Essentials of Aesthetic Surgery

772
Part VIII Breast Surgery
A useful technique in
19
ADVANTAGES
Smaller scars
Preserves lactation and vascular supply to the NAC
Preserves existing sensation
Can be easily performed with local and intravenous sedation
DISADVANTAGES
Most surgeons agree that with suction
lipectomy alone and may be worsened in patients with poor skin quality.
Postoperative edema and induration often take months to resolve.
The evacuated breast tissue
• Unexpected breast malignancy may go undetected.20,21
• The absence of adequate pathological evaluation has brought controversy.15,22-24
TECHNIQUE



Postoperative compressive bras are worn for 6 weeks.
NOTE:


EXCISIONAL TECHNIQUES
PEDICLE SELECTION
Options include inferior pedicle, superior/superomedial pedicle, and central mound
technique.

Has been the preferred method (in the United
States) and is easily teachable25
NAC maintained on an inferior dermal-
parenchymal pedicle

be removed.
Usually paired with an inverted-T skin excision
May use short-scar periareolar inferior pedicle
(SPAIR) introduced by Hammond26


safely.
• Reliable neurovascular supply

14,15
27
Inferior pedicle technique.

773
Chapter 55 Breast Reduction


• Passive creation of breast shape from tailoring skin around parenchyma
• Often creates a boxy breast
• High rate of bottoming out

A
Superomedial
pedicle areas of
deepithelialized
tissue
B
Superior pedicle. B, Superomedial pedicle.
28,29 is credited with introduction of the superior pedicle technique.
22,30
Hall-Findlay31popularized the superomedial pedicle.
32 33 made contributions.
34
NAC is maintained on a superior or superomedial dermal-parenchymal pedicle.



tissue.
• Pedicle is created from main blood supply of
NAC.
35
• Pedicle is superior, where fullness is commonly
desired.
• Allows creation of inferior pillar support to limit
bottoming out
• Ease of use with short-scar techniques
• Nipple-areolar sensation reliably maintained


• Creates dead space at dependent part of


NAC is maintained on a central parenchymal
pedicle (without dermis).
Central pedicle/mound.

774
Part VIII Breast Surgery
Breast tissue can be excised laterally, medially, superiorly, and inferiorly, leaving a
central glandular component.


• Ideal to preserve lactation
• Allows variable resection of parenchyma in multiple quadrants

• Underresection is common.
• Safety issues with undermining pedicle as blood supply comes from chest wall.
• Breast shape/support largely dependent on dermal support
• Possible bottoming out.
TIP: With all pedicle patterns, nipple viability should be checked before thinning the

and the pedicle debrided to the appropriate level without compromising breast volume.
SKIN RESECTION PATTERNS
Mastopexy procedures (or very small reductions) allow periareolar incisions and skin
resection alone, but this is inappropriate for use in patients with true hypermastia.

Vertical pattern.
Allows excision of lax skin in horizontal dimension
With lateral (lazy-J) extension lax skin in the vertical dimension36,37
Some authors advocate tailor-tacking to facilitate incision placement.
Once desired shape and skin contour are obtained, the “tailored” resection pattern is
marked and excised.
Other techniques avoid a transverse scar by gathering the skin in the vertical closure,
leaving a dog-ear in the inframammary fold (IMF).31 This skin redundancy requires
delayed excision in approximately of patients.
• More recent evidence, however, cautions against the use of gathering sutures
38
change
the areola-to-IMF distance or pucker revision rate.

775
Chapter 55 Breast Reduction
SENIOR AUTHOR TIP: If the remaining dog-ear appears exceptionally large in the IMF,
do not hesitate to excise it with a small horizontal excision. A small horizontal incisional


Inverted-T pattern.
Skin excision includes both a vertical and horizontal excision.
is removed through the
is removed with the placed in the inframammary
fold.
Especially useful in large reductions with excessive amounts of skin redundancy
Wound separation is fairly common at the intersection point in the IMF.
SURGICAL TECHNIQUES
INFERIOR PEDICLE WITH INVERTED KIN RESECTION
A
B
C
D
A
B
C
D
Inferior pedicle with inverted-T skin resection.

776
Part VIII Breast Surgery

Place patient in an upright position.
Mark the midline.
Mark the breast meridian to determine a new horizontal nipple position.
Mark the vertical nipple location (Pitanguy point) by transposition of IMF to
front of breast.
Mark the IMF position, elevating mark a few millimeters onto the breast. This
keeps the IMF scar on the breast and not on the chest, because the base of the breast is
narrowed during reduction.
Measure bilaterally from notch to nipple and from midline to ensure symmetry.
Mark the vertical limbs, which should measure approximately 7-8 cm under
tension.

in closure under tension, which may compromise shape and skin viability.
• The angle of divergence determines amount of skin resection.
Connect vertical limbs to the medial and lateral aspects of the IMF marking,
following a lazy-S pattern.
Mark the pedicle approximately 10-12 cm from the midline.
Mark the areola at 42 mm; replace at 38 mm to minimize traction and
distortion on the areola.
Mark all areas to be liposuctioned.


pedicle.
Place the patient in a sitting position and tailor-tack, as needed, to achieve desired
shape.
Hidalgo40
improve aesthetic outcome.
SUPEROMEDIAL PEDICLE WITH INVERTED KIN RESECTION
Superomedial pedicle with inverted-T skin resection.
A
D
B
C
A
D
B
C

777
Chapter 55 Breast Reduction

Place patient in an upright position.
Mark the midline.
Mark the upper breast border.
Mark the position of the IMF.

at the intersection of the breast meridian.
Mark the top of the areolar opening 2 cm above the new nipple position.
Extend areolar markings to create 4 cm diameter opening on closure.
Mark the vertical limbs by rotating the breast medially and laterally.
Join the vertical limbs at the meridian 2-4 cm above the IMF.
Design the pedicle with a 6-10 cm base; carry base slightly lateral to the
meridian if a superomedial pedicle is desired.
Mark areas to be liposuctioned.

Creating a V pattern rather than a U when joining the vertical limbs above the IMF will
prevent skin pucker on closure.
After parenchyma is excised, approximate breast pillars, inset the NAC, and close the
vertical incision in a gathering fashion, as needed.
31,41
TIP:
by what is removed.
BREAST REDUCTION IN ADOLESCENTS
Patients should generally have stable breast size for 12-24 months. Surgery is performed
earlier only if patients have severe physical or psychological symptoms.
42
• Study included 48 women whose average age was 17.8 years at reduction.
• 94% reported satisfaction (i.e., would recommend the surgery to a friend).
• 60% complained of a prominent scar.
• 35% reported changes in nipple sensation.
• About 80% had relief of pain.
• 72% had some regrowth of tissue; only one had reoperation for hypermastia.
SECONDARY BREAST REDUCTION
Causes include recurrence and inadequate primary reduction.
Revision must be tailored to the presenting deformity, cause of deformity, previous
surgical technique, and patient expectations.
Published evidence is controversial on using same pedicle.43

778
Part VIII Breast Surgery
Algorithm for the workup and treatment of recurrent mammary hypermastia44 (Fig.
55-8)
• Rule out malignancy as a possible cause.
• With inadequate primary excision, surgical approach is dictated by the amount of
tissue to be resected and knowledge of primary pedicle.
History and records
(operative report) review
Physical examination
and mammogram
Suspicious

or clinical history
<500 g to be reduced
from each side
and NAC position
satisfactory
Reduction based
on primary pedicle
if known or inferior
wedge resection
Consider liposuction
Reduction
based on
primary pedicle
with adjunct
liposuction

from each side
and NAC requires
reposition
Biopsy and
treatment

macromastia
Primary pedicle
known
Pseudoptosis
only
Primary pedicle
unknown
Free-nipple graft
technique
Inferior wedge
resection
Recurrence
Juvenile macromastia
Reduction versus
mastectomy and
unilateral or bilateral
reconstruction
Inadequate primary
excision
Algorithm for workup and treatment of recurrent mammary hypermastia.

779
Chapter 55 Breast Reduction
DATA DEMONSTRATED MIXED OUTCOMES FROM USE
OF TRANSECTED PEDICLES
45
• 2 patients had previous pedicle transected; both developed NAC compromise.
• 1 of 5 developed healing complications when pedicle was not transected.
• Authors recommended free-nipple graft if primary pedicle is unknown.
l46
• Two thirds of patients with transected pedicles had a complication that healed
conservatively.
• Authors concluded that it was safe to change pedicles.
43
• Breast re-reduction can be performed safely and predictably, even when the
previous technique is not known.
• Four key principles were developed:

re-creating or developing a new pedicle.


inframammary fold.

REDUCTION OF IRRADIATED BREASTS
l47
• No complications in three cases
• Waited 6 months between cessation of radiation and surgery

48
• 12 patients had bilateral reduction; mean 86 months after lumpectomy and
radiation.
• 42% complication rate in irradiated breasts

• 25% postoperative asymmetry
• Four of 12 had secondary surgery: two for complications and two for asymmetry.
BREAST INFILTRATION

reduces operative blood loss.
49

without

• 40 ml to each breast: 20 ml injected to retroglandular space + 20 ml injected along
incision markings
• Reduction patterns: Superomedial pedicle, inferior pedicle, or McKissock (bipedicle)
• Average resection in each group approximately 1000 g

780
Part VIII Breast Surgery






operation time
50



• 200 ml injected to retroglandular space + 40 ml injected along incision markings
• Reduction patterns: Superomedial pedicle or inferior pedicle


untreated contralateral control.


TECHNICAL REFINEMENTS
The following are suggestions for improving postoperative breast shape and ultimate
aesthetic result.
NIPPLE POSITION

• The nipple should be slightly lower in mature, fatty breasts.

SENIOR AUTHOR TIP: In superior pedicle vertical reductions, the nipple will move
higher in the larger breast on closure of the pillars,
than on the larger side.

INVERTED KIN EXCISION
As the superior keyhole angle widens, the skin margins at the inferior aspect of the T


healing problems and scar widening.


pole.
51
Short vertical limbs were encouraged in the past as a method to minimize inferior
parenchymal descent, but relying on dermal support for long-term shape is now
outdated.
• Short limbs increase tension in the T region.
• Vertical limbs should be kept in length, and limbs of 8-10 cm may be

781
Chapter 55 Breast Reduction
TIP: Some suggest leaving a small wedge of skin at a three-cornered closure of the

VERTICAL SKIN EXCISION

inverted-T because of the required
tailoring
Tension should be on
and not on skin.
Avoid horizontal bunching, because
this can cause train-track scars.
can be useful to
shorten the nipple-to-fold distance.
If lazy-J extension is needed, make
sure it curves up with the new breast
fold.
AXILLARY FULLNESS
Hypertrophic breasts are typically wider than normal.

The breast appears to extend upward and laterally into the axilla and the midaxillary
line.
Subcutaneous fat can be directly excised in this region and the overlying skin sutured.

POSTOPERATIVE DRAINS
Studies do demonstrate lower complication or hematoma rates attributable to
drain use.

52




53





54

performed without drains

style reduction



(2%)

A small wedge of skin at the site of

782
Part VIII Breast Surgery

patients with drains

is unnecessary

55


output


postoperative drains
OUTCOME STUDIES
56
• 93% of patients reported decrease in symptoms.
• 62% of patients reported increase in activity.
57
• 97% of patients reported symptom improvement (59% had complete elimination of
symptoms).
6
• Patients reported 87% overall satisfaction rate.
• Main sources of dissatisfaction were breast size, shape, and scars.
CANCER DETECTION
Recommendations for preoperative mammography vary widely.
• At a minimum, follow American Cancer Society guidelines.

age.
58
• Send all specimens to a pathologist.
• Incidence of cancer in reductions is reported at 0.06%-1.8%.
• Obtain new baseline mammograms 1 year postoperatively.

breast carcinoma.
• CT or MRI can be used when routine screening is unclear.
SPECIAL CONSIDERATIONS
FREE IPPLE GRAFTING

• Patients with severe hypermastia in which traditional pedicles will too greatly limit
the ability of the surgeon to reduce the breast to the desired size
• Patients with systemic illnesses that may impair vascular supply to the NAC (e.g.,
diabetes mellitus)
• Patients requiring short anesthesia times

783
Chapter 55 Breast Reduction

• NAC is removed at the beginning of the procedure.
• NAC is defatted like a skin graft.
• The redundant skin and breast tissue is then excised and shaped into a new breast
mound. (Inverted-T pattern skin resection is used almost exclusively.)

59 can be performed to improve volume

• NAC is grafted at the desired nipple position.
• Bolster is placed over graft.

• Complete loss of lactation potential can occur.
• Sensory recovery is poor.
• Patchy hypopigmentation occurs routinely.
• Breast shape is rarely ideal.
NOTE:

POSTOPERATIVE CARE

Drains are not required for all breast reductions.
Postoperative pain is treated with oral analgesics.
Scar treatment begins 3 weeks postoperatively with the surgeon’s preferred technique.
Scar revisions, when necessary, are performed after 1 year.
COMPLICATIONS
VASCULAR COMPROMISE OF THE NIPPLE REOLA COMPLEX
A devastating complication of breast reduction is loss of the NAC.

More common in patients with systemic illness, tobacco use, very large breasts, and
patterns closed under excessive tension

clinical examination is the most commonly used method to assess intraoperative
viability.


1. Stop dissection.
2. Ensure patient has adequate blood pressure (BP), urinary output, and temperature.
3. Observe for 10-15 minutes for red bleeding from areola or pedicle borders.
4. Consider conversion to free-nipple graft if clear venous congestion without
resolution and fear of complete nipple compromise; be sure nonviable parenchyma
underlying nipple is also resected.

784
Part VIII Breast Surgery
During closure:

2. Evacuate hematoma if present.
3. Check pedicle for kinking.
4. Ensure patient has adequate BP, urinary output, and temperature.

6. If nipple returns to normal color, close.
7. Options are available if nipple is compromised with reclosure.
Convert to free-nipple graft.

Postoperatively:
• If hematoma is obvious, release periareolar suture and return to operating room.
• If no hematoma is obvious, release periareolar suture(s).
If nipple returns to pink, leave wound open and close when edema resolves.
If nipple remains blue, return to operating room and use previous algorithms.
CHANGES IN NIPPLE SENSIBILITY
After reduction mammaplasty, the nipple-areolar sensibility may be lost, decreased,
and even become more sensitive51 (thought to be from relief of chronic neural
traction).
Altered nipple sensation: 9%-25% of patients
Increased rates with increased amounts of resection
Improved sensation in patients with gigantomastia; probably from reduced traction on
nerves to NAC
61-63 (up to 52% in very
large reductions).
Some studies indicate that areolar sensibility is better maintained with an inferior
pedicle design, compared with medial32 or superior64 pedicles.
NOTE:



OTHER COMPLICATIONS
4% of patients
Up to 19% of patients; more prevalent in larger
reductions, especially if closed with excessive tension
BREAST EEDING
65
• 91% of patients reported normal lactation postoperatively.
66
• 65% of patients could breast-feed.
• Supplemental feeding was needed in all cases.

785
Chapter 55 Breast Reduction
15
• 69% of patients could breast-feed.
• 18% needed supplemental feeding.

• Fat necrosis, hypertrophic scarring and scar widening, asymmetry, underresection
or overresection, persistent pain, infection, change in breast shape over time,
hematoma (incidence is not decreased with placement of drains; more common in
patients with hypertension)
TOP TAKEAWAYS

Excessive breast size in proportion to body habitus may result in unsatisfactory
breast aesthetics and the medical and physical complications of hypermastia.

Breast reduction has an and has been
shown to

Determining the aesthetic or medical necessity of reduction mammaplasty
is ambiguous and nonstandardized by health insurance carriers in the United
States.

Although noninvasive monitoring options are available (laser Doppler

intraoperative viability.
REFERENCES
1. Pang S. Premature thelarche and premature adrenarche. Pediatr Ann 10:29, 1981.
2. Root AW, Shulman DI. Isosexual precocity: current concepts and recent advances. Fertil Steril
45:749, 1986.
3. Jabs AD, Frantz AG, Smith-Vaniz A, et al. Mammary hypertrophy is not associated with increased
estrogen receptors. Plast Reconstr Surg 86:64, 1990.

Surg 99:386, 1997.

Reconstr Surg 109:64, 2002.

and patient satisfaction. Plast Reconstr Surg 96:1106, 1995.
7. Glatt BS, Sarwer DB, O’Hara DE, et al. A retrospective study of changes in physical symptoms
and body image after reduction mammaplasty. Plast Reconstr Surg 103:76, 1999.
8. Netscher DT, Meade RA, Goodman CM, et al. Physical and psychosocial symptoms among 88
volunteer subjects compared with patients seeking plastic surgery procedures to the breast.
Plast Reconstr Surg 105:2366, 2000.
-
constr Surg 108:1591, 2001.

breast hypertrophy. Plast Reconstr Surg 106:280, 2000.
11. Shermak MA, Chang D, Buretta K, et al. Increasing age impairs outcomes in breast reduction
surgery. Plast Reconstr Surg 128:1182, 2011.

786
Part VIII Breast Surgery
12. Nahai FR, Nahai F. MOC-PSSM CME article: breast reduction. Plast Reconstr Surg 121(1 Suppl):1,
2008.

in plastic surgery. Aesthet Surg J 26:157, 2006.

Reconstr Surg 89:836, 1992.
15. Brzozowski D, Niessen M, Evan HB, et al. Breast-feeding after inferior pedicle reduction mam-
maplasty. Plast Reconstr Surg 105:530, 2000.

Plast Reconstr Surg 114:890, 2004.

18. Matarasso A. Suction mammaplasty: the use of suction lipectomy alone to reduce large
breasts. Clin Plast Surg 29:433, 2002.

1993.
20. Brown MH, Weinberg M, Chong N, et al. A cohort study of breast cancer risk in breast reduction
patients. Plast Reconstr Surg 103:1674, 1999.
21. Colwell AS, Kukreja J, Breuing KH. Occult breast carcinoma in reduction mammaplasty speci-
mens: 14-year experience. Plast Reconstr Surg 113:1984, 2004.

94:100,1994.
23. Goldwyn RM. Outcome study in liposuction breast reduction [discussion]. Plast Reconstr Surg
114:61, 2004.
24. Brauman D. Reduction mammaplasty by suction alone. Plast Reconstr Surg 94:1095, 1994.
25. Courtiss EH, Goldwyn RM. Reduction mammaplasty by the inferior pedicle technique: an al-
ternative to free nipple and areolar grafting for severe macromastia or extreme ptosis. Plast
Reconstr Surg 59:500,1977.
26. Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast
Reconstr Surg 103:890, 1999.
-
ferior pedicle technique: early and late complications in 371 patients. Br J Plast Surg 49:442,
1996.


11:107, 1987.

Plast Reconstr Surg 104:764, 1999.

Plast Reconstr Surg 104:748, 1999.
-
tion mammaplasty. Ann Plast Surg 49:24, 2002.

of 250 consecutive cases. Plast Reconstr Surg 117:2152, 2006.
34. Strombeck JO. Mammaplasty: report of a new technique based on the two pedicle procedure.
Br J Plast Surg 13:79, 1960.
35. Michelle le Roux C, Kiil BJ, Pan WR, et al. Preserving the neurovascular supply in the Hall-Findlay
superomedial pedicle breast reduction: an anatomical study. J Plast Reconstr Aesthet Surg
63:655, 2010.

787
Chapter 55 Breast Reduction


1992.

does gathering the incision matter? Ann Plast Surg 77:25, 2016.
39. Jones G, ed. Bostwick’s Plastic and Reconstructive Breast Surgery, ed 3. New York: Thieme
Publishers, 2010.
40. Hidalgo DA. Improving safety and aesthetic results in inverted T scar breast reduction. Plast
Reconstr Surg 103:874; discussion 887, 1999.
41. Hall-Findlay EJ, Shestak KC. Breast reduction. Plast Recontr Surg 136:531e, 2015.

Ann Plast Surg 35:227, 1995.

Reconst Surg 139:1313, 2017.
44. Rohrich RJ, Thornton JF, Sorokin ES. Recurrent mammary hyperplasia: current concepts. Plast
Reconstr Surg 111:387,2003.
45. Hudson DA, Skoll PJ. Repeat reduction mammaplasty. Plast Reconstr Surg 104:401, 1991.

pedicle safe? Plast Reconstr Surg 106:1004, 2000.

conservation surgery and radiation therapy. Plast Reconstr Surg 102:1913, 1998.
48. Parrett BM, Schook C, Morris D. Breast reduction in the irradiated breast: evidence for the role
of breast reduction at the time of lumpectomy. Breast J 16:498, 2010.
49. Wilmink H, Spauwen PH, Hartman EH, et al. Preoperative injection using a diluted anesthetic/

Surg 102:1913, 1998.

reduction mammaplasty: an early survey. Scand J Plast Reconstr Hand Surg 26:211, 1992.

1972.
52. Wrye SW, Banducci DR, Mackay D, et al. Routine drainage is not required in reduction mam-
maplasty. Plast Reconstr Surg 111:113, 2003.

controlled inter-patient study. J Plast Reconstr Aesthet Surg 62:865, 2009.
54. Matarasso A, Wallach SG, Rankin M. Reevaluating the need for routine drainage in reduction
mammaplasty. Plast Reconstr Surg 102:1917, 1998.
55. Ngan PG, Igbal HJ, Jayagopal S, et al. When to use drains in breast reduction surgery? Ann Plast
Surg 63:135, 2009.



Plast Surg 35:337, 1995.


reduction mammaplasties. Plast Reconstr Surg 110:960, 2002.
-
lishers, 2011.
61. Gonzalez F, Brown FE, Gold ME, et al. Preoperative and postoperative nipple-areola sensibility
in patients undergoing reduction mammaplasty. Plast Reconstr Surg 92:809, 1993.

788
Part VIII Breast Surgery
-
plasty. Ann Plast Surg 41:370, 1998.
63. Greuse M, Hamdi M, DeMey A. Breast sensitivity after vertical mammaplasty. Plast Reconstr
Surg 107:970, 2001.
64. Hamdi M, Greuse M, DeMey A, et al. A prospective quantitative comparison of breast sensation
after superior and inferior pedicle mammaplasty. Br J Plast Surg 54:39, 2001.
65. Aboudib JH Jr, de Castro CC, Coelho RS, et al. Analysis of late results in postpregnancy mam-
moplasty. Ann Plast Surg 26:111, 1991.
66. Sandsmark M, Amland PF, Abyholm F, et al. Reduction mammaplasty: a comparative study of
the Orlando and Robbins methods in 292 patients. Scand J Plast Reconstr Hand Surg 26:203,
1992.

789
INDICATIONS AND CONTRAINDICATIONS
Typically, and resolve with expectant management.1
• Neonatal cases: Resolved within several weeks
• Pubertal cases: 75% of cases resolved within 2 years without treatment2


Pathological causes necessitate formal medical evaluation with special attention to the
associated comorbidities.

of male breast cancer. (The prevalence of Klinefelter syndrome in males with breast
cancer is 7.5%.)
3,4

5,6
DEMOGRAPHICS
Reported incidence: Up to 36% in general population7
8
ETIOLOGIC FACTORS
Often involving excess estrogens, decreased androgens, and/or androgen
receptor defects.
CLINICAL CLASSES



• Pubertal: Elevated estradiol/estrogen ratio
• Senile: Peripheral conversion of testosterone to estrogen by aromatase
Cirrhosis, kidney failure, testicular/adrenocortical/pituitary tumors,
hypogonadism, hyperthyroid, adrenal hyperplasia, and bronchogenic carcinoma
Estrogens, gonadotropins, androgens, antiandrogens, chemotherapy
agents, calcium channel blockers, ACE inhibitors, digitalis, CNS agents, antituberculosis
medications, and drugs of abuse
HISTOLOGY
Represents the cellular changes seen with prolonged gynecomastia
Symptoms <4 months; cellular stroma and ducts increased

790
Part VIII Breast Surgery
PREOPERATIVE EVALUATION
HISTORY
Age of onset
Duration
Additional symptoms
Current/recent medications
Illicit drug use
Past medical history
Family history (breast cancer)
SENIOR AUTHOR TIP: Be certain to note whether or not the presence of the excess
breast tissue causes pain. This can be an important symptom that may determine
whether or not insurance coverage will be extended for treatment.
PHYSICAL EXAMINATION

milky discharge (prolactin-secreting tumor)



Feminine features
Absence of masculine attributes (i.e., hair pattern)
LABORATORY TESTS
Beta-human TSH/free thyroxine, chorionic gonadotropin, follicle-stimulating hormone,
luteinizing hormone, serum testosterone, and estradiol levels to correlate abnormal

Consider liver function tests for hepatomegaly.
• Endocrine consult and chromosomal analysis when indicated
IMAGING
Breast imaging through mammography or ultrasonography: May be controversial,
because gynecomastia is much more common than male breast cancer
Mammography: When breast cancer is suspected.9 Helpful for assessing the quality of

TIP: Completion of a testicular exam needs to be documented in the medical record.
If there is any concern for potential scrotal mass or inconsistency in testicular exam,
ultrasound imaging of the scrotum/testicles is indicated.
STAGING
Minimal hypertrophy (<250 g) and no ptosis
Moderate hypertrophy (250-500 g) and no ptosis

791
Chapter 56 Gynecomastia
INFORMED CONSENT
If surgery is indicated, the planned incisions and appearance are discussed.
• Pictures/diagrams are used to reinforce the discussion.
Both the general and the most relevant potential complications (see preceding section)
are included.
Asymmetry, contour irregularities, and the need for further procedures are discussed,
especially when liposuction is used alone or staged excision is planned.
TECHNIQUE
NONOPERATIVE
is recommended for neonatal (weeks to months), pubertal
(up to 2 years), and idiopathic cases.

source suspected.
Hormonal therapy is considered where appropriate.

For pathological causes, the underlying disease or source (i.e., testicular tumor; liver,
pituitary, or thyroid disease) is treated.

of and
OPERATIVE
SENIOR AUTHOR TIP:
normal social development of the patient resulting in social withdrawal, avoidance of
normal sports activities, or embarrassment in situations where the chest is exposed as
in swimming, a low threshold for operative treatment should be instituted.
Markings are made while patients are standing.
• Boundaries for treatment are outlined.
• A topographic technique is employed involving concentric circles extending
outward from areola.



needed.
The procedure is performed with the patient under general anesthesia or local
anesthesia with IV sedation in the operating room or a licensed surgery center.
A standard instrument tray is used for surgical excision and includes lighted breast
retractors or a headlight.
TIP: Disruption of the IMF is a key technical consideration in redraping of the soft
tissue for cosmesis. This is a distinguishing feature between female breast surgery where
obliteration of the IMF would be considered technically improper.

792
Part VIII Breast Surgery
SURGICAL EXCISION
Still referred to as the mainstay of treatment for excessive and refractory cases (grades
III and IV), although many think surgery has become less indicated
Excess glandular tissue without skin excess
• Incisions: Inferior areolar semicircle (preferred), transverse transareolar, radial/
hemitransverse areolar (last resort)
• Dense subareolar glandular tissue resected with any adipose tissue
• Creation of “saucer deformity” with overresection prevented by

Skin and glandular removal both required
• Reduction-pattern mammaplasty with dermal pedicle or mastectomy with free
nipple grafts
• Extensive resections may necessitate drainage.
TIP: While creation of a “saucer deformity” is considered technically incorrect, some
overresection of the subareolar tissue is often performed in order to meet patient
expectations for removal of “all” the symptomatic tissue.
SENIOR AUTHOR TIP: In cases of severe skin excess, a horizontal ellipse is the best
pattern to use to resect the redundant skin. This avoids the vertical scar and places the
surgical scar in the inframammary fold. The blood supply to the NAC is preserved via
an inferior pedicle.
ULTRASOUND SSISTED LIPOSUCTION
The point is marked as described previously.
General anesthesia or local with IV sedation is used.
The patient is placed in a supine position with arms abducted.
3 to 4 mm stab incisions are made with a No. 11 blade scalpel along the lateral IMF for
optimal access to all treatment areas. (Some authors advocate similar exposure through
superior axillary and periareolar incisions.)

4 mm golf tee cannula, and a surgical aspirator are needed.


• A “superwet” technique is used.
• All injected volumes are recorded for comparison between sites.

and the cannula is used to create deliberate uniform strokes in a radial pattern,
concentrating on the areas of interest based on the preoperative markings.
• A Mentor generator is set at an energy level between 70% and 90%. 90% is most


to tissue density and treatment response.
• A bimanual technique is recommended to guide the cannula and to assess depth of
treatment.

tissue.
The IMF should be thoroughly obliterated to allow redraping of the overlying skin.

793
Chapter 56 Gynecomastia
The time for each treatment area is recorded.
• Endpoints for treatment are and of resistance.

• Volumes from distinct areas are recorded for comparison between sides.
Final contouring and feathering should be performed with a 3.7 mm cannula (or smaller
based on surgeon preference).
• Irregularities are smoothed, disrupting the IMF and avoiding adherence zones


Incisions are closed with fast-absorbable sutures.
Dressings are applied.
SUCTION SSISTED LIPOSUCTION


lipectomy is undertaken with a 2.7 to 5.2 mm cannula.



grasp and elevate the breast tissue being treated.
• Endpoints are determined by and
• A greater degree of resistance is noted with the treatment of the dense subareolar
area.
Radial patterns are again employed.

COMBINED/STAGED APPROACH
Some authors advocate a combination of both liposuction and excision based on the
11,12
and the remaining
bud needs direct excision.
• This is usually best seen after the liposuction portion.
• It can be performed using a limited-incision “pull-through approach.”
11

• The delay may preclude the need for surgery or lessen the extent of resection if

POSTOPERATIVE CARE
If drains are placed after excision technique, the patient should be counseled regarding
drain care and output recording.
• Removed when output <25 cc/24 hours
Dressings: External support with compression vest or tight “T-shirt” is needed at all

Perioperative prophylactic antibiotics are given.
Histopathologic evaluation: According to a literature review, the possibility of accrual
breast cancer in adolescents with gynecomastia is 1% (maximum).13 Some authors
argue that routine histopathologic examination incurs negative productivity costs.14
However, the prevalence of malignancies in gynecomastia specimens increases with

794
Part VIII Breast Surgery
patient age.15 Histologic evaluation is recommended for all patients with pathologic
gynecomastia.
SENIOR AUTHOR TIP: Standard post-operative vests are often ill-fitting and

athletic compression shirt before surgery and bring this garment with him to surgery.

the patient can wear comfortably, thus enhancing compliance.
COMPLICATIONS
Complication and revision rates vary widely, depending on the techniques and author.
Complications typically range from 10% to 25%16,17 and include hematoma, seroma,
underresection/overresection, scarring (hypertrophic scar, nipple retraction), areolar
hypopigmentation, and cicatricial alopecia of chest hair.
Revision rates vary from 0% to 42%, depending on the source and technique.
The presence of skin excision, whether at the initial procedure or delayed, is associated
with increased complication rates, from 14% to 40% in some studies.
OUTCOMES
18
• Comparison of liposuction only (16 patients) versus combination (liposuction and
excision) therapy (48 patients)
• Retrospective comparison of 64 patients
• Improved outcomes and patient satisfaction for combined treatment group

Excision19

• Patient expectations predicated on body types
• All underwent subcutaneous mastectomy

• Complications: 312 cases; 6 seromas (2%), 3 hematomas (1%)
Excision6
• Overresection in 18.7% of cases
• Poor scarring in 18.7% of cases
• Hematomas in 16% of cases
• Seromas in 9% of cases
• Underresection in 22% of cases
UAL ( 20
• No hematomas, skin necrosis, or other complications
• Results uniformly good to excellent at 4-year follow-up
UAL10
• 61 patients

795
Chapter 56 Gynecomastia

• Staged skin excision was required by 33% of stage III and 57% of stage IV patients.

retraction.
11
• No nipple-areola complex (NAC) necrosis, hematoma, or infection
• One patient each with scar retraction, seroma, access port skin burn, epidermolysis,
or decreased NAC sensation
• All patients pleased with results
12
• Treated 20 patients who used anabolic steroids
• Resulted in two hematomas, two seromas, three recurrences
21
• 76 patients of 226 treated with combination liposuction and tissue shaver for
gynecomastia
• Resulted in two seromas, one hematoma, one ultrasound burn, one skin buttonhole,
four operations for recurrence

single therapy (excision or liposuction)

TOP TAKEAWAYS

Approximately 75% of pubertal gynecomastia cases resolve without treatment.



The cause of gynecomastia is unknown in around 25% of cases.

Gynecomastia can be caused by medication and pathological conditions such as
tumor and chronic disease. A thorough medical history should be obtained and
an extensive physical examination performed.


and a combination of excision and liposuction can be used for treatment of
gynecomastia.

Delayed skin excision after liposuction leaves a minimal scar and can preclude
the need for extensive excision.
REFERENCES
1. Wise GJ, Roorda AK, Kalter R. Male breast disease. J Am Coll Surg 200:255, 2005.

and Therapeutics Committee. Use of aromatase inhibitors in children and adolescents with
disorders of growth and adolescent development. Pediatrics 121:e975, 2008.
3. Hultborn R, Hanson C, Köpf I, et al. Prevalence of Klinefelter’s syndrome in male breast cancer
patients. Anticancer Res 17:4293, 1997.

100:814, 2011.
5. Banyan GA, Hajdu SI. Gynecomastia: clinicopathologic study of 351 cases. Am J Clin Pathol
57:431, 1972.

796
Part VIII Breast Surgery
6. Courtiss EH. Gynecomastia: analysis of 159 patients and current recommendations for treat-
ment. Plast Reconstr Surg 79:740, 1987.

1979.
8. Niewoehner CB, Nuttal FQ. Gynecomastia in a hospitalized male population. Am J Med
77:633,1984.
9. Mathew J, Perkins GH, Stephens T, et al. Primary breast cancer in men: clinical, imaging, and


the role of ultrasound-assisted liposuction. Plast Reconstr Surg 111:909, 2003.
11. Hammond DC, Arnold JF, Simon AM, et al. Combined use of ultrasonic liposuction with the
pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg 112:891, 2003.
12. Babigian A, Silverman RT. Management of gynecomastia due to anabolic steroids in bodybuild-
ers. Plast Reconstr Surg 107:240, 2001.
13. Kwan D, Song DH. Discussion. Breast cancer incidence in adolescent males undergoing sub-

and literature review. Plast Reconstr Surg 127:8, 2011.
-
mastia necessary? A 15-year retrospective pathological and literature review. Can J Plast Surg
22:112, 2014.

Ann Plast Surg 74:163, 2015.

53:97, 2004.

Ann Plast Surg 69:510, 2012.
-
tectomy and liposuction. Aesthetic Plast Surg 40:877, 2016.

body types: considerations on 312 consecutive treated cases. Ann Plast Surg 78:492, 2017.
20. Gingrass MK, Shermak MA. The treatment of gynecomastia with ultrasound-assisted lipoplasty.
Semin Plast Surg 12:101, 1999.
21. Petty PM, Solomon M, Buchel EW, et al. Gynecomastia: evolving paradigm of management
and comparison of techniques. Plast Reconstr Surg 125:1301, 2010.

PART IX
Body Contouring

(Trang không có chữ)

799
First recorded attempt at lipectomy is attributed to the French surgeon who,
in the 1920s, attempted to remove fat from a dancer’s calves using a uterine curette.1
• Vascular damage resulted in amputation of the leg.
In the mid-1970s and his father, developed the
“cellusuctiotome,” an instrument made of a hollow curette and blade attached to a
suction pump. This method had a high rate of bleeding complications.
and improved on the prior techniques by replacing
the sharp curettes of the 1970s with a cannula and suction system, the introduction
of a “wetting solution” containing saline solution and hyaluronidase, and the use of a
“crisscross” technique.
• These methods decreased bleeding and contour-associated complications.
In the 1980s a dermatologist, introduced the tumescent technique.

and epinephrine that expands the fat compartment causing it to become swollen

• Provides local anesthesia and reduces blood loss
ANATOMY
SUBCUTANEOUS LAYERS
Superficial
Deep
Intermediate

Subcutaneous adipose tissue is divided into and deep layers throughout the
2

800
Body Contouring
For purposes of body contouring, the subcutaneous fat is arbitrarily divided into
3





layer

• Deep


ZONES OF ADHERENCE
Gluteal
crease
Distal
posterior
thigh

Distal iliotibial tract
Middle medial thigh

Distal iliotibial tract
Gluteal crease

Middle medial thigh
Distal posterior thigh
CAUTION:

SENIOR AUTHOR TIP:
relaxed using an exploded tip cannula without suction (i.e., separation and equalization).
The tissue will become more pliable to allow smooth transitions into surrounding areas
and enable these zones to be traversed or treated safely.
CELLULITE YNOID LIPODYSTROPHY
Peau d’orange and mattresslike deformity seen primarily in women and obese patients
4
Results from hypertrophic fat cells

801
Chapter 57


Results from



PREOPERATIVE EVALUATION
PHYSICAL EXAMINATION
Check for deviation from ideal contour (Fig. 57-3).
Ideal contour. A, Female. B, Male.
A
B


thighs




thighs


• Note any of the following:





• Check skin
• Examine spine for

• Assess for

802
Body Contouring
MEDICAL HISTORY
Agents that interfere with coagulation should be avoided.
• Aspirin
• NSAIDs
• St. John’s wort
• Vitamin E
• Herbal supplements
• Other anticoagulants
Note personal and family history of deep venous thrombosis or clotting disorders.
Photographs
• Standard photographs of areas to be treated should be obtained.
• See Chapter 3 for further details on photography.
SENIOR AUTHOR TIP: Patient selection is critical. Common pitfalls include:
redundant and poor quality skin, obesity with excess intraabdominal fat and
unreasonable expectations.
PERIOPERATIVE CONSIDERATIONS
PREOPERATIVE
Complete blood cell count if expecting to perform
lipoaspirate) procedure
Perioperative IV antibiotics
Deep venous thrombosis prophylaxis
• Intermittent pneumatic compression devices should be used intraoperatively.
• Chemoprophylaxis may be given to those at higher risk (see Chapter 11).
HYPOTHERMIA
Forced-air warming blankets
Consider circulating warm water mattresses
Cover exposed body areas.

Warm operating room.
Warm wetting solutions.
POSITIONING
Pad all pressure points.
Prone position
• Protect face, breasts, and genitals.
• Soft hip roll beneath iliac crest
Supine position
• Arm abduction <90 degrees to prevent brachial plexus injury

803
Chapter 57
SENIOR AUTHOR TIP: Using multiple patient positions allows for target areas to
be treated thoroughly, without the distortion and compression from the operating
table seen when using a single supine position, or even in supine/prone positioning.
Three positions: Supine, lateral decubitus, and the opposite lateral decubitus allow
for complete exposure of the body circumferentially while avoiding the more onerous
and time-consuming prone position. As a caveat, if the operating surgeon is strongly
one-handed, adding the prone position to the standard three position routine can help
intraoperative assessment and prevent asymmetries. Additionally, multiple patient
positions allow cross-hatching and help ensure complete treatment. It also reduces
the risk of creating iatrogenic contour deformities.
MARKINGS
Patients should be marked when they are in
an upright position or standing.
Use marker to outline areas to be treated.
Mark zones of adherence and other areas to
be avoided with parallel lines or cross-hatch
marks.
INCISIONS



respectively).
Incisions can be placed anywhere adjacent to
areas being treated.
Multiple incisions are used for access to target
areas, and ideally they are strategically located to allow

(Fig. 57-5; Box 57-1)
Incisions for buttocks, medial thighs, and abdomen.
Markings. Circled Xs are over
zones of prominence, and lines are over
zones of adherence.

804
Body Contouring
Box INCISION LOCATIONS FOR LIPOSUCTION
• Breast (male): Anterior axillary fold and/or periareolar
•
• Vertical back: Midline
• Flank/hip: Sacral, groin crease, midaxillary line in panty line
•
• Buttock: Sacral, midaxillary line in panty line
•
• Posterior thigh: Midaxillary line in panty line
• Medial thigh: Medial groin crease and inguinal crease
• Anterior thigh: Inguinal crease
• Upper arm: Anterior and posterior axillary folds, olecranon radial elbow crease
LIPOSUCTION CANNULAS
Most tips are with multiple openings set back from the end to allow suctioning of
fat with passage of the cannula.
• Blunt tips limit risks of penetration of unwanted structures such as fascia,
peritoneum, vessels, and nerves.
Suction cannulas range from 1.8 mm up to 1 cm in diameter (typical use for liposuction
is 2.5-5.0 mm) with varying cannula lengths.
suction cannulas are typically used for tissue.
• As suction cannula size increases, the rate of fat removal with each pass increases, as
does the risk of contour irregularities.
PHYSICS AND THEORY OF LIPOSUCTION



• The avulsion of fat into the islets of the cannula as the cannula moves in and out

• Directly proportional to the diameter of the cannula and suction tubing
• Directly proportional to vacuum pressure
• Inversely proportional to the length of the cannula
• Poiseuille law concepts

4
of the tube, and K is a constant factor
WETTING SOLUTIONS
PURPOSES
Volume replacement
Hemostasis
Analgesia

805
Chapter 57

Dissipate heat

• 1000 ml of lactated Ringer solution at 21o C
• 30 ml of 1% lidocaine plain (15 ml if large volume)
• 1 ml of 1:1000 epinephrine
7
• 1000 ml normal saline solution
• 50 ml 1% lidocaine plain
• 1 ml 1:1000 epinephrine
• 12.5 ml of 8.4% sodium bicarbonate

anesthesia.
WETTING SOLUTION TECHNIQUE




Dry
None
20-45
Wet
200-300 ml/area
4-30
Superwet

<1
Tumescent

<1

LIDOCAINE IN WETTING SOLUTION
Analgesia is provided for up to postoperatively.
Recommended maximum is in the presence of epinephrine ( in the
absence of epinephrine).
The estimated maximum safe lidocaine dosage using the is






• Diluted solution

• Vasoconstriction of epinephrine
• Relative avascularity of fatty layer
• High lipid solubility of lidocaine

NOTE:

806
Body Contouring
LIDOCAINE TOXICITY12
Plasma Lidocaine Levels and Symptoms of Toxicity


3-6
Subjective (circumoral numbness, tinnitus, drowsiness, lightheadedness,

5-9
Objective (tremors, twitching, shivering)
8-12
Seizures, cardiac depression
12-14
Unconsciousness, coma
15-20
Respiratory arrest

Cardiac arrest
LIPOSUCTION TECHNIQUES
SUCTION SSISTED LIPOSUCTION
Surgeon’s arm provides energy.
Movement of cannula results in mechanical disruption and avulsion to allow fat cell
aspiration.
External source of suction to facilitate fatty tissue removal (usually 300-600 mm Hg)
ULTRASOUND SSISTED LIPOSUCTION
15 in 1992
Piezoelectric crystals in the probes convert electric energy into high-frequency
sound waves that interact with tissue to create interstitial cavities and cellular
fragmentation—a process termed, “cavitation.”
• Adipose is more susceptible than muscle, fascia, or neural tissue.

• Heat is generated as a byproduct.
Use a hollow cannula or a solid probe.
such as:
• Upper abdomen
• Back
• Flanks
• Gynecomastia


: Ultrasound treatment to emulsify fat


• The
• The dry technique should
environment).
• The cannula/probe must be to limit thermal injury.
• The endpoint is a to probe advancement (Table 57-3).

807
Chapter 57
Surgical Endpoints for UAL and SAL/PAL

UAL
SAL/PAL
Primary

Blood aspirate
Final contour
Symmetrical pinch test
Secondary
Treatment time
Treatment volume
Treatment time
Treatment volume
Power-assisted liposuction; suction-assisted liposuction; ultrasound-assisted liposuction.

• Thermal injury (burn or blisters of skin)
• Seroma
• Hyperpigmentation

• Can result in increased skin retraction but at the risk of increased contour
deformities
• Power settings and suction should be decreased compared to those used in deeper
planes.



• May improve skin tightening

• Equipment cost
• Slightly larger incisions

• Increased risk of thermal injury to skin
• Increased scarring in adipose tissue bed
• Cannula misguidance due to diminished cannula resistance
POWER SSISTED LIPOSUCTION

fro motion of the operator’s arm 19
Approximately 2 mm motion at rates of up to 4000-6000 cycles/minute
• Electric energy source or medical grade compressed air


• Decreased surgeon fatigue

• Revision liposuction
• Shortened procedure times

• Operator discomfort induced by vibrating handpiece
• Noise generation
• Equipment cost

808
Body Contouring
LASER SSISTED LIPOSUCTION


Most commonly used wavelengths in the United States
• 924/975 nm, 1064 nm, 1319/1320 nm, and 1450 nm


and photocoagulation of small vessels while excluding surrounding structures.

• Theory: Heating of the subdermal tissue contributes to possible skin-tightening

• Studies have shown


: Application of energy to the subcutaneous tissues with laser probe



Subdermal skin stimulation

• Decreased intraoperative blood loss
• Decreased postoperative ecchymosis


• Potential thermal injury to skin
• Equipment cost
• Prolonged procedure time
• Increased scarring in adipose tissue bed
• Cannula misguidance due to diminished resistance
WATER SSISTED LIPOSUCTION 21,22
Technique uses a to emit pulsating, pressurized, fan-shaped jets








• Endpoint: Final contour and pinch test

• Reduced pain for patient
• Decreased need for general anesthesia
• Patient awake and able to change positions

• Equipment cost
• Prolonged procedure time

809
Chapter 57
RADIOFREQUENCY SSISTED LIPOSUCTION
Technique uses to disrupt the adipose cell membrane
and facilitate lipolysis.

Allows a constant treatment depth

The external electrode has a thermal sensor that measures skin temperature to prevent
thermal injury.
• Once the skin reaches 38
o-42o


17


: Radiofrequency energy treatment to emulsify fat

• Endpoint


• Decreased ecchymosis


• Potential thermal injury
• Equipment cost
• Prolonged procedure time
TIP: Thermal methods of liposuction (laser, ultrasonic, radiofrequency, and others)
dramatically reduce cannula resistance within the tissues indiscriminately, narrowing

precision is compromised as the tactile feedback is blunted. Additionally, these devices

generated predisposes the patient to dermal adherence to underlying tissues, which
can result in contour deformities and unnatural contours.
SEPARATION, ASPIRATION, AND FAT EQUALIZATION LIPOSUCTION
IPO®
First described by Wall in 2004, published in 2010
A nonthermal, multistep process approach for comprehensive fat management that


Developed in response to the unique challenges presented by revision liposuction cases
and correcting contour deformities

: Separation, aspiration and fat equalization
expanded tip, multiwinged cannula without suction


structures to allow greater control, precision, and safety

810
Body Contouring
SENIOR AUTHOR TIP:
device is utilized in order to provide immediate vasoconstriction and separation of
targeted fat, dramatically reducing operative time.
multiport, non-
expanded, blunt cannula with suction


aspirated without causing avulsion
injury to blood vessels and stromal
network

expanded
tip, multiwinged cannula without
suction (Fig. 57-6)

aspirated, residual areas of
uneven fat removal are equalized,
with treatment undertaken in a

original area of excess, in order to
maximize skin retraction.

more fat, all of which will remain

in any imperfections and prevent
adhesions.




Separation and equalization soften the deep septal stromal network that runs
throughout the subcutaneous layer and loosen fascial adherences.
Rigid subcutaneous adherences tether the skin and are one etiology of contour
irregularities.

of coverage and provide enhanced control.
allows for simultaneous equalization and fat


• Reduced incidence of contour deformities

• Ability to treat areas completely, widely or circumferentially, beyond areas of excess,
or through zones of adherence without fear of creating a contour deformity
• Decreased ecchymosis
• Enhanced precision, with ability to combine with fat shifting and expansion


• Increased operative time to properly execute the technique
Examples of angled, multi-
winged wall cage cannulas used for fat
separation, fat equalization, and expansion

of the cannula, in combination with rapid
movement (vibration) create high and low
pressure zones in the subcutaneous fat,
causing the relatively low-resistance solid
fat to liquefy, while allowing the relatively
higher resistance unintended structures
(blood vessels, stromal support structures)
to remain intact and undamaged.

811
Chapter 57
TIP: by relaxing the attachments of the skin to underlying structures, the skin can be
predictably manipulated and redistributed as needed from areas of excess into areas

FLUID RESUSCITATION DURING LIPOSUCTION
1 L

normal homeostatic mechanisms.
CAUTION:

29 is preferred over tumescent technique with
equivalent blood loss and decreased potential of volume overload and congestive heart
failure.

• Crystalloid IV at maintenance rate (adjust to urine output and vital signs)








GENERAL DETAILS OF TRADITIONAL LIPOSUCTION STAGES
STAGE I: INFILTRATION

Record delivered amount to each area.
Endpoint is uniform blanching and skin turgor.
Allow at least 7-10 minutes for maximal vasoconstriction from epinephrine.
SENIOR AUTHOR TIP: Simultaneous separation and tumescence (SST) allows a more

31
STAGE II: UAL TREATMENT MIT IF PERFORMING SAL/PAL ONLY
Place access incisions asymmetrically.
Use port protector and wet towels to protect skin.
of the circumference from this position).
Withdraw to within 3 cm of incisions to redirect and minimize torque.

STAGE III: EVACUATION AND FINAL CONTOURING
Set aspirator to 60%-70% of usual suction.

812
Body Contouring
SENIOR AUTHOR TIP: The use of angled cannulas can reduce skin abrasions, improve
manipulation and “driveability” of cannulas, allow for more thorough coverage of an
area, and decrease operator fatigue. A rolling pinch test can check for tissue thickness
discrepencies at treatment completion.
LIPOSUCTION BY AREA
HIPS AND FLANKS

• Begins in paraspinous area
• Widest just above iliac crest
• Anteriorly blends with lower abdominal adiposity of lateral rectus sheath

crests



crests


• Convexity between the hips and above the lateral thigh below
• Also known as the area

• Jackknife when prone

• Avoid violation of the lateral gluteal depression.
THIGHS
Thigh should be a shallow convex arc on both anterior and posterior surfaces.

Buttock extends from the sacrum to the inferior gluteal fold.
is the fullness from inferior gluteal fold to the posterior upper thigh zone
of adherence.
There should be an unbroken curve from the iliac crest to the distal thigh.
Medially there should be a slight convexity of the upper third of the medial thigh;


• Prone position allows operator to work on both sides and assess symmetry of lateral
and posterior thighs.
position is used to treat the medial thigh area.
• Suction both deep and intermediate planes.

BUTTOCKS

• Slightly convex
• Nonptotic
• Firm with a slight lateral gluteal depression

813
Chapter 57
In the buttocks are
buttocks are more angular and almost (more muscle, less fat,


• Area should be approached with caution, because an aesthetically pleasing buttock
varies across age groups, geography, and ethnicity.
to preserve the integrity of the inferior gluteal crease.

• Excessive suctioning of the lateral proximal posterior thigh may result in extension
of gluteal fold in female patients and masculinization of the gluteal area.
ABDOMEN


• Pubic ramus inferiorly

Clearly delineated linea alba depression from top to bottom


• Slight supraumbilical concavity
• Infraumbilical convexity
Women

rib to the iliac crest
Men
• Do have bilateral concavity
at the iliac crest
• Infraumbilical region should be

• Short, controlled strokes should be used to prevent inadvertent fascial perforation.

ARMS
Ideal arm is lean and has an anterior convexity of the deltoid merging with a convexity
of the biceps.
Posterior surface of the arm should be slightly convex from axilla to elbow.
Patients with at least 1.5 cm of fat by the pinch test are good candidates.


radial elbow
• Along the distal third of arm and elbow region, the and

injury.

CAUTION:
BACK
Prone jackknife positioning is preferred.

814
Body Contouring

and excess fat removed.
Technical details
• Place incisions in bra/bathing suit line.
• Avoid forceful excursion to prevent unsafe cannula redirection by dense tissue.
NECK
Patient is positioned with the neck hyperextended on a shoulder roll.
Overzealous suctioning can lead to hollowing and skeletonizing of the neck or potential
neuropraxia of the marginal mandibular nerve.
SENIOR AUTHOR TIP: The senior author prefers a full-body prep and three positions
for most body cases—supine and both lateral decubitus positions. Prone positioning
is usually unnecessary. Minimizing incisions and keeping all incisions in hidden areas
has been made possible by the use of long, angled cannulas in association with the

of seroma. Careful analysis and planning is required in order to avoid feminization of

liposuction procedures has shown improved results, and can be easily incorporated

thighs can prevent buttock collapse and other severe contour deformities of the thighs
and buttocks. Most “banana rolls” are actually bulging posterior pillars of support of
the buttock, and are not improved with liposuction. Instead, they can be treated with

minimizing the bulging and improving the “banana roll.”
DRAINS
Not routinely used, except in large-volume liposuction of the circumferential trunk
Consider for liposuction procedures combined with resection
ACCESS SITE MANAGEMENT

May close or leave open to drain.
Cover with antibiotic ointment, gauze, and paper tape or adhesive dressing.
Place compression garment that is customized based on surgeon’s preference and
procedure performed.

contouring.
POSTOPERATIVE CARE
Begin ambulating the day of surgery.
May shower 1-2 days postoperatively

815
Chapter 57
Postoperative compression garment
• Based on surgeon’s preference, no consensus on regimen
• Example: Patient should wear compression garment at all times for 2 weeks then at
night for 2 additional weeks.
Patients return to work 3-5 days after small-volume procedures.
After a large-volume procedure, patients may require 7-10 days before returning to
work.
Full activities are resumed in 3-4 weeks as tolerated.

over time.
SENIOR AUTHOR TIP: The senior author prefers that all liposuction access sites are
treated with fat equalization to minimize any contour depression, and all are left open
to drain. Half-inch or one-inch foam is utilized postoperatively for several weeks, with
a minimally compressive compression garment only serving to hold the foam in place.
NOTE:

Regardless of the anesthetic route,
should be performed in an acute-care hospital or in a facility that is either accredited or
licensed.
Vital signs and urinary output should be monitored postoperatively, and patients

the perioperative care of liposuction patients.
35
HEALING COURSE
Access incisions drain until healed.
Edema peaks and drainage slows.
Ecchymosis resolves.
Edema resolves.
Induration in large-volume areas
Final aesthetic result (revision liposuction cases will take a year to
equilibrate.)
COMPLICATION PREVENTION AND INTERVENTION
SAFETY GUIDELINES IN LIPOSUCTION
Appropriate patient selection (ASA class I, within 30% of ideal body weight)

Meticulous monitoring of volume status (urinary catheter, noninvasive hemodynamic
monitoring, communication with anesthesiologist)


appropriate health care facility
Use of pneumatic compression devices in patients under general anesthesia or if case

Maintenance of total lidocaine doses <35 mg/kg (wetting solution)

816
Body Contouring
LOCAL ANESTHETIC SYSTEM TOXICITY TREATMENT
Infuse
• Bolus 1.5 ml/g (lean body mass) intravenously over 1 minute.
• Provide continuous infusion at 0.25 ml/kg/minute.
• Repeat bolus once or twice for persistent cardiovascular collapse.
• Double the infusion rate to 0.5 ml/kg/minute if blood pressure remains low.
• Continue infusion for at least 10 minutes after circulatory stability is achieved.

30 minutes.
TOP TAKEAWAYS

Consider whether the correct procedure has been chosen: liposuction versus
skin resection.

Mark patients while they are awake and standing; allow them to provide
guidance in choosing the areas to be treated.

Thermal methods of liposuction diminish cannula resistance and reduce surgeon
fatigue, but can burn the patient, resulting in uncorrectable contour deformities.

Perform repeated assessments of progress to prevent contour deformities.

Underresection is preferable to an overtreatment leading to contour deformities



deformities.

Use of compression garment in the postoperative setting is essential to prevent
contour deformities and chronic seroma formation and provides patient comfort
in the acute healing period.
REFERENCES
1. Grazer FM. Suction-assisted lipectomy, suction lipectomy, lipolysis, and lipexeresis. Plast Re-
constr Surg 72:620, 1983.

Reconstr Surg 87:1009, 1991.
3. Rohrich RJ, Smith PD, Marcantonio DR, et al. The zones of adherence: role in minimizing and
preventing contour deformities in liposuction. Plast Reconstr Surg 107:1562, 2001.

Reconstr Surg 87:1009, 1991.
5. Neligan P, Warren RJ, eds. Plastic Surgery, vol 2, ed 3. Philadelphia: Saunders Elsevier, 2013.

7. Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction.
Plast Reconstr Surg 92:1085; discussion 1099, 1993.
8. Iverson RE, Pao VS. MOC-PS(SM) CME article: liposuction. Plast Reconstr Surg 121(4 Suppl):S1,
2008.

66:91, 2002.

for liposuction. Dermatol Surg 22:921, 1996.

817
Chapter 57



Surg 64:985, 2011.
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818
INDICATIONS
Excess skin and/or subcutaneous tissue of the arm refractory to conservative treatment
such as diet and exercise
CONTRAINDICATIONS
ABSOLUTE
Neurological or vascular disorders of the upper extremity
Collagen-vascular disorders (Ehlers-Danlos syndrome, progeria, elastoderma)

Unrealistic patient expectations
RELATIVE
Severe comorbid conditions (including heart disease, thromboembolic disease,
diabetes)
Unstable weight gain or loss
Expecting future pregnancy
Active smoker
Patients with a history of keloids or hypertrophic scars
ANATOMY
The skin covering the shoulder and arm is smooth and very mobile over the
underlying structures.
• It is thin on medial aspect and progressively thicker laterally.
Fat accumulates on the inferoposterior aspect of the arm, with a
minimal amount medially.

encases the fat of the arm from the axilla to the elbow.
• This fascia weakens with age and weight gain, causing ptosis of the posteromedial
arm.
Deep fascia: The deep fascia invests all muscles and important neurovascular
structures.
• This layer should during brachioplasty or suction-assisted
lipectomy.
TIP: Along the distal third of the arm and in the region of the medial elbow, the basilic

deep fascia and vulnerable to injury, especially where they pierce the deep fascia an
average of 14 cm proximal to the medial epicondyle.1

819
Chapter 58 Brachioplasty
TIP:
the and the All other
important neurovascular structures are deep to the investing fascia.
Medial
cubital
sulcus
Biceps
brachii
muscle
Vertical
excess
Horizontal
excess
Brachial
groove
Anterior
axillary
fold
Posterior
axillary
fold
Triceps
brachii
muscle
Medial
epicondyle
A
Basilic vein
Humerus
Medial nerve
Brachial artery
Ulnar nerve
Medial antebrachial
cutaneous nerve
Radial
nerve
Biceps
muscle
Triceps
muscle
B
Anatomy of the arm. A, External
landmarks. B, Cross section.
PREOPERATIVE EVALUATION

weight stability, tobacco use, and scarring.
TIP: Weight should be stable for 6-12 months before performing any body contouring
procedure on a massive-weight-loss patient.
Physical examination should focus on excess
and degree of ptosis present in the arm.

An algorithm (Fig. 58-2) can then be used to help guide surgeons to the procedure that
is best suited to achieve optimal results.2

820
Body Contouring

Type



I
Minimal
Moderate
n/a
IIA
Moderate
Minimal
Proximal
IIB
Moderate
Minimal
Entire arm
IIC
Moderate
Minimal
Arm and chest
IIIA
Moderate
Moderate
Proximal
IIIB
Moderate
Moderate
Entire arm
IIIC
Moderate
Moderate
Arm and chest
Algorithm for treatment of
upper arm lipodystrophy. ( Suction-
assisted liposuction; ultrasound-
assisted liposuction.)
Type III

excess skin?
Proximal
third
Entire
upper arm
Arm and
chest wall

brachioplasty

Traditional
brachioplasty

Extended
brachioplasty

UPPER ARM

Excess fat?
Yes
Skin laxity?
Yes
No
Type I

No
Type II

excess skin?
Proximal
third
Entire
upper arm
Arm and
chest wall

brachioplasty
Traditional
brachioplasty
Extended
brachioplasty
INFORMED CONSENT
Patients need to be informed that, with a brachioplasty, they are trading a more
pleasing shape and contour of the arm for a scar.
The and will be visible depending on the type of clothing
worn.
Scars may stay thick and heavy for a prolonged period of time.

SENIOR AUTHOR TIP: In the preoperative consult, use a skin marker to draw the
potential scar on the patient’s arms to help them understand the procedure and to align
their expectations with reality. Document this in their medical record.