The body mass index, calculated from the patient’s height and weight in metric units of kilograms per meter squared, is a good method with which to assess the patient’s relative risk-to-benefit ratio for the procedure. Although liposuction may reduce cardiovascular risk, blood pressure, and fasting insulin levels, it should not be considered a treatment for obesity. Patients with inherent risks including those with poor wound healing, infection, deep venous thrombosis, sleep apnea, or a body mass index greater than 30 would benefit from additional counseling, and lifestyle modification should be considered before a body-contouring procedure.

Dr Koo performs a thorough physical examination which includes documentation of the patient’s height, weight, and circumferences of all pertinent body areas. Dr Koo will look at all previous surgical scars including, of course, a possible previous C Section scar and will attempt to remove all possible scars and stretch marks that are within the area that can be removed with an abdominoplasty.

Typically, Dr Koo recommends waiting a minimum of 6 months after childbirth prior to considering any plastic surgery to reshape the breasts and body. This allows time to lose the water weight gain, establish good eating and exercise habits, and allows the skin to retract. With weight and skin tone stabilization, the breasts and abdomen will revert to as mich of the pre-pregancy condition that is possible. For some women, depending on activity level, eating habits, and genetics, this could take up to one or more years.

Dr Koo also recommends waiting until the patient is not considering any more children before major skin resection such as a tummy tuck (abdominoplasty) to prevent relapse of stretch and split of the abdominal muscles again with recurrent pregnancies.

The saggy, flat breasts and lax, loose abdomen and hanging skin can all be removed and abdominal muscles tightened completely to a pre-pregnancy state. The maintenance of the shape and appearance is then up to the patient to continue to eat healthy with regular activity levels which Dr Koo encourages and helps with suggested excercise classes and trainers. If the patient is looking for firm, lifted breasts that are full and round, then a breast implant along with the breast lift may be necessary. She will discuss all the possibilities and let the patient know what surgery is in her best interest for long term results.

Lipodystrophy can be located in the following areas: abdomen, flanks, thighs, arms, neck, knees, back, buttocks, and breasts. Careful physical examination entails site-specific evaluation. Dr Michele Koo examines patients for the presence of occult hernias. Men who present for abdominal liposuction should be examined with particular care, as abdominal prominence may often be attributed to intraabdominal fat, which is not addressed by liposuction. In men interested in body contouring of the anterior chest, the examination of those with gynecomastia may direct the method of surgical treatment. Ultrasound-assisted liposuction or direct excision of skin and breast tissue may be necessary in those with additional fibrous tissue.

Other anatomical areas that require special attention if liposuction is to be performed are the legs and ankles. Patient satisfaction is not as high with liposuction in these areas. Pain can be a prolonged problem and complications are more frequent than with liposuction of most other areas. It is important to understand the patterns of fat distribution and how they relate to the anatomy of the area. The preoperative markings, careful attention to the suction area, and close postoperative follow-up are extremely important for liposuction of the legs and ankles.

Skin evaluation is pertinent in the evaluation of any patient seeking body-contouring procedures. For those seeking liposuction, adequate skin elasticity should be present to allow for skin retraction after surgery. Particular attention should be given to associated wrinkles, laxity, and surface irregularities, including dimpling. Scars should be noted.

Cellulite is a term that is used to describe the lipomatous deposits under the skin that outwardly give the skin a lumpy or orange peel-like appearance. Cellulite is often noted in areas such as the hips, buttocks, or thighs. Cellulite is predetermined by genetics, so even thin women can develop the appearance. Factors such as hormones, pregnancy, and aging may all attribute to the appearance of cellulite. Patients should be aware that liposuction procedures do not address cellulite and may in fact worsen its appearance. In contrast, dimpling is usually considered to be a more isolated area of concavity that may be secondary to underlying scar or fascial attachments and may be improved by the liposuction process.

Any asymmetry or contour irregularities is noted and brought to the patient’s attention. Dr Koo makes additional effort to correct any dimpling or asymmetry intraoperatively; however, this is frequently difficult to achieve. The patient should be aware of possible persistent asymmetry, depressions, and dimpling after the liposuction procedure.

Society of Anesthesiologists status of a patient before scheduling liposuction because it is an important factor in determining the most appropriate location for the procedure to be performed safely.

Various types of anesthesia or anesthesia combinations are appropriate for liposuction, depending on the overall health of the patient, the estimated volume of the aspirate to be removed, and the postoperative discharge plan. Dr Michele Koo is extremely careful about her anesthesia provider and hand picks those that give anesthesia to her patients. Dr Koo is the patients’ best advocate and ensures that all precautions are taken for the safety and well being of her patients.

In smaller volume liposuction cases, anesthetic infiltrate solutions alone may provide adequate pain relief. Termed wetting solution, this anesthetic infiltration solution not only facilitates the procedure but also provides preemptive and prolonged postoperative local analgesia.

5 Doses of lidocaine up to 50 mg/kg have been used; however, it is important to note that plasma lidocaine levels can peak 10 to 12 hours after infiltration when epinephrine is present in the wetting solution. Lidocaine toxicity has been implicated in a series of liposuction-related deaths. Signs and symptoms of lidocaine toxicity can be seen at plasma levels between 3 and 6 μg/ml. Initially, patients may experience lightheadedness, drowsiness, tinnitus, a metallic taste in the mouth, slurred speech, and numbness of the lips and tongue. At higher plasma concentrations, shivering, muscle twitching, tremors, convulsions, central nervous system depression, and coma may result. Respiratory depression and cardiac arrest can also occur with higher doses. Marcaine is rapidly absorbed, poorly reversed, and has a long half-life, making it a less suitable agent for subcutaneous infiltration in liposuction procedures.

Epinephrine is a critical additive in the infiltrate solution. It is recommended that doses of epinephrine not exceed 0.07 mg/kg, although doses as high as 10 mg/kg have been used safely.

Moderate sedation or analgesia, termed conscious sedation, is defined as purposeful responsiveness, with response to verbal or tactile stimulation evident. No airway intervention is required; however, supplemental oxygen may be administered as indicated. Patients demonstrate adequate spontaneous ventilation, with maintenance of cardiovascular function. Although numerous agents can be administered to achieve this level of sedation, it is imperative that the physician be adequately trained in anesthetic medications and airway management if intravenous sedation is planned without the presence of an anesthesia professional. In limited, smaller volume liposuction cases, intravenous sedation may be administered to maintain patient comfort.

In general anesthesia, the patient is unarousable, even with repeated painful stimulation, and independent ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. As with any surgical procedure, medication is titrated to effect, and a certified anesthetic provider is present for any procedure under general anesthesia.

The physician is primarily responsible for providing and supervising anesthesia and analgesia. A certified registered nurse anesthetist or other qualified health care provider may administer anesthesia, but only under direct physician supervision, unless state law specifically provides otherwise. Dr Koo has a core staff that she works with that is completely trained and familiar with her methods, techniques, and preferences and only that staff is allowed in her operating room. Dr Koo and all operating room and key facility personnel are fully trained to recognize emergencies and complications.

The dry technique was the first method developed. It was performed under general anesthesia without the infiltration of subcutaneous solutions before insertion of the liposuction cannula. Substantial swelling and discoloration is a common consequence of the dry technique. This technique is also associated with a large amount of blood loss, with suction aspirate consisting of 20 to 45 percent blood. These sequelae sharply limited the amount of fat that could be removed without transfusion or hospitalization, which resulted in the abandonment of this approach, except in limited applications. The dry technique is not recommended for suction volumes greater than 1000 ml because of the amount of blood loss incurred. The dry technique should never be used in conjunction with ultrasound-assisted liposuction.

The wet technique entails injecting 200 to 300 ml of infiltrate or wetting solution, with or without additives, into the operative field before insertion of the liposuction cannula. Small doses of the vasoconstrictor epinephrine were added to the infiltrate, which significantly decreased the blood loss to 4 to 30 percent of the aspirate. The wet technique was the method of choice in the early 1980s.

The superwet technique, developed in the mid-1980s, uses 1 ml of solution for each 1 ml of fat to be removed. The surgeon’s preoperative estimate of the suction aspirate is considered in this technique. The infiltrate solution consists of saline or lactated Ringer’s solution with epinephrine and, in some cases, lidocaine. Using larger volumes of subcutaneous infiltrate, blood loss generally decreases to less than 1 percent of the aspirate volume.

The tumescent technique was introduced in 1985. It uses the largest volume of infiltrate and involves infusing 3 to 4 ml of the infiltrate solution for each planned milliliter of aspirate. Drug concentrations in the tumescent infiltrate solution vary, but typically they consist of a range of 0.025% to 0.1% lidocaine and epinephrine 1:1,000,000 in a lactated Ringer’s or normal saline solution. Estimated blood loss with the tumescent technique is approximately 1 percent of the aspirate, comparable to the superwet technique.

Since the advent of epinephrine-containing wetting solutions and sophisticated fluid management techniques, increasingly larger volumes of liposuction aspiration have been reported. Large-volume liposuction, defined as a total aspirate of 5000 ml or greater, can be a safe and effective procedure when patients are carefully selected and when anesthetic and surgical techniques are properly performed. Meticulous fluid balance calculations are necessary to avoid volume abnormalities, as metabolic alterations and fluid shifts result from medication effect, hypodermoclysis, and surgical technique. General practice guidelines recommend overnight observation postoperatively for patients undergoing large-volume liposuction.

Dr Koo is very precise and accurate with the preoperative marking and discusses the areas of liposuction during the preoperative consultation several times prior to the surgery and again on the day of surgery to ensure that the patient understands completely the areas to be contoured and they coincide with the areas of concern for the patient. This is essential to satisfactory results. Patients are marked with a fiber-tip marking pen in the upright position or standing. Areas to be avoided, such as the zones of adherence, is noted carefully.

Dr Michele Koo uses multiple-access incisions for almost all areas because removing all fat from a single access incision may lead to depressions around the access site and contour deformity. Incisions are placed in natural skin folds and asymmetrically to limit visibility of the resultant scars.

Dr Koo places the patient in the appropriate position for access to the treatment site. If multiple areas are to be treated during a single operation, it is convenient to prepare the patient circumferentially so that all areas of the trunk and extremities may be treated without repeated preparation and repositioning. Dr Koo feels that she is able to achieve the most optimal results with circumferential liposuction along with the tummy tuck (abdominoplasty) repositions the patient intraoperatively to better treat and evaluate surgical progress and symmetry.

A thorough operative record includes documentation of each stage of the liposuction procedure. The infiltration solution mixture should be documented and the volume of subcutaneous infiltrate used should be noted as well. Oftentimes, surgeons will note the amount of infiltrate and volume of aspirate by body area and record the total volumes for the entire procedure. This information, along with intravenous fluid administration and monitoring of vital signs and urine output, are important factors for maintaining adequate fluid management intraoperatively and postoperatively. A diligent fluid management strategy between the surgeon and anesthesia provider is important for avoiding volume overload sequelae.

Sequential compression devices should be in place before a general anesthetic is used in most liposuction procedures. Patients who undergo other types of anesthesia or minor procedures may do so without sequential compression devices.

The use of postoperative compression for 6 weeks is usually indicated after liposuction procedures to minimize edema and support the soft tissues. The various compression modalities and garments available for each area can be extremely useful but must be tailored to the area of treatment. The use of a foam material underneath the compression garment to increase compression and protect areas of irritation is frequently beneficial.

No single liposuction technique is best suited for all patients in all circumstances. Factors such as the patient’s overall health, body mass index, the estimated volume of aspirate to be removed, the number of sites to be addressed, and any other concomitant procedures to be performed should be considered by the surgeon to determine the best technique for the individual patient.

Ultrasound-assisted lipoplasty. Introduced in the late 1980s, ultrasound-assisted liposuction uses a cannula or probe to deliver fat-liquefying ultrasound subcutaneously. This technique permits the removal of fat from fibrous areas such as the upper abdomen, back, and flanks with greater ease, especially during secondary procedures. To prevent thermal injuries while performing ultrasound-assisted liposuction, two technique rules are of critical importance. First, the ultrasound probe or cannula must be kept in motion. Second, the infiltrate solution is a required component of ultrasound-assisted liposuction because it plays a crucial role in the process of fat emulsification and cooling the heat generated in the process. The dry technique should never be used in ultrasound-assisted liposuction, regardless of the planned volume of aspirate.

Suction-assisted lipoplasty. Suction-assisted lipoplasty is the most commonly performed aesthetic procedure in the United States. Suction-assisted lipoplasty procedures use an external source of suction to facilitate the removal of fatty tissue.

Power-assisted lipoplasty. Power-assisted lipoplasty is an approach in which the system that drives the cannula is a power source other than the surgeon’s arm. Systems are either electrically driven or gas-driven by nitrogen or compressed air tanks. A small motor moves the 2- to 4-mm cannula tip in a forward and backward motion, replicating the motion of the surgeon and decreasing physician fatigue. The cannulas are small and flexible and are comparable in length and diameter to standard suction-assisted liposuction cannulas. Power-assisted liposuction is effective for large-volume removals, fibrous areas, and revisions. It is typically used in conjunction with the tumescent or superwet technique. The excessive vibration of the cannula and the noise of the power system are the two main disadvantages of this technique.

Combination ultrasound-assisted lipoplasty and suction-assisted lipoplasty. A combination of techniques may be used for treatment of various areas of lipodystrophy.

Other. Syringe aspiration of fat has been used for addressing superficial irregularities independently or in conjunction with another liposuction modality. This method for aspiration may result in less blood loss and has been reported to be a more precise and accurate mode of fat removal. The main disadvantage of syringe aspiration is prolonged operating time. This technique is effective for sensitive and smaller volume areas, such as the neck. It also is commonly used for harvesting fat for transfer, as less mechanical damage to the fat cells allows for a greater percentage of viable cells for transfer.

Embolism may occur from fat or venous thrombosis. The signs of pulmonary embolism may be shortness of breath or difficulty breathing. Deep venous thrombosis may be present with calf or leg pain, Homan’s sign, swelling or erythema of the lower extremity, persistent tachycardia, and/ or mild pyrexia. The thrombus is not usually palpable. Treatment of deep venous thrombosis may entail anticoagulation or placement of a venous filter. Patients who develop a pulmonary embolus may undergo thrombectomy or thrombolysis as well. Although the exact pathophysiology of fat embolism syndrome remains somewhat controversial, signs or symptoms of fat emboli after liposuction require emergency medical care, as permanent disability or fatality may result.

Advances in the understanding of fluid management in the care of the patient undergoing liposuction has increased the margin of safety of this procedure. Firm guidelines for the appropriate amount of fluid resuscitation have yet to be established; however, there are multiple formulas and fluid balance calculations for determining the appropriate balance of intravenous fluid administration and subcutaneous infiltration. The key to appropriate perioperative fluid homeostasis is proper patient selection and consistent communication between the surgeon and the anesthesiologist with regard to perioperative fluid replacement and urine output. The surgeon should be cognizant of all fluid administered and removed with aspirate and excreted as urine output to avoid problems with hypovolemia or fluid overload.

Fatal complications secondary to liposuction may be attributed to anesthetic cardiopulmonary complications, necrotizing fasciitis with overwhelming infection, hypovolemic shock, fat embolism, pulmonary embolism, disseminated intravascular coagulopathy, or intraperitoneal and bowel perforation. Less common reports of death resulting from liposuction procedures have also included toxic shock syndrome, acute respiratory distress, and hypersensitivity to medications or instruments used during the procedure.

Intestinal or organ perforation from the liposuction cannula, though rare, usually occurs with a preexisting abdominal scar. The abdomen, thorax, retroperitoneum, and major vessels in the subcutaneous space are all potential areas into which a cannula can be misdirected and potentially result in major injury. Kidney perforation has been reported. Symptoms of organ perforation may not become apparent for several days. When internal organs are violated, patients may present for follow-up with symptoms of an acute abdomen, and an emergent laparotomy may be indicated to assess the extent of damage and to repair injury, as visceral perforations and their associated infections may be fatal. Gentle technique and awareness of the possibility of misdirection of the cannula in the presence of a scar will prevent this complication.

The total blood loss involved in suction-assisted lipectomy is principally dependent on (1) the amount of blood present in each milliliter of aspirate and (2) the absolute amount of aspirate. Total blood loss can be estimated as the percentage of blood in the aspirate multiplied by the total amount suctioned. Clinically, the blood loss is rarely a limiting or significant factor in cases in which total aspirate is less than 1000 ml, regardless of the infiltration method used. The dry technique results in a suction aspirate containing 20 to 45 percent blood.

Any of the complications described in the previous section can also occur in the later postoperative period. Surgeons should recognize additional complications that may present as convalescence continues.

Patients with a higher body mass index have been found to have a significantly increased risk for developing postoperative seromas. Ultrasound-assisted liposuction has also been associated with a slightly increased risk of seroma formation. Suggestions for decreasing the incidence of seroma include expressing any remaining fluid before closure; using a single suture to close incisions, allowing for fluid egress; applying a well-fitting compression garment; and encouraging the patient to ambulate soon after surgery. Simple aspiration is the most common treatment for a seroma. An implantable catheter or drain can be used to avoid repeated aspiration.

Although large areas of skin loss is rare, ulceration or friction injury is more commonly noted at the entrance site from incorrect use of the cannula, tension on skin margins, or an incision that is too small for the instruments used. Burns have also been associated with ultrasound-assisted liposuction, as the ultrasound cannula can become very hot, and prolonged contact with the skin may result in skin damage.

Infections can occur and have been known to progress to serious and life-threatening conditions if not appropriately attended to. Many surgeons will prescribe perioperative antibiotics to minimize the risk of infection. Physicians who perform liposuction should be familiar with the signs and symptoms of conditions such as toxic shock syndrome and necrotizing fasciitis.

The most common postoperative sequelae of liposuction are contour irregularities; these may be considered complications if they persist for over 6 months. Because contour irregularities may be secondary to postoperative swelling and skin elasticity, they may be treated conservatively for at least 6 months after the initial operation. However, for areas of excessive fat removal or insufficient fat removal, secondary liposuction, fat grafting, and dermolipectomy can be considered to address the persistent area(s) of concern. Nonsurgical treatments for early contour irregularities include manual lymphatic massage and Endermologie (LPG Systems, Valence, France). Long-term swelling may be noted in a small number of liposuction patients.

Skin hyperpigmentation may be attributed to several factors. Hemosiderin deposition by ecchymosis, external pressure from bandages applied, and possible friction from the inlet holes of the cannula have been suspected of increasing the likelihood of hyperpigmentation postoperatively. Several areas are known to be prone to hyperpigmentation (e.g., the medial thigh). This effect is more often attributed to ultrasound-assisted liposuction and extended treatment time to a single area (>10 minutes). Patients should also be cautioned that oral iron therapy, exogenous drug administration (particularly estrogen), and sun exposure may contribute to the development of hyperpigmentation after liposuction.

Patients may experience paresthesias after surgery. Patients have reported hypersensitivity and numbness after surgery that may persist for weeks or months. In a small number of patients, these paresthesias may be permanent.

The analysis of the sequelae of liposuction and tummy tucks does not provide specific percentages of complications associated with liposuction. Seromas, infection, and tissue irregularities are the most common minor problems. Deep venous thrombosis, associated with pulmonary embolism and death, is the most frequent serious complication of liposuction. Thus, the prevention and, if necessary, the expeditious diagnosis and treatment of deep venous thrombosis are integral to the care of the liposuction patient.

Dr Koo examines patients who may desire secondary surgery to correct contour irregularities carefully and counsels them to ascertain their realistic goals for surgery. Previous surgical procedures are considered and careful notation is made to document the site of secondary surgery and the anticipated amount of secondary lipoaspirate or augmentation with dermal fat grafts of lipotransfer. Skin resection may be necessary for areas of inadequate skin retraction.

Physical outcome and ease of recovery are not the only factors that define patient and physician satisfaction, as successful body contouring surgery requires a patient to embrace positive lifestyle habits. Dr Koo recognizes the importance of patient education on postoperative alternatives in diet and exercise and will help the patient establish a connection with nutritionists as well as exercise trainers. This will ultimately help the patient maintain successes achieved with the liposuction and tummy tuck procedures.

Dr Michele Koo always maintains a relationship with her patients seeing them post operatively indefinitely thereby making sure that they “check in” for annual breast examinations as well as keeping track of their weight and exercise maintenance. Dr Koo wants to change and enhance the patients life and lifestyle and continues to take care of her patients years after any procedures at no further follow-up charges.

Dr Michele Koo, MD, Board Certified Plastic Surgeon, St Louis, Missouri, 314-984-8331.

Breast augmentation is an extremely popular and safe surgical procedure that 100’s of thousands of woman have undergone without any complications. The majority of these woman are extremely happy and would choose to have to surgery again if given the choice to do over again. In 2007, the FDA again allowed the use of silicone gel implants for elective breast augmentation for cosmetic reasons.

However, with time and aging of the implant, the breasts may change and the implant become encapsulated (scar formation around the implant). The breasts may become hard and misshapened and painful. The breasts may become too saggy and heavy and extremely uncomfortable for the woman.

Breast implant removal and replacement along with a breast lift is very safe and often a normal sequelae to breast augmentation that is over 15-20 years old. The recommended life of a saline or silicone implant is approximately 15-20 years. Whether a breasts starts to show the changes of encapsulation (hardening) and pain depends on where the original breast implants were placed, the original type of implant, and, of course, the patient herself.

The surgery that needs to be performed to change the breast implants is largely dependent on what was done at the time of the original surgery, whether the implant was placed under the breast or under the muscle, what type of implant was used, and what the breasts look and feel like in its current condition.

A breast implant exchange or a complete breast implant removal without an implant replacement can be performed. If the breasts have become saggy and have fallen so that they are too low on the chest, a breast lift may have to be performed at the same time as the breast implant replacement or removal. All of the above procedures can be performed very safely in one procedure by DR MICHELE KOO, MD of St Louis, MISSOURI, 314-984-8331.

There are a few points that Dr Koo wants you to understand about breast implants and breast augmentation according to an article by John B Tebbets in the Journal of Plastic and Reconstructive Surgery.

Factors That Affect Responses to a Breast Implant

Every medical device implanted into the human body is placed in an environment where certain factors cannot be predicted or controlled by the surgeon or the patient, especially factors related to a patient’s individual wound-healing characteristics and the genetic characteristics of each individual patient’s tissues.

A breast implant has a range of effects when placed into the body, effects that continue for the entire time the device is implanted. Short- and long-term effects of a breast implant in the body depend on three different sets of factors: device-related factors, surgery-related factors, and factors related to the patient’s wound-healing and genetic tissue characteristics. Surgeons and patients have some level of control over device-related and surgery-related factors, including implant type and size, maximal soft-tissue coverage over the implant, and optimal surgical techniques to minimize tissue trauma and bleeding. Neither surgeons nor patients, however, can predict or control patient wound-healing and genetic tissue characteristics.

Factors That No Surgeon or Patient Can Predict or Control

No surgeon or patient can predict or control a patient’s wound-healing characteristics or a patient’s genetic tissue characteristics, factors that can affect outcomes following breast augmentation. Each patient has unique, individual wound-healing and genetic tissue characteristics that influence the interaction between a breast implant and the surrounding tissues. Individual wound-healing characteristics influence the characteristics of the capsule or lining that forms around every breast implant and affect the degree to which that capsule tightens or contracts, which in turn determines whether capsular contracture will cause excessive firmness of the breast or other deformities. A patient’s wound-healing characteristics may also affect the quality of incision scars, the risks of infection or fluid production around an implant, and other factors that can affect the aesthetic result. Genetic and hormonal effects of pregnancy and nursing vary from patient to patient and can affect aesthetic results and outcomes.

A patient’s genetically determined tissue characteristics can affect the response of the patient’s tissue to the implant, including how much the skin will stretch and thin in response to a specific size implant and how the breast tissue overlying the implant will respond. Surgeons and patients can avoid selecting excessively large implants, but even an appropriate-size implant for a patient’s visible tissue characteristics may cause excessive stretch of the breast skin envelope in patients whose tissues do not adequately support the weight. Unfortunately, surgeons have no tests available to predict a patient’s wound-healing or tissue responses to a breast implant. As a result, no surgeon can predict or control the occurrence or severity of capsular contracture, infection, tissue stretch deformities, or other conditions relating to patient wound-healing and tissue characteristics.

Reoperations: The Risks, the Tradeoffs, and the Logic

Every additional reoperation that is required following placement of breast implants imposes additional risks, costs, and tradeoffs to the patient. Some reoperations are medically necessary, but others are not. Severe capsular contracture, infection, and fluid accumulation around an implant are medical reasons to perform an additional operation. A patient’s request for a size change to a larger or smaller implant, though desirable to the patient, is not medically necessary and imposes risks and costs that may not be logical medically. For example, although the risk of infection with implant exchange is small, it is not zero, and for the patient who experiences such a complication, the incidence is 100 percent and may require implant removal without replacement or may produce an uncorrectable deformity.

Every reoperation causes additional surgical trauma and bleeding, and healing after each additional surgery produces more scar tissue, the effects of which are uncontrollable. Seemingly simple operations such as a minor revision for implant malposition or excessive stretch, though usually safe, invoke healing mechanisms that are uncontrollable and can result in exchanging one deformity for another. Logically, reoperations should not be performed for reasons that have no medical necessity or to address relatively mild aesthetic conditions where the risks and effects of the surgery might possibly produce a change that is worse or different compared with the existing condition.

Implant Removal without Replacement: The Logic

Breast implants are not medically necessary devices. Regardless of the efforts and costs to place breast implants, if certain conditions or complications occur, continuing to attempt to salvage the implants or leaving implants in place can cause permanent damage to a patient’s tissues, producing deformities that are uncorrectable.

Once a patient has breast implants, virtually every surgeon and patient wants to keep the implants in place. The positive effects of implants make some patients unwilling to even consider removal without replacement under any circumstances. Removal without replacement must be a joint decision of the patient and surgeon, both of whom must recognize and acknowledge that the aesthetic consequences of removing implants may be far more preferable to possible permanent, uncorrectable deformities and additional reoperations with additional costs and risks if the implants are left in place. Surgeons and patients should define criteria for removal without replacement before the patient has a breast augmentation, and the patient should understand and document her acceptance of these conditions in informed consent documents. A surgeon’s willingness to adhere to stringent criteria for reoperations directly influences reoperation rates, risks, tradeoffs, and costs to the patient.

Unilateral versus Bilateral Implant Removal

When a condition requiring implant removal occurs unilaterally, removal of one implant creates a deformity (asymmetry) that virtually guarantees at least one reoperation to replace the implant. Unilateral implant removal encourages patients and surgeons to prioritize implant replacement, often sooner than is medically optimal. Unilateral implant removal can compromise future decisions and the timing of those decisions. When removal is indicated, bilateral implant removal totally avoids these compromises and eliminates a demand for reoperation based on asymmetry.

Implant Removal without Replacement: The Criteria

Every surgeon must define personal criteria for implant removal without replacement, based on clinical experience, medical indications, and logic. On the basis of more than two decades of experience, I recommend breast implant removal without replacement for the following clinical conditions or situations, and I require that every patient accept and acknowledge these criteria in informed consent documents before the primary augmentation

* Recurrence of capsular contracture after having performed a complete capsulectomy and implant replacement with a new (textured saline if the primary was silicone gel filled) implant for a first capsular contracture of grade III or IV (limits total reoperations for capsular contracture to two).

* Recurrence of stretch deformity (bottoming, lateral malposition) after having performed a previous capsulorrhaphy, partial capsulectomy (if indicated), and exchange to a smaller implant (limits total reoperations for stretch to two).

* Traction rippling or visible implant edges medially when there is no additional tissue coverage available locally (e.g., conversion of submammary to subpectoral), or when pectoralis coverage has been previously compromised by division of medial pectoralis origins.

* Culture-documented contamination or infection of the periprosthetic pocket, regardless of implant type or pocket location (any occurrence of documented infection). This approach optimizes rapid resolution and minimizes inflammatory effects on tissues that occur with prolonged salvage efforts, effects that may produce significant and sometimes uncorrectable tissue deformities over time. Further, this approach minimizes the risks and costs of future reoperations attempting reimplantation, and it eliminates reoperations for recurrent infection or capsular contracture that can occur after attempted reimplantation.

* Recurrent seroma, regardless of negative cultures, after treatment of an initial seroma with exploration, capsulectomy (if indicated), and prolonged drainage.

* Inadequate soft-tissue coverage, when pinch thickness of tissues covering any area of the implant is less than 0.5 cm (except when coverage deficit is medial or superior and can be improved by dual plane or retropectoral implant placement).

* In any situation where two previous reoperations have been performed, for any reason (limits reoperations to three, including removal without replacement).

Criteria to Limit Reoperations

The following criteria have evolved over more than two decades to limit reoperations with their inevitable risks, tradeoffs, and costs:

* No reoperations for implant size exchange if not medically necessary (e.g., a slightly larger implant after performing a capsulectomy, provided adequate soft-tissue coverage is available).

* No reoperations for grade II capsular contracture.

* No reoperations for minor stretch deformities [<3 cm of additional widening of the intermammary distance due to lateral envelope stretch, <2 cm of elongation of nipple-to-inframammary fold distance (bottoming) 6 months or more postoperatively regardless of emptying of upper breast or slight excess volume in lower breast].

* No reoperations to adjust nipple-areola position if sternal notch-to-nipple distances are within 1.5 cm bilaterally (for either primary or secondary procedures).

* No implant replacement if patient has previously required bilateral implant removal for any condition or suspected condition, including replacement of saline-filled implants following removal of silicone gel-filled implants to address concerns of connective tissue disease or other undefined symptom complexes or psychological conditions.

* No reoperations if patient is unwilling to sign detailed informed consent documents acknowledging that she understands and accepts that every reoperation involves additional risks, tradeoffs, and costs, that correction of any condition by reoperation is not guaranteed, and that with any reoperation, we may exchange one set of problems or compromises for a different and not necessarily better set of conditions.

Results

The above-described criteria, combined with implant selection based on quantifiable tissue characteristics and more detailed patient education and informed consent were applied in 1662 reported cases using textured, saline-filled breast implants with up to 7 years of follow-up. The resulting overall reoperation rate was 3 percent. Acknowledging the limitations of comparing the studies, this 3 percent overall reoperation rate at up to 7 years compares favorably to the overall reoperation rates of 13 and 21 percent at 3 years in the saline premarket approval studies of Mentor and McGhan and to the 20 percent reoperation rate at 2 years in the most recent silicone gel premarket approval submission by Inamed Corporation.

Discussion

Factors such as the surgeon’s experience, the surgeon’s technical skill, the reasons for reoperations (device-related versus surgery-related), and other factors preclude direct, scientifically valid comparisons between our reoperation rates and those of the premarket approval studies. Nevertheless, the large clinical experience with long-term follow-up reported in our studies includes every reoperation for any reason, similar to the premarket approval study results. In the premarket approval study, capsular contracture was categorized as a device-related reason for reoperation when in fact surgical tissue trauma and bleeding are significant if not major stimuli for capsular contracture. A reoperation is a reoperation, regardless of whether the patient requests it for size change or an improvement in aesthetics. Selective categorizing and analysis to shade interpretation of results and causes is largely nonproductive, if reducing reoperation rates is a goal. By defining and implementing out points and decision and management algorithms, we have dramatically reduced reoperation rates in our practice over the past two decades.

Conclusion

To reduce the rate of reoperations, with their inevitable risks, tradeoffs, and costs to patients, and to reduce the incidence of tissue-compromising deformities resulting from multiple reoperations, surgeons must define strict criteria for reoperations following breast augmentation and for bilateral implant removal without replacement. The criteria described in this article resulted in overall reoperation rates that are substantially lower compared with overall reoperation rates in recent large premarket approval submissions to the Food and Drug Administration. Each surgeon must define criteria according to his or her individual surgical experience and practice characteristics, but current Food and Drug Administration rulings and guidance suggest that continued availability of breast implant devices for patients demands that patients experience lower reoperation rates.

Dr Michele Koo feels very strongly that her patients can benefit from primary breast augmentation for elective cosmetic reasons as well as from breast implant revisions should the need arise. However, as the article above emphasizes, re-operation for breast implants have certain risks and complications that are out of the control of the surgeon and the patient. Dr Koo wants the best outcome for her patients and she feels that the better informed one is when going into the initial surgery, the easier it will be for all subsequent surgeries.

Dr Koo wants her patients to understand that no matter how pleased you may be with the original breast augmentation or revision surgery that once a breast implant is used, that will then obligate you to subsequent surgeries whether it is for an implant replacement after many years, or whether it is due to your breasts changing shape and size after children or weight gain and loss.

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.

Before Breast Reduction 40 EE/FF

After Breast Reduction 38 C/D

If you have ever been frustrated with your large, heavy, pendulous breasts that make you feel overweight and matronly, you need to see Dr Koo for a consultation on how to reduce the size of your breasts and lift them onto your chest and off of your tummy.

Most insurance carriers covers breast reductions and Dr Koo and her staff will help you through this process. Dr Koo will be able to let you know how much weight she will be able to take off depending on what size you ultimately want to go to. The important thing is that your breasts will be lifted, lighter and be so much shaplier.

You do not need to feel trapped by your body with heavy breasts that prevent you from exercising and losing weight. Dr Koo understands that you are in a vicious cycle where the heavier your breasts, the less able you are to exercise, and the less you are able to exercise, the heavier your breasts become. She understands how depressing it is for you not to be able to buy normal bras and clothes that are pretty.

Dr Michele Koo, MD, FACS, also understands the terrible discomfort you have to endure because of the weight and pull of your large breasts. You probably have deep shoulder grooving, neck and back pain, and headaches from your saggy heavy breasts. You also probably have terrible sweating and rashes under your breasts from rubbing on your abdomen.

Dr Koo lifts and reduces the breasts but preserves the attachment of the nipple so there is a very little chance of losing sensation to the nipple. The scars will fade in time and around the nipple areolar complex, down the center under the nipple, and a short scar under the breasts. Dr Koo creates your own underwire support with the scar under the breasts to preserve the shape of your breasts.

See Dr Michele Koo, MD, FACS in St Louis, Missouri for a consultation to begin your new life with lighter shaplier breasts that finally will allow you to get back to a normal healthier lifestyle. You do not have to hide in large dresses and tops because of your heavy, saggy breasts. You can have them reduced, lifted, and reshaped to make you feel and look so much better.

Why not start today on your way to being healthier with lighter, lifted breasts that will finally allow you to lose weight and feel better about yourself.

Call Dr Michele D Koo, Board Certified Plastic Surgeon, St Louis, Missouri 314-984-8331 and ask for a consultation today.

BREAST REDUCTION ST LOUIS-ILLINOIS-SPRINGFIELD

314-984-8331

DR MICHELE KOO, MD, FACS

BOARD CERTIFIED PLASTIC SURGEON

BEFORE BREAST REDUCTION 36 HH

AFTER BREAST REDUCTION 38 C BRA

Have you always wanted shaplier, lifted, lighter perkier breasts?

Did you know that was possible and have your insurance cover the surgery?

Are you sick and tired of your skin sweating under your breasts and getting rashes all the time?

Are you tired of not being able to exercise and walk comfortably? Are you sick of the grooves in your shoulders?

The patient pictured in the photograph is a 36 year old woman from St Louis, Missouri who complained of skin rashes under her breasts, neck, shoulder, and back pain from her very heavy, pendulous breasts.

She underwent a breast reduction by DR MICHELE KOO, MD, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI, 314-984-8331 and has been transformed from a 38 DDD/EE to a 36D.

She is ecstatic about her beautiful new breasts and has gained so much self confidence. Her friends keep asking her if she’s lost a great deal of weight. Her shoulders and neck no longer hurt and she is able to walk and exercise comfortably. She loves wearing pretty bras and cute tops and dresses.

She no longer has to spend a fortune on ugly big bras that look like parachutes.

Dr Michele D Koo, MD, FACS, Board Certified Plastic Surgeon, St Louis-Kansas City,Missouri and Illinois can reduce, lift, and reshape your breasts with a breast reduction (reduction mammaplasty) so that your back, neck, and shoulders are relieved of the grooving, pull, and pain.

The breast reduction surgery takes approximately 2 to 2 1/2 hours under general anesthesia and is extremely safe. You may either go home on the day of surgery or stay over night if you choose. You will drive the next day and you will be able to return to a office type of occupation in 1-3 days and in 7-14 days to a physical type occupation.

Your recovery time is minimal.

You will be given a surgical compressive bra after your breast reduction and may have some drains out the side of your breasts when you go home. Dr Koo will see you in the office 4 days after the surgery when the drains will likely be removed. Most patients rarely complain of pain after the surgery and are pleasantly surprised that the recovery is very minimal.

Dr Koo’s patients will tell you that the breast reduction surgery is one of the best things they have ever done for themselves.

The pre- breast reduction patients often feel so trapped by their heavy breasts. They feel they are unable to exercise adequately to loose weight and the more weight they gain the larger their breasts become. They are caught in a vicious cycle that they cannot break themselves.

Dr Koo sees patients from throughout Missouri, Cape Girardeau, Kansas City, Springfield, Farmington, Illinois and the remainder of the United States. Her office will make arrangements for your out of town stay and help you in any way you need.

Dr Michele Koo, MD, of St Louis, Missouri, 314-984-8331, can help you break that weight gain cycle and reduce, lift, and reshape your breasts.

You will have freedom like you’ve never had before and relief of shoulder, neck, and back pain. Your tension headaches should also lessen from the relief of the pull on your shoulders and neck.

You can feel like your breasts are youthful again, lifted, off of your tummy and back on your chest. The areola will be made smaller and shaplier and you will not have to deal with all of that excess breast tissue getting in your way.

Please feel free to call Dr Koo’s office, 314-984-8331, with questions and to talk to other patients who have undergone this exact surgery.

Begin your new life after breast reduction today, DR MICHELE D KOO, MD., 314-984-8331, ST LOUIS, MO.

BREAST LIFT

(MASTOPEXY)

AND

BREAST

AUGMENTATION

FOR FULLER

SEXIER  BREASTS

Before Breast Lift and Breast Augmentation

DR MICHELE D KOO, MD, FACS is a Board Certified Plastic Surgeon and a Member of the Aesthetic Society located in St Louis, Missouri. She is an expert on breast lift and breast augmentation surgery in the United States and especially in St Louis, Kansas City, Columbia, and Springfield, MO and throughout the midwest.

Dr Koo is often asked by her patients what can be done about their breasts after childbirth, weight loss, or breast feeding.

After weight loss, just as after breast feeding, the breast volume decreases but the amount of skin most often stays the same. Therefore, the breast skin sags and the breasts are smaller and without any remaining fullness. The breasts also may lose shape. Many women experience this after breast feeding when the breasts become very full and the skin stretches.  After breast feeding just like after weight loss, the breasts lose volume and the skin sags.

Dr Michele Koo who specializes in returning breasts to a natural full shape and position can help you feel better about yourself.  She will perform a breast lift (mastopexy) alone or a combination surgery of a breast lift (mastopexy) and breast augmentation (breast implant) to achieve the perfect results for her patients.

Depending on how much weight loss or loss of volume of breasts one experiences, most women will need either a breast lift (mastopexy) alone, a breast augmentation (implant) alone, or a breast lift (mastopexy) with breast implants (breast augmentation) to regain  the sexy full breasts with nice full cleavage. Some of Dr Koo’s patients will experience significant change in shape of their breasts with only a 5 lb weight loss some will not experience significant change in shape until they have lost at least 20 or more pounds.  

Dr Michele Koo approaches the breasts with the patients’ goals in mind of whether they wish to just have their breasts lifted back into position so that the nipple is not pointing downward or whether they wish to have a little fullness in the upper portion of their breasts with some cleavage. If the latter is their goal then certainly a breast augmentation (breast implant) is absolutely necessary.  

Dr Michele Koo performs the breast lift (mastopexy) and breast enhancement in one surgery which takes  approximately 1 ½ to 2 hours and the recovery is minimal. It is an outpatient surgery under general anesthesia and her patients return to driving the next day and an office occupation in 1-2 days but wait approximately 2 weeks before any kind of a cardiovascular workout.  

Dr Koo gives her patients the option of saline or silicone breast implants and they make the decision together taking into account the patients’ level of comfort with the types of breast implants and their age.

Dr Koo, St Louis, MO will recommend the different types of profile of breast implants depending on the patients’ anatomy and ultimate cosmetic desires. She makes the recommendation for the location of the incision, type of breast implant, and the exact nature of the surgery depending on what her patient wants her breasts to ultimately look like.

If the patients’ breasts only have to be lifted very slightly, a breast implant alone will achieve the breast lift (mastopexy) and breast augmentation (enhancement) with a minimal incision. If the breasts have to be lifted a significant distance then that determines the length of the scar. Dr Koo only creates the smallest incision possible given how much re-shaping she has to achieve and what the patients’ desires are.

A breast augmentation with or without a breast lift is a very frequently requested and performed procedure by Dr Michele Koo and she will make you feel extremely comfortable with all your questions and concerns. Dr Koo feels that this is a very common and very safe procedure which she performs on a regular basis and these patients are some of her absolutely most satisfied patients.

AFTER 38 C/D

BEFORE 42 DDD/EE

Are you tired of your heavy sagging breasts rubbing the skin of your abdomen and being too low?

Dr Michele Koo, MD, FACS, Board Certified Plastic Surgeon, St Louis, Missouri 314-984-8331 can lift them and make them perky and put them back on your chest instead of sitting on your abdomen.

Dr Michele Koo, St Louis, MO, lifts the breasts, makes them shaplier and smaller relieving the pain and pull in your shoulders, relieving the tension in your neck that causes the constant headaches and back pain.

Dr Koo, preserves the nipple areolar complex attached to the underlying breast tissue thereby allowing the best chance of preserving the sensation of the nipple. She lifts the breasts and removes the excess skin and reshapes the breasts to give you comfort and allow you to go on to be more active and to allow you to try to be healthier and more active.

The patient that is pictured was able to go on to lose 25 lbs slimming her waists and hips which can be seen in the after picture.

You do not have to live with the constant skin rashes and sweat under your breasts.

They will be shaplier, lighter, and, of course, prettier. Your friends will ask if you have lost weight, and you will think your neck, back and shoulders feels so much better. You’ll have shaplier breasts that you may never have had with a breast reduction which is often covered under your medical insurance. 

Dr Koo’s staff is extremely experienced and helpful in obtaining insurance approval of your breast reduction. Dr Koo will be able to determine if she thinks that insurance will cover the procedure after she examines you to see how much breast tissue she feels she can remove safely and in keeping with the size you ultimately want to become. If she does not think that you will qualify for insurance coverage, her office will help you obtain financing should you still decide to go forth with the breast reduction surgery.

Dr Michele Koo utilizes the most delicate surgical techniques and newest sutures so as to minimize the appearance of your scars. She also tries to hide them in the natural folds of your skin and breasts, disguising them to the optimal locations.

After the breast reduction, you will wish you had done this so much sooner. You will be able to return to an office type of work in 4 days and you may return to a more strenuous type of job between 2-3 weeks. You will wear a compressive surgical bra continuously for 4 days after the surgery and then will be able to switch to a tight sports bra thereafter for the next 2 weeks.

Call DR MICHELE D KOO, BOARD CERTIFIED PLASTIC SURGEON (314) 984-8331 TO CHANGE YOUR LIFE.