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Immediate Prepectoral Implant Breast Reconstruction

Introduction Prepectoral implant–based breast reconstruction is a recent addition to the breast reconstructive armamentarium that is rapidly being adopted given its simplicity and reported potential benefits. The technique involves placing the implant subcutaneously over the pectoralis major muscle, as opposed to under the muscle (subpectoral), which is the current established practice. By placing the implant over the pectoralis major muscle, the prepectoral approach preserves the anatomic…

Immediate Implant Breast Reconstruction With Total Muscle Coverage – Two-Stage

Introduction The rates of mastectomy and immediate breast reconstruction have increased over the past two decades, according to a number of large population-based datasets. Changes in the oncologic approach to breast cancer have contributed to increasing rates of bilateral mastectomies. Looking more closely at immediate reconstruction, the trends demonstrate increased utilization of implant-based reconstruction modalities, but a relatively constant rate of autologous reconstruction. Throughout this time,…

Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix

Disclosure : The authors have no financial interest to declare in relation to the drugs, devices, and products mentioned in this article. Introduction There continues to be a steady annual growth in breast reconstruction within the United States, with over 100 000 procedures performed in 2016 and a 39% increase in reconstructive breast procedures since the year 2000. Immediate two-stage prosthetic breast reconstruction is well accepted in…

Immediate Implant Breast Reconstruction – One-Stage

Introduction Implant-based, or alloplastic, breast reconstruction is the most commonly performed method of breast reconstruction. Within implant-based reconstruction, myriad techniques and reconstructive strategies are at the surgeon's disposal to provide each individual patient with a successful breast reconstruction. Traditional immediate alloplastic breast reconstruction involves a two-stage approach in which a temporary tissue expander is placed and variably expanded in the outpatient setting, after which it is…

Latissimus Dorsi Flap Breast Reconstruction

Introduction The latissimus dorsi (LD) flap is a reliable option for primary autologous breast reconstruction and for salvage of failed prior breast reconstruction because of its robust perfusion, consistent vascular anatomy, and concealable donor site scar. However, the traditional LD flap is limited by its volume, and often requires augmentation with either an implant, additional autologous tissue flaps, or fat grafting to obtain the desired shape…

Free Transverse Upper Gracilis Flap Breast Reconstruction

Introduction The armamentarium available to both the plastic surgeon and breast reconstruction patient has continued to expand with improvement of techniques and the actual number of flaps and implant alternatives available. The transverse upper gracilis (TUG) flap provides just such an alternative. Although the deep inferior epigastric perforator (DIEP) flap is often the first choice for autologous breast reconstruction, not all patients are good candidates. Patients…

Free Profunda Artery Perforator Flap Breast Reconstruction

Introduction Breast reconstruction is a common challenge faced by many surgeons working in the plastic and reconstructive arenas. There are various options for autologous breast reconstruction. The more commonly performed procedures include the deep inferior epigastric perforator flap (DIEP) and the superior and inferior gluteal artery perforator flaps (SGAP, IGAP). Despite the refinements in the latter donor sites, specific reconstructive needs and body habitus sometimes call…

Free Gluteal Perforator Flap Breast Reconstruction

Introduction The advent of gluteal artery perforator (GAP) flaps has served to increase the surgeon's armamentarium in autologous breast reconstruction. In 1993, Koshima et al. originally described local-regional GAP flaps for repair of sacral pressure sores. Later in 1995, Allen and Tucker described the utility of the free superior gluteal artery perforator (SGAP) flap in breast reconstruction. Even in thin patients, GAP flaps offer an excellent source…

Free SIEA Flap Breast Reconstruction

Introduction The superficial inferior epigastric artery (SIEA) flap relies on its namesake vessels to perfuse the ipsilateral abdomen skin and fat, generally for autologous breast reconstruction. This type A fasciocutaneous flap was described in 1971 for head and neck reconstruction by Antia and Buch. Grotting introduced the SIEA for use in breast reconstruction in 1991. The advantage of this flap is the lack of fascial and…

Free DIEP Flap Breast Reconstruction

Introduction Breast reconstruction using the deep inferior epigastric perforator (DIEP) flap has become the gold standard for autologous breast reconstruction for most plastic surgeons. The principle benefit of the DIEP flap compared to other flaps is that the abdomen is the preferred and favorable donor site for most women because many will achieve an improvement in abdominal contour with minimal impairment in function. The DIEP flap…

Free or Free Muscle-Sparing TRAM Flap Breast Reconstruction

Introduction Abdominally based reconstructions have been utilized for the last 40 years. In 1979, Holstrom used tissue normally discarded from abdominoplasty as a free flap for breast reconstruction. In 1982, Hartrampf described and popularized the pedicled TRAM (transverse rectus abdominis muscle) flap. In 1989, Grotting improved upon the design and began using free TRAM flaps based off the deep inferior epigastric artery (DIEA) as opposed to…

Rejuvenation of the aging face and skeleton with implants

In his article “Anatomy and pathophysiology of facial aging”, Zimbler states, “Facial aesthetics begin with the marriage of hard and soft tissue integration; however, it is the changing balance of these elements that is the hallmark of the aging process … A youthful face therefore represents a point in time when a particular set of skeletal proportions are ideal for their soft tissue envelope.” Soft Tissue…

Breast Reconstruction With the Pedicled Transverse Rectus Abdominis Musculocutaneous (TRAM) Flap

Introduction Pedicled transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction has been performed in patients for nearly four decades now. Many technical modifications have developed since Dr. Hartrampf's first operation, and these strategies have improved our ability to offer this operation to our patients while minimizing morbidity. Plastic surgeons continue to perform pedicled TRAM flaps on a frequent basis. The choice to perform a pedicled TRAM flap…

Mandible

Indications Three groups of patients benefit from implant augmentation of the mandibular body, angle, and ramus. These include patients with normal, deficient, or surgically altered anatomy. Normal dimensions Most patients who desire mandible augmentation have lower face horizontal dimensions that relate to the upper and middle thirds of the face within a normal range ( Figs. 12.1 and 12.2 ). These patients, usually males, perceive a…

Chin

Chin augmentation with implants is the most frequently performed facial implant surgery. It has long been considered a simple procedure, often done in the office setting, and one that always gives gratifying results. Unfortunately, outcomes after chin augmentation are often less than ideal. It is not uncommon for the augmented chin to be asymmetric, to be too large (especially in women), to have a poor transition…

Pyriform aperture

A relative deficiency in lower midface projection may be congenital or acquired, particularly after cleft surgery and maxillary fractures. Since the majority of white faces are convex, midface concavity is often considered less attractive. Fig. 10.1 shows the average midface inclination of white North Americans as determined by Farkas. Patients with satisfactory occlusion and lower midface concavity can have their aesthetic desires satisfied with skeletal augmentation.…

Malar

Prominent malar bones are considered attractive. Hence, the malar area is frequently augmented with implants. Although not documented in the literature, personal experience with primary and secondary malar implant surgery has shown that there is a significant incidence of patient dissatisfaction with this surgery. Patients presenting for secondary surgery have three main complaints: implant asymmetry; displeasing implant contours – too wide, too large, too low, or…

Infraorbital rim

The upper midface skeleton has direct and indirect influences on the appearance of the face and, particularly, the eyes. The relationship between the globe and the orbital rims will determine if the eyes appear prominent or deep set. Because the infraorbital rim and upper midface skeleton support the lower eyelids and the cheek soft tissues, their projection impacts on lid and cheek position. Patients with deficient…

Internal orbit

The size and shape of the internal orbit determines orbital volume and the position of the eye. An increase in orbital volume results in enophthalmos – the recession of the ocular globe within the bony orbit. The principal mechanism in its development is the displacement of a relatively constant volume of orbital soft tissue into an enlarged bony orbit. Posttraumatic fat atrophy and scar contracture are…

Temporal augmentation

Concavity in the temporal area is often referred to as “temporal hollowing.” It reflects a deficiency in the bulk of the temporalis muscle, the temporal fat pad, and/or an underlying bone defect ( Fig. 6.1 ). Open full size image Fig. 6.1 An example of temporal hollowing after a bicoronal incisional neurosurgery procedure. Etiology of Temporal Hollowing When the temporal area has not been surgically violated,…