Breast reconstruction after mastectomy.

The mastectomy patient presenting to the plastic surgeon often relates a profound sense of deformity. The current state of the art in breast reconstruction allows the plastic surgeon to intelligently address this deformity with procedures capable of achieving pleasing aesthetic results. If adequate soft tissue is present, implantation in the submuscular plane has proved satisfactory. However, if soft tissue deficiencies exist, highly acceptable results have been consistently achieved using the latissimus dorsi myocutaneous flap.

Concepts of neck lift.

Traditional skin-tightening or neck-lifting has been and still is a satisfactory method for correcting an unsightly neck. In cases of fatty neck, prominent platysmal bands, or both, additional measures must be employed if the defects are to be corrected. Excellent techniques have been developed in the past several years to correct these defects but are not without their own problems. A more conservative approach to the platysma has been used satisfactorily, but in all cases the patient should be appraised of the anatomic problems and provide some input into the approaches used.

Direct alternatives for neck skin redundancy in males.

The problem of redundancy of tissue of the neck, often called "turkey gobbler neck," can be corrected satisfactorily without performing a traditional face--neck lift (Fig. 4). This can be achieved with a vertical excision of skin, resection of fat, Z-plasty to the medial platysmal edges, and skin closure in a Z fashion. This operation is limited to males who distinctly prefer not to have a face-neck lift and is done only after description of the resulting scar which, because of its direction and location, has not been obtrusive.

Augmentation mammaplasty: retropectoral versus retromammary implantation.

Although the weight of evidence generally indicates that improved contracture rates with retropectoral placement of the prosthesis and excellent aesthetic results can be obtained with this approach, there remains a significant cadre of surgeons who believe their own retromammary results are equal to or better than the alternative. Our experience with retromammary augmentation since 1963 indicates that fibrous capsular contracture around the implant is a persistent sequela. By placing the prosthesis behind the pectoral muscle, we believe we have achieved a significant decrease in this occurrence. Whereas there are a variety of hypothetical explanations for this observation, it may be that interposition of additional soft tissue between the implant and the observer may disguise the otherwise apparent problem, thus making its correction more apparent than real. Whatever the explanation, however, we have had fewer patients requiring fibrous capsule release and a higher incidence of patient satisfaction by placing the prosthesis behind the pectoral muscle.

Augmentation mammaplasty: a comparative analysis.

With the continuation of augmentation mammaplasty as a desirable operation for a large segment of the female population in the United States, the problem of fibrous capsular contracture that has been present since the inception of the operation has persisted. Various approaches to the problem have been entertained, and a lessening of the incidence has occurred as reviewed in our earlier report, which follows augmentation mammaplasty in our clinic from 1962 through 1979. In this retrospective study, no significant difference in contracture rate was seen based on patient smoking habits, operative approach used, or implant type. It is important to note that the total experience with the low-bleed implant was significantly lower in terms of number of patients meeting the criteria of this retrospective study than the standard gel mammary implant. Greater follow-up time and number of patients will be evaluated in future retrospective studies. We have demonstrated in this study that placement of the implant beneath the pectoral muscle has significantly diminished the incidence of capsular contracture both as Baker grades II, III, and IV and as Baker grades III and IV. The retropectoral site has become the preferred location for the prosthesis in our clinic. There is no appreciable alteration in the overall shape of the breasts from this approach, and therefore, it will continue to be the preferred method. Rates of incidence of hematoma, the most frequent adverse reaction after contracture, were not significantly different between the retropectoral and retromammary implant sites.(ABSTRACT TRUNCATED AT 250 WORDS)

Augmentation mammaplasty: a review of 18 years.

We have reviewed the experience of our clinic since 1962, when the first augmentation mammaplasty using a silicone implant was performed. All-inclusive, this review of 1,567 patients has taken us through a metamorphosis of improved prostheses and refined surgical and postoperative techniques that have resulted in a significantly lower incidence of breast firmness. Since the purpose of all aesthetic surgery is to improve the quality of life of the patient through an enhancement of her or his own self-image, the results of present-day augmentation mammaplasty with the Silastic gel prosthesis indicate that this surgery is worthwhile and should be continued. It is anticipated that further improvement in results will be noted when the problem of subclinical infection is resolved.

Simultaneous bilateral breast reconstruction using latissimus dorsi myocutaneous flaps: a retrospective review of an institutional experience.

A single institution's experience in the simultaneous reconstruction of both breasts using bilateral latissimus dorsi myocutaneous flaps is presented. The procedure was performed on 24 patients by the attending staff of the department of plastic surgery at St. Joseph Hospital in Houston, Texas, between 1979 and 1999. Of the 24 patients reviewed, six had immediate reconstructions, 13 had delayed primary reconstructions, and five had secondary reconstructions of failed or unsatisfactory primary procedures. In the group with delayed reconstructions, the average time between mastectomy and reconstruction was 46.4 months, with a range from 7 days to 21 years. The operative method, results, and outcomes of our experience in these patients is presented.

Mastopexy in conjunction with subcutaneous mastectomy.

A subcutaneous mastectomy without mastopexy can result in downward directed nipples, over-augmentation or asymmetry in cases of contralateral reconstruction. A mastopexy can prevent these problems without adding to the morbidity or complicating the procedure. The procedure described provides a dermal sling to support the implant and give greater protection to the implant through the closure.

Assessment and longevity of the silicone gel breast implant.

Many patients are now consulting plastic surgeons for evaluation of their silicone gel breast implants. This study assesses the accuracy of a clinician's ability to determine if a silicone gel breast implant has failed. In addition, it sheds light on the long-term integrity of the silicone gel breast implant. This study examined the condition of 350 silicone gel breast implants in a group of 159 of the authors' patients who previously had undergone augmentation mammaplasty or breast reconstruction. These women underwent secondary open procedures including capsulotomy or capsulectomy for fibrous capsule contractures, exchange of implants, or other revisional surgery. The condition of the implant was noted at the time of this secondary operation. The preoperative evaluation, which included the patient's history and physical examination and often mammography, was then matched against the operative findings to determine the pertinent factors that predict the integrity of a silicone gel breast implant. A history of trauma and/or a reported change in shape of a patient's breast correlated with implant failure. An analysis of implant failure as a function of implant age revealed that 63 percent of silicone gel breast implants in place 12 years or greater in this study population were not intact. A change in the patient's physical examination, including a softened breast consistency and/or the presence of a nodule or mass adjacent to an implant, also was suggestive of implant failure. Several different mammographic presentations of implants that were not intact were identified. This modality predicted implant failure in 89 percent of implants studied. It is hoped that this information will help clinicians to make a more accurate assessment of the condition of a patient's silicone gel breast implant. It should be noted that all women in our study underwent secondary procedures, as stated above. The results obtained apply to this patient group but may not specifically pertain to the general implant-bearing population.

Our experience with endoscopic brow lifts.

This is a retrospective review of our experience with the endoscopic brow lift. We reviewed 128 procedures performed by two senior faculty members over the last 5 years. We evaluated the age, gender, operating time, complications, and outcome and conclude that endoscopic brow lift is a safe, efficient procedure with a low complication rate. The operating time is short, and there is a very high patient acceptance. The procedure has taken its place as an integral part of facial rejuvenation in our practice.

Technical aspects of the latissimus dorsi myocutaneous flap in breast reconstruction.

The authors review the technical refinements that have come about through their increased use of the latissimus dorsi flap for reconstruction of the female breast following mastectomy, referring to over 90 of their cases. These refinements involve careful selection of patients in whom the flap is used; planning the flap, including determination of the limits of the muscle; and the location and shape of the skin island. Placement of the patient on the table and the position of her arms and hips are discussed. The dissection and transfer of the flap, as well as closure of the donor defect, can present particular problems, which are outlined. Implant placement, wound closure, and postoperative care of the patient are also discussed.

Breast reconstruction following mastectomy.

The mutilating effect of surgery for cancer of the breast has left many women needful of reconstruction to restore the body contour and self-image. Reconstruction involves replacement of the three elements that have been lost: breast mass, skin, muscle and nipple-areolar complex. Methods for accomplishing this have been devised and are in common use. Because of the increased predisposition to malignancy in the remaining breast and the difficulty in achieving symmetry in both breasts, the remaining breast must be considered, with subcutaneous mastectomy being the most appropriate course in most cases. Patient acceptance has been excellent.

Breast shape: a technique for better upper pole fullness.

The authors offer a new technique that provides a better long-term upper pole fullness to the shape of the breasts following reduction mammoplasty, thus creating an overall more satisfactory aesthetic appearance for both breasts.