Reoperative Aesthetic & Reconstructive Plastic Surgery

1576
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The cutaneous ap that had been elevated for access was closed over the inset mus-
cles with subcutaneous suction catheters in place to complete the closure. The
wound went on to heal externally with obliteration of the cavity. Not surprisingly,
the air leak did persist, requiring maintenance of one of the chest tubes in place
within the subtotally obliterated cavity. Approximately 7 weeks postoperatively the
patient had a fatal episode of hemoptysis.
At postmortem examination the cavity itself was well obliterated. It was found that
the hemoptysis resulted from a ruptured, previously unappreciated false aneurysm
at the subclavian–Gore-Tex anastomosis.This anastomosis had been wrapped with
a Silastic sheet during the previous operation, resulting in even more foreign body
material than was appreciated, further isolating the vascular prosthesis from inspec-
tion, debridement, or removal, and from the muscle aps used to ll the cavity.
Successful healing of this contaminated wound and vascular prosthesis was unlikely
without the removal of all foreign material, and probably would have resulted in a
pneumonectomy.
Dissection of the airway through the wound in the pleural space should proceed
until enough of a bronchial stump margin is available for repair. In reoperative
and/or irradiated cases the safe but de nitive dissection of stump margins adequate

for repair can be challenging, given the close proximity of vital organs usually en-
cased in a block of brotic scar. One alternative to dissecting the mainstem bron-
chus in such cases is the transpericardial ligation of the bronchus through a midline
sternotomy counterincision.
1577
Chapter 40
Reoperative Surgery of the Chest Wall
Left mainstem bronchus
Esophagus
Bronchus
Fluid
Air
Ao
Svc
PA
Adequate closure of a bronchopleural stula can be dif cult and dangerous in re-
operative cases because of the intense brosis that surrounds the air leak at the pul-
monary hilum. Ideally the airway can be adequately dissected to allow a suf cient
margin for delayed primary repair, ap repair, or a combination thereof. In select
cases, especially chronic ones or those in which reoperation is indicated, control of
the bronchial leak can be more safely achieved via median sternotomy and a
transpericardial approach. The dissection proceeds lateral to the aorta and pul-
monary artery in the pericardial space without the hindrance of the hilar and peri-
hilar brotic tissue, which would impede visualization.
The pulmonary vessels are rst ligated, and the bronchial stump is isolated for sta-
pling central to the original bronchial suture line. Ideally the distal stump is re-
sected to eliminate this site as a possible source of future collections or infection.

1578
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Furthermore, the stump can be sent for histopathologic examination because one
cause of persistent or recurrent bronchial stula is residual tumor at the suture line.
Peripheral air leaks occurring in the reoperative setting, with the implied increased
degrees of contamination, prior radiation therapy, and obstructive disease, have a
high risk of not sealing or healing. If the tissues are in reasonable condition, primary
suture with ne, absorbable material on a tapered, noncutting needle, with the su-
ture carefully tied, can secure most minor leaks. When this method is impractical,
pledgeted absorbable sutures with bits of autogenous pledget material such as mus-
cle or fascia can be used to help to secure these small areas of air leak.
An alternative approach was taken with this patient, who had a postlobectomy
bronchopleural stula refractory to local care. A cotton-tipped applicator had been
placed in the wound.
Posteroanterior and lateral chest radiographs show the superior location of the as-
sociated cavity with the indwelling tube and surrounding hemoclips. Arrows indi-
cate an empyema cavity associated with the postlobectomy bronchopleural stula.

The patient was positioned in the lateral decubitus position on a beanbag device
with the right arm prepared in the operative eld.Before initiation of the procedure,
an indwelling epidural catheter was placed for perioperative/intraoperative admin-
istration of narcotics. Narcotic administration minimizes the depth of anesthesia
required for the operation.The catheter may be left in place for postoperative de-
livery of narcotics to minimize splinting and associated pulmonary complications.
1579
Chapter 40
Reoperative Surgery of the Chest Wall
The locations of the posterolateral thoracotomy incision and empyema- stula tube
are illustrated. The former incision was used with a superoanterior extension, and
a counterincision was used around the stula site.The cutaneous ap was fully el-
evated to the axilla.

1580
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
On the top left, the underlying, previously divided latissimus dorsi and serratus an-
terior muscles are visualized.The cutaneous ap has been elevated. Note the stula
counterincision and excision site. The previously divided and repaired latissimus
dorsi and serratus anterior muscles are seen with the extent of the underlying cav-
ity indicated by the dotted line. As a prelude to exposure of the underlying cavity,
the latissimus dorsi and serratus anterior remnants are elevated and preserved for
later use (top right). Again, the underlying cavity is demarcated with the dotted line.
The latissimus dorsi and serratus anterior aps have been elevated. The scapula is
held with the scapula retractor.The site of the stula is outlined in methylene blue
(bottom).

1581
Chapter 40
Reoperative Surgery of the Chest Wall
The ribs were removed to fully expose the underlying cavity. Intercostal aps were
held away from the wound with the forceps, both superiorly and inferiorly. The
cavity was marked with methylene blue.Several small stulas were discovered within
the wound. Any areas that could not be safely debrided sharply were curetted to re-
move the exudative peel and debris so that fresh tissue margins could be attained
for repair without further injury to the lung.
The overlying rib segments were subperiosteally resected, preserving both the su-
perior and inferior intercostal aps that may be used to buttress the repair. The
subperiosteally resected rib segments are visualized in situ.The second visualized rib
fractured at the stula site and resultant segments are seen protruding into the s-
tula cavity.

1582
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Each fistula was repaired with a pledgeted suture using small pieces of adjacent
muscle as autogenous pledget material. An airtight repair was formed and veri ed
before wound closure.The resultant cavity was lled with latissimus dorsi and ser-
ratus anterior remnants.The aps were inset and secured with absorbable sutures.

The intercostal aps were then sutured to rmly secure and buttress the underly-
ing latissimus dorsi and serratus anterior muscles.The inset muscle flaps can be seen
with methylene blue outlining the muscle repair margins. The cutaneous wound
was closed in a meticulous fashion over suction catheters placed in the subcuta-
neous plane. Because the lung was adherent to the pleura in the area surrounding
the cavity, there was no risk of lung collapse.The use of a pleural catheter or tho-
racostomy tube was avoided to prevent predisposing to a recurrent air leak by the
suction. The patient was placed on high-frequency ventilation postoperatively to
minimize recurrent air leak until extubation.
If the air leaks are refractory and the prognosis for healing is considered poor, they
should be treated more centrally with a preemptive wedged, segmental or lobar re-
section to achieve adequate tissue for a more secure bronchial repair.
Regardless of the technique of closure, the risk of breakdown is minimized by but-
tressing and protecting the repair with vascularized tissue.
1583
Chapter 40
Reoperative Surgery of the Chest Wall

1584
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
In total pneumonectomy defects or in situations in which a secure bronchial clo-
sure is not ensured, especially when prior radiation has not been delivered to the
site, it may be desirable to stage the wound closure. Open packing of the residual
pleural space can be used to maintain wound hygiene as the airway repair suture
line heals. If necessary, the patient can subsequently be returned to the operating
room for de nitive staged closure of the persistent or remaining cavity.The recon-
structive problem is thus less complicated, with secure closure of the airway having
been achieved.
In the case of a large thoracic defect, such as a pneumonectomy wound in which
it is occasionally impractical or impossible to adequately obturate or ll the wound
with vascularized tissue, a second-stage Clagett procedure may be helpful.This pro-
cedure can complement the achievement of the limited but critical goal of airway
closure by completing the closure, as demonstrated by Arnold and Pairolero.2
The Clagett procedure eliminates the need to eradicate the empyema space if
wound contamination can be reduced adequately and there is no underlying bron-
chopleural fistula. It is performed by the sequential debridement, internal open
drainage and wound care, and instillation of antibiotic solutions, with the open
wound surface being sutured and closed over the pneumonectomy defect surgically.
This cachectic 72-year-old man presented 1 year after pneumonectomy for carci-
noma of the lung. His recovery was complicated by bronchopleural stula forma-
tion refractory to attempted repair by the original thoracic surgeon. After evalua-
tion, two-stage reconstruction was planned:(1) suture repair of the bronchial stump
by the transpericardial approach (see p. 1569) and (2) closure of the remaining to-
tal unilateral/ hemithoracic empyema cavity after an interval of local wound care
and nutritional support.

At the nal stage, further collapse of the cavity was achieved by multiple rib resec-
tion and debridement of the cavity. Given the lack of ap donor sites with suitable
bulk, the cavity was lled with antibiotic solution and the ori ce was closed with
local muscle and skin aps (modi ed Clagett procedure).
1585
Chapter 40
Reoperative Surgery of the Chest Wall
The postoperative chest radiograph and the healed wound are shown 2 months
postoperatively. The patient later required open packing after recurrent drainage
from a much smaller cavity after hip fracture and bacteremia from contralateral
pneumonia.
Bony Reconstruction
When more than two or three rib segments are to be resected, consideration should
be given to reconstructing the bony skeleton.This is especially true if the segments
are lengthy, if they do not lie beneath the support of the scapula (obviating the
need for bony reconstruction), or if there is limited pulmonary reserve.

1586
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Signi cant pulmonary air leakage also has the potential for contaminating any bone
grafts or prosthetic mesh. It is usually true that bony resection is better tolerated
than anticipated.The exception is young children in whom the thoracic skeletons
are cartilaginous and prone to baseline paradoxical motion.
In patients who have had radiation or in whom future radiation therapy is indi-
cated, and in patients in whom there has been signi cant contamination or intra-
operative air leakage, it is preferred that skeletal reconstruction be deferred or omit-
ted. These patients have a high incidence of infection or nonunion of the skeletal
reconstruction. However, when resection is performed in the absence of contami-
nation, or when the bony defect is quite large, resulting in a problematic respiratory
paradox, skeletal reconstitution must be undertaken.
Options for skeletal reconstruction include free-rib grafts or split-rib grafts in
which the residual split ribs are returned to their donor sites to minimize resultant
or secondary donor site paradox. Another option is prosthetic mesh secured in a
very taut manner to the margins of the wound via sutures to the periosteum or to
holes punched in the marginal rib or sternum.The mesh must be secured tautly or
respiratory paradox will certainly persist.
Prosthetic mesh incorporated into a “sandwich” with methacrylate, custom-made
at the time of the operation, is another option for the reconstruction of skeletal
defects. Some have reported dif culty with migration or loosening of this material
postoperatively, and there is the additional problem of the presence of a signi cant
foreign body in contaminated cases.
One nal option for bony reconstitution in select cases is the transposition of mar-
ginal pedicled ribs.This reconstruction can be performed by transecting ribs adja-
cent to the defect, maintaining the opposite end of the rib in bony continuity with
its intercostal bundle, and securing it to a transected margin of the adjacent rib that
has been resected. Thus the rib is maintained as a vascularized rib ap and more
evenly distributes the respiratory paradoxical tendencies over a larger area.This re-
construction can be performed both inferior and superior to the resection.
Any bony reconstitution must be accomplished in a way that is mindful of the need
to drape muscle aps over or tunnel muscle aps beneath these rm grafts.Thus cir-
culatory embarrassment of the grafts can be avoided and enough three-dimensional
space can be allowed for all necessary bony and soft tissue reconstruction to coex-
ist without one jeopardizing the other.
Soft Tissue Reconstruction
At this point the soft tissue de cit must be addressed. After soft tissue aps are el-
evated and placed into these typically concave defects, they must be secured in the

wound to prevent the recurrence or persistence of a signi cant potential space.
Usually one is confronted with a paucity of structures at the depths of the wound
that can tolerate anchoring sutures.
Techniques that can compensate for this problem include suturing superiorly and
inferiorly based intercostal aps to the tissues and obturating the defect under slight
tension so that their elasticity and tension secure the soft tissues in the depths of the
wound. Similarly the fascia overlying any muscles whose bases geometrically oppose
each other can be sutured together, thus indirectly securing the infolding of these
muscles in their new location in the wound. Peripheral suturing of inset aps to the
margins of the reconstructed wound also helps to achieve this goal.
It must be remembered that large potential spaces that result from the extensive dis-
section of cutaneous and other aps must be adequately drained because they tend to
form signi cant uid collections.The aggressive use of suction drains is favored, al-
though care must be taken to avoid the placement of drains near areas of repaired air
leaks because this proximity will encourage a recurrence of the air leak.These drains
are brought out through separate stab wounds and rmly secured with sutures.
Meticulous cutaneous closure must be ensured to complete a successful thoracic re-
construction. At times, additional cutaneous ap dissection may be necessary to ac-
complish tension-free closure, and local aps must be designed as needed for this
purpose. A thorough knowledge of prior incisions helps to ascertain that cutaneous
ap circulation will be adequate. Once appropriate cutaneous aps have been iden-
ti ed or selected, meticulous attention is paid to achieving layered, watertight, and
airtight wound closure. Even a small technical indiscretion, causing what would
otherwise be an insigni cant breach in the incision, can lead to contamination of
a massive subcutaneous space resulting from an air leak, or can extend leakage of a
uid collection with resultant contamination, prolonged morbidity, and possibly
indication for further reoperation.
DEPRESSION AND PROTRUSION DEFORMITIES:
PECTUS CARINATUM AND PECTUS EXCAVATUM
The primary correction of protrusion and depression deformities usually requires
dramatic resection of costal cartilages with sternal osteotomy and repositioning.
These extensive maneuvers must then be followed by adequate stabilization of the
repositioned osseous structures. Many methods have been described for this bony
stabilization including suture xation and a variety of hardware devices, metal bars,
and pins.
Reoperation in these patients is usually indicated for recurrence or nonunion. An
analysis of each case must be performed to formulate a surgical plan based on the
cause of the patient’s problem and the surgical anatomy.
1587
Chapter 40
Reoperative Surgery of the Chest Wall

1588
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
PATIENT EXAMPLE
A three-dimensional CT scan or MRI can be helpful in the preoperative evaluation
of these complex problems, and in planning surgical intervention. Several years af-
ter having undergone correction, this teenager presented with recurrent pectus ex-
cavatum. Examination revealed a marked depression in the epigastric–lower sternal
region.The presence of bone between the respective costal margins and in the en-
tire area of concavity could not be con rmed on palpation.
A three-dimensional CT scan reveals the presence of all sternal fragments. They
were freely mobile so that it was not possible to de nitively palpate them. This
nding highlights the importance of adequate bony stabilization and the degree to
which inadequate xation leads to recurrence.

TECHNIQUE
Although midline incisions can be used for such procedures, the primary procedure
usually requires a long transverse incision in the infrasternal or midsternal region.
This incision is usually used again for reoperation, but it may need to be extended
to allow for adequate cutaneous and muscular ap elevation because total exposure
of the defect is essential.
Adequate bony margins are identified and prepared for stabilization. Subperi-
chondrial dissection of these cartilages is performed to remove the cartilages dur-
ing the repositioning. The perichondrium is left in place to allow regeneration of
cartilage as a means of achieving a new cartilaginous contour. Internal fixation
plates with or without split-rib grafts can offer an effective means of stabilizing the
reoperative correction of the depression or protrusion deformity if adequate ossi-
cation has occurred. To avoid fragmenting the rib grafts or sternum, drill holes
must be created and plates secured in a cautious manner, with plates and screws of
the appropriate size. Circumcostal wires can also help to augment xation of rib
grafts.
The patient and his family must be alerted to the dif culties of achieving a perfect
thoracic contour in reoperations of this area. Some rib or cartilage margins may not
perfectly regenerate or have the exact or curvilinear contour when the ultimate
result is achieved. In many cases subsequent revisions can help to re ne this con-
touring.
As with other thoracic reoperations, adequate vascularized musculocutaneous cov-
erage and suction drainage minimize postoperative complications and must be
tended to meticulously.
LATERAL CHEST WALL DEFORMITIES:
POLAND’S SYNDROME
Reoperation for lateral congenital chest wall deformities is most commonly re-
quired for inadequate soft tissue and/or bony reconstruction. In severe thoracic de-
fects, adequate bulk must be transferred to the recipient site in the most anatomic
manner possible, with the transfer of both the origin and insertion of any muscle
units used. For example, in the case of Poland’s syndrome, the latissimus dorsi mus-
cle is transferred to mimic the absent or hypoplastic pectoralis major muscle.When
the entire muscle is not transferred as a neuromuscular unit with preservation of
motor activity, and when both the origins and insertion of the muscle are not trans-
ferred, an inadequate correction is achieved. Even when the muscle is transferred in
toto in this manner, additional soft tissue bulk may be necessary in severe cases, es-
pecially in the infraclavicular region.To augment persistent de cits, free ap trans-
fer of donor units such as the omentum, opposite latissimus dorsi, or rectus abdo-
minis is helpful.
1589
Chapter 40
Reoperative Surgery of the Chest Wall

1590
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
PATIENT EXAMPLE
This 16-year-old patient requested evaluation for persistent Poland’s syndrome–
variant chest wall deformity. Nine years earlier he had undergone multiple rib grafts
and segmental latissimus dorsi transfer.

Examination revealed a complex sternocostal and soft tissue deformity.The sternal
portion of the deformity had both asymmetric protrusion and depression compo-
nents.There were multiple segmental rib de ciencies at and lateral to the left mid-
sternal border. Although an anterior axillary fold was established by the margin of
the transferred latissimus dorsi muscle, it was suboptimal because the insertion was
not transferred anteriorly and the amount of bulk delivered was de cient to mimic
the aplastic pectoralis major muscle. For similar reasons, a marked infraclavicular
hollow was evident as well.The patient’s ipsilateral nipple was hypoplastic, and there
was an abnormal superior extension of the rectus abdominis muscle into the
chest—a persistent rectus thoracis.
“Corrected” patients may also express concern about residual bony de cits that
may be dif cult to remedy.The thoracic skeleton serves as a platform for overlying
soft tissues, and unless this platform is elevated or corrected to adequately support
and protect the overlying musculocutaneous cover, it can further accentuate soft tis-
sue de cits.
Segmental rib absence can be corrected by placement of bone grafts to bridge the
resultant gaps. At times, however, adequate correction of the thoracic skeleton can
require very signi cant takedown and dissection of many levels of the sternocostal
region. A very stable repositioning akin to that for sternal depression and protru-
sion deformities must be performed. It is equally critical to the success of the result
to adequately stabilize these structures as well.
It is dif cult, however, to anticipate every operative maneuver that will be neces-
sary until the actual anatomic structures are exposed. Accordingly, it should be re-
membered that individualized surgical plans cannot be completed or executed un-
til the procedure is under way. Both the surgeon and patient must be comfortable
with this aspect of the correction to allow selection from a wide range of recon-
structive techniques to achieve the best possible result.
In every case, to avoid unrealistic expectations, the patient must understand that
perfect correction of these deformities is impossible. However, the patient should be
encouraged to understand that signi cant or great improvement can be achieved in
most instances.
POSTOPERATIVE CARE
In the postoperative period careful attention must be paid to not only general crit-
ical care issues but also those matters relating directly to the care of the recon-
structed wound. Extubation should be achieved as early as the patient’s condition
will permit because positive pressure ventilation places stress on airway suture line
closure and also increases the degree of air leak that may be present. These spaces
are thus more likely to collect air or become contaminated. Pulmonary toilet, es-
pecially with vigorous voluntary forced inspirations, is the safest way to combat
1591
Chapter 40
Reoperative Surgery of the Chest Wall

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
tendencies toward atelectasis or pneumonia, and yet maintain the lowest possible
airway pressures and minimize stress on bronchopulmonary wound margins.
Patients must be adequately monitored for maintenance of uid balance and circu-
lation.These patients are at risk for pulmonary embolism, and a combination of in-
termittent antiembolic compression devices and minidose heparin administration
can minimize this risk. As early as possible, the patient should be mobilized and ad-
equate nutrition should be initiated.When necessary, aggressive nutritional support
with central hyperalimentation or nasogastric feedings are instituted early in the
postoperative period without waiting to see “if the patient takes enough food orally.”
Certain issues of postoperative care also depend on the particular aps selected for
soft tissue reconstruction. For example, it may be desirable to minimize shoulder
motion during the rst few days after reconstruction if pectoralis major aps have
been inset in a relatively taut manner, especially if the muscular insertions have
been preserved.The most important issue of postoperative management relative to
speci c ap selection involves the greater omentum. Patients are particularly prone
to prolonged gastric ileus after the greater curvature gastric dissection required for
omental harvest. Accordingly, it is crucial to maintain nasogastric suction long
enough for de nitive gastrointestinal function to resume.
Specific antibiotic coverage is maintained for 24 hours postoperatively in clean
cases (for example, when bone grafts or prosthetic material is used). In contami-
nated cases culture-speci c antibiotic coverage is continued for 1 to 2 weeks de-
pending on the extent of resection debridement possible during the procedure and
the resultant con dence of the surgeon in the clearance of contamination from the
wound and its margins. In some cases the location of vital organs can preclude ag-
gressive debridement or resection of some portions of the wound. In these cases
and in patients who are immunocompromised or who have had protracted, multi-
ply recurrent courses of infection, antibiotic coverage will occasionally need to be
continued for 4 to 6 weeks.
Observation and maintenance of the suction catheters is crucial, especially in the
first few days postoperatively. Failure to establish or maintain adequate suction
drainage is a signi cant cause of recurrent wound complications.
It is helpful to mobilize the patient even if it involves merely a move to a cardiac
chair or a few steps at the bedside for an intubated patient. Intermittent antiembolic
pneumatic compression stockings are kept in place until the patient is reasonably
mobilized.
Depending on the circumstances and technique of incisional closure, sutures are
removed approximately 2 weeks postoperatively, but only if it appears that wound
edges have adequately healed. Otherwise, the surgeon should be prepared to leave
sutures in place for longer periods of time in patients with risk factors for poor
wound healing.

Reconstructed thoracic wounds must be watched carefully for the rst 3 to 4 weeks
postoperatively because it is not uncommon for wound complications to arise as
late as 1 month postoperatively after such complex procedures. In the setting of
prior radiation therapy, obesity, diabetes mellitus, or immunocompromised states
the critical period of complication-free wound healing should be considered to
extend this surveillance period to 6 to 8 weeks postoperatively.
FUTURE CHALLENGES
Major advances have been achieved in the surgical treatment of diseases and defor-
mities of the thorax.Yet with each new development, new demands and challenges
arise in primary and secondary reconstructive thoracic surgery. Although improved
plastic surgical techniques have increasingly met these demands, many problems
could be solved more elegantly and practically. Further improvement is needed in
restoring an adequately rigid yet physiologically pliable and dynamic thoracic skele-
ton in cases of resection or anomaly. Improvements are needed in methods of de-
bridement of wounds involving vital organs. Dynamic imaging or other monitor-
ing during the debridement—or perhaps a topical, enzymatic, or more selective
technique—would help to expedite what can be a tedious and treacherous wound
resection.
Reconstructive efforts can achieve the restoration of thoracic form, a protective
cover, and some physiologic functions. Efforts are under way to perform functional
although primitive cardiac reconstruction, for example, with neuromuscular trans-
fers and cardiac muscle augmentations. Not only should these efforts be redou-
bled, but further efforts should be made to dramatically improve respiratory func-
tion with reconstructive methods. Similarly, tracheobronchial reconstruction with
autogenous tissue is by no means perfected.
Finally, closer monitoring of all children with cardiothoracic interventions will al-
low us to understand and better classify the growth disturbances that follow such
surgery. Only then can analysis and appropriate intervention—or even preven-
tion—be possible.
References—With Key Annotated References
1. Argenta LC, Morykas MJ.Vacuum-assisted closure:A new method for wound control and treat-
ment: Clinical experience. Ann Plast Surg 38:563, 1997.
Landmark publication that detailed the bene ts and clinical applications of the wound VAC.
2. Arnold PG, Pairolero PC. Intrathoracic muscle aps:An account of their use in the management
of 100 consecutive patients. Ann Surg 211:656, 1990.
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Suggested Readings
Alday ES, Goldsmith HS. Surgical technique for omental lengthening based on arterial anatomy.
Surg Gynecol Obstet 135:103, 1972.
Arnold PG. Abdominal and Chest Wall Reconstruction. Atlanta: Medical Association of Georgia,
1982.
Arnold PG, Irons GB.The greater omentum:Extension in transposition and free transfer. Plast Re-
constr Surg 67:169, 1981.
Arnold PG, Pairolero PC. Surgical management of the radiated chest wall. Plast Reconstr Surg
77:605, 1986.
Arnold PG, Pairolero PC. Use of pectoralis major muscle aps to repair defects of anterior chest
wall. Plast Reconstr Surg 63:205, 1979.
The authors present a de nitive description of the use of muscle aps for intrathoracic applications and
a good “how to”article that can guide the reconstructive surgeon in the management of complex clin-
ical scenarios such as empyema and bronchopleural stula.
Arnold PG, Pairolero PC,Waldorf JC.The serratus anterior muscle:Intrathoracic and extrathoracic
utilization. Plast Reconstr Surg 73:240, 1983.
Arnold PG, Witzke BJ, Irons GB, et al. Use of omental transposition aps for soft-tissue recon-
struction. Ann Plast Surg 11:508, 1983.
Ascherman JA, Patel SM, Malhotra, SM, et al. Management of sternal wounds with bilateral pec-
toralis major myocutaneous advancement aps in 114 consecutively treated patients: Re ne-
ments in technique and outcomes analysis. Plast Reconstr Surg 114: 676, 2004.
Bryant LB, Spencer FC, Trinkle JK.Treatment of median sternotomy infection by mediastinal ir-
rigation with an antibiotic solution. Ann Surg 169:914, 1969.
Chicarilli ZN, Ariyan S, Glen WWL, et al. Management of recalcitrant bronchopleural stulas by
muscle ap obliteration. Plast Reconstr Surg 75:882, 1985.
Chicarilli ZN, Ariyan S, Stahl RS. Costochondritis:Pathogenesis, diagnosis, and management con-
siderations. Plast Reconstr Surg 77:50, 1986.
Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Tho-
rac Cardiovasc Surg 45:141, 1963.
DeMeester TR, Lafontaine E. The pleura. In Sabiston DC, Spencer FC, eds. Gibbon’s Surgery of
the Chest, 4th ed, vol 1. Philadelphia:WB Saunders, 1983.
Dotty DB, Hawkins JA. A turnover operation for pectus excavatum at the time of correction of in-
tracardiac defects. J Thorac Cardiovasc Surg 86:787, 1983.
Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 60:1096, 1935.
Classic text that establishes the technique of de nitive drainage of empyemas, written by the author
whose name the operation bears.
Gray SW, Skandalakis JE, eds. Embryology for Surgeons. Philadelphia:WB Saunders, 1972.
Haller JA. Pectus excavatum: A 20-year surgical experience. J Thorac Cardiovasc Surg 60:375,
1970.
Haller JA Jr, Shermeta EW, Tepas JJ, et al. Correction of pectus excavatum without prosthesis or
splints, objective measurement of severity and management of asymmetrical deformities. Ann
Thorac Surg 26:73, 1978.
Haller JA,Turner CS. Diagnosis and operative management of chest wall deformities in children.
Surg Clin North Am 61:216, 1982.
Hartrampf CR, Sche an M, Black PW. Breast reconstruction with a transverse abdominal island
ap. Plast Reconstr Surg 69:216, 1982.
Hawkins JA, Ehrenhaft JL, Doty DB. Repair of pectus excavatum bisternal eversion. Ann Thorac
Surg 38:368, 1984.

Herrera HR, Mijangos J,Weiner RS, et al. Mediastinal cutaneous stulae arising as a complication
of major cardiac surgery: The value of sinography and injection of methylene blue in their
radical excision and immediate repair. Br J Plast Surg 36:421, 1983.
Hersh RE, Jack JM, Dahman MI, et al. The vacuum-assisted closure device as a bridge to sternal
wound closure. Ann Plast Surg 46:250, 2001.
Higgins R, Stahl R, Baldwin JC. Skin grafting for repair of a cardiac laceration. Ann Thorac Surg
52:1161, 1991.
Hodgkinson DJ, Arnold PG. Chest-wall reconstruction using the external oblique muscle. Br J
Plast Surg 33:216, 1980.
Jones G, Jurkewicz MJ, Bostwick J, et al. Management of the infected median sternotomy wound
with muscle aps:The Emory 20-year experience. Ann of Surg 225:766, 1997.
These authors established and con rmed with meticulous long-term follow-up that de nitive debride-
ment and muscle ap closure are the gold standard treatment of infected median sternotomy wounds,
supplanting previous methods.
Jurkiewicz MJ, Arnold PG.The omentum:An account of its use in the reconstruction of the chest
wall. Ann Surg 185:548, 1977.
Jurkiewicz MJ, Bostwick J, Hester TR, et al. Infected median sternotomy wound:Successful treat-
ment by muscle aps. Ann Surg 191:738, 1980.
These authors established and con rmed with meticulous long-term follow-up that de nitive debride-
ment and muscle ap closure are the gold standard treatment of infected median sternotomy wounds,
supplanting previous methods.
Kiricuta I. [The use of the great omentum in the surgery of breast cancer] Presse Med 71:15, 1963
(in French).
This landmark article introduced the reconstructive capacity of the greater omentum.
Lemmer JH, Gomez MN, Symreng T, et al. Limited lateral thoracotomy. Arch Surg 125:873, 1990.
Nahai F. Personal communication, 1983.
Nahai F, Rand RP, Hester TR, et al. Primary treatment of the infected sternotomy wound with
muscle aps: A review of 211 consecutive cases. Plast Reconstr Surg 84:434, 1989.
Nuss D, Kelly RE Jr, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the
correction of pectus excavatum. J Pediatr Surg 33:545, 1998.
This description of a minimally invasive technique revolutionized the treatment of most cases of pec-
tus excavatum in patients other than adults. It has essentially rendered other preexisting methods of
repair obsolete.
Ochsner A, DeBakey M. Chone-chondrosternon: Report of a case and review of the literature. J
Thorac Surg 8:469, 1939.
Pairolero PC, Arnold PG. Bronchopleural stula treatment by transposition of pectoralis major
muscle. J Thorac Cardiovasc Surg 79:142, 1980.
Pairolero PC, Arnold PG. Management of infected median sternotomy wounds [editorial]. Ann
Thorac Surg 42:1, 1986.
Price G, Stahl RS. Reconstruction of penetrating cardiac injuries in infected sternal wounds. Inter-
national Forum on Plastic Surgery, Florence, Italy, 1994.
Ravitch MM. Asymmetric congenital deformity of the ribs:Collapse of the right side of the chest.
Ann Surg 191:534, 1980.
Ravitch MM. Congenital Deformities of the Chest Wall and Their Operative Correction. Philadel-
phia:WB Saunders, 1977.
Ravitch MM. The operative correction of pectus carinatum (pigeon breast). Ann Surg 162:29,
1965.
Ravitch MM.The operative treatment of pectus excavatum. Ann Surg 129:429, 1948.
Ravitch MM. Pectus excavatum and heart failure. Surgery 30:178, 1951.
Ravitch MM. Repair of pectus excavatum in children under 3 years of age: A 12-year experience.
Ann Thorac Surg 23:4, 1977.
1595
Chapter 40
Reoperative Surgery of the Chest Wall

1596
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Ravitch MM. Unusual sternal deformity with cardiac symptoms operative correction. J Thorac
Surg 23:138, 1952.
Scholl L, Chang E, Reitz B, et al. Sternal osteomyelitis:Use of vacuum-assisted closure device as an
adjunct to de nitive closure with sternectomy and muscle ap reconstruction. J Card Surg
19:453, 2004.
Shumacker HB Jr, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection.
Arch Surg 86:384, 1963.
Smith DE, Karish AF, Chapman JP, et al. Healing of the bronchial stump after pulmonary resection.
J Thorac Cardiovasc Surg 46:548, 1963.
Song DH,Wu LC, Lohman RF, et al.Vacuum assisted closure for the treatment of sternal wounds:
The bridge between debridement and de nitive closure. Plast Reconstr Surg 111:92, 2003.
Stahl RS, Kopf GS. Reconstruction of infant thoracic wounds. Plast Reconstr Surg 82:1000, 1988.
This publication was the rst description of the muscle ap treatment of sternal wounds in children.
Stahl RS, Sando WC. Reconstruction of defects of thorax and spine. In Jurkiewicz MJ, Krizek TJ,
Mathes SJ, et al, eds. Plastic Surgery: Principles and Practice. St Louis: Mosby, 1990, p 1169.
Stahl RS, Seyfer AE. Chest wall reconstruction. In Russell RC, ed. Plastic Surgery Educational
Foundation Instructional Courses, vol 3. St Louis: Mosby, 1990, p 258.
Zacharias A, Habib RH. Delayed primary closure of deep sternal wound infections.Tex Heart Inst
J 23:211, 1996.

1597
Chapter 40
Reoperative Surgery of the Chest Wall
1. A 45-year-old man has undergone a three-vessel coronary artery bypass graft
procedure. Seven days postoperatively, the sternotomy wound separates and
drains purulent uid. The sternum is exposed with a sternal fracture and asso-
ciated loose circumsternal wire is evident.Which of the following is the optimal
treatment option?
a. Sternal debridement and delayed primary closure with sternal reapprox-
imation
b. Sternal debridement and bilateral pectoralis ap and overlying skin closure
c. Sternal debridement, dressing changes until granulation tissue appears and
then ap closure
d. Sternal debridement, placement of VAC until granulation tissue appears
and then skin closure
2. Which of the following is an appropriate and very effective adjunct in relieving
postoperative pain after a full-thickness chest wall resection involving multiple ribs?
a. Use of high frequency mechanical ventilation to minimize respiratory ex-
cursions
b. Ablation of affected intercostal nerve roots by injection with absolute
ethyl alcohol
c. Preoperative placement of an indwelling epidural infusion catheter
d. Maintenance of the lateral decubitus position on the operated side to fa-
cilitate splinting of respiratory motions
3. Poland’s syndrome is always characterized by:
a. Ipsilateral breast hypoplasia
b. Hypoplasia of the sternal head of the pectoralis major
c. Bilateral abnormalities of the ribs
d. Ipsilateral athelia
4. Vacuum-assisted closure of a wound should absolutely not be applied in which
of the following situations?
a. Contaminated chest wound
b. Directly over exposed heart
c. Directly over exposed rib
d. Open chest with bronchopleural stula
5. Which of the following is optimal treatment for persistent empyema after open
thoracostomy and serial dressings?
a. Repeat open thoracostomy and intravenous antibiotic therapy
b. Extension of antibiotic therapy alone
c. Establish closed-tube thoracostomy and intravenous antibiotic therapy
d. Resection of overlying ribs, debridement, and ap closure
R EVIEW QUESTIONS

(Trang không có chữ)

P a r t V
REOPERATIVE SURGERY
OF THE TRUNK

(Trang không có chữ)

1601
Reoperative Liposuction
Kristoffer Ning Chang
C ha pter 4 1
Reoperative Problems
Inadequate fat removal
Contour irregularities
Aesthetic disproportion
Reaccumulation of fat
Excessive fat removal
Skin laxity
Skin and subcutaneous scarring
The only source of knowledge is experience.
Albert Einstein
The introduction of suction-assisted lipectomy (SAL) more than 20 years ago
ushered in a new era of body-contouring surgery. The technique has provided a
simpler, safer, and more effective method of improving the body contour than what
was available before. Subsequent re nement and development, including the use
of wetting solution, large-volume liposuction, and ultrasound-assisted lipoplasty
(UAL) have further enhanced our ability to contour the body.Today liposuction is
the most frequently performed aesthetic operation in the United States. Good re-
sults are usually expected, and dramatic results are not uncommon. However, these
procedures may also produce aesthetically undesirable results. These problems can
be grouped into four general categories:
1. Skin problems
2. Contour irregularities
3. Disproportion
4. Skin excess

1602
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Skin problems include hyperpigmentation, discoloration, loss of smoothness, tex-
tural changes, atrophy, wrinkling, and scarring. Contour problems include indenta-
tion, depressions, grooves, waves, dents, divots, dimples, and protuberances. Aes-
thetic disproportion is characterized by altered proportion in various parts of the
body, rendering a disharmonious, displeasing look. For example, excessive removal
of fat in a woman’s thighs may result in an emaciated or a masculinized appearance.
Excessive skin results from a discrepancy between the overlying skin envelope and
the underlying subcutaneous tissue and fat.The junction of the lower buttock and
upper posterior thigh is prone to this type of problem. Some of these changes have
been referred to as postliposuction contour irregularities.
FACTORS CONTRIBUTING TO POOR
AESTHETIC RESULTS
The outcome of lipoplasty is in uenced by many variables, including skin condi-
tion, the patient’s age, extractability of the fat, the equipment used (SAL, UAL,
power-assisted lipoplasty [PAL]), in ltration of wetting solution, artistic planning,
surgical execution, and postoperative care. Careful planning, understanding the po-
tential pitfalls to be avoided, and individualizing treatment for a particular anatomic
situation in each patient are some of the keys to preventing postliposuction defor-
mities. Although we can correct some of the problems related to liposuction, it is
always best to avoid them. Understanding these problems will help prevent their oc-
currence.
A common cause of contour irregularity is overresection of adipose
tissue, which may result from a cannula that is too large or from mak-
ing too many passes with the cannula in the same location. In some
patients, especially fair, thin-skinned women, the adipose tissue may
be loose and prone to overresection.
Areas immediately next to the incision that is to be the site of cannula entry may
be susceptible to overresection because of repeated cannula movement in a limited
space.This patient developed a groove and loose skin above the umbilicus where an
incision was made.

1603
Chapter 41
Reoperative Liposuction
Wetting solution containing epinephrine and lidocaine provides hemostasis and
analgesia. At the same time, it renders the fat more easily removed.
When an excessive amount of wetting solution is used in an area of the fat that is
loose and non brous (such as the buttock or lateral thigh), fat extraction can eas-
ily exceed what is necessary to achieve the desired result.
In ltration of excessive wetting solution, combined with the use of a cannula in the
subdermal layer, may result in diffuse, multicentric contour irregularities. To en-
sure a good surgical outcome, one should leave a smooth, unscarred layer of adipose
tissue beneath the skin and dermis.

1604
PART V
R EOPERATIVE SURGERY OF THE TRUNK
In some patients, the aesthetic limit of fat extraction may be exceeded. Removal of
too much fat from the thighs may transform a desirable female shape into a more
masculine one.The midsection of the medial thigh is especially susceptible.
Overresection may occur as a result of underlying bony prominence, which leads
to erroneous assessment of the amount of remaining adipose tissue to be removed.
The medial condyle of the femur can mask overresection in the medial knee while
the patient is in the supine position with the leg extended. This soft tissue de -
ciency becomes evident when the patient assumes a sitting position.The posterior
lateral buttock is susceptible to overresection, which can lead to a depression.

1605
Chapter 41
Reoperative Liposuction
Uneven resection may occur where more brous adipose tissue is juxtaposed with
looser adipose tissue.The periumbilical area is an example in which dense subcu-
taneous tissue around the umbilical stalk changes into softer adipose tissue of the
lower abdomen. Similarly, a preexisting abdominal surgical scar may interfere with
smooth fat extraction near the scar.
Suboptimal incision placement may lead to unsatisfactory results. Ideally, an incision
should permit application of smooth, radiating cannula movements, which are ap-
propriate for the three-dimensional con guration of the adipose tissue to be mod-
ified. When the cannula is torqued or forced to go around a curved surface, or
when movement of the cannula is impeded, results may be suboptimal.To achieve
smooth coverage of the area to be aspirated, two incisions may be placed at 90-
degree angles from each other to form a crisscross pattern.
In circumferential liposuction or liposuction of
extensive body surfaces, variable-sized grid pattern
markings can be drawn on the skin surface intra-
operatively to assist with the placement of inci-
sions (indicated by the solid triangles) and smooth
cannula movement.1

1606
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Removal of adipose tissue from an inappropriate level of the subcutaneous tissue
may contribute to unsatisfactory results. For example, when fat is removed from the
deep layer of the lower buttock and the upper posterior thigh region, the support
is lost and the buttock becomes ptotic. Improvement of the upper posterior thigh
(subgluteal regions) and the anterior superior knee is accomplished by removal of
more super cially located fat.
Incorrect preoperative surgical markings may lead to unsatisfactory results. The
shape of the body may change from standing to the recumbent position or when
the wetting solution is in ltrated. Without the guidance of proper surgical mark-
ings, extraction of fat may be compromised. Lack of proper feathering at the pe-
riphery of the liposuction site may lead to visible demarcation between the treated
and untreated areas.
When UAL is used, excessive application of ultrasound energy from the mechan-
ical impact or thermal effect may lead to prolonged edema, overresection, and tis-
sue damage.2
Postoperative compression can have an effect on the result. Uneven compression
may lead to temporary or permanent deformation of the skin and the subcuta-
neous tissue. Prolonged and tight postoperative compression may accentuate tissue
ischemia secondary to administration of epinephrine and tissue trauma from fat
extraction, leading to more brosis and scarring.

1607
Chapter 41
Reoperative Liposuction
CLINICAL ANATOMY OF THE SUBCUTANEOUS
ADIPOSE TISSUE3-5
In liposuction, the extractability of fat varies, depending on the individual, the pa-
tient’s sex, and anatomic location.The following is a list of body regions ranked in
increasing effort required to extract the fat: buttocks, medial knees, lateral thighs,
central lower abdomen, medial thighs, upper arms, calves, ankles, hips, upper ab-
domen, anks, chest wall, and the back. In general, it takes more effort to extract the
fat from men than from women.
Paralumbar deep
adipose layer
Rectus abdominis muscle
External oblique muscle
Muscular fascia
Abdomen deep adipose layer
Superficial (subcutaneous) fascia
Superficial adipose layer
The subcutaneous adipose tissue of the trunk and the extremities is organized into
a continuous super cial layer and localized deep fatty layer that is present in the ab-
domen, paralumbar, and gluteal–upper thigh regions. Subcutaneous fascia, or the su-
per cial fascia system, is the brous connective tissue network that, depending on
the location, contains single or multiple horizontal membranous layers and verti-
cally oriented extensions attaching to the subdermal layer above and the deep fas-
cia layer below.

1608
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Varying zones of adherence of the super cial fascia system extend over the trunk
and extremities.The encased fat produces bulges, valleys, plateaus, creases, and folds.
The most adherent zones exist as skin creases and valleys, such as the inframammary
fold, groin crease, gluteal crease, and anterior, posterior midline, and lateral gluteal
depression. Zones of least adherence are the bulges of the truncal area and the ex-
tremities, where the super cial fascia system forms a roof over the localized deep
fatty layer. Intermediate zones of adherence exist in all areas of the trunk and ex-
tremities without signi cant deep fat. Surgical alteration within certain zones of
adherence, such as the lateral gluteal depression and the gluteal crease, may predis-
pose to postliposuction contour irregularities.
Extractability of fat depends on the density and strength of the connective tissue
that encases the fat. Loosely organized deeper fat tends to be more easily removed
than the more compact superficial fat. In lipoplasty, depending on the aesthetic
goals, the super cial fatty layer and the deep layer are targeted for fat extraction. It
is important to leave a smooth, healthy layer of fat beneath the skin after liposuc-
tion. Liposuction and fat grafting can be used to correct postliposuction contour ir-
regularities by modifying and restoring the super cial and deeper fatty layers.
Some patients return for additional procedures after the initial liposuction with sat-
isfactory results.The time interval may be several years or more.The initial surgery
involves areas such as the lower abdomen, hips, and outer thighs, where localized fat
collection commonly occurs. As a result of aging, weight gain, and hormonal
changes, the body accumulates fat in previously untreated areas, such as the upper
abdomen, ank, waist, and back. These regions develop increased fatty deposits in
the superficial fatty layer, which are more fibrous and more difficult to remove
compared with the localized fatty deposits at the initial sites of surgery. In this sit-
uation, or when the fat has returned in areas previously aspirated, increased amounts
of wetting solution or UAL facilitate the fat removal.
ß Inferolateral iliotibial tract
ß Gluteal crease
ß Lateral gluteal depression
ß Middle medial thigh
ß Distal posterior thigh
ZONES OF ADHERENCE

1609
Chapter 41
Reoperative Liposuction
PATIENT EVALUATION
During consultation with the patient regarding secondary procedures to correct
postliposuction irregularities, the surgeon obtains information regarding the pa-
tient’s preoperative body appearance and desired changes, as well as the actual re-
sults obtained, anesthesia technique, surgical technique, complications, and other
details of the surgery, if known. For my own patients, the analysis also includes a re-
view of the preoperative photographs, the surgical markings, and the amount of
fat extracted from the involved areas.
Patients are asked about speci c areas of concern and the improvement they are
seeking.
Physical examination includes assessment of the thickness of the subcutaneous fatty
layer by means of the skin pinch test.The underlying musculoskeletal contour is as-
sessed by palpation and by asking the patient to contract the muscles. Laxity and
sagging is assessed by lifting the skin up against the gravitational pull and by observ-
ing body contours in the upright, reclining, sitting, and exed positions. Areas of fat
excess and fat de ciency are determined.
Fibrotic area
Ideal plane
Fat grafting to areas of depression
Muscle
Fascia
Adipose layer
The surgeon visualizes the ideal contour, determines the sites for harvesting the
fat, and discusses the surgical plan with the patient. Areas of fat excess and de -
ciency can be marked on the patient’s skin. Photographs are taken to identify the
areas where correction is needed.Variable retention of the fat graft, realistic expec-
tations, limitations, and the potential need for additional procedures are all thor-
oughly discussed. For major contour irregularities, both early (3 to 6 months) and
late intervention appears to be effective. Patients will frequently indicate how many
additional surgical procedures they are willing to undergo to obtain improvement.
They may express strong feelings about the dermolipectomy procedure, which re-
sults in longer scars compared with the original liposuction incisions.
Liposuction of areas of protuberance

1610
PART V
R EOPERATIVE SURGERY OF THE TRUNK
PROCEDURES FOR TREATING
POSTLIPOSUCTION DEFORMITIES6-8
Secondary procedures are performed after liposuction to remove residual fat excess
and to correct postliposuction contour irregularities. Residual fat excess with
smooth, normal-appearing contour is amenable to additional liposuction. Protuber-
ance in contour, which appears visually distinct and does not blend into the sur-
rounding surface contour, also requires additional liposuction. Minor contour irreg-
ularities can be treated by limited additional liposuction, which is often performed
under local anesthesia.The more severe and complex cases of postliposuction con-
tour irregularities require a systematic approach that includes the following:
1. Liposuction of areas of protuberance
2. Liposuction around the area of depression
3. Simultaneous fat grafting
4. Dermolipectomy
Autologous fat grafting has been used since the 1980s.5,9-12 Liposhiftinginvolves the
loosening of subcutaneous fat and shifting it into an adjacent area of de ciency by
manual manipulation.13 The technique described in this chapter has the advantage
of being simple and safe. Fat collection, preparation, and injection use commonly
available equipment. Many patients have ample amounts of fat available for har-
vesting, modifying, and further improving the contour. However, patients with ma-
jor soft tissue de ciencies may not have suf cient fat available for autologous fat
grafting.
INDICATIONS AND CONTRAINDICATIONS
Autologous fat grafting is indicated for the replacement of volume de ciency and
for lling postliposuction contour irregularities in various body sites including the
thighs, abdomen, hips, waist, buttocks, arms, and chest.
This 54-year-old woman underwent liposuction,
which resulted in indentation in the anterior lateral
thigh, distal medial thigh, left groin, and lower ab-
domen. A number of factors made her a good can-
didate for corrective liposuction and fat grafting:(1)
abundance of subcutaneous fatty tissue around the
areas of depression to work with, (2) a gentle slope
in the areas of indentation, (3) preservation of good
skin quality in the areas of indentation, and (4) ab-
sence of dense subcutaneous scarring (see p. 1620
for postoperative result).

1611
Chapter 41
Reoperative Liposuction
Some patients develop extensive skin changes and subcutaneous brosis.They have
diffuse and multiple indentations. These problems respond less well to the tech-
nique of corrective liposuction and fat grafting (see p. 1630 for postoperative result).
Dermolipectomy is indicated in a patient who has extensively altered skin or re-
dundant skin. This 45-year-old woman developed loose skin in the medial thighs
and an uneven contour in the medial and anterior thighs after liposuction.
First, she was treated with corrective liposuction and fat grafting.This was followed
by medial thigh dermolipectomy after 1 year 8 months. Postoperative results show
smoother, tighter skin 10 months later.

1612
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The same patient also developed an extra crease in the left upper posterior thigh
and buttock junction after her original liposuction. This deformity was improved
with posterior thigh dermolipectomy, which was an extension of and continuous
with the medial thigh dermolipectomy.
The location of the redundant skin determines where dermolipectomy is per-
formed. Dermolipectomy procedures include but are not limited to medial thigh
lift, transverse flank, thigh/ buttock lift, lower abdominal dermolipectomy, ab-
dominoplasty, upper abdominal dermolipectomy, and brachioplasty.

1613
Chapter 41
Reoperative Liposuction
OPERATIVE TECHNIQUES
MARKINGS
A detailed topographic contour map is essential to the planning and execution of
corrective surgery.
Areas of maximal depression (solid red), areas of
maximal protuberance, and the adjacent transition
zones are indicated precisely. Markings should re-
ect differences in the amount of fat to be removed
in different areas.
Although skin markers of different colors provide a
contrast, all marking can be performed with a black
skin marker. Areas of maximum depression are
marked in solid black. Areas of maximal protuber-
ance or fat excess are marked with multiple Xs or
crosshatching.The transition zone between the two
extremes is left unmarked. The marking is per-
formed with the patient in an upright position.
Photographs of the surgical markings are obtained
for viewing intraoperatively. Tattooing with meth-
ylene blue of features such as areas of maximal de-
pression is helpful for maintaining accurate surgi-
cal markings intraoperatively.

1614
PART V
R EOPERATIVE SURGERY OF THE TRUNK
R EDO LIPOSUCTION
In planning the cannula entry sites for corrective liposuction, the surgeon should se-
lect the most direct approach to the areas to be aspirated. Attempts to hide the in-
cision may compromise cannula movement and the nal results.
Pretunneling before fat removal facilitates localization of the excess
fat, helps to establish the correct cannula pathway, avoids unwanted
fat removal, and maximizes the accuracy of fat extraction. It is impor-
tant to avoid overresection in corrective liposuction.
FAT HARVESTING AND PREPARATION
For harvesting of fat, in ltration of wetting solution is minimized or avoided in
order to obtain fat of maximal solidity. Lidocaine 0.25% with 1:400,000 to
1:800,000 epinephrine is injected with a 22-gauge spinal needle. In ltration into
the operative sites requiring correction is minimized or avoided to facilitate intra-
operative evaluation of the contour as fat is aspirated or added. General anesthesia
is used in patients with more extensive and complex problems.
The fat is collected by pouring it directly from the patient end of the liposuction
tubing or with an interposed sterile specimen trap.To maximize the quality of the
fat used for reinjection, the vacuum is reduced to 26 to 28 inches of mercury dur-
ing fat harvesting.The fat is allowed to settle, and the liquid portion is discarded. No
special processing is required. If the fat is dilute or if the amount is small, a cen-
trifuge or absorbent gauze can be used to concentrate the fat.

1615
Chapter 41
Reoperative Liposuction
FAT GRAFTING
When there is dense subcutaneous adhesion and scarring, a blunt-tipped cannula
without suction is passed beneath the area of depression to make multiple tunnels
before fat grafting.
Fat is injected with a small blunt-tipped cannula with an outside diameter of 1.5 to
1.8 mm, a 14- or a 16-gauge intravenous catheter, or an appropriately sized sharp
needle.The plastic catheter and metal needle are inserted together; the metal nee-
dle is removed, and the fat is injected on withdrawal of the plastic catheter.
A blunt-tipped cannula is preferred because it is less likely to cause bleeding dur-
ing fat injection.
A sharp needle offers the advantage of more precise and effective fat deposition, es-
pecially in densely brotic areas.

1616
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The process is repeated.The fat is injected in small increments, in multiple passes,
and at multiple depths.The path of the fat injection may be parallel or crisscross as
needed. Fat injection may be carried out as the reversal process of fat extraction in
liposuction. During the injection, visual inspection of incremental changes in the
contour is correlated with the amount of fat injected.The skin pinch test provides
an additional means of assessing the adequacy of fat replacement. The aim of the
corrective surgery is to create a smooth contour while the patient is on the oper-
ating table. In the areas of fat grafting, a small degree of overcorrection is acceptable.
Excessive tissue turgor or overcorrection is avoided.
POSTOPERATIVE CARE
The postoperative care of patients who have undergone corrective liposuction and
fat grafting is similar to that of patients who have undergone primary liposuction.
A compression garment is not used if there is a chance that it may apply uneven
pressure to the treated areas. Postoperative manual massage is applied when there is
prolonged induration and rmness.
Smooth contour established via fat transfer
Fat injected in
multiple tunnels
Protuberant
area reduced

OUTCOME
Reoperation for postliposuction contour irregularity is expected to produce correc-
tion or improvement in most patients when properly selected. In a series of 22 pa-
tients with 43 areas of postliposuction contour irregularities, two areas were treated
with dermolipectomy; 22 areas were treated with liposuction only, and 19 areas
were treated with fat grafting in combination with liposuction. Ninety- ve percent
of the areas showed improvement, near-complete correction, or complete correc-
tion. Five percent of the areas had overcorrection consisting of minor indentation.
The outcome depends on the severity of the postliposuction contour irregularities.
In major contour irregularities, de ned as an area greater than 100 cm2, greater
dif culty of correction, and increased severity of visual impact, 31% had complete
or near-complete correction. Forty-seven percent of areas of minor contour irreg-
ularities had near-complete or complete corrections. Most of the patients required
one or two corrective procedures;two patients required three procedures.The av-
erage number of procedures required was 1.4 per patient. The only complication
noted was hyperpigmentation of the skin in one patient.7
RESULTS
CORRECTION OF CONTOUR IRREGULARITIES,
PROTUBERANCES, DEPRESSION, AND SKIN EXCESS
1617
Chapter 41
Reoperative Liposuction
This 55-year-old woman underwent simultaneous liposuction of the abdomen and
mini-abdominoplasty. Her surgeon performed additional corrective liposuction.
She presented with multiple contour irregularities in the abdomen 31⁄2 years after
the initial operation. Examination revealed uneven contour, protuberant areas in
the lower abdomen, and areas of depression below the umbilicus.
The corrective procedure was performed with the patient under general anesthe-
sia. No wetting solution was used in the abdomen. A 3 mm Mercedes-type cannula
was used to aspirate areas of protuberance in the lower abdomen, around the peri-
umbilical and supraumbilical areas. Liposuction was tapered from the point of max-

1618
PART V
R EOPERATIVE SURGERY OF THE TRUNK
imum protuberance into areas of maximum depression. The adhesion below the
area of depression was freed by passing the liposuction cannula without suction to
create space for fat grafting.
To obtain fat for grafting, liposuction in the medial thighs and medial knees was
performed after in ltration of 0.25% lidocaine with 1:400,000 epinephrine. A to-
tal of 35 cc of fat was injected into the areas of depression using an intravenous
catheter. Additional minor liposuction was performed around the periumbilical
area 5 months later.
Improvement was noted 22 months after the major corrective procedure.
The result remained stable after 9 years 10 months when the patient turned 68
years of age. In the meantime she had upper abdominal dermolipectomy to correct
upper abdominal skin laxity.

CORRECTION OF CONTOUR IRREGULARITIES,
DISPROPORTION, PROTUBERANCE, AND INDENTATIONS
1619
Chapter 41
Reoperative Liposuction
This 39-year old woman presented 3 years after undergoing liposuction of the
truncal and thigh areas. Examination revealed disproportional fullness in the iliac
crest area, protuberance in the sacral area, and three areas of indentation at and be-
low the level of the iliac crest posteriorly. Under general anesthesia, this patient un-
derwent liposuction of the hips and sacral region and fat grafting into the indented
areas with a blunt-tipped cannula. Sixteen months after the corrective surgery, the
waist, hips, and lumbar and sacral areas all had a smooth contour. The right lateral
buttock depression appeared improved without any corrective surgical procedure.

1620
PART V
R EOPERATIVE SURGERY OF THE TRUNK
CORRECTION OF MULTIPLE INDENTATIONS
This 54-year old woman presented 7 months after liposuction that resulted in mul-
tiple indentations in the anterior, distal, and medial thigh, groin, and lower ab-
domen. Corrective surgery consisted of liposuction of the thighs, knees, and ab-
domen, and fat grafting to the thighs and abdomen. A total of 70 cc of fat was
injected into the left anterior thigh, 40 cc was injected into the right anterior lat-
eral thigh, and 25 cc was injected into each of the areas above the medial knees. She
also had fat grafting to the right lower abdomen.
The fat was injected with a blunt-tipped cannula. One year later, she underwent a
second procedure for limited fat removal.Two years later, improvement was noted
in the treated areas.

CORRECTION OF LARGE SOFT TISSUE DEFICIENCY
OF THIGHS AND BUTTOCK PTOSIS
1621
Chapter 41
Reoperative Liposuction
This 46-year old woman underwent liposuction of the lateral, medial, and ante-
rior thighs, and the lower legs. She developed contour irregularities at multiple
sites. She was particularly concerned with changes in the lateral and medial thighs,
around the knees, and in the posterior calves.

1622
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Corrective surgery was performed with the patient in the supine position rst. Li-
posuction was performed in the upper medial thighs, medial knees, and anterior su-
perior knees.The fat was injected into the right anterior thigh (23 cc), right and left
midmedial thighs (10 and 55 cc), and the abdomen (25 cc). The patient was next
placed in the prone position. Liposuction was performed in the posterior thighs. Fat
was injected into the right and left posterior lateral thighs (90 and 100 cc), poste-
rior gluteal folds (40 and 20 cc), and the calves (25 and 28 cc).The total amount of
fat aspirated was 480 cc.The total amount of fat injected was approximately 420 cc.
Approximately 200 ml of 0.125% lidocaine with 1:800,000 epinephrine was in-
jected into various sites before fat aspiration.The recipient areas were pretunneled
before the fat was injected with a blunt-tipped cannula.

The postoperative results show improvement of the contour in the medial, lateral,
and posterior thighs, and around the knees at 25 months.The patient was returned
to the operating room for additional improvement in the outer thighs, buttocks,
knees, and legs.
1623
Chapter 41
Reoperative Liposuction

1624
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Liposuction was performed in the abdomen, anterior and medial thighs, anterior
superior knee, and anterior proximal legs.The arms, waist, hips, and right midpos-
terior thigh were aspirated as additional fat donor sites. Fat was injected into the
abdomen (40 cc), right anterior thigh (60 cc), left anterior thigh (30 cc), left leg
(20 cc), right leg (10 cc), and right and left lateral thighs, gluteal folds, and right pos-
terior upper thigh (400 cc). A blunt-tipped cannula was used for fat grafting at all
the sites. At the right lateral thigh, upper posterior thigh, and gluteal fold, 16- and
18-gauge needles were used in addition to the blunt cannula.