Scarpa's Fascia Research Articles

Effectiveness of Wound Closure With V-Loc 90 Sutures in Lipoabdominoplasty Patients

Barbed sutures have gained wider acceptance, especially among plastic surgeons. However, limited information exists about the effectiveness of wound closure using these sutures. The authors compare closure times and clinical outcomes of 2-layer wound closure using V-Loc 90 barbed sutures (Covidien, Inc, Mansfield, Massachusetts) with conventional, 3-layer closure with nonbarbed, nonlocking sutures. The lipoabdominoplasty wounds of 30 consecutive patients were divided into 2 equal halves, and the control and study halves of the wound were randomly assigned for each patient. On the control side, a conventional 3-layer wound closure (Scarpa's fascia, deep dermis, and upper dermis) was performed using polyglactin 910 and polyglecaprone 25 sutures. On the study side, the wound was closed in 2 layers (Scarpa's fascia and upper dermis) using a running suture of V-Loc 90 sutures. Closure of each layer and of the entire half of the wound was performed by a single surgeon and timed. Patients were followed for an average of 13 months postoperatively. Postoperative complications were recorded and scar appearance was evaluated with the Vancouver Scar Scale (VSS). Data were collected from a total of 30 control and 30 study sides. The mean closure time for each layer was faster with barbed sutures than with nonbarbed sutures, and the total average closure time was 4.4 minutes (36.1%) faster using barbed sutures compared with conventional sutures (7.9 vs 12.3 minutes, respectively; P < .0001). Postoperative wound complications occurred in 4 (13.3%) control sides compared with 1 (3.3%) study side of the wound. The VSS scores were similar between the 2 sides. The lateral section of the scar received lower VSS scores than central sections. Two-layer wound closure using V-Loc 90 barbed sutures was safe and faster and resulted in fewer postoperative complications than 3-layer closure with conventional, nonbarbed sutures. V-Loc 90 sutures did not produce better scar cosmesis. Wound closure with barbed sutures may be financially and clinically advantageous in lipoabdominoplasty patients as it requires less wound closure time. 2.

Minimising complications in abdominoplasty: An approach based on the root cause analysis and focused preventive steps

Significant complications still occur after abdominoplasty, the rate varies widely in different series. This variation suggests that there is a lot of scope for improvement. This paper reviews the various complications and also the technical improvements reported in the last 20 years. The root cause of each complication is analysed and preventive steps are suggested based on the literature and the author's own personal series with very low complication rates. Proper case selection, risk stratified prophylaxis of thromboembolism, initial synchronous liposuction, flap elevation at the Scarpa fascia level, discontinuous incremental flap dissection, vascular preservation and obliteration of the sub-flap space by multiple sutures emerge as the strongest preventive factors. It is proposed that most of the complications of abdominoplasty are preventable and that it is possible to greatly enhance the aesthetic and safety profile of this surgery.

Technical Considerations in Abdominoplasty of Huge Abdomen

In abdominoplasty, the surgeon aims to contour the abdominal wall and create a balanced relationship with the lower body contour. The condition huge abdomen is characterized by severe lipohypertrophy; marked laxity of the abdominal skin, which almost overlaps the mons pubis and upper thighs; divarication of the recti; and ptosis of the mons pubis. Abdominoplasty of huge abdomen carries a higher risk of postoperative complications and unaesthetic results. This study presents certain technical considerations in liposuction: preservation of the vascular perforators and subumbilical scarpa fascia, undermining/resection of the abdominal skin, performance of umbilicoplasty, and lifting of the mons pubis. From June 2009 to June 2011, abdominoplasty were performed on 112 patients with the condition huge abdomen. Body weights ranged from 89 to 105 kg, with a mean of 92 kg. Body mass index ranged from 32.7 to 37.4, with a mean of 35.2. After an average follow-up period of 1 year, 93 patients (83%) achieved good aesthetic results and had no major or local postoperative complications. In 4 patients (3.6%), seroma was an early postoperative complication. Six patients (5.4%) developed long-term unfavorable aesthetic results, which required secondary revisions. This study focuses on certain type of abdominal wall obesity that requires abdominoplasty and provides some technical considerations to achieve a safe and aesthetic outcome.

Deep and Superficial Fat Ratio in Dietary and Surgically Induced Weight Loss Patients

Architecture of abdominal fat above and below Scarpa's fascia is morphologically different. Little information is available about the relative distribution patterns of deep and superficial fat layers in massive weight loss (MWL) patients. This study aimed to evaluate the relative distribution patterns of deep and superficial abdominal fat layers in two groups of MWL patients presenting for abdominoplasty: (1) MWL via nutritional management and (2) MWL via bariatric surgery. All MWL patients with stable body weight for a minimum of 24months presenting for abdominal body contouring at Lausanne University Hospital, Department of Plastic Surgery between July 2008 and June 2009 were included. Patients with preexisting metabolic diseases were excluded. Patients with nutritional deficiencies were deferred until corrected. Nineteen consecutive patients were included in the study, 7 post-bariatric patients and 12 patients after dietary-induced weight loss (5 were males and 14 were females; average age 45.5years, range 36-64years), with an average weight loss of 48kg (57kg post-bariatric, 28kg dietary induced) and a mean body mass index of 29.2kg/m(2) (range 24.0-40.7) at the time of abdominoplasty. Morphologic evaluation yielded a relative distribution of deep to superficial fat layers of 42 to 58% in the post-bariatric group versus 31 to 69% (p < 0.05) in the nutritionally induced group. These data show that the morphologic distribution patterns of deep and superficial abdominal fat layers differ with regards to mode of weight loss.

Diagnosis and Management of Cryptorchidism

Among males born at full term or prematurely, 1–30% are affected by cryptorchidism. Approximately 70% of cryptorchid testes will spontaneously descend by 3 mo.The cause of cryptorchidism is multifactorial. A prerequisite for testicular descent is a normal hypothalamic-pituitary-gonadal axis. In addition, an undisturbed interaction with the anatomic structures is required, as well as the appropriate hormonal milieu and environmental conditions. Hereditary factors also play a major role.The Kaplan classification distinguishes between palpable testes (80%) and nonpalpable testes (20%). The nonpalpable group includes intra-abdominal, inguinal, and absent (vanishing) testes, whereas palpable testes can be between the internal and external inguinal ring, high scrotal, or in a superficial pouch between the oblique and the Scarpa fascia in the so-called Denis Browne pouch.Therapy for undescended testis (UDT) is usually carried out when a child is between 6 and 12 mo; individuals with high UDT especially benefit from an early orchidopexy. The lower the pretreatment position, the more chance there is of spontaneous descent as well as better results of surgical intervention.Although the management of a palpable testis is standardized, there are no guidelines for the management of boys with a nonpalpable testis. It seems that both preoperative and postoperative hormonal treatment may have a beneficial effect on fertility later in life. Because of the increased risk of testicular malignancy, lifelong follow-up is mandatory.

Resolution of critical haemodynamic instability with urgent decompressive mini-laparotomy for abdominal compartment syndrome - a case report

Abdominal compartment syndrome, a relatively recently identified disorder [1,2], is traditionally managed in theatre with a semi-elective surgical decompressive laparotomy leaving the abdomen open [3]. Fewer options exist, however, in patients who develop critical haemodynamic instability in the ICU. We describe the case of a 58-year-old woman admitted to the ICU with hypotension and abdominal distension. She had been discharged from the ICU 48 hours earlier after a prolonged admission with complications of a caecal perforation including ischaemic small bowel, fungal bloodstream infection and renal failure. On readmission to the ICU her abdomen was significantly distended without bowel sounds. Her haemoglobin was 88 g/l and lactate was 4.1 mmol/l. The patient was intubated, commenced on low-dose noradrenaline and taken for an abdominal computed tomography scan with oral contrast, which showed a large intraperitoneal fluid collection (Figure ​(Figure11). Figure 1 Abdominal computed tomography scan demonstrating intraperitoneal free fluid. Arrow indicates site of mini-laparotomy. A pigtail catheter was inserted into her left flank, but <100 ml clear fluid could be drained. Critical haemodynamic instability soon developed, with her mean arterial blood pressure falling to 35 mmHg, despite escalating the noradrenaline infusion to 70 μg/minute, repeated adrenaline boluses of between 100 and 500 μg (2 g total), and additional fluid resuscitation via the central access. Given the dire situation, after urgent consultation and instruction from the surgeon (who was not in the hospital) by telephone, an immediate bedside mini-laparotomy was performed to decompress her abdomen. This was performed by the ICU registrar who had no formal surgical training. A left-sided 7-cm lateral scalpel incision was made parallel to the midline laparotomy, through the abdominal layers of skin, scarpa's fascia, muscle and peritoneum. Care was taken not to damage with abdominal viscera by making the incision away from the patient's stoma site and digital insertion through the peritoneal layer. After the peritoneum was opened, vigorous abdominal compressions were performed evacuating approximately 3 l of straw-coloured fluid. The patient's abdomen became less tense, her circulation improved and she was weaned off noradrenaline over the next 20 minutes. The incision was covered with a stoma bag (Figure ​(Figure2)2) and a further 1.75 l were drained. Figure 2 Site of mini-laparotomy over the left flank. We describe a patient with abdominal compartment syndrome, secondary to tense ascites, which was a key factor resulting in the development of critical haemodynamic instability. An urgent decompressive mini-laparotomy resulted in resolution of the patient's haemodynamic instability. We wish to highlight that abdominal compartment syndrome is a reversible factor that can be corrected to prevent cardiac arrest.

Scarpa Fascia Preservation during Abdominoplasty: A Prospective Study

Scarpa Fascia Preservation during Abdominoplasty: A Prospective Study

One Hundred Consecutive Lipoabdominoplasty Procedures: Modified Avelar Technique for Full Abdominoplasty Without Panniculus Undermining—Advances, Morbidity, and Complications

Introduction: Abdominoplasty can be limited by preexisting scars and is associated with postoperative drains, seromas, and deep vein thrombosis (DVT). The Avelar technique has been described as an alternative to extensive flap dissection. We adopted this technique in 2007. Materials and Methods: The lower abdomen is marked for planned resection. Liposuction is performed throughout the entire abdomen below Scarpa's fascia and superficially in the lower abdomen to thin the redundant pannus. The skin is sharply incised, and the thinned pannus is bluntly avulsed, leaving the subcutaneous fat and vessels intact. The upper abdominal skin can be slid over the deep fascia, preserving the perforating vessels. A narrow tunnel is dissected from the umbilicus to the xiphoid for rectus plication. The umbilicus is transposed in the usual manner. All patients receive DVT prophylaxis with perioperative heparin, sequential compression devices, and Lovenox. Surgery is ambulatory, and drains are not routinely used. Results:...

One Hundred Consecutive Lipoabdominoplasty Procedures: Modified Avelar Technique for Full Abdominoplasty without Panniculus Undermining—Advances, Morbidity, and Complications

Introduction: Abdominoplasty can be limited by preexisting scars and is associated with postoperative drains, seromas, and deep vein thrombosis (DVT). The Avelar technique has been described as an alternative to extensive flap dissection. We adopted this technique in 2007. Materials and Methods: The lower abdomen is marked for planned resection. Liposuction is performed throughout the entire abdomen below Scarpa's fascia and superficially in the lower abdomen to thin the redundant pannus. The skin is sharply incised, and the thinned pannus is bluntly avulsed, leaving the subcutaneous fat and vessels intact. The upper abdominal skin can be slid over the deep fascia, preserving the perforating vessels. A narrow tunnel is dissected from the umbilicus to the xiphoid for rectus plication. The umbilicus is transposed in the usual manner. All patients receive DVT prophylaxis with perioperative heparin, sequential compression devices, and Lovenox. Surgery is ambulatory, and drains are not routinely used. Results: Between April 2007 and December 2010, 100 consecutive lipoabdominoplasty procedures were performed. There were no DVTs and no deaths. One patient sustained small-bowel injury during liposuction, which was immediately recognized and successfully repaired. Five hematomas (28 ± 28 mL) occurred within the early postoperative period, 2 of which became infected. Four hematomas responded to local drainage, but 1 required surgical evacuation 3 months later. The incidence of late seroma was 0%. Two marginal skin necroses occurred in patients with preexisting Kocher and laparotomy scars, which healed without ill effect. Conclusions: The incidence of wound dehiscence, seroma, hematoma, and DVT after lipoabdominoplasty is less than that reported for traditional abdominoplasty.

Scarpa Fascia Preservation During Abdominoplasty

Background: Abdominoplasty is one of the most popular body-contouring procedures. Previous studies described a superficial and deep compartment in the lower abdominal wall separated by Scarpa fascia. 1,2 Preservation of this fascial plane has been suggested as a way to lower the complication rate associated with conventional abdominoplasty. 3,4 The purpose of this study was to evaluate the effect of preservating Scarpa Fascia during a full abdominoplasty. Methods: A prospective study was perfomed, between November 2005 and November 2007, involving patients submitted to abdominoplasty, at the Department of Plastic Surgery of Sao Joao Hospital, Porto Medical School. Two groups of patients were created: classical full abdominoplasty (group A) and full abdominoplasty with preservation of Scarpa fascia in the infra-umbilical region (group B) (Figure 1) 4 . The variables analyzed were: age, body mass index (BMI), previous abdominal surgery, comorbid medical conditions, specimen weight, time to suction drain removal, total volume of drain output and length of hospital stay. T-student and Mann-Whitney test and χ2 test were used. Results: A total of 208 full abdominoplasties were performed (group A, 143 patients; group B, 65 patients). There were no statistically differences between groups respecting BMI, previous abdominal surgeries, comorbid medical conditions or surgical specimen weight (p>0.05). There were statistically significant differences respecting total volume of drain output (p recovery, reducing total drain output, time to drain removal and hospital stay.

Assessment of vertical scar migration after classical abdominoplasty followed by lower abdominal flap fixation

BACKGROUND: In plastic surgery, the postoperative scar is a frequent concern. It is very important for the surgeon to understand the natural evolution of the scar. The abdominoplasty scar has a natural tendency to move upwards over time. In this study, the extent of natural vertical scar migration after abdominoplasty was calculated and the effect of fixing the lower abdominal flap to prevent this rise was assessed. METHODS: This prospective and randomized study was conducted at the 38th Nursing service of Santa Casa de Misericordia do Rio de Janeiro, during 2010, and included 20 female patients with an indication for abdominoplasty. The patients were randomly divided into two groups, A and B. Classical abdominoplasty was performed in group A patients, according to the technique recommended by Prof. Ivo Pitanguy. Patients in group B also underwent lower abdominal flap fixation by suturing of Scarpa's fascia and the rectus abdominis muscle aponeurosis. At both two weeks and six months after surgery, the distance of vertical scar movement was measured in 16 patients after application of exclusion criteria. The average vertical migration and the mean difference between the groups were calculated. RESULTS: The average difference between the groups in vertical migration throughout the scar was 0.4 cm, with a mean overall migration of 1.06 cm and 0.68 cm in groups A (control group) and B (cases with fixation), respectively. CONCLUSIONS: The scar formed after abdominoplasty undergoes vertical migration over time; this migration is decreased when the lower abdominal flap is fixed. The surgeon should be aware of scar migration for better planning of the incision location

A Combined Anatomical and Clinical Study for Quantitative Analysis of the Microcirculation in the Classic Perfusion Zones of the Deep Inferior Epigastric Artery Perforator Flap

Sir:FigureWe read with interest the article by Rahmanian-Schwarz et al., “A Combined Anatomical and Clinical Study for Quantitative Analysis of the Microcirculation in the Classic Perfusion Zones of the Deep Inferior Epigastric Artery Perforator Flap.”1 Although the study itself is well designed and well reported, and certainly adds some valuable anatomical and physiologic information to our understanding of deep inferior epigastric artery (DIEA) perforator (DIEP) flaps, we would like to comment on the terminology used in the mapping of perfusion zones of the lower abdominal wall. The authors make the statement that “since the description of the vascular territories of the DIEP flap was published in 1983, many surgeons have used it for the selection of well-perfused tissue in microvascular autologous breast reconstruction. Our study disputes a generally accepted definition of the classic perfusion zones of the DIEP flap.” In making this statement, the authors appear to have confused the previously described perfusion zones of the transverse rectus abdominis myocutaneous (TRAM) flap with the DIEP flap. The TRAM flap perfusion zones are based on skin perfusion by means of all the cutaneous perforators of the DIEA, whereas a DIEP flap is necessarily perfused by only one or several perforators. The terminology in the recent literature has thus changed from the TRAM perfusion zones (or the angiosome of the DIEA) to the DIEP perfusion zones (or the perforator angiosome of DIEA perforators), based on a range of cadaveric and clinical studies performed by both ourselves and by Wong et al. and Saint-Cyr et al.2–4 When describing the perfusion of the abdominal wall based on one or several perforators, the perfusion zones are markedly different from the TRAM perfusion zones. In our clinical and cadaveric studies,2 in which we looked at 200 hemiabdominal walls from both cadavers and patients, analyzing over 1500 DIEA perforators, we found that there is a specific “perforator” angiosome for each individual perforator, and that these differ between medial and lateral row perforators. “Perforator angiosomes” mirror the angiosome patterns described by Taylor and Palmer5; however, the subangiosomes of individual perforators present some unique features. We found that each DIEA perforator has its own territory of supply, independent of the zone of supply by the source vessel. Of these, lateral row perforators and medial row perforators have fundamental differences in their zones of perfusion. Figure 1 demonstrates the perforator angiosomes of the DIEP flap, with several key features evident: Zone I of medial row perforators is larger, has more extensive branching, and has larger caliber vessels than lateral row perforators. Zone I of medial row perforators is centered over the position of perforators as they emerge from the anterior rectus sheath, as they have a relatively direct course to the Scarpa fascia, at which point branching occurs; whereas zone I of lateral row perforators is centered lateral to the location of the perforator at the anterior rectus sheath, as there is a lengthy lateral course traversed by lateral row perforators before reaching the Scarpa fascia and branching. The primary zones (zones I and II) of medial row perforators routinely cross the midline to perfuse the medial parts of the contralateral hemiabdominal wall, whereas lateral row perforators do not primarily communicate with branches that cross the midline. Zones I and II (the territories of maximal perfusion within a perforator flap) comprise more than the entire ipsilateral hemiabdomen for a medial row perforator, but are more limited for a lateral row perforator. Fig. 1: The perforator perfusion zones. Perfusion zones of the lower abdominal flap are supplied by a medial row perforator (red arrow, above) or a lateral row perforator (red arrow, below). (Reproduced with permission from Rozen WM, Ashton MW, Le Roux CM, Pan WR, Corlett RJ. The perforator angiosome: A new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery 2010;30:1–7.)These findings match similar studies by Wong et al., and a close look at the results of the current study demonstrate that Rahmanian-Schwarz et al. have similar findings themselves: the perfusion studies in their Figure 6 demonstrate very nicely the “perforator angiosome” of a single perforator—shown nicely to not fill an entire TRAM flap zone. Warren M. Rozen, M.B.B.S., B.Med.Sc., Ph.D. Iain S. Whitaker, M.A.Cantab., M.B.B.Chir., Ph.D. Mark W. Ashton, M.B.B.S., M.D. Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy, University of Melbourne, Parkville, Victoria, Australia

Scarpa Fascia or Rectus Fascia in Abdominoplasty Flap Elevation: A Prospective Clinical Trial

Postoperative seroma formation remains the most frequent complication after full abdominoplasty. This study aimed to evaluate postoperatively the formation of a minor seroma when the superficial fascia is used for preparation. The study enrolled 50 patients who underwent a full abdominoplasty with umbilicus transposition between February 2008 and February 2010. The patients were alternated to the scarpa group or the rectus group. The two groups differed in terms of postoperative seroma formation and amount of average drain output. Scarpa fascia preservation seems to reduce postoperative seroma formation. The mechanism of the decreased fluid collection is not clear and needs further investigation.

The Scarpa Lift—A Novel Technique for Minimal Invasive Medial Thigh Lifts

Abdominoplasty and lower body lift procedures are the most common and sufficient procedures to correct abdominal tissue redundancy. Frequently, patients who undergo these procedures have lost a relevant amount of weight and additionally present tissue redundancy in the area of the medial thighs. Patients with mild to moderate skin surplus in the medial thigh region often refuse an additional scar in this specific region. For these cases, the medial thigh region can be indirectly treated by the vertical scarpa lift, sparing the medial thigh approach and consequent complications such as scar descent or vulvar distortion. Additionally, the lymphatic vessels below the scarpa fascia can be preserved, reducing the postoperative abdominal seroma rate.

The Use of the Scarpa Fascia as a Lifting Layer in Abdominoplasty Procedures

Sir: Preservation of the Scarpa fascia in abdominoplasty flap elevation is not new.1 Its benefits have been described previously.2 Of importance is the minor lymphatic vessel harvest that should lead to minor seroma formation.3 However, empirical evidence regarding this is low. There is room for more prospective studies investigating the benefits of Scarpa fascia preservation in abdominoplasty flap elevation. At our department, we have been performing flap elevation on Scarpa fascia since 2008. The main reason why we preserve it is not concern regarding seroma. Our experience has shown the Scarpa fascia to be an excellent lifting layer in full abdominoplasty. It is part of the superficial fascial system of the trunk, and its function has been described by Lockwood.4 One can lift the superior aspect of the anterior thighs, the sagging skin of the mons pubis, and the lateral gluteal region when pulling the Scarpa fascia upward after abdominal flap resection. One important side effect is the decreased tension on the skin flap after skin wound closure. This technique was presented at the Annual Meeting of the German Society of Plastic Surgery in 2008 by D. Richter5 (Fig. 1).Fig. 1.: Intraoperative view showing the Scarpa fascia flap fixed to the rectus fascia with several sutures.At our department, 50 patients have been treated successfully with Scarpa fascia lifting during abdominoplasty since 2008. Beginning with preparation from the suprapubic incision, we leave the Scarpa fascia approximately 3 cm beneath the umbilicus and use the rectus fascia for further preparation. After tissue resection, the Scarpa fascia is suspended onto the rectus fascia with absorbable sutures. Starting centrally, two sutures suspend the area of the mons pubis, and two others are fixed more lateral in an inner outer direction. These are supposed to suspend the anterior thigh region. To shape the lateral thigh region, we lift the Scarpa fascia in the very lateral aspect of the incision. Pulling the Scarpa fascia flap with the forceps helps to find the proper tension and direction for the lift. This is of course a very individual maneuver, as the amount of sagging skin needing suspension is variable as well. In case of rectus diastasis, we excise the Scarpa fascia in the area of plication. In our opinion, patients with a low body mass index are better candidates for this procedure. These patients present with less subscarpal fatty tissue. If the Scarpa flap remains thick after abdominal flap resection, it could lead to a more bulgy abdominal contour. Patients with a low body mass index benefit most from the lifting effect, not only because of thinner subscarpal fat but also because of thinner subcutaneous tissue. Contouring of the superficial fascial system is more visible in these patients. Matthias Koller, M.D. Thomas Hintringer, M.D. Department of Plastic and Reconstructive Surgery Sisters of Mercy Hospital Linz Linz, Austria

Reply

Sir: We appreciate the interest that Dr. Antonio Araco and his colleagues have taken in our article,1 and we thank them for their insightful comments and stimulating questions. As they have noted, massive weight loss patients appear to have a high morbidity rate following abdominoplasty or other body contouring procedures. This observation has been shared by several others.2–6 Specifically, many have found an increased seroma rate in their operative experience with this patient population.7,8 However, the roles of body mass index, weight loss, and other clinical factors in the complication rate remain incompletely understood. In our series, we did treat a number of patients who had lost a significant amount of weight before presenting for their initial surgical consultation, but we must note that our patient population did have a fairly uniform body mass index at the time of surgery, averaging 24 kg/m2. Although our experience certainly does not compare with others with a significant body contouring patient population, we would suggest that preservation of the suprafascial layer containing what we believe to be a lymphatic-rich plane could be just as beneficial in reducing the seroma rate in massive weight loss patients as compared with nonobese patients. However, we acknowledge that the factors leading to postoperative seroma in massive weight loss patients may not be analogous to nonobese patients and that the microanatomy of the suprafascial tissue plane may also be markedly altered. Although we agree with Dr. Araco that a thin skin flap from a more superficial dissection could predispose to necrosis in the event of a large hematoma or seroma, we should clarify that the layer of tissue that we have preserved with our technique is a thin areolar layer just superficial to the abdominal wall muscular fascia. Thus, we have found that the change in the thickness of the skin flap when using this dissection plane is rather insignificant. In patients with more adipose tissue along the abdominal wall, this plane typically lies well beneath the Scarpa fascia and the vascular plexus of the skin. In our approach to the weight loss patient, we believe that preservation of as many of the skin perforators laterally and superiorly as possible is certainly essential for reducing the risk of necrosis. The combination of tumescence with sharp dissection allows us to identify and preserve these perforators during skin flap elevation. We limit dissection superiorly and laterally more so than in the nonobese patient, and we close under considerable tension to allow adequate skin resection. Although there have been multiple clinical investigations that have analyzed potential factors affecting the postoperative complication rate in massive weight loss patients, there remains a paucity of studies exploring the anatomy and physiology of seroma formation in both the nonobese and massive weight loss populations. In the recent literature, we have noted a handful of studies focusing on the changes of the skin structure after massive weight loss, the composition of seroma fluid, and anatomy of abdominal wall lymphatics.9–13 Such continued pursuits will be needed to further elucidate the physiology of our findings and other similar clinical observations that have been reported in the contemporary literature. Thomas A. Mustoe, M.D. Robert C. Fang, M.D. Division of Plastic Surgery Northwestern University Feinberg School of Medicine Chicago, Ill. Samuel J. Lin, M.D. Division of Plastic Surgery Beth Israel Deaconess Medical Center Harvard Medical School Boston, Mass.

Scarpa Fascia Preservation during Abdominoplasty: A Prospective Study

Preservation of the Scarpa fascia has been suggested as a way of lowering complications associated with conventional abdominoplasty. Objective evidence regarding this strategy is lacking. The purpose of this investigation was to evaluate the effect of preserving the Scarpa fascia in the infraumbilical area during a full abdominoplasty. A prospective study was performed at a single center from November of 2005 to November of 2007 of the patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, classic full abdominoplasty; and group B, full abdominoplasty with preservation of infraumbilical Scarpa fascia. Several variables were determined: age, body mass index, previous surgical procedures, comorbid conditions, specimen weight, time to suction drain removal, total volume of drain output, and length of hospital stay. A total of 208 full abdominoplasties were performed (group A, 143 patients; group B, 65 patients). There was no statistically significant difference between groups with respect to body mass index, previous abdominal operations, comorbid medical conditions, or weight of the surgical specimen (p > 0.05). The group with preservation of the Scarpa fascia had an average reduction of the total amount of drain output of more than 50 percent (p < 0001). This group also had an average reduction of 2.0 days until the time to drain removal (p < 0.001) and 1.9 days of the hospital stay (p < 0.001). Preservation of the Scarpa fascia during abdominoplasty has a beneficial effect on patient recovery, as it reduces the total drain output, time to drain removal, and length of hospital stay.

Discussion: Scarpa Fascia Preservation during Abdominoplasty: A Prospective Study

Discussion: Scarpa Fascia Preservation during Abdominoplasty: A Prospective Study

Communication Between Spaces Formed by Fasciae of Male External Genitalia and Perineum

The purposes were to evaluate the communication and the extent of the spaces formed by fasciae of the male external genitalia and the perineum and to correlate the spaces with clinical observations regarding anatomic progression of diseases. Multi-detector row computed tomography (CT) was performed through the perineum and the pelvis of 5 fresh cadavers injected with contrast material in the space between dartos and Buck fasciae of the penis. Two of the 5 cadavers, injected with the contrast material mixed with blue ink, were dissected to confirm the observations made on multi-detector row computed tomography. Computed tomographic images of 11 patients with diseases involving the potential spaces formed by the fasciae of the male genitalia and the perineum were correlated with observations made on CT of the cadavers. The contrast material filling the scrotal cavity extended posteriorly in the perineum, remained far below the urogenital diaphragm, and reached superiorly to the potential space along Scarpa fascia in all cadavers. At cadaveric dissection, the ink-stained spaces were confined by the fascial planes involving Colles, Buck, dartos, and Scarpa fasciae. Spread of disease in the 11 patients (6 patients with localized genital edema, 4 with Fournier gangrene, and 1 with bulbous urethral rupture) was confined in the spaces demonstrated on CT images of the cadavers. Free communication and disease spread occur within the confines of the superficial perineal, scrotal, penile, and abdominal wall spaces formed by Colles, Buck, dartos, and Scarpa fasciae.

Arterial and Venous Anatomies of the Deep Inferior Epigastric Artery Perforator and Superficial Inferior Epigastric Flaps

Sir: We have read with great interest the comments of Dr. Uraloğlu and colleagues on our recently published article, “Arterial and Venous Anatomies of the Deep Inferior Epigastric Artery Perforator and Superficial Inferior Epigastric Flaps.”1 We are very grateful to the authors for giving us the opportunity to further discuss our findings on these flaps using new imaging modalities, and would like to respond to each point in turn. The authors discuss our finding of absent perfusion deep to the Scarpa fascia in zone IV of the deep inferior epigastric perforator (DIEP) flap even if a medial row perforator is used, which is in accord with previous findings by Moon and Taylor,2 and ask whether skin vascularization and survival could be increased by fatty tissue trimming. The relative underperfusion of this region in our study despite maximal flap filling suggests that where zone IV is included in a DIEP flap, this part of the flap should be thinned to the Scarpa fascia. Although this region is a likely source of the fat necrosis seen clinically in certain cases, it is unlikely to cause vascular steal, and we would conclude that it is unlikely that trimming the fatty tissue in this region would increase the skin perfusion. The authors ask whether we found a correlation between the diameter of deep inferior epigastric artery perforators and area of flap perfusion. We investigated the diameters and deep inferior epigastric artery perforator vessel wall thickness histologically and found no significant differences in the diameters of the medial or lateral row perforators, or between perforators in the same row. All flaps investigated were based on the single largest perforator from either the medial or lateral row. We found that flap perfusion was dependent on the branching pattern of the perforator, and that a single medial row perforator with wide subcutaneous branching crossing the midline was capable of perfusing the entire flap. In contrast, a single lateral row perforator preferentially vascularized the ipsilateral hemiabdomen and rarely crossed the midline. Both medial and lateral row perforators were investigated under the same experimental conditions; thus, we would expect similar results clinically. We use the superficial inferior epigastric artery flap for breast reconstruction in selected cases where a DIEP flap is planned but where vessel diameter is found to be suitable to harvest a superficial inferior epigastric artery, to reduce donor-site morbidity.3 We aimed to determine the perfusion mechanism of the superficial inferior epigastric artery and its area of perfusion. We found that the superficial inferior epigastric artery perfused the flap as a lateral row perforator would, and that no perfusion was seen across the midline. We were not suggesting application of superficial inferior epigastric artery flaps together with DIEP flaps, but sought to elucidate the common mechanisms in perfusion of the lower abdominal integument. We are very grateful to the authors for their comments and hope that we have provided further clarity on the mechanisms of DIEP flap perfusion. DISCLOSURE Neither of the authors has a financial interest in the content of this communication or of the article it relates to. Michel Saint-Cyr, M.D. Mark Schaverien, M.R.C.S. Department of Plastic Surgery University of Texas Southwestern Medical Center Dallas, Texas