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Afd Z Journal Club

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by

Ram Ibrahim

on 22 June 2016

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Transcript of Afd Z Journal Club

Abnormal response of the breast to circulating estrogens --> Breast proliferation (fibrous and fat tissue >> glandular tissue).
Normal levels of estrogens and receptors.
HISTORIE
PRÆOPERATIVE VURDERING
OPERATIV STRATEGI
Anamnese

Ryg, nakke & hovedpine
Strop mærker
IMF intertrigo.
Emotional påvirkning.
Sårheling- Diabetes & rygning.
DVT risici
Brystkræft
Graviditet og amning
BH størrelse
Følesans omkring papil
Forventningsafstemning


22.juni.2016, Journal Club, Afd Z OUH
INTRODUKTION - ANATOMI
INVERTERET T INFERIOR PEDICLE- WISE PATTERN
Pedicle: Inferior
Volume reduction: Medial, superior, lateral.
Skin pattern: keyhole

BRYST REDUKTION
Paulus Aegentia- correction of genycomastia, 7th century AD.
Dieffenbach- lower 2/3 reduction 1848.
Pousson- superior wedge resektion til ptose and overskydende parenchym, 19. århundrede.
Thorek- nederste pole amputation med free nipple graft, 1922.
Passot- papil transposition til nøglehulsincision 1925.
Schwartzman- dermoglandular pedicle.
Biesenberger- Parenchimal pedicle, inverteret T incision, 1928.
Aufricht- preoperative planning and skin redraping, 1949.
Penn - ideal breast mesurements, 1955.
Wise- keyhole pattern for skin resection, 1956.
Strombeck- horizontal bipedicaled flap, 1960.
McKissock- vertical bipedicaled flap, 1970.
Lassus, Lejour - superior pedicle vertical scar technique, 1970.
Hester- central mound technique, 1980.
Hall- Findlay- supero-medial pedicle vertical scar technique.
SWARTZMANN REDUKTION
BIESENBERGER REDUKTION
NAC PLACERING-PENN
1955
OPERATIVE MULIGHEDER VED BRYST REDUKTION
SHORT- SCAR PERIAREOLAR
Pedicle: Inferior
Volume reduction: Medial, superior, lateral.
Skin pattern: circumvertical
Shape: Active/ passive
KOMPLIKATIONER
Mammary hypertrophy:
Objektiv undersøgelse

BMI
Standard brystundersøgelse
Konsistens, form, asymmetri, intertrigo, stria distensiones,
Jugulum –papil afstand, NAC’s størrelse og form.
Brystets størrelse i gram.

Mammagrafi ( FIND anbefalinger)
> 30 Y
> 25 Y if family history.

Klinisk foto
PRÆOPERATIV INFORMATION
Arrets placering
Midlertidig eller permanent ændring i papillens følesans
Problemer med amning
Risiko for bryst assymmetri
Risiko for sårdannelse
Risiko for nekrotisk papil
Risiko for hæmatom
Risiko for serom
4 vigtige elementer i brystrekontruktiv kirurgi:
1. Valg af pedicle som skal forsyne NAC vaskulært og innervation.
2. Valg af quadranter der skal excideres for at opnå volume reduktion
3. Valg af procedure for at fjerne overskydende hud.
4. Æstetisk bryst formation
LIPOSUCTION BRYST REDUKTION
Pedicle: central
Volume reduction: All quadrants
Skin pattern:
Shape: passive
Short scar periareolar inferior pedicle reduction (SPAIR)
BREAST AMPUTATION AND FREE NIPPLE GRAFT
Large (> 2000gr) reductions
Ptotic breasts.
Long NSN distance.
Free nipple graft on a deeithelialized bed.
Skin pattern: Wise pattern
PRÆOPERATIVE OPTEGNING
Hovedprincipperne:
MCL, sternallinje og breast midtlinje.
Breast support when marking NAC & IMF.
Ny placering af NAC.
Marker NAC orientering
Marker vertikale og horizontale lines
BI PEDICLE TECHNIQUE
McKissok vertical bi- pedicle technique
Stromback horizontal bi- pedicle technique
Tidlige komplikationer
Forlænget sårheling
Nedsat NAC vaskularitet
Hæmatom
Flap nekrose
DVT
Infektion
Sene komplikationer
Serom
Breddeøget ar
NAC position
Asymmetry
Fedt nekrose
Permanent ændret følesans
Buttom out
VERTICAL MAMMOPLASTY
Hall- Findlay BR- operative technique
WISE PATTERN
VERTICAL MAMMOPLASTY
INVERTED T INFERIOR PEDICLE
Forskydning af fylde fra øverste kvadranter til nederste
Kliniske billeder
Kliniske billeder
WISE PATTERN
VERTICAL MAMMOPLASTY
Breddeøget ar og assymmetri
-Medial Pedicle
- "Wise pattern
parenchyman resection"

VERTICAL MAMMOPLAST
Hall- findlay BR
VERTICAL MAMMOPLAST
Hall findlay BR
Juvenile Gigantomastia
Pathophysiology of hypermastia
Juvenile virginal hypertrophy of the breast
More severe, rarely regresses
Occurs with 1st menses; 11 - 14 years
Normal endocrine studies
~1800g removed per breast
Risk of recurrence with pregnancy
Normal estrogen levels and number of receptors
Abnormal end-organ response/ hypersensitivity to circulating estrogens
Primary increase in fibrous tissue and fat, smaller increase of glandular tissue
Puberty and pregnancy
Gynecomastia
Obesity
Enlargement of male breast
Increased estrogens, decreased androgens or receptor
Causing breast hypertrophy with adipose tissue
Medial
: anteromedial grene af n. thoracic intercostalis T3-5
Lateral
: lateral cutaneous grene af n. thoracic intercostals T3-6
Superior
: n. intercostobrachialis og supraclavicular nervegrene fra plexus ccervicalis C3,4
NAC
: anteromedial and anterolateral grene af T4 intercostal
"Unique nerve" of NAC
: lateral cutaneous grene af T4 n.intercostalis
Inferior pedicle w Wise pattern
:
Patient upright, shoulders even
Midline
Breast meridian (new horizontal nipple position)
Pitanguy's point (new vertical nipple position
IMF position (elevate a few mm)
Check notch-to-nipple measurements
Vertical limbs (7-8cm under tension); angle of divergence determines amount of skin resection
Connect limbs to IMF w lazy-S
Pedicle (10-12 cm from midline)
Areola
Superomedial pedicle w vertical pattern
:
Patient upright, shoulders even
Midline
Upper breast border
IMF position
New nipple position: Pitanguy's point and breast meridian; 8-10cm below upper breast border
Areolar opening 2 cm above new nipple position; 4cm diameter upon closure
Vertical limbs
Connect limbs with meridian 2-4cm above IMF
Pedicle base 6-10cm
Drains
:
Do not lower complication or hematoma rate
Higher complication rate with drains? (
Corion et al
: 40% v 23%)
Pedicle choice and BMI have no influence on drain ouput
May be unnecessary

Cancer detection
:
Preoperative mammogram
Send all specimens; 0.06 - 1.8% incidence of cancer
6 month postoperative mammogram
Complications
:
NAC compromise: 4 - 7%
Altered nipple sensation: 9 - 25%
Increased rates with increased resection amounts
Wound-healing: 19%
Breast feeding: 65 - 91% able
Blodforsyning
Innervation
PRÆOPERATIVE OPTEGNING
Rami Ibrahim
Signe Muus
Ann Udson
PRÆOPERATIVE OPTEGNING
POSTOPERATIV BEHANDLING
ORLANDO- WISE PATTERN-1975
Pedicle: Superomedial
Volume reduction: lateral.
Skin pattern: WISE

BENNELLI- 1988
ORLANDO- WISE PATTERN
Pedicle: Superomedial
Volume reduction: lateral.
Skin pattern: WISE
Shape: passive
VERTICAL SCAR
RUTH GRAF 2000:
LEJOUR 1989
-Moske dome
-Vertikal mammaplasty + liposuction
-Superior dermoglandulært pedicle
- hud underminering
-Pedicle sutured to chest wall
-no reliance on the skin envelope to shape the postoperative breast.
The use of liposuction leads to less tissue resection

-Superior pedicle
-vertical scar
-Inferior glandellap fikseres oppe
under supiore pedicle under Bipedicle muscel flap

REGNAULT 1974:
KESSELRING- 1983
B-pattern
-Ingen underminering
-Resection af inferiore og dybe del af glandlen
-v=new upper limit of areola
-M-new medial limit of areola
-XM=1/2 SV
-Ny areola markeret, 4,5-5,5 cm i diameter


-Superior pedicle
-Breast parechyma is removed
centrocaudalt below the pedicle
- Breast shaping occurs through medial
and lateral pillar plication and is
¨covered with a circumferentiel skin
envelope with a short vertical scar
and lateral L- shape wing.
Full transcript