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.

Analysis of Body Contouring and Sustained Weight Loss in a Diverse, Urban Population: A 7-Year Retrospective Review.

BACKGROUND: Studies demonstrating the positive impact of body contouring on sustained weight loss in bariatric patients describe a narrow cohort. The authors sought to evaluate the impact of postbariatric body contouring procedures on sustained weight loss in minority race patients. METHODS: A retrospective review of bariatric surgery patients at a single institution was performed. Patients were grouped as follows: (1) those who underwent body contouring, (2) those who had consultation but did not undergo body contouring, and (3) those without consultation. Body mass index (BMI) and excess body weight loss (EBWL) over 7 years were the primary outcomes. RESULTS A TOTAL OF: 2531 patients were analyzed: 350 in group 1, 364 in group 2, and 1817 in group 3. At postoperative year 7, groups 1 and 2 had average BMIs 4.71 and 2.31 kg/m 2 lower than group 3, respectively, while adjusting for covariates. After exclusion of 105 patients in group 2 who were not offered body contouring because of inadequate weight loss, however, group 2 had an average BMI 4.07 kg/m 2 lower than group 3 at postoperative year 7. During postoperative year 1, group 1 had an average EBWL of 74.38%, which declined 1.51% yearly, and group 2 had an average EBWL of 70.12%, which declined 1.86% yearly. After exclusion of the aforementioned patients, group 2 had an average EBWL of 74.9% at postoperative year 1, which declined 1.88% yearly. CONCLUSIONS: Body contouring after bariatric surgery did not impart a clinically significant, long-term sustained weight loss benefit in the authors' cohort. In the authors' study population, patients identifying as black had significantly worse sustained weight loss. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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.

Revisiting the internal mammaries as recipient vessels in breast reconstruction: considerations in current practice.

BACKGROUND: The internal mammary artery (IMA) has supplanted the thoracodorsal artery as the primary recipient vessel in autologous breast reconstruction. Additionally, the IMA continues to be the preferred bypass graft choice in patients undergoing coronary artery bypass grafting (CABG). However, practice patterns in breast reconstruction have evolved considerably since the adoption of the IMA for this application. The authors sought to evaluate the safety of IMA harvest for breast reconstruction in our current practice, given the possibility that patients may require CABG in the future. METHODS: The authors reviewed the prospective database of free flaps for breast reconstruction performed at their center from 2009 to 2017. Patients were divided into three groups (2009-2011, 2011-2013, 2014-2017) and compared on the basis of demographics, medical comorbidities, and laterality of reconstruction. Patients were further risk stratified for 10-year risk of cardiovascular events using the American College of Cardiology's atheroscletoric and cardiovascular disease (ASCVD) risk calculator. RESULTS: There was a marked increase in the number of patients who underwent microsurgical breast reconstruction at our institution over the past three years (2009-2011, n = 55; 2012-2014, n = 50; 2015-2017, n = 145). The distribution of unilateral versus bilateral flaps changed meaningfully; however, they did not change statistically significantly over the study period (2009-2011 = 32.7%, 2012-2014 = 28.0%, 2015-2017 = 49.0%, p = 0.12). The rise in bilateral reconstructions over the study period is commensurate with the observed significant rise in contralateral prophylactic mastectomies (2009-2011 = 25.5%, 2012-2014 = 20.0%, 2015-2017 = 42.1%, p = 0.022). The mean 10-year risk of major cardiovascular events in the entire sample was 6.3 ± 7.1% (median 4.0%). The maximum individual risk score exceeded 25% in all three groups. CONCLUSION: Given overall trends in breast reconstruction and the sometimes-elevated cardiac risk profiles of our patients, the authors recommend risk stratification of all patients using the proposed Breast Reconstruction Internal Mammary Assessment (BRIMA) scoring system and consideration of left internal mammary artery preservation in select cases.

Patient-Reported Satisfaction and Quality of Life in Obese Patients: A Comparison between Microsurgical and Prosthetic Implant Recipients.

BACKGROUND: Patients undergoing autologous breast reconstruction have higher rates of patient-reported satisfaction compared to patients undergoing prosthetic reconstruction. Obesity has been shown to increase postoperative complications in both microsurgical and implant reconstructions. The authors evaluated the effects of microsurgical breast reconstruction and prosthetic breast reconstruction on patient-reported outcomes and quality of life in obese patients. METHODS: A retrospective review of obese patients who underwent breast reconstruction from January of 2009 to December of 2017 was conducted. Patients were divided into two cohorts: microsurgical and two-stage tissue expander/implant-based reconstruction. BREAST-Q survey response, demographic information, complications, and need for revision procedures were analyzed. RESULTS: One hundred fifty-five patients met the inclusion criteria: 75 (48.4 percent) underwent microsurgical breast reconstruction and 80 (51.6 percent) underwent implant-based reconstruction. Cohorts were similar in body mass index, mean mastectomy specimen weight, laterality, indication for surgery, smoking status, and postoperative complications. Microsurgical reconstruction patients were younger (49.0 years versus 53.0 years; p = 0.02) and more likely to have delayed reconstruction [n = 70 (64.2 percent) versus n = 0 (0.0 percent); p = 0.0001]. BREAST-Q responses showed that microsurgery patients were more satisfied with their breasts (Q-Score of 63.4 ± 6.9 versus 50.8 ± 12.8; p = 0.0001), overall outcome (Q-Score 70.5 ± 13.0 versus 60.3 ± 10.8; p = 0.0001), and chest physical well-being (Q-Score of 69.1 ± 10.9 versus 63.8 ± 8.2; p = 0.01). CONCLUSIONS: Microsurgical breast reconstruction in obese patients yields higher satisfaction with breasts, overall outcomes, and chest physical well-being than implant-based reconstruction. Despite increased postoperative complications associated with obesity, microsurgical breast reconstruction appears to be a good choice for women who understand its risks and benefits and choose to proceed with it.

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.

Risk Factors for Postoperative Venous Thromboembolic Complications after Microsurgical Breast Reconstruction.

BACKGROUND: Venous thromboembolism (VTE) is a significant cause of postoperative morbidity and a focus of patient safety initiatives. Despite giving appropriate prophylaxis in accordance with the Caprini risk assessment model, we observed a high incidence of VTE in patients undergoing microsurgical breast reconstruction at our institution. To explore factors contributing to these events, we compared patients undergoing microsurgical breast reconstruction who sustained postoperative VTEs to those who did not. METHODS: A retrospective review of all patients who underwent microsurgical free flap breast reconstruction at Montefiore Medical Center from January 2009 to January 2016 was conducted. Patients were divided into two cohorts; those sustaining postoperative VTE and those who did not. Patients were compared based on demographics, comorbidities, operative time, estimated intraoperative blood loss, need for transfusion, volume of transfusion, and discharge on postoperative aspirin. RESULTS: A total of 133 patients underwent microsurgical breast reconstruction during the study period. Nine patients (6.8%) had postoperative VTE and there was one (0.8%) death. Patients having VTE were more likely to be Hispanic (33.3%, n = 3) in the VTE group versus 8.1% (n = 6) in the control group (p = 0.011), more likely to have an increased mean transfusion volume (455.5 ± 367.8 vs. 139.51 ± 221.7 mL, p = 0.03), and were more likely to be discharged without aspirin (77.8%, n = 7 and 58.1%, n = 72; p = 0.003). CONCLUSION: Patients sustaining postoperative VTE after microsurgical breast reconstruction are more likely to have an increased volume of blood transfusions and lack of discharge on postoperative aspirin.

Abdominal Contouring: Can the American Society of Anesthesiologists Classification System Help Determine When to Say No?

BACKGROUND: The purpose of this study was to determine whether the American Society of Anesthesiologists classification system could be used preoperatively to identify patients at high risk for complications after abdominal contouring. METHODS: Using the National Surgical Quality Improvement Program database from 2007 to 2012, patients undergoing abdominal contouring procedures were identified and stratified by American Society of Anesthesiologists class. The primary outcome was any complication within 30 days. Secondary outcomes included minor wound, major surgical, and medical complication. Adjusted odds ratios were calculated using logistic regression. RESULTS: A total of 3637 patients were analyzed; 14.6 percent of patients were class I, 59.1 percent were class II, 23.4 percent were class III, and 2.9 percent were class IV. Overall complication and mortality rates were 12 percent and 0.2 percent, respectively. There was a significant trend of increasing odds of any complication with increasing class (class I, OR, 1.0; class II, OR, 1.5; class III, OR, 2.5; class IV, OR, 5.6; p-trend < 0.001). This trend was seen consistently for minor wound complications, medical complications, and major surgical complications (p = 0.007, p = 0.005, and p = 0.001, respectively). CONCLUSIONS: The American Society of Anesthesiologists classification system, which is simple and universally applicable, appears to predict significant complications and can be used to rapidly screen patients before abdominal contouring. Furthermore, the authors' results can be used to inform patient-physician discussion about the risks incurred when undergoing these procedures based on their individual class. Together with optimization of high-risk patients, patient selection using American Society of Anesthesiologists classification may prevent complications and improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Single-stage maxillary and nasal floor reconstruction with the double-paddle rectus abdominis musculocutaneous free flap.

Palatal integrity is essential for useful speech, deglutition, good oral hygiene, and prevention of nasal regurgitation. Maxillary defects after tumor extirpation, therefore, can have serious functional and cosmetic implications. Given the often disappointing results obtained with local and regional pedicled flaps for maxillary reconstruction, a variety of microvascular free flaps have been utilized in recent years, including the rectus abdominis, fibular, radial forearm, and latissimus dorsi flaps. Experience with these techniques has been documented in a limited number of case reports. We describe our single-stage approach to maxillary and nasal floor reconstruction with the double skin-paddle rectus abdominis musculocutaneous free flap. A series of five patients is presented; six of these immediate free flap reconstructions were performed for defects resulting from tumor resection. A vertical rectus abdominis musculocutaneous free flap was used in all cases, designing two separate skin paddles to accommodate the measured maxillary and nasal floor deficiencies. Anastomoses of the deep inferior epigastric artery and vena comitans were performed end-to-end to the facial artery and vein, respectively. In addition, orbital floor reconstruction with calvarial bone grafts or titanium mesh was performed in all five patients. Separation of the oral and nasal cavities was maintained postoperatively. No intraoperative complications, perioperative mortalities, flap losses, instances of skin paddle necrosis, hematomas, or oronasal fistulae were observed. One patient required bedside drainage of a surgical site abscess that resolved without adverse sequelae. Over the past 4 years, the double skin-paddle rectus abdominis musculocutaneous free flap has provided reliable results at our institution for single-stage reconstruction of maxillary and nasal floor defects. This reconstructive technique should be considered a viable method that can alleviate the functional and cosmetic debility associated with these defects.

Palmar arch revascularization for arterial occlusion of the distal upper extremity.

During a period of nine years, 10 patients, ages 42 to 66 years (55 +/- 7, mean +/- SD) underwent upper extremity bypass for ischemic changes to the hand not responsive to conservative management. Patients were referred from the vascular department at the authors' institution. Preoperative angiograms were performed and attempts at angioplasty or intravenous attempts to dissolve clots were carried out (with tissue plasminogen activator-tPA) when appropriate. Patients with persistent upper extremity ischemia and an obvious occlusion with reconstitution in the hand were candidates for upper extremity bypass to the palmar arch. All patients had upper extremity bypasses performed with reverse saphenous vein grafts. The proximal anastomoses (end-to-side) were performed by either the vascular or plastic surgery team, while all distal anastomoses (end-to-side) were performed by plastic surgery team microscopic magnification to the deep or superficial palmar arch. Postoperative follow-up ranged from 3 months to 3 years. The bypass graft to the hand resulted in improved pain and resolution of tissue ischemia in all cases. Patients with preoperative ulcers were completely healed by 3 months. The results are in accordance with previous studies demonstrating that improved blood flow afforded by the procedure can improve the healing of recalcitrant ulcers and mitigate the symptoms of ischemic changes. In addition, end-to-side anastomosis to the palmar arch offers significant advantages, in that the continuity of the arch is maintained with all possible outflow vessels, and the problems associated with size discrepancy in the anastomosed vessels are eliminated.