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Biomedical subjects

J M Serletti

Publications and source records attributed to J M Serletti.

At least 19 recordsLinked to original sources
PubMed2001

Soft tissue coverage options for dorsal foot wounds.

The soft tissue of dorsum of the foot consists of a thin pliable surface that allows for significant excursion and tendon gliding. Reconstructive options must preserve these important functions and allow for reasonable contour so the patient may wear a shoe postoperatively. Special attention must be given to the mechanism of injury and overlying pathophysiology involved with each wound. Local flaps can provide adequate wound coverage in settings in which the vasculature and subcutaneous structures have been preserved. In wounds in which the regional vascularity is compromised or in which tendon and bone have been lost, a free-tissue transfer can provide for more substantial coverage. The multiple options available with free-tissue transfer allows for the possibility of composite tissue transfer, including vascularized bone or tendon, and the ability to create a sensate flap with excellent contour.

Foot↗
PubMed2001

Hypothenar hammer syndrome after radial forearm flap harvest: a case report.

A case of acute hypothenar hammer syndrome (HHS) in a high-risk laborer in whom the radial artery had been surgically removed during a prior radial forearm flap harvest is reported. Studies estimating the true incidence of HHS among laborers are reviewed to define the risk of this complication. Two major risk factors must be considered in the assessment of a patient for radial forearm flap harvest. First, the risk for immediate vascular compromise is determined by using a standard Allen's test to assess ulnar artery contribution to hand perfusion. Second, the risk for future vascular compromise is determined. When patients at high risk for HHS are recognized the surgeon should consider other reconstructive alternatives. If the superficial palmar arch is patent and complete and a radial forearm flap is performed, postoperative activity modification and risk counseling should be provided.

Fingers↗
PubMed2001

Outcome comparison between free and pedicled TRAM flap breast reconstruction in the obese patient.

Obesity can be a contraindication for TRAM flap breast reconstruction. This study reviewed the authors' experience with free TRAM and pedicled TRAM flap breast reconstruction in the obese patient to examine the complication rates associated with each reconstructive method and to determine whether TRAM flap reconstruction can safely be used in these high-risk patients. The records of 221 consecutive TRAM flap reconstructions were reviewed. Preoperative risk factors for morbidity were noted, as well as the incidence of TRAM flap success, operative time, length of hospital stay, and postoperative complications. Patients were categorized as obese if their body mass index was greater than 25.8 kg/m2. Data were tabulated using contingency tables and analyzed using chi-squared statistics. Multiple logistic regression was used to determine risk factors for flap complications. Of the 221 patients studied, 114 patients were found to be obese (body mass index >25.8 kg/m2). Of these 114 patients, 78 were reconstructed with free TRAM flaps and 36 were reconstructed with pedicled flaps. In these obese patients, the average body mass index was 32 kg/m2 in the free TRAM and 30 kg/m2 in the pedicled TRAM flap reconstructions. There were no significant differences between groups with regard to age or preoperative risk factors. Length of hospital stay and operative time did not differ significantly between the two reconstructive methods. The average duration of follow-up was 24 months in both groups. Complications occurred in 26 percent of free TRAM flap reconstructions and 33 percent of pedicled reconstructions. There was no significant difference between reconstructive methods with regard to overall complication rates. Increasing body mass index was found to have a significant effect on free TRAM flap complications (p = 0.008) but not on pedicled TRAM flap complications. There were no partial or total flap losses in obese free TRAM flap patients; however, there was one case of total flap loss and four cases of partial flap loss in the obese pedicled TRAM flap group. The incidence of flap loss was significantly higher when pedicled TRAM flaps were used for reconstruction in obese patients (p = 0.04). Obese patients who underwent reconstruction with pedicled TRAM flaps were more likely to experience a complication if they also smoked (p = 0.001). There was no significant difference in operating time or length of stay when pedicled and free TRAM flap reconstructions in obese patients were compared. There were more cases of flap necrosis in the pedicled TRAM flap group. Free TRAM flaps may provide some benefit in reducing partial flap loss in obese patients, but overall complication rates were not significantly different between reconstructive methods. Of 114 patients, there was only one case of total reconstructive failure. From these findings, it seems that the free or pedicled TRAM flap can be used successfully for breast reconstruction in the majority of patients with obesity. Surgeons should use the technique with which they are most familiar to obtain consistent results.

Body Mass Index↗
PubMed2000

TRAM flap breast reconstruction with expanders and implants.

Breast reconstruction has become an essential part of breast cancer management. The transverse rectus abdominis myocutaneous (TRAM) flap has replaced the prosthetic implant as the first choice for breast reconstruction. There are several incidences in which the volume of autogenous tissue cannot fulfill the requirements for symmetric reconstruction, especially in those patients with limited abdominal tissue and large ptotic breasts. The TRAM flap can be combined with tissue expanders and implants to obtain symmetry in these difficult reconstructive situations.

Adult↗
PubMed2000

Pfannenstiel incision as an alternative approach for harvesting the rectus abdominis muscle for free-tissue transfer.

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

Adolescent↗
PubMed2000

Factors affecting outcome in free-tissue transfer in the elderly.

Free-tissue transfers have become the preferred surgical technique to treat complex reconstructive defects. Because these procedures typically require longer operative times and recovery periods, the applicability of free-flap reconstruction in the elderly continues to require ongoing review. The authors performed a retrospective analysis of 100 patients aged 65 years and older who underwent free-tissue transfers to determine preoperative and intraoperative predictors of surgical complications, medical complications, and reconstructive failures. The parameters studied included patient demographics, past medical history, American Society of Anesthesiology (ASA) status, site and cause of the defect, the free tissue transferred, operative time, and postoperative complications, including free-flap success or failure. The mean age of the patients was 72 years. A total of 46 patients underwent free-tissue transfer after head and neck ablation, 27 underwent lower extremity reconstruction in the setting of peripheral vascular disease, 10 had lower extremity traumatic wounds, nine had breast reconstructions, four had infected wounds, two had chronic wounds, and two underwent transfer for lower extremity tumor ablation. Two patients had an ASA status of 1, 49 patients had a status of 2, 45 patients had a status of 3, and four had a status of 4. A total of 104 flaps were transferred in these 100 patients. There were 49 radial forearm flaps, 34 rectus abdominis flaps, seven latissimus dorsi flaps, seven fibular osteocutaneous flaps, three omental flaps, three jejunal flaps, and one lateral arm flap. Four patients had planned double free flaps for their reconstruction. Mean operative time was 7.8 hours (range, 3.5 to 16.5 hours). The overall flap success rate was 97 percent, and the overall reconstructive success rate was 92 percent. There were six additional reconstructive failures related to flap loss, all of which occurred more than 1 month after surgery. Patients with a higher ASA designation experienced more medical complications (p = 0.03) but not surgical complications. Increased operative time resulted in more surgical complications (p = 0.019). All eight cases of reconstructive failure occurred in patients undergoing limb salvage surgery in the setting of peripheral vascular disease. Free-tissue transfer in the elderly population demonstrates similar success rates to those of the general population. Age alone should not be considered a contraindication or an independent risk factor for free-tissue transfer. ASA status and length of operative time are significant predictors of postoperative medical and surgical morbidity. The higher rate of reconstructive failure in the elderly peripheral vascular disease population compares favorably with other treatment modalities for this disease process.

Aged↗
PubMed2000

Clinical applications of the posterior rectus sheath-peritoneal free flap.

Soft-tissue injuries involving the dorsum of the hand and foot continue to pose complex reconstructive challenges in terms of function and contour. Requirements for coverage include thin, vascularized tissue that supports skin grafts and at the same time provides a gliding surface for tendon excursion. This article reports the authors' clinical experience with the free posterior rectus sheath-peritoneal flap foil dorsal coverage in three patients. Two patients required dorsal hand coverage; one following acute trauma and another for delayed reconstruction 1 year after near hand replantation. A third patient required dorsal foot coverage for exposed tendons resulting from skin loss secondary to vasculitis. In all three patients, the flap was harvested through a paramedian incision at the lateral border of the anterior rectus sheath. After opening the anterior rectus sheath, the rectus muscle was elevated off of the posterior rectus sheath and peritoneum. When elevating the muscle, the attachments of the inferior epigastric vessels to the posterior rectus sheath and peritoneum were preserved while ligating any branches of these vessels to the muscle. Segmental intercostal innervation to the muscle was preserved. The deep inferior epigastric vessels were then dissected to their origin to maximize pedicle length and diameter. The maximum dimension of the flaps harvested for the selected cases was 16 X 8 cm. The anterior rectus sheath was closed primarily with non-absorbable suture. Mean follow-up was 1 year, and all flaps survived with excellent contour and good function in all three patients. Complications included a postoperative ileus in one patient, which resolved after 5 days with nasogastric tube decompression.

Adult↗
PubMed2000

Secondary reduction mammaplasty: is using a different pedicle safe?

Reduction mammaplasty is a frequently performed procedure and one with consistent patient satisfaction. Few patients present for revisional procedures, and even fewer present for a secondary or repeated reduction mammaplasty. This study defines secondary reduction mammaplasty as performing an additional reduction using a pedicled nipple-areola complex. Few reports of secondary reduction are found in the literature. Operative guidelines for secondary reduction mammaplasty have been published recently. However, the experience of others has differed from these guidelines, and herein is presented another experience with secondary reduction mammaplasty. Ten cases of secondary reduction over a 37-year period were identified and reviewed. The initial reductions were performed using six different techniques. An average of 307 g of tissue per breast (range, 130 to 552 g) was removed at the initial operations. The secondary reductions were performed using four different techniques, and an average of 458 g of tissue per breast (range, 147 to 700 g) was removed at the secondary operations. Three of the 10 patients underwent initial and secondary reduction with the same technique. An average of 4 years (range, 1 to 10 years) separated these surgeries. Seven of the 10 patients underwent initial and secondary reductions with different technique. An average of 15 years (range, 5 to 19 years) separated these procedures. There was an average 5-year follow-up (range, 1 to 20 years) in this series. Four of the 10 patients experienced self-limiting complications after secondary reduction, including delay in wound healing, delay in the return of nipple sensitivity, and mild fat necrosis. Three of the four patients with complications had undergone secondary reduction with a different pedicle technique. No significant or long-lasting skin, pedicle, or nipple-areola complex compromise was found after secondary reduction mammaplasty. In contrast to the recently published guidelines, this study demonstrates that secondary reduction mammaplasty is a safe and viable option when performed with either similar or different technique. This finding allows secondary reduction mammaplasty to be tailored to the individual breast type and to the abilities of the specific surgeon.

Adolescent↗
PubMed2000

Immediate free TRAM reconstruction in lumpectomy and radiation failure patients.

Local recurrence after lumpectomy and radiation therapy indicates failed breast conservation surgery. These patients often proceed to mastectomy and are candidates for autogenous breast reconstruction. Free transverse rectus abdominus muscle (TRAM) reconstruction in these patients is complicated by repeated axillary dissection and the use of irradiated tissue. Complication rates for pedicled TRAMs have been reported at 33 percent when used in irradiated tissue beds. We report our results using the free TRAM for breast reconstruction after lumpectomy and radiation failure. All patients within this study developed a local recurrence after lumpectomy and radiation therapy. All patients had undergone axillary dissection for staging at the time of their lumpectomy. Patient records were reviewed for patient age, total radiation dose, associated risk factors for TRAM failure, operative time, donor vessels used for anastomosis, status of the native thoracodorsal vessels at the time of surgery, and postoperative complications. Over a 7-year period, 16 TRAM patients had undergone previous breast conservation surgery. Of these 16 patients, 14 underwent reconstruction with a planned free TRAM after simple mastectomy. Average operating room time was 7 hours. There were no partial or total flap losses. Complications were seen in 14 percent of the overall group. Overall, we found that the free TRAM provided an excellent aesthetic result with a lower complication rate than previously reported for pedicled TRAM flaps in irradiated beds. The thoracodorsal vessels provided an adequate donor vessel in 93 percent of the cases. The free TRAM provides a superior alternative in immediate reconstruction in patients who have failed breast conservative surgery.

Age Factors↗
PubMed2000

Transverse lag screw fixation in midline mandibulotomy. A case series.

Vertical midline mandibulotomy has provided a relatively simple and efficient means of obtaining access to intraoral tumors that are too large or too posterior to be removed transorally. Midline mandibulotomy has had the advantage of nerve and muscle preservation and places the osteotomy outside the typical field of radiotherapy, in contrast to lateral and paramedian osteotomies. Plate and screw fixation has been the usual means of osteosynthesis for these mandibulotomies; however, plate contouring over the symphyseal surface has been a time-consuming process. Unless the plate was contoured exactly, mandibular malalignment and malocclusion in dentulous patients has occurred. Use of parallel transverse lag screws has become a popular method of osteosynthesis for parasymphyseal fractures, and we have extended their use for mandibulotomy fixation. This paper reports our clinical experience with transverse lag screw fixation of midline mandibulotomies in 9 patients from 1994 to 1997. There were 7 men and 2 women with a mean age of 56 (range 35 to 71 years). The pathological diagnosis in all patients was squamous cell carcinoma; 8 cases were primary, and 1 patient presented with recurrent tumor. No tumors involved the mandibular periosteum. One patient had had previous radiotherapy, and 3 patients underwent postoperative radiotherapy. The mean follow-up has been 17 months (range 9 to 27). There was 1 minor complication and 1 major complication related to our technique. The major complication was a delayed nonunion of the mandibulotomy. This occurred because the 2 parallel screws were placed too close to one another, and this placement resulted in a delayed sagittal fracture of the anterior cortex and subsequent nonunion. Transverse lag screw fixation has not affected occlusion in our dentulous patients. Speech and diet were normal in the majority of our patients. Transverse lag screw fixation of the midline mandibulotomy has been a relatively safe, rapid, and reliable method for tumor access and postextirpation mandibular stabilization and has significant advantages over other current methods of mandibulotomy and fixation.

Adult↗
PubMed1999

Thoracodorsal vessels as recipient vessels for the free TRAM flap in delayed breast reconstruction.

The internal mammary vessels have been recommended as the first choice recipient vessels for delayed breast reconstruction with the free TRAM flap. This approach has avoided surgery in the previously operated axilla, has required a shorter pedicle length, and has allowed for more medial placement of the TRAM tissue. Frequency of nonusable axillary vessels has been reported at 11 percent, with a 6 percent incidence of flap loss in the delayed reconstructive setting. We reviewed our experience with the thoracodorsal vessels as recipient vessels in delayed free TRAM breast reconstruction to assess more accurately the adequacy of these potential recipient vessels. All patients undergoing delayed TRAM reconstruction were reviewed. Forty-seven of 300 consecutive TRAM procedures were for planned delayed free reconstruction. In seven of the patients (15 percent), the thoracodorsal vessels were found to be inadequate for free reconstruction. A supercharged pedicled TRAM was used for reconstruction in each of these seven patients. Average operating room time was 7 hours. Mean follow-up time was 38 months. Nineteen percent of all patients developed at least one complication. Twelve percent of free TRAM patients developed a complication, whereas 57 percent of supercharged patients developed a postoperative complication. The difference in complication rates was statistically significant. The thoracodorsal vessels have provided an adequate recipient vessel in 85 percent of delayed free TRAM reconstructions, comparable to previous reports. Pedicling and supercharging the flap, in those situations in which the thoracodorsal vessels were inadequate, were associated with an increased incidence of postoperative complications. This suggests that in the delayed reconstructive setting, higher-risk patients benefit from free reconstruction over supercharged reconstructions. A second recipient vessel should be used when the thoracodorsal vessels are inadequate for planned free TRAM reconstruction. In these circumstances, we would recommend the use of the internal mammary vessels followed by the thoracoacromial vessels as reliable alternative recipient sites for delayed free TRAM reconstruction.

Adult↗
PubMed1999

Epidermal nevus syndrome: a review and case report.

The epidermal nevus syndrome is a disease complex of epidermal nevi and developmental abnormalities of different organ systems. The authors present a case of congenital systematized epidermal nevus syndrome in a patient with skin lesions covering approximately 80% of the total body surface area. The patient underwent staged treatment of the epidermal nevi with a carbon dioxide laser utilizing two different techniques. The larger verrucous lesions were debulked initially, and the resulting defects and thinner lesions were treated using the Silk Touch modality. The lesions were dermaplaned sequentially until they were ablated completely. All wounds healed without complication, and in a 2-year follow-up the patient has experienced no recurrence in the treated areas. Epidermal nevi can be treated safely, effectively, and without recurrence with carbon dioxide laser ablation.

Adult↗
PubMed1998

Simultaneous transfer of free fibula and radial forearm flaps for complex oromandibular reconstruction.

Several composite free flaps have been described for use in oromandibular reconstruction. Particularly in extensive defects, there may be no single flap which combines sufficient bone stock with thin, pliable, soft tissue. By combining two free flaps, the best osseous and soft-tissue elements may be independently selected, to yield a result superior to that achievable with one free flap alone. Thirteen patients underwent reconstruction of extensive oromandibular defects using the free fibula for mandibular reconstruction and the free radial forearm flap for oral lining and soft-tissue reconstruction. Mandibular defects were usually extensive, involving over half of the mandibular contour. Soft-tissue defects were all complex and involved multiple surfaces of the oral, oropharyngeal, and nasopharyngeal mucosa. All patients were operated on in the supine position by two surgical teams (extirpative and reconstructive) working simultaneously. Each free flap was supplied by its own set of recipient vessels. The mean total operating time was 12 hr. Postoperative courses were without mortality or significant morbidity. There were no flap failures. Soft-tissue and osseous reconstructions healed completely. Aesthetic contour was judged good to excellent in 11 patients. Soft and solid diets were achieved in five patients, with six patients on a purée or liquid diet. Oral competence was present in 11 patients. Speech was excellent to good in six patients and fair in four patients. The mean follow-up has averaged 18 months. Three patients have died of recurrent disease, and two of unrelated causes. The remaining eight patients are currently free of disease. In combining the free flaps, the best tissue for bone and soft-tissue reconstruction was selected independently. The two-team approach avoided excessive operating time and operating team fatigue. The added degree of freedom provided by the two free flaps with their independent pedicles made insetting easier, compared to working within the limitations of a single composite flap. For extensive oromandibular defects, the simultaneous free fibula and radial forearm free flaps provided ideal osseous and soft-tissue reconstruction, with acceptable operating times and reasonable functional results.

Adult↗
PubMed1998

The combined use of the TRAM and expanders/implants in breast reconstruction.

The transverse rectus abdominis musculocutaneous (TRAM) flap has replaced the prosthetic implant as the first choice for breast reconstruction. However, we have found several incidences when the volume of autogenous tissue cannot fulfill the requirements for symmetry, especially in those patients with limited abdominal tissue and large ptotic breasts. The TRAM flap can be combined with tissue expanders and implants to obtain symmetry in these difficult reconstructive situations. Here we present our experience with the use of the TRAM flap in conjunction with expanders and saline implants. Between June 1993 and November 1996, 4 patients underwent immediate TRAM reconstruction in conjunction with saline implants or tissue expanders. In 3 patients a tissue expander was placed beneath the pectoralis muscle following the microanastomoses and prior to insetting the flap. Expansion was initiated 2 to 6 weeks postoperatively and continued over a period of 1 to 3 months. Permanent implants were placed at 3 to 4 months following the initial procedure. The final patient underwent a bilateral free TRAM with the placement of bilateral saline implants at the time of the initial reconstruction. One implant was placed beneath the pectoralis whereas the other was placed beneath the TRAM flap. Saline implants were used in all patients. The decision to use the combination of implants and TRAM flap was multifactorial and included position of donor scar in all patients, large ptotic breasts in 2 patients, request for contralateral augmentation in 2 patients, and an absence of adequate abdominal tissue in all patients. In addition, large skin deficits were present in 3 patients following mastectomy requiring the skin coverage provided by the TRAM flap. The average age of the patients was 41 years. Expanders were left in place for an average of 16 weeks. Average final implant volume was 210 cc. The average follow-up was 24 months, during which time there were no episodes of flap compromise, partial flap loss, or fat necrosis. The TRAM flap in combination with tissue expansion and implants provides an additional alternative in postmastectomy reconstruction. This technique is particularly useful in those patients in whom the need for TRAM skin coverage is combined with inadequate autogenous tissue and the patient request for large ptotic breasts.

Adult↗
PubMed1998

Functional outcome after soft-tissue reconstruction for limb salvage after sarcoma surgery.

Limb salvage has been achieved for patients with sarcoma by means of compartmental resection, soft-tissue reconstruction, and adjuvant therapy without increased rates of local recurrence, metastasis, or mortality. Despite the prevalence of limb salvage procedures in the treatment of these tumors, relatively little information has been published regarding late functional results in these reconstructed extremities. This study reports on the functional outcome for soft-tissue reconstruction for limb salvage in patients with sarcoma. Over the past 6 years, 28 patients were treated for sarcomas of the extremity in which soft-tissue reconstruction was needed for complete limb salvage. The mean age of these patients was 48 years (range, 14 to 83 years); there were 14 male and 14 female patients. Of the 28 sarcomas, 23 cases involved the lower extremity and 5 cases were in the upper extremity. Reconstruction was performed primarily in 12 patients; 16 reconstructions were performed secondarily because of wound complications after initial extirpation. Adjuvant radiation therapy was administered either preoperatively or postoperatively in all cases. Of the 33 reconstructive procedures performed in these 28 patients, 16 involved free flaps and 17 involved local flaps. All patients achieved initial limb salvage after the reconstructive procedure(s). Mean follow-up was 38 months. Twenty patients were available for the evaluation portion of the study. Two patients had delayed amputations: one for recurrent disease and another for osteoradionecrosis. Two patients died before beginning the examination process: one patient from the sarcoma and another patient from colon cancer. Twenty of the remaining 24 patients agreed to participate and were examined using the Enneking outcome measurement scale. Patients were examined for range of motion, deformity, stability, pain level, strength, functional activity, and emotional acceptance and assigned a numerical score for each category. Based on this, an overall rating of excellent, good, fair, or poor was assigned. Nine patients (45 percent) achieved an overall rating of excellent, five patients (25 percent) achieved a rating of good, and six patients (30 percent) achieved a fair score. None had received a rating of poor. There were no differences in the results obtained comparing upper versus lower extremity, immediate versus delayed reconstruction, or reconstructions performed with a free flap versus a pedicled flap. This study supports the continued use of soft-tissue reconstruction for limb salvage in sarcoma surgery with good to excellent late functional results obtained in the majority of patients.

Adolescent↗
PubMed1998

Urokinase protocol for free-flap salvage following prolonged venous thrombosis.

The incidence of free-flap failure is reported at 4 to 5 percent. Often, these failures are attributed to postoperative venous thrombosis with salvage rates reported at 42 percent. The use of thrombolytics has been effective in laboratory protocols; however, there have been only case reports to substantiate their use in humans. In this study, we establish a protocol for the administration of urokinase for postoperative venous thrombosis. Upon clinical evidence of venous thrombosis, all patients were urgently returned to the operating room, where the venous anastomosis was resected and a new venous anastomosis was performed. A solution of 250,000 units of urokinase was then infused over 30 minutes through a 25-gauge butterfly inserted into the recipient artery just proximal to the arterial anastomosis. Patients were continued on a daily aspirin (325 mg). More than 600 free flaps have been performed by our group since 1990. In that group of patients, five were diagnosed with postoperative venous thrombosis. Flaps consisted of four radial forearm flaps and one free transverse rectus abdominis muscle flap. All patients were diagnosed late based upon significant changes within the flap. Thromboses were clinically apparent on postoperative days 1 through 6, with an average of 3.6 days. All five patients received urokinase as described. The average age of the patients treated was 43. There were no postoperative hematomas, blood transfusions, or bleeding complications. There were no allergic or anaphylactic reactions to the urokinase. All flaps survived (100 percent) with a mean follow-up of 27 months. The use of urokinase as described in our protocol has been an effective thrombolytic, capable of reversing clinically advanced venous thrombosis when combined with repeated venous anastomosis. We believe this protocol provides a viable option for the treatment of postoperative venous thrombosis.

Adult↗
PubMed1997

Reduction mammaplasty in patients with bulimia nervosa.

Women with eating disorders have been disqualified as candidates for plastic surgery. We present a group of 6 young women with bulimia nervosa who presented with clinically symptomatic evidence of macromastia. All patients reported that dysfunctional eating habits, at least in part, where due to breast enlargement. Five patients underwent bilateral reduction mammaplasty. Patients were interviewed postoperatively and reported relief of physical symptoms and improvement in psychological well-being. Symptoms of eating disorders were completely eliminated or greatly reduced. This series has supported the contention that macromastia can produce a distortion of body image and become a secondary cause of eating disorders. Surgical correction of large breasts has improved body image, leads to the amelioration of associated eating disorders, and may in part represent a surgical treatment for a psychological abnormality. The presence of an eating disorder should not, therefore, automatically exclude a patient from surgical consideration. Routine preoperative evaluation of young women seeking plastic surgery should include a set of standard questions regarding eating behaviors.

Adolescent↗