Ultrasound-assisted breast reduction

Published on 23/05/2015 by admin

Filed under Plastic Reconstructive Surgery

Last modified 23/05/2015

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Chapter 8 Ultrasound-assisted breast reduction

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Introduction

Ultrasound energy has been applied to the adipose component of the breast parenchyma in cases of breast hypertrophy in order to reduce the volume of the breast mold.

As is known, ultrasound energy was initially used by Zocchi16 to emulsify fat. A special instrument, composed of an ultrasound generator, a crystal piezoelectric transducer, and a titanium probe transmitter was utilized to target adipocyte cells. This new technology was first applied to body fat to emulsify only fat cells while sparing the other supporting vascular and connective components of the cutaneous vascular network. More recently, Goes,7 Zocchi,16 Benelli8 and di Giuseppe,912 have started to apply this technology to breast tissue to achieve breast reduction and correction of mild to medium-degree breast ptosis.

Preoperative Preparation

Surgical Technique

Skin Incisions

The operation begins with the introduction of the skin protector placed at the incision site, normally placed 1 cm below the inframammary crease. Another incision is normally placed at the axilla, at the same length.

A further incision is placed around the areola margin, and is utilized to address the superficial layers of the upper quadrants, if required. This skin port is designed to protect against friction injuries by the probe during its continuous movement.

The fatty breast is emulsified in the lateral and medial compartments, the upper quadrants and the inferior aspect of the periareolar area. All the periareolar area, where most of the glandular tissue is localized (5 cm circumference around the nipple–areola complex), is preserved.

The deep portion is also emulsified, allowing the breast mold to regain a natural shape through upward rotation, thus increasing the elevation from its initial position, taken from the midclavicular notch. Up to 4 cm of elevation is obtained after proper reduction and stimulation to allow skin retraction and correction of the ptosis.

Two 1.5–2.0 cm stab incisions, one at the axillary line and the other 2 cm below the inframammary crease, are made to allow entrance of the titanium probe.

Through these incisions the surgeon can reach all the breast tissues, working in a criss-cross manner. Recently, the ultrasound device software has been upgraded to provide the same degree of cavitation with less power, which reduces the risk of friction injury and burn at the entrance site; this even allows discontinuing the use of the skin protector.

Probes

With existing technology, a solid probe is more efficacious than a hollow probe for cavitation, which is the physical phenomenon that allows fat fragmentation and destruction. Moreover, the level of ultrasound energy conveyed by a hollow probe is limited, and consequently the level of the cavitations obtained in the tissue is diminished.

The Vaser system (Sound Surgical Technologies, Denver, CO, USA) provides different sizes and lengths of solid titanium probes (Box 8.1) expressly designed to fulfill all purposes in body contouring, as well as being capable of emulsification through the cavitation effect produced by the ultrasound energy. The piezoelectric transducer transforms electric energy into “vibration energy”, thus allowing the solid titanium probe to emulsify the target fat cells.

The efficacy of these probes, which are narrower than the previous technologies available on the market, is connected to their design, as they are provided with rings (one, two, or three) at the tip of each probe. These rings have two special functions:

The number of rings to be chosen depends on the type of tissue: the most fibrotic is treated with one ring, the less dense tissue (pure fat ) with three rings.

These options are not purely an academic difference: the energy and the wavelength of each probe is selected for the target tissue, avoiding unnecessary extra power and wasted energy, which is a potential cause of secondary unwanted complications (already seen with previous technologies).

In breast reduction with pure Vaser, I prefer the 2.9 mm probe, with one ring, for deep layers, and the 3.7 mm, with three rings, for superficial layers.