Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKbH4TTImqenVPWx2hcEpdL/J2H0RCVRGnSIOuBf3z+p458p+RKUKsiA on 05/31/2020 Preoperative Evaluation of the Superficial Fascial System Can Predict Wound Complications in Body Contouring Surgery David M. Straughan, MD, a Michelle E. McCarthy, MS, b Richard F. Guidry, BS, c Abigail E. Chaffin, MD, FACS, a Hugo St. Hilaire, MD, DDS, d Michael Dancisak, PhD, e and John T. Lindsey, MD, FACS a Background: The demand for body contouring surgery continues to rise. The in- clusion of the superficial fascial system (SFS) during closure of such procedures has been shown to improve outcomes; however, currently reported wound com- plication rates remain high. The authors assess whether decreased quantities of SFS are associated with wound complications in these patients. Methods: A retrospective study of patients undergoing body contouring surgery was performed. Preoperatively, ultrasound images were obtained of the SFS. Using Cellprofiler, the mean gray values (MGVs) of the SFS were calculated to quantify this structure. Chart review was performed to identify postopera- tive wound complications. Results: Thirty-six patients were included: 30 abdominoplasties, 3 bilateral me- dial thigh lifts, and 3 bilateral brachioplasties. The overall wound complication rate was 22.5%. There were no significant differences in body mass index, age, smoking status, weight of resected specimen, or diabetes when comparing the complication and noncomplication groups. However, the MGV was significantly greater in the noncomplication group compared with the complication group (0.135 ± 0.008 vs 0.099 ± 0.005, respectively, P = 0.03). The average MGV for the entire cohort was 0.127. Patients with an MGVof greater than 0.127 had a wound complication rate of 0% compared with that of 39% for patients with an MGVof 0.127 or less (P = 0.005). Conclusions: Poor quantities of SFS identified by ultrasound were associated with increased wound complications in patients undergoing body contouring sur- gery. Furthermore, patients with better than average SFS seem to be protected from such complications. Key Words: body contouring surgery, superficial fascial system, ultrasound, wound complications (Ann Plast Surg 2020;84: S401–S404) E ven with modern techniques, attention to preoperative medical opti- mization, and adoption of an array of intraoperative and postopera- tive safety measures, wound complication rates remain high in patients undergoing body contouring surgery. 1 Sentinel articles by Lockwood 2–6 were the first to describe the superficial fascial system (SFS), as well as its importance in body contouring surgery. Furthermore, Song et al 7 demonstrated that the inclusion of the SFS increases the biomechanical strength of closure techniques. With the continued high wound complication rates associated with body contouring surgery, surgeons continue to attempt to identify ways to improve outcomes. Identification of patient-specific qualities of the integument, specifically the SFS, which provides strength to the subcutaneous tissues, has never been assessed as a factor related to patient outcomes despite its relevance in the literature. Anatomical and radiological literature is replete with studies of the SFS. Previous investigations of the SFS have included the use of computed tomography, magnetic resonance imaging, and ultrasound, all of which identify variability of the SFS throughout the body of a given patient and among patients. 8–10 Furthermore, our group has previously demonstrated that currently available, high-resolution portable ultrasound can identify the SFS with the same resolution as much larger, hospital- based devices. 11 New portable, high-resolution ultrasound technology has now made it easy and convenient to identify patient-specific SFS in any anatomical area at low cost and at no risk to the patient at the bedside. There have been no studies to date that investigate the possible relation- ship between patient-specific variability of the SFS and postoperative wound complications. Therefore, we set out to investigate whether SFS quantity correlates to patient outcomes, specifically wound complica- tions, in patients undergoing body contouring surgery. METHODS After approval by the institutional review board, a retrospective chart review was performed on all patients who underwent body contouring pro- cedures by the senior author (J.T.L.) between June 2017 and July 2018. Pre- operatively, all patients were examined with portable ultrasound using the Lumify 12-4 linear probe (Philips Ultrasound, Inc, Reedsville, Penn) to assess the SFS within a particular region of the body. All images were ob- tained on the superficial setting and gain of 54. Multiple images were ob- tained from the region of interest. For abdominoplasties, imaging of the SFS was performed in the periumbilical, suprapubic, and flank areas. For brachioplasties, imaging was done of the soft tissue to be resected in the upper, mid, and lower inner arm areas. For the thigh lifts, imaging was performed of the soft tissues to be resected just below the thigh- perineal crease anteriorly, midcrease, and posteriorly. The operating surgeon (J.T.L.) had no knowledge of the SFS nor mean gray value (MGV) for these patients preoperatively. Using CellProfiler, MGVs were calculated postoperatively and tabulated for each image per the equation hereinafter. 12,13 To account for intrapatient variability, the multiple MGVs for a particular body re- gion of an individual patient were then averaged to give an overall pa- tient MGV, which served as a measure of the quantity of SFS. MGV ¼ ∑Echogenecity of Each Pixel Number of Pixels in Image ¼ Total Echogenecity of Image Area All quantified data values are represented as mean ± standard deviation. Continuous variables were compared using the Student t test. Categor- ical variables were compared using the Fisher exact test. Received July 15, 2019, and accepted for publication, after revision September 3, 2019. From the a Division of Plastic and Reconstructive Surgery, Tulane University; b Tulane University School of Medicine; c Louisiana State University Health Sciences Center; d Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center; and e Center for Anatomical and Movement Sciences, Tulane University, New Orleans, LA. Conflicts of interest and sources of funding: none declared. Presented at the Glancy Award Competition at the 62nd Annual Scientific Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, Naples, FL, June 8–12, 2019. The institutional review board approval was obtained by the Louisiana State University Health New Orleans Institutional Review Board (#9493). Reprints: David M. Straughan, MD, Division of Plastic Surgery, Tulane University School of Medicine, 1430 Tulane Ave, SL22 New Orleans, LA 70112-5645. E-mail: David.m.straughan@gmail.com. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/20/8405–S401 DOI: 10.1097/SAP.0000000000002155 CLINICAL ARTICLES Annals of Plastic Surgery • Volume 84, Supplement 5, June 2020 www.annalsplasticsurgery.com S401 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.