Office-based outpatient plastic surgery utilizing total intravenous anesthesia.

BACKGROUND: Office-based plastic surgery procedures continue to increase in popularity and a range of anesthetic techniques can be utilized, from light conscious sedation to general anesthesia requiring intubation. Total intravenous anesthesia (TIVA) is well suited for the office environment because it allows for moderate to deep sedation without the need for intubation. OBJECTIVE: The authors review plastic surgery procedures performed in an outpatient office-based operating room under TIVA to assess patient outcomes and complications. METHODS: A retrospective chart review was conducted of patients who underwent surgical procedures performed by 2 senior surgeons at American Association for Accreditation of Ambulatory Surgery Facilities-certified outpatient operating rooms between 2003 and 2011. TIVA was always administered by a board-certified anesthesiologist because it required the use of propofol. Conscious sedation with midazolam and fentanyl was always administered by the plastic surgeon. Patient outcomes and complications were analyzed to assess the safety of TIVA in an office operating room. RESULTS: A total of 2611 procedures were performed on 2006 patients. No deaths, cardiac events, or transfers to the hospital occurred in any patients, regardless of the type of sedation utilized. Six hundred forty-two patients were given TIVA, which included propofol and/or ketamine, in addition to midazolam and fentanyl. The remaining 1364 patients received conscious sedation. There was 1 documented case (0.05%; 1/2006) of deep vein thrombosis/pulmonary embolism in a patient who had an implant exchange under TIVA; this patient was taking oral contraceptive pills at the time of surgery. CONCLUSIONS: Office-based surgery is an attractive option for many patients. This review suggests that a variety of procedures can be performed in a safe manner under TIVA. Although patient selection for outpatient surgery is paramount, TIVA offsets the risks of general anesthesia and is associated with minimal postoperative complications. LEVEL OF EVIDENCE: 4.

The Graf/Biggs flap to increase upper pole projection in breast reductions with free nipple grafts.

BACKGROUND: Macromastia necessitating breast reduction with free nipple grafts often results in a breast shape that lacks upper pole projection. This study aimed to describe and review the experience with use of the Graf/Biggs flap to improve upper pole fullness in patients requiring breast reductions with free nipple grafts. METHODS: A retrospective review evaluated patients treated by the senior author who had breast reductions with free nipple grafts and simultaneous use of the Graf/Biggs flap. Reduction amount, aesthetic result, and complications including hematoma, seroma, infection, fat necrosis, wound breakdown, and nipple hypopigmentation were studied. RESULTS: A total of six patients, with an average follow-up period of 22 months, underwent breast reductions with free nipple grafts and simultaneous use of the Graf/Biggs flap. The average reduction amount was 2,583 g per side. There were no complications except for some early wound breakdowns at the lower T incision of the inframammary fold. These wounds resolved with local care. All the patients exhibited hypopigmentation of the grafted nipples and desirable breast shape, with excellent upper pole projection. All were universally happy with their result. CONCLUSION: The Graf/Biggs flap is a reliable technique for increasing upper pole projection in the patient requiring breast reduction with free nipple grafts.