Garrett A Wirth

University of California, Irvine, Irvine, California, United States

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Publications (40)53.06 Total impact

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    ABSTRACT: The authors present a new technique of alteration of the acellular dermal matrix through strategically placed fenestrations, improving the reconstructive experience and overall cosmetic outcome. The authors present a retrospective chart review following two surgeons' experience at the University of California, Irvine, Department of Plastic Surgery using surgeon-designed fenestrated acellular dermal matrices in two-stage tissue expander breast reconstruction. The authors found that this leads to improved intraoperative fill volume, decreased number of postoperative expansions, increased expansion rate with subjectively less pain, decreased time to full expansion, and subjectively improved cosmetic outcome.
    Plastic and reconstructive surgery. 11/2014; 134(5):901-4.
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    ABSTRACT: Introduction: Despite attempts to minimize exposure to allogeneic blood, there is limited data in blood transfusion following abdominoplasty especially in post-bariatric surgery patients. Purpose: To evaluate: 1) the frequency of blood transfusion in post-bariatric surgery patients who underwent abdominoplasty, 2) the effect blood transfusion in surgical outcomes and 3) predictive risk factors of blood transfusion in this patient population. Methods and Materials: Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients with prior history of bariatric surgery who underwent abdominoplasty from 2007 to 2011 in the United States. Multivariate regression analysis was performed to identify predictive risk factors of blood transfusion. Results: A total of 20,130 post-bariatric patients underwent abdominoplasty during this period in the United States. The mean age was 50 years and 71% were Caucasian. Overall, 1871 patients (9.3%) received blood transfusion. Chronic anemia patients had the highest rate of blood transfusion (25.6%). Post-bariatric surgery patients had a significantly higher rate of blood transfusion compared to others undergoing abdominoplasty (9.3 % vs. 6.1%; p<0.01). Post-bariatric patients who received blood transfusion experienced a significantly higher complication rate (10.1% vs. 4.8% p<0.01), longer mean hospital stay (4.0 days vs. 2.4 days; p<0.01) and higher mean total hospital charges ($49,116 vs. $33,927; p<0.01). Multivariate regression analysis showed chronic anemia (adjusted odds ratio [AOR], 3.8), congestive heart failure (AOR, 2.4), concurrent breast reduction (AOR, 1.5), diabetes mellitus (AOR, 1.4), African American race (AOR, 1.4), Hispanic race (AOR, 1.4), and female gender (AOR, 1.2) were all independent risk factors for blood transfusion. This data set showed no association between age, Asian race, Native American race, hypertension, chronic lung disease, chronic kidney disease, liver disease, smoking, concurrent abdominal hernia repair, concurrent breast augmentation and teaching status of hospitals on blood transfusion. Conclusions: The blood transfusion rate in post bariatric abdominoplasty patients is not insignificant (9.3%). It is associated with higher complication rates, longer hospital stays and higher total cost. We identified several risk factors for blood transfusion in these patients, with chronic anemia and congestive heart failure being the two major predictors of transfusion. Modifying risk factors such as anemia prior to abdominoplasty might significantly decrease the possibility of blood transfusion.
    Plastic and reconstructive surgery. 10/2014; 134(4S-1 Suppl):105-106.
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    ABSTRACT: Breast reconstruction often requires multiple surgeries, which demands additional expense and time and is often contrary to the patient's expectation. The aim of this study was to review the number of operations that were needed for completion of breast reconstruction and to determine patient and clinical factors that influenced this number. We retrospectively reviewed the medical records of 254 cases of breast reconstructions (in 185 patients) that were performed between February 2005 and August 2009. We investigated the numbers of operations that were performed for individual case of breast reconstruction and analyzed the influence of variable factors. The purpose of the additional operations was also analyzed. The mean number of operations per breast was 2.37 (range, 1-9). The mean number of operations for mound creation was 2.24. Factors associated with an increased number of operation were use of an implant, contralateral symmetrization, complications, and nipple reconstruction. Considering the reconstruction method, either the use of a primary implant or the use of free abdominal tissue transfer demonstrated fewer surgeries than the use of an expander implant, and the number of operations using free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps was less than the number of operations using pedicled transverse rectus abdominis musculocutaneous flaps. These data will aid in planning breast reconstruction surgery and will enable patients to be more informed regarding the likelihood of multiple surgeries.
    Plastic and reconstructive surgery. Global open. 10/2014; 2(10):e242.
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    ABSTRACT: Goals/Purpose: Combined procedures involving elective breast surgery at the time of abdominoplasty are frequently performed procedures in aesthetic plastic surgery. To date, few studies have investigated the demographics and safety of this combined procedure. The purpose of this study was to explore the frequency, complications, and costs of the combined procedure in the United States Methods/Technique: We evaluated the Nationwide Inpatient Sample (NIS) database from 2004-2011. We used ICD-9 CM procedural codes to identify hospitalizations where patients underwent abdominoplasty combined with an elective breast procedure (reduction mammoplasty, mastopexy, and/or augmentation mammoplasty). We trended the frequency of this combined procedure, and evaluated the rate of peri-operative complications, length of inpatient hospitalization, and total hospital charges. Results/Complications: From 2004-2011, 29,235 combined abdominoplasty/breast procedures were performed. After peaking in 2005, the frequency of the combined procedure down-trended in subsequent years. Patients were most likely to be Caucasian (77.5%), privately insured (47%), and in the Southern United States (36.6%). Average patient age was 44 years; the portion of patients older than 50 years increased from 2004 (24.7%) to 2011 (32.7%). The majority of these procedures were performed in teaching hospitals (56.7%). The overall complication rate for the combined procedure was 3.6% (ranged from 2.4-5.6%), with the most frequent being hematoma (1.2%) followed by acute respiratory failure (0.6%). The combined procedure resulted in low rates of mortality (0.02%), VTE (0.1%), wound dehiscence (0.3%), wound infection (0.2%), and seroma (0.3%). The mean hospital stay was 1.8 days and the majority of these procedures were performed as an outpatient surgery. The mean total hospital charge was $31,177. The mean hospital stay demonstrated minimal variation (1.7 days to 1.9 days) during these years, however, the mean total hospital charges significantly increased each year from 2004 ($22,194) to 2011 ($44,302). Conclusion: In the United States, combined abdominoplasty and elective breast surgery procedures are being performed in significant numbers. The combined abdominoplasty and elective breast surgery procedure appears to be a safe surgical option that is associated with a low mortality rate, low complication rate, and short inpatient hospitalization.
    Plastic and reconstructive surgery. 10/2014; 134(4S-1 Suppl):100.
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    ABSTRACT: The burn wound exudate represents the burn tissue microenvironment. Extracting information from the exudate relating to cellular components, signaling mediators and protein content can provide much needed data relating to the local tissue damage, depth of the wound and probable systemic complications. This review examines the scientific data extracted from burn wound exudates over the years and proposes new investigations that will provide useful information from this underutilized resource.
    Burns: journal of the International Society for Burn Injuries 06/2014; · 1.95 Impact Factor
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    ABSTRACT: The aims of this study were (1) to evaluate the frequency of various reconstructive techniques for autologous breast reconstruction and (2) to compare perioperative outcomes of autologous breast reconstruction in teaching versus nonteaching hospitals.
    Plastic and Reconstructive Surgery 04/2014; 133(4 Suppl):981. · 3.33 Impact Factor
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    ABSTRACT: Vascular thrombosis is one of the major postoperative complications of free flap microvascular breast reconstruction operations. It is associated with higher morbidity, higher cost, increased length of hospital stay, and potentially flap loss. Our purpose is to evaluate the rate of this complication and whether patient characteristics play a role. Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent free flap breast reconstruction between 2009 and 2010 in the United States. Multivariate and univariate regression analyses were performed to identify independent risk factors of flap thrombosis. A total of 15,211 patients underwent free flap breast reconstruction surgery (immediate reconstruction: 43%). The most common flap was the free deep inferior epigastric perforator (DIEP) flap (53.6%), followed by free transverse rectus abdominis myocutaneous (TRAM) flap (43.1%), free superficial inferior epigastric artery (SIEA) flap (2%), and free gluteal artery perforator (GAP) flap (1.3%). The overall rate of flap thrombosis was 2.4 %, with the highest rate seen in the SIEA group (11.4%) and the lowest in the TRAM group (1.7%). Peripheral vascular disease (adjusted odds ration [AOR] 10.61), SIEA flap (AOR, 4.76) and delayed reconstruction (AOR, 1.42) were found to be statistically significant risk factors for flap thrombosis. Other comorbidities were not linked. While the overall rate of flap thrombosis in free flap breast reconstruction was relatively low (2.4%), Plastic Surgeons should be aware that patients with peripheral vascular disease and those undergoing free SIEA flap are at higher risk of flap thrombosis and they should closely monitor flaps to increase the chance for early salvage. © 2014 Wiley Periodicals, Inc. Microsurgery, 2014.
    Microsurgery 03/2014; · 1.62 Impact Factor
  • Emil J Kohan, Garrett A Wirth
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    ABSTRACT: The neck is the region of the body between the clavicle and the mandible. It contains several vital structures and serves to separate the head from the torso. A detailed discussion of surgical neck anatomy is presented, including comments relevant to aesthetic surgery. This discussion begins by describing the divisions of the neck and their contents. Subsequently, the layers of the neck are discussed and, finally, relevance with regards to surgery. Risks of complications are increased with secondary and tertiary surgeries.
    Clinics in plastic surgery 01/2014; 41(1):1-6. · 0.95 Impact Factor
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    ABSTRACT: Introduction The burn wound exudate represents the burn tissue microenvironment. Extracting information from the exudate relating to cellular components, signaling mediators and protein content can provide much needed data relating to the local tissue damage, depth of the wound and probable systemic complications. This review examines the scientific data extracted from burn wound exudates over the years and proposes new investigations that will provide useful information from this underutilized resource. Method A literature review was conducted using the electronic database PubMed to search for literature pertaining to burn wound or blister fluid analysis. Key words included burn exudate, blister fluid, wound exudate, cytokine burn fluid, subeschar fluid, cytokine burns, serum cytokines. 32 relevant articles were examined and 29 selected as relevant to the review. 3 papers were discarded due to questionable methodology or conclusions. The reports were assessed for their affect on management decisions and diagnostics. Furthermore, traditional blood level analysis of these mediators was made to compare the accuracy of blood versus exudate in burn wound management. Extrapolations are made for new possibilities of burn wound exudate analysis. Results Studies pertaining to burn wound exudate, subeschar fluid and blister fluid analyses may have contributed to burn wound management decisions particularly related to escharectomies and early burn wound excision. In addition, information from these studies has the potential to impact on areas such as healing, scarring, burn wound conversion and burn wound depth analysis. Conclusion Burn wound exudate analysis has proven useful in burn wound management decisions. It appears to offer a far more accurate reflection of the burn wound pathophysiology than the traditional blood/serum investigations undertaken in the past. New approaches to diagnostics and treatment efficacy assessment are possible utilizing data from this fluid. Burn wound exudate is a useful, currently under-utilized resource that is likely to take a more prominent role in burn wound management.
    Burns. 01/2014;
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    ABSTRACT: Venous thromboembolism (VTE) can be a significant cause of morbidity and mortality in autologous breast reconstruction surgery. The aim of this study was to evaluate the effect of patient characteristics, comorbidities, payer type, reconstruction type, reconstruction timing, radiation, chemotherapy, and teaching status of hospital on VTE (deep venous thrombosis and/or pulmonary embolism) in autologous breast reconstructive surgery. Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent autologous breast reconstructive surgery in 2009 to 2010 in the United States. Univariate and multivariate regression analyses were performed to identify factors predictive of in-hospital VTE. A total of 35,883 patients underwent autologous breast reconstructive surgery during this period. Overall rate of VTE was 0.13%. The highest rate of VTE (0.26%) was observed in pedicled transverse rectus abdominis myocutaneous flap. Patients who experienced VTE had significantly longer mean hospital stay (11.6 vs 3.9 days; P < 0.001) and higher mean total hospital charges ($146,432 vs $61,794; P < 0.001) compared with non-VTE patients; however, there was no significant difference observed in mortality rate (VTE, 0.0% vs non-VTE, 0.04%; P = 0.886). Using multivariate regression analysis, immediate reconstruction after mastectomy (adjusted odds ratio [AOR], 5.4), older than 65 years (AOR, 4.2), obesity (AOR, 3.7), history of chemotherapy (AOR, 3.5), and chronic lung disease (AOR, 2.5) were associated with higher risk of VTE. There was no association between race, payer type, diabetes, hypertension, liver disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, smoking, reconstruction type, radiation, or teaching status of hospital on VTE. In patients undergoing autologous breast reconstruction surgery, immediate reconstruction, older than 65 years, obesity, history of chemotherapy, and chronic lung disease are all independent predictors of higher VTE. Surgeons should consider these factors and use appropriate prophylaxis to minimize the risk of VTE development.
    Annals of plastic surgery 12/2013; · 1.29 Impact Factor
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    ABSTRACT: Pyoderma gangrenosum is a great masquerader in wound diagnosis and management. Frequently misdiagnosed as a necrotizing infection, the elusive nature of its etiology and pathogenesis has thwarted the establishment of a standardized management algorithm, leaving immunosuppressant therapies as the mainstay of treatment. The present report describes a 61-year-old woman presenting with temporally discrete bilateral dorsal hand lesions successfully managed with distinctive multimodality therapies. The initial lesion was managed under the auspices of a necrotizing process using a combination of hyperbaric oxygen therapy and skin grafting with a negative-pressure dressing, both individually demonstrated to be effective for prompt wound stabilization and coverage. A subsequent contralateral hand lesion was similarly managed as a necrotizing infection before a diagnosis of pyoderma gangrenosum was considered. Stabilization and eventual resolution was achieved using intravenous and topical steroids followed by hyperbaric oxygen therapy, again highlighting the benefits of multimodality therapy in the setting of pyoderma gangrenosum.
    The Canadian journal of plastic surgery, Journal canadien de chirurgie plastique 01/2013; 21(4):239-42. · 0.21 Impact Factor
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    ABSTRACT: Due to similarities in skin characteristics, the authors hypothesise that a pig model would most accurately show the ability of autologous, enhanced cryoprecipitate (eCryo) to improve the wound healing of split thickness skin grafts (STSGs) and corresponding donor sites. Fifty-two STSGs (5 × 5 cm) were fashioned and treated according to a randomised protocol with an autologous eCryo-treated and a control group. Macroscopic assessment, histological evaluation and cellular composition were completed at days 7, 14, 21 and 28. Thirty-two donor sites were also created and assessed in a similar fashion. Histologic analysis showed enhancement of healing over all time points for eCryo-treated donor sites. All other results showed no statistically significant improvement with the use of eCryo. Autologous cryoprecipitate appears to be a safe, inexpensive and easy to use alternative to fibrin glue, which carries risks and is in many cases prohibitively expensive. Further studies are necessary to evaluate the full potential of eCryo. Interestingly, eCryo application may improve donor site aesthetic appearance. We believe that a pig model most reliably simulates eCryo's behaviour in humans to accurately reflect its future clinical applicability.
    International Wound Journal 08/2012; · 1.60 Impact Factor
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    ABSTRACT: A 73-year-old Caucasian male presented to the Aesthetic and Plastic Surgery Institute at the University of California Irvine with a poorly differentiated squamous cell cancer of the scalp, located at the parietal/occipital junction. After Moh's excision with Dermatology and definitive wide local excision by Surgical Oncology, a multiple-stage plan was utilized by the plastic surgery team. The first step involved utilization of a rotational advancement flap and split thickness skin graft. Due to the patient's very public occupation, internal/subgaleal inflatable expanders were unacceptable. He was, however, willing to undergo a longer-term process using elastomer-based adhesive strips (DynaClose, Canica Design Inc., Almonte, Ontario, Canada) to definitively close the area overlying the skin graft. Over the next three months, the strips were replaced as needed and progress monitored. Excision of the skin graft and tension-free closure of his native scalp was performed once the surrounding tissue had expanded sufficiently. The authors present this original work as a unique reconstructive option for closure of difficult wounds.
    Journal of Plastic Reconstructive & Aesthetic Surgery 07/2012; 65(10):e297-9. · 1.44 Impact Factor
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    ABSTRACT: Pixie ear is a condition in which the posterior edge of the helix extends straight down to the cheek-jaw intersection, without sweeping back up anteriorly to form a lobe. It occurs congenitally, but more commonly is a postoperative condition, following facelift surgery. Over the years, a handful of methods have been proposed to restore a normal earlobe contour in patients with pixie-ear defects, regardless of etiology. However, virtually all either result in an exposed scar or have limited or undocumented follow-up. The technique described here, resulting in a hidden scar on the mastoid-facing portion of the newly formed lobe and at the mastoid, behind the lobe, has been performed 26 times, with follow-up as long as 20 years.
    Annals of plastic surgery 04/2012; 68(4):360-1. · 1.29 Impact Factor
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    ABSTRACT: Extensive abdominal wall defects may result from tumor extirpation, traumatic injury, or soft tissue infections. Extensive traumatic injuries can often disrupt the soft tissue content of the abdomen as well as the bony support provided by the pelvis. Reconstruction of the lower abdomen should aim to recreate dynamic stability. Five patients with extensive lower abdominal wall disruption following traumatic injuries or infection were treated using a novel flap for functional reconstruction. We devised a free neurotized osteomyocutaneous tensor fasciae latae (TFL) flap that would restore bony continuity by providing a vascularized bone graft and simultaneously maintain the integrity of the attachment of the tensor fascia latae muscle to the iliac crest, reestablishing musculofascial continuity. A branch of the superior gluteal nerve was harvested with this composite flap and coapted to an intercostal nerve for reinnervation, thereby creating a dynamic muscle in these patients. All patients underwent successful free tissue reconstruction with 100% flap survival. The lower abdominal wall and bony integrity of the pelvis were successfully reconstructed. Reinnervation has shown clinical signs of maintained dynamic stability. The innervated TFL osteomyocutaneous flap is an ideal option for lower abdominal reconstruction in patients with complex abdominoperineal defects with loss of bony integrity.
    Journal of Reconstructive Microsurgery 03/2012; 28(3):211-9. · 1.00 Impact Factor
  • Plastic and Reconstructive Surgery 03/2012; 129(3):582e-583e. · 3.33 Impact Factor
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    ABSTRACT: The purpose of this study was to investigate the incidence of postoperative venous thromboembolism in chronic spinal cord injury patients undergoing plastic and reconstructive surgery. Previous studies show a venous thromboembolism incidence of 9.3 percent; however, based on anecdotal evidence, the authors hypothesize that the incidence is actually much lower. As postoperative venous thromboembolism prophylaxis is becoming mandated by the Surgical Care Improvement Project, more data are necessary so that recommendations for chronic spinal cord injury patients can be given. A retrospective chart review was undertaken using electronic medical records from a Veterans Affairs hospital from 2004 through 2009 in which the perioperative course of the chronic spinal cord injury cohort was evaluated for the primary endpoint of venous thromboembolism evolution. The Pearson correlation was used for statistical analysis. Of the 415 operative cases evaluated, 155 cases were excluded secondary to operative time under 1 hour, use of mechanical or chemical venous thromboembolism prophylaxis, unknown operative time, or unknown prophylaxis use. Of the 260 cases evaluated without venous thromboembolism prophylaxis, there were no cases where venous thromboembolism developed within a 2-month postoperative time period. Postoperative venous thromboembolism is a common surgical complication with significant morbidity and mortality. This study demonstrates that in the chronic spinal cord injury patient cohort, the incidence of postoperative venous thromboembolism evolution is extremely low and that a benefit from perioperative mechanical or chemical prophylaxis is not evidence based. Further prospective studies are required to fully elucidate the true venous thromboembolism incidence in these patients and give recommendations on this issue. Therapeutic, IV.
    Plastic and Reconstructive Surgery 12/2011; 128(6):1230-5. · 3.33 Impact Factor
  • Plastic and Reconstructive Surgery 12/2010; 126(6):309e-310e. · 3.33 Impact Factor
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    ABSTRACT: Abdominoperineal resection (APR) after pelvic radiation can be complicated by an increased rate of difficult to treat perineal wound complications. In an effort to improve postoperative morbidity after APR, myocutaneous flap reconstructions have been used. We review our recent experience with APR with vertical rectus abdominis myocutaneous flap reconstruction (VRAM) after preoperative pelvic radiation. A retrospective review of patients who underwent APR with VRAM reconstruction after pelvic radiation from December 2004 to July 2008 was conducted. Outcome measures included demographics, comorbidities, length of stay, wound complications, and morbidity and mortality. Fifteen patients with a mean age of 61 +/- 9 years underwent APR with VRAM reconstruction. Five patients also required posterior vaginectomy with the APR. Indications for APR were rectal cancer (n = 14, 93%) and anal canal cancer (n = 1, 7%). There were no intraoperative complications. Mean estimated blood loss was 635 +/- 446 mL and mean intraoperative blood transfusion requirements were 1 +/- 2 units. Mean length of hospital stay was 11 +/- 4 days. Six (40%) patients had minor perineal wound complications. One (7%) patient had a perineal wound infection requiring reoperation with washout and reapproximation. There was no 30-day or in-hospital mortality. All VRAM flaps remained viable through follow-up. APR with VRAM flap reconstruction after preoperative pelvic radiation can be performed safely with limited wound complications and no mortality.
    The American surgeon 10/2009; 75(10):995-9. · 0.92 Impact Factor
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    ABSTRACT: Postoperative pain control after abdominal procedures can be an area of significant concern. Continuous local-anesthetic infusion pain pumps have been clearly documented in recent literature to provide effective early postoperative pain control, in addition to other benefits. Our goal was to evaluate any increase in the risk of infection with the use of pain pumps with aesthetic and reconstructive abdominal procedures. A retrospective chart review evaluated 159 patients who underwent abdominoplasty (with or without suction-assisted lipectomy), panniculectomy, or a transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction. Information was collected on descriptive and demographic information, and the incidence of postoperative infection. Of the 159 patients who underwent abdominal procedures, 100 (62.9%) received the pain pump for postoperative pain control. None of those 100 patients developed an infection. Fifty-nine patients did not receive a pain pump, and 2 of those patients (3.3%) developed an infection. Overall, 1.3% (2 of 159) of patients in our study developed a postoperative infection. There is no increase in the risk of postoperative infection with the use of continuous local-anesthetic infusion pain pumps used after aesthetic and reconstructive abdominal procedures.
    Annals of plastic surgery 04/2009; 62(3):237-9. · 1.29 Impact Factor