Clayton L. Moliver

Surgical Timing and the Menstrual Cycle Affect Wound Healing in Young Breast Reduction Patients.

Background: Young female subjects are known to have the highest baseline menstrual hormone levels of any female age group. Studies have found an association between hormone levels and wound healing. This has been researched in the orthopedic, gynecologic, and dermatologic literature, and more recently, in young patients undergoing augmentation mammaplasty. The purpose of this study was to determine whether the timing of surgery relative to the menstrual cycle plays a role in surgical complications following bilateral reduction mammaplasty. Methods: All female patients aged 25 years or younger with a documented last menstrual cycle undergoing a bilateral reduction mammaplasty from 2005 to 2013 were reviewed. Surgical timing and postoperative complications relative to the last menstrual cycle were recorded. The preovulatory phase referred to days 1 to 14 after the patient’s last menstrual cycle, whereas the postovulatory phase referred to days 15 to 28. Results: Forty-nine patients met inclusion criteria. Undergoing bilateral reduction mammaplasty during the postovulatory phase was associated with development of wound dehiscence and hypertrophic scarring (p < 0.005), which were the most common postoperative complications. Surgery in the preovulatory or postovulatory phase did not affect hematoma, seroma, wound infection, or nipple-areolar complex necrosis rates (p > 0.05). Age, race/ethnicity, body mass index, large resection mass, and medical comorbidities did not affect wound dehiscence or scar hypertrophy rates (p > 0.05). Conclusions: Young patients undergoing bilateral reduction mammaplasty during the postovulatory phase of the menstrual cycle have an increased risk of wound healing issues and poor scarring. This may be attributable to hormonal fluxes occurring during this phase and the already high hormone levels in this population.

Anatomic Relationship of the Pectoralis Major and Minor Muscles

BACKGROUND Although the anatomy of the individual pectoralis major and minor muscles has been described previously, never before has the anatomic relationship between these muscles been investigated. OBJECTIVE The authors identify the anatomic relationship of the costal origins of the pectoralis major and minor muscles. METHODS Bilateral thoracic wall dissection was completed in 102 cadavers. In each dissection, the chest wall soft tissue was removed, and the distance between costal origins of the pectoralis major and the pectoralis minor muscles was measured. RESULTS In 49 female and 53 male cadavers, 202 pectoralis major muscles were lifted to expose the costal origins of the pectoralis major and minor muscles. Distances between pectoralis major and pectoralis minor muscles were separated into 3 categories: less than 1 cm, between 1 and 3 cm, and greater than 3 cm. Forty-nine (24%) pectoralis muscle dissections displayed a distance of less than 1 cm between costal muscle origins. Eighty-three dissections (41%) showed an intermediate distance of between 1 and 3 cm, while the remaining 70 (35%) were over 3 cm. No significant difference was observed in these percentages with regard to sex. Ten cadavers displayed asymmetry in pectoralis muscle origin distance. Eight specimens displayed shared fibers between pectoralis major and minor muscles. CONCLUSIONS The anatomic relationship between the costal origin of the pectoralis major and minor muscles is highly variable. Understanding this spatial relationship has important implications for cosmetic and reconstructive breast surgery.

Safety in Office-Based Full Abdominoplasty

BACKGROUND As demand for outpatient procedures has increased, abdominoplasties are now judiciously being performed in accredited outpatient facilities. Previous reports on outpatient abdominoplasties are limited by small cohorts and have not distinguished among different types of body contouring procedures. Furthermore, these reports included patients who remained in the hospital overnight, rather than patients who were discharged within hours postoperatively. OBJECTIVES The authors review a case series of patients who underwent full abdominoplasty procedures performed in an outpatient facility with same-day discharge. METHODS Charts were retrospectively reviewed for 319 consecutive patients who underwent full abdominoplasty with the senior author (CLM) between 1992 and 2010. The charts of 206 patients for whom complete electronic medical record data were available were analyzed as a separate cohort. Demographic, operative, and postoperative data were collected. Systemic and local complications were assessed, as were revision rates. RESULTS No patients in this series developed any systemic complications, including deep venous thrombosis or pulmonary embolism, blood transfusion, intra-abdominal perforation, or death. The most common local complication was seroma, at a rate of 19.4%. CONCLUSIONS This report serves to add to the literature a large cohort of patients who underwent full abdominoplasty and were discharged within hours of surgery. The study shows that full abdominoplasty procedures can be safely performed without systemic complications in an outpatient setting. Based on these data, the ever-present sentiment that abdominoplasty is the plastic surgery procedure associated with the highest rate of venous thromboembolism should be carefully evaluated. LEVEL OF EVIDENCE 4.

Anatomy of the Sternal Origin of the Pectoralis Major: Implications for Subpectoral Augmentation

BACKGROUND The pectoralis major typically is manipulated for implant coverage and pocket design in subpectoral breast augmentation. An understanding of its anatomy can guide successful creation of the implant pocket. OBJECTIVES The authors evaluated the anatomy of the sternal origin of the pectoralis major to inform surgical planning, help establish a technique for subpectoral augmentation mammaplasty, and identify the most common locations of perforators. METHODS The sternal origins of 24 pectoralis major muscles were dissected and examined in 15 female cadavers to determine the structure and width of the pectoralis major sternal origin and its relationship to the locations of internal mammary perforators. RESULTS The average width of the sternal origin of the pectoralis major was 7.1 mm (range, 3 mm-1.8 cm). This width decreased slightly from the second rib to the second intercostal space and then increased progressively in the caudal direction toward the fifth rib. The sternal origin terminated an average of 5.4 mm (range, 1-16 mm) from the midline, with the greatest distance at the fifth rib and large variability throughout. A row of perforators from the internal mammary artery traversed the subpectoral space an average of 2.7 cm from the midline (range, 1-3.7 cm). CONCLUSIONS The sternal origin of the pectoralis major was thin and highly variable, suggesting that its partial release for implant medialization during subpectoral augmentation is unsafe.

Breast striae after cosmetic augmentation.

BACKGROUND Breast augmentation is the most popular cosmetic surgery procedure in the United States. Postoperative striae is a known but incompletely understood complication of breast augmentation. OBJECTIVES The authors investigated their own patient population to discern risk factors for new-onset striae after cosmetic breast augmentation. METHODS A retrospective chart review was performed for patients who underwent primary breast augmentation from 2005 to 2012 in a single-surgeon practice. Initial chart review revealed that only patients aged ≤25 years exhibited new striae; therefore, only patients from this age group were included. Potential risk factors examined included age, body mass index (BMI), oral contraceptive use, time of last menstrual period (LMP), parity, smoking and alcohol status, diabetes mellitus, and personal history of striae. Implant and surgical factors examined included implant material (silicone vs saline), volume, and location (submuscular vs subglandular placement) and the site of incision. RESULTS Of the 549 patients included in the study, 17 (3.10%) had new-onset striae, observed at a mean of 58 days postoperatively. The risk of striae was statistically significantly higher (P<.05) among patients who were younger (3.3 times), were nulliparous (14.38 times), began their LMP>14 days before surgery (9.24 times), and had a history of striae (6.11 times). There was a strong correlation between new-onset breast striae and implant size, as well as BMI (P=.07). CONCLUSIONS There is a strong correlation between new-onset striae and hormone levels, genetic factors, and tissue stretch components in patients who undergo cosmetic breast augmentation. This information can be utilized to better educate patients about this potential complication. LEVEL OF EVIDENCE 4.

Treatment of Nipple Hypertrophy by a Simplified Reduction Technique

BACKGROUND Nipple hypertrophy is associated with physical and psychological sequelae, leading patients to seek corrective treatment. OBJECTIVES The authors present a simple surgical technique to reduce nipple height with minimal tissue manipulation. METHODS Between November 2000 and October 2010, the senior author (CM) employed a nipple amputation technique to correct nipple hypertrophy in 30 consecutive patients. A horizontal incision was made through the distal portion of the nipple in the nonerect state to remove the predetermined nipple height. After nipple amputation, epinephrine-soaked gauze was applied to the surgical site for 5 minutes, followed by a postoperative dressing of nonstick gauze with antibacterial ointment. In 29 of the 30 patients, simultaneous breast procedures were also performed, primarily breast augmentation. RESULTS A total of 60 nipple reductions were performed on 29 women and 1 man (mean age, 37.8 ± 7.14 years). The mean follow-up was 35.9 weeks. All patients reported being satisfied with the procedure. Three patients noted decreased sensation, 1 noted a size discrepancy requiring further surgical intervention, and 1 noted persistent oozing from the surgical site on postoperative day 1. One patient who became pregnant postoperatively was identified; this patient was able to lactate in the postpartum period but was not able to produce enough milk bilaterally to perform breastfeeding. CONCLUSIONS This simplified surgical technique for correction of nipple hypertrophy was easy to perform, both alone and in combination with additional surgical procedures, and provided reproducible, satisfactory aesthetic results in this case series. LEVEL OF EVIDENCE 4.

A Muscular Etiology for Medial Implant Malposition Following Subpectoral Augmentation.

BACKGROUND Implant malposition is becoming an increasingly recognized complication following subpectoral breast augmentation. Although several causes of medial malposition have been previously demonstrated, medial implant malposition secondary to unintended pectoralis muscle slips has not been previously described. OBJECTIVE The goal of this study is to describe a form of medial implant malposition caused by pectoralis major and minor musculature vectors on the implant. METHODS The primary investigator performed a retrospective review of all patients who underwent revisional breast surgery for the diagnosis of symmastia or medial implant malposition following subpectoral augmentation. Those patients with muscular-type etiology for medial implant malposition were identified. RESULTS Five patients with pectoralis muscle slips causing medial implant malposition were identified. The pectoralis muscle slips were successfully diagnosed on preoperative exam and corrected with specific surgical procedures aimed at balancing surrounding forces and thus correcting malposition. CONCLUSIONS Pectoralis muscle slips contributing to medial malposition can be found in some patients after subpectoral breast augmentation. The etiology of this deformity is unknown, but theorized to be caused by anatomic predisposition, with slips inadvertently formed during subpectoral pocket formation arising from the pectoralis minor and/or incompletely released or accessory pectoralis major muscles.

Transition to Nonopioid Analgesia Does Not Impair Pain Control After Major Aesthetic Plastic Surgery

Background Multimodal analgesic protocols are increasingly favored over traditional opioid regimens due to decreased adverse side effects and reduced opioid consumption. Concomitant use of selective cyclooxygenase (COX)-2 inhibitor celecoxib and anticonvulsant gabapentin have been proposed to adequately control acute postoperative pain. Objectives To determine efficacy of postoperative pain control using nonopioid pain regimen vs traditional opioids for all aesthetic plastic surgery procedures. Methods A retrospective chart review was performed on 462 consecutive outpatient plastic surgery procedures by a single surgeon between November 2015 and July 2017. Procedures in the historical control group (n = 275) received traditional postoperative narcotic, hydrocodone-acetaminophen. Patients in the more recent nonopioid study group (n = 187) received a pre-, peri-, and postoperative regimen of celecoxib and gabapentin. Results Similar demographic characteristics between the control and study groups were observed: mean age, 39.7 vs 39.5 years; BMI, 24.6 vs 24.4 kg/m2; and ratio of female patients 92.7% vs 92.4%. A significant reduction in rescue analgesia (meperidine 44.6% vs 14.9%, P < 0.001) and antiemetic use (ondansetron 24.2% vs 16.3%, P < 0.05; promethazine 17.0% vs 4.7%, P < 0.001) in postanesthesia recovery unit (PACU) was noted in the nonopioid group compared to the control. The average stay in PACU also decreased in the study group (82 ± 39 min vs 70 ± 22 min, P < 0.001). Both groups reported low numbers of adverse events and need for additional pain prescriptions. These findings were reproducible in the breast subgroup. Conclusions This nonopioid regimen is as effective as traditional opioid use for acute postoperative pain control and decreased recovery time for outpatient aesthetic plastic breast surgeries. Level of Evidence 3

Commentary on: An Anatomic Appraisal of Biplanar Muscle-Splitting Breast Augmentation.

Thank you very much to the editors for the invitation to comment on the cadaveric study, “An Anatomic Appraisal of Biplanar Muscle-Splitting Breast Augmentation.”1 I commend the authors for going back to the anatomy lab to further elucidate the nuances associated with this relatively new approach to breast augmentation. This laboratory study aims to identify a safe zone for performing the biplanar muscle-splitting (BMS) augmentation mammaplasty. I would like to offer my compliments and complements. First let me compliment the authors on a well-structured study and an honest presentation of the weaknesses of the study and areas for future research. Let me also say that I have no personal experience with the BMS technique. Before delving into the merits of the article, it is instructive to revisit the pectoral nerve anatomy to avoid confusion interpreting the literature and this study. The anatomy of the pectoral nerves is a bit confusing. The classic description has the pectoralis major innervated by two nerves; the lateral pectoral nerve and the medial pectoral nerve.2-7 Some authors describe three separate nerves.8-11 One author describes four different nerves.12 The nomenclature can cause confusion as well, anatomists name the nerves according to their origin from the brachial plexus. Unfortunately the course of the medial pectoral nerve is lateral to the lateral pectoral nerve. A very detailed and wonderfully illustrated study of the pectoral nerves by David et al deserves special attention by any aspiring surgeon of the pectoral region.9 In it, they describe a superior, middle, and inferior branch consistently found during 26 brachial plexus dissections. Most importantly the upper two branches (classically referred to as the …

Response to “Comments on ‘Breast Striae after Cosmetic Augmentation’”

Thank you very much for your comments on our paper.1 We absolutely agree with you that “a potentially significant hormonal imbalance is paramount in the development of striae distensae.” We recently performed a study on young women undergoing breast reduction. We found a statistically significant increased incidence of wound problems in women who had their surgery in the postovulatory period compared with women who …