Faculty Bibliography

Despite the clinical relevance of bottoming out, or pseudoptosis, associated with reduction mammaplasty (RM) its evaluation remains an imprecise science. This study aims to further define the kinetics of postoperative pseudoptosis over an extended period of time, after our previous study investigating pseudoptosis in the early postoperative period. Patients undergoing medial pedicle RM had 3-dimensional photographs taken at year 1 and year 2 intervals postoperatively (year 1 = 300-450 days; year 2 = 700-900 days). Bottoming out was assessed with various 3-dimensional parameters. The total breast volume and the percent tissue distribution in the upper pole of the breast did not change from year 1 to year 2. The anterior-posterior projection as well as vector measurements for internipple distance and sternal notch to nipple distance also remained stable from year 1 to year 2. Although previous data from our group documented the occurrence of bottoming out and continued size reduction over the first postoperative year after breast reduction, the present study shows that pseudoptosis does not seem to occur during the second postoperative year

Breast augmentation is one of the most common plastic surgery procedures performed in the United States today. Evaluation of postoperative results lacks true objective measurements. The following study reports the application of 3-dimensional (3D) photography to document changes that occur in breast morphology after breast augmentation. Patients undergoing augmentation mammaplasty with a periareolar incision were offered pre- and postoperative 3D photographs. 3D models were constructed and the following parameters were assessed: maximum anterior-posterior projection from the chest wall, angle of breast projection, total breast volume, volumetric tissue distribution in the superior and inferior poles, and surface and vector distance measurements to key landmarks. A completed series of 3D images were obtained from 14 augmentation patients (28 breasts) at an average postoperative day of 143. Saline and silicone implants were used equally (n = 14 for each). Total volume of the breast changed in correlation with the implant size (1.9% difference, P = 0.83). There were no significant changes in the volumetric distribution within the upper and lower poles of the breasts noted between pre- and postoperative scans (P = 0.81). The internal angle of breast projection was found to increase (13.6 degrees, P < 0.01), as did the sternal notch to nipple distance (11 mm, P = 0.018). Anterior-posterior projection significantly increased by 23.3 mm. However, this increase in projection was 20.9% less than expected based on implant dimensions (72.7-58.7 mm, respectively, P < 0.01). This study documents objective changes in breast morphology after augmentation mammaplasty. 3D imaging scans were able to document true changes that occur with breast augmentation including breast volume, the increase in the internal angle of the breast projection, and the sternal notch to nipple distance. 3D photography further highlighted that breast augmentation results in less than expected anterior-posterior projection, possibly due to tissue attenuation occurring anterior to the implant

The current approach to breast reconstruction remains largely subjective and is based on physical examination and visual-estimates of breast size. Thus, the overall success of breast reconstruction is limited by the inability of plastic surgeons to objectively assess breast volume and shape, which may result in suboptimal outcomes. A potential solution to this obstacle may be three-dimensional (3D) imaging, which can provide unique clinical data that was previously unattainable to plastic surgeons. The following study represents a prospective analysis of patient volunteers undergoing unilateral tissue expander (TE)-implant reconstruction by one of the two senior authors (MC, NSK). All patients underwent unilateral mastectomy with immediate or delayed insertion of a TE, followed by an exchange for a permanent silicone or saline implant. 3D scans were obtained during routine pre- and postoperative office visits. The 3D breast-volume calculations served as a guide for surgical management. Twelve patients have completed 3D-assisted unilateral breast reconstruction to date. These patients represent a wide range of body habitus and breast size/shape; 3D volume range from 136 to 518 cm(3). The mean baseline breast asymmetry in this group was 12.0 +/- 10.8%. Contralateral symmetry procedures were performed in eleven patients, consisting of the following: mastopexy (n = 6), augmentation (n = 1), mastopexy/augmentation (n = 2), and reduction mammoplasty (n = 2). Reconstruction was completed in a total number of 2 (n = 10) or 3 (n = 2) operations. Overall breast symmetry improved at the completion of reconstruction in the majority of patients, with an average postoperative symmetry of 95.1 +/- 4.4% (relative to 88% preoperatively). 3D imaging serves a valuable adjunct to TE-implant breast reconstruction. This technology provides volumetric data that can help guide breast reconstruction, such as in choosing the initial TE size, total volume of expansion, and final implant size/shape. 3D imaging technology also provides benefit as a method for assessing tissue expansion, the need for symmetry or revision procedures, and critically analyzing the final reconstructive outcome

BACKGROUND: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three-dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. METHODS: Preoperative and postoperative three-dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. RESULTS: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively; p < 0.01). The point of maximal breast projection was elevated in the cranial-caudal direction (4.8 +/- 0.4 cm; p < 0.01), with a corresponding elevation in the lowest point of the breast (4.8 +/- 0.5 cm; p < 0.01). Volumetric three-dimensional measurements identified a significant change in percentage tissue distribution after reduction mammaplasty (45 +/- 2 percent above the inframammary fold preoperatively versus 76 +/- 2 percent postoperatively; p < 0.01). CONCLUSIONS: This study is the first to demonstrate the technical feasibility and clinical utility of three-dimensional geometric data in medial pedicle breast reduction surgery. This novel approach suggests new opportunities to define long-term operative changes following various breast procedures

There is no doubt that reduction mammoplasty (RM) results in significant improvement in a myriad of patient macromastia-related symptoms and other macromastia-related quality of life factors. Whether this improvement is correlated with the amount of tissue resected remains unknown because no previous study of RM has stratified patients by the amount of breast tissue resected. In this study, all patients were given a custom-designed questionnaire designed to evaluate their macromastia-related symptoms and other macromastia-related quality of life issues. Patients were then provided the same questionnaire at their final postoperative visit between 3 and 12 months after surgery. A total of 188 patients completed pre- and postoperative surveys. Before the initiation of this study, patients were stratified by the total weight of breast tissue resected into the following cohorts: 1000 g or less (66 patients), 1001 to 1500 g (55 patients), 1501 to 2000 g (30 patients), and greater than 2000 g (37 patients). RM resulted in significant improvement in all macromastia-related symptoms and quality of life factors analyzed (P < 0.000001). There were no significant differences (P > 0.05) in pre- and postoperative macromastia-related symptoms across our 4 groups with the exception of lower back pain (preoperative P = 0.026), shoulder pain (preoperative P = 0.014), and painful bra strap grooves (preoperative P = 0.0059). Analysis of the symptomatic burden of macromastia on several quality of life factors showed no significant differences (P > 0.05) in either the pre- or postoperative symptom scores across all groups in any of the categories assessed. This study demonstrates that women seeking breast reduction have a similar preoperative symptom burden across a wide range of breast sizes. Furthermore, the symptomatic improvement derived from RM is not significantly different between women of different breast sizes

BACKGROUND: Breast reduction is one of the most frequently performed plastic surgical procedures in the United States; more than 160,500 patients underwent the procedure in 2005. Many outpatient reduction mammaplasty patients report the greatest postoperative discomfort in the first 48 hours. The authors' investigated the effect of intraoperative topical application of the long-acting local anesthetic agent bupivacaine (Sensorcaine or Marcaine) on postoperative pain, time to postanesthesia care unit discharge, and postoperative use of narcotic medication. METHODS: In a prospective, randomized, single-blind trial, intraoperative use of Sensorcaine versus placebo (normal saline) was compared. Postoperative pain was quantified using the visual analogue scale, and time to discharge from the postanesthesia care unit was recorded. Patients documented their outpatient pain medication usage. RESULTS: Of the 37 patients enrolled in the study, 20 were treated with intraoperative topical Sensorcaine and 17 received placebo. Patients treated with Sensorcaine were discharged home significantly faster (2.9 hours versus 3.8 hours, p = 0.002). The control arm consistently had higher pain scores in the postanesthesia care unit (although not statistically significant) than the Sensorcaine group using the visual analogue scale system. Furthermore, patients receiving Sensorcaine required significantly less narcotic medication while recovering at home (mean, 3.5 tablets of Vicodin) than the control group (mean, 6.4 tablets; p = 0.001).There were no complications resulting from Sensorcaine usage. CONCLUSIONS: This prospective, randomized, single-blind study demonstrates that a single dose of intraoperative Sensorcaine provides a safe, inexpensive, and efficacious way to significantly shorten the length of postanesthesia care unit stay and significantly decrease postoperative opioid analgesic use in patients undergoing ambulatory reduction mammaplasty

BACKGROUND: Reduction mammaplasty has been shown to be efficacious in reducing the burden of symptoms and improving the quality of life for patients with macromastia. However, most insurance carriers will not reimburse for mammaplasties involving less than 1000 g of total tissue resected. To refute this arbitrary policy, the authors set out to examine the effect of reduction mammaplasty in which less than 1000 g of breast tissue was resected on patients' macromastia-related symptoms and macromastia-related quality-of-life factors. METHODS: All patients were given a custom-designed questionnaire designed to evaluate macromastia-related symptoms and other macromastia-related quality-of-life issues. Patients were then provided the same questionnaire at their final postoperative visit between 3 and 12 months after surgery. RESULTS: A total of 59 patients underwent reduction mammaplasty of less than 1000 g. Reduction mammaplasty less than 1000 g resulted in significant decreases in all macromastia-related symptoms analyzed, including upper back pain, lower back pain, neck pain, arm pain, shoulder pain, hand pain, breast pain, headaches, rashes, and/or itching and painful bra strap grooving (all p < 0.00002). Furthermore, reduction mammaplasty resulted in significant improvement in all quality-of-life factors analyzed, including difficulty buying clothes and bras, difficulty participating in sports, and difficulty running (all p < 0.00001). CONCLUSIONS: Reduction mammaplasty totaling less than 1000 g offers substantial relief of macromastia-associated symptoms and results in significant improvement in patients' quality of life. This prospective study conclusively demonstrates that reduction mammaplasty totaling less than 1000 g should be a fully reimbursable procedure

BACKGROUND: Lower-extremity reconstruction with microvascular free flap coverage is often the only option for limb salvage. Flap failure rates, however, continue to have higher complication rates than those to other anatomic sites; a significant number of flaps that fail result in amputation. This study retrospectively analyzed patients treated at a single institution who underwent attempted lower-extremity limb salvage with microsurgical techniques over a 25-year period. Of particular interest are the outcome data for patients who had initial free flap failure. PATIENTS AND METHODS: A prospectively maintained database was used to identify patients who satisfy criteria. Every patient who was treated with a microvascular free flap to their lower extremities was identified and included in this analysis. All records were reviewed from 1980 through 2004. Patients who had free flaps to the lower extremity fail after the initial operation were identified and selected for further analysis. RESULTS: Five hundred eighty-eight patients who underwent microsurgical reconstruction of lower extremity wounds had a failure rate of 8.5%. Trauma patients (83%) had a failure rate of 9%. On subset analysis, the failure rate for trauma patients decreased from 11% (1980-1992) to 3.7% (1993-2004). Of patients who had a failed free flap, 18% went on to limb amputation; the remainder was salvaged with secondary free flaps, local flaps, or skin grafting. CONCLUSION: This single institutional experience spanning 25 years represents the longest continual series of lower-extremity free flaps reported in the literature. The improved success rate seen in the second half of the study period is attributed to a more critical selection of free-flap candidates, improved understanding of the physiology surrounding acute trauma and a more sophisticated multidisciplinary team organization