WHAT'S NEW

The patient is a high school student with a several year history of gynecomastia who presented for a combination liposuction / open approach reduction operation.

Gynecomastia AP view

Gynecomastia post op

Gynecomastia Oblique view

Gynecomastia post op

The patient is a woman who is dissatisfied with deep grooves extending downward from the corners of her mouth (marionette lines).  She had injection of a relatively small amount (0.8 cc) of hyaluronic acid filler (Juvederm) into the area under local anesthetic.  She is shown a few weeks post procedure with improved contours more consistent with a youthful face.

Before Juvederm filler injection

After Juvederm filler injection

I wrote in the February 2011 Blog about Nipple Sparing Mastectomy.  It is a procedure that was previously associated with poor outcomes, especially capsular contracture  (tightening of the scar capsule around the implant).  Surgery to improve these patients’ outcomes is particularly challenging and not everyone can be helped.  The procedure has much better outcomes now secondary to improved patient selection and the use of acellular dermis.  I have current plans with several local General Surgeons to do immediate breast reconstruction post nipple sparing mastectomy.

The June Case of the Month is presented as a reminder of these previous bad outcomes and how far we have come as a specialty in minimizing their occurrence.  The patient is a woman in her 50’s who had nipple sparing mastectomy greater than 20 years ago for fibrocystic changes and breast pain.  Soon thereafter, she had onset of capsular contracture .  She was recently referred for obviously misshapen breasts suggesting silicone implant rupture.  The patient noted that she wished her previous primary care providers had told her that her breasts were not “normal” and had suggested treatment.

The patient had bilateral capsulectomy with implant exchange for new cohesive silicone gel implants (a vastly improved product and approved by the FDA).  She also had placement of acellular dermis in the lower part of the breast to optimize support and minimize recurrent contracture.

The patient presented had mastectomy and radiation therapy on the left for breast cancer.  She elected to have a right prophylactic mastectomy.  A latissimus flap was indicated on the left to minimize problems related to the radiation.  The patient, however, had enough relatively thick preserved skin after her right to make a lattisimus flap on that side unnecessary.  In this setting, additional tissue would have made the right droop more than the left and actually contribute to  asymmetry.  In some instances where the non radiated side has little extra tissue or if the patient desires thicker coverage or larger implants, bilateral latissimus flaps may be indicated.  Sometimes, however, the right decision is not completely evident and alterations at the time of implant exchange may be needed.

Baseline

Post right tissue sparing mastectomy

Post bilateral expander and left latissimus flap

Post implant exchange and nipple areolar reconstruction

The patient is a woman in her early 20’s who had breast cancer treated with bilateral mastectomies.  She had reconstruction with expander placement and later silicone implant exchange and nipple reconstruction.