Sub-muscular Breast Augmentation Using Tumescent Local Anesthesia

New Frontiers in Wide-Awake Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery.

SUMMARY

Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.

Retrospective Study on Optimizing Breast Augmentation Outcomes in Transgender Patients: A Comprehensive Analysis of Tumescent Local Anesthesia Technique

BACKGROUND

Tumescent local anesthesia (TLA) involves the infusion of a saline solution containing lidocaine and epinephrine into tissues to achieve localized anesthesia and vasoconstriction. While the use of TLA in sub-glandular augmentation mammoplasty has been documented, we present a modified TLA approach for primary sub-muscular breast augmentation in transgender patients based on our experience over the past years.

METHODS

Between the years 2014 and 2021, we performed primary sub-muscular breast augmentation on 20 transgender patients under TLA and conscious sedation. The tumescent solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Initially, the solution was infiltrated between the pectoral fascia and the mammary gland, and subsequently, during the surgery, under the pectoralis major muscle.

RESULTS

The average volume of tumescent solution infiltrated during TLA was 740 mL per breast. There were no reports of adrenaline or lidocaine toxicity, and no cases required a conversion to general anesthesia. Patients experienced no pain or discomfort during the preoperative infiltration or surgical procedure. Reoperations due to short-term complications never occurred. We observed a major complication rate of 5%, represented by 1 hematoma. Long-term complications comprised one case of implant dislocation and one occurrence of dystrophic scar formation. No cases of capsular contracture needing reoperation, asymmetry, and implant rupture occurred. In total, one individual (5%) requested larger implants. Follow-up time ranged from 30 days to 1 years.

CONCLUSIONS

Overall, augmentation mammaplasty is a valuable choice for transgender women aiming to enhance their feminine characteristics and alleviate gender dysphoria. It is imperative for patients to conduct thorough research, grasp the potential pros and cons, and consult experienced healthcare professionals in transgender care. Additionally, tumescent local anesthesia (TLA) has proven to be a safe and efficient method for sub-muscular breast augmentation, providing effective pain control with minimal postoperative complications, resulting in high patient satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes of Abdominoplasty in Tumescent Local Anesthesia Combined with Subdural Anesthesia

BACKGROUND

Abdominoplasty is a common surgical procedure performed under general anesthesia, and although the use of TLA combined with subdural anesthesia has never been reported in abdominoplasty, it offers several benefits such as safe and effective local anesthesia and vasoconstriction. We outline our experience with the TLA technique for primary abdominoplasty over the last 7 years.

METHODS

From 2014 to 2021, TLA and subdural anesthesia have been used in primary abdominoplasty surgeries for 106 patients. The TLA solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) diluted in 1000 mL of 0.9% saline solution. The solution was then injected with a 2-mm cannula into the subcutaneous adipose tissue in the suprafascial plane. The subdural anesthesia was performed at intervertebral level L1-L2 using Ropivacaine 15/18 mg in 4 ml.

RESULTS

Patients aged from 32 to 75 years. The amount of tumescent solution infiltrated ranged between 500 and 1000 mL. Mean surgery time was 70 minutes, and recovery room time averaged at 240 minutes. Major complications related to the surgery were observed in 12.26% of patients, including eight hematomas and five seromas. Two patients experienced wound dehiscence, and no dystrophic scar formation was observed. Eventually, there was no need for a conversion to general anesthesia.

CONCLUSIONS

Tumescent local anesthesia combined with subdural anesthesia is a highly effective and safe method for performing abdominoplasty. This technique has proven to be an excellent choice for primary abdominoplasty, providing significant benefits to patients and surgeons alike due to its safe administration, precise pain management during and after surgery, and minimal postoperative side effects.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of Radiofrequency-Assisted Liposuction (BodyTite) for Upper Arms Lifting

BACKGROUND

Body contouring surgery is increasingly requested by patients, both for aesthetic and post-bariatric purposes. There has also been a rapid increase in demand for noninvasive aesthetic treatments. While brachioplasty is burdened by numerous complications and unsatisfactory scars, and conventional liposuction is unsuitable for all patients, nonsurgical arm remodeling performed with radiofrequency-assisted liposuction (RFAL) allows to effectively treat most of patients, regardless of the amount of fat and ptosis of the skin and avoiding surgical excision.

METHODS

A prospective study was conducted on 120 consecutive patients who presented to the author's private clinic and required upper arm remodeling surgery for aesthetic purposes or after weight loss. Patients were classified according to the modified classification of El Khatib and Teimourian. Pre- and posttreatment upper arm circumferences were taken after 6 months of follow-up to assess the degree of skin retraction obtained by treating the arm with RFAL. A satisfaction questionnaire regarding the appearance of the arms (Body-Q upper arm satisfaction) was administered to all patients before surgery and after 6 months of follow-up.

RESULTS

All patients were effectively treated with RFAL, and no cases required conversion to brachioplasty. The average reduction in arm circumference was 3.75 cm at 6 months follow-up, and patients' satisfaction increased from 35 to 87% posttreatment.

CONCLUSIONS

Radio frequency is a valid tool to treat most patients with upper limbs skin laxity, with significant aesthetic results and a high degree of patient satisfaction, regardless of the degree of skin ptosis and lipodystrophy of the arm.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes of Intramuscular Gluteal Augmentation With Implants Using Tumescent Local Anesthesia

BACKGROUND

Tumescent local anesthesia (TLA) describes the practice of injecting a very dilute solution of local anesthetic combined with epinephrine and sodium bicarbonate into the tissue until it becomes firm and tense to obtain local anesthesia and vasoconstriction. The use of TLA in augmentation intramuscular gluteoplasty has never been described for implants positioning. Advantages of the TLA technique include a reduction in blood loss through epinephrine-induced vasoconstriction and hydrostatic compression from the tumescent effect. We describe TLA technique for primary intramuscular gluteal augmentation, reporting our experience during the last 5 years.

METHODS

From 2017 to 2021, 20 patients underwent bilateral primary gluteal augmentation under TLA and conscious sedation. The tumescent solution was prepared with 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. The solution was infiltrated with a cannula inside the gluteus maximus muscle intra-operatively.

RESULTS

The mean age of the patients was 39, 15 years. The average amount of tumescent solution infiltrated was 240 mL per gluteus. Operating time was 1 h and 40 min, and recovery room time averaged 240 min. Major surgery-related complications were found in 15% of patients (2 hematomas and 1 seroma) and minor complications were described in a total of 8 patients (4 wound dehiscence and 1 dystrophic scar formation). No signs of adrenaline nor lidocaine toxicity were reported and conversion to general anesthesia was never required.

CONCLUSIONS

The tumescent local anesthesia technique represents a safe and efficacious technique for performing gluteal augmentation surgery with an intramuscular implant positioning. The advantages of this technique are safety, reasonable pain control during and after surgery and a low incidence of postoperative side effects due to general anesthesia avoidance.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

How long to wait after local infiltration anaesthesia: systematic review

BACKGROUND

Conflicting evidence exists regarding the optimal waiting time for stable analgesic and vasoconstrictive effects after local infiltration of lidocaine with epinephrine. An objective review is needed to dispel surgical dogma.

METHODS

This systematic review (PROSPERO ID: CRD42022362414) included RCTs and prospective cohort studies. Primary outcomes were (1) onset of analgesia and (2) onset of stable hypoperfusion, assessed directly, or measured indirectly using perfusion imaging. Other data extracted include waiting strategies, means of outcome assessment, anaesthetic concentrations, volume/endpoint of infiltration, and injection sites. Methodological quality was evaluated using the Cochrane risk-of-bias tool for randomized trials. Articles describing waiting strategies were critically appraised by the Joanna Briggs Institute tools.

RESULTS

Twenty-four articles were analysed, comprising 1013 participants. Ten investigated analgesia onset. Their pooled mean was 2.1 min (range 0.4-9.0 min). This varied with anatomic site and targeted nerve diameter. Fourteen articles investigated onset of stable hypoperfusion. Four observed bleeding intraoperatively, finding the minimum time to hypoperfusion at 7.0 min in the eyelid skin and 25.0 min in the upper limb. The ten remaining studies used perfusion imaging, reporting a wide range of results (0.0-30.0 min) due to differences in anatomic sites and depth, resolution and artefacts. Studies using near-infrared reflectance spectroscopy and hyperspectral imaging correlated with clinical observations. Thirteen articles discussed waiting strategies, seven relating to large-volume tumescent local infiltration anaesthesia. Different waiting strategies exist for emergency, arthroscopic and cosmetic surgeries, according to the degree of hypoperfusion required. In tumescent liposuction, waiting 10.0-60.0 min is the norm.

CONCLUSION

Current literature suggests that around 2 min are required for most patients to achieve complete analgesia in all sites and with all anaesthesia concentrations. Waiting around 7 min in eyelids and at least 25 min in other regions results in optimal hypoperfusion. The strategies discussed inform decisions of when and how long to wait.

Back to the future: breast surgery with tumescent local anesthesia (TLA)?

PURPOSE

Breast surgery is usually performed under general anesthesia. Tumescent local anesthesia (TLA) offers the possibility to anesthetize large areas with highly diluted local anesthetic.

METHODS

In this paper, the implementation, and experiences with TLA in the field of breast surgery are discussed.

CONCLUSION

For carefully selected indications, breast surgery in TLA represents an alternative to ITN.

The efficacy of pectoral nerve block for pain control after breast augmentation: A meta-analysis of randomized controlled studies

BACKGROUND

The efficacy of pectoral nerve block for pain control remains unknown in patients undergoing breast augmentation. This meta-analysis aims to explore the analgesic efficacy of pectoral nerve block for breast augmentation.

METHODS

We systematically searched PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases, and included randomized controlled trials reporting pectoral nerve block versus no block for breast augmentation.

RESULTS

Five randomized controlled trials were included in this meta-analysis. Compared with control group after breast augmentation, pectoral nerve block was associated with substantially reduced pain scores at 1 hour (standard mean difference [SMD] = -1.63; 95% confidence interval [CI] = -2.81 to -0.44; P = .007), maximal pain scores at 1 to 6 hours (SMD = -1.72; 95% CI = -2.75 to -0.69; P = .001) and 6 to 24 hours (SMD = -2.06; 95% CI = -3.40 to -0.72; P = .003), rescue analgesic (odd ratio = 0.17; 95% CI = 0.05-0.57; P = .004), nausea (SMD = 0.21; 95% CI = 0.08-0.54; P = .001), and vomiting (odd ratio = 0.15; 95% CI = 0.05-0.39; P = .0001).

CONCLUSIONS

Pectoral nerve block benefits to alleviate pain intensity after breast augmentation.

Breast augmentation under local anesthesia with intercostal blocks and light sedation

INTRODUCTION

This study of breast augmentations performed under local anesthesia with intercostal blocks and light sedation describes the outcomes and evaluates benefits and complications.

METHOD

From December 2005 until August 2019, 335 women consecutively underwent bilateral breast augmentation procedures. The anesthetic protocol consisted of an initial intravenous bolus of 1 mg midazolam and 0.25 mg alfentanil preoperatively. In 2017, this was changed to 2-4 mg midazolam intramuscularly, 1 mg midazolam intravenously, and 2.5 µg sufentanil intravenously. Intercostal blocks were injected at the midaxillary line into the intercostal spaces two to seven. The operating field was infiltrated with tumescent local anesthesia. Retrospective data extraction from patients' medical charts was done, registering demographics, dosage of anesthesia, surgical characteristics, complications, and reoperation rates.

RESULTS

Two hundred and eighty-one women underwent primary augmentation and 54 had implant replacement. The most common complications included suboptimal cosmetic results, asymmetry, and healing-related problems. The overall rate of reoperation was 16.1% within an average follow-up period of 2 years, ranging from 0 to 12.5 years. The majority of the reoperations were due to cosmetic reasons. The change in anesthetic regime was associated with a significantly (p < 0.0001) decreased need for supplementary medication with no increased risk of complications.

CONCLUSION

Breast augmentations in local anesthesia with intercostal blocks and light sedation can be performed safely and can serve as an alternative to procedures in general anesthesia.

PEC block versus local anesthetic infiltration in breast implant augmentation surgery: a retrospective study

INTRODUCTION

Pectoral plane (PEC) blocks are routinely used in analgesia for patients undergoing dual-plane breast augmentation with implants. Local anesthetic infiltration (LAI) is a simple alternative technique with the same aim. We evaluated both techniques.

MM

In this single-center retrospective study, patients received PEC block (ropivacaine 0.2%, 10 ml PEC I, 20 ml PEC II) or LAI. The primary outcome measure was pain, according to the visual analog scale (VAS), at 24h post-surgery. Secondary outcomes included the measure of pain at 1, 2, 6, and 12 hours post-surgery, total opioid consumption at 24h, and opioid side effects.

RESULTS

81 were finally recruited: 37 in the PEC group and 44 in the LAI group. Patient characteristics were comparable between the two groups. At 24h post-surgery, the LAI group showed a decrease in pain, with a VAS score of 0.7 vs 1.5 in the PEC group (p = 0.007). There was no difference in VAS between the two groups at 1, 2, 6, or 12 hours post-surgery. The duration of anesthesia was increased in the PEC group with 153 minutes vs 120 minutes in the LAI group (p < 0.001). There was no difference in rescue morphine consumption between the two groups.

CONCLUSIONS

We found that LAI had a superior analgesic effect at 24h after surgery for dual-plane breast implant augmentation compared with PEC block. These findings are a good indication that the LAI technique is at least as effective as PEC block while being safe, fast, and easy to use.

Complication Differences Between the Tumescent and Non-Tumescent Dissection Techniques for Mastectomy: A Meta-Analysis

Purpose

We conducted a systematic literature search and pooled data from studies to compare the incidence of complications between the tumescent and non-tumescent techniques for mastectomy.

Methods

We searched PubMed, Embase, BioMed Central, Ovid, and CENTRAL databases for studies comparing the two mastectomy techniques up to November 1^st, 2020. We used a random-effects model to calculate odds ratios (OR) with 95% confidence intervals (CI).

Results

Nine studies were included with one randomized controlled trial (RCT). Meta-analysis indicated no statistically significant difference in the incidence of total skin necrosis (OR 1.18 95% CI 0.71, 1.98 I² = 82% p=0.52), major skin necrosis (OR 1.58 95% CI 0.69, 3.62 I² = 71% p=0.28), minor skin necrosis (OR 1.11 95% CI 0.43, 2.85 I² = 72% p=0.83), hematoma (OR 1.19 95% CI 0.80, 1.79 I² = 4% p=0.39), and infections (OR 0.87 95% CI 0.54, 1.40 I² = 54% p=0.56) between tumescent and non-tumescent groups. Analysis of studies using immediate alloplastic reconstruction revealed no statistically significant difference in the incidence of explantation between the two groups (OR 0.78 95% CI 0.46, 1.34 I² = 62% p=0.37). Multivariable-adjusted ORs on total skin necrosis were available from three studies. Pooled analysis indicated no statistically significant difference between tumescent and non-tumescent groups (OR 1.72 95% CI 0.72, 4.13 I² = 87% p=0.23).

Conclusion

Low-quality evidence derived mostly from non-randomized studies is indicative of no difference in the incidence of skin necrosis, hematoma, seroma, infection, and explantation between the tumescent and non-tumescent techniques of mastectomy. There is a need for high-quality RCTs to further strengthen the evidence.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

Partition of Pectoralis Major Musculocutaneous Flap as a Salvage Procedure for Simultaneous Coverage of the Exposed Carotid Artery and Reconstruction of Cervical Esophagus

BACKGROUND

In advanced pharyngoesophageal cancer patients, a critical event is represented by the failure of primary reconstruction with exposure of the carotid artery and partial or total defect of the cervical esophagus. For these high-risk patients, a partitioned pectoralis major musculocutaneous (PMMC) flap can prevent carotid blowout and provide skin for simultaneous esophageal reconstruction.

METHODS

Twenty-six patients needing pharyngoesophageal reconstruction together with coverage of carotid artery exposure were included in this retrospective case series. The patients were treated with a partitioned PMMC flap, based on the branching pattern of the pectoral branch of the thoracoacromial artery and the perforators of the pectoralis major muscle, to simultaneously reconstruct the defect and provide coverage for the carotid artery.

RESULTS

In 25 patients, the partitioned PMMC flap reconstructions resulted in complete wound healing without occurrence of carotid blowout syndrome or fistula formation. Minor complications as partial flap necrosis (7.7%) and strictures formation (7.7%) were recorded but did not compromise reconstruction. Twenty-two patients were able to adopt a semisolid diet, and 4 had recurrence of cancer.

CONCLUSIONS

The partitioned PMMC flap reconstruction represents a useful salvage solution to simultaneously restore the continuity of the alimentary tract and provide reliable coverage for the exposed carotid artery.

Helix Thigh Lift. A Novel Approach to Severe Deformities in Massive Weight Loss Patients

BACKGROUND

After massive weight loss, the severe gynoid body contour deformities are not always faceable with optimal results. The thigh is one of the most demanding area to address; therefore, the approach should be virtually individualized. The authors describe the helix thigh lift: A novel technique that combines vertical with horizontal axis of pull. The goal of this ultimate customization is to dramatically impact physical functioning and esthetics of this patient population.

METHODS

Thigh lift patients from 2016 to 2019 were assessed retrospectively; fourteen patients were selected for helix thigh lift procedure. Preoperative markings, surgical technique and outcomes were described. The mean follow-up time was 14.8 ± 3.2 months. A questionnaire was administered to evaluate the results.

RESULTS

Fourteen female patients (mean age, 42 ± 4.8 years) underwent helix thigh lift after massive weight loss. The overall complication rate was 36 percent. They were all minor complications and were treated in an outpatient setting. Seroma formation was the most frequent, at 29 percent. No skin necrosis was reported. Complication development was straight related to the age of the patient (p = 0.0455). The patients were very satisfied with the overall outcome.

CONCLUSIONS

Helix thigh lift effectively addresses the severe gynoid body contour deformities. The high satisfaction and the reasonable complication rate suggest that this is a safe and effective technique. The age of the patient was significantly associated to complication development. A dramatic improvement of ease in performing activities of daily living along with reduction of the skin problems leads to significant improvement of the quality of life.

Muscle-Sparing Skin-Reducing Breast Reconstruction with Pre-Pectoral Implants in Breast Cancer Patients: Long-Term Assessment of Patients' Satisfaction and Quality of Life

INTRODUCTION

Breast cancer is the most frequently diagnosed tumor in women; globally, it accounts 23% of all cancer deaths. Breast reconstruction after oncologic surgery has become crucial to enhance patients' quality of life and alleviate the psychological distress related to the disease. The aim of this study was to assess quality of life and esthetic satisfaction of breast cancer patients undergoing muscle-sparing skin-reducing breast reconstruction (MS-SR) with pre-pectoral implants.

METHODS

Sixty-three patients who met definite oncological and reconstructive criteria were enrolled in the study. Specific questionnaires (EORTC QLQ-C30, QLQ-BR23) were administered preoperatively, 1, and 12 months after MS-SR breast reconstruction to evaluate patients' QoL. Satisfaction with procedure and related Quality of Life were assessed through BREAST-Q questionnaire preoperatively and 12 months after surgery.

RESULTS

Sixty-three breast cancer patients underwent MS-SR. Seventy-eight procedures were carried out; in 15 patients a bilateral reconstruction was performed. One month after surgery, both EORTC QLQ-C30 and QLQ-BR23 average scores demonstrated a slight drop since preoperative values, but a significant improvement in QoL was documented 12 months after BR (p < 0.05). BREAST-Q test showed significant psychophysical and esthetic satisfaction 12 months postoperatively.

CONCLUSIONS

Muscle-sparing skin-reducing breast reconstruction is an established and reliable technique. EORTC QLQ-C30, QLQ-BR23 and BREAST-Q scores showed an improvement of patients' QoL and esthetic satisfaction. Reduction of pain and other surgery-related symptoms are cornerstones of patient well-being. Both physicians and patients should build a thorough awareness of the silver lining of muscle-sparing skin-reducing breast reconstruction based on the high safety profile and highly satisfactory patient-reported results.

Complications after breast augmentation with hyaluronic acid: a case report

Breast augmentation is a very requested procedure in aesthetic surgery. Over time, various techniques of breast augmentation have been described, both through the use of alloplastic materials and autologous tissues: implants, fat grafting, flap surgery, and injectable fillers. According to the international current trend to perform minimally invasive procedure, injectable fillers have progressively increased their uses and notoriety in aesthetic medicine. Among the various available products, hyaluronic acid is likely to be the most popular synthetic filler all over the world. Nowadays many brands are on the market and this paper focuses on Macrolane which is a NASHA-based (stabilized hyaluronic acid of non-animal origin) filler. However, although highly biocompatible, as any material, foreign to our body, also hyaluronic acid fillers undergo a process of degradation and disposal. In our work, we report the first case in literature of migration of Macrolane in an axillary lymph node in a 45-year-old woman three years after injection for breast augmentation and its related management. The aim of the paper is to discuss and underline further complications and their treatment besides the ones already described in literature in order to provide a deeper knowledge concerning the use and the side effects of injectable fillers in aesthetic medicine.

Aesthetic Breast Surgery Under Cold Tumescent Anesthesia: Feasibility and Safety in Outpatient Clinic

Throughout the last decade, aesthetic breast surgery has enormously spread in the outpatient clinic setting where plastic surgeons perform the vast majority of procedures under local anesthesia as day-case operations. The "tumescent anesthesia" is defined as the injection of a dilute solution of local anesthetic combined with epinephrine and sodium bicarbonate into subcutaneous tissue until it becomes firm and tense, which is "tumescent." The "cold tumescent anesthesia" (CTA) derives from Klein's solution with the introduction of a new concept, which is the low temperature (4°C) of the injected solution. This novelty adds further anesthetic and hemostatic power to the well-known benefits of tumescent anesthesia. The authors report their experience with CTA in the last 15 years in the setting of aesthetic breast surgery, describing in detail the anesthesia protocol, surgical outcomes, and patient satisfaction. A total of 1541 patients were operated on during the study period and were included in this retrospective analysis. The types of breast procedures were breast augmentation in 762 cases (49.4%), mastopexy with implants in 123 patients (8.0%), mastopexy without implants in 452 cases (29.3%), and breast reduction in 204 cases (13.3%). Patient mean age was 42.8 years (range, 18-67 years). The mean operating time was 37 ± 32 minutes for breast augmentation, 78 ± 24 minutes for mastopexy with implants, 58 ± 18 minutes for mastopexy without implants, and 95 ± 19 minutes for breast reduction. No major complications occurred, and no conversion to general anesthesia was required. The median recovery time was 150 minutes (range, 120-210 minutes), and all patients were discharged within 3 hours after surgery. Wound or implant infections occurred in 33 patients (2.1%), wound dehiscences in 21 (1.4%), and postoperative bleeding requiring return to theater in 2 cases (0.1%). Thirteen patients (0.8%) developed capsular contracture. Fifteen patients (1%) required reintervention due to implant rotation or rupture. The median visual analog scale score was 1.8 (interquartile range, 1-3) after discharge. Patient satisfaction was very high in 91.3% (n = 1407) of the cases. In experienced hands, CTA can shorten operating time with high patient satisfaction and a low complication rate. These preliminary data could be hypothesis generating for future multicenter prospective trials done to confirm the benefits of CTA in other surgical fields.

Subfascial Breast Augmentation with Crossed Fascial Sling, Under Tumescent Anaesthesia With or Without Sedation and Lower Periareolar Access

The tumescent technique is very effective for subfascial breast implant surgery. A total amount volume of 330 cc (120/160 cc for each breast) ensures a clean and bloodless field, leading to less postoperative bruising and prolonged local anaesthesia effects. The surgical procedure can be performed with or without associated sedation. Lower periareolar anaesthesia allows for good and painless infiltration of the surgical field, up to the prepectoralis plane. A smooth, vertical dissection reached the pectoralis fascia, which was smoothly opened, leaving the gland adhesions in place. Subfascial pocket dissection was performed, and the implant was then inserted. The fascial sling, consisting of 2 strips of approximately 4/5 cm × 2 cm each, was prepared superiorly and crossed for inferior fixation. One hundred patients were included over 18 months, and all surgeries were performed under tumescent anaesthesia with general sedation. Overall, we did not need to convert from local anaesthesia in general. No complications were observed, and good cosmetic results were achieved. The follow-up periods lasted for 6 months or, in a few cases, for 1 year.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Enhancement of Viable Adipose-Derived Stem Cells in Lipoaspirate by Buffering Tumescent with Sodium Bicarbonate

Background:

Fat grafting is a growing field within plastic surgery. Adipose-derived stem cells (ASCs) and stromal vascular fracture (SVF) may have a role in fat graft survival. Our group previously demonstrated a detrimental effect on ASC survival by the lidocaine used in tumescent solution. Sodium bicarbonate (SB) buffers the acidity of lidocaine. The purpose of this study was to determine whether SB buffering is a practical method to reduce ASC and SVF apoptosis and necrosis seen with common lidocaine-containing tumescent solution.

Methods:

Human patients undergoing bilateral liposuction for any indication were included in this study. An internally controlled, split-body design was utilized. Tumescent liposuction on one side of the body was conducted with tumescent containing lidocaine. On the opposite side, liposuction was conducted by adding SB to the tumescent. Tumescent solution and lipoaspirate pH were measured. Lipoaspirate from each side was processed for SVF isolation and ASC culture. The number of viable ASCs was counted and SVF apoptosis/necrosis was examined.

Results:

The pH of the SB-buffered tumescent was significantly higher than that of the standard tumescent, an effect also seen in the lipoaspirate. Adipose-derived stem cell survival in the SB-buffered lipoaspirate was approximately 53% higher. However, there was no significant difference in SVF apoptosis and necrosis between the groups.

Conclusions:

The acidic standard tumescent solution commonly used in liposuction diminishes ASC viability from lipoaspirates. Sodium bicarbonate buffering tumescent solution can enhance ASC viability, but does not affect SVF apoptosis and necrosis. We recommend buffering tumescent with SB to potentially improve fat graft take. Our findings advocate for further research investigating mechanisms and optimal harvest techniques that maximize SVF/ASC survival and the clinical effect on overall fat graft viability.