Laparoscopic cholecystectomy (LC) has served as the igniting spark in the laparoscopic surgery explosion; however, it is unclear who created the spark. The question remains: Who did the first LC?

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice for establishing enteral access in patients unable to take oral feedings. Serious complications are rare; however, misplaced PEGs and PEG/ Jejunums can lead to hollow viscus injuries with intra-abdominal contamination and subsequent peritonitis, septicemia, and death. The presence of free intra-abdominal air is a reliable indicator of a perforated viscus and often points to a surgical emergency; however, in the case of PEGs, pneumoperitoneum without a perforated viscus, or “benign pneumoperitoneum” creates a diagnostic dilemma. To determine the incidence and clinical significance of pneumoperitoneum after PEG or PEG/Jejunum (J) we reviewed the records of 722 patients who underwent these procedures at our institution. Of 39 patients found to have free air after PEG/PEG/J placement, 33 (85%) had “benign pneumoperitoneum” and were discharged without complication or surgical intervention. Of the six patients with serious complications related to their procedure, five (83%) had clinical signs of intra-abdominal complications (peritonitis) that helped guide their management. Of these six patients, the two receiving abdominal radiographs instead of abdominal CT scanning had a 50 per cent negative laparotomy rate. We present an algorithm for the management of patients found to have pneumoperitoneum after PEG or PEG/J placement.

Background:Patients with moderate to severe ptosis are often considered poor candidates for nipple-sparing mastectomy. This results from the perceived risk of nipple necrosis and/or the inability of the reconstructive surgeon to reliably and effectively reposition the nipple-areola complex on the breast mound after mastectomy.Methods:A retrospective review identified patients with grade II/III ptosis who underwent nipple-sparing mastectomy with immediate perforator flap reconstruction and subsequently underwent a mastopexy procedure. The mastopexies included complete, full-thickness periareolar incisions with peripheral undermining around the nipple-areola complex to allow for full transposition of the nipple-areola complex relative to the surrounding skin envelope.Results:Seventy patients with 116 nipple-sparing mastectomies met inclusion criteria. The most common complications were minor incisional dehiscence (7.7 percent) and variable degrees of necrosis in the preserved breast skin (3.4 percent) after the initial mastectomy. There were no cases of nipple-areola complex necrosis following the secondary mastopexy.Conclusions:The authors demonstrate that full mastopexy, including a complete full-thickness periareolar incision and nipple-areola complex repositioning on the breast mound, can be safely performed after nipple-sparing mastectomy and perforator flap breast reconstruction. The underlying flap provides adequate vascular ingrowth to support the perfusion of the nipple-areola complex despite complete incisional interruption of the surrounding cutaneous blood supply. These findings may allow for inclusion of women with moderate to severe ptosis in the candidate pool for nipple-sparing mastectomy if oncologic criteria are otherwise met. These findings also represent a significant potential advantage of autogenous reconstruction over implant reconstruction in women with breast ptosis who desire nipple-sparing mastectomy.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.

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Liposuction is one of the most commonly performed aesthetic surgery procedures in the United States, and most plastic surgeons perform suction-assisted, ultrasound-assisted, or power-assisted liposuction. The past decade has seen a growing interest in laser-assisted liposuction (LAL) and the proposed advantages of traditional liposuction methods. However, it is performed by a minority of plastic surgeons. In fact, many LAL providers are not trained in aesthetic practice, and many offer LAL as their only body-contouring procedure. When only one method of body contouring is available to a provider, it may lead to inappropriate patient selection with associated poor outcomes. This report discusses the use of laser liposuction in body contouring and the demographics of those performing liposuction, including LAL. Complications from laser-assisted liposuction performed by noncore practitioners are illustrated.

Background:When a single perforator flap does not provide adequate volume or projection for satisfactory breast reconstruction, the addition of an implant may be considered at the time of second-stage revisions. Dissection of an implant pocket beneath the flap may lead to the inadvertent injury of the flap pedicle as the tissue planes have been obscured by tissue ingrowth. The authors present a technique in which the boundaries of the implant pocket are predetermined at the time of flap reconstruction allowing an implant to be inserted at the second stage in ideal position with greater ease of dissection and minimal risk to the flap pedicle.Methods:Forty patients (80 bilateral perforator flap breast reconstructions) treated with the creation of central under flap pocket technique in anticipation of subsequent sub flap implant augmentation within an 18-month period were assessed retrospectively.Results:Sixty-eight patients with flaps (85%) went on to receive secondary augmentation with silicone implants. The average percentage increase in volume contributed by the implant was 41%. The undersurface of the acellular dermal matrix was readily identified, and its medial most extent safely determined, allowing the expeditious recreation of the predelineated central under-flap implant pocket. No flap pedicles were injured during the process, and the implants were placed in a favorable position providing maximum projection to the reconstruction. No subsequent development of fat necrosis was identified after augmentation.Conclusion:The creation of central under flap pocket technique allows for safe, effective, and expedient delayed implant augmentation of perforator flap breast reconstruction.

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