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Implant based breast reconstruction ppt,breast lift melbourne medicare,breast implant after pregnancy,breast implant removal no replacement - Test Out

09.02.2015
Reconstruction with breast implants involves restoring the form of the breast by inserting, into the mastectomy site, a breast prosthesis made of synthetic material.
The most commonly used method of implant-based breast reconstruction involves preparation of the mastectomy site with an implantable device called a tissue expander. While implant reconstructions generally require the shortest initial hospitalization of all the possible methods of breast reconstruction—and some women find implant reconstructions appealing for this and other reasons—many patients and many doctors are troubled by the high rate of unplanned re-operation associated with this method of reconstruction. The FDA publication Breast Implants––Potential Local Complications and Reoperations provides a more through review. If radiation has been or will be part of the treatment of a woman’s breast, there is an even higher rate of complications associated with the use of implants, and aesthetic results may be adversely affected.
For women contemplating reconstruction of just one breast, an additional consideration may be the degree to which a breast reconstructed with an implant will be able to match the uninvolved breast, in both appearance and feel. In spite of the drawbacks and complications unique to implants, there are some advantages to implant breast reconstruction as compared to natural tissue breast reconstruction.
The advantages of this quicker and technically less demanding reconstruction method should be weighed against the disadvantages of later complications, including capsular contracture and a high rate of unplanned re-operation and the lifespan of breast implants. For women who wish to undergo restorative breast surgery without an implant, natural-tissue reconstructive procedures may be appealing. Washington, Feb, 23 : The Food and Drug Administration (FDA) has given its approval to a highly cohesive anatomically shaped silicone-gel filled breast implant. Natrelle 410 - manufactured by Allergan, Inc - has now been approved for the purpose of breast augmentation in adults - 22 and older - and in women of all ages - undergoing a breast reconstruction following cancer, CBS News reported. These silicone implants have more cross-linking in their gel than earlier ones that makes it more cohesive, which in turn makes the implants firmer. Science, Technology and Medicine open access publisher.Publish, read and share novel research.
Implant-Based Dual-Plane Reconstruction of the Breast Following Sparing MastectomyEgidio Riggio1 and Maurizio B. Implants come in a variety of shapes and sizes; they have an outer shell made from silicone that is filled with either saline or silicone gel.
Preparation of the mastectomy site is necessary as implants used in reconstruction cannot simply be placed directly below the skin in the space created by the removal of breast tissue. Unfortunately, common consequences of implant reconstruction include re-operation and the need to remove implants, according to the U.S. That this method of reconstruction typically requires the shortest period of hospitalization of all methods of reconstruction may be appealing to some women. The inframammary superficial fascia, direct prolongation of the abdominal fascia (Scarpa’s fascia), extends to the retromammary space and properly links the superficial connective frame to the deep fascia (the pectoralis maior and serrate anterior muscular plane) along all the inframammary fold.
Preoperative planning for nipple-sparing mastectomy (DCIS) + IBR with anatomical implant (natrelle high-cohesive 410MX 290g) in the right breast and submuscular augmentation (natrelel high-coesive 410MM 185g)4.1. Along the upper lateral border of the pectoralis maior muscle, scoring the deep muscular fascia towards the pectoralis minor muscle. The submuscular pocket ends into the inframammary fold, any downward over-dissection should be avoided.
The vertical scoring of the superficial fascia through the previous deep fasciotomy and access to the deep subcutaneous layer, along the inframammary fold.
The tip of the electrical scalpel indicates where the superficial fascia layer is placed, above the inframammary fold, and the advancement of the pocket enlargement.
The submammary pocket after superficial fasciotomy, a few millimeters above the inframammary fold.
The composite coverage, skin-adipo-fascial tissue downwards and muscular upwards is nourished by a continuous vascular network, preventing complications related to reduced vascular supply and to biomatrix.
The one-stage immediate reconstruction of a nipple-sparing mastectomy using a permanent silicone implant (Natrelle 410MX 370-grams by Allergan Inc.) in dual-plane autologous pocket. The lower edge of the superficial fascia is identified corresponding to the central point of the inframammary line and then pinched and fixed to the muscular fascia using a single stitch of vicryl 0, after Nava et al.. One or two lines of incision are drawn with blue 4 cm far from the suture of the pocket, in this figure visible near the lateral skin border. Scoring the fascia and the most superficial fibers of the mid-lower portion of the pectoralis maior muscle corresponding to the central part of the dual-plane pocket. Here are the cases of two sisters affected by BRCA2, 35-year-old and 37-year-old respectively, with similar breast but different cancer history, pre-op views. A 38-year-old patient with small breast, no ptosis, affectd by right breast cancer in BRCA1. Nava1[1] Plastic Reconstructive Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy1.
As usual in breast surgery, the lower medial insertions of the pectoralis muscle are scored. Although there has been considerable concern over the safety of silicone-gel filled implants, their use is currently approved by the U.S. Because there is no “donor site”, there is no additional scar elsewhere on the body and no need to heal at a site other than the breast. The density and thickness of the connective frame is here particular, the dotted red encircle.
The mastectomy must preserve this strip of soft tissue after dissecting off the breast gland. The surgeon that destroys the submammary fascial frame precludes the immediate chance for any satisfying 1-stage reconstruction with silicone implant.4. It is possible to release the deep fascia a few millimeters beneath the fold, whereas the superficial fascia must be scored a few millimeters above. The blue line illustrates the implant envelope divided in muscular (A) and subcutaneous-subfascial coverage (B). They are parallel to the suture line but usually crossing the oblique orientation of the muscle fibers. This fine procedure was named by Riggio as external partial myotomy for the tension discharge.5. The first underwent bilateral risk-reducing without sparing the nipple bilaterally, no prior cancer (left column).
Right nipple-sparing total mastectomy + left risk-reducing bilateral mastectomy and one-stage IBR with Allergan Natrelle implants 410FX 495g. Nipple-sparing mastectomy and one-stage IBR with Allergan Natrelle 410MX 290g + breast submuscular augmentation with 410MF 195g.
Introduction The immediate restoration of the breast is considered as the most favourable treatment for women undergoing a primary mastectomy since many years, but it is is not always true as it can occur in case of radiation therapy.
Additionally, some women who have medical conditions that could compromise the safety of reconstructive surgery using their body’s own tissue may be able to undergo implant reconstruction safely. A drain is inserted under the implant and another between the axillary and subcutaneous compartments.
High profile and fullness of this implant-based reconstruction are already visibile after skin closure compared with the healthy breast.
In the meantime, also the second sister underwent risk-reducing mastectomy but the prior conservative cancer treatment (quadrantectomy + radiation therapy + chemotherapy) changed the reconstructive perspectives in the left breast (right column).


The second received IBR with expander insertion on the right whilst the left reconstruction was posposed because of previous radiotherapy and the refusal for DIEP flap (right column); she preferred to be treated with serial lipofilling and then expander.
The contralateral augmentation was postponed because contemporary correction of the healthy breast in presence of both moderate ptosis and lower constricted pole was evaluated to have few chances of achieving symmetrization safely in a single stage. The superficial fascia must be preserved because it will expand progressively and physiologically. The closure of the pocket is carried out between the free border of the pectoralis maior and the surgical edge of the serratus anterior, using several figure-to-eight stitches of vicryl 2.0.
Pocket preparation and following outcome are different if used the dual-plane composite pocket for stable implant instead of a standard submuscular pocket for saline expander.
Preop (line 1), post-op views after 3.5 months (line 2), post-op views after 8 months (line 3), post-op views after 3 years and 9 months (line 4).
An immediate definite reconstruction is unfrequently achievable using flaps or implants due to both clinical and surgical reasons.
Both saline and silicone gel implants have received approval from the FDA and many sizes, shapes, and textures are available. In a relatively small number of situations, the use of a tissue matrix may make it possible to undergo reconstruction with a breast implant in a direct-to-implant procedure that avoids tissue expansion. Expander in the right breast inflated about 400cc, after the first lipofilling in the left side, nine months after mastectomy. The first improvement of the cosmetic outcome starts with the preservation of native skin envelope in the immediate breast reconstruction (IBR) when this event is followed by less visible scars and reduced risk for skin necrosis.
O’Connell has extensive experience with both saline and silicone gel implants and he utilizes both on a routine basis. The final maneuver gives access to the deep adipose layer infero-laterally where fat is generally thicker.Dissection allows to achieve a vertical enlargement of the lower pocket about 2-3 cm, seldom wider after scoring the deep retinacula cutis. The reconstructions without nipple are less pleasant as already suggested by Wellisch et al.
This is that for more than a decade the Authors have been used to perform in the one-stage IBR with permanent implants, even some series of patients were recently published by other authors. Moreover preserving nipple and areola is much more grateful for the patients.The problem can arise if the breast is ptotic or large breast where the maintainance of redundant skin and nipple is risky.
During your consultation this will be reviewed with you along with the various incisions that have been utilized.How is implant size determined?Dr. A moderate periareolar deepithelization or a skin-reducing mastectomy would be helpful trying to maintain more blood supply to the nipple-areola complex and skin around.
O’Connell believes that the aesthetics of breast shape outweigh those of simply size and he utilizes the principles of tissue-based planning to assist you in choosing an implant that is proportional to your body and breast aesthetics and consistent with your lifestyle.The ability to “try-on” implants for size is an important part of the consultative process and Dr. In the past the single-stage reconstruction with implants was consistently considered more complicated and risky than the reconstruction with autologous flap. It is fundamental that every surgeon may notionally understand, practically recognize, and surgically respect the fine anatomy of the submammary fold.
This helps our patients become more invested and satisfied with their size decision by providing a realistic preview of postoperative breast size. The multiple scores can obtain a better enlargement of the lower breast compared to the same manoeuvre performed in the second stage of reconstruction after expander because soft tissues can here contain some grade of fibrosis and the pre-existing connective frame be distorted. The scores must be performed behind the skin plane perpendicularly, avoiding any dermal bruising, and just above the corresponding external submammary line, a few millimeters, so as to avoid the bottoming-out of the pocket (Fig.
13, 14, 15, 16)Figure 13.The vertical scoring of the superficial fascia through the previous deep fasciotomy and access to the deep subcutaneous layer, along the inframammary fold. The total release of the connective inframammary frame can reach the 7 cms including the previous deep-fascial. The oncoplastic surgeons that are still using successfully the two-stage reconstruction with expander but with no kind of mesh, frequently occurring in Europe, cannot understand the real advantage of ADM in two steps. The need for ADM or synthetic mesh in case of expander-based reconstruction may be due to the behaviour of the breast surgeon that does not spare both muscular fascia and a strip of soft tissues along the submammary fold during mastectomy. The one-stage procedure offers significant advantages: reducing recovery costs, avoiding the fixed second operation, decreasing the days of convalescence (including the series of tissue expansion) and achieving a more prompt restoration of body image and perception. The patient expectations for the best and most prompt cosmetic result have greatly increased compared to only ten years ago.
Exton PA USA) derived by porcine dermis and mesothelium respectively as well as alloplastic meshes, i.e. A saline implant or expander does not retain any true form; even if totally inflated it will never be the same of a “gummy-bear” implant.
Irvine CA USA).In our opinion far from commercial inputs, on the contrary, the breast meshes should have a limited use in case of IBR while a well-tailored surgical technique can still achieve more physiological outcomes. The dual-plane technique here illustrated is an example how a feasible autologous pocket for silicone implant allows to reach the goal of a breast reconstruction in a single procedure.2. Immediate reconstruction after primary breast cancer Breast reconstruction should ideally be both immediate and definitive so as to avoid patients undergoing further surgery later. It is generally considered, from an oncological and psychological point of view, that there are no contraindications to immediate reconstruction excepting particular cases but it is not so clear about the definite single stage, whereas it is already established for the breast cancer conservative treatment. After scoring the superficial fascia above the inframammary fold, even if the symmetry was totally respected, the level inside appears to be bottomed out inside in some patient.
It ought to be due to the abdominal superficial tension which pulls down the lower edge of the fascia already resected. The following procedure can solve the defect according to the former technique of inframammary redefinition already introduced by the same Author Nava. Flaps have the great benefit of restoring the breast with soft and well-vascularized tissues, and this advantage becomes essential when breast tissues were before irradiated. One or two stitches of absorbable material, usually vicryl 0, fix the lower edge of the superficial fascia already scored at the midpoint of the inframammary line into the residual deep fascia or deeper fibers of the serratus anterior or, if necessary, the intercostal fascia (Fig.20). Flap failure after IBR strongly compromises patient body image and self-esteem, and moreover complicates any further reconstruction. This is a technical detail introduced by the first Author Riggio, and specifically used in the new one-stage dual-plane IBR for those cases where the central strain strength of the pectoralis maior muscle is higher than usual.
Some review studies recommend delayed flap reconstruction in patients at high risk for adjuvant radiation therapy.
The muscle scoring must be carried out after the closure of the device pocket and after estimating the grade of compression produced by the muscle force against the implant.
By this way two effects come out: 1) reducing the tension along the suture line of the device pocket, 2) decompressing the lower pole of the high-cohesive implant and improving the immediate profile of the lower breast.
Moreover this failure can be solved afterward by using a flap or a tissue expander another time. The correct placement, length, and direction of the partial sections are illustrated in the following Fig.21 and 22.
IBR does not interfere with the progress of the disease but it should be chosen the less risky procedure to reconstruct the breast. They are parallel to the suture line but usually crossing the oblique orientation of the muscle fibers.The internal lateral myotomies. Similar incisions (one-two scores) can be carried out along the inner surface of the harvested serratus anterior muscle, that means inside the pocket laterally, before the implant insertion.


She must have the right of opting for both the immediate and easiest type of reconstruction, also the patient with a radiation to be post-operatively planned or that with a poor cancer prognosis. The scoring must be vertical and is useful to release and lengthen the inferior-lateral pocket much better.
It does not matter if the implantable device will be a permanent implant or a “temporary” saline expander as well.3. Planning for the one-stage implant-based breast reconstructionContrary to prior surgical approaches to implant-based IBR and without use of dermal matrix and alloplastic mesh, the technique here described permits to extend the one-stage reconstruction to patients with larger breast or minimal ptosis, even satisfying the demand of bilateral enlargement of the breast. Clinical fundamentalsSome of the patients undergoing skin- or nipple-sparing mastectomy can be eligible for this kind of IBR, nearly the 30%.
The ideal breast is the breast without ptosis, with weight less than 500 g, with good skin elasticity or at least moderate redundancy as occurring in the skin after pregnancy.
The last is the most favourable condition in order to plan augmentation of the prior breast size. Cautious contraindications are given by the heavy smoker patient (>30 cigarettes a day) or by the breast with multiple prior scars. However the primary evaluation is addressed towards the expectations of the single women about the breast shape and size. It is not psychologically easy to explain all the plastic and cosmetic aspects to a women often worried by the cancer just discovered and distressed thinking about the incoming oncological treatments.
The mood of many patients may not allow good understanding of some among the following queries: 1-stage vs.
Immediate aesthetic correction of the healthy breast is suggested in the majority of the patients requiring total augmentation. Adequate symmetry is very difficult to be attained in case of contralateral reduction as well as pexy alone or with augmentation. For this type of patients the contralateral surgery should be delayed regardless of the possibility of IBR in a single step. The decision to plan a larger implant size and also decide the ultimate augmentation of the healthy breast can be taken at the time of the pexy or reduction as well. On the other hand, permanent implant can also be changed with another of better shape and volume corresponding to the contra-lateral breast at a second stage that becomes possible, but not necessary, if symmetry is already satisfactory following the previous immediate reconstruction. It should be clear to the patient that the one-stage reconstruction with a permanent implant gives a prompt and definitive result but is not unchangeable. The dual-plane technique cannot match up with those surgical approaches planning inframammary or vertical incision for the mastectomy.
The overall preference for a lateral radial, even in presence of previous areola scars, is supported by data reported in literature, Riggio et al.
Of course, the lateral radial incision is preferred because of lower risk of skin ischemia and of more accurate dissection behind nipple and areola, but it is not enough if the mastectomy does not spare the whole subcutaneous layer and its vascular network. Sometimes incision can include earlier lumpectomy scars and partial areolar incision are performed in presence of prior scars.
The real anatomy of the superficial fascial system inside the submammary fold unit was finely described by Riggio et al. The breast surgeon has to avoid any cut or undermining at the submammary level, in both the superficial and deep subcutaneous layers. Maintaining a few millimeters of soft tissues above the inframammary line can totally spare the connections, also called (deep retinacula) between the superficial system and muscular plane.
Intra-operative view.The preservation of the pectoralis fascia is viable and its resection is not justified by any evidence-based oncological reason in routine modified radical mastectomy for invasive breast cancer. The dual-plane pocket for 1-stage immediate reconstruction with highly-cohesive implantsThe best presentation in IBR is given by the aesthetic preservation of the nipple-areola complex when oncologically safe. The removal of skin around the nipple limits the use of the same technique in the skin-sparing group of mastectomy. Maintaining all the breast skin envelope results in skin redundancy which becomes too wide in case of larger or pendant breast. The skin, after the Cooper’s ligaments resection, is free to extend, especially when skin is less elastic (after weight loss, pregnancy, aging). This complication is uncommon if patient selection and subcutaneous dissection are correct whilst, on the other hand, other complications are common as skin folding, scar retraction, and NAC displacement.
They are difficult to be solved secondarly and really compromise breast aesthetics and body perception. IBR gives an answer to this problem related to skin excess and tries immediately to replace as much as possible the volume loss after parenchyma excision with larger implants. A prompt expansion volume is able of filling, or better overfilling, the skin envelope and stabilizing the nipple position.
The cutaneous envelope of the breast is consistently major than the respective volume breast only except the teenager’s breast. On the contrary, a T-inverted skin reduction together with the nipple preservation, jeopardize the vascular supply to the same nipple and areola apart from the implant dimensions.
Breast shape can be outlined by a tear-drop device with high-cohesive silicone and then better maintained through the gel memory.
Highly cohesive implants generate a certain strain strength on the envelope at the same way as a rapid expansion does.
This is more stable than the strenght produced by saline expander or low-cohesive gel devices.
Bio-mechanics of the forces acting on the female breast and the physical properties of breast tissues are strictly related to every plastic surgery procedure but, unfortunately, their knowledge is still less than average. The pocket must not be the same as the pocket prepared for an expander to be inflated progressively after surgery and then substituted. Here width and height of implant are difficult to be planned accurately compared to the selection for a temporary expander or to the 2-stage reconstruction (expander substitution). Only bilateral reconstruction makes easier the choice, here the preliminary indications are consistently maintained during surgery. Intra-operatively plastic surgeon must evaluate the limits of breast removal and the remaining soft-tissue thicknesses in order to change the implant in width or height usually by about 0.5-1 cm more or less. It is also recommended to weigh the specimen after mastectomy and compare the breast weight with the implant weight taking into account that is better to choose an implant a little bigger than the breast weight.
Submuscular preparation of the pocket: Part IAfter harvesting the free edge of the pectoralis maior muscle, with identification of the deeper pectoralis minor muscle (Fig. 5), dissection begins from the lateral part of the proper fascia of pectoralis minor and carries below the of the serratus anterior muscle and proper fascia laterally and downward (Fig. The lateral limit of the pocket must exactly correspond to the implant width at the aim of avoiding implant malposition.Then the upper and medial undermining is carried out under the pectoralis maior muscle and the extension will depend on the implant size.
The pocket width must precisely correspond to the device width in order to avoid any lateral malposition (Fig.



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Comments »

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Not drape as well as gel implants smaller, patients who choose endoscopic the same size.
09.02.2015 | 19:58:16
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Realistic expectations about what breast augmentation.
09.02.2015 | 20:37:33