The Internal Negative-Pressure Wound Control System: A Paradigm Shift for Promoting Deep Space Healing in Complex Surgically Created Wounds.

This article introduces a new technology to minimize seroma and promote more predictable healing in surgically created deep space wounds. Its novel design internalizes the delivery of a continuously generated high negative pressure (-125 mmHg) throughout the surgically created space by means of a multibranched Manifold. In a small prospective cohort case study of 24 patients undergoing full abdominoplasty, all patients underwent placement of this device, which was removed 7 days postoperatively. Results at 30 days revealed no evidence of wound-healing problems, no clinical seroma, and no device malfunction. The internalization of a constant negative-pressure wound therapy provided by this system has the potential to significantly reduce clinical seroma, and to produce more consistent apposition of interfaces in deep tissue spaces in complex wounds seen in plastic surgery and other surgical disciplines.

Evidenced-Based Approach to Abdominoplasty Update.

The following publication was compiled as an evidence-based update for plastic surgeons performing abdominoplasty from a review of the published literature on that subject between January 2014 and February 2017. It is an overview of various aspects of abdominoplasty including preoperative patient assessment, variations and advances in both surgical and anesthetic technique, patient safety, and outcomes. It is intended to serve as an adjunct to previously published evidence-based reviews of abdominoplasty.

Components Separation for Abdominal Wall Reconstruction in the Recalcitrant, High-Comorbidity Patient: A Review of 311 Single-Surgeon Cases.

PURPOSE: Components separation of the abdominal musculature remains a mainstay for closure of complicated midline and paramedian abdominal wall defects. The authors critically analyzed their experience with this technique to identify prognosticators affecting long-term clinical outcomes. METHODS: A retrospective review was performed of patients undergoing components separation by a single senior surgeon (J.M.R.) between 2000 and 2010. Numerous perioperative patient characteristics were collected and analyzed to determine their effects on long-term clinical outcomes. Multivariable logistic regression was used to predict hernia recurrence and other adverse clinical outcomes. RESULTS: A total of 311 patients were identified (male, 51.1%). Mean age was 53.1 ± 14.0 years, preoperative body mass index was 33.1 ± 8.2 kg/m, and defect width was 11.4 ± 7.5 cm. Patients who had prior hernia repair were 97.4%, with 38.3% having prior mesh placement. Average follow-up was 2.9 ± 2.4 years. Overall hernia recurrence rate was 18.3%. Postoperative complications included seroma (9.3%), superficial wound infection (9.0%), skin dehiscence (4.82%), hematoma (3.2%), deep vein thrombos or pulmonary emolbus (3.2%), and skin flap ischemia (1.0%). Respiratory comorbidity (odds ratio, [OR], 2.02; P < 0.029), prior failed mesh repair (OR, 1.86; P < 0.045), and occurrence of any postoperative complication (OR, 2.02; P < 0.034) significantly increased the risk of eventual hernia recurrence. Preoperative body mass index was not associated with hernia recurrence (P < 0.351) or increased incidence of any aforementioned postoperative complications. CONCLUSIONS: This study provides a comprehensive review of one of the largest single-surgeon experiences using components separation to date. Patients with respiratory comorbidities, prior failed mesh repair, and the occurrence of any postoperative complication are at significantly increased risk for hernia recurrence.

Acellular dermal matrix inlays to correct significant implant malposition in patients with compromised local tissues.

Breast implant malposition is an increasingly recognized complication of breast augmentation and implant-based breast reconstruction. Etiologic factors include technical imprecision during surgery with overdissection or inadequate dissection of the pocket, inappropriately large implant selection, and the compromise of the local breast tissues, which produces an inability of a patient's natural tissues to support an implant in the placed position. In this article, the author describes a series of 19 patients with significant breast implant malposition following staged implant breast reconstruction in the setting of locally compromised tissues. Given the results, the author believes that an effective technique in the correction of severe implant malposition is reconfiguration and reconstruction of the periprosthetic capsular space, with a combination of focal "mirror image" capsule excision and permanent suture repair to restore breast folds, along with an acellular dermal matrix inlay technique designed to confer structural support to this repair. This strategy merits consideration in patients who have significant implant malposition in the face of severely compromised local breast tissues.

Separation of anatomic components method of abdominal wall reconstruction--clinical outcome analysis and an update of surgical modifications using the technique.

This article describes some of the benefits and complications of the components separation technique. It additionally highlights some of the modifications that have been made to the technique over the years.

Biomechanical properties of the superficial fascial system.

BACKGROUND: Surgical repair of the superficial fascial system (SFS) has been claimed to both increase wound strength and enhance surgical outcome through anchoring of deeper tissues. OBJECTIVE: The authors assessed the biomechanical properties of the SFS to determine whether repair of the SFS layer improved early and long-term postoperative wound strength. METHODS: Four complementary studies were conducted to study the dermis and SFS junctional architecture and connective tissue content: gross dissection using a dehydrating agent (Pen-Fix; Richard-Allan Scientific, Kalamazoo, MI), a histologic study with hemotoxylin and eosin staining, soft tissue radiography, and immunofluorescence staining. Freshly excised human abdominal and lower back/buttock tissues underwent a midline incision, followed by repair using dermal sutures only (DRM), dermal sutures plus SFS sutures (DRM/SFS) or repair of the SFS only (SFS). Fresh swine abdominal tissues were similarly excised and repaired. Biomechanical tests were undertaken to compare the ex vivo human and swine tissues. Three types of closure-dermal sutures only (DRM), dermal sutures plus permanent 0-braided nylon suture in the SFS (DRM/SFS/N), and dermal sutures plus absorbable 0-vicryl suture in the SFS (DRM/SFS/V) were also tested in an in vivo swine model. RESULTS: Immunofluorescence studies showed collagen and elastin content and ratios to be comparable in the dermis and SFS. In ex vivo studies of human abdominal and back tissues, cyclic creep did not vary significantly among the different types of repair. DRM/SFS repair had a significantly higher failure load than dermal repair alone in both human abdominal and back tissues. In the in vivo swine study, normal tissue had a significantly higher failure load than all repair groups. The wounds where SFS had been repaired in addition to dermis exhibited an increased tensile strength and, among these, the wounds closed with SFS repair with a nonabsorbable suture exhibited greater tensile strength compared to absorbable suture repair. However, no statistically significant difference was noted, due to the small sample size. CONCLUSIONS: We have determined, using an ex vivo model, that repair of the SFS layer in addition to dermis repair significantly increases the initial biomechanical strength of wound repair. This has the potential to decrease early wound dehiscence. In our in vivo model, the use of a nonabsorbable suture to approximate the SFS demonstrated a trend toward increased long-term wound strength. We believe our studies provide scientific data documenting that SFS is a key contributory strength layer in the early postoperative period, and is likely to be a strength layer even in the later stages of wound healing.

Assessing Risk and Avoiding Complications in Breast Reduction.

Assessing risk and avoiding complications in breast reduction requires a meticulous history, systematic physical examination, management of expectations, and careful consideration and execution of operative technique. Attention should be paid to comorbidities. Shape, symmetry, contours, scar location, skin quality, nipple-areolar complex (NAC) shape, NAC position relative to inframammary fold, and NAC position relative to the volume of the breast should be evaluated. Because complications cannot always be anticipated, informed consent is a vital part of managing expectations. Intraoperative considerations include blood pressure control, limiting tension, delayed healing and tissue loss, and using applied anatomy to avoid malposition and asymmetry.

Breast Reduction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify the anatomy of both the vascular supply and the innervation to the breast to design the appropriate pedicle in breast reduction. 2. Understand various approaches to breast reduction to be able to maximize both functional and aesthetic results. 3. Understand each step in the operative procedure to be able to provide consistent predictable results in breast reduction. SUMMARY: The objective with breast reduction surgery is to reposition the nipple, remove excess parenchyma, and tailor the skin to fit the new shape. This is a CME article meant to provide an overview of principles while trying not to provide a single practitioner viewpoint. The article includes a brief history, a review of the anatomy, and patient selection. The preoperative markings and operative technique for both inverted-T and vertical approaches are detailed. Postoperative care and potential complications are included.

A potential role for mast cells in the of bFGF from normal myocytes during angiogenesis in vivo.

Basic fibroblast growth factor (bFGF) is a potent angiogenic factor produced by cells of mesodermal and neuroectodermal origin. Despite numerous advances, the precise mechanism of bFGF release from cells still remains unknown. Upon release from cells, the protein is stored and protected in the extracellular matrix by binding to heparan sulfate proteoglycans. A number of reports suggest that degrading enzymes secreted by mast cells may play a role in the release of bFGF from connective tissue stores. Additionally, mast cells are believed to play a role in the formation of new blood vessels. In this report, we studied the events involved in neovascularization using a well-characterized model of angiogenesis in rabbits where neovascularization is induced by transfer of a well-perfused rectus abdominis muscle flap to an ischemic limb. Using this model, we demonstrate that bFGF expression is induced in normal myofibers and bFGF is released in the wound fluid at the ischemic/nonischemic interface. The highest concentrations of bFGF were detected on days 14 and 21 postoperation. We also show that the number of mast cells and their degranulation correlate with the release of bFGF from adjacent muscle tissue and the appearance of the growth factor in the wound fluid. There appears to exist a temporal correlation between number of mast cells, their degranulation, and the release of bFGF during angiogenesis in vivo.

"Marriage" abdominoplasty: body contouring with limited scars combining mini-abdominoplasty and liposuction.

The "marriage" or union of aggressive truncal liposuction with modified abdominoplasty techniques has been applied by the authors to treat patients with abdominal deformities marked by lower abdominal skin excess, abdominal muscle laxity, and excess adipose tissue on the abdominal wall and in adjacent contours. In the appropriately selected patient this form of "mini-abdominoplasty" has resulted in excellent contour improvement and a more rapid return to life activities than is seen with "full" abdominoplasty. In the authors' experience, it is applicable to the majority of patients (over 50%) presenting for abdominal contour improvement.

Assessment of long-term nipple projection: a comparison of three techniques.

Nipple-areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast facsimile that more closely resembles the original breast. Although numerous nipple reconstruction techniques are available, all have been plagued by eventual loss of long-term projection. In this report, the authors present a comparative assessment of nipple and areola projection after reconstruction using either a bell flap, a modified star flap, or a skate flap and full-thickness skin graft for areola reconstruction. The specific technique for nipple-areola reconstruction following breast reconstruction was selected on the basis of the projection of the contralateral nipple and whether or not the opposite areola showed projection. Patients with 5 mm or less of opposite nipple projection were treated with either the bell flap or the modified star flap. In patients where the areola complex exhibited significant projection, a bell flap was chosen over the modified star flap. In those patients with greater than 5-mm nipple projection, reconstruction with a skate flap and full-thickness skin graft was performed. Maintenance of nipple projection in each of these groups was then carefully assessed over a 1-year period of follow-up using caliper measurements of nipple and areola projection obtained at 3-month intervals. The best long-term nipple projection was obtained and maintained by the skate and star techniques. The major decrease in projection of the reconstructed nipple occurred during the first 3 months. After 6 months, the projection was stable. The loss of both nipple and areola projection when using the bell flap was so remarkable that the authors would discourage the use of this procedure in virtually all patients.

"Marriage" abdominoplasty: a short scar technique.

Short scar abdominoplasty-that is, a marriage of aggressive superwet lipoplasty, rectus abdominis muscle plication, and excision of lower abdominal skin and excess adipose tissue-can be used as an alternative to conventional abdominoplasty in properly selected patients. According to the authors, this technique offers the advantages of less invasive surgery, decreased pain, and faster return to work. (Aesthetic Surg J 2002;22:294-301.).

The extended abdominoplasty.

This article illustrates the author's approach of directly excising adipose tissue excess in the lateral and posterior hip region by extending the lateral extent of the horizontal incision in a full abdominoplasty toward the posterior axillary line to produce a superior contour in this region. It is most applicable in patients with a significant adipose tissue excess in the lateral hip area that produces an outward convexity seen in the frontal, posterior, or oblique view. Such an excess represents a soft tissue "dog ear" composed of skin, and adipose tissue both deep and superficial to the superficial fascial system.

Short scar abdominoplasty update.

Techniques for abdominal contouring have proliferated and evolved over the past 2 decades. Now more than ever, aesthetic operations are tailored to fit the anatomic features and aesthetic goals of each individual patient, stressing the absolute importance of patient selection. This short scar procedure relies on a combination of liposuction and modified skin resection and muscle tightening in the lower abdomen. It has been the author's experience that this results in a more rapid recovery in most patients. It is almost always performed in conjunction with liposuction of the posterior trunk to achieve a harmonious recontouring of the aesthetic unit of the trunk. The techniques employed are familiar to all plastic surgeons performing body contouring procedures. Patient selection is the absolute key to achieving successful outcomes. Short scar abdominoplasty results in significant contour improvement in the properly selected patient. The procedure relies on a combination of liposuction and modified excisional surgery to produce the desired outcome.