THIS WEEK'S ARTICLES
Plastic Surgeons Use CETE to Reduce Wound Burden and Provide Wound Closure - Sponsored Content
How Common Are Major SSIs After Plastic Surgery?
Identifying risk factors can help keep these rare infections at bay.
A recent study of tens of thousands of patient records that examined the prevalence of major surgical site infections (SSIs) after cosmetic procedures performed in the United States found incidences remain largely infrequent, with some caveats.
The study, published in the Aesthetic Surgery Journal, reviewed records of patients who underwent plastic surgery between 2008 and 2013. It found only 0.46% of those patients suffered from a major SSI. Patients who smoked or were diabetic had a slightly higher rate, however. They also found female patients acquired SSIs slightly more frequently than male patients, at a rate of 0.5% as compared to 0.3% in males. The procedures displaying the highest incidence of SSI were trunk/extremity surgeries, at 0.9%, while the rate of infection for breast or face surgeries was lower, at 0.3%.
Researchers cited potential SSI risk factors for cosmetic surgeries, including age, BMI, type of surgical facility, smoking, pre-existing diabetes mellitus and combined procedures, the last of which applied to 68% of the patients in the study. A higher, although still low, incidence of postoperative SSIs was found in patients undergoing multiple procedures (0.8%) when compared with single procedures (0.3%).
"The incidence of SSIs in the literature for some of the common aesthetic surgical procedures vary, such as breast augmentation ranging from 0.001% to 7%, breast reduction 0.11% to 22%, abdominoplasty 0.16% to 32.6%, and body lifts 3% to 25%," the researchers wrote. "In our analysis, the incidence of SSIs for these procedures were noted to be at the lower end of these ranges at 0.2%, 0.5%, 1.0%, and 1.9%, respectively."
The researchers believe the multi-institutional, multi-surgeon study resulted in significant findings. "We demonstrated that the overall incidence of major SSIs after aesthetic surgery is very low but not irrelevant, given the fact that these procedures should carry a minimal risk of major complications since they are performed with an ultimate goal of cosmesis in healthy individuals," they write. They also advise that although minor SSIs may be common following these procedures, they should not be underestimated by providers.
"Careful preoperative evaluation and addressing some of the modifiable risk factors is thus critical, and may decrease SSIs even further in this patient population," conclude the authors.
Handling the Zoom Boom
Working remotely has spiked a demand for cosmetic procedures.
During the pandemic, many people working from home have enjoyed a sudden surplus of disposable income because they didn't need to spend money on gas, work lunches and other living expenses. On the downside, they have spent many hours at work and in their social lives looking at themselves in Zoom or Teams video chats. These two converging factors have led to what many providers characterize as the "Zoom Boom," a nationwide spike in demand for cosmetic surgery.
Plastic surgeons should be aware of patients exhibiting "Zoom dysmorphia," a term coined by Arianne Shadi Kourosh, MD, MPH, a board-certified dermatologist at Massachusetts General Hospital in Boston. It describes the phenomenon of people developing a negative self-opinion after constantly seeing themselves onscreen. "This creates a dangerous cycle of self-criticism based on preoccupations with real or imagined defects that causes them to seek cosmetic corrections they wouldn't have considered had they not spent months staring at themselves on a video screen," she says.
After a three-month shutdown during the height of the pandemic, Frank Fechner, MD, a plastic surgeon in Worcester, Mass., found that his volume of new patient consults exceeded his expectations. During the pandemic, he has seen a 50% increase in requests for rhinoplasties, blepharoplasties and facelifts since the previous year. He says the Zoom Boom is only one aspect of the increased demand he is seeing. "Working professionals have often hesitated to dedicate their hard-earned vacation time to recovering from plastic surgery," he says. "Now that they're working remotely, and had nowhere to go when the pandemic essentially shut down the nation, they see a once-in-a-lifetime opportunity to get the work done they've always considered."
While this new business is obviously enticing to plastic surgeons, they must balance its lure with the core responsibility of providing proper patient care. "Board-certified physicians trained in an aesthetic specialty understand healthy facial proportions and are able to work with patients to establish realistic post-op goals," notes Dr. Kourosh.
Plastic Surgeons Use CETE to Reduce Wound Burden and Provide Wound Closure
Soft tissue injury management improves surgical outcomes for overall patient satisfaction.
In the world of plastic surgery, the surgeons deal with a variety of challenging wounds and soft tissue injuries. Some injuries that appear include massive soft tissue defects that may be further complicated by varying degrees of accompanying orthopedic and peripheral nerve damage. To address the severe soft tissue defect, various combinations of advanced reconstructive methods are typically required to achieve definitive wound coverage.
Soft tissue management with a continuous external expander has been used successfully to provide wound closure in plastic surgery, according to a report in the Annals of Plastic Surgery. The authors note, "Continuous external tissue expansion has been used by our institution to significantly reduce wound burden and provide for definitive wound closure in certain blast-injured patients."1
The authors present an early series of 14 patients who suffered massive extremity soft tissue injuries and were treated with an external tissue expansion system (DERMACLOSE RC). Outcome measurements included time to definitive closure and the method of definitive wound closure. A 5-patient subset of this group was prospectively analyzed to determine measurements including initial wound surface area (WSA), percentage reduction in WSA and related complications.
According to the study, "Overall time to wound coverage ranged from 1 to 6 days, with mean time to wound coverage being 4.4 days. Of the 14 patients included in the series, 12 (85.7%) were able to undergo delayed primary closure, whereas 2 required split thickness skin grafting."1
The results provided a tool to achieve effective wound closure. As the authors note, "In the management of large complex wounds, external tissue expansion has proven to be a valuable adjunct in achieving definitive wound closure. It can often aid in successful delayed primary closure of certain soft tissue wounds, has low associated morbidities, and can reduce the need for more complex or morbid procedures when used properly."1
Additionally, the authors propose an algorithm for the use of continuous external tissue expansion system to achieve successful wound closure, while potentially reducing the need for increased donor-site morbidities associated with more complex or larger reconstruction measures.
DERMACLOSE provides plastic surgeons with a tool to use their creativity when treating challenging wounds.
- Fasciotomy repair
- ALT donor site wound closure
- Wound dehiscence
- Oncologic excisions
- Complex, non-healing wounds
- Scar revisions
The clinical benefits of DERMACLOSE include the following:
- Reduces time to closure
- Proven in multiple surgical specialties and applications
- Helps avoid skin grafts donor sites, and associated risks and complications
- Quickly becoming a standard of care for fasciotomy wounds
- Reduces time to closure, surgical complexity, and risk of open wound complications
- Improves surgical outcomes, cosmesis and patient satisfaction
Note: For more information, go to www.synovismicro.com.
1. Santiago, Gabriel F. MD; Bograd, Benjamin MD; Basile, Patrick L. MD; Howard, Robert T. MD; Fleming, Mark DO; Valerio, Ian L. MD, MS, MB, "Soft Tissue Injury Management With a Continuous External Tissue Expander, Annals of Plastic Surgery: October 2012 - Volume 69 - Issue 4 - p 418-421 doi: 10.1097/SAP.0b013e31824a4584
Understanding Skin and Soft Tissue Infections in Plastic Surgery
Study says providers should be more proactive about addressing MRSA and its risk factors.
A recent study on skin and soft tissue infections (SSTIs) that can arise after plastic surgery sought to better understand their connections with pathogenic organisms, antibiotic resistance and treatment results.
The study, recently published in the Journal of Wound Management and Research, evaluated 229 patients who had exhibited a range of SSTIs, including those with superficial cellulitis or simple abscess, decubitus ulcer, surgical wound infection, surgical device-associated or prosthesis associated infection, diabetic foot ulcer. Infections were located on the lower extremity, head and neck, upper extremity, pressure sore sites and trunk.
The authors note an alteration in the microbiology of SSTIs throughout the past decade. Previously, methicillin-sensitive Staphylococcus aureus (MSSA) was the common origin of SSTIs, but recent studies cite community-acquired methicillin-resistant S. aureus (CA-MRSA) as the current predominant pathogen.
Initially a hospital-acquired bacterium, MRSA infections are now occurring in unexposed patients. As a result, β-lactam antibiotics are not as effective as they once were. Meanwhile, MRSA-infected patients tend to have higher mortality rates, longer length of admission and higher hospital costs than those with MSSA infections, write the authors. Antimicrobial resistance has been steadily increasing, exacerbated by high use of single agents, cross-transmission of resistance genes, suboptimal dosages and poor isolation techniques.
In the study, the researchers found MRSA present in a "remarkable" 33.6% of patients, and 80.2% of all S. aureus isolates were MRSA. "The increasing incidence rate of methicillin resistance among community-acquired and hospital-acquired S. aureus isolates is faced with challenging decisions regarding the choice of antibiotic therapy, greater financial costs for persons with SSTI and worse outcomes," they write.
Patients in the study were evaluated for the appropriateness of the first antibiotic treatment on the basis of culture outcome acquired, with 61% receiving what the authors deemed appropriate therapy and 39% who did not. The latter group had an average of nearly seven days of IV antibiotic treatment compared with those who had successful first antibiotic therapy. They also cited a comparative study that found patients with MRSA infections had worse clinical and economic results.
Overall, they write, rapid diagnosis and proper treatment of MRSA are highly important for improving outcomes. "MRSA-related SSTIs are increasing at a significant rate," they conclude. "These patients are more likely to be exposed to improper initial antibiotic therapy. Antibiotic therapy guidelines must consider this change to minimize the cost and morbidity, while maximizing success. We recommend that practitioners execute a culture-based treatment for all SSTIs and analyze the MRSA trends in their own society to adapt local therapy regimens for empiric MRSA coverage."
How Plastic Surgeons Are Helping Burn Patients
Specialists who employ new treatment options improve the recovery process.
According to the American Burn Association, 97% of people treated in burn centers will survive their injuries, but many end up living with significant scarring and life-long physical disabilities. Now the American Society of Plastic Surgeons (ASPS) is expounding on how the specialty can aid patients through the recovery process.
For example, plastic surgeons who specialize in burn care treatment may provide acute burn care such as debridement, skin grafts and amputations, or secondary treatments such as scar revisions after acute burn care, flaps and tissue expansion.
"Nearly 50 percent of burn patients experience chronic pain and itching as they go through their rehabilitation process, which often gets in the way of work, school and other day-to-day activities," says C. Scott Hultman, MD, a professor of plastic surgery at University of North Carolina. "This is a problem that plastic surgeons have been trying to solve. We've taken different techniques we've learned over the years from aesthetic and reconstructive surgery and applied them to the burn population."
With current treatment options including laser resurfacing of burn scars, fat grafting and nerve decompression to reduce pain and itching, and the availability of biologic materials to simplify reconstructive procedures, patients can achieve better aesthetic results with less pain. "We first had a breakthrough roughly 10 years ago when we noticed that laser treatment not only improved burn scars, but also reduced the patient's pain by decreasing the inflammation of the scar and making the skin a little more supple," says Dr. Hultman. "Many of these patients had real anatomic causes of their pain, which led me to operate on the nerves on a macro level and perform nerve releases."
While Dr. Hultman never expected he would be using fat grafting procedures for burn scars at the onset of his career, he says the surgical technique delivers an 80% success rate. Laser treatments help the outer layer of the skin, but fat grafting addresses the skin's undersurface. "The most exciting thing is that only 10% of this patient population had a surgical solution a decade ago, but today 90% have undergone some type of surgery that benefited them," says Dr. Hultman.