Madeleine Lejour

Vertical mammaplasty and liposuction of the breast

Since 1989, I have used vertical mammaplasty without a submammary scar for all breast reductions. This technique uses adjustable markings, an upper pedicle for the areola, and a central breast reduction with limited skin undermining. The shape of the breast is created by suturing the gland and does not rely on the skin. A personal series of 100 consecutive patients (192 breasts) operated on from 1990 through 1992 is reviewed. Mastopexy was performed in 39 breasts. Among the 153 breasts that required reduction, liposuction was attempted as a complementary procedure before the surgical reduction in the 120 fattest breasts. Between 100 and 1000 cc of fat (mean 300 cc) could be suctioned in 86 breasts. This figure represents 50 percent of the large breasts in patients under 50 years of age and 100 percent of the breasts in patients older than 50 years. In these cases, liposuction made modeling of the gland easier and produced breasts with more useful and stable components. When liposuction was performed, surgical resection was adjusted to obtain the desired breast volume. The amount excised ranged from 120 to 1600 gm per breast (mean 480 gm). There were few complications, none of which required early reoperation. These complications were related to the weight of the breasts and not to the patients obesity or to the liposuction procedure. In 10 percent of the patients, mostly those with very large and ptotic breasts, some skin redundancy was excised at the lower extremity of the scar after several months to improve the final result. This series proves that vertical mammaplasty can be used in all cases of breast reduction, producing consistently good, stable results with limited scars. The adjunctive use of liposuction in fatty breasts can be considered safe and efficient.

Abdominal wall function after rectus abdominis transfer

The abdominal wall function of 57 patients who have undergone TRAM flap breast reconstructions using the whole rectus muscle, on one side (33 patients) or both (24 patients), was evaluated 6 months to 2 years after surgery. The defect was repaired with a Teflon mesh buried in the reclus sheath. There was a perfect tolerance to the mesh, and no hernia or bulging of the abdominal wall developed. Patients had less back pain after (10 patients) than before (18 patients) the operation and found their sit-up and sport possibilities about the same as before. Detailed assessment of the abdominal muscles by the physiotherapist showed, however, a decreased function, more evident in bilateral cases. CT scans demonstrated a medialization of the lateral muscles, leaving only a small medial portion of the abdominal wall devoid of muscles. On the whole, no problem of clinical significance was encountered, and patients showed a high degree of satisfaction with the operation.

vertical Mammaplasty: Update and Appraisal of Late Results

Vertical mammaplasty was evaluated after 10 years of experience and the study of 250 personal consecutive cases, and a few minor technical modifications are presented. In the beginning, the main advantage of the technique seemed to be the reduced amount of scarring, as this technique avoids submammary scars. With more experience, the major advantages seem to be its adaptability to breasts of various sizes and shapes and its good, consistent, and stable results. Liposuction is useful and reliable, but it cannot be applied to all fatty breasts because fat is sometimes intimately mixed with parenchyma and cannot be reached by a blunt cannula. Vertical mammaplasty raises many questions among surgeons. The most frequent were collected and answered in this report.

Innervation of the rectus abdominis muscle: Implications for rectus flaps

The usefulness of leaving lateral strips of the rectus abdominis muscle in place during a transverse rectus abdominis musculocutaneous (TRAM) flap procedure is questioned. Since textbooks do not agree on the course of the intercostal nerves in the rectus fascia and no precise description is given of the exact site of penetration of the nerves in the rectus muscle, six fresh cadavers were dissected. It has been observed that the nerves enter the deep face of the muscle in its middle portion. Lateral parts of the muscle are consequently denervated during a transverse rectus abdominis musculocutaneous flap, which preserves them. This has been confirmed by CT scan of the abdominal wall in 10 patients 2 to 37 months after a transverse rectus abdominis musculocutaneous flap. In these patients, a progressive fibrosis and disappearance of the remaining muscle could be demonstrated. It is concluded that a partial taking of the rectus abdominis muscle does not preserve its muscular function.

Late results and current indications of latissimus dorsi breast reconstructions

One hundred and fifty latissimus dorsi flaps were used in 145 patients out of a series of 483 breast reconstructions performed from 1977 to 1988. There were few immediate complications and a durable, good cosmetic result was obtained in two-thirds of the 103 cases reviewed after at least one year. The main reasons for dissatisfaction with long-term results were capsular contracture (grades III and IV) and upper displacement of the implant. The rate of these late complications was 30%, the same as found in the simpler subpectoral reconstruction. However, prostheses with a thick outer envelope induced only 10% of severe capsular contracture. Reconstructions with autologous tissue are currently replacing latissimus dorsi flap reconstructions unless local or general conditions contraindicate such major surgery or when the patient lacks motivation.

Incidence of calcifications in the breast after surgical reduction and liposuction.

Liposuction of the breast in combination with vertical mammaplasty was applied to 250 breasts among 386 reductions of large breasts performed in 2 years (1989 to 1991). To evaluate the possible damage to the breast caused by this combined procedure, especially in terms of the occurrence of the postoperative development of calcifications, a comparative study of preoperative and postoperative mammograms was undertaken in 60 randomly selected cases (120 breasts), 34 with and 26 without liposuction. Altogether, 13 calcifications (11 percent) were discovered during the 6- to 30-month follow-up, representing the lowest rate reported in the literature. Deep intraparenchymal calcifications were more frequent after liposuction; most (5 of 7) were macrocalcifications. None could be confused with malignant calcifications because they were more scattered, more regular, and less numerous. Attempts to evaluate the fat content of breasts via preoperative mammography failed to prove this examination a useful way to predict the viability of breast liposuction.

Evaluation of fat in breast tissue removed by vertical mammaplasty.

&NA; Breast liposuction, performed immediately prior to surgical reduction, has proven to be an efficient adjuvant method to reduce large breasts, even in young patients. Experience has shown, however, that liposuction is difficult or impossible in breasts in which fat is intimately mixed with glandular tissue. Clinical examination gives no information about the breast content. In order to evaluate the fat content of the breast, 33 unselected specimens removed during breast reductions (20 with liposuction and 13 without liposuction) were subjected to melting in a microwave oven. The fat separated from the residue could be weighed. This confirmed that pure glandular breasts are uncommon and that breast fat varies largely from one patient to another, with extremes of 2 and 78 percent and a mean value of 48 percent. Breast fat increases with age, with the body mass, and with the total volume of the breast. Clinical implications of these new data deserve investigation.

Anatomy of the orbicularis oris muscle in cleft lip

The anatomy of the orbicularis oris muscle was studied using histological sections of 18 operative specimens of unilateral cleft lip (14 incomplete and 4 complete). In incomplete clefts the intrinsic part of the orbicularis, located in the vermilion, is simply interrupted without distortion. The extrinsic part, lying higher in the lip, crosses the cleft but is distorted vertically according to the degree of the nasal deformity. In complete clefts the intrinsic bundle ends in the submucosa of the vermilion as in incomplete clefts. The extrinsic bundle is deviated towards the ala nasi on the lateral side. On the medial side, the fibres are rarer and more horizontal. Conclusions are drawn regarding reorientation of the muscle fibres during cheiloplasty.

Treatment of palatal fistula by expansion

Treatment of a large anterior fistula of the hard palate remains a problem. A new approach is presented by expansion of the palatal mucosa by custom-made implants, allowing closure in two layers without tension or extensive undermining.

Early one-stage repair of complete unilateral cleft lip and palate.

Background: The purpose of this prospective study was to evaluate craniofacial morphology in children with complete unilateral cleft lip and palate treated at the Brussels cleft center after a 1-stage complete closure at 3 months and compare the results with a series of children operated on at 3 and 6 months of age according to the Malek surgical protocol. Methods: A series of 72 consecutive patients who were operated on for nonsyndromic complete unilateral cleft lip and palate were included in this study at approximately the age of 10 years. Thirty-four were treated according to the Malek surgical treatment protocol: the soft palate was closed at a mean (SD) age of 3.04 (0.20) months, followed by simultaneous repair of the lip and hard palate at 6.15 (0.67) months. Thirty-eight underwent 1-stage all-in-one (AIO) closure of the lip and hard and soft palates at 2.98 (0.16) months. Craniofacial morphology was evaluated by means of a digital cephalometric analysis. Cephalometric data were compared with a noncleft control group (n = 40) matched according to age. The same 2 series of children were followed up until 15 years of age, and the results were again compared. Results: Statistical analysis (analysis of variance with post hoc Tukey test) showed in both groups who were operated on a decreased anteroposterior growth compared with the children without cleft at 10 years but the AIO group only was not different from the group without cleft. The maxillary (MxPI/SN) plane was significantly (P = 0.002) increased in the Malek cleft group compared with the AIO group with cleft. At 15 years of age, a difference was not observed anymore between the 2 groups for the anteroposterior growth or for the maxillary plane inclination. Conclusions: One-stage AIO closure based on the Malek surgical principles provided good anteroposterior midfacial morphology and resulted in less opening of the maxillary plane to the anterior cranial base.