M. Abboud and S. Dibo · 2018. 10. 2. · breast hypertrophy, gigantomastia, and severely ptotic breasts (NAC elevation up to 28 cm). In the authors’ experience, the resection pattern

269© Springer-Verlag GmbH Germany 2018 M. Hamdi (ed.), Vertical Scar Mammaplasty, https://doi.org/10.1007/978-3-662-55451-7_18

Short Scar Mammaplasty in Gigantomastia: Power-Assisted-Liposuction-Mammaplasty (P.A.LM.)

M. Abboud and S. Dibo

18.1 Introduction

Reduction mammaplasty and mastopexy tech-niques include free nipple [1], wise pattern [2], bipedicle [3–5], inferior pedicle [6, 7], vertical pedicle [8–11], superomedial [12–14], supero-lateral [15, 16], and septal based pedicle [17, 18]. Each technique has specific advantages, yet most of these surgical approaches share challenges recreating upper-pole fullness, maintaining sensitivity of the nipple areola complex (NAC), and preserving adequate blood supply in cases of massive breast ptosis.

Contemporary reduction mammaplasty tech-niques emphasize parenchymal reshaping and resection as a key practice for maintaining shape. Breast liposuction [19–27] alone or com-bined with parenchymal resection has been a safe and reliable option for reduction mamma-plasty since the early 1980s. Reduction mam-maplasty with liposuction, with aspirate

volumes exceeding 2000 cc, is a suitable tech-nique for breasts of varying sizes. Liposuction-assisted reduction mammaplasty yields favorable results and is associated with extremely low morbidity rates. The safety and reliability of liposuction-assisted vertical reduc-tion mammaplasty has been confirmed over a 10-year postoperative monitoring period [8, 9, 26, 28]. Complications of liposuction- assisted vertical reduction mammaplasty include kink-ing of the pedicle in the markedly fibrous breasts, an ill-defined inframammary fold, reduction in NAC sensitivity, and delayed wound healing [28–33].

The power-assisted liposuction mammaplasty (PALM) technique was developed to address the limitations of existing breast reduction tech-niques and the complications of liposuction- assisted vertical reduction mammaplasty. The key procedural steps of PALM include:

1. Maximizing the NAC arterial supply and venous return by relying on breast liposuction for volume reduction, minimizing glandular resection, and preserving the central, lateral, and superior pedicles.

2. Liposuction of the lower pole and areolar zones to minimize tension and kinking of the NAC and gland during transposition.

3. Tunnelization of the area below the inframam-mary fold to facilitate skin retraction and redraping and avoid puckering.

M. Abboud, M.D. Head Of Division, Plastic Surgery Department, CHU Tivoli, La Louvière, Belgiume-mail: [email protected]

S. Dibo, M.D. Fellow, Plastic Surgery Department, CHU Tivoli, La Louvière, Belgium

18

Electronic Supplementary Material The online version of this chapter (doi:10.1007/978-3-662-55451-7_18) contains supplementary material, which is available to authorized users.

https://doi.org/10.1007/978-3-662-55451-7_18mailto:[email protected]://doi.org/10.1007/978-3-662-55451-7_18

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4. Facilitating glandular rotation and NAC eleva-tion by creating a subcutaneous upper-pole pocket that can fit the elevated and transposed breast tissue comfortably and without tension while providing upper-pole fullness.

5. Placement of sutures from the dermis to the chest wall for glandular suspension to maintain and ensure longevity of upper-pole fullness and to recreate the inframam-mary fold.

6. Liposuction of the lower lateral quadrant of the breast to improve the contour and shape of the breast or overall breast liposuction to fur-ther reduce breast size or refine symmetry.

The authors share their experience with the PALM technique by presenting the indications, surgical approach, and outcomes.

18.2 Indications

The PALM technique preserves maximal arterial and venous blood supply to the breast and NAC by basing the NAC on the central, lateral, and superior pedicles. Resected parenchymal tissue is minimized and parenchymal transposition is facilitated with the use of power-assisted lipo-suction as the primary tool for reducing breast volume. Robust sutures from the dermis to the chest wall provide glandular suspension, main-taining upper-pole fullness and recreating the inframammary fold. Since PALM preserves blood supply to the breast and NAC, the tech-nique can be safely performed for patients with breast hypertrophy, gigantomastia, and severely ptotic breasts (NAC elevation up to 28 cm). In the authors’ experience, the resection pattern is dependent on the planned NAC elevation. When the planned NAC elevation is less than 10 cm, vertical wound closure is planned preoperatively. For NAC elevations greater than 10 cm, a short T or J wound- closure pattern is determined intra-operatively following elevation of the NAC to the desired position and redraping the parenchy-mal tissues.

18.3 Operative Technique (Video 18.1)

18.3.1 Preoperative Planning and Markings

Preoperative markings are made with the patient in standing. The nipple-to-sternal notch (N-SN) distance for each breast is decided using a mea-suring meter and then marked on the patient. Additional preoperative markings include the midline axis, breast meridian, vertical axis of the breast, inframammary fold, planned position of the NAC, zones of liposuction, borders of the superior pocket, and position of the dermal-chest wall glandular suspension sutures. The planned superior pocket extends laterally from the pecto-ralis muscle, medially to 3 cm from the midline, superiorly to the first rib, and inferiorly to the third rib space. The dermal-chest wall sutures extend medially from the second, third, fourth, and sixth rib spaces.

Periareolar markings are drawn in a mosque pattern as described by Le Jour et al. [9]. The circumference of the mosque is dependent on the breast size [34] and ranged from 14 to 20 cm in length and 4 and 10 cm in width. Vertical wound closure lines are drawn along the breast axis by rotating the breast superolaterally and then superomedially and marking 6 cm from the lower edges of the mosque pattern. The lines are joined 2–4 cm above the inframammary fold to indicate the planned vertical wound closure. When a short t or J wound-closure is planned, the vertical lines are interrupted at 6 cm and con-tinued as diagonal lines pointing medially and laterally at opposite directions from 2 to 4 cm above the original inframammary fold. These lines are joined by a horizontal line parallel to the original inframammary fold to represent the position of the new inframammary fold. Following the conclusion of preoperative mark-ings on one breast, symmetric markings are made on the contralateral breast by pushing the breasts together and duplicating the periareolar and medial/vertical markings (Fig. 18.1).


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ba

c d

Fig. 18.1 Indications for power-assisted liposuction mammoplasty (PALM). (a) Blue dotted line and shading indicate the upper pocket. Red shading indicates the shape of the ptotic breast. (b) Gland is rotated 180° superomedi-ally to lift the breast and fill the pocket. (c) Resection of glandular excess. (d) Solid white lines denote V-Loc

suture placement from dermis to chest wall for glandular suspension. Suturing extends from the second, third, fourth, and sixth rib space to the breast axis to recreate the inframammary fold. With the same V-Loc device, suturing is continued superficially to close the wound

18.3.2 Infiltration

General anesthesia is administered and then the patient is placed in the supine position with the arms abducted. The zone of deepitheliazation, breast gland, and lower pole of each breast are infiltrated with Klein’s solution through the use of a power-assisted liposuction system (Lipomatic Eva SP, Euromi SA, Verviers, Belgium). The infiltration volume is dependent on breast size, mean 280 mL (range 100–800 mL).

18.3.3 Breast Liposuction

In the PALM technique, liposuction of the breast is performed with the lipomatic system.

However, breast liposuction can be equally per-formed by using a conventional liposuction with the hand piece attached to a suction system. The authors’ extensive experience with the lipo-matic device enables more precise zones of liposuction, less surgeon fatigue, and reduced operative times. A multiple-hole blunt cannula (diameter 4 or 5 mm) is used to perform lipo-suction to the lower outer quadrant, retroareolar and inferior parts of breast (Fig. 18.2). Additional subcutaneous tunnelization is per-formed at the retroareolar space, lateral aspect and lower poles of the breast. Tunnelization extends below the inframammary fold to facili-tate transposition of the breast to its new posi-tion under minimal tension and assist redraping of the skin. The aspirate volume is dependent on

18 Short Scar Mammaplasty in Gigantomastia: Power-Assisted-Liposuction-Mammaplasty (P.A.LM.)

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ba

c d

Fig. 18.2 Preoperative planning and markings in 41-year- old woman presenting for PALM. (a) The dis-tance from sternal notch to nipple, the midline axis, the inframammary fold, and the new position of the NAC are marked on the patient. (b) Periareolar markings are made in the shape of a mosque. (c) Vertical incision lines are marked along the breast axis by rotating the breast supero-

laterally then superomedially and drawing 6-cm lines from the lower edge of the mosque pattern. The lines are then joined together 2 to 4 cm above the inframammary fold. (d) Borders of the superior pocket (green) and pat-tern for placement of suspension sutures from the dermis to the chest wall (purple) are marked

shape and size of the breast, extent of breast ptosis, type of breast parenchyma, and intended amount of breast tissue to be resected.

18.3.4 Deepithelialization

The NAC is delineated with a 42-mm areolar marker and the pedicle is deepithelialized along preoperative markings with a scalpel. At the bor-der of the incision, the scalpel is beveled to deep-ithelialize 2 mm of epidermis, an important maneuver for subsequent wound closure.

18.3.5 Pedicle Dissection and Inferior Resection of the Gland

A scalpel is used to incise the gland along preop-erative markings. Dermal dissection is performed 3 mm from the edge of the wound with a rim of dermis extending beyond the epidermis along the wound edge. A wide surface area of deepithelial-ized skin is preserved circumferentially during NAC dissection. Inferior and lower lateral dissec-tion of the gland is then performed to the pectora-lis fascia. Lateral dissection is initiated 6 cm


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ba

dc

Fig. 18.3 Intraoperative views of 41-year-old woman who underwent PALM. (a) Zones are marked in prepara-tion for power-assisted liposuction of the lower outer quadrant (zone 1), retroareolar (zone 4), and inferior parts of the breast (zones 1 and 3). Transposition of the gland is facilitated by additional subcutaneous tunnelization of zones 2 and 4 and by redraping of the skin to recreate the

new inframammary fold. (b) Intraoperative view follow-ing aspiration of 950 mL from the right breast. (c) Deepithelialization of the breast. Blue markings indicate glandular dissection. (d) Inferior and lower lateral dissec-tion of the gland to the pectoralis fascia. Lateral dissection was initiated 6 cm from the base of the mosque pattern

from the base of the mosque pattern and is facili-tated by the liposuction and tunnelization per-formed earlier in the procedure (Fig. 18.3). The thickness of the inferior pole flap is similar to the postmastectomy skin flap; skin undermining is limited. Medial dissection is performed in bev-eled fashion 2–3 cm from the edge of the medial vertical line to the pectoralis fascia, to maintain fullness of medial flap. A wide upper-inner sub-cutaneous pocket is created subcutaneously and dissected on the pectoralis fascia. This pocket is extended laterally from the axis of the breast, medially, 2–3 cm from the midline, superiorly to the first rib and inferiorly to the third rib space. Since the upper-inner pocket will ultimately con-tain the upper bulk of the transposed gland, it is extended to minimize tension on the NAC and

ensure upper-pole fullness. The dissection approach preserves the rich periareolar venous network of the NAC and the superior, central, and lateral pedicles (Fig. 18.4).

The NAC and breast parenchyma are rotated superomedially by 180° to fill the upper-inner pocket and lift the breast. The NAC is then fixed to its predetermined position. Barbed running sutures (V-Loc 180, 2-0, Covidien, Mansfield, MA) are placed from the dermis to the chest wall to suspend the breast tissue inside the subcutaneous pocket. Needle bites at the caudal edge of the dermal flap are used to avoid medial tension on the NAC and a medially pointing nipple. Sutures extend medially in a horizontal fashion from the middle aspect of the pocket at the level of the second to the medial edge of the pocket 2–3 cm from the midline.


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ba

dc

Fig. 18.4 (a) Subcutaneous dissection of the wide upper- inner pocket with preservation of the superior, central, and lateral pedicles. (b) Resection of glandular excess of the lower pole by pulling the gland medially and superiorly. (c, d) Superomedial rotation of the gland by 180° to fill

the pocket and placement of glandular suspension sutures (2-0 V-Loc) from the dermis to the chest wall. Suturing extended from the second, third, fourth, and sixth rib spaces and then was directed laterally to the breast axis line to create the new inframammary fold

Suspension then continues caudally with V-Loc sutures placed in a vertical fashion from the sec-ond, third, fourth, and sixth rib cartilages. Glandular to chest wall sutures are used if the peri-areolar deepithelialized dermis length is short, pre-venting tension on the transposed gland and maintaining adequate shaping of the breast mound.

Once the breast is suspended in the desired position, estimation and resection of excess tis-sue below the inframammary fold is performed. Following transposition of the gland, excess tis-sue in the inferior region is derived from the lower lateral area of the breast in the inverted T technique. V-Loc sutures are placed horizontally and laterally along the sixth rib space to the breast axis line and then continued superficially.

Skin staples are used to redrape the periareo-lar and vertical wounds and they are removed as final skin closure is proceeding. If a vertical

wound closure was not determined preopera-tively, the decision is made intraoperatively regarding the pattern of skin closure (i.e., short t or J closure). The vertical and periareolar wounds are approximated with 2-0 V-Loc running sutures, achieving skin closure under minimal tension (Fig. 18.5). A subcutaneous drain is placed and secured to the skin at the lower part of the wound closure. The same procedure is per-formed on the contralateral breast.

Subsequent liposuction is performed when necessary. Indications for additional liposuction include: treatment of breast asymmetry or full-ness at the lower lateral quadrant requiring cor-rection, excess fat necessitating additional volume reduction, and the need for subcutaneous undermining of the lateral breast to relieve per-sistent tension following the transposition of the breast to its new position.


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ba

dc

Fig. 18.5 (a, b) Redraping of the breast skin envelope and closure of the periareolar and vertical wounds under minimal tension. (c) The right breast with reduction com-pleted. (d) The patient following bilateral reduction. Additional liposuction of the lower lateral quadrants was

performed to decrease fullness and achieve bilateral sym-metry. This patient underwent total liposuction of 1050 and 1100 mL from the right and left breasts, respectively, and resection of 100 g glandular tissue from each breast

18.4 Postoperative Care

A drain is left in place at the lower area of each breast for 48 h or until drainage becomes serosan-guinous or serous and decreased in daily amount. Gauze dressing is used to cover the breast wounds. The patient is discharged from the hos-pital 1–2 days postoperatively with instructions to wear a compression bra for 6 weeks. Patients receive annual postoperative breast imaging.

18.5 Outcome

From January 2008 to January 2013, 200 consecu-tive women (400 breasts) underwent breast reduc-tion with the PALM technique. NAC was based on the central, lateral, and superior pedicles. Parameters of interest included age, BMI, smok-ing, previous breast surgery, N-SN distance, preop-erative breast size, weight of the resected specimen, total volume of fat aspirated per breast, extent of

NAC elevation, and the type of final wound clo-sure. Patient comorbidities such as obesity, diabe-tes mellitus, coronary artery disease, hypertension, breast cancer, and smoking were noted. Exclusion criteria included patients presenting following implant removal, as well as those presenting for unilateral or breast reduction following any kind of breast oncologic surgery. Complications such as seroma, hematoma, partial areolar necrosis, wound infection, and/or dehiscence were also recorded. Data was integrated and analyzed in a computer-ized database. All patients maintained a 2-year postoperative follow-up period.

The mean age of the patients was 37 years (range, 21–67 years), the mean BMI was 32 kg/m2 (range, 25–43 kg/m2), the mean N-SN dis-tance was 36 cm (range, 29–47 cm), and the mean NAC elevation was 16 cm (range, 10–28 cm). Sixteen of 200 patients (8%) were smokers. The mean lipoaspirate volume was 700 mL per breast (range, 300–3000 mL), and the mean glandular resection mass was 230 g


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(range, 40–600 g). Eleven patients (5.5%) pre-sented with gigantomastia. The mean body weight of these 11 patients was 91 kg (range, 82–99 kg), and the mean glandular resection mass per breast was 3.1 kg (range, 2.9–3.5 kg) (Table 18.1).

A short T wound-closure pattern was applied for 292 of 400 breasts (73%), whereas vertical and J closure patterns were applied for 86 breasts (21.5%) and 22 breasts (5.5%), respec-tively. Patients were monitored for an average of 26 months (range, 12–48 months) (Table 18.1). All patients presented with main-tenance of the upper-pole fullness at ≥12 months postoperatively (Figs. 18.6, 18.7, 18.8, and 18.9).

Postoperative complications included devel-opment of wound infections in six breasts (1.5%), wound dehiscence in three breasts (0.75, and seroma detection in 10 breasts (2.5%) (Table 18.2). No patients developed total areolar necrosis; however, partial areolar necrosis occurred in two patients (1%) both of whom were current smokers. The revision surgery rate was

5%. All the patients who suffered from partial areolar necrosis were smokers. All instances of postoperative complications were successfully treated conservatively.

Table 18.1 Patient demographics and statistics

No. of patients 200No. of breasts 400Age (years) Av 37 (21–67)BMI (kg/m2) Av 32 (25–43)No. of current smokers 16 (8%)NAC elevation (cm) Av 16 (10–28)Liposuction per breast (mL) Av 700

(300–3000)Glandular resection (g) Av 230 (40–600)No. of breasts treated with Vertical Scar

86 (21.5%)

No. of breasts treated with Short T Scar

292 (73%)

No. of breasts treated with J Scar 22 (5.5%)Follow-up (months) 12–48

Av average, No number, NAC nipple areola complex, BMI body mass index

a b c

d e f

Fig. 18.6 (a, d) Preoperative photos of 53-year-old patient presenting with bilateral ptosis with distance from nipple-to-sternal notch of 47 cm on the right breast and 46 cm on the left. (b, c, e, f) Patient underwent PALM with NAC elevation of 21 cm on the right breast and

20 cm on the left, liposuction of 1850 mL on the right breast and 1800 mL on the left breast, glandular resection of 280 g of the right breast and 300 g from the left. (b, e) 24 months postoperatively. (c, f) Result at 2 years postoperatively


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a b c

d e f

Fig. 18.8 (a, d) Preoperative photos of a 43-year-old patient presenting with bilateral ptosis with distance from nipple-to-sternal notch of 35 cm on the right breast and 34 cm on the left. (b, c, e, f) Patient underwent PALM

with NAC elevation of 13 cm on the right breast and 12 cm on the left, liposuction of 400 mL on the right and left breast, glandular resection of 75 g on the right and left breast. (f) Result at 2 years postoperatively

a

d e f

b c

Fig. 18.7 (a, d) Preoperative photos of 60-year-old patient presenting with bilateral ptosis with distance from nipple-to-sternal notch of 47 cm on the right breast and 45 cm on the left. (b, c, e, f) Patient underwent PALM with NAC elevation of 26 cm on the right breast and

24 cm on the left, liposuction of 1500 mL on the right breast and 1450 mL on the left, glandular resection of 490 g on the right breast and 530 g on the left. (f) Result at 3 years postoperatively


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18.6 Discussion

The goals of reduction mammaplasty and masto-pexy include safety and predictability; minimal complications; fast recovery; long-lasting results, and the achievement of an appropriate size, shape, and projection of the breast [35]. Successful outcomes are attributed to skin qual-ity, patient age and expectations, degree of ptosis, and the surgeon’s experience and understanding of breast anatomy [17]. The PALM surgical tech-nique affords a customizable approach to reduc-

tion mammaplasty and mastopexy that also accommodates patients with gigantomastia and massive breast ptosis, avoiding the challenges of conventional vertical mammaplasty such as kink-ing of the pedicle, venous congestion of the NAC, and reduced NAC sensitivity postoperatively.

Breast liposuction as a sole procedure or in conjunction with parenchymal resection has been well established as a safe and reliable [19–28] approach to decrease breast weight and volume. Our personal experience shows liposuction to be suitable for breasts with lateral fullness, and infe-rior excess. Liposuction promotes longevity of a desired breast shape and delays ptosis when excess tissue is removed, a natural contour is restored, pulling forces are decreased, and supe-rior rotation of the breast is facilitated. If asym-metry presents following bilateral breast reduction, liposuction is an adequate and reliable option to reestablish breast symmetry and refine the shape of the breast. The PALM technique includes liposuction for volume reduction and breast shaping, limiting parenchymal resection to the inferior pole of the breast.

Table 18.2 Complications following PALM

Complication No. of breasts (%)

Wound infection 6 (1.5)Wound dehiscence 3 (0.75)Seroma 10 (2.5)Hematoma 0Partial areolar necrosis 2 (1)Total necrosis 0

No. of patients (%)Revision surgery 10 (5)

a b c

d e f

Fig. 18.9 (a, d) Preoperative photos of a 45-year-old- presenting with bilateral ptosis with distance from nipple- to- sternal notch of 33 cm on the right and left breast. (b, c, e, f) Patient underwent PALM with NAC elevation of

10 cm on the right and left breast, liposuction of 1200 mL on the right and left breast side and glandular resection of 300 g on the right and left breast. (f) Result at 3 years postoperatively


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By reducing volume above the NAC, liposuc-tion ensures tension-free folding of the NAC dur-ing its superior transposition. This remains true even in the cases of severe ptosis in which mas-sive folding and substantial NAC elevations are anticipated and the superior pedicle does not pro-vide sufficient blood supply to the NAC. Liposuction and tunnelization below the inframammary fold through the use of the lipo-matic system can better define the breast contour while enhancing skin retraction and redraping vertical wound closure to minimize wrinkling, puckering, and the need for scar revision.

The PALM technique preserves maximal blood supply to the breast by minimizing the extent of tissue dissection and resection; with PALM breast liposuction is relied on for volume and weight reduction. Dissection is restricted to a portion of inferior pole and the medial aspect of the breast, and minimal tissue resection is restricted to a portion of the lower outer quadrant. A robust blood supply to the breast parenchyma and NAC is ensured through the preservation of the lateral, superior, and central pedicles.

The PALM technique also maintains NAC sensitivity by means of a lateral pedicle contain-ing Wu¨ringer’s horizontal septum [37], which carries a neurovascular supply to the NAC and can be integrated into septum-based mamma-plasty with the methods developed by Hamdi et al. [17]. Greater NAC elevations are feasible with a continuous blood supply to the NAC. Deepithelialization of a wide surface area of skin around the NAC allows for protection of the periareolar vein polygon [36] and maintains the venous networks supplying the NAC. Breast tissue resection is minimized with PALM to sup-port adequate venous drainage of the NAC through large transposition distances that are required for patients with gigantomastia and pro-nounced breast ptosis. NAC elevations as large as 28 cm were achieved with PALM.

The rate of wound healing complications is decreased with PALM since the blood supply to the breast is preserved. Because a 3-mm dermal rim is maintained around the edge of the breast wound, PALM facilitates wound closure and ensures apposition and eversion of the wound

edges under minimal tension, improving wound healing and minimizing excessive scaring. The preservation of a large area of deepithelialized tissue around the gland carrying the NAC also creates a firm anchoring structure at the deepithe-lialized edges for sutures from the dermis to the chest wall during glandular transposition. PALM also involves the creation of a superior pocket, comfortably fitting the transposed parenchymal tissue that minimizes tension on the NAC upon final wound closure. PALM can be completed with only two V-Loc sutures. V-Loc sutures are advocated for glandular suspension and skin clo-sure because they minimize operating times, foreign- body interaction, and wound complica-tions since they require less suture material and fewer knots. Additionally, V-Loc sutures involve minimal compression of glandular and fatty tis-sue during suspension of the gland in its new position since fewer knots are required. In our opinion, the application of V-Loc sutures can decrease fat necrosis from compression of the parenchyma and gland when approximating the two pillars in superior pedicle breast reduction.

There are several benefits associated with glandular suspension sutures from the dermis to the chest wall sutures. V-Loc sutures are placed from the second rib at the upper pole to the sixth rib inferiorly to fix the breast parenchyma in its new position. V-Loc sutures are robust and ensure parenchyma support and prolong upper-pole full-ness by joining the dermal edges of the breast glandular flap to the rib perichondrium in the presence of a superior pocket accommodating the flap. V-Loc sutures are also employed to define the new inframammary fold, positioned 2–4 cm cephalad to its original location, depending on the extent of ptosis. Following glandular suspen-sion in the desired position, a single 3-0 V-Loc sutures is applied for vertical and periareolar wound closure under minimal tension.

Various patterns of skin closure are compati-ble with PALM. A vertical wound closure is determined preoperatively when the NAC eleva-tion is less than 10 cm. When the NAC elevation is greater than 10 cm, the decision for a short T or J wound closure is determined intraoperatively following the elevation of the NAC to the desired


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position and redraping of the parenchymal tis-sues. The majority of patients in this study pre-sented with ptotic breasts that required NAC elevations greater than 10 cm. As a result, a short T wound-closure pattern was dominant.

Postoperatively 24 patients (12%) became pregnant, including nine primary and 15 second-ary or tertiary pregnancies. All patients were able to breastfeed after PALM; the preservation of breastfeeding capacity was attributed to limited glandular resection and maintenance of maximal amount of breast parenchyma.

While liposuction is a commonly performed procedure in plastic surgery, few surgeons are experienced with breast liposuction and specifi-cally power-assisted breast liposuction. Therefore a limitation of PALM is the learning curve required for surgeons to obtain the skills required to undertake power-assisted breast liposuction. Due to the meticulousness and precision required for breast liposuction, the senior author recom-mends that liposuction is performed in small vol-umes and that cases of gigantomastia and massive ptosis are avoided until adequate skills are developed.

Glandular breasts are an additional challenge for PALM since glandular tissue is difficult to treat with liposuction. However, glandular breasts do not constitute a contraindication for the PALM technique. Increasing the amount of glandular resection from the lower pole while preserving the lateral septum, applying delicate and precise liposuction of the breast, and dissecting a larger upper-pole pocket to accommodate the trans-posed glands are all measures that can be taken to help achieve satisfactory results and overcome the challenges associated with glandular breasts.

Tips for PALM Precise preoperative markings are primordial for obtaining an aesthetically pleasing and symmetrical breast shape at the end of the procedure.• Maximize the NAC arterial supply and venous

return by relying on breast liposuction and minimize glandular resection.

• Liposuction the lower lateral and areolar zones to minimize tension and kinking of the NAC and gland during transposition.

• Liposuction the lower lateral quadrant of the breast at the end of the procedure for enhanced breast contour and shape.

• Liposuction the breast at the end of procedure to correct asymmetry and allow for additional volume and size reduction.

• Tunnelization of the area below the inframam-mary fold to allow better skin retraction and redraping; this also helps avoid puckering.

Conclusion

PALM combines breast liposuction and mam-maplasty into a surgical approach that ensures maximal blood supply to the breast by pre-serving the superior, lateral, and central pedi-cles and minimizing skin undermining and glandular resection. PALM is a safe and reli-able alternative for reduction mammaplasty and mastopexy. PALM is indicated for patients with gigantomastia and extensive ptosis because of the preservation of the blood sup-ply to the breast. The long-term outcomes of PALM include an aesthetically pleasing breast shape with superior pole fullness and without bottoming out or boxiness.

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18: Short Scar Mammaplasty in Gigantomastia: Power-Assisted-Liposuction-Mammaplasty (P.A.LM.)18.1 Introduction18.2 Indications18.3 Operative Technique (Video 18.1)18.3.1 Preoperative Planning and Markings18.3.2 Infiltration18.3.3 Breast Liposuction18.3.4 Deepithelialization18.3.5 Pedicle Dissection and Inferior Resection of the Gland

18.4 Postoperative Care18.5 Outcome18.6 DiscussionReferences

Documents

M. Abboud and S. Dibo · 2018. 10. 2. · breast hypertrophy, gigantomastia, and severely ptotic breasts (NAC elevation up to 28 cm). In the authors’ experience, the resection pattern