Search

The ideal body is characterized by a muscular physique and defined anterior abdominal wall. Despite diet and exercise, many are unable to achieve this desired result. Liposuction with abdominal etching is used to achieve high-definition abdominal aesthetics. The etching technique is performed with liposuction in a superficial plane, to create indentures consistent with "six-pack abs," or definition of vertical abdominal lines.The authors' abdominal etching preoperative markings, surgical technique, and postoperative care are discussed. The surgeons' experience with abdominal etching in 50 consecutive patients is reviewed, including rate of complications and patient satisfaction.The average patient age was 36.4 years. We had an almost equal number of men (n = 26) and women (n = 24), with an average body mass index of 26.7 kg/m. The average blood loss was 275 ml, the average tumescence was 6 liters, and the average lipoaspirate was 5 liters. There were no major complications such as fat embolus, deep venous thrombosis, or intraabdominal injury. The most common minor postoperative complications were contour irregularities (12 percent), seromas (10 percent), and hyperpigmentation (2 percent). The majority of patients were satisfied (98 percent). The average length of postoperative follow-up was 27 months.Abdominal etching is a safe and effective method of creating a defined anterior abdominal wall for patients who desire the muscular definition of vertical abdominal lines. Almost all of our patients reviewed were satisfied with this procedure, maintained long-term results, and had an acceptable rate of complications.Therapeutic, IV.

Phalloplasty is often the final stage of gender-affirmation surgery for transgender men. Obtaining penile rigidity is important for sexual function, but may also bring complications, including supersonic transporter deformity, in which the glans becomes ventrally displaced and flaccid. Two cases of supersonic transporter deformity are presented here, one with a hydraulic penile implant and one with an autologous bone transplant. Attempt at surgical correction was performed in both. Careful attention must be paid to the unique anatomy of the neophallus and type of penile prosthesis to prevent or correct supersonic transporter deformity in transgender men. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Complications in free-tissue transfer patients cannot be completely prevented; however, the incidence may be significantly reduced by a thorough preoperative evaluation and initiation of prophylactic strategies, meticulous surgical technique, and diligent postoperative monitoring. Emergent exploration must be performed soon after obstruction occurs if it is to be successful, and early exploration and repair is likely in compromised flaps if they are monitored frequently in the initial postoperative period. This article reviews the importance of clinical management in this patient population, the recommended frequency of flap monitoring, and the most commonly used methods of monitoring the transferred tissue whether or not the flap is readily visible. The authors also review the anticoagulants used and a postoperative flap monitoring protocol.

Background: Radical excision of advanced hypopharyngeal and laryngeal tumors usually compromises both swallowing and speech. Among the available reconstruction methods, the free ileocolon flap allows rehabilitation of both functions in one stage. The donor-site morbidity of this flap has not been addressed in head and neck cancer patients. Methods: A retrospective study was conducted in 34 patients between April of 2003 and December of 2007 to investigate donor-site morbidity in patients undergoing reconstruction with free ileocolon flaps. Complications such as diarrhea, upper gastrointestinal tract distress, bowel leak, abscess, or hernia formation were evaluated. Significant association of diarrhea and upper gastrointestinal distress, previous abdominal operations, systemic diseases, primary versus secondary reconstruction, flap length, and postoperative chemotherapy were subsequently evaluated. Differences were considered significant for values of p ≤ 0.05. Results: There were no perioperative or postoperative deaths. Nineteen patients (56 percent) experienced temporary diarrhea. In all but two patients, diarrhea discontinued by 4 months. Chemotherapy was significantly associated with diarrhea (p < 0.01). Colchicine, terbinafine, and heroin withdrawal episodically caused diarrhea but statistical conclusions could not be drawn. Six patients (18 percent) suffered from upper gastrointestinal tract problems (gastroduodenal ulcer, erosive gastritis, and minor bleeding), probably because of insufficient gastric protection. Conclusions: The free ileocolon flap proved to be a reliable method when simultaneous restoration of swallowing and speech was required, with donor-site morbidity comparable to that of the other intestinal flaps.

BACKGROUND Free colon and jejunal flaps have been described as reliable and safe conduits for pharyngoesophageal reconstruction. Compared with free colon flaps, free jejunum flaps have a smaller diameter and intrinsic peristaltic movement, both of which are considered possible causes of dysphagia. In this investigation, the authors evaluated motility differences in free jejunum and colon flaps using radionuclide esophageal scintigraphy. METHODS Patients who received free jejunum flaps (n = 12) or free colon (n = 1) or ileocolon flaps (n = 13) for reconstruction after pharyngoesophagectomy for cancer were included. Radionuclide esophageal scintigraphy was performed using technetium-99m-labeled sulfur colloid. Transit rate was evaluated at 1 second (pharyngeal or initial clearance) and 10 seconds (esophageal or clearance throughout). Clinical progression of swallowing was recorded postoperatively. Statistical analysis was performed using the t test. RESULTS Mean pharyngeal clearance was 61 +/- 20 percent for free colon and ileocolon flaps and 70 +/- 16 percent for free jejunum flaps. Mean esophageal clearance was 50 +/- 27 percent for free colon and ileocolon flaps and 69 +/- 17 percent for free jejunum flaps. Esophageal transit rate was significantly shorter in patients who underwent reconstruction with free jejunum flaps (p = 0.04). At 1 year, 10 of 12 free jejunum patients and eight of 14 patients were tolerating solid foods. CONCLUSIONS Although neither flap showed normal swallowing characteristics, free jejunum flaps displayed greater esophageal clearance and should represent the first choice in hypopharyngeal reconstruction. Free colon and ileocolon flaps should be reserved for very proximal oropharyngeal defects and when simultaneous voice reconstruction is desired.

Background Mastodynia is among the most frequently reported symptoms in women with breast complaints; it is usually classified as cyclic, noncyclic, or nonbreast in origin. A useful response with medical or conservative therapy is obtained in the majority of these patients. There is a subset of patients, however, who have exhausted every medical effort and psychiatric counseling and will desire mastectomy with breast reconstruction in the hope of alleviating their chronic pain. Methods Three patients with noncyclical, bilateral mastodynia referred for breast reconstruction options from December of 2000 to March of 2004 are presented in this article. Daily breast pain charts with a visual analogue scale for pain assessment were analyzed and recorded for all patients throughout the study period. Results Two patients underwent delayed reconstruction and had complete resolution of pain 6 to 8 weeks after bilateral mastectomy, with no recurrence of mastalgia after reconstruction. One patient underwent bilateral mastectomy with immediate reconstruction and achieved complete resolution of her pain 3 months postoperatively. Histopathologic findings of all breast specimens revealed benign breast tissue with proliferative breast disease consistent with mastodynia. Conclusions This modality, which includes mastectomy with or without reconstruction, is a viable alternative after exhaustion of all other nonsurgical options and when quality of life is significantly affected. Although mastectomy for the treatment of mastodynia refractory to medical therapy does not guarantee alleviation of chronic breast pain, it should be considered in these often desperate patients.

Several authors have cited renal disease as a risk factor for free flap failure. The authors performed a retrospective analysis of all patients who underwent free tissue transfer with concomitant renal disease, including acute renal failure, end-stage renal disease, chronic renal insufficiency, and functional kidney transplants, to determine what effect renal disease has on flap survival and overall reconstructive outcome. More than 1053 free flaps were examined. Renal disease was identified in 32 patients who underwent 33 free tissue transfers. Average patient age was 57 years (range, 36 to 80 years). Twelve patients (38 percent) were on chronic dialysis (end-stage renal disease), 18 patients (56 percent) had chronic renal insufficiency, and three patients (9 percent) had the diagnosis of acute renal failure at the time of surgery. Three patients in the chronic renal insufficiency group had a functioning renal transplant. Average follow-up was 16 months. Immediate postoperative complications occurred in 14 patients (42 percent of the 33 flaps). Overall perioperative mortality was 3 percent. Within the first 30 days there were two cases (6 percent) of primary flap failure; an additional four legs were lost as the result of complications related to their bypass grafts. There were no primary flap failures after 30 days; however, within the first year after surgery an additional seven limbs were lost as the result of progressive ischemia or infection, and an additional three patients died. This resulted in a 52 percent incidence of major morbidity or mortality during the first year and a 55 percent reconstructive success rate in survivors at 1 year. No significant difference was seen in postoperative morbidity or mortality when comparing the end-stage renal disease group to the chronic renal insufficiency group; however, patients with renal disease and diabetes tended to have poorer outcomes. Renal disease, especially renal disease associated with diabetes and peripheral vascular disease, can be a strong indicator of possible reconstructive failure. The surgeon and patient should be aware of the medical and surgical complications associated with this procedure at the outset.

The rectus abdominis muscle has been one of the most commonly used donor tissues for free-flap reconstruction of defects in the extremities and in selected head and neck patients. The rectus abdominis has provided adequate soft-tissue mass with predictable anatomy and results for the majority of its applications in free-flap reconstruction. Harvesting of this muscle has typically been done through a paramedian or midline incision, which has left a lengthy notable scar on a patient's abdomen. To avoid the late aesthetic deformity associated with this typical approach for the rectus abdominis, we began harvesting the muscle through a Pfannenstiel incision. Patients were initially selected based on young age and limited soft-tissue requirements. With additional experience, this technique was extended to include all healthy patients regardless of age. Also, soft-tissue limitations no longer became an issue, as we learned the entire rectus abdominis muscle could be harvested from this approach. An extended Pfannenstiel incision was made from the ipsilateral anterior superior iliac spine to the lateral border of the contralateral rectus abdominis. A superiorly based flap was raised to expose the full length of the anterior rectus sheath from pubis to costal margin. In our earlier patients, a periumbilical incision was made for presumed easier access, but we discovered this was an unnecessary maneuver. With the anterior sheath fully exposed, the muscle was harvested and the sheath repaired in a routine manner. The elevated abdominal flap was returned to its anatomic position and closed over a suction drain. Since 1993, 10 patients have undergone a Pfannenstiel approach for harvesting of the rectus abdominis muscle. The mean age was 16. The areas requiring coverage included a traumatic elbow defect, seven traumatic lower extremity defects, one lower extremity sarcoma defect, and one lower extremity septic joint defect. Mean follow-up for these patients was 12 months. There were no flap failures. One patient developed an arterial thrombosis on postoperative day 5 and was treated with successful revision. There were no abdominal wall complications. Cosmesis was judged as good in all patients. We would recommend avoiding this approach in heavy or moderate smokers, diabetic patients, and patients with significant obesity. The Pfannenstiel approach to the rectus abdominis muscle has allowed for complete harvest of the muscle, improved aesthetic results compared with alternative techniques, and avoidance of donor-site morbidityin healthy patients.

This report elucidates the continued and relatively rare problem of congenital symmastia and its surgical repair without concomitant bilateral breast reduction. This case highlights the use of suction-assisted lipectomy techniques to address the excess fat in the presternal web and a periareolar approach for access to the intermammary space. The periareolar incision allows for the use of a concealed approach and the avoidance of a central scar that could result in hypertrophy or keloid formation, especially in this patient who is more prone to hypertrophic scarring. Furthermore, plication of the central web dermis to the sternal periosteum in a more superior position serves to not only correct the symmastia but also redrape the excess skin and restore the blunted inframammary folds.

Background: Esophageal defects are reconstructed using a variety of methods and tissue types. The choice depends on the location of the defect, the condition of the patient, and the flaps that are available for reconstruction. Often, patients with esophageal defects also lack a mechanism for voice production following a total laryngectomy procedure. Methods: A review of the literature was performed for esophagus reconstruction and voice rehabilitation following laryngectomy. Methods of voice restoration using intestinal transfers are presented based on the authors' experience. Results: Several methods of esophagus and voice restoration can achieve excellent functional outcomes. Conclusion: Esophagus reconstruction and voice rehabilitation following esophageal resection and total laryngectomy are possible using a variety of flaps with good functional outcomes.

Surgical treatment of chronic osteomyelitis requires aggressive debridement followed by wound coverage and obliteration of dead space with vascularized tissue. Controversy remains as to the effectiveness of different tissue types in achieving these goals and in the eradication of disease.Chronic osteomyelitis was induced in 26 goat tibias using Staphylococcus aureus as an infecting inoculum. In a single stage, debridement followed by reconstruction using either a muscle flap (n = 13) or a fasciocutaneous flap (n = 13) was performed. Flap donor sites were closed primarily and antibiotics were given for 5 days postoperatively. Daily clinical evaluation for 1 year was performed and monthly radiographs were obtained for 9 months and 1 year after the reconstruction.Twenty-five flaps survived completely, and one nonmuscle flap underwent partial flap loss following a period of venous congestion. There were no postoperative complications in the muscle flap group. Two goats (15 percent) in the nonmuscle group developed superficial wounds in the immediate postoperative period that resolved with conservative management. No limbs had recurrent osteomyelitis wounds at 1 year of clinical follow-up examination. Radiographic evidence of osteomyelitis was present in two goats (15 percent) in the muscle group and one goat (8 percent) in the nonmuscle group. There was no statistically significant difference in the incidence of recurrent osteomyelitis between the groups by clinical and radiographic assessment.The findings in this study demonstrate that vascularized tissue flaps in the form of muscle or nonmuscle flaps provide viable options for wound coverage of osteomyelitis defects following adequate surgical debridement.

Background: Poliomyelitis is a disease that can render affected individuals incapacitated to a variable degree. A normal lifespan is expected and therefore the patients deserve every effort at curative cancer resection and reconstruction. Those with lower extremity paralysis rely heavily on their upper limbs and torso for ambulation; therefore, their compromised limbs may be a better donor site for flaps. Methods: All poliomyelitis patients with lower extremity paralysis over a 20-month period who underwent head and neck reconstruction were selected for a retrospective review. Perioperative complications were noted and outpatient follow-up was performed. Results: Three patients underwent reconstruction of defects using the posterior tibial artery flap. Two patients required reconstruction of a buccal defect and one patient required soft palate reconstruction. All patients healed without complications and none required reexploration. At a mean follow-up of 10 months, there was no incidence of donor limb vascular compromise, cold intolerance, or long-term paresthesias. Conclusions: The posterior tibial artery free flap has been used successfully in the past; however, its popularity has been limited because of sacrifice of the posterior tibial artery. Nevertheless, in patients with lower extremity paralysis, this flap may fulfill the requirements of a thin, pliable flap with minimal hair that has a long pedicle and a reliable blood supply. Most importantly, the use of this flap obviates the need to use flaps that fulfill the same requirement, such as forearm flaps, that would be taken from patients’ functioning limbs.

Mechanical bowel preparation before any intestinal operation, especially when the large intestine is involved, is routine practice for most surgeons. This practice has been questioned by many colorectal surgeons, with convincing data showing the lack of benefit of preoperative mechanical bowel preparation. Free microvascular transfer of the large intestine is occasionally performed for reconstruction of the upper esophagus, as it provides a better size match for the oropharynx than other visceral organs. Nine patients underwent reconstruction of the cervical esophagus and voice tube using a segment of ileoclolon. In all patients, the cervical esophagus was reconstructed using the ascending colon and the voice tube was reconstructed using the ileal segment. Both were transferred as one free flap. All patients underwent the procedure without any form of preoperative mechanical bowel preparation. The patients were able to tolerate a solid diet at the end of the mean follow-up period of 7 months, and all esophagograms showed no evidence of stricture formation. One patient developed a fistula at the recipient site that was treated with a regional flap, one patient developed a superficial wound infection of the abdominal wall, and one patient developed a postoperative abdominal wound dehiscence after several episodes of excessive coughing. Microvascular transfer of a large intestinal segment without preoperative mechanical bowel preparation for the reconstruction of the esophagus is a safe procedure. It can avoid the discomfort and complications associated with mechanical bowel preparation. If preoperative mechanical bowel preparation is preferred, the results of this study, which are based on nine patients, demonstrate the safety of this practice in cases where the patient did not follow proper instructions or in cases where the use of the colon was not anticipated preoperatively.

Despite advances in head and neck reconstruction with free-tissue transfer techniques, oropharyngocutaneous fistulas continue to present challenging and potentially lethal complications. The authors present a system for prioritizing these fistulas and the surgical management of nine patients in whom critical fistulas developed after microsurgical head and neck reconstruction. The indications for aggressive management of these fistulas were primarily dependent on their location. Three peristomal and six midneck fistulas were considered critical because of the risk of aspiration pneumonia and carotid artery blowout, respectively. Fistulas located in the submental and/or submandibular region were considered noncritical and were managed conservatively. Using the concept of a "tissue plug" for fistula repair, a dermal component (i.e., a deltopectoral or pectoralis major pedicled flap) is guided through the fistula, and with external traction the tissue "plugs" the tract. No sutures are placed directly in the surrounding friable tissue. There were no partial or total flap losses. There were two fistula recurrences in patients who had received postoperative radiation therapy. One of these recurrences was due to tumor recurrence within the previous fistula and was managed with palliative measures. The other fistula recurrence was closed with a local-flap procedure on an outpatient basis. All patients resumed oral feeding, except for the patient in whom tumor recurrence was suspected. This tissue-plug technique can be used in the management of critical peristomal and/or midneck oropharyngocutaneous fistulas not only to obliterate the tract but also to augment volume and vascularity in already damaged, ischemic, and deficient tissue.