Mammaplasty with a Periareolar Dermal Cloak for Glandular Support

Analyzing the main surgical element of mammaplasty, almost all procedures incorporate a smaller or bigger dermal flap. The periareolar dermal cloak is a dermis flap corresponding to the skin pattern and pedicled to the nipple areola. The shape of the flap can be tailored as required but 2 cm of the dermis flap around the nipple should not be touched. The periareolar dermal flap has been used as a cloak; this dermal cloak is suitable for positioning the nipple and covering a part of the glandular tissues with support. With fastening of the cloak, a better tone of the breast tissues can be achieved. Mastopexy, reduction mammaplasty presented by technical detail of dermal cloak positioning and glandular support, has been done in 178 breast operations since 1992. The dermal cloak technique was used in 114 cases. The technique, clinical results, advantages, disadvantages, and complications are discussed.     

Mammoplasty: Breast Fixation with Dermoglandular Mono Upper Pedicle Flap Under the Pectoralis Muscle

A surgical procedure for breast fixation to avoid secondary ptosis of the lower quadrants and nipple–areola complex bascule and to maintain the breast upper pole projection is described and evaluated after long-term pexy and reduction mammoplasty. A superior monopedicle dermal–adipose–glandular flap with the areola–nipple complex placed in its base is mobilized and its extremity sutured to a ``trapdoor' type of flap dissected in the pectoralis muscle. This procedure determines the permanent areola–nipple complex and the upper breast quadrant position, avoiding the common secondary breast ptosis, when the breast tissue is sutured to the pectoralis muscle. One thousand seven hundred patients have undergone this procedure in the last 15 years.     

A New Surgical Procedure for the Very Severe Inverted Nipple

Severe cases of inverted nipple usually cannot be corrected by a simple procedure, especially if the nipple cannot be pulled out above the areolar level by manipulation. We describe a new method for these cases and we classify the inverted nipple into 3 grades following the choice of their required operative procedure. Our classification for inverted nipple is as follows. Grade I: The inversion is corrected simply by manipulation; the nipple protrusion is long-lasting. Grade II: The inversion can be corrected by manipulation, but recurrence of the inversion is frequent. Grade III: The inversion cannot be corrected without a surgical procedure. Cases of Grades I and II can be corrected by conventional simple surgical procedures. But some cases of Grade II and almost all of Grade III cannot be corrected by conventional methods, in spite of the high frequency of relapse. Cutting of the lactiferous duct, such as the Pitanguy and Broadbent methods, can correct the very severely inverted nipple. But if we want to maintain the lactiferous function after correction, we had better not cut the lactiferous ducts. Our new procedure for correcting very severe cases can keep the lactiferous function after correction without any relapse. In order to avoid the recurrence of nipple retraction and to maintain the lactiferous function, the new surgical procedure that we performed makes an incision deeply and vertically on the nipple to free the lactiferous ducts from the contracted tissues surrounding them. After extension or resection of the restricting tissues, the nipple is raised easily. This procedure will preserve the feeding function and prevent the recurrence of nipple inversion. For very severe cases, using a dermal flap inserted into the base of the nipple may be necessary due to its role of interposing tissue to prevent reverting to inversion.     

Repair of the Partial Loss of the Helix

This article presents a new technique for the repair of small and medium-sized defects of the helix using a retroauricular flap whose advance is obtained by the displacement of the auricular fold.     

Repair of Full Thickness Defect of the Nose Using an Expanded Forehead Flap and a Glabellar Flap

We describe a method to repair full thickness defects of the nose using a glabellar flap as the lining of the nasal cavity and an expanded forehead flap for external closure. We consider our method useful in the reconstruction of a nose with a full thickness defect for which the flap donor site is limited. The patient was a 45-year-old man who underwent resection of a basal cell carcinoma located over the dorsum of the nose which was associated with a hemangioma simplex on the face. As a result, about two-thirds of the nose, from the dorsum to the tip, as well as a part of the right cheek became deficient and the right nasal cavity became exposed. The nose was reconstructed using the above-mentioned method. The result was satisfactory both cosmetically and functionally.     

Reconstruction of Scalp Defects Using Simple Designed Bilobed Flap

We have devised a novel rational method to design a bilobed flap. In our method, two triangle flaps are designed; the angle of the first flap is three-fourths the angle of a rhombus at the defect site, and the angle of the second flap is also three-fourths that of the first flap. We have successfully performed reconstruction of scalp defects as large as 50 × 45 mm using simple designed bilobed flaps. The location of the defect was the parietal region in 10 cases, the frontal region in 6 cases, the temporal region in 3 cases, and the occipital region in one case. The advantages of this method for use in reconstruction of scalp defects are as follows: (1) the dispersion tension on the flap provides stable circulation and prevents expansion of scar formation; (2) since the suture line is zigzag, alopecia at the suture line can be hidden under the hair; (3) since this flap is a random pattern flap using galea aponeurotica with blood flow to the skin, flap design is possible for any part of the scalp; and (4) design and elevation of this flap are easy and do not take much time.     

A new surgical technique for the correction of the inverted nipple

Many techniques have been proposed over the years to correct the inverted nipple, a condition which causes both aesthetic and functional problems. In more severe cases, other than causing infections and inflammations, breastfeeding is impossible because of the lack of nipple erection. Reconstructive surgical techniques today are oriented toward methods that allow adequate filling to maintain the nipple permanently everted. In the technique we propose, the nipple is pulled out and extruded by way of a periareolar incision after sectioning the galactophorous ducts and fibrous tissue. To guarantee a permanent eversion, a single trilobed dermoglandular flap is created, overturned, and fixed to fill the ``dead space' below the nipple after the lobes have been sutured together. Finally, two transfixed U-shaped sutures are employed to keep the flap in place. From an analysis of the various techniques and results obtained, this method appears to be effective above all in resolving the aesthetic problem in a stable manner and is simpler than the techniques that employ multiple flaps.     

对偶交叉真皮瓣法在严重乳头内陷整形中的应用

目的探讨对偶交叉真皮瓣在严重乳头内陷整形中的应用。方法 39侧严重乳头凹陷患者行手术整形,以内陷为中心,设计4个方向的对偶交叉真皮瓣,于乳头下方双向交叉固定,支撑内陷乳头组织。结果本组患者术后乳头均保持良好形态,无复发,未出现感染、血肿、乳头永久麻木以及皮肤坏死等并发症。结论在Ⅲ度乳头内陷的治疗中,对偶交叉真皮瓣提供了两个方向上的立体支撑,复发率低,能获得良好且稳定的疗效。     

Reconstruction of the Helical Rim with the Rubber Band-Conditioned Postauricular Tubed Flap: A Case Report

Objective: A case with posttraumatic tissue loss of the auricle is presented, where successful reconstruction with the aid of a tubed flap is achieved by gradual lysis within three stages. Background: Helical rim losses may be reconstructed with a tubed flap created from postauricular tissue. Method: The vascularity of the tubed flap was increased with the intermittent application of a rubber band tourniquet. Conclusion: The use of a tourniquet before completing the third stage of the helical rim reconstruction may enhance the reliability of this procedure.     

Immediate nipple reconstruction in combination with implant reconstruction using dermal sling

The inferior de‐epithelialized dermal flap with implant is increasingly used for immediate breast reconstruction. We have adapted the technique to provide concurrent immediate nipple reconstruction by recruiting the triangle of skin above the excised nipple as a modified C‐V flap. The safety and efficacy of this technique has been assessed in 15 patients, of which eight were bilateral and seven were unilateral cases. We suggest that this is a safe, reliable, and original technique for immediate nipple reconstruction in patients undergoing immediate breast reconstruction with an inferior dermal sling and implant.     

Stenosis of the Nasal Vestibule and Its Treatment

From our own experience and a review of the literature, we present a few techniques which, in our eyes, give the surgeon the possibility to treat most encountered cases of stenosis of the nasal vestibule. During 1991 to 1998 the author in Stuttgart (W.G.) performed simple z-plasty combined with local flaps in 6 patients and composite grafts only in 12 cases, to correct nasal vestibule stenosis. The author in Lausanne (R.M.), who first described the paranasal myocutaneous flap to correct not only nasal vestibule stenosis but also alar base malposition has treated over 50 patients with this technique and with composite grafts during the last 20 years.     

The RSVP Facelift: A Highly Vascular Flap Permitting Safe, Simultaneous, Comprehensive Facial Rejuvenation in One Operative Setting

This study describes our effort to develop a reliably safe method for combining currently available treatment modalities in an effort to obtain comprehensive facial rejuvenation in one operative setting. Detailed evaluation of 101 available consecutive patients, their per- and postoperative photos and charts was undertaken. Five groups of patients were studied: (1) traditional facelift with wide subcutaneous undermining and SMAS plication. (2) Similar traditional facelift with regional laser resurfacing. (3) RSVP (rejuvenation with sparing of vascular perforators) facelift. Subcutaneous undermining stops 3 cm lateral to the nasolabial fold to preserve the rich angular/facial arterial supply and venous drainage, still permitting lateral SMASectomy or SMAS plication. Subcutaneous neck undermining is discontinuous, the posterior dissection being limited to that which is necessary for identification of the posterior edge of the platysma and its plication to the mastoid and SCM muscle. The anterior dissection is limited to that necessary for anterior platysmal repair leaving intact a vertical subcutaneous non-undermined zone 4–6 cm in width, preserving the submental perforating artery. If indicated, gentle liposuction with a fine cannula is performed through this area. (4) RSVP facelift and regional laser resurfacing. (5) RSVP facelift with total facial laser resurfacing. Mean follow-up was 13.6 months, minimum 6 months. There were no additional major complications associated with the addition of laser resurfacing or fat grafting to the RSVP group. The patients with laser resurfacing were pleased with their result, and estimated that their apparent age had been reduced by a mean of 10.4 years, compared with 6.6 years for the non-lased group. We conclude that the RSVP flap is a hardy, vascular flap permitting simultaneous laser resurfacing, fat grafting, and other adjunctive procedures without significant fear of flap loss.     

Nummular Nipple Hypertrophy and Repair as Part of an Aesthetic Nipple-Areola Unit

The author suggests that an aesthetically pleasing ratio between nipple and areola diameter exists which should always be taken in consideration during nipple and areola reconstruction. In a study of 40 nipple–areola complexes of 20 healthy, nulliparous, Caucasian female volunteers with a mean age of 25.5 years, the average nipple diameter measured 28% of the areola diameter, that is, a ratio of 1:3.6. A hitherto undescribed form of macrothelia is presented in which the nipple width rather than the projection (length) is increased. A successful technique for reconstruction is described, based on the new method of assessing the aesthetic relations within the nipple–areola complex and known anatomy.     

Combination of the square flap method and the dermal sling to correct flat or inverted nipples

A technique for the correction of flat or inverted nipples is presented. The procedure is a combination of the square flap method, which better shapes the corrected nipple, and the dermal sling, which provides good support for the repaired nipple.     

The Top Hat Flap: For One Stage Reconstruction of a Prominent Nipple (Top Hat Flap)

Nipple reconstruction is an important adjunctive procedure in breast reconstruction. Local flap procedures and tattoo-only techniques rarely provide sufficient projection in a patient with prominent nipples. We describe a method to reconstruct such a nipple termed the top hat flap. A retrospective chart review of 38 patients was performed to determine adequacy of projection and complication rates of 46 nipples created between 1989 and 1994. Forty-three (93%) of the nipples resulted in adequate and sustained projection at a minimum of 1-year follow-up. The complication rate was found to be low and patient satisfaction high with this simple outpatient procedure.     

Effects of Retinoic and Glycolic Acids on Neoangiogenesis and Necrosis of Axial Dorsal Skin Flaps in Rats

Retinoic acid (RA) and glycolic acid (GA) are frequently used in the treatment of acne and skin aging, as well as improving skin healing after dermabrasion and in photoaged skin. Examples of histologic alterations caused by these substances are vascularization increase and interference with inflammatory as well as regenerative skin processes. The objective of this study was to evaluate the possible decrease of skin flap necrosis areas in rats, by applying both substances to the skin 14 and 30 days before surgery, and analyzing histopathologic skin alterations after treatment. Fifty Wistar rats were divided into five groups of 10 animals each. They received daily retinoic acid application for 14 and 30 days, daily glycolic acid application for 14 and 30 days, and vehicle application (control group) for 14 days. After treatment, each rat was submitted to random dorsal skin flap (10 × 3 cm) elevation; flaps were sutured back in place over isolating plastic strips. The rats were sacrificed after 7 days and flap necrosis areas were measured through transparency and then analyzed using computer scanning. Statistical analysis was carried out using monocaudal nonpaired t tests and histopathologic examination was performed in all cases. Compared with the control group, treatment with both acids did not decrease average flap necrosis areas. Though groups RA 30 days and GA 14 days presented larger necrosis area averages (p < 0.05), groups RA 14 days and GA 30 days showed no statistically significant difference (p > 0.05) when compared to the control group. Both substances caused spongiosis, stratum corneum thickening, and vascularization increase, with GA inducing greater granulomatous reaction and RA more spongiosis and queratinization. Group RA 30 days showed the most significant dermo-epithelial (including vascular) regenerative and proliferative effects. Retinoic and glycolic acid treatment led to significatuve and well-known skin alterations, with group RA 30 days showing most notable dermo-epithelial proliferative effects. In our experimental model, preoperatory RA and GA application did not decrease rat dorsal skin flap necrosis area when compared to the control group.     

The inferior dermal-pyramidal type breast reduction: long-term evaluation

The evolution of the technique of breast reduction using an inferior dermal pyramidal flap is discussed, including the changes we have found to enhance this procedure. The recommended use of a wide-based pyramidal breast parenchyma with a dermal pedicle nipple-areola flap is based on our 12-year study of 1,001 breast reductions in 519 patients ranging in age from 13 to 73 years; 37 of the patients underwent a unilateral breast reduction. The weight of tissue excised ranged from 207 g to 3,350 g from each breast. Occult carcinomas were found in two of the breast specimens. The longest sternal notch-to-nipple distance was 52 cm. The essential goals of predictability of the result, retainment of nipple sensitivity, excellent aesthetic results, and the possibility of lactation are satisfied by the use of this surgical technique. This technique appears to have continued application in younger women, in whom nipple sensation and lactation are particularly important.     

Mammographic findings following reduction mammoplasty

Breast reduction mammoplasty is becoming an increasingly common procedure. A baseline mammogram is recommended after 35 years of age as the most effective method for detection of small breast cancers. A prospective study was conducted for the evaluation of the mammographic findings after reduction mammoplasty. During the last 7 years, 113 patients over 35 years of age underwent bilateral reduction mammoplasty. All patients had a preoperative mammogram. A new mammogram was obtained at 6 and 18 months after the procedure. All films were reviewed by the same two radiologists. Breast reduction was performed with the vertical bipedicle flap technique (McKissock) and the inferior pedicle technique. There were no apparent differences in the findings between the two methods. Most common findings were parenchymal redistribution in 102 (90.2%) and elevation of the nipple in 96 (84.9%), produced by a shift of the breast tissue to a lower position. Calcifications were seen in 29 (25.6%), and ``oil cysts' in 22 (19.4%), caused by localized fat necrosis. A retroareolar fibrotic band was found in 23 (20.3%), from the transposed flap. Areolar thickening was observed in six (5.3%), and skin thickening in only two (1.7%), from scar tissue. Mammographic findings after reduction mammoplasty are predictable, thus preventing unnecessary biopsies and making the diagnosis of lesions unrelated to the procedure easier. All patients over 35 years of age should have a preoperative and a postoperative mammogram for future reference.     

Increasing Projection in Patients Undergoing Free Nipple Graft Reduction Mammoplasty

Reduction mammoplasty in patients with gigantomastia has traditionally been performed by a technique involving free nipple grafting. These patients usually have only a small amount of breast tissue above the inframammary fold and therefore this type of procedure has often left patients with an insufficient amount of superior pole projection. I have performed free nipple grafting in three patients with gigantomastia using a technique that utilizes two deepithelialized pedicles to increase projection. This technique is simple to perform, does not significantly lengthen the operative time, and results in a breast that provides significant projection.     

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??Surgical treatment of inverted nipple WEN Bing??XIE Kun. Department of Plastic Surgery, Peking University First Hospital??Beijing 100034,China
Corresponding author:WEN Bing,E-mail: wenzhenhe16@sina.com
Abstract The basic principles of inverted nipple correction surgery are adequate release of fibrous bands pulling the nipple retraction and nipple substrate support tissue reconstruction. The most commonly used corrective surgery includes breast tissue flap method and areola dermal flap method. In recent years, acellular allograft dermal matrix or artificial dermis filling method as a new simple minimally invasive corrective surgery has better prospects.