Can It Be Safe and Aesthetic? An Eight-year Retrospective Review of Mastopexy with Concurrent Breast Augmentation.

BACKGROUND: The safety of concurrently performing mastopexy and breast augmentation is controversial, due to the risk of breast tissue and nipple neurovascular compromise and overall potential high complications rates. This article describes a concurrent procedure of augmentation with implants and a "Tailor-Tack" mastopexy that consistently achieves an aesthetically pleasing breast with acceptable complication rates. METHODS: This is a retrospective chart review of all consecutive breast augmentations performed concurrently with mastopexy using the "Tailor-Tack" technique by the 2 senior authors (M.M. and O.T.) over an 8-year period. Independent variables were patient demographics, surgical approach, implant type, shape, size, duration of follow-up, and complications. Complications were categorized as "early" (ie, first 30 days) or "late" (ie, after 30 days). Potential early complications include hematoma, skin necrosis, infection, and nipple loss. Potential late complications include recurrent breast ptosis, poor shape of the nipple areolar complex, hypertrophic scarring, implant rupture, capsular contracture, decreased nipple sensation, implant extrusion, reoperation, and scar revisions. The key principle of the technique is to place the breast implant in the dual plane first, and then perform the tailor tacking of the skin for the mastopexy second. RESULTS: Fifty-six consecutive patients underwent augmentation and mastopexy over 8 years with this technique. The average age of the studied patients was 41.2 years. The average follow-up time period was 2.1 years (±8.9 months). Fifty-four patients (96.4%) had implants placed through the periareolar approach, 2 patients (3.6%) had implants placed via the inframammary approach. All implants were placed in a dual plane. Fifty-two patients (92.9%) received silicone implants and 4 patients (7.1%) received saline implants. Patient preference determined implant choice. All but 5 patients had textured implants. Average implant size was 277 cm3 (range 120-800 cm3). Ten patients had complications (17.9%). Complications included hypertrophic scarring in 5 (8.9%) patients; poor nipple-areola complex shape in 4 patients (7.1%); implant ruptures in 3 patients (5.4%); capsular contracture in 3 patients (5.4%); and recurrent ptosis in 2 patients (3.6%). There were no reported early complications such as nipple loss, breast skin necrosis, decreased nipple sensation, implant infections, or extrusions. However, 6 patients (10.7%) required return trips to the operating room for revisions, and 1 patient (1.8%) had a nipple areolar complex scar revised in the office, yielding a 12.5% surgical revision rate for the late complications. CONCLUSIONS: It is safe to concurrently perform mastopexy and breast augmentation. In our 8-year review, there were no early catastrophic complications such as skin loss, nipple loss, implant extrusion, or infection. The complications that occurred were the same complications known to occur with the independent performance of mastopexy alone or breast augmentation alone, and they occurred at rates comparable to or less than the national averages for those procedures when they are performed independently. The paramount principle for the success of this technique is to first adjust breast volume and then perform an intraoperatively determined skin resection to fit the new breast volume.

Stacked Lateral Thigh Perforator Flap as a Novel Option for Autologous Breast Reconstruction.

BACKGROUND: Autologous breast reconstruction using perforator flaps offers excellent outcomes, minimizes donor-site morbidity, and allows for precise donor-site selection. The deep inferior epigastric artery perforator, profunda artery perforator, and gluteal artery perforator flaps along with the stacked flap technique are the most common options. This study reports the first series of the stacked lateral thigh perforator flap. METHODS: A retrospective review of all stacked lateral thigh perforator flaps done by a single group of surgeons was performed. Demographics, flap weights, complications, indications, and surgical technique were tabulated for each patient. RESULTS: Eight female patients with a history of breast cancer underwent delayed unilateral breast reconstruction with stacked lateral thigh perforator flaps for a total of 16 flaps. Mean patient age, body mass index, flap weight, and stacked flap weight were 47.3 years, 26.2 kg/m, 333.1 g, and 666.1 g, respectively. Microsurgical revascularization was completed in anterograde and retrograde fashion to the internal mammary vasculature. Flap survival was 100 percent and one subsequent flap revision was performed. Two patients developed a seroma at the donor site. Indications included insufficient abdominal tissue, prominent lateral thigh lipodystrophy, prior abdominal surgery, and failed prior abdominally based autologous reconstruction. CONCLUSIONS: This series demonstrates that the lateral thigh perforator flap is a reliable and effective option for a stacked breast reconstruction. Its ease of harvest (stemming from reliable anatomy), straightforward dissection, and intraoperative positioning make it an appealing flap option. The stacked lateral thigh perforator flap allows the reconstructive surgeon to tailor breast reconstruction to the patient, focusing on body habitus and minimizing morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complications and liability related to regional and neuraxial anesthesia.

Regional anesthesia is responsible for approximately one-fifth of professional liability claims. The present investigation evaluated common and rare complications related to regional and neuraxial anesthesia, including postdural puncture headache, backache, transient neurological symptoms, inadvertent intrathecal injection, epidural hematoma and abscess, meningitis, arachnoiditis, postoperative urinary retention, local anesthetic systemic toxicity, and cardiac arrest. Regional anesthetic techniques are increasingly used in perioperative care of surgical patients for acute pain management and for chronic pain states. This manuscript also provides an overview and analysis of the existing literature and makes some recommendations in terms of strategies to prevent or minimize the potential patient injury, with a focus on those more commonly associated with patient injury and liability exposure. The role of ultrasound in preventing patient injury during regional anesthesia is also discussed.