Breast augmentation with bilateral deepithelialized TRAM flaps: an alternative approach to breast augmentation with autologous tissue

Since the 1980s, many patients have benefited from the use of the transverse rectus abdominis musculocutaneous (TRAM) flap for postmastectomy reconstruction. In addition to cancer reconstruction, this technique has recently been used to treat patients with breast implant intolerance and for reconstruction after siliconoma resection. However, physicians and patients alike believe that such an extensive procedure should not be used for aesthetic purposes, and to the authors' knowledge, no study has been reported on the use of pedicled TRAM flaps for aesthetic augmentation mammaplasty. In the past several years, a number of the authors' patients have requested simultaneous breast augmentation and abdominoplasty. These patients objected to the use of prosthetic implants because of potential complications such as implant failure, capsular contracture, wrinkling, and palpability. Therefore, from 1995 to 2000, the authors performed 14 cases of bilateral breast augmentation with deepithelialized, pedicled TRAM flaps. In this series, the donor-site complication rate was similar to that of the traditional TRAM flap. Surprisingly, no cases of complete or partial flap loss were clinically detected. The only complaints were pedicle bulges at the costal margins. These patients were all extremely satisfied with the results. It was concluded that the TRAM flap is safe for augmentation in a subset of carefully selected women with hypoplastic or atrophic breasts. The authors discuss patient selection, technique, and their experience with this method of breast augmentation.     

A review of psychological outcomes and suicide in aesthetic breast augmentation

Aesthetic surgery is an essential component of plastic surgery and has become increasingly popular in American society. In 2002, 1.8 million surgical cosmetic procedures were performed in the United States, representing a 294 percent increase from 1992. The 1992 U.S. Food and Drug Administration moratorium on silicone breast implants arose in response to numerous reports of connective tissue disease associated with silicone gel breast augmentation and has led to a decade-long battle over the safety of silicone breast implants that continues today. Numerous scientific and epidemiologic studies of the past decade have established that there is no association between silicone breast prostheses and systemic disease. Recently, a new front has opened in the conflict regarding the safety of breast augmentation: the psychological impact of breast augmentation. Quality studies assessing the psychological characteristics of breast augmentation patients and the psychological impact of breast augmentation surgery are few and most studies are flawed in their methods. Recent reports have provided corroborating evidence to support the psychological benefits of cosmetic surgery and breast augmentation. New reports citing an increased risk for suicide among women with breast implants have brought renewed concerns but are unable to demonstrate a cause-and-effect relationship between breast implants and suicide. The present challenge is to determine whether the increased risk reported in epidemiologic studies is falsely associated with breast implants or whether it represents underlying risk factors or psychopathology in women undergoing breast augmentation that puts them at increased risk for suicide. The purpose of this article is to review the literature regarding the psychological impact of breast augmentation and assesses current scientific findings, with emphasis on the validity of suicide risk in breast augmentation patients.     

Estimating selection pressures from limited comparative data

We recently introduced a novel method for estimating selection pressures on proteins, termed "volatility," which requires only a single genome sequence. Some criticisms that have been levied against this approach are valid, but many others are based on misconceptions of volatility, or they apply equally to comparative methods of estimating selection. Here, we introduce a simple regression technique for estimating selection pressures on all proteins in a genome, on the basis of limited comparative data. The regression technique does not depend on an underlying population-genetic mechanism. This new approach to estimating selection across a genome should be more powerful and more widely applicable than volatility itself.     

Differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation

There has been little discussion in the published literature regarding breast shape preferences. This study was conducted to ascertain previously undocumented differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation, with respect to upper-pole contour. Sixty-six respondents, grouped into three cohort categories (plastic surgeons, breast augmentation patients, and lay people), were asked to evaluate a series of 12 nonptotic breast profiles representing a range of upper-pole contours. Five profiles exhibited convex upper-pole contours, five exhibited concave contours, and two exhibited upper poles with flat slopes. A five-point Likert-type scale was used to rate attractiveness, naturalness, how close the shape was to each respondent's personal ideal, and how close the shape was to what the respondent believed was our society's ideal. Statistical comparisons were made among the three cohorts. The plastic surgeon cohort (n = 11) rated concave upper-pole contours significantly higher than did the patient cohort (n = 13) for attractiveness, naturalness, and personal ideal (p < 0.01). For convex contours, the plastic surgeon cohort gave significantly lower scores than did the patient cohort (p < 0.01). The lay category (n = 42) demonstrated preferences intermediate between those of the other groups. There are no known studies in the literature documenting the breast shape preferences of plastic surgeons and their patients. This study suggests that plastic surgeons and patients seeking breast augmentation may have drastically different images in mind regarding what constitutes an attractive, natural, and ideal breast shape. These findings have potential implications for patient treatment and satisfaction.     

Breast augmentation

The optimal technique for breast augmentation has always been debated, and numerous variables fit the needs of the variously shaped patients in our population. The purpose of this article is to present the advantages and disadvantages of the various techniques available in breast augmentation so that, in conjunction with the patient's physical examination, a sound surgical plan can be developed for aesthetic augmentation of the breast.     

Clinical applications of three-dimensional photography in breast surgery

Three-dimensional imaging in breast surgery has several uses clinically. The most practical applications are for the evaluation of breast asymmetries, both congenital and acquired, and for the evaluation of factors affecting breast shape in augmentation mammaplasty. Other uses of three-dimensional imaging that we have found clinically helpful are for evaluation of patients desiring reduction mammaplasty and for evaluation of patients undergoing unilateral breast reconstruction to determine the expander and permanent implant size that gives the best symmetry with the contralateral breast. We present five cases in which we investigate the use of three-dimensional imaging clinically by using the images to determine quantitative information about the breast, such as volume or projection. Overall, three-dimensional imaging is very helpful in providing objective information about the breast for use in preoperative planning. In addition, by analyzing clinical cases, it can provide objective data about the breast and surgical mammaplasty (especially augmentation mammaplasty) that may help surgeons better understand those factors that contribute to breast shape and influence surgical outcomes. There are currently some limitations of this system, influenced by patients with significant ptosis or obesity, which may introduce errors into the three-dimensional data, making them unreliable. However, we believe three-dimensional imaging has great clinical potential in surgical mammaplasty.     

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.     

An approach that integrates patient education and informed consent in breast augmentation

Informed consent requires surgeons to provide information about all available alternatives and their associated risks and tradeoffs to every prospective breast augmentation patient. The informed patient and surgeon then make decisions based on the information the patient has received, clinical parameters that may affect those decisions, and the patient's willingness to accept specific risks and tradeoffs. During the authors' 22 years of clinical practice, substantial changes have occurred in the requirements for adequate informed consent and the methods of ensuring that patients receive it.The numbers of alternatives for augmentation and the relative benefits and risks of each method have changed substantially over the past two decades. Four specific areas of postoperative issues stimulated major changes in the authors' approach to patient education and informed consent: 1) questions or dissatisfaction with implant size postoperatively, 2) questions about financial responsibility for costs associated with untoward events requiring reoperation postoperatively including capsular contracture or other problems, 3) spouses or other concerned parties rendering opinions postoperatively when they had not been involved in the informed consent process, and 4) criteria for whether reoperations were indicated, how many were indicated, and when implant removal without replacement might be most logical.This paper describes an approach that integrates patient education and informed consent in stages by 1) providing detailed, highly specific written and verbal information, 2) utilizing a staged approach to education and informed consent that provides information and requires simultaneous, informed consent in stages, 3) repeating each critical topic at least two or three times during the process, requiring repetitive written documentation by the patient on at least three different occasions, 4) emphasizing patient accountability for choices selected, and 5) organizing the education and informed consent process so that it is clinically practical and also increases thoroughness and documentation while conserving surgeon time.This staged, integrated system of patient education and informed consent uses a comprehensive set of informed consent documents that are available for downloading from the Plastic and Reconstructive Surgery Web site (www.plasreconsurg.org).Before incorporating any of the informed consent documents or statements reported in this paper, each surgeon should seek review by the surgeon's malpractice insurance carrier and by appropriate legal counsel to ensure compliance with state and federal laws applicable to the surgeon's practice. These documents have evolved to prospectively address patient management issues that have occurred over the authors' 22-year experience in augmentation. The documents are not endorsed by ASPS and do not necessarily represent the views of ASPS.     

Breast reduction for asymmetrical hypertrophy

Design details of reduction of asymmetrical hypertrophy of the breasts are discussed. The concepts apply to nearly any breast reduction technique, although here they are presented in the context of the inferior segment method, which we favor. Although most of these points may seem self-evident to the experienced plastic surgeon, there has been little written about the details.     

Cryopreservation of adipose tissue

The main obstacle to achieving favorable outcome of soft-tissue augmentation after autologous fat transplantation is unpredictable long-term results due to the high rate of absorption in the grafted site. At the present time, adipose aspirates can only be used for immediate autologous fat grafting during the same procedure in which liposuction is performed; therefore adipose aspirates obtained from the procedure are usually discarded. It has been a strong desire of both surgeons and patients to be able to preserve the adipose aspirates, if an optimal technique were available, for potential future applications. For the last several years, cryopreservation of adipose tissue has been studied extensively in the author’s laboratory. Several findings from this exciting translational research will lead to develop a reliable method for long-term preservation of adipose tissue in the future. In addition, successful long-term preservation of adipose tissue may open a new era in adipose tissue related tissue regeneration.     

Illegitimate authorship and flawed procedures: Fundamental,formal criticisms of the Declaration of Helsinki

Some of the recent criticisms published during and after the last revision process of the Declaration of Helsinki are directed at its basic legitimacy. In this article we want to have a closer look at the two criticisms we consider to be the most fundamental. The first criticism questions the legitimate authorship of the World Medical Association to publish a document such as the Declaration. The second fundamental criticism we want to examine argues that the last revision process failed to meet the standards for fair, democratic procedures. Although both criticisms deny the formal legitimacy of the Declaration in the most fundamental way, they have never been addressed in detail in a single article. We refute most of the related arguments. However, acknowledging some of the points made, improvements for future revision processes and versions of the Declaration of Helsinki are outlined.     

Transumbilical endoscopic breast augmentation: submammary and subpectoral

Endoscopic techniques have recently been applied to aesthetic cosmetic surgery procedures. Endoscopic bilateral augmentation mammaplasty through a transumbilical approach ("TUBA") has recently been advocated as an alternative technique. The purpose of this article is to describe the author's transumbilical technique, to identify procedural limitations and special considerations, and to retrospectively analyze preliminary results. Five hundred thirteen patients (n = 1026 breasts) who underwent submammary transumbilical augmentation from January of 1993 through December of 1998 were evaluated. In 1997, the technique was further developed to permit subpectoral placement of implants; an additional 140 patients (n = 280 breasts) who underwent subpectoral transumbilical augmentation from September of 1997 through February of 1999 will also be presented. Success of the technique was based upon a number of criteria, including completion of the operation without conversion to an inframammary incision or reoperation, normal nipple-areola sensation, absence of hematoma formation, absence of infection, no umbilical scar revision, and patient satisfaction. Complications included hematoma (n = 2 breasts), conversion to inframammary incision (n = 5 breasts), and required secondary corrective procedure (n = 3 breasts). The majority of these complications occurred early in the learning curve. The successful augmentation rate in 1306 breasts was 99.2 percent. Based upon these results, transumbilical endoscopic breast augmentation is believed to be a safe alternative technique with excellent results.     

Dual-pedicle dermoparenchymal mastopexy

Mastopexy for treatment of breast ptosis, with or without augmentation or reduction, is often followed by recurrent ptosis. A new mastopexy technique is described which appears to offer long-term correction. After conservative resection of excess skin, the breast parenchyma is elevated from the chest wall, and redundant caudal deepithelialized breast tissue is divided into two equal (or unequal) superiorly based pedicles. These are criss-crossed (as in folding of arms), overlapped, and secured to the pectoral fascia in a position cephalad to the nipple-areolar complex. This technique, dual-pedicle dermoparenchymal mastopexy (DPM), forms a cone of the breast tissue and provides a "cradle" of support. It permits insertion of a prosthesis if needed. Based, in part, on concepts of traditional and more recently described pedicled breast reductions, it enjoys the advantage of preserving skin attachment to underlying unresected breast parenchyma. In addition, it repositions ptotically displaced breast parenchyma into a cephalad position and fixes it (the "pexy") to the chest wall. A 10-year experience is presented with representative cases to illustrate the basic mastopexy and its use with augmentation or reduction.     

Evaluation and comparison of aesthetic results and patient satisfaction with bilateral breast reduction using the inferior pedicle and McKissock's vertical bipedicle dermal flap techniques

In the last two decades, McKissock's technique for reduction mammaplasty was largely replaced by Robbins's inferior pedicle technique. However, a substantial number of plastic surgeons still perform McKissock's technique in the belief that it is superior to the inferior pedicle technique in terms of aesthetic results and complication rate. In this study, the authors compared the aesthetic results, complication rates, and patient satisfaction with the two techniques. Numerous studies in the past few years have shown an improvement in physical symptoms in addition to excellent patient satisfaction after breast reduction. However, almost all of these studies have used questionnaires that were mailed to the patients for evaluation. In the present study, aesthetic evaluations by the surgeon and an objective observer were performed in addition to evaluations by the patients themselves, thereby increasing the objectivity and the significance of the patients' evaluations. Two groups of 24 and 27 patients were compared. The groups were almost identical in terms of demographic data and the amount of breast tissue removed. The aesthetic results were good to excellent in both groups, and the groups had similar complication rates. When the patients' evaluations were compared with those of the surgeon and the objective observer, no significant difference was found between the observer and the patients. In one of the groups, the surgeon's evaluations were significantly higher than those of the patients, although they were not significantly higher than the observer's. In terms of aesthetic results, complication rates, and patient satisfaction, no differences existed between the groups. In addition, the patients' evaluations were determined to be a reliable index of aesthetic results and, in these cases, they were often identical to objective evaluations.     

Pectoralis major "trapdoor" flap for silicone breast implant medial knuckle deformities.

Loss of breast parenchyma through surgery and physiologic involution can lead to problems of subglandular silicone breast implant palpability and even contour irregularities. This can give rise to patient concern and detracts from the aesthetics of the breast augmentation, particularly when it occurs medially. We present a simple solution to this problem on the medial side of the breast in the form of a small segmental medially based pectoralis major "trapdoor" flap that augments the implant soft-tissue cover intracapsularly, at the site where it is deficient. The technique, which has been used with success in five patients over 3 years, is described.     

Augmentation rhinoplasty with dermal graft and review of the literature

Nasal augmentation required following a trauma or a rhinoplasty operation poses a challenging problem to many plastic surgeons. Currently, allografts and autologous tissues are used for nasal augmentation; however, an ideal technique has not yet been described. Although preferred for augmentation of different parts of the body, pure dermal graft use has not been described for nasal augmentation. The authors performed nasal augmentation using a dermal graft in 90 patients in their hospital between 1994 and 2000, and they followed up the patients for 6 months to 8 years. In this article, the early and late results of dermal grafts for nasal augmentation are presented, and their advantages and disadvantages are discussed with a review of the literature. It was concluded that the easily obtained dermal graft could be an appropriate alternative in nasal augmentation, though it has not been used widely for this purpose.     

Breast reduction

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the preoperative considerations that must be weighed to appropriately assess operative risk of breast reduction. 2. Have a full understanding of the basic techniques that are available to treat the patient with macromastia. 3. Identify which patients are best suited to a particular technique. 4. Identify common complications associated with breast reduction and understand how to treat them. SUMMARY: Breast reduction remains a basic plastic surgery procedure designed to alleviate upper torso complaints resulting from macromastia. Historically, the inverted-T inferior pedicle procedure was the dominant technique for the treatment of macromastia for 40 years. The past two decades have seen a reexamination of breast reduction technique in an attempt to improve on the results and minimize complications. As a result, a new genre of procedures based on different pedicles and short-scar skin management techniques has been introduced. With these new procedures, the plastic surgeon now has a variety of different techniques that can be offered for reducing the hypertrophic breast. Strategically applying the concepts inherent in these procedures to the correct patient can provide outstanding results with few complications. In this article, the concepts and results of these various procedures are discussed to give the reader a basic understanding of the options available for breast reduction.     

Transaxillary subpectoral augmentation in the ptotic breast: augmentation by disruption of the extended pectoral fascia and parenchymal sweep

A new approach to transaxillary subpectoral breast augmentation based on an understanding of the anatomy of the extended pectoral fascia and the inframammary fold allows for the widespread application of this technique. Previous authors have stated that transaxillary augmentation is only applicable to a small subset of the general population and is contraindicated in mild degrees of ptosis or in large augmentations. The new approach, augmentation by disruption of the extended pectoral fascia technique and the parenchymal sweep maneuver, prevents high-riding implants and double folds. By disrupting the fascia, the lower portion of the implant is able to sit in a partially subglandular rather than subfascial plane. The anatomy and clinical implications of the extended pectoral fascia are discussed, as is the augmentation by disruption of the extended pectoral fascia technique. The parenchymal sweep maneuver is also described. Clinical cases are presented.     

The relationship between breast cancer and augmentation mammaplasty: an epidemiologic study

Surgical implantation of breast prostheses for cosmetic purposes has become increasingly popular, and by 1981, it was estimated that three-quarters of a million women had had such an operation. The long-term potential risks, particularly of breast cancer, of such procedures have not been properly investigated. To evaluate the potential breast cancer risk, we have conducted a retrospective cohort study of 3111 women followed through various public and medical records for a total of 18,476 person-years, with a median of 6.2 years per person. The cases of breast cancer were detected by means of a computerized match with the Los Angeles County Cancer Surveillance Program, a population-based cancer registry. Overall, 15.7 breast cancer cases were expected and 9 were observed, a nonsignificant deficit [standardized incidence ratio (SIR) = 57 percent, 95 percent confidence limits: 26 percent, 109 percent]. The cancers were generally diagnosed at an early stage. Among the 573 women aged 40 or older at implantation, 7.1 cases were expected and 8 were observed (SIR = 113 percent). In women whose implants were performed before the age of 40, only 1 case was observed whereas 8.6 cases were expected (SIR = 12 percent, 95 percent confidence limits: 0.3 percent, 65 percent), a significant difference. These data do not support an increased risk of breast cancer following augmentation mammaplasty. The low breast cancer rate in women having augmentation mammaplasty at a young age that many such women may have a reduced amount of breast tissue, but data on this are unavailable.