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USING INFERIOR PEDICLE WISE-PATTERN TECHNIQUE
After almost 15 years in practice, I still consider the inferior pedicle Wise-pattern technique for breast reduction surgery to be the safest, with the most predicable results, as well as allowing the greatest chance in maintaining survivability of the nipple areolar complex. The patient examples show a woman with 40GG breasts, presenting with significant symptomatology of breast hypertrophy and gigantomastia, including neck pain, grooving along the shoulder blades, rashes under the breasts and massive pendulous breasts with inability to wear normal brassieres. The patient’s frontal and oblique views are notable.
The patient was brought to the operating room and after administering general anesthesia via laryngeal mask airway, the chest was prepped with Betadine solution. The de-epithelialization of the base pedicle was maintained with a 10-to 12 cm base along the inframammary fold to the pedicle to maintain vascularity. The next photograph shows the inferior pedicle with excellent blood supply. It’s a bipedicle flap with only a small portion of the superior central wedge removed. Notice the inner and outer breast tissue have been removed and the dissection was carried out just above the level of the fascia of the pectoralis major muscle. The tissue removed is weighed at well over 600 grams per breast to bring her down to a “D” size breast. This is proportional for her size. The blood supply is maintained to the nipple areolar complex through the inferior pedicle, even better if some of the superior pedicle can be maintained, leaving it as a bipedicle flap.
Once again, after 15 years experience in private practice using the inferior pedicle Wise-pattern technique for breast reduction surgery, this is my favorite choice due to safety and predictability.
Sizing of breast implants requires experience and judgment by a Board Certified Plastic Surgeon. Patients present to my office every day for breast enhancement and breast revision surgery. One of the most difficult decisions between the patient and the plastic surgeon is the final size of the implant. Many factors are required to determine this final size. Looking at the patient’s height, weight, measuring the inframammary fold distance, the parasternal distance between the medial inframammary folds, amount of breast tissue, and thickness of the muscle are all important variants. Also, equally important is the patient’s specific desires in terms of final cosmetic appearance as well as feel of the breasts; the first determinate will silicone versus saline implants. Depending upon the patient’s age, they must be 22 or older, to undergo silicone augmentation by FDA standards. Secondly, will be the patient’s desire for the appearance of the breast. The less natural breasts are often saline implants when placed under the muscle versus the smooth silicone which can be softer and more natural in appearance. The next variable will be specific proportionality to a female form. Looking at the height and weight of the patient will help to determine the size of the breasts in order to maintain proportionality. In most of our patients a mid to full C does yield proportionality. Other specifics include the industry of the patient, i.e., entertainment industry.
Negatives of going too large will include increased risk of visible rippling, wrinkling as well as skin laxity with the breast implant sagging over time. It can also lead to increased scar tissue formation with larger implants placed due to pulling of the capsule with tears and seroma formation. Remember, overly enlarged implants without proper support throughout the years will lead to skin laxity requiring possible breast lifting and further scarring. It is most important that the patient understand the proportionality should be the key to breast enhancement sizing.
Bottoming out may occur from either gravitational descent of the implants over time or technical error leading to excessive lowering of the inframammary fold . Correction may include capsuloraphy or inframammary tightening with a formal lift .
In this case correction included implant exchange with High profile implant and breast lift .
The patient presents with severe Baker IV capsular contracture with a left double-bubble breast deformity with superior retroposition of the left implant causing a very unnatural appearance of her breast as well as severe pain. The patient has increasing pain in the left breast with swell consistent with a seroma-induced capsular contracture subsequently leading to superior retropositioning of the left implant causing a double-bubble breast deformity. She also had inadequate release of the attachments of the pectoralis major muscle along the parasternal ridge and the lateral inframammary fold. Postoperative photographs show high profile saline implant replacement with left open periprosthetic capsulectomy, removal of fluid seroma and complete release of the parasternal and the lateral inframammary attachments of the pectoralis major muscle. Note, the symmetry is now good. The upper pole fullness is even and the inframammary folds are in proper position. This is approximately six weeks postoperative. The next photographs will be taken in three months.
Only breast revision surgeries such as this should be performed by Board Certified Plastic and Reconstructive Surgeons who have experience and judgement to perform this difficult operation.
CASE STUDY FLIGHT ATTENDANTS AND BREAST AUGMENTATION
The patient below presents as a flight attendant for a major airline with bilateral enlarging painful breasts. In the operating room it was found that she had bilateral seromas with a massive amount of fluid, over 125 cc, with increased pressure. Upon opening the capsule, the immediate pressure caused squirting out of the serous fluid, as can be noted in the photograph.
I believe that flight attendants with implants are at a higher risk for seroma formation and thereby scar tissue hardening. Because of the excessive labor associated with the job description as a flight attendant, including putting large luggage into the overhead bins, there can be an increased risk of tearing of the capsule, leading to seroma formation. Patients who are flight attendants or others who do significant labor-intensive occupations with the chest wall should be pre-warned that they are at a higher risk of seroma formation as well as increased hardening and scar tissue.
This patient presents with bilateral Baker IV capsular contractures and in the operating room found to have large seromas of clear yellow fluid. Upon decompressing, the breasts were significantly softer after also performing capsulectomies.
We recommend our patients who are flight attendants with implants to try to reduce the overhead bin placement of large luggage as well as any type of exertion of the pectoralis major muscle which could lead to seroma formation.
The patient below presents to us unhappy with her laterally displaced implants. She has low profile saline implants with a pocket that was released too far to the outer edge of her breast. In order to fix this without performing an internal capsulorraphy or internal suturing, I performed a medial open capsulotomy, superior capsulectomy, removal and replacement with slightly larger over-filled high profile 465 cc to 490 cc bilateral, style 68 Natrelle implants in order to increase upper pole fullness as well as to allow medial displacement of the implant to retain the medial breast pocket and enhance her cleavage. Equally as important was the postoperative compression with the Dr. Linder Bra. The patient was fit into a small brassiere which allowed her to have repositioning of the implants medially without the use of lateral suturing or lateral capsulorraphy.
The postop photo shows her at three weeks out. Sutures have been removed through the periareolar. Patient should remain in the Dr. Linder Bra for the next three weeks in order to maintain the position of the implants and then can be positioned with an underwire brassiere.
Patients present for breast revision surgery throughout the week in my practice. Whenever I am able to perform a repositioning of implant medially without capsulorrhaphies that can be unpredictable, we prefer the method of replacement with these larger high profile salines and significant compression with the Dr. Linder Bra postoperatively.
The below example shows patient is a 34A. Good candidate for augmentation mammoplasty procedure. She is 19 years old. Patients under 22 by FDA regulations should undergo saline implant augmentation rather than silicone. At this time high profile saline implants placed in the dual plane technique, two-third under, one-third over and laterally will yield an excellent result with a nice slope to the upper pole as long as there is muscle coverage. These implants are tapered. They are narrow and they have a nice shape without leading to a widened laterally matronly appearance. High profile saline implants are an excellent implant choice for patients who are under 22 years of age and who are not yet considered candidates for silicone gel by the FDA regulations. High profile saline implants can then be overfilled which reduces visibility and rippling along the lateral breast. They may also be used for reconstruction and revision breast augmentation surgery in order to reduce visibility of the implant edges.