Initial experiences and usefulness of porcine acellular dermal matrix-assisted prepectoral breast implant surgery: a case series and systematic review

Background@#We report our experiences with prepectoral placement breast implant surgery using Supporix (HansBioMed), a porcine acellular dermal matrix (PADM), for cosmetic and reconstructive indications. The clinical efficiency, safety, and cost-effectiveness of PADM were also discussed. @*Methods@#A single-center, retrospective study was designed from December 2017 to December 2019. The participants were Korean women who underwent PADM-assisted prepectoral breast implant surgery performed by two surgeons. All complications were registered and analyzed. A systematic review and meta-analysis of complication rates after PADM-assisted prepectoral breast implant surgery were conducted for comparison with other studies. A subgroup analysis was performed according to the operation type: the cosmetic breast surgery (CBS) group, the immediate implant-based breast reconstruction (IIBR) group, and the delayed implant-based breast reconstruction (DIBR) group. @*Results@#Twenty breasts in 16 patients were included in our study (median follow-up period, 8.25 months). In a systematic review, 20 publications with a total of 2,504 breasts in 1,921 women were quantitively analyzed. The overall complication rates in our study and other studies were 14% and 24% in the total group analysis, 0% and 12% in the CBS group, 62% and 26% in the IIBR group, and 0% and 28% in the DIBR group, respectively. @*Conclusions@#Our data support the effectiveness of PADM-assisted prepectoral breast implant surgery, which was comparable to other studies. PADM was effective for reducing seroma and hematoma in the revision CBS group and the DIBR group. In the IIBR group, it was helpful in preventing implant loss and explantation.

Endoscopic transaxillary prepectoral conversion for submuscular breast implants

BACKGROUND: During breast augmentation, the transaxillary approach provides the advantage of allowing the mammary prosthesis to be placed through incisions that are remote from the breast itself, thereby reducing the visibility of postoperative scars. For patients experiencing capsular contracture who do not want additional scars, the previous transaxillary scar can be used for site change and implant exchange. METHODS: This study analyzed 17 patients (34 breasts) with submuscular breast implants with grade III-IV capsular contracture who received treatment from 2010 to 2015. The mean age of the patients was 29 years (range, 20–38 years). The inclusion criterion was a pinch test of more than 3 cm at the upper pole of the breast. Previous axillary scars were used to expose the pectoralis fascia, and submuscular breast implants were removed carefully. The dissection underneath the pectoralis fascia was performed with endoscopic assistance, using electrocautery under direct visualization. RESULTS: The mean follow-up period was 14 months (range, 6–24 months). The entire dissection plane was changed from the submuscular plane to the subfascial plane. Round textured gel implants were used, with a mean implant size of 220 mL (range, 160–300 mL). Two patients developed grade II capsular contracture. There were no cases of malposition or asymmetry. Three patients complained of minor implant palpability. None of the patients required additional surgery. CONCLUSIONS: Endoscopic subfascial conversion may be an effective technique for treating capsular contracture and avoiding scarring of the breast in selected patients.

Deep-Plane Lipoabdominoplasty in East Asians

BACKGROUND: The objective of this study was to develop a new surgical technique by combining traditional abdominoplasty with liposuction. This combination of operations permits simpler and more accurate management of various abdominal deformities. In lipoabdominoplasty, the combination of techniques is of paramount concern. Herein, we introduce a new combination of liposuction and abdominoplasty using deep-plane flap sliding to maximize the benefits of both techniques. METHODS: Deep-plane lipoabdominoplasty was performed in 143 patients between January 2007 and May 2014. We applied extensive liposuction on the entire abdomen followed by a sliding flap through the deep plane after repairing the diastasis recti. The abdominal wound closure was completed with repair of Scarpa's fascia. RESULTS: The average amount of liposuction aspirate was 1,400 mL (700-3,100 mL), and the size of the average excised skin ellipse was 21.78×12.81 cm (from 15×10 to 25×15 cm). There were no major complications such as deep-vein thrombosis or pulmonary embolism. We encountered 22 cases of minor complications: one wound infection, one case of skin necrosis, two cases of undercorrection, nine hypertrophic scars, and nine seromas. These complications were solved by conservative management or simple revision. CONCLUSIONS: The use of deep-plane lipoabdominoplasty can correct abdominal deformities more effectively and with fewer complications than traditional abdominoplasty.

Deep-Plane Lipoabdominoplasty in East Asians

BACKGROUND: The objective of this study was to develop a new surgical technique by combining traditional abdominoplasty with liposuction. This combination of operations permits simpler and more accurate management of various abdominal deformities. In lipoabdominoplasty, the combination of techniques is of paramount concern. Herein, we introduce a new combination of liposuction and abdominoplasty using deep-plane flap sliding to maximize the benefits of both techniques. METHODS: Deep-plane lipoabdominoplasty was performed in 143 patients between January 2007 and May 2014. We applied extensive liposuction on the entire abdomen followed by a sliding flap through the deep plane after repairing the diastasis recti. The abdominal wound closure was completed with repair of Scarpa's fascia. RESULTS: The average amount of liposuction aspirate was 1,400 mL (700-3,100 mL), and the size of the average excised skin ellipse was 21.78×12.81 cm (from 15×10 to 25×15 cm). There were no major complications such as deep-vein thrombosis or pulmonary embolism. We encountered 22 cases of minor complications: one wound infection, one case of skin necrosis, two cases of undercorrection, nine hypertrophic scars, and nine seromas. These complications were solved by conservative management or simple revision. CONCLUSIONS: The use of deep-plane lipoabdominoplasty can correct abdominal deformities more effectively and with fewer complications than traditional abdominoplasty.

Transaxillary Endoscopic Breast Augmentation

The axillary technique is the most popular approach to breast augmentation among Korean women. Transaxillary breast augmentation is now conducted with sharp electrocautery dissection under direct endoscopic vision throughout the entire process. The aims of this method are clear: both a bloodless pocket and a sharp non-traumatic dissection. Round textured or anatomical cohesive gel implants have been used to make predictable well-defined inframammary creases because textured surface implants demonstrated a better stability attributable to tissue adherence compared with smooth surface implants. The axillary endoscopic technique has greatly evolved, and now the surgical results are comparable to those with the inframammary approach. The author feels that this technique is an excellent choice for young patients with an indistinct or absent inframammary fold, who do not want a scar in the aesthetic unit of their chest.

Desmoid Tumor Following Augmentation Mammoplasty with Silicone Implants

No abstract available.

Breast Reduction through an Inframammary Incision

PURPOSE: Reduction mammaplasty is a procedure with a relatively high patient satisfaction rate, however, associated scarring around the areola can be a serious problem. This study proposes a new modification of the breast reduction procedure by means of an inframammary incision alone. METHODS: The breast is marked out preoperatively with standing position. Under the general anesthesia, an inframammary incision of approximately 7-8cm is done. The subcutaneous plane is made in the lower pole of the breast, then the subglandular plane is entered and a sharp dissection is made up to 2cm below the areola. The breast is mobilized from the chest wall and a cone-shaped parenchyme is removed in en-block except from the retroareolar central part. The remaining both pillars are gathered together with absorbable sutures and the base of the gland is narrowed to project the breast forward. The wound is closed in a layered fashion and taping of the breast mound is applied to redistribute the breast skin. RESULTS: 21 patients(36 breasts) underwent this procedure from December 2004 to December 2009. Average follow up was 9 months(ranged from 6 months to 12 months). No major complication occurred. Most patients were pleased with the breast size, shape, and scars. However, 2 patients complained their hypertrophic scars which were corrected by revision. CONCLUSION: This technique is a simple approach to mild to moderate breast reduction through an inframammary incision alone. And, this technique provides an option with minimal complications and invisible scarring, which is especially important in the young patient group.

A Correction of Inverted Nipple by Partial Ductal Division and V-Y Advancement of Parenchyma

The pathophysiology of the inverted nipple is characterized by less connective tissue beneath the nipple, dense fibrous tissue at nipple-areola junction and shortened fewer functional lactiferous ducts. For grade I and II nipple inversion, the dissection of dense fibrous tissue at nipple-areola junction is sometimes not enough to completely bring out the nipple and also the recurrence rate is high. These findings suggest that the shortened hypoplastic ducts might play a considerable role in grade I and II nipple inversion. The purpose of this study was to prove the effectiveness of partial ductal division and V-Y advancement of glandular tissue to correct the inverted nipple. Through a 3mm slit incision around the nipple base, partial division of lactiferous ducts was performed and V-Y advancement of parenchyma was followed. The extent of ductal division was limited only to the central portion until the nipple protrusion persisted without any support. A deep purse-string with a 4-0 permanent suture reinforced the advancement of glandular tissue to add bulk beneath the nipple, and a superficial purse-string was applied at the subcutaneous layer to avoid instability of the nipple. 168 female patients(309 nipples) underwent this procedure from April 2000 to June 2008. 37 nipples were grade I and 272 nipples were grade II. No major complication occurred. Overall recurrence rate was 4.2%(13/309). Among 17 women who had breast-fed after correction of inverted nipples, 2 women failed to breast- feed. This safe and simple technique can correct almost all pathologic factors of nipple inversion, and it can also be easily applied to reoperation cases.

Nipple Reduction with a Pentahedral Excision Technique

PURPOSE: Several methods of the nipple reduction have been reported. However, the methods described previously are difficult or have some demerits. This study proposes a simple technique for reduction of the nipple height as well as diameter. METHODS: The purposed nipple height is marked. A pentahedral design of excision was marked around thenipple. Local anesthetic solution was infiltrated and a 4- 0 Nylon traction suture was applied at the nipple apex. Excision of the nipple inside both two triangles and a rectangle was made. Remaining two flaps were approximated using 5-0 Nylon simple interrupted sutures. However, a part of wound closure was not done in the central area of the nipple. RESULTS: Eighty-three patients (166 nipples) underwent this procedure from December 1999 to December 2008. Follow-up period ranged from 6 months to 2 years with a mean of 10 months. Seventy-eight patients were female and 5 patients were male. No major complications occurred and remaining scars were very inconspicuous. CONCLUSION: This simple technique has the advantage of nipple reduction in both height and diameter, and provides good aesthetic outcomes.

Endoscope-Assisted Transaxillary Approach in Gynecomastia Correction

Various approaches for gynecomastia correction have been described to remove glandular tissue. In recent years, standard and ultrasound-assisted liposuction became popular methods. However, these methods cannot meet all their needs in some patients who do not want to have scars on their breast's esthetic units and are known to have a tendency to form keloid. The purpose of this study is to introduce the usefulness of endoscope-assisted transaxillary removal of breast tissue in selected patients. Through a stab incision in the axilla, the entire surgical area was infiltrated using the tumescent technique. Ultrasoundassisted liposuction(UAL) was initially performed, followed by power-assisted liposuction(PAL). Then, the endoscope was introduced through a 3 cm axillary incision, and endoscopic electrocautery dissection of glandular tissue was performed under direct vision throughout the procedures. Adjuvant subcutaneous dissection around areola was done via 1 cm subareolar incision. Twelve male patients(22 breasts), whose age ranged from 19 to 38 years, underwent this technique from April 2007 to July 2008. Follow-up ranged from 2 to 16 months with a mean of 9 months. Average volume of aspirate was 290 mL, and mean amount of glandular tissue removed was 35g. No major complications occurred. The resulting scar in the axilla was inconspicuous, and patients were satisfied with postoperative breast contour. These results show that the combined use of an endoscope with the subareolar technique enables an effective treatment of gynecomastia and provides a smooth masculine breast contour without stigma of breast surgery.

Early Metabolic Changes and Its Considerations after Liposuction

PURPOSE: Advanced techniques now make it possible to remove considerable amounts of subcutaneous adipose tissue more safely with minimum blood loss. However, few have analyzed the metabolic consequences of liposuction. The purpose of this study was to identify the early effects of the surgical removal of subcutaneous fat on metabolic changes in patients who have undergone liposuction. METHODS: Nineteen patients were evaluated from June 2005 to December 2005. Preoperative body weight, serums levels of lipids, apolipoprotein A1, dehydroepiandrosterone(DHEA), uric acid, insulin, and glucose were evaluated. Insulin resistance was determined using the homeostasis model assessment of insulin resistance (HOMA-IR), which is based on fasting glucose and insulin concentrations. All of these data were remeasured in 1 and 4 weeks postoperatively. Tumescent fluid was infiltrated using the superwet technique. The liposuction device used was a Liposlim(R) power-assisted unit. RESULTS: Average volumes of infiltrate and aspirate were 3,268mL and 2,892mL, respectively. Results in 1 week postoperatively demonstrated a significant difference in high-density lipoprotein(HDL) cholesterol, apolipoprotein A1, insulin, and HOMA-IR levels. However, all values were within normal limits and returned to baseline in 4 weeks postoperatively. CONCLUSION: This study provides little to support the presumed therapeutic effect of liposuction. And, it is unclear whether liposuction can prevent or be used to treat the metabolic complications of obesity. However, the results of the present study lead us to believe that liposuction is a metabolically safe procedure.

The Management of Capsular Contracture: Conversion to "Dual-Plane" Positioning through a Periareolar Approach

PURPOSE: The capsular contracture has been the most common complication of augmentation with breast implant, a side effect quite difficult to treat. The latest trends in the correction of capsular contracture include total capsulectomy or conversion of implant pocket. In this study, in an attempt to correct capsular contracture, the authors performed reoperation which involved capsulectomy through peri-areolar approach and dual- plane conversion. The authors hereby report the clinical results of such correction of capsular contracture and examine the efficacy. METHODS: The authors selected 46 patients who were admitted to the clinic from January 2004 to January 2007 (37 months), and performed dual-plane conversion through solely peri-areolar approach. Two types of operation were done: dual-plane conversion from subglandular plane or from submuscular plane. RESULTS: The average follow-up time after conversion to the dual-plane position was 10 months. During the follow-up period, 83.1% of patients recovered from capsular contracture and were Baker class I, and in 10.9% the condition had relapsed into Baker class II or III contracture. CONCLUSION: This study has proven the effectiveness of the dual-plane conversion operation for correcting established capsular contracture after previous augmentation mammaplasty. In this study, all cases of dual-plane conversion operation was performed through peri-areolar approach, which can prevent the occurrence of visible scar on inframammary fold.

Endoscopic Transaxillary Dual Plane Breast Augmentation

PURPOSE: The transaxillary approach for breast augmentation has been advocated for patients and surgeons for several decades. However, this blind technique had many disadvantages including, traumatic dissection, difficult hemostasis, displacement of implants, and ill-defined asymmetrical location of inframammary crease. In the present study, the precise endoscopic electrocautery dissection was applied to eliminate the limits of blunt dissection throughout the procedures. METHODS: From December 2006 to December 2007, a total of 103 patients with an average age of 29.5 years underwent endoscopic assisted transaxillary dual plane augmentation mammoplasty. The mean implant size was 243 cc with the range between 150 and 350cc. Through a 4cm axillary incision, electrocautery dissection for submuscular pockets was carried out under the endoscopic control. The costal origin of pectoralis muscle was completely divided to expose subcutaneous tissue and to make type I dual plane. RESULTS: Using the endoscopic dissection, we achieved good aesthetic results including a short recovery period, less morbidity, and symmetrical well-defined inframammary crease. Type I dual plane procedure could support the consistent inframammary fold shape and be applied to most patients without breast ptosis. Minor complications did not occur, however, four major complications of capsular contracture occurred. CONCLUSION: In contrast to the era of the blind techniques, endoscopic assisted transaxillary dual plane breast augmentation can now be performed effectively and reproducibly. With Its advantage, the axillary application of endoscopy for augmentation mammaplasty is useful to achieve the optimal cosmetic outcomes.

Transumbilical Subpectoral Breast Augmentation: Personal Surgical Tips

Subpectoral augmentation mammaplasty through umbilical approach has several advantages including minimal scarring, remote incision, rapid recovery and little pain. The purpose of this article is to describe in detail the authors' transumbilical technique and provide indications for subpectoral augmentations and important surgical tips. 86 patients(n=172 breasts) who underwent subpectoral transumbilical augmentation from April of 2003 through October of 2005 were evaluated. Complications included local inflammation on umbilicus due to previous piercing(1 case), hypertrophic scar(1 case), partial superficial slough on umbilicus (1case) and capsular contractures (3/86, 3.5%). But there was no breast infection, hematoma, and the need for a change to other incisions, intraoperatively. The majority of these complications occurred early in the learning curve. All patients were satisfied with the results. The ideal indication of this procedure is the cases of adequate thickness of lower portion, no ptosis, no lower pole constriction and relatively long distance from nipple to inframammary fold. Based upon these results, transumbilical subpectoral breast augmentation is believed to be a safe alternative technique with fewer complications.

Breast Reduction using Free Nipple Graft

PURPOSE: Free nipple graft reduction mammaplasty is a simple and effective way to reduce huge breasts. However, this technique is frequently criticized for producing poor projection and hypopigmentation of the nipple areola complex(NAC). METHODS: Sixty three patients(126 breasts) underwent the procedure from 1998 to 2005. Authors' method is similar with the modified Gradinger's technique except the keyhole pattern. After skin flap closing, the position of NAC is determined considering symmetry. The NAC is initially harvested and then resection of the breast followed, leaving a deepithelized inferior parenchymal pedicle(5 x 5cm). The upper point of inferior pedicle is sutured to the fascia of the pectoralis to produce the upper bulge. The nipple is replaced as a free and composite graft. RESULTS: An average of 823grams of breast tissue per breast was removed. There was no major complications. All grafted nipples showed long lasting projection. And also, all NAC eventually regained their normal color except for 3 patients who needed medical tattoos. The overall results were good and patient satisfactory score was high. CONCLUSION: This useful technique greatly enhances long lasting projection and recovers nipple color.

Breast Reduction using Free Nipple Graft

PURPOSE: Free nipple graft reduction mammaplasty is a simple and effective way to reduce huge breasts. However, this technique is frequently criticized for producing poor projection and hypopigmentation of the nipple areola complex(NAC). METHODS: Sixty three patients(126 breasts) underwent the procedure from 1998 to 2005. Authors' method is similar with the modified Gradinger's technique except the keyhole pattern. After skin flap closing, the position of NAC is determined considering symmetry. The NAC is initially harvested and then resection of the breast followed, leaving a deepithelized inferior parenchymal pedicle(5 x 5cm). The upper point of inferior pedicle is sutured to the fascia of the pectoralis to produce the upper bulge. The nipple is replaced as a free and composite graft. RESULTS: An average of 823grams of breast tissue per breast was removed. There was no major complications. All grafted nipples showed long lasting projection. And also, all NAC eventually regained their normal color except for 3 patients who needed medical tattoos. The overall results were good and patient satisfactory score was high. CONCLUSION: This useful technique greatly enhances long lasting projection and recovers nipple color.

Periareolar Subfascial Breast Augmentation: Comparison with Submuscular and Dual Plane Breast Augmentation

PURPOSE: Subfascial augmentation mammaplasty was introduced by Dr. Graf in 2000. Subfascial placement of breast implants for augmentation was advocated as an option that has some of the advantages of both the subpectoral and subglandular placement while minimizing the disadvantages of each. The clinical experiences of 23 breast augmentations in the subfascial placement are reported. The indications for this technique are proposed. The incidence of complications is described from clinical experiences and compared with that of other methods. METHODS: From January of 2004 through December of 2005, 23 patients underwent periareolar subfascial augmentation mammaplasty. The mean postoperative follow-up time was 8 months. RESULTS: In comparing the results of the subpectoral augmentation group(57 patients) with those of the dual plane(124 patients) and subfascial groups(23 patients), the total rate of complications didn't represented the significant difference. The benefits of this technique include avoiding hematoma(as seen in the dual plane) and muscle action(in the subpectoral), and minimizing postoperative chest pain(inherent to subpectoral), and the ability to correct ptosis. And also this subfascial technique can be used for changing the plane from submuscular to subfascial in case of the reoperations. CONCLUSION: We're thinking that the periareolar subfascial augmentation mammaplasty would be the very useful tool for the primary and secondary breast augmentations.

Periareolar Subfascial Breast Augmentation: Comparison with Submuscular and Dual Plane Breast Augmentation

PURPOSE: Subfascial augmentation mammaplasty was introduced by Dr. Graf in 2000. Subfascial placement of breast implants for augmentation was advocated as an option that has some of the advantages of both the subpectoral and subglandular placement while minimizing the disadvantages of each. The clinical experiences of 23 breast augmentations in the subfascial placement are reported. The indications for this technique are proposed. The incidence of complications is described from clinical experiences and compared with that of other methods. METHODS: From January of 2004 through December of 2005, 23 patients underwent periareolar subfascial augmentation mammaplasty. The mean postoperative follow-up time was 8 months. RESULTS: In comparing the results of the subpectoral augmentation group(57 patients) with those of the dual plane(124 patients) and subfascial groups(23 patients), the total rate of complications didn't represented the significant difference. The benefits of this technique include avoiding hematoma(as seen in the dual plane) and muscle action(in the subpectoral), and minimizing postoperative chest pain(inherent to subpectoral), and the ability to correct ptosis. And also this subfascial technique can be used for changing the plane from submuscular to subfascial in case of the reoperations. CONCLUSION: We're thinking that the periareolar subfascial augmentation mammaplasty would be the very useful tool for the primary and secondary breast augmentations.

Simultaneous Periareolar Augmentation Mastopexy: Dual Plane Versus Subfascial Plane

PURPOSE: The major drawback of submuscular augmentation of the ptotic breast is a "double-bubble" deformity. If a traditional mastopexy is added to correct the ptosis, there would be additional scars. This article describes simultaneous periareolar mastopexy with dual plane or subfascial breast augmentations. METHODS: A series of 81 patients with grade I or II ptosis underwent the procedure from 1999 to 2005. Out of these, dual plane augmentation was done in 71 cases and subfascial plane in 10. After periareolar skin excision, an incision is made perpendicularly down to the fascia of pectoralis. At the lower pole, all breast implants are inserted into the subfascial plane. In case of upper pole thickness of above 20mm, we inserted the implant into the subfascial plane, whereas below 20mm, we inserted that into the submuscular plane. RESULTS: No major complications were noted and patients' satisfactory score was high. This technique avoids the "double-bubble" deformity and leaves a minimal periareolar scar. CONCLUSION: Simultaneous periareolar mastopexy/ breast augmentation is useful for correction of the ptotic breast, increasing the volume of breast and providing the natural breast shape with minimal scars. We consider that subfascial plane augmentation with periareolar mastopexy to be an alternative for cases with breast upper pole thickness of at least above 20mm.

Simultaneous Periareolar Augmentation Mastopexy: Dual Plane Versus Subfascial Plane

PURPOSE: The major drawback of submuscular augmentation of the ptotic breast is a "double-bubble" deformity. If a traditional mastopexy is added to correct the ptosis, there would be additional scars. This article describes simultaneous periareolar mastopexy with dual plane or subfascial breast augmentations. METHODS: A series of 81 patients with grade I or II ptosis underwent the procedure from 1999 to 2005. Out of these, dual plane augmentation was done in 71 cases and subfascial plane in 10. After periareolar skin excision, an incision is made perpendicularly down to the fascia of pectoralis. At the lower pole, all breast implants are inserted into the subfascial plane. In case of upper pole thickness of above 20mm, we inserted the implant into the subfascial plane, whereas below 20mm, we inserted that into the submuscular plane. RESULTS: No major complications were noted and patients' satisfactory score was high. This technique avoids the "double-bubble" deformity and leaves a minimal periareolar scar. CONCLUSION: Simultaneous periareolar mastopexy/ breast augmentation is useful for correction of the ptotic breast, increasing the volume of breast and providing the natural breast shape with minimal scars. We consider that subfascial plane augmentation with periareolar mastopexy to be an alternative for cases with breast upper pole thickness of at least above 20mm.