Nonfacial Aesthetic Surgery

Thomas S. Satterwhite MD¹

David M. Kahn MD¹

George W. Commons MD (Liposuction)¹

Vanila Singh MD²

Bruce D. Halperin MD (Liposuction)²

¹SURGEONS

²ANESTHESIOLOGISTS

AUGMENTATION MAMMOPLASTY

SURGICAL CONSIDERATIONS

Description: Augmentation mammoplasty is accomplished through the use of saline or silicone gel-filled breast implants. The surgery may be performed under GA or local anesthesia with sedation. The patient is positioned either with the arms abducted at 90° or with the hands tucked at the sides. Local anesthetic (± epinephrine) is infiltrated into the skin at the incision site and under the glandular tissue. Implant insertion can be done through inframammary, periareolar, transaxillary, or transumbilical incisions. The implant is placed in a pocket that is created beneath the mammary gland (subglandular), under the pectoralis muscle (submuscular), partially subglandular and partially submuscular (dual plane), or beneath the pectoralis fascia (subfascial), depending on the surgeon’s preference and the amount of tissue available. An endoscope may be used to assist with dissection of the pocket. When the implant is placed in the submuscular position, the pectoralis muscle is divided from its insertion along the inframammary fold and sometimes along the sternal insertion to allow the muscle to drape over the implant. Regardless of the location of the pocket, the surgical wound is carefully irrigated and inspected for hemostasis. Sizers, either predetermined volumes of silicone gel or adjustable saline- or air-filled temporary implants, may be used to help determine the appropriate final volume and placement. The patient may be placed in the seated position to assess the size, shape, and symmetry of the breasts. The sizers are then replaced with the permanent prostheses. If permanent saline implants are used, they are filled with saline until the desired volume is reached; gel-filled implants do not have alterable volumes. The wounds are closed, and dressings are applied (Fig. 11.2-1).

Augmentation mammoplasty usually is performed as an outpatient procedure, although some patients may want an overnight stay for pain management and antiemetics. PONV is not uncommon, and all efforts should be made to decrease its frequency.

Variant procedure or approaches: The endoscopic transumbilical approach is used much less frequently.

Preop diagnosis: Hypomastia, breast ptosis

Figure 11.2-1. Breast augmentation. Implants may be placed in a subglandular or subpectoral position. (Reproduced with permission from Spear SL: The Breast: Principles and Art. Lippincott-Raven: 1998.)

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Inframammary, periareolar, transaxillarym, or transumbilical
Antibiotics	Cefazolin 1 g iv
Unique considerations	May place patient in sitting position during procedure.
Surgical time	1 h
Closing considerations	May need patient in sitting position for application of dressings.
EBL	Minimal
Postop care	Outpatient procedure
Mortality	Rare
Morbidity	Prosthesis failure: 5% Capsular contracture: 5% Hematoma: 3% Infection: 2% Wound dehiscence: < 1% Cosmetic disappointments
Pain score	3-4

▪ PATIENT POPULATION CHARACTERISTICS

Age range	Typically 17-45 yr but also may be done on the contralateral breast in a patient undergoing breast reconstruction.
Incidence	307,180 performed in the United States in 2011; the most common cosmetic surgical procedure
Etiology	Developmental; involution after breast-feeding; age-related atrophy or ptosis
Associated conditions	Not common but can be seen with Poland’s syndrome.

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Mastopexy/Breast Lift, p. 1113.

Suggested Readings

1. Alpert B, Lalonde D: MOC-PS CME article: breast augmentation. Plast Reconstr Surg 2008; 121:1.

2. Coopey SB, Specht MC, Warren L, Smith BL, Winograd JM, Fleischmann K: Use of preoperative paravertebral block decreases length of stay in patients undergoing mastectomy plus immediate reconstruction. Ann Surg Oncol 2013; 20(4):1282-6.

3. Gardiner S, Rudkin G, Cooter R, Field J, Bond M: Paravertebral blockade for day-case breast augmentation: a randomized clinical trial. Anesth Analg 2012; 115(5):1053-9.

4. Graf RM, Bernandes A, Rippel R, et al: Subfascial breast implant: a new procedure. Plast Reconstr Surg 2003; 111(2): 904-8.

5. McLaughlin JK, Lipworth L, Murphy DK, et al: The safety of silicone gel-filled breast implants: a review of the epidemiologic evidence. Ann Plast Surg 2007; 59(5):569-80.

6. Nahabedian MY, Patel K: Management of common and uncommon problems after primary breast augmentation. Clin Plast Surg 2009; 36:127-138.

7. Tebbetts JB: Dual plane breast augmentation: optimizing implant-soft tissue relationships in a wide range of breast types. Plast Reconstr Surg 2001; 107(5):1255-72.

8. Thorne CH: An evidence-based approach to augmentation mammaplasty. Plast Reconstr Surg 2012; 126:2184.

9. See Suggested Readings Mastopexy/Breast Lift, p. 1114.

REDUCTION MAMMOPLASTY

SURGICAL CONSIDERATIONS

Description: Breast reduction surgery can be done as an outpatient procedure or with an overnight stay. One might choose to admit the patient overnight in a hospital setting to monitor for hematoma formation and evidence of decreased blood supply to the nipple-areola complex. For these patients, the pain from this procedure is relatively low; therefore, PONV tends to be the greater issue in the immediate postoperative period.

The traditional type of breast reduction performed in the United States is the inferior pedicle technique using a Wise pattern (“anchor-type” scar) for the skin excision (Fig. 11.2-2). Markings are made with the patient upright in the preoperative holding area. The areola is marked circumferentially with an areola sizer and incised. The remaining incision lines are scored with a scalpel. Next, the inferior pedicle, which contains the neurovascular supply to the nipple-areola complex, is deepithelialized. Excess skin and breast tissue are excised, preserving the pedicle of tissue that will compose the breast mound. The resected tissue from each breast, which can range from 200-1000 g, is weighed as to an adjunctive method of ensuring symmetry. Temporary skin closure with staples allows the patient to be placed in a sitting position so that the breasts can be evaluated for symmetry. When the surgeon is satisfied with the appearance of the breasts, they are closed with sutures. Drains may be placed, depending on surgeon preference (Fig. 11.2-2). After the skin has been closed, the location of the nipple and areola is marked and excised, and the nipple-areola complex is delivered and sutured into position. Soft, supportive dressings are placed.

A technique that has gained in popularity recently is the vertical reduction mammoplasty, which shares the fundamental principles of excision of excess breast tissue and preservation of blood flow to the nipple-areola complex but differs in choice of skin incision and pedicle. Relatively more time is spent performing the tissue excision and pedicle shaping, but wound closure time is greatly decreased (resulting in a “lollipop-type” scar) compared with the traditional Wise-pattern technique.

Figure 11.2-2. Reduction mammoplasty using an inferior pedicle technique. A: The skin and breast tissue on the medial and lateral sides of the pedicle are resected. B: The medial and lateral skin envelopes are sutured at the midline, leaving an inverted T-shaped scar. (Reproduced with permission from Spear SL: The Breast: Principles and Art. Lippincott-Raven: 1998.)

Variant procedure or approaches: Liposuction may be used in combination with this procedure. Reduction mammoplasty using liposuction alone has increased in popularity.

Preop diagnosis: Macromastia, gigantomastia, mammary hypertrophy

▪ SUMMARY OF PROCEDURE

Position	Supine, arm abducted 90°
Incision	Marked preop. Most have circumareolar incision with an inferior anchor-shaped extension (Fig. 11.2-2) or a short vertical component (“lollipop” scar).
Antibiotics	Cefazolin 1 g iv
Unique considerations	May place patient in sitting position during procedure to assess symmetry; Foley catheter; SCDs
Surgical time	2-5 h, depending on volume of reduction and technique
Closing considerations	May place patient in sitting position for application of dressings.
EBL	100-200 mL
Postop care	Outpatient or 24-h stay for pain/nausea management. Avoid the use of Toradol in the first 24 h because of the large, raw surface created between the skin flaps and breast tissue.
Mortality	Minimal
Morbidity	Dehiscence: 5% Infection: 1% Seroma/hematoma: < 1% (may require reexploration) Skin flap necrosis Loss of nipple-areola complex (may require urgent reexploration) Loss of nipple-areola sensation Hypertrophic scarring Cosmetic disappointments
Pain score	3-4

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Mastopexy/Breast Lift, p. 1113.

Suggested Readings

1. Hall-Findlay E: A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999; 104(3):748-59.

2. Lund HG Jr, Kumpf AL: Aesthetic breast surgery: emerging trends and technologies. Mo Med 2010; 107(3):203-9.

3. Palmieri B, Benuzzi G, Costa A, et al: Breast reduction and subsequent cancer: a prophylactic perspective. Breast 2006; 15(4):476-81.

4. See Suggested Readings Mastopexy/Breast Lift, p. 1113.

MASTOPEXY/BREAST LIFT

SURGICAL CONSIDERATIONS

Description: Mastopexy procedures reduce the volume of the skin envelope to match the volume of the breast gland. Depending on the degree of ptosis (“droopy breasts”) and the wishes of the patient, the ptosis may be treated by augmentation alone to increase the volume of the breast, by skin excision alone to reduce the skin envelope appropriately, or by a combination of a mastopexy and an augmentation.

The operation itself resembles a reduction mammoplasty, except that breast tissue is generally excised minimally or not at all, and an implant may be added (mastopexy/augmentation). The patient is marked before surgery in the upright position. After the induction of anesthesia, the arms are positioned either tucked at the patient’s sides or abducted 90°. The procedure begins with the areola being marked circumferentially with an areola sizer and then incised. Next, the skin flaps are elevated. The breast tissue is moved to a higher position on the chest wall, and the skin is redraped and tailor-tacked closed. The patient is placed in a sitting position to assess for symmetry and nipple location. The nipple-areola complex is then brought out into its new position, and dressings are applied.

Preop diagnosis: Breast ptosis

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Circumareolar ± inferior vertical extension or complete anchor
Antibiotics	Cefazolin 1 g iv
Unique considerations	May place patient in sitting position during procedure.
Surgical time	2-4 h
Closing considerations	May place patient in sitting position for application of dressings.
EBL	> 100 mL
Postop care	Outpatient or 24-h stay
Mortality	Minimal
Morbidity	Wound healing: 5% Infection: 1% Seroma/hematoma: < 1% Hypertrophic scarring Cosmetic disappointments
Pain score	3-4

ANESTHETIC CONSIDERATIONS FOR MAMMOPLASTY/MASTOPEXY

PREOPERATIVE

Typically, three patient populations present for mammoplasty: (a) healthy individuals, for breast reduction/augmentation/ lift or removal of an implant; (b) morbidly obese, for breast reduction; and (c) breast cancer patients, for reconstruction after mastectomy. (For preop considerations in the morbidly obese patient, see Anesthetic Considerations for Abdominoplasty, p. 1118.) Breast cancer patients undergoing mastectomy with immediate reconstruction will not have had either chemotherapy or radiation. The following considerations are for breast cancer patients undergoing delayed reconstruction post-chemotherapy.

Respiratory	Pulmonary fibrosis may complicate chemotherapy. Alkylating agents (e.g., cyclophosphamide and melphalan), used to treat breast cancer, have some pulmonary toxicity. Consider pulmonary fibrosis in a patient reporting dyspnea, nonproductive cough, and fever.
Tests:	Consider CXR; ABG, PFTs as indicated from H&P. Cardiovascular Cardiomyopathy and CHF may result from chemotherapy, especially doxorubicin (Adriamycin) > 550 mg/m². Tests: Consider ECG; ECHO, if indicated from H&P.
Neurologic	Note any pre-existing injury to long thoracic nerves, as evidenced by winged scapula deformity.
Musculoskeletal	Avoid upper extremity iv and BP cuff on mastectomy side.
Hematologic	Leukopenia, thrombocytopenia, and anemia from chemotherapy may be present. Tests: CBC; Plt count
Renal/Hepatic	Methotrexate can produce some renal and hepatic dysfunction. Tests: Cr; LFTs
Laboratory	Other tests as indicated from H&P, prior chemotherapy
Premedication	Midazolam 1-2 mg iv immediately preop. Surgeon may want to mark the patient’s skin preop, with patient standing. Delay premedication until this has been done.

INTRAOPERATIVE

Anesthetic technique: GETA

Induction	Standard induction (see p. B-2). [check mark] with surgeons regarding use of a nerve stimulator during dissection (and the need to avoid muscle relaxants). Consider intratracheal lidocaine 4% LTA to minimize coughing during position changes.
Maintenance	Standard maintenance (see p. B-3). Surgeons may want patient sitting for part of the procedure. Pneumothorax should be considered with any change in lung inflation pressure, O₂ sat, or BP.
Emergence	During some of the procedure and for application of dressing, patient may be moved to sitting position, with consequent coughing, bucking, etc. (Rx: deeper anesthesia, e.g., propofol 0.5 mg/kg or lidocaine 1 mg/kg.) Watch BP carefully and treat orthostatic hypotension if it occurs, usually with a fluid bolus if the patient is not volume sensitive (Hx of CHF or renal failure).
Blood and fluid requirements	IV 16-18 ga × l NS/LR @ 4-8 mL/kg/h	Minimal blood loss for simple reconstruction, augmentation, or reduction; larger blood losses anticipated for combined procedures (e.g., mastectomy with immediate reconstruction or flap reconstruction).
Monitoring	Standard monitors (p. B-1)	Arterial line in the morbidly obese may be necessary to obtain accurate BP measurements.
Positioning	Patient may need to be sitting for application of dressing.	Avoid HTN, bucking, and straining; these may cause or exacerbate bleeding at reconstruction site. Careful padding of arms to protect them during position change.