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

SECTION V THE BREAST
616
leads to wound-healing problems.26 The gathering
suture causes constriction of the blood supply to the
skin edges, which results in breakdown. Some surgeons
suggest using a purse-string closure at the inferior as­
pect of the vertical incision, but that is also prone to
dehiscence, presumably because of constriction22 (Figs.
36D.3 and 36D.4).
Parenchymal Tension and Breast Shape
The parenchymal pillars should also be closed with­
out tension. Initially I believed that the lateral pedicle
would have better sensation (which ended up not be­
ing the case), and I would pull it around to meet the
medial pillar hoping that it would help prevent recur­
rence of lateral fullness. Unfortunately the tension on
the lateral pedicle would loosen and the pedicle would
sink back out, resulting in unacceptable lateral fullness.
Because there was no tension on the parenchymal clo­
sure with the medial pedicle, the shape persisted over
the following years. I was impressed with the sensation
recovery using the medially based pedicle.27–29 I used a
patient-reported questionnaire and found that 85% of
patients recovered normal to near-normal sensation
after a medial pedicle but only 76% did with a lateral
pedicle and only 67% did with a superior pedicle.29 I
also started seeing more of my own inverted-T inferior
pedicle breast reductions for follow-up, and several of
them developed bottoming out not only of the lower
pole but also the inframammary fold itself. Gravity
clearly has a detrimental effect on the inferior pedicle
over time (Fig. 36D.5).
Removing Excess Parenchyma Inferiorly
and Laterally
It is best to remove the excess where it is—inferior and
lateral. Gravity thus has less ability to cause bottom­
ing out over time. With the superomedial pedicle, the
breast tissue is removed laterally and inferiorly and the
remaining breast tissue is left attached to the upper
skin flaps. The breast holds it shape for far longer than
with the inferior pedicle techniques. Dermal suspen­
sion to the chest wall can help, and it has been shown
to be effective when the breast tissue is sutured up
to rib periosteum, especially in massive-weight-loss
patients.30 Suturing the breast to the pectoralis fascia
does not work. McKissock31 stated “The thought that
suturing the inferior pedicle to the chest wall will sus­
pend the breast for a prolonged period of time is naïve
. . . Perhaps its intrinsic seductiveness is so great that
plastic surgery is doomed forever to repeat cycles of
this idea being rediscovered and rediscarded.” I sutured
the breast up to the pectoralis fascia in 77 patients and
was able to follow up with 72 of them. I used perma­
nent sutures in 34 patients and absorbable sutures in
43 patients. The increased upper pole fullness did not
last more than 5 months in any of the patients.32 There
was a significantly better angle of takeoff of the breast
from the chest wall, but the upper breast border of the
footprint did not change32 (Fig. 36D.6, Video 36D.1).
Dermal Flaps and Slings
I tried overlapping dermal flaps in mastopexies, and
I tried using fascial slings to hold up implants in aug­
mentation mastopexy patients. Neither of these meth­
ods lasted, despite promising initial results. Dermis
stretches when tension is applied (which is why skin
expansion techniques are used). The best way to pre­
Fig. 36D.5 (a) This patient had a vertical breast reduction using
lateral pedicles. Tension on the pedicle to try to hold it in a more
medial position failed. (b) This patient had a vertical breast re­
duction performed using a lateral pedicle on her right breast
and a medial pedicle on her left breast. The lateral pedicle was
pulled medially and sutured to give a good shape. Over time,
the lateral pedicle relaxed and the parenchyma slipped back out
laterally. Tension on the skin causes wound-healing problems,
and tension on the parenchyma results in loss of initial shape.
A medially based pedicle helps prevent an unfavorable result in
both shape and sensation.
a
b

617
Chapter 36 Reduction Mammaplasty
Fig. 36D.6 (a) This patient had a medial pedicle vertical breast reduction; the upper breast tissue was elevated and sutured to the
pectoralis fascia in an attempt to improve upper pole fullness. (b) At 9 days postoperatively she has temporarily increased eleva­
tion of the upper breast. (c) At 4 months after surgery the upper breast border settled back into its original position.
a
b
c
Fig. 36D.7 This patient had a left breast reduction using an inferior wedge resection
and a right mastopexy using overlapping dermal flaps 6 years previously. The final
result shows that removal of the inferior wedge on the left breast gave a long-last­
ing result, but the dermal flaps on the right side did not work. Rearranging breast
tissue in a mastopexy rather than pushing the breast up and hoping that the skin
will hold it in place will give better results.
vent bottoming out is to remove the tissue that will
respond to gravity (i.e., mainly inferiorly) (Fig. 36D.7).
Blood Supply to the True Superomedial
Pedicle
The superomedial pedicle may not be the best choice
when the suprasternal notch–to–nipple distance is
long, but I believe it is actually the safest under almost
all circumstances. I do not believe that the suprasternal
notch–to–nipple distance or even the pedicle length it­
self is actually that important. The true superomedial
pedicle has a dual axial blood supply (from the internal
mammary system at the second and third interspaces),
and it stretches with growth as the nipple descends. The
arterial supply to an inferior pedicle comes up mainly
at the level of the fourth interspace accompanied by
venae comitantes. The rest of the blood supply to the
nipple–areola complex (NAC) is in the subcutaneous
tissue curving up around the breast parenchyma about
a centimeter deep to the skin surface. The veins travel
separately just under the dermis. This means that a su­
peromedial pedicle can be debulked as needed to allow
for easier inset. Lejour33,34 often used liposuction in the
breast itself, which makes it easier to fold up a superior
pedicle, but because the blood supply is superficial, the
pedicle can (and should) be thinned to prevent com­
pression. The artery and vein from the fourth (usually)
interspace is the only system that courses through the
breast parenchyma to supply the NAC. The rest of the
blood supply is in the subcutaneous tissue external to
the parenchyma itself.35 The blood supply to a lateral
pedicle comes from the superficial branch of the lateral
thoracic artery, but it is more variable in location and
may enter the breast more inferiorly than the usual lat­
eral pedicle design36 (Fig. 36D.8).
Infiltration for Areas That Require
Liposuction
I used to infiltrate the incisions, but the veins travel just
under the dermis, and they were often damaged with
the process of infiltration. I now only infiltrate the ar­
eas where liposuction is to be performed (lateral chest
wall, preaxillary areas, and around the inframammary
fold) with either direct infiltration of lidocaine with
epinephrine or tumescent fluid if there is significant
fat to be removed. Infiltration can reduce blood loss by

SECTION V THE BREAST
618
Fig. 36D.8 (a) The main blood supply to the breast curves up around the parenchyma in the subcutaneous tissue. The true su­
peromedial pedicle has a dual axial blood supply. (b) If it does not inset easily, the pedicle can be safely debulked at the paren­
chyma level, because the only significant blood supply to the nipple that travels through the parenchyma comes up straight from
the chest wall at the fourth interspace. (Reproduced from Hall-Findlay, EJ. Aesthetic Breast Surgery: Concepts & Techniques. New
York: Thieme Publishing; 2010.)
2
3
4
5
6
Duct
Gland
Cooper’s ligaments
Pectoralis major muscle
Pectoralis minor muscle
Second superficial branch of
internal mammary artery
Rib
Deep layer of enveloping breast fascia
Superficial layer of enveloping breast fascia
Internal intercostal muscle
External intercostal muscle
Würinger’s septum
Fifth superficial branch of
internal mammary artery
Fourth deep branches of
internal mammary vein and artery
Deep fascia
a
b

619
Chapter 36 Reduction Mammaplasty
190 to 200 mL, but with most vertical techniques, the
extent of total blood loss, even with limited infiltration,
is not much more than that.
Use of Drains
My experience is that patients who have had superior
and medially based pedicle reductions are not at higher
risk for postoperative drainage. I rarely use drains, and
they will not prevent a hematoma. Seromas do occur
but they tend to absorb without intervention. Drains
to prevent and treat seromas often need to be in place
for extended periods, and they are really not needed
because spontaneous resolution is the norm.
The Wise Pattern
Robert Wise21 designed a skin pattern to hold the
breast shape (he did not describe an inferior pedicle),
but because skin will stretch under tension, I have
found that the pattern is better for the parenchyma
that is left behind in a breast reduction than it is for the
skin resection. The inferior wedge of breast tissue be­
low the pattern is removed, and all extra tissue beyond
the borders of the Wise pattern is removed by direct
excision complemented with liposuction. With this ap­
proach, the pillars are closed without tension and skin
will redrape over the new shape. The skin is not used to
hold anything up. The Wise pattern, when coned after
the inferior wedge excision, results in a nicely project­
ing breast shape (Fig. 36D.9).
Action and Inaction in the Treatment
of Impending Nipple Necrosis
Unless it is clear that there is some compression or
kinking of the pedicle, it is probably best not to inter­
vene when impending nipple necrosis is observed.36 If
there is clear venous congestion with purplish discol­
oration and swelling, sutures should be removed and
surgical exploration may be necessary. The decision to
convert to a free nipple graft is not only difficult but is
not without consequences. Once it is clear that some
necrosis will develop, it is best to wait and not débride
tissue. It can be surprising how well the nipple and
areola will do with expectant observation. Prescribing
antibiotics to prevent bacteria from taking advantage
of the necrotic tissue is wise (Fig. 36D.10).
Repeat Reduction and New Pedicle
Involvement
The blood supply to a new pedicle is random. Because
nipples do not usually need to be moved significantly,
it is best to just deepithelialize as needed and keep the
NAC based on a random-pattern blood supply. This al­
lows the surgeon to remove the excess inferiorly with­
out regard to the original pedicle. Even when it is known
that an inferior pedicle was used at the first operation,
it is best to reduce the excess where it is (inferiorly and
laterally) while maintaining a random pattern blood
supply to the nipple. This gives a better breast shape
and allows the inframammary fold to rise without ex­
cising horizontal skin37 (Figs. 36D.11 and 36D.12).
The Upper Breast Border Versus the
Inframammary Fold for a Landmark
The inframammary fold has often been used as the
best landmark for determining the new nipple posi­
tion. Although it is a good landmark in about 80% of
patients, it can be misleading. Some patients have a
very high or a very low inframammary fold, and expe­
rienced surgeons can adjust automatically from experi­
ence. The upper breast border (a line drawn across the
top of the breast at the junction of the preaxillary fold
with the curve of the breast), on the other hand, will
not change with a breast reduction. The lower border
of the footprint (the inframammary fold) is more vari­
Fig. 36D.9 The Wise pattern helps the surgeon decide how much parenchyma should be left behind. Any excess tissue beyond
the Wise pattern should be removed and tailored out with liposuction (cross-hatched areas marked). This principle helps prevent
unsatisfactory postoperative shapes.

SECTION V THE BREAST
620
a
b
c
Fig. 36D.10 (a) It can be tempting to intervene once nipple necrosis has
occurred, but the nipple–areola complex is somewhat privileged, and
watchful waiting without débridement may actually give a good final re­
sult. (b) Degree of necrosis at 4 weeks. (c) Beginning of resolution at 6
weeks. (d) At 3 months with no intervention performed, which helped
avoid a potentially unfavorable result.
d
Fig. 36D.11 (a) Some patients with an inferior pedicle develop bottoming out of the inframammary fold over time; this means
that chest skin has become breast skin. The process can be reversed by removing the weight with liposuction between the new
low inframammary fold and the scar. It is important not to remove skin because it is needed to revert to chest wall skin once the
weight is removed. (b) The skin below the inframammary scar has been converted back to chest wall skin.
a
b
Fig. 36D.12 Removal of weight inferiorly
with a medial pedicle vertical breast re­
duction allows the inframammary fold
to rise. It is important to keep the ver­
tical skin resection high to avoid a scar
extending down onto the chest wall. This
principle of removing weight off the in­
framammary fold can be used in breast
repeat reduction to improve results.

621
Chapter 36 Reduction Mammaplasty
able. An ideal nipple is about 10 cm down from the up­
per breast border on an average woman (and about 10
cm drawn straight from the chest midline), and using
the upper breast border as a landmark is more likely to
give good, consistent, predictable results.38 The breast
footprint varies from patient to patient, and the foot­
print will not change after a breast reduction. Some
patients are “high-breasted” and some patients are
“low-breasted.” It is best not to pick a standard number
for the suprasternal notch–to–nipple distance because
of this variability. When nipples look too high after a
breast reduction, they were invariably placed too close
to the upper breast border (Fig. 36D.13).
Conclusion
An unfavorable result can be avoided in most breast re­
duction surgeries by following the principles outlined
in this discussion. Obviously the best breast reduction
is the breast reduction that the individual surgeon per­
forms the best. I apply these principles in my practice
based on careful analysis of my results over the years—
both good and bad.
Fig. 36D.13 The difference between a low footprint (a) and a high footprint (b). The upper breast border is shown with the black
arrow. The upper breast border will not change with a breast reduction, and it can be found at the indentation where the preaxil­
lary fold meets the breast. To avoid an unfavorable result with a breast reduction, it is better to use the upper breast border as a
landmark for the new nipple position than to use the inframammary fold.
a
b
References
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reduction mammaplasty. Plast Reconstr Surg 2013;
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2. Cruz-Korchin N, Korchin L. Breast-feeding after verti­
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oblique method]. Ann Chir Plast 1961;6:45
7. Biesenberger H. Eine neue methode der mammaplas­
tik. Zentralbl Chir 1928;38:2382–2387
8. Strombeck JO. Mammaplasty: report of a new tech­
nique based on the two-pedicle procedure. Br J Plast
Surg 1960;13:79–90
9. Skoog T. A technique of breast reduction; transposi­
tion of the nipple on a cutaneous vascular pedicle.
Acta Chir Scand 1963;126:453–465
10. Pitanguy I. Surgical treatment of breast hypertrophy.
Br J Plast Surg 1967;20(1):78–85
11. Weiner DL, Aiache AE, Silver L, Tittiranonda T. A sin­
gle dermal pedicle for nipple transposition in sub­
cutaneous mastectomy, reduction mammaplasty, or
mastopexy. Plast Reconstr Surg 1973;51(2):115–120
12. McKissock PK. Reduction mammaplasty with a verti­
cal dermal flap. Plast Reconstr Surg 1972;49(3):245–
252
13. Robbins TH. A reduction mammaplasty with the are­
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Reconstr Surg 1977;59(1):64–67
14. Courtiss EH, Goldwyn RM. Reduction mamma­
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26. Matthews JLK, Oddone-Paolucci E, Lawson DC, Hall-
Findlay EJ. Vertical scar reduction. Does gathering the
incision matter? Ann Pl Surg 2016;77(1):25–31
27. Würinger E, Mader N, Posch E, Holle J. Nerve and ves­
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29. Hall-Findlay EJ. Vertical Breast Reduction. In: Aes­
thetic Breast Surgery Concepts and Techniques. St
Louis: Quality Medical Publishing; 2011:384
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623

Gynecomastia
Dennis C. Hammond and Kuylhee Kim
Gynecomastia is defined as an excessive development of
mammary tissue of the male breast. It is the most common
condition of the male breast, affecting up to 65% of normally
developing adolescent boys.1 The severity of the condition
may range from a small subareolar fibrotic bud to enlarge­
ment indistinguishable from the normal female breast (Fig.
37.1). Male breast enlargement is overwhelmingly a benign
finding, but malignancy must be considered and ruled out
in patients with asymmetric enlargement, a discrete lesion,
or symptoms of pain and tenderness. Azzopardi2 and McDi­
vitt et al3 demonstrated that although breast cancer is rare
in men, it does occur and can account for 1% of all breast
cancers. In particular, patients with Klinefelter’s syndrome
show an association of breast cancer and gynecomastia.4,5
Gynecomastia can be subdivided into four categories
based on the cause: (1) idiopathic (25%, most common),
CHAPTER
37
a
b
c
Fig. 37.1 Manifestations of gynecomastia. (a) A firm and fibrous
mass of tissue may develop directly under the areola. This mass
herniates through the elastic areolar skin and causes widening of
the areolar diameter. (b) In more obese patients, accumulation of
fibrofatty stroma surrounding the breast results in a more promi­
nent breastlike contour. (c) As the subareolar breast bud enlarges
along with a general increase in the volume of the breast, the breast
bud herniates through the elastic areolar skin, resulting in a wid­
ened areolar diameter.

SECTION V THE BREAST
624
Avoiding Unfavorable
Results and Complications in
Gynecomastia
Summary Box
Most Common Complications
•• Seroma
•• Contour irregularity
•• Persistent subareolar mass
•• Skin excess
•• Insufficient volume reduction
•• Hematoma
Preoperative Planning and Patient
Selection
The character of the breast should be examined by palpa­
tion to assess for the presence of any type of discrete mass.
Also, the consistency and size of the fibrous subareolar
component is estimated as compared with the surround­
ing fibrofatty stroma. Fatty accumulation under the arm or
up onto the chest wall must be noted along with the de­
gree of areolar herniation or widening. Breast imaging is
not usually recommended; however, when breast cancer is
suspected, mammography should be performed.10
If surgery is indicated, the physician should thoroughly
discuss the patient’s expectations. With patients with a high
body mass index (BMI), there is sometimes a discrepancy be­
tween a surgeon’s perception of the appropriate chest wall
contour in relation to the rest of trunk and the patient’s expec­
tation from surgery. Setting realistic expectations and iden­
tifying areas of specific concern are helpful in allowing the
surgeon to judge when an appropriate end point is reached
intraoperatively. Specifically, any preoperative asymmetry
and contour irregularity should be noted and patients should
(2) physiologic, (3) pathologic, and (4) pharmacologic (Ta­
ble 37.1). Pseudogynecomastia is an increase in breast size
that occurs with weight gain. Typically, gynecomastia in ado­
lescent males can be treated with patience and reassurance,
because in most cases the breast simply regresses back to a
normal appearance over a period of 1 to 2 years.6 However,
the presence of hypertrophic breast tissue for more than
12 months warrants surgical treatment because of the ten­
dency toward fibrotic transformation, which can be perma­
nent.7,8 Also, if any degree of social withdrawal is noticeable
as a result of even a mild condition, surgical correction is
entirely reasonable and recommended.
To determine the appropriate means of treatment, the
cause of gynecomastia must be identified and an evaluation
of the extent of deformity should be completed. The cause is
often ascertained by careful history taking, physical examina­
tion, and laboratory studies. The staging of gynecomastia is
based on the degree of breast hypertrophy and ptosis9 (Table
37.2). The determination of the volume of the breast, fibrotic
content versus fatty accumulation, and skin excess on the sur­
rounding chest wall are important factors to assess in relation
to the whole chest wall contour. These determinations will
then guide the most appropriate treatment method.
Table 37.1 Types of gynecomastia
Cause
Comments
Idiopathic
Most common (25%)
Physiological
Neonatal: Influence of maternal estrogens
Pubertal: Elevated estradiol to estrogen ratio
Senile: Peripheral conversion of testosterone to estrogen by aromatase
Pathologic
Liver cirrhosis; kidney failure; testicular, adrenocortical, or pituitary tumors; hypogonadism;
hyperthyroid; adrenal hyperplasia; or bronchogenic carcinoma
Pharmacologic
Estrogens, gonadotropins, androgens, antiandrogens, chemotherapy agents, calcium channel
blockers, angiotensin-converting enzyme inhibitors, digitalis, central nervous system agents,
antituberculosis medications, or drugs of abuse
Table 37.2 Staging system of
gynecomastia
Grade
Degree
Grade I
Minimal hypertrophy (< 250 g) and no
ptosis
Grade II
Moderate hypertrophy (250 to 500 g) and
no ptosis
Grade III
Severe hypertrophy (> 500 g) and grade I
ptosis
Grade IV
Severe hypertrophy (> 500 g) and grade II
or III ptosis

625
Chapter 37 Gynecomastia
cant surrounding fibrofatty stroma in the periphery of the
breast. In this case, the subareolar mass creates a very obvi­
ous contour deformity as it herniates through the areola.
Direct excision is especially helpful for young patients be­
cause the skin will often shrink to an acceptable diameter.
The primary concern of this technique is leaving adequate
tissue under the nipple to prevent nipple retraction (saucer
deformity). The fibrous bud is sharply transected such that
approximately 5 to 10 mm of evenly layered fibrous tissue
remains attached to the underside of the areola. Because
there is no fat directly under the areola, if the subareolar
breast bud is removed at the dermal level, a step-off will be
created at the junction of the areola, creating a postopera­
tive contour deformity. After removing the subareolar tis­
sue, if any contour irregularity is noticed, sharp dissection
can be used to further thin the peripheral margins to create
a smooth contour. With removal of the subareolar tissue,
the areola will typically retract to a more normal diameter
because the mass effect of the underlying breast bud has
been removed (Fig. 37.2).
be informed about the need for further procedures, especially
when liposuction is used alone or staged excision is planned.
There are various surgical options, chosen based on
the individual patient characteristics. The two factors that
must be addressed are the volume of the breast and the de­
gree of skin redundancy. The breast tissue may be removed
with either liposuction or direct excision or a combination
of the two. Excision of the skin envelope is recommended
if enough spontaneous skin contraction cannot occur in the
setting of significant excess and poor elasticity.
Intraoperative Decisions
Volume Reduction
Direct Excision
Direct excision of glandular tissue through an inferior peri­
areolar incision is preferable for cases of an isolated fibrous
mass found directly under the areola without any signifi­
a
b
c
d
e
Fig. 37.2 This 14-year-old young man presented with bilateral
gynecomastia of 2 years’ duration. (a) The breast enlargement
consisted mostly of a firm subareolar fibrous mass with little sur­
rounding fibrofatty accumulation. (b) At surgery, a well-demar­
cated subareolar fibrous mass was noted directly under the areola.
(c) The mass was dissected free from the surrounding breast tissue
through an inferior periareolar incision. (d) A thin layer of fibrous
tissue remained attached to the underside of the areola to prevent
a central depression deformity. (e) At 15 months postoperatively he
has a smooth chest wall contour and the scar has healed well along
the inferior border of the areola.

SECTION V THE BREAST
626
suction is started with a small cannula first to feather and
break up the fibrous tissue followed by a larger cannula to
separate the fat from the surrounding fibrous stroma. Par­
ticular attention is directed to the subareolar area to reduce
the possibility of any remaining residual subareolar bulge
postoperatively. Pinch compression with the opposite hand
can help drive the dense fat into the tip of the cannula to
further reduce the volume of the breast. End points are de­
termined by a pinch test and a contour assessment in a sit­
ting position (Fig. 37.3).
Liposuction
When gynecomastia presents as a largely fibrofatty accu­
mulation of tissue, liposuction is recommended to restore
a normal chest wall contour. The incision is placed at the
junction of the pigmented areolar skin with the nonpig­
mented chest wall skin to hide the subsequent scar. Ad­
ditional incisions can be made anywhere along the in­
framammary fold, or laterally along the chest wall. After
infiltration using the tumescent technique, standard lipo­
a
b
c
d
e
Fig. 37.3 (a) This 43-year-old man presented with bilateral gynecomastia. Because most breast enlargement consists of a fibrofatty com­
ponent, simple liposuction can be used to manage the volume excess. (b) Preoperative markings outlining the areas to be treated. (c) The
stab incision for liposuction was made in the lateral part of the inframammary fold, and liposuction was performed over the entire breast
including under the arm, superiorly along the upper chest, and inferiorly below the fold to create a smooth contour. (d) When viewed from
below, a flat and smooth contour of the chest wall can be confirmed on the right side; the left side was not yet treated. (e) At 2 months
postoperatively he has a smooth chest wall contour.

627
Chapter 37 Gynecomastia
Skin Envelope Retailoring
With a reduction of breast volume, the skin may be exces­
sive enough that some type of skin resection becomes nec­
essary. In most patients, primary skin envelope retailoring
is not required, because the skin envelope of the breast has
a propensity to retract after direct excision or liposuction.
However, if patients present with a significant skin excess
along with extreme skin laxity and poor elasticity, a pri­
mary skin-reducing procedure may be indicated. One al­
ternative is to perform the volume reduction initially and
then proceed with a staged skin excision at a later time.
This strategy allows the skin to retract and can make the
subsequent skin resection a less involved procedure, pos­
sibly with a reduced scar burden (Fig. 37.4).
The design for skin envelope reduction in gynecomastia
surgery is very similar to that used in mastopexy procedures
in female patients. Based on the amount of excess skin, vari­
ous patterns can be used to remove the excessive skin enve­
lope, including direct local excision using either a periareo­
lar pattern, a circumvertical pattern, or a simple horizontal
ellipse. Drains should be used when extensive resection and
undermining are performed to prevent seroma formation.
The major goal of this procedure is the removal of the excess
Combination of Direct Excision and
Liposuction
When a firm subareolar fibrous breast bud is present with
a peripherally located supporting fibrofatty stroma, sub­
areolar tissue is removed by direct excision. Liposuction is
then used to reduce the general volume and recontour the
peripheral margins. After the breast is tumesced through
a stab incision, standard or ultrasonic liposuction is per­
formed to evenly remove fatty tissue throughout the entire
breast, including the centrally located fibrous component.11
Although the dense subareolar tissue is relatively refrac­
tory to liposuction, every effort should be made to hon­
eycomb through the subareolar area as much as possible.
Because the architectural integrity of subareolar tissue is
interrupted by liposuction, the margin between the fibrous
mass and fatty stroma becomes obvious, and it expedites
the subsequent dissection of the fibrous bud through an in­
ferior periareolar incision. When removing the subareolar
mass by direct excision, leaving enough tissue under the
nipple is critical to prevent a central depression or sau­
cer deformity. Additional liposuction can be performed to
feather the edges of the dissection to prevent a contour ir­
regularity.
Fig. 37.4 (a) This 26-year-old man had bilateral gynecomastia. (b) At 10 months postoperatively, after liposuction treatment alone, the
breast volume was significantly reduced; however, the skin envelope was redundant along the inframammary fold. (c) Preoperative mark­
ing in preparation for excision of the redundant skin. At surgery, the redundant skin and subcutaneous fat was excised to reshape the chest
wall contour. (d) At 3 weeks postoperatively he has a smooth chest wall contour with a well-hidden scar in the fold.
a
b
c
d

SECTION V THE BREAST
628
Gore-Tex technique is used to limit the amount of postop­
erative areolar spreading that occurs.12
Circumvertical Pattern
The circumvertical pattern has the advantage of lifting the
NAC as well as reducing the skin excess in patients who
need skin envelope reduction in both the vertical and hori­
zontal directions. After most of the excess breast volume
has been reduced by liposuction, the redundant lower pole
skin is plicated by staples in the sitting position. After con­
firming the limits of skin resection, the inferior pedicle
supporting the NAC is developed, leaving sufficient tissue
on the pedicle to prevent compromise to the blood supply.
The intervening skin on the vertical and periareolar seg­
ments is deepithelialized, and a purse-string suture is ap­
plied to close the periareolar incision.
Horizontal Pattern
A horizontally oriented pattern centered on the inframam­
mary fold is a powerful technique that allows the removal
of significant amounts of excess skin while leaving behind
skin, lifting of the nipple–areola complex (NAC), and the re­
shaping of the breast to restore a normal chest wall contour
with minimal cutaneous scars.
Nipple–Areola Complex
Periareolar Pattern
When lifting of the NAC and a small reduction of the skin
envelope are required, the periareolar pattern is a use­
ful technique, because the resulting scar is camouflaged
around the areolar border. The location and size of the NAC
should be given special attention when marking a patient
with gynecomastia. Because the nipple position is natu­
rally located slightly lower than in females, the top of the
periareolar incision should be located no more than 2 to 3
cm above the inframammary fold. The periareolar pattern
is drawn in a circular fashion with the areola under stretch
at a maximum diameter of 3 cm, a diameter that is some­
what smaller than that used for women. Once the marking
is completed, the intervening skin is deepithelialized and
the resulting defect is managed with a periareolar purse-
string suture. From a technical perspective, the interlocking
a
b
c
d
Fig. 37.5 (a) This 23-year-old man had bilateral gynecomastia with significant volume and skin excess. (b) Preoperative marking in prepa­
ration for volume and skin reduction using an inferior pedicle technique in conjunction with a horizontal resection of skin. (c) Tissue is
removed from around and under the inferior pedicle, and the apron flap is closed along the inframammary fold. The nipple–areola com­
plex is brought out through a separate incision. (d) At 1 month postoperatively he has a normal chest wall contour and a well-healed scar
located in the inframammary fold.

629
Chapter 37 Gynecomastia
These maneuvers are performed concurrently in an at­
tempt to prevent an abrupt change in contour. Healthy skin
flaps are left behind to ensure uncomplicated wound heal­
ing. When revision surgery is planned, it is recommended
to treat the prominent areas first with specifically targeted
liposuction using small cannulas, then treat any residual
depressed areas using lipofilling.
Periareolar Scar Formation
Periareolar scar formation is a spectrum of complications
in and around the NAC that includes hypertrophic scar of
the incision site, nipple retraction, and areolar hypopig­
mentation. Nipple retraction can be preventable by leaving
enough tissue under the NAC, and areolar hypopigmenta­
tion can be masked by tattooing.
Hematoma and Seroma
As with any soft tissue undermining procedure, the po­
tential for hematoma formation and seroma accumula­
tion must be anticipated. Direct hemostasis at the time of
surgery and the use of a compression garment for several
weeks postoperatively are helpful in preventing postopera­
tive bleeding. When bleeding occurs, it generally develops
within the first 24 hours. It is recommended that any type
of hematoma be drained operatively to prevent subsequent
scar contracture and deformation of the breast or NAC. The
use of a drain is a matter of preference. Routine placement
of a drain after tissue resection can certainly be supported;
however, many patients can heal primarily without the in­
convenience of dealing with a drain postoperatively. If a pa­
tient does develop seroma, simple intermittent aspiration
until resolved will successfully treat the condition.
Infection
Although infection after gynecomastia excision is a very
unusual finding, a short course of perioperative antibiotics
is prudent, because surgery involves potentially contami­
nating lactiferous ducts. One dose given at the time of sur­
gery is likely adequate prophylaxis.
Conclusion
The major goal in the surgical treatment of gynecomastia
is to create a normal masculine chest wall contour with
the least conspicuous scar possible. To develop a success­
ful surgical plan for each patient, breast volume, degree of
ptosis, amount of excess skin envelope, quality of breast
tissue, and combined chest wall deformity should be as­
sessed preoperatively. The volume reduction must be
performed with precision to prevent overcorrection, un­
dercorrection, or surface irregularity. Furthermore, the
skin retailoring pattern must be strategically designed to
address the skin excess with a minimal amount of scar.
When these variables are carefully controlled, excellent
results can be achieved.
an inconspicuous scar. With this pattern, the blood supply
to the NAC is provided by the inferior pedicle. The pedicle
itself can be mildly undermined to create a smooth chest
wall contour. When the horizontal incision is closed, the
NAC is brought out through a separate incision to complete
the procedure (Fig. 37.5).
Postoperative Complications
Although the treatment of gynecomastia is usually
straightforward, certain postoperative problems can occur
that are unique to the procedure. Because the procedure
is essentially a subcutaneous mastectomy, two problems
that are common to all plastic surgery “undermining” pro­
cedures certainly come into play: seroma and hematoma.
The rest relate to the contour of the chest wall left over
after the tissue is removed. Perhaps the most important
potential complication is irregularity of the soft tissue
envelope after resection of the fibrous bud and fat. Every
aspect of treatment is geared toward preventing this com­
plication, and it is here that a considered operative tech­
nique becomes most important. Conversely, in an attempt
to avoid an overdone resection, the opposite problem can
occur from time to time: underresection of tissue, too
much retained tissue under the NAC, or an excessive or
ptotic skin envelope. It is achieving this balance between
resection and result that distinguishes a technically adept
approach (Video 37.1).
Managing Unfavorable
Results and Complications in
Gynecomastia
Asymmetry
All patients are asymmetrical preoperatively, but postop­
erative asymmetry is a very common complication noted
by patients after any kind of breast surgery. Careful mea­
surement of the amount of excised tissue and lipoaspirate
removed and examination of the remaining tissue in the
sitting position intraoperatively can minimize the possibil­
ity of significant postoperative asymmetry.
Incomplete Volume Reduction
Whereas overresection can create a concavity in the breast,
underresection can result from too cautious an approach
to management of the excess volume. Care must be taken
to merge the two techniques of tissue removal, liposuction
and direct removal of the fibrous bud from under the NAC,
in such a way that a contoured chest wall is created while
adequately reducing the size of the breast.
Surface Irregularity
Intraoperatively, the edges of the resection should be feath­
ered by careful excision either with or without liposuction.

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630
8. Courtiss EH. Gynecomastia: analysis of 159 patients and
current recommendations for treatment. Plast Reconstr
Surg 1987;79(5):740–753
9. Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr. Classifica­
tion and management of gynecomastia: defining the role
of ultrasound-assisted liposuction. Plast Reconstr Surg
2003;111(2):909–923, discussion 924–925
10. Mathew J, Perkins GH, Stephens T, Middleton LP, Yang
WT. Primary breast cancer in men: clinical, imaging, and
pathologic findings in 57 patients. AJR Am J Roentgenol
2008;191(6):1631–1639
11. Hammond DC, Arnold JF, Simon AM, Capraro PA. Com­
bined use of ultrasonic liposuction with the pull-through
technique for the treatment of gynecomastia. Plast Re­
constr Surg 2003;112(3):891–895, discussion 896–897
12. Hammond DC, Khuthaila DK, Kim J. The interlocking
Gore-Tex suture for control of areolar diameter and shape.
Plast Reconstr Surg 2007;119(3):804–809
References
1. Niewoehner CB, Nuttal FQ. Gynecomastia in a hospital­
ized male population. Am J Med 1984;77(4):633–638
2. Azzopardi JG. Problems in breast pathology. Philadelphia,
PA: WB Saunders; 1979:322–324
3. McDivitt RW, Stewart FW, Berg JW. Tumors of the breast.
In: Atlas of Tumor Pathology, series 2, fascicle 2. Wash­
ington, DC: Armed Forces Institute of Pathology; 1968
4. Hultborn R, Hanson C, Köpf I, Verbiené I, Warnham­
mar E, Weimarck A. Prevalence of Klinefelter’s syn­
drome in male breast cancer patients. Anticancer Res
1997;17(6D):4293–4297
5. Brinton LA. Breast cancer risk among patients with Kline­
felter syndrome. Acta Paediatr 2011;100(6):814–818
6. Wise GJ, Roorda AK, Kalter R. Male breast disease. J Am
Coll Surg 2005;200(2):255–269
7. Bannayan GA, Hajdu SI. Gynecomastia: clinicopathologic
study of 351 cases. Am J Clin Pathol 1972;57(4):431–437
Discussion by Mordcai Blau and Ron Hazani
Gynecomastia surgery is a relatively safe procedure
among cosmetic surgeries. Multiple procedures and
techniques have been described to treat this deformity,
including direct excision, standard liposuction, ultra­
sound-assisted, and laser-assisted procedures.1–6 There
were more than 27,000 gynecomastia procedures per­
formed in the United States in 2015.7 However, not
many plastic surgeons have sufficient exposure to this
subgroup of patients. Occasional complications can be
the result of poor patient selection or a suboptimal sur­
gical technique. The overall rate of complications after
this procedure ranges between 12 and 21%.8,9 There are
very few major complications such as recurrence, con­
tour deformities, skin slough, and large hematomas;
these require surgical intervention. The likelihood of
major complications can be reduced with proper expe­
rience.9
My career (M.B.) has evolved to an exclusively gy­
necomastia practice. I currently perform approximately
500 procedures for gynecomastia each year, 2% of the
gynecomastia cases in the United States. I would hum­
bly like to dedicate this chapter to patients who suffer
from this deformity and to surgeons who are looking to
help these patients.
Managing Complications in
Gynecomastia
Seroma
Seroma is the most common complication after gland
excision.10 As with every subcutaneous procedure, it is
expected that some serous fluid collection can form.
Creation of a dead space in the subcutaneous tissues
results in filling of the cavity with lymphatic fluids
and thus the formation of a seroma. Most seromas
are rather minor, do not require drainage, and resolve
spontaneously within a few weeks after the procedure.
If the fluid collection can be clearly identified and
easily palpated, evacuation can be done (Fig. 37D.1). The
aspiration is performed using 14-gauge needles, even
with relatively small seromas (2 to 4 mL of fluid con­
tent). Often seroma can be identified within 2 to 7 days
after surgery, and when minor often one aspiration is
sufficient and there is no need to insert a drain.

631
Chapter 37 Gynecomastia
If the seroma still contains 5 to 10 mL after one as­
piration, I usually do not insert a drain after the evacu­
ation of the fluid. When the fluid accumulation is more
than 10 mL, a small opening can be made with a no. 15
blade to insert a 0.25-inch Penrose drain, which must be
left in place until the discharge stops, typically 4 to 14
days. In most cases once the drain is removed the wound
is left open to granulate spontaneously, and a future scar
revision may be needed in some cases. 
When the patient is febrile and the wound is edem­
atous and tender with discharge of purulent fluid a cul­
ture should be obtained. The wound then can be irri­
gated with fluid mixed with antibiotic, and a drain must
be inserted through a separate incision. The drain is su­
tured to the unaffected skin. The patient should begin
oral antibiotics, which can be changed according to the
culture results. The patient often requires referral for
consultation with an infectious disease specialist.
Recurrence
According to the literature the recurrence rate can be
as high as 10 to 15%.11 It is important to distinguish
true recurrence from insufficient excision, as described
later in this discussion. When liposuction alone is done,
recurrence is much more likely, because all true gyne­
comastia cases are the result of parenchymal hyper­
trophy (Fig. 37D.2). Therefore liposuction alone is not
sufficient to prevent recurrence. The addition of partial
glandular excision reduces the recurrence rate to 10%.
Only true complete excision can prevent recurrence,
as demonstrated in our recent survey.9 These statistics
Fig. 37D.1 Evacuation of a large seroma. (a) Late-stage evacuation of a seroma at 1 week postoperatively. (b) Early-stage evacu­
ation of a seroma at 3 to 4 days postoperatively. Most of these are relatively small and the body absorbs the collection with time.
Larger seromas are more clinically relevant and require intervention in the form of syringe aspiration as an outpatient procedure.
a
b
Fig. 37D.2 (a) This patient had only partial excision of the glandular tissue. (b) The result after the revision demonstrates improved
symmetry after complete excision of the glands.
a
b

SECTION V THE BREAST
632
pertain only to patients who sought additional proce­
dures and who did not give up. In my practice, 20% of
my initial surgical consultations are patients who had
surgery elsewhere and report the recurrence of the gy­
necomastia condition (Fig. 37D.3). Revision surgery ac­
counts for more than 100 of my 500 patients per year.
This number raises some questions.
These very high recurrence rates and the need for
revision cause several problems:
•• There is an increase in internal scarring, which
makes the subsequent dissection much more
difficult.
•• Increased and more diffuse bleeding occurs that is
more difficult and time consuming to control.
•• Scattered remaining breast tissue islands require
meticulous exploration for the residual glandular
tissue.
•• Adherence of the soft tissue to the muscle fascia
requires more tenuous dissection and increases
bleeding.
•• Less commonly, missing parts of the pectoralis
muscle cause irregularity and may result in
asymmetries.
My experience with over 1,000 cases of recurrent gyne­
comastia after operations performed elsewhere is that
many surgeons are too conservative and perform lipo­
suction of the breast without glandular excision. Often
surgeons have the tendency to not remove the entire
gland out of fear of creating a future depression; unfor­
tunately, removing only part of the gland is the leading
cause of recurrence of gynecomastia. I always excise al­
most all of the gland, and I try to remove about 95% of
the glandular tissue in one block. The remaining 5% or
less is under the areola and is usually 2 to 4 mm thick. In
bodybuilders in whom the fat content is minimal I usu­
ally leave 2 to 3 mm of the gland right under the areola;
as much as 5 mm can be left in obese patients.
Depression occurs in less than 1% of patients.
Therefore aggressive thinning of the areola is neces­
sary to achieve good aesthetic results and avoid recur­
rences. Depression can be corrected with adipose tis­
sue transfer or adipose flaps to the depressed area (Fig.
37D.4). An implant is rarely necessary.
Skin Slough
Skin slough occurs in about 2% of my patients. Skin loss
of the NAC is limited, and I have never witnessed loss
Fig. 37D.3 (a) This patient experienced left breast recurrence after incomplete excision of the gynecomastia by another surgeon.
(b) The result demonstrates complete reexcision of the gland, with subsequent undermining and redraping of the skin.
a
b
Fig. 37D.4 Static areola depression after gynecomastia surgery.

633
Chapter 37 Gynecomastia
of the entire complex (Fig. 37D.5). Skin slough is usu­
ally minor. It heals spontaneously and results in minor
scarring. When more significant skin loss occurs (Fig.
37D.6), it can heal as a hypertrophic scar, keloid, or flat
and wide scar.
Skin slough may result from extensive cauteriza­
tion for significant bleeding (Fig. 37D.7), especially if
the bleeding is superficial, just beneath the skin. The in­
terference with blood supply can result in ischemia, or it
can be caused by direct, unintentional injury by a sharp
instrument. Rarely, it can be the result of extreme com­
pression by postsurgical garments. Allergic reaction to
tape can result in blistering with superficial skin slough.
It presents as a second-degree burn that may heal with
some pigment changes.
When deep skin slough is present, débridement
may be necessary to remove the necrotic tissue and fa­
cilitate spontaneous healing (Fig. 37D.8). The need for
scar revision is determined only after 6 to 12 months of
observation. In most cases, the repair is done by excis­
ing the skin edges and recruiting adjacent tissues. The
closure is performed in layers to reduce tension on the
wound edges and in most cases requires at least a two-
layer closure (Fig. 37D.9). In rare difficult cases when
the wound is large and results in significant scarring
other measures such as tattooing can be used to cam­
ouflage the area and distract the viewer from the scar­
ring. For a raised scar, Kenalog injections (a cortisone
derivative that reduces the size of the internal scar)
Fig. 37D.5 (a) Partial areola slough after gynecomastia surgery. These skin changes heal well without additional surgical treat­
ment. (b) Minor areola slough after surgery. Treatment is with topical ointment and observation.
a
b
Fig. 37D.6 Complete loss of the left nipple–areola complex af­
ter gynecomastia surgery. The loss is confined to the areola and
does not extend to the surrounding skin.
Fig. 37D.7 A combination of deep and superficial skin slough
after gynecomastia surgery.

SECTION V THE BREAST
634
may be beneficial. In some cases silicone sheets can
also be applied.
Infection
True deep tissue infection involving purulent discharge
is extremely rare, but if it occurs it requires surgical
intervention in the form of incision and drainage. Cul­
ture-guided antibiotic therapy is necessary to treat the
soft tissue component of the infection.
Cellulitis is very uncommon, because no pros­
thetic implant or foreign body is used for the proce­
dure (Fig 37D.10). However, should it occur, antibiotic
therapy is the mainstay of treatment. In my experi­
ence, skin flora is the most common organism found
in cultures.
a
b
Fig. 37D.8 (a) Full-thickness skin slough with edematous edges after gynecomastia surgery, likely as a result of hemostasis of
superficial excessive bleeding. These require excision and healing by secondary intention. Revision is performed at a later date
when the edema has subsided and the scar is mature. (b) Postsurgical skin slough after gynecomastia surgery. Granulation tissue
is present, but it is not appropriate for revision at this point.
a
b
Fig. 37D.9 (a) Skin slough after cauterizing a superficial bleed on the lateral edge of the nipple–areola complex. The treatment
included observation, excision, and revision after granulation tissue formed. (b) Healing of skin slough in another patient 1 year
postoperatively. This patient required surgical revision.

635
Chapter 37 Gynecomastia
The best way to avoid complications is by using a
low-voltage coagulator, with care not to approach the
epidermis, and using caution with the use of sharp in­
struments while undermining tissues.
Insufficient Gland Excision
By far the most common reason for a patient to be
unhappy with his gynecomastia correction is that not
enough glandular tissue was excised (Fig. 37D.11). Al­
though some surgeons leave behind glandular tissue
intentionally to avoid depression in the chest, I have
learned from experience that it is possible to excise 95%
of the gland with extremely minimal chance of creating
a depression. Even with the swelling that immediately
follows surgery, early signs of improvement should be
evident if the procedure was successful (unless there
is a hematoma or seroma, which occurs in about 5 to
10% of cases). If no initial improvement can be seen, the
final results are less likely to be satisfactory, even after
further healing. In my opinion, compression garments
are necessary for a few days only. I have found that
even months of wearing this uncomfortable, cumber­
some garment will hardly change the surgical results
if insufficient gland was excised. The remaining glan­
dular tissue is not going to diminish or disappear by
weight loss, exercise, use of medications, or wearing a
compression dressing or vest for a prolonged time. The
only way it can be eradicated is by a proper surgical
excision of the remaining mass. When performing gy­
necomastia surgery on bodybuilders, it is imperative
that the surgeon pay special attention to removing the
entire gland because of the likelihood of future steroid
use. I have never seen a bodybuilder who had a recur­
rence after proper excision, even among patients who
used steroids after surgery.
The use of an axillary incision as a minimally inva­
sive approach is rarely sufficient for proper glandular
excision. Axillary incisions can only be used for lipo­
suction. The entire glandular tissue can only be reliably
removed with a subareolar incision. Inexperienced sur­
geons who attempt to remove the entire gland through
the axillary approach often leave multiple residuals or
islands of glandular tissue that cause unwanted recur­
rence. Surgeons with less experience should start with
smaller, less complex cases and proceed with a subareo­
lar approach.
When a patient comes for a consultation complain­
ing of recurrence, it is important to make a proper diag­
nosis and distinguish recurrence from an immature scar.
If a lesion persists for more than a year and a mass is pal­
pated, the only solution is excision. Intralesional Kenalog
injections are ineffective when true gynecomastia recur­
rence is present. If exploration is indicated, it should be
meticulous and detailed, with the aim of removing all
the remaining glandular islands. The surgeon must look
for the glandular body, head, and most importantly the
tail. This exploration can be bloody because of the adhe­
sions that result from previous procedures.
Internal scarring can be seen in more than 5% of pa­
tients and is managed with observation to avoid unnec­
essary revision surgery.
Fig. 37D.10 Postoperative minor cellulitis and skin slough.
Treatment is with oral antibiotics.
Fig. 37D.11 Bilateral breast deformity with residual scattered
glandular tissue, mostly on the right side. The patient has severe
asymmetry after gynecomastia surgery performed elsewhere.

SECTION V THE BREAST
636
Excessive Skin Scarring
Unflattering scarring of the skin is unfortunately much
more difficult to remedy than other complications. I
have seen six different types of incisions from my sec­
ondary patients: around the inframammary crease
(Fig. 37D.12); across the breast from medial to lateral;
laterally extending; and above, below, and in the arm­
pit. One of the more common complaints is a circum­
areolar scar—the Benelli pattern (Fig. 37D.13).
The Benelli Technique Applied to
Gynecomastia Patients
Making an incision all around the areola is usually un­
necessary. This incision heals nicely at times, but on oc­
casion it can be unsightly and disfiguring. A circumare­
olar incision can develop into a thick, wide scar that is
extremely difficult to repair. It is possible to inject cor­
tisone to reduce a raised scar, but with excessive wid­
ening, not much can be done to improve the result. In
some cases, it may be advisable to suggest chest tattoos
to distract the viewer from the scarring (Fig. 37D.14).
When done properly and conservatively, gynecomastia
surgery should leave minor scarring under the areola
at a transition zone where the NAC and the native skin
pigments blend, making the scar almost inconspicuous.
Internal scarring and adhesions are considered a dif­
ferent type of a complication that cannot be avoided. Pa­
tients may develop adhesions after any procedure, but
some can be clinically unnoticeable whereas other may
require treatment with steroid injections to possibly re­
verse the process. 
Fig. 37D.12 Unnecessary skin excision in the inframammary
fold, after excision for moderate gynecomastia. The result is un­
sightly and objectionable scarring, which is especially deforming
in men because the scar cannot be covered with a bra.
a
b
c
Fig. 37D.13 (a) Extreme deformity and debilitating result after
a Benelli (purse-string) technique with severe scarring, widening
of the nipple–areolar complex (NAC), and rippling. (b) Severe
circumareolar scarring 1 year after a Benelli pattern surgery. The
result demonstrates the opposite effect. The attempt to create
a smaller and more natural NAC resulted in a widened scar and
enlarged NAC. (c) Bilateral, severe unstable skin deformity with
extensive scarring 3 months after a Benelli excision.

637
Chapter 37 Gynecomastia
Loose Skin
Loose skin is generally caused by a lack of skin elastic­
ity and is more common in older patients.12 Formerly
obese men who have lost a great deal of weight or
any patient who has undergone drastic weight fluc­
tuation may also experience loose skin (Fig. 37D.15).
In severe cases, this problem can be corrected with a
mastopexy, which is essentially a breast lift. However,
I avoid mastopexy whenever I can because it can lead
to very noticeable scarring. Simple excision of the glan­
dular tissue does not significantly improve the result in
a lumpy-looking chest. This problem can be resolved
through a combination of liposuction or direct fat exci­
sion with proper gland excision, which is essentially a
remodeling of the chest to achieve an optimal aesthetic
result.
In addition, I use my own technique of creating the
usual small incision under the areola and undermin­
ing the skin all over the chest. At times the undermin­
ing may extend as much as 5 inches or more in each
direction. By extensively undermining the skin beyond
the chest borders, the excess skin over the breast is al­
lowed to take a more even distribution over the upper
abdomen and chest. This maneuver reduces the appear­
ance of a distinct inframammary crease that was pres­
ent under the expanded breast skin and redistributes
the skin more evenly. This requires more time and may
incur more bleeding but can prevent additional deform­
ing scars.
Mastopexy is very common for women, but this
procedure creates a scar on the areola and in an anchor
shape that extends beneath the breast in the inframa­
mmary crease. Women can hide the scar under a bra or
bathing suit, but if the goal of the chest contouring sur­
gery is for a man to finally feel comfortable removing
his shirt at the beach, a tremendous scar would defeat
the whole purpose.
Fig. 37D.14 This patient presented 2 years after a circumareo­
lar Benelli skin excision. The severe scarring required tattoos to
camouflage the deformity.
Fig. 37D.15 (a) Bilateral breast deformity with excessive skin after incomplete excision of the gynecomastia tissue. The patient
had lost significant weight before the initial surgery. (b) Contour improvement after reexcision and significant skin undermining
below the inframammary crease to redrape the skin appropriately.
a
b

SECTION V THE BREAST
638
Rashes and Skin Sensitivity
As with any procedure that requires compression
dressings, a garment, or elastic wrapping, it is pos­
sible to develop skin changes, reactions, and allergies
to the fabric in the form of contact dermatitis. These
are not related to the actual procedure, and the reac­
tion can expand beyond the borders of the dressings
(Fig. 37D.16). The treatment is removal of all offending
agents such as the compression garment, the tape, and
any ointment. Oral and topical treatment is adminis­
tered as antihistamines or steroid creams.
Postoperative “Puffy Areola”
In more than 5% of my cases, patients develop deep
scar tissue underneath the areola. This may appear at
first to be recurrence of glandular tissue, but that is not
the case. The tail of the gynecomastia gland is usually
short but may extend deep into the armpit. Therefore,
I always attempt to remove all glandular tissue and re­
move the tail in its entirety. Thus if these patients no­
tice a hard nodule in the axilla after surgery, it is almost
certainly not glandular tissue. The scar tissue often re­
solves spontaneously over time, but if not, serial Kena­
log injections may reduce the size of the scar and may
dissolve it. Ultimately, massages and observation will
ameliorate the problem, but it may take as much as a
year or more for resolution.
Radiologic studies are available for our skeptical pa­
tients who need reassurance to confirm that what they
are feeling is not glandular tissue but internal scarring.
This can be verified through mammography, computed
tomography, or magnetic resonance imaging. If the sur­
gery was performed competently, the patient is likely
palpating scar tissue, muscle, or soft tissue other than
gynecomastia. If test results demonstrate minimal gy­
necomastia under the areola, that does not mean that
a suboptimal procedure was performed. A minimal
amount of breast tissue remains deep to the areola to
prevent a depression. Surgical removal of scar tissue is
possible but rarely necessary.
Bruising, Swelling, and Hematomas
Bruising can last up to 3 to 4 weeks after surgery. The
patient is instructed to avoid sun exposure during this
time because of the risk of permanent skin pigment
changes. Bruises start as black and blue discoloration
and become yellow after about 5 to 7 days, disappear­
ing in 3 to 4 weeks. The key is not to mistake a bruise
for a hematoma (Fig. 37D.17).
During the first 3 days after surgery, patients may
use a cold compress to reduce the swelling; after that,
I recommend a warm compress. Patients should be in­
structed to contact their surgeon if they experience se­
vere swelling or extreme pain, which may indicate a
large hematoma (Fig. 37D.18). Large hematomas are
extremely rare in our practice. Either way, neither se­
roma nor hematoma will affect the long-term results
of the surgery, and both can be treated (Fig. 37D.19).
Swelling can vary depending on the patient and the
severity of the case. Sometimes it is localized to small
areas around the breast. Other times, it spreads through­
out the chest and abdomen (Fig. 37D.20). Generally
speaking, swelling and pigment changes start to recede
Fig. 37D.16 Severe skin rash from postoperative dressing. Con­
tact dermatitis and excessive sweating are likely the culprits.
Fig. 37D.17 Hematoma presenting as blood-tinged staining of
the dressing with soft tissue swelling 1 hour after gynecomas­
tia surgery.

639
Chapter 37 Gynecomastia
toward the end of the first week. They improve by the
second week and dissipate after 3 weeks.
Although much of the initial swelling will disappear
within a few weeks, it can take a long as 3 to 12 months
for all of the swelling to entirely disappear. It can take
even longer in secondary and severe cases.
Understanding Dynamic and
Static Depressions
To better understand the surgical results after gyneco­
mastia surgery, it is important to note the difference
between dynamic and static depressions. A dynamic de­
pression is a naturally occurring phenomenon in which
the breast changes shape when the arm is lifted or the
pectoral muscle is flexed. In my experience, about 20% of
normal-weight men without gynecomastia experience
an indent in their chests when flexing or lifting their
arms. Dynamic depressions occur naturally because of
a difference in muscle position, thickness, contraction,
and bone structure on one or both sides of the chest.
These include pectus excavatum or pectus carinatum.
Dynamic Depression
One important way to change or gauge results after
surgery is to test the muscle for a dynamic depression
Fig. 37D.18 Classic presentation of a large hematoma after gynecomastia surgery. The ecchymosis and swelling are clear to the
examiner, and the patient may report severe pain.
Fig. 37D.19 Evacuation of an organized-clot hematoma 5 days
postoperatively.
Fig. 37D.20 Severe ecchymosis 2 days after gynecomastia sur­
gery with excision and liposuction. The ecchymosis is scattered
over the chest and abdomen.

SECTION V THE BREAST
640
before surgery. Lifting the patient’s arms all the way
above his head or asking the patient to flex his pecto­
ralis muscle in a standing position, the surgeon looks
for any indent or depression in the chest. If gynecomas­
tia flattens when the patient lifts up his arms, it may
indicate a natural dynamic depression. For some men,
this natural dynamic depression may be asymmetrical,
showing on only one breast. If a patient has a dynamic
depression already, he can expect it to remain after
gynecomastia surgery. The good news about dynamic
depression is that it only appears when the arms are
raised or are flexed. Patients do not walk around with
their arms above their head, so the dynamic depression
is usually unnoticed (Fig. 37D.21).
It is possible to develop a dynamic depression in re­
sponse to gynecomastia surgery, especially if the patient
is already prone to it (Fig. 37D.22). This is often caused
by scar tissue and will diminish within 6 months to 1
year for most patients (although it can take longer, es­
pecially for severe or secondary cases).
Some people are more prone than others to adhe­
sions after surgery. A knot of scar tissue can tug on the
nipple to create a dynamic depression. The more severe
the internal scar tissue that builds up, the deeper the
dynamic depression. In my experience with secondary
patients who have already had gynecomastia surgeries,
it can sometimes take up to 3 years for the internal scar
tissue to subside.
Dynamic depressions after surgery are more com­
monly asymmetrical because of differences in the way
each side of the chest heals, though they can appear on
both sides of the chest. This, too, is normal, because no
body is perfectly symmetrical. The pectoralis muscles
may be more developed on one side than the other, or
the musculature may be slightly asymmetrical. For both
men and women, asymmetry is a fact of life.
Although it is possible to treat dynamic depressions,
I do not recommend it. Injecting fat into the chest to fill
the indent would basically re-create the appearance of
gynecomastia whenever the patient is not moving or
flexing. Given the choice, men virtually always prefer
an idealized appearance when at rest and can accom­
modate dynamic depression. Among my bodybuilder pa­
tients, I have never received a complaint about dynamic
depressions, and this demographic flexes for a living.
However, they know their own muscles and understand
that dynamic depression is normal.
Fig. 37D.21 Dynamic depression is caused by flexion of the pec­
toralis muscle and is apparent only with motion.
Fig. 37D.22 (a) Postoperative dynamic depression, which does not appear without flexion. The skin is adherent to the underlying
muscle. This results in a skin fold and deformity that is apparent upon movement of the pectoralis muscle. (b) Bilateral deformity
and depression of the breast after surgery performed by another surgeon.
a
b

641
Chapter 37 Gynecomastia
Simply put, surgeons and patients have a choice. On
the one hand, the surgeon might remove only a small
portion of the glandular tissue to reduce the chance of
dynamic depression, but doing so leaves gynecomastia
tissue behind. On the other hand, the surgeon can excise
the vast majority of the glandular tissue. Doing so drasti­
cally reduces the chances that the gynecomastia will re­
turn but slightly elevates the risks of creating a dynamic
depression. For most patients, the value of eradicating
gynecomastia outweighs the risk of dynamic depression,
because that dip is common in men who do not have
gynecomastia.
Static Depression
Static depression is an indent in the chest when relaxed
or standing still. Creating this type of breast depression
is very uncommon for experienced gynecomastia sur­
geons, but it is a problem when it occurs (Fig. 37D.23).
Fortunately, static depressions are amenable to treat­
ment. If the problem persists over a long time, it will
require surgical correction with fat injection or an adi­
pose flap (Figs. 37D.24 and 37D.25). As with dynamic
depressions, they may improve with time. Before a pa­
tient seeks treatment for a static depression, I recom­
mend waiting at least 1 year (up to 3 years if this is not
his first chest surgery), because there is a good chance
it will go away on its own.
Static depression is extremely rare, and although
many surgeons are wary of removing too much gland
lest it lead to this problem, it is possible in most cases to
remove almost the entire gland without creating a de­
pression. Both types of chest depression are more com­
mon in men older than 35 years because of the dimin­
ished skin elasticity that occurs with age.12 Even muscles
become less resilient with aging. Socially speaking a man
in his 30s is not old, but biologically speaking, his recov­
Fig. 37D.23 Significant and debilitating static depression after
gynecomastia surgery performed by another surgeon. The right
breast demonstrates removal of part of the pectoralis muscle
and only partial excision of the lower aspect of the gland. The
deformity was corrected with a local fat flap and later additional
fat injections.
Fig. 37D.24 Fat transfer to correct static depression of the
breast.

SECTION V THE BREAST
642
ery may not be as seamless as it would be if he were 20
years of age.
If a patient believes his depression is a direct result
of the gynecomastia surgery, he must provide a photo­
graph taken from at least 4 feet away. The plastic sur­
geon can then pick up expert clues from the posture
and stance to help determine whether the depression
is static or dynamic. This is a vital distinction. Physical
examination is preferred and is much more accurate.
Should the patient be unable to come for a postopera­
tive visit, however, photographs are the next best way
to accurately diagnose depression.
Choosing an experienced board-certified plastic
surgeon will significantly decrease the likelihood of de­
veloping a depression, but every body is different, from
bone structure to musculature to fat. Especially because
dynamic depressions are common naturally, it is impos­
sible to promise that a person definitely will not develop
a depression of any sort. Depressions may be caused, in
rare cases, by the excision of the gynecomastia tissue,
so every patient should think seriously about whether
surgery is a good option for him.
Conclusion
As gynecomastia surgery becomes more popular, more
complications will occur and be recognized. Of my ex­
perience with more than 7,000 gynecomastia patients
from around the world, approximately 15 to 20% are
patients from other practices searching for a revision or
improvement of their primary procedure. This discus­
sion highlights the most common and significant com­
plications that a surgeon might encounter while caring
for these patients to avoid and treat these outcomes in
the best manner.
Fig. 37D.25 (a,b) Bilateral breast static depression and asymmetry. (c,d) Significant improvement of both breasts after fat trans­
fer surgery.
a
b
c
d

643
Chapter 37 Gynecomastia
References
1. Guenther D, Ha RY, Rohrich RJ, Kenkel JM. Treatment
of gynecomastia. In: Nahai F, ed. The Art of Aesthetic
Surgery, Principles and Techniques. St. Louis, MO:
Quality Medical Publishing, Inc.; 2011
2. Kenkel JM, Gingrass MK, Rohrich RJ. Ultrasound-as­
sisted lipoplasty. Basic science and clinical research.
Clin Plast Surg 1999;26(2):221–234, vii
3. Gingrass MK, Kenkel JM. Comparing ultrasound-
assisted lipoplasty with suction-assisted lipoplasty.
Clin Plast Surg 1999;26(2):283–288, ix
4. Fára M, Hrivnáková J. Reduction mammaplasty in se­
rious gynaecomastias using a single superiorly based
flap. Acta Chir Plast 1981;23(3):159–162
5. Morselli PG. “Pull-through”: a new technique for
breast reduction in gynecomastia. Plast Reconstr Surg
1996;97(2):450–454
6. Rohrich RJ, Raniere J Jr, Beran SJ, Kenkel JM. Patient
evaluation and indications for ultrasound-assisted
lipoplasty. Clin Plast Surg 1999;26(2):269–278, viii
viii.
7. National Plastic Surgery Statistics Website. http://

es/statistics/2015-statistics/2015-plastic-surgery-
statistics-infographic.pdf. Accessed July 31, 2015
8. Courtiss EH. Gynecomastia: analysis of 159 patients
and current recommendations for treatment. Plast
Reconstr Surg 1987;79(5):740–753
9. Blau M, Hazani R. Correction of gynecomastia in body
builders and patients with good physique. Plast Re­
constr Surg 2015;135(2):425–432
10. Târcoveanu E, Lupaşcu C, Vasilescu A, et al. [Surgi­
cal treatment of gynecomastia]. Chirurgia (Bucur)
2008;103(6):643–650
11. Babigian A, Silverman RT. Management of gyneco­
mastia due to use of anabolic steroids in bodybuild­
ers. Plast Reconstr Surg 2001;107(1):240–242
12. Uitto J. The role of elastin and collagen in cutaneous
aging: intrinsic aging versus photoexposure. J Drugs
Dermatol 2008;7(2, Suppl)s12–s16

644

Breast Reconstruction with Implants
Amy S. Colwell
Implant reconstruction is the most common means to re­
build the breast in the United States. There has been a para­
digm shift in the past 10 years, with more patients choosing
mastectomy and bilateral mastectomy over lumpectomy and
implant instead of autologous reconstruction.1,2 The reasons
for this shift are multifactorial and include the enhanced
ability to create reconstructions that closely resemble the
native breasts. Improvements in mastectomy technique with
skin and nipple preservation and refinements in reconstruc­
tion with partial muscle release and acellular dermal matrix
(ADM) have contributed to the improved overall result.3–5
Despite advances in techniques, implant-based breast
reconstruction has one of the highest rates of infection and
complications of any procedure in plastic surgery.6–8 With
mastectomy, the breast skin vascular supply is compro­
mised, and in this compromised setting a foreign body is
introduced. However, implant reconstruction is largely suc­
cessful and has the advantage of a quicker recovery com­
pared with autologous reconstruction with no donor site
morbidity. A thorough understanding of surgical technique
and the potential for complications or unfavorable results
can reduce risks and help minimize avoidable mistakes. This
chapter discusses surgical planning and technique for breast
reconstruction with implants, identifies possible untoward
events, and provides a template for management and pre­
vention.
CHAPTER
38
Summary Box
Complications and Unfavorable Results in
Breast Implant Reconstruction
Immediate/Early
•• Skin necrosis/nipple necrosis
•• Delayed healing
•• Erythema
•• Infection
•• Seroma
•• Hematoma
•• Dehiscence or exposure
•• Suboptimal shape
•• Implant malposition or inadequate size
•• Nipple malposition

Late
•• Capsular contracture
•• Implant rupture
•• Animation deformity
•• Keloid or hypertrophic scar
•• Upper pole deficiency or divots
•• Implant rippling
•• Implant malposition or inadequate size
•• Symmastia or overdissection of the medial border
•• Suboptimal shape
• Chronic pain
Avoiding Unfavorable Results and Complications in Breast
Reconstruction with Implants

645
Chapter 38 Breast Reconstruction with Implants
ume is assessed to ensure the correct implants and/or ex­
panders are available at the time of the surgery. Routine lab
values are obtained. A nasal swab to assess the skin flora
is considered for health care workers, recently hospitalized
patients, or those receiving neoadjuvant chemotherapy.9
The flora in these patients may include methicillin-resis­
tant Staphylococcus aureus (MRSA) or gram-negative rods.
These would not be covered in routine perioperative anti­
biotic administration.
Incisions
An increasing proportion of mastectomies are nipple-spar­
ing. The surgical oncologist decides whether the patient is
a candidate for nipple preservation based on the oncologic
risk, and the plastic surgeon then decides whether it is a
good idea aesthetically. Patients with grade I or grade II
ptosis are often good candidates for nipple-sparing mas­
tectomy (NSM). Breasts with grade III ptosis or very large
breast size are assessed on an individual basis with con­
siderations for premastectomy staged mastopexy or a two-
stage tissue-expander implant reconstruction using an
inferior vertical approach. For NSM, incision placement is
planned with the surgical oncologist4 (Fig. 38.1). A lateral
radial incision optimizes blood supply to the nipple and
may therefore be optimal for those inexperienced with the
technique. An inferolateral IMF incision optimizes cosme­
sis.10 The incision starts at approximately the 6 o’clock po­
sition and extends to the 3 or 9 o’clock position. Therefore
the incision becomes longer with increased breast size. This
is advantageous for removing the upper pole breast tissue
and also for axillary lymph node sampling. The incision
curves along the natural border of the breast and is thus
hidden. With experience, this incision minimizes the risk
of complications, which may be related in part to the in­
creasing thickness of breast skin as it nears the abdominal
transition. Full-thickness periareolar incisions are avoided
because of the higher risk of nipple necrosis. As previously
mentioned, an inferior vertical incision is chosen for ptotic
breasts for greater uplift and improved nipple centraliza­
tion.
If nipple preservation is not possible, skin-sparing or
skin-reducing incisions are planned according to current and
desired breast size. Incisions may be oriented transversely or
vertically depending upon the width of the breast and an­
ticipated axillary extension. Although the Wise/inverted-T
skin pattern optimizes cosmesis for large breasts, it is asso­
ciated with a higher rate of complications.
Direct-to-Implant or Tissue
Expander–Implant Reconstruction
The gold standard of implant reconstruction remains a
two-stage approach with a tissue expander followed by ex­
change with an implant at a second surgery. However, there
Surgical Planning and Technique
Preoperative Planning and Considerations
Initial Consult
Planning for implant reconstruction starts at the initial
consultation. General health is assessed with age, BMI, and
comorbidities. Whether the mastectomy is for cancer or
prophylaxis can influence decisions on nipple preserva­
tion, laterality, and adjuvant treatment with chemotherapy
and/or radiation. Specific attention is focused on identify­
ing risk factors for implant failure. Active smoking, morbid
obesity, uncontrolled diabetes, anticoagulation, and immu­
nosuppression all pose challenges to reconstruction and in
some cases require no or delayed reconstruction for patient
safety (Box 38.1).
Patients who are actively smoking at the time of con­
sultation are strongly encouraged to quit. If still smoking
at the time of surgery, these patients must understand that
immediate reconstruction may be deferred until a later time
depending upon how the skin responds to the mastectomy.
I will not use ADM in active smokers and would only con­
sider two-stage tissue expander–implant reconstruction
with near-total muscle coverage or delayed reconstruction.
Morbidly obese patients pose challenges for both implant
and autologous reconstruction in relation to risk profile and
overall cosmetic result. Immediate one- or two-stage sur­
gery is considered on an individual basis depending upon
the quality of the mastectomy skin envelope. Similarly, un­
controlled or severe insulin-dependent diabetes and im­
munosuppression increase the risk of complications. Mod­
est immunosuppression from neoadjuvant chemotherapy
is typically not considered a contraindication to immediate
breast reconstruction, but transplant recipients on chronic
immunosuppressant regimens require delayed or no recon­
struction. Active therapeutic anticoagulation with coumadin
or unfractionated or low-molecular-weight heparin poses
too high of a risk for bleeding to consider immediate recon­
struction if it cannot be suspended perioperatively.
The physical examination records important anatomic
landmarks, including notch–nipple, nipple–fold, and breast-
base width dimensions. Overall breast and inframammary
fold (IMF) symmetry is noted. An estimation of breast vol­
Box 38.1
•• Active smoking
•• Morbid obesity
•• Uncontrolled diabetes
•• Anticoagulation
•• Immunosuppression
High-Risk Patients for
Implant Reconstruction

SECTION V THE BREAST
646
plications, because the muscle covers the expander, but the
disadvantage is difficulty in achieving a natural shape and
in performing DTI reconstruction.
Surgical Technique
The IMF is marked on each breast, and its relation to the
opposite breast is noted for symmetry. The incision is
marked with input from the surgical oncologist. A paraver­
tebral block gives significant analgesia during the surgical
procedure and for the next 24 to 36 hours. If resources are
available, this block can be offered to all immediate implant
reconstructions. Before induction, pneumatic compression
devices are placed and intravenous antibiotics are given.
The anterior chest, and extending laterally to the operat­
ing room table, is prepped with chlorhexidine or iodine
povacrylex, and sterile drapes are placed. Once the mas­
tectomy is complete, the patient’s skin is reprepped with
chlorhexidine, avoiding the open incisions. New sterile
drapes are placed over the existing drapes. The patient’s
arms are angled approximately 75 degrees from the operat­
ing room table, and muscle paralysis is used in conjunction
with general anesthesia to facilitate subpectoral muscle
dissection.
Skin Inspection
The skin is inspected for color and overall thickness (Fig.
38.2). A blue-gray hue, exposed dermis on the undersur­
face, button holes, or excessive thinness of the skin flap pre­
dict ischemia. If present, a DTI procedure should typically
be avoided and delayed reconstruction contemplated. No­
tably, the thickness of the flap alone cannot be relied upon
as the only marker of the quality of the skin flap, because
traction and cautery injury manifest as changes in the color
of the skin rather than in the overall thickness. It may seem
logical that very large breasts would have ample skin to
work with and thus make them ideal DTI candidates. How­
ever, often the skin is more compromised in these patients,
is increasing interest in direct-to-implant (DTI), single-
stage reconstruction.11 With DTI, the final implant is placed
at the time of the mastectomy, which obviates a second­
ary surgery to replace a temporary expander. Patients are
considered candidates for DTI if their goal is to stay about
the same size. The best candidates are nonsmokers within
normal weight range who are also relatively symmetrical
and overall healthy. A reliable breast surgeon is critical to
the success of DTI reconstruction. Patient preferences also
strongly influence whether one- or two-stage surgery is
performed. The final decision is made at the time of sur­
gery after the mastectomy and depends on how the breast
skin responds to the mastectomy.
Acellular Dermal Matrix
The advent of ADM offered the ability to release the pec­
toralis muscle inferiorly, thus creating a pleasing breast
contour, while avoiding pectoralis muscle retraction and
implant malposition laterally or inferiorly (bottoming out).
The first and most commonly used ADM is human ADM.
Human ADM is very malleable, thus contouring to the im­
plant, yet it retains the strength necessary to uphold im­
plant reconstructions. It yields another advantage of long-
term soft tissue support, which most patients undergoing a
mastectomy benefit from. A number of other products have
been developed from porcine dermis, fetal bovine dermis,
and synthetic products such as silk or Vicryl. ADM is used
for most one- and two-stage reconstructions, although
some surgeons still prefer two-stage reconstruction with
total or near-total muscle coverage. The advantage of total
muscle coverage includes a potentially lower risk of com­
Periareolar incision
Horizontal radial incision
Inferolateral inframammary
fold incision
Inferior radial incision
Fig. 38.1 Common incisions used in nipple-sparing mastectomy.
Full-thickness periareolar incisions are typically avoided because of
the increased risk of complications. (Modified from Colwell AS, Tes­
sler O, Lin AM, et al. Breast reconstruction following nipple-sparing
mastectomy: predictors of complications, reconstruction outcomes,
and 5-year trends. Plast Reconstr Surg 2014;133(3):496–506.)
Fig. 38.2 After mastectomy, the skin is evaluated for perfusion and
thickness. In this patient, the color of the skin appears completely
normal and the skin thickness appropriate for her size, with a mot­
tling of subcutaneous fat.

647
Chapter 38 Breast Reconstruction with Implants
ically fits the skin envelope the best, whereas in skin-sparing
mastectomies a small decrease in size is often necessary.
A tissue expander is chosen to match the breast width,
with nipple centralization for NSM, and to accommodate
the desired increases in breast volume. I prefer to sew the
ADM to the chest wall as the initial step, and subsequently
to tailor the ADM–pectoralis muscle border with the im­
plant in place. The rectangular or contoured ADM is ori­
ented in place in the pocket. I prefer permanent sutures (0
Ethibond) for the ADM–chest wall stitches and absorbable
sutures from the ADM to the pectoralis muscle (2–0 Vicryl),
although some authors prefer absorbable sutures for both.
Permanent sutures may be advantageous for defining a new
IMF or lateral breast border.
The ADM is first stitched medially to the released border
of the pectoralis muscle. It is important to leave some redun­
dancy medially to accommodate the implant. A tight medial
pocket will serve to push the implant laterally. The second
stitch is sewn to the IMF to prevent medial constriction, and
the subsequent sutures are then sewn to the chest wall. If
the IMF is intact, the ADM can be sewn to the fold; however,
round implants will drop 1 to 2 cm postoperatively; shaped
implants will also drop, but not to the same degree. If the
IMF is not intact and the ADM is sutured to the skin flap, this
will lead to bottoming out.
As the pocket proceeds laterally, horizontal mattress
sutures are placed from the ADM to the serratus muscle,
avoiding redundancy. A medial and lateral stitch from the
ADM to the pectoralis muscle is then placed along with a
sizer. The most commonly used sizers are disposable saline
sizers. Although the sizers do not exactly match the look of
the silicone implants, they approximate it well, and with
experience predictable results are achieved. Silicone sizers
are available but cost more, and many institutions do not
have the correct equipment for their sterilization for mul­
tiple uses. A sizer is sewn into the pocket with a U-stitch to
keep it in place.
The skin is stapled shut and the patient is positioned up­
right to check symmetry and pocket dimensions and for the
which may be related to the distance the blood needs to
travel to cover the entire anterior breast surface and to the
traction injury that may occur when removing the large
volume of tissue.
Partial Pectoralis Muscle Release
The pectoralis muscle is released from its lateral edge to
the medial sternal attachment using electrocautery. Care
is taken to coagulate the vessels with electrocoagulation in
two places and perform division in between. Inferiorly, the
pectoralis muscle is typically divided approximately 1cm
above its attachment to prevent disruption of the IMF, if
intact. Dissection proceeds medially until the 4 or 8 o’clock
position on the chest wall (Fig. 38.3). This extent of dissec­
tion is necessary to avoid lateralization of the implant. Fur­
ther dissection can be performed, but this results in more
subcutaneous coverage of the implant and requires a larger
piece of ADM.
Pocket Creation
The lateral border definition for most mastectomies is the
anterior border of the latissimus dorsi muscle, which is sig­
nificantly more lateral than the desired border of the new
reconstruction. The width of the new breast pocket is de­
signed approximately 1 cm more narrow than the desired
implant to account for the stretch inherent in human ADM
(Fig. 38.4). If alternative stiffer products are used, the di­
mensions may more closely resemble the base width of the
implant.
For DTI, the implant volume is estimated based on
breast-base width, breast weight, and desired postoperative
size. For NSM, a small increase in the size of the implant typ­
Pectoralis major
muscle
Fig. 38.3 The pectoralis muscle is released inferiorly to allow a natu­
ral breast shape with tissue expander–implant or direct-to-implant
reconstruction. The pectoralis muscle is released to the 4 or 8 o’clock
position to allow the implant to fit under it.
Fig. 38.4 The pectoralis muscle is released to the 4 or 8 o’clock
position. A ruler is inserted to the medial point of dissection, and a
pocket is planned for the anticipated implant or expander.

SECTION V THE BREAST
648
commonly involved in implant infections and implicated in
the biofilm that may be related to capsular contracture. He­
mostasis is achieved with particular attention paid to bleed­
ing on the surface of the pectoralis muscle and in the axil­
lary region. The surgeon’s gloves are changed, and the skin
is washed with an antibiotic solution.
During DTI, it is important to check that the patient re­
mains paralyzed; otherwise it may be difficult to get the
implant into the pocket, and the muscle will contract away
with attempts to stitch it to the ADM.
The implant or expander is then placed and the ADM is
tailored and trimmed if necessary to give a tight fit to the
implant. A tight fit will put tension on the muscle and help
prevent a retraction contour abnormality; it will also help
position the implant medially and help prevent lateraliza­
tion and bottoming out12 (Figs. 38.6 and 38.7, Video 38.1).
The expander is filled with a closed system consisting
of a bag of saline and a three-way stopcock to deliver the sa­
line to the expander (Fig. 38.8). The pocket is irrigated once
again before closure.
Closure
The skin edges are trimmed or deepithelialized. Deepitheli­
alization has the advantage of leaving more dermal support
and contact and can leave three solid layers to close with ab­
sorbable sutures. The incisions are then sealed with a sur­
gical glue followed by clear adhesive dressings. Biopatches
(Johnson & Johnson) are impregnated with chlorhexidine
and are used around the drains to help prevent drain-site
infections. Microfoam tape is often applied laterally to push
the implant more medially and minimize the suction defor­
mity that can be caused by the drain, which may lie close
to the medial border of the pocket (Fig. 38.9). This is also
final decision-making steps for DTI (Fig. 38.5) As the sizer
is inflated, significant red or blue discoloration indicates the
skin cannot withstand a full-sized implant, and a decision is
made to place an expander or a smaller implant.
If available, objective measuring devices using indocya­
nine green (SPY, Novadaq) or other perfusion imaging mo­
dalities may help determine whether it is possible to place
an implant and whether the skin will be viable. Although the
exact cut-off numbers have not been determined for the SPY
system, values in the low teens or significant drops in num­
ber with inflation of the sizer should be viewed with cau­
tion. The pocket IMF position and lateral border are viewed;
it is important to have a hand-in-glove fit of the ADM with
the lower pole breast skin. If the vertical dimension of the
ADM is too short, the implant or expander will be pushed
superiorly and/or flattened, and the breast skin may hang
below the implant. This space is prone to seroma forma­
tion when the drains are removed, and the ADM will not
be incorporated.
Implant Insertion
Two drains are placed, with one running along the IMF and
the other in the axilla and over the muscle. The exit sites
should be tunneled 1 to 2 cm away from the breast pocket
to allow and encourage closure soon after drain removal.
Ideally these sites are placed above the position of the
IMF so that they cannot be seen when the patient wears a
swimsuit. However, the extent of lateral dissection with the
mastectomy may preclude this.
The pocket is first irrigated with dilute betadine solu­
tion, followed by two rinses of a triple antibiotic solution
containing cefazolin, gentamycin, and bacitracin. These com­
binations have been shown to target the organisms most
Fig. 38.5 A sizer is placed into the pectoralis–ADM pocket and sewn
into place. The skin is stapled shut, and the sizer is inflated to the
desired size. The pocket dimensions and skin color are observed dur­
ing the inflation. The patient is then positioned upright to assess
symmetry.
Fig. 38.6 The implant or expander is placed into the pocket, and
the pocket is closed using absorbable sutures. A tight fit is impor­
tant for implants, whereas a slightly looser pocket is tolerated for
expanders to accommodate the anticipated fill. Too loose a fit for
expanders or implants can lead to bunching of the muscle and a
step-off deformity.

649
Chapter 38 Breast Reconstruction with Implants
muscle spasms. Activity and arm movement are restricted
until the drains are removed. Arm range of motion is
started 3 to 4 weeks after surgery, and strenuous exercise
is avoided for 2 to 3 months. Implant massage is started at
4 weeks for round implants. Gentle massage can help pre­
vent capsular contracture, whereas aggressive massage is
avoided to help prevent implant malposition and rippling.
If the patient has textured implants, no implant massage is
recommended. For women working outside the home at a
desk job, the average time off work is around 4 to 6 weeks.
At 3 months, there are no restrictions. Figs. 38.10–38.13
show case examples.
covered by clear adhesive dressings to allow the patient to
shower postoperatively.
Postoperative Care
No bra is worn until postoperative day 1. At this time, a
loose-fitting bra is used for some support. Compression
garments should not be used, because they place too much
pressure on the healing skin. While the patient is in the
hospital, oxygen is administered by nasal cannula and is
not weaned. Patients are discharged on postoperative day
1 or 2. Oral antibiotics are continued until the drains are
removed, and medication is provided for pain control and
Pectoralis muscle
released inferiorly
Acellular dermal
matrix sewn to
pectoralis muscle
and chest wall
Implant
Fig. 38.7 Acellular dermal matrix acts as an extension of the pectoralis muscle to the chest wall. The inferior aspect of the pectoralis muscle
is sewn to the acellular dermal matrix, which is sewn to the chest wall, creating a complete pocket around the implant.
Fig. 38.8 A closed system is used to inflate the tissue expander for
sterility.
Fig. 38.9 Microfoam tape is often placed to help secure the lateral
border of the implant or expander. Clear adhesive dressings cover
the tape for showering and can assist in positioning the nipple.

SECTION V THE BREAST
650
Fig. 38.10 (a–c)This 40-year-old woman had breast cancer of the left breast. (d–f) She underwent bilateral nipple-sparing mastectomy and
direct-to-implant reconstruction using smooth round silicone gel implants.
a
b
c
d
e
f
Fig. 38.12 (a–c) This patient desired a significant enhancement in breast size. A two-stage tissue expander–implant reconstruction most
reliably obtains this goal. (d–f) Her postoperative course was complicated by a fall yielding a quarter-sized area of thinning in the inferolat­
eral region of her right breast. This was excised and closed at the time of tissue expander exchange, yielding a mild flattening of the region,
which eventually resolved.
a
b
c
d
e
f
Fig. 38.11 (a) In a larger-breasted patient
with ptosis, direct-to-implant reconstruction
remains possible. (b) Although a vertical in­
cision would have served to raise the nipple
position to a greater degree, the inferolateral
inframammary fold incision has the advantage
of a hidden scar, which many patients find
preferable, at the expense of a slightly lower
nipple position.
a
b

651
Chapter 38 Breast Reconstruction with Implants
these situations, the patient is closely followed and main­
tained on antibiotics. The skin may be covered in bacitracin
and/or a xeroform dressing to encourage wound healing
and minimize bacterial contamination. Typically skin de­
marcates by 2 to 3 weeks.
The nipple has a remarkable ability to heal after surgery,
and significant discoloration does not necessarily correlate
with full-thickness necrosis. In general, demarcation often
ensues around 4 weeks postoperatively and can be managed
with surgical excision at that point if necessary. If the areola
is not involved, it may be worth preserving for future nipple
reconstruction and to minimize tension on the closure.
Delayed Healing
As mentioned previously, delayed healing presents as skin
discoloration without full-thickness necrosis (Fig. 38.15).
Antibiotic ointment is typically applied, and expansion is
delayed until full recovery.
Erythema
Skin erythema presents as red or pink discoloration after
reconstruction. It is fairly common but may cause a diag­
nostic dilemma in determining which patients have ery­
thema related to infection versus those with erythema for
other reasons. The most common cause is related to isch­
Managing Unfavorable Results
and Complications in Breast
Reconstruction with Implants
Immediate Postoperative
Complications and Unfavorable Results
Skin or Nipple Necrosis
The most common complication in immediate breast re­
construction is inadequate blood supply to the skin or nip­
ple (Fig. 38.14). During mastectomy, the blood supply may
be compromised by making the skin flaps too thin or by
traction or cautery injury. As noted, skin thickness is only
one variable in determining whether the skin will survive.
Traction or cautery injuries are more commonly observed
by skin color and capillary refill and may not be related to
skin thickness. The blood supply may also be compromised
during the reconstruction by excessive traction on the skin,
or from the pressure resulting from an implant that is too
large or excessive volume in the expander. If skin necro­
sis is noted immediately after surgery, the patient is taken
back to the operating room for excision and exchange,
downsizing, or explant of the implant or expander. How­
ever, delayed healing is often difficult to distinguish from
full-thickness skin necrosis immediately postoperatively. In
Fig. 38.13 This young patient with the BRCA mutation had a two-stage tissue expander–implant reconstruction after nipple-sparing mas­
tectomy.
Fig. 38.14 This patient had a history of smoking and had reportedly quit for the sur­
gery. The patient later admitted to active smoking. The discoloration of the nipple is
consistent with partial-thickness injury, which later completely recovered. The lower
area near the incision was consistent with full-thickness necrosis and required surgi­
cal débridement.

SECTION V THE BREAST
652
is unlikely to be successful. In the absence of fluid, a trial of
antibiotics is started. The most common antibiotics are van­
comycin and linezolid, with or without ciprofloxacin or levo­
floxacin. The assumption is that the perioperative antibiotic
choice of a cefazolin or clindamycin was not effective in pre­
venting an infection, and therefore broader spectrum antibi­
otics to cover MRSA and gram-negative rods are attempted.
If the antibiotics fail to clear the infection, the patient
is taken to the operating room for implant exchange or ex­
plant (Fig. 38.16). If there is no fluid in the pocket and it is
otherwise clean, the implant is exchanged; however, if there
is clearly infection in the pocket, the implant is removed.
In either case, a drain is placed and postoperative antibiot­
ics are continued for 2 to 4 weeks. Perioperative cultures
are performed and antibiotics are tailored to the bacterial
sensitivities.
Critics argue that any clear cellulitis should be treated
with explantation and delayed reconstruction performed
once the infection has cleared. However, in our institutional
experience, implant salvage is successful in around 40% of
patients.14 Furthermore, implant reconstruction after ex­
plantation can be very challenging, especially for nipple-
sparing mastectomies, and it may be impossible, such as in
cases with coexistent radiotherapy (Fig. 38.17).
After explantation, reconstruction is considered once
the swelling and redness have completely resolved. In most
cases, it is beneficial to wait at least 3 months. Although
some argue for waiting 6 months to 1 year, there is little
objective data to support this. I initiate antibiotic therapy
specific to the original infection 1 or 2 days before the sec­
ondary reconstruction to help prevent a second infection.
emic changes with the stress of surgery. This manifests
either immediately after surgery or within the first week.
Typically erythema worsens after postoperative day 1 and
is likely related to surgical swelling. The erythema of isch­
emia is not associated with fever, purulent drain discharge,
or unexpected pain. Timing is the best determinate of the
erythema of ischemia, because it is present soon after sur­
gery and gradually resolves after 1 week. Erythema may
also be present with infection and seroma, which are dis­
cussed in the following sections. A diagnosis of red breast
syndrome or allergic reaction is typically a diagnosis of ex­
clusion and related to a skin local reaction to preservatives
in the ADM, mesh, implant, or sutures.
Infection
An infection presents as pink or red skin, fever, pain, and/or
a generalized feeling of being unwell. Infections range from
mild cellulitis to severe periprosthetic infections. A severe
infection typically is associated with high fever, elevated
white blood cell count, and a red swollen breast in a patient
who looks and feels unwell. These are best managed with
operative washout and explant.
However, a spectrum of infection is encountered clini­
cally and can be managed in a stepwise approach.13 The first
step in management is oral or intravenous antibiotics. If it
is unclear, an ultrasound can be used to determine whether
there is a periprosthetic fluid collection. A cellulitis with a
periprosthetic fluid collection most commonly indicates the
infection has spread to the implant pocket and that salvage
Fig. 38.15 (a) This patient was considered for direct-to-implant reconstruction; however, at the time of mastectomy, the quality of her skin
was not sufficient and expanders were placed. (b,c) After surgery, she had skin discoloration suggestive of ischemia. Further fluid was re­
moved from the expander and the patient was followed closely. (d–f) The skin and nipple recovered completely and she was exchanged for
implants. Her nipples remain slightly lateral; however, mastopexy options in patients with significant perioperative ischemia may be risky.
e
d
f
b
c
a

653
Chapter 38 Breast Reconstruction with Implants
The first step in management is drainage. This can be
done in the office if a tissue expander is in place. The port
site is localized and a needle is introduced into the port. The
needle is then pulled back just out of the port but inside the
breast pocket, and the surgeon attempts to aspirate and push
the fluid toward the needle. At the same visit the tissue ex­
pander is inflated to take up volume previously filled by the
fluid. If the fluid appears to be at the most inferior aspect of
the breast and the breast skin hangs below the level of the
expander or implant, it is safe to introduce a needle into
this space and drain the fluid. The fluid should be sent for
Gram stain and culture. If the fluid is not readily drainable,
consideration is given to interventional radiology aspiration
or operative drainage. Operative drainage is performed for
infected seroma, failed attempts or recurrent drainage de­
spite aspiration, or if a mismatch in the pectoralis muscle
and ADM pocket exists and is not likely to resolve on its own.
Seroma
Fluid production after mastectomy routinely occurs while
the body is adjusting to the trauma and the lymphatic ves­
sels are sealing. Drains remove this fluid until the body is
capable of absorbing it on its own, which typically corre­
sponds to a drain output of less than 20 to 30 mL per day. Af­
ter drain removal, seroma fluid can accumulate if the body
continues to produce fluid at a rate that is higher than it can
absorb. This often occurs if the drains are removed before
the output meets criteria. Drains are typically removed 3
to 4 weeks after surgery regardless of output, because they
serve as a direct portal into the breast implant pocket.
Seroma may also develop if the skin is not opposed to
the pectoralis-ADM pocket. A space between the two will
fill with fluid and is difficult to fully eradicate. Finally, pro­
longed fluid production and seroma may be the result of
an infection.
Fig. 38.16 (a) In this patient, bilateral direct-to-implant reconstruction was performed after mastectomy. (b) She initially did well but then
presented with right lower pole erythema 3 weeks after surgery and 1 week after drain removal. She had no fever and generally felt well.
Her erythema improved with antibiotics but did not completely resolve, and she had significant tightness on the right side. She was taken
to the operating room where the pocket looked pristine with no signs of fluid or pus. A lateral capsulectomy was performed to remove a
thickened lateral capsule, and a new implant was placed with a drain. (c) She is shown 3 months after the procedure with no signs of recur­
rent infection or capsular contracture.
a
b
c
Fig. 38.17 After explant, the nipple position rises superiorly. When the expander is replaced, it is important to place the expander higher
than typical to avoid pushing the nipple more superior. Despite our best efforts, the breasts remain relatively asymmetrical when one im­
plant is lost. This patient had bilateral nipple-sparing mastectomy procedures with tissue expanders. At the time of her tissue expander
exchange, she was recovering from an active finger infection with methicillin-resistant Staphylococcus aureus (MRSA) and didn’t think to in­
form us for the procedure. (a) After exchange, she developed MRSA of her left implant, requiring explantation. (b) Three months later her
expander was reinserted with acellular dermal matrix and she was filled to the appropriate volume. After exchange, the implants remain
soft and mobile; however, her breasts are still asymmetrical.
a
b

SECTION V THE BREAST
654
nipple position. Lateralization of the nipple is common and
is exaggerated when a higher profile (more narrow) implant
is used and secured in a medial position, thus shifting the
nipple to the lateral aspect of the breast reconstruction. It
is also common and predictable in a large breast with grade
II to III ptosis. Lateralization can be minimized with selec­
tion of the correct base width implant or expander at the
initial surgery. These implants and expanders are typically
wider than would be selected for skin-sparing mastecto­
mies to keep the nipple as central as possible with implant
placement or with tissue expansion. For large breasts, an
inferior vertical incision is often chosen to help with nipple
position. This particular incision minimizes lateralization
more than any other incision currently used. If lateraliza­
tion occurs, it is difficult to correct. If it is bothersome to
the patient, periareolar mastopexies can be used to mod­
estly improve the position, or the nipple may simply be
removed and reconstructed. For nipples that remain lower
than ideal, a superior periareolar mastopexy or an inferior
tightening along the vertical incision can be performed to
shift the position superiorly. In bilateral cases, inferior or
superior mastopexies can be used secondarily to achieve
the best position. Although a complete circumvertical mas­
topexy can be performed if the dermal blood supply is left
intact, there is a risk of nipple loss with this procedure. The
patient should be counseled for the possibility of loss, and if
something less than a complete circumferential mastopexy
can be performed, it may minimize the risk. Implant mal­
position contributing to nipple malposition is more easily
corrected with repositioning of the implant.
Late Complications and Unfavorable
Results
Capsular Contracture
The most common long-term complication in implant-
based reconstruction is capsular contracture (Fig. 38.18).
Although the mechanisms remain largely unknown, certain
risk factors undoubtedly contribute to its development. Risk
factors include significant ischemia at the time of a DTI re­
construction, hematoma or bleeding, implant rupture, radi­
ation, and bacterial contamination or biofilm. In the absence
of radiotherapy, early capsular contracture is managed by
first obtaining MRI to rule out rupture. In the absence of rup­
ture, the patient is instructed to aggressively massage the
implant and potentially start taking montelukast. Evidence
in the literature and personal experience suggest that mon­
telukast may mitigate the forces of contracture and either
resolve an early contracture or prevent contracture progres­
sion.15 If capsular contracture does persist or worsen, op­
erative intervention is undertaken to remove the thickened
capsule and replace the implant. If implant rupture is pres­
ent, capsulectomy or near-total capsulectomy is performed
with replacement of the implant either with or without re­
Other Complications
Wound dehiscence or exposure may stem from tissue isch­
emia or may be a result of too much tension placed on the
skin envelope at the time of closure, particularly in the
setting of radiation. Dehiscence is treated with urgent op­
erative removal of the implant or expander and possible
replacement if no signs of infection exist. Replacement pro­
ceeds with a smaller implant or smaller fill volume to the
expander. Bleeding most commonly presents 24 to 48 hours
after surgery but may be delayed for several weeks. A hema­
toma is always treated with operative evacuation to identify
the source of bleeding and control it with washout and im­
plant replacement. Small delayed hematomas should also
be operatively washed out to help mitigate against long-
term capsular contracture.
Implant Malposition and Size Changes
Unfavorable implant position may occur immediately or
early after surgery if the correct position was not obtained
at the time of surgery. Similarly, if a smaller implant than
desired was placed in an attempt to perform DTI reconstruc­
tion safely, the outcome may be unfavorable and a secondary
surgery necessitated to correct the size. Typically revisions
for implant malposition or size are performed 3 to 6 months
after the initial surgery to allow for skin recovery and wound
healing. However, if a tissue expander is severely misaligned,
it should be repositioned early to avoid unusual expansion
of the breast skin envelope, which may not be correctable at
the second stage.
Poor Implant Shape
With total muscle coverage the breast had a flat lower pole
and a teardrop shape was difficult to achieve. With partial
muscle coverage this problem has largely resolved. How­
ever, patients undergoing a skin-sparing or skin-reducing
mastectomy should be prepared that the breast will have a
flattened appearance that may resemble the look of natural
breasts in a sports bra, despite the use of the highest profile
and most projecting implants. The flattened appearance is
largely avoided if nipple preservation is possible. If total
muscle coverage is planned, obtaining a natural appearance
to the breast can be challenging.
Nipple Malposition
The position of the nipple after nipple-sparing mastectomy
is largely reflective of the preoperative position. Although it
is expected that the nipple will elevate superiorly 1 to 2 cm
with mastectomy, it does not magically obtain a completely
normal position. Therefore, for patients with significant
ptosis, the decision on whether to preserve the nipples lies
in part with the patient in her acceptance of a relatively low

655
Chapter 38 Breast Reconstruction with Implants
Animation Deformity
Animation deformity typically occurs when the pectora­
lis muscle scars to the implant capsule. Contraction of the
muscle thus contracts the implant and causes visible dis­
tortion. Treatment options include transfer to the subcu­
taneous plane, which may not be possible in thin patients.
If subcutaneous reconstruction is performed, fat transfer
may be necessary in the upper pole of the implant for a
natural transition.
Hypertrophic or Keloid Scarring
An exaggerated scar response after a mastectomy is sur­
prisingly uncommon. Four weeks after surgery patients are
instructed on scar massage to facilitate healing over time.
Caution should be exercised in using steroid injections
for breast reconstruction scars, because the incisions may
weaken and this could conceivably contribute to dehiscence.
Upper Pole Deficiency or Divots
The extent of the mastectomy is sometimes not completely
replaced by the implant reconstruction. Aggressive thin­
ning of the upper pole mastectomy skin flaps, inadequately
sized implants, and inadequate lower pole support all con­
insertion of ADM to stabilize the implant position. Grade II
capsular contracture is common after radiotherapy. When
grade II contracture is observed on the radiated breast im­
plant reconstruction, the most common secondary proce­
dure is to operate on the contralateral side in an attempt to
match the radiated breast. If grade IV capsular contracture is
observed on the radiated breast, autologous reconstruction
is discussed as a salvage operation.
Implant Rupture
The average life span of an implant is 10 to 15 years. If an
implant rupture is documented, removal and replacement
is advised with complete capsulectomy if possible. Implant
rupture may be silent and have no clinical manifestation,
or it may present similar to capsular contracture with de­
creased mobility of the implant, a shift superiorly, and a
perception of smaller size. The concern with implant rup­
ture is that with impact, the rupture may become more sig­
nificant and difficult to remove, and it can become painful.
Silicone can become imbedded in skin and the pectoralis
muscle over time in severe cases, making complete removal
challenging. Therefore if the patient can withstand an op­
eration from a general medical standpoint, it is typically
advised to have the implant removed, with or without re­
placement, when rupture is identified.
Fig. 38.18 (a) This young patient requested direct-to-implant reconstruction and nipple preservation using an inframammary fold incision.
She understood the limited ability to lift the breasts and the potential for nipple lateralization and the limited ability to correct asymmetries.
(b) She was happy after her reconstruction but returned 1 year later with capsular contracture of her right breast (c). Magnetic resonance
imaging showed a possible implant rupture. She was taken to the operating room, where the implant appeared intact but thickening of the
lateral capsule was discovered. (d) She underwent implant exchange and partial capsulectomy and is shown in follow-up.
a
b
c
d

SECTION V THE BREAST
656
tomic or a round implant with greater fill ratio, and inferior
and/or lateral capsulorraphy to tighten the pocket, with or
without ADM to buttress the repair.
Implant Malposition
The implant may be displaced in any direction. Malposition
can occur at the time of the original surgery, or it may be
delayed and manifest once the patient becomes more ac­
tive and sutures resorb. Treatment of implant malposition
involves reshaping the breast pocket to the desired dimen­
sions with capsulotomies and capsulorrhaphies. Consider­
ation is given to using ADM to span the capsulotomy when
it is inferior or lateral to prevent excessive implant migra­
tion. Similarly, ADM is sometimes used to reinforce a cap­
sulorrhaphy to prevent recurrence (Fig. 38.20).
tribute to upper pole deficiency (Fig. 38.19). Upper pole
deficiency may be seen in conjunction with bottoming out
and rippling. Treatment is aimed at correction of the cause.
Fat grafting is the most common way to add volume to the
upper pole. It may be combined with capsulorrhaphy to el­
evate the implant position and an increase in size.
Implant Rippling
Implant rippling allows the wrinkling of the implant to be
visible. Rippling characteristically occurs in the following
scenarios: thin skin, inadequate volume of the implant,
bottoming out, and/or too much movement of the implant
in the breast pocket. Treatment of implant rippling includes
fat grafting to thicken the skin envelope, increasing the
implant size, changing the implant style to a shaped ana­
ADM
ADM
Fig. 38.20 For implant malposition or bottoming out, acellular der­
mal matrix (ADM) can be used to bridge the capsulorrhaphy to help
strengthen the repair and prevent recurrence. The breast capsule is su­
tured to itself. Then a rectangular piece of ADM is sewn spanning the
repair. In this case it spans inferiorly.
Fig. 38.19 (a,b) This patient was referred after direct-
to-implant reconstruction with fetal bovine dermis and
one attempt at revision. She had significant upper pole
divots and implant rippling, which was exaggerated by
poor posture. (c,d) She underwent revision with capsu­
lorrhaphy buttressed with human acellular dermal ma­
trix, fat grafting, and increase of the size of her implants.
A change from smooth round implants to textured ana­
tomic ones was advised; however, the patient declined,
because she wanted the ability to push the implants up
with her bra to create cleavage. This patient had diabe­
tes, so no attempt at mastopexy was performed at the
time of her revision because it was deemed too risky,
but this may be considered in a future surgery to bring
her nipples more medial.
b
a
d
c

657
Chapter 38 Breast Reconstruction with Implants
with exchange of the tissue expander to a permanent im­
plant. These patients benefit from consulting pain service
to try alternative means to narcotics to treat the pain that
is likely related to nerve injury. Neurontin or amitriptyline
is sometimes helpful to control pain and lidocaine patches
can also be used. Patients should be counseled that re­
moval of the implant may have no effect on overall pain
levels.
Conclusion
Implant-based breast reconstruction is the most common
means to reconstruct the breast following mastectomy and
has a high degree of success and implant retention. Me­
ticulous technique helps avoid preventable complications
and unfavorable results; however, even in the best of hands
complications can and do occur. Recognition and manage­
ment of complications is important to get the best outcome
for the patients. A stepwise approach to problems helps
avoid further unfavorable outcomes.
Future directions in reconstruction undoubtedly involve
refinements in fat transfer for a hybrid reconstruction cou­
pled with the use of implants. Interest has resurged in sub­
cutaneous reconstruction to simplify recovery and prevent
animation deformity. Since the original subcutaneous re­
constructions, the mastectomy techniques have improved
leaving some patients with enough soft tissue coverage to
adequately cover the implant, with or without fat transfer,
and without the need for muscle coverage. Long-term fol­
low-up will determine whether ADM helps mitigate against
the forces of capsular contracture, which was the other main
problem in subcutaneous reconstructions of the past.
Symmastia or Overdissection of the
Medial Border
When the breast implant pockets connect, it creates a con­
dition known as symmastia. Symmastia occurs with over­
dissection during the mastectomy and reconstruction (Fig.
38.21). Treatment involves suturing the soft tissues back
down to the chest wall to separate the pockets. If the mas­
tectomy skin flaps connect, care is taken not to overdis­
sect the pectoralis muscle release. The pectoralis muscles
will thus form the medial border of the implant pocket
and avoid symmastia. However, if excessive fatty tissue is
removed medial to the insertion of the pectoralis muscle,
this is difficult to correct. With this type of dissection, the
skin flaps are typically very thin and not conducive to sub­
cutaneous reconstruction. Fat grafting can be performed as
a secondary procedure but may not completely correct the
contour abnormality.
Suboptimal Shape
As discussed earlier, skin-sparing procedures leave the
breast with a flattened appearance, and total muscle cov­
erage may result in poor shape with lack of ptosis that is
difficult to correct.
Chronic Pain
Prolonged pain is uncommon after mastectomy and imme­
diate reconstruction. However, rarely, patients experience
pain more severe than would be expected immediately or
soon after mastectomy that does not resolve over time or
Fig. 38.21 (a) This patient was never able to wear a bra after her reconstruction because she could not find something that fit and was
comfortable, which was likely related to symmastia. (b) Many years after reconstruction, she was referred and had magnetic resonance
imaging that showed implant rupture and symmastia. Her implants were removed with total capsulectomy, leaving very little soft tissue
to work with. Medially, the soft tissues were sewn to the chest wall and the repair was buttressed with acellular dermal matrix to hold the
separation. (c) She is shown 1 year in follow-up with separate breast pockets.
a
b
c

SECTION V THE BREAST
658
9. Craft RO, Damjanovic B, Colwell AS. Evidence-based pro­
tocol for infection control in immediate implant-based
breast reconstruction. Ann Plast Surg 2012;69(4):446–
450
10. Colwell AS, Gadd M, Smith BL, Austen WG Jr. An infero­
lateral approach to nipple-sparing mastectomy: optimiz­
ing mastectomy and reconstruction. Ann Plast Surg 2010;
65(2):140–143
11. Colwell AS, Damjanovic B, Zahedi B, Medford-Davis L,
Hertl C, Austen WG Jr. Retrospective review of 331 con­
secutive immediate single-stage implant reconstructions
with acellular dermal matrix: indications, complications,
trends, and costs. Plast Reconstr Surg 2011;128(6):1170–
1178
12. Spear SL, Seruya M, Clemens MW, Teitelbaum S, Nahabe­
dian MY. Acellular dermal matrix for the treatment and
prevention of implant-associated breast deformities. Plast
Reconstr Surg 2011;127(3):1047–1058
13. Spear SL, Seruya M. Management of the infected or ex­
posed breast prosthesis: a single surgeon’s 15-year expe­
rience with 69 patients. Plast Reconstr Surg 2010;125(4):
1074–1084
14. Reish RG, Damjanovic B, Austen WG Jr, et al. Infection fol­
lowing implant-based reconstruction in 1952 consecu­
tive breast reconstructions: salvage rates and predictors
of success. Plast Reconstr Surg 2013;131(6):1223–1230
15. Graf R, Ascenço AS, Freitas Rda S, et al. Prevention of Cap­
sular Contracture Using Leukotriene Antagonists. Plast
Reconstr Surg 2015;136(5):592e–596e
References
1. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift
in U.S. breast reconstruction: increasing implant rates.
Plast Reconstr Surg 2013;131(1):15–23
2. Fitzpatrick AM, Gao LL, Smith BL, et al. Cost and outcome
analysis of breast reconstruction paradigm shift. Ann
Plast Surg 2014;73(2):141–149
3. Breuing KH, Colwell AS. Inferolateral AlloDerm hammock
for implant coverage in breast reconstruction. Ann Plast
Surg 2007;59(3):250–255
4. Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction
following nipple-sparing mastectomy: predictors of com­
plications, reconstruction outcomes, and 5-year trends.
Plast Reconstr Surg 2014;133(3):496–506
5. Salzberg CA, Ashikari AY, Koch RM, Chabner-Thompson
E. An 8-year experience of direct-to-implant immediate
breast reconstruction using human acellular dermal ma­
trix (AlloDerm). Plast Reconstr Surg 2011;127(2):514–524
6. Hirsch EM, Seth AK, Kim JY, et al. Analysis of risk factors
for complications in expander/implant breast reconstruc­
tion by stage of reconstruction. Plast Reconstr Surg 2014;
134(5):692e–699e
7. Selber JC, Wren JH, Garvey PB, et al. Critical evaluation of
risk factors and early complications in 564 consecutive
two-stage implant-based breast reconstructions using
acellular dermal matrix at a single center. Plast Reconstr
Surg 2015;136(1):10–20
8. Kim JY, Davila AA, Persing S, et al. A meta-analysis of hu­
man acellular dermis and submuscular tissue expander
breast reconstruction. Plast Reconstr Surg 2012;129(1):
28–41
Discussion by Neil A. Fine and Michelle Grim
Reconstruction of any type after mastectomy increases
complication rates when compared with mastectomy
alone. When contemplating reconstruction, then, it is
inevitable that the discussion will revolve around ac­
ceptable trade-offs in relation to the potential risks and
unfavorable results.
No procedure comes without risk; even the healthi­
est patient may experience postoperative complications
that lead to unfavorable results. Skin-sparing mastec­
tomy with immediate tissue expander placement fol­
lowed by exchange is more risky than delayed recon­
struction but less risky than a nipple-sparing procedure
followed by direct-to-implant (DTI) reconstruction.1,2
This discussion offers a perspective on ways to avoid
potential problems and achieve optimal outcomes in
breast reconstruction. The important variables and de­
cision points involved in this type of surgery, each of
which impacts the success of the reconstruction, are re­
viewed. With these points in mind, the surgeon is better
able to approach reconstruction in a thoughtful manner,
optimizing patient outcomes.
Patient Selection and Education
Patient selection and patient education is needed to
balance the benefits of each approach against the risks.
It is both intuitive and supported by observation that
the more that is done surgically, the more risk is un­
dertaken. Psychological strain, precision of the result,
the ability to make decisions with patient input, and
natural outcome are also factors worth considering
when deciding the reconstructive pathway. With mul­
tiple variables involved, there is no one “best” answer,
but, instead, goals can be stratified to guide surgical
decision-making. This is the basis for the discussion
surgeons must have with their patients. If the surgeon
chooses the approach that involves the least number
of surgeries (DTI reconstruction after nipple-sparing

659
Chapter 38 Breast Reconstruction with Implants
mastectomy [NSM]), this is also the approach with the
greatest healing risk. If the surgeon chooses the route
with least risk (delayed reconstruction), the number of
surgeries increases, psychological strain increases, and
the natural outcome is limited.
I often find that precision in the final result is the
highest priority for most patients. Despite the fact that
more surgeries may be involved, most patients choose
two-stage reconstruction. This optimizes patient input,
precision with the final result, and natural outcome, and
although it requires an additional surgery, this second
surgery is much simpler (Table 38D.1).
With implant-based reconstruction, this is best il­
lustrated by the options for delayed versus immediate
reconstruction and skin-sparing versus nipple-sparing
techniques. Obviously if the mastectomy skin flaps are
allowed to heal before a reconstruction, the risk of mas­
tectomy skin flap necrosis is greatly reduced. It is poorly
vascularized skin flaps that lead to necrosis, seroma,
and infection. The better the surgeon is at identifying
healthy skin, the fewer the complications that will oc­
cur. If reconstruction is delayed until the skin flaps have
proven to be healthy, the complications related to skin
flap viability are reduced, but this also adds steps or pro­
longs the process.
This is where surgeon experience, patient selection,
and patient education come together to make the best
decision for each patient. This decision should not be
uniform if it takes all the factors into account. A patient
who is a good candidate for DTI reconstruction, has skin
flaps after mastectomy that are well vascularized, and
is working with a plastic surgeon experienced in DTI
reconstruction will predictably do well with this choice
and shorten the time and expense required to achieve
a favorable final result. Similarly, a patient who is not
a good candidate for DTI reconstruction, has marginal
perfusion after mastectomy, and is being treated by a
plastic surgeon with limited experience in DTI proce­
dures will predictably have complications if DTI surgery
is attempted.
The more options that are available, the more likely
the surgeon will be able to achieve a predictably favor­
able result. If the surgeon evaluates the patient, and she
understands that shorter, faster, surgical tracks incur
more risk and still decides to pursue those options, and
the surgeon judges her situation to be favorable, then a
shorter and faster surgical plan is acceptable. Conversely,
a risk-averse patient or a patient deemed to be of higher
risk for complications should have a surgical plan that
is slower and has more steps to prevent problems and
increase the chance for success.
Surgical Options
Direct to Implant
The success of a DTI reconstruction relies heavily on
the breast surgeon. The goals of the breast surgeon and
the reconstructive surgeon are the same: optimal pa­
tient outcome. However, components of the procedure
do have to be balanced. The breast surgeon will focus
on oncologic safety and completeness of resection; the
reconstructive surgeon will focus on tissue coverage
and viable flaps and may have to alter techniques or
choice of procedure. For instance, DTI reconstruction
may be changed to an expander with less fill if the skin
perfusion is questioned.
With the exception of very small breasts, it will be
necessary to use some variety of soft tissue support to
Table 38D.1 Trade-offs to consider in breast reconstruction surgery
Surgical plan
No. of
planned
surgeries
Healing
risk
Psychological
strain
Precision in final
result without
unplanned surgery
Patient
input in
final result
Natural
outcome
Delayed
reconstruction
4
+
++++
+
++
+
Two-stage skin-
sparing mastectomy
3
++
+++
++++
+++
++
Two-stage nipple-
sparing mastectomy
2
+++
++
+++
+++
++++
Direct-to-implant
nipple-sparing
mastectomy
1
++++
+
++
+
+++

SECTION V THE BREAST
660
contour the lower pole and inframammary fold (IMF)
when performing DTI reconstruction. As pointed out
earlier, this will be a multifactorial decision involving
the patient, the breast surgeon, and the experience of
the reconstructive surgeon.
Staged Immediate Implant
Reconstruction
Another option for decreased postoperative complica­
tions is delayed immediate reconstruction with either
an expander or a DTI procedure. This is an alternative
to a truly delayed reconstruction, which minimizes
the amount of time without a breast reconstruction
that the woman must experience. It does mean an ad­
ditional procedure, but as mentioned, having an addi­
tional procedure reduces risks.
Mastectomy is performed without reconstruction,
sparing as much skin as possible, including the option of
nipple sparing. Tissues are given 1 to 3 weeks to recover,
at which time a tissue expander or implant is placed in a
“delayed” fashion. This allows for tissue recovery and re­
sults in less risk for tissue necrosis. It also provides more
stable tissues, making a DTI procedure more precise, but
still enables the advantage of maintaining the breast
skin envelope. In addition, this gives more flexibility for
patients who may have access to a breast surgeon but
no reconstructive surgeon. By removing the need for a
combined surgical case, women may separate both the
time and location of their mastectomy and their recon­
struction. This is particularly important in areas where
plastic surgeons are not readily available.
Nipple-Sparing Versus Skin-Sparing
Mastectomy
NSM is another example of how a push to do more
entails more risk. NSM is a faster, more direct path to
final reconstruction than skin-sparing mastectomy. It
eliminates the need for nipple reconstruction and more
often sets up a favorable situation for DTI. NSM spares
or saves all the skin and is the total or maximal expres­
sion of skin sparing. Nipple-sparing reconstruction is
the option that can lead to the most natural appearance
of the reconstructed breast. When this is successful, it
is the “best” option.
NSM is optimal in patients with smaller breasts
without significant ptosis. It is not an option if the tu­
mor is too close to the nipple; generally within 2 cm is
too close. If a patient’s breasts are larger, nipple “delay”
may be used, in which the planned mastectomy inci­
sion is performed and the dissection to and under the
nipple is done and then the incisions are closed. One
to three weeks later, the incision is reopened and used
to perform the NSM. For very large breasts, it is pos­
sible to perform a breast reduction with a superior or
superomedial pedicle and again come back 1 to 3 weeks
later, or more in the case of increased genetic risk so
delayed tumor treatment is not a concern. This allows
for reduction of the skin envelope and division of the
deep vessels to the nipple. This effectively transforms
a woman with larger, pendulous breasts into a woman
with smaller, nonptotic breasts who is a good candidate
for nipple sparing.
In NSM, sensation is lost, because the nerves to the
nipple are always removed. This needs to be explained
to patients, because it is not always understood. Finally,
we will ask, “how do you feel about the visual aspect of
your nipples on your breast?” With NSM, this look will
be saved and is the most natural and most often desired
(although not always).
Surgical Considerations
Incisions
Incision location is determined in conjunction with the
surgical oncologist. Multiple options exist. A lateral ra­
dial incision may be favored in higher-risk patients who
desire nipple sparing, because it allows for extension of
the incision to remove the nipple should necrosis occur
without creating an additional scar. This is a more sub­
tle move toward decreased complications than nipple
delay or premastectomy breast reduction. It has the ad­
vantage of not being an extra procedure, but it is not as
powerful, and lateralization of the nipple is more com­
mon with this incision. Clear adhesive dressings can be
placed to medialize the nipple and therefore minimize
lateralization at the time of the mastectomy and first-
stage reconstruction, because the tissues and skin are
mobile at that time (Video 38D.1).
When closing a skin-sparing incision, it can be
tempting to close with a purse-string closure. This is a
natural thought, because the nipple excision area is cir­
cular and any linear closure will lead to a longer scar and
a dog-ear deformity. The full purse-string closure almost
always has healing difficulty and should be avoided.
However, a modified purse-string, in which the incision
is shortened and bunched but still has the ability to be
closed “linearly,” will leave the shortest scar with the
most predicable healing and is my (N.F.) current favored
technique (Fig. 38D.1).
Use of Acellular Dermal Matrix Versus
Full Muscle Coverage
For pocket creation, the pectoralis major muscle is el­
evated (except in the prepectoral approach). This may
be approached from the lateral border of the pectoralis

661
Chapter 38 Breast Reconstruction with Implants
or the inferior origin, or the muscle can be split follow­
ing the orientation of its fibers. Total soft tissue cov­
erage offers a potentially lower risk of complications,
because skin flaps are then in contact with perfused
tissues covering the expander. Release of the pectoralis
major muscle is essential for lower pole expansion, and
this can be accomplished while still maintaining total
soft tissue coverage of the implant. At the level of the
IMF, the pectoralis major muscle can be divided from
its origin and, as long as there is soft tissue coverage at
this level, the subcutaneous fat will be entered, allow­
ing release of the lower pole without interfering with
total tissue coverage. This negates the need for exog­
enous soft tissue support.
Acellular dermal matrix (ADM) may be used if tissue
coverage is inadequate or the tissues are unable to ac­
commodate the desired expansion volume to adequately
fill the breast skin envelope. Meshing ADM with a stan­
dard skin meshing device has the effect of increasing
the size of and the distensibility of ADM. We have found
that meshing 1.5:1 works better and handles better than
meshing 2:1 (Fig. 38D.2).
Although some form of soft tissue support is re­
quired for DTI reconstruction, in a two-stage recon­
struction it is possible to contour and fill out the lower
pole with expansion and capsulotomy at the second
stage. I (N.F.) use soft tissue support mesh if I need it
to maintain the position of the pectoralis major muscle
but avoid using foreign material if I believe that it is not
necessary to achieve a favorable outcome. This some­
times results in soft tissue support on one side and not
on the other. In these cases, the early result generally
favors the soft tissue support side, whereas the final re­
sult is not typically affected (Fig. 38D.3).
Use of Nitroglycerin Paste
Application of nitroglycerin paste to the mastectomy
skin flaps, approximately 1 cm to each breast, has been
shown to decrease complications related to delayed
Fig. 38D.1 (a) This patient’s original mastectomy incision, including circular nipple excision. (b) Full purse-string suture. (c) Modi­
fied purse-string suture. (d) Subsequent linear closure.
a
b
c
d
Fig. 38D.2 Meshed acellular dermal matrix after expander in­
flation.

SECTION V THE BREAST
662
healing and necrosis. In the case of nipple sparing and
an inferolateral IMF incision, this would be placed at
the upper border of the areola and between the nip­
ple–areola complex and the incision. For a skin-sparing
mastectomy, nitroglycerin paste is applied just supe­
rior to the incision and just inferior to the incision at
the midline of the breast. The paste is then covered
with a transparent adhesive dressing and left in place
until the first postoperative appointment.
Postoperative Care
The patient leaves the operating room with a 6-inch
fabric elastic bandage around the chest to provide mild
compression and support. This can be removed on post­
operative day 1 if desired. Any garment that is placed
thereafter should be loose enough as to not leave any
marks on the skin. Most women will feel better with
something on, and a 6-inch fabric elastic bandage with
hook-and-loop fasteners seems to be a good balance of
comfort and “support” without excessive pressure.
Oral antibiotics are continued 1 week postopera­
tively regardless of drain removal. In the past I (N.F.)
would maintain patients on antibiotic therapy until the
drains were removed. There may be benefit to antibi­
otics being continued beyond a single dose in the op­
erating room, but there does not seem to be benefit to
extended antibiotics.3 In this setting, I have arbitrarily
chosen to continue antibiotics for 1 week regardless of
drain placement. I have not seen an increase in infection
with this change.
To minimize arm mobility problems, activity involv­
ing arm movements are not restricted. Women are en­
couraged to engage in normal day-to-day activities, in­
cluding those involving full shoulder range of motion.
They are sent home with exercises, all of which may
be done as stretches immediately after discharge. They
are advised not to repeatedly do the “exercises” until
after the drains are removed. Strenuous activity is re­
stricted for 2 weeks after surgery and then is increased
as tolerated.
Infection
A spectrum of infection is encountered in the setting
of implant reconstruction. Although explantation and
delayed reconstruction are considered the most de­
finitive treatment, implant salvage is often an option.
A lack of fluid in the pocket and a relatively clean-
appearing pocket both imply a positive outcome with
exchange, but tissue quality is often one of the most
significant factors contributing to success. Explanta­
tion should be favored in patients with tenuous soft
tissue coverage regardless of fluid or pocket appear­
ance. Implant exchange may still be a viable option in
patients who have fluid or infection if the soft tissues
are robust.
Fig. 38D.3 Two-stage reconstruction. (a) Preoperatively. (b) Bilateral tissue expander placement, with acellular dermal matrix used
on the left breast only. (c) After expansion. (d) Just before nipple tattoo.
a
b
c
d

663
Chapter 38 Breast Reconstruction with Implants
Radiation and Second-Stage Incision
When choosing the location for the second-stage ex­
change procedure, the surgeon must keep in mind that
it is common for radiation oncologists to “boost” the in­
cision with an extra dose of radiation. This means that
the incision has a high likelihood of not healing if it is
reopened. For this reason, it is always best to avoid a
radiated incision. If the first stage was skin sparing, this
is easy—an IMF incision is used. If the mastectomy was
done with an IMF incision, the new incision choice is
more difficult. I (N.F.) generally favor lowering the inci­
sion onto the upper abdomen and moving it more me­
dially (Fig. 38D.4).
Radiation and Nipple Reconstruction
Along a similar line of reasoning, I no longer attempt
surgical nipple creation in women who have under­
gone radiation. I consider it if they have subsequently
had a flap procedure, but if they had an implant-only
reconstruction and radiation, I advise three-dimen­
sional nipple tattooing to create the nipple visually.
The risk of the nipple incision breaking down and then
requiring a flap salvage procedure is too great, and the
results of three-dimensional nipple tattooing have ad­
vanced to the point where it no longer makes sense to
attempt surgical nipple creation in a woman with a ra­
diated implant reconstruction.4
Conclusion
There are many techniques available to provide excel­
lent results in breast reconstruction using implants
and remaining chest and breast skin. The needs and
risk tolerance of patients and their anatomic situation
must be balanced with the combined skill set of the
breast surgeons and reconstructive surgeons. When
this is successful, the best result can be achieved in the
most expeditious way possible, avoiding complications
and setbacks. Choices that lead to a faster end result
with fewer steps increase the risk of complications. It
is natural for women to want the fastest track and for
surgeons to want to provide it. It is up to surgeons, in
concert with their patients, to make the choice that
best fits each situation. A thorough discussion of the
risks and benefits is paramount, because each patient
will see these aspects in a slightly different light. Re­
constructive surgeons should strive to bring all of these
elements together with each patient and each opera­
tion, recognizing the uniqueness of each setting but
bringing to bear the full armamentarium of options
and techniques.
Fig. 38D.4 Planned surgical approach for second-stage
surgery after left breast radiation therapy.
References
1. Sullivan SR, Fletcher DRD, Isom CD, Isik FF. True inci­
dence of all complications following immediate and de­
layed breast reconstruction. Plast Reconstr Surg 2008;
122(1):19–28
2. Alderman AK, Wilkins EG, Kim HM, Lowery JC. Com­
plications in postmastectomy breast reconstruction:
two-year results of the Michigan Breast Reconstruc­
tion Outcome Study. Plast Reconstr Surg 2002;109(7):
2265–2274
3. Clayton JL, Bazakas A, Lee CN, Hultman CS, Halvorson
EG. Once is not enough: withholding postoperative
prophylactic antibiotics in prosthetic breast recon­
struction is associated with an increased risk of infec­
tion. Plast Reconstr Surg 2012;130(3):495–502
4. Northestern Plastics. 3D Nipple Tattoo and Nipple Re­
construction Chicago. Retrieved from
westernplastics.com/breast-procedures-chicago/nip­
ple-tattoo/

Statuette of Aphrodite, from the theater quarter 2, 1st century
BC. (Delos Museum, Greece. © Hellenic Ministry of Culture and
Sports/Archeological Receipts Fund.)