Practical Plastic Surgery - part 7 pptx

A strong family history of breast cancer isanother relative contraindication to the subglandular approach because a smallamount of breast tissue may be obscured during a mammogram when t

middle crura which continue from the most anterior portion of the medial cruratowards the tip of the nose and begin the turn laterally to form part of the genu (i.e.,curve) of the lower lateral cartilages The lateral crura comprise the remainder of thegenu by continuing laterally, posteriorly and slightly cephalically It is important tonote that as one traces the lateral crura from the tip posterolaterally, the crura projectmore cephalically (Fig 64.1) Hence, the lateral crura provide structural support tothe nasal rim predominantly at their medial portions, leaving the very lateral por-tions of the nasal alae devoid of cartilage This portion of the nose is comprised offibrofatty tissue covered by overlying skin

The nasal septum is composed of three structures: the perpendicular plate of theethmoid posteriorly and cephalically, the vomer posteriorly and caudally and thequadrangular (i.e., cartilaginous) septum anteriorly The septum functions as a sup-port structure for the mid-portion of the nose and it also comprises the medialcomponent of the internal nasal valve (completed posteriorly by the nasal floor andlaterally by the upper lateral cartilages) The average internal valve angle is 12˚.The arterial anatomy of the nose is important to consider for several reasons.While the blood supply to the nose is abundant making tissue necrosis a rare com-plication, the potential for clinically significant bleeding exists Bleeding can be sig-nificant in that it can compromise tissue due to compression (e.g., septal hematoma)

or compromise visualization during the rhinoplasty Again, beginning cephalically,the blood supply to the dorsal nose is derived from the dorsal nasal artery and theexternal nasal branches of the anterior ethmoidal artery The lateral nasal arterywhich arises from the angular artery supplies blood flow to the nasal sidewalls andthe caudal nasal dorsum and tip The columellar branches of the superior labialartery anastomose with the distal branches of the lateral nasal artery to supply thenasal tip from below The blood supply to the septum comes from the anterior andposterior ethmoidal arteries, the sphenopalatine artery and the posterior septal ar-tery The convergence of the anterior and posterior ethmoidal plexuses in theanterosuperior septum is known as Little’s area and is the most common site ofinjury causing epistaxis Because of its location, the anterior ethmoidal artery is themost often injured in nasal trauma

The cutaneous nerve supply to the nose is important because adequate localanalgesia can allow the plastic surgeon to perform a rhinoplasty without generalanesthesia Since the local anesthetics contain epinephrine, appropriate infiltrationcan also reduce blood loss Furthermore, the local anesthetics can be used tohydrodissect delicate nasal tissues facilitating subsequent sharp dissection For ex-ample, local anesthesia infiltrated submucosallly in the septal area, not only providesexcellent hemostasis, but also separates the septal mucosa from the underlying carti-laginous septum Beginning cephalically, the nasal branches of the supraorbital nerveare infiltrated to anesthetize the radix and proximal nasal dorsum Sensation alongthe nasal sidewalls, alae and columella is blocked using local anesthesia on the nasalbranches of the infraorbital nerve The middle and distal thirds of the nasal dorsum

as well as the tip of the nose are anesthetized by blocking the external nasal branches

of the anterior ethmoidal nerve The anterior septum is blocked by anesthetizing themedial and lateral branches of the anterior ethmoidal nerve If a septoplasty will beperformed in addition to the rhinoplasty, the nasopalatine and posterior nasal nerves,which supply sensation to the posterior septum medially and laterally, respectively,should be blocked Once the nose is adequately blocked, the rhinoplasty procedurecan begin

397Rhinoplasty

Surgical Technique

Whether to perform an open or a closed rhinoplasty remains a controversialtopic To be sure each technique has its advantages and disadvantages and these,along with the requests of the patient, should be used to guide the surgical ap-proach The open rhinoplasty involves any of a variety of mid-columellar incisions

to expose the nasal anatomy much like one would expose the engine of a car byopening the hood Clearly, the advantages of this approach are the excellent visual-ization which facilitates the operative procedure and teaching Disadvantages in-clude the external scars, the longer operative time and the increased postoperativeswelling secondary to more aggressive manipulation of the nasal tissues During aclosed rhinoplasty, no external incisions are made and access to the nasal framework

is obtained via any number of internal incisions (e.g., inter-, intra- or infracartilage,

or rim) Advantages with this technique are the lack of external scarring and therelative expeditiousness of the procedure Its primary disadvantage is the limitedvisualization which therefore limits the manipulations than can be performed Thisapproach is best suited for patients requiring minor tip work, straight-forward re-section of a prominent dorsal hump, or those with a wide alar base

Dorsal Hump

One of the most common complaints is a prominent dorsal hump In ation of the anatomy just reviewed, one can understand that this prominence can becaused either by projecting nasal bones, upper lateral cartilages, cephalic dorsal carti-laginous septum or some combination thereof Resection of this dorsal hump can beperformed either with the closed or open rhinoplasty technique Once the overlyingsoft tissues have been dissected in the subcutaneous plane from the underlying bonyand cartilaginous anatomy, the reason(s) for the projecting dorsum can be determined.While many techniques are used to achieve a more balanced nasal dorsum, the generalprinciples are to sharply resect the cartilaginous components of the dorsal hump and touse either an osteotome or rasp to resect the bony dorsum The rasp is generally usedfor more subtle bony adjustments Two points about dorsal hump resection deserveemphasis First, conservative resection is best One can always resect more and as notedearlier, small changes often make pronounced differences in appearance Secondly, it isimportant to avoid resection of the mucoperichondrium as this tissue layer providessupport to the upper lateral cartilages and can lead to an inverted-V deformity

consider-Tip Projection

Under-projection of the nasal tip is another common problem Tip projectioncan be enhanced in a number of ways A transdomal suture bringing the genuacloser together will add a mild degree of projection Placement of an onlay tip graftcan enhance tip projection as well as widen the nasolabial angle and increase lobularvolume Other ways of achieving the same effect are placement of a columellar strutgraft and suturing the medial footplates together In addition, lowering a dorsalhump will often give the impression of a cephalically oriented tip Each of thesetechniques has its unique degree of tip enhancement and differing effects on sur-rounding nasal structures (e.g., columella, lobule, upper lip)

The over-projecting tip (Pinocchio nose) is due to excess length of the medial andlateral crura Resection of the medial or lateral crura or scoring of the dome-medial crurajunction with or without resection of the lateral crura can be combined with a transfix-ion incision to reduce tip support to allow immediate posterior settling of the tip

Boxy Tip

A boxy nasal tip is due to either an increased angle of divergence of the medialcrura or a wide arc in the dome segment of the lateral crura This problem is com-monly treated by resection of the cephalic portion of the lateral alar cartilages andinterdomal suturing

Widened Alar Base

A wide alar base is a masculinizing feature Since most patients seeking plasty are female, a wide alar base is a commonly encountered problem The sim-plest way to narrow a wide alar base is through resection of a portion of the fibrofattytissue making up the lateral-most portion of the alar rim (e.g., Weir excision) Thistechnique has the disadvantage of placing visible (albeit small and well-hidden) scars

rhino-on the external nasal skin Transdomal sutures often used to augment tip projectirhino-oncan also pinch the lateral crura together thus slightly narrowing the alar width

Wide Nasal Bridge

A wide nasal bridge is also a frequent complaint This problem can be dealt withdirectly and indirectly Clearly, nasal osteotomies will allow medialization of theupper and middle nasal vaults These osteotomies can be performed via either open

or closed approaches, using a continuous or perforated technique This maneuver isoften performed when a prominent dorsal hump has been resected, leaving the dor-sal edge of the nose with a widened, open roof, appearance Preoperatively, the patient’sinternal nasal valve angle must be evaluated because in-fracturing will narrow thenasal passage If the internal nasal valve <12˚, the patient will have obstructed air-flow Dorsal augmentation also gives the appearance of a narrower nose, again high-lighting the interplay of the various nasal components

Complications

Retracted Ala

A retracted ala occurs in patients who have had overresection of the cephalicportions of the lateral crura in an attempt to improve tip definition As healingprogresses, wound contraction rotates the lateral crura cephalically and with it thealar rim To avoid this pitfall, it is recommended that at least 6-9 mm of lateral crusremain after resection and that one make every attempt to leave as much vestibularmucosa as possible during the procedure To fix this problem, a free cartilage graftcan be used to augment the remaining lateral crura in minor cases If a severe retrac-tion is encountered, composite grafts from the contralateral ear can be used to pro-vide, lining, coverage and support

Parrot Beak Deformity

A parrot beak deformity refers to excessive supratip fullness following plasty This problem can be caused by either underresection of the supratip dorsalhump or overresection of the nasal dorsum If the cause is the former, further resec-tion to achieve a proper tip-to-supratip proportion is mandated If the cause is thelatter, a dorsal graft is appropriate When the parrot beak deformity occurs in theearly postoperative period it is attributed to edema and wound contraction In thissituation, a trial of conservative management with taping and steroid injection isappropriate Careful technique with frequent assessments of the appearance of thenose during the procedure is the best way to avoid this problem

399Rhinoplasty

Saddle-Nose Deformity

The saddle-nose deformity appears as a disproportionately flattened dorsum,akin to a boxer’s nose The most common cause is over-resection of the cartilaginousseptum leaving less than 15 mm of support Treatment in mild to moderate casesinvolves placing additional graft material over the depressed areas to restore thelateral and frontal profile In severe cases, cantilevered bone grafts suspended fromthe frontal bone may be required

Open Roof Deformity

An open roof deformity occurs after resection of a dorsal hump without equate in-fracture of the nasal bones The dorsal bony edges become visible within aflattened area of the dorsum Treatment is intuitive and consists of adequatelyin-fracturing the nasal bones

ad-Inverted-V Deformity

If the mucoperichondrium of the upper lateral cartilages is inadvertently resected,support to the upper lateral cartilages is lost This problem causes the upper lateralcartilages to collapse inferomedially On frontal view, the caudal edges of the nasalbones become visible The best treatment is avoidance, but if it occurs, dorsal carti-lage grafting to restore dorsal nasal balance is the preferred treatment

Pearls and Pitfalls

Each case has it own challenges and requires a careful estimation of the deformitypreoperatively, a clear understanding of the techniques available, a proposed plan ofaction and sequence, and a meticulous, uncompromising surgical technique Everyoperation has a risk for complication, and only the surgeon who does not operate has

no complications Under-correction and over-correction of a preexisting deformitymay lead to either persistence of the deformity or the introduction of a new one Anew deformity may introduce functional deficits Some deformities are illusory andcorrection can only follow accurate diagnosis For example, when a patient requestsdorsal reduction, first examine the nose in thirds If the nasal radix is too low, augment

it, don’t reduce the dorsum The radix augmentation will give the illusion of a smallernose Furthermore, the nose must also be examined in relation to the face For in-stance, a nose may appear large because the chin is small; a chin implant may be thebest choice in some cases to achieve the illusion of facial harmony

4 Guyuron B Dynamics in rhinoplasty Plast Reconstr Surg 2000; 105:2257

5 Rohrich RJ, Muzaffar AR Primary rhinoplasty Plastic Surgery: Indications, tions and Outcomes V 2000:2631

Opera-6 Sheen JH, Sheen AP Aesthetic Rhinoplasty 2nd ed St Louis: Mosby, 1998:1-1440

7 Sheen JH Rhinoplasty: Personal evolution and milestones Plast Reconstr Surg 2000;105:1820

8 Zide BM, Swift R How to block and tackle the face Plast Reconstr Surg 1998; 101:840

Practical Plastic Surgery, edited by Zol B Kryger and Mark Sisco ©2007 Landes Bioscience.

Genioplasty, Chin and Malar Augmentation Jeffrey A Hammoudeh, Christopher Low and Arnulf Baumann

Introduction

The chin provides harmony and character to the face A strong chin or nent jaw line is considered to be aesthetically pleasing, especially in males Whenchin surgery is indicated, whether by anterior horizontal mandibular osteotomy(AHMO) or by alloplastic implant augmentation, it can create an aesthetically pleas-ing facial contour and establish proportionate facial height In addition, the AHMOcan improve obstructive sleep apnea by elevating the hyoid bone

promi-Most genioplasty procedures are done to improve the mandibular profile in der to obtain a more natural profile Genioplasty can shorten or lengthen the lowerthird of the face Facial asymmetry may be corrected by rotation of the chin-point tocoincide with the midline The advantages of osseous genioplasty are versatility,reliability and consistency in correcting problems in the sagittal and vertical planes

or-to achieve greater chin projection

In order to be able to make an appropriate recommendation, the correct erative workup should be performed, including soft and hard tissue analyses Ide-ally, cephalometrics and video cephalometric predictions would also be performed

preop-Anatomy and Analyses

It is important for the surgeon to be familiar with the classic soft tissue analysisand diagram of facial proportions The size, shape and position of soft and hardtissue can enhance facial harmony and symmetry The relationship between softtissue and bone is important for planning the chin correction For chin advance-ment, the bone to soft tissue proportion is 1:0.8, meaning that 1 mm of bony change

is associated with 0.8 mm of soft tissue change

The face can be divided into upper, middle and lower thirds The upper third ofthe face spans from the hairline to the glabella (G); the middle third from glabella tosubnasale (Sn); and the lower third from subnasale to menton (Me) The lower third

of the face can be further divided into an upper half (Sn to vermilion of the lowerlip) and a lower half (Me to vermilion of the lower lip) The face is “balanced” whenthe three thirds are of similar height Cephalometric analysis ensures that skeletaland occlusal disparities are identified and can be corrected before or at the sametime as a genioplasty

Many patients that complain of a small chin truly do not have microgenia.They often have a true deficit of the mandible in the sagittal plane, which can be

a class 2 malocclusion (retrognathia) or normo-occlusion (retrogenia) Retrognathia

is ideally corrected with a bilateral sagittal split osteotomy (BSSO); however if thediscrepancy is small, advancement genioplasty may sufficiently camouflage thefacial profile into an orthognathic appearance Retrogenia (chin point deficiency

401Genioplasty, Chin and Malar Augmentation

in the setting of a class I occlusion) and mild retrognathia (≤3 mm) are ideal casesfor a genioplasty It is important to understand the relationship of the dentition tothe chin point The boney chin point should be about 2 mm posterior to thelabial surface of the mandibular incisors This will help maintain a natural labio-mental fold The position of the labiomental angle is paramount and profoundlyinfluences the aesthetic outcome Cephalometric analysis helps the surgeon toplan the operative procedure The treatment plan is based on incorporation ofthese data into clinical assessment that will facilitate a postsurgical profile that isesthetically pleasing

Perceived Chin Abnormalities Due to Anomalies of the Maxilla

When facial analysis identifies disharmony within a patient’s profile, the surgeonmust determine whether there is an underlying occlusal and skeletal deformity ormerely a poorly or over-projected mentum True maxillomandibular discrepanciesshould be addressed with orthognathic surgery In the case where occlusion is stableand a small mandibular deficiency exists (retrogenia), an isolated mandibular sagit-tal deficiency may be a candidate for an AHMO

To highlight the importance of the correct diagnosis, one can take the commonoccurrence of a patient complaining of a “small chin.” A recessed chin may beretrogenia or microgenia An over projected chin may be macrogenia or prognathia.Micrognathia and macrognathia are rare Prognathia and retrognathia more com-monly contribute to chin point abnormalities In the setting of a patient complain-ing of a small chin, the lateral profile should be evaluated Concavity or convexity inconjunction with the proportions of the middle and lower third of the face should

be considered in the planning The maxilla should be evaluated If the maxilla is setappropriately in the sagittal plane and there is mild retrognathia (≤3 mm) orretrogenia, then a genioplasty is appropriate However, if a maxillary developmentaldysplasia is present, a formal orthognathic work-up should be done

In contrast, patients complaining of a “prominent chin” often havepseudomacrogenia These individuals may have maxillary sagittal hypoplasia, whichmanifests with a retruded upper lip, a midfacial concavity or deficiency, and achin that may appear prominent in the sagittal plane Since the true etiology ismaxillary hypoplasia, the corrective procedure would be a Le Fort I osteotomy toadvance the maxilla anteriorly to coincide with the chin point.A pitfall would befor a novice surgeon to perform a genioplasty to set the chin point back to coin-cide with the maxilla

In maxillary vertical deficiency, the patient presents with pseudomacrogenia due

to the counterclockwise rotation of the mandible In this case, the chin is ated and appears larger than normal Patients with this condition have a short lowerthird facial height and present with poor maxillary tooth show at rest and whensmiling When the mandible is placed in the normal centric relation, the chin pointincreases in the sagittal plane Maxillary vertical height correction will allow for amore natural position of the chin and only then can a decision be made on the needfor genioplasty

accentu-Maxillary vertical excess may manifest as pseudomicrogenia due to the sive downward growth of the maxilla causing a clockwise rotation of the man-dible In such cases, the rotation of the mandible results in the appearance of asmall chin due to poor projection of the chin in the sagittal plane The patient willlikely have excess gingival show, a long lower third facial height and mentalis

muscle strain from the forces needed to close the interlabial gap The treatmentfor this type of facial anomaly may be to reposition the maxilla superiorly, particu-larly in the posterior area

Maxillary sagittal hyperplasia is extremely rare Patients may complain of a smallchin as well Once again, this is most likely a case of pseudomicrogenia, where thechin appears relatively small due to the prominence of the maxilla in the sagittalplane These patients will have a convex facial profile associated with maxillary pro-trusion and an acute nasolabial angle This form of microgenia can be correctedwith repositioning of the maxilla, after which a decision can be made on the needfor an adjunct genioplasty

Evaluation of the Mandible

After a thorough investigation to rule out any maxillary discrepancies, the nextstep is to evaluate the mandible For a patient with mandibular hypoplasia witheither gross malocclusion or severe hypoplasia (greater than 4 mm), a formalorthognathic work-up is necessary The risks of advancing or augmenting a chingreater than 5-6 mm include an unnatural appearance, a deep labiomental angle,and the risk of advancing the chin point past the lower central incisor Severe man-dibular sagittal hypoplasia is corrected with a BSSO, and genioplasty should beviewed as an adjunct procedure Prognathia in the setting of class 3 malocclusionshould be corrected by a setback with a BSSO Isolated true macrogenia in thepresence of a normal class 1 occlusion can easily be treated with a genioplasty, set-ting the chin point back and even reducing chin height if needed

Indications for Isolated Genioplasty

After careful scrutiny of the skeletal, dental and soft tissue structures, there existcertain cases that are amenable to isolated genioplasty An isolated genioplasty can

be considered if functional occlusion is present and the lower third profile has mildhypoplasia or hyperplasia in the sagittal or vertical plane A sagittal hypoplasia (3-4mm) in the setting of functional normo-occlusion with acceptable facial propor-tions is an ideal candidate for AHMO with advancement A variation of the stan-dard sliding genioplasty is the “jumping” genioplasty The “jumping” genioplasty isideal for sagittal advancement when vertical reduction is needed

Patients who are considered for isolated genioplasty should have a good overallprofile and occlusion The surgical goals for these patients include creating an aes-thetically pleasing facial contour and establishing proportionate facial height Idealcandidates for a genioplasty are: (1) retrogenia, i.e., recessed chin point with class Iocclusion; (2) mild retrognathia (≤4 mm) with a functional occlusion; and (3)macrogenia

For example, in a patient that may have a long lower third of the face, a tion genioplasty is performed to reduce the vertical dimension of the chin Verti-cal reduction is done by performing a second horizontal osteotomy that is parallel

reduc-to the first osteoreduc-tomy, and a segment of bone is removed.Another indication for

an isolated genioplasty may be a mild asymmetry, when the chin does not cide with facial midline An oblique triangular wedge of bone can be removedfrom one side and transplanted to the other side to correct chin asymmetry In allcases, the chin has to be rigidly fixed by miniplates, wire or screws A variety ofgenioplasty is the “jumping” genioplasty This type of procedure allows the sur-geon to both increase the chin projection and shorten the vertical dimension of

403Genioplasty, Chin and Malar Augmentation

the chin simultaneously After the osteotomy is completed, the basilar segment iselevated on top of the upper symphysis

Surgical Technique

Genioplasty can be performed under local anesthesia with IV sedation or undergeneral anesthesia General anesthesia is more commonly used with this procedure.Lidocaine with epinephrine is infiltrated along the depth of the buccal vestibule Anincision is made in the buccal vestibule, initially perpendicular to the mucosa thenperpendicularly to the muscle and bone The dissection is continued in the subperi-osteal plane to identify the mental foramen on both sides After identification of themental foramen, the mental nerves should be protected from both direct and trac-tion injury The osteotomy is done under the apices of the teeth and the mentalnerve Upon completion of the osteotomy, the chin is then rigidly fixated A step-off(sharp edge) at the posterior part of the genioplasty should be avoided The contour

of the mandible should be smooth There are a variety of techniques used for tion of the chin including wires, resorbable or titanium bone plates Closure should

fixa-be done in multiple layers The mentalis muscle must fixa-be reapproximated The musclelayer can also be reattached to the chin using Mitek anchors We prefer using twoMitek anchors to secure the mentalis muscle to bone Alternatively, simplereapproximation with two horizontal mattress sutures is acceptable This preventsptosis of the mentalis muscle Nonfixation may result in a “witches chin.” A com-pressive chin dressing is worn for 5 days postoperatively The oral mucosa is closedwith a running 3-0 chromic suture The advantage of this procedure is its versatility,reliability and reproducible correction of chin point discrepencies The disadvan-tages, when compared to alloplastic augmentation, include increased operative time,bleeding and incidence of mental nerve hypoesthesia

Chin Augmentation Using an Alloplastic Implant

An alternative to genioplasty in correcting chin hypoplasia is the use of a chinimplant The use of implantable biomaterials and devices plays a potential role inmost forms of reconstructive surgery The common locations for alloplastic aug-mentation are the chin and malar regions There are numerous synthetic implant-able materials that can be classified as carbon based polymers, noncarbon-basedpolymers, metals and ceramics.This wide selection allows the surgeon to choose amaterial tailored to the individual needs of the patient Silicone (silastic), anoncarbon-based polymer, was one of the first materials used in facial implants.Silicone is resistant to degradation and when fixed against a bony surface its longterm stability is very high Carbon-based polymers include polytetrafluoroethylene(PTFE), polyethylene (PE) and aliphatic polyesters PE is currently being used in itshigh density form (HDPE), which allows for contouring by the surgeon The solidimplantable form of HDPE (Medpor®) allows for increased fibrous ingrowth lead-ing to long-term stabilization of the implant

Alloplastic chin augmentation is a well-accepted technique used in the tion of mild retrognathia or true retrogenia The advantages of alloplastic augmen-tation include the material being readily available without donor morbidity, shorteroperating time and less blood loss The disadvantages include bone resorption,infection, extrusion and displacement

correc-When an implant is used, either an intraoral or extraoral approach can be used.With the extraoral approach, the incision placement is in a natural crease location

The extraoral approach has a lower rate of infection although it is more difficult toachieve precise placement of the implant The intraoral technique introduces oralflora into the pocket of dissection, increasing the risk of infection and extrusion

Malar Augmentation

The malar prominences contribute to aesthetic balance and beauty Deficiencies orasymmetry in the malar region are usually secondary to trauma, congenital anomalies,such as Treacher Collins syndrome, cancer, or aging Malar augmentation can be used

in either aesthetic or reconstructive practices to achieve symmetry and balance of theface For example, patients that have undergone repair of a cleft lip and palate mayrequire a LeFort I osteotomy to correct midface deficiency and malocclusion Correc-tion of the occlusion can be done with the LeFort I osteotomy The concave profilecan be enhanced by malar augmentation (or doing a high osteotomy) to help reestab-lish overall facial harmony and proportions In the aging patient, the face may have atired appearance due to resorption of the maxilla and descent of the malar fat over thezygoma Malar augmentation may help to create a more youthful appearance.Preoperative assessment of the deficient or asymmetric malar region is impor-tant prior to any augmentation The facial skeleton can be analyzed usingthree-dimensional CT generated models from which custom-made implants can befabricated Any asymmetries found should be pointed out to the patient and docu-mented Malar augmentation can be done with autologous bone or with alloplasticimplants

Technique

A number of approaches have been described, including the lower eyelid, nal, temple and preauricular incisions However, the most popular approach is by

coro-an intraoral incision This approach leaves no visible scar coro-and allows the procedure

to be performed under local anesthesia if desired The intraoral approach is donethrough an upper buccal sulcus incision followed by subperiosteal dissection of apocket in the malar region It is important to identify the infraorbital nerve andprotect it The implant is contoured and placed after creation of an adequate pocket

It should remain “uncontaminated “during its placement in order to decrease therisk of infection In the no touch technique, the implant does not come in contactwith gloved hands, skin, or oral mucosa in hopes to decrease any bacterial contami-nation load Finally, the implant should be secured with either screws, nonabsorb-able sutures, or held in place by a tight pocket of periosteum

Pearls and Pitfalls

Over the long-term, genioplasty is much more durable than alloplastic tation of the chin At some point, most implants will require replacement due tomalposition, extrusion, infection or overlying soft tissue changes Osseous genio-plasty, however, can last a lifetime It is important to discuss this with the patient.When designing the proposed osteotomy for genioplasty, one has to pay particu-lar attention to the apices of the teeth and the mental nerve The intraoral approachprovides a simple access without a visible scar The mental foramen lies on the samevertical plane defined by the second bicuspid tooth, infraorbital foramen and pupil.The mental nerve should be dissected out, retracted superiorly and protected duringthe osteotomy The three branches of the mental nerve exit the mental foramen and

405Genioplasty, Chin and Malar Augmentation

supply general sensation to the chin point The osteotomy line should be about 3

mm below the mental canal to avoid the route of the inferior alveolar nerve

Genioplasty by AHMO has also found a functional role in patients with structive sleep apnea Advancement of the genioglossal muscle leads to indirect el-evation of the hyoid, thus serving as an adjunct to bimaxillary surgery A long distance(>15 mm) from the hyoid to the mandibular plane angle can contribute to a de-crease in the posterior airway space By advancing the genial tubercle and muscles,this will indirectly pull the hyoid closer to the mandibular plane and away from theposterior airway

3 Millard DR Chin implants Plast Reconstr Surg 1954; 13(1):70

4 Spear SL, Kassan M Genioplasty Clin Plast Surg 1989; 16(4):695

5 Spear SL, Mausner ME, Kawamoto Jr HK Sliding genioplasty as a local anestheticoutpatient procedure: A prospective two-center trial Plast Reconstr Surg 1987; 80(1):55

6 Wolfe SA Chin advancement as an aid in correction of deformities of the mental andsubmental regions Plast Reconstr Surg 1981; 67:5

7 Yaremchuk MJ Facial skeletal reconstruction using porous polyethylene implants PlastReconstr Surg 2003; 111(6):1818

Practical Plastic Surgery, edited by Zol B Kryger and Mark Sisco ©2007 Landes Bioscience.

Augmentation Mammaplasty

Richard J Brown and John Y.S Kim

Introduction

Breast augmentation, also known as augmentation mammaplasty, is performed

to balance a difference in breast size (developmental or involutional), to improvebody contour, or for reconstruction after breast cancer resection Clinical trials haveshown that breast implants are a safe technique for breast augmentation Attention

to detail during patient evaluation and preoperative planning can significantly pact outcomes in breast augmentation Women requesting the procedure are mostcommonly in their twenties or thirties It is imperative to assess a patients’ motiva-tion for seeking augmentation mammaplasty in an effort to avoid dissatisfactionafter the procedure The best candidates for surgery are women who are looking forimprovement, not perfection, in physical appearance, and who understand that aug-mentation only enhances breast size and will not change their social situation

im-Anatomy

The female breast is a modified integumentary and glandular structure Thedimensions vary depending on the patients’ body habitus and age It covers theanterior chest wall from the second rib superiorly to the fourth or fifth rib inferiorly.The upper half overlies the pectoralis major muscle, the lower half overlies the serra-tus anterior, and part of the lateral breast overlies the axillary fascia Blood supply tothe breast is supplied via the internal mammary artery from the medial aspect, thelateral thoracic artery from the lateral aspect and the third through seventh intercos-tal perforating arteries Deep venous drainage accompanies the arterial supply andsuperficial drainage arises from the subdermal plexus Lymphatic drainage is prima-rily from the retromammary plexus located within the pectoral fascia Sensory in-nervation is derived primarily from the intercostal nerves Nipple sensation is derivedfrom the third through fifth anterior cutaneous nerves and the fourth and fifthlateral cutaneous nerves The anterior branch of the fourth lateral intercostal nerveprovides the main sensation to the nipple-areolar complex

Patient Selection

As with any elective surgery, certain severe systemic illnesses may preclude apatient from being considered an acceptable candidate for augmentation Severeptosis is a relative contraindication and may concomitantly require mastopexy Theone absolute contraindication to the subglandular placement of implant is in pa-tients with a history of breast irradiation Radiation impairs blood supply makingthe submuscular approach much safer A strong family history of breast cancer isanother relative contraindication to the subglandular approach because a smallamount of breast tissue may be obscured during a mammogram when the implant is

in the subglandular position Relatively contraindicated is the patient with severepsychosocial issues, grossly unrealistic expectations, or body dysmorphic disorder

407Augmentation Mammaplasty

Preoperative Planning

History and Physical

The importance of the initial consultation cannot be overemphasized ing breast volume, selecting the type and shape of the implant, deciding on place-ment (subglandular or submuscular) and choosing the surgical approach should all

Determin-be discussed Evaluation of anatomic features is an essential element when planningaugmentation Noting asymmetry is important because the patient may be unaware

of the problem In such cases, the surgeon should explain that efforts to correct metry will be attempted, but that perfectly symmetric results are unrealistic Attempting

asym-to meet the patient’s expectations regarding size without compromising a naturalappearance is very important In young healthy patients, routine blood tests are notrequired It is, however, important to rule out a personal or family history of clottingdisorders A urine pregnancy test should be performed in most cases

Choice of Incision

The trend in plastic surgery is to minimize scarring by remote placement ofaccess incisions The position of the incision is important and should be individual-ized since no single incision works best for all patients Most surgeons have theirown preference as to the surgical approach used in the procedure In addition, mostpatients are knowledgeable about the various incisions and have their own prefer-ences as well The choice of incision should be discussed with the patient in anonbiased manner highlighting pros and cons of each approach (Fig 66.1) Cur-

rently, there are four commonly used types of incisions: periareolar, inframammary crease, axillary and umbilical Some patients are candidates for an endoscopic

transaxillary or inframammary approach; however results depend in part on thesurgeon’s familiarity and experience with endoscopic techniques

Type of Implant

Silicone gel-filled implants were the most common implants used prior to theirremoval from the market by the Food and Drug Administration (FDA) and areavailable only through FDA approved clinical trials Currently, saline-filled implantsare the type of implant most widely used They can be classified as smooth or tex-tured, round or contoured and as having a high or low profile

Cancer Detection

It is important to educate patients about the potential long-term effects on breastcancer surveillance A woman’s risk of developing breast cancer is not affected bybreast implants, and to date there is no evidence to support a relationship betweensilicone or saline implants and breast cancer in humans Slight modifications inmammographic technique (Eklund displacement technique) may be required foradequate visualization of all breast tissue Capsular contracture has the greatest im-pact on mammography Severe contracture can reduce the accuracy of the mammo-graphic findings Current recommendations suggest women aged 30 or older shouldhave baseline and postaugmentation mammograms and should follow the same sched-ule of routine mammography as all other women They should also perform monthlyself-exams and become familiar with the new feel of their breast tissue Self-examsare much more likely to detect a breast cancer in augmented patients compared tononaugmented women

Sensation

Breast and nipple sensation are usually compromised only temporarily (weeks tomonths) due to nerve stretching from aggressive lateral dissection Accidental nervedivision is uncommon With the subglandular approach, the reported incidence ofnerve injury is 10%, and even lower with the submuscular approach The degree ofsensation loss is directly proportional to the size and diameter of the implant due tothe large pocket that must be dissected Impaired breast sensation is more likelyafter secondary procedures, especially extensive capsulotomy which may subject sen-sory nerves to injury

Pregnancy and Lactation

Many women seek breast augmentation prior to their childbearing years Breastaugmentation is extremely unlikely to impair lactation or breast-feeding, especiallywhen implants are placed in the submuscular position Many surgeons will advisepatients to undergo breast augmentation a minimum of 6 months prior to preg-nancy or at least 6 months after the termination of lactation Breast appearance afterchildbirth varies in patients who have had augmentation prior to pregnancy Somewill return to their prepregnancy appearance while others do not

Figure 66.1 Commonly used incisions for breast augmentation

409Augmentation Mammaplasty

gives complete visualization of the subpectoral plane and offers a great deal of trol over placement of the implant If the patient needs revision surgery in the fu-ture, this incision can be reused without the need to create a new scar A potentialproblem with this incision occurs when patients decide to undergo an implant ex-change to a different size This can cause migration of the inframammary fold, thusexposing the original scar

con-Periareolar Incision

This approach involves an incision within the pigmented areolar tissue and oftenresults in the least conspicuous scar A medially placed incision avoids the fourthintercostals nerve, which supplies sensation to the nipple-areola complex Dissectionmay be carried through the breast parenchyma or towards the imframammary foldsubcutaneously around the lower pole of the breast Since most breast ducts containbacteria there is an increased risk of infection when dissecting through breast tissue

If a patient is undergoing simultaneous mastopexy, this is a favorable approach sincethe two procedures may share the same incision This approach works well with everytype of implant and for placement both above and below the pectoralis muscle

Transaxillary Incision

The benefit of this approach is the inconspicuous scar The incision is in theaxilla, where it is only seen when raising the arm This scar heals well with onlyslight discolorization, although there is a greater risk of forming a hypertrophic scarcompared to incisions at the breast The implant may be placed on, above or belowthe muscle with this technique However, there are many disadvantages to thetransaxillary incision The main disadvantage with this approach is the poor expo-sure obtained during placement of the implant; however this can be improved usingthe endoscopic technique It is difficult to create symmetric pockets so patience andskill are required There is also an increased incidence of paresthesia to thenipple-areolar complex with this approach Another downside to this incision is inthe event of a complication or the need for future corrective surgery, removal of theimplant would require conversion to one of the previously discussed incisions Otherpotential complications that have been reported are damage to the intercostobra-chial nerve and subclavian venous thrombosis

Periumbilical Incison

Placement of the implant using this approach is restricted to a prepectoral plane,and this approach provides the worst control for dissection of the pockets Dissection ofthe superior pole and symmetry of placement are difficult even in the most experiencedhands Complications of hematoma or infection require conversion to one of the previ-ously discussed incisions The periumbilical approach is the least utilized technique

Location of the Implant Pocket

Implants are commonly placed in the submuscular position, the subglandular position, or in a position that combines the two, termed the biplanar approach In

the submuscular technique, the implant is placed in a plane below the pectoralismajor muscle, whereas in the subglandular approach the implant is deep to theglandular breast tissue but superficial to the muscle Advantages to submuscularplacement include a decreased rate of capsular contracture, and reduced sensorychanges in the nipple In addition, with this technique there is a decreased incidence

of hematoma formation since the plane below the muscle is relatively avascular

Disadvantages to this approach include limitations on the size of the pocket that can

be dissected, increased postoperative pain, potential lateral displacement of the plant and the inability to obtain significant medial fullness, or cleavage Releasingthe inferior portion of the pectoralis muscle from its medial sternal attachments canhelp improve cleavage appearance Advantages to the subglandular approach in-clude ease of dissection, the ability to use larger implants and a more predictable sizeand contour Furthermore, breast ptosis may be better addressed with subglandularplacement Disadvantages include an increased risk of capsular contracture, higherrisk of nerve injury, abnormal contour appearances such as rippling and a greaterrisk of rupture during a future breast biopsy

im-Postoperative Considerations

For the first few hours while in the recovery room, the patient’s incisions andbreasts should be examined for evidence of hematoma Oral narcotics are given forpostoperative pain, and the patient should refrain from vigorous activity for the first

48 hours A soft elastic bra may be worn after the operation for comfort, supportand molding of the breast, but is not required At the first postoperative visit, thepatient is encouraged to begin massaging her breasts daily Movement of the im-plant against the walls of its cavity helps maintain an expanded capsule and result in

a softer breast If used, patients are instructed to remove Steri-strips about two weekspostoperatively At that time, unrestricted activity may commence

Complications

Hematoma

One to two weeks prior to surgery patients should discontinue medications thatmay impair platelet activity The frequency of hematoma formation is less than 2% Thebest prevention is operative technique utilizing blunt dissection and meticulous hemo-stasis A hematoma may form slowly with no symptoms or rapidly with symptoms such

as unilateral pain, swelling and fever Immediate postoperative hematomas should betaken back to the operating room for evacuation Late-onset hematomas that are symp-tomatic should be drained due to the risk of infection and capsular contracture

Infection or Seroma

The incidence of infection is about 2% and usually manifests 7-10 days eratively, but may occur at any time Either the wound or the periprosthetic spacemay be involved Symptoms include fever, swelling, discomfort, pain, drainage and

postop-cellulitis of the breast The two most common organisms are Staphylococcus epidermidis

or Staphylococcus aureus Uncomplicated wound infections should be treated with a

course of antibiotics for 1-2 weeks Wounds draining pus should be opened, and theimplant will often need to be removed If seroma fluid is clinically present,ultrasound-guided aspiration with culture and sensitivity should be performed Posi-

411Augmentation Mammaplasty

tive culture results should prompt appropriate antibiotic therapy and consideration

of implant removal If cultures are negative, seromas may be followed clinically Ifthey do not resolve, then patients should be presented with management alterna-tives, including repeat aspiration or implant removal It is important to rememberthat infection and seroma are both risk factors for subsequent capsular contracture

Capsular Contracture

Capsular contracture is the most common cause of dissatisfaction after breast mentation It occurs due to the formation of a fibrous scar that may become thick andconstrict a soft implant (Table 66.1) Etiology is unknown, but the two main theoriesare hypertrophic scar formation or infection-induced contracture Saline-filled im-plants have a lower incidence of contracture compared to silicone-filled implants Tex-tured surface saline implants have a lower rate of contracture when placed in thesubglandular position provided the patient has adequate tissue for coverage, whilesmooth surface saline implants have a lower rate of contracture in the subpectoralposition Steps to help minimize the risk of contracture include meticulous hemostasisand sterile technique The implant should be soaked in antibiotic irrigation solutionand handled as little as possible In addition, creating an adequately sized pocket isimportant The implant should fit into the pocket without being tight or firm, allow-ing mobility during postoperative massage exercises

aug-Treatment options include closed or open capsulotomy and capsulectomy The

goal of closed capsulotomy is to rupture the scar capsule by manually squeezing thebreast until there is an audible pop without fracturing the implant Complicationssuch as hematoma, rupture of the implant and migration make this an unfavorableprocedure Open capsulotomy is best when capsular contracture is less severe, andinvolves stripping or scoring of the capsule Capsulectomy, or complete capsule re-moval, should be reserved for a firm, thick, calcified capsule Implants may be re-placed and repositioned if necessary with open capsulotomy or capsulectomy Thepatient may also choose to remove the implants without replacement

Implant Displacement

Asymmetry and displacement are the second most common causes of faction after breast augmentation Implants can be placed too high, too low or ex-cessively lateral Displacement may also rarely occur after a capsulotomy procedure.Displacement can occasionally be treated conservatively with prolonged taping andclosed manipulation More commonly, however, persistent dissatisfaction with dis-placement usually culminates in surgical revision

dissatis-Table 66.1 The Baker classification of capsular firmness in

augmented breasts

Grade I No palpable capsule The augmented breast feels as soft as an

unoperated one

Grade II Minimal firmness The breast is less soft and the implant can be

palpated, but is not visible

Grade III Moderate firmness The breast is harder, the implant can be

palpated easily, and it can be seen

Grade IV Severe contracture The breast is hard, tender, painful and cold

Distortion is often marked

Rupture or Deflation

Implants begin to lose their integrity approximately 10 years after insertion netic resonance imaging is the most sensitive method for visualizing breast implantsand determining their integrity When saline implants rupture there is usually anoticeable change in size, shape, feel and appearance of the breast Saline is ab-sorbed, and the implant should be replaced to avoid the possibility of capsular con-tracture Silicone implants may leak or rupture, and usually the gel remains withinthe breast capsule Many are silent ruptures discovered at the time of routinemammograms or during implant replacement If a significant portion of the gelmoves outside of the implant capsule, it can then migrate into the breast or sur-rounding tissue The body reacts by depositing collagen around the silicone, leaving

Mag-a firm mMag-ass Ruptured silicone implMag-ants need to be removed Mag-along with the truded gel, which may involve simple implant replacement, or in the case of severeleaks, subcutaneous mastectomy with reconstruction

ex-Pearls and Pitfalls

Upward displacement of the implant can be caused by incomplete release of thepectoralis muscle If the proper position of the implant is not judged correctly, up-ward displacement of the implant in a submuscular plane can also result in ptotic,

“snoopy” deformity with the projection of the implant mismatched with the bulk ofthe breast tissue around the nipple-areolar complex Advocates of the biplanar ap-proach (in which dissection and release occurs in both a subglandular and submuscularplane) believe that a more natural curve displacement is possible with their approach

It is essential to be aware of the dissection planes to avoid asymmetricinframammary folds Similarly, care must be taken not to go too far medially withthe dissection as symmastia can result

In particularly thin patients, a pneumothorax may result from overly aggressivedissection through the intercostals (small leaks can be corrected with temporaryplacement of a small suction catheter)

Relative underfilling—especially in thin patients or with a subglandular proach—may result in rippling and is also believed to impair the overall structuralintegrity of the capsule

ap-While the subglandular approach will allow a modest lift of the nipple areolarcomplex, concomitant mastopexy may be necessary; however, if the skin integrity isweak it may be prudent to stage the procedures to avoid lowering of the nipple-areolarcomplex

Consistent postsurgical massage is believed to ameliorate the onset of capsularcontracture and yield softer breasts

Finally, it is essential that a final intraoperative view is taken of the patient in an

upright position after all surgical adjustments have been made.

Gynecomastia is defined as a benign enlargement of the male breast due to

pro-liferation of the glandular tissue The term is derived from the Greek words gyne and mastos meaning female and breasts, respectively Gynecomastia is the result of

an imbalance between estrogens and testosterone in the male body whereby thestimulatory effect of estrogen on breast tissue exceeds the inhibitory effects of test-osterone The cause of this imbalance has many etiologies that will be discussed inthis chapter Often gynecomastia occurs at birth, but most cases are discovered dur-ing puberty, with the peak incidence between 14-15 years of age When occurringduring puberty the condition is usually self-limited and will regress within 2 years.Gynecomastia can involve one breast; however 75% of the time it is bilateral Itmay be secondary to hormonal imbalances, medications, illicit drug use, geneticconditions and exogenous hormone use Frequently gynecomastia is misdiagnosed

as pseudogynecomastia, which is an increase in male breast size that develops fromfat deposition, not glandular proliferation Medical management of gynecomastia isimportant in ruling out serious underlying pathology Treatment of persistent gy-necomastia itself is predicated on surgical removal

of age It often produces asymmetrical enlargement with accompanying breast ness Declining testosterone levels in aging men can lead to mild gynecomastia

Drugs that interfere with estrogen-testosterone balance include: estrogens,estrogen-like compounds (marijuana, heroin), gonadotropins, inhibitors of testoster-one (spironolactone, cimetidine and alkylating agents) and several drugs with anunknown mechanism of action (isoniazid, methyldopa, D-penicillamine, captopril,diazepam and tricyclic antidepressants)

Evaluation and Diagnosis

History

The history should include the age of onset, laterality of disease, tenderness andsymmetry of the deformity A thorough assessment of any hepatic, testicular, pul-monary, adrenocortical, or thyroid dysfunction is important in ruling out an endo-crine etiology An abnormal exam should guide the surgeon to order focused testsand consult specialists Gynecomastia is common in older men Enlargement ofbreast tissue is usually central and symmetric arising from the subareolar position.Unilateral eccentric gynecomastia may be secondary to neurofibromas, hematoma,lipomas, lymphangiomas, or dermoid cysts A careful review of systems focusing onmedications, alcohol and drug use is important in revealing any conditions associ-ated with gynecomastia The most difficult condition to differentiate from gyneco-mastia is pseudogynecomastia Patients with this condition are often obese, havebilateral enlargement and do not complain of breast pain or tenderness

Physical Exam

Patients should be examined in the supine position The examiner grasps thebreast between the thumb and forefinger (pinch test) and gently moves the twodigits toward the nipple If gynecomastia is present, a firm, rubbery, mobile, disk-likemound of tissue arising from beneath the nipple-areolar region will be felt Whenpseudogynecomastia is present it may be difficult to palpate this firm disk of tissue.Breast exam should also include evaluation of the axillary contents to rule out lym-phatic involvement Simon et al graded gynecomastia into four groups (Table 67.1).Young patients with no previous medical history and new onset bilateral gyneco-mastia should have a testicular exam looking for atrophy, enlargement or abnormalmasses If indicated, an ultrasound of the testicles should be performed If physicalexam demonstrates characteristics of feminization, it is prudent to check the appropri-ate hormone levels (e.g., estradiol, leutenizing hormone, testosterone and DHEA) Amarfanoid body habitus should prompt a karyotype to rule out Klinefelter’s syndrome.Findings such as axillary lymphadenopathy or a unilateral hard mass fixed tounderlying tissues should prompt further evaluation Skin dimpling, nipple retrac-tion, nipple discharge and axillary lymphadenopathy are all associated with breastcarcinoma Breast cancer must be ruled out even though it accounts for less than 1%

of cancers in men If cancer is suspected, imaging of the breasts (mammography orMRI), and a coreneedle biopsy or fine-needle aspiration (FNA) should be performed

Table 67.1 Grading of gynecomastia

415Gynecomastia Reduction

to rule out carcinoma Gynecomastia in conjunction with Klinefelter’s syndromecarries a sixteen-fold increased risk of male breast cancer

Finally, patients with gynecomastia and an otherwise normal history and cal exam may be observed if the condition has been present for less than 12 months.However, when the disease has been present for over a year, surgery should be con-sidered since breast tissue may become irreversibly fibrotic as time progresses be-yond this stage

physi-Treatment

Before considering treatment, it is important to keep in mind that gynecomastiamay regress spontaneously Although surgery is indicated as a diagnostic procedure,patients often request surgery as treatment for the physical discomfort or emotionaldistress that is common in men with this condition Most patients who visit a plasticsurgeon request treatment for psychological reasons

Discontinuing offending medications or correcting any underlying imbalance tween estrogens and androgens should result in spontaneous regression of new-onsetgynecomastia Medical treatment with androgens, anti-estrogens and aromatase in-hibitors has been used with minimal efficacy Surgery remains the accepted standardfor management of gynecomastia, especially in patients with long-standing gyneco-mastia and fibrotic breast tissue Surgical options can range from simple excision to amore complex, inferior pedicle breast reduction The two most widely used surgicaltechniques are the subcutaneous mastectomy and liposuction-assisted mastectomy

be-Subcutaneous Mastectomy

Several approaches may be used when performing an open subcutaneous tectomy The choice of incision should be guided by the degree of gynecomastiapresent Patients with small or moderate gynecomastia may have an intra-areolarincision along the inferior hemisphere of the nipple (Webster incision) This inci-sion can be extended medially or laterally for better exposure An alternative inci-sion that helps maximize exposure is the triple-V incision It is made along thesuperior border, parallel to the nipple Moderate or massive gynecomastia may re-quire skin resection along with nipple relocation or nipple grafting The most com-mon incision for moderate gynecomastia is the Letterman incision This approachallows for the nipple-areola complex to be rotated superiorly and medially after skinresection With massive gynecomastia, en bloc resection of skin and breast tissuewith free nipple grafting can be performed through an elliptical incision In cases ofsevere gynecomastia, the dissection may be carried to the level of the pectoralis ma-jor fascia and may require the use of postoperative suction drains

mas-Liposuction-Assisted Mastectomy

Experienced surgeons may perform endoscopic-assisted mastectomy withliposuction through an axillary incision in lieu of open mastectomy In the past,liposuction-assisted mastectomy was utilized after open excision to assist with breastcontouring In an effort to avoid large visible scars on the chest wall,liposuction-assisted mastectomy (suction lipectomy) is becoming the preferred sur-gical technique for most cases of gynecomastia It is the most commonly used tech-nique for correcting pseudogynecomastia With this technique there is lesscompromise of the blood supply as well as a decreased risk of nipple distortion.Postoperative complications such as hemorrhage, infection, hematoma, seroma andnipple necrosis have been minimized with suction lipectomy

This technique allows removal of glandular and fibrotic tissue from the breast.However, pure glandular gynecomastia may still require an open technique Morerecently, ultrasound-assisted liposuction (UAL) has been introduced in conjunctionwith standard liposuction as a safe and effective method of treatment for gyneco-mastia, especially in cases where dense fibrous tissue is involved The ultrasoundprobe is introduced through an axillary or inframammary incision and advancedthrough the dense parenchymal tissue Energy from the ultrasound waves cavitatesand emulsifies breast parenchyma that may be removed via suction lipectomy UALstimulates the dermis, allowing for postoperative skin retraction to occur In thefuture, it may become standard treatment to utilize the UAL technique first, fol-lowed by an excisional procedure 6-9 months later (once maximal skin contractionhas occurred) if excess skin or breast tissue persists

Complications

Hematoma and seroma are the most common complications and can be avoided

by judicious hemostasis and the coordinate use of pressure dressing and suctiondrains postoperatively Appropriate care must be taken with liposuction to ensureviability of the overlying skin Skin or nipple/areola necrosis can occur if the vascu-larity is compromised Pigment changes in the areola have also been reported, espe-cially in free-nipple grafts Asymmetry and discontent with scars are frequent patientcomplaints

Pearls and Pitfalls

The treatment of gynecomastia is predicated on the exclusion of potentially gerous (or easily reversible) causes As is the case with surgery of the female breast,the surgical approach should consider the magnitude of skin and volume excess aswell as the quality of that excess For instance, an elderly man’s skin will not retractwith liposuction as well as a young man’s Hence, an informed discussion of issuesrelated to skin redundancy is important In cases in which there is a fair degree ofdense, fibrotic tissue, ultrasound-assisted liposuction may be the treatment of choice.For milder forms of gynecomastia, liposuction with mastectomy through a periareolarincision may be helpful While gynecomastia may regress spontaneously, it is im-portant to note that the longer the gynecomastia is present, the more fibrotic thebreast tissue can become Once fibrosis sets in, surgical removal of the tissue remainsthe optimal treatment option

dan-Suggested Reading

1 Bostwick IIIrd J Gynecomastia Plastic and Reconstructive Breast Surgery Vol.1, 2nd

ed St Louis: Quality medical publishing Inc., 2000:239-369

2 Eaves IIIrd FF et al Endoscopic techniques in aesthetic breast surgery Clin Plast Surg1995; 22:683

3 Rohrich RJ, Ha RY, Kenkel JM et al Classificaiton and management of gynecomastia:Defining the role of ultrasound-assisted liposuction Plast Reconstr Surg 2003;111(2):909

4 Simon BB, Hoffman S, Kahn S Classification and surgical correction of tia Plast Reconstr Surg 1973; 51:48

gynecomas-5 Spear SL, Little IIIrd JW Gynecomastia Grabb and Smith’s Plastic Surgery 5th ed.Lippincott-Raven Publishers, 1997

6 Wilson JD Gynecomastia Harrison’s Principles of Internal Medicine 11th ed NewYork: McGraw-Hill Book Co., 1987

There are no absolute contraindications to breast mastopexy Planned futurepregnancy is a relative contraindication because lactation and subsequent involu-tion can change the shape of breast tissue Capsular contracture after breast aug-mentation is another relative contraindication to mastopexy In many of these patients,the breasts appear ptotic when in fact they truly are not Therefore, removal andinspection of the implants while in the operating room is paramount prior to com-mitting to mastopexy Finally, women with a high risk of breast cancer should beevaluated carefully since surgery may alter the architecture of breast tissue makingdetection and treatment of cancer difficult

Preoperative Considerations

Judicious care should be taken during patient assessment and selection to clarifyexpectations and ensure that desired results are obtainable A complete physical ex-amination should be performed which includes inspection as well as palpation ofthe breast parenchyma to rule out suspicious masses All patients 40 years or oldershould have a baseline mammogram prior to surgery, a follow-up mammogram 6months after surgery, and then follow the American Cancer Society recommenda-tions for annual screening mammograms Determining the degree of breast ptosis iscentral to planning mastopexy as it will guide which technique is best suited toachieve the optimal aesthetic appearance (Table 68.1)

Determining the correct level of the nipple areolar complex (NAC) is criticalwhen planning a mastopexy The nipple should be placed at or slightly above theinframammary fold taking care to avoid placing the nipple too high on the breastmound, which can be difficult to fix Breast volume is important to consider whenplanning a mastopexy, and any parenchyma that falls below the inframammary creaseshould be reduced or elevated

Next, the position, length and definition of the inframammary crease should beevaluated When augmentation is used in conjunction with mastopexy, the implantpocket is used to define and retain the new inframammary crease Breast mobility isdirected by the firmness of glandular attachment to the underlying deep fascia andshould be assessed prior to surgery Skin and tissue quality should be assessed sincewomen with ptosis have an excess of breast skin compared to the amount of under-lying parenchymal tissue The appearance of striations indicates a weakness in un-derlying dermis, and this skin usually has poor elasticity that will not support orshape the breast Recurrence of breast ptosis in these patients is predictable; there-fore planning skin removal and incision placement is an important preoperativeconsideration These are planned on a continuum from periareolar to circumareolar

to vertical scars and finally to horizontal scars Should ptosis recur, additional breasttissue can be excised through old incisions

Women with small breasts and upper pole flatness may benefit from neous augmentation The addition of an implant can enhance the size and contourwhile increasing the longevity of the uplifting effects of mastopexy Simultaneousbreast augmentation and mastopexy should be considered carefully since the twohave somewhat conflicting goals The goal of breast augmentation is to enlarge thebreast, which involves stretching the skin and NAC, while mastopexy is designed toreduce the skin that envelopes the parenchymal tissue Patients should be aware of

simulta-Table 68.1 Grades of Ptosis according to the Regnault classification

Minor Ptosis Nipple at the level of inframammary fold, above lower(Grade I) above lower contour of gland

Moderate Ptosis Nipple below level of inframammary fold, above lower(Grade II) contour of gland

Major Ptosis Nipple below level of inframammary fold, at lower contour(Grade III) of gland

Pseudoptosis Inferior pole ptosis with nipple at or above the

inframammary foldGlandular Ptosis Nipple is above the fold but the breast hangs below the fold

419Mastopexy

the increased risk of poor scarring, implant-nipple misalignment and implant sion The best scenario occurs when the implant fills out the excess skin envelopewhile leaving enough excess skin to reshape the breast Depending on the complex-ity of the problem and quality of the skin support, it may be better to perform twoseparate, staged procedures

extru-Preoperative markings vary with surgical plan and are essential for obtainingoptimum results In most patients the nipple should be at or slightly above theinframammary fold Once the proper nipple location has been determined, an in-delible marker may be used to mark the remainder of the skin incision

Intraoperative Considerations

Since scars are the greatest drawback to aesthetic breast surgery, it is best tochoose techniques that minimize the length of incisions and place them in hiddenareas Intraareolar and periareolar incisions are tolerated best because they are lesslikely to become hypertrophic provided there is no tension on the incision A me-dian inferior vertical incision is also tolerated well compared to a horizontalinframammary incision As a rule, incisions should be kept off of the superior hemi-sphere of the breast because women often wear clothing that exposes this area Thereare several techniques available to correct breast ptosis, and no single technique isconsidered ideal The degree of ptosis varies from patient to patient and treatmentshould be individualized The primary focus is on altering breast volume and con-tour by removing excess skin and repositioning the NAC

The common surgical options for ptosis correction are:

1 Augmentation with or without mastopexy

2 Periareolar scar technique

3 Circumareolar scar with periareolar purse-string closure (Benelli mastopexy)

4 Wise-Pattern mastopexy

5 Vertical mastopexy Vertical mastopexy can be combined with the horizontalinverted T technique or the short horizontal scar technique

Augmentation for Ptosis

Patients that are well suited for augmentation alone are those that have ptosis or grade I ptosis In these patients, minimal elevation of the NAC is required.Their breasts usually have flattened upper poles and are hypoplastic and involuted

pseudo-It is important to be aware that if the nipple is below the inframammary fold, animplant may actually enhance the deformity giving a more ptotic appearance Pa-tients who seek a more elevated NAC may require circumareolar incisions withaugmentation When augmentation is used to correct breast ptosis, the implant isplaced in either the submuscular position in the upper portion of the breast or in thesubglandular position in the lower portion of the breast When placing the implant

in the submuscular position, it is important to maintain a loose submusculofascialpocket to avoid the appearance of a double silhouette (double bubble) This occurswhen breast parenchyma descends over the implant while the implant remains fixed

at the upper pole

Periareolar Technique

This approach is best utilized in patients with a minor degree of ptosis whorequire minimal elevation of the NAC The periareolar technique involves acrescenteric excision and lift of the NAC It affords the shortest possible scar and is

well hidden within the NAC Patients that require a greater degree of elevation ofthe NAC should have a different technique performed since the risk of areola defor-mity is proportional to the amount of skin removed Skin quality is important toconsider for healing purposes as well as for assessing the risks of recurrent ptosis

Circumareolar Scar (Benelli) Technique

Circumareolar mastopexy alone tightens the breast envelope without raisingthe NAC and may cause central breast flattening Patients who have large areola

or tubular breasts may benefit from this technique Two incisions are required: aninner incision around the areola and a second parallel outer incision demarcatingthe area for skin excision The final diameter of the new NAC should be 40-45

mm A pursestring, nonabsorbable suture is placed around the outer dermal cumference in order to reduce tension on the suture line and limit the risk of scarwidening This procedure is called a “Benelli or “round block” mastopexy Theround block technique allows control of the diameter of the areola and maintains

cir-it in a fixed circular scar thus avoiding protrusion Limcir-iting the size of the outerdiameter to three times that of the inner diameter helps minimize tension as well

In addition to a pursestring suture, a Benelli mastopexy may also include pexyingthe retroglandular surface of the breast parenchyma to underlying rib periostium

in a crisscross fashion

Vertical Scar Technique

Vertical mastopexy is needed to correct more severe breast ptosis, such as grade II

or III, where the nipple is below the level of the inframammary crease If the tance the nipple needs to be elevated is significant, and there is excess skin requiringexcision, then a vertical limb is required Removing skin in a vertical direction al-lows the medial and lateral breast skin to be moved toward the center and preventflattening of the breast apex The scar is usually minimally visible with time and islocated inconspicuously on the lower portion of the breast out of view when low-cutclothing is worn

dis-The procedure begins by determining the new position of the NAC With thepatient standing or sitting upright, the apex and the width of the new NAC positionare marked An ellipse is drawn starting from the top of the new position of theNAC around the existing NAC and downward to the inframammary crease Inci-sions are made along the lines of the ellipse as well as around the NAC, and skin isdeepithelialized within the ellipse If implants are being used, they are placed into asubpectoral pocket Patients with upper pole flattening may benefit from a lowerpole deepithelialized parenchymal flap turned beneath the NAC into a new position

in the upper pole of the breast Prior to making any further incisions through breastparenchyma, a technique called tailor tacking may be employed to help the surgeonpredict the final outcome This technique is useful for determining the position ofthe NAC The deepithelialized areas are invaginated and the skin edges approxi-mated with staples The outer edges are marked, the staples are removed and theexcess breast tissue is then excised

Wise-Pattern Mastopexy

Patients with significant ptosis, very full lower breast poles, or those who require

a long transposition of the NAC may opt for the Wise-pattern technique A hole incision is made around the NAC with a vertical limb and a horizontal exten-sion resulting in an inverted T type scar after removal of excess tissue Different

421Mastopexy

pedicles can be used with this approach depending on surgeon preference (if comitant implants are to be placed, a superior or medial pedicle may be suitable;

con-if signcon-ificant lcon-ift of the NAC is required, an inferior pedicle may be preferable).Once the skin and pedicles have been incised and dissected, judicious undermin-ing and removal of excess tissue can be performed The vertical and horizontallimbs are approximated and the NAC is sutured in place with a tension-free sub-cuticular closure

Postoperative Considerations

Postoperatively an elastic bandage or surgical bra is worn over gauze dressings.Several days later, a soft support bra can be worn continuously for 3-4 weeks Liftingobjects above the head should be avoided during the immediate postoperative pe-riod Patients should be instructed about potential complications such as numbnessand hematoma formation Breastfeeding should be normal after some types of mas-topexy; however other techniques increase risk of loss of lactation Many of the samecomplications seen after breast augmentation apply to mastopexy as well Theseinclude hematoma or seroma formation, infection, nipple sensory loss and implantcontracture There are several other complications worth mention These are necro-sis of the nipple-areolar complex, recurrent ptosis, nipple and breast asymmetry,upper pole flattening and unacceptable scarring

Nipple-Areolar Necrosis

Adequate nipple-areolar microcirculation is imperative to the survival of the NAC.Patients who are heavy smokers or have predisposing vascular diseases such as diabe-tes or collagen vascular disease are at risk for nipple-areolar necrosis All patientswho smoke should quit smoking prior to and after surgery in order to help decreasenipple necrosis Placing a subglandular implant or a periareolar pursestring suturemay also increase the risk of nipple necrosis because the central parenchyma may bedamaged to a point where the blood supply to the NAC is compromised

Recurrent Ptosis

Many surgeons leave large amounts of lower pole breast tissue beneath their skinclosure Subsequently, many women return with lower pole ptosis, termed “bot-toming out.” Ptosis may recur when there is asynchrony between breast parenchymaand NAC descent Correction during a secondary procedure requires removal of thelower pole parenchyma with simultaneous skin revision

Nipple and Breast Asymmetry

The goal of breast surgery is to obtain perfect symmetry; however, most womenhave some degree of asymmetry preoperatively Postoperative asymmetry of the NAC

or patient dissatisfaction may be corrected during a follow-up procedure ing this issue prior to surgery may help alleviate anxiety when there is postoperativeasymmetry Periareolar techniques may afford a modest correction of asymmetry;however in cases of significant asymmetry, a complete revision mastopexy may benecessary

Discuss-Upper Pole Flattening

Mastopexy alone may not be sufficient to correct breast ptosis To avoid upperpole flattening the surgeon may place implants, rotate lower breast parenchymalflaps beneath the upper pole, or perform a reverse periareolar pursestring mastopexy

Poor Scarring

Patients with the highest risk of poor scar outcome are cigarette smokers and anypatients with comorbidities that predispose them to microvascular disease Closingwounds in a tension free manner offers the best chance for optimal scar outcome Ifthe surgeon anticipates a tight skin closure below the NAC, then extrapigmentedskin may be left inferiorly and excised at a later time Horizontal incisions com-monly heal with hypertrophy due to the amount of tension on these wounds Ef-forts to minimize incision length combined with proper wound taping may helplimit hypertrophic scarring If hypertrophic scarring does occur, silicone gel therapy

or steroid injections should be attempted prior to scar revision

Pearls and Pitfalls

Choosing a periareolar technique for significant ptosis will result in poor ring, deformity of the nipple and recurrence The vertical mastopexy approach mayallow a sufficient lift; however, the use of a variable length of horizontal incision inconjunction with this may allow for the necessary removal of excess skin A modifi-cation of the vertical mammaplasty is the use of a curvilinear J-type incision Thismay obviate the need for a short horizontal scar for more moderate forms of ptosis

scar-An adjunctive internal suspension of the breast parenchyma may be necessary withthese approaches depending on the quality of skin and its ability to be an activeelement in shaping and holding form With the Benelli approach, care must betaken with preoperative counseling about the scar and the relatively long process ofsmoothening of contours While concomitant implant placement may improve notonly ptosis but also the overall aesthetic result, it is critical to judiciously evaluatethe timing of implant placement in light of patient expectation and anatomy Insome instances it may be more prudent to stage the augmentation and mastopexy

3 Regnault P Breast ptosis: Definition and treatment Clin Plast Surg 1976; 3(2):193

4 Rohrich RJ, Thornton JF, Jakubietz RG et al The limited scar mastopexy: Currentconcepts and approaches to correct breast ptosis Plast Roconstr Surg 2004; 114(6):1622

5 Spear SL, Little III rd JW Reduction mammoplasty and mastopexy Grabb and Smith’sPlastic Surgery 5th ed Lippincott-Raven Publishers, 1997

6 Weinzweig J Augmentation mammaplasty Plastic Surgery Secrets Philadelphia: Hanley,1999:238

Chapter 69

Practical Plastic Surgery, edited by Zol B Kryger and Mark Sisco ©2007 Landes Bioscience.

Abdominoplasty

Amir H Taghinia and Bohdan Pomahac

Classification and Choice of Procedure

Procedures used to change the shape of the anterior abdomen include liposuction(suction-assisted lipectomy), mini-abdominoplasty (infraumbilical elliptical skin andfat excision), abdominoplasty and panniculectomy Patient selection and preferencedetermines which operation to perform A thorough history and physical examina-tion usually reveals the best operation for a given patient The physical examinationshould determine the amount of excess skin, the amount of excess subcutaneous fatand the laxity of abdominal fascia Classification schemes have been developed toassist the surgeon in decision-making:

Type 1 Fat deposit with normal fascia and skin 

liposuction only

Type 2 Mild excess skin, normal fascia with or without excess fat 

infraumbilical elliptical skin excision with liposuction for excess fatType 3 Mild excess skin, infraumbilical fascia laxity with mild to moderatefat excess 

infraumbilical elliptical skin resection, infraumbilical fascia

tightening and liposuction or direct lipectomy

Type 4 Mild excess skin, total fascia laxity with or without excess fat infraumbilical elliptical skin excision, supra- and infraumbilicalfascia tightening and liposuction or direct lipectomy for excess fatType 5 Large excess skin, total fascia laxity with or without excess fat 

complete abdominoplasty with supra- and infraumbilical fascia tightening

In general, abdominoplasty addresses excess skin and lax abdominal fascia whereasliposuction addresses only excess fat The ideal abdominoplasty patient has excessskin, mild excess fat and mild to moderate fascia laxity (Type 5) In contrast, theideal abdominal liposuction patient has excess fat with normal, taut fascia and tautskin (Type 1) Liposuction alone is not recommended for patients with lax or excessskin In these patients, liposuction without concomitant skin excision results in anunsightly ‘deflated balloon’ look

The mini-abdominoplasty is reserved for patients with mild excess skin with orwithout excess fat (Types 2, 3 and 4) An infraumbilical ellipitical skin and fat excision

is performed If the infraumbilical fascia is lax (Type 3), it may be tightened directly.Panniculectomy is removal of excess abdominal wall tissue (skin and fat) withoutassociated undermining or umbilical transposition It is usually performed in previ-ously massively obese patients who have lost weight These patients have a large seg-ment of overhanging abdominal skin and fat The “pannus” can lead to problems withskin breakdown or panniculitis These patients have poor vascularity of the abdominalwall tissue; therefore even limited flap undermining can lead to complications

Patients with excess abdominal wall fat usually benefit from weight loss prior to

an operation Successful preoperative weight loss heralds a motivated patient andpromises a pleasing outcome Certain patients will present with a somewhat bulgingabdomen with minimal to moderate excess abdominal wall fat, normal fascia and

no excess skin Typically these patients will have significant excess intraabdominalfat Weight loss is encouraged in these patients as well

Preoperative Considerations

In the preoperative setting, the surgeon should pay close attention to the uniqueneeds, characteristics and concerns of the patient A thorough history and physicalexamination is crucial—not only to determine the surgical strategy but also to un-cover potential sources of future complications Previous abdominal surgery shouldraise the possibility of incisional hernias Scars from prior abdominal surgery mayalso indicate the need for a more conservative approach For example, an obliqueright upper quadrant incision (e.g., from a previous open cholecystectomy) indi-cates potential interruption of the superolateral blood supply to the abdominoplastyflap (Fig 69.1) The astute surgeon may consider flap delay, minimal undermining,

Figure 69.1 Blood supply to the anterior abdominal wall The superficial gastric artery perfuses the abdominal skin directly The deep epigastric arteries(inferior and superior) perfuse the abdominal skin and subcutaneous tissue viaperforators through the rectus abdominus muscle Once fully raised, theabdominoplasty flap receives its main blood supply from the deep superior epi-gastric and intercostal arteries A subcostal right upper quadrant incision (e.g.,from an open cholecystectomy) can interrupt the superolateral blood supply tothe abdominal wall Liposuction of the lateral abdominoplasty flap can jeopar-dize blood supply from the lateral intercostal vessels

425Abdominoplasty

restrained resection, or a combination of these approaches Smoking should bestopped at least 1 month prior to surgery Aggressive resection in smokers invitescomplications

Hernia repair during abdominoplasty needs to be considered carefully sionally, hernia repair requires extensive lysis of adhesions Possible bowel injuryduring these operations may result in significant wound infections In addition,these patients inevitably endure a longer hospital stay (for return of bowel function),thus providing a set up for other complications such as deep vein thrombosis andhospital-acquired infections

Occa-Suction-assisted lipectomy during abdominoplasty can lead to feared tions of flap necrosis and infection It is important to note that raising theabdominoplasty flap disrupts the blood supply from the deep superior and inferiorepigastric perforators (Fig 69.1) Thus, the predominant blood supply to the lowerflap comes from the laterally-based segmental perforators of the intercostals vessels.Lateral liposuction of the abdominoplasty flap can injure these vessels, thus com-promising blood supply of the flap, especially in the lower midline watershed area.Liposuction should not be performed in the lateral abdominoplasty flap Whendone in the midline or inferior far-lateral flanks, it should be done very conserva-tively and in experienced hands

complica-Operations and Techniques

With the patient standing, the midline is determined A pinch test is performed

to determine the amount of excess skin The lower border of the dissection is marked

at a point 5-7 cm above the vulvar commissure Lines are drawn laterally curving up

to the anterior superior iliac spines The superior borders of excision are then drawnlaterally from a point just above the umbilicus The superior lines serve only asuseful guides for preliminary planning-rarely do they determine the final extent ofexcision (Fig 69.2)

Figure 69.2 Markings for plasty The lower incision is made andthe flap is elevated The superiormarkings serve as a guideline andmay be modified once the flap israised and redraped

The patient is placed in the supine position with arms abducted An intravenousantibiotic is administered, and pneumatic compression boots are fitted After in-duction of adequate general anesthesia, a Foley catheter is inserted and the abdomen

is prepped and draped from the xyphoid to the pubis Abdominoplasty can also beperformed under sedation and local anesthesia

The umbilicus is sharply circumscribed and dissected down to the anterior dominal wall fascia (Fig 69.3) The inferior incisions are made and carried to thefascia Injury to the lateral femoral cutaneous nerve is avoided by leaving a smallamount of redundant fat attached to the anterior superior iliac spine The dissection

ab-is directed cephalad towards the xiphoid along the plane anterior to the abdominalfascia Perforating vessels must be identified and coagulated before being divided orthey can retract and may cause delayed hematomas

If the abdominal fascia is lax, it may be tightened with running or figure-of-eightinterrupted nonabsorbable sutures (Fig 69.4) This tightening is usually performed

Figure 69.3 Umbilical incision Twoskin hooks elevate the umbilicus andprovide tension for making the inci-sion An 11-blade incises the umbi-licus circumferentially The incision

is then carried down to the fasciausing heavy curved scissors to cutthe fibrous bands that tether theumbilicus (not shown)

Figure 69.4 Fascial plication Buried, nonabsorbablefigure-of-eight interrupted sutures approximate the fas-cia in the midline below the umbilicus A running,heavy gauge suture can also be used

427Abdominoplasty

at the midline above and below the umbilicus depending on the degree of laxity (seeclassification scheme) Arguing that the lax midline fascia may not support tighten-ing in the long-term, some authors prefer to plicate the fascia laterally at the lineasemiluminaris (the adjoining border of the external oblique and rectus fascia as shown

in Fig 69.5)

The patient’s hips are flexed and the excess skin of the flap is excised (Figs 69.6,69.7) It is crucial to avoid excessive skin removal that could cause undue tension onthe closure The new site for the umbilicus is determined, and an opening is made toaccommodate the umbilicus In general, a smaller umbilicus looks more natural andless conspicuous Most surgeons err towards a smaller, more inferiorly positionedumbilicus Some prefer a vertical incision for the umbilical opening whereas othersprefer a V-shaped incision (Fig 69.8)

Figure 69.5 Tightening patterns forcomplete abdominoplasty Verticalmidline curves are drawn and approxi-mated above and below the umbili-cus Alternatively, tightening can beperformed at the linea semiluminaris(the intersection of rectus fascia andexternal oblique fascia)

Figure 69.6 Gauging excess tissue.Once the flap is fully raised, thepatient’s hips are flexed and the flap

is pulled inferiorly to assess the amount

of excess tissue to be excised

If there is significant excess fat in the flap, it can be directly excised from belowScarpa’s layer To accentuate the midline, fat may be directly excised from thesub-Scarpa’s layer in the midline At this point, careful hemostasis is achieved Theflap is brought down, and the umbilicus is housed in its new location Jackson-Prattclosed suction drains are placed through stab incisions in the pubic area It is impor-tant to reapproximate Scarpa’s fascia prior to dermal closure The flap and umbilicusare then closed with interrupted deep dermal and running subcuticular sutures

Figure 69.7 Gauging excess tissue.The lower flap can be cut in half toprovide better visualization of excesstissue-especially in the midline

Figure 69.8 Techniques for umbilicoplasty Some surgeons prefer a V-shaped sion (A) whereas others prefer a short vertical incision (B) The umbilical stalk may

inci-be sutured to the periumbilical anterior fascia (not shown)

429Abdominoplasty

patients monitor and record drain output The drains are usually removed after aweek during the first office visit At that point, activity is gradually increased untilfull return to activities, including sports and heavy lifting, at six to eight weeks

Complications

Fortunately, worrisome complications of abdominoplasty rarely occur Theseinclude deep vein thrombosis, pulmonary embolism and major skin necrosis Themore common complications of abdominoplasty include seroma, infections, he-matoma and minor skin edge necrosis Infections should be treated with antibioticsand debridement of nonviable tissue Small hematomas self-absorb and may be ob-served Larger hematomas should be treated more aggressively by open or percuta-neous drainage Observation is usually warranted for most seromas Large seromasmay be drained percutaneously, but often times the fluid reaccumulates Minor skinedge necrosis is treated with conservative debridement and, if necessary, late scarrevision to improve cosmetic appearance

Pearls and Pitfalls

• Design of the skin incision should take into consideration patient preference.Some women wear very low-riding pants, and an incision that approaches theiliac crest may be visible

• The larger caliber, periumbilical perforating vessels should be cauterized andtransected well above the level of the fascia so that if one bleeds it will not fullyretract into the rectus muscle below If this occurs, a figure-of-eight suture should

be used to achieve hemostasis

• Any palpable bulge on the fascia will be a visible one on the surface when thepatient stands and should be tightened Occasionally this may involve horizon-tal tightening of the fascia

• Plication of the fascia should span from xyphoid to pubis, otherwise a bulge willoccur above or below the tight suture line

• Many surgeons use tacking sutures to help adhere the abdominoplasty flap tothe fascia in order to reduce dead space This has the theoretical benefit of de-creasing seroma formation

• Never make the superior skin incision until there is no doubt that the skin willclose without undue tension It is better to have a small vertical scar (from theumbilicus incision) than central skin necrosis or hypertrophic scarring from ex-cess tension

com-3 Greminger RF The mini-abdominoplasty Plast Reconstr Surg 1987; 79(3) :356-65

4 Hester Jr TR, Baird W, Bostwick IIIrd J et al Abdominoplasty combined with othermajor surgical procedures: Safe or sorry? Plast Reconstr Surg 1989; 83(6):997-1004

5 Lockwood TE High-lateral-tension abdominoplasty with superficial fascial systemsuspension Plast Reconstr Surg 1995; 96(3):603-15

6 Lockwood TE Maximizing aesthetics in lateral-tension abdominoplasty and body lifts.Clin Plast Surg 2004; 31(4):523-37

7 Pitanguy I Abdominal lipectomy Clin Plast Surg 1975; 2(3):401-10