Revisiting Prepectoral Breast Augmentation: Indications and Refinements.

BACKGROUND: Prepectoral breast reconstruction is receiving renewed attention as a viable alternative to retropectoral reconstruction. Prepectoral breast augmentation needs to be reappraised, because patients increasingly demand safer and less invasive procedures with a shorter recovery period. OBJECTIVE: This study aimed to evaluate prepectoral breast augmentation combined with a microtextured prosthesis to determine whether it could be a useful alternative to retropectoral augmentation. METHODS: This study included 76 women (152 breasts) who were indicated for primary breast augmentation. The inclusion criterion was a pinch test result of more than 3 cm at the upper pole of the breast. A total subfascial dissection was performed with endoscopic assistance. Microtextured implants were placed through an axillary approach in the subfascial space. RESULTS: The mean follow-up period was 12 months (range, 6-23 months). The mean implant volume was 278.1 mL (range, 185-360 mL). Autologous fat grafts were applied in 12 patients. No patients developed seroma, capsular contracture, or malposition during the follow-up period. Two patients expressed concerns of minor contour visibility, but no patients required revisional surgery. CONCLUSIONS: The drawbacks of prepectoral implant placement were sought to be managed by fascial coverage and microtextured prostheses. Although the follow-up duration was short, major complications were not encountered with Motiva Ergonomix SilkSurface implants. Therefore, prepectoral augmentation with microtextured prostheses should be reconsidered as a potential alternative to retropectoral methods because of the recent advances in surgical techniques and device technology.

Transaxillary endoscopic breast augmentation with shaped gel implants.

BACKGROUND: At its inception, transaxillary breast augmentation was a blind technique associated with complications and unpredictable outcomes. The transaxillary approach now involves electrocautery dissection with direct endoscopic visualization and yields excellent aesthetic outcomes with a concealed scar. Shaped implant devices can be combined with transaxillary augmentation for natural-appearing results that can be individualized to the patient. OBJECTIVES: The authors sought to improve the results of transaxillary endoscopic breast augmentation by placing shaped gel implants in patients with an indistinct or absent inframammary fold (IMF), who wished to avoid a breast scar. METHODS: One hundred sixteen Asian women underwent transaxillary endoscopic breast augmentation with electrocautery dissection and were evaluated in a prospective study. A partial retropectoral plane pocket was created in 4 sequential dissection steps with direct endoscopic visualization and careful control of bleeding. Shaped cohesive gel implants were placed to produce smooth, natural-appearing breast mounds and well-defined IMFs. RESULTS: Patients were monitored for 6 to 24 months after surgery (mean, 10 months; median, 12 months). There were no instances of pneumothorax, instrument-related skin burns, or severe implant deformation due to rotation or displacement of the implants postoperatively. Three of 116 patients (2.6%) experienced Baker 3 unilateral capsular contracture. One patient developed a unilateral hematoma at 3 weeks after surgery. CONCLUSIONS: Endoscopic breast surgery is associated with shortened recovery times, a reduced need for drainage, and excellent outcomes, including a well-defined and symmetric IMF. This approach, combined with shaped gel implants, can yield natural-appearing results of transaxillary breast augmentation. LEVEL OF EVIDENCE: 4 Therapeutic.

Nipple Reduction With the Chullo-Hat Technique.

BACKGROUND: Although various techniques of nipple reduction have been described in the literature, many are difficult to design or have unreliable outcomes. For men, as well as women who do not plan to breastfeed, it is not necessary to apply a complicated technique that protects the lactiferous ducts. OBJECTIVES: The authors introduce a simple technique for nipple reduction that has achieved consistent, reproducible results. METHODS: The desired nipple length is marked, and a chullo-hat excision pattern is drawn. After infiltration of a local anesthetic solution around the nipple, excision of the excess nipple tissue is performed, comprising 2 triangular flaps. The remaining 2 pillars are approximated with 5-0 Nylon simple interrupted sutures. However, the wound is not completely closed in the central area of the nipple, which promotes the drainage of discharge. RESULTS: Fifty-three women (106 nipples) underwent this surgery between December 2009 and December 2013. The follow-up period ranged from 6 months to 2 years (mean, 10 months). No major complications occurred, and the scars were very inconspicuous. The postoperative appearance of nipples was consistently similar in size and shape. CONCLUSIONS: This simple technique was safe and effective in nipples of different sizes. The results were reliable and consistent with expectations. Although this study included only women, the authors believe that outcomes would be successful in men as well. LEVEL OF EVIDENCE: 4 Therapeutic.

Anatomy and tensile strength of the abdominal head of the pectoralis major muscle in relation to transaxillary breast augmentation.

BACKGROUND: This study aimed to elucidate the anatomy of the abdominal head of the pectoralis major (AHPM) in relation to transaxillary breast augmentation (TBA). METHODS: In 20 hemithoraxes of fresh Korean cadavers, the width, thickness, and location of the origin of the AHPM were measured in relation to the seventh rib-costal cartilage junction. A force gauge was used to measure the force needed to detach the AHPM from its origin. In another four breasts, an implant pocket was made first, followed by observation of the AHPM. In 92 patients who underwent surgery, the AHPM was observed at its origin during performance of endoscopic TBA. RESULTS: The AHPM was observed in 23 (96%) of 24 hemithoraxes dissected. The AHPM was observed in 170 (92.4%) of 184 breasts subjected to surgery. The AHPM originated from the rectus fascia at the sixth (60%) and seventh (35%) costochondral junctions. The width of the AHPM was 23.5±5.2 mm at its origin, 15.2±3.9 mm at midbelly, and 7.3±4.3 mm at insertion. The thickness of the AHPM at its origin was 1.6±0.5 mm. The force needed to detach AHPM from its origin was 23.5±12.0 N. In two cadavers of mock surgery, the AHPM could limit the boundary of the implant pocket after division of the costal origins. After division of the AHPM, the free inferior space was obtained. CONCLUSION: In submuscular or dual-plane breast augmentation, the AHPM should be cut to place the implant in the correct desired position. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Three-dimensional circumferential liposuction of the overweight or obese upper arm.

UNLABELLED: Due to recent trends in liposuction, anatomic consideration of the body's fatty layers is essential. Based on this knowledge, a circumferential approach to achieving maximal aesthetic results is highlighted. In the upper arm, aspiration of fat from only the posterolateral region can result in skin flaccidity and disharmony of the overall balance of the upper arm contour. Different suction techniques were applied depending on the degree of fat accumulation. If necessary, the operation area was extended around the axillary and scapular regions to overcome the limitations of the traditional method and to achieve optimal effects. To maximize skin contracture and redraping, the authors developed three-dimensional circumferential liposuction (3D-CL) based on two concepts: circumferential aspiration of the upper arm, to which was applied different fluid infiltration and liposuction techniques in three anatomic compartments (anteromedial, anterolateral, and posterolateral), and extension of liposuction to the periaxillar and parascarpular areas. A total of 57 female patients underwent liposuction of their excess arm fat using this technique. The authors achieved their aesthetic goals of a straightened inferior brachial border and a more slender body contour. Complications occurred for five patients including irregularity, incision-site scar, and transient pigmentation. Through 3D-CL, the limitations of traditional upper arm liposuction were overcome, and a slender arm contour with a straightened inferior brachial border was produced. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at http://www.springer.com/00266.

Myofibroblasts and capsular tissue tension in breast capsular contracture.

BACKGROUND: This study aimed to observe the relationship between the number of myofibroblasts, the tensile strength of the breast implant capsule, and the degree of breast capsular contracture. METHODS: The study enrolled 21 women with 31 capsular contractures after aesthetic breast augmentation. The capsular tissue specimens were obtained during capsulectomy, open capsulotomy, and other revisional procedures. The tensile strength of capsular tissues (1 × 3 cm) was measured by tensiometer. The capsular tissues were immunostained by alpha smooth muscle actin, and the immunostained myofibroblasts all were counted on a 2.5-mm length of the capsule. RESULTS: Myofibroblasts were detected in 22 (71%) of 31 specimens. The myofibroblasts were on the outer layer of the capsule and made up 7.3% to 50% (average, 26.9% ± 12.7%) of the capsule thickness. The number of myofibroblasts varied according to the degree of capsular contracture, but grades 2, 3, and 4 contracture did not differ significantly (p = 0.102). The average tensile strength of the capsule was 44 ± 38 N. Tensile strength was the lowest for grade 2 (27.0 ± 22.2 N), increased for grade 3 (38.0 ± 22.6 N), and was highest for grade 4 (66.5 ± 55.4 N; p = 0.044) contracture. The tensile strength of the capsule correlated positively with the degree of capsular contracture (p = 0.029). CONCLUSION: The tensile strength of breast capsules correlated with the degree of capsular contracture. The authors think myofibroblasts appear during an active phase of wound contraction and diminish when the wound has matured.

Promoter hypomethylation of the N-acetyltransferase 1 gene in breast cancer.

Arylamine N-acetyltransferase type 1 (NAT1) is reported to be involved in the transfer of an acetyl group from acetyl-CoA to the terminal nitrogen of hydrazine and arylamine drugs or carcinogens. Gene-specific hypomethylation frequently occurs in a range of cancers and hypomethylation of the genes often correlates well with increased transcription levels. This study was conducted in order to evaluate the methylation status and the transcriptional activity of NAT1 in breast cancer tissues (n=72), benign breast tissues (n=31) and morphologically normal breast tissues (n=30). Our findings showed that the methylation of the NAT1 gene was identified in 39 of the breast carcinomas (54.2%), 23 normal (76.7%) and 25 benign breast tissue samples (80.6%). The breast cancer tissues showed significantly lower methylation rates of the NAT1 promoters than the normal and benign tissues (P=0.012). Furthermore, cancer tissues showed lower methylation density rates than normal and benign breast tissues (P=0.012). The tissues that showed aberrant methylation of NAT1 showed significantly less mRNA expression compared with the unmethylated cases by a thousand fold (P<0.001). Twenty cancers from the methylated group showed positive staining for the estrogen receptor (ER) (51.3%), while 72.7% from the unmethylated group stained positive (P=0.063). Our results suggest that DNA hypomethylation in the NAT1 gene appears to be present in cancerous breast tissues thus indicating that this type of methylation may significantly influence the transcriptional activation of the gene. Therefore, hypomethylation of the NAT1 gene plays a significant role in breast carcinogenesis.

Endoscopic transaxillary prepectoral conversion for submuscular breast implants.

BACKGROUND: During breast augmentation, the transaxillary approach provides the advantage of allowing the mammary prosthesis to be placed through incisions that are remote from the breast itself, thereby reducing the visibility of postoperative scars. For patients experiencing capsular contracture who do not want additional scars, the previous transaxillary scar can be used for site change and implant exchange. METHODS: This study analyzed 17 patients (34 breasts) with submuscular breast implants with grade III-IV capsular contracture who received treatment from 2010 to 2015. The mean age of the patients was 29 years (range, 20-38 years). The inclusion criterion was a pinch test of more than 3 cm at the upper pole of the breast. Previous axillary scars were used to expose the pectoralis fascia, and submuscular breast implants were removed carefully. The dissection underneath the pectoralis fascia was performed with endoscopic assistance, using electrocautery under direct visualization. RESULTS: The mean follow-up period was 14 months (range, 6-24 months). The entire dissection plane was changed from the submuscular plane to the subfascial plane. Round textured gel implants were used, with a mean implant size of 220 mL (range, 160-300 mL). Two patients developed grade II capsular contracture. There were no cases of malposition or asymmetry. Three patients complained of minor implant palpability. None of the patients required additional surgery. CONCLUSIONS: Endoscopic subfascial conversion may be an effective technique for treating capsular contracture and avoiding scarring of the breast in selected patients.

Deep-Plane Lipoabdominoplasty in East Asians.

BACKGROUND: The objective of this study was to develop a new surgical technique by combining traditional abdominoplasty with liposuction. This combination of operations permits simpler and more accurate management of various abdominal deformities. In lipoabdominoplasty, the combination of techniques is of paramount concern. Herein, we introduce a new combination of liposuction and abdominoplasty using deep-plane flap sliding to maximize the benefits of both techniques. METHODS: Deep-plane lipoabdominoplasty was performed in 143 patients between January 2007 and May 2014. We applied extensive liposuction on the entire abdomen followed by a sliding flap through the deep plane after repairing the diastasis recti. The abdominal wound closure was completed with repair of Scarpa's fascia. RESULTS: The average amount of liposuction aspirate was 1,400 mL (700-3,100 mL), and the size of the average excised skin ellipse was 21.78×12.81 cm (from 15×10 to 25×15 cm). There were no major complications such as deep-vein thrombosis or pulmonary embolism. We encountered 22 cases of minor complications: one wound infection, one case of skin necrosis, two cases of undercorrection, nine hypertrophic scars, and nine seromas. These complications were solved by conservative management or simple revision. CONCLUSIONS: The use of deep-plane lipoabdominoplasty can correct abdominal deformities more effectively and with fewer complications than traditional abdominoplasty.

Transaxillary endoscopic breast augmentation.

The axillary technique is the most popular approach to breast augmentation among Korean women. Transaxillary breast augmentation is now conducted with sharp electrocautery dissection under direct endoscopic vision throughout the entire process. The aims of this method are clear: both a bloodless pocket and a sharp non-traumatic dissection. Round textured or anatomical cohesive gel implants have been used to make predictable well-defined inframammary creases because textured surface implants demonstrated a better stability attributable to tissue adherence compared with smooth surface implants. The axillary endoscopic technique has greatly evolved, and now the surgical results are comparable to those with the inframammary approach. The author feels that this technique is an excellent choice for young patients with an indistinct or absent inframammary fold, who do not want a scar in the aesthetic unit of their chest.