CHAPTER 15: AESTHETICS - GENERAL, BREAST, ABDO Flashcards
Aesthetic assessment
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
What are the properties of an ideal implant?
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)
History of breast implants and silicone controversy
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)
What is silicone?
polydimethyl siloxate - polymer of silicon
What are the indications for breast augmentation
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
Scott Spears contraindications for BBA?
PULSE DOOMED Poor historian Unco-operative Litigious Surgaholic unrealistic Expectations
Depressed OCD Over flattering Minimal / imagined deformity Extremely rude inDecisive
What are the main reasons for dissatisfaction postop?
poor preop info
poor communication
physical difficulties / complications
Poor results likely
- ptosis
- thin small chests
- tubular breasts
- chest wall deformity
- body builders
- asymmetry
PREOP ASSESSMENT
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
What are the goals of BBA?
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
What happens to breast tissue after implants?
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
What are Tebbetts High FIve?
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
Explanation of Tebbetts high five
- 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.
TEPID system
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
Implant shape: Round vs anatomical?
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
What are the different types of implant constituents?
silicone gel saline inflatable double lumen salin-gel filled (Beckers) polyurethane-covered gel filled Polyvinylpyrrolidone (PVP) hydrogel
Describe the classification for capsular contracture?
Baker 1975 - 4 grades 1 soft (no contracture) 2 palpable 3 visible 4 painful
What are the theories behind capsular contracture?
- 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)
What materials can be used to revise bottoming out?
prolene mesh (Frank - Indiana)
alloderm, mesh (Spear) 15-20% need re-revision
Strattice in UK?
What is the pathology behind silicone synovitis?
Macrophages phagocytose silicone bleed
silicone cannot be lysed by lysosome
macrophage ruptures, re-releasing particles
What is the association between breast cancers and a rare form of cancer?
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
What are the causes of synmastia?
implants too wide
subglandular pocket made too medial
What is the management of BBA? RWS 13S
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
Describe the procedure of BA
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.
What is dual plane approach?
Who described it?
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
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
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)
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♀
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
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)
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
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
What are the principles of mastopexy?
uplift of breast with little / no reduction
- elevate ptotic breast
- reposition nipple
- improve breast shape
Why does ptosis occur?
stretching of skin loss of parenchymal volume weight loss pregnancy lactation menopause
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
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
What types of mastopexy are there?
- Implant only - only to fill out skin redundancy for low volume breast
- Skin only (Above)
- Implant and mastopexy
- excise inferior breast tissue rather than infold. Submuscular or subglandular implant
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
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
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
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
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.
What is a mini-abdominoplasty?
removal of infra-umbilical skin without repositioning umbo
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.
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)
What is a fleur-de-lis abominoplasty?
conventional abdominoplasty with midline scar to remove vertical skin excess
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
Is pregnancy safe after abdominoplasty? Are there any papers?
Menz 1996 - safe, but monitor closely if plication has been performed
Total body lift
see massive weight loss
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.
