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--- resident:david_mathes [2021/02/14 14:00] – [Operative Reports] jonathan
+++ resident:david_mathes [2023/08/21 13:55] (current) – [Tissue Expander] ally
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 Clip the artery or vein first on a flap? The artery first so the flap isn't engorged with blood\\
 Dr. Mathes preferred markings for breast cases? 9cm limbs always. prefers 6 cm NAC to IMF distance for final appearance.\\
+\\
+Thoughts on TE: Need to decide BW, height, volume and textured. Low height TE will preferentially expand the inferior pole, but have low volume. Sub-pect vs pre-pect. Always goes pre-pect except if the patient has had a previous breast augmentation in sub-pect position. Will still have an animation deformity.\\
+\\
+Pre-pect TE how do you place alloderm? Personal preference, two ways - drape vs wrap. 2 dead layers vs 3 layers. Draping uses less material. Wrapping constricts. Wrapping easier .\\
+Total submuscular drawback? Pain, pushes implant up (very constricting), slow expansion.\\
+\\
+Why not subcutaneous recon? Capsular contracture. But these studies were done in the 80s with radical mastectomies.\\
+\\
+If you are the only one doing something, you are likely the lone genius.\\
+\\
+The book is being written on how well all the pre-pect alloderm recon will hold up.\\
+\\
+Immediate vs delayed reconstruction? Smoking -- complication rate high. Can delay a few weeks. Some say if getting radiation and wants autologous, then can wait later. Can delay for very poor flaps. \\
+Previous irradiation? - Would not offer breast tissue expanders.\\
+If they have are GOING to have radiation? "Late" complication rate increases. Radiated skin does not expand as well. Most would expand completely, radiate and then perform implant exchange. Sloan Kettering paper - radiated after TE implant exchange. Most patients happy in that paper.\\
+Factor for delay for radiation - Obesity. UT SW paper - ostoperative complications delay the commencement of radiation therapy in patients who received neoadjuvant chemotherapy and undergo mastectomy with immediate breast reconstruction. The period from the last dose of neoadjuvant chemotherapy was equivalent between those that experienced postoperative complications and those that did not. Patients with a higher body mass index are more likely to experience postoperative complications, and this should be considered when offering tissue expanders to obese patients who have received neoadjuvant chemotherapy and require adjuvant radiation treatment.\\
+\\
+Direct to implant requirements - Good flaps, wants to be smaller.\\
+\\
+When using areola markers, he likes you to suture the vertical limb. TAKE OUT THE STAPLES OVERLYING THE NIPPLE POSITION. And REMARK the nipple with the skin loose. This is for all breast reductions/mastopexy etc. Hates the "Aycock" Areola markers. Uses 42 mm to cut and downsizes to 38 mm to inset the NAC.\\
 ==== Free Gracilis Flap ====
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 Marking and Sizing the Nipple:
-Sit patient up once all incisions are stapled closed. Mark nipple position at area of greatest projection. Lie patient back flat and remove the staples within the marked nipple circle. With the same nipple sizer, make a new circle in the center of the prior marked circle. This smaller circle is now the new nipple position. De-epithelialize the skin within the circle and then cruciate the dermis. Pull nipple through and secure with interrupted 3-0 monocryl and then running 4-0 monocryl. ***Mathes does not like 4-0 suture to cross T-junctions. Do individual running sutures for each limb.\\
+Sit patient up once all incisions are stapled closed. Mark nipple position at area of greatest projection. Lie patient back flat and remove the staples within the marked nipple circle. With the same nipple sizer, make a new circle in the center of the prior marked circle. This smaller circle is now the new nipple position. De-epithelialize the skin within the circle and then cruciate the dermis. Pull nipple through and secure with interrupted 3-0 monocryl and then running 4-0 monocryl. **Mathes does not like 4-0 suture to cross T-junctions. Do individual running sutures for each limb.**\\
 {{:resident:whatsapp_image_2020-05-16_at_3.44.35_pm.jpeg?400|}}
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 ==== Tissue Expander ===
 Intraoperative antibiotics. Antibiotics for home\\
-Sutures: 3-0 PDS for TE and alloderm, 3-0 monocryl deep dermal, 4-0 monocryl subcuticutlar, mastisol and steris\\
+Sutures: 3-0 PDS for TE and alloderm, 3-0 monocryl deep dermal, 4-0 monocryl subcuticutlar, Dermabond\\
-If going pre-pectoral, make sure that there are 2 pieces of alloderm in the room per side.\\
-Pre-Pec- 2 pieces of alloderm sew into IMF and circumferentially at Breast "SFS" dont really sew into muscle
-Horizontal mattress sutures to secure alloderm, make sure expander is as low as can go the lower the better. Sew alloderm in first superior and inferior than place TE secure inferior and lateral and if can get medial as well. then sew both alloderms together. Place drain. Close\\
+Pre-Pec- Duracell (16x20, cut to breast foot print) sew into IMF and circumferentially at Breast "SFS" don't really sew into muscle
+Horizontal mattress sutures to secure Duracell, make sure expander is as low as can go, the lower the better. Sew Duracell inferiorly first. Then place TE secure medially, then inferiorly (6 o'clock tab has bump). Then once TE's secured, sew Duracell superiorly/laterally. Place drain. Fill TE. Close with 3-0 and 4-0 Monocryl\\
 Placing the alloderm at the edge at the sternal edge of the pectoralis muscle may be a good option for Dr. Mathes' cases. Remember that the alloderm should be placed at the, at the IMF and the breast surgeon will violate the IMF on a regular basis. So you should be actually sewing the alloderm to the top of the flap, not to the chest wall. \\
 Places central tab at the breast meridian.\\ Only sews in 2 tabs for the TE.\\
+Hemostasis was first obtained. The base-width of the pocket was measured as 11 cm and a Mentor Artoura High Profile 300 cc tissue expander was chosen. A piece of alloderm was cut in the shape of the breast footprint and sutured into place with 3-0 PDS interrupted sutures. The tissue expander was then placed and the meridian, medial and lateral tabs sutured with 3-0 PDS interrupted sutures. A 15 french round drain was placed with the exit point in the lateral fold of the breast. Tissue expander was filled. The incision was closed with 3-0 monocryl deep dermal sutures followed by 4-0 monocryl running subcuticular sutures. The incision was dressed with Dermabond.
 ==== Tissue Expander to Implant Exchange====
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 ==== bilateral nipple reconstruction  ====
-We then turned our attention to the nipple reconstruction, which we had marked at 31 cm.  We then drew out a Tennessee-type flap, excised around the edges of the Tennessee flap, preserved the dermis and subdermal plexus as well as some flap fat in order to give it some projection.  We then folded these areas and closed the donor site with deep 3-0 Monocryl and running 4-0 Monocryl for the lateral portion.  The nipple reconstruction itself was constructed by sewing the ends together with 5-0 Monocryl.  Once this was completed and showed pink and viable nipple reconstruction, we then put Dermabond on that area.  We then applied Steri-Strips.  Dressings were applied.  The patient was then extubated and brought to the recovery room in stable condition.
+We then turned our attention to the nipple reconstruction, which we had marked at 31 cm.  We then drew out a Tennessee-type flap, excised around the edges of the Tennessee flap, preserved the dermis and subdermal plexus as well as some flap fat in order to give it some projection.  We then folded these areas and closed the donor site with deep 3-0 Monocryl and running 4-0 Monocryl for the lateral portion.  The nipple reconstruction itself was constructed by sewing the ends together with 5-0 Monocryl.  Once this was completed and showed pink and viable nipple reconstruction, we then put Dermabond on that area.  We then applied Steri-Strips.  Dressings were applied.  The patient was then extubated and brought to the recovery room in stable condition.\\
+\\
+\\
+Resident Tips:\\
+Measure the base of the contralateral nipple and make that the base of the reconstructed nipple. Dr. Mathes' default is 12 mm. Some are smaller.\\
+\\
+As you raise the nipple, it looks like a "man trying to escape." Raise the wings first. Remember to try and keep some fat (from the flap) on them or the tips will die. Once you raise the flap, you want to raise the cap. DO NOT CUT THE BASE. When you are cutting the cap, think about keeping a nice chunk of fat on it so once it's cut, it will be "standing up" on that fat you raised. Before closing the nipple, close the wings. The first stitch you should take is near the base to close it. If you made the base too wide, you can always de-ep and then close. These should be deep dermals with 3-0 monocryl for the wings. The rest of the wing will now be almost an ellipse and you can close. Finish with a 4-0 running subq. Okay for a tail For the nipple, The parallelegram corners close top to top and bottom to bottom with simple interrupted 5-0 monocryl. Close the top and cap again with simple interrupted. He then dermabonds all of it and puts steri strips along the wings.\\
 ==== Bialateral Tissue expander exchange to implants - bilateral circumaerolar mastopexy ====
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 Photos\\
+{{:resident:screen_shot_2021-08-04_at_12.44.05_pm.png?600|}}
 Drain: 10 french round blake drain with 3-0 nylon suture\\
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 Dressing: Mastisol Steristrips\\
-Marking: Mark bicpital groove. Mark out a line a couple cm above and see if it will pull down to groove. Pinch test and mark just shy of that. Can do same for inferior line. Doesn’t usually go into axillae \\
+**Marking:** Mark bicpital groove. Mark out a line a couple cm above and see if it will pull down to groove. Pinch test and mark just shy of that. Can do same for inferior line. Doesn’t usually go into axillae \\
 Position: Arms out bilaterally. NO IVs in arms (put in legs). \\
 Procedure: Remark lines. Place several hash marks transversely. Make superior incision. Stay superficial. Make incisions along hash marks only as far as you know you can close. Staple this (true tailor tack). Can either excise the triangle you've created as you go or all at once after you've made and stapled each hash mark incision. Place a drain. usually smaller (7fr). Close with 3-0, 4-0, dermabond. Wrap with ACE. \\
-Anatomy: Pertinent anatomy should be listed\\
+**Anatomy:** \\
-Post-operative care: Include restrictions, splints, etc...\\
+With the arm abducted and flexed at 90 degrees, the important landmarks for assessment are from the apex of the axillary crease to the olecranon\\
-Learning points/Pimp Questions:\\
+The bicipital groove is the area between the biceps brachii above and the long head of the triceps below.\\
+In the bicipital groove, below the brachial fascia, lie several important neurovasculatur structures including the median and ulnar nerves and the axillary artery and vein.\\
+In the midportion of the upper arm over the bicipital groove, superficial to the brachial fascia, lies the medial brachial cutaneous nerve.\\
+In the distal portion of the upper arm over the bicipital groove, superficial to the brachial fascia, lies the medial antebrachial cutaneous nerve and the basilic vein.\\
+\\
+**Post-operative care:** \\
+Arm compression garment for 4 to 6 weeks.\\
+Keep arms elevated as much as possible.\\
+Do not exceed 90 degrees at the shoulder for 4 weeks.\\
+At 2 weeks, begin massage therapy +/- silicone.\\
+\\
+**Learning points/Pimp Questions:**\\
+Always perform excision in a segmental fashion. Failure to do so may lead to an incision that cannot be closed.\\
+If performing liposuction in combination with a brachioplasty, be sure to do liposuction and the excision immediately afterward on one arm at a time (unless a two-team approach). Otherwise, swelling can lead to decreased ability to excise the desired tissue or can lead to failure to close the arm.\\
+What is the most common complication? - Seroma\\
+What is the most commonly injured nerve? - Medial antebrachial cutaenous nerve.\\
 </WRAP>
 </WRAP>
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 \\
 The patient was brought to the operating room and placed in a supine position.  Bilateral sequential compression devices were not placed because we needed to prep her whole leg.  All pressure points were well-padded.  Surgical timeout was performed.  We had marked her in the preoperative holding area for a thighplasty incision, which included a bucket-handle extension.  We made our medial incision, then dissected laterally to our lateral marks, dissecting down, leaving a layer of fat over the muscle and fascia.  Multiple large vessels were encountered, which had to be divided with medium and large clips.  For hemostasis, we used electrocautery.  We then reached our dissection line.  We were then able to mobilize our medial skin laterally and then mark the excision marks along the entire thigh.  In her more inferior left thigh, she had a very large amount of skin.  We were able to debulk this and get a satisfactory closure once we had marked it, and we did tailor-tacking-type technique and then excised the skin and then stapled it closed.  We then unstapled, irrigated, and hemostasis achieved with electrocautery.  We placed a drain distally and proximally sutured with a 3-0 nylon.  We then closed with deep 3-0 Monocryl and running 4-0 Monocryl, Mastisol, and Steri-Strips.  This was done bilaterally.  We removed approximately 6.5 pounds of tissue, including the left and right thighs.  This was sent to pathology for final analysis.  Dressings were applied.  The patient was extubated and brought to recovery in stable condition.\\
+{{:resident:8e5a6a90-a7b9-4647-ad2a-e10cbf238e3b.jpeg?400|}}
 </WRAP>
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 Photos\\
 {{:resident:screen_shot_2021-01-05_at_4.59.13_pm.png?400|}}
 Drain: 10 french round blake x2 for each side\\
 Sutures: deep 3-0 Monocryl and running 4-0 Monocryl\\
 Dressing: Mastisol, and Steri-Strips\\
+\\
+**MUST READ:** Mathes thighplasty paper with Kenkel [[https://pubmed.ncbi.nlm.nih.gov/18061810/]] \\
-Marking: Mark patient in standing position with legs at shoulder width. At this point can see if you need a transverse or vertical excision. Doesn't like to combine them as doesn't like the T-point incision. Pinch test to see what will close and be conservative. Doesn't necessarily follow the 4cm from vulva guideline-just places incision in the groin crease if transverse. \\
-Position: Frog leg. Uses 2 U drapes, one across belly and one across both legs. Can have SCDs below.\\
+**Marking:** Mark patient in standing position with legs at shoulder width. At this point can see if you need a transverse or vertical excision. Doesn't like to combine them as doesn't like the T-point incision. Pinch test to see what will close and be conservative. Doesn't necessarily follow the 4cm from vulva guideline-just places incision in the groin crease if transverse. \\
+**Position:** Frog leg. Uses 2 U drapes, one across belly and one across both legs. Can have SCDs below.\\
 Procedure: Remark lines. Place several hash marks transversely. Make superior incision. Stay superficial and above deep fascia, especially over sartorius. Can go deeper more lateral. Make incisions along hash marks only as far as you know you can close. Staple this (true tailor tack). Can either excise the triangle you've created as you go or all at once after you've made and stapled each hash mark incision. Place a drain. Close with 3-0, 4-0, dermabond. Wrap legs with ACE. \\
-Anatomy: Pertinent anatomy should be listed\\
+**Anatomy:**\\
-Post-operative care: Include restrictions, splints, etc...\\
+Muscles in this should not be visualized as the muscular fascia is not penetrated; surgery only involves the skin and subcutaneous fat of the inner thigh.\\
-Learning points/Pimp Questions:\\
+{{:resident:screen_shot_2021-08-04_at_12.55.33_pm.png?600|}}
+**Post-operative care:** \\
+Patients are followed on a weekly basis after surgery to assure optimal wound healing and drain care for the vertical approach.
+Drains can be removed when drainage is 30 cc or less for a few days.\\
+Compression of the leg from the toe to knee assists in preventing calf swelling.\\
+If suspicious swelling develops, particularly unilaterally, ultrasound should be performed to rule out deep venous thrombosis.\\
+Strenuous activity may be resumed 4 to 6 weeks after surgery as long as healing is uncomplicated.\\
+Longer-term care is provided for scar management, including topical therapies to reduce scar visibility and massage to assist in dysesthesias and edema.\\
+**Learning points/Pimp Questions:**\\
+If the patient has varicose veins, they should be treated first before the thigh lift.\\
+Thighplasty is rife with complications. At least small wound healing issues are almost inevitable.\\
+Other complications include:
+Lymphedema: Best minimized by avoiding any interruption of lymphatics or veins. Compression from toe to knee and elevation may help. If swelling is asymmetrical, workup for venous thrombosis should be considered.\\
+Labial spread: With any procedure that creates some tension with tissue removal and lack of proper suspension of tissues around the mons. Multiple interrupted sutures suspending tissue to periosteum helps reduce risk.\\
+Wound healing problems are more of an issue with higher weight patients; undermining and adjunctive liposuction should be minimized. Permanent large caliber sutures around the groin may become infected with wound healing\\
+problems, necessitating removal of the exposed suture.
+Unsatisfactory scar: symmetrical treatment with sequential, stepwise tissue excision and avoidance of high tension closure assists in optimizing scar. Irregular contour of the inner thigh with vertical thigh lift is not uncommon as posterior thigh tissue is thicker than the anterior tissues, so it is important to not pull posterior tissue forward.\\
+Venous thromboembolism: It is necessary preoperatively to check on any history or elevated risk as per the modified Caprini scale. Patients must be encouraged to ambulate after surgery.\\
+Infection is not common, and risk can be reduced by optimizing surgical conditions like addressing efficiency with reduced operative time and hypothermia, as well as initial dose of antibiotics prior to making incision. Seromas can become sources of infection and should be treated.\\