The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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XI Breast Surgery
abdomen. Humans are distinct in that they develop only a single
pair of glands on the thoracic portion of the milk line. This becomes
evident at around 9 weeks’ gestation, at which time the milk line
regresses except for a small span in the pectoral region, where
breast development will ultimately occur. Failure of this regression
gives rise to polymastia, characterized by accessory mammary
glands (Fig. 66.2), and polythelia, in which supernumerary nipples
are present. The axilla is the most common location of extraglan-
dular breast tissue, whereas additional nipples are usually found
on the chest wall below the breast and often in the inframammary
crease (Fig. 66.3). Amastia, or the absence of a breast, is a rare
congenital anomaly; it occurs as a result of an arrested mammary
ridge at about the sixth week of fetal development.
The mammary gland develops as an invagination of ectoderm.
Squamous epithelium essentially invaginates to form a primary
bud, which in turn stimulates the development of 15 to 20 second-
ary buds. These epithelial extensions continue to grow and extend
into the connective tissue of the chest wall. By 20 to 24 weeks’
gestation, these invaginated epithelial cords develop lumina
and will eventually form the lactiferous ducts. The surrounding
mesenchyme will become the supporting structures of the breast.
At birth, the individual branched ducts drain into more major
ducts, which then coalesce into shallow epithelial pits. These
pits become elevated and transformed into the nipple. Failure
to do so results in a congenitally inverted nipple; this occurs in
2 to 4% of individuals (Fig. 66.4). In some newborns, the breast
will secrete colostrum as a result of maternal hormones passing
into fetal circulation through the placenta. Overall, however, the
gland remains largely undeveloped until puberty, at which time
hormonal stimulation will cause proliferation of glandular tissue.
66.3 Surface Anatomy
There is tremendous variation in the size and configuration of
the mature female breast. The gland typically extends from
the second or third rib down to the sixth or seventh rib, where
the inframammary fold is defined. It extends medially from
the sternocostal junction across to the anterior or midaxillary
line. The superolateral part of the mammary gland extends
toward the axilla, forming the axillary tail of Spence. Along its
deep surface, the breast mound overlies the pectoralis major
superiorly, the serratus anterior muscle more laterally, and the
external oblique and upper rectus muscles most inferiorly (Fig.
66.5). Between the superficial and deep layers of the pectoral
fascia is a potential space called the retromammary bursa. This
space is identifiable during mastectomy and allows a bloodless
plane of dissection.
The breast assumes a conical form with a base usually measur-
ing 10 to 12 cm and a thickness of 5 to 7 cm. Fat lobules confer a
rounded contour to the breast; the deposition of fat and branch-
ing of the lactiferous ducts that occur at puberty lead to breast
enlargement. By contrast, the decrease in adipose and glandular
tissue that accompanies aging can give a flaccid, pendulous con-
figuration to the breasts of elderly women.
The 1AC consists of pigmented, stratified squamous epithe-
lium and is where the lactiferous ducts converge. The complex
typically measures 2 to 4 cm in diameter, and although its posi-
tion is variable, ideally it is located in the center of the breast
mound. The internal mammary artery is traditionally consid-
ered the main blood supply to the NAC. The areola contains
sebaceous glands, sweat glands, and visibly elevated accessory
glands called Montgomery’s tubercles, which provide lubrica-
tion during lactation. Beneath the skin of the areola, smooth
muscle fibers are arranged radially and circumferentially as
well as longitudinally along the lactiferous ducts up to the
nipple. These muscles respond to tactile as well as autonomic
sympathetic stimulation and are responsible for nipple erection
and areolar constriction. The entire complex, particularly the
nipple, has a rich sensory innervation that is important during
lactation and milk letdown.
The nipple typically measures between 19 and 25 cm from
the suprasternal notch and between 7 and 10 cm from the
Fig. 66.2 Patient with left-sided polymastia. (Reproduced from
Pediatric breast anomalies. In: Bentz M, Bauer B, Zuker R, eds.
Principles & Practice of Pediatric Plastic Surgery. 2nd ed. New York,
NY: Thieme Medical Publishers; 2016.)
Fig. 66.3 An accessory nipple is seen in the left inframammary fold.
(Reproduced from Pediatric breast anomalies. In: Bentz M, Bauer B,
Zuker R, eds. Principles & Practice of Pediatric Plastic Surgery. 2nd ed.
New York, NY: Thieme Medical Publishers; 2016.)

66 Applied Anatomy of the Breast
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inframammary fold (Fig. 66.6). There is a wide range in these dis-
tances attributable to many factors, including genetics, thoracic
wall contours, overall skin quality, and pregnancy history. Because
the nipple is the focus of the breast, optimizing its location and
maintaining its function are critical factors in almost all types of
breast surgery.
66.4 Glandular Anatomy
The 15 to 20 lactiferous ducts extend from deep within the
breast lobules and terminate as openings in the nipple. These
ducts define the lobes of the breast, each of which consists of
all the lobules and alveoli that drain into a single excretory duct
(Fig. 66.7). In the subareolar tissue, each lactiferous duct dilates
to form a lactiferous sinus. Milk is stored here and ultimately
ejected by the nipple. The ducts are lined with stratified squa-
mous epithelium and gradually transition to a double layer, then
a single layer of cuboidal cells toward the nipple.
Each duct drains 15 to 20 breast lobules. The lobule is the
functional unit of the breast. Each lobule drains from 10 to 100
alveoli (Fig. 66.8). The walls of the alveolar ducts consist of an
inner layer of columnar glandular cells overlying a stratum of
myoepithelial cells. Connective tissue surrounds the lobules,
but there is no distinct fascia separating the lobules. The stroma
surrounding the lobules contains lymphatic vessels that bring
lymph to the collecting ducts. Adipose tissue around the lobules
accounts for most of the mass of the breast. There is a distinct
layer between superficial breast tissue and the deep fascia of the
overlying skin; this relatively avascular plane is readily identified
during surgery and used as a plane of dissection. Most of the
glandular tissue is found in the central and upper portions of
the breast mound, particularly the upper-outer quadrant. This
probably accounts for the higher incidence of breast cancer in
this region.
66.5 Breast Fascial System
Originally described by Sir Astley Cooper, the suspensory
ligaments of Cooper are septa that extend from the skin to the
pectoralis fascia and provide some structural framework to the
breast parenchyma. These fascial ligaments separate the mam-
mary gland into lobes and lobules and are typically the conduit
for guiding arteries, veins, nerves, and lymphatics within the
glandular tissue. These ligaments have a degree of laxity and
stretch to them that allows breast mobility while maintaining
structural integrity. In cases of breast malignancy, these
ligaments can become encased by tumor and shorten, causing
dimpling of the skin known as peau d’orange. Factors like weight
fluctuation, pregnancy, and aging can also attenuate these
ligaments and lead to mammary ptosis. A gradation system
for mammary ptosis was initially described by Regnault and is
based on the nipple position in relation to the inframammary
fold (Fig. 66.9). First-degree ptosis exists when the nipple lies
at the level of the inframammary fold. Second-degree ptosis
describes the condition wherein the nipple lies below the level
of the inframammary fold but still above the most projected
portion of the breast. In third-degree ptosis, the nipple lies
both below the inframammary fold and at the lowest part of
the breast mound. Pseudoptosis is present when the NAC still
sits above the level of the inframammary fold but a portion of
breast tissue has descended below the level of the crease. More
recent articles have offered different definitions of ptosis based
on actual numerical distances of the nipple in relation to the
inframammary fold, with the intended benefit of more appro-
priately delineating which surgical procedure should be used to
correct the specific degree of ptosis.
While Cooper initially described the breast fascial system in 1840,
more recent anatomical studies have much more clearly delin-
eated the ligamentous structures and underscored their surgical
Fig. 66.4 Inverted nipple. (Reproduced from Nipple inversion. In: Pu L,
ed. Aesthetic Plastic Surgery in Asians. Principles & Techniques. 1st ed.
New York, NY: Thieme Medical Publishers; 2015.)
Fig. 66.5 The relationship of the breast to the underlying musculature.
(Reproduced from Breast Anatomy. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st ed. New York, NY: Thieme Medical Publishers;
2018.)

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XI Breast Surgery
relevance. Biesenberger described the ligamentum suspensorium
mammae, which starts at the clavicle and reaches to the upper
border of the breast and the retromammary space (Fig. 66.10). In
some, this is a rather robust and well-defined structure, yet it is
almost indistinct in others. This may well correlate to the individual
development of ptosis in some women but not in others.
Fig. 66.7 The ductal collecting system as it drains into the nipple-areolar complex.
Fig. 66.6 Typical surface measurements of the nipple on the breast and chest wall. (Reproduced from Jones GE. Bostwick’s Plastic and Reconstructive
Breast Surgery. 4th ed. New York, NY: Thieme Medical Publishers; 2019.)

66 Applied Anatomy of the Breast
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Intraoperative experience, particularly with implant inser-
tion, has demonstrated a fibrous bridge between the pectoralis
muscle and the skin of the inframammary crease. This infra-
mammary crease ligament gives rise to the inframammary fold
and acts as a sling for the breast parenchyma. Cadaver studies
have elucidated the relationship of the inframammary crease
ligament to the underlying bony framework. The ligamentous
structure was found to be continuous with the fifth rib medi-
ally and the fascia between the fifth and sixth ribs laterally.
Histologic sections show the presence of fibrous tissue abut-
ting rib perichondrium. Medially this structure seems to be a
condensation of the rectus abdominis fascia, and laterally the
fascia of the serratus anterior and external oblique muscles.
The firm and fixed nature of this structure, particularly in com-
parison to Cooper’s ligaments, has clinical relevance. During an
augmentation mammaplasty, release of the pectoralis muscle
with preservation of the ligament to the bony framework will
minimize the risk of the breast’s bottoming out. In reconstruc-
tive surgery, maintaining the integrity of this structure helps to
create a more natural breast and maximize symmetry with the
contralateral breast.
Further investigation has demonstrated a horizontal septum at
the level of the fifth rib that traverses the glandular tissue. This
septum thickens along the medial and lateral edges and curves
upward into vertically oriented ligaments that attach the breast to
the thoracic wall. These ligaments appear to have a superficial and
a deep component; medially they connect to the inframammary
crease ligament and laterally to the axillary fascia. Tension on
these structures acts as an internal brassiere that lifts the breast
superiorly. By corollary, decreased elastin in these ligaments or
their stretching over time probably contributes to loss of shape
and firmness.
In 2017, Awad et al used a combination of preoperative mag-
netic resonance imaging (MRI) and surgical dissection in a cohort
of women to describe a reliable vertical septum in the inferior
pole, which separates the lower half of the breast into two defi-
nite anatomical compartments: medial and lateral. This proved
to be a bilaminar structure extending from the inframammary
fold to the NAC, often containing an intercostal perforator from
the pectoralis muscle to the NAC. The authors were able to use
the lamina separately to support either a superiorly, medially, or
laterally based pedicle in reduction mammaplasty or an implant
in augmentation procedures to minimize the risk of postoperative
bottoming out. They theorized that this structure may also have
a role in delaying the spread of breast cancer from one quadrant
to another.
Fig. 66.8 Lobular anatomy of the breast. The lobule is the functional unit of the breast and drains the alveoli, terminating in the lactiferous ducts.
(Reproduced from Jones GE. Bostwick’s Plastic and Reconstructive Breast Surgery. 4th ed. New York, NY: Thieme Medical Publishers; 2019.)

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66.6 Microscopic Anatomy
In response to the hormonal stimulus of puberty, the layers
lining the ducts and alveoli increase in number and form addi-
tional buds. The mature female breast has three cell types lining
the ducts: superficial A cells, basal B cells, and myoepithelial
cells. The A cells contribute to milk production. They are rich in
cytoplasmic RNA and ribosomes within the cytoplasm. B cells,
also known as chief cells, are abundant and provide energy for
the luminal secretory cells. Myoepithelial cells contain myofil-
aments and perform a contractile function. They surround the
alveoli of the milk duct and contract in response to sex steroids
and prolactin. This provides the mechanism whereby a milk-
filled alveolus can empty into the milk ducts and ultimately up
toward the lactiferous sinuses.
66.7 Hormonal Regulation
Breast growth, development, and function occur in response to a
variety of hormones and growth factors. Intracellular receptors
and cell membrane receptors allow binding of these substances,
which in turn trigger physiologic responses in the tissues.
Estrogen is the principal hormone responsible for breast
growth and maintenance. Because it is lipid soluble, estrogen can
diffuse through the cell membrane of both normal and malignant
breast cells, where it binds with estrogen receptors. This complex
initiates messenger RNA (mRNA) transcription and subsequently
protein translation. This mechanism mediates ductal maturation,
metabolism, and new receptor development. The result is prolif-
eration of ductal epithelium, myoepithelial cells, and surrounding
stroma. The drug tamoxifen prevents the binding of hormones
to target receptors, thereby inhibiting the growth of estrogen
receptor–positive mammary tumors.
Released from the ovaries, progesterone contributes to lobular
development. It initiates the formation of the secretory com-
ponents of the mammary epithelium, located at the terminal
aspects of the ductules. Both progesterone and estrogen can
increase connective tissue and fat in the breast, thereby leading
to the rounded form of the fully developed breast. Gonadotropin-
releasing hormone from the hypothalamus stimulates the release
of luteinizing hormone (LH) and follicle-stimulating hormone
(FSH) from the anterior pituitary. LH and FSH are responsible
for ovarian synthesis and release of progesterone and estrogen,
respectively.
Prolactin acts synergistically with estrogen in ductal develop-
ment and with progesterone in lobuloalveolar development. It
is the hormone responsible for lactogenesis in the postpartum
period. Cortisol and insulin are required along with prolactin
to differentiate alveolar cells into milk-secreting cells. Prolactin
is secreted by the acidophilic cells of the anterior pituitary at
parturition.
The menstrual cycle is characterized by alternating levels of
hormones. In the premenstrual phase, rising levels of LH and FSH
contribute to a rise in estrogen. After ovulation, estrogen levels
continue to increase and progesterone rises. These elevated
hormones cause an increase in breast volume from water reten-
tion, increased basement membrane thickness, ductal dilation,
widened alveolar diameter, and increased intra-alveolar secre-
tions. After the onset of menses and withdrawal of sex steroids,
the breast volume decreases in response to edema regression,
reduction in glandular and alveolar cell size, and diminished
secretions.
With pregnancy, high levels of estrogen and progesterone are
maintained, initially by the corpus luteum and, after the 12th week
of gestation, the placenta. In the first trimester, estrogen causes
the ducts and lobules to proliferate. Glandular epithelium replaces
fatty tissue. The latter part of the first trimester is characterized
by breast enlargement, venous dilation, and increased pigmenta-
tion of the NAC. In the second trimester, the secretory epithelium
becomes active in response to progesterone. By the third trimes-
ter, colostrum fills the alveolar and ductal spaces, accompanied
by increased blood flow and enlargement of myoepithelial cells.
Fig. 66.9 The various grades of mammary ptosis as initially described
by Regnault. The ptosis is determined by the level of the nipple in
relation to the inframammary fold. (a) Pseudoptosis. (b) Grade I ptosis.
(c) Grade II ptosis. (d) Grade III ptosis. (Reproduced from Natural
history and classification. In: Janis J, ed. Essentials of Aesthetic Surgery.
1st ed. New York, NY: Thieme Medical Publishers; 2018.)

66 Applied Anatomy of the Breast
1029
Toward the end of pregnancy, prolactin circulates and initiates
synthesis of milk fat and proteins.
Following delivery, the placentally induced sex steroids cease
and the breast is influenced by prolactin. The milk released
in the first few days after parturition, called colostrum, has a
low lipid content but is rich in antibodies; 4 to 5 days after
parturition, the milk becomes laden with lipids, protein, car-
bohydrates, and immunoglobulins. The ongoing secretion of
prolactin by the anterior pituitary is necessary to sustain milk
production and secretion. A nursing infant’s tactile stimulation
of the NAC maintains this and will also initiate release of oxyto-
cin from the posterior pituitary. Oxytocin causes myoepithelial
cells to contract, which pushes milk from the lobules into the
lactiferous ducts. The presence of milk in the ductal system
provides an ideal culture medium for bacterial overgrowth.
Obstruction to flow along the ducts, usually from areolar
inflammation, leads to suppurative mastitis. With cessation
of nursing there is regression of the extralobular stroma and
atrophy of the formerly proliferative glandular and ductal ele-
ments. The breast usually returns to its prepartum state over
the next 3 months.
During menopause, the body no longer produces sex steroids as
a consequence of diminished ovarian function, and there is actual
loss of glandular tissue. Adipose tissue can replace lobular ele-
ments, although there is usually a loss in total mass of fat volume
in the breast. The result is decreased breast volume, and the breast
takes on a flatter, more pendulous shape.
66.8 Blood Supply
It is the general consensus that the main blood supply to the
breast is derived from the internal mammary artery. This artery
supplies multiple perforating branches, which pass through the
intercostal muscles along the second to fifth ribs, a few centi-
meters lateral to the parasternal border. These perforators run
approximately 1 cm deep to the chest wall skin surface. Once
these ventral branches enter the breast, they collateralize with
two other major sources of blood supply: the lateral thoracic
artery and the cutaneous branches from the posterior intercostal
arteries. These anastomoses create a segmental pattern of blood
supply to the breast. The lateral thoracic artery can originate
from either the axillary artery or the thoracoacromial artery. It
traverses along the lower border of the pectoralis minor muscle.
Along its course of the muscle, the lateral thoracic artery gives
off the external mammary artery, which will eventually come
ventrally through the muscle to supply the upper outer quad-
rant of the breast. Branches of the third through fifth posterior
intercostal arteries supply the lower outer quadrant of the breast
(Fig. 66.11). Cutaneous perforators of the skin of the breast are
concentrated along the perimeter of the pectoralis major muscle,
the midline costal margin, and the lateral chest wall, where
the pectoralis muscle interdigitates with the serratus anterior
muscle. By contrast, very few perforators arise from the anterior
surface of the pectoralis muscle, creating a relative hypovascular
skin zone in these areas.
Fig. 66.10 Demonstration of the ligamentous support of the breast.

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XI Breast Surgery
Venous drainage occurs via a superficial and deep system with
anastomoses between the two. The superficial system of veins
originates in the periareolar region and primarily drains into the
internal mammary vein and the anterior superficial jugular vein.
With regard to the deep plexus of veins, primary egress occurs
through the internal mammary vein, intercostal veins, and ver-
tebral system (Fig. 66.12). Metastatic malignant cells can course
through any of these channels and explain the typical pattern of
metastases from a breast primary to the lungs, ribs, and vertebra
via the intercostal veins.
Fig. 66.11 The vascular supply to the breast. (Reproduced from Losken A, Hamdi M, eds. Partial Breast Reconstruction: Techniques in Oncoplastic
Surgery. 2nd ed. New York, NY: Thieme Medical Publishers; 2017.)

66 Applied Anatomy of the Breast
1031
Although venous anatomy is less explored than arterial anatomy,
most vascular compromise encountered during breast reduction
surgery results from venous compromise. This underscores the
importance of maintaining venous architecture in breast surgery
to minimize complications. Developments in infrared photography
have helped to elaborate the venous architecture of the breast. A
subareolar plexus has been identified, with venous radiation from
this plexus, probably to the deep venous structures. Preservation
of this plexus with de-epithelialization techniques should theo-
retically minimize the risk of venous outflow problems in breast
surgery by maintaining a connection between superficial and
deep vessels.
While there is general consensus about the main vascular
inputs to the breast, there is considerable variation in how these
main arteries branch and ultimately supply breast tissue and the
nipple–areola complex. Van Deventer and Graewe conducted
research and compared findings to historical studies to demon-
strate the considerable variety that can exist in breast vascular
anatomy. They identified cases where the lateral thoracic artery
was completely absent or underdeveloped, which significantly
altered the normal segmental blood supply and often led to
unanticipated anastomoses to supply the NAC. They concluded
that it was impossible to predict the NAC blood supply in any
individual and therefore recommended surgical techniques that
included arterial branches from more than one source in an effort
to minimize complications.
The work of Hamdi et al further pinpointed vascular anatomy
and lent further credence to the use of breast reduction tech-
niques with a dual blood supply. Hamdi published the existence
of a horizontal fibrous septum arising from the pectoralis fascia
at the level of the fifth rib, similar to an intestinal mesentery. This
septum lies between a cranial and caudal vascular network and
courses toward the 1AC. The cranial portion carries inflow from
the thoracoacromial artery at the level of the fourth intercostal
space and a branch of the lateral thoracic artery. The caudal
network is supplied by perforating branches from the fourth and
fifth and occasionally sixth intercostal arteries. Along the breast
borders, this septum coalesces into medial and lateral ligaments,
attaching the breast to the sternum and pectoralis minor, respec-
tively. Medially, the ligament contains perforating branches from
the internal thoracic artery, across the second to fourth intercostal
spaces. Laterally, it branches off the lateral thoracic artery from
the second to the fourth intercostal spaces.
These vessels within the septum essentially bisect the breast
into cranial and caudal parts. This division may well be rooted in
embryology, with the formation of cranial and caudal ingrowths
of ectoderm separated by a mesenchyme that ultimately forms
the vascular network. Because the glandular tissue in these two
parts is identical, this configuration led Hamdi and his colleagues
to develop a breast reduction technique that consists of a two-
part glandular resection both above and below the septum. The
remaining pedicle maintains the septal attachment of the gland to
the thorax. Because this septum contains the vascular perforators,
the blood supply to the pedicle and NAC is maintained, and the risk
of fat necrosis and nipple loss is minimized. Additionally, because
this technique maintains a dual blood supply to the pedicle, with
inflow both medially and laterally via the septum, more lateral
breast resection can be performed, which is often an area of pre-
operative concern for patients.
66.9 Innervation
Sensory innervation to the skin overlying the breast is princi-
pally derived from lateral and anterior cutaneous branches of
the second through sixth intercostal nerves. A portion of skin
along the superior pole is also supplied by branches from the
supraclavicular nerve, off of the cervical plexus. The lateral
branches of the intercostals nerves exit through the intercostal
spaces to supply the breast. The third through sixth branches are
known as lateral mammary branches. The lateral branch of the
second intercostal nerve is the intercostobrachial nerve and sup-
plies the upper medial aspect of the arm and axilla. This nerve
can be inadvertently divided during axillary dissection and
endoscopic transaxillary augmentation mammaplasty, causing
anesthesia and paresthesia of the upper medial arm. Care should
be taken when passing a latissimus flap anteriorly to create the
tunnel high enough to avoid injury to the lateral breast nerves
(Fig. 66.13).
Of utmost importance to plastic surgeons is preservation
of the sensitivity of the NAC. The fourth lateral cutaneous
branch has long been held to be the most important nerve for
sensation to the nipple. Its course, however, is somewhat more
controversial, largely because of the difficulty in dissecting this
small nerve as well as its anatomical variations. Schlenz et al
Fig. 66.12 The venous drainage of the breast is a dual system based on
a superficial subdermal plexus and a deep system, which parallels the
deep arterial supply. (Reproduced from Losken A, Hamdi M, eds. Partial
Breast Reconstruction: Techniques in Oncoplastic Surgery. 2nd ed.
New York, NY: Thieme Medical Publishers; 2017.)

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XI Breast Surgery
performed a relatively large number of cadaver dissections to
confirm the importance of the fourth lateral intercostal nerve,
which supplied the nipple in 93% of specimens. They showed
that while a superficial course of the nerve exists as a variant,
the overwhelming majority of the time the lateral cutaneous
nerve takes a subglandular course within the pectoral fascia to
approach the nipple from the posterior surface. Resections at
the base of the breast are therefore more likely to jeopardize
sensation to the NAC.
Medial nipple innervation is most commonly derived from
anterior cutaneous branches of the third and fourth intercostal
nerves. Unlike their lateral counterparts, these nerves take a more
superficial approach in the subcutaneous tissue and become
more superficial as they reach the medial areola. Incisions around
the medial areolar edge are therefore more likely to injure these
nerves.
The same septum that carries the vascular network to the NAC
also guides the main nerves to the nipple. Overwhelmingly, this
consists of a deep branch of the lateral cutaneous branch off the
fourth intercostal nerve. The nerve consistently runs down the
fibrous septum along the retromammary space from lateral to
medial, passing through the gland to redirect toward the nipple.
Once again, preservation of the septum in breast surgery pro-
cedures will maximize the chances of maintaining sensation in
the NAC.
66.10
Lymphatic Drainage
The majority of lymphatic flow from the breast is into the axilla;
the remainder of flow is through the internal mammary nodes.
This anatomy is reflected in the tendency of breast cancer to
involve axillary nodes. Both the axillary nodal groups and the
internal mammary nodal group are pathways for the metastatic
spread of breast cancer to the systemic circulation.
The lymph nodes within the axilla are divided into three levels
based on the location of the nodes relative to the pectoralis minor
muscle. Level I nodes are lateral to or below the level of the lower
border of the pectoralis minor muscle. This group includes the
external mammary, axillary vein, and scapular lymph nodes.
Nodes deep to or behind the pectoralis minor muscle are level II
lymph nodes and include the central lymph node group and the
subclavicular nodes. Nodes above the upper border of the pecto-
ralis minor muscle are level III; the subclavicular and apical node
groups contribute to level III (Fig. 66.14).
Lymphatic drainage from the breast can occur by lateral, medial,
transpectoral, and retropectoral routes. The lateral route is the
most important. The majority of breast and breast skin lymph will
drain laterally through the external mammary node group. Lymph
that drains medially will drain via the parasternal lymphatics and
ultimately into the internal mammary lymph node chain. The
lymph that drains medially can originate from all quadrants of
Fig. 66.13 The abundant nerve supply to the breast. (Reproduced from Losken A, Hamdi M, eds. Partial Breast Reconstruction: Techniques in
Oncoplastic Surgery. 2nd ed. New York, NY: Thieme Medical Publishers; 2017.)

66 Applied Anatomy of the Breast
1033
the breast and is not limited to the medial aspects of the breast.
Transpectoral drainage is via Rotter’s nodes, which are located
beneath the lateral aspect of the pectoralis major muscle. Rotter’s
nodes will drain into lymphatics along the thoracoacromial artery
to the subclavicular group of level III. The final route of drainage
is retropectoral, in which the superior and internal aspects of the
breast drain into lymphatic vessels located along the lateral and
inferior portions of the pectoralis muscles and eventually termi-
nate in the subclavicular node group in the axilla.
The development of breast lymphatic mapping has assumed
greater importance as the sentinel lymph node biopsy in breast
cancer has become the standard of care. The vastness of the
lymphatic system poses a challenge, and until recently most
knowledge of breast lymphatic anatomy was derived from gross
clinical studies dating back to antiquity. More modern techniques
incorporate injection, cross-sectional analysis, and radiography
to elucidate lymphatic structures. These methods verify that
lymph-collecting vessels along the anterior torso drain preferen-
tially into the axillary lymph nodes. The previously held dogma
relating breast lymphatics to upper torso lymphatics was that the
two were connected by a subareolar plexus that ultimately drained
into the axilla. Undoubtedly this is the case for some lymph chan-
nels located within breast parenchyma. However, it appears that
there are also some lymphatics that drain breast tissue without
passing through the subareolar plexus and instead drain directly
into the axilla. Additionally, there are perforating lymph vessels
that course beside the branches of the internal mammary vessels
and drain into the ipsilateral internal mammary lymphatics. In
some studies, one sentinel node in the axilla drained almost the
entire breast. In most, more than one sentinel node is represented.
The prevalence of breast cancer and now-standard performance
of sentinel lymph node biopsy raises the question of whether
transaxillary breast augmentation interferes with breast lym-
phatic drainage patterns and ultimately the detection of cancer.
Lymphoscintigraphy has been employed to evaluate lymphatic
patterns in patients immediately before, immediately after, and
in the long term following transaxillary breast augmentation.
1o statistically significant differences in patterns or time of
uptake have been identified among the subjects at the various
time intervals. The accepted consensus is that preserved axillary
drainage patterns from the breast allow successful sentinel lymph
node biopsies in those who later require this procedure after a
transaxillary augmentation.
66.11 Relation to Muscle and the
Inframammary Fold
The bulk of the breast mound overlies the pectoralis major
muscle. This muscle originates from the sternum and costal
Fig. 66.14 The lymphatic drainage of the breast (Reproduced from Losken A, Hamdi M, eds. Partial Breast Reconstruction: Techniques in Oncoplastic
Surgery. 2nd ed. New York, NY: Thieme Medical Publishers; 2017.)

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XI Breast Surgery
cartilages of ribs 2 through 6 and inserts onto the humerus. It
is innervated by the medial and lateral pectoral nerves, which,
if damaged during the course of axillary surgery, can cause
atrophy, retraction, and loss of function of the muscle. The
pectoralis muscle is relevant in discussing the breast because of
its use for implant coverage in both reconstructive and aesthetic
procedures.
Sanchez et al focused on the anatomy of the pectoralis muscle
to assist with surgical planning and define a safe method of
subpectoral breast augmentation, particularly as it related to the
common practice of releasing a portion of the sternal origin of the
pectoralis major muscle to create medial cleavage. They dissected
and measured the medial edge of the pectoralis muscle specifically
looking at the distance of the internal mammary perforators to
the midline and the width of the sternal origin of the muscle. They
concluded that the width of the sternal origin is often narrow and
unable to be accurately assessed with the typical lateral-to-medial
dissection performed during subpectoral pocket dissection.
Based on the narrow diameter, they concluded that any pocket
medialization afforded by sternal release was minimal and may
in fact predispose to symmastia or medial implant malposition.
Their recommendation was to perform dissection either up to the
row of perforators or to the origin itself, because this adequately
created an acceptable intermammary distance without untoward
risk.
Sanchez et al furthermore performed cadaveric dissections
to study the relationship of the pectoralis major muscle to the
pectoralis minor muscle, specifically the anatomic relationship of
the muscle costal origins and the possibility of conjoined origins.
Their rationale was that both of these muscles develop from the
same embryonic mass, with a split at week 8 of development that
usually leads to the two distinct muscles. What they found was
variability in the distance of the costal origins of these muscles,
in some cases being less than 1 cm. The relevance of this finding
was that in patients with these virtually shared muscle origins,
the distinction between the two muscles could be obscured such
that unintentional dissection under the pectoralis minor could
occur during subpectoral breast implant placement. The results
could be excessive bleeding, pain, and implant malposition. As the
lateral muscle fibers could be shared and intertwined, the authors
recommended dissecting a subpectoral pocket from medial to lat-
eral to improve accuracy in implant pocket formation by staying
above the pectoralis minor.
An often seen aesthetic deformity in subpectoral implant cases
is dynamic breast deformity, seen as animation of the implant
when the muscle contracts. Saleh et al performed cadaver dis-
sections to elucidate the anatomy of the pectoralis muscle as it
relates to breast implant procedures and thereby define the ideal
parameters for biplanar muscle-splitting breast augmentation.
They found that a biplanar muscle-splitting pocket initiated at
the caudal third of the septum left the pectoral nerves intact
and thereby minimized the risk of denervation and muscle
atrophy of the inferior portion of the muscle. Their technique also
maintained muscle origin and insertion to avoid animation of the
implant secondary to dissected muscle fiber contraction.
66.12 Concluding Thoughts
Performing safe and high-caliber surgery of the breast, aesthetic
or reconstructive, requires thorough knowledge of its structures.
Surgeons performing breast procedures must be aware of not
only the technical alternatives in this space but also the anatomic
basis for them and must appreciate the variants that can guide
surgical planning strategies. Just as breast surgery will continue
to change and in some cases become increasingly complex,
breast anatomy will take on additional importance and require
continuous updating. Understanding both the established
and newer tenets of breast anatomy is important to be able to
effectively examine, diagnose, and surgically treat conditions
including breast cancer, hypomastia, macromastia, mammary
ptosis, and congenital breast deformities..
Clinical Caveats
• The continued demand for both reconstructive and aesthetic
breast procedures means plastic surgeons performing these
surgeries must be knowledgeable about breast anatomy.
• Greater understanding of the breast fascial system has impli-
cations for surgical techniques that look to correct mammary
ptosis and resuspend breast parenchyma.
• Breast septal structures often carry neurovascular bundles,
and the preservation of these during breast surgery can
minimize risk of vascular or nerve injury.
• Cadaver studies of the pectoralis muscle indicate that more
precise pocket formation during implant-based surgery can
minimize the risk of complications.
Suggested Reading
[1] Awad MAR, Sherif MM, Sadek EY, Helal HA, Hamid WRA. A new septum in the
female breast. Arch Plast Surg 2017;44(2):101–108
[2] Bayati S, Seckel BR. Inframammary crease ligament. Plast Reconstr Surg
1995;95(3):501–508
[3] Biesenberger H. Die Fixation der Brustdrüse. In Deformitäten und kosmetische
Operationen der weiblichen Brust. Vienna, Austria: Maudrich; 1931
[4] Bostwick J III, Jones GE. Anatomy and physiology. In: Jones GE, ed. Bostwick’s
Plastic and Reconstructive Breast Surgery, 3rd ed. St Louis, MO: Quality Medical
Publishing; 2010
[5] Corduff 1, Rozen :M, Taylor GI. The superficial venous drainage of the breast:
a clinical study and implications for breast reduction surgery. J Plast Reconstr
Aesthet Surg 2010;63(5):809–813
[6] Cooper AP. Of the internal parts of the breast or mammary gland. In: Cooper A,
ed. On the Anatomy of the Breast. London, UK: Longman, Orme, Green, Brown,
and Longmans; 1840:48–58
[7] Hamdi M, Hammond DC, Nahai E. Septum-based lateral or medial mammaplas-
ty. In: Hamdi M, Nahai F, Hammond DC, eds. Vertical Scar Mammaplasty. Berlin,
Germany: Springer-Verlag; 2005
[8] Hamdi M, Van Landuyt K, Tonnard P, Verpaele A, Monstrey S. Septum-based
mammaplasty: a surgical technique based on Würinger’s septum for breast
reduction. Plast Reconstr Surg 2009;123(2):443–454
[9] .irwan L. A classification and algorithm for treatment of breast ptosis. Aesthet
Surg J 2002;22(4):355–363
[10] Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola com-
plex: an anatomic study. Plast Reconstr Surg 2000;105(3):905–909
[11] Farina MA, Newby BG, Alani HM. Innervation of the nipple–areola complex. Plast
Reconstr Surg 1980;66(4):497–501

66 Applied Anatomy of the Breast
1035
[12] Regnault P. Breast ptosis: definition and treatment. Clin Plast Surg
1976;3(2):193–203
[13] Saleh DB, Callear J, Riaz M. An anatomic appraisal of biplanar muscle-splitting
breast augmentation. Aesthet Surg J 2016;36(9):1019–1025
[14] Sanchez ER, Howland N, Kaltwasser K, Moliver CL. Anatomy of the sternal origin
of the pectoralis major: implications for subpectoral augmentation. Aesthet Surg
J 2014;34(8):1179–1184
[15] Sanchez ER, Sanchez R, Moliver C. Anatomic relationship of the pectoralis major
and minor muscles: a cadaveric study. Aesthet Surg J 2014;34(2):258–263
[16] Suami H, Pan WR, Mann GB, Taylor GI. The lymphatic anatomy of the breast and
its implications for sentinel lymph node biopsy: a human cadaver study. Ann
Surg Oncol 2008;15(3):863–871
[17] Suami H, O’1eill -., Pan :R, Taylor GI. Superficial lymphatic system of the upper
torso: preliminary radiographic results in human cadavers. Plast Reconstr Surg
2008;121(4):1231–1239
[18] van Deventer PV, Graewe FR. The blood supply of the breast revisited. Plast
Reconstr Surg 2016;137(5):1388–1397
[19] Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous
suspension of the mammary gland. Plast Reconstr Surg 1998;101(6):1486–1493

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67 The Process of Breast Augmentation: Optimizing Clinical
Decisions and Outcomes in Breast Augmentation
Willam P. Adams Jr. and Foad Nahai
Abstract
The process approach to breast augmentation has been proven
to result in superior patient outcomes. This chapter reviews
the details of this process and important considerations for
implementation.
Keywords
process, breast augmentation, patient education, tissue-based
planning, surgical technique, defined postoperative plan
For at least the past 15 years breast augmentation has been
one of the top surgical procedures performed by plastic
surgeons, yet there exists a significant outcome gap with
this procedure; specifically, we know the current revision/
reoperation rate is typically around 20% within 2 to 3 years
postprocedure. This paradox has roots in the misconcep-
tion that breast augmentation is a simple procedure which
involves simply inserting the implant into a pocket. To
optimize outcomes with this procedure, it must be based on
the scientific data and the concept of the process itself. The
process of breast augmentation described some 15 years ago
breaks the procedure down into four critical steps performed
sequentially, resulting in a synergistic overall process that
optimizes patient outcomes and enhances the overall breast
augmentation experience.
67.1 The Process of Breast
Augmentation
There are four primary subprocesses used for patient care
(Fig. 67.1):
1. Structured patient education—informed consent
2. Tissue-based preoperative planning
3. Refined surgical technique/fast-track recovery
4. Defined postoperative care/regimen
The following subsections describe the highlights of each
subprocess.
67.1.1 Patient Education
In the refinement of the process concept that, all patients
participate in a structured patient education and informed
consent process using a multimodality approach. Patients are
required to complete documents prior to their educational
consult, which is performed either over the phone or in person
by a patient education specialist, for an average duration of 45
to 60 minutes. During the educational consult, all concepts,
issues, and nuances are directly addressed and discussed with
the patient. The educational consult is never the same and is
tailored to what the patient knows and has questions about.
The overriding tenet is the more patients know, the better
they do.
67.1.2 Tissue-Based Planning
Tissue-based planning involves choosing an implant that fits the
breast according to an objective breast analysis. The surgeon
consultation is performed only after successful completion of
the educational consult. The average surgeon consult lasts 30
minutes. The two primary goals of the surgeon consult are to
objectively evaluate the patient’s breast and to ensure that the
patient’s goals/objectives (previously defined in writing during
the educational consult) are reasonable based on the patient’s
breast dimensions and tissue. The tissue evaluation is based on
previously published techniques (High Five). The basics of the
High Five process enable the surgeon to preoperatively make
the five critical decisions that determine outcomes for a breast
augmentation:
1. Pocket plane
2. Implant size³based on tissue-based optimal fill volume of the
breast
3. Implant type
4. Inframammary fold position
5. Incision
Concepts of the Surgical Procedure
The author has found that all patients except true body builders
do exceptionally well with a properly performed dual-plane
pocket. Similarly, the new inframammary fold incision has been
exclusively used because it offers the most control, and predict-
ability, with far lower capsular contracture rates.
The implant size is based on a breast width and breast type
(envelope compliance and preoperative fill). The implant type is
based on discussion with the patient as well as simulation with
three-dimensional (3D) imaging. The patient’s breast photographs
are reviewed directly with the patient on a high-definition 3D
imaging monitor to review the importance of breast asymmetries
and current breast morphology in the postoperative outcome. An
Image Analysis sheet (Fig. 67.2) is completed and initialed by the
patient.
The specific type of implant is less important than matching
the size to fit the patient’s breast. All implants when selected
properly work well. We tend to use primarily smooth, round
implants with a high level of success, and anatomic implants for
constricted-lower-pole breasts and at the patient’s request.

67 The Process of Breast Augmentation: Optimizing Clinical Decisions and Outcomes in Breast Augmentation
1037
In this key patient interaction, which is the surgeon’s main
role in the patient’s educational process, patient asymmetries are
identified as to size and shape. They are discussed and directly
addressed as they are viewed and drawn on the photographs. The
discussion covers the reality that the postoperative breasts will
not identically “match,” realistic expectations for cleavage based
on the current intermammary relationship, the rationale for a rec-
ommended pocket plane, and the likelihood of implant palpabil-
ity, particularly in the inferior and lateral parts of the breast. The
catch phrase “managing patient expectations” is commonly heard
in plastic surgery forums; however, specifics are rarely given. This
Image Analysis sheet is a tangible tool for effectively managing
patient expectations in breast augmentation. The author has
found 3D imaging technology to be a comprehensive consultation
tool that has improved the consultation and communication.
67.1.3 5eÀned SurgiFDO 7eFKniTue
Fast-Track Recovery
The surgical plan is developed preoperatively following the sur-
geon consultation. This includes implant size and type. Sizers are
not used and only two implants (and one backup) are ordered for
the case. All cases are performed under general anesthesia with
short-acting full muscle paralysis, and patients are premedicated
with celecoxib 400 mg. The new inframammary fold incision is
planned and executed using known relationships based on breast
width/implant volume and nipple-to-fold distance.3 Implant
pocket planes are created under direct vision with no blunt
dissection using techniques to minimize tissue trauma. Pocket
preparation follows the 14-point plan (Deva et al 2013), which
includes the use of proper antimicrobial breast pocket irrigation
and other techniques to minimize bacterial load in the implant
pocket, such as glove changes and prepping the skin prior to
implant placement. Using this approach sizers have not been
found to be necessary in 297 (99%) of 300 cases, and the implant
selection was determined during the preoperative consultation
prior to the operative day. Incision closure is performed in three
or four layers, including a deep absorbable suture (3–0 polydiox-
anone suture >PDS@) for closure of the superficial fascia of the
breast, a deep subdermal suture (4–0 PDS), and a subcuticular
suture for skin closure (4–0 Monocryl, Ethicon).
67.1.4 Postoperative Regimen
All patients are given detailed defined postoperative instructions
(Table 67.1). These are reinforced prior to the day of surgery and
on the day of surgery, and verification of compliance as well as
the ability of the patient to resume normal activities are deter-
mined following the patient’s return home after surgery.
Fig. 67.1 The four primary subprocesses used for patient care.

1038
XI Breast Surgery
67.2 Final Thoughts
Despite common misconceptions, breast augmentation is not a
simple procedure, and it encompasses more than simply placing
an implant in a pocket. Advances in this procedure have been
significant in the last 10 years; however, controlled clinical
trials have demonstrated that reoperation rates continue to be
significant (15–24 at 3 years). This elective procedure is more
complex than has been typically perceived, and the nonsurgical
aspects of the process (education, tissue-based planning, and
postoperative regimen) are at least as important as the surgical
part of the process.
The educational component cannot be overemphasized; it
remains the most critical yet often neglected part of the process.
There are two key components of the educational subprocess:
1. Educate the patient on the practice philosophy and have the pa-
tient assume mutual responsibility for implant selection based
on her chosen preferences and in accordance with her breast di-
mensions.
2. Via direct doctor–patient interaction, review the patient’s pho-
tographs with the patient and point out key aspects that should
be addressed preoperatively, including 100% asymmetry in all
patients and the limitations involved in correcting these asym-
metries, and the reasons for implant palpability and its likeli-
hood in the inferior and lateral poles. The Image Analysis sheet
(see Fig. 67.2) is an extremely powerful yet simple tool that is
part of the educational process and the surgeon consultation.
The tissue-based preoperative planning allows the surgeon
to get “on base” and prevents the patient from striking out on
her first try. The High Five process is one of two published and
peer-reviewed tissue-based systems in the literature. Patients
often come to the office wanting to look like ´this centerfoldµ or
“this bathing suit model” or to be this bra cup size, but the educa-
tional process and tissue-based planning can clarify that selecting
an implant type and size is about selecting an implant that fits
the breast.
Also cogent is the artist versus the engineer issue, and whether
the patient or the doctor should pick the breast implant size. No
Fig. 67.2 Patient image analysis sheet.

67 The Process of Breast Augmentation: Optimizing Clinical Decisions and Outcomes in Breast Augmentation
1039
doubt much of plastic surgery is both art and science; however,
art in itself is truly unstructured and without definable boundar-
ies. The notion that a process-oriented approach will obstruct the
“skills of the artist” is a misconception. Realistically, the process
will only serve to enhance one’s artistic qualities as it defines the
limits that the artistic-only approach cannot clearly elucidate. We
prefer to view this approach as that of a craftsperson, rather than
an artist or engineer.
Formerly, surgeons considered only the surgical technique for
a breast augmentation. Surgical advances have not only enhanced
the actual surgical procedure but clearly defined the importance
of the educational and tissue-based planning portions of the pro-
cess, which enable surgeons to make nearly every decision before
entering the operating room. This not only enables surgeons to
make better decisions than have historically been made in the
operating room (particularly in regard to implant size) but also
allows the surgical procedure to proceed as efficiently as possible.
The concept of a precise, atraumatic dissection with prospective
hemostasis (identifying/controlling vessels/perforators under
direct vision before they bleed) allows for both breast pockets
to be typically dissected in a total time of typically less than 10
minutes. Not only does this immensely reduce the amount of
tissue trauma, but it reduces the use of intraoperative narcotics
and additional paralytics and the need for reversing agents, all of
which slow postoperative recovery. Although the use of an appro-
priate antimicrobial breast pocket irrigation has been widely
accepted, surgeons often inadvertently ignore other potential
points of periprosthetic contamination, including handling
implants without clean gloves or contact of the implant with the
surgical site components. These practices are not in keeping with
this refined surgical process and should be avoided to minimize
complications, including capsular contracture and reoperation.
This follows the same practices recommended 20 years ago, and
recently codified as the 14-point plan.
Interestingly, a fringe benefit/by-product of this refined surgi-
cal process is recovery, the second-best indicator of the quality of
the procedure delivered (reoperation rate being the first). In fact,
the recovery benefit is truly a favorable by-product of the whole
process. In the original publication, 97% of patients (291 of 300)
returned to full normal activities of daily living, which includes
washing/drying hair, getting dressed, picking up children younger
than 3 years old, driving a car, and other similar activities. We have
also demonstrated this process and Fast-Trak 24-hour recovery in
eight live surgeries from 2008 to 2016.
Surgeons/patients and medical personnel are often skeptical
about the feasibility of 24-hour/fast-track recovery. The process
is often modified based on personal biases of various surgeons,
but as discussed earlier, a process functions only if it is completed
in proper order and procedures. Other adjuncts added to the pro-
cess, such as injectables, drains, pain pumps, straps, special bras,
narcotics, and limitation of arm movements, all detract from the
goal of speeding the recovery.
The issue of size exchange has also been of interest. It has been
suggested that the rate of actual size exchange is dependent on
the tendency of the surgeon to respond to patients’ request for
size change. This opinion does not take into account the theme
of this text on the true power of “the process” of breast augmen-
tation. Size exchange requests within the first 2 years postopera-
tively that result in reoperations for size/style exchange indicate
a failure of the surgeon and staff with patient education and the
tissue-based planning process. A patient who has decided to pick
her implant based on her individual optimal fill volume and what
will be safest for her tissues understands the limitations. Such
patients remain well educated postoperatively and generally do
not request size-exchange procedures. This does not mean that
these patients do not go through the normal human psychological
acclimatization of “getting used to their new breast size” and “for-
getting how they were preoperatively,” which is normal human
nature; approximately 20% of patients may make a comment to
our staff regarding size postoperatively, but they are reminded
of the reasons that the implant size was chosen and shown their
side-by-side pre- and postoperative photographs. This usually
results in the patient’s reaffirmation of the initial decision about
implant size selection.
Also cogent is that surgeons and manufacturers often like to
talk in terms of results with specific implants, but in the end it is
not about the implant but rather the process, as this is of the most
significant benefit to patients. Implant advances in the future will
enhance the process but never replace it. The process determines
the patient experience, reoperation rate, and recovery, and the
overall quality of the process delivered is directly proportional to
the overall success.
Perhaps the most significant factor is that the process is trans-
ferable. Through focused education and a defined curriculum,
surgeons can easily acquire the skill, knowledge, and expertise to
deliver the process described in this study. Independent surgeons
in different stages of their career have reported using similar
concepts to produce similar patient outcomes. This transferability
of the process has also been routinely demonstrated in our res-
idency program at UT Southwestern in Dallas, Texas. Interested
residents have been introduced individually to this process and
taken through its phases with direct supervision. It is clear with
their own developing practices that they are using these concepts
to obtain excellent patient outcomes.
67.3 Summary
Similar to the use of unique processes in successful businesses
and industry, implementing a defined process in breast augmen-
tation serves to systematize this procedure, which ultimately
helps reduce outcomes resulting in reoperation. The economic
impact of the process of breast augmentation for patients and
surgical practices, although not the focus of this study, is
Table 67.1 Postoperative instructions
Wound care
Band-Aid Gel Strip placed intraoperatively and left for 1
week and then scar therapy of choice instituted
Bra
Round implants not required, provided and may be
used per patient preference. Anatomical implants—bra
for 6 weeks—no “push-up” bra for 6 weeks
Activity
2-hour nap on arrival home, then out of bed into
shower—20-min hot, and get dressed. Do not lie in
bed. Prescribed arm raises completed 5 × every hour
while awake for the next 5 days.
Exercise
Commence aerobic activity at 2 weeks.
Non-chest weights at 4 weeks
Chest/situps at 6 weeks

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XI Breast Surgery
profound both immediately and over time as the trend positively
impacts the global breast augmentation market. In the end the
biggest winner in this process-oriented approach to breast aug-
mentation is the patient—as it should be.
Suggested Reading
[1] Adams W Jr. (2004) . Optimizing outcomes in breast augmentation. Paper pre-
sented at the ASAPS Annual Meeting S8 symposium; New Orleans; 2005
[2] Adams WP Jr. The process of breast augmentation: four sequential steps for
optimizing outcomes for patients. Plast Reconstr Surg 2008;122(6):1892–1900
doi:10.1097/PRS.0b013e31818d20ec
[3] Adams WP Jr, Conner WC, Barton FE Jr, Rohrich RJ. Optimizing breast pocket
irrigation: an in vitro study and clinical implications. Plast Reconstr Surg
2000;105(1):334–338, discussion 339–343
[4] Adams WP Jr, Conner WC, Barton FE Jr, Rohrich RJ. Optimizing breast-pocket
irrigation: the post-betadine era. Plast Reconstr Surg 2001;107(6):1596–1601
[5] Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in aesthetic and
reconstructive breast surgery using triple antibiotic breast irrigation: six-year
prospective clinical study. Plast Reconstr Surg 2006;117(1):30–36
[6] Deva A., Adams 😛 -r, Vickery .. The role of bacterial biofilms in
device-associated infection. Plast Reconstr Surg 2013;132(5):1319–1328
doi:10.1097/PRS.0b013e3182a3c105
[7] Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using
five measurements in 5 minutes: the High Five decision support process. Plast
Reconstr Surg 2005;116(7):2005–2016
[8] Tebbetts JB, Tebbetts TB. An approach that integrates patient education and
informed consent in breast augmentation. Plast Reconstr Surg 2002;110(3):971–
978, discussion 979–981

68 Choosing the Right Breast Implant
1041
68 Choosing the Right Breast Implant
David A. Sieber
Abstract
Implant selection can be one of the most difficult problems for
both patients and surgeons. This chapter outlines a brief history
of breast implants as we know it today. Breast implants continue
to evolve; we now have shaped, highly cohesive implants with
higher fill ratios. :ith so many options, it can be difficult to
narrow down which size, shape, and type of breast implant will
give patients the best results. Using simple breast measurements,
implant selection should become easy and reproducible.
Keywords
breast implant, silicone, saline, highly cohesive, implant selec-
tion, anatomically shaped, breast implant history
68.1 Introduction
Choosing the proper breast implant can be one of the most
difficult steps of the breast augmentation process for both the
patient and the surgeon. Cronin and Gerow are credited with
creating the first silicone breast implant in 1962. Two years
later Arion developed the first saline breast implant. These
early silicone implants had a Dacron patch fixed to the posterior
surface of the implant to prevent rotation and malposition, a pre-
cursor to present-day texturing. Since then the breast implant
has gone through numerous iterations leading to the current
fifth-generation silicone implants.
Second-generation implants were introduced in the 1970s
with the hope of reducing capsular contracture rates seen in the
first-generation implants. These newer implants were round with a
thinner shell and a more viscous silicone fill to provide a more nat-
ural feel. Due to the viscous nature of the gel and the thin silicone
shell, these second-generation implants were plagued by silicone
bleed, creating an oily residue around the implant, which was seen
during explantation. To reduce gel bleed, third-generation implants
were developed in the 1980s with multilayered shells, which were
thicker to reduce the incidence of shell failure. However, 1992
marked the beginning of the moratorium on silicone implants,
during which these third-generation devices were restricted for
use in the United States until 2003. Before reapproval, the U.S.
Food and Drug Administration (FDA) imposed more stringent
regulations under the guidance of the American Society for Testing
Methodology. The current fourth- and fifth-generation implants
were developed under these new regulations. There are currently
five silicone gel–filled breast implants approved by the FDA:
Allergan (Irvine, CA) Natrelle (approved November 2006), Allergan
Natrelle 410 (approved February 2013), Mentor (Santa Barbara, CA)
MemoryGel (approved November 2006), Mentor MemoryShape
(approved June 2013), and Sientra (Santa Barbara, CA) Silicone Gel
Breast Implants (approved March 2012, with approval of a premar-
ket approval application [PMA] supplement in April 2018).
68.2 Surface (Texture)
The original silicone implant developed by Cronin in 1962 was
teardrop shaped, similar to today’s anatomic devices. Texturing
was added, in the form of Dacron patches affixed to the back of
the implant, and side tabs were later added to prevent rotation
and malposition. In 1970, Ashley developed the first implant
with polyurethane surface texturing. The implant was known
as the Ashley Natural Y Implant and had an internal Y-shaped
ba̧e designed to maintain the implant shape in the upright
position. Surface texturing was ultimately added to the shells
in the form of a polyurethane foam in the hope that it would
prevent implant malposition and because it was found to
reduce the incidence of capsular contracture dramatically. It
was believed that the irregular nature of the implant surface
prevented a highly organized capsule from forming and sub-
sequently contracting around the implant. However, due to
issues with degradation of the polyurethane foam over time,
newer texturing technologies were developed to provide the
implant with a more durable surface texturing. These methods
were precursors to what is now known as implant texturing.
Each implant manufacturer has its own novel texturing, for
example, Allergan (Biocell), Mentor (Siltex), and Sientra (True
Texture). These types of texturing are achieved using slightly
different methods.
68.2.1 Biocell
Allergan’s Biocell surface is created through a salt-loss technique.
In this method the uncured silicone implant shell is coated with
salt granules that remain in place as the shell dries. Once cured,
the granules are washed from the shell with water, creating deep
vacuoles on the surface of the implant. This method creates an
irregular surface morphology containing small and large pores
shaped by the salt granules, leaving behind a more “aggressive”
texturing as seen in the scanning electron micrograph (SEM)
(Fig. 68.1).
68.2.2 Siltex
Mentor’s Siltex implants are coated with a soft, flexible,
silicone-based polymer called polydimethylsiloxane (PDMS),
which is the silicone polymer currently found in all fifth-gener-
ation implants. These coated pieces of silicone are then pressed
by a textured polyurethane foam to transfer the pattern into the
PDMS. Once cured, these patterned sheets of silicone are bonded
to the implant shell. This approach provides precise control over
the surface roughness and pattern that are transferred onto
each implant surface. The SEM shown demonstrates the surface
roughness of the Siltex texturing (Fig. 68.2). This texturing
process results in a more uniform and less aggressive surface
texturing when compared to that of Biocell.

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XI Breast Surgery
68.2.3 Sientra Texture
(Formerly TRUE Texture)
Sientra’s Sientra Texture is proprietary but is believed to use a
process similar to that for Siltex. In Sientra’s process, the man-
drel is dipped into uncured silicone and then is pressed into
polyurethane foam, heated, and cured. The heating and curation
process causes the foam to form a mesh network in the silicone
that is characteristic of this technique. The potential downside
is that these implants may still contain traces of polyurethane
at the shell surface interface. The SEM shown demonstrates the
patterns seen with this technique (Fig. 68.3). Although this is
still considered to be a less aggressive type of texturing, the loss
of polyurethane still develops deep wells within the shell.
68.2.4 Shortcomings of Texturing
The purpose of texturing is twofold: reduction of capsular con-
tracture and prevention of implant malposition. The core data for
each implant manufacturer show a reduction in the rate of capsu-
lar contracture when comparing smooth and textured implants,
but the benefit becomes less clear when the implants are placed
into a submuscular pocket. The benefit of texturing to prevent
malposition/rotation, however, is even less clear. Although ana-
tomical implants have a clinically evident rotation rate of only
5%, the Biocell and Siltex have been shown to rotate more than 30
degrees off midline in approximately 27 of implants, yet these
rotations were clinically relevant only 5% of the time. Two other
issues with anatomical implants is that the gel tends to be stiffer
than the gel in round implants. This “one breast” feel is more of
a personal preference for the patient; many patients are dissat-
isfied with how firm the implants feel. Shaped implants are also
significantly more expensive than comparable round implants.
Although there are newer, highly cohesive gels in some round
implants, they still maintain a softness that cannot be achieved
with the anatomical devices.
68.2.5 Breast Implant–Associated
Anaplastic Large-Cell Lymphoma
No discussion on implant texturing is complete without mention-
ing breast implant–associated anaplastic large-cell lymphoma
(BIA-ALCL). Anaplastic large-cell lymphoma was first described
in 1985, but it wasn’t until 1997 that the first report of BIA-ALCL
was reported by .eech and Creech. BIA-ALCL has been identified
as a lymphoproliferative disorder associated with the bacteria
Ralstonia spp. There have so far been a total estimate of 800 to
900 cases worldwide since its description in 1997. To date there
have not been any reported cases in patients with only smooth
implants. Although there is a risk of death from BIA-ALCL, that
risk is relatively low compared to other daily activates such as
driving or flying in planes. Treatment of patients diagnosed with
BIA-ALCL is aimed at implant removal and total capsulectomy.
68.3 Saline
Shortly after the introduction of silicone breast implants in 1963,
the first saline implant was developed with the intention of
Fig. 68.1 Scanning electron micrograph (SEM) of Allergan’s Biocell
texturing demonstrating deep wells as a result of the salt-loss
technique of texturing.
Fig. 68.2 Scanning electron micrograph of Mentor’s Siltex texturing
using polyurethane, showing a more uniform and shallow texturing.
Fig. 68.3 Scanning electron micrograph of Sientra’s Sientra Texture
(formerly TRUE Texture) demonstrating shallower wells with a uniform
texturing.

68 Choosing the Right Breast Implant
1043
placing the implant into the breast through a smaller incision,
which still holds true today. The benefits of saline are apparent
in that it is readily available and the fill material (saline) is totally
physiologic. In the case of rupture, the saline is absorbed and
excreted with no long-term consequences. Another benefit of
saline implants is the ability to fill the implants differentially in
the operating room to correct asymmetries. That benefit has also
been translated to silicone implants now available in a myriad of
sizes, allowing for more precise correction of breast asymmetry
with either device.
Although saline breast implants prevailed during the FDA mor-
atorium on silicone breast implants from 1992 to 2006, a recent
study of the American Board of Plastic Surgery Maintenance of
Certification (ABPS MOC) Tracer Database demonstrated that only
25% of plastic surgeons are in favor of using saline breast implants
for primary breast augmentation. Saline implants have the benefit
of costing less than their silicone counterparts, but they have a
higher incidence of rippling when compared to silicone. Women
receiving silicone implants have a higher satisfaction with their
breasts and a higher psychosocial sense of well-being when com-
pared to women with saline implants. This is likely due in part to
the fact that saline implants feel less like natural breast tissue and
more like a water-filled balloon, which they essentially are.
68.4 Silicone
Silicone implants have come a long way since their introduction
in 1963. The first generation (1963–1970) of implants had thick
shells filled with a dense, viscous silicone. Due to surgeon feed-
back desiring a softer feel, the second-generation (1970–1982)
implant was developed with less cross-linked gel contained in
a thinner, more permeable shell. Due to high rupture rates from
the thinner shells, the third-generation (1982–1992) implants
came to market with a more viscous gel but a thicker shell. After
being reintroduced in the U.S. market in 2006, fourth-generation
(1993–present) implants were developed with more durable
shells and new, more highly cross-linked gels. The newest,
fifth-generation (1993–present) implants were developed with
the same silicone elastomer and low-bleed shell, but with higher
fill ratios and more highly cross-linked silicone to provide more
upper-pole fullness and better shape retention while upright.
Three main factors determine silicone implant characteristics:
form stability, gel properties, and shell thickness. Form stability
is a measure of the implant’s ability to maintain its shape when
moved from a horizontal to a vertical position. The form stability
of the gel is in large part determined by how highly cross-linked
the silicone polymers are, meaning there is a higher density of
bonds between these polymers. Form stability within a gel tends
to be a relative term, as no single implant is able to maintain 100%
of its absolute shape. That being said, the Allergan 410 implants
containing TruForm 3 (cohesive) gel are able to maintain close to
100% of their original dimensions (height, lower-pole depth, and
upper-pole depth) when moved from a horizontal to a vertical
orientation. This of course is an example of the most cohesive
implant on the market today.
68.5 Gel Properties
With the creation of anatomically shaped devices, there was a
need for a gel with better cohesiveness and form stability, both
of which are directly related to the degree of cross-linking
within the gel. Silicone is composed of varying length chains of
the monomer PDMS combined into larger polymeric molecules.
The properties of the silicone gel vary depending on the polymer
lengths and degree of cross-linking. The current fifth-generation
implants have best captured these subtle differences in gel com-
posure to create implants with varying degrees of cohesivity,
creating a more form-stable gel. There are also slight variations
in the silicone polymer lengths between manufacturers, lending
to subtle differences in the characteristics of the implants and
the feel of the gel. The highest to lowest cohesivities of gels are
depicted in Fig. 68.4. Consumers commonly refer to these newer
gels as “gummy-bear” type implants. In cases of implant rupture,
these more highly cross-linked gels are able to maintain both
their shape and their structure inside the shell.
A new area being expanded by current fifth-generation round
implants is the ratio of gel fill volume to mandrel volume, or fill
ratio. The Allergan Inspira, Mentor XRT, and Sientra 106/107 all
take advantage of these higher fill ratios resulting in optimally
filled implants. According to manufacturer data the Allergan style
10, 15, 20, and 45 implants have a fill ratio of a 84, with the
new Inspira implants having a ratio of a 96. Sientra style 105
implants are filled between 87 and 90, depending on the size of
the implant, with the newer style 106/107 implants being filled to
97–100. This translates to an implant shell that is optimally filled
and less likely to have visible rippling in both the horizontal and
vertical position. It mimics to some degree what has been done
by overfilling a saline implant to reduce the amount of rippling.
68.6 Combination
In 2014 a new combination implant was approved by the FDA. The
Ideal Implant is a “structured” saline implant composed of sili-
cone ba̧e shells to provide better upper-pole support. Although
6-year manufacturer data for the implant are comparable to
those for other saline and silicone devices, there is a paucity of
Fig. 68.4 This image lists the various manufacturers and models of
implants by level of cohesivity.

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XI Breast Surgery
information to support its use over existing implants already on
the market. The newer technology within the implant does come
at a cost; this implant is more expensive than current-generation
silicone implants.
68.7 Shell
Implant shells have come a long way from the original thick,
firm shells used in the first generation of implants. The newer
fourth- and fifth-generation implants have a low-bleed shell.
Shell thicknesses ranges from < 0.47 mm in most smooth, round
implants to 0.78 mm in textured implants. Although important,
this shell thickness probably isn’t as critical as is the gel–shell
interaction, that is, how strongly the gel is bonded to the sur-
rounding shell. When there is a strong relationship between
the gel and the shell, they behave as one independent unit. This
single-unit phenomenon is important because the implant char-
acteristics as a whole should mimic those of natural breast tissue
in the ideal scenario. When there is poor gel–shell interaction,
the individual characteristics of both the gel and the shell must
be independently accounted for.
68.8 Round
Round breast implants are used in the majority of breast cases
within the United States; the opposite is true in non-U.S. markets.
The preference for round implants in the United States was likely
a result of the moratorium of the 1990s and early 2000s. With
only saline implants available for use during this time, many
surgeons became more comfortable using round saline breast
implants. This preference for round implants then propagated
additional generations of plastic surgeons trained in using only
smooth round implants placed into a submuscular pocket.
With the introduction of form-stable gel and advances in gel
characteristics there are still only two implant shapes (round
and anatomically shaped) used today. Round implants have
identical horizontal and vertical dimensions with an apex, or
point of maximal projection, situated at the center of the implant.
All implant manufacturers offer round implants in three basic
projections: low, moderate, and high. For an equivalent volume
the implant base width narrows as the projection increases (Fig.
68.5). Implant projection is an important concept to understand
as is the relationship between projection and base width. The
differences in implant projection allow for better customization
of implant selection depending on the needs of the patient. For
instance, a thin, postpartum patient might desire an increase of
breast volume to where she was while breastfeeding. Using a
low-profile implant with an appropriate volume will result in a
base width that is too wide and thus with inadequate projection
to fill out the deflated skin envelope. A better choice of implant is
of a similar volume but with a more appropriate base width and
higher projection for optimal soft tissue fill.
Implant fill, as discussed, plays a large part in overall perfor-
mance. Since saline is a highly viscous fluid with very low cohe-
sivity, it is unable to maintain its own shape, instead taking on the
shape of the vessel it fills. This lack of cohesivity also results in the
inability of the liquid to provide much if any support, resulting in a
dramatic change in upper-pole volume when moving the implant
from horizontal to vertical. In underfilled saline implants this lack
of support for the shell results in visible wrinkling, which, over
time, may result in fold flaw deformities and subsequent rupture.
To reduce the appearance of rippling it is common practice to
overfill saline implants, which reduces the incidence of rippling
but then results in a firm, unnatural-feeling implant. For these
reasons, most surgeons and patients prefer silicone implants for
their more natural feel and decreased incidence of visible rippling.
68.9 Anatomically Shaped
These devices were designed with the intention of creating a
more natural breast shape once inside the body. The implant
shape was designed in the form of a teardrop to allow for some
but not excessive upper-pole fullness, with the majority of the
implant volume in the lower pole (Fig. 68.6). The dimensions
deviate from those of the round implant in that the shaped
devices typically have a greater height-to-width ratio. As a
result, the apex of projection tends to be at the lower third of
the implant, instead of at the center as seen in round devices.
Although the intention of creating a more natural breast shape
was sound, those benefits have not held true in multiple studies
Fig. 68.5 Examples of smooth, round silicone implants of varying projections; (a) low, (b) moderate, (c) high.
a
b
c

68 Choosing the Right Breast Implant
1045
comparing final breast shapes of round and anatomically shaped
devices. 1ewer fifth-generation anatomically shaped devices
come in a variety of different height-to-width ratios, allowing for
a much more customizable approach to implant selection.
Although the rationale for using shaped devices was to create a
more natural breast shape in any patient, indications have become
more refined with continued use. Shaped devices are now being
used preferentially in those patients who require differential
expansion of the lower pole of the breast, such as in those patients
with a constricted breast, a tight fold, or poor soft tissue coverage
who are dependent on the implant to provide the final breast
shape. Anatomically shaped implants were also initially seen as
superior to round silicone implants because of their more highly
cross-linked gel, which essentially eliminates the possibility of
palpable or visible wrinkling commonly seen in older generations
of implants. However, since the introduction of more optimally
filled round silicone implants with more highly cohesive gel, this
argument no longer holds as much ground.
68.10 Implant Selection
Proper implant selection doesn’t need to be a challenging or
complicated process for the patient or the surgeon. With knowl-
edge of the types of implants available and through some simple
breast measurements, this process is easy to understand and
results in reproducible and predictable outcomes. The days of a
one-size-fits-most approach are long gone. Implant selection is a
highly customizable process that considers not only the patient’s
desires but also each patient’s unique anatomic differences.
68.10.1 Tissue-Based Planning
The TEPID (tissue characteristics of envelope, parenchyma,
implant, and dynamics) and later High Five methods of tis-
sue-based planning described by Tebbetts and Adams are simple
to both understand and implement into practice. The philosophy
behind this approach is that each breast is biometrically different.
These differences need to be accounted for, allowing an implant
to be chosen that optimally fills the breast soft tissue envelope.
Although smaller or larger implants may be used, these implants
may result in a less than ideal breast shape or an overly augmented
appearance. These five measurements are the building blocks for
a true understanding of breast augmentation surgery.
Breast Base Width (BBW)
A caliper is used to take this measurement from the medial
border of the breast at the location of the sternal attachments
of the pectoralis muscle to just inside the lateral breast fold
(Fig. 68.7). This is one of the most important measurements,
as it provides a range of implant widths from which to start
the selection process. It is important to measure from the same
anatomic location in each point so as to maintain consistency
in this measurement. A general rule is not to have an implant
that is more than 1 cm wider than the measured base width for
the patient; this prevents exaggeration of the lateral breast into
the axilla. Using an implant narrower than the measured base
width will result in enlargement of the breast but may lack upper
pole fullness and/or greater definition of breast shape. One of the
benefits of breast augmentation surgery is that you are able to
modify, to a degree, the shape of the breast through using the
implant as a scaffold to which the skin and soft tissue adhere.
This creates better definition of the lateral breast fold and pro-
vides the desired medial fullness and shape.
Sternal Notch to Nipple
Using a plastic tape measure, this measurement is taken from the
sternal notch to the center of the nipple on each side (Fig. 68.8).
It is normal for there to be a difference between the two breasts,
and these differences should be pointed out to the patient as they
may become more evident after surgery. A normal distance in a
nonptotic breast is usually in the range of 19 to 21 cm. Longer
distances usually signify the need for a mastopexy in order to
achieve ideal breast shape. Distances longer than 21 cm do not
always mean the patient has breast ptosis, however. In taller
women, or those with a longer torso, it is not uncommon for the
breast footplate to sit lower on the chest wall with no glandular
ptosis (Fig. 68.9). Taking measurements in these women will
give longer sternal-notch-to-nipple (SN) distances, suggesting
the need for a mastopexy, which is often not actually needed. For
this reason, it is important to take note of where the glandular
breast mound sits on the chest wall.
Fig. 68.6 Examples of (a) lower-, (b) moderate-, and (c) high-profile anatomically shaped silicone implants.
a
b
c

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Nipple to Inframammary Fold
The measurement from the nipple to the inframammary fold
(NIMF) is also taken with a plastic measuring tape and should
be performed under maximal stretch of the lower-pole breast
skin (Fig. 68.10). It is important to take this measurement under
stretch because once augmented the lower pole will expand from
the weight of the implant. The measurement is usually in the
range of 7 to 9 cm. Distances shorter than 6 cm may signify the
presence of a constructed lower pole or the presence of tuberous
breast. A 1IMF distance greater than 10 cm usually signifies that
the patient may require a mastopexy either alone or in addition
to the augmentation. This NIMF distance is also important
because it determines the location of the inframammary fold
(IMF) incision. The base width and volume of implant determine
whether there will be a need to lower the IMF as a part of the
augmentation procedure (Fig. 68.11).
Lower Pole Skin Pinch Thickness
Using a caliper, the medial portion of the breast tissue and skin
thickness is measured at a location medial to the nipple–areola
complex (NAC) (Fig. 68.12). This measurement ultimately deter-
mines the amount of soft tissue coverage that is present over an
implant in the subglandular position. Ideally at least 2 cm of skin
Fig. 68.7 Base width measurement.
Fig. 68.9 This 45-year-old woman desired breast augmentation. She
has a measured sternal-notch-to-nipple distance of 22 cm yet does not
have glandular ptosis. Her breast footplate sits lower on her chest wall.
Fig. 68.8 Sternal-notch-to-nipple measurement.
Fig. 68.10 Nipple-to-inframammary-fold measurement under
maximal stretch.

68 Choosing the Right Breast Implant
1047
pinch are required to provide adequate soft tissue coverage of the
implant. Less than 2 cm means the implant should be placed in
a partial submuscular (dual-plane) pocket to minimize implant
visibility and rippling.
Skin Stretch
The skin stretch is again measured with the caliper. With the
patient in an upright position, the caliper is set to a predeter-
mined distance, usually 2–3 cm, and is held at the level of the
nipple. With the dominant hand, the skin of the areola is gently
pinched and the skin of the breast is pulled out toward the other
end of the caliper (Fig. 68.13). This measurement signifies the
degree of skin laxity and the capacity of the soft tissue. A skin
stretch measurement of greater than 4 cm indicates soft tissue
laxity, meaning a mastopexy may be needed for ideal results.
Patients with tight soft tissue envelopes (< 2 cm skin stretch)
may need a slightly smaller implant, whereas those patients
with a skin stretch greater than 3 cm will need larger implants
for optimal fill of the soft tissue envelope. .eep in mind that
these numbers are a guideline. Patients with tighter soft tissue
envelopes will be able to accommodate larger implants, but this
may result in a more unnatural and overly augmented breast
shape.
68.11 Variations in
Implant Selection
The pros and cons of round and anatomic implants have been
discussed previously. With the prevalence of BIA-ALCL, there is
a trend in the United States to move away from textured, shaped
devices in favor of smooth, round implants. There are a few sce-
narios in which patients require additional considerations when
choosing breast implants.
68.11.1 Low Breast Footplate
As previously discussed, there is a subgroup of patients who
have a long SN distance, yet do not have glandular ptosis. In
these cases the breast mound physically sits lower on the chest
wall. This type of situation is seen most commonly in those
women who are taller and have long torsos. Placing a narrow,
more projecting implant in these patients will result in good
projection of the breast tissue but may lack upper-pole fullness
or result in a harsh chest to breast transition. In these patients,
it may be a good idea to choose a tall anatomic implant or a
wider, moderately projecting round implant. It is important to
keep in mind that when using a round implant, the base width
defines both the horizontal and the vertical dimension of the
breast.
68.11.2 1DrrRZ:ide %reDVW 'iVWDnFe
Patients often ask whether they can have the distance between
their breasts increased or decreased as a result of their aug-
mentation. Although it is tempting to place the implant further
medial or lateral to accomplish this goal, it seldom results in
a cosmetically acceptable outcome. Placing implants further
medially in someone with already widely spaced NACs may
provide the patient with more cleavage but at the expense of
having nipples that appear overly lateralized on the breast
mound. A better alternative is to perform a composite breast
augmentation, where fat may be used to provide the additional
medial or lateral fullness as desired without changing the apex
of projection from beneath the NAC.
Fig. 68.11 Recommendations for the new distance from the nipple to inframammary fold based on implant volumes.
Fig. 68.12 Skin pinch measurement performed medial to the nipple–
areola complex.

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XI Breast Surgery
68.11.3 Poor Soft Tissue Coverage
Patients with poor soft tissue coverage can be a difficult subset of
patients. These patients often have little to no breast tissue either
since going through puberty or as a result of breastfeeding. They
also commonly have a shorter than normal NIMF length. A saline
implant would need to be overfilled to minimize wrinkling but
would then result in an overly defined shape and a firm feeling.
A round silicone implant with a lower volume-to-fill ratio would
give an acceptable result. However, an even better outcome is
achieved through using an optimally filled round implant with
a more cohesive gel or a shaped anatomic implant. In these
patients, the implant shape will to some degree dictate the final
breast shape. If the patient desires more of a round shape versus
a more natural shape, then the appropriate patient-specific
implant should be chosen.
68.11.4 Short Nipple to
Inframammary Fold
In patients with a short NIMF distance, anatomic implants work
well because the point of maximal projection is about a third of
the way up from the base of the implant. This additional fullness
in the lower pole helps to maintain the NIMF distance while still
providing additional support to the NAC. When using round
implants, it is important not to use an implant that is too wide.
Choosing an implant with excessive width will tend to drive the
NAC down, giving the breast a ptotic appearance.
68.12 Use of Three-Dimensional
Imaging
Although 3D imaging has been around for a number of years,
today there are more and more companies attempting to stream-
line the process. These technologies allow patients to see how
they will look after a breast augmentation with various sizes,
shapes, and projections of implants. Patients often present desir-
ing a “natural-looking” breast only to like the look of implants
larger than they would have chosen without the use of 3D imag-
ing. Although some offices still have patients place implants into
their bra to see if they like the look, this has been shown to be a
very imprecise approach to implant selection.
Three-dimensional imaging takes much of the guesswork out
of the procedure and allows the patient to participate actively
in the sizing process. The Vectra XT system (Canfield Scientific,
Parsippany, NJ) has an accuracy greater than 90% in predicting the
final 3D breast volume. The use of 3D imaging in my practice has
shortened the consultation time and decreased operative time
because I now bring only a single pair of implants into surgery
Fig. 68.13 Skin stretch measurements are performed by placing (a) gentle retraction on the nipple–areola complex and (b) measuring this distance
from the breast position at rest.
a
b

68 Choosing the Right Breast Implant
1049
for the majority of patients, even for those patients receiving
different-sized implants due to breast asymmetry.
68.13 Patient Desires
Patient desires always need to be taken into consideration when
choosing a breast implant. Asking about what cup size the patient
desires to be does provide a general guideline, but most women
either currently wear incorrectly fitting bras or do not even know
what size they are. Tissue-based planning should always be the
starting point for implant selection, followed by consideration of
the patient’s goals for the procedure. There are typically a few
types of patients who present for breast augmentation surgery.
68.13.1 Patient 1
This patient has poor soft tissue coverage with little breast tissue
and desires improvement in the size and shape of her breasts. In
this subgroup of patients an anatomic implant may be a better
choice. Patients such as these usually have a high and tight IMF,
which can benefit from the shape and projection of an anatomic
implant. The implant can be used to create the definitive shape of
the breast. That being said, if the patient does not like the idea of a
textured implant given the risk of BIA-ALCL or for other reasons,
then a round implant will still be able to create an acceptable
breast shape.
68.13.2 Patient 2
The patient has good soft tissue coverage and breast shape and
desires improvement in the size of her breasts with a natural
appearance. After taking breast measurements, these patients
will usually fall within an acceptable range of implants from
which to choose. Either a round or an anatomic implant may be
chosen, but both will result in a similar long-term appearance
with improvement in breast size and upper-pole fullness.
68.13.3 Patient 3
This patient presents with sufficient soft tissue coverage and
wants an augmented look without distortion or changing of
the breast shape. Soft tissue planning should again be used to
determine the patient-specific implant that will provide maxi-
mal fill of the soft tissue envelope and a rounder, fuller shape to
the breast.
68.13.4 Patient 4
This patient wants the largest implants possible and does not
care if there is distortion of the breast shape as a result. In this
small group of patients, tissue-based planning should again be
implemented to determine a correct base width from which
to start. From there a maximally projecting implant may be
chosen that satisfies the patient’s desires. If the patient demands
implants that exceed my recommended base widths, I refer them
elsewhere. Any patient you operate on is a reflection not only of
your surgical skill but also of your personal aesthetics.
68.14 Concluding Thoughts
Breast implant selection has evolved since its introduction in the
1960s. This evolution has transpired due to advances in breast
implant technology. The approach for implant selection needs to
be simple, easy to understand, and reproducible. An understand-
ing of the concepts of tissue-based planning is fundamental to
success in breast implant–based procedures. A patient-specific
approach allows the surgeon to select the best implant for the
patient while considering the patient’s desires for a successful
outcome.
Clinical Caveats
• We do not practice in a time where the same implant should
be used in each patient; instead implant selection should be a
highly individualized process.
• Although less expensive for the patient, saline implants
tend to feel unnatural and are associated with lower rates of
patient satisfaction.
• The High Five method for implant selection is easy to under-
stand and simple to implement and practice.
• Be careful about patients with a low breast footplate; these
patients are often able to achieve a nice result but require a
taller implant.
• In patients with poor soft tissue coverage a shaped implant in
the submuscular position should be considered.
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2012;32(8):956–963

69 Breast Augmentation
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69 Breast Augmentation
Patrick Mallucci
Abstract
Since the first breast augmentation was carried out in 1963, it has
become the most popular procedure in aesthetic surgery throughout
the world. It has been an ever-changing and evolving field. Implant
development has changed dramatically over this period of time,
with much improved manufacturing standards and, importantly,
ever better understanding of the interaction between these devices
and the body, both short and longer term. Silicone gel consistency,
shell manufacture, varied surface texturization, and vast shape
availability have been some of the focal points in development.
In tandem with device evolution, a better understanding of
specific elements of surgical planning and technique has resulted
in improved results with more predictable outcomes.
Just as both implant development and surgical technique have
continued to improve, so too has the fundamental understanding
of breast aesthetics, fundamental norms of natural breast beauty,
and, consequently, the ultimate aims in breast augmentation.
This chapter focuses largely on the latter, in the knowledge that
planning has to begin with an ultimate aesthetic goal in mind. The
understanding that volume distribution is more important than
the simple addition of volume itself, is fundamental to the process
of understanding the attractiveness of the breast. The recognition
of key aesthetic parameters ultimately serves as a template around
which planning and execution can occur to produce pleasing,
long-lasting, and predictable results.
Keywords
breast augmentation, volume distribution, aesthetic, surgical
planning, breast beauty
69.1 Introduction
Since the early 1960s, from the onset of the first breast aug-
mentation, the process of the most popular cosmetic procedure
globally has continued to develop with relentless refinement in
an attempt to produce safer devices with greater longevity, more
predictable outcomes, and increased patient safety.
Not only has the technology behind breast implants improved
and advanced over time, but our understanding of the interaction
of these devices with the soft tissues of the breast has also become
clearer, with a better knowledge of both the indications and the
limitations of such devices for any particular individual.
Breast augmentation has also undergone a cyclical change
in terms of “look.” Breast enlargement of the 1980s and 1990s
largely focused on volume-driven augmentation, with increase
in volume being the sole aim of the procedure irrespective of
the consequences of such volumetric increase. Today breast aug-
mentation has developed into a process driven by the anatomic
environment and architecture, focusing on volume distribution
and hence shape rather than simply increasing the volume per se.
The era of tissue-based planning in combination with a better
understanding of the aesthetics of the breast has led to better
outcomes, greater longevity, and fewer complications as a result.
This chapter explores and seeks to define the notion of breast
attractiveness. Understanding the aesthetic objectives at the
beginning of any planning process enables choices to be made
around implant selection and technique to achieve better out-
comes. Traditional concepts are challenged in the pursuit of a new
era in breast augmentation, focusing on beautiful form and volume
distribution rather than simplistic volumetric enlargement at the
expense of any regard for shape or anatomy.
69.2 History
The desire to enlarge the breast is not new. Prior to the advent
of breast implants, almost anything and everything had been
injected into breasts to achieve enlargement: ox cartilage, glass
beads, Ivalon sponge (First Aid Bandage Co., New London, CT),
paraffin, rubber, free silicone, and more recently Macrolane
(Nestlé Skin Health, Lausanne, Switzerland) hyaluronic acid
(HA; 2008–2012). This is by no means an exhaustive list, and
more or less anything that can be injected into the breast has
been injected at some point, invariably with disastrous conse-
quences. While most of these products are obsolete, even today,
nonabsorbable fillers persist in the market, including Aquafilling
gel (Beauty World Enterprises Ltd., British Virgin Islands)—a
polyamide derivative. It is not uncommon to have to deal with
the complications of these substances leading to challenging
and complex revisional procedures. In 1895 Czerny transferred
a lipoma to the breast as the first attempt at a ´naturalµ filler. All
of these methods are obsolete, with very high complication rates
and largely disastrous consequences.
In 1962 Cronin and Gerow developed the first concepts of
silicone implants with a silicone liquid encased by a thin silicone
shell. The first augmentation was carried out in Houston, Texas,
in 1963.
Since then breast implant design and manufacture has contin-
ued to improve and change, with successive developments often
being referred to as the implant generations.
It is generally recognized that most of the current breast
implants on the market form part of the fifth generation of devices.
These are characterized by high standards of manufacturing, reli-
able barrier layers in their shells, and form stability of the gel, as
well as wide ranging anatomic and round matrices. Each comes in
a range of textures, from smooth to nano-, micro-, and macrotex-
turization as well as polyurethane. The discussion around texture
has become increasingly pertinent given the advent of breast
implant–associated anaplastic large-cell lymphoma (BIA-ALCL)
but is beyond the scope of this chapter and will be dealt with in
detail elsewhere .
Perhaps the most recent innovation in breast implant design has
heralded the era of the sixth-generation devices—the lightweight

1052
XI Breast Surgery
implants. The first of these to gain market approval outside of the
United States is the B-Lite (Polytech, Dieburg, Germany) implant.
This device has been designed to be 30% lighter than standard
silicone gel–filled implants. It achieves this by incorporating air-
filled borosilicate spheres bound to the silicone, rendering the
implants less dense. The borosilicate–silicone bond is extremely
strong, being stronger than the silicone–silicone bond, and this
combination is extremely stable.
The idea of having a lighter-weight implant is highly appealing
in many clinical situations. The impacts of oversized implants of
excessive weight on the soft tissues of the breast are well doc-
umented and include distortion of anatomy, glandular atrophy,
skin stretch, malposition, inframammary fold (IMF) instability,
traction rippling, and edge visibility. Therefore, the development
of a lighter-weight implant appears to be a significant step for-
ward in implant design.
Breast augmentation continues to be one of the most popular
procedures carried out in cosmetic surgery worldwide, and it
remains a priority to continue to improve not only the devices but
our understanding of the consequences of using them. We need to
continually refine our techniques and to monitor our patients in
order to maximize safety in the long term.
69.3 Body Proportions and Analysis
The notion of breast beauty is controversial, and as with all ele-
ments of human appearance, subjectivity has a potent influence
on any possible objectivity. Therefore, any definition of ´beautyµ
is expressed with caution in the knowledge that variance from
any defined norms is to be expected and is part of subjective
preference for any given individual. However, it is possible to
make generalizations through observation as well as clinical
evidence and investigation.
The analysis of body proportion is not a new concept. It dates
back to the works of Plato, who compared body proportions to
the symmetry of columns in Greek temples. Vitruvius, a Roman
scholar and architect, described body proportions in some detail,
and his writings went on to form the template for Leonardo da
Vinci’s Vitruvian Man in 1530. Albrecht Dürer also paid much
attention to mathematical proportion in his writings of 1528,
numerically defining ratios of different body parts. Da Vinci’s
iconic facial analysis dividing the face into thirds transversely
and fifths longitudinally remains as important today as it did at
the time of his description. More recently, much more has been
written about facial proportion and orthognathic angles as guides
for facial and craniofacial reconstruction. In a similar fashion the
work of Gunther and colleagues describing in detail the propor-
tions of the nose have served as a map for aesthetic rhinoplasty,
mathematically identifying key relationships within the bound-
aries of the nose itself, as well as its relationship to neighboring
anatomy. Likewise, the establishment of the aesthetic subunits of
the nose by Burget and Menick has provided a basis by which nasal
reconstruction can be planned to maximize the aesthetic outcome.
With the continued popularity and acceptance of aesthetic
surgery, society continues to demand improvement of form. The
development and sophistication of body contouring procedures
have been facilitated by the understanding of ideal body shape.
Numerous publications on abdominal beauty, including umbilical
shape and positioning, have been described. Gluteal and but-
tock reshaping and enhancement have also demanded a better
understanding of aesthetic goals and proportions, with a clearer
understanding of regional anatomy in order for surgical planning
and interpretation to be carried out.
69.4 Breast Beauty—the Ideal Breast
Given the effort and analysis that have gone into understanding
beauty in the face and other body parts, it would seem natural to
attempt to apply the same standards of analysis to the breast. As
with all elements of reconstruction or amelioration of form per-
tinent to the art and practice of plastic surgery, an understanding
of basic or “ideal” anatomical norms is essential in order to be
able to interpret, plan, and execute the appropriate procedure to
re-create an aesthetically pleasing outcome. This chapter deals
in some detail with the analysis of breast attractiveness as a
basis for which to be able to plan and execute surgery to achieve
optimal outcomes.
Although much has been written on breast form throughout
the literature it has often been vague, incomplete, and not par-
ticularly helpful with regard to planning or interpretation of out-
come. The latter is important, particularly for secondary surgery.
When a poor outcome of surgery presents itself, it is important
to understand why it is a poor outcome and more importantly
what steps can be undertaken to correct or improve upon the final
result. Therefore, terms such as ÁRZ, harmony, and proportionate
are not useful as measurable or quantifiable parameters by which
standards can be set or planning can occur.
Penn looked at a group of nurses he had selected for their attrac-
tive breasts and measured the average nipple-to-sternal-notch-
distance—the so-called Penn’s triangle—where the average
nipple to sternal notch distance was found to be 21 cm, as well
as the internipple distance. Although these values still have some
relevance today, they do not consider breast shape or form. It is
perfectly possible to have a constricted or tuberous breast with
a Penn triangle of 21 cm. Likewise, a pseudoptotic breast or one
that has bottomed out can also have nipples at 21 cm and yet be
highly unattractive or disproportionate. As values per se, these
measurements therefore have little relevance when considering
the much broader picture of breast beauty.
Other studies have looked at some mathematical elements relat-
ing to breast or nipple–areola complex (NAC) dimensions in relation
to body length, as well as trying to come to conclusions about nipple
position. However, none of them address shape directly, and as such
they are of little help as guides for practice. Hsia and Thompson
carried out a small study of hand-drawn line drawings looking at
different profiles of the breast, analyzing the different response
between surgeons and laypeople. They concluded that the latter
group selected a slightly less natural look than did the surgeons.
However, the numbers were very small and consequently difficult to
draw conclusions from. However, the study highlighted the impor-
tance of considering breast profile as an analysis of breast shape.
69.4.1 Analysis of Breast Shape
Detailed analysis of breast shape through profile examination
has been carried out by the author previously. In a pivotal study,

69 Breast Augmentation
1053
100 topless models selected for the attractiveness of their breasts
in a well-known UK publication were analyzed. Until recently,
page 3 of the Sun newspaper (News International Ltd—the
10th-largest circulation in the world in any language) published
an image of a topless model on a daily basis. The models were
chosen by an editorial panel specifically because of their breasts,
with the condition that none of them had had previous surgery
to their breasts. Profile images were examined of 100 models
to determine whether a common pattern could be established
linking the profiles of the breasts in these individuals. Four key
features were identified as highly consistent in virtually all of the
images. These can be summarized as follows:
1. The upper pole–to–lower pole ratio as observed in profile is such
that the lower pole is always slightly fuller than the upper pole.
If a horizontal line is drawn at the level of the nipple—the nipple
meridian, 45% of the breast lies above this and 55% below. This is
the critical 45:55 ratio. This ratio is fundamental to the under-
standing of naturally attractive breasts.
2. As a consequence of this volume distribution, the slightly greater
volume in the lower pole has an important effect on nipple
position and angulation. The nipple is always skyward pointing
with an average angulation from the horizontal meridian of 20
degrees. It also means that the nipple sits just above the maxi-
mum projection of the breast.
3. The upper-pole slope from the chest wall ´takeoffµ to the nipple
is either a straight line or very mildly concave.
4. The lower-pole curvature from the nipple to the IMF is a tight
convex curve, with the angle of the lower pole emanating from
the chest wall being slightly obtuse.
These observations are fundamental in understanding breast
shape, which is naturally attractive. The salient feature is the
45:55 ratio—the other observations arise largely as a result of this
volume distribution. The significance of this finding is that it con-
travenes traditional thought about the importance of upper-pole
fullness. The latter has always been seen as the end goal of breast
augmentation and is the most talked-about aspect in aesthetic
breast surgery. For the first time these observations lead us to an
about turn in philosophy about how we should approach breast
augmentation and aesthetic breast surgery in general.
The importance of the lower pole appears to be much more
significant in determining aesthetic outcome than that of the
upper pole. Upper-pole shape and position come about only as a
result of lower-pole stability. Upper-pole fullness per se is of little
importance in the absence of an aesthetic lower pole; indeed it
can be highly distortional to the overall form of the breast.
The four key elements described serve as a template not only
around which planning can occur in primary cases but also as
a means of interpreting poor outcomes in secondary cases. By
looking at each key element as part of the assessment process,
decisions can be made as to how best to reverse or improve those
poor outcomes. In the author’s original publication a series of
outcomes that were deemed as poor were analyzed against the
four features described. It was demonstrated that the greater the
variation form the template, the less attractive the breast became.
Corrective surgery was aimed at returning the breast as closely as
possible to the four key elements.
It is interesting to speculate as to why such importance has
been given to the upper pole at the expense of discussion of the
lower pole. One of the conclusions the authors came to was the
very fundamental difference between the ´clothedµ look and the
naked breast. Most women who seek breast augmentation rarely
think of themselves naked. The focus is mostly around how they
might look in a bikini or a particular dress or blouse. In these
clothed situations upper pole fullness or prominence is often
seen as desirable and a necessary part of the process. However,
the creation of this form does not necessarily correspond to
attractiveness in the naked breast. Indeed, a breast that has too
much volume in its upper pole will reverse the template of the
four parameters described.
An overly filled upper pole will mean that more volume is
distributed above the nipple meridian; this in turn will lead to a
downward-pointing nipple, a convexity rather than a straight line
of the upper-pole slope, and a reversal of the 45:55 ratio to 55:45
or worse.
Therefore, the importance of volume distribution, as opposed
to the sole addition of volume irrespective of its consequences,
has become an increasingly important element in planning
and surgical practice. It is the author’s view that it is no longer
acceptable simply to add volume. Modern breast augmentation
is about enhancement not distortion, shape, and simply addition
of volume.
The principles described have equal application in all forms of
aesthetic breast surgery, not only breast augmentation. Therefore,
whether it be a breast reduction, a mastopexy, or an augmenta-
tion mastopexy, the end goal is always the same—to re-create as
closely as possible the four parameters described.
As a means of verification of these principles Mallucci and
Branford carried out the largest population study of its kind look-
ing at breast profile and volume distribution in a series of morphed
photographic images. In total, five photographic plates, each
containing four morphed images, were put forward for assessment
by the general population. In each plate the profile of the breast
was morphed into four different upper-pole/lower-pole ratios as
follows: 45:55, 50:50, 55:45, 35:65. The five different plates were
morphed in exactly the same way; however, different breast sizes
were used in the different plates to eliminate for size bias.
The plates were distributed to a total of 1,315 individuals: 655
men and 660 women.
All social backgrounds, ages, ethnic backgrounds, and sexes
were targeted and asked to grade each of the five plates as to
which one of the four morphed breast ratios they preferred. The
results are illustrated in Table 69.1.
Table 69.1 Groups that scored the 45:55 ratio most highly
82%
Women overall
N = 660
87%
Women under 40
N = 190
90%
Men
N = 655
94%
Plastic surgeons
N = 56
92%
North Americans
N = 89
95%
South Americans
N = 23
86%
Europeans
N= 982
87%
Caucasians
N = 1,016
87%
Asians
N = 209

1054
XI Breast Surgery
In brief, the most striking feature of the study was that across
all groups 84% selected the 45:55 ratio as their preferred breast
proportion. Breaking this down into more detail unveils signifi-
cant findings that override many previously held views relating to
breast attractiveness. The notion that men prefer or see something
different than women do is not upheld by this study. In fact the
men, across all ages, preferred the 45:55 ratio slightly more than
the women did (90% as opposed to 82%, respectively), and this was
statistically significant.
Also, of great interest was the effect of ethnicity on profile
selection. It is often stated that our Western ideal is aesthetically
very different from that of other cultural groups, and therefore,
what may appear attractive to a “westerner” may not appeal
to an Asian, African, or South American, for example. Perhaps
surprisingly, this notion was also not upheld by the results of
the study. The 45:55 ratio was the most predominantly selected
profile across all ethnic groups. Even in the lowest-scoring
groups, 75 chose the 45:55 ratio as their preferred profile.
Social background also had little influence on overall selection
of profile, with the vast majority selecting 45:55 as their pre-
ferred ratio.
Of the 54 plastic surgeons who responded, 95% chose the 45:55
ratio as their preferred breast proportion. This is an interesting
finding as it is probable that the majority do not apply this visual
preference to their own working practices in planning outcomes.
Dissecting into more detail the category for women, the study
looked at the preference of women below the age of 40 as well as
those over 40, the presumption being that the “captive” audience
for breast augmentation would reside mainly in the under-40
group and might observe differently or desire another outcome
than those over 40. In the younger group 85% demonstrated a
preference for the 45:55 ratio, whereas in the older group 76%
selected the same ratio. This difference was statistically signifi-
cant. It is interesting to speculate as to why with increasing age
there is a slight shift in preference. It may represent the fact that
with age the more mature group of women are more aware of
their own loss of shape and see greater upper-pole fullness as
representative of youthfulness and therefore desirable. Only 1:8
of the younger women opted for the fuller 50:50 volume distribu-
tion as their preferred look.
An independent online study carried out by Rohrich et al for
the journal Plastic and Reconstructive Surgery asked 1,201 respon-
dents to rate the panels taken from the publication by Mallucci
and Branford’s population analysis in exactly the same manner.
The respondents were predominantly from the United States. The
outcome was very similar to that of Mallucci and Branford’s find-
ings; over 70% of respondents selected the 45:55 ratio, whereas
27% selected the 50:50 ratio.
The conclusion from both the original study and subsequently
that of Rohrich is that clearly there is a powerful universal and
fundamental appeal of the 45:55 ratio and the other key param-
eters described. This globally encompassing, rudimentary appeal
or recognition of attractiveness transcends age, race, sex, or social
background. The postulated reason for this attraction is that the
four key parameters identified simply describe the characteristics
of the beautiful, youthful breast, untouched by the forces of
nature, weight gain/loss, pregnancy, or the aging process. These
features are recognizable to all and are in-built as a visual reflex
in recognition of this.
69.5 Using a Template for
Breast Beauty as Part of
the Planning Process
Establishing an aesthetic norm is the first important step in
understanding the aims and goals of breast augmentation and
aesthetic breast surgery in general. Our breast analysis has led us
to understand not only subjectively but also objectively the pref-
erences around breast shape and form as validated generalizations
regarding breast attractiveness among the population as a whole.
It must also be understood, however, that although the over-
whelming majority of women preferred the 45:55 distribution,
at least 12% preferred the fuller 50:50 volume distribution.
Therefore, a tailor-made approach to suit individuals’ needs and
desires must take into consideration personal patient preference
when planning surgery and implant selection.
There is a strong argument to suggest that given the findings
of Mallucci and Branford’s original study, and their subsequent
population analysis, anatomic implants would be best suited to
achieve a natural 45:55 outcome in many instances—especially
those seeking a “natural” appearance.
However, it is also the case that in many situations, where
implant selection is precise and preexisting anatomy is good, a
round implant can also give a very natural result replicating the
four parameters indicated.
There have been a number of publications historically reporting
the inability of clinicians to distinguish between round and anatomic
implants in postoperative images, the implication being that if this
is the case, there is no point in using anatomic implants, thereby
avoiding complications such as rotation and any implications of
BIA-ALCL. However, these observations reflect the limitations of
the studies rather than addressing the advantages or disadvantages
of each type of implant shape. The author’s strong belief is that
there are very significant differences between round and anatomic
implants, and it is important to be able to distinguish between these
and to understand the indications for use in each case.
Undoubtedly the onset of BIA-ALCL has influenced the prac-
tices of a number of clinicians regarding the use of anatomic
implants. At the writing of this chapter, all anatomic implants are
textured; however, the association of texture with BIA-ALCL and
texturization has not been sufficiently understood by the regu-
latory authorities (Food and Drug Administration, World Health
Organization, American Society of Plastic Surgeons, American
Society for Aesthetic Plastic Surgery, European Association of
Societies of Aesthetic Plastic Surgery) to instigate a change of
practice or a ban on texturization. A detailed discussion about
BIA-ALCL is beyond the scope of this chapter; therefore, planning
will be considered for both anatomic and round implants.
69.6 The ICE Principle
Having established a norm of attractiveness the next logical
step is to replicate this norm in practice (i.e., to put theory and
concept into practice). The ICE principle takes into consideration
implant placement around the NAC as well as the projection of
the implant, computing these against the natural capacity of the
lower pole of the breast.

69 Breast Augmentation
1055
I = Implant factors are defined as i/2 , the height of the implant +
its projection.
C = Capacity is defined as the nipple-to-IMF distance on maxi-
mum stretch.
E = Excess is the difference between the I and C values and
represents the extra skin needing to be recruited to accom-
modate a selected implant.
Thus I − C = E.
The ICE principle is a guide, therefore, to accurate implant
selection and placement in order to be able to re-create a 45:55
volume distribution predictably as part of breast augmentation.
It is particularly important to be able to predict the position of
the incision in the new IMF, and the ICE principle facilitates this
process by simply knowing three measurements:
1. The implant height (this is halved for an anatomic implant)
2. The implant projection
3. The nipple to fold distance on stretch
69.7 Measurement Principles
The base width of the breast is used as the initial determinant of
implant selection. Implants that are 0.5–1.0 cm narrower than
the base width are generally selected to ensure adequate tissue
cover over the implant (Fig. 69.1).
The next most important consideration is the vertical height
of the implant and its projection. The latter two parameters will
determine the demand on the lower pole of the breast and how
much skin will be recruited (if any) into the lower pole to accom-
modate the selected implant (Fig. 69.2).
69.7.1 Positioning of the Implant
For an anatomic implant the implant is placed at the midheight
point relative to the nipple meridian. This reflects the fact that
an anatomic implant has more volume in its lower half than in its
upper half, thereby replicating the 45:55 volume distribution by
placing it in this position (Fig. 69.3).
For a round implant, in order to achieve the same volume dis-
tribution, approximately 55% of the height of the implant is placed
below the nipple meridian and 45 above it. This reflects that a
form-stable round implant is equal in its volume distribution
when viewed vertically from the side (Fig. 69.4).
1R ([FeVV 5eTuired
In this example (Fig. 69.5) the implant factors (I) ï ô height (h)
+ projection (p) do not exceed the capacity (C) of the breast, and
therefore there is no extra recruitment of the skin into the lower
pole or movement of the inframammary fold; that is, I ï C = 0.
Fig. 69.1 Measurement principles: tissue-based planning.
Fig. 69.2 Measurement principles: tissue-based planning.

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XI Breast Surgery
([FeVV 5eTuired
In this example (Fig. 69.6) the implant factors h and p (I) exceed
the capacity of the breast (C), and the difference between these
two values (E) is the excess skin required in the lower pole in
order to accommodate this implant and will be the position of
neo-IMF incision. I ï C = E where E is the excess or the difference
between the implant factors and the capacity of the lower pole
of the breast.
Marking Capacity and Excess
In the preceding example, the capacity (C) ï IMF-to-nipple distance
on stretch and the excess (E) are visualized in the photographic
image for the given implant and its characteristics (I) (Fig. 69.7).
Planning for an anatomic implant is shown in Fig. 69.8.
The photograph illustrates a deficit of 1.4 cm for the implant
selected for the breast:
Implant height is 10.6 cm.
Implant projection is 4.6 cm. Therefore I ô of 10.6  4.6
9.9 cm.
IMF to NAC on stretch is 8.5 cm. Therefore C = 8.5.
According to the principle I ï C = E, 9.9 – 8.5 = 1.4 cm.
This is the amount of skin to be recruited below the existing
IMF to accommodate the implant; that is, the incision is placed 1.4
cm below the existing fold.
With the implant in situ the IMF incision is illustrated, situated
accurately within the neo-IMF according to the ICE calculation
(Fig. 69.9).
Postoperative images for the foregoing case demonstrate good
implant position and creation of the 45:55 volume distribution
with accurate incision placement in the IMF (Fig. 69.10). A demon-
stration of how poor incision planning can have a devastating
effect on overall outcome despite good breast shape is shown in
Fig. 69.11.
69.7.2 Analysis of the ICE Principle
To test the accuracy of the ICE principle for producing consistent
results, Mallucci and Branford conducted a prospective study
of 50 patients undergoing primary augmentation with either
round or anatomic implants. In each case the ICE principle was
applied to calculate the position of the IMF. Standardized pre-
and postoperative photographs were analyzed to assess two
factors: (1) the accuracy of placement of the resultant incision
in the neo-IMF was calculated and (2) the volume distribution
between the upper and lower poles of the breast was analyzed as
well as the nipple angulation. The results demonstrated that the
50 patients conformed much more closely in terms of the four
parameters previously described postoperatively than they did
preoperatively.
Analysis of the 50 patients preoperatively demonstrated a
mean upper-pole/lower-pole ratio of 52:48, which was corrected
to 45:55 postoperatively. The nipple angulation went from a
preoperative mean of 11% to 19% postoperatively. The spread
of the variable was also narrowed significantly postoperatively
compared with preoperative images. The study was important
in order to validate the accuracy and usefulness of the ICE prin-
ciple. It is a simple technique for planning breast augmentation.
Accurate incision placement is essential in order to optimize out-
come, and the concept of volume distribution around the NAC is
equally important in order to obtain a naturally augmented breast
by replicating the four parameters identified as key features of an
attractive breast.
Fig. 69.3 Positioning of the implant: anatomic implant.
Fig. 69.4 Positioning of the implant: round implant.

69 Breast Augmentation
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Fig. 69.5 Diagram 1. In this example the Implant factors (I)
− ½ height (h) + projection (p) do not exceed the capacity
(C) of the breast; therefore, there is no extra recruitment of
the skin into the lower pole or movement of the inframam-
mary fold; that is, I − C = 0.
Fig. 69.6 Diagram 2. In this example the implant factors h and p (I) exceed the
capacity of the breast (C), and the difference between these two values (E) is the
excess skin required in the lower pole in order to accommodate this implant and
will be the position of the neo-inframammary fold incision. I − C = E where E is
the excess or the difference between the implant factors and the capacity of the
lower pole of the breast.
Fig. 69.7 Diagram 3. In the example shown, the capacity (C) − IMF-to-nipple distance on stretch and the excess (E) are visualized in the photographic
image for the given implant and its characteristics (I).

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XI Breast Surgery
Figs. 69.10 (a,b) Preoperative photographs. (c,d) Postoperative photos showing how following the ICE principles results in the desired 45:55 proportion.
Fig. 69.8 The photograph illustrates a deficit of 1.4 cm for the implant
selected for the breast. Implant height is 10.6 cm. Implant projection
is 4.6 cm. Therefore, I = ½ of 10.6 + 4.6 = 9.9 cm. Inframammary fold
(IMF) to nipple–areola complex (NAC) on stretch is 8.5 cm. Therefore C
= 8.5. According to the principle I − C = E, 9.9 – 8.5 = 1.4 cm. This is the
amount of skin to be recruited below the existing IMF to accommodate
the implant; that is, the incision is placed 1.4 cm below the existing fold.
Fig. 69.9 Incision is illustrated.

69 Breast Augmentation
1059
69.8 The ICE Principle and
Problem Solving
The ICE principle can also be used in reverse. In other words, if
the implant factors—the height of the implant and its projection
(I), exceed the natural capacity (C) of the breast excessively
such that the IMF is going to be lowered dangerously with a
risk of double bubble, the implant can be reselected, reducing
the implant height and/or its projection and thereby reducing
the demand on the lower pole of the breast. In this situation
as in a constricted breast or tight IMF, as little lowering of the
IMF as possible is ideal (Fig. 69.5, Fig. 69.12). In these situations
short-height anatomical implants are often the preferred choice
because the width can be preserved while reducing the height
and the projection (Fig. 69.12).
(̵eFW RI SKRrWer ,mSODnW +eigKW
A shorter-height implant with volume distributed around the
NAC (nipple meridian) in a 45:55 ratio will not lower the IMF as
much as the taller-height implant when its volume is distributed
in the same fashion. This may be indicated in a constricted breast
or in a short lower pole (Fig. 69.12).
69.9 Round versus Anatomic
Implants
Although a comprehensive discussion around the advantages
and disadvantages of round versus anatomic implants is beyond
the scope of this chapter, it is worth noting the differences
between the two types of implant. The fundamental difference
is that anatomic implants have three variable dimensions,
whereas round implants have only two (Fig. 69.13, Fig. 69.14).
In the majority of situations where the anatomy of the breast
is not challenging, this is not of importance, and if selected and
positioned appropriately during surgery, a satisfactory outcome
can be achieved with either.
However, this chapter has focused on the significance of
volume distribution as opposed to the simple addition of volume.
Anatomic implants are “preset” in a favorable form, encouraging a
45:55 distribution by virtue of their shape, thus facilitating a more
natural profile to the breast. In addition, the ability to vary width,
height, and projection allows for great flexibility in planning for
more complex anatomic situations. This is particularly pertinent
in cases of constricted or short lower poles, pseudoptosis with
lower-pole laxity, or complex asymmetries.
The only potential disadvantage of anatomic implants is the
small risk of rotation. Frequency of reported rotation varies in
the literature from 1 to 2% to up to 40%. It is thought that good
surgical technique and accurate pocket dissection are key to min-
imizing this risk. Hand-in-glove dissection of the breast pocket
(whether pre- or subpectoral), closely matching the dimensions
of the implant to those of the dissected pocket, reduces the risk of
rotation. In addition, appropriate postoperative steps can be taken
Fig. 69.11 A demonstration of poor incision planning.
Fig. 69.12 Diagram 4. Illustrates how a shorter-height implant with volume distributed around the nipple–areola complex (NAC) (nipple meridian) in
a 45:55 ratio will not lower the inframammary fold (IMF) as much as the taller-height implant when its volume is distributed in the same fashion. This
may be indicated in a constricted breast or in a short lower pole.

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XI Breast Surgery
to avoid rotation by minimizing overzealous upper body activity
for a defined period of time following surgery.
The benefits of anatomic implants have to be considered against
the backdrop of current knowledge about anaplastic large-cell
lymphoma. All anatomical implants to date are textured; there-
fore, an open discussion with patients is mandatory in order for
an informed decision to be made as to the ideal choice of implant
for any individual.
69.10 Results
69.10.1 Case 1
For case 1 results, see Fig. 69.15.
69.10.2 Case 2
For case 2 results, see Fig. 69.16.
69.10.3 Case 3
For case 3 results, see Fig. 69.17.
69.10.4 Case 4
For case 4 results see Fig. 69.18.
69.11 Concluding Thoughts
Successful breast augmentation is a combination of many factors.
Surgical planning according to patient anatomy is a key step—the
concept of tissue-based implant selection, the principle being
that the implant should fit the footplate of the breast to minimize
distortion and to mitigate the negative consequences of oversized
implants on the soft tissues. It also requires precise surgical exe-
cution, including appropriate soft tissue handling, correct plane
selection, and accurate pocket dissection, using any measures
Fig. 69.14 The “third dimension” of anatomic implants—for the same width, the height can be varied. In a round implant, the height is always the
same as the width.
Fig. 69.13 The many different projections of both round and anatomic implants.

69 Breast Augmentation
1061
required to stabilize the soft tissues. However, even before any of
these maneuvers or steps are contemplated, it is essential to have
an aesthetic goal in mind; a clear definition of breast attractive-
ness must precede any surgical step or technical detail.
Modern breast augmentation necessitates much more than the
outdated approach of simple addition of volume to the breast.
Volume per se not only contributes little to the aesthetic outcome;
if poorly distributed, it can positively detract from breast attrac-
tiveness. Therefore, the concept of volume distribution dominates
the aim of successful breast augmentation. Volume distribution
above and below the nipple meridian defines breast beauty.
Paradoxically, naturally attractive breasts are always slightly fuller
Fig. 69.15 Case 1. (a,b) Pre- and (c,d) 18 months postoperative images of short-height 285-mL anatomic implants. The oblique view illustrates the
salient features of the natural augmentation: a 45:55 upper-pole ratio, skyward nipple angulation, a tight convex lower curvature, and a straight line
upper-pole slope.

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Fig. 69.16 Case 2. (a,b) Pre- and (c,d) 18 months postoperative images; dual-plane breast augmentation with moderate-height, full-projection,
325-mL anatomic implants. Once again, oblique views illustrate preservation of the features illustrated in Fig. 69.1 in terms of upper-pole/lower-pole
proportion, nipple angulation, lower-pole curvature, and upper-pole slope.

69 Breast Augmentation
1063
in the lower pole than they are in the upper pole—according to
the 45:55 ratio. This knowledge, and the definition of an aesthetic
template, allows for planning according to these principles.
Implant selection, surgical execution, and implant placement can
be planned to replicate this volume distribution.
Clinical Caveats
• A clear understanding of breast aesthetics is essential prior to
embarking upon breast augmentation.
• A tissue-based approach should be taken for implant selec-
tion—respecting anatomy is key.
• Oversized implants not only detract from the aesthetic
appearance but are also physically destructive over time.
• Modern breast augmentation is about volume distribution,
not just the addition of volume.
• Good shape should prevail over volume.
• Methodology to help plan selection and placement of
implants is recommended. The ICE principle is one of the
existing techniques.
• Versatility in the selection of implant shape is important—
different shapes confer different advantages in certain
anatomic situations.
• It is important to have an open and honest discussion with
patients about advantages and disadvantages of different
implant types, including risks of reoperation and breast
implant–associated anaplastic large-cell lymphoma.
Fig. 69.17 Case 3. (a,b) Pre- and (c,d) 15-month postoperative images using a 245-mL, moderate-height, moderate-profile anatomic implant dual-
plane technique. The same features are illustrated as in cases 1 and 2.

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Suggested Reading
[1] Adams WP Jr, Mallucci P. Breast augmentation. Plast Reconstr Surg
2012;130(4):597e–611e
[2] Adams WP Jr, Mallucci P. Breast augmentation. Plast Reconstr Surg
2012;130(4):597e–611e Review
[3] Bohmert H, Gabka C. Plastic and Reconstructive Surgery of the Breast: A surgical
Atlas. New York, NY: Thieme Publishers; 1997
[4] Botti G. Aesthetic Mammaplasties. Practical Atlas of Plastic Surgery. Florence,
Italy:S.E.E.; 2008
[5] Brody GS. The perfect breast: is it attainable? Does it exist? Plast Reconstr Surg
2004;113(5):1500–1503
[6] Hauben DJ, Adler N, Silfen R, Regev D. Breast-areola-nipple proportion. Ann Plast
Surg 2003;50(5):510–513
[7] Hedpn P, Bronz G, Elberg --, et al. Long-term safety and effectiveness of
style 410 highly cohesive silicone breast implants. Aesthetic Plast Surg
2009;33(3):430–436, discussion 437–438
Fig. 69.18 Case 4. (a,b) Preoperative and (c,d) 1-year postoperative images. Dual-plane technique moderate-height, moderate-projection 210-mL
anatomic implant.

69 Breast Augmentation
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[8] Hsia HC, Thomson -G. Differences in breast shape preferences between plastic
surgeons and patients seeking breast augmentation. Plast Reconstr Surg
2003;112(1):312–320, discussion 321–322
[9] Jewell ML, Jewell JL. A comparison of outcomes involving highly cohesive,
form-stable breast implants from two manufacturers in patients undergoing
primary breast augmentation. Aesthet Surg J 2010;30(1):51–65
[10] Mallucci P, Branford OA. Concepts in aesthetic breast dimensions: analysis of the
ideal breast. J Plast Reconstr Aesthet Surg 2012;65(1):8–16
[11] Mallucci P, Branford OA. Population analysis of the perfect breast: a morphomet-
ric analysis. Plast Reconstr Surg 2014;134(3):436–447
[12] Mallucci P, Branford OA. Design for natural breast augmentation: the ICE princi-
ple. Plast Reconstr Surg 2016;137(6):1728–1737
[13] Mallucci P, Branford OA. The definition of breast beauty, analysis, and surgical
practice. Clin Plast Surg 2015;42(4):451–464
[14] Maxwell GP, Van Natta BW, Murphy DK, Slicton A, Bengtson BP. Natrelle style
410 form-stable silicone breast implants: core study results at 6 years. Aesthet
Surg J 2012;32(6):709–717
[15] Penn J. Breast reduction. Br J Plast Surg 1955;7(4):357–371
[16] Spear SL, Bulan EJ, Venturi ML. Breast augmentation. Plast Reconstr Surg
2006;118(7, Suppl):188S–196S, discussion 197S–198S
[17] Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using
five measurements in 5 minutes: the High Five decision support process. Plast
Reconstr Surg 2005;116(7):2005–2016
[18] Tebbetts JB, Teitelbaum S. High- and extra-high-projection breast implants:
potential consequences for patients. Plast Reconstr Surg 2010;126(6):2150–2159
[19] Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue
relationships in a wide range of breast types. Plast Reconstr Surg 2006;118(7,
Suppl):81S–98S, discussion 99S–102S
[20] Weum S, de Weerd L, Kristiansen B. Form stability of the Style 410 anatomi-
cally shaped cohesive silicone gel-filled breast implant in subglandular breast
augmentation evaluated with magnetic resonance imaging. Plast Reconstr Surg
2011;127(1):409–413

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70 Fat Grafting of the Breast
Emmanuel Delay and Andreea Carmen Meruta
Abstract
Fat grafting to the breast has been a controversial procedure,
but today it has gained an important role in the plastic surgeon’s
armamentarium as a safe and easy-to-use tool for the experi-
enced surgeon. Fat grafting has the advantage of using autologous
tissue that allows natural reshaping and volume augmentation
and the secondary benefit of liposuction in the donor sites. There
is no evidence that shows an increasing risk for breast cancer
after fat-grafting procedures.
This chapter describes the use of fat grafting to the breast in
aesthetic and reconstructive surgery to correct defects and mal-
formations, for breast augmentation, as an adjuvant to implant
breast augmentation and other aesthetic breast surgeries, in the
treatment of breast sequelae after conservative breast cancer
surgery, as an associated procedure in breast reconstruction, and
as a method of exclusive breast reconstruction.
The fat is harvested by liposuction from areas of excess fat
deposits and then is treated to obtain purified fat grafts that
are transferred to the breast in a crisscross, three-dimensional
pattern. The final result can be evaluated at least 3 months after
surgery.
Fat grafting has proved to be an essential procedure in breast
surgery, and we believe it is going to become one of the most
important tools in breast surgery.
Keywords
fat grafting, breast surgery, breast reconstruction, fat transfer,
lipofilling, lipomodeling
70.1 Introduction
Transferring fat from areas of the body with fat excess to the
breast is not a new concept. It has been suggested since the
beginning of liposuction, particularly after publications by Illouz
and Fournier. However, the concept remained controversial for
years because it was feared that autologous fat transfer would
generate fat necrosis and calcifications that could interfere with
breast screening methods and early identification of breast
cancer. It was also feared that the stem cells from the adipose
tissue might have a role in cancer development.
Fat grafting regained popularity after the confirmation by
Coleman that fat tissue can be transplanted safely if a good surgi-
cal technique is applied. Coleman’s preliminary work was mainly
on facial rejuvenation. In 1998, given the proven efficacy of fat
grafting in facial rejuvenation, we started evaluating the efficacy
and safety of the procedure in thoracomammary reconstruction.
We adapted the technique for breast procedures and named it
lipomodeling. :e assessed the efficacy and tolerance in patients
and demonstrated an absence of significant clinical and radiologic
signs of adverse effects.
This chapter describes new developments in fat transfer to the
breast, our surgical technique for breast procedures, the indica-
tions and contraindications, the advantages and disadvantages,
and the possible complications and their solutions. Some of the
results obtained with this procedure are also presented.
70.2 Historical Points
The first attempt mentioned in the literature to use fat for
breast surgery was that of Czerny, in 1895, who transferred a
lipoma from the buttock region to reconstruct a breast defect.
There were several subsequent descriptions of different surgical
techniques with fasciocutaneous flaps, fat implants, or local
pedicled flaps, or of fat injection directly into the breast or into
a previously inserted implant. There have even been described
cases of trials of cadaver fat transferred, with cellular rejection
either immediately or later due to the nonself body reaction.
In 1991 Fournier described the technique of fat grafting that he
used for small breast augmentation in patients who did not desire
implant breast augmentation. The quantity of fat grafts trans-
ferred was small, and the fat was placed into the retroglandular
space and not into the mammary parenchyma.
70.3 The Controversy
The procedure of fat grafting to the breast, for breast augmen-
tation, was first presented by Bircoll in 1984 in Bangkok and in
1985 at the California Society of Plastic Surgeons, and it became
highly controversial. The patient was a 20-year-old woman
who requested a moderate augmentation of her breasts while
undergoing fat grafting to repair damage caused by a dog bite.
At first, Bircoll and 1ovack believed the technique should be
used for women requesting a moderate augmentation because of
the potential risk for necrosis when large quantities of fat were
grafted. In 1987 Bircoll reported the principal advantages of the
procedure: its simplicity, the absence of scar, rapid recovery, no
additional prosthesis required and thus no prosthesis-associated
complications, and the body contouring capability. Bircoll and
Novack also reported a case of a patient that had bilateral fat
grafting after unilateral breast reconstruction by transverse
rectus abdominis myocutaneous (TRAM) flap; the fat grafting
improved the aesthetic results and symmetry. The two papers
triggered reactions from the medical community, and many
voices expressed strong disapproval, claiming that autologous
fat injections to the breast could generate microcalcifications
and cysts that could interfere with the detection of early breast
carcinoma. Bircoll argued that cancer-related calcifications and
those following fat transfer occur in different sites and have dif-
ferent radiologic aspects and therefore cannot be mistaken, and
further, that breast-reducing surgery also results in microcalcifi-
cations. But in 1987, the Ad-Hoc Committee on New Procedures

70 Fat Grafting of the Breast
1067
of the American Society of Plastic and Reconstructive Surgeons
issued a position paper stating the following: “The committee
is unanimous in deploring the use of autologous fat injection in
breast augmentation,” and further that “much of the injected fat
will not survive, and the known physiologic response to necrosis
of this tissue is scarring and calcifications. As a result, detection
of early breast carcinoma through xerography and mammog-
raphy will become difficult and the presence of disease may go
undiscovered.”
There was no reference in the paper to scientific findings, and
the report expressed only the opinion of the members of the com-
mittee. Despite the paucity of scientific information, and although
it has long been recognized that any mammary surgery can cause
oil cysts or mammographic changes, the injection of fat into the
breasts became a taboo among surgeons, which limited research
and experimentation on this topic.
Ironically, in the same journal, in 1987, Brown et al published
a retrospective study of mammographic changes after breast
reduction, reporting that calcifications were detected in 50 of all
mammograms at 2 years after surgery. The authors insisted that in
most cases, these benign calcifications were easily distinguishable
from changes associated with cancer. Despite this high incidence
of calcifications and risk that mammographic abnormalities
might interfere with cancer detection, there was no subsequent
discussion of discontinuing breast reduction mammoplasties on
the basis that such a procedure might interfere with breast cancer
detection.
70.3.1 Lifting the Taboo
Fat grafting had proven very efficient for facial rejuvenation and
for the correction of facial deformities. Thus, in 1998, we focused
our research on the subject and adapted the technique to breast
reconstruction. First, we used fat grafting in conjunction with
autologous latissimus dorsi flap reconstruction. This flap recon-
struction, previously developed by our surgical unit, allowed
satisfactory reconstruction in 70% of cases, but the other 30%
resulted in insufficient breast volume. Reduction of the contra-
lateral breast was needed or prosthesis had to be inserted, which
was precisely what we wanted to avoid in the first place, because
the procedure would no longer be autologous and because of
the drawbacks associated with prostheses (unnatural shape and
texture and the need to replace the prosthesis at some point).
We started using fat grafting in patients undergoing autolo-
gous latissimus dorsi flap reconstruction who were at low risk
of local recurrence. We named the technique lipomodeling, from
the Greek root lipo (fat), and the Latin modello (to give shape or
volume), which is precisely the objective of this procedure. At
first, we used the fat grafting technique only on 20 volunteer
patients who agreed to undergo strict initial follow-up for 1 year.
After the efficacy of the technique had been demonstrated, with
results yielding optimal shape and texture, as well as a natural
décolleté, we proposed lipomodeling to almost all patients that
had latissimus dorsi reconstruction. The study of mammography,
CT, and MRI findings conducted on patients in parallel demon-
strated that fat grafting did not interfere with patients’ screening.
It was thus progressively extended to other indications for breast
reconstruction, then to the correction of breast deformities, and
finally to use in conservative treatment. Our first presentations
at the Societe Francaise de Chirurgie Plastique Reconstructrice
et Esthetique and the International Confederation for Plastic
Reconstructive and Aesthetic Surgery raised considerable
controversy, of the same order as the criticism made in 1987.
Point-by-point debate gradually overcame the skepticism of the
clinical community.
70.3.2 Where Are We Now?
After years of controversy, fat grafting to the breast became a
common procedure among plastic surgeons, being a reliable tool
in reconstructive and aesthetic surgery. In 2009, the American
Society of Plastic Surgeons reversed the recommendation against
the procedure.
It has been shown that fat grafts have more than a filler role,
because of their high content of adipose stem cells, mesenchymal
cells, capable of differentiating into types of cells with a role in
regenerative medicine and an important role in improving irradi-
ated tissues, fibrosis, and scars.
In 2011, Petit et al published a retrospective multicentric study
analyzing cases of lipofilling to the breast and showed that fat
transfer is a safe procedure with no impact on screening but with
a higher risk of breast cancer recurrence in cases with in situ car-
cinoma than in patients with invasive carcinoma. This result of the
study was inconclusive due to the small case series. A follow-up
article showed an increase of local recurrences in patients with
intraepithelial neoplasia and lipofilling, but further studies should
be performed on a higher number of patients. In 2016, Kronowitz
et al published a match-controlled study on a large number of
patients without showing an impact of fat grafting on the local
relapse or global oncologic outcome. This result was also supported
by a retrospective study performed by Cohen et al in 2017.
In our experience, fat grafting to the breast is a safe procedure
with no impact on oncologic safety or cancer screening. Even
though the data today support the safety of fat transfer, further
studies should be performed to consolidate the general opinion
of oncologic safety and to increase confidence in the procedure.
70.4 Indications
Lipomodeling of the breast and chest wall has many indications. It
has been of great benefit in reconstructive breast surgery. In aes-
thetic breast surgery and in selected cases, fat transfer precludes
the need for an implant (augmentation, and mastopexy with a
slight lack of fullness in the upper pole). It can also efficiently
correct certain defects of implant augmentation. Fat grafting
has become a standard and useful procedure for enhancing the
outcomes of breast aesthetic surgery.
70.4.1 Aesthetic Surgery Indications
Bilateral Breast Augmentation or
Lipoaugmentation
Lipomodeling in aesthetic surgery is developing rapidly. Our
studies have shown that if lipomodeling is carried out according
to the technique we describe in this chapter, it does not generate
radiologic images that raise problems of differential diagnosis

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XI Breast Surgery
with breast malignancy or problems of radiologic follow-up for
radiologists who specialize in breast imaging.
The main radiologic risk is that breast cancer may occur coin-
cident with lipomodeling. To reduce this risk, imaging studies
(mammography and ultrasonography) are carried out before
lipomodeling by a specialized radiologist to confirm the absence
of any suspicious lesions. If there is any doubt, lipomodeling is
deferred or contraindicated. The radiologist must concur before
lipomodeling is performed and thereby becomes co-responsible
for the follow-up. The patient gives written consent to undergo the
same studies by the same radiologist 1 year after the procedure. If
the radiologist observes a suspicious lesion on imaging at 1 year,
a microbiopsy is performed to establish a definitive diagnosis. In
this indication, the information given to the patient must be par-
ticularly thorough and extensive, with comprehensive handouts
provided during the preoperative consultations (Fig. 70.1).
The indications for breast augmentation with fat grafting
(lipoaugmentation) differ from those of implant augmentations.
Lipoaugmentation is suitable for patients requesting a moderate
or even slight increase of breast volume or who want to recover
the upper-pole fullness they had before weight loss or pregnancy.
The ideal patient is a young woman with a slim upper body and
moderately small breasts who has sufficient localized adiposity of
the lower body to allow one or even two lipomodeling sessions. In
such a patient, fat harvesting should enhance the lower body con-
tour and can be combined with standard liposuction to improve
the final result. :e encourage the patient to maintain a stable
weight after this procedure, because any change in weight might
affect the shape of the breasts.
Composite Breast Augmentation
(Implant + Fat Transfer)
This is a solution for patients requiring larger breast but also a
natural result. It also has the advantage that the implant can be
smaller because the desired volume can be compensated with
fat grafts. It improves the global body image of the patient. This
technique also allows retroglandular implant placement even for
patients with a small pinch test that diminishes the unnatural
contraction of the pectoralis muscle in active patients.
The fat is transferred in the cleavage and around the implant
borders in order to diminish the implant visibility and the artifi-
cial aspect, and it is preferable to do it while a sizer is in place. It
is also important that these patients maintain a stable weight for
result stability.
Revision after Implant Augmentation
Aesthetic lipomodeling is a treatment option for correction of
the imperfections of implant augmentation. It enhances the
cleavage and décolleté area; improves tissue coverage of the
implant, especially in the lower pole; reduces rippling in thin
patients; and reduces the demarcation of the implant in the
upper pole. We also have the clear clinical impression, though
as yet no scientific data, that complementary fat grafting might
improve capsular contractures in moderate cases. We usually
recommend fat transfer with the previous implant still in place.
After all deformities are corrected, the implant is replaced; this
avoids any risk of leaving a punctured implant.
Additional Procedure to Mastopexy
Fat can be transferred to the upper-pole area in women who
undergo breast mastopexy and do not want an implant but desire
a full décolleté. Once the mastopexy was performed, the fat can
be transferred to the breasts as in the case of lipoaugmentation.
Managing Severe Complications of Breast
AeVWKeWiF Surgery ZiWK 5eViduDO SeTueODe
Breast reduction, breast augmentation, and mastopexy are com-
monly performed procedures in aesthetic breast surgery. The
outcomes are usually satisfactory for the patient and surgeon.
In rare cases, complications occur. In thin patients who smoke,
exposure of an implant can result in the need to remove the
implant. Reduction of large breasts can result in fat and skin
necrosis with subsequent breast deformity.
Some patients are referred to our clinic for revision and sec-
ondary procedures (Fig. 70.2). :e find lipomodeling to be very
useful in these cases. It efficiently enhances tissue thickness and
improves tissue quality. After implant complications leading to
implant removal, lipomodeling prepares the tissues to render the
secondary augmentation safer. After complicated breast reduc-
tions, fat transfer can restore the suppleness of the breast while
improving the quality of the damaged skin.
These complementary fat grafting procedures have reduced
donor site morbidity while reducing the incidence of breast
sequelae. We have also found lipomodeling to be very useful in
the management of difficult patients with high expectations who
may present a risk of medicolegal issues.
70.4.2 Reconstructive Surgery Indications
Poland’s Syndrome
Correction of the deformities of the breast and thorax associated
with Poland’s syndrome remains a daunting challenge (Fig. 70.3).
Lipomodeling appears to be very effective in these cases. Breast
rehabilitation with only fat grafting leads to excellent outcomes
with simple but repeated procedures, resulting in very limited
scarring and donor site morbidity. We have treated 35 patients
with different severities of Poland’s syndrome. In this series,
three sessions, on average, were required to obtain the desired
result, with a mean of 244 mL injected during each session. The
results were notable: it was possible to restore the breast, giving
it a shape almost identical to that of the contralateral breast.
The introduction of this technique appears to be a major break-
through for the management of thorax and breast deformities in
patients with Poland’s syndrome.
Pectus Excavatum
Pectus excavatum is a complex deformity with hollowing
of the anterior sternocostal wall; it usually has little or no
impact on respiratory function. Most patients are principally
concerned about structure and aesthetics when there is signif-
icant deformity of the breast, especially in severe or lateralized
pectus excavatum. Fat transfer techniques can be used alone
to produce satisfactory correction for mild to moderate forms,

70 Fat Grafting of the Breast
1069
or in association with a custom-made rigid implant (based on
three-dimensional CT images) for more severe forms.
Tuberous Breasts
Tuberous breast deformity is an uncommon breast anomaly in
which there is a constriction in the lower pole of the breast. It
becomes apparent at puberty with the growth of the breast.
Various surgical approaches have been described, and a wide
range of techniques can produce an optimal result. Among them,
lipomodeling can correct the lack of volume (especially if this
is unilateral) and improve the base and shape of the breast. It
is a very useful adjunct in the treatment of tuberous breasts.
Coleman reported encouraging results in patients with tuberous
breast deformity treated by fat injection.
The ideal indication is a unilateral hypoplastic tuberous breast
(which usually requires two fat transfer sessions) associated with
a lack of fullness of the upper pole.
In cases of bilateral breast hypoplasia associated with tuberous
deformity, implants remain the standard treatment, unless the
condition is associated with sufficient lower body adiposity to
augment the two breasts satisfactorily. Lipomodeling can signifi-
cantly enhance the results of these corrections by improving the
décolleté area.
Asymmetrical Breasts
Asymmetry is a difficult problem when one breast has satis-
factory fullness and perfect shape and the other is hypoplastic
(Fig. 70.4). Conventionally, augmentation with an implant in the
Fig. 70.1 A patient who requires autologous breast augmentation.
Fig. 70.3 A patient with stage I Poland’s syndrome.
Fig. 70.2 A patient with severe breast deformity after mastopexy who
consulted for result improvement.
Fig. 70.4 Patient with breast asymmetry.

1070
XI Breast Surgery
underdeveloped breast is the standard treatment. Although the
initial results of this approach are generally satisfactory, asym-
metry of shape and volume often reappears several years later. In
this indication, lipomodeling yields a breast very similar to the
normal breast, and the change over time is natural, particularly
in regard to ptosis. Depending on the degree of asymmetry and
hypoplasia, one to three fat transfer sessions will be needed for
an optimal result.
Adjuvant Procedure for Breast Reconstruction
Lipomodeling gained an important place as an adjuvant procedure
in breast reconstruction, either for skin preparation before expan-
sion (due to its regenerative potential), for patients with poor skin
quality after mastectomy and radiation therapy, as an associated
gesture after implant breast reconstruction for a better aesthetic
aspect, or in association with autologous breast reconstruction.
In our practice, we perform total autologous breast reconstruc-
tion with short-scar latissimus dorsi and one to three sessions of
lipomodeling for volume augmentation and shape amelioration.
We wait 2 to 3 months between the latissimus dorsi reconstruc-
tion and the lipomodeling sessions, and there is a delay of 2ô to 3
months between each session of lipomodeling.
Fat can also be successfully transferred to other types of autol-
ogous breast reconstruction, for improving the décolleté area,
volume, and the new breast shape.
Total Breast Reconstruction with Fat Grafting
Despite the seductive perspective of breast reconstruction with-
out additional scars and with complete autologous tissue, the
indications for breast reconstruction exclusively with fat grafts
are limited to patients with small breasts and enough donor sites
that accept multiple surgeries. Reconstructing a breast with lipo-
modeling requires two to five sessions in nonirradiated breasts
and four to seven sessions in irradiated breasts. The quantity of
fat grafts that can be transferred increases with every session
because the receiving tissue increases in volume.
Breast Reconstruction with BRAVA
At the beginning we were very enthusiastic about the BRAVA
device (Brava LLC, Miami, FL), but with time and experience
we reached the conclusion that the device reduces the required
number of sessions with about one fat grafting operation and
adds important social discomfort and supplementary costs
linked to the domes , which are not covered by insurance. There
are teams that use the BRAVA system with good results.
Reverse Expansion
Reverse expansion is a technique of autologous breast recon-
struction that requires an expander to be used at the time of
mastectomy. The device should be inflated until the satisfactory
volume is achieved. Then the expander is deflated progressively;
in every session the volume of fat transferred is equal to the
removed volume from the expander. This technique requires
several surgical interventions, and it has the advantage of result-
ing in a breast with constant volume.
Breast Conservative Treatment
SeTueODe &RrreFWiRn
Patients with sequelae after breast conservative surgery are dif-
ficult cases because they have always had radiation therapy, and
defects can be very severe. Usually they need several fat grafting
sessions. It should be started with small quantities in order to
avoid fat necrosis.
Our protocol states that we operate these patients at least 2
years after the end of radiation therapy and only after a thorough
examination (ultrasound, mammogram, and MRI) to exclude a
local relapse. The patients are informed that the negative imag-
ing exams do not exclude a relapse that can coincide with the
lipofilling.
Breast Reconstruction Conversion from
Prosthesis to Autologous
This is most common in the case of patients that had reconstruc-
tion several years before and had latissimus dorsi and implant
reconstruction. They have implant-related complications and
capsular contracture and desire implant removal. The process
usually requires one or more fat grafting procedures depending
on the size of the implant, and it might also require an interven-
tion on the contralateral breast.
70.5 Contraindications
The only absolute contraindication for fat grafting is the pres-
ence of a suspect lesion in the breast or on the thoracic wall. Also,
lipofilling should not be performed in women with breast cancer
with positive margins or with a very high risk of relapse (e.g.,
the triple negative or sarcoma). It is also recommended not to
perform fat transfer into the contralateral breast in women with
breast cancer. These are precautions, because fat grafting can
produce artifacts, but our experience and the existing studies in
the literature have not proved a delay in cancer diagnosis due to
fat transfer.
Other contraindications include unstable weight, insufficient
fat deposits, or unreasonable expectations of the patient regard-
ing the fat grafting procedure.
70.6 Preoperative Assessment
The patient’s weight should be stable at the time of the proce-
dure because the injected fat will retain the characteristics of
the fat deposits in the donor site. If the patient loses weight after
lipomodeling, she will lose some of the benefits of the procedure.
The operative technique, its benefits, and potential risks and
complications are thoroughly discussed with the patient, and
she is provided with an informational handout with an informed
consent to sign. We have four handouts: lipomodeling in breast
reconstruction, lipomodeling to correct the sequelae of conser-
vative treatment, lipomodeling to correct breast deformities, and
aesthetic breast lipomodeling.

70 Fat Grafting of the Breast
1071
70.7 Preoperative Planning
70.7.1 Markings
The areas of the breast that require correction are identified
and marked on the patient. In some patients we now perform a
three-dimensional morphologic study, in addition to the usual
two-dimensional photographs; this provides further useful
information for assessing the amount of fatty tissue to be trans-
ferred and evaluating secondary fat resorption.
The various adipose areas of the body are examined to identify
excess fat deposits. Generally, we harvest fat from the abdomen,
because harvesting in this area does not require a change in the
patient’s position during the procedure, and liposuction in the
region can lead to beneficial recontouring. The second site is the
trochanteric region (saddlebags) and the inside of the thighs and
knees. The areas to be harvested are outlined with a skin marker.
70.8 2SerDWiYe 7eFKniTue
70.8.1 Anesthesia
Because of the significant amounts of fat harvested, lipomodeling
is performed with the patient under general anesthesia in most
cases. Conventional prophylactic antibiotics are usually given
perioperatively, as we customarily do in various plastic surgery
procedures. Local anesthesia can be used for minor revisions to
correct any residual defect.
70.8.2 Incision Placement
In the harvest sites, incisions are made with a no. 15 blade. For
abdominal harvesting, four incisions are made around the umbili-
cus, and a lateral incision is made on each side if lateral abdominal
and suprailiac fat is to be harvested. For harvesting from the thighs,
the patient is placed in a ventral decubitus position, and an incision
is made in each subgluteal fold. A complementary incision on the
inside of the knees can be made for fat harvesting of this area.
At the recipient site on the breast, punctiform incisions are
done with a 14-gauge needle; it is ideal to hide these sites in
previous scars. To create a network of transfer tunnels, five or six
incisions are needed, two of which are in the inframammary fold
and one in the décolleté area. The incisions are usually made with
the sharp bevel of a trocar.
70.8.3 Fat Harvesting
The new popularity of fat transfer has contributed to stan-
dardization of the procedure for harvesting and injection, thus
reducing the potential pitfalls at each stage. Meticulous tech-
nique throughout the process enhances fat survival in the short,
medium, and long term. A disposable or Coleman cannula is
used for harvesting. These cannulas have a blunt tip that can be
inserted in a 4-mm incision made with a no. 15 blade. Harvesting
is done with a syringe. Subcutaneous infiltration is done with
500 mL of a 9% normal saline solution and 0.5 mg of epinephrine.
A 10-mL Luer lock syringe is fitted directly onto the harvesting
cannula (Fig. 70.5).
Moderate suction will minimize damage to the fat cells;
mechanical suction that is too strong might have a harmful
effect on adipocyte survival. More fat than has been calculated
for transfer must be harvested in anticipation of the separation
resulting from centrifugation and the expected resorption of fat in
the breast after transfer.
Finally, to perfect the morphologic result, the harvested areas
are smoothed with conventional liposuction using a 4-mm can-
nula. The cutaneous incisions are closed with fine, rapid-absorbing
sutures.
70.8.4 Fat Preparation
As harvesting continues, the assistant prepares the syringes for
centrifugation (Fig. 70.6a). They are sealed with a screw top
and then centrifuged in batches of six for 15 seconds at 3,000
rpm. Centrifugation separates the harvested fat into three layers
(Fig. 70.6b): a top layer of oily fluid containing chylomicrons
and triglycerides resulting from cell lysis; a lower layer of blood,
debris, and serum, as well as the infiltration fluid, especially if
the harvesting is done with a local anesthetic; and a middle layer
of purified fat. This is the useful layer that will be injected.
The other two layers are disposed of, the lower layer simply by
removing the cap (Fig. 70.7a) and the upper layer by pouring off
the oil that covers the middle layer (Fig. 70.7b). The team must be
well organized so that fat preparation is carried out efficiently and
rapidly. :ith a three-way tap, the purified lipoaspirate is grouped
into 10-mL syringes by transfer from one syringe to another, thus
producing a sufficient quantity of 10-mL syringes of purified fat
(Fig. 70.7c).
70.8.5 Fat Transfer
After the fat has been prepared, the 10-mL syringes of fat are
ready for transfer. The fat is transferred directly to the breast
areas with the 10-mL syringes fitted with 2-mm transfer
cannulas of 13 cm and 20 cm (Fig. 70.8a). These cannulas are
longer and stronger than the cannulas used for facial fat grafting
Fig. 70.5 Fat harvesting with a Luer lock 10-mL syringe linked to the
harvesting multihole cannula.

1072
XI Breast Surgery
procedures, because the recipient breast tissue is firmer and
more fibrous. The incisions are made using a 17-gauge trocar
(Fig. 70.8b). This produces an adequate incision while limiting
scarring. Several incisions are made to create a honeycomb of
multiple microtunnels for fat transfer.
The fat is injected at 1.5 to 2 mL per pass in the form of fine
cylinders resembling spaghetti (Fig. 70.9a). Microtunnels must be
created in many directions. Transfer is performed from the deep
to the superficial layer. Good spatial visualization is necessary
to form a three-dimensional matrix and to avoid areas of fatty
collections that would lead to fat necrosis. Each microtunnel must
be designed to be surrounded by well-vascularized tissue. Fat is
injected under light pressure as the cannula is gently withdrawn,
not during advancement of the cannula (Fig. 70.9b).
As noted, one must overestimate the quantity of fat transferred
when possible, anticipating a 30% expected fat resorption. A 140%
rule must be applied, meaning that 140 mL of fat must be injected
for a desired final volume of 100 mL.
When the recipient tissues are saturated and cannot absorb
more fat, it is useless to persist because of the risk of inducing
areas of fat necrosis. Oversaturation of the recipient site with fat
grafts must be avoided. Planning a supplementary session in a few
months is preferable and leads to more stable results. Very fine,
rapid-absorbing sutures are placed, and the breast is covered with
an ordinary dry dressing for a few days.
Fig. 70.6 (a) The centrifuge is used for 15 seconds at 3,000 rpm. (b) The three layers that result from centrifugation.
Fig. 70.7 (a) The fluid is drained after cap removal. (b) The oil is poured off. (c) Rack of syringes ready to transfer.