Reconstructive microsurgery

What is microsurgical free tissue transfer ?

In modern Plastic and Reconstructive surgery, free tissue transfer is used to

a)close or fill soft tissue defects following trauma, burns or tumor resection
b)Reconstruct organs (breast reconstruction following cancer or congenital anomalies, tongue reconstruction) also f.i. phalloplasty in transgender surgery
c)Reconstruct muscle function (functional muscle transfer following facial palsy)
d)Reimplantation of severed extremities

When is microsurgical soft tissue transfer carried out ?

Guidelines are the so called “ladder of repair”, which recommends that surgeons should always endeveaour to first embark on any procedure that is easier and more straightforward than microsurgical free tissue transfer.
The  “ladder of repair” has to be followed under consideration of comparable results, which have to be adequate or not inferior with view to form , function and aesthetic outcome.
In other words, sometimes a solution using local, pedicled tissue transfer may be possible , but in the long-term the patient may benefit more from the more extensive solution of microsurgical free tissue transfer.

In summary, the expected result bot with view to form and function have to be superior when microsurgical free tissue transfer is used, as compared to local, pedicled transfer.

Who is suitable ?

Generally everybody with a reasonable indication. Medically, microsurgical free tissue transfer is an extensive operation. Therefore patients must be fit to undergo such extensive surgery. This is normally a mutual decision between anestesist and surgeon.

What are the risks ?

Whenever free tissue is harvested for transfer as a so called “free flap”, there is a certain donor-site morbidity.
Ideally this is only a scar.

Some donor site scars are better and easier to hide than others, this depends on the case.
If muscle is harvested, there maybe functional deficits, which are held as small as possible by selecting muscle tissue which anatomically results in small donor site defects.
There is always the risk of flap loss, this may be technical (failure of anastomisis of vessel), or patient related ( smoker, small vessel disease, extended trauma zone, irradiation f.e. in breast reconstruction). There is no absolute percentage since preconditions depend on very individual factors.
A surgeon who performs many “free flaps” f.e. to cover lower extremity defects in acute trauma patients will lose more flaps than a surgeon performing rather selective breast reconstruction in well-conditioned patients.

Smoking is a key risk factor, especially in microsurgical breast reconstruction. Excessive smokers face a high risk of complete or partial flap failure. Long term smoking may leave vessels irreversably damaged, which may make any microsurgical procedure very hazardous.

What are the benefits ?

Microsurgical free tissue transfer enables surgeons to select optimum tissue for optimum form and function. In the ideal case, the donor site morbidity adds up to an aesthetic benefit for the patient.
An example is free tissue transfer harvesting tissue from the abdomen (TRAM, DIEP flaps) which is used for breast reconstruction.
The donor site closure results in a situation very comparable to an abdominoplasty, therefore the patient seeking breast reconstruction via this operation has actually got an aesthetic benefit from harvesting the flap.

This results in very high satisfaction rates with this kind of flap in breast reconstruction.

Other common options for harvest of tissue for microsurgical transfer in breast reconstruction are the thighs and the buttocks.

These breast reconstruction are mainly used when there is not enough tissue excess available to harvest as a flap.

Is it true that microsurgical breast reconstruction needs to be carried out in multiple stages ?

Normally yes. Again there is a certain range of opinion as to whether to perform an additional, adjusting procedure on the contralateral “healthy” breast, frequently a breats uplift. I mostly prefer to leave that for a second step because the results are more predictable once the reconstructed breats has fully settled.

Reconstruction in one session is fully acceptable, but from my view and experience at the price of a higher revision rate for the adjusting breast uplift.

Also, there may be requirement for additional nipple reconstruction in an additional session.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:

Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

How to prevent breast cancer

Unfortunately, you cannot prevent breast cancer. What you can do is make sure that should it occur, you detect at the earliest possible stage when it is surgically curable. The earlier treatment is initiated, the better the prognosis
Most people who are vulnerable to this disease should be happy to learn that they can prevent the development of this disease.There strong threads of family history.
Should your family history for breast cancer be positive you should watch out to do the following steps.
Here are some measures you can take in order to prevent breast cancer:
1.Restrict your alcohol consumption
2.Control your weight
3.Move. A physically active lifestyle has a role in preventing the disease. Try to “run away from cancer”
4.Restrict smoking
5. Most importantly: Self examination. Your physician can assist you instructing you how to do this. Early detection is the best cure.

Read more about breast reconstruction here.

Dr.Alexander Amir Aslani, MD, EBOPRAS

Hospital:
Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Dr.Ramin  Pakzad, Consultant gynecologist , Director, Clinica Banus, Marbella, Malaga Spain, Clinica GynBanus Marbella

Can abdominoplasty and hernia repair be done in one operation ?

They can and they normally should.

A lot depends on the extent of the hernia, and BMI guidelines for repairing larger hernias together with a tummy tuck a normally somewhat stricter.

Especially in patients seeking abdominoplasty  after bariatric surgery (gastric band) it is not uncommon to also find hernias of varying sizes, mostly umbilical hernias which can be repaired together with the abdominoplasty (tummy tuck) without problems.

In some cases, and larger hernias, I use the deepithelialised dermis of the resected skin as a kind of natural mesh (so called coriumplasty) to reinforce the abdominal wall.

If hernia repair and abdominoplasty is done together, this may lead to a slightly raised risk of serome (fluid collection). This is not a grave compliacation but nevertheless happens more often after beformentioned combination.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Breast reconstruction with tissue from the buttocks

….is labelled I-GAP or S-GAP-flap in Plastic surgery literature depending on the orientation of the skin island.

The technique is a so called “free flap”,meaning that a block of skin and fat are dissected together with their feeding vessels, and those vessels reattached to a donor vessel, next to the sternum or in the axilla, using microsurgical techniques. This is essential because such a large block of tissue would not nor survive without adequate tissue perfusion.

It is mostly applied in very thin breast cancer patients with mastectomy(amputation of the breast) who do not have enough donor tissue on the  abdomen for a similar breast cancer reconstruction procedure. In breast surgery reconstruction, flaps from the abdomen remain first choice normally, nevertheless they may not be possible very thin patients. In these cases breast reconstruction options, should autologous tissue be desired, are buttock free flaps or pedicled muscle flaps from the back, the so-called latissimus dorsi flap, which may, or may not , be combined with an implant.

Read more about breast reconstruction here.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Breastfeeding after breast augmentation?

Is not normally a problem after straightforward breast enlargement, since the majority of techniques does not interfere with the breat tissue itself, but works underneath the breast  muscle or the breast gland.

Exception applies to breast augmentationthrough with an incision through the nipple, which may necessitate dissection through the breast gland. breast augmentation or breast enlargement through a nipple incision is particurlarly popular in Spain

But even with this  breast augmentation technique it is not normally a problem.

Read more about  breast augmentation here.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Is mammography necessary before aesthetic breast surgery ?

The decision depends also on the preference of the individual surgeon; it is not absolute necessary.

In our Cirumed specialist group , we solved the question in the way that a highly qualified gynecologist furnishes patients before breast enlargement, breast uplift or a breast reduction with a so-called 4-D- ultrasound.

Dr.Ramin Pakzad, extremely experienced in the field of  breast disease and especially in the area of the breast cancer treatment and is our partner in these cases and since I can absolutely depend on the accuracy of his assessments, I prefer the ultrasound diagnostics done by him.

That provides me and my patient the security of a thorough preoperative diagnostics and saves young patients partly extensive -x-ray exposure.

A possible history of breast cancer within the family will also endorse the indication for preoperative breast screening. There are different approaches to breast screening before aesthetic surgery like breast augmentation, but we regard this one as best. Suspective findings in the age group seeking for breast augmentation are lessthan 0.5%, but nevertheless they occur.

Although the chance of a positive finding is very low especially in young patients, who are the majority of patients requesting breast augmentation, it still merits the effort. “If we are able to spot 1:1000 breast cancer cases just by the coincidence of screening for a breast augmentation operation, it was totally worth it”, says Dr.Pakzad, who teams up with Dr.Aslani and two oncologists forming a breats cancer unit in the Malaga area.

The 4-D-ultrasound technique does also play a significant role in spotting ruptured implants after breast augmentation.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Dr.Ramin Pakzad Pakzad, Consultant gynecologist , Director, Clinica Banus, Marbella, Malaga Spain, Clinica GynBanus Marbella

Incision placement in breast enlargement

What is the perfect incision placement for breast augmentation ?

Well, there is none. There is different options, the most popular ones being

1.The armpit. This is a very elegant approach, implying the the breast implant is brought in through an incision in the armpit. I personally have used it for quite a while and on very special patient request I still do, but a few points have to be taken into account. Firstly, the skin of the armpit can impossibly be made sterile, so there is a higher risk of infection, secondly, I have had patients who, after axilar breast enlargement, reported certain restrictions in movement to me. This has to be taken into account.

2.The nipple. In planning breast enlargement, I guess half of the patient is very keen to have their incision through the nipple and half are terrified just by the thought of that. there are really very different views on that. Since I personally only use cohesive gel implants, a certain size of the nipple is necessar. This does not have to be excessive but should be sufficient to accommodate a 3cm cut along the lower nipple border.The scar will fade with any of the three incisions mentioned, but probably quickest here.

3.The inframammary crease. Great advantage of this incision in breast enlargement is that it heralds the smallest risk of infection, and the inframammary fold can be planned very accurately.Length of incision is normally around 3-4 cm.

There are some exotic variations like endoscopic approaches through the  bellybutton just to name one example, who I feel make restricted sense from the physiological point of view since when placing a foreign body large dissection pathes make the procedure somewhat more risky.

In Spain, breast augmentation remains the most popular aesthetic surgical procedure.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es