WP Chung O T in in Breast Surgery, Trunk Reconstruction and

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Operative Techniques in Breast Surgery, Trunk Reconstruction and Body Contouring FIRSTEDITION Published May 2019 SAMPLE CHAPTER PREVIEW

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When you have to be right

Operative Techniques in Breast Surgery, Trunk Reconstruction and Body Contouring

FIRST EDITION

ISBN 978-1-4963-4809-8 Price £195.00/ €220.00

Part of the best-selling Operative Techniques series, Operative Techniques in Plastic Surgery provides superbly illustrated, authoritative guidance on operative techniques along with a thorough understanding of how to select the best procedure, how to avoid complications and what outcomes to expect. This stand-alone volume offers focused, easy-to-follow coverage of breast, trunk reconstruction and body contouring, all taken directly from the larger text. It covers nearly all plastic surgery operations for these specific areas that are in current use, and is ideal for residents and physicians in daily practice.

Features include: Succinct text, bulleted points, and quick-reference tables allow you to review information quickly and understand best practices and potential problems for each procedure.

Perfect for a quick preoperative review of the steps of a procedure.

Hundreds of full-color intraoperative photographs and illustrations, as well as numerous high- quality videos, capture procedures step by step and help you immediately apply your knowledge.

Comprehensively covers techniques for botulinum toxins, injection of fillers, laser resurfacing, browlifting, upper and lower blepharoplasty, rhinoplasty, facial skeleton augmentation with implants, and much more.

Published May 2019 Sample Chapter Preview

When you have to be right

Contributors

Amy S. Colwell, MD, FACS Associate Professor, Harvard Medical School Division of Plastic Surgery Massachusetts General Hospital Boston, Massachusetts Kasandra Dassoulas, MD Richmond Aesthetic Surgery Midlothian, Virginia Joseph J. Disa, MD, FACS Vice Chair of Clinical Activities Department of Surgery Attending Surgeon Memorial Sloan Kettering Cancer Center Professor of Surgery Weill Medical College of Cornell University New York, New York Gregory A. Dumanian, MD Lucille and Orion Stuteville Professor of Surgery Chief of Plastic Surgery Feinberg School of Medicine Northwestern University Chicago, Illinois Sean M. Fisher, MD Plastic and Reconstructive Surgery Resident University of Washington Seattle, Washington Jordan D. Frey, MD Resident Hansjörg Wyss Department of Plastic Surgery Katherine M. Gast, MD, MS Assistant Professor of Surgery Plastic and Reconstructive Surgery Medical Director, Comprehensive Gender Services Program University of Wisconsin Madison, Wisconsin David Gerth, MD NYU Langone Health New York, New York

Bernard W. Chang, MD Chief of Plastic Surgery Mercy Medical Center Baltimore, Maryland

Jeffrey A. Ascherman, MD Thomas S. Zimmer Professor of Reconstructive Surgery at CUMC Site Chief, Division of Plastic Surgery Columbia University Medical New York, New York Fadi Bakal, MD

Ming-Huei Cheng, MD, MBA, FACS Professor Division of Plastic Reconstructive Microsurgery Department of Plastic & Reconstructive Surgery Chang Gung Memorial Hospital Taoyuan City, Taiwan Pierre M. Chevray, MD, PhD Houston Methodist Institute for Reconstructive Surgery Associate Professor Weill Cornell Medical College Adjunct Associate Professor Baylor College of Medicine Program Director Houston Methodist Plastic Surgery Residency Houston, Texas

Plastic Surgery Department Brussels University Hospital Vrije Universiteit Brussel Brussels, Belgium Devra B. Becker, MD, FACS Associate Professor

Department of Plastic Surgery Chief of Plastic Surgery, UPMC Passavant Director of Wound Healing Services, UPMC Passavant Department of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Maureen Beederman, MD Resident Section of Plastic and Reconstructive Surgery Department of Surgery The University of Chicago Medicine Chicago, Illinois Charles E. Butler, MD, FACS Professor and Chairman Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Houston, Texas Bradley Calobrace, MD CaloAesthetics Plastic Surgery Center CaloSpa Louisville, Kentucky Chris A. Campbell, MD, FACS Associate Professor Department of Plastic Surgery University of Virginia Charlottesville, Virginia Jennifer Capla, MD

Carrie K. Chu, MD, MS Assistant Professor

Department of Plastic Surgery The University of Texas MD Anderson

Cancer Center Houston, Texas

Mark W. Clemens, MD, FACS Associate Professor Department of Plastic Surgery MD Anderson Cancer Center University of Texas Houston, Texas

Zachary J. Collier, MD Division of Plastic & Reconstructive Surgery Department of Surgery USC Keck School of Medicine Los Angeles, California Brendan Collins, MD Attending Physician and Microsurgical Fellowship Director

Plastic Surgeon Private Practice

Plastic Surgery MOSA Surgery Miami Beach, Florida

Department of Plastic Surgery Northwell–Lenox Hill Hospital New York, New York

Mercy Medical Center Baltimore, Maryland

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Contributors

Gabriel M. Kind, MD Attending Staff Division of Microsurgery Department of Plastic Surgery California Pacific Medical Center San Francisco, California Associate Clinical Professor Division of Plastic and Reconstructive Surgery Department of Surgery University of California–San Francisco San Francisco, California Clinical Instructor Department of Surgery (Plastic & Reconstructive Surgery) Stanford School of Medicine Stanford University Medical Center Palo Alto, California Jennifer A. Klok, MD, MSc Associate Staff Division of Plastic Surgery Department of Surgery Peterborough Regional Health Centre Peterborough, Ontario, Canada Bill Kortesis, MD, FACS Co-owner and Partner Hunstad/Kortesis/Bharti Cosmetic Surgery Huntersville, North Carolina Jeffrey H. Kozlow, MD, MS Associate Professor (Clinical Track) Section of Plastic Surgery University of Michigan Ann Arbor, Michigan Theodore A. Kung, MD Assistant Professor of Surgery Section of Plastic and Reconstructive Surgery University of Michigan Michigan Medicine Ann Arbor, Michigan William M. Kuzon, Jr, MD, PhD Reed O. Dingman Collegiate Professor of Plastic Surgery

Amir Inbal, MD Section of Plastic and Reconstructive Surgery Department of Surgery University of Chicago Medical Center Chicago, Illinois Jeffrey E. Janis, MD, FACS Professor of Plastic Surgery, Neurosurgery, Neurology, and Surgery Chief of Plastic Surgery University Hospitals Ohio State University Wexner Medical Center Columbus, Ohio Sahil K. Kapur, MD Assistant Professor Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Houston, Texas Nolan Karp, MD Professor of Plastic Surgery New York University School of Medicine New York, New York Ibrahim Khansa, MD Division of Plastic and Maxillofacial Surgery Children’s Hospital Los Angeles Los Angeles, California Hana Farhang Khoee, MD, MSc, FRCSC Adjunct Professor Department of Surgery Schulich School of Medicine & Dentistry Western University London, Ontario, Canada Plastic, Reconstructive, and Aesthetic Surgeon Department of Surgery Jeff J. Kim, MD Resident Physician, PGY6 Section of Plastic and Reconstructive Surgery Department of Surgery The University of Chicago Medical Center Chicago, Illinois Windsor Regional Hospital Windsor, Ontario, Canada

Paul A. Ghareeb, MD Fellow Division of Plastic and Reconstructive Surgery Emory University School of Medicine Atlanta, Georgia Nicholas Haddock, MD Associate Professor Department of Plastic Surgery University of Texas Southwestern Dallas, Texas Eric G. Halvorson, MD Halvorson Plastic Surgery Asheville, North Carolina Moustapha Hamdi, MD, PhD Professor and Chairman of Plastic Surgery Department Brussels University Hospital–Vrije Universiteit Brussel Brussels, Belgium Alexes Hazen, MD, FACS Associate Professor Peter Henderson, MD, MBA Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery Icahn School of Medicine at Mount Sinai NYU Langone Health New York, New York Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Chang Gung University Linkou, Taiwan John Hulsen, MD Clinical Fellow, Aesthetic and Reconstructive Breast Surgery Division of Plastic and Reconstructive Surgery Massachusetts General Hospital/ Harvard Medical School Boston, Massachusetts Dennis J. Hurwitz, BS, MD Clinical Professor of Plastic Surgery Plastic Surgery University of Pittsburgh Medical Center Attending Plastic Surgeon UPMC Magee-Womens Hospital Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania New York, New York Jung-Ju Huang, MD Associate Professor

Section of Plastic Surgery University of Michigan Chief of Surgery VA Ann Arbor Healthcare

Ann Arbor, Michigan David L. Larson, MD Professor Emeritus

Department of Plastic Surgery Medical College of Wisconsin Milwaukee, Wisconsin Accreditation Field Representative Accreditation Council for Graduate Medical Education Chicago, Illinois

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Contributors

Edward C. Ray, MD, FACS Assistant Professor of Surgery Chair, Microsurgery Advisory Committee Division of Plastic & Reconstructive Surgery Cedars-Sinai Medical Center Los Angeles, California David J. Rowe, MD, FACS Assistant Professor, Plastic Surgery MetroHealth Medical Center Cleveland, Ohio J. Peter Rubin, MD University of Pittsburgh Pittsburgh, Pennsylvania Christopher J. Salgado, MD Professor and Interim Chief of Plastic Surgery Division of Plastic Surgery Medical Director of the LGBTQ Center for Wellness Gender and Sexual Health Department of Surgery University of Miami Miller School of Medicine/Jackson Memorial Hospital System Miami, Florida Ann R. Schwentker, MD Associate Professor of Pediatric Plastic and Craniofacial Surgery Cincinnati Children’s Hospital Medical Center Program Director, Plastic Surgery University of Cincinnati Cincinnati, Ohio Deana Shenaq, MD Resident Section of Plastic & Reconstructive Surgery Department of Surgery University of Chicago Medical Centre Section of Plastic and Reconstructive Surgery The University of Chicago Medicine & Biological Sciences Chicago, Illinois Michele A. Shermak, MD, FACS Associate Professor of Plastic Surgery Johns Hopkins Department of Plastic Surgery Baltimore, Maryland Private Practice Plastic Surgery Lutherville, Maryland Endowed Professor and Chair Department of Plastic Surgery

Adeyiza O. Momoh, MD Associate Professor of Plastic Surgery Program Director, Integrated Plastic Surgery Residency University of Michigan Ann Arbor, Michigan Peter Neligan, MB, FRCS(I), FRCSC, FACS Professor of Surgery Director, Center for Reconstructive Surgery University of Washington Medical Center Seattle, Washington Ajani G. Nugent, MD Assistant Professor Division of Plastic and Reconstructive Surgery Department of Surgery Miller School of Medicine University of Miami Miami, Florida Adrian S. H. Ooi, MBBS, MMed (Surgery), MRCS, FAMS (Plastic Surgery) Consultant Plastic Surgeon Department of Plastic, Reconstructive and Aesthetic Surgery Singapore General Hospital SingHealth Head & Neck Disease Center SingHealth Singapore, Singapore Julie E. Park, MD Assistant Professor Section of Plastic & Reconstructive Surgery University of Chicago Medical Centre Department of Surgery The University of Chicago Medicine & Biological Sciences Chicago, Illinois Chad A. Purnell, MD Resident Physician

Albert Losken, MD, FACS William G. Hamm Professor of Plastic Surgery, Program Director Emory Division of Plastic and Reconstructive Surgery Atlanta, Georgia Ryan P. Ter Louw, MD Plastic Surgeon Muskegon Surgical Associates Muskegon, Michigan Alan Matarasso, MD, FACS Clinical Professor of Surgery Hofstra University/Northwell School of Medicine President-Elect American Society of Plastic Surgeons, Executive Committee & Board of Directors Past President, the Rhinoplasty Society & Chair Board of Trustees, & 2016- 2017 Traveling Professor Past President, New York Regional Society of Plastic Surgeons & Chair Board of Trustees Department of Plastic Surgery MD Anderson Cancer Center University of Texas Houston, Texas Joseph Michaels, MD Private Practice North Bethesda, Maryland Assistant Professor of Plastic Surgery Department of Plastic Surgery John Hopkins Medicine Baltimore, Maryland Lauren M. Mioton, MD Resident Physician Division of Plastic and Reconstructive Surgery Northwestern University Chicago, Illinois Arash Momeni, MD Assistant Professor of Surgery Director, Clinical Outcomes Research Ryan-Upson Scholar in Plastic and Reconstructive Surgery Division of Plastic & Reconstructive Surgery Stanford University Medical Center Palo Alto, California Chet Mays, MD Private Practice CaloAesthetics Plastic Surgery Center Louisville, Kentucky Alexander F. Mericli, MD Assistant Professor

Division of Plastic Surgery Feinberg School of Medicine Northwestern University Chicago, Illinois Charalambos “Babis” Rammos, MD, FACS Assistant Professor of Surgery Division of Plastic Surgery Department of Surgery Vice Chairman of Research Department of Surgery

College of Medicine University of Illinois Peoria, Illinois

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Contributors

Essie Kueberuwa Yates, MD Plastic & Reconstructive Surgeon Yates Institute of Plastic Surgery Lauderdale, Florida Toni Zhong, MD, MHS, FRCS(C) Associate Professor Departments of Surgery and Surgical Oncology University of Toronto Fellowship Director Division of Plastic and Reconstructive Surgery University of Toronto Plastic Surgeon–Scientist Belinda Stronach Chair of UHN Breast Cancer Reconstructive Surgery Director of the UHN Breast Reconstruction Program University Health Network Mount Sinai Hospital Toronto, Ontario, Canada Yasmina Zoghbi, MD Resident Division of Plastic Surgery Department of Surgery Icahn School of Medicine at Mount Sinai New York, New York

Louis L. Strock, MD Assistant Clinical Professor Department of Plastic Surgery University of Texas Southwestern Medical Center Dallas, Texas Private Practice Fort Worth, Texas Sergey Y. Turin, MD Resident Physician Division of Plastic and Reconstructive Surgery Feinberg School of Medicine Northwestern University Chicago, Illinois Katie E. Weichman, MD Assistant Professor of Surgery Department of Surgery Albert Einstein School of Medicine/ Montefiore Medical Center Bronx, New York Eric J. Wright, MD Reconstructive and Aesthetic Breast Fellow Division of Plastic Surgery Harvard Medical School Massachusetts General Hospital

Wesley N. Sivak, MD, PhD Fellow Department of Plastic Surgery University of Pittsburgh Pittsburgh, Pennsylvania Darren M. Smith, MD Plastic Surgeon, Aesthetic Surgeon New York, New York David H. Song, MD, MBA, FACS Physician Executive Director MedStar Health Plastic & Reconstructive Surgery Professor and Chairman Department of Plastic Surgery Georgetown University Washington, District of Columbia Scott Spear, MD † Founding Chair Department of Plastic Surgery Georgetown University Hospital Washington, District of Columbia Dhivya R. Srinivasa, MD Resident Plastic and Reconstructive Surgery University of Michigan Ann Arbor, Michigan John T. Stranix, MD Chief Resident Hansjörg Wyss Department of Plastic Surgery

Boston, Massachusetts Liza C. Wu, MD, FACS Chief of Microsurgery PENN Plastic Surgery Professor of Surgery University of Pennsylvania Philadelphia, Pennsylvania

Terri A. Zomerlei, MD Clinical Instructor House Staff Columbus, Ohio

NYU Langone Health New York, New York

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Preface

I am grateful for the interest in our textbooks. I have worked with Dr. Disa the editor of this volume and all the outstanding experts in this field to create an encyclopedic offering that will enhance your practices in an efficient learning module. I hope you enjoy reading this textbook from cover to cover. Thank you for your interest and support. Kevin C. Chung, MD, MS Chief of Hand Surgery, Michigan Medicine Director, University of Michigan Comprehensive Hand Center Charles B. G. de Nancrede Professor of Surgery Professor of Plastic Surgery and Orthopaedic Surgery Assistant Dean for Faculty Affairs

Reconstruction of trunk defects illustrates the application of innovative reconstructive principles. Breast reconstruc- tion for conditions, such as cancer treatment, augmentation, and reduction, is essential to women’s health. Other trunk problems such as hernias, body contouring procedures after weight loss, or buttock deformities tax the creativity of the surgeon to design an operation for the problem and to fit the patient. The authors were selected based on their expertise in diagnosing the anatomic concerns and to articulate surgi- cal treatments of each body region of the trunk by referring to principles in an illustrative approach. Each operation is described in a step-by-step fashion with professional sketches to highlight essential components of the operation so that the procedure can be conducted safely to yield predictable outcomes.

Associate Director of Global REACH University of Michigan Medical School Ann Arbor, Michigan

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Contents

Contributors vi Preface x PART 1 PLASTIC SURGERY OF THE BREAST

SECTION IV BREAST RECONSTRUCTION FOR PARTIAL MASTECTOMY DEFECTS 11 Partial Breast Reconstruction With Local Tissue Rearrangement 73 Moustapha Hamdi 12 Local Flaps in Partial Breast Reconstruction 79 Moustapha Hamdi and Fadi Bakal SECTION V PROSTHETIC BREAST RECONSTRUCTION 13 Delayed Tissue Expansion 89 Hana Farhang Khoee, Edward C. Ray, and Joseph J. Disa 14 Tissue Expander With Acellular Dermal Matrix 92 Gabriel M. Kind 15 Immediate Tissue Expander 97 Eric G. Halvorson and Joseph J. Disa 16 Replacement of Expander With Permanent Implant 105 Eric G. Halvorson and Joseph J. Disa 17 Direct-to-Implant Breast Reconstruction 110 Amy S. Colwell and Eric J. Wright

SECTION I AUGMENTATION MAMMOPLASTY 1 Transaxillary Breast Augmentation 2 Louis L. Strock 2 Breast Augmentation: Subglandular, Subfascial, and Submuscular Implant Placement 9 Chet Mays and Bradley Calobrace 3 Breast Augmentation Plane: Dual Plane 26 Bill Kortesis and Charalambos “Babis” Rammos 4 Breast Augmentation With Round and Anatomic Implants 31 Bill Kortesis and Charalambos “Babis” Rammos 5 Female to Male Transgender Breast Surgery 39 Ann R. Schwentker SECTION II MASTOPEXY 6 Mastopexy: Periareolar, Vertical, and Wise Pattern 43 Ryan P. Ter Louw and Scott Spear † SECTION III REDUCTION MAMMAPLASTY 7 Reduction Mammaplasty 52 Peter Henderson and Joseph J. Disa 8 Inferior Pedicle 57 Paul A. Ghareeb and Albert Losken 9 Breast Reduction With Free Nipple Graft 62 Paul A. Ghareeb and Albert Losken 10 Gynecomastia 67 John T. Stranix and Alexes Hazen

SECTION VI LATISSIMUS FLAP BREAST RECONSTRUCTION 18 Latissimus Flap 116 Peter Henderson and Joseph J. Disa

SECTION VII ABDOMINAL FLAP BREAST RECONSTRUCTION 19 TRAM 120 Peter Henderson, Jeffrey A. Ascherman, and Joseph J. Disa 20 Free TRAM 126 Jennifer A. Klok and Toni Zhong 21 Muscle-Sparing Free Transverse Rectus Abdominis Myocutaneous (TRAM) Flap 135 Arash Momeni and Liza C. Wu

† Deceased

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Contents

22 DIEP Flap Breast Reconstruction 141 Pierre M. Chevray 23 Abdominal Breast Reconstruction Using a SIEA Flap Approach 150 Adrian S. H. Ooi, Deana Shenaq, Julie E. Park, and David H. Song 24 Recipient Vessel Exposure—Internal Mammary and Thoracodorsal 159 Theodore A. Kung and Adeyiza O. Momoh 25 Inferior Gluteal Artery Perforator Flap Breast Reconstruction 164 Katie E. Weichman 26 Superior Gluteal Artery Perforator Flap Breast Reconstruction 171 Katie E. Weichman SECTION VIII OTHER FREE FLAPS 27 Profunda Artery Perforator Flap for Breast Reconstruction 176 Katie E. Weichman and Nicholas Haddock 28 Transverse Upper Gracilis Flap for Breast Reconstruction 181 Adeyiza O. Momoh 29 Skate Flap for Nipple Reconstruction 188 Katie E. Weichman 30 C-V Flap for Nipple Reconstruction 194 Katie E. Weichman 31 Nipple Reconstruction 197 Kasandra Dassoulas, Brendan Collins, and Bernard W. Chang 32 Low-Volume Fat Grafting for Contour Correction 202 Nolan Karp and Jordan D. Frey 33 Large-Volume Fat Grafting for the Breast 208 Wesley N. Sivak and J. Peter Rubin

2 Sternal Debridement and Application of Muscle Flaps 234 Sean M. Fisher, Jeff J. Kim, and David H. Song 3 Rectus Abdominis Flap for Thoracic Reconstruction 240 Maureen Beederman and David H. Song 4 Omental Flap for Thoracic Reconstruction 244 Amir Inbal and David H. Song 5 Latissimus Dorsi Flap for Chest Wall Defects 255 Essie Kueberuwa Yates and David H. Song 6 Serratus Anterior Flap for Chest Wall Reconstruction 259 Zachary J. Collier and David H. Song SECTION II RECONSTRUCTION OF THE ABDOMINAL WALL 7 Hernia Repair With Open Component Separation 268 Ibrahim Khansa and Jeffrey E. Janis 8 Ventral Hernia: Component Separation Technique 275 Mark W. Clemens and Charles E. Butler 9 Abdominal Hernia Reconstruction With Synthetic and Biologic Mesh 284 Sergey Y. Turin and Gregory A. Dumanian 10 Rectus Femoris Flap for Abdominal Wall Reconstruction 292 Alexander F. Mericli and Charles E. Butler 11 Lower Abdominal Wall Reconstruction With Lateral Thigh-Based Flaps 300 Dhivya R. Srinivasa and Jeffrey H. Kozlow Alan Matarasso and Darren M. Smith 13 Abdominal Panniculectomy 314 Devra B. Becker 14 Abdominal Panniculectomy in Super Obese Patients 321 David J. Rowe 15 Buttock Lift 324 Michele A. Shermak 16 Circumferential Body Lift 331 Joseph Michaels and Jennifer Capla 17 Lower Posterior Torso and Buttock Sculpting 337 Dennis J. Hurwitz SECTION III BODY COUNTOURING 12 Abdominoplasty 308

SECTION IX LYPHEDEMA 34 Lymphedema Microsurgery for Breast

Cancer–Related Upper Limb Lymphedema 214 Ming-Huei Cheng and Jung-Ju Huang

PART 2 TRUNK RECONSTRUCTION AND BODY CONTOURING

SECTION I RECONSTRUCTION OF THE CHEST WALL 1 Pectoralis Flap for Chest Wall Reconstruction 226 Jeff J. Kim and David H. Song

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Contents

18 Gynecomastia Procedures After Massive Weight Loss 347 Michele A. Shermak 19 Mons Pubis Reduction 352 Michele A. Shermak 20 Upper Arm Lift (Brachioplasty) 357 Jennifer Capla and Joseph Michaels 21 Upper Thigh Lift 361 Michele A. Shermak SECTION IV RECONSTRUCTION OF PERINEAL DEFECTS 22 Vertical Rectus Abdominis Myocutaneous Flap for Perineal Reconstruction 367 Sahil K. Kapur and Charles E. Butler 23 Gluteal Thigh Flap for Perineal Reconstruction 372 David Gerth and Christopher J. Salgado 24 Omental Flap for Pelvic Floor Reconstruction 375 Carrie K. Chu and Charles E. Butler 25 Posterior Labial Artery Flap for Vulvar and Vaginal Reconstruction 383 Chris A. Campbell 26 Vertical Rectus Abdominis Flap for Perineal Reconstruction 387 Dhivya R. Srinivasa and Jeffrey H. Kozlow 27 Gracilis Flap for Perineal and Vaginal Reconstruction 393 Ajani G. Nugent, Yasmina Zoghbi, and Christopher J. Salgado 28 Gender-Affirming Surgery 399 Katherine M. Gast and William M. Kuzon, Jr

SECTION V RECONSTRUCTION OF PRESSURE INJURIES 29 Gluteal Flaps for Sacral Pressure Injuries 410 Terri A. Zomerlei and Jeffrey E. Janis 30 Posterior Thigh and Hamstring Flaps for Ischial Ulcers 417 John Hulsen and Jeffrey E. Janis 31 Tensor Fascia Lata Flaps for Trochanteric Ulcers 427 Terri A. Zomerlei and Jeffrey E. Janis 32 Repair of Flank and Lumbar Defects 433 Sergey Y. Turin, Chad A. Purnell, and Gregory A. Dumanian SECTION VI POSTERIOR TRUNK RECONSTRUCTION 33 Erector Spinae (Paraspinous) Muscle Flap 439 Lauren M. Mioton and Gregory A. Dumanian 34 Trapezius Muscle Flap 442 Lauren M. Mioton and Gregory A. Dumanian 35 Superior Gluteal Artery Perforator Flap 446 Lauren M. Mioton and Gregory A. Dumanian 36 Tissue Expansion for Trunk Defects 450 Ibrahim Khansa and Jeffrey E. Janis 37 Keystone Flaps 455 Theodore A. Kung and Peter Neligan 38 Treatment of Axillary Hyperhidrosis 461 David L. Larson Index 465

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Video Clips

PART 1 Chapter 5 Transgender Breast Chapter 13 Delayed Tissue Expander

Chapter 9 Anterior Components Release Technique Ventral Hernia Repair Chapter 15 Buttock Lift, Part 1 Buttock Lift, Part 2 Chapter 17 VASERlipo Buttock Augmentation Lipoabdominoplasty/Flankplasty/ Lipoaugmentation of the Buttocks Silicone Elastomer Buttock Augmentation

Chapter 17 Direct to Implant Breast Reconstruction Chapter 20 Free TRAM Flap: Fascial and Intramuscular Dissection PART 2 Chapter 7 Minimally Invasive Anterior Components Separation

Chapter 32 Flank Hernia Repair Technique Chapter 33 Erector Spinae Muscle Flap

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Section I: Augmentation Mammoplasty

Transaxillary Breast Augmentation

C H A P T E R

Louis L. Strock

DEFINITION

moderate plus profile silicone gel device. Other options considered included the same device type in moderate and high profile versions, and a moderate height, moderate projection shaped highly cohesive gel device. She stated preference of a partial subpectoral plane of placement over a subfascial approach. Incision choices offered to this patient included inframammary and transaxillary, with the latter preferred by the patient to attempt to avoid incisions visible on her breasts. Nipple reduction was requested by the patient, to be performed following completion of the breast augmentation procedure and access incision closure. Equipment ■ A standard HD endoscopic tower and camera are used in this procedure. This equipment is identical to that used for any subspecialty that utilizes an endoscopic tower and cam- era. The endoscope that is preferred is a 10-mm 30-degree angled scope, that is intended to fit correctly into the Emory Endoscopic retractor ( FIG 3 ). A cautery handle with a suc- tion end is used, and holds a cautery tube with a spatu- lated end. This is the basis for the dissection at the heart of this procedure. Additionally, 4-prong Freeman skin hooks, 2 mirror image Agris-Dingman dissectors, a 1-in fiberoptic retractor with suction port, facelift scissors, and two 1-in short Deaver retractors make up the instrument set for the procedure. 1 ■ The patient is positioned with the arms out ninety degrees and straightened on armboards. All equipment, cords, and tubing are directed toward the feet of the patient in the midline. This allows for ease of transition during the proce- dure for device placement on either side. There is adequate Positioning

■■ Hypomastia. This patient requested that she have a proce- dure to enlarge her breasts in a conservative way. She also stated that she preferred to have her breast implants placed in a way that would allow her to avoid incisions on her breasts ( FIG 1A,B ). ANATOMY ■■ To manage the request of this patient, the level and shape of the inframammary fold (IMF) will be lowered with the aid of endoscopic assistance. The pectoralis major muscle and overlying fascia will be divided according to external mark- ings and correlated with internal muscle anatomy. PATIENT HISTORY AND PHYSICAL FINDINGS ■■ This patient is a 34-year-old woman who presented for breast augmentation after having had three children. She requested that her breasts be enlarged to a small C cup, with as soft a feel as possible. Her examination was remarkable for mild asymmetry, thin tissue, and large nipple size. Her breast base width measurement was 11 cm, and pinch thick- ness measurements were 1.5 cm laterally, superiorly, and medially. She was also noted to have extremely large nipples that she requested to have reduced at the time her breast implants were placed ( FIG 2 ).

SURGICAL MANAGEMENT Preoperative Planning

■ Preoperative planning centered on the choice of breast implant type in the context of her aesthetic goals and tissue type. She preferred the feel and intermediate pro- jection of a Mentor MemoryGel smooth wall, round,

FIG 1 • A,B. Preoperative photos showing thin tissue patient. She has minimal breast volume, poor inframammary fold definition, and distinctly large nipples.

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Chapter 1 Transaxillary Breast Augmentation

FIG 2 • Frontal markings show plan to lower the inframammary fold to accommodate dimensions of device to be used.

separation of the anesthesia equipment from the head and shoulders of the patient to allow the surgeon to stand above the shoulder on each side during the endoscopic tissue release portion of the procedure on each side ( FIG 4 ). Approach ■■ The procedure can be performed adequately in this patient with use of inframammary or transaxillary approaches for incision access. The periareolar approach is more difficult given the relatively small size of the areola in this patient. Her thin tissue makes a partial subpectoral, or dual plane, approach preferred to maximize soft tissue cover over the implants. FIG 4 • All equipment is positioned at the foot of the bed, including the endoscopic tower. All cords are kept in a central position to prevent hav- ing to move them during the procedure, regardless of which side is being augmented. The patient is positioned with the arms out at 90 degrees. The endoscopic portion of the procedure is performed with the surgeon above the shoulder.

FIG 3 • Instrument tray used for the procedure. The Emory Endoscopic retractor is with paired 10-mm 30-degree-angled endoscope. The cau- tery handle has a suction port in back, and a hub for hollow cautery rods with spatulated ends. The author prefers mirror image J-shaped rods, but other variants are available. Four-prong skin hooks, two mirror image Agris-Dingman dissectors, two 1-in. Deaver retractors, facelift scissors, and Adson-Brown forceps complete the set.

T E C H N I Q U E S

■■ Incision and Initial Dissection

■■ An S-shaped incision was planned, centered in the axil- lary apex ( TECH FIG 1 ). This incision pattern was selected because it allows for a long functional length in a patient with a narrow area of hair-bearing skin in the axilla. The long portion of the incision was marked within the lon- gest existing skin crease. The anterior extension is placed to stay behind the posterior aspect of the pectoralis major muscle. This is critical to keep the incision hid- den during recovery. A cross-hatch is made centrally to facilitate skin closure. The incision is made through the hair-bearing skin to the subcutaneous tissue. The ante- rior skin flap is raised in an anterior direction toward the lateral edge of the pectoralis major muscle. The skin flap is kept thin to avoid entry into the axillary contents. This helps to avoid damage to the intercostobrachial nerve. Once the lateral border of the pectoralis major muscle is identified, its fascia is incised, and the subpectoral space is entered under direct vision. A finger sweep technique is used to further develop the separation between the pec- toralis major and pectoralis minor muscles.

TECH FIG 1 • In this patient, an S-shaped incision was planned. This incision design was used due to the narrow width of the seg- ment of hair-bearing skin. This design permits a longer functional length to attempt to minimize potential damage to the device during placement, and minimize ultimate incision visibility during recovery.

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T E C H N I Q U E S 4 Breast Reconstruction for Partial Mastectomy Defects, Trunk Reconstruction and Body Contouring ■■ Optical Cavity

to not be a problem. This is performed in a uniform fash- ion to create optimal visualization of the pectoralis major muscle in preparation for the muscle release. The author feels that using the cautery to create the optical cavity is critical to avoid significant blood staining of tissues that can otherwise make endoscopic tissue dissection difficult. The key to this procedure is to avoid bleeding in the tissue pocket! ( TECH FIG 2B–D ). Though the initial descriptions of this procedure advocated use of the Agris-Dingman dis- sectors, the author has found that the occasional bloody outcome from that approach can be avoided with use of the cautery to create the optical cavity. 2

■■ Once the entry between the incision and the space between the pectoralis major and minor muscles has been defined, the endoscopic retractor is introduced. Once correctly positioned, the 10-mm 30-degree-angled endoscope is brought into the operative field and placed into the retrac- tor sheath. The camera head on the endoscope is checked for proper orientation, a critical step to ensure safety with the technique. The suction cautery is then used to create an optical cavity from the undersurface of the pectoralis major muscle ( TECH FIG 2A ). Staying on the undersurface of the muscle allows for variations in rib cage anatomy

TECH FIG 2 • A. The endoscopic equipment is used in a way that ensures proper orientation of the endoscopic tower. The camera head is checked to confirm correct alignment and orientation for the endoscopic dissection. The suction cautery allows for successful smoke evacuation, vital to correct endoscopic visualization. B–D. Endoscopic view of the entry into the subpectoral space. Note areolar plane and lack of anatomic markings. Orientation on this right sided dissection is as follows: left is medial, right is lateral, the rib cage is inferior, and the pectoralis major muscle is superior. The optical cavity is created using the cautery off the undersurface of the pectoralis major muscle. The entire base of the pectoralis major muscle is dissected to complete creation of the optical cavity.

■■ Pectoralis Major Muscle Release

to dissect in a very controlled and limited fashion in a plane superficial to the lower muscle cuff. Because of the magnification of the endoscope, limited tissue cuts make powerful and significant changes in the area of the IMF. Transillumination can again be used to confirm that the release is to the desired level of the new IMF. The muscle edges of the upper and lower cuffs are inspected and con- tacted with the cautery if any bleeding points are noted. It is of critical importance that overdissection be avoided! ( TECH FIG 3E–G ) Additionally, it is critical to understand that when planning to lower the IMF, the actual release of the pectoralis major muscle should never be below the existing IMF , as such a release will consistently result in a double bubble deformity. If the goal is to maintain the IMF at the same level without change, then the pectora- lis major should be divided at a level 1.5 to 2 cm above the existing IMF. When properly performed, visual clarity afforded by the endoscope allows for the prepectoral fas- cia to be divided or maintained as needed.

■■ Successful creation of an optical cavity facilitates release of the pectoralis major muscle. The first step to release of the pectoral muscle is to correlate internal anatomy with exter- nal landmarks. This is the key step to the technical control needed to control the level and shape of the IMF ( TECH FIG 3A–D ). An advantage of the axillary approach is that, when performed as described, the surgeon has a direct and clear view of the pectoralis major muscle and fascial layers that cannot be matched with an inframammary approach. Additionally, the incision itself has no bearing on the IMF or the level it is placed. ■■ In the patient shown, the plan was to lower the IMF. The initial muscle release is performed to divide the muscle at a level several millimeters above the existing IMF, medial to lateral, again carefully correlating external landmarks to internal anatomy. Transillumination can be very helpful in confirming that the muscle has been divided at the desired level. Once this has been confirmed, the cautery is used

Chung-Breast1e9781496348098-P1-ch001.indd 4

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