Practical Plastic Surgery

Rupture or Deflation

Implants begin to lose their integrity approximately 10 years after insertion. Magnetic resonance imaging is the most sensitive method for visualizing breast implants and determining their integrity. When saline implants rupture there is usually a noticeable change in size, shape, feel and appearance of the breast. Saline is absorbed, and the implant should be replaced to avoid the possibility of capsular contracture. Silicone implants may leak or rupture, and usually the gel remains within the breast capsule. Many are silent ruptures discovered at the time of routine mammograms or during implant replacement. If a significant portion of the gel moves outside of the implant capsule, it can then migrate into the breast or surrounding tissue. The body reacts by depositing collagen around the silicone, leaving a firm mass. Ruptured silicone implants need to be removed along with the extruded gel, which may involve simple implant replacement, or in the case of severe leaks, subcutaneous mastectomy with reconstruction.

Pearls and Pitfalls

Upward displacement of the implant can be caused by incomplete release of the pectoralis muscle. If the proper position of the implant is not judged correctly, upward 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 of the breast tissue around the nipple-areolar complex. Advocates of the biplanar approach (in which dissection and release occurs in both a subglandular and submuscular plane) believe that a more natural curve displacement is possible with their approach.

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

In particularly thin patients, a pneumothorax may result from overly aggressive dissection through the intercostals (small leaks can be corrected with temporary placement of a small suction catheter).

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

While the subglandular approach will allow a modest lift of the nipple areolar complex, concomitant mastopexy may be necessary; however, if the skin integrity is weak it may be prudent to stage the procedures to avoid lowering of the nipple-areolar complex.

Consistent postsurgical massage is believed to ameliorate the onset of capsular contracture 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.

Suggested Reading

661. Bostwick IIIrd J. Augmentation mammaplasty. Plastic and Reconstructive Breast Surgery. Vol. 1. 2nd ed. St. Louis: Quality medical publishing Inc., 2000:239-369.

2.Salomon JA, Barton JR FE. Augmentation mammaplasty. Selected Readings in Plastic Surgery. 2004; 28(8):1-34.

3.Spear SL, Elmaraghy M, Hess C. Textured-surface saline-filled breast implants for augmentation mammaplasty. Plast Reconstr Surg 2000; 105:1542-1552.

4.Tebbetts JB. A surgical perspective from two decades of breast augmentation. Clin Plast Surg 2001; 28(3):425-434.

Drugs that interfere with estrogen-testosterone balance include: estrogens, estrogen-like compounds (marijuana, heroin), gonadotropins, inhibitors of testosterone (spironolactone, cimetidine and alkylating agents) and several drugs with an unknown 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 and symmetry of the deformity. A thorough assessment of any hepatic, testicular, pulmonary, adrenocortical, or thyroid dysfunction is important in ruling out an endocrine etiology. An abnormal exam should guide the surgeon to order focused tests and consult specialists. Gynecomastia is common in older men. Enlargement of breast 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 on medications, alcohol and drug use is important in revealing any conditions associated with gynecomastia. The most difficult condition to differentiate from gynecomastia is pseudogynecomastia. Patients with this condition are often obese, have bilateral enlargement and do not complain of breast pain or tenderness.

Physical Exam

Patients should be examined in the supine position. The examiner grasps the breast between the thumb and forefinger (pinch test) and gently moves the two digits toward the nipple. If gynecomastia is present, a firm, rubbery, mobile, disk-like mound of tissue arising from beneath the nipple-areolar region will be felt. When pseudogynecomastia 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 lymphatic involvement. Simon et al graded gynecomastia into four groups (Table 67.1).

Young patients with no previous medical history and new onset bilateral gynecomastia should have a testicular exam looking for atrophy, enlargement or abnormal masses. If indicated, an ultrasound of the testicles should be performed. If physical exam demonstrates characteristics of feminization, it is prudent to check the appropriate hormone levels (e.g., estradiol, leutenizing hormone, testosterone and DHEA). A marfanoid body habitus should prompt a karyotype to rule out Klinefelter’s syndrome.

Findings such as axillary lymphadenopathy or a unilateral hard mass fixed to underlying tissues should prompt further evaluation. Skin dimpling, nipple retraction, nipple discharge and axillary lymphadenopathy are all associated with breast carcinoma. 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 or MRI), and a coreneedle biopsy or fine-needle aspiration (FNA) should be performed

67Table 67.1. Grading of gynecomastia

Grade I Small enlargement, no skin excess Grade IIA Moderate enlargement, no skin excess Grade IIB Moderate enlargement with extra skin Grade III Marked enlargement with extra skin

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

Finally, patients with gynecomastia and an otherwise normal history and physical 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 considered since breast tissue may become irreversibly fibrotic as time progresses beyond this stage.

Treatment

Before considering treatment, it is important to keep in mind that gynecomastia may regress spontaneously. Although surgery is indicated as a diagnostic procedure, patients often request surgery as treatment for the physical discomfort or emotional distress that is common in men with this condition. Most patients who visit a plastic surgeon request treatment for psychological reasons.

Discontinuing offending medications or correcting any underlying imbalance between estrogens and androgens should result in spontaneous regression of new-onset gynecomastia. Medical treatment with androgens, anti-estrogens and aromatase inhibitors has been used with minimal efficacy. Surgery remains the accepted standard for management of gynecomastia, especially in patients with long-standing gynecomastia and fibrotic breast tissue. Surgical options can range from simple excision to a more complex, inferior pedicle breast reduction. The two most widely used surgical techniques are the subcutaneous mastectomy and liposuction-assisted mastectomy.

Subcutaneous Mastectomy

Several approaches may be used when performing an open subcutaneous mastectomy. The choice of incision should be guided by the degree of gynecomastia present. Patients with small or moderate gynecomastia may have an intra-areolar incision along the inferior hemisphere of the nipple (Webster incision). This incision can be extended medially or laterally for better exposure. An alternative incision that helps maximize exposure is the triple-V incision. It is made along the superior border, parallel to the nipple. Moderate or massive gynecomastia may require skin resection along with nipple relocation or nipple grafting. The most common incision for moderate gynecomastia is the Letterman incision. This approach allows for the nipple-areola complex to be rotated superiorly and medially after skin resection. With massive gynecomastia, en bloc resection of skin and breast tissue with free nipple grafting can be performed through an elliptical incision. In cases of severe gynecomastia, the dissection may be carried to the level of the pectoralis major fascia and may require the use of postoperative suction drains.

Liposuction-Assisted Mastectomy

Experienced surgeons may perform endoscopic-assisted mastectomy with liposuction through an axillary incision in lieu of open mastectomy. In the past, liposuction-assisted mastectomy was utilized after open excision to assist with breast contouring. In an effort to avoid large visible scars on the chest wall, 67 liposuction-assisted mastectomy (suction lipectomy) is becoming the preferred sur-

gical technique for most cases of gynecomastia. It is the most commonly used technique for correcting pseudogynecomastia. With this technique there is less compromise of the blood supply as well as a decreased risk of nipple distortion. Postoperative complications such as hemorrhage, infection, hematoma, seroma and nipple 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. More recently, ultrasound-assisted liposuction (UAL) has been introduced in conjunction with standard liposuction as a safe and effective method of treatment for gynecomastia, especially in cases where dense fibrous tissue is involved. The ultrasound probe is introduced through an axillary or inframammary incision and advanced through the dense parenchymal tissue. Energy from the ultrasound waves cavitates and emulsifies breast parenchyma that may be removed via suction lipectomy. UAL stimulates the dermis, allowing for postoperative skin retraction to occur. In the future, it may become standard treatment to utilize the UAL technique first, followed by an excisional procedure 6-9 months later (once maximal skin contraction has 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 suction drains postoperatively. Appropriate care must be taken with liposuction to ensure viability of the overlying skin. Skin or nipple/areola necrosis can occur if the vascularity is compromised. Pigment changes in the areola have also been reported, especially in free-nipple grafts. Asymmetry and discontent with scars are frequent patient complaints.

Pearls and Pitfalls

The treatment of gynecomastia is predicated on the exclusion of potentially dangerous (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 as well as the quality of that excess. For instance, an elderly man’s skin will not retract with liposuction as well as a young man’s. Hence, an informed discussion of issues related to skin redundancy is important. In cases in which there is a fair degree of dense, fibrotic tissue, ultrasound-assisted liposuction may be the treatment of choice. For milder forms of gynecomastia, liposuction with mastectomy through a periareolar incision may be helpful. While gynecomastia may regress spontaneously, it is important to note that the longer the gynecomastia is present, the more fibrotic the breast tissue can become. Once fibrosis sets in, surgical removal of the tissue remains the optimal treatment option.

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 Surg 1995; 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 gynecomas-

67tia. Plast Reconstr Surg 1973; 51:48.

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. New York: McGraw-Hill Book Co., 1987.

418 Practical Plastic Surgery

the increased risk of poor scarring, implant-nipple misalignment and implant extrusion. The best scenario occurs when the implant fills out the excess skin envelope while leaving enough excess skin to reshape the breast. Depending on the complexity of the problem and quality of the skin support, it may be better to perform two separate, staged procedures.

Preoperative markings vary with surgical plan and are essential for obtaining optimum results. In most patients the nipple should be at or slightly above the inframammary fold. Once the proper nipple location has been determined, an indelible 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 to choose techniques that minimize the length of incisions and place them in hidden areas. Intraareolar and periareolar incisions are tolerated best because they are less likely to become hypertrophic provided there is no tension on the incision. A median inferior vertical incision is also tolerated well compared to a horizontal inframammary incision. As a rule, incisions should be kept off of the superior hemisphere of the breast because women often wear clothing that exposes this area. There are several techniques available to correct breast ptosis, and no single technique is considered ideal. The degree of ptosis varies from patient to patient and treatment should be individualized. The primary focus is on altering breast volume and contour 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 horizontal inverted T technique or the short horizontal scar technique.

well hidden within the NAC. Patients that require a greater degree of elevation of the NAC should have a different technique performed since the risk of areola deformity is proportional to the amount of skin removed. Skin quality is important to consider 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 raising the NAC and may cause central breast flattening. Patients who have large areola or tubular breasts may benefit from this technique. Two incisions are required: an inner incision around the areola and a second parallel outer incision demarcating the 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 circumference in order to reduce tension on the suture line and limit the risk of scar widening. This procedure is called a “Benelli or “round block” mastopexy. The round block technique allows control of the diameter of the areola and maintains it in a fixed circular scar thus avoiding protrusion. Limiting the size of the outer diameter 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 pexying the 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 distance the nipple needs to be elevated is significant, and there is excess skin requiring excision, then a vertical limb is required. Removing skin in a vertical direction allows the medial and lateral breast skin to be moved toward the center and prevent flattening of the breast apex. The scar is usually minimally visible with time and is located inconspicuously on the lower portion of the breast out of view when low-cut clothing is worn.

The procedure begins by determining the new position of the NAC. With the patient standing or sitting upright, the apex and the width of the new NAC position are marked. An ellipse is drawn starting from the top of the new position of the NAC around the existing NAC and downward to the inframammary crease. Incisions are made along the lines of the ellipse as well as around the NAC, and skin is deepithelialized within the ellipse. If implants are being used, they are placed into a subpectoral pocket. Patients with upper pole flattening may benefit from a lower pole 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 breast parenchyma, a technique called tailor tacking may be employed to help the surgeon predict the final outcome. This technique is useful for determining the position of the NAC. The deepithelialized areas are invaginated and the skin edges approximated with staples. The outer edges are marked, the staples are removed and the excess breast tissue is then excised.

68 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 keyhole incision is made around the NAC with a vertical limb and a horizontal extension resulting in an inverted T type scar after removal of excess tissue. Different

pedicles can be used with this approach depending on surgeon preference (if concomitant implants are to be placed, a superior or medial pedicle may be suitable; if significant lift of the NAC is required, an inferior pedicle may be preferable). Once the skin and pedicles have been incised and dissected, judicious undermining and removal of excess tissue can be performed. The vertical and horizontal limbs are approximated and the NAC is sutured in place with a tension-free subcuticular 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. Lifting objects above the head should be avoided during the immediate postoperative period. Patients should be instructed about potential complications such as numbness and hematoma formation. Breastfeeding should be normal after some types of mastopexy; however other techniques increase risk of loss of lactation. Many of the same complications seen after breast augmentation apply to mastopexy as well. These include hematoma or seroma formation, infection, nipple sensory loss and implant contracture. There are several other complications worth mention. These are necrosis 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 diabetes or collagen vascular disease are at risk for nipple-areolar necrosis. All patients who smoke should quit smoking prior to and after surgery in order to help decrease nipple necrosis. Placing a subglandular implant or a periareolar pursestring suture may also increase the risk of nipple necrosis because the central parenchyma may be damaged 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 skin closure. Subsequently, many women return with lower pole ptosis, termed “bottoming out.” Ptosis may recur when there is asynchrony between breast parenchyma and NAC descent. Correction during a secondary procedure requires removal of the lower pole parenchyma with simultaneous skin revision.

Nipple and Breast Asymmetry

The goal of breast surgery is to obtain perfect symmetry; however, most women have some degree of asymmetry preoperatively. Postoperative asymmetry of the NAC or patient dissatisfaction may be corrected during a follow-up procedure. Discussing this issue prior to surgery may help alleviate anxiety when there is postoperative asymmetry. Periareolar techniques may afford a modest correction of asymmetry; however in cases of significant asymmetry, a complete revision mastopexy may be

necessary.

68

Upper Pole Flattening

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