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Breast Surgery

Breast Surgery

1.What is cosmetic breast surgery?

The aim of cosmetic breast surgery is to create beautiful and symmetrical breast.

What define beautiful breast shape depends on the individual patients body stature and what she consider attractive ,as well as on her particular cultural concepts of beauty.

What are cosmetic breast surgery?

  1. Breast augmentation- Increase in size of breast.
  2. Fat grafting
  3. Mastopexy- firming of breast.
  4. Reduction Mammaplasty- reduction in size of big breast.
  5. Breast reconstruction- usually done after breast cancer surgery.

Breast Augmentation

Augmentation is procedure to increase in size of breast.

This can be done with

1.Autologus tissue like fat grafting

2. Breast Implants.

Breast Implants:

All implants on the market today are made of two separate components, outer silicon shell and inner filling that can be of Saline or Silicone.

Surface Characteristics

The outer shell of breast implant are either smooth or textured .

Smooth Texured
1.Round 1. Anatomic
2. Free rotation within the capsule 2. Tethered to capsule
3.May bottom out 3. More rippling
4.Loss of superior pole 4.Better retention of shape
5.Possibly higher contracture rate 5. Possibly low contracture rate

What are shapes of Implant?

Breast implant may be round or anatomical shape.

The newest generation of implants –the cohesive silicon gel implant-promises increased gel integrity and a more natural appearance.

That are the approaches for breast agumentation?

There are four approaches

  1. Inframammary
  2. Sub-areolar (Trans-nipple)
  3. Transaxillary
  4. Periumbulical

Commonly dual plane breast augmentation is done in which implant is placed under both muscle and breast tissue.

Advantages of dual plane implant placement

1.Minimal capsular contracture

2.Implamt is not visible hence no rippling

3.No alteration in normal breast function as breast feeding

What are complication?

1 Most common complication is capsular contracture.

2. Implant malposition

3.Asymentry

4. Infection and implant removal.

Breast Augmentation with FAT GARAFTING

Fat grafting to enlarge the breast can be performed for cosmetic reasons, for correction of asymmetry ,and for reconstruction of deformity.

Advantages of fat grafting

  1. Absence of autoimmune response
  2. The ease in accessing donor fat
  3. Minimal complications.

 

Indications

  1. Augmentation of the breast in patients with small breast, tuberousbreast, or Poland syndrome or the patient refusesilicone implants.
  2. Correction of contour breast deformity or asymmetrical after removal of breast implant or breast lumpectomy or after reconstructive surgery
  3. Creation of thick envelope of breast tissue after placement of silicon implant.

              Donor area for fat harvest

            The most common donor siteare

  1. Abdomen
  2. The thigh

Procedure:

Procedure is performed under general or regional anaesthesia.

Fat is aspitratedmanualy with liposuction cannula attached to syringe or vaccume pump.

Lipospirated is washed with 0.9 % normal saline solution

Centrifugation is done at 1000 rpm for 2 minutes.

Then this purified fat is injected in to breast.

Postoperative Case

It is recoomonded that patient should wear a supportive bra day and night for 7 days after breast augmentation with fat grafting.

Oral antibiotics areadmistered for 3 days postoperatively.

Compression garments for donor area for 3 months.

Mastopexy

Mastopexy is asthetic breast surgery in which breast is lifted and reshaped without increasing size of breast to look aesthetically pleasing and more youthful.

In modern mastopexy ,restoration of upper pole fullness with possible parenchyma rearrangement can be an essential part of the procedure, even without implant augmentation.

Indication and Selection of Procedure

Ptosis of beast is main indication for mastopexy

Mastopexy can be combined with breast augmentation with implant.

There are basically two technique of Masxtopexy

  1. Verticalmastopexy
  2. Inverted-T mastopexy

Complications:

  1. Blood loss
  2. Infection
  3. Necrosis
  4. Haematoma
  5. Seroma
  6. Dehiscence

Breast Reduction

Breast Reconstruction

Why breast reconstruction

The presence of breast is a defining feature of adult mammalian gender.

It must therefore be considered an essential element of human feminity, and the role it play in female psychology cannot be understated.

Hence reconstruction of breast is almost exclusively consequent on surgery for breast cancer.

What are aims of breast reconstruction

Creating a symmetrical ptotic conus precisely positioned on the breast footprint embodies the art of breast reconstructive sculpture.

The ultimate goal of breast reconstruction is to create symmetrical,natural-looking breast and not necessarily a specific shape or volume.

Indication for breast reconstruction

  1. Mastectomy for breast cancer
  2. Development of breast conservative surgery for breast cancer

Immediate Versus delayed Reconstruction

Delayed Reconstruction:

  1. More certain about cancer clearance
  2. Adjuvant therapy is completed like radiotherapy
  3. Allows patient to adjust to life without breast
  4. Less surgical time
  5. Give time for consideration of the reconstructive options and their risk.

Primary Reconstruction

  1. One stage reconstruction
  2. Facilitates reconstruction when much of the breast skin envelope,and the IMF, can be preserved.

Immediate Delayed Reconstruction

This is indicated when patient may require adjuvant therapy as radiotherapy. In this reconstruction an expander is placed in skin envelop which helps in maintain suitable subcutaneous cavity to accommodate implant or tissue of reconstruction at later stage.

What are Type of reconstruction

  1. Autologus tissue
  2. Implants
  3. Combination of autologous tissue and Implants.

Which are flaps are used for breast reconstruction

  1. Latissimus dorsi flap
  2. Pedicled transverse rectus abdominis myocutaneous flap
  3. Pedicled or Free TRAM flap
  4. Deep Inferior epigastric artery perforator flap
  5. Superior gluteal artery perforator flap
  6. Inferior gluteal artery perforator flap
  7. Transverse upper gracilis flap

Complications

  1. Blood loss
  2. Infection
  3. Necrosis
  4. Haematoma
  5. Seroma
  6. Dehiscence

Gynaecomastia and tuberous breast

Gynaecomastia: Gynaecomastia is commonly described as benign ( Noncancer) proliferation of male breast tissue or persistant enlargement of male breast tissue.

Incidence

32 to 36% of males suffer from gynaecomastia, and as high as 65% in adolescent boys.

Bilateral disease is reported to occur in 25-75% of cases

Causes of Gynaecomastia

1.Idiopatic- exact cause is not known.

Oestrogen,androgens ad their receptors are thought to play a major role in the development of the condition

An imbalance in the concentrations of the hormone’s, with a relative increase in ostrogen, is thought to bring about breast tissue proliferation.

2. Physiological

  1. Neonatal-no treatment required(Maternal Oestrogens through placenta)
  2. Puberertal: transient development of breast tissue is common in adolescent boy.

A relative increase in plasma estradiol compared to testosterone is thought to cause pubertal gynecomastia.

  1. Elderly : This is after age of 65 years. It is due to decrease testosterone level

In addition ,weight gain increases conversion of testosterone to ostrogen.

Pathological Gynaecomastia

Due to various metabolic and endocrine disorders

Aquired and congenital hypogonadal states leading to an increased overall estrogen state.

Pharmological Gynaecomastia

Drugs are major etiological factor

It occurs due to direct increase in ostrogen and decreased testosterone

Classification

Webster classification

  1. Glandular
  2. Fatty-glandular
  3. Fatty

Bannayan and Hajdu

  1. Florid-increased number of ducts
  2. Intermediate-overlap of florid and fibrous types
  3. Fibrous type- extensive stromal fibrosis with minimal ducts.

Simon(1973)

  1. Grade 1:  small enlargement, no skin excess.
  2. Grade2 a: Moderate enlargement with no skin excess.
  3. Grade2 b:Moderate enlargement with skin excess.
  4. Grade3: Marked  enlargement with  skin excess.

Rhorich (2003)

  1. Grade I:Minimal hypertrophy(<250 grams of breast) without ptosis.
  2. Grade II:Moderated hypertrophy(250 -500 grams of breast) without ptosis.
  3. Grade III: Severe hypertrophy(>500 grams of breast) with ptosis.
  4. Grade IV:Sever  hypertrophy with  grade II or III ptosis.

Cordova and Moschella

  1. Grade I: Increase in diameter and protrusion limited to the areolar
  2. Grade II: Hypertrophy of all the components, NAC is above the IMF.
  3. Grade III: Hypertrophy of all the components, NAC is at the same height as or 1 cm below the IMF.
  4. Grade III: Hypertrophy of all the components, NAC is at the more than 1 cm below the IMF.

Assessment

History

Clinical Examination

Opinion of Endocrinologist

Evaluation of liver,renal and thyroid function

Tumourmarkersfot testicular such as bhCG,alphaferoprotein and basal prolactin level(Prolactinoma)

Radioloagy:

X-ray chest to rule out ca lung

Mammmography: To rule out ca breast

CT head to rule out pituitary tumours.

Management

Medical: Tab Tamoxifen(anti-oestrogen), TabClomiphen( act on hypothalamic pituitary axis to increase LH & FSH) and Tab Danazole( acts on by suppressing pituitary –ovarian axis by inhibiting the out put of both LH & FSH)  can be used for spontaneous regression.

Surgical

The aim of surgical treatmentare volume reduction with or without retailoring of redundant skin.

Liposuction and Excision of gland: Minimal invasive surgery through periareoral incision.

Excision of Skin: May require when there is excessive skin that would not be retracted after liposuction.

Complications

  1. Blood loss
  2. Dehiscence
  3. Seroma
  4. Haematoma
  5. Necrosis
  6. Infection

Postoperative Care

Patient have to wear pressure garments for 3 to 4 months.

Liposuction and Liposclupture

In women,the creation of smooth and well defined curves will always improves their figures. As surgeons, we aims to improve the shape of our patients,but the results of our effort are closely linked to the expectations of each patients being realistic rather than unrealizable.

In male , a more angular and muscular shape is sought ,paying attention to the definition of abdomen and chest wall muscularity.

Improvement in shape and figure generally makes patients feel more comfortable about themselves ,enabling more versatility wearingdifferentsclothes,sporting fashions and/or swimwear.

Liposuction has estabilished itself as the most valuable body –contouring plastic surgergical procedures available and the demand for it is not abating.

Improved instrumentation and anesthetic techniques have facilitated better and upgraded results since the introduction of technique 30 year ago.

Indication:

  1. The optimal patient is who have completed diet and exercises,but still have localized areas of fat deposition.
  2. In men these areas are abdomen, male breast, and love handle area.
  3. In females these areas are inner thigh, outer thighs, hips and abdomen.
  4. Obese patient should be accepted with proper counselling explaining that that liposuction is procedure for body sculpturing and not for weight reduction. Hence expectation should be realistic with proper understanding of limitation of liposuction.

What is safe liposuction?

It is generally accepted that large -volume liposuction is anything over 5000 mL of fat removal and that greater volumes of aspiration are associated with increasing complication rates.

Liposuction Machines

Normal suction machine which generates about 30 mmHg negative pressure.

Ultrasonic liposuction Machines

Power assisted liposuction machine

Manually with syringe cannula

Liposuction Cannulas

There are various cannulas of different sizes varying from 1 mm to 6 mm and in different shapes with varying  tips.

Anaesthesia

Liposuction can be done undergeneral ,regional or local infiltration with IV sedation.

Dressing,Compresion and postoperative management

After closure of all access ports with an absorbable suture, a guaze dressing applied

There will be some fluid leakage from the incisions overnight.

Patient have to wear pressure garments for 2 to 3 months.

Adjunctive measures postoperatively

Lymph drainage, massage and ultrasound treatment by a qualified physiotherapist are recommended for persistent swelling and tissue that are woody, indurated or bruised.

Complications

Immediate

  1. Haematoma ,
  2. blood loss
  3. Infection
  4. Venous thrombosis are rare
  5. Pulmonary embolism are very rare
  6. Visceral perforation- again very rare

Late

  1. Seroma
  2. Swelling
  3. Bruising
  4. Contour deformity
  5. Loose skin which is not contracted.
  6. Numbness and paresthesia are usually self-limiting.