ࡱ> egd5@#bjbj22BVXXTTTTDDD8|,D62( "BBB5555555$47R95I?^II5TTBB5 ITRBB5 I5 0 !r+T",B @[ LDIg+4l506u+,:,:,TTTT,,:2 >, $+55$ DB Title: Proper Timing of Breast Reduction in Menstrual Cycle Authors: Yener Demirtas, MD, Suhan Ayhan, MD, Yakup Sariguney, MD, Fulya Findikcioglu, MD, Osman Latifoglu, MD, Seyhan Cenetoglu, MD, Cemalettin Celebi, MD Breast is well-known to be responsive to hormonal changes observed during menstrual cycle, and speculations have been made on ideal timing of breast surgery in this extent,1 but the clinical evidence to support their acceptance and application is lacking. We planned this study to establish the relationship of intraoperative bleeding, postoperative drainage and early postoperative complications with the menstrual period of the reduction mammoplasty patient. Material and Methods: Thirty-nine consecutive women scheduled for bilateral reduction mammoplasty between May 2003 and November 2003 were available to participate into the study. Routine preoperative work-up was done, and preoperative hemoglobin-hematocrit levels were recorded. The operation was performed under standard general anesthesia. After the induction of general anesthesia, each breast was infiltrated with 20 cc of 1% lidocaine with 1:160000 adrenalin. The inferior pyramidal pedicle technique was used in all breasts. Pedicle deepithelialization and tissue excision was performed with scalpel utilizing bipolar electrosurgery for hemostasis. Amount of tissue resected per breast was also recorded. Ten mm silicone flat suction drain was inserted into each breast and the postoperative drainage was collected for 72 hours. All operations were performed by the same surgical team who had no information concerning the menstrual histories. Blood loss during the operation was evaluated by the analysis of hematocrit levels from total soiled swabs.2,3 The patients were interviewed postoperatively, and detailed obstetrical-menstrual history was obtained, including the date of their last menstruation, the usual length of their menstrual cycle, and previous use of hormones or hormone-containing preparations. Four of them using various drugs were excluded and 35 patients with no history or symptoms of any systemic disease were included in the study. Menstrual dates of these women were normalized to a 28-day cycle according to following formula:4 Adjusted day of cycle = 14 x day of the cycle at the time of surgery length of the follicular phase (cycle length of the patient-14) The collected data were analyzed using the Mann-Whitney U test and p<0,05 was considered to be statistically significant. All values are expressed as meanSD. Results: Sixteen of the patients were in the perimenstrual phase, 13 were in the periovulatory phase and 6 were postmenopausal. No statistically significant differences between groups 1 and 2 were found for age, bodyweight, preoperative hematocrit level and amount of tissue resected per breast (p>0.05). The average intraoperative blood loss was 14611 ml in Group 1 and 694 ml in Group 2 (p<0,001). The average postoperative drainage at 72 hours was 1757 ml in group 1 and 12510 ml in group 2 (p=0,002). Both of the parameters were significantly higher in group 1 compared to group 2. The results are given in Table and Figures 1 and 2. No patient needed a blood transfusion and there were no cases of wound infection, hematoma, seroma or nipple-areola necrosis. Conclusion: Reduction mammoplasty is a common surgical procedure that is sometimes associated with significant volumes of blood loss, reaching to 500 to 1000 ml in some series.5,6 Avoiding the breast surgery during menstruation was suggested by LaTrenta and Hoffman1 in an attempt to reduce intraoperative blood loss, but this proposal was probably based on clinical observations which have not been confirmed by any objective data yet. On the other hand, breasts are well-known to show cyclic changes associated with the menstrual cycle that affect all aspects of breast morphology, protein expression, and cell kinetics.4,7 The results of the present study indicate that planning an elective reduction mammoplasty considering the patients menstrual date may have profound effects on perioperative blood loss, which is directly related to the comfort of the patient and the surgeon. Minimizing the blood loss of the patient will certainly result in a shorter recovery period, and a faster and easier surgery in a bloodless operative field is the benefit of the surgeon. In conclusion, timing a breast reduction surgery in the periovulatory phase, which is between days 8 to 20 of menstrual cycle, significantly reduces the intraoperative blood loss and postoperative drainage. It may be reasonable to remove early or even avoid drains in this period. However, we suggest their use if the surgery is done in the perimenstrual phase, since the amount of peri- and postoperative blood loss is more prominent in this period. The patients should also be warned for sustained postoperative drainage and possible prolonged hospitalization. Table: Patient demographic data and the results of the measurements. The results are expressed as mean SD. Group 1Group 2Group 3Age in years377386544Resected tissue in gr930433848398951517Intraoperative blood loss in ml14611694575Drain product at 24 h in ml985555595Drain product at 72 h in ml17571251014016Figure 1: A; intraoperative blood loss of the patients versus the day of menstrual cycle at the time of surgery. B; postoperative 24 hours ( SHAPE \* MERGEFORMAT  ) and 72 hours ( SHAPE \* MERGEFORMAT  ) drainage of the patients versus the day of menstrual cycle at the time of surgery. Figure 2: Comparison of intraoperative blood loss and postoperative drainage between groups. Statistical significance (p < 0.05) as indicated: *p < 0.001 vs. group 2; #p = 0.002 vs. group 2. References LaTrenta GS, Hoffman LA. Breast reduction. Rees TD, LaTrenta GS (Eds): Aesthetic Plastic Surgery, Vol. 2, 2th ed. Philadelphia, Saunders; 1994: 932-34. Keith I. Anaesthesia and blood loss in total hip replacement. Anaesthesia. 32: 444, 1977 Abrams PH, Shah PJ, Bryning K, Gaches CG, Ashken MH, Green NA. Blood loss during transurethral resection of the prostate. Anaesthesia. 37: 71, 1982. Ramakrishnan R, Khan S, Badve S, Morphological changes in breast tissue with menstrual cycle. Modern Pathology. 15: 1348, 2002. Wilmink H, Spauwen PH, Hartman EH, Hendriks JC, Koeijers VF. Preoperative injection using a diluted anesthetic/adrenaline solution significantly reduces blood loss in reduction mammaplasty. Plast Reconstr Surg. 102: 373, 1998. Mandel M. A. Autotransfusion in elective plastic surgical operations. Plast Reconstr Surg. 77: 767, 1986. Olsson H, Jernstrm H, Alm P, Kreipe H, Ingvar C, Jnsson P-E, Ryden S. Proliferation of the breast epithelium in relation to menstrual cycle phase, hormonal use, and reproductive factors. Breast Cancer Res Treat. 40: 187, 1996. 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