Correction of Lipomastia through a Stab Incision on the Nipple Areolar Junction

BACKGROUND: Lipomastia (pseudogynecomastia, fatty-type gynecomastia) is defined as the benign enlargement of the male breast attributable to accumulation of the adipose tissue. The aim of this study is to describe the experiences of a stab incision on the nipple areolar junction method to the correction of lipomastia. The authors present a combined method ultrasound-assisted liposuction in conjunction with a shaver technique to effectively remove the fatty and fibro-glandular tissues of the male breast and avoid noticeable scar. METHODS: A retrospective analysis was made of 500 cases of lipomastia operated on in the last 16 months via sub-nipple approach. The extent of the clinical result, the technique employed, and the complications were observed. RESULTS: The volume of liposuction from each side ranged from 30 to 500 mL (median, 175 mL) and the median weight of the fibro-glandular tissue was 10.5 grams. Major complications from this procedure include undercorrection, overcorrection, infection, and hematoma. Our total major complication rate was 1.8%. CONCLUSIONS: These techniques of a sub-nipple stab incision are also alternative to correct lipomastia, avoiding undesirable scars.

The New Classification for Fatty-Type Gynecomastia (Lipomastia) and 1000 Cases Review

PURPOSE: The authors propose the new classification of fattytype gynecomastia (lipomastia) which can serve as a guide for modifying the periareolar technique. METHODS: A retrospective analysis was made on 1000 cases of lipomastia operated on in the last 17 months. The extent of the clinical result, the technique employed, and the complications were observed. On the basis of this review the authors observed that at grade I (fat component 500 mL, > 30 g and ptosis), small incision (78 mm), UAL, SAL, fibroglandular excision using large angulated scissors, cutting IMF, upper repositioning of NAC and delayed circumareolar skin reduction or chest lifting becomes necessary. RESULTS: The complications were minimal but there occurred hematoma (n = 7), infection (n = 3) and hypertrophic scar (n = 13). Most of the patients were satisfied with the outcome. CONCLUSION: This simple classification may help in choosing the most suitable treatment, thus avoiding insufficient or invasive treatments and undesirable scars.

Male Nipple Reduction using Modified Pentahedral Excision

PURPOSE: Male hypertrophic nipples can lead to psychological distress and physical discomfort. The authors present a new technique of male nipple reduction and describe its advantages. METHODS: The neonipple is designed to reduce diameter and height of nipple while preserving the subdermal plexus. After the central wedge excision, additional four triangular section of nipple skin is excised. One of the remaining two flaps is amputated partially and both flaps were approximated using 4-0 PDS and 6-0 Nylon sutures. RESULTS: From December 2007 to January 2009, 52 nipple reductions were performed in 30 male patients (mean = 29.5 years). Postoperative recovery was rapid and few complications were observed. The mean diameter of the hypertrophic nipple was 9.1 +/- 2.5 mm (range, 7 to 15 mm). The mean diameter of the neonipple was 5.0 +/- 0.7 mm (range, 4 to 6 mm), with an average reduction of 3.8 +/- 0.6 mm (range, 2 to 11 mm). In follow-up, the neonipple had a natural appearance, with less projection and an inconspicuous scar. CONCLUSION: The wedge and triangular skin excision and partial amputation are easy to perform and yields consistent results. This technique decreases both the diameter and height of any size nipple and can be modified to meet patients' preferences.

The Correction of Severe Inverted Nipple: Using Under Skin Dermal Flaps, Through-and-Through Suture and Purse-String Sutures

PURPOSE: Severe type of inverted nipple (cannot be pulled out above the areola plane by manipulation, grade III) usually cannot be corrected by a relatively simple pursestring suture technique. Most patients want to avoid visible scars. To treat the severe case and avoid visible stigma, we introduce this invisible dermal flap method. METHODS: This new surgical procedure makes bilateral incisions on the sidewall of nipple and dissections vertically to free the ducts from the contracted tissues. After dissection, the tunnel is formed. We insert "dermal flaps" into the tunnel underneath nipple base. Then through-and-through sutures are performed vertically (6 o'clock and 12 o'clock positions) and the purse-string suture is added with 4-0 nylon. RESULTS: We had treated 35 primary inverted nipples (grade III) in 27 patients and 13 recurrent nipples in 7 cases. The results were excellent in 45 nipples (93.7%). All but 3 recurred cases was fully or very satisfied with the results. CONCLUSION: This technique is effective for the correction of severe inverted nipples and recurrent cases. We can avoid the visible scars on the areola surface

Correction of Inverted Nipple Using Lateral Minimal Incision and Twice Purse-String Sutures

Inverted nipples are histologically characterized by shortened lactiferous ducts and less connective tissue beneath the nipple. Some authors suggested that the major pathophysiologic basis in mild to moderated cases, is shortened ducts, but not lack of connective tissue at the base of the nipple. Under local or intravenous sedation, the nipple was everted. A small incision was made on lateral side at the nipple-areola junction. The lactiferous ducts and surrounding connective tissues were divided by sharp dissection only through vertical direction. Two purse-string sutures using Nylon 4-0 were performed for the maintenance of corrected nipple. The small incision was closed by the tissue adhesive. From May 2007 to January 2008, 137 nipples in 70 patients were treated. Twenty five nipples were graded as grade I and 112 nipples as II. There were no major complications except recurred inversion in 2 cases. Of these, one case had some inflammatory discharge. Almost patients(97.1%) were satisfied with their results. Advantages to using this technique include(1) no scars on the flat surface of the areola,(2) adequate blood and nerve supply to the nipple,(3) simple and easy to learn, and(4) no need of external stent or traction.

Power-Assisted Liposuction and Periareolar Pull-Out Technique for the Treatment of Gynecomastia

Gynecomastia is an abnormal increase in the volume of the male breast. Surgical techniques include a variety of incisions, excisions, suction-assisted lipopectomy, ultrasound-assisted liposuction, power-assisted liposuction, or some combination of these methods. The purpose of this article is to introduce the authors' method of using power-assisted liposuction and periareolar pull-out technique. Six men were treated from June 2005 through August 2008 for gynecomastia. Fatty breast tissue is removed by power-assisted liposuction. The periareolar pull-out technique is then performed to glandular enlargement. A mean of 120cc of breast tissue was aspirated, and 18.3g of glandular tissue were excised per breast. There were no complications such as skin flap necrosis or hematoma. The cosmetic outcome was good in all and the patients' satisfaction was high. Power-assisted liposuction in combination with periareolar pull-out technique effectively corrects gynecomatia. This combination has little morbidity, minimize scars, and leads to good cosmetic results.

Decrease of Areola Diameter after Gynecomastia Correction

The mean diameter of nipple-areolar complex(NAC) is 24.3 mm(range 21-29mm) in young Korean men, and patients usually, expect the decrease of NAC after gynecomastia correction. Therefore, the, authors studied the rate of decrease of NAC after ultrasound-assisted liposuction and fibroglandular excision via periareolar approach. Series of 121 cases(242 NAC) were reviewed from May to September 2007 with mean follow-up of 5 months. Inclusion criteria were the followings; 1) NAC diameter > 30 mm, 2) Bilateral cases within 3 mm difference between right and left NACs, and 3) Patients who agreed to take photographs longer than at least 3 month after operation. The decreased NAC ranged from 5.1% to 44.7%(mean 23.8%). The patient's satisfaction was high, and most of them were pleased with the decreased NAC diameter. Based on these results, we can provide the more informations about gynecomastia to patients.

Lipoabdominoplasty using Intravenous Sedation

Careful attentions to design, liposuction, adequate positioning of the incision, musculofascial plication, umbilicoplasty and meticulous closure are very critical for optimal outcomes of abdominoplasty. In addition to the above factors, the mode of anesthesia is also an important factor. The ability to perform abdominal cosmetic surgery in the intravenous setting provides a more comfortable environment for patients, ease of scheduling for surgeons and less complications related to anesthesia. Between May 2007 and November 2008, 11 patients underwent lipoabdominoplasty under epidural anesthesia and 19 patients under local anesthesia with intravenous anesthesia. The results of these approaches were evaluated in terms of procedure time, length of hospital stay, rate of complications and level of patient satisfaction. There were no complications related to anesthesia (cardiac problem, deep vein thrombosis, fat emboli, and pulmonary embolism) and no surgery(flap loss or wound dehiscence) except 3 seroma cases. All intravenous anesthesia patients reported adequate postoperative pain and nausea control. Patients in both groups were generally pleased with the results of surgery. Advantages of lipoabdominoplasty using intravenous anesthesia included a low incidence of nausea and vomiting, and reduction or elimination in the risk of serious complications as a deep vein thrombosis.

Experiences of Seroma after Lipoabdominoplasty

The popularity of abdominoplasty appears to be increasing. Lipoabdominoplasty consist of liposuction around abdominal subcutaneous fatty tissue and excision of lower abdominal flap. This procedure allows aggressive thinning and sculpting of abdominal flap, while preserving neurovascular supply to the abdominal skin. As a result, the flap necrosis which is one of the serious postoperative complications requiring the secondary touch can be avoided. From May 2007 to August 2008, 20 women and 2 men underwent the lipoabdominoplasty and were highly satisfied with no significant complications, such as pulmonary embolism, deep vein thrombosis and distal necrosis. Between 130 and 4,660cc(average, 1,310cc) were obtained through liposuction. The abdominoplasty flap weight fluctuated between 170 and 1,240g(average, 488g). Patients can return to normal activity within a few weeks. Three complications of seroma occurred in our series. To prevent these complications, we recommend the Baroudi's stitches. This lipoabdominoplasty is an effective and safe alternative means without flap necrosis.

Treatment of Osmidrosis Using Combination Techniques

Elimination of the apocrine glands by a radical surgical procedure has been known to be the best solution for axillary osmidrosis; however, it is often accompanied with a marked scar. Ultrasonic tumescent liposuction is a safe procedure for removal of subcutaneous fat tissue. Herein, we describe our modification of the traditional osmidrosis operation(subdermal excision or superficial liposuction). The first, pre-suction "scrape" could require adequate plane of skin flap; the second, "ultrasound-assisted liposuction"; the third, post-suction "rasp" helped subdermal curettage; the last, "endoscopic approach" could visibly remove remaining apocrine glands. It is named SURE technique. From April 2007 to September 2008, 43 patients underwent our "SURE" method for axillary osmidrosis. All patients were followed up for 3 to 12 months with an average of 6 months. The total satisfaction rate was 91 percent(39/43). The complications(skin slough and subdermal band formation) rate was 14 percent(6 of 43). However these complications were temporary and complete recovery occurred without special cares. We emphasize four components of our SURE method procedures. In conclusion, "SURE" method can be one of alternatives for osmidrosis treatment.

The Treatment of Gynecomastia using Ultrasound-Assisted Liposuction with Pull-Out Method or Excision through Periareolar Incision

PURPOSE: Gynecomastia is an abnormal increase in the volume of the male breast. Patients affected by gynecomastia with significant glandular enlargement may respond to suction alone and/or sharp dissection and excision. The purpose of this report is to introduce the indications and results of authors' two techniques. METHODS: The diameter of parenchyme was determined by a pinch test after liposuction. For the parenchymal diameter less than 4cm, ultrasound-assisted liposuction was performed, in conjunction with the "pull- out technique" to effectively remove the fibrofatty tissue of the male breast through a single 5-7mm incision. For the parenchymal diameter more than 4cm, ultrasound-assisted liposuction and excision were applied through 2.5cm periareolar approach. RESULTS: A total of 94 patients (185 breasts) underwent the operation from October 2000 to October 2003 and mean follow-up period was 12 months. The volume of aspirates ranged from 50 to 450 cc per breast. There were no major complications such as skin flap necrosis. Five reoperations were performed for 1 hypertrophic scar, 2 under-resected and 2 hematoma cases. The patient's satisfaction was high and most of them were pleased with the shape of the breasts and scars. CONCLUSION: These procedures can minimize scars and reduce the incidence of contour problem such as saucer deformity, and provides consistent results. Patients can return to full activities in 48 hours. It can be offered as an option for the treatment of gynecomastia.

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.

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.

The Effect of Laser Assisted Liposuction

The 635-nm low-level laser therapy was reported to "liquefy" or release stored fat in adipocytes by causing a transitory pore in the cell membrane to open, which permitted the fat content to go from inside to outside the cell. But some data do not support the belief that low-level laser therapy treatment before lipoplasty procedures disrupts tissue adipocyte structure. The purpose of this study was to determine the effectiveness of low-level laser- assisted liposuction. The use of low-level laser-assisted lipoplasty was evaluated in a series of 90 cases. There were 2 treatment groups in the clinical study. Subjects in the test group(39 patients; 31 thighs and 17 abdomen) received only liposuction on one side and laser-assisted liposuction on the other side during early 1liter aspiration time. 51 patients in the operated group received laser-assisted liposuction on both side. After adequate infiltration was obtained in all targeted body areas, a 635-nm electric diode laser was applied to the targeted areas for 12 to 15 minutes to liquefy the fat which was extracted immediately after laser treatment. On the side which received laser-assisted liposuction of the 39 test-group patients, we could gain much fat component(71+/-7.2 vs 63+/-8.6%) and it took short time(26+/-5.7 vs 31+/-7.7 minutes). Postoperative recovery was rapid, and complications were minimal. Low-level laser-assisted lipoplasty can be a valuable adjunctive tool for the performance of lipoplasty.

Simplified Insetting Strategy in Pedicled TRAM Flap Breast Reconstruction

Various method of insetting the transverse rectus abdominis myocutaneous flap for breast reconstruction has been reported in literature. The Bostwick's principle is commonly applied, which utilizes contralateral pedicle in a vertical or oblique flap inset position and ipsilateral pedicle in the transverse position. But it is relatively a complex and difficult technique, thus requires a more simplified strategy. We have formulated a new insetting method, in which the contralateral pedicled TRAM flap with an oblique(0 degree - 90 degrees) flap inset was carried out. We used this method in 100 cases from July 2001 to June 2003. This maneuver places Hartrampf's zones I and III with good vascularity in the medial side, and zone II in lateral side of breast. Fat necrosis was observed in 14 patients(14%) and of these, only three cases needed surgical excision. This simplified method is easy to learn. Specifically, fat necrosis removal is easy with more tolerable aesthetic results, especially in Asian patients with smaller breasts.