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Kilian K, Panayi A, Matar D, Hamwi C, Bigdeli A, Kneser U, Vollbach F. Similarity of Seroma Rate at the Medial Thigh following Free Flap Harvesting or Medial Thigh Lift: A Systematic Review and Meta-analysis. JPRAS Open 2024; 40:360-374. [PMID: 38770115 PMCID: PMC11103577 DOI: 10.1016/j.jpra.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/30/2024] [Indexed: 05/22/2024] Open
Abstract
Despite the growing use of autologous breast reconstruction with medial thigh-based free flaps, such as transverse upper gracilis (TMG) or profunda artery perforator (PAP) flaps, these procedures are infrequently performed on patients with obesity. This systematic review and meta-analysis aimed to compare the frequency of seroma occurrence, a common complication after medial thigh flap surgery. Comparison was performed between TMG and PAP flaps, as well as medial thigh lifts (MTL), a procedure with a similar operative technique but which is typically offered to patients with a higher body mass index (BMI). Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we analyzed EMBASE, PUBMED, and MEDLINE data (English/German). The primary outcomes assessed were occurrence of seroma, as well as hematoma and wound dehiscence. Subgroup analyses explored age, BMI, and various surgical factors. This meta-analysis incorporated 28 studies, totaling 1096 patients. MTL patients had significantly higher BMIs, whereas seroma rates were similar among TMG, PAP, and MTL patients. The incidence of hematoma and wound dehiscence was also similar across the groups. In the metaregression analysis, factors such as age and BMI showed no significant correlation with seroma occurrence in all groups. This systematic review and meta-analysis identified comparable rates of seroma formation after TMG flap, PAP flap, and MTL procedures. Considering that this phenomenon occurred despite the elevated BMI of the MTL group, we propose that patients with higher BMI need not be excluded as candidates for autologous medial thigh-based breast reconstruction. Hence, these procedures should not be limited to small- to medium-sized breasts. Large-scale prospective studies are imperative to validate these conclusions and reveal the underlying factors contributing to seroma formation.
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Affiliation(s)
- K.K. Kilian
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - A.C. Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - D.Y. Matar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C. Hamwi
- Department of Data Science, Saint Louis University, St. Louis, MO, USA
| | - A.K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - U. Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - F.H. Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University (LMU), Munich, Germany
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Gesuete F, Molle M, Cagiano L, Annacontini L, Verdura V, Nicoletti G, Ferraro G, Parisi D, Portincasa A. Surgical approach to a rare case of Beckwith Wiedemann syndrome with left thigh hyperplasia. JPRAS Open 2024; 39:303-306. [PMID: 38375434 PMCID: PMC10875232 DOI: 10.1016/j.jpra.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/03/2023] [Indexed: 02/21/2024] Open
Abstract
Thigh lift surgery is generally performed in patients with severe weight loss outcomes, particularly those undergoing bariatric surgery. However, there are other congenital malformation conditions that may require the same treatment, such as Beckwith Wideman syndrome.
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Affiliation(s)
- F. Gesuete
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Clinical and Experimental Medicine. University of Foggia - Medical School of Foggia, Italy
| | - M. Molle
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Napoli, Italy
| | - L. Cagiano
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Clinical and Experimental Medicine. University of Foggia - Medical School of Foggia, Italy
| | - L. Annacontini
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Clinical and Experimental Medicine. University of Foggia - Medical School of Foggia, Italy
| | - V. Verdura
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Clinical and Experimental Medicine. University of Foggia - Medical School of Foggia, Italy
| | - G.F. Nicoletti
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Napoli, Italy
| | - G. Ferraro
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Napoli, Italy
| | - D. Parisi
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Clinical and Experimental Medicine. University of Foggia - Medical School of Foggia, Italy
| | - A. Portincasa
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Clinical and Experimental Medicine. University of Foggia - Medical School of Foggia, Italy
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Beaufils T, Berkane Y, Freton L, Richard C, Watier É, Qassemyar Q, Bertheuil N. A New Surgical Technique for Female-to-Male Top Surgery: The Posterioinferior Pedicle (PIPe) Approach. Aesthetic Plast Surg 2023; 47:2283-2294. [PMID: 37684416 DOI: 10.1007/s00266-023-03552-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/23/2023] [Indexed: 09/10/2023]
Abstract
INTRODUCTION Most of the time, female-to-male (FtoM) chest surgery involves mastectomy techniques and free transplantation of the nipple-areola complex. With the increasing prevalence of gender dysphoria and the demand for female-to-male gender reassignment surgery, the need for FtM top surgery is also rising. To meet this demand, we present a new approach: the PIPe technique, based on a fasciocutaneous flap with a posteroinferior pedicle. MATERIALS AND METHODS All patients with FtoM gender dysphoria undergoing surgery using the posteroinferior pedicle flap technique in the Plastic Surgery Department at Rennes University Hospital Center were included. The procedure involved extensive liposuction of the lower internal and external mammary quadrants, followed by liposuction of deep tissues in the upper quadrants, except in the pedicle area. After removing skin from the lower quadrants down to the dermis and de-epithelializing the posteroinferior pedicle flap, the thoracic flap was lowered and the areola transposed. RESULTS From July 2022 to March 2023, fifteen patients underwent surgery, and their results were collected prospectively. The average age was 25 years, the mean weight was 76.6 kg, and the average BMI was 28.1 kg/m2. The average operating time was 102 min, and the mean weight excised was 459.5 g. The average length of hospital stay was 3.3 days, and the drainage duration was 2.4 days. No major complications were reported, and there were no cases of reintervention or recurrence. CONCLUSIONS Our study presents a novel surgical approach utilizing the posteroinferior pedicle technique. Its key benefit lies in the preservation of neurovascular function, which makes it an attractive option for patients seeking to retain nipple sensitivity. This procedure is reliable, reproducible, and recommended as a first-line treatment for grade II and III gynecomastia due to its low rate of major complications and favorable functional and aesthetic outcomes. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Tristan Beaufils
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital Center, 16 Boulevard de Bulgarie, 35200, Rennes, France
| | - Yanis Berkane
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital Center, 16 Boulevard de Bulgarie, 35200, Rennes, France
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- INSERM U1236, University of Rennes 1, Rennes, France
- SITI Laboratory, Etablissement Français du Sang Bretagne, Rennes University Hospital, Rennes, France
| | - Lucas Freton
- Department of Urology, Rennes University Hospital Center, Rennes, France
| | - Claire Richard
- Department of Urology, Rennes University Hospital Center, Rennes, France
| | - Éric Watier
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital Center, 16 Boulevard de Bulgarie, 35200, Rennes, France
| | | | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital Center, 16 Boulevard de Bulgarie, 35200, Rennes, France.
- INSERM U1236, University of Rennes 1, Rennes, France.
- SITI Laboratory, Etablissement Français du Sang Bretagne, Rennes University Hospital, Rennes, France.
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Sabbagh E, Ferreira N, Giot JP. Enhanced Avulsion Technique for Brachioplasty and Cruroplasty: Minimizing Complications and Ensuring Patient Safety. Cureus 2023; 15:e45390. [PMID: 37854748 PMCID: PMC10579839 DOI: 10.7759/cureus.45390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/20/2023] Open
Abstract
Background Brachioplasty and cruroplasty are commonly performed aesthetic procedures, but they are not without their risks. Among the potential complications, the development of seroma or hematoma is particularly concerning. In this article, we present a modified avulsion technique designed to reduce complications and improve patient outcomes. Methods Our study included all consecutive patients (n=28) who underwent brachioplasty and/or cruroplasty using the modified avulsion technique at the Plastic Surgery Department of the University Hospital of Grenoble between September 2019 and November 2022. Data collection was conducted retrospectively to evaluate the complications of the procedure. Histological analysis was performed on samples of excised tissues from five patients operated on with the avulsion technique and five patients operated on with electrocautery resection. Results A total of 28 patients were reviewed, with a mean follow-up of 22 months. Among the 28 patients, regarding the Common Terminology Criteria for Adverse Events (CTCAE), there were no major complications, with minor complications occurring in 55% of the cases. Conclusion Dermolipectomies of the extremities are associated with a high level of patient satisfaction with a low risk of major complications. The avulsion technique practiced by the authors proved to be a safe and efficient procedure.
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Affiliation(s)
- Elias Sabbagh
- Plastic and Reconstructive Surgery, Centre Hospitalier Universitaire (CHU) Grenoble Alpes, Grenoble, FRA
| | - Nathan Ferreira
- Plastic and Reconstructive Surgery, Centre Hospitalier Universitaire (CHU) Grenoble Alpes, Grenoble, FRA
| | - Jean Philippe Giot
- Plastic and Reconstructive Surgery, Centre Hospitalier Universitaire (CHU) Grenoble Alpes, Grenoble, FRA
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Weber J, Kalash Z, Simunovic F, Bonaventura B. Prolonged postoperative antibiotic administration reduces complications after medial thigh lift. J Plast Surg Hand Surg 2022; 56:361-368. [PMID: 34928776 DOI: 10.1080/2000656x.2021.2010738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There is widespread consensus that there is no indication for postoperative antibiotic administration after elective surgery. However, medial thigh lift (MTL) remains a procedure with a notoriously high rate of wound-healing disorders and infections. This study investigates the correlation between prolonged antibiotic administration and complications after MTL in massive weight loss patients. We performed a single-institution retrospective review of 121 patients undergoing MTL between 2009 and 2020. Data on postoperative outcome, demography, surgery and comorbidities were collected. All patients received intravenous antibiotics preoperatively. One group was continued on oral antibiotics for two weeks postoperatively. Complications and surgical site infections were observed and evaluated. There was no difference between the groups regarding age, BMI, or presence of obesity-associated risk factors. We observed complications in 76 patients (71%), with 60 (56%) minor and 16 (15%) major complications. The group without prolonged antibiotic administration had a higher number of total complications (OR 3.5; p = 0.0037), major complications (OR 4; p = 0.01), and wound infections (OR 6.8; p = 0.0004). Logistical regression analysis showed that this effect was independent of type of weight loss, resection volume, and age. Reduction of major infections by prolonged antibiotics was, however, dependent on BMI Δ. No side-effects associated with antibiotics were registered in this series. This study suggests that prolonged antibiotic administration may decrease complications in MTL. We thus continue to use prolonged antibiotic administration after MTL. Further research is needed to determine the optimal duration of antibiotic treatment. Level of Evidence: Level IV: therapeutic study.
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Affiliation(s)
- J Weber
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Z Kalash
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - F Simunovic
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - B Bonaventura
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
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Physical measurements and patients’ perception of excess skin on arms and thighs before and after bariatric surgery. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-021-01934-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Background
Bariatric surgery is an effective weight loss method for patients with obesity. One side effect of bariatric surgery is uncomfortable excess skin. Much remains to be learned about physical measurements and patients’ subjective perceptions of it. Here, we investigated the pre- to post-bariatric changes in patients’ perception and physical measurements of the skin on the arms and thighs, in order to find possible subgroups especially affected by post-operative excess skin and to identify predicting factors.
Methods
One hundred forty-seven patients eligible for bariatric surgery completed the Sahlgrenska Excess Skin Questionnaire (SESQ) and underwent measurements of their skin before and 18 months after the procedure.
Results
Although most physical measurements decreased post-operatively, many patients reported increased discomfort. We identified one subgroup particularly prone to report excess skin on the arms post-operatively: women with high discomfort from excess skin on the arms and high body mass index (BMI), pre-operatively. Ptosis of the excess skin seems to be a feasible measurement for predicting post-operative discomfort. For every centimetre of ptosis pre-operatively, patients had 1.37- and 1.31-fold higher odds of achieving a score for post-operative discomfort from excess skin on the upper arms and thighs, respectively, of ≥ 6 (on a 0–10 scale).
Conclusions
We identified a subgroup especially affected by discomforting excess skin on arms and thighs after weight loss. Furthermore, we suggest a pre-operative pro-operative ptosis measuring to predict post-operative discomfort level. The result of this study further increases the knowledge of excess skin and should be useful in further improving patient education.
Level of Evidence: Level III, risk / prognostic study.
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Mocquard C, Pluvy I, Chaput B, Hoogbergen MM, Watier E, Gandolfi S, Bertheuil N. Medial Thighplasty Improves Patient's Quality of Life After Massive Weight Loss: a Prospective Multicentric Study. Obes Surg 2021; 31:4985-4992. [PMID: 34378158 DOI: 10.1007/s11695-021-05654-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The aim of this study was to assess the impact of medial thighplasty following massive weight loss on the quality of life of patients and on their sexual life. METHODS We performed a multicentric, prospective study on the quality of life after massive weight loss using the Short-Form 36 questionnaire, the Female Sexual Function Index questionnaire, and the Moorehead-Ardelt Quality of life questionnaire. Forty-nine patients who underwent medial thighplasty were included in three centers and evaluation was made pre- and post-operatively. RESULTS The mean age of the patients was 44 ± 12.5 years. The average pre-medial thighplasty body mass index was 27 ± 3.8 kg/m2. All the categories of the SF36 questionnaire scored higher after surgery apart from "health change" but only the "role limitations due to emotional problems" category was significantly improved (p = 0.0081). Similarly, the Moorehead-Ardelt questionnaire showed a positive impact of the surgery on the quality of life in general (mean total score 1.04 ± 1.37) and on self-esteem, physical activity, social relationships, and work performance. Interestingly, sexual activity was not improved by the surgery and this result is in line with the FSFI, which showed no effect of medial thighplasty on sexual life. CONCLUSIONS Medial thighplasty improves the quality of life of patients after massive weight loss but does not seem to modify the sexual quality of life. These results clearly indicate that this surgery should be widely offered to patients seeking reconstruction of massive weight sequelae.
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Affiliation(s)
- Camille Mocquard
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35200, Rennes, France.
- INSERM U1236, University of Rennes 1, 35000, Rennes, France.
- SITI Laboratory, Etablissement Français du Sang Bretagne, Rennes University Hospital, 35000, Rennes, France.
| | - Isabelle Pluvy
- Department of Plastic, Reconstructive and Aesthetic Surgery, CHU of Besancon, 25000, Besançon, France
| | - Benoit Chaput
- Department of Plastic, Reconstructive and Aesthetic Surgery, CHU of Toulouse, 31000, Toulouse, France
| | - Maarten M Hoogbergen
- Department of Plastic, Reconstructive and Hand Surgery, Catharina Hospital Eindhoven, 5623 EJ, Eindhoven, The Netherlands
| | - Eric Watier
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35200, Rennes, France
| | - Silvia Gandolfi
- Department of Plastic, Reconstructive and Aesthetic Surgery, CHU of Rouen, 76000, Rouen, France
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35200, Rennes, France
- INSERM U1236, University of Rennes 1, 35000, Rennes, France
- SITI Laboratory, Etablissement Français du Sang Bretagne, Rennes University Hospital, 35000, Rennes, France
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Lipo-Bodylift Reconstruction Following Massive Weight Loss: Our Experience with 100 Consecutive Cases. Aesthetic Plast Surg 2021; 45:2220-2228. [PMID: 33492477 DOI: 10.1007/s00266-020-02118-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 12/26/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND We report our experience using the Lipo-Bodylift technique for circumferential lower trunk reconstruction following massive weight loss. METHODS The procedure combines extensive circular liposuction with circular skin resection immediately under the dermis. We classify lower trunk deformities using three parameters: (1) excess skin (in the horizontal direction, or both horizontally and vertically); (2) the body mass index (BMI); and, (3) skin quality (hyperlaxity or a normal tone). All patients can be divided into four groups, of whom groups I and II are the best candidates for the Lipo-Bodylift procedure. We also describe our perioperative management and patient outcomes, with a focus on postoperative complications. RESULTS Between January 2015 and January 2020, 100 patients underwent Lipo-Bodylift treatment. The median patient age was 41 years. The median preoperative BMI was 26.3 kg/m2. The median drainage duration and hospital stay were both 3 days. Of all patients, 30% experienced at least one complication, 2% of which were major. Of the minor complications, 27 patients evidenced wound dehiscence. Only (positive) smoking status was significantly associated with postoperative complications (p < 0.001). CONCLUSION We developed the Lipo-Bodylift technique after analyzing changes in the skin and subcutaneous fat after massive weight loss. The technique completes the arsenal of body contouring techniques, appears to be less invasive than the undermining that is usually performed during circumferential reconstruction of the lower trunk, and is associated with a lower rate of major complications. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Risk Factors for Complications after J Medial Thighplasty following Massive Weight Loss: A Multivariate Analysis of 94 Consecutive Patients. Plast Reconstr Surg 2021; 148:540e-547e. [PMID: 34550932 DOI: 10.1097/prs.0000000000008386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bariatric surgery has increased the number of patients requiring medial thighplasty after massive weight loss. However, despite the various complications, the procedure improves quality of life. The authors report postoperative complications of vertical J-shaped medial thigh lift in a series of patients and identify preoperative risk factors. METHODS For almost 5 years, the details of all J medial thighplasties performed by a single surgeon were recorded; detailed medical records were also available. Complications can be major (e.g., need for early surgical revision or readmission) or minor (delayed wound healing). RESULTS During the study period, 94 patients were treated and only minor complications were recorded (42.5 percent). On multivariate analysis, older age (OR, 1.05; 95 percent CI, 1.01 to 1.10) and a body mass index greater than or equal to 30 kg/m2 (OR, 2.82; 95 percent CI, 1.10 to 7.22) were independent risk factors for postoperative complications. CONCLUSIONS As with other postbariatric operations, medial thighplasty is associated with significant morbidity, but the risk thereof can be easily established and managed. Specific algorithms for determining the risk of postoperative complications based on age and body mass index are needed to guide preoperative discussions with patients and perform patient selection. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Bonaventura B, Weber J, Kalash Z, Stark GB, Simunovic F. The Edmonton Obesity Staging System as a predictor for postoperative complications after medial thigh lift in massive weight loss patients. J Plast Reconstr Aesthet Surg 2021; 74:3120-3127. [PMID: 34045144 DOI: 10.1016/j.bjps.2021.03.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/02/2021] [Accepted: 03/13/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND This study investigates the correlation between the Edmonton Obesity Staging System (EOSS) and the occurrence of postoperative complications after medial thigh lift in formerly obese patients. PATIENTS AND METHODS A single-institution retrospective review of patients undergoing medial thigh lift between 2009 and 2019 after massive weight loss. Data on demography, comorbidities, surgery, and postoperative outcome were extracted from patients' charts. Patients were grouped into EOSS categories. Complications were classified into minor and major. Logistic regression analysis was performed to determine the association between risk factors and complications. RESULTS One hundred and eight patients were included in the study. Complications occurred in 76 (70%) of the patients, most of which were minor (60/108, 56%). Complications increased with increasing EOSS stage, and all EOSS 3 patients had complications. Classification as EOSS 2 or 3 significantly associated with occurrence of postoperative complications (OR 99.3, p<0.001) as well as minor and major complications individually (OR 3.1 and 6.5, p<0.05). This effect was independent of body mass index (BMI), maximum BMI loss, type of weight loss, volume of liposuction, weight of resected tissue, and type of surgery. CONCLUSION EOSS is a robust and independent predictor for postoperative complications in medial thigh lift surgery after massive weight loss.
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Affiliation(s)
- B Bonaventura
- Department of Plastic and Hand Surgery, Freiburg University Medical Center, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - J Weber
- Department of Plastic and Hand Surgery, Freiburg University Medical Center, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Z Kalash
- Department of Plastic and Hand Surgery, Freiburg University Medical Center, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - G B Stark
- Department of Plastic and Hand Surgery, Freiburg University Medical Center, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - F Simunovic
- Department of Plastic and Hand Surgery, Freiburg University Medical Center, Hugstetterstr. 55, 79106 Freiburg, Germany.
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A Cross-sectional Analysis of Insurance Coverage of Extremity Contouring After Massive Weight Loss. Ann Plast Surg 2020; 84:253-256. [DOI: 10.1097/sap.0000000000002150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Does Medial Thighplasty Improve the Sexual Quality of Life of Patient After Massive Weight Sequelae? Obes Surg 2020; 30:1147-1149. [DOI: 10.1007/s11695-019-04376-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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13
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Barreiro G, de Lima VS, Cavazzola LT. Abdominal skin tensile strength in aesthetic and massive weight loss patients and its role in ventral hernia repair. BMC Surg 2019; 19:68. [PMID: 31242888 PMCID: PMC6595693 DOI: 10.1186/s12893-019-0523-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 05/27/2019] [Indexed: 11/23/2022] Open
Abstract
Background Clarifying the biomechanics of abdominal skin could lead to different uses for this tissue such as the ventral repair of hernias in patients with excess skin and incisional hernias. The objective of this study was to compare the maximum tensile strength of abdominal skin to commercial meshes and to verify whether or not it varies between aesthetic patients and massive weight-loss patients. Methods Experimental cross-sectional study. Skin samples sized 32 × 20 mm were taken from 15 abdominoplasties and 10 panniculectomies. The skin specimens were analyzed in vertical and horizontal tensile strength tests. Results were compared between the two groups including their traction directions. Commercial meshes were also tested. The results were analyzed using the Generalized Estimating Equation. Results The maximum tensile strength supported vertically by abdominal dermis was 403.5 ± 27.4 N in the abdominoplasty group and 425.9 ± 33.9 N in the panniculectomy group. Horizontally, the values were 596.5 ± 32.2 N and 612.5 ± 43.9 N respectively. The strengths between traction directions were significantly different (p < 0.001). There were no differences between the groups with regard to the maximum tensile strength (p = 0.472). Tested commercial meshes had the following values: polypropylene 104.6 N, low-weight polypropylene 54.4 N, polytetrafluorethylene (PTFE) 82.2 N, and hydrated porcine small-intestinal submucosa 60.0 N. Conclusion In our study, the tensile strength of the tested human abdominal dermis samples, both aesthetic and post-bariatric, was superior to the commercial meshes. Therefore, in selected cases, abdominal dermis could be an alternative tool in abdominal reconstruction during panniculectomies with concomitant hernia repair. Electronic supplementary material The online version of this article (10.1186/s12893-019-0523-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Guilherme Barreiro
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil. .,Hospital Conceição, Porto Alegre, Brazil. .,, Sinop/MT, Brazil.
| | | | - Leandro T Cavazzola
- Case Western Reserve University, Cleveland, OH, USA.,Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Clinical, Biomechanical, and Anatomic Investigation of Colles Fascia and Pubic Ramus Periosteum for Use During Medial Thighplasty. Ann Plast Surg 2017; 78:S305-S310. [DOI: 10.1097/sap.0000000000001033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Thiénot S, Bertheuil N, Carloni R, Méal C, Aillet S, Herlin C, Watier E. Postero-Inferior Pedicle Surgical Technique for the Treatment of Grade III Gynecomastia. Aesthetic Plast Surg 2017; 41:531-541. [PMID: 28204931 DOI: 10.1007/s00266-017-0810-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 01/24/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Surgical treatment of Grade III gynecomastia generally utilizes mastectomy techniques and free transplantation of the nipple-areola complex. Moreover, with rising obesity rates and the development of bariatric surgery, an increasing demand for correctional surgery for pseudogynecomastia has been observed, which is comparable to Grade III gynecomastia in terms of its surgical management. Here, we describe an innovative technique to deal with these new demands: fascio-cutaneous flap by postero-inferior pedicle. MATERIALS AND METHODS All patients in the Department of Plastic Surgery from our University Hospital suffering from Grade III gynecomastia or pseudogynecomastia underwent surgery via the postero-inferior pedicle flap technique. Briefly, we performed extensive liposuction of the infero-internal and infero-external mammary quadrants followed by liposuction of the deep tissues of the superior quadrants, except in the area of the pedicle. After removing the skin just above the dermis of the inferior quadrants and performing de-epithelialization of the postero-inferior pedicle flap, the thoracic flap was lowered and the areola transposed. RESULTS Nine patients underwent surgery between March 2015 and March 2016, and their results were collected prospectively. The mean patient age was 46.6 years, the mean weight was 94.2 kg, and the mean body mass index was 30.8 kg/m2. In addition, the mean operative time was 132 min, the mean liposuction volume was 633 mL, the excised weight was 586 g, and the mean hospitalization and drainage durations were 3.8 days. No major complications occurred, no re-intervention was required, and no recurrence was found. CONCLUSIONS We report a new operative technique using a postero-inferior pedicle. Its main advantage is preservation of neurovascular function, which makes this a promising technique for patients who wish to maintain nipple sensitivity. This surgery is reliable and reproducible. We recommend it as the first line treatment for Grade III gynecomastia because of its low rate of major complications and favorable functional and esthetic results. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Sophie Thiénot
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35200, Rennes, France
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35200, Rennes, France.
- SITI Laboratory, Etablissement Français du Sang Bretagne, Rennes University Hospital, Rennes, France.
- STROMAlab, UMR5273 CNRS/UPS/EFS - INSERM U1031, Rangueil Hospital, Toulouse, France.
| | - Raphaël Carloni
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nicolle Hospital, University of Rouen, Rouen, France
| | - Cécile Méal
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35200, Rennes, France
| | - Sylvie Aillet
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35200, Rennes, France
| | - Christian Herlin
- Department of Plastic and Burn Surgery, CHU of Montpellier, Montpellier, France
| | - Eric Watier
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35200, Rennes, France
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Postero-Inferior Pedicle Surgical Technique for the Treatment of Grade III Gynecomastia. Aesthetic Plast Surg 2017; 41:749-750. [PMID: 28374303 DOI: 10.1007/s00266-017-0865-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 03/19/2017] [Indexed: 12/25/2022]
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The Lipo-Body Lift: A New Circumferential Body-Contouring Technique Useful after Bariatric Surgery. Plast Reconstr Surg 2017; 139:38e-49e. [PMID: 28027231 DOI: 10.1097/prs.0000000000002926] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND After bariatric surgery, lifting of the lower body involves a contouring technique used to achieve optimal lower trunk reconstruction. The authors describe an innovative procedure applicable after massive weight loss: the lipo-body lift method. The authors describe their experience with this novel, safe procedure. METHODS Twenty-five abdominal body-contouring reconstructions following massive weight loss were treated by means of circumferential lipo-body lift. The authors describe the indications for the procedure and their perioperative and postoperative management. RESULTS The mean patient age was 39.4 years. The mean pre-body lift body mass index was 26.71 kg/m; the average weight loss before surgery was 56.6 kg, with a mean delta body mass index loss of 20.82 kg/m. The average hospital stay was 3.52 days and the drainage duration 3.56 days. No patient experienced any major complication (e.g., hematoma, thromboembolism, bleeding, skin necrosis, or a need for revision surgery to treat complications). Minor complications including wound dehiscence, wound infection, and fat necrosis were reported in 40 percent of patients. The occurrence of complications was associated with smoking status (p = 0.0280), the volume of liposuction (p = 0.0399), and the liposuction volume per unit of body mass index (p = 0.0071). CONCLUSIONS The authors' novel technique is less invasive than the traditional lower body-lifting method, as shown by the absence of major complications, and allows excellent conservation of connective tissue and vessels; undermining is minimal. As obesity becomes a major problem worldwide, lifting procedures that are safe and effective are important components of reconstructive strategies and should be widely offered to patients who experience massive weight loss. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Ellart J, Grolleau JL, Gangloff D, Meresse T, Garrido I, Bertheuil N, Carloni R, Chaput B. [Morbidity of bodylift. Evaluation of 111 patients over 5 years]. ANN CHIR PLAST ESTH 2016; 61:820-826. [PMID: 27666182 DOI: 10.1016/j.anplas.2016.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 08/23/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The management of patients with weight loss sequelae, sometimes major, is increasingly well standardized. However, this surgery is not without risk. Complications of bodylift are more frequent than those of conventional abdominoplasties. The objective of this study was to evaluate the morbidity associated with this surgery through a retrospective, single-center study. MATERIALS AND METHODS One hundred and eleven circular abdominaloplasties were conducted between June 2011 and September 2015 in the plastic surgery department of the university hospital of Toulouse. Minor and major complications were identified and analyzed. RESULTS Frequency of postoperative complications was 44.1% in our series. Major complications have involved 15.3% of patients. Blood transfusions (9%) and hematoma requiring reoperation (7.2%) were the most frequent major complications. We found significantly more major complications in patients with important fat resection with a cut off at 3200 g (P=0.02). Men experienced significantly more major complications than women (P=0.005). The average delta-BMI (before and after weight loss) was significantly higher in the group of patients with the highest percentage of minor complications (P=0.045). Indeed, a high delta-BMI (greater than 19.5) was associated with an excess risk of minor complications in our population. CONCLUSION Democratization and progress in the field of bodylift should not obscure the fact that it is, in reality, a procedure at risk. While we manage increasingly better cosmetic results and thromboembolic complications, it still persists many complications.
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Affiliation(s)
- J Ellart
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Lille, rue Émile-Laine, 59037 Lille, France
| | - J-L Grolleau
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Toulouse, 1, avenue Jean-Poulhès, 31059 Toulouse, France
| | - D Gangloff
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Toulouse, 1, avenue Jean-Poulhès, 31059 Toulouse, France
| | - T Meresse
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Toulouse, 1, avenue Jean-Poulhès, 31059 Toulouse, France
| | - I Garrido
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Toulouse, 1, avenue Jean-Poulhès, 31059 Toulouse, France
| | - N Bertheuil
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Sud, université de Rennes 1, 2, rue Henri-Le-Guillax, 35000 Rennes, France
| | - R Carloni
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - B Chaput
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Toulouse, 1, avenue Jean-Poulhès, 31059 Toulouse, France.
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[Lower bodylift after massive weight loss: Retrospective study of satisfaction, complications and quality of life. About 76 patients over 4years]. ANN CHIR PLAST ESTH 2016; 61:827-835. [PMID: 27473934 DOI: 10.1016/j.anplas.2016.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/08/2016] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Massive weight loss leads to important cutaneous deformities with physical and psychological repercussions for patients. Lower bodylift is a procedure, which can restore the body contour. The aim of this study is to evaluate satisfaction and quality of life in patients who underwent lower bodylift and to review the complications of these procedures. MEANS AND METHODS This is a retrospective study of 76 patients who underwent lower bodylift between 2012 and 2016. We reviewed the complications of these procedures. Satisfaction and quality of life were assessed using Body-QoL questionnaire. RESULTS Seventy-six patients were included with a mean age of 39.2years. The average body mass index was 27.6kg/m2 with a mean weight of 71.2kg at the time of surgery and a mean weight loss of 48.6kg. Twenty-three patients developed one complication: 22 minor and 1 major. Forty-eight patients answered the questionnaire. Satisfaction was rated "very good" by 41 patients (85.4%) and "good" by 5 patients (10.4%). The Body-QoL questionnaire's analysis showed an improvement of quality of life socially, sexually, in the body regard and in physical symptoms. CONCLUSIONS Lower bodylift is the only procedure, which can restore circumferential body contour. Despite the minor complications reviewed, the degree of satisfaction of the patients is very high. The quality of life of these patients, after massive weight loss, is also highly improved by these procedures. With the worldwide development of obesity and bariatric surgery, this study demonstrated that the operation should be proposed to patients with massive weight loss to improve quality of life.
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Simone P, Carusi C, Del Buono R, Persichetti P. Medial thigh lift in post-bariatric patients: Our encouraging experience. J Plast Surg Hand Surg 2016; 50:359-366. [DOI: 10.1080/2000656x.2016.1184157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Combined Abdominoplasty and Breast Surgery versus Isolated Abdominoplasty: Results of a Systematic Review. Plast Reconstr Surg 2016; 137:248e-249e. [PMID: 26389750 DOI: 10.1097/prs.0000000000001919] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sisti A, Cuomo R, Zerini I, Tassinari J, Brandi C, Grimaldi L, D'Aniello C, Nisi G. Complications Associated With Medial Thigh Lift: A Comprehensive Literature Review. J Cutan Aesthet Surg 2016; 8:191-7. [PMID: 26865783 PMCID: PMC4728900 DOI: 10.4103/0974-2077.172189] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Medial contouring of the thigh is frequently requested to improve appearance and function of medial thigh deformities, following massive weight loss or aging process. This surgical procedure can be associated with a significant rate of complications. Our aim was to consider the complications and outcomes according to the performed technique, through a wide and comprehensive review of the literature. A search on PubMed/Medline was performed using “medial thighplasty”, “medial thigh lifting” and “technique” as key words. As inclusion criteria, we selected the clinical studies describing techniques of medial thighplasty. We excluded the papers in which complications related to medial thighplasty were not specified. We also excluded literature-review articles. We found 16 studies from 1988 to 2015. Overall, 447 patients were treated. Different techniques were applied. Complications were observed in 191/447 patients (42.72%). The most frequent complications were wound dehiscence(18.34%) and seroma (8.05%). No major complications, such as thromboembolism and sepsis, were observed. Minor complications occurred in a high percent of patients, regardless of the performed surgical procedure. Patients should be informed about the possible occurrence of wound dehiscence and seroma, as common complications associated with this surgical procedure.
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Affiliation(s)
- Andrea Sisti
- Plastic Surgery Division, Department of General and Specialist Surgery, University of Siena, Siena, Italy
| | - Roberto Cuomo
- Plastic Surgery Division, Department of General and Specialist Surgery, University of Siena, Siena, Italy
| | - Irene Zerini
- Plastic Surgery Division, Department of General and Specialist Surgery, University of Siena, Siena, Italy
| | - Juri Tassinari
- Plastic Surgery Division, Department of General and Specialist Surgery, University of Siena, Siena, Italy
| | - Cesare Brandi
- Plastic Surgery Division, Department of General and Specialist Surgery, University of Siena, Siena, Italy
| | - Luca Grimaldi
- Plastic Surgery Division, Department of General and Specialist Surgery, University of Siena, Siena, Italy
| | - Carlo D'Aniello
- Plastic Surgery Division, Department of General and Specialist Surgery, University of Siena, Siena, Italy
| | - Giuseppe Nisi
- Plastic Surgery Division, Department of General and Specialist Surgery, University of Siena, Siena, Italy
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Michot A, Alet JM, Pélissier P, Grolleau-Raoux JL, Bodin F, Chaput B. Morbidity in combined-procedure associating abdominoplasty and breast surgery: A systematic review. ANN CHIR PLAST ESTH 2016; 61:e9-e19. [DOI: 10.1016/j.anplas.2015.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 07/24/2015] [Indexed: 10/23/2022]
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Bertheuil N, Carloni R, De Runz A, Herlin C, Girard P, Watier E, Chaput B. Medial thighplasty: Current concepts and practices. ANN CHIR PLAST ESTH 2016; 61:e1-7. [PMID: 26433317 DOI: 10.1016/j.anplas.2015.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/30/2015] [Indexed: 12/18/2022]
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Medial Thigh Lift in the Massive Weight Loss Population: Outcomes and Complications. Plast Reconstr Surg 2015; 136:110e-111e. [PMID: 25803159 DOI: 10.1097/prs.0000000000001351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reply: Medial Thigh Lift in the Massive Weight Loss Population: Outcomes and Complications. Plast Reconstr Surg 2015; 136:111e-112e. [PMID: 25803161 DOI: 10.1097/prs.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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