Các Vấn Đề Trong Phẫu Thuật Tuyến Vú: Cẩm Nang Sửa Chữa (Repair Manual)

Part III: Problems in Mastopexy and Augmentation-Mastopexy
422
to the midpoint o the IMF. However, be ore we actually made the skin incision, we
used staples to tailor-tack the breast. This suggested that the skin markings were
too aggressive and that the closure might be excessively tight; there ore the masto-
pexy pattern was redrawn with more conservative skin excision. It is always impor-
tant to be conservative in the initial plan or skin resection, because additional skin
can always be removed at the completion o the procedure i deemed necessary.
A second practical point illustrated by this case is that surgical procedures are not
always executed as planned preoperatively. In this patient the replacement o one or
both implants was not anticipated. However, during the procedure it became evi-
dent that the circulation to the right nipple might be compromised by urther resec-
tion o breast parenchyma. There ore it was necessary to replace the implant with a
smaller device. It is our practice to maintain a ull array o di erent-sized implants
in the surgery center consignment. It is crucial that contingency plans, and the nec-
essary equipment and supplies, be in place i there is an intraoperative change in
strategy.
BIBLIO GRAPHY
Akyurek M. Short scar reduction mammaplasty in the bariatric patient. Ann Plast Surg 66:602-606,
2011.
Albino FP, Koltz PF, Guseno JA. A comparative analysis and systematic review o the wound-
healing milieu: implications or body contouring a ter massive weight loss. Plast Reconstr Surg
124:1675-1682, 2009.
Coriddi M, Koltz PF, Guseno JA. Reduction mammaplasty, obesity, and massive weight loss: tempo-
ral relationships o satis action with breast contour. Plast Reconstr Surg 128:643-650, 2011.
de Kerviler S, Hüsler R, Banic A, et al. Body contouring surgery ollowing bariatric surgery and dietet-
ically induced massive weight reduction: a risk analysis. Obes Surg 19:553-559, 2009.
Michaels JV, Coon D, Rubin JP. Complications in postbariatric body contouring: postoperative man-
agement and treatment. Plast Reconstr Surg 127:1693-1700, 2011.

C h a p t e r 2 6
SPREADING OF THE AREOLAE
26a Conversion of Circumareolar Mastopexy to Vertical
Mastopexy
Nea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 32-year-old mother o two presented 6 years a ter primary breast augmenta-
tion in which she had subglandular 300 cc moderate pro le smooth saline implants
(Mentor, Santa Barbara, CA) inserted through a periareolar approach. She was ini-
tially satis ed with the result; however, a ter bearing and breast eeding two chil-
dren, her breasts became larger and “saggy.” She also noted a dramatic increase in
the diameter o her areolae and increased areolar pigmentation. The patient desired
more youth ul, upli ted breasts and a substantial reduction in areolar diameter;
however, she adamantly re used the scars associated with traditional mastopexy.
Physical examination revealed that the patient had bilateral breast augmentation
with saline implants, and well-healed periareolar scars. Her breasts had an exces-
sively wide and f at appearance, lacking both adequate projection and upper pole
ullness. The nipple position was slightly asymmetrical; the le t nipple was 1 cm
higher than the right nipple. The areolae were elliptically shaped and very wide,
measuring 8 cm in height and 6 cm in width. The patient had only mild ptosis, with
the nipples nearly at the level o the IMFs, and her breasts were so t (Baker grade I
bilaterally).
423

Pa III: P b ms i Mas p a d Augm a i -Mas p
424
During her initial consultation, the patient was given several options: replacement
o her saline implants with slightly smaller-volume, higher-pro le silicone implants;
lateral capsuloplasty i deemed appropriate at the time o surgery; and a mastopexy
primarily to reduce areolar diameter, but also to tighten the skin envelope and in-
crease upper pole ullness. Either a conventional Wise pattern mastopexy or a verti-
cal mastopexy was recommended. She re used the scars associated with traditional
breast upli ts; there ore a modi ed Benelli mastopexy was o ered as an alternative.
She elected to proceed with implant replacement and pocket modi cation in con-
junction with a circumareolar mastopexy.
At the time o surgery, preoperative skin markings were made with the patient up-
right. The top o the new areola was marked on the breast meridian, 19 cm rom
the clavicle. Eccentric circumareolar incisions were drawn; the larger outer circle
was just wide enough to encompass all o the areolar skin (8 cm diameter), and the
inner circle was 4 cm in diameter. Circumareolar incisions were made and the area
between them deepithelialized. The wound was deepened just through the dermis,
1 cm inside the outer circle (to create a cu o dermis or placement o the periare-
olar purse-string suture). The saline implant was accessed and removed through the
old scar; inspection revealed that the periprosthetic pocket extended well beyond
the anterior axillary line on each side. Lateral capsuloplasty was per ormed by exci-
sion o a crescent-shaped segment o capsule on each side and closure o the capsu-
lar de ect with a running, locked suture (1 Prolene). Preoperatively the patient had
selected an implant in the range o 225 to 250 cc. A ter use o intraoperative sizers,
smooth round high pro le 250 cc gel- lled implants were chosen. Once the deep
layers were closed, a periareolar pinwheel mastopexy suture (described by Ham-
mond) o nonabsorbable polypropylene (1 Surgipro) was placed. The outer bites
were care ully positioned slightly within the peripheral border o the dermal cu ,
about 2 mm proximal to the surrounding epithelial edge; this ensured preservation
o an adequate layer o dermis or placement o the nal buried running subcuticu-
lar suture (4-0 Monocryl). As the pinwheel purse-string suture was tightened, the
areola was reduced to the desired diameter (in this case, 3.5 cm—the target diam-
eter agreed on with the patient). The knot was tied and securely buried to prevent
later exposure.

Chap 26 • Sp adi g f h A a

425
The patient’s early postoperative result (3 months a ter surgery) was promising
but not entirely satis actory. The volume and width o her breasts were decreased,
and upper pole ullness and projection were improved. The areolar diameter was
reduced to approximately 4 cm, but early, recurrent areolar spreading and protru-
sion (particularly o the in erior hal o the right areola) were evident, the result o
edema and the trapdoor e ect o the purse-string suture.
By 9 months postoperatively, the contours
o her breast had smoothed, the circumare-
olar scars were maturing well, and the pro-
tuberance o the lower hal o the areolae
had almost entirely subsided. The patient
was satis ed with her overall surgical re-
sult, but her areolae had widened slightly.
Over the next several months, they contin-
ued to stretch at a relatively rapid rate.
The appearance o her breasts exactly 1 year
postoperatively was suboptimal. The areolae
had stretched to a diameter o nearly 6 cm
and were no longer round and symmetrical;
they had an irregular, elliptical shape.

Pa III: P b ms i Mas p a d Augm a i -Mas p
426
By 18 months postoperatively, the appearance o the areolae had deteriorated even
urther, and the patient requested a revision.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s breasts are so t (Baker grade I), and the lateral capsulorrhaphy is in-
tact. Her major concern is the marked dilation o her areolae, now measuring 8 cm
in diameter. Although the border o the areolae has spread considerably, the large-
caliber, nonabsorbable pinwheel purse-string sutures are intact and readily palpable
beneath the attenuated areolar tissues. They measure 3.5 cm in diameter—the size
to which they had been reduced at the previous operation. In addition to dramatic
spreading o the areolae, her circumareolar scars are widened and her breasts have
less projection because the so t tissue envelope is relaxed. The patient wishes to
have these de ciencies corrected with another revision procedure.
ANALYSIS O F THE PRO BLEM
This patient, who initially presented with wide, slightly ptotic breasts and large are-
olae, requested a revision that would not place additional scars on her breasts. She
was encouraged to undergo either a vertical or Wise-pattern mastopexy in conjunc-
tion with capsulorrhaphy and implant exchange. Because o her aversion to scars,
she opted or a circumareolar mastopexy. The initial results looked promising.
However, over 18 months, the aesthetic result steadily deteriorated. Although the
circumareolar purse-string suture remained intact, the so t tissues spread beyond
the border o the suture, resulting in very dilated, unattractive areolae, widened cir-
cumareolar scars, and some loss o breast shape. The patient was in ormed that the
best solution was conversion to a more aggressive mastopexy. A vertical mastopexy
was recommended, because it would provide the opportunity to de nitively re-
duce the diameter o the areolae and prevent recurrent spreading, tighten the lower
poles, increase projection, and enhance upper pole ullness with minimal additional
scars.

Chap 26 • Sp adi g f h A a

427
RECOMMENDED SOLUTION TO THE PROBLEM
Conversion o the circumareolar mastopexy to a vertical mastopexy
Reduction in the diameter o the areolae to 3.5 cm
Maintenance o the current nipple position
Tightening o the lower pole by plication o the medial and lateral parenchymal
pillars
Use o the existing silicone gel implants
TECHNIQ UE
Preoperative measurements and skin markings were made with the patient stand-
ing. A modi ed mosque dome pattern was drawn on each breast, with the apex o
the mosque at the 12 o’clock position o the areola. The length o the limbs o the
dome was designed to result in a nal areolar diameter o 3.5 cm. The circum er-
ence o the desired areolae was calculated to equal 11 cm using the equation C 5
p d, where C is circum erence and d is diameter. Each limb o the mosque dome was
there ore drawn 5.5 cm in length.
Be n e l l I MASt o Pe x y
A i capsu ,
cu
Imp a mai s
i p ac
12 ’c ck p si i
Ve r t ICAl MASt o Pe x y

Pa III: P b ms i Mas p a d Augm a i -Mas p
428
The rest o the vertical mastopexy skin pattern was outlined with the patient under
anesthesia in the supine position (arms adducted at her sides). Two converging lines
were drawn, but instead o extending directly in eriorly, they curved laterally and
in eriorly. The two lines converged at the level o the IMF, just medial to the ante-
rior axillary line. The exact location o these two lines was determined with the use
o tailor-tacking to achieve the desired breast contour without excessive tension on
the closure.
The width o the upper portion o the vertical pattern was based on the diameter o
the existing areola. The pattern was drawn superiorly just wide enough to encom-
pass all o the pigmented areolar skin (8 cm). It represented the most conservative
skin resection that would ensure no residual pigmented tissue remained in erior to
the new areolae; i necessary, additional skin could be resected during the nal tai-
loring at the end o the procedure. The circular marking (new border o the areola)
was 5 cm in diameter and centered on the nipple. The diameter was larger than that
o the desired areola to ensure that the areolar skin would be closed with virtually
no tension, and the sur ace texture o the areola would not be taut.
During surgery the appropriate areas were deepithelialized; the resulting superi-
orly based dermal parenchymal pedicle was very short, so there was little chance
o compromising circulation to the NAC. A ull-thickness wedge o skin and breast
parenchyma was excised down to and including the anterior capsule surrounding
the implant. Excision o this tissue was unlikely to a ect blood supply to the nip-
ple, because the prosthetic pocket had been accessed twice previously through an
in erior periareolar incision. The superior pedicle that supplied the NAC was con-
servatively reed by dissection o the parenchyma on both sides, just enough to al-
low the nipple to be easily transposed the short distance superiorly. The nipple was
temporarily stapled into its new position. The implant was le t in situ as the medial
and lateral pillars were sutured to one another in layers, rom deep to super cial.
The deepest layer (including a bite o the capsule on each side o the wound) was
closed with 2-0 PDS, the more super cial parenchyma with 3-0 PDS, and the der-
mis and skin with 4-0 Monocryl.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 1 year a ter her secondary vertical mastopexy.

Chap 26 • Sp adi g f h A a

429
The shape o her breasts is enhanced, projection and upper pole ullness are in-
creased, and lower pole contour is improved. The areolar diameter is decreased to
the desired dimension (3.5 cm) and stable in size.
TEACHING PO INTS
A number o interesting issues arose in the course o this patient’s treatment. At her
initial presentation, her main goals were to have smaller breasts with better shape
and smaller-diameter areolae. Although a variety o approaches potentially may
have addressed these concerns, the patient re used any procedure that would leave
more scars on her breasts. There ore the only option was a circumareolar masto-
pexy with pocket modi cation and implant exchange.
Circumareolar mastopexy typically f attens the breast. To overcome this tendency,
use o an anatomically shaped (teardrop) or high-pro le device is recommended.
The areolar diameter is very e ectively reduced by circumareolar mastopexy, but
the areolae tend to spread again, especially in large-breasted patients or i tension
is placed on the skin closure. The use o a permanent purse-string suture ( or exam-
ple, Prolene or Gore-Tex) and the pinwheel technique may help to reduce the risk
o recurrent spreading. However, in some cases, such as this one, undesirable
Continued

Pa III: P b ms i Mas p a d Augm a i -Mas p
430

spreading o the areolae occurs. This is typically accompanied by deterioration o
breast shape.
The only viable solution in these cases is to convert to a more power ul mastopexy.
By using either a vertical or traditional Wise skin pattern mastopexy, the circum-
erential pull on the areolae is eliminated. In this case, vertical mastopexy was se-
lected, because it allows tightening o the lower pole o the breast by plication o
the medial and lateral parenchymal pillars. This increases nipple projection (by con-
verting the breast mound to a cone shape) and promotes lasting upper pole ullness.
Vertical mastopexy also results in less scarring than traditional Wise-pattern masto-
pexy, which was appealing to this patient.
This case illustrates that there are o ten several options available to treat a patient’s
problems. When presented with choices, patients have the right to make decisions
based on their personal pre erences. Issues such as complexity o the procedure,
cost, postoperative recovery time, the amount o scaring, and the likelihood o a
success ul outcome need to be considered. As long as patients are adequately in-
ormed, the approach that they select is reasonable, and the procedure meets the
standard o care, they should make the nal decision about their treatment. In this
case, the patient initially elected to have an operation that was less likely to achieve
a satis actory long-term result, but it was less involved and resulted in minimal
scarring. She proceeded with an operation whose bene ts were within her com-
ort zone at that time. However, a ter the result deteriorated, she was receptive to
the trade-o o more scars or improved breast shape and the promise o a longer-
lasting result. She proceeded with the more aggressive surgery, accepted the addi-
tional scarring, and was very pleased with her outcome.
BIBLIO GRAPHY
Hall-Findlay EJ. Simpli ying the vertical reduction mammaplasty. Plast Reconstr Surg 113:173-174,
2004.
Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture or control o areolar diam-
eter and shape. Plast Reconstr Surg 119:804-809, 2007.
Handel N. Secondary mastopexy in the augmented patient: a recipe or disaster. Plast Reconstr Surg
118(7 Suppl):S152-S163, 2006.
Lassus C. Vertical scar breast reduction and mastopexy without undermining. In Spear SL, ed. Surgery
o the Breast: Principles and Art. Philadelphia: Lippincott-Raven, 1998.
Lejour M. Vertical mammaplasty: early complications a ter 250 personal consecutive cases. Plast
Reconstr Surg 104:764-770, 1999.
Spear SL, Howard MA. Evolution o the vertical reduction mammaplasty. Plast Reconstr Surg
112:855-869, 2003.
Spear SL, Boehmler JH IV, Clemens MW. Augmentation/mastopexy: a 3-year review o a single sur-
geon’s practice. Plast Reconstr Surg 118(7 Suppl):S136-S147, 2006.

26b Interlocking Gore-Tex Permanent Purse-String
Suture Technique
Den n is C. h a mmo n d
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 33-year-old woman presented with complaints o areolar spreading and un-
sightly scar ormation 1 year a ter a periareolar augmentation mastopexy. The
periareolar pattern incorporated a signi cant li t to an already enlarged and ptotic
NAC. The implants were smooth round gel devices that were placed in a partial
subpectoral pocket.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The implant size and position seem appropriate or the patient’s body habitus.
However, the enlarged diameter and irregular contours o her areolae detract rom
the overall result. The scar itsel is somewhat widened, and the diameter and shape
o the areolae are asymmetrical.
ANALYSIS O F THE PRO BLEM
Because o the inherent elasticity o areolar skin, the tension placed on the periareo-
lar closure at the time o the rst procedure resulted in stretching o areolar skin
until the size o the areolae became excessive and the contours irregular. One year
a ter the original procedure, the orces placed on the periareolar closure have stabi-
lized. The patient is ready or a revision that has a good chance o success.
431

Pa III: P b ms i Mas p a d Augm a i -Mas p
432
RECOMMENDED SOLUTION TO THE PROBLEM
Use o an interlocking Gore-Tex permanent purse-string suture technique
TECHNIQ UE
The outer periareolar incision was marked to indicate the existing borders o the
stretched areola medially, laterally, and in eriorly. (In cases in which the periareo-
lar pattern is used to accomplish mastopexy o the NAC, the superior mark is made
high enough to li t the areola to the desired level.) Incisions were made, and the in-
tervening skin was deepithelialized.
The procedure was per ormed with the patient
under general anesthesia. When it is not com-
bined with other procedures such as capsulot-
omy or capsulectomy, it can be per ormed un-
der local anesthesia. A new areolar diameter o
40 to 44 mm was diagrammed on the existing
areola with the aid o a multidiameter areolar
marker, with the areola under maximal stretch.

Chap 26 • Sp adi g f h A a

433
A 5 mm dermal shel was ashioned around the periphery o the periareolar pat-
tern. The edges were slightly undermined to allow the purse-string suture to be
cinched without excessive bunching along the closure.
A Tef on suture equivalent to a USP 2-0 size attached to a Keith needle was then
passed in an interlocking ashion around the periphery o the periareolar de ect.
The uniquely smooth nature o Tef on suture allowed the material to pass easily
through the extensive so t tissue ramework created with the interlocking pattern,
acilitating ne control o the shape and diameter o the areola. To guide suture
placement, eight cardinal points were drawn on the areolar and periareolar mar-
gins, with the goal o aligning these points as precisely as possible during suture
passage. The suture was initially passed through the dermal shel at the most me-
dial margin o the pattern rom super cial to deep. Then a small bite o areolar
dermis was taken. The needle was brought back to the dermal shel , where it was
passed within the dermis o the shel over to the next cardinal point.

Pa III: P b ms i Mas p a d Augm a i -Mas p
434
This pattern was repeated around the entire circum erence o the periareolar de ect
at all eight cardinal points to create a wagon wheel–type appearance o the suture
strand. Suture placement was completed by passing the needle rom super cial to
deep where the pattern started. This ensured that the knot was buried securely un-
der the dermal shel to prevent postoperative exposure. Because o the very smooth
sur ace o Tef on suture, slight tension on the strand allowed closure o the peri-
areolar de ect to the desired size. However, when tying the knot ends, seven to ten
knots were required to prevent knot slippage and areolar spreading postoperatively.
With this technique, the two dermal edges o the areolar and periareolar incisions
were joined together with one suture strand to lock the closure in a ashion that re-
sisted postoperative spreading.
Final closure was accomplished with a subcuticular suture o 4-0 absorbable mono-
lament, or even more e ectively an equivalent 4-0 barbed suture. Small pleats can
orm along the wound edge, because the outer diameter o the periareolar incision
is longer than that o the inner, areolar incision. These so ten with time and in most
instances completely disappear over the course o nal wound maturation.

Chap 26 • Sp adi g f h A a

435
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 1 week and 4 months postoperatively. Her areolae have a
round, symmetrical contour and reduced diameter.
Periareolar pleating has almost completely resolved. The overall appearance o her
breasts is much improved, with better proportion between the diameter o the are-
ola and the overall breast size.

Pa III: P b ms i Mas p a d Augm a i -Mas p
436
TEACHING PO INTS
When revising a widened areola, two principles need to be respected. First, the re-
vision must involve a complete periareolar approach to evenly distribute the inher-
ent dog-ear that develops because o di erent dimensions o the areolar and peri-
areolar incisions. Partial or crescent-type approaches will only serve to distort the
areolar shape, because they apply uneven orces on the elastic areolar skin. Second,
the wound closure must be supported with a suture that will su ciently support
the wound until the incision line is completely healed, a process that can take many
months to a year. For this reason, a permanent suture has an advantage over an ab-
sorbable material, because it can provide wound support or years while orces that
a ect the closure stabilize. The continued presence o the purse-string suture may
even be unnecessary. Finally, passage o the suture in the manner described locks
the two edges together in a way that helps to prevent postoperative spreading. The
airly signi cant sur ace tension created by passing the suture strand through the
dermal shel requires a smooth mono lament suture. Tef on’s unique handling char-
acteristics make it well suited or this use. Other options include 2-0 Prolene or ny-
lon suture on a Keith needle.
BIBLIO GRAPHY
Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture or control o areolar diam-
eter and shape. Plast Reconstr Surg 119:804-809, 2007.
Righi B, Robotti E. Success ully exploiting two opposing orces: a rational explanation or the “inter-
locking suture.” Aesthetic Plast Surg 35:177-183, 2011.

26c Secondary Mastopexy
a l l en Ga br iel , G. pa t r ic k Ma x w el l
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 42-year-old woman presented 2 years a ter having a breast augmentation and
a periareolar mastopexy. She had dual plane augmentation with style 20 600 cc im-
plants (Allergan, Irvine, CA). Within 3 months, she started to notice stretching o
her areolae and a pulling sensation. To treat these problems, it was recommended
that she continue wearing her bra at all times. As the patient became more active,
she noticed increased stretching o her tissues and spreading o her areolae. Dur-
ing the original surgery, her periareolar incision was closed with a Gore-Tex purse-
string suture. She was a healthy nonsmoker with no signi cant medical issues.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient demonstrates a common problem that resulted rom a minimal mas-
topexy combined with placement o a larger implant. Surgeons may be persuaded
to per orm these techniques together with the goal o achieving a better shape.
Though larger implants can improve shape immediately, they do not provide the
desired long-term solution. This patient probably required excision o additional
so t tissue instead o a periareolar mastopexy.
437

Pa III: P b ms i Mas p a d Augm a i -Mas p
438
ANALYSIS O F THE PRO BLEM
An areolar stretch de ormity can result rom excessive tension on the incision.
This can happen either with excision o too much skin alone (elevation o the nip-
ple more than 1 to 2 cm) or with placement o an implant. Once a simple one-
dimensional mastopexy is added, then two orces are acting against each other,
making the outcome unpredictable. In this patient’s original surgery, a large implant
was placed and her so t tissue envelope was corrected to some degree. The strain
on the incision stretched her surrounding tissues, leading to an unpleasant aesthetic
outcome. In this case, both the anterior axillary line and IMFs were stable.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the existing implants
Revision using an inverted-T mastopexy
Removal o additional tissue bilaterally in conjunction with an inverted-T
mastopexy
Insertion o a smaller implant with less projection
TECHNIQ UE
The revision procedure was per ormed through the in ramammary incision. The
implants were removed. The capsules were so t, and no de ormities were noted. The
muscle had been released rom its origin during her previous surgery. No changes to
her pocket, including the capsule, were made. A sizer was placed, and tailor-tacking
was per ormed to achieve the desired result. The NAC was positioned at 1 cm
above the original location. A 42 mm cookie cutter was used on minimal stretch to
outline the new NAC. A superior pedicle was deepithelialized. The previous NAC
measured 55 mm horizontally and 65 mm vertically. The vertical pillars were set at
t acki g su u s
Imp a cha g d
H iz a i cisi a IMF
t acki g su u b gi
i v d-t c su

Chap 26 • Sp adi g f h A a

439
6.0 cm rom the in erior edge o the areola, and the horizontal dimension was
added. Style 15 457 cc implants were selected. An additional 56 g o tissue was
removed rom the le t breast and 64 g rom the right breast. The new implants were
placed. Vertical pillars were approximated to shape the breasts and closed with 2-0
Vicryl. The horizontal, vertical, and periareolar incisions were closed with 4-0 Vic-
ryl and 4-0 Monocryl.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 12 months a ter her secondary procedure. She has a stable
so t tissue envelope with some reactive scars, which she wanted to avoid with her
rst operation. They were treated with scar cream and a silicone barrier. Her NAC
is in good position, and it has maintained its original shape and size.

Pa III: P b ms i Mas p a d Augm a i -Mas p
440
TEACHING PO INTS
When planning correction o a stretch de ormity, the actors that contributed to the
problem need to be understood. There are times that patients would like to have
minimal scarring and are willing to accept a less desirable aesthetic outcome to
avoid the scarring. It is important to explain the components o so t tissue stretch
and orces that act on the areola. Sometimes staging a procedure may be more ben-
e cial i circumareolar mastopexy is involved or requested, to avoid the central
pressure rom the implant that counteracts the f attening circumareolar pressure.
Volume removal and tissue rearrangement to disperse tension are essential in the
treatment o tension-related problems. Pillars were approximated with Vicryl su-
tures a ter removal o excess tissues (the minus/plus technique). Horizontal and ver-
tical pillars were approximated in three layers, and the areola was inset in two lay-
ers (4-0 Vicryl and 4-0 Monocryl).
BIBLIO GRAPHY
Nahai F, Fisher J, Maxwell PG, et al. Augmentation mastopexy: to stage or not. Aesthet Surg J 27:297-
305, 2007.
Spear S. Augmentation/mastopexy: “surgeon, beware.” Plast Reconstr Surg 112:905-906, 2003.
Spear SL, Boehmler JH IV, Clemens MW. Augmentation/mastopexy: a 3-year review o a single sur-
geon’s practice. Plast Reconstr Surg 118(7 Suppl):S136-S147, 2006.
Swanson E. A measurement system or evaluation o shape changes and proportions a ter cosmetic
breast surgery. Plast Reconstr Surg 129:982-992, 2012.
Tessone A, Millet E, Weissman O, et al. Evading a surgical pit all: mastopexy-augmentation made
simple. Aesthetic Plast Surg 35:1073-1078, 2011.

27a Total Submuscular Capsulectomies and Replacement
With Shaped Implants
Dav id A. Ca pl in
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 54-year-old woman presented 10 years a ter an uncomplicated submuscular
breast augmentation with textured round 400 cc gel implants and a periareolar
mastopexy. She had noted progressive ptosis o the breast tissue o the implants
over the past 3 to 4 years as well as an increase in the rmness o her breasts. She
wanted to keep her current breast size or increase it slightly. A ter detailed discus-
sion, she pre erred to use a highly cohesive contoured gel implant i possible, and to
not undergo a secondary mastopexy at this time.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient’s primary concerns are the ptosis o her breast tissue o her submus-
cular implants and the increasing capsular contracture noted over the past 3 to
4 years. Her NAC is 23 cm rom the suprasternal notch bilaterally with a 13.5 cm
breast width. She has Baker grade III capsules with marked ptosis o the paren-
chyma o the submuscular implants. There are mature periareolar scars and, by
palpation, the Gore-Tex suture used during the mastopexy remains intact. She is
5 eet 5 inches tall, weighs 130 pounds, and has moderate breast thickness with a
more than 3 cm pinch in the upper pole.
C h APt e r 27
RECURRENT PTOSIS
441

Part III: Problems in Mastopexy and Augmentation-Mastopexy
442
ANALYSIS O F THE PRO BLEM
This patient wanted correction o her ptosis and an implant exchange with highly
cohesive gel implants equal in size to, or larger than, her current 400 cc implant
size. A neosubpectoral pocket was considered or this patient but deemed unnec-
essary because it was anticipated that the pocket size created by the capsulectomy
would not be excessively large and could be tailored to exactly t a larger highly
cohesive contoured implant. A ptosis procedure was not required at this time, but
might have been a consideration as well.
RECOMMENDED SOLUTION TO THE PROBLEM
Use o an in ramammary approach
Total submuscular capsulectomies
Use o MemoryShape sizers to aid in selecting the implant style and size, with
patient in the erect position
Precise dissection o the submuscular pocket to the exact dimensions o the cho-
sen contoured highly cohesive gel implants
Selection o style MM MemoryShape 440 cc implants, based on an implant base
diameter o 14 cm, which closely approximated her preoperative breast width o
13.5 cm
Placement o drains be ore closure, use o Ioban sheeting, backf ushing through
the drains with an antibiotic concentrate, and use o Biopatch around the drains
TECHNIQ UE
RIGHT SIDE
Shaped
implant placed
in pocket
A total submuscular capsulectomy was
per ormed through an in ramammary ap-
proach, which avoided disruption o the
periareolar Gore-Tex suture. With the pa-
tient in the erect position, the implant style
and size was care ully selected using Memo-
ryShape sizers. A style MM MemoryShape
440 cc implant was chosen. The contoured
implant was care ully seated in the lowest
part o the pocket to maximize correction o
her ptosis and to keep the nipple centered on
the breast mound.
Round implant and
capsule removed through
inframammary incision

Chapter 27 • Recurrent Ptosis

443
LEFT SIDE
The procedure was repeated on the contralateral side. A drain was placed in each
breast and Ioban sheeting was used to cover the breasts be ore the implants were
introduced with a no-touch technique. Antibiotic concentrate was backf ushed
through the drains at the completion o the layered closures, and Biopatches were
applied around the drains.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The 5-year postoperative photos show a nice correction o this patient’s ptosis as
well as centralization o the NAC on the breast mound. The contoured implant
provides a gentle slope to the upper pole o the breast. On long-term ollow-up,
Baker grade I capsules are noted with good preservation o contour.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
444
TEACHING PO INTS
The aesthetic improvement in this case came rom lowering the position o the im-
plant on the chest wall and utilizing a contoured implant to provide slope to the
upper pole o the breast. Contoured highly cohesive implants can do a remarkable
job o camouf aging breast ptosis. The patient’s willingness to have larger implants
assured that the MemoryShape device would t snugly in the new pocket and thus
limit the risk o rotation. The in ramammary approach gives better exposure or
the capsulectomy and implant placement, and the periareolar Gore-Tex suture was
preserved.
BIBLIO GRAPHY
Cunningham B. The Mentor study on contour pro le gel silicone MemoryGel breast implants. Plast
Reconstr Surg 120(7 Suppl 1):33S-39S, 2007.
Giordano S, Peltoniemi H, Lilius P, Salmi A. Povidone-iodine combined with antibiotic topical irriga-
tion to reduce capsular contracture in cosmetic breast augmentation: a comparative study. Aes-
thet Surg J 33:675-680, 2013.
Hammond DC, Migliori MM, Caplin DA, et al. Mentor contour pro le gel implants: clinical out-
comes at 6 years. Plast Reconstr Surg 129:1381-1391, 2012.
Lesavoy MA, Trussler AP, Dickinson BP. Di culties with subpectoral augmentation mammaplasty
and its correction: the role o subglandular site change in revision aesthetic breast surgery. Plast
Reconstr Surg 125:363-371, 2010.
P ei er P, Jørgensen S, Kristiansen TB, et al. Protective e ect o topical antibiotics in breast augmenta-
tion. Plast Reconstr Surg 124:629-634, 2009.
Spear SL, Dayan JH, Bogue D, et al. The “neosubpectoral” pocket or the correction o symmastia.
Plast Reconstr Surg 124:695-703, 2009.

27b Conversion to Partial Subpectoral Pocket
and Bilateral Vertical Mastopexy
An d r e Y. Lev esq u e, Ja mes C. Gr o t t in g
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 40-year-old patient had hypomastia and requested augmentation 7 years pre-
viously. She presented with baseline Baker grade II breast ptosis and was o ered
augmentation with vertical mastopexy. She declined and elected to proceed with
augmentation alone. A sub ascial augmentation with smooth saline 390 cc implants
was per ormed.
445

Part III: Problems in Mastopexy and Augmentation-Mastopexy
446
A ter the surgery, she was pleased with her size breast despite the implant base di-
ameter being slightly larger than her chest wall.

Chapter 27 • Recurrent Ptosis

447
She returned 7 years later with a def ation o her le t saline implant. This provided
an opportunity to correct her breast ptosis, among other issues that had developed.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
448
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
On the patient’s le t side, she has an implant def ation with pseudoptosis o the
remaining breast tissue and an oblong areola. On the patient’s right side, she has
Baker grade III capsular contracture with ptosis as well as descent o her implants
and an oblong areola. Her implant is readily visible laterally rom and in eriorly
to the NAC. In addition, she has poor tissue coverage over both her implants. The
patient is thin, and the original sub ascial augmentation has not provided adequate
coverage a ter 7 years.
ANALYSIS O F THE PRO BLEM
This slender patient has developed thinning o her native breast tissue, and she has
inadequate support as a result o the size o her implants. She has also developed
implant descent and ptosis; these were not corrected at the time o her original aug-
mentation, at the patient’s request. There is a distinct separation between the supe-
rior pole o the implant and the tissue superior to it.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal and replacement o her implants with textured silicone 340 cc devices.
Smaller devices will place less stress on the remaining breast tissues, and a tex-
tured device may help with recurrent capsular contracture and may help to sta-
bilize the implant position. This patient continued to push or a “ ull” look.
Pocket change to the partial subpectoral plane, which will provide additional
implant coverage and will be a new tissue plane or the new implant/so t tissue
healing inter ace.
Use o a posterior capsular f ap or in erior and lateral implant coverage and
support. The posterior capsular f ap will be sutured to the lateral pectoralis bor-
der. This not only creates a place or the new tissue but also helps to provide me-
chanical support. The portion o the capsule in contact with the old implant will
be in contact with parenchymal tissue rather than the new implant.
Bilateral vertical mastopexy, which will correct oblong areolae and improve the
position o the NAC. This patient exhibits not only pseudoptosis but also bot-
toming out o the lower pole o the breast.

Chapter 27 • Recurrent Ptosis

449
TECHNIQ UE
The markings on this patient are shown. An incision was made in the lateral ver-
tical limb o the mastopexy marking, and the sub ascial saline implant removed.
The pocket was irrigated with triple antibiotic solution, and the posterior capsule
marked or the f ap, which was in eriorly based and dissected ree o the pectoralis
major and chest wall. The posterior capsule was marked or the in erior-based f ap
within the old sub ascial pocket. The posterior capsular f ap was dissected rom
pectoralis and chest wall down to the in erior and lateral breast border.
A subpectoral pocket was then devel-
oped to accommodate the new implant
in a standard augmentation mammo-
plasty ashion. The excess redundant
capsule was then excised. The pocket
was irrigated copiously with triple anti-
biotic solution, and hemostasis ensured.
The implant was then introduced into
the subpectoral pocket, and the poste-
rior capsular f ap closed over the im-
plant to the overlying pectoralis major.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
450
Capsulotomies were per ormed in the remaining anterior capsule to enable proper
so t tissue redraping over the new implant. Another option was to per orm a com-
plete capsulectomy, but in this patient, we thought that that would risk blood
supply to the NAC and diminish the so t tissue coverage. The mastopexy inci-
sions were then made and deepithelialization per ormed. The excess skin that was
marked with mastopexy was deepithelialized.
The areola was then secured at the 12 o’clock position with a temporary staple.
The in erior breast tissue was thin in this patient, so we thought that imbrication
was superior to the parenchymal f aps or the excision. The in erior point o the ver-
tical closure was closed. The superior point o the vertical closure was then closed.

Chapter 27 • Recurrent Ptosis

451
Temporary closure was per ormed with staples, and the patient placed in an up-
right position to assess the shape o the breasts and to make any necessary adjust-
ments. The right side was then per ormed in a similar ashion. The nal closure was
per ormed in layers o 2-0 Vicryl to imbricate the deep so t tissue, 3-0 PDS or deep
dermis, and 3-0 PDS subcuticular or mastopexy incisions. The periareolar closure
was per ormed using a 5-0 Nylon hal -buried mattress and a 4-0 PDS subcuticular
suture. One side was closed temporarily with staples, and then the procedure was
per ormed on the other side. The right side was def ated to prepare or the augmen-
tation-mastopexy.
In an upright position, the patient was
closed on both sides as a nal check.
The dressing was then applied using
large Tegaderm to provide additional
support and to allow the patient the
ability to shower immediately. A win-
dow was cut in the Tegaderm or the
patient’s nipple, allowing more com-
ort.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
452
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient’s postoperative photos at 7 months show excellent support o her aug-
mentation-mastopexy. Although this is a relatively early postoperative result, we
expect over time that the implants will have a tendency to descend and round out
the lower pole o the breast.

Chapter 27 • Recurrent Ptosis

453
TEACHING PO INTS
Using capsular f aps when available can provide implant coverage and support, and
they do not carry the added cost that come with ADMs. The early postoperative
views o this patient demonstrate the holding ability o the posterior capsular f ap.
Continued implant descent is anticipated over time. In slender patients with poor
tissue support at the baseline, larger devices will over time develop the issues seen
in this patient.
Changing to smaller implants can correct the common sequelae o previous large
augmentation.
Per orming temporary tailor-tacking be ore committing to the mastopexy incisions
ensures that an adequate skin envelope is present to cover the implant.
BIBLIO GRAPHY
Bengtson BP, Ringler SL, George ER, et al. Capsular tissue: a new local f ap. Plast Reconstr Surg
91:1073-1079, 1993.
Gargano F, Moloney DM, Arnstein PM. Use o a capsular f ap to prevent palpable wrinkling o im-
plants. Br J Plast Surg 55:269, 2002.
Voice SD, Carlsen LN. Using a capsular f ap to correct breast implant malposition. Aesthet Surg J
21:441-444, 2001.
Yoo G, Lee PK. Capsular f aps or the management o malpositioned implants a ter augmentation
mammoplasty. Aesthetic Plast Surg 34:111-115, 2010.

(Trang không có chữ)

28a Fat Grafting to Correct Flattening or Loss
of Upper Pole Fullness
Lo u is P. Bu c k y
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 43-year-old woman was originally seen or breast ptosis; she had had no pre-
vious breast surgery. She is shown 5 months a ter a mastopexy and at gra ting
with 300 cc to the right breast and 400 cc to the le t. She is 5 eet 11 inches tall,
weighs 147 pounds, and is a healthy nonsmoker. She returned 1 year later request-
ing more ullness in the upper poles o her breasts. It was decided to use at to build
out her upper poles.
c h a Pt e r 2 8
FLATTENING OR LOSS OF UPPER
POLE FULLNESS
455

Part III: Problems in Mastopexy and Augmentation-Mastopexy
456
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has loss o upper pole volume but good nipple-areola position. Her
base width is 15 cm bilaterally. Her nipple-to-in ramammary old is 9 cm bilater-
ally, and she has a long distance rom sternal notch to nipple. She has good skin
quality and a well-healed mastopexy incision.
ANALYSIS O F THE PRO BLEM
The patient had inadequate volume in her upper pole with mild bottoming out o
her lower breast. She had mild adiposity in other areas o her body, particularly in
her abdomen, hips, and saddlebags.
RECOMMENDED SOLUTION TO THE PROBLEM
Per orm large volume at gra ting to the breast, particularly in the upper pole
Per orm secondary skin tightening using the vertical limb o her mastopexy
The patient’s goal was to have upper pole ullness but not to have her breasts be
much bigger. The ability to selectively ll the upper pole o the breast with at
rather than globally enlarging the entire breast with an implant was a signi cant
advantage. This obviates the need or uture implant maintenance, and the oppor-
tunity to use at rom areas o excess o her lower torso was an additional bonus.
TECHNIQ UE
The patient is shown a ter 300 cc o at was added to her le t breast and 255 cc
to her right breast with a tightening o the vertical limb. The surgical plan was to
achieve maximal at survival, so the patient used the Brava preoperative expansion

Chapter 28 • Flattening or Loss of Upper Pole Fullness

457
system or 3 weeks. The primary goal was to increase the vascularity to prime the
recipient site. The patient wore the Brava device 6 hours a day, 7 days a week. First
the NAC is positioned through a periareolar mastopexy incision per ormed with a
Gore-Tex purse-string around a 26 mm cookie cutter. A 36 mm areola cutout was
made, with the purse-string drawn down around a 26 mm template with Gore-Tex
to reduce the tension on the incision. The Gore-Tex was not buried within the
parenchyma.
No tissue was removed; only a tightening procedure was per ormed. Then we
tailor-tacked the vertical component. The tailor-tacking is a temporary attempt to
reshape the smaller breast to see where volume is needed. My pre erence was to do
the mastopexy rst, tighten the lower pole, and then use the at where needed. Then
tumescence o areas or liposuction was initiated, the at was processed with low-
speed centri ugation, and the at was injected in areas o each breast as necessary.
The Coleman ringed cannula is used to inject at, and the at is harvested with a
Del Vecchio harvesting cannula. The idea is not to do the liposuction rst and then
the mastopexy, because the goal is to minimize hypoxia. The least amount o ex
vivo time possible is pre erred, so the processed at is not le t sitting aside. The at
was harvested rom her hips, abdomen, and saddlebags. Once the injection process
was complete, the patient was positioned upright and assessed. I the goals o at
trans er appear to have been achieved, with pleasing shaping and volume, we deepi-
thelialize the vertical component to complete the mastopexy.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient has good upper pole and lower pole proportions with a so t, natural-
appearing breast and maintenance o her nipple-areola position. Improvement is
seen in the medial aspects or cleavage o her breasts. She is seen be ore her proce-
dures, 2 months a ter her mastopexy and rst at gra ting session, and again 1 year
a ter at gra ting with recent revision o vertical scar.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
458
TEACHING PO INTS
The operation should be per ormed with sensitivity to ischemia time; this is why
at is harvested in the middle o the procedure. Fat is harvested with the goal o
improving contours and avoiding contour de ects. Fat is injected in very small ali-
quots to improve tissue survival. The Brava preexpansion system may be bene cial
or priming the recipient site.
Preoperative
2 months after mastopexy and
first fat grafting session
1 year postoperatively

Chapter 28 • Flattening or Loss of Upper Pole Fullness

459
BIBLIO GRAPHY
Bircoll M. Autologous at transplantation. Plast Reconstr Surg 79:492-493, 1987.
Bircoll M. Cosmetic breast augmentation utilizing autologous at and liposuction techniques. Plast
Reconstr Surg 79:267-271, 1987.
Coleman SR, Saboeiro AP. Fat gra ting to the breast revisited: sa ety and e cacy. Plast Reconstr Surg
119:775-785; discussion 786-787, 2007.
Del Vecchio DA, Bucky LP. Breast augmentation using preexpansion and autologous at transplanta-
tion: a clinical radiographic study. Plast Reconstr Surg 127:2441-2450, 2011.
Galiè M, Pignatti M, Scambi I, Scarbati A, Rigotti G. Comparison o di erent centri ugation pro-
tocols or the best yield o adipose-derived stomal cells rom lipoaspirates. Plast Reconstr Surg
122:233e-234e, 2008.
Kurita M, Matsumoto D, Shigeuroa T, et al. Inf uences o centri ugation on cells and tissues in lipo-
suction aspirates: optimized centri ugation or lipotrans er and cell isolation. Plast Reconstr Surg
121:1033-1041; discussion 1042-1043, 2008.

28b Loss of Upper Pole Fullness After Mastopexy
el iz a bet h J. h a l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 57-year old patient requested a breast upli t.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
She was in ormed that her breast ootprint could not be changed and that her up-
per breast border would not rise on the chest wall with a mastopexy. Some o the
lower breast tissue could be repositioned to give her better projection, which could
remove some o the glandular ptosis.
ANALYSIS O F THE PRO BLEM
A skin-only mastopexy does not hold the breast tissue up. The in erior wedge o
breast tissue that would be removed in a breast reduction needs to be moved up.
The tissue cannot be held up with just a skin bra, and the in erior wedge needs
to be dissected ree rom the surrounding tissue and repositioned so that the new
breast tissue can heal to the existing breast tissue in a new arrangement.
460

Chapter 28 • Flattening or Loss of Upper Pole Fullness

461
RECOMMENDED SOLUTION TO THE PROBLEM
Per orming a superior pedicle extension f ap
Moving up the in erior glandular breast tissue by turning over the extension, as
shown in the photographs
TECHNIQ UE
The blood supply to a superior pedicle extension f ap comes rom the descending
branch o the internal mammary system rom the second interspace. The in erior
tissue that would be removed in a vertical type o breast reduction was dissected
ree and turned under the superior pedicle.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
462
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The initial result at 5 weeks a ter surgery was good, but the patient elt the breast
“give” and she lost upper pole ullness. An in erior f ap that is completely separated
rom the surrounding tissue will not have the tendency to slip in the same way as
the superior pedicle extension f ap. Neither f ap can produce increased upper pole
ullness, but the in erior f ap rearranges the breast tissue enough to give more pro-
jection and to remove the glandular ptosis.

Chapter 28 • Flattening or Loss of Upper Pole Fullness

463
The patient is shown 8 weeks a ter surgery and again 4 years postoperatively.
An implant is needed to increase the upper pole ullness and to raise the upper
breast border. My measurements have shown that an implant will only raise the
upper breast border 2 cm on average; the rest o the volume will end up lowering
the breast itsel and lowering the IMF.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
464
This 44-year old patient had lost 150 pounds and requested a breast li t. An in e-
rior f ap was used and held up under a pectoralis muscle strip, as described by Ruth
Gra . The 1-month postoperative photo shows the e cacy o an in erior f ap that is
placed under a strip o pectoralis muscle; even at 11⁄2 years postoperatively, the in e-
rior f ap can still be seen sitting higher than the remaining breast tissue, which has
allen back down around it.
The patient is shown 1 month a ter surgery, with a prominence in the upper pole
rom the in erior f ap held up by a pectoralis strip.

Chapter 28 • Flattening or Loss of Upper Pole Fullness

465
The patient is shown 11⁄2 years later, still having a noticeable bump.
She is shown 1 year a ter an additional correction involving elevation o the are-
olae. There was still some urther ptosis o the glandular tissue over the f ap; this is
a recurrent problem in patients with massive weight loss.
TEACHING PO INTS
The in erior f ap, as described by Liacyr Ribeiro, is sutured to the pectoralis as-
cia to hold it in place long enough to heal to the breast tissue in a new arrange-
ment, and this lasts longer than a superior pedicle extension f ap. The in erior f ap
does not adhere to the pectoralis ascia; this has been con rmed when revisions
have been per ormed to add an implant in cases when patients have decided subse-
quently that they did want more upper pole ullness.
An in erior f ap that is placed under a strip o pectoralis muscle can actually be too
power ul in massive-weight-loss patients (as shown in the previous patient). In this
patient, the pectoralis strip holds the in erior f ap up to the chest wall, and the re-
maining breast tissue then alls back down around this f ap.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
466
BIBLIO GRAPHY
Daniel MJB. Mammoplasty with pectoral muscle f ap. Presented at the Sixty-Fourth Scienti c Meeting
o the American Society o Plastic and Reconstructive Surgeons, Montreal, 1995.
Gra R, Biggs TM, Steely RL. Breast shape: a technique or better upper pole ullness. Aesthetic Plast
Surg 24:348-352, 2000.
Gra R, Biggs TM. In search o better shape in mastopexy and reduction mammaplasty. Plast Reconstr
Surg 110:309-317, 2002.
Gra RM, Auersvald A, Bernardes A, Biggs TM. Reduction mammaplasty and mastopexy with shorter
scar and better shape. Aesthet Surg J 20:99-106, 2000.
Gra RM, Mansur AE, Tenius FP, et al. Mastopexy a ter massive weight loss: extended chest wall-
based f ap associated with a loop o pectoralis muscle. Aesthetic Plast Surg 32:371-374, 2008.
Kim P, Kim KK, Casas LA. Superior pedicle autoaugmentation mastopexy: a review o 34 consecutive
patients. Aesthet Surg J 30:201-210, 2010.
McKissock PK. Discussion o Mathes SJ, Nahai F, Hester TR. Avoiding the f at breast in reduction
mammaplasty. Plast Reconstr Surg 66:70, 1980.
Ribeiro L. A new technique or reduction mammaplasty. Plast Reconstr Surg 55:330-334, 1975.
Ribeiro L, Accorsi A Jr, Buss A, Marcal-Pessoa M. Creation and evolution o 30 years o the in erior
pedicle in reduction mammaplasties. Plast Reconstr Surg 110:960-970, 2002.

C h a p t e r 29
INFERIOR STRETCH DEFORMITY
AND BOTTOMING OUT
29a Correction of Bottoming Out With Unilateral Fold
Elevation and Contralateral Periareolar Mastopexy
Den n is C. h a mmo n d
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 57-year-old woman presented with a history o multiple previous procedures
related to an initial breast augmentation per ormed in the 1970s using silicone gel
implants. Her rst episode o capsular contracture was treated in the early 1990s
with an implant exchange and unspeci ed procedures to the capsule. Six years be-
467

Part III: Problems in Mastopexy and Augmentation-Mastopexy
468
ore presentation, she underwent repeat bilateral capsulectomies, along with im-
plant exchange using High Pro le 550 cc silicone gel devices (Mentor, Santa Bar-
bara, CA), pocket exchange to the subpectoral position, and bilateral periareolar
mastopexy. Shortly therea ter, she had a revision to reposition her high-riding im-
plants, and new High Pro le 700 cc devices (Mentor) were placed. Complications
rom in ection necessitated removal o the right implant. Approximately 1 year
later, a tissue expander was placed in the right breast and inf ated to 800 cc. The
expander and the opposite breast implant were subsequently replaced with 600 cc
Moderate Pro le silicone gel implants (Mentor). She presented 4 years a ter her last
procedure. She had bilateral breast de ormity that was greater on her right side,
with distortion, shape irregularity, and asymmetry. With contraction o her pectora-
lis major muscles, the distortion in the lower pole o the right breast was magni ed.
She thought that her breast size was acceptable and was seeking improvement in
their overall appearance.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has an obvious asymmetry that a ects her overall breast shape and
the position o the NACs and IMFs, with the old lower on the right where the im-
plant has bottomed out slightly. A prominent crease runs obliquely across the right
breast and is associated with signi cant f attening o the lower pole. Both breasts
are moderately rm. The le t breast has a 9 cm IMF scar. The scar on the right mea-
sures 14 cm. With contraction o the pectoralis major muscle, each implant li ts in
an upward and outward direction and the lower poles f atten, indicating that both
implants are under at least a portion o the muscle.
ANALYSIS O F THE PRO BLEM
In such patients, an abundant amount o scar is expected to be associated with the
capsule, the skin f aps, and the muscle. Old capsules may well exist both above and
below the muscle, depending on the nature o the previous treatments. This scar
was largely responsible or the distorted appearance o the breasts. Complicating
the situation was the in erior implant displacement on the right, which exacerbated
asymmetry in the breast ootprint, shape, and NAC position.
RECOMMENDED SOLUTION TO THE PROBLEM
Release and removal o thick segments o capsule
Redraping o so t tissues around the implant
Elevation o the right IMF
Restoration o NAC symmetry with a unilateral repeat periareolar mastopexy
on the le t

Chapter 29 • Inferior Stretch Deformity and Bottoming Out

469
TECHNIQ UE
The patient’s skin was marked or bilateral capsulotomy, implant exchange, eleva-
tion o her right IMF, and le t periareolar mastopexy. Thick scar was present in the
so t tissue envelope, and capsules were well developed. On each side an extensive
capsulotomy was per ormed to release the so t tissues and allow them to redrape
around the implants. The devices were Biocell textured round implants (Allergan,
Irvine, CA). No tissue ingrowth was noted on the le t, and partial ingrowth was
present on the right. On the right, the texture had worn smooth in several areas and
both implants had a deep yellow color. For this reason, the decision was made to
replace the implants with Mentor 600 cc Moderate Pro le Plus silicone gel devices.
The muscle on the right side was urther released medially in an attempt to so ten
the step-o along the medial breast border. The position o the IMF was li ted us-
ing a capsular f ap technique in which an incision was made along the lower chest
wall, and the capsule was li ted down to and around the old, creating an in eriorly
based capsular f ap.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
470
A segment o capsule was then resected away rom the chest wall, just widely
enough to approximate the amount needed to elevate the old. The f ap was sutured
to the cut capsular edge superiorly to create a hammock to support the implant,
li ting the position o the IMF. The capsule was repaired with both interrupted and
running 3-0 permanent mono lament sutures. Finally, a periareolar mastopexy was
per ormed using an interlocking Tef on suture technique.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had a prolonged postoperative course related to management o her
drains. Continued drainage necessitated keeping the drains in place or several
weeks. Persistent mild erythema was treated with oral antibiotics. Mild contrac-
tures recurred bilaterally, with more distortion on the right side; there ore repeat
capsulotomies were per ormed to urther so ten her breasts. Fat was gra ted to the
superior and superomedial pole on the right to so ten her upper pole contour. Scar
was revised on the right side, because it had thinned over time.