Essentials of Aesthetic Surgery

722
Part VIII Breast Surgery
TOP TAKEAWAYS


menopause and age, some women retain their baseline dense glandular
breast, which can make rotation of breast pedicles during reductions more


The fourth intercostal nerve appears to be the primary supply for nipple
sensation; however, every attempt should be made to protect all lateral
intercostal nerves during augmentation mammaplasty to minimize sensory loss.

During a mastectomy, the second and third internal mammary perforators

breast perfusion.

The nipple areolar complex is innervated by the anterolateral branch of the
fourth intercostal nerve.

Supernumerary nipples and breasts can occur along the milk line from the axilla
to the groin.

Attenuation of Cooper ligaments leads to ptosis and increased breast mobility.

Injury to the intercostal brachial nerve results in paresthesia/anesthesia of the
upper medial arm.

Three levels of axillary lymph nodes exist.

Poland syndrome results in absence of the sternal head of the pectoralis major.
REFERENCES

2. Bostwick J III. Anatomy and physiology. In Bostwick J III, ed. Plastic and Reconstructive Breast
Surgery, ed 2. New York: Thieme Publishers, 2000.
3. Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the nipple-areola complex: an anatomic
study. Plast Reconstr Surg 105:905, 2000.
4. Würinger E, Mader N, Posch E, et al. Nerve and vessel supplying ligamentous suspension of the
mammary gland. Plast Reconstr Surg 101:1486, 1998.
5. Würinger E, Tschabitscher M. New aspects of the topographical anatomy of the mammary
gland regarding its neurovascular supply along a regular ligamentous suspension. Eur J Morphol
40:181, 2002.
6. O’Dey DM, Prescher A, Pallua N. Vascular reliability of nipple-areola complex-bearing pedicles:
an anatomical microdissection study. Plast Reconstr Surg 119:1167, 2007.
7. Muntan CD, Sundine MJ, Rink RD, et al. Inframammary fold: a histologic reappraisal. Plast
Reconstr Surg 105:549, 2000.
8. Jones G, ed. Bostwick’s Plastic and Reconstructive Breast Surgery, ed 3. New York: Thieme
Publishers, 2010.
-
lishers, 2011.

723
BACKGROUND
Breast augmentation is the cosmetic surgery (after
liposuction).1
Silicone implants were introduced in 1964.
Saline implants were introduced in 1970s as an alternative to silicone.
The U.S. FDA placed a moratorium on silicone implants in 1992 for primary
augmentation because of concerns about autoimmune and connective tissue disease.
• In 1999 the NIH Institute of Medicine and the National Academy of Sciences
reviewed 17 epidemiologic studies and were

• Studies found silicone in local macrophages, lymph nodes, and breast tissue.
• Studies did not demonstrate elevated systemic levels (normal liver, lung, and
spleen).
2
Saline implants increased in popularity during the 1990s because of silicone scare.

Generations of Silicone Gel–Filled Breast Implants



First
1960s
Thick shell (0.25 mm average)
Thick viscous gel
Dacron patch
Second
1970s
Thin shell (0.13 mm average)

No patch
Third
1980s
Thick, silica-reinforced barrier coated shells
Fourth
1992-present
Stricter manufacturing standards

Fifth
1993-present

Inner laminar layer to prevent gel bleed
Form-stable devices
NOTE:

Restriction on use of silicone gel implants for primary breast augmentation was lifted in
November 2006.
• Before this change, silicone implants were approved only for breast reconstruction,
silicone implant exchange, and replacement of saline implants with complications.
3,4

724
Part VIII Breast Surgery

• In Europe since 1995
• In Canada since 2000
More natural shape, less rippling, limited gel migration in event of
rupture

INDICATIONS AND CONTRAINDICATIONS
INDICATIONS
Increase breast size
Restore prelactation breast appearance
Correct breast asymmetry
Enhance breast shape and volume
Improve body image, symmetry, and balance

Provide the appearance of a breast lift and increased cleavage

CONTRAINDICATIONS

cancer)
Collagen vascular disease
Body dysmorphic disorder
Psychological instability
Social instability (e.g., divorce or separation, searching for a relationship)
Patient responding to pressure from friends, family, or partner
Patient <18 years of age
(see Chapter 1).
The following situations require mindfulness6:
• After obtaining the history, the surgeon does not like the patient.
• Patient desires an outcome the surgeon cannot deliver.
• Patient desires an outcome outside the surgeon’s aesthetic sense of normal.
• Patient is critical of previous surgeons or praises the current surgeon excessively.
• Patient lies, provides a false history or information.
• Patient refuses to be examined or photographed.
• Patient is a perfectionist and wants a guarantee of results.
• Patient is paranoid, delusional, or depressed.
• Patient fails to communicate or is unable to understand what informed consent entails.
PREOPERATIVE EVALUATION
HISTORY/INTERVIEW
Begins with open-ended questions
The patient talks and the surgeon listens.
Assessment:
• Motivation for surgery
• Psychological state of mind and stability

725
Chapter 52 Breast Augmentation
• Expectations
• Self-esteem
MEDICAL HISTORY
Full medical history
• Personal or family history of breast disease or cancer
• Pregnancy history and plans for future pregnancies
• Breast size before, during, and after pregnancy



starting at 40 years of age, and every year beginning at 50 years of age.
7
• Previous surgeries or procedures on breasts
• Previous cosmetic procedures
• Tobacco or nicotine replacement use, drug use
• Anticoagulation use
• Current breast size
• Desired breast size (many patients will bring pictures to clinic)
PHYSICAL EXAMINATION

• Masses, dimpling, discharge, lymph nodes
• Cancer screening

• Stretch marks, tone, elasticity
Chest wall, scoliosis, breast




• <2 cm, may obtain a better result with a submuscular implant placement
• Ptosis (see Chapter 53)
• Mild ptosis is improved by augmentation.
• Moderate to severe ptosis may require mastopexy.
(patient sitting up straight)
• Breast width at its widest point
• Breast height
• Intermammary distance
• Mark true midline of the chest
• Mark IMF
• Height, weight, body frame (small to large)
• Sternal notch to nipple (SN-N)
• Nipple to inframammary fold (N-IMF) during stretch
• Base width (width of breast base)
• Parenchymal coverage (pinch test)
• Superior pole

• Anterior-pull skin stretch (centimeters of anterior stretch with pull at edge of areola)

726
Part VIII Breast Surgery
(all jewelry and identifying markers removed) (see Chapter 3)
• Chin to below navel
• Front, lateral, oblique, with arms at rest and elevated

• Chest wall deformities
• Spinal curvature
• Asymmetries (nipple shape and size, nipple position, IMF position, breast size, breast
ptosis)
INFORMED CONSENT
Not just signing a paper

• Note asymmetries, ptosis, cleavage.
• Note that asymmetries, ptosis, and cleavage are often unchanged or even
accentuated by breast augmentation alone.


and access incisions.
• Review and discuss previous restrictions on silicone implants.

• Risks and complications
• Bleeding
• Infection
• Capsular contracture
• Change in nipple and skin sensation
• Scarring


• Seroma
• Hematoma
• Breast venous thrombosis
• Implant failure
• Implant extrusion
• Changes in mammography detection
• Implant visibility and palpability
• Implant wrinkling or rippling
• Implant malposition or displacement


• Chest wall deformation
• Animation deformities (if submuscular)

• Unsatisfactory result
• The need for additional surgeries

complications that may arise from surgery, and changes that necessitate revision
surgery.

727
Chapter 52 Breast Augmentation
• Implant weight, aging, weight loss or gain, and pregnancy will result in expected
changes in breast appearance.





• Alternatives





Document desired implant type, size, and shape discussed with patient.
EQUIPMENT
INSTRUMENTATION
Double hooks

Army-Navy retractors
Extended Bovie tip
Endoscopic retractor (transaxillary approach, transumbilical augmentation)

Implant sizers (if applicable)
Triple antibiotic solution
• 50,000 units bacitracin, 1 g cefazolin, 80 mg gentamicin per 500 ml saline solution
(may reduce infection rate and capsular contracture)
8
Keller funnel (Allergan)
• Allows no-touch insertion of silicone implant through minimal-sized incision
Implants
FILLER MATERIAL


• Historically lower contracture rates
• Adjusts quickly to body core temperature

• Size more customizable—easier to adjust for size and correct breast asymmetry

• Wrinkling






• More natural feel and appearance than saline implants

728
Part VIII Breast Surgery

• Historically higher contracture rate

• Adjusts slowly to temperature change (e.g., implants remain cold after swimming)

• MRI recommended 3 years after surgery, then every 2 years to monitor for rupture,
as per FDA
• More expensive



linking lead to increased viscosity.


• Natural feel of silicone
• Allows postoperative adjustments to inner-lumen saline volume
• Useful for asymmetry and for patients uncertain of desired size

• Fill port temporarily implanted, requiring second procedure to remove




VOLUME

• Sizers put in bra to establish desired volume (not recommended)
• Photos of other women
• Digital imaging

• 125-150 cc to increase by one cup size



9
• Objective measures to determine optimal implant and volume
• Volume based on breast base width



• Stretching and stressing of tissues
• Atrophy and thinning of parenchyma and skin
• Increased palpability
• Traction rippling
CAUTION:

729
Chapter 52 Breast Augmentation
TEXTURE
SMOOTH

• Thinner capsule formed


• Higher contracture rates
• Requires larger pocket dissection
• Requires displacement exercises to prevent contracture
TEXTURED





• Require precise pocket dissection
• More palpable
• Traction rippling more common


• Intraoperative positioning of implant is critical, because textured surface resists
migration or movement in pocket.
• Base must be properly oriented along IMF.
POLYURETHANE OVERED

• Dramatically low contracture rates (<1% over 10 years)

• Pulled from U.S. market, because polyurethane breaks down as a carcinogenic


• Polyurethane coating separates over weeks to months and becomes incorporated
into the capsule, helping to disperse contractile forces.

capsule.
SHAPE/DIMENSION
ROUND IRCULAR IMPLANT

730
Part VIII Breast Surgery

• Increased projection for given base width
• Increased projection with less volume
• Advantage with a constricted lower pole or a narrow breast base width
SHAPED/ANATOMIC

Increased implant height and projection for a given base width

pole of breast
Most textured to maintain position

• Designed to give more natural appearance

• More natural upper pole contour

• Must be oriented properly and symmetrically
• More prone to malposition
• Fewer available implant sizes in the United States
SIZE
Based on:
• Patient’s desired size and projection
• Breast base width
• Implant should be slightly narrower than the patient’s breast width
• Dimensions and compliance of the patient’s breast

• Many surgeons have special consent forms for such implants.
• Rule of thumb: 125-150 cc per cup size increase
SENIOR AUTHOR TIP: While the anatomically shaped implants may help with the
creation of natural breast contours, the real advantage of these devices is that they
are wrinkle resistant. As a result of the anatomic shape of the shell combined with the
more cohesive gel, these devices resist collapse and wrinkle formation which greatly

at 10 years for these devices are impressively low which can make these implants an
attractive option for patients and surgeons alike.
TECHNIQUE
MARKINGS
IMF
True midline
Incisions

731
Chapter 52 Breast Augmentation
POCKET POSITION
(Fig. 52-1).
• Smooth gel implants can use larger pockets and displacement exercises to prevent
capsular contracture formation.
• Textured implants are placed in and are only slightly larger than the footprint of the
implant to minimize malposition.
Pocket plane and dissection.
A, Subglandular augmentation.
B, Submuscular augmentation.
C, Biplanar augmentation.
A
B
C

The implant rests under the breast gland.
The implant is placed under the anterior pectoralis major fascia and the
pectoralis major muscle.

• Avoids implant distortion with pectoralis activity and in muscular patients
• More anatomic
• Better implant projection

• Higher capsular contracture rate
• Visible implant wrinkling or rippling, especially if paucity of native breast tissue
• Implant edges may be palpable
• Interference with mammography

• Dissection on top of pectoralis major, below gland
the implant can safely be placed in the
subglandular/subfascial plane.


Rarely performed in cosmetic surgery


• Thick soft tissue coverage
• Good preservation of nipple sensation

732
Part VIII Breast Surgery

• Implant shifts with pectoralis activity
• “Dancing breasts” during pectoralis contraction
• Implant malposition over time (superiorly and laterally)


• Muscular or active patient

• Dissection below pectoralis major but above pectoralis minor
• The implant is placed completely under the pectoralis major muscle


The origin of the pectoralis major is completely divided from its origin at the level of the
IMF, stopping at the medial aspect of the IMF.
The of the implant is placed and the is
placed
The attachments of the pectoralis to the breast parenchyma are selectively divided.


• Decreases implant displacement caused by pectoralis contraction
• Provides thick upper pole soft tissue coverage with subpectoral placement

• Increased control of IMF position compared to submuscular
• The breast parenchyma and the pectoralis can be dissected apart to adjust for


• Increases implant-parenchymal interface, which expands lower pole and prevents
double-bubble deformity

• Usually restricted to IMF incision when performing dual plane II and III

• IMF pinch test <0.4 cm

• Complete muscle coverage restricts expansion of inferior pole, forcing implant
superiorly and laterally.
• Especially with ptotic and loose breast parenchyma, breast tissue may slide inferior

causing a type A double-bubble deformity.
• Dual plane techniques release inferior pectoralis attachments, allowing some
pectoralis retraction superiorly.
• This maximizes implant contact with lower pole breast parenchyma, with the
advantage of upper pole coverage by the pectoralis.
10 (Fig. 52-2)

733
Chapter 52 Breast Augmentation
Dual plane augmentation techniques. The extent of dissection at the parenchyma-
muscle (PM) (top). The position of the inferior edge of the divided pectoralis origins (center). The
pectoralis position relative to the implant ( ). ( Inframammary fold.)
Parenchyma
Type I
No PM interface separation
Complete division
along IMF
Type I

DIVISION

SEPARATION


N
o

d
i
v
i
s
i
o
n
PM interface separation to
inferior edges of areola
Type II
Type II
N
o

d
i
v
i
s
i
o
n
Complete division
along IMF
Type III
PM interface separation to
superior edges of areola
Type III
N
o

d
i
v
i
s
i
o
n
Complete division
along IMF

734
Part VIII Breast Surgery
• Complete division of the pectoralis from its origin at level of IMF, stopping at the
medial aspect of the IMF, in addition to subpectoral dissection


• Indications: Most “routine breasts”
• All breast parenchyma located above the IMF
• Tight attachments at the parenchyma-pectoralis interface
• Minimally stretched lower pole (NAC-IMF distance 4-6 cm)

• Complete division of the pectoralis from its origin at level of IMF, stopping at the
medial aspect of the IMF
• Pectoralis separated from breast parenchyma in the retromammary plane

• Indications: “Highly mobile parenchyma”
• Most of the parenchyma located above IMF

to pectoralis major)
• Moderate lower pole stretch (NAC-IMF distance 5.5-6.5 cm)

• Complete division of the pectoralis from its origin at level of IMF, stopping at the
medial aspect of the IMF
• Separation of pectoralis from parenchyma in the retromammary plane is continued

• Indications: “Glandular ptotic” and “constricted lower pole breasts,” including
tuberous breasts

is below the projected IMF

pectoralis surface)



base width
• Short NAC-IMF distance (tuberous breasts) (2-5 cm)
• Use radial and concentric scoring through breast parenchyma
SENIOR AUTHOR TIP: It is possible to consider an even more aggressive release of
the muscle, essentially separating the breast from the muscle along its leading edge
all the way up into the axilla. This allows the muscle to further “window shade” to a
location above the NAC. This could be thought of as a dual plane type IV, or as the senior
author calls it, a “combination pocket” and results in a great reduction in postoperative
breast animation and yet still provides contour softening in the upper inner quadrant
of the breast.

735
Chapter 52 Breast Augmentation
INCISION CHOICE
Incision Options for Breast Augmentation






Submuscular
+
+
+

Subglandular

+
+
+

Saline, round
+
+
+
+
Saline, shaped

+
+

Silicone, round or
shaped

+
+



+
+
+
+

+
+

+

High
+
+
+
+


+
+
+

Tubular

+


Glandular ptosis
+
+
+
+
Ptosis (grades I and II)

+



Small diameter
+

+
+

+

+
+

None
+
+

+
High
+
+

+

+
+
+
+


+
+

*Included for completeness, but generally not recommended.
+, Applicable; –, not generally recommended.

736
Part VIII Breast Surgery



• Best control
• Complete visualization of subglandular or submuscular pocket



• Incision is placed rather than in existing one.
• Incision is made along IMF lateral to nipple.
• Most (two thirds) of incision is because it is more visible when
placed medially.
implants can be placed through incisions
implants may require incisions based on implant size.
• Dissection proceeds through Scarpa fascia.

• Dissection continues either subglandularly, or the origin of the pectoralis major is
completely divided from its origin at the level of the IMF, stopping at the medial
aspect of the IMF for dual plane technique.
• For subpectoral placement, initial dissection is carried out laterally to identify the
lateral border of the pectoralis major.
• Be mindful of medial intercostal perforators, which should be prospectively
coagulated using insulated forceps.

avoiding lifting

• Once the pocket is dissected, sizers can be used (if surgeon preference)
• Patient is placed in sitting position to 90 degrees to evaluate symmetry and implant
position.
• Corrections are made and hemostasis obtained.
• Pocket is thoroughly irrigated with triple antibiotic solution.
• Gloves are changed.
• Skin reprepared with Betadine.
• Implant is inserted using “no-touch” technique or the Keller funnel.
• Closure is completed in multiple layers.

Placed in the
Subglandular or submuscular plane

• Well hidden at interface of NAC and skin
• Allows adjustment of IMF
• Good access if areolar diameter


• Transection of parenchymal ducts, leading to possible
colonization
• Possible nipple sensitivity changes

737
Chapter 52 Breast Augmentation
• Visible scar: White or hypopigmented scar when placed within areola
• Potential for visible hypertrophic scarring
• May traverse and scar a cancer-prone organ
• Should not be used if areolar diameter

• Incision is placed around the lower half of the areola precisely at the junction of
areola and breast skin.
• Incision is limited to a
• Dissection proceeds through breast parenchyma to the pectoralis fascia.
• Dissection of a subglandular, dual plane or submuscular pocket is then the same as
for an IMF incision, and the implant is placed in the standard fashion.
• For inferior pole constricted breasts, of the parenchyma is used to
redrape the soft tissues over the implant.




scar breast parenchyma


subcutaneous plane to the inferior edge of the breast mound, and a pocket is
created.



• Can perform bluntly or with endoscope
• Endoscope allows precise dissection and release of pectoralis major inferior
attachment for dual plane technique and precise hemostasis.
• Avoids breast scars
• Saline or silicone implant in submuscular, subglandular plane or dual plane

• Need for second incision for any revision surgery


• Potential scar visibility when sleeveless and raising arms


• Patients arm fully adducted, and anteriormost point of the axilla marked (limit of
the incision)
• Arm abducted to 90 degrees
• Incision made and dissection carried out to the lateral border of the pectoralis major
to prevent injury to the intercostal nerve
• Subglandular, dual plane, or submuscular pocket dissected either bluntly with
a Montgomery dissector or using an endoscope for visualization and standard
electrocautery dissection
• Implant placed in the standard fashion
• Incisions closed in layers

738
Part VIII Breast Surgery


• Single, hidden incision
• Scar hidden and distant from breast



• Can only use saline implant

• High or asymmetrical placement
• Revision surgery requires second incision
• Additional specialized equipment required

• Additional preoperative mark from umbilicus to the medial border of the NAC while
patient supine
• 2-3 cm horizontal incision at highest point of axilla, 1 cm behind border of pectoralis

posterolateral border of pectoralis, incising vertically to enter subpectoral or
subglandular plane

• Endotube with blunt obturator passed above rectus fascia
• Pocket dissected bluntly
• For subglandular implants, force directly upward at IMF level
• Tunnel stops just cephalad to the NAC
• Obturator removed and endoscope used to evaluate pocket and hemostasis
• Endoscope and endotube removed and rolled expander is moved up the tunnel


• Permanent saline implant inserted in similar fashion
• Incision closed in layers
11
TECHNICAL POINTS12

• First-generation cephalosporin 30-59 minutes before incision
Pocket irrigated with 8
• 1 g cefazolin, 80 mg gentamicin, 50,000 units bacitracin per 500 ml saline
• Pocket soaked for 5 minutes
• In 2000 FDA banned povidone iodine (Betadine) contact with implants because of
complications when used intraluminally (implant delamination and leakage), but

13
Precise dissection
Meticulous hemostasis
Hand-switched monopolar cautery
Deep closing sutures placed before implant inserted, with knots away from implant
Skin wiped with antibiotic solution
Only talc-free gloves used
Change gloves before the implant is handled or placed.

739
Chapter 52 Breast Augmentation
always used
• Prevents implant contamination from skin14

TIP: Avoid deep dissection in axilla; intercostobrachial and median brachial cutaneous
nerves are vulnerable.
TREATMENT OF INFRAMAMMARY FOLD
Appropriate IMF height centers the axis of the implant behind or just below the NAC.
N-IMF length should correspond to implant volume (Table 52-3).
• Approximately 7 cm at 250 cc, 8 cm at 300 cc, 8.5 cm at 350 cc, 9 cm at 375 cc, and
9.5 cm at 400 cc
• Areola-IMF distance: Should approximate radius of implant and half of breast base
width
Relationship of Implant Volume and Nipple–Inframammary Fold Length






N-IMF length (cm)
7
8
8.5
9
9.5
TIP:
implant size and N-IMF distance, or when asymmetry exists.
POSTOPERATIVE CARE
Outpatient procedure
MEDICATIONS
Acetaminophen or NSAIDS preferred for routine pain control
• Narcotics only as needed for severe pain
Carisoprodol (Soma, Vanadom): Helps pectoralis relax
No data to support routine antibiotic use, but many surgeons provide 3 days of oral
antibiotics
BRASSIERE AND DRESSING
Steri-Strips for 6 weeks
Brassiere optional
• No underwire or push-up bras for 6 weeks
ACTIVITY
Patients may shower 24 hours postoperatively.
For smooth implants, displacement exercises are initiated between postoperative day 1
and day 3 or when they do not cause pain.
• Push implant medially and superiorly
• Ten pushes three times a day for 1 month, then once daily
Aerobic activity is restricted for 2-3 weeks.

740
Part VIII Breast Surgery
Heavy lifting is restricted for 6 weeks.
Postoperative visits are scheduled for 1-3 days, 2 weeks, 4-6 weeks, 3 months, and 1 year.
Photos should be taken at each postoperative visit.
COMPLICATIONS
PERIOPERATIVE

have permanent sensory changes.
Hyperesthesia/anesthesia
Secondary to traction or transection of lateral intercostal cutaneous nerve
Incidence and severity are the same with all techniques.

Most surgeons do not use drains for cosmetic breast implant cases.

Persistent seromas should be drained under ultrasound visualization.

Rare: 0.5% of patients
Can lead to pain, asymmetry, and capsular contracture

<1% of patients
Most often cultured organism
Implant generally removed

Rare
Thought to be secondary to transection of the thoracic nerves
Treated with bromocriptine

DELAYED COMPLICATIONS

Secondary to of one or both implants across midline

• Overdissection of the medial pocket
• Excessively large implants
• Disproportionately wide implants compared to chest wall

Thoracic hypoplasia, pectus excavatum
Simultaneous augmentation and mastopexy

741
Chapter 52 Breast Augmentation




Traction rippling seen in textured implants
• Prevented by ensuring adequate soft tissue over implant and matching pocket size
with implant


• 2%-5% rate at 5 years, 5%-10% rate at 10 years, or 1% per year19



• Requires implant exchange
20




When silicone rupture is contained within the implant
capsule
When silicone leaks outside of the capsule (also called
extrusion)
• Often leads to granuloma formation
• FDA recommends MRI 3 years after surgery and then every 2 years to monitor for
rupture (“linguine sign”).




• Technical errors
• Higher problem rates with thin-shell implants (second generation)

742
Part VIII Breast Surgery
• MRI
Linguine sign, silicone extrusion






leak
• Removal of implant and residual implant material
• Capsulotomy (or capsulectomy) as needed
• Possible replacement of implants
21
Related to implant age
0% occurrence for implants <10 years old

Remove by capsulectomy


• Increased N-IMF distance, less than half of base width
• Related to poor tissue characteristics, large implant size, and overdissection of IMF
SENIOR AUTHOR TIP: Bottoming out of the breast implant can be prevented by
suturing Scarpa fascia down to the chest wall with 3-0 Prolene sutures after the implant
has been placed. This maneuver must be done with patient at least 60 degrees in the

loose deep subscarpal space, proper support of the fold is provided, thus ensuring a
stable implant position.

(Fig. 52-3)
• Implant is above breast mound.
• Implant is held high on chest wall by total
pectoral coverage or contracture, and loose

inferior to axis of the implant.

• Implant is breast mound.

implant can slide caudal to the breast
mound and create a second IMF below the
native IMF and breast mound.

The body naturally forms capsules around all
implants.
Double-bubble deformity
appearance.

743
Chapter 52 Breast Augmentation
Capsular contracture is tightening of the capsule, with compression and distortion of the
implant.
• Can lead to asymmetry, pain, and implant rupture
22
No palpable capsule. The augmented breast feels as soft as an unoperated
breast.

but is not visible.

easily, and it (or distortion from it) can be seen.
Severe contracture. The breast is hard, tender, and cold. Associated with




23

















needed anteriorly with thin soft tissue coverage

capsule is densely adherent to chest wall, to avoid entering chest cavity








recurrence rates (31%-80%)

744
Part VIII Breast Surgery


skin erosion, atrophy, and ptosis


• Subclinical infection24-27
• Correlation well established, but causal relationship uncertain
most common, but many other types of bacteria implicated
• Hypertrophic scar hypothesis

• Most contractures occur

maturation.

20



28



29,30 (Fig. 52-4)


0
10
1
2
3
4
5
Years
%

C
o
n
t
r
a
c
t
u
r
e
6
7
8
9
10
20
30
40
50
60
70
Smooth
Textured
Ten-year development of subglandular capsular contracture in smooth versus textured
implants.
(Boxes 52-1 and 52-2)31-37


• Saline trial: 2001, Mentor Corporation (Santa Barbara, CA)
32


• Saline trial: 2001, Inamed (Allergan) Corporation (Irvine, CA)
33


• Silicone gel premarket approval trial: Mentor 2006, Allergan (previously Inamed)
2006, Sientra (Santa Barbara, CA) 2012
34

745
Chapter 52 Breast Augmentation
Box 2006 DATA BY MANUFACTURER

Primary augmentation (551 patients)
• Overall complication rate 36.6%
• Overall reoperation rate 15.4%
• Capsular contracture III/IV 8.1%
• MRI cohort rupture 0.5% (0% in non-
MRI cohort)
Revision augmentation (146 patients)
• Overall complication rate 50%
• Overall reoperation rate 28%
• Capsular contracture III/IV 18.9%
• MRI cohort rupture 7.7% (0% in non-
MRI cohort)

Primary augmentation (455 patients)
• Overall complication rate 41.3%
• Overall reoperation rate 23.5%
• Capsular contracture III/IV 13.2%
• MRI cohort rupture 2.7% (0.4% in
non-MRI cohort)
Revision augmentation (147 patients)
• Overall complication rate 56.9%
• Overall reoperation rate 35.3%
• Capsular contracture III/IV 17.0%
• MRI cohort rupture 7.7% (0% in non-
MRI cohort)

Primary augmentation (1115 patients)
• Overall complication rate 20.2%
• Overall reoperation rate 12.6%
• Capsular contracture III/IV 6.0%
• MRI cohort rupture 2.5% (0% in non-
MRI cohort)
Revision augmentation (362 patients)
• Overall complication rate 26.3%
• Overall reoperation rate 20.3%
• Capsular contracture III/IV 5.2%
• MRI cohort rupture 0% (0.4% in non-
MRI cohort)
Box FDA UPDATE 2011 DATA


follow-up)
• 41,900 patients silicone, 1030 saline
• Primary augmentation rupture rate
10.1%
• Revision augmentation rupture rate 6.3%
• Reoperation rate primary augmentation
10.8%
• Reoperation rate revision augmentation
14.6%
• Rupture rate primary augmentation 0.2%
• Rupture rate revision augmentation 1.0%
• Capsular contracture III/IV primary
augmentation 5.3%
• Capsular contracture III/IV revision
augmentation 11.8%


follow-up)
• 41,342 patients silicone, 15,646 saline
• Primary augmentation rupture rate
13.6%
• Revision augmentation rupture rate
15.5%
• Reoperation: 6.5% silicone
augmentation; 4.5% saline augmentation
• Rupture silicone 0.5%

• Capsular contracture III/IV: 5.0% silicone;
2.8% saline

746
Part VIII Breast Surgery
BREAST IMPLANT SSOCIATED ANAPLASTIC LARGE
CELL LYMPHOMA

implants.


implant sales data over the past two decades.

predominantly a B-cell lymphoma with an incidence of approximately 1:4 million.

as part of the informed-consent process.38

years, with a median of 8 years.


association with smooth implants at this time.


in surface texturing among manufacturers may mean there are variable risks for the


The disease has been associated with both silicone and saline implants in aesthetic as
well as reconstructive patients.
The majority of patients present as a delayed seroma. Diagnosis is based on


PET-CT and MRI scans are investigations performed following a positive diagnosis.
Mammograms are not helpful.
Consideration should be given to a multidisciplinary approach including, when
required, an oncological breast surgeon and an oncologist specializing in lymphoma.
Incomplete capsular resection has been associated with both recurrence and

The majority of patients can be cured of their disease by bilateral total capsulectomy
and implant removal. Rare patients will present with a mass and have an increased
risk of requiring radiotherapy and chemotherapy. Treatment approach should follow
international guidelines established by the National Comprehensive Cancer Network

• 93 percent of patients are disease-free at 3-year follow-up, which is an excellent
prognosis when treated appropriately.
Current treatment recommendation is for bilateral complete capsulectomy and
implant removal, as a small number of women have had contralateral disease found
incidentally.
39

747
Chapter 52 Breast Augmentation


. To submit a case to the FDA’s Manufacturer
and User Facility Device Experience (MAUDE) database, which collects medical
device reports (MDRs) of suspected device-associated deaths, serious injuries and
malfunctions, visit
REOPERATION
28-30
Current 3-year reoperation rate: 13% for saline and 21% for silicone
CANCER SURVEILLANCE
Implants cause interference with normal mammogram imaging.
displace breast and implant to increase parenchymal
imaging after breast augmentation.
With appropriate imaging, no increased risk for cancer is found; diagnosis not later; no
40,41
SENIOR AUTHOR TIP: The preoperative consult must determine the precise goals
of the patient.
Three variables must be measured during the preoperative evaluation, including implant
base diameter, volume, and projection.
Visualization tools such as external bra sizers, computer-generated images, and virtual
reality technology can help to ensure physicians understand fully the goals of their
patients.
The IMF should be lowered only in selected circumstances, because lowering of the
fold can lead to distortion.
In lieu of lowering the fold, the use of a smaller implant can help to reduce the risk of
fold distortion.
Aggressive dual or combination plane dissection can help to reduce distortion along
the fold.
Implants that resist wrinkling, such as anatomically shaped cohesive gel devices, lead
to longer-term performance with reduced 10-year rupture rates.
Anatomic implants can help to prevent the need for a mastopexy in selected patients.

748
Part VIII Breast Surgery
TOP TAKEAWAYS

Early mammograms are recommended for patients undergoing breast surgery
(by age 30-35 years).

Eklund mammographic views improve radiographic imaging of breast tissue
after augmentation.

During preoperative evaluations, asymmetries should be noted and discussed
with the patient. If asymmetries are present before surgery, asymmetries will be
present afterward.

Mild ptosis is improved with augmentation. However, patients whose N-IMF


Subglandular augmentation is not recommended with thin upper pole coverage
(superior pole pinch test is <2 cm).



Historically, higher contracture rates occur with smooth implants, silicone
implants, and subglandular placement.

Textured implant surfaces disorient collagen deposition, thereby reducing
contracture.

Subglandular placement potentially increases risk of implant contamination,
subclinical infection, and subsequent contracture.

The use of antibiotic irrigation, and other techniques, dramatically reduces
contracture rates.

The dual plane (biplanar) technique takes advantage of extra upper pole
pectoralis coverage while maximizing the implant-parenchymal interface in the
lower pole.




textured implant.
REFERENCES
1. American Society of Plastic Surgeons. Procedural statistics trends 1992-2004. Available at


mammaplasties at autopsy. Plast Reconstr Surg 100:197, 1997.



Breast Implants, November 17, 2006.
5. Rohrich R. Streamlining cosmetic surgery patient selection—just say No! Plast Reconstr
Surg:104:220, 1999.
6. Gorney M. Patient selection criteria. Medico-legal issues in plastic surgery. Clin Plast Surg 26:37,
1999.
7. National Breast Cancer Foundation. Early detection. Available at

749
Chapter 52 Breast Augmentation
8. Adams WP, Rios JI, Smith SJ. Enhancing patient outcomes in aesthetic and reconstructive breast
surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg 117:30, 2006.


10. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in
a wide range of breast types. Plast Reconstr Surg 107:1255, 2001.
11. Price CI, Eaves FF III, Nahai F, et al. Endoscopic transaxillary subpectoral breast augmentation.
Plast Reconstr Surg 94:612, 1994.
12. Rohrich RJ, Kenkel JM, Adams WP. Preventing capsular contracture in breast augmentation: in
search of the Holy Grail. Plast Reconstr Surg 103:1759, 1999.
13. Wiener TC. Betadine and breast implants: an update. Aesthet Surg J 33:615, 2013.
14. Mladick RA. “No-touch” submuscular saline breast augmentation technique. Aesthetic Plast
Surg 17:183, 1993.
15. Courtiss EH, Goldwyn RM. Breast sensation before and after plastic surgery. Plast Reconstr
Surg 58:1, 1976.

augmentation: a comparison of periareolar and inframammary incision approaches. Plast Re-
constr Surg 117:1694, 2006.

treated with bromocriptine. Br J Plast Surg 43:373, 1990.

118(7 Suppl):S168, 2006.
-
cational Foundation multicenter outcomes study. Plast Reconstr Surg 100:1019, 1997.
20. Biggs TM, Yarish RS. Augmentation mammoplasty: a comparative analysis. Plast Reconstr Surg
85:368, 1990.
-
ing factors. Ann Plast Surg 34:8, 1995.



102:884, 1998.
24. Virden CP, Dobke MK, Stein P, et al. Subclinical infection of the silicone breast implant surface
as a possible cause of capsular contracture. Aesthetic Plast Surg 16:173, 1992.

silicone mammary implants. Ann Plast Surg 34:563, 1995.
26. Burkhardt BR, Dempsey PD, Schnur MD, et al. Capsular contracture: a prospective study of the

-
cal practice. Plast Reconstr Surg 114:711, 2004.


29. Collis N, Coleman D, Foo IT, et al. Ten-year review of a prospective randomized controlled
trial of textured versus smooth subglandular silicone gel breast implants. Plast Reconstr Surg
106:786, 2000.
30. Marotta JS, Widenhouse CW, Habal MB, et al. Silicone gel breast implant failure and frequency
of additional surgeries: analysis of 35 studies reporting examination of more than 8000 ex-
plants. J Biomed Mater Res 48:354, 1999.

750
Part VIII Breast Surgery
31. U.S. Food and Drug Administration. Center for Devices and Radiological Health. FDA update



32. Mentor Corporation. Saline implant premarket approval information, 2001. Available at http://


33. Allergan Corporation. Saline implant premarket approval information, 2001. Available at www.


34. Mentor, Allergan, and Sientra Corporations. Silicone breast implant premarket approval infor-
mation, 2003, 2005, 2012. Available at

35. Mentor Corporation. Saline implant premarket approval information, 2001. Available at http://


36. Inamed Corporation. Saline implant premarket approval information, 2001. Available at http://


37. Inamed Corporation. Silicone breast implant premarket approval information, 2003 and
2005. Available at

38. Clemens MW, Miranda FN, Butler CE. Breast implant informed consent should include the risk
of anaplastic large cell lymphoma. Plast Reconstr Surg 137:1117, 2016.

management of patients with breast implant-associated anaplastic large-cell lymphoma. J Clin
Oncol 34:160, 2016.
40. Hoshaw SJ, Klein PJ, Clark BD, et al. Breast implants and cancer: causation, delayed detection,
and survival. Plast Reconstr Surg 107:1393, 2001.
41. Jakubietz M, Janis JE, Jakubietz R, et al. Breast augmentation: cancer concerns and mammog-
raphy: a review of the literature. Plast Reconstr Surg 113:117e, 2004.

751
NATURAL HISTORY AND CLASSIFICATION1,2
BREAST CHANGES: MULTIFACTORIAL
The amount of breast parenchyma changes with and

• The skin envelope is stretched when the parenchyma enlarges.
• Supporting ligaments and ductal structures are also stretched.
results when the parenchymal volume decreases, and the skin envelope and
supporting structures do not retract.

youthful breast contour is lost.
REGNAULT CLASSIFICATION1



the level of the inframammary fold.

the level of the inframammary fold, but remains above the most
dependent part of the breast parenchyma.

the inframammary fold and at the most dependent part of
the breast parenchyma along the inferior contour of the breast.

the level of the inframammary fold, but most of the breast
parenchyma has descended the level of the fold.


Joshua Lemmon, Smita R. Ramanadham, James Christian Grotting
D
A
Nipple
Inframammary
fold
B
Inframammary
fold
Nipple
C
A, Pseudoptosis. B, Grade I ptosis. C, Grade II
ptosis. D, Grade III ptosis.

752
Part VIII Breast Surgery
INDICATIONS AND CONTRAINDICATIONS
INDICATIONS
Women who desire an improvement in breast contour without a change in volume
Women who seek a more lifted, “perky,” youthful breast appearance and aim to correct

envelope
CONTRAINDICATIONS
Active smoking
Women who desire volume change
PREOPERATIVE EVALUATION
HISTORY
Involution of breast after menopause

tumors, previous procedures, family history of breast cancer, recent mammogram

including psychotropic, oral contraceptive, and hormone replacement6
MEASUREMENTS
Allows detection of asymmetry in nipple position
A measurement of the redundancy of the
lower pole skin envelope
(see Fig. 53-1)
OTHER CONSIDERATIONS

7

skin; degree of skin laxity

Areola are often stretched and large with asymmetries.
PHOTOGRAPHS
and photographs should be obtained (see Chapter 3).
PATIENT EXPECTATIONS

• Mastopexy techniques combine small amounts of parenchymal resection (<300 g
traditionally in literature
3) and redistribution with reduction of the skin envelope—
this can result in a reduction in breast size.

3
• Many patients desire restoration of upper pole fullness, which may necessitate the
placement of an implant simultaneously.


combined with mastopexy.
8

753
Chapter 53 Mastopexy
7 (see
Chapter 54).

• Mastopexy procedures trade scars for improved contour.
• Patients should be informed in detail preoperatively about scar placement and scar
quality.

• Thorough patient education regarding procedural complications, use of drains, and
recurrence of ptosis are essential components of preoperative preparation.
INFORMED CONSENT
Recommend items to be included in the informed consent:
A general description of the procedure and location of incisions and the potential need
for placement of drains

• Bleeding and hematoma
• Infection
• Delayed healing and wound separation
• Change in nipple and skin sensation
• Potential changes in breast-feeding
• Asymmetry and poor cosmetic result

TIP: Postoperative scars are a frequent source of litigation; therefore they are an
essential component of the informed consent process. However, breast shape should
not be compromised to reduce the scar burden.
MASTOPEXY TECHNIQUES
Historically, mastopexy was based on primary skin excision; however, since the mid-
1990s, internal shaping of tissue using various supportive materials or parenchymal
pillars has also been emphasized.
4
Technique depends on degree of ptosis.
PERIAREOLAR TECHNIQUES
GENERAL
Incisions are made and closed around the areola.

PATIENT SELECTION
Useful with and moderate ptosis

glandular.

754
Part VIII Breast Surgery
TECHNIQUES

• Breast parenchyma is repositioned; therefore only useful with mild ptosis
• Permits

2
9 (Fig. 53-2)
• A periareolar technique that can be applied to patients with larger degrees of breast
ptosis
• Allows parenchymal repositioning
• Areolar sizers are used to mark the new areolar diameter, and a wider ellipse is
marked to reposition the NAC and resect redundant skin envelope.
• Undermining separates the breast gland from the overlying skin.
• The breast parenchyma is then incised leaving the NAC on a superior pedicle.

midline, narrowing the breast width and coning the breast shape.
• The periareolar incision is closed in a purse-string fashion with permanent suture.
Benelli periareolar
mastopexy. Markings, undermining,
and parenchymal coning.
A
B
C
D
A
B
C
D

• Variations on the technique discussed above include use of mesh to support the
parenchyma
10 or routine use of breast implants to reduce the amount of skin
resection required.11,12
ADVANTAGES
Short scar

755
Chapter 53 Mastopexy
DISADVANTAGES
Scar and areolar widening occur frequently.

Purse-string closure results in skin pleating that takes several months to resolve.
SENIOR AUTHOR TIP: If periareolar purse-string suture remains palpable, it can be

VERTICAL SCAR TECHNIQUES
GENERAL
Vertical mastopexy techniques are variations of vertical reduction mammaplasty
techniques.
Incisions are closed around the areola and inferiorly toward the inframammary fold.
Techniques rely on parenchymal support inferiorly to narrow and cone the breast.
PATIENT SELECTION
Techniques can be applied to patients with all degrees of ptosis.
TECHNIQUES
13 (Fig. 53-3)
• Skin incised (see Fig. 53-4, )
• The inferior, ptotic skin; fat; and gland are resected en bloc, and the nipple is
transposed superiorly without undermining.
• Medial and lateral breast pillars are closed.
Vertical mastopexy without undermining. Inferior skin, fat, and gland are resected
en bloc. The nipple is transposed to the desired position. The medial and lateral breast pillars are
closed vertically.
14
B)

facilitate mobilization of the superior dermal-parenchymal pedicle.

756
Part VIII Breast Surgery


inferiorly.

between the inferior sutures.

15
C)



pattern.
A
B
C
Vertical scar mastopexy techniques. A, B, C, Hammond.
16






MODIFICATIONS
17

tunneled superiorly to secure it in place.
• Designed to restore upper pole fullness and increase breast projection
ADVANTAGES

Parenchymal closure inferiorly provides additional support to limit recurrent ptosis.
DISADVANTAGES
Immediate postoperative result frequently displays pronounced upper pole fullness that
settles over time.
Skin redundancy inferiorly will occasionally not retract, requiring horizontal excision at a
later date.

757
Chapter 53 Mastopexy
TIP: In an attempt to limit the redundancy in the inferior pole skin, the vertical closure

inferior skin redundancy and still prevents a medial horizontal scar.

GENERAL
Incisions are closed around the areola, vertically to the inframammary fold, and
horizontally within the fold itself.
PATIENT SELECTION
Employed for ptosis
Should also be considered for mastopexy in patients with both
and
TECHNIQUES
Most frequently a Wise-pattern skin incision technique is used because of the
popularity of the Wise-pattern breast reduction technique.
Other skin excision patterns exist (Fig. 53-5), which attempt to reduce the length of the
horizontal scar.
Several skin incision patterns for inverted-T mastopexy techniques.
Parenchymal resection is indicated in hypertrophic breasts.
In most mastopexy patients, parenchymal support can be obtained with

Inferior parenchyma can be repositioned superiorly to restore superior pole fullness or
used to support the inferior pole of the breast.
• Tunneled under a pectoralis sling
17
• Folded under a superior pedicle and secured to the pectoralis fascia18
• Folded over to create a supportive sling for the lower pole19

758
Part VIII Breast Surgery
TIP: In traditional inverted-T mastopexy techniques, breast shape is maintained only
by the skin envelope. Modern variations rely heavily on parenchymal support to lend
longevity to the result.
ADVANTAGES
Surgeon familiarity with technique because of widespread use in reduction
techniques20
Predictable results
DISADVANTAGES
Scar burden
Recurrent ptosis occurs frequently if parenchymal support not used
POSTOPERATIVE CARE

Postoperative pain is treated with oral analgesics.
A supportive bra is required for 6 weeks postoperatively for full support during the
healing process.
Scar treatment begins 3 weeks postoperatively with the surgeon’s preferred technique.
If scar revisions are necessary, they are performed after 1 year.
COMPLICATIONS

• Relatively infrequent
• Patients should not take aspirin and antiplatelet medications for 10 days
preoperatively.
• Tight hematomas require urgent reoperation for evacuation, hemostasis, and
closure.

• Also uncommon

21

• Mostly present in inferior-T–designed procedures
• More common among smokers. Mastopexy should not be performed on active
smokers for this reason.

• Patients should be counseled preoperatively that absolute breast symmetry will
never be achieved.
• Vast asymmetries in nipple position, areolar size, and breast shape require revision
surgery.

• Periareolar scar widening and medial horizontal inframammary fold scars are a
source of frequent patient dissatisfaction.
• Scar revisions can be performed 1 year after the initial surgery.

759
Chapter 53 Mastopexy
• Inferior parenchymal (not dermal) support is thought to decrease the likelihood of
recurrent ptosis.
• Mastopexy is a temporary procedure, and long-term results usually reveal some
recurrence of the deformity.
2
SPECIAL CONSIDERATIONS
AUGMENTATION ASTOPEXY see C
The loss of upper pole fullness with breast ptosis has led many surgeons to advocate
placement of subglandular or subpectoral breast implants during mastopexy
procedure.
2,6,12
Augmentation and mastopexy techniques work against each other.22
• Mastopexy is designed to reposition the nipple, reshape the breast without tension
to limit scarring, and reduce the size of the redundant skin envelope.
• Augmentation increases the size of the skin evelope, increases the mass of the
breast subjecting it to a greater force of gravity, and increases the tension of wound
closure.
Surgeons should consider augmentation and mastopexy in patients with
moderate or severe ptosis.
MASTOPEXY AFTER EXPLANTATION
Many patients with previously placed silicone gel implants now present for explantation
for various reasons, including rupture, fear of rupture, and capsular contracture.

the capsulectomy and implant exchange.23,24
• Preexplantation ptosis is rarely corrected without formal mastopexy.
• Good candidates are nonsmokers, with mild to moderate ptosis, and adequate

• In patients with sparse soft tissue coverage or severe ptosis, mastopexy should be
staged 3 months following explantation.
TIP: Avoid mastopexy in all smokers.

53-1).




Pseudoptosis
Adequate volume
Good nipple position
Nipple-to-inframammary fold: 6 cm
Inframammary fold wedge excision
Grade I
Nipple repositioned <2 cm
Areola: <50 mm diameter
Periareolar mastopexy
Vertical mastopexy
Grade II
Nipple repositioned 2-4 cm
Wise-pattern mastopexy
Grade III

<4 cm breast thickness
Delayed mastopexy
(3 months, smoker)

760
Part VIII Breast Surgery
TUBEROUS BREAST DEFORMITY

• A spectrum of deformity with variable severity26




large areola
These patients often present in consultation desiring mastopexy or augmentation.
SENIOR AUTHOR TIP: Distinguishing these patients is essential. They are often
unaware of their anatomic abnormalities, and typical mastopexy techniques are not
adequate.
27
• Expand breast circumference.
• Expand skin envelope in the lower pole.
• Release constriction at the breast-areolar junction.

• Increase breast volume (when appropriate).
• Reduce areolar size and correct herniation.
• Correct nipple location and breast ptosis.
26
techniques can be used to reduce the areolar size and
reposition the NAC on the breast mound.

mobilization, or division.
• Augmentation with permanent implants or expandable permanent implants is
usually required to restore parenchymal volume.
OUTCOMES

29 reviewed 1700 vertical scar procedures and evaluated
measurements over time to determine position of the NAC.

postoperative day 5 and 1 cm higher at 4 years.

time, and pseudoptosis did not occur.
• Swanson
28 reviewed 82 publications on mastopexy and reduction and various
assessments on measurements such as breast projection, upper pole projection,
nipple level, and breast convexity.

inferior pedicles), vertical, periareolar, inframammary, and lateral.

any of the mastopexy or reduction procedures.

761
Chapter 53 Mastopexy


techniques.

autoaugmentation, generally did not maintain shape in the long term.
30
SURVEY COMPARISON OF VARIOUS TECHNIQUES
had the
31 and the
Although most popular,
frequency of bottoming out (p = 0.043) and
(p = 0.001), compared with the short-scar and periaroeolar groups.
SENIOR AUTHOR TIP: Tissue expansion is necessary in patients with severe inferior

TOP TAKEAWAYS


relative to the inframammary fold.

Modern mastopexy techniques rely on inferior parenchymal support to elevate
the gland on the chest wall and limit recurrent ptosis.

Mild ptosis can be corrected with periareolar techniques alone.

Moderate and severe ptosis require vertical or vertical/horizontal skin excision.

Mastopexy and augmentation procedures have contradicting properties and
should be combined with caution.

Identifying patients with tuberous breast deformities is essential, because

REFERENCES

2. Bostwick J III. Mastopexy. In Bostwick J III, ed. Plastic and Reconstructive Breast Surgery, ed 2.
New York: Thieme Publishers, 1999.
3. Weichman K, Doft M, Matarasso A. The impact of mastopexy on brassiere cup size. Plast Re-
constr Surg 134:34e, 2014.
4. Nahabedian MY. Breast deformities and mastopexy. Plast Reconstr Surg 127:91e, 2011.
5. Ibrahim AM, Sinno HH, Izadpanah A, et al. Mastopexy for breast ptosis: utility outcomes of
population preferences. Plast Surg (Oakv) 23:103, 2015.
6. Grotting JC, Chen SM. Control and precision in mastopexy. In Nahai F, ed. The Art of Aesthetic
Surgery: Principles and Techniques. New York: Thieme Publishers, 2005.
7. Hidalgo DA, Spector JA. Mastopexy. Plast Reconstr Surg 132:642e, 2013.
8. Swanson E. Prospective photographic measurement study of 196 cases of breast augmen-
tation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg
131:802e, 2013.

762
Part VIII Breast Surgery

14:99, 1990.
10. Goes JC. Periareolar mammaplasty: double skin technique with application of polyglactin or
mixed mesh. Plast Reconstr Surg 97:959, 1996.

2001.
-
mentation. Aesthet Surg J 19:34, 1999.


1994.
15. Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast
Reconstr Surg 103:890, 1999.

Plast Reconstr Surg 104:748, 1999.

Plast Surg 24:348, 2000.

19. Svedman P. Correction of breast ptosis utilizing a “fold over” de-epithelialized lower thoracic

20. Rohrich RJ, Gosman AA, Brown SA, et al. Current preferences for breast reduction techniques:


following breast surgery. J Antimicrob Chemother 31(Suppl B):43, 1993.
22. Spear S. Augmentation/mastopexy: “Surgeon, beware.” Plast Reconstr Surg 112:905, 2003.
23. Rohrich RJ, Beran SJ, Restifo RJ, et al. Aesthetic management of the breast following explanta-
tion: evaluation and mastopexy options. Plast Reconstr Surg 101:827, 1998.
24. Rubin JP, Toy J. Mastopexy and breast reduction in massive-weight-loss patients. In Nahai F, ed.
The Art of Aesthetic Surgery: Principles and Techniques, ed 2. New York: Thieme Publishers,
2011.
25. Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg 3:339, 1976.

treatment. Br J Plast Surg 49:339, 1996.
27. Versaci AD, Rozzelle AA. Treatment of tuberous breasts utilizing tissue expansion. Aesthetic
Plast Surg 15:307, 1991.
28. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast
reduction. Plast Reconstr Surg 128:1282, 2011.
-
tion and inferior pole length. Plast Reconstr Surg 121:1084, 2008.

3. New York: Thieme Publishers, 2010.

plastic surgeons. Plast Reconstr Surg 118:1631, 2006.

763
GENERAL PRINCIPLES
Augmentation-mastopexy is a technique used to simultaneously correct low volume
and skin excess.
alone corrects relative
alone corrects relative

will result in a persistent relative mismatch, combined procedure is needed.
1-3
Gonzales-Ulloa4 described the technique in 1960, followed by Regnault5 in 1966.
Surgical planning depends on relative locations of nipple and inframammary fold (IMF)
(i.e., ptosis). Regnault described three categories6,7 (Fig. 54-1):
Inframammary
fold
Nipple
A
Inframammary
fold
Nipple
B
C
Inframammary
fold
Nipple
A, Grade I. B, Grade II. C, Grade III.
• Nipple at IMF
• Nipple below IMF
• Nipple at the lowest point on breast
Nipple at or above IMF but breast parenchyma below IMF8 (Fig. 54-2, )
Excess gland in the lower pole of the breast8 (Fig. 54-2, B )

Purushottam A. Nagarkar

764
Part VIII Breast Surgery
Pseudoptosis
A
Glandular
ptosis
B
Pseudoptosis.
B, Glandular ptosis.
ALTERNATIVES
AUGMENTATION ALONE
Use if skin excess is minimal: i.e., minimal gland below IMF, minimal ptosis, AND
Augmentation alone can provide appropriate projection and adequately correct ptosis
by decreasing relative skin excess.
MASTOPEXY ALONE

Skin resection alone will appropriately raise the nipple position and adequately correct
projection by decreasing relative
INDICATIONS

Periareolar mastopexy with augmentation requires9:
• Nipple no more than 2 cm below the fold
• Nipple-areola complex (NAC) at or above breast border, not pointing inferiorly
• No more than 3-4 cm of associated breast ptosis


SINGLE TAGE PROCEDURE
Thought to be unpredictable, with higher revision rate than that of both procedures
combined11
12
13,14:

• Unclear whether both procedures will be necessary

13:


15 skin stretch <4 cm and nipple-to-
IMF (N-IMF) distance <10 cm

765
Chapter 54 Augmentation-Mastopexy


TWO TAGE PROCEDURE
15 is indication for staging procedure.

augmentation.

stage the mastopexy.
OUTCOMES see T and
• Multiple large series have shown ~8%-20% reoperation rate for one-stage procedures.1-3
• Using his algorithm to select patients for two-stage procedures, Adams achieved:


PREOPERATIVE EVALUATION
Mammogram within the last year for selected patients: AMA and ACOG16 guidelines
• Age over 40 years, or
• Age over 35 years with high risk for breast cancer, or
• Personal history of breast cancer
Detailed breast history, including previous breast surgery
Understand goals. Does the patient want
• Greater volume?
• Greater projection?
• A “lift” (i.e., nipple and glandular elevation)?
therefore it is common at
endpoint as well.
Set expectation of reoperation rate of up to 20%.
SURGICAL PLANNING AND TREATMENT
Measurements (tissue-based planning)15,17
• Pinch thickness in the superior pole of the breast: Results useful for choosing
implant.
• Skin stretch (SS): Nipple excursion on light traction; provides information on laxity in
the anteroposterior dimension
15 (Fig. 54-3, and B )
15
(Fig. 54-3, C ).
• Vertical excess (VE): Anticipated excess skin/parenchyma to be resected

15 (Fig. 54-4).

• Material: Silicone versus saline; usually based on preference of patient and surgeon
• Tissue-based planning to guide choice of implant volume and tissue plane


soft tissue disruption

766
Part VIII Breast Surgery
• Incision: Depends on choice of mastopexy incision


A
Inframammary fold
Nipple
B
Skin stretch. B, Nipple-to-IMF stretch.
Algorithm for selecting mastopexy, one-stage augmentation-mastopexy, or two-stage
mastopexy. ( Nipple-to-IMF distance; skin stretch; VE, vertical excess.)
Hypomastia/Ptosis
SS <4 cm
and N-IMF <10 cm
Breast
augmentation


VE <6 cm
One-stage
augmentation-
mastopexy

Two-stage
augmentation-
mastopexy
9,18
• Periareolar for patients with:



• Vertical for patients with:



• Wise pattern for patients with:

767
Chapter 54 Augmentation-Mastopexy

• Markings





short.
19
POSTOPERATIVE CARE
Consider covering incisions with semipermeable dressing (e.g., Tegaderm) or skin
adhesive (e.g., Dermabond).

No stress should be placed on internal and external incisions for 6 weeks to allow
healing.
OUTCOMES AND COMPLICATIONS
Complication Rates for One-Stage Augmentation-Mastopexy

1




Reoperation
Tissue related
Implant related
14.6
3.7
10.9
20
11.5
8.5
Implant rupture
3.7
0.4
Unattractive scarring
2.5
2.1
Recurrent ptosis or bottoming out
2.2
3.0
Nipple malposition or asymmetry
2.2
3.0
Capsular contracture
1.9
3.8
Breast asymmetry
1.6
2.1
Infection
1.3
0.4

1.2

NA
Nipple loss or depigmentation
0.6
2.6
Implant malposition
0.3
0.4
Hematoma
0.6
1.3
Seroma

NA
0.4
Comparison of Complication Rates




One-stage augmentation-mastopexy
91
10
6.5
Two-stage augmentation-mastopexy
14
7
7
Mastopexy alone
71
14
1.4

768
Part VIII Breast Surgery
TOP TAKEAWAYS

The goal of augmentation-mastopexy is to correct ptosis while increasing
volume.


breast characteristics and forces are treated simultaneously.

Augmentation-mastopexy requires excellent patient selection and meticulous
technique.


then reassess to prevent being skin-short.
REFERENCES
1. Stevens WG, Freeman ME, Stoker DA, et al. One-stage mastopexy with breast augmentation:
a review of 321 patients. Plast Reconstr Surg 120:1674, 2007.

surgeon’s practice. Plast Reconstr Surg 118(7 Suppl):S136, 2006.
3. Calobrace MB, Herdt DR, Cothron KJ. Simultaneous augmentation/mastopexy: a retrospective
5-year review of 332 consecutive cases. Plast Reconstr Surg 131:145, 2013.
4. Gonzales-Ulloa M. Correction of hypotrophy of the breast by exogenous material. Plast Reconstr
Surg Transplant Bull 25:15, 1960.
5. Regnault P. The hypoplastic and ptotic breast: a combined operation with prosthetic augmenta-
tion. Plast Reconstr Surg 37:31, 1966.

-
mentation. Aesthet Surg J 19:34, 1999.
-
lishers, 2011.

Plast Surg 18:189, 2004.

Publishers, 2011.

Suppl):S133, 2006.
12. Gorney M. Ten years’ experience in aesthetic surgery malpractice claims. Aesthet Surg J 21:569,
2001.

2000.


mastopexy. Plast Reconstr Surg 245:215, 2014.
16. American College of Obstetricians-Gynecologists. Practice bulletin no. 122: breast cancer
screening. Obstet Gynecol 118(2 Pt 1):372, 2011.



2002.
19. Jones GE, ed. Bostwick’s Plastic and Reconstructive Breast Surgery, ed 3. New York: Thieme
Publishers, 2010.

769
PATHOPHYSIOLOGY
Breast hypertrophy is thought to be an abnormal end-organ response to circulating
estrogens.1,2
Normal number of estrogen receptors and normal levels of circulating estrogens have
been found in women with hypermastia; thus an increased sensitivity to the hormone is
suspected.
3
Hypermastia typically begins within the hormonal milieu of puberty or pregnancy.
With the increasing obesity epidemic, breast hypertrophy is often from excess adipose
rather than glandular hyperplasia.
Studies suggest that fat accounts for of modern breast reduction
specimens.4,5
INDICATIONS FOR SURGERY
Breast reduction has an and has been shown to
6,7
MEDICAL INDICATIONS
Neck pain
Back pain
Shoulder pain
Bra strap grooving
Persistent or recurrent intertriginous infections, rashes, maceration, and irritation
Chronic headaches
In extreme cases, degenerative arthritis of the cervical and thoracic spine
EVIDENCE
8

tissue removed.
9,10

medical conditions (e.g., kidney transplant, living with moderate angina pectoris).
• Symptoms are more important than volume in determining health burden and

• Weight loss, special bras, and medical treatments are not successful.

770
Part VIII Breast Surgery
AESTHETIC INDICATIONS
Women with hypermastia frequently report aesthetic dissatisfaction with breast size
and shape.
Complaints include pendulous appearance and wide nipple-aerola complex.
Excessive size may limit clothing selection and athletic participation.
TIP: Determining the aesthetic or medical necessity of reduction mammaplasty is
ambiguous and nonstandardized by health insurance carriers in the United States.
PREOPERATIVE EVALUATION
PATIENT HISTORY
11)
Medical history of comorbid disease(s), clotting disorders
Surgical history pertaining to breast
Social history of smoking or nicotine use
Familial history of breast disease, anesthesia problems, deep vein thrombosis (DVT)

Previous medical or therapeutic treatment for hypermastia
PHYSICAL EXAMINATION
Allows detection of asymmetry in nipple position
Serves as a measurement of the redundancy
of the lower pole skin envelope
Allows detection of asymmetrical breast footprint
Widening of the areola is very common in patients with hypermastia
(normal areolar diameter is 38-45 mm).
severity (see Chapter 52)
Breast examination for mass or
ADDITIONAL CONSIDERATIONS


MAMMOGRAM
When indicated
PHOTOGRAPHY see C
Anteroposterior (AP), lateral, and oblique photographs should be obtained.
Photographs of shoulder grooving and rashes, when present.
PATIENT EXPECTATIONS

• Reduction mammaplasty will not result in a virginal breast.
• Most techniques will naturally result in a pendulous, mature-looking breast, but with
a size more proportionate to the body habitus of the patient.

• The desired postoperative breast size can vary widely between patients and should
be dicussed at length at the initial consultation.