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A possible new way of managing breast implant rippling using an autogenous fascia lata patch
372
Both attach to the trochlea and then run inferolaterally, though slightly different. Together these data might support the idea that both structures probably originate from the same organ derived from the orbital septum. However, how the histological difference came about is still unknown. The LPTL can be divided into RLT and diaphanous retinaculum.1 Most Mongoloids have a LPTL,1 46% of which are RLT1 (all cases and 40%, respectively, in the present study). As the LPTL, particularly RLT, is a robust and hard structure, eyelids become less flexible and opening movements are restricted. Hence, this structure must be treated as an important part of the upper eyelids. Especially in blepharoptosis surgery or double fold operations, the RLT needs to be incised to ensure free eyelid opening. There is a surgical method in blepharoptosis surgery called the Whitnall’s sling,3,4 in which the LPTL can sometimes be mistaken for the WL.4,5 If so, and the LPTL is fixed to the tarsus in such an operation,4,5 the result is that the elevation is insufficient. Because the LPTL exists at a more distal position than the WL and is one of the structures restricting fissure height, it is important to recognize the LPTL to ensure satisfactory results in blepharoptosis surgery.
References 1. Yuzuriha S, Matsuo K, Kushima H. An anatomical structure which results in puffiness of the upper eyelid and a narrow palpebral fissure in the Mongoloid eye. Br J Plast Surg 2000; 53:466—72. 2. Hwang K, Kim DJ, Chung RS, et al. An anatomical study of the junction of the orbital septum and the levator aponeurosis in orientals. Br J Plast Surg 1998;51:594—8. 3. Anderson RL, Jordan DR, Dutton JJ. Whitnall’s sling for poor function ptosis. Arch Ophthalmol 1990;108:1628—32. 4. Ra K. Congenital blepharoptosis (Whitnall’s ligament sling). In: Maruo T, editor. Practical ophthalmology 19. Treatment and surgery of the outer ocular area. Tokyo: Bunkodo; 1995. p. 66—9. 5. Kubota N. Blepharoptosis. Tokyo: Bunkodo; 2000. p. 133.
Hirohiko Kakizakia, Masahiro Zakoa, Takashi Nakanob, Masayoshi Iwakia, Hidenori Mitoc a Department of OphathalmologyAichi Medical University, Nagakute-cho, Aichi-gun, 480-1195 Aichi-ken, Japan b Department of Anatomy, Aichi Medical University, Nagakute-cho, Aichi-gun, 480-1195 Aichi-ken, Japan
Short reports and correspondence c
Ide Eye Hospital, 3-6-12 Kasumi-cho, 990-0039 Yamagata, Japan
doi:10.1016/j.bjps.2003.12.001
A possible new way of managing breast implant rippling using an autogenous fascia lata patch Palpable, and sometimes visible ‘lumpiness’ known as ‘rippling’ seems to be a fairly frequent observation associated with textured surface silicone breast implants placed in a sub-glandular prepectoral muscle pocket. It is probably the result of several factors including reduced capsular production, lack of substantial subcutaneous fat, and the natural tendency of these implants to form folds or ridges in a dependent position. A recent study related to Trilucent breast implant patients indicated an occurrence in 60% of studied cases so the problem is not necessarily related to the implant filler.1 It has been suggested that undue folding of an implant shell can produce an area of mechanical weakening and this may increase the chance of implant filler leakage.2,3 The senior author has tried several methods and also sought advice from experienced breast surgeons regarding management. Possible ways include changing the implant position to submuscular pockets or changing the size or nature of the implant. None of these methods appeared to give a consistently good result. A possible solution to the problem, which we believe has not been tried before (to the best of our knowledge), is to use a fascia lata patch either
Figure 1 This shows site of prominent edge of silicon implant (arrow) and surrounding surface markings of proposed placement fascial patch. The old inframammary scar is also marked.
Short reports and correspondence
Figure 2 The fascial patch obtained from the lateral aspect of the left thigh and donor site before closure.
within or on the outside surface of the area of the capsule where the problem exists. After careful discussion with a suitable patient, who while happy with the overall result of her silicon breast implants (inserted into pre-pectoral pockets), was concerned about a visible edge of implant on the medial aspect of her right breast (Fig. 1), it was decided to use an autogenous fascial strip to patch the area concerned. She was made fully aware of the possible donor scar on her thigh and given no promise that this new technique would work. The procedure was carried out under general anaesthetic, the fascial patch (Fig. 2) being inserted through the original sub-mammary approach while the implant was temporarily removed to allow access to the inner aspect of the capsule in the area where the rippling occurred. The fascial patch was then carefully sutured in place using 5/0 vicryl sutures. The implant was washed in Betadine solution and replaced. Antibiotic cover was given. There have been no postoperative problems and 8 months after the surgery,
Figure 3 The healed donor site scar 8 months after surgery.
373
Figure 4 The right breast at 8 months with pressure applied to breast implant from above showing no visible rippling in operated area.
the donor area scar is virtually invisible (Fig. 3) and the rippling area is no longer visible or palpable (Fig. 4). On the basis of this, and because the patient was pleased, further fascia lata patching has been performed to try to correct two further areas of rippling in the left sub-mammary fold (Fig. 5). In this situation the fascial patch was able to be placed on the outside of the capsule without necessitating removal of the implant within (Fig. 6). The early results of this appear to be encouraging. It may be the case that the use of synthetic mesh or similar material could equally well be used though the possibility of infection may be higher. The use of a pectoralis major ‘trapdoor flap’ for similar deformities has also been described recently but involves slightly more extensive surgery and may therefore be riskier.4
Figure 5 The left breast preoperatively showing two areas of palpable rippling in the inframammary fold and surface markings of proposed subcutaneous fascial patch to be placed over the exposed capsule.
374
Figure 6 This shows the fascial patch in place just prior to closure of the wound.
References 1. McGregor JC. Trilucent breast implant—a personal review of the current controversies (May 1999). Scot Med J 2000;45: 176—9. 2. Rizkalla M, Duncan C, Mathews RN. Trilucent breast implants: a 3 year series. Br J Plast Surg 2001;54:125—7. 3. McGregor JC, Brown DT. Observations on a consecutive series of patients who have had Trilucent breast implants removed as recommended by the MDA Hazard Notice (May 2000). Br J Plast Surg 2002;55:231—4. 4. Collis N, Platt AJ, Batchelor AG. Pectoralis major ‘Trapdoor’ flap for silicone breast implant medial knuckle deformities. Plast Reconstr Surg 2001;108:2133—5.
John C. McGregor, Hilal Bahia Plastic Surgery Department, St John’s Hospital at Howden, Howden Road West, Livingston, West Lothian, Edinburgh, Scotland EH54 6PP, UK doi:10.1016/j.bjps.2003.11.028
Short reports and correspondence
We have, therefore, devised a facial model that can be used to demonstrate and teach such techniques. The requirement of such a model is a realistic one with accurate facial landmarks and pliable surface that could be incised, transposed and stitched. The facial model was made in our prosthetic department (Fig. 1). An impression of a skull was first taken and poured in acrylic to create the base of the model. Then, a wax pattern of the face was carved complete with various skin lesions on top of the skull base. This formed the basis of the facial mould, where a soft silicone rubber was used to simulate subcutaneous tissue and a separate layer of silicone was used to simulate skin. We used the model to teach our new SHOs (total of 20) who had joined our unit. A formal workshop session that included didactic lectures was organized before they were given the responsibilities of assisting minor procedures in the day surgery unit. The basic principles of z-plasty and rhomboid flaps were taught, and the planning and execution of these were practiced on the models we devised. Being an in house programme, slow or difficult learners were easily identified, and their weakness addressed. All 20 participants felt that such a teaching session was invaluable in further improving their knowledge of flap planning, and all felt much more confident in using them should such necessity arise. In the current climate of endemic virus disease in animals, the recent human tissue retention censure, and increasing patient expectation, we believe that this is an effective method of teaching fundamental plastic surgery skills. We are hoping to extend our teaching of other local flaps on this model in the future. Note: This article had been presented in the following meetings: BAPS winter meeting, 28 – 30th November 2001,
A non-animal facial model for teaching local flaps to trainees The excision of lesions on the face and skin coverage of the resulting defects often requires local flaps. The planning and execution of these procedures are crucial to their success. It is, therefore, important for the trainees to understand the mechanics of local transposition flap and zplasty in a three-dimensional sense, which would be difficult to learn from the textbooks alone. These procedures are often carried out in a day surgery unit under local anaesthesia, and teaching of them is often awkward and takes valuable clinical time.
Figure 1 The facial model-on the right is the initial skull base, and on the left, the finished model with pliable surface and realistic anatomical landmarks.
Both attach to the trochlea and then run inferolaterally, though slightly different. Together these data might support the idea that both structures probably originate from the same organ derived from the orbital septum. However, how the histological difference came about is still unknown. The LPTL can be divided into RLT and diaphanous retinaculum.1 Most Mongoloids have a LPTL,1 46% of which are RLT1 (all cases and 40%, respectively, in the present study). As the LPTL, particularly RLT, is a robust and hard structure, eyelids become less flexible and opening movements are restricted. Hence, this structure must be treated as an important part of the upper eyelids. Especially in blepharoptosis surgery or double fold operations, the RLT needs to be incised to ensure free eyelid opening. There is a surgical method in blepharoptosis surgery called the Whitnall’s sling,3,4 in which the LPTL can sometimes be mistaken for the WL.4,5 If so, and the LPTL is fixed to the tarsus in such an operation,4,5 the result is that the elevation is insufficient. Because the LPTL exists at a more distal position than the WL and is one of the structures restricting fissure height, it is important to recognize the LPTL to ensure satisfactory results in blepharoptosis surgery.
References 1. Yuzuriha S, Matsuo K, Kushima H. An anatomical structure which results in puffiness of the upper eyelid and a narrow palpebral fissure in the Mongoloid eye. Br J Plast Surg 2000; 53:466—72. 2. Hwang K, Kim DJ, Chung RS, et al. An anatomical study of the junction of the orbital septum and the levator aponeurosis in orientals. Br J Plast Surg 1998;51:594—8. 3. Anderson RL, Jordan DR, Dutton JJ. Whitnall’s sling for poor function ptosis. Arch Ophthalmol 1990;108:1628—32. 4. Ra K. Congenital blepharoptosis (Whitnall’s ligament sling). In: Maruo T, editor. Practical ophthalmology 19. Treatment and surgery of the outer ocular area. Tokyo: Bunkodo; 1995. p. 66—9. 5. Kubota N. Blepharoptosis. Tokyo: Bunkodo; 2000. p. 133.
Hirohiko Kakizakia, Masahiro Zakoa, Takashi Nakanob, Masayoshi Iwakia, Hidenori Mitoc a Department of OphathalmologyAichi Medical University, Nagakute-cho, Aichi-gun, 480-1195 Aichi-ken, Japan b Department of Anatomy, Aichi Medical University, Nagakute-cho, Aichi-gun, 480-1195 Aichi-ken, Japan
Short reports and correspondence c
Ide Eye Hospital, 3-6-12 Kasumi-cho, 990-0039 Yamagata, Japan
doi:10.1016/j.bjps.2003.12.001
A possible new way of managing breast implant rippling using an autogenous fascia lata patch Palpable, and sometimes visible ‘lumpiness’ known as ‘rippling’ seems to be a fairly frequent observation associated with textured surface silicone breast implants placed in a sub-glandular prepectoral muscle pocket. It is probably the result of several factors including reduced capsular production, lack of substantial subcutaneous fat, and the natural tendency of these implants to form folds or ridges in a dependent position. A recent study related to Trilucent breast implant patients indicated an occurrence in 60% of studied cases so the problem is not necessarily related to the implant filler.1 It has been suggested that undue folding of an implant shell can produce an area of mechanical weakening and this may increase the chance of implant filler leakage.2,3 The senior author has tried several methods and also sought advice from experienced breast surgeons regarding management. Possible ways include changing the implant position to submuscular pockets or changing the size or nature of the implant. None of these methods appeared to give a consistently good result. A possible solution to the problem, which we believe has not been tried before (to the best of our knowledge), is to use a fascia lata patch either
Figure 1 This shows site of prominent edge of silicon implant (arrow) and surrounding surface markings of proposed placement fascial patch. The old inframammary scar is also marked.
Short reports and correspondence
Figure 2 The fascial patch obtained from the lateral aspect of the left thigh and donor site before closure.
within or on the outside surface of the area of the capsule where the problem exists. After careful discussion with a suitable patient, who while happy with the overall result of her silicon breast implants (inserted into pre-pectoral pockets), was concerned about a visible edge of implant on the medial aspect of her right breast (Fig. 1), it was decided to use an autogenous fascial strip to patch the area concerned. She was made fully aware of the possible donor scar on her thigh and given no promise that this new technique would work. The procedure was carried out under general anaesthetic, the fascial patch (Fig. 2) being inserted through the original sub-mammary approach while the implant was temporarily removed to allow access to the inner aspect of the capsule in the area where the rippling occurred. The fascial patch was then carefully sutured in place using 5/0 vicryl sutures. The implant was washed in Betadine solution and replaced. Antibiotic cover was given. There have been no postoperative problems and 8 months after the surgery,
Figure 3 The healed donor site scar 8 months after surgery.
373
Figure 4 The right breast at 8 months with pressure applied to breast implant from above showing no visible rippling in operated area.
the donor area scar is virtually invisible (Fig. 3) and the rippling area is no longer visible or palpable (Fig. 4). On the basis of this, and because the patient was pleased, further fascia lata patching has been performed to try to correct two further areas of rippling in the left sub-mammary fold (Fig. 5). In this situation the fascial patch was able to be placed on the outside of the capsule without necessitating removal of the implant within (Fig. 6). The early results of this appear to be encouraging. It may be the case that the use of synthetic mesh or similar material could equally well be used though the possibility of infection may be higher. The use of a pectoralis major ‘trapdoor flap’ for similar deformities has also been described recently but involves slightly more extensive surgery and may therefore be riskier.4
Figure 5 The left breast preoperatively showing two areas of palpable rippling in the inframammary fold and surface markings of proposed subcutaneous fascial patch to be placed over the exposed capsule.
374
Figure 6 This shows the fascial patch in place just prior to closure of the wound.
References 1. McGregor JC. Trilucent breast implant—a personal review of the current controversies (May 1999). Scot Med J 2000;45: 176—9. 2. Rizkalla M, Duncan C, Mathews RN. Trilucent breast implants: a 3 year series. Br J Plast Surg 2001;54:125—7. 3. McGregor JC, Brown DT. Observations on a consecutive series of patients who have had Trilucent breast implants removed as recommended by the MDA Hazard Notice (May 2000). Br J Plast Surg 2002;55:231—4. 4. Collis N, Platt AJ, Batchelor AG. Pectoralis major ‘Trapdoor’ flap for silicone breast implant medial knuckle deformities. Plast Reconstr Surg 2001;108:2133—5.
John C. McGregor, Hilal Bahia Plastic Surgery Department, St John’s Hospital at Howden, Howden Road West, Livingston, West Lothian, Edinburgh, Scotland EH54 6PP, UK doi:10.1016/j.bjps.2003.11.028
Short reports and correspondence
We have, therefore, devised a facial model that can be used to demonstrate and teach such techniques. The requirement of such a model is a realistic one with accurate facial landmarks and pliable surface that could be incised, transposed and stitched. The facial model was made in our prosthetic department (Fig. 1). An impression of a skull was first taken and poured in acrylic to create the base of the model. Then, a wax pattern of the face was carved complete with various skin lesions on top of the skull base. This formed the basis of the facial mould, where a soft silicone rubber was used to simulate subcutaneous tissue and a separate layer of silicone was used to simulate skin. We used the model to teach our new SHOs (total of 20) who had joined our unit. A formal workshop session that included didactic lectures was organized before they were given the responsibilities of assisting minor procedures in the day surgery unit. The basic principles of z-plasty and rhomboid flaps were taught, and the planning and execution of these were practiced on the models we devised. Being an in house programme, slow or difficult learners were easily identified, and their weakness addressed. All 20 participants felt that such a teaching session was invaluable in further improving their knowledge of flap planning, and all felt much more confident in using them should such necessity arise. In the current climate of endemic virus disease in animals, the recent human tissue retention censure, and increasing patient expectation, we believe that this is an effective method of teaching fundamental plastic surgery skills. We are hoping to extend our teaching of other local flaps on this model in the future. Note: This article had been presented in the following meetings: BAPS winter meeting, 28 – 30th November 2001,
A non-animal facial model for teaching local flaps to trainees The excision of lesions on the face and skin coverage of the resulting defects often requires local flaps. The planning and execution of these procedures are crucial to their success. It is, therefore, important for the trainees to understand the mechanics of local transposition flap and zplasty in a three-dimensional sense, which would be difficult to learn from the textbooks alone. These procedures are often carried out in a day surgery unit under local anaesthesia, and teaching of them is often awkward and takes valuable clinical time.
Figure 1 The facial model-on the right is the initial skull base, and on the left, the finished model with pliable surface and realistic anatomical landmarks.