Improving the Results of Inferior Pedicle Breast Reduction Using Pedicle Suspension and Plication

The inferior pedicle technique of breast reduction is a widely-used safe technique. It has been criticised as prone to producing inferior quadrant fullness, called variously “pseudoptosis” or “bottoming out.” Described are the results of a technique of inferior pedicle suspension and plication which overcome these problems.     

New options in breast reconstructive surgery: Alternatives to the latissimus dorsi musculocutaneous flap

Transposition of the latissimus dorsi musculocutaneous flap is still considered by most authors a first-choice technique for breast reconstruction. However, the aesthetic drawbacks of the technique are significant: In our experience the posterior scar and the patchlike skin island are of concern to more than 30% of patients. Recent alternatives have sharply reduced the use of the latissimus dorsi myocutaneous flap as our first-choice technique. The utilization of a latissimus dorsi muscular flap in association with submuscular placement of a tissue expander is now our favorite technique for the majority of patients: Residual scarring is insignificant since the whole muscle can be raised through a 5–7-cm-long, S-shaped incision placed along the anterior border of the latissimus dorsi. The results obtained in a group of 35 patients demonstrate that the final results of the procedure in terms of shape and projection of the reconstructed breasts are absolutely similar to those obtained using the latissimus dorsi musculocutaneous flap. However, in patients with heavy body structure and large contralateral breast, satisfactory symmetry and a natural-looking reconstructed breast are obtained more effectively by transposition of a rectus abdominis myocutaneous flap. The precautions to be taken in order to make the procedure suitable for overweight patients are described and the results are discussed.     

Reduction Mammaplasty Using Bipedicled Dermoglandular Flaps and Free-Nipple Transplantation

Background  

Secondary revisions due to deflation, flattening, and ptosis have been the major concerns after free-nipple breast reduction procedures. This study used a new modification of the standard technique known as the “bipedicled dermoglandular flap method” to reduce reoperation rates.     

Anatomical study of the breast superficial fascial system: the inframammary fold unit

The subcutaneous fascial system of the breast was investigated. The aim was to demonstrate splitting of the superficial fascia and the existence of an inframammary ligament. The inframammary region was studied in six cadavers (12 breast dissections) and in 21 patients during breast surgery (12 surgical and nine histological investigations). The superficial fascial system is related to sex, age, breast size, weight and adiposity. In females, the inframammary fold depends on the situation of the superficial fascia which, without true splitting, becomes deeper due to an absence of fat in the deep subcutaneous space, and on more adherence to the deep fascia through thickened retinaculum; there is a connective band, the anterior breast capsule, erroneously called ”superficial layer of the superficial fascia,” and mistaken for ”inframammary ligament”, which detaches from the superficial fascia. In males, there is a zone of adherence only at the inframammary midline. The microstructure of the breast fascial system at the inframammary region is demonstrated histologically. Surgical implications are suggested. Received: 18 June 1999 / Accepted: 10 January 2000     

Impact of prior surgery on the feasibility of laparoscopic surgery for children: a prospective study

Background This study aimed to determine the impact of prior surgery on the feasibility of laparoscopic surgery for children. Methods A prospective study analyzed 471 consecutive children who underwent laparoscopic surgery over a 4-year period. Laparoscopic procedures were classified “easy,” “difficult,” or “demanding.” The end points of the study were conversion rate, intraoperative events, and duration of operation. Results A total of 89 patients (19%) had undergone previous abdominal surgery. The conversion rate was 18% for the patients with prior surgery versus 9% for those without a prior operation (16/89 vs 35/382; p < 0.05). This difference reflects a significantly higher conversion rate for “easy” procedures among patients with than among those without prior surgery, but not for “difficult” and “demanding” procedures. The type of prior surgery had no significant impact on the mean duration of the operation. Of 71 procedures, 12 (17%) after prior conventional surgery were converted, as compared with 4 (22%) of 18 after prior laparoscopy (p > 0.05). Intraoperative events, mainly attributable to adhesions and lack of overview, occurred in 8% of patients with prior procedures, as compared with 2% without former surgery (7/89 vs 9/382; p < 0.05). Relevant complications were not significantly more frequent after prior surgery. The incidence of conversions decreased with increased time between current and previous surgery. It was 64% for surgeries less than 1 year later, 25% for surgeries 1 to 5 years later, and 5% for surgeries more than 5 years later (7/11 vs 6/24 vs 3/54; p < 0.001). Conclusions Prior surgery has a limited impact on the feasibility of laparoscopic surgery for children. The conversion rate and the incidence of intraoperative events, mainly because of adhesions and lack of overviewing, is increased, but not the incidence of relevant complications. The feasibility improves considerably with increased time between surgery and prior surgery. The authors consider laparoscopy to be the first-choice technique after prior surgery.     

Long-Lasting Evolution of Ptosis Control After Reduction Mammaplasty Using the Hammock Technique

Background The hammock technique combines inferior pedicle mammaplasty with retropectoral and inferior suspensions to prevent displacement of breast tissue toward the inferior mammarian pole. This study aimed to assess the long-lasting internal suspension with the author’s mammary reduction technique. Methods From 1987 to 2005, the hammock technique was performed for 623 breast reduction patients (1,201 breasts), including 318 women (636 breasts) who underwent the technique between 1994 and 2005. From the latter group, the author retrospectively reviewed the case histories of 281 patients who had come for long-term follow-up evaluation. All had significant ptosis associated with breast hypertrophy. Preoperative and postoperative examinations included evaluation of postoperative bottoming out by monitoring of three measurements: the sternal notch-to-nipple length, the inferior areolar border-to-inframammary fold length, and the distance between the inframmary fold and the projection of the lowest breast contour on the chest wall. Results The evaluation data on postoperative ptosis are derived from a control study at 30 months, 5 years, and 7 years or more for 281 women (562 breasts) of the 318 who underwent surgery using this technique over the 11-year period. Review after 2.5 to 7 years or more shows that inferior areolar border-inframammary fold distance increases no more than 10 mm. Conclusions The hammock technique suspension achieves true permanent breast lifting through dermis strips from the inferior pedicle itself. This procedure also gives predictable results, a low morbidity rate, and good breast shape.     

Temporary Closure of the Open Abdomen: A Systematic Review on Delayed Primary Fascial Closure in Patients with an Open Abdomen

Background  This study was designed to systematically review the literature to assess which temporary abdominal closure (TAC) technique is associated with the highest delayed primary fascial closure (FC) rate. In some cases of abdominal trauma or infection, edema or packing precludes fascial closure after laparotomy. This “open abdomen” must then be temporarily closed. However, the FC rate varies between techniques. Methods  The Cochrane Register of Controlled Trials, MEDLINE, and EMBASE databases were searched until December 2007. References were checked for additional studies. Search criteria included (synonyms of) “open abdomen,” “fascial closure,” “vacuum,” “reapproximation,” and “ventral hernia.” Open abdomen was defined as “the inability to close the abdominal fascia after laparotomy.” Two reviewers independently extracted data from original articles by using a predefined checklist. Results  The search identified 154 abstracts of which 96 were considered relevant. No comparative studies were identified. After reading them, 51 articles, including 57 case series were included. The techniques described were vacuum-assisted closure (VAC; 8 series), vacuum pack (15 series), artificial burr (4 series), Mesh/sheet (16 series), zipper (7 series), silo (3 series), skin closure (2 series), dynamic retention sutures (DRS), and loose packing (1 series each). The highest FC rates were seen in the artificial burr (90%), DRS (85%), and VAC (60%). The lowest mortality rates were seen in the artificial burr (17%), VAC (18%), and DRS (23%). Conclusions  These results suggest that the artificial burr and the VAC are associated with the highest FC rates and the lowest mortality rates.     

Mesh assisted direct closure of bilateral TRAM flap donor sites.

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a popular choice for patients requesting breast reconstruction. Criticism of all techniques that harvest the rectus abdominis muscle centre on abdominal wall weakness.[Dulin WA, Avila RA, Verheyden CN, Grossman L. Evaluation of abdominal wall strength after TRAM flap surgery. Plast Reconstr Surg 2004; 113: 1662-1665] Primary fascial closure of the donor site has been shown to reduce abdominal wall weakness and the subsequent risk of hernia and bulge. [Mizgala CL, Hartrampf CR Jr, Bennett GK. Abdominal function after pedicled TRAM flap surgery. Clin Plast Surg 1994; 21: 255-272]2 Primary fascial closure of all uni-lateral and most bilateral muscle preserving TRAM flap donor sites is possible. In a series of 23 bilateral TRAM flaps, excessive abdominal tension prevented direct fascial closure of the donor site in seven. Using a technique that includes muscle preservation, muscle relaxation and mesh assistance; tensionfree, direct fascial closure was achieved in all. The mesh buttress supports the rectus sheath during closure and provides long term shape and stability.     

Historical Evolution of Limb Amputation

The amputation of a limb is one of the oldest surgical procedures. In the course of medical history operative techniques and surgical instruments have been improved continuously. As early as the first century Celsus described an amputation. A major step in the development of the operative technique was the introduction of an artery forceps by Paré during the sixteenth century. Nevertheless, due to a lack of analgesics and narcotics the operation had to take only a few minutes. Therefore the amputation was completed in one cut (i.e., detachment of the skin, muscles, and bone at the same level). This technique, known as “classic circular cut,” was modified several times in the following period: to reduce suture tension Petit recommended that we transect the skin first and the muscles and bone more proximally (“two-stage circular cut,” 1718), and Bromfield approved that the skin be cut first, the muscles more proximally and the bone most proximal (“three-stage circular cut,” 1773). Lowdham (1679), Verduyn (1696), and Langenbeck (1810) changed the operative technique in that they used a soft-tissue flap to cover the bone without tension (“flap amputation”).     

Upper extremity resurfacing via an expanded latissimus dorsi musculocutaneus flap for large circumferential defects: the “spiral” reconstruction technique

We present an expanded latissimus dorsi musculocutaneus (LDMC) flap to treat circumferential upper extremity defects via resurfacing and “spiral reconstruction” in 5 patients during a 17-year period. Five patients with different indications for tissue expansion from burns to congenital hairy nevi were operated. The expansion was done in a longitudinal direction, and a rectangular tissue expander (TE) was inserted under the LD muscle to expand the flap in a longitudinal direction thereby forming a “long” flap rather than a “wide” one. After excising the circumferential lesion, the expanded “elongated” flap was wrapped spirally around the extremity to cover the defect; the donor site was closed as usual. The 5 patients we treated via LDMC flaps in a spiral fashion were free of complications, and all were satisfied with the outcome. All the flaps survived and the spiral reconstruction allowed for a tension-free donor site closure and near complete recipient coverage. This technique is indicated for large circumferential extremity skin defects and deformities. Application of expanded LDMC flaps in a spiral fashion can be used by the reconstructive surgeon to resurface large circumferential upper extremity lesions when indicated. The idea of a long and thinned expansion flap must be in a longitudinal direction and we need this long expanded and thin flap to “spiral” it around the extremity to cover a large defect. The “spiral” flap coverage introduced here for large circumferential extremity defects enables the surgeon to cover the defect with simultaneous donor site closure and good results.     

Influence of Reoperations on Long-Term Quality of Life After Restrictive Procedures: A Prospective Study

Quality of life improves after bariatric surgery. However, long-term results and the influence of reoperations are not well known. A prospective quality of life assessment before, 1 and 7 years after laparoscopic adjustable gastric banding (LAGB) and vertical banded gastroplasty (VBG) was performed in order to determine the influence of reoperations during follow-up. One hundred patients were included in the study. Fifty patients underwent VBG and 50 LAGB. Patients completed the quality of life questionnaires prior to surgery and two times during follow-up. Health-related quality of life (HRQoL) questionnaires included the Nottingham Health Profile I and II and the Sickness Impact Profile 68. Follow-up was 84% with a mean duration of 84 months (7 years). During follow-up, 65% of VBG patients underwent conversion to Roux-en-Y gastric bypass while 44% of LAGB patients underwent a reoperation or conversion. One year after the procedure, nearly all quality-of-life parameters significantly improved. After 7 years, the Nottingham Health Profile (NHP)-I domain “physical ability”, the NHP-II and the SIP-68 domains “mobility control”, “social behavior”, and “mobility range” were still significantly improved in both groups. The domains “emotional reaction”, “social isolation” (NHP-I), and “emotional stability” (SIP-68) remained significantly improved in the VBG group while this was true for the domain “energy level” (NHP-I) in the LAGB group. Both the type of procedure and reoperations during follow-up were not of significant influence on the HRQoL results. Weight loss and decrease in comorbidities were the only significant factors influencing quality of life. Restrictive bariatric surgery improves quality of life. Although results are most impressive 1 year after surgery, the improvement remains significant after long-term follow-up. Postoperative quality of life is mainly dependent on weight loss and decrease in comorbidities and not on the type of procedure or surgical complications.     

Implications of Transaxillary Breast Augmentation: Lifetime Probability of Breast Cancer Development and Sentinel Node Mapping Interference

After the “fifth-generation” breast implants with ultracohesive silicone gel technology are introduced, the Food and Drug Administration (FDA) will sooner or later retire the ban on the use of these devices in the United States. When this happens, the plastic surgery community must be prepared to face a massive demand for reoperations to change saline-filled breast implants because cohesive gel devices have the potential to provide a more natural breast shape, to minimize the risk of postoperative rippling, and to provide a greater degree of safety if the implant loses its integrity. Despite these advantages and extensive use throughout the rest of the world during the ban in the United States, silicone implants also have disadvantages. One drawback is that transaxillary breast augmentation with more “rigid” gel-filled implants may produce trauma to the armpit, may interfere with sentinel node mapping for breast cancer treatment, and may have future medicolegal implications.     

Dermoglandular rotation flap with subaxillary advancement flap as an oncoplastic technique for breast cancer

We propose a novel oncoplastic surgical technique, dermoglandular rotation flap with subaxillary advancement flap, as a feasible one‐stage operation. Breast conserving surgery, incorporating the dermoglandular rotation flap with subaxillary advancement flap, was performed in 49 female patients with breast cancer, between January and December 2015. After a full‐thickness fibroglandular resection including the tumor, an inferior‐ or a superior‐based rotation flap was performed according to the location of the defect. The subaxillary flap consisted of skin, dermis, and subcutaneous fat tissue and was mobilized from the chest wall musculature. Since subaxillary skin has greater redundancy, it can be easily moved to reach the lateral aspect of the breast. Approximation of the subaxillary flap to the lateral side of rotated dermoglandular flap served to relieve skin tension and avoid displacement of the nipple‐areola complex (NAC). Consequently, there was wider dermoglandular tissue rotation and efficient filling of defect without any significant postoperative deformity. The mean follow‐up period was 46.5 ± 3.1 months (range, 42.4‐52.1 months). Mean tumor size, on pathology, was 2.1 cm (range, 0.4‐6.0). Mean excised breast tissue weight was 78.4 g (range, 28.6‐195.0). More than half of the patients (51%) studied had excised breast tissue weighing more than 80 g. None of the included patients had positive surgical margins in final pathologic reports. Most patients answered excellent or good for self‐estimated cosmetic outcomes including symmetry of the breast and NAC, breast shape, scarring, and overall satisfaction. A modified dermoglandular rotation flap technique along with subaxillary advancement flap is a feasible and effective oncoplastic technique for breast cancers.     

Another Look at Breast Projection After Breast Reduction

A controversy exists between vertical mammoplasty and the “traditional” keyhole\inferior pedicle method of breast reduction. This article examines factors affecting breast projection by considering the difference in concept between vertical mammaplasty (using the modification proposed by Hall-Findley as an example) and the inferior pedicle\keyhole pattern. This article is not about “how to do” but rather about “why” things are done in a certain way. The emphasis is on understanding what is done and its effects rather than on technique. The breast can be considered a cone. Breast projection then is the ratio between the nipple projection and the breast base. Two key concepts need to be considered: the orientation of the ellipses during excision of breast tissue in breast reduction and the role of the breast base\inframammary fold. Breast projection is not determined by the scars. After an examination of each technique, methods to enhance projection are discussed.     

The Expanded “Flying-Wings” Scalp Flap for Aesthetic Hemiscalp Alopecia Reconstruction in Children

Background  For a large lesion of the scalp (e.g., up to 50% scalp loss), restoration of the scalp with a hair-bearing scalp flap to achieve a pleasing aesthetic outcome and hair growth matched to the direction of the lesion, especially for a hemiscalp defect in children, often becomes very difficult and challenging for plastic surgeons. Methods  Treatment was performed for 18 children with severe hemiscalp losses after burns. The technique was carried out by initially positioning a tissue expander in the subgaleal pocket of the scalp and serially inflating it with normal saline in 5- to 7-day intervals for about 3 months. Thereafter, a “flying-wings” expanded scalp flap was designed by combining advancement and rotation flap transplantation principles. This design was based on at least one nominated vascular system of the scalp used as the pedicle, with the wings often working to correct the distant part of the lesion in which the hair direction is greatly changed. After the lesion was excised, the expanded hair-bearing flap was advanced and rotated to the recipient site when the expander was removed. Results  For the 18 patients, the flap used for hemiscalp reconstruction could be transferred to repair the hemiscalp loss totally (for 17 patients) or mostly (for 1 patient) in a single-tissue expansion process without flap necrosis. The patient with a remaining lesion was treated completely with a secondary tissue expansion in the postauricular area. All the patients showed good aesthetic results, with the hair growth direction matching the recipient site well. Conclusions  The described technique strongly indicates that tissue expansion is a simple, safe, and efficient technique for large scalp restoration. The “flying-wings” design of the expanded scalp flap can properly distribute the expanded hair-bearing scalp in the recipient site.     

Flag flap - Kite flap Dorsal metacarpal flap

The flag flap is a pedicled dorsal digital flap, combining a skin paddle (the “flag”) and a vascular pedicle (the flag “pole”). Its vascularisation depends on the dorsal metacarpal arteries (DMCA). It has been described in 1963, by Holevitch [1] with harvest of a cutaneovascular pole; it has been brilliantly modified in 1979 by Foucher et al. [2–4] under the form of a unipedicled “kite” flap, although we would like to point out that Vilain has been using it since 1952 [5]. Usually harvested from the dorsum of the metacarpophalangeal region of the index finger, this flap is reliable, but it is more uncertain and less movable at the level of the other digits. Owing to its small size, it proves useful in hand traumatology because it does not sacrifice any major vascular axis. The kite flap is considered as a sensory flap (presence of a nerve supply) with a two-point discrimination, which can be assessed from 11 to 16 mm [1–6].     

Breast reduction: evolution of a technique--a single vertical scar

In the past 20 years, patients have become more critical about the result of a breast reduction operation. Natural lasting shape and minimal residual scarring are now expected by most of the candidates to that surgery. In 1969 the author described a vertical technique that achieved reduction and good shape but the end of the vertical scar could be seen below the brassiere line. In 1977 the author modified the technique by adding a small horizontal scar that eliminated the visible part of the vertical scar. In this article the author demonstrates that the same technique he described in 1969 and modified in 1977 can produce a single residual vertical scar if properly used.     

Breast reduction: Evolution of a technique—A single vertical scar

In the past 20 years, patients have become more critical about the result of a breast reduction operation. Natural lasting shape and minimal residual scarring are now expected by most of the candidates to that surgery. In 1969 the author described a vertical technique that achieved reduction and good shape but the end of the vertical scar could be seen below the brassiere line. In 1977 the author modified the technique by adding a small horizontal scar that eliminated the yisible part of the vertical scar. In this article the author demonstrates that the same technique he described in 1969 and modified in 1977 can produce a single residual vertical scar if properly used.     

Dermafascial Fixation Suture: A Technique for a More Durable Projection with Short-Scar (Vertical) Reduction Mammaplasty

Background Short-scar reduction mammaplasty has several advantages over the traditional technique, mainly reduced scarring and superior long-term breast shape. Multiple modifications of the short scar reduction mammaplasty technique have been made in an effort to decrease the learning curve while improving the results. The authors present another modification of the short-scar technique for a more durable projection without reliance on a skin envelope. Methods The perimeters of the medial pedicle and the nipple–areola complex are marked, and the medial pedicle is deepithelialized. A 2 × 5-cm skin area at the inferior border of the pedicle is further deepithelialized, then pexied to the pectoralis fascia in a superomedial direction using a nonabsorbable monofilamanet suture with a horizontal mattress suturing technique. Results Taking the suture bites from the dermis rather than the breast parenchyma for the pexy aims to spare the pedicle’s circulation. This durable internal rearrangement of the breast parenchyma with dermafascial pexy further decreases the tension at the nipple–areola complex because the final breast shape no longer relies on the skin closure. Suture spitting at the nipple–areola complex also is prevented with elimination of the purse-string suture because there is no need for a further decrease in the tension with the purse-string suture after the dermafascial pexy. Conclusions The authors believe that the dermafascial pexy is a concept more than a technique. It incorporates the two strongest structures, the dermis and the fascia, to achieve more durable results not only with reduction mammaplasty, but also with any aesthetic breast surgery that uses the pedicles.     

Fascial Suspension Mastopexy Combined with Augmentation Mammaplasty

Background  We have modified our technique of fascial suspension mastopexy to be used in combination with augmentation mammaplasty. This study aimed to assess the results of the combined procedure in our first consecutive 10 patients. The surgery aims to maximize long-term upper-pole fullness as well as optimal projection and shape in volume-depleted ptotic breasts. Methods  A retrospective case notes review was carried out, with details of patient demographics, indications, operative detail, and postoperative assessment recorded. In addition, patients were directly questioned to gain their opinion of the procedure. Results  Nineteen breasts were operated on in ten patients. On preoperative assessment two women (20%) had grade 3 ptosis and the rest had grade 2 (83%). The majority of women had had children and had breast-fed (70%). The mean follow-up period was 33 months (range = 4–55) and overall patient satisfaction was high despite six of the 10 patients undergoing minor scar revisions for dog-ears under local anesthetic and two undergoing implant exchange to correct minor asymmetries. There were no major postoperative complications in this series. All patients demonstrated good projection and upper-pole fullness at postoperative review. Conclusion  The combined technique of fascial suspension mastopexy and breast augmentation with implants is a safe and reliable method to correct ptosis in volume-depleted breasts. Patients should be counseled on the possible need for minor revisional procedures. Importantly, the technique achieves excellent upper-pole fullness and the projected and rejuvenated breast has an overall pleasing result.