Henry A. Mentz

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.

Abdominal etching: differential liposuction to detail abdominal musculature

Male athletes seeking improvement in the detail of their abdominal musculature have traditionally utilized vigorous exercise and a tightly controlled diet. Abdominal etching is a technique devised to enhance the appearance of the abdominal musculature by removing fat with liposuction at variable levels. The abdominal musculature is topographically visualized as the linea alba, linea semilunaris, and the transverse tendinous intersections within the rectus abdominous muscle. These landmarks are enhanced with localized superficial liposuction to deepen the natural grooves or furrows in these areas. We have performed abdominal etching on eight male patients with good to excellent results and minimal risks.

Fat Emboli Syndromes Following Liposuction

Fat embolism is a rare but serious complication following liposuction. There have been several case reports of fat embolism following liposuction reported in the literature [1–7], but the risks are generally regarded as extremely rare. However, since the symptoms are nonspecific, fat emboli after liposuction is most likely underestimated. It has been speculated that most patients who have liposuction will likely have some fat emboli [2]. The exact risk is unknown; however, we know that the prognosis is poor with a 15% risk of death when the syndrome is diagnosed. Fat emboli syndrome (FES) was defined as the presence of two of three clinical findings including petechial rash, pulmonary distress, and mental disturbances within the first 48 h after trauma. It is a common occurrence after longbone fractures. The diagnostic criteria defined by Gurd and Wilson have been used to assist with diagnosis. FES after liposuction is rarely reported and also has been associated with combination procedures and large-volume fat injections to the gluteal area [8], a procedure that is gaining popularity. The association with liposuction has been proven in two animal studies [9, 10] that demonstrated in lab rat and porcine models that 100% of the animals had fat emboli in the lungs following liposuction with blunt-tipped canulas and tumescent infiltration. There was also evidence of embolic injury to liver, brain, and renal tissue. It has been theorized that all human liposuctions will have some embolic effects, through either mechanical or chemical injury. Despite the technique, manual disruption of both fatty tissue and blood vessels likely causes a shower of fat emboli into the venous system. After liposuction, the treated area has residual particulate fat and lipid globules in the suctioned areas. The patients tend to be hypotensive with a compression device in place. It is a setup for particulate fat and/or triglyceride globules to enter the venous circulation and either mechanically obstruct pulmonary circulation or cause a biochemical inflammatory reaction. Both situations cause damage to endothelium leading to pulmonary vasospasm, hemorrhage, edema, and pulmonary compromise. Emboli that have passed through pulmonary circulation can also damage the brain, liver, and kidneys causing other problems. FES-diagnosed patients have had fat droplets in both bronchoalveolar lavage and urine and serum, and have had symptoms of tachycardia, tachypnea, elevated temperature, hypoxemia, hypocapnia, thrombocytopenia, and neurologic symptoms. Diagnosis is primarily by evaluation of symptoms and treatment is supportive. How many borderline clinical cases have gone undiagnosed? It is difficult to assess since diagnostic tests are hospital-based. We should keep our minds tuned to this and carefully evaluate postoperative symptoms so that we can treat immediately. The treatment of thrombotic pulmonary embolism and of FES is not the same and so it is necessary to differentiate the two. Clear risks for FES include liposuction and combinations with liposuction. Risks that are unclear might include the existence of varicose veins, ultrasonic liquidation of fat cells, cannula size, speed of surgery, volume of aspirate, number of treated areas, use of postoperative IV hydration, and large-volume lipoinjections. We may be able to lower the risk and morbidity of FES by choosing patients carefully, keeping patients well hydrated, staging procedures, keeping intraoperative time to a minimum, and using careful and effective intraoperative and postoperative monitoring. Most importantly, we must do our best to quickly diagnose FES in the event of compromise and treat patients with accuracy and effectiveness. H. A. Mentz (&) Aesthetic Center for Plastic Surgery, 12727 Kimberley Lane, Suite 300, Houston, Texas 77024, USA e-mail: drmentz@yahoo.com

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.