The Use of Celecoxib for Reduction of Pain After Subpectoral Breast Augmentation

A study was conducted to determine whether a single 400-mg dose of oral celecoxib administered 30 min before surgery reduces the opioid requirement for patients undergoing aesthetic subpectoral breast augmentation. A total of 695 patients undergoing breast augmentation were randomly selected into either a placebo or a treatment group. The findings showed that patients who received 400 mg of celecoxib 30 min before surgery required significantly fewer opioid analgesics after the operation than those given a placebo (p < 0.001). It also was found that nonsmokers and multiparous women required significantly fewer opioids than smokers and nulliparous women (p < 0.001). On the basis of this prospective study, the authors recommend a single 400-mg dose of celecoxib administered 30 min before surgery to decrease opioid analgesic requirements after subpectoral breast augmentation. Disclaimer: The authors have no financial interest in any of the medications reported in this article and received no funding from the makers of any named medication.     

Combined Preoperative Use of Celecoxib and Gabapentin in the Management of Postoperative Pain

Background  In 2005 we reported a study on the efficacy of the preoperative use of the selective COX-2 inhibitor celecoxib (Celebrex) for reducing both postoperative pain and opioid requirements in patients undergoing bilateral subpectoral breast augmentation. Our findings showed that patients who received 400 mg of celecoxib 30 min before surgery required significantly less postoperative opioid analgesics compared with those given a placebo. Gabapentin (Neurontin) is an agent commonly used to control neuropathic pain. Here we describe a prospective study assessing the efficacy of preoperative gabapentin in combination with celecoxib for reducing postoperative pain and opioid requirements in elective subpectoral breast augmentation. Methods  One hundred eighteen patients were given 1200 mg of gabapentin and 400 mg of celecoxib 30–60 min before surgery. From the day of surgery until postoperative day 5, patients documented any use of analgesics and recorded their degree of pain. Results were then compared with those of our previous study in which only celecoxib was used. Results  The combination of gabapentin and celecoxib was found to be significantly superior (p < 0.001) in reducing postoperative pain and opioid requirements than celecoxib alone in the management of postoperative pain and opioid requirements. Conclusion  To decrease postoperative opioid requirements, we recommend 400 mg of celecoxib and 1200 mg of gabapentin taken 30–60 min before surgery by patients undergoing subpectoral breast augmentation or a comparable plastic surgery procedure.     

A Technique to Decrease Breast Shape Deformity During Muscle Contraction in Submuscular Augmentation Mammaplasty

The main objective of this study was to decrease breast shape distortion during pectoralis muscle contraction following submuscular augmentation mammaplasty. We followed 348 patients who had retromuscular augmentation mammoplasty: 251 (72.1%) had polyurethane-covered gel-filled, 97 (27.9%) had textured-silicone gel-filled implants. Among the 348, 46 had surgery following the Regnault technique and 302 had surgery by the below-mentioned technique. Periareolar incision, bipartision of breast parenchima down to the fascia, undermining of breast base from the fascia downward to the inframammary sulcus or a little below it, detaching of muscle off the thoracic cage, disinsertion of abdomino-costal pectoralis attachments. Full thickness incision of pectoralis muscle on a vertical line on the nipple projection for 2–5 inches. Placing of prothesis. Drainage. Closure. No objective evaluation was used, only clinical judgments by three observers—the surgeon, a nurse and the patient herself. The results showed a definite decrease of the dynamic deformity among patients in whom the authors technical variation was carried out. This technique allows also, for decreasing the upward pushing of the implant during pectoralis muscle contraction and facilitates stretch of the breast tissue in patients with tighter breast envelopes. Despite lack of precise measurements, conclusions drawn from clinical judgments, taken as objectively as possible, suggest that the use of this technique may offer the solution of an otherwise disturbing collateral effect, frequently seen after this operation.     

Aesthetic Breast Augmentation and Thoracic Deformities

To ensure the best results from aesthetic breast augmentation, preoperative evaluation and adequate patient information are essential. However, assessment of the underlying thoracic shape often is neglected. Patients with obvious deformities are aware of the problematic reconstruction, whereas patients with mild or moderate deformities often are not aware of their condition and fail to see that standard breast augmentation will lead to unsatisfying results. The authors reviewed their charts for patients with breast augmentation and mild to moderate thoracic deformities, then compiled the therapeutic possibilities and the outcome. Of the 548 patients who underwent breast augmentation, 7.1% (n = 39) exhibited low- or midgrade thoracic wall deformities. Almost none of the patients were aware of their deformity. The patients were augmented with silicone-filled, textured round implants. Placement and volume were adapted to the anatomic situation. A reoperation was not performed in any case, and both patient and physician satisfaction was high. The percentage of patients with thoracic deformity in this group was high compared with an overall incidence of less than 2%. This emphasizes the need for cautious physical examination and preoperative documentation. By individualized surgical planning and diligent implant selection, optimal results and patient satisfaction can be achieved.     

Bloqueio PECS I para analgesia pós‐operatória em pacientes submetidos a mamoplastia de aumento: estudo randomizado,duplo‐cego,controlado por placebo

Background and objectivesPECS I block was first described for surgery involving the pectoralis muscles. No randomized clinical trial has been conducted on surgeries that directly involve these muscles, such as subpectoral breast augmentation. We hypothesized that PECS I block would decrease pain in the postoperative period in this population.MethodsThis was a randomized, double‐blind, placebo‐controlled trial in women undergoing subpectoral breast augmentation surgery. PECS I block was performed using 0.4 mL.kg^‐1 of 0.9% saline on one side and bupivacaine (0.25%) on the other side, each patient being her own control. Numeric Rating Scale (NRS) pain scores (0 − 10) were measured at rest and during movement. The primary outcome was pain score at rest 30 minutes after arrival in the PACU. To detect a clinically significant difference of 50% in pain reduction, 14 volunteers were enrolled (power of 90% and alpha < 0.05).ResultsIn the PACU, three patients had no difference in pain between sides, five had reduced pain on the placebo side, and six had reduced pain on the bupivacaine side. In the bupivacaine group, pain scores at rest at 5, 30 and 60 minutes and 24 hours were 4.89 (4.23 − 5.56; mean 95% CI), 3.75 (3.13 − 4.37), 3.79 (2.93 − 4.64), and 2.29 (1.56 − 3.01), respectively, whereas in the placebo group, they were 4.96 (4.32 − 5.60), 4.00 (3.50 − 4.49), 3.93 (3.12 − 4.73), and 2.29 (1.56 − 3.01), respectively.ConclusionsPECS I block in patients undergoing breast augmentation surgery does not provide better pain relief than placebo. Therefore, the indications for PECS I block in breast augmentation surgery should be reconsidered.     

A critical look at capsule contracture in subglandular versus subpectoral mammary augmentation

A critical comparison of the contracture rate in subglandular versus subpectoral augmentations was done in a personal series (senior author's) of 100 consecutive augmentation patients, 50 with subglandular augmentation and 50 with subpectoral augmentation. The average followup for the series was 27 months. Baker's classification of capsule contracture was utilized. Overall contracture rate in the subglandular group was 58% (29 of 50 patients) while in the subpectoral group it was 22% (11 of 50 patients),p<0.0002. Considering only the more severe contractures (Baker III & IV), the subglandular patients had 48% (24/50) while the subpectoral patients had 14% (7/50),p<0.0002. Comparing the more severe contractures in individual breasts, the subglandular group had 41% and the subpectoral group had 8%,p<0.0001. We conclude that in this personal series of patients, subpectoral placement of the prosthesis has significantly reduced but not eliminated the occurrence of capsule contracture without sacrificing a normal breast appearance.Presented at the American Association of Plastic Surgeons 65th Annual Meeting May 7, 1986, Washington, D.C.     

Subpectoral breast augmentation through the abdominoplasty incision

Abdominoplasty and breast augmentation are often performed together, and subglandular augmentation through the abdominoplasty incision has been previously described. Nine cases of subpectoral breast augmentation and abdominoplasty performed through a single low transverse abdominal incision were performed between 2002 and 2005. The selection criteria included women who were healthy, nonsmokers, without true breast ptosis or breast deformity requiring additional shaping. The subpectoral space was accessed and the pectoralis major origins were mobilized under direct vision, and the implant pocket was shaped with the aid of a breast sizer and breast dissector. The mean follow-up was 22 months. The surgical goals were realized in all cases, with no asymmetry or implant-related complications. The standard abdominoplasty incision provides ample exposure for the creation of a subpectoral pocket and precise placement of implants. The procedure should be considered in patients who wish abdominal recontouring and breast augmentation and have minimal ptosis.     

Delayed Breast Reconstruction with Latissimus Dorsi Flap

Background  The ideal method of breast reconstruction should be safe, reliable, and have minimal or no donor-site morbidity. We present our experience with the latissimus dorsi musculocutaneous flap for delayed breast reconstruction with immediate permanent implant insertion. Methods  The latissimus dorsi musculocutaneous flap was performed on patients who presented for delayed breast reconstruction. From 1999 to 2007, charts of patients were reviewed for age, type of mastectomy, history of chest wall irradiation, nipple-areola complex reconstruction, and complications at both the donor site and the reconstructed breast site. Results  The latissimus dorsi was used as a musculocutaneous flap in 33 patients who had breast cancer surgery. The mean age was 51.14 (range = 30–63) years. Nine patients (27%) asked for nipple-areola reconstruction. Three patients had major complications (9%), including infection, partial flap ischemia, and liponecrotic pseudocysts. Eight patients required revision. Seroma was the most common problem observed at the donor site. Conclusion  The latissimus dorsi flap provides adequate soft tissue with a reliable blood supply for the enhancement of missing tissue after mastectomy. It is a safe method for breast reconstruction and an excellent alternative flap for patients at high risk for abdominal flap complications.     

Areola-Nipple Perception Threshold to Faradic Electricity: A New Measure of Sensibility of the Breasts

Background  We describe a new method to study the sensibility of the nipple-areola complex of the breast with faradic electricity delivered through an electromyographic device used to monitor peripheral nerve conduction. Methods  The objective results of faradic pulses (2–50 mA per pulse) delivered to the nipple-areola complex of the breast through a Nihon-Kohden II machine (Evoked potential/Electromyographs, Nihon-Kohden Co., Japan) were evaluated in normal volunteers to get a basal measure that was defined by the patient as “a soft electric discharge.” The measures were recorded and their output discharges averaged (at least 5 to each complex). Results  Twenty-eight volunteers with normal breasts, 28 patients with breast hypertrophy before and after breast reduction, and 28 patients before and after breast augmentation were studied. The faradic pulses were perceived from 1.5 to 3.5 mA in the areola and from 3 to 5.5 mA in the nipple in the control group and from 4.5 to 7.0 mA in the areola and from 6.5 to 9.5 mA in the nipple in the breast hypertrophy group with no significant changes before and after surgery. In the breast augmentation group the faradic pulses were very similar to the volunteers that had normal breasts, but 13 months after breast augmentation with silicone gel prosthesis, a difference was found because all the patients had a higher threshold and three cases had lost sensibility of the nipple-areola complex. Conclusion  In normal breasts the areola had a lower threshold for faradic pulses compared to the nipple. Hypertrophic breasts had a higher threshold to the faradic stimulation than normal subjects in the pre- and postoperative period. Hypoplastic breasts before breast augmentation had a perception threshold similar to that of the normal volunteers but after breast augmentation this perception was much higher. This study received the Scientific Exhibit Award at the ASAPS/ASERF Annual Meeting in Vancouver, British Columbia, Canada, 2005.     

Management of Tuberous Breast Deformity with Anatomic Cohesive Silicone Gel Breast Implants

Background  Tuberous breast deformity is a rare congenital condition that often requires surgical correction. Numerous surgical techniques have been described, reflecting the reconstructive challenge of this deformity. The anatomic cohesive gel breast implant is a powerful tool in both aesthetic and reconstructive breast surgery. In the authors’ experience, its use in treating tuberous breast deformity has provided the opportunity for a single-stage approach, with very good results. Methods  The senior author has managed more than 50 cases of single-stage reconstruction for tuberous breast deformity using anatomic cohesive gel breast implants. His surgical technique is described with suggestions for achieving optimal results. Representative case examples are provided. Conclusions  The anatomic cohesive silicone gel breast implant is an excellent device for treating tuberous breast deformity. It often can be used as a single-stage correction of the deformity with very good results. The authors strongly advocate consideration of its use in tuberous breast deformity reconstruction.     

Dynamic Breasts: A Common Complication Following Partial Submuscular Augmentation and its Correction Using the Muscle-Splitting Biplane Technique

Background  Dynamic breast deformity following partial submuscular augmentation is not uncommon. The complication is due primarily to the release of the pectoralis and the true incidence of this complication is not known. The submuscular biplane pocket is a new pocket and is used to correct dynamic breasts following augmentation mammaplasty in the partial submuscular plane. Methods  After the first submuscular biplane muscle-splitting augmentation mammaplasty in October 2005, the author has performed 58 secondary augmentation mammaplasties for various reasons. Of these, nine patients showed marked dynamic breast deformity following partial submuscular augmentation and the submuscular muscle-splitting biplane was used to correct this complication. Results  Good to excellent results were achieved in all patients with complete elimination of the dynamic breast deformity. Conclusion  The submuscular biplane is a new and versatile pocket and is used to correct dynamic breast deformity seen following partial submuscular augmentation mammaplasty.     

Acellular Dermis-Assisted Breast Reconstruction

BACKGROUND: In 2004, the authors reported their findings with placement of tissue expanders for breast reconstruction in the partial submuscular position, the equivalent of the "dual-plane" technique for breast augmentation. Limitations with subpectoral expander placement include difficulty controlling the lower pole of the pocket during expansion, unprotected device coverage by a thin inferior mastectomy flap, possible effacement of the inframammary fold, and limited control over the superior migration of the pectoralis major muscle. This study aimed to examine the safety and efficacy of an acellular dermal sling in providing inferolateral support to the device during immediate breast reconstruction and expansion. METHODS: This study prospectively investigated 58 breasts of 43 consecutive women who underwent immediate breast reconstruction with tissue expanders and acellular dermis. After completion of adjuvant therapy and expansion, the devices were exchanged for implants. The patients were tracked through January, 2007. The study parameters included demographic information, oncologic data, complications, and aesthetic outcomes. RESULTS: The mean time required to complete reconstruction was 8.6 months. The overall complication rate after expander/acellular dermis placement was 12%, whereas the complication rate after exchange to implants was 2.2%. The aesthetic outcome for reconstructed breasts did not differ significantly from that for the control subjects who had no surgery. CONCLUSIONS: Acellular dermis appears to be a useful adjunct in immediate prosthetic breast reconstruction. Acellular dermis-assisted breast reconstruction has a low complication rate, helps to reconstruct an aesthetically pleasing breast, and facilitates expeditious completion of the reconstruction.     

Advantages and Outcomes in Subfascial Breast Augmentation: A Two-Year Review of Experience

BACKGROUND: One of the most popular surgical cosmetic procedures, breast augmentation, has enjoyed large acceptance in the last few decades. One of the most important factors in the dynamics established between the implants and the soft tissues after breast augmentation is the pocket plane. Surgeons have been seeking the proper plane into which the implant might be placed. The subglandular approach resulted in implant edge visibility and was thought to result in a higher incidence of fibrous capsular contractures. Despite the advantage of concealing the implant edges using the subpectoral approach, implant displacement occurred with contraction of the pectoralis muscle. The use of the retrofascial plane seems to yield the benefits of both planes without the deficits. METHODS: Since 2006, 45 patients with hypomastia have undergone subfascial breast augmentation using anatomical contour profile gel cohesive III textured implants. RESULTS: Pleasing long-term results have been obtained by using subfascial breast augmentation, with maintenance of a natural breast shape and a smooth transition between the soft tissue and implant in the upper pole. There were no capsular contractures and no complaints regarding displacement of the implants with contraction of the pectoralis major muscle. CONCLUSIONS: The subfascial breast augmentation technique offers improved long-term aesthetic results because the dynamics between the implant and soft tissues have been optimized. This technique is extremely versatile and may also be used in patients requiring removal and replacement of breast implants.     

Breast-conserving therapy and sentinel lymph node biopsy are feasible in cancer patients with previous implant breast augmentation

BACKGROUND: Breast-conserving therapy (BCT) is reported to result in a significant rate of complications and local recurrences in patients with prior implant breast augmentation. The role of sentinel lymph node (SLN) biopsy in these patients is unknown. METHODS: Retrospective review of patients with prior breast augmentation treated with BCT or SLN biopsy. RESULTS: Nineteen breast cancers were treated with BCT. Of 17 breasts undergoing adjuvant radiotherapy, 11 (64.7%) retained favorable aesthetic results. Of 9 subpectoral implants, capsular contracture developed in only 1 (11.1%). During follow-up (median 3 years), 1 local recurrence (5.3%) occurred in a patient who refused adjuvant radiotherapy and systemic therapy. Eleven patients underwent SLN biopsy with an identification rate of 100% and a false-negative rate of 0%. CONCLUSIONS: Breast-conserving therapy inclusive of radiotherapy after implant breast augmentation produced acceptable cosmetic results in nearly two-thirds of patients. Sentinel lymph node mapping in the setting of prior implant augmentation was highly successful and accurate.     

Sentinel Node Biopsy in Patients with Previous Breast Aesthetic Surgery

Background  Sentinel lymph node biopsy (SLNB) is the standard method for axillary staging of early breast cancer. Recent studies have focused on questioning the initial contraindication to the technique. There has been insufficient data to recommend SLNB in patients with previous aesthetic breast surgery. Materials and Methods  Between April 2001 and June 2007, 70 patients with previous breast aesthetic surgery underwent SLNB. Fifty had a previous breast augmentation and 20 had breast reduction mammoplasty. All patients underwent lymphoscintigraphy with 99Tc according to our standard technique and sentinel node was identified in all cases. Results  Mean age at cosmetic surgery was 38 years. Mean number of years from aesthetic surgery to the development of the tumour was 10 years. Forty-nine patients underwent conservative breast surgery and 21 patients underwent mastectomy. The sentinel node identification rate was 100%. SLN was positive in 23 patients (32%); there were 18 cases with macrometastasis and 7 cases with micrometastasis. After median follow-up of 19 months, no axillary recurrences have been observed. We observed two ipsilateral local recurrences, one contralateral tumour and one patient developed lung metastasis. Conclusions  Past history of breast augmentation or reduction is not a contraindication to SLNB technique.     

Breast Augmentation in Asymmetrically Placed Nipple-Areola Complex in the Horizontal Axis: Lateralisation of Implant Pocket to Offset Lateralised Nipples

Background  Nipple-areola complex (NAC) lateralisation in the horizontal axis is understudied with respect to its potential effects on the outcome of augmentation mammoplasty. An implant pocket dissected slightly laterally on the affected side offsets the lateralised nipple and improves the quality of breast enhancement in the lateral quadrant with an aesthetically positioned NAC. It also prevents the appearance of medially malplaced implants. Methods  Medial and lateral halves of breasts were measured in 312 mammaplasties performed by the author in 2007; of these, 39 (12%) had NAC asymmetrically positioned in the horizontal plane, 29 (9%) were right lateralised, 4 (1.2%) left lateralised, 5 (1.5%) bilaterally lateralised, and 1 (0.3%) was bilaterally medialised. In the more common right-lateralised group (n = 25), the mean medial half measurement was 8.76 ± 1.22 cm compared with 8.96 cm in the control group (n = 170), with no statistical significance (P = 0.45). However, the lateral half measurement in the lateralised nipple group (n = 25) was 9.06 ± 1.53 cm compared with 9.7 ± 1.67 cm in the control group (n = 169) and it showed a borderline significant value (P = 0.06). On the affected side, the medial boundary of the breast pocket is marked 0.25–0.5 cm further away from the routine 2.5-cm intermammary distance with the goal of offsetting the lateralised NAC and to improve its visual aesthetic position on the breast. Results and Conclusion  Lateralisation of the breast pocket in a breast with a lateralised nipple improves the aesthetic position of the NAC. In compensated augmentation mammaplasties, lateral quadrant enhancement of the breast is aesthetically superior to uncompensated cases and prevents the appearance of medially malplaced implants. The intermammary distance in compensated cases was acceptable without any compromise to the aesthetic outcome. Presented as a poster presentation at the Sixth Croatian Congress of Plastic, Reconstructive and Aesthetic Surgery with International Participation, Split, Croatia, 1–5 October 2008, and as an invited lecture at the International Master Course on Ageing Skin (IMCAS), Agra, India, 1–2 December, 2008.     

Brava辅助自体脂肪移植矫正乳房局部缺损

目的探讨Brava辅助自体脂肪移植矫正乳房局部缺损的可行性。方法 2010年1月至2010年10月,共39例乳房局部组织缺损、凹陷畸形患者接受Brava负压辅助自体脂肪移植治疗。在接受自体脂肪注射移植隆乳术前1个月,患者按照要求佩戴Brava,每天佩戴8 h,直至手术当日。自体脂肪抽取处理后,分层均匀注射至组织缺损部位,同时以16 G注射器针头松解黏连。结果术后随访1~12个月,未发现脂肪液化、结节、钙化等并发症。术后效果满意度调查,37例对手术效果非常满意(94.9%),1例对手术效果基本满意(2.6%),1例由于乳房畸形矫正不彻底而对手术效果不满意(2.6%)。结论对于乳腺肿瘤的局部切除后,以及PHAG取出以后形成的局部缺损凹陷,Brava辅助自体脂肪移植是理想的手术方法。     

Augmenting the narrow-based breast: The unfurling technique to prevent the double-bubble deformity

Routine subpectoral or subglandular mammary augmentation in women with a small breast (particularly lower pole deficiency) often results in poor late results with the appearance of a double-bubble deformity. We describe our experience with a technique of unfurling the breast tissue at augmentation in an effort to avoid this complication and improve the long-term results.