Surgical Management of Axillary Tissue Hypertrophy

Prior to surgical incision, antibiotic prophylaxis is administered with appropriate intravenous antibiotics. The skin is incised and the posterior incision dissection is done perpendicular, straight down, through the subcutaneous fat. After the skin is incised, the dissection is beveled outward anteriorly. This creates a subcutaneous flap anteriorly. At all locations, the dissection is done down to, but not violating, the clavipectoral fascia. Anteriorly, any axillary creases or folds are obliterated by scoring of the subcutaneous tissue. The axillary breast tissue is then excised, marked for appropriate laterality, and submitted for permanent pathology. The resulting void is copiously irrigated and hemostasis is ensured. Long acting anesthetic is used to infiltrate the regional sites for postoperative analgesia. A 15-French Blake drain is placed posteriorly through a separate stab incision. The skin edges are meticulously aligned at the anterior and posterior edges with redundancy kept in the middle (Figure 6). The incisions are closed in two layers. An absorbable suture is used in interrupted buried fashion followed by an absorbable subcuticular stitch. 2-octyl cyanoacrylate liquid adhesive and self-adhering mesh (Dermabond Prineo) is placed superficially. Video 1 summarizes the technique.

Breast Reduction Mammoplasty: Inferior Pedicle Technique

Patient X is a  20-year-old Caucasian woman who suffers from symptomatic macromastia. A Wise pattern skin resection was drawn, beginning by marking a point 20.5cm from the suprasternal notch on each breast along the breast meridian, indicating the apex of the skin resection and position of the future nipple placement.  A triangle was then drawn with sides of 8cm each and a base of 7cm, with the apex again at the point noted above. The base of the inferior pedicle was drawn by marks 5.5cm to either side of this intersection, giving a pedicle with a 11cm base.  Additional anatomic landmarks were also marked, including the suprasternal notch, and the sternal midline.

Upper Eyelid Blepharoplasty

Introduction: Cosmetic Upper Blepharoplasty involves removing excess skin from the upper eyelid to enhance the appearance of the upper eyelids.

Methods: Markings were made for the inferior incision on the upper eyelid between 8-10 mm above the upper lash line.  Forceps are used to pinch the excess upper eyelid skin in the middle, nasal, and temporal, aspects of the upper eyelid.  Markings are then made superiorly at the middle, nasal, and temporal points and are connected. Toothed forceps are used to pinch the excess upper eyelid skin, using the markings as a guide.  Iris scissor is used to excise the pinched excess skin and the underlying orbicularis muscle. The skin between the two eyelids was closed.

Conclusions: In our experience, cosmetic upper blepharoplasty is an efficient way to enhance the appearance of the eyes.  

By: Peyton Yee, Addison Yee

Surgeon: Suzanne Yee, MD, FACS

Dr. Suzanne Yee Cosmetic and Laser Surgery Center, Little Rock, AR, USA

Recruited by: Gresham T Richter, MD

Bilateral Wise Pattern Inferior Pedicle Reduction Mammoplasty

We present a 16-year-old female with hypertrophic breasts of bra size 38H, bra strap grooving, and worsening back and posterior shoulder pain limiting activity and affecting posture, who underwent bilateral reduction mammoplasty using the Wise pattern inferior pedicle technique. 998 g of tissue was removed from the patient’s right breast, and 852 g of tissue was removed from the patient’s left breast. The procedure was uncomplicated; however, the postoperative period was complicated by minor skin breakdown at the most inferior portion of the incision along the inframammary fold, as well as some serous drainage that shortly resolved with treatment. Overall, the patient is satisfied with the results of the reduction. She reports comfortably wearing size 38C bras and has noticed significant improvement in back pain, shoulder pain, and bra strap grooving six months after the procedure.

Deep Inferior Epigastric Perforator Flap: Abdominal Closure and Flap Inset

Deep Inferior Epigastric Perforator Flap: Abdominal Closure and Flap Inset

This video depicts the abdominal closure and DIEP flap inset for a delayed bilateral deep inferior epigastric perforator (DIEP) flap reconstruction in a 53-year-old patient status post bilateral mastectomy for breast cancer.

Authors: Eva Niklinska B.S., Vincent Riccelli M.D., Ashkan Afshari M.D., Stephane Braun M.D., Kent K. Higdon M.D., Galen Perdikis M.D., Julian Winocour M.D.

Affiliations: Vanderbilt University Medical Center

Corresponding Author: Eva Niklinska

Deep Inferior Epigastric Perforator Flap: Microvascular Anastomosis and Neurotization

Deep Inferior Epigastric Perforator Flap: Microvascular Anastomosis and Neurotization

This video depicts the microvascular anastomosis of the deep inferior epigastric artery and vein to the internal mammary artery and vein in an anterograde fashion for a delayed bilateral deep inferior epigastric perforator (DIEP) flap reconstruction in a 53-year-old female patient status post bilateral mastectomy for breast cancer.

Authors: Vincent Riccelli M.D., Eva Niklinska B.S., Ashkan Afshari M.D., Stephane Braun M.D., Kent K. Higdon M.D., Galen Perdikis M.D., Julian Winocour M.D.

Affiliations: Vanderbilt University Medical Center

Corresponding Author: Eva Niklinska

Deep Inferior Epigastric Perforator Flap: Abdominal Flap Dissection

Deep Inferior Epigastric Perforator Flap: Abdominal Flap Dissection

This video depicts the abdominal flap dissection for a delayed bilateral deep inferior epigastric perforator (DIEP) flap reconstruction in a 53-year-old female patient status post bilateral mastectomy for breast cancer.

Authors: Eva Niklinska B.S., Vincent Riccelli M.D., Ashkan Afshari M.D., Stephane Braun M.D., Kent K. Higdon M.D., Galen Perdikis M.D., Julian Winocour M.D.

Affiliations: Vanderbilt University Medical Center

Corresponding Author: Eva Niklinska

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