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1.
Ann Plast Surg ; 69(4): 412-4, 2012 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-22964679

RESUMEN

Body contouring has a higher rate of thromboembolism than traditional plastic surgery procedures. Although risk stratification protocols exist, few offer specific therapeutic guidelines for deep venous thrombosis prevention. This single surgeon series classifies 105 consecutive patients into low, moderate, high, and highest risk groups. The respective thromboembolism prevention treatment included pneumatic compression devices alone, postoperative low-dose unfractionated heparin (LDUH), preoperative and 2 doses of postoperative LDUH, and preoperative and postoperative LDUH/low-dose molecular weight heparin for 7 days. Complications included 1 reoperation for bleeding. There were no clinically detected deep venous thromboses. In conclusion, this treatment algorithm for thromboembolism prevention results in a low rate of bleeding and thrombosis. Further studies are warranted to determine optimal timing and duration of chemoprophylaxis in plastic surgery patients.


Asunto(s)
Abdominoplastia , Anticoagulantes/uso terapéutico , Heparina/uso terapéutico , Aparatos de Compresión Neumática Intermitente , Complicaciones Posoperatorias/prevención & control , Trombosis de la Vena/prevención & control , Adulto , Anciano , Algoritmos , Técnicas de Apoyo para la Decisión , Esquema de Medicación , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Persona de Mediana Edad , Cuidados Posoperatorios , Complicaciones Posoperatorias/epidemiología , Hemorragia Posoperatoria/epidemiología , Cuidados Preoperatorios , Estudios Retrospectivos , Medición de Riesgo , Resultado del Tratamiento , Trombosis de la Vena/epidemiología , Trombosis de la Vena/etiología
2.
Ann Plast Surg ; 69(4): 446-50, 2012 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-22964685

RESUMEN

Immediate breast implant reconstruction has among the highest incidence of infections in plastic surgery. A literature search returned key articles that showed a significant decrease in surgical-site infections by performing nasal swab evaluation to treat methicillin-sensitive and methicillin-resistant Staphylococcus aureus before surgery with mupirocin nasal ointment and 5 days of chlorhexidine scrub to the surgical area. Additional Level 1 data supported the use of chlorhexidine-alcohol over povidone-iodine solutions for skin preparation. Intraoperative data on breast pocket irrigation showed the benefits of povidone-iodine as well as a triple antibiotic solution. Nasal swabs from 120 patients showed no methicillin-resistant S. aureus but did identify 10 patients with methicillin-sensitive S. aureus, 1 with streptococcus, and 3 with gram-negative rods, which changed perioperative antibiotic management. On the basis of the previously mentioned data, an evidence-based protocol for infection control was developed to potentially decrease infection rates. Further cost and efficacy data are warranted.


Asunto(s)
Antibacterianos/uso terapéutico , Profilaxis Antibiótica/métodos , Implantación de Mama , Atención Perioperativa/métodos , Infecciones Estafilocócicas/prevención & control , Staphylococcus aureus/aislamiento & purificación , Infección de la Herida Quirúrgica/prevención & control , Antisepsia/métodos , Protocolos Clínicos , Desinfección/métodos , Medicina Basada en la Evidencia , Femenino , Humanos , Mastectomía , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Estudios Prospectivos , Factores de Tiempo
3.
Ann Plast Surg ; 69(2): 129-33, 2012 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-21734537

RESUMEN

One of the most serious complications in plastic surgery is a thromboembolic event. However, little physiologic evidence exists to support the observed hypercoagulable state seen in contouring procedures. Twenty-one consecutive patients were enrolled prospectively to assess thrombin generation, which measures activity of the coagulation cascade, at baseline, intraoperative, and 24 hours after surgery. Compared with preoperative values, total thrombin generation increased by a mean of 997 nM intraoperatively (1.3-fold, P<0.004) and 1406 nM postoperatively (1.4-fold, P<0.001) in 9 patients undergoing abdominoplasty without deep venous thrombosis (DVT) chemoprophylaxis. The mean thrombin generation did not significantly change during or after surgery in 12 patients who received heparin for DVT prophylaxis (P=0.3). Thrombin generation was significantly less in patients receiving chemoprophylaxis compared with those who received no prophylaxis (P<0.01). This suggests abdominal contouring procedures induce a significant increase in the activity of the coagulation cascade that can be prevented by DVT chemoprophylaxis.


Asunto(s)
Abdominoplastia , Complicaciones Intraoperatorias/enzimología , Complicaciones Posoperatorias/enzimología , Trombina/metabolismo , Trombosis de la Vena/enzimología , Adulto , Anticoagulantes/uso terapéutico , Biomarcadores/sangre , Dalteparina/uso terapéutico , Humanos , Aparatos de Compresión Neumática Intermitente , Complicaciones Intraoperatorias/prevención & control , Persona de Mediana Edad , Periodo Perioperatorio , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Trombosis de la Vena/etiología , Trombosis de la Vena/prevención & control
4.
Plast Reconstr Surg ; 131(6): 1223-1230, 2013 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-23714788

RESUMEN

BACKGROUND: Few studies address salvage rates for infection in implant-based breast reconstruction. An understanding of success rates and clinical predictors of failure may help guide management. METHOD: A retrospective analysis of multisurgeon consecutive implant reconstructions from 2004 to 2010 was performed. RESULTS: Immediate implant-based reconstructions (n=1952) were performed in 1241 patients. Ninety-nine reconstruction patients (5.1 percent) were admitted for breast erythema and had a higher incidence of smoking (p=0.007), chemotherapy (p=0.007), radiation therapy (p=0.001), and mastectomy skin necrosis (p<0.0001). There was no difference in age, body mass index, or acellular dermal matrix usage. With intravenous antibiotics, 25 (25.3 percent) reconstruction patients cleared the infection, whereas 74 (74.7 percent) underwent attempted operative salvage (n=18) or explantation (n=56). Patients who failed to clear infection had a higher mean white blood cell count at admission (p<0.0001). Of the attempted operative salvage group, 12 cleared the infection with immediate implant exchange and six eventually lost the implant. Patients who failed implant salvage were more likely to have methicillin-resistant Staphylococcus aureus (p=0.004). The total explantation rate was 3.2 percent. Following explantation, 32 patients underwent attempted secondary tissue expander insertion. Twenty-six were successful and six had recurrent infection and implant loss. There were no differences in time interval to tissue expander insertion between successful and unsuccessful secondary operations. CONCLUSIONS: Salvage with intravenous antibiotics and implant exchange was successful in 37.3 percent of patients. Smoking, irradiation, chemotherapy, and mastectomy skin necrosis were predictors for developing infection. Patients with a higher white blood cell count at admission and methicillin-resistant S. aureus were more likely to fail implant salvage. There was no association with time interval to tissue expander insertion and secondary explantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Asunto(s)
Implantes de Mama , Mamoplastia , Complicaciones Posoperatorias/cirugía , Infecciones Relacionadas con Prótesis/cirugía , Terapia Recuperativa , Infección de la Herida Quirúrgica/cirugía , Dermis Acelular , Adulto , Antibacterianos/uso terapéutico , Índice de Masa Corporal , Neoplasias de la Mama/terapia , Quimioradioterapia Adyuvante , Femenino , Humanos , Infusiones Intravenosas , Mastectomía , Staphylococcus aureus Resistente a Meticilina , Persona de Mediana Edad , Necrosis , Complicaciones Posoperatorias/etiología , Infecciones Relacionadas con Prótesis/etiología , Recurrencia , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Piel/patología , Fumar/efectos adversos , Infecciones Estafilocócicas/etiología , Infecciones Estafilocócicas/cirugía , Infección de la Herida Quirúrgica/etiología , Resultado del Tratamiento
5.
Plast Reconstr Surg ; 128(6): 1170-1178, 2011 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-22094736

RESUMEN

BACKGROUND: Immediate single-stage direct-to-implant breast reconstruction with acellular dermal matrix optimizes aesthetics by preserving the mastectomy skin envelope. The authors report trends, early complications, and costs. METHODS: A retrospective review of three surgeons' experience was performed for immediate single-stage implant reconstruction with acellular dermal matrix and tissue expander reconstruction without it at Massachusetts General Hospital. RESULTS: Two hundred eleven patients had 331 direct-to-implant reconstructions using AlloDerm following nipple-sparing (n = 66) or skin-sparing (n = 265) mastectomy for cancer (n = 216) or prophylaxis (n = 115). The number of single-stage implant reconstructions increased from seven in 2006 to 116 in 2009. The percentage performed for prophylaxis increased from 29 percent to 41 percent. Fifty-one patients underwent preoperative (n = 33) or postoperative (n = 18) irradiation. Total complications included 10 infections (3.0 percent), five seromas (1.5 percent), four hematomas (1.2 percent), and 30 reconstructions (9.1 percent), with skin necrosis leading to five implant losses (1.5 percent). Tissue expander reconstruction without AlloDerm had a similar total complication rate (158 reconstructions) (p = 0.18), including nine infections (5.7 percent), three seromas (1.9 percent), three hematomas (1.9 percent), and 16 reconstructions (10.1 percent), with skin necrosis leading to 11 implant losses (7.0 percent). A higher complication rate occurred in the surgeons' combined first year performing single-stage implant reconstruction (21.4 percent) compared with subsequent years (10.9 percent) (p < 0.02) and in one- or two-stage reconstruction patients undergoing irradiation (p = 0.005). There was no significant difference in total overall costs (p = 0.8). CONCLUSIONS: Immediate single-stage implant reconstruction using acellular dermal matrix offers a cost-effective reconstruction with a low complication rate. This may be the procedure of choice in select patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Asunto(s)
Materiales Biocompatibles , Implantes de Mama , Colágeno , Mamoplastia/métodos , Complicaciones Posoperatorias/etiología , Adulto , Anciano , Anciano de 80 o más Años , Materiales Biocompatibles/economía , Implantes de Mama/economía , Implantes de Mama/tendencias , Costos y Análisis de Costo , Femenino , Humanos , Mamoplastia/economía , Mamoplastia/tendencias , Mastectomía/métodos , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/cirugía , Reoperación , Estudios Retrospectivos , Factores de Riesgo
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