Deep Vein Thrombosis (DVT) and Abdominoplasty: A Holistic 8-Point Protocol-Based Approach to Prevent DVT.

BACKGROUND: Plastic surgery as a specialty is afflicted with one of the highest incidence rates of thromboembolic events, with abdominoplasty procedures known to assimilate the greatest rates of deep vein thrombosis (DVT). OBJECTIVES: The aim of this study was to develop a prophylactic protocol to reduce the rate of DVT occurrence postabdominoplasty. METHODS: Over a 7-year period 1078 abdominoplasty patients were enrolled onto a holistic 8-point prophylaxis protocol. For a 4-week period before the operation all patients were required to stop smoking, and to cease hormone replacement therapy and combined oral contraception. All patients were required to have a preoperative BMI of less than 40 kg/m2. Participants were supplied with compression stockings, external pumping devices, and enoxaparin. Individuals with a history of DVT were also required to be 1-year treatment free prior to surgery. Furthermore, the protocol required postoperative ambulation of fit patients within 4 hours. RESULTS: Between 2008 and 2013, no incidence of DVT was recorded in all 1078 abdominoplasty surgery patients, indicating the potential for this protocol to lead to a significantly lower incidence than any previously published methodology. Previous studies of DVT incidence were reviewd to identify rates statistically significantly similar to our sample, thereby providing conservative incidence rate estimates. CONCLUSIONS: This 8-point DVT prophylaxis protocol is the first noncriteria-based inclusive protocol aimed at preventing abdominoplasty-associated DVT. A holistic and procedure-specific approach to prophylaxis can drastically reduce the occurrence of DVT in abdominoplasty surgery.With over 116,000 procedures performed annually in the United States, abdominoplasty has become one of the most popular and sought-after surgeries in the plastic and cosmetic field.1 Despite its ever-increasing popularity and the advancement of techniques, abdominoplasty-as with any other surgery-has its complications, including infection, seroma, hematoma, thrombosis, embolism, scarring, and even death. Complication rates as high as 37% have been reported, with some studies reporting a 16% major complication rate.2 One of the most serious and troubling complications for both surgeon and patient is deep vein thrombosis (DVT). With over 1 million patients tested, an estimated 250,000 cases of DVT are diagnosed per year in the United States alone.

Unraveling Factors Influencing Early Seroma Formation in Breast Augmentation Surgery.

Background: It is often assumed that seroma formation trails closely behind with incidence rates reported at 1 to 2%. Seroma is highly problematic for both the surgeon and patient and results in both patient anxiety and discomfort, succeeded by frequent outpatient visits, follow-up treatment, increased costs, and potentially hampered aesthetic outcomes. Consequently, it is now more important than ever to study seroma and to assess its pathophysiology and mechanisms of prevention. Objectives: The aim of this study was to isolate and identify risk factors that may be associated with early seroma formation. Methods: The authors reviewed 539 female patients who had undergone bilateral breast augmentation with silicone cohesive gel implants in a period of 12 months. Five possible risk factors were isolated for analysis: patient's age, body mass index (BMI), smoking habit, implant pocket position, and implant size. A total of 15 patients developed early seromas within the one-year postoperative period. Results: Using exact logistic regression with the independent variables treated as binary variables, we found that smoking, BMI, and pocket are associated with increased risk of seroma while we cannot reject the hypothesis that pocket size and age do not affect the development of seroma at 5% significance level. Conclusions: A high BMI, large implant size, submammary pocket, and smoking are factors significantly associated with seroma development whilst age is not. Smoking however was found to be the most detrimental factor as it significantly amplified the effects of other variables. Level of Evidence: 2

A Preliminary Assessment of the Predictability of Fat Grafting to Correct Silicone Breast Implant-Related Complications.

BACKGROUND: Fat grafting in breast augmentation surgery is becoming increasingly popular and is allowing surgeons to fill the gaps that implant augmentation alone cannot. However, one current issue surrounding fat grafting is resorption. OBJECTIVES: In this prospective study, the authors present their experience of fat grafting and resorption in 26 patients who had fat transfer to correct deformities or asymmetries following primary breast enlargement surgery. METHODS: The fat utilized was harvested and processed using the Puregraft system. Fat grafting was performed until the problem was visually corrected, followed by an additional 30% overcorrection. Photographs were taken preoperatively and 1 year postoperatively, and analyzed utilizing cloud-based 3-dimensional imaging software to measure the breast volumes and calculate 1-year resorption rates. Both patients and physicians were asked to rate their satisfaction. RESULTS: The total volume of fat transferred ranged from 160 cc to 360 cc, with an average of 280 cc per procedure. The absolute volume of tissue resorption showed considerable variation (median, 42.6 mL; range, 5.5-62 mL). However, there was a very close correlation between the volume resorbed and the volume implanted: the more volume injected, the more volume absorbed. When expressed as a percentage of implanted tissue, the resorption rate was 27.5 ± 0.8% (mean ± standard deviation) with a very narrow range (25.7%-28.9%). Patients and physicians reported a satisfaction rate of "excellent" in 83.3% and 75% of cases, respectively. CONCLUSIONS: At 1 year, 25.7% to 28.9% of the injected fat had been resorbed in a predictable, reproducible, and effective manner. LEVEL OF EVIDENCE: 4 Therapeutic.

Use of Quilting Sutures During Abdominoplasty to Prevent Seroma Formation: Are They Really Effective?

BACKGROUND: Abdominoplasty surgery is one of the most popular cosmetic procedures performed in plastic surgery. As with any surgical procedure, it is associated with risks and complications, primarily that of seroma formation. Quilting sutures are a recent development in abdominoplasty surgery that aim to prevent the incidence of seroma. OBJECTIVES: The aim of this article was to assess the effectiveness of quilting suturing in the prevention of seroma formation. METHODS: In our retrospective clinical study, 414 female patients underwent abdominoplasty surgery with liposculpture contouring. The patients were divided in to three groups. The first group, comprising of 100 patients, were fitted with two drains postoperatively and no quilting sutures. The second group of 226 patients underwent quilting suturing in addition to receiving two drains. And the final group of 88 patients also underwent quilting suturing, but received only one drain. Post-operative seroma diagnosis was confirmed with the presence of clinical signs and symptoms. RESULTS: The data was analysed using Fisher's exact test. With P < .000, we rejected our null hypothesis that there is no difference in results between the procedure with sutures and that without sutures. We calculated that the probability of having seroma with sutures to be <0.02. In contrast, abstinence from quilting sutures resulted in a 12% risk of seroma formation. CONCLUSIONS: The use of quilting sutures is a significantly effective measure for the prevention of seroma formation. LEVEL OF EVIDENCE: 4 Therapeutic.

Will 1-stage implant salvage after periprosthetic breast infection ever be routine? A 6-year successful experience.

BACKGROUND: Concomitant with the recent increase in breast augmentations has been an increase in periprosthetic infections necessitating further surgery. The conventional treatment of periprosthetic infections has been a multistage procedure involving explantation, control of infection, and reimplantation. OBJECTIVES: The authors describe a 1-stage salvage procedure for the management of periprosthetic infections. This technique may become the standard for managing infection following cosmetic breast surgery. METHODS: The authors performed a retrospective review of all patients who had periprosthetic infection following cosmetic breast augmentation. The treatment included explantation, sequential cleaning of the wound, and immediate insertion of a new prosthesis and drain. All patients received intravenous antibiotics postoperatively. Of 3012 patients undergoing primary breast augmentation, periprosthetic infection developed in 17 patients. These 17 patients underwent 1-stage implant salvage. Patients were monitored for ≤6 years. RESULTS: All implants were retained; aesthetic results were satisfactory; and no significant adverse events were recorded after implant salvage. CONCLUSIONS: One-stage implant salvage for periprosthetic infection has similar outcomes to conventional multistage procedures and may be preferred by patients. LEVEL OF EVIDENCE: 4.

Assessing the Efficacy of the S-PECS Block in Breast Augmentation Surgery: A Randomized, Double-Blind, Controlled Trial.

BACKGROUND: Postoperative acute and chronic pain following breast surgery is a common complication that needs resolving to allow for improved patient outcomes. Previously, thoracic epidurals and paravertebral blocks have been the accepted standard administered intraoperatively. However, more recently the introduction of the pectoral nerve block (PECS and PECS-2 blocks) has appeared promising to control the pain more effectively, but further robust analysis is required to prove its efficacy. The authors aim to study the efficacy of a new block, S-PECS, that combines a serratus anterior and a PECS-2 block. METHODS: In this study, the authors performed a single-center, randomized, controlled, double-blind group trial in 30 female patients undergoing breast augmentation surgery with silicone breast implants and the S-PECS block. Divided into two groups of 15, the PECS group received local anesthetics and the no-PECS control group received a saline injection. All participants were followed up at recovery and at 4, 6, and 12 hours postoperatively. RESULTS: The authors' results showed that the pain score in the PECS group was significantly less than in the no-PECS group across all time points: recovery, and at 4, 6, and 12 hours. Furthermore, the patients who received the S-PEC block were 74% less likely to request pain medications compared with the no-PECS group ( P < 0.05). CONCLUSION: Overall, the modified S-PECS block is an effective, efficient, and safe method of controlling pain in patients undergoing breast augmentation surgery, with additional applications yet to be explored.

Using Ginger Oil to Treat Nausea and Vomiting Following Breast Augmentation Surgery.

We conducted a double-blind, randomized, placebo-controlled, single-center study involving 30 women undergoing breast augmentation surgery with silicone breast implants. All patients had an A cup breast size and a similar body mass index. We placed the same type of implant in a subpectoral dual plane in each patient. We randomly allocated the study participants to receive either three drops of ginger oil (110 mg Zingiber officinale) or three drops of a placebo control oil placed on their laryngeal mask before insertion. We used a postoperative nausea and vomiting (PONV) and a visual analog scale (VAS) scores as outcome measures and compared the scale results with the dose of morphine used by the patient. The results of the multivariate analysis of variance showed that the ginger oil had a significant effect on PONV/VAS scores, V = 0.87, F(3, 16) = 34.78, p < .001. The results of the univariate analysis of variance showed that using the ginger oil provided significant treatment effects on PONV, F(1, 18) = 73.05, p < .001. These results are also reflected in the descriptive statistics. The mean PONV score for the experimental group and the control group was 1.70 ± 0.48 and 4.20 ± 0.79, respectively. The mean VAS score for the experimental group and the control group was 5.0 ± 1.63 and 5.9 ± 2.33, respectively. The results of our study showed that ginger oil has an important role in preventing PONV and reducing the use of postoperative opioids in women who have undergone breast augmentation surgery.

Retroperitoneal fibrosis-the long and winding path.

Retroperitoneal fibrosis (RPF) is a rare systemic disease. Two-third of the cases are idiopathic but assumed to have autoimmune process related to IgG-4. It is often a diagnosis of exclusion due to its non-specific clinical presentation. Early manifestation commonly causes back pain, raised erythrocyte sedimentation rate level and renal impairment. Investigations of choice are MRI and contrast-enhanced CT but biopsy should be performed for diagnostic confirmation. This case report describes a delay in diagnosing RPF in a 57-year-old female who initially presented to primary care with back pain, mild anaemia, raised erythrocyte sedimentation rate and progressive renal function decline. She was seen urgently in haematology clinic who arranged bone scan to rule out osteoblastic metastases, finding demonstrated possible pelviureteric junction dysfunction. The investigation was followed by a MAG3 renogram 4 weeks later instead of an abdominal CT leading to diagnostic delay. She then presented acutely 1 day after renogram with life-threatening hyperkalaemia and AKI 3. RPF was then suspected. Renal ultrasound scan and CT scan consecutively showed bilateral gross hydronephrosis and retroperitoneal mass around the aorta. The pelviureteric junction dysfunction was due to ureters getting embedded into the dense retroperitoneal fibrous tissue. She subsequently underwent bilateral ureteric stent placement and was commenced on steroid therapy, with satisfactory outcome on follow-up. Laparoscopic retroperitoneal biopsy later confirmed the diagnosis. This case not only highlighted important learning points on the presenting features and radiographic findings of RPF, but also the clinician's cognitive biases leading to diagnostic delay of a rare but life-threatening disease.

Safety and Efficacy of Subfascial Calf Augmentation.

BACKGROUND: Calf augmentation surgery is one of the least popular procedures among plastic surgeons; in contrast, it is by far one of the most gratifying procedures among patients. In this article, the authors present a retrospective analysis of a surgeon's extensive experience with calf implants. METHODS: The authors retrospectively analyzed 134 patients having calf augmentation for cosmetic and reconstructive surgery in their practice from 2003 to 2015. All patients were divided into two groups: primary cases and patients who had previously been operated on and who were referred to our service as patients who had complications after calf augmentation surgery. The subfascial approach was the preferred approach by authors for all primary cases. The authors analyzed indications, complication rates, results, and pitfalls. Secondary cases were further divided into three groups according to the origin of the problem and some possible solutions. RESULTS: Subfascial calf augmentation surgery is safe and easy to reproduce, with a short recovery period and a low complication rate (<1 percent). To achieve the best aesthetic results, surgeons should choose appropriate implants for each case. In secondary cases, fat grafting is a powerful tool and can be used alone or in combination with calf implants. CONCLUSIONS: There are several groups of patients seeking calf augmentation surgery (e.g., bodybuilders, women, those with reconstructive problems). Therefore, treatment should be planned individually. The development of a new implant is necessary and should be based on detailed anatomical findings and in accordance with surgical techniques. The process is intriguing and rewarding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.