体表恶性肿瘤切除后的皮瓣修复

目的探讨体表恶性肿瘤切除后局部组织严重缺损的有效修复方法。方法采用吻合血管的游离皮瓣和邻近的轴型或随意皮瓣修复体表恶性肿瘤切除后的组织缺损，并尽可能地纠正畸形，恢复功能。结果临床应用１７例皮瓣全部成活，伤口均在术后１０～１５ｄ愈合拆线，功能恢复良好。１４例外形满意，２例稍微臃肿，１例有“猫耳”形成经再次手术修复满意。结论携带其他组织的复合皮瓣血运丰富，修复能力强，是目前体表恶性肿瘤切除后较为理想的修复方法，适合于部位深和范围广的体表肿瘤切除后局部组织严重缺损的修复。     

Body Contouring Following Massive Weight Loss

Background: Obesity and its associated medical morbidities carry substantial health risk. While massive weight loss allows improvement in health status and lifestyle, physical sequelae due to symptomatic skin redundancy still require treatment. Areas affected include the arms, breasts, abdomen, back, and thighs. After open gastric bypass, patients often have poor abdominal support and incisional hernias. To completely address the treatment of patients following massive weight loss, body contouring procedures are performed, often in one stage and tailored to each patient, to rid the functional and esthetic impairment from skin redundancy. Methods: This retrospective study includes 30 patients treated from March 1998 to August 2002 by a single surgeon at an academic hospital. Average weight loss had been 71 kg, and average weight and BMI at the time of contouring surgery were 98.6 kg and 33 kg/m² respectively. Procedures included abdominal panniculectomy, thighlift, backlift, brachioplasty, mastopexy and incisional hernia repair, performed either alone or in combination. Results: Average weight of resected tissue was 5.9 kg. Average length of stay was 3 days. Complications included seroma, wound breakdown, hematoma requiring surgical drainage, and lymphocele after brachioplasty. One patient died of a pulmonary embolus within weeks after surgery. Conclusion: Patients requiring surgical skin excision after massive weight loss for functional and/or esthetic reasons are challenging, and require individualized approaches with intensive follow-up.     

Dermolipectomies Following Weight Loss after Surgery for Morbid Obesity

Background: Dermolipectomies play a major role in the functional and esthetic deformities which result from massive weight loss. Methods: From June 1994 to June 2000, 148 morbidly obese patients underwent various bariatric surgical procedures. After at least 1 year, 33 patients underwent 51 regional dermolipectomies performed by the same plastic surgeon. Results: All 33 patients underwent abdominal dermolipectomy. The average operative time was 194.2 min (110-420 min). The average amount of tissue excised was 2948.6 g (850-7525 g). 4 patients (12.1%) required blood transfusion. 6 patients (18.1%) developed complications, which included 1 case of post-operative bleeding, 3 wound infections and 2 skin dehiscences. Average length of hospital stay was 9.5 days (5-22 days). 15 of these patients (45.4%) simultaneously underwent abdominal incisional hernia repair; in 9 (24.2%), a Gore-Tex? mesh was used. In 2 patients the procedure was performed under emergency conditions due to small bowel obstruction. In 2 patients, simultaneous cholecystectomy was also performed. In 1 patient, a suction-assisted lipectomy of both thighs was necessary. 7 patients (21.2%) had mammaplasty, with average operative time 175.7 min (140-210 min). In 1 of them, breast implants were placed. There was no morbidity, and the average hospitalization was 6 days (4-9 days). Flankplasty was done in 4 patients (12.1%), thigh reduction plasty in 4 patients (12.1%), and arm reduction plasty in 3 patients (9%). The average operative time was 302.5 min (160-420), 246.2 min (230-280) and 203.3 min (180-240) respectively. Average tissue excised was 1503 g (725-2400 g), 1342.5 g (1050-1550 g), and 572.6 g (400-848 g), respectively. Morbidity was related to wound infection in 1 patient, and persistent edema of the left lower extremity in another. 4 of these 18 patients required blood transfusion. Average hospitalization was 8.2 days (6-11), 8 days (7-9) and 6 days (5-7) respectively. Conclusions: Regional dermolipectomies constitute the only available treatment for deformities following massive weight loss after bariatric surgery. Based on our experience, these procedures are safe, without serious complications and with good functional and esthetic results.     

Breast Reconstruction Facilitated by Vertical Banded Gastroplasty

Background: Vertical banded gastroplasty (VBG) causes weight loss, which is often associated with redundant abdominal tissue. This redundant tissue can be used successfully for breast reconstruction or breast augmentation in case of mastectomy or ptotic hypotrophic breasts. Method: One patient with bilateral mastectomy is described in whom the weight fell from BMI 52 to BMI 26 after VBG, giving the patient an abdominal "apron", which facilitated bilateral breast reconstruction. Results: Bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction after weight reduction following VBG resulted in an esthetic pleasing result with additional correction of the cutis laxa abdominis. Conclusion: Autologous breast reconstruction can be performed safely with the methods used today, after successful weight loss following obesity surgery.     

Dermalipectomy for Body Contouring after Bariatric Surgery in Aegean Region of Turkey

Background: The only proven effective long-term treatment for morbid obesity is bariatric surgery. After surgery, additional problems may arise such as redundant hanging skin and a poor body image. The patient's quality of life and social acceptance may thus still be hindered. Body contouring operations remain the only hope here. Methods: Body contouring surgery was performed on 11 patients out of 38 who had had vertical banded gastroplasty. General self-consciousness, social self-consciousness of appearance and sexual and bodily self-consciousness of appearance were measured with a retrospective questionnaire. Results: Timing of body contouring surgery was determined according to the demand of the patient and stabilization of the patient's weight status. On average the first plastic surgery operation was performed after 17 (12-25) months. Mean age was 37.4 (34-65) and mean excess weight loss was 57.6 (37-129). In the 11 patients who underwent plastic procedures, a total of 23 such operations were performed, and 8 complications were encountered in these 23 operations. General self-consciousness and sexual bodily self-consciousness of appearance showed improvement after bariatric surgery and further improvement after the plastic surgery. Conclusion: For markedly redundant skin after massive weight loss, dermalipectomy is the only treatment. This improves the patient's general, sexual and bodily self-consciousness.     

Circumferential Abdominoplasty for Sequential Treatment after Morbid Obesity

Background:The severely obese patient, after considerable loss of weight, has large remaining skin folds. Classic transverse abdominoplasties leave bulges in the flanks. This article presents an alternative procedure, circumferential abdominoplasty, which involves the perimeter of the abdomen. Methods: Average age of the patients was 39.5 years, consisting of 10 females and two males. Incisions were made like those of the classic transverse abdominoplasty, but were extended dorsally without tension on the suture-line. Results: Pre and postoperative aspects revealed the huge impact achieved after resection of the excess panniculus, with improvement of body contour, posture, ambulation, social and psychological integration, hygiene and sexual performance. In some patients, seromas, partial dehiscences, flap infection and atelectasis were immediate complications. Hyperthopric scars and some remaining skin folds were late complications. Conclusion:The major disadvantage of the circumferential abdominoplasty is the resulting scar. However, this procedure should be taken into consideration as an option to achieve a more harmonious body contour. Complications are not enough to contraindicate the surgery, because the patients preferred better social and professional integration, as well as behavioral improvement due to enhancement in their self-confidence.     

The Plastic Surgeon in the Treatment of Obesity

Obesity is an increasingly common disease, whose complex treatment often terminates with the patient's discontinuation of therapies. The authors suggest how to improve a multidisciplinary approach to the obese, to increase compliance with therapy. A characterization of obesity is a helpful initial step. It consists of an accurate anatomic definition of fat distribution, which can more accurately be performed by imaging (U/S, CT, MRI). The patient's obesity should also be identified based on the physical characteristics that we propose. The plastic surgeon's intervention is often required and beneficial in every type of obesity. Many body areas are appropriate for contouring. Apart from providing a gain in esthetic appearance, plastic surgery also results in several benefits for the patient's general health.     

Use of PlasmaJet™ System in Patients Undergoing Abdominal Lipectomy following Massive Weight Loss Resulting from Bariatric Surgery: Early Experience

Background: Abdominoplasty has become a popular operation among patients seeking body contouring surgery due to the recent development of laparoscopic procedures in bariatric surgery and the epidemic diffusion of obesity. The wide surface of dissection is responsible for common postoperative complications such as seroma and hematoma. Methods: PlasmaJet^™ system (PJS), a high energy flow of ionized gas, can be used to stop capillary bleeding from blood and lymph vessels. We tested the PJS in a prospective series of 15 consecutive patients undergoing abdominoplasty after bariatric surgery-induced weight loss. Results: 14 women underwent abdominoplasty with the PlasmaJet^™ system after a mean weight loss of 48 kg (range 37-53). Mean operative time was 73 min (range 60-87). There was no postoperative complication. Mean fluid output from drains was 351.1 ml/patient (range 60 to 568), and drains were removed at a mean time of 4.8 days (range 3 to 6). Conclusion: These results are in favor of the efficacy of the PJS in reducing the amount of fluid production, and the rate of postoperative complications. However, this should be confirmed in a randomized trial comparing the PJS with standard technique.     

Medial thigh lift free flap for autologous breast augmentation after bariatric surgery

Background: Massive weight loss following bariatric surgery frequently results in body contour deformities like ptotic and hypoplastic breasts, redundant abdominal tissue and loose skin especially in the medial thigh area.This redundant tissue can be used for breast augmentation in the case of hypertrophic ptotic breasts. Method: In 3 patients who underwent a vertical banded gastroplasty and consecutively lost more than 60% of their body weight, a breast augmentation with a transverse gracilis myocutaneous free flap was performed. Results: Bilateral myocutaneous gracilis free flap breast augmentation resulted in an esthetic, pleasing result, with additional correction of the redundant skin from the medial thigh region. Conclusion: Autologous breast augmentation with a simultaneous medial thigh lift can be performed safely, after successful weight loss following bariatric surgery.     

Body Contouring after Biliopancreatic Diversion

Background: From Nov 2001 to Mar 2006, 176 patients underwent body contouring plastic surgery after prior biliopancreatic diversion (BPD). Weight loss had varied from 30-100 kg. The plastic surgery targeted the arms (24 patients), breast (58), abdomen (62) and thighs (20), plus torsoplasty (12). Methods: BPD is a "non-cosmetic" bariatric operation which results in malabsorption and subsequent major weight loss within 12 to 18 months. The typical "empty" aspect of the slimmed areas directed our surgical choices to specific techniques: brachioplasty, reduction mammaplasty and/or mastopexy (with or without prosthesis or "self-prosthesis" technique), thigh-lift, abdominoplasty and torsoplasty. We do not consider any liposuction technique suitable for this kind of patient, because of the specific histological changes caused by BPD. Results: The metabolic discrepancies following BPD affect postoperative management of these patients. A higher incidence of complications has been reported, of both systemic and local nature; the local ones, common in the abdominal wall, convinced us to perform an arteriographic study preoperatively, to check anatomical alterations following the BPD. Conclusions: Although the characteristics of BPD patients limit the choices, we are satisfied with the results of cosmetic correction and quality of life. All the patients, without exception, noted a high rate of positive thinking and have undergone further body-contouring surgery (or plan to do so).