Revisions Related to Scars

Hypertrophic or keloid scars can occur with any surgical episode, and the standard treatment protocols of pressure dressing, silicon gels, and or local corticos-teroid injections should be employed as necessary. Most scars respond to conservative treatment. Persistent reddish or dark scars can improve by pulsed ruby laser therapy. Resistant keloid scarring with significant symptoms (pain, irritation, pruritis) may occasionally require reexcision and brachytherapy (iridium threads). It is rare...

Ft

Final appearance of the right breast after SPAIR mammaplasty. The breast base diameter has been reduced, the nipple-areola complex raised, and the upper pole fullness restored, and a pleasing contour is evident with no inferior pole notching Fig. 6.11. Preoperative appearance of a 38-year-old woman before undergoing a SPAIR mammaplasty (a,b). Preoperative marks (c). Postoperative appearance 6 months after removal of 239 g of tissue from the right breast and 291 g from the left (d, e)...

Contributors

Niteroi,RJ 24210-430, Rio de Janeiro, Brazil Phillip Blondeel, MD, PhD Professor, Plastic Surgery Department, Gent University Hospital, Gent, Belgium Claudio Cardoso de Castro, MD Professor and Chairman, Plastic Surgery Service, University of the state of Rio de Janeiro, Rua Carlos Goes, Rio de Janeiro, Brazil Sheyla Maria Carvalho Rodrigues, MD Plastic Surgeon, For a A rea do Gale o Hospital -HFAG, Rio de Janeiro, Brazil Elizabeth J. Hall-Findlay, MD, FRCSC Private practice, Mineral Springs...

Springer

MousTAPHA Hamdi, MD, FCCP University Hospital of Gent Department of Plastic Surgery De Pintelaan 185 9000 Gent, Belgium Center for Breast and Body Contouring Paces Plastic Surgery & Recovery Center 3200 Downwood Circle Atlanta, GA 30327, USA Springer Verlag Berlin Heidelberg New York Library of Congress Control Number 2004110371 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation,...

Nipple Areola Viability

The longer the pedicle, the wider should be the base Fig. 13.4. The longer the pedicle, the wider should be the base Fig. 13.6. Small area of delayed healing at the lower end of the vertical scar. Late result shows that the open area closed with the impression of a small horizontal T Fig. 13.6. Small area of delayed healing at the lower end of the vertical scar. Late result shows that the open area closed with the impression of a small horizontal T

Anatomy

The breast is a subcutaneous structure that consists of 15 to 25 separate lobules. We all know that the breast is a functional organ for breastfeeding, but we also need to remind ourselves that it is a very important cosmetic aspect of a woman's sense of self - both physically and psychologically. The blood supply comes in from several different directions. Because the nature of breast reduction surgery is a blood-supply-reducing operation, we need to preserve and maximize the remaining blood...

Indications

Breast reduction surgery is indicated to reduce back and neck pain, shoulder strap grooving, and overall breast discomfort. The surgery helps to improve the problem of rashes in the area of overlapping skin underneath the breasts, and there is no question that many patients have improvement in headaches, posture, and ability to exercise. The psychological improvement in patients' self-esteem can be hard to measure, but many patients comment that their only regret was not having the surgery...

Lateral Beveling

The tissue is excised by beveling out laterally and medially. The lateral resection can be extended up toward the breast meridian superiorly, but care must be taken to evaluate upper pole fullness. If the patient has very little fullness (and attempting to push the breast tissue up is doomed to failure), then all efforts must be made to maintain as much fullness as possible. There are some patients who have excess upper pole fullness, and some tissue can be safely resected in this area, but in...

Inferior Undermining

The tissue is actually undermined, not beveled, down to the inframammary fold. This area needs to be cleared out otherwise a pucker will be left behind. Often the puckers are a result of excess subcutaneous tissue rather than excess skin. Enough fat needs to be left on the un-dersurface of the skin to prevent scar contracture - usually about 1 cm. The fibrous tissue at the level of the in-framammary fold can be difficult to suction, and direct excision is often necessary in this area. It is...

Am

Resection of excess of skin under local anesthesia 6 months after reduction of 550 g on right and 610 g on left breast ever, in order to reduce this risk, in large breasts with abundant inelastic skin, we correct primarily the dog ear, leaving a small horizontal scar in the submamma-ry fold. This scar has always been shorter than what would have resulted after traditional Wise pattern skin excision. Finally, the highest risk of complication was observed in large breasts in...

Joining the Vertical Lines

When joining these vertical lines, you must stay several centimeters above the inframammary fold. There are two reasons for this. The first has to do with the fact that closure of an ellipse results in a longer vertical line - and it could extend down below the infra-mammary fold. The second is that the resection pattern described in this chapter results in a change in the position of the inframammary fold itself. While the inframammary fold tends to drop with a Wise pattern, it rises with this...

Septumbased Lateral Pedicle SLM

The gland is first incised at the medial side to the pec-toralis major (PM) fascia and then extended cranially until the base of the pedicle. With this incision the septum is cut at the medial side, and the vessels within are easily seen (Fig. 9.4 a). Consequently,the pedicle is separated from the rest of the breast except for the lateral and central attachments. The resection is per Fig. 9.6 a,b. Closure of breast. a Fixation of lateral pillar onto pectoralis fascia. b Closure of skin through...

Discussion

It is very difficult to invent a new technique in plastic surgery nowadays. Something new is something old that has been forgotten, so we still adopt old ideas in order to improve them to incorporate them into our contemporary techniques. Skoog was the first to describe the lateral dermoglandular pedicle 12 . The concept of pedicle rotation medially 4,13-14 or laterally in breast reduction has been reported by many authors 12,15,16 . However, these authors have not relied on determined...

Conclusion

Ongoing studies concerning level of satisfaction and complications, as well as evaluation of short-term and long-term results and patient opinion 12 , allow me to assert that the final aspect of the breasts is the most important issue in breast reduction or mastopexy, regardless of the length of the scar (if the quality is good). Patients are concerned with scar quality, not with the extension of the scar. The patient must be totally pleased with the outcome of the surgery regardless of the...

References

Georgiade NG, Serafin D, Riefkohl R, Georgiade GS (1979) Is there a reduction mammaplasty for all seasons Plast Reconstr Surg 63 165 2. Hall-Findlay EJ (1999) A simplified vertical reduction mammaplasty shortening the learning curve. Plast Reconstr Surg 104 748 3. Lejour M (1994) Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 94 100 4. W ringer E (1999) Refinement of the central pedicle breast reduction by application of the ligamentous suspension. Plast Reconstr Surg...

Vertical Lines

Because this procedure does not rely on the skin to hold the shape, the design of the skin resection is less important than in the inverted T technique. I like Madeline Lejour's rotation of breast tissue laterally and medially to determine the breast meridian. She initially marks the breast meridian down to the new nipple position and then marks the meridian at the level of the inframammary fold (which on average is 9 to 11 cm from the midline of the chest). She then takes the breast and...

Resection

The resection of the residual cranial glandular layer is then performed. In this technique, advantage is taken of the preexisting bipartition of the breast. As soon as the retromammary space is reached, gentle, blunt finger dissection is used to follow the plane of areolar connective tissue down to the level of the fourth intercostal space. Here the retromammary space ends and merges into areolar tissue, which can be progressively opened up with the fingers in an anterior direction to the...

Complications Statistical Review

In 1999 Lejour 22 reported her personal series of 250 consecutive patients who had vertical mammaplasties during an 8-year period. This series included breast reductions on 324 breasts and mastopexies on 152 breasts. There was a wide range of breast sizes including 42 between 100 and 500 g, 24 between 500 and 800 g, and 34 over 800 g. The overall complication rate consisted of 5 seroma, 1.3 hematoma, 0.4 infection, 0.4 partial areola necrosis, and 5.5 delayed wound healing. These figures were...

Correction of Breast Deformity after Conservative Therapy

Location may lead to a major nipple-areola displacement. The combination of a large amount of scar tissue due both to tumorectomy and axillary lymph node dissection and to irradiation makes the defect too difficult to correct by mammaplasty techniques alone. In this specific case, a locoregional tissue transfer is required. Pedicled flaps from the axillary region may still be available, but pedicled latissimus dorsi, scapular, or perforator flaps might be better options for resolving this...

In the Hands of a Young Surgeon Which Pattern Should be Used in Reduction Mammaplasty

As far as the vertical scar in Lejour's technique (superior pedicle) is concerned, one must admit that some patients do not accept the aspect of the vertical scar with multiple wrinkles in the early postoperative period. Furthermore, scar correction at the bottom of the vertical scar is needed for many patients in our experience. The vertical technique is far more than just a scar it is a concept. Breast shaping and modeling are the most important elements of this technique. We believe in scar...

Different Approaches for Different Breasts

Claudio Cardoso de Castro, Sheyla Maria Caryalho Rodrigues reasts are the symbol of a woman's femininity. The possibility of restoring a breast's form is a gift God gave to man. Techniques for breast reduction and mastopexy have evolved, as have philosophical concepts. The goal of a mastopexy or a reduction mammaplasty is to achieve breasts with pleasant appearance and firm, adequate size and form with minimal scarring and low rate of complications. Lactation and sexual functions must be...

Planning the Mammaplasty

When breasts are assessed, it is noticed that there are some similarities between the two breasts, but no two breasts are identical. The volume and consistency of breast tissue, the grade of ptosis, the position of the nipple-areola complex in relation to the breast, and the distance of the nipples from the sternal notch vary so much that it is impossible to make an acceptable classification grouping every breast. Every technique for breast reduction or mastopexy requires skin resection and...

Results

The results obtained using the SPAIR mammaplasty have been uniformly satisfying to both patient and surgeon alike. Because the operative steps are essentially the same in all patients ranging from mastopexy to large reductions of 1000 g or more, the technique is easily learned and applied. The pleasing shape that is created immediately only improves with time as the breast settles and swelling resolves, a process that is usually complete by 6 months postoperatively. In most instances, this...

Oncoplastic Surgery

Choice of pedicle depending on location of defect Table 12.1. Choice of pedicle depending on location of defect Inferior, inferomedial, or inferolateral Superior, superomedial, or superolateral pedicle Superolateral pedicle with an inferocentral component to fill the defect Superomedial pedicle with an inferocentral component to fill the defect Fig. 12.3 a,b. Preoperative views of the same patient in Fig. 12.2b. a A centroinferior pedicle was designed to reconstruct the defect. b...

Who is the Ideal Candidate for the Vertical Mammaplasty

In patients who have simple breast ptosis or who require only a small reduction of 400 to 500 g or less, the vertical mammaplasty can provide an excellent aesthetic result. Addition of an aggressive vertical skin resection is particularly helpful in cases of pseudop-tosis, where the lower pole of the breast is excessively prominent. As in any other breast reduction techniques, vertical scar mammaplasty works most easily in moderate-sized breasts with good tissues and elastic skin in young...

Vertical Mammaplasty The Era of Maturity

Breast reduction is one of the most difficult operations in plastic surgery because it should produce a beautiful, symmetrical, and durable result with minimal scarring. Raymond Vilain, the humorist of our profession, used to say that it takes 5 years to learn how to operate a breast properly and 5 more years for the other. In addition, so many techniques are described that it is a real challenge to choose the best. Twenty years ago vertical mammaplasty was practically unknown by most surgeons...

Personal Evolution

Being a former trainee in Lejour-De Mey's department, I have been using the technique as described by Lejour with a superior pedicle, skin undermining, and vertical scar 3 . When I moved to Canniesburn-Glas-gow during my fellowship in 1996, I found it difficult to convince patients, nurses, and colleagues to accept temporarily overprojected narrow breasts with many skin wrinkles. Giving lectures to medical staff and showing pictures to patients may overcome this kind of problem, which is...

Tissue Resection

Years Old Breast Hypertrophy

Representation of the tissue resection. a Plane resection. b Operative view. c Posterior resection. d Operative view. e Keel resection. f Operative view Fig. 10.3 a-f. Representation of the tissue resection. a Plane resection. b Operative view. c Posterior resection. d Operative view. e Keel resection. f Operative view Fig. 10.4 a, b. Preoperative view of a patient with mammary ptosis. There is no tissue on the upper mammary pole. Voluminous skin excesses. c, d One year after...

Septumbased Medial Pedicle SMM

A 30-year-old patient who had 380 g and 420 g of gland resection from the right and left breast, respectively. The nipple was 35 cm preoperatively and elevated to 22 cm from the sternal notch. a Preoperative views. b, c Postoperative views Fig. 9.7 a-c. A 30-year-old patient who had 380 g and 420 g of gland resection from the right and left breast, respectively. The nipple was 35 cm preoperatively and elevated to 22 cm from the sternal notch. a Preoperative views. b, c...

Postoperative Care

A support garment is worn continuously for the first week to provide support and comfort. Drains are emptied three times a day and as needed. There is no need to change dressings as the opsite dressing is occlusive therefore, the patient can shower the day after surgery. At 7 to 10 days postoperatively, the patient is seen in the office, where dressings and steristrips are removed, exposed suture ends are clipped, and drains are removed. Scar treatment begins at this visit with a vitamin...

Owl Technique Breast Reduction

Arie G (1957) Una nueva tecnica de mastoplastia. Rev Iber Latino Am Cir Plast 3 28 2. Lassus C (1972) A new technique for breast reduction. Int Surg 53 69 3. Lejour M (1994) Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 94 100 4. Hall-Findlay EJ (1999) A simplified vertical reduction mammaplasty shortening the learning curve. Plast Recon-str Surg 104 748 5. Hammond DC (1999) Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast Reconstr Surg 103...

Long Lasting Results of Vertical Mammaplasty

Ohe breast will feed the baby and will delight the father. This sentence from the Koran summarizes the two main functions of the breast Feeding It is obvious that any type of surgery on the breasts must protect those two functions. This is why, to me, safety is first shape is second in mammaplasty. Achieving beautiful and long-lasting results in a safe way is mandatory in breast reduction. Aubert, a French surgeon from Marseille, described in 1923 what is supposed to be the first tru...

Revisions Related to Skin Excess

Persistent skin excess, usually the most frequent complication, occurs at the inferior pole of the breast and is reported in approximately 10 of cases of vertical scar mammaplasty. It may be caused by various factors 1. Excessively high positioning of the pedicle, producing a dead space in the inferior pole and subsequent skin excess. 2. Insufficient excision of skin at the inferior end of the vertical incision (Figs. 14.2,14.3). It is absolutely essential to look for potential dog ears at this...

Infection Hematoma Seroma

Infections are rare and usually occur in the setting of necrotic tissue, which facilitates bacterial growth. Therefore, the application of techniques to avoid tissue necrosis will also reduce the incidence of infections. Hematomas are uncommon, and the risk can be diminished with meticulous hemostasis. Small hematomas may be evacuated through the wound without reoperation however, larger hematomas require reoperation with evacuation, hemostasis, and drainage. The frequency of seroma formation...

Liposuction for Final Tailoring

Prior to final skin closure, I perform liposuction not only along the lateral chest wall and in the preaxillary area, but also along the inframammary fold. I try to follow the Wise pattern for final parenchymal resection and remove the excess tissue just above the fold Fig. 7.8. This drawing shows the outline of the parenchymal re-section.Very little tissue is removed superiorly unless the patient has significant upper pole fullness preoperatively. The tissue resection follows a Wise pattern....

Anatomy of the Breast A Clinical Application

Breast Anatomy

MoUSTAPHA HaMDI, ELISABETH WURINGER, InGRID SCHLENZ, RAFIC KUZBARI Ohe breast, by definition, is the soft protuberant body adhering to the thorax in females, in which the milk is secreted for the nourishment of infants or the seat of affection and emotions the repository of consciousness, designs and secrets The epidermis of the nipple and areola is highly pig-mented and somewhat wrinkled, and the skin of the nipple contains numerous sebaceous and apocrine sweat glands and relatively little...

The Operation

Immobilized Boob Size

The skin is deepithelialized within the markings (Figs. 11.1e, 11.6). A horizontal incision is made immediately below the areola and carried down to the muscular layer dividing the breast into two halves, superior and inferior (Figs. 11.1f, 11.7,11.8). The inferior half is freed from the skin with the use of a pair of scissors, leaving it attached to the muscle plane, while one is careful not to injure the fourth and fifth intercostal perforating vessels, which provide the nutrition for this...

Vertical Reduction Mammaplasty Using the Medial Pedicle

And make us lose the good we oft might win By fearing to attempt There are many approaches to breast reduction, and all have their advantages and their disadvantages the challenge is in achieving the ideal balance for each patient. I have found that the vertical approach using the medially based pedicle has given me improved results for the majority of my breast reduction patients 1-3 . Reducing volume is the object of the procedure,but maintaining blood supply to the nipple and breast skin,...

Preface

Aesthetic improvement and scar reduction has become the new front line in breast reduction surgery. It is probably easier to show surgeons who have spent many years honing their skills how to modify their own techniques to optimize scarring and achieve a better aesthetic outcome than to convince them to learn a new technique. I have tried in this book to assemble the techniques and thought processes involved in the evolution of the vertical scar mammaplasty over the last 10 years. It is a...

Skin Resection

Breast Reduction Immages

First a line is drawn from the midclavicle to the submammary sulcus passing through the nipple. At the projection of this line, a point is marked on the submammary fold. This point, A, corresponds to the new position of the nipple-areola complex. It can be placed lower in some cases when the breast tissue is firm and the surgeon notices that lifting the nipples will be difficult. Sometimes it is easier to elevate the nipple and areola several centimeters and sometimes even 2 cm is very...

Operative Design and Markings

Vertical Scar Technique Breast Reduction

There are numerous approaches to breast reduction surgery using a vertical skin resection pattern. Lassus 23-25 usually uses a superior pedicle and does not bevel his resection or undermine the skin. He resects the breast tissue directly down to the chest wall and does not resect the parenchyma along the Wise pattern. His inframammary fold stays in place. Marchac 26 uses a superior pedicle but adds a small horizontal scar or T to the bottom of the vertical incision. Lejour 27-30 uses a superior...

Superior Pedicle Vertical Scar Mammaplasty Surgical Technique

Breast Reduction Scarring

Man honours himself by not displaying all the knowledge he has acquired. I first tried the vertical reduction technique to minimize scars but have stayed with it because I saw improved results that hold up over time. It is my preferred method for breast reduction and mastopexy. Vertical scar techniques have not gained popularity in the United States as rapidly as in Europe and South America. The reluctance to abandon the Wise pattern in favor of the vertical reduction has been related to...

Breast Hypertrophy Young

Breast Hypertrophy

In mammaplasty achieving an aesthetic shape with the shortest scar possible and longest-lasting results has been the aim of most plastic surgeons. However, no single technique can accomplish all these goals. A great variety of surgical techniques are available. Vertical scar mammaplasty has allowed a significant reduction of scar length by eliminating the horizontal scar, with less resection of skin. As most vertical scar mammaplasties rely on the support of the skin envelope, a greater...

Breast Reduction Scars

Breast Reduction Scars

Enlargement of the vertical and or areolar scar is present in 5 of patients. We believe this is due to technical reasons, either because of improper closure or because of inadequate compensation for the excess skin around the areola. The solution is simple revi Fig. 11.17. a-c Preoperative view of a young patient with hypertrophy and ptosis. d-f Postoperative view 17 months later. g Arms are elevated to allow visualization of the vertical scar, not extending beyond the submammary fold Fig....

Areas for Liposuction

Breast Pedicle

Liposuction is performed not for volume reduction but for shaping. Any preaxillary fullness and any lateral chest wall fullness are marked. If one inframam-mary fold is higher than the other, then this fold is marked for more aggressive resection and liposuction along the inframammary fold. Fig. 7.4. The medial pedicle is a full-thickness pedicle carried down to the breast meridian. The base width measures about 6-10 cm (approximately a one-to-one ratio of length to base width). Although tissue...

Vertical Scar Mammaplasty with a Superior Pedicle

Extreme Breast Growth Teens

Ohe best of men is he who acquires learning but better than him is he who transmits it. in training who performed the operation in the university hospital. The same unfavorable results were published by Pickford 15 . Therefore, we tried to make the technique safer, keeping in mind the basic principles of the vertical scar mammaplasty. Operative Technique (Figs. 5.1-5.12) The goal of breast reduction is the correction of the volume, shape, and symmetry of the breast while preserving nipple...

Pedicle Choices in Breast Reduction

Breast Innervation

Hall-Findlay y failing to prepare, you are preparing to fail. Surgeons should choose the right technique for the right patient. We plastic surgeons may be artists, but even artists still need to plan and to trace lines to create beautiful works. Breast reduction surgery usually combines a skin and parenchymal resection with a pedicle to maintain blood supply to the nipple-areola complex. This pedicle should allow adequate movement of the nipple to its new, more...

To the Nipple Areola Complex NAC

Stop Hypertrophic Scars Around Areola

The most serious complication of breast reduction surgery is nipple-areola complex (NAC) or breast necrosis. Very large breasts and or significant breast ptosis are the main reasons for such a disastrous complication, particularly in inexperienced hands. However, partial or total necrosis of the NAC can still occur in patients with high risk factors such as smoking, diabetes, or chronic corticosteroid therapy. Free nipple techniques in breast reduction are a viable alternative option for...

Short Scar Periareolar Inferior Pedicle Reduction Spair Mammaplasty

Inferior Pedicle Breast Reduction

Reast reduction offers an opportunity rarely seen in plastic surgery, for not only is there too much volume, there is too much skin. With a sound operative strategy, excellent technique, and a discerning artistic eye, the sculpting of an artistic and stable breast shape can occur every time, and now we can do it with half the scar What an exciting time to be a plastic surgeon. pattern technique have been thrown into sharper focus. Specifically, the inframammary scar can be problematic in some...

Underresection Pseudoptosis

Pseudoptosis Breast

This is the second most common reason for revision. I still have problems with underresection with this technique. I cannot get breasts as small with the vertical approach as I could with the inverted T, inferior pedicle approach. The technique itself does not allow as much resection, but the result at the end of the procedure can be misleading. The breast looks smaller than it is. If the plan is to remove about 700 g, then it is important to get as close to 700 g as possible. I will use...

Markings

Breast And Nipple Reduction For Women

The markings are made in the operating room after the patient falls asleep. The areola is marked using a 3.5-cm-diameter areola marker (Figs. 11.1a, 11.2). A line is drawn from the midclavicular point to the nipple -the meridian line of the breast. Point A is marked on the projection of the submammary fold on the previ- Fig. 11.1. a The new areola is outlined with a 3.5-cm diameter. b Points B and C are marked by pinching the skin at the level of the nipple and seeing the amount of resectable...

Revisions Related to Lateral Fullness

Lateral Breast

Patients with a high body mass index are at risk for developing this complication. Lateral fullness occurs more often in techniques in which a superolateral, lateral, or inferolateral pedicle is used. The fear of jeop- Fig. 14.8. A 28-year-old patient who underwent a breast reduction of 550 g on the right and 480 g on the left breast using the septum-based lateral mammaplasty Dr. Hamdi . A lateral fullness is seen because of insufficient resection on the lateral side of the left breast and...

Suturing the Pucker

The deep dermis is closed with interrupted buried 3-0 Monocryl. No attempt is made to suture the skin up to the breast tissue. If sutures are used from the dermis to the breast parenchyma, the final settling of the breast shape will be delayed. I think any suturing of the pucker down to the chest wall is a mistake. First, it is not necessary. Second, it is difficult to know exactly where to put it, and it will cause more postoperative distortion. The dog ear infe-riorly sticks out initially and...

Mastectomy Through a Vertical Incision

Vertical Scar Breast Reduction

The standard modified radical mastectomy includes removal of the breast gland with the nipple-areola complex NAC as well as the skin overlying the tumor. However, more conservative techniques have been used if the tumor is not too close to the skin. Pe-riareolar incision is used widely nowadays to perform the mastectomy, which allows the removal of the gland with the NAC. Besides immediate reconstruction, excellent aesthetic results can be obtained. A vertical component can be added to the...