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Background Many patients that have undergone mastectomy surgery are left with residual lateral fat under the arm. While the fat may be associated with pain and cause undesirable bulges in clothing and skin irritation, most post-mastectomy patients are not interested in additional surgery. Objectives Cryolipolysis is a nonsurgical procedure for fat reduction. The procedure is typically performed for aesthetic improvement in the abdomen, thighs, and flanks, but cryolipolysis was explored in this study for reconstructive purposes. Efficacy was evaluated for nonsurgical reduction of lateral chest wall thickness post-mastectomy. Methods A contoured cup vacuum applicator was used to treat 31 post-mastectomy patients under the arms. All subjects had undergone mastectomy but had never received cryolipolysis or any surgical procedures to reduce lateral chest wall fat. Treatments were evaluated by independent photo review and patient surveys. Results Three blinded, independent physicians correctly identified 84% of the baseline photographs, demonstrating treatment efficacy. The surveys also found that 87% of subjects reported that cryolipolysis met their expectations; 84% noticed reduction in undesirable tissue; 85% reported better bra fit; and 74% noted that clothing fit more comfortably. Patient questionnaires reveal quality of life improvements post-treatment. While 61% of subjects reported pain in the lateral wall prior to the study, when queried post-treatment, only 13% reported pain; the remaining 87% reported no lateral wall pain. Conclusions Results from this study indicate that cryolipolysis nonsurgically reduces unwanted fat and may reduce discomfort from residual lateral chest wall fat in post-mastectomy patients. Level of Evidence 4

BACKGROUND The AlloX2 Breast Tissue Expander (Sientra, Santa Barbara, Calif.) is a unique device that contains a second port to allow for transdermal communication with the pocket around the implant. The injection dome of this expander contains two ports; one is used for traditional saline injection, and a new second port facilitates fluid drainage from the periprosthetic space through an integral drain. The AlloX2 allows for the treatment of seromas and diagnostic fluid sampling to identify bacteria and hone antibiotic treatment in the setting of periprosthetic infection. This device has a significant advantage over traditional expanders, given that seromas and infections are the most common complications in implant-based breast reconstruction, with or without the use of soft-tissue support matrix. METHODS This article provides short-term case studies and surgical pearls from 3 surgeons who utilize the AlloX2 in primary breast reconstruction patients. Three surgeons implanted 40 primary reconstruction patients with AlloX2. Follow-up was approximately 6 months, per the standard of care. All patients implanted with AlloX2 underwent immediate reconstruction, with the exception of 1 delayed reconstruction. RESULTS The most common complications the patients experienced were seromas. In most cases, the surgeons successfully used the second port to drain periprosthetic fluid. CONCLUSIONS The AlloX2 has been successful in treating seromas and should be considered a tool for noninvasive treatment of common complications of implant-based breast reconstruction. Three surgeons with varied backgrounds and techniques provide their surgical and postoperative management experiences and recommendations.

Despite the increased understanding of surgical best practices, capsular contracture remains the most commonly reported complication and reason for reoperation following breast implant surgery. This study provides a long-term update to a previous investigation of potential contributing risk factors for capsular contracture in primary augmentation patients.The data used for this analysis include 5,122 implants in 2,565 primary augmentation patients implanted by 34 surgeons based on long-term results from Sientra's clinical study. Potential risk factors, including patient and implant attributes, surgery characteristics, pocket irrigation, and postsurgery characteristics, were analyzed using frequency and multivariate models.A total of 333 capsular contracture events in 224 patients were reported. The overall Kaplan-Meier rate for capsular contracture was 10.8% by device through 10 years. Results from the multivariate analysis found 8 factors to be independently associated with capsular contracture (implant placement, implant surface, incision site, hematoma or seroma development, device size, surgical bra, steroid, and antibiotic pocket irrigation; all P values0.05). Results from correlation analysis found 2 of the 8 factors to be more strongly associated with early onset capsular contracture events, compared with those occurring after 2 and 5 years of implantation (implant surface and steroid pocket irrigation).The results of this large-scale, multivariate analysis identified several significant risk factors for capsular contracture, including device features (smooth surface, smaller size), surgical factors (periareolar incision, subglandular placement, antibiotic irrigation), the development of hematoma/seroma, and the use of a surgical bra.

A panel of board-certified plastic surgeons chaired by Dr Michael Schwartz convened to discuss their respective experiences with the Sientra High-Strength Cohesive (HSC+) shaped silicone gel breast implants (Sientra, Inc., Santa Barbara, CA). The authors have implanted a combined total of over 700 patients. Preoperative planning, surgical techniques, and practice integration tips are among the topics reviewed. The surgeons also present breakthrough cases and describe how the HSC+ textured implants helped them achieve a successful outcome. Level of Evidence 5![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (

Although there are a few broadly agreed on contributory factors, the multifaceted causes of capsular contracture have remained unresolved for decades. This study investigates a variety of potential risk factors that contribute to capsular contracture in primary augmentation patients.The data used for this analysis include 5109 implants in 2560 primary augmentation patients implanted by 34 surgeons based on 5-year results from Sientra's clinical study. Patients were evaluated at annual visits where the capsular contracture Baker grade was recorded. Potential risk factors, including patient attributes, implant attributes, surgery characteristics, pocket irrigation, and postsurgery characteristics, were analyzed using frequency and multivariate models.A total of 265 capsular contracture events in 179 patients were reported through 5 years. The overall Kaplan-Meier rate for capsular contracture was 7.6 percent by device. The unadjusted analysis showed increased odds of capsular contracture in smooth devices, periareolar incision, subglandular placement, antibiotic and steroid pocket irrigation, recommended massage, and surgical bra (p0.05 for all). Results from the multivariate analysis, adjusting for all variables in the model, found six factors to be independently associated with capsular contracture (i.e., implant placement, implant surface, incision site, hematoma or seroma development, device size, and surgical bra; p0.05 for all).This analysis has provided evidence that submuscular placement and textured implants, in addition to other factors, are significant in reducing the incidence of capsular contracture.

PURPOSE: To analyze the demographics, hospital course, functional outcome, and reimbursement for elderly patients sustaining multisystem trauma. METHODS: The Trauma Registry was searched for patients > or = 65 years old with an Injury Severity Score (ISS) > or = 10 admitted with multisystem trauma from January 1991 through December 1991. Hospital data were obtained from the Trauma Registry; reimbursement data from the business office; and complete follow-up (mean, 12 months) data by telephone survey for all patients. RESULTS: Of the 1,931 trauma patients admitted during the study period, 601 (31%) were > or = 65 years old and 94 (5%) met the study criteria. Of these 94 patients, 52 were women and 42 were men; their mean age was 79 years (range, 65-100). Falls (59%) and motor vehicle crashes (36%) were the predominant causes of injury; closed head injury (CHI) and fractures were the most frequent injuries. The mean ISS was 18 (range, 10-57), and hospital stay averaged 10 days. Intensive care unit admission was necessary for 37%, and 38% required surgical intervention. Factors associated with mortality included previous myocardial infarction, chronic renal insufficiency, ventilatory or inotropic support (or both), shock (systolic BP < or = 90 mm Hg) at admission, bradycardia (HR < or = 60 bpm) at admission, and severe CHI (Glasgow Coma Scale score < or = 8). Mortality was 23% (22 of the 94 patients); three quarters of the deaths occurred in the first 24 hours--most from severe CHI. At discharge, 53% of patients (38 of 72) went home and 36% (26 of 72) went to nursing homes. At a mean follow-up of 12 months, an additional seven patients had died, and three quarters of the patients were at home with an independent functional status. The percentage of reimbursement for care was two thirds of cost. CONCLUSIONS: Mortality rates are high for elderly patients who sustain multisystem trauma. Most deaths occur within the first 24 hours, and most injuries are severe CHIs. More than half of survivors are discharged home, and most are independent at long-term follow-up. Reimbursement is not commensurate with the functional outcome achieved and the care provided.

Free-floating tumor debris or mucobilia as a cause of intermittent obstruction has been described infrequently. A patient with intermittent jaundice caused by tumor emboli from an intrahepatic polypoid mucinous cholangiocarcinoma is presented. Symptoms of intermittent jaundice and midepigastric pain persisted over 5 years despite an initial cholecystectomy and common bile duct exploration before definitive diagnosis and treatment of an hepatic trisegmentectomy (segments II, III, and IV). Intraductal mucin was confirmed intraoperatively and pathologically as the cause of the obstructive jaundice. The patient remains asymptomatic and without evidence of disease more than 5 years postoperatively. This report of a predominantly mucin-producing intrahepatic cholangiocarcinoma details a rare protracted clinical course of intermittent biliary obstruction from mucus emboli and highlights the possibility of long-term survival after complete resection.

Background and Objective: With the increasing use of laser resurfacing, concerns have arisen about the biological hazards associated with the procedure. This study analyzed the potential bacterial and viral exposure to operating room personnel as a result of the laser smoke plume in CO2 laser resurfacing. Study Design/Materials and Methods: Thirteen consecutive patients underwent CO2 laser resurfacing. A HEPA filter in the smoke evacuator was used to collect specimens of the laser plume smoke for cultures. The study was controlled by a second filter exposed to room air. Results The 13 patients each had one bacterial, one viral, and one control culture (total, 39 specimens). In the control group, none of the 13 specimens had any growth. No viral growth has been found to date. Of 13 bacterial cultures, 5 resulted in growth of coagulase-negative Staphylococcus. Of these five positive specimens, one also had growth of Corynebacterium and one had growth of Neisseria. Conclusion The potential exists for operating personnel to be exposed to viable bacteria during laser resurfacing. Lasers Surg. Med. 23:172–174, 1998. © 1998 Wiley-Liss, Inc.

Complex open wounds of the distal third of the leg and ankle remain a reconstructive challenge for the plastic surgeon. In many cases, these wounds are best addressed with a free tissue transfer. Although this group has performed more than 400 free flaps to the leg during the past 6 years, free tissue transfer can be an arduous operation that requires a team approach and substantial donor site morbidity for the patient. In recent years, the authors have favored the reverse sural artery fasciocutaneous flap in 11 patients for its ease of dissection, limited morbidity, and preservation of major vessels to the limb. Caveats for successful performance of the reverse sural artery flap include Doppler evidence of patent peroneal perforators, placement of a lazy T-shape skin paddle over the distal gastrocnemius muscle bellies, inclusion of the lesser saphenous vein to augment venous drainage, and, lastly, careful dissection to provide a wide adipofascial pedicle.

The surgical registry was reviewed for mandibular reconstruction from 1988 to 1992. During this time, 51 patients underwent mandibular reconstruction. Of this group, 17 patients had their microvascular bone grafts secured with lag-screw fixation. An AO technique, utilizing 2.7-mm cortical screws, was used to provide rigid fixation. Mandibular defects ranged from 6 to 20 cm. AO vascularized bone grafts were studied with bone scans and remained viable. Follow-up revealed no flap losses or oral cutaneous fistulae. Lag-screw fixation, in conjunction with mandibular reconstruction, results in rigid fixation, obviates the need for mandibulamaxillary fixation, has the advantage of ease of application, and is safe to use.

Pneumopericardium caused cardiac tamponade in a patient who was struck in the chest by a motor vehicle. Subxiphoid pericardial window and pericardial drainage successfully treated this condition. Diagnosis of this rare form of tamponade depends on clinical examination supported by chest radiographic findings.