Reoperative Plastic Surgery of the Breast

SEROMA
In my experience seroma following breast reduction is
rare. It can present as a localized fluid collection that may
be apparent as an area of swelling. There may be a fluid
wave when the tissue is gently balloted. If such a collec-
tion is suspected, it can be aspirated using sterile tech-
nique in a fashion similar to that used to treat hematoma.
I generally prefer to use an 18-gauge needle. Seromas may
require multiple aspirations in most locations of the body.
As previously mentioned, an alternate strategy is to open
the previous incision and place a Penrose drain in the
seroma cavity.
WOUND SEPARATION AND OPEN
WOUND FORMATION
Some degree of wound separation is very common fol-
lowing breast reduction. Although I do not have precise
data on its incidence, I believe it is in the range of 10% to
15% in patients undergoing inferior pedicle breast reduc-
tions and is higher in patients who have vertical pattern
reductions. These numbers are much higher in smoking
patients, and I inform them of this preoperatively. As pre-
viously noted, the most common site for ischemia of the
flaps is at the T junction, and this is where open wounds
are most commonly noted when the inverted T incisional
pattern is used for breast reduction.
Open wounds following a breast reduction or
mastopexy will almost always heal in time. Delays in
wound healing are most often due to retained foreign
bodies in the wound (usually suture material) or to infec-
tion. When infection in such wounds is present it must
be treated. Depending on presentation, this may require
a combination of systemic antibiotics, the topical appli-
cation of antibiotic ointment, and wound dressing
changes.
These wounds heal by the process of epithelialization
and contraction. There can be considerable exudation
from their surface, making them messy for patients to
care for. I commonly ask patients to have patience during
the process of wound healing. Simple wound care
includes washing the wound in the shower and applying
bacitracin ointment topically. The moist environment and
local bacteriostatic activity of this topical emollient will
facilitate healing. The scars resulting from this secondary
healing tend to be larger, usually hypopigmented, thinner
in texture, and more depressed relative to the skin surface
than the remainder of the scars. However, patients almost
never request additional treatment, even when scarring is
extensive as is seen in this patient (Fig. 5-8A), who under-
went an inferior pedicle breast reduction with the resec-
tion of 900 g of tissue from each breast. She developed
significant skin loss on each breast (Fig. 5-8B). The total
time to complete wound healing was 6 months, during
which she was seen frequently in the office so that we
could give her the appropriate psychologic support while
we performed the necessary wound care. She was indeed
a patient patient, and her eventual cosmetic result was
satisfactory (Fig. 5-8C,D).
Another example of prolonged healing following skin
loss is seen in this 45-year-old patient (Fig. 5-9A) who will
undergo a vertical breast reduction using a medial der-
moglandular pedicle (Fig. 5-9B). There was excessive ten-
sion on the inferior aspect of the vertical skin closure,
which resulted in skin necrosis and large open wounds
that failed to show any progress toward healing over the
first 6 weeks postoperatively (Fig. 5-9C). There were
changes on the surface of the granulation tissue suggest-
ing a secondary wound infection, and cultures were con-
sistent with a Staphylococcus sp. She was treated with
both mupirocin (Bactroban) topical ointment and oral
dicloxacillin [500 mg by mouth (PO) four times daily
(q.i.d.)] with rapid epithelialization and wound contrac-
tion that led to healing within 1 additional month. She
shows a very acceptable appearance of her breasts at 1
year following surgery (Fig. 5-9D,E), and the wound is sta-
ble (Fig. 5-9F).
This patient is interesting from several perspectives.
During vertical mammoplasty the tension in the line of
closure should be on the parenchyma, not the skin edges.
It is a parenchymal reshaping procedure, and I made an
error in placing too much tension on the skin wound clo-
sure.8–10 In addition, it is important to recognize when a
wound fails to show normal progress toward healing. The
most common etiologies are wound infection or the pres-
ence of a foreign body, which in this setting is most often a
contaminated suture.
In general the wounds resulting from skin loss after a
breast reduction progress relatively quickly toward com-
plete healing. It is almost never necessary for the surgeon
to perform additional surgery to promote healing of such
wounds. In the well over 1,000 breast reductions I have
performed, I have had to resort to a split-thickness skin
graft only once. This was in a patient who was mentally
incapable of complying with the wound care regimen nec-
essary to achieve complete wound healing. Likewise,
wound excision and reclosure is almost never an option
because the wound is usually indurated and will not hold
sutures well, especially if there is any tension at the site of
wound edge closure.
The one exception to this may be an open wound sec-
ondary to wound dehiscence that occurs at the time of
suture removal. In this situation immediate resuturing
after infection of a local anesthetic agent can prevent a
more prolonged course of healing for this wound. I reop-
erated on one patient who developed a prolapse of her
inferior central breast area through an area of skin necro-
sis at 1 year following surgery.
192
Reoperative Plastic Surgery of the Breast

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
193
FIGURE 5-8. A, Preoperative AP view of patient who will undergo an inferior pedicle breast reduc-
tion. B, The procedure is complicated by skin loss involving the inferior medial aspect of the lateral skin
flap on both breasts. There is extensive skin loss on the left side C, The result after 5 months of dressing
changes shows complete healing of the wound and, D, the AP view reveals a very acceptable cosmetic
result.

194
Reoperative Plastic Surgery of the Breast
FIGURE 5-9. A, Preoperative AP view of patient who will undergo a vertical reduction mammoplasty
using B, a superior medial dermoglandular pedicle. C, She developed skin loss in the lower aspect of the
vertical incision on both breasts. This was due to excessive tension on the incision line at the time of
wound closure. The wound showed no sign of healing during the first 6 weeks postoperatively. There
was a low-grade wound infection with a Staphylococcus sp. that was treated with topical mupirocin
(Bactroban) ointment, along with oral dicloxacillin. D–F, This led to rapid epithelialization and con-
traction of the wound and an acceptable cosmetic appearance of her breasts. (continued)

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
195
CELLULITIS
Infection following breast reduction is very uncommon.
Most series will reflect an incidence of 1% to 2%. This is
interesting given the length of time that wounds are open
and the magnitude of the dissection carried out during
breast reduction. The breast is endowed with a robust
blood supply, and there are probably other local immuno-
logic mechanisms that are protective against and mini-
mize the incidence of infection.
When infections occur following a breast reduction
they usually present as a cellulitis. In such cases there is
almost always an open wound that is the portal of entry.
The most common causative microbial organisms are
Streptococcus sp. and Staphylococcus aureus. Typically the
patient presents with erythema; tenderness at the site of
infection; and, if the process is significant enough, fever.
In cases of pronounced cellulitis the patient may present
with shaking chills.
The treatment is prompt institution of appropriate
antibiotic therapy. For small areas of involvement diag-
nosed early, oral antibiotics may be sufficient. I usually
begin with cephalexin [(Keflex) 500 mg PO q.i.d.]. If
patients are penicillin allergic I substitute ciprofloxacin
[750 mg PO two times daily (b.i.d.)]. If the process is
more advanced I usually begin parenteral antibiotic ther-
apy using a second-generation cephalosporin [cefazolin
(Ancef) 1 g intravenous (IV) q8h]. If the patient has a
penicillin allergy I prescribe ampicillin [(Unasyn) 3 g IV
q6h].
If an open wound is part of this picture a culture of the
wound is obtained by swabbing the surface or unroofing
an eschar. This specimen is processed for aerobic and
anaerobic organisms. At times obtaining such cultures
may help the clinician readjust the antibiotic treatment
regimen.
In every case it is important to monitor the result of
the infection process. Toward this end the patient is
checked on a 24-hour basis and rechecked daily. An
improvement in the cellulitis is expected within 48 hours
of treatment. The average duration of therapy is between
7 and 10 days.
FIGURE 5-9. (CONTINUED)

RECURRENT CELLULITIS
A significant cellulitis that recurs may suggest a number
of potential etiologies, including a retained foreign body
(usually suture material), a scar that has become embed-
ded beneath the surface or a scar that is unstable and
prone to small cracks that may become portals of re-entry,
an infected hematoma or occult abscess, and fat necrosis
with associated infection. Additional alternative diag-
noses are hidradenitis suppurativa of the breast or an
immunocompromised host.
Such clinical presentations may merit a workup with a
magnetic resonance imaging (MRI) scan to rule out a
retained foreign body, retained fluid collection, fat necro-
sis, or a foreign body. Appropriate additional therapy is
then undertaken as needed depending on the breast imag-
ing findings and ancillary diagnoses.
Recurrent cellulitis of the breast often presents a chal-
lenge. It is important for the surgeon to make a diagnosis
regarding the etiology and to refrain from surgical
overtreatment. Consultations with the infectious disease
service or other surgical colleagues with special training
in the area of wound healing may be helpful. There is
probably little indication for long-term suppressive
antibiotic therapy.
NIPPLE AREOLAR ISCHEMIA
Ischemia of the NAC is a dreaded potential complication
of every predicted breast reduction procedure. It is most
often related to arterial insufficiency and it usually occurs
in the setting of a large reduction where a long pedicle is
used to carry the circulation to the NAC. In such situa-
tions the tissue resection compromises the arterial perfu-
sion of the nipple and surrounding areola. In addition,
there may be a component of venous insufficiency in
those cases where the pedicle is excessively folded during
wound closure.
The latter situation presents with a hyperemic con-
gested appearance of the NAC, which shows dark deoxy-
genated blood emanating from its cut edges. In the
former condition of arterial ischemia the nipple and areo-
lar tissue appears pale and dusky and there is little or no
blood entering its substance or noted at the cut edges of
the areola.
Nipple areolar necrosis in the setting of breast reduc-
tion is very uncommon, occurring with a frequency of 1%
to 2%. It is probably much rarer following mastopexy.
Predisposing factors at the time of the primary surgery
include a lengthy pedicle (in an inferior pedicle reduction a
distance of greater than 15 cm from the nipple to the IM
fold), a nipple transposition distance exceeding 18 cm, and
extremely large reductions (>2,000 g) done with pedicle
techniques where resection of the parenchyma can cause a
decrease in nipple blood supply due to excessive folding at
the time of closure.
In the setting of reoperative surgery this problem may
result from an incomplete or inaccurate understanding of
the previous pedicle orientation or blood supply used dur-
ing the initial surgery. I have previously alluded to the
importance of obtaining the most accurate information
about the techniques used during previous procedures
when reoperating on a patient who has had a previous
breast reduction or mastopexy. When the surgeon cannot
obtain such information and nipple relocation is planned,
it is best to maintain a broad central pedicle as the source
of blood supply to the NAC. Finally, cases of a previous
subglandular breast augmentation may pose a real prob-
lem in maintaining blood supply to the nipple when a sig-
nificant nipple transposition distance is planned.
Nipple areolar necrosis is a small but real possibility in
every mammoplasty procedure, including reoperative
procedures. As such it must be a part of the informed con-
sent for the patient who is considering these operations.
It is important for the surgeon to recognize nipple are-
olar ischemia on the operating table. However, this is not
always easy to do, especially when operating on dark-
skinned patients of African descent or others with dark
areolar skin. If there is concern about the color changes in
the areola or about capillary refill following pressure
placed with a finger or surgical instrument, abrading the
edge of the incision with a gauze sponge and examining
the quality of the bleeding may be helpful. In some situa-
tions the administration of IV fluorescein (Chapter 8)
might be of benefit.
If real concern about nipple ischemia exists during
wound closure, the wound should be opened and the pedi-
cle checked for any evidence of folding or kinking. I prefer
to place warm saline-soaked sponges on the pedicle to try
to reverse any vasospasm that might be present. If there is
obvious ischemia of the nipple following these maneuvers
surgical treatment is undertaken. The nipple should be
removed from its position on the pedicle by excising it as a
full-thickness skin graft (Fig. 5-10A). It is prepared by
aggressively defatting the areola and resecting the tissue
on the undersurface to the level of the superficial dermis. I
prefer to leave some of the nipple elements (the ductal tis-
sue) in place so that when the nipple areolar graft heals,
there will be some degree of nipple projection. The
ischemic portion (distal aspect) of the pedicle is usually
resected at this point to minimize the chance of fat necro-
sis and to more easily accommodate breast skin flap
redraping. The free graft of the NAC is then placed on the
de-epithelialized skin flaps if an inverted V pattern has
been used to develop the skin flaps (Fig. 5-10B), or on a
de-epithelialized portion of the original breast pedicle
closer to the origin of its blood supply (Fig. 5-10C). If a
Wise pattern design has been employed for the original
skin incisions and the areolar cutout has been made, it is
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Reoperative Plastic Surgery of the Breast

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
197
closed with a purse string suture technique and the area
where the nipple should be placed is de-epithelialized
(Fig. 5-10D). Alternatively, the previous areolar cutout can
be closed as a linear scar creating a T; however, the extent
of the horizontal incision should not fall outside of the
periphery of the nipple areolar graft. The graft is then
secured by placing sutures at its periphery and finally by
constructing a tie over bolster-type dressing. In my experi-
ence this gives the frankly ischemic NAC noted at the time
of the original surgery the best chance for survival.
If the problem does not become apparent until later in
the postoperative course, some degree of nipple necrosis
usually ensues. In this situation, and in countless others
involving the management of acute complications, it is
important for the surgeon to “be a doctor” by supporting the
patient through this difficult period from both a wound
healing and a psychological standpoint. The surgeon must
tell the patient that although it will take time for her tissues
to heal, reliable techniques exist that will enable the surgeon
to construct a new nipple and NAC when the time is right.
Nipple graft placed closer to blood
supply of inferior pedicle
A
B
D
C
resected ischemic
distal
pedicle
FIGURE 5-10. A, The treatment of frank nipple ischemia recognized at surgery requires that the
nipple be removed as a full-thickness graft. B, It can then be transplanted to the area where it would
have been brought through if an inverted V design for the skin flaps had been used. The area of skin is
simply de-epithelialized. C, Alternatively, the nipple can be placed back on the pedicle closer to its base
where the blood supply is better, the distal (ischemic) area of the pedicle is resected, and the pedicle is
draped by the skin flaps. D, The preferred option for when a circular cutout of the breast skin has been
made at the start of the operation is illustrated on p.198. It entails a purse string closure of the circular
cutout and a subsequent de-epithelialization of this area to establish a recipient bed for a full-thickness
graft, which is the nipple areola complex. (continued)

198
Reoperative Plastic Surgery of the Breast
FIGURE 5-10. (CONTINUED) E, If a Kehole pattern has been used and an areola cut-out created.
F, This circular opening in the skin can be closed with a purse-string suture. G, This area subsequently
deepithelialized to allow application of the nipple areola complex as a free graft.
In this setting, loss of the nipple and NAC is often
accompanied by necrosis of the underlying tissues.
Treatment includes careful superficial wound care with
dressing changes performed several times a day, along
with conservative débridement of the wound judiciously
performed as needed. Often careful wound management
and patience result in a better outcome than may have
been anticipated immediately following surgery.
The most likely long-term sequelae of nipple areola
complex ischemia are asymmetries of nipple projection;
altered areolar shape; and, most commonly, problems with
hypopigmentation. Management of these problems is best
deferred until the later stages of wound healing.
LONG-TERM COMPLICATIONS
As previously stated, the complications following breast
reduction can be thought of as aesthetic imperfections or
related to the operation per se. The most commonly
encountered complications in the immediate postopera-
tive period have just been described. The most commonly
noted aesthetic problems following breast reduction are
dog ears, unattractive scars, breast asymmetries, nipple
areolar problems, fat necrosis, loss of shape, underreduc-
tion, and overreduction. The secondary procedures most
often used to address these problems will now be
reviewed.
DOG EARS
Dog ears occur because of either insufficient skin excision
or improper skin redraping, or both. Following the
inverted T incisional pattern they occur medially or later-
ally in the IM incision or in both locations.
Dog ears are usually a result of the surgeon’s well-inten-
tioned effort to limit the length of the scar. When they
occur on the breast they are visible in either location and
can be particularly bothersome to the patient. Experience
with my own patients has taught me that it is most often
better to resect them at the time of the original surgery,
unless they are very small.
The IM scar in a breast reduction should be kept on or
in the shadow of the breast contour when the patient is in
the upright position. This usually can be accomplished by
careful planning done preoperatively. However, when a
dog ear is noted at the conclusion of surgery and it is
greater than 1 cm in length, it is easily resected. The
patient is placed in the sitting position on the operating
table as close as possible to 90 degrees.10 At this time an
excision can be planned to direct the scar onto the breast

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
199
contour or in the shadow of the breast. That is to say, the
dog ear excision can be directed superiorly or inferiorly by
adjusting the position of the lines of excision. Altering the
direction of the scar is helpful, especially when placing it
on a structure with the three-dimensional convexity
exhibited by the breast. When performing an excision,
both the skin and the subcutaneous adipose tissue must
be resected, with more of the latter than the former.
Alternatively, if the dog ear is small (≤1 cm), it may be wise
to allow time for it to settle down. The patient should be
instructed to massage the dog ear on a consistent basis
and the surgeon should follow its progress periodically. If
a resection is indicated secondarily, this can be done in the
office under local anesthesia (Fig. 5-11). Using this strat-
egy the resulting scar is often shorter than it would have
been if an excision of a dog ear had been done at the origi-
nal surgery.
UNATTRACTIVE SCARS DUE TO
HYPERTROPHY OR SPREADING
HYPERTROPHIC SCARS
Unattractive scarring is probably the most commonly
noted adverse effect of breast reduction. The problem is
most commonly due to scar hypertrophy; however,
spreading of the scars following a breast reduction is also
not uncommon.
Scars demonstrate a thickened or hypertrophic appear-
ance predominantly because of a tight skin closure. When
performing a breast reduction, the surgeon should avoid
the temptation of relying too heavily on the skin closure in
forming the new breast shape. As I have previously stated,
in my opinion the parenchymal configuration largely
determines the shape of the breast, and I believe that it
should precisely fit the wound resulting from the resec-
tion, with an almost passive redraping of the skin flaps.
This requires careful planning and consistent surgical
technique. The surgeon should avoid excising extra lateral
skin as part of an exaggerated lazy S closure in an effort to
suspend or shape the breast. This leads to lateral scar
hypertrophy. The divergence of the medial limbs on a
Wise pattern design should not be excessive. I find that
a pattern that permits minor adjustments of this medial
skin excision is helpful. The nipple areola should be cut
with a larger diameter than the skin cut out at the site
where it is to be placed. Finally, I believe that using a two-
layered wound closure is important, paying particular
attention to the deep dermal closure, which in my opinion
must be precise. I have just begun having my patients
place paper tape on their wounds for 3 months postopera-
tively. This may be helpful in decreasing the incidence of
scar hypertrophy.
In general all scars fade and soften with time. This is
true of breast scars. For that reason I encourage patients
to wait as long as possible (at least 1 year) before deciding
to pursue scar excision.
The treatment of established hypertrophic scars entails
the application of pressure dressings, the intralesional
injection of a depot steroid that acts at the site of injection
or excision, and reclosure of the wound. I find it difficult
to outfit patients with a device that will apply continuous
pressure to the postreduction scars. I have had little expe-
rience with and have little enthusiasm for the topical
application of silicone gel sheeting.
On the other hand, I know that the intralesional injec-
tion of a locally acting steroid is effective in reducing scar
thickness (the height that it projects above the skin) but
not the width of a scar. It does this by inhibiting the activ-
ity of a down regulator of collagenase, therefore allowing
this enzyme to tip the scales in favor of scar resorption in
a wound. This has been effective in my hands for treating
hypertrophic scars of the breast. I use a 25-gauge needle
and a 5-cc syringe to inject triamcinolone in a concentra-
tion of 10 mg per 5 cc. I re-evaluate the patient at a
3-month follow-up and perform an additional injection if
requested. A final injection may be performed 6 months
later if the patient is still not satisfied with the result of the
treatment. The injections typically hurt, and applying ice
FIGURE 5-11. A dog ear noted on the most posterior lateral
aspect of the IM incision that will be resected. It is often best to
perform such resections at the primary surgery.

200
Reoperative Plastic Surgery of the Breast
topically to the scar before the injections is helpful in
blunting this. Steroid injections can alter scar color, i.e.,
producing not only hypopigmentation but also causing a
purplish discoloration or producing very apparent telang-
iectases, and they can cause adipose tissue atrophy and
even a sunken appearance of the scars. Any of these effects
can produce an unattractive appearance in the scar, which
may prompt the patient to seek scar excision and reclo-
sure. Patients should be informed about these risks before
the injection of the steroid medication.
SCAR EXCISION AND WOUND
RECLOSURE
As stated earlier, I usually want patients to wait at least a
year and most of the time longer (18 months) before
proceeding with a scar excision and reclosure. The opti-
mal time to proceed is indicated when the scars exhibit
signs of maturation, typically marked by lightening and
softening.
When scar excision is elected by the patient, I excise
the scar tissue by incising through the entire dermis on
both sides of the scar. I undermine the skin just below the
dermis until the wound edges can be reapproximated
without tension. I perform a layered wound closure with
interrupted 4-0 coated polyglycolic acid sutures [PDS
(Ethicon, Inc., Somerville, NJ) or Maxon (Sherwood-Davis
& Geck, St. Louis, Mo)] with the knots buried. The skin
edges are then apposed using a removable subcuticular
nylon suture, also of 4-0 gauge. This suture is removed 1
week following surgery and the wound edges are splinted
with Steri-Strips (3M Corp., St. Paul, Minn), which are
continuously reapplied for 2 months to eliminate tension
on the wound edges. I then have the patient place paper
tape over the wound for 3 months unless she has a sensi-
tivity to the tape, which will become apparent as she uses
it. The patient is instructed to massage the scar twice daily
with vitamin E cream; this is continued for 2 years or until
all of the hyperemic appearance of the wound has
resolved.
Following wound separation the scar typically is wide,
thin, and depressed in its contour. The problem is almost
always located at the T junction or in the area of the verti-
cal incision. I find that it is usually necessary to excise the
entire vertical scar in the middle of the lower pole of the
breast, along with excising and recreating some length of
both the IM and periareolar incision. This is necessary to
redrape the skin flaps in a way that will not distort the
NAC. The technique is illustrated in this patient who sus-
tained skin loss on both breasts following an inferior
pedicle breast reduction (Fig. 5-12A). The patient went on
to heal by secondary intention with epithelialization of
her wound. She developed a picture of prolapse of the
parenchyma through the wound that produced a contour
deficit (Fig. 5-12B). She then requested a revision of her
wound closure that was done as outlined in Figure 5-12C.
Her postoperative breast appearance was improved
(Fig. 5-12D) in terms of both scar quality and breast
shape.
FAT NECROSIS
Fat necrosis can occur following any surgical procedure
on the breast, including breast reduction. It most often is
the result of focal devascularization of an area of fat in the
breast but it can also result from trauma, including sur-
gery. It usually occurs in an area of decreased blood sup-
ply. The process usually presents as an area of induration
or thickening, and not uncommonly it may be appreci-
ated in the most distal aspect of an inferior pedicle
employed in breast reduction, where a firmness may be
palpated above the NAC in the central superior breast
(Fig. 5-13A). When it occurs, the condition often persists
for 6 to 12 months. If the insult is severe enough to result
in pronounced ischemia, the area in question may
become a hard lump that is noticeable to the patient and
easily appreciated by the examining physician. In my
experience, areas that present firm masses usually resolve
with time (within 9 to 15 months) unless they are very
large. In contrast, areas that become hard do not resolve
and never completely soften. Such areas may develop
microcalcifications as part of the saponification process
involved with the genesis of fat necrosis, and these micro-
calcifications may be visible on a mammogram (Fig.
5-13B). These microcalcifications have a characteristic
appearance on mammography that is different and dis-
tinct from the microcalcifications associated with certain
breast cancers.
If these firm or hard areas in the breast noted after a
breast reduction persist, they should be evaluated. The
workup of such lesions includes a physical examination,
a mammographic imaging of the breast, and not uncom-
monly a needle aspiration performed in multiple sites of
the mass using an 18-gauge needle attached to a 10-cc
syringe. The aspirated cells are plated and processed by a
trained cytology technician and then read by a
cytopathologist.
In the vast majority of these cases the combination of
the temporal relationship of the mass to the breast reduc-
tion procedure, its characteristic on physical examina-
tion, the typical x-ray appearance, and a benign needle
aspiration cytology report are sufficient to allay any anxi-
ety and fears of the patient.
Some patients are sufficiently bothered by the presence
of the mass that they request an excision. If excision of the
mass is elected, it should be performed through the previ-
ous incision on the breast. If such a lesion is of sufficient
size, its excision may produce a contour abnormality in

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
201
FIGURE 5-12. A, Acute skin loss following an inferior pedicle breast reduction performed with a Wise
pattern. B, There is actual prolapse of breast tissue through the thin segment of scar tissue that has
resulted in a contour deformity of the breasts. C, This was treated by operative wound excision and
reclosure. D, The appearance of the breast contour and wounds 3 years following the reoperative surgi-
cal intervention.

202
Reoperative Plastic Surgery of the Breast
the breast. If in the mind of the surgeon this sequela is a
likely result of such an excision, he or she must mention
this to the patient preoperatively. I believe that in this situ-
ation, most often it is preferable to perform a subtotal
excision of such a mass rather than produce a potentially
major adverse cosmetic effect on the breast from the sur-
gical treatment of a benign process. It has been my experi-
ence that when it is presented in these terms, most
patients opt for a subtotal excision of the area of fat necro-
sis. Long-term follow-up in terms of office visits and
mammographic surveillance are part of the normal man-
agement of such a patient.
ASYMMETRY
Asymmetry following breast reduction is common. By this
I mean subtle differences in the size, shape, nipple appear-
ance, or position and contour of the breasts. In fact, I tell all
patients to expect some degree of asymmetry. Because most
breast reduction patients have some element of asymmetry
before their surgery and they are so grateful for and grati-
fied by the relief of their macromastia symptoms, they will
most often tolerate minor asymmetries. To obtain the best
possible symmetry following each breast reduction, I have
the anesthesiologist place the patient in the sitting position
at 90 degrees on the operating table so that I can analyze
the breast from the foot of the table.10 If adjustments in vol-
ume, contour, nipple position, or skin envelope draping are
necessary, I pursue them before completing the wound clo-
sure. This method produces a level of symmetry that is
acceptable to most patients. However, as I critically evalu-
ate the photographic images before and after breast reduc-
tion in my own patients, I am impressed by the fact that
some element of asymmetry is the rule rather than the
exception.
The overwhelming majority of asymmetries seen fol-
lowing breast reduction are readily accepted by the
patient. I believe that this is because they are so gratified
by the relief of symptoms that they have obtained from
the breast reduction procedure. However, some asymme-
tries are significant enough that they are objectionable to
patients. The most common asymmetries relate to vol-
ume, contour, IM fold level, NAC appearance, and scar
position. The following section discusses approaches for
achieving their correction.
VOLUME ASYMMETRY
Discrepancies in breast volume following a breast reduc-
tion are common. Usually these are minor or subtle in
extent. Occasionally they are more obvious. If the discrep-
ancy is bothersome to the patient, it can be addressed
FIGURE 5-13. A, The most common location of fat necrosis following an inferior pedicle breast
reduction that is superior to the NAC at the most distal aspect of the pedicle. B, The mammogram
shows a characteristic appearance of fat necrosis, which is easily differentiated from other processes.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
203
using either liposuction of the breast of by open excision
of tissue.
It is most desirable to localize the area of breast tissue
excess with the patient in the sitting position in much the
same way as adipose tissue excess is localized before a
body contouring procedure. My custom is to use a mark-
ing pen to place marks on the skin over the areas of vol-
ume excess that will not be erased by the surgical prep. I
employ the same analysis and marking procedure at the
end of essentially every original breast reduction. After
this marking, the surgeon can address the specific areas
with the patient in the supine position on the operating
table.
If the asymmetry relates to volume excess only, i.e.,
without an accompanying skin envelope disparity or nip-
ple areola asymmetry, then suction lipectomy alone can be
used for the correction, unless the breast tissue is
extremely dense. I prefer to infiltrate the breast with a
wetting solution containing 12.5-mg % lidocaine
(Xylocaine) and adrenaline in a concentration of
1:1,000,000. This is made by placing 12.5 cc of 1%
Xylocaine and 1 cc of adrenaline 1:1000 into 1 liter of nor-
mal saline. I will inject the breast tissues using a 30-cc
syringe and an 18-gauge spinal needle. After allowing 15
minutes for the hemostatic effect of the epinephrine to
take hold, I will perform the liposuction using 3.0- and
3.7-mm cannulae.
The following patient (Fig. 5-14A) underwent an infe-
rior pedicle breast reduction for bilateral symptomatic
macromastia. She had the resection of 400 g of tissue
from the right breast and 425 g from the left breast. The
breasts were largely fat replaced. She was noted to have
an obvious asymmetry postoperatively (Fig. 5-14B). The
plan for correction of this asymmetry includes only suc-
tion lipectomy of the right breast (Fig. 5-14C,D), mainly in
its lateral aspect. The skin envelope symmetry is good,
and I believe that a good correction of her asymmetry is
possible with this minimally invasive approach.
This next patient noted a volume discrepancy in her
breasts following a right breast reconstruction with an
implant and a vertical breast reduction on the left side to
optimize symmetry (Fig. 5-15A–C). The postoperative
result showed the left breast to be larger than the right,
and this asymmetry was bothersome to her. This situation
was addressed using liposuction of the breast as outlined
in Figure 5-15D,E, which produced a good outcome from
the standpoint of reducing the volume excess and the dis-
crepancy in projection (Fig. 5-15F).
Suffice it to say that liposuction is a valuable tool for
contour adjustment and volume reduction in the breast,
just as it is elsewhere. It is becoming increasingly popular
as the sole means of accomplishing primary breast reduc-
tion. I predict it will have far greater application in the
area of breast reduction in the upcoming years. The
advantages of this approach include the extremely mini-
mal incisions required for access, elimination of skin flap
and pedicle dissection, the ease of adjusting contours and
facilitating symmetry, and maximal preservation of nipple
sensation and much less postoperative patient morbidity.
The potential drawbacks are the slight risk of nipple are-
ola retraction due to ductal injury and the other risks
associated with liposuction.
When the asymmetry involves not only a volume differ-
ence but a skin envelope disparity and or a discrepancy of
nipple position, the use of a standard open surgical
approach is indicated because it can be used to address all
of these disparities. The plan in such cases almost always
calls for the use of the previous incisions. With this
approach the flaps are easily elevated, and most often they
are well vascularized because of what is analogous to a
previous delay from the original surgery. After flaps are
elevated, the areas to be addressed by additional resection
are directly visualized and correction is easily carried out.
If adjustments of the skin envelope are required, these can
be done using the tailor-tracking method, which is applied
to the original incisional pattern (see Fig. 2-32A,B).
The open correction of asymmetry with surgical resec-
tion of parenchyma is most often the method of choice if
there is a skin flap asymmetry. The same pedicle should be
used as was used in the first procedure. After the previous
pedicle is recreated, the necessary tissue resection is car-
ried out and peripheral to it in the appropriate areas of the
breast.
NIPPLE AREOLAR COMPLEX
ASYMMETRY
Following almost every type of breast procedure the
appearance of the NAC (Fig. 5-16) contributes greatly to
the symmetry of the breasts. If an asymmetry of this key
structure is very apparent, it may represent a source of
patient dissatisfaction. Such asymmetries may be related
to size, shape (Fig. 5-17), position, projection (Fig. 5-18),
or pigmentation (Fig. 5-19). As outlined in Chapter 2,
these are all important factors in breast aesthetics.
Following a breast reduction or mastopexy, it is not
uncommon for the patient to exhibit mild asymmetries of
the NAC. The type of asymmetry depends on the surgical
technique used because surgical techniques differ in their
pattern of skin resection and wound closure. For example,
an elongated or teardrop deformity of the NAC following a
Wise pattern skin reduction is not uncommon, whereas
perioareolar techniques often produce enlarged areolae
with stellate scar irregularities around the periphery
because of bunching of the skin and spreading of the NAC.
Revision of any of these asymmetries should be deferred
until the postoperative edema in the breasts has com-
pletely resolved. This usually means for a period of at least
6 months following surgery.

204
Reoperative Plastic Surgery of the Breast
A typical asymmetry following the Wise pattern skin
resection with an inferior pedicle reduction is illustrated by
the patient in Figure 5-17, who underwent a 400-g resection
of tissue from each breast. She was bothered by the dis-
crepancy in the size, shape, and position of the NACs
(Fig. 5-17A). This prompted a reoperation, which was per-
formed 8 months following the original procedure. At that
time the left NAC was reduced in size and elevated. This
prompted a reoperation, which was performed at 12
months following surgery. The pre-operative plan begins
with identifying the appropriate new level for the top of the
areola. This is marked from the fixed reference point of
the supra-sternal notch (Fig. 5-17B). The desired size of the
new areola is then marked. This is based on the size of the
FIGURE 5-14. A, Preoperative appearance of a 70-year-old patient requesting breast reduction. B,
She underwent a bilateral breast reduction using an inferior pedicle technique. There was slightly more
tissue resected on the left side than on the right side, and she shows an obvious asymmetry with the
right breast being larger than the left. C–D, Correction is planned and will entail liposuction alone to
achieve better contour and volume symmetry between the breasts.

FIGURE 5-15. A, A 55-year-old patient who has undergone a right mastectomy and immediate first
stage breast reconstruction with a short height tissue expander placement. B, The second stage plan is
for an implant reconstruction on the right and a vertical breast reduction on the left. C, The results of
that treatment show suboptimal symmetry with the left breast still too large. D, The plan for reopera-
tion includes liposuction of the left breast and a revision areola size of the nipple position. The mark-
ings for the revision are illustrated. E, The liposuction cannula attached to the syringe aspiration
system is being used to achieve correction. F, Markedly improved symmetry from the standpoint of vol-
ume and breast shape is demonstrated after the liposuction.

206
Reoperative Plastic Surgery of the Breast
opposite areola. The actul dimensions are marked on the
areola to be repositioned (Fig. 5-17C). An area of areola and
breast skin outside this is marked for resection as a periph-
eral “donut” (Fig. 5-17C). This area is de-epithelialized at
surgery. The superior border of the de-epithelialization is
the intended level of the new areola (Fig. 5-17D). The open
wound around the areola is considerably larger than the
areola size at this point. This skin opening must be reduced
and fixed with a peri-areola purse string suture to minimize
subsequent spreading of the areola post-operatively. To
accomplish this I use a permanent suture. In the past I used
a braided 3-0 suture such as Ethibond or Mersilene. Over
the past 3 years I have exclusively used a no. 2 Gortex
suture that is swaged onto a straight Keith needle (Fig. 5-
17E). This suture is placed into the deep dermis. Each pass
is initially made deep in the dermis, but as a 1.0-cm bite is
taken, the needle moves closer to the skin and then comes
out again in the deep dermis. Passes are made across to the
areola every 60 degrees, so a “spoke wheel pattern” is noted.
The suturing proceeds around the entire circumference of
the peri-areola incision to be closed (Fig. 5-17F). Next the
ends of the suture are tightened so as to make the periph-
eral skin slightly overlap the areola, making it slightly
smaller than the opposite side. This is checked by measur-
ing the areola diameter on the opposite breast and setting
the areola size exactly where it needs to be to achieve a
slightly smaller opening (Fig. 5-17G). The Gortex suture
requires at least 6 knots to avoid slippage. The knots must
be buried in the subcutaneous tissue and the suture is
pulled through the skin outside the closure and cut flush
with the skin so that it can retract. This will minimize any
possibility of suture exposure. This method has produced
long-term stabilization of periareolar wound closure in this
setting (Fig. 5-17H) and that of peri-areola mastopexy and
circum, vertical mastopexy.
NIPPLE RETRACTION
Nipple retraction can be seen with any technique used for
breast reduction. In the past it was most commonly noted
with the Strombeck procedure. Nipple retraction results
when the volume of breast tissue beneath the nipple is
insufficient to allow the nipple to maintain its position as
the most anteriorly projecting part of the breast gland. To
avoid this deformity, a concerted effort must be made to
maintain breast parenchyma beneath the NAC. When per-
forming an inferior pedicle reduction, I create a pyrami-
dal pedicle by resecting the breast tissue away from the
central portion of the pedicle. As mentioned previously in
this chapter, regardless of the pedicle used, sufficient tis-
sue must be maintained in the pedicle so that the skin
envelope is filled by the remaining breast tissue (see
Fig. 5-7).
FIGURE 5-16. Excellent postoperative nipple areola aesthetics are noted on frontal view in this
patient who has undergone a breast reduction.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
207
FIGURE 5-17. A, Postoperative asymmetry following inferior pedicle breast reduction. Note signifi-
cant difference in the size of the NACs. B, The plan entails equalizing the heights of the areolae. This is
done with the patient standing upright. C, The skin to be removed from the periphery of the new areola
is estimated by the pinch test. D, At surgery this skin is excised into the deep dermis. An incision is
made at the periphery of the opening, leaving 3 cm of dermis inside the skin excision. (continued)

208
Reoperative Plastic Surgery of the Breast
When correction of this deformity is undertaken, it is
usually necessary to tighten the skin envelope by advanc-
ing the medial and lateral flaps centrally, along with tight-
ening the periareolar skin cutout. It may also be necessary
to increase the parenchymal support below the nipple by
mobilizing and suturing breast tissue beneath the NAC, or
perhaps by unfolding the de-epithelialized from the lower
breast or unfolding a de-epithelialized skin flap as illus-
trated for treatment of nipple malposition in the following
section.
NIPPLE MALPOSITION
Nipple malposition is often noted as being the most com-
mon long-term complication of breast reduction. Most
often the nipple is placed too superiorly on the breast. I
believe that plastic surgeons are responsible for most of
the nipple malposition that is seen. That is to say that we
place our nipple too high in the first place.
Following a mammoplasty procedure, the nipple stays
where the surgeon puts it but the rest of the breast tissue
FIGURE 5-17. (CONTINUED) E, The Gortex suture is passed. The position of the suture is in the der-
mis. The bites go from deep to superficial and then deep in the dermis. F, A complete circumference of
the peri-areola cut-out is encircled by the Gortex. G, The suture is used to bring the peripheral skin into
a dimension slightly smaller than the opposite areola and the suture is tied. H, The patient is shown 8
months following surgery with a stable correction and excellent areola symmetry.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
209
settles away from it. That is to say that the distance
between the lower aspect of the areola and the IM fold
increases following surgery, resulting in a decrease in
breast projection and the appearance that the nipple is
superiorly displaced.11 For this reason it is important to
select the correct nipple position before surgery. As noted
in Chapter 2 (see Fig. 2-11A,B), this is commonly done by
transposing the IM fold level anteriorly onto the breast
using a finger behind the breast. For surgeons using this
landmark, I believe that the best method of accurately
establishing the position of the IM fold is by placing a tape
measure directly in the fold (Fig. 5-20A). This allows the
nipple to be positioned appropriately in virtually every
case, and nipple position tends to remain in a more appro-
priate aesthetic location, as seen in this patient on 4-year
follow-up (Fig. 5-20B,C).
Nevertheless, nipple malposition is the most common
problem following breast reduction and mastopexy. There
is a range of superior nipple malposition in every plastic
surgeon’s breast reduction practice (Fig. 5-21A–D), rang-
ing from mild to significant. Once again, many women
will tolerate most of the upward inclination of the nipple,
and some even find this appearance attractive.
Superior malposition of the NAC can be corrected by
moving the NAC inferiorly on a pedicle, usually with a
skin graft for closure of the previous nipple position. I
have no experience with this method because it results in
a scar above the nipple. Another strategy is to place a tis-
sue expander beneath the skin in the upper central part of
the breast and move the entire skin envelope inferiorly.
I have done this in the reconstruction of Poland
syndrome, where I have first expanded the skin envelope
and at a second stage done a latissimus dorsi muscle flap
and subflap implant. The expansion of the skin envelope
has lowered the nipple as much as 3.5 cm.
For superior nipple malposition following breast
reduction or mastopexy, I prefer the method of shortening
the distance from the nipple to the IM fold by excising the
skin excess that exists in that location. The technique is
illustrated in Figure 5-22. This works in two ways: it
directly decreases the skin excess that exists between the
lower part of the areola and the IM fold, and folding tissue
inferiorly under the breast increases the fullness in the
upper pole, providing the illusion that the nipple is better
centered behind the breast mound.
The patient pictured in Figure 5-21D is one of the first
women, on whom I performed a vertical breast reduction.
This breast reduction entailed the resection of 640 g of
tissue on the right breast and 630 g of tissue on the left
(Fig. 5-23A). It was carried out with a superior pedicle
FIGURE 5-18. Nipple loss following previous breast reduction
in patient seen for correction of this problem.
FIGURE 5-19. Hypopigmentation of the areola after breast
reduction using the resection and nipple graft technique in this
black patient. Hypopigmentation of the areola is a definite poten-
tial problem in any case of nipple ischemia and is not uncommon
with full-thickness reapplication of a nipple and areola. This
hypopigmentation can be treated with intradermal tattoo.

210
Reoperative Plastic Surgery of the Breast
FIGURE 5-20. A, The optimal way of precisely locating the
new nipple position in a breast reduction procedure is with a
tape measure placed in the IM fold. This provides the correct
position for nipple location at surgery, and the position is often
maintained as in these 4-year follow-up photographs. B, AP
view. C, Lateral view.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
211
FIGURE 5-21. A–D, Various degrees of nipple malposition following breast reduction seen in four dif-
ferent patients.

A
D
C
B
A
B
De-epithelialized tissue
turned under breast mound
to increase projection
FIGURE 5-22. A–D, My preferred technique for correcting superior nipple malposition secondary to
bottoming out following a previous breast reduction.
FIGURE 5-23. Superior nipple malposition following one of my early vertical breast reductions. A,
The nipples were placed at 21 cm from the SSN during the original procedure. B, Note the skin excess
between the lower areola and the IM fold on each side. The planned correction should include a cres-
centic excision of skin from the lower aspect of the areola (C) and a resection of skin in a horizontally
oriented ellipse from the lower pole of the breasts (D).

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
213
technique. She exhibited significant superior nipple areola
malposition. I was more bothered by this than she was.
The SSN to nipple distance was 21 cm (Fig. 5-23B);
however, there was a lengthy distance between the lower
areola area and the IM fold on both breasts (Fig. 5-23C).
My plan was to resect a large amount of skin on the lower
pole of the breast only (Fig. 5-23D) and to turn under-
neath the breast a large de-epithelialized flap of subcuta-
neous fat and breast tissue to increase the upper pole
fullness while revising the long lower pole distance as
illustrated in Figure 5-22. The patient relocated to
another city before our planned surgery, but she is a good
example of a patient with superior nipple areola malposi-
tion who could have been helped with the strategy just
outlined.
INFERIOR NIPPLE MALPOSITION
When the NACs are asymmetric with one placed too low,
it is possible to produce a superior relocation of the
lower NAC. Small discrepancies (<2 cm) in the position
of the upper portion of the areola can be addressed by
directly excising a crescent of skin directly above the are-
ola (Fig. 5-24). This allows advancement of the areola
and better symmetry. This technique should not be used
when elevation greater than 2 cm is needed because it
will produce an elliptical or elongated appearance in the
areola.
For more significant elevations of the NAC I find that
the combination of a periareolar incision and a vertical V
incision in the central part of the breast works very well
(Fig. 5-25). This technique moves the medial and lateral
edge (or pillar) of breast tissue in behind the nipple areola,
thereby creating support for holding it in place. In addi-
tion, it has the added benefit of conifying the breast and
potentially improving its shape in that way.
CHALLENGING PROBLEMS
FOLLOWING BREAST REDUCTION
Nipple Loss
Loss of the NAC is a potential complication of every
mammoplasty procedure. I mention this preoperatively
to my patients. Fortunately it is very rare. We have
already discussed the intraoperative maneuvers that can
be undertaken to address the problem of nipple ischemia
when it is recognized in the operating room.
In rare instances the problem will be noted for the first
time in the postoperative period. In these cases it is impor-
tant for the surgeon to take a very conservative approach,
maintain a positive outlook, and to “be a doctor” from the
standpoint of supporting the patient through what is a dif-
ficult situation. As previously stated, conservatism with
active wound care, including the application of topical
antibiotics and very judicious wound débridement, often
leads to a good outcome.
Such a case is illustrated by this 22-year-old patient
requesting a bilateral breast reduction (Fig. 5-26A). She
requested a minimal scar reduction and we proceeded
with a superior pedicle vertical reduction despite that she
was a smoker. The procedure went well, but in a follow-up
office visit on postoperative day 4 she was noted to have
ischemia of her right NAC (Fig. 5-26B). I did not feel that
the application of nitrates had any role in her care at this
point, and therefore we had her apply bacitracin ointment
4 times daily. She was seen frequently, and we began very
judicious débridement on postoperative day 16 when
there was evidence of demarcation (Fig. 5-26C) of her are-
olar and nipple tissues. Her appearance after débriding
the eschar is noted on postoperative day 23 (Fig. 5-26D).
She subsequently went on to a long course to healing over
4 months (Fig. 5-26E,F). Eventually an intradermal tattoo
provided a reasonably good appearance to the NAC
(Fig. 5-23G).
This case represents the worst complication involving
the NAC that I have had in a breast reduction. In retro-
spect, I probably should have selected another technique
for this smoking patient. I no longer perform vertical
mammoplasty in smokers because I believe the complica-
tions related to imperfect healing in the vertical incision
are simply too great. Other lessons to be learned and rein-
forced from this case are the need to be very conservative
with débridement in this type of a situation involving tis-
sue necrosis of the NAC; to monitor the wound conditions
for healing and any evidence of infection very carefully;
and to support the patient through what is a difficult time
for her (and the surgeon), maintaining optimism and tak-
ing every measure to provide the best possible outcome.
The circumstance of nipple areola ischemia does not
always end as favorably. Complete nipple loss following
reduction mammoplasty can be treated with a nipple
reconstruction procedure. In my opinion this can be best
accomplished using a pull-out flap (modified star flap or
double opposing periareolar flap, both derivatives of the
skate flap design) and a subsequent intradermal tattoo.
The procedure can be done as an outpatient under local
anesthesia in an office setting. I usually recommend wait-
ing at least 2 months between the completion of the nipple
reconstruction and the medical tattoo. With a well-done
tattoo the results can be quite satisfactory.
Such a situation is illustrated by this 43-year-old
patient who was self-referred after sustaining a loss of her
right nipple during an inferior pedicle breast reduction
(Fig. 5-27A). The nipple loss was accompanied by
hypopigmentation of the surrounding areolar complex tis-
sue. There was reasonably good projection of the opposite
nipple (Fig. 5-27B), and the patient requested a procedure

214
Reoperative Plastic Surgery of the Breast
to restore a more symmetric appearance with the opposite
nipple. We used a modified star flap (Fig. 5-27C), which
was elevated in the appropriate location (Fig. 5-27C),
overbuilding it slightly in anticipation of some loss of pro-
jection with healing (Fig. 5-27D).12 The patient healed
without difficulty and underwent intradermal tattooing of
the areolar tissue 3 months postoperatively. This restored
satisfactory symmetry between her nipple areola regions
(Fig. 5-27E).
Nipple areolar asymmetries produced by hypopig-
mentation of the areola (see Fig. 5-19) are not uncom-
mon, especially when the technique of breast
parenchymal resection and nipple transplantation is
used in breast reduction. This is particularly a problem
in dark-skinned patients. The use of intradermal tattoo-
ing has allowed the plastic surgeon a straightforward
way to successfully manage such problems for patients
who experience it. Like all such tattoos, these often fade
with time and will need to be redone. When there is
dense scar tissue at the site of the areola, which is
exactly what happens in the setting of nipple areola loss,
tattooing is more difficult, and very often these tattoos
need to be repeated. As outlined in Chapter 10, the sur-
geon or medical tattoo artist should avoid the tempta-
tion to use a darker pigment than is present on the
opposite nipple. This can produce a color mismatch that
might require excision and full-thickness skin graft
placement as a means of correction.
Massive Fat Necrosis
Massive fat necrosis is a rare problem. It can result when
the blood supply to the pedicle is significantly compro-
mised. Fat necrosis involving a large segment of tissue can
present with erythema, fever, and pain. The acute inflam-
matory process must be given adequate time to settle
down. Antibiotics may be necessary only if there is accom-
panying infection.
If there is good skin coverage, a long period can elapse
before any surgical treatment is contemplated. The area
will most often organize itself into a firm mass that may
be hard and uncomfortable. If it produces discomfort or
visible distortion, surgical resection may be indicated.
Resection of the area can be undertaken. If the resection
involves a large area, a defect in the contour of the breast
may result. In this situation a rearrangement of the
remaining breast tissue in the form of flaps can minimize
such a contour abnormality.
Such a case is illustrated by this 68-year-old female
who had undergone a right lumpectomy and radiation
for breast cancer. This resulted in a significant breast
asymmetry that was treated 2 years later with a bilateral
inferior pedicle breast reduction. This latter operation
produced a large area of fat necrosis in the upper central
aspect of the breast, with accompanying contour defor-
mity (Fig. 5-28A). The area was exquisitely painful and
very hard on palpation. The patient had difficulty lying
on her right side, and there was pain in the chest region
at the extremes of shoulder motion. Breast imaging stud-
ies did not suggest cancer recurrence. We allowed 9
months to elapse before proceeding with a surgical
excise crescent of tissue and
move nipple superiorly
must not
exceed 2 cm
Elevating a nipple that is too low
}
Vertical Incision Pattern
De-epithelialize
skin here
resect skin
above and with
parenchymal below
FIGURE 5-24. The correction of mild inferior nipple malposi-
tion by the excision of a crescent of skin from the area above the
areola.
FIGURE 5-25. Correction of a more significant inferior nipple
malposition often requires a vertical incision to achieve stable
relocation of the NAC.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
215
FIGURE 5-26. A, Preoperative AP view of patient who will undergo a vertical breast reduction using
the superior pedicle technique. There were no abnormalities noted at surgery. B, Appearance on post-
operative day 4 in the office with obvious ischemia of the right nipple and areola. Treatment was begun
with the application of bacitracin ointment around the clock to keep the areola moist. C, An eschar is
noted at 16 days postoperative. D, It is débrided at 23 days following surgery. (continued)

216
Reoperative Plastic Surgery of the Breast
FIGURE 5-26. (CONTINUED) Appearance of the nipple areola
at 10 weeks (E) and at 4 months (F) without any additional
surgery. G, An intradermal tattoo solves what was a difficult
problem.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
217
resection of the mass, which had not shown any ten-
dency toward softening. For that reason we undertook a
surgical exploration for resection of the mass after veri-
fying that an inferior pedicle was used for the breast
reduction (Fig. 5-28B).
The mass was subtotally excised but all of the hard, cal-
cified tissue (Fig. 5-28C) was resected. This specimen
measured 9 × 6 × 8 cm (Fig. 5-28D) and the adjacent breast
tissue was mobilized medially. The patient healed with a
small anticipated asymmetry, but her pain completely
resolved (Fig. 5-28E).
The other and more dreaded scenario involving fat
necrosis is that which is accompanied by skin loss and
an open wound exposing the hypovascular breast and
fat tissue. This situation requires serial, conservative,
judicious débridement. The exposed tissue that is obvi-
ously necrotic must be débrided. Wound care with
moist dressings and antibiotic ointments facilitates
wound contraction and epithelialization. Secondary
surgery is timed such that the wound conditions are
optimal.
This situation was posed by this 55-year-old patient who
presented with bilateral nipple areola loss and significant
fat necrosis in the central area of her breasts, allegedly
after undergoing a breast reconstruction by a nonplastic
surgeon (Fig. 5-29A). She was seen frequently in the office
for judicious débridement and maintained on a wet to dry
dressing regimen. This plan enabled her to obtain a healed
wound, and we subsequently sought to resect the necrotic
tissue in her central breast and reconstruct her breast form
along with the NAC after the wounds had matured.
Unfortunately she was lost to follow-up before the planned
second procedure.
Such a case could be treated after 6 months of complete
uninterrupted wound healing by the central transposition
of the remaining medial and lateral breast segments, which
are elevated as full-thickness composites after the resection
of the central necrotic fat tissue in the form of an inverted
V. It is important to maximize the circulation to the
remaining breast tissue segments. My plan was to simulta-
neously perform a nipple reconstruction with a superiorly
based wrap around a skin flap (see Fig. 8-10D).
FIGURE 5-27. Loss of the nipple and hypopigmentation of the NAC of the right breast following a pre-
vious breast reduction. A, AP view. B, Oblique view C, The reconstruction is done with a modified star
flap. D, The nipple is overbuilt in anticipation of some loss of projection with normal healing, which
will include some element of contraction of the nipple. E, An intradermal tattoo completes the recon-
struction of the areola and restores relatively normal breast and nipple symmetry. (continued)

218
Reoperative Plastic Surgery of the Breast
FIGURE 5-27. (CONTINUED)

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
219
FIGURE 5-28. A, Patient presents 8 months after a breast
reduction done on a right breast that had undergone a previous
lumpectomy with a painful, hard mass in the upper aspect of the
breast above the areola. B, The mass is outlined. The imaging
studies were all consistent with fat necrosis. C, Exploration of
the breast is undertaken through the incisions outlined. D,
Subtotal resection of this area of fat necrosis produces this spec-
imen. E, AP view 6 months postoperatively.

220
Reoperative Plastic Surgery of the Breast
Fat necrosis of this degree following breast reduction
is decidedly rare in my experience. It may be more com-
mon in patients with an underlying vasculitis such as
lupus erythematosus or scleroderma. Surgery in the face
of previous whole breast radiation also probably puts the
patient at increased risk for its occurrence. As indicated,
I prefer to perform subtotal resections of such areas to
minimize the deformity. If the volume loss due to the
excision of such a focus is too substantial, a breast recon-
struction can be performed either by placing a subpec-
toral breast implant or developing a musculocutaneous
flap in the form of a latissimus dorsi flap or a rectus
abdominis flap.
Subsequent Volume Loss with Loss of
Breast Fullness
A dreaded complication of breast reduction is overresec-
tion of tissue, which leaves the patient with significantly
smaller breasts than anticipated. This can largely be
avoided with careful preoperative communication
between the surgeon and the patient and a precise surgi-
cal resection.
I encountered a form of this problem in a patient on
whom I performed a breast reduction at age 20. She was
an athletic young woman who ran on the college track
team and whose full D cup breasts often impeded her
performance. We performed an inferior pedicle reduc-
tion, reducing her to the full B cup size that she had
requested. Over the next 6 years she lost 20 lb and her
breast volume further decreased and descended inferi-
orly (Fig. 5-30A). This produced a significant lack of
superior pole fullness, which was bothersome to her
(Fig. 5-30B). We decided to pursue a breast augmenta-
tion to restore upper pole breast fullness (Fig. 5-30C).
This was done with the retropectoral placement of high-
profile smooth-walled silicone gel implants (11.7 cm, 375
cc) using her existing IM incision. This patient had
undergone the placement of a permanent defibrillating
device in the subcutaneous tissue layer of her upper left
chest region approximately 8 months earlier. In addition
to placing the silicone gel breast implants, we treated the
slight settling away of her breast tissue from the implant
with a mastopexy, also done using her previous breast
incisional pattern (Fig. 5-30D). This produced a satisfac-
tory result (Fig. 5-30E-G).
FIGURE 5-29. A, Massive bilateral fat necrosis and nipple loss in patient presenting to me for analysis
and proposed treatment options. B, Six months of judicious office débridement and wound care by the
patient have produced healed wounds. She is now ready for excision of the necrotic areas, breast
reshaping, and nipple areola reconstruction.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
221
The plastic surgeon performing breast reduction
should do everything possible to avoid having to place an
implant to treat volume overresection. This is almost
always possible to do with regard to the foreseeable post-
operative period. However, the passage of time, weight
loss, and the settling of a patient’s breast parenchyma can
produce the clinical situation just described. In such
cases implant placement may be a good solution.
However, the key is to avoid getting into this situation
whenever possible.
REDO REDUCTION
Another uncommon scenario in my practice is recurrent
breast hypertrophy, which prompts the patient to seek a
redo reduction. However, weight gain, which is so com-
monly seen as the patient moves into her second, third,
and fourth decades of life, can be reflected in a recrudes-
cence of large breasts in a patient who has had a previous
reduction.
Such patients may be candidates for a breast reduction
done by liposuction alone if the recurrent enlargement is
due to adipose tissue content and there is not significant
accompanying breast ptosis. This technique is being per-
formed more widely, and it can be quite effective for
reducing breast volume without redo flap elevation and
parenchymal dissection. However, many patients who
have noted a weight gain also report and show a change in
shape that requires a re-elevation of the skin flaps and a
formal redo reduction.
Alternatively, a patient may seek not only another vol-
ume reduction but an enhancement of breast shape. In
this situation a formal redo breast reduction can pro-
vide not only a smaller breast but an enhancement in
projection,
An example is seen in this next patient who had
undergone an inferior pedicle breast reduction in her
late teenage years with a good outcome. I saw her 10
years later with recurrence of her breast enlargement
(Fig. 5-31A) as an accompanying feature of a 50-lb
weight gain. The plan was to perform a redo breast
reduction, again using an inferior pedicle (Fig. 5-31B,C),
and abdominal liposuction. We used the tailor-tacking
method of guiding skin excision (Fig. 5-31D). She
achieved smaller, more symmetric appearing breasts
(Fig. 5-31E,F) with this redo breast reduction and was
pleased with the outcome.
Redo breast reduction is a rare plastic surgery proce-
dure. If it is undertaken, I believe it is important to use
the same pedicle orientation that was used in the
primary operation. In addition, it is also most common
to use the same skin incisions. If the skin envelope is rel-
atively normal with an expectation of skin contraction,
the liposuction alone with or without minimal skin
tightening can be used to achieve a redo breast reduc-
tion.
REDO MASTOPEXY
Mastopexy is a procedure that reshapes and uplifts the
breast parenchyma and repositions the NAC, placing it in
a more aesthetically desirable location while tightening
the skin envelope and sometimes the parenchyma itself.
It is a procedure with a finite lifespan. The duration of the
benefit derived from the operation depends on a number
of factors, including the degree of existing ptosis, the
elasticity of the skin and breast parenchyma, and the
patient’s heredity and overall health.
The challenge that all plastic surgeons face when per-
forming a mastopexy is to reposition the existing breast
tissue in a more favorable (almost always superior) posi-
tion and keep it there using parenchymal suspension or,
more commonly, skin support. Often it is difficult or
impossible to move the breast tissue substantially cepha-
lad; however, the vertical mastopexy technique is a power-
ful breast shaping tool in this regard. This is illustrated by
this 48-year-old patient with grade III ptosis who desires a
breast uplift (Fig. 5-32A,B). The vertical technique using a
superior pedicle produces a dramatic change in the breast
shape on the operating table (Fig. 5-32C). The patient is
shown 2 years postoperatively with maintenance of an
excellent appearance of her breasts (Fig. 5-32D,E). The
vertical technique is a parenchymal reshaping procedure
where the medial and lateral breast tissue segments or pil-
lars are closed in behind the central segment that moves
up, thereby providing an intrinsic means of support to
keep this central segment in its new position.
With time an inevitable degree of tissue relaxation and
settling occurs. This settling is aided by the factors noted
earlier and also by the constant force of gravity acting on all
of our body parts, including the breasts. Therefore, the real-
ity of the situation is that the most common complication
or unwanted side effect of every mastopexy is that of recur-
rent ptosis. All patients must be informed about this before
surgery. They must understand that while the scars that are
necessary for the completion of the mastopexy procedure
are permanent, the result will in all likelihood not be.
The most common reasons for reoperation following
previous mastopexy are dissatisfaction with breast shape
due to recurrent ptosis, suboptimal scarring, inadequate
breast fullness, and nipple malposition. In those cases
where a patient has undergone a previous augmentation
mastopexy, there may be problems related to the implant
such as capsular contracture, implant malposition, or set-
tling of the breast tissue away from the implant. My per-
sonal reoperation experience includes patients who have
undergone previous mastopexy alone, and patients who
have undergone previous augmentation mastopexy. I have
(continued on p. 227)

222
Reoperative Plastic Surgery of the Breast
FIGURE 5-30. A–B, AP and lateral views of patient who underwent breast reduction by me 8 years
earlier. With a 20-lb interval weight loss she has lost the superior pole fullness in the breasts. C–D, The
plan is for a silicone gel submuscular breast augmentation. (continued)

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
223
FIGURE 5-30. (CONTINUED) E–G, The 4-month postoperative
views demonstrate a nice restoration of breast fullness.

224
Reoperative Plastic Surgery of the Breast
FIGURE 5-31. A–B, Preoperative photographs of a patient who had undergone a breast reduction 10 years ear-
lier. There has been an interval weight gain of 50 lb. C, The plan is for redo breast reduction. D, The skin excision is
guided by a tailor-tacking maneuver. (continued)

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
225
FIGURE 5-32. A, AP view of the breasts in a patient with grade
III ptosis. There is decreased skin and parenchymal elasticity.
B, The vertical mastopexy is a powerful breast reshaping tool,
as is demonstrated by this photograph after performing the
superior pedicle vertically on the right side only. (continued)
FIGURE 5-31. (CONTINUED) E–F, The postoperative appear-
ance at 8 months shows a satisfactory appearance of the breast
reduction.

226
Reoperative Plastic Surgery of the Breast
FIGURE 5-32. (CONTINUED) C, AP view of the breasts at
2 years following surgery. D, Preoperative lateral view.
E, Postoperative lateral view at 2 years following surgery.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
227
seen many patients who have had a previous augmenta-
tion and whose tissue over time has settled away from the
implant. All of these patients may be candidates for a redo
mastopexy procedure.
As with the reoperative procedures following breast
reduction, it is important for the surgeon to know what
pedicle was used to carry the NAC. For those patients who
are seen in consultation for consideration of a secondary
procedure, the most reliable way to know this is by read-
ing the previous surgeon’s operative report. Most often the
same incisional pattern or a portion of it will be used. If
the patient has undergone a previous augmentation
mastopexy, important information for the surgeon to have
includes the type of implant used and the implant posi-
tion, as well as the most recent imaging data of the breast,
which may provide information as to the status of the
implant, i.e., whether it is intact or possibly ruptured.
Once again, it is important to realize that the presence of a
subglandular implant does reduce the blood supply to the
breast parenchyma. This must be taken into account if
part of the plan is to move the NAC a long distance on the
glandular pedicle.
Patients with advanced ptosis that occurs at an early
age are especially prone to relapse after a mastopexy pro-
cedure. Such a situation is illustrated by this case of a 36-
year-old nulliparous athletic female who presented with
dissatisfaction related to her breast shape (Fig. 5-33A,B).
There was markedly decreased elasticity of both the skin
and the parenchymal tissue as evidenced by striae on the
skin and the shape of the breasts. The plan was for a verti-
cal mastopexy using a superior pedicle (Fig. 5-33C). There
was nipple transposition of 8 cm on the right and 7 cm on
the left. No breast tissue was resected. The procedure was
complicated by skin loss involving the vertical incision
bilaterally and ischemia at the periphery of the right are-
ola (Fig. 5-33D). She developed widening of the scars and
some loss of the correction we had achieved (Fig.
5-33E–G). Fourteen months after the original operation
we reoperated to revise the previous mastopexy. This
entailed the excision of additional periareolar skin and
recreation of the pillars with resuspension of the gland
(Fig. 5-33H). The appearance at the completion of that
revision procedure is illustrated in Fig. 5-33I. The 8-
month postoperative view (Fig. 5-33J,K) reveals satisfac-
tory appearance of the breasts with an improvement in
the shape, symmetry, and scar condition of both breasts.
This case illustrates the rather rapid relapse of some
of this patient’s ptosis. The early reoperation was precipi-
tated by the suboptimal scar appearance and the subopti-
mal breast form.
This next patient highlights some of the same issues.
She too is a 36-year-old nulliparous female who pre-
sented to my office for a breast augmentation. Her
breasts had a settled appearance and her tissue exhibited
a generalized looseness. I felt that given her anatomy and
soft tissue laxity a breast augmentation alone would have
produced fuller but matronly appearing breasts, a look
that she was definitely not interested in. After two con-
sultations we settled on the procedure of augmentation
mastopexy.
The plan was to perform a vertical augmentation
mastopexy (Fig. 5-34C) with the partial subpectoral place-
ment of smooth-walled saline implants (11.9 cm, 320 cc)
with a nipple transposition distance of 3.5 cm, using the
tailor-tacking method for skin adjustment (Fig. 5-34D). At
a 4-month follow-up office visit she showed excellent
upper pole breast fullness and a good appearance of the
breasts on lateral view (Fig. 5-34E,F). At 16 months post-
operatively there was settling of her implants with loss of
upper pole fullness (Fig. 5-34G,H). The patient requested
another operation to try to regain the upper breast full-
ness. The plan was to repeat the vertical mastopexy, tight-
ening the parenchyma and excising additional skin, and to
exchange the saline implants (Fig. 5-34I) for larger ones
(12.3 cm, 390 cc). At a 7-month postoperative follow-up
visit the patient has regained her upper pole breast full-
ness and the contour of the breasts is improved in every
respect (Fig. 5-34J–L).
The final patient was presented with dissatisfaction
related to her breast appearance. She had undergone a
bilateral subglandular breast augmentation with smooth-
walled silicone gel implants 18 years earlier. Approximately
10 years after that she had a second procedure to address
bilateral capsular contracture with the placement of
polyurethane implants. She noted that the implants
seemed high and that her breast tissue had begun to settle
away from her implants. For this reason 4 years before
these photographs (Fig. 5-35) were taken she had an
inverted T mastopexy with a superior pedicle. She pre-
sented with excess superior fullness (Fig. 5-35A) and a pic-
ture of her breast tissue settling away from her implants
(Fig. 5-35B). She wanted softer breasts with better nipple
position. The plan was for an explantation of her
polyurethane implants through the vertical limb of her pre-
vious incisions, through which we accessed (Fig. 5-35C)
and removed the polyurethane implant by performing a
total periprosthetic capsulectomy (Fig. 5-35D). We sutured
the subglandular space closed (Fig. 5-35E) and inserted
shaped textured saline implants [McGhan style 363, base
width 12.2 cm, height 10.2 cm, 315 cc (McGhan Medical
Corp., Santa Barbara, Calif)] into the subpectoral space.
These implants were selected to give a maximum of lower
pole projection with a minimum of superior pole fullness
as desired by the patient. On the operating table she shows
an improved breast appearance (Fig. 5-35F). On her 3-year
postoperative follow-up examination she has maintained
an excellent result on both the AP (Fig. 5-35G) and lateral
views (Fig. 5-35H).
These three patients illustrate the type of breast tissues
that are especially prone to reoperation following

228
Reoperative Plastic Surgery of the Breast
FIGURE 5-33. A–B, Marked ptosis in this 36-year-old fit and athletic nulliparous female. C, The initial
mastopexy will be done with the superior pedicle vertical technique. D, Postoperatively there is
ischemia of the skin of the lateral pillar flap and the periphery of the areola on the right. (continued)

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
229
FIGURE 5-33. (CONTINUED) The appearance at 10 months following surgery shows some loss of
correction (E–F) and suboptimal scarring (G). H, The plan for redo mastopexy includes resection of
skin and remaking the pillars. (continued)

230
Reoperative Plastic Surgery of the Breast
mastopexy. The guiding principles for reoperative surgery
are to establish the appropriate aesthetic or correct nipple
position; communicate with the patient about her breast
volume and decide whether an implant is needed to achieve
the desired superior breast fullness; and use the previous
incisions, or a portion of them, to perform the procedure.
I firmly believe that mastopexy is a challenging but fun
operation. My impression is that when well done it car-
ries with it a high degree of patient satisfaction.
Augmentation mastopexy is an operation whose degree
of difficulty and potential hazards is greater than the sum
of its parts. However, I strongly feel that it can be learned
and that it is possible to do well on a consistent basis. The
key to success is communicating with your patient to
make sure she is informed of the risks, complications,
and realities of the procedure. Perhaps the most common
reality of mastopexy and augmentation mastopexy is that
of reoperation.
FIGURE 5-33. (CONTINUED) I, The appearance of the breasts
on the operating table at the end of the second procedure. J–K, An
improvement in the overall breast appearance is seen 8 months
following the second surgery.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
231
FIGURE 5-34. This is a 36-year-old nulliparous patient with grade II ptosis requesting breast rejuve-
nation. A, AP view. B, Lateral view. Note the extreme laxity of the tissues. C, The plan is for a vertical
pattern augmentation/mastopexy. D, The tailor-tack method guides the skin excision on the table.
(continued)

FIGURE 5-34. (CONTINUED) E–F, She shows a nice appearance of the breasts at 4 months following
surgery. G–H, One year later (16 months postoperatively) she demonstrates loss of upper pole breast
fullness.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
233
FIGURE 5-34. (CONTINUED) I, The redo augmentation/mastopexy requires redoing the vertical
mastopexy and placing a larger implant. J–L, This results in a much improved breast appearance at 7
months following the second operation.

234
Reoperative Plastic Surgery of the Breast
FIGURE 5-35. A–B, AP and lateral views of a patient who has undergone two previous breast sub-
glandular silicone gel implant breast augmentations. The first was performed 18 years ago and the
second one 10 years later. Note that the breast tissue has settled away from the implants. C–D,
A total periprosthetic capsulectomy completely removes the implant. (continued)

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
235
FIGURE 5-35. (CONTINUED) E, The subglandular space is closed with sutures. F, There is no nipple
transposition and new shaped textured saline implants are placed and the lower pole tissue is tightened.
Note improved contour lower pole of breast parenchyma and skin when compared with preoperative
stage (A, B). G–H, At a 3-year follow-up the patient shows excellent maintenance of her breast
correction and good relationship between the breast implants and the soft tissue envelope of the
breasts.

236
Reoperative Plastic Surgery of the Breast
REFERENCES
1. Hoffman S. Recurrent deformities following reduction mam-
moplasty and correction of breast asymmetry. Plast Reconstr
Surg. 1986;77:55–60.
2. Ryan RF, Pernoll ML. Virginal hypertrophy. Plast Reconstr
Surg. 1985;75:737–742.
Bostwick J III. Plastic and Reconstructive Surgery of the
Breast. St. Louis: Quality Medical Publishers; 1990.
3. Courtiss EH, Goldwyn RM. Breast sensation before and
after plastic surgery. Plast Reconstr Surg. 1976;58(1):1–13.
4. Gonzalez F, Walton RL, Shafer B, et
al. Reduction
mammaplasty improves symptoms of macromastia. Plast
Reconstr Surg. 1993;91(7):1270–1276.
5. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness
of surgical and nonsurgical interventions in relieving the
symptoms of macromastia. Plast Reconstr Surg. 2002;109(5):
1556–1566.
6. Gorney M. Personal communication.
7. Lejour M. Vertical mammoplasty: early complications after
250 personal consecutive cases. Plast Reconstr Surg. 1999;104
(3):764–770.
8. Lassus C. Update on vertical mammaplasty. Plast Reconstr
Surg. 1999;104(7):2289–2298; discussion 2299–2304.
9. Hall-Findlay EJ. Pedicles in vertical breast reduction and
mastopexy. Clin Plast Surg. 2002;29(3):379–391.
10. Reus WF, Mathes SJ. Preservation of projection after reduc-
tion mammoplasty: long-term follow-up of the inferior pedi-
cle technique. Plast Reconstr Surg. 1988;82(4):644–652.
11. Shestak KC, Gabriel A, Landecker A, et al. Assessment of long-
term nipple projection: a comparison of three techniques.
Plast Reconstr Surg. September 1, 2002;110(3):780–786.

237
C h a p t e r 6
◗Revision of Implant Breast
Reconstruction
Preoperative Evaluation 238
Selecting the Right Device 242
Begin with the End in Mind 243
Preoperative Patient Assessment 243
Difficult Patients for Implant-Based Breast
Reconstruction 246
First-Stage Breast Reconstruction with Tissue
Expansion Using Short-Height Tissue
Expanders 248
Technique of Tissue Expander Placement—
Immediate Reconstruction 250
Surgical Technique—Delayed Breast
Reconstruction with Tissue Expander
Placement 255
Acute Complications Following Tissue Expander
and Implant Placement 256
Hematoma 256
Seroma 256
Infection 259
Skin Loss 259
Expander Malposition 264
Reinsertion of Another Tissue Expander to Revise
an Inadequate Implant Reconstruction—
Revision of the Periprosthetic Capsular Space
with Change in Device Dimension 269
Revision at the Second Stage, or Adjustments at
the Time of Implant Exchange 271
Superior Malpositions of Expander or
Implant 271
Expander or Implant Too Low 272
Raising the Inframammary Fold—Capsular Suture
Technique 272
Raising the Inframammary Fold—Focal Capsule
Excision and Direct Capsular Suture Technique
(Raw Edge to Raw Edge of Capsule) 273
Establishing Better Definition of the
Inframammary Fold 277
Superior Implant Malposition—Correction in the
Obese Patient with a Thick Lower Thoracic
Adipose Tissue Layer 280
Lateral Implant Malposition 280
Medial Implant Malposition 282
Increasing Projection of an Implant Breast
Reconstruction 284
Folds 287
Folds Following Implant Reconstruction—
Periprosthetic Capsular Space–Implant
Disproportion 289
Implant Deflation 291
Implant Rupture Following Breast Reconstruction
with a Silicone Gel Implant 291
Combination Breast Deformity—Implant
Malposition, Advanced Capsular Contracture,
Implant Immobility, and Qualitative Tissue
Deficiency—Treatment by Autogenous
Conversion 291

238
Reoperative Plastic Surgery of the Breast
Breast reconstruction with implants remains very popular.
It represents the majority of breast reconstructions per-
formed in the United States.1 Since the introduction of tis-
sue expansion for breast reconstruction,2 the most common
method of implant-based breast reconstruction is a two-
stage process of tissue expansion followed by the insertion
of either a silicone gel or saline-filled breast implant.
The essential goals of breast reconstruction remain
creating a breast mound, maximizing symmetry between
the reconstructed mound and the contralateral breast,
and reconstructing a nipple in the appropriate position to
transform the mound into a true breast facsimile. A final
finishing touch is providing skin pigmentation to the nip-
ple and areola area to produce the best possible color
patch symmetry between the reconstructed nipple and the
nipple areola complex (NAC) of the opposite breast. This
process occurs in stages, and in fact breast reconstruction
in every patient occurs as a continuum. This must be
stressed to each patient who is seen in consultation for
breast reconstruction. This is especially true for implant-
based breast reconstruction, which as stated is almost
always a two-stage process consisting of the placement of
a tissue expander followed by the placement of an
implant.
Although prosthetic breast reconstruction is a simpler
procedure for the patient, I find it much harder to obtain
consistently good results with implant-based breast recon-
structions than with autologous tissue methods. It must be
borne in mind by the surgeon that by their very nature
such procedures are much more likely to require surgical
revision, especially with the passage of time.3 This fact
must be explained to every patient preoperatively.
There are many challenging problems and situations
that may present themselves in the course of implant-
based breast reconstruction, either between the position-
ing of the tissue expander and the planned implant
exchange, or after the second stage when a saline-filled or
silicone gel–filled implant has been placed. This chapter
will discuss my approach to treating problems encoun-
tered at either stage in this process.
Most often these problems include capsular contrac-
ture around the previously positioned implant, asymme-
tries relating to improper expander or implant size
(volume or base width), implant or expander malposition,
inframammary (IM) fold asymmetries, skin rippling with
the appearance of ripples or folds, compromised local
covering soft tissue, saline implant deflation, and silicone
gel implant rupture.4 In addition, there may be breast
asymmetries that are most often derived from a combina-
tion of all of the above, or are related to the patient’s oppo-
site breast, which may not be inherently well matched by
the placement of an implant.
This chapter focuses on the most commonly encoun-
tered problems seen in patients who are in the implant-
based breast reconstruction continuum, with the exception
of implant rupture, which is covered in the chapter on
explantation (Chapter 4). These challenges are often com-
plex, but if handled appropriately the outcome can be very
satisfying for the patient and rewarding for the surgeon.
PREOPERATIVE EVALUATION
When evaluating a patient who has a problem during or
after any of the stages of implant breast reconstruction, it
is essential to obtain a careful history and to perform a
systematic and compulsive physical examination. If the
patient has been previously operated on by a different sur-
geon(s), I find it helpful to obtain the previous operative
reports so that I have precise information about implant
type, position, and volumes. Only with this information is
it possible to accurately assess the factors that may be
contributing to the specific problematic situation with a
given breast reconstruction.
There are four issues for the surgeon to consider in
evaluating each particular patient. First, it is important
for the treating surgeon to determine whether an implant-
based reconstruction is or was a reasonable or even feasi-
ble operation in the first place for a given patient. In many
patients it is the “default option.” By this I mean that this
method is chosen because there is no other good option.
The typical scenario is a patient with significant skin defi-
ciency (>6 cm in the vertical or horizontal dimension—
a situation where the addition of flap tissue is highly
preferable but declined by the patient) who is recon-
structed with an implant, or a patient with extremely thin
Capsular Contracture, a Vexing Unsolved
Problem—Thoughts and Possible Therapeutic
Approaches 294
Radiation-Induced Capsular Contracture—
Treatment with Autogenous Tissue
Supplementation Using the Latissimus Dorsi
Muscle Flap 294
Advanced Capsular Contracture Treated with
Autogenous Conversion—Implant Removal,
Capsulectomy, and TRAM Flap Breast
Reconstruction 297
Finishing Touches 298
References 301

Chapter 6
Revision of Implant Breast Reconstruction
239
FIGURE 6-1. Preoperative (A–B) and postoperative (C–D) AP and oblique views of patient treated for
cystosarcoma of the left breast with staged left breast reconstruction with tissue expansion followed by
the placement of a round moderate-profile textured silicone gel implant. Excellent symmetry is noted
because of the shape of the patient’s unoperated right breast.
local tissues who exhibits a poor result because of inade-
quate covering tissues. The surgeon must understand
what local conditions may have existed that would most
likely have predisposed a suboptimal outcome such as sig-
nificant scars at the site of breast reconstruction, previous
infection, and most importantly antecedent radiation
therapy. It is also important to know if there was a history
of failure of a previous breast reconstruction.
A second issue relates to the implant that was used. It is
important for the surgeon to decide if the appropriate
implant or tissue expander was used for the initial stage(s)
of the reconstruction, i.e., whether the device had suffi-
cient surface dimensions in the form of base width,
height, and volume to appropriately contour the local soft
tissues to best match the opposite breast.
Third, if the patient’s problem is asymmetry, the surgeon
must determine whether opposite breast modification in
the form of breast augmentation, mastopexy, augmentation
mastopexy, or reduction, all of which may sometimes be
necessary to optimize symmetry, was discussed before sur-
gery. In my experience, it is most often difficult, if not
impossible, to achieve really good symmetry by placing an
implant beneath tissues remaining after a mastectomy
without placing an implant on the opposite side as either a
breast augmentation or augmentation mastopexy. Said
another way, I believe that patients in whom it is possible to
achieve truly excellent symmetry with an implant on one
side and no surgery on the opposite breast are indeed very
rare. In these rare individuals the opposite breast almost
looks like an implant, with a round appearance (Fig. 6-1).

Finally, the surgeon must ask whether there has been
any intervening condition that has changed the appear-
ance of the previous implant reconstruction. The most
common condition in this context is radiation therapy. In
my experience, radiation administered at any stage of the
process of implant-based breast reconstruction usually
produces an accelerated form of capsular contracture,
which often results in a profound change in the visual
and tactile characteristics of the reconstructed breast
(Fig. 6-2). Such a situation is most often an indication for
the addition of flap tissue to address the firmness in the
existing tissues.5
I have found that in the setting of an implant recon-
struction, modification of the opposite breast is a common
consideration (Fig. 6-3A). This can be discussed in a sim-
ple and straightforward manner with the patient. I find
that having the patient view photographs of other patients
who have undergone the combination of implant recon-
struction on the side of mastectomy and the placement of
an implant with or without mastopexy (Fig. 6-3B) on the
opposite breast is very helpful and educational for her. It is
also important to show the patient photographs of out-
comes in other patients who have not undergone this com-
bination (Fig. 6-4). The patient can then decide whether to
have the opposite breast modified. I have a book contain-
ing photographs of each procedure I perform available in
the office for patients to review before their surgery.
The treating surgeon must explain the risks and bene-
fits of opposite breast modification. The risks include
scars on the breast, loss of nipple sensation and decreased
sensation in the skin of the breast, alteration of breast
parenchyma, and decreased sensitivity to mammography
when an implant is placed. In the latter situation the
amount of tissue that is hidden from the mammogra-
pher depends on the size of the breast, the size and posi-
tion of the implant, and the presence and degree of
capsular contracture.6 For this reason, in the setting of a
previous contralateral breast cancer, I place virtually all
implants in the submuscular position. In this location
the risk of capsular contracture is reduced and the inter-
ference with mammography is minimized. I have per-
formed opposite breast modification with increasing
frequency over the past decade, to the point where a sig-
nificant majority (>60%) of my patients have the oppo-
site breast adjusted when an implant reconstruction is
performed.
240
Reoperative Plastic Surgery of the Breast
FIGURE 6-2. Appearance of right breast following completion
of radiation therapy in patient with tissue expander in place.
Skin changes are those of subacute and chronic radiation injury.
FIGURE 6-3. Preoperative (A) and postoperative (B) AP views
of patient who underwent delayed reconstruction of the left
breast with low-height tissue expander and implant. Symmetry
in this patient (and in many cases) is optimized by contralateral
vertical mastopexy at the time of nipple reconstruction.