Topical Tranexamic Acid Does Not Reduce The Incidence Of Hematoma In Reduction Mammoplasty: A Double-Blinded, Randomized Placebo-Controlled Trial.

BACKGROUND: Breast reduction mammoplasty (BRM) is among the most common procedures in plastic surgery, with a 1-7% postoperative hematoma incidence reported. Tranexamic acid (TXA) has been shown to reduce perioperative bleeding and need for transfusion when administered intravenously or topically, but remains underutilized in plastic surgery. This study aims to investigate whether topical administration of topical TXA reduces postoperative hematoma following BRM. METHODS: A double-blinded, randomized controlled trial of 98 patients (196 breasts) undergoing bilateral primary reduction mammoplasty at a single academic institution was performed. Patients were used as internal matched controls, with one breast randomized to receive 1000mg of topical TXA before closure, and the other receiving saline. All members of the surgical team and patient were blinded as to which breast received the study drug. Postoperative complications, including hematoma, within 30 days of surgery, drain outputs, and duration of drain use, were compared between treatment and placebo breasts. RESULTS: The overall hematoma rate was 1.5%. There was no significant association between application of TXA and development of a hematoma (p=0.56) or other complications. The hematoma rate of patients enrolled in the trial was similar to the overall rate of hematoma during the study time period (1.5% versus 2.4%, p=0.511). In a multivariate model, TXA was not significantly associated with differences in drain output after controlling for resection weight, age, and duration of drain use (p=0.799). No adverse effects or thromboembolic events from TXA were observed. CONCLUSION: Topical application of TXA does not decrease the incidence of hematoma following reduction mammoplasty.

Topical Nitroglycerin Ointment Reduces Mastectomy Flap Necrosis in Immediate Autologous Breast Reconstruction.

BACKGROUND: Mastectomy flap necrosis (MFN) is a common complication of immediate breast reconstruction that greatly affects patient satisfaction and cosmetic outcomes. Topical nitroglycerin ointment, with its low cost and negligible side effects, has been shown to significantly decrease the incidence of MFN in immediate implant-based breast reconstruction, but its utility has not been studied in immediate autologous reconstruction. METHODS: With institutional review board approval, a prospective cohort study was performed of all consecutive patients undergoing immediate free-flap breast reconstruction by a single reconstructive surgeon at a single institution between February of 2017 and September of 2021. Patients were divided into two cohorts: those who received 30 mg of topical nitroglycerin ointment to each breast at the conclusion of the operation (September of 2019 to September of 2021) and those who did not (February of 2017 to August of 2019). All patients underwent intraoperative SPY angiography, and mastectomy skin flaps were débrided intraoperatively based on imaging. Independent demographic variables were analyzed, and dependent outcome variables included mastectomy skin flap necrosis, headache, and hypotension requiring removal of ointment. RESULTS: A total of 35 patients (49 breasts) were included in the nitroglycerin cohort and 34 patients (49 breasts) were included in the control group. There was no significant difference in patient demographics, medical comorbidities, or mastectomy weight between cohorts. The rate of MFN decreased from 51% in the control group to 26.5% in the group that received nitroglycerin ointment ( P = 0.013). There were no documented adverse events associated with nitroglycerin use. CONCLUSION: Topical nitroglycerin ointment significantly decreases the rate of MFN in patients undergoing immediate autologous breast reconstruction without significant adverse effects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Postoperative pain and opioid use after breast reduction with or without preoperative nerve block.

BACKGROUND: Physician-prescribed opioids have been implicated as key contributing factors in the current opioid epidemic in the United States. Breast reduction mammoplasty is one of the most commonly performed procedures in plastic surgery and patients are often prescribed large amounts of postoperative opioids. Here we investigate the effects of erector spinae nerve blocks on postoperative pain, opioid consumption, and quality of life after breast reduction. METHODS: Following the institutional review board (IRB) approval, a prospective cohort study of some patients undergoing breast reduction mammoplasty at Montefiore Medical Center between June and September 2019 was undertaken. The patients were stratified into two cohorts for further analysis: those who received preoperative erector spinae nerve block and those who did not. Primary outcomes measures analyzed included Likert pain scores, patient-reported outcome measures, and opioid consumption for the first five postoperative days. RESULTS: Forty-seven patients were enrolled in the analysis. Thirteen patients (28%) received nerve blocks, 34 (72%) did not. On average, the patients were prescribed 114.3 (±34.6) morphine equivalents postoperatively and they consumed 45% (±35.3) by the end of the first five days post-surgery. There were no significant differences between cohorts in morphine equivalents prescribed or consumed, postoperative pain scores, or patient-reported outcome measures. CONCLUSIONS: Following breast reduction mammoplasty, patients on average consumed < 50% of prescribed opioids, suggesting over-prescription of postoperative opioids for breast reduction recovery. Preoperative nerve block did not improve pain scores or decrease opioid consumption for the first five days after surgery.

Do larger reductions yield larger returns? patient-reported outcomes as a function of specimen weight in bilateral reduction mammoplasty.

BACKGROUND: Patients undergoing breast reduction mammoplasty for symptomatic macromastia have a significantly improved quality of life postoperatively. However, there are no data that examine the effect of reduction mammoplasty on quality of life as a function of the weight of tissue removed. Because the process by which insurance providers consider patients' candidacy for this breast reduction mammoplasty is most often based on the proposed weight of tissue to be removed, this gap in our understanding is particularly glaring. We therefore designed a prospective trial with the intent of investigating the correlation between breast reduction specimen weight and postoperative pain and quality of life. METHODS: After obtaining institutional review board (IRB) approval, patients presenting for breast reduction mammoplasty at a single academic medical center between January 2016 and September 2019 were prospectively enrolled in the study. Study participants completed the Numerical Pain Rating Scale (NPRS), the short-form McGill Pain Questionnaire (SF-MPQ), and the BREAST-Q at set time points (preoperatively, 1 week/1 month/3 months/6 months postoperatively). Patients were divided into three cohorts based on breast reduction specimen weights: small (<500 g reduction), intermediate (500-1000 g reduction), and large (>1000 g reduction). The surveys were then analyzed while controlling for demographic factors and complications. RESULTS: A total of 85 women were enrolled in the study and completed pre- and postoperative surveys (small reduction n = 21 (25%), intermediate n = 45 (53%), and large n = 19 (22%)). Regardless of reduction specimen weight, patients reported decreased overall pain and increased satisfaction with their breasts, as well as improved psychosocial, sexual, and physical well-being at each postoperative visit. Preoperative SF-MPQ pain scores were significantly lower in the small specimen weight group compared with either the intermediate or the large group (p = 0.001). Postoperatively, both the intermediate and large groups reported significant improvement in pain at each time point. The small specimen weight group did not report significant pain improvement until 3 months postoperatively. CONCLUSIONS: Patients undergoing breast reduction mammoplasty experience decreased pain and improved quality of life regardless of reduction specimen weight. Improvement in these parameters manifests as early as 1 week postoperatively and maintained at 3 months postoperatively. These data suggest that many patients who are denied coverage for reduction mammoplasty on the basis of low projected reduction specimen weight would derive significant benefit from the procedure.

Analysis of Immediate versus Delayed Sternal Reconstruction with Pectoralis Major Advancement Versus Turnover Muscle Flaps.

BACKGROUND: The pectoralis major muscle flap is a versatile reconstructive option for deep sternal wound infections (DSWI). The timing and surgical technique of bilateral pectoralis major muscle advancement flaps versus unilateral pectoralis major muscle turnover and unilateral pectoralis major muscle advancement flap on patient outcomes remain to be elucidated. The purpose of this investigation was to compare timing, immediate versus delayed reconstruction, and the surgical technique in patients with deep sternal wounds infections on patient outcomes. METHODS: A retrospective review of patients who underwent sternal reconstruction with pectoralis major muscle was conducted. Patients diagnosed with DSWI after undergoing cardiac surgery were included for analysis. Patients were divided by flap timing and flap type for analyses. Bivariate tests were performed to compare patient clinical characteristics. Outcomes of interest were rates of postoperative complications, same admission mortality, reoperation, readmission, operating room time, and length of stay. RESULTS: A total of 88 patients were included for analyses (n = 57 bilateral advancement, n = 31 unilateral advancement with unilateral turnover; n = 62 immediate, and n = 26 delayed). Baseline characteristics did not differ between groups of flap type or timing. When postoperative complication rates were compared, the rate of tissue necrosis was significantly greater in patients with unilateral advancement with unilateral turnover flaps (n = 6 [19.4%]) compared with bilateral advancement flaps (n = 2 [3.5%]; p = 0.021). Mortality during admission did not differ with respect to flap type but differed significantly with respect to flap timing (immediate n = 7 [11.3%], delayed n = 9 [34.6%]; p = 0.015). Length of stay differed significantly by both type and timing (type: bilateral advancement = 26.9 ± 22.6 days, unilateral turnover = 38.0 ± 26.7 days, p = 0.042; timing: immediate = 26.8 ± 22.1 days, delayed = 40.2 ± 27.8, p = 0.019). CONCLUSION: Patients who underwent pectoralis major muscle advancement flaps had lower incidence of tissue necrosis. Furthermore, the timing of immediate sternal reconstruction was associated with a decreased hospital length of stay.

Patient-Reported Satisfaction and Quality of Life in Postmastectomy Radiated Patients: A Comparison between Delayed and Delayed Immediate Autologous Breast Reconstruction in a Predominantly Minority Patient Population.

BACKGROUND: Delayed immediate (DI) autologous breast reconstruction consists of immediate postmastectomy tissue expander placement, radiation therapy, and subsequent autologous reconstruction. The decision between timing of reconstructive methods is challenging and remains to be elucidated. We aim to compare patient reported outcomes and quality of life between delayed and DI reconstruction. METHODS: A retrospective review of all patients, who underwent autologous breast reconstruction at Montefiore Medical Center from January 2009 to December 2016, was conducted. Patients who underwent postmastectomy radiotherapy were divided into two cohorts: delayed and DI autologous breast reconstruction. Patients were mailed a BREAST-Q survey and their responses, demographic information, complications, and need for revisionary procedures were analyzed. RESULTS: A total of 79 patients met inclusion criteria: 34.2% (n = 27) in the delayed and 65.8% (n = 52) in the DI group. 77.2% (n = 61) of patients were a minority population. Patients in each cohort had similar baseline characteristics; however, the DI cohort was more likely to have bilateral reconstruction (46.2% [n = 24] vs. 7.4% [n = 2]; p = 0.0005) and to have major mastectomy flap necrosis (22.4% [n = 17] vs. 0.0% [n = 0]; p = 0.002). Premature tissue expander removal occurred in 17.3% (n = 9) of patients in the DI group. BREAST-Q response rates were 44.4% (n = 12) in the delayed group and 57.7% (n = 30) in the DI group. Responses showed similar satisfaction with their breasts, well-being, and overall outcome. CONCLUSION: Delayed and DI autologous breast reconstruction yield similar patient-reported satisfaction; however, patients undergoing DI reconstruction have higher rates of major mastectomy necrosis. Furthermore, patients in the DI group risk premature tissue expander removal.

Population Health Implications of Medical Tourism.

BACKGROUND: Fifteen million U.S. patients each year seek medical care abroad; however, there are no data on outcomes and follow-up of these procedures. This study aims to identify, evaluate, and survey patients presenting with complications from aesthetic procedures abroad and estimate their cost to the U.S. health care system. METHODS: A single-center retrospective review was conducted. A cohort of patients presenting with complications from aesthetic procedures performed abroad was generated. Demographic, complication, and cost data were compiled. Patients were surveyed to assess their overall experience. RESULTS: Over a 36-month period, 42 patients met inclusion criteria (one man and 41 women), with an average age of 35 ± 11.4 years (range, 20 to 60 years). Comorbidities included four active smokers, two patients with hypertension, and one patient with diabetes. Average body mass index was 29 ± 4.4 kg/m (range, 22 to 38 kg/m). Procedures performed abroad included abdominoplasty (n = 28), liposuction (n = 20), buttock augmentation (n = 10), and breast augmentation (n = 7), with several patients undergoing combined procedures. Eleven patients presented with abscesses and eight presented with wound dehiscence. Eight of the 18 patients who were surveyed were not pleased with their results and 11 would not go abroad again for subsequent procedures. Average cost of treating the complications was $18,211, with an estimated cost to the U.S. health care system of $1.33 billion. The main payer group was Medicaid. CONCLUSIONS: Complications from patients seeking aesthetic procedures abroad will continues to increase. Patients should be encouraged to undergo cosmetic surgery in the United States to improve patient outcomes and satisfaction and because it is economically advantageous. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Do acellularized dermal matrices change the rationale for immediate versus delayed breast reconstruction?

This article focuses on the contribution of acellular dermal matrices (ADMs) to immediate breast reconstruction. The current literature on ADMs is reviewed and the potential advantages and disadvantages of their use are highlighted. Technical considerations on how to effectively use these materials is presented.

Successful non-operative management of an iatrogenic recto-urethral fistula in a 13-year-old boy.

Here we present a case of successful non-operative management of an iatrogenic recto-urethral fistula in a 13-year-old boy. The fistula was created when urethroscopic repair of a urethral stricture was attempted. Due to the anatomy of the lesion and previous urinary diversion, it was deemed possible to spare this patient diverting colostomy or surgical repair of the fistula. The result was successful closure of the fistula, which was confirmed on retrograde urethrogram. While we do not support the routine use of non-operative management for recto-urethral fistulas we have demonstrated that there are circumstances where it can be safely applied.

Lower lid deformity secondary to autogenous fat transfer: a cautionary tale.

Although autogenous fat grafting is performed with increasing frequency, its safety around the periorbital area remains ill defined. This article presents the case of a young woman whose tear troughs were treated using autogenous fat transfer (AFT), with resultant bilateral lower lid deformities. Secondary correction of this aesthetic deformity caused by AFT to the tear trough proved extremely difficult and resulted in a temporary lower lid ectropion. After resolution of her ectropion, the patient was very satisfied with her postoperative appearance. The authors recommend a judicious approach to the correction of this deformity with AFT until objective outcome studies on this technique become more widely available.

Routine use of microvascular coupling device for arterial anastomosis in breast reconstruction.

BACKGROUND: Although microvascular coupling devices are used routinely and successfully for venous anastomosis, there are few published reports demonstrating their efficacy for performing arterial anastomosis. It has been the senior author's (C.Y.A.) preference to perform arterial anastomosis using the microvascular coupling device when feasible. METHODS: All microsurgical breast reconstructions performed by the senior author at the New York University Medical Center between 1998 and 2004 were retrospectively reviewed. A total of 60 patients underwent microsurgical breast reconstruction, of which 20 were bilateral, for a total of 80 flaps. RESULTS: Of the 80 flaps performed, there were 47 muscle-sparing TRAM and 22 deep inferior epigastric perforator (DIEP) flaps, and 11 were superior gluteal flaps. Arterial coupling was successfully performed in 60 of 69 flaps based on the deep inferior epigastric artery (87%) and 2 of 11 gluteal flaps (18%); arterial coupling was performed successfully 62 of 74 times (83.9%) when the thoracodorsal artery was the recipient vessel and never performed when the internal mammary artery was the recipient vessel. The overall flap success rate was 100%. CONCLUSIONS: In our large series, we were able to perform a coupled arterial anastomosis in nearly 80% of the cases, without the loss of any flaps. With proper vessel selection and sufficient experience using the microvascular coupler, arterial coupling may be performed in an expeditious, safe, and reliable fashion with minimal morbidity. Though not commonly practiced, use of the coupling device for arterial anastomosis can provide significant time savings, especially in bilateral breast reconstructions.

Nipple-areola reconstruction following chest-wall irradiation for breast cancer: is it safe?

Radiation therapy (RT) is considered by some to be a contraindication to nipple-areola reconstruction (NAR) particularly in patients with breast implant reconstruction. In this retrospective chart review, all patients who underwent breast reconstruction with tissue expanders and implants from 1997-2003 were reviewed. A subset of patients with a history of radiation therapy (pre- or postoperative) was identified. Postoperative complications, surgical technique, and the time course of reconstructive procedures were analyzed. Thirteen percent of patients with a history of RT had NAR compared with 36% of similarly reconstructed patients without a history of RT. Reconstruction was accomplished using a variety of local flaps, with an overall complication rate of 25%. Nipple-areola reconstruction after chest-wall irradiation in patients reconstructed with breast implants should be performed in carefully selected patients. Acceptable surgical candidates demonstrate resolution of acute radiation changes, no evidence of late radiation changes, and appropriate thickness of the mastectomy skin flaps.