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Plast Reconstr Surg ; 144(1): 18e-27e, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31246797


BACKGROUND: Reduction mammaplasty is a highly effective procedure for treatment of symptomatic macromastia. Prediction of resection weight is important for the surgeon and the patient, but none of the current prediction models is widely accepted. Insurance carriers are arbitrarily using resection weight to determine medical necessity, despite published literature supporting that resection weight does not correlate with symptomatic relief. What is the most accurate method of predicting resection weight and what is its role in breast reduction surgery? METHODS: The authors conducted a retrospective review of patients who underwent reduction mammaplasty at a single institution from 2012 to 2017. A senior biostatistician performed multiple regression analysis to identify predictors of resection weight, and linear regression models were created to compare each of the established prediction scales to actual resected weight. Patient outcomes were evaluated. RESULTS: Three-hundred fourteen patients were included. A new prediction model was created. The Galveston scale performed the best (R = 0.73; p < 0.001), whereas the Schnur scale performed the worst (R = 0.43; p < 0.001). The Appel and Descamps scales had variable performance in different subcategories of body mass index and menopausal status (p < 0.01). Internal validation confirmed the Galveston scale's best predictive value; 38.6 percent and 28.9 percent of actual breast resection weights were below Schnur prediction and 500-g minimum, respectively, yet 97 percent of patients reported symptomatic improvement or relief. CONCLUSIONS: The authors recommend a patient-specific and surgeon-specific approach for prediction of resection weight in breast reduction. The Galveston scale fits the best for older patients with higher body mass indices and breasts requiring large resections. Medical necessity decisions should be based on patient symptoms, physical examination, and the physician's clinical judgment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Mama/anormalidades , Hipertrofia/cirurgia , Adulto , Índice de Massa Corporal , Peso Corporal , Mama/cirurgia , Feminino , Humanos , Reembolso de Seguro de Saúde , Mamoplastia/métodos , Pessoa de Meia-Idade , Tamanho do Órgão , Análise de Regressão , Estudos Retrospectivos
Reprod Sci ; 26(9): 1243-1248, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30486735


OBJECTIVE: There is no consensus on which risk stratification approach to use for thromboprophylaxis in pregnancy, and most available risk assessment models (RAMs) for venous thromboembolism (VTE) events have not been validated in pregnancy. Our objective was to compare the performance of some of the most commonly used VTEs RAMs in our patient population in the peripartum period. STUDY DESIGN: This is a retrospective cohort of women who delivered at our institution in 2015 and 2016. We excluded patients with history of prior or current VTEs or those already receiving anticoagulants. Antepartum, intrapartum, and postpartum records were reviewed. Data were collected on known risk factors for VTEs in order to calculate scores for 3 RAMs on admission for delivery: Padua, Caprini, and Royal College of Obstetricians and Gynaecologists (RCOG). The primary objective was to the estimate the performance of the various RAMs in preventing postpartum VTEs. We calculated the proportion of women who would have been high risk, determined the number of VTEs cases within high- and low-risk categories, as well as calculated the number needed to treat (NNT) for each RAM. We performed analyses using different RAM scores cutoffs, VTEs outcome rates, and effectiveness of anticoagulation to prevent VTEs. The P value <.05 was considered statistically significant. RESULTS: A total of 6094 women were included. Three women had VTEs for an overall rate of 0.04% (N = 3; 95% confidence interval [CI]: 0.01-0.15). The proportion of women categorized as high risk for VTEs were 62% (95% CI: 61-64) for RCOG, 0.8% (95% CI: 0.6-1.0) for Padua, and 94% (95% CI: 94-95) for Caprini. Of the 3 VTEs, the RCOG model classified 1 woman as high risk and Padua model classified 3 women as high risk; whereas the Caprini did not identify any women as high risk. Assuming 100% effectiveness of thromboprophylaxis, the observed NNT was 3838 using RCOG, not able to calculate using Padua (no VTEs cases occurred in the high-risk group, thus none were prevented), and 1927 using Caprini. CONCLUSION: The rates of VTEs in pregnancy are very low and the available RAMs do not identify most of them. The RCOG and Caprini RAMs would categorize a large proportion of women as high risk and are associated with high NNTs. The Padua RAM appears to have the lowest NNT but missed all the VTEs in our cohort.

Ann Plast Surg ; 80(3): 223-227, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29095194


BACKGROUND: Postoperative pain control can be challenging in reduction mammaplasty patients. This study compares perioperative liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, Inc, San Diego, Calif) with standard local anesthetics to determine if liposomal bupivacaine decreases opioid and antiemetic use, impacting length of stay and complication rates, thus improving patient outcomes. METHODS: A retrospective review of 170 reduction mammaplasty patients was performed. Patients were divided into groups based on local anesthetic used (bupivacaine only and liposomal bupivacaine) and into subgroups based on obesity classification. Length of hospital stay; pain scores immediately postoperatively, at discharge, and at follow-up; and postoperative analgesics and antiemetics were compared. Further analysis was performed after weight stratification within pre- and postmenopausal categories. RESULTS: Liposomal bupivacaine resulted in less pain than bupivacaine immediately postoperatively and at discharge in obesity class I (P = 0.021 and P = 0.018). In obesity class II, antiemetic use was lower in the liposomal bupivacaine group (P = 0.012). Length of stay was persistently lower with liposomal bupivacaine for premenopausal women, and this difference was significant in obesity class I (P = 0.038). In premenopausal women, discharge pain scores were lower in the overweight liposomal bupivacaine group (P = 0.034) and analgesic use was lower in obesity class III (P = 0.004). CONCLUSIONS: Liposomal bupivacaine decreases postoperative pain, opioid, and antiemetic use in select patients. Liposomal bupivacaine might not be equally efficacious in pain reduction in obese or postmenopausal women given the theoretical increased absorption by adipose tissue. In addition, liposomal bupivacaine may have a dose-dependent effect, and weight-based dosing should be investigated.

Anestésicos Locais/administração & dosagem , Mama/anormalidades , Bupivacaína/administração & dosagem , Hipertrofia/cirurgia , Mamoplastia/métodos , Dor Pós-Operatória/prevenção & controle , Seleção de Pacientes , Adulto , Mama/cirurgia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Lipossomos , Pessoa de Meia-Idade , Medição da Dor , Estudos Retrospectivos , Texas
Plast Reconstr Surg ; 138(3 Suppl): 232S-40S, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27556767


BACKGROUND: Pressure ulcers (PUs) challenge many in the healthcare field requiring costly and complex care. PUs result from prolonged ischemia and subsequent soft-tissue injury caused by unrelieved pressure over a bony prominence. Proper risk assessment and implementation of prevention strategies for PUs are crucial to providing comprehensive care while reducing healthcare costs. The emphasis has led to the expansion of research in PU prevention technologies in the recent years. The aim of this review is to present an evidence-based summary of some of the new innovations in PU prevention. METHODS: A literature search was performed. Articles were included if the article discussed the cost, prevalence, assessment, diagnosis, and/or prevention of PUs. The literature search was limited to 2013 to 2016. RESULTS: A total of 1393 potential studies were identified using the search criteria. Three hundred fifty-three articles were reviewed and when possible, preference for inclusion was given to those studies with a higher level of evidence or those discussing novel ideas/innovations. CONCLUSION: The summary of topics explored includes the following: the use of risk assessment scales as an adjunct in risk identification, the benefit of alternative support surfaces to aid in prevention as compared with standard hospital mattresses, effective repositioning strategies, silicone prophylactic dressing for shear reduction, microclimate control, nutritional considerations, use of electrical stimulation for spinal cord injury patients, and the importance of patient participation.

Lesão por Pressão/prevenção & controle , Bandagens , Leitos , Terapia Combinada , Medicina Baseada em Evidências , Humanos , Apoio Nutricional , Assistência ao Paciente/métodos , Posicionamento do Paciente , Lesão por Pressão/etiologia , Medição de Risco , Fatores de Risco