Reduction mammaplasty: a safe and effective outpatient procedure.

Traditionally, reduction mammaplasty has been performed on an inpatient basis with a one to two day hospitalization. Many procedures once commonly performed on an inpatient basis have been shown to be safe and effective when performed in an outpatient setting. The purpose of this study was to determine if reduction mammaplasty could be performed safely on an outpatient basis and to compare findings between inpatient and outpatient groups. An outcome based retrospective review of patients who had bilateral reduction mammaplasty from 1989 to 1993 was performed at two centers. Minimum follow-up was nine months. Of 331 patients, 161 were outpatients and 170 were inpatients. Seventy-six percent of the surgeries were performed in the hospital and 24 percent at a free-standing surgical facility. There were no statistical differences between the two groups when comparing age, marital status, preoperative health status, operative technique, and resection weight. Evaluation of patient body weights, use of antibiotics, and complications did reveal statistical differences between the two groups. The inpatients were heavier, more likely to experience a complication, and less likely to receive antibiotics. There was, however, no difference between the two groups for incidence of rehospitalization, return to the emergency department, or reoperation.A patient satisfaction survey was conducted with both outpatient and inpatient groups reporting high satisfaction with their results. Over 95 percent of patients in both groups felt the experience was a positive one. The survey indicated high patient acceptance of breast reduction on an outpatient basis for the outpatient population. The data confirms that reduction mammaplasty is a safe and effective procedure when performed on an outpatient basis. The cost savings associated with outpatient surgery is significant and an important consideration in this era of health care reform.

Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction.

This retrospective study was designed to determine if reduction mammaplasty relieved preoperative symptoms in patients with macromastia. Seven-hundred and eighty women who had reduction mammaplasties between 1981 and 1992 were surveyed. Responses to questions concerning the preoperative and postoperative symptoms, breast size, complications, and satisfaction were elicited. Completed surveys were returned by 406 patients (52 percent) who had bilateral operations. The mean age at surgery was 38 years, with an average follow-up of 4.7 years. Preoperative complaints of shoulder grooving (94 percent), shoulder pains (93 percent), and back pains (81 percent) were significantly reduced following surgery (McNemar test, p < 0.0001). Cup size decreased an average of two sizes in 72 percent. There were 215 women (53 percent) with postoperative complications, and although most were minor, 20 (5 percent) required surgical correction. Self-esteem improved in 358 (88 percent), and most would have surgery again (93 percent) and would encourage others to have the same (94 percent). Reduction mammaplasty decreases breast size and significantly relieves preoperative symptoms associated with mammary hypertrophy. Relief of symptoms was the most common reason women gave for having the operation, and 87 percent were satisfied with the results despite frequent minor postoperative complications.

Anticoagulants and hematomas in free flap surgery.

A review of systemic anticoagulant use in 517 free flap procedures was performed to determine the associated risk of hematoma formation. Patients were divided retrospectively (not randomly) into five groups: no anticoagulation (227 flaps, 5.3 percent hematomas), low-dose heparin bolus of 2000 to 3000 units and postoperative infusion at a rate of 100 to 400 units/hr for 5 to 7 days (192 flaps, 6.7 percent hematomas), intraoperative bolus of 5000 units of heparin without postoperative anticoagulation (46 flaps, 6.5 percent hematomas), high-dose heparin infusion at a rate of 500 to 1200 units/hr (30 flaps, 20 percent hematomas), and dextran 40 infusion at a rate of 25 ml/hr (22 flaps, 9.1 percent hematomas). Intraoperative blood loss was similar for all groups. The flap loss rate was lower in the bolus (1.0 percent) and low-dose (1.0 percent) heparin groups than in the no-anticoagulation group (4.4 percent), but this difference was not statistically significant. The pedicle thrombosis rate also was lower in the bolus (2.2 percent) and low-dose (2.1 percent) heparin groups than in the no-anticoagulation group (6.2 percent). A cause-and-effect relationship between the use of anticoagulants and flap loss or prevention of thrombosis could not be established. We can conclude, however, that the use of low-dose heparin does not increase significantly the risk of hematoma or intraoperative bleeding.

Reconstruction of the pharynx and cervical esophagus using free jejunal transfer.

Although FJT has been perceived as unreliable, current FJT survival rates of 94% or greater, FJT salvage rates of up to 100%, and perioperative mortality of 6% or less demonstrate that FJT is a safe, reliable, one-stage method of reconstructing partial and circumferential pharyngoesophageal defects. FJT is associated with some morbidity; however, the procedure is well tolerated, and swallowing function is restored in 80% or more of patients within an average of 9 to 12 days after surgery. The success of the technique requires careful attention to details, such as designing the flap to avoid vein grafts, selecting large recipient vessels with high blood flow, careful in setting of the flap, meticulous microvascular anastomotic technique, close postoperative monitoring, and early, aggressive treatment of infection. If FJT failure should occur, a repeat FJT should be performed in the immediate postoperative period to increase the possibility of salvage and to decrease the risk of infection and mortality.

Influence of prior radiotherapy on the development of postoperative complications and success of free tissue transfers in head and neck cancer reconstruction.

The purpose of this study was to determine whether prior radiotherapy had any effect on the development of postoperative complications in patients undergoing microvascular tissue transfers for reconstruction of head and neck cancer. A prospective database was used to review 354 consecutive patients who had a total of 368 free tissue transfers limited to the head and neck during the 4-year period from July 1988 to June 1992. Postoperative complications in 167 patients who received preoperative radiotherapy (XRT) were compared with those of 187 patients who did not undergo radiotherapy preoperatively (NR). No statistical differences in complications or flap loss between the two groups were noted using the chi 2 test or Fisher's exact test (p > 0.2). Total flap loss occurred in 5.3% of the XRT group (9 of 169) and 5.0% of the NR patient group (10 of 199), and partial flap loss occurred in 4.1% of the irradiated patients and 2.5% of the nonirradiated patients. Major wound complications requiring additional surgery occurred in 16% of the XRT group and 11% of the NR group. Minor wound complications that did not require further surgery occurred in 21% of the irradiated patients and 18% of the nonirradiated patients. No significant difference in the timing or dose of preoperative radiation, previous neck dissection, or anastomotic type could be documented in failed versus successful flaps (two-tailed t-test, p > 0.80, and chi 2, p > 0.2). Our results show that, in a large group of cancer patients undergoing free tissue transfers to the head and neck, prior radiotherapy or surgery did not predispose them to a higher rate of acute flap loss or wound complications than their nonirradiated cohorts.

Capsular tissue: a new local flap.

Capsular tissue, the interface that forms between an implanted device and the body's own soft tissues, has recently been shown to develop its own unique blood supply. This capsular tissue with its extensive vascular plexus has not been described previously as an isolated flap. The purpose of our study was to determine whether an isolated flap of capsular tissue would survive as a local pedicle flap and provide enough inherent vascularity to support a skin graft. Isolated expanded and nonexpanded capsular flaps were compared by using 20 expanders (10 expanded and 10 nonexpanded) in two mixed-breed female pigs. Expanded and nonexpanded capsular flaps were elevated 8 weeks following expander placement. These flaps were raised on their capsular bases alone, and skin grafts were placed onto the capsular surfaces. All the expanded capsular flaps and their skin grafts had 100 percent survival. Skin grafts on the nonexpanded flaps survived an average of 28 percent, with graft survival corresponding to flap survival. This study confirms that flaps of isolated expanded capsular tissue survive and provide enough inherent vascularity to support a split-thickness skin graft.

Symptomatic neuroepithelial (colloid) cysts of the third ventricle. A unique case report in nontwin brothers.

Colloid cysts are relatively rare benign tumors comprising less than 2% of all intracranial mass lesions. However, since the advent of computed tomography of the head, these tumors are being recognized more frequently, occasionally before their symptomatic presentation. Much controversy remains as to the true cells of origin and pathogenesis of these cysts. Although a neuroepithelial origin has become increasingly accepted, Rathke cleft cysts, ectopic respiratory tissue, and other endodermal sources have been postulated. The first familial occurrence in middle-aged identical twin brothers was cited recently in the literature. Described here are the first reports of symptomatic colloid cysts in two nontwin brothers, lending further support to the potential for genetic expression of neuroepithelial cysts. Also included are preoperative computed axial tomographic images, histopathologic photomicrographs with case descriptions and comparisons, and suggestions to elucidate further the development and presentation of colloid cysts.