Plastics 1

Question 1

Breast Reduction Symptoms

5

Answer 1

1. Neck, back, and shoulder pain
2. Headaches
3. Difficulty sleeping
4. Intertrigo
5. Difficulty exercising

Question 2

Physical Findings

for breast reduction 4

Answer 2

1. Normal nipple position at 21 cm from sternal notch
2. Can be 40 cm or greater
3. Deep shoulder grooves
4. Intertrigo

Question 3

Workup for BR? 5

Answer 3

1. Screen for medical illnesses
2. Good diabetic control
3. Smokers take a hike
4. Usual screens for medical illness
5. Mammogram

Question 4

Indications for BR

4

Answer 4

1. Lots of variation in insurance coverage
2. Most require resections of 350-500 grams of tissue per breast
3. Primary care referral, orthopedics, chiropractor
4. BMI may be an issue

Question 5

Patient Education

4

Answer 5

1. Patients must understand that there is a trade-off of a better size and shape for scars
2. Nipple sensitivity may be effected
3. Breast feeding is 50 50
4. Breasts can get bigger again with weight gain

Question 6

Procedure for BR:

1. Takes about how long?
2. Inpatient or Outpatient?
3. Anesthetic?
4. What is needed for a few days?
5. What is the shape like initially and then what does it do after?

Answer 6

1. Takes about 3 hours
2. Outpatient
3. General anesthesia
4. Drainage for a couple of days
5. Shape boxy at first, later softens

Question 7

Complications for BR?

5

Answer 7

1. Healing problems–skin loss
2. Nipple problems–loss, sensitivity
3. Breast feeding problems
4. Scars
5. Fat necrosis

Question 8

Post Mastectomy Reconstruction: Who may need this?

5

Answer 8

1. Breast Cancer
2. BRCA Gene
3. Severe Fibrocystic Disease
4. Breast never develops
5. Trauma, cosmetic disaster

Question 9

Considerations in Reconstruction

6

Answer 9

1. Do it or don’t do it
2. Immediate or delayed
3. Chances of chemo or radiation
4. Tissue reconstruction or implant based
5. Body type
6. How much do you want to put into breast reconstruction?

Question 10

For reduction of gynectomastia what do you need to do before surgery?

Answer 10

testicular exam

Question 11

Immediate versus Delayed
1. Advanatges? 2

2. Unexpected findings could do what?
3. Slightly higher risk of what?

Answer 11

1. • Immediate reconstruction avoids the postmastectomy defect
   • Consolidates operations
2. compromise reconstruction (radiation)
3. infection

Question 12

Delayed Reconstruction
1. Advantages? 2

2. Disadvanatges? 2

Answer 12

1. • Chance to let therapeutic options get sorted out
   • lower risk of infection
2. • Skin flaps are delayed and thus a little tougher
   • More tissue contraction though

Question 13

Assessing Chances of Chemo or Radiation

4

Answer 13

1. Size of tumor
2. Skin changes
3. Presence of nodes
4. Histology

Question 14

Single versus Double
1. What leans toward bilateral?

2. What may influence decision? 2
3. Things to take into consideration? 2

Answer 14

1. BRCA gene or malignant family history
2. DCIS or lobular
3. • Symmetry
   • Long term risks

Question 15

Body Type

Considerations?

Answer 15

1. Slim versus non slim
2. Available tissue for reconstruction
3. History of other incisions or procedures
4. Radiation history

Question 16

Preop Visit

6

Answer 16

1. Establish rapport–very charged subject
2. Gentle education
3. Stress the positive
4. Realistic expectations
5. Exam and measurements
6. Careful history

Question 17

Expander Implant Method
1. Procedure involves placing a what where?

2. HOw long after surgery begin expanding muscle and skin?
   - Adjust expansion to desired size
3. Replace expanders with what?

Answer 17

1. tissue expander under the pectoral muscle and an acellular dermal matrix sling (Alloderm)
2. Three weeks
3. implants

Question 18

Latissimus Dorsi Flap

1. Used when?
2. Adds what to the reconstruction?
3. Advantages? 3
4. Where is the scar?
5. Drainage from where?

Answer 18

1. Useful when radiation is anticipated
2. Adds skin and muscle volume to reconstruction
3. • Hearty Flap,
   • rarely dies,
   • usually donor site not a problem
4. Scar on back

5 .Drainage from harvest site

Question 19

What are the different kinds of tissue flaps?

5

Answer 19

1. TRAM
2. DIEP
3. SGAP
4. SIEP
5. Abdominal and sometimes buttock tissue flaps used for breast reconstruction

Question 20

Tissue Flaps

1. Advanatge? 1
2. Disadvanatges? 4

Answer 20

1. • Advantage of no implants
2. • Donor site defects can be a problem
   • Flaps can die or lose volume
   • Reimbursement is poor
   • Requires microsurgical team and instruments, lots of time

Question 21

Modifying the Other Breast
1. Other breast may be too big, too small, too saggy: What are our options for this? 3

2. What procedures are covered by law?

Answer 21

1. Options are
   - breast reduction,
   - breast augmentation,
   - breast lift
2. Symmetry procedures are covered by law

Question 22

Typical areas for excess skin? 5

Answer 22

Typical areas are

1. arms,
2. neck,
3. breasts,
4. abdomen,
5. thighs

Question 23

What do you need to know:
before body contouring?
4

Answer 23

1. Good to have stable weight for best results
2. Nutritional and physical condition need to be good
3. Lots of inches to heal, so proteins need to be up and the cardiovascular output good
4. Good medical condition otherwise—this is elective surgery and has to go well

Question 24

Complications

of body contouring? 5

Answer 24

1. Don’t get talked into doing too much at one time
2. Complications are heavily related to length of procedure
3. I don’t go over four hours
4. Bleeding and infection aren’t common, maybe 5% if conservative approach used
5. Small wound breakdowns are not uncommon

Question 25

Abdominoplasty/Panniculectomy 1. Incision where? 2. Takes how long? 3. Blood loss? 4. Pain control? 5. Sutures? 6. Scars take how long to fade?

Answer 25

1. Incision from hip to hip 2. Takes about 2-3 hours 3. Usually little blood loss 4. We use long acting injectable pain killers 5. No outside stitches usually 6. Scars take 6-12 months to fade

Question 26

Arm Reduction/Brachioplasty 1. Incision from where? 2. Sometimes just where? 3. Scars? 4. Healing?

Answer 26

1. Incision from elbow to armpit 2. Sometimes just in armpit 3. Scars aren’t the greatest 4. Can be slow healing

Question 27

Breast lift 1. Incsions where? 3 2. Takes how long? 3. Usually back to work when? 4. Sometimes some open areas that take how long to heal? 5. Satisfaction rate?

Answer 27

1. Incisions around areola, vertical from the areola, and in the fold under the breast 2. Takes about 2.25 hours 3. Usually back to work in 1-2 weeks 4. Sometimes some open areas that heal in 2-3 weeks 5. Very high satisfaction rate

Question 28

Thigh lift 1. Incision where? 2. What dictates the incision? 3. Higher rate of what? 4. When should we decide to do this surgery?

Answer 28

1. Incision either down the inside of the thigh or in the groin 2. Amount of excess thigh skin dictates the incision 3. Higher rate of wound breakdown 4. Patients are happy if they have a lot of excess skin - Minor excess—probably not worth it