Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_591_Библиотеки_им_академика_М_И_Перельмана
.pdf
21 Importance of Evaluation of the Breasts by Photos and Photometry Related…
https://t.me/medicina_free
347
Photographic Equipment
The ideal photographic machine should allow the use of JPEG (Joint Photograc
Experts Group)+RAW image les. A blue background provides the best contrast.
The mammary groove as a whole and its central point are not visible in the photo
on the left. In the central photo, visualization of the nal mammary groove in its
most lateral portion is impaired, for patients with hypomastia. The photo on the
right does not allow accurate denition of the lateral end of the mammary groove,
for breasts showing extension of this point.
Discussion
All factors described above provide linear image capturing and consequently regular evaluation and recording of the necessary measures (Quieregatto etal. 2020a, b,
2014a, b).
As described for breasts, detailing is essential for each body segment so that patterns can be established to obtain regularity in photography (Quieregatto et al.
2020a, b).
The frontal plane was chosen since it allows evaluation of the largest number of
patients. For cases of severe ptosis, in which the caudal position of the breast surpasses the navel, those framing limits should be extended.
Visualization of the mammary fold in frontal position and its lateral points is not
possible for a certain number of patients; thus, they were not included in this study
(Quieregatto etal. 2020a, b).
JPEG and RAW image les can be simultaneously captured with a semiprofessional machine (Quieregatto etal. 2018a, b). Lens of 18×55mm provided
appropriate framing. A low-denition photographic machine may cause distortion
of measures for scientic documentation (Quieregatto etal. 2014a, b).
The established focal distance was 2.5 meters between the lens and the patient,
which resulted in more linear and parallel image with slight distortion.
To analyze these images, Adobe Photoshop CS8® is most recommended since it
was the only software capable of analyzing images that were simultaneously
obtained as JPEG and RAW les (Quieregatto etal. 2020a, b, 2018a, b).
It must be highlighted that the breast is subject to the interference of bone structures of the thorax; thus, evaluation based on photographs involves a specic
moment. Changes in respiration and position of the arms and the spine affect the
measures. These criteria must be considered especially when the photos under analysis were captured at different moments, e.g., evaluation of pre- and postoperative
periods.
348
https://t.me/medicina_free
P. R. Q. do Espirito Santo et al.
Conclusion
Photographs cannot be obtained indiscriminately. Standardization is required for an
objective evaluation with parameters that t both research purposes and daily
practice.
Studies of other body segments must be conducted with the aim of developing
photography patterns to be adopted by a larger number of surgeons either in their
daily practice or in clinical research.
References
Hochman B, Nahas FX, Ferreira LM (2005) Photograph aplicada na pesquisa clínico-cirúrgica.
Acta Cir Bras [serial online] 20(Suppl 2):19–25
Jakowenko J (2009) Clinical photography. J Telemed Telecare 15(1):7–22
Nechala P, Mahoney J, Farkas L (1999) Digital two-dimensional photogrammetry: a comparison
of the three techniques of obtaining digital photographs. Plast Reconstr Surg 103(7):1819–25
Quieregatto PR, Sabino Neto M, Furtado F etal (2020a) JPEG and raw image les compared to
direct measurement of the breast region. Acta Cir Bras 35(10): e202001008
Quieregatto PR, Machado AL, Ferrara S etal (2020b) Medidas da região mamária: antropometria
direta ou indireta? Rev Bras Cir Plast 35(3):261–8
Quieregatto PR, Hochman B, Furtado F etal (2014a) Image analysis software versus direct anthro-
pometry for breast measurements. Acta Cir Bras 29(10):688–95
Quieregatto PR, Hochman B, Ferrara SF etal (2014b) Anthropometry of the breast region: how to
measure? Aesthetic Plast Surg 38(2):344–349
Quieregatto PR, Hochman B, Furtado F etal (2015) Photographs for anthropometric measure-
ments of the breast region. Are there limitations? Acta Cir Bras 30(7):509–16
Quieregatto PR, Sabino Neto M, Furtado F etal (2018a) Conhecendo os tipos de arquivo de foto-
graa JPEG e RAW utilizados em pesquisa. Rev Bras Cir Plast 33(1):99–105
Quieregatto PR, Sabino Neto M, Furtado F et al (2018b) Medição das mamas com o Adobe
Photoshop®. Rev Bras Cir Plast 33(1):106–13
Sacchini V, Luini A, Tana S et al (1991) Quantitative and qualitative cosmetic evaluation after
conservative treatment for breast cancer. Eur J Cancer 27(11):1395–400
Chapter 22
https://t.me/medicina_free
Breast Anomalies: Diagnosis
andTreatment
RicardoCavalcantiRibeiro, CarlosJoséRamírezHanke,
andLuisFernandezde Córdova
Abstract Congenital and acquired breast asymmetries represent an enormous
challenge during their treatment approach by the plastic surgeon, especially in pediatric patients. Another difculty lies in the categorization of these deformities,
which tends to be confusing. For this reason, a classication was extracted from the
craniofacial literature and applied to pediatric breast anomalies. This classication
system includes three categories, hyperplasias, deformities, and hypoplasias, thus
providing a useful tool for decision-making regarding the conduct to be adopted
according to the clinical nding.
In this chapter, we will address the diseases that predominantly generate asymmetries of the mammary gland.
Keywords Poland syndrome · Breast hyperplasia · Asymmetries · Hypoplasia ·
Athelia · Polythelia
R. C. Ribeiro (*) · L. F. de Córdova
Plastic and Reconstructive Surgery, Federal University of the State of Rio de Janeiro,
Rio de Janeiro, Brazil
Plastic and Reconstructive Surgery, Carlos Chagas Institute, Rio de Janeiro, Brazil
Division of Plastic and Reconstructive Surgery, Casa de Portugal Rio de Janeiro,
Rio de Janeiro, Brazil
Division of Plastic and Reconstructive Surgery, Global Plastic Surgery, Mexico City, Mexico
e-mail: rribeiro@centroin.net.br
C. J. R. Hanke
Plastic and Reconstructive Surgery, Nürnberg, Germany
e-mail: info@nuernbergerklinik.de
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_22
349© The Author(s), under exclusive license to Springer Nature
350
https://t.me/medicina_free
R. C. Ribeiro et al.
According to the American Society for Aesthetic Plastic Surgery (ASAPS) (2011),
individuals under 18 years old represent 2% of the aesthetic procedures in the
United States. Although this percentage has remained constant over 10years, there
has been an increase in the total number of cosmetic procedures, due to greater
demand each year. During 1996, 14,000 procedures/year were performed, increasing 14 times to 203,000/year by 2009.
Approximately 33,600 (26%) of the 125,400 cosmetic procedures in minors in
2010 were surgical, being breast augmentation (12%) and breast reduction (12%).
With an increasing demand of patients under the age of 18, there is a need to
understand the specic aspects involved in the treatment of this age group.
Understanding body image in adolescent patients is essential because puberty is
a period when the appearance of the body undergoes major changes that reect on
the adolescent and increase interest in the opinions of his peers.
Body image was rst described by (Schilder 1934; Zuckerman and Abraham
2008), who theorized that a person’s condence is formed from a combination of
general life satisfaction, body image, and self-esteem.
Recently, a Dutch study (Simis et al. 2000, 2001, 2002) sought to understand if
the changes in attitudes exceeded the natural increase in the importance of body
image in adolescent patients with cosmetic procedures when compared to patients
without cosmetic procedures in the same age group. The study concluded that adolescents undergoing cosmetic procedures generated an improvement in body satisfaction and relief from physical, social, and psychological concerns related to
appearance.
In general, adolescent candidates for cosmetic surgery were less condent in
physical appearance and sex appeal than their age-matched controls, but were no
different in overall self-condence or mental health standards. More recent studies,
also from the Netherlands, report that adolescent patients have a realistic view of
their body, with parents and surgeons serving as control groups. It is worth mentioning that parents and adolescents had an equivalent assessment of psychological and
social biases related to appearance.
From the surgeons’ point of view, patients accepted for cosmetic surgery saw
realistic aws in themselves that correlated with their primary reason for seeking
surgery. A study from the same group showed that patients accepted for cosmetic
surgery were equally satised with their overall appearance compared to controls,
but were more dissatised with a specic body part.
22 Breast Anomalies: Diagnosis andTreatment
https://t.me/medicina_free
351
Hyperplastic Breast Abnormalities
Hyperplastic breast anomalies are characterized by excessive breast tissue and can
be either symmetrical or asymmetrical.
Juvenile Breast Hypertrophy
Juvenile breast hypertrophy or hyperplasia (Fig.22.1) is a rare condition of unknown
etiology. Endocrinological studies are normal, and the patient shown exhibits normal body growth with the exception of breast tissue. The main goal of surgery is
volume reduction with breast size symmetrization and repositioning of the nippleareola complex (NAC) in the anatomically correct position (Simis et al. 2001;
Malata et al. 1994; Schmidt 1998; Gilmore et al. 1996; Grossl 2000; Simmons et al.
2000; Sugai et al. 2002).
Fig. 22.1 Juvenile breast
hypertrophy
352
https://t.me/medicina_free
R. C. Ribeiro et al.
Virginal Breast Hypertrophy
Prepubertal hypertrophy (which is usually bilateral) and virginal hypertrophy
(which develops after menarche and which can be either unilateral or bilateral)
(Fig.22.2) are also treated with breast reduction techniques. Classication of asymmetry in hyperplasia includes unilateral hyperplasia, bilateral symmetrical hyperplasia, and a combination of hypertrophy and hypoplasia. Treatment involves a
combination of reduction techniques (our preference is the inferior pedicle technique), which may require differential amounts of breast tissue resection to achieve
symmetry. Surgery should be delayed until the end of puberty, when breast growth
is complete; otherwise, revision surgery may be necessary due to continued
breast growth.
Fig. 22.2 Virginal
hypertrophy
22 Breast Anomalies: Diagnosis andTreatment
https://t.me/medicina_free
353
Polythelia
Polythelia, the presence of supernumerary nipples or nipple-areola complexes, is
the most common anomaly of the pediatric breast and can occur in both genders.
The condition usually occurs sporadically, but can be familial, and has been reported
to have an incidence as high as 5.6%. Sporadic polythelia may be associated with
kidney problems.
Polythelia can occur at any point along the embryonic milk line, from the axilla
to the groin (Fig.22.3). They are pigmented lesions within these embryonic lines
that must be excised before puberty; after the onset of puberty in girls, resection
may require a wider tissue excision because of the growth of glandular tissue.
Cancerous degeneration of the accessory complex has been reported and provides
additional justication for excision of these lesions. Elliptical excision of the nippleareola complex is usually sufcient for removal (Sugai et al. 2002; Hsieh et al.
2001; Selamzde et al. 1999; Murphy et al. 2000; Lin et al. 2000; Smith et al. 1986;
Rees and Aston 1976; Meara et al. 2000).
A particularly challenging problem can arise if multiple nipple-areola complexes
occur in the breast. Magnetic resonance imaging may be needed to determine which
nipple-areola complex is associated with glandular/ductal tissue.
Fig. 22.3 Polythelia
354
https://t.me/medicina_free
R. C. Ribeiro et al.
Polymastia
Polymastia is another anomaly that can occur anywhere along the embryonic milk
line. The condition usually occurs sporadically, but familial cases have been
reported; latent cases may become visible during puberty, pregnancy, or lactation.
Polymastia can occur as an isolated nding or with a congenital renal syndrome.
Treatment requires removal of the anomalous accessory gland, with primary closure. Long-term follow-up should be indicated to the patient because of the possibility of developing cancer in any retained breast tissue.
Giant Fibroadenoma
Giant broadenomas are benign, discrete breast lesions that appear unilaterally during puberty and present rapid growth. The lesion is the result of the hypersensitivity
of the breast tissue’s reaction to normal sex hormone levels. The diagnosis is made
by biopsy. Treatment involves breast reduction with conservative techniques.
Intuitively, it may seem that a skin excision proportional to the excised tissue should
be performed; however, that approach is too aggressive. Timing for surgery is dictated by the onset of broadenoma growth.
Iatrogenic Breast Abnormalities
One of the most common lesions of the pediatric breast is secondary to pleural
drainage. The thoracotomy site develops a scar and a brous tract that ties the breast
tissue to the costal wall, leading to a localized contour deformity. These patients
require release of the brous tract to accommodate normal breast growth during
puberty. No other intervention is usually necessary.
Girls who have undergone previous thoracotomy. In addition, they may have
breast tissue adhered to the anterior chest wall because of the violation of the breast
bud by the initial thoracotomy incision. It further results in breast hypoplasia. Scar
tissue must be excised to free the breast.
Breast hypoplasia, which can be either segmental or total, requires breast reconstruction with implant placement. Pediatric breast tumors are usually benign and
may rarely become malignant.
22 Breast Anomalies: Diagnosis andTreatment
https://t.me/medicina_free
355
Breast Injury
The burned chest is a particularly difcult challenge for the plastic surgeon who
treats pediatric patients. During puberty, breast growth may be compromised by a
burn injury, if the development of the burned breast is inhibited by a constricting
scar, acute tissue excision is recommended, and grafting should be done conservatively keeping in mind that the breast bud must be protected.
If the gland was not injured during the initial burn, breast growth will occur but
may be hindered by scar contractures. Z-plasties and scar release from contractures
and additionally skin grafts may be required to accommodate breast growth. Breast
hypoplasia will result if the breast bud is injured during the initial burn. These
patients will require breast reconstruction with tissue expanders, followed by placement of a submuscular implant.
If the contralateral breast has not been injured, it can be used as a source of
reconstruction. NAC’s reconstruction should be performed with skin graft ap techniques or with micropigmentation. It should be performed after complete breast
reconstruction. Long-term follow-up of the patient is always necessary and aims to
detect any subsequent changes.
Penetrating trauma to the breast presents a similar problem to those caused by
thoracotomy. Correction requires release of the brous bonds between the gland
wall followed by breast reconstruction using implants. Intervention during puberty
is recommended when breast asymmetry increases with normal breast growth.
Secondary surgeries are often necessary because the breast at the time of the initial
operation has not reached its full growth.
Hypoplastic Breast
Athelia (absence of nipple), amastia (total absence of breasts and nipple), and amazia (absence of the mammary gland) are rare hypoplastic congenital anomalies of
the breast.
According to Lin and colleagues, there are three groups of patients with amastia:
those with bilateral absence of the breast secondary to congenital ectodermal
defects, unilateral absence of the breast (a variant of Poland syndrome), and bilateral absence of the breast.
Amastia is associated with ectodermal birth defects, which affects both males
and females; it is associated with changes in the skin and its appendages, teeth,
and nails.
Bilateral absence of the breast may occur as an isolated abnormality or may be
associated with other congenital anomalies of the palate and upper extremity. The
defect can be sporadic or familial.
356
https://t.me/medicina_free
R. C. Ribeiro et al.
Breast volume reconstruction in patients with amastia can be performed with
autologous tissues, including the transverse, the latissimus dorsi, and/or the rectus
abdominis ap. The creation of the inframammary fold can be particularly difcult
in these patients because of a lack of parameters. The breast can be created through
tissue expansion and subsequent implant placement. Expansion should be done
with caution due to possible damage to skin vascularization.
Breast hypoplasia (with intact NAC) can be unilateral or bilateral and requires
reconstruction with implants in an attempt to improve breast symmetry. Treatment
requires augmentation of a single breast in unilateral hypoplasia. In bilateral asymmetric hypoplasia, it may require a differential augmentation of the two breasts.
Tuberous breast (Fig.22.4), a term rst coined by Rees and Ashton, describes a
hypoplastic deformity of the breast with reduced diameter, herniation of breast tissue through the areola, decient skin envelope, and elevated inframammary crease.
Various classication systems have been developed to describe the tuberous
breast. The three-layer system proposed by Meara etal. is the most used.
Worsening type I, II, and III deciencies include progressive elevation of the
inframammary fold, increasing skin scarcity, decreasing breast volume, and increasing ptosis. Unfavorable features for reconstruction with an implant include a short
distance from the areola to the crease and a constriction of the base of the breast,
making it difcult to accommodate implants. Division of breast tissue is often
necessary to increase the base of the breast; however, an attractive result is difcult
to obtain. More favorable features in a tuberous breast include a wider base, which
adequately encompasses an implant, and compliance with the inframammary- nipple
crease distance, allowing for simple release of the herniated breast tissue into the
nipple-areola complex. The results in these cases are more favorable.
Fig. 22.4 Tuberous breast
Соседние файлы в папке Библиотека им академика М.И. Перельмана