[Anesthetic and perioperative management of patient for breast reconstruction in an outpatient clinic].

BACKGROUND: Our clinic provides various reconstructive surgeries but does not have facilities for patient admission, but there is a hospital providing satisfactory post-operative treatments in our area. METHODS: During the past 3 years, 276 patients received reconstructive mammoplasty under general anesthesia at our clinic. Their post-operative conditions immediately after the recovery were evaluated with the Modified Post-Anesthesia Discharge Scoring System (MPADSS). After observation for 4 to 5 hours in a recovery room, all the patients were transferred to another hospital by car. RESULTS: The score was 9 or 10 points in 45% of the patients. This indicates that the patients can be transferred to another hospital without problems. Twenty percent of patients had 6-7 points. These patients had mild bleeding, pain and/or unsteadiness/nausea/vomiting while walking. Among the 256 patients who were transferred to another hospital by car, one patient vomited in the car and 5 patients had nausea after the transfer. The other 20 patients whose score was 7 or lower were transferred by special vehicle with a stretcher and their conditions did not aggravate at all. CONCLUSIONS: At present, it is dangerous to perform all breast reconstructive surgeries as a day surgeries. A system is indispensable in which patients are transferred after surgery to another hospital with over-night stay facilities enabling observation.

Cranial remodeling to treat craniosynostosis by gradual distraction using a new device.

OBJECT: The authors describe their experience in remodeling the shape of the cranium in children with craniosynostosis by using gradual distraction. In half of the cases, a new distraction device developed by the authors was used. METHODS: Twenty children with craniosynostosis underwent frontoorbital advancement and cranial remodeling assisted by gradual distraction. There were five children with brachycephaly, two with oxycephaly, five with scaphocephaly, two with plagiocephaly, one with combined scaphocephaly and plagiocephaly, and five with trigonocephaly. Four cases were syndromic and 16 were nonsyndromic. The patients ranged in age from 3 to 50 months (mean 14.5 months) at the first surgery. Simulated surgery was first performed on a three-dimensional solid model made of polyurethane, which accurately represented cranial flexibility, to determine the most favorable osteotomy line. Distraction was initiated 1 week postoperatively. The speed and extent of advancement (maximum extension 45 mm) were predetermined on the basis of previously reported criteria and the results of simulated surgery. Postoperatively, the cranial configuration was favorable in all cases. Spontaneous remodeling of irregularities and/or gaps apparent after distraction was found to occur 2 to 5 months after removal of the distraction devices, especially in patients with trigonocephaly or scaphocephaly. No major perioperative complication was observed in any patient. There were minor complications in six of the first 10 cases, including exposure of the device, shaft slippage, and fluid discharge. A new device was developed and used on the last 10 patients treated; it successfully eliminated device exposure and shaft slippage. A 3-year follow-up review confirmed that there was no relapse of advanced bones. CONCLUSIONS: Highly satisfactory results were achieved in cases of both syndromic and nonsyndromic craniosynostosis when gradual distraction was performed.