Simultaneous Breast Augmentation and Lift

Often, both augmentation and mastopexy are necessary to solve the problems of breast ptosis with hypoplasia. These two procedures can be done simultaneously with no increased risks. Patients who have any degree of ptosis may benefit from some lifting of the nipple areola complex if the nipple is not in the central portion of the general contour of the breast mound when seen in the upright position. A simple crescent or eccentric excision in the upper quadrant may be sufficient to lift the nipple–areola complex 1–2 cm. If the nipple needs to be moved more than a couple of centimeters, or if the distance between the nipple and the inframammary crease is already excessive, an inframammary skin excision and redraping will be necessary. We have been using these combined techniques for 20 years with universal patient satisfaction.     

``Flip-Flap' Mastopexy

The ``flip-flap' mastopexy modifies the McKissock vertical bipedicle design by creating a wide superiorly based flap of breast tissue deep to the vertical bipedicle. Transposition of this flap up and beneath the upper breast, with suture anchoring to the pectoralis fascia at the level of the second rib, restores upper breast fullness, decreases mastopexy-wrecking lower breast bulk, and provides a pleasant forward thrust of the nipple–areolar complex. The ``flip-flap' is effective for improving the long-term aesthetic outcome for both reduction mammaplasty and mastopexies of moderate- to full-sized breasts.     

Periareolar reduction mammaplasty utilizing the inferior dermal pedicle

The critical points which should not be overlooked when performing reduction mammaplasty are to minimize scar on the breast and to ensure a sufficient blood supply for the viability of the nipple–areolar complex. Periareolar reduction mammaplasty has been widely used because it left only one scar around the areola. However, with the typical periareolar reduction mammaplasty technique, it is difficult to remove a large amount of breast tissue and mobilize the remaining breast tissue. It may result in necrosis of the nipple–areolar complex in some cases. To overcome these limitations we combined the periareolar incision with the inferior dermal pedicle, which has a relatively good blood supply. This new technique was employed in 22 consecutive women (44 breasts) with hypertrophy and a varying degree of ptosis. Infiltration of a tumescent solution and liposuction were performed in all cases. After periareolar incision, dissection of the skin was performed, and the breast was elevated from the fascia of the pectoralis major muscle, leaving the inferior dermal pyramidal pedicle. An adequate amount of tissue was resected in the superior, medial, and lateral areas. After mastopexy, closure was done with a purse-string suture. The amount of tissue resected ranged from 180 to 1510 g per breast, and the mean was 466.1 g. The mean length of elevation of the nipple was 10.6 cm along the meridian of the breast. There were a few complications which needed revision operation: hematoma collection in one breast (2.3%), wound dehiscence in one breast (2.3%), and fat necrosis in one breast (2.3%). There was no necrosis of the nipple–areolar complex. With this new technique of periareolar reduction mammaplasty utilizing the inferior dermal pedicle, we were able to minimize the scar, preserve the nipple–areolar complex, and improve the motility of the breast tissue. But we also observed a flat or square appearance in the case of a large amount of resection in the patients with poor skin elasticity. This technique is safe and versatile and produces aesthetically acceptable results in selected patients.     

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.     

真皮乳腺组织瓣悬吊纠正乳房下垂

目的 应用真皮乳腺组织瓣悬吊纠正乳房下垂.方法 本组共6例乳房下垂病人,采用乳晕周围双环切口,在新乳标记点处斜向下方切开腺体组织使乳房下部形成包含双环之间真皮的乳腺组织瓣,将组织瓣向上牵拉覆盖乳腺上部并悬吊固定于胸肌筋膜.组织瓣切取根据乳房下垂程度及组织量多少而定,同时要确保组织瓣血液循环.结果 6例病人均获得满意的乳房外形.结论 该方法是目前比较理想的纠正乳房下垂的方法     

乳房下垂伴小乳房的综合修复术

目的 探讨针对不同程度乳房下垂伴小乳房综合修复治疗的有效手术方法.方法 根据乳房下垂的轻重进行分度,针对不同的分度进行治疗.Ⅰ度下垂伴小乳房,应用胸大肌后间隙置入假体隆胸;Ⅱ度下垂伴小乳房,在Ⅰ度下垂治疗的基础上应用深层乳腺与胸大肌表面脱套剥离及乳腺组织悬吊固定;Ⅲ度下垂伴小乳房,在Ⅱ度下垂治疗的基础上结合双环法多余皮肤切除、深层乳腺与胸大肌表面脱套剥离及乳腺组织悬吊固定;Ⅳ度下垂伴小乳房,应用直线瘢痕法乳房悬吊结合假体隆乳.结果 综合修复治疗乳房下垂伴小乳房116例,无血肿、无感染、无乳头乳晕坏死等并发症发生.术后随访6～31个月,平均随访时间13.3个月,乳房丰满挺拔,乳房下垂得到矫正,乳头乳晕感觉功能正常.结论 针对乳房下垂伴小乳房的不同情况,应用规范化的手术方案可取得较好的临床治疗效果.     

Correction of Inverted Nipple with Modified Star Flap Technique

The authors describe the application of the modified star flap technique for correction of inverted nipples. This technique allows easy identification and dissection of the lactiferous ducts under a clear direct view without trans-nipple incision. The secure deep dermal buried sutures around the nipple base in three directions maintain the newly everted nipple. The blood supply to the nipple flap is reliable through the dermal and subdermal plexus from the remaining non-incised site of the nipple and areola region.     

Muscle-Splitting Breast Augmentation: A New Pocket in a Different Plane

Background Breast augmentation usually is performed in subglandular, subfascial, or partial submuscular pockets, including the dual plane. A new pocket has been described and used by the author. The initial pocket was made in the subglandular plane up to the lower level of the nipple–areolar complex, and the submuscular plane was reached by splitting the pectoralis major muscle without its release from the costal margin. The implant lies in this plane simultaneously behind and in front of the pectoralis. Methods From October 2005 to November 2006, 125 patients underwent bilateral breast augmentation using the new technique. Soft cohesive gel microtextured round implants ranging in size from 230 to 440 ml were used. Results All the patients experienced a quick recovery with three-dimensional enhancement and having the benefits of both subglandular and submuscular planes. No rippling, lateral displacement, double-bubble deformity, or muscle contraction–associated deformities were seen. All the patients had aesthetically natural cleavage, with the nipple at the most projected part of the breast. Postoperative analgesia requirements were reduced because of dissection in natural planes. Conclusion For adequate cover of the prosthesis, only the upper part of the pectoralis major muscle is required. This can be achieved by using the pectoralis muscle-splitting technique. The pectoralis major was split in the direction of its fibers, avoiding extensive muscle release. Surgical morbidity was reduced, resulting in a quick postoperative recovery and a more natural three-dimensional appearance of the breast. Oral presentation at the 6th Croatian Congress of Plastic, Reconstructive, and Aesthetic Surgery, Optija–Rijeka, Croatia, 6–11 October 2006     

Pectoralis Major Muscle Flap: A New Support Approach to Mammaplasty, Personal Technique

Despite the significant evolution of mammaplasty techniques, some undesirable changes on the operated breasts result in evident dissatisfaction for both patients and doctors. The main reason is that the breast has a tendency to resume its previous shape months after the operation. In pursuit of a procedure that would avoid this untoward morphologic evolution, we set to work on the development of a new approach of broad fixation to maintain the breast shape and to avoid ptosis by using the inferior third of the pectoralis major muscle. The authors report their experience with 46 consecutive cases of breast reduction and mastopexy operated between March 1994 and November 1995, studying the surgical procedure employed, its advantages, limitations, and possible complications.     

Short Scar Mastopexy with Flap Transposition

A personalized technique using a vertical scar mastopexy is described. The breast tissue is utilized as a transposition flap behind the nipple–areolar complex to increase its projection. The inferior pole of the breast can be developed either as a superiorly pedicled or inferiorly pedicled flap for that purpose and the indication for each version is described. The technique has been successfully utilized in 80 patients with pleasing results. Illustrative cases are presented.     

Radial Plication in Concentric Mastopexy

Concentric mastopexy presents many challenges to the plastic surgeon, especially when breast augmentation is part of the treatment plan. Radial plication is a reproducible and accurate technique for elevating the nipple–areolar complex and shaping the breast mound. Patient selection is important to the success of the radial plication procedure and concentric mastopexy in general. Although most surgeons agree that patients with smaller degrees of nipple ptosis and smaller breasts have better results than patients with greater degrees of nipple ptosis and larger breasts, there has never been an algorithm for patient selection. Regnault’s classification of breast ptosis addresses the degree of nipple ptosis, but no consideration is given to breast volume. Radial placation proved to be a valuable tool in the treatment of 87 patients undergoing concentric mastopexy in the author’s practice over the past 30 months. An algorithm addressing degrees of breast ptosis and breast volume is provided. The plastic surgeon can anticipate gratifying results if the algorithm provided is incorporated into his or her patient selection for concentric mastopexy. The concentric mastopexy technique is similar to the tailor tack procedure for standard mastopexy, allowing the plastic surgeon to mold and shape the breast before making a critical incision.     

Augmentation of the Columella-Labial Angle to Prevent the ``Smiling Deformity' in Rhinoplasty

Aesthetic diagnosis of the smiling deformity, which is functional rather than anatomical, is essential to provide the best treatment in rhinoplasty. The nasal tip tends to rotate inferiorly during smiling, and the central upper lip moves superiorly. A posteriorly sloping upper lip with a retrodisplaced columella–labial junction gives an unaesthetic appearance. Downward movement of the tip and a sharper nasolabial angle are usually aesthetically unpleasant. In 28 nasal surgeries, augmentation of the columella–labial angle with cartilage strip grafts has been performed. The augmentation of the angle and additionally cutting of the depressor septi muscle created a wider nasolabial complex, and this angle looks full and more pleasant. This procedure has mainly been used as an additional procedure to standard reduction rhinoplasty in order to improve smiling deformity. Strip cartilage grafts were inserted subcutaneously into the upper lip extending half way to the columella and secured with a transcutaneous suture under the columella–labial angle to prevent misslocation. Augmentation by the cartilage graft together with cutting the depressor septi muscle prevented elevation and shortening of the upper lip, and also drooping of the nasal tip. This procedure provided an aesthetically pleasant appearance both at rest and during smiling.     

Breast Ptosis Managed by Mastopexy Using the Triple Flaps Procedure

Breast ptosis is a highly unattractive appearance of the breast. In the mind, it is associated with aging, multiple pregnancies, lactation, and senile changes. Its correction by mastopexy presents one of the greatest challenges to the breast surgeon aiming at a pleasant full conical shape and stability of the results. The authors present their mastopexy procedure using a triple-flap method based on the principle of a superior pedicle flap mammaplasty. The technique, presented in detail, basically consists of a superior pedicle dermaglandular flap that carries the nipple–areola complex between outer and inner flaps. The outer flap is rotated inward and upward behind the main superior pedicle to give fullness to the breast and fixed to the chest wall. The inner flap is double-breasted on top or superficial to outer flap, and both are sutured to each other resembling a hammock or a cradle that carries the main superior pedicle middle flap. The results are presented and advantages discussed. This method, besides its simplicity, gives good projection with a pleasant and attractive conical shape to the breast and upper fullness, frequently negating the need for an implant. In addition, the results were stable in the long term, with no need for a mesh or any other foreign material.     

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.     

Breast Reconstruction by Expansion and Advancement of the Upper Abdominal Flap

Inspired by successful reconstruction obtained using the Lewis–Ryan lower thoracic advancement flap to rebuild missing breast, we have adapted that extremely simple technique to prior serial expansions, in order to create more natural mounds, better defined submammary folds, and when possible, some grade of ptosis, without additional, new scarring. The procedure is introduced and compared to other such flaps as the TRAM and the latissimus dorsii. In our series, 30 patients were evaluated according to the quality of the final results, and the most frequent complications are pointed out and discussed.     

Inferior Dermal Flap in Immediate Breast Reconstruction

Background

The inferior dermal flap can be used in conjunction with implants or tissue expanders to avoid need for acellular dermal matrix in breast reconstruction and on occasion can serve as an alternative to an autologous flap by functioning as a reconstructed breast mound. Candidates for this procedure are women with high BMI or breast ptosis who desire a decrease in breast size at time of mastectomy with reconstruction. This procedure recruits the de-epithelialized excess skin inferiorly and laterally from a skin-sparing mastectomy and uses this to eliminate the need for acellular dermal matrix in a cost-conscious environment.

Methods

The skin-sparing mastectomy is performed, and the inferior skin flap is de-epithelialized to create the inferior dermal pedicle. A gel implant is placed retropectorally, and the inferior dermal flap is sutured to the inferior border of the pectoralis major muscle and laterally to a muscle-sparing serratus pedicle to provide support and coverage of the implant.

Results

We have performed this procedure in several patients and present a video outlining the technique of this procedure in a 54-year-old female diagnosed with left breast DCIS. Postoperative pictures taken at 6 weeks showed an excellent cosmetic result without complications.

Conclusions

The inferior dermal flap is a simple and reproducible procedure that can reduce cost by eliminating the use of acellular dermal matrix. It provides an excellent cosmetic outcome in women undergoing mastectomy with large BMI and breast ptosis seeking reduction in breast size.     

Immediate breast reconstruction using an external oblique rectus musculofascial turnover flap

The development of the external oblique rectus musculofascial turnover flap has recently received a great deal of attention. With this method, the upper part of the external oblique muscle is lifted off the lower thoracic wall along with a segment of the rectus muscle, pedicled in the sixth intercostal space and subsequently connected with the lower margin of the pectoralis major muscle. This approach bridges the weak regions of the thin muscle layers in the medioinferior breast area. Because this procedure avoids the need for a second operation to restore the contour and enables production of a natural ptosis and a well-accentuated lower breast fold, it has become increasingly important in immediate breast reconstruction. Compared with the complex myocutaneous flaps techniques, this procedure is characterized by relative simplicity and ease of performance. Compared with the tissue expansion technique, the oblique rectus turnover flap allows restoration of the female form in a one-stage procedure with a better, more natural ptotic breast shape and well-defined inframammary crease. Results have been encouraging. In fact, this procedure has almost completely replaced other techniques for immediate reconstruction of the female breast following mastectomy.     

Circumareolar Dermo-Glandular Plication: A New Concept for Correction of Breast Ptosis

Circumareolar dermo-glandular plication is the latest advancement of the periareolar dermopexy with a retromammary mastopexy technique I published in 1969. Rather than a technique, the new concept is a procedure which originates new techniques covering multiple indications, i.e. for all conditions combined with ptosis: for mastopexy in ptotic breasts, for hypertrophic or hypoplastic breasts with resection or implant augmentation, respectively; for subcutaneous mastectomy, gynecomastia, asymmetries, and tuberous breasts. It is useful for reoperations to correct secondary ptosis as well as to reduce the length of the scar in vertical techniques. The corresponding techniques are described. The procedure has proved to be safe and reliable in over 200 patients with the following advantages: no full thickness skin incision or excisions are performed; only the epidermis is excised. Except for hypertrophies, the skin is not dissected from the gland, nor the gland from the pectoralis fascia, which increases vascular safety and preserves NAC innervation; the dermoglandular unit of the breast through Cooper's ligaments is stabilized by a single or multiple plications. The scar is only circumareolar, reducing psychological stress and discomfort and achieving an early recovery and patient satisfaction. The inconveniences are puckering and some widening of the periareolar scar, which requires a secondary revision in approximately 50% of the cases, also frequently necessary in conventional techniques. There is a tendency to flattening of the NAC and periareolar bulging with tendency to a ``tomato breast appearance.' The prevention of the latter is described.     

Evolution of the Vertical Reduction Mammaplasty: The S Approach

The vertical reduction mammaplasty has been popularized over recent years. It always produces marked puckering of the excess skin and requires revision surgery for the persistent dog-ears that develop. Minor complications are often common. As a result, the evolution with S approach is developed. A series of 36 consecutive patients who underwent the S approach reduction mammaplasty is presented. The S approach can be described as having 1) superior dermoglandular pedicle, 2) simple and safe S-shaped skin marking, 3) suspension of the residual glandular tissues transversely to the periosteum of the 5th rib, and 4) short-scar closure. The surgical techniques are described in a step-by-step fashion. An analysis is made of the results obtained from these patients. The mean follow-up period of this study is 21 months. As a result of surgical operation, the symptoms of breast hypertrophy were markedly improved. According to patient assessment, neck, back, or chest pain decreased from 64% to 25%, shoulder grooving improved from 56% to 25%, stooped posture decreased from 42% to 14%, intetrigo improved from 36% to 8%, psychological embarassment decreased from 33% to 8%. The postoperative complications included minimal areolar epidermolysis (11%), hypertrophic scar (8%), etc. All mammograms revealed hypertrophic patterns of the breast. The glandular tissues removed had a mean of 480 g from each breast. Two breasts (3%) had fibroadenomas. The sternal notch–nipple distance changed from a mean of 30.5 cm preoperatively to 20.5 cm, the length of infraareolar scar was 9 cm in average. Eighty-one percent of patients had minimal postoperative ptosis, and the sensitivity of nipple–areola complex was unchanged in 75% of patients. Nine patients (24%) retained the ability to lactate for more than 1 month postoperatively. Twenty-two patients (61%) were very satisfied with their operation, and eight (22%) were adequately satisfied. The technique presented is a simple and safe procedure that provides satisfactory results for patients with breast hypertrophy.     

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.