How This Plastic Surgery Team is Changing Lives
Last Updated: 20 July 2019
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Plastic & Reconstructive Surgery
Today’s post is part of an effort to bring you more clinically-focused work by amazing healthcare professionals. The following piece was written by Inessa Shlifer, PA-C, DFAAPA, a plastic and reconstructive surgery physician assistant (PA) and past president of the Association of Plastic Surgery PAs (APSPA).
She writes about a complex reconstructive case of a trauma patient, complete with before and after images.
Plastic Surgery Clinic in the Morning
On one of our surgical days, my plastic surgeon showed me pictures of a girl with a deformed buttock and multiple scars on her back. His question to me was, “how can we help her to look better?”
Pre-Operative Plastic Surgery Images:
I looked at those photos and it took me a while to “browse my brain” through all the possible surgical choices. The case was not ordinary.
The Life-Altering Trauma
A few years ago, this young girl went on a hiking trip in the mountains with her boyfriend. On one particular trail, she found herself walking too close to a cliff with no option to reverse course.
Tragically, she lost footing and fell; over one hundred feet down the rocky, unforgiving terrain. She sustained a traumatic brain injury, C7 vertebral fracture, thoracic aortic injury, and calcaneus and pelvic fractures.
After being airlifted to the nearest medical center, she underwent multiple surgeries.
During her stay at the rehabilitation facility, she developed stage 4 sacral pressure ulcer. After developing a fever, the medical team readmitted her to the hospital for wound evaluation.
There, the plastic surgery team debrided the ulcer, taking part of sacral bone. The wound was then closed with a gluteal muscle flap. It healed technically well, but with great disfigurement. For a young girl, full of life and potential, it was devastating.
The Next Plastic Surgery Consultation
When I met her in consultation, she struck me with her optimism and a positive outlook on life. No wonder she survived that hundred-foot fall. She also had a good support system; her family always there for her during her stay in the hospital.
In our office, we commonly perform buttock augmentation procedures, and at times, even deal with complications from other surgical teams.
However, we knew this case would be challenging, even for us. A re-operation is never easy and the multiple surgeries she went through only adds to the difficulty.
We decided to use implants to give her the projection she lacked after the full thickness gluteal flap. Unfortunately, that alone would not correct the problem. We knew we would also need to work on modifying the gluteal flap. Additionally, she had multiple deforming scars that needed refining in both shape and quality of cosmesis.
We added liposuction of her abdomen and lower back to give her a more defined waistline. The autologous fat we collected would be used to inject her left lateral buttock and hips. The risks and benefits were discussed with the patient who agreed to the procedure as planned.
Positioning & Abdominal Liposuction
She was positioned supine on the operation table and underwent general endotracheal anesthesia. The abdomen was prepared and draped in a sterile fashion.
Tumescent fluid was infiltrated into lower abdomen and Vaser ultrasound technology was applied to soften the subcutaneous fat.
Liposuction was performed until desired shape was achieved. The patient was then placed prone for the main part of the operation.
Gluteal Flap Modification
First, we decided to modify the gluteal flap to reduce the abnormal indentations in the gluteal muscle each time she contracted it.
However, the left trochanter area was obviously deformed. The placement of a gluteal implant alone would not correct it. Anatomically, the lateral border of gluteal muscles run out laterally from the greater trochanter at the lateral border of the hip.
Violating that structure results in implant displacement laterally – a complication everyone needs to avoid.
We used existing scar tissue and dissected through skin, subcutaneous tissue, fascia, and muscle. That gave us the ability to precisely advance the well-healed gluteal muscle flap so it would cover the lateral trochanter area.
This move was key; it almost eliminated the indentation and gave her a more uniform, aesthetically pleasing appearance of the lateral side of left buttock.
We use a midline incision to place gluteal implants. Our patient already had a deforming scar that ran through the midline down to the left side of the buttock as a result of original gluteal flap.
We modified it by rearranging the soft tissue to create a straighter line and removing the “dog ears” that were on her left buttock. This gave the buttocks a uniform, flat, and pleasing look.
Our next step was to place the gluteal implants. The right side was done first. Using a lighted fiber optic retractor and long-tip Bovie electrocautery, the subfascial plane was created.
We irrigated the pocket with cefazolin antibiotic solution along with betadine solution to provide the best environment for implant survival.
The left side was more challenging because of the previous gluteal muscle rotation. We paid special attention to the lateral border during dissection and created just enough space to accommodate the implant.
After irrigation and satisfactory hemostasis, we installed the AART Inc, round gluteal implants, style 3, size 2. Both sides were closed separately with 2.0 Vicryl sutures to eliminate communication between the pockets. The midline incision was closed using 3.0 Vicryl followed by 4.0 Biosyn for the final layer.
Low Back Liposuction with Fat Harvesting
The third step was liposuction of her lower back with fat harvesting. We prefer to use Vaser ultrasound technology to soften the fat and shake it from its attachments. It makes liposuction easier and faster.
The outcome is a smoother appearance than when performed with the conventional technique.
We infiltrated Tumescent liposuction solution made up of 0.05% Lidocaine with 1cc Epinephrine 1:1000,000 mixed into 1 liter of Lactated Ringer’s solution. Vaser ultrasound energy was applied at an amplitude of 80, using continuous mode with a 4 ring, 3.7 mm probe. This part of procedure went very well and gave her nice, slim waistline.
The deficiency on her left side needed fat injections to restore her normal hip and lateral buttock anatomy.
We decided to inject fat into both lateral buttocks and hips. The fat was aspirated into a sterile container and was separated from tumescent fluid by gravity.
The prepared fat was then injected using peristaltic pump and reciprocating cannula through the incision in the superior lateral buttock. Close attention was paid to inject fat to a central and lateral part of the buttock, especially the indented left side over the trochanter area.
We also supplemented each scar with fat injections to provide better healing. It took art and medical knowledge to create a much better-looking body.
The postoperative period went well; neither side had any seroma formation and the revised scars healed well. In three weeks, she looked great, and in five weeks, even better.
The patient and her family were thrilled with the outcome. She is back to college and planning to go hiking in the near future.
I applaud her enthusiasm for life and her positive attitude. The road to recovery is long, including additional physical therapy to strengthen her left calf muscles, which atrophied since the injury. With her surgical reconstruction behind her, she can now concentrate on completing her recovery.
Plastic Surgery Resources & Education
If you are looking for additional plastic surgery readings and resources, you can find some here.
Perioperative Management – Johns Hopkins Clinical Update