Hematomas in Aesthetic Surgery

The GLAND-IQ Technique for Surgical Correction of Moderate to Severe Gynecomastia

Surgical correction of gynecomastia currently ranks in the top five cosmetic procedures performed in men in the United States. Although removal of excess gland is relatively straightforward, the combination of glandular/fatty excess, significant skin redundancy, nipple ptosis, and nipple-areolar complex hypertrophy poses a significant challenge in the male patient desiring inconspicuous scars. The latter renders any form of skin and nipple reduction/elevation using traditional mastopexy patterns or breast amputation with free nipple grafting less favorable due to the surgical stigmata and scars produced with these techniques. To that end, we present our experience treating cases of moderate to severe gynecomastia involving significant skin excess (defined as Simon grade IIb and III) with a technique focused on avoiding visible extra-areolar scars, called the glandular excision, liposuction-assisted, areolar mastopexy for nipple repositioning and skin reduction with internal quilting sutures.

The Critical Blood-Sparing Effect of Tranexamic Acid (TXA) in Liposuction: A Systematic Review and Meta-Analysis

Introduction

Tranexamic acid (TXA) has been used to improve bleeding outcomes in many surgical procedures. However, its blood-sparing effect in liposuction is not well established.

Methods

A systematic literature search was performed using PubMed, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central, ClinicalTrials.gov, and WorldWideScience.org databases from their inception to October 8, 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors focused on 3 main topics: 1) TXA, 2) liposuction, and 3) complications. We included articles evaluating the potential blood-sparing effects of TXA in liposuction. Studies were excluded if they were systematic review articles or protocol papers, animal studies, conference abstracts, survey studies, or non-English publications.

Results

A total of 711 articles were identified, with 1 retrospective and 4 prospective (3 randomized) studies meeting our inclusion criteria. TXA was used in various forms: administered intravenously either on induction or after the procedure, mixed into the tumescent solution, or infiltrated into the liposuction sites after lipoaspiration. A significantly smaller reduction in hematocrit was noted in the TXA group compared with that in the non-TXA group (p<0.001) despite a significantly greater amount of lipoaspirate removed in the TXA group (p<0.001). Patients in non-TXA cohorts experienced adverse effects (such as seroma and need for transfusion) that were not seen in TXA cohorts.

Conclusion

TXA use in patients undergoing liposuction seems to be associated with a beneficial blood-sparing effect, which may enhance safety in this population. Future studies should aim to determine the optimal route and dosing for TXA in liposuction.

Evidence Based Medicine

Level IV.

Tranexamic Acid Irrigation in Liposuction: A Double-Blind, Half-Body, Randomized, Placebo-Controlled Trial

BACKGROUND

Hematomas are common complications following plastic and esthetic surgeries. Large and complex hematomas might result in prolonged hospitalization, further interventions, additional expenses, and poor esthetic outcome. Tranexamic acid (TXA), an antifibrinolytic agent, has long been used to reduce blood loss. Its use in the field of plastic surgery has gained popularity recently. Several studies have presented the ability of TXA to reduce blood loss, hematomas, and ecchymoses after liposuctions. However, the proper dose and the route of administration remained controversial.

OBJECTIVE

The objective of the study was to quantify the effect of a low dose of TXA in an irrigation method in reducing hematomas and ecchymoses following liposuction.

METHODS

A prospective randomized controlled trial was conducted. Following liposuction, 400 mg of TXA were administered in an irrigation protocol to one side of the body in each patient, while the other side was administered with saline. The patients were photographed on 1, 2, 4, and 11 post-operative days. Ecchymosis and hematoma were measured and rated.

RESULTS

No statistical difference was observed between the intervention and control groups in terms of RBC in liposuction area (p = 0.11), RBC in lipoaspirate (p = 0.79), bruising size on days 1, 2, 4, and 11 (p = 0.68, 0.21, 0.42, and 0.75), and average ecchymosis score on the same days (p = 0.34, 0.72, 0.09, and 1) CONCLUSIONS: The use of a low-dose TXA irrigation solution did not demonstrate a statistically significant difference in post-operative hematoma formations rates and subsequent ecchymosis size and scale.

LEVEL OF EVIDENCE II

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 .

Venous Thromboembolism Prophylaxis in Plastic Surgery Patients Undergoing Facelift

Background

In 2011, the American Society of Plastic Surgeons approved the Venous Thromboembolism (VTE) Task Force Report, which recommended the use of the Caprini scoring system, which has been adopted for VTE prophylaxis by most surgical societies in America.

Objectives

The aim of this study is to investigate the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing facelifts at a single institution who did not undergo VTE chemoprophylaxis based on the Caprini scoring system.

Methods

A retrospective chart review was conducted of patients who underwent facelift at a single institution. Patients were included if they were operated on between 2016 and 2021 by the lead surgeon and excluded if they received VTE prophylaxis. Descriptive statistics were conducted to analyze the collected data.

Results

In total, 136 patients were isolated after chart review, and no patients were found to have had DVT or VTE. The average Caprini score was 5.625 and ranged from 3 to 10. There were 3 patients with evidence of postoperative hematoma (Caprini score = 5, 5, 7). The overall hematoma percentage was 2.21%.

Conclusions

Based on the average Caprini score for the patients, all patients should have received VTE chemoprophylaxis. The authors found no VTE-related events in the patients without chemoprophylaxis. This study suggests that while the Caprini scoring system is a critical diagnostic tool for certain surgical procedures, it might not be optimal in predicting VTE in aesthetic patients undergoing surgical procedures.

Level of Evidence: 4

A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery

BACKGROUND

Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients.

OBJECTIVES

This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes.

METHODS

A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL and postoperative hematoma were performed.

RESULTS

Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3 mL average blood loss reduction (95% CI, -40.0 to -12.7 mL; P < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (odds ratio, 0.280; 95% CI, 0.076-1.029; P = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, 3 studies found statistically significant reductions in postoperative drain output, and 1 study reported significantly improved surgical site quality for patients who received TXA (P = 0.001).

CONCLUSIONS

TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation.

LEVEL OF EVIDENCE: 4

Applications of Ultrasound in the Postoperative Period: A Review

Background Recent advances in ultrasound technology have further increased its potential for routine use by plastic and reconstructive surgeons.

Methods An extensive literature review was performed to determine the most common applications of ultrasound in the postoperative care of plastic and reconstructive surgery patients.

Results In contrast with other available imaging modalities, ultrasound is cost-effective, rapid to obtain, eliminates the need for ionizing radiation or intravenous contrast, and has virtually no contraindications. In addition to its diagnostic capabilities, ultrasound can also be used to facilitate treatment of common postoperative concerns conveniently at the bedside or in an office setting.

Conclusion This article presents a review of the current applications of ultrasound imaging in the postoperative care of plastic and reconstructive surgery patients, including free flap monitoring following microsurgery, diagnosis and treatment of hematoma and seroma, including those associated with BIA-ALCL, and breast implant surveillance.

The Use of Hemostatic Agents to Decrease Bleeding Complications in General Plastic Surgery Procedures

Within plastic surgery, hematomas and seromas are frequently reported complications that can negatively impact wound healing and result in significant morbidity in patients. As a result, there has been considerable interest in hemostatic agents to complement traditional methods of hemostasis. The purpose of this study was to evaluate postoperative bleeding complications and duration of Jackson-Pratt (JP) drain use in general plastic surgery procedures with and without hemostatic agents.

Delayed unilateral hematoma after reconstructive and aesthetic breast surgery with implants in Asian patients: two case reports

Hematomas represent one of the postoperative complications in patients undergoing reconstructive or aesthetic breast surgery with a silicone implant. Although there are few reports of intracapsular hematoma, those presenting late hematoma after reconstructive and aesthetic augmentation surgeries are rarer. This study reported two Asian patients with late hematoma after reconstruction and aesthetic breast surgery. A 54-year-old female patient underwent bilateral nipple-sparing mastectomy with immediate breast reconstruction using anatomically shaped textured implant for intraductal carcinoma in August 2019. Contralateral nipple-sparing mastectomy was performed for the BRCA gene mutation on the left breast, which was immediately reconstructed with an anatomically shaped textured implant. In a 1-year postoperative magnetic resonance imaging evaluation, an extracapsular hematoma was found on the right side, which was removed following the removal of both implants. Another case was a 63-year-old female patient who underwent augmentation of both breasts with smooth round implants and experienced right unilateral swelling and painless firmness about 30 years postoperatively. A preoperative magnetic resonance imaging evaluation showed both intracapsular and extracapsular ruptures on the right breast and a bulging implant herniation on the left breast. During the operation, hematoma, implants, and capsule were all removed. The excised capsule was sent for histological evaluation. Slightly dark colored blood was emptied before removing the semisolid-state intracapsular hematoma. In both cases, the patients responded well postoperatively and were discharged to their homes with no postsurgical complications, including seroma, or additional hematoma on the breasts. The etiology of late hematoma following breast augmentation or reconstruction has been poorly characterized. Further reports are needed to clearly establish the reasons for this increase in late hematoma formation.

The Role of Tranexamic Acid in Aesthetic Plastic Surgery: A Survey of the British Association of Aesthetic Plastic Surgeons

BACKGROUND

Tranexamic acid (TXA) can reduce intra- and postoperative bleeding as well as minimizing postoperative swelling and ecchymosis. It can be administered both intravenously and topically during surgery with minimal side effects.

OBJECTIVES

To assess the evidence of TXA use in aesthetic surgery and to complete a survey of current practice of full British Association of Aesthetic Plastic Surgeons members.

METHODS

The authors performed a literature review and online survey of full British Association of Aesthetic Plastic Surgeons members.

RESULTS

There is an increased indication of TXA utilization in aesthetic surgery. It provides multiple surgeon and patient benefits.

CONCLUSIONS

TXA is a useful adjunct in aesthetic surgery.

Drainage on augmentation mammoplasty: Does it work?

BACKGROUND

Breast prostheses could be associated with complications, despite many studies on surgical materials and techniques. The role of surgical drainage in preventing complications on breast prostheses surgery is controversial.

OBJECTIVES

This study aimed to evaluate the role and effectiveness of vacuum drainage in the augmentation mammoplasty.

METHODS

A prospective multicentric randomized comparative clinical trial was conducted with 150 patients, who were the candidates for breast augmentation. The candidates were split into two groups to analyze the breast drain role. Group1: closed-suction drainage; measurements were taken every 24 h for 48 h. Group2: control (no drainage); all the patients were submitted to a clinical and postoperative ultrasonography evaluation (7th day and 3rd month). The late consultations (1st-, 2nd-, and 3rd-year postoperative time) were carried out to identify any complication, such as infection, seroma, hematoma, asymmetry, hypertrophic scarring, rippling, implant position, visible edges, and sensibility alteration.

RESULTS

A total of 150 female patients were operated with 300 breast implants placed into subglandular pocket. In the first 24 h postoperative (D1), the drainage volume ranged from 12 ml to 210 ml (mean= 74.90 ml; SD= 43.29 ml). After 24 h, on the second day (D2), the collected volume ranged from 10 ml to 120 ml (mean= 44.76 ml; SD= 24.80 ml). The total drainage volume in the 48 h ranged from 22 ml to 320 ml (mean= 119.7 ml; SD= 62.20 ml). The breast ultrasonography series (BUSGS) analysis was done on the 7th day and 3rd month in both groups. There was no significant difference between G1 and G2 groups (p = 0.05 and 0.25, respectively). In the follow-up, some patients (33-44%) declared sensitivity disturbing on the nipple-areola complex (NAC) and lower breast segment.

CONCLUSIONS

The closed-suction breast drainage in breast augmentation was associated with high cost and time-consuming and not demonstrated any benefit in a recent postoperative time.

Venous Thromboembolism Prophylaxis in Aesthetic Surgery: A Survey of Plastic Surgeons' Practices

BACKGROUND

Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), are among the most feared yet preventable surgical complications. Although many recommendations exist to reduce the risk of VTE, the actual VTE prophylaxis practices of aesthetic plastic surgeons remain unknown.

OBJECTIVES

The primary aim of this study was to elucidate plastic surgeons' experiences with VTE, preferred VTE prophylaxis practices, and areas in which VTE prevention may be improved.

METHODS

Members of The Aesthetic Society were queried via a 55-question electronic survey regarding their experience with VTE as well as their VTE prophylaxis practices. Anonymous responses were collected and analyzed by the Mayo Clinic Survey Research Center.

RESULTS

The survey was sent to 1729 of The Aesthetic Society members, of whom 286 responded. Fifty percent, 38%, and 6% of respondents reported having had a patient develop a deep venous thrombosis, pulmonary embolism, or death secondary to VTE, respectively. Procedures performed on the back or trunk were associated with the highest rate of VTE. Lower extremity procedures were associated with a significantly higher rate of VTE than expected. Over 90% of respondents reported utilizing a patient risk stratification assessment tool. Although at least one-half of respondents reported that the surgical facility in which they operate maintains some form of VTE prophylaxis protocol, 39% self-reported nonadherence with these protocols.

CONCLUSIONS

Considerable variability exists in VTE prophylaxis practices among The Aesthetic Society responders. Future efforts should simplify guidelines and tailor prophylaxis recommendations to the aesthetic surgery population. Furthermore, education of plastic surgeons performing aesthetic surgery and more diligent surgical venue supervision is needed to narrow the gap between current recommendations and actual practices.

Combining total laparoscopic hysterectomy and bilateral salpingo-oophorectomy with subcutaneous mastectomy in trans men: The effect on safety outcomes

Background: Masculinizing mastectomy is the most requested gender affirming surgery (GAS) in trans men, followed by genital GAS. Mastectomy and total laparoscopic hysterectomy, with or without bilateral salpingo-oophorectomy (TLH ± BSO), can both be performed in one single operation session. However, data on complication rates of the combined procedure is scarce and no consensus exists on the preferred order of procedures. Aims: To compare safety outcomes between mastectomy performed in a single procedure with those when performed in a combined procedure and assess whether the order of procedures matters when they are combined. Methods: A retrospective chart review was performed of trans men who underwent masculinizing mastectomy with or without TLH ± BSO in a combined session. The effects of the surgical procedure on complication and reoperation rate of the chest were assessed using logistic regression. Results: In total, 480 trans men were included in the study. Of these, 212 patients underwent the combined procedure. The gynecological procedure was performed first in 152 (71.7%) patients. In the total sample, postoperative hematoma of the chest occurred in 11.3%; 16% in the combined versus 7.5% in the single mastectomy group (p = 0.001). Reoperations due to hematoma of the chest were performed in 7.5% of all patients; 10.8% in the combined versus 4.9% in the single mastectomy group (p = 0.017). The order of procedures in the combined group had no significant effect on postoperative hematoma of the chest (p = 0.856), and reoperations (p = 0.689). Conclusion: Combining masculinizing mastectomy with TLH ± BSO in one session was associated with significantly more hematoma and reoperations compared with separately performing mastectomy. This increased risk of complications after a combined procedure should be considered when deciding on surgical options. The order of procedures in a combined procedure did not have an effect on safety outcomes.

External Quilting: New Technique to Avoid Haematoma in Gynaecomastia Surgery

BACKGROUND

Haematoma after gynaecomastia surgery is the most common early complication. It may necessitate a return to the theatre and cause increased infection risk, poor wound or delayed healing, and abnormal scar. Strategies to avoid haematoma range from perioperative blood pressure control to the use of tranexamic acid and compressive dressings.

OBJECTIVE

To demonstrate a new technique that would avoid haematoma or limit its expansion should it occur, after gynaecomastia surgery.

METHODS

One hundred and forty-nine patients had surgery for gynaecomastia between 2018 and 2019 by the senior author. External quilting sutures are used to obliterate any dead space following liposuction and piecemeal excision to address fatty, stromal, and glandular components. No drains are used. Patients receive cooling therapy before discharge, and they reattend clinic the following day for suture removal.

RESULTS

Two patients had haematomas which were managed conservatively and healed well. Fine suture tracks, which were observed in another two patients, became unnoticeable at 3 months. Overall, the complication rate in our cohort was 2.7% (haematoma 1.3%, temporary suture track 1.3%).

CONCLUSIONS

Our method is useful in minimising haematoma. It limits expansion of haematoma should it occur. Suture track is the other transient complication. This new technique in gynaecomastia correction is simple, yields good results, and gives the surgeon another option to deal with haematoma.

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.

50 Shades of Red: The Predictive Value of Closed Suction Drains for the Detection of Postoperative Bleeding in Breast Surgery

BACKGROUND

While closed suction drains (CSDs) are still frequently employed in clinical practice, the supporting evidence is limited with some studies demonstrating a failure of routine CSD use in preventing hematoma or seroma. Nonetheless, CSD quantity and quality fluid assessment is still appreciated by clinicians to detect postoperative bleeding. This study investigates the value of routine CSD use, in breast surgery, to predict postoperative bleeding.

METHODS

A retrospective, intra-individual analysis, of CSD fluid volumes between the hematoma side and the unaffected contralateral breast, was undertaken in patients (n = 20) with unilateral postoperative bleeding following bilateral breast surgery (2003-2018). Statistical analysis was undertaken to establish a minimum cutoff fluid volume that might assist in the detection of postoperative bleeding. To determine the usefulness of quality assessment of CSD fluid output by visual inspection, surgeons (n = 56) prospectively matched six eligible hemoglobin concentrations corresponding to pre-filled CSDs.

RESULTS

Statistical analysis did not yield a clinically reliable cutoff fluid volume indicating postoperative bleeding. All six eligible hemoglobin concentrations were completely successfully matched to pre-filled CSDs by 30.4% (17/56) of surgeons.

CONCLUSIONS

This study questions the significance of routine CSD use to assist in the decision-making process to return to the theater and address postoperative bleeding. Quantity as well as quality analysis of CSD fluid output failed the reliability and diagnostic validity tests. Hemoglobin measurements in drain fluid specimens via blood gas analysis might contribute to the detection of postoperative bleeding.

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 .