Buffered Versus Nonbuffered Local Anesthetics and Local Pain Scores in Upper Eyelid Blepharoplasty: Randomized Controlled Trial.

PURPOSE: This split-face study aimed to see whether different types of local anesthetics or their buffered/nonbuffered combinations produce lower pain scores in upper eyelid blepharoplasty. METHODS: The study involved 288 patients, randomly divided into 9 groups: 1) 2% lidocaine with epinephrine-Lid + Epi; 2) 2% lidocaine with epinephrine and 0.5% bupivacaine (1:1)-Lid + Epi + Bupi; 3) 2% lidocaine with 0.5% bupivacaine (1:1)-Lid + Bupi; 4) 0.5% bupivacaine-Bupi; 5) 2% lidocaine-Lid; 6) 4% articaine hydrochloride with epinephrine-Art + Epi; 7) buffered 2% lidocaine/epinephrine with sodium bicarbonate (SB) in a 3:1 ratio-Lid + Epi + SB; 8) buffered 2% lidocaine with SB in a 3:1 ratio-Lid + SB; 9) buffered 4% articaine hydrochloride/epinephrine with SB in a 3:1 ratio-Art + Epi + SB. Following the injection of the first eyelid and a 5-minute period of soft pressure on the injection site, patients were asked to rate their pain level on the Wong-Baker Face Pain Rating Visual Analogue Scale. Rating of the pain level was repeated 15 and 30 minutes following anesthetic administration. RESULTS: The lowest pain scores at the first time point were observed in Lid + SB when compared with all of the other groups ( p < 0.05). At the final time point, significantly lower scores were also observed in Lid + SB, Lid + Epi + SB, and Art + Epi + SB when compared with the Lid + Epi group ( p < 0.05). CONCLUSION: These findings could help surgeons select an appropriate combination of local anesthetics, particularly in patients with lower pain threshold and tolerance because buffered combinations of local anesthetics produce significantly lower pain scores compared with nonbuffered solutions.

Management of Nipple-Areola Deformity.

BACKGROUND: Herniated or pseudoherniated nipple-areolar complex (NAC), also called protuberant or "domed nipple," is an entity that can be present both in males and females and represents a therapeutic challenge. It can be an isolated deformity, but in most cases is found within another breast deformity, such as tuberous breast or can appear following pregnancy. Its diagnosis and appropriate treatment become important when patients search for correctional breast surgery. OBJECTIVE: To review some common techniques for the treatment of tuberous breasts that address the nipple-areola problem as well, but also to present our experience with some newer and less invasive surgical techniques that could be useful for isolated treatment of herniated or pseudoherniated nipple. METHOD: We performed a retrospective study that included all patients operated from December 2013 to December 2018. We reviewed existing techniques which in addition to our personal experience helped us to create an algorithm to assist surgeons in this matter. RESULTS: A total of 125 patients with herniated or pseudoherniated NAC were treated. There were 87 women and 38 men. The average age of the patients was 30, 8 ± 8.1 years (ranging from 20 to 63). We analyzed the results of four following techniques: periareolar mastopexy (52 patients), release of fibrous tissue in combination with lipofilling (19 patients), resection of herniated breast tissue (23 patients) or controlled electrocoagulation of relaxed erectile muscle (31 patients). The minimum follow-up for all cases was 4 months. CONCLUSION: The achievement of a successful aesthetic result is possible in a single-stage procedure with initial surgery. It depends on careful individual preoperative evaluation of anatomical features and a surgical approach chosen accordingly. 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Safe Composite Calf Augmentation: A Staged Procedure.

BACKGROUND: Calf augmentation can be achieved by fat grafting, calf implants, or a combination of both methods (composite augmentation). For safety reasons, it is important to be aware of important calf anatomic features, specific physiologic considerations, and some health conditions that can hinder the outcome of these procedures. OBJECTIVES: The aim of this study was to present our experience with performing composite calf augmentation, and to describe indications, surgical techniques and safety issues. METHODS: We retrospectively analyzed 63 patients who had undergone composite calf augmentation for cosmetic and reconstructive surgery in our practice. We reviewed group demographics, complications, and results, and identified all the pitfalls encountered in our cases. Additionally, dissection of the calf regions in fresh cadavers was performed to obtain more accurate anatomy. We also measured intracompartmental pressures before and after calf augmentation with implants in 6 cases to determine pressure changes. RESULTS: All cases received subfascial implant insertion and fat grafting as a delayed procedure. If there is a need for multiple implants, we recommend a staged procedure. Our study showed high muscle sensitivity to pressure increase after augmentation. Hence, from the standpoint of safety, we advocate subcutaneous fat grafting only. No patients developed compartment syndrome. CONCLUSIONS: Composite calf augmentation surgery is safe and easy to reproduce, with a short recovery period and a low complication rate when done as a staged procedure and respecting specific anatomic and physiologic calf features.

Aesthetic Improvement of Undeveloped Calves After Treatment of Congenital Clubfoot Deformity.

BACKGROUND: Even when clubfoot deformity is treated in a timely manner, the consequences observed in adulthood include hypoplasia of the calf muscles, gait impairment, decreases in foot size, and it can also affect the tibial length. These consequences may have negative impacts on the patient's subjective appraisal of long-term outcomes, and can influence the patient's self-esteem in both male and female patients. OBJECTIVES: We present our experience in the treatment of undeveloped calves after surgical treatment of congenital clubfoot. METHODS: In total, 72 patients underwent corrective surgery in order to improve undeveloped calves resulting from a congenital clubfoot deformity. We used calf silicone implants in combination with fat grafting in multistaged procedures, in order to decrease complication rates and improve aesthetic outcome. RESULTS: Amongst our patients there were 54 (75%) females and 18 (25%) males. All of the patients, except one, had unilateral calf hypoplasia. The procedures were divided into several groups: (1) medial calf augmentation with silicone implants; (2) medial calf augmentation with silicone implants and fat grafting; and (3) medial and lateral calf augmentation with silicone implants and fat grafting. We had one case of a hyperpigmented scar and one case of partial scar dehiscence. There were no cases of compartment syndrome. The average follow-up period was 9.8 months. CONCLUSIONS: Calf enhancement surgery in patients with congenital clubfoot deformity is very gratifying. When combining calf implants with fat grafting in multistaged procedures, we can achieve excellent results with low complication rates.

Gland Suspension Improves Breast Augmentation Outcomes.

BACKGROUND: While dual plane breast augmentation successfully addresses low ptosis grades, concomitant hypomastia and greater ptosis often requires combined immediate or staged mastopexy with extended incisions beyond those required for breast augmentation. In an attempt at offering a minimal scar in a single procedure, we evaluated the benefit of a gland suspension maneuver in addition to a dual plane dissection and implant placement to improve breast contour, avoid postoperative ptosis, and thus reduce staged reintervention procedures. METHODS: A consecutive group of 73 patients presenting ptotic hypomastia were jointly categorized and underwent implant placement, dual plane dissection level 3, and gland suspension maneuver. An age, implant volume, ptosis degree matched historical cohort was used as control (no gland suspension). All subjects were followed longer than 1 year postoperatively. Outcome analysis included reintervention rates and objective geodesic changes using objective morphometric parameters as measured by 3D scan analysis. RESULTS: When experimental and control cohorts were segregated according to ptosis grade, gland suspension maneuver was associated to a lower frequency of subsequent ancillary mastopexy procedures (reintervention rate) for all ptosis grades except ptosis grade III. When gland suspension was compared with ptosis equivalent control groups, gland suspension was associated to a higher upper pole volume increment and higher pole convexity and lower pole morphometry. CONCLUSION: The addition of gland suspension to implant dual plane breast augmentation appears to be a clinically beneficial maneuver with measurable contour impact and appears to avoid subsequent mastopexy procedures, except for high ptosis grade candidates.

The use of pedicled tram flap for delayed breast reconstruction.

The pedicled TRAM flap based on superior epigastric artery is very safe and reliable flap which provides sufficient autologous tissue for natural breast reconstruction. Depending on quantity of abdominal tissue used for the reconstruction, the breast can be sufficiently large and ptotic to achieve symmetry in a single operative procedure. The importance of appropriate patient selection should never be underestimated, especially in risky patients like heavy smokers, those with previous vascular diseases or heavy scarring of the abdominal wall, where delayed procedure is strongly indicated. Adequate patient selection, preoperative management, monitoring of the flap and routine postoperative care with oxygenation, together with the selection of proven surgical technique is the key for the safety of the procedure and reduced patient morbidity.