Replacement of Shaped Textured Implants with Round Smooth Implants in Breast Reconstruction: Long Term Patient- and Surgeon- Reported Outcomes.

BACKGROUND: The number of patients undergoing exchange of textured implants for smooth devices has greatly increased due to concern over BIA-ALCL. The authors examine long-term patient- and surgeon-reported outcomes in terms of aesthetics, comfort, and complications. METHODS: Patients who underwent reconstruction with shaped, textured implants replaced with round, smooth implants between 1994-2022 with a minimum follow-up of 1 year were included. Patient-reported outcomes were collected using the BREAST-Q Reconstruction Module as well as a survey evaluating aesthetics and comfort. Surgeon-reported outcomes included evaluation of aesthetics and capsular contracture. RESULTS: 530 patients were reviewed, and 307 patients were included. Pairwise comparison of BREAST-Q data demonstrated psychosocial well-being (72.68 to 76.45; p=0.0075) and physical well-being (78.79 to 81.88; p=0.0078) significantly increased. Overall breast satisfaction (61.94 to 67.27; p=0.0082) and sexual well-being (53.89 to 57.98; p=0.0002) were also significantly higher in parallel with a clinically meaningful increase in BREAST-Q score of 5.33 and 4.09 points, respectively. Most patients felt they looked better (56.4%) or similar (27.3%) and were more comfortable (54.4%) or similar (39.4%) after the exchange procedure. The senior surgeon rated 40.1% of patients as a better aesthetic grade after replacement and 50.3% as the same. 36.8% of patients were rated as having a decrease in Baker capsular contracture grade. 2.9% of patients experienced a peri-operative complication and there were no reconstructive failures. CONCLUSION: Exchange of textured to smooth implants is safe, does not sacrifice aesthetic outcome, and provides a more comfortable and satisfactory outcome for patients with minimal complications.

Utility of local anesthesia for open carpal tunnel release in patients with psychiatric diagnoses.

PURPOSE: Carpal tunnel release, one of the most commonly performed procedures in Veterans Affairs (VA) medical centers, is often performed under local anesthesia alone. In this patient population, there is an increased prevalence of psychiatric disorders. Our hypothesis is that there is no difference in operating time, request for sedation, or complications in the veteran population with or without a recognized psychiatric history. METHODS: A retrospective cohort study was performed at a VA medical center from January 2013 to January 2017 by the senior surgeon (E.S.L). Patients were divided into two groups: patients with no known psychiatric history (n = =33) and patients with an active psychiatric diagnosis (n = =25), including post-traumatic stress disorder, anxiety disorder, bipolar disorder, depression, substance abuse, or panic disorder. Primary endpoints included operation time, time in operating room, request for sedation, and complication rates. RESULTS: Fifty-nine percent of patients successfully underwent wide-awake hand surgery, while 41% requested sedation. Patients with no known psychiatric history had a 45.5% rate of requesting sedation compared to 36% in those with a psychiatric diagnosis. No patients converted from wide-awake surgery to sedation. There was no statistically significant difference in operation time, time in the operating room, need for sedation, or complication rate between all groups. CONCLUSIONS: Wide-awake hand surgery is an excellent technique that can be safely used in patients with a history of psychiatric illness. Without the need for monitored anesthesia care, the cost for carpal tunnel releases done in military medical centers could decrease dramatically. TYPE OF STUDY: Prognostic. LEVEL OF EVIDENCE: Level II.

Lower-limb reconstruction with chimeric flaps: The quad flap.

Early soft-tissue coverage is critical for treating traumatic open lower-extremity wounds. As free-flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free-tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower-extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft-tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft-tissue loss. In case 1, a 51-year-old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53-year-old man sustained a right tibia plateau fracture with large soft-tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft-tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long-term complications in either case. Both patients achieved adequate soft-tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad-flap technique is promising for reconstructing the lower extremity.

Managing barriers to recycling in the operating room.

BACKGROUND: Among hospital staff, little is known concerning barriers to recycling and perception of waste in the operating room (OR), despite continued improvement in recycling programs. This study sought to identify barriers to OR recycling and implement a recycling improvement educational program. METHODS: A survey was administered within Mayo Clinic at four campuses. Based on survey results, a recycling improvement program was devised and implemented at a surgery center in Paradise Valley, Arizona. A cost-savings analysis was performed thereafter. RESULTS: Of 524 participants, 56.7% reported being unclear which OR items are recyclable, and 47.7% thought the greatest barrier to recycling was lack of knowledge. After implementation of the recycling educational program, cost savings of 10.3% (p = 0.004) were achieved in sharps waste disposal when compared to the previous year at the surgery center. CONCLUSIONS: Addressing barriers to recycling in the OR can significantly reduce waste and save valuable healthcare dollars.

Case of late hematoma after breast augmentation.

We present a case report of a patient who experienced a late, spontaneous breast hematoma 26 years after primary breast augmentation. Late hematomas are a rare complication of breast augmentation with uncertain etiology. In this case, there was no trauma, calcifications, or implant rupture. We believe the patient's hematoma was secondary to erosion of a capsular vessel due to capsular contracture.

Bilateral Breast Reduction Without Opioid Analgesics: A Comparative Study.

BACKGROUND: Breast reduction has traditionally been performed under general anesthesia with adjunct opioid use. However, opioids are associated with a wide variety of adverse effects, including nausea, vomiting, constipation, postoperative sedation, dizziness, and addiction. OBJECTIVES: This study compares bilateral breast reduction using a multimodal opioid-free pain management regimen vs traditional general anesthesia with adjunct opioids. METHODS: A total of 83 female patients were enrolled in this study. Group 1 includes a retrospective series of 39 patients that underwent breast reduction via general anesthesia with adjunct opioid use. This series was compared to 2 prospective groups of patients who did not receive opioids either preoperatively or intraoperatively. In group 2, twenty-six patients underwent surgery under intravenous sedation and local anesthesia. In group 3, eighteen patients underwent surgery with general anesthesia. All patients in groups 2 and 3 received preoperative gabapentin and celecoxib along with infiltration of local anesthetics during the operation and prior to discharge to the Post-Anesthesia Care Unit (PACU). Primary outcome measures included the duration of surgery, time from end of operation to discharge home, postoperative opioid and antiemetic use, and unplanned postoperative hospitalizations. RESULTS: When compared to group 1, groups 2 and 3 experienced a shorter time from end of operation to discharge home (P < 0.05), fewer unplanned hospital admissions (P < 0.05), and highly significant decrease in postoperative opioid use (P < 0.001). CONCLUSIONS: This multimodal approach allows patients to safely undergo opioid-free bilateral breast reduction either under local or general anesthesia as an outpatient. This method resulted in significantly less morbidity, use of opioids postoperatively, as well as unplanned hospital admissions compared to "traditional" breast reduction under general anesthesia with the use of opioids. LEVEL OF EVIDENCE: 3.

Impact of Helmet Use on Injury and Financial Burden of Motorcycle and Moped Crashes in Hawai'i: Analysis of a Linked Statewide Database.

Helmet use reduces injury severity, disability, hospital length of stay, and hospital charges in motorcycle riders. The public absorbs billions of dollars annually in hospital charges for unhelmeted, uninsured motorcycle riders. We sought to quantify, on a statewide level, the healthcare burden of unhelmeted motorcycle and moped riders. We examined 1,965 emergency medical service (EMS) reports from motorcycle and moped crashes in Hawai'i between 2007-2009. EMS records were linked to hospital medical records to assess associations between vehicle type, helmet use, medical charges, diagnoses, and final disposition. Unhelmeted riders of either type of vehicle suffered more head injuries, especially skull fractures (adjusted odds ratio (OR) of 4.48, P < .001, compared to helmeted riders). Motorcyclists without helmets were nearly three times more likely to die (adjusted OR 2.85, P = .001). Average medical charges were almost 50% higher for unhelmeted motorcycle and moped riders, with a significant (P = .006) difference between helmeted ($27,176) and unhelmeted ($40,217) motorcycle riders. Unhelmeted riders were twice as likely to self-pay (19.3%, versus 9.8% of helmeted riders), and more likely to have Medicaid or a similar income-qualifying insurance plan (13.5% versus 5.0%, respectively). Protective associations with helmet use are stronger among motorcyclists than moped riders, suggesting the protective effect is augmented in higher speed crashes. The public financial burden is higher from unhelmeted riders who sustain more severe injuries and are less likely to be insured.

A Modified, Direct Neck Lift Technique: The Cervical Wave-Plasty.

BACKGROUND: Major problems with cervicoplasty by direct skin excision include the subjective nature of skin markings preoperatively and the confusing array of procedures offered. This technique incorporates curved incisions, resulting in a wave-like scar, which is why the procedure is called a "wave-plasty". METHODS: This prospective study includes 37 patients who underwent wave-plasty procedures from 2004 to 2015. Skin pinching technique was used to mark the anterior neck preoperatively in a reproducible fashion. Intra-operatively, redundant skin was excised, along with excess fat when necessary, and closed to form a wave-shaped scar. Patients were asked to follow up at 1 week, 6 weeks, and 6 months after surgery. RESULTS: The mean operation time was 70.8 minutes. The majority (81.3%) was satisfied with their progress. On a scale of 1 to 10 (1 being the worst, and 10 being the best), the scars were objectively graded on average 5.5 when viewed from the front and 7.3 when seen from the side 6 months after surgery. Complications consisted of one partial wound dehiscence (2.3%), one incidence of hypertrophic scarring (2.3%), and two cases of under-resection requiring revision (5.4%). CONCLUSIONS: In select patients, surgical rejuvenation of the neck may be obtained through wave-like incisions to remove redundant cervical skin when other options are not available. The technique is reproducible, easily teachable and carries low morbidity and high patient satisfaction in carefully chosen patients.

Polyurethane-coated breast implants revisited: a 30-year follow-up.

BACKGROUND: Polyurethane coating of breast implants has been shown to reduce capsular contracture in short-term follow-up studies. This 30-year study is the longest examination of the use of polyurethane-coated implants and their correlation with capsular contracture. METHODS: This study evaluates the senior surgeon's (F.D.P.) experience with the use of polyurethane-coated implants in aesthetic breast augmentation in 382 patients over 30 years. Follow-up evaluations were conducted for six months after surgery. After the six-month follow-up period, 76 patients returned for reoperation. The gross findings, histology, and associated capsular contracture were noted at the time of explantation. RESULTS: No patient during the six-month follow-up period demonstrated capsular contracture. For those who underwent reoperation for capsular contracture, Baker II/III contractures were noted nine to 10 years after surgery and Baker IV contractures were noted 12 to 21 years after surgery. None of the explanted implants had macroscopic evidence of polyurethane, which was only found during the first five years after surgery. The microscopic presence of polyurethane was noted in all capsules up to 30 years after the original operation. CONCLUSIONS: An inverse correlation was found between the amount of polyurethane coating on the implant and the occurrence of capsular contracture. Increasingly severe capsular contracture was associated with a decreased amount of polyurethane coating on the surface of the implants. No contracture occurred in patients whose implants showed incomplete biodegradation of polyurethane, as indicated by the visible presence of polyurethane coating. We recommend research to find a non-toxic, non-biodegradable synthetic material as an alternative to polyurethane.