Ptosis Grade Research Articles

Risk factors of mastectomy skin flap necrosis in immediate breast reconstruction using low abdominal flaps

Background: The purpose of this study was to determine the risk factors associated with mastectomy skin flap necrosis during immediate reconstruction with TRAM or DIEP flaps.Methods: This study reviewed 1116 cases of immediate breast reconstruction over 10 years. Patients ranged in age from 29–76 years (average = 45.1 years), and had an average follow-up period of 65.6 months. Thirteen factors (age, BMI (body mass index), smoking habits, diabetes ptosis grade, midclavicle-to-nipple distance, neoadjuvant chemotherapy, free or pedicled flap, mastectomy method, surgeon, stage, axillary dissection, mastectomy weight) known to be associated with mastectomy flap necrosis were retrospectively analysed. The odds ratios of the risk factors were calculated using logistic regression analyses.Results: Mastectomy skin flap necrosis occurred in 247 cases (22.1%). Univariate regression analysis showed that the odds ratio of age, BMI, ptosis grade, midclavicle-to-nipple distance, free flap, mastectomy method, surgeon, stage, and mastectomy weight were significant and the odds ratios determined using multivariate analysis were significant for mastectomy method, surgeon, and mastectomy weight.Conclusion: During breast reconstruction using abdominal tissue, the independent risk factors that affect mastectomy skin flap necrosis include the mastectomy method, surgeon, and the weight of the mastectomy specimen. Awareness of the impact of each risk factor will lead to the modification and individualisation of surgical techniques and continually improve outcomes.

Late radiation side effects, cosmetic outcomes and pain in breast cancer patients after breast-conserving surgery and three-dimensional conformal radiotherapy : Risk-modifying factors.

The purpose of this work was to identify parameters influencing the risk of late radiation side effects, fair or poor cosmetic outcomes (COs) and pain in breast cancer patients after breast-conserving therapy (BCT) and three-dimensional conformal radiotherapy (3D-CRT). Between 2006 and 2013, 159 patients were treated at the Hannover Medical School. Physician-rated toxicity according to the LENT-SOMA criteria, CO and pain were assessed by multivariate analysis. LENT-SOMA grade 1-4 toxicity was observed as follows: fibrosis 10.7 %, telangiectasia 1.2 %, arm oedema 8.8 % and breast oedema 5.0 %. In addition, 15.1 % of patients reported moderate or severe breast pain, and 21.4 % complained about moderate or severe pain in the arm or shoulder. In multivariate analysis, axillary clearing (AC) was significantly associated with lymphoedema of the arm [odds ratio (OR) 4.37, p = 0.011, 95 % confidence interval (CI) 1.4-13.58]. Breast oedema was also highly associated with AC (OR 10.59, p = 0.004, 95 % CI 2.1-53.36), a ptosis grade 2/3 or pseudoptosis and a bra size ≥ cup C (OR 5.34, p = 0.029, 95 % CI 1.2-24.12). A ptosis grade 2/3 or pseudoptosis and a bra size ≥ cup C were the parameters significantly associated with an unfavourable CO (OR 3.19, p = 0.019, 95 % CI 1.2-8.4). Concerning chronic breast pain, we found a trend related to the prescribed radiation dose including boost (OR 1.077, p = 0.060, 95 % CI 0.997-1.164). Chronic shoulder or arm pain was statistically significantly associated with lymphoedema of the arm (OR 3.9, p = 0.027, 95 % CI 1.17-13.5). Chronic arm and breast oedema were significantly influenced by the extent of surgery (AC). Ptotic and large breasts were significantly associated with unfavourable COs and chronic breast oedema. Late toxicities exclusive breast pain were not associated with radiotherapy parameters.

Sexual reassignment surgery in female-to-male transsexuals: An algorithm for subcutaneous mastectomy

Subcutaneous mastectomy is one of the first steps in sexual reassignment in female-to-male transsexuals (FTMTS). The main goal is to masculinize the chest by removing the female contour. In this study, we introduce an algorithm to facilitate choosing the appropriate mastectomy technique depending on morphological aspects. The records of 173 patients (346 mastectomies) from January 2008 to December 2013 were retrospectively reviewed. The authors conducted four different surgical techniques depending on breast volume, grade of ptosis and skin elasticity. The outcome parameters such as complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and surgical correction rate were obtained and related to the employed technique. From January 2008 to December 2013, we performed 346 mastectomies, of which 48 breasts (13.9%) were treated by a semicircular incision in combination with water-jet-assisted liposuction, 66 breasts (19.1%) by an additional circumferential mastopexy, 170 breasts (49.1%) by an inferior pedicled mammaplasty and 62 breasts (17.9%) by mastectomy with free nipple grafting. The mean operation time lasted 103.6min. The overall complication rate was 11.8%. Secondary revisions were necessary in 9%. Of the patients, 88% rated the aesthetic results as "very good" or "good." Nipple sensitivity was rated as "very good" or "good" in 80.3% of the breasts. FTMTS are a well-informed patient population and therefore increasingly more demanding for aesthetic outcomes. If possible, the most scar-saving procedure should be preferred. With ascending degrees of ptosis, a larger skin envelope and lesser elastic skin, an extended-incision technique is required. The presented surgical algorithm facilitates the selection of the appropriate mastectomy technique and shows a high patient satisfaction with the aesthetic result, a preservation of nipple sensitivity and a low rate of complications and secondary aesthetic corrections.

Aperfeiçoando a mensuração do volume mamário na reconstrução imediata com expansores permanentes

INTRODUÇÃO: A determinação precisa do volume mamário pode melhorar o resultado dos procedimentos de reconstrução. O objetivo deste estudo é correlacionar a mensuração pré-operatória do volume mamário utilizando o método de conchas plásticas e a aplicação intraoperatória do princípio de Arquimedes para a avaliação volumétrica das mamas, em pacientes submetidas a reconstrução mamária imediata utilizando expansores permanentes, portadoras de mamas de pequeno volume e grau ptótico leve. MÉTODO: Dez pacientes foram incluídas em um estudo retrospectivo não-randomizado. O volume da mama foi mensurado, no pré-operatório, com conchas plásticas com volumes predeterminados e, no período intraoperatório, com o método de Arquimedes. Expansor apropriado permanente foi selecionado e inserido de maneira retromuscular. A equipe classificou a simetria da mama como pobre, boa ou muito boa. RESULTADOS: As diferenças entre as medidas pré e intraoperatórias foram estatisticamente significantes (P < 0,01, teste t de Student). Os valores pré-operatórios foram subestimados em 70% dos casos e foram 15% menores que os valores intraoperatórios. CONCLUSÕES: A avaliação do volume da mama em procedimentos de reconstrução imediata utilizando expansores permanentes pode ser aperfeiçoada pela combinação de diferentes técnicas de mensuração pré e intraoperatórias, levando a resultados mais previsíveis. O método de conchas plásticas de volume preestabelecido tende a subestimar o volume ressecado da mama quando comparado aos valores obtidos com método de mensuração intraoperatória utilizando o princípio de Arquimedes.

The Three Dermoglandular Flap Support in Reduction Mammaplasty

Bilateral breast reduction is an established procedure performed to relieve the physical pain and psychological discomfort associated with heavy, pendulous breasts. Numerous techniques have been developed over the years with several refinements to obtain safe nipple-areola complex transposition and harmonious breast shape. Based on the experience of the senior author (M.P.), the three dermoglandular flap technique is proposed to achieve a safe and aesthetically pleasing breast reduction through the surgical concept of dermal support. The authors analyzed the benefits of the three dermoglandular flap technique performed in a selected group of smoking patients with a potentially high risk of postoperative complications and high probability of breast ptosis recurrence (each patient had breast volume >1000 cc, breast nipple ptosis grade 3 on Regnault's scale, and body mass index >27). Blood supply to the nipple-areola complex was based on an inferior-central pedicle. Between 1995 and 2007, 47 smokers underwent bilateral breast reduction using the three dermoglandular flap technique. Their ages ranged from 37 to 63 years (mean, 49 years), and their average body mass index was 31.2 kg/m (range, 27 to 38). The overall complications rate was 14.9 percent. No wound breakdowns and no complete or partial necrosis of the nipple-areola complex was observed. Follow-up ranged from 18 to 48 months (mean, 32 months). : Three dermoglandular flap reduction mammaplasty produced good cone shape, soft texture, and fullness in the central and inferior pole with satisfactory breast projection and was stable over time. It offers a safe and practical approach in the treatment of challenging breast hypertrophy. Therapeutic, IV.

Kongenitale Ptosis

Simple congenital ptosis is the most common form, characterised by fatty dystrophy and fibrosis of the levator muscle, which leads to a restricted elevation in upgaze and a lid lag in downgaze. In the complicated form additional changes will be found: fibrosis of extraocular muscles, synkinesia or anomalies of the lids. Moreover, congenital ptosis is relatively often associated with refractive errors and/or disturbance of the binocular vision. Therefore a careful examination is necessary. Therapeutic management includes first prevention of amblyopia either by occlusion or by early surgical intervention. The choice of operation depends on the grade of ptosis, the actual levator function and the presence of lid anomalies as well.

Invited Commentary: Ideal Anthropomorphic Values of the Female Breast

Pursuit of a reliable quantitative aesthetic breast ideal has been elusive, and at times controversial. 1,2 For decades, many surgeons have based their operative planning on outmoded anthropometric guidelines derived from a homogeneous sample of a single surgeon's aesthetic 3 Although these measurements have been useful for approximation, they are relatively crude and cannot be applied with great reliability to patients of varying body habitus. They do not take into account certain volumetric attributes or anatomic characteristics that would maximize individual patient aesthetic desires or outcomes. In an attempt to make sense of the human gestalt, Liu and Thomson 4 have taken a more egalitarian and sophisticated approach in assessing and defining the ideal breast anthropometrics. The authors set out to define ideal aesthetic standards by querying cosmetic and reconstructive patients as well as plastic surgeons, and to distinguish possible biases harbored by plastic surgeons. They cite, and we agree with, the importance of gaining aesthetic input from the patient. The authors contend that their study is more robust and comprehensive than that of older reports. 3,5―8 They attempt to quantify ideal anthropometric values of the breast by correlating the aesthetic evaluations of many with measurements taken from 109 female volunteers. In doing so, plastic surgeons are ultimately provided with a set of optimized values from an aggregated source. This is in contradistinction to historic average anthropometric values taken from the general populace without regard for aesthetics, or measurements derived from singular opinion of aesthetic 3,5 Arguably, there are some shortcomings in the methodology of this study. A random sample of pictures was shown to 252 plastics surgeons, 15 cosmetic breast patients, and 25 breast reconstruction patients. The authors state that the evaluations were uniformly distributed across all breasts with each breast pair evaluated 41 times. There is a large discrepancy in the number of times the breast pairs were analyzed by each type of evaluator: 3641 (14.5 pair/surgeon), 368 (24.5 pair/cosmetic patient), 437 (17.5 pair/reconstructive patient). Many more breasts were, therefore, evaluated by trained plastic surgeons. Because anthropomorphic measurements differed so little between the 3 evaluator types, this discrepancy should not have affected the ideal measurements. In all, 47% of the subjects had prior breast surgery. Assuming a uniform distribution, 47% of evaluated breast pairs were subject to evaluator bias as it relates to surgical scar, nipple shape, color, and various postsurgical contour deformities. Unlike the layperson, the plastic surgeon may be able to recognize these issues and disregard them in the same way the authors have asked the surgeon evaluators to ignore breast size. Alternatively, surgeons may assign an artificially inflated aesthetic score to postsurgical patients on the basis of understanding the limitations and sequelae of surgery. Ideal measurements were derived from evaluators' responses to the electronic survey. Those images wherein vertical and horizontal nipple position and areolar size were deemed normal served as the basis for these calculations. In our view, it can not necessarily be presumed that normal vertical and horizontal nipple position can be translated into ideal. Aesthetic scores were only used to grade the nonanthropometric measurements of asymmetry and cleavage in the nonsurgeon evaluators. Interestingly, the authors included the evaluation of in surgeons' questionnaires only. The authors designated no ptosis as the aesthetic ideal and generated additional measurements on the basis of these data. Predictably, lower aesthetic scores were elicited with increasing grades of ptosis. In this way, the authors have preselected the particular evaluator group, biased by their training, to equate higher degrees of with a lesser aesthetic It would be interesting to explore this characteristic with nonsurgeon evaluators to assess whether their notions correlate with surgeon dogma. Reconstructive patients were noted to have the greatest concern about asymmetry. Inherent bias may exist in this evaluator group based on focused preoperative discussions surrounding the inevitability of some degree of postoperative asymmetry.

Operatives Management und Techniken der Mastektomie bei Frau-zu-Mann Transsexuellen

Subcutaneous mastectomy in female to male transsexuals is one first important step in gender adjustment. Beside proper surgical technique, operative management of mastectomy procedures is important to allow for an optimised process of gender transformation including all necessary individual operations. 126 female-to-male transsexuals were prospectively included in the observation period, all undergoing a step 1 operation of gender adjustment. The mastectomy procedure is conventionally embedded in an overall approach for gender transformation and was regularly combined with procedures like colpectomy, extension of the urethra as well as hysterectomy and ovariectomy. 4 different methods for mastectomy were introduced at our institution, depending on and adjusted to the breast volume, grade of breast ptosis, the breast size and envelope and skin elasticity. For patient evaluation a standardised survey was conducted using a semiquantitative score (1-4) for grading aesthetic results and nipple sensibility. Between 2006 and 2009 a total of 126 patients underwent a step 1 procedure of gender adjustment, 63 had mastectomy and 29 a revision procedure after external prior mastectomy. In 64/126 (50.8%) mastectomy was performed using a one-third edge cut, 30/126 (23.8%) were operated by a submammarian approach and pedicled nipples technique, in another 22/126 cases (17.5%) mastectomy was performed using circular tightening and 10/126 (7.9%) received freely transplanted nipples. For improving the aesthetic results, additional procedures were performed on 29 patients (46%). The patient survey revealed a high level of satisfaction with the aesthetic result, 42/50 (84%) of the patients rated results as good or very good. We newly introduced an operative concept of mastectomy being embedded and adjusted in an overall approach for gender adjustment (Munich Modular Operative Kit; MMOK). Using the presented individualised surgical techniques of mastectomy, all procedures were conducted in a very scar-saving manner, however, a higher rate of correction procedures was necessary to individually adjust skin shrinking and thereby optimising the prior aesthetic results. The new Munich Modular Operative Kit allows for gender reassignment including breast corrections usually using 4 operative steps.

A review of 100 consecutive secondary augmentation/mastopexies

Simultaneous breast augmentation and mastopexy has historically been a controversial topic, and it has been considered by some to be a difficult and unpredictable procedure. Secondary breast augmentation and mastopexy after previous breast surgery is rarely discussed in the literature, and little is known about the outcomes of these secondary procedures. The authors present the indications, surgical techniques, and outcomes in a series of 100 consecutive secondary simultaneous breast augmentation and mastopexy cases. One hundred consecutive patients who underwent secondary combined augmentation mammaplasty and mastopexy from 1992 to 2005 were retrospectively reviewed. The complications and revision rates in this group of patients were analyzed and compared with primary mastopexy alone, as well as with primary combined augmentation and mastopexy. Independent variables such as patient age, history of smoking, body mass index, type and size of implant, and type of mastopexy incision were analyzed for correlation with complication and revision rates. No major complications were noted in an average of 3.5 years follow-up (range 13 months to 13 years). Minor complications occurred in 13 patients, of whom 8 required revision surgery. The most common tissue-related complications were poor scarring (3%) and recurrent ptosis (3%). The most common implant-related complications were infection (3%) and capsular contracture (2%). In addition, 6 patients underwent reoperation for implant size exchange, and 1 patient underwent revision surgery to receive silicone implants. Patient age, history of smoking, body mass index, type and size of implant, type of mastopexy incision, type and number of previous breast surgeries, surgical time, concurrent non-breast operations, and preoperative ptosis grade were not statistically significant risks when correlated to the complication and revision rate. Simultaneous breast augmentation and mastopexy after previous breast surgery is a commonly performed procedure that is not adequately reported in the literature. Our study indicates that the procedure is safe and has complication and revision rates comparable to primary augmentation/mastopexy.

Sutureless levator plication by conjunctival route

The experiences of sutureless levator plication by conjunctival route surgery are described in 80 primary operations performed for all grades of congenital ptosis in the past 2 years. The surgical steps, postoperative care and postoperative complications are reviewed.

Sutureless levator plication by conjunctival route

The experiences of sutureless levator plication by conjunctival route surgery are described in 80 primary operations performed for all grades of congenital ptosis in the past 2 years. The surgical steps, postoperative care and postoperative complications are reviewed.

Resultados y complicaciones del politetrafluoroetileno expandido en la cirugía de ptosis palpebral por suspensión al frontal: Estudio de 59 casos

To evaluate the functional results and complications of the use of expanded polytetrafluoroethylene (ePTFE) in frontalis suspension surgery for the treatment of moderate-severe palpebral ptosis (> 3 mm) with poor or absent levator muscle function. Retrospective study of 59 frontalis suspension procedures performed between 1992 and 2003 on 38 patients with palpebral ptosis (21 bilateral). Seventeen (44.7%) cases were women and 21 (55.3%) men. The mean age was 51.7 S.D. 27.6 years (range, 2 to 87). The surgical techniques used were performed by a Wright fascia needle. The etiology, ptosis grade, levator function, Bell's phenomenon and frontalis compensation were studied. After a median follow-up time of 35.9 S.D. 18.5 months (range, 6 to 72), we observed that the functional results were good in 55 cases (93.2%). Infection with preseptal cellulitis appeared in 1 case (1.7%) and required removal of the material, and in 2 cases (3.4%) there were foreign body granulomas that were resolved by excision. Two cases (3.4%) had to be reoperated due to recurrence. The ePTFE, in our experience, is a good material with excellent functional results and relatively few complications in the surgical treatment of eyelid ptosis for frontalis suspension. Other synthetic materials or fascia lata may be used, but all carry the risk of potential infection, extrusion, granuloma formation or recurrence.

Surgical Design and Algorithm for Correction of Earlobe Ptosis and Pseudoptosis Deformity

A previously described classification system for earlobe ptosis and criterion for earlobe pseudoptosis deformity was based on height measurements of the two earlobe components: the free caudal segment and the attached cephalic segment. The "ideal" ear lobule free caudal segment was found to be between 1 and 5 mm (grade I ptosis), and the "ideal" attached cephalic segment was 15 mm or less. Earlobe pseudoptosis was defined by an attached cephalic segment measuring greater than 15 mm. Previous studies revealed an association between the elongated free caudal segment and increasing patient age and between the elongated attached cephalic segment and rhytidectomy. Sixteen fresh cadaver earlobes were used to design surgical patterns that would differentially reduce the free caudal segment, the attached cephalic segment, or both. A horizontal, medially based triangular excision pattern was designed. Triangular excisions limited to the attached cephalic segment resulted in 98 +/- 5 percent reduction of excision height from the attached cephalic segment but also resulted in an unexpected 32 +/- 2 percent augmentation of the excision height in the free caudal segment. Triangular excisions limited to the free caudal segment resulted in 88 +/- 4 percent reduction of the excision height from the free caudal segment and negligible reduction of 4 +/- 4 percent of excision height in the cephalic attached segment. An algorithm for correction of earlobe ptosis and pseudoptosis was subsequently derived and implemented in a clinical case. The authors propose that surgical treatment of patients with pseudoptosis be dependent on the ptosis grade. If the ptosis is grade I (1 to 5 mm), then excision of only the attached cephalic segment is recommended. If the ptosis is grade II or higher (more than 5 mm), then a combined attached cephalic and free caudal segment excision is recommended. In cases of isolated ptosis grade II or higher without pseudoptosis, then excision location of only the free caudal segment is recommended. The above simple algorithm and surgical designs will enable plastic surgeons to differentially correct earlobe ptosis and pseudoptosis.

The Limited Scar Mastopexy: Current Concepts and Approaches to Correct Breast Ptosis

The literature on short scar mastopexy was reviewed, with a focus on the different techniques. Currently four techniques have been described: the periareolar, the vertical, the inverted-T, and the L-shaped scar. The different techniques were evaluated with regard to patient selection, operative techniques, scar length, and complications. A large number of techniques have been published for minimal ptosis, whereas for significant ptosis, the number of surgical options is limited. It is evident that limited scar techniques can be applied to all grades of ptosis, but there is no one technique that can satisfactorily correct all degrees of ptosis. Plastic surgeons should weigh the advantages and limitations of each technique to correctly address breast ptosis. This article reviews an algorithmic approach to correct all degrees of ptosis with mastopexy.

One-Stage Augmentation Combined with Mastopexy: Aesthetic Results and Patient Satisfaction

Since the original descriptions by Gonzales-Ulloa in 1960 and Regnault in 1966, breast augmentation in combination with mastopexy has remained a difficult, and often polarizing, topic in plastic surgery, not only because of its results but also because of its litany of potential complications. Over the past few years, there has been an increase in the discussion of one-stage augmentation combined with mastopexy throughout the literature. However, a critical analysis of the aesthetic results, as well as patient satisfaction with the procedure, continues to be absent. Because there have not been any reported studies on the aesthetic results or patient satisfaction with augmentation and mastopexy, we undertook this retrospective review in an attempt answer a fundamental question: is one-stage breast augmentation combined with mastopexy aesthetically and functionally worthwhile for both the physician and patient? All 34 patients reviewed for this retrospective study underwent bilateral, one-stage breast augmentation and mastopexy between April 1996 and December 2002. Patient charts were reviewed for a number of parameters including previous breast surgery, degree of preoperative ptosis, type of mastopexy used, size and type of implants placed, implant position, postoperative complications, and any revision surgeries performed. Patient photographs were evaluated by observers blinded to the study, and patients were asked to complete a satisfaction questionnaire. Ptosis was graded according to the Regnault classification. As a result, 14 women had grade 1 ptosis (41%), fourteen had grade 2 ptosis (41%), one had grade 3 ptosis (3%), two had pseudoptosis (6%), and two had tuberous breasts (6%). The grade of ptosis in one patient was not defined. The patient complication rate was 8.8% (3 patients). For the aesthetic rating scale, preoperative and postoperative photographs taken after more than 1 year were evaluated. On the scale of 1 (poor) to 4 (excellent), overall ptosis correction was rated as 3.4, asymmetry correction as 3.4, postoperative breast symmetry as 3.2, scar quality as 3.3, breast shape as 3.1, nipple/areola size as 2.9, and overall result as 3. Only 13 of the 34 patients were available for completion of the satisfaction survey. Evaluation of the 13 patient satisfaction surveys showed that, on the average, the patients were satisfied with the various aspects of their surgery. The average overall result and surgical goals both were 3.1. However, 54% of the patients (n = 7) desired revision surgery for various reasons, the most common being a desire for more breast lift. A review of the patients and results, brought a number of issues to light. First, aesthetic results for augmentation and mastopexy truly depend on a number of different factors that must work in harmony to yield an excellent result. Second, what is aesthetically pleasing to the surgeon may not be pleasing to the patient, and vice versa. Third, although the patient aesthetic results were good, they were not consistently rated as excellent, nor were the patients totally satisfied with their outcomes. This perhaps reflects the more complex nature of both the patient's problems and the surgical procedure itself. Finally, although the overall results of one-stage breast augmentation and mastopexy are good, and the patients generally are satisfied, this study raises the question whether staging the surgery by performing the mastopexy first may not yield significantly better results than the combined simultaneous procedure.

Breast reconstruction by expansion and advancement of the upper abdominal flap.

Inspired by successful reconstruction obtained using the Lewis-Ryan lower thoracic advancement flap to rebuild missing breast, we have adapted that extremely simple technique to prior serial expansions, in order to create more natural mounds, better defined submammary folds, and when possible, some grade of ptosis, without additional, new scarring. The procedure is introduced and compared to other such flaps as the TRAM and the latissimus dorsii. In our series, 30 patients were evaluated according to the quality of the final results, and the most frequent complication are pointed out and discussed.