Download Atlas of Aesthetic Breast Surgery - D. Hammond (Saunders, 2009) WW PDF

TitleAtlas of Aesthetic Breast Surgery - D. Hammond (Saunders, 2009) WW
TagsMedical
LanguageEnglish
File Size19.8 MB
Total Pages224
Table of Contents
                            Cover
Preface
Acknowledgements
Chapter 1 Applied Anatomy
Chapter 2 Optimizing Success in Aesthetic Breast Surgery
	General Concepts
	Preoperative Considerations
	Intraoperative Considerations
	Summary
Chapter 3 Implant Basics
	Implant Construction
	Implant Behavior
	Surface Texturing of Breast Implants – Historical Perspective
	Implant Types
	Personal Thoughts
	Summary
Chapter 4 Breast Augmentation
	Introduction
	Preoperative Planning
	Preoperative Evaluation
	Summary
Chapter 5 Mastopexy
	Breast Ptosis – Definitions
	Surgical Techniques in Mastopexy
	Operative Strategies
	Postoperative Care
	Summary
Chapter 6 Augmentation Mastopexy
	Introduction
	Indications
	Staging
	Technique
	Summary
Chapter 7 Breast Reduction
	Preoperative Evaluation
	Examination
	Operative Technique
	Summary
Chapter 8 Management of the Tuberous Breast
	Clinical Presentation
	Surgical Strategies
	Clinical Applications
	Summary
Chapter 9 Management of Gynecomastia
	Workup
	Indications for Treatment
	Surgical Technique – General Concepts
	Summary
Further Reading
	Chapter 1
	Chapter 2
	Chapter 3
	Chapter 4
	Chapter 5
	Chapter 6
	Chapter 7
	Chapter 8
	Chapter 9
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	K
	L
	M
	N
	O
	P
	R
	S
	T
	U
	V
	W
                        
Document Text Contents
Page 2

SAUNDERS an imprint of Elsevier Inc.

© 2009, Elsevier Inc. All rights reserved.

First published 2009.

No part of this publication may be reproduced or transmitted in any form or
by any means, electronic or mechanical, including photocopying, recording,
or any information storage and retrieval system, without permission in
writing from the publisher. Permissions may be sought directly from
Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44)
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elsevier.com. You may also complete your request on-line via the Elsevier
website at http://www.elsevier.com/permissions.

ISBN: 978-1-4160-3184-0

British Library Cataloguing in Publication Data
Hammond, Dennis C.

Atlas of aesthetic breast surgery
1. Mammaplasty
I. Title

618.1’90592


Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress

Notice
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Page 112

108

Hammond’s Atlas of Aesthetic Breast Surgery

screened via mammography. While the oncologic issues are
debatable, my personal feelings regarding the technique
have more to do with possible constriction of the blood
supply to the fl ap with potential ischemia and fat necrosis
being the result of a tight muscle sling, either initially at the
time of fl ap elevation, or subsequently as the muscle swells
during the early phase of healing. This coupled with the
fact that the fl ap can be reliably sutured up into position
by simply directly affi xing it superfi cially to the fascia of the
pectoralis major muscle has led me to choose the direct
approach in those patients who are candidates for use of the
fl ap as opposed to the use of the muscle sling. Certainly, further
research into this area will clarify the utility of the muscular sling
in utilizing this fl ap.

Breast resuspension One variation to the fl ap reshaping strat-
egy involves the use of the entire underside of the breast to
resuspend the breast superiorly. In this technique, the breast is
approached from an inferior direction, using either an inframam-
mary fold incision or the lower portion of a vertical incision. A
subglandular pocket is created that extends up to and slightly
beyond the superior pole of the breast. Once the breast is
released from its attachments to the pectoralis major muscle, it
is lifted superiorly and reattached by suturing the deep surface
of the breast to the pectoralis major fascia in a location that is
higher up on the chest wall. This serves to shift the entire breast
position superiorly and thus functions as an operative correc-
tion for positional breast ptosis. Also, upper pole concavity can
be addressed by using the superior translocation to effectively
‘autoaugment’ the upper pole of the breast. Although an element

P

S

V
W

X

T U

Q R

Y

Figure 5.34 (Continued ) (O,P) After the breast has been lifted, the inferior pole is plicated with a row
of sutures placed along the vertical axis, extending from the inframammary fold to the areola to shape
the breast further and increase the projection. (Q,R) With patient upright, the effect of the strategy
can be seen as the pre-existing ptosis of the NAC (Q) is corrected by the parenchymal plication and
the NAC is lifted to a higher position (R). (S,T) In the oblique view, the effect of the vertical plication in
particular can be seen as the post-plication view (T) demonstrates increased breast projection with a
more contoured lower pole. (U,V) After the breast has been reshaped with internal suture plication, the
redundant skin envelope is re-draped using a purse string suture. (W) Immediate appearance of the
lifted breast in the upright position. (X,Y) Appearance after 6 weeks, demonstrating an early correction
of the breast ptosis and effective reduction in the diameter of the areola. The patient has been well
prepared for her subsequent second-stage reconstructive procedure.

Page 113

109

C h a p t e r 5 • Mastopexy

A B

C D

Circumvertical
skin pattern

Inferiorly based pedicle flap

Inferior pedicle flap
based on breast septum

Flap rotated into
superior pole of breast

NAC advanced superiorly

Flap sutured
superiorly
under breast

Figure 5.35 Using a vertical technique based on a superior pedicle
to provide neurovascular support to the NAC allows the creation
of an inferiorly based fl ap that can be rotated superiorly to fi ll in a

preoperative upper pole concavity. This fl ap can be constructed to
include the breast septum with the associated neurovascular support
to ensure viability of the fl ap.

A B C

D E F

Figure 5.36 (A,B) Preoperative appearance of a 34-year-old woman who
has previously undergone removal of a benign tumor from the superior
aspect of the left breast, resulting in a signifi cant contour depression in the
region above the NAC. (C) Preoperative marks in preparation for a right-sided

circumvertical (SPAIR) mastopexy in conjunction with a left superior pedicle
circumvertical mastopexy using an inferiorly based fl ap to fi ll in the upper
pole defect. (D,E) The previous incision in the left breast was made just below
the areola, which necessitated a superior pedicle approach to ensure

Page 223

220

index

Reshaping, breast , 159
mastopexy , 102–112 , 105
SPAIR mastopexy , 122 , 123

Resuspension , 108
augmentation mastopexy , 144–145 , 145
circumvertical mastopexy , 116 , 118 , 119
mastopexy , 108 , 110 , 111
strategy , 116

Rotation , 29
Round implants , 34–35 , 69 , 132

profi les , 34
saline see Saline implants
shape , 34
silicone gel see Silicone gel implants
vs anatomic , 77 , 77 , 78 , 79
see also Wrinkling

S
Safety, patient , 11
Saline implants , 43 , 69 , 76

ease of use , 38
fully fi lled , 28
incisions , 42
insertion of , 69 , 75
round , 20–22 , 22 , 23 , 23 , 25 , 25 , 34
smooth round , 24 , 47 , 54

high-profi le , 61 , 70 , 71 , 77 , 143
moderate-profi le , 60 , 61 , 71

soft tissue , 57
see also Anatomically shaped implants ;

Wrinkling
‘ Saucer ’ deformity , 201
Scalloping edge distortion , 22–23 , 23 , 24 ,

25
Scarpa’s fascia , 3–5 , 4–9 , 65–66 , 65 , 76 ,

137 , 142 , 160 , 163 , 164
Scars , 123

areolar , 207
biopsy , 88 , 148
contraction , 93
fi ne line healing , 116
inframammary fold (IMF) , 7 , 8 , 9

augmentation , 40 , 41 , 72 , 79 , 79
augmentation mastopexy , 130 , 133 ,

137
breast reduction , 155 , 159 , 175
gynecomastia , 203 , 207

limiting , 90 , 132 , 201
liposuction breast reduction (LBR) , 155
nipple-areola complex (NAC) , 105
patient marking , 156
pattern in skin , 100
periareolar , 41 , 41 , 101 , 112 , 113 , 176 ,

201 , 206
personal relationships , 149
short scar techniques , 102
stabilization , 91
subareolar , 199
transaxillary , 43 , 43 , 130
treatment , 128 , 163
vertical , 102 , 104 , 116 , 128 , 132 , 133 ,

135 , 142 , 176 , 207
widened , 92 , 99 , 137

Wise pattern inverted T , 102 , 206
see also SPAIR entries

Senescent gynecomastia , 196 , 197 , 200
preoperative appearance , 204
postoperative appearance , 204

Sensation, retaining , 43
Septum , 4 , 4 , 5 , 49 , 50 , 66 , 170 , 171
Serratus anterior muscle , 1 , 9 , 44–45 , 44
Shape, areolar , 90–91 , 90
Shape, breast , 17 , 18 , 55 , 74 , 150

implant shape , 50 , 51
management of , 154
/size , 46 , 61 , 88 , 142 , 148
subglandular pocket , 48
vertical technique , 124 , 161

Shape, implant , 19 , 50 , 51
assessment , 25–26

Shaping, breast , 172
constricting layer model , 74–75
maneuvers , 122 , 173
SPAIR mammaplasty , 171–173 , 172
see also Reshaping, breast

Shaping measurements, augmentation ,
55 –58

breast base diameter , 55 , 56
breast height , 57 , 57 , 58
implant base diameter , 57–58 , 58
medial/lateral pinch thickness , 55–56 , 56
upper pole pinch thickness , 56–57 , 56
see also Reshaping, breast

‘ Sharpie’ brand of markers , 11 , 12
Shell, outer implant , 19 , 21 , 28 , 76

cracks in , 27 , 75
design , 22
surface texture , 30 , 42 , 43 , 75

Biocell , 30–33 , 32 , 37
Siltex , 33 , 33 , 34 , 37

Short scar strategies , 154
see also SPAIR (short scar, periareolar,

inferior pedicle, reduction) entries
Shoulder

level , 13 , 17 , 17
position , 12

Silicone gel implants , 48 , 59 , 60
ease of use , 38
fully fi lled , 28
gel bleed , 48
insertion of , 69
round , 23–25 , 25 , 30 , 31 , 34 , 57 , 69 ,

75 –76
smooth round , 30 , 38 , 135 , 145

high-profi le , 24 , 35 , 61 , 190
moderate-profi le , 24 , 26 , 189 , 191 ,

192
soft tissue , 57
textured round , 42
see also Anatomically shaped implants ;

Wrinkling
Siltex , 33 , 33

surface , 34 , 37
Size, breast , 148 , 149 , 150 , 150 , 159

/shape , 46 , 61 , 88 , 142 , 148
smaller appearance , 89 , 89

Sizers, implant , 63 , 63 , 64 , 67 , 139 , 142 , 143

Skin
anatomy , 1 , 6–7
elasticity , 6 , 42 , 83 , 85 , 98 , 99 , 100
excess , 154 , 156 , 160 , 208
misalignment , 75
only circumvertical mastopexy , 116
plication of , 135
ptosis , 85 , 85 , 88 , 89
reduction technique, circumvertical ,

100 –102 , 101 , 103–104
stretching , 100
texture, lower pole , 151 , 152

Skin envelope , 98 , 147–148
augmentation results , 58–61 , 59 , 60 , 61
characteristics , 58–61

grading , 59
elasticity , 79
managing, mastopexy , 100–102 , 113
plication of , 173
ptosis , 196
recontouring , 158
reduction , 98 , 156 , 201 , 203
SPAIR mammaplasty , 172 , 174
to volume relationship , 35
tuberous breast , 184–186 , 185
wrinkling in , 205

Skin retailoring , 201 , 203–207 , 204 , 206
circumvertical pattern , 204–205 ,

206–207
direct local resection , 203
horizontal pattern , 205 , 207 , 208
periareolar pattern , 203–204

Skip areas, dermal shelf , 93
Smoking , 149 , 153 , 159
‘ Snoopy dog ’ type deformity , 44 , 45 , 116
Social history , 149
Soft tissue

constriction , 190 , 191
distortion , 43
elasticity , 52
expansion , 83
framework , 19 , 74
layer , 40
paucity of , 20
pinch thickness , 50 , 55 , 56–57 , 56 , 58
reconstruction , 187–189 , 187 , 188
recurrent ptosis of , 116
relaxation , 119
release , 80 , 185
wrinkling , 28

SPAIR (short scar, periareolar, inferior
pedicle, reduction) technique,
tuberous deformity , 187–188 , 187 ,
188 , 193

SPAIR mammaplasty , 163–175
marking for skin envelope reduction ,

156
patient marking , 163 , 167 , 167–168 , 169 ,

176–177
preoperative appearance , 167–168 , 176 ,

177
postoperative appearance , 148 , 175 , 176 ,

177
surgical strategy , 163

Page 224

221

i n d e x

surgical technique , 169–174
initial dissection , 169 , 170–171 , 171
nipple-areola complex (NAC)

management , 173–174 , 175 ,
176–177

shaping , 171–173 , 172
skin envelope management , 172 , 174

SPAIR mastopexy , 89 , 102 , 116–126 , 161
measurements for , 120
patient marking , 109 , 117 , 119–120 ,

120 –121 , 126 , 127 , 127–128
preoperative appearance , 126 , 127
postoperative appearance , 126 , 127–128

Stab incision , 156 , 202 , 203
Stacking, of implants , 29
Staging , 134 , 135–136 , 137
Subareolar breast bud , 197 , 203
Subfascial plane, pocket , 49–50 , 50
Subglandular augmentation see under

Inframammary fold (IMF),
augmentation

Subglandular plane , 43 , 48–49 , 49 , 185 , 192
Subglandular pocket , 67 , 67 , 108 , 116

partial , 74
tuberous breast , 184

Submuscular pocket plane, complete ,
44 –45 , 44 , 45

Subpectoral augmentation, inframammary
fold , 72–75 , 74

‘ dual plane ’ technique , 74–75
Subpectoral plane , 43

partial pocket , 45–46 , 45 , 46 , 47 , 48 , 48
Subpectoral pocket, partial , 77
Superior fl ap tissues , 122–123 , 172
Support garment , 126 , 128
Surface texturing , 38

implant , 29–34 , 30 , 31 , 42 , 43 , 75
Surgical history , 148
Sutures , 69 , 128

absorbable monofi lament , 91 , 93 , 95 , 123 ,
144 , 180

accordion type , 160
horizontal mattress technique , 101
internal techniques , 154

fl aps fi xation , 105–112
knots , 92–93
materials , 91–92 , 92
monofi lament material, permanent , 91
non-absorbable monofi lament , 92 , 105
parenchyma fi xation , 102–105 , 106 , 107
periareolar lift placement , 92–93 , 93 ,

94–95
periareolar mastopexy techniques , 101
placement technique , 91
plication of , 106 , 108
shaping , 113
see also Interlocking Gore-Tex sutures ;

Purse string sutures
Swelling, differential elasticity , 98

T
Tailor stapling technique , 165 , 204
Tailor tacking , 90 , 124 , 140 , 171 , 173 , 174

Textured implants , 42 , 43
insertion of , 75
see also under Anatomically shaped

implants
Tissue

bunching , 93 , 204
crowding effect , 92
expanders see Expanders, tissue
expansion , 75
layers , 74
resected specimen removal , 154 , 171
stretching , 85
swelling , 119
see also Soft tissue

TRAM fl ap reconstruction , 114 , 193
Transaxillary augmentation , 76–77

incision , 43 , 43
subpectoral , 129
tuberous deformity , 189

Transumbilical breast augmentation
(TUBA) , 43–44

Tuberous breast , 49 , 183–193
clinical applications , 187–193
clinical presentation , 183–184 , 183 , 184 ,

185
gynecomastia , 195 , 196
preoperative appearance , 86 , 183 , 185 ,

187–190 , 192 , 193
postoperative appearance , 187 , 188 , 189 ,

190 , 191 , 192 , 193
round gel implants , 75 , 189 , 190 , 191 ,

192
surgical strategies , 184–187

Tumor, benign , 109–110
Tunneling technique , 203

U
Ulcerative colitis , 148 , 148
Ultrasound assisted liposuction (UAL) , 155 ,

156 , 200
Upper pole tissues

bulging , 46 , 61
concave , 102 , 104 , 116 , 126
contour , 151 , 152 , 158 , 165

deformity , 36 , 36 , 37 , 110
control, implants , 38
fullness , 45 , 134 , 152
hollowing out , 159
reshaping , 105
shape , 55

V
Variability, evaluation , 39 , 39
Variables, implant selection , 62–63 , 62
Venous drainage , 3
Vertical breast reduction , 150 , 159–163

parenchyma , 159–160 , 160
patient marking , 161–163 , 161–162
pedicle , 159
preoperative appearance , 161 , 166
postoperative appearance , 166
shape , 161

surgical strategy , 159
surgical technique , 163 , 164–165 , 166

Vertical mattress
bite , 100
suture , 101

Vertical plication , 103 , 106 , 133 , 142 , 143 ,
144

SPAIR mastopexy , 123–125 , 123–124
Vertical scars , 102 , 104 , 132 , 133 , 142 , 176 ,

207
Vertical technique , 87 , 101 , 109
Vitamin E-based scar cream , 163
Volume

breast/implant , 55 , 55
as primary variable , 62 , 62 , 63 , 64

Volume ptosis , 83 , 84 , 85 , 85 , 115 , 119
Volume reduction , 198–200

combination approach , 200–201 , 201 ,
202–203

direct excision , 198–199 , 199
liposuction , 200 , 200
see also Reduction, breast

W
Weight

body mass index (BMI) , 198
breast , 147 , 147 , 152
gain , 128 , 150 , 204
implant , 5
loss , 83 , 84 , 127 , 137 , 150 , 198 , 206
patient , 51 , 151 , 178
resected specimen , 154 , 171

Weight lifting activities , 157
Wise pattern inverted T approach , 102 , 103 ,

105
augmentation mastopexy , 144
inferior pedicle breast reduction , 137 ,

154 , 159 , 175–181 , 180 , 188
measurements for , 178
patient marking , 178 , 178 , 179 , 180
preoperative appearance , 137 , 179 ,

180 , 181
postoperative appearance , 137 , 181
surgical strategy , 175 , 178
surgical technique , 178 , 179 , 180–181 ,

180 , 181
mastopexy , 102 , 104 , 105 , 181
skin envelope retailoring procedure , 206
skin pattern , 110
surgical options , 113

Wound
contracture , 100
dehiscence , 92

Wrinkling , 93 , 100
anatomically shaped implants , 25 , 28 ,

29 , 37
round implants , 25–26 , 34–35

saline , 23 , 25 , 29 , 29
silicone gel , 24 , 25–26 , 29

Wuringer, E. , 4

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