Belt lipectomy for circumferential truncal excess: the University of Iowa experience

When some patients with circumferential truncal excess undergo traditional abdominoplasty, the trunk is not addressed as a unit. Belt lipectomy, a procedure that combines abdominoplasty with circumferential excision of skin and fat, is often more ideal for these patients. In this article, the authors review the literature on belt lipectomy and evaluate their series of 32 patients who underwent belt lipectomy at the University of Iowa. The evolution and current preoperative markings, intraoperative surgical technique, and postoperative care are described. The patients' charts and their preoperative and postoperative photographs were examined retrospectively. It was found that belt lipectomy improved abdominal contour, abdominal wall laxity, mons pubis ptosis, back rolls, waist contour, and buttocks contour. Initially, the procedure was performed on post-weight-reduction patients only, but its indications were extended to three other groups: patients who were 30 to 50 pounds overweight, patients of normal weight who desired a significant overall truncal improvement, and an obese patient with persistent intraabdominal excess. The improvements were significant in all groups of patients except for the latter patient. Complications included a 37.5 percent seroma rate, a 9.3 percent pulmonary embolus rate, and one dehiscence that required reoperation. The authors concluded that belt lipectomy should be seriously considered for patients who present with circumferential truncal excess and for a select group of normal-weight patients. It is not recommended for the obese patient with excessive intraabdominal content. Furthermore, belt lipectomy should be undertaken only in patients who are well informed about the possible risks and complications.     

Nipple reconstruction using the C-V flap technique: a long-term evaluation

Numerous procedures are available for nipple reconstruction with no true universal favorite. This study presents long-term follow-up data for nipple reconstruction using the C-V flap technique. Patients were identified by searching the Breast Reconstruction Database, and they were asked to return for a follow-up visit. All those who underwent nipple reconstruction using the C-V flap technique between January of 1992 and December of 1996 were reviewed in an attempt to conduct a long-term follow-up evaluation. The response was poor, and 11 patients participated in the study and returned for follow-up. They all completed a questionnaire, which focused on patient satisfaction using a visual analogue scale. Nipple measurements were taken with a caliper and compared with the opposite breast for symmetry. Fourteen nipple reconstructions were evaluated in 11 patients with an average follow-up of 5.3 years. All patients had undergone transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Patient satisfaction was 42 percent with nipple projection, 62 percent with pigmentation, and 26 percent with sensation. Overall patient satisfaction with the procedure was 81 percent. Average nipple projection of the reconstructed nipple was 3.77 mm and was not statistically different when compared with the opposite nipple. Long-term subjective evaluation of the C-V flap technique does report a loss in nipple projection; however, overall patient satisfaction at 5.3 years is good, as is the ability to restore symmetry with the opposite breast.     

Cytokine phenotype,genotype, and renal outcomes at cardiac surgery

BackgroundCardiac surgery modulates pro- and anti-inflammatory cytokine balance involving plasma tumour necrosis factor alpha (TNFα) and interleukin-10 (IL-10) together with urinary transforming growth factor beta-1 (TGFβ1), interleukin-1 receptor antagonist (IL1ra) and tumour necrosis factor soluble receptor-2 (TNFsr2). Effects on post-operative renal function are unclear. We investigated if following cardiac surgery there is a relationship between cytokine (a) phenotype and renal outcome; (b) genotype and phenotype and (c) genotype and renal outcome. Since angiotensin-2 (AG2), modulates TGFβ1 production, we determined whether angiotensin converting enzyme insertion/deletion (ACE I/D) genotype affects urinary TGFβ1 phenotype as well as renal outcome.MethodsIn 408 elective cardiac surgery patients we measured pre- and 24 h post-operative urinary TGFβ-1, IL1ra and TNFsr2 and pre- and 2 h post-operative plasma TNFα and IL-10. Post-operative responses were compared for each cytokine in patients grouped according to presence or absence of renal dysfunction defined as a drop from baseline eGFR of greater than 25% (as calculated by the method of modification of diet in renal disease (MDRD)) occurring (1) within the first 24 and (2) 48 postoperative hours (early renal dysfunction), (3) on the fifth postoperative day (late renal dysfunction) or (4) at any time throughout the 5 day postoperative period (early and late combined). Patient genotype was determined for TNF/G-308A, TGFβ1-509 C/T, IL10/G-1082A and ACE I/D.ResultsPost-operative plasma IL-10 and urinary TGFβ1 responses were significantly higher in patients who developed early renal dysfunction. IL1ra and TNFsr2 responses were significantly lower 24 h post-operatively in patients who developed late renal dysfunction. Genotype did not alter cytokine phenotype or outcome.Conclusions/inferencesCytokine profiling may help predict early and late renal dysfunction. Genotypes studied did not alter phenotype or outcome.     

Latissimus dorsi myocutaneous flap for breast reconstruction: long-term results.

A review was performed on 170 patients who underwent 173 consecutive latissimus dorsi myocutaneous flap breast reconstructions between 1978 and 1989. The majority of the patients had modified radical mastectomies, and reconstruction was usually delayed for 3 to 18 months after mastectomy. Acceptable symmetry was obtained in the majority of patients without the need for surgery on the opposite breast. Perioperative and long-term complications are reviewed. Patients were followed for an average of 4.7 years after reconstruction. Ninety-four percent of patients demonstrated little or no change in the reconstructed breast after the first year. This method of reconstruction has met patient expectations with a minimum number of procedures and low morbidity.     

Aerodynamic assessment of the results of pharyngeal flap surgery: a preliminary investigation

Voice-quality (i.e., nasality) judgments are commonly used to evaluate the results of pharyngeal flap surgery. However, these are subjective judgments of questionable validity and reliability. This project was designed to systematically evaluate the outcome of pharyngeal flap surgery utilizing objective, quantifiable physiologic (pressure-flow) information. Thirty-one patients who had undergone pharyngeal flap surgery were selected. Pressure-flow measurements and perceptual judgments of speech were obtained following surgery. Results indicated that using pressure-flow criteria, only 52 percent of the outcomes were considered successful. Results also indicated that 35 percent of the cases were characterized by substantial nasopharyngeal airway obstruction. In the present study, these findings, along with the related perceptual phenomenon of denasality, were considered unsuccessful. Finally, results suggest that aerodynamic measurements can be used to assess other surgical techniques designed to correct velopharyngeal insufficiency.     

The groin flap in reparative surgery of the hand

The historical literature of the use of axial vascular pattern flaps from the hypogastric and iliofemoral regions in reparative surgery of the hand is concisely reviewed. Thirty-six iliofemoral (groin) flaps were utilized for delayed primary resurfacing and secondary reconstruction of defects of the hand and forearm. Two flaps (6 percent) were complicated by partial necrosis. We caution against the immediate resurfacing (within 24 hours of injury) of acute crushed hand wounds by distant flaps. The immediate application of a healthy flap on a soiled or crushed wound invites complications of local tissue necrosis, infection, and subsequent loss of the flap. When distant flaps are indicated for coverage of acute hand wounds, delayed primary coverage following complete removal of all nonviable tissue is a safe and reliable regimen. It is advantageous to design the serviceable portion of the flap on the distal area of the vascular territory of the groin flap. Thoughtful yet "radical" defatting can be performed on the lateral portion of the groin flap territory. Constructed in this way, the long medial base of the groin flap allows freedom for movement at the wrist and metacarpophalangeal and interphalangeal joints, thus decreasing edema and stiffness. In the management of soft-tissue defects in the hand requiring distant flap coverage, we choose to utilize the conventional groin flap in preference to the microvascular free flap when both techniques will deliver equal results.     

Measuring outcomes in aesthetic surgery: a comprehensive review of the literature

Outcomes research examines the end results of medical interventions, taking into account patients' experiences, preferences, and values. The purpose of assessing outcomes is to provide evidence on which to base clinical decisions. The assessment of outcomes in aesthetic surgery is especially pertinent because patient satisfaction is the predominant factor in determining success. In cosmetic surgery, various scales have been used to assess outcomes. Unfortunately, none of these methods has achieved widespread use. The adoption of broadly accepted, relevant scales to measure outcomes would be advantageous, because this would allow the comparison of techniques, quantification of positive effects, and identification of patients unlikely to benefit from surgery. The purpose of this study was to critically review the present literature to identify the appropriate instruments to assess outcomes in aesthetic surgery. After a comprehensive review of aesthetic surgery outcome instruments, the authors identified body-image and quality-of-life measures to be of the greatest value in determining aesthetic surgery outcomes. These conclusions were based on a critical evaluation of the feasibility, validity, reliability, and sensitivity to change of these measures. The Multidimensional Body-States Relations Questionnaire (MBSRQ), a psychological assessment of body image, was selected as a potential candidate for further study. Two additional body-image assessment instruments, the Facial Appearance Sorting Test (FAST) and the Breast Chest Ratings Scale (BCRS), may be useful in the assessment of rhinoplasty and breast surgery, respectively. The Derriford Scale (DAS59), an instrument that assesses appearance-related quality of life, was also selected. In addition, the authors recommend the use of a generic, utility-based quality-of-life instrument, such as the Health Utilities Index (HUI) or the EuroQol (EQ-5D).     

Use of the galeal frontalis myofascial flap in craniofacial surgery

The anatomy and the technique of raising the galeal frontalis myofascial flap is described. In 38 patients with various pathologies, congenital anomalies, tumors, and trauma, this technique was employed. There were no extradural infections. The applications and complications of the flap are discussed. It is highly recommended wherever there is a possibility of direct intracranial nasopharyngeal communication.     

Stature and long-term labor market outcomes: Evidence using Mendelian randomization

We use the Young Finns Study (N = ∼2000) on the measured height linked to register-based long-term labor market outcomes. The data contain six age cohorts (ages 3, 6, 9, 12, 15 and 18, in 1980) with the average age of 31.7, in 2001, and with the female share of 54.7. We find that taller people earn higher earnings according to the ordinary least squares (OLS) estimation. The OLS models show that 10 cm of extra height is associated with 13% higher earnings. We use Mendelian randomization, with the genetic score as an instrumental variable (IV) for height to account for potential confounders that are related to socioeconomic background, early life conditions and parental investments, which are otherwise very difficult to fully account for when using covariates in observational studies. The IV point estimate is much lower and not statistically significant, suggesting that the OLS estimation provides an upward biased estimate for the height premium. Our results show the potential value of using genetic information to gain new insights into the determinants of long-term labor market success.     

From Bacteriology to Biochemistry: Albert Jan Kluyver and Chester Werkman at Iowa State

This essay explores connections between bacteriology and the disciplinary evolution of biochemistry in this country during the 1930s. Many features of intermediary metabolism, a central component of biochemistry, originated as attempts to answer fundamental bacteriological questions. Thus, many bacteriologists altered their research programs to answer these questions. In so doing they changed their disciplinary focus from bacteriology to biochemistry. Chester Hamlin Werkman's (1893–1962) Iowa State career illustrates the research perspective that many bacteriologists adopted. As a junior faculty member in the Bacteriology Department in the late 1920s, Werkman faced a powerful professional dilemma: establishing a research identity that distinguished him from his colleagues with flourishing national and international reputations. His solution was to radically alter his research program from traditional bacteriology to a biochemistry program, which reflected the influence of the Dutch microbiologist/biochemist, Albert Jan Kluyver (1888–1956). Werkman was extremely successful in this career change. His laboratory made significant contributions to biochemistry, and Werkman achieved a notable degree of personal success. His career began in the shadow of his departmental bacteriological colleagues; within a decade he became the department's dominant research figure, as a biochemist. Werkman's personal success, however, had profound consequences for the disciplinary future of bacteriology at Iowa State. This revised version was published online in July 2006 with corrections to the Cover Date.     

The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications

The purpose of this study was to examine the effect of postreconstruction radiation therapy on patients undergoing pedicled TRAM flap breast reconstruction. Post-TRAM radiation patients were compared with patients who received pre-TRAM radiation and a control TRAM-only group who received no radiation. Overall aesthetic appearance, evidence of symmetry, flap contracture, and hyperpigmentation were assessed by blinded reviewers. A total of 171 pedicled TRAM reconstructions were performed in 150 patients. Total flap complications were seen in 49.5 percent of the control patients, 57.1 percent of pre-TRAM radiation patients, and 50 percent of post-TRAM radiation patients but were not statistically different. The complete flap necrosis rate was 0.6 percent and the partial flap necrosis rate was 7.6 percent, again with no statistical differences among the groups. Donor-site complications occurred in approximately one third of patients in each of the groups. Deep venous thrombosis and pulmonary embolus each occurred once and only in the post-TRAM radiation group. In terms of overall aesthetic outcome, symmetry, and contracture, the control group consistently rated better than the pre-TRAM (p = 0.021, p = 0.03, p = 0.03, respectively) and the post-TRAM (p = 0.0001, p = 0.0001, and p =0.0001, respectively) radiation groups. The control group also had clinically and statistically significant less hyperpigmentation than the post-TRAM radiation group (p = 0.0002). In contrast, irradiated postreconstruction patients had scores, including aesthetic outcome, symmetry, and contracture, worse than those of irradiated prereconstruction patients. When these two groups were compared with each other, except for contracture, no statistical significance, because of a small patient sample, was found. Neither preoperative nor postoperative radiation increased the risk for flap or donor-site complications. In contrast, radiation of any type did affect aesthetic appearance, symmetry, contracture, and hyperpigmentation. The authors recommend that TRAM flap breast reconstruction be postponed in those patients known or expected to receive postmastectomy radiation.