Problems in Breast Surgery A REPAIR MANUAL Edited by Jack Fisher • Neal Handel Thieme
(Trang không có chữ)
Problems in
Breast Surgery
A Repa ir Ma n u a l
(Trang không có chữ)
Problems in
Breast Surgery
A Repa ir Ma n u a l
E d i t e d b y
Jack Fisher, MD, FACS
Associate Clinical Professor, Department of Plastic Surgery,
Vanderbilt University, Nashville, Tennessee
Neal Handel, MD, FACS
Associate Clinical Professor, Division of Plastic Surgery,
David Geffen School of Medicine, University of California, Los Angeles,
Los Angeles, California
Director, Editorial Services: Mary Jo Casey
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International Marketing Director: Fiona Henderson
International Sales Director: Louisa Turrell
Director of Sales, North America: Mike Rosem an
Senior Vice President and Chief Operating Of cer: Sarah Vanderbilt
President: Brian D. Scanlan
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is available from the publisher upon request.
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To my loving wi e, Clare, who has supported and encouraged me
throughout my career.
J.F.
Although my children are too young to understand why dad spends
so many hours during the evenings, weekends, and holidays poring
over the laptop at his home o f ce, they do understand that it is time
he could be spending with them. So, or their tolerance, patience,
and unconditional love, despite sometimes being deprived
o my undivided attention, this book is dedicated to my three young
children, Brooke-Lynn, Hendrix, and Hunter.
Equally, this book is dedicated to my wi e,
Kristen Miwa Fujieki, whose love, support, commitment,
and loyalty give this e ort—as well as everything else I do in li e—
worth and meaning.
N .H.
PUBLISHER Karen Berger
ASSISTANT EDITOR Heather Yocum
DIRECTOR OF EDITING Suzanne Wakef eld
PROJECT MANAGER Glenn Floyd
VICE PRESIDENT OF PRODUCTION AND MANUFACTURING Carolyn Reich
DIRECTOR OF GRAPHICS Brett Stone
GRAPHICS TECHNICIAN Ngoc-Thuy Khuu
ILLUSTRATORS Brenda L. Bunch, Jenni er N. Gentry
LAYOUT ARTISTS Madonna Gauding, Elaine Kitsis, Susan Trail
PRODUCTION Carol Hollett, Chris Lane, Linda Maulin
CONTRIBUTORS
vii
Jamil Ahmad, MD, FRCSC
Director, Research and Education, The Plastic
Surgery Clinic, Mississauga, Ontario, Canada
Frank P. Albin , MD
Resident Physician, Department o Plastic
Surgery, Georgetown University Hospital,
Washington, DC
Khalid Alm airi, MD, MSc, FRCSC
Clinical Instructor and Microsurgery Lecturer,
Department o Surgery, University o Nevada
Las Vegas (UNLV), Las Vegas, Nevada
Kei h M. Blechman, MD
Private Practice, New York, New York
L is P. B cky, MD, FACS
Clinical Pro essor o Surgery, Department o
Surgery, University o Pennsylvania School o
Medicine; Chie o Plastic Surgery, Pennsylvania
Hospital, Philadelphia, Pennsylvania
David A. Caplin, MD, FACS
Clinical Instructor, Department o Plastic Surgery,
Washington University, St. Louis, Missouri
Sydney R. C leman, MD
Clinical Assistant Pro essor, Department o
Plastic Surgery, Institute o Reconstructive
Plastic Surgery, New York University Medical
Center, New York, New York; Clinical Assistant
Pro essor, Department o Plastic Surgery,
University o Pittsburgh Medical Center,
Pittsburgh, Pennsylvania
Daniel A. Del Vecchi , MBA, MD
Instructor in Surgery, Division o Plastic Surgery,
Massachusetts General Hospital, Boston,
Massachusetts
Emman el Delay, MD, PhD
Head, Department o Plastic and Reconstructive
Surgery, Centre Léon Bérord, Lyon, France
Jack Fisher, MD, FACS
Associate Clinical Pro essor, Department o
Plastic Surgery, Vanderbilt University, Nashville,
Tennessee
Allen Gabriel, MD, FACS
Associate Pro essor o Surgery, Department o
Plastic Surgery, Loma Linda University Medical
Center, Loma Linda, Cali ornia; Peacehealth
Plastic Surgery, Vancouver, Washington
James C. Gr ing, MD, FACS
Clinical Pro essor o Plastic Surgery, Department
o Surgery, University o Alabama at Birmingham,
Birmingham, Alabama; University o Wisconsin,
Madison, Wisconsin
Elizabe h J. Hall-Findlay, MD, FRCSC
Private Practice, Ban , Alberta, Canada
M s apha Hamdi, MD, PhD
Pro essor and Chairman, Department o Plastic
and Reconstructive Surgery, University Hospital
o Brussels, Brussels, Belgium
Dennis C. Hamm nd, MD
Assistant Program Director, Clinical Assistant
Pro essor, Department o Surgery, Michigan State
University College o Human Medicine, Grand
Rapids, Michigan
Neal Handel, MD, FACS
Associate Clinical Pro essor, Division o Plastic
Surgery, David Ge en School o Medicine,
University o Cali ornia, Los Angeles,
Los Angeles, Cali ornia
Contributors
viii
Glyn J nes, MD, FRCS(Ed), FCS(SA), FACS
Pro essor o Surgery, Section o Plastic Surgery,
University o Illinois College o Medicine at
Peoria, Peoria, Illinois
R ger K. Kh ri, MD
Medical Director, Department o Plastic Surgery,
Miami Breast Center, Miami, Florida
S even J. Kr n i z, MD, FACS
Pro essor, Department o Plastic Surgery,
University o Texas MD Anderson Cancer Center,
Houston, Texas
Andre Y. Levesq e, MD
Assistant Pro essor, Division o Plastic Surgery,
University o Alabama at Birmingham,
Birmingham, Alabama
Frank Lis a, MD, FRCSC
Medical Director, The Plastic Surgery Clinic,
Mississauga, Ontario, Canada
Alber L sken, MD, FACS
Pro essor o Surgery, Division o Plastic and
Reconstructive Surgery, Emory University,
Atlanta, Georgia
G. Pa rick Max ell, MD, FACS
Clinical Pro essor, Department o Plastic Surgery,
Loma Linda University Medical Center,
Loma Linda, Cali ornia
Ma rice Y. Nahabedian, MD
Pro essor, Department o Plastic Surgery,
Georgetown University, Washington, DC
F ad Nahai, MD, FACS
Pro essor o Plastic Surgery, Department o
Surgery, Emory University, Atlanta, Georgia
Brian D. Pe ers n, MD, FRCSC, FACS
Associate Pro essor, Division o Plastic Surgery,
University o British Columbia, Kelowna, British
Columbia, Canada
J. Pe er R bin, MD, FACS
Pro essor and Chair, Department o Plastic
Surgery, University o Pittsburgh School o
Medicine, Pittsburgh, Pennsylvania
Jeremy C. Sinkin, MD
Resident Physician, Department o Plastic
Surgery, Medstar Georgetown University
Hospital, Washington, DC
Sc L. Spear, MD
Department Chairman, Department o Plastic
Surgery, Georgetown University Hospital,
Washington, DC
L is L. S r ck, MD, FACS
Private Practice, Fort Worth, Texas
FOREWORD
W
hen I was asked to write the oreword and to contribute a problem case or
this book, the f rst question that came to mind was: “Do we need another book on
breast surgery?” However, a ter seeing the title or the book: Problems in Breast
Surgery: A Repair Manual, and learning more about the book’s unique ormat and
approach, my skepticism was quickly converted to enthusiasm. What a brilliant
idea! This is a project unlike any other that I have been involved with, and I predict
that it will be a orerunner to other repair manuals in our specialty.
This book is the brainchild o Jack Fisher, whose passion or model trains and his
years reading “repair manuals” inspired him to recognize the need or a repair
manual in breast surgery—a problem-solving approach to the range o aesthetic
and reconstructive challenges that we con ront in our practices. Jack recruited Neal
Handel, a highly respected and skilled plastic surgeon, to be his co-editor in this
venture. I have known and have been great riends with Jack and Neal or a long
time—Jack since he was a medical student at Emory, and Neal over the years as
I observed his growing career accomplishments. Jack is one o the most talented
surgeons with whom I have been associated, because he is as com ortable in the
operating room as he is talking with his patients. Neal combines decision-making
skills with surgical expertise in dealing with di f cult aesthetic and reconstructive
breast surgery problems. The combination o Jack and Neal is inspired. They have
published and lectured extensively on this topic, and they are both innovative and
skilled problem-solvers who command great respect or their achievements in plas-
tic surgery.
Drs. Fisher and Handel have organized this book to ocus on common postopera-
tive complications or suboptimal aesthetic outcomes encountered in aesthetic and
reconstructive breast surgery. They cover a broad range o problems that are a-
miliar to all surgeons who operate on the breast— rom periprosthetic in ection,
capsular contracture, and synmastia to upper pole def ciency, recurrent ptosis, im-
plant and expander malposition, necrosis, and de ormities a ter lumpectomy, radia-
tion, and breast reconstruction. The editors have wisely selected a world-renowned
group o expert contributors who share their problem-solving skills, and they have
challenged these contributors to present a variety o di erent solutions to specif c
problems. The ormat or each chapter is conducive to this problem-solving ap-
proach. Each case begins with a presentation o a problem and a discussion o
ix
Foreword
x
how this unsatis actory result or complication occurred and what caused it. Next,
a ull analysis o the patient’s situation, a discussion o the solution, the surgical
plan, and a technical description o how this solution was executed according to
plan is presented. Finally, the results are demonstrated along with a ull and critical
evaluation.
This manual isn’t just or the trainee; it is or all surgeons who operate on the e-
male breast. Even those o us who eel we are “experts” who can handle any prob-
lem, have a lot to learn rom this book, because there are o ten various solutions to
a problem, yet the best solution o ten depends on the individual patient.
The quality o production and the many high-quality photos and illustrations are
typical o the great work that Quality Medical Publishing does, and the consistent
ormat throughout each case makes this publication an ideal teaching tool and a
pleasure to read. In short, this is an amazing and innovative book that takes surgi-
cal education to the next level beyond the standard textbook. I am conf dent that
readers will easily recognize similar cases that they have encountered and will be
able to apply the lessons they learn to uture patients, making this “repair manual”
a constant companion or anyone per orming breast surgery.
Foad Nahai, MD, FACS
Pro essor o Plastic Surgery,
Department o Surgery,
Emory University, Atlanta, Georgia
T he concept or this book originated several years ago. It was a simple idea
based on a li elong hobby. Since I was young I have collected and repaired model
toy trains. Each train routinely comes with a repair manual. This is no di erent
rom other products we purchase that o ten include a manual listing the compo-
nents o the device as well as possible repairs in the event o ailure.
For 25 years I have been teaching courses and lecturing on revision breast surgery.
It is an area that has provided me with a rewarding career as well as the opportu-
nity to teach and lecture on this important topic. So the thought arose: Why not
create a manual based on revision breast surgery—whether aesthetic or reconstruc-
tive—not unlike the repair manuals that I have been using or decades or my be-
loved hobby? Thus began a several-year process in which I started collating and
collecting important and relevant cases specif c to revision breast surgery that ulti-
mately ormed the core o Problems in Breast Surgery: A Repair Manual.
Another important consideration in the decision to embark on this project was my
personal historic journey through plastic surgery. When I was a medical student at
Emory University, John Bostwick III was a chie resident in general surgery. Know-
ing even as a medical student that I wanted to be a plastic surgeon, I attached my-
sel like a remora f sh to a shark, ollowing John Bostwick everywhere he went.
Even as a general surgery resident, John was already per orming plastic surgery. For
me, as or all o us, our mentors have a tremendous impact on our careers. Years
later, when I began my plastic surgery residency at Emory, John had already be-
come an established innovator and educator in plastic surgery, and the journey be-
gan or me with a ocus on breast surgery.
Why would one write a book, especially a repair manual, on revision breast sur-
gery? The answer is simple: Primary breast surgery is one o the most commonly
per ormed procedures or most plastic surgeons—and the incidence o revision
breast surgery is high. This high revision rate does not necessarily mean the initial
surgery was done incorrectly. In many instances the reason or the revision is part
o the natural evolution and aging o the breast, or the consequence o the long-
term presence o a breast implant, and or many patients a secondary operation is a
positive experience.
PREFACE
xi
Preface
xii
On the other hand, there is no question that breast surgery in general, whether or
aesthetic or reconstructive purposes, is technically challenging and can lead to sig-
nif cant complications and suboptimal outcomes. Another consideration is that the
boundary between aesthetic and reconstructive surgery is somewhat arbitrary. The
cause o the problems encountered, as well as the options available or correction,
are requently similar in both groups.
A ter several years o working on this book, I ound the task somewhat over-
whelming and realized that to really make this a publication that was both use-
ul and o high quality, I needed a co-editor. I was ortunate to be able to entice Dr.
Neal Handel to join me on this project and journey. Neal is known worldwide or
his accomplishments in breast surgery and in particular, revision breast surgery. The
other reason Neal was the per ect choice as a co-editor is that he is compulsive, or-
ganized, and takes incredible photos in the operating room—three characteristics
or which I am not known. Now the journey included the two o us working to-
gether as a team.
The next step was the realization that no matter how experienced or accomplished
one or two plastic surgeons may be, the topic o revision breast surgery is so broad
that to create a worthwhile book, it was crucial to recruit experts rom around the
world. As can be seen by the contributor list o this book, we have succeeded in as-
sembling a world-class team o renowned surgeons to assist in this exciting project.
What is unique about this book is that it is organized in a “problem and solution”
ormat. This is not a traditional textbook; this is a re erence manual or the surgeon
who encounters a specif c problem (either aesthetic or reconstructive) and wishes to
see how others con ronting similar dilemmas have solved them. No single book, no
matter how comprehensive, can cover every possible problem and solution, but we
requently can generalize using a problem-solution template, which can be applied
to a variety o di erent situations.
This book is intended or novices as well as highly experienced surgeons. No mat-
ter what level we may be in our careers, we all encounter problems that can be
daunting and rustrating to deal with. That makes this book universally relevant to
all who per orm breast surgery. I’ve ound that in working on this project, I have
learned a great deal, because I’ve had the opportunity to learn rom my colleagues.
It has also given me the opportunity to relearn rom my own personal experience.
It is our hope that this book will serve as an invaluable tool or all surgeons when
struggling with a di f cult reoperative problem in breast surgery. It should also pro-
vide com ort to our colleagues to realize that no matter how experienced or accom-
plished we may be, all o us periodically encounter these di f cult situations, and
that corrective techniques are available.
Jack Fisher
Neal Handel
W
e all experience seminal events in our careers that have a major impact on
the choices we make. Mine occurred during my junior and senior years o medical
school at Emory University. I knew I was interested in plastic surgery, even in col-
lege, but knew very little about it.
At the beginning o my junior year in medical school, Emory was just starting a
plastic surgery division under the leadership o M.J. Jurkiewicz. He brought Louis
Vasconez with him. I sought out these two leaders in plastic surgery and even had
“Dr. J” as my advisor.
I took every elective in surgery possible. The general surgery residents were Foad
Nahai, Rod Hester, Steve Mathes, and John Bostwick III. The plastic surgery resi-
dent was John McGraw. Being surrounded by this incredible group o uture lead-
ers in plastic surgery had a major impact on me. I ollowed this group everywhere
and developed li elong riendships.
One person in this group stands out in particular. Dr. Foad Nahai was a junior gen-
eral surgery resident during my last 2 years o medical school, and we have had a
our-decade riendship that has been one o my great joys. Foad has taught me both
general surgery and then later, as an attending, plastic surgery.
A ter f nishing plastic surgery training at Emory, I went on the sta at the Mayo
Clinic. The department was headed by Ian Jackson, with John Woods and P.G.
Arnold on the sta . The education and incredible experience continued or 6 years.
I had wonder ul colleagues at Mayo who taught and stimulated me.
Then in 1986, we moved to Nashville, Tennessee, where I joined Pat Maxwell, one
o the outstanding leaders in plastic surgery, and over the next 18 years, enjoyed
a rewarding relationship. In 2004 I embarked on a solo practice, but Pat and I re-
main great riends, interacting both pro essionally and socially.
So as anyone can see, I have been blessed by working with an incredible group o
colleagues. They all have mentored me as I progressed through my career.
ACKNOWLEDGMENTS
xiii
Acknowledgments
xiv
Finally, I must acknowledge the incredible sta o QMP, led by Karen Berger. Karen
has the patience o a saint and the perseverance o an arctic explorer. Andrew
Berger, Michelle Berger, Amy Debrecht, and the entire team o talented editors and
artists have made this project possible.
Last but not least, a great deal o credit or this book goes to Dr. Neal Handel,
without whom this project would have never come to ruition.
To all, I express my deepest appreciation.
Jack Fisher
A lthough there are many individuals who play an important role in the devel-
opment o any surgeon’s career, most o us can identi y one person who sparked
our inter est in pursuing plastic surgery. In my case it was Dr. Harvey Zarem. When
Dr. Zarem was Pro essor and Chie o Plastic Surgery at UCLA, I was a neophyte
f rst-year resident in general surgery. I knew virtually nothing about the specialty
o plastic surgery. But a ter a 1-month rotation on Dr. Zarem’s service, I did know I
wanted to spend the rest o my pro essional career in this innovative and rewarding
specialty. Dr. Zarem embodied all the best qualities o a plastic surgeon—enthusi-
asm, compassion or patients, superb technical skill, kindness, humility, and a great
sense o humor—all characteristics that are indispensable in our specialty. I have no
doubt that I was but one o innumerable young residents who chose a path in plas-
tic surgery because o his example.
Later in my career I had the good ortune to become associated in practice with
Melvin Silverstein. Dr. Silverstein is truly one o the giants o breast oncology. In
addition to being an outstanding clinician and caring physician, he has throughout
his career been committed to the advancement o surgical knowledge. He is an ex-
emplary “clinician scientist” who stimulated my own interest in clinical research,
scientif c writing, and surgical education. My association with Dr. Silverstein
greatly enriched my surgical career.
With regard to my role in this book, I must acknowledge a debt o gratitude to Jack
Fisher or extending the invitation to participate with him in its creation. Dr. Fisher
is universally acknowledged as one o the leading authorities in the f eld o breast
surgery and is particularly recognized or his expertise in revision breast surgery.
Dr. Fisher has urther established himsel as one the most sought-a ter speakers,
Acknowledgments
xv
moderators, and educators in the f eld o plastic surgery. The idea o writing a book
in this unique ormat, that o a problem-oriented repair manual, was entirely his in-
spiration. I eel privileged to have been invited to be his partner in this enterprise.
Obviously, the creation o a book o this scale requires the collaborative e orts o
many individuals. Without the wisdom and guidance o Karen Berger and Andrew
Berger and the contributions o their capable sta at Quality Medical Publishing,
this book would never have come into being.
I would be remiss not to acknowledge the contributions o all o the talented plas-
tic surgeons who submitted the case reports that compose this manual. All o these
individuals took time rom their busy practices and personal lives to share their ex-
pertise in dealing with a wide range o challenging breast revision cases. Their valu-
able contributions add immeasurably to the quality, depth, and scope o this repair
manual.
Neal Handel
(Trang không có chữ)
Par I: F ndamen als
1. A Reader’s Guide to Problems in Breast Surgery: A Repair Manual 3
Jack Fisher, Neal Handel
2. The Art o Analysis: Mechanisms o Failure and Key Anatomic Factors 7
Jack Fisher, Neal Handel
Par II: Pr blems in A gmen a i n Mammaplas y
SECt Io N o NE: Po St o PERAt IVE Co MPLICAt Io NS
3. Periprosthetic In ection A ter Augmentation 17
a. Salvage o an In ected Implant With Secondary Use o ADM 17
Neal Handel
b. Unilateral Explantation With Delayed Implant Reinsertion and
Mastopexy 24
Jack Fisher
c. Bilateral Explantation With Delayed Implant Reinsertion 29
Louis L. Strock
d. Salvage o an In ected Augmentation With a Tissue Expander and
Secondary Implants 36
Brian D. Peterson
4. Late Seroma A ter Augmentation 43
a. Implant Removal and Replacement 43
Elizabeth J. Hall-Findlay
b. Surgical Drainage With Implant Exchange 49
Frank Lista, Jamil Ahmad
CONTENTS
xvii
Contents
xviii
5. Capsular Contracture A ter Augmentation 55
a. Periareolar Capsulectomy With Implant Replacement 55
Jack Fisher
b. Saline Implant Removal, Total Capsulectomy, and Replacement With Gel
Implants 60
Neal Handel
c. Implant Removal, Tissue Expansion, and Replacement With Contoured
Gel Implants 67
David A. Caplin
d. Creation o a Neopectoral Pocket, Breast Tissue Reshaping, and Implant
Insertion With ADM 71
Allen Gabriel, G. Patrick Maxwell
e. Revision Augmentation With Total Explantation, Site Change, and
Insertion o Silicone Implant With ADM 77
Allen Gabriel, G. Patrick Maxwell
6. Impending Implant Exposure/Extrusion 83
a. Two-Stage Salvage With Placement o Smaller Implants 83
Neal Handel
b. Management o Impending Saline Implant Exposure Resulting
From Intraluminal Steroids 87
Jack Fisher
c. Impending Implant Exposure Treated by Explantation and Delayed Fat
Gra ting With Implant Reinsertion 92
Neal Handel
7. De ated Saline Implants 99
a. Pocket Modif cation With Insertion o Silicone Gel Implants 99
Neal Handel
8. Intracapsular Rupture and Gel Bleed 103
a. Pocket Exchange—Subglandular to Subpectoral—With ADM 103
Maurice Y. Nahabedian
b. Explantation, Capsulectomy, and Conversion to a Submuscular
Pocket 107
Brian D. Peterson
c. Explantation, Capsulectomy, Tissue Expansion, and Delayed Implant
Placement 111
Brian D. Peterson
d. Explantation, Capsulectomies, and Conversion to Subpectoral Pockets 115
Louis L. Strock
e. Explantation, Capsulectomy, and Conversion to Submuscular Pocket
With Secondary Mastopexy 120
Brian D. Peterson
Contents
xix
9. Extracapsular Rupture, Gel Migration, and Silicone Injections 125
a. Submuscular Capsulectomies and Implant Exchange 125
David A. Caplin
b. Multistage Repair With Fat Gra ting 129
Andre Y. Levesque, James C. Grotting
c. Bilateral Mastopexies With Implant Insertion 135
Neal Handel
d. Silicone Injection Correction With Bilateral Mastectomies With TRAM Flaps 141
Jack Fisher
10. Implant Rotation With Shaped Implants 145
a. Removal o Shaped Implants, Pocket Conversion, Mastopexy, and Insertion
o Round Implants 145
Neal Handel
b. Correction o Anatomic Implant Rotation With Manual Manipulation 150
Frank Lista, Jamil Ahmad
c. Shaped Implant Rotation 154
Elizabeth J. Hall-Findlay
11. Special Problems: Malignancy A ter Augmentation 159
a. Reconstruction With an Expander and a Latissimus Dorsi Flap 159
Jack Fisher
b. Latissimus Dorsi Flap With Expander 164
Jack Fisher
SECt Io N t w o : Su Bo Pt IMAL AESt HEt IC o u t Co MES
12. Implant Malposition 171
a. Pocket Modif cation With Parenchymal Scoring and Posterior Capsular Flap 171
David A. Caplin
b. Pocket Modif cation With Pectoralis Muscle Release 176
Jack Fisher
c. Asymmetrical Capsule Modif cation With Site Change 181
Elizabeth J. Hall-Findlay
d. Capsulorrhaphy and Conversion to Submammary Pocket 187
Neal Handel
e. Conversion to Neosubpectoral Pocket 192
Elizabeth J. Hall-Findlay
. Capsulorrhaphy With Re-creation o a Stable Lower Pole Sling With ADM
to Support an Implant 197
Glyn Jones
g. Form Stable Implants in a Subglandular Pocket With Revision Mastopexy
and ADM 201
Brian D. Peterson
13. Synmastia Repair 205
a. Synmastia Repair Using a Neosubpectoral Pocket 205
Jeremy C. Sinkin, Scott L. Spear
b. Conversion to a Subpectoral Pocket With ADM 210
Jeremy C. Sinkin, Scott L. Spear
c. Use o ADM or Treatment o Combined De ormities: Double-Bubble
and Synmastia 215
Neal Handel
d. Correction o Unilateral Synmastia by Conversion o Implants
From Submammary to Subpectoral 222
Neal Handel
14. Double-Bubble De ormity 227
a. Conversion to a Subglandular Pocket With a Capsular Flap 227
Jack Fisher
b. Site Change, Capsulectomy, and Conversion to Subglandular
Pockets 232
Elizabeth J. Hall-Findlay
c. Site Change to Subglandular Pockets With Mastopexy 236
Elizabeth J. Hall-Findlay
d. Capsuloplasty and Implant Conversion to Submammary Pocket 242
Neal Handel
e. Radial Capsular Scoring With Insertion o Wider-Base Implants 248
Jack Fisher
15. Upper Pole Def ciency or Contour De ormity 253
a. Fat Gra ting to Treat Wrinkling and Contour De ormity 253
Moustapha Hamdi
b. Anatomic Implants or Upper Pole Def ciency 259
Brian D. Peterson
c. High Prof le Silicone Gel Implants or Correction o Rippling 263
Jack Fisher
16. In erior Pole Stretch De ormity 267
a. ADM and Eccentric Periareolar Mastopexy 267
Neal Handel
b. Inverted-T Mastopexy With Conversion to Submuscular Silicone Gel
Implants 276
Jack Fisher
17. Animation De ormity Associated With Subpectoral Implants 281
a. Use o a Neosubpectoral Pocket 281
Dennis C. Hammond
Contents
xx
b. Conversion to Subglandular Pockets 286
Jack Fisher
c. Pectoralis Repositioning With ADM 290
Allen Gabriel, G. Patrick Maxwell
18. Overaugmented Breast 295
a. Mastopexy With Conversion to Submuscular Pocket 295
Jack Fisher
b. Conversion to Subglandular Pocket 301
Neal Handel
c. Implant Replacement and ADM 306
Foad Nahai
d. Multidirectional Capsulorrhaphy Rein orced With ADM 310
Neal Handel
19. Ptosis in Previously Augmented Breasts 317
a. Conversion to Partial Subpectoral Pockets With Mastopexy 317
Louis L. Strock
b. Neosubpectoral Pocket Exchange 323
Louis L. Strock
c. Mastopexy Without Implant Exchange 329
Jack Fisher
d. Conversion to Subglandular Pockets With Periareolar Mastopexy 335
Jack Fisher
e. Circumareolar Mastopexy to Correct Ptosis and Other De ormities
A ter Augmentation 339
Neal Handel
. Explantation and Wise Pattern Mastopexy in a Patient With Prior
Augmentation-Mastopexy 347
Neal Handel
20. Asymmetries in Previously Augmented Breasts 355
a. Lipomodeling and IMF Fixation to Correct Asymmetry A ter Failed Breast
Implants 355
Emmanuel Delay
b. Asymmetrical Mastopexies, Unilateral Volume Reduction, and Implant
Replacement 359
Jack Fisher
21. Explantation 365
a. SIEF: Simultaneous Implant Exchange With Fat Gra ting 365
Daniel A. Del Vecchio
b. Explantation Without Replacement (Mastopexy) 371
Jack Fisher
Contents
xxi
Par III: Pr blems in Mas pexy and A gmen a i n-
Mas pexy
SECt Io N o NE: Po St o PERAt IVE Co MPLICAt Io NS
22. Ischemia o the Nipple-Areola Complex 379
a. Autologous Bilateral Nipple-Areolar Reconstruction 379
Neal Handel
b. Conservative Treatment o Nipple-Areolar Ischemia Following Mastopexy 391
Neal Handel
23. Compromised Skin Flaps 399
a. De ormity Following Failed Augmentation-Mastopexy Corrected With
Local Flaps Using a Vertical Mastopexy 399
Neal Handel
SECt Io N t w o : u NSAt ISFACt o RY AESt HEt IC o u t Co MES
24. Nipple Malposition 409
a. Correction o Nipple Malposition in a Patient With Previously Augmented
Breasts 409
Neal Handel
25. Unsatis actory Scarring 415
a. Secondary Mastopexy, Unilateral Reduction Mammaplasty, and Implant
Replacement 415
Neal Handel
26. Spreading o the Areolae 423
a. Conversion o Circumareolar Mastopexy to Vertical Mastopexy 423
Neal Handel
b. Interlocking Gore-Tex Permanent Purse-String Suture Technique 431
Dennis C. Hammond
c. Secondary Mastopexy 437
Allen Gabriel, G. Patrick Maxwell
27. Recurrent Ptosis 441
a. Total Submuscular Capsulectomies and Replacement With Shaped
Implants 441
David A. Caplin
b. Conversion to Partial Subpectoral Pocket and Bilateral Vertical
Mastopexy 445
Andre Y. Levesque, James C. Grotting
Contents
xxii
28. Flattening or Loss o Upper Pole Fullness 455
a. Fat Gra ting to Correct Flattening or Loss o Upper Pole Fullness 455
Louis P. Bucky
b. Loss o Upper Pole Fullness A ter Mastopexy 460
Elizabeth J. Hall-Findlay
29. In erior Stretch De ormity and Bottoming Out 467
a. Correction o Bottoming Out With Unilateral Fold Elevation and
Contralateral Periareolar Mastopexy 467
Dennis C. Hammond
b. Correction o In erior Stretch De ormity With Mastopexy and Implant Site
Change 473
Jack Fisher
30. Revision in Bariatric Patients o Unsuccess ul Outcome A ter Mastopexy
or Augmentation-Mastopexy 479
a. Secondary Mastopexy With Lower Pole Reshaping 479
Khalid Almutairi, J. Peter Rubin
Par IV: Pr blems in Red c i n Mammaplas y
SECt Io N o NE: Po St o PERAt IVE Co MPLICAt Io NS
31. Ischemia o the Nipple, Areola, and/or Skin Flaps 491
a. Watch ul Waiting 491
Elizabeth J. Hall-Findlay
b. Healing by Secondary Intention 496
Elizabeth J. Hall-Findlay
c. Watch ul Waiting With Antibiotics 501
Elizabeth J. Hall-Findlay
d. Complete Nipple Reconstruction With Skate Flaps 505
Jack Fisher
SECt Io N t w o : Su Bo Pt IMAL AESt HEt IC o u t Co MES
32. Overresection o Breast Tissue 513
a. Breast Reshaping With Expander-Implants 513
Jack Fisher
b. Implant Insertion With Skin Envelope Modif cation 519
Jack Fisher
c. Overresection o Breast Tissue 523
Elizabeth J. Hall-Findlay
Contents
xxiii
Contents
xxiv
33. Underresection o Breast Tissue 529
a. Secondary Vertical Reduction Mammaplasty 529
Elizabeth J. Hall-Findlay
b. Liposuction With Circumvertical Mastopexy 533
Dennis C. Hammond
34. Nipple Malposition 537
a. Correction With Subpectoral Breast Implants 537
Elizabeth J. Hall-Findlay
b. Correction With Breast Repositioning 542
Jack Fisher
35. Bottoming Out 547
a. Reduction o Excess Lower Pole Volume 547
Elizabeth J. Hall-Findlay
36. Unsatis actory Shape or Contour 551
a. Fat Transplantation 551
Daniel A. Del Vecchio
Par V-A: Pr blems in Breas Rec ns r c i n
w i h Pr s he ic Devices
SECt Io N o NE: Po St o PERAt IVE Co MPLICAt Io NS
37. In ection A ter Breast Reconstruction 561
a. Debridement and Drainage 561
Maurice Y. Nahabedian
b. Expander Replacement Combined With Autologous Tissue Trans er 565
Allen Gabriel, G. Patrick Maxwell
38. Capsular Contracture A ter Breast Reconstruction 571
a. Rigottomy and Fat Trans er (RAFT) 571
Roger K. Khouri
b. Capsulotomies With ADM A ter Radiotherapy 576
Maurice Y. Nahabedian
c. Explantation, Capsulectomy, and Reconstruction A ter Silicone Implant
Rupture and Chronic Hematoma 581
Neal Handel
Contents
xxv
39. Implant and Expander Malposition 591
a. Secondary Expansion With Implant Replacement 591
Jack Fisher
b. Secondary In ramammary Fold Correction During Expander
Removal 595
Jack Fisher
c. Bilateral TRAM Flaps Combined With Expander-Implants 600
Jack Fisher
40. Failed Expander/Implant Reconstruction 605
a. Two-Stage Reconstruction Using Local Flaps 605
Albert Losken
b. Reconstruction Using Local Tissue 610
Neal Handel
c. Reconstruction With Tissue Expansion and Contralateral Reduction
Mammaplasty 619
Neal Handel
d. Reconstruction With Tissue Expander and Implant Replacement 627
Allen Gabriel, G. Patrick Maxwell
e. Salvage With Latissimus Dorsi Flap and Expander 635
Jack Fisher
. Revision Tissue Expander–Implant Reconstruction With Latissimus Dorsi
Flap and Adjustable Implant 639
Jack Fisher
g. Salvage o Failed Bilateral Expander Reconstruction With TRAM
Flaps 644
Jack Fisher
h. Reconstruction With Free DIEP Flap 649
Moustapha Hamdi
i. Salvage o Failed Bilateral Expander Reconstruction With Autologous
Tissue Trans er 654
Glyn Jones
j. Implant Exposure A ter Nipple Reconstruction: Correction With Implant
Replacement and Latissimus Dorsi Flap 659
Allen Gabriel, G. Patrick Maxwell
Contents
xxvi
SECt Io N t w o : Su Bo Pt IMAL AESt HEt IC o u t Co MES
41. Asymmetry 667
a. Fat Gra ting 667
Emmanuel Delay
b. Correction With Implant Exchange, Capsulotomy, and Pocket
Adjustment 671
Albert Losken
c. Capsulorrhaphy With In erior Skin Recruitment and Implant
Exchange 678
Glyn Jones
42. Unsatis actory Shape or Contour 683
a. Unilateral TRAM Flap 683
Jack Fisher
b. Correction o Tissue Breakdown and Failed Tissue Expansion
Reconstruction Using Rigottomies, Brava External Expansion, and Serial
Lipof lling 688
Roger K. Khouri
c. Fat Gra ting 696
Sydney R. Coleman
Par V-B: Pr blems in Breas Rec ns r c i n
w i h A l g s t iss e
SECt Io N o NE: Po St o PERAt IVE Co MPLICAt Io NS
43. Ischemic and Necrotic Tissue 705
a. Salvage With Tissue Expansion Combined With a Bipedicled DIEP
Flap 705
Steven J. Kronowitz, Keith M. Blechman
b. Correction With a Latissimus Dorsi Flap A ter TRAM Flap
Reconstruction 709
Glyn Jones
44. Failed Tissue Trans er A ter Autologous Breast Reconstruction 713
a. Revising Autologous Breast Reconstruction With a DIEP Free Tissue
Trans er 713
Moustapha Hamdi
b. Revising Autologous Breast Reconstruction With an SGAP Free Tissue
Trans er 719
Moustapha Hamdi
Contents
xxvii
SECt Io N t w o : Su Bo Pt IMAL AESt HEt IC o u t Co MES
45. Persistent Volume Def ciencies 727
a. Salvage With Fat Gra ting, Implant Insertion, and a TRAM Flap 727
Maurice Y. Nahabedian
b. Tissue Expansion With TRAM Flap Repositioning and Implant
Insertion 731
Jack Fisher
Par V-C: Def rmi ies Ass cia ed w i h L mpec my,
Par ial Mas ec mies, and Radia i n
SECt Io N: Co MPLICAt Io NS AND Su Bo Pt IMAL
AESt HEt IC o u t Co MES
46. De ormities A ter Lumpectomy, Radiation, and Breast
Reconstruction 741
a. Fat Gra ting 741
Emmanuel Delay
b. Capsulectomy With Implant Replacement and Contralateral Reduction
Mammaplasty 745
Neal Handel
c. Correction o a Lumpectomy De ect With a Latissimus Dorsi Flap and
Implant 753
Jack Fisher
d. Latissimus Dorsi Flap Reconstruction and Contralateral Mastopexy 758
Steven J. Kronowitz, Keith M. Blechman
e. Combined Latissimus Dorsi Myocutaneous Flap With Implants and Fat
Trans er 764
Albert Losken
. Repair With a Latissimus Dorsi Flap and an Adjustable Implant 769
Jack Fisher
g. Revision o TRAM Flap Breast Reconstruction 773
Dennis C. Hammond
h. Completion o Previous Lumpectomy and Radiation With Nipple-Sparing
Mastectomy and a Buried TRAM Flap 779
Jack Fisher
Contents
xxviii
Par V-D: Cancer Rec rrence Af er Breas
Rec ns r c i n
47. Cancer Recurrence A ter Implant Reconstruction 789
a. Salvage With Latissimus Dorsi Myocutaneous Flap Reconstruction and
Tissue Expander Placement 789
Albert Losken
b. Latissimus Dorsi Flap With Implant Salvage 794
Glyn Jones
48. Cancer Recurrence A ter Autologous Reconstruction 799
a. Revision With DIEP Flap Advancement 799
Steven J. Kronowitz, Keith M. Blechman
Par VI: Pr blems Ass cia ed w i h he Nipple-Are la
C mplex
SECt Io N: Co MPLICAt Io NS AND Su Bo Pt IMA L
AESt HEt IC o u t Co MES
49. Malposition, Asymmetry, Loss o Projection, Overprojection, and Areolar
Spreading 807
a. Combined Expander-Implant Exchange With Capsulorrhaphies and Fat
Gra ting 807
Steven J. Kronowitz, Keith M. Blechman
b. Repeat Free Nipple Gra t With Periareolar Mastopexy 810
Albert Losken
c. Reciprocal Transposition Flaps 815
Scott L. Spear, Frank P. Albino
d. Wraparound Flap to Restore Nipple Projection 821
Glyn Jones
Index 825
Pa r t I
Fundamentals
(Trang không có chữ)
Ja c k Fish er , Nea l Ha n d el
Aesthetic and reconstructive breast surgery is an important ocus or many plastic
surgery practices. Although success ul outcomes are always the goal, surgical pro-
cedures do not always deliver the desired results. For a variety o reasons, outcomes
may all short o expectations. Perhaps the aesthetic appearance is suboptimal, with
breasts too high or too low, too small or too large. Complications such as implant
extrusion, in ection, ap ailure, or nipple necrosis may also occur. When address-
ing the need or corrective breast surgery, the surgeon must consider the wide spec-
trum o tools and techniques that can be employed to “repair” an unsatis actory
result. O primary importance is the surgeon’s ability to e ectively evaluate the
problem, to assess the di erent options or addressing it, and to ormulate a plan
that takes into account all actors that will in uence the outcome. This problem-
solving process is what this “repair manual” is all about. The value o this book
comes rom the clinical judgment and surgical skill o the talented breast surgeons
who have shared their experiences and approaches to treating patients with these
challenging problems.
As you will discover, this is not a traditional technique-oriented textbook. Rather, it
ocuses on problems and provides a number o di erent clinical solutions or solv-
ing complex secondary breast surgery problems. The goal o this book is not to
judge which solution is the best; that decision is le t to the reader. Rather, by draw-
ing on the collective wisdom o these experts, we present a detailed road map o
how to move rom point A, the problem, to point B, the solution; hence this book is
called a repair manual.
To help you ollow the thought process o each surgeon as he or she evaluates the
patient’s problem or problems and arrives at a solution or solutions, we have used a
highly structured case ormat; each patient example is organized into eight separate
sections.
C H a Pt e r 1
A READER’S GUIDE
TO PROBLEMS IN BREAST SURGERY:
A REPAIR MANUAL
3
Part I: Fundamentals
4
I. Pat Ien t HIs t o r y Lea d In g t o t He s Pec If Ic Br ea s t Pr o BLem
In this introductory section, the preoperative patient photos are shown with a de-
scription o the patient history and the patient presentation. Particular emphasis is
placed on the patient’s previous breast surgery procedures.
II. a n at o m Ic d es c r IPt Io n o f t He Pat Ien t ’s c u r r en t s t at u s
Altered anatomy is a signif cant consideration in the planning process; there ore
this section describes the status o the patient’s de ormity when she presented or
correction, as well as the characteristics o the tissues or structures that are present
or are no longer available or surgical intervention. In this section the authors de-
scribe important considerations such as the position and def nition o the in ramam-
mary old, breast asymmetry, chest wall de ormity, upper breast pole def ciency,
and the status o so t tissue structures including the skin, muscle, and at.
III. a n a Lys Is o f t He Pr o BLem
This section analyzes why the problem exists and considers possible strategies or
correction. The choice o a particular solution is identif ed, along with a rationale
or selecting it. I applicable, the authors also discuss one or two alternative options
that are worthy o consideration.
IV. r ec o m m en d ed s o Lu t Io n t o t He Pr o BLem
The surgical plan is highlighted in this part o the case presentation; it includes a
bulleted list outlining the surgical steps or correction.
V. t ec Hn Iq u e
The technique section o each case presentation provides a step-by-step description
o the procedure with accompanying images. The illustrations or intraoperative
photos used to depict the procedural steps are provided to help readers replicate the
procedure; the steps are based on the process o going rom the problem to the so-
lution. It’s the journey, or how the surgeon accomplishes the repair or revision, that
is most important and there ore the key element o this repair manual.
VI. Po s t o Per at IVe PHo t o g r a PHs a n d c r It Ic a L eVa Lu at Io n
o f r es u Lt s
The postoperative photos show the results that were achieved with the particular
technique described. Accompanying the photos is a critical evaluation o the result
and a discussion by the surgeon o the advantages and disadvantages o alternative
approaches that might have been chosen.
VII. t ea c HIn g Po In t s
The key maneuvers or points are listed; they e ectively summarize the approach
used and provide salient details to assist you when this option is selected.
Chapter 1 • A Reader’s Guide to Problems in Breast Surgery: A Repair Manual
5
VIII. BIBLIo g r a PHy
A bibliography o relevant literature on each problem and its surgical approaches
concludes each case discussion.
We hope that this text will aid experienced surgeons and trainees alike in assessing
the patient with secondary breast surgery problems, considering a variety o op-
tions and selecting the best approach or each particular situation. The case ormat
has been designed to easily convey the most important considerations in uencing
the problem-solving process. Using this ormat, we have attempted to expose read-
ers to the variety o clinical solutions available or a given clinical condition, so that
readers can decide which ones will work best in their hands.
An additional goal o this repair manual is to explore the causes and mechanisms
o specif c problems so that we can understand the nature o potential problems be-
ore they occur and there ore take preemptive steps to avoid them.
(Trang không có chữ)
C h a p t e r 2
THE ART OF ANALYSIS:
MECHANISMS OF FAILURE AND
KEY ANATOMIC FACTORS
Ja c k Fish er , Nea l h a n d el
Breast surgery represents an important part o most plastic surgery practices. In
recent years, the number o breast operations per ormed by plastic surgeons has
increased dramatically, with the combined rate o all procedures—augmentation,
mastopexy, and breast reduction—more than doubling in the past decade. The
growing popularity o cosmetic surgery, combined with the increasing proportion
o cases represented by breast operations, has resulted in exponential growth in the
absolute numbers o breast surgeries per ormed each year.
The growth in the popularity o reconstructive breast surgery parallels that o cos-
metic breast surgery. Factors contributing to this increased demand include the
technical advances in reconstructive procedures, awareness among women and
their physicians o the improved quality o li e ollowing breast reconstruction, and
government mandates or insurance coverage o breast reconstruction a ter cancer
treatment.
Numerous studies have documented the high rates o patient satis action a ter
cosmetic and reconstructive breast surgery. It has also been well documented that
there is a signi cant rate o complications, suboptimal outcomes, and reoperations
among breast surgery patients. Published studies reveal that approximately 25% to
30% o primary breast augmentation patients undergo a revision within the rst 3
years a ter surgery, a similar percentage o revision patients undergo yet another re-
vision within the same time rame, and up to 40% o breast reconstruction patients
require reoperation within the rst 3 years a ter surgery. The popularity o aes-
thetic and reconstructive breast surgery procedures among plastic surgery patients,
combined with the signi cant incidence o suboptimal outcomes and reoperations,
make it mandatory that plastic surgeons per orming breast surgery be well versed
in secondary or revision breast surgery.
7
Part I: Fundamentals
8
MECHANISMS O F FAILURE
Understanding the mechanisms o ailure is the key to avoiding problems be ore
they occur and correcting problems that need to be addressed. The ollowing mech-
anisms o ailure can occur when planning or executing surgical procedures:
Failure in patient selection
Failure to identi y the high-risk patient
Failure in procedure selection
Failure to accommodate the altered anatomy
Failure o execution
We have identi ed two broad categories o problems contributing to the need or
revision breast surgery. One set o problems results rom complications or poor re-
sults that are directly related to the original operative procedure; such events usu-
ally mani est in the early postoperative period. Many actors contribute to early
complications and suboptimal results; some variables are within the surgeon’s con-
trol, whereas others are not. For example, patient or procedure selection, implant
choice, and timing and staging o operations are all within the surgeon’s control. In
revision breast surgery, the principles o good surgical technique become even more
important. There are many critical actors that assist in achieving optimal results,
including care ul handling o tissues; placement o incisions in accordance with the
natural lines, creases, and contours o the breast; and avoidance o undue tension
on closure. Factors beyond the surgeon’s control include previous scars, diminished
circulation to the tissues, previous irradiation, and patient-speci c comorbidities;
however, care ul patient selection and planning, which take into consideration these
anatomic and physiologic actors, will help to mitigate their adverse e ects.
The second category o problems relates to actors that result in the need or revi-
sion surgery that occurs months, years, or even decades a ter the primary operation.
These actors are related to natural anatomic and physiologic changes associated
with the aging process, f uctuations in weight, and the e ects o gravity, pregnancy,
and breast- eeding on the anatomy and physiology o the breast. A multitude o
changes may also occur because o the presence o breast implants, including cap-
sular contracture, tissue atrophy, and skin stretching. Some patients may simply
wish to change their breast appearance and there ore desire a secondary procedure.
When treating patients in the rst group, who have had complications or poor re-
sults that are directly related to the original operative procedure, the surgeon needs
to be attuned to the special needs o this patient population. There may be an emo-
tional component o disappointment or dissatis action because their goals have not
been achieved already and their expectations have not yet been met. These women
have already experienced a disappointing outcome rom plastic surgery. Whether
they are having additional surgery to treat a complication or to improve an unsat-
is actory aesthetic result, the operation they are about to undergo is one that was
not initially planned. Because o their dissatis action with the preceding operation,
these patients have become sensitized and are at greater risk o being disappointed
i they experience yet another complication or an additional disappointing aesthetic
outcome. For that reason, surgeons per orming revision breast surgeries need to
have the requisite skills and tools to ensure reliable correction o existing problems,
Chapter 2 • The Art of Analysis: Mechanisms of Failure and Key Anatomic Factors
9
lasting results with minimal possibility o recurrence, and the lowest possible risk
o creating new problems or complications. The rst physician’s principle—do no
harm—is particularly applicable to this group o patients.
Patients in this second category, those presenting with delayed complications, have
di erent motivations than women who present with early problems. For many pa-
tients in the second group, the need or revision surgery arises rom the natural
evolution in the appearance o the breasts that has occurred over time; the patient
now seeks to urther modi y or improve what was originally a positive result. In
such cases, the act that a patient can bene t rom revision does not automatically
imply that an adverse event has occurred or that she has had a complication. Over
time, breasts continue to age, and their cosmetic appearance tends to deteriorate.
Many o the revision operations commonly per ormed in patients who have had
aesthetic or reconstructive breast surgery all under the category o “maintenance”
or “restorative” procedures. For example, a woman who had breast implants in her
early twenties may now, at age 50, want a breast li t with or without implants. Or
a previously overweight patient who had a breast reduction years earlier may now,
a ter weight loss, request revision surgery to augment or li t her breasts. These pa-
tients may eel or look better than they have in years, but their breasts have become
def ated and ptotic; thus urther surgery is appropriate. Similarly, a patient who had
breast reconstruction years earlier with a tissue expander and implant placement
may now present with marked asymmetry because o weight gain, weight loss, or
the natural aging changes o the contralateral breast. Obviously, there is an un-
limited number o variations o clinical situations in which secondary or revision
breast surgery is viewed by the patient as a positive experience; there ore it is im-
portant to recognize that revision surgery does not necessarily have a negative con-
notation or many patients.
ANATOMIC ANALYSIS
As in any eld o medicine, accurate anatomic diagnosis is the key to ormulating
the correct treatment plan or a patient in need o breast revision. There are two
anatomic actors to consider:
1. Preexisting anatomic conditions present at the time o the original procedure
have contributed to the current problem. For example, were there high, tight
in ramammary olds (IMFs) or chest wall de ormities that were not properly
diagnosed? An undiagnosed pectus excavatum can lead to medial implant
displacement with nipple-areola complex (NAC) malposition, or an undiag-
nosed asymmetry o the patient’s IMFs, no matter how minimal, can result
in signi cant asymmetry a ter implant insertion. I a patient originally had
high and tight IMFs that were not appropriately corrected, a myriad o ana-
tomic complications could result, including double-bubble de ormity, supe-
riorly displaced implants, and NAC malposition. Failure to properly analyze
the patient’s underlying anatomy and to identi y abnormalities at the time o
the original surgery is a major cause o secondary problems.
2. Changes in the patient’s anatomic status over time have prompted her to
seek revision surgery. In this situation, it is critical or the surgeon to de-
termine what anatomic components remain that may now be use ul to re-
solve the current problems. What is the status o the so t tissues, the blood
supply, and the musculature? Is there signi cant scarring, and what is the
Part I: Fundamentals
10
location and positioning o important anatomic landmarks such as the IMFs
and NACs? All o these actors require care ul analysis and sound decision-
making be ore proceeding with revision breast surgery.
ANATOMIC FACTORS FOR CONSIDERATION
The ollowing anatomic actors need to be evaluated:
Scarring
Symmetry and altered anatomic
relationships
NAC location
IMF status
Muscle and chest wall status
Blood supply status
Anterior axillary old status
Altered tissue characteristics
Breast shape
Each o these anatomic actors must be assessed in terms o its impact on other re-
lated structures. In other words, breast symmetry, nipple-areolar location, breast
shape, and any o the other key anatomic landmarks and structures are all inter-
connected. When a patient presents or revision surgery, there is requently one
primary problem that is identi ed; however, it is also important to understand that
other anatomic abnormalities may play a role as secondary contributing actors.
The key to devising the correct treatment plan or a patient in need o breast re-
vision is to make an accurate diagnosis o the problem; however, plastic surgery
di ers rom many other areas o medicine because the “symptoms”—that is, the
things the patient nds troublesome—are subjective and can vary greatly rom one
individual to another. One good example o this is o ten seen in women with breast
implants. There is a wide range in what is considered “desirable” in terms o breast
rmness. Some patients, and most plastic surgeons, aspire to having the so test,
most compliant, and most “natural”- eeling breasts that can be achieved, which are
typically classi ed as Baker grade I. But other patients indicate a clear pre erence
or a rmer and thus somewhat “unnatural” breast, which are usually classi ed as
Baker grade II or III. Likewise, there are wide variations in what is perceived as an
attractive breast size, desirable nipple position, or appropriate areolar diameter.
Although there are wide variations about what is perceived to be an attractive
breast shape, some anatomic characteristics are universally considered aesthetically
desirable. It is against these universal characteristics that a particular surgical result
can be judged and that serve as the benchmarks or the desired outcome o revision
surgery. When evaluating the breast contour and shape, it is generally accepted that
the upper pole o the ideal breast mound should have a straight or slightly convex
silhouette. The nipple is ideally positioned at the most prominent projecting por-
tion o the breast mound; usually this is in the lower third o the breast. From the
rontal view, the NAC should be slightly lateral to the breast meridian and should
have a slightly upward and outward tilt. Despite these aesthetic norms, we have all
encountered patients whose aesthetic goals call or upper pole ullness, which is not
necessarily consistent with what is typically considered a desirable breast contour.
As a result, it is di cult to speak o absolutes; “ideal” breast contour is like “ideal”
Chapter 2 • The Art of Analysis: Mechanisms of Failure and Key Anatomic Factors
11
breast size, because it is ultimately subjective, and both are based on the needs and
desires o the individual patient.
One physical characteristic that is considered universally desirable in virtually ev-
ery region o the body is symmetry. Although normal breasts are never identical,
a reasonable amount o symmetry in size or volume, shape or contour, and topog-
raphy, such as nipple position, is highly desirable. Many secondary procedures are
aimed at addressing persistent or recurrent asymmetry. One goal o revision surgery
should be to achieve the best symmetry possible.
Cosmetic units o the breasts are another important concept to consider when evalu-
ating patients or revision surgery. Thinking o cosmetic units within the breast in the
same way that we think about cosmetic units o the ace may minimize noticeable
scars, yielding a more aesthetic and natural result. There ore it is important to place
incisions in the lines, creases, or shadows o the breast, where they are less obvious.
Visually obvious patches or segmental reconstructions can have an unaesthetic ap-
pearance, which de eats the goal o creating the most natural-appearing result pos-
sible. I the border o a f ap, such as a latissimus skin island, runs transversely across
the middle o the breast, it is much more obvious and much less aesthetic than i the
f ap is inset adjacent to the IMF, where the in erior scar is hidden in the breast crease.
Typically, visible scarring on the breast is considered undesirable. Revision breast sur-
gery should there ore aim to create the best quality and least visible scars.
Revision breast surgery is a challenging endeavor that tests a surgeon’s analytic
and clinical skills. The chapters that ollow are intended to help surgeons overcome
these challenges by understanding the underlying surgical principles and anatomic
considerations that contribute to success ul outcomes. Using the problem-solving
ormat, readers have the unique ability to literally view the problems rom the per-
spective o another expert surgeon and learn rom his or her analysis, decision-
making, and surgical experience.
The authors and contributors to this book present a wide variety o problem cases.
Obviously, not every possible complication or suboptimal result can be included.
But our hope is that by evaluating the basic principles presented in the large num-
ber o cases presented, the reader will gain a sound oundation o problem-solving
approaches that can be used in all aspects o revision breast surgery. Throughout
this book, you will see that critical anatomic assessment plays a major role in solv-
ing these di cult problems. Attention to the basic principles o revision surgery and
meticulous surgical technique will help to achieve predictable, long-lasting results
and to avoid ailure and recurrence o de ormity.
BIBLIO GRAPHY
Grewal NS, Fisher J. Why do patients seek revisionary breast surgery? Aesthet Surg J 33:237-244,
2013.
Hanwright PJ, Hirsch EM, Seth AK, et al. A multi-institutional perspective o complication rates or
elective nonreconstructive breast surgery: an analysis o NSQIP data rom 2006 to 2010. Aesthet
Surg J 33:378-386, 2013.
(Trang không có chữ)
Pa r t II
Problems in
Augmentation
Mammaplasty
Silicone implants were rst introduced more than 50 years ago. Since that time, there has been
steady growth in the popularity o breast augmentation. It is now estimated that nearly 400,000
American women undergo cosmetic breast enlargement annually. While there are alternatives
to the use o implants ( or example, autologous at trans er), the overwhelming majority o
breast augmentations are per ormed using prosthetic devices. Patient satis action a ter breast
augmentation is high—studies consistently report that more than 90% o patients are very sat-
is ed with their results. At the same time, it is widely acknowledged that there is a signi cant
rate o local complications and a recognized incidence o un avorable aesthetic outcomes a ter
breast implant surgery. Over 30% o primary augmentation patients undergo a reoperation
within the rst three years. Because o the relatively high incidence o suboptimal outcomes and
the requent need or reoperations, plastic surgeons per orming breast augmentation need to
have the tools and skills to success ully per orm breast revision surgery. Common indications
or reoperation include capsular contracture, implant malposition, waviness, palpability, anima-
tion de ormities, double-bubble de ormity, implant exposure or rupture, and asymmetry. Even
in patients with good initial results, the progressive changes in the breast that accompany aging,
pregnancy, lactation, and f uctuations in weight may cause alterations in breast appearance that
compel patients to seek revision surgery. In this section contributors present a wide array o in-
novative strategies to address problems arising rom breast augmentation. But these cases by no
means represent the de nitive set o solutions available. Procedures available to correct subopti-
mal outcomes ollowing breast augmentation are limited only by the imagination and ingenuity
o talented plastic surgeons.
Se c t Io n o n e
Postoperative Complications
Chapter 3 Periprosthetic Infection After Augmentation
3a Salvage o an In ected Implant With Secondary Use o ADM
3b Unilateral Explantation With Delayed Implant Reinsertion and Mastopexy
3c Bilateral Explantation With Delayed Implant Reinsertion
3d Salvage o an In ected Augmentation With a Tissue Expander and Secondary Implants
Chapter 4 Late Seroma After Augmentation
4a Implant Removal and Replacement
4b Surgical Drainage With Implant Exchange
Chapter 5 Capsular Contracture After Augmentation
5a Periareolar Capsulectomy With Implant Replacement
5b Saline Implant Removal, Total Capsulectomy, and Replacement With Gel Implants
5c Implant Removal, Tissue Expansion, and Replacement With Contoured Gel Implants
5d Creation o a Neopectoral Pocket, Breast Tissue Reshaping, and Implant Insertion With ADM
5e Revision Augmentation With Total Explantation, Site Change, and Insertion o Silicone Implant
With ADM
Chapter 6 Impending Implant Exposure/ Extrusion
6a Two-Stage Salvage With Placement o Smaller Implants
6b Management o Impending Saline Implant Exposure Resulting From Intraluminal Steroids
6c Impending Implant Exposure Treated by Explantation and Delayed Fat Gra ting With Implant
Reinsertion
Chapter 7 Deflated Saline Implants
7a Pocket Modi cation With Insertion o Silicone Gel Implants
Chapter 8 Intracapsular Rupture and Gel Bleed
8a Pocket Exchange—Subglandular to Subpectoral—With ADM
8b Explantation, Capsulectomy, and Conversion to a Submuscular Pocket
8c Explantation, Capsulectomy, Tissue Expansion, and Delayed Implant Placement
8d Explantation, Capsulectomies, and Conversion to Subpectoral Pockets
8e Explantation, Capsulectomy, and Conversion to Submuscular Pocket With Secondary
Mastopexy
15
Chapter 9 Extracapsular Rupture, Gel Migration, and Silicone Injections
9a Submuscular Capsulectomies and Implant Exchange
9b Multistage Repair With Fat Gra ting
9c Bilateral Mastopexies With Implant Insertion
9d Silicone Injection Correction With Bilateral Mastectomies With TRAM Flaps
Chapter 10 Implant Rotation With Shaped Implants
10a Removal o Shaped Implants, Pocket Conversion, Mastopexy, and Insertion o Round Implants
10b Correction o Anatomic Implant Rotation With Manual Manipulation
10c Shaped Implant Rotation
Chapter 11 Special Problems: Malignancy After Augmentation
11a Reconstruction With an Expander and a Latissimus Dorsi Flap
11b Latissimus Dorsi Flap With Expander
16
c h a Pt e r 3
PERIPROSTHETIC INFECTION
AFTER AUGMENTATION
3a Salvage of an Infected Implant With Secondary Use
of ADM
n ea L h a n DeL
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 43-year-old woman had undergone a breast augmentation 10 years earlier
with textured saline- lled implants. She presented to a cosmetic surgeon with a de-
f ated right implant and underwent bilateral removal and replacement with smooth
saline implants (inf ated to 550 cc). Postoperatively, the patient was placed on oral
cephalosporin or 5 days.
Several weeks a ter surgery the patient developed a seroma on the right side; this
was aspirated by her surgeon and f uid was sent or culture and sensitivity test-
ing; there was “no growth.” She was maintained intermittently on oral antibiotics.
Over the next week she noted increasing rmness, redness, and warmth o her right
breast. Approximately 1 month postoperatively, the periareolar incision separated,
with drainage o clear f uid. A physician assistant explored the wound in the sur-
geon’s exam room using a local anesthetic, and a large piece o Vicryl suture was
removed; probing with a cotton-tipped applicator revealed that the wound commu-
nicated with the periprosthetic space.
17
Part II: Problems in Augmentation Mammaplasty
18
The patient was re erred by her cosmetic surgeon or evaluation and treatment. She
was immediately placed on broad-spectrum antibiotic coverage (levof oxacin [Leva-
quin] 500 mg every day and trimethoprim/sul amethoxazole [Bactrim DS] twice a
day) or 10 days. The antibiotics suppressed all external mani estations o in ection
(erythema, swelling, warmth, and tenderness) and the incision healed. However,
several days a ter antibiotics were discontinued, the in ection recurred.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is an a ebrile, slightly overweight white emale who underwent bilateral
augmentation through a periareolar approach. The le t breast is normally healed;
on the right breast, the periareolar incision has healed ( ollowing prolonged double
antibiotic treatment) but with depression o the scar at the site o the prior stula.
There is recurrence o cellulitis involving the entire in erior hal o the breast, along
with di use swelling, generalized tenderness, and increased warmth.
ANALYSIS O F THE PRO BLEM
This patient presented with a chronic in ection involving the periprosthetic space.
Broad-spectrum antibiotics were temporarily e ective in suppressing the in ection,
but the in ection f ared up a ter antimicrobial therapy was discontinued, resulting
in f uid accumulation around the implant, cellulitis o the in erior hal o the breast,
and di use swelling and tenderness. The patient was o ered two possible treatment
options. The more conservative approach would be explantation, pocket irrigation,
and insertion o a drain (without reimplantation). A ter a suitable waiting period
(approximately 3 to 6 months), a new prosthesis could be sa ely inserted. The pa-
tient was also given the option o attempting to salvage the implant by capsulec-
tomy, aggressive pocket lavage, and immediate insertion o a new prosthesis. She
was told that there was a distinct possibility that this approach might ail, the in-
ection could reemerge, and de nitive explantation might be necessary. The patient
opted to attempt implant salvage.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the in ected implant
Capsulectomy, pocket lavage, and insertion o a new prosthesis
As a result o a total capsulectomy, the new implant was in eriorly and laterally
displaced, causing asymmetry o the in ramammary olds (IMFs), asymmetrical
nipple position, and excessively wide cleavage
Implant malposition was corrected secondarily by capsuloplasty and insertion o
a Strattice acellular dermal matrix (ADM) sling
Chapter 3 • Periprosthetic Infection After Augmentation
19
TECHNIQ UE
To ensure the best chance o clearing the in ection and salvaging the implant, this
patient underwent explantation and replacement with a new prosthesis in conjunc-
tion with a complete capsulectomy. Be ore the new implant was inserted, high-
pressure pulse lavage o the pocket was per ormed with 2 L o double antibiotic
(bacitracin, neomycin) solution. The right breast healed unevent ully, and the op-
eration was success ul in terms o eradication o in ection and retention o the im-
plant. However, several weeks a ter surgery it became evident that the right implant
was in eriorly and laterally displaced as a result o pocket enlargement rom the
aggressive capsulectomy that was necessary to eradicate the in ection. As a conse-
quence, there was noticeable asymmetry o the IMFs, obvious asymmetry in nipple
position, and lateral dri t o the right implant (especially with the patient in the su-
pine position). The patient requested corrective surgery to improve symmetry and
to achieve the best nal cosmetic result.
The revision procedure was per ormed 3 months a ter treatment o the in ection.
An in erior and lateral capsuloplasty was per ormed to reduce the dimensions o
the periprosthetic space, and a sling o ADM (Strattice) was inset to rein orce the
repair and to support the weight o the relatively large implant.
Markings depict 2 cm downward displacement and 1.3 cm lateral displacement o
the right implant.
Part II: Problems in Augmentation Mammaplasty
20
The capsuloplasty excision was marked and the capsule incised. The appropriate
crescent o redundant capsule was excised and the de ect closed with running, con-
tinuous, locked, nonabsorbable suture. A sizer was inserted into the revised pocket,
demonstrating adequate correction o in erior and lateral implant malposition.
Strattice ADM was inset as a sling to rein orce the capsular repair and support the
weight o the permanent implant. The cardinal points or inset o the ADM gra t
were marked on the skin, and marionette sutures were placed to acilitate proper
positioning o the gra t in the pocket. The ADM gra t was seated and the posterior
repair to the chest wall was completed.