Evaluating breast parenchymal maldistribution with regard to mastopexy and augmentation mammaplasty

Mammary parenchymal maldistribution or lower-pole hypoplasia, a first cousin of the tubular breast deformity, is a common condition complicating the selection of patients for retropectoral augmentation mammaplasty and/or mastopexy. The eccentric mammary parenchyma must be released from the pectoral fascia to obtain good results with augmentation mammaplasty and to minimize the necessity for mastopexy.     

Transaxillary subpectoral augmentation mammaplasty: long-term follow-up and refinements

Transaxillary subpectoral augmentation locates the scar in a less visible position in multiple body positions than approaches that locate scars on the aesthetic unit of the breast. In 90 patients, 63 with 2 to 5 years of follow-up, using the surgical technique described, the Baker III/IV capsular contracture rate was 5.6 percent. There was no occurrence of hematoma, periprosthetic space infection, permanent loss of nipple sensation, or significant axillary wound morbidity. Scar results suggest that the axilla is an anatomically favorable location for both high-quality final appearance and minimal visibility. The transaxillary subpectoral approach is an excellent alternative to inframammary and periareolar approaches in all types of breasts requiring augmentation except the ptotic breast or breasts requiring extremely large prostheses.     

Calf augmentation: a new calf prosthesis

This paper describes a method of calf augmentation by using gel-filled implants to correct thin or asymmetrical legs. The implants are placed over both heads of the gastrocnemius muscle beneath the fascia cruris superficialis. In order to simplify Glitzenstein's procedure, modified implants were developed by the author. In over 25 cases, this technique gave encouraging results.     

Mammographic measurements before and after augmentation mammaplasty

Thirty-five augmented women underwent mammography using both the standard implant-compression technique and, when possible, the implant-displacement technique; all had preaugmentation film-screen mammography available for evaluation. The area of mammographically visualized breast tissue before and after augmentation mammaplasty was measured using a transparent grid. Patients with subglandular implants had a mean decrease of 49 percent of measurable tissue area with compression mammography and a 39 percent decrease with displacement mammography. Patients with submuscular implants had a 28 percent decrease in measurable tissue area with compression mammography and a 9 percent decrease with displacement mammography. Anterior breast tissue was seen better with displacement mammography; posterior breast tissue, with compression mammography. Most patients had some degree of parenchymal scarring and lower image quality after augmentation. State-of-the-art mammography was not possible in most patients augmented with silicone-gel-filled implants.     

Mandibular augmentation

Porous polyethylene implants are available that are designed to augment the mandibular ramus and body. They can be used to increase the bigonial distance in patients with normal mandibular anatomy who desire an increase in lower facial width. When used in combination with extended chin implants, they can camouflage the skeletal contour inadequacies associated with class II mandibular deficiency. The implants are placed through intraoral incisions and fixed with titanium screws. In a clinical experience with 11 patients over 6 years, this technique has proven to be safe and effective.     

Multiple augmentation with partial missing regressors

In large cohort studies, it is common that a subset of the regressors may be missing for some study subjects by design or happenstance. In this article, we apply the multiple data augmentation techniques to semiparametric models for epidemiologic data when a subset of the regressors are missing for some subjects, under the assumption that the data are missing at random in the sense of Rubin (2004) and that the missingness probabilities depend jointly on the observable subset of regressors, on a set of observable extraneous variables and on the outcome. Computational algorithms for the Poor Man's and the Asymptotic Normal data augmentations are investigated. Simulation studies show that the data augmentation approach generates satisfactory estimates and is computationally affordable. Under certain simulation scenarios, the proposed approach can achieve asymptotic efficiency similar to the maximum likelihood approach. We apply the proposed technique to the Multi-Ethic Study of Atherosclerosis (MESA) data and the South Wales Nickel Worker Study data.     

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.     

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.     

Breast augmentation using the expander mammary prosthesis

The expandable mammary prosthesis that has been successfully used for breast reconstruction has been modified for breast augmentation procedures. A new microreservoir that can be buried subcutaneously for extended periods has been developed. The unique design of this implant allows its size to be adjusted postoperatively as many times as desired, thus eliminating the possibility of a second operation to replace an implant whose size is unsatisfactory. Accurate, aesthetically satisfactory results are possible because the volume adjustments are made after the swelling has decreased and the implant has settled into position. Almost all patients offered this opportunity requested postoperative volume adjustments. The results of 59 patients are reported. The surgery was performed over a 3-year period, with the average follow-up time being 6 months. The incidence of capsular contracture has been less than 10 percent. Leakage was a problem in the original implant design; however, since the introduction of the new valve, there has been no leakage to date.     

Early results of vermilion lip augmentation using acellular allogeneic dermis: an adjunct in facial rejuvenation

The definitive approach to lip augmentation has yet to be defined. Herein is described a technique using acellular allogeneic dermal grafts that is easy, effective, and reproducible. Our results over the past 2 years include 47 patients (94 grafts). Three grafts to the upper lip have exhibited significant resorption, which warranted further augmentation. Early in the series, one graft was malpositioned too superiorly along the vermilion-cutaneous border. There have been no cases of infection, hematoma, or graft exposure. The overall complication rate was 4 percent (4 of 94). Our early results by using acellular allogeneic dermal grafts for lip augmentation are encouraging. Further studies are under way to better objectively define long-term results.     

Premaxillary augmentation: adjunct to rhinoplasty

Recession of the premaxillary area is a relatively common deformity. Typically, it presents as a mild weakness of the central maxilla, but in certain instances, such as in the Black and Asian communities, it may be moderate to severe. This condition can be compounded by a narrow nasolabial angle, recessed alar bases, and sunken cheeks. To resolve this deficiency, a new design for premaxillary augmentation is suggested. A bat-shaped premaxillary implant is used for correction. The implant is introduced by means of an intranasal or intraoral approach, while the patient is under either local or general anesthesia. Thirty-three patients have been managed for premaxillary recession and have been corrected by premaxillary augmentation. Satisfactory cosmetic results have been achieved, with only a few minor complications.     

Subfascial periareolar augmentation mammaplasty

Subfascial placement of implants was introduced 3 years ago. Collected data reveal very promising short-term and long-term results in comparison with subglandular and subpectoral positioned implants. The clinical experiences of 69 breast augmentations in the subfascial position are reported. The indications for this technique are proposed. The incidence of complications is described from clinical experiences and compared with that for other methods. From January of 1998 through May of 2002, 328 patients underwent periareolar augmentation mammaplasty; 105 patients had a subglandular mammaplasty, 154 patients had a subpectoral mammaplasty, and from August of 1999 through May of 2002, 69 patients had a subfascial augmentation mammaplasty. The mean postoperative follow-up time was 3.6 years in the subglandular group, 3.5 years in the subpectoral group, and 2.9 years in the subfascial group. In comparing the results of the subglandular augmentation group with those of the subpectoral and subfascial augmentation groups, the total rate of complications diminished significantly. The long-term complications of severe capsular contracture, rippling, and nipple sensation and numbness in subglandular augmentation mammaplasty could be significantly reduced (p < 0.05). The subfascial augmentation mammaplasty unites all the advantages of the subpectoral augmentation mammaplasty but eliminates the disadvantages of increased postoperative discomfort and disturbing muscle movement of the breast.     

Crescent mastopexy and augmentation

We have defined a group of patients with a lesser degree of moderate breast ptosis whose ptosis correction is not adequately improved by augmentation alone but requires some elevation of the nipple-areola complex. We have selected the crescent excision mastopexy to provide this additional needed lift. Experience with 26 patients employing this technique has helped to define the indications and limitations for this approach. It seems to adequately provide the additional needed lift when nipple descent has been no more than 1.5 to 2 cm below the inframammary crease. Complications such as scar widening (46 percent) were reviewed, but seemed to be well tolerated by the patients.     

Dispelling the myths and misconceptions about transumbilical breast augmentation

Since its invention in 1991, the transumbilical breast augmentation (TUBA) technique has gained popularity, and it has been proven safe and effective. In addition, the technique has several advantages over other methods of breast augmentation. Nevertheless, the method has often been the subject of a great variety of criticisms. Careful examination of those criticisms reveals that most are, in fact, untrue; they are misconceptions at best and falsehoods at worst. In this article, the author examines the 20 most common misconceptions about this procedure, clarifies or corrects them as appropriate, and suggests possible reasons for their having arisen in the first place. In addition, the actual drawbacks of the technique are reviewed. The author also outlines what he considers to be the criteria necessary for a surgeon to criticize any technique being used successfully by others: the surgeon must have proper plastic surgical training and certification, have completed training in the specific technique, and have a personal experience with performing a minimum number of cases.     

Permanent lip augmentation employing polytetrafluoroethylene grafts.

There is a paucity of literature regarding aesthetic enhancement of the lips. This is due to the lack of reliable techniques employing autogenous tissue and the reluctance on the part of surgeons to use an alloplastic implant in this anatomic region, which is superficial, subject to trauma, and must conform to innumerable geometric shapes. The ideal lip augmentation procedure should provide for a predictable, permanent enlargement without visible scars or donor-site deformity, can be customized to the particular patient's anatomy, and can be reversed if so desired. A series of 21 alloplastic lip implants employing polytetrafluoroethylene with a mean follow-up of 14.33 months is presented. The overall complication rate was 9.52 percent. Permanent lip augmentation can be achieved with alloplastic sheet grafts of polytetrafluoroethylene in a safe and predictable fashion. Stiffness of the lips develops with progressive thickness of the grafts. Grafts exceeding 3 mm in thickness should be avoided.     

The evolution of cooperative breeding through group augmentation

Some individuals (helpers) in cooperatively breeding species provide alloparental care and often suppress their own reproduction. Kin selection is clearly an important explanation for such behaviour, but a possible alternative is group augmentation where individuals survive or reproduce better in large groups and where it therefore pays to recruit new members to the group. The evolutionary stability of group augmentation is currently disputed. We model evolutionarily stable helping strategies by following the dynamics of social groups with varying degrees of subordinate help. We also distinguish between passive augmentation, where a group member benefits from the mere presence of others, and active augmentation, where their presence as such is neutral or harmful, but where helping to recruit new group members may still be beneficial if they in turn actively provide help for the current reproductives ('delayed reciprocity'). The results show that group augmentation (either passive or active) can be evolutionarily stable and explain costly helping by non-reproductive subordinates, either alone or leading to elevated help levels when acting in concert with kin selection. Group augmentation can thus potentially explain the weak relationships between relatedness and helping behaviour that are observed in some cooperatively breeding species. In some cases, the superior mutualistic performance of cooperatively behaving groups can generate an incentive to stay and help which is strong enough to make ecological constraints unnecessary for explaining the stability of cooperatively breeding groups.     

Autogenous augmentation mammaplasty with microsurgical tissue transfer

Many patients dream of reducing their abdominal or gluteal fat tissue and, in the same procedure, enlarging their breasts without the need for implants and their related problems. Following this demand, a new "natural" alternative to breast augmentation with autogenous tissue is presented. Since 1993, 16 patients have undergone either unilateral or bilateral breast augmentation with free fat transfer. These 20 augmentation mammaplasties consisted of nine deep inferior epigastric perforator flaps, eight superior gluteal artery perforator flaps, and three superficial inferior epigastric artery flaps. The postoperative results were judged aesthetically by independent examiners and by the patients according to Netscher's score. The additional operations for final shaping of the breasts and the postoperative complications at the donor and recipient sites are reported. The augmented breasts improved the aesthetic proportions more than 100 percent. All flaps survived, and except for minor postoperative complications such as small areas of wound dehiscence, the breasts could be shaped aesthetically in a second-stage procedure several weeks later. Breast augmentation with autogenous tissue offers a natural alternative to alloplastic augmentation mammaplasty.     

Nasal augmentation with Surgicel-wrapped diced cartilage: a review of 67 consecutive cases

Cartilage grafting has been used extensively to correct both the functional and aesthetic aspects of the nasal framework. The technique described by Erol ( 105: 2229, 2000) uses Surgicel-wrapped diced cartilage grafts in rhinoplasties. The advantages include its ease of preparation, the large volume of graft substrate available for use, and the avoidance of contour irregularities in the areas of placement. A retrospective case review of 67 consecutive patients who were treated with a Surgicel-wrapped diced cartilage graft as part of an aesthetic and/or functional rhinoplasty, in a 5-year period between 1995 and 2000, was performed in this study. All cases of congenital nasal deformities or deformities caused by trauma or tumors in which the technique was used were excluded. The charts were reviewed to determine demographic variables, the surgical procedures performed, prior operations, the rhinoplasty approach used, and the graft donor and recipient sites. Preoperative and postoperative photographs were examined, and the results were assessed. Data on the donor and recipient sites, complications, and the necessity for revisionary procedures were tabulated. There were two complications, namely, an infection, which resolved with aspiration and oral antibiotic therapy, and a recurrence of a dorsal depression, which necessitated repeated augmentation within 6 months. The technique of using Surgicel-wrapped diced cartilage proved to be effective for the augmentation of various areas of the nose. The complication and revision rates were acceptable and comparable to those of other techniques. Patient satisfaction with the aesthetic results was rated highly, with no reports of graft extrusion or contour irregularities. This technique is recommended for nasal augmentation and contouring for selected rhinoplasty patients.     

Improving aesthetic outcomes after alloplastic chin augmentation

A novel approach to increase chin projection with alloplastic material is presented. Key aspects of the technique include the consideration of anthropometric normal values in preoperative assessment and planning, a submental approach with wide subperiosteal exposure of the area to be augmented, the use of two-piece porous polyethylene implants for augmentation, and screw fixation of the implant to the mandible. Screw fixation improves the predictability and precision of reconstruction by preventing implant displacement, by obliterating gaps between the implant and the facial skeleton, and by facilitating final implant contouring. In a series of 46 patients (24 primary and 22 secondary) operated on over a 6-year period, this approach allowed anatomically correct, stable chin contours to be created. Iatrogenic problems with macrogenia, mentalis dysfunction, and soft-tissue distortion resulting from implant migration and capsular contracture have been avoided. There have been no infections. Two patients who had had multiple previous chin operations requested revisional surgery to refine contour.