Sixteen patients were treated for sternal wound infections after undergoing cardiac procedures. Their management involved prompt surgical debridement and quantitative wound biopsies. At the time of the initial debridement, the Vacuum-Assisted Closure Device (V.A.C.) was placed in the open sternal wound. A subatmospheric environment was maintained by the device at a level of 75 to 150 mmHg. The V.A.C. sponge was changed every 2 to 3 days, and operative debridement was performed until quantitative biopsies showed resolution of infection or until systemic signs of sepsis had resolved. At this time the sternal wounds were closed with regional muscle flaps. Patients were excluded from the use of the device if the pleural cavity was entered during operative debridement. Fifteen of the 16 patients survived and went on to complete wound healing and discharge from the hospital (average length of stay, 16.7 days). One patient sustained a cardiac dysrhythmia during the muscle flap procedure and died. There were no complications related directly to the use of the V.A.C. It is the opinion of the authors that the V.A.C. offers several advantages over their traditional methods of treatment. They noted improvement in sternal wound stabilization during the perioperative period and a decreased need for paralysis and mechanical ventilation. Wound management was improved by avoiding the need to perform debridement or to make desiccating dressing changes to an open sternum. Moreover, they also think that this device may lessen the risk for ventricular rupture because of better control of the wound environment and markedly improved stabilization of the debrided sternal elements.
Open reduction and internal fixation (ORIF) with refined titanium plates and screws have revolutionized the surgical treatment of complex facial fractures, but its outcome remains relatively unknown. The purpose of this study is to review the results of modern surgical treatment of complex facial fractures involving at least two of the three zones of the face. From 1996 to 2002, 54 consecutive patients (41 males, 13 females; age 5-74 years) with complex facial fractures were treated by the plastic surgery service in our institution. All patients had their fractures repaired within 10 days after injury. ORIF of the fractures was performed through standard surgical approaches for the upper, middle, or lower face in a preferred sequence. Multiple rigid fixations were completed with current titanium plates and screws. Postoperative functional problems, residual cosmetic deformities, and reoperations for any complications in each patient were evaluated. All patients have been followed for up to 5 years. Overall, of the 54 consecutive patients in this study, 8 (14.8%) patients had postoperative functional problems, and 7 (13.0%) developed variable postoperative cosmetic deformities. Only nine (16.7%) patients underwent a subsequent reoperation for correction of the functional or cosmetic concern. Thus, we believe that modern surgical treatment of complex facial fractures by way of open treatment and rigid fixation with refined titanium plates and screws has resulted in overall good to excellent outcomes and a relatively low postoperative complication rate.
Abdominoplasty and breast augmentation are often performed together, and subglandular augmentation through the abdominoplasty incision has been previously described. Nine cases of subpectoral breast augmentation and abdominoplasty performed through a single low transverse abdominal incision were performed between 2002 and 2005. The selection criteria included women who were healthy, nonsmokers, without true breast ptosis or breast deformity requiring additional shaping. The subpectoral space was accessed and the pectoralis major origins were mobilized under direct vision, and the implant pocket was shaped with the aid of a breast sizer and breast dissector. The mean follow-up was 22 months. The surgical goals were realized in all cases, with no asymmetry or implant-related complications. The standard abdominoplasty incision provides ample exposure for the creation of a subpectoral pocket and precise placement of implants. The procedure should be considered in patients who wish abdominal recontouring and breast augmentation and have minimal ptosis.
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