A Novel Approach for Tuberous Breast Correction Using Power-Assisted Liposuction, Loops, and Lipofilling (PALLL).

BACKGROUND: Autologous fat grafting has recently gained popularity in breast and reconstructive procedures. OBJECTIVES: The aim of this paper was to describe a tricomposite tuberous breast reconstruction that comprises matrix dissociation through extensive tunnelization, tissue recruitment with loops, and autologous fat transfer. This approach, called "matrix modeling," was implemented by the power-assisted liposuction, loops, and lipofilling (PALLL) technique as a method to expand the lower pole, reshape the breast, and increase breast volume. METHODS: Between 2014 and 2020, a total of 47 patients underwent tuberous breast correction by combined lipofilling and the use of breast loops. The patient population included patients with unilateral or bilateral tuberous breasts of any stage. Patients who were active smokers, lean, or who desired large breasts were excluded from the study. RESULTS: Of the 47 patients (mean age, 26 years), 31 had bilateral malformations. The mean recruited flap volume was 212 mL. A single session (mean transfer volume, 163 mL) was required in 34 cases (72%). A second session (mean transfer volume, 182 mL) was necessary in the remaining 28% of cases. Patients were very satisfied in 93% of cases and satisfied in 7% of cases. One infection was observed. The mean operative time was 67 minutes. Imaging performed preoperatively and 1 year postoperatively did not reveal any anomalies other than oil cysts (4%). CONCLUSIONS: Tricomposite breast reconstruction by PALLL is a novel, simple, safe, and alternative technique for tuberous breast correction by remodeling the matrix. The aesthetic outcome is natural, implant free, and long lasting.

Scarless Composite Breast Reconstruction Utilizing an Advancement Skin Flap, Loops, and Lipofilling.

BACKGROUND: Autologous fat grafting has gained popularity in breast reconstructive surgery. To further increase the breast volume and provide a reliable breast shape, a skin flap can be advanced from the upper abdomen and lateral thorax to the breast. OBJECTIVES: The aim of this study was to propose a method of breast reconstruction utilizing the principles of power-assisted liposuction and lipofilling (PALL) for breast matrix dissociation applied through infiltration, tunnelization, extensive undermining and lipofilling, in combination with loops (PALLL) to recruit a vascularized flap to reshape the breast. METHODS: A prospective study was performed from January 2014 to January 2019. Demographic data, surgical procedure information (including volumes of the recruited advancement flap and lipofilling, and stages of lipofilling), and complication data were collected. Patient-reported outcomes, including satisfaction and well-being, were measured by a questionnaire. RESULTS: In total, 37 women (41 breasts) underwent breast reconstruction by PALLL with an average follow-up of 26 months. The mean age of the patients was 54 years, and their mean BMI was 29 kg/m2. The mean recruited flap volume was 197 mL, and the mean lipofilling volumes were 153 mL for the first session, 190 mL for the second session, and 110 mL for the third session. Nine patients needed 3 sessions, 27 patients 2 sessions, and 1 patient only 1 session. Overall, 94% of patients were satisfied with their breast shape. All patients reported sensitive breasts. There were minimal complications. CONCLUSIONS: Breast reconstruction with PALLL is a minimally invasive alternative to reconstructing and reshaping sensate breasts in which a vascularized skin flap recruited by loops from breast surroundings is combined with fat grafting. This approach provides long-term shape stability with minimal scarring and low complication rates.

The Combined Effect of Intravenous and Topical Tranexamic Acid in Liposuction: A Randomized Double-Blinded Controlled Trial.

BACKGROUND: Tranexamic acid (TXA) use in surgical procedures due to its hemostatic effects has been gaining an increased interest. In plastic surgery, the effects of TXA have been studied intravenously (IV), and there have been some reports regarding local use. OBJECTIVES: A comparative study examining the combined effect of IV and local TXA was conducted. METHODS: A randomized double-blinded controlled trial was performed for patients undergoing breast reduction treatment with liposuction and resection following the power-assisted liposuction mammaplasty (PALM) technique. All patients received 5 mL IV of 0.5 g/5 mL TXA on induction. Before installation, one researcher prepared two solutions of 1 L normal saline: one with 5 mL of 0.5 g/5 mL TXA associated with epinephrine 1:100,000 and the other with only epinephrine 1:100,000. These were randomly infiltrated in either the left or right breast. Clinical dermal bleeding was assessed for both breasts after deepithelialization. The lipoaspirate from these breasts was then compared with each other. A postoperative evaluation at 24 hours was performed to compare the ecchymosis rate. RESULTS: Ratios of decanted volume to total lipoaspirate was measured in bottles and compared between breasts. There was a statistical difference (P = 0.0002) in the ratio of decanted to lipoaspirated volume when comparing the control group (ratio: 0.21) with the treatment group (0.13). Video analysis revealed decreased dermal bleeding in the TXA group and postoperative evaluation less ecchymosis. CONCLUSIONS: The combined use of IV and local TXA can help reducing blood loss in liposuction as measured by decantation in separate drain bottles and as assessed clinically preoperatively and postoperatively.

Composite Breast Remodeling After Implant Removal by Tissue Recruitment and Loops Fixation With Power-Assisted Liposuction and Lipofilling (PALLL).

BACKGROUND: An increasing number of women wish breast implant removal whilst maintaining an acceptable projection and form were possible. OBJECTIVES: The authors propose a technique to remodel the breast after implant removal utilizing internal suture loops to project the breast, recruit abdominal and axillary tissue cranially and medially, and provide a matrix for lipofilling. METHODS: A prospective analysis was performed of consecutive patients undergoing implant extraction followed by power-assisted liposuction loops and lipofilling. Patient characteristics were measured. The aesthetic results were evaluated by 2 independent raters. Patient-reported satisfaction was measured by standardized questionnaires. RESULTS: Implants in 52 patients with an average age of 55 and body mass index of 23.7 were extracted followed by breast remodeling. A total of 73% of patients had implants for aesthetic reasons, 41% were smokers, and 43% of the reconstruction cases received radiotherapy. A total of 28% had implant extraction for rupture, 58% for capsular contracture, and 14% due to pain and migration. The average volume of the implants removed was 292 cc, followed by an average lipofilling of 223 cc, yielding a ratio of 0.76 to 1. The average tissue recruited by loops was 82.5 cc. Independent raters measured 79% of results as good, 13% as acceptable, and 8% as requiring improvement; 80% of patients were satisfied to very satisfied. CONCLUSIONS: The authors propose implant extraction followed by power-assisted liposuction loops and lipofilling can provide footprint definition, sustained projection, and high patient satisfaction. Moreover, the recruitment of a vascularized adipo-cutaneous flap by loops allows a reduced ratio of fat grafting to implant volume.

Improving the Female Silhouette and Gluteal Projection: An Anatomy-Based, Safe, and Harmonious Approach Through Liposuction, Suspension Loops, and Moderate Lipofilling.

BACKGROUND: Liposuction is the main technique to improve body contour, emphasize appealing curves, and highlight one's muscular definition. The number of procedures in which the harvested fat is utilized for gluteal augmentation has greatly increased. OBJECTIVES: The authors aim to demonstrate their technique in order to obtain a sculpted harmonious body through a safe procedure, as well as review their 101 consecutive cases between 2014 and 2018. METHODS: Anatomical guidelines and preoperative markings were provided to guide the 3-step procedure: zones of maximal and mild liposuction, barbed wire suspension, and moderate fat grafting. Novel concepts are introduced as the anterior body diagonal, posterior body diagonal as well as other specific axes the pubic unit, and a vertical ratio for the buttock, which are the basic foundations for sculpting the female body into a pleasing hourglass shape with a well projected buttock. Recommendations for location of sacral diamond, sacral dimples, and the maximally projected point of the buttock are given. The authors explain their philosophy through 4 principles: knowledge of anatomy, the relationship between specific body areas and surrounding zones, a balanced gluteal augmentation is not achieved through large volume fat grafting alone, and grafting in the subcutaneous layer. RESULTS: A total of 101 patients were treated following the described technique and examples are shown. The complication rate was low. No serious adverse effects were recorded apart from 1 ruptured suspension loop. CONCLUSIONS: The described anatomy-based approach, including liposuction, suspension loops, and fat grafting, is a novel and safe technique leading to a desirable, long-lasting outcome.

No-Scar Breast Reduction Utilizing Power-Assisted Liposuction Mammaplasty, Loops, and Lipofilling.

BACKGROUND: In continued interest to develop and refine minimally invasive procedures, recent publications reported a scarless approach in breast lifting. OBJECTIVES: The authors sought to describe a power-assisted lipomodeling technique combined with surgical loops to achieve breast reduction and reshaping with minimal scars. METHODS: Between 2014 and 2018, 94 patients underwent breast reduction by combined liposuction and loops. Following infiltration of the breasts, liposuction of the outer quadrants and the lower pole was achieved to reduce the breast footprint and the lateral and inferior heaviness of the breast. After multiaxial multiplanar tunnelization, 3 types of loops were taken around the breast to suspend and elevate the breast skin envelope and parenchyma. Each loop was guided through a 3-mm, 3-hole cannula passed through skin stab incisions. The first loop was designed to reduce the breast footprint and enhance the breast projection, whereas the second loop was designed to achieve breast conus remodeling. The third loop was passed circumferentially around the areola and then cephalad along the breast axis and pulled until the desired nipple-areola complex elevation was reached. Each loop was pulled to achieve the desired breast projection and shape. RESULTS: The authors achieved breast reduction with a mean nipple elevation of 7.3 cm, and 88% of patients were satisfied with their breast shape. The total complication rate was 1%, including mild cellulitis in 1 breast, treated efficiently with oral antibiotics. CONCLUSIONS: The proposed technique is a novel, simple, and safe alternative to achieve breast reduction and reshaping without a scar.

A New Suturing Method for Optimal Wound Healing: Technique and Experience.

BACKGROUND: Wound closure utilizing barbed sutures has been associated with healing problems, such as thread extrusion, infection, and the increase of an inflammatory response around the scar. OBJECTIVES: In our study, the senior author described a novel technique of skin incision and wound closure based on de-epithelization and bi-layer tension-free closure that minimizes complications. METHODS: In this retrospective study, the authors reviewed the evolution of wound healing for the novel technique developed by the senior author by analyzing clinical reports of 817 patients who underwent surgery for abdominoplasty or breast reduction utilizing power-assisted liposuction mammaplasty with the new incision and closure technique. In addition, three separate plastic surgeons reviewed the wound characteristics and overall appearance by analyzing photographs that were taken over the course of 12 months to document the healing process. RESULTS: The overall complication rate was 14.1%, with 0.4% hematoma, 1.25% infection, 0.8% seroma, 1.5% necrosis, 3.75% erythema, 3.3% delayed wound healing, and 3.1% suture extrusion. The authors reported the rate of step-off border (9%), contour irregularities (6.5%), margin separation (1.25%), edge inversion (3.2%), excessive distortion (0.9%), and bad overall appearance (6.4%) of the cases. CONCLUSIONS: This new technique in wound incision and closure based on de-epithelization and bilayer tension-free closure reduces the complications associated with barbed sutures.

Corrigendum to: A New Suturing Method for Optimal Wound Healing: Technique and Experience.

[This corrects the article DOI: 10.1093/asjof/ojaa008.].

Power-Assisted Liposuction and Lipofilling: Techniques and Experience in Large-Volume Fat Grafting.

BACKGROUND: Power-assisted liposuction and lipofilling (PALL) is a simple and reproducible surgical technique for large volume fat grafting. OBJECTIVES: The authors share their 7-year experience with their large-volume fat transfer technique, PALL. METHODS: A total of 417 patients who underwent PALL-related surgeries involving the breast and buttock were evaluated in a retrospective study. Liposculpting and fat harvesting were performed with power-assisted liposuction. Fat was transferred with simultaneous power-assisted vibration and tunnelization to provoke expansion of the recipient site. Following lipofilling, additional external vibration of the recipient site was performed to enhance diffusion of the injected fat. RESULTS: Liposuction volumes up to 5000 mL were recorded, and injection volumes ranged from 300 to 900 mL per side for each session. Operating times ranged from 45 to 120 minutes. Patients were followed-up for 1 to 4 years. No major complications were recorded. CONCLUSIONS: PALL is an efficient, safe, and reproducible procedure with myriad applications in aesthetic and reconstructive surgery.Level of Evidence: 4.

Brachioplasty by Power-Assisted Liposuction and Fat Transfer: A Novel Approach That Obviates Skin Excision.

BACKGROUND: Current brachioplasty techniques include excisional surgery alone or in combination with liposuction. These techniques are associated with poor outcomes, such as residual contour deformities and unfavorable scarring. OBJECTIVES: The authors proposed a new classification system and treatment algorithm for brachial ptosis and described their experience with power-assisted liposuction and lipofilling to treat brachial ptosis without excisional surgery. METHODS: Ninety-five patients with grades 1, 2, or 3 brachial ptosis who underwent brachioplasty were evaluated in a prospective study. Power-assisted liposuction was applied to the posterior arm and para-axillary region, and power-assisted lipofilling was applied to the so-called "bicipital triangle" of the medial arm. RESULTS: The patients' mean age was 39 years, mean body mass index was 28 kg/m(2), mean lipoaspirate volume was 240 mL per arm, and mean fat-injection volume was 110 mL per side. The mean operating time was 50 minutes, and the average follow-up period was 24 months. Hematoma developed in 2 patients who underwent brachioplasty in combination with another body contouring procedure (1 abdominal hematoma and 1 thigh hematoma; 2.1% complication rate). No other complications were recorded. CONCLUSIONS: Brachioplasty by means of power-assisted liposuction and lipofilling is a safe and reliable option that obviates excisional surgery in patients with mild to moderate brachial ptosis. LEVEL OF EVIDENCE: 4 Therapeutic.

Power-Assisted Liposuction Mammaplasty (PALM): A New Technique for Breast Reduction.

BACKGROUND: Resection and reshaping of the parenchyma are common procedures to produce a natural breast shape in reduction mammaplasty and mastopexy. The challenges of these practices include maintaining sensitivity of the nipple-areola complex (NAC), achieving upper-pole fullness, and preserving an adequate blood supply for patients with massive breast ptosis. OBJECTIVES: The authors describe their experience with power-assisted liposuction mammaplasty (PALM), a novel technique for breast reduction. METHODS: One hundred fifty consecutive women (300 breasts) who underwent PALM were evaluated in a prospective study. Minimizing skin undermining and glandular resection ensured maximal blood supply to the breast. A lateral pedicle was created to preserve NAC sensitivity. The transposed gland was contained within a large pocket made in the upper-inner quadrant. Glandular suspension sutures from the dermis to the chest wall stabilized the breast and recreated the inframammary fold. RESULTS: The mean distance from the nipple to the sternal notch was 36 cm, the mean NAC elevation was 16 cm, the mean lipoaspirate volume per breast was 650 cc, and the mean glandular resection mass per breast was 240 g. Complications included wound infection (6 of 300 breasts, 2%), wound dehiscence (3 breasts, 1%), and seroma (9 breasts, 3%). Partial areolar necrosis occurred in 2 of 150 patients (1.3%), and 9 patients (6%) underwent revisional surgery. CONCLUSIONS: PALM is a safe and reliable option for breast reduction and is indicated for patients with massive breast ptosis. LEVEL OF EVIDENCE 4: Therapeutic.

Power-assisted gluteal augmentation: a new technique for sculpting, harvesting, and transferring fat.

BACKGROUND: A simple and reproducible surgical technique for gluteal shaping and augmentation with autologous fat is needed. OBJECTIVES: The authors describe a novel approach to large-volume gluteal augmentation that combines power-assisted liposculpting and fat harvesting of the zones around the buttock with autologous fat transfer. METHODS: One hundred ten patients who underwent gluteal augmentation were evaluated in a prospective study. Liposculpting and fat harvesting were performed with power-assisted liposuction. Fat then was transferred to the gluteal region with simultaneous power-assisted vibration and tunnelization. A questionnaire to assess patient satisfaction was administered at 6 months postoperatively. RESULTS: The mean body mass index of the patients was 30 kg/m(2) (range, 26-36 kg/m(2)). Liposuction volumes ranged from 1400 to 5000 mL, and injection volumes ranged from 300 to 900 mL per side for each session. Operating times ranged from 60 to 120 minutes. Patients were monitored for an average of 20 months (range 12-48 months). Complications included a burning sensation in 5 of 110 patients (4.5%), persistent swelling in the lower back in 3 patients (2.7%), and a mild infection in 1 patient (0.9%). CONCLUSIONS: Power-assisted gluteal augmentation with autologous fat is an efficient, safe, and reproducible procedure that produces an aesthetically pleasing gluteal projection and contour. LEVEL OF EVIDENCE: 4 Therapeutic.

Immediate Large-Volume Grafting of Autologous Fat to the Breast Following Implant Removal.

BACKGROUND: To optimize autologous breast augmentation, a simple and reproducible surgical approach that maximizes the volume of fat transferred to the breast while minimizing the number of sessions and the operating time is needed. OBJECTIVES: The authors describe a novel approach for large-volume fat grafting to the expanded skin and subcutaneous tissue of the breast immediately after explantation, exchanging the volume provided by the implants with transplanted fat in a single session. METHODS: Eighty patients (160 breasts) undergoing explantation and autologous fat transfer were evaluated in a prospective study. Fat was harvested with the lipomatic power-assisted liposuction machine (Lipomatic Eva SP, Euromi SA, Verviers, Belgium) and was injected with simultaneous vibration and tunnelization of the recipient site by means of the same machine with suction disabled. Changes in breast volume were measured in terms of bra cup size, and patients were monitored by mammography and ultrasonography. Patient satisfaction was assessed with a questionnaire administered 6 months postoperatively. RESULTS: Injected fat volumes ranged from 300 to 600 mL per breast. Operating times ranged from 45 to 90 minutes. For all patients, one injection session was sufficient to replace the volume of the previous implant. Patients were monitored for an average of 2 years, and complications included cyst formation in 9 of 160 breasts (5.6%) and infection in 2 breasts (1.25%). CONCLUSIONS: Power-assisted transfer of autologous fat to the breast improves the ability of the recipient site to receive the graft and allows for explantation and fat transplantation in a single session. This approach is suitable for patients who desire a natural-appearing breast that is similar in volume to their previous implant.

Retalho toracodorsal desepitelizado: um novo conceito para a reconstrução autóloga da mama / Deepithelialized thoracodorsal flap: a new concept for autologous breast reconstruction

INTRODUÇÃO: A associação de retalho muscular toracodorsal com uma extensão fasciocutânea resulta em um amplo retalho, que permite recobrir o defeito cutâneo residual da mastectomia. O objetivo deste estudo é compartilhar 11 anos de experiência com um novo conceito em reconstrução autóloga da mama, utilizando um retalho cutâneo toracodorsal desepitelizado pediculado com músculo grande dorsal como vetor. MÉTODO: Foi realizado um estudo retrospectivo com 247 pacientes operadas de 1999 a 2009. Os parâmetros de interesse incluíram idade, índice de massa corporal, história de tabagismo, radioterapia e quimioterapia, tamanho da mama, dimensões do retalho, tempo cirúrgico, expansão do tecido mamário e índice de complicações. O desenho do retalho toracodorsal em formato de elipse se estende da região da linha dorsal média até a linha inframamária média, com largura máxima na linha axilar média. A extensão fasciocutânea desepitelizada é colocada dissecada juntamente com o músculo grande dorsal como seu veículo e pedículo responsável pelo suprimento sanguíneo, que são levados em monobloco até a área de pele da nova neomama previamente dissecada. O formato e a projeção da mama são restaurados gradualmente como uma expansão de tecido. RESULTADOS: Reconstruções imediata e tardia da mama foram realizadas em 14,5% e 85,5% das pacientes, respectivamente. A reconstrução bilateral da mama foi realizada em 8,9% das pacientes. Nenhuma das pacientes submetidas a radioterapia mamária (76,7%) recebeu implantes para reconstrução. O tempo cirúrgico médio foi de 2 horas e 20 minutos. A expansão da pele mamária não irradiada foi realizada em um período de 3 meses, enquanto a expansão da pele irradiada levou um período médio de 5 meses após a reconstrução tardia. A taxa de complicações foi de 11,3%. Não houve perda total do retalho. A taxa de seroma foi de 7% após a remoção dos drenos. O tempo de hospitalização médio foi de 3 dias. Foi realizado remodelamento da mama contralateral em 92% dos casos e enxerto de gordura em 14% das pacientes. Em um período médio de acompanhamento de 4 anos, a taxa de satisfação das pacientes foi elevada. CONCLUSÕES: O retalho toracodorsal é uma opção cirúrgica segura e confiável para a reconstrução autóloga da mama. As principais vantagens são a obtenção de grandes volumes de mama contornando o uso de material protético, evitando-se a aparência de retalho na mama reconstruída, obtendo-se expansão tecidual e, ao mesmo tempo, garantindo morbidade aceitável no sítio doador.

BACKGROUND: The association the thoracodorsal muscular flap with a thoracic fascio-cutaneous extension results in a large flap, that allowed to cover the mastectomy residual skin defect. The purpose of this study is to share 11 year experience with a new concept in autologous breast reconstruction using a deepithelialized thoracodorsal skin flap pedicle with the latissimus dorsi muscle as vector. METHODS: A retrospective study of 247 operated patients from 1999 to 2009 was performed. Parameters of interest included age, body mass index, smoking, radiation and chemotherapy histories, breast size, flap dimensions, operative time, breast tissue expansion and complication rates. The thoracodorsal flap design under an ellipse shape extends from near the mid dorsal line extended up to the mid-infra-mammary line with maximal width at the mid axillary line. The deepithelialized fascio-cutaneous extension is lumped together with the latissimus dorsi as its vehicle and blood supply pedicle, together are brought to the neo-mammary previous dissected skin area. Gradual as a tissue expansion the breast shape and projection are restored. RESULTS: Immediate and delayed breast reconstructions were done in 14.5% and 85.5%, respectively. Bilateral breast reconstruction was done in 9% of the patients. Implants were not used for reconstruction purposes in any of the 77% of the patients received breast radiotherapy. The average operative time was 2 hours and 20 minutes. Expansion of non irradiated breast skin occurred over a three months period, whereas that of irradiated skin took an average of five months following delayed reconstruction. The complication rate was 11.4%. No total flap loss was reported. The seroma rate was 7% after the drains had been removed. The mean hospital stay was 3 days. Contra lateral breast remodeling was performed in 92% of the cases and fat grafting in 14% of the cases. With an average follow-up of 4 years, patient satisfaction was rated high by the patients. CONCLUSIONS: The thoracodorsal flap is a safe and reliable surgical option for autologous breast reconstruction. Its main advantages achieving large breast volumes circumventing the use of prosthetic material, avoiding the patch look on the reconstructive breast, achieving tissue expansion, while insuring acceptable donor site morbidity.