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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the upper border of the ellipse is incised to the thoracic wall with
cautery.
The de-epithelialized flap is kept attached to the thoracic
skin while the deep plane is undermined for 5 to 6 cm. This
de-epithelialized flap is pulled up under the breast and sutured
to the thoracic wall with 1 Vicryl at the predefined position of the
inframammary fold. The lower pole of the breast is undermined
at the level of the pectoralis muscle, then rolled to define the
lower-pole contour and sutured to the fixed inframammary fold.
The disadvantage of this technique is the resulting 6-cm scar,
but this can usually be hidden in the inframammary fold. The
main advantage is the enhancement and efficient correction of
the inframammary fold. In the rare cases in which this technique
is used for lipomodeling augmentation of the breast, we start by
fixating the inframammary fold, and then we do the fat transfer.
70.9.3 Release of Fibrous Strings
and Adhesions
While transferring fat to the breasts, the surgeon sometimes
encounters fibrous strings or adhesion areas, making lipo-
modeling difficult. The inferomedial area in tuberous breasts
is a typical example. In such cases we recommend the use of
V-shaped transfer cannulas or the tip of a 14-gauge trocar to
selectively rupture these strings and adhesions under local
tension. Care must be taken not to undermine the area, because
the transferred fat will not take if it is not in proper contact with
a vascular recipient site.
70.9.4 Processed Fat Grafting with
Enrichment Procedures
There are two types of enrichment procedures: platelet-rich
plasma (PRP) and adipose stem cells. The theory behind the
PRP enrichment is that it is a concentrate of growth factors that
may favor better integration of the transferred fat. In practice,
the results are not constant, and the procedures are not stan-
dardized, so it remains an interesting perspective to be further
analyzed.
It is well known that fat is rich in adipose-derived stem cells
(ADSCs) that in the transferred fat divide into new adipose cells
and are also more resistant and have a higher survival rate than
the adipocytes. Because of these properties it was considered to
enrich the fat grafts with ADSCs, a process called cell-assisted
lipotransfer (CAL). Even though it is seductive, this technique
did not increase the fat survival rate for large lipofillings. Adding
ADSCs increases fat integration for small volumes of fat grafts (<
100 mL), but so far it has increased the cost, has increased the
fat quantity that needs to be harvested, and has not reduced the
number of required fat transfer sessions.
70.10 Postoperative Care
70.10.1 Harvest Sites
Pain in the harvested areas is similar to the pain after liposuc-
tion. Patients complain of moderate pain that typically lasts 48
hours; this can be treated with level 1 analgesics, prescribed for 2
weeks. :e infiltrate diluted ropivacaine at the end of harvesting
to control pain during the first 24 hours.
Considerable bruising occurs in the harvest sites and persists
for 2 weeks. Postoperative edema resolves totally or almost
totally in 3 months. To hasten resorption, we ask patients to
massage the harvest sites with a circular motion. An abdominal
support belt may be advisable for 6 weeks but is not prescribed
routinely. In rare cases, if edema persists, we advise 10 sessions of
Endermologie drainage (LPG Systems, Letchworth, UK).
70.10.2 Breast
Bruising resolves in 2 weeks, edema in 1 month. During the first
3 postoperative months, 30 to 40% of the added volume is grad-
ually lost. But because of the initial edema, the patient may have
the impression that she has lost about 50% of her breast volume
because she saw the breast the day after the procedure, when the
breast was the most swollen.
70.11 Complications
At the harvest site, scars must be concealed as much as possible,
generally in a fold or in the periumbilical region. No patients have
complained of unaesthetic scars in a donor site. We had one case
of irregularity in the suprailiac region that required secondary
correction by lipomodeling. The majority of patients are satis-
fied with the slimming of the donor site; this additional benefit
probably contributes to the very high rate of satisfaction with
this technique. Irregularities at the donor site may be caused by
uneven harvesting of the fat grafts, so harvesting is sometimes
completed by liposuction to further improve the result and for
greater patient satisfaction.
This procedure must be carried out by experienced plastic sur-
geons, who have completed their learning curve, because previous
experience with cosmetic liposuction is essential in these circum-
stances to limit the risk of complications and to produce the best
possible cosmetic result.
Local infection of the donor site occurred in only 1 of our 3,500
lipomodeling procedures done by the first author (ED). This was
seen as redness around the umbilicus and was treated with anti-
biotics and local ice applications, with no long-term sequelae.
In the breast the incisions must be well placed, in the infra-
mammary fold, in its axillary tail, or in the areolar region, where
scars are always of good quality. The presternal area should be
avoided because there is an increased risk of hypertrophic scar-
ring, seen as small, red, hypertrophic, punctate scars. The incisions
are usually invisible: because they are made with a trocar, they
measure only 1.5 mm.
Infections occurred at the recipient site in 13 of our 3,500
lipomodeling patients. Redness at the recipient site was seen, and
sutures were removed. An effusion of fat and pus was evacuated.
Topical treatment, antibiotics, and applications of ice completely
resolved the problem in each case, with no impact on the final
results.
We had one case of intraoperative pneumothorax in 3,500 pro-
cedures, probably as a result of the transfer cannula piercing the
pleura. The pneumothorax was revealed by oxygen desaturation

70 Fat Grafting of the Breast
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during the procedure. In the recovery room, a pleural drain
was inserted, and oxygen saturation returned to normal, with
total recovery and no sequelae. To avoid this complication, the
projection of the areolar region should be improved through
two incisions in the inframammary fold, not through the areolar
region itself.
There were no instances of fat embolism in our series. There is
a potential risk of this if fat is injected into a large vessel. Extreme
caution is recommended in the subclavian area, especially in the
breast and chest wall deformities of Poland’s syndrome, where the
subclavian vessels may lie lower than in a patient with normal
anatomy.
In 3% of cases we observed focal fat necrosis. The risk is higher
during a surgeon’s early experience (15 in the first 50 cases). In
these cases, fat necrosis occurred in areas overtreated and over-
saturated with fat; the recipient site could not absorb the amount
of fat grafted. When the recipient tissue is saturated with fat, the
surgeon should not persist, because areas of fat necrosis may
develop. Clinical signs of fat necrosis are typical: tender, slightly
sensitive but stable over time, then gradually decreasing.
Any increase in the size of a hard swelling, even in a reconstructed
breast, should signal the need for microbiopsy by a radiologist to
rule out a malignant change.
Fat necrosis nodules are mainly seen in the early stages of the
surgeon’s learning curve and decrease as experience increases, if
he or she respects the principle of the three-dimensional injection
network and avoids oversaturation of the recipient site.
70.12 Outcomes and Long-Term
Follow-Up
Based on the first author’s (ED) personal experience of 3,500 pro-
cedures of reconstructive and aesthetic breast surgery and with
a 20-year follow-up for the first patients, reliable indications on
long-term follow-up can be stated.
70.12.1 Clinical
All patients were clinically followed and seen in consultation
after 15 days, 3 months, and 1 year. Photographs were taken at
each visit. A detailed follow-up protocol was used to assess the
quality of the result from the patient’s and surgeon’s viewpoint,
to document patient satisfaction, and to note any adverse effects
or complications.
The results were considered very good or good in the majority
of cases. Very few results were considered to be moderately good,
and none was evaluated as poor. The percentage of good or very
good results depends on the subpopulation studied in relation to
the indications. For example, for correction by lipomodeling of
sequelae of breast-conserving therapy, 50% were considered very
good, 40% good, and 10% moderately good.
Patients who had had breast cancer and underwent a lipo-
modeling procedure after breast-conserving therapy or breast
reconstruction were then followed by their oncologist, who
referred them to us if there was any change in the follow-up clin-
ical and imaging findings. For the other patients, computerized
medical records were shared among the radiologist, oncologist,
breast surgeons, and plastic surgeons to complete the long-term
follow-up.
70.12.2 Radiologic
In 1998, when we developed this area of research, the main fear
concerning fat transfer in the breast was the risk that it would
compromise imaging studies. This fear had in fact led to the
earlier described controversy of 1987 and its consequences.
For this reason, we undertook analysis of the effect of fat
transfer on breast imaging. We carried out three studies with
imaging of breasts reconstructed by autologous latissimus dorsi
flaps and lipomodeling (mammography, ultrasonography, and
MRI), imaging of breasts treated with breast-conserving surgery
after lipomodeling (mammography, ultrasonography, and MRI),
and imaging of breasts with defects corrected by lipomodeling
(asymmetry, tuberous breasts, and Poland’s syndrome).
Our findings showed that if lipomodeling is carried out accord-
ing to modern standardized principles, it does not hinder correct
breast imaging and follow-up. It is noteworthy that all procedures
were performed by a surgical team that has completed its learning
curve and with specialized radiologists who are familiar with the
analysis of image findings potentially induced by fat transfer.
These prerequisites are of fundamental importance for successful
fat transfer in aesthetic breast surgery.
Imaging in the majority of reconstructed breasts yielded
normal results, with some images of oily cysts and fat necrosis.
Any abnormal findings observed indicated benign lesions, easily
distinguished from suspicious lesions. Abnormal images were
essentially oily cysts, occurring in 15% of cases.
The most complex situation concerned lipomodeling for the
sequelae of conservative partial mastectomy. In this population
fat necrosis develops in about 20% of patients postoperatively;
lipomodeling doubles this incidence, generating mainly oily cysts
but sometimes more complex lesions of fat necrosis.
Because of the spontaneous local carcinoma recurrence rate of
1.5% per year, follow-up must be rigorous. We believe that this
indication should be restricted to multidisciplinary teams work-
ing with radiologists who have excellent mastery of the subject.
70.12.3 Oncologic
Twenty years of oncologic follow-up have not revealed an
increased risk of local recurrence after mastectomy or after
conservative treatment. In fact, the clinical impression seems
to be to the contrary. But to confirm this clinical impression,
more complex oncologic studies must be performed that match
treated populations with reference populations with the same
oncologic status.
70.13 Evaluation of the Success Rate
70.13.1 Clinical Evaluation
The success rate of fat transfer is easy to evaluate by clinical
examination, the patient’s opinion, and comparison of the pho-
tographs taken at each consultation with earlier photographs. Of
the volume initially obtained through fat transfer, 30 to 40% is

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gradually lost. Volume is stable after 3 to 4 months and remains
so if the patient maintains her weight. If the harvested fat is very
oily (retains a very high percentage of oil after centrifugation),
resorption may be higher (up to 40–50%) and may continue over
a longer period (5–6 months).
If the patient loses weight, the volume of the transferred fat
decreases, and the result is a smaller breast with possible asym-
metry. Therefore it is important for the patient to understand that
she must maintain a stable weight. Inversely, if she gains weight,
breast volume increases.
When a second fat transfer session is performed to produce
sufficient volume, resorption seems to be lessened to between 20
and 30%.
Very long term evaluation (5–6 years) confirms that breast volume
remains stable. If asymmetry appears after weight loss or gain (e.g.,
after discontinuation of antihormonal treatments in adjuvant ther-
apy for breast cancer), a complementary lipomodeling session can
easily be performed. This technique offers flexibility and precision
for a long-lasting revision that is appreciated by the patients.
70.13.2 Evaluation by Interferometry
Using three-dimensional interferometry technology, we studied
changes in breasts over time after lipomodeling. The technique
consists of light projection and reflection over three-dimensional
structures (in this case, the fat-grafted breasts). The reflected
Fig. 70.10 Lipoaugmentation in a 38-year-old patient. One lipomodeling session was performed (left breast 235 mL, right breast 220 mL). (a)
Preoperative frontal view, (b) preoperative ¾ right view, (c) preoperative ¾ left view, (d) shortly postoperative frontal view showing bruising and
edema, (e) shortly postoperative ¾ right view, (f) shortly postoperative ¾ left view, (g) 1-year postoperative frontal view, (h) 1-year postoperative ¾
right view, (i) 1-year postoperative ¾ left view.
a
d
g
b
e
h
c
f
i

70 Fat Grafting of the Breast
1077
light is processed using modeling algorithms. This produces a
three-dimensional representation of the breasts from which
measurement of distance and volumes can be calculated. By
comparing the models of the breast, breast volume can be accu-
rately studied, and the quantity of fat remaining after resorption
can be assessed. This study confirmed our clinical impression:
the rate of fat absorption at 3 months was estimated to be 30
to 40. It also confirmed that volume remains stable after this
period if the patient maintains a constant weight.
70.14 Results
The 38-year-old woman shown in Fig. 70.10 had bilateral breast
augmentation with one lipomodeling session (left breast 235 mL,
right breast 220 mL). She is shown shortly postoperatively with
bruising and edema and 1 year postoperatively.
The 40-year-old patient with tuberous breasts and asym-
metry shown in Fig. 70.11 desired breast augmentation and
had composite breast augmentation with round silicone breast
implants, 300 mL for the left breast, 330 mL for the right breast,
and bilateral lipomodeling: 120 mL transferred for each breast.
Results are shown at 2 years follow-up.
The 37-year-old patient shown in Fig. 70.12 had aesthetic
augmentation with anatomical implants 8 years earlier. She com-
plained of pain in the right breast and implant visibility. She had
implant replacement with round silicone breast implants, 360 mL,
and fat grafts: 110 mL to the right breast and 90 mL to the left
breast. Results are shown at 9 months follow-up.
The 48-year-old patient shown in Fig. 70.13 was seen as a second-
ary case with severe sequelae after failure of many breast implant
augmentations and further mastopexy. She was treated with one
lipomodeling session (left breast 250 mL, right breast 280 mL) and
inframammary fold fixation. The flap was marked, then incised and
de-epithelialized. Incision of the upper part of the flap is shown, and
finally flap fixation to the thoracic wall. A second fat transfer was
performed 3 months after the first procedure (left breast 310 mL,
right breast 270 mL). Three months after the procedure, the restored
Fig. 70.11 Composite breast augmentation in a 40-year-old patient with tuberous breasts and asymmetry had composite breast augmentation with
round breast implants, 300 mL for the left breast, 330 mL for the right breast, and bilateral lipomodeling: 120 mL transferred for each breast. (a)
Preoperative frontal view, (b) preoperative ¾ right view, (c) 2 years postoperative frontal view, (d) 2 years postoperative ¾ right view.

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inframammary fold is evident; a second session of lipomodeling is
scheduled. Results are shown at 2 years follow-up.
The 17-year-old patient with Poland’s syndrome shown in Fig.
70.14 was treated with two sessions of lipomodeling (205 mL,
297 mL) at an interval of 6 months. She is shown 1 year after the
second procedure.
The 41-year-old patient with a history of tumorectomy for
breast cancer on the left breast, breast hypotrophy, asymmetry,
and pectus excavatum shown in Fig. 70.15 wanted breast augmen-
tation. She was treated with one 140-mL fat grafting session and
a second session of 90 mL associated with breast augmentation
with round silicone implants. The patient refused symmetrization
of the nipple position. Results are shown 1 year after surgery.
The 17-year-old patient with lateralized pectus excavatum
shown in Fig. 70.16 was treated with two lipomodeling sessions
of the right breast (200 mL, 360 mL). She is shown 1 year after the
second procedure.
70.15 Concluding Thoughts
Lipomodeling is a major development in reconstructive and
aesthetic surgery of the breast; we consider it to be one of the
major advances of the past 20 years. The technique is now
well codified, and the associated complication rate is very low.
Clinical long-term follow-up shows that the morphologic result
regarding volume is stable 3 to 4 months after the procedure. The
development of focal fat necrosis is strongly operator dependent,
occurring in 15% of cases in the surgeon’s early experience and
becoming stable at 3% after more experience. The radiologic
appearance of the breasts is usually normal, sometimes with
images of fat necrosis seen as oily cysts or, more rarely, calci-
fications or complex cysts. 1one of these images is likely to be
confused with a diagnosis of cancer for radiologists who are
experienced in breast imaging. If there is the slightest doubt,
the next step must always be microbiopsy of the suspect area to
obtain a definitive diagnosis. Oncologic follow-up (now 20 years
for our first patients) shows no increased risk of local recurrence
or of development of a new cancer.
Evaluation of the success rate by clinical examination and by
interferometry shows that 30 to 40% of the injected fat is resorbed.
The final volume is reached in 3 to 4 months and is stable over
time if the patient maintains a constant weight. If a second fat
transfer session is performed, resorption will be somewhat less,
usually between 20 and 30%.
Fig. 70.12 Implant replacement and fat grafting in a 37-year-old patient who had aesthetic augmentation with anatomic implants 8 years earlier.
She had implant replacement with 360-mL round silicone breast implants and fat grafts: 110 mL to the right breast and 90 mL to the left breast.
(a) Preoperative frontal view, (b) preoperative ¾ right view, (c) preoperative ¾ left view, (d) 9 months postoperative frontal view, (e) 9 months
postoperative ¾ right view, (f) 9 months postoperative ¾ left view.

70 Fat Grafting of the Breast
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Because of the low complication rate, the very good results
obtained, and the excellent acceptance of the technique by
patients, lipomodeling has completely modified our indications in
plastic, reconstructive, and aesthetic surgery of the breast.
The use of lipomodeling to correct deformities of the chest
wall and breast is rapidly being adopted. For the treatment of
Poland’s syndrome, lipomodeling appears to represent a major
advance and will probably revolutionize the treatment of severe
cases, producing reconstruction of unequaled quality after fat
transfer procedures with a simple postoperative course and little
scarring. Lipomodeling can also correct the breast and chest wall
deformities associated with some cases of pectus excavatum and
is a useful adjunct to custom-made implants for more severe
forms of pectus excavatum. It is a promising alternative treatment
for tuberous breasts and implant-free correction of asymmetry
caused by unilateral hypoplasia.
Fat grafting also has an established role in breast reconstruc-
tion as an ancillary procedure for autologous and implant breast
reconstruction, and in selected patients as a solution for total
breast reconstruction.
Finally, the applications of lipomodeling will no doubt continue
to develop in aesthetic surgery for the correction of inadequate
mammaplasty, correction of defects or complications of implants,
and in lipoaugmentation for patients desiring moderate, natural
breast enhancement and who have sufficient adipose deposits.
Preoperative and postoperative imaging by a radiologist who
specializes in breast imaging is essential to limit the risk that a
cancer may occur coincident with lipomodeling.
Fig. 70.13 Secondary aesthetic breast correction in a 48-year-old patient seen as a secondary case with severe sequelae after failure of many breast
implant augmentations, and further mastopexy. She was treated with one lipomodeling session (left breast 250 mL, right breast 280 mL) and infra-
mammary fold fixation. The flap was marked, then incised and de-epithelialized. Incision of the upper part of the flap is shown, and finally flap fixation
to the thoracic wall. A second fat transfer was performed 3 months after the first procedure (left breast 310 mL, right breast 270 mL). (a) Preoperative
frontal view, (b) preoperative ¾ left view, (c) marking of the de-epithelialized flap, (d) flap de-epithelialized, (e) incision of the upper part of the flap,
(f) flap fixation to the thoracic wall, (g) postoperative frontal view after the first procedure, (h) postoperative ¾ left view after the first procedure, (i)
frontal view at 2 years follow-up after the second procedure, (j) ¾ left view at 2 years follow-up after the second procedure.

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Fig. 70.14 Correction of Poland’s syndrome deformity in a 17-year-old patient treated with two sessions of lipomodeling (205 mL and 297 mL) at an
interval of 6 months. (a) Preoperative frontal view, (b) preoperative ¾ right view, (c) preoperative ¾ left view, (d) 1 year postoperative frontal view,
(e) 1year postoperative ¾ right view, (f) 1 year postoperative ¾ left view.

70 Fat Grafting of the Breast
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Clinical Caveats
• Careful preoperative clinical and radiologic assessment and
clearance for the procedure are essential before a fat transfer
procedure.
• Fat must be injected in a multilayered fashion, starting from
the deep plane and moving to the superficial plane.
• Fat must be injected in fine tunnels in a consistent fashion to
avoid fat necrosis.
• Fat transfer should be stopped at each injection site when the
recipient site is saturated.
• Resorption rates, the quality of the fat transferred, and char-
acteristics of the recipient site must be taken into account
in initially overcorrecting volumes to produce the desired
contour and volume.
Fig. 70.15 Breast composite augmentation, correction of pectus excavatum and asymmetry after tumorectomy for breast cancer in a 41-year-old
patient. She was treated with one 140-mL fat grafting session and a second session of 90 mL associated with breast augmentation with round silicone
implants (325 mL on the right breast and 350 mL on the left breast). The patient refused symmetrization of the nipple position. (a) Preoperative
frontal view, (b) preoperative ¾ right view, (c) preoperative ¾ left view, (d) 1 year postoperative frontal view, (e) 1 year postoperative ¾ right view,
(f) 1 year postoperative ¾ left view.

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Fig. 70.16 Lipomodeling for pectus excavatum correction in a 17-year-old patient with lateralized pectus excavatum treated with two lipomodeling
sessions of the right breast (200 mL, and 360 mL). (a) Preoperative frontal view, (b) preoperative ¾ right view, (c) preoperative ¾ left view, (d) 1 year
postoperative frontal view, (e) 1 year postoperative ¾ right view, (f) 1 year postoperative ¾ left view.

70 Fat Grafting of the Breast
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[36] Hicok KC, Hedrick MH. Processed lipoaspirate for fat enhancement. In: Coleman
SR, Mazzola RF, eds. Fat Injection: From Filling to Regeneration. St Louis: Quality
Medical Publishing; 2009
[37] Illouz YG. La Sculpture Chirurgicale par Lipoplastie. Paris: Arnette; 1988
[38] Khouri RK, Del Vecchio DA. Breast reconstruction and augmentation with Brava
external expansion and fat grafting. In: Coleman SR, Mazzola RF, eds. Fat Injec-
tion: From Filling to Regeneration. St Louis: Quality Medical Publishing; 2009
[39] Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar treatment. J
Craniofac Surg 2013;24(5):1610–1615
[40] .ronowitz S-, Mandujano CC, Liu -, et al. Lipofilling of the breast does not in-
crease the risk of recurrence of breast cancer: A matched controlled study. Plast
Reconstr Surg 2016;137(2):385–393
[41] Laloze J, Varin A, Gilhodes J, et al. Cell-assisted lipotransfer: Friend or foe in
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2018;12(2):e1237–e1250
[42] Linder RM. Fat autografting [letter to the editor]. Plast Reconstr Surg
1987;80(4):646–647
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regenerative medicine. Stem Cell Rev 2011;7(2):269–291
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[45] Oustehout DK. Breast augmentation by autologous fat injection [letter to the
editor]. Plast Reconstr Surg 1987;80(6):868–869
[46] Petit JY, Lohsiriwat V, Clough KB, et al. The oncologic outcome and immediate
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2005;55(6):696–697

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71 Composite Primary and Revision Breast Augmentation
Michael Scheflan, Adi Maisel Lotan, and Bradley Bengtson
Abstract
Patient standards of outcomes in aesthetic breast surgery have
risen dramatically in the last decade. Accordingly, demands
and expectations of the final surgical result have risen as well.
Formerly, patient requests with compromised tissues, such as “I
would like my breasts closer together,” “Please make my breasts
wider,” “Please make my breasts bigger but softer,” and “I wish
to enhance my lower pole,µ could not be met without significant
complications. The advent of fat grafting to the breast and tissue
reinforcement with acellular dermal matrices (ADMs) or syn-
thetic mesh have added significant tools to the plastic surgeon’s
armamentarium. Currently, ADMs, surgical scaffolds, and fat are
common modalities practiced widely in breast surgery to maxi-
mize patient outcomes and minimize future complications.
A composite approach using either fat or tissue reinforcement
or both is a useful adjunct in aesthetic primary and revision breast
augmentation. Patients who are likely to benefit from either or
both adjuncts are those who lack overlying soft tissue coverage;
patients who desire small implants; patients with breast asym-
metry or a constricted or tuberous breast; and patients needing
correction of complications of a previous breast surgery with
implants, including rippling, malposition, bottoming out, anima-
tion deformity, symmastia, and capsular contracture. This chapter
reviews the indications for fat grafting and tissue reinforcement
use in primary and revision breast augmentation surgery. Aspects
of the authors’ experience, indications for using the composite
approach, and surgical techniques and outcomes are presented.
Keywords
composite breast augmentation, hybrid breast, bioengineered
breast, fat injection, acellular dermal matrix, breast implant
revision
71.1 Introduction
A composite approach in aesthetic primary augmentation and
revisional breast augmentation, using either or both fat and
tissue reinforcement is a useful adjunct when the patient’s
overlying soft tissues are inadequate. Acellular dermal matrices
(ADMs) and synthetic scaffolds may be used to produce improved
aesthetic outcomes, particularly in complex breast patients.
ADMs, surgical scaffolds, and fat are common modalities
practiced in immediate and delayed implant-based breast recon-
struction and are important strategies for maximizing patient
outcomes and minimizing future complications.
71.2 Background
Implant-based breast augmentation surgery is one of the
commonest aesthetic surgical procedures performed. It aims at
providing greater breast volume to hypoplastic breasts, creating
a natural shape and a durable result. One of the major drawbacks
of breast implants may be their unnatural appearance when the
implant and soft tissue that overly it are uneven and unbalanced.
Several techniques have been suggested to overcome this and
improve surgical outcomes. Fat grafting to the breast has been
reported both in cosmetic and reconstructive surgery and
has proven to be a powerful tool to manage the soft tissue of
the breast. Implants and fat in primary augmentations allow
placement of smaller implants, narrowing of the intermammary
distance, enhancing the upper pole, and correcting asymmetries
and tuberous deformities.
71.3 Composite Breast
Augmentation
The concept of composite breast augmentation that entails usage
of an implant along with fat grafting in primary augmentation
was introduced by Del Vecchio et al in 2013. The combination of
both classic implant augmentation and simultaneous fat injection
achieves larger breast volume, which cannot be obtained solely
with fat, with smaller implants and a better implant-to-soft
tissue ratio. The added benefit of liposuction remains appeal-
ing to patients as well (Fig. 71.1). Potential drawbacks of this
technique are longer operative times, possible increased risk of
infection, and inadequate donor or recipient sites.
Another adjunct in composite breast augmentation is usage of
acellular dermal matrices (ADMs) or scaffolds. To date, due to high
costs, ADMs and scaffolds are mostly used in breast reconstruc-
tion to stabilize the implant pocket, provide additional coverage,
and reduce capsular contracture in both partial muscle and the
prepectoral position. Following their common use in breast
reconstruction, ADMs and scaffolds have been implemented in
cosmetic breast surgery, in both primary and revisionary breast
augmentation. Reported indications for ADMs or fat in the liter-
ature are inadequate soft tissue coverage, wide intermammary
space, prevention or treatment of capsular contracture, rippling,
implant displacement, malposition, bottoming out, and symmas-
tia. Studies performed to date deal mostly with secondary cases
where fat and ADMs were found to be effective in these instances.
• Implants, ADMs/scaffolds, and fat are used in revision breast
augmentation to help correct wrinkling, implant visibility and
palpability, malposition, symmastia, and bottoming out.
• The incidence of capsular contracture may be reduced and
treated using ADMs, and soft tissue irregularity and asymme-
try are improved with fat.
• Soft tissue padding with lipofilling masks the outline of an
implant. This in turn enables the use of more round, smooth
implants and the potential for over-the-muscle placement.
• The composite approach in implant-based breast surgery
helped indirectly change the process of implant selection

71 Composite Primary and Revision Breast Augmentation
1085
for breast augmentation and address issues like prepectoral
implant placement, breast animation, and anaplastic large-cell
lymphoma (ALCL).
• Scaffolds and ADMs are used in primary and secondary breast
surgery in order to maximize outcomes and minimize compli-
cations when the patient’s own tissues are lacking.
• Composite breast augmentation is a powerful tool to solve
difficult challenges and complications in primary and revision
breast augmentation.
71.3.1 Indications for Composite Breast
Augmentation
• Patient desire for unnoticeable, unpalpable, invisible implants
(smaller implants and more soft tissue coverage)
• Inadequate soft tissue coverage
• Patient with breast asymmetry
• Patient with constricted/tuberous breast
• Complications of previous breast augmentation
• Rippling, malposition, bottoming out, animation, symmastia
• Contour deformities
• Capsular contracture
• Support in primary (or revisional surgery) for augmentation/
mastopexy in weight loss or poor–tissue quality patients
None of the patients discussed in this chapter, who received fat
grafting and an implant with or without a scaffold, were pre-ex-
panded using BRAVA (Brava LLC, Miami, FL).
None of the patients had intentional overgrafting of the breasts.
71.4 A'0 Dnd SFD̵ROd in 3rimDry
and Secondary Breast
Augmentation
Every patient brings individual anatomic or postsurgical chal-
lenges to the surgical table, and we strive to achieve the best
Fig. 71.1 A 22-year-old patient who desired small implants and liposuction underwent composite subglandular breast augmentation with Motiva
(Establishment Labs, S.A., Alajuela, Costa Rica) 180-g implants and 250 mL of fat. (a–f) Preoperative; (g) 6 months postoperative.

1086
XI Breast Surgery
possible outcome for each and every patient we serve. Many
primary augmentation patients present with various forms of
breast constriction or tuberosity, or thin, irregular tissue thick-
ness genetically or from significant weight loss or other circum-
stances. It is up to the surgeon to determine with each patient
what, if any, additional technologies or techniques would be
helpful to achieve the best desired outcome, either at the primary
operation or in subsequent breast revisions. In surgical practices
that do a large amount of revision surgeries and have become
known for breast revision work, nearly every revision patient
will undergo a more advanced technique and have additional
tissue reinforcement or fat added because the patient’s own
tissues cannot be relied on to provide support, control scarring,
or create a uniform outcome. In addition, implants are improving
with increased fill ratios and more cohesive fillers that lead to
less inherent wrinkling of the implant shell. Surgeons who do
the most breast revisions have learned that their patients are
hoping to be “one and done,” many having had multiple failed
procedures leaving them desperate for a solution.
In primary augmentation it is much more difficult to discern
and determine which patient will best be treated with these tech-
niques and technologies. Scaffolding or ADMs are beneficial for
patients with massive weight loss, patients seeking large breast
reduction, patients who are very thin with atrophic soft tissue,
and patients with breast constriction. In general, the larger the
breast and the more elastic the skin, the more benefit is gained
from scaffold support. In addition, patients with breast constric-
tion after adequate release who are very thin and deficient in
the lower pole will benefit from a combination of coverage and
support in this region (Fig. 71.2).
Thin and irregular soft tissue is present to some degree in
every breast revision patient and surprisingly a large number
of primary patients as well, particularly those requiring a mas-
topexy. Fat transfer in these patients has become an important
part of primary procedures and the majority of revision patients.
This chapter addresses these challenging questions and patient
presentations. In addition, we will share our evolving algorithm in
trying to determine which primary augmentation patients would
most benefit from these procedures at the onset of their journey.
71.4.1 Indications and Contraindications
Primary Augmentation Patients
Patients present with three primary challenges that would
benefit from considering ADM, scaffold, or fat in the primary
operation: (1) a soft tissue envelope that is too loose, (2) a soft
tissue envelope that is too tight, or (3) insufficient or variable soft
tissue thickness.
Patients with prior significant weight loss or genetically poor
skin elasticity, along with a larger planned residual breast volume,
will benefit from support. :e have initiated several studies to
help objectively define which patients will most benefit to make
the added time and expense worthwhile. We have 500 patients
who have received a variety of ADMs and scaffolds, and it appears
patients with a residual 600-g breast or larger (combined breast
and implant weight) will benefit from support because these
patients typically undergo the most stretch of their lower pole.
Control of the lower pole of the breast controls the outcome in
these patients. Many patients with less than 600 g will also
benefit, but the benefit is harder to quantify in these cases. As of
yet there is no objective accurate elasticity measurement scale;
however, the more elastic the skin that is loaded, the greater the
potential stretch (Fig. 71.3).
In patients with tight, unelastic skin and in various forms
of breast constriction, ADM and scaffold are used for more of
their support, coverage, and expansion effects to accept larger
Fig. 71.2 (a–c) Patient with large breasts, breast ptosis, and increased elasticity. (d–f) 18 months following augmentation-mastopexy with scaffold
support of the lower pole of the breast.

71 Composite Primary and Revision Breast Augmentation
1087
devices (which in return thin the skin) and hence the extra
support provided by the matrix, and also to set and support
the new inframammary fold after it is lowered. Lowering of the
fold is difficult to maintain without additional tissue or scaffold
support.
Other primary augmentation patients that would benefit from
primary fat transfer include patients with wide intermammary
distance, patients with constricted lower poles, and patients with
significant breast asymmetries (Fig. 71.4, Fig. 71.5).
Primary indications for tissue reinforcement with either ADMs
or synthetic mesh are in patients with loose and elastic tissue, and
patients where larger residual breast weights are expected and in
tightly constricted patients.
Contraindications arise in patients that would not necessarily
benefit from these materials, such as patients with smooth, uni-
form tissues and skin, and normal breast dimensions. In addition,
there is the occasional patient that has such a dramatic amount of
fibrocystic disease or blue cysts that the degree of contamination
of the ADM or scaffold may be at risk to place a nonvascularized
foreign body .
A contraindication to fat placement would be placing fat into
a surgically elevated flap space. In the instance of full mastopexy
patients, it would certainly be best to stage the fat transfer
(Fig. 71.6).
Secondary or Breast Revision Patients
Entire books and countless articles have been written on breast
revision and the use of ADMs, scaffolds, and fat in the breast
revision patient. Use of these techniques and technologies is
best categorized by the complication or deformity the surgeon
is attempting to correct or enhance. The most common com-
plications in revisional surgery include capsular contracture,
malposition, stretch deformity, wrinkling and rippling, and
hyperanimation. Fortunately, we have and are developing more
advanced materials, techniques, and strategies to correct chal-
lenging patient presentations.
In patients with too much scar, such as in capsular contrac-
ture, the best revision option consists of capsulectomy and
replacement with an ADM. Using this technique with total cap-
sulectomy and replacement with a minimum of 7 cm vertical
height of ADM, over 300 patients have been successfully treated
with zero recurrence of their contracture (in an ongoing patient
series). Scaffolds have been used in patients with subglandu-
lar capsular contracture with a pocket change and scaffold
placement and may be effective, but with such a high degree
of success and support from the reconstruction literature with
very low capsular contracture rates with ADM in primary
reconstruction, this is clearly the tissue and method of choice
(Fig. 71.7, Fig. 71.8).
Malpositions, on the other hand, are treated with scaffold
that provides a better framework for long-term support. ADM
after incorporation, although preferred for capsular contracture
with better long-term data, can stretch and lose support in the
lower pole over time. :e have used scaffolds such as Galaflex
(Galatea Surgical, Lexington, MA) in over 200 consecutive
patients having malposition repairs with excellent consistent
outcomes and less than a 1% complication rate. There is an
average of 10–15% stretch of the nipple-to-fold distance for the
inframammary fold and lower-pole stretch deformity repairs
with up to a 6-year follow-up (unpublished patient series—
Bengtson; Fig. 71.9).
Because we have yet to develop the perfect implant, nearly
every revision patient has wrinkling and rippling to some degree
and would benefit from fat transfer, which is one of the most
rapidly advancing procedures in our practices.
Fig. 71.3 (a,b) Patient with large breasts, breast ptosis, and increased elasticity. (c–f) 18 months following augmentation-mastopexy with scaffold
support of the lower pole of the breast.

1088
XI Breast Surgery
Often, revisionary patients may present with multiple deformi-
ties, including thin and irregular soft tissue coverage, rippling, and
bottoming out (Fig. 71.10).
Hyperanimation may be treated with a combination of pro-
cedures, including pocket change to prepectoral, muscle fiber
reattachment or release and occasionally fat transfer, and ADM
or scaffold placement bridging the muscular defect. This also
appears to redistribute the vector forces on the muscle and limit
the motion. There is a trend for initial subglandular implant place-
ment in breast reconstruction, and this may also be performed
in breast revision patients; however, it sometimes creates other
complications, such as greater implant visibility, malposition, soft
tissue stretch, or capsular contraction, so the surgeon needs to be
careful about trading one complication for another.
71.4.2 Pertinent Anatomy and
Preoperative Assessment
It is critical to accurately diagnose the actual deformity creating
the anatomical complication or primary deformity in order to
achieve an improved outcome. For instance, there is a significant
difference between a stretch deformity of the lower pole of the
breast and a fold malposition. In the case of a stretch deformity,
the solution is wedge resection of redundant tissue with soft
tissue support, whereas in fold malposition the solution is fold
repair and scaffold support with reattachment of the recruited
abdominal skin back down to the chest wall with support.
In the case of visible wrinkling and rippling, the solution usually
involves using the implant with the greatest degree of cohesivity,
Fig. 71.4 (a–c) Thin primary augmentation patient with chest wall deformity. (d–f) Primary deferential augmentation was performed with a deep,
thick acellular dermal matrix on the left, and an implant with superficial fat in the cleavage and upper pole on the right.

71 Composite Primary and Revision Breast Augmentation
1089
fat transfer to the areas of thinning, and occasionally pocket and
lower-pole support of the device with scaffold.
71.4.3 Preoperative Planning and Patient
Marking
The main guidelines in preoperative planning include making
the correct diagnosis of the patient problem in primary
patients and correct complication in breast revision patients.
However, the general guidelines are the same. In general,
we recommend making use of prior scars with preference to
the inframammary fold access, using tissue-based planning
techniques and principles, choosing and matching the implant
to the patient, and using additional ADM, scaffolds, and the
patient’s own fat to maximize the patient’s outcome and min-
imize recurrent complications. The key focus is to break the
cycle of revision.
The inframammary fold is the foundation of the breast, and it
is vitally important to maintain or reconstruct and reinforce this
structure. Identification of the preoperative fold is sometimes
difficult, particularly if prior fold incisions were not used. In
primary cases it is very important to understand the differences
in what has been identified as the resting and the actual inframa-
mmary fold. Because of the oblique nature of the fibers that attach
from the skin down to the chest wall, the actual fold is typically
1–2.0 cm below the resting fold where patients are typically
marked. Reinforcing this fold and not disrupting it with primary
cases is thus critical (Fig. 71.11).
Next, the ideal nipple-to-fold distance is determined based on
the patient’s breast and implant combined volume. (Several meth-
ods have been described for this purpose including High 5, Tepid,
ICE, and others.) A general starting point is 8.0 cm on stretch from
the nipple to fold based on a 300 mL implant. This calculation and
method has not been established for breast revision patients and
requires further study by future aesthetic surgeons.
Fig. 71.6 Biopsy from breast with fat necrosis after fat grafting.
Fig. 71.5 (a–c) Repair of breast asymmetry and left breast lower pole constriction. Left breast augmentation with implant and fat in the upper pole
along with a right augmentation mastopexy.
Fig. 71.7 Hand-in-glove Strattice (Allergan, Dublin, Ireland) acellular
dermal matrix in position following total capsulectomy, and an 8 ×
16 cm Strattice Contour 2 placement from the leading edge of the
pectoralis muscle to the inframammary fold.

1090
XI Breast Surgery
Fat in primary cases, while less common than in revisional
breast surgery, is indicated in patients with large intermammary
distance for cleavage enhancement as well as for tubular breasts
and breast asymmetries.
71.4.4 2SerDWiYe 7eFKniTue
The operative technique for these procedures has been defined
and presented in other texts and articles. The focus here is to
present a series of surgical techniques and strategies surgeons
may use to maximize their patient outcomes and minimize
complications when using scaffolds and ADMs in the breast.
Caveat  7reDW AOO SFD̵ROdV Dnd A'0V /iNe Dn
Implant
Do not place the tissue or scaffold on the skin. Place any scaffold
or ADM directly into the breast or pocket. Use triple antibiotic
Fig. 71.8 (a–c) Bilateral Baker IV capsular contracture following periareolar augmentation. (d–f) Shown 2 years following total capsulectomy with
Strattice Contour 2, acellular dermal matrices (Allergan, Dublin, Ireland) as pectoral extensions.
Fig. 71.9 Significant lateral and inferior malposition with saline implants shown (a–c) pre- and (d–f) postoperatively and (g) intraoperatively in the
supine position.

71 Composite Primary and Revision Breast Augmentation
1091
irrigation, phase I, dilute povidone–iodine solution (Betadine or
your normal strategy for these materials (Fig. 71.12).
Caveat 2. Bring the Incision Lines Straight
Down along the Areolar Margin versus Out at
an Angle with a Typical Wise-Type Pattern
Because using these tissues typically involves mastopexy-type
patterns with removal of significant redundant skin, care should
be taken to remove the correct amount of skin. Instead of plan-
ning in significant stretch postoperatively, skin stretch with
scaffold support is typically only 10–15 of the nipple-to-fold
distance on stretch (i.e., 1–2 cm). It is critical to plan for minimal
skin stretch (Fig. 71.13).
Caveat 3. Use Nipple Shields, Funnels, Protect
the Implant, and Cover the Nipples
Similar to techniques used to reduce capsular contracture and
biofilm development, the same techniques should be used for
ADMs and surgical scaffolds (Fig. 71.14).
Caveat 4. Limit Surgical Lint That Can Attach to
SFD̵ROdV Dnd A'0V Dnd ,nWernDO 7iVVueV Dnd
Sterilize the Pockets
Surgeons need to be more aware that there are significant
amounts of surgical debris and lint that can collect on
all devices and inside surgical pockets during surgery.
Furthermore, implants are electronegatively charged during
their sterilization process. This creates an electrostatic field
around them that further attracts particles and possibly even
bacteria. The field can be discharged by wetting the implant
with liquid (our current implant irrigation solution is 1 g of
cefazolin, 80 mg of gentamicin, and 50 mL of povidone–iodine
solution in 500 mL of normal saline). There will be increasing
awareness of these issues in the future, and development of
new materials and methods to decrease contamination with
PhaseOne, a solution of hypochlorous acid (McKesson, San
Francisco, CA), is also gaining data and support. In the mean-
time, copious use of irrigation and minimal use of laparotomy
sponges and towels around the surgical site are important
(Fig. 71.15).
Caveat 5. Use of an Abdominal Tab versus a
Straight “Inverted T” When This Approach
Is Used
Often patients with poor skin quality and prior significant weight
loss have significant extra skin that needs resection during the
procedure. Use of the abdominal tab that was described in breast
Fig. 71.10 (a–d) Revision for bottoming out in a thin patient. A
360 mL round, textured implant replaced with the same volume
B-Lite round, smooth high-profile implant (Polytech, Dieburg,
Germany). No change in implant pocket; dual plane 3; lower-pole
fixation/support with acellular dermal matrix and fat grafting in
upper cleavage.
Fig. 71.11 (a) Resting versus (b) the actual fold based on the oblique
fibers connecting the inframammary skin to the chest wall. (c) This skin
insertion can be accentuated by pulling on the fibrous attachments.

1092
XI Breast Surgery
reductions is useful in these procedures to minimize wound
breakdown and dehiscence (Fig. 71.16).
Caveat 6. Double-Hand-in-Glove Fit of the
,mSODnW%reDVW WR WKe SFD̵ROdA'0 Dnd Dn
AddiWiRnDO +Dnd-in-GORYe )iW RI WKe SFD̵ROd
ADM to the Skin Envelope
Tissue-based planning is critical to the appropriate volume
and projection of the implant used. The scaffold is templated to
create a gentle, round lower pole without being overly loose or
flat/tight, and the skin is snug without placing too much tension
on the skin closure. Use of a 2–0 absorbable suture approximat-
ing the breast fascia is also important to take tension off the skin
closure (Fig. 71.17).
Fig. 71.12 Caveat 1. Treat all scaffolds and acellular dermal matrices
like an implant.
Fig. 71.14 (a,b) Caveat 3. Use nipple shields and funnels, protect the
implant, and cover the nipples.
Fig. 71.13 Caveat 2. Bring the incision lines straight down along
the areolar margin versus out at an angle with a typical Wise-type
pattern.
Fig. 71.15 Caveat 4. Limit surgical lint that can attach to scaffolds
and acellular dermal matrices and internal tissues and sterilize the
pockets.

71 Composite Primary and Revision Breast Augmentation
1093
Caveat 7. Use Three-Dimensional Templating
with a Moldable Template
Surgical glove paper, scaffold packaging material may be used to
properly trim and template the scaffold. Use slightly more scaf-
fold or ADM than you anticipate, and trim as needed. In addition,
do not trim or orient the scaffold until you know the soft tissue
requirements and have re-created the defect (Fig. 71.18).
&DYeDW  ,nVeW WKe SFD̵ROd Rr A'0  Fm 2̵
the Incision Line or Nipple
In case there is a small dehiscence or exposure, it is preferable
not to have the material right under the incision line (Fig.
71.19). The majority of complications are not actually compli-
cations of these materials but actually wound dehiscence or
Fig. 71.16 (a,b) Caveat 5. Use of an abdominal tab versus a straight
“Inverted T” when this approach is used.
Fig. 71.17 (a,b) Caveat 6. Double-hand-in-glove fit of the implant/
breast to the scaffold/acellular dermal matrix (ADM) and an additional
hand-in-glove fit of the scaffold/ADM to the skin envelope.
Fig. 71.18 Caveat 7. Three-dimensional templating is used with a
moldable template.

1094
XI Breast Surgery
wound healing issues that result in exposure of the material.
Any exposed material may be simply excised. I have not seen an
increase in complications directly related to over 150 Galaflex
cases, for instance, over prior cases where scaffolds were not
used, with complications related to the wound healing itself.
In instances where scaffold or ADM is placed inside the breast
adjacent to the implant, it is important to look at these tissues
as a capsule reinforcement or replacement. In cases of malpo-
sition repair I prefer to use a capsular flap, which is essentially
a neosubpectoral pocket using the posterior capsule. In cases
of capsular contracture, it is important to remove as much of
the capsule as possible and use an ADM to replace the diseased
capsule. I prefer not to place scaffold or ADM directly on top of
the capsule. Although it may work in some situations, as the
capsule has been shown to have its own blood supply and sup-
port a skin graft, it is more reliable to place these materials and
tissue directly on more vascularized tissue versus the capsular
surface.
&DYeDW  ,mmREiOi]e WKe A'0 Rr SFD̵ROd
Properly
Typically, these materials are inset with 2–0 polydioxanone
suture (PDS) with placement of enough sutures to immobilize
the scaffold. Some surgeons use minimal suture, and this is not
ideal in that mobile structures typically do not heal as well—
motion may prevent healing, and we have occasionally seen
collapse and an accordion effect of the scaffold (see Fig. 71.12,
Fig. 71.20).
Caveat 10. Imbrication and Stabilization of the
SFD̵ROdA'0 WR WKe AnWeriRr SNin )ODSV
The anterior scaffold or ADM can be sutured to the anterior
skin flaps with a 3–0 PDS or Monocryl suture similar to quilt-
ing or progressive tension suture placement in the abdomen.
This helps prevent shearing effects, with this and fluid being
the most common reasons for lack of integration and revas-
cularization. Wedge cuts can also be placed in nonfenestrated
ADMs with these small openings sutured to the overlying skin
(Fig. 71.21).
Caveat 11. Flaps of Tissue 1.5–2.0 cm in
Thickness Are Recommended, Particularly in
the Distal Skin Flap Areas
Thick flaps are critical for blood flow and success. In addition,
approximation of the deep fascia should be performed to take
the tension off the closure and reinforce the strength, typically
using 2–0 polyglactin 910 (Vicryl; Johnson & Johnson, New
Brunswick, NJ) or poliglecaprone 25 (Monocryl, Johnson &
Johnson, New Brunswick, NJ; Fig. 71.22). Fat grafting may
be used as well to thicken thin flaps anywhere in the breast
quadrants.
Caveat 12. Immobilization of the Breast
The breast is immobilized with tape, Ioban (3M, St. Paul, MN), and
a surgical bra, and an upper-pole strap is considered to further
stabilize the breast and help push and compress the breast into
the ADM and scaffold, further immobilizing it and maximizing
integration and revascularization. Surgical drains should also be
considered, particularly when an ADM rather than a perforated
scaffold is used (Fig. 71.23).
71.5 Fat Grafting
71.5.1 Indications
• Patient desires unnoticeable, nonpalpable, invisible implants
(smaller implants and more soft tissue coverage).
• Patient requires soft tissue augmentation with adequate adi-
pose donor sites.
• Patient desires a narrower intermammary distance or a wider
base width of the breast.
• Patient has soft, pliable breasts.
71.5.2 Contraindications
• Smokers, obese patients, or patients without adequate donor
sites
Fig. 71.19 (a,b) Caveat 8. Inset the scaffold or acellular dermal matrix
1.5 cm off the incision line or nipple.

71 Composite Primary and Revision Breast Augmentation
1095
• Patients with tight, tense breasts
• Patients with inadequate adipose donor sites
71.5.3 2SerDWiYe 7eFKniTue
)DW +DrYeVWing Dnd ,nMeFWiRn 7eFKniTue
• Fat is harvested after infiltrating donor sites with a 2:1 ratio of
wetting solution containing 1,000 lactated ringers + 40 mL 1%
lidocaine and 1 mg adrenalin. A roller pump is used to infiltrate
the donor areas, and closed-circuit aspiration proceeds either
manually or with power-assisted liposuction (PAL) depending
on the amounts required for grafting (small- or large-volume
grafting).
• For small-volume fat grafting (< 200 mL) we prefer a 20-mL
Luer lock syringe connected to a 3-mm multihole cannula and
left for decantation.
• Lipofilling of micrografts in small-volume engraftment (2-mm
pearls of fat tissue) is done with 10-mL syringes and a corre-
sponding small cannula using Coleman’s principles.
• Large-volume lipofilling is performed using a vibration/
expansion technique with a PAL device as described by Del
Vecchio and Wall.
Caveat 1. It Is Important to Harvest Small
Parcels (Micrografts) of Fat to Maximize Take
Harvesting for breast lipofilling may be done manually with a
20-mL syringe attached to a 3-mm multihole (2-mm holes)
Fig. 71.22 Caveat 11. Thick flaps of tissue 1.5–2.0 cm in thickness are
recommended, particularly in the distal skin flap areas.
Fig. 71.23 Caveat 12. Immobilization of the breast postoperatively.
Fig. 71.20 Caveat 9. Immobilize the acellular dermal matrix or scaffold
properly.
Fig. 71.21 (a ,b) Caveat 10. Imbrication and stabilization of the
scaffold/acellular dermal matrix to the anterior skin flaps.

1096
XI Breast Surgery
cannula when small volumes (up to 200 mL per breast) of fat
are necessary. Alternatively, when large volumes (> 200 mL per
breast) are required, PAL devices are very useful, efficient, and
time sparing. Either way, the holes at the end of the cannula
determine the size of the fat particles to be grafted, which in turn
is critical to timely revascularization and “take.”
&DYeDW  )DW 3ODFemenW 7eFKniTue
Lipofilling must adhere to Coleman’s principles of distributing
the fat in a way that facilitates neovascularization of the grafted
tissues. At no time, regardless of volume, should the breast or any
part of it become indurated nor overfilled.
As much as possible, lipofilling should be aimed to the non-
glandular tissues of the breast (subcutaneous, subglandular, and
intramuscular).
&DYeDW  :Ken 3erIRrming /iSRÀOOing IRr
Revision Augmentation Surgery, It Is Highly
Recommended That the Pocket Be Explored for
Inadvertent Placement of Fat
Exploring the pocket for inadvertent fat placement may
prevent placement of graft in a nonvascularized environment
in proximity to the implant, reducing potential complications
such as fat necrosis, implant rupture, and periprosthetic
infections.
Caveat 4. Maximize Fat “Take” by Proper
Handling of the Graft and Optimizing Recipient
Site Vascularity
Most issues with lipofilling have to do with inadequate ´takeµ and
fat fibrosis. Both may be reduced by proper surgical techniques
of harvesting and injection. Smokers are poor candidates for fat
grafting in general. A careful harvesting, as detailed earlier, and
even distribution of mini or micro fat grafts above the glandular
tissue in the subcutaneous fat and occasionally the pectoralis
muscle reduce complications. Decanting is often an adequate
preparation.
71.6 Postoperative Care
It is important to keep breasts immobilized following complex
revision cases where scaffolds, ADMs, and fat are used. In breast
reconstruction with expanders, the expansion effect will ´pushµ
the ADM into the soft tissues to help facilitate integration
and revascularization. In revision cases with no expansion it
becomes important for the implant and tissues to be placed with
a ´hand-in-gloveµ fit and also to apply some external pressure
using a band and bras to apply pressure and maximize contact
and integration potential of the materials into the patient’s soft
tissues.
Postoperatively, patients can move and stretch and resume
normal day-to-day activity but the breasts should remain “quiet”
for 4 weeks, with no impact or chest-focused activities.
71.7 Results and Outcomes
Results with combinations of fat transfer to the breast, ADM, and
scaffold support continue to evolve. :ith fine attention to detail
and surgical technique, along with improving products and
techniques, the results may often create far superior outcomes.
Although fat transfer to the breast has low complications, such
as oil cysts or rare calcifications, the revascularization remains
variable. Fat is usually very uniform, as the resorption is quite
uniform; however, 50% graft take would be considered a good
outcome. Advancements continue in the area as techniques and
technologies improve.
ADM usage mainly for capsular contraction treatment has
become standardized and consistent, with low complications
in the 2–3% range attained with good technique and following
the caveats presented. Scaffold support of the breast, used pri-
marily for prevention of stretch deformities and secondarily for
malposition repair, has been an important adjunct in achieving
improved patient outcomes. Scaffolds resist the weight of the
breast and help limit lower-pole stretch to 10 to 20% of the
nipple-to–inframammary fold set at surgery that may double in
length without support in weight loss and patients with high soft
tissue stretch. Increased complications have not been seen when
the new absorbable scaffolds are used.
71.8 Concluding Thoughts
Complication rates continue to be unacceptably high in primary
and particularly revision surgery, with some complications
exceeding 30% in primary and 50% after a patient has had at
least one prior revision. It is thus important to take on new
strategies and bring in new techniques and technologies to
mitigate complications and break the cycle of revision. Fat trans-
fer in both primary and revisional patients is one of the more
significant advancements in breast surgery, with new research
and advancements in fat constantly evolving. Embracing new
techniques and technologies such as ADMs, scaffolds, and fat
grafting in our breast revision algorithms and even occasionally
in high-risk primary breast augmentation patients will be criti-
cal to improving future outcomes.
Clinical Caveats
• Determine which patients are at risk for developing
complications.
• Employ strategies in primary patients to limit development of
less than ideal outcomes.
• Make an accurate diagnosis of patient complications and
develop a good strategic plan for repair.
• Maximize techniques and technologies to minimize compli-
cations and maximize outcomes.
• Use fat to correct and improve areas of soft tissue loss or
irregularity.
• Use scaffolds and ADM for malposition support or scar con-
tracture repair in primary or revisional breast surgery.

71 Composite Primary and Revision Breast Augmentation
1097
Suggested Reading
[1] Auclair E, Blondeel P, Del Vecchio DA. Composite breast augmentation: soft-tissue
planning using implants and fat. Plast Reconstr Surg 2013;132(3):558–568
[2] Auclair E, Anavekar N. Combined use of implant and fat grafting for breast aug-
mentation. Clin Plast Surg 2015;42(3):307–314, vii
[3] Bengtson BP. Complications in breast surgery. In Bucky LP, Mottura AA, eds.
Aesthetic Breast Surgery. Philadelphia, PA: WB Saunders; 2009
[4] Bengtson BP, Teitelbaum S. Revision breast augmentation. In Adams WP, ed.
Breast Augmentation: An Operative Atlas. New York, NY: McGraw-Hill; 2011
[5] Bengtson BP, Teitelbaum S. Revision breast augmentation. In Adams WP, ed.
Breast Augmentation Video Atlas. 2nd ed. New York, NY: Thieme; 2019
[6] Bengtson BP. Atlas of Aesthetic Breast Surgery, Ed Jewell. Using capsular tissue
to optimize breast revision outcomes with posterior capsular flap techniques.
Publication Pending 2019
[7] Bengtson BP. Complications, reoperations, and revisions in breast a Clin Plast
Surg 2009; 36(1):139–156
[8] Bravo FG. Parasternal infiltration composite breast augmentation. Plast Reconstr
Surg 2015;135(4):1010–1018
[9] Burkhardt BR, Dempsey PD, Schnur PL, Tofield --. Capsular contracture: a
prospective study of the effect of local antibacterial agents. Plast Reconstr Surg
1986;77(6):919–932
[10] Del Vecchio DA. “SIEF”—simultaneous implant exchange with fat: a new option
in revision breast implant surgery. Plast Reconstr Surg 2012;130(6):1187–1196
[11] Del Vecchio D, :all S -r. Expansion vibration lipofilling: a new technique in
large-volume fat transplantation. Plast Reconstr Surg 2018;141(5):639e–649e
[12] Friedman T, Davidovitch 1, Scheflan M. Comparative double blind clin-
ical study on round versus shaped cohesive gel implants. Aesthet Surg J
2006;26(5):530–536
[13] Handel N, Cordray T, Gutierrez J, Jensen JA. A long-term study of outcomes,
complications, and patient satisfaction with breast implants. Plast Reconstr Surg
2006;117(3):757–767, discussion 768–772
[14] Handel N. Managing complications in augmentation mammaplasty. In Spear SL,
ed. Surgery of the Breast. 2nd ed. Vol. 102. Baltimore, MD: Lippincott Williams &
Wilkins; 2006:1417–1435
[15] Hedpn P, Montemurro P, Adams 😛 -r, Germann G, Scheflan M, Maxwell GP. Ana-
tomical and round breast implants: how to select and indications for use. Plast
Reconstr Surg 2015;136(2):263–272
[16] Kerfant N, Henry AS, Hu W, Marchac A, Auclair E. Subfascial primary breast
augmentation with fat grafting: a review of 156 cases. Plast Reconstr Surg
2017;139(5):1080e–1085e
[17] Lotan AM, Cohen D, Nahmany et al. Histopathological study of meshed versus
solid sheet acellular dermal matrices in a porcine model. Ann Plast Surg
2018;81(5):609–614
[18] Maisel Lotan A, Ben meshed and nonmeshed acellular dermal matrix in immediate breast recon-
struction. Plast Reconstr Surg. 2019 Nov;144(5):1045-1053
[19] Maxwell GP, Gabriel A. Bioengineered breast: concept, technique, and preliminary
results. Plast Reconstr Surg 2016;137(2):415–421
[20] Mofid MM, Singh 1.. Pocket conversion made easy: a simple technique using
alloderm to convert subglandular breast implants to the dual-plane position.
Aesthet Surg J 2009;29(1):12–18
[21] Muntan CD, Sundine MJ, Rink RD, Acland RD. Inframammary fold: a histologic
reappraisal. Plast Reconstr Surg 2000;105(2):549–556, discussion 557
[22] Sampaio Goes JC, Munhoz AM, Gemperli R. The subfascial approach to primary
and secondary breast augmentation with autologous fat grafting and form-stable
implants. Clin Plast Surg 2015;42(4):551–564
[23] Scheflan M. Building a breast without a prosthesis. The transverse abdominal
island flap. Clin Plast Surg 1984;11(2):303–315
[24] Scheflan M. Commentary on: Clinical applications of mesenchymal stem cells in
soft tissue augmentation. Aesthet Surg J 2010;30(6):843–844
[25] Scheflan M, Colwell AS. Tissue reinforcement in implant-based breast recon-
struction. Plast Reconstr Surg Glob Open 2014;2(8):e192
[26] Scheflan M, Grinberg-Rashi H, Hod .. Bovine acellular dermal matrix in immedi-
ate breast reconstruction: a retrospective, observational study with SurgiMend.
Plast Reconstr Surg 2018;141(1):1e–10e
[27] Spear SL, Carter ME, Ganz JC. The correction of capsular contracture by conver-
sion to “dual-plane” positioning: technique and outcomes. Plast Reconstr Surg
2006;118(7, Suppl):103S–113S, discussion 114S

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72 Capsular Contracture: Current Science, Prevention, and
Management
Nicholas Lahar, Jason Roostaeian, and William P. Adams Jr.
Abstract
Despite significant improvements in the prevention of capsular
contracture, it remains the leading complication of aesthetic
breast surgery. With breast augmentation representing the
single most common aesthetic procedure performed world-
wide, a significant patient and economic burden exists. In
recent years there have been significant advances in our under-
standing of the mechanisms behind capsular contracture,
particularly as we investigate a related but separate disease
process called breast implant–associated anaplastic large-
cell lymphoma (BIA-ALCL). Capsular contracture incidence
has been shown to be reduced with measures that minimize
bacterial contamination, such as appropriate antimicrobial
breast pocket irrigation; however, when encountered, capsular
contracture can be successfully managed only with surgical
intervention.
Keywords
capsular contracture, breast implants, breast augmentation,
breast augmentation outcomes, antibiotic irrigation
72.1 Introduction
Breast augmentation has remained the most common cosmetic
surgical procedure since 2006, and its complications have a
significant personal and economic impact. Capsular contrac-
ture is the most common complication of aesthetic breast
surgery, and plastic surgeons must frequently manage it.
Approximately 1.5 million breast augmentations are done each
year outside the United States and 300,000 within the United
States. With contracture rates ranging between 7 and 15%,
180,000 women are affected by capsular contracture each year
globally. Because it is primarily managed surgically, it is the
most common cause for reoperation following breast implant
placement.
Subclinical infection of the implant during the perioperative
period has come to the forefront as the leading etiology behind
capsular contracture. Other etiologies that may play a role include
hypertrophic scar hypothesis, activated myofibroblasts, silicone
gel bleed, hematoma, or infection-related inflammation.
72.2 Capsular Contracture:
Current Science
The connection between capsular contracture and bacterial
contamination of the implant was first described in the early
1980s. Shah et al demonstrated significant capsular contracture
in rabbit implant pockets inoculated with Staphylococcus epi-
dermidis bacteria. Also in 1981, Burkhardt et al demonstrated a
connection of subacute periprosthetic infection to capsular con-
tracture in human patients. Frustrated by a capsular contracture
rate of 50%, they began to culture pockets of open capsulotomy
patients. The cultures revealed a high percentage of S. epider-
midis despite no acute infection. Postulating the microbes were
causing the capsular contracture, they investigated the effect
of intraoperative antibiotic solution on their rates of capsular
contracture. They were able to lower their capsular contracture
rate significantly by using intraluminal antibiotic fluid during
their breast augmentations. The silicone shells for these aug-
mentations were permeable to the antibiotic and able to leach
out into the surrounding breast pocket. In a follow-up study by
the same group that was prospective, randomized, and double
blinded using intrapatient controls, prophylactic treatment
of the implants with antibiotic solution demonstrated an 85%
reduction in capsular contracture as compared to the contra-
lateral untreated side. Although the Burkhardt study and others
first implicated S. epidermidis, further studies have implicated
multiple bacterial types in the formation of capsular contrac-
ture. S. epidermidis was first implicated and has been the most
described species, but Propionibacterium acnes, Escherichia coli,
and other bacteria have been cultured from capsular contracture
pockets as well.
Despite the association of bacteria with pathologic peripros-
thetic capsules, microscopic and pathologic examination of cap-
sules and the implants were initially inconsistent. The pathologic
capsules frequently demonstrated negative cultures with “typical”
swabs of the implant pocket. In one early study by Rudolph et al,
examinations of the capsules using electron microscopy revealed
little evidence of bacteria in the capsules. Some of these studies
may have slowed our understanding of bacterial inoculation as
a significant etiology for capsular contracture. A retrospective
review by 1etscher et al references the relative difficulty of
obtaining a “standard culture” of breast implant pockets due to
the protective biofilm layer that entraps offending pathogens.
In this study, the group examined 389 implants removed for
reasons other than overt infection. They too correlated positive
staphylococcus with the development of significant III/IV capsular
contractures.
In addition to these studies within the plastic surgery realm,
there was mounting evidence in other medical subspecialties that
bacterial biofilm formation was a ubiquitous phenomenon affect-
ing various medical devices, urinary catheters, central lines, and
orthopaedic implants. Biofilms are ubiquitous, and these support-
ing studies within other specialties helped clarify an etiology for
capsular contracture. Increasingly sophisticated studies helped
our understanding of bacteria/biofilm as the key cause/effect
factor in capsular contracture. Pajkos et al examined 48 implant/

72 Capsular Contracture: Current Science, Prevention, and Management
1099
capsule samples during explantation in 27 breasts with capsular
contracture. They evaluated the presence of bacteria using routine
culture methods as well as by maceration with sonication. No
samples via routine culture demonstrated bacteria, yet 17 of 19
samples taken from patients with significant contracture were
positive for bacteria using the maceration method. In a porcine
model, Tamboto et al performed submammary breast augmenta-
tions and inoculated some of these pockets with S. epidermidis.
Inoculated pockets were significantly associated with biofilm
formation. The presence of biofilm was in turn strongly associated
with the development of capsular contracture. Additionally, the
uninoculated pockets that ultimately did develop biofilm and
capsular contracture were found to be “self-inoculated” by native
porcine S. epidermidis.
The evaluation of implant shell texturization and its ability
to inhibit capsular contracture has furthered our understanding
of the processes occurring at the implant–capsule–pericapsular
interface. Texturization of breast implants occurred early in their
development, when the “natural Y” implant was introduced in
1968. This implant incorporated a polyurethane foam coating on
its surface. It was felt that this coating prevented the contraction
of capsular myofibroblasts, thereby disrupting the progression of
the capsule. After the carcinogen 2,4-toluenediamine was found
in the urine of patients with these polyurethane implants, the
implants were voluntarily removed from the market. However,
manufacturers still sought methods for texturization of these
implants to mimic the polyurethane surface. To date, there are a
total of four processes used to create texturizaton of the implant
surface: salt loss, vulcanization, imprinting, and a proprietary
nanotexurization technique.
Studies of the effect of texturization on the development of
capsular contracture have resulted in mixed conclusions. Various
studies comparing smooth and textured implants showed either
modest reduction of capsular contracture or no significant
improvement. Proponents of texturing argue the texturing allows
improved integration of the host tissues into the textured surface
of the implant. They claim they have better control of implant
position as well as a reduction in the rate of capsular contracture.
Other studies suggest there is improved fibroblast adhesion and
blood supply to the immediate area. Texturing, on the other hand,
significantly increases the surface area of the implant, leading to
more area for bacterial ingrowth and biofilm deposition. To inves-
tigate the effect texturing had on biofilm development, -acombs
et al used the previously established porcine model to evaluate
a total of 121 smooth or textured implants. Sixty-six implants
were inoculated with S. epidermidis. They found no difference in
the rates of capsular contracture for inoculated smooth versus
textured implants, with a capsular contracture rate of about 80%
in both groups. However, at 2 hours, 6 hours, and 24 hours, the
textured implants demonstrated an 11-, 43-, and 72-fold higher
bacterial load on the surface, respectively, compared to smooth
implants. The contracted implants had a 250-fold higher number
of bacteria in the capsules, whether from smooth or textured
implants. Furthermore, there are clinical studies that have
demonstrated less capsular contracture in smooth implants as
compared to textured implants. These studies highlight the ambi-
guity in the literature surrounding texturization and capsular
contracture. The purported reduction in capsular contracture is
not consistently supported by data. However, the significantly
increased surface area of textured implants cannot be disputed.
It is without question that the increased surface area in turn
increases the bacterial load within the pocket. Above a certain
threshold, the bacteria may lead to an increased risk for capsular
contracture and also other bacterially mediated processes, such
as breast implant–associated anaplastic large-cell lymphoma
(BIA-ALCL).
Through these investigations the primary process behind cap-
sular contracture has been further elucidated: inoculation of the
implant and implant pocket with a biologically significant mass of
bacteria, attachment and accumulation of the bacteria on implant
and capsule surfaces, formation of an antibiotic-resistant protec-
tive biofilm, and subsequent low-grade inflammatory response by
the local host, manifesting as pathologic and progressive capsular
contracture (Fig. 72.1). Additionally, our understanding of capsu-
lar contracture and its relation to the microbiome has helped us
to better understand what remains a heavily investigated topic,
BIA-ALCL.
As capsular contracture remains the most common complica-
tion, surgeons see patients for revision of this malady frequently,
and it remains the single most common reason behind revision
breast augmentation. Although this chapter concentrates on
the surgical treatment of contracture, the best defense for con-
tracture is good offense. :e will start with prevention, as these
concepts are critical to the management of existing capsular
contracture.
72.3 Capsular Contracture:
Prevention
With subclinical infection implicated as the major cause of cap-
sular contracture, various groups began to investigate optimal
means of reducing perioperative bacterial contamination. The
porcine inoculation study by Tamboto et al suggested that below
a certain bacterial density threshold, capsular contracture may
not occur. Perhaps the body is able to control a certain bioburden
associated with an implant but is unable to clear bacteria beyond
this point. There is merit to reducing, to the best of our ability,
the bacterial burden at the time of surgery. Antibiotic irrigation
would be a relatively easy means for surgeons to sterilize the
breast pocket. The irrigation would bring the bacterial density
below a critical threshold to minimize the infectious contribution
toward capsular contracture. The ideal breast irrigation would
maximally reduce bacterial numbers (broad spectrum), be min-
imally cytotoxic, and have relatively available and cost-effective
ingredients that would be easy to create. While surgeons were
recognizing the relationship of bacterial contamination and
capsular contracture, there was no standard irrigation that was
clinically proven to reduce bacterial numbers and reduce capsu-
lar contracture. Adams et al sought to optimize and standardize
antibiotic irrigation. Their concern was that surgeons were
conscious of the importance of antibiotic irrigation (at least for
the reduction of acute infection), but there was no gold standard.
They evaluated various antibiotic combinations in vitro that
would neutralize the most common bacterial species cultured
from implants and implicated in capsular contracture (S. epider-
midis, P. acnes, E. coli) as well as species implicated in more acute
infections (Staphylococcus aureus, Pseudomonas aeruginosa). The

1100
XI Breast Surgery
result was Betadine–triple antibiotic (50 mL of povidone-iodine,
1 g of cefazolin, and 80 mg of gentamicin in 500 mL of sterile
saline) for irrigation of the breast pocket and “non-Betadine triple
antibiotic” (50,000 U bacitracin, 1 g cefazolin, 80 mg gentamicin,
500 mL normal saline). Without it, it’s only a double antibiotic.
1 g of cefazolin, and 80 mg of gentamicin in 500 mL of sterile
saline for irrigation of the breast pocket) and non-Betadine triple
antibiotic (50,000 U bacitracin, 1 g cefazolin, 80 mg gentamicin,
500 mL normal saline). In a follow-up study, the triple antibiotic
solutions were then evaluated clinically in a 6-year prospective
study that examined the rate of capsular contracture in breast
augmentation, reconstruction, and augmentation mastopexy.
Capsular contraction rates were found to be significantly lower
than in previous series, at 1.8%, 9.5%, and 0%, respectively. A
20-year follow-up study by the same group has demonstrated
further reduction in capsular contracture rates to 0.57%.
To create uniformity in capsular contracture prevention, Deva
et al developed clinical recommendations that address the clinical
data regarding breast implants and minimization of bacterial load.
These recommendations are summarized in a “14-Point Plan” that
aims to minimize capsular contracture formation. Each point uses
data to support its inclusion on the list.
1. Use intravenous antibiotic prophylaxis at the time of anesthetic
induction.
2. Avoid periareolar/transaxillary incisions; these have been
shown in both laboratory and clinical studies to lead to a higher
rate of contracture.
3. Use nipple shields to prevent spillage of bacteria into the pocket.
4. Perform careful atraumatic dissection to minimize devascular-
ized tissue.
5. Perform careful hemostasis.
6. Avoid dissection into the breast parenchyma.
7. Use a dual-plane pocket, which has anatomic advantages.
8. Perform pocket irrigation with the correct proven Betadine
triple, non-Betadine triple antibiotic solution, or 50% (1:1 dilu-
tion) or stronger Betadine.
9. Take steps to minimize skin contamination.
10. Minimize implant open time and replacement of implant or
sizers.
11. Change surgical gloves prior to handling and use new or cleaned
instruments and drapes.
12. Avoid using a drainage tube, which can be a potential site of
entry for bacteria.
13. Use a layered closure.
14. Use antibiotic prophylaxis to cover subsequent dental
procedures.
These points can be applied easily to a well-defined surgical
process in both primary and revisionary breast surgery without
significant additional time commitment or burden to the operat-
ing room staff or surgeon. All of these interventions can be per-
formed with supplies readily available in most surgical centers.
For instance, an introduction sleeve can even be fashioned from a
surgical glove, and nipple shields can be created from clear tape
commonly used for intravenous sites.
Ellenbogen suggested a causal relation between dental prophy-
laxis and rapid breast encapsulation within weeks of the surgical
procedure based on personal experience. Within the dental and
orthopaedic literature, clinical data are mixed with regard to
antibiotic prophylaxis for patients at risk for bacterial endocardi-
tis or seeding of orthopaedic implants. The general consensus in
these papers recommends discussion of risk versus benefit with
patients. Given the relative infrequency of these procedures, the
Fig. 72.1 Bacterial contamination at the time of breast implant placement, from endogenous bacteria, or from seeding through transient bacte-
remia, may contribute to biofilm formation and subsequent inflammation. Long-term sequelae include capsular contracture and a sustained T-cell
response that may lead to breast implant–associated anaplastic large-cell lymphoma.

72 Capsular Contracture: Current Science, Prevention, and Management
1101
reduction of transient bacteremia would potentially impart some
protective measures. We recommend to our patients antibiotic
prophylaxis to cover subsequent procedures that breach skin/
mucosa, such as dental procedures.
The 14-Point Plan’s effectiveness was examined using pooled
data from eight plastic surgeons performing breast augmentation
with macrotextured implants from multiple areas globally. While
the study’s primary goal was to examine the incidence of ALCL
in macrotextured implants, this group achieved low capsular
contracture rates of 2.2% in 42,035 implantations over a mean
follow-up of 8 years. Additionally, there were no incidences of
ALCL despite estimates as high as 1 in 2,400 to 1 in 4,500 incidence
in certain regions. Capsular contracture prevention via this plan
easily reduces the rates to low levels, and even lower rates (< 1%)
have been demonstrated by single-surgeon series adopting the
14-Point-Plan.
72.4 Capsular Contracture:
Management
Despite the significantly reduced rates of capsular contracture
since the early 1980s with improved antibacterial interventions,
plastic surgeons will be faced with these patients despite best
practices. Given the popularity of breast augmentation, there
will continue to be patients with capsular contracture.
Capsular contracture has been typically graded on the Baker
scale, first described in 1975:
Grade 1—The augmented breast feels as soft as an unaugmented
one.
Grade 2—Minimal. The breast is less soft and the implant can be
palpated but not visible.
Grade 3³Moderate. The breast is more firm, the implant can be
palpated easily, and it (or distortion from it) can be
seen.
Grade 4—Severe. The breast is hard, tender, painful, and cold.
Distortion is often marked.
Typically Baker grades I and II have generally been managed
conservatively, whereas Baker grades III and IV have been man-
aged surgically.
72.4.1 Nonsurgical
Nonsurgical interventions have been proposed and employed to
manage capsular contracture. The most commonly mentioned
medications are the leukotriene inhibitors, such as zafirlukast
(Accolate, AstraZeneca) and montelukast (Singulair, Merck).
In Scuderi’s preliminary report, 20 women were examined for
response to zafirlukast. The study concluded that zafirlukast
may reduce pain and breast capsule distortion for patients with
long-standing contracture. One conclusion was that this drug
could potentially be offered to patients who either are not surgi-
cal candidates or do not wish to undergo surgery. In a follow-up
long-term study, the same group demonstrated improvement
in breast capsule distortion while the drug was being taken,
but contracture progressed once the drug was no longer taken.
Despite being a nonsurgical intervention, the drug does not
have a benign safety profile. The drug is associated with a risk
of hepatotoxicity and other side effects. The drug (used off-label)
also simply treats the symptoms of the capsular contracture but
does not address the root cause of the problem. While they may
have a role in patients unwilling or unable to undergo surgery,
leukotriene inhibitors are not a mainstay of treatment for cap-
sular contracture.
72.4.2 Surgical
Surgery is the primary treatment of Baker grades III and IV
capsular contracture. Historically, there is a generalized dogma
for capsular contracture: capsulectomy, site change, implant
exchange. There are multiple factors that should be assessed
when evaluating a surgical candidate. These include implant
site, presence of malposition, tissue quality, and implant type.
Management should be geared toward the patient’s personal
clinical scenario. Unfortunately, much of the data in breast
surgery is moderately heterogeneous with regard to surgical
technique, and it can be difficult to develop clinical guidelines.
Variable recurrent contracture rates can be found in the liter-
ature. There are some studies that do offer insights into man-
agement of capsular contracture, and we include some here for
clinical decision making.
Total Capsulectomy versus Partial
Capsulectomy versus Capsulotomy
Total capsulectomy involves the complete removal of the con-
tracted capsule, whereas partial capsulotomy consists of a subto-
tal excision, usually the anterior leaf of the capsule. Capsulotomy
disrupts the capsule, with the goal being to break the continuity
of fibrous scar but leave the majority of the capsule within the
pocket.
Much of the data gathering, surgical management, and fol-
low-up related to capsulotomy versus capsulectomy is hetero-
geneous, and the recurrence rates are widely divergent, ranging
from 0 to 53. In the most definitive study comparing anterior
versus total capsulectomy, Collis and Sharpe demonstrated
recurrent capsular contracture in 46% of patients treated with
only anterior capsulectomy versus 11% in the total capsulectomy
group. Capsules demonstrating contracture have repeatedly
shown significant levels of biofilm and associated bacteria when
processed appropriately, and to leave them adjacent to a new
implant and pocket invites contracture recurrence. If we know
that bacteria are the most significant contributors to capsular
contracture, why would we leave an affected capsule" However,
data also suggest that a site change using a neosubpectoral
pocket, excluding the old capsular contracture pocket from the
new implant space, does not predispose to recurrent capsular
contracture. Essentially, if performed appropriately, the new
implant interface does not encounter the previous contaminated
pocket but is merely adjacent to it. Maintaining this isolation
of the new implant from the old pocket is key to reducing
recurrence.
We recommend that total capsulectomy be performed when-
ever possible. :e find that it is rare for a total capsulectomy to be
difficult to perform. If the posterior leaf is adherent to the chest
wall, hydrodissection can facilitate elevation of the capsule safely
(Fig. 72.2).

1102
XI Breast Surgery
Site Change versus No Site Change
The surgeon can choose to maintain the location of the implant
or perform a site change. The site of the implant can be divided
into the following: subpectoral, subglandular, or neosubpectoral.
Multiple studies find a low capsular contracture recurrence rate
with site change. Additionally, the best data are consistent with
placement of new implants under the muscle.
For a subglandular implant with associated capsular contrac-
ture, we recommend total capsulectomy and implant removal. If
an implant is still desired, we strongly recommend replacement
of the old implant with a new implant to avoid reintroducing a
contaminated implant into the pocket. As stressed earlier, implant
biofilms are tenacious and difficult to eradicate. A site change is
performed with placement of the new implant under the pectora-
lis muscle. Because the subglandular space has been undermined,
there is a risk of windowshading of the pectoralis superiorly, as in
an aggressive dual-plane breast augmentation. The lower edge of
the pectoralis muscle can be controlled with a sheet of acellular
dermal matrix or natural scaffold mesh to re-create the normal
virgin anatomy as much as possible. We also typically use a drain
to minimize seroma formation under the raw subglandular space.
We have a low threshold for staging any secondary mastopexy
procedures in these cases given the violation of the intercostal
perforators and the extent of dissection.
For a submuscular implant with associated capsular con-
tracture, we also recommend total capsulectomy and implant
removal. If an implant is still desired, we strongly recommend
replacement of the old implant with a new implant to avoid rein-
troducing a contaminated implant into the pocket. We maintain
the subpectoral position of the implant and do not perform a site
change in this case. We will perform a dual plan adjustment as
necessary for the outcome. We typically use a drain to minimize
seroma formation given the significant raw subpectoral space, as
well (Fig. 72.3).
If there is concern that risk of elevation of the posterior leaf
of the capsule will be difficult and the capsule is rather thick, a
neosubpectoral pocket can be used to create a new pocket for
the new implant. The neosubpectoral pocket can also be useful
Fig. 72.2 This patient underwent multiple prior breast revisions,
capsulectomies, and site changes. She ultimately underwent implant
exchange with capsulectomy and placement of Strattice and then
right implant exchange with capsulectomy by the senior author.
Fig. 72.3 This patient had three previous breast surgeries due to
capsular contracture. Implants were initially subglandular with periare-
olar incision. She underwent implant exchange with capsulectomy, site
change, and placement of mesh.

72 Capsular Contracture: Current Science, Prevention, and Management
1103
in cases of malposition. A new dissection outside of the malpo-
sitioned pocket can be carefully crafted to accept a new implant
in the exact position desired. This technique offers a significant
degree of control of the pocket size. The capsule space should be
obliterated with electrocautery and stitches through the anterior
and posterior leaves to minimize seroma formation. Conceptually,
it is important to exclude the contaminated pocket completely
by dissecting between the posterior pectoralis and the anterior
capsule and to minimize tears that may introduce bacteria sec-
ondarily from the old pocket into the new pocket.
Special mention should be made of acellular dermal matrix
(ADM) and reports of reduced capsular contracture rates. While
ADM offers a form of pocket control and possible contour
improvement if necessary, in our experience it does not prevent
the formation of capsular contracture in revisionary surgeries
we have encountered. Additionally, it has an associated risk of
seroma. Its cost can make secondary revisions prohibitive, as well.
While ADM is a viable option for pocket control, we do not use it
routinely (Fig. 72.4, Fig. 72.5).
72.5 Concluding Thoughts
Capsular contracture has been a pathologic entity married with
breast augmentation surgery since the surgery’s inception.
Advances in our understanding of the etiology for capsular
contracture and an evidence-based, tissue-based planning and
surgical process have reduced the rates of capsular contracture
by all measures. Patient outcomes have likewise improved.
However, because of the heterogeneity of surgical practice and
patient factors, capsular contracture is still a common entity
and the most common cause of reoperative breast surgery. By
optimizing revisional surgery, a second chance is offered to
“get it right.” Furthermore, these preventive maneuvers may
potentially reduce the development of lymphoproliferative
reactive processes/BIA-ALCL against bacterial antigens by
reducing the bioburden. Further insights will develop as our
understanding of capsular contracture, its prevention, and its
treatment evolves.
Fig. 72.4 (a,c) This patient had right lateral malposition with supine positioning and left capsular contracture. (b,d) A neosubpectoral pocket with
implant exchange was performed to correct both the malposition and the capsular contracture.

1104
XI Breast Surgery
Clinical Caveats
• Capsular contracture is primarily a bacterially mediated
phenomenon leading to chronic inflammation.
• Texturization of breast implants dramatically increases the
surface area of the implant and therefore the potential bacte-
rial contamination of the implant.
• Textured implants can still result in capsular contracture.
• Prevention is the best means to combat capsular contracture.
Maneuvers included in the “14 Point Plan” can help to reduce
bacterial contamination as well as minimize tissue trauma
and inflammation.
• Clinically proven antibiotic irrigations have been demon-
strated to reduce bacterial loads as well as decrease capsular
contracture rates. Betadine–triple antibiotic consists of 50 mL
of povidone-iodine, 50,000 U bacitracin, 1 g of cefazolin, and
80 mg of gentamicin in 500 mL of sterile saline for irrigation
of the breast pocket.
• Once capsular contracture occurs, it is primarily managed
with surgical intervention. The goals are to isolate the new
implant from a previous pocket by site change or complete
removal of the pathologic capsule.
• Capsulectomy is preferred to capsulotomy or partial cap-
sulectomy to minimize contamination.
• Subpectoral breast implant position decreases the implant
exposure to breast parenchyma and bacterial contamination.
Site change is suggested if the implant is subglandular.
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73 Primary and Revision Augmentation Mastopexy:
7eFKniTueV Dnd &RnViderDWiRnV
Robert Cohen
Abstract
Augmentation mastopexy is a spectrum of surgery that requires
thorough evaluation, thoughtful planning, and precise execution
in order to achieve the best possible results. In properly selected
patients, a well-performed augmentation mastopexy can achieve
some of the most satisfying and dramatic results in aesthetic
plastic surgery.
This chapter first discusses how to understand and manage
patient expectations prior to surgery. This is followed by a focus on
how to assess the various types of breasts needing augmentation
mastopexy, and how to properly plan and perform various levels
of surgery for a variety of anatomical starting points. Discussion
includes the full range of techniques from a simple augmentation
with a crescent lift to a complicated inverted-T scar mastopexy
with tissue resection and material reinforcement. Ancillary pro-
cedures, such as fat grafting and adjustments to the nipple–areola
complex, are discussed as well.
Although this chapter focuses primarily on how to avoid
complications during augmentation mastopexy, it also discusses
complications of surgery and how to apply various revision breast
augmentation techniques to correct a wide array of problems that
may occur.
Keywords
augmentation mastopexy, circumareolar mastopexy, ptosis,
revision breast augmentation
73.1 Introduction
Breast augmentation mastopexy is an anxiety-producing proce-
dure for many plastic surgeons due to its reputation as a chal-
lenging, unpredictable surgery with many variables to consider.
While augmentation mastopexy surgery can be complex and
certainly requires thoughtful planning, detailed understanding
of breast tissue and implant dynamics, and a wide array of opera-
tive techniques, it is also a very satisfying procedure for patients
and can produce some of the most dramatic improvements in
breast aesthetics when performed properly.
This chapter seeks to demystify the concept of augmentation
mastopexy (focusing on one-stage procedures), in addition to
providing basic techniques for assessment, marking, and planning
that can be universally applied to patients needing this procedure.
In addition to primary surgery, this chapter also addresses var-
ious types of revision augmentation mastopexy techniques and
demonstrates how breasts in need of revision can be systemati-
cally analyzed and corrected.
73.2 Indications and
Contraindications
Indications for augmentation mastopexy include any patient
with breast ptosis who wants correction of ptosis as well as an
increase in overall volume, or, specifically, improvement in upper
pole breast volume where achieving this goal is unlikely based on
the patient’s starting volume, tissue density, and skin elasticity.
Very few absolute contraindications exist; however, patients will
need an accurate assessment and management of expectations
based on their goals and anatomy, as will be discussed later in
this chapter. Patients who refuse a scar pattern that is necessary
for success are poor candidates. Active smokers should not be
operated on due to the risk of poor perfusion with subsequently
increased infection rates and wound-healing issues. Patients
with poor tissue elasticity should be selected cautiously, and the
use of reinforcement material should be considered.
73.3 Preoperative Assessment and
Management of Expectations
in Primary Augmentation
Mastopexy
Planning an augmentation mastopexy surgery starts with the
initial consultation, where the surgeon begins to understand
each prospective patient’s specific goals. Patients will present
with a wide variety of anatomic differences involving breast
volumes, tissue elasticity, tissue density, base width, and degrees
of ptosis, among other factors. During the first discussion, it is
imperative for the surgeon to elicit what specifically bothers
each patient and to understand what the patient’s ultimate
aesthetic goals are. This ideal end point can (during the physical
exam) be merged with the patient’s actual anatomy to synthe-
size realistic expectations for the predicted final surgical result.
Comprehensive and honest communication leads to a properly
informed patient, which in turn reduces the risk of a mismatch
between expectations and results—a common trigger for dissat-
isfaction (Fig. 73.1, Fig. 73.2, Fig. 73.3).
Specific knowledge of a patient’s goals comes from asking
appropriate questions and listening carefully to the patient’s
answers. Important questions include whether the patient finds
her breasts too large, too small, or about right with regard to
volume, whether she is bothered by drooping or overhanging
skin of the breasts, whether she has concerns about asymmetry,
and whether she is bothered by the appearance of the areolas,
nipples, axillary areas, or other peripheral parts of the breasts.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
1107
Fig. 73.1 (a) When asked to demonstrate what she wanted to look like, the revision augmentation/mastopexy patient showed (b) a picture of
another patient, which clearly was not an anatomically realistic goal.
Fig. 73.2 (a) Once the general goal of smaller, more proportionate breasts was understood, the author was able to provide the patient with a more
anatomically realistic goal based on (b) another patient’s result, which she liked and which the author felt was an achievable result.

1108
XI Breast Surgery
Having patients pick out cases they like from surgical before-and-
after galleries can be particularly helpful in demonstrating their
aesthetic preferences.
It is also essential to understand what patients’ lifestyle goals
are (i.e., are they willing to accept the additional maintenance of
having implants), their level of concern about scars, and whether
they are willing to participate in the upkeep of breasts that will
generally succumb to recurrent ptosis over time. During this ini-
tial conversation, it is helpful for the surgeon to discuss why ptosis
occurred in the first place (loss of tissue elasticity, weakening of
Cooper’s ligaments, breast changes due to pregnancy or weight
fluctuation, etc.) and to explain to the patient that the need to
address recurrent ptosis and implant exchange surgically in the
future is generally not an “if” but rather a “when” situation.
73.4 Pertinent Anatomy for
Augmentation Mastopexy
There are many variables to note during the physical exam,
which are common to both general breast augmentation and
mastopexy planning. Many types of anatomy fit under the
umbrella of augmentation mastopexy, but these cases often
require different techniques (Fig. 73.4).
Proper breast measurements and biodimensional planning, as
described by multiple authors, such as Tebbetts and Adams, are
important to assess for details like asymmetry, tissue thickness
and elasticity, base width, and inframammary fold (IMF) location.
Base width is perhaps the key measurement and will determine
the appropriate size range of the implants used. This measure-
ment should be based on ideal breast width, not actual breast
width in the case of narrow or constricted breasts.
Breast density should also be evaluated; softer breasts with
higher percentages of fat will tend to distribute more easily over
an implant but will provide less stable upper-pole fullness. Firmer
breasts with a higher percent of glandular tissue will hold their
shape better and provide more reliable upper-pole volume but
can create excessive projection in certain cases unless debulking
or internal scoring is performed to thin out and spread the tissue
over the implants.
Each breast’s size, both as a baseline and in relation to the
other breast, should be assessed closely. Patients with fuller,
denser natural breasts can be good candidates for a mastopexy
with upper-pole fat grafting as a lower-maintenance alternative
to augmentation with implants. For patients with significant
asymmetry, tissue debulking on the larger side can be offered as
an alternative to using significantly different sized implants and
can reduce the risk of a waterfall deformity.
Skin elasticity should be assessed; patients with thicker, more
elastic skin will maintain their results better over time, whereas
patients with thinner, weaker tissues will be more prone to
complications, such as malpositions and recurrent ptosis. These
Fig. 73.3 (a) The patient’s final result compared to (b) the other patient’s result, which the author had previously presented as a realistic goal. By
setting a realistic preoperative goal, the author was able to achieve that goal and satisfy the patient.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
1109
patients should be considered for the placement of textured
implants, or reinforcement materials, such as acellular dermal
matrices (ADMs) or resorbable mesh in order to stabilize results.
Each patient’s chest wall should also be assessed from both the
upright and the “worm’s eye” supine view, as chest wall abnor-
malities, such as a pectus excavatum or a laterally sloping rib
cage, will be prone to medial malpositions or lateral malpositions,
respectively, and may require a textured device or reinforcement
material for long-term implant stability (Fig. 73.5). Asymmetry in
projection of the rib cage can affect ultimate implant projection
and will sometimes necessitate different implant sizes or profiles
on each side.
General soft tissue thickness needs to be assessed, as patients
with less breast tissue will be at higher risk for implant palpability
and rippling issues. In these patients, consideration should be
given to using silicone gel implants with a higher degree of gel
cross-linking to minimize implant distortion and rippling. Care
should also be taken not to select overly large implants that would
be prone to stretching the tissues. Once again, the use of reinforce-
ment materials should be considered as a pectoralis extension to
stabilize the implants. Fat grafting should also be considered to
increase the “padding” between the implant and the skin.
After the previously mentioned breast assessments, all ancil-
lary structures, such as the nipple–areola complex (NAC), axillary
fat, and lateral chest wall fat, should be assessed because some
patients will benefit from further procedures, such as nipple
reduction, inverted nipple correction, and axillary or lateral chest
liposuction, for optimal results.
73.5 Preoperative Planning for
Primary Augmentation
Mastopexy: Implant Selection
The first detail in planning for augmentation mastopexy involves
deciding whether the addition of implants is appropriate. In
patients with a significant amount of dense, natural breast tissue
and good skin elasticity, the author offers a mastopexy with
upper-pole fat grafting as a lower-maintenance alternative to
implants. For patients who have minimal donor site fat, or those
who want a large-volume increase, implants are generally the
best choice (Table 73.1).
If implants are chosen, the pros and cons of each implant
type need to be discussed in detail. The first basic choice is the
use of saline or silicone implants. Although saline implants are a
reasonable option, they tend to look and feel less natural and will
still subject the tissues to a water hammer effect, leading to an
increased risk of stretch deformity or malposition.
Fig. 73.4 Variations in augmentation mastopexy patients require different management strategies. (a,e) Milder ptosis can be corrected with
augmentation and a circumareolar mastopexy. (b,f) More moderate ptosis can require augmentation with a vertical mastopexy. (c,g) More severe
ptosis with poor elasticity can require augmentation with a vertical or inverted-T scar mastopexy with tissue reinforcement (acellular dermal matrix
vs. mesh). (d,h) Severe ptosis with skin excess can be corrected with an inverted-T scar mastopexy with upper-pole fat grafting or, in this case, an
addition-subtraction with implants, lower-pole tissue resection, and an inverted-T scar mastopexy.

1110
XI Breast Surgery
Silicone implants offer a huge array of size, surface coating,
and profile options, as well as various levels of cohesiveness.
1ew, fifth-generation gel implants are resistant to rupture and
reduce the risk of gel migration in the case of a rupture. Increased
degrees of cohesivity will reduce the implants’ tendency to ripple
in patients with thinner tissues.
With regard to surface coating, patients have the option of
smooth or textured implants, which each have their own set of
pros and cons. Smooth implants can be less palpable in thinner
patients and are more forgiving with regard to the precision of
pocket dissection. They are also less positionally stable and have
been shown in some studies to have higher rates of capsular con-
tracture than textured implants, particularly in the subglandular
plane (Table 73.2).
Textured implants are more positionally stable and also allow
for the option of anatomic (teardrop) implants, which, via their
geometry, apply preferential expansion to the lower breast and
can be helpful with constricted lower poles (i.e., tuberous breasts).
Textured implants do have a higher risk of late seromas, and the
rare possibility of breast implant–associated anaplastic large-cell
lymphoma (BIA-ALCL), so these issues and risks must be discussed
with patients in detail prior to surgery.
Fig. 73.5 (a,b) Standing and (c,d) supine photos for this primary augmentation patient demonstrate how subtle a laterally sloping rib cage can be
in the standing position, whereas it is much more obvious from the supine position. Textured anatomic implants were used for positional stability in
this patient.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
1111
Regardless of the implant surface and fill, preoperative selec-
tion of size, shape, and profile should be done using multiple
data points for maximum accuracy. Preoperative biodimensional
planning with particular attention to base width is crucial.
73.6 Preoperative Planning for
Primary Augmentation
0DVWRSe[y ,mSODnW ,nFiViRn
Plane Selection
After implant selection, planning of the mastopexy pattern
should be performed. In general, the scar pattern will be primar-
ily determined by the patient’s anatomy, with some “gray area”
cases allowing multiple options, depending on the patient’s goals
and concerns.
The location for implant placement should generally be
via an inframammary or low vertical access point. Although
periareolar and transaxillary approaches are options, these
increase the risk of implant contamination by bacteria residing
in the axillary glands and milk ducts. Contamination leads to
the risk of biofilm, which thereby increases the risk of capsular
contracture. Additionally, the use of nipple shields, a funnel
device, gentle tissue handling with a “no-touch” technique, and
the use of antibiotic irrigation will further minimize bacterial
contamination.
With regard to the plane of the implant placement, the author
generally prefers a dual-plane approach due to its multiple advan-
tages, including more soft tissue coverage of the superomedial
implant, better control of the medial limits of the breast pockets,
and lower capsular contracture rates. Disadvantages include a
slightly longer recovery period and the risk of animation defor-
mities (Fig. 73.6).
Table 73.1 Pro/con chart for implants versus fat graft
Type
Pro
Con
Fat graft
• All-natural tissue
• Less weight to lower
breast poles
• Selective volume increase
• No implant complications
/ maintenance
• Aesthetic improvement
at donor sites
• Unpredictable volume /
potentially limited donor
site material
• Variable degree of fat
resorption
• Less predictable upper-
pole volume
• Donor site pain
Implant
• Predictable volume,
• Significant control of
upper-pole volume, many
sizes / shapes / surface
variations
• No donor site harvest
• Implant maintenance and
complications
• Additional weight on
breast with possible
increased rate recurrent
ptosis
Table 73.2 Pro/con chart for smooth vs. textured implants
Type
Pro
Con
Smooth
• Thinner shells
• Low risk of seroma
• No current risk of
BIA-ALCL
• Easier to place, more
forgiving implants
• Less positional stability,
• Higher capsular
contracture rate
• Higher risk of malposition
/ stretch deformity
• Need for postoperative
massage
Textured
• Positionally stable
• No postoperative
massage
• Option of round versus
anatomical
• Small risk of BIA-ALCL
• Higher risk of late seroma
and double capsule
compared to smooth
• Requires more precise
dissection and implant
placement
Abbreviation: BIA-ALCL, breast implant–associated anaplastic large-cell
lymphoma.
Fig. 73.6 Dual-plane diagrams. (a) Dual plane 1- only the inferior
muscle border is released. (b) Dual plane 2- the pectoralis muscle is
dissected from the overlying breast tissue to the lower areolar border.
(c) Dual plane 3- the pectoralis muscle is dissected from the overlying
breast tissue to the upper areolar border.

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XI Breast Surgery
73.7 Preoperative Planning for
Primary Augmentation
Mastopexy: Mastopexy
Pattern Selection
Preoperative examination of the breasts will determine if the
issue is simply a low-set NAC, a grade 2 or grade 3 ptosis, or
glandular ptosis. Which of these anatomic variations is present
will highly influence which technique should be selected (Fig.
73.7). In rare cases of severe asymmetry, different patterns can
be used on each breast.
73.7.1 Crescent Lift
The least powerful mastopexy is a crescent lift, where a crescent
of excess skin is removed above the areola in order to elevate the
areolar position by 1 to 1.5 cm. Due to a risk of areolar elongation,
this technique should be applied where only a mild elevation of
one or both areolas is needed (Fig. 73.8).
Fig. 73.7 Different levels of ptosis. (a) Nonptotic breast, (b) glandular ptosis, (c) Grade 1 ptosis (d) Grade 2 ptosis (e) Grade 3 ptosis.
Fig. 73.8 (a) Mild glandular ptosis and low nipple positions (b) corrected with primary augmentation and bilateral 1.5-cm crescent lifts.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
1113
73.7.2 Circumareolar Mastopexy
The next level of mastopexy is the circumareolar (periareolar)
mastopexy technique. This involves a full, circumferential
partial- or full-thickness skin excision around the areola with
the vertical height of skin resection being longer than the
transverse width to avoid a horizontally oriented oval shape
once closure is completed. This technique has garnered a bad
reputation due to its overuse in situations where a vertical
mastopexy is the better choice. If used in appropriate cases,
the circumareolar mastopexy is a very safe, useful, and versa-
tile option (Fig. 73.9).
Circumareolar mastopexies can generally be used to elevate
an areola by 2 to 2.5 cm and can shift an areola in any direction
desired on the breast mound, depending on how the outer oval
position is designed relative to the inner circle scoring. The
weaker and thinner the skin (as determined by manually pinch-
ing the skin together), the larger the outer oval of skin can be
resected without causing distortion or scar spread. Circumareolar
mastopexies can be performed with de-epithelialization only,
so they are extremely safe with regard to nipple–areola blood
supply in even the thinnest patients. Finally, this technique has
a compressive effect on the breast, so it is excellent for ´pointyµ
breasts, as in the case of tuberous breast deformities, but it is
usually an inappropriate technique for flatter breasts, as in the
case of glandular ptosis, or more significant grade 2 or grade 3
ptosis (Fig. 73.10).
73.7.3 Vertical Mastopexy
The vertical mastopexy is a powerful technique that can elevate
the NAC multiple centimeters while reducing lower-pole trans-
verse skin excess, elevating the IMF, and creating more breast
projection. This scar pattern also gives access to lower-pole
tissue debulking as needed to reduce the risk of a waterfall
deformity (Fig. 73.11).
73.7.4 Inverted-T Scar Mastopexy
The inverted-T scar mastopexy is the most powerful skin resec-
tion technique and is usually reserved for more severe grade 2
or grade 3 ptosis cases. In situations where a vertical mastopexy
results in an excessively long (> 6–7 cm) distance from the lower
areolar border to the IMF, a transverse skin resection can be per-
formed to reduce the length of the lower pole with the scar being
hidden in the inframammary crease. This technique allows an
even greater degree of lower-pole soft tissue debulking and can
be used to create a sharper inframammary crease (Fig. 73.12).
73.8 Preoperative Planning:
Universal Markings
Preoperative marking is very important to ensure proper ori-
entation for implant placement, skin resection, and symmetry
Fig. 73.9 (a) Moderate ptosis (b) corrected with primary silicone augmentation and circumareolar mastopexies with approximately 2.5 cm elevation.

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XI Breast Surgery
Fig. 73.10 (a–d) Tuberous breasts corrected with placement of silicone implants (dual plane 2) and circumareolar mastopexies. The circumareolar
mastopexy has the benefits of reducing areolar size, elevating the areolar position, and flattening a pointy breast shape.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
1115
during surgery. The markings themselves need not be excessively
complicated and should allow for accurate on-table adjustments
during surgery (Fig. 73.13).
These marks will allow for accurate nipple placement even if
the patient shifts under the drapes while being examined in the
seated position during surgery.
73.9 2SerDWiYe 7eFKniTueV³
Implant Placement
As noted earlier, augmentation mastopexy generally starts with
placement of the implants, creating a precise pocket dissection
based on the implant selected. Particular care should be taken to
avoid excess lateral dissection or overdissection of the pectoralis
origins. The surgeon must avoid superior dissection of the muscle
origins at the sternum to avoid “window-shading.” A dual-plane
2 or 3 dissection can be performed after the pocket is completed
if needed for increased lower-pole expansion. Once the pocket
is completed, sizers can be used to check the shape, size, and
symmetry of the breasts after designing and tailor-tacking the
mastopexy pattern. Alternatively, the final implants can be
placed without sizers if the surgeon is confident in the size and
profile selection. Once the final implants are in proper position,
the pockets should be closed in the deeper layers to seal off the
implant space and minimize contamination as the mastopexy
portion begins.
73.10 2SerDWiYe 7eFKniTueV³
Crescent Lift
For this technique, a crescent is designed above one or both
areolas from the 9 o’clock position to the 3 o’clock position with
maximum elevation being approximately 1 to 1.5 cm to avoid
significant distortion. De-epithelialization alone is an option
to maintain the superior subdermal plexus if needed for future
mastopexy surgery.
73.11 2SerDWiYe 7eFKniTueV³
Circumareolar Mastopexy
While it is a much more versatile technique than a crescent lift,
a circumareolar mastopexy still needs to be applied appropri-
ately for aesthetically favorable results. As mentioned earlier,
the physics of circumareolar tightening creates a compressive
effect on the breast, and because of this it should be avoided in
breasts that need more projection, such as those with significant
grade 2 or 3 ptosis, or in patients with notable glandular ptosis.
Circumareolar mastopexy is thus most favorable for “pointy” or
overprojected breasts, such as tuberous breasts. It can also work
well in patients who need areolar elevation, areolar reduction,
and tightening of moderately lax skin over an implant framework
(Fig. 73.14).
Fig. 73.11 Patient 1 (a–d) and patient 2 (e–h) with significant grade 2 ptosis corrected with silicone implant augmentation and vertical mastopexies.

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XI Breast Surgery
Fig. 73.12 (a–d) Grade 3 ptosis corrected with silicone augmentation and inverted-T scar mastopexy.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
1117
After implants are in position, the areola is placed on stretch and
marked with a 38- to 42-mm cookie cutter. The desired degree
of elevation per side (up to a maximum of approximately 2.5 cm,
depending on tissue elasticity) is marked equally down from one
of the 5-mm reference marks discussed in the universal marking
section to ensure symmetrical nipple positions. The distance from
the IMF to the bottom of the proposed circumareolar incision
is also marked, leaving approximately 6 to 7 cm of distance. A
vertically oriented oval is then designed, with the vertical limb
being approximately 1 cm taller than it is wide. If concentric circle
Fig. 73.13 (a) Initially, the patient’s sternal notch is marked and a midline is drawn straight down from the sternal notch to the umbilicus. (b) After
this, a tape ruler is draped around the neck and used to bisect the breasts. (c) The breast meridian lines are then drawn and extended down on the
abdomen. (d,e) The inframammary creases are marked bilaterally, and the inframammary crease is transposed on the breast manually or with a large
caliper. Once the inframammary marks are transposed onto the breasts (in this case they coincided with the nipple position), they are double-checked
for distance from the sternal notch and then reference marks are made every 5 cm up the meridian lines so that the distance from the clavicles to the
new nipple positions can be assessed accurately, even if some of the marks are accidentally washed off or lost during the procedure.

1118
XI Breast Surgery
patterns are designed prior to the incision, the end result will be
a horizontally oriented oval due to greater lateral forces on the
breast skin (Fig. 73.15).
A realistic approximation of how much skin can be safely
resected in a given case can be performed by simply pinching the
skin together manually to see how much force is needed for clo-
sure. Alternatively, staples can be used to test the circumareolar
mastopexy markings before the final incisions are made. There
are many described techniques for circumareolar mastopexy that
are outside the scope of this chapter. What follows is the author’s
technique, which was designed to maximize precision and wound
healing, while minimizing disruption to the areolar blood supply.
Once the proper markings for incisions are confirmed, they are
scored and the skin within the pattern is de-epithelialized. Cautery
can be used for hemostasis and to contract the dermis in order to
reduce tension on the closure. The first suture layer is a circumfer-
entially running 3–0 polydioxanone suture (PDS), which imbricates
the dermis and sets up the final areolar size and position. This
suture o̧oads tension from the skin and sets the areolar diameter
within 3–4 mm of its desired diameter. After the PDS, a 3–0 Prolene
suture is placed in a “deep subcuticular” fashion to further lock
the areolar diameter at the desired size, with the knot completely
buried under the dermis. Finally, a 4–0 poliglecaprone (Monocryl,
Johnson & Johnson, New Brunswick, NJ) suture is used in a running
subcuticular fashion in order to achieve a tension-free closure.
By thus minimizing knots and using monofilament, most suture
exposure and superficial infections can be avoided (Fig. 73.16).
73.12 2SerDWiYe 7eFKniTueV³
Vertical Mastopexy
To start the mastopexy markings after implant placement,
a simple template is made by marking a rectangle of paper
towel from the sterile gown pack with a 38- to 42-mm cookie
cutter. This template is centered on the breast mound where
the new nipple position should be. Determining the ideal nipple
placement can be challenging and should be verified with the
patient in the seated position. This point will vary depending on
skin laxity and the implant size; however, the top edge of the
keyhole pattern often coincides with the first 5 cm marking
above the transposed IMF mark. The keyhole pattern is opened
and marked, with the area of skin resection extending down to
the IMF. As a rule of thumb, the distance between corners of the
lower keyhole generally measures close to 5 cm, and the widest
point of the vertical resection is usually 6 to 8 cm. These numbers
will obviously vary between patients and should be checked and
adjusted with tailor tacking (Fig. 73.17).
Once the skin resection pattern is worked out for the first
breast, the second breast can be matched using the preoperative
reference marks to ensure equal distance from the sternal notch to
the new nipple position. After both breasts are tailor-tacked and
appropriate shape, size, and symmetry are confirmed in both the
supine and seated position, the final tissue resection and closure
can be performed.
To complete the mastopexy, the areola is marked on stretch
with a 38- to 42-mm cookie cutter and scored, and the area
within the mastopexy pattern is de-epithelialized. Electrocautery
of the entire dermal surface can be used for both hemostasis and
to shrink the dermis. Minimal undermining is needed in most
cases, and a superior or superomedial dermoglandular pedicle is
maintained to preserve the subdermal plexus to the NAC.
The subcutaneous soft tissue of the lower pole can be debulked
if desired to create a tighter lower pole. Then 3–0 PDS is used in an
interrupted, buried fashion to reapproximate the vertical pillars.
A full-length 3–0 PDS suture is then set at the 6 o’clock position
of the areolar keyhole, and this suture is run down the vertical
incision, back up the vertical incision, and around the areola as a
deep dermal closure and support. Any imperfections in the size
and circular shape of the areolas can be adjusted at this time, and
a subcuticular closure of the circumvertical incision is performed
with 4–0 Monocryl. Once completed, the areolar diameter should
be approximately 40 mm, the areola should be centered on the
breast mound, and the distance from the lower areolar border to
the new IMF should be approximately 6 to 7 cm.
73.13 2SerDWiYe 7eFKniTueV³
Inverted-T Scar Mastopexy
Inverted-T scar mastopexy is performed in a very similar
fashion to the vertical mastopexy, and a vertical should be
tailor-tacked first in most cases to see whether avoiding an
inframammary scar provides a good aesthetic outcome. If, after
tailor tacking, the vertical limb is too long (> 7–8 cm from the
lower areolar border to the IMF), a transverse elliptical skin
resection is marked and tailor-tacked to shorten the lower pole
and improve the breast aesthetics. This skin can be removed full
thickness, with debulking of the underlying soft tissue if needed
and closure with 3–0 PDS. In cases where a patient has excess
lower-pole parenchyma with poor-quality tissues, but desires a
very augmented appearance, an addition-subtraction technique
can be incorporated into the inverted-T scar mastopexy. During
surgery, the excess tissue of the lower pole is resected, and the
pectoralis is stabilized by suturing it back up to the overlying
parenchyma, or adding a reinforcement material (Fig. 73.18).
73.14 Skin Removal and Incisions
Skin removal for mastopexy is planned to permit periareolar, cir-
cumareolar, vertical, and, when necessary, horizontal excisions
allowing a remolding of the breast to a more natural, uplifted,
and aesthetic shape. This skin removal should also allow reposi-
tioning of the nipple and areola and, if ptosis recurs, additional
corrections through the initial incisions. The incisions and skin
excisions are planned on a continuum from periareolar to cir-
cumareolar to vertical scars and then to horizontal scars. With
this approach, additional breast tissue can be excised later.
When the nipple–areola complex is low, requiring only a small
degree of elevation of 1 to 1.5 cm, an upper periareolar crescentic
ellipse can be excised to elevate it (Fig. 73.19).
A circumareolar skin excision with a multilayered, purse-string
closure tightens the skin and can be used to (1) reduce the size and
protrusion of the areolas, (2) reposition the areolas, (3) tighten
the skin envelope around an implant, and (4) flatten a ´pointyµ
or tuberous-appearing breast. This technique is generally most
useful when combined with implant placement. Please note that
the resection pattern should be approximately 0.5 to 1 cm longer
in the vertical direction than the horizontal direction (Fig. 73.20).

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
1119
Fig. 73.14 (a,b) Augmentation with circumareolar mastopexies used to round out and compress pointy-appearing tuberous breasts.
Fig. 73.15 (a,b) Circumareolar mastopexy patterns can be applied to adjust asymmetric nipple areolar complexes. The distance from the top of the
oval resection to the nearest cross-hatch mark should be the same on each side, and the distance from the bottom of the oval to the inframammary
fold should also be the same (approximately 6–7 cm) to ensure a final symmetrical position.

1120
XI Breast Surgery
The circumareolar skin resection pattern can be shifted when
specific lateral or medial positioning of the 1AC is necessary to
move it to a more aesthetic position on the breast (Fig. 73.21).
For more significant ptosis the vertical mastopexy pattern
should be used, as it will allow significant vertical skin resection
and nipple–areolar repositioning, with minimal risk of areolar
scar spread while simultaneously adding to the breast projection
(Fig. 73.22).
For patients with major ptosis and excessive amounts of
inelastic skin who need maximal breast elevation, a vertical and
horizontal excision (inverted-T scar pattern) provides effective
breast elevation, even though this approach produces a longer
inframammary scar. When planned and closed carefully, this scar
tends to heal well and is nicely hidden in the natural inframam-
mary crease (Fig. 73.23).
73.15 Fat Grafting
If fat grafting is chosen over the use of implants, the mastopexy
should be performed first. Mastopexy pattern selection, skin
excision, and closure are performed as described in the tech-
niques section earlier in the chapter. After fat harvesting and
processing, thin threads of fat are injected in multiple planes
to maximize blood supply to each row of grafted fat cells. Fat
is usually grafted primarily in the subcutaneous fat planes of
Fig. 73.16 (a,b) After marking and confirming the mastopexy, the area within the pattern is de-epithelialized. (c) Cautery is used at a setting of 40 for
hemostasis and to contract the dermis to reduce tension on the closure. (d) 3–0 polydioxanone suture (PDS) is run circumferentially to imbricate the
dermis and sets up the final areolar size and position. At this point, a cookie cutter can be used to remark and adjust the pattern if it is not perfectly
circular. (e) 3–0 Prolene is placed in a “deep subcuticular” fashion to further lock in the desired areolar diameter. (f) 4–0 poliglecaprone (Monocryl) is used
in a running subcuticular fashion in order to achieve a tension-free, watertight closure. If done properly, there should be minimal irregularities or rippling.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
1121
the upper poles and medial breasts for maximum aesthetic
impact (Fig. 73.24).
73.16 Ancillary Procedures—Nipple
Reduction, Inverted Nipple
Correction, Liposuction
The difference between a good and an excellent result with
augmentation mastopexy comes from attention to details. In
addition to refining the breast mound and the areolar positions
and diameters, assessment of the nipples themselves as well as
the breast periphery is important.
For patients with excessively large, drooping, or overprojected
nipples, a nipple reduction can be performed. Many techniques
have been described; however, the author’s preferred approach is
to remove circumferential skin at the base of the nipple, leaving a
central column of vascularized tissues to the nipple tip. This dis-
section is followed by telescoping the now-shortened nipple into
the areola and suturing the base in position with 5–0 Monocryl
(Fig. 73.25).
Inverted nipple correction generally involves internal dissec-
tion of shortened or abnormal milk ducts. The author’s preferred
technique is to place the nipple on traction with a temporary
suture, and make a 3-mm incision with a no. 11 blade scalpel at
the base of the nipple (the 6 o’clock position where it meets the
areola). With the nipple on traction, tenotomy scissors are used to
divide abnormal milk ducts and internal structures at a level flush
with the areola. A 4–0 PDS is then run circumferentially under the
skin of the nipple (where it connects to the areola) as an internal
purse string, and is tied down with the knot buried internally
under the nipple (Fig. 73.26).
Axillary and lateral chest liposuction can be effective ways
to further refine the shape and proportion of the breasts. In
many patients, even with a low body mass index, a collection of
diet-resistant fat is located in the anterior axillary areas, which
can protrude from bras or create a wide appearance to the upper
breast. In these cases, liposuction is used to contour the upper/
outer breast. In patients with lateral fullness on the rib cage,
liposuction can be used to create a narrower appearance of the
chest base width to accentuate the lateral curvature of the breasts
(Fig. 73.27).
73.17 Postoperative Care
Postoperatively, gentle range-of-motion exercises (raising arms
slowly overhead, rotating shoulders back) can be helpful for
mobility and to reduce stiffness. Brief showers are started after
48 hours. Early ambulation, periodic deep breathing, and bowel
care are encouraged. Steri-Strips (3M, St. Paul, MN) are removed 1
week postoperatively, and scar treatment (silicone sheeting, top-
ical silicone gel, etc.) can be started at week 2 or 3. Light activity
Fig. 73.17 (a,b) A template is made with a surgical towel and a 38- to 42-mm cookie cutter. (c) The template is centered where the nipple should be
and the pattern opened. (d) The distance between the corners at the bottom of the areolar keyhole is usually around 5 cm in most patients. (e) The
remainder of the skin resection pattern is marked as a gentle curve stopping at the inframammary fold. The pattern at its widest point tends to be 6 to
8 cm but can very depending on the degree of skin excess. (f) The pattern is tailor-tacked and examined in the supine and seated positions. If the nipple
position is too high or too low, or the degree of vertical skin resection is incorrect, adjustments are made, and the tailor tacking is performed again.

1122
XI Breast Surgery
only is recommended for the first month, with exercise increas-
ing over time.
73.18 Outcomes and Complications
Many complications, such as severe stretch deformities, wound
dehiscence, tissue necrosis, and capsular contracture can be
minimized with proper implant selection, appropriate planning
of skin resection, and excellent tissue/implant handling and
postoperative care. Some complications are more difficult to
avoid, such as mild asymmetry and recurrent ptosis. It is import-
ant to discuss realistic expectations with patients, particularly
with regard to their specific preoperative anatomical limitations,
such as poor skin elasticity or bony asymmetries. Assessment
and correction of many augmentation mastopexy issues will be
discussed in the revision surgery section to follow.
73.19 Revision Augmentation
Mastopexy—Basic Concepts
and Assessment
Revisions are often significantly more complicated than primary
surgery and can require a sophisticated evaluation and vast
array of techniques in order to correct a range of problems.
Conceptually, when assessing a breast for revision, it is important
Fig. 73.18 (a) Severe ptosis, poor skin elasticity, and dense lower breast parenchyma make achieving a youthful final appearance difficult without
an addition-subtraction. This patient rejected mastopexy with upper-pole fat grafting as an alternative. (b) An inverted-T scar pattern was marked,
and all tissue deep to the lower-pole skin resection was amputated. The parenchyma of the upper flaps was thinned to 3 cm. (c) After thinning the
flap, the pectoralis major muscle was destabilized and was restabilized with acellular dermal matrix as a pectoralis extension. (d) The skin within the
mastopexy pattern is de-epithelialized, and the lateral dermis released with minimal undermining, leaving the nipple based on a broad, superior
dermoglandular pedicle. (e,f) Intraoperative photos demonstrate central projection and stability of the breasts after surgical correction. (g–j)
Preoperative and postoperative photos show transformation of the breast anatomy and an 11 cm elevation of the nipple–areola complexes after
a one-stage addition-subtraction augmentation mastopexy. Note that with the flaps thinned, the patient has normal projection and a low risk for
waterfall deformity.