Myo-Glandular Flap Breast Reduction: Preventing the Bottoming out Deformity-A Novel Technique.

Large, heavy breasts are a common complaint among women causing various functional and aesthetic concerns. The plastic surgery community has offered a variety of surgical techniques to address this condition. Most of these operations developed during the 1970s-1980s cemented their place in history as fundamentals of breast reduction surgery and are still widely taught today. Despite ongoing plastic surgery advances, long-term complications surrounding breast reduction surgery remain a concern, even to experienced surgeons. Its apparent trends have shifted focus over time; from the basics of developing a patient-safe and easily replicable technique, toward developing more refined maneuvers allowing surgeons to reach desired and long-lasting outcomes while preventing known complications. The bottoming out phenomena, lack of nipple areola complex sensitivity, upper pole emptiness with low setting breasts and high revision rates still plague the breast reduction landscape. We present a novel technique involving a pectoralis major-based myo-glandular flap with breast parenchymal suspension to the upper chest wall to combat bottoming out and upper pole emptiness. These procedural elements allow the breasts to attain not only acceptable results, with smaller, round and well-projected breasts, but also to create an active opposing vector to resist the gravitational forces which otherwise pull breast tissue inferiorly creating the bottoming out deformity.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Split gluteal muscle flap for autoprosthesis buttock augmentation.

BACKGROUND: Several flaps have been described to provide autologous augmentation to the gluteal area. Since the authors' original description of a dermal fat flap for buttock augmentation during lower body lift in 2005, the procedure has been refined considerably. Unique to previously described flaps, the technique results in maximum projection of the buttock at its midportion. A decrease in fatty necrosis and greater mobility has been achieved by transitioning to a split gluteal musculocutaneous flap. METHODS: In a retrospective review from January of 2004 to August of 2010, 200 patients, aged 24 to 57 years, underwent autologous buttock augmentation. The last 50 patients of the series underwent an incorporation of a split section of gluteus maximus muscle. Patients were followed for 6 months to 4 years. RESULTS: Of the 200 patients, 30 had the buttock flap as an isolated buttock lift and augmentation; the remainder of the procedures were performed in conjunction with a circumferential body lift. Incorporation of the split gluteus maximus muscle facilitated the rotation of the flap caudally and increased the vascular supply to the flap. Ten percent of the patients had minor complications, which included small areas of delayed wound healing and partial fat necrosis of the dermal flaps. In the group with split musculocutaneous flaps, there was no fatty necrosis. Results were maintained over time. CONCLUSIONS: This is a reliable, versatile, and efficient flap for autologous buttock augmentation. With recent modifications, the incidence of fatty necrosis has been substantially decreased. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Pedicled fat flap to increase lateral fullness in upper blepharoplasty.

INTRODUCTION: The eyelid of a young person can be distinguished by the lateral fullness of the upper eyelid. With aging, lateral fullness decreases. Volume restoration in the periorbital area has been previously addressed by fat draping and grafting. More recently, techniques for regaining lateral fullness of the upper eyelid have focused on fat grafting, although effective graft take, reabsorption, and irregularities have been a concern. To address these issues, the concept of pedicled fat draping in the upper eyelid was explored. METHODS: In a retrospective study from June 2006 to August 2008, 31 patients underwent upper blepharoplasty with augmentation of the lateral fullness with a pedicled fat flap from the central fat pad. The fat from the central compartment was elevated, dissected, and then transposed to the lateral upper eyelid below the orbicularis muscle. RESULTS: All patients were women ranging in age from 43 to 68 years. Pre- and postoperative picture comparison demonstrated a more youthful appearance with increased lateral fullness of the upper eyelids. There were no cases of fat necrosis encountered. Increased volume remained stable over an average of one-year follow-up. No complications were recorded. CONCLUSION: Transposing a pedicled fat pad from the central compartment laterally has proven to be an effective technique for achieving predictable upper lateral eyelid fullness and thus achieving a long-lasting, more youthful appearance.

Autologous augmentation gluteoplasty with a dermal fat flap.

BACKGROUND: Buttock contouring represents a surgical challenge, particularly when both ptosis and volume deficit are present. Isolated buttock lifts may cause a flattened buttock contour, whereas augmentation with implants or fat injections alone my not correct the ptosis. OBJECTIVE: We describe a buttock lift with a dermal fat flap that provides correction of the buttock contour in such cases. METHODS: A retrospective review was conducted of 10 patients, aged 26 to 57 years, who underwent a buttock lift with autologous dermal flap augmentation. Patients were followed up between 6 months and 2 years. RESULTS: A comparison of preoperative and postoperative photographs indicated improved buttock contour and maximum augmentation at the midlevel of the buttocks. There were no major or minor complications. Patient satisfaction was high. CONCLUSIONS: Autologous dermal flap gluteal augmentation is a versatile technique that addresses both buttock ptosis and volume deficit. Drawbacks include an extended incision line that, however, is easily concealed by underwear or a bikini.

Spiral lift: medial and lateral thigh lift with buttock lift and augmentation.

BACKGROUND: Patients with a pear- or guitar-shaped body contour deformity are not frequently encountered, but represent a surgical challenge. Traditionally, these patients have been treated with belt lipectomies, lower body lifts, medial thigh lifts, and liposculpture because liposuction alone often is insufficient. This article describes an alternative method for performing a medial, anterior, and lateral thigh lift with a buttock lift and autoprosthesis augmentation through a single spiral incision easily concealed by underwear. METHODS: A retrospective study of patients treated for body contour deformities from January 2004 to June 2006 was conducted. The inclusion criteria for spiral lift were lipodystrophy and excess skin and subcutaneous tissue of the thighs, flanks, and buttocks without contour deformities of the abdomen. The incision extends from the inferior crease of the buttocks along the inguinal crease and continues just inferior to the anterior iliac spine, spiraling above the buttocks and meeting the contralateral incision at the sacrum. A dermal fat flap is rotated to function as an autologous buttock implant. Pre- and postoperative views, patient satisfaction, complications, and operative details are analyzed and described. RESULTS: Of the 253 consecutive patients treated for body contour deformities, 5 met the inclusion criteria for the spiral lift. All the patients were women ranging in age from 30 to 43 years. Comparison of pre- and postoperative views demonstrated improved contour and firmness of the thighs and gluteal region with easily concealed scars. The inferior gluteal sulcus became less evident, and the buttock mass was elevated and augmented with maximum projection at midlevel. Patient and surgeon satisfaction was high. One patient experienced delayed wound healing. Stability in the body contour repair was demonstrated at the 1-year follow-up assessment. CONCLUSIONS: A reliable, versatile, and effective technique is described. Applicability and experience with the procedure are limited due to infrequent presentation of patients seeking correction for such a body contour deformity.

Decision making in abdominoplasty.

BACKGROUND: Improvements and variations in abdominoplasty techniques have complicated patient and procedure selection. The authors describe their guidelines for selecting the ideal procedure to be used with patients by stratifying them into treatment groups according to the presence and location of excess skin and subcutaneous tissue, lipodystrophy, and abdominal wall laxity. METHODS: A prospective study analyzed 151 female patients treated for abdominal contour deformities from January 2004 to July 2005. The patients were systematically classified into five treatment groups: mini-abdominoplasty (5%), standard abdominoplasty (42%), abdominoplasty with liposuction and minimal midline undermining (10%), standard abdominoplasty with removal of deep fat (13%), and circumferential abdominoplasty (30%). RESULTS: The patients had a mean age of 42 years and a mean body mass index (BMI) of 26 kg/m(2). The prevalence of overweight (BMI, 25.0-29.9) was 37%, and that of obesity (BMI > 30.0) was 19%. Comparison of pre- and postoperative photographs included improved tension of the entire abdominal wall, enhancement of the waistline, and increased uniformity of the contour of the abdomen. There was a significant difference in mean BMI between preabdominoplasty (26 kg/m(2)) and postabdominoplasty (24 kg/m(2)) (p = 0.01). The prevalence of overweight and obesity decreased by 8% and 9%, respectively (p = 0.01), and a decrease in BMI occurred within each abdominoplasty subgroup (p = 0.01). The prevalence of complications was 11%. Seroma (4%) and delayed wound healing (4%) were the most common. One case of pulmonary embolus was encountered. Although there was a positive trend in complications with higher BMI, no statistically significant difference was found (p = 0.74). Half of the patients had additional procedures performed without a significant increase in complications (p = 0.5). CONCLUSIONS: The described algorithm for abdominoplasty selection is safe, effective, and flexible, with long-term improvement in abdominal contour and BMI.

Triple plication in miniabdominoplasty.

A novel method for plication of the abdominal fascia in miniabdominoplasty addresses abdominal laxity and improves the waistline. The design comprises a vertical plication of the rectus fascia from xiphoid to pubis and fusiform plication of the oblique fascias with limited undermining and scars, all in the setting of a miniabdominoplasty. The procedure was performed for 10 women undergoing surgery between January and December 2004. The technique resulted in improved tension of the entire abdomen, a decreased perimeter of the waist, and improved uniformity in the contour of the anterior and lateral view, avoiding the epigastric bulking generated when infraumbilical vertical plication is used alone. There were few minor and no major complications. At the follow-up assessment 6 months to 2 years after surgery, there was no loss of the improved muscle-aponeurotic tension or abdominal contour. Triple plication of the fascia provides a good method for improving both the waistline and abdominal laxity in the setting of a miniabdominoplasty.

Autoprosthesis buttock augmentation during lower body lift.

With the increasing popularity of bariatric surgery, patients with multiple body contour deformities have become more common in plastic surgery practice. Most of the deformities involving the abdomen, thighs, and buttocks can be effectively corrected with belt lipectomy and lower body lift. A common problem with this procedure is postoperative loss of gluteal projection and resulting flattened buttock contour, which is directly proportional to the extent of lower body lift achieved. The use of local myocutaneous flaps to provide coverage for the lumbosacral defects is a common plastic surgery procedure. The authors have used these techniques to create an autologous buttock implant for additional projection during a lower body lift. A local myocutaneous flap originating within the regularly excised supragluteal tissue is rotated caudally to function as an autologous buttock implant. This flap has reliable circulation, can be custom designed for each patient, requires minimal additional operating time, and allows the creation of more than one flap if necessary. This article describes the results of this procedure used for 20 consecutive women. There were no major complications, and the most common minor complications included delayed wound healing and local hardness in the area, suggesting fat necrosis, which resolved without intervention in a few months. High patient satisfaction combined with a low complication rate suggests that this reliable, versatile technique nicely complements the lower body lift procedure.