Nazareth Papazian

Preoperative Assessment Tool for the Planning of Inframammary Incision and Implant Profile in Breast Augmentation

AbstractWhen using the inframammary access incision for breast augmentation, careful planning is critical to allow the surgeon to set the inframammary fold (IMF) at the most optimal position, minimize scar visibility, and mitigate the main disadvantage of this approach. Current popular evaluation systems for breast augmentation include the High Five and Randquist systems and they base their calculations on inconsistent variables like skin stretch measurements. We propose a simple method that is not dependent on skin stretch measurements to properly determine implant size, profile, and position of the inframammary fold. Excluding digital scans and computer-based systems that are not universally available, the proposed simplified assessment tool was compared to the two most popular manual measuring tools (High Five and Randquist). Twenty-five female volunteers were included in the study. The projected IMF positions over the midsternal line for each measuring tool were recorded on each patient and the sternal notch (SN) to projected IMF distance SN–IMF1 (simplified evaluation system), SN–IMF2 (High Five System), and SN–IMF3 (Randquist system) were compared. The anticipated new IMF position is determined based on the vertical implant dimension and not on breast base width. For most subjects, the differences between the three evaluation systems were minimal. The proposed breast measurement tool constitutes a new, much simpler, and practical method that proved to be successful in our hands. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Erratum to: Simplified skin excision pattern for skin-sparing/reducing mastectomy and direct-to-implant single-stage immediate (DISSI) breast reconstruction

Background One-stage implant-based breast reconstruction with minimal scarring is a highly appealing option to most patients. In fact, expander/implant reconstruction accounts for nearly 70 % of all breast reconstructions. We present our experience with a simplified skin-preserving/reducing excision pattern in association with immediate breast reconstruction using permanent expander or prosthesis.

Tensioned reverse abdominoplasty for reconstruction of large post-mastectomy defects

1 American University of Beirut Medical Center, Beirut, Lebanon. Conflicts of interest: none. As opções reconstrutivas para defeitos da parede anterior do tórax podem ser desafiadoras especialmente quando o defeito é extenso e sujeito a radioterapia pré-operatória. Apresenta-se caso de paciente com carcinoma ductal invasivo de mama não tratado que realizou radioterapia e quimioterapia incompleta no pré-operatória. O exame patológico revelou carcinoma ductal invasivo de 11,5 cm, grau III, com invasão linfovascular e linfonodos axilares positivos (20/20). Após a mastectomia, defeitos estendidos seguido de longa excisão de pele mediram 25 x 20 cm, sendo esses cobertos imediatamente com retalhos em abdominoplastia reversa tensionada. Trata-se do primeiro caso relatado de excisão larga de mastectomia reconstruída exclusivamente com retalhos avançados em abdominoplastia reversa e alta tensão progressiva de pontos de adesão demostrando que nos pacientes selecionados, a pele abdominal pode ser avançada superiormente com segurança e facilidade para atingir a área superior do tórax e cobrir a área com defeito significante. ■ RESUMO

Perforator mapping and optimizing design of the lateral arm flap: Anatomy revisited and clinical experience

Background: The lateral arm flap remains an underused flap, especially as a free flap. In this article, the authors describe the perforator anatomy to optimize flap design and harvest. Methods: Perforator locations were mapped in 12 cadavers (24 arms), and a retrospective review was conducted of 51 patients undergoing lateral arm flap surgery. Results: One to three reliable perforators supply the lateral arm flap. Based on cadaveric dissections, from the deltoid insertion, the A, B, and C perforators were located at 7.2 ± 1.0 cm, 9.9 ± 1.2 cm, and 11.8 ± 0.8 cm, which was 0.44, 0.61, and 0.72 of the distance from the deltoid insertion, respectively. The average pedicle length was 7.0 ± 1.1 cm. The cadavers were entirely symmetric in the number and location of the perforators between the right and left arms. All 51 patients (24 male and 27 female patients) had at least one perforator with an average pedicle length of 7.0 ± 1.3 cm, an average arterial diameter of 1.7 ± 0.3 mm, and a vein diameter of 2.5 ± 0.5 mm. All but one flap was performed as a free flap for head and neck reconstruction, with one pedicled flap for shoulder reconstruction. The average flap size was 72.2 ± 37.1 cm2 (range, 21 to 165 cm2). The nondominant arm was used for all free flaps. There were no total or partial flap losses. Twenty-eight patients reported donor-site numbness, with one infection, one hematoma, and one wound dehiscence. Conclusion: The lateral arm flap can be harvested reliably based on well-defined perforators and anatomical landmarks with minimal donor-site morbidity and should be included among the techniques used by reconstructive microsurgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Overcoming limitations of short scar minimal access cranial suspension facelift for enhanced rejuvenation.

AbstractThe minimal access cranial suspension lift, a short-scar facelift, has been described to correct sagging and laxity of the lower and middle third of the face. It does not, however, fully address the neck or the lateral periorbital area frequently needing rejuvenation in most patients. Another shortcoming of the minimal access cranial suspension lift technique is visible scarring anterior to the temporal hairline that usually occurs despite the suggested surgical maneuvers consisting in zigzag beveled incisions. We describe modifications of the standard subcutaneous musculoaponeurotic system lift technique, increasing its indications for full-face and neck rejuvenation (excluding the forehead) and improving final aesthetic outcome.

Ulnar Collateral Ligament (UCL) Repair

Ulnar collateral ligament (UCL) rupture is often seen in patients practicing sports activities, particularly in ski falls. It usually occurs secondary to chronic metacarpophalangeal instability and degenerative osteoarthritis of the thumb. It is the result of repetitive stretching and abduction stresses of the ulnar collateral ligament and the adductor pollicis aponeurosis. Most UCL ruptures are distal. Pain at the phalangeal insertion of the UCL and joint swelling are the most common symptoms the patients with acute UCL rupture present with. To avoid the displacement of an associated undisplaced fracture, it is of utmost importance to the surgeon to obtain radiographs before applying any stress on the joint. Conservative nonoperative treatment with 4 weeks plaster immobilization of the fully extended joint is the treatment of choice for most partial or complete UCL ruptures provided that there is no interposition of the adductor pollicis aponeurosis between the extremities of the ligamentous fragments (Stener lesion), no displaced fracture, no spontaneous radiological palmar or lateral joint subluxation, no supination deformity, and no painful chronic laxity. If any of the abovementioned conditions is present, a surgical intervention is indicated.

Lateral Arm Flap

The lateral arm flap is a reliable flap with a constant moderate diameter size pedicle which length ranges from 4–8 cm according to the design of the flap. The flap is bound by the insertion of the deltoid muscle proximally and the lateral epicondyle distally. The lateral arm flap could be raised as a fascial, fasciocutaneous, or osteocutaneous flap with or without sensory innervation. It can be used as a direct, distant or a free flap to cover various regional defects of the upper extremity and distant defects especially the head and neck region with minimal donor site morbidity.

Medial Thigh Lift

One of the areas of greatest concern for both the surgeon and the massive weight loss (MWL) patient is the medial thigh, which remains a troublesome region for body contouring in patients with generalized lipodystrophy and skin flaccidity. Suction-assisted liposuction (SAL) of the medial thigh is effective in patients with lipodystrophy without skin laxity. However, SAL fails to remodel and tighten the inner thigh in cases of severe skin laxity especially if extending down to the level of the knee.

Gluteal Auto-augmentation

After massive weight loss, patients suffer deformities secondary to severe laxity of skin, subcutaneous tissues, and superficial fascial suspensory ligamentous systems in most areas of the body including the gluteal region. Sequelae of massive weight loss in the gluteal area are a combination of fat atrophy with volume loss and skin laxity with relaxation of the superficial fascial apron, all contributing to gluteal ptosis making the surgical attempt to restore the aesthetics of the buttocks a reconstructive challenge. Several surgical modalities have been described to enhance gluteal contour. Autologous tissue augmentation can be achieved by using adipo-fascial flaps from the lower back that are normally resected in circumferential lower body lift. Large volume autologous fat transfers as well as alloplastic implants also contribute to the restoration of gluteal aesthetics in massive weight loss patients. Additional refinement of the results can be achieved by posterior thigh lift and infragluteal diamond lift.

An original case of symmetric lipohypertrophy: case report and review of the literature

1 American University of Beirut Medical Center, Beirut, Lebonon. Conflicts of interest: none. Paciente do sexo feminino, saudável, meia-idade e com história prolongada de massas com crescimento lento localizadas bilateralmente e simetricamente nos membros superiores e inferiores, próximas às principais articulações. Exames de imagem e patológicos após excisão das massas revelaram massas constituídas por gordura subcutânea normal. Não houve evidências de lipomas bem-circunscritos. Na revisão de literatura, destacaramse diversos distúrbios lipo-hipertróficos, com possível apresentação simétrica. As características das afecções encontradas não eram, porém, totalmente concordantes com as características de nossa paciente. Embora não de modo absoluto, a doença que mais estreitamente se assemelhou ao caso foi lipodistrofia simétrica rara, conhecida como doença de Madelung. Dos 150 casos relatados, em apenas 3 foi descrito comprometimento dos membros inferiores, como ocorreu em nosso caso. Este relato apresenta descrição detalhada do caso, seu manejo e seguimento no pós-operatório. Os tipos distintos de lipodistrofias simétricas também são discutidos. ■ RESUMO