Massive liposuction in the moderately obese patients: a preliminary study.

The purpose of this study was to evaluate the efficacy and safety of large-volume liposuction on moderately obese women (>125% of ideal body weight) after diet and exercise routines had been established. Twelve consecutive women with an average ideal body weight greater than 130.6% underwent liposuction after demonstrating certain lifestyle changes. An average aspirate of 5393 ml (range, 2250 to 9390 ml) was removed with a combination of superficial syringe liposculpture and deep machine vacuum. Ancillary procedures were performed on five patients. none of the patients had transfusions. The patients returned to work in 10 days (range, 3 to 16 days) and felt "normal" in 19 days. Three months after surgery, the average weight loss was 6.8 kg. Six months after surgery, the average weight loss was 5.6 kg. Under certain circumstances, large volume aspiration liposuction appears to be a safe and effective weight reduction technique.

Postoperative abdominal wall defects with enterocutaneous fistulae.

BACKGROUND: Abdominal wall dehiscence with an associated enterocutaneous fistula is a surgical complication with high morbidity and mortality. Management of the abdominal wall defect is complicated by the continued emergence of liquid bowel contents. PATIENTS AND METHODS: Large abdominal wall wounds of 10 patients with postoperative abdominal wall dehiscence and active enterocutaneous fistulae were managed with early skin grafting directly onto the granulated abdominal viscera. RESULTS: Skin graft take averaged 93 +/- 12%, and there were no perioperative complications related to the skin grafting procedure. Overall mortality was 1 out of 10 patients. Enterocutaneous fistula output did not prove overly injurious to the skin grafts. Wound care was simplified in all but 1 patient with fitting of an ostomy appliance. CONCLUSION: Temporary abdominal wall wound closure with skin grafts improved patient comfort and simplified wound care in a staged reconstructive approach to this surgical complication.

Pharmacokinetics of 2-ethyl-1,3-hexanediol. III. In vitro skin penetration comparisons using the excised skin of humans, rats, and rabbits.

Excised skin from Fischer 344 rats, New Zealand White rabbits, and human females (obtained from mammoplasty patients) were compared for their in vitro skin penetration potential with 2-[14C]-ethyl-1,3-hexanediol (EHD). EHD was applied as both an undiluted dose and a 3% v/v aqueous dose using a flowthrough skin penetration chamber design and was analyzed over 0-6 hr. The undiluted dose was equivalent to a 150 mg/kg dose used in vivo with rats (Frantz et al., Drug Metab. Dispos. 20(1), 6-18, 1992), but normalized on a per cm2 surface area basis, and applied under occluded conditions (covered as for in vivo studies). Undiluted applications of EHD did not substantially penetrate skin, with effluent recoveries of approximately 0.9% of the applied dose for human skin, 2-4% for rat skin, and 3-6% for rabbit skin. By comparison, nonoccluded human skin showed lower effluent radioactivity (0.6%), which was attributed to EHD evaporation from skin. With undiluted EHD, approximately 97% of the recovered 14C was an unabsorbed dose for human skin, with 94% for rat skin and 85% for rabbit skin (expressed as a percentage of the recovered dose). Based on HPLC analysis of effluent samples, 99-100% of the undiluted [14C]EHD penetrated rat, rabbit, and human skin in the unmetabolized form. In contrast, approximately 5% of the applied aqueous dose was recovered in the effluents for human skin, while 6-9% appeared in effluents for rat skin; rabbit skin was not evaluated for aqueous doses. The fraction of unabsorbed aqueous EHD dose totaled 53% of the applied dose for human skin and 63% for rat skin. Evaporative loss of undiluted [14C]EHD was also measured (captured on activated charcoal) in separate experiments and compared with a known standard chemical, N,N[14C]diethyl-m-toluamide (DEET). Evaporation of EHD was clearly a competing factor with penetration, particularly for human skin preparations, and evaporative losses were similar to those seen in previous studies. Penetration of skin was also greater for both EHD and DEET when evaporation was not permitted (stopped chamber). Permeability constant (kp) values were calculated using the pseudo steady-state slopes from plots for cumulative mg/cm2 penetration vs time. For undiluted EHD, human skin had the slowest penetration rate, while rabbit skin kp values were the largest. The kp values for water solutions of EHD on rat and human skin demonstrated a slightly higher penetration, with values of the same order of magnitude as that observed for a concurrently run [14C]ethanol control. The minimal skin penetration observed in vitro in this study, taken together with in vivo percutaneous pharmacokinetic studies (Frantz et al., 1992) and the known percutaneous toxicology of EHD, suggests that penetration through human skin and systemic adverse effects should be minimal.

Use of double gloves to protect the surgeon from blood contact during aesthetic procedures.

The potential for blood contact with nonintact skin puts operating room personnel at an increased risk of exposure to hepatitis or HIV virus. Frank needle-stick injury to the surgeon has been shown to occur once every 20-40 operations. It has been shown that blood contact exposure during aesthetic surgery occurs in 32% of the operations in which a single pair of surgical gloves is used (surgeon 39.7%, assistant 23%). The reduction of blood contact exposure during aesthetic surgical procedures by using two pairs of gloves was tested and demonstrated. Contact rates decreased by 70%. Outer-glove perforations occurred in 25.6% of the cases, while inner-glove perforations occurred in only 10% of the cases (surgeon 8.7%, assistant 3.5%). All of the inner-glove perforations occurred during procedures that lasted longer than two hours, and in no case was there an inner-glove defect without a corresponding outer-glove perforation. The nondominant index finger (33%) was the most common location. Double gloving during aesthetic procedures reduced the operating room personnel's risk of blood contact exposure by 70% when compared with single-glove use.

Potential dangers of oxygen supplementation during facial surgery.

The use of local anesthesia and intravenous sedation has made same-day outpatient surgery a viable option for many aesthetic and reconstructive procedures. These procedures often include the use of supplemental oxygen. Oxygen-enriched environments increase the combustibility of most materials, and "oxygen pooling" has been suspected to play an integral role in intraoperative fires. A personal experience with an intraoperative explosion and fire during a cosmetic blepharoplasty compelled us to explore the potential danger inherent in the use of supplemental oxygen as well as potential strategies to minimize that danger. This study systematically examines the microenvironment created by the use of oxygen both in the operative field and beneath the surgical drapes under conditions simulating routine facial surgery and various recommended modifications of its delivery. With the use of oxygen supplementation, oxygen concentration beneath the drapes was found to be consistently elevated when compared with ambient air (20.9 percent) and reached levels as high as 53.5 percent. Oxygen concentration in the operative environment was mildly but not significantly elevated. Although criteria for the use of oxygen supplementation are not clear, when administration is deemed necessary, the use of a posterior pharyngeal catheter for its delivery had no advantage over nasal prongs. However, appropriate alternatives include the use of "open face" draping techniques, the use of compressed air beneath the drapes as a substitute for oxygen supplementation in unsedated patients, and cessation of oxygen supplementation for 60 seconds prior to the use of a possible ignition source with oxygen flow rates of less than 3 liters per minute.

Two-staged breast reconstruction in patients with symptomatic macromastia requiring mastectomy.

Patients with symptomatic macromastia undergoing mastectomy for the treatment of malignant breast disease are candidates for a two-staged operation resulting in breast reconstruction and contralateral breast reduction. Five patients with symptomatic macromastia underwent a skin-sparing mastectomy for breast disease using a modified Wise incision. The first stage of the breast reconstruction was performed with a de-epithelialized transverse rectus abdominis musculocutaneous (TRAM) flap. Second-stage breast reconstruction was conducted 4 to 6 months later when revision of the TRAM reconstructed breast and concurrent contralateral breast reduction were performed with the intent of tailoring the reduced breast to approximate the revised TRAM breast mound. Excess areola from the reduced breast was harvested and used as a full-thickness graft to reconstruct the TRAM areola complex. Patients followed for 5 to 30 months postoperatively confirm resolution of macromastia symptoms, correction of the mastectomy defect, and symmetrical breast mound creation in a timely two-staged procedure. The two-staged breast reconstruction described represents an expedient plan for patients with symptomatic macromastia requiring mastectomy for breast disease. Skin-sparing mastectomy, modified Wise pattern incisions, utilization of usually discarded areola tissue, and creation of symmetrical breast mounds during the second stage of the reconstruction highlight the salient features of this patient management paradigm.

Partial mastectomy and breast reduction as a valuable treatment option for patients with macromastia and carcinoma of the breast.

The essential goals of every reconstructive procedure of the breast are to create a breast mound and establish symmetry. Breast conservation operation is now a widely accepted treatment for carcinoma of the breast. Four patients who presented with macromastia or mammary hypertrophy and a simultaneous carcinoma of the breast were treated by combined partial mastectomy and bilateral breast reduction. Incisions on the breast were made using standard Wise pattern (keyhole) markings. In each instance, the tumor was removed with a generous margin of normal surrounding mammary tissue. Two procedures used the inferior pedicle technique and two were done by resection and transplantation of the nipple. The average mammary tissue resection was 825 grams. All incisions healed primarily and necessary adjuvant chemoradiation was not delayed. Each patient is alive and well without evidence of disease with a follow-up period ranging from seven to 43 months. Postoperatively, the appearance of the breast is esthetically improved and all symptoms related to macromastia have resolved. Advantages of combining these two techniques include improved symmetry, easier postoperative self-examination of the breast and decreased radiation effect noted with larger breasts. Postoperative mammograms have been useful for patient follow-up evaluation. Combined segmental mastectomy and breast reduction represents a valuable treatment option for the patient who presents with macromastia and carcinoma of the breast. The carcinoma ablative procedure is not compromised and the improved symmetry of the breast has resulted in an excellent cosmetic outcome in these patients.

Carpal tunnel release complicated by necrotizing fasciitis.

We report a 31-year-old diabetic woman who underwent carpal tunnel release for median nerve compression followed by a laparoscopic tubal ligation. The procedure was complicated by a severe postoperative necrotizing fasciitis infection of the carpal tunnel release incision. This has not been previously reported. The wound was poorly responsive to antibiotic therapy and serial wound debridements. Control of the woman's infection required total excision of the palmar skin and fascia. Complicating factors in this case included the woman's long history of insulin-dependent diabetes and a concomitant clean-contaminated procedure.

Risk of blood contact through surgical gloves in aesthetic procedures.

Evidence of glove perforation, and therefore blood contact, was evaluated in 100 consecutive pairs of gloves used in aesthetic surgical procedures. The surgeon (38.3%) was more likely than the assistant (22.5%) to have exposure. In only 15% of these cases were they aware of the exposure. The left index finger (44%) was the most common location of perforation and 29 of the 32 holes (90.6%) were in cases that lasted more than 2 hours.

The surgical anatomy of the scalp.

Cadaveric dissections and surgical observations have led to the description and clarification of the boundaries. blood supply, and nomenclature of the layers of the scalp. Special attention was directed to the layer of "loose connective tissue" that lies beneath the entire galea and above the cranial periosteum centrally, and the temporalis fascia laterally. It has been named the subgaleal fascia (SGF). The subgaleal fascia is a trilaminar structure with unusual potential in reconstructive surgery. Histologic study reveals the subgaleal fascia to be composed of a central dense collagenous layer surrounded by vascularized areolar tissue. It is readily dissected from surrounding galeal and periosteal layers. The subgaleal fascia was probably included in previously described "pericranial flaps," which were often based beyond the periosteum. The blood supply of the subgaleal fascia originates from the proximal portion of the peripheral vessels of the scalp and continues within the areolar lamina. The subgaleal fascia is an exceptionally thin, malleable, and well-vascularized flap useful for facial reconstruction.

Clinical applications of the subgaleal fascia.

The anatomic boundaries and vascular supply of the subgaleal fascia have been described previously. The thin and malleable subgaleal fascia was selected for difficult reconstructive problems in seven patients. This flap has been based on either the supraorbital or the superficial temporal vascular leash. The subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and a skin-graftable calvarium. The flap conforms to a cartilage framework for ear reconstruction. It takes a skin graft well. The subgaleal fascia can patch dural defects and fill sinus dead space. It has been used to augment facial contour. Free vascularized transfer of the subgaleal fascia has included the temporoparietal fascia, which was partially split from the subgaleal fascia for bilobed flap resurfacing of the hand. The subgaleal fascial flap should be considered when ultrathin, vascularized coverage is needed.

Hydrofluoric acid-induced hypocalcemia.

Among patients exposed to hydrofluoric acid the potentially lethal effect of calcium depletion induced by binding with fluoride ion has not been well reported. Three patients exposed to hydrofluoric acid had acute fluoride poisoning with serum calcium levels equal to or below 4.1 mgm/dl. Treatment included administration of large amounts of calcium, both intravenously and by subsechar injection, to replenish the biologically active calcium and to bind fluoride. This report describes successful treatment of two survivors, apparently the first two, of severe hypocalcemia caused by hydrofluoric acid.

Bronchoalveolar cell carcinoma of the lung.

A multivariable analysis was performed of all patients registered and confirmed to have bronchoalveolar cell carcinoma of the lung in the Tumor Registry of Thomas Jefferson University Hospital between 1969 and 1983. These 122 patients were reviewed for age, sex, smoking history, occupational exposure, symptoms, radiographic findings, methods of diagnosis, clinical and pathologic staging, methods of treatment, survival, and complications of treatment. No correlation could be found in this series between a patient's age, sex, smoking history, or occupational exposure and the incidence or outcome of the disease. Seventy-one of the 122 patients in this series were asymptomatic, and the carcinoma was discovered in them by routine chest roentgenogram. Of these asymptomatic patients, 50 were seen with pathologic stage I disease. Of the 51 symptomatic patients, 32 (65%) were seen with stage IIIm0 or IIIm1 disease. Despite medical evaluations, 77% of the T1 and T2 lesions required thoracotomy for diagnosis. The overall five-year survival rate was 42.3%, ranging from 75% for those with stage I disease to 8.7% for those with stage IIIm1 disease.