Eugene H. Courtiss

Reduction mammaplasty by the inferior pedicle technique. An alternative to free nipple and areola grafting for severe macromastia or extreme ptosis.

Patients with massive macromastia, or severe ptosis, should be candidates for a reduction mammaplasty by the inferior pedicle transposition technique, instead of by free nipple and areola grafting. With the inferior pedicle technique the blood supply to the nipple and areola remains generous, coming from the entire width of the inframammary fold. By using a keyhole skin flap pattern, a conical breast shape is achieved when the medial and lateral skin flaps are brought together as a skin brassiere. The methods seems safe and simple, and the results have been satisfactory. An unexpected benefit has been the excellent postoperative sensation of the nipple, areola, and the skin of the breasts.

Breast sensation before and after plastic surgery.

Patients undergoing various plastic surgical procedures on their breasts were studied before and after operations with respect to sensation from crude touch, light pressure, and pain. The more extensive the operation on the breast (the more skin and breast tissue removed) the greater the postoperative decrease in sensation. Reduction mammaplasty and subcutaneous mastectomy were associated with decreased sensation in a significant number of patients. An unexpected finding was that patients having augmentation mammaplasty by either the inframammary or areola route showed a significant decrease in sensation to the nipple and apeola. At two years, 15 percent of the patients still had impaired sensory perception, although crude touch and light pressure appreciation had returned. Many of these patients had normal erectility with normal, and even enhanced, sensuality.

The fate of breast implants with infections around them.

In a retrospective study of 41 infected breasts following the insertion of implants, a high incidence of postoperative hematoma was noted. When infection occurred, cultures usually demonstrated the causative organism to be Staphylococcus aureus. Treatment by conservative drainage and vigorous antibiotics was generally successful in salvaging those implants which had been inserted through an areolar incision for simple augmentation, or under the pectoralis muscle (or a dermal pedicle) after a subcutaneous mastectomy. Those patients whose augmentations had been done through an inframammary incision, or whose implant after a subcutaneous mastectomy was under the skin flap, had a statistically higher incidence of implant loss. Most breasts will salvaged implants became firm.

Gynecomastia: analysis of 159 patients and current recommendations for treatment.

Gynecomastia has been treated surgically in 159 patients during the past 22½ years. Prior to 1980, all patients had traditional excision, which was followed by a high incidence of complications and undesired sequelae, not the least of which was that the results of this aesthetic operation were often unaesthetic. Since 1980, when suction lipectomy became the cornerstone of treatment, the results have been much better. As a result, current recommendations for treatment are as follows: If the gynecomastia is entirely due to fat, suction lipectomy alone is sufficient treatment. However, since suction will not remove breast parenchyma, those patients whose gynecomastia is due to parenchymal hypertrophy also require local excision of the parenchyma. Skin excision is rarely, if ever, necessary.

Suction mammaplasty: the use of suction lipectomy to reduce large breasts.

In 1989, when I began performing breast liposuction, suction-assisted lipectomy had evolved into an important plastic surgery operation, becoming the most frequently performed aesthetic surgery procedure. As surgeons continued to seek alternatives to large incisions, the plastic surgery climate reflected the popularity of suction-assisted lipectomy, incorporating it as both a primary procedure (sole technique) and an adjunct to many operations. My first experience using liposuction alone as a method of breast reduction was with a teenage girl who had breast asymmetry caused by an arteriovenous malformation in one breast. I was able to successfully achieve symmetry, avoiding any additional disfigurement or scars on the unaffected breast by reducing its size with liposuction. Shortly thereafter, during a discussion with Eugene H. Courtiss, we realized that we had reached a similar conclusion and that liposuction could be safely applied to female breast reduction surgery as the sole method of treatment. The indications for the technique that we described1 were for patients with a well-located nipple-areola complex and in whom the enlargement was primarily the result of fibrofatty tissue. A wetting solution was injected, and liposuction was used according to principles then established for the rest of the body. Systemic anesthesia was administered by an anesthesiologist. Subsequently, we collaborated on a series of patients who underwent this procedure and studied the histology of our specimens and mammogram results. That series included a select group of patients with breast hypertrophy or asymmetry, either congenital or after conventional breast reduction surgery with an inverted “T” scar. We found that in the appropriate patient, suction mammaplasty was a feasible alternative, offering several advantages including smaller scars, avoidance of pedicle and flap dissection, minimal disturbance of supporting dermal or parenchymal structures, an undisturbed blood supply, preservation of sensation, ease of matching symmetry, and a rapid recovery with a high degree of patient acceptance.1

Large-volume suction lipectomy: an analysis of 108 patients.

Suction lipectomy was initially advocated for the treatment of localized collections of fat and for the removal of less than 1500 ml of material. However, many patients wished to have multiple areas treated or had diffuse collections of fat. In such instances, the removal of over 1500 ml of material and circumferential lipectomy are necessary to provide optimal aesthetic results. However, when over 1500 ml of material is removed, anesthetic requirements, fluid replacement, and treatment of blood loss become important if the operation is to be performed safely. We have treated 108 patients who had over 1500 ml of material removed. Eight-eight percent of the patients were female; 12 percent were male. Using the body-mass index, 3 percent of patients were underweight, 70 percent were normal weight, and 27 percent were overweight. Fifty-five patients (51 percent) had 1500 to 2499 ml of material removed, 26 patients (24 percent) had 2500 to 3499 ml removed, 16 patients (15 percent) had 3500 to 4499 ml removed, and 11 patients (10 percent) had over 4500 ml removed. All patients were treated in the hospital; 44 percent were admitted after surgery. A total of 227 units of autologous and 2 units of homologous blood were transfused. As measured by a computerized monitor, the average amount of blood in the material removed from thighs was 30 percent; from abdomens, the blood loss was 45 percent. The aesthetic results were generally excellent. No complications were encountered. A few patients developed undesired sequelae, the most common of which was seroma formation, which occurred in 19 percent of those who had suction of abdominal-wall fat. We believe that large-volume suction lipectomy is safe and efficacious, provided attention is directed to such important aspects of patient care as anesthesia, fluid replacement, and blood loss.

The effects of nasal surgery on airflow.

Although nasal surgery for form and function is commonplace, knowledge of its effects on nasal airflow has been scanty. This study was undertaken to clarify that relationship. Prior to our investigation, we reviewed the pertinent physics of airflow. We noted that during laminar flow, the air in contact with the walls of a tube is motionless, whereas the air in the center moves. Moreover, according to Poiseuilles law, as the radius of the tube increases, the flow increases to the fourth power. Finally, tubes that are irregular, such as the nose, cause turbulent flow. When air passes through the nose, the flow is regulated by four values: the external valve, the internal valve (the angle formed by the junction of the upper lateral cartilages and the septal cartilages are the most important), the nasal turbinates, and the septum. Using anterior rhinomanometry, the nasal airflow was measured in 69 control subjects and in 329 patients who underwent a rhinoplasty, septoplasty, septectomy (submucous resection), or inferior turbinate resection, alone or in combination. We found that a rhinoplasty does not adversely affect the nasal airflow, and those patients who had procedures to improve their nasal airflow did indeed obtain it. These data were statistically significant. The data from our airflow studies frequently failed to correlate with patient assessments of their own nasal airways as well as our evaluations by rhinoscopy. Furthermore, rhinomanometric findings varied considerably even within the same testing session. At present, on the basis of our investigations, we cannot recommend rhinomanometry with enthusiasm because of its questionable reliability and validity.

Temporalis fascia grafts in open secondary rhinoplasty.

Parchment thin skin is a common problem associated with secondary rhinoplasty. When such skin is present, the underlying osseocartilaginous skeleton often becomes visible. Although many techniques have been used to treat the condition, we have found that an onlay graft of temporalis fascia is a most satisfactory method to cover the underlying osseocartilaginous framework or cartilage grafts. Temporalis fascia grafts have been advocated for this purpose in closed rhinoplasty; however, precise placement of the graft is difficult because the graft rolls. On the other hand, when used in open rhinoplasty, the graft may be placed accurately and secured under direct vision. This paper presents our experience with temporalis fascia grafts in open secondary rhinoplasties. Six female patients ages 31 to 57 underwent open secondary rhinoplasty. Five patients also had autologous cartilage grafts. Our average follow-up was 24 months; the minimum was 1 year, and the longest 7 years. All patients had excellent dorsal contours and osseocartilaginous irregularities were not observed. One patient developed a culture-proven nasal infection that responded successfully to antibiotics without removal of the fascia or cartilage graft, a result unlikely to occur when alloplastic materials are used. Biopsy of the temporalis fascia and cartilage grafts was obtained in one patient 12 months after placement. Microscopic examination confirms the long term viability of both grafted tissues, inasmuch as the temporalis fascia was vascularized and normal chondrocytes were present in the cartilage grafts. In summary, we have found that temporalis fascia grafts are a very satisfactory method for managing thin skin in open secondary rhinoplasty.

Suction lipectomy: a retrospective analysis of 100 patients.

Suction lipectomy has been used to treat localized collections of fat in 100 patients. Best results were obtained in patients with good skin tone and near normal weight. Good candidates achieved good results; however, lesser candidates also achieved improvement. The technical details have been reviewed, and particular note has been taken of the difficulty of assessing contour during the operation. This is suggested to be the cause of the most frequent undesired sequelae, postoperative contour irregularities.

Experience with 326 inflatable breast implants

Inflatable breast implants, which have been available for 27 years, have been accepted with varying enthusiasm. Advocates suggest that they result in breasts that look and feel natural because they have a low incidence of capsular contracture. Others note the obvious: Anything that is inflated may deflate. The purposes of this report are to present our experience with inflatable breast implants and to focus on deflation. We examined the records of all our patients who underwent breast augmentation or reconstruction. The 173 patients who had 326 inflatable breast implants form the basis of this report. Eighty-four percent of the patients were treated for aesthetic reasons; 16 percent were for reconstruction after mastectomy. The longest follow-up was 14.5 years, and the shortest was 3 months. Our findings indicate that inflatable breast implants remain soft. Overall, 256 implants (78.5 percent) were Baker I, 39 (12.0 percent) were Baker II, 28 (8.6 percent) were Baker III, and 3 (0.9 percent) were Baker IV. Twenty (6.1 percent) of the 326 implants deflated. No patient whose implant deflated had a closed capsulotomy nor gave a history of a proximate athletic endeavor. Most deflations were associated with pain, not previously present, and over the next few days the patient noted that her breast became smaller. All deflations were explored surgically, usually within 1 week. At surgery, a white fold was noted usually where the leak in the implant occurred. It was easy to slide out the old implant and insert a new one. The shortest interval between the surgery and deflation was 3 months; the longest was 9 years and 9 months. Kaplan-Meier product limit survival analysis was performed. The cumulative percentage implant survival at 117 months was 67.3 percent; median survival was not reached over the period of this study. In conclusion, we believe that inflatable implants result in soft breasts (90 percent were Baker I or II) and that the deflation rate (6.1 percent) is acceptable. However, with the passage of time, the cumulative number of deflations increases. Should deflation occur, the patient is inconvenienced, but no dangerous medical problem occurs. (Plast. Reconstr. Surg. 93: 118, 1994.)