A local anesthetic pump reduces postoperative pain and narcotic and antiemetic use in breast reconstruction surgery: a randomized controlled trial.

BACKGROUND: The purpose of this study was to conduct a double-blind, randomized, prospective trial evaluating the efficacy of a local anesthetic pain pump in reducing postoperative pain, narcotic use, and the incidence of postoperative nausea and vomiting in breast reduction surgery. METHODS: Thirty-one patients undergoing bilateral breast reduction using a single technique (inferior pedicle, Wise pattern with supplemental liposuction) were enrolled. The patients were randomized to receive either 0.25% bupivacaine (n = 16) or 0.9% saline (n = 15) delivered over a period of 48 to 55 hours. All patients were monitored postoperatively and completed a written survey and telephone interview. Parameters measured over a period of 48 hours included subjective pain, episodes of postoperative nausea and vomiting, and the amount of narcotics and antiemetics used. RESULTS: There were no statistically significant differences between the two groups regarding patient age, body mass index, weight of the breast reduction, complication rate, and standardized subjective pain perception. Patients randomized to bupivacaine reported significantly lower pain scores on the day of surgery and on the first and second postoperative days when compared with patients receiving placebo (p < 0.01). The amount of intravenous and oral narcotics used paralleled the reduction in pain (p < 0.01), and there were fewer episodes of postoperative nausea and vomiting and antiemetics used in the patients randomized to the bupivacaine group (p < 0.01). CONCLUSION: The results of this study support the efficacy of a postoperative local anesthetic pain pump in reducing pain, narcotic use, and postoperative nausea and vomiting in women undergoing breast reduction.

Decreased postoperative pain, narcotic, and antiemetic use after breast reduction using a local anesthetic pain pump.

The purpose of this study was to conduct a prospective trial evaluating the efficacy of a local anesthetic pain pump in breast reduction surgery. Ninety-eight women undergoing bilateral breast reduction were enrolled. Thirty-seven patients received a pain pump containing 0.25% bupivicaine, and 61 patients received no pain pump. Parameters measured included subjective pain, episodes of postoperative nausea and vomiting (PONV), and the amount of narcotics and antiemetics used. Patients receiving a pain pump reported significantly lower pain scores on the day of surgery, as well as on the first and second postoperative days when compared with patients who did not (P < 0.01). The amount of intravenous and oral narcotics used paralleled the reduction in pain (P < 0.01), and there were fewer episodes of PONV and antiemetics used in the patients receiving a pain pump (P < 0.01). A postoperative local anesthetic pain pump can reduce pain, narcotic use, and PONV in women undergoing breast reduction.

Temporal expression of the transforming growth factor-Beta pathway in the rabbit ear model of wound healing and scarring.

BACKGROUND: Despite numerous studies that have investigated the cellular and molecular mechanisms underlying scar formation, this process still remains poorly understood. The importance of transforming growth factor-beta (TGF-beta) in these processes has been well recognized, and this study sought to define the temporal expression of the key members in this pathway in a well-established, clinically relevant, rabbit ear model of hypertrophic scarring. STUDY DESIGN: Seven-millimeter (hypertrophic) and 5-mm (nonhypertrophic) punch wounds were made on the ears of 12 rabbits. Wounds were harvested at days 0, 7, 15, 28, and 40. RESULTS: There were no appreciable histologic differences between the 5- and 7-mm wounds at days 7 and 15. At day 28, however, the 7-mm scars were considerably more hypertrophic compared with the 5-mm control scars (p<0.001). The mRNA levels of TGF-beta1 and collagen Ialpha2 were notably higher in the hypertrophic 7-mm scars at day 28 than in the nonhypertrophic 5-mm scars (p<0.03). Although not pronounced, levels of TGF-beta2 were higher in the hypertrophic scars. There were no other statistically significant differences between the 7- and 5-mm scars. CONCLUSIONS: Elevated levels of TGF-beta1, and possibly TGF-beta2, are associated with hypertrophic scar formation.

Synergistic activation of extracellular signal-regulated kinase in human dermal fibroblasts by human telomerase reverse transcriptase and transforming growth factor-beta1.

BACKGROUND: Human telomerase reverse transcriptase (hTERT) is primarily known for its ability to elongate telomeres for maintaining chromosomal integrity and delaying cellular senescence. Recently, hTERT has emerged as having a role in promoting cellular proliferation that is independent of telomere elongation. How hTERT elicits this novel function is a fundamental question in cell biology. Understanding this question may have therapeutic implications in regenerative medicine for patients with damaged organs or tissues, cardiovascular disorders, stroke, ischemic chronic wounds, and other ischemia-reperfusion injuries. Toward this end, we treated hTERT-transfected human dermal fibroblasts (HDFs) with transforming growth factor (TGF)-beta1 and investigated the activation of extracellular signal-regulated kinase (ERK) 1/2, vital mediators of cell proliferation. MATERIALS AND METHODS: Primary HDFs were transfected with either recombinant adenovirus expressing hTERT (Ad-hTERT) or control adenovirus (Ad-NULL) and subsequently treated with TGF-beta1 (2 pg/mL). ERK 1/2 activation was determined by Western blotting using an antibody recognizing only activated ERK 1/2 that is dually phosphorylated at Thr(202) and Tyr(204). TGF-beta1, TGFbeta-RI, TGFbeta-RII, and Col1 A1 mRNA levels were analyzed by real-time PCR. RESULTS: Ad-hTERT-transfected HDFs showed more than 7-fold up-regulation of phospho-ERK 1/2 over Ad-NULL-transfected HDFs upon TGF-beta1 treatment. The synergistic ERK 1/2 activation in Ad-hTERT-transfected HDFs occurred as early as 10 min and was sustained for at least 30 min after TGF-beta1 treatment. There were no statistically significant differences in TGF-beta1, TGFbeta-RI, TGFbeta-RII, and Col1 A1 mRNA levels between HDFs that were transfected with Ad-hTERT and those that were transfected with Ad-NULL after TGF-beta1 treatment. CONCLUSIONS: hTERT and extremely low concentrations of TGF-beta1 (2 pg/mL) synergistically activate ERK 1/2 in HDFs by a mechanism that is independent of the autocrine TGF-beta1 loop.

The temporal effects of anti-TGF-beta1, 2, and 3 monoclonal antibody on wound healing and hypertrophic scar formation.

BACKGROUND: A number of studies have implicated transforming growth factor (TGF)-beta1, 2, and 3 (TGF-beta) in wound healing and hypertrophic scarring. We propose that TGF-beta has a temporal effect on these processes. To test this hypothesis, we applied anti-TGF beta1, 2, and 3 monoclonal antibody topically to our dermal ulcer model in the rabbit ear. STUDY DESIGN: Rabbit ear wounds were treated intradermally with anti-TGF-beta1, 2, and 3 antibody at early, middle, and late time points. Treated and untreated control wounds were harvested at various time points and examined histologically to quantify wound healing and scar hypertrophy. Real-time polymerase chain reaction was performed to determine TGF-beta mRNA expression in the treated and control wounds. RESULTS: The early treatment group demonstrated decreased new epithelium and granulation tissue (p < 0.05 versus controls). Scars harvested on days 28 and 40 displayed no difference in scar hypertrophy. Both the middle and late treatment groups demonstrated a significant decrease in scar hypertrophy (p < 0.05). CONCLUSIONS: Treated wounds from the early treatment group displayed delayed wound healing, with no reduction in scar hypertrophy. Later treatment of wounds with the same antibody, beginning 7 days after wounding, resulted in a reduction in scar hypertrophy. These results support our hypothesis and clearly demonstrate that TGF-beta1, 2, and 3 have differential temporal effects during the wound-healing process, and are important for optimal wound healing in the first week after wounding; beyond 1 week, TGF-beta1, 2, and 3 play a critical role in hypertrophic scar formation.

The efficacy of continuous local anesthetic infiltration in breast surgery: reduction mammaplasty and reconstruction.

BACKGROUND: Pain control after reduction mammaplasty and breast reconstruction with tissue expanders often requires intravenous narcotic analgesia and inpatient hospitalization. Regional and local anesthetic techniques are increasing in popularity because they decrease the use of intravenous analgesic medications and offer comparable pain relief without the systemic side effects. METHODS: This study examined the use of indwelling catheters for the continuous infiltration of local anesthetic (bupivacaine) in 74 consecutive breast reduction and 74 consecutive tissue expander breast reconstruction patients. Patients entering the study before February of 2003 had conventional methods of analgesia (39 patients for each group), whereas those entering afterwards received the infusion pumps (35 patients for each group). RESULTS: The number of hospital admissions among the breast reduction patients with infusion pumps was significantly less than that for those without pumps (p < 0.01). Pain, measured on a verbal response scale of 0 to 10, while in the recovery room was significantly less in the pain pump group than in the comparison group (p < 0.01), as were cumulative amounts of pain medications (p < 0.01). There were no statistically significant differences in the number of complications or in the rate of nausea or vomiting. The number of inpatient days among the tissue expander reconstruction patients with infusion pumps was not significantly different from that for those without pumps; the average pain score was significantly lower (p < 0.01). The cumulative amounts of pain medication in patients receiving the infusion pump were significantly lower than those in patients without the pumps (p < 0.01). There were no statistically significant differences in the number of complications or in the rate of nausea or vomiting. There were no tissue expander infections in patients with the indwelling catheters adjacent to the implant. CONCLUSIONS: The continuous infiltration of local anesthetic with an infusion pump represents another tool for pain management in surgical patients.