Differences

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--- resident:david_mathes [2021/08/04 14:49] – jonathan
+++ resident:david_mathes [2023/08/21 13:55] (current) – [Tissue Expander] ally
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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. \\
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 Places central tab at the breast meridian.\\ Only sews in 2 tabs for the TE.\\
-UPDATED INSTRUCTIONS 7/30/21:\\
-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 inferior aspect of the breast and sutured into place with 3-0 PDS interruped sutures. Next, a piece of alloderm was cut in the shape of the superior aspect of the breast 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. The superior alloderm piece was draped over the inferior piece and the inferior piece was trimmed. The alloderm was than sutured together with 3-0 PDS interrupted sutures. A 15 french round drain was placed with the exit point in the lateral fold of the breast. The incision was closed with 3-0 monocryl deep dermal sutures followed by 4-0 monocryl running subcuticular sutures. The incision was dressed with benzoin and steri-strips along the direction of the incsion.
+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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 \\
 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\\
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 Dressing: Mastisol, and Steri-Strips\\
 \\
-MUST READ: Mathes thighplasty paper with Kenkel [[https://pubmed.ncbi.nlm.nih.gov/18061810/]] \\
+**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. \\
+**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.\\
+**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.\\