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.

Preliminary 3-Year Evaluation of Experience With SilkSurface and VelvetSurface Motiva Silicone Breast Implants: A Single-Center Experience With 5813 Consecutive Breast Augmentation Cases.

BACKGROUND: Silicone breast implants have been in use for breast augmentation for more than 50 years, but technological innovation has been lacking in implant design until recently. OBJECTIVES: This study was designed to evaluate the complication and reoperation rates following breast augmentation utilizing the Motiva silicone breast implants. METHODS: This retrospective study evaluated the safety of Motiva implants in 5813 consecutive cases of breast augmentation. Implants with two different textured surfaces were evaluated: SilkSurface (nanotextured) and VelvetSurface (micro-textured). RESULTS: Implants were placed between April 2013 and April 2016. A total of 44 complications were reported, with an overall complication rate of 0.76%, and the rate of reoperation was 0.76% over an interval of 3 years. There were no late complications and no cases of primary capsular contracture. No differences in complication rates were observed because of the implant date. However, among patients who received implants 300 to 499 cc in volume, complication rates were significantly lower with SilkSurface compared with VelvetSurface implants. Advanced statistical analysis supported the validity of the low complication rate reported in this study. CONCLUSIONS: Overall, these findings suggest that Motiva silicone breast implants are associated with very low rates of complication and reoperation, and that the nano-textured SilkSurface implant is associated with fewer complications than micro-textured implants.

Unraveling Factors Influencing Early Seroma Formation in Breast Augmentation Surgery.

Background: It is often assumed that seroma formation trails closely behind with incidence rates reported at 1 to 2%. Seroma is highly problematic for both the surgeon and patient and results in both patient anxiety and discomfort, succeeded by frequent outpatient visits, follow-up treatment, increased costs, and potentially hampered aesthetic outcomes. Consequently, it is now more important than ever to study seroma and to assess its pathophysiology and mechanisms of prevention. Objectives: The aim of this study was to isolate and identify risk factors that may be associated with early seroma formation. Methods: The authors reviewed 539 female patients who had undergone bilateral breast augmentation with silicone cohesive gel implants in a period of 12 months. Five possible risk factors were isolated for analysis: patient's age, body mass index (BMI), smoking habit, implant pocket position, and implant size. A total of 15 patients developed early seromas within the one-year postoperative period. Results: Using exact logistic regression with the independent variables treated as binary variables, we found that smoking, BMI, and pocket are associated with increased risk of seroma while we cannot reject the hypothesis that pocket size and age do not affect the development of seroma at 5% significance level. Conclusions: A high BMI, large implant size, submammary pocket, and smoking are factors significantly associated with seroma development whilst age is not. Smoking however was found to be the most detrimental factor as it significantly amplified the effects of other variables. Level of Evidence: 2

A Preliminary Assessment of the Predictability of Fat Grafting to Correct Silicone Breast Implant-Related Complications.

BACKGROUND: Fat grafting in breast augmentation surgery is becoming increasingly popular and is allowing surgeons to fill the gaps that implant augmentation alone cannot. However, one current issue surrounding fat grafting is resorption. OBJECTIVES: In this prospective study, the authors present their experience of fat grafting and resorption in 26 patients who had fat transfer to correct deformities or asymmetries following primary breast enlargement surgery. METHODS: The fat utilized was harvested and processed using the Puregraft system. Fat grafting was performed until the problem was visually corrected, followed by an additional 30% overcorrection. Photographs were taken preoperatively and 1 year postoperatively, and analyzed utilizing cloud-based 3-dimensional imaging software to measure the breast volumes and calculate 1-year resorption rates. Both patients and physicians were asked to rate their satisfaction. RESULTS: The total volume of fat transferred ranged from 160 cc to 360 cc, with an average of 280 cc per procedure. The absolute volume of tissue resorption showed considerable variation (median, 42.6 mL; range, 5.5-62 mL). However, there was a very close correlation between the volume resorbed and the volume implanted: the more volume injected, the more volume absorbed. When expressed as a percentage of implanted tissue, the resorption rate was 27.5 ± 0.8% (mean ± standard deviation) with a very narrow range (25.7%-28.9%). Patients and physicians reported a satisfaction rate of "excellent" in 83.3% and 75% of cases, respectively. CONCLUSIONS: At 1 year, 25.7% to 28.9% of the injected fat had been resorbed in a predictable, reproducible, and effective manner. LEVEL OF EVIDENCE: 4 Therapeutic.

Use of Quilting Sutures During Abdominoplasty to Prevent Seroma Formation: Are They Really Effective?

BACKGROUND: Abdominoplasty surgery is one of the most popular cosmetic procedures performed in plastic surgery. As with any surgical procedure, it is associated with risks and complications, primarily that of seroma formation. Quilting sutures are a recent development in abdominoplasty surgery that aim to prevent the incidence of seroma. OBJECTIVES: The aim of this article was to assess the effectiveness of quilting suturing in the prevention of seroma formation. METHODS: In our retrospective clinical study, 414 female patients underwent abdominoplasty surgery with liposculpture contouring. The patients were divided in to three groups. The first group, comprising of 100 patients, were fitted with two drains postoperatively and no quilting sutures. The second group of 226 patients underwent quilting suturing in addition to receiving two drains. And the final group of 88 patients also underwent quilting suturing, but received only one drain. Post-operative seroma diagnosis was confirmed with the presence of clinical signs and symptoms. RESULTS: The data was analysed using Fisher's exact test. With P < .000, we rejected our null hypothesis that there is no difference in results between the procedure with sutures and that without sutures. We calculated that the probability of having seroma with sutures to be <0.02. In contrast, abstinence from quilting sutures resulted in a 12% risk of seroma formation. CONCLUSIONS: The use of quilting sutures is a significantly effective measure for the prevention of seroma formation. LEVEL OF EVIDENCE: 4 Therapeutic.

Will 1-stage implant salvage after periprosthetic breast infection ever be routine? A 6-year successful experience.

BACKGROUND: Concomitant with the recent increase in breast augmentations has been an increase in periprosthetic infections necessitating further surgery. The conventional treatment of periprosthetic infections has been a multistage procedure involving explantation, control of infection, and reimplantation. OBJECTIVES: The authors describe a 1-stage salvage procedure for the management of periprosthetic infections. This technique may become the standard for managing infection following cosmetic breast surgery. METHODS: The authors performed a retrospective review of all patients who had periprosthetic infection following cosmetic breast augmentation. The treatment included explantation, sequential cleaning of the wound, and immediate insertion of a new prosthesis and drain. All patients received intravenous antibiotics postoperatively. Of 3012 patients undergoing primary breast augmentation, periprosthetic infection developed in 17 patients. These 17 patients underwent 1-stage implant salvage. Patients were monitored for ≤6 years. RESULTS: All implants were retained; aesthetic results were satisfactory; and no significant adverse events were recorded after implant salvage. CONCLUSIONS: One-stage implant salvage for periprosthetic infection has similar outcomes to conventional multistage procedures and may be preferred by patients. LEVEL OF EVIDENCE: 4.

Severe burn on 81% of body surface after sun tanning.

We report herein the case of a 42-year-old woman who presented to the Burns Unit with 81% of her body surface severely burned following sun bathing, after applying fig leaf tea as a tanning agent. The patient was hospitalized for 13 days in a Burns Intensive Care Unit, and was discharged for an ambulatory follow-up. The treatment of such burns does not differ from any conventional treatment for heat- induced second-degree burns. The physiopathology of the phytophotodermatitis induced by such homemade tanning solutions rich in psoralen is discussed in detail.

The "Brazilian" bikini-shaped lip-reduction technique: new developments in cheiloplasty.

BACKGROUND: The lips, one of the most illustrious facial features, have a key role in forming facial expressions. In the past, hypertrophic lips were an aesthetic issue among certain ethnic groups. Although full lips are a desirable feature sought by many people, the current world of fashion tends emphasize equilibrium and significant matching of features, encouraging people to seek refinement through cosmetic surgery. The purpose is to reach the standard level of perceived attractiveness in current society. This article aims to present a novel lip reduction technique that restores an attractive labial contour by shifting the shape toward a more "Brazilian way" and resulting in more aesthetically appealing lips. METHODS: The technique described in this report was performed on more than 40 patients between 2008 and 2010. The major difference between this technique and others is that it transforms the shape of the bikini lines to a more "Brazilian" way. The upper resection is more conservative, whereas the lower resection is less triangular and more curved, displaying more of the bilateral "bands" on the lips. The reported patients did not present any infections or any other complications. CONCLUSION: The nature of human beings urges them to seek routes of assimilation into their society. This also applies to the rules of perceived attractiveness. The technique presented in this article has recaptured specific attention to the resultant lip contour, altering the shape of the marks on the lower lip. The new technique yields a harmonious relationship between the upper and lower lips. The aesthetic results and patient satisfaction attained through this novel technique of lip reduction have been very satisfactory. 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 the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Transversus abdominis plane block anesthesia in abdominoplasties.

BACKGROUND: The transversus abdominis plane block is a promising approach to the provision of postoperative analgesia following abdominal incision. This effective method blocks the sensory nerve supply to the anterior abdominal wall. The authors evaluated its analgesic efficacy over the first 12 postoperative hours after abdominoplasty with liposculpture in a randomized, controlled, double-blind clinical trial. METHODS: Twenty-eight women undergoing abdominoplasty by means of a lower abdominal incision were randomized to undergo transversus abdominis plane block (n = 14) in addition to standard care therapy (n = 14). The investigators, who were blinded to the conditions of the study, assessed the patients in the postanesthesia care unit at 4, 6, and 12 hours postoperatively. RESULTS: The transversus abdominis plane block group reported reduced pain scores (F = 12.73, p < 0.001). Morphine requirement was also reduced in the first 12 postoperative hours (χ2 = 19.27; p < 0.005). Transversus abdominis plane block group patients also exhibited early ambulation compared with the control group (F = 65.15, p < 0.001). All of the patients in the transversus abdominis plane block group reported lower levels of pain with their postoperative analgesic regimen, which was demonstrated by their rates of recovery. The Mann-Whitney test was performed on the data, which illustrated that mean ranks consistently corresponded to the trend the authors predicted. CONCLUSIONS: The transversus abdominis plane block seems to hold considerable promise for patients undergoing abdominoplasty by providing effective postoperative analgesia in the first 12 postoperative hours after major abdominoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

An unusual case of ascariasis of the appendix.

INTRODUCTION: Amongst various causes responsible for the obstruction of digestive tract, intestinal ascariasis is certainly one of the least frequent. CASE OUTLINE: We report an extremely rare case of a 5-year-old male patient operated on for appendicitis due to adult Ascaris Lumbricoides worms intraoperatively detected in the appendiceal lumen. CONCLUSION: On examination patient's clinical features indicated acute appendicitis. Therefore, the treatment-of-choice could only be surgical. Classic appendectomy was performed and the postoperative course was uneventful, with full recovery.

No recurrence in otoplasty: is that possible?

INTRODUCTION: Otoplasty or correction of prominent ears, is one of most commonly performed surgeries in plastic surgery both in children and adults. Until nowadays, there have been more than 150 techniques described, but all with certain percentage of recurrence which varies from just a few up to 24.4%. OBJECTIVE: The authors present an otoplasty technique, a combination of Mustardé's original procedure with other techniques, which they have been using successfully in their everyday surgical practice for the last 9 years. The technique is based on posterior antihelical and conchal approach. METHODS: The study included 102 patients (60 males and 42 females) operated on between 1999 and 2008. The age varied between 6 and 49 years. Each procedure was tailored to the aberrant anatomy which was analysed after examination. Indications and the operative procedure are described in step-by-step detail accompanied by drawings and photos taken during the surgery. RESULTS: All patients had bilateral ear deformity. In all cases was performed a posterior antihelical approach. The conchal reduction was done only when necessary and also through the same incision. The follow-up was from 1 to 5 years. There were no recurrent cases. A few minor complications were presented. Postoperative care, complications and advantages compared to other techniques are discussed extensively. CONCLUSION: All patients showed a high satisfaction rate with the final result and there was no necessity for further surgeries. The technique described in this paper is easy to reproduce even for young surgeons.

Trilucent breast implants: voluntary removal following the Medical Device Agency recommendation. Report on 115 consecutive patients.

In June of 2000, the U.K. Medical Device Agency recommended the removal of Trilucent implants as a precautionary maneuver in response to reports of local inflammatory reactions. This decision allowed the authors to operate on 115 consecutive patients between June of 2000 and January of 2001. On the preoperative examination, the authors found a very high incidence of rippling (66 percent), whereas capsular contracture was seen in only three patients (2.6 percent). Rippling was significantly more common in patients with subglandular implants. Five implants were found ruptured during the operation. This figure, together with the relative ease of implant breakage at removal, shows a premature deterioration of the implant shell. The authors also comment on implant bleeding, which seems common in this type of breast implant. The authors think that this is a possible cause for the rippling phenomenon, resulting from a reduction of the implant content. On the basis of these findings, the authors conclude that Trilucent implants are associated with a poor cosmetic outcome and a high rate of complications.