Andreas Foustanos

A double-flap technique: an alternative mastopexy approach.

If we review the history of mammaplasty, we see that several techniques have been described. Although the subsequent reduction mammaplasties were probably performed by Dieffenbach (1848), Morestin (1909), and Villandre (1911), the first publication was made by Lexer (1921) describing a technique with nipple-areola complex transposition using an inverted T scar.1–4 The superiorly based dermal pedicle, the vertical bipedicle dermal flap, the inferior pyramidal free nipple graft, the concentric mastopexy techniques, and Benelli modifications of the old “donut” mastopexy are some of the previously described techniques.5–11 Pitanguy12 described the inverted-T incision with a superior pedicle carrying the areola. Strombeck13 used a horizontal bipedicle cutaneous flap; McKissock14 described a vertical bipedicle flap. Courtiss and Goldwyn15 used an inferior pedicle. Lassus,16 Lejour,17 Peixoto,18 Hall-Findlay,19 Skoog,20 Qiao et al.,21 and Hinderer22 described other techniques. Goes23 used a large sheet of mesh placed over the entire upper pole. Flowers and Smith24 described the “flip-flap” mastopexy technique. Hammond described the short scar periareolar inferior pedicle reduction mammaplasty.25 Ali Eed26 described a technique creating a cone in which the nipple-areola complex is carried on a subcutaneous inferior pedicle. Some surgeons proposed the L-shaped or Jshaped incision.27–29 De Araujo Cerqueira30 described breast fixation with a dermoglandular upper pedicle flap under the pectoralis muscle. Marchac and Olarte31 introduced the concept of upper glandular plication and suspension to the pectoralis fascia. Ribeiro32 mobilized a chest wall–based flap into the upper pole. Daniel33 suggested the passage of the flap under an elevated loop of pectoral muscle. Regardless of the degree of ptosis, the theme of a mastopexy is to achieve long-term maintenance of upper pole volume, to contour the gland, to reposition the nipple-areola complex preserving its vascular supply, and to resect the redundant skin. A reasonable solution to upper pole deficiency is to relocate and secure tissue from the caudal breast into the upper chest. Our experience showed us that there is no one perfect technique. It is important for the plastic surgeon to improve the technique that he or she uses. Our goal of achieving an ideal breast through mastopexy led us to a combination of superior and inferior breast flap approach. It is a modification of Pitanguy’s mammaplasty technique of the superior pole. The concept of internal suspension to support the breast is not new.36–39 However, the advantages of our approach are as follows: it fills out the deficient upper breast, it maintains the vascular supply to the breast tissue and the nipple-areola complex, it places the nipple-areola complex in an acceptable position, it preserves normal sensation, it allows a more comfortable closure, and it avoids exaggerated scar tension. It is a safe and versatile technique suitable for all degrees of breast ptosis. It produces excellent aesthetic and long-lasting results, and it is an easy procedure to learn.

Surgical Reconstruction of Tuberous Breasts

Tuberous breast deformity is a rare entity affecting young women bilaterally or unilaterally. It requires surgical correction, depending on the severity of the clinical expression, because of its aesthetic appearance. Since the presentation of the malformation by Rees and Aston in 1976, many surgical procedures have been developed, but the deformity still is one of the most challenging congenital breast anomalies. Between September 1999 and September 2005, eight patients with tuberous breast deformity underwent surgery in our department. A two-stage approach was used to manage 14 tuberous breasts. We used a combination of anatomic textured tissue expanders with magnetic injection sites and silicone gel implants. Other reconstructive procedures such as mastopexy, breast reduction, and areolar reduction can be considered. Our long-term results, with a maximum follow-up of 6 years, were satisfying. They have been uniformly good and compare favorably with those presented in the literature when the use of other methods. This two-stage approach is a relatively simple, safe, and technically easy procedure that is easy to learn. The results achieved with this approach seem to be reliable and gratifying.

An alternative fixation technique for the endoscopic brow lift.

Background:Endoscopic brow lift has become widely accepted as a procedure for restoring a youthful brow, since only 3 hardly noticeable incisions of the scalp are needed for this subperiosteal dissection and final repositioning of the brow. It has become an acceptable technique, an alternative to the conventional technique or transcoronal browpexy. One of the controversial points is the fixation of the flap in the elevated position. Method:Endoscopic brow lift allows separation and repositioning of the periosteum of the orbital rims and zygomaxilla. In a 6-year period from September 1999, 300 patients underwent endoscopic brow lift using our fixation approach, which was accomplished with an absorbable suture subperiosteally. Results:Satisfactory forehead rejuvenation was obtained in all patients, with correct eyebrow movement. Conclusions:Long-term results of 6 years confirm the strength and durability of this fixation approach. We consider this approach to be a simple, secure, and reliable forehead fixation method, an alternative to other fixation methods, that allows satisfactory and long-lasting cosmetic results.

Surgical approach for nevoid hyperkeratosis of the areola.

Nevoid hyperkeratosis of the breast is a rare condition affecting the nipple, the areola or both. It appears in both sexes and it can by lateral or unilateral. It can also accompany other skin diseases or systemic conditions including malignancies. Treatment may not be easy due to aesthetic consequences but surgery seems to be the most preferable therapeutic option. We report such a case successfully managed by surgical intervention.

Lateral Brow Lift: A Multi-Point Suture Fixation Technique

Background Descent of the lateral aspect of the brow is one of the earliest signs of aging. The purpose of this study was to describe an open surgical technique for lateral brow lifts, with the goal of achieving reliable, predictable, and long-lasting results. Methods An incision was made behind and parallel to the temporal hairline, and then extended deeper through the temporoparietal fascia to the level of the deep temporal fascia. Dissection was continued anteriorly on the surface of the deep temporal fascia and subperiosteally beyond the temporal crest, to the level of the superolateral orbital rim. Fixation of the lateral brow and tightening of the orbicularis oculi muscle was achieved with the placement of sutures that secured the tissue directly to the galea aponeurotica on the lateral aspect of the incision. An additional fixation was made between the temporoparietal fascia and the deep temporal fascia, as well as between the temporoparietal fascia and the galea aponeurotica. The excess skin in the temporal area was excised and the incision was closed. Results A total of 519 patients were included in the study. Satisfactory lateral brow elevation was obtained in most of the patients (94.41%). The following complications were observed: total relapse (n=8), partial relapse (n=21), neurapraxia of the frontal branch of the facial nerve (n=5), and limited alopecia in the temporal incision (n=9). Conclusions We consider this approach to be a safe and effective procedure, with long-lasting results.