The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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25. Serra F, Aboudib JH. Gluteal implant displacement: diag­
nosis and treatment. Plast Reconstr Surg 2014;134(4):
647–654
26. Manafi A, Emami AH, Pooli AH, Habibi M, Saidian L. Unac­
ceptable results with an accepted soft tissue filler: poly­
acrylamide hydrogel. Aesthetic Plast Surg 2010;34(4):
413–422
27. Claude O, Bosc R, Pigneur F, Lantieri L. Treatment of HIV-
infected subjects with buttock lipoatrophy using stabi­
lized hyaluronic acid gel. Plast Reconstr Surg Glob Open
2015;3(7):e466
28. Camenisch CC, Tengvar M, Hedén P. Macrolane for volume
restoration and contouring of the buttocks: magnetic
resonance imaging study on localization and degradation.
Plast Reconstr Surg 2013;132(4):522e–529e
29. Becchere MP, Farace F, Dessena L, et al. A case series study
on complications after breast augmentation with Macro­
lane™. Aesthetic Plast Surg 2013;37(2):332–335
30. Mayer JE, Goldberg DJ. Injuries attributable to cosmetic
procedures performed by unlicensed individuals in the
United States. J Clin Aesthet Dermatol 2015;8(10):35–37
31. Toy BR, Frank PJ. Outbreak of Mycobacterium abscessus
infection after soft tissue augmentation. Dermatol Surg
2003;29(9):971–973
32. Serra MS, Gonçalves LZ, Ramos-e-Silva M. Soft tissue aug­
mentation with PMMA-microspheres for the treatment
of HIV-associated buttock lipodystrophy. Int J STD AIDS
2014;26(4)
17. Clark RF, Cantrell FL, Pacal A, Chen W, Betten DP. Subcu­
taneous silicone injection leading to multi-system organ
failure. Clin Toxicol (Phila) 2008;46(9):834–837
18. Gold H, Gold HL, Wang I, Meehan S, Sanchez M, Smith
GP. Gluteal silicone injections leading to extensive filler
migration with induration and arthralgia. J Issue Derma­
tology Online J. 2015;21(2):
item/4xf2m886
19. Gurvits GE. Silicone pneumonitis after a cosmetic aug­
mentation procedure. N Engl J Med 2006;354(2):211–212
20. Murariu D, Holland MC, Gampper TJ, Campbell CA. Illegal
silicone injections create unique reconstructive challenges
in transgender patients. Plast Reconstr Surg 2015;135(5):
932e–933e
21. Narins RS, Beer K. Liquid injectable silicone: a review of
its history, immunology, technical considerations, com­
plications, and potential. Plast Reconstr Surg 2006; 118(3
Suppl):77S–84S
22. Salgado CJ, Sinha VR, Desai U. Liposuction and lipofill­
ing for treatment of symptomatic silicone toxicosis of the
gluteal region. Aesthet Surg J 2014;34(4):571–577
23. Senderoff DM. Aesthetic surgery of the buttocks using im­
plants: practice-based recommendations. Aesthet Surg J
2016;36(5):559–576
24. Sinno S, Chang JB, Brownstone ND, Saadeh PB, Wall S Jr.
Determining the safety and efficacy of gluteal augmenta­
tion: a systematic review of outcomes and complications.
Plast Reconstr Surg 2016;137(4):1151–1156
Discussion by J. Abel de la Peña and Guillermo J. Gallardo
There has been an increasing demand for buttock aug­
mentation. In 2015 alone, according to the American
Society of Plastic Surgeons (ASPS),1 14,705 buttock aug­
mentations with fat grafting, 4,767 buttock lifts, and
2,540 buttock implants were placed, which represents
28, 36, and 36% increases, respectively, compared with
the previous year.
In 2013, we published a survey analysis which gave
a better understanding and complication rate estimate
of buttock augmentation with implants placed by ASPS
members. The complication rate was found to be around
the same range as that for breast augmentation with im­
plants, an astonishing 38.1%, much below the estimated
value. The most common complication was wound de­
hiscence, in 7.9% of cases. Other complications included
those listed in Table 32D.1.2
In my (J.A.P.) practice, most buttock complications I
treat are in secondary outpatients from other surgeons.
Table 32D.1 Frequency of gluteal
implant complications
Wound dehiscence
7.9%
Need for implant revision
5.0%
Postoperative pain lasting
longer than 12 weeks
4.2%
Need for implant removal
3.8%
Chronic seroma
3.7%
Minor infection not requiring
implant removal
3.6%
Excessive implant palpability
3.4%

517
Chapter 32 Gluteal Augmentation
One of the key factors I use to reduce complications is
to follow a strict protocol from patient analysis to post­
operative care.
Avoiding Unfavorable Results
and Complications in Gluteal
Augmentation
Preoperative Care
The ideal patients for implants are young, with an ath­
letic build with little or no buttock ptosis and are not
candidates for any fat trimming (Fig. 32D.1). Morbidly
obese patients are good candidates for implant place­
ment after they lose weight, but residual tissue laxity
requires skin excisional procedures to correct the lower
back and gluteal areas. These patient groups are con­
sidered to be the best candidates for implant placement
because gluteal pexy causes flattening of the gluteal re­
gion that cannot be satisfactorily corrected otherwise3
(Fig. 32D.2). Obese patients are referred to a nutrition­
ist or a bariatric surgeon before surgery is considered.
Patients with a low hemoglobin value are replenished
with liposomal iron for at least a month before surgery.
Patients are to stop using any anticoagulant drugs and
any supplements that might increase the risk of bleed­
ing, such as aspirin or vitamin E.
Intraoperative Care
During preparation, the patient should undergo any
mechanical or pharmaceutical thromboembolic pro­
phylaxis treatment depending on the patient’s risk
factor score.4,5 Intravenous prophylactic antibiotics are
given 1 hour before the procedure and continued post­
operatively for 7 days.6 The patient is prepped with a
4% clorhexidine solution and polyvinyl alcohol.7 Dur­
ing surgery, we place a Betadine-soaked gauze (Purdue
Products) over the anus and secure a laparotomy pad
on top with a 2–0 silk suture after antisepsis.
We concur that the most important part of the but­
tock augmentation surgical treatment is body contour­
Fig. 32D.1 Preoperative (top) and postoperative (bottom) photographs of an ideal candidate for buttock augmentation in whom
225-cc highly cohesive gel implants were placed in a subfascial pocket through two incisions.

SECTION IV AESTHETIC SURGERY
518
ing, remodeling of the buttock frame, the lower back,
waist, and flanks. Therefore patient analysis is crucial
to offer the patient the best surgical treatment and to
plan it accordingly.8–10
Two paramedian skin incisions 6 to 7 cm long ex­
tending cephalad, starting 4 cm from the dorsal tip of
the coccyx, are planned 1 cm lateral to the intergluteal
crease preoperatively.11 We have found that this mea­
sure reduces the incidence of wound dehiscence from
a single intergluteal median incision from 30 to around
10% (Fig. 32D.3). Implant type (shape and size) and
placement location are crucial for a successful outcome.
We try not to use the submuscular plane because of the
risk of sciatic nerve injury. The intramuscular plane can
be used in thin patients with poor subcutaneous cov­
erage, but we seldom use it primarily in this group of
patients.12 At our practice, most implants for gluteal
augmentation are placed in the subfascial plane.13 This
plane was described by Abel de la Peña and provides a
good and complete coverage of the whole implant, even
in thin patients. Subfascial implant placement may pro­
vide better augmentation of the lower pole of the but­
tock, especially in patients with a long buttock, and de­
livers a better transverse gluteal increase than any other
technique14–16 (Fig. 32D.4).
Implant selection depends on muscle height-to-
width ratio and intraoperative sizer fitting. A patient
with a tall buttock (2:1 height-to-width ratio) is best
augmented with an anatomic implant; a short buttock
(1:1 ratio) benefits most from an almond-shaped implant.
Intermediate buttocks should be addressed individually.3
Because most patients desire a larger volume that
can be safely achieved through an implant alone, fat
transfer should always be considered in combination
to attain the desired volume. If fat transfer is going to
be performed together with implant placement, great
care should be taken to avoid grafting inside the implant
pocket, because this increases the chance of an infection.
We use highly cohesive gel–filled implants because they
are easy to handle and they are less palpable and more
pliable, which in turn allows for a shorter skin incision
and less wound damage by implant placement.15,17 The
Fig. 32D.2 Preoperative (top) and postoperative (bottom) photographs of a 42-year-old patient who desired gluteal augmentation.
Instead, a gluteoplasty was done, after which an augmentation with silicone implants was performed.

519
Chapter 32 Gluteal Augmentation
Fig. 32D.3 A 51-year-old patient who had gluteal augmentation with implants and had a midline wound dehiscence and left im­
plant removal. Wound closure was aided with vacuum-assisted closure therapy, and an implant was placed in the subfascial plane
after wound closure was achieved.
Fig. 32D.4 (a) The dissection of the pocket is performed from medial to lateral and from cephalic to caudal. Long instruments are
used to maintain a good field exposure. (b) A sizer is used to evaluate the implant pocket. The implant should fit loosely in the
space. (Reproduced from Mendieta CG. The Art of Gluteal Sculpting. New York: Thieme Medical; 2011:310–311.)
a
b
implant is placed in a solution with gentamicin before
placing it in the pocket.
There should never be any tension on a wound at
closure, especially when closing the fascia.17 Patients re­
questing more volume can always undergo a gluteal im­
plant exchange for a larger size 3 to 6 months after the
initial procedure. We try not to leave any drains; instead,
we prefer to do a complete and thorough hemostasis;
the pressure on the cavity walls will maintain a blood­
less field after the gluteal fascia is sutured.
Postoperative Care
Postoperative care is even more important to the pa­
tient’s outcome than the surgical procedure itself. Pa­
tients should come back for follow-up every week. If
any wound abnormality is noticed, a smear and culture
is done and specific antibiotic therapy is initiated. We
print out a postoperative care guideline sheet for pa­
tients to follow. We instruct patients not to sit down on
their buttocks for at least a month, because wound ten­
sion increases as a patient lowers down to take a seat,
and the tension increases the lower one goes. Patients
may lay down either face down, on their side, or face up
with a pillow under the lower back and another under
the knees. Any kind of exercise is strictly forbidden. We
keep postoperative gowns all day for at least 6 weeks.
Patients do a careful but thorough cleaning after void­
ing and use a chlorine-based antiseptic solution every
24 hours over the wound.

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520
Other Considerations
By following these measures, we seldom have the
complications listed earlier, and we have good long-
lasting results (Fig. 32D.5). Chronic pain after sub­
fascial and well-performed intramuscular techniques
is not an issue because the implant never gets close
enough to the neuromuscular bundle, including the
sciatic nerve.
Secondary cases require magnetic resonance imag­
ing to evaluate the anatomy of the area and the integrity
of the muscles and gluteal fascia. Once a diagnosis of the
area is made, a new implant should be placed in a new
pocket; closure of the subcutaneous space is mandatory.
If there is a space between the sciatic nerve and the pos­
terior capsule, the surgeon should attempt to open the
new pocket below the last one and close any opening of
the subcutaneous space.
Chronic seromas are common when elastomer im­
plants are used but are uncommon with highly cohe­
sive gel–filled implants. Textured implants also tend to
develop seromas, but microtextured and smooth-cover
implants do not.
Fig. 32D.5 The 12-year postoperative result of a gluteal augmentation with subfascial 225-cc highly cohesive gel implant.
References
1. Cosmetic Surgery National Data Bank Statistics, The
American Society for Aesthetic Plastic Surgery; 2015
2. Mofid MM, Gonzalez R, de la Peña JA, Mendieta CG,
Senderoff DM, Jorjani S. Buttock augmentation with
silicone implants: a multicenter survey review of 2226
patients. Plast Reconstr Surg 2013;131(4):897–901
3.
Bruner TW, de la Peña JA Salcedo, Mendieta CG, Roberts
TL III. In: Neligan PC, ed. Plastic Surgery. Vol 2. 3rd ed.
Philadelphia, PA: Elsevier Saunders; 2013:599
4. Caprini JA. Risk assessment as a guide for the preven­
tion of the many faces of venous thromboembolism.
Am J Surg 2010;199(1 Suppl):S3–S10
5. Iorio ML, Venturi ML, Davison SP. Practical guidelines
for venous thromboembolism chemoprophylaxis in
elective plastic surgery. Plast Reconstr Surg 2015;
135(2):413–423
6. Bratzler DW, Dellinger EP, Olsen KM, et al; American
Society of Health-System Pharmacists (ASHP); Infec­
tious Diseases Society of America (IDSA); Surgical In­
fection Society (SIS); Society for Healthcare Epidemi­
ology of America (SHEA). Clinical practice guidelines
for antimicrobial prophylaxis in surgery. Surg Infect
(Larchmt) 2013;14(1):73–156
7. Darouiche RO, Wall MJ Jr, Itani KMF, et al. Chlorhexi­
dine-alcohol versus povidone-iodine for surgical-site
antisepsis. N Engl J Med 2010;362(1):18–26
8. Mendieta CG. The Art of Gluteal Sculpting. New York:
Thieme Medical Publishers; 2011
9. Mendieta CG. Gluteoplasty. Aesthet Surg J 2003;23(6):
441–455
10. Mendieta CG. Classification system for gluteal evalua­
tion. Clin Plast Surg 2006;33(3):333–346
11. Tardif M, de la Peña JA. Gluteal augmentation. In:
Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic
Plastic Surgery. Philadelphia, PA: Elsevier Saunders;
2009:837
12. Mendieta CG. Intramuscular gluteal augmentation
technique. Clin Plast Surg 2006;33(3):423–434
13. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés
MT. History of gluteal augmentation. Clin Plast Surg
2006;33(3):307–319
14. De la Peña JA, López HM, Gamboa LF. Augmentation
gluteoplasty: anatomical and clinical considerations.
Key Issues Plast Cosmetic Surg 2000;17:1–12
15. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés
MT. Subfascial gluteal augmentation. Clin Plast Surg
2006;33(3):405–422
16. Mendieta CG. The Art of Gluteal Sculpting. New York:
Thieme Medical Publishers; 2011
17. de la Peña JA. Subfascial technique for gluteal aug­
mentation. Aesthet Surg J 2004;24(3):265–273

521
CHAPTER
33

Female Aesthetic Genital Surgery
Christopher J. Salgado, Lydia A. Fein, Natalie R. Joumblat,
and Ajani Nugent
In recent years, women have been increasingly seeking aes­
thetic genital surgery.1,2 One possible explanation for this
trend sources from the media highlighting an idealistic form
of the female genitalia: hairless and symmetrical with non­
visible labia minora. Although aesthetic modification is the
most common motivation, women seek genital surgery for a
variety reasons, including functionality, discomfort, chafing,
and impaired sexual pleasure.3–6 Regardless of the reason,
the increased demand in female aesthetic genital surgery
warrants detailed attention to surgical techniques, compli­
cations, and prophylactic precautions. Thus far, outcomes
have generally been favorable, with most series reporting
high patient satisfaction and low rates of complications.6–9
Avoiding and Managing Unfavor­
able Results and Complications in
Female Aesthetic Genital Surgery
Summary Box
Procedure
Complications
Mons pubis lift
Overresection
Labia majora
resection
Overreduction causing scar
hypertrophy
Hematoma
Transient hypersensitivity
Labia majora
augmentation
Overfilling
Adipose cysts
Contour irregularities
Labia minora
reduction
Wound dehiscence
Scar contracture
Dyspareunia
Chronic pain
Overresection
Hematoma
Labial fistula
Clitoral hood dog-ears
Labia minora necrosis
Vulvar agglutination
Procedure
Complications
Deepitheli­
alization
labiaplasty
Residual tissue
Wound dehiscence
Abrupt color change at suture
line
Clitoral hood
resection
Wound dehiscence
Clitoral hood dog-ears
Suture granuloma of the hood
Damage to dorsal nerve of the
clitoris
Hypersensitivity
Perineoplasty
Vaginal constriction
Dyspareunia
Wound dehiscence
Chronic pain
Vaginoplasty
Wound dehiscence
Infection
Postoperative bleeding
Vaginal apex stricture causing
dyspareunia
De novo incontinence
Common Complications When Performing Female Aesthetic Genital Procedures

SECTION IV AESTHETIC SURGERY
522
thetic surgery are discussed in the following sections with
a focus on their accompanying complications, ways to avoid
these complications, and management strategies for when
complications arise.
Surgical Techniques
Mons Pubis Lift
A mons pubis lift corrects mons pubis ptosis by a low trans­
verse suprapubic incision, similar to that used in abdomino­
plasty. The goal is to create a youthful contour to the junction
between the mons and the lower abdomen. Therefore the
incision must extend far enough laterally to give a natural
triangular appearance to the mons. To achieve a successful
mons lift, both excess pubic skin and fat must be removed.
The fibrofatty tissue of the pubic skin flap should be resus­
pended to the anterior rectus sheath fascia as well.13 If the
mons pubis lift is to be performed with concomitant abdom­
inoplasty, any planned labia majora reduction should then
be delayed, because a pubic lift can cause increased labia
major swelling. To avoid complications and revisions, over­
resection of mons fat should be avoided, because it can cause
an unnatural appearance such as contour irregularities, and
the closure of the defect must be tension-free to avoid el­
evating the intervulvar cleft and clitoris.9,11 In addition, care­
ful attention must be paid to the dorsal clitoral nerves so that
they are not injured during the resection.
Labia Majora
Labia Majora Resection
The goal of labia majora resection is to eliminate excess skin
or tissue from the outer labia while avoiding overreduction.
Primary labia majora hypertrophy causing tissue excess
must be distinguished from secondary labia major hyper­
trophy resulting from volume loss leading to skin excess.
This delineation determines the appropriate technique for
correction. Volume excess can be treated by full-thickness
reduction with debulking, but care should be taken not to
remove too much tissue, which can create sagging and ex­
cess skin.14,15 Excess skin can be removed using a longitu­
dinal wedge excision. To avoid transfer of hair-bearing skin
medially and secondary irritation, the incision should be
placed on the lateral aspect of the labia majora skin and
the smooth skin of the intervulvar cleft.16 Excessive resec­
tion can lead to exposure of the vagina and can be avoided
by continuous reassessment of the labial flap in the posi­
tion of inset. The scar in labia majora resection is long and
visible, underscoring the importance of both appropriate
incision planning and tension-free closure. In addition to
overreduction causing scar hypertrophy, complications of
this procedure are hematoma and transient hypersensitiv­
ity for 4 to 6 weeks.16 Hematomas tend to form because the
large vessels of the labia majora retract into the fatty tissue
during resection, making them difficult to cauterize. If a he­
Preoperative Planning and Patient
Selection
Preoperative patient counseling is essential in aesthetic
genital surgery. Surgeons need to educate patients in the
normal variations of female genitalia and discuss both
the risks and benefits of each procedure to endorse in­
formed decisions with realistic expectations. For example,
a patient desiring complete amputation of the labia minora
should be informed of these structures’ importance in nor­
mal micturition as well as lubrication and should be dis­
couraged from pursuing such an extreme procedure. The
physician also needs to oversee that the patient’s decisions
are made autonomously and not through coercion. To en­
sure this, surgeons need to be cognizant of common “red
flags,” such as friends and family members who display
intrusive behavior and seem overly concerned with the
surgical details and outcomes. Mothers to teenage patients
are an exception and may display this level of involvement
without warranted concern.9 Because patients with body
dysmorphia tend to not benefit from cosmetic procedures,
it is imperative to screen for this disorder before surgery.
Any underlying pelvic floor or urinary conditions must also
be screened for so that they are treated preoperatively and
the increased risk of complications is avoided.10
Assessing preoperative sexual function should be a com­
ponent of the preliminary consultation. Although some data
suggest that aesthetic genital surgery can improve sexual
function and satisfaction,6 it must be determined whether
the underlying cause of dysfunction is psychological, hor­
monal, or anatomic. If a psychological cause is suspected,
it is important to inform the patient that aesthetic surgical
modifications have the potential to increase confidence and
in turn improve one’s sexual experience.11 The patient must
also be informed that the dissatisfaction is unlikely due to
any anatomic abnormalities and that surgery may not be the
solution to these needs. Counseling patients in this fashion
allows them to make an informed decision and form more
realistic expectations before surgical intervention.
Standardized photographs of the patient should be taken
in both standing and lithotomy positions during preopera­
tive planning. These are useful to review with the patient
before surgery to discuss any preexisting asymmetry and
the anticipated scar location.11
Wound-healing complication rates are higher in those
who smoke, are overweight, or have diabetes.11 Therefore
smoking cessation, weight loss, and medical optimization of
comorbidities are encouraged before surgery. It is impera­
tive for patients not to smoke for at least 4 weeks before sur­
gery. All patients should be counseled to rest for 3 to 5 days
following surgery to prevent hematoma and postoperative
swelling.11 In addition, patients should be discouraged from
resumption of sexual intercourse until reevaluation at their
postoperative visit.
In general, complications related to female aesthetic
genital surgery are low, with most studies reporting a prev­
alence of 5% or less.10,12 Specific procedures in genital aes­

523
Chapter 33 Female Aesthetic Genital Surgery
patient in advance. The edge-trim technique may also not be
ideal for patients who are interested in preserving the natu­
ral color of the labial edge.
Documented complications of direct excision techniques
include hematoma, wound dehiscence, and overexcision24
(Fig. 33.1). Small hematomas will likely drain spontaneously,
but if they do not they should be drained in the operating
room promptly. Wound dehiscence can often be managed
by allowing for secondary intention. Overexcision is often
irreversible because of resultant tissue deficit. However, an
island clitoral hood flap that is vascularized randomly based
on dartos muliebris fascia of the lower clitoral hood and me­
dial labium majus can be transposed to the labial defect.23
Avoiding lateral tension during reduction is imperative to
prevent overresection. Patient selection is also important.
Other deformities that do not involve overresection
can often be reconstructed with wedge excisions, labial Y-V
advancements, and touch-up trimming.23 In general, indi­
viduals with prominent clitoral hoods are not ideal candi­
dates for the direct excision technique, and another method
should be undertaken.11
Wedge Resection Labiaplasty
Alter22 first described the wedge resection technique in
1998 as an alternative to direct excision to preserve the la­
bial edge and avoid chronic scar tenderness. The original
technique involved a V-shaped central wedge resection.
One modification of the technique added two z-plasties
to reduce the deformity at the free border and create a
tensionless suture line by interdigitating two rectangular
flaps. This serves to avoid wound dehiscence and potential
tightening of the introitus.25 To minimize introital constric­
tion, the vagina should accommodate two fingers, without
excessive tension on the incision closure.9 Alter eventually
updated his technique to include the addition of an ante­
matoma forms it must be drained quickly in the operating
room under general anesthesia.16 Use of passive drainage
may also be appropriate in select patients.
Labia Majora Augmentation
The purpose of volume augmentation is to counteract the
deflation of the mons pubis and labia majora that can occur
after weight loss or hormonal changes. Facial fillers such as
calcium hydroxyapatite and hyaluronic acid can be used,
but large amounts are often required, which can be cost
prohibitive. Fat transfer using lipoinjection or dermal fat
grafts can be used as an alternative (Video 33.1).17 Fat can
be harvested from the abdomen, flank, or thighs, and 10 to
50 cc can be injected in each labia majora, although the de­
finitive end point ultimately relies on aesthetic judgment.
Fat can also be injected into the mons pubis if this region
appears deflated. It is important to overfill the areas by 20
to 30% to allow for fat resorption, which is a known con­
sequence of fat grafting. Lipoinjection can cause palpable
fatty cysts to form or create contour irregularities.18 There­
fore it is reasonable to consider dermal fat grafting as an
alternative, particularly if an abdominoplasty is performed
concurrently, because the dermal fat can be harvested from
the resected specimen and has been reported in the litera­
ture to have increased graft survival.19
Labia Minora
Surgical reduction of the labia minora is the most common
female aesthetic genital procedure and thus has the most
options for surgical technique.1,2,16 The optimal technique
should be selected based on the amount and anatomic loca­
tion of tissue requiring resection as well as surgeon comfort.
Edge-Trim Labiaplasty
Edge-trim techniques, in which the labia minora are resected
and the epithelial edges reapproximated, were the first tech­
niques described and are useful for selectively trimming
areas of tissue redundancy. Complications related to direct
excision include scar contracture (potentially causing a tight
introitus and suture dehiscence), wound infection, and stiff,
painful scars that can cause local irritation and pain with
ambulation.20,21 Keeping the incision out of the posterior
fourchette can prevent postoperative dyspareunia caused by
scar contracture in the introitus.22 Asymmetry and scallop­
ing of the labial edges are also potential concerns.21 To pre­
vent scar contraction, a nonlinear incision such as the “lazy
S” introduced by Felicio or the W modification developed by
Maas and Hage can be used.22 Avoiding interrupted sutures
at the labial edge can also help to preserve a natural appear­
ance.23 Running, absorbable suture is a good choice for the
closure.11 Felicio’s lazy S incision is intended to maintain
the natural asymmetry of women’s labia.24 However, many
women desire symmetry when seeking genital surgery, and
if this technique is to be used, it should be discussed with the
Fig. 33.1 Overreduced labia minora after labiaplasty.

SECTION IV AESTHETIC SURGERY
524
pareunia, and clitoral hood “dog-ears.” Dog-ear deformities
can be avoided by incorporating the hockey-stick resection
described by Alter.23,26,29 To avoid dyspareunia, the labial re­
section should not be extended to the posterior fourchette,
and labial width should be kept to at least 1 cm so that the
labia will protrude past the introitus (Fig. 33.2).17
Loss of a smooth pigment transition zone is another
possible complication, but unfortunately this may be un­
avoidable in some patients. Discussing this preoperatively
with patients is important. If an aesthetic pigment transi­
tion is not possible with a wedge technique, an edge-trim
technique may be a better option.11 Another postoperative
complication of labiaplasty is vulvar agglutination, which
can be treated with an estrogen-derived cream (Fig. 33.3).
rior, hockey-stick resection to excise lateral clitoral hood
excess.9 Other variations include the star labiaplasty, which
includes a vertical V resection with horizontal wedge re­
section, and the inferior wedge resection with superior
pedicle flap.26
Intraoperative use of local anesthesia (1% lidocaine with
1:100,000 epinephrine) is beneficial for vasoconstriction
and hydrodissection of the subcutaneous space between the
lateral and medial skin layers of the labia. This facilitates tis­
sue resection and placement of skin sutures. It is important
to mark the proposed site of surgical incisions before the
injection of the anesthetic.
Proper closure of the wedge defect, which is often cre­
ated centrally, is important for an optimal aesthetic re­
sult. Monofilament absorbable sutures on a tapered needle
should be used to close the defect followed by interrupted or
running absorbable Vicryl or monofilament sutures for the
mucosal layer. To avoid notching of the free edge of the labia
minora, the edges of the mucosa can be everted distally and
closed with a 5–0 Monocryl suture using the vertical mat­
tress technique. If a patient has thin, atrophic labia minora,
the wedge should be demucosalized rather than resected in
a full-thickness fashion.11
The main complication of wedge labiaplasty is wound
dehiscence, particularly when taken from the inferior
edge.9,22,26–28 The blood supply of the labia is variable, and
the tension imposed on the outwardly pulled edges can re­
sult in improper healing. To prevent wound dehiscence and
fistula formation it is important to preserve as much subcu­
taneous tissue as possible and precisely reapproximate the
wound edges. The subcutaneous tissue should be closed in
one or two layers and the labium reapproximated and closed
in three layers with 4–0 and 5–0 absorbable sutures. Using
an atraumatic, noncutting needle is also helpful in prevent­
ing tissue damage during reapproximation. Other compli­
cations, albeit rare, include labium fistula, hematoma, dys­
a
b
Fig. 33.2 (a) Markings for wedge resection labiaplasty. (b) Resection includes the posterior fourchette with perineoplasty to prevent entry
dyspareunia postoperatively.
Fig. 33.3 Vulvar agglutination after wedge resection labiaplasty.

525
Chapter 33 Female Aesthetic Genital Surgery
the excision, which must be kept superficial to avoid the
dorsal clitoral nerve located deep to the investing fascia of
the clitoris.11
If labial hypertrophy is also present, the clitoral hood re­
section can be combined with a wedge resection labiaplasty.
This technique also protects the dorsal nerve of the clitoris.
Alter’s hockey stick modification to his central wedge re­
section technique23 addresses redundant clitoral tissue. If
the hypertrophic tissue is more medial, a vertical medial
ellipse resection can be used instead of the lateral hockey
stick. Clitoral hood tissue can be closed with 5–0 Monocryl
in the subcutaneous tissue and a subcuticular Monocryl
skin closure.8 Some suggest using Vicryl sutures, instead of
monofilament, in the areas closest to the clitoris to minimize
postoperative irritation and pain.30
Complications associated with clitoral hood resection
are wound dehiscence, clitoral hood dog-ears, clitoral hy­
persensitivity, and suture granuloma.9,32 Care should also
be taken to limit scar formation that may cause hypersensi­
tivity, in addition to vigorous closure resulting in damage to
the clitoris.14 It is also important to make the patient aware
that in the case of combined procedures, healing time is pro­
longed and swelling and discomfort may persist for several
weeks.11,24
Perineoplasty
The goal of perineoplasty is to reconstruct the vaginal in­
troitus with a minor low-posterior compartment repair. Re­
approximation of the levator ani muscles is also performed
and is important to strengthen the resulting perineal body
and elevate the perineum. A diamond-shaped wedge tech­
nique is used (Fig. 33.4).
The primary complication of perineoplasty is overcor­
rection resulting in perineal constriction.17 To avoid this, a
dilator can be inserted into the vagina intraoperatively to
ensure that it can be inserted distal to the introitus with­
Labiaplasties performed using the inferior wedge resec­
tion technique in conjunction with transposition of a su­
periorly based flap are particularly susceptible to skin tip
necrosis, as previously stated.27,29 This will typically heal
secondarily, but it is important to avoid aggressive under­
mining and hemostasis that can compromise the vascular
supply of the flap.29 The inferior wedge technique is used
less often in the United States because of the increased
wound dehiscence rates.
Deepithelialization Labiaplasty
The only technique that completely respects the labial edge
and avoids violation is the deepithelialization technique
described by Choi and Kim.29 In this method, both the
medial and lateral sides of the labia are marked to iden­
tify areas of hypertrophy located centrally and are subse­
quently deepithelialized with either a scalpel or laser. This
technique is best for patients with very little hypertrophy
(approximately 2–3 cm from baseline).29 Otherwise the
surgeon runs the risk of leaving behind too much tissue,
resulting in a bulky labium and poor aesthetic outcome. In
addition to residual tissue redundancy, poor outcomes can
result from wound dehiscence and abrupt color change at
the suture line.17
Clitoral Hood Resection
The primary goal of clitoral hoodectomy is to remove re­
dundant or hypertrophic clitoral hood tissue.6 The loca­
tion of excess tissue determines the ideal technique for
resection. Excess tissue in the sagittal plane, appearing as
a wrinkled clitoral hood, can be resected with an inverted-
V curvilinear approach. Widened clitoral hoods with ex­
cess lateral tissue can be reduced with triangular excisions
along the lateral borders of the clitoral hood. With these
excisional techniques, the primary concern is the depth of
a
b
Fig. 33.4 (a) Diamond-shaped wedge excision. (b) One year after diamond-shaped perineoplasty and central wedge resection labiaplasty.

SECTION IV AESTHETIC SURGERY
526
continence, postoperative vaginal bleeding, and dyspareu­
nia resulting from vaginal apex stricture. There has been one
reported case of rectal entry when performing combined vag­
inoplasty and perineoplasty. If this occurs, immediate iden­
tification and closure of the defect should be performed.6,10
Other methods of vaginal tightening have recently
emerged, including the use of autologous fat grafting or
bulking agents such as hyaluronic acid. These have their lim­
itations, however, because hyaluronic acids get resorbed and
only provide temporary improvement, whereas the long-
term viability of grafted fat is variable.17 Occasionally foreign
body injections to the proposed G-spot are also performed,
despite poorly demonstrated safety and efficacy, and these
have led to significant complications.31
Conclusion
The growing popularity of female aesthetic genital surgery
has been accompanied by the advent of many procedures
and techniques. To achieve optimal aesthetic outcomes, it is
imperative that the surgeon be able to determine the most
appropriate procedure given the patient’s anatomy and to
approach each in a manner to minimize complications and
manage any that should arise.
out much resistance. Vaginal dilators can also be used post­
operatively to resolve perineal constriction with stretching.
Perineoplasty will only be successful if the underlying pelvic
floor’s muscle strength and function are intact. Training by a
pelvic floor physical therapist has been associated with im­
proved long-term outcomes of perineoplasty.6
Vaginoplasty
The goal of vaginoplasty is to tighten the vagina by recon­
structing the lateral wall segment. This is generally per­
formed by excising and primarily closing mucosa and mus­
cle at each vaginal fornix. Lateral colporrhaphy is the most
commonly used technique when reducing the size of the
vagina is the primary operative goal. This technique avoids
placing scars in areas of high sensitivity, which causes less
postoperative dyspareunia.17 In addition to lateral colpor­
rhaphy, posterior vaginal epithelium can be dissected and
trimmed to an appropriate diameter and rectovaginal mus­
cles can be plicated. Occasionally levator ani muscles may
be plicated, but this may cause significant dyspareunia and
is not recommended in isolated aesthetic cases.10
Reported complications of vaginoplasty by colporrha­
phy include wound dehiscence, local infection, de novo in­
References
1. Committee on Gynecologic Practice, American College of
Obstetricians and Gynecologists. ACOG Committee Opin­
ion No. 378: Vaginal “rejuvenation” and cosmetic vaginal
procedures. Obstet Gynecol 2007;110(3):737–738
2. American Society of Aesthetic Plastic Surgery. Labiaplas­
ty and buttock augmentation show marked increase in
popularity, 2014,
releases/labiaplasty-and-buttock-augmentation-show-
marked-increase-in-popularity
3. Braun V. In search of (better) sexual pleasure: female gen­
ital ‘cosmetic’ surgery. Sexualities 2005;8(4):407–424
4. Koning M, Zeijlmans IA, Bouman TK, van der Lei B. Female
attitudes regarding labia minora appearance and reduc­
tion with consideration of media influence. Aesthet Surg J
2009;29(1):65–71
5. McDougall LJ. Towards a clean slit: how medicine and no­
tions of normality are shaping female genital aesthetics.
Cult Health Sex 2013;15(7):774–787
6. Goodman M, Placik O, Benson R, et al. A large multicenter
outcome study of female genital plastic surgery. J Sex
Med 2010;7:1565–1577
7. Mirzabeigi M, Moore J, Mericli A, et al. Current trends in
labiaplasty. Ann Plast Surg 2012;68:125–134
8. Cihantimur B, Herold C. Genital beautification: a concept
that offers more than reduction of the labia minora. Aes­
thetic Plast Surg 2013;37(6):1128–1133
9. Alter GJ. Aesthetic labia minora and clitoral hood reduc­
tion using extended central wedge resection. Plast Recon­
str Surg 2008;122(6):1780–1789
10. Hamori C, Salgado CJ, Dalke KA. Female aesthetic genital
surgery. In: Salgado CJ, Redett R, eds. Aesthetic and Func­
tional Surgery of the Genitalia. New York, NY: Nova Sci­
ence Publishers, Inc.; 2014
11. Iglesia CB, Yurteri-Kaplan L, Alinsod R. Female genital cos­
metic surgery: a review of techniques and outcomes. Int
Urogynecol J Pelvic Floor Dysfunct 2013;24(12):1997–2009
12. Guo S, Dipietro LA. Factors affecting wound healing. J
Dent Res 2010;89(3):219–229
13. Goodman MP. Female genital cosmetic and plastic sur­
gery: a review. J Sex Med 2011;8(6):1813–1825
14. Alter GJ. Management of the mons pubis and labia ma­
jora in the massive weight loss patient. Aesthet Surg J
2009;29(5):432–442
15. Hamori CA. Aesthetic surgery of the female geni­
talia: labiaplasty and beyond. Plast Reconstr Surg
2014;134(4):661–673
16. Dobbeleir JM, Landuyt KV, Monstrey SJ. Aesthetic surgery
of the female genitalia. Semin Plast Surg 2011;25(2):130–
141
17. Di Saia JP. An unusual staged labial rejuvenation. J Sex
Med 2008;5(5):1263–1267, discussion 1263–1267
18. Salgado CJ, Tang JC, Desrosiers A. Vulvar rejuvenation us­
ing dermal fat graft to augment the labia majora. J Plast
Reconstr Aesthet Surg 2011;65:267–270
19. Triana L, Robledo AM. Refreshing labioplasty tech­
niques for plastic surgeons. Aesthetic Plast Surg
2012;36(5):1078–1086
20. Sawhney CP, Banerjee TN, Chakravarti RN. Behaviour of
dermal fat transplants. Br J Plast Surg 1969;22(2):169–
176
21. Alter GJ. A new technique for aesthetic labia minora re­
duction. Ann Plast Surg 1998;40(3):287–290
22. Alter GJ. Labia minora reconstruction using clitoral hood
flaps, wedge excisions, and YV advancement flaps. Plast
Reconstr Surg 2011;127(6):2356–2363
23. Felicio YdeA. Labial surgery. Aesthet Surg J 2007;27(3):322–
328

527
Chapter 33 Female Aesthetic Genital Surgery
29. Munhoz AM, Filassi JR, Ricci MD, et al. Aesthetic labia
minora reduction with inferior wedge resection and su­
perior pedicle flap reconstruction. Plast Reconstr Surg
2006;118(5):1237–1247, discussion 1248–1250
30. Choi HY, Kim KT. A new method for aesthetic reduction of
labia minora (the deepithelialized reduction of labioplas­
ty). Plast Reconstr Surg 2000;105(1):419–422, discussion
423–424
31. Gress S. Composite reduction labiaplasty. Aesthetic Plast
Surg 2013;37(4):674–683
32. Park HJ, Jung KH, Kim SY, Lee JH, Jeong JY, Kim JH. Hy­
aluronic acid pulmonary embolism: a critical conse­
quence of an illegal cosmetic vaginal procedure. Thorax
2010;65(4):360–361
24. Maas SM, Hage JJ. Functional and aesthetic labia minora
reduction. Plast Reconstr Surg 2000;105(4):1453–1456
25. Ellsworth WA, Rizvi M, Lypka M, et al. Techniques for la­
bia minora reduction: an algorithmic approach. Aesthetic
Plast Surg 2010;34(1):105–110
26. Giraldo F, González C, de Haro F. Central wedge nymphec­
tomy with a 90-degree Z-plasty for aesthetic reduction of
the labia minora. Plast Reconstr Surg 2004;113(6):1820–
1825, discussion 1826–1827
27. Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hyper­
trophy of labia minora: experience with 163 reductions.
Am J Obstet Gynecol 2000;182(1 Pt 1):35–40
28. Marchitelli CE, Sluga MC, Perrotta M, Testa R. Initial ex­
perience in a vulvovaginal aesthetic surgery unit within
a general gynecology department. J Low Genit Tract Dis
2010;14(4):295–300
Discussion by Gary J. Alter
There are myriad procedures available for female aes­
thetic genital surgery. As with facial surgery, the sur­
geon must also think of the genital area as a combined
aesthetic unit that should be synchronous. A patient
with a ptotic mons pubis and enlarged labia minora,
clitoral hood, and labia majora may not be completely
rejuvenated if these areas are not all addressed. Obvi­
ously, the wishes of the patient take priority. It is easy
for the surgeon to be confused by the choices and indi­
cations for each genital unit, because there are advan­
tages and disadvantages for each procedure. This dis­
cussion is based on my more than 20-year experience
and bias doing these procedures, most of which were
being developed over that time. My personal prefer­
ences and suggestions for each element are explained.
Aesthetic genital surgery has several goals:
•• A nonptotic mons pubis with a mild convexity that
does not visibly protrude when wearing clothes
•• Labia majora that are full and smooth but don’t hang
significantly or bulge in clothes
•• A clitoral hood that is reasonably short,
nonprotuberant, narrow, and lacks excessive folds or
hyperkeratotic tissue
•• Labia minora that are smooth, thin, symmetrical,
light in color, and do not hang lower than the labia
majora when standing
•• A vaginal introitus that is closed when laying down
and does not open or only opens mildly on leg
abduction
These ideals can be achieved in many cases, because
tremendous strides have been made in the past several
decades. However, overzealous or careless surgery can
result in a worsening of appearance and severe com­
plications.
Avoiding Unfavorable Results and
Complications in Female Aesthetic
Genital Surgery
Mons Pubis Lift
Several important considerations should be kept in
mind when performing a mons pubis lift:
1. A normal amount of escutcheon should be left.
2. The anterior labial commissure should not be
elevated too high.
3. Adequate nonabsorbable tacking sutures should be
used.
A normal-appearing escutcheon should have a length of
7 to 8 cm above the anterior labia commissure.1,2 A hori­
zontal skin incision is placed just below a panniculus fold
or just above the escutcheon. The amount of skin excision
can be estimated in advance but can be accurately deter­
mined after fat removal, undermining, and tacking. Lack
of normal escutcheon length is unsightly and unnatural,
as is a long, high anterior labial commissure. Therefore
care must be taken that the anterior labial commissure is
not elevated past the pubic symphysis.
The mons fat is primarily removed by liposuction
rather than excision because it is easier, limits open
undermining of the flap to between the external rings,
causes less morbidity, and preserves the Scarpa’s fascia
that stabilizes the tacking sutures. Some sharp excision
of the fat may be necessary near the commissure. Clitoral
sensation will not be injured if dissection remains anterior
to the pubic symphysis.
Tacking sutures prevent recurrent ptosis of the mons
and stabilize its position. This is especially important if
a combined abdominoplasty is performed. The tacking
sutures must be placed to stabilize the mons before the

SECTION IV AESTHETIC SURGERY
528
upward pull of an abdominoplasty. When in the supine
position, the anterior commissure is palpated and placed
at or just below the cephalic level of the symphysis. The
first row of No.1 Prolene tacking sutures is placed several
centimeters cephalic to the commissure between the ex­
ternal inguinal rings. Placing sutures at the commissure
will deepen the commissure and make it appear more
elevated. Usually, three rows of at least three horizontal
tacking sutures stabilize the mons to give it a pleasing
height. Mild dimpling of the tacking sutures is usually
necessary and commonly resolves in several months.
Patients with massive skin excess in the horizontal
vector should have the excess removed by lateral pu­
bic ellipses or darts, which locates the scars laterally.
The lateral darts may be based at the horizontal incision
line, but this creates two T junctions with the atten­
dant healing issues. Therefore I prefer bilateral elliptical
excisions if possible. I do not excise excess skin in the
midline, because it causes an unsightly, unnatural scar.
It also removes normal escutcheon skin and pubic hair
and makes pubic tacking more difficult.
Labia Majora Reduction
Enlarged labia majora with skin excess may have nor­
mal, excess, or deficient fat. If there is no skin excess in
enlarged labia majora, the patient may have fat excess.
If the skin is ptotic with a lack of fullness, then she may
have fat deficiency. The procedure of choice depends
on the diagnosis.
Patients with skin excess should have the skin re­
moved with bilateral crescent excisions of skin from
the anterior to the posterior labial commissures1 (Figs.
33D.1 and 33D.2). The incisions should not meet in the
a
b
c
d
Fig. 33D.1 (a) A 51-year-old woman with labia minora and majora enlargement. She also desired revision of the excess skin of
the posterior perineum and labium. (b) Labia minora and excess posterior labial skin. (c) The labia minora were reduced and pos­
terior lip reconstructed. Markings for the labia majora skin reduction have been made. (d) Result 4 months after the procedure.

529
Chapter 33 Female Aesthetic Genital Surgery
midline. Asymmetry of the majora is not uncommon, so
excision is adjusted to achieve symmetry. The medial in­
cision line is placed in the lateral labial sulcus in an area
that will match the color and skin texture as well as pos­
sible. The patient should be told that a color contrast be­
tween the medial and lateral sides of the suture line can
occur, which may make the scar more visible. However,
patients rarely object when told in advance. The lateral
incision should leave about 1.8 to 2.0 cm of pigmented
labia majora skin laterally at the midportion of the la­
bium, which will almost certainly prevent overresection
of labia majora skin. Overly aggressive labia majora re­
moval can cause opening of the vaginal introitus with
hip abduction. Therefore the patient should be checked
before resection with maximal hip abduction. A gaping
vagina from overresection can be a disastrous complica­
tion, because it can cause discomfort with clothes, vagi­
nal dryness, and a severe cosmetic deformity.
Extreme care must be taken with patients who have
had or are planning to undergo a medial thigh lift if the
thigh lift incisions extend along the medial thigh crease.
Tacking sutures to the Colles fascia and ischium with a
medial thigh lift often fail to hold, causing posterior mi­
gration of the suture line and labia majora. This causes
wide introital gaping that is usually uncorrectable.
If fat is also excised, care must be taken to leave a
normal amount of fat, which prevents hollowing (see
Fig. 33D.2). Usually, more fat is present in the anterior
labium. If the patient has fat deficiency, fat injections
can be done alone or in conjunction with a skin excision,
because the fat is injected below the superficial Colles
fascia. I rarely inject more that 10 cc into each labium,
because patients typically do not want a large bulge in
the genital region when wearing tight clothes.
A drain is not used unless a large amount of fat is
excised. Meticulous hemostasis is mandatory. If fat is
a
b
c
d
e
f
Fig. 33D.2 (a) A 30-year-old patient who presented for labia majora skin and fat excision and pubic liposuction. The markings are
visible. (b) The medial and lateral majora markings. (c) The fat to be excised. (d) Excised fat with the majora temporarily closed.
(e) The majora with significant fat remaining. (f) After closure of the majora and pubic liposuction.

SECTION IV AESTHETIC SURGERY
530
removed, the superficial Colles fascia is closed with a
running 4–0 Monocryl suture. The subdermal layer is
closed with a running 5–0 Monocryl while catching the
superficial Colles fascia to eliminate the dead space. The
skin is closed with a subcuticular 5–0 closure.
Labia Minora Reduction
The most common labiaplasty procedures performed
are a trimming labia minora reduction or a central
wedge reduction. The trimming is performed using
a scalpel, scissors, laser, or radiothermy. Because the
ideal goal of an aesthetic operation is to achieve as
natural an appearance as possible, I believe the central
wedge labiaplasty best fulfills that goal without surgi­
cal stigmata3 (see Fig. 33D.1 and Fig. 33D.3).
The advantages of edge-trimming techniques are
that they are quicker, usually require less technical train­
ing, and eliminate dark pigmentation on the labial edge.
Alternatively, there can be quite a few complications4,5
(Box 33D.1).
Nonetheless, studies by surgeons experienced in the
trim techniques show a high patient satisfaction rate
with low complications.6,7 These results indicate that
meticulous technique with small sutures can eliminate
most, but not all, of these disadvantages. However, I do
not believe that the final appearance of the labia after a
trim looks as natural as the labia after a central wedge
labiaplasty. As in most aesthetic studies, results are sub­
jective, so patient and surgeon satisfaction are based on
expectations as to what is possible and what is consid­
ered a good result.
The central wedge labiaplasty remains my preferred
technique despite the disadvantages of longer operating
time, persistence of some darker pigmentation on the
labial edges even though the darkest portion is usually
eliminated, potential color mismatch on the suture lines,
possible stretching of the labia over time, and reports
of wound dehiscence. Having performed thousands of
these procedures, I believe that most of the complica­
tions of perforation and wound dehiscence result from
lack of meticulous surgical technique. Successful perfor­
mance of this procedure without complications is time
consuming, which is often discounted as unnecessary by
the surgeon. However, the complications of the wedge
resection are generally less serious and more easily cor­
rectable than the complications of the trimming tech­
niques.
Box 33D.1
•• Unnatural labial edges with scalloping and
scar separation
•• Asymmetry
•• Overresection and possible labial
amputation
•• Protrusion and hanging of the tips of the
frenula and edges of the clitoral hood
•• Anterior rotation of the clitoral hood and
frenula resulting in elongation of the
introitus
•• Sexual dysfunction from painful scars
Complications Related
to Edge-Trimming
Techniques
a
b
Fig. 33D.3 (a) A 23-year-old patient with labia minora enlargement. (b) Three months after central wedge labiaplasty with lateral
extended wedge clitoral hood reduction.

531
Chapter 33 Female Aesthetic Genital Surgery
Resection is planned such that the labia minora will
be straight without any tension (Fig. 33D.4). The introi­
tus must fit two fingerbreadths. If the introitus is tight,
the surgeon must determine whether the tightness is
a result of medial extension of the internal wedge or a
tight hymen. The surgeon must use caution in the pres­
ence of a very protuberant, long, wide labium, because
the medial wedge may extend so deep into the introitus
that it overly narrows it. This variant is very uncommon,
but a modification of the central wedge labiaplasty as
reported by Gonzalez et al,7 named the custom flask la­
biaplasty, will prevent narrowing. This technique does
not extend the medial incision line internal to the mu­
cocutaneous junction, thus avoiding a deep resection.
A meticulous four-layer labial closure with 5–0
Monocryl virtually eliminates perforations, dehiscence,
and major separations. Two layers of interrupted 5–0
Monocryl are placed in the subcutaneous tissue even if
there is very little of this tissue. The leading edge of the
repair is closed with vertical mattress 5–0 Monocryl to
prevent notching and minor separation. The remainder
of the closure is performed with interrupted simple and/
or vertical mattress sutures, except for the deepest me­
dial labium, which is closed with a running suture. Since
I began using the four-layer closure more than 15 years
ago, I have not had a major dehiscence, only uncommon,
mild notching separations at the leading edge.
Perforations are extremely rare. Meticulous clo­
sure with loupe magnification has been instrumental
in achieving these results. If a notch or minor dehiscence
occurs, it is relatively easy to repair after 4 to 6 months.
A z-plasty at the edge or internally is unnecessary, be­
a
b
c
d
e
Fig. 33D.4 (a) A 22-year-old patient with labia minora enlargement. (b) Markings for medial excision. (c) Markings for lateral
clitoral hood extended wedge excision. (d) Immediately postoperatively. (e) Immediately postoperatively with the labia open.

SECTION IV AESTHETIC SURGERY
532
cause contraction is opposite to the vector of vaginal
tightness, and the skin and mucosa are very thin, mak­
ing hypertrophic scars very rare.
The darkest portion of the labia is usually removed
with the central wedge excision. On occasion, the color
anterior to the labial edge suture line may be lighter
than the posterior edge, resulting in a color mismatch at
the suture line. If patients are told in advance that there
may be a color contrast, they rarely dissent. This color
discrepancy usually improves with time. If it is still un­
acceptable, the suture line and labium can be medically
tattooed to blend the color.
The central wedge labiaplasty can cause the pos­
terior lip of the introitus to pull up, which can make
intercourse difficult. If the posterior lip is pulled up or
is hypertrophic, reconstruction of the lip must be per­
formed. The type of reconstruction varies depending
on the situation. An elevated thin lip is released with a
midline incision. The posterior fourchette mucosa is su­
tured to the perineal skin. When this is performed, the
dog-ears must be removed, and the posterior labia may
need to be repositioned or reduced to give a cosmeti­
cally acceptable appearance. The posterior aspect of the
labia minora can be laterally reduced using a posterior-
based triangle excision to give an acceptable appearance.
A thick hypertrophic lip may need to be excised and to­
tally reconstructed, which can be difficult, challenging,
and time consuming. If the introitus is too tight despite
release of the posterior lip, then dissection superficially
under the posterior vaginal mucosa past the hymen will
release the bands and allow the posterior mucosa to be
advanced and sutured to the perineum.
At times, a patient may have protuberant posterior
labia minora and require two wedge excisions, which
can be done safely. Another variation or protrusion may
require lateral and/or medial elliptical excisions in ad­
dition to the central wedge to reduce posterior protru­
sion.9 These are simple and safe and can be done at the
same time or secondarily if desired. These ellipses com­
bined with a central wedge labiaplasty are simpler with
theoretically fewer healing issues than the star labia­
plasty with intersecting suture lines.10
The scar line of the reduced labia minora can widen
over time, causing asymmetry. If this is an issue, the la­
biaplasty can be repeated without difficulty.
The advantages of the central wedge labiaplasty over
the posterior wedge are that it eliminates the thickest
portion of the labium; it has better vascularity, which
decreases possible dehiscence rate; it eliminates the
darkest pigmented tissue; and it makes reconstruction
of the posterior lip, including a perineoplasty, easier.
Clitoral Hood
The clitoral hood can be addressed with various meth­
ods. Some surgeons reduce an overhanging prepuce
by trimming its end. In many cases, this causes an un­
natural scar with irregularity and may leave the glans
clitoris exposed. If a central wedge labiaplasty is per­
formed, extending the lateral labial excision anteri­
orly in a hockey stick shape up to the anterior labial
commissure can reduce the lateral clitoral hood3 (see
Fig. 33D.4). A lateral ellipse or crescent excision can be
done with a trimming labiaplasty. Some of the dartos
fascia of the clitoral hood can be removed to reduce the
bulk of the hood at the same time, but care needs to
be taken to prevent clitoral injury. If the hyperkeratotic
tissue or folds are medial, vertical ellipses of the hood
can be performed. If a central wedge labiaplasty is done
in that situation, the lateral labial wedge excision ends
in the labial sulcus.
If the clitoral hood is long without significant
glans clitoral exposure, then a horizontal or inverted-
V excision of the hood can be performed. However, the
amount of hood resected should be conservative, be­
cause a relatively small horizontal excision can result
in overexposure of the glans. For patients with a very
long, protuberant, thick, wide clitoral hood, I developed
a technique in which the clitoral hood skin is elevated
and the clitoris is repositioned deeper and more anterior
on the pubic symphysis (clitoropexy). This allows for
aggressive thinning of the clitoral hood subcutaneous
tissue, more aggressive resection of clitoral hood skin,
and less protrusion with shortening and narrowing of
the hood. This technique has not yet been published, but
care must be taken to prevent burying or overexposure
of the clitoris or damage to the dorsal nerves of the cli­
toris. This procedure is often performed in conjunction
with a labiaplasty. It is not indicated in clitoromegaly,
because the clitoral fixation sutures will not hold.
Patients must be assessed for clitoral size. If the
clitoris is enlarged, a reduction should be performed
to create synchrony of the aesthetic units. It is an in­
tricate procedure, because the corporal spongy tissue
is removed, the glans clitoris is reduced, the remain­
ing clitoris is repositioned, and the clitoral hood is re­
duced. Removal of a significant portion of the clitoral
hood without performing a clitoral reduction is often
counterproductive and results in a greater deformity.
The techniques for clitoropexy and clitoral reduction
are beyond the scope of this discussion.
Perineoplasty and Vaginoplasty
Combining a perineoplasty or vaginoplasty with a la­
biaplasty can result in overtightening of the introitus.
Most vaginal tightening procedures are performed
with a posterior colporrhaphy with tightening of the
levator muscles and excision of midline mucosa. Vagi­
nal tightening is rarely done on nulliparous women. A
high percentage of these women will have a rectocele,
which should be repaired at the same time. Surgery in

533
Chapter 33 Female Aesthetic Genital Surgery
conjunction with an urogynecologist can provide bet­
ter patient care and allow simultaneous treatment of
associated urinary incontinence. To prevent overtight­
ening of the introitus, the vaginal repair is usually per­
formed up to the hymen, followed by the central wedge
labiaplasty. Once the labiaplasty is complete, the final
perineal repair distal to the hymen is done safely while
verifying that the introitus is not being narrowed. If it
is too tight, the vaginal mucosa needs to be advanced
distally to the perineum.
Combined Procedures
To create synchrony of the genital aesthetic unit, com­
bined procedures are often performed. I prefer to do the
procedures in the following order if all need to be done:
1. Pubic lift
2. Vaginal tightening
3. Labia minora reduction
4. Clitoral hood reduction
5. Perineoplasty
6. Labia majora reduction
Reconstruction
Unfortunately, the incidence of women with failed la­
biaplasties has markedly increased as the number of
procedures and surgeons has grown. The resulting de­
formities seriously affect patient self-esteem and often
cause pain, tenderness, and even orgasmic dysfunction.
The highest incidence of revisions occur on trim labia­
plasties, usually performed by poorly trained, cavalier
Fig. 33D.5 (a) This 53-year-old woman had a trimming labiaplasty that resulted in amputation of the right labium and irregularity
and protrusion of the left labium. She had a posterior lip deformity from a previous episiotomy. (b) Markings for the right clitoral
hood flap and for the incision along the introitus. (c) The right clitoral hood flap on its pedicle at the junction of the lower clitoral
hood and labia majora. (d) Markings for the two wedge excisions of the left labium to make the labia symmetrical. The right cli­
toral hood flap is inset. (e) The end result after labial and posterior lip reconstruction. Her perineum was revised with inverted-V
lateral excisions and reapproximation. (f) Result 3 months after the procedure. The patient has a very good result but could have
an improved appearance with a minor excision of the right lateral clitoral hood.
a
b
c
d
e
f

SECTION IV AESTHETIC SURGERY
534
surgeons who discount the importance of these proce­
dures. Dehiscence of a wedge labiaplasty can usually be
repaired without any lasting deformity.
Fortunately, reconstructive procedures have been
developed for many of these complications, but they are
only possible if adequate remaining labial and clitoral
hood tissue is available4 (Fig. 33D.5). Local rearrange­
ment of residual labial tissue or small wedge excisions
can often improve the scalloping, asymmetry, or labial
concavities resulting from a trimming labiaplasty. In ad­
dition, the abrupt ends of the clitoral frenula and clitoral
hood can be reattached to the introitus or upper labia.
An island transposition flap of clitoral hood tissue can
be used to reconstruct an amputated labium, but only if
enough clitoral hood is present. Too often, the surgeon
using an aggressive trimming technique excises clitoral
hood tissue along with overresecting the labia, which
makes it impossible to adequately reconstruct the la­
bia minora.
Orgasmic and sexual dysfunctions may result from
persistent scar tenderness or possibly from a lack of
frenular attachments to the remaining labia minora,
which theoretically can decrease clitoral stimulation
during intercourse. The causes of sexual dysfunction
need to be studied by the surgeon and thereby pre­
vented.
Conclusion
Many new, innovative procedures have been developed
to address all areas of the female genitalia. A thorough
understanding of anatomy and the numerous proce­
dures should enable the surgeon to fulfill most patients’
expectations. The search for excellence in performing
all procedures persists. Judgment and experience are
imperative in achieving the best possible result. Re­
grettably, many surgeons are performing these proce­
dures without adequate training and without due care
for their importance. Thus women seeking cosmetic
improvement by undergoing genital aesthetic surgery
may instead obtain a poor result, or even worse, a di­
sastrous, life-changing complication.
References
1. Alter GJ. Pubic contouring after massive weight loss
in men and women: correction of hidden penis, mons
ptosis, and labia majora enlargement. Plast Reconstr
Surg 2012;130:936–947
2. Alter GJ. Management of the mons pubis and labia ma­
jora in the massive weight loss patient. Aesthet Surg J
2009;29(5):432–442
3. Alter GJ. Aesthetic labia minora and clitoral hood re­
duction using extended central wedge resection. Plast
Reconstr Surg 2008;122(6):1780–1789
4. Alter GJ. Labia minora reconstruction using clitoral
hood flaps, wedge excisions, and YV advancement
flaps. Plast Reconstr Surg 2011;127(6):2356–2363
5. Hamori CA. Postoperative clitoral hood deformity after
labiaplasty. Aesthet Surg J 2013;33(7):1030–1036
6. Goodman MP, Placik OJ, Benson RH III, et al. A large
multicenter outcome study of female genital plastic
surgery. J Sex Med 2010;7(4 Pt 1):1565–1577
7. Lista F, Mistry BD, Singh Y, Ahmad J. The safety of aes­
thetic labiaplasty: a plastic surgery experience. Aesthet
Surg J 2015;35(6):689–695
8. Gonzalez F, Dass D, Almeida B. Custom flask labiaplasty.
Ann Plast Surg 2015;75(3):266–271
9. Choi HY, Kim KT. A new method for aesthetic reduc­
tion of labia minora (the deepithelialized reduction of
labioplasty). Plast Reconstr Surg 2000;105(1):419–422,
discussion 423–424
10. Tepper OM, Wulkan M, Matarasso A. Labioplasty: anat­
omy, etiology, and a new surgical approach. Aesthet
Surg J 2011;31(5):511–518

S E C T I O N V
The Breast

Snake-goddess idol (faience), Knossos palace, Temple Repositories, Neopalatial period, 17th century BC.
(Archeological Museum of Heraklion, Crete, Greece. ©Hellenic Ministry of Culture and Sports/Archeological Receipts Fund.)

537

Breast Augmentation
G. Patrick Maxwell and Allen Gabriel
Glandular hypomastia may occur as a developmental or
involutional process and affects a significant number of
women in the United States. Developmental hypomas­
tia is often seen as primary mammary hypoplasia or as
a sequela of thoracic hypoplasia (Poland’s syndrome) or
other chest wall deformity. Involutional hypomastia may
develop in the postpartum setting and may be exacer­
bated by breast-feeding or significant weight loss. Com­
pared with the norm, inadequate breast volume may lead
to a negative body image, feelings of inadequacy, and low
self-esteem.1 These disturbances may adversely affect a
patient’s interpersonal relationships, sexual fulfillment,
and quality of life.2 Breast augmentation is the most com­
mon aesthetic procedure performed in the United States
and perhaps in the world.3 In preparing for a breast aug­
mentation, one must understand each patient’s goals
and expectations and see if they can be achieved. Three
important variables that must be addressed before the
surgery:
1. Incision length and placement (inframammary, peri­
areolar, transaxillary, transumbilical)
2. Pocket plane (subfascial, subglandular, submuscular,
subpectoral with dual plane 1, 2, and 3)
3. Implant choice (saline versus silicone, round versus
anatomic, smooth versus textured)
CHAPTER
34
Summary Box
Potential Unfavorable Results and Complications of Breast Augmentation
Perioperative Complications
•• Nipple sensitivity
•• Seroma
•• Hematoma
○
○Pain
○
○Blood loss
○
○Disfigurement
○
○Capsular contracture
•• Postoperative wound infection
•• Mondor’s disease (thrombophlebitis)
Delayed Complications
•• Capsular contracture (grades I–IV)
•• Malposition and ptosis
○
○Palpability
○
○Rippling
○
○Implant extrusion
○
○Double bubble
○
○Snoopy deformity
○
○Symmastia
○
○Bottoming out
○
○Implant malposition
•• Implant rupture
•• Implant deflation

SECTION V THE BREAST
538
istics include a profile with a sloping or full upper pole and a
gently curved lower pole with the nipple–areola complex at
the point of maximal projection. The breast structure itself
may be thought of as the breast parenchyma resting on the
anterior chest wall surrounded by a soft tissue envelope made
up of skin and subcutaneous adipose. Clearly, the resulting
form of the breast after augmentation mammaplasty will be
determined by the dynamic interaction of the breast implant,
the parenchyma, and the soft tissue envelope.5
A thorough physical examination begins with observa­
tion and careful documentation of any signs of chest wall de­
formity or spinal curvature. It is imperative to document and
draw attention to any asymmetry of breast size, nipple posi­
tion, or inframammary fold (IMF) position. Careful palpation
of all quadrants of the breast and axilla is required to rule
out any dominant masses or suspicious lymph nodes. While
palpating the breast, the surgeon should carefully assess the
quantity and compliance of the parenchyma and soft tissue
envelope. The soft tissue pinch test is a useful method of as­
sessment in which the superior pole of the breast is gath­
ered between the examiner’s thumb and index finger and
the thickness of the intervening tissue is measured. In gen­
eral, a pinch test result of less than 2 cm will often indicate
a need for subpectoral placement of the implant. It is also
important to characterize the amount, quality, and distri­
bution of the breast parenchyma, because it may be neces­
sary to reshape or redistribute the parenchyma to achieve
the desired shape of the breast mound. The elasticity of the
skin should also be characterized by observing its resis­
tance to deflection and noting any signs of skin redundancy
or stretch marks. Manufacturers have developed different
preoperative planning systems to facilitate patient assess­
ment and implant selection. Precise measurements must be
taken using the IMF, the nipple–areola complex, and the su­
prasternal notch as key landmarks6 (Fig. 34.2). The surgeon
should measure the breast width (BW) at its widest point,
the breast height (BH), and the distance from the nipple–
areola complex to the IMF (N:IMF). The distance from the
suprasternal notch to the nipple–areola complex (SSN:N)
and the intermammary distance (IMD) should also be docu­
mented. It is often helpful to make markings with the pa­
tient in the seated position with a permanent marker just
before surgery. It is imperative to mark the original IMF, and
a good idea to mark the true midline of the anterior chest.
In addition to manual measurements, three-dimensional
tools are available to facilitate the measurement process in
addition to enhancing the patient’s overall experience by
increasing physician–patient interaction in selecting the
appropriate implant.7 The visual display of the implant se­
lected increases the confidence of the patient in the results
that will be achieved. Three-dimensional imaging systems
can automatically measure and characterize both the soft
tissue and chest wall, an important step in surgical plan­
ning. Minor chest wall or soft tissue asymmetries may be
missed by manual measurement and visualization. The sys­
tem (Vectra, Canfield, Inc.) captures all of the asymmetries
preoperatively so that appropriate preoperative planning can
Avoiding Unfavorable Results
and Complications in Breast
Augmentation
Patient Selection
The initial consultation for augmentation should begin with
open-ended questions about the patient’s goals and expec­
tations for the procedure. Patients have often spent some
time researching the procedure either through friends or
through the Internet. The surgeon should be able to form
an impression of the patient as a well-informed, psychiatri­
cally stable person with appropriately realistic expectations
for the procedure. Any concerns about the patient’s level of
understanding, unrealistic expectations, or self-esteem is­
sues should be fully explored before proceeding with sur­
gery. A careful medical history and physical examination is
essential for the assessment of risk factors and candidacy for
breast augmentation. Preoperative mammography is recom­
mended for patients older than 35 years of age or patients of
any age with significant risk factors for breast cancer.
The ideal size and shape of the female breast is inherently
subjective and relates to both personal preference and to cul­
tural norms. However, most surgeons will agree that there
are certain shared characteristics that represent the aesthetic
ideal of the female breast form4 (Fig. 34.1). These character­
Slope of
upper pole
Breast height
Projection
Lower
pole
Upper
pole
Fig. 34.1 The aesthetic breast form is composed of measurable
parameters. The resultant breast form desired after surgical aug­
mentation is determined by the dynamic interaction between the
character and compliance of the soft tissue envelope; the quality,
volume, and consistency of the breast parenchyma; and the dimen­
sions, volume, and characteristics of the breast implant. This form
can be attained by the careful planning and surgical performance
of a breast augmentation.

539
Chapter 34 Breast Augmentation
a
b
c
d
Fig. 34.3 Hard tissue asymmetry. (a) Initial image. (b) After automated biodimensional measurements and volume characterization.
(c) Basal view. The red line delineates the soft tissue envelope, and the blue line the chest wall. (d) Soft tissue and chest wall outlines are
superimposed as mirror images to identify chest wall asymmetry. Although the volume is identical, the presenting anatomy is very different.
a
b
c
d
Fig. 34.4 Soft tissue asymmetry. (a) Initial image. (b) After automated biodimensional measurements and volume characterization.
(c) Basal view. The red line delineates the soft tissue envelope, and the blue line the chest wall. (d) Soft tissue and chest wall outlines are
superimposed as mirror images to identify soft tissue asymmetry.
Fig. 34.2 Preoperative measures (taken before breast
augmentation) include the suprasternal notch to nipple,
nipple to inframammary fold (IMF), breast width, breast
height, and intermammary distance (IMD). (Adapted
from Nahai F, ed. The Art of Aesthetic Surgery. 2nd ed.
New York: Thieme; 2016.)

SECTION V THE BREAST
540
munication, and be able to understand the information.
The informed consent documentation must be thorough
and specific to the operation and preferably the surgeon.
A checklist of specifics (which must be initialed by the pa­
tient) is advisable.
Before and after photographs may be shown but should
be realistic. Photographs of the patient are a necessary form
of documentation but require appropriate permission. Their
confidentiality is essential unless permission is given for
any use other than medical review documentation. A male
surgeon should be accompanied by a female chaperone
during all breast photography and examinations. Because
of the multiple options in breast augmentation surgery, a
second office visit is advisable. There must be a clear un­
derstanding (documented in the medical record) between
the patient and surgeon of the specific desired outcome (in
terms of size and shape), the alternative ways by which this
can be achieved, and the risk-to-benefit ratio of the chosen
“pathway.”
Surgical Considerations
Incision Length and Placement
Four types of incision are commonly used in breast aug­
mentation: transaxillary, inframammary, periareolar, and
transumbilical. After implant selection, the decision re­
garding the type of incision should be made by the patient
and surgeon, with a thorough explanation of the options,
risks, and benefits of each. Surgeons should offer only the
techniques that they are comfortable performing. The fi­
nal choice should allow the surgeon optimal control and
visualization to deliver the desired outcome for the specific
patient and the specific implant.
a
b
c
d
Fig. 34.5 Hard and soft tissue asymmetry. (a) Initial image. (b) After automated biodimensional measurements and volume characteriza­
tion. (c) Basal view. The red line delineates the soft tissue envelope, and the blue line the chest wall. (d) Soft tissue and chest wall outlines
are superimposed as mirror images to identify chest wall and soft tissue asymmetry.
be performed, and the patient is advised with an accurate
informed consent.7
We use three-dimensional technology to asses both
the patient’s chest wall and soft tissue abnormalities. Chest
wall abnormalities, soft tissue asymmetries, and combi­
nations of both are important to identify preoperatively
(Figs. 34.3–34.5). This tool can also be used to understand
the patient’s perception of the desired look by showing the
outcomes of using different size and style implants. This is
also then projected in the operating room for surgical plan­
ning.7 This system is based on the biodimensional principles
previously described. As aesthetic surgeons continue to pur­
sue increased patient safety and satisfaction while decreas­
ing reoperation rates, three-dimensional imaging systems
will serve as another tool in their armamentarium to achieve
these goals. This serves as an excellent consultation tool to
be able to better understand the patient expectations re­
garding the size and shape of the implant.
Informed Consent
It is incumbent on the surgeon to evaluate the patient’s
emotional state, timing, and appropriateness of the de­
sired outcome. It is the surgeon’s responsibility to listen,
educate, and evaluate; this process and the communica­
tion that takes place between the patient and surgeon are
documented in the medical record. Informed consent is
not simply the signing of a paper or contract but refers to
the entire process between the patient and physician and
the physician’s staff. To be “informed,” the patient must be
provided with adequate information about risks, benefits,
and treatment alternatives to the proposed procedure. We
recommend the use of official American Society of Plastic
Surgeons (ASPS) informed consents. To “consent,” the pa­
tient must be an adult (by age), be capable of rational com­

541
Chapter 34 Breast Augmentation
attachments of the pectoralis major as well as direct visual­
ization for hemostasis. This approach avoids any scarring on
the breast mound and can be used with both saline and gel
implants in either a subpectoral or subglandular pocket. Dis­
advantages include difficulty with parenchymal alterations
and the probable need for a second incision on the breast
mound for revision surgery. Precise implant placement can
be more difficult with this incision, and enhanced cohesive
gel and anatomic implants may be precluded.
Transumbilical breast augmentation has the obvious ad­
vantage of a single, well-hidden, remote incision. It can be
used only with saline implants, however, and precise pocket
dissection requires experience. The pocket is dissected
bluntly, and hemostasis can be difficult from the remote ac­
cess port. As with the transaxillary approach, revisions often
necessitate a second incision on the breast mound.
Pocket Position
The decision between (1) subglandular or subfascial or
(2) subpectoral implant placement depends on implant se­
lection (fill and texture) and tissue thickness6 (Fig. 34.6). In
theory, the best position for a mammary implant is in the
subglandular plane. This is the most anatomically correct
position to maintain natural shape and form. However, we
no longer use the subglandular plane and instead prefer the
subfascial plane. Implants may be placed in the subpecto­
ral plane to minimize the risk of implant visibility and pal­
pability. The risk of capsular contracture in either plane is
The inframammary incision permits complete visu­
alization of either the subpectoral or subglandular pocket
and allows precise placement of virtually all implants. The
technique does leave a visible scar within the IMF. Smaller
incisions (smaller than 3 cm) can be used for saline-filled
implants, but silicone gel implants often require incisions
up to 5 to 6 cm in length. The incision should be placed in
the projected IMF rather than in the existing fold to avoid
visibility and widening of the subsequent scar. A variety of
techniques have been described identifying the expected
IMF and are discussed elsewhere in this book.
The periareolar incision is placed at the areolar–
cutaneous junction and generally heals inconspicuously in
light-pigmented patients. The dissection allows easy ad­
justment of the IMF and direct access to the lower paren­
chyma for scoring and release when a constricted lower
pole is present. Disadvantages include limited exposure
of the surgical field, transection of the parenchymal ducts
(which are often colonized with Staphylococcus epidermi­
dis), potentially increased risk of nipple sensitivity changes,
and visible scarring on the breast mound. This technique
should not routinely be used on patients with an areola di­
ameter smaller than 40 mm and may not allow for the in­
troduction of larger gel or enhanced cohesive gel implants.
There have been some reports of a possibility of increased
capsular contracture rates with the use of this incision.
The transaxillary approach can be performed either
bluntly or with the aid of an endoscope. The endoscope allows
precise dissection and release of the inferior musculofascial
a
b
c
Fig. 34.6 When ample soft tissue is present, implants may be placed in the subglandular (a) position or subfascial (b) position. When there
is soft tissue inadequacy, the subpectoral position (c) is generally preferable. (From Nahai F, ed. The Art of Aesthetic Surgery. 2nd ed. New
York: Thieme; 2016.)

SECTION V THE BREAST
542
Implant Selection
Filling Material
In the United States, two implant materials are available: sa­
line- and silicone-filled. The decision between a saline-filled
prosthesis and a silicone gel implant is based on the patient’s
preferences after the surgeon’s conveyance of information.
Experience has shown the results of silicone gel implants
in primary breast augmentation to be generally soft and to
have a natural feel and appearance, assuming capsular con­
tracture is not present. Although we prefer silicone gel im­
plants, saline implants placed in the subpectoral position can
produce good results with a low incidence of capsular con­
tracture. The thicker the soft tissue under which a saline im­
plant is placed, the better it performs. Despite our preference
for silicone gel, some patients will undoubtedly continue to
have concerns about silicone-filled devices, and subpectoral
saline implants have proved to be a reasonable alternative.
Ultimately, the patient must feel comfortable with the im­
plant device, so the final decision rests with the patient. The
addition of shaped devices has given another option for pa­
tients to choose an implant that is more natural appearing.13
Implant Size
The selection of the implant size is initiated during the pre­
operative consultation period based on both the patient’s
goals and the surgeon’s assessment. In general, the critical
factors in selecting a specific implant size are the dimen­
sions of the nascent breast, the compliance and character­
istics of the soft tissue envelope, and the desired volume
for the resulting augmented breast. The base width of the
breast is related to the width of the patient’s chest and is
proportional to the overall body habitus. It is imperative
that this dimension is respected during augmentation to
maintain the normal anatomic landmarks such as the lat­
eral breast fold in the anterior axillary line and the IMD.
The same is true for BH, but to a lesser degree than BW.
Violation of these landmarks may yield an unnatural and
deformed appearance. Generally, the surgeon should se­
lect an implant that is slightly less wide than the existing
breast. Implant manufacturers are now producing implants
with varying degrees of projection for a given base width.
In this way, the surgeon should be able to attain the de­
sired amount of projection while preserving the normal
aesthetic proportions of the breast4,6 (Fig. 34.8).
The patient’s desires will largely determine the dimen­
sions of the breast implant used. In addition to a thorough
discussion with the patient regarding her desire for the re­
sultant form and size, the three-dimensional imaging system
can be used to show the patient the outcomes based on the
selection of a particular implant.
dependent on surgical preparation and technique and not
necessarily the pocket. With sound surgical techniques and
appropriate postoperative management, capsular contrac­
ture can be minimized in either pocket. We believe that the
subfascial pocket is superior to the subglandular, because it
provides an additional durable layer between the implant
and the gland.
The subfascial implant position has been advo­
cated for augmentation mammaplasty in certain pa­
tients.8,9,10,11,12 Theoretically, placement of the implant
in the subfascial position between the anterior fascia of
the pectoralis major and the muscle itself may provide
additional support to the overlying soft tissue envelope,
causing less distortion of the breast form and decreasing
mobility of the implant within the pocket. The long-term
outcome studies of breast augmentation using this posi­
tion are not yet available, but the procedure is gaining
popularity worldwide.9
In patients with a pinch test result of more than 2 cm,
the implant can safely be placed in the subfascial plane.
Textured implants are the preferred implant for subfascial
placement. If smooth gel implants are selected for the sub­
fascial plane, additional measures to prevent capsular con­
tracture must be taken. These include larger pocket dissec­
tions with displacement exercises or possible dilute steroid
pocket irrigation. Anatomically shaped textured implants
are placed in the appropriate pocket as determined by soft
tissue thickness. Pockets for these implants are made only
minimally larger than the footprint of the device to mini­
mize displacement or malrotation.
When subpectoral pockets are used, the surgeon gen­
erally divides the origin of the pectoralis major muscle
just above the IMF to allow better projection in the lower
pole of the augmented breast and to maintain a natural
IMF6 (Fig. 34.7). This places the superior portion of the
implant in a subpectoral position; the inferior portion
is subglandularly located. In constricted breasts (tuber­
ous breasts) or ptotic breasts, for which more parenchy­
mal surgical manipulation is necessary, or when there is a
greater need for the implant to fill out the lower soft tis­
sue envelope, more dissection between the parenchyma
and muscle will allow the muscle to cover less of the im­
plant with a resultant greater subglandular implant cover­
age. Alternatively, the pectoral muscle can be divided at a
higher level to give a similar result (see Fig. 34.7).6 These
pocket manipulations have been described as dual-plane
maneuvers to allow varying degrees of subpectoral-to-
subglandular implant coverage.5 This dual-plane dissection
allows the pectoralis muscle to retract superiorly or window-
shade upward while the breast parenchyma is redraped over
the inferior portion of the implant, avoiding deformity of the
resulting augmented breast (see Fig. 34.7).6

543
Chapter 34 Breast Augmentation
Fig. 34.7 Subpectoral implant placement generally involves release or division of the pectoralis major muscle, resulting in varying coverage re­
lationships of muscles and parenchyma to implant. (a) For most routine breasts, muscle division near the inframammary fold results in muscle
coverage of most of the implant. (b) For breasts with a mobile parenchyma muscle interface, muscle division (or muscle–parenchymal detach­
ment) to the lower areolar level results in muscle coverage of the upper half of the implant. (c) For breasts with glandular ptosis or lower pole
constriction, muscle division (or muscle–parenchymal detachment) to the upper areolar level results in muscle coverage of the upper third of
the implant. (Adapted from Nahai F, ed. The Art of Aesthetic Surgery. 2nd ed. New York: Thieme, 2016.)
Implant
a
b
c

SECTION V THE BREAST
544
upper pole convexity than a round implant of the same
base width and volume. This characteristic of anatomically
shaped implants can be extremely useful when the patient
desires a significant volume augmentation but has a rela­
tively narrow BW.14
Treatment and Surgical Technique
Preoperative markings are made with the patient in the up­
right position and are useful as a reference point during the
actual procedure The surgeon should mark the chest mid­
line in the frontal view from the suprasternal notch to the
xiphoid process, the existing IMFs, and the likely position of
the new IMFs as the proposed limits of the dissection. The
patient is then asked to place her arms behind her head to
visualize the displacement of the nipple and the true IMF.
The “yoga”-type stretching exercises are also reviewed with
the patient at this point. These light movements ensure the
shoulders are not pulled anteriorly to further tighten the
pectoralis major.
After review of the consent and the plan, the patient
is taken to the operating room. The patient is then placed
in the supine position and centered on the operating table
with the pelvis directly over the flexion point of the bed.
The arms must be well secured to the arm boards, which
are placed at 90-degree angles to the torso. These prepara­
tions are necessary so that the patient can be placed in the
upright seated position as often as needed during the pro­
cedure. The sterile preparation and draping of the anterior
chest must provide visualization of the patient’s shoulders
as an important anatomic reference point. Triple antibiotic
solution irrigation is used for all implant cases regardless of
the incision type.
Inframammary Incision
The inframammary approach permits complete visual­
ization of the implant pocket with either subglandular,
subfascial, or subpectoral placement. The incision should
be placed in the predicted location of the new IMF, which
has been determined and marked preoperatively. Smaller
incisions (smaller than 3 cm) may be used for inflatable
saline-filled implants, but prefilled implants (silicone gel or
saline) often require incisions up to 5 cm in length. The in­
cision should be designed with most of the incision lateral
to the breast midline, because this will place the resulting
scar in the deepest portion of the new IMF.
The incision is made along the proposed markings, and
the dissection is continued with an insulated electrocautery
instrument through Scarpa’s fascia. A fiberoptic headlight
is worn throughout the procedure, or a variety of lighted
fiberoptic retractors are available to aid illumination and
direct visualization within the pocket. If the implant is to
be placed in the subfascial pocket, the dissection proceeds
below the pectoralis fascia but above the pectoralis major
fascia. Once the fascia is identified, it will be thicker, be­
cause dissection proceeds more ­cephalad. Several medial
Implant Surface Texture
The decision between textured and smooth-walled im­
plants is only applicable for round implants. Anatomic im­
plants are all textured by design to minimize malrotation.
With round implants, the choice between textured and
smooth-walled implants is based primarily on minimizing
capsular contracture. For subpectoral augmentation, either
implant can likely be used with comparable results. When
the device is placed in the subfascial pocket, a textured
implant is preferred to minimize capsular contracture. If a
smooth-walled implant is chosen, generally the same prin­
ciples are applied; we do not use displacement exercises.
Implant Shape
It is important to reiterate the principle that the shape of
the natural female breast is not a semicircle or a hemi­
sphere. Dimensional analysis of an aesthetically pleas­
ing breast form reveals a gently sloping upper pole and a
curved lower pole with the nipple–areola complex at the
point of maximum projection. The typical round breast im­
plant has its greatest projection centrally, with the remain­
der of the volume distributed evenly along the base of the
implant. In contrast, anatomically shaped breast implants
have a flatter upper pole with most of the volume and pro­
jection in the lower pole. Thus the anatomically shaped im­
plant of a given base width and volume will produce less
0
5
10
15
0
5
10
15
13cm
14.5cm
Resultant
breast width
Original
breast width
12.5cm
Fig. 34.8 After the width of the existing breast is measured and the
desired resultant breast form is formulated, an implant is selected
(generally just narrower than the original breast, shown on the pa­
tient’s right) that in combination with the preoperative breast tissue
will achieve the desired postoperative dimensions and form (shown
on the patient’s left). (Adapted from Nahai F, ed. The Art of Aesthetic
Surgery. 2nd ed. New York: Thieme; 2016.)

545
Chapter 34 Breast Augmentation
advantage of this incision is that the resulting scar is usu­
ally well camouflaged and quite inconspicuous. The peri­
areolar approach allows easy adjustment of the IMF and di­
rect access to the parenchyma for scoring and release when
the lower pole of the breast is constricted. However, visual­
ization and the dissection are typically inadequate with the
periareolar incision in patients with areolas smaller than 3
cm in diameter. Other disadvantages of this approach in­
clude the potential risk of contamination if the lactiferous
ducts are transected, the increased risk of changes in nipple
sensitivity, and the risk of a hypopigmented scar in patients
with darkly pigmented areolas.
The markings for a periareolar approach are similar to
those for an inframammary augmentation. The incision is
marked along the junction of the areola and the breast skin.
The limits of the incision are the 3 o’clock and 9 o’clock po­
sitions.
The positioning of the patient is identical to that for an
inframammary approach. It is imperative that the patient be
able to fully flex at the waist for evaluation of the intraopera­
tive appearance of the implants.
The precise incision is made. Wound edges are elevated
directly up from the chest wall with an opposing pair of small
sharp retractors. An insulated electrocautery unit is used to
dissect straight down through the breast parenchyma to the
pectoralis major fascia. The dissection is the same as de­
scribed through the inframammary incision. If the inferior
pole of the breast is constricted, radial scoring of the gland in
the inferior pole can allow proper redraping of the soft tissue
over the implant to correct the deformity. Before final im­
plant placement, the pocket is once again checked for hemo­
stasis and irrigated with an antibiotic solution. The closure is
particularly important with this technique. The gland must
be precisely reapproximated and closed with several layers
of interrupted absorbable sutures to prevent distortion of the
nipple–areola complex. The skin is closed with deep evert­
ing dermal sutures and a running subcuticular absorbable
monofilament. Steri-Strips are applied to the closed incision.
Transaxillary Incision
The transaxillary approach was described by Hoehler in
197318 and popularized by Bostwick and others. This proce­
dure can be performed either bluntly using a Montgomery
dissector or using an endoscope for precise visualization
and dissection of the implant pocket. The transaxillary ap­
proach avoids incisional scarring directly on the breast and
places the incision in the inferior and anterior area of the
axilla. The transaxillary incision usually provides adequate
access when placing an inflatable round breast implant; this
incision is more difficult for placement of a large prefilled
implant or an anatomically shaped device but can be used.
The markings for transaxillary breast augmentation
are also made with the patient in the sitting or upright po­
sition. The existing and resultant IMFs are marked, as are
the boundaries of the proposed dissection. To locate and
mark the incision, the patient’s arm is placed in complete
­adduction and the most anterior aspect of the axilla is
­intercostal ­perforating vessels may be encountered. These
should be avoided or coagulated with insulated forceps if
needed. For smooth-walled implants, a larger pocket is dis­
sected to allow mobility of the implant. For anatomic im­
plants, the pocket is precisely dissected to snugly accom­
modate the implant. Care should be taken to preserve the
lateral intercostal cutaneous nerves, especially the fourth
intercostal, which contains the primary sensory innerva­
tions of the nipple–areola complex.
If a subpectoral pocket is chosen, the dissection is ini­
tially carried out laterally to identify the lateral border of
the pectoralis major muscle. The muscle edge can be lifted
by forceps to allow easy entry into the submusculofascial
plane. This plane is readily identified by the wispy areolar
connective tissue and ease of dissection. An extended elec­
trocautery instrument is used to complete the dissection.
The inferior origin of the pectoralis major is released from
lateral to medial at the level of the IMF. Various slips of ori­
gin of the pectoralis major muscle are generally encountered
and divided. Division of the pectoralis continues medially
to the sternal border. Partial deep division may selectively
be carried out 1 to 3 cm above the xiphoid, depending on
which implant is to be used. Lateral dissection can be done
bluntly with a finger to avoid injury to the lateral neurovas­
cular bundles. The nerves can be stretched to accommodate
the implant but should be preserved to minimize postopera­
tive sensory changes. When the pectoralis major muscle is
elevated, care must be taken to leave the pectoralis minor
down on the chest wall. This will minimize bleeding and
allow proper placement of the implant. At times, several
muscle interdigitations may be present between the pec­
toralis minor and major, and these are carefully dissected
to prepare the pocket. In addition, if a dual-plane pocket is
planned preoperatively, further dissection over the muscle
is carried out pending the level of the desired dual plane fol­
lowed by release of the pectoralis major at the IMF.
Exact implant sizers (gel or saline) are used when avail­
able to evaluate the pockets and resultant breast form. After
the sizers are in place, the patient is placed in a 90-degree
upright position and evaluated from various perspectives.
Any asymmetry or underdissected areas are marked, and the
patient is placed back in the supine position. Once adequate
hemostasis is obtained and pocket dimensions are finalized,
the pocket is irrigated with an antibiotic-containing solu­
tion, and the implants are carefully placed by a minimal-
touch technique.15 The final results are assessed, again with
the patient in a sitting position, and a multilayer closure is
performed with absorbable suture. It is important to close
off the implant pocket with a separate layer of suture before
closing the skin. Once closure is complete, Steri-Strips (3M)
are applied along the direction of the incisions.
Periareolar Incision
The periareolar approach for augmentation mammaplasty
described by Jenny in 197216 is used widely by plastic sur­
geons.17 The periareolar incision is placed along the inferior
portion of the areolar–cutaneous junction. The principle

SECTION V THE BREAST
546
beneath the pectoralis major. The tunnel ends just cepha­
lad to the nipple.
Subpectoral positioning is possible by careful technique
with use of special instruments to enter the fascial plane
high laterally. The obturator is then removed, and an endo­
scope may be used to verify correct pocket identification.
Hemostasis is also ensured. Both the endotube and endo­
scope are removed from the tunnel, and an expander is
rolled up and placed within the incision. The expander is
“milked” up the tunnel by manual external pressure. The
expander is filled with saline to 150% of the final volume of
the implant. Pocket adjustments can be made manually dur­
ing filling. When the expansion is complete, the expander
is drained and removed from the pocket by traction on the
fill tube. The implant is placed and filled in exactly the same
manner as the expander. The endotube is then replaced, and
an endoscope may be used to verify implant position, valve
patency, and hemostasis. The incision is closed with a single
layer of absorbable suture. An abdominal binder is used for
compression on the abdominal tunnels.
Postoperative Care
In the overwhelming majority of cases, augmentation
mammaplasty is performed as an outpatient procedure.
Patients are given prescriptions for oral analgesics and a
3-day course of prophylactic oral antibiotics. The patient
is shown yoga-type stretching exercises of the chest to be
performed on the day following her surgery. Patients are
allowed to remove operative dressings and shower as de­
sired starting on postoperative day one. The first follow-up
visit is scheduled for 1 to 3 days after the procedure. Re­
gardless of the texture of the implant used (nontextured
versus smooth), the authors do not utilize implant mobility
exercises. Patients are usually able to return to work a few
days after surgery, but are not permitted to resume rigor­
ous exercise for 4 to 6 weeks. Additional follow-up visits
are scheduled at 4 to 6 weeks, 3 months, and 1 year.
The importance of postoperative photo documentation
and critical analysis of the operative outcomes cannot be
overemphasized. It is the author’s practice to place patients
on vitamin E 400 IU once a day for two years to minimize
capsular contracture. Although there are no evidence-based
studies in the augmentation population on the use of Vita­
min E, there is encouraging evidence in the treatment of
RIF (radiation-induced fibrosis) in mastectomy patients with
radiation-induced morbidities related to scarring.19
Managing Complications in
Breast Augmentation
Perioperative Complications
Alterations of nipple sensitivity after augmentation mam­
maplasty may be manifested as either anesthesia or
marked. The incision should not extend beyond this line.
The arm is then abducted approximately 45 degrees, and
a prominent axillary crease is identified. Any fold may be
used, but preference is given to one high in the axilla, which
aids in instrumentation during the procedure. For saline-
filled implants, the incision should generally be 2.5 to 3.5
cm. Silicone implants require larger incisions.
The patient is positioned supine on the operating ta­
ble with her arms abducted 90 degrees and secured to arm
boards that allow 10- to 15-degree variations in abduction
and adduction from 90 degrees. She must be able to flex
90 degrees at the waist during the procedure. The incision
is made, and small sharp retractors are used to elevate the
medial aspect of the incision. Superficial subcutaneous dis­
section to the lateral border of the pectoralis major prevents
injury to the intercostobrachial nerve. Scissor dissection is
used with electrocautery and insulated forceps to control
any bleeding. The fascia of the pectoralis major muscle is
visualized at the lateral edge of the muscle, and the dissec­
tion is carried deep to this for a subfascial placement or deep
to the muscle for subpectoral placement. The surgeon must
be certain the correct plane is entered before continuing the
dissection further.
For an endoscopically assisted augmentation, the endo­
scope is passed into the transaxillary tunnel, and the sub­
pectoral space is seen under direct vision. This allows a more
controlled release of the pectoralis major origin with a long,
insulated electrocautery instrument. On completion of the
dissection, implant sizers are used to evaluate the pocket
and identify any areas that need final adjustment. This must
be done with the patient in the sitting position. The pockets
are then irrigated with an antibiotic solution, and the final
implants are inserted.15 Before closure, the patient is once
again placed in the sitting position for a final check of the
implant position. The pectoralis muscle fascia is repaired
with a single absorbable suture, and the incision is closed
in one or two layers. Steri-Strips are applied to the incision.
Transumbilical Approach
The markings for transumbilical breast augmentation are
similar to those for a standard IMF approach. The patient
is positioned on the operating table in the same manner
as for an inframammary augmentation. An additional mark
is made with the patient supine: a line is drawn from the
umbilicus to the medial border of the areola bilaterally. An
incision is made within the umbilicus, large enough to eas­
ily accommodate an index finger. An endotube with a blunt
obturator is passed just above the rectus fascia along the
line from the umbilicus to the areola. Care is taken to con­
stantly palpate the progress of the obturator with the sur­
geon’s other hand, always keeping the force up and away
from the abdominal and thoracic cavities. The endotube is
advanced over the costal margin. For subglandular implant
placement, the force applied to the endotube is directed
upward at the IMF to prevent the obturator from slipping

547
Chapter 34 Breast Augmentation
Mondor’s disease is a superficial thrombophlebitis of
the breast that may occur in up to 1 to 2% of augmentation
patients.24,25 This process usually affects the veins along the
inferior aspect of the breast and is most common with the
inframammary approach. Fortunately, this is a self-limiting
process that usually resolves with warm compresses over a
period of several weeks.
Delayed Complications of
Augmentation Mammaplasty
Based on current data, between 15 and 30% of women who
have breast augmentation will have a reoperation within
5 years of their initial procedure.17,26,27 Unfortunately this
rate climbs to 35% in patients with prior history of revision
breast augmentation.15 Capsular contracture, malposition,
and ptosis are the most common long-term complications
of aesthetic breast surgery, and capsular contracture re­
mains the primary reason for most revision surgeries.26–29
Although increasing data suggests capsular contracture can
be minimized in primary augmentation by technical details,
including precise, atraumatic, bloodless dissection; appro­
priate antibiotic breast pocket irrigation; and minimizing
any points of contamination during the procedure,15,30
treatment of an established capsule remains a challenge.
All surgical implants undergo some degree of encapsula­
tion because of the natural foreign body reaction by the
surrounding tissues. Clinically significant periprosthetic
capsular contracture is characterized by excessive scar for­
mation that leads to firmness, distortion, and displacement
of the breast implant. Histologic examination of these con­
tractures reveals circumferential linear fibrosis, which is
especially severe when formed in response to smooth shell
implants. In 1975, Baker proposed a clinical classification
system of capsular contracture after augmentation that is
still commonly used to describe periprosthetic contrac­
tures (Box 34.1).31
Although several factors have been identified that con­
tribute to capsular contracture, the precise cause remains
unknown. The hypertrophic, circumferential linear scar
probably involves stimulation of myofibroblasts that are
known to be present within the periprosthetic capsule. Ir­
ritation caused by periprosthetic hematoma, seroma, or sil­
icone gel bleed may incite the capsular contracture. Other
foreign body particles such as glove powder, lint, or dust
may also contribute to the process.30 Infectious etiologies
have also been studied and are believed to play a role.30 This
theory describes a chronic subclinical infection located im­
mediately adjacent to the implant shell within a micro­
scopic biofilm that is relatively inaccessible to cellular and
humoral immune function. Many strategies have been used
to prevent periprosthetic capsular contracture. One strategy
has been the creation of a large implant pocket and mainte­
nance of this oversized pocket with implant displacement
exercises. The use of implants with textured surfaces was
­hyperesthesia and are believed to result from traction in­
jury, bruising, or transection of the lateral intercostal cuta­
neous nerves. The incidence and severity of nipple sensation
changes does not vary with the surgical approach used.20
Periprosthetic seroma fluid is usually resorbed by the
soft tissues within the first week of surgery, and use of topi­
cal antibiotics intraoperatively has been shown to decrease
the rates.21 We do not use drains for primary breast augmen­
tation regardless of the device or texture; however, drains
are used in revision cases.
The development of a hematoma after breast augmenta­
tion has several deleterious effects in both the early and late
postoperative period, including pain, blood loss, disfigure­
ment, and capsular contracture.22 Preoperatively, patients
should receive a list of prescription and over-the-counter
medications that may contribute to excessive postopera­
tive bleeding. It is imperative that the patient discontinue
any medications and herbal supplements that impair clot­
ting or platelet function at least 1 week prior to surgery23
(Table 34.1). If a hematoma does develop in the periopera­
tive period, immediate evacuation of the hematoma and ex­
ploration of the pocket is recommended. Unfortunately, the
source of the hematoma is only rarely identified at the time
of the exploration. Patients may occasionally present with a
delayed hematoma 1 to 2 weeks or even months to years af­
ter augmentation, and commonly a history of breast trauma
is elicited. Expanding hematomas require exploration and
drainage regardless of the length of time from the augmen­
tation. Nonoperative management of small nonexpanding
hematomas is one option but places the patient at a higher
risk of subsequent periprosthetic capsular contracture.
Postoperative wound infection may present with a
spectrum of severity ranging from a mild cellulitis of the
breast skin to a purulent periprosthetic space infection. S.
epidermidis is part of the normal skin flora and is the most
commonly identified pathogen in postoperative wound in­
fections. Patients are given prophylactic antibiotics intra­
operatively and postoperatively to reduce the risk of infec­
tion. Sterile technique is maintained during the procedure,
and the implant pocket is irrigated with an antibiotic so­
lution containing 50,000 units of bacitracin, 1 g of cefazo­
lin, and 80 mg of gentamicin per 500 mL of saline.15 Fur­
ther reduction of risk for bacterial contamination may be
achieved by adhering to the no-touch technique, in which
only the surgeon handles the implant with fresh, powder-
free gloves. The implant is then inserted through a ster­
ile sleeve to minimize contact with the patient’s skin and
inflated using a sterile closed filling system. A significant
number of postoperative wound infections will respond to
oral or intravenous antibiotics if therapy is initiated very
early in the course of the infection. If the infection per­
sists or progresses, the implant should be removed and the
wound should be allowed to heal over a drain or in severe
cases by secondary intention. Once the infection has totally
cleared, a secondary augmentation and scar revision should
be planned in 6 to 12 months.

SECTION V THE BREAST
548
Table 34.1 Herbs, herbal teas, homeopathic medicines, and dietary
supplements associated with an increased risk of bleeding
Supplement type
Supplement name(s)
Treatment uses
Herbs and herbal extracts
Garlic
  Allium sativum
  Ajo
Hypertension, hypercholesterolemia, fungal infections, cancer,
MI prevention, PVD
Ginger
  Zingiber officinale
Nausea, vomiting, GI bloating, dyspepsia, OA, RA, migraine,
homeostasis restoration, weight loss
Stimulant, nausea, cancer prevention, CAD, DM2, dyspepsia,
colic, infections, aging, stress, homeostasis restoration
Ginkgo
  Ginkgo biloba
  Maidenhair tree
Circulatory stimulant, dementia (Alzheimer’s, multi-infarct),
memory enhancement, PVD, ED
Feverfew
  Tanacetum parthenium
Fever, migraine, OA, GI upset, infertility
Bromelain
Inflammation, OA, autoimmune disorders, menstrual pain,
digestion, gout
Liquorice/licorice
  Glycyrrhiza glabra
Aphthous ulcers, peptic ulcers, cancer, OA, adrenal insufficiency
Red chili pepper
  Capsaicin
Analgesic, chronic neuropathy, OA, uremic pruritus, psoriasis
Saw palmetto
  Serenoa repens
BPH, urinary tract infections
Oil of wintergreen
  Methyl salicylate
OA, joint discomfort, hypertension, inflammation, cellulite,
flavoring agent
Devil’s claw
  Harpagophytum
  procumbens
Analgesic, fever, digestion aid, OA, appetite stimulant
Chinese agrimony
  Agrimonia pilosa
Analgesic, bacterial infection, helminthic infection, diarrhea,
inflammation, cough, sore throat
Danshen
  Salvia miltiorrhiza
Atherosclerosis, stroke, angina pectoris, hypercholesterolemia,
cancer, HIV, menstrual disorders, OA, insomnia, prostatitis
Baical skullcap root
  Scutellaria baicalensis
Anxiety, inflammation, cancer, seizures, infections, insomnia,
dysentery, diarrhea, rabies, menstrual disorders
Geum japonicum
Diuretic, astringent, CAD, hypercholesterolemia
Chinese peony
  Paeoniae rubra
Inflammation, GI discomfort, spasm
Abbreviations: BPH, benign prostatic hyperplasia; CAD, coronary artery disease; DM2, diabetes mellitus type 2; ED, erectile dysfunction; GI,
gastrointestinal; HIV, human immunodeficiency virus; INR, International Normalized Ratio; MI, myocardial infarction; OA, osteoarthritis; PVD,
peripheral vascular disease; RA, rheumatoid arthritis.
Source: From Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding risks of herbal, homeopathic, and dietary supplements: a hidden night­
mare for plastic surgeons? Aesthet Surg J 2012;32(3):332–346.

549
Chapter 34 Breast Augmentation
Other side effects (in addition to intrinsic bleeding risks)
Perioperative recommendations
Nausea, vomiting, hypoglycemia, halitosis, potentiation of warfarin,
increased INR, abdominal pain, diarrhea, oral ulcers, anaphylaxis (rare)
Discontinue 7 days before surgery.
Resume 7 days after surgery.
Nausea, GI bloating, worsened cholecystitis, arrhythmia (possible),
hypoglycemia
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Nausea, diarrhea, headaches, hypotension, hypertension, breast tenderness,
hypoglycemia, insomnia (possible), interaction with warfarin
Discontinue 7 days before surgery.
Resume 2 weeks after surgery.
Nausea, vomiting, diarrhea, GI discomfort, headaches, palpitations,
potentiates warfarin
Discontinue 36 hours or more before surgery.
Resume 7 days after surgery.
Oral ulcers, allergic reactions, GI discomfort and bloating
Taper and discontinue by 2–3 weeks before
surgery to avoid withdrawal syndrome
with abrupt cessation.
Resume 2 weeks after surgery.
GI discomfort, diarrhea, tachycardia, menorrhagia (possible)
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Hypokalemic paralysis, hypertension, weight loss or gain, infertility,
temporary vision loss
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Burning and stinging on contact, hypoglycemia, cough
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Nausea, vomiting, diarrhea, rhinitis, decreased libido, headache
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Displaces warfarin, nausea, vomiting, dizziness, increased INR
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Diarrhea, GI discomfort, tinnitus, headache, hypoglycemia, arrhythmia
(possible)
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Hypotension, GI discomfort, reduced appetite, pruritus, seizures (possible),
potentiates warfarin
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Hepatotoxicity, pneumonitis
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Continued

SECTION V THE BREAST
550
described previously and has been shown to reduce the rate
of capsular contracture in breast augmentation. Other ef­
forts have focused on minimizing operative trauma to re­
duce the risk of seroma or hematoma formation. Seromas,
hematomas, and even blood staining of the periprosthetic
tissues may incite capsular contracture. Any bleeding that
does occur during the dissection needs to be controlled and
tissues stained with blood should be diluted with copious
irrigation fluid.
Leukotriene receptor antagonists, zafirlukast and mon­
telukast, which are used to treat asthma, were studied in
capsular contracture but are recommended to be used cau­
tiously because of their side effects.32,33 Treatment of estab­
lished capsular contractures usually requires operative in­
tervention, which is beyond the scope of this chapter.
The next two key drivers to revision breast surgery are
malposition and ptosis. Over the last 20 years, an increased
number of larger implants have been placed in patients ei­
Table 34.1 Herbs, herbal teas, homeopathic medicines, and dietary
supplements associated with an increased risk of bleeding—cont’d
Supplement type
Supplement name(s)
Treatment uses
Herbs and herbal
extracts, continued
Poncitrin
  Poncirus trifoliata
Constipation, diarrhea, spasm, expectorant
Fritillaria bulbs
  Fritillaria cirrhosa
Spasm, expectorant, hypertension, cough, asthma, opium
toxicity
Japanese honeysuckle
  Lonicera japonica
Fever, headache, cough, sore throat, bacterial infection,
inflammation, ulcers
Herbal formulas
Kangen-karyu
Hypertension, arteriosclerosis, memory impairment, headache
Bak foong pill
GI disturbances, cardiovascular disturbances, gynecologic
dysfunction
Herbal teas
Te gastronol
GI ulcers, intestinal inflammation, colitis, gastritis, flatulence
Seasonal tonic
Appetite suppressant
Homeopathic medicines
and other dietary
supplements
Guīlinggāo
  Tortoise jelly
Fever, acne, enhancing circulation, improving intestinal
function, constipation
Vitamin E
Peyronie’s disease, bladder cancer prevention, RA, Alzheimer’s
disease, PMS, movement disorders
Arnica montana
  Leopard’s bane
  Wolf’s bane
OA, sprains, joint pain, inflammation
Fish oil
  Eicosapentaenoic acid
Hypertension, hypertriglyceridemia, RA, angina pectoris,
atherosclerosis
Chondroitin
OA
Glucosamine
OA
Abbreviations: BPH, benign prostatic hyperplasia; CAD, coronary artery disease; DM2, diabetes mellitus type 2; ED, erectile dysfunction; GI,
gastrointestinal; HIV, human immunodeficiency virus; INR, International Normalized Ratio; MI, myocardial infarction; OA, osteoarthritis; PVD,
peripheral vascular disease; RA, rheumatoid arthritis.
Source: From Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding risks of herbal, homeopathic, and dietary supplements: a hidden nightmare
for plastic surgeons? Aesthet Surg J 2012;32(3):332–346.

551
Chapter 34 Breast Augmentation
•• Palpability
•• Rippling
•• Implant extrusion
•• Double bubble
•• Snoopy deformity
•• Symmastia
•• “Bottoming out”
•• Implant malposition
ther at patient request or to try to avoid a breast shaping
procedure (mastopexy). Because many of these implants
were of larger volumes, many patients experienced thin­
ning of breast parenchyma and the overlying soft tissue,
whether the implants were in subglandular or subpectoral
positions. The thinned tissues in turn can lead to long-term
complications17,34,35:
Other side effects (in addition to intrinsic bleeding risks)
Perioperative recommendations
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
None documented
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Allergic reaction, fatigue, weakness, headache, nausea, diarrhea, vision
disturbance, congenital heart defects in utero, heart failure
Discontinue 2–3 weeks before surgery.
Resume when healing is complete.
Gastroenteritis
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Hemorrhagic stroke, GI disturbances and bloating, diarrhea, hyperglycemia
(possible)
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Nausea, diarrhea, constipation, GI disturbances
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.
Hypoglycemia, nausea, diarrhea, headache, insomnia, GI disturbances
Discontinue 2–3 weeks before surgery.
Resume 2 weeks after surgery.

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552
With the advent of acellular dermal matrix (ADM), the in­
dications for and the spectrum of possibilities for correcting
secondary deformities has improved.38
ADM is used as an adjunct to the sound surgical prin­
ciples necessary to diagnose and treat the underlying causes
necessitating revision aesthetic breast surgery. Clinical data
shows the four main indications (drivers) for revision sur­
gery are capsular contracture, implant malposition, ptosis,
and implant visibility or palpability.39,40,41 Each patient must
be individually evaluated for several factors:
•• Patient concerns
•• Patient goals
•• Previous surgical and implant specifics
•• Careful evaluation of breasts
•• Dimensions
•• Quality and quantity of overlying soft tissue
•• Scarring (critical in planning surgery and maintaining
necessary vascularity to manipulated tissues)
Despite the apparent complexity of a given clinical presen­
tation, there are five underlying basic components that may
be the cause, or contribute to the cause, of the problem:
the skin, soft tissue, capsule, implant, and chest wall. These
underlying components must be carefully and systemati­
cally analyzed from outside in, or inside out, until all layers
involved are evaluated.
Patient Selection
The main drivers for repeat surgery mentioned previously
should always be kept in mind as these five components are
evaluated. We have learned from our revision and recon­
structive breast experience that one or more of these com­
ponents and layers may need to be addressed, in addition to
the use of ADM. Such surgical manipulations may include
skin envelope reduction, fat injection, lamellar separation,
capsulectomy, capsulotomy, site change, and replacement
of the implant. To help plan for the surgery, some general
principles can be followed.
Historically, the options for revision and improvement
have included replacing saline implants with gel implants,
capsulorrhaphy, use of capsular flaps, or performing a site
change operation. The site change principle, described in
the mid-1980s, combined total or partial capsulectomy
with conversion to a different pocket (generally a sub­
glandular to subpectoral site change) for the replacement
implant.36 Although site change procedures have been suc­
cessful, none of these procedures alone have resulted in
complete resolution of the described complaints. Notwith­
standing the importance of the site change concept, the
most important addition to our clinical armamentarium
has been the use of acellular dermal matrix as a regen­
erative construct to help solve these challenging clinical
­presentations.37
Implant Rupture and Deflation
Any defect in the silicone elastomer shell of a saline-filled
breast implant will ultimately result in deflation of the im­
plant. The saline filling material leaks out of the implant
and is harmlessly absorbed by the surrounding tissues.
Clinical recognition of deflation is usually made by the pa­
tient and virtually always requires surgical explantation
and replacement of the implant. A history of recent trauma
is commonly elicited with deflation, and true spontaneous
failure of the implant shell is relatively rare.
Magnetic resonance imaging (MRI) of the breast is
considered the state-of-the-art technique for evaluat­
ing breast implant integrity. Modern fourth- and fifth-
generation silicone gel are substantially more cohesive than
the second- and third-generation gel and less likely to leak
into the surrounding tissues—even when the implant shell
is ruptured.
Managing Delayed Complications of
Breast Augmentation
In the past options were limited to working with only
the native tissues that were available for these procedures.
Box 34.1
Grade I: Capsular contracture of the augmented breast feels as soft as an unoperated breast.
Grade II: Capsular contracture is minimal. The breast is less soft than an unoperated breast. The implant can be
palpated but is not visible.
Grade III: Capsular contracture is moderate. The breast is firmer. The implant can be palpated easily and may be
distorted or visible.
Grade IV: Capsular contracture is severe. The breast is hard, tender, and painful, with significant distortion. The
capsule thickness is not directly proportional to palpable firmness, although some relationship may exist. Finally,
it should be noted that some concepts to follow don’t claim to be of universal value.
The Grades of Capsular Contracture

553
Chapter 34 Breast Augmentation
muscle inferior pull after its release. This lower pole cover­
age situation is best achieved by suturing of the ADM along
the entire length of the lower pectoral border, draping it
over the implant inferiorly, and securing it (under more
taughtness) at or near the IMF. This application is similar
to the “reconstructive model,” as a “pectoral muscle exten­
sion”42 (Fig. 34.10). In all instances, an adequate environ­
ment, cover, and stability over the nonmuscle covered por­
tion of the implant (lower pole) by the ADM allows the skin
envelope to be safely lifted and tightened (mastopexy), as­
suming adequate respect for the vascularity to the redraped
tissue and compliance with all sound surgical principles
(Figs. 34.11 and 34.12).
Regarding the biomechanical properties of the desired
ADM, rapid revascularization is required for conformabil­
ity of the ADM to allow it to redrape over the surface of the
implant (intimate engagement of surface contours). If the
patient has capsular contracture, a more compliant mate­
rial may be desired. If the patient has more laxity or stretch
deformity, a more taught material might be preferable.
Implant Stabilizer
ADM allows the surgeon enhanced control in maintain­
ing implant position in a newly created “neo” pocket or
for reinforcement after capsulorrhaphy in various forms
of implant malposition correction. Inferior malposition
(double bubble), medial malposition (symmastia), or lat­
eral malposition are generally treated by capsulorrhaphy
or site change (our preference and recommendation). In
some patients, the tissue is strong enough to support this
correction with a new pocket and appropriate suturing
alone. A number of these patients, however, will have thin
tissue, previous scar, or problematic bony contour slopes,
such that reinforcement of the site change (i.e., neopectoral
pocket of appropriate dimensions in the correct location
with old pocket obliteration) with ADM is highly advised
to reinforce or buttress the corrected implant position
Principles for Revision
For patients whose original implants were subglandular, a
pocket change to a subpectoral plane and lower pole cover­
age with ADM is generally performed. For patients whose
original implants were subpectoral, a neopectoral pocket
with the addition of acellular dermal matrix is generally
performed. For patients who do have adequate breast tis­
sue, a subfascial pocket may be used with ADM coverage
for support as indicated. As always, appropriate candidate
selection is important for achieving a successful outcome,
and high-risk patients (e.g., smokers and those with a body
mass index higher than 35) should be discouraged from
having elective surgery.
The use of ADM can be categorized into four distinct
indications based on the underlying clinical presentation:
1. Coverage of implant lower pole (usually for revision
mastopexy or site change)
2. Implant stabilizer (usually for malposition correction)
3. Tissue thickener (usually superomedially or inferiorly)
4. Treatment of capsular contracture (which may be
technically similar to lower pole cover or superomedial
thickening)
Coverage of Lower Pole
Coverage of the lower pole, which is our most commonly
used ADM placement, is used when performing soft tissue
and skin envelope alterations in repeat surgery (revision
mastopexy with augmentation).
Because many patients with previously placed implants
develop laxity, sag, or tissue thinning over time, mastopexy
or revision mastopexy over the replacement implant is re­
quired to achieve the aesthetic breast form. If the existing
implant is subglandular, a subpectoral (subpectoral-fascial)
pocket is created (after capsule treatment), the new implant
inserted in the newly created subpectoral pocket, and the
lower portion of the implant is covered with ADM. This al­
lows a circumvertical or “inverted-T” mastopexy to be safely
performed without underlying muscle, because the ADM
separates the skin closure from the implant. If the existing
implant is already subpectoral, a neopectoral site change is
carried out, and the ADM used similarly.
If there has been a previous implant in both the subglan­
dular and subpectoral pockets, “lamellar separation” (dis­
secting the pectoralis muscle from its superficial and deep
scarred attachments) may be necessary (Fig. 34.9) ADM is
considered to be the outer layer of the underlying implant
(to which it is intimately engaged by proximity of place­
ment) and may also require suture stabilization. Thus the
ADM may be tacked to the inferior border of the pectoralis
major above and to Scarpa’s fascia or deep fascia below (at
the level of the IMF).
Parachute pull-out sutures may alternatively be used to
redrape the ADM. When there is lamellar scarring requir­
ing lamellar separation, the remaining pectoralis muscle
may be “window-shaded” up in the pocket, requiring lower
Fig. 34.9 Lamellar separation.

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554
Treatment of Capsular Contracture
Even if the presenting problem is capsular contracture,
additional deformities may be identified after detailed
analysis from the skin envelope to the chest wall, as noted
previously. This can include thinned tissue over an encap­
sulated implant, malposition of the encapsulated implant,
or stretch deformity, snoopy deformity, or ptosis over an
encapsulated implant. If the encapsulation is in the sub­
glandular position, a total capsulectomy with site change
to the subpectoral position is usually performed. If the en­
capsulation is in the subpectoral position, a neopectoral
pocket with partial anterior capsule excision and residual
capsule obliteration or total (perhaps partial) capsulectomy
is performed. In these cases the ADM is again selected for
rapid revascularization, conformability to the implant, and
performance. The technique is most commonly similar to
the “lower pole cover” concept but may be closer to a “me­
dial thickener” or “malposition reinforcer” depending on
the presenting problem (Fig. 34.14). There is an increas­
ing body of documentation that the coupling of the ADM
to the implant will further reduce the incidence of capsular
contracture.37,38,39 If capsular contracture is the only clini­
cal diagnosis, we recommend placement of the ADM at the
lower or middle poles.
The surgical techniques used are based on the preopera­
tive findings and the indications as described previously. The
ADM should be conformed to, and in intimate contact with,
the outer surface of the implant (like a hand in a glove). The
appropriate pocket is created whether it is neopectoral, sub­
pectoral, or subfascial.34,44 Three to five half-mattress stabi­
lizing “parachute” sutures are placed between the skin and
ADM to stabilize the tissue and place it in the desired loca­
(Fig. 34.13; see also Fig. 34.12). These materials are sutured
in the appropriate position with proper purchase to achieve
support. The biomechanical properties of the ADM for this
indication are strength and taughtness to maintain implant
stabilization.
Tissue Thickener
The use of a tissue thickener is an extension of second-
stage breast reconstruction in which expander-to-implant
conversion is facilitated by superomedial placement of an
extra-thick ADM to enhance the soft tissue cover of the
implant and give a better visual and palpable confluence
of chest to breast form.43 In aesthetic revisions this is also
most commonly applied to the upper pole (or superome­
dial area) to thicken tissue, minimize visibility of traction
rippling, camouflage implant edges, and enhance cleavage.
An extra-thick allograft material is generally used and ap­
propriately trimmed. It is draped over the implant (inti­
mate engagement on its deep surface) and in contact with
the existing capsule or neopocket on its superficial surface.
Parachute 2–0 Prolene sutures with Keith needles are used
in the ADM corners and interspersed on the medial side
to facilitate placement and redraping. The suture ends are
tied to themselves externally, under no tension, and cov­
ered with a transparent adhesive dressing for 7 to 10 days.
This same application is occasionally used laterally or infer­
olaterally for implant visibility or palpability and inferiorly
to “thicken” a very thin cutaneous cover. The key to success
is proper pocket alteration with incorporation of the extra-
thick ADM providing bulk, yet allowing for revasculariza­
tion and cellular repopulation.
a
b
Fig. 34.10 Interposition of acellular dermal matrix between implant and skin closure. This is similar to the “reconstructive model.” (Repro­
duced from Jones GE. Bostwick’s Plastic and Reconstructive Breast Surgery. 3rd ed. New York: Thieme; 2010.)

555
Chapter 34 Breast Augmentation
Fig. 34.11 Preoperative (left) and 32 month–postoperative (right) views of a 37-year-old woman who had revision augmentation masto­
pexy (inverted-T), which included the development of a neopectoral pocket, lower pole coverage with ADM, and replacement of implants
with form-stable, highly cohesive gel anatomic implants (style 410 implants).
tion. Sizes selected are normally in the 6 to 8 by 10 to 16 cm
range (depending on the size of the implant), rectangle or
“contour” shaped, and trimmed as needed. Seroma forma­
tion should be prevented in all breast revisions to allow fur­
ther revascularization and cellular repopulation of the ADM,
so drains are always recommended.
Results and Outcomes
The case examples in Figs. 34.16 through 34.20 summarize
our philosophy and practice.
Conclusion
Breast augmentation is the most common aesthetic pro­
cedure performed in the United States and perhaps in the
world.45 Plastic surgeons strive to achieve perfection and
continue to improve their surgical techniques to achieve
the aesthetic breast form. All precautions should be taken
during the perioperative period to minimize both immedi­
ate and delayed complications of primary breast augmen­
tation (see Figs. 34.15–34.20). This starts with appropri­
ate patient selection followed by the techniques and tips

SECTION V THE BREAST
556
benefit ratio. When a decision is made to move forward, the
goal should be to plan and execute the most precise and ef­
ficient surgical correction. To achieve this goal, the surgeon
must understand the problems and variables involved and
then look for new solutions.
described in this chapter. Despite advances in implant
technology and surgical techniques, undesired outcomes
are encountered that lead to revision surgeries. In prepar­
ing for a revision breast augmentation, the surgeon must
understand patients’ goals and expectations and evaluate
the probability of their accomplishment, as well as the risk-
Fig. 34.12 Preoperative (left) and 30 month–postoperative (right) views of a 49-year-old woman who had revision augmentation masto­
pexy (inverted-T), which included the development of a neopectoral pocket, lower pole coverage, and reinforcement of inferior and lateral
walls with ADM and replacement of implants with form-stable, highly cohesive gel anatomic implants. Successful correction of inferior and
lateral malposition was achieved.

557
Chapter 34 Breast Augmentation
Fig. 34.13 Preoperative (left) and 26 month–postoperative (right) views of a 38-year-old woman who had revision augmentation through
an IMF incision that included the development of a neopectoral pocket, lamellar separation, lower pole coverage with ADM, and replace­
ment of implants with textured gel implants.

SECTION V THE BREAST
558
Fig. 34.14 Preoperative (left) and 22 month–postoperative (right) views of a 45-year-old woman who had revision augmentation through
an inframammary fold incision that included the development of a neopectoral pocket, lower pole coverage with acellular dermal matrix,
and replacement of implants with higher-profile, lower-volume textured gel implants.

559
Chapter 34 Breast Augmentation
Fig. 34.15 Preoperative (left) and 12 month–postoperative (right) views of a 39-year-old woman who received style 410 implants at 12
months (right, full-height full projection 425 cc; left, full-height full projection 425 cc in a dual plane location).

SECTION V THE BREAST
560
Fig. 34.16 Preoperative (left) and 12 month–postoperative (right) views of a 36-year-old woman with style 410 implants (right, moderate-
height moderate projection 360 cc; left, moderate-height moderate projection 360 cc in a dual-plane position).

561
Chapter 34 Breast Augmentation
Fig. 34.17 Preoperative (left) and 24 month–postoperative (right) views of a 51-year-old woman who had style 410 implants (right, full-
height full projection 375 cc; left, full-height full projection 375 cc in a dual plane position).

SECTION V THE BREAST
562
Fig. 34.18 Preoperative (left) and 12 month–postoperative (right) views of a 40-year-old woman with style 410 implants (right, full-height
moderate projection 270 cc; left, full-height moderate projection 270 cc in a dual plane position).

563
Chapter 34 Breast Augmentation
Fig. 34.19 Preoperative (left) and 24 month–postoperative (right) views of a 24-year-old woman who had style 15 implants (right, 286 cc;
left, 286 cc in a dual plane position).

SECTION V THE BREAST
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6. Nahai F. The Art of Aesthetics. 2nd ed. St. Louis: CRC Press;
2010
7. Gabriel A, Maxwell GP, Creasman C, Fritzsche S. Efficacy
of manual and 4D imaging in identifying breast asymme­
tries. California Society of Plastic Surgeons. 2009
8. Hunstad JP, Webb LS. Subfascial breast augmenta­
tion: a comprehensive experience. Aesthetic Plast Surg
2010;34(3):365–373
9. Tijerina VN, Saenz RA, Garcia-Guerrero J. Experience of
1000 cases on subfascial breast augmentation. Aesthetic
Plast Surg 2010;34(1):16–22
10. Siclovan HR, Jomah JA. Advantages and outcomes in sub­
fascial breast augmentation: a two-year review of experi­
ence. Aesthetic Plast Surg 2008;32(3):426–431
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2. Baker JL Jr, Kolin IS, Bartlett ES. Psychosexual dynamics of
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3. Procedural statistics pk. 2010
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Grotting D, eds. Plastic Surgery, Vol 5. Breast. Elsevier; 2013
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breast types. Plast Reconstr Surg 2001;107(5):1255–1272
Fig. 34.20 Preoperative (left) and 24 month–postoperative (right) views of a 36-year-old woman with style 15 implants (right, 371 cc; left,
371 cc in a dual plane position).