Background: Approximately one in 2000 babies are born with craniosynostosis, and primary open repair is typically performed before 1 year of age. Historically, the procedure has been associated with nearly 100 percent transfusion rates. To decrease the rates of transfusion, the authors’ center has developed a novel multimodal blood conservation protocol. Methods: The authors administered their standard of care to children aged 1 year or younger undergoing primary repair of craniosynostosis between 2008 and 2014. In 2014, the authors implemented the following protocol: (1) preoperative erythropoietin and ferrous sulfate, (2) local anesthetic with epinephrine infiltration of the incision, (3) PlasmaBlade incision and subgaleal dissection, (4) hypervolemic hemodilution, and (5) intravenous tranexamic acid. Procedures performed before the protocol implementation served as controls. The authors performed classic fronto-orbital advancement with anterior cranial vault remodeling for coronal and metopic craniosynostosis. For lambdoid and sagittal craniosynostosis, barrel stave osteotomies, cranial base outfracture, and interposition bone grafting were performed. Results: A total of 279 children with a mean age of 6 months who had craniosynostosis repairs were included. One hundred forty-five underwent repair before the authors’ protocol, and 134 had repairs during the authors’ blood conservation protocol. Both groups were similar in demographics. Overall blood loss and operative times were significantly reduced by 73 percent and 11 percent, respectively. Blood transfusion rate decreased 92 percent (p < 0.001). Conclusions: These results show a strong association between the authors’ blood conservation protocol and significantly reduced transfusion rates. The authors believe this is a significant step forward and can be safely applied in the great majority of children undergoing craniosynostosis repairs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background Classically large, ptotic breasts have been a contraindication for nipple preservation during breast reconstruction. We present our technique of “Smile Mastopexy” to address some of these issues. This reduces the excess skin in both vertical and transverse directions, avoids a “T-junction”, preserves the nipple areolar complex, and adds thickness to the upper pole of the breast at the time of mastectomy. Objectives To demonstrate the safety and reliability of a novel technique that addresses the excess skin envelope during breast reconstruction, while preserving the NAC in large, ptotic breasts. Methods This is a retrospective review of a single surgeon performing the “Smile Mastopexy” for immediate 2 stage prosthetic breast reconstruction. All were performed in the pre-pectoral pocket without the use of acellular dermal matrices. Results Our study included 30 patients and a total of 54 breasts with a mean age of 50 years, BMI of 30 kg/m 2, and mastectomy specimen weight of 683 grams. All had class 2 or 3 ptosis. There were no cases of complete nipple loss. Overall complication rate was 14.8%. There were 3 explantations, with 1 (1.8%) being due to infection and 2 (3.7%) due to implant exposure. Radiation was associated with a higher complication rate. Patients reported outcomes were evaluated using the Breast-Q questionnaire. Conclusions The “Smile Mastopexy” is a safe and reliable technique in large, ptotic breasts during prosthetic breast reconstruction. It preserves the NAC, reduces the excess skin envelope, adds thickness to the upper pole, and allows for future skin revisions using the same scar if necessary.