dr kamal murdia -case planing in cosmetic surgery 2

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dr kamal murdia - case planing in cosmetic surgery & gynaecomastia.

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Case planning in Plastic Surgery & Gynaecomastia Dr. kamal murdia Mbbs, MS(surgey), M.Ch (plastic surgery) Mbacs (London, UK) Plastic cosmetic surgeon

Basic definitions : 

Basic definitions Plastic surgery (General term ) (from Greek , plastikos - to shape) Subnormal to normal Restorative surgery Reconstructive surgery Normal to better Cosmetic surgery

Plastic surgery - classification : 

Plastic surgery - classification General plastic surgery Reconstructive surgery Cleft lip-palate surgery Burns –acute & late management Microsurgery Hand surgery Facio - maxillary surgery Cranio facial surgery Cosmetic surgery

Aims of plastic surgery : 

Aims of plastic surgery Improve body function Improve appearance X can become X+ X cannot become Y A mango tree cannot become a banyan tree

Basic principles : 

Basic principles Defect- Apparent / True true defect always bigger than apparent Deformity Planning in reverse (Mock drill) Barter principle- paul is robbed to pay peter provided paul can afford it.

Slide 6: 

What is an Ideal attractive face in plastic surgery?

What is an ideal face? : 

What is an ideal face? Ideal Face is- oval,5L/3B , 1/8 th of body Face has 3 equal divisions = 3 nose Nose is all triangles- front /side/ down Distance bet”n two eyes equal=nose thumb = nose = ear in length Pupil width = mouth width Upper lower lip ratio is 1/1.5 Eye slant 2 degree up laterally

Role of photography : 

Role of photography One picture is worth 10 thousand words … Chinese proverb What X- ray is to d radiologist, photography is to the plastic surgeon Photographs - Case Planning - Comparison (before / after) - medico-legal reasons - patient education - scientific discussion

Case planning in plastic surg.1 : 

Case planning in plastic surg.1 Planning, preparation and precise execution.(3 P s) Let the patient earn his surgery- don’t suggest, unless asked. Listen more – speak half (u have 2 ears) The operation is a project (art work) Nothing is taken to chance, its like airlines no precaution is unnecessary

Case planning in plastic surg.2 : 

Case planning in plastic surg.2 Plan your work, work your plan Educate the patient sensibly, be clear about expected results. Under promise rather than over, Take informed consent. Do a mental mock drill Sometimes 80% success is better than 100% failure The secret of good result is thoroughness, Assess d patients I.Q in terms of compliance Try to make plastic operation a pleasant journey for d patient.

Cosmetic surgery : 

Cosmetic surgery * Cosmetic surgery: (kosmein-to adorn) *Highly sophisticated and demanding *Improves quality of life, self-image. *Research shows imp. Of LOOKS Every personality has a face… changing the face also changes the personality

Latest - Stem cells / face transplant collagen / botox / thread face lift etc : 

Latest - Stem cells / face transplant collagen / botox / thread face lift etc

The Jack of cosmetic surgery> 36 cosmetic operationsmax operations in one pt. > 100 : 

The Jack of cosmetic surgery> 36 cosmetic operationsmax operations in one pt. > 100

Part 2Part 2 cosmetic surgery for Gynaecomastia : 

Part 2Part 2 cosmetic surgery for Gynaecomastia

Slide 16: 

introduction GYNAECOMASTIA The pain behind d shirt

Pain behind the shirt : 

Pain behind the shirt Gynaecomastia is the story of millions of men world wide who suffer only in silence, unless treated....

Gynae-female Mastia-breast : 

Gynae-female Mastia-breast Female like breast in a male Manchester (reverse of gynaecomastia) Boobs surgery Moobs surgery 4th most common cosmetic surgery in males (hair transplant ,eyelid, nose, Gynaecomastia, liposuction)

Types of gynaecomastia : 

Types of gynaecomastia Class 1- only breast tissue Class 2-breast tissue + fatty tissue Class3- only fatty tissue also called (pseudogynaecomastia)

basic etiology : 

basic etiology Idiopathic physiological Drugs Disturbed hormonal balance e.g.. Liver malfunctions / various syndromes Also ABCDEF…I basic patho physiology seems to be some form of disturbed hormonal balance

Drugs causing gynaecomastia : 

Drugs causing gynaecomastia ICDS-Isoniazid cimetidine, digoxin, spirolactone, reserpine Diazepam, metronidazole Amphetamines Tricyclic antidepressants… many more Drug addicts

Disease’s n syndrome’s : 

Disease’s n syndrome’s Klienfelter’s syndrome Gilberts syndrome Hepatomas Liver d’s, hepatoma’s Testicular tumors, hypogonadism Hyperthyroidism Disturbed hormonal balance

Gynaecomastia work up : 

Gynaecomastia work up History Onset Bilateral/unilateral Pain Change in size Nipple discharge/ mumps in childhood Drugs/medications Personal history Family history

Examination : 

Examination Complete Physical Exam Gynaecomastia related Exam. Look for signs and sx of liver and kidney disease Evaluate for hyperthyroidism, eg. Weight loss, tachycardia, goiter, tremor, or exophthalmoses. Seek for signs and sx that may suggest hypogonadism, eg. Impotence, decreased libido, strenght, and change in testicular size. Check for abdominal mass and testicular mass. Careful breast exam.

Work-up : 

Work-up #(hormonal study) BMP, LFT’s, TSH, LH, FSH, hCG, Prolactin, Estradiol, Testosterone, Androstenedione #Ultra Sound and mammogram for any eccentric or discrete mass.

Physical Exam : 

Physical Exam Breasts: diagnosis is mostly visual Visually enlarged breast. Enlarged breast tissue with rubbery amorphous mass below nipple, no discrete masses. No skin discolorations, dimpling, nipple retraction or discharge. Areola may be enlarged like female also. Rule out male breast cancer(1 %), if suspected

Treatment Options : 

Treatment Options Watchful Waiting Medications tamoxiphen, testosterone, danazol, clomiphen Surgery – mainstay of Tt.

Treatments : 

Treatments Watchful waiting In healthy adolescent with normal PE and genital exam, reevaluate in 6 months Gynecomastia attributed to a medication or known cause should be managed and patient reassessed after stopping medication

Surgical management : 

Surgical management Patient is given all options to rule out medical solutions.. Once formed true gynaecomastia will not resolve without removal .. No recurrence after complete excision. Cosmetic problem best addressed by cosmetic surgery.

Surgical approaches : 

Surgical approaches Options Include # Gillard Thomson's approach (x) # Circum areolar approach # Doughnut mastopexy approach (new versatile technique) # Liposuction alone/ or as adjunct # Laser and endoscopic techniques (if facilities exist)

Gillard Thompson's XXX : 

Gillard Thompson's XXX Old days technique (obsolete) adv: wide access but ugly scar over chest One cosmetic problem replaced by another (scar over chest) Most cruel joke a surgeon can do to a pt. in today's.. Era almost obsolete

Liposuction for gynaecomastia : 

Liposuction for gynaecomastia Liposuction: lipo-fat . Breast tissue is glandular-rubbery, lipo canula cannot cut it away Liposuction alone for fatty gynaecomastia Lipo can be as adjunct to circum areolar approach/ other excision techniques

Liposuction-fat : 

Liposuction-fat

Peri - areolar anddoughnut incision approach : 

Peri - areolar anddoughnut incision approach

Circum areolar approach : 

Circum areolar approach Advantage: scar in half of areola, cosmetically pleasing, pt. very satisfied disadvantage: key hole surgery, needs expertise, control of bleeding , operation is done more with feel than direct vision Liposuction usually added for wider class 2 gynaecomastia Leave 1cm tissue below nipple - imp

Circum- areolar approach : 

Circum- areolar approach

Before and After : 

Before and After

Before and After : 

Before and After

Circum- areolar approachBefore and After : 

Circum- areolar approachBefore and After

Doughnut mastopexy approachnew technique : 

Doughnut mastopexy approachnew technique Wide access / Scars around areola so.. Cosmetically like circum areolar approach Surgeon more comfortable Wide application of this technique for gynaecomastia, areola balancing, mastopexy and breast lumps in females especially in upper breast for surgeons

Case study using new technique : 

Case study using new technique 27 year old , student, non smoker, well built and nourished, with h/o fullness in the breast area for 10 years Work up- no h/o drugs ,lab tests ,blood gp, hormonal study, USG, informed consent, counseling, testes – mild atrophy diagnosis- bilateral idiopathic (class 2) moderate to severe gynaecomastia Plan- doughnut incision approach

Doughnut incision approach : 

Doughnut incision approach

Pre operative markings : 

Pre operative markings

Right Side view : 

Right Side view

Left side view : 

Left side view

Acceptable peri areolar scar : 

Acceptable peri areolar scar

Post op : 

Post op Drains removed after 3 days. Dressings over 10-12 days. Compression dressing after surgery to continue up to 3 months. 4 wks pt is presentable / free of major pain 6 wks - 6 months- best results

Dedicated to those patients : 

Dedicated to those patients Gynaecomastia surgery without scars is the most noble act a surgeon can do to cure the immense pain in patients heart. This presentation is dedicated to many such patients…

Video on : 

Video on Gynaecomastectomy by the doughnut mastopexy approach Thanks

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