With the rise in obesity in the United States, there has been a similar increase in bariatric surgery. This has resulted in numerous patients losing significant weight with accompanying circumferential body contouring issues. This has led to an amazing increase in the number of body contouring procedures performed, both traditional excisional techniques as well as new emerging techniques emphasizing tissue preservation, rearrangement, and dermal reshaping. Although China's rates of obesity lag behind the United States, there is a recipe for obesity that will eventually surpass the United States. Thus, China has the opportunity to learn from the United States experience with regards to obesity treatment and contouring procedures after significant weight loss. Time will tell whether China will choose to use similar tissue preservation techniques to address issues of soft tissue ptosis and volume deficiency seen after significant weight loss, make refinements of these techniques, or develop new uniquely Chinese solutions.

Background

Photographic standards issued by the Plastic Surgery Educational Foundation ensure accurate comparisons between preoperative and postoperative imaging. These standards, however, do not properly display the circumferential body ptosis seen in massive weight loss (MWL) patients. Photographic standardization for massive weight loss patients is needed for patient consultation, surgical planning, and accurate analysis and comparison of postoperative results.

Patients and methods

A 10-year review of the photographic standards used for MWL patients at the University of California Davis Medical Center were reviewed and compared to current photographic standards in plastic surgery and clinical photo documentation seen in the literature for body contouring after MWL. Evaluation of arm position in obscuring the evaluation of circumferential ptosis in the upper and lower body was performed.

Results

Current photographic standards in plastic surgery do not capture the circumferential ptosis often seen in MWL patients, and there are no consistent modifications or standards recommended for MWL patients. Arm position was noted to affect shadowing and obstruction as well as distortion of circumferential excess. During the first 5 years reviewed, initial consultations included 8 images captured at 45-degree increments with the arms abducted to 90 degrees to document the circumferential excess from shoulders to the knees (Total Body, Fig. 1). They also included 8 images focused on the lower body (Fig. 2) and 8 images focused on the upper body. This required a total of 24 images captured per consultation. During the latter 5 years reviewed, the 8 Total Body images continued to be captured whereas the 16 images focusing on the upper and lower body have been discarded and replaced with 10 images (Fig. 3), captured from shoulders to knees at 45-degree increments with arms positioned behind the back (5) and in the lap (5) for a total of 18 images captured per consultation.

Conclusion

Currently there are no photographic standards for MWL patients that accurately capture their circumferential ptosis. All arm positions affect the evaluation of the circumferential excess to some degree, thus any choice of arm position represents a compromise between visibility and distortion of anatomy. Having considered these issues, we recommend the use of 360-degree clinical photo documentation obtained at 45-degree increments with arms abducted to 90 degrees to capture the total body. We have discarded focused upper and lower body images as these are visible in the Total Body images, thus decreasing patient fatigue and discomfort from excessive pictures. As techniques in post-bariatric body contouring have improved, we now routinely compare our results to non-post-bariatric body contouring patients and thus have added more standard arm positioning to facilitate these comparisons.

Introduction

Common upper body findings after massive weight loss (MWL) include breast ptosis, projection loss, flattening, inframammary fold descent, and back rolls. Although implants address volume loss, manifestations of circumferential excess (ie, back rolls) are ignored. We review our experience with extended lateral fasciocutaneous flaps incorporating circumferential excess tissue, typically removed in upper body lifts (UBLs), for autologous augmentation mastopexy.

Methods

We reviewed all cases of simultaneous autoaugmentation mastopexy and UBL, using extended lateral chest wall fasciocutaneous flaps, performed after MWL. Donor sites were designed with scars residing within the bra line (UBL) or midaxillary line [modified UBL (mUBL)]. We analyzed demographics, clinical indications, and complications.

Results

Between 2007 and 2013, 7 patients underwent 13 extended fasciocutaneous flap reconstructions for autoaugmentation mastopexy, combined with UBL or mUBL. All patients underwent procedures with flaps taken from the back or from the midaxillary line. Mean initial body mass index (BMI) was 50.1 kg/m2 with a preoperative, post-MWL BMI of 28.5 kg/m2, weight loss of 58 kg, and BMI decrease of 21.6 kg/m2. Among 6 patients who underwent bariatric surgery, the average interval between gastric bypass and autoaugmentation mastopexy was 41 months. Five patients underwent these procedures for aesthetic reasons, whereas 2 patients underwent breast reconstruction. Follow-up averaged 18 months. Complications occurred in 3 patients, with only 1 requiring reoperation.

Conclusions

Massive weight loss patients frequently present with breast volume loss and ptotic upper body soft tissue excess. Simultaneous mastopexy augmentation can be safely and reliably performed using extended fasciocutaneous flaps to autologously may be placed in aesthetically acceptable locations. Patients undergoing mUBLs with midaxillary line donor scars may conceal them with arms at their sides. Patients choosing back donor scars may conceal them within the bra line while having greater volumes available for augmentation. As is true with all flaps, one should assess distal tip perfusion before final inset, especially when using a flap extending to the midline back.

Background

Most surgical specialties working with bone have transitioned from wire fixation to more stable plate and screw fixation. Rigid plate fixation results in more rapid bony healing with decreased rates of nonunion, malunion, and infection. Despite sternotomies being the most frequently performed osteotomy, cerclage wire fixation remains the standard technique of closure. This study reviews our 5-year experience with rigid fixation at the University of California Davis Medical Center.

Materials and methods

A retrospective review of patients who underwent rigid sternal fixation between January 2006 and December 2012 at UC Davis Medical Center was performed. Demographic factors, indications for surgery, and risk factors for postoperative complications including mediastinitis and nonunion were reviewed. The type of fixation system was recorded. Outcomes assessed included dehiscence, deep and superficial infections, sternal instability, and need for reoperation.

Results

Fifty-seven rigid sternal fixations were performed (M/F, 37:20; average age, 54 years; range, 16-79 years). Indications for operation included prophylaxis against mediastinitis (61.4%), sternal nonunion (24.6%), sternal fractures (7.0%), and pectus deformities (7.0%). Of the rigid fixation systems used, 87.3% used SternaLock, 12.7% used Talon, 1.8% Lactosorb, and 1.8% Flexigrip. Thirty-five patients were plated for prophylaxis against mediastinitis. In the prophylactic group, the average number of risk factors per patient was 3.92, indicating very high-risk patients. Fourteen patients were plated for sternal nonunion. The average number of risk factors in the nonunion group was 1.57. Other less common indications for rigid sternal stabilization included sternal fracture (4 patients) and pectus deformity (4 patients). Eight patients had a pectoralis flaps performed at the time of their sternal fixation, 7 for soft tissue coverage of plates and 1 for coverage of a contaminated wound bed. All patients went on to heal their sternums without evidence of mediastinitis.

Conclusions

Rigid sternal fixation is a natural extension of principles learned from bone stabilization in other parts of the body. It can be used for rigid bony fixation of osteotomies performed after median sternotomy as well as in sternal reconstructions for traumatic fractures, nonunions, and pectus deformities. Rigid sternal fixation can be used safely and effectively in the prophylaxis against the development of mediastinitis in addition to the treatment of sternal nonunion or malunion in high-risk patients.

Introduction

To evaluate the effect of web-based education on (1) patient satisfaction, (2) consultation times, and (3) conversion to surgery.

Methods

A retrospective review of 767 new patient consultations seen by 4 university-based plastic surgeons was conducted between May 2012 and August 2013 to determine the effect a web-based education program has on patient satisfaction and consultation time. A standard 5-point Likert scale survey completed at the end of the consultation was used to assess satisfaction with their experience. Consult times were obtained from the electronic medical record. All analyses were done with Statistical Analysis Software version 9.2 (SAS Inc., Cary, NC). A P value less than 0.05 was considered statistically significant.

Results

Those who viewed the program before their consultation were more satisfied with their consultation compared to those who did not (satisfaction scores, mean ± SD: 1.13 ± 0.44 vs 1.36 ± 0.74; P = 0.02) and more likely to rate their experience as excellent (92% vs 75%; P = 0.02). Contrary to the claims of Emmi Solutions, patients who viewed the educational program before consultation trended toward longer visits compared to those who did not (mean time ± SD: 54 ± 26 vs 50 ± 35 minutes; P = 0.10). More patients who completed the program went on to undergo a procedure (44% vs 37%; P = 0.16), but this difference was not statistically significant.

Discussion

Viewing web-based educational programs significantly improved plastic surgery patients' satisfaction with their consultation, but patients who viewed the program also trended toward longer consultation times. Although there was an increase in converting to surgical procedures, this did not reach statistical significance.