BEFORE JUVEDERM ULTRA PLUS INJECTION

AFTER JUVEDERM ULTRA PLUS INJECTION

Introduction

BEFORE BREAST REDUCTION BY DR MICHELE KOO

AFTER BREAST REDUCTION BY DR KOO

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON

314-984-8331

ST LOUIS, MISSOURI, AND ILLINOIS

Did you know that breast reductions to relieve your back, neck and shoulder pain may be covered by your health insurance? DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI will let you know if she thinks that your breasts will qualify for insurance coverage when she examines you.

BREAST REDUCTIONS are extremely safe and can be performed on an outpatient basis under general anesthesia. There are no age limitations and DR MICHELE KOO will let you know if she feels that it is safe for you to undergo this procedure which takes approximately 1 1/2 hours to 2 1/2 hours.

While DR KOO feels that the surgery is a wonderful life enhancing surgery, she also wants you to know that there are limitations and complications that can occur with any surgery and BREAST REDUCTIONS are not exception. The BREAST REDUCTION surgery will lift your breasts, reshape your breasts, and lighten them to the point of allowing you to feel that you can exercise to improve your health and weight. DR KOO often says that the BREAST REDUCTION surgery will be one of the absolute best things that you have ever done for yourself. The surgery will relieve the sweaty skin rashes under your breasts, relieve the grooving in your shoulders from the weight of your breasts, help relieve the headaches, neck and back pain you suffer from your saggy heavy breasts.

According to Farzad and Foad Nahai, MDs, in the Plastic Surgery Journal on Breast Redutions in 2006, “there were 145,822 breast reductions performed in the United States, positioning breast reduction as the fifth most common plastic surgical procedure performed by plastic surgeons.  Breast reduction has one of the highest patient satisfaction rates among plastic surgery procedures, with 93 percent of women reporting they would undergo the surgery again.  Reduction mammaplasty has also been shown to improve body self-image.

There are many procedures available to accomplish breast reduction, each with its unique combination of skin incision and resection patterns and approach to breast reshaping. The inferior pedicle Wise pattern reduction mammaplasty has long been the favored procedure in the United States.  Lassus and Lejour were instrumental in popularizing the vertical pattern breast reduction in Europe, and this trend is now being adopted by North American surgeons as well.  

In-depth knowledge of breast anatomy-in particular, the blood and nerve supply to the nipple-areola complex-is prerequisite to any type of surgical procedure on the breast. Key sensory nerves are the lateral and medial cutaneous branches of the intercostal nerves T3, T4, and T5. The lateral branches exit the chest wall at the midaxillary line and progress medially along the pectoralis major fascia, with terminal sensory endings in the breast skin and the nipple-areola complex.  Branches from the lower cervical plexus supply sensation to the upper breast.

The blood supply to the breast is based on musculocutaneous perforators from the internal mammary, anterolateral intercostal and anteromedial intercostal, and fasciocutaneous perforators from the lateral mammary branches of the long thoracic artery. This network of vessels communicate with each other and branch and terminate at all four quadrants of the nipple-areola complex. In addition, the subdermal plexus is arranged in a radial pattern around the nipple-areola complex and provides for numerous pedicle options, including inferior, central, medial, superior, and lateral pedicles.  The viability of breast skin flaps is dependent on flap thickness, flap length-to-base width ratio, the presence of inflow vessels, and subdermal microcirculation. Factors such as smoking, radiation, and previous surgery can affect blood flow at these levels and result in breast flap necrosis. Cooper’s suspensory ligaments are the connective tissue support structures within the breast. These ligaments originate from the pectoralis muscle fascia and course through the breast parenchyma to attach to the dermis of the overlying skin. These attachments can be stretched with pregnancy, weight gain, and aging, resulting in excess breast mobility and ptosis.

The physical examination includes patient height, weight, and calculation of the body mass index [weight in kilograms ÷ (height in meters)²]. A breast examination should be performed to asses the breasts for symmetry, the presence of masses, any evidence of shoulder notching from the bra, intertrigo, and the degree of breast ptosis. The description and grading of breast ptosis has been reported previously.  A set of objective breast measurements should be taken with a minimum measurement of the sternal notch to nipple distance and nipple to inframammary fold distance. Other helpful measurements are nipple-areola complex width, breast width, and nipple-to-sternal midline distances. Some authors include measurement of breast circumference and width to estimate breast weight.

Deep Venous Thrombosis/Pulmonary Embolism Prophylaxis

Women with a body mass index greater than 30 undergoing breast reduction have a low but real risk of deep venous thrombosis/pulmonary embolism.  Operative times greater than 2 hours can increase this risk. Established effective precautionary practice includes the use of pneumatic compression devices with or without thromboembolic disease hose. A recent meta-analysis has demonstrated a 60 percent decrease in the incidence of deep venous thrombosis/pulmonary embolism with the use of pneumatic compression devices.  To be fully effective, these devices should be on the patient and functioning before the induction of general anesthesia. The use of chemoprophylaxis administered subcutaneously in the perioperative period for plastic surgery procedures is currently controversial. There are no randomized clinical trials to evaluate the role of chemoprophylaxis in plastic surgery, and the risk of hematomas is unknown. Although the benefits and safety of chemoprophylaxis in general surgical and orthopedic procedures has been demonstrated, we cannot extrapolate the safety profile, in particular, the risk of hematoma, to plastic surgery procedures that involve a significant amount of undermining and raw surfaces. Current recommendations are that mechanical prophylaxis is used on any procedure lasting more than 1 hour and that chemoprophylaxis be used on major procedures such as abdominoplasty, thigh lift, belt lipectomy, transverse rectus abdominis myocutaneous flap reconstruction, surgical positions likely to contribute to venous stasis and/or compression, combined procedures, and procedures lasting more than 4 hours.

Smoking and Breast Reduction

Informed consent includes a discussion of the location of surgical scars, the possibility that these scars can widen or thicken and that they are permanent. Temporary and permanent changes in nipple sensation, difficulty with breast-feeding or lactation, postoperative breast asymmetries, delayed wound healing, skin necrosis, partial or total nipple loss, hematoma, and seroma should be discussed. In addition to sharing preoperative and postoperative photographs of good results, it is beneficial to share photographs demonstrating some of the possible long-term complications and less favorable outcomes. Preoperative breast asymmetry is brought to the patient’s attention and the possibility of asymmetry postoperatively is discussed. A well-educated and well-informed patient with realistic expectations is more likely to tolerate a complication or less than ideal result than one who is not informed and ill prepared for the possibility of a suboptimal outcome. As Goldwyn said, the more the patient considers her reduction an aesthetic procedure, the less likely she is to be satisfied. The more she considers it a reconstructive procedure, the more likely she is to be satisfied. Breast reduction is a procedure covered by most insurance companies, provided that a minimum weight of tissue is removed. It can be challenging in some patients to estimate an accurate amount of tissue to be removed. These patients are informed of the possibility that their breast reduction may not meet certain insurance company criteria and thus the cost will not be covered.

For women considering breast reduction that have yet to have children, the question of lactation following surgery should be addressed. Any significant resection of subareolar breast tissue will decrease the amount of breast tissue that is potentially milk producing. Several studies have demonstrated that approximately 70 percent of breast reduction patients can breast-feed but that only 30 percent do, similar to the rates in an unoperated population.  Although milk production may occur, lactation will be impossible following free nipple grafting.

Preoperative mammograms are obtained based on the recommendations made by the American Cancer Society. Women younger than 40 years with a family history of breast cancer or other risk factors and any woman older than 40 should have a mammogram before breast reduction to rule out the presence of abnormal findings. Women are informed that reduction mammaplasty will result in scarring and possible calcifications within the breast parenchyma that may be seen on future mammograms. For that reason, all women are advised to have a baseline mammogram 3 to 6 months after surgery that will serve as a baseline study with which to compare future studies.

The incidental finding of a cancer in breast reduction specimens is rare, less than 0.5 to 0.8 percent in large series.  A positive finding after surgery should be followed with a thorough workup, oncologic consultation, and treatment recommendations made based on findings. In the rare event that a suspicious mass is found during the breast reduction, an intraoperative frozen section can be performed to establish a diagnosis. Confirmation of a benign diagnosis does not require further action and the procedure can be completed as planned. If an equivocal or malignant diagnosis is made, the entire mass can be resected and the biopsy site marked (with clips or staples), and once an appropriate stopping point is reached, the breast can be closed and the case terminated. A formal workup should then take place with proper staging and oncologic consultation. This management strategy leaves most options available and involves the patient in the decision process. In some cases where the resection specimen contains the entire malignancy; radiation treatment according to a breast conservation therapy protocol may be the only adjuvant therapy necessary. Any formal oncologic procedure without proper staging, planning, and consent is not advised.

For the vast majority of patients, breast reductions are performed on an outpatient basis, either in a hospital, outpatient surgical center, or office-based surgicenter that has been accredited by the Association of Accrediting Ambulatory Surgical Facilities or state authorities. An office-based operating room that is not accredited is not the ideal setting and should be avoided. The patient’s general health, body mass index, and American Society of Anesthesiologists classification are taken into account when making the decision on an inpatient or outpatient procedure.

There are many surgical options for breast reduction. Often the choice of surgical procedure is based on patient morphology, including body mass index and degree of nipple displacement, and the surgeon’s comfort level, training, and experience with certain procedures. Excellent results are produced with a variety of procedures; the key is to couple the patient’s needs and goals with a suitable operation. All procedures, except for liposuction only and reduction with free nipple graft, center on maintaining a vascular pedicle to the nipple-areola complex. There are four major steps in a reduction procedure: access incisions, parenchymal resection, breast shaping, and management of excess skin. Preinjection of the breast with epinephrine-containing solution should avoid the planned vascular pedicle to the nipple-areola complex. The safety and efficacy of epinephrine use and tumescent solution infiltration in reduction mammaplasty has been reported.  These methods decrease blood loss and decrease operative times. Although there is a theoretical increased risk of postoperative bleeding, this has not been proven.

The central mound technique of breast shaping is perhaps one of the easiest to visualize and execute, as it essentially mimics the shape of a round breast implant. The inferior pedicle Wise pattern shapes the breast by transposing the pedicle cephalad and supporting it with medial and lateral breast flaps.  The superior pedicle and superomedial pedicle techniques preserve upper breast tissue and use the medial and lateral breast pillars for projection, pedicle support, and eventual lower breast shape.  In the case of breast amputation and free nipple grafting (where a vascular pedicle to the nipple-areola complex is not a concern), Wise pattern lateral and medial breast flaps are closed around superocentrally preserved breast tissue. Ways of improving long-term results have been described, including an inferior breast mound to preserve the rounded appearance of the lower pole of the breast.  Whichever method of parenchymal resection is used, it is important to remember that it is not what is removed but what is left behind that counts.

In the final stage, excess skin is addressed. With the Wise pattern resection, excess skin is typically resected with the breast parenchyma. Final tailoring usually involves resection of medial and lateral dog-ears along the horizontal inframammary fold incision. If possible, final skin tailoring is performed in curvilinear fashion to mimic the curve on the cut end of a spherical object.  This maintains a rounded appearance and avoids a boxy flattened breast, especially in the inferior pole. With the vertical pattern incision, once the medial and lateral pillars are brought together, the excess vertical skin is tailor tacked to flatten the breast on lateral view, much like the inverted image of a naturally appearing breast. The excess skin at the base of the vertical component can be tailored for a purse-string closure, a mini-T closure, or a laterally extended L or J closure. The Benelli technique removes excess skin only in a concentric manner around the nipple-areola complex and relies on a purse-string closure to gather the wound edges around the nipple-areola complex. In larger resections, this can result in pleating, a starburst scar pattern, and flattening of the breast. The best results are achieved with a small resection. Another method of breast reduction is the no vertical scar technique originally described by Passot and more recently reported on by Lalonde et al. and Nagy et al. Its proponents claim that the elimination of the vertical scar improves safety and aesthetic results. 

Liposuction-alone breast reduction is most effective in patients with mild volume excess, normal skin elasticity, and minimal ptosis. It is generally low impact and safe.  Liposuction alone is not a good choice in the young, more fibrous breast that has little fatty tissue. Furthermore, liposuction alone would not be covered by insurance.

This procedure accesses the breast parenchyma through a circumareolar incision. A central mound is preserved and surrounding breast tissue is removed. A donut skin excision is performed, and closure depends on a purse-string suture. This procedure is best for the mild to moderate reductions (approximately 200 g or less) with up to 3 cm of nipple-areola complex elevation needed. The circumareolar reduction has not gained wide acceptance in the United States because most reductions here are larger volumes. The purse-string closure can result in a flattened breast, pleating, and a starburst scar.

The Wise pattern skin excision and inferior dermoglandular pedicle represents the most popular breast reduction technique used by plastic surgeons in the United States. This skin pattern excision is very versatile and can accommodate an inferiorly, superiorly, or centrally based dermoglandular pedicle. It is applicable to a wide range of reductions, has a relatively easy learning curve, achieves predictable results, and has one of the safest and most reliable vascular pedicles to the nipple-areola complex, with a good record of maintaining nipple sensibility. Some of the disadvantages of this procedure are the lengthy scars, the need for significant flap undermining, and the risk of bottoming-out and pseudoptosis of the breast over time. A reliance on the skin to shape the breast rather than breast shaping through parenchymal sutures can result in flat, boxy, nonprojecting breasts.

The vertical pattern breast reduction has been slowly gaining popularity in the United States. It has a circumareolar scar and a scar vertically down to the inframammary fold. It is particularly effective at preserving breast projection and shape. A vertical skin pattern may be combined with superior, medial, lateral, or inferior pedicles. This technique is effective for a wide range of reductions, reaching its limits as the inframammary fold to nipple-areola complex distance increases beyond 15 to 18 cm. In these patients, the redundant skin at the inframammary fold is less likely to be adequately managed with a purse-string suture alone, so a small T, L, or J excision of skin may be needed. This technique does have a long learning curve and does require some time postoperatively for tissue settling until the final breast shape is achieved.

For extremely large (>2000 g) reductions and very ptotic breasts with very long nipple to notch distances, a reliable pedicle to the nipple-areola complex cannot always be preserved. In these patients, an amputation is performed based on the Wise skin pattern and the nipple is preserved and repositioned as a free graft on a deepithelialized bed. This is a safe and effective procedure for extremely large breasts and a less risky option for smokers. The nipple often undergoes desquamation in the course of healing, leading to partial pigment loss and loss of nipple projection. Pigment loss is more distressing and harder to manage in patients with black skin. This is very rare for DR MICHELE KOO, she usually is able to perform any amount of surgery up to 2800-3000 gms from each breast without a free nipple graft.

Markings should be made with the patient standing or sitting upright with the shoulders relaxed and slightly rolled back and face looking forward. There are many descriptions of particular marking techniques in breast reduction. Whatever the technique, there are several key principles common to all. Sternal midline and breast midlines are marked. The key marking that all other markings depend on is the new location of the nipple-areola complex. There are many methods and anatomical landmarks by which the new position of the nipple-areola complex can be based such as the anterior projection of the inframammary fold. Markings made with the breast weight partially supported (breast supported with the nonmarking hand) can aid in avoiding positioning the nipple-areola complex too high and keeping the horizontal incision within the inframammary fold. For the vertical technique, the nipple should be marked 1 to 2 cm lower than these standard markings. It is advisable to not fixate on a single measurement when deciding on the new position of the nipple-areola complex but rather to take into account the collective anatomical findings. These might include the patient’s height, new location of the nipple-areola complex relative to the humerus, and an imaginary line from the xiphoid to the anterior axillary fold, estimating the location of a low cut bra, shirt, or bathing suit line. Paying attention to these relationships avoids positioning the nipple-areola complex too high. The inframammary fold is marked, also with the breast supported to avoid placing this mark too low. If liposuction is to be performed as an adjunct, markings are made before surgery. Additional guidelines for markings that will enhance results are listed in. 

Breast incisions can be topped with adhesive tapes in the operating room. Liquid adhesives, such as benzoin or Mastisol (Ferndale Laboratories, Ferndale, Mich.), can prolong the adherence of tapes but may cause skin irritation and blistering. If drains are placed, they are typically removed on the first postoperative day, unless concomitant breast liposuction was performed, in which case the drains may be left in longer. Inpatients are monitored for nipple viability and hematoma by observing symmetry and firmness. All patients are given instructions to limit physical activity for 2 weeks or more. Activities of daily living are typically resumed on the first postoperative day. The first postoperative visit is at 1 week or earlier if needed. The tapes are exchanged and an examination confirms the state of the nipple, incisions, skin flaps, and overall breast symmetry.

Patients are given taping instructions for all incisions. In the absence of skin irritation, taping can be continued for 3 months to minimize scar appearance. A soft elastic nonwire support bra can be worn for the first 2 weeks and then weaned until the end of the fourth week, when the patient may wear their bra of choice. Follow-up should be arranged at 6 and 12 months to assess final breast shape, symmetry, and nipple-areola complex sensibility.

Complications range from mild to severe and may be early or late. Total complication rates have been reported to range from 6 to 43 percent. The most common complication, independent of reduction technique, is delayed wound healing, which has been reported to be as low as 2.2 to 10 percent to as high as 20 to 30 percent.  Proper patient selection and surgical planning will help decrease the chances of certain undesirable outcomes. Gentle handling of tissues, being mindful of the dermoglandular neurovascular pedicle, maintenance of breast flaps of adequate thickness, and closure without undo tension are also important. Despite all this, in the best of hands and in the optimal patient, complications will occur. Fortunately, many of the complications that occur with reduction mammaplasty can be resolved with favorable outcomes.

Delayed wound healing is the most common complication in reduction mammaplasty regardless of technique and is related to closure with undue tension, underlying pressure from a seroma or hematoma, flap necrosis and ischemia, infection, or background disease that delays wound healing (diabetes, poor nutrition, smoking, steroids).  Typical locations for wound dehiscence are the T-junction: the three-way intersection of the vertical and horizontal incisions, the purse-string closure of a vertical reduction, and the junction of the nipple-areola complex and vertical limb incision. Sometimes, delayed primary closure can be performed; however, these areas are often managed conservatively and left to close on their own once the underlying problem has been addressed.

Partial or total nipple necrosis can be a devastating complication. Early and frequent nipple monitoring with appropriate identification of a nipple with vascular compromise followed by appropriate action may avoid total nipple loss. Sometimes, the appearance of the nipple during inset is the initial sign that a problem may occur. A pale or bluish nipple with limited bleeding on the cut edge warrants very close postoperative observation. Poor or dark blue blood flow from a pin prick is also worrisome. Sometimes, the closure of all wounds, emergence from general anesthesia, patient rewarming, and a normal nonpharmacologic blood pressure will reverse the changes associated with poor vascularity to the nipple, and it will turn pink with normal capillary refill within the first hour after the end of general anesthesia. An objective assessment of the blood flow to the nipple is the fluorescein intravenous dye test and a Wood’s lamp.  If there is an indication of compromised vascularity, an immediate free nipple graft should be performed. A free nipple is grafted to healthy deepithelialized vascularized dermis. Grafting onto fat or a poorly vascularized area will not work. If the nipple shows signs of ischemia in the early postoperative period despite normal blood pressure and core body temperature, immediate action is taken. Provided that undue pressure on the nipple pedicle from a hematoma is ruled out, the nipple should be released from its inset position, effectively relieving undue tension on the nipple pedicle. The nipple will generally retract 1 or 2 cm. If the nipple does not show immediate signs of improved blood flow, the patient should be taken back to the operating room for conversion to a free nipple graft onto a well-vascularized bed. For cases where partial or total nipple necrosis was not identified or apparent in the early postoperative period, conservative wound care until closure is achieved by primary healing is best. Nipple reconstruction is then undertaken at an appropriate time. Depigmentation can be treated with tattooing, but results vary. Total nipple loss will require reconstruction with skin grafts and/or local flaps.

Although not common, a hematoma may be hard to recognize until it is sizable. The presence of breast swelling, distensibility of the skin, and large areas of undermining can make a small hematoma hard to identify. Hematoma may occur within hours after surgery or up to 2 weeks postoperatively. Presentation of a hematoma can include unilateral pain, swelling beyond expectation with significant asymmetry, tight and discolored skin flaps, or excessive bloody output from a drain or suture line. Hematomas should be drained at the time of diagnosis in the operating room, with adequate lighting and access to hemostatic devices. Often, a definitive bleeding point is not found, but it should be pursued. Fluid resuscitation and blood administration are prescribed as indicated. Late hematomas should be aspirated with a large-bore needle or surgically drained to avoid abscess formation and contour deformities.

Flap necrosis may be devastating and occurs when flaps are made too thin, the patient smokes (or is exposed to secondary smoke), or pressure necrosis occurs from dressings that are too tight or because of pressure from an underlying hematoma. As with the worrisome nipple, blood flow to suspect skin flaps can be measured objectively with intravenous fluorescein. If debridement and immediate direct closure without undo tension can be achieved, it is preferable. In more severe cases with large areas of tissue loss, conservative wound management with healing by secondary intention or early skin grafting is advised. Skin graft take on soft breast fat with poor circulation can be difficult to achieve. Hyperbaric oxygen therapy can accelerate healing but is costly.  A wound vacuum-assisted closure device may be considered in severe cases or in preparation for a skin graft.

The most worrisome and life-threatening complication is deep venous thrombosis and/or pulmonary embolism. In the event of difficulty breathing or poor oxygen saturation within the first several days after surgery, deep venous thrombosis/pulmonary embolism is the assumed diagnosis until proven otherwise. The most rapid and minimally invasive method of diagnosis is a contrast-enhanced computed tomographic scan of the chest.  If contrast is contraindicated or a computed tomographic scan is unavailable, a ventilation/perfusion lung scan can be performed. A Doppler ultrasound examination of the lower extremities can also be performed looking for evidence of thrombosis. Management of deep venous thrombosis/pulmonary embolism has been described previously.

Cellulitis can occur and may present as local erythema, increased pain or drainage, and/or fever. It should be treated immediately with the appropriate antibiotics and followed closely. Passage of a needle into the breast can rule out seroma or diagnose an underlying abscess. Abscess is rare, but should it occur, it should be drained.

Untreated seromas can cause wound separation and delayed healing. If a seroma is suspected, it can be needle aspirated in the clinic. Often, multiple aspirations are required before the seroma resolves. Seromas recalcitrant to multiple aspirations can be excised directly and closed over drains with suturing to obliterate the dead space.

Scars can be a problem because of poor location or hypertrophy/keloid formation. Simple taping is a very effective means of avoiding scar hypertrophy.  Should hypertrophy or keloids occur, treatment should start at the earliest indication. When they do occur, the vertical limb is usually spared. Direct lesional injections with steroids alone or in combination with 5-fluorouracil have been shown to be effective.  Scars above or below the inframammary fold can be distressing to the patient. Effort should be made to minimize medial extension of incisions on the breast, as the scar can be seen with low-cut clothing. With vertical scar reduction, the inframammary fold is often raised as a result of the reduction; thus, the vertical incision marking should end within 2 to 4 cm above the inframammary fold or the scar may extend below the inframammary fold. With circumareolar procedures, as the reduction volume increases, so does the risk of permanent skin pleating and starburst scar formation. These can be treated with conversion to a vertical or Wise scar pattern reduction for extra skin removal and formation of a new circumareolar skin-to-nipple-areola complex relationship that will avoid pleats and starburst scars.

A problem shared by all breast reduction techniques is bottoming-out or pseudoptosis, defined as an excess amount of breast tissue extending below the inframammary fold with a normal nipple position. This is more often associated with the Wise pattern inferior pedicle reduction. Any effort to reshape a breast that has been previously reduced must take into account the pedicle to the nipple-areola complex and avoid its injury. Regardless of the access incisions, breast reshaping and skin tightening is used to recapture an acceptable breast shape. Small puckers, more common in vertical reductions, are excised directly, as are dog-ears that can occur with Wise pattern incisions.

Abnormal nipple position is very unforgiving and can mar the appearance of otherwise well-shaped symmetric breasts. Any effort to reposition a nipple must take into account the original pedicle to the nipple-areola complex and avoid vascular compromise. Minor nipple asymmetry can be managed with crescent skin removal from above the nipple. Nipples that need to be raised more than 1 cm must be released circumferentially and repositioned with the excess skin inferior retailored and incorporated into the vertical incision. Nipples that are too high are very problematic and difficult to manage. If there is concomitant bottoming-out of the breast, it is best to reshape the breast relative to the nipple. If the nipple is truly too high, it must be repositioned lower on the breast mound, leaving a scar above the nipple.

Minor asymmetry in shape or size is often acceptable to the patient, especially if the same asymmetric right-to-left relationship that was present preoperatively is maintained postoperatively. Significant size asymmetry can be managed with liposuction or further parenchymal resection.

Fat necrosis presents as a local area of firm or hard tissue. This is usually noted close to the breast surface, as it is more easily palpated there. Deeper areas of fat necrosis may be diagnosed only by radiography. Should fat necrosis occur, it should be needle aspirated to confirm the diagnosis and to rule out a neoplasm followed by excision or aspiration if symptomatic.

All patients are informed during the consent process that nipple sensation can permanently decrease, increase, or not change after reduction mammaplasty. Early changes in sensation are often temporary and should be managed expectantly until at least 6 months after surgery. Changes in nipple sensation have been documented up to 1 year after surgery. Multiple reports exist comparing techniques based on sensory outcomes. One demonstrated that no difference exists between medial and inferior dermoglandular pedicles and that resection weight was not a variable in sensory outcomes.  Another study did not find a difference between the techniques that preserved breast tissue at the base of the breast, but found that decreased sensation occurred with techniques that resected base of breast tissue.  No difference based on amount of breast tissue resected was found, confirming prior reports.

With one of the highest satisfaction rates among plastic surgery procedures, breast reduction can be rewarding for both the patient and the physician. A clear understanding of breast anatomy is a prerequisite to performing any of the many techniques available. Common and critical to all techniques is the preservation of the vascularity to the nipple-areola complex. Currently, the most frequently used method for breast reduction is the Wise pattern inferior pedicle technique, although the vertical reduction method is gaining in popularity.

Excellent results can be achieved with many different types of procedures. Identification and proper early intervention of complications are important and integral to practicing safe and efficacious reduction mammaplasty.”

DR MICHELE KOO wants you to understand that still overall the BREAST REDUCTION procedure is one of the best things you will ever do for yourself, to enable yourself, and to break the cycle of large heavy breasts and the inability to exercise and then weight gain and further increase in breast size.

Take charge of your life now and call DR MICHELE KOO, MD, FACS. BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI for a BREAST REDUCTION consultation.  314-984-8331.

Dr Michele Koo, Board Certified Plastic Surgeon, in the St Louis, Missouri area specializes in body contouring and liposuction to remove excess skin and stretch marks that can occur after massive weight loss or pregnancies.

Dr Koo of St Louis, Missouri sees patients from all over Missouri, Kansas, Illinois and the United States for body contouring, liposuction, and specifically removing significant amounts of excess skin.

There has been tremendous growth in the number of patients seeking body contouring procedures after massive weight loss. Most patients desire improvement of the abdominotorso region first. After massive weight loss, there is enormous variability of body proportions, and therefore Dr Michele Koo will present many surgical options based on the quality of the skin, subcutaneous fat component, and location of the lax tissue. Each area needs to be assessed to see whether there is a significant lower abdominal component, an upper midline abdominal component, or contributions from the buttocks and flanks. 

Dr Koo is a Member of the Aesthetic Society, and will discuss all of the options available to the patient for removing the abdomen skin, thigh skin, entire lower body skin or whatever different combinations of liposuction and skin removal procedures are necessary to regain the shape to the patients’ torso, waist, and entire body.

Dr Michele Koo, MD, plastic surgeon, will repair the rectus abdominus muscles that may be separated in your abdominal area which adds to the laxity of your abdomen when she performs the tummy tuck (abdominoplasty). The roundedness of the abdomen and loss of the waist may be due to the complete loss of support in the entire abdomen area and a flat stomach can be regained with a tummy tuck (abdominoplasty) when the muscles are sutured back together in the midline thereby supporting the back and abdominal contents.

If the patient also has excess skin in the thigh and buttock regions, Dr Koo will stage and prioritize the body rejuvenation as to whether to address the abdomen first or the lower body first depending on which area aggravates the patient the most and where the most excess skin is.

As a result of the increasing popularity of bariatric surgery, plastic surgeons are treating greater numbers of massive weight loss patients. These patients typically lose more than 100 pounds and have significant skin laxity with varying amounts of subcutaneous tissue excess. Commonly, the abdominotorso region is treated first; it often gives patients the most grief. The overhanging pannus may predispose this region to rashes and can make it difficult for patients to wear properly fitted clothing.

It is rare for a massive weight loss patient to undergo just a full abdominoplasty; treatment of the flanks and buttocks has become common. Therefore, many patients require a more involved procedure such as a circumferential abdominoplasty or even one that uses a fleur-de-lis approach.

Dr Koo will have a discussion with the patient regarding their surgical goals, the various surgical treatment options, and the impact that their medical conditions can have on the surgical outcome. Surgery is usually delayed until the weight loss has plateaued; for a bariatric surgery patient, this is usually after at least a 100-pound weight loss or longer than 1 year after the gastric procedure. Sometimes, surgery is performed sooner for a patient who requires a panniculectomy to assist in the management of other conditions.

The patient is first examined in supine position and evaluated for hernias and the extent of rectus diastasis. A patient that has had an open abdominal procedure has an increased risk of hernia formation. A massive weight loss patient may have an excess subcutaneous fat component, which can make palpation of a hernia difficult. Therefore, the hernia can remain hidden (occult) until the time of surgery.

The patient is then examined in the standing position. The abdominal region is evaluated for skin laxity and the extent of the subcutaneous fat component. Often, the patient will have striae, poor skin elasticity, and recalcitrant rashes not amenable to conservative treatment. A pinch test is performed in a horizontal fashion to evaluate the amount of tissue that can be excised. The horizontal pinch is performed on the lower transverse abdominal tissue that would be excised commonly during a routine full abdominoplasty. The laxity and quality of the skin are evaluated in a vertical dimension in the supraumbilical region as well. Using the vertical upper abdominal midline as a reference point, a vertical pinch is performed pinching tissue from each side of the midline to evaluate the upper abdominal midline excess and laxity. If a vertical pinch improves the upper abdominal waistline and can eliminate supraumbilical fullness, the possibility of performing a vertical midline incision is discussed. The threshold for using this additional incision is lowered if the patient has a preexisting paramedian or midline vertical scar.

The patient is then examined for mons pubis ptosis. This is marked in accordance with Baroudi’s description, leaving a 5- to 7-cm length from the vulvar commissure to the top of the mons pubis.  The patient is evaluated in a right lateral, left lateral, and posterior standing position using the horizontal pinch test to evaluate the impact the pinch has on lateral and anterior thigh laxity and buttock ptosis.

Dr Michele Koo, MD, St Louis, MO believes that the preoperative examination is essential because there is tremendous variability of skin quality, amount of the subcutaneous fat, and distribution of tissue laxity in these patients. Furthermore, it is during this period when the risks, benefits, and alternatives of all procedure options can be discussed thoroughly with the patient. She feels it is very important that the patient fully understand the lenghthiness of the surgery, recovery period, and the overall risks that come with this body rejuvenation process. She feels that the surgeries can be very safe but wants the patient to understand the emotional and physical comittment that is required to undergo the procedures to remove the excess skin and fat after massive weight loss.

Please visit Dr Michele Koo’s website at www.drmkoo.com or call her office 314-984-8331 in St Louis, MO for more information.