Ruth Graf

Subfascial breast implant: a new procedure.

Breast augmentation techniques using the submuscular and subglandular planes to introduce the implant are well known and widely used procedures. The authors have been using the subfascial dissection plane, a new concept for breast augmentation. From October of 1998 to September of 2001, 263 patients underwent breast augmentation. In all cases, the implants were inserted into the subfascial plane. McGhan 410 anatomic biodimensional, cohesive gel implants (size, 155 to 310 g) were used. There are additional benefits using this technique; these include avoiding implant deformation or distortion (as seen in the retromuscular position), leaving additional soft tissue between the implant and the skin, and minimizing implant edge prominence (inherent to retroglandular placement). These technical details lead to fewer patient complaints. Morbidity is similar to that of other techniques.

Subfascial Endoscopic Transaxillary Augmentation Mammaplasty

Abstract. Video endoscopy for breast hypoplasia and glabellar frown lines has been used since 1996 at our private clinic. Breast augmentation with an S-shape incision for transaxillary access is utilized to introduce the implant, in a submuscular or subglandular and, recently (since October 1998), in a subfascial location. From August 1998 through January 1999, 62 patients underwent endoscopic surgeries; 49 were submuscular, 5 subglandular, and 8 subfascial. McGhan 410, anatomical biodimensional implants 155 to 235 g, were used. We observed three cases of complications, two of them malpositioning (rotation), needing reoperation, and one hematoma, treated with drainage. Patient satisfaction was high, especially regarding the axillary incision. There have been no capsular contractions to date.

Lipoabdominoplasty: Liposuction with Reduced Undermining and Traditional Abdominal Skin Flap Resection

Abdominoplasty surgery has spread universally, as both an aesthetic and a reconstructive procedure, and new techniques are appearing with the goal of minimizing ischemic complications of the flap and bettering body contour. The purpose of this article is to demonstrate that an abdominoplasty technique with limited undermining and preservation of the flap perforator vessels makes it possible to reduce the complication rate attributable to flap necrosis and seroma in abdominoplasty. Doppler flowmetry color study of the abdominal wall was performed before the surgical procedure and on postoperative day 15 after lipoabdominoplasty for a series of 20 patients to evaluate the blood supply of the abdominal wall. This study confirmed the preservation of perforator arteries in the periumbilicus area and right upper quadrant after abdominoplasty with liposuction and reduced undermining.

Reduction mammaplasty and mastopexy using the vertical scar and thoracic wall flap technique

Breast surgery has been greatly modified in the past few years as surgeons sought to shorten scars and improve and maintain of breast shape in the late postoperative period. Working with both the periareolar technique and vertical scar technique, it is possible to reduce scar length, avoiding the area below the inframammary crease by compensating skin excess around the areola. From January 2001 to July 2002, 53 patients underwent reduction mammaplasty and/or mastopexy using the vertical scar technique associated to a thoracic-based flap kept under a bipedicled flap of the pectoralis major muscle. The goal of this combination is to achieve a good aesthetic result: a reduced scar, minimal breast descent, and good upper pole fullness.

Breast Shape: A Technique for Better Upper Pole Fullness

Abstract. The authors offer a new technique that provides a better long-term upper pole fullness to the shape of the breasts following reduction mammoplasty, thus creating an overall more satisfactory aesthetic appearance for both breasts.

Poland’s Syndrome: Different Clinical Presentations and Surgical Reconstructions in 18 Cases

BackgroundThe literature reports many variations of Poland’s syndrome. This article describes 18 cases of Poland’s syndrome in different stages of treatment, with variable clinical presentations and reconstructive techniques.MethodsThis study evaluated 15 females and 3 males, ages 2 to 43 years, for breast deformity, nipple–areolar complex position, pectoralis muscle malformation, thoracic deformities, and the presence of brachysyndactyly. Surgical treatment was performed for 14 patients, individualized for each case.ResultsFor the women, the hypoplastic breast was treated with a latissimus dorsi muscular flap associated with silicone gel implant in five cases. Two other patients still are receiving tissue expansion for a future muscular and prosthetic reconstruction. Prosthetic implants alone were used on the affected side in four cases. The nipple–areolar complex was reconstructed for two patients. Seven women underwent contralateral breast surgery: reduction mammoplasty in three cases, mastopexy in two cases, and prosthetic implants in two cases. The only man who underwent surgery was treated with endoscopic rotation of the latissimus dorsi muscle flap.ConclusionsThis study demonstrated several breast reconstruction options for patients with Poland’s syndrome, reinforcing the importance of an individualized treatment to achieve complete and adequate rehabilitation.

Mastopexy After Massive Weight Loss: Extended Chest Wall–Based Flap Associated with a Loop of Pectoralis Muscle

Mammaplasty for patients who have experienced massive weight loss involves some concepts that differ from those that apply to mammaplasty for normal patients. Breast anatomic characteristics make this procedure a very challenging situation. The authors present their experience with a new mammaplasty technique using an extended thoracic wall flap associated with a loop of pectoralis. This procedure is a simple and reproducible method for patients with massive weight loss that results in a pleasing breast shape and long-lasting results.

Intraabdominal Pressure in Abdominoplasty Patients

Abdominal compartment syndrome is directly related to an increase in intraabdominal pressure (IAP), which can lead in severe cases to serious clinical consequences. Routine measurement of IAP in specific cases has been advocated by some surgical specialties. However, few studies in plastic surgery have focused on the use of IAP. The authors review the literature and describe a method of IAP analysis used for 12 patients who underwent abdominoplasty.

Facial rejuvenation with SMASectomy and FAME using vertical vectors.

The quest for better results in the midface after a face lift has led to the repositioning of a structure called the malar fat pad. Finger-assisted malar elevation (FAME) consists of detaching the malar fat pad from the underlying SMAS, which allows for the elevation of this structure. Two hundred five patients (189 females and 16 males) from January 2002 to August 2007 underwent a facial rejuvenation procedure comprising short-scar rhytidoplasty, SMASectomy, and FAME, with or without a simultaneous endobrow, blepharoplasty, and lipofilling. The midface fixation technique consisted of a stitch from the malar fat pad and SMAS flap to the periosteum at the zygomatic arch which was performed in every case. Elevation of the midface and improvement of the nasolabial fold and the mandible contour were obtained in all cases. Facial aging should be evaluated as a global process instead of a segmented one. Aging occurs in every structure of the face in different ways, depending on the vector of descent, thereby treatment must be individualized. We have observed improvement of the midface when using the FAME procedure in a rhytidoplasty with SMASectomy with deep fixation.

Implications of Transaxillary Breast Augmentation: Lifetime Probability for the Development of Breast Cancer and Sentinel Node Mapping Interference

The article entitled ‘‘Implications of Transaxillary Breast Augmentation: Lifetime Probability for the Development of Breast Cancer and Sentinel Node Mapping Interference’’ by Arturo Prado and Patricio Leniz, from Division of Plastic Surgery, School of Medicine, Clinical Hospital, JJ Aguirre University of Chile is an updated article and deserves some consideration. Currently, transaxillary breast augmentation is being performed worldwide. Among main incisions, transaxillary access has gained popularity because of good aesthetic results and the possibility of minimizing scar visibility [3,4,6,12,14]. As we know, women currently have an average risk of 13.2% (often expressed as 1 in 8) for receiving a diagnosis of breast cancer at some time in their lives [10]. From an epidemiologic point of view, as this population ages, breast cancer among women with previously augmented breasts can be expected to increase. Conservative oncologic surgery is a current tendency for the treatment of early breast cancers, and pathologic analysis of axillary lymph nodes is the single most important predictor of long-term survival [2,5,11,13]. As mastologists perform sentinel node staging for adequate treatment of breast cancer, they are very concerned about any previous surgery involving the axilla. To date, little literature is available on the interference of transaxillary breast implants in future sentinel lymph node detection. Munhoz et al. [9], in a preliminary study, performed lymphoscintigraphy preand postoperatively on a transaxillary breast augmentation patient. They did not observe alterations in sentinel node localization, and thus concluded that sentinel node assessment in the setting of prior breast implant augmentation through the transaxillary approach is feasible. Authors of the discussed paper explained very well the importance of an untouched sentinel node for preservation of axillary drainage and prevention of breast cancer spread through ways other than the axilla. However, their study with a limited number of cadavers did not elucidate how sentinel node damage could be avoided during the introduction of a high cohesive gel implant through an axillary approach. The authors simply laid the implant over the axilla and measured the prosthesis diameter movement during implant insertion into the pocket. An important unexplored aspect of the study was observation of lymphatic vessels after implant insertion. The authors observed lymphatic vessels without this maneuver, after simply laying the implant over the axillary area. The mammary gland and its skin envelope have a common origin and share the same lymphatic drainage pathways. On the basis of this, the breast is essentially a single unit with a specialized lymphatic system that presents preferential drainage through selected channels to a designated (sentinel) lymph node in the lower axilla [1]. Periareolar blue dye injection is a good and simple method for identifying axillary lymphatic structures. Some authors compare it with peritumoral radiocolloid injection used to identify the lymphatic metastasis route [1,7,8]. As we know, transaxillary breast augmentation can damage lymphatic vessels during subcutaneous tunnel dissection for introduction of the implant into the breast pocket. Thus, some landmarks need to be defined so damage to lymphatic structures can be Correspondence to R. M. Graf, M.D., Ph.D.; email: ruthgraf@bsi.com.br Aesth. Plast. Surg. 31:322 324, 2007 DOI: 10.1007/s00266-006-0204-7