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_654_Библиотеки_им_академика_М_И_Перельмана
.pdf
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
https://t.me/medicina_free
15.9 De-epithelialization
Inferior dermal pedicle measuring 8cm in diameter is then
marked (Fig.15.33). Prior to de-epithelialization, an incision
is made around the nipple areolar complex down to the dermis, measuring 4cm in diameter. A cookie cutter can also be
used to make this incision around the nipple areolar complex
prior to commencing the de-epithelialization.
The bipedicle inferior dermal pedicle is then deepithelialized. This is done by dividing the pedicle into two
halves. It is easier to de-epithelialize each half rather than
de-epithelialize the whole pedicle (Fig. 15.34). Hemostats
are placed on the epidermis on either side. An assistant will
make the breast taut by retracting it above and below. Using
sharp dissection, the area is de-epithelialized.
De-epithelialization is facilitated by dening the plane
between the epidermis and the deep dermis. This plane of the
reticular dermis facilitates rapid de-epithelialization while
preserving the subdermal vascular plexus. It is important not
to leave any epidermal islands behind as these will result in
implantation cysts.
227
Fig. 15.33 Marking of the pedicle
Fig. 15.34 De-epithelialization of the verticle pedicle
15.10 Development ofDermal Glandular
Pedicle
Using electrocautery, an incision is made through the dermis
on either side of the pedicle (Fig.15.35). It is then extended
down with electrocautery to the depths of the breast tissue
short of the pectoralis fascia. This dissection is performed on
both sides. In doing so, it is important to maintain the width
of the pedicle by keeping it in its anatomic position while
228
https://t.me/medicina_free
K. S. Bhangoo
making the incisions through the breast tissue. Care should
be taken to keep the dissection perpendicular and avoid tangential dissection which can result in making the pedicle
base narrow. Bleeding is controlled by electrodesiccation.
Larger vessels can be suture ligated.
Fig. 15.35 De-epithelialized verticle pedicle
15.11 Glandular Resection
This technique is different from the McKissock technique in
which glandular tissue is resected from under the verticle
dermal pedicle (McKissock 1972). In this technique, no
glandular tissue is resected from under the dermal pedicle
(Fig.15.36a, b). This avoids sacrice of deep perpendicular
pectoral perforators into the central breast mound.
Resection of the glandular tissue is performed by excising
the redundant skin and the underlying breast tissue from
medial and lateral aspects. This is facilitated by placing a
skin hook at the apex of the inverted T incision and at the
point C for the medial resection. An incision is then made
with electrocautery through the breast tissue down to just
above the pectoral fascia. The volume of tissue resected from
the medial segment is then recorded by weighing it on a
scale. Hemostasis is established.
Lateral resection is then performed by placing a single
hook at point A and point B and elevating this vertically
(Fig. 15.37). Using electrocautery, redundant skin and the
redundant underlying breast tissue are then resected down to
an area above the pectoral fascia. A thickness of at least 1cm
is maintained in the lateral and medial skin aps in order to
maintain its circulation and sensation. The volume of tissue
resected from the lateral side is then recorded. This is done to
ensure symmetry when resecting the contralateral side.
Figures 15.38 and 15.39 show the dermoglandular pedicle
after medial and lateral glandular resection.
Fig. 15.36 Dermoglandular verticle pedicle and medial glandular resection
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
https://t.me/medicina_free
Fig. 15.37 Lateral glandular resection
229
Fig. 15.39 Dermoglandular vertical pedicle after glandular resection
15.12 Approximation ofSkin Flaps
Fig. 15.38 Dermoglandular vertical pedicle after glandular resection
Following resection of the breast tissue as described above,
the nipple areolar complex is approximated to the apex of the
inverted T using a towel clip (Fig.15.40a, b). The skin aps
are then approximated by approximating points B and C to
F.A towel clip is also inserted in the middle of the vertical
incision. This will give an idea of the extent of resection and
volumetric and congurational outcome. The towel clips are
left in place. The procedure is then performed on the contralateral side in a similar manner.
If both breasts are noted to be both congurationally and
volumetrically similar, then denitive closure is
commenced.
230
ab
https://t.me/medicina_free
Fig. 15.40 (a, b) Flaps approximated with towel clips
15.13 Closure
K. S. Bhangoo
The wound is irrigated with an antibiotic solution. The author
uses a mixture of Gentamicin and Cephalosporin. Exacting
hemostasis is established. A 10mm Jackson-Pratt drain is
then inserted across the dermal glandular pedicle from the
medial to the lateral side and then brought out through the
lateral extremity of the inframammary incision. It is sutured
in place with a 3–0 silk suture to prevent its displacement.
A 2–0 vicryl suture is then placed at the nipple areolar
complex at 12 o’clock position at the apex of the inverted T
incision, this being point A.Again using a key 2–0 vicryl
suture, points B and C are approximated to point F.The incisions are then closed in layers using 2–0 vicryl for the deeper
layer and another layer of 3–0 vicryl for the subcuticular
sutures are inserted, and surface closure is carried out using
Fig. 15.41 Marking for nipple transposition
skin staples.
a circular incision is marked at the apex of the vertical incision measuring 4cm in diameter. Incision is then made and
15.14 Nipple Areolar Complex Transposition
extended down into the dermis. This area is then deepithelialized. A cruciate incision is made through the der-
The nipple areolar complex is then transposed (Fig.15.41).
The position of the nipple areolar complex on both breasts is
checked by measuring it from the suprasternal notch using a
3–0 silk suture on a hemostat. The advantage of using the
inverted T incision as opposed to the Wise pattern is that, at
this point, the position of the nipple areolar complex can be
adjusted if need be. A circular incision is marked at the upper
extremity of the inverted T incision.
mis. The nipple areolar complex is then delivered into this
circular defect by applying traction on the pedicle. The nipple areolar complex is then transposed in layers using 4–0
vicryl for the subcuticular layer and 5–0 nylon for surface
closure (Fig. 15.42). On completion, the circulation of the
nipple areolar complex is checked and noted to be satisfactory as evidenced by its pink color, blanching on digital pressure and rapid capillary rell.
After it is established that the nipple areolar complex is
equidistant from the suprasternal notch and the midline, then
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
https://t.me/medicina_free
231
Fig. 15.42 Nipple transposed
15.15 Liposuction
This technique will frequently result in a square and boxy
appearance of the lateral breast (Fig.15.43). This can be corrected by doing liposuction. A solution of one half percent
xylocaine in 1:200.000 epinephrine is then ltrated into the
areas to be liposuctioned as shown in the diagram (Figs.15.44
and 15.45). If the patient has accessory axillary breasts, these
can also be inltrated.
Using a 4mm cannula and using micro airpower assisted
liposuction instrumentation, suction assisted lipectomy is
performed to contour the lateral aspect of the breast and to
correct accessory axillary breasts if need be (Fig.15.46).
Liposuction can also be used to correct any asymmetries
if present.
Fig. 15.43 Square lateral look prior to liposuction
232
https://t.me/medicina_free
Fig. 15.44 Liposuction to improve the lateral contour
K. S. Bhangoo
Fig. 15.45 Improved lateral appearance
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
https://t.me/medicina_free
233
Fig. 15.46 Pre and post 350g resected
15.16 Dressings
The wounds are covered with xeroform petrolatum gauze,
and steri-strips are applied. The purpose of steri-strips is to
minimize see-sawing on the wound edges post-operatively
which decreases edema at the incision site and also minimizes pain. Padding is then placed over the breasts and an
elastic garment is applied.
15.17 Post-operative Care
The drains are usually removed in 48h. The skin staples are
removed on the eighth day. The stitches from the nipple areolar complex are usually left in longer and removed after
2weeks, as it takes longer for these incisions to heal because
of two different types of skin.
15.18 Complications
1. Inadequate reduction: The most common complication
of breast reduction is under correction. It is, therefore,
important to ensure that enough tissue is removed.
2. Hematoma: Hematomas are rare in spite of the large raw
surface. To ensure prevention of hematoma, the patient
should be advised not to take any blood thinners and
avoid the use of aspirin and some of the diet supplements which can cause bleeding. If a patient is hypertensive, their blood pressure should be controlled. If a
hematoma is detected, it is important to evacuate it
immediately. Undetected or untreated hematomas can
cause compression on the pedicle and result in necrosis
of the nipple areolar complex.
3. Infection: Infection is rare. Intra-operative antibiotics
and 5 days of post-operative antibiotics are administered, usually a cephalosporin.
234
https://t.me/medicina_free
K. S. Bhangoo
4. Seromas: Seromas are very rare following breast reduction but can occur. If one is suspected, a sonogram can
be ordered and it can be aspirated under ultrasound
guidance.
5. Fat necrosis: Fat necrosis is a late complication and is
evidenced as rm nodules in the breast. These can be
painful; if so, after a few months they can be resected.
Fat necrosis usually occurs as a result of impaired
vascularity.
6. Nipple areolar necrosis: Nipple areolar necrosis can
result due to vascular compromise. It is important to
ensure that the patients do not smoke. Smoking is a portent cause of nipple areolar vascular impairment. If it
occurs and if it is due to venous congestion, medicinal
leaches can be utilized to enhance venous drainage. In
cases of small marginal necrosis, these areas should be
allowed to demarcate and then debrided. Usually these
will heal spontaneously with minimal scarring.
7. Flap necrosis: Flap necrosis can occur due to vascular
compromise and usually occurs at the conuence of
aps. It is also more frequent in smokers. If it occurs, it
should be allowed to demarcate, and many times these
will heal spontaneously.
8. Loss of nipple sensation: Impairment of nipple sensation
can occur. Many times this will recover with time.
Inversion of nipple can also occur, particularly with the
classical inferior pedicle technique. Some patients have
inverted nipples to start with.
9. Breast asymmetry: It is extremely important to ensure
that both breasts are symmetric in volume and conguration at the end of the operative procedure. If there is
any disparity, it should be corrected either by doing further resection or by utilizing liposuction. Many breasts
are asymmetric to start with, and this should be noted
and taken into consideration during the resection.
10. Scars: Hypertrophic scars and keloids can occur. These
usually happen in dark skinned individuals. It is
extremely important in such individuals to avoid excessive tension on the skin. Less skin resection should be
performed in dark skinned individuals to avoid skin ten-
sion. Also, during closure, the bites should be taken at
least half a centimeter away from the skin edges through
the dermis on either side of the wound to avoid tension
on the one margin. Post-operatively, if there is any indication of impending hypertrophic scarring or keloid formation, Kenalog injection should be administered.
11. Dog ears: Sometimes dog ears can result along the
medial and lateral extremity of the inframammary incision. This can be avoided by accurate pre-operative
markings as described above. If noted at the end of the
procedure, the problem should be addressed at the time
or else it can ruin an otherwise good overall esthetic
result.
12. Too highly placed nipple areola complex: It is very
important not to place the nipple areola complex too
high, as it will show in a low neckline. It is difcult to
correct a highly placed nipple areola complex as opposed
to one which is too low.
Pitfalls
1. Lack of accurate markings can result in difculties
intra-operatively.
2. Changing the plan intra-operatively can result in
asymmetry.
3. The pedicle will be thinned if the dissection is performed
tangentially. It is important to maintain the wider base of
the pedicle. Adequate thickness of the aps should be
maintained. The thickness of the aps should be symmetric on both aps.
4. Dissection, if performed down to the muscle, can result in
impairment of sensation and also circulation to the aps.
5. Asymmetric resection will result in asymmetry of the
conguration of the breasts. It is extremely important not
to place the nipple areolar complex too high. If the nipple
areolar complex is placed too high, it is extremely difcult to correct. If there is any doubt, the nipple areolar
complex should be placed lower rather than higher. The
inverted T markings will allow for adjustment of the nipple areolar complex which cannot be done with the Wise
pattern.
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
https://t.me/medicina_free
15.19 Results: (Figs.15.47, 15.48, 15.49,
15.50, 15.51, 15.52, 15.53, and15.54)
235
Fig. 15.47 500g resected
236
https://t.me/medicina_free
K. S. Bhangoo
Fig. 15.48 Pre and post 600g resected
Соседние файлы в папке Библиотека им академика М.И. Перельмана