Expanding the Progressive Tension Suture Concept: A Study of its Utility in Body Contouring Procedures

Background Seroma is one of the most common complications following body contouring. Progressive tension sutures have been shown to decrease the seroma rate following abdominoplasty, component separation, facelifts and following latissimus flap and DIEP flap harvest. Objectives The objective of our study was to look at the effects of progressive tension suture techniques and their role on the seroma rate in body contouring flap procedures. Methods A retrospective review was performed of all patients undergoing a flap procedure (defined as any procedure that produces a dead space and subsequent susceptibility to seroma) by a single surgeon at a single institution over 3 years. All patients/procedures utilized progressive tension techniques, as is routine in the surgeon’s practice. No drains were used. Patient demographics and complications, including seroma, were tracked. Results A total of 441 flap procedures were performed in 351 patients over the 3-year study period. There were 305 abdominoplasties, 68 lower body lifts, 17 medial thigh lifts, 36 brachioplasties and 15 torsoplasties. Progressive tension sutures were used in all procedures. No drains were utilized. Complications occurred in 72 procedures (16.3%), with the most common complication being minor wound dehiscence without infection. There were no cases of seroma. Conclusions Progressive tension sutures represent an effective technique for reducing the seroma rate, eliminating the potential space and promoting tissue adherence in flap procedures for body contouring. This is the first study of its kind demonstrating the use and role of this technique in body contouring procedures beyond the scope of abdominoplasty.

Latissimus Denervation: A Review of Evidence

Background Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. Among the many reconstructive options available, the latissimus dorsi flap has experienced a renewal in popularity because of its favorable properties and outcomes when used for breast reconstruction. However, a limitation unique to latissimus-based reconstruction is inappropriate breast animation postoperatively, due to persistent thoracodorsal innervation of the latissimus dorsi muscle after transfer to the mastectomy site. Methods A comprehensive literature search of PubMed and MEDLINE was conducted for studies investigating the role of thoracodorsal denervation in latissimus-based breast reconstruction. Data on surgical techniques, type of intervention, objective outcome measurements, and patient satisfaction-based outcomes were reported. Additional data included patient sample size, follow-up length, and treatment of thoracodorsal nerve (e.g., resection versus transection and length of transection) when applicable. Results Sixty-six search results were reviewed for inclusion and nine qualified after exclusion criteria for a total of 361 patients undergoing either unilateral or bilateral latissimus flap reconstruction. Successful thoracodorsal denervation rates were included in most studies and outcomes measurements were heterogeneous. Eight out of nine studies included patient-reported symptoms of breast animation postoperatively. Based on these findings, a systematic approach is presented. Conclusion We present this review to elucidate successful practices, identify current gaps in knowledge, and offer a systematic approach to this clinical challenge.

The Pedicled Latissimus Dorsi Flap Provides Effective Coverage for Large and Complex Soft Tissue Injuries Around the Elbow

Background: The pedicled latissimus flap has been shown to provide effective coverage of wounds around the elbow with an average size of 100 to 147 cm2 but with complication rates of 20% to 57%. We believe the pedicled latissimus dorsi flap is an effective and safe technique that provides reliable and durable coverage of considerably larger soft tissue defects around the elbow and proximal forearm. Methods: A retrospective review was performed including all patients from Harborview Medical Center between 1998 and 2012 who underwent coverage with pedicled latissimus dorsi flap for defects around the elbow. Demographic information, injury mechanism, soft tissue defect size, complications (minor vs major), and time to surgery were collected. The size of the soft tissue defect, complications, and successful soft tissue coverage were the primary outcome measures. Results: A total of 18 patients were identified with variable mechanisms of injury. Average defect size around the elbow was 422 cm2. Three patients had partial necrosis of the distal most aspect of the flap, which was treated conservatively. One patient required a secondary fasciocutaneous flap, and another required conversion to a free latissimus flap secondary to venous congestion. Two were lost to follow-up after discharge from the hospital. In all, 88% (14 of 16) of the patients had documented (>3-month follow-up) successful soft tissue coverage with single-stage pedicled latissimus dorsi flap. Conclusions: The pedicled latissimus dorsi flap is a reliable option for large and complex soft tissue injuries around the elbow significantly larger than previous reports. However, coverage of the proximal forearm remains challenging.