Breast Surgery Procedures Research Articles

Inferiorly Based Parenchymal Flap Mammaplasty

Breast reduction and mastopexy are among the most frequent procedures in aesthetic breast surgery. Many approaches have been described, and various types of dermaglandular pedicles for the nipple-areola complex have been used. The authors present a technique suitable for either mastopexy or breast reduction whereby the superior or superomedial pedicle supplying the nipple-areola complex is combined with an inferior dermaglandular flap to restore the upper pole fullness, thereby improving breast shape and projection. From January of 2008 to January of 2010, 83 patients underwent inferiorly based parenchymal flap mammaplasty. Patients' ages ranged from 23 to 65 years. The mean follow-up period was 27 months. The inferior breast tissue that is usually removed in a superior/superomedial pedicle technique is spared and shaped as a small implant and stitched to the pectoralis major muscle. The superior/superomedial pedicle is used for the nipple-areola complex. All the procedures were successful. No major complications were reported. All the patients were very satisfied with the shape, size, projection, and upper pole fullness of their breast postoperatively as reported by the questionnaire. Comparative evaluation test scores of a four-member jury were significantly higher regarding breast shape (p = 0.007), projection (p = 0.0041), and upper pole fullness (p = 0.0028). The inferiorly based parenchymal flap mammaplasty is a safe, versatile, and reproducible technique. It demonstrates ease of pedicle shaping and breast remodeling in patients undergoing mastopexy and breast reduction. Therapeutic, IV.

A new breast marker

Sir, The cookie cutter has for long been the standard instrument for marking the areola in breast surgery procedures. However, it is limited in its usage for marking the areola, and different cookie cutters are needed to vary the areola size. Further, planning the periareolar skin depithelisation or excision also needs an accurate marking using other means, if the final result must be aesthetically pleasing. I have designed a new ‘breast marker’ that incorporates different sizes in one instrument and obviates the need for different sizes of cookie cutters. In addition, this new breast marker helps to design the periareolar depithelisations and excisions accurately. The instrument is a flat circular plate 12 cm in diameter with circular slots cut out into the plate starting from 3, 3.5, 4, 5, 6, 7 cm and so on (Fig. 1a). The outer diameter is 12 cm. The innermost diameter of 2.5 cm helps to mark out small areola size as in a male, while 3, 3.5 or 4 cm should help to mark the areola in a female patient. The proposed breast marker should be placed on the breast with the nipple or nipple position centralized and the areola marked at 2.5, 3, 3.5 or 4 cm as needed (Fig. 1b). If a periareolar skin excision is planned during breast surgery, then the size of the excision is first determined on the breast manually, and then the actual marking is done by drawing in the slot on the breast marker at the correct measure (Fig. 1c). The breast

Breast Volumetry Using a Three-Dimensional Surface Assessment Technique

Breast volume is a relevant measure for the prevention and prediction of diseases and for aesthetic surgery. This study evaluated a new technique to determine breast volume and compared measures using a three-dimensional (3D) body surface scanner and magnetic resonance imaging (MRI) scans, with the latter used as the standard method. Both MRI scans and body surface 3D scans were obtained from 22 women. For each method, breast volumes were assessed. The MRI calculations of the breast volumes were performed by a specially trained radiologist using analysis software. A textured 3D image was generated by a calibrated digital texture camera after breast surface data acquisition. The volume assessment of the 3D photography was calculated using a software package after manual outlining of the breast and automated projection of a dorsal limit. Linear regression was used to predict the MRI volume assessment with the 3D image volume assessment. The mean breast volume according to MRI volumetry was 442.8ml on the left side and 471.8ml on the right side. The mean breast volume using a 3D body surface volume assessment method was 273.8ml (observer A) and 226.2ml (observer B) on the left side and 284.4ml (observer A) and 234.9ml (observer B) on the right side. The use of linear regression models showed R (2) values of 0.59-0.77. The mean time for MRI recording and volume assessment was 68.0±14.1min for both sides and 11.6±1.5min for 3D recording and volume assessment. The 3D surface-based volume measurements are feasible in terms of time and can predict the MRI breast volume with sufficient accuracy. This might facilitate the broad use of such an assessment technique in a large-scale epidemiologic study using breast volume as a study aim. Additionally, further development of volume assessments could help to implement this technique in breast surgery procedures.

Opening of Ambulatory Surgery Centers and Procedure Use in Elderly Patients

Ambulatory surgery centers (ASCs) potentially deliver care more efficiently than hospitals. However, ASC proliferation may increase discretionary surgery use because of financial incentives for the physicians who staff them. To explore this possibility, we measured the impact of the opening of an ASC in a health care market, as defined by the hospital service area (HSA), on rates of procedure use. With a 100% sample of outpatient surgery encounters, we measured annual rates of use for discretionary (cataract surgery, colonoscopy, and upper gastrointestinal [GI] tract endoscopy) and imperative (cancer-directed breast surgery) procedures among Medicare-eligible persons. Using a multiple time series research design, we compared the change in procedure use for HSAs where ASCs opened with that of HSAs where an ASC was never present. Florida HSAs. All patients 65 years or older undergoing outpatient surgery from January 1, 1998, through December 31, 2006. Main Outcome Measure Adjusted HSA-level rates of procedure use. In HSAs where an ASC opened, colonoscopy use increased by 1610 procedures per 100 000 per year (95% confidence interval, 736-2485; P < .001) and upper GI tract endoscopy use increased by 775 procedures per 100 000 per year (159-1391; P = .01). However, rates of cancer-directed breast surgery remained flat. Among HSAs where an ASC opened, the relative increases in colonoscopy and upper GI tract endoscopy use were approximately 117% and 93% higher, respectively, 4 years after the opening compared with HSAs without ASCs. The opening of an ASC within an HSA is associated with significant increases in discretionary surgery use.

Enhancing Pedicle Safety in Mastopexy and Breast Reduction Procedures: The Posteroinferomedial Pedicle, Retaining the Medial Vertical Ligament of Würinger

Nipple necrosis, a potential postoperative complication of breast surgery procedures, should be avoided. Because of the great variation in the blood supply to the nipple, it is advisable to include as many arteries in the pedicle as possible. According to the literature, the perforators of the internal thoracic artery are the most constant and reliable sources of blood to the nipple-areola complex. It is also supplied by the lateral thoracic artery and the anterior intercostal arteries. If two of the above-mentioned main vessel branches are included in the pedicle, the vascular supply to the breast will be more reliable. According to the anatomical studies of Würinger and van Deventer, we can safely include the dual blood supply to the nipple-areola complex. In the authors' technique, a pedicle is raised that includes the horizontal septum and the medial vertical ligament of the breast (i.e., inferior and superomedial pedicles), but with the breast tissue remaining attached to the pectoral fascia. The second, third, and fourth perforators of the internal thoracic artery are found in the medial vertical ligament, and the inferior mammary branches of the anterior intercostal arteries are in the horizontal septum. The authors have performed this technique in 106 consecutive patients (211 breasts) between 2001 and 2009. Good results regarding breast shape, nipple projection, and upper breast fullness were obtained. The posteroinferomedial pedicle technique is safe and versatile and can be used with a periareolar, vertical scar, or inverted-T skin approach. The technique is easy to perform and has a short learning curve.

A simple aid to wire localisation procedure in breast surgery: ‘covering the hook-wire with a needle

The hooked wire used for localising impalpable lesions in the breast is soft and malleable. Inadvertent cutting with diathermy or scissors1 and difficulty in locating its tip may be problematic during operation. To overcome this, we use a blunt 18-G needle to cover the wire. It prevents inadvertent cutting of the wire (Fig. 1), helps in locating wire tip accurately by moving the hub of the needle (Fig. 2) and minimises breast deformity as less tissue is removed due to better identification of the position of the lesion. In our experience, this is a useful tip for breast surgeons. Figure 1 Protecting needle prevents inadvertent cutting of wire. Figure 2 Position of wire tip can be assessed by moving the hub of the needle up, down or sideways.

Single Stage Augmentation Mastopexy

Mastopexy with augmentation is not an uncommon procedure in breast surgery. This combined procedure has been reported to result high rate of recurrent ptosis by several recent studies. The goal of this study is to introduce a novel technique that addresses the importance of 2 variables--breast position and inframammary fold location via autologous dermal graft, for an improved end results in augmentation mastopexy. Twenty-one patients operated over a period of 2 years from August 2005 through August 2007 were included in the study. The augmentation was performed first followed by adjusting the skin envelope and breast parenchyma to contour around the new breast volume. Augmentation/mastopexy with autologous dermal graft interpositioning, presented in this article, is a novel technique and the technique is described in detail. There were no major vital complications like death, major flap, or nipple necrosis. The most common complications seen were: inadequate circumvertical skin incision, inadequate transposition of nipple-areolar complex, overprojection of areola, and minor complications such as suture abscess. All complications were revised under local anesthesia. No recurrent ptosis was seen in any of the patients. Mean follow-up was 20.6 months (range, 14-36 months). Simultaneous augmentation mastopexy with autologous dermal graft interpositioning is a safe procedure. The dermal graft is easy to harvest. It is cost-effective. This technique ensures an improved breast appearance via securing the breast position and delineating the inframammary location. The very early results are promising but long-term results needed to be evaluated.

Postoperative Nipple-Areola Complex Monitoring: The “Trapdoor” Dressing

Postoperative monitoring of the nipple-areola complex is a common procedure in breast surgery [1]. Following reconstructive and aesthetic surgery a compressive and stable dressing may be used in supporting the new shape of the breast [2]. During the postoperative period the dressing should be easily removable to check the nipple-areola complex viability. Many custom-made dressings, with more than one sterile drape or gauze, are used in many centers but very few are discussed in the literature. We introduce a simple, fast, practical, and easily reproducible dressing for postoperative monitoring of the nipple-areola complex. A double layer of sterile gauze is opened and folded in two specular layers, defining an anterior and a posterior layer (Fig. 1a, b). The posterior layer is folded in two other specular layers (Fig. 1c). A hole is made by an ovalar or triangular cut in the posterior layer (Fig. 1d–f). The posterior layer is applied over the nipple-areola complex and fixed to the skin using sterile tape (Fig. 2a, b). Leaving the dressing intact, the anterior layer can be used as a ‘‘trapdoor’’ to visualize the nipple-areola complex (Fig. 2c, d). The ‘‘trapdoor’’ dressing is very comfortable for the patients and very practical for the health care providers because it avoids dressing change and allows nipple-areola monitoring without affecting the sterile field. The dressing saves time and money and is also very easy to remove in case of bleeding or nonsterile contamination.

Skin-sparing mastectomy

Skin-sparing mastectomy (SSM) is a new technique being used in a variety of clinical settings. This article reviews the published data on SSM to establish its current role in clinical practice. A Medline search was carried out using the key words 'skin-sparing mastectomy' to identify English-language articles published between 1990 and 2004 and further material referenced in these publications. SSM is most commonly used for surgical prophylaxis and to treat in situ and early invasive disease in patients who request immediate breast reconstruction. SSM and non-SSM result in similar surgical and oncological outcomes, but skin flap ischaemia is more common after SSM and is associated with a range of risk factors, including smoking. SSM has become an established procedure in breast surgery, but there is a lack of prospective data on which to make evidence-based decisions about its use in individual patients.

Surgical caseload in army general surgery programs: A 10-year retrospective

PURPOSE: Over the past decade, the Army Medical Department (AMEDD) has been affected by a military-wide drawdown. The volume and acuity of patients appears to be declining, raising questions regarding quantity and quality in Army surgical training programs. The purpose of this study is to examine the caseloads of Army general surgery programs compared with national averages, and to compare the board examination performance of Army residents with national pass rates. METHODS: The program directors of all 6 Army training programs were requested to submit resident caseloads and performance on qualifying and certifying examinations from 1990 to 2000. The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery (ABS) provided resident statistics summaries and board examination statistics, respectively, for the same period. Total caseloads, chief resident cases, performance in defined categories, and board pass rates of military residents were compared with national averages. RESULTS: Four of the 6 programs submitted the requested data. The average caseload for Army residents, both total and chief residents, has been lower than the national average over the past decade. Nationally, total case numbers have gradually increased while military changes have been variable. The number of chief resident cases has trended steadily downward in Army programs at a rate exceeding the national average. The volume of procedures in endoscopy, thoracic, and breast surgery in the Army generally exceeds those recorded outside of the military. Despite the decline in surgical cases in the military, the pass rates in both the certifying and qualifying examinations among Army graduates have been consistently higher than the national average. CONCLUSIONS: Residents who train in Army programs perform fewer operative cases than do their counterparts in civilian programs. The downward trend in the number of chief resident cases over the last 10 years is likely reflective of the changes in military medicine. Despite these trends, Army residency graduates continue to exceed national performance averages on the ABS qualifying and certifying examinations.

Ultrasound-assisted breast reduction and mastopexy

Background: The development of technology for ultrasound-assisted lipoplasty (UAL) offers the aesthetic surgeon a new tool for breast surgery procedures including breast reduction, breast lift, and the correction of mild- to medium-degree ptosis. Objective: The authors report on a series of 120 patients who underwent breast surgery with the use of UAL from 1995 through 2000. Methods: Preoperative screening, including mammography, was performed to evaluate breast tissue and determine whether patients were good candidates for surgery. Variants of Klein's tumescent solution were infiltrated, depending on the form of anesthesia administered. Stab incisions 2-cm long were made at the axillary line and 2 cm below the inframammary crease to allow entry of a 35-cm solid titanium probe. With use of a 50% power setting, ultrasound energy was applied from 10 to 15 minutes to up to 30 minutes to emulsify the fat. Ultrasound stimulation of the superficial layers of subcutaneous tissue was applied to promote retraction of the breast skin. Results: A mean of 500 mL of fat emulsion from each breast was obtained without major complications. Nipple elevation of up to 5 cm was possible if a large-volume reduction was performed in combination with ultrasound stimulation of the subcutaneous layer. Conclusions: The use of UAL to achieve breast reduction and mastopexy is both safe and effective for selected patients when performed by a surgeon experienced in the technique. ( Aesthetic Surg J 2001;21:493-506.)

Minimal Incision Breast Surgery

Dr. Slavin: Some of the most important recent advances in breast surgery have involved modification of the traditional incisions that we use for breast augmentation, mastopexy, augmentation combined with mastopexy, and moderate-size breast reductions. Nationally, we are witnessing an increased demand for these different minimal incision breast surgery procedures. The first patient is a 29-year-old woman who is seeking an enlargement from her current bra size of C to a D (Figure 1). Dr. Grotting, is she a good candidate for a breast augmentation, and how would you perform this? Figure 1 A 29-year-old woman seeking breast augmentation from her current bra size of C to a D. A , Frontal view. B and C , Lateral views, left and right breasts. Dr. Grotting: This patient's request reflects a rather common problem that I see. I believe many women are under the impression that adding a breast implant can completely correct an aesthetic shape problem. This is a patient who has an adequate volume of breast tissue that is consistent with her lower body habitus. However, to me, the problem is primarily one of breast shape. I would try to educate this patient about what a breast implant would do for her as opposed to a mastopexy and would encourage her to consider a mastopexy procedure alone rather than an augmentation mastopexy. Dr. Slavin: Dr. Goes, can you improve this patient's appearance with an enlargement alone or would you need to add a skin tightening procedure? Dr. Goes: The right breast is a little more ptotic and a bit bigger than the left breast. I agree with Dr. Grotting on the need to correct the ptosis and to improve the symmetry of both breasts. If the patient really wanted augmentation, I would perform it through a periareolar incision. Sumner A. Slavin, MD …

Prophylaxis against wound infection following herniorrhaphy or breast surgery.

The effect of perioperative antibiotic prophylaxis on definite wound infections was assessed for 3202 herniorrhaphies or selected breast surgery procedures. Patients were identified preoperatively and monitored for greater than or equal to 4 weeks. Thirty-four percent of patients (1077/3202) received prophylaxis at the discretion of the surgeon; 86 definite wound infections (2.7%) were identified. Prophylaxis recipients were at higher risk for infection, with a higher proportion of mastectomies, longer procedures, and other factors. Patients who received prophylaxis experienced 41% fewer definite wound infections (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.35-0.99; P = .04) and 65% fewer definite wound infections requiring parenteral antibiotic therapy (OR, 0.35; 95% CI, 0.15-0.88; P = .02) after adjustment for duration of surgery and type of procedure. Additional adjustment for age, body mass index, the presence of drains, diabetes, and exposure to corticosteroids did not change the magnitude of this effect meaningfully. The effect of prophylaxis was similar for all procedures studied. In the absence of formal guidelines, surgeons at these institutions administered prophylaxis preferentially to patients at highest risk.