German Newall

Use of abdominal field block injections with liposomal bupivicaine to control postoperative pain after abdominoplasty.

BACKGROUND It is well known that improving postoperative pain control in plastic surgery procedures leads to earlier mobilization, shortened hospital stay, reduced hospital costs, and increased patient satisfaction. OBJECTIVE The authors evaluate the use of abdominal field block injections with liposomal bupivicaine (Exparel; Pacira Pharmaceuticals, Inc, San Diego, California) in postoperative pain management in patients undergoing abdominoplasty with rectus plication. METHODS Case records from 64 female patients who underwent abdominoplasty with rectus plication were reviewed. We performed a total of 118 abdominoplasties with rectus plication, alone or in combination with other surgical procedures, from August 2012 to December 2012, but 54 patients were excluded from the series due to inadequate follow-up. Patients received liposomal bupivicaine injections in an abdominal field block fashion. Patient age, height, weight, and smoking status were recorded. Delivery of standardized postoperative intramuscular or intravenous injections and oral pain pills was recorded. Postoperative data and questionnaires were used to evaluate clinical efficacy. RESULTS The average number of procedures (including abdominoplasty with rectus plication) per patient was 7. Average patient body mass index was 27 kg/m(2). Average pain scores were 3.5 (postoperative visit 1) and 2.8 (visit 2). The average number of oral pain pills required was 14 at the first postoperative visit and 11.5 at the second postoperative visit. Patients were able to resume normal activity at an average of 6.4 days. CONCLUSIONS Our experience with liposomal bupivicaine injections for regional blocks in abdominoplasty with rectus plication indicates that patients experienced reduced postoperative pain, required less postoperative narcotic medication, and resumed both earlier ambulation and normal activity. Further investigation is warranted with more clinical cases to recommend the use of this medication for routine pain management after an abdominoplasty.

Use of a Regional Infusion Pump to Control Postoperative Pain After an Abdominoplasty

This study presents the clinical results for 20 patients who underwent abdominoplasty. A subset of these patients were given a pain relief system that provides continuous infusion of a nonnarcotic medication directly into the surgical wound to reduce postoperative pain. Whereas patients received a pain pump in addition to standard oral/intramuscular pain medication, 10 patients received only the standard oral and intramuscular postoperative pain medications. All 20 patients then were asked to complete an evaluation of their postoperative discomfort and pain. The findings show a significant reduction in postoperative pain with the use of the ambulatory pain pump. The simplicity of installing and running the pump and the benefits obtained, including early ambulation and less pain as well as reduced need and strength of narcotic medications lead the authors to believe that the implementation of this pain control technology soon will become widespread in their specialty. The study indicates that patients require less sedation and get out of bed sooner with this device, thereby reducing the incidence of deep venous thrombosis, pulmonary emboli, and narcoticdependency.

A Retrospective Study on the Use of a Low-Molecular-Weight Heparin for Thromboembolism Prophylaxis in Large-Volume Liposuction and Body Contouring Procedures

This retrospective study was designed to evaluate the efficacy of low-molecular-weight heparin (enoxeparin) as a prophylaxis for venous thromboembolism and deep venous thrombosis (DVT) in the management of large-volume liposuction, added body-contouring procedures, or both. The author present an 18-month experience with the use of this therapy for 291 consecutive patients. All the patients fell into the categories of high risk and highest risk for the development of deep vein thrombosis, embolism, or both. Three patients experienced transient DVT-like symptoms and underwent a thorough workup by an independent highly specialized critical care medical team. The results were found ultimately to be inconclusive for DVT and pulmonary embolism. However, all the patients experienced a complete recovery. The results show a 0% incidence of DVT and pulmonary embolism among patients who received enoxeparin as prophylaxis. The medication did not precipitate major bleeding when administered 1 h after surgery. This study offers the first report that describes the use of enoxeparin in aesthetic surgery for high-risk patients. The authors feel the need to inform their colleagues of the benefits obtained over the past 18 months by incorporating this therapy in large-volume liposuction and extensive body-contouring procedures performed during the same operative session. This study was conducted by a highly experienced surgical team in a fully accredited outpatient facility with established protocols for handling these types of procedures on a daily basis. The authors are optimistic about the results, and the use of enoxeparin is now part of their postoperative regimen in high-risk aesthetic surgery cases.

Thromboembolism in High-Risk Aesthetic Surgery: Experience With 17 Patients in a Review of 3871 Consecutive Cases

BACKGROUND Pulmonary embolism (PE) represents the third most frequent cause of postoperative death in the United States. In recent years, there has been an increasing demand among plastic surgeons for patient safety guidelines that specifically address the complications of deep venous thrombosis (DVT) and PE in relation to aesthetic surgery. OBJECTIVE In this study, we review 3871 consecutive major body contouring procedures performed over the last 8 years in our surgery center in an attempt to identify common factors that could have contributed to the onset of DVT/PE in 17 of these patients. METHODS We conducted a retrospective chart review to identify common factors associated with the occurrence of DVT/PE in high risk patients who undergo aesthetic surgery. RESULTS Among these patients, we calculated the following incidence rates: 0.46% for DVT and 0.08% for PE. We discovered that a culmination of factors working synergistically play a significant role in the development of DVT/PE. CONCLUSIONS We conclude that a carefully planned, comprehensive, appropriately enforced protocol is necessary to reduce the rate of thromboembolic events. Practical safety measures and technical recommendations are presented that strongly encourage the use of thromboprophylaxis during the pre-, intra-, and postoperative phases of aesthetic surgical procedures. We feel that DVT and PE prevention should involve a partnership between patient and surgeon.

Correction of Gynecomastia Through a Single Puncture Incision

In men, the development of feminized breasts may cause significant emotional distress and embarrassment, particularly in young men and adolescents. Unfortunately, gynecomastia responds poorly to diet and exercise, and conventional corrective surgery may produce large stigmatizing areolar or chest scars and a flattened or concave chest. In 2004, board-certified plastic surgeons performed 16,275 corrective procedures, and in 2005 there was a 17% increase, according to The American Society of Plastic Surgeons (ASPS) procedural statistics. This report describes a surgical approach for removal of both glandular and adipose tissue using a small 3-mm areolar stab wound incision and a piecemeal glandular resection to correct gynecomastia with minimal and imperceptible external scarring. Pectoral etching of the chest and suction lipectomy are performed simultaneously to enhance and define the thoracic musculature and further virilize the upper thorax. Excellent results have been obtained with minimal complications. The authors present their experience with more than 200 consecutive cases over the past 4 years. They are very optimistic with these results because they have obtained a high degree of patient satisfaction.

Facelift: Measurement of Superficial Muscular Aponeurotic System Advancement With and Without Zygomaticus Major Muscle Release

Multiple authors have sought ways to improve nasolabial folds, jowls, and jaw lines with face-lifting procedures. The retaining ligaments of the face support facial soft tissue in the normal anatomic position. However, with age, gravitational changes occur, and fat descends into the plane between the superficial and deep facial fascia. Face-lift procedures are designed to lift these sagging tissues. To date, the authors have not found a study that quantifies the amount of vertical advancement gain when a face-lift operation is performed with elevation of the superficial muscular aponeurotic system (SMAS). The movement was studied in 22 rhytidectomy SMAS flaps, and measurements of the vertical advancement were compared using two different SMAS patterns. Elevation and fixation of the SMAS was accomplished under the same conditions, and by the same surgeon. A high SMAS elevation was performed after skin and retaining ligaments were released. Precise measurements were obtained at the medial and lateral edges of the SMAS and before and after a backcut release from the zygomaticus major muscle. The results demonstrated an average improvement in medial flap shift gain of 14.04 mm after the release. There were no complications from these measurements during a 16-month follow-up period. The authors believe this is a particularly interesting finding because it demonstrates and quantifies an increased medial SMAS advancement shift with this maneuver, and therefore improves the cosmetic appearance of the jowls and the midface. Excellent aesthetic results were obtained with a high level of patient satisfaction.

Pectoral etching: a method for augmentation, delineation, and contouring the thoracic musculature in men.

In sculpture, pectoral muscles in the idealized Greek tradition are slab-like in appearance and fully developed from the clavicle, to a widening lower line below the areola that clearly delineates the lower pectoral border.1 The lateral edge of the pectoralis muscle begins at the anterior axillary line and continues downward along the lateral muscle bulk, seemingly to connect to the linea semilunaris or the lateral edge of the rectus muscle. There is a four-corner area where the lateral edge of the pectoral muscle, the inferior edge of the pectoralis, the linea semilunaris, and the edges of the serratus origin all converge. This outline provides a surgical roadmap for contouring the male chest according to objective and longstanding artistic ideals. Despite the passing of centuries, these standards still resonate in our contemporary culture, as is evident in popular advertising. The pectoral etching procedure aims to create an enhanced athletic profile, virilizing chest contours with minimal scarring, and to protect areolar anatomy and position. Since 1991, we have performed more than 1000 abdominal etching procedures and more than 200 cases of pectoral etching. Tumescent liposuction is typically used to correct breast lipodystrophy and excess deposits of fat over the chest wall.2 However, uniform removal of tissue may produce an adolescent, nonmuscular appearance. Our culture idealizes an exaggerated muscular chest and physique. Quite often, this hypermasculinity remains unattainable without a rigorous workout schedule and strictly controlled, high-protein nutritional supplements. We feel that the use of silicone implants is best suited for pectus excavatum and other anatomical chest deficiencies.3– 6 Pectoral implants are not without the potential for serious complications.3,5,6 Furthermore, although implants do provide a degree of instant gratification, some patients report that the pectoral implants impede their ability to exercise the chest musculature, and routine strength training may encourage lateral shifting of the implants, requiring surgical repositioning. It was with “weekend athletes” in mind that we introduced the first article on abdominal etching in 1993, inscribing the abdominal fat to mimic the palpable rectus abdominis muscle inscriptions seen in bodybuilders.7 Aggressive etching along the linea semilunaris, linea alba, and transverse inscriptions of the rectus, while conserving fat over the central muscle body, enhances the perceived fullness and appearance of the musculature. Modified abdominal etching was simultaneously introduced in 1993,7 designed for less athletic patients, leaving out the inscription etching. It is a popular approach to male contouring because of the inconspicuous scars and dramatic, chiseled results. The chest may be treated with a method borne of the same philosophy, removing fat from the lateral and inferior borders of the pectoralis major to enhance muscular appearance and projection. Liposuction is perform while leaving a modest fat pad covering the muscle bulk to enhance the profile of the pectoral muscle. Glands are typically From the Aesthetic Center for Plastic Surgery; the Department of Plastic Surgery, Baylor College of Medicine; and the Division of Plastic and Reconstructive Surgery at the University of Texas Medical School at Houston. Received for publication March 8, 2006; accepted July 18, 2006. Copyright ©2007 by the American Society of Plastic Surgeons

Safety and Efficacy of Novel Oral Anticoagulants vs Low Molecular Weight Heparin for Thromboprophylaxis in Large-Volume Liposuction and Body Contouring Procedures

BACKGROUND Preventing venous thromboembolism (VTE) remains an important topic in the plastic surgery community. However, there is little consensus regarding appropriate VTE prophylaxis for patients undergoing common body contouring procedures. OBJECTIVES This study compared the use of two novel oral anticoagulants (Rivaroxaban and Apixiban) vs low molecular weight heparin (LMWH) for postoperative chemical prophylaxis in body contouring plastic surgery procedures. METHODS A single center retrospective chart review of 1572 patients who underwent body contouring plastic surgery procedures from January 2012 to February 2015 was performed. Major complications associated with chemical prophylaxis were reviewed including hematomas requiring surgical evacuation, acute blood loss anemia requiring transfusions, and thrombotic or hemorrhagic events. RESULTS Drug-related adverse events occurred in 1.27% (n = 20) of patients. The complications encountered by the 454 patients on LMWH consisted of 0.88% (n = 4) with hematomas requiring surgical evacuation, 0.44% (n = 2) with decreased hemoglobin requiring transfusions, and 0.22% (n = 1) with a deep vein thrombosis (DVT). The complications encountered by 703 patients on with Rivaroxaban consisted of 1.3% (n = 9) with hematomas requiring surgical evacuation, 0.43% (n = 3) with decreased hemoglobin requiring transfusions, and 0.1% (n = 1) with a DVT and pulmonary embolism. The complications encountered by 415 patients on with Apixaban consisted of 0.48% (n = 2) with a DVT. CONCLUSIONS Novel oral anticoagulants (Rivaroxaban and Apixiban) are comparable to LMWH for chemical prophylaxis after body contouring procedures with similar rates of drug-related complications. Further investigation is warranted with more clinical cases in order to recommend the use of this medication for routine postoperative chemical prophylaxis after body contouring procedures. LEVEL OF EVIDENCE 3 Therapeutic.

Safest Practices for Autologous Buttock Augmentation With Fat Grafting Using a Roller Pump Injection Technique

Background Autologous buttock augmentation with fat grafting has emerged as one of the preeminent modalities for body contouring employed by plastic surgeons today. Since 2009, we have used the roller pump injection technique. Objectives This procedure can be performed safely without specialized equipment and eliminates the tasks of manual graft preparation and injection. We describe our technique and standard safety measures. The anatomy of and complications associated with liposuction and fat grafting were recorded and reviewed. Methods Retrospective chart review of 916 patients who underwent autologous buttock augmentation by this method from February 2009 to November 2016 was performed. All procedures were performed under general anesthesia at the same surgical center. Liposuction was performed and using a roller pump, the fat layer was propelled through an open-ended cannula into the recipient site. Results Mean volume of fat removed and fat grafted in each patient was 3156 mL and 1807 mL per patient, respectively. There were complications in 13 patients for a rate of 1.4% with 10 (1.1%) related to fat grafting. Fourteen patients (1.5%) had subsequent procedures for volume and four patients (0.44%) for asymmetry. There were no venous thrombolic events, fat embolic events, or deaths. Conclusions The roller pump injection technique for buttock augmentation with fat grafting is safe and efficient. This technique minimizes preparatory effort and does not require additional equipment. We were unable to identify variables associated with complication risk due to the power of this study and the low percentage of complications. Level of Evidence 4

Response to “Comparing a Propofol Infusion with General Endotracheal Anesthesia in Plastic Surgery Patients”

We appreciate the opportunity to continue further discussion on our article1 about chemoprophylaxis. Relating to Dr Swanson’s recent reply,2 there is little if any new information in regard to the original topic of deep vein thrombosis (DVT) chemoprophylaxis. His letter is focused more specifically on the type of anesthesia. Anesthesia is very complex with patient comorbidities, dosages, drug choices, etc. Dr Swanson’s personal anesthesiologist’s opinion is not evidence-based medicine and sheds no scientific light on DVT prophylaxis. Anesthesia safety is another topic and is best suited for a separate article.3 As a rebuttal, our anesthesiologists believe that general anesthesia is the safest modality for our patients. We only use board certified anesthesiologists (who have an average tenure of 14 years with the practice) throughout the entirety of every procedure in our fully accredited outpatient surgery center. As with all specialties, each practitioner has his or her own beliefs in how they deliver medical care. Therefore, we choose to trust our anesthesiologists and their recommendations, as it is in the best interest of safety for our patients. Regarding the excellent article by Kenkel et al, there is a relationship of hemodynamics and thermoregulation with moderate to high volume liposuction.4 However, Swanson tangentially correlates the reported hemodynamic findings to DVT. These clinical findings are multifactorial in origin4 and not directly correlated to anesthesia and DVT.5 Accurate information is obviously attained from high-quality clinical research studies. We fail to find the evidence-based medicine of high-quality clinical studies that have proven “S.A.F.E” anesthesia to be the ideal modality of anesthesia outside of Dr Swanson’s experience in his surgicenter.3 His published articles on the technique are statistically underpowered, “IRB approved” within his own facility, and still reported complications of DVT and (pulmonary embolism) PE.3,7,8 We encourage ASJ readers and practitioners to make the safest decision for your patients in conjunction with your anesthesiologist. We would like to conclude by refocusing the discussion on the original topic of thromboprophylaxis. We take every precaution to minimize the dreaded complication of DVT and PE, and we believe in multimodal therapy in the pre and postoperative period and use chemoprophylaxis when indicated. The risk of DVT and PE is elevated substantially with some plastic surgery procedures, especially liposuction with abdominoplasty. It is higher still in selected patients with elevated risk profiles. Some surgeons feel chemoprophylaxis is unwarranted because it raises the risks of bleeding and hematoma formation; however, medicine often is a balance of risks and benefits. We accept a small number of easily resolvable hematomas to offset the risk of DVT and the rare risk of death by pulmonary embolus. We published our article with the hope that other