Adipofascial Perforator Flaps for Peripheral Nerve Resurfacing after External Neurolysis.

Background: External neurolysis is an important approach to treating symptomatic peripheral nerve entrapment. In cases of recurrent neurolysis or particularly extensive neurolysis, a paucity of overlying soft tissue for closure over the freshly liberated nerve presents a challenge to long-term surgical success as primary closure of this tissue may predispose the patient to recalcitrant epineural scarring. We report the intermediate term outcomes of the use of adipofascial perforator flaps as a means of vascularised tissue resurfacing of nerves in these difficult scenarios. Methods: We retrospectively reviewed patients undergoing external neurolysis for painful peripheral nerve lesions who subsequently had soft tissue reconstruction with local adipofascial flaps. Data with regard to age, gender, limb involved, duration of symptoms, number of prior surgeries, operative time, type of flap, vascular basis of flap, duration of follow-up, visual analogue pain score, monofilament sensory testing and complications were collected. Results: We included six patients (four women) with a minimum follow-up period of 17 months (range: 17-25 months). Age ranged from 39 to 60 years of age. Four cases involved the upper extremity and two the lower extremity. Symptoms had been present between 1 and 10 years. All operations utilised a local adipofascial flap perfused by a named perforating vessel emanating from an adjacent axial vessel. Operative time for flap creation and inset was 74 minutes, on average. There was one minor complication owing to superficial wound dehiscence. All patients reported substantial pain relief (≥five-point reduction on visual analogue scale; scores 0-3 at last follow-up) and objective sensory testing demonstrated improvement. Conclusions: Our report pays particular attention to surgical technique that is applicable to both upper and lower extremities in addition to intermediate term safety and pain outcomes. Level of Evidence: Level IV (Therapeutic).

Use of Vascularized, Denervated Muscle Targets for Prevention and Treatment of Upper-Extremity Neuromas.

Purpose: Neuroma formation following upper-extremity peripheral nerve injury often results in persistent, debilitating neuropathic pain with a limited response to medical management. Vascularized, denervated muscle targets (VDMTs) offer a newly described surgical approach to address this challenging problem. Like targeted muscle reinnervation and regenerative peripheral nerve targets, VDMTs are used to redirect regenerating axons from an injured nerve into denervated muscle to prevent neuroma formation. By providing a vascularized muscle target that is reinnervated via direct neurotization, VDMTs offer some theoretical advantages in comparison with the other contemporary surgical options. In this study, we followed the short-term pain outcomes of patients who underwent VDMT surgery for neuroma prevention or treatment. Methods: We performed a retrospective chart review of 9 patients (2 pediatric and 7 adult) who underwent VDMTs either for symptomatic upper-extremity neuromas or as a prophylactic measure to prevent primary neuroma formation. In-person and/or telephone interviews were conducted to assess their postoperative clinical outcomes, including the visual analog pain scale simple pain score. Results: Of the 9 patients included in this study, 7 underwent VDMT surgery as a prophylactic measure against neuroma formation, and 2 presented with symptomatic neuromas that were treated with VDMTs. The average follow-up was 5.6 ± 4.1 months (range, 0.5-13.2 months). The average postoperative pain score of the 7 adult patients was 1.1 (range, 0-8). Conclusions: This study demonstrated favorable short-term outcomes in a small cohort of patients treated with VDMTs in the upper extremity. Larger, prospective, and comparative studies with validated patient-reported and objective outcome measures and longer-term follow-ups are needed to further evaluate the benefits of VDMTs in upper-extremity neuroma management and prevention. Type of study/level of evidence: Therapeutic III.

Automated 3D ultrasound enables novice users to measure arteriovenous fistula maturation parameters with comparable accuracy to conventional duplex by trained sonographers: Results of a benchtop study.

BACKGROUND: Arteriovenous fistulae (AVF) are considered the preferred hemodialysis access but up to 50% of all AVF created in the United States never mature. Doppler ultrasound (DUS) is useful for predicting fistula maturity and impending fistula failure. DUS is resource-intensive and is associated with poor compliance rates in dialysis patients, ranging from 12% to 33%. METHODS: EchoSure is an FDA-cleared 3D Doppler ultrasound device that automatically delivers quantitative blood flow and anatomic vascular information. The technology can be used at the bedside by personnel without formal sonographic training, nullifying limitations of traditional Duplex ultrasound imaging. This study compared the EchoSure system in the hands of inexpert personnel to a traditional expert-operated DUS for rapid assessment of a benchtop model vascular system with flow, diameter, and depth expected in a human AVF. RESULTS: Both Duplex and EchoSure performed within the expected tolerance of ultrasound readings (35%) for volume flow, with the average error (AE) between the observed measurement and the ground truth being 8% for Duplex and 8% for EchoSure. However, the average coefficient of variation (CV) for Duplex pooled over all flow rate measurements was 17% versus 4% for EchoSure. Regarding diameter, Duplex measurements had AE of 15% with an average CV of 6% across all measurements versus EchoSure AE of 4% and average CV of 2%. Duplex and EchoSure measurements over all depths had the same AE of 2%. The two modalities were not statistically different for depth measurement (p = 0.05) but EchoSure measured closer to the ground truth for flow rate and vessel diameter (flow: p = 0.028, ρ = -0.07; diameter: p < 0.001, ρ = 0.69). The inexpert personnel using EchoSure acquired data 62% faster than the expert sonographers using the Duplex ultrasound (141 min for Duplex vs 87 min for EchoSure). CONCLUSIONS: EchoSure may offer an accurate and convenient alternative for imaging fistulas in the clinic.

Vascularized, Denervated Muscle Targets for Treatment of Symptomatic Neuromas in the Upper Extremity: Description of Operative Technique.

Symptomatic neuromas of the upper extremity often cause persistent, debilitating pain that is resistant to medical management. Following upper extremity amputation, painful neuromas may disrupt rehabilitation efforts and pose a barrier to prosthetic use. Several surgical approaches have been attempted to treat neuromas, each of which suffers from limitations. We have developed a novel technique, the vascularized, denervated muscle target, that offers a compelling new option for primary prevention and secondary treatment of symptomatic neuromas of the upper extremity. Here, we provide a detailed description of our surgical technique as it is applied to neuromas of the upper extremity.

Approach to Diagnosis and Treatment of Dorsoradial Hand and Forearm Pain.

Dorsoradial forearm and hand pain was historically considered difficult to treat surgically due to a particular susceptibility of the radial sensory nerve (RSN) to injury and/or compression. A nerve block, if it were done at all, was directed at the region of the anatomic snuff box to block the RSN in an effort to provide diagnostic information as to the pain etiology. Even for patients with pain relief following a diagnostic block, resecting the RSN often proved unsuccessful in fully relieving pain. The solution to successful treatment of this refractory pain problem was the realization that the RSN is not the sole source of sensory innervation to the dorsoradial wrist. In fact, in 75% of people the lateral antebrachial cutaneous nerve (LABCN) dermatome overlaps the RSN with other nerves, such as the dorsal ulnar cutaneous nerve and even the posterior antebrachial cutaneous nerves, occasionally providing sensory innervation to the same area. With this more refined understanding of the cutaneous neuroanatomy of the wrist, the diagnostic nerve block algorithm was expanded to include selective blockage of more than just the RSN. In contemporary practice, identification of the exact nerves responsible for pain signal generation informs surgical decision-making for palliative neurolysis or neurectomy. This approach offers a systematic and repeatable method to inform the diagnosis and treatment of dorsoradial forearm and wrist pain.

Sensibility, Sensation, and Nerve Regeneration after Reconstructive Genital Surgery: Evolving Concepts in Neurobiology.

BACKGROUND: Sensory recovery following phalloplasty and vaginoplasty for gender dysphoria is essential to the overall success of gender-confirming surgery. Anecdotal evidence suggests that superior reinnervation results are seen in genitoplasty compared to other peripheral nerve repair scenarios. Despite these observed differences, the quality of available literature is poor. METHODS: The authors reviewed the body of English language literature regarding sensory outcomes following genitoplasty for gender confirmation. RESULTS: The available body of literature discussing the basic science and clinical science aspects of sensory recovery following gender-confirming genitoplasty is small. Available data show that sensory recovery following vaginoplasty produces high rates of reported orgasmic ability, largely through the neoclitoris, and a neovagina with vibratory and pressure sensation similar to that of the native vagina. Phalloplasty sensory outcomes are variable, with the largest series reporting return of sensation in the neophallus that is slightly less than what is measured in control men. Erogenous sensation, including the ability to orgasm, is present in nearly all patients after several months. CONCLUSIONS: Existing series indicate that genitoplasty patients experience faster and more complete recovery than any other peripheral nerve regeneration scenarios. However, there are many potential confounding factors in assessment and reporting, and more consistent and reproducible measure endpoints measures are needed. Further research is needed to better understand both the basic science and clinical science of peripheral nerve regeneration in genitoplasty, which may change fundamental aspects of current paradigms of peripheral nerve regeneration.

Upper-Extremity Venous Thromboembolism Following Operative Treatment of Distal Radius Fractures: An Uncommon but Dangerous Complication.

PURPOSE: Distal radius fractures are the most common long bone fracture in the United States, with an estimated incidence of 640,000 cases per year. Operative fixation presents a theoretical risk factor for the development of upper-extremity venous thromboembolism (UE-VTE). Additionally, patients presenting with distal radius fracture commonly have preexisting comorbidities that further increase the risk of UE-VTE. Finally, UE-VTE is considered the highest risk for eventual development of pulmonary embolism. Despite this, scant attention has been paid to studying UE-VTE in this population. The purpose of this study was to measure the incidence of this complication and to identify possible medical factors that increased the risk of developing UE-VTE. METHODS: We queried the Truven MarketScan Commercial Claims and Encounters Database for all patients who experienced a distal radius fracture and were subsequently treated with open reduction and internal fixation between 2012 and 2016. Patients were identified using relevant Common Procedural Terminology codes. Demographic and medical variables were tabulated. Our primary outcome was the development of ipsilateral UE-VTE or pulmonary embolism in the first 60 days after surgery. RESULTS: The study included 24,494 patients. The mean age was 50.7 years (range, 18-91), and 58% were women. There were 79 cases (0.3%) of UE-VTE and 19 cases of pulmonary embolism in the study population (24.1% of all UE-VTE cases; 0.08% of total sample). Multivariable logistic regression showed that coexisting heart failure and estrogen use were associated with increased risk of UE-VTE. CONCLUSIONS: Although uncommon, the development of UE-VTE after open reduction and internal fixation for distal radius fractures is a concerning complication. Coexisting heart failure and estrogen use are associated with increased risk of UE-VTE. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

An Algorithm for the Prevention and Treatment of Pain Complications of the Radial Forearm Free Flap Donor Site.

BACKGROUND: The radial forearm free flap (RFFF) is a staple of microsurgical reconstruction. Significant attention has been paid to donor-site morbidity, particularly vascular and aesthetic consequences. Relatively few authors have discussed peripheral nerve morbidity such as persistent hypoesthesia, hyperesthesia, or allodynia in the hand and wrist or neuroma formation in the wrist and forearm. Here, we present a diagnostic and therapeutic algorithm for painful neurologic complications of the RFFF donor site. MATERIALS AND METHODS: The peripheral nerves that can be involved with the RFFF are reviewed with respect to the manner in which they may be involved in postoperative pain manifestations. A method for prevention and for treatment of each of these possibilities is also presented. RESULTS: Nerves from the forearm that can be harvested with the RFFF will have the most likelihood for injury and these include the lateral antebrachial cutaneous nerve, the radial sensory nerve, and the medial antebrachial cutaneous nerve. A nerve that may be injured at the distal juncture of the skin graft to the forearm is the palmar cutaneous branch of the median nerve. The "prevention" portion of the algorithm suggests that each nerve divided to become a recipient nerve should have its proximal end implanted into a muscle to prevent painful neuroma. The "treatment" portion of the algorithm suggests that if a neuroma does form, it should be resected, not neurolysed, and the proximal portion should be implanted into an adjacent muscle. The diagnostic role of nerve block is emphasized. CONCLUSION: Neurological complications following RFFF can be prevented by an appropriate algorithm as described by devoting attention to the proximal end of recipient nerves. Neurological complications, once present, can be difficult to diagnose accurately. Nerve blocks are critical in this regard and are employed in the treatment algorithm presented.

Surgical Residents as Certified Bilingual Speakers: A Quality Improvement Initiative.

BACKGROUND: The objective of this quality improvement initiative was to identify general surgery residents proficient in a non-English language and have each attempt the Clinician Cultural and Linguistic Assessment (CCLA) to become qualified bilingual staff speakers. METHODS: General surgery house staff were asked to self-identify as proficient in a language other than English. Fees for the certification examination were waived, and each resident was excused from clinical duties to complete the exam. McNemar's test was used for statistical analysis. RESULTS: All residents responded to the initial survey, with 18/65 reporting a non-English language proficiency. Of the 12 residents who sat for the CCLA exam, 9 (75.0%) passed, with 5 certifying in the most commonly spoken non-English languages at this institution. The number of certified residents increased from 1 to 10 (1.5 % to 15.4%, p = 0.004). CONCLUSION: Language barriers result in health care disparities for patients with limited English proficiency. This reproducible quality improvement initiative significantly increased the number of qualified bilingual speakers, while 25.0% of self-described proficient speakers did not demonstrate adequate language proficiency. These newly certified providers allow for increased language concordant care, which may be associated with improved outcomes.

Outpatient Reduction Mammaplasty Offers Significantly Lower Costs with Comparable Outcomes: A Propensity Score-Matched Analysis of 18,780 Cases.

BACKGROUND: Breast reduction mammaplasty is a common plastic surgery operation. Although many contemporary surgeons provide breast reduction mammaplasty as an outpatient procedure, roughly 15 percent of patients are still observed postoperatively. The authors hypothesize that observation confers no safety benefit but engenders significant cost. METHODS: The authors reviewed cases of breast reduction mammaplasty in a commercial database and formulated three propensity score-matched cohorts: inpatient, 23-hour observation, and outpatient. Comparisons were made between inpatients and outpatients and between 23-hour observation patients and outpatients. The primary outcome variable was 14-day re-presentation rate to the emergency department or readmission. Financial data were also collected. RESULTS: Comparison of inpatients and outpatients included 1237 patients each (n = 2474 total patients). The 23-hour observation-outpatient comparison included 8153 patients each (n = 16,306 total patients). For inpatients versus outpatients, the 14-day re-presentation rate was 1.4 percent for inpatients and 0.3 percent for outpatients (p < 0.01). The overall surgical complication rate was higher for inpatients (7.8 percent) than for outpatients (4.9 percent) (p < 0.01). Comparing outpatients to 23-hour observation patients, the 14-day re-presentation rate was similar (0.5 percent observation versus 0.3 percent outpatient; p = 0.10). The complication rate was higher for 23-hour observation patients (4.8 percent) than for outpatients (3.2 percent) (p < 0.01). When compared with outpatients (median, $9077), inpatients (median, $19,975) generated $10,898 more in costs. Similarly, 23-hour observation patients (median, $12,451) generated $4050 more in costs than outpatients (median, $8401) (p < 0.01). CONCLUSIONS: Outpatient breast reduction mammaplasty is equally safe when compared to observation or admission. Non-outpatient breast reduction mammaplasty had median costs of 148 to 220 percent that of outpatient breast reduction mammaplasty. In an era of cost consciousness, ambulatory reduction mammaplasty may offer a relatively simple method of decreasing expenditures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Initial Opioid Prescriptions Predict Continued Narcotic Use: Analysis of 24,594 Reduction Mammaplasty Patients.

BACKGROUND: The objective of this study was to establish whether a particular perioperative opioid regimen was associated with a higher risk of opioid refilling in the reduction mammaplasty patient population. METHODS: A retrospective cohort study was conducted on subjects that underwent bilateral reduction mammaplasty with no history of opioid use in the year before surgery. Patients were followed for a period of 4 months after surgery. Multivariable logistic regression was used to establish factors associated with prescription refilling. Predictive probabilities of opioid refilling, given various perioperative opioid regimens, were explored. RESULTS: A total of 24,594 subjects met all criteria for inclusion in the study, 13 percent of whom demonstrated continued opioid use following surgery. The probability of refill in patients receiving 15 to 59 daily morphine milligram equivalents perioperatively was significantly lower than in those receiving less than 15 daily morphine milligram equivalents (e.g., 15 mg of codeine every 4 hours) or more than 60 daily morphine milligram equivalents (e.g., 10 mg of oxycodone every 6 hours). CONCLUSIONS: The probability of refilling prescription opioids is increased by nonmodifiable risk factors, such as age. However, modifiable risk factors exist as well, most notably the amount of narcotic prescribed during the perioperative period. Overprescribing was found to be common in the reduction mammaplasty patient population. Limiting outpatient opioid exposure to a range of 15 to 59 daily morphine milligram equivalents (e.g., 5 mg of hydrocodone every 6 hours) during the perisurgical period may reduce the probability that the surgeon will need to prescribe further narcotics. Further studies are needed to validate our findings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Reconstruction options and outcomes for breast sarcoma patients.

Breast sarcomas constitute a rare and heterogeneous group of tumors. Given their aggressive nature and the potential for extensive resections, rates of reconstruction have been low. We retrospectively reviewed subjects derived from our institutional registry presented between 2003 and 2015. Thirty-four patients with primary breast sarcoma were identified. The average age was 51.9 years and the average follow-up was 58 months. The most common histological type was malignant phyllodes (61.8%). Two patients suffered cancer recurrence. Twelve patients (35.3%) underwent reconstruction. Four underwent implant-based reconstruction, seven had autologous-based reconstruction, and one had combined reconstruction. Major complications were one flap loss and one implant removal. Our relatively high rates of breast reconstruction suggest a newly increased willingness to offer reconstruction to this rarer patient population.

Free Gracilis Muscle Flap for Sarcoma Reconstruction: 19 Years of Clinical Experience.

BACKGROUND: Sarcoma treatment necessitates high-dose chemoradiation therapy and wide surgical margins that create wounds that are difficult to reconstruct. Many techniques have been developed to cover these defects, originating with muscle flaps such as the rectus abdominis and latissimus dorsi. The gracilis flap, which is best known in contemporary practice as a microneurovascular flap for functional reconstructions, is not usually considered a robust option for reconstruction after sarcoma extirpation. METHODS: We reviewed records of 22 patients (9 women) at our institution who underwent reconstructive surgery after sarcoma extirpation using gracilis flaps for soft-tissue coverage from 1998 to 2017. Neurotized gracilis flaps were excluded. The mean patient age was 51 years (range, 18-85 years), and mean length of follow-up was 53 months (range, 9-156 months). Patients had 7 tumor types, with fibrosarcomas and undifferentiated tumors being most common. There were 23 defects (mean size, 118 cm2 (range, 54-200 cm2)). Defects were located most commonly in the foot and leg (n=9 each), upper extremity (n=4), and head and neck (n=1). The primary outcome was the flap success rate. Secondary outcomes were rates of major complications (unplanned reoperations, infections requiring intravenous antibiotics, and amputations); minor complications (superficial infections, partial skin-graft loss, partial flap necrosis, fluid collections treated in the office, and cosmetic reoperations); and sarcoma recurrence. RESULTS: Twenty-one flaps (91%) survived. Six patients (27%) experienced a major complication, and 12 patients (54%) experienced a minor complication. There were 2 amputations, for a limb salvage rate of 91%. CONCLUSIONS: This series shows that the gracilis is well suited to covering large, compromised wounds across diverse anatomic features, which are the hallmark of sarcoma resections. The high rate of limb salvage and minimal donor-site morbidity further support the use of this flap as a first-line option for sarcoma reconstruction.

Gracilis musculotendinous free flap for lower extremity reconstruction after surgical removal of malignant tumors: A report of five cases.

BACKGROUND: Lower extremity reconstruction is challenging because of the need to restore form and function. Despite the many options for soft-tissue coverage, little research has addressed combined tendon and soft-tissue reconstitution. We present a series of patients undergoing lower extremity tendon reconstruction and wound coverage with a single free gracilis flap and its tendon. METHODS: We studied five patients (age range, 51-81 years) undergoing lower limb reconstruction for defects involving soft tissue and tendon between 1998 and 2016 in the senior author's practice. Wounds (all in the foot and ankle region) were caused by sarcoma (n = 4) and Merkel cell carcinoma (n = 1) and ranged from 6.5-10 × 8-12 cm. Donor tendons, 2-18 cm long, were used to reconstruct the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and extensor retinaculum. Patient characteristics and outcomes were reviewed retrospectively. RESULTS: Reconstructions used a gracilis muscle free flap and its tendon. Flap sizes ranged 5-6.5 × 11-14 cm. Complications were one case of cellulitis and one case of reoperation for flap thinning and tenolysis. All patients had at least 7 months of follow-up (mean: 37 months; range: 7-104 months). At latest follow-up, all patients were ambulatory. On average, patients resumed assisted ambulation 27 days postoperatively and unassisted ambulation 62 days postoperatively. CONCLUSIONS: For complex wounds with soft-tissue and tendinous defects, the gracilis muscle free flap may be a reconstructive option. We recommend it be considered as a single-donor incision option for lower extremity reconstruction.

Early ambulation after colorectal oncologic resection with perineal reconstruction is safe and effective.

BACKGROUND: Post-operative bedrest is common following perineal reconstruction despite little supporting data. We sought to determine the safety of early ambulation following colorectal oncologic resection and flap-based perineal reconstruction. METHODS: A retrospective cohort study was conducted with two cohorts: standard bedrest (BC) and early ambulation (EAC). Ambulation capacity was objectively assessed. Regression analysis was performed to determine the effects of ambulation timing on 60-day reoperations or readmissions and other surgical outcomes. RESULTS: There were 57 participants. Those in the EAC were significantly more ambulatory on post-operative days one through three (p < 0.0001). There was no significant difference in 60-day reoperations (25% BC versus 9% EAC, p = 0.14) or readmissions (33% BC versus 15% EAC, p = 0.12). Early ambulation significantly reduced minor complication rates (38% BC versus 9% EAC, p = 0.02). CONCLUSIONS: Early ambulation following perineal reconstruction is safe and may potentially decrease wound complications. SUMMARY AND KEYWORDS: Institution of early ambulation protocols is rapidly becoming the standard of care for many oncological surgery patients. In cases requiring perineal reconstruction with vascularized flaps, however, there is no data to uproot the historical practice of mandatory bedrest. Our study demonstrates that the benefits of early ambulation are attainable in these patients without compromising reconstructive outcomes.

The Gracilis Free Flap Is a Viable Option for Large Extremity Wounds.

BACKGROUND: Traditionally, the gracilis free flap is used for coverage of small- to medium-sized wounds (<50 cm) or as a functional muscle transfer. The purpose of this study is to examine the use of the gracilis free flap in the reconstruction of large extremity wounds (>100 cm). METHODS: We retrospectively reviewed records of 34 patients who underwent extremity soft-tissue reconstruction using gracilis free flaps for wounds larger than 100 cm from 1998 to 2016. The primary outcome was overall flap success rate. Secondary outcomes were rates of major and minor complications. Mean defect size was 145 cm (range, 104-240 cm). Seven flaps covered defects greater than 175 cm. Indications were tumor extirpation (n = 18) and traumatic/posttraumatic wounds (n = 16). The most common time period for flap coverage was immediately (3 days or less) after the defect was created (n = 14). Most flaps were solely muscle (n = 28) and were used for lower extremity or foot coverage (n = 29). RESULTS: The overall success rate was 94%. Major and minor complications occurred in 5 and 13 cases, respectively. The most common major complication was unplanned reoperation (n = 5), and the most common minor complications were partial skin graft loss (n = 3), partial flap necrosis (n = 3), and planned recipient-site reoperation (n = 5). CONCLUSIONS: Reconstruction of large extremity wounds using the gracilis free flap showed a 94% success rate with few major complications.

Surgical Management of the Giant Pannus: Indications, Strategies, and Outcomes.

The obesity pandemic continues to produce an inexorable increase in the number of patients requiring surgical treatment of obesity and obesity-related complications. Along with this growing number of patients, there is a concomitant increase in the complexity of management. One particular example is the treatment of patients with an exceptionally large and morbid pannus. In this report, we detail the management of seven patients suffering from a giant pannus. Medical and surgical variables were assessed. A quality of life questionnaire was administered pre- and postoperatively. All seven patients suffered some obesity-related medical morbidity and six of seven (86%) had local complications of the giant pannus. Each patient underwent giant panniculectomy [resection weight > 13. 6 kg (30 lb)]. The mean resection weight was 20.0 kg. Four of seven (57%) patients experienced postoperative complications, with two (29%) requiring re-operation and blood transfusion. Six patients were available for long-term follow-up; 100% of participants indicated an increased quality of life while five (83%) reported additional postoperative weight loss, increase in exercise frequency and walking ability, and improved ability to work. Our results indicate that giant panniculectomy is a challenging and risky procedure, but careful patient selection and intraoperative scrutiny can ameliorate these risks and afford patients a dramatically improved quality of life. 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 .