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Published online: 2019-11-21

Letters to Editor

Social and Preventive Medicine, 20th ed. Jabalpur: Banasidas productive cough associated with mild dyspnoea during Bhanot Publishers; 2009. p. 333. immediate postoperative period. 3. Dikshit RP, Yeole BB, Nagrani R, Dhillon P, Badwe R, Bray F. Increase in cancer incidence among older women in Mumbai: 30-Year trends and predictions to 2025. Cancer On examination, she was conscious, oriented, acyanotic, Epidemiol 2012;36:e215-20. tachypnoeic, dyspnoeic, tachycardic and her oxygen 4. Centers for Medicare and Medicaid Services. Available from: http://www.cms.gov/HealthInsReformforConsume/06_Th saturation was 89% on room air with bilateral decreased ewomen’sHealthandCancerRightsAct.asp. [Last cited on air entry and hyper resonant on percussion. Her arterial 10 Feb 2012]. blood gas analysis revealed acute respiratory alkalosis 5. Alderman AK, McMahon L Jr, Wilkins EG. The national utilization and hypoxemia. Chest radiograph showed bilateral of immediate and early delayed and the effect of sociodemographic factors. Plast Reconstr Surg with collapsed lung (30% on right side, 20% 2003;111:695-703. on left side). Chest drain was inserted into both pleural 6. Quinn McGlothin TD. Breast as a specialized practice. cavities, subsequently her dyspnoea improved and drain Am J Surg 2005;190:264-8. was removed on day four. Her thoracic CT scan did not

Access this article online demonstrate any emphysematous change or bulla in the Quick Response Code: expanded non-atelectatic lung . Website: www.ijps.org On further discussion with the operated cosmetic surgeon, the bilateral breast augmentation was done with DOI: 10.4103/0970-0358.105985 saline gel implants (210 ml on right and 230 ml on left), via the axillary route in the subpectoral plane, under local anaesthesia with intravenous sedation. He infiltrated lidocaine with 22-gauge spinal needle to achieve field Bilateral pneumothorax block and at no stage there was a suspicion of penetration of the needle through the intercostal space. Subpectoral pocket was created under direct visualisation by blunt following breast augmentation: Beware and dissection with his fingers. The surgery lasted for about two hours and it was uneventful. be aware Pneumothorax has been reported as a rare of breast augmentation but the exact incidence is not Sir, known.[1] However, a recent survey of Californian Plastic Breast augmentation is one of the most commonly Surgeons concluded that the incidence of pneumothorax performed aesthetic across the globe. The could be more prevalent than previously reported and common complications reported with the procedure no definite precipitating factor could be established.[2] are haematoma, , capsular contracture, breast Various mechanisms of its causation have been observed asymmetry, rupture or rotation of the implant. and hypothesised. Among possible aetiologies, accidental needle penetration during local infiltration, direct Here, we report a case of bilateral pneumothorax following trauma to the pleura during surgery, thermal damage breast augmentation in order to create awareness among from diathermy, rupture of pre-existing bleb, or high plastic surgeons and practitioners. anaesthetic ventilation pressure have been observed.

A 25-year-old unmarried woman was brought to the Barotrauma during implant insertion has also been emergency room for difficulty in breathing and chest proposed as another mechanism which was supported discomfort of four days which got worse over three hours. by a South African case series;[3] they drained the air in She denied any history of , breath-holding activity, the subpectoral pocket before implant insertion and fever, chills, night sweats, cough, haemoptysis, or any noted that patients did not develop pneumothorax previous illnesses. She was a non-smoker and denied any in post-operative period in contrast to their previous illicit drug use. She underwent bilateral breast augmentation observations where three consecutive patients surgery four days ago as a day care procedure elsewhere. underwent breast augmentation without drainage of air She had been complaining of pleuritic chest pain and non- and had developed asymptomatic pneumothoraces. The

579 Indian Journal of September-December 2012 Vol 45 Issue 3 Letters to Editor author concludes that by advancing implant, particularly Access this article online large implants through small incisions have a risk of Quick Response Code: pneumothorax due to local barotrauma. Fayman[4] Website: www.ijps.org suggested that air drainage should be introduced as a routine step in breast augmentation procedures in order DOI: to prevent the development of pneumothorax. Verma 10.4103/0970-0358.105986 and Hodgkinson[5] propose that pneumothorax should be included in the informed consent prior to the surgery and the necessary equipment for treating should be kept ready. Evidence-based demerits Also, patients may be counselled to note down on the use of rectus any chest discomfort or breathlessness after breast abdominis musculo- augmentation procedure and report to the nearest doctor. The doctors involved in the treatment of these peritoneal flap for bladder cases or the emergency physicians if happened to see such cases shall consider pneumothorax as a possibility augmentation in children and evaluate them accordingly and intervene if required. with exstrophy bladder Thus, patient empowerment helps to recognise such unusual complication much earlier and assist physicians to mitigate sufferings and consequences. Sir, We read the article “Closure and augmentation of Subramanian Senthilkumaran, Namasivayam bladder exstrophy using rectus abdominis musculo- [1] Balamurugan, Ritesh G Menezes1, peritoneal flap (RAMP).” The authors reported the 2 results of RAMP for primary bladder augmentation

Ponniah Thirumalaikolundusubramanian Department of Plastic Surgery and Critical Care Medicine, (BA) in children presenting late with bladder exstrophy Sri Gokulam Hospitals and Research Institute, Salem, (BE) with poor bladder template.[1] The technique 1 Tamil Nadu, Department of Forensic Medicine and claimed to decrease the morbidity and postoperative Toxicology, Srinivas institute of Medical Sciences and [1] Research centre, Mangalore, 2Department of Internal complications. We would differ with these Medicine, Chennai Medical Colleges and Research Center, observations. The ideal management of BE aims not Irungalur, Trichy, India just to achieve an anatomical closure of the defect, as Address for correspondence: illustrated in the present study,[1] but also to achieve a Dr. Subramanian Senthilkumaran, compliant urinary reservoir of adequate capacity with Department of Emergency and Critical Care Medicine, Sri Gokulam hospital and Research institute, preserved upper urinary tract along with continence Salem - 636 004, Tamil Nadu, India. and cosmetically pleasing external genitalia.[2] The E-mail: [email protected] major limitation of this report[1] is the nonassessment REFERENCES of the functional status of the reconstructed bladder by uroflowmetry and filling cystometry. Moreover, 1. Codner MA, Cohen AT, Hester TR. Complications of breast the postoperative ultrasonography (USG) mentioned surgery. Clin Plast Surg 2001;28:587. 2. Osborn J, Stevenson T. Pneumothorax as a complication of just about bladder capacity and failed to mention breast augmentation. Plast Reconstr Surg 2005;116:1122-8. the status of kidneys, ureters, and postvoid residual 3. Fayman MS, Beeton A, Potgieter E. Barotrauma: An unrecognized urine.[1] Though USG and intravenous pyelography are mechanism for pneumothorax in breast augmentation. Plast Reconstr Surg 2005;116:1825-6. useful tools to assess upper tract dilatation, yet they 4. Fayman MS. Air drainage: An essential technique for preventing lack functional information. In the absence of the renal breast augmentation-related pneumothorax. Aesthetic Plast radionuclide scans, the assessment of upper urinary Surg 2007;31:19-22. [1] 5. Verma S, Hodgkinson D. Not so uncommon: Pneumothorax tracts in this study is incomplete. It is also pertinent to during breast augmentation. A case report and literature review. learn from the authors that when they intend to do the Cosmetex 2012 held at Cairns, Australia: Queensland; 2-5th May, 2012 (Abstract). www.cosmetex.org/.../Cosmetex_2012_ epispadias repair, as the mean age at presentation was Abstract_Verma_Sanjay.pdf Accessed on August 15th 2012. 8 years and patients already had a follow-up of 3 years.[1]

Indian Journal of Plastic Surgery September-December 2012 Vol 45 Issue 3 580