Dr. Kenneth Hughes Navigates Difficult Patient Scenarios Every Day
As a combination procedure and complex revision plastic surgery expert, Dr. Kenneth Hughes has a plastic surgery practice unlike that of anyone else. The practice is not limited to face or breast or body surgeries. The practice is not limited to straightforward first time or primary plastic surgery. The practice is also not limited to one surgery per patient. In your mind, envision the most complicated of scenarios from trauma, genetics, or multiple previous surgeries and that is the practice of Dr. Kenneth Hughes.
It stands to reason then that patient considerations and technical and intellectual demands will be sweepingly different than a more common practice. The following description will be very difficult to follow and Dr. Hughes intends to start a new series of videos to discuss some of the evaluations and results of these complex revision surgeries.
A 52 yo female patient comes to the clinic with a history of exploratory surgery after pancreatitis, has a large midline exploratory laparotomy scar. In addition, the patient has a remote history of liposuction to the abdomen and perhaps the flanks. More recently she had a laparoscopic gallbladder surgery. Finally, she had a liposuction revision surgery 2 years ago with many dents, divots, irregularities, and deformities. She has been depressed and on medication and is otherwise healthy and has received medical clearance for a revision abdominal procedure to improve the appearance of her abdomen. Patient denies presence of hernias and has had CT scan that was otherwise negative. Her physical exam reveals no hernia but shows the aforementioned scars and extreme skin and fat irregularities of the abdomen. The exploratory laparotomy scar is wide and irregular.
What is the surgical plan? Most plastic surgeons would either not operate or recommend scar revision of the abdominal scar or tummy tuck to remove whatever skin possible to improve the abdominal irregularities. These plans are reasonable and straightforward but will not yield much improvement in a patient without abdominal wall laxity or skin laxity.
Flexibility in operative plan and intraoperative decision making help avoid disaster and provide for the best result. Dr. Kenneth Hughes opened the exploratory laparotomy scar first. He elevated the incision away from the midline laterally. Despite CT scan that was negative, several small hernias were observed near the midline scar intraoperatively. Each of these hernias was meticulously repaired to close fascial defects. If the dissection were rushed or the surgeon was not constantly aware, these hernias would have been missed and aside from not repairing them the intestines could have been injured with Bovie electrocautery or during liposuction.
Upon completion of the hernia repairs, the scar tissue was freed widely from the midline scar. Four small chronic fluid collections were removed. Finally, the flaps were liposuctioned away from the area of the hernias to reduce the unevenness. Bodytite was further utilized to improve flap smoothness. Throughout the entire surgery, flap viability is preserved by precise flap dissection and precise removal of the chronic fluid collections. The liposuction was used sparingly, and the delay that occurred throughout the multiple procedures allowed for a very robust subdermal and subcutaneous blood supply that allowed the surgery to become a reality.