"I" becomes "L": modification of vertical mammaplasty

The problems of the vertical mammaplasty by Lejour (i.e., gathering the skin envelope in one vertical suture, frequent secondary healing problems, and later sagging of the inferior glandular part in the case of large and very large breasts) are well known. A simple modification of the Lejour technique, that is, adding a lateral inframammary scar to shorten the vertical scar length, is presented. The modified L technique was used in 45 patients (90 breasts) between October of 1999 and August of 2001. With an average follow-up of 13 months, the jugular notch-to-nipple distance was 21 cm, the vertical scar length was 8.4 cm, the lateral inframammary scar length was 11 cm, and the average resection weight was 625 g per breast (range, 200 g to 2080 g). Even among patients who had very large glandular bases and resection weights it was possible to achieve a breast base reduction, modeling the glandular corpus to a harmonic, well-projecting, and youthful shape. Slight wound-healing problems with spontaneous cicatrization within 2 weeks occurred in six patients. In two patients who exhibited gigantomastia up to 2080 g per breast, partial mamilla necrosis occurred on one side. Ninety-one percent of the patients reported being "very satisfied" with the outcome, and 9 percent reporting being "satisfied." The authors' modification of the vertical mammaplasty to an L-shaped scar technique enables the surgeon to apply the principles of the Lejour technique for higher resection weights and diminishes wound-healing problems, and it is still a scar-minimizing technique that results in a scar-free cleavage. It is easy to learn and an ideal standard technique for a teaching hospital.     

Direct closure of round skin defects: a four-step technique with multiple subcutaneous and cutaneous "figure-of-8" sutures alleviating dog-ears

Excisional biopsies of rounded lesions are performed daily by surgeons. The objective of this article is to establish a surgical technique for direct closure of circular and elliptical defects without the need for additional excision of dog-ears. A four-step technique based on multiple cutaneous and subcutaneous "figure-of-8" sutures is presented. When correctly placed, these sutures can equally distribute the excess tissue along the scar and alleviate dog-ears. The results of the 65 presented cases show that this technique yields short scars and saves healthy skin. A significant reduction of the length-to-width ratio and the arc-to-scar length ratio is obtained. Direct closure of a circular or elliptical defect without stipulating a 3:1 length-to-width ratio is feasible. Among the advantages of the technique are that no excessive healthy tissue is removed and that the scar length is reduced. The long-term outcome is a scar that is thin, linear, flat, and concealed in the body structure.     

Hiding the posterior scar in rhytidectomy: the omega incision

A periauricular pattern of incision is presented for rhytidectomy that resembles an inverted omega. Although the anterior component remains similar to existing recommended patterns, the posterior component allows confinement of the scar to the postauricular sulcus and superior scalp. Although hidden, the scar placement permits full correction of redundant neck skin. The technique entails significant posterior dissection of the scalp, adding operative time and costs, along with increased potential for hematoma and sensory alteration of the scalp. On the other hand, the pattern of scar appears to reduce significantly the incidence of scar hypertrophy, whereas it conceals the scar from view, allowing an unrestricted range of postoperative hair styles.     

Infracture technique for reduction malarplasty with a short preauricular incision

The infracture technique for reduction malarplasty has been widely used as an aesthetic surgical procedure in northeast Asia. Since 1988, the authors' original method of infracture technique was performed through the combined approach of intraoral and temporopreauricular incision, which may leave a rather long scar on the temporal region. To shorten the external scar, a new technique using a short preauricular incision instead of a long temporopreauricular incision was developed. From September of 2000 to June of 2001, this new approach was applied to 142 patients for correction of prominent zygoma. In this procedure, anteriorly, incomplete fracture of the zygomatic body was performed through an intraoral approach for bending inward. Posteriorly, full-thickness cutting of the zygomatic arch was performed through a preauricular incision. Then, lateral bulging of the zygomatic arch was reduced with infracturing, and the infractured site was fixed in a new position with a microplate and three screws. The advantages of this technique are reduction of the operation time, reduction of the length of the external scar, and reduction of postoperative edema around the operative region. With this combined approach, the authors were able to sufficiently expose the zygomatic arch and body and able to change the lateral convex arch into a concave one. Under direct vision, the authors could effectively and precisely perform the infracture technique through a much shorter preauricular incision that did not result in a long, conspicuous external scar.     

The limited scar mastopexy: current concepts and approaches to correct breast ptosis

The literature on short scar mastopexy was reviewed, with a focus on the different techniques. Currently four techniques have been described: the periareolar, the vertical, the inverted-T, and the L-shaped scar. The different techniques were evaluated with regard to patient selection, operative techniques, scar length, and complications. A large number of techniques have been published for minimal ptosis, whereas for significant ptosis, the number of surgical options is limited. It is evident that limited scar techniques can be applied to all grades of ptosis, but there is no one technique that can satisfactorily correct all degrees of ptosis. Plastic surgeons should weigh the advantages and limitations of each technique to correctly address breast ptosis. This article reviews an algorithmic approach to correct all degrees of ptosis with mastopexy.     

The vertical mammaplasty: a reappraisal of the technique and its complications

Since 1989, superior pedicle vertical scar mammaplasty as described by Lejour has been used in the authors' department as the only technique for breast reduction. From 1991 through 1994, a series of 170 consecutive patients (330 breasts) underwent an operation. In these patients, minor complications were observed in 30 percent of the patients and major complications in 15 percent. Surgical revision for scar or volume corrections was necessary in 28 percent of the breasts, which seemed unacceptable. Therefore, the original technique was modified by decreasing the skin undermining and avoiding liposuction in the breast. Primary skin excision was performed in the submammary fold at the end of the operation if the skin could not be puckered adequately. This modified technique was used from 1996 through 1999 in 138 consecutive patients (227 breasts). In the second series, minor complications were observed in 15 percent of the patients and major complications in 5 percent. However, the technical modifications did not significantly change the rate of secondary scar and volume corrections, which were still necessary in 22 percent of the breasts. In large breasts, the addition of a horizontal scar at the end of the operation did not change the rate of secondary revision, which however compares favorably with the figures obtained with the inverted T, superior pedicle mammaplasty.     

Widening of scars: foe coaxed into a friend? The Millard technique revisited

Widening of scars is a frustrating event that most if not all plastic surgeons have encountered. Several therapeutic modalities have been proposed, but frequently the result is disappointing. During revision surgery, it is advocated that the dermal scar be used in providing support to the tissues instead of being discarded. The author proposes a technique by which tension on the wound is carried by tough scar tissue instead of the suture line, thereby reducing the incidence of postoperative widening. This technique was used to treat 35 nonburn scars that had widened: 31 scars were facial (24 patients) and 4 were inframammary (2 male patients). All scars were at least 4 months old. The operations were performed between February of 1996 and December of 1998; follow-up was 9 to 14 months. Only one scar widened during the follow-up period. Overall, 71 percent of patients rated the improvement as marked. This is a revisiting of the original Millard's technique, which seems to have fallen into oblivion. The author recommends this technique in dealing with widened scars during revision surgery.     

瘢痕疙瘩及增生性瘢痕中MMP-2、MMP-9的表达

目的探讨基质金属蛋白酶-2、基质金属蛋白酶-9(MMP-2、MMP-9)在瘢痕疙瘩(keloid,Ke)及增生性瘢痕中(hypertrophic scar,HS)的表达。方法免疫组织化学SP法检测MMP-2、MMP-9在20例瘢痕疙瘩、15例增生性瘢痕及10例正常皮肤中的表达,采用图像分析技术对免疫组化结果进行定量分析。结果Ke中MMP-2表达高于正常皮肤(t=2.366,P<0.05),高于HS(t=2.223,P<0.05);MMP-9表达高于正常皮肤(t=3.198,P<0.01),高于HS(t=2.110,P<0.05)。HS中MMP-2表达与正常皮肤无差异(t=0.218,P>0.05),MMP-9表达与正常皮肤无差异(t=1.873,P>0.05)。正常人皮肤仅见MMP-2、MMP-9蛋白的弱阳性或阴性表达。结论MMP-2、MMP-9蛋白的表达与皮肤损伤后的过度增殖及肿瘤化倾向有关。     

Outcome study: periareolar mammaplasty patients' perspective

Residual scars on occasion compromise patient satisfaction with breast reduction procedures. Periareolar breast reduction was proposed to minimize the scarring produced by the operation. This technique was criticized predominantly for producing a breast with low projection, for recurrence of ptosis after surgery, and for widening of the periareolar scar. The purpose of this study was to evaluate patient satisfaction from this technique. In the first branch of the study, 11 patients who had periareolar or circumareolar breast reduction were compared with 13 patients who had vertical scar reduction mammaplasty. The groups were matched for patient's age, size of reduction, and follow-up period. The patients were contacted by phone and requested to comment on four aspects of their operation: breast size, symmetry, quality of scars, and appearance and position of the nipple-areola complex. The replies were converted to numerical values and analyzed statistically. A panel of three women, prospective patients for breast reduction, were presented with standardized five-view before-and-after photographs and requested to score the results using the same criteria. Their responses were analyzed in the same manner. Both phases of the study produced similar results. Breast reduction done through a periareolar scar scored higher than a vertical scar technique. The operation did not differ with respect to shape, symmetry, or nipple-areola shape but did with respect to dissatisfaction with scars, which affected the overall result. This experimental model of assessing results of cosmetic operations is proposed as a tool to assess the patient's rather than the surgeon's perspective of a surgical technique, and it could find application in assessing other cosmetic operations.     

Reliability of inferior pedicle reduction mammaplasty in burned oversized breasts

Heavy pendulous breasts cause physical and psychological trauma. Postburn deformity of breasts results in significant asymmetry, displacement of nipple-areola complex, due to burn scar contracture, and significant scarring; these factors add more psychological discomfort and subsequent behavioral changes. The use of the inferior pedicle procedure in burned breasts can solve many problems. The technique reduces the size of the large breast, eliminates the scar tissue by excising both medial and lateral flaps, and brings the mal-located nipple and areola to a normal position. This study stresses the possibility of harvesting the inferior dermal pedicle flap from within the postburn scar tissue without necrosis of the nipple and areola, because of the excellent flap circulation. Acceptable aesthetic appearance and retainment of nipple viability and sensitivity can be achieved with the inferior pedicle technique even with postburn deformity of the breast. The study was conducted on 11 women, all of whom had sustained deep thermal burns to the breasts and anterior torso and whose breasts were hypertrophied and pendulous.     

A new method utilizing the bipedicle flap for reconstruction of the external auditory canal in microtia

A new technique using the bipedicle flap for reconstruction of microtia is described. This technique makes possible construction of a well-shaped new auricle in the presence of scar formation because of tympanoplasty in which the external auditory canal has been created posteriorly.     

Immediate hair transplantation into a newly closed wound to conceal the final scar on the hair-bearing skin

A surgical incision after suturing usually leaves a visible scar on the hair-bearing skin, even after optimal wound conditions. The conspicuousness of such a scar results from its linear continuity and hairlessness. To prevent this effect, a row of micrografts or minigrafts was inserted between the wound edges immediately after wound closure. The hair grafts that were transplanted were dissected from the discharged skin in the same surgical procedure, if feasible. Otherwise, a mini donor strip was harvested from the mastoid scalp to dissect the hair grafts. The final linear scar was interrupted and concealed sufficiently with the growth of the transplanted hairs. Tension-free closure is required to obtain a satisfactory result with this technique.     

An anatomical method for re-siting the umbilicus

The umbilicus is the only normal scar on the body and it is the most noticeable scar following abdominoplasty and TRAM or DIEP flap procedures. We describe a technique for resiting the umbilicus that attempts to recreate the anatomical structure by attaching the superficial fascia to the periumbilical skin to produce a fullness around the depression in which the umbilicus sits. This is aesthetically desirable and avoids the uncomfortable tethering of the umbilicus to the rectus sheath associated with other techniques.     

改良手术方法在腮腺肿瘤手术中的运用

目的：改良腮腺肿瘤手术方法,以期最大程度恢复术后患者美容及功能。方法：采用以下改良术式：①采用隐蔽的面部除皱切口,避免了常规术式的颈部切口;②采用总干法解剖面神经,减少了面神经周围支损伤的机率;③保留耳大神经,避免术后耳垂麻木;④采用口腔修复膜,减少了术后Frey综合征的发生;⑤采用蒂在上方的胸锁乳突肌肌瓣填塞腮腺切除后的凹陷区,避免了常规术式后的面部畸形。结果：采用该方法对36例患者行腮腺切除术,术后随访6月～4年,患者面部疤痕不明显,外形恢复良好,无面瘫,无Frey综合征出现。结论：改良的腮腺切除术克服了传统术式的缺陷,值得进一步推广和普及。     

The short-lip deformity after triangular flap repair: a lengthening technique

A method for lengthening of the short lip after triangular-flap repair of the unilateral cleft lip is documented. This technique offers a minimal additional scar line and a maximum effect.     

Medial epicanthoplasty combined with plication of the medial canthal tendon in Asian eyelids

The authors present a new technique for the correction of the medial epicanthal fold using the Y-W-plasty or inverted Y-V-plasty combined with plication of the medial canthal tendon. From January of 1996 to April of 2001, 10 patients with epicanthal folds received a medial epicanthoplasty combined with plication of the medial canthal tendon. The patients ranged in age from 20 to 49 years (average, 27.3 years). Eight patients with epicanthal folds received the Y-W-plasty with plication of the medial canthal tendon. Two patients were operated by inverted Y-V-plasty. The follow-up period ranged from 5 months to 2 years. Neither injury of the lacrimal apparatus nor asymmetry of the eyes was noted. Fibrosis and redness of the operated scar was noted in the first 2 to 3 months. However, the scar maturated by 3 months in all patients, and the hypertrophic scar was unnoticeable in all patients. Two key modifications of this technique are plication of the outer leaflet of the medial canthal ligament and lateral advancement of the central triangular flap. These modifications remarkably reduce the tension along the skin suture line. This method is very effective for the correction of the moderate-to-severe epicanthal fold. In addition, these modifications can be applied in most other medial epicanthoplasty techniques.     

Arch reduction mammaplasty

Arch mammaplasty is a breast reduction technique based on the inferior pedicle. It uses all the specific advantages of the inferior pedicle while avoiding the inframammary scars and dead space that occur with the inverted T technique. Arch mammaplasty has proven versatile and extremely safe, and it has a surprisingly good rate of acceptance by the patients. The scarring is aesthetically superior to that obtained with the well-accepted, inverted-T scar technique of the past.     

Donor-site morbidity comparison between endoscopically assisted and traditional harvest of free latissimus dorsi muscle flap

Endoscopically assisted harvest of free latissimus dorsi muscle flaps is being used more frequently in reconstructive microsurgery because it requires a smaller incision and leaves a more acceptable scar in the donor site. Donor-site morbidity was compared between groups of 22 latissimus dorsi muscles harvested using the endoscopically assisted technique and 26 using the traditional technique. The results revealed no statistically significant differences in the amount of intraoperative bleeding, the incidence of postoperative hematoma and seroma, and the incidence of donor-site wound infection as assessed by the surgeon. However, a patient questionnaire revealed that even though it did not reach a statistically significant difference, endoscopically assisted harvest of the latissimus dorsi muscle had less pain and allowed earlier and better movement of the upper extremity of the donor site. The patients' attitudes and feelings about the scar and overall satisfaction were also higher in the endoscopic group, which demonstrated a statistically significant difference.     

A versatile breast reduction technique: Conical plicated central U shaped (COPCUs) mammaplasty

Background

There have been numerous studies on reduction mammaplasty and its modifications in the literature. The multitude of modifications of reduction mammaplasty indicates that the ideal technique has yet to be found. There are four reasons for seeking the ideal technique. One reason is to preserve functional features of the breast: breastfeeding and arousal. Other reasons are to achieve the real geometric and aesthetic shape of the breast with the least scar and are to minimize complications of prior surgical techniques without causing an additional complication. Last reason is the limitation of the techniques described before. To these aims, we developed a new versatile reduction mammaplasty technique, which we called conical plicated central U shaped (COPCUs) mammaplasty.

Methods

We performed central plication to achieve a juvenile look in the superior pole of the breast and to prevent postoperative pseudoptosis and used central U shaped flap to achieve maximum NAC safety and to preserve lactation and nipple sensation. The central U flap was 6 cm in width and the superior conical plication was performed with 2/0 PDS. Preoperative and postoperative standard measures of the breast including the superior pole fullness were compared.

Results

Forty six patients were operated with the above mentioned technique. All of the patients were satisfied with functional and aesthetic results and none of them had major complications. There were no changes in the nipple innervation. Six patients becoming pregnant after surgery did not experience any problems with lactation. None of the patients required scar revision.

Conclusion

Our technique is a versatile, safe, reliable technique which creates the least scar, avoids previously described disadvantages, provides maximum preservation of functions, can be employed in all breasts regardless of their sizes.     

"Zigzag" wavy-line periareolar incision

There is almost no mention of improvement in the aesthetics of areolar incisions in the plastic and reconstructive surgery literature. The most visible area of the breast is the central mound; therefore, it behooves surgeons to make an areolar incision as inconspicuous as possible. Minimal incision breast operations and short-scar operations, such as mastopexy and vertical reduction mammaplasty, use a circumareolar incision. This circumareolar technique, which specifically avoids a purse-string support suture, is useful in all periareolar incisions. This method creates a scar that mimics the elusive, natural irregularity between the areola and periareolar skin. The goal is to have an irregular, random, wavy line that appears more natural. Between August of 1998 and August of 1999, 104 "zigzag" wavy-line procedures were performed. The complications seen in this series included delayed healing in four patients and hypertrophic scar in two patients. No scars were surgically revised. The results demonstrated a definite difference compared to a circular scar. The zigzag wavy-line technique complements the innovative methods that shorten scars while they create a more natural, lasting breast mound. For areolar incisions, good results are deceptively subtle, but unnatural results can be painfully obvious. The zigzag wavy-line incision subtly eludes the eye in diminishing the signs the patient has undergone an operation.