Plastic Surgery


Macromastia >500gm/breast
Gigantomastia >1000gm/breast

Breast Surgery Types

Breast Augmentationsurgery to increase breast sizeinvolves placing breast implants under breast tissue or chest muscles
Breast Implantssilicone or saline filled prosthesis
Lumpectomy local surgery for breast caonly taking out the problem
Mastopexy putting breast tissue back where it’s supposed to be w/ a small implant
Breast Augmentation
Breast Augmentation Types
areolar small incision just around the areolar complex small implants only
heals really well – scar barely seen
axillary tunnel a pocket in the breast scar pretty well healed
inframammary incision directly in the fold under the breast heals well but you will see a scar
transumbilical incision made in the navel area roll it up & then fill with saline & watch how it inflates
Breast Augmentation Post-op

Breast Implants

Breast Implant Types
Silicone Saline
Viscositymore viscous viscous
Look and texturelook and feel more naturalfeel harder
Show thru skinless likelyfolds may be visible
FDA approved Breast Augmentationat least 22 yo at least 18 yo
FDA approved Breast Reconstructionany ageany age
Placement of implants
dual-plane placing the implants partly behind the breast and partly behind the muscle– Fewer complications
– natural result particular for thin patients with very small breasts
– Rippling possible on the bottom of implant
• More pain and longer recovery
• Bottoming out may occur 
subfascial it places the breast implant in front of the muscle, under the connective tissue that covers the pectoral muscle– less injury to the breast tissue during surgery
– placement more comfortable after healing
– much lower risk of breast implant failure
– reduced risk of capsular contraction and maintaining its proper positioning
– patient can return to an active lifestyle sooner
subglandular TUBA
between the normal breast tissue & muscle of the chest
more encapsulation
submuscular axillary incision bc you are sep the serratus & pec minor from the sideMost natural-appearing breast implant

avoid breadloafing
Not good for an athletic pt – they will look deformed

Mastectomy Types

Simple only breast tissue
Modified radical breast tissue + some invasion into axilla + sentinel node
Radical breast tissue + pectoralis muscle + axillary LNs
Partial removal of the cancerous part of the breast tissue and some normal tissue around it
Nipple-sparing all of the breast tissue is removed, but the nipple is left alone
Post Mastectomy Breast Reconstruction

reconstructive ladder Secondary intention –> direct tissue closure –> skin graft –> local tissue transfers –> distant tissue transfers –> free tissue transfers
Post Mastectomy Breast Reconstruction – Implant Types
Direct to Implant reconstructionbypass a preliminary surgery where temporary breast tissue expander implants are inflated over time to stretch the overlying skin and muscle– shorter, less complex surgery
– uses the mastectomy incision for procedure (doesn’t create new scars)
– take longer (multiple steps, multiple office visits to receive tissue expander injections)
– look and feel less like natural breast
– subject to future problems such as rupture, deflation, capsular contracture
– implant won’t last a lifetime
Two-stage reconstruction1. Tissue Expander Surgery
2. Implant Reconstruction
– simple and predictable
– No donor site morbidity
– Shorter surgery time
– Shorter recovery
– Req. a minimum of two operations
– Lengthy process (numerous and frequent visits for expansion)
– Req. good quality skin
– Increased potential for capsular contracture

Alternative to Implants

Flap Procedures
Flap Procedures Types
deep inferior epigastric perforator flap deep inferior epigastric perforators (DIEP), the skin and fat connected to them, are removed from the lower abdomen and transferred to the chest
free TRAM flap same procedure as the pedicle TRAM flap but without the pedicle

you must take it out & perform a microsurgical vascular reattachment when you get it to the site of reception
no connection to the blood supply

no tunnelling under
gluteal free flap take it from their butt or inner thigh without connection to vascular supply
latissimus dorsi flap skin, muscle, fat tunneled from back under the skin to the front of the chest
keeps the vascular supply

most successful in women who smoke
pedicle TRAM flap skin fat & muscle from abdomen is tunneled under the skin to the chest

site of donor tissue remains attached w/ blood supplyhigher incidence of hernias
transverse upper gracilis flap take it from their butt or inner thigh without connection to vascular supply
transverse rectus abdominis muscle flap
Reduction Mammoplasty
Recommend for pts w/
– inframammary intertrigo
– degree of breast proptosis
– degree of enlargement
– skin lesion on breast envelope
– sensation of nipple-areolar complex
– nipple dc
– shoulder notching
– kyphosis
Reduction Mammoplasty Types
Inferior pedicle tech

(Anchor type or inverted T)
leaving a pedicle of tissue with the nipple in the superior portion of the pedicle, creating a wedge-shaped pedicle down to the chest wallMost Common procedure
Free nipple graft technipple and areola are completely removed and then replaced as a skin graft at the end of a breast reduction It is performed very rarely in cases in which the breasts are extremely large
Liposuction removing excess fat from under the skin by suction
Horizontal Scar tech horizontal incision along the inframammary fold (IMF) and a NAC pedicle
Vertical scar tech shorter scar that does not extend medially and laterally along the inframammary fold– Reduced scarring, improved shape, long-term shape retention, and good nipple sensation
– best for removing small areas of the skin envelope and small volumes of internal tissues 

Liposuction Types
laser-assisted uses laser energy to liquefy fat cells melting the fat to make the suction of the fat out of the body easier
tumescent several quarts of a solution are pumped below the skin in the area from which fat is to be suctioned
US-assisted uses ultrasonic vibrations to turn fat cells into liquid melting the fat to make the suction of the fat out of the body easier
Post-op Liposuction


Facial Surgery

Face/neck lift excess skin and fat of face and neck, vertical bands of neck
Blepharoplasty excess skin and/or fat of eyelids
Functional indication: impairing vision
Browlift excess forehead and “heavy” brows, constant “angry” look – usually performed w/ blepharoplasty.

Rhytidectomy Types
Main focuses AdvantagesDisadvantages
SMAS Mobilization
deeper dangerous due to all of the nerves
Deep plane facelift better nasolabial fold appearance in rhytidectomy greater auricular nerve
facial nerve
Thread lifts nasolabial fold younger people
a small opening
only placed under the skin
minimally invasive
Minimal access cranial suspension lift minimally invasive procedure that will help to lift the nasolabial fold

Skin Graft

CharacteristicsIdeal siteFull Thickness utilizedInappropriateLead to Failure
Blood supply
Underlying tissue
Graft thickness
Structures present that need covering
Over muscle or fascia or other vascularized, stable tissueover precarious takes

eyelides, nose, hand, joints
Over hardware
Over a fracture
Over tendons devoid of paratenon
Over repaired tendons
Over bone without periosteum
Poorly vascularized bed
Colonized/infected wound bed
Shearing stress before graft adherent
Excessive swelling
Three phases of a graft take

Contraindications & increased risk of post-op complications