CONCLUSIONS: Early feeding after abdominoplasty did not lead to an increased incidence of PONV, increased use of antiemetic medications, or delayed return of bowel sounds. In routine abdominoplasties, early feeding may permit patients to sustain adequate hydration and possibly allow for earlier discharge.

Current methods for brow fixation: are they safe?

BACKGROUND: No single technique for fixation of the scalp after forehead-lift is universally accepted. Complications such as alopecia, loss of elevation, implant palpability, paresthesia, and dural injury are possible with the variety of techniques used currently. This anatomic study was designed to evaluate the thickness of the calvarium at selected points used in brow fixation. The depth of cranial penetration necessary for currently used techniques is measured and compared. METHODS: In a study of 14 fresh adult cadavers, calvarial thickness was measured at selected points (A-F) used in various brow-lifting procedures. This was accomplished by drilling holes in selected points and using a depth gauge to measure thickness. Immediately adjacent to selected points, the cranium is prepared for brow fixation using the following techniques: cortical tunnels, 2.0-mm screw fixation (10, 12, and 14 mm), the Mitek 2.0-mm Quickanchor screw, and the Endotine 3.5 Forehead Device. The depths required for adequate fixation and the potential for cranial penetration through the inner table with all the standard techniques are compared. RESULTS: Depth analysis by mean values showed that sites posterior to the coronal suture (points C-F) were thickest. Depth analysis of sites stratified by gender showed that mean values for the thickness of female skulls were greater than those for males. A review of fixation methods found that cortical tunnels at 45 degrees angles never penetrated the inner table in any of the 14 skulls. Mitek screws never penetrated the inner table, and one Endotine post penetrated the inner table on the left side of one cadaver skull. After placement of 10-, 12-, and 14-mm miniscrews at each of the sites, it was found that three penetrated the inner table. The penetrations all were at far lateral sites, posterior to the coronal suture. CONCLUSION: Variation in skull thickness exists among cadaver specimens at different sites on the skull. In this study, thickness increased medially and posteriorly. Women tended to have thicker skulls than men, and age was not a major variable. This is consistent with findings in previous work. Given the unpublished reports of inner table penetration, with cerebrospinal fluid leak after invasive brow fixation, it behooves the surgeon to keep in mind the anatomy of the calvarium and its nuances.