Infected Mesh is an Infected Implant -- It must be removed.

      Prosthetic mesh is often used in hernia repair surgery, with over 20 million such procedures done annually around the world.   Mesh is used to augment tissue repair in hernias to reduce tension at the suture line where the "weakness" is strengthened or plugged to hold back internal structures (such as intestine or omentum) that want to bulge through these areas.    The mesh can be made of various materials, such as Polypropelene, Gortex, and other plastic materials which allows the body to grow scar tissue around it.  The thing remember about prosthetic mesh, is that it is NOT alive or biologically active.  Your body recognizes it as a foreign substance, and because of that, there are inherent risks.
     For the most part, prosthetic mesh works and does its job; however, when it becomes a problem, it usually becomes a BIG problem.   The worst problem of all is when the mesh becomes infected.  In that situation, with rare exception, the mesh must be removed--completely.   It must be completely removed because any portion that remains may harbor bacteria which the body cannot clear away (even with the most powerful antibiotics), leading to a chronic wound, deeper infection, absesses, or systemic infection.
     The treatment of infected mesh requires a step-wise approach with the first step in removing the mesh and debriding (cleaning) the wound.  This step may be repeated multiple times until the area is clean. Once deemed clean, the area that the mesh covered will need to be reconstructed, preferably with your own tissue (flaps), or in combination with a Biologic mesh that can grow with your tissues and that your body ultimately recognizes as "self" tissue.   It will take at least 6 weeks from the time of the final reconstruction to fully heal, and depending on the complexity of the wound, infection, and anatomy of the infected mesh, several months in total.
      Far too often, I have seen patients who have lived with this problem for too long.  A small, chronic wound, may be a sign of a much bigger problem deep down below.  Appropriate evaluation, diagnosis, and management is critical, but just as importantly, it is important to first recognize and know that you may have mesh in your body.  If it is close to an area that is draining or infected, the mesh must be ruled out as a potential source of problem.   Afterward, it may be necessary to find a team of surgeons, including a general surgeon and plastic surgeon, to work together to solve this difficult problem.

Where can the lymph nodes be taken for a lymph node transplant for Lymphedema surgery?

There are several accessible areas around the body where lymph nodes may be harvested with its blood vessels to be transplanted in an arm or leg for lymphedema treatment.   This includes the groin area (the area near the hip bone (Groin Flap)), the subaxillary region (arm pit region(Subaxillary Flap), and the neck/collar bone area (Transverse Cervical Flap)).   Each area contains a lymph node basin which can be harvested with the flap tissue.  Careful dissection and evaluation of the area needs to be done prior to using the tissues from each specific area.

Be sure to have a thorough discussion with your surgeon regarding your "donor site" options for lymph nodes when considering lymph node transplant to treat lymphedema.

Angelina Jolie and Breast Cancer Reconstruction

I applaud Angelina Jolie's candid approach to her recent treatment for breast cancer.  Because of her “star” status, she is able to put a significant spotlight upon current issues in breast cancer treatment today.  This includes the BRCA gene, which places her at high risk for breast cancer, that many people may not know much about.   It also highlights her approach to this situation with her getting prophylactic bilateral mastectomies and immediate breast reconstruction with tissue expander implants.

 Many people may wonder why someone would want to undergo bilateral mastectomies at this stage of her life while not actually having breast cancer but having a high risk gene.   She explains it quite well:  she wants to decrease her chances as best as possible, even at the cost of losing her breasts.   The complete removal of the breast tissue (mastectomy) early on decreases the chances for breast cancer significantly in the future.   In the meantime, she can undergo breast reconstruction which will still allow her to have excellent breast aesthetics.   By undergoing prophylactic mastectomy with nipple preservation, she will also avoid any radiation treatment which can severely deform the breasts--radiation has its own set of problems including wound issues, implant infections, contracture, radiation changes to the heart and lung.

 The other option that she may have considered is autologous breast reconstruction using her own tissues without an implant. This includes the DIEP breast flaps from her abdomen transplanted to her chest via microsurgical technique which would preserve her “super six pack.”   This would allow her to have breast reconstruction at the same time with her own tissues and would get a potential tummy tuck as well.    My guess is that Angelina Jolie did not have enough abdominal tissue to undergo bilateral breast reconstruction and that is why she chose tissue expander and implants.   She will need to undergo several expander injections and another operation for a final silicone implant.

It is very common now for me to see patients who seek to undergo prophylactic mastectomies and immediate breast reconstruction.  It allows the patient to be treated at an earlier stage stage in a proactive way,  based on genetic information or early diagnosis.  Our team of breast surgeons, oncologists, pathologists, and plastic surgeons can treat women in the same, proactive way that Angelina Jolie sought with outstanding results.  

I thank and applaud Angelina Jolie’s courage in sharing this deep and personal part of her life to help others.   She is a super star in my book.

 

 

Advanced Treatment for Lymphedema of the Arm and Leg

Lymphedema is a very difficult condition to treat and many patients are told that they must suffer with lifelong compression dressings, pain and swelling. Anyone suffering from arm lymphedema from postmastectomy lymph node dissection and/or radation, or lymphedema of the legs from injury or pelvic lymph node removal/radiation understands that this is not an acceptable option. Very often, patients are young and active and maybe otherwise healthy and are seeking more long-term solutions to improve their quality of life.

Lymphatic venous anastomosis has been a treatment option for over 30 years. It has waxed and waned in terms of treatment efficacy and therein lies the controversy. Only more recently, with the advent of super microsurgical techniques and instruments, have higher rates of success with vessels and lymphatics at 0.5 mm and less, become the norm. There have been significantly improved outcomes since the early days of microsurgery. Dr. Isao Koshima in Tokyo, Japan has been pushing the envelope for decades with advanced super microsurgery techniques. He is a pioneer in super microsurgery and has some of the most extensive experience and long-term follow-up of lymphatic patients in the world.

Lymphatico Venous Anastomsis as seen under the Operating Microscope

(Performed by Dr. Charles K. Lee at St.Mary's Medical Center, San Francisco, CA, October 2012)

I was fortunate to learn from Dr. Isao Koshima directly on his techniques and share knowledge and experience with colleagues from around the world about the latest treatments for lymphedema. I am fortunate to have both Drs. Koshima and Dr. David Chang at M.D. Anderson Cancer Center as my mentors in this regard.

With Drs. David Chang (Left) and Dr. Isao Koshima (Center)

at Tokyo University, Tokyo, Japan, September 2012.

In combination with lymph node transplantation as a free tissue transfer from the groin, abdomen, axilla, shoulder, or neck (large lymph node basins) with additional lymphatic venous anastomosis, this two-pronged approach to addressing improved lymphatic flow has likely made the greatest advances in the treatment for lymphedema to this date. This two-pronged approach allows to redirect lymphatic flow from the interstitial space in the subcutaneous layer to the venous system and helps regenerate lymphatics in areas where they may have been removed.

Liposuction to address lymphedema has also been described. It is more of a cosmetic treatment for lymphedema as the patient is still is left with permanent lifelong compression and reaccumulation of lymph as soon as the compression garment is removed. Liposuction does not treat the cause of lymphedema and therefore does not cannot be a long-term solution.

The power of Lymphatic Venous Anastomosis (LVA) and Lymph Node Transplant (LNT) lies in its ability to treat the causal pathway to lymphedema; it is a physiologic and long-term solution to improving lymphatic flow and ultimately, patient's quality of life. I have personally seen and treated patients with dramatic improvements, that can range from 40% to 80% reduction in circumference, 60%-80% reduction in pain and swelling, with improved range of motion, wound healing, and improved quality of life by not having to wear compression or decrease the amount of time in compression.


I encourage patients who are trying to learn more about the latest treatments for lymphedema contact our office for more information and to continue learning more about the most advanced treatments for this difficult condition.

Exparel for Post Surgical Pain Relief in Reconstructive Surgery

Exparel is a high-tech new form of a commonly used local anesthetic (bupivicaine/marcine).   It is FDA approved and is catching on quickly with surgeons who want the best for their patients in post surgical pain relief.     I have been fortunate to have been one of the first plastic surgeon in the Bay Area to have used Exparel since April 2012.     Patients who have undergone both cosmetic plastic (breast augmentation, tummy tuck) and reconstructive plastic surgery (breast reconstruction, hand and leg surgery) have benefited from this medication.  It is currently also being used in general surgery (eg: hernia), orthopedics, and other procedures.

Typically, Marcine/Bupivicaine lasts only 6-8 hours after it is injected in the surgical area.  With Exparel-- Marcaine + Depofoam technology-- it can last up 72 hours.   The most painful time after surgery is within the first 48-72 hours, so the timing is excellent to address this critical time.   In addition, my patients can avoid the use of the "pain pump" which basically infuses marcaine over a period of time, but the inconvenience of the additional tubing and bulbs, and the possibility of this tubing sitting near an implant, is avoided.

Ultimately, using this medication can help significantly with pain relief and decrease the use of narcotics which come with significant side effects -- nausea, vomiting, constipation, mood changes, etc.

Exparel is an excellent addition to my practice and I am fortunate to be able to offer this high-tech pain reliever to my patients. Ask your surgeon if you might benefit from Exparel for your next procedure.

Preventing Total Knee Arthroplasty Infection with Microsurgery -- The Prophylactic Free Flap

Total knee arthroplasty (TKA, knee replacement surgery) is a common procedure to treat knee pain and arthritis.  Over 120,000 knee replacement surgeries are performed per year in the United States.

The surgery involves making a midline incision over the knee joint and allowing the orthopedic surgeon access to the joint area to place an implant that acts like a joint.  Once the joint is in, the skin is  closed over and allowed to heal.  Often, the knee is started on a range of motion protocol to prevent stiffness.

On rare occasions, the knee skin may not be viable, sturdy, or durable to allow the surgeon to perform the knee replacement surgery because the closure of the soft tissue may be difficult   (history of trauma with scar, thin skin, skin grafts, psorasis, etc)  .  If the skin can be properly closed over the implant, this is a serious situation for the viability of the implant and the leg.  An exposed implant is an infection and can lead to serious complications.

At our center, we have worked with several of our orthopedic surgeons who have had the foresight to seek plastic surgery consultation to avoid a "skin" or soft tissue problem prior to the TKA.   This allows for us to create a coordinated effort to first place durable, strong skin tissue/flap over the knee area prior to the TKA.  Typically, a skin flap from the thigh or back can be transplanted over the knee area as a microsurgical free tissue transfer.  After 3-6 months when the flap is well healed and ready for elevation, the orthopedic surgeon can then place the TKA under the flap tissue and can easily close over the implant with the additional durable skin cover.

This sequence of events is a shift away from current treatment strategies that may lead to a higher rate of failure and infection. Often times, the skin/soft tissue issue is not addressed early, and the plastic surgeon is called in on an "emergency" basis to help close over the implant.  This is not an ideal situation as this prolongs the operation, may not allow for proper setup or anatomic exposure of the tissues, etc.

To learn more about the the "prophylactic free flap over the total knee", please feel free to contact us.  Lplasticsurgery@gmail.com

Most Efficient Procedure Available to Treat Varicose Veins?

A: Efficient treatments include endovenous ablation with laser and radiofrequency, and correct diagnosis

Varicose veins are almost never formed in isolation; there is most often, a deeper, larger, vein that is "incompetent" that connects to the superficial, visible varicose vein.  This incompetent vein is usually the greater or lesser saphenous vein with valves that are not functioning normally.   These root cause veins typically give rise to the varicose veins seen on the surface, and thus, to treat the varicose most effectively, the incompetent saphenous vein needs to be diagnosed first with a duplex ultrasound.  Once identified, the vein can be treated with laser or radiofrequency (EVLT or VNUS), and the microphlebectomies performed at the same time to remove the varicose veins.  This can most often be performed under local anesthesia under 1 hr with the patient able to walk right away.   
These treatments are highly efficient and effective and far less problematic than the old "vein stripping" techniques of the past.