Augmentation Mammoplasty, Mastopexy, and Mastopexy-Augmentation Flashcards
the primary goal of breast augmentation
the primary goal to increase the size ofthe breast
Mastopexy-augmentation can be performed as a single-stage procedure to alter both the size and shape of the
breast
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The main goal of BA is to increase the volume ofthe breast and centralize the nipple on the breast mound
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The chest wall is the foundation
upon which a prosthetic device will sit
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Standard
measurements before BA
base width (BW),
sternal notch to nipple distance (SN-N),
nipple to the inframammary fold (N-IMF),
NAC diameter, and internipple distance
The BW is a key measure for determining the appropriate transverse
dimension ofa breast implant and chest wall diameter
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2 cm of pinch thickness is considered the minimum necessary for placement of an implant in the subglandular or subfacial
plane
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The
interface between the skin and the breast parenchyma should also
be evaluated why?
as postpartum women or patients with poor dermis
due to massive weight loss may have skin that very easily glides over
the underlying breast parenchyma.
The lower pole of the breast can
be constricted in patients with micromastia or mild tuberous breast
deformity
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In case of lower pole constriction what you will do to treat the like this patients?
Lowering of the IMF and recruitment of upper abdominal
skin may be warranted in these patients and should be considered
during the evaluation.
An assessment of the width of the sternum is
important why?
That can help the surgeon talk to a patient about expected
superomedial fullness and interbreast distance that will likely persist
after augmentation
the width of sternal can be decreased by placing the implant submuscular
F This distance can be decreased and even lead
to symmastia when the implant is placed subglandularly, but is less
likely with submuscular placement because the medial pectoralis
muscle attachments are left intact and prevent medial migration.
BA can lead to increase the risk for Breast cancer
F Women with augmented breasts are at no
increased risk of breast cancer compared to women with nonaugmented breasts.
Women with breast implant can not make mamogram screening
F Women with
a history of breast augmentation undergo screening mammography
with special implant-displaced or Eklund views to better assess the
tissue anterior to the implant
The sensitivity is increased with ultrasound (US) or magnetic resonance imaging (MRI) compare with mamogram alone
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(FDA) recommended screening with MRI
for silent ruptures 3 years after placement and then every 2 years
thereafter
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Mamogram mandatory for women seeking BA
F For women desiring breast augmentation, routine mammographic screening should be performed or reviewed if indicated
preoperatively using the US Preventative Services Task Force guidelines based on age over 40 and risk
Patients who seek
BA who have no visible breast skin below the NAC on a frontal view
(grade II ptosis)
F Patients who seek
BA who have no visible breast skin below the NAC on a frontal view
(grade III ptosis) likely need a mastopexy as well to reposition the
NAC on the breast mound
patients who have visible breast skin below the NAC (pseudoptosis or grade I and II ptosis)
on a frontal view may be candidates for BA alone
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patientwith an IMF at the junction ofthe middle and distal thirds ofthe
humerus may be considered “high” breasted
F patientwith an IMF at the junction ofthe middle and distal thirds ofthe
humerus may be considered “low” breasted
IMF at the middle of the humerus may be considered “high” breasted
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The pectoralis major’s inferior attachments can be above or below the NAC and at
or above the IMF.
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Why the location pf pectoralis major muscle important relative to the NAC ?
For example,
a low breasted patient with a pectoralis major muscle attachment that
is higher than the NAC may not benefit from subpectoral placement
of the breast because the implant will ride high behind the pectoral
muscle whereas the NAC will remain in a lower position and not be
centered on the implant and augmented breast mound
Silicone implants are considered “off label” when
used in women less than 18 years old per the FDA
F Silicone implants are considered “off label” when
used in women less than 22 years old per the FDA
A major difference besides cost and feel is that saline and silicone
implants differ in how a device rupture is detected
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First and
second generation silicone ruptures led to free floating silicone in the
pocket leading to inflammation and silicone granuloma formation
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Ruptures of the current fifth-generation implants are just like the first and second generation rapture
F Ruptures of the current fifth generation implants are very different.
Silicone ruptures with cohesive gel implants can be detected on mammogram but more often require MRI to confirm a suspected rupture.
Often delayed capsular contracture can be due to a silent rupture ofa
highly cohesive gel implant
For a round device,
height and width will be the same
T for a given base width
with a round device, an implant can vary in volume and projection
it is not possible to accurately detect a shaped versus round implant in the submuscular plan
intraoperatively
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Round implant has a more round superomedial curve whereas an
anatomic implant has a more teardrop look when placed in the submascular
f round implant has a more round superomedial curve whereas an
anatomic implant has a more teardrop look when placed in the subglandular or subfascial plan
Which factors play a role in soft tissue integration with the breast implant surface
Surface area, pore size, and distribution may
play a role in soft tissue integration with the breast implant surface,
the organization of myofibroblasts and matrix proteins, and potential for accumulation of bacterial biofilms
Textured devices have lower rates
of capsular contracture, or the formation of a capsule that leads to
deformity and/or pain in the breast following BA
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Textured devices are thought to be less likely to migrate
beyond the dissected pocket
F anatomic, textured devices have demonstrated that even these implants can have rotation and malposition necessitating reoperation
anatomic implants are all textured devices. Round devices can come as
either textured or smooth.
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The subglandular plane used by the breast surgeons
when they perform mastectomies
F The subfascial plane is below the fascia of the pectoralis muscle and above
the muscle itself
retropectoral pocket
Submascular plane
Dual-plane breast augmentations, as
graded I, II, and Ill, vary by the amount of pectoralis muscle release
inferiorly and subsequent amount of contact between the implant
and breast parenchyma inferiorly.
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The IMF incision is placed in the original IMF crease
The IMF incision is placed in the desired IMF crease,
which may be below the native IMF if the IMF is going to be lowered in a BA
Transaxillary incisions are made in the
hair-bearing region of the axilla
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Delayed seromas with or without an associated mass should raise suspicion for breast implant-associated anaplastic large cell lymphoma
(BIA-ALCL)
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A MRI is recommended to visualize a suspicious seroma or mass
F A PET-CT scan is recommended to visualize a suspicious seroma or mass
Treatment of BIA-ALCL always requires complete capsulectomy, and depending on the stage of disease, it may also need adjuvant
chemotherapy or immunotherapy
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complications after
BA
1 % to 2% for hematoma
1 % for infection and deep vein thrombosis/pulmonary embolism (DVT/PE)
Capsular contracture rates from long-term studies
demonstrate variability based on implant manufacturer
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The Baker classification system of capsular contracture depend on what ?
It relies on physical examination to assess how soft
the augmented breast and whether or not the patient reports pain
Applanation tonometry, adopted for measuring intramammary compliance, and ultrasound elastography are routinely used for breast contracture
F Applanation tonometry, adopted for measuring intramammary compliance, and ultrasound elastography represent more modern less widely adopted techniques for assessing capsular contracture
Capsular
contracturescanoccur “early” within 1 year of placement or in adelayed
fashion several years later
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smooth devices placed in the
subglandular plane have had the highest rates of capsular contracture
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Baker
I Soft No pain
II Palpable, minimal firmness No pain
III Easily palpable ,firmness, moderate Pain
IV Firm distorted Painful
Patients with grade III or IV capsular contracture can be treated conservatively if there are not capsule rapture
F Patients with grade III or IV capsular contracture with or without
concomitant silicone rupture or silicone granulomas, and those with
asymmetry requesting a revision procedure will require operative
management
Treatment involves either open capsulectomy or capsulotomy.
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Closed capsulotomy that involved external, manual compression to break through the capsule is utelized till now
F Is no longer recommended due to risk of implant rupture or possible hematoma formation and incomplete management of the problematic capsule
leukotriene
inhibitors has shown some benefit in preventing and improving capsular contracture
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Intraluminal steroids and pocket irrigation with
steroids were once performed, but no longer are common practice
due to risk of implant rupture, wound dehiscence, and atrophy of
tissues.
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Recurrent capsular contracture often requires placement in
an alternative plane or neosubpectoral pocket after a capsulectomy.
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Acellular dermal matrices (ADM) have no role in breast contracture
F Acellular dermal matrices (ADM) have also been used in recalcitrant
cases of capsular contracture to create an interface between implant
and breast tissue
Implant rupture can occur regardless of implant fill material
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Saline
rupture can easily be identified by unilateral deflation and breast
asymmetry that occurs suddenly always proceeded by trauma
F This can sometimes be preceded
by trauma
Silicone rupture can present with the presence of silicone granulomas or can be silent and diagnosed on mammography
or MRI
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Treatment
of rupture often requires removal of one or both implants and any
ruptured material in the case of silicone rupture with capsulectomy or capsulotomy.
F with or without capsulectomy or capsulotomy.
Fat grafting has unpredictable rates of long-term fat graft survival
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with fat graft can easly adjust the breast to the reliable breast size
F it may be difficult to reliably
augment a breast to a desired cup size.
More than one surgery or
round of fat grafting may be required to achieve a patient’s goals
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In Composite BA the fat graft is mainly put in the inferior pole to augment the breast
F often placed in the superior pole to blunt the
transition between native tissue and the implant
Fat can be placed
laterally and inferiorly when the soft tissue envelope is thin to reduce
visible rippling or mask implant palpability
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Autologous BA with flaps
are common in patients who have had a massive weight loss because
they have a paucity of breast tissue
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Mastopexy focuses on changing the shape of the breast to one that
appears youthful and beautiful; it also addresses descent of the NAC
relative to the IMF.
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the discrepancy between the skin and breast tissue can be reduced with mastopexy
T By addressing the outer lamella of the breast (the skin)
and/or the inner lamella of the breast (the parenchyma)
Benelli demonstrated that skin
only mastopexies address
the skin only
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Benelli demonstrated that skin
only mastopexies were not as durable as mastopexies that address
the skin and parenchyma by redistributing the parenchyma.
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addressing both the outer lamella
(skin) and inner lamella (parenchyma), more durable and predictable
changes can be achieved in the ptotic, involuted breast
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Periareolar mastopexies can be used in patients who have grade II
or III ptosis, nipple asymmetry, or widened areola
F Periareolar mastopexies can be used in patients who have grade I
or II ptosis, nipple asymmetry, or widened areola
Periareolar mastopexies can elevate the nipple up tO 5 CM
F 2 CM
All The periareolar mastopexy can decrease the projection of the breast
F The concentric pattern peri areolar mastopexy only
Removing skin in a concentric pattern can,
Can flatten and reduce breast projection.
Scar widening and eventual widening of the areola can occur, . If there is circumferential full thickness violation of the
dermis, decreased nipple sensitivity may occur
some have advocated the use of a barbed or permanent suture to
control this
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vertical techniques is to
both incorporate ptosis correction with excision of glandular material
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vertical techniques can be used for severe ptosis only
This technique can be used for all grades of breast ptosis.
What are the two most surgical technique in vertical mastopexy
The short-scar periareolar inferior-pedicle reduction (SPAIR) and Hall-Findlay mastopexy techniques are the
two vertical mastopexies with the highest surgeon satisfaction
SPAIR mastopexy relies on the
third intercostal perforator or inferior pedicle for blood supply to
the nipple
F SPAIR mastopexy that relies on the
fourth intercostal perforator or inferior pedicle for blood supply to
the nipple
It involves a periareolar closure in a pin-wheel or interlocking pattern, sometimes with a permanent suture
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Suspension
sutures to the pectoralis fascia can be used to elevate the breast to higher position in the chest wall in SPAIR tech
T but the durability is debated
Draw back of SPAIR tech
Because weight remains in the inferior portion
of the breast, bottoming out remains a shortcoming. The periareolar
closure can widen or have pleating that persists
Breast Implants can be used with SPIAR tech
F This technique is not
typically complemented with implant placement
The Hall-Findlay vertical mastopexy most commonly uses the
superomedial or medial pedicles for the NAC based on the second and third intercostal perforators, respectively
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the inferior pole of breast tissue is preserved in the Hall-Findlay
technique
Different from the SPAIR technique that preserves the inferior pedicle, the inferior pole of breast tissue is excised in the Hall-Findlay
technique.
An implant cannot be placed with hall-Findlay tech
F An implant can be placed in the subglandular, subfascial or submuscular planes without concern for blood
supply to the NAC as the second and/or third intercoastal perforators travel superficially in the gland and remain undisturbed by an
augmentation
vertical mastopexies create an inverted breast shape
at the end of the procedure with exaggerated upper pole fullness and
a sloped inferior pole
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The Wise-pattern can be used for all types of ptosis but carries a large scar burden
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The Wise-pattern can be used with practically with superior pedicles only
to the NAC.
F can be used with practically any pedicle for blood supply
to the NAC.
The Wise-pattern or inverted-T mastopexy adapted from traditional Wise-pattern inferior-pedicle
reduction mammoplasty techniques.
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The bottoming up is treated with Wise pattern tech
F can experience bottoming out when combined with an inferior pedicle
An
implant can be placed in the subglandular, subfascial, or submuscular plane depending on where the blood supply to the NAC is
coming from.
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Complications less than I% rates for hematoma, infection, and DVT/PE.
The most common reported complication
complications found suture spitting, excess scarring, and bottoming
out to be the most commonly reported complications
excess scarring with wich tech ?
was noted with the periareolar technique
suture
spitting
with the SPAIR technique
persistent asymmetry with wich tech
with the
vertical technique
bottoming out
with the inverted-Tor Wise pattern mastopexy.
Revision rates in periareolar approaches.
have been reported to be as high as
50% in
Meta-analyses of reports ofsingle-stage
mastopexy-augmentation have found an overall complication rate of
13% with a reoperation rate of 11 %
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There
is no consensus of whether augmentation or mastopexy should be
performed in a two-staged plan
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. Macrotextured devices are characterized by heterogeneously arranged pores
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Microtextured devices possess a more uniform pore distribution
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The submuscular plane is below
the pectoralis muscle superiorly and inferiorly below the pectoralis muscle fascia as it interdigitates with the rectus muscle fascia
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Dual-plane breast augmentations, as
graded I, II, and Ill, vary by the amount of pectoralis muscle release
inferiorly and subsequent amount of contact between the implant
and breast parenchyma inferiorly
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Transaxillary incisions are made in the
hair-bearing region of the axilla
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Capsular contracture rates based on implant manufacturer
The redundant skin inferiorly can be excised
in a “J” or “T” pattern in SPAIR tech
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Lateral malposition is a common problem seen
in mastopexy-augmentation in the massive weight loss patient
population
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Areola can widen after an augmentation
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If a diagnosis of BIA-ALCL is made
(CD30+/ALK-), then a PET-CT scan of the chest is indicated
to further characterize the mass and fluid collection associated
with the implant capsule and breast tissue
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Recurrent ptosis was the most commonly encountered complication after single stage mastopexy augmentation at 5.2%. This
was followed by poor scarring (3.74%), capsular contracture
(2.97%), asymmetry (2.94%), and seroma (1.42%).
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