Diazepam Premedication in Primary Augmentation Mammoplasty.

Goals/Purpose: To evaluate the effects of preoperative oral diazepam on the postoperative course of patients undergoing primary augmentation mammoplasty in an outpatient surgical center. Methods/Technique: A retrospective review was conducted of 189 patients undergoing primary breast augmentation at an outpatient surgical center from 2012 to 2015. Patients receiving same-day premedication with oral diazepam were compared with a control group without premedication. Patients with combined surgical procedures were excluded with the exception of minor, superficial procedures. Patient demographics, perioperative medication use, operative details, and postoperative numeric pain scale (0-10) scores were collected. Results/Complications: Ninety-three patients (49%) were included in the premedication group and 96 (51%) in the control group. Difference in age, body mass index, implant size, and intraoperative opioid use were not statistically significantly different between the treatment and control groups (P > .05). No difference was noted in postoperative nausea, emesis, or antiemetic use between the 2 groups. The operative time was slightly longer in the control group (64.5 minutes vs 58.5 minutes, P = .006). Immediate postoperative pain (3.6 vs 4.4) and time to discharge (101 minutes vs 110 minutes) were slightly decreased in the premedication group; however, these values did not reach statistical significance. Intraoperative narcotic use was the same between groups, but postoperative narcotic pain medication use was higher in the premedication group (9.68 mg vs 8.26 mg, P = .036). Predischarge pain scores (2.87 vs 2.29, P = .006) were also noted to be slightly higher in the premedication group. Conclusions: Preoperative diazepam administration does not significantly decrease time to discharge in primary breast augmentation mammoplasty. Furthermore, its use may result in increased postoperative narcotic use and higher pain scores at the time of discharge.

Reduction of post-surgical scarring with the use of ablative fractional CO2 lasers: A pilot study using a porcine model.

BACKGROUND AND OBJECTIVE: Wound healing inevitably leads to scarring, which leads to functional and cosmetic defects. It is the goal of this study to investigate the immediate use of ablative fractional CO2 lasers to reduce post-operative scarring secondary to surgical wounds. STUDY DESIGN/MATERIALS AND METHODS: In this prospective controlled study, 20 surgical incisions were created on each of three pigs. Fifteen of the incisions were treated with an ablative fractional CO2 laser at one of three laser settings. The remaining five incisions served as a control. Punch biopsies were taken post-operatively over time. Digital photographs were taken of each incisional scar at each time period. Blinded evaluators used a previously verified scoring system to score photographs of the incisional scars taken at the 6 month time period. RESULTS: With regards to the comparison between the three individual laser treatment groups and the control, there were no statistically significant effects for treatment (P = 0.40), time (P = 0.48), or for the interaction of time and treatment (P = 0.57). With regards to the visual assessment tool, there were no statistically significant differences between treatments for Overall Appearance (P = 0.21) or for Total Score (P = 0.24). CONCLUSIONS: In the limited setting of this pilot study, treatment of surgical incisions with ablative fractional CO2 lasers does not significantly lessen scar formation. In addition, photographic analysis was not able to demonstrate a significant difference. Future studies on this topic will need a larger sample size to better answer whether a statistically significant difference may exist. Lasers Surg. Med. 49:122-128, 2017. © 2016 Wiley Periodicals, Inc.

Brachioplasty outcomes: a review of a multipractice cohort.

BACKGROUND: Upper arm deformities secondary to massive weight loss or senile elastosis have led to an increased demand for aesthetic contouring procedures such as brachioplasty. METHODS: The records of all patients who underwent a brachioplasty procedure from a multipractice medical center were reviewed. Outcomes measured included patient demographics, operative interventions, and postoperative course. RESULTS: Ninety-six patients were analyzed. Fifty-three patients (55.2 percent) underwent a concomitant procedure, with 53.1 percent undergoing arm liposuction at the time of brachioplasty. Major and minor complications rates were 17.7 percent and 44.8 percent, respectively. Common complications included hypertrophic scarring (24.0 percent) and infection (14.6 percent). The total revision rate was 22.9 percent, with residual contour deformity (40.9 percent of revisions) and hypertrophic scarring (36.4 percent of revisions) representing the most common causes for revision. Patients who underwent a previous bariatric procedure were at an increased risk of developing a major complication (p = 0.02). Concomitant upper arm liposuction and concomitant procedures were not associated with a significantly increased complication rate. CONCLUSIONS: Brachioplasty, despite being an effective treatment for contour irregularities of the upper arm, is associated with significant revision and complication rates. Post-bariatric surgery patients should be informed of the potential for increased complications. Additional procedures performed at the time of brachioplasty do not significantly increase complications. Liposuction of the upper arm can be performed safely in conjunction with brachioplasty.

Outcomes of traditional cosmetic abdominoplasty in a community setting: a retrospective analysis of 1008 patients.

BACKGROUND: Abdominoplasty is one of the most commonly performed cosmetic operative procedures. Few large studies have examined outcomes of cosmetic abdominoplasty in a community setting. The authors explored postoperative outcome and the preoperative and intraoperative factors that may contribute to these complications. METHODS: A retrospective review of consecutive patients undergoing abdominoplasty over an 11-year period was performed. Baseline patient demographics, intraoperative technique, and postoperative outcomes were recorded. Preoperative and intraoperative characteristics were analyzed to determine characteristics that predispose patients to complications and undesirable outcomes. RESULTS: The 1008 study patients underwent either a full or modified abdominoplasty with a total complication rate of 32.6 percent. The most common complication was seroma (15.4 percent). Liposuction of the abdominal flap was performed in 469 patients (46.5 percent) and liposuction of the flanks was performed in 555 patients (55.1 percent). Chi-square analysis followed by logistic regression revealed that liposuction of the flanks and abdomen was independently associated with seroma formation in addition to major and minor complications (p < 0.05). CONCLUSIONS: Seroma formation following abdominoplasty is the most common complication. Concomitant liposuction of the flanks and abdomen with the addition of aggressive undermining leads to higher seroma rates. This association is likely multifactorial and may be secondary to increased resorptive demands placed on the abdominal lymphatics in the setting of greater dead space and larger fluid shifts as a result of liposuction. To reduce seroma rates, surgeons should avoid aggressive liposuction and undermining, particularly in high-risk patients.

Cosmetic rhinoplasty: revision rates revisited.

BACKGROUND: Cosmetic rhinoplasty has great potential to change a patient's appearance. It also carries the very real risk of patient dissatisfaction and request for revision. Although there have been many published patient series studying various aspects of rhinoplasty, questions remain regarding revision rates, as well as risk factors for complications, dissatisfaction, and revision. OBJECTIVES: The authors investigate the rate of cosmetic rhinoplasty revision at a plastic surgery group practice and identify risk factors for revision. METHODS: Medical records were retrospectively reviewed for all patients who presented to a single multisurgeon practice for primary rhinoplasty, septorhinoplasty, and revision rhinoplasty between 1998 and 2008. Patient demographics, preoperative complaints, preoperative physical examination findings, detailed operative data, and postoperative outcomes were abstracted from the charts. Complication rates, revision rates, and postoperative patient satisfaction were calculated and analyzed for identifiable risk factors. RESULTS: Of 369 consecutive cosmetic rhinoplasties performed during the study period, 279 (72.7%) were conducted with an open approach. The overall complication, dissatisfaction, and revision rates were 7.9%, 15.4%, and 9.8%, respectively. Postoperatively, most patients (87%) were identified by their surgeons as having had successful anatomical correction of their nasal deformity. History of previous nasal operation or facial fracture, lack of anatomical correction, and occurrence of postoperative complications were associated with both revision and dissatisfaction (P < .05). Failure to address the nasal tip at the time of primary rhinoplasty was associated with a higher level of dissatisfaction. CONCLUSIONS: Cosmetic rhinoplasty is one of the most challenging procedures in plastic surgery; however, these data indicate that a high level of patient satisfaction is attainable within a plastic surgery group practice if certain factors are considered. Specifically, surgeons should be aware of risk factors that are potentially associated with dissatisfaction and revision. LEVEL OF EVIDENCE: 4.

Vertical reduction mammaplasty utilizing the superomedial pedicle: is it really for everyone?

BACKGROUND: Classically, the vertical-style reduction mammaplasty utilizing a superomedial pedicle has been limited to smaller reductions secondary to concerns for poor wound healing and nipple necrosis. OBJECTIVES: The authors reviewed a large cohort of patients who underwent a vertical-style superomedial pedicle reduction mammaplasty in an attempt to demonstrate its safety and efficacy in treating symptomatic macromastia. METHODS: A retrospective review was performed of 290 patients (558 breasts) who underwent a vertical-style superomedial pedicle reduction mammaplasty. All procedures were conducted by one of 4 plastic surgeons over 6 years (JDR, MAA, DLV, DRA). RESULTS: The average resection weight was 551.7 g (range, 176-1827 g), with 4.6% of resections greater than 1000 g. A majority of patients (55.2%) concomitantly underwent liposuction of the breast. The total complication rate was 22.7%, with superficial dehiscence (8.8%) and hypertrophic scarring (8.8%) comprising the majority. Nipple sensory changes occurred in 1.6% of breasts, with no episodes of nipple necrosis. The revision rate was 2.2%. Patients with complications had significantly higher resection volumes and nipple-to-fold distances (P = .014 and .010, respectively). CONCLUSIONS: The vertical-style superomedial pedicle reduction mammaplasty is safe and effective for a wide range of symptomatic macromastia. The nipple-areola complex can be safely transposed, even in patients with larger degrees of macromastia, with no episodes of nipple necrosis. The adjunctive use of liposuction should be considered safe. Last, revision rates were low, correlating with a high level of patient satisfaction.

Prophylactic sternal plating with pectoralis advancement flaps after sternotomy in patients with a history of chest irradiation.

Deep sternal infections secondary to bony instability and malunion, can result in mediastinitis. Previous authors have described the use of prophylactic rigid plate fixation in high-risk patients. The purpose of our study is to review the use of prophylactic sternal platting with pectoralis advancement flaps in high-risk patients with a history of chest irradiation. Fourteen patients (July 2003-September 2008) with a history of chest irradiation who underwent a median sternotomy followed by prophylactic rigid plate fixation of the sternum were reviewed. Breast cancer was the most common etiology of chest irradiation (n=11, 78%). The average EuroSCORE was 24.06% with 72% of patients having a preoperative New York Heart Association (NYHA) class≥III. There were no episodes of sternal non-union, mediastinitis or death. Follow-up was 100% with a 0% 30-day and a 7.1% one-year mortality rate (non-cardiac). A comparison between mean preoperative left ventricular ejection fraction (LVEF) (49.6%) and postoperative LVEF (59.7%) was statistically significant (P<0.0001). All living patients currently maintain a NYHA class I/II. Prophylactic rigid plate fixation and pectoralis flap coverage decreases the risk of developing sternal dehiscence and postoperative wound complications and should therefore be considered in high-risk patients with a history of chest irradiation.

Outcomes of fractional CO2 laser application in aesthetic surgery: a retrospective review.

BACKGROUND: Despite the effectiveness of ablative CO(2) laser resurfacing for facial rejuvenation, its application has been limited owing to an undesirable side-effect profile, including prolonged hyperemia and potential pigmentary changes. However, newer fractional CO(2) laser technology has reduced the recovery time and led to decreases in postprocedural hypo- and hyperpigmentation. OBJECTIVES: The authors investigate the application and outcomes of ablative fractional technology in a private cosmetic surgery practice. METHODS: In this retrospective cohort study, the charts of patients who received fractional CO(2) laser resurfacing between March 2007 and May 2008 were reviewed. Data regarding patient demographics, pretreatment regimens, detailed operative data, and posttreatment findings were obtained. The length of hyperemia (less than five weeks, five to eight weeks, and more than eight weeks), complication rates, and revision rates were analyzed. A satisfaction survey was also sent to all patients. RESULTS: Throughout the 19-month study period, 97 patients received 101 treatments with an average follow-up of 4.5 months. Full-face laser resurfacing was performed in 81.1% of patients, with 64.3% receiving their treatment under local anesthesia without sedation. Length of hyperemia was less than five weeks in 93%, five to eight weeks in 5.9%, and more than eight weeks in 0.9% of patients. Hyperpigmentation (9.9%), milia (6.9%), acne breakout (5.9%), and transient ectropion (0.9%) were less common. Patient satisfaction surveys revealed that a majority of patients were satisfied with their results. CONCLUSIONS: New fractional CO(2) laser skin resurfacing is associated with shorter periods of hyperemia, resulting in shorter recovery time in comparison with older ablative technology. The side-effect profile is minor and infrequent. This new technology provides significant clinical improvement with high patient satisfaction.

Sternal salvage with rigid fixation in the setting of a massive mediastinal aortic pseudoaneurysm: a case report and review of the literature.

Reconstruction of sternal nonunion following surgical resection can be difficult. Presented here is a case of sternal salvage with rigid fixation in the face of a massive aortic pseudoaneurysm. Plating is a safe and efficient technique that provides bone approximation and results in long term rigid sternal fixation. This case report highlights the history and biomechanical theory and examines the safety and clinical outcomes of sternal reconstruction with plating fixation.

Sternal nonunion: a review of current treatments and a new method of rigid fixation.

Sternal nonunion as the result of cardiac intervention or trauma remains a morbid condition with serious sequelae. Patients often report pain with breathing, coughing, and/or movement. The authors present 6 patients that were diagnosed with sterile sternal nonunion after cardiac procedure (4) or trauma (2). The cardiac patients presented 5, 7, 15, and 60 months after their cardiac procedure; the trauma patients presented 8 and 12 months after the accident. Diagnosis was made based on the clinical triad of sternal instability, pain, and absence of infection. Management with open reduction and internal rigid plate fixation with Sternalock plates (W. Lorenz Surgical, Inc., Jacksonville, FL) was performed on all 6 patients. There was no incidence of subsequent infection. Pain completely resolved in all patients. All wounds healed to completion, and bone healing was assessed clinically with the absence of instability and pain and follow-up chest radiographs.

Primary sternal plating in high-risk patients prevents mediastinitis.

OBJECTIVE: Sternal wound infection leading to post-operative mediastinitis is a devastating complication of cardiac surgery carrying nearly a 15% mortality rate despite current treatment methods. Instability of bone fragments pre-disposes a patient to have non-union, mal-union and can subsequently lead to deep sternal wound infections progressing to mediastinitis. Rigid plate fixation has been utilized for acquired and surgically created fractures of virtually every bone in the body to prevent instability. However, the current standard for sternotomy closure remains the method of wire-circlage. Application of rigid plate fixation for sternal osteotomies affords greater stability of the sternum. We report on our preliminary experience with this technique in high-risk patients. METHODS: From July of 2000 to December 2001, rigid plate fixation was applied to 45 patients designated as having high risk for sternal dehiscence and subsequent mediastinitis. High risk was defined as patients having 3 or more established historical risk factors, including: COPD, Re-Operative Surgery, Renal Failure, Diabetes, Chronic Steroid Use, Morbid Obesity, Concurrent Infection and Acquired or Iatrogenic Immunosuppression. Intra-operative risk factors included off-midline sternotomy, osteoporosis, long cardio-pulmonary bypass runs (>2 h), transverse fractures of the sternum. Rigid plate fixation was performed using a combination of plates secured by bi-cortical screws, after the cardiac surgical procedure was complete and hemostasis was secured. RESULTS: Rigid plate fixation was performed on 26 males and 19 females. The average age of patients was 63 (43-88) years. The average follow-up was 15 weeks (range 8-41 weeks). While there were 4 peri-operative deaths unrelated to sternal closure: one from aspiration pneumonia (post-operative day 9), one from a pulmonary embolus (post-operative day 29), one from overwhelming sepsis from pre-existing endocarditis (post-operative day 15), and one for primary respiratory failure (post-operative day 12). All others healed successfully. One patient who had a sterile dehiscence subsequently underwent successful re-operative rigid fixation. Comparing the cohort of patients who received rigid plate fixation to a matched population of high-risk patients during a similar time period who received wire closure, revealed a significant difference in the incidence of post-operative mediastinitis. The wire closed group (n = 207) had 18 deaths unrelated to sternal closure and had 28 patients who developed mediastinitis (14.8%). The rigid plate fixation group had no mediastinitis (Fisher's exact test, P = 0.006). The total incidence of post-operative mediastinitis during the designated study period was 4.2%. CONCLUSION: Patients who benefited from sternal closure with rigid plate fixation showed a significant decrease in the incidence of post-operative mediastinitis when compared to similar population of patients whose sterna were closed with wire.