Assessing the Efficacy of the S-PECS Block in Breast Augmentation Surgery: A Randomized, Double-Blind, Controlled Trial.

BACKGROUND: Postoperative acute and chronic pain following breast surgery is a common complication that needs resolving to allow for improved patient outcomes. Previously, thoracic epidurals and paravertebral blocks have been the accepted standard administered intraoperatively. However, more recently the introduction of the pectoral nerve block (PECS and PECS-2 blocks) has appeared promising to control the pain more effectively, but further robust analysis is required to prove its efficacy. The authors aim to study the efficacy of a new block, S-PECS, that combines a serratus anterior and a PECS-2 block. METHODS: In this study, the authors performed a single-center, randomized, controlled, double-blind group trial in 30 female patients undergoing breast augmentation surgery with silicone breast implants and the S-PECS block. Divided into two groups of 15, the PECS group received local anesthetics and the no-PECS control group received a saline injection. All participants were followed up at recovery and at 4, 6, and 12 hours postoperatively. RESULTS: The authors' results showed that the pain score in the PECS group was significantly less than in the no-PECS group across all time points: recovery, and at 4, 6, and 12 hours. Furthermore, the patients who received the S-PEC block were 74% less likely to request pain medications compared with the no-PECS group ( P < 0.05). CONCLUSION: Overall, the modified S-PECS block is an effective, efficient, and safe method of controlling pain in patients undergoing breast augmentation surgery, with additional applications yet to be explored.

Using Ginger Oil to Treat Nausea and Vomiting Following Breast Augmentation Surgery.

We conducted a double-blind, randomized, placebo-controlled, single-center study involving 30 women undergoing breast augmentation surgery with silicone breast implants. All patients had an A cup breast size and a similar body mass index. We placed the same type of implant in a subpectoral dual plane in each patient. We randomly allocated the study participants to receive either three drops of ginger oil (110 mg Zingiber officinale) or three drops of a placebo control oil placed on their laryngeal mask before insertion. We used a postoperative nausea and vomiting (PONV) and a visual analog scale (VAS) scores as outcome measures and compared the scale results with the dose of morphine used by the patient. The results of the multivariate analysis of variance showed that the ginger oil had a significant effect on PONV/VAS scores, V = 0.87, F(3, 16) = 34.78, p < .001. The results of the univariate analysis of variance showed that using the ginger oil provided significant treatment effects on PONV, F(1, 18) = 73.05, p < .001. These results are also reflected in the descriptive statistics. The mean PONV score for the experimental group and the control group was 1.70 ± 0.48 and 4.20 ± 0.79, respectively. The mean VAS score for the experimental group and the control group was 5.0 ± 1.63 and 5.9 ± 2.33, respectively. The results of our study showed that ginger oil has an important role in preventing PONV and reducing the use of postoperative opioids in women who have undergone breast augmentation surgery.

Predicting the expansion of the lower pole of the breast following smooth breast implant augmentation: A novel shear wave elastography study.

OBJECTIVES: This study aimed to educate and demonstrate how the use of shear wave elastography (SWE) can be used to determine the elasticity of patient tissues preoperatively, which can then be used to predict the level of lower pole expansion postoperatively, following breast augmentation surgery. MATERIALS AND METHODS: This study evaluated 60 breasts in 30 patients that were divided in 3 equal groups (n = 20) according to their predefined elastography criteria measured via SWE (loose, moderate, and tight tissue elasticity). All measurements were taken under maximum stretch between the inferior border of the nipple alveolar complex (NAC) and inframammary fold (IMF) using a measuring tape in millimetres (mm). The follow-up appointments for routine assessments and measurements were done at 3, 6, 12, 18, and 24 months. RESULTS: The study engaged 38 patients over 4 years, but only 10 patients in each group attended all the appointments. Statistical analysis showed the elastic skin types (loose, moderate, and tight) had significantly different rates of lower pole expansion, and the rate of expansion increased significantly after 6 months postoperatively, whereas prior to 6 months, the rates were comparable (p < 0.05). DISCUSSION: The results showed that increasingly elastic skin types have a greater rate of lower pole expansion. This is important for the operating surgeon to be aware of as looser skin types will be more prone to lower pole expansion, and thus, a higher surgical IMF suture may be advised to manage patient expectations. CONCLUSION: This study can be used as a guideline for surgeons, which will allow for a more predictable surgical planning system that will ultimately lead to fewer revisions and risks for patients worldwide.

Clinical outcomes of anterior prostate cancers treated with robotic assisted radical prostatectomy.

Introduction: A prospective cohort study comparing peri- and postoperative outcomes for patients with predominantly anterior prostate cancer (APC) identified preoperatively against non-anterior prostate cancer (NAPC) treated via robotic-assisted radical prostatectomy (RARP). Patients and Methods: Of the 757 RARP's completed between January 2016 and April 2018, two comparative cohorts for anterior and an equivalent group of non-anterior prostate tumours each consisting of 152 patients were compared against each other. Data were collected on the following variables: patient age; operating consultant; preoperative PSA, ISUP grade, degree of nerve sparing; tumour staging; presence and location of positive surgical margins; PSA density, postoperative ISUP grade; treatment paradigm and postoperative PSA, erectile function, and continence outcomes with 2-year follow-up. Results: APCs were found to have significantly lower ISUP grading postoperatively; increased diagnosis via active surveillance over new diagnosis; more frequently undertaken bilateral nerve-sparing and long-term poorer continence outcomes at 18 and 24 months postoperatively (p < 0.05). Pre- and post-op PSA levels, erectile function, PSA density, positive surgical margins (PSM), age and tumour staging showed no significant differences between the APC and NAPC cohorts (p > 0.05). Conclusion: The lower ISUP grading could indicate APC as overall being less aggressive than NAPC, whereas the poorer long-term continence outcomes require further investigating. The non-significant differences amongst tumour staging, PSA density, preoperative PSA levels and PSM rates suggest that APC may not be as significant as predicted in diagnostic evaluation. Overall, this study provides useful information on the growing literature of anterior prostate cancer. Being the largest comparative cohort study to date on APC post-RARP, these results indicate the true characteristics of anterior tumours and their functional outcomes to help improve education, patient expectations and management.

The Revised PENIS Score and proposal of the PACKAGE Checklist: a meta-epidemiologic study on penile amputation and replantation.

INTRODUCTION: Penile amputation causes severe physical and psychosocial distress. Microsurgical implementation in penile replantation is presumed to be superior to surgical repair. This assumption has been difficult to verify. OBJECTIVES: The purpose of this study was threefold: (1) to produce an updated review of penile replantation, substantiated by the largest sample size to date; (2) to appraise the comparative value of the novel PENIS Score and propose the PACKAGE Checklist, a guide for standardization of future case reports and reviews; and (3) to improve confusing terminology and recommend the standardization of vocabulary. METHODS: A literature review assessed 432 full-text case reports in 20 languages and identified 123 microsurgical and 40 surgical cases of penile replantation. The novel PENIS Score stratified penile amputations based on 5 criteria: position along the shaft, extension through the penis, neurovascular repair, ischemia time and type, and severed edge condition and contamination. For the outcome measurements, a Kendall tau coefficient evaluated the association between each PENIS criterion for short-term postoperative complications and 3 outcome measures: erection, urination, and sensation. RESULTS: Less than half of surgical reports on penile replantation are sufficiently detailed to complete all PENIS Score criteria. The viability of microsurgical and surgical replantation was equivalent at 92% and 94%, respectively. A statistically significant correlation was found between microsurgical repair and the return of sensation but not with nerve repair. Return of sensation with nerve repair was 51%, and microsurgical replantation without nerve repair was 42%; both were significantly higher than the 14% for surgical replantation. Preservation of a skin bridge was associated with a 40% reduction in severe postoperative complications. CONCLUSION: Microsurgical replantation is superior in return of sensation, with or without nerve repair. Implementing the PACKAGE Checklist and PENIS Score will help inform case reports and reviews.

WALANT: A Discussion of Indications, Impact, and Educational Requirements.

Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.

Deep Vein Thrombosis (DVT) and Abdominoplasty: A Holistic 8-Point Protocol-Based Approach to Prevent DVT.

BACKGROUND: Plastic surgery as a specialty is afflicted with one of the highest incidence rates of thromboembolic events, with abdominoplasty procedures known to assimilate the greatest rates of deep vein thrombosis (DVT). OBJECTIVES: The aim of this study was to develop a prophylactic protocol to reduce the rate of DVT occurrence postabdominoplasty. METHODS: Over a 7-year period 1078 abdominoplasty patients were enrolled onto a holistic 8-point prophylaxis protocol. For a 4-week period before the operation all patients were required to stop smoking, and to cease hormone replacement therapy and combined oral contraception. All patients were required to have a preoperative BMI of less than 40 kg/m2. Participants were supplied with compression stockings, external pumping devices, and enoxaparin. Individuals with a history of DVT were also required to be 1-year treatment free prior to surgery. Furthermore, the protocol required postoperative ambulation of fit patients within 4 hours. RESULTS: Between 2008 and 2013, no incidence of DVT was recorded in all 1078 abdominoplasty surgery patients, indicating the potential for this protocol to lead to a significantly lower incidence than any previously published methodology. Previous studies of DVT incidence were reviewd to identify rates statistically significantly similar to our sample, thereby providing conservative incidence rate estimates. CONCLUSIONS: This 8-point DVT prophylaxis protocol is the first noncriteria-based inclusive protocol aimed at preventing abdominoplasty-associated DVT. A holistic and procedure-specific approach to prophylaxis can drastically reduce the occurrence of DVT in abdominoplasty surgery.With over 116,000 procedures performed annually in the United States, abdominoplasty has become one of the most popular and sought-after surgeries in the plastic and cosmetic field.1 Despite its ever-increasing popularity and the advancement of techniques, abdominoplasty-as with any other surgery-has its complications, including infection, seroma, hematoma, thrombosis, embolism, scarring, and even death. Complication rates as high as 37% have been reported, with some studies reporting a 16% major complication rate.2 One of the most serious and troubling complications for both surgeon and patient is deep vein thrombosis (DVT). With over 1 million patients tested, an estimated 250,000 cases of DVT are diagnosed per year in the United States alone.