Reoperative Aesthetic & Reconstructive Plastic Surgery

1176
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
It is probably safer to use the contouring burr to remove bone down to the dura,and
then to harvest a full-thickness cranial graft.The advantages of this technique are that
thicker bone can be obtained and it is not necessary to use an osteotome to harvest
the graft.The very reason that this is safer is because an osteotome is not used.There
is always the possibility that the latter could penetrate the dura,resulting in disastrous
bleeding.The burring technique is much safer for the inexperienced surgeon.
There are two ways to stabilize the graft, and both will be described. In the rst
method,the nose is widely undermined in the subcutaneous plane to obtain as much
length and protrusion as possible using a vertical skin incision. A slot is cut in the
frontonasal area in a manner that allows the lower edge to function as a fulcrum. The
nasal skin is dissected and elevated to the nasal tip.The bone graft is inserted the full
length of the nose. As the screw is tightened the graft is cantilevered and the tip of
the nose becomes more prominent. If there is tension and pallor on the tip, the
screw should be released slightly to produce pinkness. Failure to do this may result
in skin loss and bone graft exposure. Using this method, the ideal shape of nose can
be achieved in a controlled fashion. Screw xation must be performed carefully
because overtightening can fragment the graft. When the ideal position has been
achieved, a second screw can be introduced to provide solid xation.
Controlled
advancement
of tip
Screw
Fulcrum

1177
Chapter 32
Reoperative Craniomaxillofacial Surgery
In the second method used to stabilize a graft, a wire may be used. A wire-passing
drill is punched through the skin low on the nasal bone with the eyes protected.The
drill is slowly advanced through the nasal pyramid to the outside of the bone on the
other side; it does not penetrate the skin. After the drill is withdrawn, an 18-gauge
hypodermic needle is passed through the track all the way through the skin and
bone. An 18-gauge wire is passed into the needle;after it exits through the hub, the
needle is withdrawn, thus leaving the wire protruding from both sides of the skin of
the nasal bridge line.A small incision is made in the glabellar region,and a ne mos-
quito forceps is passed under the skin and subcutaneous tissue from above to grasp
the wire, which is then pulled out superiorly. This maneuver is performed on the
contralateral side of the bone graft. As the wire is tightened, the bone graft is canti-
levered.Thus any degree of projection of the nasal tip can be achieved, skin vascu-
larity permitting. As mentioned above, the tip is frequently tight and pale. It is a
matter of judgment as to whether this appearance is acceptable or not. It is impor-
tant to get maximum length and good tip projection as in any nasal reconstruction.
Controlled
advancement
of tip
Wire
Fulcrum

1178
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
PATIENT EXAMPLE
This patient requested nasal reconstruction after correction of hypertelorism. She
is shown 2 years postoperatively after nasal reconstruction has been performed us-
ing a cranial bone graft and a forehead ap.
COSTOCHONDRAL GRAFTS
A large number of patients with craniomaxillofacial conditions who undergo sec-
ondary surgery require costochondral grafting or costochondral grafts to be re-
placed. Careful planning for this procedure is essential. A Panorex lm is of some
help, but three-dimensional CT scanning, especially interactive CT, is almost essen-
tial. This analysis provides information about the ascending ramus, temporo-
mandibular joint, skull base, and zygomatic arch. Thus the total area to be recon-
structed is clearly de ned.

It is strongly advised to always use the coronal ap for approach;in this way the pro-
cedure can be performed under direct vision. Arch and glenoid fossa reconstruction
are easily accomplished with split-rib grafts. An incision is made in relation to the
angle of the mandible, and a deep tunnel is created up to the fossa region.The cos-
tochondral graft can then be inserted virtually under direct vision.The graft can be
seated in the fossa while it is trimmed inferiorly and stabilized to the original
mandible with two or three lag screws. Superiorly the new condyle can be held in
position by placing a small lip of bone anteriorly on the zygomatic arch.Vascular-
ized temporalis fascia can then be placed between the reconstructed glenoid fossa
and the new condyle.This reconstruction helps to avoid the anterior malposition-
ing and superior dislocation that is occasionally seen with these reconstructions.
UPPER LID PTOSIS
Ptosis of the upper lids often accompanies craniomaxillofacial deformities, espe-
cially Apert’s syndrome and Crouzon’s syndrome, and requires correction after the
main skeletal surgery has been completed.
The degree of ptosis and the function of the levator muscle are estimated by immo-
bilizing the frontalis muscle and asking the patient to raise the upper lid.When the
levator muscle is functioning, levator shortening is performed. When the levator
muscle is not functioning, a frontalis advancement is the procedure of choice.
Levator Shortening
The amount of shortening necessary is determined by the amount of ptosis. Short-
ening should be three times the estimated amount and is rarely less than 10 to 15 mm.
The standard shortening method is used with a modi cation that makes the pro-
cedure easy and quick.20 With the lid everted, two small vertical incisions are made
in the lateral aspect of the upper edge of the tarsal plate. A dissection is made
under the conjunctiva, and an umbilical tape is passed through the subconjunctival
tunnel.The lid is placed in its normal position and an incision is made transversely
in the middle area of the lid. The orbicularis oculi muscle and the orbital septum
are divided.The tarsal plate is identi ed and its upper edge is dissected.The dissec-
tion is then taken medially and laterally, and the tape is found and pulled out bilat-
erally;what lies above the central part of the tape is the levator muscle and Müller’s
muscle. The levator muscle is now dissected extensively, transected, advanced,
trimmed, and sutured to the superior edges of the tarsal plate with ne Vicryl.
Frontalis Advancement
Frontalis advancement is preferable and more predictable than the frontalis sling
technique, which is usually advised when the standard procedure is not applicable
or fails as the result of a lack of levator muscle function (J. Mustardé, personal com-
1179
Chapter 32
Reoperative Craniomaxillofacial Surgery

1180
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
munication, 1992). A standard transverse lid incision is made, and the tarsal plate is
dissected in its upper part as for a levator shortening procedure. From the upper
edge of the incision the dissection is taken up subcutaneously until the frontalis
muscle is visualized. Extensive undermining of the frontalis muscle is performed
deep to the skin. Similarly the undersurface of the muscle is undermined until the
frontalis muscle can be advanced and sutured to the upper edge of the tarsal plate
with 5-0 Vicryl under moderate tension. Postoperatively the patient will be able to
open the lid without any training and without the effort required in some patients
after the standard frontalis fascia sling reconstruction.
FREE TISSUE TRANSFER
In many craniofacial cases there is a shortage of soft tissue and, occasionally, of bone
or complex structures such as the nose or eyelids.These de ciencies may occur in
cases of hypertelorism, severe facial clefts, hemifacial microsomia or atrophy, Gold-
enhar’s syndrome, radiation deformity, posttraumatic deformity, or after tumor re-
section.
More and more frequently, free tissue transfer is being used for reconstruction in
such cases. Interactive CT scanning can supply volume and shape estimations, allow-
ing greater ease in choosing the best reconstructive option.With small-volume de-
ciencies the groin ap is ideal; in large reconstructions the rectus abdominis ap
with a small segment of muscle is preferred. If possible, the ap skin is not used. It is
preferable to expand facial skin for cover and use the free ap as ller. Although the
groin ap and rectus ap have been used in the past, there are now many new aps
to choose from, depending on the size of the defect to be reconstructed.
PATIENT EXAMPLE
This patient’s facial deformity resulted from facial radiation treatment for retinoblas-
toma in infancy. Several previous reconstructive attempts had been made.

In addition to skull and orbital reconstruction, a bimaxillary procedure was per-
formed.
1181
Chapter 32
Reoperative Craniomaxillofacial Surgery
All involved soft tissue was replaced with rectus abdominis free tissue transfer. The
rectus abdominis ap was thinned in preparation for a composite eyelid prosthesis.
Occasionally, in situations requiring small volumes, a pedicled ap of temporal and
occipital galea may be used as ller;this tissue will supply a volume of 23 to 25 cm3
in an adult.10
Prefabrication is becoming more common, and on special occasions when more
acceptable material is not available, it may be necessary to manufacture special parts
elsewhere.These must have a well-established blood supply, which will allow trans-
fer of the prefabricated part to the recipient site and to be vascularized by microvas-
cular anastomosis.This approach has been most useful for nose,eyelid,and socket re-
construction. The problems are color match and the total loss phenomenon if the
anastomosis fails.This technique offers exciting possibilities for the future.

1182
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
PATIENT EXAMPLE
Galeal Flaps
Galeal aps can be raised on a well-established blood supply, and they can be used
to close off defects in the anterior skull base that lead directly into the nasopharynx.
This procedure was performed for this patient, who had an anterior skull base de-
fect with brous dysplasia of the left frontonasal area.The approach involved using
a coronal ap and frotonasal osteotomies.
A frontal craniotomy was performed
and the galeofrontalis ap was elevated;
it was wider than the defect.

The ap was placed overlapping the defect and sutured into place using the drill
holes placed around the anterior skull base defect. In this way a secure closure of the
anterior skull base was achieved.This technique has virtually eliminated ascending
infection of the intracranial cavity.
1183
Chapter 32
Reoperative Craniomaxillofacial Surgery
The patient is shown preoperatively and 4 years postoperatively.

1184
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
SKULL BASE APPROACHES FOR TUMORS
AND TUMOR RECURRENCES
The maxilla can be osteotomized and displaced laterally to gain access to the ex-
tracranial and intracranial midline compartment of the skull base, the sella turcica,
and the lower two thirds of the clivus down to the foramen magnum.

An incision was made from the nasal spine down to the interincisal gap.This inci-
sion was continued backward in the center of the bony palate and the soft palate
was split. A central osteotomy was made from the interincisal area to the uvula. A
straight osteotome was used to split the maxilla in the midline.
1185
Chapter 32
Reoperative Craniomaxillofacial Surgery
This patient presented with intractable headaches. A CT scan revealed a tumor, and
on consideration it was felt that this could be resected without signi cant morbid-
ity. The skin approach involved a Weber-Fergusson incision on the right lateral as-
pect of the nose and through the upper lip.The bone technique was basically that
of a hemi-LeFort III swing procedure.
PATIENT EXAMPLE

1186
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The end result was very aesthetically acceptable.This technique is suitable for mi-
crosurgical resection of clival tumors.
A curved osteotome was then placed in the posterolateral area between the max-
illary tuberosity and the pterygoid plates, and an osteotomy was performed. At this
point, a cut was made transversely on the maxilla and the lower maxilla was swung
out. For more exposure of the skull base, the medial orbital wall was then os-
teotomized and the whole maxilla was swung laterally.This maneuver gave excel-
lent exposure from the cribriform plate to the clivus, allowing complete resection.

This 36-year-old man presented with swallowing dif culties and chronic throat-
clearing. A CT scan revealed a postpterygoid tumor on the right side. For this pa-
tient, the lip was split in the midline using a contoured incision. Intraorally, an in-
cision was made in the oor of the mouth back to the ascending ramus. A similar
incision was made on the neck skin. A midline osteotomy of the midline was per-
formed, and the mandible was mobilized.
1187
Chapter 32
Reoperative Craniomaxillofacial Surgery
MANDIBULAR SW ING
The mandibular swing approach is an excellent choice for tumors of the skull base in
the pterygomandibular space and the infratemporal fossa supramedial to the internal
carotid.The lip is split in the midline using a straight line or a stepped incision.
PATIENT EXAMPLE

1188
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This exposure allowed remaining soft tissue to be dissected back to the ascending
ramus.The carotid arteries were identi ed and followed to the skull base.The tu-
mor was safely dissected out and removed.
The mandibular osteotomy was accurately plated and the soft tissue was recon-
structed. Intermaxillary xation was not used. These swing approaches are often
used to treat recurrent skull base tumors in this area and can give an excellent ex-
posure that allows radical and safe block resection.
R EIRRADIATION OF SKULL BASE TUMORS
A considerable problem is presented when a tumor recurs after having been treated
using radiotherapy, with or without radical resection. Although data are not avail-
able to support this claim, it seems that reresection with microsurgical free tissue
transfer may be helpful. This procedure supplies a new vascularized environment
and reirradiation is performed using the appropriate doses.

PATIENT EXAMPLE
1189
Chapter 32
Reoperative Craniomaxillofacial Surgery
This patient had undergone irradiation for a retinoblastoma during the rst year of
life.The tumor recurred when the patient was 5 years old. Both the dura in the area
and the orbit were involved.
A radical resection of the orbit and its contents, together with the related dura was
performed. A dural repair was carried out using fascia.

1190
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The repaired area was covered with a free vascularized rectus abdominis ap. The
osteotomized frontal and nasal bone segment was replaced in position and xed
with plates and screws. A further full dose of radiation was administered to this
previously irradiated area.
The patient remains in good health and is tumor-free 6 years after the resection.
The concept of reirradiation through a vascularized composite ap is safe and gives
the patient a second chance.
This case provides a very good example of how plastic surgery concepts and tech-
niques, in conjunction with those of other specialties, can offer our patients treat-
ment that otherwise seemed risky and unrewarding. Cooperation with profession-
als in other disciplines is essential.

CONCLUSION
It is dif cult in this short chapter to provide the justice that is deserved for the
topic of reoperative craniomaxillofacial surgery. As experience has increased and
our ability to reconstruct has become more sophisticated, this aspect of craniofacial
surgery has expanded and will continue to expand. It is not at all uncommon now
to see a patient with what would previously have been considered a good result be-
ing referred for an even more extensive secondary procedure. Our criteria for a
satisfactory outcome have become more stringent and better de ned.
The surgeon’s ability and con dence may determine whether more complex pro-
cedures are offered to achieve total rather than partial correction. In our own group,
intracranial manipulations have become much more common treatments for our
patients; microsurgical reconstruction is almost a daily event; small, tailored aps
are becoming routine; and there is no doubt that results are improving.
Methods of assessment are becoming more sophisticated;interactive three-dimensional
CT scanning with many new additions to the “tool box” can give insight into a de-
formity and offer possibilities of correction never before imagined. Other entities
such as modeling from the scanning systems, holography, and three-dimensional
MRI scans are expanding our assessment horizons.
Another phenomenon contributing to improved results is patient sophistication;
our patients know more about their deformity and its correction. They are less
likely to accept suboptimal results. These patients are a strong stimulus for us to
constantly improve, and are frequently seeking secondary correction.
As all of these aspects come together, we are forced to look more critically at our
results.The assessment tools are available, we have patient encouragement, and we
have more advanced techniques.These factors drive our desire to produce better re-
sults using every surgical technique available. Performing secondary surgery is de-
manding, but extremely satisfying. This attitude is leading to an understanding of
how to achieve improved results—not only with our secondary procedures, but
also with our primary procedures.
References—With Key Annotated References
1. Fukuta K, Jackson IT. New developments in three-dimensional imaging: Clinical application
of interactive surgical planning for craniofacial disorders. Perspect Plast Surg 6:155-177, 1992.
2. Marsh JL,Vannier MW, Bresnia S, et al. Applications of computer graphics in craniofacial sur-
gery. Clin Plast Surg 13:441-448, 1986.
The principles of three-dimensional reformation, the production of surface images, and recent advances
in modi cation of these images for speci c clinical needs are presented.
3. Jackson IT. Midface retrusion. In Whitaker LA, Randall P, eds. Symposium on Reconstruction
of Jaw Deformity. St Louis: Mosby, 1976, pp 276-310.
1191
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Reoperative Craniomaxillofacial Surgery

1192
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
4. Ortiz-Monasterio F, del Campo AF, Carillo A. Advancement of the orbits and the midface in
one piece, combined with frontal repositioning, for the correction of Crouzon’s deformities.
Plast Reconstr Surg 61:507-516, 1978.
The use of radical craniofacial osteotomies to improve the correction of exorbitism and to obtain bet-
ter aesthetic results in children with Crouzon’s syndrome is described.The procedure presented con-
sists of advancement of both orbits and the midface in one piece, plus advancement and reshaping of
the frontal area.
5. David JD, Sheen R. Surgical correction of Crouzon syndrome. Plast Reconstr Surg 85:344-354,
1990.
6. Jackson IT, Adham MN, Marsh WR. Use of the galeal frontalis myofascial ap in craniofacial
surgery. Plast Reconstr Surg 77:906-910, 1986.
The anatomy and the technique of raising the galeal frontalis myofascial ap is described.The appli-
cations and complications of the ap are discussed. Use of this ap is highly recommended wherever
there is a possibility of direct intracranial nasopharyngeal communication.
7. Fisher J, Jackson IT. Microvascular surgery as an adjunct to craniomaxillofacial reconstruction.
Br J Plast Surg 42:146-154, 1989.
8. Jones NF, Sekhar LN, Schramm V. Free rectus abdominis muscle ap reconstruction of the
middle and posterior cranial base. Plast Reconstr Surg 78:471-479, 1986.
This article discusses a multidisciplinary approach used by a neurosurgeon, an ENT surgeon, and a
plastic surgeon for patients with extensive tumors involving the middle and posterior skull base.Wide
resection of these tumors was accomplished, and the resultant defect of the cranial base was recon-
structed using free rectus abdominis muscle aps.
9. Fukuta K, Jackson IT, McEwan C, et al.Three-dimensional imaging in craniofacial surgery:A
review of the role of mirror image production. Eur J Plast Surg 13:209, 1990.
10. Fukuta K, Jackson IT, Collares MV, et al.The volume limitation of the galeal temporalis ap in
facial augmentation. Br J Plast Surg 44:281-284, 1991.
11. Jackson IT. Reconstruction of the lower eyelid defect in Treacher-Collins syndrome. Plast Re-
constr Surg 67:365-367, 1981.
12. Moreira-Gonzalez A, Jackson IT, Miyawaki T, et al. Augmentation of the craniomaxillofacial
region using porous hydroxyapatite. Plast Reconstr Surg 111:1808-1817, 2003.
This retrospective study analyzes the use of porous, coral-derived hydroxyapatite granules in cra-
niomaxillofacial augmentation for cosmetic and reconstructive purposes and evaluates the long-term
clinical result.The surgical technique is described and discussed.
13. Wolfe SA. Lengthening the nose: A lesson from craniofacial surgery applied to posttraumatic
and congenital deformities. Plast Reconstr Surg 93:78-87, 1994.
14. Imai K,Tajima S.The growth patterns of normal skull by using CT scans and their clinical ap-
plications for preoperative planning and postoperative follow-up in craniofacial surgery. Eur J
Plast Surg 14:80-84, 1991.
15. Wilkes GH, Wolfaardt BDS, Dent M. Osseointegrated alloplastic versus autogenous ear re-
construction: Criteria for treatment selection. Plast Reconstr Surg 93:967-979, 1994.
16. Munro IR, Chin B, Chen UR. Radical treatment for fronto-orbital brous dysplasia:The chain
link fence. Plast Reconstr Surg 67:719-729, 1981.
17. Smith AW, Jackson IT,Youse J. The use of screw xation of methyl methacrylate to recon-
struct large craniofacial contour defects. Eur J Plast Surg 99:17-21, 1999.
18. Jackson IT, Simman R,Tholen R, et al. A successful long-term method of fat grafting:Recon-
touring of a large subcutaneous postradiation thigh defect with autologous fat transplantation.
Aesthetic Plast Surg 25:165-169, 2001.
19. Kelly CP, Cohen AJ,Yavuzer R, et al. Medial canthopexy: A proven technique. Ophthal Plast
Reconstr Surg 20:337-341, 2005.
A technique used successfully with a low rate of complications for more than 25 years to repair the
medial canthal tendon is described in a stepwise manner.The long-term outcomes of using this tech-
nique are reviewed.Traditional methods of medial canthopexy frequently result in complications;the
technique described eliminates most if not all of these.
20. Jackson IT. A simple approach to identi cation of the levator aponeurosis in the correction of
eyelid ptosis. Plast Reconstr Surg 80:448-451, 1987.

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Chapter 32
Reoperative Craniomaxillofacial Surgery
1. What is the main concern with monobloc advancement?
a. Postoperative facial asymmetry
b. Bleeding
c. Dental malocclusion
d. Intracranial infection
e. Overcorrection
2. How is the soft tissue volume determined for a patient with hemifacial micro-
somia?
a. Clinical assessment
b. Three-dimensional CT scans incorporating mirror imaging
c. CT scans and standard radiographs
d. Casting of facial mask
e. Photography
3. When is a facial bipartition technique indicated for the treatment of hyper-
telorism?
a. In cases of wide intercanthal distances
b. When the midface is retruded
c. In patients with mirror deformity
d. When the nose is bi d
e. When the intercanthal area is V-shaped
4. What is the most common cause of a long-nose telecanthus?
a. Crouzon’s syndrome
b. Apert’s syndrome
c. Frontonasal encephalocele
d. Hemifacial microsomia
e. Severe nasal polyps
5. After readvancement of the frontofacial block in patients with Apert’s syndrome,
there may be a connection into the nasopharynx.What is the most convenient
management for this condition?
a. Free tissue transfer
b. Cranial bone graft
c. Fascia lata graft
d. Pericranial patch
e. Galeal frontalis myofascial ap
R EVIEW QUESTIONS

(Trang không có chữ)

P a r t IV
REOPERATIVE SURGERY
OF THE BREAST AND
CHEST WALL

(Trang không có chữ)

1197
Reoperative Breast Surgery After
Reduction Mammaplasty and Mastopexy
James C. Grotting and Carl C. Askren
C ha pter 3 3
Reoperative Problems
Complications
Nipple-areola complex
Hematoma/seroma
Malposition
Fat necrosis
Irregular size and shape
Skin necrosis
Depigmentation
Wound dehiscence
Retraction or protrusion
Infection
Scarring
Nipple-areola complex loss
Other conditions
Aesthetic problems
Occult cancer
Breast mound
Virginal hypertrophy
Asymmetry
Irradiated breast
Contour deformity
Recurrent ptosis
Overreduction
Insuf cient reduction
Scarring
Try as hard as we may for perfection,
the net result of our labors is an amazing variety
of imperfectness.We are surprised at our own versatility in
being able to fail in so many different ways.
Samuel McChord Crothers

1198
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Every surgeon tries to obtain a perfect result in aesthetic breast surgery without
resorting to revisional surgery. If a secondary surgery is needed following reduction
mammaplasty or mastopexy, this situation implies that an unfavorable result devel-
oped and that the patient is somehow dissatis ed.The source of this dissatisfaction
may range from inadequate counseling of the patient with unrealistic expectations
(resulting in inadequate reduction) to a surgical mishap (resulting in massive fat
necrosis).
In the past some surgeons advocated planned two-stage reductions in order to min-
imize the incidence of complications. As our understanding of the blood supply to
the breasts has improved, these techniques have fallen by the wayside.l In an effort
to maintain short scars, new approaches have also recommended staged reduction
for large-volume breasts.2
The multitude of procedures available for breast reduction attest to the inability to
nd a universally applicable solution to the many different patient presentations.
Most reduced breasts, no matter what technique is performed, change shape with
time.The need for reoperation for aesthetic reasons depends on the original tech-
nique selected and the judgment used in applying that technique to a particular pa-
tient.This decision also depends on the ability of the patient and surgeon to cope
with that imperfection.3,4 Long-term follow-up is essential to fully assess the results
of surgery. However, as these patients are among the most satis ed and gratifying to
treat, they are also a mobile population and often may not return for follow-up
once they are completely healed.
Reoperative surgery of the breast may be indicated for aesthetic problems or for
complications of the primary surgery. Reoperation may also be necessary for mis-
cellaneous conditions such as occult cancer or regrowth in cases of virginal hyper-
trophy.
The optimal timing for reoperation is determined by the clinical situation. For
most secondary deformities reoperation is best carried out after the scars have fully
matured (that is, when the edema has resolved and the scars have become pale and
soft). Complete healing may take up to 1 year or longer. Some situations such as
impending nipple loss or wound dehiscence do require early intervention.
The goals of treatment echo those of the primary procedure:attractive breast shape,
symmetry, minimal scars, round nipples with good sensibility, appropriate nipple-
areola position, and long-lasting result.

1199
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
ANATOMIC CONSIDERATIONS
The blood supply to the breast and the innervation of the nipple are two impor-
tant anatomic considerations when planning reoperation of the breast.The incisions
and parenchymal dissection performed in the previous surgery alter the vascular
architecture, and these factors must be considered and integrated into the operative
plan. For example, the inferior pedicle technique separates the nipple from the in-
ternal mammary perforators and the external mammary artery;the pedicle is based
on the anterolateral and anteromedial intercostal perforators contained in the fat
above the pectoralis fascia and in the subcutaneous plexus.
Deepithelialized
area
Original
pedicle
Inferior pedicle incised
Ingrowth of small
vessels from superior
aspect of breast
may be inadequate
Area
deepithelialized
at revision
Division of old inferior pedicle may render nipple-areola complex ischemic
due to inadequate collateral vessels from above
Old inferior
pedicle with
large perforators
supplying
nipple-areola
complex
Secondary revisions based on a superior pedicle or other techniques that divide the
inferior pole of the breast can risk causing necrosis of the nipple-areola complex.
Fortunately, most secondary surgeries do not require a large-volume reduction.

1200
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The risk of decreased sensibility in the nipple following secondary surgeries is in-
creased with any procedure that involves resection of breast parenchyma. Since the
course of the segmental nerves that supply the nipple follows that of the arteries,
the same principles that hold true for the blood supply also apply to the nerves.The
state of nipple-areola sensation should be documented before secondary revisions
are done.
PATIENT EVALUATION
In general, patients who undergo reduction mammaplasty are among the most sat-
is ed patients. However, no matter how much care is taken, complications occa-
sionally occur. A discussion of complications is an integral part of the preoperative
patient consultation. Complications involving the nipple-areola complex are partic-
ularly troublesome, and the possible need for intraoperative conversion to free nip-
ple grafts must be discussed preoperatively. Preoperative consultations with the pa-
tient are essential for developing rapport, assessing whether the patient is a suitable
candidate and does not have unreasonable expectations, and selecting the proper re-
operative technique. Information learned from these sessions will aid in reducing
the risk of postoperative complications or problems.
There are multiple reasons for patient dissatisfaction, not all of which can be reme-
died by additional surgery. Poor communication between the surgeon and patient
may result in misunderstandings and unrealistic expectations. For example, in obese
patients with true gigantomastia it is virtually impossible to reduce a breast to an
aesthetically shaped B cup in a single stage; however, this scenario is often what
patients request and expect.The patient may also expect that axillary folds of fat and
skin will disappear with breast reduction alone, so it is important that the nature of
these deformities be understood by the patient before proceeding in order to avoid
postoperative disappointment.
The need for a secondary procedure may become obvious anytime from the rst
postoperative day to years later. However, aside from early complications, most de-
formities are well established by approximately 3 months postoperatively.Therefore
the 3-month postoperative visit is an important turning point for the patient and
surgeon. Does the patient like the result? Has her body image altered? Has her
lifestyle changed? Has her ability to wear normal clothing improved? It is remark-
able how many patients will be totally satis ed at this stage regardless of the small
aesthetic deformities or asymmetries that the surgeon may notice! The surgeon
must resist the urge to point out these minor imperfections to the patient.Why pre-
cipitate dissatisfaction in an otherwise “happy customer”?
On the other hand, there are a variety of secondary deformities that the patient may
wish to have treated. If these problems become a source of concern for the patient,
a clear plan must be laid out.The patient should be told what to expect and given
a timetable for any secondary surgery that may be necessary.

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Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
COMPLICATIONS
Complications have a wide range of presentations: some minor, others major. Mi-
nor complications include nipple cyanosis (which may progress to necrosis), wound
dehiscence, local infections, and inclusion cysts. Major complications include slough
of the nipple-areola complex, large skin sloughs or hematomas, infection, necrosis
of large areas of fat or breast parenchyma, and pain.5
HEMATOMA AND SEROMA
Hematomas are identi ed by an acute breast asymmetry with pain and ecchymo-
sis. The patient usually complains of disproportionate unilateral pain. Hematomas
may occur as late as 9 days postoperatively6 and should be evacuated once detected.
Exploration to rule out the presence of a hematoma is also indicated if there is im-
pending necrosis of the nipple.We prefer to drain acute hematomas in the operat-
ing room with the patient under general anesthesia.To treat hematomas that are de-
tected several days postoperatively, it may be possible to aspirate or drain the site by
reopening only a small portion of the wound. We place a 1-inch Penrose drain,
which seems to maintain an evacuated cavity better than a closed suction system.
Hematomas can occur after secondary surgery as well as after primary surgery. Af-
ter an inferior pedicled breast reduction, this patient had redundant fat and skin in
the low area of the axilla, a common postoperative deformity in overweight pa-
tients. Because the lateral portion of the inframammary scar extended into this area,
a direct excision was planned in addition to revision of the scars.

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If no additional skin is to be resected, these deformities can be contoured using
suction-assisted lipectomy. In this case direct defatting was performed. No drains
were placed.
Five days postoperatively the patient returned to the of ce with an obvious hema-
toma at the operative site as well as early cellulitis, possibly related to chronic axil-
lary hidradenitis.
The hematoma was aspirated and an antibiotic regimen was prescribed.The patient
recovered uneventfully. Placement of drains after breast reduction remains the sur-
geon’s choice. We prefer to place a drain in most reduction wound beds for 24
hours, but it is well accepted that drains do not prevent hematomas, and many sur-
geons opt not to use them.
Seromas may have a more insidious onset. They usually occur laterally or even in
the low axilla.Treatment is similar to that for small late-onset hematomas. If small,
seromas may be aspirated once or twice a week. However, a seroma of 50 cc or
more will resolve most predictably by the placement of a Penrose drain for 1 week,
which prevents reaccumulation.

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Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
NIPPLE NECROSIS
Nipple necrosis results from vascular compromise. Vascular complications occur
when the vasculature of the breast is disregarded, when technique selection is in-
appropriate, or in rare cases in association with certain conditions such as collagen
vascular disease or sickle cell disease.7
Fortunately, vascular complications diminish in frequency as a surgeon gains expe-
rience.The Biesenberger technique had a high percentage of these complications—
up to one third of patients in some series experienced these problems.8 Vascular
compromise occurred as a result of the elevation of long, thin skin aps, and there
was little regard for or understanding of the blood supply to the breast. With bet-
ter knowledge of the vascular anatomy of the breast, the rate of such complications
has dropped signi cantly.
During the primary procedure the circulation of the nipple must be assessed at the
nal closure of the aps.The vascularity of the pale, soft nipple can be expected to
improve.The blue and engorged state of a nipple, however, may be the rst signs of
impending necrosis.9 Fluorescein has been used to assess nipple viability.10-12 If a
viable nipple becomes congested as the keyhole window is closed, delayed primary
closure with preplaced mono lament suture is an alternative.11 If the closure is too
tight, compromising the nipple or skin ap circulation, sutures may be released to
“Dusky” nipple
and distal pedicle
3-4 hours
postoperatively
Buried imbricated
inferior pedicle
If distal flap is still dusky,
dusky portion is amputated
Free nipple graft
Wound is reopened, pedicle is unfolded, and pedicle is
irrigated with warm saline solution

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improve circulation.The pedicle should be evaluated for kinking and/or excessive
tension. Conversion of the pedicled nipple-areola complex to a free composite
graft should be considered if no correctable cause can be identi ed.9 Leeches have
also been successfully employed to treat venous congestion when improvement
cannot be obtained with any other mechanical manipulation.13
Free Composite Nipple Graft
Once the decision has been made to convert the pedicled nipple-areola complex
to a free composite nipple graft, the most important consideration is the vascular-
ity of the recipient bed. Almost without exception if the nipple-areola complex is
poorly perfused, then the pedicle from which it is excised will also have marginal
vascularity for a variable distance. One has two choices—either to trim the pedi-
cle back to healthy perfused tissue and advance the pedicle into the keyhole or to
debride the pedicle as necessary and then close the keyhole with a purse-string su-
ture or transversely. Since the pedicle often will not reach the keyhole, we prefer to
graft directly to the breast skin. The keyhole can be closed either with a purse-
string suture or transversely with medial advancement of the dog ears at either end
of the closure. Regardless of how the keyhole is closed, one should attempt to limit
the scar so that it does not extend beyond the perimeter of the graft.
Transverse closure

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The nipple-areola complex is defatted, keeping in mind that this graft is intended
to be a composite graft rather than a skin graft. As such, it should include at least
some muscle bers so that theoretically contractility of the complex is maintained.
However, under these circumstances graft take with appropriate pigmentation is
preferable to the inclusion of deep tissue components.Therefore one should err on
the side of a thin composite graft. We prefer to stabilize the graft with a tie-over
bolster dressing.
Intraoperatively the nipple-areola complex is noted to be soft and pale following
the placement of dermal plication sutures to shorten the pedicle length.Therefore
the sutures are immediately removed and the pedicle is irrigated with warm saline
solution. No improvement in the perfusion occurs and the decision is made to
convert to free nipple grafts.

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The nipple-areola complex is removed as a composite graft.
The inferior pedicle is trimmed back to the level at which satisfactory red bleed-
ing is noted.This ap can then be simply tacked to the chest wall to improve pro-
jection and ll.The medial and lateral skin aps are reapproximated, and a disk of
skin is deepithelialized at the appropriate position to accept the composite graft.

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The composite graft is sutured into position and secured with a tie-over bolster
dressing.The postoperative result is shown.
Postoperatively reoperation is indicated if the removal of a few stitches does not im-
prove the situation. Hematoma or torsion of the pedicle may cause necrosis; these
possibilities must be explored and addressed immediately. More breast tissue may
need to be resected to decrease the tension of the closure. Areas for tissue resection
are determined based on the blood supply of the nipple-areola. Again excision and
free nipple grafting may be required.
Minor necrosis of the skin or areola will result in wound separation and can be
treated conservatively with dressings. Major skin or nipple loss is best treated by
surgical debridement. Delayed primary closure may be accomplished if the wound
bed permits. Large sloughs should be treated with surgical debridement to reduce
healing time. Loss of the nipple areola complex, either partial or complete, requires
reconstruction by the same methods used for nipple-areola complex reconstruction
after mastectomy.

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The following sequence represents a major complication after breast reduction and
the treatment required to salvage it.
This 32-year-old woman was known to have sickle cell trait but no other ongoing
medical problems.She underwent bilateral reduction mammaplasty using the supero-
medial pedicle vertical approach.
One week after surgery, she was noted to have adequate perfusion of the nipple-
areola complexes; however, at 2 weeks postoperatively, she returned with progres-
sive bilateral nipple-areola ischemia.

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Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
Ultimately the patient required debridement of both nipple-areola complexes and
the underlying pedicle into the central breast mound.
With conservative care and a trial of wound VAC treatment, the patient eventually
healed by 6 months after her initial surgery.

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The plan for secondary revision included excision of dense scar and any residual fat
necrosis. On the right breast a small segment remaining from the areola was used to
construct a nipple using two “ shtail” aps.
On the left side a similar technique was used, fashioning the nipple from scar tissue.

The patient is shown 3 months after the completion of her revision and 15 months
after her initial surgery. She is awaiting nipple-areola tattooing.
We believe that sickle cell trait represents a signi cant risk factor for
any type of ap surgery.We agree with Spear et al7 that these patients
must be handled with great care when random pattern skin aps are
used. There are guidelines in the medical literature for preventing a
sickle cell crisis in patients with sickle cell disease.
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Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
FAT NECROSIS
Fat necrosis, if minor, manifests itself as localized drainage for days to weeks that
ends with a wide scar or dimpling of the drainage tract. Secondary infection may
develop. These problems may require a revisional procedure to improve the ap-
pearance. If fat necrosis is massive, there is associated glandular necrosis and the
healing process is prolonged. Signi cant asymmetry can result because of volume
loss. A major reconstructive effort may be needed, possibly requiring an implant,
scar revision, and partial or total nipple reconstruction.
This patient underwent breast reduction via the inferior pedicle technique. Three
months postoperatively an area of fat necrosis developed in the superior aspect of
the left breast, which was manifested as a subtle fullness.
One year postoperatively, the mass was smaller but persistent. For this reason the
dense, calci ed, necrotic tissue was excised through a periareolar incision. Healing
was uneventful.

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Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
This 23-year-old woman underwent a vertical reduction mammaplasty but pre-
sented 2 years later with a small mass at the inframammary fold of the left breast.
Although we initially diagnosed this as a small area of fat necrosis, biopsy revealed
a benign broadenoma.
Not all masses that occur after reduction mammaplasty represent fat
necrosis; other pathologic conditions may develop as they do in patients
who have not had surgery.
W OUND DEHISCENCE
Wound dehiscence occurs most often after very large reductions. Breast weight is
thought to be a major factor. It most commonly develops at the inverted-T of the
incision as a result of excessive tension. To prevent this complication, an adequate
amount of breast tissue must be excised to allow closure with minimal tension.
However, the breast aps must not be thinned so much that circulation is impaired
as this also will lead to wound breakdown.
Early suture removal occasionally may account for wound disruption. In this event
the skin should be immediately resutured. However, if other factors such as exces-
sive tension or marginal devascularization contribute to the dehiscence, resuturing
will fail, and the wound should be allowed to heal by secondary intention.

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Local wound care is all that is required for the treatment of wound dehiscences
that are not amenable to resuturing. Antibiotic therapy should be administered if
there is associated infection.These patients must be examined frequently and reas-
sured that in most cases conservative treatment yields the best results. A wide scar
invariably results; scar revision can be performed secondarily.
AESTHETIC PROBLEMS
Aesthetic problems range from wide scars to nipple distortion to gland asymme-
tries. In general, breasts are asymmetrical to varying degrees preoperatively. Point-
ing this fact out to the patient preoperatively will avoid a postoperative explanation
by the surgeon that sounds like an excuse. Depending on the magnitude of the re-
duction, small degrees of asymmetry are common postoperatively.The smaller the
breast, the more the asymmetry will be apparent.
BREAST MOUND PROBLEMS
ASYMMETRIES
Correction of primary breast asymmetries can be a tremendous challenge to the
plastic surgeon because the operated breast continues to change shape postopera-
tively, whereas the normal unoperated breast does not. Therefore one must try to
preoperatively assess how these dynamic forces will eventually in uence the nal
breast shape. Fortunately asymmetries that occur after primary reduction usually are
not severe and the surgeon has a variety of surgical options from which to choose
for revision.These asymmetries may be the result of differences in either volume or
contour. With contour problems the patient will state usually that the problem is
disguised by wearing a brassiere.With major volume discrepancies, one cup of the
brassiere may t normally, whereas she may “spill out” of the other side. Careful
study of the postoperative photographs may assist the reoperative surgeon better
than direct examination in diagnosing the problem. Although still considered ex-
perimental as of this writing, three dimensional imaging and computer calculation
of volume differences can give remarkably accurate information on the degree of
asymmetry.
Many women do not recognize that their breasts are asymmetrical to
begin with. It is important to point out these asymmetries with a re-
view of the preoperative photos.
We often ask our patients, “Do you have to do anything with your clothing or
your bra to correct the differences in your breasts?” If the answer is “yes,” then the
asymmetry is enough of a problem that it should be addressed at the time of sur-
gery. Rohrich et al recently published a retrospective analysis of breast augmenta-
tion in which they analyzed the incidence of breast asymmetry in respect to breast
shape and the chest wall and its subsequent impact on the postoperative result.14
There was an overall 88% incidence of asymmetry present and 65% of all women
had asymmetries involving more than one parameter such as nipple position, are-
olar size, and glandular volume.

The following computer-generated images show dramatically how a patient with-
out awareness of her asymmetry can appreciate the differences in her breasts.
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Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
Chest wall
Degree of ptosis
Level of the inframammary fold
Breast size and shape
Volume of breast mound
Base diameter
Nipple areolar irregularities
Factors to Consider in Judging Asymmetry
The computer-generated images show that the left breast with its mirror image is
considerably different from the right breast with its mirror image.
Major asymmetries are largely preventable by careful preoperative assessment and
removal of the correct amount of tissue. Sitting the patient up intraoperatively to
assess symmetry before nal closure is the best way to assess the volume of both
breasts. In addition, palpating the thickness of the aps on each side helps to judge
whether excess tissue is being left behind.
More attention should be paid to the volume of tissue left behind than
to that which is removed.
Left breast
Right breast
Computer-generated mirror image of right and left breasts
Preoperative photo
Correction of volume asymmetries is accomplished in much the same way that
primary breast asymmetries are treated. It is usually best to reduce the large breast
further rather than to augment the small side. The small breast is used as a model.
If the smaller breast is to remain unaltered, the larger breast is reduced to the vol-
ume of the smaller one, with the reduction pattern designed to result in a sym-
metrical shape. Primary correction of breast asymmetry has a very high percentage
of reoperation to correct recurrent asymmetry. Careful measurements are taken

1216
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
from sternal notch to nipple, nipple to inframammary fold in the midline of the
breast, and medial sternal line laterally to the nipple.These measurements are trans-
ferred to the larger breast.The amount of additional volume resection necessary is
sometimes dif cult to determine. One must imagine how the nal breast mound
will look by pinching the marked lines together and comparing the appearance
with that of the opposite side. Some settling of the breast mound will invariably oc-
cur in the rst 3 postoperative months. Thus the nipple-areola complex will usu-
ally become elevated to some degree as the parenchyma settles into the lower pole
of the breast, with resultant lengthening of the vertical limb of the closure.
Following reduction of the periareolar skin, the skin of the lower pole of the breast
was elevated from the parenchyma. The base of the breast was then elevated from
the pectoral fascia. A radial wedge of breast tissue was removed from the inferior
pole and the base was trimmed.The immediate postoperative result is shown.
This 28-year-old patient sought correction of breast asymmetry. Since the right
breast was to be matched, the initial operative plan was to attempt a periareolar re-
duction mammaplasty of the left breast.15

1217
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Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
Unfortunately, the postoperative result was unacceptable to both the patient and
surgeon, with excessive spreading of the areola and excess breast tissue inferiorly
and laterally. We waited 1 full year before correction; the tissues were completely
soft and stable by this time.The revision required a similar operative pattern of ad-
ditional parenchymal resection. However, we did not believe that optimal shape
could be achieved without resecting skin from the vertical midline of the breast.
This resection would achieve a reduction in the base width, an important goal in
obtaining symmetry.
The nal postoperative result is shown 1 year after nal correction.
When asymmetry is to be treated with augmentation of the smaller side, we prefer
to reduce the larger breast to a volume equal to the smaller side and then place the
same size implants.
Symmetry is more predictable when the ultimate correction is accom-
plished with the same combination of parenchymal volume and im-
plant.

1218
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This 33-year-old woman desired correction of her obvious asymmetry and aug-
mentation.
The operative plan is illustrated above. The left breast required reduction of ap-
proximately 40 g of tissue and lowering of the inframammary fold.The implant in
this case was inserted through the lateral limb of the vertical mastopexy pattern in
the subpectoral position. After optimal in ation the markings for the mastopexy are
adjusted to allow a tension-free closure.

The resected specimen from the left side is shown. With the nal closure, the im-
plant volumes as well as the parenchymal volumes are equal on each side.
1219
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
The nal result is shown at 1 year postoperatively with adequate size and good
nipple-areola symmetry. It is quite common for us to remove small amounts of tis-
sue on one side or the other when performing augmentation/mastopexy.

1220
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As for insuf cient reduction, correction of asymmetry by further resection of a sin-
gle breast should be accomplished using the same technique that was performed for
the initial reduction. For instance, in the case of an inferior pedicle technique, since
the skin overlying the previous inferior pedicle is probably not contributing to the
circulation of the nipple-areola complex, the incisions can simply be reopened and
the previous breast aps dissected from the inferior pedicle.
Point A
Flaps must be
raised off old
inferior pedicle
Inframammary
crease
Old scar
Old inferior pedicle
deep to flap

After the aps are dissected from the previous pedicle to its lateral margin, the dis-
section plane is then continued deep around the lateral walls of the previous pedi-
cle, thereby essentially redissecting the inferior pedicle in roughly the same shape
and size as in the primary reduction procedure.
1221
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
Old pedicle
(deepithelialized at first
operation) is redissected
and elevated to new
nipple-areola complex
position (point A)
The resection can then be carried out after approximation of the breast shape us-
ing approximating clamps.The excess tissue is excised in both the vertical and hor-
izontal directions depending on the amount of reduction necessary.

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
With the skin aps temporarily closed, the patient should be placed in the upright
sitting position so that volume and shape can be assessed. The lower pole of the
breast should be kept somewhat at and high in anticipation of the later dissent of
the lower pole of the gland. One should anticipate the lengthening of this vertical
limb by at least 1 to 2 cm, depending on the volume of remaining breast tissue.The
incisions are closed in layers.
If the surgeon is unsure what type of technique was used initially and medical
records cannot be obtained, the safest technique to equalize volume discrepancies
is liposuction alone or in combination with skin envelope modi cation. This will
work only in patients who have less-dense, fatty breast parenchyma. However, it is
simple and safe, and if the nipple-areola complexes are symmetrical, no opening of
old scars is necessary. Residual devascularized fat that is not aspirated may calcify and
be visible mammographically, so liposuction patients should always inform mam-
mographers that reduction mammaplasty and liposuction of the breast have been
performed. Calci cations caused by fat necrosis usually can be distinguished from
those associated with neoplasms. If one must resect signi cant parenchymal vol-
umes and the previous technique is unknown, we simply plan the secondary reduc-
tion in any manner we feel will give the best nal shape. We attempt to leave as
much of the nipple areolar blood supply intact as possible and even maintain both
a superior and inferior pedicle when the shape will allow. We prepare the patient
for the possibility of conversion to free nipple graft should we nd intraoperatively
that the blood supply to the nipple areolar area has been critically reduced as a re-
sult of division of the previous pedicle.We have also divided the old pedicle when
the required nipple elevation was minimal, but have clearly seen dusky nipples even
under these circumstances, so one must be very cautious.

With contour asymmetries the problem is usually a result of excess skin left behind
with roughly symmetrical parenchymal volumes. These corrections can be per-
formed in exactly the same manner, although often the inferior pedicle does not
need to be completely dissected to make the correction. Rather the skin aps are
simply reelevated, approximation of the resection is performed, asymmetry is
checked with the patient in the upright position, and excess skin is trimmed.
Minor discrepancies in breast volume are common after reduction and do not usu-
ally require correction. Final evaluation of symmetry must be deferred until post-
operative edema has completely resolved because the size of the breasts will uc-
tuate for several months postoperatively. Such asymmetries are usually caused by an
asymmetrical resection. If correction is desired by the patient, volume changes can
be effected by suction lipectomy coupled with skin resection if necessary.
In secondary surgery to correct asymmetry it is better to reduce the large breast fur-
ther rather than insert an implant.16 The breast volume and the skin envelope are
two components that must be addressed in secondary aesthetic breast surgeries.
Skin tightening alone without resection of breast tissue does not seem to maintain
the correction as well because of stretching.17 Reduction of the skin envelope in the
vertical direction will aid in projection and reduce the length of the lower scar.18-21
1223
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
This 20-year-old patient was evaluated for correction of signi cant breast asym-
metry. One might be tempted to place different volume implants in order to make
up for the parenchymal volume discrepancy. However, we have found that a much
more predictable result can be obtained when the parenchymal volumes are equal-
ized and identical breast implants placed.Therefore in this patient we elected to per-
form a reduction mammaplasty on the right side and bilateral augmentation with
subpectoral saline implants and vertical mastopexy.

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The patient is shown at 1 year postoperatively with satisfactory equalization of
shape and size.
CONTOUR DEFORMITIES
Many factors affect breast contour.The appearance of the breast is a function of the
relationship between the breast volume and the skin envelope. With time, various
in uences have an effect on breast volume and the condition of the skin envelope.
For example, with lactation, there is a temporary increase in breast volume that
stretches the skin, at times to the point that the skin loses some of its elasticity.With
involution, the breast volume decreases while the skin envelope remains dispro-
portionately large, depending on its intrinsic residual elasticity. Of course, gravity
exerts a constant effect.The result is breast ptosis.
Following reduction mammaplasty and mastopexy, some typical deformities may
develop. Restoring an aesthetic appearance to the breast means correcting the re-
lationship between parenchymal volume and skin envelope. Techniques that use a
wedge excision of breast tissue22 may produce a tubular deformity when performed
on large-volume breasts. Vertical as well as horizontal skin excision is needed to
correct the deformity.
Periareolar mammaplasty also may result in predictable patterns of deformity when
inappropriately applied, particularly in the wrong type of patient. The amount of
skin excess following large-volume reductions cannot be effectively removed with
the maintenance of an appropriate breast contour. A attened breast with stellate
wrinkles in the surrounding skin often results when the technique is pushed to its
limits. Recurrent ptosis and enlarged areolae are common. Correction requires ex-
cision of vertical excess.