Modification Of Surgical Technique Research Articles

Surgical Planning and Procedures for Difficult Total Knee Arthroplasty

Most total knee arthroplasties (TKAs) are performed for minimal knee joint deformities with standard techniques and instrumentation. However, patients with extra-articular deformities, severe varus and valgus deformities, and posttraumatic arthrosis pose unique challenges to surgeons. Each deformity requires different modifications of surgical technique or prosthesis used to successfully perform TKA and optimize postoperative results. The surrounding tissues connect the femur and the tibia at the anterior, posterior, medial, and lateral walls of the knee joint. The medial soft tissues should be released for varus deformities and lateral soft tissues should be released for valgus deformities. The posterior soft tissue may be released for flexed deformities. The anterior quadriceps and patellar tendon may be adjusted while approaching the knee joint for posttraumatic arthrosis. A more constrained knee prosthesis may be needed for more severe deformities.

Latissimus Dorsi Flap Breast Reconstruction

The latissimus dorsi musculocutaneous flap has reemerged as an effective method for both immediate and delayed breast reconstruction. However, the technique is not without disadvantages, as the quality of the aesthetic result can at times be less than desired and complications at the donor site can be troublesome. It is proposed that modifications related to surgical technique and the use of higher quality expanders and implants can improve the aesthetic results while minimizing the incidence and severity of complications. Five technical modifications in surgical technique, including orientation of the skin island along the relaxed skin tension lines, harvesting the deep layer of fat with the flap, cutting the thoracodorsal nerve, partially dividing the insertion of the muscle, and using a staged expander/implant sequence, are included in an overall surgical strategy designed to reconstruct the breast in both delayed and immediate settings. As a result of these technical modifications, a thin line and smooth donor-site scar is created in the back. The flap advances completely to the breast because of the partial release of the insertion of the muscle, and the volume provided by the flap is increased by keeping the deep layer of fat attached to the flap. This more effectively softens the contours of the reconstructed breast. Breast animation is minimized as a result of sectioning of the thoracodorsal nerve, and the consistency and quality of the result are improved by using a staged tissue expander/implant strategy. With advancements in surgical technique and improvements in tissue expander and implant design, outstanding results can be obtained using the latissimus dorsi flap in breast reconstruction.

Modification of surgical technique in isolated zygomatic arch fracture repair: seven case studies

Closed reduction is applied in most cases of isolated zygomatic arch fracture. Open reduction and internal rigid fixation through a coronal incision have to be performed in other comminuted arch fractures. The authors introduced an endoscopic-assisted approach via a small preauricular incision to achieve reposition and osteosynthesis of isolated zygomatic arch fractures. The endoscopic-assisted surgical technique was performed in 7 patients with unilateral isolated zygomatic arch fractures. Endoscopically controlled management of the isolated zygomatic arch fracture was feasible in all 7 patients. The follow-up period was 1 year. All preauricular scar and facial lateral contour were aesthetically satisfactory. The endoscope-assisted approach via a small preauricular incision can achieve in situ reduction and fixation in zygomatic arch fracture and it should become an integral part of isolated zygomatic fracture repair, assuming the development of specialized training programs and improvements in endoscopes.

Osteotomy, compression and other modifications of surgical techniques for internal fixation of extracapsular hip fractures

Many different surgical techniques have been described for the internal fixation of extracapsular hip fractures. To compare different aspects of surgical technique used in operations for internal fixation of extracapsular hip fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE, EMBASE, CINAHL, Current Controlled Trials, orthopaedic journals, conference proceedings and reference lists of articles. Date of last search was January 2008. No language restriction was applied. All randomised and quasi-randomised trials investigating operative techniques used in operations for the treatment of extracapsular hip fractures in adults. Two review authors independently selected trials, assessed trial quality and extracted data. Wherever appropriate, data were pooled. Predominantly older people with trochanteric fractures were treated in the 11 included trials.One trial (65 participants undergoing fixation with a fixed nail-plate) found no statistically significant differences between osteotomy versus anatomical reduction. Four trials, involving 465 participants undergoing fixation with a sliding hip screw (SHS), compared osteotomy versus anatomical reduction. Osteotomy was associated with an increased operative blood loss and length of surgery. There were no statistically significant differences for mortality, morbidity or measures of anatomical deformity.Two trials (138 participants) compared SHS fixation of a trochanteric hip fracture augmented with cement against a standard fixation. There were no reoperations even for the four cases of fixation failure in the cement group. The cement group had significantly better quality of life scores at six months. One trial (200 participants) comparing compression versus no compression of a trochanteric fracture in conjunction with SHS fixation found no significant differences between the two groups. One trial (120 participants) found a tendency to improved outcomes with a hydroxyapatite coated lag screw, but none reached statistical significance. One trial (19 participants) reported reduced temperatures when using a modified reaming method. Another trial (50 participants) found reduced bone marrow intravascular embolism, detected by oesophageal ultrasound, when a Gamma nail was inserted with a distal pressure venting hole in the femur. There is inadequate evidence to support the use of osteotomy for internal fixation of a trochanteric hip fracture. Similarly, there is insufficient evidence to support the use of the other techniques examined in the trials included in this review.

A Systematic Approach to Minimizing Wound Problems for De Novo Sirolimus-Treated Kidney Transplant Recipients

Wound healing problems and lymphoceles have been reported with greater frequency in kidney recipients given de novo sirolimus. This problem has led to increased patient morbidity and cost; and has been an impediment to the completion of randomized controlled trials in which wound problems have necessitated premature discontinuation of mammalian target of rapamycin inhibitors. We developed a systematic program to reduce these problems based on patient selection (body mass index [BMI] <32 kg/m2), the use of closed suction drains, modifications of surgical technique, and avoidance of a loading dose of sirolimus. Consecutive series of adult kidney-only recipients given antibody induction followed by de novo sirolimus, mycophenolate mofetil, and steroids were compared; group 1: 204 patients transplanted with few restrictions and group 2: 103 patients transplanted using the above program. This approach resulted in a significant reduction (group 2 vs. group 1) in cumulative wound complications (7.8% vs. 19.6%, P=0.007), and nonoperative wound complications (2.9% vs. 14.2%, P=0.001). In addition, the incidence of lymphoceles detected (22.3% vs. 47.1%, P<0.0001), treated (4.8% vs. 24.5%, P<0.0001), or needing surgical intervention (1.9% vs. 14.2%, P=0.001) was significantly reduced. Multivariate analysis demonstrated that a BMI more than 30 to 32 kg/m2 was the most significant variable related to delayed wound healing (odds ratio [OR] 3.01, 0.02) or surgical repair (OR 8.05, P=0.0001), whereas BMI (OR 1.54, P=0.038) and acute rejections (OR 1.34, P=0.03) were most associated with lymphocele treatment. A systematic program of wound care using de novo sirolimus can produce wound healing complications comparable with that reported with other agents.

A Humeral-Sided, Subscapularis-Splitting Capsulorrhaphy Procedure for Multidirectional Shoulder Instability

The humeral-sided, subscapularis-splitting capsulorrhaphy (HSSSC) procedure is a modification of Neer and Foster's inferior capsular shift surgical technique for treating multidirectional shoulder instability. As it is currently described in the literature, when a humeral-sided capsulorrhaphy is performed, access to the capsule is gained by incising the subscapularis tendon near its insertion into the humerus. Our approach to capsular reconstruction differs in that it preserves the subscapularis tendon insertion by combining a subscapularis muscle-splitting approach with a humeral-sided T-plasty. To our knowledge, combining these 2 techniques has not been previously described. We report the clinical results at 39-month average follow-up for 5 female overhead athletes who underwent HSSSC by the senior author (C.E.G.). A theoretical argument for performing capsular reconstruction in this manner is also presented. In our small series, HSSSC resulted in excellent shoulder stability, excellent patient satisfaction, and restoration of a high level of athletic performance. We believe that our approach will better preserve subscapularis function, but further studies are necessary to prove this and to compare the results of this procedure with other shoulder-stabilizing techniques.

Extravesical Ureteral Reimplantation: An Outpatient Procedure

We determined whether implementation of a critical pathway and modification of the extravesical ureteral reimplantation surgical technique to repair unilateral and bilateral vesicoureteral reflux would consistently result in same day patient hospital discharge without increased morbidity. We evaluated all children undergoing extravesical ureteral reimplantation using a modified technique that limits ureteral dissection, ureteral mobilization and detrusor dissection to as distal as possible. No surgical dissection is done in proximity to the obliterated umbilical artery, nor is the artery ligated. Patients follow a strict postoperative critical pathway, and parents receive extensive preoperative and postoperative education. The child is required to fulfill strict criteria to be discharged home. A total of 51 girls and 9 boys 0.9 to 10.5 years old (mean age 5.1) were evaluated. A total of 24 unilateral and 36 bilateral procedures were performed with and without ureteral tapering, and for single systems, duplex systems and an associated Hutch diverticulum. Overall 54 children (90%) were discharged home the same day, while only 6 (10%) went home the next day. All patients who underwent a unilateral procedure and 83% who underwent a bilateral procedure were outpatients. However, when evaluating the last 40 consecutive patients, including 14 with a unilateral and 26 with a bilateral procedure, all (100%) were discharged home the day of surgery without increased morbidity or an additional analgesic requirement. All outpatients were discharged within 5 hours after surgery. All patients tolerated the procedure well without major complications and without any patients requiring an emergency department visit or hospitalization after discharge home. After the urinary catheter was removed all patients were able to spontaneously void postoperatively without any acute or chronic urinary retention. This study demonstrates that implementation of a strict critical pathway and a unilateral or bilateral extravesical ureteral reimplantation surgical technique with limited dissection can consistently result in same day discharge from the hospital within a few hours postoperatively without increased morbidity or rehospitalization.

Anomalies of Left Coronary Artery Origin Affecting Surgical Repair of Hypoplastic Left Heart Syndrome and Shone Complex

There has traditionally been less concern regarding coronary anomalies with left-sided congenital heart lesions such as hypoplastic left heart syndrome (HLHS)or Shone complex than with other lesions. However, coronary anomalies in this setting can profoundly affect surgical intervention, particularly when surgical repair involves the ascending aorta. We describe four patients with congenital left-sided heart lesions in which left coronary artery (LCA) anomalies substantially affected intervention and outcome. In the first two cases, the coronary anomalies were not identified prospectively and resulted in surgical injury directly to the coronary or to its surrounding region. In the latter two cases, successful identification of the coronary anomaly preoperatively allowed for modification of surgical technique and/or intervention. We conclude that detailed coronary artery assessment should be part of the routine echocardiographic evaluation of congenital left-sided heart lesions that require surgery.

Predictors for aneurismal formation

Predictors for aneurismal formation

Radical Nephrocapsulectomy and Caval Thrombectomy with Extracorporeal Circulation and Deep Hypothermic Circulatory Arrest in Right Anterior Minithoracotomy: A Minimally Invasive Approach

Radical nephrocapsulectomy and cavoatrial thrombectomy with median sternotomy and abdominal access, using extracorporeal circulation (ECC) and deep hypothermic circulatory arrest (DHCA), has become the gold standard treatment for renal cell carcinoma (RCC) with neoplastic thrombosis of the suprahepatic and intrapericardial inferior vena cava (IVC) and right atrium (RA). Any modification of surgical techniques should be compared with this therapeutic strategy. In our quest to identify a minimally invasive approach and to apply available technology to ensure patient safety, even in cases of RCC with suprahepatic IVC and RA thrombosis, we identified a therapeutic approach that foresees en bloc radical nephrocapsulectomy, with ECC and DHCA in right anterior minithoracotomy. Furthermore, to make surgery even safer, we made some modifications and used auxiliary maneuvers. We present the case of a 39-year-old man with a neoplasm that involved the right kidney and suprahepatic IVC thrombosis, undergoing radical nephrocapsulectomy and thrombectomy with ECC and DHCA in right anterior minithoracotomy. Radical nephrocapsulectomy and thrombectomy of the suprahepatic and intrapericardial IVC and/or of the RA with ECC and DHCA in right anterior minithoracotomy for RCC is a valid minimally invasive alternative to standard surgical techniques. Compared with standard median sternotomy access, right anterior minithoracotomy allows a more rapid functional recovery, a reduction in risk of infection of the wound, and a reduction in pain during postoperative convalescence, and has considerable esthetic advantages, without limiting surgical therapeutic chances, regardless of the cranial extension of the thrombus.

Effect of BioGlue® on the Incidence of Pancreatic Fistula Following Pancreas Resection

BackgroundDespite numerous modifications of surgical technique, pancreatic fistula remains a serious problem and occurs in about 10% of patients following pancreas resection. BioGlue is a new sealant that creates a flexible mechanical seal within minutes independent of the body’s clotting mechanism. HypothesisApplication of BioGlue sealant will reduce the incidence of pancreatic fistula following pancreas resection. MethodsA retrospective cohort study was performed with 64 patients undergoing pancreas resection. BioGlue sealant was applied to the pancreatic anastomosis (Whipple) or resection margin (distal pancreatectomy) in 32 cases. Factors that could affect the rate of postoperative pancreatic fistula were recorded. Pancreatic fistula was defined as greater than 50 ml of drain output with an amylase content greater than three times normal serum value after postoperative day 10. To improve the sensitivity of our study, we also examined pancreatic fistula with a strict definition of any drain output on or after postoperative day 3 with a high amylase content and graded the fistulas in terms of clinical severity. Grade A leaks were defined as subclinical. Grade B leaks required some response such as making the patient nil per os, parenteral nutrition, octreotide, antibiotics, or a prolonged hospital stay. Grade C leaks were defined as serious and life threatening. They were associated with hemorrhage, sepsis, resulted in deterioration of other organ systems, and mandated intensive care. Comparisons between the two groups were made using the chi-square test or Fisher’s exact test for categorical variables and by the Wilcoxon rank-sum test for continuous variables. P values of 0.05 or less were deemed statistically significant. ResultsThere were no differences between the patients who received BioGlue and the control cohort in terms of comorbid conditions, tumor location, texture of the pancreas, size of the pancreatic duct, or surgical technique. By the common definition, pancreatic fistula occurred in 6% (control) vs. 22% (BioGlue). By the strict definition, a fistula occurred in 41% (control) vs. 60% (BioGlue). In the control group, ten were subclinical (grade A) and two were clinically apparent leaks (grade B). In the BioGlue group, seven were subclinical (grade A), five were clinically apparent (grade B), and three were severe (grade C). There were no statistically significant differences in the incidence or severity grades of postoperative pancreatic fistulas between the two groups. ConclusionApplication of BioGlue sealant probably does not reduce the incidence of pancreatic fistula following pancreas resection.

Variation in the venous drainage of left lateral segment liver graft requiring reconstruction of segment III vein with donor iliac artery

Variation in the venous drainage of left lateral segment liver graft requiring reconstruction of segment III vein with donor iliac artery

Category-specific naming and recognition deficits in temporal lobe epilepsy surgical patients

ObjectiveBased upon Damasio's “convergence zone” model of semantic memory, we predicted that epilepsy surgical patients with anterior temporal lobe (TL) seizure onset would exhibit a pattern of category-specific naming and recognition deficits not observed in patients with seizures arising elsewhere. MethodsWe assessed epilepsy patients with unilateral seizure onset of anterior TL or other origin (n=22), pre- or post-operatively, using a set of category-specific items and a conventional measure of visual naming (Boston Naming Test: BNT). ResultsCategory-specific naming deficits were exhibited by patients with dominant anterior TL seizure onset/resection for famous faces and animals, while category-specific recognition deficits for these same categories were exhibited by patients with nondominant anterior TL onset/resection. Patients with other seizure onset did not exhibit category-specific deficits. Naming and recognition deficits were frequently not detected by the BNT, which samples only a limited range of stimuli. InterpretationConsistent with the “convergence zone” framework, results suggest that the nondominant anterior TL plays a major role in binding sensory information into conceptual percepts for certain stimuli, while dominant TL regions function to provide a link to verbal labels for these percepts. Although observed category-specific deficits were striking, they were often missed by the BNT, suggesting that they are more prevalent than recognized in both pre- and post-surgical epilepsy patients. Systematic investigation of these deficits could lead to more refined models of semantic memory, aid in the localization of seizures, and contribute to modifications in surgical technique and patient selection in epilepsy surgery to improve neurocognitive outcome.

Percutaneous multilevel decompressive laminectomy, foraminotomy, and instrumented fusion for cervical spondylotic radiculopathy and myelopathy: assessment of feasibility and surgical technique

Extensive muscle dissection associated with conventional dorsal approaches to the cervical spine frequently results in local pain, muscle wasting, and temporarily painful and restricted neck movement. The utility of a percutaneous muscle-sparing access technique and specifically modified instrumentation for multilevel posterior cervical decompression and fusion were evaluated. Eleven patients (six men, five woman; mean age 72.8 +/- 6.3 years) presenting with refractory neck pain and progressive multilevel cervical radiculopathy and/or myelopathy due to cervical spondylosis with spinal canal and neural foraminal stenosis underwent multilevel laminectomy, foraminotomy, and subsequent instrumented posterior fusion via bilateral or unilateral percutaneous muscle dilation approaches. A novel cannulated polyaxial instrumentation system was used for unilateral transpedicular/translaminar fixation. Significant reduction of Neck Disability Index and Nurick Scale scores and partial or complete recovery of upper extremity radicular deficits was observed during follow-up (mean 14.6 months). Mean procedural blood loss was 45.5 ml, and mean length of stay in hospital was 5.7 days. Fusion was demonstrated in 10 patients between 12 and 14 months postoperatively. Operative exposure and instrumentation were significantly facilitated by specific modifications of retractor/access port systems, surgical instruments, and implants. Muscle sparing posterior decompression and instrumented fusion constitutes a safe and effective surgical option in a selected subgroup of patients with multilevel cervical spondylotic radiculomyelopathy. Specific modifications in surgical technique, instrumentation, and implants are mandatory for effective achievement of the surgical goals. The use of refined image guidance technology and intraoperative imaging can further improve surgical safety and efficacy.

Medical Management of the Failing Fontan

The Fontan operation accomplishes complete separation of systemic venous blood from pulmonary venous circulation in patients with single ventricle anatomy. Operative survival since the first description of the Fontan operation is excellent in the current era through modifications in surgical techniques, identification of patient-specific risk factors, and advances in postoperative care. Improved early outcomes have also resulted in a decline in late mortality for patients who have undergone staged palliation with the Fontan operation. As the number of late survivors from the Fontan operation increases, caregivers will be evermore faced with the challenge of recognizing and managing the patient with failing Fontan physiology. Even after excellent early results, patients with single ventricle lesions remain at risk of progressive ventricular dysfunction, dysrhythmias, progressive hypoxemia, elevated pulmonary vascular resistance, and protein-losing enteropathy, which can result in morbidities including but not limited to, myocardial failure, thromboembolism, and stroke. Consequently, continued long-term survival of patients who undergo the Fontan operation is dependent upon preservation of single ventricle function, avoidance of late complications, and, in the patient with a failing Fontan, recognition and treatment of the underlying pathophysiologic process that has resulted in Fontan failure.

The role of distraction osteogenesis in mandibular reconstruction

Distraction osteogenesis is finding increasing application in the management of mandibular defects. It provides an alternative method of mandibular reconstruction in varied clinical settings, notably following trauma and ablation of malignant tumors. Many recent studies have explored modifications in surgical technique, refinements in device design, and experiments in animal models. This review attempts to discuss all of the above. In addition to managing the segmental mandibular gap, the vertical distraction technique is highly useful for increasing fibular bony height, allowing osseointegrated implant placement and dental rehabilitation. Variations in distraction planes, parameters and device placement have made it possible to tailor appropriate reconstructive strategies to the specific patient. Newer developments in distractor design and constituents, and the application of staged distraction procedures, have facilitated optimal management of the challenging defect. Distraction osteogenesis is a continually evolving field of research and study, and an aesthetically and functionally acceptable option for managing extensive mandibular defects, and those not amenable to conventional methods. It offers distinct advantages over other available reconstructive options, but does have its disadvantages. With further improvement in devices and technique, it has the potential of being much more widely used in the future.

Accurate Course and Relationships of the Intraorbital Part of the Ophthalmic Artery in the Sagittal Plane

Knowledge of variations in the course and distribution of the intraorbital part of ophthalmic artery (OA) is necessary for the diagnosis and treatment of anterior cranial and orbital disorders. 38 human cadaver dissections to demonstrate the microsurgical anatomy of the intraorbital part of the OA were studied in three stages, considering its neighbourhood with the optic nerve in the sagittal plane. The first part of the OA was located on the inferolateral aspect of the optic nerve in 89.47%. The diameter and the length of the first part of the OA were 1.69+/-0.34 mm and 7.58+/-0.89 mm. 73.68% of the cases crossed the optic nerve superiorly, and 26.31% inferiorly. The diameter and length of the second part of the OA were as 1.52+/-0.29 mm and 4.12+/-0.85 mm. The diameter and length of the third part of the OA were 1.07+/-0.18 mm and 4.12+/-0.85 mm. The first branch of the intraorbital part of the OA was the central retinal artery in 26.31% of the specimens. A better understanding of the vascular anatomy of the orbit should allow for the modification of surgical techniques to reduce bleeding during biopsy or excision of orbital structures.

Preliminary experience in adult-to-adult living donor liver transplantation in a single center in China

The aim of this paper is to report the authors' experience in performing adult-to-adult living donor liver transplantation (LDLT) by using a modified technique in using grafts of the right lobe of the liver. From January 2002 to September 2006, 56 adult patients underwent LDLT using right lobe grafts at the West China Hospital, Sichuan University Medical School, China. All patients underwent a modified operation designed to improve the reconstruction of the right hepatic vein (RHV) and the tributariers of the middle hepatic vein (MHV) by interposing a vessel graft, and by anastomosing the hepatic arteries and bile ducts. There were no severe complications or deaths in all donors. Fifty-two (92.8%) recipients survived the operations. Among the 56 recipients, complications were seen in 15 recipients (26.8%), including hepatic vein stricture (one case), small-for-size syndrome (one case), hepatic artery thrombosis (two cases), intestinal bleeding (one case), bile leakage (two cases), left subphrenic abscess (one case), renal failure (two cases) and pulmonary infection (five cases). Within three months after transplantation, four recipients (7.14%) died due to small-for-size syndrome (one case), renal failure (one case) and multiple organ failure (two cases). All patients underwent direct anastomoses of the RHV and the inferior vena cava (IVC), and in 23 cases, reconstruction of the right inferior hepatic vein was also done. In 24 patients, the reconstruction of the tributaries of the MHV was also done by interposing a vessel graft to provide sufficient venous outflow. Trifurcation of the portal vein was seen in nine cases. Thus, veno-plasty or separate anastomoses were performed. The graft and recipient body weight ratios (GRWR) were between 0.72% and 1.43%, and in three cases it was <0.8%. The graft weight to recipient standard liver volume ratios (GV/SLV) were between 31.86% and 71.68%, among which four cases had <40%. No "small-for-size syndrome" occurred. With modification of the surgical technique, especially in the reconstruction of the hepatic vein to provide sufficient venous outflow, living donor liver grafts in adults using the right lobe of the liver can become a relatively safe procedure and prevent the "small-for-size syndrome".

Wartość wielorzędowej tomografii komputerowej w wykrywaniu wad wrodzonych ucha wewnętrznego oraz przydatność metody w klinicznej kwalifikacji do implantacji

Summary Aim The aim of the study was retrospective review of multidetector computed tomography (MDCT) findings in group of patient with suspected congenital inner ear malformation and comparison of CT reports with the data concerning qualification for cochlear implantation, electrode choice and surgical technique modification. Material and method 40 subjects, aged from 18 months to 32 years, with suspected inner ear malformation, underwent MDCT in protocol for temporal bone assessment as a part of preoperative assessment before cochlear implantation. CT results were compared with the data concerning qualification for implantation, electrode choice, ear choice and possible technique modification. Results Normal CT scan were found in 18 subjects. Bilateral Michel deformity was found in 1 patient, bilateral cochlear aplasia in 1 case, common cavity in 1 case. One side cochlear hypoplasia with the cochlear aplasia was found in 1 case. Bilateral cochlear hypoplasia was found in 2 cases, bilateral incomplete partition type I in 2 cases, bilateral incomplete partition type II in 4 cases, bilateral large vestibular aqueduct without notable malformation of the cochlea in 2 cases. Various malformations of semicircular canals without notable malformations of the cochlea were found in 8 cases. MDCT affected ear choice in 6. In 2 cases decision of implantation was cancelled. In 1 case two stage procedure was conducted. Conclusions MDCT is valuable method in diagnosing inner ear malformations. It is an essential part of preoperative assessment as its results affect decision of implantation, ear choice, and possible procedure modification.

Achieving a Predictable 24-Hour Return to Normal Activities after Breast Augmentation: Part II. Patient Preparation, Refined Surgical Techniques, and Instrumentation

The goal of this study was to develop practices that would allow patients undergoing subpectoral augmentation to predictably return to full normal activities within 24 hours after the operation, free of postoperative adjuncts. Part I of this study used motion and time study principles to reduce operative times, medication dosages, perioperative morbidity, and recovery times in augmentation mammaplasty. Part II of the study focuses on details of patient education, preoperative planning, instrumentation, and surgical technique modifications that were identified, modified, and implemented to achieve the results reported in part I. Two groups of 16 patients each (groups 1 and 2) were studied retrospectively for comparison to a third group of 627 patients (group 3) studied prospectively. Patients in group 1 had axillary partial retropectoral breast augmentations in 1982-1983, using dissociative anesthesia, blunt instrument implant pocket dissection, and Dow Corning, double-lumen implants containing 20 mg of methylprednisolone and 20 cc of saline in the outer lumen of the implants. Patients in group 2 (1990) had inframammary, retromammary augmentations by using a combination of blunt and electrocautery dissection, Surgitek Replicon polyurethane-covered, silicone gel-filled implants, and general endotracheal anesthesia. Patients in group 3 (1998 to 2001, n = 627) had inframammary partial retropectoral, inframammary retromammary, and axillary partial retropectoral augmentations under general endotracheal anesthesia. Refined practices and surgical techniques from studies of groups 1 and 2 were applied in group 3. Videotapes from operative procedures of groups 1 and 2 were analyzed with macromotion and micromotion study principles, and tables of events were formulated for each move during the operation for all personnel in the operating room. Extensive details of surgical technique were examined and reexamined in 13 different stages by using principles of motion and time studies described in part I of this study to maximize efficiency without any change in quality. Unnecessary or unproductive motions and techniques were progressively eliminated, and essential, productive techniques were streamlined to eliminate wasted time and motion. Instrumentation and surgical techniques were evaluated in detail and modified to minimize bleeding and tissue trauma. Detailed data were presented in part I of this study that document shorter operative times, recovery times, time to discharge home, and time to return to normal activities. This part focuses on the patient education, preoperative planning, instrumentation, and surgical technique changes that were implemented on the basis of the findings in part I of the study. More extensive patient information integrated with staged informed consent resulted in a more in formed and confident patient. Applying motion and time study principles to analysis and refinement of instrumentation and surgical techniques resulted in a substantial reduction in perioperative morbidity and a simpler, shorter 24-hour return to full normal activity for 96 percent of the patients undergoing breast augmentation in group 3 compared with groups 1 and 2. More than 96 percent of patients in group 3 were able to return to normal activities, lift their arms above their heads, lift normal-weight objects, and drive their car within 24 hours after their partial retropectoral breast augmentation. Patient education, preoperative planning, instrumentation, and surgical technique modifications based on motion and time study video analyses reduced surgical trauma and bleeding, reduced perioperative morbidity, and allowed 96 percent of 627 breast augmentation patients in group 3 a predictable return to full, normal activity in 24 hours or less. Specific surgical factors that contributed to these results included (1) prospective hemostasis techniques with a zero tolerance for even the smallest amount of bleeding, (2) strict "no-touch" techniques for periosteum and perichondrium, (3) eliminating all blunt dissection, (4) performing all dissection under direct vision, (5) modified and simplified instrumentation, and (6) optimal use of muscle relaxants during subpectoral dissection.