• Archives of Plastic Surgery
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• v.37 no.1
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• pp.26-30
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• 2010

Purpose: Common complications of immediate breast reconstruction with implant are capsular contracture, malposition of implant, hematoma and seroma. Especially, the most severe complication is implant exposure caused by inflammation or necrosis of skin flap margin of mastectomy site. This article reports the experience of cases of salvage in such an exposure of implant. Methods: From July, 2002 to Feb., 2009, sixty-five patients who underwent immediate breast reconstruction with implant were retrospectively analyzed. Exposure of implant was happened in 5 of 65 patients and they were treated at out patient district. Two of five patients were reconstructed with saline implnt and all of them underwent the enveloping of the implant with AlloDerm$^{(R)}$ and Serratus muscle flap. Remaning three patients were reconstructed with silicone implant and all of them underwent the enveloping of the implant with AlloDerm$^{(R)}$. Results: In the group of patients who underwent reconstruction with saline implant, implant exposure was found in one patient due to partial necrosis of the margin of skin flap and debridement and primary repair were done. In the other one patient, dressing with antibiotic ointment were done. And debridement and primary repair were proceeded. In the group of patients who underwent reconstruction with silicone implant, implant exposure was found in one patient. After removal of the implant, tissue expansion was done and a new silicone implant was inserted. Implant exposure were found in the other two patients, antibiotics ointment application and primarily repaired. Conclusion: It was the common knowledge that the exposed implant should be removed. But salvage of the exposed implants may be possible with proper treatment. Four of five patients (80%) with exposed breast implant were salvaged with conservative management.

• Archives of Plastic Surgery
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• v.36 no.6
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• pp.750-754
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• 2009

Purpose: The thoracodorsal vessels have been the standard recipient vessels for the majority of surgeons performing free abdominal flap breast reconstructions. Recently, the internal mammary vessels have been recommended as the first - choice recipient vessels for microvascular breast reconstruction. To approach the internal mammary vessel, 3rd or 4th rib cartilage excision is needed, but this method has some demerits - vessel injury, post operative pain and post operative chest hollowness. So, authors propose the approach method to the internal mammary vessel through intercostal space without rib cartilage resection. Methods: From November, 2008 to May, 2009, 13 patients underwent free abdominal flap breast reconstruction with approach to the internal mammary vessel through intercostal space without rib cartilage resection. Results: The mean patient age was 41.8 years, and the mean height was 159.3 cm. 11 patients underwent immediate breast reconstruction. Free DIEP flap reconstruction was performed in 7 patients, Free TRAM flap was performed in 5 patients, and Free SIEA flap was performed in 1 patient. Except 1 case, approach to the internal mammary vessel was took through 3rd intercostal space, and all width of intercostal space exceeded 1 cm. Conclusion: In the authors' experience, use of approach to the internal mammary vessels without rib cartilage resection method is safe and reliable to overcome demerits of rib cartilage resection method.

• Archives of Plastic Surgery
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• v.36 no.2
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• pp.161-166
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• 2009

Purpose: Using the implant for the breast reconstruction still remains the options, despite the breast reconstruction using autologous tissue is an ideal method. In this study, we used AlloDerm$^{(R)}$ to extend subpectoral pocket for covering implants to reduce implant related complications. Met hods : From January 2005 to June 2007, 18 breasts in 16 patients were reconstructed using implant and AlloDerm$^{(R)}$ immediately after mastectomy. Hospital records, database files, and clinical photographs were reviewed. A ten - point scale was used to evaluate the patient's satisfaction, with a range from 2(poor) to 10(excellent). Results: Mean age of the patients was 38.7 years at the time of operation. Mean weight of removed breast tissue was 287g. AlloDerm$^{(R)}$ was used to extend subpectoral coverage. Any systemic complication was not reported. Breast complication was developed in 4 cases. Implant removal or change was not experienced. Conclusion: Immediate breast reconstruction using Implant is useful methods for certain conditions, when donor tissue is insufficient and breast is non ptotic with round shape. In those cases, extension of muscle coverage using AlloDerm$^{(R)}$ could reduce complications and lead more acceptable results.

• Archives of Plastic Surgery
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• v.36 no.6
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• pp.761-766
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• 2009

Purpose: Secondary breast reconstruction is defined as a whole reconstructive procedure to correct complications and to improve the aesthetics when a patient is dissatisfied with her initial reconstruction. We would like to present these particular procedures on previously failed breast reconstruction with analysis of unsatisfactory results. Methods: From June 2002 to August 2008, we performed secondary breast reconstructions for 10 patients with failed breasts. Six patients with implant failure underwent secondary breast reconstructions using free TRAM flaps after the removal of implants. Two patients with partial loss of pedicled TRAM flaps underwent secondary breast reconstruction using Latissimus Dorsi flaps. Two patients with 1 total loss of free TRAM flap and 1 extensive fat necrosis underwent secondary breast reconstruction using implants. Results: The average age of the patients were 36.4 years (26 ~ 47 years). All flaps survived completely and had relatively good aesthetic results in free TRAM cases. There was breast asymmetry in one patient using cohesive gell implants in total loss of previously free TRAM patient, which was corrected by exchanging the implants and placing dermofat grafts. Conclusion: Secondary breast reconstruction differs from primary procedures in several aspects; there are changes in the anatomy and tissue environment of the breasts, and various limitations in choosing reconstruction methods. In addition, the patients may be uncomfortable with previous complication. It is important to consider various factors before deciding to undergo a secondary breast reconstruction carefully with informed consent.

• Archives of Plastic Surgery
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• v.36 no.6
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• pp.755-760
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• 2009

Purpose: Breast surgeons usually insert tissue expander or implant beneath the subpectoral - subglandular dual plane in breast reconstruction. But sometimes it happens unsatisfactory lower pole fullness, asymmetric inframammary fold and breast shape because there is implant migration due to the pectoralis major muscle contraction and gravity. To solve all the problem like these, we introduce implant breast reconstruction using AlloDerm$^{(R)}$(LifeCell Corp., Branchburg, N.J.) sling. Methods: The AlloDerm$^{(R)}$ sling was used in 13 patients and 18 breasts for implant breast reconstruction. After mastectomy, costal and lower sternal insertion of pectoralis major muscle was detached. Rehydrated AlloDerm$^{(R)}$ was sutured to the chest wall and serratus anterior fascia at the level of inframammary fold downward and to lower border of the pectoralis major muscle upward like crescent shape with tension free technique after implant insertion into the subpectoral - subAlloDerm dual pocket. Results: We make satisfactory lower pole fullness, symmetric inframammary fold and breast shape. In conclusion, patients obtain relatively natural breast shape. There was no complication except one case of capsular contracture and one case of breast cellulitis. Conclusion: Implant breast reconstruction using AlloDerm$^{(R)}$ sling makes easy to get natural breast shape through satisfactory lower pole fullness, symmetric inframammary fold and implant positioning.

• Archives of Plastic Surgery
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• v.36 no.6
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• pp.773-778
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• 2009

Purpose: The authors propose the new classification of fatty - type gynecomastia(lipomastia) which can serve as a guide for modifying the periareolar technique. Methods: A retrospective analysis was made of 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 < 50 ml, fibroglandular component < 3 g each breast), flattening of the thorax can be achieved by means of stab incision, ultrasound - assisted lipectomy(UAL), scavenging suction - assisted lipectomy(SAL) and tissue shaving. At grade II(50 < < 150 ml, 3 < < 5 g), stab incision, UAL, SAL and pull - out method(POM) using small curved scissors. At grade III(150 < < 300 ml, 5 < < 15 g and prominent inframammary fold(IMF)), minimal incision (5 - 6 mm), UAL, SAL and POM using small angulated scissors, and blunting IMF. At grade IV (300 < < 500 ml, 15 < < 30 g, and glandular ptosis), minimal incision (5 - 6 mm), UAL, SAL, fibroglandular excision using small angulated scissors, cutting IMF and fixation of nipple - areola complex(NAC) becomes necessary. At grade V (> 500 ml, > 30 g and ptosis), small incision (7 - 8 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 were hematoma (n = 7), infection (n = 3) and hypertrophic scar (n =13). Almost 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.

• Archives of Plastic Surgery
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• v.36 no.6
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• pp.806-810
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• 2009

Purpose: Gynecomastia is an abnormal increase in the volume of the male breast. Subcutaneous mastectomy was the first surgical treatment for gynecomastia. But because of the complications such as nerve injury and scar formation, subcutaneous mastectomy has been substituted with liposuction. Recently various techniques including ultrasound - assisted liposuction has been used for treatment of gynecomastia. The purpose of this study is to evaluate the results of XPS$^{(R)}$ microresector(Shaver) for treatment of gynecomastia. Methods: 17 patients, 33 breasts of gynecomastia, Simon grade I or II have been treated with XPS$^{(R)}$ microresector(Shaver). The mean age was 24.5. The subcutaneous tissue and glandular tissue were removed with XPS$^{(R)}$ microresector(Shaver). The operation time, the weight of removed tissue and patients' satisfaction score were accessed. Results: The mean operation time was 78.2 minutes. The mean weight of removed tissue was 113.8 g. There was no significant complications such as necrosis, hematoma, infection or scar contracture. Patients' satisfactory score of scar, shape and confidence were 8.4, 8.2 and 8.4 respectively. As the average score was 8.3, almost patients were satisfied with their breasts. Conclusion: The authors have treated 17 patients suffering from gynecomastia with XPS$^{(R)}$ microresector(Shaver). We obtained short operation time, early recovery, minimal operative scar and less complications with XPS$^{(R)}$ microresector(Shaver) for the treatment of gynecomastia, and patients were satisfied with the results of our method. We concluded XPS$^{(R)}$ microresector(Shaver) is an alternative option for the treatment of gynecomastia.

• Archives of Plastic Surgery
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• v.34 no.2
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• pp.229-236
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• 2007

Purpose: Breast reconstruction with deep inferior epigastric perforator(DIEP) free flap is known to be the most advanced method of utilizing autologous tissue. The DIEP free flap method saves most of the rectus abdominis muscle as well as anterior rectus sheath. Therefore, the morbidity of the donor site is minimized and the risk of hernia is markedly decreased. Methods: We chose the internal mammary artery and its venae comitantes as recipient vessels, and deep inferior epigastric vessels as donor vessels. The number and location of the perforators derived from medial or lateral branch of deep inferior epigastric artery(DIEA) in 23 DIEP flaps were identified. Ten patients underwent evaluation of their abdominal wall function preoperatively and 6 months postoperatively by using Lacote's muscle grading system. Results: Of the 23 patients, a patient with one perforator from lateral branch of DIEA experienced partial necrosis of flap. Total flap loss occurred in one patient. Mild abdominal bulging was reported in one patient 4 months postoperatively probably because of early vigorous rehabilitational therapy for her frozen shoulder. Postoperative abdominal wall function tests in 10 patients showed almost complete recovery of muscle function upto their preoperative level of upper and lower rectus abdominis and external oblique muscle function at 6 months postoperatively. All patients have been able to resume their daily activities. Conclusion: The breast reconstruction with DIEP free flap is reliable and valuable method which provide ample soft tissue from abdomen without compromising the integrity of abdominal wall. Selection of reliable perforators is important and including more than two perforators may decrease fat necrosis and partial necrosis of flap.

• Archives of Plastic Surgery
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• v.34 no.4
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• pp.436-440
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• 2007

Purpose: TRAM flap surgery has settled down as a common method for breast reconstruction after mastectomy. We investigated how TRAM flap surgery influences on the patients' physical movement capability by observing their capability of sit-ups as well as exercises they usually enjoy. Methods: A total of consecutive 375 patients were investigated who had breast reconstruction with unilateral pedicled TRAM flap surgery at Asan Medical Center from July 2001 to August 2005. The patients were asked to sit up right before the surgery and do it again 6 months later and 1 year later. 221 patients were followed up 6 month after the surgery. And 132 patients were followed up 1 year after the surgery. In addition, 155 patients who used to exercise before the surgery were also asked to show us the change in their physical movement capability one year after their surgery. Results: 139 patients showed decrease in the counted number of sit-ups, 48 increase, and 34 showed no change between 6 months in the first group of 221 patients. Among the second group of 132 patients, 64 showed decrease, 39 increase, and 29 no change a year later. There was a statistical significant decrease in the number of sit-ups between pre-operation and six months later and between pre-operation and one year later. According to the research on the exercise that 155 patients participated, 3 of them showed improvement in athletic ability, 7 showed decrease, while the rest, 145 patients, showed no change at all. Conclusion: Considering no difference in usual exercise ability, some patients' increase in the number of sit-ups and the effect of anticancer treatment, we found that the loss of abdominal wall function on this research is not too serious to exclude TRAM flap surgery in the field of breast reconstruction

• Archives of Plastic Surgery
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• v.34 no.2
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• pp.237-242
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• 2007

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 4 cm, 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 5-7 mm incision. For the parenchymal diameter more than 4 cm, ultrasound-assisted liposuction and excision were applied through 2.5 cm 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.