Safety issues in ultrasound-assisted large-volume lipoplasty.

Ultrasound-assisted large volume lipoplasty is controversial because of the potential for increased morbidity and mortality. The plastic surgeon must pay attention to details in patient selection, anesthesia considerations, intraoperative fluid balance, and the technical aspects of ultrasound-assisted lipoplasty to be consistently successful. The avoidance or early detection of complications such as intracavitary penetrations, fluid overload, hypovolemia, deep venous thrombosis, and lidocaine toxicity requires frequent examination by the surgeon. When properly executed, large volume lipoplasty can be gratifying to both patient and surgeon.

CAST liposuction: an alternative to brachioplasty.

The aging female with excess arm fat and poor skin tone frequently refuses a brachioplasty scar due to permanent detectability. Traditional deep liposuction localized to the posterolateral aspect of the arm frequently leaves sagging, wrinkled skin. Circumferential para-Axillary Superficial Tumescent (CAST) liposuction was developed to maximize skin retraction and create regional harmony by preparatory compartment magnification with dilute lidocaine and epinephrine followed by circumferential treatment of the arm and adjacent areas utilizing superficial and/or subdermal liposuction. Early CAST liposuction results in patients with moderate fat and excess skin revealed excellent skin retraction. CAST liposuction was then offered as the first of two stages to patients with excess fat and poor skin tone to avoid or shorten the brachioplasty scar. Twenty-six patients underwent CAST liposuction with 9-22 months follow up. Only two patients (7.7%) eventually required brachioplasty. Although postoperative seromas were frequent (38.5%) and preexisting skin wrinkling usually returned, the final result is acceptable to the vast majority of patients (84.6%) who refuse a brachioplasty scar.

CAST liposuction of the arm improves aesthetic results.

Lipocontouring the arm has a lower degree of patient satisfaction compared to other regions since untoward sequelae such as sagging and wrinkled skin may result. Circumferential para-Axillary Superficial Tumescent (CAST) liposuction was offered as an alternative to traditional arm liposuction or brachioplasty to 59 patients. Fifty-three of 59 patients (89.9%) were satisfied or very satisfied with the procedure; six patients (10.2%) requested secondary procedures; four, further liposuction (6.8%); two, brachioplasty (3.4%). Although temporary untoward sequelae (15.3%) and minor complications (8.5%) were not infrequent and more vigorous postoperative care necessary, the final aesthetic result was rarely compromised and patient satisfaction was high.

Tumescent liposuction complicated by pulmonary edema.

In tumescent liposuction, large volumes of dilute lidocaine and epinephrine are infused subcutaneously to prepare fat for extraction. Reported cardiopulmonary complications of tumescent liposuction have been few, and the anesthetic and hemodynamic advantages are several. We report an instance of pulmonary edema in a healthy 55-year-old male body-builder who received 7900 cc subcutaneous and 2200 cc intravenous fluid. With normal cardiopulmonary and renal function, the patient responded promptly to intravenous diuretics without sequelae. Out of over 900 patients who have had tumescent liposuction with up to 15 liters infused parenterally, this is the first case of pulmonary edema.

Gastroesophageal reflux following male abdominoplasty.

: Complications of female abdominoplasty are well known. Males prone to centripetal obesity may have minimal subcutaneous fat and significant hypogastric skin laxity making them apparent good candidates for abdominoplasty. We describe a case of severe gastroesophageal reflux following male abdominoplasty presumably secondary to increased intraabdominal pressure. This type of regional obesity should be recognized preoperatively as it may place the patient at higher risk. A preoperative diet and exercise program is a consideration.

Abdominal etching: differential liposuction to detail abdominal musculature.

Male athletes seeking improvement in the detail of their abdominal musculature have traditionally utilized vigorous exercise and a tightly controlled diet. Abdominal etching is a technique devised to enhance the appearance of the abdominal musculature by removing fat with liposuction at variable levels. The abdominal musculature is topographically visualized as the linea alba, linea semilunaris, and the transverse tendinous intersections within the rectus abdominous muscle. These landmarks are enhanced with localized superficial liposuction to deepen the natural grooves or furrows in these areas. We have performed abdominal etching on eight male patients with good to excellent results and minimal risks.

Esophageal obstruction caused by mediastinal histoplasmosis: beneficial results of operation.

A patient presented with progressive dysphagia and chest pain. Radiologic investigation showed extrinsic compression of the esophagus by enlarged, calcified, mediastinal lymph nodes. Immunologic studies suggested that this was due to previous histoplasmosis, currently inactive. The nodes were excised at thoracotomy, with complete relief of symptoms. Operative management was most appropriate because of the apparent inactivity of the infection, the severity and progressive nature of the symptoms, and the possible prophylaxis of mediastinal fibrosis, a well-documented complication of histoplasmosis.

Appropriate timing for breast reconstruction.

Once a chest-wall recurrence is diagnosed, it should be treated by modalities effective for both local and systemic disease, since it is a cutaneous marker of distant metastases. If the chest-wall recurrence can be controlled, short-term prognosis is much improved, although all patients in this study eventually died of systemic breast cancer. The results of this retrospective study suggest that appropriate timing of breast reconstruction depends on the pathologic status of the axillary nodes and completion of adjunctive therapy. A patient with stage I breast cancer can undergo a subpectoral or musculocutaneous flap reconstruction of the breast without fear of masking a local chest-wall recurrence.

The implications of local recurrence of breast cancer as the first site of therapeutic failure.

Sixty patients who had ipsilateral chest wall recurrence of breast cancer and no detectable distant metastases were evaluated retrospectively to determine the implications of chest wall recurrence as the first site of therapeutic failure. Mean time intervals between treatment of the primary breast cancer and discovery of local recurrence, between treatment of local recurrence and distant metastases, and between treatment of local recurrence and death in order and, respectively, in years for pathologic Stages I, II, and III patients were 6.2, 4.3 and 2.1; 4.2, 3.5, and 1.2; and 7.2, 6.0, and 2.5. Surgical resection resulted in the best local control. All patients eventually died of metastatic breast cancer, one as late as 23 years after treatment of the local recurrence. No Stage I patients recurred before two years. An arbitrary delay of two years before recommending breast reconstruction to avoid masking local recurrence seems unjustified for pathologic Stage I patients.

Factors affecting mortality in pelvic fractures.

Review of 100 consecutive patients with pelvic fractures admitted to a trauma service during an 11-month period was undertaken in order to define the factors which affected the mortality. Mortality was most significantly affected by severity of injury, presence of a head injury, admitting blood pressure, admitting hemoglobin level, and requirements for blood and blood products. Evaluation of anatomic configuration of fractures demonstrated that posterior fractures required larger amounts of blood and blood products, had a significantly decreased admitting blood pressure, and had a significantly higher mortality, despite there being no significant difference in injury severity between patients having anterior or posterior fractures.