Search

BackgroundRigid sternal fixation (RSF) has been shown to reduce sternal wound complications in high-risk patients. However, the higher initial cost continues to deter its use. This study evaluates the cost of caring for high-risk sternotomy patients who underwent RSF compared with those who underwent sternal closure with a modified wire technique (MWT).MethodsA retrospective single institution review of high-risk patients who underwent MWT (n = 45) and RSF (n = 30) for primary sternal closure from 2006 to 2009 was conducted. Total hospital cost, revenue, and net cost associated with surgery and subsequent care were analyzed.ResultsOverall rates of wound dehiscence and wound infections (superficial and deep) were higher in MWT patients (n = 14, 13, and 7, respectively) than RSF patients (n = 3, 2, and 0, respectively; P < 0.05). Modified wire technique patients also required more operations (mean ± SEM: 0.4 ± 0.1 vs 0.1 ± 0.1; P = 0.045), and had longer follow-up time (55.0 ± 9.1 vs 13.4 ± 10.5 days; P = 0.004). Overall, the hospital suffered a greater loss caring for MWT patients (US $18,903 ± 2,160) than RSF patients (US $8,935 ± 2,647). Modified wire technique patients who developed a complication had higher costs associated with their operative hospitalization, outpatient care, and home health than RSF patients (total net loss: US $41,436 ± 7327 vs US $10,612 ± 4,258; P = 0.034).ConclusionsIn high-risk patients, RSF is associated with lower rates of infections, including the "never event" mediastinitis, compared with MWT. Moreover, despite the initial higher cost, RSF affords an overall lower cost of care compared with MWT in patients at high-risk for developing sternal complications.

Regional and neuraxial anesthesia for pain management after breast surgery is not widely used despite data showing improved postoperative pain control and patient satisfaction scores. We report a case of a 61-year-old woman who underwent bilateral mastectomies, and received postoperative analgesia via pectoral nerves 1 and 2 nerve blocks. This case highlights a previously undescribed technique of prolonged postoperative pain control by intraoperative placement of pectoral nerves 1 and 2 regional anesthesia catheters under direct visualization. Intraoperative placement has the potential benefits of more accurate plane targeting, time saving, and widening the scope of use to practitioners are not trained in the ultrasound guided technique. We also present a review of the regional block techniques and present a preliminary algorithm for the selection of block method in breast surgery.

With the rise in obesity in the United States, there has been a similar increase in bariatric surgery. This has resulted in numerous patients losing significant weight with accompanying circumferential body contouring issues. This has led to an amazing increase in the number of body contouring procedures performed, both traditional excisional techniques as well as new emerging techniques emphasizing tissue preservation, rearrangement, and dermal reshaping. Although China's rates of obesity lag behind the United States, there is a recipe for obesity that will eventually surpass the United States. Thus, China has the opportunity to learn from the United States experience with regards to obesity treatment and contouring procedures after significant weight loss. Time will tell whether China will choose to use similar tissue preservation techniques to address issues of soft tissue ptosis and volume deficiency seen after significant weight loss, make refinements of these techniques, or develop new uniquely Chinese solutions.

BackgroundObese patients can develop a large lower abdominal panniculus (worsened by significant weight loss). Patients with advanced chronic kidney disease (CKD) affected by this obesity-related sequela are not infrequently declined for kidney transplantation because of the high risk for serious wound-healing complications. We hypothesized that pretransplant panniculectomy in these patients would (1) render them transplant candidates, and (2) result in low posttransplant wound-complication rates.MethodsIn a pilot study, adult patients with CKD who had a high-risk panniculus as the only absolute contraindication to kidney transplantation subsequently were referred to a plastic surgeon to undergo a panniculectomy in order to become transplant candidates. We analyzed the effect of panniculectomy on (1) transplant candidacy and (2) wait list and transplant outcomes (04/2008-06/2014).ResultsOverall, 36 patients had panniculectomy (median prior weight loss, 38 kg); all were wait-listed with these outcomes: (1) 22 (62%) patients were transplanted; (2) 7 (19%) remain listed; and (3) 7 (19%) were removed from the wait list. Survival after panniculectomy was greater for those transplanted versus not transplanted (at 5 years, 95% vs 35%, respectively; P = .002). For the 22 kidney recipients, posttransplant wound-complication rate was 5% (1 minor subcutaneous hematoma).ConclusionFor obese CKD patients with a high-risk abdominal panniculus, panniculectomy was highly effective in obtaining access to the transplant wait list and successful kidney transplantation. This approach is particularly pertinent for CKD patients because they are disproportionally affected by the obesity epidemic and because obese CKD patients already face multiple other barriers to transplantation.

BackgroundHand trauma call duties at university medical centers are traditionally split among plastic surgeons and orthopedic surgeons, frequently without additional fellowship training in hand and upper-extremity surgery. Differences in operative approach between these groups have never been specifically described. The University Health Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual, billing and coding data from 90 academic medical centers in the United States and can be used to characterize the practice patterns of various academic surgical specialties.ObjectiveTo characterize and compare the clinical experience of academic plastic, orthopedic, and hand surgeons in addressing traumatic distal upper extremity injuries (using the Faculty Practice Solutions Center data set).MethodsAnnual data for CPT defined procedures related to traumatic injuries of the nail bed, finger, hand, wrist, and forearm performed by plastic, orthopedic, and hand surgeons during calendar years 2010 to 2013 were included in the study.ResultsFrom 2010 to 2013, the experience of fellowship-trained hand surgeons in treating traumatic distal upper extremity injuries was consistently greater than that of plastic surgeons and general orthopedic surgeons across all categories. Injuries of the nail bed were repaired more frequently by plastic surgeons than orthopedic surgeons (average 1.3 annual procedures per surgeon for plastic surgeons compared with 0.3 for orthopedic surgeons). Fractures and dislocations involving the phalanx and metacarpal were repaired equally by both groups, with plastic surgeons using predominantly percutaneous (38%) or open methods (45% of repairs), and orthopedic surgeons using mostly closed reduction (59% of repairs), splinting, and casting. Fractures and dislocations involving the carpal bones, radius, and ulna were more frequently repaired by orthopedic surgeons (average 23.2 procedures versus 2.6 for plastic surgeons), whereas tendon repairs in all segments were performed more frequently by plastic surgeons (average 13.7 procedures versus 2.5 for orthopedic surgeons). Replantation and repair of neurovascular injuries were exceedingly rare (less than 1 occurrence) in all groups for all years and are not specifically reported in Table 1. Similarly, incision and drainage procedures and decompressive fasciotomies of the distal upper extremity were uncommonly performed and also not included (Table 1 displays the mean annual procedures per surgeon by grouped CPT coded procedures, with overall averages displayed to the right. Figure 1 displays the proportions of intra-articular and extra-articular bony hand injuries treated by closed, open, and percutaneous methods by each specialty).ConclusionsA large degree of variation exists in the treatment of distal upper extremity injuries, based on specialty service. Hand surgeons, not surprisingly, have the most robust clinical experience, whereas plastic surgeons and orthopedic surgeons each display varying strengths and weaknesses, perhaps a consequence of their respective training.

IntroductionBariatric surgery has emerged as an effective method of combating the morbid obesity epidemic. However, the massive weight loss that follows may result in contour changes that can affect body image and quality of life. Our study examines the effects and consequences of bariatric surgery and subsequent body contouring on body image and quality of life.MethodsPatients were prospectively followed up through their experience with bariatric surgery and subsequent body contouring surgery. Using 2 validated survey instruments, the Multidimensional Body-Self Relations Questionnaire and the Short Form 36 (SF-36), patients completed questionnaires preoperatively and at 6, 12, and 24 months postoperatively. Mean scores were determined by repeated measures analyses of variance F tests.ResultsOne hundred seventy-five patients were surveyed before bariatric surgery, with noted declines in survey completion at 6, 12, and 24 months. Appearance Evaluation scores improved significantly at all intervals (P = 0.0033), as did Body Area Satisfaction Scale and Appearance Orientation scores (P = 0.0079 and P = 0.044, respectively). While Overweight Preoccupation and Self-Classified Weight scores decreased over time, only the latter was significant (P < 0.0001). The composite SF-36 score for patients awaiting bariatric surgery (54.1%) with postoperative scores at 6 (67.6%,), 12 (at 74.0%), and 24 (76.7%) months being significantly higher (P < 0.0001). The body contouring group consisted of 41 patients who primarily had lower body procedures, with 31 patients surveyed at 6 months and 27 patients at 12 months. For this cohort, Appearance Evaluation and Body Area Satisfaction Scale scores both improved significantly (P = 0.0001 and P = 0.0005, respectively) whereas Appearance Orientation scores declined significantly (P = 0.0055). Both Overweight Preoccupation and Self-Classified Weight scores decreased with only the latter being statistically significant (P = 0.0286). Postoperative SF-36 scores at 6 (72.9%) and 12 (64.5%) months were no different than patients awaiting body contouring (71.3%).ConclusionsUsing 2 validated survey instruments, we show that patients undergoing bariatric surgery have improvements in body image and quality of life. Subsequent postbariatric body contouring surgery results in further improvements in body image. Our findings provide measurable evidence for the value of body contouring after significant weight loss, which may favor greater insurance coverage for this patient population.

IntroductionBariatric surgery has emerged as an effective method of combating the morbid obesity epidemic. However, the massive weight loss that follows may result in contour changes that can affect body image and quality of life. Our study examines the effects and consequences of bariatric surgery and subsequent body contouring on body image and quality of life.MethodsPatients were prospectively followed up through their experience with bariatric surgery and subsequent body contouring surgery. Using 2 validated survey instruments, the Multidimensional Body-Self Relations Questionnaire and the Short Form 36 (SF-36), patients completed questionnaires preoperatively and at 6, 12, and 24 months postoperatively. Mean scores were determined by repeated measures analyses of variance F tests.ResultsOne hundred seventy-five patients were surveyed before bariatric surgery, with noted declines in survey completion at 6, 12, and 24 months. Appearance Evaluation scores improved significantly at all intervals (P = 0.0033), as did Body Area Satisfaction Scale and Appearance Orientation scores (P = 0.0079 and P = 0.044, respectively). While Overweight Preoccupation and Self-Classified Weight scores decreased over time, only the latter was significant (P < 0.0001). The composite SF-36 score for patients awaiting bariatric surgery (54.1%) with postoperative scores at 6 (67.6%,), 12 (at 74.0%), and 24 (76.7%) months being significantly higher (P < 0.0001). The body contouring group consisted of 41 patients who primarily had lower body procedures, with 31 patients surveyed at 6 months and 27 patients at 12 months. For this cohort, Appearance Evaluation and Body Area Satisfaction Scale scores both improved significantly (P = 0.0001 and P = 0.0005, respectively) whereas Appearance Orientation scores declined significantly (P = 0.0055). Both Overweight Preoccupation and Self-Classified Weight scores decreased with only the latter being statistically significant (P = 0.0286). Postoperative SF-36 scores at 6 (72.9%) and 12 (64.5%) months were no different than patients awaiting body contouring (71.3%).ConclusionsUsing 2 validated survey instruments, we show that patients undergoing bariatric surgery have improvements in body image and quality of life. Subsequent postbariatric body contouring surgery results in further improvements in body image. Our findings provide measurable evidence for the value of body contouring after significant weight loss, which may favor greater insurance coverage for this patient population.

BackgroundHand trauma call duties at university medical centers are traditionally split among plastic surgeons and orthopedic surgeons, frequently without additional fellowship training in hand and upper-extremity surgery. Differences in operative approach between these groups have never been specifically described. The University Health Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual, billing and coding data from 90 academic medical centers in the United States and can be used to characterize the practice patterns of various academic surgical specialties.ObjectiveTo characterize and compare the clinical experience of academic plastic, orthopedic, and hand surgeons in addressing traumatic distal upper extremity injuries (using the Faculty Practice Solutions Center data set).MethodsAnnual data for CPT defined procedures related to traumatic injuries of the nail bed, finger, hand, wrist, and forearm performed by plastic, orthopedic, and hand surgeons during calendar years 2010 to 2013 were included in the study.ResultsFrom 2010 to 2013, the experience of fellowship-trained hand surgeons in treating traumatic distal upper extremity injuries was consistently greater than that of plastic surgeons and general orthopedic surgeons across all categories. Injuries of the nail bed were repaired more frequently by plastic surgeons than orthopedic surgeons (average 1.3 annual procedures per surgeon for plastic surgeons compared with 0.3 for orthopedic surgeons). Fractures and dislocations involving the phalanx and metacarpal were repaired equally by both groups, with plastic surgeons using predominantly percutaneous (38%) or open methods (45% of repairs), and orthopedic surgeons using mostly closed reduction (59% of repairs), splinting, and casting. Fractures and dislocations involving the carpal bones, radius, and ulna were more frequently repaired by orthopedic surgeons (average 23.2 procedures versus 2.6 for plastic surgeons), whereas tendon repairs in all segments were performed more frequently by plastic surgeons (average 13.7 procedures versus 2.5 for orthopedic surgeons). Replantation and repair of neurovascular injuries were exceedingly rare (less than 1 occurrence) in all groups for all years and are not specifically reported in Table 1. Similarly, incision and drainage procedures and decompressive fasciotomies of the distal upper extremity were uncommonly performed and also not included (Table 1 displays the mean annual procedures per surgeon by grouped CPT coded procedures, with overall averages displayed to the right. Figure 1 displays the proportions of intra-articular and extra-articular bony hand injuries treated by closed, open, and percutaneous methods by each specialty).ConclusionsA large degree of variation exists in the treatment of distal upper extremity injuries, based on specialty service. Hand surgeons, not surprisingly, have the most robust clinical experience, whereas plastic surgeons and orthopedic surgeons each display varying strengths and weaknesses, perhaps a consequence of their respective training.

With the rise in obesity in the United States, there has been a similar increase in bariatric surgery. This has resulted in numerous patients losing significant weight with accompanying circumferential body contouring issues. This has led to an amazing increase in the number of body contouring procedures performed, both traditional excisional techniques as well as new emerging techniques emphasizing tissue preservation, rearrangement, and dermal reshaping. Although China's rates of obesity lag behind the United States, there is a recipe for obesity that will eventually surpass the United States. Thus, China has the opportunity to learn from the United States experience with regards to obesity treatment and contouring procedures after significant weight loss. Time will tell whether China will choose to use similar tissue preservation techniques to address issues of soft tissue ptosis and volume deficiency seen after significant weight loss, make refinements of these techniques, or develop new uniquely Chinese solutions.

IntroductionTo evaluate the effect of web-based education on (1) patient satisfaction, (2) consultation times, and (3) conversion to surgery.MethodsA retrospective review of 767 new patient consultations seen by 4 university-based plastic surgeons was conducted between May 2012 and August 2013 to determine the effect a web-based education program has on patient satisfaction and consultation time. A standard 5-point Likert scale survey completed at the end of the consultation was used to assess satisfaction with their experience. Consult times were obtained from the electronic medical record. All analyses were done with Statistical Analysis Software version 9.2 (SAS Inc., Cary, NC). A P value less than 0.05 was considered statistically significant.ResultsThose who viewed the program before their consultation were more satisfied with their consultation compared to those who did not (satisfaction scores, mean ± SD: 1.13 ± 0.44 vs 1.36 ± 0.74; P = 0.02) and more likely to rate their experience as excellent (92% vs 75%; P = 0.02). Contrary to the claims of Emmi Solutions, patients who viewed the educational program before consultation trended toward longer visits compared to those who did not (mean time ± SD: 54 ± 26 vs 50 ± 35 minutes; P = 0.10). More patients who completed the program went on to undergo a procedure (44% vs 37%; P = 0.16), but this difference was not statistically significant.DiscussionViewing web-based educational programs significantly improved plastic surgery patients' satisfaction with their consultation, but patients who viewed the program also trended toward longer consultation times. Although there was an increase in converting to surgical procedures, this did not reach statistical significance.

Fat grafting is increasingly popular and is becoming a common practice in plastic surgery for postmastectomy breast reconstruction and aesthetic breast augmentation; however, concerns over the oncologic safety remains a controversial and hot topic among scientists and surgeons. Basic science and laboratory research repeatedly show a potentially dangerous effect of adipose-derived stem cells on breast cancer cells; however, clinical research, although limited, continually fails to show an increase in breast cancer recurrence after breast fat grafting, with the exception of 1 small study on a subset patient population with intraepithelial neoplasm of the breast. The aim of this review is to summarize the recent conflicting basic science and clinical data to better understand the safety of breast fat grafting from an oncological perspective.

ObjectiveThe present status of global mission trips of all of the academic Plastic Surgery programs was surveyed. We aimed to provide information and guidelines for other interested programs on creating a global health elective in compliance with American Board of Plastic Surgery (ABPS) and Accreditation Council for Graduate Medical Education Residency Review Committee (ACGME/RRC) requirements.DesignA free-response survey was sent to all of the Plastic Surgery Residency program directors inquiring about their present policy on international mission trips for residents and faculty. Questions included time spent in mission, cases performed, sponsoring organizations, and whether cases are being counted in their resident Plastic Surgery Operative Logs (PSOL).ResultsThirty-one programs responded, with 23 programs presently sponsoring international mission trips. Thirteen programs support residents going on nonprogram-sponsored trips where the majority of these programs partner with outside organizations. Many programs do not count cases performed on mission trips as part of ACGME index case requirement. Application templates for international rotations to comply with ABPS and ACGME/RRC requirements were created to facilitate the participation of interested programs.ConclusionsMany Plastic Surgery Residency programs are sponsoring international mission trips for their residents; however, there is a lack of uniformity and administrative support in pursuing these humanitarian efforts. The creation of a dynamic centralized database will help interested programs and residents seek out the global health experience they desire and ensure standardization of the educational experience they obtain during these trips.

BackgroundPatients with end-stage renal disease evaluated for renal transplantation are frequently declined secondary to obesity and decreased functional status. As a result, many of these patients lose weight intentionally in an effort to gain candidacy on the transplant waiting list. This frequently produces a panniculus encompassing the lower abdominal surgical site used for renal transplantation. These patients are declined for renal transplantation secondary to predictable wound-healing complications.Materials and methodsWe previously identified significant weight loss (>10 kg) before renal transplantation as a risk factor for wound-healing complications after kidney transplant. Since that time, we have successfully performed 21 panniculectomies in renal transplant candidates (5 men and 16 women) with an average age of 55 years (range, 27-67 years) and an average body mass index of 30.2 kg/m2 (range, 24.5-38.7 kg/m2) after significant weight loss, with an average maximum weight loss before panniculectomy of 37.7 kg (range, 5.5-83.2 kg), and median body mass index decrease before panniculectomy of 14 kg/m (range, 2.0-23.6 kg/m2).ResultsWe observed minor wound-healing complications (cellulitis or superficial wound separation) in 8 patients (38%), major wound-healing complications (hematoma, seroma, or unplanned return to the operating room) in 3 patients (14%), and no medical complications (defined as urinary tract infection, pulmonary embolism, pneumonia, deep venous thrombosis, central venous access loss, or myocardial infarction). Seventeen patients have been relisted on the transplant waiting list. Of the patients who have not been relisted on the transplant waiting list, no patient had his or her candidacy delayed secondary to complications of their panniculectomy. Of the patients who have been relisted, 6 have undergone transplantation. Of these 6 patients, no one has experienced wound-healing complications, 1 patient experienced delayed graft function and 1 patient experienced mild transaminitis resolved by discontinuing statin therapy.ConclusionsPanniculectomies in preparation for renal transplant may be performed in patients with end-stage renal disease with an acceptable complication rate, converting previously ineligible patients into eligible candidates for kidney transplant. It also seems those who undergo panniculectomy before kidney transplant may expect to have lower rates of wound complications after their transplant had they not had a panniculectomy.

IntroductionCommon upper body findings after massive weight loss (MWL) include breast ptosis, projection loss, flattening, inframammary fold descent, and back rolls. Although implants address volume loss, manifestations of circumferential excess (ie, back rolls) are ignored. We review our experience with extended lateral fasciocutaneous flaps incorporating circumferential excess tissue, typically removed in upper body lifts (UBLs), for autologous augmentation mastopexy.MethodsWe reviewed all cases of simultaneous autoaugmentation mastopexy and UBL, using extended lateral chest wall fasciocutaneous flaps, performed after MWL. Donor sites were designed with scars residing within the bra line (UBL) or midaxillary line [modified UBL (mUBL)]. We analyzed demographics, clinical indications, and complications.ResultsBetween 2007 and 2013, 7 patients underwent 13 extended fasciocutaneous flap reconstructions for autoaugmentation mastopexy, combined with UBL or mUBL. All patients underwent procedures with flaps taken from the back or from the midaxillary line. Mean initial body mass index (BMI) was 50.1 kg/m2 with a preoperative, post-MWL BMI of 28.5 kg/m2, weight loss of 58 kg, and BMI decrease of 21.6 kg/m2. Among 6 patients who underwent bariatric surgery, the average interval between gastric bypass and autoaugmentation mastopexy was 41 months. Five patients underwent these procedures for aesthetic reasons, whereas 2 patients underwent breast reconstruction. Follow-up averaged 18 months. Complications occurred in 3 patients, with only 1 requiring reoperation.ConclusionsMassive weight loss patients frequently present with breast volume loss and ptotic upper body soft tissue excess. Simultaneous mastopexy augmentation can be safely and reliably performed using extended fasciocutaneous flaps to autologously may be placed in aesthetically acceptable locations. Patients undergoing mUBLs with midaxillary line donor scars may conceal them with arms at their sides. Patients choosing back donor scars may conceal them within the bra line while having greater volumes available for augmentation. As is true with all flaps, one should assess distal tip perfusion before final inset, especially when using a flap extending to the midline back.

BackgroundPrevious studies have examined national trends in breast reconstruction, using various data sets demonstrating increases in implant-based reconstruction and decreases in autologous reconstruction. However, academic breast reconstruction practices have never been specifically characterized. The University Health Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual billing and coding data from 90 academic medical centers in the United States, and has been used to characterize practice patterns of various academic surgical specialties.ObjectiveTo describe breast reconstruction trends unique to academic surgical practices, using the Faculty Practice Solutions Center database.MethodsAnnual data for defined breast reconstruction procedures (current procedural terminology codes: 19340, 19342, 19357, 19361, 19364, 19366, 19367, 19369, and 19380) performed by university plastic surgeons during calendar years 2007 to 2013 were included in the study.ResultsFrom 2007 to 2013, a 2-fold increase in the number of breast reconstruction procedures was observed (from a mean of 45.3 to 94.2 procedures per surgeon). During this period, implant-based reconstructions and autologous reconstructions rose in tandem (28.9-44.6 and 11.4-19.3, respectively), with a preserved 2.5:1 ratio between the 2 categories each year. When compared to reconstructions overall, the proportion of both implant reconstruction and autologous reconstruction procedures declined, since revision and other types of reconstructions increased (11% of all reconstructions in 2007 vs 32% in 2013). With regard to autologous reconstruction, microsurgical free flaps (mostly comprised of deep inferior epigastric artery perforator flaps) have supplanted latissimus flaps as the favored modality and comprised 13% to 14% of breast reconstruction cases overall from 2011 to 2013.ConclusionIn contrast to national trends, university-based plastic surgeons are performing a growing number of microsurgical free flaps as the preferred method for autologous breast reconstruction. Whereas implant-based reconstructions still predominate in academic practices, the trend of increasing preference toward implant-based reconstructions has slowed in recent years and revision reconstructions are on the rise.

BackgroundPatients with end-stage renal disease evaluated for renal transplantation are frequently declined secondary to obesity and decreased functional status. As a result, many of these patients lose weight intentionally in an effort to gain candidacy on the transplant waiting list. This frequently produces a panniculus encompassing the lower abdominal surgical site used for renal transplantation. These patients are declined for renal transplantation secondary to predictable wound-healing complications.Materials and methodsWe previously identified significant weight loss (>10 kg) before renal transplantation as a risk factor for wound-healing complications after kidney transplant. Since that time, we have successfully performed 21 panniculectomies in renal transplant candidates (5 men and 16 women) with an average age of 55 years (range, 27-67 years) and an average body mass index of 30.2 kg/m2 (range, 24.5-38.7 kg/m2) after significant weight loss, with an average maximum weight loss before panniculectomy of 37.7 kg (range, 5.5-83.2 kg), and median body mass index decrease before panniculectomy of 14 kg/m (range, 2.0-23.6 kg/m2).ResultsWe observed minor wound-healing complications (cellulitis or superficial wound separation) in 8 patients (38%), major wound-healing complications (hematoma, seroma, or unplanned return to the operating room) in 3 patients (14%), and no medical complications (defined as urinary tract infection, pulmonary embolism, pneumonia, deep venous thrombosis, central venous access loss, or myocardial infarction). Seventeen patients have been relisted on the transplant waiting list. Of the patients who have not been relisted on the transplant waiting list, no patient had his or her candidacy delayed secondary to complications of their panniculectomy. Of the patients who have been relisted, 6 have undergone transplantation. Of these 6 patients, no one has experienced wound-healing complications, 1 patient experienced delayed graft function and 1 patient experienced mild transaminitis resolved by discontinuing statin therapy.ConclusionsPanniculectomies in preparation for renal transplant may be performed in patients with end-stage renal disease with an acceptable complication rate, converting previously ineligible patients into eligible candidates for kidney transplant. It also seems those who undergo panniculectomy before kidney transplant may expect to have lower rates of wound complications after their transplant had they not had a panniculectomy.

IntroductionCommon upper body findings after massive weight loss (MWL) include breast ptosis, projection loss, flattening, inframammary fold descent, and back rolls. Although implants address volume loss, manifestations of circumferential excess (ie, back rolls) are ignored. We review our experience with extended lateral fasciocutaneous flaps incorporating circumferential excess tissue, typically removed in upper body lifts (UBLs), for autologous augmentation mastopexy.MethodsWe reviewed all cases of simultaneous autoaugmentation mastopexy and UBL, using extended lateral chest wall fasciocutaneous flaps, performed after MWL. Donor sites were designed with scars residing within the bra line (UBL) or midaxillary line [modified UBL (mUBL)]. We analyzed demographics, clinical indications, and complications.ResultsBetween 2007 and 2013, 7 patients underwent 13 extended fasciocutaneous flap reconstructions for autoaugmentation mastopexy, combined with UBL or mUBL. All patients underwent procedures with flaps taken from the back or from the midaxillary line. Mean initial body mass index (BMI) was 50.1 kg/m2 with a preoperative, post-MWL BMI of 28.5 kg/m2, weight loss of 58 kg, and BMI decrease of 21.6 kg/m2. Among 6 patients who underwent bariatric surgery, the average interval between gastric bypass and autoaugmentation mastopexy was 41 months. Five patients underwent these procedures for aesthetic reasons, whereas 2 patients underwent breast reconstruction. Follow-up averaged 18 months. Complications occurred in 3 patients, with only 1 requiring reoperation.ConclusionsMassive weight loss patients frequently present with breast volume loss and ptotic upper body soft tissue excess. Simultaneous mastopexy augmentation can be safely and reliably performed using extended fasciocutaneous flaps to autologously may be placed in aesthetically acceptable locations. Patients undergoing mUBLs with midaxillary line donor scars may conceal them with arms at their sides. Patients choosing back donor scars may conceal them within the bra line while having greater volumes available for augmentation. As is true with all flaps, one should assess distal tip perfusion before final inset, especially when using a flap extending to the midline back.

BackgroundPhotographic standards issued by the Plastic Surgery Educational Foundation ensure accurate comparisons between preoperative and postoperative imaging. These standards, however, do not properly display the circumferential body ptosis seen in massive weight loss (MWL) patients. Photographic standardization for massive weight loss patients is needed for patient consultation, surgical planning, and accurate analysis and comparison of postoperative results.Patients and methodsA 10-year review of the photographic standards used for MWL patients at the University of California Davis Medical Center were reviewed and compared to current photographic standards in plastic surgery and clinical photo documentation seen in the literature for body contouring after MWL. Evaluation of arm position in obscuring the evaluation of circumferential ptosis in the upper and lower body was performed.ResultsCurrent photographic standards in plastic surgery do not capture the circumferential ptosis often seen in MWL patients, and there are no consistent modifications or standards recommended for MWL patients. Arm position was noted to affect shadowing and obstruction as well as distortion of circumferential excess. During the first 5 years reviewed, initial consultations included 8 images captured at 45-degree increments with the arms abducted to 90 degrees to document the circumferential excess from shoulders to the knees (Total Body, Fig. 1). They also included 8 images focused on the lower body (Fig. 2) and 8 images focused on the upper body. This required a total of 24 images captured per consultation. During the latter 5 years reviewed, the 8 Total Body images continued to be captured whereas the 16 images focusing on the upper and lower body have been discarded and replaced with 10 images (Fig. 3), captured from shoulders to knees at 45-degree increments with arms positioned behind the back (5) and in the lap (5) for a total of 18 images captured per consultation.ConclusionCurrently there are no photographic standards for MWL patients that accurately capture their circumferential ptosis. All arm positions affect the evaluation of the circumferential excess to some degree, thus any choice of arm position represents a compromise between visibility and distortion of anatomy. Having considered these issues, we recommend the use of 360-degree clinical photo documentation obtained at 45-degree increments with arms abducted to 90 degrees to capture the total body. We have discarded focused upper and lower body images as these are visible in the Total Body images, thus decreasing patient fatigue and discomfort from excessive pictures. As techniques in post-bariatric body contouring have improved, we now routinely compare our results to non-post-bariatric body contouring patients and thus have added more standard arm positioning to facilitate these comparisons.

BackgroundMost surgical specialties working with bone have transitioned from wire fixation to more stable plate and screw fixation. Rigid plate fixation results in more rapid bony healing with decreased rates of nonunion, malunion, and infection. Despite sternotomies being the most frequently performed osteotomy, cerclage wire fixation remains the standard technique of closure. This study reviews our 5-year experience with rigid fixation at the University of California Davis Medical Center.Materials and methodsA retrospective review of patients who underwent rigid sternal fixation between January 2006 and December 2012 at UC Davis Medical Center was performed. Demographic factors, indications for surgery, and risk factors for postoperative complications including mediastinitis and nonunion were reviewed. The type of fixation system was recorded. Outcomes assessed included dehiscence, deep and superficial infections, sternal instability, and need for reoperation.ResultsFifty-seven rigid sternal fixations were performed (M/F, 37:20; average age, 54 years; range, 16-79 years). Indications for operation included prophylaxis against mediastinitis (61.4%), sternal nonunion (24.6%), sternal fractures (7.0%), and pectus deformities (7.0%). Of the rigid fixation systems used, 87.3% used SternaLock, 12.7% used Talon, 1.8% Lactosorb, and 1.8% Flexigrip. Thirty-five patients were plated for prophylaxis against mediastinitis. In the prophylactic group, the average number of risk factors per patient was 3.92, indicating very high-risk patients. Fourteen patients were plated for sternal nonunion. The average number of risk factors in the nonunion group was 1.57. Other less common indications for rigid sternal stabilization included sternal fracture (4 patients) and pectus deformity (4 patients). Eight patients had a pectoralis flaps performed at the time of their sternal fixation, 7 for soft tissue coverage of plates and 1 for coverage of a contaminated wound bed. All patients went on to heal their sternums without evidence of mediastinitis.ConclusionsRigid sternal fixation is a natural extension of principles learned from bone stabilization in other parts of the body. It can be used for rigid bony fixation of osteotomies performed after median sternotomy as well as in sternal reconstructions for traumatic fractures, nonunions, and pectus deformities. Rigid sternal fixation can be used safely and effectively in the prophylaxis against the development of mediastinitis in addition to the treatment of sternal nonunion or malunion in high-risk patients.