Month: November 2015

The breast has a tendency to age due to a combination of tissue changes in the skin, breast tissue, the ligaments within the breast, the position on the chest wall and the size of the nipple/areolar. Changes to these tissues occur most acutely with fluctuation in weight, and pre/post pregnancy. Mastopexy is a technique used to lift and change the tissues of the breast. Each component of the breast can be lifted and each component needs to be addressed individually. The consultation must take into account the patients ideal size and a discussion regarding previous shape and desired shape. Often breasts are slightly different both in terms of size and shape and the position of the nipples. The crucial question is whether there is enough volume of current breast tissue to provide the desired size and the position of the nipple areola complex. Where volume is deficient and the nipple areola is sitting in a reasonable position anatomically shaped implants may be able to give the perception that the nipple areola has been lifted. It may be over time that patients may require a lift subsequently but in some scenarios a good result can be obtained by breast augmentation only. Where the nipple areola is sitting low and the volume of the breast is satisfactory a mastopexy can improve the shape and position of the breast. The overall size and shape needs to be tailored to the individual using methods to minimise risk to the blood supply to the tissues. The breast mound is designed in order that the breast can be lifted into a new position. The skin is re-draped over the breast and the nipple/areolar size adjusted to the needs of the patients. Sometimes the nipples need be lifted a considerable distance in combination with the breast tissue. Often the nipples point into the armpit and these need to be relocated centrally at the same time. Contour defects as a result of stretching of the breast ligaments needs to be addressed by relocating the breast tissue higher up the muscle on the chest wall.

Mastopexy Methods

There are a number of different ways of performing a mastopexy and these are determined by the incisions performed. The donut or benelli mastopexy is performed through a scar placed around the areola. It may be used to increase the height of the nipple areola by 2-3 cm. It does have a tendency to form stretched scars but does not involve a vertical incision. The lollipop mastopexy is performed via a scar around the areolar and a vertical incision. It is useful in patients where there is no need to remove excess skin. The nipple areola can be lifted significantly higher than in a benelli mastopexy. Where there is significant excess skin and the breast tissue and nipple areola need to be raised significantly an anchor scar mastopexy is the proffered rejuvenation technique. The scars are place around the areola and a vertical scar that meets a horizontal scar in the crease/ fold of the breast. Where the nipple areola complex has dropped and there is also insufficient volume one should consider a combination of a mastopexy with an implant or autologous fat transfer. This can be done as a one stage procedure using the mastopexy techniques described above. Autologous fat transfer involves the removal of fat from the body and transferring it into the breast to try and give extra projection at the upper part of the breast which is the place that is usually most empty. Autologous fat transfer does allow patients the potential of an increase in volume without an implant but often patients may require more than one treatment of autologous fat transfer and the volume improvements are not as predictable as an implant. Using an implant at the same time as a mastopexy in a one stage operation is an excellent means of providing breast rejuvenation in patients who want a moderate increase in volume. For patients wishing to have a dramatic increase in size and wish to have large implants or in those who need the nipple areola lifting considerably mastopexy implant is better performed as a 2 stage operation. Patients undergoing any form of breast lift should be aware that the breast will sit high on the chest wall and will drop over time. Usually this can take 3 months. All the operations described above are usually performed under general anaesthetic. Patients are usually able to drive after a week and may start gentle exercises at this time building up to normal exercising by 4 weeks. A consultation regarding the pros and cons of mastopexy will help to clarify the expectations of patients and provide results that are achievable to meet these expectations. One should consider all the possible options, and if consulting with myself, one will be able to look at results related to all the operations above and make an informed decision

 

Download Article

 

Often excess skin or fat can be a problem for patients in the thigh area and thigh rejuvenation is being more frequently requested. For patients with excessive weight loss thigh lifting can be combined with other procedures in other areas of the body.

The distribution of excess fat and skin and the quality of skin of the thighs will often determine what the best options for patients are. Surgical treatments combining skin tightening and fat removal without skin excision may offer some promise and a discussion regarding the pros and cons should be addressed in any consultation relating to thigh rejuvenation. Liposuction on its own can provide some skin tightening and the perception of skin rejuvenation, although where excess skin is present surgical excision is often the only reliable way to improve contour. If there is excess fat only liposuction can be used, although patients must be aware that excessive fat removal alone will often lead to visible skin excess that may only be correctable by surgical excision at a second stage.

There are many areas of the thighs that can be troublesome to patients but most often it is the appearance of the thighs from the front. The appearance of the thighs from behind and rejuvenation in this area only is less frequently requested although for some the appearance of the thighs all the way around the body is of concern. The most frequently requested rejuvenation procedures on the thighs are for excess skin and/or fat in the inner and/or outer thighs.

It is important for patients to discuss the various options and pros and cons of thigh lifting, liposuction, buttock lifting and total body lifting when considering surgery for thigh rejuvenation. Each of the techniques has pros and cons and help to address different areas.

Traditionally the terminology of thigh lifting has been applied to an inner thigh lift where the scars are placed in the groin crease and/or a vertical line along the inside of the leg. The extent and the position of the scar need to address the skin excess present and the needs of the patient.

If the patient has good quality skin a thigh lift using a groin incision may be sufficient in combination with liposuction to give a pleasing result. If excessive skin is present a vertical scar may be a better option. The vertical scar can be limited or extended depending on what one is trying to achieve. It is not recommended that the scar go past the knee.

Thigh lifting can also be performed from under the buttock crease or the thighs can be lifted by incisions above the buttocks. In certain circumstances a total body lift is a good option in addressing the upper thighs. In a total body lift the scars are placed all the way around the body. Where there is excessive skin excess in the upper thighs in combination with excess tissue all the way around the body a total body lift remains a good option. Often scars in the buttock crease can be become troublesome and the pros and cons of thigh lifting via this method should be discussed with the patient.

With modern surgical techniques recovery following thigh lifting is relatively short. It is uncommon to require drains and although it is recommended that thigh lifting be performed using general anaesthetic, patients are able to mobilise as soon as they have recovered from the anaesthetic.

Thigh rejuvenation may involve many different options and a consultation regarding all these different options will help you make a decision as to what the best option is for you.

 

Download Article

 

Revisionary breast augmentation is an increasingly specialised field of breast surgery.With all breast reconstruction one must consider the patients wishes for improvement in terms of size, shape and symmetry. Both clinician and patient need to establish what can be achieved and whether all expectations can be met. The timing of revisionary breast augmentation must take into account the type of implants, the age of the implants, the associated changes of the implant, the capsule and the differences and changes of the breast.

Many patients will have experienced mild changes and often reassurance is all some patients require. For some patients changes to the implants may require a more immediate treatment. The majority of patients will have seen a gradual change in the aesthetics of their breast over a period of years and the timing of surgery can be based on the pros and cons of what can be achieved. Assessment of the implant for leak or rupture is imperative and may alter the timing of future surgery. It is uncommon for these complications to occur and occasionally if doubt remains and there is no immediate decision to perform surgery a diagnostic scan is warranted. It is rare for patients to have associated lymphadenopathy but again if present the pros and cons of managing this surgically need to be discussed. Often implants will develop creases or ripples and these need to be separated from the more troublesome changes mentioned above. The quality of the capsule needs to be assessed to determine whether the capsule should be removed in its entirity (en bloc resection – total capsulectomy), whether part of the capsule needs to be removed (partial capsulectomy) or whether the capsule needs to be released (capsulotomy). Capsules develop in all patients and are a protective barrier.

Over time however they can have a detrimental effect on the breast implant and can result in pain and visible changes. The visible changes are related to the squeezing of the implants in a confined space. This can compress the implants and make them feel hard and alter the position on the chest wall. Implants can move upwards creating an upper fullness or double bubble effect, downwards (bottoming out), outwards or inwards.

During surgery it may be necessary to place the implants in a different pocket ie where patients have implants above the muscle a new pocket can be made under the muscle.

Often with time the breast tissue will drop and one must determine whether a lift or mastopexy should be performed at the same time as implant replacement or whether it is advisable to perform the augmentation first and then a mastopexy at a second stage if needed. The need for mastopexy is dependent on both the quality of the skin and the breast tissue with particular importance taken to assess the height of the nipple areola complex on the breast and the breast’s position on the chest wall. Depending on the quality of the implant, the capsule, the skin and breast tissue one must consider the pros and cons of separating the removal of implant / surgery on the capsule with a second definitive operation. It is often possible to remove / replace implants at the same stage and mastopexy can often be performed at the same time. The pros and cons of each of these options needs to be addressed by a plastic surgeon with experience in revisionary breast augmentation. Patients often do not appreciate the complexity of the decision making process and what is involved in revisionary surgery. All patients should have the details of their previous implants available. From this information one can determine the width of the current pocket and adjust implant size and shape to improve any deformity that has occurred. There are pros and cons of using different implants, sizes and shapes in breast augment revisionary surgery and patients must be informed of the pros and cons of these and be part of the decision making process.

Download Article

The diagnosis of breast cancer can be devastating and decisions regarding reconstruction are often seen as a secondary consideration when dealing with so many other painful issues. However, women often feel that breast reconstruction is essential to recovering their self-confidence once the ordeal is over, and for those women there are different options available. Patients may undergo autologous reconstruction at the same time as the initial mastectomy or may choose to wait until after mastectomy and subsequent oncological treatments such as chemotherapy and radiotherapy. A careful discussion with the surgeon is imperative to guide the patient in the decision making process. This often requires multiple consultations with both the doctor and the specialist reconstructive nurse within a multidisciplinary oncological team. Breast reconstruction can be provided by either autologous or non-autologous tissue, or a combination of both techniques. Non-autologous methods of reconstruction include the use of tissue expanders and implants. Autologous reconstruction uses one’s own tissue. The advantages of this are that the tissue ages naturally and the reconstruction changes minimally with time.

Initially, an autologous reconstruction may be more time consuming in terms of surgery and recovery, however the benefits often outweigh the risks. It is important that the surgeon discusses the pros and cons of each form of reconstruction with each patient individually to determine suitability. For autologous breast reconstruction the gold standard technique is the deep inferior epigastric perforator flap (DIEP), which is a modification of the transverse rectus abdominis muscle flap (TRAM). With newer techniques to protect the muscle and its function (DIEP), tissue from the abdomen can be used to reshape the breast with minimal side effects to the abdomen. The tissue that would normally be excised during a cosmetic tummy tuck is dissected carefully with its blood supply (the diep inferior epigastric artery) to avoid damage to the tummy muscles creating a flap of tissue. Blood vessels in the chest or the armpit are also dissected free and the artery and veins of the veins in the chest and the veins in the tummy tissue are sutured together using fine suture material under a microscope. The tummy is closed in the same way as a tummy tuck or abdominoplasty and the new tummy tissue is reshaped onto the chest wall to create a new breast. The most important aspects of breast reconstruction include size, shape and symmetry. The initial operation provides the basis with which the surgeon can mould the final result. Often a second operation is required in order to achieve these goals. In order to achieve these goals.

With increasing refinements such as lipo modelling – combining liposuction (removal of fat) and autologous fat transfer (injection of fat) – the new breast can be remodelled to give an even more natural result. This can be combined with a nipple reconstruction to give a result that is similar in size, shape and symmetry The advent of microsurgery in the field of plastic, aesthetic and cosmetic practice has made the provision of this form of autologous reconstruction more widely available. Although it is not suitable for everyone and can never replace the original breast tissue, those that choose this form of surgery benefit from longer lasting breast aesthetics and abdominal contour. As with all aesthetic surgery, autologous breast reconstruction is not without its inherent risks and these need to be discussed with surgeons experienced in this highly specialised form of breast reconstruction.

 

Download Article