Pedicled perforator flaps: a new principle in reconstructive surgery.

BACKGROUND: In the evolution of flap physiology and reconstruction, there has been a trend of decreased donor-site morbidity. In this article, the chronology of flap reconstruction is discussed, with particular emphasis on the current state of nonmicrosurgical perforator based flaps. METHODS: A literature search was conducted to study the evolution of flap physiology and reconstruction. Using this database, the authors describe the evolution of pedicled perforator flap reconstruction. Various examples of perforator-based flaps are discussed in this article. RESULTS: The literature review identified examples of scenarios where pedicled perforator flaps from various regions of the body are viable options. Several clinical cases are presented with respect to each region. CONCLUSION: Pedicled perforator flaps are a new concept in nonmicrosurgical perforator flap reconstruction.

The posterior tibial artery perforator flap: an alternative to free-flap closure in the comorbid patient.

Wounds of the distal third of the leg with exposed bone traditionally require free flaps for coverage. Although this often provides good results, patients with multiple comorbidities cannot undergo the long operating times and multiple surgical sites required for these complex procedures. We reviewed the use of posterior tibial (PT) perforator flaps as an alternative to free flaps for distal leg wound coverage in ill patients. Six patients (mean age, 53 years) with multiple comorbidities that precluded free-flap closures were treated with PT perforator flaps to cover complex distal leg wounds. The most common comorbidity was cardiac disease. Five patients had Gustilo grade IIIB open tibial fractures and one had a chronic wound. Mean flap size was 8x5.5 cm with a mean of one perforator per flap. Mean operating room time was 103 minutes. Four flaps were done without general anesthesia. There were no perioperative cardiopulmonary events. With a mean follow-up of 15 months, all flaps survived and all patients were ambulatory. There were no cases of malunion, nonunion, infection, wound breakdown, or partial flap loss. The PT perforator flap is a reliable choice for patients with open leg wounds and comorbidities precluding free-flap closure.

Excisional lipectomy for HIV-associated cervicodorsal lipodystrophy.

BACKGROUND: The development of effective antiretroviral therapy for the treatment of human immunodeficiency virus (HIV) has allowed for prolonged and healthier lives for affected patients. However, significant side effects from the drugs have been well documented, including syndromes of abnormal fat distribution. Cervicodorsal lipodystrophy, or "buffalo hump" deformity, is a common presentation of lipodystrophy syndrome and can cause significant disfigurement to the patient. Surgical correction has been the mainstay of treatment. OBJECTIVE: The authors report on the use of excisional lipectomy to correct cervicodorsal lipodystrophy. METHODS: Six male patients and one female patient (mean age, 47.2 years) underwent excisional lipectomy for buffalo hump deformity caused by HIV protease inhibitor use. Common complaints on presentation included disfigurement, neck pain, and difficulty sleeping. Deformity had first been observed an average of 4.75 years before presentation (range 2 to 7 years). At the time of consultation all patients were on antiretroviral regimens that included protease inhibitors. RESULTS: Excisional lipectomy of the hypertrophied cervicodorsal fat pad was performed on all patients, with suction-assisted lipoplasty (SAL) additionally to optimally contour the nondystrophic fat at the periphery of the resection. One patient also underwent simultaneous abdominoplasty, another underwent rhytidectomy with autologous fat transfer, and one patient received malar autologous fat injections. The average operative time for all procedures was 2.7 hours (range 1.0 to 5.8 hours). Complications included seroma in three cases and wound dehiscence in one patient, none of which required reoperation. At an average of 26.6 months of follow-up, all patients report satisfaction with their results, and there have been no recurrences. CONCLUSIONS: Cervicodorsal lipodystrophy is a well-described complication of extended use of HIV protease inhibitor therapy. Patients may seek consultation with plastic and reconstructive surgeons for correction of the aesthetic and functional morbidity associated with the deformity. Because of the fibrous nature of the hypertrophied cervicodorsal fat and the high rate of recurrence after SAL alone, an approach with excisional lipectomy (with or without SAL) may provide improved results and superior long-term outcomes.

Optimization of patient safety in postbariatric body contouring: a current review.

Postbariatric body contouring is a major growth field in plastic surgery as a direct result of the increasing incidence of bariatric surgery performed in the United States. As experience has accumulated in this subspecialty, technical procedures have been refined and dramatic aesthetic benefits have been seen in postoperative results. However, few objective guidelines exist on the optimization of patient care and safety in this complex patient population. This study sought to review the literature on body contouring after massive weight loss and patient safety to provide the reader with a summary of current recommendations. A literature review was performed with PubMed and MEDLINE. Eighty relevant articles, ranging from case reports and expert opinions to prospective randomized trials, were identified and reviewed in detail. Literature consensus guidelines included completion and stabilization of weight loss before surgery with a body mass index ideally less than 32, smoking cessation, nutritional assessment, anemia screening, usage of mechanical prophylaxis against thromboembolism, and strong consideration for usage of chemoprophylaxis with low molecular weight or unfractionated heparin. Procedures should be performed in accredited facilities with appropriately trained staff, and special intraoperative consideration should be given to patient positioning and avoidance of hypothermia. Postoperative management is optimized by the development of clinical pathways involving the surgeon, patient, and support staff.

Learning from a lymphedema clinic: an algorithm for the management of localized swelling.

BACKGROUND: Lymphedema is a chronic disease causing significant morbidity for affected patients. It can be difficult to diagnose, and patients are often frustrated by multiple referrals and inadequate therapies. Centralized, comprehensive care for the patient presenting with lymphedema or other causes of localized swelling allows for appropriate evaluation and provides improved management and treatment. METHODS: A 4-year review of the first 100 patients seen at the Beth Israel Deaconess Medical Center Lymphedema Clinic was performed. On the basis of the clinical experience from these patients, an algorithm for diagnosing and managing patients with localized swelling was developed. RESULTS: The mean age of the patients was 50 years, and 81 percent of the patients were women. On average, patients had experienced their symptoms for 11.6 years (range, 3 months to 60 years). Lymphoscintigraphy was performed on 43 patients, 81 percent of whom showed lymphatic obstruction or dysfunction. In total, 75 percent of patients were diagnosed with lymphedema based on clinical presentation or additional testing. Fourteen of these patients underwent subsequent excisional procedures, whereas the rest were managed conservatively with compression garments. CONCLUSIONS: Patients presenting with swollen extremities can frequently be diagnosed through history and physical examination alone, but many patients require more extensive diagnostic workup. An algorithm for the management of these patients can facilitate evaluation and treatment.

Lymphedema: a comprehensive review.

BACKGROUND: Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology, as well as diagnostic and therapeutic tools that are changing this perspective. OBJECTIVE: To provide a systematic approach to evaluating and managing patients with lymphedema. METHODS: We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed. RESULTS: In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy, several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms. CONCLUSIONS: The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy.

Surgical management of scrotal lymphedema using local flaps.

Lymphedema affects all parts of the body, including the scrotum and penis. Genital lymphedema can be a functionally and emotionally incapacitating problem for patients. Patients suffer pain, chronic irritation, repeated infections, drainage, and sexual dysfunction. No ideal surgical or medical therapy exists for the treatment of male genital lymphedema. Fasciocutaneous thigh flaps have been used for coverage of the testes after scrotal lymphedema resection, but these flaps alter testicular thermoregulation and may cause infertility. Skin grafts have also been used for coverage. Use of posteriorly based perineal flaps may preserve perirectal lymphatics that provide collateral lymphatic drainage. We present 2 cases of severe scrotal lymphedema treated by lymphangiectomy and reconstruction with local flaps. Both patients were satisfied with their results and had improved quality of life. We present our miniseries of scrotal lymphedema treated by excision and anterior and posterior flap reconstruction as a successful treatment of this difficult problem.

The use of bioimpedance analysis to evaluate lymphedema.

BACKGROUND: Lymphedema, a chronic disfiguring condition resulting from lymphatic dysfunction or disruption, can be difficult to accurately diagnose and manage. Of particular challenge is identifying the presence of clinically significant limb swelling through simple and noninvasive methods. Many historical and currently used techniques for documenting differences in limb volume, including volume displacement and circumferential measurements, have proven difficult and unreliable. Bioimpedance spectroscopy analysis, a technology that uses resistance to electrical current in comparing the composition of fluid compartments within the body, has been considered as a cost-effective and reproducible alternative for evaluating patients with suspected lymphedema. PATIENTS AND METHODS: All patients were recruited through the Beth Israel Deaconess Medical Center Lymphedema Clinic. A total of 15 patients (mean age: 55.2 years) with upper-extremity or lower-extremity lymphedema as documented by lymphoscintigraphy underwent bioimpedance spectroscopy analysis using an Impedimed SFB7 device. Seven healthy medical students and surgical residents (mean age: 26.9 years) were selected to serve as normal controls. All study participants underwent analysis of both limbs, which allowed participants to act as their own controls. The multifrequency bioimpedance device documented impedance values for each limb, with lower values correlating with higher levels of accumulated protein-rich edematous fluid. RESULTS: The average ratio of impedance to current flow of the affected limb to the unaffected limb in lymphedema patients was 0.9 (range: 0.67 to 1.01). In the control group, the average impedance ratio of the participant's dominant limb to their nondominant limb was 0.99 (range: 0.95 to 1.02) (P = 0.01). CONCLUSIONS: Bioimpedance spectroscopy can be used as a reliable and accurate tool for documenting the presence of lymphedema in patients with either upper- or lower-extremity swelling. Measurement with the device is quick and simple and results are reproducible among patients. Given significant limitations with other methods of evaluating lymphedema, the use of bioimpedance analysis may aid in the diagnosis of lymphedema and allow for tracking patients over time as they proceed with treatment of their disease.

Components separation combined with abdominal wall plication for repair of large abdominal wall hernias following bariatric surgery.

BACKGROUND: Abdominal wall hernias frequently occur after open bariatric surgical procedures. Standard repair with synthetic mesh may be suboptimal, with a recurrence rate as high as 50 percent. Patients often seek hernia repair in conjunction with abdominal body contouring procedures following substantial weight loss. METHODS: In 66 consecutive patients undergoing abdominal surgery after open bariatric surgery, abdominal wall hernias of some size were found in 50 patients. In 65 of these patients, panniculectomy was performed simultaneously. The majority of these hernias could be closed primarily in conjunction with abdominal wall plication [38 of 50 (76 percent)]. In 12 patients (24 percent of hernias), the defects were too large (median, 10.8 cm) or located too close to the xiphoid to permit primary closure without undue tension. RESULTS: Using a components separation technique, primary fascial closure was achieved in all 12 patients. The technique was modified to include abdominal wall plication above and below the repaired hernia defect and the use of an absorbable mesh onlay. Although these patients had a high rate (50 percent) of minor or major superficial wound complications, all wounds closed subsequently without additional operative procedures. Despite the high-risk nature of this group, ventral hernia recurred in only one of 12 patients (8.3 percent) after a median follow-up of 16 months. The single recurrence occurred in one of the two patients with the largest diameter (15 cm) hernias in the series. CONCLUSIONS: The components separation technique combined with abdominal wall plication was assessed as the preferred technique for the repair of large hernias not amenable to primary repair in the massive weight loss patient following open bariatric procedures. Because this technique avoids placement of permanent mesh, it is particularly advantageous in the post-bariatric surgery patient at high risk for wound dehiscence and infection.

Modified vertical abdominoplasty in the massive weight loss patient.

BACKGROUND: Patients with massive weight loss following bariatric surgery are now presenting in large numbers for body contouring. To achieve optimum cosmetic results in these patients, a comprehensive circumferential approach is usually required that includes the lateral thighs and buttocks. For a number of reasons, many patients are not candidates for these comprehensive procedures. Some patients view the circumferential procedures as too extensive or aggressive. Others have large hernias or other medical conditions that necessitate a more limited approach. Still others do not have sufficient resources to treat multiple areas. METHODS: A 2-year review of patients presenting with a chief complaint of anterior lower abdominal tissue excess as a consequence of massive weight loss following bariatric procedures was conducted. In 64 cases, patients opted for anterior-only treatment of the lower trunk. RESULTS: Average operative time in patients undergoing modified abdominoplasty alone was 2.5 hours. The mean mass of the excised panniculectomy specimens was 3.8 kg (range, 1.1 to 10.0 kg). The most common complication was wound dehiscence at the T-junction (27 percent), which was treated successfully with local wound care in all cases and did not require reoperation to achieve wound closure. There were no known thromboembolic events. CONCLUSIONS: Not all massive weight loss patients are suitable candidates for comprehensive circumferential body contouring procedures, and many patients desire a limited anterior approach to the frontal abdomen. The modified vertical abdominoplasty should be considered as an option in these patients.

Microvascular reconstruction of the pediatric mandible.

BACKGROUND: Free tissue transfer for adult mandibular reconstruction is a well-established technique; however, there are few reports of pediatric microvascular lower jaw reconstruction. METHODS: This retrospective study was undertaken to review the range of indications, choices, safety, and efficacy of pediatric free tissue transfer to the lower jaw. All patients underwent a parascapular, scapular, or fibula free tissue transfer. Flap choice was based on preoperative clinical examination, radiographic findings, need for linear or multiplanar mandibular reconstruction, need for dental restoration, severity of soft-tissue deficit, and peroneal artery anatomy. RESULTS: Over a 10-year period (1989 to 1999), we performed eight free tissue transfers to reconstruct the mandibles of seven children, aged 6 to 17 years. Indications included radiation-induced hypoplasia (n = 1), postsurgical resection of fibrous dysplasia (n = 1), hemifacial microsomia (n = 3), Robin sequence with severe micrognathia (n = 1), and osteomyelitis (n = 1). The authors transferred four parascapular osseocutaneous, two scapular osseocutaneous, one fibular osseocutaneous, and one fibular osseous flap to reconstruct five ramus, four condyle, and two subtotal mandibular defects. All bony defects were successfully bridged and all osseous flaps successfully integrated. Postoperatively, mandibular symmetry and Angle class I occlusion were restored in all patients throughout the 10.5-year follow-up period (range, 9 to 14 years). Two patients received osseointegrated dental implants. Our only complication was the partial loss of a skin paddle. CONCLUSION: Microvascular reconstruction of the pediatric mandible, in selected patients, is a safe, reliable procedure that provides the bone stock and soft tissue necessary to restore normal maxillomandibular growth and dental rehabilitation.

Evaluation and management of the fat leg syndrome.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Discuss the initial evaluation of a patient presenting with lower extremity enlargement. 2. Distinguish underlying medical conditions causing lower extremity enlargement, including lymphedema and lipedema. 3. Discuss appropriate management and treatment for patients presenting with these conditions. BACKGROUND: Given the epidemic of obesity in the United States, many patients will consult the plastic surgeon with complaints of lower extremity enlargement secondary to "fat legs." In addition to cosmetic disfigurement, some patients may suffer from underlying medical conditions that are responsible for their symptoms. Knowledge of these other causes, including lymphedema and a disorder of abnormal fat deposition known as lipedema, ensures appropriate management and/or surgical treatment for affected patients. METHODS: Initial evaluation for lower extremity enlargement should include a discussion of pertinent medical history and a focused physical examination for findings that might indicate a pathologic underlying cause. When indicated, patients should undergo additional testing, including radiologic studies, to confirm their diagnoses. RESULTS: For those patients found to have lymphatic dysfunction, conservative management, such as massage therapy, use of compression garments, and limb elevation, should be initially recommended. Excisional or suction-assisted lipectomy may be considered in patients who fail conservative therapy. More extensive consultation with the plastic surgeon is recommended for patients seeking aesthetic improvement in contour and shape of large legs without a specified underlying abnormality. CONCLUSIONS: Patients with lower extremity enlargement may present to the plastic surgeon unsure of the specific cause of their deformity. A broad differential diagnosis exists for their presentation, which can be narrowed by using the common features and unique manifestations of the conditions.

Autologous gluteal augmentation after massive weight loss: aesthetic analysis and role of the superior gluteal artery perforator flap.

BACKGROUND: Anatomical features that make the buttocks attractive include adequate volume, projection, and a defined infragluteal fold. The gluteal region in patients with massive weight loss after gastric bypass is characterized by excessive skin and exaggerated fat loss. Lower body lift procedures remove excess skin and lift sagging buttock tissue, but they typically result in further gluteal flattening. Procedures designed to augment the inferomedial aspect of the gluteal region restore projection and help define the infragluteal crease. The authors describe their technique of lower body lift with gluteal autologous augmentation using the superior gluteal artery perforator flap. METHODS: Eighteen consecutive patients with massive weight loss after gastric bypass had lower body lifts with autoaugmentation performed by one surgeon. Superior gluteal artery perforator flaps were designed within the lower body lift markings, raised lateral to medial, and transferred to the inferomedial quadrant of the buttocks. RESULTS: Patients with a median age of 41 years (range, 24 to 56 years) had lower body lifts 2.8 years (range, 1.2 to 4.9 years) after gastric bypass after losing an average of 141 pounds (range, 92 to 272 pounds). Median body mass index decreased from 49 to 29 at the time of contouring. The autoaugmentation procedure added approximately 60 minutes to the overall buttock lift procedure time; there were no intraoperative complications. Postoperatively, patients were surveyed anonymously and reported noting substantial improvement in the volume and contour of the buttocks. CONCLUSIONS: Superior gluteal artery perforator flaps can be transferred reliably during lower body lifts to add volume and projection to the buttocks. Key anatomical landmarks for vascular anatomy and aesthetic design are emphasized.

Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap.

The reconstruction of breast and upper-body deformities in massive weight loss (MWL) patients presents specific challenges to the plastic surgeon. In addition to significant breast ptosis and loss of breast volume, bariatric patients also have excessive lateral axillary and posterior truncal tissue that may require dermolipectomy for correction. A wise-pattern mastopexy was designed with a pedicled fasciocutaneous flap based on the intercostal artery perforators (ICAP) to correct breast ptosis, to restore breast volume, and to eliminate redundant upper truncal tissue. Five MWL patients underwent mastopexy with ICAP flap augmentation. All patients had stable and esthetically pleasing results 1, 3, and 6 months postoperatively. There were no complications of infection, wound dehiscence, seroma, or hematoma. Furthermore, there was no evidence of flap loss or tissue necrosis. Mastopexy with autologous augmentation using the ICAP flap was found to be a reliable method of breast reconstruction in the MWL patient.

Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy.

For the purpose of treatment, obstetric brachial plexus palsy can be subdivided into two distinct phases: initial obstetric brachial plexus palsy, and late obstetric brachial plexus palsy. In the latter, nerve surgery is no longer practical, and treatment often requires palliative surgery to improve function of the shoulder, elbow, forearm, and hand. Late obstetric brachial plexus palsy in the forearm and hand includes weakness or absence of wrist or metacarpophalangeal or interphalangeal joint extension; weakness or absence of finger flexion; forearm supination, or less commonly pronation contracture; ulnar deviation of the wrist; dislocation of the radial or ulnar head; thumb instability; or sensory disturbance of the hand. Palliative reconstruction for these forearm and hand manifestations is more difficult than for the shoulder or elbow because of the lack of powerful regional muscles for transfer. This report reviews the authors' experience performing more than 100 surgical procedures in 54 patients over a 9-year period (between 1988 and 1997) with a minimum of 2 years' follow-up. Surgical treatment is highly individualized, but the optimal age for forearm and hand reconstruction is usually later than for shoulder and elbow reconstruction because of the requirement for a preoperative exercise program. Multiple procedures for forearm and hand function were often performed on any given patient. Frequently, these were done simultaneously with reconstructive procedures for improving shoulder and/or elbow function. Traditional tendon transfer techniques do not provide satisfactory reconstruction for those deformities. Many of the authors' patients required more complex techniques such as nerve transfer and functioning free-muscle transplantation to augment traditional techniques of tendon and/or bone management. Sensory disturbance of the forearm and hand in late obstetric brachial plexus palsy seems a minor problem and further sensory reconstruction is unnecessary.