Advances in breast reconstruction after mastectomy.

Over the past 40 years, surgical reconstruction of the breast following mastectomy has become an important aspect of the cancer patient's rehabilitation process. While the surgical emphasis remains on a cure for the cancer, experience with breast reconstruction has not demonstrated any increased rate of cancer recurrence, even when reconstruction is performed immediately following tumor resection. Advances in surgical technique and biotechnology have made post-mastectomy reconstruction possible. The development of silicone gel and saline-filled implants as well as tissue expanders has revolutionized breast reconstruction. The elucidation of musculocutaneous flaps now provides the surgeon with the ability to transfer adequate quantities of vascularized tissue to reconstruct the surgical defects. The advent of microsurgical techniques has provided an additional reconstructive option, with free tissue transfer allowing the plastic surgeon to move musculocutaneous flaps from remote or distant sites to reconstruct the defect. The option of having the reconstruction immediately following the mastectomy procedure is now available to the patient. When reviewing the anatomy of the breast region, the surgeon must consider the mammary gland, its vascular supply, and its lymphatic system. The surgical techniques involved in reconstruction after mastectomy include the use of breast implants and tissue expansion, as well as reconstruction with autogenous tissues. Reconstruction with autogenous tissues includes the use of latissimus dorsi musculocutaneous flap, transverse rectus abdominus musculocutaneous flap, free flap transfer, as well as nipple-areola reconstruction. Breast reconstruction after mastectomy should be undertaken by a plastic and reconstructive surgeon with considerable training and experience with these diversified procedures.

Lidocaine metabolism pathophysiology, drug interactions, and surgical implications.

A thorough understanding of the pathophysiology of lidocaine metabolism is an important prerequisite to minimizing the risk of morbidity and mortality associated with lipoplasty. Although the tumescent technique has greatly improved the safety of large-volume lipoplasty through decreased blood loss and reduced anesthetic needs, it has introduced the possibility for lidocaine toxicity. Because lidocaine is metabolized by the cytochrome P450 system, the potential for drug interactions is heightened. These drug interactions are implicated as a cause of lidocaine toxicity. A comprehensive review of the patient's preoperative, intraoperative, and postoperative medication profile is critical to perioperative patient safety.