Marriage abdominoplasty expands the mini-abdominoplasty concept

The marriage of aggressive superwet liposculpture of the abdomen and adjacent anatomic regions with a modification of well-established open surgical techniques to address skin excess and perform muscle plication was used to treat 29 patients presenting for aesthetic abdominal contouring over the past 3 1/2 years. The charts of 57 patients who had aesthetic contouring procedures on the abdomen performed from December of 1994 to July of 1998 were retrospectively reviewed. Fifteen patients underwent suction lipectomy alone, 13 patients were treated with conventional abdominoplasty, and 29 underwent "marriage abdominoplasty." The 29 patients who underwent marriage abdominoplasty presented with deformities marked by excess lower abdominal skin and adipose tissue, with or without muscle laxity (Psillakis types II, III, and IV). Seventeen procedures were performed under local anesthesia with deep conscious sedation on an outpatient surgical basis. In 12 patients, the operation accompanied a hysterectomy, urologic procedure, or additional aesthetic surgical procedure(s) and was done under general anesthesia. Suction aspirates ranged between 540 and 2600 cc (mean, 1160 cc) and were accompanied by lower abdominal skin excision in every case, which was performed predominantly through short and medium-length incisions (mean, 15 cm). Rectus abdominis muscle plication was performed where necessary, using vertical plication of the infraumbilical rectus muscles in 27 patients (93 percent) and full-length plication in two patients (7 percent). All patients demonstrated significantly improved contours and have seemed to manifest less pain when compared with patients treated by full traditional abdominoplasty. Postoperative complications have included upper abdominal skin waviness (2), annoying paresthesias and discomfort persisting for 6 months (1), seroma (1), and marginal skin necrosis with an open wound (1). The latter problem occurred in the only patient who was treated with a revision procedure. Thus, the complication rate was 17 percent (5 of 29 patients). The marriage of aggressive superwet liposculpture of the entire abdomen with standard open surgical techniques used to treat skin excesses and allow abdominal muscle plication where necessary offers the advantage of reduced surgery when compared with full abdominoplasty, while consistently achieving significant contour improvement. This concept is applicable to the majority of patients presenting for the treatment of abdominal deformities and has markedly expanded the application of the mini-abdominoplasty concept.     

Laparoscopic cholecystectomy as a safe and effective treatment for severe acute cholecystitis.

OBJECTIVE--To evaluate the feasibility and safety of laparoscopic cholecystectomy in severe acute cholecystitis. DESIGN--Analysis of data collected prospectively from a consecutive series of 350 laparoscopic operations. SETTING--Two general surgical units in a teaching hospital. SUBJECTS--31 patients with a diagnosis of severe acute cholecystitis based on clinical examination, investigation results, and operative findings. INTERVENTIONS--Initial intravenous fluids and broad spectrum antibiotics followed by laparoscopic cholecystectomy within 72 hours of presentation. MAIN OUTCOME MEASURES--Failure to complete the operation laparoscopically, length of postoperative stay in hospital, early postoperative morbidity, interval from operation to full activity, and return to work. RESULTS--Laparoscopic cholecystectomy was attempted in 19 patients with empyema of the gall bladder and 12 who had severe cholecystitis which failed to settle on medical management. A total of 29 operations were successfully completed with two conversions to open surgery. Two minor postoperative complications occurred, and one case of retained common bile duct stones with jaundice was treated by endoscopic retrograde cholangiopancreatography and papillotomy. Median postoperative hospital stay was two days, with return to normal activity in seven days and to work in two weeks. There were no deaths related to the operation. CONCLUSIONS--In the presence of severe acute cholecystitis laparoscopic cholecystectomy is feasible in most patients, with minimal risk of injury to surrounding structures and considerable benefits. It is recommended that laparoscopic cholecystectomy should be attempted in these patients when appropriate surgical skill is available.     

A 10-year review of perioperative complications in pharyngeal flap surgery

A 10-year retrospective study was undertaken to investigate perioperative complications in pharyngeal flap surgery in one institution using inferiorly and superiorly based flaps. In this fashion the current practice of surgical technique based on local findings and perioperative care, through regular monitoring by experienced nurses on the ward, was evaluated for adequacy. The charts of 275 patients who had 287 pharyngeal flap procedures were studied. Demographics, type and duration of operation, associated procedures, surgeon, anesthetist, duration of hospital stay, associated medical conditions, and perioperative complications such as bleeding, respiratory insufficiency, or flap dehiscence were evaluated. In this series a total complication rate of 6 percent was found, with 2.4 percent early (<6 weeks) and 3.8 percent late (>6 weeks) complications. Only two patients (0.7 percent) had postoperative bleeding requiring reoperation, and one patient (0.3 percent) needed reintubation. The most frequent complication was flap dehiscence in nine patients (3.1 percent), which occurred early in three and late in six. Pharyngeal flap surgery can be performed safely with very few complications provided the correct experience and infrastructure are present. Careful surgery, in conjunction with adequate anesthesia and postoperative monitoring, makes these procedures safe and rewarding.     

Role of Imaging Tests for Preoperative Location of Pathologic Parathyroid Tissue in Patients with Primary Hyperparathyroidism

Objective: Primary hyperparathyroidism (PHPT) can be cured by parathyroidectomy, and the preoperative location of enlarged pathologic parathyroid glands is determined by imaging studies, especially cervical ultrasonography and scintigraphy scanning. The aim of this retrospective study was to evaluate the use of preoperative cervical ultrasonography and/or parathyroid scintigraphy in locating pathologic parathyroid tissue in a group of patients with PHPT followed in the same endocrine center.Methods: We examined the records of 61 patients who had undergone parathyroidectomy for PHPT following ^99mTc-sestamibi scintigraphy scan and/or cervical ultrasonography. Scintigraphic and ultrasonographic findings were compared to histopathologic results of the surgical specimens.Results: Ultrasonography detected enlarged parathyroid glands in 87% (48/55) of patients with PHPT and ^99mTc-sestamibi scintigraphy in 79% (37/47) of the cases. Ultrasonography was able to correctly predict the surgical findings in 75% (41/55) of patients and scintigraphy in 72% (34/47). Of 7 patients who had negative ultrasonography, scintigraphy correctly predicted the surgical results in 2 (29%). Of 10 patients who had negative scintigraphy, ultrasonography correctly predicted the surgical results in 4 (40%). When we analyzed only patients with solitary eutopic parathyroid adenomas, the predictive positive values of ultrasonography and scintigraphy were 90% and 86%, respectively.Conclusion: Cervical ultrasonography had a higher likelihood of a correct positive test and a greater predictive positive value for solitary adenoma compared to ^99mTc-sestamibi and should be used as the first diagnostic tool for preoperative localization of affected parathyroid glands in PHPT.Abbreviations:Ca = calciumIEDE = Instituto Estadual de Diabetes e Endocrinologia Luiz CapriglionePHPT = primary hyperparathyroidismPTH = parathyroid hormone     

Cystic Lymph Nodes in the Lateral Neck As Indicators of Metastatic Papillary Thyroid Cancer

ObjectiveTo determine whether radiographic findings portend to metastatic disease in patients with papillary thyroid carcinoma (PTC) and whether cystic lymph node metastasis can be recognized by preoperative, ultrasound-guided fine-needle aspiration (FNA).MethodsWe performed a retrospective review of patients with cystic lymph nodes in the lateral neck identified on preoperative ultrasonography between March 1996 and December 2009. Factors examined included demographic information; stage; cytologic and final pathologic findings; and imaging characteristics including location, size, and presence of vascularity and calcifications. Time of cystic node identification in relationship to initial diagnosis was also recorded.ResultsThirty patients had cystic lymph nodes in the lateral neck on cervical ultrasonography during the study period. Among this group, 28 (93%) had PTC, 1 (3%) had papillary serous carcinoma of the ovary, and 1 (3%) had poorly differentiated thyroid cancer. Median age at initial cancer diagnosis was 41 years (range, 16-64 years). Twenty-one patients (70%) were women, and median lymph node size was 1.8 cm (range, 0.6-4.8 cm). Twenty-three patients (77%) had a solitary cystic lymph node, and the remainder had more than 1 cystic lymph node. Cystic lymph nodes were identified at initial presentation in 11 patients (37%), while cystic lymph nodes were discovered in 19 patients (63%) after the initial operation. FNA was performed on the cystic lymph nodes of 23 patients (77%). Cytologic findings were positive for metastatic disease in 18 of 23 patients (78%). Among the 5 of 23 patients with negative cytologic findings, thyroglobulin aspirate was obtained in 1 patient, confirming metastatic PTC. Final pathologic review after surgical resection of cystic lymph nodes with negative cytologic findings from FNA was consistent with metastatic disease in 4 of 5 patients (80%).ConclusionsIn patients with PTC, the presence of a cystic lymph node by ultrasonographic examination is highly suggestive of locally metastatic disease. Confirmation of metastatic PTC may sometimes be achieved with thyroglobulin aspirate from cystic lymph nodes when cytologic findings are negative. Clinicians should strongly consider surgical lymph node resection of cystic lymph nodes regardless of the preoperative cytologic findings by FNA. (Endocr Pract. 2011;17:240-244)     

Large-volume suction lipectomy: an analysis of 108 patients.

Suction lipectomy was initially advocated for the treatment of localized collections of fat and for the removal of less than 1500 ml of material. However, many patients wished to have multiple areas treated or had diffuse collections of fat. In such instances, the removal of over 1500 ml of material and circumferential lipectomy are necessary to provide optimal aesthetic results. However, when over 1500 ml of material is removed, anesthetic requirements, fluid replacement, and treatment of blood loss become important if the operation is to be performed safely. We have treated 108 patients who had over 1500 ml of material removed. Eight-eight percent of the patients were female; 12 percent were male. Using the body-mass index, 3 percent of patients were underweight, 70 percent were normal weight, and 27 percent were overweight. Fifty-five patients (51 percent) had 1500 to 2499 ml of material removed, 26 patients (24 percent) had 2500 to 3499 ml removed, 16 patients (15 percent) had 3500 to 4499 ml removed, and 11 patients (10 percent) had over 4500 ml removed. All patients were treated in the hospital; 44 percent were admitted after surgery. A total of 227 units of autologous and 2 units of homologous blood were transfused. As measured by a computerized monitor, the average amount of blood in the material removed from thighs was 30 percent; from abdomens, the blood loss was 45 percent. The aesthetic results were generally excellent. No complications were encountered. A few patients developed undesired sequelae, the most common of which was seroma formation, which occurred in 19 percent of those who had suction of abdominal-wall fat. We believe that large-volume suction lipectomy is safe and efficacious, provided attention is directed to such important aspects of patient care as anesthesia, fluid replacement, and blood loss.     

Barium swallows after free jejunal transfer: should they be performed routinely?

Fistula formation after free jejunal transfer for pharyngoesophageal reconstruction is a serious complication with potentially critical consequences. Barium swallow is used postoperatively to check for anastomotic competence before feeding but has been unreliable as a predictor of leak at our institution. The objective of this study was to evaluate the role of routine postoperative barium swallow in 41 consecutive jejunal transfers. Thirty-nine patients who underwent 41 consecutive free jejunal transfers had a routine barium swallow performed between postoperative days 12 and 17. Radiologic findings and clinical outcome were evaluated and correlated. All barium swallows were reviewed by a single experienced radiologist in a blinded fashion. One total and one partial flap failure necessitated a second free jejunal transfer. Pharyngocutaneous fistulae developed after nine free jejunal transfers, of which the barium swallow was normal in four (44 percent) and showed a leak in five (56 percent). In the 32 free jejunal transfers with no clinical leaks, 6 (19 percent) had radiologic leakage of contrast. Thus, barium swallow was normal in 30 patients and showed leakage in 11 patients. Normal barium swallow correlated with uncomplicated clinical course in 26 of 30 cases. In the remaining four cases (13 percent), however, a delayed fistula developed, which was secondary to flap necrosis in one case (negative predictive value 87 percent). On the other hand, radiologic leaks corroborated clinical fistula in 5 of 11 cases (45 percent), whereas no fistula developed in 6 cases (positive predictive value 46 percent). Of the five patients with clinical fistulae, four had early leaks (within 1 week), and the barium swallow did not provide additional information. The fifth patient developed a delayed leak 2 weeks after the barium swallow. Review of these barium swallows at the time of this study reversed the initial report of leakage in three patients, improving the predictive value to 63 percent. These patients had an uncomplicated clinical course. The positive predictive value of clinical assessment alone was 63 percent. We conclude that barium studies following free jejunal transfers can be difficult to interpret, but an experienced radiologist can improve their accuracy. A normal barium swallow, however, does not ensure an uneventful clinical course. Similarly, radiologic leaks do not imply a clinical complication of fistula. Clinical judgment should therefore be exercised in initiating oral intake after free jejunal transfer. Barium swallow should be used only as an adjunct to aid in patient management.     

Traumatic optic neuropathy: a review of 61 patients

The outcome of traumatic optic neuropathy was evaluated following penetrating and blunt injuries to assess the effect of treatment options, including high-dose steroids, surgical intervention, and observation alone. Factors that affected improvement in visual acuity were identified and quantified. Sixty-one consecutive, nonrandomized patients presenting with visual loss after facial trauma between 1984 and 1996 were assessed for outcome. Pretreatment and posttreatment visual acuities were compared using a standard ophthalmologic conversion from the values of no light perception, light perception, hand motion, finger counting, and 20/800 down to 20/15 to a logarithm of the minimum angle of resolution (log MAR). The percentage of patients showing visual improvement and the degree of improvement were calculated for each patient group and treatment method. Measurements of visual acuity are in log MAR units +/- standard error of the mean.Patients who sustained penetrating facial trauma (n = 21) had worse outcomes than patients with blunt trauma (n = 40). Improvement in visual acuity after treatment was seen in 19 percent of patients with penetrating trauma compared with 45 percent of patients with blunt trauma (p < 0.05). Furthermore, patients with penetrating trauma improved less than those with blunt trauma, with a mean improvement of 0.4 +/- 0.23 log MAR compared with 1.1 +/- 0.24 in blunt-trauma patients (p = 0.03). The patients with blunt trauma underwent further study. There was no significant difference in improvement of visual acuity in patients treated with surgical versus nonsurgical methods; however, 83 percent of patients without orbital fractures had improvement compared with 38 percent of patients with orbital fractures (p < 0.05). The mean improvement in patients without orbital fractures was 1.8 +/- 0.65 log MAR compared with 0.95 +/- 0.26 in patients with orbital fractures (p = 0.1). Twenty-seven percent of patients who had no light perception on presentation experienced improvement in visual acuity after treatment compared with 100 percent of patients who had light perception on admission (p < 0.05). The mean improvement in patients who were initially without light perception was 0.85 +/- 0.29 log MAR compared with 1.77 +/- 0.35 in patients who had light perception (p < 0.05). There were no significant differences in improvement of visual acuity when analyzing the effect of patient age and timing of surgery. Patients who sustain penetrating trauma have a worse prognosis than those with blunt trauma. The presence of no light perception and an orbital fracture are poor prognostic factors in visual loss following blunt facial trauma. It seems that clinical judgment on indication and timing of surgery, and not absolute criteria, should be used in the management of traumatic optic neuropathy.     

Medical problems of adults who were sexually abused in childhood.

The aim of the study was to see whether adults who had been sexually abused in childhood were vulnerable to physical symptoms and therefore investigation and intervention. The case histories of seven patients who were aged 22-39, were under the care of three consultant psychiatrists, had experienced childhood sexual abuse, and had a history of medical or surgical intervention were surveyed. The patients had had a mean of 18 contacts with non-psychiatric consultant teams and a mean of eight operations, with a high rate (66-70%) of normal findings. They had experienced many somatic symptoms, which led to investigations and interventions in the specialties of gynaecology, obstetrics, gastroenterology, urology, rheumatology, haematology, orthopaedics, neurology, and neuropsychiatry. The history of childhood sexual abuse was recognised only in the later stages of this medical and surgical intervention. The possibility of childhood sexual abuse should be considered earlier in such cases to prevent further unnecessary intervention.     

Surgical treatment of migraine headaches

This prospective study was conducted to investigate the role of removal of corrugator supercilii muscles, transection of the zygomaticotemporal branch of the trigeminal nerve, and temple soft-tissue repositioning in the treatment of migraine headaches. Using the criteria set forth by the International Headache Society, the research team's neurologist evaluated patients with moderate to severe migraine headaches, to confirm the diagnosis. Subsequently, the patients completed a comprehensive migraine headaches questionnaire and the team's plastic surgeon injected 25 units of botulinum toxin type A (Botox) into each corrugator supercilii muscle. The patients were asked to maintain an accurate diary of their migraine headaches and to complete a monthly questionnaire documenting pertinent information related to their headaches. Patients in whom the injection of Botox resulted in complete elimination of the migraine headaches then underwent resection of the corrugator supercilii muscles. Those who experienced only significant improvement underwent transection of the zygomaticotemporal branch of the trigeminal nerve with repositioning of the temple soft tissues, in addition to removal of the corrugator supercilii muscles. Once again, patients kept a detailed postoperative record of their headaches. Of the 29 patients included in the study, 24 were women and five were men, with an average age of 44.9 years (range, 24 to 63 years). Twenty-four of 29 patients (82.8 percent, p < 0.001) reported a positive response to the injection of Botox, 16 (55.2 percent, p < 0.001) observed complete elimination, eight (27.6 percent, p < 0.04) experienced significant improvement (at least 50 percent reduction in intensity or severity), and five (17.2 percent, not significant) did not notice a change in their migraine headaches. Twenty-two of the 24 patients who had a favorable response to the injection of Botox underwent surgery, and 21 (95.5 percent, p < 0.001) observed a postoperative improvement. Ten patients (45.5 percent, p < 0.01) reported elimination of migraine headaches and 11 patients (50.0 percent, p < 0.004) noted a considerable improvement. For the entire surgical group, the average intensity of the migraine headaches reduced from 8.9 to 4.1 on an analogue scale of 1 to 10, and the frequency of migraine headaches changed from an average of 5.2 per month to an average of 0.8 per month. For the group who only experienced an improvement, the intensity fell from 9.0 to 7.5 and the frequency was reduced from 5.6 to 1.0 per month. Only one patient (4.5 percent, not significant) did not notice any change. The follow-up ranged from 222 to 494 days, the average being 347 days. In conclusion, this study confirms the value of surgical treatment of migraine headaches, inasmuch as 21 of 22 patients benefited significantly from the surgery. It is also evident that injection of Botox is an extremely reliable predictor of surgical outcome.     

Secondary abdominal contour surgery: a review of early and late reoperative surgery

A retrospective chart review of 400 abdominal contour operations produced a series of 24 patients who underwent both their primary and then their secondary abdominal contour surgeries with the senior author (Matarasso). The majority of patients were classified and treated according to the abdominoplasty classification system previously described; however, a subgroup could not be categorized according to this system. In this study, the authors identified the secondary abdominal contour surgical experience of one surgeon. A comparison was made between two groups of patients treated for both primary and secondary operations: group I, considered early, less than 18 months after the previous operation; and group II, considered late, 18 or more months after the previous operation. There was a significant difference between groups I and II (chi2 = 4.12, p = 0.05); most patients had their surgical procedures before 18 months. For patients who underwent either a miniabdominoplasty or a full primary abdominoplasty, there was a statistically significant difference between the number of patients treated in group I and the number in group II (Fisher's exact test, D = 0, p = 0.05). Next, the nature of the secondary procedure was determined to be either a revisional procedure or a completely new reoperative procedure. The majority of patients underwent revision or "touch-ups," accomplished with either liposuction alone or in combination with scar revision. There was no significant difference between types of primary and secondary procedures performed in group I or group II. Secondary abdominal contour surgery accounted for 6 percent (24 of 400) of all abdominal contour procedures performed by one surgeon. Complete secondary surgery, performing an additional open procedure, occurred in 21 percent of cases (five of 24). Revision surgery (scar revision or removal of dog-ears) was performed in 29 percent of all cases (seven of 24). There was a 4 percent (one of 24) complication rate requiring operative intervention. This rate is consistent with that reported in the literature for primary abdominal contour surgery. With the overall acceptance of aesthetic surgery increasing, the number of patients undergoing abdominoplasty increasing, an aging population, and the safety of secondary abdominal contour surgery suggested from this review, it is likely that plastic surgeons will see more patients requesting secondary abdominal contour surgery in the future.     

Is the treatment of axillary osmidrosis with liposuction better than open surgery?

Axillary osmidrosis is an annoying, although not life-threatening, problem that includes unpleasant odor and the occasional staining of clothing. Suction-assisted lipectomy has been tested as a treatment for axillary osmidrosis with variable success. The authors retrospectively reviewed 134 patients who underwent superficial liposuction for bilateral axillary osmidrosis in their division between June of 1998 and June of 2002. The surgical complications and results were compared with those reported in their previous report of 343 patients (102 available for postoperative result evaluation) who received open surgical treatment with partial excision of axillary skin and subcutaneous tissue. The overall complication rate was 3.73 percent, significantly lower than the 11.08 percent complication rate seen with open surgical treatment. Of their 134 patients, 114 were available for long-term follow-up. Thirteen patients (11.40 percent) had very good results, 79 patients (69.30 percent) had good results, and 22 patients (19.30 percent) had poor results. Significant differences were found between those who underwent superficial liposuction and those who underwent open surgery. The number of patients with very good and good results decreased significantly from 91.18 percent (open surgery) to 80.70 percent (liposuction), and those with little or no improvement increased from 8.82 percent (open surgery) to 19.29 percent (liposuction). Compared with open surgery for the treatment of osmidrosis, liposuction produces significantly fewer complications but is less effective. Of the patients who underwent liposuction for osmidrosis, 80 percent were satisfied with the result. Further study is needed to determine whether liposuction for osmidrosis can be improved.     

Hip fractures in healthy patients: operative delay versus prognosis.

One hundred and forty five women who had undergone hemiarthroplasty for a subcapital fracture of the femoral neck but who were otherwise fit were studied to determine whether undue delay between injury and operation influenced their social circumstances three months after surgery. The median delay for those patients who showed good rehabilitation at three months was 29 hours, but for those who showed poor rehabilitation it was 57 hours. This difference was significant. It is suggested that a subcapital fracture in an otherwise fit elderly patient should therefore be regarded as a surgical emergency.     

Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients

Although much is written concerning breast augmentation, few authors have addressed preoperative chest wall analysis as it pertains to postoperative outcome. In the present study, 100 patients were randomly selected, underwent bilateral augmentation, and were examined retrospectively by four independent physicians using standardized preoperative photographs. Each patient was examined for ptosis and asymmetry of the nipples, breast mound, and chest wall. Results revealed significant asymmetries in all parameters. Nipple-areola complex asymmetry was present in 24 percent (nipple/areola size) and 53 percent (nipple position) of the women. Mound asymmetry was noted in 44 percent (volume), 29 percent (base constriction), and 30 percent (inframammary fold position) of the women, and finally, 29 percent of the women had grade I to III ptosis. Chest wall asymmetry was observed in 9 percent of the women. Overall, 88 percent of the women had some degree of asymmetry, and 65 percent of the women had more than one parameter of asymmetry. These findings underscore the importance of developing a systematic preoperative breast and chest wall analysis that can be individualized for each patient. The resulting asymmetries should then be discussed with the patient, along with the potential for continued or even more pronounced asymmetry postoperatively.     

Results with Furlow palatoplasty in management of velopharyngeal insufficiency.

A retrospective study was undertaken to assess speech outcomes in patients undergoing Furlow palatoplasty. Since 1994, the authors have used the position of the levator veli palatini musculature to determine type of surgical intervention recommended for the management of velopharyngeal insufficiency. Furlow palatoplasty has been used in patients with clinical evidence of sagittally oriented levator veli palatini musculature. Forty-eight patients who underwent a Furlow palatoplasty between June of 1994 and August of 1998 were included. All patients underwent preoperative and postoperative perceptual speech analyses to describe velopharyngeal insufficiency severity, nasal air emissions, and resonance, and preoperative nasendoscopy to assess velopharyngeal gap size and palatal and lateral pharyngeal wall movement. Other patient characteristics considered included gender, age at time of surgery, previously repaired cleft palate, submucous cleft palate, and syndrome diagnosis. Speech outcomes were determined on the basis of postoperative perceptual speech analyses and were categorized in one of three ways: (1) complete resolution of velopharyngeal insufficiency, (2) substantial improvement of velopharyngeal insufficiency, and (3) audible residual velopharyngeal insufficiency. Complete resolution of velopharyngeal insufficiency was defined as normal resonance and an absence of nasal air emissions. Substantial improvement of velopharyngeal insufficiency was defined as an improvement of at least two categories in velopharyngeal insufficiency severity in those patients without complete resolution. Audible residual velopharyngeal insufficiency refers to patients with postoperative velopharyngeal insufficiency severity ratings of mild, moderate, or severe. The male:female ratio in the study was 27:21. Twelve patients were syndromic; three had velocardiofacial syndrome. The median age at surgery was 6.5 years (range, 2 to 22 years). The average duration of follow-up was 14.7 months (range, 1.3 to 58.6 months). Postoperatively, the severity of velopharyngeal insufficiency was rated as none in 19 of the 48 patients (39.6 percent), minimal in eight (16.7 percent), mild in six (12.5 percent), moderate in nine (18.75 percent), and severe in six (12.5 percent). Substantial improvement was seen in seven of the 29 patients without complete resolution. There was a significant association between male gender and complete resolution of velopharyngeal insufficiency (p < 0.05). Presence of syndrome and female gender was associated with audible residual velopharyngeal insufficiency (p < 0.05). The main complication was palatal fistula (two cases). In conclusion, most patients who underwent a Furlow palatoplasty had a complete resolution or substantial improvement of velopharyngeal insufficiency postoperatively, and there were few surgical complications.     

Outcomes of Transsphenoidal Surgery in Cushing Disease Patients with Negative Pituitary Magnetic Resonance Imaging Findings: A Single-Center Experience

Objective: Transsphenoidal surgery (TSS) is a first-line treatment for Cushing disease (CD). However, a subset of patients with CD have no visible adenoma on magnetic resonance imaging (MRI), and whether MRI results affect surgical outcomes is controversial. The aim of this study was to compare the surgical outcomes of CD patients with negative MRI findings to those of patients with positive MRI findings.Methods: The clinical features and outcomes of CD patients who underwent TSS between January 2000 and July 2019 at Peking Union Medical College Hospital were collected from medical records. The clinical, endocrinologic, histopathologic, surgical outcomes, and a minimum 12-month follow-up of 125 consecutive CD patients with negative MRI findings were compared with those of 1,031 consecutive CD patients with MRI-visible adenomas.Results: The total remission rate was 73.3% after TSS, and 11.8% of patients experienced recurrence. Of 1,031 patients with MRI-visible adenomas, postoperative remission was achieved in 762 patients (73.9%), and the recurrence of CD was observed in 94 (12.3%) patients. Of the 125 patients with negative MRI findings, postoperative remission was achieved in 85 (68%) patients, and recurrence was observed in 6 (7.1%) patients. The remission rate and recurrence rate were not significantly different between patients with negative MRI findings and those with positive MRI findings (all P>.05). The remission rate was not significantly different between patients who did or did not undergo bilateral inferior petrosal sinus sampling (BIPSS) in patients with negative MRI findings (P>.05). In the patients with negative MRI findings who underwent BIPSS, the remission rate of patients with positive BIPSS results was not different from that in patients with negative BIPSS results (P>.05). The lack of prior TSS, the detection of a tumor during operation, and pathologic confirmation of adenoma were associated with a higher surgical remission rate in patients with negative MRI findings (all P<.05). Similar results were observed in the patients with positive MRI findings (all P<.05). In addition, the major perioperative complications, including intraoperative cerebrospinal fluid leakage, hypopituitarism, and transient diabetes insipidus, were not related to the MRI results (all P>.05).Conclusion: The remission rate and recurrence rate were not different between patients with negative MRI findings and those with positive MRI findings. If CD is clearly diagnosed according to biochemical tests, radiologic examinations, and BIPSS, we recommend TSS as the first-line treatment for patients, even if the MRI results are negative.     

Achieving a predictable 24-hour return to normal activities after breast augmentation: Part II. Patient preparation, refined surgical techniques, and instrumentation.

The goal of this study was to develop practices that would allow patients undergoing subpectoral augmentation to predictably return to full normal activities within 24 hours after the operation, free of postoperative adjuncts. Part I of this study used motion and time study principles to reduce operative times, medication dosages, perioperative morbidity, and recovery times in augmentation mammaplasty. Part II of the study focuses on details of patient education, preoperative planning, instrumentation, and surgical technique modifications that were identified, modified, and implemented to achieve the results reported in part I.Two groups of 16 patients each (groups 1 and 2) were studied retrospectively for comparison to a third group of 627 patients (group 3) studied prospectively. Patients in group 1 had axillary partial retropectoral breast augmentations in 1982-1983, using dissociative anesthesia, blunt instrument implant pocket dissection, and Dow Corning, double-lumen implants containing 20 mg of methylprednisolone and 20 cc of saline in the outer lumen of the implants. Patients in group 2 (1990) had inframammary, retromammary augmentations by using a combination of blunt and electrocautery dissection, Surgitek Replicon polyurethane-covered, silicone gel-filled implants, and general endotracheal anesthesia. Patients in group 3 (1998 to 2001, n = 627) had inframammary partial retropectoral, inframammary retromammary, and axillary partial retropectoral augmentations under general endotracheal anesthesia. Refined practices and surgical techniques from studies of groups 1 and 2 were applied in group 3.Videotapes from operative procedures of groups 1 and 2 were analyzed with macromotion and micromotion study principles, and tables of events were formulated for each move during the operation for all personnel in the operating room. Extensive details of surgical technique were examined and reexamined in 13 different stages by using principles of motion and time studies described in part I of this study to maximize efficiency without any change in quality. Unnecessary or unproductive motions and techniques were progressively eliminated, and essential, productive techniques were streamlined to eliminate wasted time and motion. Instrumentation and surgical techniques were evaluated in detail and modified to minimize bleeding and tissue trauma.Detailed data were presented in part I of this study that document shorter operative times, recovery times, time to discharge home, and time to return to normal activities. This part focuses on the patient education, preoperative planning, instrumentation, and surgical technique changes that were implemented on the basis of the findings in part I of the study. More extensive patient information integrated with staged informed consent resulted in a more informed and confident patient. Applying motion and time study principles to analysis and refinement of instrumentation and surgical techniques resulted in a substantial reduction in perioperative morbidity and a simpler, shorter 24-hour return to full normal activity for 96 percent of the patients undergoing breast augmentation in group 3 compared with groups 1 and 2. More than 96 percent of patients in group 3 were able to return to normal activities, lift their arms above their heads, lift normal-weight objects, and drive their car within 24 hours after their partial retropectoral breast augmentation.Patient education, preoperative planning, instrumentation, and surgical technique modifications based on motion and time study video analyses reduced surgical trauma and bleeding, reduced perioperative morbidity, and allowed 96 percent of 627 breast augmentation patients in group 3 a predictable return to full, normal activity in 24 hours or less. Specific surgical factors that contributed to these results included (1) prospective hemostasis techniques with a zero tolerance for even the smallest amount of bleeding, (2) strict "no-touch" techniques for periosteum and perichondrium, (3) eliminating all blunt dissection, (4) performing all dissection under direct vision, (5) modified and simplified instrumentation, and (6) optimal use of muscle relaxants during subpectoral dissection.     

Wound healing problems in smokers and nonsmokers after 132 abdominoplasties

To study the effects of smoking on wound healing, the authors retrospectively analyzed the records of 132 patients (121 women and 11 men) who had undergone abdominoplasty in the previous 5 years. All patients had received a full abdominoplasty, with large mobilization up to the ribs and a belly transposition. Patients were excluded from the study if they had arteriosclerosis, diabetes mellitus, or other systemic diseases, and if they had received a simple pannus resection without a belly transposition.The following study parameters were taken for analysis: age at the time of operation, body mass index, preoperative weight loss, amount of resection, and smoking habits indicated by the patients preoperatively. Smokers were interviewed by telephone postoperatively concerning their perioperative smoking habits. Wound healing problems were registered when medical intervention was necessary, such as débridement, treatment for infection, lavage after fat necrosis, or a secondary skin closure after skin slough. Hematoma and seroma were not considered to be wound healing problems and were registered separately.Among the 132 patients, 53.8 percent admitted to smoking and 46.2 percent reported being nonsmokers. No significant difference was seen between smokers and nonsmokers concerning age or body mass index. Smokers reported consuming, on average, 18.4 cigarettes per day. The rate of wound problems and wound dehiscence showed a statistical difference between smokers and nonsmokers (p < 0.01); 47.9 percent of the smokers showed wound healing problems before hospital discharge versus 14.8 percent of the nonsmokers. The patients had been asked to quit smoking 2 weeks before the operation through 2 weeks postoperatively. The retrospective telephone inquiry found that just 14.7 percent stopped smoking preoperatively and only 41.2 percent quit temporarily after the operation.Smokers should be informed about their possible higher risk of wound healing problems. Because it seems impossible to turn smokers into nonsmokers, the authors continue to perform abdominoplasties in smokers. During the operation, they try to mobilize and resect less tissue and to immobilize patients for the critical first 3 postoperative days to prevent them from smoking.     

Macromastia: how much of it is fat?

A total of 25 patients who underwent bilateral breast reduction were included in this study. Each patient's age, weight, height, and amount of breast tissue removed from each breast were recorded. The body mass index was calculated for each patient. On the day of the operation, tissue samples (two each) were taken from the central, lateral, and preaxillary areas of the breast. One of the samples was weighed, placed in a closed glass container, and heated for 10 minutes in a microwave oven at full power. The liquid fat was separated from the solid residue, and the percentage of fat was calculated. The other sample from each area was examined grossly, and representative sections, corresponding to the distribution of fat and connective tissue, were submitted for evaluation. In these samples, the percentage of fat, gland, and connective tissue was estimated using low-magnification light microscopy. In this group of patients (who had an average age of 34 years and who were significantly overweight as determined by a mean body mass index of 28), it was found (using the microwave method) that there was a mean fat percentage of 61 percent in the central breast area, 74 percent in the lateral breast area, and 73 percent in the preaxillary area. Upon microscopic examination, the pathologist reported that fat accounted for 64 percent of the central breast area, 92 percent of the lateral breast area, and 94 percent of the preaxillary area. On average, the central breast area in macromastia patients had only seven percent gland and 29 percent connective tissue. The lateral and preaxillary areas of the breast had one to three percent gland and five percent connective tissue. The two methods had a significant (p < 0.05) positive correlation in the central breast area, but in the lateral and preaxillary regions, the correlation was poor. In the microscopic examination, there was a tendency to overestimate the amount of fat. Both methods of evaluation used in the study concur that the enlarged breast of macromastia consists primarily of fat and that the glandular element is rather small.     

Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients

Chest wall irradiation is becoming increasingly common for mastectomy patients who have opted for immediate breast reconstruction with tissue expanders and implants. The optimal approach for such patients has not yet been defined. This study assesses the outcomes of a reconstruction protocol for patients who require irradiation after tissue expander/implant reconstruction. The charts of all patients who underwent immediate tissue expander/implant reconstruction at Memorial Sloan-Kettering Cancer Center between January of 1995 and June of 2001 and who had not previously undergone irradiation were retrospectively reviewed. A subgroup of patients who required chest wall irradiation after mastectomy and reconstruction was identified. Those patients were treated according to the following treatment algorithm: (1) reconstruction with tissue expander placement at the time of mastectomy , (2) tissue expansion during postoperative chemotherapy, (3) exchange of the tissue expander for a permanent implant approximately 4 weeks after the completion of chemotherapy, and (4) chest wall irradiation beginning 4 weeks after the exchange. All irradiated patients with at least 1 year of follow-up monitoring after the completion of radiotherapy were evaluated with respect to aesthetic outcomes, capsular contracture, and patient satisfaction. A control group of nonirradiated patients was randomly selected from the cohort of patients treated during the study period. During the 5-year study period, a total of 687 patients underwent immediate reconstruction with tissue expanders. Eighty-one patients underwent postoperative irradiation after placement of the final implant. A total of 68 patients who received postoperative chest wall irradiation underwent at least 1 year of follow-up monitoring after the completion of radiotherapy, with a mean follow-up period of 34 months. Seventy-five nonirradiated patients were evaluated as a control group. Overall, 68 percent of the irradiated patients developed capsular contracture, compared with 40 percent in the nonirradiated group (p = 0.025). Eighty percent of the irradiated patients demonstrated acceptable (good to excellent) aesthetic results, compared with 88 percent in the nonirradiated group (p = not significant). Sixty-seven percent of the irradiated patients were satisfied with their reconstructions, compared with 88 percent of the nonirradiated patients (p = 0.004). Seventy-two percent of the irradiated patients stated that they would choose the same form of reconstruction again, compared with 85 percent of the nonirradiated patients. The results of this study suggest that tissue expander/implant reconstruction is an acceptable surgical option even when followed by postoperative radiotherapy and should be considered in the reconstruction algorithm for all patients, particularly those who may not be candidates for autogenous reconstruction.