Preoperative and postoperative considerations in elective breast operations

The number of young women undergoing elective breast operations is increasing rapidly. The lifetime breast cancer risk in the female population is 1 in 10. As this group ages, it is obvious that surgeons will encounter carcinoma of the breast in these patients more frequently. The surgical implications of breast cancer in these patients are discussed, and guidelines for preoperative and postoperative management in patients being considered for augmentation mammaplasty, mastopexy, and reduction mammaplasty are suggested.     

Adjustment of the contralateral breast following breast reconstruction

Surgery on the contralateral breast was performed in 64 of 100 patients for adjustment of size and shape or for diagnostic purposes. The patients found it more desirable to adjust size than shape asymmetry on the contralateral breast. There was only one early complication and six late ones. The former was a postoperative hematoma after a reduction mammaplasty. The latter were three cases of capsular contractures after augmentation mammaplasties. In these cases the implant was placed in a submuscular position. In three cases, patients asked for a secondary reduction mammaplasty because of poor symmetry. There were some difficulties in comparing pre- and postoperative mammography after augmentation mammaplasty. In the other adjustment procedures, there were only minor difficulties in a few cases comparing pre- and postoperative mammography. Patients with a high risk of bilateral breast cancer needing size and/or shape symmetry correction should be considered for mastectomy and immediate reconstruction.     

Short scar reduction mammaplasty in the bariatric patient

Reduction mammaplasty may be necessary even after massive weight loss. Patients typically present with unfavorable breast features such as significant loss of upper pole volume, inelastic skin, and severe ptosis. The most common approach in the United States has been the Wise-pattern inferior pedicle technique, emphasizing skin excision. This report presents the short scar vertical reduction mammaplasty approach for the bariatric patient population. It aims to demonstrate improved outcomes with less scar burden. The study included 15 women (n = 29 breast reductions) with mean age of 41.8 years. All the patients had undergone gastric bypass surgery, with mean weight loss of 109 pounds and mean body mass index of 33.3 kg/m(2). A modified superomedial pedicle vertical mammaplasty technique was used. New nipple position was placed lower than the inframammary fold in accordance with vertical lack of upper pole fullness. Suction-assisted lipectomy was used to contour the inferior pole of the breast before glandular resection. A full-thickness superomedial pedicle and median incision of the upper pole maximized pedicle safety. The mean breast resection was 605 g on the right side (range, 352-945) and 592 g on the left side (range, 360-908). Patient satisfaction was high, with pleasing and stable breast shape at long-term, and a mean patient-related aesthetic ranking of 4.3 of 5.0. No major complications were noted. It is shown that superomedial pedicle vertical reduction mammaplasty can be an alternative approach in bariatric patients, achieving long-term pleasing and stable results with significantly decreased scar burden.     

Breast augmentation after reduction mammaplasty: getting the size right

Although patients are typically satisfied after reduction mammaplasty, a subgroup later deems the volume of remaining breast tissue inadequate and presents for breast enhancement. Our purpose was to identify patient and procedural risk factors that may contribute to an over-reduced breast and the desire for breast augmentation after initial reduction. Seven patients were identified who had breast augmentation an average of 13 years after breast reduction. Four patients were satisfied with breast size immediately after reduction mammaplasty but lost breast volume subsequent to weight loss or childbearing. Three patients with a body mass index of 18 to 20 were dissatisfied immediately after reduction. Body image improved in 100% of patients after enhancement. Getting the size right depends upon thorough discussion with the patient regarding desired size, insurance requirements, and potential for decreased size after weight loss or childbearing. Breast augmentation may improve body image in patients with small breasts after reduction.     

Prolactin secretion in women after plastic breast augmentation and reduction

Prolactin secretion in women undergoing augmentation and reduction mammaplasties was studied by determining serum prolactin concentrations preoperatively, intraoperatively, and for one year postoperatively. Thyrotropin-releasing hormone tests for prolactin secretion were performed in a small subgroup of these patients. The subjects were 7 women undergoing reduction mammaplasty, 13 women undergoing augmentation mammaplasty, and 14 normal control women. Short-term (up to three days postoperatively) but not long-term changes in prolactin secretion were identified. Persistent hyperprolactinemia does not appear to be a common complication of plastic breast operations.     

A False-Positive Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) Imaging Result for a Patient After Augmentation Mammaplasty

Background  Various materials and methods have been used for augmentation mammaplasty since it was first performed in Japan in the late 1940s. Although augmentation mammaplasty is not associated with an increased risk of breast cancer, a number of studies have reported that breast implants, or subsequent changes around these foreign substances, can affect images made by mammography, CT, or MRI during breast cancer screening. A method that is increasingly being used to detect cancer is positron emission tomography (PET). Methods  To determine the effect of augmentation mammaplasty on PET imaging, we subjected ten women who had previously undergone augmentation mammaplasty to PET imaging as well as other imaging methods. We also measured tumor markers and performed pathologic studies. Results  The histologic analyses failed to detect any cases of malignancy. We assess the efficacy of PET for detecting breast cancer in women who had undergone augmentation mammaplasty and describe the features of the PET images of these women. Finally, we discuss future research objectives in relation to PET-based screening for breast cancer. Conclusion  It is important to identify an imaging methodology that improves the detection of breast cancer in patients with a previous mammaplasty. We show here that FDG-PET may improve breast cancer detection after mammaplasty.     

New view in the mammary asymmetry treatments

AIM: Breast asymmetry is a huge chapter of breast abnormalities. Surgical therapy is the exclusive one. The breast of women can vary in shape, volume and position, thus creating esthetic, social and psychological problems. METHODS: We classified breast asymmetry into 6 categories and then we treated them with different surgical techniques: reduction mammaplasty according to Planas; augmentation mammaplasty with prosthesis; grafts or both; ultimately mamma-prosthesis (association of mastopexy and prosthesis). We obtained satisfactory esthetic results often with one surgery procedure. Rarely we performed 2 or more procedures of symmetry. We treated 77 patients suffering from breast asymmetry. We excluded in this study the giant-mammary asymmetry (anomaly determined by severe and asymmetric mammary hypertrophy). RESULTS: We found a low number of complications at short and long term. These results are likely due to the ability of the surgeon in the appropriated preoperative evaluation of the patients and of their expectancy and correct surgical techniques. CONCLUSIONS: We tried to obtain 3 results: shape and position of the sick breast as same as possible to the contralateral breast and less evident scars located in hidden regions.     

A new technique of reduction mammaplasty: dermis suspension and elimination of medial scars.

In the last decades new techniques of reduction mammaplasty significantly improved the results obtained and led to a reduced incidence of complications. However, some important problems like the loss of a natural submammary fold and alteration in the shape of the breast with time still remained mostly unsolved and the medial scars in the inverted T techniques are aesthetically unsatisfying. A new strategy for reduction mammaplasty has been developed based on a combination of advantages of other techniques. The principle of using de-epithelialized infra-areolar skin for dermis suspension prevents sagging of the remaining breast tissue behind the inframammary fold to create a long-lasting, natural shape of the reduced breast with an accentuated submammary fold. The central pedicle is favoured because of good modelling even in big reductions. Better vascular and nerve supply of the nipple-areola complex and the continuity of the lactiferous ducts are further advantages of the central pedicle. Secondary operations after reduction mammaplasty or augmentation usually dictate the use of a superior pedicle together with the dermis suspension technique. B-shaped skin incisions prevent medial submammary scars and can be used up to a 10 cm transposition distance of the nipple without disadvantage. The operative technique is described in detail. Examples are given for the primary procedure and the technique as a secondary correction. The principle of dermis suspension in combination with the prevention of a medial scar is applicable to reduction mammaplasty as well as mastopexy.     

Mastopexy After Massive Weight Loss: Extended Chest Wall–Based Flap Associated with a Loop of Pectoralis Muscle

Mammaplasty for patients who have experienced massive weight loss involves some concepts that differ from those that apply to mammaplasty for normal patients. Breast anatomic characteristics make this procedure a very challenging situation. The authors present their experience with a new mammaplasty technique using an extended thoracic wall flap associated with a loop of pectoralis. This procedure is a simple and reproducible method for patients with massive weight loss that results in a pleasing breast shape and long-lasting results.     

A型肉毒素肌注胸大肌对硅凝胶假体隆乳术形态影响的临床研究

目的:本研究旨在探讨A型肉毒素对假体隆乳病人术后乳房形态变化的影响。方法:40例小乳症患者行硅胶囊乳房假体隆乳术。试验组术中在胸大肌中下段注射A型肉毒素,对照组直接行隆乳术,术后两组采取照片测量进行形态评估。结果:在整体乳房形态上,试验组术后3个月大部分乳房乳头位置基本位于乳房中部,术后6个月可稍上移,幅度不大,对照组于术后3月乳头位置基本固定,大部分乳房乳头位置集中于乳房分区中部靠下,P<0.05。结论:A型肉毒素在早期可以使乳房形状更自然。     

Polyacrylamide hydrogel injection for augmentation mammaplasty: loss of ability for breastfeeding

Polyacrylamide hydrogel (PAAG) has been widely used for injection augmentation mammaplasty in Russia, China, and Iran for more than 2 decades. In recent years, it has been advocated as a safe permanent filler for soft-tissue augmentation. However, the complications associated with PAAG injection in soft-tissue augmentation have not been extensively investigated. Augmentation mammaplasty through PAAG injection is associated with some complications. The incidence of infection during breastfeeding was reported to be higher than 50%. Herein, we report 58 cases of infection in breastfeeding women receiving PAAG injection, including 50 with unilateral injection (36 on the right, 14 on the left) and 8 bilateral injection. They experienced large breast autoinflation and some severe symptoms, such as local and systemic fever, breast swelling, nipple bulging, tenderness, and pain, which lead to surgical removal of galactocele or intraprosthetic collection of sterile pus resulting in deformity. Operation and comprehensive measures including removal of the injected material, clearing residual cavity, and pharmacotherapy were carried out to control infection and inflammation for 1 to 2 weeks. In the following 12 months, no relapse or recurrence of residual cavity was noted. Therefore, we do not recommend PAAG injection for augmentation mammaplasty, especially in women intending to breastfeed. Patients undergoing PAAG injection for augmentation mammaplasty should avoid breastfeeding. PAAG injection will cause serious consequences resulting in tissue atrophy and breast resection if inappropriately handled.     

Swelling of the breast following augmentation mammaplasty and minimally invasive cardiac surgery

Complications following breast augmentation procedures occur in the acute setting, usually in the form of hematoma, seroma, wound breakdown or infection. Late complications of augmentation mammaplasty usually manifest as either a failure of the prosthesis (eg, leak, rupture) or capsular contracture. We present an interesting case of a hematoma following augmentation mammaplasty that occurred 7 years postoperatively. What makes this case particularly intriguing is that in the time period between the augmentation mammaplasty and the late hematoma, the patient underwent minimally invasive cardiac surgery to treat a malfunctioning mitral valve. Ultimately, the breast implant was salvaged and the patient obtained a very satisfactory result. This case is important to report because as more women choose to have breast augmentation procedures and as more people have minimally invasive cardiac surgery, this clinical scenario will be encountered with greater frequency. We also make several suggestions that we feel may help avoid the problems seen with this patient in the future.     

Large Unilateral Breast Autoinflation After Breastfeeding Linked to Polyacrylamide Hydrogel Injection Augmentation Mammaplasty

Augmentation mammaplasty using polyacrylamide hydrogel (PAAG) injection is associated with myriad complications. A patient treated by the authors had bilateral breast augmentation with PAAG injection and experienced large unilateral right breast autoinflation after breastfeeding, which required surgical clearance of a likely galactocele or sterile pus collection that resulted in deformity. Patients with PAAG filler injection-augmented breasts should avoid breastfeeding. The authors recommend against using PAAG injection for augmentation mammaplasty, especially in women intending to breastfeed. Physicians and patients must be aware of the complications associated with PAAG before gel administration.     

Customized Planning of Augmentation Mammaplasty with Silicon Implants Using Three-Dimensional Optical Body Scans and Biomechanical Modeling of Soft Tissue Outcome

The aesthetic results of augmentation mammaplasty are essentially determined by the size and the shape of the implant as well as its position on the chest. To achieve successful aesthetic results, customized surgery planning based on a reliable visual concept of the prospective surgery outcome and quantitative methods for assessment of three-dimensional (3D) breast shape could be of considerable additional value. This report evaluates a novel method for customized planning and quantitative optimization of breast augmentation based on 3D optical body scanning of the patient’s breast and computational modeling of soft tissue mechanics. This method allows a 3D photo-realistic appearance of postsurgery breasts to be simulated for different surgical scenarios. It also allows the result of a virtual simulation to be implemented using measurements derived from a computationally predicted breast model. A series of clinical studies are presented that demonstrate the feasibility and accuracy of the proposed approach for customized 3D planning of breast augmentation, including direct comparison between simulated and postsurgery results. Our experimental results show that for 89% of the breast surface, the average difference between the simulated and postsurgery breast models amounts to less than 1 mm. The presented method for customized planning of augmentation mammaplasty enables realistic prediction and quantitative optimization of postsurgery breast appearance. Based on individual 3D data and physical modeling, the described approach enables more accurate and reliable predictions of surgery outcomes than conventionally used photos of prior patients, drawings, or ad hoc data manipulation. Moreover, it provides precise quantitative data for bridging the gap between virtual simulation and real surgery.     

Breast Asymmetries: A Brief Review and Our Experience

The authors describe their personal experience with the management of mammary asymmetries. A review of their database from January 1998 to January 2005 identified 177 patients with idiopathic breast asymmetries. All these cases had been classified previously into six groups. Bilateral asymmetric hypertrophy and unilateral hypertrophy were treated with reduction mammaplasty. Unilateral hypertrophy with amastia or hypoplasia of the contralateral side was managed with reduction and augmentation mammaplasty. Unilateral amastia or hypoplasia (Poland’s syndrome) was treated with a single monopedicle transverse rectus abdominis muscle (TRAM) flap, and asymmetric bilateral hypoplasia was managed with augmentation mammaplasty. Unilateral mammary ptosis was treated with mastopexy and augmentation mammaplasty. The proposed classification, derived from the authors’ experience in this field, gives an idea of how they usually treat these patients. It is useful for a first evaluation, but after that, every treatment must always be individualized on a patient-by-patient basis.     

Augmentation mammaplasty: the surgical and psychological effects of the operation and prediction of the result

The aim of this research was to evaluate the effect of augmentation mammaplasty on women and to determine if it is possible to predict which women will benefit most from the operation. Interviews were conducted with both women who were about to undergo augmentation mammaplasty and those who had undergone the surgery. These interviews were compared with interviews from a control group composed of a normally distributed population. The women who apply for augmentation mammaplasty are a homogeneous group who experience their breast problems in a very similar way. Our study revealed that they are distinctly different from the control group in personality and childhood environment. Most of the women were generally satisfied with the operation even though many had complaints about the technical result. Certain behaviors had changed, but despite these positive results these changes were not radical and in reality the improvement was not as the women initially described it. The women's behavior reactions rarely changed enough to become similar to the reactions of the control group. Using a personality test, it is possible to predict which women will benefit most from the operation. When an assessment of psychiatric problems was made using the neurosis scale in a personality test, the women who scored low on a scale of neurotic self-assertion were satisfied with the operation to a greater extent.     

Safety, Complications, and Satisfaction of Patients Undergoing Submuscular Breast Augmentation via the Inframammary and Endoscopic Transaxillary Approach

Background Since its introduction, augmentation mammaplasty has gained widespread popularity, as demonstrated by the fact that an estimated 2 million women in the United States have received implants. During recent decades, several surgical approaches have evolved in terms of implant placement or site of access to the surgical plane. Debate has existed concerning the questionable superiority of a particular technique for achievement of optimal results. Thus, the inframammary approach, an established and widely accepted technique for breast augmentation, and endoscopically assisted transaxillary breast augmentation were retrospectively compared in terms of safety and aesthetic outcome, as measured, respectively, by the rate of postoperative complications and patient satisfaction. Methods This study analyzed 78 patients undergoing augmentation mammaplasty between 1997 and 2004. Only patients seeking primary augmentation mammaplasty solely for aesthetic reasons were included in the study. Previously performed breast surgery and simultaneously conducted ipsilateral mastopexy were among the exclusion criteria. Patient satisfaction was assessed using the client satisfaction questionnaire (CSQ-8) because of its easy applicability. Results The complication rate was low in both patient subsets, thus confirming the safety of the transaxillary approach, as compared with the more common submammary technique. However, a higher level of satisfaction was detected in the former patient group, indicating a more favorable aesthetic outcome with the transaxillary augmentation mammaplasty. Conclusion Endoscopically assisted transaxillary augmentation mammaplasty is a safe method with predictable results associated with a high level of patient satisfaction. If applied in the setting of appropriate indications, it is an excellent tool for use with patients who prefer to have an incision at a distant site.     

A comparison of the LeJour and Wise pattern methods of breast reduction

Supporters of the vertical mammoplasty state the resultant breast shape and scar are superior to the Wise pattern breast reduction. This study contains a comparison of the LeJour vertical reduction with the Wise pattern reduction by analysis of pre- and postoperative photographs, as well as a retrospective review comparing operative times, blood loss, complications, and a postoperative patient questionnaire. Of the 112 women who had moderate to large reductions (>500 g/breast) between 1999 and 2002, 65 subjects had adequate standard perioperative photographs. Esthetic appearance, symmetry, nipple quality, and scarring were assessed using a Likert scale (10 = superior, 1 = poor) by 30 evaluators. Based on the photographic analysis, there is no difference in the esthetic outcome between the vertical reduction mammaplasty and the inferior pedicle Wise pattern mammaplasty. Additionally, this study indicates that vertical patients with moderate to large reductions have a significantly higher rate of complications when their body mass index is greater than 30 kg/m.     

Augmentation mammaplasty: the surgical and psychological effects of the operation and prediction of the result

The aim of this research was to evaluate the effect of augmentation mammaplasty on women and to determine if it is possible to predict which women will benefit most from the operation. Interviews were conducted with both women who were about to undergo augmentation mammaplasty and those who had undergone the surgery. These interviews were compared with interviews from a control group composed of a normally distributed population. The women who apply for augmentation mammaplasty are a homogeneous group who experience their breast problems in a very similar way. Our study revealed that they are distinctly different from the control group in personality and childhood environment. Most of the women were generally satisfied with the operation even though many had complaints about the technical result. Certain behaviors had changed, but despite these positive results these changes were not radical and in reality the improvement was not as the women initially described it. The women's behavior reactions rarely changed enough to become similar to the reactions of the control group. Using a personality test, it is possible to predict which women will benefit most from the operation. When an assessment of psychiatric problems was made using the neurosis scale in a personality test, the women who scored low on a scale of neurotic self-assertion were satisfied with the operation to a greater extent.