Vertical mammaplasty: early complications after 250 personal consecutive cases.

No surgeon likes to face complications. It takes effort to treat them personally and more effort to note, count, analyze, and demonstrate them. The author carefully followed 250 personal consecutive patients (476 breasts) who underwent vertical mammaplasties between 1990 and 1998; studying the complications and their relationship with the types of breasts and patients was very instructive. The main observations from this study follow. The most frequent benign complication was seroma (5 percent of breasts), which usually required one or two aspirations after surgery. Hematomas occurred in six patients (1.2 percent of breasts), who had all had mastopexies. Hematomas required immediate surgical evacuation. The major complication of breast reduction, i.e., areola necrosis, was rare (only two partial necroses occurred), but it left deformities that were difficult to correct. Infection without tissue necrosis was rare (two cases), and healing complications happened in only 5.4 percent of all cases. Healing complications were directly related to the size and fat content of the breasts. None occurred in mastopexy cases. For reductions, delayed skin healing was observed in 5 percent of cases and delayed breast tissue healing in 3 percent of cases. More healing complications occurred after liposuction of the breast, which was performed in the more fatty breasts. Delayed healing of skin and breast tissue was bothersome because healing was slow, but it left only a moderate deformity. In cases of delayed healing, frequent dressings, rinsing the wound with antiseptic solutions, giving antibiotics if needed, and refraining from early surgical intervention are the keys to success. Good personal contact with the patient, especially if healing is slow, is the best way of helping her and avoiding aggressive attitudes. In conclusion, this survey revealed few complications; however, it does show that the risk of delayed and slow healing is greater in larger breasts. In obese patients, a simpler operation may be indicated, such as liposuction with skin reduction alone or a free nipple graft, as long as the patient is not motivated to obtain the best possible result.     

Large-volume liposuction: a review of 631 consecutive cases over 12 years.

Since the advent of epinephrine-containing wetting solutions and sophisticated fluid management techniques, increasingly larger and larger volumes of liposuction aspirations have been reported. Unfortunately, with these larger volumes of liposuction being routinely performed, greater rates of complications have also been reported, with the worst of these resulting in deaths. In a response to the increasing concerns over the safety of large-volume liposuction, a critical review of the senior author's own series has been performed to evaluate risks and benefits and to recommend guidelines for safe and effective large-volume liposuction. A retrospective chart review was performed on 631 consecutive patients who underwent liposuction procedures of at least 3000 cc total aspirate. All procedures were performed by the same senior surgeon between January of 1986 and March of 1998. Before September of 1996, traditional liposuction techniques were used. After September of 1996, ultrasound-assisted liposuction was performed. The superwet technique of fluid management was employed for all procedures performed after 1991. The particulars of the surgical and anesthetic techniques used are reviewed in the article. Data collection included preoperative patient demographics, preoperative and postoperative weights and measurements, and preoperative and postoperative photographs. Total aspirate volumes, fluid intakes, and fluid outputs were measured, and all complications were tallied. Average follow-up was 1 year.Results showed the majority of patients to be women, aged 17 to 74 years old. Of the preoperative weights, 98.7 percent were within 50 pounds of ideal chart weight. Total aspirate volumes ranged from 3 to 17 liters, with 94.5 percent of these under 10 liters. Fluid balance measurements showed an average of 120 cc/kg positive fluid balance at the end of the procedure, with none of these patients experiencing any significant fluid balance abnormalities. Cosmetic results were good, with a 2- to 6-inch drop from preoperative measurements, depending on the area treated. Ten percent of patients experienced minor skin contour irregularities, with most of these patients not requiring any additional surgical procedures. One year after surgery, 80 percent of patients maintained stable postoperative weights. No serious complications were experienced in this series. The majority of the complications consisted of minor skin injuries and burns, allergic reactions to garments, and postoperative seromas. The more serious complications included four patients who developed mild pulmonary edema and one patient who developed pneumonia postoperatively. These patients were treated appropriately and went on to have uneventful recoveries. The results show that large-volume liposuction can be a safe and effective procedure when patients are carefully selected and when anesthetic and surgical techniques are properly performed. Meticulous fluid balance calculations are necessary to avoid volume abnormalities, and experience is mandatory when performing the largest aspirations. Cosmetic benefits are excellent, and overall complication rates are low.     

Beyond abortion: refusal of caesarean section

Social pressures and legal restrictions are proliferating against pregnant women. A dramatic infringement on women's rights is the court ordered cesarean section, as illustrated by the case of Angela C., a terminally ill cancer patient, 26 weeks pregnant, whose refusal of a cesarean section was overridden by a District of Columbia court. The premature infant and the mother died within two days. This case epitomizes a developing judicial pattern whose ethical reasoning the author criticizes. Within the context of the right to privacy and the concept of viability, which could legally override that right, Mahowald analyzes different situations where cesarean delivery is refused. After arguing that court ordered cesarean sections are inconsistent with court refusals to force persons to undergo less invasive procedures (e.g., bone marrow donation for the benefit of family members), she proposes alternatives to the present inconsistent practice.     

Reducing the incidence of infection after caesarean section: implications of prophylaxis with antibiotics for hospital resources.

OBJECTIVES--To estimate the cost effectiveness of giving prophylactic antibiotics routinely to reduce the incidence of wound infection after caesarean section. DESIGN--Estimation of cost effectiveness was based, firstly, on a retrospective overview of 58 controlled trials and, secondly, on evidence about costs derived from data and observations of practice. SETTING--Trials included in the overview were from obstetric units in several different countries, including the United Kingdom. The costing study was based on data referring to the John Radcliffe Maternity Hospital, Oxford. SUBJECTS--A total of 7777 women were included in the 58 controlled trials comparing the effects of giving routine prophylactic antibiotics at caesarean section with either treatment with a placebo or no treatment. Cost estimates were based on data on 486 women who had caesarean sections between January and September 1987. MAIN OUTCOME MEASURE--Cost effectiveness of prophylaxis with antibiotics. RESULTS--The odds of wound infection are likely to be reduced by between about 50 and 70% by giving antibiotics routinely at caesarean section. Forty one (8.4%) women who had caesarean section were coded by the Oxford obstetric data system as having developed wound infection. The additional average cost of hospital postnatal care for women with wound infection (compared with women who had had caesarean section and no wound infection) was estimated to be 716 pounds; introducing routine prophylaxis with antibiotics would reduce average costs of postnatal care by between 1300 pounds and 3900/100 pounds caesarean sections (at 1988 prices), depending on the cost of the antibiotic used and its effectiveness. CONCLUSIONS--The results suggest that giving antibiotics routinely at caesarean section will not only reduce rates of infection after caesarean section but also reduce costs.     

Prevalence and determinants of caesarean section in Jamaica.

The prevalence and determinants of primary caesarean section in Jamaica were estimated from a survey of women aged 14-49 years. Among 2328 women reporting 2395 live hospital births during the period January 1984 to May 1989, the prevalence of caesarean section was 4.1%. Repeat caesarean sections accounted for 1.3% of the hospital births during that period. Of the medical complications studied, prolonged labour and/or cephalopelvic disproportion carried the highest risks of primary caesarean section, followed by breech presentation, maternal diabetes, a high birth-weight baby, maternal hypertension, and a low birth-weight baby. The risk of primary caesarean section increased with maternal age, decreased with parity, was higher for urban than for rural residents, and was higher for births in private versus government hospitals.     

The acutely painful scrotum in children: review of 113 consecutive cases

A young boy who presents with an acutely painful scrotum can be a diagnostic challenge to his physician. It is important to differentiate the various causes of this symptom and to institute prompt management. Failure to do so could jeopardize the patient''s future fertility. In a review of 113 consecutive cases of a painful scrotum at a children''s hospital, torsion of the testicle was found in 51 patients (45%). Torsion of the appendix testis was found in 40 patients (35%) and acute epididymitis, once considered rare in children, was diagnosed in 17 (15%). The importance of prompt diagnosis of torsion is emphasized. The clinical diagnosis of the acutely painful scrotum is notoriously difficult, and in this series of cases surgical exploration was required in 92%. Only 2 of the 17 cases of epididymitis were associated with a bacterial urinary tract infection.