Introduction: Class 3 (severe) obesity is defined as a body mass index (BMI) greater than 40 kg/m 2 . Obesity is common and an independent risk factor for breast cancer.The plastic surgeon will be tasked with providing reconstruction for obese patients after mastectomy. This presents a surgical dilemma because patients with elevated BMI are known to have greater rates of morbidity when undergoing free flap reconstruction, however free flap reconstruction is associated with greater functional and aesthetic outcomes. This study quantifies complication rates in a cohort of patients with class 3 obesity that underwent abdominally based free flap breast reconstruction. This study may be able answer whether this surgery is feasible or safe.Methods: Patients with a class 3 obesity who underwent abdominally-based free flap breast reconstruction between January 1, 2011 and February 28, 2020 at the authors' institution were identified. A retrospective chart review was performed to record patient demographics and peri-operative data.Results: Twenty-six patients met inclusion criteria. Eighty percent of patients had at least one minor complication including infection (42%), fat necrosis (31%), seroma (15%), abdominal bulge (8%), and hernia (8%). Thirty-eight percent of patients had at least one major complication (requiring readmission (23%) and/or a return to the operating room (38%)). No flaps failed. Conclusion:Abdominally based free flap breast reconstruction in patients with class 3 obesity is associated with great morbidity, however, no patients experienced flap loss or failure which may imply that this population can safely undergo surgery so long as the surgeon is prepared for complications and takes steps to mitigate risk.
BackgroundHeparin‐induced thrombocytopenia (HIT) an immunologically mediated reaction to heparin products, can lead to severe thrombocytopenia and potentially life‐threatening thrombotic events. In microsurgery, a missed or delayed diagnosis of HIT can cause complications requiring revision operations, flap loss, or limb loss. Surgeons must remain vigilant for this uncommon yet potentially devastating condition and keep abreast of management strategies.MethodsCPT and ICD‐10 codes in electronic medical records were used to collect demographic information, clinical courses, and outcomes for patients with a HIT diagnosis who underwent lower extremity free tissue transfer in one institution.ResultsThe authors' institution performed 415 lower extremity free flaps in 411 patients during the 10‐year study period. Flap salvage rate was 71% for compromised lower extremity flaps without HIT, and 25% in those with HIT. Four patients (four flaps) met study inclusion criteria during the study period. Three of the four flaps failed and were later debrided; one was rescued after a takeback for anastomosis revision. Two patients successfully underwent a delayed second free flap procedure after recovery, and one was salvaged with a pedicled muscle flap.ConclusionsSurgeons should monitor for HIT by establishing coagulation panel and platelet count baselines and trending these values in the early post‐operative period for patients treated with heparin products. The 4T score can be used to screen for HIT with high clinical suspicion. Arterial thrombosis or poor flap perfusion despite sound microvascular technique could suggest HIT. Surgical and medical management including strict heparin avoidance can prevent adverse events for these patients.
INTRODUCTION: The incidence of vaginal cuff dehiscence is higher following total laparoscopic hysterectomy (TLH) compared to vaginal and abdominal hysterectomy. Theorized factors include energy, anatomy, stitch size, and other variables. Following a rise in our dehiscence rate to above 2%, several of our surgeons switched to PDS instead of barbed suture based on clinical observations. We present the results below. METHODS: Vaginal cuff handling at laparoscopic hysterectomy was reconsidered. Our group performs a significant volume of relatively homogeneous TLHs. Several physicians transitioned away from a two way barbed suture closure instead using two way running #1 polydioxanone monofilament suture (#1PDS). PDS closure was performed tensioning as in abdominal or vaginal hysterectomy cuff closure. During a 6 month period the two rates of vaginal cuff separation/dehiscence following TLH were compared using the Chi-squared test. RESULTS: 334 TLHs were included in our 6-month study. No eviscerations were noted. Separations (managed surgically or expectantly) were observed in nine out of 175 cases (9/175, 5.1%) when barbed suture was used vs zero of 159 cases when PDS suture was used (0/159, 0%, p-value .0000028). CONCLUSION: Etiology of observed associations of dehiscence with TLH remains unclear. Postulated solutions include optimization of amputation and cuff closure. Our data show that, in a large multispecialty gynecologic group performing high volume TLHs, dehiscence rate is reduced using PDS monofilament. Techniques employed strive to mimic abdominal hysterectomy cuff closure tension and anatomic stitch bite sizes. This study is limited by cuff closure techniques being performed by different physicians.
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