Mastopexy for breast ptosis: Utility outcomes of population preferences.

BACKGROUND: Breast ptosis can occur with aging, and after weight loss and breastfeeding. Mastopexy is a procedure used to modify the size, contour and elevation of sagging breasts without changing breast volume. To gain more knowledge on the health burden of living with breast ptosis requiring mastectomy, validated measures can be used to compare it with other health states. OBJECTIVE: To quantify the health state utility assessment of individuals living with breast ptosis who could benefit from a mastopexy procedure; and to determine whether utility scores vary according to participant demographics. METHODS: Utility assessments using a visual analogue scale (VAS), time trade-off (TTO) and standard gamble (SG) methods were used to obtain utility scores for breast ptosis, monocular blindness and binocular blindness from a sample of the general population and medical students. Linear regression and the Student's t test were used for statistical analysis; P<0.05 was considered to be statistically significant. RESULTS: Mean (± SD) measures for breast ptosis in the 107 volunteers (VAS: 0.80±0.14; TTO: 0.87±0.18; SG: 0.90±0.14) were significantly different (P<0.0001) from the corresponding measures for monocular blindness and binocular blindness. When compared with a sample of the general population, having a medical education demonstrated a statistically significant difference in being less likely to trade years of life and less likely to gamble risk of a procedure such as a mastopexy. Race and sex were not statistically significant independent predictors of risk acceptance. DISCUSSION: For the first time, the burden of living with breast ptosis requiring surgical intervention was determined using validated metrics (ie, VAS, TTO and SG). The health burden of living with breast ptosis was found to be comparable with that of breast hypertrophy, unilateral mastectomy, bilateral mastectomy, and cleft lip and palate. Furthermore, breast ptosis was considered to be closer to 'perfect health' than monocular blindness, binocular blindness, facial disfigurement requiring face transplantation surgery, unilateral facial paralysis and severe lower extremity lymphedema. CONCLUSIONS: Quantifying the health burden of living with breast ptosis requiring mastopexy indicated that is comparable with other breast-related conditions (breast hypertrophy and bilateral mastectomy). Numerical values have been assigned to this health state (VAS: 0.80±0.14; TTO: 0.87±0.18; and SG: 0.90±0.14), which can be used to form comparisons with the health burden of living with other disease states.

HISTORIQUE: La ptose mammaire découle du vieillissement, d'une perte de poids et de l'allaitement. La mastopexie est une intervention utilisée pour modifier la taille, le contour et l'élévation des seins affaissés sans en modifier le volume. Pour en savoir plus sur le fardeau d'une ptose mammaire exigeant une mastectomie sur la santé, on peut utiliser des mesures validées pour la comparer à d'autres états de santé. OBJECTIF: Quantifier l'évaluation utilitaire de l'état de santé des personnes qui présentent une ptose mammaire et qui profiteraient d'une mastopexie et déterminer si les scores d'utilité varient selon la démographie des participants. MÉTHODOLOGIE: Les chercheurs ont utilisé des évaluations utilitaires au moyen d'une échelle analogique visuelle (ÉAV), de l'arbitrage temporel (AT) et de la méthode du pari standard (PS) pour obtenir les scores d'utilité de la ptose mammaire, de la cécité monoculaire et de la cécité binoculaire d'un échantillon de la population générale et d'étudiants dans une profession médicale. La régression linéaire et le test t de Student ont été utilisés pour l'analyse statistique. P<0,05 était considéré comme statistiquement significatif. RÉSULTATS: Les mesures moyennes (± ÉT) de la ptose mammaire de 107 volontaires (ÉAV : 0,80±0,14, AT : 0,87±0,18, PS : 0,90±0,14) étaient statistiquement différentes (P<0,0001) des mesures correspondantes de cécité monoculaire et de cécité binoculaire. Par rapport à un échantillon en population, des connaissances médicales démontraient une différence statistiquement significative dans la moins grande susceptibilité à échanger des années de vie et à parier sur le risque d'une intervention comme la mastopexie. La race et le sexe n'étaient pas statistiquement significatifs, quels que soient les prédicteurs d'acceptation du risque. EXPOSÉ: Pour la première fois, le fardeau de la ptose mammaire exigeant une intervention chirurgicale a été établi au moyen de mesures validées (ÉAV, AT et PS). Ainsi, le fardeau de la ptose mammaire sur la santé était comparable à celui de l'hypertrophie mammaire, de la mastectomie unilatérale, de la mastectomie bilatérale et de la fente labiopalatine. Par ailleurs, la ptose mammaire était considérée comme plus près de la « santé parfaite ¼ que la cécité monoculaire, la cécité binoculaire, la défiguration exigeant une transplantation faciale, une paralysie faciale unilatérale et un lymphœdème des membres inférieurs. CONCLUSIONS: La quantification du fardeau de la ptose mammaire exigeant une mastopexie sur la santé est comparable à d'autres problèmes mammaires (hypertrophie mammaire et mastectomie bilatérale). Des valeurs numériques ont été attribuées à cet état de santé (ÉAV : 0,80±0,14, AT : 0,87±0,18 et PS : 0,90±0,14), et peuvent être utilisées pour former des comparaisons avec le fardeau d'autres états pathologiques sur la santé.

Does acellular dermal matrix really improve aesthetic outcome in tissue expander/implant-based breast reconstruction?

BACKGROUND: The expectation for improved results by women undergoing postmastectomy reconstruction has steadily risen. A majority of these operations are tissue expander/implant-based breast reconstructions. Acellular dermal matrix (ADM) offers numerous advantages in these procedures. Thus far, the evidence to justify improved aesthetic outcome has solely been based on surgeon opinion. The purpose of this study was to assess aesthetic outcome following ADM use in tissue expander/implant-based breast reconstruction by a panel of blinded plastic surgeons. METHODS: Mean aesthetic results of patients who underwent tissue expander/implant-based breast reconstruction with (n = 18) or without ADM (n = 20) were assessed with objective grading of preoperative and postoperative photographs by five independent blinded plastic surgeons. Absolute observed agreement as well as weighted Fleiss Kappa (κ) test statistics were calculated to assess inter-rater variability. RESULTS: When ADM was incorporated, the overall aesthetic score was improved by an average of 12.1 %. In addition, subscale analyses revealed improvements in breast contour (35.2 %), implant placement (20.7 %), lower pole projection (16.7 %), and inframammary fold definition (13.8 %). Contour (p = 0.039), implant placement (p = 0.021), and overall aesthetic score (p = 0.022) reached statistical significance. Inter-rater reliability showed mostly moderate agreement. CONCLUSIONS: Mean aesthetic scores were higher in the ADM-assisted breast reconstruction cohort including the total aesthetic score which was statistically significant. Aesthetic outcome alone may justify the added expense of incorporating biologic mesh. Moreover, ADM has other benefits which may render it cost-effective. Larger prospective studies are needed to provide plastic surgeons with more definitive guidelines for ADM use. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Highest Impact Articles in Microsurgery: A Citation Analysis.

BACKGROUND: Microsurgery has developed significantly since the inception of the first surgical microscope. There have been few attempts to describe "classic" microsurgery articles. In this study citation analysis was done to identify the most highly cited clinical and basic science articles published in five peer-reviewed plastic surgery journals. METHODS: Thomson/Reuters web of knowledge was used to identify the most highly cited microsurgery articles from five journals: Plastic and Reconstructive Surgery, Annals of Plastic Surgery, Journal of Plastic, Reconstructive & Aesthetic Surgery, Journal of Reconstructive Microsurgery, and Microsurgery. Articles were identified and sorted based on the number of citations and citations per year. RESULTS: The 50 most cited clinical and basic science articles were identified. For clinical articles, number of total citations ranged from 120 to 691 (mean, 212.38) and citations per year ranged from 30.92 to 3.05 (mean, 9.33). The most common defect site was the head and neck (n = 15, 30%), and flaps were perforator and muscle/musculocutaneous flaps (n = 10 each, 20%, respectively). For basic science articles, number of citations ranged from 71 to 332 (mean, 130.82) and citations per year ranged from 2.20 to 11.07 (mean, 5.27). There were 27 animal, 21 cadaveric, and 2 combined studies. CONCLUSIONS: The most highly cited microsurgery articles are a direct reflection of the educational and clinical trends. Awareness of the most frequently cited articles may serve as a basis for core knowledge in the education of plastic surgery trainees. LEVEL OF EVIDENCE: III.

The ideal nasolabial angle in rhinoplasty: a preference analysis of the general population.

BACKGROUND: In aesthetic rhinoplasty, the described ideal nasolabial angle ranges from 90 to 120 degrees, with variable anthropologic differences. The authors sought to verify the most aesthetic nasolabial angle as specifically perceived by a random prospective sample of the general population and determine whether age, sex, race, and education were independent associated predictors. METHODS: The authors prospectively recruited 98 random volunteers from the general population. They were asked to rank three different nasolabial angles for the female nose (100, 105, and 110 degrees) and the male nose (90, 100, and 105 degrees) as "most," "moderately," and "least aesthetic." Demographic data were used to determine correlations between aesthetic preferences. Pearson chi-square test and t test were used to determine statistical significance RESULTS: The most aesthetic female nasolabial angle was 104.9±4.0 degrees. The most aesthetic male nasolabial angle was 97.0±6.3 degrees. Male subjects, younger volunteers, Native Americans, and African Americans preferred more acute male nasolabial angles (90 degrees). Female subjects, volunteers older than 50 years, college graduates, those with a previous rhinoplasty, and Caucasian and Asian subjects preferred more obtuse male nasolabial angles. CONCLUSIONS: In the authors' sample of the general population, the ideal and most aesthetic nasolabial angle ranged from 100.9 to 108.9 degrees in the female nose and 90.7 to 103.3 degrees in the male nose. Age, sex, race, education, and having undergone a previous rhinoplasty were predictors of differences in the ideal male nasolabial angle but did not change preference of the female nasolabial angle.

The interface of cosmetic medicine and surgery: working from the inside and the outside.

Minimally invasive or noninvasive procedures account for an overwhelming majority of cosmetic procedures. These procedures include botulinum toxin injections, soft tissue fillers, chemical peel, dermabrasion, and laser hair removal. This article reviews some of the principles involved in these procedures. Plastic surgeons need to be equally familiar with surgical and nonsurgical approaches to cosmetic medicine to provide a complete set of therapeutic options to their patients.

Infection risk from the use of continuous local-anesthetic infusion pain pumps in aesthetic and reconstructive abdominal procedures.

Postoperative pain control after abdominal procedures can be an area of significant concern. Continuous local-anesthetic infusion pain pumps have been clearly documented in recent literature to provide effective early postoperative pain control, in addition to other benefits. Our goal was to evaluate any increase in the risk of infection with the use of pain pumps with aesthetic and reconstructive abdominal procedures. A retrospective chart review evaluated 159 patients who underwent abdominoplasty (with or without suction-assisted lipectomy), panniculectomy, or a transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction. Information was collected on descriptive and demographic information, and the incidence of postoperative infection. Of the 159 patients who underwent abdominal procedures, 100 (62.9%) received the pain pump for postoperative pain control. None of those 100 patients developed an infection. Fifty-nine patients did not receive a pain pump, and 2 of those patients (3.3%) developed an infection. Overall, 1.3% (2 of 159) of patients in our study developed a postoperative infection. There is no increase in the risk of postoperative infection with the use of continuous local-anesthetic infusion pain pumps used after aesthetic and reconstructive abdominal procedures.

Continuous-infusion local anesthetic pain pump use and seroma formation with abdominal procedures: is there a correlation?

BACKGROUND: Seroma formation is the most commonly occurring complication in plastic surgery abdominal procedures. Continuous local anesthetic pain pump delivery systems are often used to decrease postoperative pain. An unreported concern with use of these devices in abdominal procedures is the effect of continuous fluid infiltration of the surgical site and a possible increase in the incidence of seroma formation. METHODS: The authors performed a retrospective chart review to evaluate all patients (n = 159) who underwent abdominal procedures (abdominoplasty, panniculectomy, and transverse rectus abdominis myocutaneous flap harvest) over a 3-year period. Patient charts were evaluated for sex, age, body mass index, procedure performed, surgeon, operation length, pain pump use, postoperative seroma formation, and any complications. In cases with pain pump use, catheter placement location, anesthetic medication and strength, continuous-infusion rate, and duration of pain pump use were also reviewed. If a postoperative seroma formation was identified, treatment and outcomes were also recorded. RESULTS: The overall seroma formation rate was 11.3 percent (18 of 159 patients). Other complications occurred at a rate of 2.5 percent (four of 159). The incidence of seroma was 11.0 percent (11 of 100) in patients with pain pump use versus 11.9 percent (7 of 59) in those who did not use a pain pump. There was no statistically significant difference (p = 0.9) in the incidence of seroma formation between those who did and did not use a pain pump device. CONCLUSION: There was no correlation between increased rate of seroma formation and use of a continuous-infusion local anesthetic pain pump system in our patient population.

Adolescent pneumopericardium and pneumomediastinum after motor vehicle crash and ejection.

A 15 year old male was an unrestrained passenger in a high speed motor vehicle crash followed by ejection. The patient was noted to have evidence of bilateral pneumothorax upon arrival in the Emergency Department. Bilateral chest tubes were placed under sterile conditions; however, the left pneumothorax remained, and a second left chest tube was placed. Repeat chest radiographs revealed extensive subcutaneous emphysema, pneumomediastinum, and pneumopericardium. Needle aspiration of the pericardium returned significant quantities of air, an immediate improvement in blood pressures followed. An 18-gauge triple lumen catheter was placed into the pericardial space for additional withdrawal of air via syringe. Mechanisms have been proposed to explain the development of tension pneumopericardium after chest trauma. Early diagnosis is crucial, and may be found on initial chest radiographs. Computed tomography is also an effective method for evaluating the presence of air in the pericardial space and may assist in establishing the diagnosis. Tension pneumopericardium requires immediate recognition and decompression to prevent cardiac tamponade with a fatal circulation collapse, an entity that is as serious as the tamponade resulting from hemopericardium. Traumatic pneumopericardium is rare, but can be a complicated finding associated with high-speed blunt chest trauma. Patients with evidence of pneumopericardium should be closely monitored, particularly those supported by positive pressure ventilation.

Three-step emergency cricothyroidotomy.

OBJECTIVE: Surgical cricothyroidotomy is the airway of choice in combat. It is too dangerous for combat medics to perform orotracheal intubation, because of the time needed to complete the procedure and the light signature from the intubation equipment, which provides an easy target for the enemy. The purpose of this article was to provide a modified approach for obtaining a surgical airway in complete darkness, with night-vision goggles. METHODS: At our desert surgical skills training location at Nellis Air Force Base (Las Vegas, Nevada), Air Force para-rescue personnel received training in this technique using human cadavers. This training was provided during the fall and winter months of 2003-2006. RESULTS: Through trial and error, we developed a "quick and easy" method of obtaining a surgical airway in complete darkness, using three steps. The steps involve the traditional skin and cricothyroid membrane incisions but add the use of an elastic bougie as a guide for endotracheal tube placement. We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal. CONCLUSIONS: Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.