Efficacy of Topical Tranexamic Acid (Cyclokapron) in "Wet" Field Infiltration with Dilute Local Anaesthetic Solutions in Plastic Surgery.

BACKGROUND: Surgical bleeding may lead to the need for blood transfusion and minimizing blood loss has been a basic principle followed by surgeons for generations. Antifibrinolytic agents are widely used to reduce perioperative haemorrhage. The present study sought to assess the efficacy of directly infiltrated tranexamic acid in ameliorating bruising in participants undergoing cosmetic plastic surgery (liposuction). MATERIALS AND METHODS: The study employed a blinded, prospective, randomized, case control design. Thirty-three patients were studied. Tranexamic acid free infiltration tumescent solution (saline, bupivacaine lignocaine and adrenalin) was infiltrated to one flank of patients undergoing liposuction of flanks. The other flank was infiltrated with the same tumescent solution (saline, bupivacaine lignocaine and adrenalin) mixed with tranexamic acid (0.1%). Bruises were photographed one and seven days after surgery and measured for size. The surface area of the bruises was calculated using ImageJ software. We compared the bruised surface are between the tranexamic acid infiltrated flank and non-tranexamic acid infiltrated flank in the same patient. The model employed involved measuring the bruises on each flank of the same patient, with surgery by a single surgeon using the same infiltration and surgical techniques for both sides. The only variable was the difference in tranexamic acid concentration between study and control flanks. RESULTS: We found that use of tranexamic acid consistently resulted in a smaller bruise area on days one and seven after liposuction of flanks. Results were statistically significant. CONCLUSIONS: This is the first study examining addition of tranexamic acid to a tumescent infiltration solution-to produce a predictable local concentration of tranexamic acid-in order to maximize surgical site effect and minimize systemic effect. The authors recommend incorporation of tranexamic acid as a routine component along with adrenaline and local anaesthetics in tumescent field infiltration solution 10-15 min before commencement of the cosmetic surgery. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Air drainage: an essential technique for preventing breast augmentation-related pneumothorax.

BACKGROUND: Pneumothorax is one of the most poorly understood and least frequently reported complications associated with breast augmentation, yet this complication presents as a dramatic and often extremely distressing event to both the patient and the surgeon. In addition, this complication is associated with an estimated 10% occurrence of medicolegal consequence. A recent survey of 363 Californian Plastic Surgeons concerning the occurrence and outcome of breast augmentation related Pneumothorax suggested that the incidence of this complication could be more prevalent than previously reported. The author previously suggested barotrauma as the underlying mechanism responsible for the development of pneumothorax associated with breast augmentation. This study aimed to analyze the role of air drainage in preventing pneumothorax during insertion of breast implants. METHODS: A control group of five patients who experienced pneumothorax was compared with a group of six consecutive patients whose surgical pocket was drained of air during insertion of the implant. RESULTS: None of the study patients experienced pneumothorax. CONCLUSIONS: Air drainage from the surgical cavity during insertion of the implant is extremely successful in preventing the development of breast augmentation-related pneumothorax. It is suggested that air drainage be introduced as a routine step in breast augmentation procedures, particularly in those that involve insertion of large implants through small incisions.

Nasal middle vault support: a new technique.

A novel technique for maintaining internal nasal valve anatomic and physiologic integrity at the time of hump reduction is proposed. The procedure involves mobilizing the anterior edge of the upper lateral cartilage after submucosal dissection. Reduction of the anterior border of the septal cartilage and reconstruction of the middle vault of the nose is accomplished by placing the upper lateral cartilage medial border on the reduced edge of the septum using a vest-over technique. The technique was successfully used for 32 nonconsecutive patients over a 4-year period.

Outcome study: periareolar mammaplasty patients' perspective.

Residual scars on occasion compromise patient satisfaction with breast reduction procedures. Periareolar breast reduction was proposed to minimize the scarring produced by the operation. This technique was criticized predominantly for producing a breast with low projection, for recurrence of ptosis after surgery, and for widening of the periareolar scar. The purpose of this study was to evaluate patient satisfaction from this technique. In the first branch of the study, 11 patients who had periareolar or circumareolar breast reduction were compared with 13 patients who had vertical scar reduction mammaplasty. The groups were matched for patient's age, size of reduction, and follow-up period. The patients were contacted by phone and requested to comment on four aspects of their operation: breast size, symmetry, quality of scars, and appearance and position of the nipple-areola complex. The replies were converted to numerical values and analyzed statistically. A panel of three women, prospective patients for breast reduction, were presented with standardized five-view before-and-after photographs and requested to score the results using the same criteria. Their responses were analyzed in the same manner. Both phases of the study produced similar results. Breast reduction done through a periareolar scar scored higher than a vertical scar technique. The operation did not differ with respect to shape, symmetry, or nipple-areola shape but did with respect to dissatisfaction with scars, which affected the overall result. This experimental model of assessing results of cosmetic operations is proposed as a tool to assess the patient's rather than the surgeon's perspective of a surgical technique, and it could find application in assessing other cosmetic operations.

Zygomaticus major advancement as an adjunct to lower blepharoplasty.

Sagging of the mid-face, deep nasolabial folds, and flat malar eminence often compromise the rejuvenation effect produced by upper and lower blepharoplasty. A simple surgical technique based on advancement of the zygomaticus major origin was developed as an adjunct to lower blepharoplasty to address this problem. The technique is predominantly suitable for ambulatory surgery setup and can be easily performed under local anesthesia and sedation. It offers rejuvenation of the midface and correction of the nasolabial fold.

Short scar mastopexy with flap transposition.

A personalized technique using a vertical scar mastopexy is described. The breast tissue is utilized as a transposition flap behind the nipple-areolar complex to increase its projection. The inferior pole of the breast can be developed either as a superiorly pedicled or inferiorly pedicled flap for that purpose and the indication for each version is described. The technique has been successfully utilized in 80 patients with pleasing results. Illustrative cases are presented.

Abdominal wall reconstruction after open management of the septic abdomen.

The increasing popularity of open management of the septic abdomen has generated a challenge that the surgeon is forced to face more frequently. The typical presentation is that of a patient with a full-thickness abdominal wall defect occurring after a protracted, severe illness. The various methods of reconstruction of the abdominal wall are reviewed and evaluated. The reconstruction should only be attempted once intra-abdominal sepsis is controlled, re-exploration of the peritoneal cavity is no longer necessary and organ support is discontinued. Although various methods of reconstruction are described, the recommended technique consists of either medial advancement of the rectus abdominis muscle or direct application of split-thickness skin grafts. Mid-line abdominal defects may also be repaired with tensor fasciae latae or rectus femoris flaps.

Verapamil improves survival of rat hyperemic island skin flaps.

Inability to maintain cellular calcium homeostasis is a critical factor in the pathogenesis of cellular ischemic injury and may mediate oxygen radical release in the reperfusion period. We assessed the effect of the selective calcium channel blocker verapamil on the performance of rat hyperemic island skin flaps. Pretreatment with verapamil markedly improved survival of skin flaps after 6 hours of venous cross-clamping compared with animals receiving placebo only (99% vs 53.3%; p less than 0.01). Verapamil also prevented the formation of lipid peroxidation products and the depletion of the endogenous antioxidant glutathione, suggesting that the beneficial effect of verapamil is the result of protection against oxygen radical injury. After 12 hours of venous cross-clamping, verapamil did not improve survival of skin flaps despite protection against lipid peroxidation. Oxygen radical release is therefore a crucial event in the pathogenesis of skin flap necrosis after short-term ischemia but is of less significance in long-term ischemia.

A modified frontalis sling in the treatment of combined blepharoptosis and facial nerve paresis.

A surgical method is proposed to treat patients with combined severe blepharoptosis and peripheral facial nerve paresis. The operation involves construction of a sling from the contralateral active frontalis muscle to the affected eyelid tarsal plate. The method has been applied in one patient, with satisfactory results. Re-education of the patient was relatively easy to achieve.

Reconstruction of the alar groove.

The obliteration of a well-defined alar groove is common after nasal alar reconstruction. A method is described that can be used at the time of reconstruction to ensure the continued definition of the groove or to restore it in cases where it has been obliterated. The technique is based on the natural tendency of the skin to tube itself. Cheek skin is advanced beneath the posterior free edge of the reconstructed ala so that this edge now comes into contact with an epidermal surface. As this edge now tends to tube itself, a natural alar groove is produced. This method has been used successfully in six cases.

Multiple myeloma presenting as localized expansile jaw tumour.

Myelomatous involvement of the maxilla is an exceptionally rare occurrence, and the presentation of the lesion as an expansile jaw bone tumour has not been reported. 2 cases, one with a maxillary lesion, the other with a mandibular lesion are presented, both of which illustrate gross bone expansions. Additionally, 1 case presented with a rare biclonal IgG kappa and IgG lambda light chain secreting myeloma. Relevant clinical, immunological, histological, biochemical and histochemical features are presented and discussed, and suggestions pertaining to surgical management made.

Treatment of postreconstructive collapsed nasal ala with a costal cartilage graft.

A technique to restore the skeletal support of the postreconstruction collapsed ala is proposed. This makes use of the elastic characteristic of costal cartilage to provide a natural spring to elevate the ala and thereby enlarge the nostril. Three illustrative cases are described.

Simultaneous dislocation of all five carpometacarpal joints.

A case of unique combination of simultaneous dislocation of all five carpometacarpal joints is presented. The mechanism of injury in this case seems to be some manner of punching with a closed fist rather than direct violence. Satisfactory results were achieved using simple principles of manipulation under anesthesia, open reduction, and skeletal fixation, followed by intensive physiotherapy.

The "Zulu" tissue expansion in construction of the helix and ear lobe.

A traditional custom has been employed in a design of a new technique to expand a rudimentary auricle. The technique involves a full thickness incision of the blob of tissue and positioning of a spacer which is gradually expanded by means of a conical obturator. The technique provides a large amount of local tissue that can be used in helix and ear lobe reconstruction. An illustrative case is reported.