CHAPTER 15: AESTHETICS - GENERAL, BREAST, ABDO Flashcards
(123 cards)
1
Q
Aesthetic assessment
A
what is patient’s perceived problem?
what are their expectations?
why do they want surgery?
any prev surgery?
Green flag S ecure Y oung L istens V erbal I ntelligent A ttractive
Red flag S ingle I mmature M ale O verly expectant N arcassistic
2
Q
What are the properties of an ideal implant?
A
SCALES (1953) TIP Sterilisable non Carcinogenic non ALlergenic chemically inErt resistant to mechanical Strains
impervious to Tissue fluids
non Irritant
Plastic (can be fabricated to desired form)
3
Q
History of breast implants and silicone controversy
A
1895 1st augment = giant lipoma from back (Czerny)
1944 dermis fat grafts (Berson)
1954 dermis fat flaps (Longacre)
1945 Japanese prostitutes injected liquid silicone
1962 1st silicone prosthesis Dow Corning (Cronin, Gerow)
Van Nunen (1982) reported 3 cases of connective tissue disease
1991 $7.34 million awarded to Marianne Hopkins for autoimmune disease + silicone
1992 FDA bans silicone implants (Spain & France)
1994 class action lawsuit. Compensation if pt developed CTD within 30yrs of implant
but DoH found no reason for ban and Mayo clinic study = no link
1995 Dow Corning filed for bankruptcy
1998 DoH independent review NO link (Sturrock)
2006 FDA approves use in >21yr olds
1998 UK INDEPENDENT REVIEW
- controversies: ?inc autoimmune, ?inc breast ca, ?difficulties in breast cancer screening
- findings: not associated with higher health risks cf other implants, including autoimmune
- need registry & monitoring as inc risk of local complications (rupture, capsules)
1999 IMNAS (Institute of medicine of national academy of science)
- no evidence of assoc with major diseases, bresat ca
- not contraindicated in breast feeding (have more silicone / silica in bottle teats, formula and cows milk)
4
Q
What is silicone?
A
polydimethyl siloxate - polymer of silicon
5
Q
What are the indications for breast augmentation
A
Patients:
(a) considered for many yrs, recently came into money, deep rooted inadequacy
(b) want immediately e.g. postpartum
3 groups
congenital breast hypoplasia
postpartum involution
exhibitionist
6
Q
Scott Spears contraindications for BBA?
A
PULSE DOOMED Poor historian Unco-operative Litigious Surgaholic unrealistic Expectations
Depressed OCD Over flattering Minimal / imagined deformity Extremely rude inDecisive
7
Q
What are the main reasons for dissatisfaction postop?
A
poor preop info
poor communication
physical difficulties / complications
Poor results likely
- ptosis
- thin small chests
- tubular breasts
- chest wall deformity
- body builders
- asymmetry
8
Q
PREOP ASSESSMENT
A
HISTORY
- menarche
- pregnancy
- breast ca / lumps, discharge
- FHx
- why BBA?
- smoking, conditions related to wound healing
- anticoagulants
- PMH, SHX, THX, ALLERGIES
ONCOLOGICAL EXAMINATION
LOOK
- skin quality (tone, elasticity, striae)
- proportions, height:weight
- asymmetry (breast size, chest wall, scoliosis, IMF, NAC)
- shape of thorax (pectus ex / car)
- Poland’s
- posture / scoliosis
FEEL / PALPATE
- pinch test (2cm superior pole, and inf pole)
MEASURE
- sternal nipple dist
- nipple to IMF dist
- base width
- ant pull skin stretch
- NAC - IMF dist under max stretch
9
Q
What are the goals of BBA?
A
natural fuller figure
improve breast shape
maintaining balance b/t native breast tissue & implant within soft tissue envelope
balance desires of pt with tissue reality
highlight potential compromises to pt
10
Q
What happens to breast tissue after implants?
A
Tebbetts 2001 - >350ml implant induces predictable -ve consequences over time on breast tissues
Nahas 2001 - progressive reduction in breast size due to
- parenchymal atrophy
- costal cartilage remodelling
11
Q
What are Tebbetts High FIve?
A
PRS Supp 2006
Used for surgical decision making
1. Optimal soft-tissue coverage / pocket location
- Implant volume
- Implant type, size, dimensions
- Optimal location for inframammary fold
- Incision location
12
Q
Explanation of Tebbetts high five
A
- Optimal soft-tissue coverage/pocket location for the implant. This determines future risks of visible traction rippling, visible or palpable implant edges, and possible risks of excessive stretch or extrusion.
- Implant volume (weight). This determines implant effects on tissues over time, risks of excessive stretch, excessive thinning, visible or palpable implant edges, visible traction rippling, ptosis, and parenchymal atrophy.
- Implant type, size, and dimensions. This determines control over distribution of fill within the breast; adequacy of envelope fill; and risks of excessive stretch, excessive thinning, visible or palpable implant edges, visible traction rippling, ptosis, and parenchymal atrophy.
- Optimal location for the inframammary fold based on the width of the implant selected for augmentation. This determines the position of the breast on the chest wall, the critical aesthetic relationship between breast width and nipple-to-fold distance, and distribution of fill (especially upper pole fill).
- Incision location. This determines degree of trauma to adjacent soft tissues, exposure of implant to endogenous bacteria in the breast tissue, surgeon visibility and control, potential injury to adjacent neurovasculature, and potential postoperative morbidity or tradeoffs.
13
Q
TEPID system
A
TEPID system
tissue characteristics of the breast (T),
envelope (E),
parenchyma (P),
implant (I),
dimensions (D) and dynamics of the implant relative to the soft tissues for breast implant selection, based on the patient’s individual tissue characteristics and breast dimensions
14
Q
Implant shape: Round vs anatomical?
A
Tebbetts 2001 - anatomical better if
- pt wants more lower pole projection
- want max size for volume (weight issue)
- have glandular ptotic breasts
- constricted lower poles
- highly mobile parenchyma so may slide off -> double bubble effect
Anatomical - better breast shape, better control of upper pole, prevent upper shell folding, collapse & shell failure
Sheflan - anatomical better if skin envelope is tight
15
Q
What are the different types of implant constituents?
A
silicone gel saline inflatable double lumen salin-gel filled (Beckers) polyurethane-covered gel filled Polyvinylpyrrolidone (PVP) hydrogel
16
Q
Describe the classification for capsular contracture?
A
Baker 1975 - 4 grades 1 soft (no contracture) 2 palpable 3 visible 4 painful
17
Q
What are the theories behind capsular contracture?
A
- Biofilm disease (Pajkos PRS 2003) subacute Staph epidermidis infection
- hypertrophic scar formation (fibroblastic foreign body type reaction)
Capsular contracture rate
smooth 50%, textured 8-10% (Collis & Sharpe PRS 2000)
18
Q
What materials can be used to revise bottoming out?
A
prolene mesh (Frank - Indiana)
alloderm, mesh (Spear) 15-20% need re-revision
Strattice in UK?
19
Q
What is the pathology behind silicone synovitis?
A
Macrophages phagocytose silicone bleed
silicone cannot be lysed by lysosome
macrophage ruptures, re-releasing particles
19
Q
What is the association between breast cancers and a rare form of cancer?
A
FDA announced a possible association between breast implants and the development of anaplastic large cell lymphoma (ALCL), a rare type of non-Hodgkin’s lymphoma.
To date, ~60 cases of ALCL in women with breast implants that were identified, small fraction of 5-10 million breast implants worldwide
20
Q
What are the causes of synmastia?
A
implants too wide
subglandular pocket made too medial
21
Q
What is the management of BBA? RWS 13S
A
RWS AUGMENTATION TECHNIQUE
Outpatient visit - 13 S’:
Size – bra size
Shape – tubular, ptosis
Symmetry → breasts, nipples, chest wall
Silicone issues
Style→ Measure breast base transverse diameter, round/anatomical, projection (In ptosis the nipple moves down and laterally → low profile wide base is needed with Nagor round non cohesive gel.)
Site → subglandular (if enough soft tissue in upper pole), subpectoral
Skin Scar → IMF usually
Sub Scar → Capsule
Sensation changes
Suction drains
Stay → 2 days in hospital, drains
Support → sports bra for 6/52 night and day then 3/12 during the day
Screening
22
Q
Describe the procedure of BA
A
Mark → IMF only pre op
On table measure from nipple down 5 cm this should be approx at IMF, then site scar slightly above this. Measure 2 cm medial and 3 cm lateral to breast meridian.
Cut through dermis then raise a fat/fascial tongue flap inferiorly to allow layered closure at the end of the procedure.
Identify placement plane (subglandular or subpectoral) outline pocket, haemostasis, suction drain → wash implant in 50% betadine solution then put in (sideways if wider base shape) → rotate into place. Close fat flap onto chest wall to outline the IMF then layered Vicryl and subcut prolene (ROS 2/52).
3 doses of Cefuroxime, drains out when serous.
23
Q
What is dual plane approach?
Who described it?
A
Tebbets PRS 2001
Type 1
- release inferior insertion of pec major (do NOT divide muscle along sternum except white tendinous insertions to avoid visible retraction along sternum and palpable implant edge)
- for patients with entire breast parenchyma above IMF, with tight attachments of parenchyma to muscle, and short nipple to IMF distance (5-6.5cm under stretch)
Type 2
- division of muscle - parenchymal attachments up to inferior edge of NAC
- for pts with most breast tissue above IMF, looser attachments of breast to muscle and NAC-IMF 5-6.5cm under stretch
Type 3
- division of muscle-parenchymal attachments up to superior edge of NAC
- for pts with very loose attachments and NAC-IMF 7-8cm, or tuberous breast deformity, constricted lower pole with radial parenchyma scoring
24
What are the complications of breast augmentation?
Re-op rate 25-30% in 5yrs
```
General
Infection 2%
Haematoma 3%
bad scar 5% (MHRA medicines and healthcare products regulatory agency)
Nipple sensation change 15% (temporary)
DVT/PE
```
Specific
Capsular contracture 10% (in 10yrs, 30% of subglandular and 10% subpectoral, smooth 58%, textured 11%, calcification 0% 10yrs, 100% 23yrs)
Rippling, palpable edge
Rupture - cumulative risk 2%/yr (MRI linguine sign, USS stepladder sign and snowstorm appearance)
Gel bleed - silicone leaks out without evidence of rupture, silicone granuloma 0.1-0.5%
Final result too big / small,asymmetry
Breast cancer family history
- may delay diagnosis but no evidence of survival rate change
- advise mammogram before op
- recommend submuscular placement
- regular screening, Eklund views
Breast feeding- milk contains less silicone that babies feeding on bottle teats, formula milk has 10x more silicone that breast milk and breast implants
25
Breast reduction techniques
LIPOSUCTION ALONE / COMBINATION
```
SKIN INCISION
- Inverted T (Wise)
- Vertical scar (Lassus, Lejour, Hall-Findlay)
- B shaped (Regnault)
Chiari etc
```
PEDICLE - GLANDULAR OR DERMOGLANDULAR
No pedicle
- Breast Amputation and free nipple graft (Thorek 1922)
Central Mound / Glanduloplasty (Balch PRS 1981)
- Round block technique, periareolar incision (Benelli 1990)
Horizontal Dermoglandular Pedicle
- Horizontal bipedicle, inverted T scar (Strombeck BJPS 1960)
- Horizontal unipedicle, inverted T scar (Skoog, Acta Chir Scand 1963)
Lateral Dermoglandular Pedicle
- Lateral pedicle and lateral scar (Dufourmentel Ann Chir Plast 1965)
Vertical Dermoglandular Pedicle
- Bipedicle, inverted T (McKissock PRS 1972)
- Superior pedicle (Weiner PRS 1973)
- Superior vertical pedicle, vertical scar only (Lejour Ann Chir Plast Esth 1990)
- Modified Lassus technique, relies on post op skin contraction and inf breast remodelling. Some numbness to nipple post op due to sup pedicle (nerves enter inferolaterally)
- Inferior pedicle, inverted T scar (Robbins PRS 1977) (Ribeiro 1975)
- Glanduloplasty technique, inferolateral resection, B shaped scar (Regnault PRS 1980)
26
How do you classify breast hypertrophy?
- Gigantomastia > 2.5 Kg reduction per breast
- Macromastia <2.5 Kg per breast
- Virginal breast hypertrophy = only in prepubertal and pubertal♀
27
What are the indications for surgery?
- Mastalgia
- 2ry back, shoulder and neck pain, poor posture
- difficulty with exercise, turn over in bed etc
- submammary maceration and infection, intertrigo
- Ψ , low self esteem
- difficulty finding clothing
28
What are the NHS criteria for BBR?
ENGLAND (LONDON)
1. BMI <30
2. 18 or older
3. virginal hyperplasia / hypertrophy or
gross asymmetry (2 or more cup size diff)
4. Symptomatic (2 min, for 1yr)
- neck pain
- upper back pain
- shoulder pain
- painful kyphosis w Xray
- pain / discomfort / ulceration from bra straps
5. Persisting symptoms despite 6mth conservative measures
- supportive devices (fitted bra wide straps)
- analgesia
- physiotherapy, exercises, posture
Chronic intertrigo, ,eczema, dermatitis (skin alone is not indication)
If criteria not met - need IFR application (individual funding request)
29
What are the complications of breast reduction?
General
- GA, DVT, PE
- scar - T wound breakdown, delayed healing, hypertrophy 4%
- infection
- haematoma
Specific
- asymmetry, under/over correction
- nipple loss 4-7%
- altered nipple sens 15%
- breast feeding compromised (70% can still breast feed after inf pedicle technique)
- fat necrosis
- scar revision (dog ears)
- nipple position too high - pseudoptosis
- incidental breast cancer
30
Who looked at breast cancers in BBRs?
Jansen PRS 1998
5000 reductions, 19 cancers (0.38%)
2500 reductions, 4 cancers (0.16%)
Titley BJPS 1996
25% abnormal path - usu fibroadenoma
60% are upper outer quadrant
Recommendations
- baseline mammogram (Am Cancer Society recommend >40yr old, earlier if +ve Fhx)
- send all specimens
31
What are the principles of mastopexy?
uplift of breast with little / no reduction
1. elevate ptotic breast
2. reposition nipple
3. improve breast shape
32
Why does ptosis occur?
```
stretching of skin
loss of parenchymal volume
weight loss
pregnancy
lactation
menopause
```
33
Who classified breast ptosis?
Regnault (degree)
1st - nipple at level of IMF
2nd - nipple below IMF
3rd - nipple at lowest contour of breast
Pseudoptosis - loose lax breast but nipple remains above IMF
34
What types of skin markings are there for mastopexy?
| Describe the procedure
```
Wise, Lejour, Regnault, circumareolar
de-epithelialise within markings
glanduloplasty
breast parenchyma sutured to breast wall
resite NAC
```
35
What types of mastopexy are there?
1. Implant only - only to fill out skin redundancy for low volume breast
2. Skin only (Above)
3. Implant and mastopexy
- excise inferior breast tissue rather than infold. Submuscular or subglandular implant
36
Concentric mastopexy
Pro - corrects mild - mod ptosis, constricted / tuberous breasts, simple technique
Cons - flattening of breast apex, widening of scar - stretched NAC
combine with sub muscular implant to avoid double bubble
Contraindicated - sternal notch - NAC >24cm, grade 2 ptosis or more
37
Periareolar round block mastopexy
Benelli Aes Plas Surg 1990
- parenchymal moulding
- superior pedicle
- gland undermind
- medial and lat parenchymal flaps are coned
- to avoid stretched scar - non-absorbable pursestring & 2 crossed sutures
Góes - mesh bra
38
Anatomy of the abdomen
- Above Scarpa’s fascia = compact fat many fibrous septae
- Below Scarpa’s fascia = globular fat, fewer fibrous septae
- Above arcuate line (b/t umbilicus and pubic symph) internal oblique aponeurosis splits to contribute to both ant and post rectus sheath
- Below arcuate line IO only to anterior sheath
- Umbilicus lies b/t xiphisternum and pubic symph, level with ASIS
39
What is the blood supply of the ant abdo wall?
Blood supply → Huger zones 1979
o Huger Zone 1 = sup & inf epigastrics
o Huger Zone 2 = external pudendal, circumflex iliac
o Huger Zone 3 = lat intercostals, subcostals, lumbar
Zones 1&2 divided in abdominoplasty
Skin flap survival dependent on zone 3
40
How is abdo classified? (Matarasso) (similar to Psillakis)
Type I = excess fat only
→ Liposuction
Type II = Mild skin excess, Infra-umbilical divarication
→ Mini abdominoplasty + infra umbo plication + liposuction
Type III = Moderate skin excess, divarication above and below umbo
→ Mini abdominoplasty + Plication above and below + liposuction.
Type IV = Severe skin excess, rectus divarication
→ standard abdominoplasty + sheath plication + liposuction.
Most abdominoplasties are Types I and IV.
41
What is a mini-abdominoplasty?
removal of infra-umbilical skin without repositioning umbo
42
what is a conventional abdominoplasty?
- dissect out umbilicus
- removal of abdominal skin and sc tissue up to just above umbo with undermining to costal margins
- lower incision within pubic hairline 5-7cm above anterior vulval commissure
- bevel upper skin flap edge
- leave fascia over rectus sheath to avoid seroma (facia of Gallaudet)
- rectus sheath plicated if divarication,
- avoid strangulating umbo
- Partially anchor the umbilicus to the rectus sheath
- De-fat in the midline below the umbilicus
- Do not make over tight → liberal use of micropore tape
- Use fleur-de-lis technique for vertical skin excess.
43
What is a Marriage abdominoplasty?
Marriage of conventional and mini-abdominoplasty with liposuction.
leave >= 10 cm of skin between umbilicus and pubis for the umbilical position to be aesthetically correct.
Umbilical stalk may need to be transected.
Liposuction in inframammary, waist and flank areas.
Preserves blood supply to Huger Zone 1.
Liposuction in zone 3 may in theory interfere with perfusion to the upper skin flap from the intercostal segmental supply but if zone 2 is left relatively undisturbed (short scar → marriage abdominoplasty) then safe.
Most post pregnancy deformity → below arcuate line where there is deficiency in post rectus sheath.
avoids full abdominoplasty in pts who could benefit from lesser procedures (↓ scar, ↓ morbidity,↓ recovery time)
44
What is a fleur-de-lis abominoplasty?
conventional abdominoplasty with midline scar to remove vertical skin excess
45
What are the complications of abdominoplasty?
```
Early
o Death → PE
o Skin necrosis (esp smokers)
o Wound dehiscence
o Wound infection
o Haematoma
o Seroma
o Umbilical necrosis
```
Late
o Scarring
o Altered sensation
o Revisional surgery to dog ears
46
Is pregnancy safe after abdominoplasty? Are there any papers?
Menz 1996 - safe, but monitor closely if plication has been performed
47
Total body lift
see massive weight loss
48
Liposuction - how is sc fat distributed?
Superficial and deep compartments (superficial fascia).
- superficial compartment : densely packed fibrous stroma arranged vertically and horizontally, responsible for the appearance of cellulite.
- Deep compartment contains less compact fibrous stroma. No. of fat cells does not ↑ after puberty or liposuction. However the remaining cells can hypertrophy.
49
What are the different liposuction techniques according to infiltrate?
Dry (Fournier)
- 40-50% aspirate = blood
Wet (Ilouz)
- 200-400ml infiltrate / area
- 10-25% blood
Superwet (Fodor)
- 1:1
- 4-5% blood
Tumescent (Klein)
- 2-3ml infiltrate for 1ml aspiration
50
What are the different types of liposuction techniques?
Standard
Mechanically assisted (MicroAir)
US assisted
Laser assisted
51
What are the different types of liposuction cannulas?
Mercedes
Double mercedes
etc look up
52
What should be covered in consent?
```
GA, DVT, PE
bleeding, haematoma
scar - configuration and dog ears, decreased sensation, scar sensitivity
delayed wound healing
seroma
umbilicus - malposition, necrosis
```
53
Describe the procedure
```
mark out areas as concentric circles
infiltrate
incisions - perpendicular
pre tunnel
feathering
redistribute / smooth out fat after?
binder
```
54
What are the complications?
General
- DVT
- Bleeding
Intraop
- Damage to adjacent structures (entering body cavity)
- Paraesthesia, injury to nerves
Early
- Seroma, haematoma
- Contour irregularity, skin laxity
- Fluid shifts
- Infection
Death 1:50000 (4 reported → 3 from PE)
55
Congenital breast deformity - what factors are considered for reconstruction?
1. operate on one or both breasts?
2. augment or reduce +/- reshape?
3. skeletal correction, recon or just augment?
4. prosthetic / autologous / injectables?
5. 1 stage / multistage?
56
Describe a tuberous breast deformity
1. widely spaced breast
2. narrow / constricted base
3. elevated IMF
4. elongated thin breast
5. herniation of breast parenchyma towards NAC
6. areola enlargement
57
What are the important features of tuberous breast deformity?
Constricted breast base
High inframammary fold
Breast herniation into areola
58
What can be involved in congenital breast deformity?
```
skin
breast parenchyma
muscle
rib cage
vertebral column
```
59
What are principles of tuberous breast correction?
Difficult to correct.
1. Reduce size of areola
2. Divide constrictions within the breast & redistribute the parenchyma
3. Lower and release the IMF
4. Insert an implant or expander
60
How is tuberous breast deformity classified?
von Heimburg Classification is commonly used (BJPS 1996)
Type 1 - hypoplasia of lower medial quadrant
Type 2 - hypoplasia of lower medial & lateral quadrants, with sufficient skin in subareolar region
Type 3 - hypoplasia of lower medial & lateral quadrants, deficiency of skin in subareolar region
Type 4 - severe breast constriction, minimal breast base
61
What is the treatment of tuberous breast deformity?
Moderate deformities → prosthesis only.
More severe deformity →
- release constriction
- prosthesis
- concentric mastopexy - skin remains lax, therefore submuscular implant helps prevent double bubble
- periareolar mastopexy and round block suture (Benelli 1990) to limit NAC herniation.
- concentric reduction of pigmented areola into the plane of the breast (donut mastopexy)
Very severe deformity →
- extra skin needed → medially based thoraco-epigastric flap from below the IMF to the lower medial quadrant
- ktissue expansion
1 stage: Augmentation & NAC reduction (Pacifico, Kang JPRAS 2007) concentric NAC reduction and IMF incision for implant
62
What are the surgical options for tuberous breast?
Type 1
Subglandular breast aug, be careful of double bubble deformity
Type 2
Augmentation and unfurling of breast tissue (internal flap) on chest wall turned downward to augment inferior pole
Inferior circumareolar incision
Type 3 and 4
Augmentation and internal flap and skin import (tissue expansion)
Consider contralateral reduction or mastopexy and/or augmentation
63
What is the method of tuberous breast correction as described by Pacifico / Kang?
- herniation of breast tissue through NAC is the only deformity (i.e. no primary skin shortage)
Procedure
- insertion of subglandular implant if necessary (IMF or periareolar)
- position NAC: IMF to inf NAC no more than 6cm, medial NAC to midline 8-10cm
- tailor tack NAC, do final positioning with patient upright
- incise around 'new' areolar margin
- circumareolar de-epithelialisation
- further subdermal undermining for 2cm
- deep tension sutures to double-breast the dermis
64
Do you know a classification of breast asymmetry?
Classification of Juri
Type I - bilateral ptosis/hyperplasia
Type II - unilateral I, normal contralateral
Type III - unilateral I, hypoplastic contralateral
Type IV - (added by von Heimburg) bilateral hypoplasia with deformity
65
How is breast asymmetry managed?
I -> reduction techniques on both breast
II -> more difficult, achieve symmetry of normal breast
III -> 2 stage approach (first augment the hypoplastic side)
66
Tell me about Poland's syndrome
1841 - Alfred Poland - Guy's med student
Unilateral congenital absence of sternocostal head of pec major muscle & ipsilateral syndactyly
1:25000 live births, M:F 3:1, R:L 2:1♂ (75% R)
67
What is the possible aetiology of Poland's syndrome?
intrauterine hypoxia / insult during limb bud formation wk7
?kinking / stenosis of subclavian artery
?genetic (but most cases sporadic)
68
What chest abnormalities may be associated with Poland's?
Chest Wall
↓ Pec Major (sternal head / total aplasia)
Variable ↓ Pec minor, serratus, LD, deltoid, sup and infraspinatus, rectus abdominis
Breast hypoplasia or aplasia with small/absent NAC
Deficient s/c tissues, Contracted anterior axillary fold, lack of axilla hair
Abnormal anterior 2nd-4th ribs, Thoracic scoliosis, Pectus excavatum
Sprengel’s shoulder deformity = congenital elevation of the scapula (bony or muscular)
69
What other deformities are associated with Poland's?
```
Limb Abnormalities
brachy-syndactyly ( simple, complete)
Hypoplasia of the hand and forearm
Foot anomalies
Cardiovascular
Dextrocardia
Hypoplastic or absent vessels (subclavian, thoraco-acromial, thoracodorsal)
o Consider angio before using LD flap
Other abnormalities
Renal hypoplasia
Congenital spherocytosis
↑ incidence of leukaemia
```
70
What are the principles of treatment of Poland's syndrome?
Usually present with
Men - absent ant axillary fold, nipple position → LD transposition, tendon reinserted into bicipital groove / custom implant
Women - breast maldevelopment → correct hypoplasia ω augments (custom made)
Fat transfer
71
What is liposuction?
| How do you classify liposuction?
fat is sucked into the openings of a cannula tip and avulsed as the cannula moves back and forth. Fibrous stroma and NVBs remain relatively intact.
Level - deep vs superficial
System - syringe vs machine
Assistance - ultrasound, mechanical
Infiltration - dry, wet, superwet, tumescent
72
What is a high lateral tension abdominoplasty?
Lockwood (1995)
less skin should be taken centrally, more laterally
results in an oblique lift vector with some anterior and lateral thigh lift
73
What are the disadvantages of large implants?
- unnatural appearance
- increased palpability and rippling
- breast atrophy, thinning and stretching of tissues
- remodelling of rib cartilages
- the larger the implant, the worse it will look over time due to stretching and tissue thinning
74
What are the different types of breast implants?
1. textured vs smooth, polyurethane (withdrawn 2001, reintroduced 2005). textured & PU - decreased capsular contracture ?due to reduced movement but more traction rippling
2. silicone vs saline
silicone:
- cohesive vs liquid gel
- biodimensional (anatomical) vs non-biodimensional
- profile: low, moderate and high
75
What are the advantages and disadvantages of subglandular and subpectoral placement of breast implants?
Subglandular
Adv
- suitable if skin envelope is sufficient, takes up skin envelope
Disadv
- more likely to be palpable / visible
- higher contracture rate
- more interference with mammography
Subpectoral - submuscular (pec and serratus) or dual plane
Adv
- less palpable
- less contracture
- nipple sensation more likely preserved
Disadv
- higher rate of implant displacement and asymmetry
- lower pole / IMF definition less attractive
- may develop double bubble deformity
76
What are the complications of breast augmentation?
MHRA (Medicines and Healthcare Products Regulatory Agency) leaflet
1 in 7 - decreased nipple sensation
1 in 10 - capsular contracture
1 in 20 - unacceptable scarring
2% / year rupture rate
Re-op rate due to complications = 1/4-1/3 over 5yrs
General
- infection 2%
- haematoma 3%
- scars 5%
- nipple sensation change (temp) 15%
- DVT, PE
Specific
- capsule contracture 25%
- rippling, palpable edge
- rupture cumulative risk 2% / yr
- gel bleed (escape of silicone oil from implant with no evidence of breach of outer shell)
- silicone granuloma - 0.1-0.5%
Aesthetic
- asymmetry
- rippling, palpable edge
- final result too big / small
77
What advice would you give regarding breast implants and breast cancer?
Silverstein Cancer 1990
- 41% false neg mammography rate (normal 5-10)
Eklund compression and displacement techniques visualise 60% of breast if subglandular vs 90% if submuscular)
- implants may delay diagnosis of breast ca BUT
- survival and stage of diagnosis same as w/o implant
FHX of breast cancer
- pre-op mammogram
- submuscular placement
- regular screening post op
Birdsell PRS 1993
13246 women with breast cancer (Alberta) c.f. non-augmented women
- same 5yr survival, same incidence of LN disease
- no difference of pathological stage at diagnosis
- smaller tumours in augmented pts
- 12yrs younger at diagnosis
78
What are the capsular contracture rates for subglandular, subpectoral, smooth, textured, silicone and saline implants?
subglandular - 30% in 10yrs
subpectoral - 10% in 10yrs
smooth - 58% at 12mths (Tebbetts BJPS 1991)
textured - 8%
(Bradford study, Malata BJPS 1997 - 59 vs 11% at 3yrs)
silicone - 8%
saline - 9%
Capsular calcification - 0% in <10yrs, 100% over 23yrs
79
How do you reduce capsular contracture rate?
Textured
Submuscular / subpectoral
Betadine wash
Prophylactic antibiotics (reduce subclinical infection)
80
What is the linguine sign on MRI?
| What is the snowstorm and stepladder signs on USS?
linguine - ruptured implant pulled away from capsule collapsing into gel and leaving multiple parallel lines
stepladder - same as above
81
What advice would you give women regarding breast implants and breast feeding?
Semple PRS 1998
silicon levels in breast milk of women with and w/o implants equal
10x more in cow's milk
even higher in formula milk
82
What is the aesthetic management of the breast following explantation and mastopexy options?
Rohrich PRS 1998
1. Explantation and capsulectomy (remove calcification to improve mammography accuracy)
2. Re-implantation (submuscular ideally)
3. Mastopexy - technique related to degree of ptosis
- Grade 1: periareolar or vertical
- Grade 2: Wise pattern
- Grade 3: delayed mastopexy esp in smokers
- psuedoptosis: inferior wedge excision
Rohrich 2007
- implant exchange (subpectoral)
- exchange with mastopexy (circumareolar with vertical scar or Wise)
- less women want explant alone
83
What is the overall satisfaction rate of BBR?
Sigurdson PRS 2007
should warn pts of all risks and complications, particularly
- change in breast shape with weight gain / loss / pregnancies
- bottoming-out, ptosis with time
- 93% report improvement in symptoms
- 62% increased their activity levels
- 87% overall satisfaction
- 93% would have surgery again
- 94% would recommend to friend
84
What are the principles of breast reduction surgery?
classified according to type of pedicle and type of skin resection / markings
- reduce and reshape parenchyma
- create pedicle for NAC
- redrape and reduce skin
- reposition NAC
85
Describe the inferior pedicle with inverted T scar technique
- NAC diameter 38-45mm
- nipple posn at Pitanguy's pt (IMF)
- sternal notch to nipple dist 21cm
- nipple to IMF dist 6-8cm
- more predictable in v large reduction
- more prone to bottoming out esp if vertical limbs >5cm
86
Vertical mammaplasty - Lassus
Lassus PRS 1996
- Mark the points:
(a) where new nipple position is
(b) 2-4cm above IMF
- Mark vertical limbs using lateral and medial breast displacement
- Draw keyhole pattern where NAC is to be inset
Excision
- raise thin superior dermal pedicle
- excise central breast parenchyma
- no skin undermining
- inset nipple temporarily
- tailor tacking of vertical scar to generate desired - breast shape and guide secondary resection
- pleat and ensure scar doesn't fall below IMF
87
Vertical mammaplasty - Lejour
- vertical superior pedicle, circumareolar and vertical scar
- liposuction (not area behind areola)
- pillar plication
- contour is overcorrected 'upside down' breast (high, projected, narrow-based)
- relies on post-op skin contraction and inferior breast remodelling
88
Vertical mammaplasty - Lassus vs Lejour
Lejour does
- liposuction
- skin undermining
Lassus
- sutures lateral pillars
- relies on skin contraction for scar
89
What does Hidalgo's vertical mammaplasty review (PRS 2005) recommend for improved outcomes?
- not using liposuction
- not suturing gland to pec major
- not undermining lower pole skin
- creating additional pillars of adequate size and careful approximation to avoid flattening or notching
- avoid excessive skin resection / tight closure
- leave nipple positioning to the end when lower limbs are closed and pt sitting up
- minimise pursestringing of vertical closure to lower portion only
- (Mr Cooper's tip - don't over-ressect at IMF level)
90
Hall-Findlay superomedial pedicle and vertical scar technique (2010 Ann Plas Surg)
- IMF is marked 3cm below Pitanguy's pt to accommodate increased projection
- mark lateral & medial limb by rotating breast inwards and outwards as well as upwards
- lines are joined up in U shape 2-6cm above IMF
- cut out short horizontal IMF scar for dog ear if necessary
91
Who should be considered for free nipple grafting in BBR?
```
>1500g resection
long nipple translocations >25cm
smokers / diabetics
revisional reduction, unknown primary pedicle
risks - hypopigmentation
```
92
Vertical / short scar technique
Graf / Biggs flap - inferior dermoglandular flap tunnelled superiorly under a loop of pec major muscle
Flowers 'flip-flap' mastopexy - inferior parenchyma is folded under superior pedicle and sutured to pec fascia
Hall-Findlay - lateral nipple pedicle, medial pedicle for inferolateral breast tissue rotated up as autoaugmention
93
Inverted T inferior pedicle (ITIP)
for severe ptosis, but more scarring and bottoming out longterm
94
Augmentation mastopexy
- most litigated procedure in USA
- unreliable results esp if >3cm nipple elevation is needed, therefore do as 2 stage
- use subpec / subfascial plane
- Spear PRS 2003: increased risk of infection and implant exposure, loss of nipple sensation or malposition (because mastopexy after augment changes breast shape)
- Cannon Ann Plas Surg 2010: use implants <4cm, good skin quality
95
Where are the zones of adherence and should be avoided in liposuction?
```
distal iliotibial tract
gluteal crease
lateral gluteal depression
middle medial thigh
distal posterior thigh
```
96
When do you need to give ivi in liposuction?
if over 5L aspirate, replace 0.25ml iv for every cc aspirate
97
What complications may arise in liposuction?
```
skin slough
skin burns (UAL)
DVT 1:3000
PE 1:3800
haemorrhage
fluid overload
fat emboli
cannula penetration into abdo cavity
lignocaine toxicity
surgical shock
```
98
How is fat distributed in the upper arm?
sc fat mostly posteriorly and inferiorly
skin and fat supported by 2 fascial systems
1. superficial (circumferential from axilla to elbow)
2. longitudinal (clavipectoral fascia, axillary fascia, then connects to superficial)
nerves superficial to deep investing fascia = medial brachial cutaneous and intercostobrachial
99
What types of upper arm rejuvenation techniques are there?
I EXCESS FAT
- good skin tone - liposuction only
II SKIN LAXITY
IIA Proximal
- horizontal only: vertical wedge / ellipse in axillary fold
- vertical and horizontal: T shaped resection on proximal arm / axilla
IIB Entire upper arm
- vertical only: horizontal excision along brachial groove
- vertical and horizontal: L shaped scar
IIC Onto lateral chest wall (MWL)
- extended brachioplasty
III EXCESS FAT and SKIN
- lose weight
- 1 or 2 staged liposuction then brachioplasty
100
How do you perform brachioplasty?
Warn patients: high risk of wound dehiscence, prominent scars, numbness
Liposuction
Minibrachioplasty - liposuction then elliptical skin excision in axilla with anchor superficial fascia to axillary and clavipectoral fascia
Standard brachioplasty
- mark patient sitting, abduct arm and flex elbow 90 degrees
- dotted line of bicipital groove from apex of axilla to elbow (= proposed scar position)
- mark 1cm above and parallel to this line (incision)
- pinch and bring inferomedial skin up to see how much can be excised
- divide ellipse into 1/5ths (castellate)
- reapproximate superficial fascial system, then dd and sc
- z plasty if wound crosses axilla
- drain, tubigrip
101
Abdominplasty: what is important in history?
```
age, BMI, smoking
weight loss, now stable?
previous pregnancies, planning more?
hernias
abdominal ops, scars
PMH
```
102
Abdominoplasty: what is important in examination?
Look: striae, scars, bulges
excess skin -standing, sitting, supine
intertrigo
adhesions (skin and fat to abdo wall - needs freeing
scars and tethering (subcostal - compromises blood supply to skin flap)
diastasis of recti
herniae
Think - does pt need liposuction, miniabdominoploasty, traditional, flour-de-lis, high lateral tension, circumferential?
103
What should be covered in consent?
```
GA, DVT, PE
bleeding, haematoma
scar- configuration and dog ears, decreased sensation, scar sensitivity
delayed wound healing
seroma
umbilcus - malposition, necrosis
```
104
What are the rates of DVT and PE in aesthetic surgery?
Facelift
DVT 0.35%
PE 0.14%
23% deaths due to thromboembolism
Abdominoplasty
DVT 1.2
PE 0.8%
50000 pts , 7500 board certified plastic surgeons
PRS 2005
105
What is considered in the procedure selection process?
```
Liposuction only
Infraumbilical miniabdominoplasty
Traditional abdominoplasty
Fleur-de-lis
Lockwood's high lateral tension
Circumferential
All +/- rectus plication
```
106
How is a traditional abdominoplasty marked?
Patient marked standing
Mark ASIS
Mark point >6cm above vulval commissure
Complete transverse lines of inferior incision (lateral scar just under ASIS)
Pull skin down, superior incision marked
Mark liposuction areas if applicable
Discuss with pt possibility of vertical scar if horizontal excess
107
How is a traditional abdominoplasty performed?
Patient on bed that can be flexed / broken intraop
GA, supine, arm boards, prep, drape, flowtrons
Circular incision around umbilicus, McIndoes to dissect out umbilical stalk to rectus sheath
Incise inferior scar
Elevate skin flap from muscular fascia leaving a small amount of fat up to xiphoid process and costal margin
Leave some fat around ASIS to prevent damage to lateral femoral cutaneous nerve
Mark rectus diastasis with ink, use 0 looped nylon continuous locking, ensuring knot is tied before umbilicus to avoid constriction
Bed is flexed at hip level, skin flap is castellated, staple midline, excise excess skin
Umbilicus is repositioned, V shaped flap
Drains inserted
Scarpa's dd and sc sutures
Abdo binder, keep hips flexed
108
What are the principles of Lockwood's HLT abdominoplasty?
mainly vertical skin excess below umbilicus, and mainly horizontal skin excess around epigastrium
oblique vector of pull will deal with both, and lift anterior and lateral thighs
direct undermining performed only centrally
therefore safer to liposuction
109
Pearls for:
Fleur-de-lis
Reverse abdominoplasty
Fleur de lis
minimal undermining of skin flaps, only enough to do rectus plication
Reverse
- deals with epigastric skin excess
- may be combined with Wise pattern breast procedures
110
Medial thigh lift algorithm
```
Classification Type
I Lipodystrophy
II L + upper 1/3 skin laxity
III L + beyond upper 1/3 skin laxity
IV L + mod skin laxity length of thigh
V Severe lipodystrophy and skin laxity (MWL)
```
Treatment
I - Liposuction only
II - Liposuction + horizontal skin excision
III - Liposuction, horizontal and vertical skin excision
IV - Liposuction, horizontal and vertical skin excision
V - MWL Staged liposuction then skin excision
111
Medial thigh lift - classic
mark standing, knees apart
mark area for liposuction
mark femoral triangle - avoid
mark line in medial thigh crease: coccyx - buttock fold - labia majora
vertical ellipse if required (T shaped scar)
Operative
Prone, liposuction, posterior skin excision, wound closure, then supine frog leg position, anterior liposuction and skin excision
Identify superficial fascia system and anchor to Colle's fascia
Drain, skin closure, compression garment
MWL
Supine frog-leg only, make anterior incision down to deep fat, raise posterior skin flap, excise in segments, no anchoring to Colle's fascia
112
Medial thigh lift - transverse incision
mark standing, knees apart
mark area for liposuction
mark femoral triangle - avoid
mark line in medial thigh crease: coccyx - buttock fold - labia majora
vertical ellipse if required (T shaped scar)
Operative
Prone, liposuction, posterior skin excision, wound closure, then supine frog leg position, anterior liposuction and skin excision
Identify superficial fascia system and anchor to Colle's fascia
Drain, skin closure
113
Fasciofascial suspension technique
Candiani
- transverse skin excision with vertical vector of pull parallel and 6-7cm inferior to inguinal crease
- gracilis and adductor longus fascia is overlapped
overlying excess skin is also excised
- no anchoring of Colle's
114
What are the specific postop complications?
```
skin irregularities, depressions
hypertrophic / stretched scars
flattening of buttocks from tension of wound closure
distribution of vulva
lymphoedema
recurrence of thigh ptosis
```
115
What is the classification for obesity?
```
BMI = kg/height 2
Obese >30
Severe obesity >35
Morbid obesity >40 (>100% / 100lbs above IBW)
Superobesity >50
```
IBW = BMI 25
116
What co-morbidities are associated with morbid obesity?
```
osteoarthritis
OSA
gastroesophageal reflux
dyslipidaemia
hypertension
DM
CHF
asthma
```
117
What bariatric surgery techniques do you know?
Restrictive Procedures
Vertical band gastroplasty
Laparoscopic adjustable gastric band
```
Restrictive and Malabsorptive Procedures
Biliopancreatic diversion (significant nutritional deficiencies)
BPD with duodenal switch
Roux-en-Y gastric bypass - gold standard
```
118
What is the preop evaluation?
Max and current BMI
Assess co-morbidities and psych issues
Smoking
Nutritional deficiencies: iron deficiency anaemia, Vit B12, Ca, Zn, Vit ADEK (fat soluble), Protein
Bloods - FBC, U&E, LFT, glucose, Ca, ferritin, TPro, Alb, x-match
Complications of skin redundancy
- intertrigo
- musculoskeletal pain
- functional: ambulation, urination, sexual activity
- psychological: depression, low self-esteem
119
What is the prep evaluation?
Max and current BMI
Assess co-morbidities and psych issues
Smoking
Nutritional deficiencies: iron deficiency anaemia, Vit B12, Ca, Zn, Vit ADEK (fat soluble), Protein
Bloods - FBC, U&E, LFT, glucose, Ca, ferritin, TPro, Alb, x-match
Complications of skin redundancy
- intertrigo
- musculoskeletal pain
- functional: ambulation, urination, sexual activity
- psychological: depression, low self-esteem
120
What is the surgical strategy for MWL body contouring?
Determine priorities
1. Trunk, abdomen, buttocks, lower thighs
2. Upper thorax, breasts, arms
3. Medial thighs
4. Face
121
What are the different procedures?
Trunk / Abdomen
Panniculectomy / melon slice (no more umbo)
Fleur-de-lis
Circumferential abdominoplasty / belt lipectomy
- mark anterior with patient standing
- mark posterior with patient bent forwards, lower incision at level of coccyx (addresses inferior rolls)
- preferentially excise anterior and lateral excess than posterior
Thighs
Lateral thigh lift more effective than medial
Staged if both required
Buttocks
Can be with belt lipectomy, consider autogenous gluteal augmentation with dermal / fat flaps
Breast
Mastopexy
Upper arms
Brachioplasty with sinusoidal excision behind bicipital groove and Z-plasty into axilla
Facelift - skin > SMAS, lipectomy, liposuction
122
What are the complications?
```
Haematoma
Seroma
Lymphocoeles
DVT, PE
Wound - dehiscence, skin necrosis, wound infection
Irregularities, dog ears
```
