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Peri-Operative Blood Pressure  and Hematoma Following  Reduction Mammaplasty W. Thomas McClellan, M.D.  American Society o...
History <ul><li>15 th  Century Serafeddin  </li></ul><ul><li>Cerrahiyet-ül Haniyye  ( Imperial Surgery ) </li></ul><ul><li...
Epidemiology <ul><li>Wise pattern, inferior pedicle most common  75% </li></ul><ul><li>Satisfaction rates ~ 95% </li></ul>...
Incidence <ul><li>Postoperative hematoma rate reported 1-5%* </li></ul><ul><li>As many as 5000 hematomas per year followin...
Hypothesis <ul><li>Peri-operative blood pressure changes play a significant role in hematoma formation following reduction...
Theory <ul><li>Low BP during hemostasis </li></ul><ul><li>Vessels sealed by blood clots </li></ul><ul><li>False impression...
Methods <ul><li>Retrospective chart review </li></ul><ul><li>Western Avenue Day Surgery Center AAAASF certified </li></ul>...
Methods <ul><li>538 reductions between 2001-2004 </li></ul><ul><li>Hematoma defined as collection which requires operative...
Methods <ul><li>Demographic Data Collected </li></ul><ul><ul><li>age  </li></ul></ul><ul><ul><li>height  </li></ul></ul><u...
Methods <ul><li>Operative Data Collected </li></ul><ul><ul><li>local anesthetic used and location </li></ul></ul><ul><ul><...
Methods 1 st  phase  2 nd  phase  3 rd  phase Total Operative Time   (Phases) Shaping Hemostatic Closing <ul><ul><li>Divid...
Methods <ul><ul><li>Pre-operative systolic and diastolic - initial office visit </li></ul></ul><ul><ul><li>High and low sy...
Results <ul><li>Drain – ½ inch Penrose on all patients </li></ul><ul><li>Local solution –  </li></ul><ul><ul><li>30cc 0.25...
Results ns = p > 0.05 No Hematoma Hematoma p value Preoperative 131 125 ns 1 st  Phase 106 101 ns 2 nd  Phase 107 93 0.005...
Results - MAP ns = p > 0.05 No Hematoma Hematoma p value Preoperative 97 93 ns 2 nd  Phase 75 67 0.01 Postoperative 94 105...
Results - MAP
Conclusions <ul><ul><li>Statistically significant findings </li></ul></ul><ul><ul><li>Post-operative hypertension </li></u...
Conclusions <ul><li>Preventative measures </li></ul><ul><ul><li>Intra-operative hemostasis performed under relative  normo...
Conclusions <ul><li>Preventative measures </li></ul><ul><ul><li>Observation in the recovery area for at least 6 hours shou...
<ul><li>Thank you </li></ul>
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Blood pressure and hematoma with breast reduction

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This is a presentation given at the American Society for Aesthetic Plastic Surgeon National Meeting in Orlando. It deals with hypotension and its effect on hemostasis and hematoma during reduction mammaplasty.

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Blood pressure and hematoma with breast reduction

  1. 1. Peri-Operative Blood Pressure and Hematoma Following Reduction Mammaplasty W. Thomas McClellan, M.D. American Society of Aesthetic Plastic Surgery - 2006
  2. 2. History <ul><li>15 th Century Serafeddin </li></ul><ul><li>Cerrahiyet-ül Haniyye ( Imperial Surgery ) </li></ul><ul><li>Crescent shaped incision for the removal of breast tissue </li></ul>Doğan, Teoman M.D. et. Al. Plastic Surgical Techniques in the Fifteenth Century by Şerafeddin Sabuncuoğlu. Plastic & Reconstructive Surgery: Volume 99(6) May 1997 pp 1775-1779
  3. 3. Epidemiology <ul><li>Wise pattern, inferior pedicle most common 75% </li></ul><ul><li>Satisfaction rates ~ 95% </li></ul><ul><li>144,374 performed in U.S </li></ul><ul><li>7 th Most common plastic surgery procedure </li></ul>Grimm, K. Reduction of the breasts, Hans Schaller and the first mammaplasty. Handchir Mikochir Plast Chir, 32(5): 316-20. 2000 Rohrich, Rod J. M.D. et al. Current Preferences for Breast Reduction Techniques: A Survey of Board-Certified Plastic Surgeons. Plastic and Reconstructive Surgery: Volume 114(7) December 2004 pp 1724-1733 American Society of Aesthetic Plastic Surgeons 2004 Report
  4. 4. Incidence <ul><li>Postoperative hematoma rate reported 1-5%* </li></ul><ul><li>As many as 5000 hematomas per year following reduction </li></ul><ul><li>Significant morbidity possible </li></ul><ul><ul><li>Skin loss </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Sensation loss </li></ul></ul><ul><ul><li>Transfusion </li></ul></ul><ul><ul><li>Increased costs </li></ul></ul><ul><li>Cunningham, Bruce L. M.D. et al. Analysis of Breast ReductionComplications Derived from the BRAVO Study. Plastic and Reconstructive Surgery: Volume 115(6) May 2005 pp 1597-1604 </li></ul><ul><li>Cruz-Korchin, Norma M.D.; et. al. Vertical versus Wise Pattern Breast Reduction: Patient Satisfaction, Revision Rates, and Complications Plastic and Reconstructive Surgery: Volume 112(6) November 2003 pp 1573-1578 </li></ul>
  5. 5. Hypothesis <ul><li>Peri-operative blood pressure changes play a significant role in hematoma formation following reduction mammaplasty. </li></ul>
  6. 6. Theory <ul><li>Low BP during hemostasis </li></ul><ul><li>Vessels sealed by blood clots </li></ul><ul><li>False impression of a dry surgical field </li></ul><ul><li>Post -operative hypertension </li></ul>Lee, H., Malyaon, A, Norrie, J. The impact of intraoperative hypotension on the development of wound hematoma after breast reduction. Br J Plas Surg. 54: 517-22. 2001.
  7. 7. Methods <ul><li>Retrospective chart review </li></ul><ul><li>Western Avenue Day Surgery Center AAAASF certified </li></ul><ul><li>Seven Board Certified Plastic Surgeons </li></ul>
  8. 8. Methods <ul><li>538 reductions between 2001-2004 </li></ul><ul><li>Hematoma defined as collection which requires operative exploration </li></ul><ul><li>8 hematomas identified (1.5%) </li></ul><ul><li>20 charts chosen randomly for comparison </li></ul>
  9. 9. Methods <ul><li>Demographic Data Collected </li></ul><ul><ul><li>age </li></ul></ul><ul><ul><li>height </li></ul></ul><ul><ul><li>weight </li></ul></ul><ul><ul><li>body mass index (kilograms per square meter) </li></ul></ul><ul><ul><li>medical history </li></ul></ul><ul><ul><li>medications </li></ul></ul><ul><ul><li>smoking status </li></ul></ul><ul><ul><li>post-exploration complications </li></ul></ul>
  10. 10. Methods <ul><li>Operative Data Collected </li></ul><ul><ul><li>local anesthetic used and location </li></ul></ul><ul><ul><li>drain type </li></ul></ul><ul><ul><li>breast tissue removed (grams per side) </li></ul></ul><ul><ul><li>ET or LMA </li></ul></ul><ul><ul><li>total operative time </li></ul></ul><ul><ul><li>reduction technique used </li></ul></ul><ul><ul><li>time to exploration </li></ul></ul>
  11. 11. Methods 1 st phase 2 nd phase 3 rd phase Total Operative Time (Phases) Shaping Hemostatic Closing <ul><ul><li>Divided into 3 equal divisions based on total </li></ul></ul><ul><ul><li>operative time </li></ul></ul>
  12. 12. Methods <ul><ul><li>Pre-operative systolic and diastolic - initial office visit </li></ul></ul><ul><ul><li>High and low systolic and diastolic pressure for each operative phase </li></ul></ul><ul><ul><li>High and low systolic and diastolic blood pressure from the post-operative recovery area. </li></ul></ul>
  13. 13. Results <ul><li>Drain – ½ inch Penrose on all patients </li></ul><ul><li>Local solution – </li></ul><ul><ul><li>30cc 0.25% Marcaine 1:200,000 </li></ul></ul><ul><ul><li>Injected subcutaneous each breast </li></ul></ul><ul><li>All patients received LMA </li></ul><ul><li>Wise Pattern inferior pedicle technique . </li></ul><ul><li>All reductions discharged home </li></ul><ul><li>One exploration admitted to hospital for observation </li></ul><ul><li>All explorations within 6 hours </li></ul><ul><li>Follow-up – no post-op infections or hypertrophic scars </li></ul>
  14. 14. Results ns = p > 0.05 No Hematoma Hematoma p value Preoperative 131 125 ns 1 st Phase 106 101 ns 2 nd Phase 107 93 0.005 3 rd Phase 111 106 ns Postoperative 132 145 ns Pre vs 2 nd Phase 24 32 ns Pre vs Post op 1 19 0.007 2 nd Phase vs Post-op 24 52 0.0001
  15. 15. Results - MAP ns = p > 0.05 No Hematoma Hematoma p value Preoperative 97 93 ns 2 nd Phase 75 67 0.01 Postoperative 94 105 0.03 Pre vs 2 nd Phase 22 26 ns Pre vs Post op -3 12 0.001 2 nd Phase vs Post-op 18 38 0.0001
  16. 16. Results - MAP
  17. 17. Conclusions <ul><ul><li>Statistically significant findings </li></ul></ul><ul><ul><li>Post-operative hypertension </li></ul></ul><ul><ul><li>Hypotension during the hemostatic phase </li></ul></ul><ul><ul><li>Large pressure swing between the hemostatic phase and post-op </li></ul></ul>
  18. 18. Conclusions <ul><li>Preventative measures </li></ul><ul><ul><li>Intra-operative hemostasis performed under relative normotensive conditions </li></ul></ul><ul><ul><li>Post-operative hypertension should be quickly and decisively controlled with IV antihypertensives </li></ul></ul>
  19. 19. Conclusions <ul><li>Preventative measures </li></ul><ul><ul><li>Observation in the recovery area for at least 6 hours should allow identification of most hematomas </li></ul></ul><ul><ul><li>Recognition and quick exploration can result in favorable outcome </li></ul></ul>
  20. 20. <ul><li>Thank you </li></ul>

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