Undermining Of Tissue Research Articles

Forehead soft tissue trauma: Concealed by the art of plastic surgery

A 22 year old lady, who is a stage performer presented with a history of trauma to the forehead following a road traffic accident (Figure 1). The post traumatic image of her face was heartbreaking for her. Patient was taken for Plastic surgery procedure under general anaesthesia. Procedure was started using the principles of microdebridement, tissue undermining, tissue stretching and relaxation, extending the incision beyond the trauma along the Langer’s lines, layered suturing and preserving the anatomical landmarks like hairline and position of eyebrows. A trapezoid-shaped defect of size 10 cm transversely and 5 cm vertically was there after debridement (Figure 2). We could close the defect primarily without the need for skin grafting or did not leave residual raw areas for secondary healing. Finally, with patience after around 2.5 hours, we could achieve a result like this following the surgery (Figure 3). Close follow up and scar reduction measures like massage, creams and direct sunlight prevention for 1 year delivered us a good result.

Closed-Incision Negative Pressure Therapy Decreases Wound Morbidity in Open Abdominal Wall Reconstruction With Concomitant Panniculectomy.

Patients undergoing abdominal wall reconstruction (AWR) with concomitant panniculectomy (CP) may be at higher risk for wound complications due to the need for large incisions and tissue undermining. The aim of this study was to evaluate whether the use of closed-incision negative pressure therapy (ciNPT) decreases wound complications in AWR patients undergoing CP. Beginning in February 2018, all patients at this institution who underwent AWR with CP received ciNPT. These patients were identified from a prospectively maintained institutional database. A standard dressing (non-NPT) group was then created in a 1:1 fashion by identifying patients who had AWR with CP immediately before the beginning of ciNPT use (2016-2018). A univariate comparison was made between the ciNPT and non-NPT groups. The primary outcome was wound complication rate; however, other perioperative outcomes, such as requirement for reoperation, were also tracked. Standard statistical methods and logistic regression were used. In total, 134 patients met criteria, with 67 patients each in the ciNPT and non-NPT groups. When comparing patients in the ciNPT and non-NPT groups, they were demographically similar, including body mass index, smoking, and diabetes (P < 0.05). Hernias was large on average (289.5 ± 158.2 vs 315.3 ± 197.3 cm2, P = 0.92) and predominantly recurrent (58.5% vs 72.6%, P = 0.14). Wound complications were much lower in the ciNPT group (15.6% vs 35.5%, P = 0.01), which was mainly driven by a decrease in superficial wound breakdown (3.1% vs 19.7%, P < 0.01). Patients in the ciNPT group were less likely to require a return trip to the operating room for wound complications (0.0% vs 13.3%, P < 0.01). In logistic regression, the use of ciNPT continued to correlate with reduced wound complication rates (P = 0.02). In AWR with CP, the use of ciNPT significantly decreased the risk of postoperative wound complications, particularly superficial wound breakdown, and lessened the need for wound-related reoperation.

Fleur-de-lis Panniculectomy After Bariatric Surgery

Plastic surgeons are faced with increasing numbers of patients presenting for insurance-covered skin excision procedures following bariatric surgery. Panniculectomy for symptomatic relief of rashes is commonly performed, but an isolated infraumbilical amputation-type panniculectomy is a highly unaesthetic procedure, leaving many patients deeply dissatisfied. It may be also fraught with complications due to large incisions and potential for dead-space. In these patients, many surgeons avoid the fleur-de-lis panniculectomy, despite the body contour aesthetic advantage, because of increased time, more scarring, and a perceived increase in complications. This is a retrospective chart review of 130 consecutive postbariatric surgery patients who had panniculectomy over a 2-year period at our institution. A total of 30 patients underwent a traditional panniculectomy and 100 patients had a fleur-de-lis panniculectomy. Mean weight loss from bariatric surgery to panniculectomy was 58.2 kg, with an average body mass index (BMI) of 30. Fifty-seven patients had additional procedures performed at the time of panniculectomy. Twenty-two patients (17%) had complications, with 5 in the traditional group (17%) and 17 in the fleur-de-lis group (17%) (P = 1.0). Six males (40%) had more complications compared with 18 females (15.7%) (P = 0.034). Patients with BMI <30 had 10 complications compared with patients with BMI ≥30 had 15 complications. There are many benefits of fleur-de-lis over traditional panniculectomy, even for medical necessity cases. There is limited undermining of tissue which minimizes/eliminates skin necrosis. Our experience with primarily fleur-de-lis panniculectomies shows a complication rate lower than most published data. Fleur-de-lis potentially creates a better symptom correction and cosmetic outcome by resecting maximal skin in both vertical and horizontal directions. These findings must be balanced against a potentially longer operation.

Components Separation Technique With Limited Subcutaneous Undermining

The purpose of this study is to evaluate the influence of the undermining of the subcutaneous tissue on the tension of the abdominal wall, after the components separation of the abdominal muscles. Twenty adult cadavers were studied. The resistance of the medial advancement of both anterior and posterior recti sheaths was represented by the traction index and measured in 2 levels-3 cm above and 2 cm below the umbilicus. Traction indices were compared in the following 3 consecutive dissection situations: (1) after the subcutaneous tissue undermining laterally to the semilunaris line; (2) after the dissection of the rectus muscle from its posterior sheath associated with the release of the external oblique muscle; (3) after the subcutaneous tissue undermining laterally to the anterior axillary line. Friedman and Spearman tests were used to compare the results. There was no statistical significant difference between the subcutaneous tissue undermining laterally to the semilunaris line and that laterally to the anterior axillary line, when associated with the musculoaponeurotic dissections. In conclusion, limited subcutaneous undermining does not influence the tension of closure of the musculoaponeurotic layer after the components separation technique in cadavers.

Single Vertical Incision for BAHA: Preliminary Results

Objective A single vertical skin incision with subcutaneous tissue undermining is a cosmetic alternative to standard dermatome skin graft elevation for bone anchored hearing aid (BAHA) placement. A vertical incision minimizes alopecia and simplifies wound closure, while maintaining thin skin flaps. We aimed to determine the preliminary complication rate using a 4cm skin inicsion with 4⋉4 cm of subcutaneous tissue removal. Methods A retrospective chart review of patients undergoing BAHA placement from January 2006 to August 2007 was performed. This search was filtered to include only vertical incision BAHA patients. Complications including skin irritation or infection, skin overgrowth, and implant extrusion were tallied. Pertinent patient risk factors were identified. 71 patients underwent vertical incision surgery, with a mean followup time of 6.8 months. 50 patients had sensorineural hearing losses and 21 had conductive hearing losses. Results No patient had spontaneous extrusion of the titanium abutment. There were 5 minor complications (skin irritation 3, wound infection requiring oral antibiotics 1, postoperative hematoma 1) and 7 major complications (irritation requiring abutment removal 1, skin overgrowth or infection requiring flap revision 6). Total complication rate was 16% and major complication rate was 9.8%. Conclusions A single vertical incision for BAHA placement has a similar complication rate to traditional dermatome use in this preliminary study, though more follow-up is necessary to identify cases of late skin overgrowth. Patients with thick scalps or risk factors for hypertrophic scarring may require placement of longer abutments.

Recalcitrant abdominal wall hernias: long-term superiority of autologous tissue repair.

Secondary repair of recurrent ventral hernia is difficult, and success depends on re-establishing the functional integrity of the abdominal wall. Current techniques used for closure of these defects have documented recurrence rates as high as 54 percent. The authors' 8-year experience utilizing variations of the components separation technique for autologous tissue repair of recalcitrant hernias emphasizes that recurrent or recalcitrant hernias benefit from the creation of a dynamic abdominal wall. A total of 389 patients were retrospectively identified as having abdominal wall defects, and 284 of these patients met the selection criteria. Study patients were grouped according to the type of surgical repair used. The recurrence rate was 20.7 percent over all study groups and was directly related to the extent of repair required. Group 1 patients (wide tissue undermining) had a recurrence rate of only 15 percent, while in group 2 (complete components separation), the recurrence rate was 22 percent. Group 3 patients (interpositional fascia lata graft) had a 29 percent recurrence rate. Time to recurrence was also significantly different across treatment groups, with study group 3 experiencing earlier hernia recurrence. The most frequent postoperative complication was wound infection, which was directly related to the repair performed. The relative odds of recurrence versus the risk factors of age, sex, perioperative steroid use, wound infection, defect size, and the presence of enterocutaneous fistula were studied with a logistic regression analysis. These factors did not possess statistical significance for predicting hernia recurrence. The preoperative presence of mesh was independently significant for hernia recurrence, increasing the relative odds 2.2 times (p = 0.01). Similarly, when other risk factors were controlled for, increasing the complexity of the treatment group, from study group 1 (wide tissue undermining) to study group 3 (interpositional fascia lata graft), also increased the odds of hernia recurrence 1.5-fold per group (p = 0.04). Average inpatient cost was $24,488. The length of inpatient stay ranged from 2 to 172 days (average, 12.8 days). The length of inpatient stay and costs were directly related to the extent of repair required. Using the analysis of variance test for multiple factors, the presence of an enterocutaneous fistula (p = 0.0014) or a postoperative wound infection (p = 0.008) independently increased the length of inpatient stay and hospital costs. A total of 108 successfully repaired patients were contacted by telephone and agreed to participate in a self-reported satisfaction survey. The patients noticed improvements in the appearance of their abdomen, in their postoperative emotional state, and in their ability to lift objects, arise from a chair or a bed, and exercise. These results suggest that recalcitrant hernia defects should be solved, when possible, by reconstructing a dynamic abdominal wall.

Postacne scarring: a review of its pathophysiology and treatment.

There has been a largely unheralded revolution in the number of techniques that can now be used in the treatment of atrophic postacne scarring. Atrophic scarring is the more common type of scarring encountered after acne. To illustrate the range of techniques useful in the therapy of postacne scarring, their relative advantages and disadvantages, and their place in treatment. A review of available techniques is used to illustrate the treatment of indented or atrophic acne scars. The individual architecture of the indented scar must be assessed so that treatment may be designed to maximize its improvement. A variety of new methods now exist, including newer resurfacing tools such as infrared lasers, dermasanding, and others in their infancy such as nonablative resurfacing and radiofrequency methods. A true explosion in autologous and nonautologous tissue augmentation and the advent of tissue undermining and the use of punch replacement techniques has added more precision and efficacy to the treatment of these scars. Atrophic postacne scars may be satisfactorily treated in many patients, but multiple methods are often required to ensure the best results.

Role of Tissue Undermining in the Trapdoor Effect of Transposition Flaps

The trapdoor or pincushioning effect is a frequent complication of transposition flaps. Several explanations have been proposed for its occurrence, including lymphatic or venous obstruction, scar hypertrophy, excessive subcutaneous fat or flap tissue, and scar contracture. To study the effects of tissue undermining and scar contracture using a guinea pig animal model. Circular wounds on the dorsal surface of guinea pigs were repaired with transposition flaps. Half of the recipient beds were undermined widely and half were not undermined. Animals were observed for evidence of the trapdoor phenomenon. Only animals in the group without undermining demonstrated evidence of the trapdoor effect. Tissue undermining may prevent the development of the trapdoor effect in transposition flaps.

Saddle Nose Deformity: Autogenous Graft Repair

Two suitable approaches are presently used for augmentation of saddle noses: the traditional endonasal approach (utilizing minimal incisions with precise pocket preparation and limited tissue undermining), and the more involved external or open approach (requiring more extensive incisions and undermining, but providing binocular vision, bimanual surgical capabilities, and a direct approach to septal deformities)

Lower Extremity Avulsion Injuries

Avulsion injuries are best treated by removal of the avulsed tissue and replacing it as a full-thickness skin graft. Additional meshed split-thickness skin grafts from a separate donor area may be necessary to complete the soft-tissue coverage. Fractures commonly accompany avulsion injuries and require appropriate treatment. The atypical avulsion injury is a special problem that occurs infrequently but results in considerable morbidity. This injury is most commonly seen in individuals run over by heavy vehicles, particularly buses. The shearing forces involved cause extensive undermining of tissues, although the external surface of these areas appears uninvolved. This results in an under-estimation of the true extent of the injury. If not recognized, there may be either delayed full-thickness necrosis of large areas of skin and subcutaneous tissue or the development of sepsis due to deep necrosis of the fat and fascia at the shear plane. If the true extent of injury is initially recognized, a dilemma exists in terms of deciding how much of the normal-appearing tissue to excise. The proper treatment plan for the atypical injury is not yet established with certainty. However, quantitative dermofluorometry has proven to be a valuable means of assessing the viability of extensively undermined areas of skin and subcutaneous tissue. This test is easily performed and can be used for serial study. Viable areas that are undermined and left in place require an early limited debridement of the undersurface to remove necrotic fascia and subcutaneous fat. This may require additional incisions for exposure. Plantar avulsions are another separate category of avulsion injury. Traditionally, the avulsed plantar surface has been sewn back into place, although this frequently resulted in the loss of this specialized tissue. It has become clear that it is possible to revascularize the plantar surface when major avulsion injuries occur. The plantar surface is thus similar to digital amputations and major scalp avulsion injuries in that replantation or revascularization is worthwhile and should be performed whenever possible. Soft-tissue loss around the ankle frequently co-exists with these injuries, and free tissue transfer may be necessary to complete soft-tissue coverage following revascularization.

Simple primary closure for sacrococcygeal pilonidal disease

A simple method of excision and primary closure for sacrococcygeal disease is described. It is applicable for all cases, except the unusual ones which penetrate the presacral fascia or extend more than 3 4 of an inch to either side of the midline. The importance of certain details is emphasized: (1) diligent pre- and postoperative removal of all hair by shaving, depilatory, and plucking; (2) the creation of a beveled symmetrical wound for accurate coaptation; (3) complete hemostasis without any suture material left in the wound, if possible; (4) obliteration of dead space by encircling wire sutures tied over a gauze bolster; (5) meticulous approximation of the skin, edge to edge. No suture material is in contact with the opposed surfaces throughout the entire depth of the wound below the dermis. No flap formation or tissue undermining is performed.