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

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Discussion by Mitchell Howard Brown, Ron B. Somogyi, and Stephanie Hoffbauer
The goals of breast augmentation are to achieve safe, re­
liable, and aesthetically superior results. Our approach
to breast augmentation is individualized and focuses
on a number of key principles that must be evaluated
for each patient:
•• Accurate patient assessment
•• Comprehensive patient education
•• Individualized decision-making regarding surgical
approach and implant selection
•• Meticulous surgical technique
•• Defined and consistent postoperative protocol
•• Decisive recognition and management of
unfavorable results
Breast augmentation surgery often involves a patient
population that is difficult to follow for long periods of
time. Despite surgeons’ best efforts, these patients are
young and mobile at the time of primary augmenta­
tion; they may travel in for surgery or move to other
cities. It is common for these patients to follow up with
other surgeons, often leaving the primary surgeon
with no knowledge of complications or unfavorable re­
sults. Even with practice principles that include yearly
follow-up for all augmentation patients, we have only
achieved an average follow-up of 17 months.1 Many
surgeons believe that their actual complication rates
and the percentage of their patients who are dissatis­
fied with their results are lower than they likely are.
As a result, there is a tendency for complacency and a
failure to recognize the need to modify approaches and
adopt best practice principles in breast augmentation.
One must first establish or define what is meant by a
favorable result. Although the characteristics of the ideal
breast shape have been described, it varies based on
geographic location, cultural norms, age of the patient,
and the specific goals and objectives of the individual
patient. Some patients may be very satisfied by their
current shape, with increased volume as their only goal,
whereas others would like to restore their breast shape
and volume to that which they recall from decades ear­
lier. Others yet are less concerned with a natural result
and are looking for substantial volumetric changes. Fail­
ure to fully understand these differences may result in
an outcome that fully satisfies the surgeon but is viewed
as unsatisfactory or disappointing to the patient.
Unfavorable results can be broadly divided into
three main categories:
1. Complications
2. Reoperations
3. Failure to meet patient goals and expectations
These can result from poor decision-making or less-
than-precise operative technique, but more often they
result from a lack of effective communication between
the surgeon and patient.
Poor outcomes can be loosely classified as those
that are at least partly avoidable and those that are not.
Adoption of best practice techniques has made a ma­
jor impact on reducing avoidable complications such as
capsular contracture and implant malposition. Compli­
cations such as late seroma and double capsule forma­
tion are more recent problems partly related to a change
in implant selection in certain markets. Further research
is required to better understand the underlying causes
of these complications that commonly require second­
ary surgery.
With this in mind, surgeons must remember that
their patients’ anatomy is constantly changing through
life. Reoperation for changes in native breast shape with
age; recurrent ptosis; and secondary changes from preg­
nancy, breast-feeding, or weight loss are unavoidable
and must be part of the patient’s presurgical education.
The surgeon’s role is to use a presurgical, surgical,
and postsurgical approach that minimizes the occur­
rence of unfavorable outcomes while addressing the
unique patient goals and expectations.
Patient Assessment and Education
Patient assessment, including the use of three-dimen­
sional imaging, can be important as part of the pro­
cess of achieving a favorable result. This technology is
valuable in allowing the surgeon to perform precise
presurgical planning with specific consideration to is­
sues of shape, volume, and asymmetry. Of equal im­
portance is the use of imaging in patient education. In
our practice, we routinely use physical examination as
well as two-dimensional and three-dimensional pho­
tography to help in this regard. During the physical
examination, measurements are taken and the patient
is assessed for any noticeable evidence of asymmetry.
Measurements can be defined as either static (supra­
sternal notch to nipple–areola complex [SSN:N], breast
width [BW], nipple–areola complex to midline) or dy­
namic (pinch test, anterior pole stretch, nipple–areola
complex to inframammary fold [N:IMF] on stretch).
Although measurements are a cornerstone of implant
selection and preoperative planning, not all commonly
recommended measurements are reliable either
across raters or within raters. When tested in a recent
study, the reliability of static breast measurements
demonstrated excellent reliability, whereas dynamic
measurements were far less reliable.2 This information

567
Chapter 34 Breast Augmentation
should be considered when using dimensional plan­
ning for implant selection.
After the examination, imaging is then performed.
Three-dimensional photographic analysis often high­
lights issues, specifically in minor volume discrepancy or
chest wall asymmetry, that are not immediately obvious
during the physical examination. The assessment results
form part of the surgical plan, are an important educa­
tion tool for the patient, and are maintained within the
patient record for future reference.
Patient-Centered Treatment Plan
In reality, no two breast augmentations are the same.
Although we strive to develop and follow defined pro­
cesses of care, each patient requires unique implant se­
lection, procedure selection, and anatomic dissection.
The preoperative assessment drives decisions of device
surface, fill, shape, and size as well as incision location
and pocket position. Specifically, we consider the ap­
propriate use of textured versus smooth and round ver­
sus anatomic devices when we consider the patient’s
aesthetic goals. Tissue characteristics drive decisions
such as implant size, incision site, and pocket position
(subglandular, subfascial, subpectoral, or dual plane).
The selection of implant size is based on dimen­
sional planning, taking into consideration patient goals
and expectations. Surgeons can generally identify a
small range of implant sizes that are appropriate given
the patient’s examination and measurements. The art
of the consultation is to guide the patient to come to
the same decision through a process of education and
informed consent. We routinely simulate outcomes
within this range using three-dimensional imaging and
then confirm the exact implant selection by having the
patient try on sizers in the office. This engages the pa­
tient in the process and empowers her in the decision-
making process. A detailed description of our approach
to implant and procedure selection has been previously
presented.3
Surgical Technique and Postoperative
Care
We strongly advocate for a defined stepwise approach
when performing breast augmentation surgery (Video
34D.1). This begins with preoperative preparation, in­
cluding the administration of nonnarcotic analgesics
and anti-inflammatories. Surgery is performed under
direct visualization regardless of the incision selected.
Direct visualization not only allows for accurate dis­
section of the pocket margins and symmetric release
of the pectoral muscle, but also allows for prospective
hemostasis, an atraumatic dissection, and minimizing
of blood or fluid in the pocket. Subpectoral dissection is
facilitated by the administration of muscle relaxation,
carefully timed to the predicted duration of pocket dis­
section. These steps promote a rapid recovery for the
patient and are important in decreasing the most likely
causes of an unfavorable result, namely capsular con­
tracture and implant malposition.
Intraoperative use of sizers increases trauma to the
carefully dissected implant pocket and has the potential
of overdissecting the pocket from the intended margins.
Accordingly, the use of sizers in this way is uncommon
and generally reserved for revision surgery or patients
with complex asymmetry. Implant selection is most of­
ten confirmed preoperatively, following the principles of
dimensional planning. Implants are inserted using mini­
mal or no-touch techniques after irrigation with antibi­
otic solution. Finally, closure is meticulously completed
with the surgeon ensuring that dissected areas such as
the inframammary fold (IMF) are restored or reinforced.
Patients are given detailed postoperative instruc­
tions before their procedure. These are reviewed with
the patient before discharge and are reiterated with a
phone call later that evening and again the following
day. Identification of problems such as bleeding or ex­
cessive swelling allows for early intervention and mini­
mizes the chances for long-term adverse outcomes. We
have a low threshold for in-office visits or intervention
when there is any potential concern. Patients receive a
short course of anti-inflammatories and oral antibiotics.
Narcotic analgesics are prescribed; however, many pa­
tients find that they are able to recover without the need
for anything stronger than anti-inflammatories. Implant
displacement massage is taught and encouraged when
smooth implants are used. A comprehensive scar man­
agement protocol is reviewed with every patient at the
first postoperative visit. This includes the use of scar
massage, application of a silicone-based scar gel, and
micropore tape for a period of 3 months.
Managing the Unfavorable Result in
Breast Augmentation
Certain circumstances dictate the need for interven­
tion. These include infection, an abnormal mass, or an
implant rupture. Otherwise, any unfavorable result can
be managed in one of three ways:
1. Do nothing. All corrective procedures have risks,
and despite best efforts, the surgeon cannot guar­
antee a successful resolution of the problem. The
old saying that “the enemy of good is better” should
always be considered; because sometimes it is best
to leave well enough alone.
2. Implant removal with or without soft tissue
modification. The only way to guarantee no further
surgery related to breast implants is to remove the

SECTION V THE BREAST
568
implant from the equation. Sometimes explantation
alone or with soft tissue reshaping will adequately
address the patient’s concerns.
3. Revision augmentation. When the decision is
made to revise an unfavorable result and main­
tain a breast implant, the surgeon should choose
whether this can safely be performed in one or two
stages. With complex revisions, it is sometimes
necessary to address the implant issues and the soft
tissue issues in two separate procedures.
The remainder of this discussion focuses on two of the
most common causes of the unfavorable result: capsu­
lar contracture and implant malposition. As with any
complication, the focus should be placed on preven­
tion, early detection, and effective resolution of the
problem.
Capsular Contracture
Capsular contracture is common and results from ex­
cessive peri-implant fibrosis. Studies show that the rate
of capsular contracture ranges from 2.4 to18.9% in pri­
mary augmentation and 10.1 to 26.8% in revision sur­
geries.4,5,6 Possible causes are listed in Box 34 D.1.
Research supports subclinical infection as a cause of
capsular contracture, demonstrating that bacteria that
have contaminated the implants before or during inser­
tion coat the device irreversibly.7,8 A biofilm forms that
is resistant to antibiotics and antiseptics and eventually
reaches a threshold, at which point it overwhelms the
host defense system, leading to a cascade of local inflam­
mation and fibrosis resulting in capsular contracture.7,8
Prevention
Prevention of capsular contracture is essential, because
its treatment is difficult. Factors related to capsular
contracture include selection of incision site, pocket lo­
cation, implant surface and fill, surgical technique, and
maintenance of a consistent postoperative protocol.
Although an extended discussion regarding preven­
tion strategies is beyond the scope of this Discussion,
our preference is to place implants through an IMF inci­
sion in a subpectoral pocket. We use perioperative an­
tibiotic prophylaxis and perform a precise dissection to
minimize fluid within the implant space and prevent the
need for drains. A minimal-touch technique is used that
includes an insertion funnel. Early postoperative mas­
sage is advocated when using smooth surface devices
and avoided when selecting a textured implant.
Management
Patients undergo treatment for capsular contracture to
either manage aesthetic changes to the breast or treat
symptoms such as localized pain. Minor degrees of con­
tracture (Baker 2) are often managed conservatively.
Although surgery remains the mainstay of treatment,
nonsurgical methods have been proposed. Medical
treatments have gained recent attention, especially leu­
kotriene antagonists such as zafirlukast and montelu­
kast.9 Leukotriene triggers smooth muscle contraction
in bronchioles; thus the use of antileukotriene agents
have been suggested for modifying the muscle response
associated with early stages of contracture. However,
these treatments have had minimal impact on the man­
agement and prevention of capsular contracture.
Surgical treatment is all encompassing, with best
efforts taken to reduce recurrence. Explantation (with
or without soft tissue modification) is an excellent op­
tion when breast volume is sufficient, and the patient is
amenable. When an implant is desired, strong consid­
eration is made for placing a new implant in a new en­
vironment. The old implant is not reused. This approach
will help to address the underlying cause of subclinical
infection or biofilm. Although an open capsulotomy is
a recognized treatment option, this does not create a
new environment for the implant. A new environment
can be created via capsulectomy or site change; how­
ever, this treatment decision must be weighed against
the increased amount of dissection and tissue trauma
with these more aggressive approaches.
When capsular contracture occurs around a sub­
glandular implant, surgical options include a complete
capsulectomy and reinsertion of a new implant in a sub­
glandular pocket, or partial or total capsulectomy and
site change to a subfascial or subpectoral pocket. We ad­
vocate for the use of ADM to act as a pectoral extender
and to assist in minimizing recurrence; however, the
cost of the ADM is often a major barrier for our patients.
In these cases, the implant is placed in a subpectoral
pocket without added lower pole support and the old
Box 34D.1
•• Bacterial biofilm
•• Subclinical infection
•• Inflammation resulting from soft tissue
trauma
•• Silicone gel bleed
•• Hematoma
•• Seroma
•• Radiation
Possible Causes of
Excessive Peri-implant
Fibrosis Leading to
Capsular Contracture

569
Chapter 34 Breast Augmentation
subglandular pocket is closed with sutures (Fig. 34 D.1).
If a previous subpectoral pocket was used, options for
treatment include capsulectomy and insertion of a new
device in the subpectoral pocket. If complete capsulec­
tomy is either problematic or undesirable, a neosubpec­
toral pocket may be considered.
Implant Malposition
Assessment
Implant malposition, defined as an incorrect or faulty
position of an implant, is one of the most common
reasons for an unfavorable result in breast augmenta­
tion.10–13 Although not all malpositions can be avoided,
adherence to best practice principles will assist in
minimizing the frequency of this complication. Many
factors may be responsible for a malposition; how­
ever, once it is established, the fundamental issue is a
problem with the implant pocket: too big, too small,
or wrong position. Understanding the factors that lead
to malposition is essential to both prevention and suc­
cessful management of an established malposition.
These factors can be divided into five basic categories:
1. Patient anatomic factors
2. Procedure selection
3. Implant selection
4. Surgical technique
5. Postoperative management
Patient Factors
Patient factors include those related to the patient’s
musculoskeletal anatomy; the quality, amount, and
distribution of the breast tissue; and the characteristics
of the overlying skin envelope. Skeletal abnormalities
such as pectus excavatum will medially displace an
implant, whereas pectus carinatum will lateralize im­
plants. A strong, high-demand pectoralis major muscle
can lead to superior malposition. A tight or high IMF
that requires lowering can lead to an inferior malpo­
sition and a thin, atrophic, poor-quality skin envelope
can lead to malposition in any direction.
Procedure Selection
Procedure selection, including the choice of appro­
priate implant pocket and access incision, is the next
important consideration. Medial malposition is more
likely with subglandular implant placement, because
the pectoralis muscle is unable to function as a medial
border of the pocket. Lateral malposition, however, is
more common with subpectoral augmentation be­
cause of the lateralizing effects of repeated muscle con­
traction. Transaxillary incisions may predispose to su­
perior malposition secondary to inadequate release of
the inferior pectoralis origin, and inframammary inci­
sions may predispose to inferior malposition as a result
of partial disruption of the native IMF. Recent clinical
trial data has demonstrated a significantly higher over­
all rate of malposition in implants placed through axil­
lary incisions and implants placed in the subglandular
pocket.14
Implant Selection
Implant selection must include thoughtful consider­
ation of both size and surface. A dimensional approach
to implant selection that focuses on patient measure­
ments instead of volume alone decreases reoperations
and improves patient outcomes.3,15,16 Implants that
a
b
Fig. 34D.1 (a) Recurrent contracture in a subglandular pocket. (b) One year after explantation, capsulectomy, and conversion to
a subpectoral pocket with larger, textured-surface implants.

SECTION V THE BREAST
570
are too large may not only violate the natural breast
footprint but will predispose to multidirectional mal­
position, excessive soft tissue stretching, parenchymal
atrophy, implant edge visibility, and visible traction
rippling. Implant surface may also play a role in the
incidence of malposition. Several studies have dem­
onstrated lower rates of malposition with the use of
a textured device.5,6 This may be related to enhanced
tissue integration, but the overall procedure is differ­
ent with smooth versus textured devices. When using
a textured-surface implant, the pocket more closely
matches the implant dimensions, resulting in less mo­
bility of the implant under the breast tissue.
Surgical Technique
Safe and effective surgical technique to prevent mal­
position begins with accurate preoperative planning
and proceeds with precise, atraumatic technique that
closely follows the surgical markings. Prospective he­
mostasis will limit postoperative inflammation, seroma
formation, and hematoma. Postoperative fluid collec­
tions are a common cause of malposition because of
unintentional expansion of the implant pocket. Techni­
cal errors, including overdissection or underdissection
of the pocket must be avoided. Care should be taken to
ensure that any release of the pectoral muscle is per­
formed precisely and symmetrically. Precise closure
with restoration of fascial support is important, espe­
cially when access is through the IMF.
Postoperative Care
Again, a thoughtful approach to postoperative care
that includes comprehensive patient education, effec­
tive support of the surgical site, and timely follow-up
is important. There is no consensus regarding the use
of postsurgical garments. Some surgeons recommend
a surgical bra for at least several weeks. Garments are
variable and fit each patient differently, so it is incum­
bent upon the surgeon to ensure that the garment is
not promoting an early malposition. Occasionally, an
implant stabilizer or bandeau may be used to maintain
lower pole position in the face of a tight pectoral mus­
cle or tight lower pole. Early and regular follow-up of
an augmentation patient is necessary, because detec­
tion and management of a fluid collection, hematoma,
or early malposition can be addressed at this stage to
limit their influence on long-term malposition.
Management
Because the fundamental issue with malposition is a
problem with the implant pocket, treatment options
can be divided into two groups: adjust the existing
pocket or change to a new pocket (Fig. 34D.2).
Adjusting the Pocket
Nonsurgical options to adjust an implant pocket in­
clude using external compression, taping, shoestrings,
or specialized garments.17 If instituted early, these sim­
ple techniques may be successful. Once a malposition
has been established, however, nonsurgical options are
of limited value.
Surgical options for adjusting the implant pocket in­
clude capsulodesis, strip capsulectomy and repair, cap­
sulorrhaphy, internal capsule flaps, thermal shrinkage,
or a combination of these techniques.18,19,20,21 Often a
mirror image capsulotomy is required opposite to where
the capsule is adjusted to allow the implant to sit in the
correct position and to take pressure off the repair dur­
ing the healing process.
The surgeon must often deal with tissues that are
thin and attenuated. In many cases the normal anatomic
position of the muscle has been disturbed. In these situ­
ations, the addition of internal support matrices may be
beneficial. However, the addition of many internal sup­
port matrices adds significant cost to the overall proce­
dure and requires justification.
If the pectoralis muscle has been overreleased or
superiorly retracted, a support matrix can be used as a
pectoral muscle extender and sutured to the native IMF
insertion. This method also provides improved defini­
tion to a previously violated or newly translocated IMF.
Occasionally, the soft tissue damage is so extreme that
tissue matrices are necessary to completely redefine a
potential implant pocket (Fig. 34D.3).
Changing the Pocket
Changing the pocket allows the surgeon to discard
the problematic pocket and to surgically create a new
pocket to the desired dimensions. A malposition of a
subglandular implant is most commonly changed to a
subpectoral pocket. In these cases, the original pocket
must be closed to prevent the implant from migrating
back into the old pocket, and the pectoral muscle must
be secured inferiorly to prevent excessive window-
shading (Box 34D.2).

571
Chapter 34 Breast Augmentation
Similarly, a subpectoral implant can be changed to
a subglandular or subfascial pocket in the presence of
adequate soft tissue cover. Occasionally, superior mal­
position results from the implant sitting in a complete
submuscular position. This can most easily be corrected
through conversion to a dual-plane pocket. Dissection
is performed inferiorly on top of the old capsule until
the inferior edge of the muscle is identified. An anterior
capsulotomy is performed at that level and the implant
is allowed to slide down into the new dual-plane pocket
(Fig. 34D.4).
The neosubpectoral pocket is a powerful option
when managing subpectoral malposition. This allows
for a new controlled pocket while maintaining the ad­
vantages of a subpectoral position.22,23,24 After dissecting
the neopocket, the old pocket is closed with plication
sutures (Fig. 34D.5).
Adjuvant techniques may be used to address con­
tributing factors of the malposition, such as a capsulec­
tomy in the case of capsular contracture or exchange of
implant where the patient would benefit from a differ­
ent implant material or size. Often, soft tissue modifi­
cation is required and may include mastopexy, lipofill­
ing, or correction of soft tissue asymmetry. Depending
on the degree of deformity, surgery may be performed
in either one or two stages. When an implant exchange
is indicated, textured surface implants may assist with
stability of the implant in the new pocket.
Conclusion
Individualized decision-making that includes a thor­
ough assessment of goals and expectations; compre­
hensive patient education; and consistent preopera­
tive, surgical, and postoperative practices will help in
minimizing unfavorable results. Early identification
and thoughtful management of adverse outcomes pro­
vide the best chance for an acceptable and favorable
final result.
Malposition
Change the pocket
Subpectoral
Neopocket
Subglandular
New pocket
Existing pocket
Subpectoral
Subglandular
Dual plane II or III
Neosubpectoral
Strip capsulectomy and repair
Capsulodesis
Thermal shrinkage
Capsulorrhaphy
Capsular flap
Soft tissue support matrix
Adjust the pocket
Fig. 34D.2 An algorithmic approach to the surgical management of implant malposition.

SECTION V THE BREAST
572
a
b
c
Fig. 34D.3 (a) A complex multidirectional malposition. This patient already had implants in both subglandular and subpecto­
ral pockets and currently had a Baker 3 contracture with right medial and inferior malposition, rippling, and nipple asymmetry.
(b,c) The deformities were treated with capsulectomy, acellular dermal matrix–assisted pocket creation, and implant replacement.
Box 34D.2
•• Suture closure: The gland is secured to the underlying pectoral muscle. Adequate soft tissue must
exist to ensure glandular sutures do not create overlying skin puckering.
•• Marionette sutures: Sutures are placed at the pectoral edge, externally through the skin, and tied over
bolsters to secure the muscle over the implant.
•• Capsular flap: The part of the capsule left attached to the pectoralis can be used to cover the new
implant and secured to the inframammary fold.
•• Surgical scaffold (acellular dermal matrix or mesh): The scaffold is secured to the pectoralis muscle
and to the inframammary fold to completely close the subpectoral pocket.
Methods for Securing an Implant in the Subpectoral Position

573
Chapter 34 Breast Augmentation
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Fig. 34D.4 (a) A superior malposition secondary to inadequate release of the inferior pectoralis insertions. The patient also had
recurrent overlying soft tissue ptosis. (b) This was treated by conversion from a total submuscular pocket to a dual-plane pocket
and revision mastopexy.
a
b
Fig. 34D.5 (a) Bilateral medial malposition secondary to insertion of large, smooth round implants and overrelease of the medial
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Chapter 34 Breast Augmentation
Special Commentary: Silicone Breast Implants Associated with Anaplastic
Large Cell Lymphoma* by Garry S. Brody
*Adapted from Brody GS, Deapen D, Taylor CR, et al. Anaplastic large cell lymphoma occurring in women with breast
implants: analysis of 173 cases. Plast Reconstr Surg 2015;135(3):695–705.
The first silicone breast implants were inserted in
1962 by Cronin and Gerow.1  The concept apparently
stemmed from a “eureka moment” when Gerow noted
that squeezing a bag of blood felt similar to squeezing
a breast. Dow Corning, at the time the leading supplier
of silicone products, was approached and produced
the first silicone implants to their specification. The
shell was cast of high-molecular-weight medical grade
silicone elastomer (dimethyl siloxane) and filled with
a lightly cross-linked silicone gel. Initially three sizes
were available: small, medium, and large. This con­
struct permitted the lower-molecular-weight gels to
diffuse through the shell into the surrounding tissue—
described as a “bleed” by the profession. Dow also at­
tached a perforated patch of silicone elastomer on the
back with a suture tab for fear that the device would
slip down the chest. (Other manufacturers used a patch
of Dacron polyester.) This later proved to be unneces­
sary and was abandoned. In the 1980s, methods to
control the bleed  were  developed  by  manufacturers.
Dow lined the inside of the shell with a barrier coat of
fluorosilicone. Most other manufacturers sandwiched
a layer of phenylsilicone into the shell (Fig. 34SC.1). At
the end of the decade a new implant became available.
Fig. 34SC.1 (a) Scanning electron microscopic cross section of a smooth-surface implant (original magnification, ×25). A-1, Outer
coat of dimethyl siloxane; A-2, central barrier layer of diphenyl siloxane; A-3, inner base of dimethyl-siloxane. (b) Electron micro­
scopic photograph of a Mentor textured shell surface (original magnification, ×25), averaging 40 to 100 μm in depth and 30 to 150
μm in width. (c) Electron microscopic photograph showing unused Allergan textured shell surface (original magnification, ×25),
averaging 600 to 800 μm in diameter and 150 to 200 μm in depth. (d) Electron microscopic photograph of Allergan textured
shell surface (original magnification, ×25), retrieved after explantation. Through the years the device was significantly modified.
A barrier coat of either fluorosilicone by Dow or phenylsilicone by other manufacturers prevented the diffusion (A-1 in a). A major
problem afflicted almost all women in those early days: The scar capsule would contract, resulting in various degrees of harden­
ing, often painful. It is now believed that capsular contracture is caused by a critical load of biofilm organisms acquired at surgery.
a
b
c
d

SECTION V THE BREAST
576
A layer of polyurethane foam was bonded to the sur­
face, resulting in a much lower incidence of contrac­
ture. The polyurethane, however, dissolved over the
years, ultimately resulting in  late  contracture. These
implants are no longer available in the United States
but are still popular in other countries.
In the 1980s, texturing the surface of the implant
was attempted with the hope of mimicking the resis­
tance to capsular contracture of the polyurethane de­
vices. Various methods were created to texture the sur­
face. Allergan, a major supplier of implants, used a “lost
salt” process. A layer of sea salt was added to the sur­
face before curing. The salt was washed out after the
cure, leaving microscopic pits for the scar to grow into
(see Fig. 34SC.1c). Mentor created a surface of silicone
that mirrored the pits in the polyurethane sponge (see
Fig. 34SC.1b). Various iterations of these techniques
were developed by European and other manufacturers
around the world.2
The index case of breast implant–associated ana­
plastic large cell lymphoma (BI-ALCL) was a report by
Keech and Creech3 in 1997 of a patient who presented
with a mass that proved to be ALCL. The implant was a
textured McGhan product. She responded well to che­
motherapy and radiation without surgery and was re­
ported to be tumor free at 2 years3 (Fig. 34SC.2).
Presentation
The most common presentation is a swelling of the
breast caused by a fluid collection contaminated by a
varying amount of debris and/or a lymphoma-lined
capsule. The second most common is a mass emanat­
ing from the capsule wall (Fig. 34SC.3). Third is axil­
lary lymphadenopathy, and fourth is widely dissemi­
nated treatment-resistant disease with B symptoms
Fig. 34SC.2 Magnetic resonance imaging scan of a breast with
anaplastic large cell lymphoma. A, Implant shell and capsule;
B, small seroma; C, palpable tumor; D, tumor. (Modified from Keech
JA, Creech BJ. Anaplastic T-cell lymphoma in proximity to a saline
filled breast implant. Plast Reconstr Surg 1997;100(2):554–555).
Fig. 34SC.3 Gross appearance of a breast implant lymphoma–involved pocket. (a) Seroma after cosmetic augmentation. (b) Se­
roma after reconstructed breast. (c) Debris-laden implant capsule. (d) Lymphoma-lined capsule.
a
b
c
d

577
Chapter 34 Breast Augmentation
(fatigue, sweats, malaise, and weight loss). There are
two cases that presented with erosion though the skin
(Fig. 34SC.4).
Diagnosis
The fluid should be sent for cytology and the capsule
tissue to pathology for analysis and histochemistry.
The histochemical signature is CD+ ALK–1. The pathol­
ogist should be requested to record the implant con­
tent, surface, size, and manufacturer. The scar should
be searched for silicone particles, but this requires a
polarizing microscope. The seroma analysis can range
from just a few positive cells to the appearance seen
in Fig. 34SC.3. The tumor may only cover parts of the
capsule or not be visually apparent, so several random
sections should be examined. In most cases the lesion
is restricted to the capsule indefinitely without pro­
gressing (in patients who did not seek care promptly
after symptoms arose and in whom, for even up to 2
years from symptom onset, there was no progres­
sion)  and would be considered a lymphoproliferative
disorder. Only when the lesion escapes the capsule is it
truly a malignancy.
Epidemiology
The number of women worldwide with breast implants
is unknown, but one estimate from several years ago
was 35 million.* Lymphomas of the breast are rare, com­
prising 0.2 to  0.3% of all breast malignancies, most be­
ing the less aggressive B cell type. Primary ALCL of the
breast parenchyma is extremely rare, reported to occur
in only 3 cases per 100,000 women per year in the
United States, with a 75% mortality.4,5 A population-
based, nationwide pathology study in Holland identi­
fied five patients with breast ALCL who had cosmetic
augmentation with textured silicone implants. Two of
the implants were from Allergan and three were from
European manufacturers using their own patented vari­
ations for surface texturing. A nested case control analy­
sis was reported to have an estimated odds risk of BI-
ALCL of 18.2 (95% confidence interval [CI], 2.1–156.8)
(i.e., the odds of a woman with implants getting ALCL
were 18.2 times that of controls).6 The U.S. Food and
Drug Administration is quoted as stating that this
“should not be of major concern to patients as the abso­
lute risk remains very low due to the extreme rarity of
breast ALCL.”7 
Etiology
The  cause of BI-ALCL is not fully understood but ap­
pears to be multifactorial with chronic irritation as the
initiator. There is no preference between gel or saline
fill or right or left breast. There is a lot of interest in the
relationship between biofilm organisms  and ALCL  in
the current literature.8 Biofilm is the apparent initia­
tor of capsular contracture, and techniques to minimize
the load are well known. Yet from the first woman im­
planted in 1962 to Keech and Creech’s index case,3 con­
tracture was very common—presumably because sur­
geons were unaware of the role of biofilm so the load of
the organisms was not controlled.
To date there has not been a report of ALCL in a pa­
tient with a history of strictly smooth-surfaced devices.
Implant capsules are rich in Th16 and 17T cells, which
are associated with the cellular immune system. They
are more common with textured devices than smooth.
Their role in this process is uncertain. 9
Silicone finger and wrist bone replacements are
prone to abrade off fine particles by rubbing on the
rough bone surfaces. The particles can end up in the
axillary nodes, producing an inflammatory lymphade­
nopathy. There were three reports of nodal lymphomas
with particles in the specimen, but they were all B cell.10
All other reports of lymphoma associated with many
other foreign bodies were B cells.11
Five of the cases had associated lymphoid papulo­
sis of the skin on the involved breast and/or adjacent
chest skin. The aggressive microscopic appearance of
the cells, aggressive immunophenotype, cytokine pro­
file, and mostly benign clinical course of both ALCL and
cutaneous T-cell lymphoma strongly suggest a relation­
*Several years ago the International Confederation of Plas-
tic Reconstructive and Aesthetic Surgery (IPRAS) posted the
results of 35 million collected self-reports of their member-
ship on their website (the site has since been taken down).
In nonmember countries such as China, Russia, and much of
East Asia, breast implants are very popular. There are many
other manufacturers in the world than the three that are in
the United States. Adding the implant population of all of the
Americas, I believe that the numbers are far greater than cur-
rently posted in the U.S. literature.
Fig. 34SC.4 A tumor eroding through the skin.

SECTION V THE BREAST
578
ship and reinforce the speculation of a genetic predispo­
sition. Lymphoid papulosis has a similar behavior with
cases of metastases and deaths.12
Pathology and Cell Culture
Thirty-six specimens submitted from colleagues were
reexamined to confirm reported immunohistochemi­
cal results (ALK–1 and CD30+). Other T-cell markers
occurred at a lower frequency. B-cell markers (CD20,
CCD79a, and PAX5) were performed in a few cases,
and all were reported as negative. Of the 13 specimens
in which T-cell gene rearrangement studies were per­
formed, 12 were reported as positive for monoclonal­
ity. B-cell (immunoglobulin H) rearrangements were
also seen in the samples of four cases that were shown
to be clonal in origin. In our samples, silicone particles
were sparsely seen in only 4 of 11 samples. 
Because sampling is necessarily random, if there is
no obvious lesion, the biopsy specimen may have come
from an area of nonattachment of the implant. Four
fresh tissue samples provided by colleagues were cul­
tured successfully, thus establishing T-cell breast lym­
phoma (TLBR) cell culture lines (TLBR-1 to TLBR-3).
Characterization of the TLBR cell lines showed them
to be interleukin-2 dependent; have high expression
of CD30, survivin, and Notch 1; and be monoclonal in
origin, with nearly triploid karyotypes13 (Fig. 34SC.5)
increased expression in these lymphomas. These TLBR
cell lines will facilitate the testing of new therapies, in­
cluding the use of anti-CD30 antibody therapy now ap­
proved for Hodgkin’s disease.11,12
Demographics
The demographics are also unusual. Cases have been
reported in only two Asians and one Native American,
with no known cases in African American women. Im­
plants are as popular or possibly more so in China, Eu­
rope, and Brazil, yet fewer cases were found in the Eu­
rozone, with a larger population than the United States,
despite the awareness generated by the recent implant
scandal in France. This may represent a lack of aware­
ness or reporting, which is seemingly unlikely, because
the characteristics of this entity have been widely pub­
licized in meetings in the Western world and in the
international plastic surgery, pathology, and oncology
literature. Both France and Britain have also established
lymphoma registries. Counterintuitively, manufactur­
ers estimate that 70 to 80% of implants sold in North
America are smooth, whereas 70 to 80% sold in Europe
are textured.14
Management
Computed tomography or positron emission tomog­
raphy to search for metastases is prudent. A total bi­
lateral  capsulotomy should be performed. Tumescing
TLBR-1
TLBR-2
TLBR-3
100
10
1
0.1
0.01
Antiapoptotic
Fold change related to
normal donor T cells
TLBR-1
TLBR-2
TLBR-3
Proapoptotic
Tumor suppressor
BCL2L2
Survivin
BID
BAK
p53
Rb
Fig. 34SC.5 Microscopic view of a stained capsular lesion. STAT3 is a transcription factor and oncogene with a critical role in cell
proliferation. A mutated version is characteristically seen in strongly CD30+ and ALK− lymphoproliferative disorders of the skin and
other T-cell lymphomas. It was expressed in all four ALCL cultured tissue samples. In a preliminary study, Hu et al8 found a variety
of biofilm organisms, including gram-negative bacteria, with an increase in T-cell response in both humans and implanted pigs.
They speculate that these findings “may point to an as yet unproven causative association between chronic bacterial biofilm in­
fection and the genesis of this rare malignancy.” Because biofilm has been ubiquitous from the beginning of breast implantation
this would be, at best, one of the components of the multifactorial cause of this emerging clinical entity. (Reproduced from Brody
GS, Deapen D, Taylor CR, et al. Anaplastic large cell lymphoma occurring in women with breast implants: analysis of 173 cases.
Plast Reconstr Surg 2015;135(3):695–705.)

579
Chapter 34 Breast Augmentation
enhances the ease of dissection, especially from the
back wall and muscle, and limits bleeding. After a mar­
gin clearance from pathology, some surgeons have re­
placed a smooth implant. There have been two reports
of recurrence, presumably related to incomplete initial
capsulotomy. A referral to an oncologist familiar with
this lesion for continuing surveillance is recommended.
Chop thereapy enhanced by rituximab is the current
oncologic therapy, with or without radiation.
Discussion
Aside from the single personally communicated report
of ALCL surrounding a tibial plate, a literature search
did not find any examples of ALCL in association with
other foreign bodies. Orthopedic prosthetic joints with
metal and polyurethane can particulate but produce
sarcomas or histiocytomas.15  A literature search of
lymphomas plaguing other foreign bodies found only
B cells. Thus BI-ALCL uniquely appears to be site- and
material-specific. As noted in Fig. 34SC.1, the seroma
around most textured implants wreaks havoc with the
capsule, and most of the silicone particles remain in the
capsule wall. 
Presumably, if a small area of the capsule separates
from the wall, it initiates the lesion and localizes as a
tumor. If the seroma propagates, the lesion infiltrates all
of the traumatized areas in the capsule. What induces
malignant mutation is yet to be discovered. 
Conclusion
BI-ALCL appears to be a new, distinct entity with a
multifactorial cause and is the first known presenta­
tion of large cell lymphoma arising in a scar. This report
is a collation of the currently known spectrum of this
extremely rare disorder with an attempt to fashion a
cohesive etiologic theory from the disparate available
information about its multiple unique properties and
behavior. The clinical presentation varies widely from
benign characteristics of an indolent lymphoprolif­
erative disorder to a fulminant malignant, treatment-
resistant demise. The common factors appear to be the
texturing of the silicone breast implant surface, sug­
gesting a unique site- and material-specific chronic in­
flammatory cause, with the demographics, associated
skin lesions, and tissue culture results suggesting a
possible rare genetic predisposition. Biofilm organisms
may also play a role. The disorder appears to be unre­
lated to the implant fill material or cosmetic versus re­
constructive indications. What remains to be resolved
is why a presumed causative factor of chronic irritation
or inflammation in the breast implant milieu results
in ALCL, whereas elsewhere it is manifested by less-
aggressive B lesions as seen in finger prosthesis lesions.
For most patients, the disease is limited to the scar
envelope; a lymphoproliferative lesion with a much
more indolent course than the cellular morphology.
The tumor is not time dependent in that it can arise
within months or up to 25 years after implantation, and
in many patients a delay from first symptoms to treat­
ment does not seem to alter the course of the disease.
A careful staging evaluation should dictate the appro­
priate treatment plan. Although the fluid and scar cap­
sule usually appear abnormal, they can seem grossly
normal; therefore it is recommended that all fluid and
capsule tissue from patients with seromas be submit­
ted for analysis.
It has been suggested that if the tumor is restricted
to the capsule, only bilateral implant removal with to­
tal capsulectomies should be considered, with close
oncologic follow-up but without oncologic treatment.
Multiagent chemotherapy (cyclophosphamide, hydroxy­
daunorubicin, vincristine, and prednisone) with or with­
out radiation has been successful for local extracapsular
involvement, but even high-dose stem cell infusion by
means of marrow transplantation in patients with ag­
gressive disseminated disease was successful in only 2
of the 14 patients.
Acknowledgment
The tissue culture studies were performed by Dr. Alan
Epstein of USC.
References
1. Cronin TD, Gerow F. Augmentation mammaplasty—
a new ‘natural feel’ prosthesis. Transactions of the
Third International Congress of Plastic Surgeons. Ex­
cerpta Medica, Amsterdam; 1964
2. Lesesne CB. Textured surface silicone breast im­
plants: histology in the human. Aesthetic Plast Surg
1997;21(2):93–96
3. Keech JA Jr, Creech BJ. Anaplastic T-cell lymphoma in
proximity to a saline-filled breast implant. Plast Re­
constr Surg 1997;100(2):554–555
4. Jeanneret-Sozzi W, Taghian A, Epelbaum R, et al. Pri­
mary breast lymphoma: patient profile, outcome and
prognostic factors. A multicentre Rare Cancer Net­
work study. BMC Cancer 2008;8:86
5. Altekruse SF, Kosary CL, Krapcho M, et al, eds. SEER
Cancer Statistics Review, 1975-2007, National Can­
cer Institute. Bethesda, MD,
csr/1975_2007/, based on November 2009 SEER data
submission, posted to the SEER web site, 2010
6. de Jong D, Vasmel WL, de Boer JP, et al. Anaplastic
large-cell lymphoma in women with breast implants.
JAMA 2008;300(17):2030–2035
7. The Center for Devices and Radiological Health, U.S.
Food and Drug Administration. Anaplastic large cell

SECTION V THE BREAST
580
lymphoma (ALCL) In women with breast implants
preliminary FDA findings and analysis; 2011
8. Hu H, Johani K, Almatroudi A, et al. Bacterial Biofilm
Infection Detected in Breast Implant–Associated Ana­
plastic Large-Cell Lymphoma. Survival Signals and
Targets for Therapy in breast implant. Plast Reconstr
Surg 2015;135:319–329
9. Wolfram D, Rabensteiner E, Gruntman C, et al. T-reg­
ulatory cells and TH17 cells in peri-silicone implant
capsular contracture fibrosis. Plast Reconstr Surg
2012;129(2):327e–337e
10. Digby JM. Malignant lymphoma with intranodal sili­
cone rubber particles following metacarpophalangeal
joint replacements. Hand 1982;14(3):326–328
11. Kadin ME, Xu H, Pavlov I, et al. Breast implant associ­
ated ALCL closely resembles primary cutaneous ALCL.
Lab Invest 2012;92:320-386
12. Davis TH, Morton CM, Miller-Cassman R, Balk SP, Ka­
din ME. Hodgkin’s diisease. Mod Pathol 2010;23:493–
501
13. Brody GS, Deapen D, Taylor CR, et al. Anaplastic large
cell lymphoma occurring in women with breast im­
plants: analysis of 173 cases. Plast Reconstr Surg
2015;135(3):695–705
14. Lechner MLG, Lade S, Liebertz DJ, Prince H. Miles,
Brody G S., Epstein AL.: Breast implant-associated
ALK-negative T cell anaplastic large-cell lymphoma:
establishment and characterization of a model cell
line (TLBR-1) for this newly emerging clinical entity.
Cancer 2011;117:1
15. Loong F, Chan AC, Ho BC, et al. Diffuse large B-cell
lymphoma associated with chronic inflammation as
an incidental finding and new clinical scenarios. Mod
Pathol 2010;23(4):493–501

581
Mastopexy and Augmentation
Mastopexy
Kenneth C. Shestak
Mastopexy and augmentation mastopexy can achieve high
patient satisfaction for properly selected patients with re­
alistic goals, treated with an appropriately selected proce­
dure that is carried out with good preoperative presump­
tive planning, and precise operative technique. It is critical
to analyze the patient’s presenting anatomy, explain to her
what particular procedure is best in your surgical opinion
and why, point out the probable location of scars resulting
from the surgery, and verify her acceptance of scars on the
breast as a “trade-off” for improvements in breast shape.
As of this writing all currently used mastectomy pro­
cedures entail the placement of scars on the breast. It is an
accepted fact of wound-healing science that scar tissue heal­
ing can never be completely predictable regardless of the
surgeon’s skill. Scars after mastopexy can be wide, elevated,
or uncomfortable. In addition, an inevitable sequela of all
mastopexy procedures is some degree of recurrent ptosis.
All patients considering mastopexy must be made aware of
these factors.
Mastopexy is a good procedure, and the demand for it
continues to increase. Breast reshaping with nipple–areola
repositioning with or without some element of breast tis­
sue excision and with incisions placed in favorable locations
can often lead to a gratifying result for both the patient and
the surgeon. The length of scars and overall “scar burden”
has decreased with the introduction of short-scar proce­
dures including vertical techniques, modified periareolar
techniques, and modified inverted-T or Wise pattern ap­
proaches1 marked by shorter inframammary incisions.
For more than 2 decades there has been more of a focus
on parenchymal reshaping and fixation, which is often used
as an adjunct in the shorter scar procedures. Incorporated
with many of these short-scar procedures is a new emphasis
on parenchymal shaping. These innovations have improved
plastic surgeons’ ability to achieve better results in many
settings. As noted previously, despite these improvements
in breast appearance some element of breast ptosis does re­
cur over time in most patients. Therefore patients request­
ing this procedure must be aware of this and accepting of it.
Patients who desire a significant increase in upper pole
fullness typically require an implant as an adjunct to the
mastopexy procedure. Although implant technology has
continued to improve and the safety of implants has been
established, implants too change over time. In addition to
capsular contracture, the inherent risks of implant place­
ment include stretching or attenuation of overlying tissue
and the periprosthetic capsule space in which the implant
resides, producing problems such as lower pole stretch, im­
plant malposition, and some element of nipple–areola mal­
position. These sequelae are not uncommon. Capsular con­
tracture is still the most common adverse effect of implant
placement. Despite this risk, the popularity of single-stage
augmentation mastopexy (both procedures done simultane­
ously) continues to increase.
CHAPTER
35

SECTION V THE BREAST
582
tion to breast history and current breast health along with
an aesthetic analysis of breast form and aesthetic anatomy
is critical. The height, weight, weight stability, number of
pregnancies, size change of the breasts during pregnancy
and breast-feeding, changes related to either weight fluc­
tuations or pregnancy, and any history of previous breast
incisions and previous breast procedures are important to
investigate thoroughly.
Mammograms are performed in patients according to
American Cancer Society guidelines. I insist on a mammo­
gram for all patients who are older than 40 years of age. In
addition I commonly request a mammogram at a younger
age if there is a strong family history of breast malignancy.
Most patients who present for mastopexy are in good
health; however, a general medical evaluation including a
careful cataloguing of medications, allergies, and complica­
tions after any previous surgery or anesthetic administration
is important. I ask patients to tell me everything they take
on a daily basis, including supplements. Cigarette smoking
and tobacco use of any kind is a contraindication to masto­
pexy in my practice.
Patient Examination
The patient is examined in the upright and supine posi­
tions. In the former position the surgeon must evaluate the
general shape of the breasts; the breast volume, weight,
and density; the presence of any asymmetries; and nipple
position relative to both the breast volume and inframa­
mmary fold (IMF). The relationship of the nipple position
to the IMF is a very important guideline for the selection
of technique. This was first pointed out and published by
Regnault in the 1970s.2 This relationship allows the plastic
surgeon to classify the ptosis (Fig. 35.1), and this serves as
a guideline for procedure selection2,3 (Table 35.1). Although
there are other important determinants for the optimal
procedure, including the elasticity of the breast skin and
parenchyma and the amount of tissue that overhangs the
IMF, the nipple–breast gland–IMF relationship has stood
the test of time.2
It is routine in my practice to quantitate important
breast dimensions using a tape measure to analyze and re­
Avoiding Unfavorable Results
and Complications in Mastopexy
and Augmentation Mastopexy
Summary Box
Common Unfavorable Results in Mastopexy
and Augmentation Mastopexy
Mastopexy
•• Recurrent ptosis
•• Poor scar healing
•• Breast asymmetry
•• Nipple malposition
•• Nipple–areola asymmetry
•• Combinations of these
Augmentation Mastopexy
•• Tissue-related
○
○Poor healing and poor scars
○
○Breast asymmetry
○
○Nipple–areola asymmetry
○
○Recurrent ptosis
○
○Combinations of these
•• Implant-related
○
○Capsular contracture
○
○Implant malposition
○
○Ripples
○
○Ridges
○
○Folds
Preoperative Planning and Patient
Selection
From the standpoint of appropriate planning and patient
selection in mastopexy, careful patient evaluation in rela­
Fig. 35.1 The conditions of glandular ptosis. (a) No ptosis. (b) Pseudoptosis. (c) First degree (mild). (d) Second degree (moderate). (e) Third
degree (severe). (Reproduced from Jones GE. Bostwick’s Plastic and Reconstructive Breast Surgery. 3rd ed. New York: Thieme Medical
Publishers; 2010.)
a
b
c
d
e

583
Chapter 35 Mastopexy and Augmentation Mastopexy
cord topographic features of the breast, which are measured
from fixed landmarks. These include the base width of the
breasts, the distance from the suprasternal notch to the nip­
ple, and the distance from the IMF to the nipple without
stretching the tissues and with the breast tissue placed un­
der stretch. These are recorded on a data sheet in each pa­
tient’s chart3 (Fig. 35.2).
Parenchymal elasticity and skin elasticity are difficult to
precisely define, but they determine the ability to which the
breast can be reshaped and the propensity of the reshaped
breast tissue to maintain the new shape. A very important
maneuver to help define this is one in which the surgeon gen­
tly compresses the lower pole of the breast to move tissue
to the upper pole (Fig. 35.3). The ability to transpose tissue
from the inferior portion of the breast in the area of the lower
Table 35.1 Classification of ptosis by Regnault
Diagnosis
Description
Treatment
Pseudoptosis; also called
glandular ptosis
Loose, drooping skin, but nipple is
above submammary fold
Augmentation mammaplasty
First degree (minor)
Nipple at submammary fold
Augmentation mammaplasty with or without
limited mastopexy
Second degree
(moderate)
Nipple below submammary fold but
remains above lowest contour of breast
Mastopexy—usually vertical and horizontal
skin excision required with or without
augmentation mammaplasty
Third degree (severe)
Nipple at lower contour
Mastopexy—major skin resection plus volume
augmentation or redistribution with or
without augmentation mammaplasty
Source: From Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg 1976;3(2):193–203.
notch
IMF
MCP
Breast width
Anterior
axillary line
Fig. 35.2 The important aesthetic breast dimensions for patients
interested in mastopexy. (Modified from Jones GE. Bostwick’s Plas­
tic and Reconstructive Breast Surgery. 3rd ed. New York: Thieme
Medical Publishers; 2010.)
Fig. 35.3 Digital compression of the lower pole of the breast in a
patient with good parenchymal elasticity produces fullness in the
upper pole of the breast, as seen in this photograph.
pole to the upper portion of the breast by gently compressing
the lower portion helps define the parenchymal elasticity and
aids in procedure selection. For example, if the maneuver il­
lustrated in Fig. 35.3 produces a nice bulge or roundness in
the upper pole, the patient is most likely an excellent candi­
date for a vertical glandular reshaping and a vertical masto­
pexy. If this maneuver fails to produce an easily discernible
bulge, then additional support measures using deepithelial­
ized skin segments for anchoring breast tissue, parenchymal
flaps, or parenchymal suturing may be necessary in placing
an implant to add fullness to the upper pole.
Careful evaluation of volume loss in the upper outer
aspect of the breast and the presence or absence of striae,
along with the general condition of the skin, gives the sur­
geon an estimate of the breast skin elasticity and provides

SECTION V THE BREAST
584
mal and skin elasticity who desires a significant increase
in upper pole fullness is likely better served by the place­
ment of an implant at the time of her mastopexy.2,4–7 The
breast dimensions in terms of base width and height and
the patient’s goal for postoperative size will provide the
best guide to implant selection. The planned skin incisions
for a mastopexy are determined by the amount and excess
of skin and the dimensions in which the skin excess exists.
The patient in Fig. 35.5 had an augmentation mastopexy
procedure and maintained a good aesthetic outcome after
2 years.
Doctor–patient communication is important in every
elective plastic surgery procedure and ideally forms the
foundation of a solid surgeon–patient relationship. Such
a relationship is important in all areas of surgery and has
many benefits such as sustaining confidence at times when
complications or untoward results follow a procedure. It has
been a key component of my practice over the past 3 de­
cades.
Therefore to minimize complications and patient dissat­
isfaction, it is incumbent upon the breast plastic surgeon to
valuable information about the degree of skin tighten­
ing necessary in both the vertical and horizontal planes to
achieve shape change. This also helps with skin incision pat­
tern selection. The breast evaluation is completed with the
patient in the supine position carefully palpating for any
masses or thickening in either breast or the axilla.
The evaluation allows the plastic surgeon to formulate a
surgical plan that is guided by the patient’s goals. A patient
who does not desire significant increase in surgical volume
and has good breast tissue elasticity, as confirmed with the
maneuver illustrated Fig. 35.3, is most likely a good candi­
date for a mastopexy alone, and often this can be carried
out using a short-scar technique. For example, the patient
shown in Fig. 35.4 underwent a vertical scar procedure us­
ing the Lassuss approach without pillar undermining using
a superior dermal glandular pedicle. The undersurface of the
pedicle was imbricated into the upper pole and was fixed to
the pectoralis muscle fascia by multiple “pexy” sutures of
2–0 coated Polyglycolic acid.
Conversely, a patient with obvious significant loss of
upper pole volume and compromised breast parenchy­
a
b
c
d
Fig. 35.4 Mastopexy. (a,b) Preoperatively, this patient had second degree breast ptosis. (c,d) Result 24 months after bilateral vertical mas­
topexy using superior dermal glandular pedicle mastopexy.

585
Chapter 35 Mastopexy and Augmentation Mastopexy
ensure that the following conditions exist in the consulta­
tion and treatment of every mastopexy patient:
•• Realistic patient goals and expectations
•• Appropriate procedure selection, including implant
selection
•• Preoperative communication with the patient about
potential complications, inevitable sequela, and the
possible need for unplanned additional surgery
•• Well-planned and well-executed surgery
An old surgical adage is, “A surgeon who has very few com­
plications is probably not doing very much surgery.” Even
with the best preparation and care, complications occur.
Their management is discussed in the next section.
Managing Revision Mastopexy
A revision of a mastopexy may become desirable because of
recurrent ptosis, poor scar healing, breast asymmetry, nip­
ple position, nipple–areola asymmetry, or combinations
a
b
c
d
Fig. 35.5 Augmentation mastopexy. (a,b) Preoperatively this patient had second degree breast ptosis. (c,d) Results 24 months after bilat­
eral vertical augmentation mastopexy using superior dermal glandular pedicle mastopexy.
of these. The surgeon must carefully listen to the patient’s
chief complaint. A careful understanding of the chief com­
plaint and the patient’s areas of disappointment and goals
combined with a thorough evaluation as outlined previ­
ously will typically allow the surgeon to formulate a good
plan to address the problem.
As noted, it is important for the surgeon to evaluate the
position of the patient’s breast gland on the chest wall. This
has been referred to as the “breast footprint.” Patients are
either high breasted, midbreasted, or low breasted. It is very
difficult, if not impossible, to permanently move the breast
footprint. This is important to point out to a patient who
believes that her breasts are low and wishes them to be el­
evated.
An evaluation of breast parenchymal volume and degree
of ptosis is important. This includes an evaluation of glandu­
lar elasticity as illustrated in Fig. 35.3. In envelope elastic­
ity is also important to note. The surgeon must look at the
position of previous scars and the scar quality. The evalua­
tion includes areas of previous skin loss. The position of the
nipple relative to the breast gland is a key aesthetic compo­

SECTION V THE BREAST
586
cluded a superior dermal glandular mastopexy performed
using a vertical technique8–13 (see Fig. 35.6c).
The patient appeared to have satisfactory transposition
of her breast gland on the operating table (see Fig. 35.6d),
but the procedure was complicated by skin loss in both the
periareolar and vertical incisions and by progressive spread­
ing of the areola and loss of upper pole fullness. The patient
developed widened scars that were hypopigmented and a loss
of correction with recurrent ptosis at 1 year (see Fig. 35.6e,f).
At 18 months postoperatively I planned a revision of her
mastopexy that included a revision vertical mastopexy with
resuspension of the gland to the pectoralis major muscle fas­
cia using multiple sutures between the deep surface of her
breast parenchyma and the anterior surface of the pectoralis
major muscle (see Fig. 35.6g,h). I was able to achieve resus­
pension of her parenchyma and downsizing of her nipple–
areola complex using a permanent Gore-Tex suture.
nent of a youthful breast. It must be evaluated in patients
seeking both primary mastopexy and revision mastopexy.
The position of the nipple relative to the IMF and the inferior
breast gland including how much tissue overhangs the fold
is important. As previously noted, a thorough breast exami­
nation and evaluation of the patient’s most recent mammo­
gram results and their official interpretation by a radiologist
is important.
The patient in Fig. 35.6 demonstrates a number of errors
I committed during a primary procedure that led to revision
mastopexy. The 36-year-old nulliparous woman presented
for a breast uplift. She had profound third-degree mam­
mary ptosis. She was athletic and exercised regularly, and
her weight was stable. She stated that the appearance of her
breast was a hereditary characteristic and she did not desire
an implant. She had slightly compromised skin elasticity but
good breast glandular elasticity. The plan and procedure in­
a
b
c
d
Fig. 35.6 (a,b) Preoperatively this patient had third degree breast ptosis. (c) Preoperative markings for superior dermal glandular pedicle
mastopexy. (d) Right breast reshaping with mastopexy, including pexy sutures from the posterior surface of the breast to the pectoralis
major muscle.
Continued

587
Chapter 35 Mastopexy and Augmentation Mastopexy
pole. The patient sustained skin loss that healed with wide
hypopigmented scars. I maintained very close contact with
the patient throughout this period of wound healing. In the
revision operation the patient still did not wish to have an
implant, but this procedure was more successful. The patient
was instructed to support her breasts with a bra at all times
An analysis of this case reveals multiple areas for learn­
ing, including failure to adequately suspend the breast pa­
renchyma from the chest wall and to support this suspen­
sion using the pillars in the lower pole of the breast. Some
consideration might have been given to resection of breast
tissue in the lower pole and placing an implant in the upper
e
f
g
h
i
j
Fig. 35.6, cont’d (e,f) At 12 months postoperatively she had recurrent ptosis, areola widening, and wide scars after skin loss along the ver­
tical incision. (g,h) Revision circumvertical mastopexy at 18 months postoperatively with multiple pexy sutures in the upper pole for supe­
rior breast imbrication. Pexy sutures were used to attach the posterior surface of the breast to the pectoralis major muscle. (i,j) Results at
7 years postoperatively.

SECTION V THE BREAST
588
portant. The quality of the soft tissue in regards to elasticity
and to thickness of the soft tissue envelope, specifically in
relationship with the underlying implant, is also important
for the plastic surgeon to note.
A plan for the revision procedure is assembled; it is
important for the surgeon to teach the patient about the
limitations, risks, and possible contraindications with cur­
rent medications. When an implant is involved it is im­
portant to provide the patient with a “full implant dis­
closure,” carefully reviewing the surgical risks, cosmetic
risks, and inherent risks of breast implants. The latter in­
cludes the problems of capsular contracture (which re­
mains an unsolved problem with implant surgery), im­
plant failure, and the possibility of unplanned additional
surgery—which rarely occurs immediately after the revi­
sion procedure but has a relatively high incidence over
several decades.
At this time the surgeon should also present the prac­
tice revision policy to the patient verbally and in writ­
ing. Time invested with the patient is critical for patient
education.
The patient in Fig. 35.7 was a 49-year-old woman who
had augmentation mastopexy 6 years prior that included
the subglandular placement of 286-mL round, moderate-
profile silicone gel breast implants using a vertical scar pat­
for a month; she showed good healing and maintenance of
shape during this time.
Managing Revision of
Augmentation Mastopexy
Revision of augmentation mastopexy can be surgically
separated into (1) tissue-related indications, which include
poor healing and poor scars, breast asymmetry, nipple–
areola asymmetry, recurrent ptosis, and combinations of
these, and (2) implant-related indications, which include
capsular contracture, implant malposition, ripples, ridges,
or folds.14 Two notable publications regarding this topic are
those by Stevens et al7 and Calobrace et al.6
I always require two visits for augmentation mastopexy
consultation. Doctor–patient communication is critical in
many spheres of revision plastic surgery and perhaps is most
critical for augmentation mastopexy. The initial evaluation
includes noting the implant position, the level of the cap­
sule, the degree of encapsulation, and the position of the
soft tissues relative to the implant. In other words the sur­
geon must first assess the gravitational settling of the tissue
away from the implant, producing the waterfall deformity.
The position of the nipple related to the breasts is also im­
a
b
c
d
Fig. 35.7 Revision augmentation mastopexy. (a) Encapsulated silicone gel breast implant (SGBI). (b) Total periprosthetic capsulectomy. (c)
Closure of the subglandular space. (d) Tailor-tacking of skin flaps.
Continued

589
Chapter 35 Mastopexy and Augmentation Mastopexy
was followed by “tailor-tacking” to guide skin excision. The
excision of a small portion of breast gland from the lower
pole on both sides completed the procedure (see Fig. 35.7c).
Tailor-tacking is key in helping to finalize the surgical inci­
sions (see Fig. 35.7d).
The results at 3 years (see Fig. 35.7e,f) demonstrate a
markedly improved overall breast shape. The left breast ap­
pears slightly smaller than the right in volume, but the rela­
tionship of the implant to the overlying soft tissue, including
the nipple–areola complex, is dramatically improved. The
implants demonstrated softness and no capsular contrac­
ture. This appearance was maintained at 7-year follow-up
(see Fig. 35.7g,h).
Patients who experience suboptimal tissue quality in
the form of markedly decreased skin and breast parenchy­
mal elasticity also may require revision. The patient in Fig.
35.8 is a 36-year-old nulliparous woman with generalized
soft tissue laxity, second degree mammary ptosis, and in­
adequate upper pole breast volume. She desired a combina­
tion of increased volume in the breast and a more youthful
appearance.
tern. She presented with dissatisfaction related to bilateral
capsular contracture (Baker 3, the most advanced degree of
capsular contracture) and breast asymmetry related to soft
tissue settling away from the implant. She desired softer and
more uplifted breasts.
A careful patient evaluation was carried out that in­
cluded understanding her goals for her breast size and
shape, a full breast evaluation as discussed previously, and
obtaining the previous operative reports. She had low nipple
position, a flattening of the anterior contour of the breasts,
a breast asymmetry with soft tissue settling of an implant
which was good on the left side than the right.
The surgical plan included explantation (see Fig. 35.7a)
through a vertical incision, total periprosthetic capsulec­
tomy, pocket reassignment to a new dual-plane position
(see Fig. 35.7b), closing of the subglandular space, implant
replacement with a device that would provide greater pro­
jection, elevating the nipple–areola complex, and tightening
the lower pole of the breast tissue.
The pocket reassignment to a dual-plane position and
placement of shaped, textured, highly cohesive gel implants
e
f
g
h
Fig. 35.7, cont’d (e,f) Results at 3 years postoperatively. (g,h) Results at 7 years postoperatively.

SECTION V THE BREAST
590
a
b
c
d
e
f
Fig. 35.8 (a,b) A 36-year-old nulliparous woman with second degree mammary ptosis and loss of upper pole breast volume. (c) Planned
incisions are marked for circumvertical augmentation mastopexy with planned nipple elevation to 4 cm above the inframammary fold.
(d) Intraoperative tailor-tacking of the skin envelope after placement of 300-mL moderate-profile saline implants. (e) The patient had sat­
isfactory results 8 months postoperatively. (f,g) At 14 months postoperatively, the patient had implant malposition on the right breast and
lower pole stretch on the left breast.
Continued

591
Chapter 35 Mastopexy and Augmentation Mastopexy
aspect of the capsule done with sutures achieved reposition­
ing with 2–0 Prolene suture. The tailor-tacked skin closure
of the skin provided a good nipple-to-implant relationship
and a much improved appearance, which was maintained
for at least 24 months (see Fig. 35.8i,j) after pocket modifi­
cation, skin envelope tightening, and a 360-mL silicone gel
implant. The patient was pleased with the outcome.
Conclusion
Revision mastopexy and revision augmentation mastopexy
are highly challenging procedures. It is critical to perform a
careful aesthetic analysis of the breast evaluating all of the
An augmentation mastopexy with a circumvertical in­
cision pattern and adjustment of her nipple position to 4
cm above her IMF was planned (see Fig. 35.8c). A 300-mL
moderate-profile saline implant was placed in a dual-plane
pocket and a tailor-tacked mastopexy was carried out (see
Fig. 35.8d). This procedure resulted in good upper pole full­
ness and a reasonable outcome at 8 months postoperatively
(see Fig. 35.8e). However, approximately 1 year later she
had evidence of lower pole stretch on the right side (see Fig.
35.8f) and lateral malposition on the left. This was addressed
by an excision of skin in the IMF region on the right with
tightening of the capsule tissues using suture techniques
(see Fig. 35.8h). On the left side an elevation of the inferior
g
h
i
j
Fig. 35.8, cont’d (f,g) At 14 months postoperatively, the patient had implant malposition on the right breast and lower pole stretch on the
left breast. (h) Markings for a planned bilateral skin envelope modification and alteration of the periprosthetic capsules bilaterally and a
change to 360-mL silicone gel breast implant (SGBI). (i,j) At 18 months postoperatively she maintained excellent improvement.

SECTION V THE BREAST
592
This is an area of surgery where gratifying improvement
is often possible. The patient must understand that results
are not permanent. It has been my experience that most pa­
tients who understand and are accepting of these realities
are usually satisfied with the outcome of treatment. I find
that, as in many areas of revision surgery, in the arena of re­
vision augmentation mastopexy it is best for the surgeon to
“underpromise and overdeliver.”
anatomic components. Good presumptive planning is es­
sential. The plastic surgeon must then apply the principles
of aesthetic breast surgery and integrate them to achieve
a better breast shape.14 Implants should not exceed 450
mL in volume whenever possible. Tailor-tacking allows the
surgeon to adjust the original plan and is essential to help
with the repositioning of the soft tissue envelope relative to
the underlying implant.
References
1. Wise RJ. A preliminary report on a method of plan­
ning the mammaplasty. Plast Reconstr Surg (1946)
1956;17(5):367–375
2. Regnault P. Breast ptosis. Definition and treatment. Clin
Plast Surg 1976;3(2):193–203
3. Jones GE, ed. Bostwick’s Plastic and Reconstructive Breast
Surgery, 3rd ed. New York, NY: Thieme Medical Publish­
ers; 2010
4. Spear SL, Boehmler JH IV, Clemens MW. Augmentation/
mastopexy: a 3-year review of a single surgeon’s practice.
Plast Reconstr Surg 2006; 118(7, Suppl)136S–147S, dis­
cussion 148S–149S, 150S–151S
5. Regnault P. The hypoplastic and ptotic breast: a combined
operation with prosthetic augmentation. Plast Reconstr
Surg 1966;37(1):31–37
6. Calobrace MB, Herdt DR, Cothron KJ. Simultaneous
augmentation/mastopexy: a retrospective 5-year re­
view of 332 consecutive cases. Plast Reconstr Surg
2013;131(1):145–156
7. Stevens WG, Macias LH, Spring M, Stoker DA, Chacón
CO, Eberlin SA. One-stage augmentation mastopexy: a
review of 1192 simultaneous breast augmentation and
mastopexy procedures in 615 consecutive patients. Aes­
thet Surg J 2014;34(5):723–732
8. Lassus C. The Lassus vertical technique. Aesthet Surg J
2011;31(8):897–913
9. Lassus C. Breast reduction: evolution of a technique—a
single vertical scar. Aesthetic Plast Surg 1987;11(2):107–
112
10. Lejour M. Vertical mammaplasty and liposuction of the
breast. Plast Reconstr Surg 1994;94(1):100–114
11. Lejour M. Vertical mammaplasty: update and appraisal
of late results. Plast Reconstr Surg 1999;104(3):771–781,
discussion 782–784
12. Hall-Findlay EJ. A simplified vertical reduction mamma­
plasty: shortening the learning curve. Plast Reconstr Surg
1999;104(3):748–759, discussion 760–763
13. Graf R, Reis de Araujo LR, Rippel R, Neto LG, Pace DT, Biggs
T. Reduction mammaplasty and mastopexy using the ver­
tical scar and thoracic wall flap technique. Aesthetic Plast
Surg 2003;27(1):6–12
14. Shestak KC. Reoperative Plastic Surgery of the Breast.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006
Discussion by M. Bradley Calobrace
Mastopexy and augmentation mastopexy are challeng­
ing operations, with reoperative rates for mastopexy
reported between 8.6 and 10.2% and augmentation
mastopexy between 15 and 25% in recently reported
studies.1–3 Even in the most experienced hands, avoid­
ance of unfavorable outcomes requires a thoughtful ap­
proach that will accomplish the patient’s goals while
minimizing postoperative complications. Just as in
breast augmentation, this is best accomplished through
incorporating a process that enhances outcomes and
includes patient education, preoperative evaluation
and planning, refined surgical technique, and postop­
erative care.4,5
The goal of a mastopexy is to reposition the breast
parenchyma and nipple–areolar complex above the in­
framammary fold (IMF) with the nipple–areolar com­
plex centered on the breast mound. There are myriad
techniques to accomplish this goal, and the ideal ap­
proach is related to not only the preoperative anatomic
considerations but also the aesthetic outcome desired
by the patient.
Common to most modern mastopexy techniques,
such as the vertical approach and its many variations,
has been breast shape creation through parenchymal
reshaping and fixation rather than through tightening
the skin brazziere alone. Techniques that depend on the
skin envelope tightening for final shape or leave excess
volume in the lower pole of the breast, such as the infe­
rior pedicle technique, ultimately result in loss of sup­
port over the long term with lower pole stretching and
bottoming out. The challenge in a mastopexy alone is
in achieving sustained upper pole volume. Techniques

593
Chapter 35 Mastopexy and Augmentation Mastopexy
such as parenchymal anchoring of the breast tissue up
on the pectoralis fascia (as is described in the chapter)
have been proposed. Additional parenchymal tech­
niques have included autoaugmentation with a paren­
chymal flap that can be sutured into the upper pole or
supported with a mesh or pectoralis sling, although the
ability to truly provide volume over the long term has
been challenged.6–8 Over the past few years, fat grafting
has gained in popularity as another technique capable
of achieving some level of improved fullness in the up­
per poles of breasts.
Certainly, it is universally agreed that long-term vol­
ume retention in the upper pole with mastopexy is most
reliably achieved through the placement of an implant,
either simultaneously with the mastopexy or as a staged
procedure.1–3,8,9 The challenges in accomplishing volume
expansion simultaneous with skin envelope reduction
are evident in the significant complication and reopera­
tive rates. It has been suggested that the complication
rates are more than additive when combining these pro­
cedures, but many publications have demonstrated the
safety of this combination and that the rates of compli­
cations are no greater than the sum of those for the two
procedures performed separately.2,3,9
The complications and unfavorable results can be
separated into tissue-based issues (in mastopexy and
augmentation mastopexy) and implant-related issues
(in augmentation mastopexy) (Table 35D.1). Mastopexy-
related complications include the following:
•• Recurrent ptosis
•• Pseudoptosis
•• Poor scarring
•• Breast and nipple asymmetry
Additional significant unfavorable outcomes include
skin flap and/or nipple–areolar complex ischemia and
necrosis. These complications are rare but can be disas­
trous to the final outcome and can lead to significant
patient hardship and dissatisfaction.10
Implant-based complications include capsular con­
tracture, implant malposition, ripples, ridges, and folds,
but additional issues such as implant device failure, dis­
satisfaction with implant size, hematoma, infection, and
seroma also occur. The additional parenchymal manip­
ulation with a mastopexy has the potential to increase
capsular contracture and infection because of implant
exposure to native breast tissue contamination com­
pared with an augmentation alone. The laxity of the
overlying tissue (especially in patients after weight loss)
can similarly increase the likelihood of implant malpo­
sition or rotation of shaped implants in combined pro­
cedures.
Avoiding Unfavorable Results
in Primary Mastopexy and
Augmentation Mastopexy
The main task in a primary mastopexy operation is se­
lecting the appropriate procedure to achieve an excel­
lent outcome and meet the expectations of the patient.
A discussion with the patient about her desired out­
come and “new look” helps determine the appropriate
approach. It is important to know what size breasts and
the desired shape she would like to achieve. Patients
desiring significant fullness in the upper pole with con­
siderable cleavage without a bra will require a proce­
dure that can achieve that look.
The preoperative evaluation, breast assessment, and
appropriate measurements provide guidance in select­
ing the procedure to achieve the desired result. The de­
gree of ptosis as described by Regnault11 based on the
relationship between the nipple–areolar complex and
the IMF provides only part of the information to for­
Table 35D.1 Unfavorable outcomes in mastopexy and augmentation
mastopexy
Tissue-related
(mastopexy and augmentation mastopexy)
Implant-related
(augmentation mastopexy)
Recurrent ptosis
Poor scarring
Pseudoptosis
Breast asymmetry
Nipple–areolar complex asymmetry
Skin flap necrosis
Nipple–areolar complex necrosis
Capsular contracture
Implant malposition
Wrinkling/ridges/folds
Device failure (rupture, fracture)
Dissatisfaction with implant size
Hematoma
Infection
Seroma

SECTION V THE BREAST
594
mulate a plan. The breast assessment for a ptotic breast
should include the following:
•• Degree of ptosis (relationship of the nipple–areolar
complex to the IMF)
•• Location of the nipple–areolar complex on the
breast mound
•• Amount of breast tissue overhanging the IMF
•• Nipple-to-IMF distance under stretch
The vertical excess is calculated to determine the
amount of vertical excessive tissue present. The vertical
excess is defined as the difference between the distance
from the new nipple position to original IMF position
and the distance from the new nipple position to new
IMF position. Vertical excessive skin can be addressed
in a variety of ways either with vertical mastopexy (in
which some of the vertical excess is redistributed be­
low the new fold as abdominal skin) or by resection.
The amount of skin required in this calculation is af­
fected by whether an implant is to be placed, in which
case the vertical excess would be calculated as less be­
cause more skin will be required to accommodate the
implant.
In patients with early ptosis (glandular ptosis,
pseudoptosis, or first degree ptosis), a breast augmen­
tation alone may be adequate to rejuvenate the breasts
if the nipple–areolar complex position is centralized
on the breast mound and there is not excessive lower
pole skin. However, when the nipple-to-IMF distance
under maximal stretch exceeds 10 cm or excessive lax­
ity is present as measured by a skin stretch of greater
than 4 cm, a mastopexy is more likely to be needed
to avoid excess lower pole relaxation and stretching
postoperatively.5
In patients who want to avoid an implant or who
have significant volume and/or firmness to the breasts,
a mastopexy with autoaugmentation of the lower cen­
tral pole tissue into the upper pole can provide mod­
est volume reliably (Fig. 35D.1). This tissue can be su­
a
b
c
d
Fig. 35D.1 (a,b) This 21-year-old woman with ptotic breasts desired correction without augmentation. (c,d) Results 1 year after
bilateral mastopexy with autoaugmentation.

595
Chapter 35 Mastopexy and Augmentation Mastopexy
tured into place, tunneled through a pectoralis sling,
or secured with a supportive mesh. Fat grafting in the
upper pole has also been very successful in achieving
some stable volume in the upper pole, with or with­
out an autoaugmentation. The placement of volume in
the upper pole using fat provides volume for coverage
or transition, but not necessarily rounded projection.
I have found upper pole volume and cleavage to be
most reliably produced by the use of an implant with
the mastopexy, either simultaneously or as a separate
procedure (Fig. 35D.2).
Most surgeons have historically believed these pro­
cedures are best accomplished separately to maximize
safety and provide the best long-term outcomes. More
recently, there has been a trend for a simultaneous ap­
proach.2,3,8,9 However, not all patients are necessarily ap­
propriate for a simultaneous procedure, even if the pa­
tient desires significant volume in the upper pole. The
surgeon must determine whether to perform a simul­
taneous or staged procedure based on each individual
patient’s risk factors. This can be critical to avoiding un­
favorable sequelae, such as recurrent ptosis, poor scar­
ring, or more disastrous nipple–areolar complex or skin
flap necrosis. Most of the procedures I perform are si­
multaneous, but relative indications for staging include
obesity (with body mass index greater than 30), neces­
sity for significant volume reduction, vertical skin excess
greater than 8 to 10 cm, and nipple elevation greater
than 5 to 6 cm.
My absolute indications for a staged procedure in­
clude patients who refuse to quit smoking and patients
with unrealistic expectations who are unwilling to ac­
cept a high revision rate.2 A recent publication demon­
strated that through a processed approach of evalua­
tion and treatment, limiting implant size, and selecting
a staged approach for ptotic breasts with vertical excess
greater than 6 cm, the reoperative rate could be signifi­
cantly reduced.5
a
b
c
d
Fig. 35D.2 (a,b) This 24-year-old woman had ptotic breasts. (c,d) Results 1 year after simultaneous augmentation mastopexy
with Sientra Classic–based shaped 400 cc moderate-profile implants.

SECTION V THE BREAST
596
Revision Mastopexy and
Augmentation Mastopexy
Managing unfavorable outcomes after a mastopexy,
with or without an augmentation, requires an even
greater level of scrutiny in preoperative planning and
expert surgical execution to achieve a successful out­
come and avoid a disastrous complication.10 The unfa­
vorable sequelae potentially requiring intervention and
management are outlined in Table 35D.1. The potential
procedures required to address those unfavorable out­
comes are listed in Box 35D.1.
Treatment of a complication commonly requires
using several of these maneuvers simultaneously to
achieve the best outcome, adding to the complexity of
these cases.
The management of implant-related complica­
tions is more straightforward than that for tissue-re­
lated complications. If the patient has good quality skin
and breast parenchyma, surgical treatment can usu­
ally be satisfactorily performed without undue risk to
the skin flaps. When performing implant-related pro­
cedures on a patient with a previous mastopexy, ac­
cess is typically through the vertical scar to provide
adequate access and visualization with minimal impact
on residual blood supply. Capsular contractures are the
most common complication; the occurrence may be
greater than with a primary augmentation because of
the additional exposure of the implant to breast duct
contamination during the mastopexy. The clinical pre­
sentation is typically a high-riding, superiorly malpo­
sitioned implant that is firm with ptosis of the breast
tissue off of the implant (snoopy deformity). Capsular
contractures can initially be managed medically, with
options including the administration of leukotriene in­
hibitors, oral vitamin E, antibiotics, manual displace­
ment massage, and ultrasound therapy. An ultrasound
device uniquely designed for the breast, such as the
Aspen System (Aspen Rehabilitation), may provide an
anti-inflammatory effect that can result in softening of
the breast and downgrading or resolution of the capsu­
lar contracture in some patients. Medical management
is most successful when initiated early. The standard
surgical treatment of a capsular contracture includes
a capsulectomy (partial or total), implant exchange be­
cause of biofilm contamination, pocket exchange, and
postoperative drainage. The addition of acellular der­
mal matrix has been shown to significantly reduce the
recurrence rate to approximately 1%.12
Implant malposition is the second most likely com­
plication and has many causes, but certainly the laxity
of the skin envelope with its propensity for stretching
in mastopexy patients is a contributing factor. Manage­
ment is directed toward the cause, but controlling the
pocket either by manipulating it (capsulorraphy or cap­
Box 35D.1
•• Secondary mastopexy
•• Implant exchange
•• Capsulectomy
•• Pocket control procedure
•• Pocket exchange
•• Soft tissue support
•• Fat grafting
Secondary Breast
Procedures

597
Chapter 35 Mastopexy and Augmentation Mastopexy
sular flap) or creation of a new pocket (such as a neo­
subpectoral or neosubglandular pocket) with or without
the use of soft tissue support will usually manage the
problem. Textured implants can provide stability and
reduce the likelihood of malposition, and thus I often
exchange a smooth implant for a textured implant in
revision cases.
Wrinkling or rippling generally represents failure
in the soft tissue coverage more than a failure in device
performance. The thinning breast tissue and skin with
associated breast laxity seen in mastopexy patients can
often lead to implant visibility and wrinkling. The treat­
ment is directed toward improving the implant–breast
tissue interface and interaction. If a textured implant or
saline implant is in place, placement of a smooth sili­
cone device can improve the wrinkling considerably. Im­
proved soft tissue coverage can be achieved by moving
a subglandular augmentation to a subpectoral position
with the addition of acellular dermal matrix or fat graft­
ing to the breasts. I have found acellular dermal matrix
useful for traction wrinkling in the upper pole of the
breast by providing control of the pocket through capsu­
lar reinforcement or as a caudal extension of the pecto­
ralis muscle when exchanging from the subglandular to
the submuscular pocket. However, an onlay of acellular
dermal matrix over the implant to provide soft tissue
thickness has proven less successful. Fat grafting into
the breast envelope overlying the implant is a powerful
and highly successful maneuver in resolving wrinkling
and rippling issues.
The management of tissue-related complications
(with mastopexy), including recurrent ptosis, asymme­
tries, and poor scarring, can be more challenging and
has inherently more risk involved. These procedures
generally involve some form of a secondary mastopexy,
which must be approached with extreme caution and
thoughtful planning to achieve a successful outcome
and avoid catastrophic complications. This is even more
significant when revising breasts that have been aug­
mented and lifted.10,13 This in part is because of the in­
evitable changes that occur to the overlying breast enve­
lope, with associated thinning and atrophy, which leads
to recurrent ptosis and an associated inadequate soft
tissue coverage. These patients may have had additional
procedures in the past, including capsulectomies and
capsulotomies for capsular contracture, that can like­
wise thin the soft tissue envelope.
Maybe even more significant is the effect previous
procedures potentially have on breast and nipple–are­
olar vascular supply. A thorough knowledge of the vas­
cular anatomy is imperative to safely plan a secondary
mastopexy. It is helpful to ascertain if possible the pre­
vious surgical procedures performed, which can guide
in planning the secondary mastopexy. The breast has a
robust blood supply with significant overlap supplied
by the internal mammary artery intercostal perfora­
tors and thoracoacromial and lateral thoracic arter­
ies. The internal mammary artery is dominant, and
the second and third superficial branches run super­
ficially 1 to 2 cm deep, providing the blood supply to
the superior (second), medial (third), and superome­
dial pedicles (second and third). The fourth intercos­
tal branch runs deep through Wuringer’s septum up
through the center of the breast and is the blood sup­
ply of the central pedicle. The inferior pedicle blood
supply is provided by this same fourth deep intercostal
branch as well as branches of the intercostal artery at
the level of the IMF. The lateral pedicle is supplied by
deep and superficial branches of the lateral thoracic
artery14 (Fig. 35D.3).

SECTION V THE BREAST
598
Fig. 35D.3 Blood supply to the breasts: The second superficial branch of the internal mammary artery (IMA) supplies the superior
pedicle, the third superficial branch of the IMA supplies the medial pedicle, the fourth deep branch of the IMA supplies the central
and inferior pedicle, and the deep and superficial branches of the lateral thoracic artery supply the lateral pedicle. (Reproduced
from Hall-Findlay EJ. Aesthetic Breast Surgery Concepts & Techniques. New York: Thieme Medical Publishers; 2011.)
Superficial branches
of the internal
mammary artery
Superficial branch of
the lateral thoracic artery
Thoracoacromial artery
Second
Third
Fourth deep branch of the
internal mammary artery
Fifth
Sixth
5
4
3
2
6
Lateral thoracic artery
(external mammary artery)
Fourth
Internal mammary artery
Superficial branch of
the lateral thoracic artery
Second
Third
Fourth
(deep)
Fifth
Superficial branches
of the internal
mammary artery

599
Chapter 35 Mastopexy and Augmentation Mastopexy
Knowledge of what blood supply was sacrificed dur­
ing previous procedures and what remains is important
in planning the design of the mastopexy. The blood sup­
ply is affected not only by the previous mastopexy de­
sign and implant placement, but also by ongoing soft
tissue thinning, atrophy, scarring, and the impact of ad­
ditional procedures such as capsulectomies, all resulting
in dramatically diminished blood supply to the soft tis­
sue envelope of the breast and nipple–areolar complex.10
It can sometimes be almost impossible to know what
reliable blood supply remains. It is quite possible to find
during a secondary mastopexy procedure that the only
blood supply remaining to supply the nipple–areolar
complex and skin flaps is random rather than axial. The
result of inadequate blood supply can have devastating
consequences, such as nipple–areolar complex or skin
flap necrosis (Fig. 35D.4). Respecting the limited blood
supply often present in revision cases and designing a
procedure to minimize this risk is critical. Using a reli­
able pedicle, often the superior pedicle, is preferable,
but limited undermining and incorporating wide areas
of vascularity in the design increases the probability of
adequate circulation. Limiting tension on incisions and
pressure on the nipple–areolar complex further mini­
mizes circulatory insult. When adequate circulation is
questionable during the procedure, sutures can be re­
leased and closure delayed. Topical nitroglycerin has also
been shown to enhance survival of the nipple–areolar
complex in compromised situations.
When managing tissue-related complications, issues
of poor scarring and minor asymmetries can be easily
managed with small-scar or periareolar revisions. More
extensive revision mastopexies are indicated for recur­
rent ptosis, which typically manifests as implants in ap­
propriate position but with the breast tissue stretched
and descending over the implant (snoopy deformity).
This can result from an inadequate lift procedure in the
primary operation, weight fluctuations, pregnancy, or
aging. This is more common with severely stretched and
lax skin envelopes, such as in patients who have lost sig­
nificant weight. The superior pedicle is generally used
in secondary mastopexies, and undermining of the skin
flaps is minimized. Often the entire area is deepitheli­
alized and imbricated rather than incised to preserve
vascularity, especially with extremely atrophic, thinned
skin flaps or when the previous operative approach is
unknown.
The more significant the mastopexy or reduction
previously and/or the presence of an implant, the more
compromised the blood supply. Thus the design should
incorporate as much vascularity as possible. A patient
with a capsular contracture can present similarly with
a superiorly malpositioned implant and ptosis of the
breast tissue off of the implant. Properly diagnosed, the
capsular contracture can be treated, often not requiring
a secondary mastopexy.
Another tissue-related sequela is the development of
pseudoptosis with inferior pole stretch deformity. This
is usually the result of lower pole thinning secondary to
an implant but can also result from bottoming out af­
ter a mastopexy or breast reduction. The design of the
mastopexy to correct the pseudoptosis is based on the
a
b
Fig. 35D.4 (a) Right nipple–areolar complex necrosis after primary simultaneous augmentation mastopexy. Superior pedicle
blood supply was inadequate because of severe breast laxity with a greater than 8 cm transposition of the nipple–areolar complex
superiorly. (b) Left nipple–areolar complex ischemia after secondary mastopexy with explantation.

SECTION V THE BREAST
600
stretched deformity. If the nipple–areolar complex is in
a good position and the vertical length is elongated, then
a simple horizontal wedge excision at the IMF (a smile
mastopexy) will be sufficient. If there is vertical and hor­
izontal laxity, an inverted-T below the nipple–areolar
complex (a sailboat mastopexy) can be performed for
correction. If the nipple–areolar complex position is also
low, then a more traditional inverted-T mastopexy with
nipple–areolar complex elevation is used.
In actuality, secondary mastopexy procedures are
rarely performed in isolation and are often part of a
combined revision breast procedure, such as with im­
plant exchange, capsulectomy, capsulorraphy, pocket
exchange, placement of soft tissue support, and/or fat
grafting (Fig. 35D.5). If the risks are excessive and it is
deemed unsafe to perform the mastopexy simultane­
ously, it may be appropriate to stage the operations.
Conclusion
Avoiding unfavorable results in mastopexy and aug­
mentation mastopexy is best accomplished by incor­
porating a process that focuses on patient education,
careful preoperative evaluation and planning, refined
surgical technique, and postoperative care. As was ac­
curately described in the chapter, good communication
with the patient, defining goals, and managing expec­
tations is critically important in these challenging pro­
cedures.
Even more difficult is managing unfavorable out­
comes of these procedures. Defining the complications
as tissue-related, implant-related, or often both can as­
sist in planning an approach that effectively addresses
the issues while optimizing safety. Most importantly,
knowledge of blood supply and the effects of the previ­
a
b
c
d
Fig. 35D.5 (a,b) This 45-year-old woman who had nine previous breast surgeries developed severe breast deformity with round
subglandular implants and window-shading of the pectoralis muscle. (c,d) Results 1 year after submuscular pocket exchange with
bilateral acellular dermal matrix placed as pectoralis caudal extensions and implant exchange to Natrelle Style 410 (Allergan) 400-
cc implants.

601
Chapter 35 Mastopexy and Augmentation Mastopexy
ous procedures is mandatory in secondary mastopexies
to avoid devastating consequences. As more and more
breast augmentations and breast lifting procedures are
performed each year, surgeons will undoubtedly see an
increasing demand for managing these unfavorable re­
sults. Fortunately, many advances in breast surgery, in­
cluding improved implant options, soft tissue support
(acellular dermal matrix or synthetic mesh), and fat
grafting, provide the surgeon many more tools to effec­
tively treat these issues. No matter how adept surgeons
are at managing these unfavorable sequelae, it is best to
remember that good surgical planning and execution in
the primary surgery and avoidance of unfavorable re­
sults is by far the best option!
References
1. Stephens WG, Stoker DA, Freeman ME, Quardt SM.
Mastopexy revisited: A review of 150 cases for safety
and efficacy. Aesthet Surg J 2007;27:150–154
2. Calobrace MB, Herdt DR, Cothron KJ. Simultaneous
augmentation/mastopexy: a retrospective 5-year re­
view of 332 consecutive cases. Plast Reconstr Surg
2013;131(1):145–156
3. Khavanin N, Jordan SW, Rambachan A, Kim JYS. A sys­
tematic review of single-stage augmentation-masto­
pexy. Plast Reconstr Surg 2014;134(5):922–931
4. Adams WP Jr. The process of breast augmentation:
four sequential steps for optimizing outcomes for pa­
tients. Plast Reconstr Surg 2008;122(6):1892–1900
5. Lee MR, Unger JG, Adams WP Jr. The tissue-based tri­
ad: a process approach to augmentation mastopexy.
Plast Reconstr Surg 2014;134(2):215–225
6. Graf R, Ricardo Dall Oglio Tolazzi A, Balbinot P, Pazio
A, Miguel Valente P, da Silva Freitas R. Influence of the
pectoralis major muscle sling in chest wall-based flap
suspension after vertical mammaplasty: ten-year
follow-up. Aesthet Surg J 2016;36(10):1113–1121
7. Hammond DC, O’Connor EA. The lower island flap
transposition (LIFT) technique for control of the up­
per pole in circumvertical mastopexy. Plast Reconstr
Surg 2014;134(4):655–660
8. Swanson E. A retrospective photometric study of 82
published reports of mastopexy and breast reduction.
Plast Reconstr Surg 2011;128(6):1282–1301
9. Stevens WG, Macias LH, Spring M, Stoker DA, Chacón
CO, Eberlin SA. One-stage augmentation mastopexy:
a review of 1192 simultaneous breast augmentation
and mastopexy procedures in 615 consecutive pa­
tients. Aesthet Surg J 2014;34(5):723–732
10. Handel N. Secondary mastopexy in the augmented
patient: a recipe for disaster. Plast Reconstr Surg
2006; 118(7, Suppl)152S–163S, discussion 164S–
165S, 166S–167S
11. Regnault P. Breast ptosis. Definition and treatment.
Clin Plast Surg 1976;3(2):193–203
12. Maxwell GP, Gabriel A. Efficacy of acellular dermal
matrices in revisionary aesthetic breast surgery: a
6-year experience. Aesthet Surg J 2013;33(3):389–
399
13. Stevens WG, Spring M, Stoker DA, et al. A review of
100 consecutive secondary augmentation/mastopex­
ies. Aesthet Surg J 2007;27(5):485–492
14. Hall-Findlay EJ. Aesthetic Breast Surgery Concepts &
Techniques. New York, NY: Thieme Medical Publish­
ers; 2011:67–98

602

Reduction Mammaplasty
Sabine Lovell, Yan T. Ortiz-Pomales, and Albert Losken
Macromastia can cause significant physical and psychologi­
cal detriment, negatively impacting women’s daily func­
tional capacity. Physical manifestations of breast hypertro­
phy can include back, neck, and shoulder pain; intertrigo;
and shoulder grooving from brassiere straps.1 Surveys dem­
onstrate a satisfaction rate of more than 95% after reduction
mammaplasty. Most patients report an improved quality of
life, self-esteem, and satisfaction with the surgery. This is
regardless of the amount of tissue removed during the oper­
ation or the patient’s preoperative body mass index (BMI).2
The surgery can positively affect a patient’s mental state
and be a stimulus for increased postoperative exercise and
weight loss.1,3 According to the Cosmetic Surgery National
Data Bank, breast reductions were the eighth most common
cosmetic surgery performed in the United States in 2014,
with a total of 114,170 surgeries completed.4 Although re­
duction mammaplasty is one of the most commonly per­
formed procedures in plastic surgery and has a low rate of
serious complications, the surgeon should be mindful of the
minor to more significant complications that can arise and
ways to potentially avoid, identify, and treat them when
necessary.
Avoiding Unfavorable Results
and Complications in Reduction
Mammaplasty
CHAPTER
36
Summary Box
Complications in Reduction Mammaplasty
•• Seromas and hematomas
•• Wound-healing issues and scars
•• Dog ears
•• Epidermal inclusion cysts
•• Asymmetry or recurrent macromastia
•• Nipple–areola complex congestion
•• Infection
•• Unplanned readmission because of pain, nausea
and vomiting, dizziness, or bleeding
Preoperative Considerations
Patient satisfaction is largely dependent on setting appro­
priate expectations in the preoperative evaluation. The fol­
lowing risk factors and their effects on surgical outcomes
must be discussed with patients before reduction mamma­
plasty. Patients should be informed that the overall com­
plication rate 6 months after surgery is approximately 19%
and that 9% of patients require operative intervention or
revision.5 This is regardless of the surgical technique used.
Complications are most common within the first 30 days
after the procedure.5
Disclaimers: The views expressed in this article are those of the au­
thors and do not necessarily reflect the official policy or position
of the Department of the Navy, Department of Defense, or the U.S.
government.
Dr. Yan Ortiz-Pomales is a military service member (or employee of
the U.S. government). This work was prepared as part of his official
duties. Title 17, USC, x105 provides that “Copyright protection un­
der this title is not available for any work of the U.S. Government.”
Title 17, USC, x101 defines a U.S. government work as a work pre­
pared by a military service member or employee of the U.S. govern­
ment as part of that person’s official duties.

603
Chapter 36 Reduction Mammaplasty
final scar appearance, elderly patients, in fact, tend to have
an improved scar appearance. This is presumed to be a re­
sult of a reduced healing and inflammatory reaction, and
thus a decreased risk for hypertrophic scars or keloids.10
Juvenile Population
Reduction mammaplasty is the most effective form of treat­
ment of mammary hypertrophy in the adolescent popula­
tion. Appropriate patient selection, however, is of para­
mount importance. Adolescents (younger than 18 years of
age) with macromastia can experience the same detrimen­
tal emotional and physical symptoms as adults with the
condition. In addition, the psychosocial impact at this young
age can have lasting psychological consequences. Physical
symptoms and not aesthetic considerations should be the
major deciding factor in whether to proceed with surgery.11
Conditions associated with adolescent breast hypertro­
phy include juvenile gigantomastia, adolescent macromastia,
and obesity-related breast hypertrophy. Juvenile giganto­
mastia generally involves an extremely rapid growth (ap­
proximately 6 months) of breast connective tissue during
puberty, sometimes occurring with the onset of thelarche.11
After the initial rapid growth, patients then experience con­
tinued growth at a slower rate. Adolescent macromastia can
be equally distressing to the patient but involves a less se­
vere and more sustained steady breast growth.11 Adolescent
patients can also have obesity-related breast hypertrophy,
which is often difficult to distinguish from adolescent mac­
romastia. Obesity should not be an absolute contraindication
to adolescent breast reduction surgery. A study by Webb et
al12 reveals favorable results and high satisfaction rates in
both obese and nonobese patients. Patients report improved
self–body image and increased participation in social ac­
tivities and sports postoperatively.11 In addition to a com­
prehensive clinical assessment and determining a patient’s
degree of debilitation, strong parental and family support
and stability of breast size for 6 months to 1 year should be
considerations before operative intervention.11
Oncologic History
A thorough history must be obtained from the patient
regarding prior biopsies, presence of masses, and date of
last mammogram. There is no evidence-based data to con­
firm the benefit of unique screening protocols for women
undergoing reduction mammaplasty. The official recom­
mendations by the American Cancer Society, the American
College of Surgeons, and the American Congress of Obste­
tricians and Gynecologists are that average-risk women be­
gin obtaining annual screening mammography at 40 years
of age. Among women younger than 40 years, the evidence
supports screening mammography only for those who have
a high risk for breast cancer.13 It is generally recommended
to obtain a mammogram 6 to 12 months after surgery to
reestablish baseline findings on surgically altered breasts.14
Tobacco Use
The patient must be informed that the perioperative com­
plication rate is doubled in smokers. The surgeon should
document whether the patient is a current or previous
smoker. If the patient is a current smoker the surgeon
should discuss cessation techniques and provide resources.
The surgeon should also consider a less-aggressive dis­
section if the patient uses tobacco, because tobacco use
increases infection risk (odds ratio [OR] 2.1; p = 0.008).6,7
Some surgeons will not perform the operation if the pa­
tient is an active smoker; nicotine urine testing can be used
as confirmation of cessation. Chan et al8 found that wound-
healing problems showed statistical significance (p < 0.05)
between smokers (55.4%) and nonsmokers (33.7%). Sev­
enty-five percent of smokers admitted denying smoking
within 4 weeks of the operation. Wound healing complica­
tions are present in 33.3% of patients if they have stopped
smoking for more than 4 weeks, 52.6% of patients if they
stopped smoking less than 4 weeks before the operation,
and 67.7% of are active smokers.8
Obesity
A BMI of 35 kg/m2 or higher increases the risk of infec­
tions (OR 2.3; p = 0.00), seromas (OR 2.9; p = 0.03), fat
necrosis (OR 2.0; p = 0.002), and minor wounds (OR 1.7;
p = 0.001).6 Massive weight loss over a short amount of
time can make surgical planning more complex. An unsta­
ble breast mound coupled with inelastic skin may require
special techniques for glandular reshaping to achieve more
lasting results.9
Comorbidities
Cardiac disease increases the risk of fat necrosis (OR 5.3; p =
0.03) and the need of reoperation for scar revision (OR 3.0;
p = 0.04).6 Independent factors associated with wound de­
hiscence are tobacco and steroid use, wound classification
at the end of the case, postoperative abscess development,
deep surgical-site infection, increased BMI, and paraplegia
or quadriplegia.10
Increasing Age
A study by Manahan et al6 showed that age greater than
50 years confers increased risk for infection (OR 2.7; p =
0.003). However, a recent study by the American College
of Surgeons National Surgical Quality Improvement Pro­
gram10 found that in regards to plastic surgery procedures,
age does not confer an increased risk of wound-healing
complications. This retrospective review revealed that oth­
erwise healthy, elderly patients and younger patients have
the same risk of developing wound dehiscence.10 Aging
does cause a temporary delay in the healing process, but
it does not impair the quality of the final scar. In regards to

SECTION V THE BREAST
604
surgery is classically described as a “clean” operation with
an infection rate of less than 3.4%, but the use of preop­
erative antibiotics helps to further decrease infection rates
postoperatively.21
Venous Thromboembolism
Deep vein thrombosis (DVT) and pulmonary embolism
(PE) can be devastating and potentially life-threatening
complications. The American Society of Plastic Surgeons
Venous Thromboembolism (VTE) Task Force uses patient
risk stratification scores to help identify patients at high
risk for DVT through the 2010 Caprini Risk Assessment
Model.22 Important patient-related factors that have been
found to increase the risk for DVT/PE include a positive
cancer history, the use of oral contraceptive pills, hor­
mone therapy, or having a bleeding disorder such as factor
V Leiden deficiency. A score of 4 to 5 indicates a patient
is at increased risk for DVT. A patient with a score greater
than 8 has a very high risk of venous thromboembolism.23
Decreased venous return and venous pooling during induc­
tion of general anesthesia make clot formation the most
likely intraoperatively. The surgeon should consider giving
high-risk patients chemoprophylaxis preoperatively. Most
studies show no increased bleeding risk postoperatively
when chemoprophylaxis is used appropriately.23,24 Over a
10-year period involving 720 patients, Lapid et al24 found
that 5.1% of patients undergoing reduction mammaplasty
who had preoperative and postoperative administration
of low-molecular-weight heparin (LMWH) for DVT/VTE
prophylaxis required reoperation for hematoma.24 Of note,
none of these patients had a documented complication as­
sociated with DVT or VTE. Their study concluded that the
risk of potential hematoma development with administra­
tion of LMWH prophylaxis outweighs the morbidity and
mortality associated with DVT/VTE.24 Mechanical prophy­
laxis through the use of stockings or sequential compres­
sion devices (SCDs) increases tissue plasminogen activator
and stimulates fibrinolytic activity. SCDs should be applied
approximately 30 minutes before induction and continued
until the patient is ambulatory again after surgery.23
Blood Loss
Epinephrine infiltration intraoperatively (with hydrodis­
section), before reduction mammaplasty, has been shown
to decrease intraoperative blood loss and reduce the need
for blood transfusion.25 After the induction of general anes­
thesia, 60 mL of a solution containing 25 mL of 1% lidocaine
with 1:100,000 epinephrine is infiltrated into the skin and
subcutaneous tissues along the outlined sites of incision.26
The solution is also infiltrated into the surrounding breast
tissue itself. The benefit is twofold: (1) Lidocaine in the so­
lution provides local anesthesia while (2) epinephrine, as
a vasoconstrictor, helps to minimize intraoperative blood
loss.26 A blood loss difference of approximately 109 to 200
Oncoplastic Reduction
In appropriately selected patients with breast cancer, tu­
mor resection with oncoplastic reduction (versus tumor
resection alone) has been shown to result in fewer positive
margins on pathologic analysis and a decreased need for
reexcision.15 This is likely a result of the ability to take gen­
erous resection margins at the time of surgery. The plastic
surgeon can work alongside the general surgeon or onco­
logic breast surgeon to not only obtain substantial margins
at the tumor site but also improve overall cosmesis.15 Al­
though complications occur, they have not been found to
affect the initiation of adjuvant cancer therapy and are of­
ten managed conservatively.
Psychological Disturbances
Clinical features of anxiety and depression are present in
one third of women presenting with macromastia. Eating
disorders are also common. These conditions alone should
not preclude a patient from having a reduction mamma­
plasty operation. In fact, anxiety and depression rates de­
cline in a large proportion of patients postoperatively, and
patients experience improvements in self-esteem. In addi­
tion, eating behaviors as measured by the Eating Attitudes
Test have shown a trend toward improved eating habits
postoperatively.3,12
Breast-Feeding
Reduction mammaplasty can potentially interfere with
breast-feeding or the ability to produce an adequate milk
volume.16–18 In a study by Makki and Ghanem,18 31% of 164
women who underwent a reduction mammaplasty with
an average of 1,037 g excised from each breast reported
decreased nipple sensation. In this same study, 31 out of
the 36 women who became pregnant after the operation
reported successful breast-feeding.18 In a cohort of seventy-
eight women who underwent an inferior pedicle reduction
mammaplasty, Brzozowski et al17 found that 53% did not
attempt lactation postoperatively, 18% were unsuccessful,
19% exclusively breast-fed, and 10% used a combination of
breast-feeding and supplemental formula. Some of these
women were discouraged to breast-feed by health care
workers for unknown reasons. Women who undergo reduc­
tion mammaplasty should be encouraged to breast-feed ac­
cording to World Health Organization (WHO) guidelines.19
Intraoperative Concerns
Antibiotics
A meta-analysis of antibiotic prophylaxis in breast reduc­
tion surgery by Shortt et al20 demonstrated a 75% reduction
in wound infections with the use of preoperative antibiot­
ics (OR 0.25; 95% confidence interval [CI] 0.09–0.72). Breast

605
Chapter 36 Reduction Mammaplasty
upward projection of the triangle wedge to prevent superior
displacement of the nipple.26
Avoidance of Dog-Ears
“Dog-ears,” excess tissue at the ends of a wound that give
an out-pouched appearance, can result from closure of a
circular or asymmetrical wound. Dog-ears can have two
shapes—standing full-cone (excess tissue on bilateral
sides) or lying half-cone (excess tissue on a single side).29
The inverted-T scar (Wise pattern) and horizontal tech­
niques have the potential for dog-ears.28 A novel suturing
technique helps to decrease the appearance of dog-ears
without extending the incision. When the dog-ear is en­
countered, a three-bite absorbable suture is placed be­
tween the deep plane and the dog-ear skin margins. The
deep fascial plane is pierced by the first bite along the skin
suture axis (a few millimeters distal to the last cutaneous
stitch). The second bite pierces the dermis in one dog-ear’s
margin in a subcuticular fashion (entering at the level of
the deep bite exit and coming out 2 mm proximal to the
apex of the dog-ear. The third bite is carried out in a sub­
cuticular fashion in the other dog-ear’s margin and is sym­
metrical to the second one. The suture is then tied, focusing
on avoiding any purse-string effect. This technique helps to
flatten the dog-ear and anchor the projecting tissue to the
deep fascial plane29 (Fig. 36.2).
When there is excess tissue on a single side (asymmetri­
cal dog-ear), the first bite is the same as previously described
(pierces the deep fascial plane along the skin suture axis a
few millimeters distal to the last cutaneous stitch). The sec­
ond bite pierces the dermis in the flat skin edge and runs in
the dermis along a large bite in a subcuticular fashion and
comes out 2 mm proximal to the apex of the skin incision.
The third bite is again carried out in a subcuticular manner
along the whole dog-ear’s margin, with the entry and exit
sites symmetrical to the opposite skin margin. This suture is
then tied down while evenly distributing the tension29 (see
Fig. 36.2). Other described techniques include straight ex­
cision with scar lengthening, Burow’s triangle, hockey stick
or right-angle excision, M-plasty, S-plasty, V-Y advancement
flap, or triangular advancement flap.29
Nipple–Areolar Complex Congestion
Nipple–areolar complex (NAC) venous congestion can
be caused by inadequate preservation of venous drain­
age, pedicle constriction, or hematoma formation. Other
risk factors include a history of diabetes mellitus, obesity,
or tobacco abuse.30,31 NAC venous congestion can lead to
NAC necrosis or conversion to a free nipple graft that can
reduce lactation ability and sensation viability. Lewin and
colleagues’ retrospective analysis31 on 512 patients re­
vealed 3.1% of patients had partial areola necrosis and 0.6%
of patients had total areola necrosis within 30 days after
reduction mammaplasty.31 Diabetic patients had a notably
mL has been demonstrated with the use of the hydrodis­
section technique.25,26
Scar Prevention
Care should be taken to avoid excessive tension on the
incisions to decrease hypertrophic scarring.9 If possible,
incisions should be made parallel to natural skin creases
(Langer’s lines).27 The three most common reduction mam­
maplasty-associated scar patterns include the inverted-T
scar (Wise pattern), vertical scar, and the “no vertical scar”
technique (horizontal breast reduction) (Video 36.1).28
The operative technique should be based on the surgeon’s
comfort level and appropriate method, taking into account
the patient’s breast size and shape. The inverted-T scar is
the most widely used technique because of its versatility.
Periareolar, horizontal, and vertical scars are associated
with the Wise pattern. The vertical technique includes a
periareolar and vertical scar; however, it has a high rate
of revision.28 The horizontal breast reduction technique is
well-suited for breasts with significant ptosis but can be
challenging in extremely heavy-breasted women. Periareo­
lar and horizontal scars are associated with the horizontal
breast reduction. A prospective analysis comparing patient
preferences in regard to the three most common reduction
mammaplasty scar patterns demonstrated that mean pref­
erence ranking was significantly higher for the horizontal
scar pattern versus vertical and Wise patterns (p < 0.001).28
One method to potentially decrease tension, scarring,
and wound dehiscence involves incorporating inframam­
mary darting, in which a small triangular section of excess
tissue is left projecting along the mid-inframammary line
to decrease tension at the future “T-junction” site closure.26
The height of the triangle nears 0.5 cm and has an angle of
120 degrees. The base of the triangle lies on the inframa­
mmary line, and each side limb of the triangle is approxi­
mately 1 cm long26 (Fig. 36.1). Care is taken to minimize
Inframammary line
Fig. 36.1 The incorporation of inframammary darting along the mid-
inframammary line to minimize tension at the future site of closure.

SECTION V THE BREAST
606
Breast Contour
A reduction mammaplasty in combination with a mastopexy
may improve breast contour in patients with recent massive
weight loss. Certain techniques such as parenchymal plica­
tion can act as an internal sling to reduce the risk for breast
ptosis. Monofilament resorbable suture is placed into the
gland or into the dermis. This is typically overcorrected to
ensure settling into position. It may require releasing of the
dermis once the skin is redraped to avoid tethering.9
Another surgical technique particularly helpful in this
patient population involves dermal suspension. This secures
the breast mound to the chest wall. Skin flaps are elevated
and the glandular or deepithelialized tissue is secured to
the chest wall with 0–0 braided permanent suture. The tis­
sue can also be secured to the rib periosteum at the level of
the third or fourth rib for better fixation. The level depends
on the breast size and level of the inframammary fold. As
always, nipple position is important to ensure appropriate
shape and level of suspension.
Placing the nipple too high is difficult to correct and
should be avoided. Autoaugmentation is a surgical technique
using local dermoglandular and fasciocutaneous flaps to im­
prove breast contour and upper pole volume. Incorporation
of perforators into the flaps, subdermal plexus preservation,
and adherence to appropriate length-to-width ratios will
allow reliable transfer with minimal potential for fat necro­
sis or flap loss.9 The surgeon should preserve superomedial
breast tissue volume during glandular tissue resection to
enhance medial fullness and the overall aesthetic result and
to preserve blood flow from the second intercostal space
perforator of the internal mammary artery.26
increased risk of areola necrosis (OR 8.2; 95% CI 2.1–32.34,
p = 0.003). Larger reduction weights and increased supra­
sternal notch–to–nipple distance have also been correlated
with increased risk for NAC congestion or compromise (OR
1.38; 95% CI 1.20–1.60, p < 0.001).30,31 An increased notch-
to-nipple distance indicates a longer dermoglandular ped­
icle. This reflects a more tenuous blood supply to the NAC
given the distance required for perfusion.31 A superiorly-
based dermoglandular flap might not be the optimal opera­
tive technique when faced with a long suprasternal notch-
to-nipple distance.31
In cadaveric studies superomedial, medial, and inferior
pedicle techniques have been shown to be the most reliable
to have consistent venous drainage. If NAC is noted intra­
operatively, the surgeon should evaluate for tight sutures
that could be released, confirm there are no kinks on the
pedicle, or do an exploration for hematoma evacuation.31
Promising new technologies, such as the SPY Elite Intraop­
erative Perfusion Assessment System (LifeCell Corporation)
can provide the surgeon with real-time perfusion informa­
tion. This is helpful because the surgeon can immediately
resect skin or fat in the operating room if there is evidence
of skin or fat necrosis.32 Also, if an extremely large reduc­
tion is being performed and the keyhole incision has not
been made, perfusion findings can help the surgeon decide
between nipple preservation versus amputation. Unfortu­
nately, in most cases when nipple perfusion is poor after re­
positioning, there is little hope for salvage other than loosely
closing the incision.33 The use of topical nitroglycerin could
also have a role in preventing permanent ischemic changes
of the NAC, because it has been proven to decrease mastec­
tomy flap loss in patients undergoing mastectomy and im­
mediate reconstruction.33
Fig. 36.2 Two different patterns of dog-ear correction. (a) The
three-bite technique applied on the standing full-cone dog-
ear. (b) The three-bit technique applied on the lying half-cone
dog-ear. (Modified from Jaber O, Vischio M, Faga A, et al. The
three-bite technique: a novel method of dog ear correction.
Arch Plast Surg 2015;42[2]:223–225.)
Out
In
Out
In
a
b

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Chapter 36 Reduction Mammaplasty
of operation. Postoperative drainage also directly correlates
with the amount of tissue resected. If drains are placed, they
should remain in place until output is less than 50 mL in a
24-hour period.36 Nonresolving seromas can often be aspi­
rated in the surgeon’s office if necessary.37
Wound Healing and Scars
Common complications after breast reduction surgery in­
clude wounds and scars. Fortunately, wounds often resolve
with simple dressing changes or bedside débridement.
Rarely, wounds require reoperation or negative pressure
wound therapy. Anemia, vitamin B12 deficiency, low cal­
cium, and decreased albumin levels can impair wound heal­
ing.9 Vitamin supplementation and nutritional support can
help with the wound-healing process. It is best for a patient
to go into surgery with an optimized nutritional status to
decrease the risk for postoperative wound-healing compli­
cations. There is an approximate 2 to 3% occurrence of mi­
nor wound dehiscence postoperatively, and this is usually
located at the T-junction areas.35 These areas are at most
risk for ischemia, and therefore tight closure increases the
risk of wound-healing complications postoperatively.35 Ma­
jor wound dehiscence is more rare (less than 2%).34 Wound
dehiscence can be partial (such as “T-junction” breakdown,
most commonly) or total (requiring further operative pro­
cedures).35,38 For more serious wound-healing complica­
tions involving frank skin necrosis, débridement with split-
thickness skin graft (STSG) has been successful (Fig. 36.4).
Treatment of Scars
Scars, as defined by the patient or physician as widened, hy­
pertrophic, misshapen, misplaced, or asymmetrical, require
revision in approximately half of cases.6 Excessive scarring
can lead to patient dissatisfaction because of physical symp­
toms such as pruritus, stiffness, and tenderness. Patients
are also usually unhappy with the unpleasant aesthetic
outcome associated with excessive scarring. Psychosocial
disturbance can cause the patient anxiety or decreased
Surgical Drains
A retrospective review by Wrye and colleagues34 demon­
strated no increased benefit to using closed suction drains
for reduction mammaplasty. Their study mainly focused on
the inferior pedicle technique. Many plastic surgeons still
use drains, however, to prevent seroma and hematoma for­
mation. Placing drains is the surgeon’s choice and should
take into account individual patient factors.
Postoperative Complications and
Treatment
Seromas and Hematomas
Seromas and hematomas are the most common postopera­
tive complications from reduction mammaplasty. This is
likely because of the large tissue dissections through non­
anatomic planes.24 Seromas and hematomas can contribute
to increased pain, infection risk, and wound-healing com­
plications (Fig. 36.3). Gulcelik et al35 prospectively evalu­
ated complications associated with 286 reduction mam­
maplasty procedures in patients with and without breast
cancer. They found an approximately 5% risk for seroma
and 2% risk for hematoma regardless of cancer status.35
Gulcelik’s study35 revealed that a BMI greater than 30 kg/m2
was associated with an increased risk of postoperative
complications. Manahan et al6 found a higher incidence of
complications related to a BMI greater than 35 kg/m.
Although uncommon, seromas and hematomas may re­
quire secondary surgical procedures for evacuation. In pa­
tients who are at risk for increased postoperative drainage,
surgical drains could help decrease the incidence of sero­
mas and hematomas. Hypotension in the operating room
decreases intraoperative blood loss but increases the risk of
postoperative bleeding and hematoma development.24 Pa­
tients who have had superior and medially based pedicle re­
ductions appear to be at higher risk for postoperative drain­
age and may benefit from drain placement at the initial time
Fig. 36.3 Hematoma. (a) This 45-year-old woman had a left lumpectomy for breast cancer and bilateral superomedial reduction and de­
veloped a left breast enlargement on postoperative day 1. (b) Given its size, a decision was made to proceed with formal evacuation in the
operating room. (c) Her result is shown with good shape and symmetry at 1 year after completing left radiation therapy.
a
b
c

SECTION V THE BREAST
608
is used and the skin is not adequately deepithelialized. Im­
plantation of the keratinizing squamous epithelium within
the dermis can develop into a cyst filled with lamellated
keratin.39 Postoperatively it can present as a lump or recur­
rent infection in the cyst area. Although most resolve with­
out intervention, some necessitate excision.
Asymmetry
Autologous fat grafting is a popular component of revision
breast surgery. It is a safe and effective tool that can improve
contour, volume, and overall breast shape and symmetry. A
patient’s own fat can be harvested from a number of places,
most commonly the abdomen, thigh, and flank regions. The
most common locations for fat grafting in secondary breast
reconstruction are the upper and medial breast quadrants
to improve upper pole volume. After 6 months’ follow-up
patients reported an improvement of about 83%.40 The av­
erage volume of injection was 40 mL. Repeat fat injections
can be a consideration depending on patient preference
and the surgeon’s judgment.40
Postoperative Nipple–Areola Complex
Congestion
One of the most dreaded complications is NAC necrosis
(Fig. 36.5). Although rare (approximate 1% incidence), this
complication can be devastating for both the patient and
surgeon.35 Glandular flaps supply the NAC perfusion.35
When NAC congestion is noted postoperatively, nitroglyc­
erin paste or leeches can be considered. Leeches increase
venous output while neovascularization occurs.30 The me­
dicinal leech (Hirudo medicinalis) can help decrease venous
congestion by injecting salivary components that inhibit
platelet aggregation and the coagulation cascade.41 The
leech concomitantly extracts blood, and the wound oozes
after detachment of the leech. Possible complications from
medicinal leech therapy include infection and anemia.
These complications can be decreased with antibiotic pro­
self-esteem.27 Cutaneous scarring has a broad spectrum of
presentation. Scars can range from mature, flat linear scars
to abnormally raised and hypertrophic scars. Keloids rep­
resent the most extreme manifestation of scarring and are
divided into minor and major variants. Major keloids are
large and raised (more than 0.5 cm) and may be painful
and pruritic.27 Hypertrophic scars and keloids are distinct
entities; hypertrophic scars stay within the boundaries of
the original lesion, whereas keloids grow beyond the mar­
gins of the original wound.27 The patient should be notified
that with time hypertrophic scars tend to settle or become
less obvious.11 Conversely, keloids (minor and major) do not
spontaneously regress and commonly recur after excision.
Patients should be advised to minimize scar exposure
to sunlight postoperatively and keep the scar moisturized.
Silicone gel sheets, pressure garments, and intralesional cor­
ticosteroid injections have also been used as treatments for
excessive scarring.27 Laser therapy can help with decreas­
ing associated erythema. Surgical excision is sometimes
required. Of note, after surgical resection of keloids, a skin
graft, flap, localized radiotherapy, or intralesional cryo­
therapy is sometimes used to reduce the high risk of recur­
rence.27
Treatment of Dog-Ears
When noticed postoperatively, dog-ears can be monitored
with no further treatment29 (see Fig. 36.2). Often the edema
and prominence at the skin edges will decrease with time.
Observation rather than immediate surgical correction is
advised if the dog-ear height is 8 mm or less.29 Removal of
subcutaneous tissue and underlying fat or direct excision
is sometimes necessary to decrease the projection of the
dog-ear.29
Epidermal Inclusion Cyst
An epidermal inclusion cyst is a complication that can often
be avoided with careful operative dissection. There is the
potential for an epidermal inclusion cyst if a dermal pedicle
Fig. 36.4 Skin necrosis. (a) This 54-year-old woman had a bilateral inferior pedicle reduction and developed full-thickness flap necrosis on
the right side. This was débrided and covered with a split-thickness skin graft (STSG). (b) Her result is shown 6 months postoperatively.
a
b

609
Chapter 36 Reduction Mammaplasty
been a controversial topic because of concerns about the
viability of the NAC and a lack of consensus regarding how
much time to wait before reoperating.44–48 Ghareeb and
Losken49 reviewed a series of 37 patients who underwent
repeat reduction and evaluated the literature on this topic.
The average repeat reduction weight in their series was
226 g, and because most of the recurrent volume is often
in the lower pole, the most common pedicle was superior
with minimal nipple repositioning. When combining the
literature on 106 patients who had a repeat reduction, the
nipple complication rate was 2.9%. The data presented is
comparable to outcomes observed after primary breast re­
duction, which vary considerably in the literature. Cunning­
ham et al50 found a 3.6% incidence of nipple necrosis when
analyzing complication data from 179 patients enrolled in
the Breast Reduction Assessment: Values and Outcomes
multicenter controlled trial. Similarly, Dabbah et al51 found
a 4% incidence of necrosis in a series of 185 patients, and
Makki and Ghanem18 reported an 8% incidence in their se­
ries. Nipple loss in repeat reductions is likely lower because
very conservative nipple repositioning is usually required
and tissue is often wedged out with limited undermining.
Wedge-type resections and minimal nipple movement will
make this a safe technique regardless of the initial pedicle
design (Fig. 36.7).
phylaxis, improved wound care, and monitoring of hemo­
globin and hematocrit levels.41
Infections
As mentioned earlier, a patient’s use of tobacco negatively
affects postoperative wound healing and confers an in­
creased risk of infections.6,42 Gravante et al42 demonstrated
that the postoperative infection odds ratio for tobacco users
is 2.04. There is also a direct correlation with the amount
of tissue removed (OR 4.7; mean 0.9 kg versus mean 0.5 kg)
and postoperative infection risk.29,42 A longer suprasternal
notch–to–nipple distance is associated with increased in­
fection risk as well (p < 0.001).29 Wound infections can be
superficial or deep (Fig. 36.6). Superficial infections gener­
ally resolve with the use of antibiotics, whereas deep infec­
tions often require surgical drainage.38
Recurrent Macromastia
Recurrent macromastia is not uncommon, and asymmetry
after unilateral reduction in breast reconstruction can de­
velop in 18 to 26% of cases.42 Repeat reduction mamma­
plasty is occasionally required to treat asymmetry or re­
current symptomatic macromastia.43 The safety of this has
Fig. 36.5 Nipple loss, débrided and healed secondarily. (a,b) This patient had a bilateral superomedial reduction and developed left nipple
areolar necrosis and hematoma postoperatively. (c) This was managed with débridement and local wound care. (d) She eventually healed
with a significant loss of areolar size. Her left side is slightly smaller than the right. Because she has improvement of her symptoms of mac­
romastia and the asymmetry does not bother her, there is no plan for revision.
a
b
c
d

SECTION V THE BREAST
610
with no history of breast carcinoma), the frequency of de­
tection of invasive and ductal carcinoma in situ lesions was
0.2%. If a specimen is sent and findings are abnormal, the
patient should be informed and referred to the appropriate
specialist. The oncologic breast surgeon can discuss with
the patient further treatment, which sometimes necessi­
tates lumpectomy or mastectomy with or without sentinel
lymph node biopsies.52
Other Considerations
Atypical Pathologic Findings
Most surgeons do not submit the resected breast tissue to
pathology, because finding incidental cancer is almost neg­
ligible and margin status is almost impossible to determine
since the specimens are generally not anatomically marked.
Desouki et al52 found that in 2,498 specimens (in patients
Fig. 36.6 Skin dehiscence, closed with reapproximation. (a) This 32-year-old former smoker had a bilateral reduction that resulted in some
skin necrosis and dehiscence of her left breast vertical incision. (b) Once the patient was stabilized the wound was débrided in the operat­
ing room and readvanced without too much distortion of the nipple–areolar complex.
a
b
Fig. 36.7 Recurrent macromastia and unfavorable scars. (a) This 42-year-old female had a bilateral superomedial reduction with approxi­
mately 950 g removed per side. (b) She presented 2 years later and wished to be smaller. (c) The Wise pattern markings were cut and the
repeat reduction was performed using a short superior pedicle and removal of an additional 450 g per side. (d) She is shown 1 year after
repeat reduction with smaller breasts.
a
b
c
d

611
Chapter 36 Reduction Mammaplasty
Conclusion
Reduction mammaplasty can greatly improve a woman’s
quality of life physically and psychologically. Although it is
a commonly performed plastic surgery operation, compli­
cations can occur. Most are self-limiting, such as a seroma
or hematoma, but more severe adverse effects like NAC
congestion and nipple loss are possible. Patients should
be strongly advised to cease tobacco use and optimize co­
morbid conditions before surgery. Reasonable expectations
between the patient and surgeon should also be set. Ap­
propriate precautions such as preoperative antibiotics and
DVT prophylaxis help to decrease complication rates, and
special attention to detail to avoid dog-ears and asymme­
try improves patient satisfaction. If a complication occurs,
prompt recognition and appropriate management are cru­
cial components to successful outcomes.
Common Reasons for Unplanned
Readmission
Many cosmetic surgeries, including reduction mammaplasty,
are performed on an outpatient basis. Unplanned readmission
within 30 days for breast reduction surgery is around 1.30%. A
significant independent predictor of readmission is the length
of operative time (OR 1.40; 95% CI 1.08–1.81; p = .010).37 This
is likely because of a higher risk for complications, such as
pulmonary compromise, wound infection, and DVT, because
the operation time increases. Pain, nausea and vomiting, diz­
ziness, and bleeding are some of the most common causes for
readmission.37 Good communication between the surgeon,
anesthesiologist or anesthetist, and patient can help minimize
postoperative pain and nausea. The surgeon should also be
mindful to send the patient with the appropriate prescriptions
(pain medications, antiemetics) upon discharge.
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32. Losken A. Commentary on: safety of vertical augmenta­
tion-mastopexy: prospective evaluation of breast per­
fusion using laser fluorescence imaging. Aesthet Surg J
2015;35(8):950–951
33. Gdalevitch P, Van Laeken N, Bahng S, et al. Effects of ni­
troglycerin ointment on mastectomy flap necrosis in im­
mediate breast reconstruction: a randomized controlled
trial. Plast Reconstr Surg 2015;135(6):1530–1539
34. Wrye SW, Banducci DR, Mackay D, Graham WP, Hall WW.
Routine drainage is not required in reduction mamma­
plasty. Plast Reconstr Surg 2003;111(1):113–117
35. Gulcelik MA, Dogan L, Camlibel M, et al. Early complica­
tions of a reduction mammoplasty technique in the treat­
ment of macromastia with or without breast cancer. Clin
Breast Cancer 2011;11(6):395–399
36. Anzarut A, Edwards DC, Calder K, Guenther CR, Tsuyuki R.
Superior pedicle breast reduction techniques increase the
risk of postoperative drainage. Ann Plast Surg 2008;60(4):
367–371

613
Chapter 36 Reduction Mammaplasty
Discussion by Elizabeth J. Hall-Findlay
There are numerous preoperative considerations when
performing breast mammaplasty, including indication,
blood loss, preventing wound-healing problems, and
prevention and treatment of nipple–areolar necrosis.
This discussion addresses each of these areas.
Preoperative Considerations
Patient Selection
Patient selection is important in reducing the incidence
of complications. Despite patient denials, smokers have
more problems with healing. Obese patients can be an­
gry when they are told to lose weight first, but there
is good evidence and surgeon experience that obese
patients not only have more problems with infections
and wound healing, they also do not achieve nearly as
good a cosmetic result. Having a breast reduction may
not be the first step in helping them deal with the con­
sequences of their obesity.1
However, teenagers with macromastia deserve to
be considered for breast reduction if they are not sig­
nificantly overweight. Large breasts may prevent them
from participating in sports and can have lifelong effects
on their lifestyle habits. They may need another breast
reduction after they have finished puberty, but with the
safety of surgery currently, it is worth considering help­
ing this group of patients so they can develop healthy
habits early (Fig. 36D.1).
A breast reduction can help patients participate in
sports and exercise programs. However, adult patients
rarely change established habits. I did a study looking at
patients who gained weight after breast reduction sur­
gery, and the results were not surprising. One third of
patients lost some weight, one third stayed the same,
and one third gained weight. It was primarily the al­
ready-overweight patients who gained weight. Breast
reduction by itself will not suddenly inspire patients to
exercise.
Postreduction Breast-Feeding
Although patients need to know that they may have
problems breast-feeding—and some will prefer to wait
until after having children before undergoing surgery—
in one of the best studies on breast-feeding Norma
Cruz-Korchin2 showed that large-breasted patients had
only about a 60 to 65% chance of successfully breast-
feeding whether or not they had a breast reduction.
Both groups had to supplement with formula in about
25% of cases. Thus it may not be necessary to postpone
breast reduction surgery to increase the chances of be­
ing able to breast-feed.
Cancer Screening
Screening for breast cancer is a contentious topic. Many
surgeons follow the American Cancer Society (ACS) rec­
ommendation for screening after age 40 years, but con­
troversy (and backlash from radiologists) arose when
it altered its recommendations.3 The ACS 2015 guide­
Fig. 36D.1 This 13-year-old patient underwent three breast reduction procedures before she finished puberty. (a) She had 930 g
removed from the right breast and 710 g from the left breast along with 400 cc of liposuction. Typically the initially good result
becomes distorted as further breast growth occurs. (b) At age 15 years she underwent a second breast reduction with removal of
760 g from the right and 495 g from the left along with 250 cc of liposuction. (c) At age 17 years she underwent a third reduction
with removal of 165 g from the right and 210 g from the left along with 200 cc of liposuction. She could have avoided somewhat
unsatisfactory interim results by waiting until she was older, but her self-confidence improved after each reduction procedure.
a
b
c

SECTION V THE BREAST
614
lines now state that patients of average risk should be
screened starting at age 45 years, and that patients be­
tween ages 45 and 54 years should have annual mam­
mograms and patients older than 55 years should have
biennial mammograms. The Canadian Cancer Society
guidelines recommend screening every 2 years be­
tween the ages of 50 and 69 years.4 This makes it clear
that the guidelines are not fixed and are likely to change
over time.
Pathology
I have always sent the specimens for examination by a
pathologist—it is in fact required by law where I prac­
tice. The pathologist will take some routine samples but
will concentrate on any gross pathology. I believe that
most plastic surgeons do send the excised tissue for
examination.5 Although most teenagers would prob­
ably not need pathologic examination, our pathologists
make that determination after reviewing the patient’s
age, history, and gross examination.
Surgical Considerations
My training involved exposure to numerous techniques
for breast reduction, from the lateral wedge resection
of Dufourmentel and Mouly6 to the extensive under­
mining of Biesenberger.7 I trained with the horizontal
bipedicle of Strombeck,8 the lateral and medial pedi­
cles of Skoog,9 and the superior pedicle of Pitanguy10
and Weiner et al.11 The McKissock vertical bipedicle
technique12 made breast reduction safe and predict­
able and, as with most currently practicing surgeons,
many of us resorted to using only one of the vertical
pedicles. In much of the world, the inferior pedicle
with an inverted-T skin resection pattern became the
preferred technique.13,14 I experimented with the verti­
cal techniques of Lassus,15,16 Marchac and de Olarte,17
and Lejour et al,18 and I was able to prevent some of the
unfavorable results that were associated with breast
reduction.19,20 The principles for avoiding unfavorable
results or complications in breast mammaplasty be­
came clear in my practice (Box 36D.1).
Tension and Wound Healing
Tension is the enemy. Because the inverted-T inferior
pedicle technique relies on the skin brassiere to hold
the shape, wound-healing issues are common. The
skin closure is tight, and the T-junction is notorious for
breaking down. The vertical approaches using a supe­
rior,22 superolateral,23 or superomedial pedicle do not
rely on the skin brassiere but instead allow the skin to
Box 36D.1
•• Tension on the skin results in wound-
healing problems.
•• Cinching the vertical incision is ineffective
and results in wound-healing problems.
•• Tension on the parenchyma results in a
loss of breast shape over time.
•• It is best to remove the excess
parenchyma inferiorly and laterally.
•• Dermal flaps and slings do not work.
•• Blood supply to the true superomedial
pedicle is the safest.
•• Infiltration is best for the areas that
require liposuction, not the incisions.
•• The use of drains is controversial.
•• The Wise pattern21 is a good pattern for
the parenchyma and less so for the skin
pattern.
•• There are consequences of action and
consequences of inaction in the treatment
of impending nipple necrosis.
•• Repeat reduction should not involve
creation of a new pedicle.
•• The upper breast border is a better
landmark than the inframammary fold.
Principles for Avoiding
Unfavorable Results
and Complications in
Breast Mammaplasty
drape over a reshaped parenchyma.24,25 Skin closure
can be relatively loose. Early in my experience, my pa­
tients continued to have wound-healing problems be­
cause I still felt that I needed to keep the skin closure
tight. Many surgeons who are switching to vertical
techniques experience the same problems until they
realize that they do not need to rely on the skin to hold
the shape. Once I performed skin closures without ten­
sion, problems with wound healing became relatively
rare; they occur far less often than with inverted-T
techniques using an inferior pedicle (Fig. 36D.2).
Cinching the Vertical Incision and
Wound Healing
The initial vertical breast reduction techniques often
used a gathering or cinching closure of the vertical
skin to try to shorten it. This does not work (as we saw
when we measured patients before, during, and after
surgery, as well as at each postoperative visit) and only