Moving a skin incision to lateral side of tibial tubercle reduces the risk of persistent skin numbness compared with a regular midline one: A randomized paired study in bilateral total knee arthroplasty.

BACKGROUND: The midline incision during total knee arthroplasty (TKA) is known to damage the infrapatellar branch of the saphenous nerve (IPBSN), leading to lateral flap numbness. The aim was to evaluate the rate of persistent skin numbness (RSN) and area of skin numbness (AON) after a lateral-based skin incision compared with the standard midline incision in bilateral TKA patients. METHODS: Thirty-six patients undergoing bilateral TKA were included and randomly assigned to receive the lateral skin incision (lateral side of the tibial tubercle) on one knee and the standard midline incision on the contralateral. All other surgical steps were identical. Primary outcomes were the RSN at 1 year and the AON at 6 weeks, 3, 6, and 12 months postoperatively. Kneeling ability test (KAT), operative time, and length of incision were also recorded. RESULTS: The lateral incision had half the RSN at 12 months compared to the midline incision (25% vs 53%; p = 0.01). The median AON at 1-year after surgery was 0 [0-0.5] cm2 in lateral incision vs 4 [0-7.5] cm2 in midline group (p < 0.001). KAT was minimally better in the lateral group at 110° of kneeling between 6-month to 1-year. Operative time and length of incision were similar between both groups. CONCLUSION: The lateral skin incision reduced RSN by approximately 50% compared with the midline incision. The AON in lateral incision was 4 cm2 smaller than midline at 1-year after surgery. Moving a skin incision more lateral may be considered to minimize the numbness after TKA.

A modified oblique incision in hamstring tendon graft harvesting during ACL reconstruction.

BACKGROUND: During anterior cruciate ligament (ACL) reconstruction, different methods of harvesting hamstring tendon may lead to different degrees of injury to the inferior patellar branch of the saphenous nerve (IPBSN). Most of recent studies in the literature suggest that the classic oblique incision (COI) can reduce the incidence of IPBSN injury. We proposed a modified oblique incision (MOI) and compared it with the COI in terms of the resulting levels of injury and sensory loss and the clinical outcome. METHODS: Patients with ACL injury admitted to our hospital from April 2015 to July 2019 were randomly selected and included in our study. Thirty patients underwent the COI to harvest hamstring tendons, and the other 32 patients underwent the MOI. The pin prick test was performed to detect the sensation loss at 2 weeks, 6 months, and 1 year after the operation. Digital photos of the region of hypoesthesia area were taken, and then, a computer software (Adobe Photoshop CS6, 13.0.1) was used to calculate the area of the hypoesthesia. The length of the incision and knee joint functional score were also recorded. RESULTS: At the final follow-up, the incidence of IPBSN injury in COI and MOI were 33.3% and 9.4%, and the areas of paresthesia were 26.4±2.4 cm2 and 9.8±3.4 cm2 respectively. There was no significant difference in the incision length or knee functional score between the two groups. CONCLUSION: The MOI can significantly reduce the risk of injury to the IPBSN, reduce the area of hypoesthesia, and lead to high subjective satisfaction. Therefore, compared with the COI, the MOI is a better method of harvesting hamstring tendons in ACL reconstruction.

Risk factors for and prevention of chronic pain and sensory disorders following inguinal hernia repair.

BACKGROUND: Inguinal hernia repair is one of the most common surgical procedures in man. Immediate postoperative pain is an important issue that can delay hospital discharge. Besides, the presence of chronic pain after herniorrhaphy, which can affect up to 50% of patients, is a growing concern. However information regarding the precise etiological factors of this chronic postoperative pain is lacking. One factor thought to contribute to post herniorrhaphy chronic pain is the surgical procedure for inguinal hernia repair used by the surgeon. MATERIALS AND METHOD: The study was conducted over a period of 5 years and included 1000 consecutive patients operated with inguinal hernia. Each patients completed a questionnaire about the presence or absence of pain or sensory disorders. After completed only 365 of patients remains in the study. From this patients, a total of 38 had different intensity of pain. From those, 13% were operated through an tissular procedure, whereas the laparoscopic procedure was responsible only for 7% of the patients with chronic postoperative pain. Most of the patients had mild or moderate pain and only one patient experienced severe pain. According to the type of procedure performed, in 25 patients were used the tissular procedure and only 12 patients with laparoscopic hernia repair had chronic pain. CONCLUSION: The etiology of chronic groin pain post hernia repair is related in part to nerve injury. This is supported by the high frequency of sensory symptoms and numbness in these patients. However other factors including the role of tissue injury and inflammatory postoperative changes need to be considered. KEY WORDS: Chronic postoperative pain, Inguinal hernia repair, Open surgery, Laparoscopic surgery.

Collaboration between the breast and plastic surgeon in restoring sensation after mastectomy.

Breast cancer is the most commonly diagnosed invasive cancer in women worldwide. While hypoesthesia is a known sequela after mastectomy, patients are now inquiring with renewed interest about the degree and timing of sensation after mastectomy. This is a topic that has generated much research interest. However, while there have been advances in the field, there are few, well-done studies that allow for an accurate answer to this question. In this article, relevant breast and donor site anatomy is reviewed for sensate autologous breast reconstruction. Additional donor sites apart from the typically utilized abdomen are analyzed with relevant anatomical discussions. Outcomes are presented; however, due to the heterogeneity of the patient population, surgical approach and postoperative sensory testing, it is difficult to compare results between studies. Future directions and unanswered questions regarding sensate autologous breast reconstruction are highlighted. While great strides have been made in providing sensate autologous breast reconstruction, there are still many unanswered questions. Thus, the collaboration between surgical teams and sharing of outcomes is crucial to allow for optimization of this powerful surgical approach.

Piezoelectric surgery versus mechanical drilling for orbital floor decompression: effect on infraorbital hypoaesthesia.

Purpose: To compare efficacy and safety of mechanical drill and piezoelectric technology in the prevention of infraorbital nerve hypoaesthesia during orbital floor decompression. Methods: Single-centre, non-randomized prospective, interventional case series. We enrolled 24 patients who underwent 3-wall orbital decompression. A total of 13 patients underwent floor decompression using 5-mm diamond dusted Piezoelectric tip (Synthes GmbH, Oberdorf, Germany), whereas 11 patients underwent conventional mechanical decompression of the floor using Stryker Core handpiece with 5-mm diamond dusted tip (Stryker, USA) and a Kerrison's bone ronguer. All surgeries were performed by a single surgeon (MNN) using standard surgical technique. The infraorbital nerve hypoesthesia was measured pre-operatively, and post-operatively on day 1, at 1 week, 6 weeks, 3 months, and final follow-up by an independent observer. Hypoaesthesia was graded on a simple numerical scale: 0 defined as "normal", 1 defined as "minimally reduced", 2 defined as "grossly reduced but perceptible", and 3 defined as "total loss". Results: The average follow-up after surgery was 16 months (range 13-48 months). The average score in the mechanical drilling group at day 1, week 6, week 12 and final follow-up was 1.9, 1.2, 0.7, and 0.6, respectively (p < 0.001). For the Piezo group, the average scores were 0.3, 0.2, 0.1, and 0.1, respectively. No procedure related complications were noted, and the average surgical time for floor decompression was comparable (p > 0.5). Conclusions: Piezoelectric technology is effective in orbital floor removal by minimizing infraorbital nerve hypoaesthesia.

Preventing hypoesthesia after a buccal plate fracture in a sagittal split procedure: A technical note.

If during a sagittal split osteotomy a buccal plate fracture occurs, it inevitably results in a time-consuming procedure with, in many cases, hypoesthesia of the mental region as a consequence of manipulation of the inferior alveolar nerve. We would like to present a novel technique to solve a (threatening) buccal plate fracture that is quick and easy to perform, and has thus far not resulted in hypoesthesia.

A Technique of Endoscopic Nipple-Sparing Mastectomy for Breast Cancer.

BACKGROUND AND OBJECTIVES: Nipple-sparing mastectomy (NSM) is a widely accepted surgical technique for patients with early breast cancer. The technique improves cosmetic outcomes, but a decrease in nipple sensitivity has been observed with NSM because of the incision into the nipple-areola complex (NAC). Endoscopic nipple-sparing mastectomy with skin lifting system (ENSMSLS) removes all breast tissue through the axillary incision used for the sentinel lymph node biopsy, to avoid incision around the NAC area. With only one incision, NAC sensitivity is less likely to be affected by this technique. We sought to investigate the effect of ENSMSLS on sensation in the NAC, compared with NSM. METHODS: A single-institution retrospective review was performed from August 2014 through August 2015. Thirty patients who underwent NSM in the past 6 years were frequency matched for age and cancer stage with those who underwent ENSMSLS between 2014 and 2015. All patients were recalled and re-examined for the study. Patients from the ENSMSLS group were recalled twice at both 3 and 6 months after surgery. Matched control subjects who underwent NSM were examined when they were recalled. The sensations of pressure, temperature, and vibration were measured. RESULTS: Patients who underwent ENSMSLS were significantly less likely to have decreased or impaired sensations of pressure, temperature, and vibration compared those who had NSM. The improvement in preservation of sensations by the use of ENSMSLS was very impressive. CONCLUSIONS: ENSMSLS, which avoids incision around the NAC, significantly decreases the possibility of decline in NAC sensation.

Modified reversed superficial peroneal artery flap in the reconstruction of ankle and foot defects following severe burns or trauma.

OBJECTIVE: Challenges persist in the reconstruction of the ankle and the foot with exposed tendons, joints, and bones as a result of severe burns and trauma. In flap elevation involving the sensitive superficial nerve, the local nerve was always sacrificed to obtain an anesthetic donor site; however, such a procedure introduced the possibility of painful neuromas. In this study, we present a desired clinical application of a modified reversed superficial peroneal artery flap, in which the superficial peroneal nerve is preserved. METHODS: From 2008 to 2015, 12 patients with ankle or foot defects were treated with the modified reversed superficial peroneal artery flap. The defects of the patients were caused by hot liquid scald (one patient), electrical injury (five patients), and trauma (six patients). The flap was utilized for covering defects on the ankle (seven patients) and the foot (five patients). The size of the flaps ranged from 4.0cm×6.0cm to 18.0cm×10.0cm. The superficial peroneal artery was involved in the flap, whereas the superficial peroneal nerve was spared by dedicate dissection. The reverse-flow flap was nourished by the superficial peroneal artery through the terminal peroneal artery perforator. RESULTS: The obtained outcomes were satisfactory functionally and aesthetically. The flaps in 11 patients survived completely without complications, whereas partial necrosis occurred in a 78-year-old patient when the flap survived a week later during follow up. CT angiography revealed the stenosis of the popliteal artery. The wound healed after interventional treatment involving placing a stent and changing the dressings. Basic functions and configurations were salvaged in all cases. All patients were completely satisfied with the proposed flap and suffered no paresthesia in their lower leg. CONCLUSION: Exhibiting beneficial characteristics such as reliable blood supply, favorable thickness, wide rotating arc, and retention of major vessels and the superficial peroneal nerve, the modified reversed superficial peroneal artery flap is useful in the reconstruction of ankle and foot defects that would not cause any hypoesthesia of the foot.

Does Liposomal Bupivacaine (Exparel) Significantly Reduce Postoperative Pain/Numbness in Symptomatic Teeth with a Diagnosis of Necrosis? A Prospective, Randomized, Double-blind Trial.

INTRODUCTION: Medical studies have shown some potential for infiltrations of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, San Diego, CA), a slow-release bupivacaine solution, to extend postoperative benefits of numbness/pain relief for up to several days. Because the Food and Drug Administration has approved Exparel only for infiltrations, we wanted to evaluate if it would be effective as an infiltration to control postoperative pain. The purpose of this study was to compare an infiltration of bupivacaine with liposomal bupivacaine for postoperative numbness and pain in symptomatic patients diagnosed with pulpal necrosis experiencing moderate to severe preoperative pain. METHODS: One hundred patients randomly received a 4.0-mL buccal infiltration of either bupivacaine or liposomal bupivacaine after endodontic debridement. For postoperative pain, patients were given ibuprofen/acetaminophen, and they could receive narcotic pain medication as an escape. Patients recorded their level of numbness, pain, and medication use the night of the appointment and over the next 5 days. Success was defined as no or mild postoperative pain and no narcotic use. RESULTS: The success rate was 29% for the liposomal group and 22% for the bupivacaine group, with no significant difference (P = .4684) between the groups. Liposomal bupivacaine had some effect on soft tissue numbness, pain, and use of non-narcotic medications, but it was not clinically significant. There was no significant difference in the need for escape medication. CONCLUSIONS: For symptomatic patients diagnosed with pulpal necrosis experiencing moderate to severe preoperative pain, a 4.0-mL infiltration of liposomal bupivacaine did not result in a statistically significant increase in postoperative success compared with an infiltration of 4.0 mL bupivacaine.

Reconstruction of nasal tip support in primary, open approach septorhinoplasty : A retrospective analysis between the tongue-in-groove technique and the columellar strut.

The reconstruction of the nasal tip support is one of the most essential issues in septorhinoplasty. A comparison of the results after using the tongue-in-groove technique and the columellar strut technique was the target of this study. Thirty-three patients who underwent a primary, open approach septorhinoplasty using the above-mentioned techniques were retrospectively analyzed. The gain in tip rotation postoperatively, the sensitivity and the rigidity of the nasal tip and the aesthetic outcome after surgery were examined and evaluated. Both techniques led to an increase in nasal tip rotation postoperatively. The gain in rotation was higher in patients, treated with the tongue-in-groove technique (p = 0.0052). The sensitivity of the tip region in the tongue-in-groove group of patients was significantly lower than that in the columellar strut group of patients (p = 0.0424). Both techniques led to high percentages of tip rigidity after surgery with satisfactory aesthetic results though. The tongue-in-groove technique and the columellar strut technique are both reliable techniques for reconstructing the nasal tip support and correcting a droopy tip. Although the tongue-in-groove technique might result in a more significant increase in tip rotation, it leads to less sensitivity in the tip region.

Can pregabalin prevent paclitaxel-associated neuropathy?--An ACCRU pilot trial.

PURPOSE: Paclitaxel can cause an acute pain syndrome (P-APS), considered to be an acute form of neuropathy and chronic chemotherapy-induced peripheral neuropathy (CIPN). Anecdotal reports suggested that gabapentin may be helpful in the prevention of these toxicities. The purpose of this pilot study was to obtain data to support or refute the utility of pregabalin for the prevention of P-APS and CIPN. METHODS: Patients scheduled to receive weekly paclitaxel (80 mg/m(2)/dose) were randomized 1:1 to receive pregabalin 75 mg or a placebo, twice daily, during the 12 weeks of chemotherapy. Patients completed the European Organization of Research and Treatment of Cancer Quality of Life (EORTC QLQ) CIPN20 questionnaire at baseline, prior to each dose of paclitaxel and monthly for 6 months post-treatment. Patients completed a post-paclitaxel questionnaire for 6 days after each dose of paclitaxel and an acute pain syndrome symptom questionnaire on day 8. The primary end point was to determine the effect of pregabalin on the maximum of the worst acute pain scores for the week following paclitaxel administration for cycle 1. RESULTS: Forty-six patients were randomly assigned to the treatment or placebo arm. There was no suggestion of a difference between the two study arms with regard to P-APS measures. While there was a suggestion that pregabalin decreased numbness, there was no suggestion that it decreased tingling, pain, or the EORTC QLQ-CIPN20 subscale scores. There were no evident toxicity differences between the two study arms. CONCLUSIONS: The results of this pilot trial do not support that pregabalin is helpful for preventing P-APS or paclitaxel-associated CIPN.

Does a minimal invasive approach reduce anterior chest wall numbness and postoperative pain in plate fixation of clavicle fractures?

BACKGROUND: Fractures of the clavicle present very common injuries with a peak of incidence in young active patients. Recently published randomized clinical trials demonstrated an improved functional outcome and a lower rate of nonunions in comparison to non-operative treatment. Anterior chest wall numbness due to injury of the supraclavicular nerve and postoperative pain constitute common surgery related complications in plate fixation of displaced clavicle fractures. We recently developed a technique for mini open plating (MOP) of the clavicle to reduce postoperative numbness and pain. The purpose of this study was to analyze the size of anterior chest wall numbness and the intensity of postoperative pain in MOP in comparison to conventional open plating (COP) of clavicle fractures. METHODS: 24 patients (mean age 38.2 ± 14.2 yrs.) with a displaced fracture of the clavicle (Orthopaedic Trauma Association B1.2-C1.2) surgically treated using a locking compression plate (LCP) were enrolled. 12 patients underwent MOP and another 12 patients COP. Anterior chest wall numbness was measured with a transparency grid on the second postoperative day and at the six months follow-up. Postoperative pain was evaluated using the Visual Analog Scale (VAS). RESULTS: Mean ratio of skin incision length to plate length was 0.61 ± 0.04 in the MOP group and 0.85 ± 0.06 in the COP group (p < 0.05). Mean ratio of the area of anterior chest wall numbness to plate length was postoperative 7.6 ± 5.9 (six months follow-up 4.7 ± 3.9) in the MOP group and 22.1 ± 19.1 (16.9 ± 14.1) in the COP group (p < 0.05). Mean VAS was 2.6 ± 1.4 points in the MOP group and 3.4 ± 1.6 points in the COP group (p = 0.20). CONCLUSIONS: In our study, MOP significantly reduced anterior chest wall numbness in comparison to a conventional open approach postoperative as well as at the six months follow-up. Postoperative pain tended to be lower in the MOP group, however this difference was not statistically significant. TRIAL REGISTRATION: ClinicalTrials.gov NCT02247778 . Registered 21 September 2014.

Post-operative benefits of Tisseel(®)/Tissucol (®) for mesh fixation in patients undergoing Lichtenstein inguinal hernia repair: secondary results from the TIMELI trial.

PURPOSE: The Tisseel/Tissucol for mesh fixation in Lichtenstein hernia repair (TIMELI) study showed that mesh fixation with human fibrin sealant during inguinal hernia repair significantly reduced moderate-severe complications of pain 12 months post-operatively compared with sutures. Further analyses may assist surgeons by investigating predictors of post-surgical complications and identifying patients that may benefit from Tisseel/Tissucol intervention. METHODS: Univariate and multivariate analyses identified risk factors for combined pain, numbness and groin discomfort (PND) visual analogue scale (VAS) score 12 months post-operatively. Variables tested were: fixation method, age, employment status, physical activity, nerve handling, PND VAS score at pre-operative visit and 1 week post-operatively. The effect of fixation technique on separate PND outcomes 12 months post-surgery was also assessed. Analyses included the intention-to-treat (ITT) population and a subpopulation with pre-operative PND VAS > 30 mm. RESULTS: 316 patients were included in the ITT, with 130 patients in the subpopulation with pre-operative PND VAS > 30. Multivariate analysis identified mesh fixation with sutures, worsening pre-operative PND and worsening PND 1 week post-surgery as significant predictors of 12-month PND in the ITT population; mesh fixation with sutures was a significant predictor of 12-month PND in the pre-operative PND VAS > 30 subpopulation (p < 0.05). Mesh fixation with Tisseel/Tissucol resulted in significantly less numbness and a lower intensity of groin discomfort compared with sutures at 12 months; there was no difference in pain between the treatment groups. CONCLUSIONS: Pre-operative discomfort may be an important predictor of post-operative pain, numbness and discomfort. Tisseel/Tissucol may improve long-term morbidity over conventional sutures in these patients.

How fast pain, numbness, and paresthesia resolves after lumbar nerve root decompression: a retrospective study of patient's self-reported computerized pain drawing.

STUDY DESIGN: A single-center retrospective study. OBJECTIVE: To compare the speed of recovery of different sensory symptoms, pain, numbness, and paresthesia, after lumbar nerve root decompression. SUMMARY OF BACKGROUND DATA: Lumbar radiculopathy is characterized by different sensory symptoms like pain, numbness, and paresthesia, which may resolve at different rates after surgical decompression. METHODS: Eighty-five cases with predominant lumbar radiculopathy treated surgically were reviewed. Oswestry Disability Index score, 36-Item Short Form Health Survey scores (Physical Component Summary and Mental Component Summary), and pain drawing at preoperative and at 6 weeks, 3 months, 6 months, and 1-year follow-up were reviewed. Recovery rate between different sensory symptoms were compared in all patients, and between the short-term compression (<6 mo) and long-term compression groups. RESULTS: At baseline, 73 (85.8%) patients had pain, 63 (74.1%) had numbness, and 38 (44.7%) had paresthesia; 28 (32.9%) had all these 3 component of sensory symptoms. Mean pain score improved fastest (55.3% at 6 wk); further resolution until 1 year was slow and not significant compared with each previous visit. Both numbness and paresthesia scores showed a trend of faster recovery during the initial 6-week period (20.5% and 24%, respectively); paresthesia recovery reached a plateau at 3 months postoperatively, but numbness continued a slow recovery until 1-year follow-up. Both Oswestry Disability Index score and Physical Component Summary scores (54.02 ± 1.87 and 26.29 ± 0.93, respectively, at baseline) improved significantly compared with each previous visits at 6 weeks and 3 months postoperatively, but further improvement was insignificant. Mental Component Summary showed a similar trend but smaller improvement. The short-term compression group had faster recovery of pain than the long-term compression group. CONCLUSION: In lumbar radiculopathy patients after surgical decompression, pain recovers fastest, in the first 6 weeks postoperatively, followed by paresthesia recovery that plateaus at 3 months postoperatively. Numbness recovers at a slower pace but continues until 1 year. LEVEL OF EVIDENCE: 4.

Lower-level laser therapy improves neurosensory disorders resulting from bilateral mandibular sagittal split osteotomy: a randomized crossover clinical trial.

Bilateral sagittal split osteotomy (BSSO) is a technique commonly used to correct mandibular disproportion but many patients experience hypoaesthesia of the inferior alveolar nerve (IAN). The purpose of this study was to verify the effectiveness of using a low-level laser therapy protocol after BSSO. The 10 patients in our study, who underwent BSSO with Le Fort I osteotomy and had low-level laser therapy on one side of the jaw, were evaluated over a period of 60 days. The data for the treated and non-treated sides were compared post-operatively. At 15, 30 and 60 days after surgery, when sensitivity was recovered on both sides. On the treated side, recovery was faster and was almost complete at the time of the last evaluation. We suggest that this lower-level laser therapy protocol can improve tissue response and accelerate the recovery of neurosensory disorders following BSSO. (NCT01530100).

Treatment of oxaliplatin-induced peripheral neuropathy by intravenous mangafodipir.

BACKGROUND: The majority of patients receiving the platinum-based chemotherapy drug oxaliplatin develop peripheral neurotoxicity. Because this neurotoxicity involves ROS production, we investigated the efficacy of mangafodipir, a molecule that has antioxidant properties and is approved for use as an MRI contrast enhancer. METHODS: The effects of mangafodipir were examined in mice following treatment with oxaliplatin. Neurotoxicity, axon myelination, and advanced oxidized protein products (AOPPs) were monitored. In addition, we enrolled 23 cancer patients with grade ≥ 2 oxaliplatin-induced neuropathy in a phase II study, with 22 patients receiving i.v. mangafodipir following oxaliplatin. Neuropathic effects were monitored for up to 8 cycles of oxaliplatin and mangafodipir. RESULTS: Mangafodipir prevented motor and sensory dysfunction and demyelinating lesion formation. In mice, serum AOPPs decreased after 4 weeks of mangafodipir treatment. In 77% of patients treated with oxaliplatin and mangafodipir, neuropathy improved or stabilized after 4 cycles. After 8 cycles, neurotoxicity was downgraded to grade ≥ 2 in 6 of 7 patients. Prior to enrollment, patients received an average of 880 ± 239 mg/m2 oxaliplatin. Patients treated with mangafodipir tolerated an additional dose of 458 ± 207 mg/m2 oxaliplatin despite preexisting neuropathy. Mangafodipir responders managed a cumulative dose of 1,426 ± 204 mg/m2 oxaliplatin. Serum AOPPs were lower in responders compared with those in nonresponders. CONCLUSION: Our study suggests that mangafodipir can prevent and/or relieve oxaliplatin-induced neuropathy in cancer patients. Trial registration. Clinicaltrials.gov NCT00727922. Funding. Université Paris Descartes, Ministère de la Recherche et de l'Enseignement Supérieur, and Assistance Publique-Hôpitaux de Paris.

Prospective outcome study of 225 cases of breast augmentation.

BACKGROUND: Despite the popularity of breast augmentation, limited information is available evaluating this procedure from the patient's perspective. No existing studies assess patient-reported data prospectively in a large number of consecutive patients with a high inclusion rate, as required by evidence-based medicine. This prospective outcome study was undertaken to obtain this information. METHODS: Over a 5-year period, 281 consecutive women underwent breast augmentation performed by the author. In-person interviews were conducted at least 1 month after surgery among 225 women (response rate, 80.1 percent). All implants, predominantly saline-filled, were placed submuscularly using primarily inframammary incisions. Questions were asked in six categories: patient data, indications, recovery, results, complications, and psychological effects. A follow-up study evaluated subjective nipple numbness. RESULTS: The mean implant volume was approximately 390 cc. The mean pain rating was 5.9 on a scale of 1 to 10. The mean time off work was 6.6 days. The mean result rating was 9.3 on a scale of 1 to 10. Expectations were met or exceeded in 98.1 percent of patients. Satisfactory size was achieved in 85.5 percent of patients and satisfactory firmness was achieved in 75.7 percent. The reported complication rate was 10.2 percent. Breast self-consciousness decreased from 86.2 percent to 12.6 percent (p < 0.001). The result rating correlated with a low rate of complications (p < 0.001). CONCLUSIONS: Breast augmentation improves self-esteem (91.1 percent) and quality of life (64.3 percent). Nipple numbness is common (39.1 percent), but persistent numbness is unusual (2.3 percent). Almost all patients (98.7 percent) would repeat the surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Bad split during bilateral sagittal split osteotomy of the mandible with separators: a retrospective study of 427 patients.

An unfavourable fracture, known as a bad split, is a common operative complication in bilateral sagittal split osteotomy (BSSO). The reported incidence ranges from 0.5 to 5.5%/site. Since 1994 we have used sagittal splitters and separators instead of chisels for BSSO in our clinic in an attempt to prevent postoperative hypoaesthesia. Theoretically an increased percentage of bad splits could be expected with this technique. In this retrospective study we aimed to find out the incidence of bad splits associated with BSSO done with splitters and separators. We also assessed the risk factors for bad splits. The study group comprised 427 consecutive patients among whom the incidence of bad splits was 2.0%/site, which is well within the reported range. The only predictive factor for a bad split was the removal of third molars at the same time as BSSO. There was no significant association between bad splits and age, sex, class of occlusion, or the experience of the surgeon. We think that doing a BSSO with splitters and separators instead of chisels does not increase the risk of a bad split, and is therefore safe with predictable results.