Reoperative Aesthetic & Reconstructive Plastic Surgery

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The excess skin in the left inframammary fold is outlined and excised under local
anesthesia in the of ce. By excising this skin secondarily, the horizontal component
of the inverted T can be kept considerably shorter.
The nal postoperative result is shown at 1 year and 2 months with good symme-
try and a newly tailored left inframammary fold.

Contour deformities are predictable in
patients undergoing major volume re-
ductions.This 27-year-old woman un-
derwent a 579 g reduction on the right
and 533 g reduction on the left.
1227
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
At 1 year, a small fold of skin is still visible beneath the right breast.This was both-
ersome to the patient, because it was somewhat painful when wearing an underwire
bra. Excision was performed under local anesthesia in the of ce.
Four months after revision surgery, the
shape,size,and inframammary fold con-
tours are greatly improved.

1228
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Obese patients with true gigantomastia will invariably have residual folds of adipose
tissue in the low area of the axilla that are not related to excess breast glandular tis-
sue. These folds must be pointed out to the patient in advance of the reduction
mammaplasty procedure because these folds often will appear more prominent
once the breast has been reduced. The patient may actually see these rolls for the
rst time! She may think they are the residual effect of the surgery, but in actuality
these folds are little changed from their preoperative contour unless vigorous fat re-
duction by liposuction or by direct excision is accomplished at the time of the re-
duction. Since vigorous fat removal by direct excision of this area can affect the
sensation of the breast or even the vascularity of the lateral ap, I usually reduce
these areas only minimally at the time of the initial surgery, but I wait 6 months to
1 year to perform a secondary revision.
R ECURRENT PTOSIS
As a result of pregnancy, weight loss, menopause, or the constant force of gravity, re-
current ptosis is just about inevitable. Breasts that contain substantial amounts of fat
may be prone to recurrent ptosis with weight reduction after aesthetic breast sur-
gery. Suctioning the fat before breast reduction compacts the rm, glandular tissue
and may reduce the likelihood of recurrent ptosis in patients with a signi cant fatty
component to the breasts after weight loss.
“Bottoming out” represents a particular type of recurrent ptosis.This glandular de-
scent is easily recognized as a lengthening of the vertical limb of the inverted T
scar used for reduction mammaplasty. It results from a stretching of skin and scar.
Attempts have been made to correct the problem using dermal strips, fascia lata
tacking sutures, and autoaugmentation with deepithelialized segments.34,35 Because
ptosis recurrence may not be evident in the early postoperative period, patients
should be followed up long term in order to assess the results of surgery properly.
The surgical treatment of recurrent ptosis following reduction mammaplasty or
mastopexy is best accomplished simply by additional skin or glandular excision us-
ing the same technique and incisions that were used for the primary procedure. Oc-
casionally, if only a vertical incision was used, a horizontal resection may be neces-
sary to shorten the vertical limb. Glandular plication may also be helpful.The gland
can be undermined from the pectoralis major muscle and sutures placed between
the parenchyma and the pectoralis fascia to draw the gland superiorly. In addition,
glandular plication sutures can be placed in a vertical row between the areola and
the inframammary fold to help to hold the gland in a higher position. The skin
can then be tailored over the reshaped gland.
The long-term stability of ptosis correction alone may be improved with the use of
a breast implant. However, if the patient does not want larger breasts, this is not an
option.

Recurrent ptosis can be unilateral as was evident in this 28-year-old patient. Reduc-
tion mammaplasty was performed using the Marchac technique.36
1229
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
One year postoperatively, the left breast was slightly larger than the right breast and
had developed recurrent ptosis. A simple correction using the previous incisions was
performed.A wedge of breast tissue in the inferior pole was resected,and the nipple-
areola complex was raised approximately 2 cm.

1230
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Correction of Ptosis Following Implant Exchange
When patients present with ptosis following breast augmentation, one may pre-
sume that it is either the result of continued aging of the breast or perhaps the
original augmentation was done in an unsuccessful attempt to correct or disguise
the ptosis. Nevertheless, these patients can be dif cult to correct in a single proce-
dure. The following case illustrates a technique for the surgical improvement of
this type of problem.
This 38-year-old woman, an active body builder, presented 10 years after a subpec-
toral silicone gel augmentation. She had pain in the axillary tail area and a sugges-
tion of rupture on mammogram. Total capsulectomy and implant site change as
well as vertical mastopexy was planned.
After total capsulectomy, the resultant pocket may be too large to predictably re-
place the implant and secure it in the most advantageous position. Therefore one
has the option of either trying to close and shape the pocket with sutures or to
move the implant to a new site—subglandular or subpectoral. In this case the im-

The nal result is shown 6 months after a skin-only revision of the right nipple-
areola complex;this procedure was performed in the of ce with the patient under
local anesthesia.
OVERREDUCTION
Overreduction in speci c quadrants of the breast may yield contour irregularities.
These depressions may be quite visible to the patient and a considerable cause of
concern.Yet treatment by parenchymal aps requires reopening of the entire breast
with the possibility of correcting one area of depression only to create another.
One also risks further sensory changes when parenchymal aps are used.
If the problem is a at, nonprojecting breast, reopening the incisions and advanc-
ing the breast gland parenchyma toward the midline of the breast medially and lat-
erally with parenchymal plication sutures may help to create a cone with the re-
maining parenchyma. Despite the small volume, this type of correction often
satis es the patient without the need for implants.
1231
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
plant was moved to the subglandular plane with the pectoral muscle placed back
against the chest wall. A superiorly based parenchymal ap was used to ll the up-
per pole. Unfortunately, the right nipple-areola complex remained too low and re-
vision was necessary.

1232
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The previous incisions were reopened and further gland plication was performed.
The lateral skin, particularly on the right breast, was tightened.
Although not an ideal result, the patient is pleased with this improvement.
This 30-year-old woman was referred for secondary correction following an infe-
rior pedicle reduction that had produced broad, at, nonprojecting breasts that she
believed had insuf cient volume. Nevertheless, she did not desire to have an implant
placed.

In this patient, a mediolateral hollow resulted from an inferior pedicle breast reduc-
tion. The patient was referred for correction. We did not consider redissection of
the breast and correction with parenchymal aps advisable. However, the patient
was offered autogenous fat injection into the depressed areas as a treatment option.
1233
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
Another possibility with small surface contour irregularities is cautious autogenous
fat injection. This procedure is not advocated for breast enlargement in general,
but it can be helpful to ll surface contour irregularities.
Donor sites were selected from the triceps area of the arm and the abdomen.The
areas to be injected are outlined.

1234
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The fat was harvested using the tumescent technique.The harvested fat was washed
with saline solution, and the pure fat component was separated for injection.
The postoperative result showed stable improvement at 1 year. Calci cation and
nodularity of the injected fat can be minimized by careful saline solution washing
and removal of the impurities before injection. In the future the patient also must
inform the mammographer that she has had autogenous fat injection into these
limited areas so that a misinterpretation of calcifications by mammography is
avoided.

Overreduction is a problem that is best avoided. Correction of severe overreduction
requires augmentation either with a prosthetic implant or autogenous tissue, either
of which may be unsatisfactory to the patient.
INSUFFICIENT R EDUCTION
Whether a patient’s breast has been suf ciently reduced is a possible source of dis-
agreement among patient, surgeon, and insurance company.This disagreement may
result from poor communication between patient and surgeon preoperatively. Pa-
tient expectations may be unrealistic, or the surgeon may not have listened to or
may disagree with the patient’s expressed desires.The insurance company is inter-
ested only in the resolution of preoperative associated symptoms such as neck and
back strain or skin problems. (Breast regrowth is discussed later in this chapter.)
In general, it is better to err on the side of a conservative reduction than to risk
overreduction.37 However, if one attempts to reduce breast size so that it is in pro-
portion with the remainder of the body, the patient will usually be satis ed as long
as the result is symmetrical. On occasion, however, insuf cient reduction may oc-
cur.This problem is most common in young women who have only a slight hyper-
trophy in whom the result of an overcautious approach may not be in keeping with
what the patient had expected.
Surgical correction of this problem is usually delayed at least 3 to 6 months until the
breasts are soft and the shape has stabilized.The patient must be counseled that the
scars may in fact be worse the second time around and sensibility may be reduced
as the anatomy may now be distorted as a result of the previous surgery. In general,
two approaches are available. One may use the same technique as the initial surgery
to minimize risk of nipple-areola necrosis. The breast aps are redissected as de-
scribed for treatment of asymmetry. One can use either predetermined markings or
a “cut as you go” approach in which the amount of resection is determined intra-
operatively with the patient in the sitting position. Great care must be taken to en-
sure that the resections are symmetrical and will result in correct breast proportion
and nipple position.
Alternatively, liposuction may be useful for secondary reduction of breast fat in an
underreduced patient.29,38,39 Clearly, only breasts that contain a considerable amount
of fat are amenable to this corrective method; breast parenchyma is not removed.
When one is uncertain of the technique that was used in the primary procedure
(for example, as in the referred patient for whom medical records are unavailable),
liposuction may afford the best margin of safety for the maintenance of circulation
to the nipple-areola complex. If necessary, a skin reduction–type mastopexy may
provide the necessary improvement in contour.
1235
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy

1236
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This young woman underwent reduction mammaplasty using the Marchac tech-
nique.36 A conservative reduction left her with fuller breasts than she wanted.
Rather than reopening all of the old incisions for additional direct parenchymal re-
section, liposuction is planned to help reduce the fat content.
Insuf cient reduction is a problem that may occur as a result of miscommunication
between the surgeon and the patient:her expectations do not match what the sur-
geon can deliver. With experience this outcome is less likely to occur. However,
some patients may return complaining of insuf cient reduction when in actuality
considerable weight gain has occurred. This scenario is not uncommon among
women in the fth and sixth decades.

This 60-year-old woman is shown 3 years after breast reduction, and 5 years after;
a 20-pound weight gain has occurred.
1237
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
Although an inferior pedicle technique had been used initially, we felt that it was
necessary to considerably reduce the bulk in the lower pole. Since the nipple-
areola complex did not require elevation, we did not feel that there was any risk of
devascularization of the nipple-areola complex with a superior pedicle.The resec-
tion pattern is shown. Liposuction was performed in the tail of the breast and ax-
illary area.

1238
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
At 1 year the patient is much more satis ed with the additional reduction.

The resulting breast shape and size were a considerable improvement for this pa-
tient.
1239
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
This 54-year-old woman was seen 20 years following breast reduction with an un-
known technique. Evaluation of the deformity reveals an extremely at upper pole
with considerable glandular ptosis. The nipple-areola position appears high but is
actually about right. Correction was achieved by creating an inferior-lateral glan-
dular ap based superiorly, rotated into the upper pole to produce projection.

1240
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
NIPPLE-AREOLA COMPLEX
Although some authors attribute late postoperative changes to characteristics of an
individual’s body tissues, most believe them to be the result of incorrect planning
or execution of the surgery. Smith and Gillen40 have described some of these tech-
nical errors. Errors in planning can result from failure to appropriately locate the
nipple-areola complex in an aesthetic position between the sternal notch and the
inframammary fold.We no longer arbitrarily locate the nipple-areola complex at a
given distance from the sternal notch or midclavicular point. Rather, the new nip-
ple position is derived from a constellation of points of reference.We begin by de-
termining the anterior re ection of the inframammary fold on the surface of the
breast.We then observe where this point falls in relation to the midhumeral point.
And nally, we determine the distance from the sternal notch to the new nipple
position. The patient’s height and the volume to be reduced may also affect these
measurements.We prefer to determine the nal position of the nipple-areola com-
plex after the vertical segment is closed. Flexibility is also required when pattern
techniques (for example,Wise, Strombeck) are used.
Symmetry of the nipple-areola complexes must be checked before nal suturing.
We have found the pendulum suture technique with the patient in the sitting po-
sition to be of great help in verifying this symmetry. One full-length 2-0 silk suture
is placed at the sternal notch and another one over the xiphoid.Triangulating these
crossed sutures from one nipple to the other gives an accurate idea of the symme-
try of the closure.
MALPOSITION
In the preoperative plan, allowances must be made for skin elasticity, which may
shorten the sternal notch to nipple distance after excess breast weight is removed.
The nipples might otherwise be somewhat higher than desirable, and secondary
repositioning may be requested by the patient. Lateral displacement can be accom-
plished by moving the nipple-areola complex medially on a central pedicle much
like mastopexy.41

1241
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
Superior displacement can be corrected using one of two methods: by reposition-
ing the nipple-areola complex directly as a free nipple graft or by shortening the
distance from the nipple to inframammary fold by direct excision of skin, tucking
the lower pole up behind the breast.42 This second method is preferred as no scars
remain in the superior pole of the breast. Areolae that are displaced medially can be
corrected by an inferior ap of dermis and fat43-48 by a crescent excision, or other
periareolar techniques.
Crescentic area
deepithelialized
(or excised if volume
reduction is desired)
Deepithelialized
area
Short deepithelialized
flap is unfolded for
small increase in
projection if desired

1242
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This woman was referred for correction 12 years after augmentation-mastopexy.
She had never been happy with the result of the primary breast surgery and desired
implant removal. She also felt that her breasts were too large. Preoperative assess-
ment revealed that the implants were positioned too high with respect to the breast
mounds and that she had glandular ptosis and high nipple-areola complexes.
Correction was accomplished by shortening the distance between the nipple and
inframammary fold, which had lengthened over time. The current inframammary
fold was marked and incised, elevating the gland from the chest wall until the cap-
sule of the implant was reached.The implants were removed, and a total capsulec-
tomy was performed as the patient had requested. A deepithelialized ap was cre-
ated from the excess gland in the inferior pole.This ap was turned up underneath
for additional projection, creating an improved contour without implants.

1243
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
This 25-year-old woman presented with severe neck and shoulder discomfort as
well as an inability to t in normal clothing. She was offered reduction mamma-
plasty, which was accomplished using the vertical approach with a superomedial
pedicle.
Postoperatively it was apparent that the nipple-areola complexes had been posi-
tioned approximately 2 cm too high.This deformity was exacerbated by a compo-
nent of bottoming out because excess glandular tissue was left behind.

Correction was accomplished by reducing the distance between the nipple-areola
complex and the inframammary fold by excising a wedge of glandular tissue and
closing as a horizontal scar. Periareolar widened scar was excised and a cinching su-
ture of 4-0 Gore-Tex placed as shown. This technique nicely controls the degree
of widening of the areola.
1244
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The patient is shown with a stable correction at 3 months postoperatively.

1245
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
Nipples that are placed too low can similarly be repositioned with a crescentic ex-
cision. Only minimal elevations (2 to 3 cm) are advisable with crescentic excision
alone because additional shape distortion may occur.
A vertical excision of skin may also need to be performed to avoid this problem.

IRREGULAR SIZE AND SHAPE AND DEPIGMENTATION
The areola should be round, with the nipple centered precisely. Segmental con-
traction of the intrinsic musculature of the nipple or careless marking can account
for an offset appearance.The oval nipple results when localized skin tension distorts
the areolar window. Overresection of the breast parenchyma in relation to the skin
envelope will result in an oval nipple, as demonstrated by observing correction
when the breast skin is placed under tension by medial and lateral compression.
Also, a tight vertical closure will cause medial and lateral bulging.6 A vertical exci-
sion of skin also may be necessary to avoid this problem. Spreading of the nipple-
areola complex can result from motor denervation; more often it is simply the re-
sult of excessive circumferential tension created by periareolar skin excision.
1246
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Depigmentation can be a source of dissatisfaction, particularly in a non-Caucasian
patient. It is especially common with the free nipple graft technique if the pig-
ment-producing basal layer is thinned from the composite graft. In this patient most
of the pigmentation of the areola returned but the pigment in the nipple did not.
If the pigmentation has not returned by 1 year, satisfactory correction can be ob-
tained with nipple-areola tattooing.
R ETRACTION
Some breast reduction techniques, such as Strombeck’s procedure, are associated
with nipple inversion. Certainly inversion will be present postoperatively if it was
present preoperatively. If the overall bulk of the residual pedicle is insuf cient to ll
the skin envelope, the central pedicle will fall back from the areolar attachment.
This situation may not necessarily require reoperation, but if needed, correction
requires further reduction of the skin by widening the keyhole and reducing the
medial and lateral inferior skin edges.6 Support of the breast tissue underlying the
nipple-areola complex by infolding the lower pole may be necessary.

1247
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
PROTRUSION
A redundant, pouting areola results from an excess of areolar tissue relative to the
size of the keyhole.This 21-year-old patient had typical symptoms related to mam-
mary hypertrophy. Reduction was carried out using the Marchac technique. The
immediate postoperative result is shown.
The pouting deformity of the left nipple-areola complex is clearly seen. Also, the
left nipple-areola complex is slightly lower on the left side.This condition may be
corrected by excising a circumferential strip of skin around the areola, including
areolar tissue and/or surrounding skin.

SCARRING
Scarring is considered the biggest drawback of aesthetic breast surgery. Scars are
generally unpredictable in appearance, and the patient should be made aware of
this fact preoperatively. Keloid scars are an especially dif cult problem. Excessive
tension at the time of closure is thought to be a major contributing factor to poor
scarring.
1248
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This patient underwent breast reduction using the inferior pedicle technique. Ex-
cessive tension on the skin aps resulted in partial-thickness loss of breast skin along
the vertical and horizontal lines of closure and caused excessive scarring.
At the time of revision the area to be resected is marked. The bidigital pinch ma-
neuver demonstrates that the scar can be easily resected and layered closure can be
accomplished. Additional trimming of the vertical margin of the skin helps to cre-
ate a straight-line closure.

1249
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
The postoperative result demonstrates improvement in the scar as well as the shape
in the inferior pole of the breast.
Scar hypertrophy can be temporary and may subside with time. Revision is typically
performed 6 months to 1 year following surgery. Even though late scar revision
may allow closure with less tension, it still may not result in scar improvement. For
this reason it is important to use the previous scars and not to add new ones. Sili-
cone gel sheeting49 offers an alternative therapy that shows some promise.Treatment
with steroid injections may result in wide scars that inevitably require scar revi-
sion. Again, prevention is the ideal solution to scarring.
Newer techniques of breast reduction and mastopexy aim at reducing the length of
the scars. L, J, or lateral scar techniques all seek to avoid creating a scar in the me-
dial region, which is the area most vulnerable to hypertrophy.2,25-27,31,47,50-54 Never-
theless, patients may still bene t from scar revision.

This 18-year-old patient underwent a 300 g reduction mammaplasty using the L-
shaped technique of Chiari.2
1250
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The postoperative result was satisfactory in terms of shape; however, at 1 year she
was dissatis ed with the periareolar and vertical scars.
A simple revision was accomplished by full-thickness excision of the skin, layered
closure with a periareolar purse-string suture, and taping.

1251
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
Three years postoperatively the scars are mature and satisfactory to the patient.
Periareolar techniques have a tendency to produce wide, radiating scars or enlarged
areolae.The latter problem has been addressed by Benelli,55 who uses a permanent
purse-string stitch to prevent areolar enlargement. However, it is the large discrep-
ancy between the areolar circumference and the skin excision that results in the
stellate pattern of wrinkles, tension, and ultimate areolar spreading. This appear-
ance does not always atten with time. Other authors have used nonabsorbable56
and absorbable57 mesh to support the reshaped gland and to relieve tension from the
periareolar closure.The best results are achieved with reductions of less than 400 g
or 40% of the breast volume.
OTHER CONDITIONS
OCCULT CANCER
Because breast cancer develops in one of every eight women, there is always a
chance that a patient who has had a reduction mammaplasty or mastopexy may
develop a mass, have an abnormal mammogram, or occasionally present for aes-
thetic surgery with an occult cancer.
Routine screening for breast cancer may reveal an indication for biopsy. In patients
who have undergone aesthetic procedures, biopsies may be performed through old
scars. Suspicious areas found during a reduction procedure should be examined
with frozen section; de nitive treatment may be performed later.58 A microscopic
focus of in situ carcinoma might be adequately treated by the reduction procedure
alone. For a large solitary tumor, radiotherapy and axillary dissection or mastec-
tomy may be required.

This 38-year-old woman presented for reduction mammaplasty with the use of
free nipple grafts. Histologic examination of the resected breast tissue revealed sev-
eral small areas of both atypical lobular and intraductal hyperplasia and one focal
area of carcinoma in situ. Postoperative mammograms revealed no other suspicious
areas.The patient has been followed carefully. No further surgery has been neces-
sary; it seems very likely that the cancer was adequately treated by the reduction
procedure alone.
Radiographically, breasts that have undergone reduction surgery exhibit a different
appearance on mammography that the experienced mammographer can easily
identify as postsurgical (see Chapter 38). When the mammographic appearance is
dif cult to differentiate from cancer, a biopsy is indicated. If modi ed radical mas-
tectomy is indicated, the same skin aps designed for the reduction procedure may
be used.The delay phenomenon should ensure a more robust skin ap and reduce
the risk of ap necrosis. Hoffman59 described a mastectomy through an inverted-T
incision.
In patients with gigantomastia, a small mass may not be palpable preoperatively.
Women 35 years of age and over should undergo screening mammography preop-
eratively to rule out the presence of these lesions.60 If there is a family history of
premenopausal breast cancer, then mammography at a younger age is indicated. If
cancer is not detected preoperatively but is suspected intraoperatively, diagnosis
may be based on histologic examination of the pathologic specimen.
1252
PART IV
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1253
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
VIRGINAL HYPERTROPHY
Regrowth is more likely to occur in young patients (12 to 15 years of age) who
have already manifested rapid breast development.61 One can anticipate a second-
ary reduction after several years in many of these patients. Lejour62 has used staged
liposuction in these patients followed by resection once breast growth ceases. Sev-
eral reports appear in the literature in which antiestrogens were administered to
prevent such regrowth,63-67 but others have not found these drugs as useful. Mastec-
tomy with reconstruction may need to be performed in unusually severe cases.59
IRRADIATED BREAST
With the increase in breast conservation treatment of early breast cancers, plastic
surgeons are seeing more women who have had their breast irradiated who also de-
sire breast reduction.
This 50-year-old patient was seen 4 years after undergoing lumpectomy and radio-
therapy of the right breast. Preoperative evaluation revealed a moderately brotic
gland with minimal evidence of postradiation skin changes. In this group of pa-
tients, preservation of blood supply is critical to avoid fat necrosis or loss of the
nipple-areola complex.We performed a vertical reduction using a superior pedicle
with minimal undermining of the gland.

One year postoperatively, the patient still feels that she is too large and is unhappy
with the residual asymmetry.
1254
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
A secondary reduction was accomplished with removal of additional gland from the
larger right side and correction of redundant skin in the left inframammary fold as
shown.
One year following the revisional surgery, symmetry is improved and fat necrosis of
the irradiated breast has been avoided through preservation of blood supply.

1255
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
UNSOLVED PROBLEMS
Scarring, contour irregularities, and durability of the postoperative result are persis-
tent problems. Presently, wound healing research is aimed at unfolding the mys-
tery of fetal wound repair. When this riddle is solved and scarring can be con-
trolled, the length of scars may no longer be an issue. Until then, our efforts are
focused on developing breast reduction techniques with short scars.
As noted in the introduction to this chapter, the diverse techniques available for
breast reduction demonstrate our inability to nd a universally applicable solution
to the many different patient presentations. Each technique tends to have its own
nuances and secondary aesthetic problems when applied to patients who are not
ideal candidates. Until a universal technique is developed, the optimal aesthetic re-
sult will have to be attained with the best technique chosen based on the surgeon’s
judgment followed by secondary revisions, if needed.
Finally, durability of the result is a problem. If all of the variables affecting the vol-
ume and the skin envelope can be controlled, then we might expect a long-lasting
result. Unfortunately, this is not the case.The effects of hormones and gravity on tis-
sue cannot be effectively controlled. Breasts change shape with time. Presently, the
results achieved with breast-lift techniques must be regarded as temporary. Reduc-
tion techniques are successful in relieving patients of the discomforts of gigan-
tomastia, but these patients are still subject to the same in uences of gravity as seen
in the mastopexy patient. Long-term follow-up remains an essential component
in the evaluation of any procedure designed to reverse these in uences, including
secondary procedures.
References—With Key Annotated References
1. Psillakis JM, deOliveira MC. History of reduction mammaplasty. In Goldwyn RM, ed. Re-
duction Mammaplasty, 2nd ed. Boston: Little Brown, 1990, pp 1-15.
2. Chiari A. The short-scar mammaplasty: A new approach. Plast Reconstr Surg 90:233-246,
1992.
3. Goldwyn RM.The Unfavorable Result in Plastic Surgery:Avoidance and Treatment, 2nd ed.
Boston: Little Brown, 1984, pp 758-759.
4. Rees TD, Flagg SV. Reduction mammaplasty. In Goldwyn RM, ed.The Unfavorable Result in
Plastic Surgery: Avoidance and Treatment, 2nd ed. Boston: Little Brown, 1984, pp 371-385.
5. Papay FA,Verghese A, Stanton-Hicks M, et al. Complex regional pain syndrome of the breast
in a patient after breast reduction. Ann Plast Surg 39:347-352, 1997.
6. McKissock PK. Complications and undesirable results in reduction mammaplasty. In Gold-
wyn RM, ed. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment, 2nd ed.
Boston: Little Brown, 1984, pp 739-759.
7. Spear SL, Carter ML, Low M. Sickle cell trait:A risk factor for ap necrosis. Plast Reconstr Surg
112:697-698, 2003.
8. Biesenberger H. Eine neue Methode der Mammaplastik. Zentralbl Chir 55:2382, 1928.

9. Wray RC, Luce EA. Treatment of impending nipple necrosis following reduction mamma-
plasty. Plast Reconstr Surg 68:242-244, 1981.
10. Casanova R, Iribarren O, Grotting JC,Vásconez LO. Clinical evaluation of ap viability with
a dermal surface uorometer. Ann Plast Surg 20:112-116, 1988.
11. Hallock GG, Cusenz BJ. Salvage of the congested nipple during reduction mammaplasty. Aes-
thetic Plast Surg 10:143-145, 1986.
12. Singer R, Krant SM. Intravenous uorescein for evaluating the dusky nipple-areola during re-
duction mammaplasty. Plast Reconstr Surg 67:534-550, 1981.
13. Gross MP, Apesos J. The use of leeches for treatment of venous congestion of the nipple fol-
lowing breast surgery. Aesthetic Plast Surg 16:343-348, 1992.
14. Rohrich RJ, Hartley W, Brown S. Incidence of chest wall asymmetry in breast augmentation:
A retrospective analysis of 100 patients. Plast Reconstr Surg 111:1513, 2002.
15. Goes JCS. Periareolar mammaplasty: Double skin technique. In Hinderer UT, ed. Plastic
Surgery, vol II. New York: Elsevier, 1992, p 575.
16. Hoffman S. Recurrent deformities following reduction mammaplasty and correction of breast
asymmetry. Plast Reconstr Surg 77:55-60, 1986.
17. Goldwyn RM. Comments on Chapter 34. In Goldwyn RM, ed. The Unfavorable Result in
Plastic Surgery: Avoidance and Treatment, 2nd ed. Boston: Little Brown, 1984, p 716.
18. Regnault P.The hypoplastic and ptotic breast:A combined operation with prosthetic augmen-
tation. Plast Reconstr Surg 37:31, 1996.
19. Lejour M.Vertical mammaplasty as secondary surgery after other techniques. Aesthetic Plast
Surg 21:403-407, 1997.
20. Spear SL, Low M, Ducic I. Revision augmentation mastopexy: Indications, operations, and
outcomes. Ann Plast Surg 51:540-546, 2003.
21. Persoff MM. Vertical mastopexy with expansion augmentation. Aesthetic Plast Surg 27:13,
2003.
22. Dufourmentel CI, Mouly R. Chirurgie Plastique. Paris: Flammarion, 1959.
23. Lejour M, Abboud M.Vertical mammaplasty without inframammary scar and with liposuction.
Perspect Plast Surg 4:67, 1990.
24. Matarasso A, Courtiss E. Suction mammaplasty:The use of suction lipectomy to reduce large
breasts. Plast Reconstr Surg 87:709-717, 1991.
25. Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg 29:379,
2002.
A nice review of the different pedicles used for the vertical technique for reductions and mastopexies.
The author stresses how skin resection patterns and pedicles are separate procedures and should not
be considered the same.
26. Lassus C. Breast reduction:Evolution of a technique. A single vertical scar. Aesthetic Plast Surg
11:107, 1987.
27. Lassus C. Update on vertical mammaplasty. Plast Reconstr Surg 104:2289, 1999.
One of the pioneers in vertical mastopexy and reduction techniques, the author demonstrates long-term
results and the evolution of his technique.
28. Lassus C. An “all-season” mammaplasty. Aesthetic Plast Surg 10:9, 1986.
29. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 94:100,
1994.
30. Lejour M.Vertical mammaplasty for breast hypertrophy and ptosis. Oper Tech Plast Surg 3:189,
1996.
31. Lejour M. Vertical mammaplasty: Update and appraisal of late results. Plast Reconstr Surg
104:771-781, 1999.
32. Berthe JV, Massaut J, Greuse M, et al.The vertical mammaplasty:A reappraisal of the technique
and its complications. Plast Reconstr Surg 111:2192-2199; discussion 2200-2202, 2003.
33. Spector JA, Kleinerman R, Culliford AT IV, et al. The vertical reduction mammaplasty: A
prospective analysis of patient outcomes. Plast Reconstr Surg 117:374-381; discussion 382-
383, 2006.
1256
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL

1257
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
34. Brink RR. Management of true ptosis of the breast. Plast Reconstr Surg 91:657, 1993.
35. Regnault P. Breast ptosis: De nition and treatment. Clin Plast Surg 3:193, 1976.
The articles by Brink and Regnault are the classics in de ning breast ptosis, and all surgeons who op-
erate on the breast should be familiar with them.
36. Marchac D, de Olarte G. Reduction mammaplasty and correction of ptosis with a short infra-
mammary scar. Plast Reconstr Surg 69:45, 1982.
37. Brink RR. Evaluating breast parenchymal maldistribution with regard to mastopexy and aug-
mentation mammaplasty. Plast Reconstr Surg 86:715, 1990.
38. Courtiss EH. Reduction mammaplasty by suction alone. Plast Reconstr Surg 92:1276, 1993.
39. Matarasso A, Courtiss EH. Suction mammaplasty.The use of suction lipectomy to reduce large
breasts. Plast Reconstr Surg 87:709, 1991.
One of the preliminary papers dealing with suction-only techniques for the breast.The authors de ne
the types of patients for which this technique is suitable and show clinical results.
40. Smith JW, Gillen FJ. Repairing errors of nipple-areola placement following reduction
mammaplasty. Aesthetic Plast Surg 4:179-187, 1980.
41. Kroll SS, Doores S. Nipple centralization for the correction of breast deformity from segmen-
tal mastectomy. Ann Plast Surg 24:271-275, 1990.
42. Millard DR, Mullin WR, Lesavoy MA. Secondary correction of the too high areola and nip-
ple after a mammaplasty. Plast Reconstr Surg 58:568-572, 1976.
43. Salema R, Abdoudib JH, DeCastro CC. Convergent nipple-areola complexes corrected by
inferior curve pedicle technique. Ann Plast Surg 19:555-557, 1987.
44. Elsahy NI. Correction of abnormally high nipples after reduction mammaplasty. Aesthetic Plast
Surg 14:21-26, 1990.
45. Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy. Plast Reconstr Surg 85:961,
1990.
46. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast Reconstr Surg 107:1294,
2001.
The authors demonstrate the technique and give long-term results.Technical maneuvers and planning
are demonstrated beautifully.
47. Benelli L. A new periareolar mammaplasty:The “round block” technique. Aesthetic Plast Surg
14:99, 1990.
48. Hinderer UT. Circumareolar dermo-glandular plication: A new concept for correction of
breast ptosis. Aesthetic Plast Surg 25:404-420, 2001.
49. Ahn ST, Monafo WW, Mustoe TA. Topical silicone gel: A new treatment for hypertrophic
scars. Surgery 106:781-786, 1989.
50. Regnault P. Reduction mammaplasty by the “B” technique. Plast Reconstr Surg 53:19-24,
1974.
51. Peixoto G. Reduction mammaplasty: A personal technique. Plast Reconstr Surg 65:217-226,
1980.
52. Marchac D, de Olarte G. Reduction mammaplasty and correction of ptosis with a short infra-
mammary scar. Plast Reconstr Surg 69:45-55, 1982.
53. Marchac D. Reduction mammaplasty with a short horizontal scar. In Goldwyn RM, ed. Re-
duction Mammaplasty. Boston: Little Brown, 1990, pp 317-335.
54. Bozola AR. Reduction mammaplasty: Preferred techniques. In Goldwyn RM, ed. Reduction
Mammaplasty. Boston: Little Brown, 1990, pp 407-437.
55. Benelli L. A new periareolar mammaplasty:Round block technique. Aesthetic Plast Surg 14:93,
1990.
56. Bustos RA. Periareolar mammaplasty with silicone supporting lamina. Plast Reconstr Surg
89:646-659, 1992.
57. Sampaio Goes JC. Periareolar mammaplasty: Double skin technique with application of
polyglactine 910 mesh. Rev Soc Bras Cir Plast 7:1-6, 1992.
58. Gulyas K, Kimble FW. Atypical pyoderma gangrenosum after breast reduction. Aesthetic Plast
Surg 27:328-331, 2003.

59. Hoffman S. Mastectomy using a T-shaped incision. Breast Dis 1:135, 1988.
60. Brown FE, Sargent SK. Mammographic changes after reduction mammaplasty. In Goldwyn
RM, ed. Reduction Mammaplasty, 2nd ed. Boston: Little Brown, 1990, pp 35-43.
61. Rohrich RJ, Thornton JF, Sorokin ES. Recurrent mammary hyperplasia: Current concepts.
Plast Reconstr Surg 111:387-393, 2003.
62. Lejour M.Vertical Mammaplasty and Liposuction. St Louis:Quality Medical Publishing, 1993.
63. Gottlieb JR, McKinney P, Walkinshaw MD, et al. Occult breast carcinoma in patients under-
going reduction mammaplasty. Aesthetic Plast Surg 13:279-283, 1989.
64. Sperling RL, Gold JJ. Use of an antiestrogen after a reduction mammaplasty to prevent recur-
rence of virginal hypertrophy of breasts: Case report. Plast Reconstr Surg 52:439-442, 1973.
65. Mayl N, Vasconez LO, Jurkiewicz MJ. Treatment of macromastia in the actively enlarging
breast. Plast Reconstr Surg 54:6-12, 1974.
66. Ryan RF, Pernoll ML.Virginal hypertrophy. Plast Reconstr Surg 75:737-742, 1985.
67. Kupfer D, Dingman D, Broadbent R. Juvenile breast hypertrophy:Report of a familial pattern
and review of the literature. Plast Reconstr Surg 90:303-309, 1992.
Suggested Readings
Gruber RP, Jones HW Jr. The “donut” mastopexy: Indications and complications. Plast Reconstr
Surg 65:34, 1980.
Lassus C. An “all-season” mammaplasty. Aesthetic Plast Surg 10:9, 1986.
Pitanguy I. Surgical correction of breast hypertrophy. Br J Plast Surg 20:78, 1967.
Spicer TE. Reduction mammaplasty and mastopexy. In Selected Readings in Plastic Surgery, vols 7-
30. Dallas: Baylor University Medical Center, 1994.
Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr Surg
17:367, 1956.
1258
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL

1259
Chapter 33
Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy
1. Of the following considerations in secondary reduction mammaplasty, which is
the most important?
a. Debulking the lower lateral aspect of the breast
b. Filling the upper pole
c. Preserving blood supply to the nipple-areola complex
d. Achieving symmetry
e. Shortening and re ning scars
2. Which of the following procedures would be least likely to result in compro-
mised blood supply to the nipple-areola complex?
a. A superior pedicle procedure following an original inferior pedicle
b. An inferior pedicle procedure following an original superior pedicle
c. A medial pedicle procedure following an original inferior pedicle
d. A superior pedicle procedure following an original superior pedicle
e. A central mound procedure following an original inferior pedicle
3. After nishing a secondary breast reduction, the patient is still on the operating
table and the nipple-areola complex is dusky, mottled, and soft.The rst maneu-
ver you would perform is to:
a. Inform the anesthesiologist you want the blood pressure higher
b. Remove the nipple and resuture it as a free nipple graft
c. Loosen the dressing and take the patient to recovery for observation
d. Remove sutures and check the pedicle for kinking, compression, or ten-
sion
e. Apply nitropaste
4. When performing free nipple grafts, the tissue should be transferred as:
a. A split-thickness skin graft
b. A full-thickness skin graft
c. A composite graft
d. A pinch graft
e. A transposition ap
5. The preferred technique to treat residual asymmetry following breast reduction
is to:
a. Place a breast implant in the smaller breast
b. Place asymmetrical breast implants to even things out
c. Reassure the patient that it will get better in time
d. Periareolar mastopexy
e. Further reduce the larger breast
R EVIEW QUESTIONS

(Trang không có chữ)

1261
Reoperative Surgery
Following Breast Augmentation
James C. Grotting, Paul M. Gardner, and Alvin B. Cohn
C ha pter 3 4
Reoperative Problems
Hypertrophic scarring
Capsular contracture
Seroma
Device failure
Hematoma
Silicone-associated problems
Wound dehiscence
The aging and augmented breast
Malposition
Those of us experienced in breast augmentation
techniques have long ago abandoned any false notions
that augmentation, or any implant surgery, for that
matter, is as routine as was once believed.
John Bostwick III, MD
Of all the procedures that plastic surgeons perform, breast augmentation con-
tinues to be one of the most popular, with a relatively low rate of complications or
reoperations. It is the third most common procedure performed by plastic sur-
geons, after liposuction and rhinoplasty, according to the American Society of Plas-
tic Surgeons (ASPS). The popularity of breast augmentation is a testament to its
high satisfaction rate. Despite periods in recent years when the safety of breast aug-

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
mentation was called into question, its resurgence indicates its ability to meet most
patients’expectations with an acceptable level of safety.
Nevertheless, as in all types of surgery, occasional untoward results are inevitable
and must be planned for if for no other reason than to try to prevent or reduce their
occurrence to an absolute minimum. Problems related to breast implants range
from immediate postoperative complications such as hematoma and infection to the
long-term problem of capsular contracture. For example, some patients may present
with implant failure. Others may express dissatisfaction with the aesthetic results.
Although implant technology continues to improve and many more choices are
currently available to surgeons, these procedures still have a certain failure rate lead-
ing to de ation or rupture requiring reintervention. Implant-tissue interactions are
unpredictable to a certain extent. and other complications can intervene. In this
chapter we will explore causes of reoperation after breast augmentation and ad-
dress concepts of treatment.
PATIENT EVALUATION
The decision to reoperate must be made with speci c goals in mind. For problems
such as infection and exposure, there is usually no other recourse than surgical in-
tervention. However, when a patient presents for correction of unsatisfactory aes-
thetic results, the surgeon must be certain the patient has realistic expectations based
on careful preoperative consultation. She should understand that augmented breasts
will never be “normal” breasts.
In the past, many breast augmentations were performed with relatively little preop-
erative counseling. The patient population was usually young, somewhat impul-
sive, and often focused only on short-term volume correction. Nevertheless, breast
augmentation has had a very high success rate when measured in terms of patient
satisfaction.1,2
The sources of dissatisfaction are often linked to aesthetic problems that can occur
early or late in the postoperative period. The most common cause of early dissat-
isfaction among patients who undergo breast augmentation is volume undercorrec-
tion. Failure to preoperatively recognize signi cant breast ptosis, asymmetry, or a
tight or high inframammary fold may also result in patient dissatisfaction, especially
if these factors were not brought to the patient’s attention before the initial aug-
mentation (see p. 1264). Subsequently various issues affecting the doctor-patient
relationship as well as nances come into play (see Chapters 2 and 3).
Breast augmentation enlarges the volume of the breast and can correct the breast’s
shape but will rarely improve signi cant ptosis. Failure to recognize the need for a
concomitant mastopexy will often lead to a poor aesthetic outcome and a dissatis-
ed patient.

1263
Chapter 34
Reoperative Surgery Following Breast Augmentation
Patient Examples
This 32-year-old patient was seen for breast augmentation and was noted to have
grade II breast ptosis. Although an augmentation/mastopexy was offered, she re-
jected the additional scars that would result from the mastopexy. An attempt to
produce a satisfactory result with subglandular, high-pro le saline implants resulted
in improvement, but the lateral view demonstrates that the entire breast was lower
on the chest wall.The patient was dissatis ed with this outcome because her breasts
still felt “droopy.”
She ultimately requested a mastopexy to relocate the implant and breast tissue in a
higher position.

1264
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
If the patient’s breasts are asymmetrical before augmentation and the
asymmetry is unrecognized preoperatively, the breasts may become
more noticeably asymmetrical postoperatively.
Careful study of preoperative photographs will generally reveal subtle volume dif-
ferences that can be corrected at the time of surgery.
The image on the left shows a patient with subtle but signi cant asymmetry. The
computer-generated images on the right show the patient with two right breasts or
two left breasts.These images dramatically amplify the asymmetry, which may not
be very apparent to the patient, even when looking at her own photograph.
Any discussion of the goals of reoperation must include the possibility of recurrence
of the problem addressed by the secondary surgery. For example, treatment of cap-
sular contracture by either capsular alteration or implant exchange may be compli-
cated by ultimate recurrence of the contracture.
Similarly, mastopexy is often complicated by recurrent ptosis. Explantation surgery
performed when systemic symptoms are present may not produce any effective
long-term relief.The patient must clearly understand all of these issues before con-
senting to reoperative surgery. Otherwise, it may be best not to reoperate.
Left breast
Right breast
Computer-generated mirror image of right and left breasts
Preoperative photo

1265
Chapter 34
Reoperative Surgery Following Breast Augmentation
REOPERATION RATES AMONG PATIENTS
WHO HAVE UNDERGONE BREAST
AUGMENTATION
Multiple reoperations to either improve the appearance of the breasts, or to re-
move ruptured or de ated implants, or both, may result in an unsatisfactory cos-
metic outcome. A retrospective study by Gabriel et al3 showed that 24% of women
with breast implants had complications resulting in a reoperation during the rst 5
years after implantation (silicone and saline implants were studied together). Ac-
cording to this study, about 12.5% of patients who had undergone breast augmen-
tation required reoperation within 5 years.
Other prospective studies4,5 by the manufacturers of saline- lled breast implants
showed reoperation rates of 13% to 21% at 3 years, and 20% to 26% at 5 years for
these patients. According to these studies implant removal rates were 8% at 3 years
and 12% to 14% at 5 years.
In a retrospective study6 of patients who underwent augmentation with silicone
gel– lled breast implants, 303 of 907 (33%) of women reported that they had at
least one reoperation in which their implant or implants were removed or replaced.
The average time to removal, as reported by the patients themselves, was 11.5 years.
TIMING
The timing of reoperation is determined by the nature of the problem. Complica-
tions such as infection often require surgery as soon as the problem is diagnosed.
For problems such as malposition or asymmetry, a certain period of time should
elapse before a secondary procedure is attempted. This delay allows edema to re-
solve, scarring to mature, and the implant to settle.
Some conservative measures can obviate the need for reoperation. For example,
Velcro strapping of the upper poles of the implants may help to lower them sym-
metrically. Implant displacement exercises and the use of support bras may in uence
the development of capsular contracture and affect the shape of smooth-walled im-
plants during the waiting period. These maneuvers are largely the surgeon’s pref-
erence, with few statistical data to prove their ef cacy.

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
One special circumstance in which early surgical intervention is indicated can oc-
cur after the treatment of capsular contracture using implant-site change. Most
commonly an implant is removed from the subglandular space and reinserted in a
subpectoral pocket. Occasionally, if the subglandular space is not sutured closed,
the implant may slip over the inferior border of the pectoralis major muscle back
into the original pocket.
Early implant displacement may also occur in patients who have undergone lateral
capsulorrhaphy to try to revise a laterally displaced implant. If the suture repair fails
early, the implant may again become displaced;implant positioning should be cor-
rected with early reoperation.
APPLIED ANATOMY
BLOOD SUPPLY
The arterial supply to the breast is derived from numerous sources, is closely related
to the underlying pectoralis major and serratus anterior muscles, and is rich in col-
lateralization. The major contributing arteries are the internal mammary, lateral
thoracic, and intercostal arteries.7 This extensive vascular network allows the plas-
tic surgeon to use a number of different augmentation approaches with little con-
cern of devascularization.

1267
Chapter 34
Reoperative Surgery Following Breast Augmentation
Axillary artery
Thoracoacromial artery
Thoracodorsal artery
External mammary
artery
Anterolateral intercostal
perforators
Anteromedial intercostal
perforator
Internal mammary
perforator
Internal mammary
artery
Subclavian artery
2
3
External
mammary
artery
Internal
mammary
perforators
4
Anterolateral
intercostal
perforators
Anteromedial
intercostal
perforators
5

1268
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The main alterations in vascularity after augmentation result from the division of
perforators as the pocket is made. With the subglandular approach, the pectoralis
major perforators from the thoracoacromial artery, some internal mammary seg-
mental perforators, and the intercostal perforators are divided. The breast can sur-
vive entirely on the blood supply of the lateral thoracic artery, which enters the
breast through perforators lateral to and through the pectoralis major muscle as
well as through perforators that are not divided.Whether a poorly vascularized area
created in the subglandular dissection is predisposed to infection and capsular con-
tracture has not been substantiated.
During dissection of a subpectoral pocket, the lower internal mammary perforators
and some of the more central intercostal perforators may be divided. Care should
be taken to avoid injuring the second and third internal mammary perforators, the
largest perforators. Injury to these vessels can be avoided by leaving the origin of the
pectoralis major muscle attached to the second and third intercostal space.8
The nipple-areola complex receives its blood supply via numerous branches from
the breast parenchyma, and from the subdermal periareolar plexus. Neither the
subglandular or subpectoral approach risks injury to the nipple-areola complex as
long as the underlying breast tissue is left intact.9
Vascular compromise of breast parenchyma is not usually an issue with implant ex-
change or removal. However, when mastopexy is performed concomitantly, certain
combinations of operations could conceivably devascularize the parenchyma. For
example, when a subglandular implant has been previously placed, any mastopexy
procedure that requires wide undermining of the skin aps could potentially result
in devascularization of the parenchyma. Review of operative records is helpful in
planning reoperation to avoid this complication.
It is good practice to avoid any secondary mastopexy procedure that
requires wide skin undermining when the integrity of pectoralis ma-
jor muscle perforators is in question.

1269
Chapter 34
Reoperative Surgery Following Breast Augmentation
NERVES
Sensation of the breast is provided by the intercostal segmental nerves as well as
branches from the cervical plexus. The most disconcerting sensory change in the
breast after augmentation is nipple hyposensitivity, which is reported to occur in
15% to 49% of cases.2,10 Permanent postoperative anesthesia of the nipple is rare;
when it occurs, it is usually caused by the division of the fourth anterolateral inter-
costal nerve,11 which penetrates the posterior aspect of the breast at the intersec-
tion of the lateral border of the pectoralis major muscle and the fourth intercostal
space. This location is approximately the 4 o’clock position on the left breast and
the 8 o’clock position on the right breast.12 Our experience with various pedicles
in breast reduction, however, leads us to believe that most patients probably have
multiple sources of nipple-areolar innervation, providing considerable crossover
sensation.
With the axillary approach, injury to the second intercostal nerve (that is, intercos-
tobrachial cutaneous nerve) can occur if dissection is carried too deeply into the
axilla.The plane of dissection should be super cial to the lateral aspect of the pec-
toralis major muscle, and then directly beneath it. Painful neuromas can occur if the
lateral cutaneous nerves are divided or caught in the capsule.8
Anteromedial
intercostal nerve
Anterolateral
intercostal nerve
Intercostal
nerve

1270
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Speci c Problems
The reoperative problems related to breast implants can be divided into complica-
tions resulting from the surgical procedure, including malposition and capsular con-
tracture and complications associated with the device itself. The overall incidence
of complications with breast augmentation is quite low if capsular contracture is ex-
cluded. Many of these complications, however, require reoperation.
HYPERTROPHIC SCARRING
Hypertrophic scarring occurs in approximately 2% to 5% of patients.12 Keloid for-
mation is rare.The best treatment is to make well-planned incisions that will cam-
ou age the scar if it becomes hypertrophic. Scar revision is most successful when
the breast is soft and pliable so that closure can be tension free. If the inframammary
approach is used, the incision should be placed at the anticipated level of the new
inframammary fold, at or below the natural inframammary crease. If the incision is
made in the axilla, a prominent crease should be chosen.The incision should never
cross a crease12 (see Chapter 5).
SEROMA
Seroma formation is predictable and usually resolves without treatment. It usually
becomes evident on the second or third postoperative day. Aspiration is performed
only if the seroma is large and discrete enough to ensure that the needle will not
be inadvertently introduced into the implant. Aspiration should not be performed
through the incision but through the lateral aspect of the breast, while mechanically
displacing the implant medially using ngertip pressure.13 With sterile technique a
16-gauge intravenous catheter is slowly and carefully introduced.The needle is re-
moved, leaving the exible catheter within the uid cavity.The uid is aspirated and
sent for the appropriate culture and sensitivity studies. This process is repeated on
a serial basis until the seroma resolves or decreases to a negligible volume. Ultra-
sound-assisted drainage is a reasonable choice; however, cost may become an issue
for patients undergoing aesthetic surgery.
HEMATOMA
The incidence of hematoma after breast augmentation ranges from 1% to 6%.14,15
Hematoma usually results from inadequate hemostasis at the time the pocket was
dissected. However, some hematomas may appear up to 3 weeks after surgery. Small
collections of blood can be observed. Large hematomas should be evacuated in the
operating room with the patient under general anesthesia. After the incision is
opened, the implant is removed and placed in a dilute antibiotic (gentamicin) so-
lution. The hematoma is evacuated, and the source of bleeding is meticulously
sought with the assistance of a beroptic retractor. Electrocautery is used to achieve

1271
Chapter 34
Reoperative Surgery Following Breast Augmentation
hemostasis. After copious irrigation with hydrogen peroxide and saline, the implant
is replaced. Some studies link the occurrence of hematoma with a higher rate of
capsular contracture (see p. 1278). In addition, a higher incidence of infection oc-
curs when the hematoma is not drained.16
Patient Example
This healthy 34-year-old patient presented for elective breast augmentation.Three
days postoperatively, she suddenly experienced pain, swelling, and a bluish discol-
oration of her left breast after physical exertion. Prompt return to the operating
room, reexploration, and evacuation of the hematoma ultimately resulted in a sat-
isfactory outcome.
INFECTION
Infection resulting from implants is rare. Some researchers report an incidence of
approximately 2% to 4%; Staphylococcus aureus and Staphylococcus epidermidis are the
most commonly cultured organisms.17 Patients with Pseudomonas infections typi-
cally present with pain out of proportion to the clinical ndings;this type of infec-
tion must be suspected in patients with a low-grade fever and severe pain in the
augmented breast.12 Mycobacterium infections occur very rarely.The presence of this
organism must be suspected when clinical signs of infection are present with neg-
ative “routine” culture results.18

1272
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
LeRoy and Given19 reported that the prophylactic administration of antibiotics does
not significantly decrease the incidence of infection. However, they irrigate the im-
plant pockets with bacitracin or povidone-iodine.We prefer to prescribe a prophy-
lactic antibiotic regimen. One gram of a rst-generation cephalosporin is admin-
istered just before the skin incision is made. For patients with cardiac valve
problems, including mitral valve prolapse, intravenous or oral antibiotics are ad-
ministered for 48 hours preoperatively.
Early cellulitis that develops around the incision or that involves the skin of the
breast will frequently respond to oral antibiotic therapy. Only in the event of a fail-
ure to respond to a course of oral antibiotics do we feel that hospitalization and in-
travenous antibiotics are necessary.The surgeon must have a high index of suspicion
of an infected seroma. If a clinical diagnosis of uid around the implant cannot be
de nitively made, an ultrasound examination of the pocket should be considered.
If hospitalization is required, we usually start a regimen of intravenous cephalo-
sporin until the erythema resolves. Methicillin-resistant S. aureus (MRSA) should
also be considered as a possible cause of infection. The patient is then discharged
from the hospital and oral antibiotics are prescribed to be taken for at least 1 week
with close follow-up.
The standard treatment for infected implants is to remove them. The complica-
tions that can result from infected implants that are not removed include exposure
with extrusion, capsular contracture, and even toxic shock syndrome.20 Once gross
purulence has formed around the implant, only open drainage with thorough irri-
gation and implant removal is the treatment of choice. There are reports of im-
plants that have been saved in the presence of infection. Courtiss et al16 reported the
salvage of 16 of 29 infected implants by draining the pocket and administering in-
travenous antibiotic agents. Our preference is to remove the implant, thoroughly ir-
rigate the pocket, and allow complete healing and softening of the breast to occur
before implant replacement. This process usually requires several months. Occa-
sionally a patient may wish to have both implants removed to avoid significant
asymmetry during the waiting period.This approach also helps to avoid the occa-
sional situation in which an infection involving one breast may lead to subsequent
infection of the contralateral breast.
W OUND DEHISCENCE
Dehiscence and exposure may result from several technical problems including in-
adequate closure, hematoma, seroma, and infection. In addition, an inadequate
pocket for the size of the implant may result in a tense closure that ultimately breaks
down.13 Implants inserted through an inframammary approach, especially large im-
plants, can exert considerable tension on the sutured wound.This tension is partic-
ularly accentuated when the patient is in the upright position. A separate layer of
sutures in Scarpa’s fascia will help to relieve tension from the skin closure and di-
minish the risk of dehiscence and exposure.

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Chapter 34
Reoperative Surgery Following Breast Augmentation
If dehiscence occurs within the rst 2 or 3 days after implant placement, the im-
plant may often be salvaged by returning the patient to the operating room, irrigat-
ing the wound carefully, and reclosing it in layers. However, when dehiscence oc-
curs 1 week or more postoperatively, the surgeon must always suspect infection as
the cause. An attempt might be made to salvage the implant using thorough irri-
gation of the pocket with an antibiotic solution, replacement of the implant, reclo-
sure of the wound, and intravenous antibiotic therapy.
The presence of frank purulence mandates removal of the implant.
If the original placement was subglandular, replacement in the submuscular position
may reduce the risk of recurrence.
When textured-surface implants are inserted, they are expected to adhere to the
surrounding capsule. Lack of adherence may result from seroma formation or infec-
tion.When dehiscence occurs as a result of seroma, pockets of nonadherence may
contribute to further seroma collections and ultimately to infection. In this situa-
tion the wound pocket should be explored under sterile conditions and drains
should be placed to try to prevent the development of further seroma collections.
On exploration, if the entire implant is adherent to the surrounding capsule, then
simple reclosure of the wound is likely to be successful.
IMPLANT MALPOSITION
Malposition can result in the implant being too high, too low, or too far laterally.
Usually malposition is suspected immediately postoperatively while the patient is
still on the operating table. However, malposition may not become apparent until
the pocket has had time to mature.
Malposition occurs as a result of multiple variables. Implant size and weight, surface
texture characteristics, the quality of the skin and breast tissue, and the age of the
patient all impact the eventual position of the implant. For example, a large, smooth
saline implant in the retropectoral space with full muscle release in a small-framed,
thin, 40-year-old woman will invariably descend well below the original native in-
framammary fold.
If the inferior dissection is too extensive, the implant will drop below the proposed
inframammary line, creating a bulge or an unnatural elevation of the nipple-areola
complex. If this problem is recognized intraoperatively, the subcutaneous tissue of
the inferior ap can be sutured to the fascia. A compression garment is used to
maintain the position postoperatively.21
If the implant descends at some point after the initial operation, repositioning the
implant using tape or an underwire bra may be attempted. Alternatively, percuta-
neous suturing to anchor Scarpa’s fascia to the deep muscle fascia in two or three

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
places can be effective. This is accomplished using a 2-0 Prolene suture on a large
needle through a “stab wound” incision at the desired fold level.The needle catches
the deep fascia and is then backed through above Scarpa’s fascia and tied at the stab
wound site with the knot buried. This simple technique can effectively prevent a
reoperation. However, this practice usually has little chance for success. Steroids
placed in the pocket intraoperatively are known to cause gradual inferior displace-
ment of the implant. Atrophy of the breast skin may also occur. Correction of the
deformity usually requires reoperation.
Patient Examples
This 38-year-old patient presented for breast augmentation. A smooth saline im-
plant was placed in the subpectoral position with release of the pectoralis major
muscle across the inframammary fold medially.
At 1 year both implants had gradually descended approximately 2 cm below the in-
framammary fold.The patient requested correction of this problem.