Plastic Surgery, Volume Five: Breast (Fourth Edition): Cẩm nang Toàn diện Phẫu thuật Thẩm mỹ và Tái tạo Vú – Maurice Y. Nahabedian & Peter C. Neligan

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SECTION I
CHAPTER 6 • Mastopexy options and techniques
Fig. 6.11  (A–D) Preoperative and postoperative views of a tuberous breast correction that utilized the author’s
preferred technique of breast augmentation, radial scoring, small volume retroareolar glandular tissue resection,
and circumareolar mastopexies.
A
B
C
D
Postoperative care for
mastopexy patients
The following is the author’s preferred postoperative
care procedure. After surgery, the patient is encouraged
to perform early ambulation and deep breathing exer­
cises. A gentle range of motion exercises are also encour­
aged, but the patient is asked to avoid strenuous activity
or lifting more than a few pounds. If drains are placed,
they are usually removed once outputs are <25 cc per
day. Light, non-impact exercise can be resumed at 4
weeks, and easing into a full exercise routine can be
started 6 weeks after surgery. The patient is kept in a
soft, non-underwire bra after surgery and can use ice
for comfort as needed. Underwire bras can be resumed
at 4–6 months, if comfortable.
Risks and complications
The risk of a major complication with mastopexy, if
performed judiciously, is fairly low. An extensive form
including all foreseeable risks should be read and signed
by the patient after a discussion with her surgeon and
an opportunity to ask any final questions. There are a
few risks more common to mastopexy surgery, which
should be discussed in more detail with patients. These
are noted below.
Scarring
As discussed earlier, acquisition of new scars on the
breasts is the primary trade-off for mastopexy surgery.
In some cases, genetics, excessive skin tension, or spit­
ting sutures can exacerbate the degree of scar thickness
or scar spreading. Patients must understand that sub­
optimal scarring is a possibility and should be prepared
for this issue. Thankfully, scarring can often be reduced
with steroid injections, silicone sheeting, scar massage,
time, and newer wound dressings designed to reduce
skin tension at the scar sites.
Wound healing issues
Small wounds can be common along the incisions (most
often near the lower portion of the vertical scar or at the

105
Risks and complications
Fig. 6.12  (A–F) Author’s preferred technique for circumareolar mastopexy. The area for mastopexy is marked (approximately 1 cm longer in height than width), scored, and
de-epithelialized, and cautery is used for hemostasis and to contract the dermis. Imbrication of the dermis is performed with 3.0 PDS suture in deep running fashion.
Stabilization is further secured with 3.0 Prolene in deep “subcuticular” fashion. True subcuticular closure is then performed with 4.0 Monocryl.
A
B
C
D
E
F

106
SECTION I
CHAPTER 6 • Mastopexy options and techniques
that caused ptosis in the first place (such as weak skin
or attenuated Cooper’s ligaments) will remain after
surgery. As with asymmetry issues, recurrent ptosis can
be improved but may require re-tightening via the
patient’s old incisions.
Nipple malposition
Significant nipple malposition can generally be avoided
with careful planning and proper preoperative marking.
Nipples should generally be situated on the center of
the breast near the point of maximum projection. This
usually coincides with the point of the IMF transposi­
tion on the breast, but it may be somewhat higher or
lower. Making reference marks preoperatively, tailor-
tacking the breasts, and examining patients in the seated
position is important because it can allow on-table
adjustments if the nipples are clearly too low or too
high. If nipple malposition is noted after surgery, the
scar tissue should be given time to mature and adjust­
ments can be made. Re-elevation of low nipples gener­
ally requires repeating a circumvertical skin resection
and closure. Lowering of areolas in the case of an exces­
sively long nipple to IMF distance can be performed by
taking out a transverse segment of skin from the lower
breast in the inframammary region. If even further
lowering is needed, tissue expansion of the upper breast
or transposition of the nipple might be necessary;
however, this can create unacceptable scars of the upper
breast. Because of these issues, it is better to err on the
side of under-elevating the nipple as opposed to over-
elevating it when performing a mastopexy.
Dissatisfaction with shape and size
Once again, as noted earlier, mastopexy surgery is rela­
tively limited by the patient’s tissues and pre-existing
volume, and as a result, extensive preoperative selection
and management of patient expectations is critical for
success. The most common disappointment will be due
to a suboptimal degree of upper pole fullness. If this is
an issue for a patient, options include fat grafting to the
upper poles or placement of implants. Hopefully, if
proper preoperative discussions were held, the patient
will know this was a possibility and will be somewhat
prepared for such an ancillary procedure if necessary.
Conclusion
Mastopexy surgery can be a highly satisfying surgery
for patients with a relatively easy recovery and less
required maintenance than augmentation mastopexy.
Unlike augmentation mastopexy, the surgeon has much
less control of the breast volume and upper pole fullness
junction of the vertical and the areolar incisions, or the
vertical and inframammary incisions when applicable).
Wounds most commonly appear between weeks 3 and
6, unless there is an early issue due to poor blood supply.
Reducing suture burdens (particularly suture knots),
resecting appropriate amounts of skin, reducing tension
to surface wound closure via deep and long-lasting
sutures, being cautious about operating on patients
with medical conditions that affect wound healing (such
as diabetes), and strictly avoiding patients that are
active smokers can all help to reduce wounds. Most
wounds are small and will heal with dressing changes
over time. Occasionally, revision surgery is necessary.
Large wounds are uncommon, but can be challenging
to heal, and may require adjunctive measures such as
hyperbaric oxygen therapy.
Tissue necrosis
Tissue necrosis, including loss of a nipple areolar
complex or a skin flap, is an extremely rare but terrible
complication. Proper patient selection (healthy, non-
smoking, etc.) is the first step in avoiding this problem.
Leaving thick lateral flaps and a broad-based pedicle
also helps to reduce the risk of this problem. If ischemia
is noted on the table, options include releasing the
skin and re-checking the pedicle to ensure there is no
kinking in the blood supply. If the nipple is clearly de-
vascularized, an option is to convert to a free nipple
graft. This is a reasonable maneuver within the first
12 h. Other options during this time period and after
12 h include suture release to reduce tension, use of
nitropaste or leeches (in the case of venous congestion),
antibiotics, and possible hyperbaric oxygen. If a nipple
is lost, it is important to wait for the tissue to demarcate,
and nipple reconstruction techniques and tattooing can
be utilized to improve the final aesthetics.
Asymmetry
Some degree of postsurgical asymmetry is to be expected
after surgery, and patients undergoing mastopexy need
to understand this. Areola size, position, and shape can
vary mildly, and breasts can be affected by different
starting volumes and base widths. Breasts can also settle
differently over time with different degrees of recurrent
ptosis. In the case of more noticeable asymmetry, skin
adjustments can often be made under local anesthesia.
While this may not totally correct the asymmetry, patients
are generally happy with significant improvements.
Recurrent ptosis
As stated earlier, some degree of recurrent ptosis over
time is more a matter of “when” than “if”. The factors

107
Conclusion
to apply a relatively low number of straightforward
surgical techniques to correct an array of breast ptosis
problems. Complications can occur but are generally
rare and relatively minor when proper preoperative
planning and intraoperative execution is performed.
and they are fairly limited by the patient’s preoperative
anatomy and volume. Consequently, great care in
patient selection and management of expectations
should be taken prior to performing this surgery.
Although many techniques are available, it is possible
1. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg.
1976;3:193–203. This paper established the standard system for assessing
and classifying various types of breast ptosis.
3. Grolleau JL, Lanfrey E, Lavigne B, et al. Breast base anomalies:
treatment strategy for tuberous breasts, minor deformities, and
asymmetry. Plast Reconstr Surg. 1999;104:2040–2048. This publication
further expanded concepts of tuberous breast assessment and management
proposed by von Heimberg, et al.
4. von Heimburg D, Exner K, Kruft S, et al. The tuberous breast
deformity: classification and treatment. Br J Plast Surg. 1996;49:339–
345. This publication established the standard for assessing and managing
tuberous breasts.
7. Benelli L. A new periareolar mammaplasty: the “round block”
technique. Aesthetic Plast Surg. 1990;14:93–100. This paper established
the basis for multiple future circumareolar mastopexy techniques, giving
particular consideration to the propensity for scar spread and areolar
stretching when a permanent suture is not used.
17. Lejour M. Vertical mammaplasty for breast reduction and
mastopexy. In: Spear SL, ed. Surgery of the Breast: Principles and Art.
Philadelphia: Lippincott-Raven; 1998:73. This chapter expands on the
concept of vertical breast reduction and mastopexy with a focus on
techniques.
19. Hall-Findlay EJ. A simplified vertical reduction mammaplasty:
shortening the learning curve. Plast Reconstr Surg. 1999;104:748–763.
This paper simplified and explained the techniques behind vertical
mastopexy procedures.
20. Hall-Findlay EJ. Pedicles in vertical breast reduction and
mastopexy. Clin Plast Surg. 2002;29:379–391. This publication discussed
the various pedicle options that could be paired with the vertical breast
reduction and mastopexy skin resection technique.
21. Higdon K, Grotting JC. Mastopexy. In: Neligan PC (ed), Grotting JC
(vol. ed). Plastic Surgery. Vol. 5. 3rd ed. Edinburgh: Elsevier
Saunders; 2013:119–151. This book chapter is a comprehensive overview
of breast lift techniques and is the inspiration and basis for this current
chapter.
33. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety
and efficacy. Plast Reconstr Surg. 2007;119:775–785. This publication is
the seminal article providing basis for modern breast reduction and
mastopexy techniques.

Access the complete reference list online at

107.e1
References
References
1. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg.
1976;3:193–203. This paper established the standard system for assessing
and classifying various types of breast ptosis.
2. Brink RR. Management of true ptosis of the breast. Plast Reconstr
Surg. 1993;91:657–662.
3. Grolleau JL, Lanfrey E, Lavigne B, et al. Breast base anomalies:
treatment strategy for tuberous breasts, minor deformities, and
asymmetry. Plast Reconstr Surg. 1999;104:2040–2048. This publication
further expanded concepts of tuberous breast assessment and management
proposed by von Heimberg, et al.
4. von Heimburg D, Exner K, Kruft S, et al. The tuberous breast
deformity: classification and treatment. Br J Plast Surg. 1996;49:339–
345. This publication established the standard for assessing and managing
tuberous breasts.
5. Stevens WG, Macias LH, Spring M, et al. One-stage augmentation
mastopexy: a review of 1192 simultaneous breast augmentation and
mastopexy procedures in 615 consecutive patients. Aesthet Surg J.
2014;34:723–732.
6. Calobrace MB, Herdt DR, Cothron KJ. Simultaneous augmentation/
mastopexy: a retrospective 5-year review of 332 consecutive cases.
Plast Reconstr Surg. 2013;131:145–156.
7. Benelli L. A new periareolar mammaplasty: the “round block”
technique. Aesthetic Plast Surg. 1990;14:93–100. This paper established
the basis for multiple future circumareolar mastopexy techniques, giving
particular consideration to the propensity for scar spread and areolar
stretching when a permanent suture is not used.
8. Benelli LC. Periareolar Benelli mastopexy and reduction. In: Spear
SL, ed. Surgery of the Breast: Principles and Art. Philadelphia:
Lippincott-Raven; 1998:685.
9. Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy.
Plast Reconstr Surg. 1990;85:961–966.
10. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast
Reconstr Surg. 2001;107:1294–1299.
11. Lassus C. Breast reduction: evolution of a technique. A single
vertical scar. Aesthetic Plast Surg. 1987;11:107–112.
12. Lassus C. A 30 year experience with vertical mammaplasty. Plast
Reconstr Surg. 1996;97:373–380.
13. Lassus C. Update on vertical mammaplasty. Plast Reconstr Surg.
1999;104:2289–2304.
14. Lassus C. Vertical scar breast reduction and mastopexy without
undermining. In: Spear SL, ed. Surgery of the Breast: Principles and
Art. Philadelphia: Lippincott-Raven; 1998:717.
15. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast
Reconstr Surg. 1994;94:100–114.
16. Lejour M. Vertical mammaplasty for breast hypertrophy and ptosis.
Operative Techniques Plast Surg. 1996;3:189–198.
17. Lejour M. Vertical mammaplasty for breast reduction and
mastopexy. In: Spear SL, ed. Surgery of the Breast: Principles and Art.
Philadelphia: Lippincott-Raven; 1998:73. This chapter expands on the
concept of vertical breast reduction and mastopexy with a focus on
techniques.
18. Lejour M. Vertical mammaplasty: update and appraisal of late
results. Plast Reconstr Surg. 1999;104:771–784.
19. Hall-Findlay EJ. A simplified vertical reduction mammaplasty:
shortening the learning curve. Plast Reconstr Surg. 1999;104:748–763.
This paper simplified and explained the techniques behind vertical
mastopexy procedures.
20. Hall-Findlay EJ. Pedicles in vertical breast reduction and
mastopexy. Clin Plast Surg. 2002;29:379–391. This publication discussed
the various pedicle options that could be paired with the vertical breast
reduction and mastopexy skin resection technique.
21. Higdon K, Grotting JC. Mastopexy. In: Neligan PC (ed), Grotting JC
(vol. ed). Plastic Surgery. Vol. 5. 3rd ed. Edinburgh: Elsevier
Saunders; 2013:119–151. This book chapter is a comprehensive overview
of breast lift techniques and is the inspiration and basis for this current
chapter.
22. Wise RJ. A preliminary report on a method of planning the
mammaplasty. Plast Reconstr Surg. 1956;17:367–375.
23. Wise RJ, Gannon JP, Hill JR. Further experience with reduction
mammaplasty. Plast Reconstr Surg. 1963;32:12–20.
24. McKissock PK. Reduction mammaplasty with a vertical dermal
flap. Plast Reconstr Surg. 1972;49:245–252.
25. Courtiss EH, Goldwyn RM. Reduction mammaplasty by the
inferior pedicle technique. Plast Reconstr Surg. 1977;59:500–507.
26. Marchac D, Olarte G. Reduction mammaplasty and correction of
ptosis with a short inframammary scar. Plast Reconstr Surg.
1982;69:45–55.
27. Rubin JP, Khachi G. Mastopexy after massive weight loss: dermal
suspension and selective auto-augmentation. Clin Plast Surg.
2008;35:123–129.
28. Góes JC. Periareolar mammaplasty: double-skin technique with
application of polyglactin 910 mesh. Rev Soc Bras Cir Plast.
1992;7:1–3.
29. Góes JC. Periareolar mastopexy and reduction with mesh support.
In: Spear SL, ed. Surgery of the Breast: Principles and Art.
Philadelphia: Lippincott-Raven; 1998:697.
30. Góes JC, Bates D. Periareolar mastopexy with FortaPerm. Aesthet
Plast Surg. 2010;34:350–358.
31. Graf R, Biggs T. In search of better shape in mastopexy and
reduction mammaplasty. Plast Reconstr Surg. 2002;110:309–317.
32. Ad-Hoc ASPRS. Committee on New Procedures: Report on
Autologous Fat Transplantation. Plast Surg Nurs. 1987;7:140–141.
33. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety
and efficacy. Plast Reconstr Surg. 2007;119:775–785. This publication is
the seminal article providing basis for modern breast reduction and
mastopexy techniques.
34. Stevens WG, Nahabedian MY, Calobrace MB, et al. Risk factor
analysis for capsular contracture: a 5 year Sientra study analysis
using round, smooth and textured implants for breast
augmentation. Plast Reconstr Surg. 2013;132:1115–1123.
35. Tebbits JB. Dual plane breast augmentation: optimizing implant-
soft-tissue relationships in a wide range of breast types. Plast
Reconstr Surg. 2001;107:1255–1272.
36. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in
aesthetic and reconstructive breast surgery using triple antibiotic
breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg. 2006;118(7 suppl):46S–52S.

SECTION I • Aesthetic Breast Surgery
7 
One- and two-stage considerations for
augmentation mastopexy
Emily C. Hartmann, Michelle A. Spring, and W. Grant Stevens
SYNOPSIS
■ Augmentation mastopexy is a particularly challenging procedure, as
the surgery has multiple opposing goals – to increase the volume of a
breast, change the shape, and simultaneously decrease the skin
envelope.
■ Successful outcomes in augmentation mastopexy, one- or two-stage,
can be expected with proper planning, technique, and patient education.
■ Patient selection is of utmost importance given the range of patients
and pathologies in need of augmentation mastopexy (e.g., massive
weight loss patients, the constricted breast, or severe ptosis).
■ Preoperative planning, markings, and surgical technique are discussed
in detail for both single stage and two-stage approaches. The author
provides a step-by-step approach.
■ Postoperative management can be crucial to ensure the best possible
outcome.
■ This chapter focuses on common indications and patient selection for
one- and two-stage augmentation mastopexy, techniques for safe and
effective procedures, challenges of the combined procedure,
postoperative care, as well as potential complications, outcomes, and
secondary procedures.
■ A review of outcomes in the literature is examined. Knowledge of
key complications is critical to stave them off during surgical planning,
and in order to recognize them postoperatively should a patient
experience a complication. Treatment for these complications is
discussed.
■ Secondary procedures may be necessary to correct implant
malposition, inframammary fold (IMF) asymmetries, scar revisions, or
nipple position asymmetries.
Access the Historical Perspective section online at

Introduction
In 2014, the number of mastopexies had increased from
1997, by 568.5%, and similarly, the number of breast
augmentations increased by 183.4%, according to the
ASAPS national statistical data.1 As these cases increase,
there is also likely to be an increase in patients who
would benefit from both an increase in breast volume
as well as lift. Whether these procedures are performed
simultaneously or in a staged approach has been the
subject of some debate over the years.2
One-stage augmentation mastopexy was initially
described more than 50 years ago by Regnault and
Gonzalez-Ulloa3,4 although many plastic surgeons prefer
a two-stage approach to the ptotic and deflated breast.
Simultaneous breast augmentation and mastopexy is,
however, gaining traction2,3,5–20 but is often considered
to be one of the most difficult cosmetic breast surgeries.
The challenge is in the fact that the surgery has multiple
opposing goals – to increase the volume of a breast,
change the shape, and simultaneously decrease the skin
envelope. Successful outcomes in augmentation masto­
pexy, one- or two-stage, can be expected with proper
planning, technique, and patient education. This chapter
focuses on common indications and patient selection
for one- and two-stage augmentation mastopexy, tech­
niques for safe and effective procedures, challenges of
the combined procedure, postoperative care, as well
as potential complications, outcomes, and secondary
procedures.
Basic science/disease process
Breast anatomy
As with any operative technique, anatomy is the foun­
dation of success. Vascular anatomy is of particular
  Access video content for this chapter online at expertconsult.com

108.e1
Historical perspective
Historical perspective
Several decades ago, the popularity of augmentation
mammoplasty soon gave rise to a group of patients with
ptotic and hypovoluminous breasts whose outcome
would not be ideal with just augmentation or mastopexy
alone.3 Over time, a host of cautionary articles were
published which aimed to dissuade surgeons from
performing the procedures simultaneously21,22 based on
the purported higher risk of patient dissatisfaction and
unpredictability when compared with a two-stage pro­
cedure. In more recent years, these concerns have not
been born out in the literature and several large-series
studies suggest that a single staged approach can be
performed safely.5–7,23,24

109
Definition and classification of ptosis
blood supply could be severely compromised. Vascular
supply to the tissue can also be compromised if the
implant size is too large and too much tension is placed
on the skin edges, leading to tissue necrosis.
Definition and classification of ptosis
In the hypomastia patient, the diagnosis of breast ptosis
is critical in the decision-making algorithm to determine
the type of mastopexy necessary when combined with
an augmentation. Regnault (Fig. 7.2) is the most well-
known classification system for breast ptosis and it is
importance in breast surgery in order to preserve blood
flow to the nipple areolar complex. The nipples form an
equilateral triangle with the sternal notch and are
located at the level of the 4th rib, approximately 9–10 cm
from the midline.25 The breast parenchyma extends
horizontally from the sternum to the anterior axillary
line and vertically from the level of the 2nd or 3rd rib
to the inframammary fold, and with variable axillary
extension as the Tail of Spence.26
The support system of the breast is comprised of
fascial layers and Cooper’s ligaments, which together
give rise to overall breast shape and integrity against
gravity. The superficial fascial layer lies between the
dermis and breast parenchyma. The deep layer lies on
the pectoralis fascia. The relationship of the deep fascia
and the retromammary space allows the breast tissue to
move on the chest wall.26
Ligamentous suspension consists of Cooper’s liga­
ments and the horizontal septum. Loss of elastic fibers
within these structures in the course of aging may
contribute to a loss of their supporting function and of
the firm shape of the breast. Cooper’s ligaments provide
suspensory support and connect the superficial fascia
and skin to the deep fascia. The horizontal septum
emerges from the pectoralis fascia at the level of the 5th
rib, which divides the gland into cranial and caudal
portions. This septum carries the weight of the breast
and prevents descent of its base. The horizontal septum
also carries the main neurovascular bundles supplying
the breast, which run along this septum and guide the
vascular supply to the nipple.26,27
Breast vascular supply
Blood supply to the nipple areolar complex is of great
importance in augmentation mastopexy surgery. Mul­
tiple arteries supply the breast, all of which overlap and
lead to variability of tissue perfusion. The dominant
arterial sources are the internal mammary artery perfo­
rators (Fig. 7.1). These perforators traverse the anterior
thoracic wall just lateral to the sternum and course
through the medial pectoralis major muscle. They can
be encountered directly when dissecting the medial
subpectoral pocket. Specifically, the 2nd–4th internal
mammary perforators are the main blood supply for a
superior or superomedial pedicle. Several in-depth
articles are available for vascular anatomy of the
breast.28–32
Subpectoral placement of the breast implants does
not disrupt the musculocutaneous perforators and is
less likely to interfere with blood supply. On the con­
trary, if the implant is placed in the subglandular plane
and significant tissue undermining is performed, the
A
Internal mammary artery
(Internal thoracic artery)
Second intercostal
artery and perforating
branches
Thoracoacromial
perforating branches
Anteriorlateral
perforators from
intercoastal artery
Fourth intercostal artery
and perforating branches
Thoracoacromial axis
Lateral thoracic artery
Fig. 7.1  (A,B) Breast vascular anatomy.
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110
SECTION I
CHAPTER 7 • One- and two-stage considerations for augmentation mastopexy
placed, to shape the breast into an aesthetically pleasing
result. It is a balance of all factors to create an aestheti­
cally pleasing breast contour with an appropriately
positioned nipple areolar complex, upper pole fullness,
tightening of the loose skin envelope, breast symmetry,
and increased breast volume.
Pseudoptosis
In this case, the nipple is in the ideal location but the
lower pole breast tissue is ptotic. The “smile” mastopexy
may be employed if the tissue needs to be reduced in
the vertical plane only, and the “sailboat” mastopexy if
both the vertical and the horizontal planes must be
reduced. The pseudoptotic breast can also be addressed
with a dual-plane augmentation, which would allow
the breast tissue to lift and create more upper pole
fullness.35
Grade 1 ptosis
These patients require no more than 2 cm of nipple
movement and can be addressed with a “crescent” or
“circumareolar” mastopexy. Circumareolar mastopexies
have higher rates of revisions and patient dissatisfac­
tion,7 and the authors avoid them unless less than 2 cm
of lift is needed. In terms of acceptable scarring, the
authors generally use the circumareolar incision, even
though some surgeons report success with the crescent
mastopexy.7,36–39
Grade 2 ptosis
These patients generally require 3–4 cm of nipple eleva­
tion. The circumvertical “owl” mastopexy is utilized if
they only require a reduction in the horizontal plane. A
triangular base of skin known as the “owl with feet” is
sometimes made to decrease the vertical plane and
shorten the nipple to IMF distance.
Grade 3 ptosis
Patients requiring more than 4 cm of nipple elevation
will benefit from a wise pattern mastopexy. This category
defined by the location of the nipple to the inframam­
mary fold.25 Other classification schemes are essentially
modifications of this system based on skin elasticity,
glandular volume, and parenchymal distribution.33,34
Diagnosis and patient presentation
In the case of augmentation mastopexy, it is the rare
patient that presents knowing exactly what they need
to achieve their desired appearance. The surgeon must
often use lay terminology and also astutely pick up on
body language and hand motions to fully understand
the patient’s desires. Patients generally fall into two
categories when they present for aesthetic breast surgery.
One group is the smaller-breasted patient who seeks
augmentation and does not recognize they have a
certain degree of ptosis. The second group is the patient
requesting a breast lift but also wants fuller breasts that
can only be achieved with an additional augmentation.
These patients present a particular challenge because
they may not have emotionally accepted the idea of
using an implant and will require extra time to process
this.
In general, patients requiring augmentation masto­
pexy are often older than patients desiring enlargement
with implants. Factors such as weight loss, pregnancy,
and breast feeding are often at play and their sequelae
of increased tissue laxity, parenchyma loss, striae, and
nipple ptosis require a mastopexy to create an aesthetic
breast shape. In the initial consultation, it is very impor­
tant to distinguish the tuberous-breasted patient, which
can present additional challenges that are not within the
scope of this chapter.
Patient selection and indications for
augmentation mastopexy
Once the desired size and shape have been established,
the surgeon can then select the appropriate mastopexy
incision (Fig. 7.3) through which an implant may be
Fig. 7.2  Regnault classification of ptosis.

111
One or two stages
often includes the massive weight loss patients who
deserve special annotation for their unique features and
underlying protoplasm. Patients often present with
medialization of the nipple areolar complex and exten­
sion to a lateral chest roll.40 Several techniques utilizing
a variety of parenchymal flaps exist to create volume
and stability to the breast,41–45 though long-term durabil­
ity of these flaps remains to be proven.
Implant selection
The base width provides a general guide for implant
selection, however skin envelope laxity and parenchyma
volume should be taken into consideration. The use of
sizers in the operating room with tailor-tacking can help
guide the surgeon in choosing the correct implant size.
For those who need a mathematical approach to deter­
mine ideal breast implant shape and volume, the Teb­
betts’ method is helpful.46 Planning excessively large
implants at the same time as a mastopexy may create
more postoperative complications given the opposing
forces on the tissues.
The type of implant shape and profile determines the
distribution of fill within the breast. The authors primar­
ily use silicone implants and avoid saline implants,
which lead to deflations, more complaints about implant
visibility and palpability, and higher revision rates.5,8,9,47
The incidence of capsular contracture, implant palpa­
bility, and excess upper pole fullness is diminished with
subpectoral implant placement, though subpectoral
placement is associated with more postoperative pain
and muscle flexion deformity when compared with
subglandular positioning.48,49 It is also known that mam­
mography is also more accurate with subpectoral
placement.50,51
One or two stages
The decision to stage or combine is based on the clinical
scenario, surgeon’s experience and the patient’s choice.
The authors believe this decision should not be based
primarily on a concern for increased risk to the patient
and a review of the single-stage augmentation masto­
pexy patients showed a revision rate and return to the
operating room of 16.9% compared with 100% of staged
patients requiring a second operation. Additionally data
compared favorably with previously reported revision
rates for breast augmentation or mastopexy alone.7 There
are, however, cases in which staging the procedure is
the safest option. Women with high risk for wound-
healing complications, such as diabetics, smokers, and
immunocompromised patients, are not good candidates
for a combined augmentation mastopexy.8,22,52,53
Fig. 7.3  Types of mastopexy incisions. (Redrawn after Spring MA, Macias LH,
Nadeau M, Stevens WG. Secondary augmentation-mastopexy: indications, preferred
practices, and the treatment of complications. Aesthetic Surgery Journal
2014;34(7):1018–1040.)
Wise
Crescent
Circumaerolar
Circumvertical ‘Owl’
‘Owl with feet’
‘Sailboat’
‘Smile’

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CHAPTER 7 • One- and two-stage considerations for augmentation mastopexy
the patients may not recognize as well as the ability
to review scar placement. The patient will also then
have the opportunity to point out areas she would
like changed and to what degree (upper pole full­
ness, areolar size, etc.). Having these discussions
preoperatively will hopefully avoid the surprised and
sometimes unhappy patient. Mild implant palpability
or rippling when patients bend over is usually the
consequence of having breast implants, particularly in
thin patients or those without substantial breast tissue.
Patients may consider it a complication when they feel
the implant edge laterally if they are not forewarned
of this.
The adage often used is that breasts are “sisters and
not twins”, when reminding the patient that no two
sides of the body are mirror images of each other. Addi­
tionally, breast implants are not designed to be lifetime
devices, and the patient should be informed that she
may need additional surgery on her breasts in the future,
as well as the FDA recommendation for surveillance of
silicone breast implants.
Treatment/surgical technique
Patient markings
The patient is always marked in the preoperative
holding area just prior to surgery – “proper planning
precludes poor performance”. As the tissues are
manipulated and the patient reviews their wants, the
surgeon can essentially perform the surgery in his/her
mind, well before an actual incision is made.
The midline and sternal notch are first marked. The
meridian of each breast is then marked to look for sym­
metry of each breast. A measurement of the meridian to
the midline marking is taken to assess any differences.
The inframammary fold (IMF) is then marked, extend­
ing to the midline. A breast caliper is Dr. Stevens’ pre­
ferred tool to measure the dimensions of the breast.
The base diameter is noted, which will determine the
approximate implant selected. The sternal notch to IMF
distance is used to mark the new nipple site on the
meridian. The new areola is then drawn with the supe­
rior edge 2 cm above the nipple mark and made circular.
This will be confirmed on the operating table with the
nipple marker. The limbs are then drawn based on how
much horizontal dimension needs to be reduced. If a
reduction in the vertical dimension is required based on
the nipple to fold distance, then the “feet” component
may be added. Once the patient is lying on the table, all
marks are re-measured and re-drawn. The length of the
vertical limb is determined by the cup size the patient
would like to be (Table 7.1 and Video 7.1
).
Should the surgery be staged, many surgeons will
proceed with the mastopexy first and then follow with
an augmentation no earlier than 3 months postopera­
tively. This allows for tissue related revisions at the time
of the second procedure if necessary. Placing the implant
first helps to stretch out the soft tissue and would not
necessarily be the wrong choice. In making your deci­
sion of whether to perform the mastopexy or the aug­
mentation first, it is important to consider the fact that
the patient may not return for the second procedure. In
this scenario, a decision must be made as to which
would be preferable – an augmented ptotic breast or a
lifted but hypovoluminous breast. The answer varies
from patient to patient.
Preoperative preparation
To ensure efficiency, repeatability, and reliability, it
is crucial to establish a preoperative checklist for
every patient. Managing patient expectations and well-
documented informed consent are important compo­
nents of preoperative preparation, as mastopexy surgery
is a frequent source of litigation in plastic surgery.54,55
The main checklist items should be:
1. Review patient history and discuss pertinent
medical clearances – labs may need to be drawn in
accordance with the patient’s age and history;
2. An information pack for the patient detailing the
day prior to surgery (skin preps, NPO status,
medications to avoid, etc.), when to arrive for
surgery, directions to get there, details of aftercare,
name of the person to be contacted, and
postoperative follow-up appointments;
3. Prescriptions for medications to be started after
surgery;
4. Consents (surgical, photo release, arbitration
agreements, anesthesia, etc.);
5. Last but not least, preoperative photos should be
taken.
With regard to mammogram status, the use of “routine”
mammograms prior to breast surgery should be avoided.
This is in accordance with the American Board of Inter­
nal Medicine and recognized by the American Society
of Plastic Surgeons. Patients should undergo annual
screening mammograms for patients of specific age
groups and additional screening is not necessary unless
there are concerning aspects of the patient’s history or
physical exam which require further investigation.56
The preoperative visit is also an opportunity for
patients to review their desires with their surgeon.
Photo documentation also provides an opportunity to
point out asymmetries and specific anatomic details

113
Step-by-step technique
Table 7.1  Vertical limb length based on desired cup size
Desired cup size
Vertical limb length (cm)
B cup
5
C cup
6
D cup
7
DD cup
8
Setting the stage
All patients are given a dose of preoperative antibiotics
and lower extremity sequential compression devices are
placed. The authors generally perform these in an out­
patient surgery center for low risk patients and patients
can recover at home with a caregiver unless combined
with another procedure when it is recommended that
they recover at an aftercare facility. The patient is placed
on the table in a position suitable for hip sitting up
multiple times during the procedure, with the arms
abducted and secured to the arm boards. Preoperative
photographs of the patient taken at the time of their
prior appointment are taped to the wall for easy refer­
ence during surgery. This is helpful due to the change
in appearance of the breasts with the patient supine.
Patients are encouraged to select photos of model breasts
that they would like to resemble, from a book provided
in the clinic. These are also placed on the wall for refer­
ence. Lastly, headlights are worn if a lighted retractor is
not used during pocket creation.
Step-by-step technique
1. The marked incisions are infiltrated with 1%
lidocaine and 1 : 100 000 epinephrine solution prior
to skin prep. The skin is then prepped with
betadine or chlorhexidine/alcohol. The field is
then draped.
2. The first step is to re-measure and mark the
incisions to reaffirm symmetry and cleanness of
the cuts. It is critical to remember that one can always
take more and to start as minimal as possible when first
getting comfortable with this procedure.
3. The areola is marked with a 42 mm ring (unless
smaller or larger is determined by patient/surgeon
preference) (Fig. 7.4).
4. The mastopexy incisions are then made and
de-epithelialization commences. The skin inferior
to the areola may be removed full thickness (Fig.
7.4). At this point if tissue is to be resected for
symmetry or to reduce the breasts slightly, tissue may
be excised from the lateral sides of the vertical opening.
This technique involves skin excision as the initial
step. It should be altered slightly if the surgeon is
just getting comfortable with augmentation
mastopexies or if the case is particularly difficult
due to asymmetries or unusual anatomy. In these
cases, it is prudent to start with implant placement and
then tailor-tacking of the mastopexy markings to ensure
enough skin is left for closure and the surgeon is
satisfied with the aesthetics. Only after the surgeon
has performed a number of them and determined
that the markings consistently do not need
adjustments should he/she proceed with the skin
excision first without tailor-tacking.
5. The nipple areolar complex (NAC) is freed using a
U incision and then a suture is used to attach the
12 o’clock position of the NAC to the new midline
incision. This maneuver tacks the NAC out of the
way to allow the parenchyma to be pulled around
inferiorly (Fig. 7.5).
6. The implant pocket is created through the vertical
incision, unless a circumareolar incision is
planned. The advantage of a vertical incision is that a
1–2 cm cuff-off tissue is maintained inferiorly, which
protects the implant should the T-junction breakdown.
The dissection is carried down to the pectoralis
major muscle edge, releasing the inferior and
inferomedial fibers of the pectoralis major muscle
to allow for ideal position of the implant. It is at
this time that a variable degree of dual-plane
may be created depending on the patient’s needs
(Fig. 7.6).
7. Meticulous hemostasis is achieved.
8. Sizers are placed into the pocket to assess for
proper position, pocket size, and adequate release
of the pectoralis muscle. The parenchyma can be
closed with temporary sutures to appropriately
emulate the soft tissue position over the implant.
9. Tailor-tacking of the mastopexy incisions is
performed to determine implant size as well as
degree of skin excision. The inferior pole of the
breast should be flat on profile rather than a gentle
curve. This is because over time, the implant will
descend and the soft tissue will stretch and lead to
a natural appearing lower pole. If the lower pole
already looks good at the time of surgery, it will
result in too much laxity over time as the skin
stretches due to the weight of the implant.
10. The pockets are irrigated with triple antibiotic
solution followed by betadine that is rinsed out
thoroughly, and once the implants are placed, the
deep tissue is closed completely. Fig. 7.7 shows the
implant in position.
11. The vertical midline tissue is brought together
with a running locking 3-0 Vicryl suture starting

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CHAPTER 7 • One- and two-stage considerations for augmentation mastopexy
A
B
C
Fig. 7.4  (A) Periareolar and mastopexy lines are incised. (B) The skin around the
areola is de-epithelialized. (C) A full thickness skin excision is made inferior to the
areola.
A
B
Fig. 7.5  (A) The parenchyma is released around the areola in a U configuration. (B) The release of the parenchyma allows the NAC to be moved superiorly and is secured
at the 12 o’clock position. This allows the NAC to be moved out of the way during pocket formation as well as an easier closure.

115
Special considerations
Special considerations
Borderline ptosis
Patients with borderline ptosis require less than 2 cm of
nipple areolar complex elevation and thus often benefit
from a circumareolar mastopexy (Figs. 7.9 & 7.10). A
non-absorbable interlocking wagon-wheel or purse-
string suture is placed in the deep dermis with the knot
buried deeply (Figs. 7.11 & 7.12). There are some nuances
to be aware of with this technique:
1. Avoid a tight purse-string suture that can cause
vascular compromise to the nipple as the areolar
skin is pulled taught.
2. There is often mild pleating of the skin that
resolves postoperatively.
3. Scar and areolar widening can occur
postoperatively, but the permanent help reduce
this consequence.
4. With significant skin excision, the breast can also
appear flattened.
inferiorly and deep and heading in the superior
direction. Once the suture reaches just underneath
the NAC it is brought more superficial to proceeds
inferiorly until it meets the T-junction. This
method approximates the deep tissue in
preparation for skin closure (Fig. 7.8).
12. Very limited undermining is performed in order to
bring the skin edges together (Fig. 7.9).
13. The skin edges are closed with 3-0 Monocryl
interrupted deep dermal sutures and a running 3-0
Monocryl. The areola is inset with a 4-0 Monocryl
interrupted deep dermal and a running 4-0
Monocryl.
14. Upon inset of the NAC, if it does not appear
perfectly round or shows a teardrop deformity
it should be addressed on the table (Fig. 7.10).
The nipple marker should be used and skin
excised.
Fig. 7.6  (A) Pocket creation via a vertical incision. (B) The edge of the pectoralis
major muscle is found and the appropriate pocket is created for implant insertion.
A
B
Fig. 7.7  The implant is shown sitting in the pocket. Here an anatomic implant was
placed and the white line indicates orientation of the implant.
Clinical tips
Tailor-tacking prior to making mastopexy incisions is a useful
technique to prevent excising too much skin
The lower pole of the breast should appear flat on profile at the
end of the procedure.
Fix areolar shape issues on the table prior to closure.

116
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CHAPTER 7 • One- and two-stage considerations for augmentation mastopexy
A
B
C
Fig. 7.8  (A–C) Pocket closure begins with a running suture starting the deep
inferior parenchyma heading up toward the NAC, then transitions more superficial
and then runs back down inferiorly in a locking fashion.
A
Fig. 7.9  (A,B) Limited flap undermining is performed just enough to take the tension off the skin and allow for closure.
B

117
Special considerations
A
B
C
Fig. 7.10  (A–C) Nipple areolar complex adjustments. If a perfectly circular areola
does not shape up once the skin is brought together then final adjustments can be
made with the areolar marker and fine scissors or scalpel. It is best to address these
issues on the table. The junction with the vertical incision should be perpendicular;
otherwise a teardrop deformity will occur.
Pseudoptosis
Patients with pseudoptosis may have adequate nipple
position and areolar size. Mild pseudoptosis can often
be corrected with an augmentation alone, however, in
the face of heavy pseudoptotic glandular tissue, the
authors find that a more pleasing breast shape is created
by performing a mastopexy to elevate the parenchyma
and excise redundant skin (Fig. 7.13). This situation can
be treated with only a sailboat or smile mastopexy,
although most patients benefit from slight repositioning
of the areolas.
The constricted breast
Constricted breast deformity can have a profound
impact on postoperative shape and it is estimated that
over 80% of women who present for breast augmenta­
tion have some form of constriction.57 Anatomic shaped
implants can be useful in this patient population, as the
form stable silicone helps to differentially put pressure
on the lower pole of the breast. Intraoperative release of
inferior and inferior-medial parenchymal bands and
tight tissue can create a more rounded lower pole. They
are better candidates for a circumareolar mastopexy,
given their lack of horizontal excess, to reduce enlarged
areolas and limit breast tissue herniation. They may also
benefit from a subglandular implant pocket,58 however,
the authors believe aggressive scoring of the inferior
pole parenchymal bands and a subpectoral pocket can
achieve a good result.
Breast asymmetry
Those with significant breast asymmetry can be treated
by reduction in parenchyma on the larger side or with
different size implants. When debating between placing
the same size implants or trying to correct a slight size
asymmetry, the authors find that patients are most satis­
fied if postoperative asymmetry corresponds with what
they are used to – i.e., if the patient’s right breast is

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CHAPTER 7 • One- and two-stage considerations for augmentation mastopexy
Fig. 7.11  Circumareolar mastopexy. (A–C) A 47-year-old woman with grade 2 ptosis. (D–F) At 1 month postoperatively, following a circumareolar mastopexy
augmentation. Of note, the implants are appear in a high position, however, gravity will slowly bring them down into an ideal position over the next several months. It is
important to educate patients about this anticipated change.
A
B
C
D
E
F

119
Special considerations
A
B
C
D
E
Fig. 7.12  Intraoperative view of circumareolar mastopexy. (A) The areola is partially
inset evenly prior to marking for the lift. (B) The nipple and areola position is
determined and re-marked using the appropriate-sized cookie-cutter.
(C) The areolar incision is made. (D) The circumareolar skin is de-epithelialized.
(E) A wagon-wheel closure is performed using a permanent suture, and the skin is
then closed using a running subcuticular suture.

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CHAPTER 7 • One- and two-stage considerations for augmentation mastopexy
for pain control; a benzodiazepine as an anxiolytic and
to lessen muscle spasms; and 7 days of postoperative
antibiotics. According to the Surgical Care Improve­
ment Project,59 antibiotics are not recommended after
24 h postoperatively and each physician must decide
which protocol works best in their practice. Patients
are also given Arnica Montana oral tabs and topical
cream that serve as a homeopathic treatment for bruis­
ing and swelling. Scientific studies of Arnica have
been equivocal.60 A randomized-control study showed
that it decreased edema in rhinoplasty patients when
compared with placebo,61 which countered an earlier
placebo-controlled study showing no difference from
placebo in post-laser ecchymosis.62 In the author’s
experience, the benefits of Arnica outweigh the risks.
Immediately following closure of the incisions, the
wounds are dressed with Xeroform, thick, soft cotton
padding, and wrapped with a Kerlix roll and ace wrap
or bias-cut cotton wrap. The configuration should create
a halter-top type appearance with tape placed at the
front V to avoid rubbing on the neck. As stated previ­
ously, drains are rarely used, however, if they are
slightly larger preoperatively, and placing a bigger
implant on the contralateral side leads to a slightly
larger left breast, patients will not tolerate this as well
as using the same size implants and accepting the fact
that they will have asymmetry based on their native
breast tissue.
Postoperative care
The following is the senior author’s (W.G.S) postopera­
tive regime. This is not to be seen as absolute but rather
an example of what has been found to work in one
practice setting.
Postoperative care is of the utmost importance to
ensure a stable recovery period and to create consistent
protocols for nursing staff to follow. Patient education
as to what to expect postoperatively is also critical and
should be started at the preoperative appointment.
Patients are given an information pack that details
medications to avoid pre- as well as postoperatively.
Unless allergic, patients are given the following post­
operative medications: a narcotic with acetaminophen
A
B
C
Fig. 7.13  (A) This woman presented with widened areola and pseudoptosis
following breast augmentation 6 years previously. Intraoperatively, she was marked
for a “sailboat” mastopexy to reduce both vertical and horizontal excess, as well as
circumareolar excision of the widened areola. (B) She underwent removal of her old
implants with capsulotomies and replacement with 547 cc silicone devices. Once
the implants were placed, the vertical component of the mastopexy was not
necessary and (C) she underwent a “smile” mastopexy to reduce the vertical excess.

121
Complications and secondary procedures
for 2 weeks and gently work up to their normal activity
until they are 6 weeks postoperative.
Returning to work depends heavily on what the
patient does for a living. If it is a desk job with minimal
activity, they may return to work as early as 1 week;
however, 2 weeks is recommended before returning to
a job with more physical activity. With regard to an
exercise routine it is recommended that they start gently
walking around the house for the first few days after
surgery and then progress to walking around the block
over the next 2 weeks. They should be cautioned not to
raise their blood pressure and heart rate in the first 2
weeks, to stave off hematoma or seroma formation. At
2 weeks postoperatively, they may start light workouts
such as the elliptical or stationary bike and slowly pro­
gress to their full workouts at 6 weeks.
Complications and
secondary procedures
An exhaustive description of complications related to
implants or mastopexy is outside the scope of this
chapter. Instead it will touch on common complications
following augmentation mastopexy as reported in the
literature.6,11,13,23,64–66
Immediate complications
Hematoma
Hematomas are a known complication of breast surgery
and can occur despite meticulous hemostasis. The
pooled hematoma rate for combined augmentation
mastopexy is 1.37%.23 Some authors condone that direct
visualization and cauterization of vessels rather than
blunt dissection can help avoid the occurrence of hema­
tomas.67 They should be drained promptly to not only
avoid excess pressure on the tissues and subsequent
ischemia but because blood collections can increase the
risk for both infection and capsular contracture.68
Infection
Infection of the soft tissues must be treated aggressively
with antibiotics and frequent follow-up to avoid wound
breakdown and involvement of the implant. Sequelae
following implant infection include the immediate
removal of the implant as well as long-term conse­
quences such as capsular contracture.69 The “no touch”
technique70 has been adopted for implant handling,
which has greatly decreased the incidence of infection.71
Intraoperative techniques such as: re-prepping the chest;
changing gloves; avoiding multiple people handling
the implants; placing an occlusive dressing over the
present, they are safety-pinned to the outside of the
wrap. Patients are discharged home with a caregiver if
they are not having another combined surgery.
Patients are then seen on POD No. 1, where their
dressings are removed completely, the incisions are
cleaned gently with dilute hydrogen peroxide and
saline. Steri-Strips are applied and the patient is placed
in a surgical bra. Prior to bra placement, a thick layer of
Arnica cream, again evidence is equivocal,60 is applied
on the entire breast bilaterally “like spreading cream
cheese on a bagel”. The patient is instructed to apply
the cream daily for 2 weeks after showering. Scar
therapy with silicone gel begins at approximately 3–4
weeks following surgery. The patient is allowed to wear
an underwired bra at 6 weeks. Standard follow-up,
including photos, proceeds at 1 week, 2 weeks, 1 month,
3 months, 6 months, and at 1 year. Patients are then
asked to return every year for photos.
The authors routinely use textured implants and thus
do not implement a massage protocol, however, if
smooth implants are used, patients are encouraged to
do gentle implant mobility exercises starting within the
first week of surgery.
If the implant appears to be too high or there is sig­
nificant upper pole swelling it may be possible to apply
a bandeau (either an ace wrap or a commercial product
designed for this use) around the top of the implant for
downward pressure to be maintained. The patient
should wear this constantly and the pressure “should
feel like a hug”, to avoid applying it too tightly.
Additional maneuvers may be implemented in an
effort to maximize the aesthetic outcome. The authors
have utilized the “shoelace cast”, as designed by Dr.
Dan Mills of Laguna Beach, in patients who need cor­
rection of mild IMF asymmetries or double bubbles.
This technique is effective and easy to implement when
following Dr. Mills’ outlined protocol.63
Postoperative reassurance for the patient is important,
since this implant settling can occur at different rates
for each patient. It is reassuring to the surgeon to recall
that when the patient was in the operating room the
pockets were symmetric and the implants were in good
position.
Patients often ask about returning to their normal
activity, which includes work and exercise routine. The
first 2 weeks are a critical time to keep seromas and
hematomas at bay. The implant should be properly
immobilized in a surgical bra at all times (except when
showering); arm movement should be limited to avoid
implant motion underneath the pectoralis major muscle;
and blood pressure should not be elevated. The patient
is asked to refrain from heavy arm activity (unless they
are a secondary mastopexy and already had an implant)

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CHAPTER 7 • One- and two-stage considerations for augmentation mastopexy
chest wall and moving the implant to a subglandular
pocket.79
Tissue-related
Pseudoptosis can be due to the relatively thin inferior
pole skin and tissue stretching under the weight of the
implants or actual violation of the inframammary fold
and displacement of the implants inferiorly. As described
above, the authors strive to create a flattened lower pole
at the time of surgery to allow for postoperative stretch.
Conservative dissection of the IMF is also important
and one should not violate the IMF unless necessary. If
the IMF needs to be lowered, tacking sutures may be
necessary to reinforce the fascia and prevent dropping
of the implant.
Capsular contracture is a common reason for revision
of breast augmentation, with or without mastopexy.80
The etiology of capsular contracture is an enigmatic
phenomenon evident by the litany of studies.49,75,81–84
Factors contributing to capsular contracture include
infection and bacterial contamination,81 subglandular
pocket placement,49 periareolar approach85 presumably
due to more bacterial contamination from the ductal
tissue,18 and smooth implants.3,4,8,17,19,80 Hematoma for­
mation has also been correlated with capsular contrac­
ture68,86 and the use of drains is associated with a higher
prevalence of capsular contracture.81
Nipple malposition, either too high or too low, is due
to either placement error during initial marking or
secondary changes as the implant shifted and tissue
laxity set. Nipple position marking is covered in the
“patient marking” section above. It is important to
remember that it is far easier to raise a nipple than to
lower one. Conservative elevation is therefore encour­
aged if one is concerned the nipple placement is too
high. In addition to nipple malposition there can also
be areolar shape distortions. A mosque-pattern areola
design is often used, however, this does not guarantee
a symmetric circular areola. The authors advise taking
care of this problem on the table when a non-circular
shape is noted. This irregularity will only get worse
with time.
A double-bubble deformity is caused by one of two
problems. The first is ptosis of glandular tissue droop­
ing over an implant. This occurs when the breast tissue
projects over and hangs below the more superiorly
located implant. Perhaps the mastopexy was not tight
enough and too much glandular tissue was left behind,
or the pectoralis major muscle was not released enough
inferiorly causing the implant to remain high. Reposi­
tioning or resizing the implant may be necessary, and a
revision of the mastopexy should be considered. Second,
a double-bubble deformity may occur if a persistent
nipple;72,73 utilizing a “no-touch” technique; irrigating
the pocket with antibiotic solution74 or Betadine solution
and rinse;75 and avoiding powdered gloves, have all
been utilized to help reduce risk. The pooled risk of
infection following simultaneous augmentation masto­
pexy is 2% (ranging from 0% to 14% in the current
literature).23
Soft tissue concerns
Nipple ischemia following breast lift can be transient
and has minimal consequences. Reported rates of mod­
erate or prolonged nipple ischemia following breast
surgery are 5–11% and full thickness ischemia/necrosis
occurs in approximately 0.5–7.3% of all cases of cos­
metic, oncologic, or reconstructive breast surgery.76,77 A
working knowledge of treatment algorithms is essential
to maximize the salvage of nipple tissue.76 It is important
to obtain any history of previous breast surgeries, and
consider nipple blood supply when performing simul­
taneous augmentation mastopexy. Skin necrosis or
breakdown can occur most commonly at the T-zone of
an anchor type mastopexy. Careful tissue handling,
closure without excessive tension, excision of trauma­
tized tissue, and minimal undermining should all be
utilized to minimize soft tissue-related complications.
Delayed complications
Implant-related
We know that saline implants tend to ripple more than
silicone implants.78 Rippling can worsen over time as
pressure from the implants thin the tissue. Methods for
correction include: exchanging textured shells to smooth;
saline to gel-filled implants; moving the implant from a
subglandular to subpectoral pocket; creating a com­
pletely new pocket in the subfascial or subcapsular
plane; utilizing acellular dermal matrix to provide more
implant coverage; or placing fat grafts to add additional
support and volume to the area.
Implant malposition is usually apparent early and
may be a result of faulty or asymmetric pocket dissec­
tion or incomplete release of the pectoralis major muscle.
In these cases, revisions require either further dissec­
tion, plication of an overly dissected pocket, or the
creation of new pockets for the implants.15,16
Animation deformity is caused by implant motion
with flexion of the chest muscles. This is even more
pronounced in thin patients who lack breast parenchyma
volume. Over-dissection of the pectoralis major muscle
from the medial insertion to the sternum can also result
in increased distortion. Correction of this deformity can
be done by suturing the pectoralis major muscle to the

123
Outcomes
inframammary crease occurs when the pocket is dis­
sected inferiorly to accommodate a large implant or
purposefully lower an asymmetric crease or a con­
stricted lower pole. Over time, this may improve as
pressure from the implant stretches the skin. Correction
includes a shoelace cast,63 placing smaller implants and
plicating the IMF versus creating a neosubpectoral
pocket with capsular reinforcement of the fold. If the
breast implant position is correct, fat grafting can be
used to camouflage the contour depression.
Outcomes
A large meta-analysis by Khavanin et al. was recently
published which examined 23 single stage, augmenta­
tion mastopexy review articles.23 The total pooled
complication rate was 13.1% with the most common
complication being recurrent ptosis (5.2%), followed by
poor scarring (3.7%). Capsular contracture rates were
3.0% and tissue-related asymmetry was 2.9%. Infection,
hematoma, and seroma rates were less than 2% each.
Reoperation rates were 10.7%. The pool of articles dis­
played extreme heterogeneity and despite inherent
drawbacks from a meta-analysis, this meta-analysis
remains a good outcomes resource.
The authors recently published a review of 615 con­
secutive one-stage mastopexy augmentations,7 Silicone
implants were placed in 79%, and textured implants
were used in 92% of cases. The average volume of the
implants was 323 cc. In total, 93% of implants were
placed in a submuscular pocket. The five most common
complications were: poor scarring (5.7%); wound
healing issues (2.9%); implant deflation (2.6%); areolar
asymmetry (1.9%); and capsular contracture (1.6%).
Over the period of the study, 16.9% of patients under­
went some kind of revision procedure. Tissue-related
complications were looked at separately, and poor scar­
ring was the most common indication, with circumareo­
lar mastopexies leading to a statistically higher rate of
revision. This finding is consistent with other studies.6,87
2. Nahai F, Fisher J, Maxwell PG, et al. Augmentation mastopexy: to
stage or not. Aesthet Surg J. 2007;27:297–305. A panel discussion from
breast surgery experts with clinical examples of augmentation mastopexy
challenges.
6. Calobrace MB, Herdt DR, Cothron KJ. Simultaneous augmentation/
mastopexy: a retrospective 5-year review of 332 consecutive cases.
Plast Reconstr Surg. 2013;131:145–156. The authors describe their large
experience with combined augmentation mastopexy procedures, resulting
in a 20 percent reoperation rate in primary combined procedures and a 30
percent reoperation rate in secondary combined procedures.
7. Stevens WG, Macias LH, Spring M, et al. One-stage augmentation
mastopexy: a review of 1192 simultaneous breast augmentation and
mastopexy procedures in 615 consecutive patients. Aesthet Surg J.
2014;34:723–732. A single-center review of 615 consecutive patients that
underwent one-stage augmentation mastopexy with demographic and
surgical descriptions, clinical examples and complication statistics.
8. Stevens WG, Freeman ME, Stoker DA, et al. One-stage mastopexy
with breast augmentation: a review of 321 patients. Plast Reconstr
Surg. 2007;120:1674–1679. A retrospective review of 321 consecutive
patients who underwent one-stage augmentation mastopxy. The review
includes information about patient demographics, operative technique,
postoperative results, complications and revision rates.
11. Spear SL, Pelletiere CV, Menon N. One-stage augmentation
combined with mastopexy: aesthetic results and patient satisfaction.
Aesthetic Plast Surg. 2004;28:259–267. A retrospective chart review of 34
patients who underwent one staged augmentation mastopexy. An aesthetic
rating scale survey was conducted, showing that on average patients were
satisfied with their result.
15. Parsa AA, Jackowe DJ, Parsa FD. A new algorithm for breast
mastopexy/augmentation. Plast Reconstr Surg. 2010;125:75e–77e.
The authors have devised an algorithm for augmentation mastopexy based
on the degree of breast ptosis. In addition they suggest a classification of
“breast nadir” rather than nipple position to classify ptosis.
52. Spear SL, Dayan JH, Clemens MW. Augmentation mastopexy. Clin
Plast Surg. 2009;36:105–115.
64. Spear SL, Low M, Ducic I. Revision augmentation mastopexy:
indications, operations, and outcomes. Ann Plast Surg. 2003;
51:540–546. An 8-year retrospective review of 20 patients who
underwent revision augmentation mastopexy. Capsular contracture and
recurrent ptosis were the most common indications for revision.
65. Spear SL, Boehmler JH 4th, Clemens MW. Augmentation/
mastopexy: a 3-year review of a single surgeon’s practice. Plast
Reconstr Surg. 2006;118:136S–151S. A retrospective study of 166 patients
who underwent primary and secondary augmentation and primary and
secondary augmentation/mastopexy. They found that primary
augmentation/mastopexy has a significantly higher complication rate than
primary augmentation. Secondary augmentation/mastopexy has higher
revision and complication rates as well.
83. Barnsley GP, Sigurdson LJ, Barnsley SE. Textured surface breast
implants in the prevention of capsular contracture among breast
augmentation patients: a meta-analysis of randomized controlled
trials. Plast Reconstr Surg. 2006;117:2182–2190. A meta analysis of 11
trials which demonstrate a decreased capsular contracture rate with
textured implants vs smooth.
Access the complete reference list online at

123.e1
References
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in a 20 percent reoperation rate in primary combined procedures and a 30
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7. Stevens WG, Macias LH, Spring M, et al. One-stage augmentation
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anatomical placement and implant device type. J Plast Reconstr
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65. Spear SL, Boehmler JH 4th, Clemens MW. Augmentation/
mastopexy: a 3-year review of a single surgeon’s practice. Plast
Reconstr Surg. 2006;118:136S–151S. A retrospective study of 166 patients
who underwent primary and secondary augmentation and primary and
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primary augmentation. Secondary augmentation/mastopexy has higher
revision and complication rates as well.
66. Cárdenas-Camarena L, Ramírez-Macías R, et al. Augmentation/
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Surg. 2002;29:337–347.

SECTION I • Aesthetic Breast Surgery
8 
Secondary aesthetic breast surgery
Scott L. Spear† and Benjamin J. Brown
SYNOPSIS
■ The best intervention is to prevent secondary deformities through
thoughtful planning and careful and principled techniques.
■ “Re-operation” is defined here as any subsequent surgery on a
previously operated breast, including non-aesthetic procedures such
as a lumpectomy.
■ Scarring, tissue atrophy, and altered blood supply make secondary
aesthetic breast surgery more challenging than primary aesthetic
breast surgery, and therefore, these revisionary procedures carry a
higher risk of complications and patient disappointment.
■ Reasons for early revisionary breast surgery are deformities that arise
shortly after the initial operation, such as implant malposition, early
capsular contracture, double-bubble deformity, and Snoopy-nose
deformity.
■ Reasons for late revisionary surgery include deformities, such as
breast ptosis, implant rupture, size change, and late capsular
contracture.
Introduction
Despite our best efforts, there are many complications
that can occur after aesthetic breast surgery. The best
intervention is to prevent these secondary deformities
through thoughtful planning and careful and principled
techniques (covered elsewhere). The focus of this chapter
is on revisionary surgery after prior breast augmenta­
tion, mastopexy, and augmentation-mastopexy. The
authors believe in making the distinction between re-
operation and revision. “Re-operation” is defined here
as any subsequent surgery on a previously operated
breast, including non-aesthetic procedures such as a
lumpectomy. In this chapter, “revision” refers to
procedures performed with the goal of correcting a
deformity caused by prior aesthetic breast surgery. Scar­
ring, tissue atrophy, and altered blood supply make
secondary aesthetic breast surgery more challenging
than primary aesthetic breast surgery, and therefore,
these revisionary procedures carry a higher risk of
complications and patient disappointment.1 Careful
analysis and planning, however, can set the stage for
and improve the likelihood of a good outcome and a
satisfied patient.
“Early” revisionary surgery is defined here as an
operation performed within 12 months of the index
aesthetic procedure. Reasons for early revisionary breast
surgery are deformities that arise shortly after the initial
operation such as implant malposition, early capsular
contracture, double-bubble deformity, and Snoopy-nose
deformity. Late revisionary surgery is performed to
correct deformities that develop after 1 year. These
deformities are less likely to be technique- or judgment-
related and may actually be inevitable and not necessar­
ily preventable. Reasons for late revisionary surgery
include deformities such as breast ptosis, implant
rupture, size change, and late capsular contracture.
Revisionary surgery after
breast augmentation
Gabriel et al. followed 1800 patients after primary breast
augmentation and found a re-operative rate of 12% at
5 years.2 Allergan 10-year data on fourth generation
smooth round silicone implants found a 10-year
re-operation rate of 36.1% (Table 8.1).3
†Deceased

125
Revisionary surgery after breast augmentation
subpectoral, subpectoral to subglandular, or creation of
a neosubpectoral pocket (Fig. 8.2).6 This new pocket,
dissected just superficial to the previous aberrant sub­
pectoral plane, allows the implant to sit on the repair
and act as a buttress reinforcing the repair, rather than
as a wedge trying to disrupt the repair. Capsular flaps,
as described by Bengtson et al. in 1993, is another useful
technique to alter the pocket.7,8 Capsular flaps can be
used to create vascularized slings to alter the implant
pocket. Unlike a simple capsulorrhaphy, the use of cap­
sular flaps can give the surgeon more freedom to place
the suture line in a more advantageous location to reduce
the ability of the device to disrupt the repair (Fig. 8.3).
Early complications
Implant malposition refers to an implant that is located
beyond the ideal borders of an aesthetic appearing
breast. Implant malposition can be superior, inferior,
medial (symmastia), and/or lateral. Some of the most
common causes of implant malposition include over-
dissection of the pocket beyond the ideal medial, lateral,
and inferior breast footprint. Inadequate lower pole
dual-plane release, hematoma, and/or an excessively
large or wide implant can also result in implant malpo­
sition. Inferior implant malposition is usually caused by
over-dissection inferiorly and disruption of the inframa­
mmary fold. Medial implant malposition is usually
caused by over-dissection medially as well as using an
excessively wide implant. Lateral implant malposition
is the most commonly observed implant malposition.
Lateral implant malposition is usually caused by over-
dissection of the pocket laterally, which can be further
exacerbated by the convexity of the chest wall and
compressive forces generated by the pectoralis major
muscle. Superior implant malposition is most com­
monly seen following transaxillary and periareolar
breast augmentation due to inadequate lower pocket
release or dissection.
The treatment for implant malposition involves recre­
ating an implant pocket of appropriate shape, location,
and size. For lateral implant malposition, the pocket
must be moved medially. This is usually accomplished
by shifting the lateral breast border more medially and,
if indicated, performing a medial capsulotomy as well.
The lateral border of the pocket can be reconstructed
in a number of ways, including a capsulorrhaphy, as
described by Spear and Little in 1988, whereby the
implant capsular tissue is incised and repaired with
sutures to reduce the size of the pocket (Fig. 8.1).4,5
Medial implant malposition, often termed “symmastia”,
is a more difficult problem to solve because it is typically
associated with the separation of pre-sternal tissues from
the sternum. Reconstructing these attachments requires
a strong and durable repair because the implant acts like
a wedge and will often re-open the undesired space if
left in the same tissue plane. For this reason, the authors’
preferred technique for the correction of symmastia is
a site change, including converting subglandular to
Table 8.1  Adverse outcomes at 10 years post-implantation with
Allergan Natrelle silicone gel-filled breast implants.
(%)
Rupture
10.1
Capsular contracture (III or IV)
19.1
Re-operation for any reason
36.1
A
Fig. 8.1  (A,B) Capsulorrhaphy to modify pocket. The implant capsular tissue is
incised and repaired with sutures to reduce the size of the pocket. (Case courtesy of
Scott Spear, MD.)
B

126
SECTION I
CHAPTER 8 • Secondary aesthetic breast surgery
The authors most commonly utilize capsular flaps or
the neo-subpectoral pocket for treating inferior implant
malposition. For superior implant malposition, the
authors have found that isolated inferior capsulotomy
is insufficient to treat the problem and the preferred
technique for treating superior implant malposition is
the dual-plane conversion, as described by Spear et al.
in 2003 (Fig. 8.4).9 Acellular dermal matrices (ADM)
can be used to reinforce a capsulotomy, capsulorrhaphy,
capsular flap, or anywhere there is a paucity of stout
tissue (Fig. 8.5).10,11 An additional benefit of ADM are
their application when the “reconstructive technique” is
used to support the weight of the implant by off-loading
the skin and glandular tissue by supporting and cover­
ing the implant with ADM and pectoralis major muscle
(Fig. 8.6).10 Although the cost of ADM is significant,
its cost is less than the cost of additional operations,
not to mention the time spent recovering. For cases of
inferior and lateral implant malposition, some surgeons
advocate a pocket change to the subglandular pocket
to remove the compressive force of the pectoralis major
muscle that squeezes the implant inferiorly and later­
ally; however, if the implant is in a dual-plane position,
Fig. 8.3  (A,B) Capsular flaps can give the surgeon more freedom to place the
suture line in a more advantageous location to reduce the ability of the device to
disrupt the repair. (Case courtesy of Ben Brown, MD.)
A
B
then the inferior and lateral portions of the pocket are
already subglandular and so would need additional
repair of some sort. It is possible that once a repair has
been performed, a textured device may be less prone to
recurrent malposition, but there is no known evidence
that would substantiate that belief.
Nipple areolar complex (NAC) malposition refers to
an unaesthetic location of the NAC after breast augmen­
tation. NAC malposition is often not caused by breast
augmentation but rather accentuated and made appar­
ent by it. All women have some degree of nipple asym­
metry, and therefore it is wise for the plastic surgeon to
point this out preoperatively. NAC malposition caused
by breast augmentation is usually related to implant
malposition, the treatment of which is described above.
If NAC malposition is due to unrecognized ptosis, it can
be treated by subsequent mastopexy, which is described
elsewhere in this text.
A scar tissue capsule inevitably forms around all
breast implants. Capsular contracture refers to the symp­
tomatic and pathologic contracture of this otherwise
non-problematic scar capsule. Capsular contracture is a
poorly understood process but is thought to be an exag­
gerated foreign body response that, if severe enough,
can produce hard, deformed, and painful breasts.12 The
Pectoralis major muscle
Neo-subpectoral
space
Implant
Anterior surface of
implant capsule
Fig. 8.2  Neo-subpectoral pocket. The neo-subpectoral plane is shown located
between the anterior surface of the anterior implant capsule and the posterior
surfaces of the pectoralis major muscle superiorly and breast parenchyma inferiorly.
Correction of symmastia is a site change including converting subglandular to
subpectoral, subpectoral to subglandular, or creation of a neo-subpectoral pocket.
(Redrawn after Spear SL. Surgery of the Breast: Principles and Art, 3, Illustrated.
Philadelphia: Lippincott Williams & Wilkins; 2010:1479.)

127
Revisionary surgery after breast augmentation
Fig. 8.5  Gutter technique. Acellular dermal matrices can
be used to reinforce a capsulotomy, capsulorrhaphy,
capsular flap, or anywhere there is a paucity of stout
tissue. (Redrawn after Spear SL, Seruya M, Clemens MW,
Teitelbaum S, & Nahabedian MY. Acellular dermal matrix
for the treatment and prevention of implant-associated
breast deformities. Plastic and Reconstructive Surgery.
2001; 127(3):1047–58. doi:10.1097/
PRS.0b013e31820436af.)
A
B
Fig. 8.4  (A,B) Converting an existing implant pocket
to a dual-plane pocket. Our preferred technique for
treating superior implant malposition and double-
bubble deformity is the dual-plane conversion. (Case
courtesy of Ben Brown, MD.)
A
B
grading system for capsular contracture around breast
implants was defined by Baker in 1977 and modified by
Spear for reconstructive cases in 1995.13,14 Early capsular
contracture refers to capsular contracture that occurs
within 1 year of implant placement. For early capsular
contracture, the authors recommend aggressive man­
agement, similar to how one might treat a periprosthetic
infection. This includes a total capsulectomy, systemic
antibiotics, creation of a virgin pocket, and placement
of a new device. The use of an ADM has also shown
promise in preventing capsular contracture.10
Visible rippling is the result of implants deforming to
a “more” anatomic shape beneath an inadequate soft-
tissue envelope. As gravity shifts the saline or gel from
the superior portion of the device to the inferior portion
of the device, the superior portion becomes relatively
“under-filled” and the redundant superior shell subse­
quently ripples. Treatment options for visible rippling
include increasing the soft-tissue coverage and decreas­
ing the rippling of the actual device. Options to improve
soft-tissue coverage include upper pole pectoralis
muscle coverage as a dual-plane conversion (Fig. 8.4) if
the device was in a subglandular plane. Fat grafting
or placement of an onlay or supporting ADM can also
be used to improve soft-tissue coverage. Options
to decrease device rippling include exchange for an
implant with a higher fill ratio or the use of a more
highly cohesive silicone gel implant.
A double-bubble deformity is the presence of a con­
stricting band or fold in the inferior pole of the breast

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CHAPTER 8 • Secondary aesthetic breast surgery
Fig. 8.6  (A,B) Moving the pectoralis major muscle into a more anatomic position by freeing its superficial surface from the overlying breast and anchoring the muscle with
an overlapping sheet of acellular dermal matrices (ADM) to the inferior and lateral breast folds similar to the ADM-assisted reconstruction technique. (Case courtesy of
Scott Spear, MD.)
Pectoralis major
Alloderm©
tissue matrix
A
B
Fig. 8.7  (A,B) A double-bubble deformity is the presence of a constricting band
or fold in the inferior pole of the breast that creates the appearance of two folds.
(Case courtesy of Scott Spear, MD.)
A
B
that creates the appearance of two folds (Fig. 8.7). This
constricting band is usually the native IMF that remains
apparent above the illusion of a new fold created by an
inferior implant malposition. It can also be the result
of incomplete detachment of the lower border of the
pectoralis major muscle associated with a submuscular
pocket dissection. Another cause of the double-bubble
deformity is failure to obliterate the native IMF during
intentional placement of the implant inferior to the
native IMF, as in cases of tuberous breast deformity.
Treatment options for double-bubble deformity include
raising the IMF to its native position as described above,
fat grafting, or obliterating the fold utilizing a dual-plane
conversion.15,16 The dual-plane conversion will ensure
sufficient freedom of the pectoralis major muscle from
the native IMF and lysis of any dermal attachments.
A “Snoopy” deformity refers to ptotic glandular
tissue that appears to be “falling” of the implant. Milder
cases can be treated by conversion to a dual-plane II
or III, which would allow the pectoralis major muscle
and overlying glandular tissue to “window-shade” or
“ascend” up over the device (Fig. 8.8).17 More severe
cases of a Snoopy-nose deformity may require a mas­
topexy to treat the ptotic glandular tissue. A Baker
grade III or IV capsular contracture can create the
appearance of a Snoopy deformity with relative ptosis
of the breast as the breast implant is deformed into a
more spherical shape and shifted superiorly. For these
patients, treatment of the capsular contracture is most
appropriate.

129
Revisionary surgery after breast augmentation
Fig. 8.8  A “Snoopy” deformity refers to ptotic glandular tissue that appears to be “falling” of the implant. Milder cases can be treated by conversion to a dual-plane II or
III, which would allow the pectoralis major muscle and overlying glandular tissue to “window-shade” or “ascend” up over the device. (Redrawn after Tebbetts JB. Dual-plane
breast augmentation: Optimizing implant-soft-tissue relationships in a wide range of breast types. Plastic and Reconstructive Surgery. 2001; 107(5):1255–72.)
Pectoralis
muscle
division
Lateral view
Pectoralis position
related to
anatomic implant
Apply to following
breast types
Most routine breast
(Type I)
Breasts with mobile parenchyma
- muscle interface
(Type II)
Glandular ptotic and constricted
lower pole breast
(Type III)
Parenchyma
muscle (PM)
interface
separation
Parenchyma
Type I
Type I
Type II
Type II
Type III
Type III
No PM interface separation
Complete division along IMF
No division
PM interface separation to interior edges of areola
PM interface separation to superior edge of areola
No division
No division
Animation deformity refers to visible distortion of the
breast implant shape or position secondary to contrac­
tions of the overlying pectoralis major muscle. This may
be made more apparent as a result of inadequate soft-
tissue coverage over the pectoralis major muscle. It may
also be related to how the subpectoral or submuscular
dissection is performed as well as the extent of muscle
development in a given patient. In reality, there is likely
more than one form of animation deformity, including
ironically, either under or overly aggressive muscle
release. One variety is likely due to excessive detach­
ment of the pectoralis major muscle from its sternal
origin, resulting in muscle fibers that “window-shade”
excessively superiorly and also may make the dislocated
muscle appear more bulky. Fortunately, animation
deformity is quite rare in correctly performed

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CHAPTER 8 • Secondary aesthetic breast surgery
safety, and cost, ultrasound will eventual become the
best option. The treatment for silicone gel implant
rupture is when possible a total capsulectomy without
disruption of the capsule, in order to contain and remove
the silicone gel. When this is not possible, the authors
recommend removing as much silicone as possible by a
combination of wiping, irrigating, and cleaning with
Shur-Clens, a useful solvent in which silicone is soluble.
Late seroma has been defined by the Dr. Spear as a
clinically symptomatic seroma that develops at least 12
months after the most recent breast implant surgery.21
The majority of late seromas are idiopathic, without
clear evidence of infection or malignancy. However, late
seromas must be taken seriously given the remote but
ominous possibility of breast implant-associated ana­
plastic large cell lymphoma (BI-ALCL). The incidence
of BI-ALCL with textured implants is thought to be
between 1 : 30 000 and 1 : 300 000, with as many as 5% of
those patients afflicted by ALCL dying from the disease.22
At the time of writing, it remains unclear whether there
were any documented cases of BI-ALCL with smooth
devices. In the published review of Dr. Spear’s practice,
the average interval from the patient’s most recent
breast surgery to late seroma onset was 4.7 years and
96% of these patients had a textured device. Ultrasound-
guided therapeutic aspiration with culture and cytology
is a rational first step, as this was successful in 56% of
the time. If this resolves the problem, nothing further
needs to be done. Indications for capsulectomy and
placement of a new smooth device include a thick
capsule, an abnormal mass within the capsule, evidence
of infection or inflammation, and failure of a prior
percutaneous drainage procedure.21
Stretch deformity refers to an increase in the nipple
to IMF distance, with maintenance of the native IMF. If
an increased nipple to fold distance is due to disruption
of the native IMF – this deformity would be more
appropriately classified as inferior implant malposition.
Lower pole stretch deformity can occur in any breast
but most commonly occurs in patients with excessively
large implants. The weight of these devices place exces­
sive stress on the soft-tissues of the lower pole of the
breast leading to atrophy of breast tissue and expansion
of the lower pole skin. After determining that the native
IMF is intact and the deformity is, in fact, a lower pole
stretch deformity – treatment options include some
form of mastopexy or skin reduction procedure (Fig.
8.9) to remove the excess lower pole skin, exchange for
a smaller device, and possible reinforcement of the
lower pole of the breast with ADM using the reconstruc­
tive technique (Fig. 8.6).23,24
Impending implant extrusion refers to severe atrophy
of breast tissue, such that the device is nearly exposed.
dual-plane breast augmentations and is usually only
seen in competitive bodybuilders.18 Inadequate release
of the lower edge of the pectoralis major, intended or
inadvertent dissection behind the pectoralis minor
muscle, or subserratus dissection may all contribute to
some variation of animation deformity. The treatment
of animation deformity is difficult and, in most cases,
unpredictable. The most predictable form of correction
is achieved by replacing the implant in a pre-pectoral
position and replacing the muscle(s) back on the chest
wall as anatomically as possible.18 Other, much less reli­
able, options include fat grafting to camouflage the
deformity or moving the pectoralis major muscle into a
more anatomic position by freeing its superficial surface
from the overlying breast and anchoring the muscle
with an overlapping sheet of ADM to the inferior and
lateral breast folds similar to the ADM-assisted recon­
struction technique (Fig. 8.6). The ADM in this maneuver
acts like a fascial attachment, which may help the muscle
from “window-shading” superiorly while also creating
an interface to promote the gliding of the soft-tissue
over the surface of the muscle and implant. It is worth
emphasizing again that pre-pectoral repositioning is by
far the most reliable approach to address this challeng­
ing problem.
Late complications
Some amount of breast ptosis is an inevitable component
of aging and may be exacerbated by breast augmenta­
tion due to the increased forces on the tissues from the
weight of the implant. The treatment for breast ptosis
with or without an implant is a mastopexy, which is
described elsewhere in this text.
Late capsular contracture appears to be more related
to the natural history of breast implants and less related
to perioperative factors such as contamination and
inflammation. Therefore, the authors take a less aggres­
sive approach to late capsular contracture than early
capsular contracture. Treatment of late capsular contrac­
ture includes total or sub-total capsulectomy and place­
ment of a new device.
Rupture refers to a disruption of the implant shell that
allows the silicone gel to escape the shell and leak into
the implant pocket and more rarely into the surrounding
tissues. The longer an implant is in place, the more likely
it is to rupture.3 Most cases of rupture are silent, espe­
cially with highly cohesive gel implants.19 Symptoms
such as palpable lumps, skin changes, and axillary ade­
nopathy are usually only present in cases of extracapsu­
lar spread of silicone. MRI currently remains the gold
standard for diagnosing implant rupture,20 although it is
expected that, for reasons of convenience, comfort,

131
Revisionary surgery after breast augmentation
pocket and skin envelope may need a reduction in size
to aesthetically accommodate a smaller implant. What
may initially seem like a rather simple operation,
exchanging large implants for smaller implants may
become a deceptively complicated procedure as it is a
mastopexy on a previously operated augmented breast.
The blood supply to the NAC has been necessarily and
significantly altered in the previously augmented breast.
This is made more significant as the breast tissue typi­
cally becomes atrophic after years of supporting an
implant (Fig. 8.10). The blood supply to the nipple and
breast skin is also altered and becomes more dependent
on the collateral circulation rather than the normal deep
circulation. One option to reduce the risk of complica­
tions in these patients is staging the operation so that
the capsule and skin are not operated on simultane­
ously. The key, however, to safely operating on these
patients is to recognize and respect the compromised
blood supply. To help unweight the skin flaps and
support the implant, one can utilize an ADM to inter­
nally support the device, thereby offloading the breast
tissue (Fig. 8.7). For women who wish to have smaller
breasts and live without implants, simply removing the
implants and doing nothing else may be sufficient,
while for others, this will leave the breasts deflated and
“aged” in appearance. A mastopexy can help in this
situation; however, this needs to be performed very
cautiously with minimal undermining in order to pre­
serve the tenuous blood supply to the nipple as well as
the rest of the breast (Fig. 8.11)
As long as there is no actual exposure and the device
pocket is not contaminated, treatment options include
device removal without replacement or exchange for
a smaller device with ADM reinforcement using the
reconstructive technique, muscle flaps, anterior capsular
rotation flaps, or posterior capsular flaps (Fig. 8.3).23,24
Nipple ptosis and excess lower pole skin may be
addressed with mastopexy techniques.
Women who underwent breast augmentation earlier
in life may wish to have smaller breasts later in life. For
the vast majority of women who want to keep their
breast implants, one option is exchanging the existing
implants with smaller implants. However, the implant
Fig. 8.9  Stretch deformity refers to an increase in the nipple to inframammory fold
(IMF) distance with maintenance of the native IMF. If an increased nipple to fold
distance is due to disruption of the native IMF – this deformity would be more
appropriately classified as inferior implant malposition. Lower pole stretch deformity
can occur in any breast but most commonly occurs in patients with excessively
large implants.
‘Sailboat’
‘Smile’
A
B
Fig. 8.10  (A,B) Exchanging existing implants with smaller implants. The implant pocket and skin envelope may need a reduction in size to aesthetically accommodate a
smaller implant. What may initially seem like a rather simple operation may become a deceptively complicated procedure as it involves mastopexy on a previously operated
augmented breast. (Reproduced with permission from Spear SL. Surgery of the Breast: Principles and Art, 3, Illustrated. Philadelphia: Lippincott Williams & Wilkins; 2010:
1542.)

132
SECTION I
CHAPTER 8 • Secondary aesthetic breast surgery
option is implant removal with a small to moderate
amount of fat grafting. Mastopexy may be necessary to
reduce the size of the breast envelope, with or without
fat grafting. A breast reduction may be an appropriate
solution for patients who have excess breast tissue after
implant removal and wish to be significantly smaller in
size.
Revisionary surgery after mastopexy
NAC malposition after mastopexy refers to an NAC that
is too high, too low, or to the right or left of the breast
meridian. Mallucci and Branford performed a morpho­
metric analysis of breasts and found that breasts with
an upper pole to lower pole ratio of 45 : 55 universally
scored the highest.26 Therefore, for the purposes of this
discussion, the “ideal” nipple position would be on the
breast meridian with a slightly fuller lower pole. An
NAC that is only a couple of centimeters too high can
sometimes be corrected with a mastopexy limited to the
lower pole of the breast by simply shortening the nipple
to IMF distance, assuming that the sternal notch to nipple
distance is not too short (Fig. 8.8). Correction of an NAC
that is too low after mastopexy involves a repeat or revi­
sion mastopexy to elevate the NAC to the appropriate
location. Interestingly, Dr. Spear has found that verti­
cal limbs of the WISE pattern form an upright “V” in
revision mastopexies and reductions, whereas primary
mastopexies and reductions generally have vertical
limbs that form an inverted or upside-down “V”.27 The
authors caution against techniques that involve lower­
ing the IMF to correct an NAC that is too low.28 Although
lowering the IMF can create the appropriate upper pole
to lower pole ratio without actually moving the NAC,
these techniques risk creating a double-bubble deformity
and women generally do not like their breast mounds
positioned low on their chests. Because most mastopexy
techniques leave a scar round the areola, one must be
vigilant in revision mastopexies to maintain continuity
between the NAC and the underlying glandular pedicle
(Fig. 8.11). For cases of more severe NAC malposition
For those women who wish to have their implants
removed but retain some semblance of their augmented
volume, one option to consider is the use of fat grafting
as described by Spear, or fat grafting with pre-expansion
as described by Del Vecchio (Fig. 8.12).1,25
Breast enlargement from weight gain and or pregnan­
cies may cause some women to request removal of their
breast implants to achieve smaller and lighter breasts.
Many techniques exist depending on the current breast
size, volume of the implants, and patient goals. One
Fig. 8.11  Some patients may wish to have smaller breasts and live without
implants. Simply removing the implants and doing nothing else may be sufficient,
while for others this will leave the breasts deflated and “aged” in appearance. A
mastopexy can help in this situation; however, this needs to be performed very
cautiously with minimal undermining in order to preserve the tenuous blood supply
to the nipple as well as the rest of the breast.
Dissected area
Fig. 8.12  Some patients may wish to have their implants
removed but retain some semblance of their augmented
volume. One option to consider is the use of fat grafting as
described by Spear or fat grafting with pre-expansion as
described by Del Vecchio. (Redrawn after Del Vecchio, DA,
Bucky, LP, Breast augmentation using preexpansion and
autologous fat transplantation: A clinical radiographic study.
Plastic and Reconstructive Surgery. 2011;127(6):2441–50.
doi:10.1097/PRS.0b013e3182050a64.)

133
Revisionary surgery after augmentation-mastopexy
not correctable with mastopexy techniques, one may
consider performing transposition flaps or composite
nipple grafting.29,30
Under-correction of glandular ptosis following mas­
topexy refers to breasts that have the NAC appropriately
placed at the IMF but have excess skin and breast tissue
hanging below the IMF. To the untrained eye, these
breasts can appear to have superior NAC malposition
due to the excess lower pole tissue. Treatment of this
deformity is revision mastopexy, typically utilizing a
sailboat or smile mastopexy pattern (Fig. 8.10).
Over-resection of tissue in a mastopexy can leave
patients dissatisfied with the size of their breasts after
surgery. In a series of 61 patients, Weichman et al.
showed that mastopexy alone may result in an average
decrease in one brassiere cup size.31 Preoperatively,
patients should be advised accordingly. For the rare
patient who after a mastopexy wishes to have a larger
breast size, treatment options include augmentation
with implants or augmentation with fat grafting.
Necrosis of the nipple areolar complex, although rare,
is one of the most feared complications in aesthetic
breast surgery. Should it occur, NAC reconstruction
becomes more complex than skin sparing mastectomy
cases because of the compromised tissue and scar
burden at the location of the former and future NAC.
The areola can be reconstructed with full-thickness skin
grafting. Dr. Spear recently utilized Integra Dermal
Regeneration Template (Integra LifeSciences, Plains­
boro, NJ) followed by skin grafting (Fig. 8.13) to recon­
struct the areola. Nipple reconstruction using local flaps
is a poor solution in these patients given the compro­
mised tissue and scar burden; for this reason the authors
recommend composite nipple grafting if the contra­
lateral donor nipple can afford it.30 If nipple sharing is
not an option, tattooing with artistic shading can create
the illusion of a 3D nipple.32
Revisionary surgery after
augmentation-mastopexy
Deformities after augmentation-mastopexy include
those resulting from the implant, those associated
with the soft-tissue envelope, and those associated
with the interaction between an altered soft-tissue
envelope and the device within. For an explanation of
implant-related problems and their solutions, refer to
the “Revisionary surgery after breast augmentation”
section above. For an explanation of soft tissue–related
deformities and their solutions, refer to the “Revisionary
surgery after mastopexy” section above. The remain­
der of this section focuses on special considerations
Fig. 8.13  Necrosis of the nipple areolar complex, although rare is one of the most
feared complications in aesthetic breast surgery. The authors were recently referred
a patient who suffered necrosis following an augmentation-mastopexy. The eschar
was excised, and Integra Dermal Regeneration Template (Integra LifeSciences,
Plainsboro, NJ) was utilized followed by skin grafting to reconstruct the areola.
(Case courtesy of Scott Spear, MD.)
A
B
in augmentation-mastopexy due to the interaction
between an altered soft-tissue envelope and the
device within.
The most important consideration in both primary
and revision augmentation mastopexy is maintenance
of an adequate blood supply to the NAC. Losee et al.
reported that secondary breast reductions can be safely
performed with a different pedicle than the primary
breast reduction.33 The authors maintain NAC perfusion
in both primary and secondary augmentation-mastopexy
by utilizing a superior glandular pedicle, even when an
inferior pedicle had been used previously. This pedicle
is maintained by performing little to no undermining
superiorly between 3 and 9 o’clock. Using this technique,
the NAC is translated superiorly, while its pedicle is
theoretically imbricated beneath the skin closure;
however, in practice this “imbrication” is not apparent
and has not, in our experience, created any subsequent
skin tethering or irregularities.

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CHAPTER 8 • Secondary aesthetic breast surgery
and reshape the breast. In cases of periareolar deformi­
ties, the addition of vertical limbs to the mastopexy
pattern allows the outer aperture to be designed nearly
the same size as the new areola, thereby reducing the
tension at closure and improving the resultant scar.
Conclusion
Armed with an understanding of the various problems
that can occur following cosmetic breast surgery, the
astute plastic surgeon can take measures to help prevent
their occurrence. When treating patients with an unsat­
isfactory result following cosmetic breast surgery,
remember that scarring, tissue atrophy, and altered
blood supply make secondary aesthetic breast surgery
more challenging than primary aesthetic breast surgery.
These revisionary procedures deserve thoughtful plan­
ning, sufficient OR time, and meticulous execution.
The risk of implant exposure following augmentation-
mastopexy can be reduced by planning the operation
such that the glandular incision to create the implant
pocket is not confluent with a T-junction at skin closure.
When certain that a vertical scar will be necessary, the
authors prefer to perform the augmentation first through
a vertical incision located between the two vertical limbs
of the planned mastopexy. The authors recommend
de-epithelializing a centimeter or so around this vertical
incision to allow future multi-layer closure, including a
dermal layer, over the device. Once the devices are in
place and the vertical parenchymal incisions are closed,
the skin is tailor-tacked using the preoperative mark­
ings as a guide. The mastopexy markings are adjusted
as deemed appropriate, and the skin within the mark­
ings is de-epithelialized. Next, the dermis along the
markings is incised full thickness with the Bovie on cut,
just enough to release it without injuring the subdermal
plexus. No flaps are created. Full-thickness dermal
scoring usually allows the skin to close and evert nicely
without any tethering or contour deformities. If under­
mining is necessary, it should be done judiciously, no
more than 1–2 cm, in a very superficial plane under the
dermis so as to not compromise the glandular pedicle
perfusing the NAC (Fig. 8.12).
Periareolar deformities are most common after peri­
areolar mastopexy techniques. Patients find periareolar
mastopexy techniques appealing because they avoid
vertical and inframammary scars on the breast. Unfor­
tunately, the power and control offered by periareolar
techniques are very limited. Not surprisingly, patient
satisfaction after periareolar techniques is lower than
with other more powerful mastopexy techniques.34
Most periareolar deformities arise when plastic sur­
geons push the limits of a periareolar mastopexy in
the hope that it will correct more severe cases of ptosis.
The authors recommend limiting the use of periareolar
mastopexy techniques for the treatment of large areolas
and minimal degrees of NAC ptosis, no more than 2 cm.
Unsightly periareolar scars around the areola are unfor­
tunately common due to excessive tension at the time
of purse-string closure of the large outer aperture to
the smaller inner aperture around the remaining areola.
Spear et al. have published guidelines for the use of
periareolar mastopexy to help reduce such complica­
tions.35 The use of a scar blocking stitch placed in a
wagon-wheel fashion around the areola, as described by
Hammond et al., is a technique used by many to help
prevent unsightly scars around the areola (Fig. 8.14).36 In
most cases, treatment of periareolar deformities involves
performing a circumvertical mastopexy. The addition
of the vertical limbs provides the plastic surgeon with
much more power and control to reposition the NAC
Fig. 8.14  (A,B) The use of a scar blocking stitch placed in a wagon-wheel fashion
around the areola, as described by Hammond, is a technique used by many to help
prevent unsightly scars around the areola. (Reproduced with permission from
Hammond DC, Khuthaila DK, & Kim J. The interlocking gore-tex suture for control of
areolar diameter and shape. Plastic and Reconstructive Surgery. 2007;119(3):804–
9. doi:10.1097/01.prs.0000251998.50345.e9.)
A
B

135
Conclusion
6. Spear SL, Dayan JH, Bogue D, et al. The “neosubpectoral” pocket
for the correction of symmastia. Plast Reconstr Surg. 2009;124:695–
703. The neosubpectoral pocket is a useful and effective technique for
correction of symmastia. By placing the implant into a new tissue plane, it
serves a buttress to help maintain closure of the former implant pocket.
9. Spear SL, Carter ME, Ganz JC. The correction of capsular
contracture by conversion to “dual-plane” positioning: technique
and outcomes. Plast Reconstr Surg. 2003;112:456–466. Capsular
contracture is a common problem that frequently presents with superior
implant malposition. Anterior/inferior capsulectomy with conversion to a
dual-plane pocket is an effective and reliable technique to treat this
problem.
10. Spear SL, Seruya M, Clemens MW, et al. Acellular dermal matrix
for the treatment and prevention of implant-associated breast
deformities. Plast Reconstr Surg. 2011;127:1047–1058. This article
summarizes the many uses of ADM in secondary aesthetic breast surgery.
We often counsel patients that although the use of ADM is an added cost,
it is generally less than the cost of yet another revisionary procedure.
17. Tebbetts JB. Dual plane breast augmentation: optimizing implant-
soft-tissue relationships in a wide range of breast types. Plast
Reconstr Surg. 2001;107:1255–1272. This is the seminal article on the
“dual-plane” technique for breast augmentation.
21. Spear SL, Rottman SJ, Glicksman C, et al. Late seromas after breast
implants: theory and practice. Plast Reconstr Surg. 2012;130:423–435.
Late seromas can be the sign of a more serious problem, and therefore all
plastic surgeons should understand how to manage these patients.
22. Clemens MW, Butler CE, Hunt KK, et al. Breast implant-associated
anaplastic large cell lymphoma: staging, disease progression, and
management strategies. Plast Reconstr Surg. 2015;135:1184. Breast
implant-associated ALCL is very rare. Because breast implants are so
common, every plastic surgeon should be aware of the current guidelines
regarding the evaluation and management of breast implant-associated
ALCL.
23. Spring MA, Macias LH, Nadeau M, et al. Secondary augmentation-
mastopexy: indications, preferred practices, and the treatment of
complications. Aesthet Surg J. 2014;34:1018–1040. Excellent article that
reviews Dr. Grant Steven’s experience with secondary breast
augmentation-mastopexy.
26. Mallucci P, Branford OA. Population analysis of the perfect breast: a
morphometric analysis. Plast Reconstr Surg. 2014;134:436–447. This
article objectively and geometrically describes the “ideal” nipple position.
35. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast
Reconstr Surg. 2001;107:1294–1300. This article is a concise overview of
the periareolar mastopexy. It describes its limitations and pitfalls as well
as how to plan, mark, and execute the procedure.
36. Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex
suture for control of areolar diameter and shape. Plast Reconstr
Surg. 2007;119:804–809. The interlocking Gore-Tex suture is one of the
greatest contributions to breast surgery in the past decade. This technique
does an excellent job insetting areolae and maintaining their size over
time.
Access the complete reference list online at

135.e1
References
References
1. Spear SL, Pittman T. A prospective study on lipoaugmentation of
the breast. Aesthet Surg J. 2014;34:400–408.
2. Gabriel SE, Woods JE, O’Fallon WM, et al. Complications leading to
surgery after breast implantation. N Engl J Med. 1997;336:677–682.
3. Spear SL, Murphy DK, Allergan Silicone Breast Implant U.S. Core
Clinical Study Group. Natrelle round silicone breast implants: core
study results at 10 years. Plast Reconstr Surg. 2014;133:1354–1361.
4. Spear SL, Little JW 3rd. Breast capsulorrhaphy. Plast Reconstr Surg.
1988;81:274–279.
5. Parsa FD. Breast capsulopexy for capsular ptosis after augmentation
mammaplasty. Plast Reconstr Surg. 1990;85:809–812.
6. Spear SL, Dayan JH, Bogue D, et al. The “neosubpectoral” pocket
for the correction of symmastia. Plast Reconstr Surg. 2009;124:695–
703. The neosubpectoral pocket is a useful and effective technique for
correction of symmastia. By placing the implant into a new tissue plane, it
serves a buttress to help maintain closure of the former implant pocket.
7. Bengtson BP, Ringler SL, George ER, et al. Capsular tissue: a new
local flap. Plast Reconstr Surg. 1993;91:1073–1079.
8. Voice SD, Carlsen LN. Using a capsular flap to correct breast
implant malposition. Aesthet Surg J. 2001;21:441–444.
9. Spear SL, Carter ME, Ganz JC. The correction of capsular
contracture by conversion to “dual-plane” positioning: technique
and outcomes. Plast Reconstr Surg. 2003;112:456–466. Capsular
contracture is a common problem that frequently presents with superior
implant malposition. Anterior/inferior capsulectomy with conversion to a
dual-plane pocket is an effective and reliable technique to treat this
problem.
10. Spear SL, Seruya M, Clemens MW, et al. Acellular dermal matrix
for the treatment and prevention of implant-associated breast
deformities. Plast Reconstr Surg. 2011;127:1047–1058. This article
summarizes the many uses of ADM in secondary aesthetic breast surgery.
We often counsel patients that although the use of ADM is an added cost,
it is generally less than the cost of yet another revisionary procedure.
11. Maxwell GP, Gabriel A. Non-cross-linked porcine acellular dermal
matrix in revision breast surgery: long-term outcomes and safety
with neopectoral pockets. Aesthet Surg J. 2014;34:551–559.
12. Imber G, Schwager RG, Guthrie RH, et al. Fibrous capsule
formation after subcutaneous implantation of synthetic materials in
experimental animals. Plast Reconstr Surg. 1974;54:183–186.
13. Spear SL, Baker JL. Classification of capsular contracture after
prosthetic breast reconstruction. Plast Reconstr Surg.
1995;96:1119–1124.
14. Wagner H, Beller FK, Pfautsch M. Electron and light microscopy
examination of capsules around breast implants. Plast Reconstr Surg.
1977;60:49–55.
15. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety
and efficacy. Plast Reconstr Surg. 2007;119:775–787.
16. Spear SL, Pittman T. Discussion: the double-bubble deformity:
cause, prevention, and treatment. Plast Reconstr Surg. 2013;132:
1444–1445.
17. Tebbetts JB. Dual plane breast augmentation: optimizing implant-
soft-tissue relationships in a wide range of breast types. Plast
Reconstr Surg. 2001;107:1255–1272. This is the seminal article on the
“dual-plane” technique for breast augmentation.
18. Spear SL, Schwartz J, Dayan JH, et al. Outcome assessment of
breast distortion following submuscular breast augmentation.
Aesthetic Plast Surg. 2009;33:44–48.
19. Hölmich LR, Lipworth L, McLaughlin JK, et al. Breast implant
rupture and connective tissue disease: a review of the literature.
Plast Reconstr Surg. 2007;120:62S–69S.
20. Handel N, Garcia ME, Wixtrom R. Breast implant rupture: causes,
incidence, clinical impact, and management. Plast Reconstr Surg.
2013;132:1128–1137.
21. Spear SL, Rottman SJ, Glicksman C, et al. Late seromas after breast
implants: theory and practice. Plast Reconstr Surg. 2012;130:423–435.
Late seromas can be the sign of a more serious problem, and therefore all
plastic surgeons should understand how to manage these patients.
22. Clemens MW, Butler CE, Hunt KK, et al. Breast implant-associated
anaplastic large cell lymphoma: staging, disease progression, and
management strategies. Plast Reconstr Surg. 2015;135:1184. Breast
implant-associated ALCL is very rare. Because breast implants are so
common, every plastic surgeon should be aware of the current guidelines
regarding the evaluation and management of breast implant-associated
ALCL.
23. Spring MA, Macias LH, Nadeau M, et al. Secondary augmentation-
mastopexy: indications, preferred practices, and the treatment of
complications. Aesthet Surg J. 2014;34:1018–1040. Excellent article that
reviews Dr. Grant Steven’s experience with secondary breast
augmentation-mastopexy.
24. Maxwell GP, Gabriel A. Acellular dermal matrix for reoperative
breast augmentation. Plast Reconstr Surg. 2014;134:932–938.
25. Del Vecchio DA. “SIEF” – simultaneous implant exchange with fat:
a new option in revision breast implant surgery. Plast Reconstr Surg.
2012;130:1187–1196.
26. Mallucci P, Branford OA. Population analysis of the perfect breast: a
morphometric analysis. Plast Reconstr Surg. 2014;134:436–447. This
article objectively and geometrically describes the “ideal” nipple position.
27. Spear SL. Surgery of the Breast: Principles and Art, 3, Illustrated.
Philadelphia: Lippincott Williams & Wilkins; 2010.
28. Hedén P. Mastopexy augmentation with form stable breast
implants. Clin Plast Surg. 2009;36:91–104, vii.
29. Spear SL, Albino FP, Al-Attar A. Classification and management of
the postoperative, high-riding nipple. Plast Reconstr Surg. 2013;
131:1413–1421.
30. Spear SL, Schaffner AD, Jespersen MR, et al. Donor-site morbidity
and patient satisfaction using a composite nipple graft for unilateral
nipple reconstruction in the radiated and nonradiated breast. Plast
Reconstr Surg. 2011;127:1437–1446.
31. Weichman K, Doft M, Matarasso A. The impact of mastopexy on
brassiere cup size. Plast Reconstr Surg. 2014;134:34e–40e.
32. Halvorson EG, Cormican M, West ME, et al. Three-dimensional
nipple-areola tattooing: a new technique with superior results. Plast
Reconstr Surg. 2014;133:1073–1075.
33. Losee JE, Caldwell EH, Serletti JM. Secondary reduction
mammaplasty: is using a different pedicle safe? Plast Reconstr Surg.
2000;106:1004–1010.
34. Rohrich RJ, Gosman AA, Brown SA, et al. Mastopexy preferences: a
survey of board-certified plastic surgeons. Plast Reconstr Surg.
2006;118:1631–1638.
35. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast
Reconstr Surg. 2001;107:1294–1300. This article is a concise overview of
the periareolar mastopexy. It describes its limitations and pitfalls as well
as how to plan, mark, and execute the procedure.
36. Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex
suture for control of areolar diameter and shape. Plast Reconstr
Surg. 2007;119:804–809. The interlocking Gore-Tex suture is one of the
greatest contributions to breast surgery in the past decade. This technique
does an excellent job insetting areolae and maintaining their size over
time.

SECTION I • Aesthetic Breast Surgery
9 
Reduction mammaplasty with
inverted-T techniques
Maurice Y. Nahabedian
SYNOPSIS
■ The inverted-T technique for reduction mammaplasty is diverse and
can be applied for the majority of women seeking reduction
mammaplasty.
■ Patient selection is a critical aspect with regard to the type of pedicle
selected for transposition of the nipple areolar complex.
■ The bipedicle techniques were among the first described and have
been performed less frequently in favor of the unipedicle methods.
■ The inferior pedicle reduction mammaplasty utilizing the inverted-T
design is the most commonly utilized technique.
■ The medial pedicle technique incorporates the dominant internal
mammary perforators as its primary blood supply and may be useful
for women with moderate to severe mammary hypertrophy.
■ The central mound technique incorporates the 4th intercostal artery to
perfuse the nipple areolar complex and is useful for mild to moderate
volume reduction mammaplasty.
■ Complications following inverted-T reduction mammaplasty are
infrequent and include delayed healing at the trifurcation, loss of nipple
areolar sensation, fat necrosis, and complex scar.
Access the Historical Perspective section online at

Introduction
The evolution of reduction mammaplasty over the past
century can be characterized as innovative, imaginative,
and diverse. It is estimated that over 50 variations and
techniques for reduction mammaplasty have been
described. These variations are based on skin pattern
design, as well as pedicle selection for transposition of
the nipple areolar complex. Skin patterns have varied
from short scar to long scar techniques and nipple
transposition techniques have varied from free graft to
dermal pedicles to dermo-parenchymal pedicles with
orientations that can be anywhere along a 360° circle.
All of these approaches have demonstrated success in
certain situations. The debate as to whether one tech­
nique for reduction mammaplasty would be sufficient
for all types of patients and breasts has been abandoned
for all intent and purposes. It is accepted that individu­
alized options for reduction mammaplasty are preferred
and will usually generate optimal outcomes.
An important concept with reduction mammaplasty
is differentiating the “cosmetic” reduction mamma­
plasty from the “functional” reduction mammaplasty.
There is an overlap between these two because all
reduction mammaplasty procedures are aesthetic in
concept and design. The principles governing cosmetic
versus functional reduction mammaplasty are impor­
tant to differentiate for a variety of reasons that include
patient expectations, surgical technique, and insurance
reimbursement. The purely cosmetic patient is usually
one that has mild to moderate mammary hypertrophy
that typically requires a minimal reduction defined as
less than 300 g. These patients usually are not symptom­
atic or debilitated by the size of their breasts and are
primarily concerned with shape and contour and often
wish to minimize scar. It is recognized, however, that
there are situations in which a thin and petite woman
with relative mammary hypertrophy would function­
ally benefit from a reduction that was less than 300 g.
There is a another subset of patients with moderate to
severe mammary hypertrophy who are symptomatic
and plagued with back pain, intertrigo, and postural
  Access video lecture content for this chapter online at expertconsult.com

136.e1
Historical perspective
Historical perspective
The debates between the long scar techniques also
referred to as the “inverted-T” and the short scar
techniques often referred to as “the vertical or hori­
zontal techniques” are long standing. Robert Goldwyn,
in his textbook Plastic and Reconstructive Surgery of
the Breast, describes many of the early techniques by
which reduction mammaplasty was performed.1 Inter­
estingly, many of the early techniques were all based
on short scar techniques. Several surgeons described
these techniques and included the inframammary
incision only by Guinard in 1903, Morestin in 1905,
and Passot in 1921. The vertical incision with a short
horizontal component was first described by Lexer in
1923. This was converted into a vertical only incision
as described by Lotsch in 1923 and Dartigues in 1925.
One of the limitations in this early era of short scar
reduction mammaplasty was that photography was not
readily available, so many of the outcomes cannot be
assessed.
In 1956, Robert Wise described the inverted-T pattern
and stated that one of the principal reasons for this
pattern was to overcome some of the shortcomings in
the shaping of the breast that was encountered with
some of the short scar methods.2,3 The inverted-T inci­
sion allowed for 3D control of the breast and improved
the predictability and reproducibility of the final
outcome. The original inverted-T operation has under­
gone numerous modifications over the years, but the
basic pattern has been retained and has been adopted
by many plastic surgeons around the world because of
its reliability and ability to deliver attractive outcomes
in the vast majority of cases.
The past decade has focused on the various incisional
patterns and pedicle types, especially in patients with
severe mammary hypertrophy.4 Some of the various
pedicles include the medial, superomedial, central
mound, inferior, lateral, superior, as well as the vertical
and horizontal bipedicle techniques. Each of these
techniques is capable of delivering a good to excellent
outcome, and these are reasons to consider one over the
other. Advocates for medial pedicle techniques cite
improved vascularity, innervation, and less bottoming
out of the breast over time. Inferior pedicle techniques
provide improved versatility because the pedicle is not
rotated; however, limitations include a tendency to
bottom out over time. The central mound provides
excellent vascularity and mobility but may be less effec­
tive for resections exceeding 1000 g/breast. Some sur­
geons feel that resections in excess of 1000 g/breast are
more susceptible to nipple and/or fat necrosis using
traditional pedicle techniques.
These diversities have spawned innovation and
advancements in reduction mammaplasty procedures.
All are based on capturing one of the many sources of
vascularity to the breast parenchyma and nipple areolar
complex. Retaining the innervation is possible with
most techniques, but on rare occasions, it is lost or
diminished. The incisional patterns are based on creat­
ing a well-shaped breast with optimal positioning of the
nipple areolar complex to improve upon the aesthetics
and reduce the degree of discomfort.

137
The inverted-T skin pattern
The implication is that sensation is more likely preserved
by minimizing the amount of medial dissection and by
preserving the deep central mound along the 4th inter­
costal segment.
The inverted-T skin pattern
The inverted-T pattern has undergone several modifica­
tions over the years. The original pattern described by
Robert Wise was based on the manufacturing process
for a woman’s brassiere taking into account the some­
what conical shape of the breast. A skin pattern was
delineated that had relationships to the chest circumfer­
ence, angulation of the chest wall, and the breast size.
The classic inverted-T pattern had vertical and horizon­
tal limbs with a keyhole pattern at the upper apex for
insetting of the nipple areolar complex. A variation of
this method, shown below, has been adopted by the
author and has provided consistent and reproducible
results.
changes and who are primarily interested in relieving
symptoms, secondarily interested in improving aesthet­
ics, and are less concerned with the amount and location
of the scars. These patients typically require a functional
reduction mammaplasty. These differences are impor­
tant to differentiate because whether the patient pays
for the operation or has it paid for by a third party will
vary based on patient characteristics, amount of breast
tissue removed, type of insurance, as well as state or
country of residence.
Breast anatomy
Reduction mammaplasty requires a specific under­
standing of breast anatomy with an emphasis on the
parenchymal architecture, vascularity, and innervation.
Although breast anatomy is covered in a previous
chapter, the salient aspects will be reviewed here. The
vascularity to the breast is diverse and includes the
perforating branches of the internal mammary and
the lateral thoracic artery and vein. Many anatomic
studies allude to the internal mammary perforators
as the dominant blood supply to the breast. Other
sources include the intercostal and thoracoacromial
vessels. Most pedicles are designed to capture one or
several sources of blood supply to the nipple areolar
complex.
The vascularity to the nipple areolar complex is
derived primarily from the subdermal plexus of vessels
that are supplied by the internal mammary and lateral
thoracic perforators (Fig. 9.1
). The intercostal vessels
are also contributors with the 4th intercostal being the
primary deep source (Fig. 9.2). Within the breast, along
the 4th intercostal space, is a horizontal structure known
as Wuringer’s septum.5,6 This contains the 4th intercostal
artery and vein that can maintain vascularity to the
nipple areolar complex. This becomes especially impor­
tant in the event that the peripheral subdermal plexus
is violated resulting in reduced blood supply to the
nipple areolar complex.
Fig. 9.1 appears online only.
The innervation to the breast and the nipple areolar
complex is through the 2–6 intercostal nerves. Preserva­
tion of sensation to the nipple areolar complex is best
achieved by understanding the neural pathways within
the breast that lead to the nipple areolar complex. In a
cadaveric study, Schlenz demonstrated that the 3–5
lateral and anterior intercostal nerves innervated the
nipple areolar complex.7 The course of the anterior
nerve was more superficial in the majority of cases,
whereas the lateral intercostal traversed more deeply
within the pectoral fascia in the majority of cadavers.
Pectoralis major
Thoracoacromial
artery
4th intercostal artery
5th intercostal artery
Fibrous septum
Inframammary crease
ligament
Pectoral fascia
Deep branches 4-6th
intercostal nerves
Fig. 9.2  Würinger’s horizontal septum including the 4th intercostal perforator to
the nipple areolar complex. (Reproduced with permission from Würinger E, Mader
N, Posch E, Holle J. Nerves and vessels supplying ligamentous suspension of the
mammary gland. Plast Reconstr Surg 1998;101:1486.)

137.e1
Historical perspective
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138
SECTION I
CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
back pain, neck pain, postural changes, bra-strap inden­
tations, and/or intertrigo. Comorbidities such as diabe­
tes mellitus, hypertension, and cardiac disease are asked
about. Other important considerations include inquiries
on whether the breast size restricts activities in daily
living and whether dieting and prior weight loss has
been effective in reducing breast volume. These are
important when considering insurance preauthoriza­
tion for reduction mammaplasty because it will reinforce
the functional importance of performing a reduction
mammaplasty. Women over the age of 35 are encour­
aged to obtain a mammogram. On examination, an
assessment of volume and symmetry is made. Important
measurements include the sternal notch to nipple,
inframammary fold, base width, and nipple to sternum
distances.
There is a thorough review of the risks and benefits.
Patients are told that their symptoms may improve, but
it is not a guarantee. Risks include but are not limited to
bleeding; infection; scar; fat necrosis; inability to ade­
quately nurse following childbirth; altered sensation of
the nipple areolar complex; delayed healing; poor cos­
metic result; partial or total nipple areolar necrosis; and
further surgery. Incisional patterns and pedicle tech­
niques are reviewed with each patient. In general, the
authors’ preference is to select the inverted-T for resec­
tions that are estimated to be greater than 300 g. Short
scar techniques are usually performed for reduction
weight that is estimated to be less than 300 g. Pedicle
techniques are usually based on the distance that the
nipple areolar complex will be elevated from the natural
position of the nipple areolar complex on the breast.
The following algorithm is the authors preferred
approach for pedicle selection and is based on nipple
elevation in centimeters (Box 9.1). The central mound or
superomedial pedicle is considered when nipple eleva­
tion is <6 cm, a medial pedicle is considered when nipple
elevation is > 6 cm, and the inferior pedicle is selected
when the length of the proposed inferior pedicle is less
than the medial pedicle. Free nipple graft is considered
when the pedicle length exceeds the perfusion capacity
of the vascularity to the nipple areolar complex. This is
usually the case for severe mammary hypertrophy with
resection volumes in excess of 2000 g/breast.
Markings
The typical markings for the inverted-T incision are as
follows (Fig. 9.3
). The sternal midline is delineated.
The breast meridian is delineated bilaterally bisecting
the midline of the breast. Any pre-existing asymmetry of
the nipple areolar complex will be corrected during the
operation in order to center the nipple along the breast
meridian and to ensure that the distance from the sternal
midline to the nipple will be equal on both sides. The
inframammary fold is delineated bilaterally. The ideal
nipple position is marked and based on the level of the
inframammary fold. This may be done with calipers or
freehand. The vertical limbs of the inverted-T pattern are
delineated with a length that ranges from 8 to 9 cm. This
will vary based on the volume of the breast. The angle of
the apex is usually 60° and can be narrowed or widened
based on the base width of the breast. For breasts with a
wide base width, the angle can be increased to 70° and
that will facilitate narrowing of the breast. For breasts
with a normal to narrow base width, the angle is reduced
to 50°. Although the keyhole pattern is described with
the original description, the authors prefer not to delin­
eate the keyhole at the time of the original markings but
rather wait for completion of the reduction mamma­
plasty to accurately place the nipple areolar complex.
The horizontal component of the inverted-T pattern is
then marked and extends from the inferior point of both
vertical limbs to the lateral and medial limits of the
inframammary fold. The horizontal incision should
never cross the sternal midline and should be tailored
laterally to eliminate any dog-ear and to follow the
desired lateral mammary fold to optimize contouring
and appearance.
Fig. 9.3 appears online only.
The primary reasons for using the inverted-T tech­
nique are numerous. The resections are accurate because
the incisions permit wide exposure of the parenchyma
with precise resection of glandular tissue. The technique
has proven useful for breasts of all sizes; however, it is
especially useful for breasts that will require at least 300 g
resections. The naturally ptotic breast almost always
conceals the horizontal scar. The complication profile is
similar with the inverted-T technique to the other short
scar techniques. Finally, the breast appearance upon
completion of the operation is usually excellent and is
not as dependent upon breast remodeling and scar con­
tracture when compared with the short scar techniques.
Patient selection
Patient selection begins with a thorough history and
physical examination. Common complaints include
BOX 9.1  Skin pattern and pedicle selection
• <6 cm of nipple elevation – central mound or superomedial
pedicle
• >6 cm of nipple elevation – medial or inferior pedicle
• <300 g resection – short scar technique
• >300 g resection – inverted-T technique

138.e1
Historical perspective
Fig. 9.3  Patient preoperative marking. With the patient in an upright position, the
midclavicular line is drawn. The nipple location is determined by a projection
through the breast from the inframammary fold. This is marked at the bottom of the
midclavicular line. Symmetry is confirmed by using a ruler to compare the distance
of each midclavicular line from the midline.
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139
Treatment/surgical technique
contour. The vertically oriented bipedicle flap was
thought to minimize some of these shortcomings. Sim­
plification of this vertical bipedicle ultimately led to the
development of the inferior pedicle technique that was
later described by Robbins in 1977.11 For a while there­
after there was controversy as to whether vertical
bipedicle was superior, equivalent, or inferior to the
inferior pedicle technique. Two groups of patients were
later studied to discern any differences. Ramon’s study12
evaluating 27 patients following the McKissock repair
and 24 patients following the inferior pedicle repair
demonstrated good to excellent aesthetic outcomes in
both. The subjective evaluations of the patients and the
surgeons were also found to correlate without any sig­
nificant differences.
Thus, with our improved understanding of the vas­
cularity and innervation of the breast these bipedicle
techniques have largely been replaced by the unipedicle
techniques described throughout the remainder of the
chapter. Although not commonly performed, these
bipedicle methods have established a foundation for the
pedicle techniques that are commonly used today.
Inferior pedicle technique
The inferior pedicle technique for nipple areolar trans­
position with the inverted-T skin pattern was one of the
first techniques described in the modern era of reduc­
tion mammoplasty.11,13,14 As mentioned, it represents an
Treatment/surgical technique
The bipedicle technique
There are two bipedicle techniques for reduction
mammaplasty that incorporate the inverted-T incision
pattern. These are the horizontal bipedicle also known
as the Strombeck, and the vertical bipedicle also known
as the McKissock, named after the surgeons that
described them.8,9,10 The horizontal bipedicle technique
was initially described in 1960 with the intent of improv­
ing the vascularity to the nipple areolar complex. A
schematic illustration of this technique is illustrated in
Fig. 9.4. Prior to the description, upper pole resections
of the breast that tended to disrupt the vascularity of the
nipple areolar complex were common. The benefit of the
bipedicle technique was that it included perforators
from the medial and lateral segments of the breast, thus
preserving the vascularity. In a review of 100 patients
following the Strombeck repair, late complications
included wide scars in 51%; loss of nipple sensation in
27%; and nipple inversion in 18%. Patient satisfaction
was achieved in 96%.
Paul McKissock initially described the vertical
bipedicle technique for reduction mammaplasty in 1972
(Fig. 9.5). The impetus for this technique was that many
of the previous techniques were plagued by skin or
nipple areolar necrosis, loss of sensation, and irregular
Fig. 9.4  Strombeck horizontal bipedicle technique. (A) The creation of a horizontal bipedicle allows for resection of parenchyma above and below the pedicle. The image
depicts the de-epithelialized horizontal bipedicle shown in pink on either side of the nipple areolar complex. The solid semilunar line above the horizontal bipedicle and the
parenchyma below the horizontal bipedicle will be resected. Point ‘a’, the confluence of the horizontal and vertical incisions of the lateral breast; point ‘b’, the medial breast
analog; point ‘c’, the point along the inframammary fold incision at the breast meridian. (B) The breast after superior and inferior parenchymal resection, creating a
horizontal bipedicle to carry the nipple areolar complex, before inset and closure. (C) Inset of the nipple areolar complex into the area of superior parenchymal resection.
The skin of the remaining breast after resection is brought together to cone the breast and allow for final closure. This is accomplished by suturing in an inverted-T type
closure the tip of the lateral breast skin flap (point ‘a’) to that of the medial breast skin flap (point ‘b’) and finally to point ‘c’ on the inframammary fold. Inframammary fold,
periareolar, and vertical incision final sutures complete the closure. (Redrawn after Lickstein LH, Shestak KC. The conceptual evolution of modern reduction mammoplasty.
Operat Tech Plast Reconstr Surg. 1999;6:88–96.)
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140
SECTION I
CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
A
B
C
a
b
c
d
e
f
Lateral
Medial
D
E
F
G
H
Fig. 9.5  (A–N) McKissock vertical bipedicled dermoglandular flap with Wise-pattern skin excision. (A) nipple position is determined; (B) base width is determined;
(C) breast markings outlined; (D) medial and lateral breast excursion determined; (E) inferior de-epithelization; (F) peripheral constriction band; (G) lower pole excision;
(H) lower pole parenchymal excision; (I) central parenchymal excision; (J) excision pattern; (K) excision completed; (L) glandular repositioning and reshaping; (M) skin
closure; (N) skin closed. (Redrawn after Lickstein LH, Shestak KC. The conceptual evolution of modern reduction mammoplasty. Operat Tech Plast Reconstr Surg.
1999;6:88–96.)

141
Treatment/surgical technique
Fig. 9.6  Blood supply of the inferior pedicle.
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Fig. 9.5, cont’d
evolution from the vertical bipedicle technique described
by McKissock. The vascularity to the nipple areolar
complex is derived from the subdermal plexus from the
intercostal and internal mammary perforators that are
included with the inferior pedicle (Fig. 9.6). An impor­
tant consideration with the inferior pedicle technique is
the length to width ratio of the pedicle. This may range
from as low as 1.5 : 1 and as high as 4 : 1. Although no
optimal ratio has been established, it is generally agreed
that ratios exceeding 2 : 1 may be associated with
increased morbidity. It is always important to assess the
arterial and venous bleeding from the distal edge of the
flap. When absent, conversion to a free nipple graft is
considered. Fluorescent angiography can assist with
this decision. Figs. 9.7 and 9.8 illustrate the technique in
a schematic format.
Markings
The patient is marked in the upright position. Important
breast measurements include the sternal notch to nipple
distance, nipple to inframammary fold distance, and the
base diameter of the breast. The sternal midline, breast
meridian, and the inframammary fold are marked bilat­
erally. The new position of the nipple areolar complex is
marked and correlates to the level of the inframammary
fold along the breast meridian. The distance from the
sternal notch to the desired nipple areolar complex will
vary but typically ranges from 22 to 27 cm. An inverted-T
pattern is delineated and based on the location of the
desired nipple areolar complex. The inferior pedicle is

142
SECTION I
CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
the areola to preserve the vascular plexus supplying the
nipple areolar plexus.
Surgical technique
The patient is transported to the operating room,
placed in the supine position, usually under general
endotracheal anesthesia. The arms are usually posi­
tioned at approximately 60° of abduction, although
they may be placed along the trunk as well. Pneumatic
compression devices are applied, and intravenous
antibiotics are administered. The preoperative mark­
ings are redelineated. The nipple areolar complex is
inscribed with a 42 or 45 mm cookie-cutter. A scalpel
is used to incise the epidermis of the nipple areolar
complex and the inferior pedicle. The inferior pedicle is
de-epithelialized preserving the subdermal plexus. The
remaining inverted-T incisions are created. Medial and
lateral dermoglandular wedge excisions are performed
taking care not to narrow the base of the inferior
pedicle. The nipple areolar complex is maintained on
a dermo-parenchymal inferior pedicle of tissue that
includes chest wall perforators. The perfusion of the
nipple areolar complex is assessed based on arterial and
venous bleeding from the cut edges. The upper breast
skin flaps are undermined to the pectoral surface and
contoured by excision of additional fat and parenchyma
to better contour the upper pole of the breast. The
excised tissues are weighed. The wounds are irrigated
with an antibiotic solution, and hemostasis is achieved
using electrocautery. A trifurcation suture is applied at
the T-junction, and the skin is temporarily closed using
staples. The patient is sat up to approximately 45°,
and the contour, volume, and symmetry are assessed.
A tailor-tack approach is used laterally to improve
contour and to better define the lateral mammary fold.
A scalpel and electrocautery is used to excise the excess
skin. The operative field is inspected for hemostasis
and irrigated with an antibiotic solution. The inferior
pedicle and nipple areolar complex are inspected for
bleeding and tissue viability. The pedicle is oriented
such that the nipple areolar complex is at the apex
of the vertical limbs. A closed suction drain is placed
through the lateral incision and secured. Layered skin
closure is completed using absorbable monofilament
sutures. A cookie-cutter is used to delineate the new
site of the nipple areolar complex. The base of the
areola is positioned at 5–6 cm from the inframammary
fold along the breast meridian. Following the incision,
the nipple areolar complex is exteriorized and sutured.
Steri-Strips and iodoform gauze are applied over the
incisions followed by dry gauze and Tegaderm. A soft
compression bra is applied. Fig. 9.9 illustrates a patient
delineated in the operating room with the patient in
the supine position. The base of the inferior pedicle
typically ranges from 6 to 10 cm and is dependent upon
the base diameter of the breast. The inferior pedicle is
usually centered along the inferior breast meridian and
always includes a cuff of tissue measuring 1 cm around
Fig. 9.7  Outline of the three segments to be resected: the medial, lateral, and
superior.
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Fig. 9.8  Inferior pedicle technique with Wise-pattern skin excision.
Gland/fat specimen removed

143
Treatment/surgical technique
A
B
C
following reduction mammaplasty using an inverted-T
approach and an inferior pedicle.
Outcomes
The inferior pedicle and inverted-T techniques have
demonstrated success since its description in the 1970s.
Complications are infrequent and seem to correlate to
volume of resection. Large resections exceeding 1000 g/
breast have been demonstrated to have an increased
rate of incisional dehiscence and clinical infection. Other
morbidities such as hematoma, seroma, nipple necrosis,
fat necrosis, and cyst formation are independent of
resection volume. Tobacco use is an independent pre­
dictor of complications and unrelated to resection
volume. Factors such as necrosis of the nipple areolar
complex are dependent on a variety of factors that
include the base width and length of the inferior pedicle
as well as the presence of intercostal perforators. Most
studies report an incidence for nipple areolar necrosis
at 2%. Delayed healing at the trifurcation point is usually
related to tension along the incisions. Wound infection
is also related to a variety of factors that include the
amount of thermal injury, length of the operation,
D
Fig. 9.9  (A) Preoperative image of a patient scheduled for an inverted-T reduction mammaplasty using an inferior pedicle. (B) Right lateral view. (C) Inverted-T pattern is
delineated. The sternal notch to nipple distance is 27 cm, and the new nipple position will be at 22 cm. (D) The inferior pedicle is delineated.
Continued

144
SECTION I
CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
E
F
G
(E) The inferior pedicle is created, and the upper skin flaps are
elevated and undermined. (F) A 1-year postoperative view is demonstrated. (G) A
right lateral view is depicted.
Fig. 9.9, cont’d
desiccation of the exposed tissues, and insufficient
antibiotic prophylaxis. Fat necrosis is related to poor
tissue perfusion, thermal injury, infection, elevated
parenchymal pressures following closure, and improper
surgical technique. Sensory changes to the nipple areolar
complex may be secondary to transection of the inter­
costal innervation between the 2nd and 6th intercostal
segments. It is estimated that approximately 10% of
women will experience some degree of permanent
sensory alteration.
The medial pedicle
The medial pedicle technique is this author’s preferred
technique for large volume resections that exceed 600 g
with a nipple areolar complex that will be elevated at
least 6 cm.15,16 The benefits of the medial pedicle are
listed in Box 9.2. The medial pedicle derives its blood
supply from the internal mammary perforators and its
innervation from the anterior branches of the intercostal
nerves. The internal mammary artery and vein have