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

Part III: Problems in Mastopexy and Augmentation-Mastopexy
472
TEACHING PO INTS
Identi cation o the various causes o breast de ormity is necessary or straight or-
ward and e cient treatment. In this case, the two key maneuvers were success ul
management o the internal scar through the use o aggressive capsulotomies, cou-
pled with success ul elevation o the right IMF. The internal scarring was so exten-
sive that a subsequent second capsulotomy was necessary to achieve the desired
result. In patients who require extensive revision, o ten it is anticipated that an ad-
ditional capsular procedure will be needed to achieve su cient so tening o the
breasts. In this patient, the second capsulotomy was much easier and less extensive
because o the gains made in the rst procedure. The lesson learned here is to never
give up, because repeat attempts at managing the internal scar can be quite success-
ul in creating a so t breast.
A capsulectomy was an option in this patient. However, her so t tissue cover was
thin, and this procedure might have resulted in extremely thin areas or necrosis o
the overlying skin. In my experience, capsulotomy is just as e ective, i not more so,
than complete removal o the capsule.
Fat gra ting to treat thin areas can be the nal adjunct or a success ul revision. In
this patient, thin areas in the upper portion o her right breast were rein orced with
gra ted at to improve the upper pole contour. These techniques can signi cantly
improve the quality o li e or patients such as this.
BIBLIO GRAPHY
Bogdanov-Berezovsky A, Silberstein E, Shoham Y, et al. Capsular f ap: new applications. Aesthetic
Plast Surg 37:395-397, 2013.
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.
Persichetti P, Langella M, Filoni A, et al. How to rede ne the in ramammary old: the “slingshot” cap-
sular f ap. Ann Plast Surg 70:636-638, 2013.
Yoo G, Lee PK. Capsular f aps or the management o malpositioned implants a ter augmentation
mammoplasty. Aesthetic Plast Surg 34:111-115, 2010.

29b Correction of Inferior Stretch Deformity
With Mastopexy and Implant Site Change
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 34-year-old woman presented 10 years a ter a bilateral subglandular augmen-
tation with gel implants. She reported that her cup size was a small B be ore the
procedure. She had relatively large implants o an unknown size.
The patient had numerous complaints. She thought that her breasts had become
progressively rm over the last ew years and had descended, with the nipples
pointing outward. She disliked the round, unnatural appearance o her breasts but
was satis ed with their volume.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Multiple components contribute to the patient’s de ormities. The capsular contrac-
tures in the subglandular plane have created tight, round spheres. Her NACs are
rotated laterally, which may be caused by overdissection o the subglandular pock-
ets medially. She has a wide separation between her breasts. The major problem is
signi cant bottoming out, with an areola-to-IMF distance o 12 cm on the le t and
14 cm on the right. The patient appears to have very little breast tissue covering her
implants.
ANALYSIS O F THE PRO BLEM
Bottoming out needs to be distinguished rom ptosis in patients with these ea-
tures. The actual distance rom the clavicles to the NACs revealed minimal ptosis,
whereas the distance rom the areolae to the IMFs demonstrated signi cant bot-
toming out. A mastopexy alone risked placement o the nipples too high. Addition-
ally, in patients with extensive bottoming out, a vertical mastopexy may not solve
473

Part III: Problems in Mastopexy and Augmentation-Mastopexy
474
the problem o extensive skin in the lower portion o the breasts. Recurrence o
bottoming out a ter a mastopexy o any type is common.
The other problem was the marked lateralization o both nipples. Overdissection o
pockets medially can rotate the nipples outward toward the anterior axillary olds.
Her right NAC was positioned at the very lateral edge o her breast. Similarly, inad-
equate lateral pocket dissection can contribute to this problem.
The capsules created an unnatural appearance, with the margin o the implant de-
ned by the contracture.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the subglandular implants with capsulectomies
Closure o the subglandular pockets
Deepithelialization o redundant lower pole skin
Correction o bottoming out with suture xation or support
Nipple repositioning with a periareolar mastopexy
Relocation o implants to a submuscular plane
TECHNIQ UE
The patient was marked preoperatively. In the rst step, the skin envelope was
tailor-tacked. The transverse ellipse o skin was then deepithelialized along the IMF
to correct the bottoming out. Once the extent o the area to be deepithelialized
was determined, the subglandular implant was removed, and a total capsulectomy
was per ormed. The subglandular space was closed with permanent sutures. A new
pocket was created in the subpectoral plane, and a sizer was inserted. Deepithelial-
ization o the skin allowed reduction o the skin envelope to correct the bottoming
out. Suture xation o the deepithelialized area to deep tissues provided mechanical
support to minimize recurrence o the de ormity.

Chapter 29 • Inferior Stretch Deformity and Bottoming Out

475
Next, the nipple was relocated using an eccentric periareolar mastopexy to slightly
elevate the NAC and move it medially.
The subpectoral pocket dissection was more medial than the original subglandular
pocket to create better cleavage. It was important to create a more lateral pocket to
reduce lateralization o the nipples. The new pocket dissection extended slightly be-
yond the anterior axillary line laterally.
With the gel implants placed in subpectoral pockets, the nal skin tailoring was
completed.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
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A permanent suture was used or the periareolar portion o the mastopexy. No skin
was excised in the transverse area; it was only deepithelialized. This was closed, in-
verting the deepithelialized area in a two-layer closure with permanent sutures to
the deep ascial plane or support. Drains were inserted in the original closed sub-
glandular pockets, and a surgical bra was placed on the patient.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient shows signi cant improvement at her long-term ollow-up. Her NACs
are better positioned. Submuscular placement has created a more natural, teardrop
shape to the breasts versus the hard, round shape be ore revision. Her interbreast

Chapter 29 • Inferior Stretch Deformity and Bottoming Out

477
distance is shorter, and cleavage is improved. This was accomplished by limited and
care ul division o the bers o the pectoralis medial to prevent overdissection and
synmastia. A vertical scar was prevented by combining a periareolar skin excision
with a transverse in ramammary incision.
TEACHING PO INTS
In patients with multiple problems, a step-by-step analysis is critical. Isolation o
each component o the de ormity allows a logical series o solutions. This patient
had bottoming out, ptosis, lateral nipple displacement, and capsular contracture—
the whole spectrum o common postaugmentation problems.
A ter an initial assessment o this patient, a basic vertical or inverted-T mastopexy
might appear to be the correct solution. The problem with a vertical approach is
that it can exacerbate an already excessive areola-to-IMF distance. The nipples only
needed slight elevation, but they required signi cant medial repositioning. This was
partially corrected by slightly eccentric periareolar mastopexies. It is more di cult
to success ully move nipples medially because o their tendency to migrate laterally
a ter surgery. The other component in improving this patient’s nipple position was
to extend the new pockets arther laterally. With the implants occupying more lat-
eral positions, the nipples appear to be less lateralized.
Repositioning o the implant in the subpectoral plane reduced the unnatural, round
appearance created by the capsules when the implants were in the original, sub-
glandular plane, and it reduced the risk o recurrent capsules. Use o the deepithe-
lialized skin o the lower pole created a dermal f ap that helped to support the im-
plant. Acellular dermis was another option, but in this case, the patient’s own tissue
was adequate.
BIBLIO GRAPHY
Brown RH, Izaddoost S, Bullocks JM. Preventing the “bottoming out” and “star-gazing” phenomena
in in erior pedicle breast reduction with an acellular dermal matrix internal brassiere. Aesthetic
Plast Surg 34:760-767, 2010.
Kau man D. Pocket rein orcement using acellular dermal matrices in revisionary breast augmentation.
Clin Plast Surg 39:137-148, 2012.
Mañero I, Montull P, Guisantes E. Bottoming out: a simple technique or correcting breast implant
displacement. Plast Reconstr Surg 124:452e-453e, 2009.
Quan M, Fadl A, Small K, et al. De ning pseudoptosis (bottoming out) 3 years a ter short-scar medial
pedicle breast reduction. Aesthetic Plast Surg 35:357-364, 2011.
Slavin SA, Lin SJ. The use o acellular dermal matrices in revisional breast reconstruction. Plast Recon-
str Surg 130(5 Suppl 2):70S-85S, 2012.
Spear SL, Seruya M, Clemens MW, Teitelbaum S, Nahabedian MY. Acellular dermal matrix or
the treatment and prevention o implant-associated breast de ormities. Plast Reconstr Surg
127:1047-1058, 2011.
Spear SL, Dayan JH, West J. The anatomy o revisions a ter primary breast augmentation: one sur-
geon’s perspective. Clin Plast Surg 36:157-165, viii, 2009.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
478
Swanson E. A measurement system or evaluation o shape changes and proportions a ter cosmetic
breast surgery. Plast Reconstr Surg 129:982-992, 2012.
Vegas MR, Martin Del Yerro JL. Sti ness, compliance, resilience, and creep de ormation: understand-
ing implant-so t tissue dynamics in the augmented breast: undamentals based on materials sci-
ence. Aesthetic Plast Surg 37:922-930, 2013.
Zehm S, Puelzl P, Wechselberger G, et al. In erior pole length and long-term aesthetic outcome a ter
superior and in erior pedicled reduction mammaplasty. Aesthetic Plast Surg 36:1128-1133, 2012.

C h a p t e r 30
REVISION IN BARIATRIC
PATIENTS OF UNSUCCESSFUL
OUTCOME AFTER MASTOPEXY
OR AUGMENTATION-MASTOPEXY
30a Secondary Mastopexy With Lower Pole Reshaping
Kh a l id a l mu t a ir i, J. pet er r u bin
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 41-year-old woman lost almost 100 pounds through diet and exercise. Mas-
sive weight loss (MWL) trans ormed her BMI rom 44.4 kg/m2 to 27.4 kg/m2 and
resulted in multiple body contour de ormities. She was a nonsmoker, and her past
medical history included hypertension and diabetes mellitus type II.
On initial presentation, her physical examination revealed grade III ptotic breasts
with medially positioned nipples, and a de ated skin envelope with volume asym-
metry. She had a single-stage Wise pattern mastopexy with implant augmentation
per ormed by the senior author (J.P.R.). Smooth round silicone implants were used.
The right implant was 304 cc, and the le t implant was 265 cc. Both were placed in
a submuscular pocket to achieve breast symmetry. The pectoralis muscle f bers were
scored with the electric cautery at the muscle origin or a partial release. The pa-
tient also had a concurrent brachioplasty, abdominoplasty, and medial thigh li t.
479

Part III: Problems in Mastopexy and Augmentation-Mastopexy
480
Medial position o the nipples is a common nding in the MWL patients. The ini-
tial Wise pattern markings were designed to move the nipples laterally.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Two years a ter the mastopexy, she presented or correction o breast ptosis and
lower pole skin envelope laxity. The patient’s nipples are ptotic relative to the posi-
tion o her implants, and she has excessive skin envelope laxity in the lower pole.
Breast projection is adequate, and an implant exchange is not needed. This is o
particular importance in secondary procedures in which dissection in multiple
planes can potentially compromise blood f ow to the nipple.
ANALYSIS O F THE PRO BLEM
Although augmentation-mastopexy is o ten a challenge, it is more di cult in MWL
patients because o the poor quality o their tissues and the propensity or recur-
rent laxity a ter any procedure. Implants commonly displace in eriorly in MWL
patients, but implant descent was not the primary problem in this patient. The pec-
toralis muscle bers were scored at their origin, rather than ully released. This has
the advantage o keeping the implant higher on the chest wall, but lax so t tissues
can descend around the implant.

Chapter 30 • Bariatric Patients After Mastopexy or Augmentation-Mastopexy

481
In this case, the implants were in an acceptable position on the patient’s chest wall,
and her skin envelope had descended. This was not a case o nipple ptosis only; the
entire lower pole skin envelope was loose and required signif cant narrowing and
reshaping. With a reshaping o the lower pole skin, her nipple position needed to be
raised only slightly to be better placed relative to the implant. The nipple distance
rom the IMF should be measured intraoperatively to assist in achieving symmetry.
RECOMMENDED SOLUTION TO THE PROBLEM
Revision mastopexy
NAC repositioning with minimal elevation
Reshaping o the lower pole
TECHNIQ UE
The patient was marked in the upright position. Her suprasternal notch and the
midline were designated on the midsternum. The IMF was marked. The new nip-
ple position was indicated at the point o maximal projection along the breast me-
ridian, in this case at 21 cm (19 cm at the top o the areola). The new areola was
drawn around the new nipple position. Additional attention was given to symmetry
by measuring the distance rom the breast meridian to the midline. A modif ed Wise
pattern was designed based on a pinch test, with care taken not to elevate the nip-
ple excessively.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
482
With the patient under general anesthesia and be ore completion o the draping,
her skin was tailor-tacked using skin staples and the markings were adjusted or
optimal shape. Tailor-tacking with staples is o great value to estimate the new
shape o the breast. This should be per ormed with the head o the bed elevated
(photographs demonstrate tailor-tacking on le t breast only (left panel), then both
breasts).
The skin within the Wise pattern was deepithelialized to preserve blood supply. The
nipple was transposed minimally to a position 21 cm rom the sternal notch (the
top o the 4 cm Wise pattern is shown at 19 cm). The closure was per ormed with
absorbable monof lament suture in the subcutaneous and intradermal layers. Paren-
chymal sutures were also placed to gain optimal projection.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 3 months postoperatively with good symmetry and correction
o lower pole laxity. This reoperation succeeded in reshaping her lower pole around
the implant. A key point is to recognize that the entire lower pole o the breast must
be manipulated. Although this approach was e ective in treating secondary de or-
mities, alternative approaches to implant-based procedures should be considered
or MWL patients. This patient was also a candidate or the dermal suspension
mastopexy technique (see pp. 483 and 484).

Chapter 30 • Bariatric Patients After Mastopexy or Augmentation-Mastopexy

483
DERMAL SUSPENSIO N MASTO PExY TECHNIQ UE
The breast de ormities observed in MWL patients are o ten severe and may involve
lateral rolls o skin and at. The severity o the de ormities, combined with inelas-
tic tissues, makes implant augmentation more di f cult, especially when per ormed
with mastopexy. Consideration should be given to dermal suspension mastopexy
with selective breast autoaugmentation using the lateral rolls o tissue. We o ten
suggest this option or MWL patients who have enough volume or a dermal sus-
pension mastopexy. The previously shown patient had a strong pre erence or add-
ing breast volume beyond what could be achieved with autologous tissue alone.
For comparison, this 38-year-old woman lost 140 pounds a ter gastric bypass
surgery. She had a de ated skin envelope and asymmetry. Despite her relatively
small breast volume and asymmetry, she was treated with a dermal suspen-
sion mastopexy.
She is shown 2 years a ter a dermal suspension mastopexy. This procedure, without
implants, should be considered as a treatment option or MWL patients to achieve
breast projection, correct ptosis, and eliminate lateral rolls o skin and at along the
chest wall.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
484
In the dermal suspension technique, the Wise pattern markings (with a 5 cm verti-
cal limb length and average divergence o 10 to 12 cm) extend laterally to include
the lateral chest roll or autoaugmentation. Meticulous deepithelialization o the
dermal pedicle and the medial and lateral dermoglandular aps o the Wise pattern
allows suspension and reshaping o the breast parenchyma. The central pedicle and
lateral and medial tissue aps are secured to the rib periosteum using nonabsorb-
able sutures. The dermis is plicated to achieve the f nal shape.
1-1.5 cm thick flap
Lateral dermal
flap elevated
and mobilized
Undermined area
Medial dermal
flap elevated
and mobilized
Pectoralis
major fascia
Central dermal
extension
Central dermal extension
suspended to rib periosteum
Second rib
Lateral flap
fixated to rib
periosteum
and plication
initiated
Central dermal extension
suspended to rib periosteum
2
3
Fourth rib
Medial flap
fixated to rib
periosteum
Dashed lines
indicate areas
to be plicated
Lateral flap
plicated
5 cm
Central dermal extension
suspended to rib periosteum
Medial flap
plicated

Chapter 30 • Bariatric Patients After Mastopexy or Augmentation-Mastopexy

485
TEACHING PO INTS
Analysis o the de ormity should f rst include assessment o implant position on
the chest wall. In MWL patients, recurrent laxity a ter a skin-tightening operation
is common. Patients should be in ormed o this potential. Most o the work o the
operation is accomplished through reshaping and narrowing o the skin envelope in
the in erior pole. Intraoperative tailor-tacking is use ul in these cases. Dissection is
minimized beyond the borders o the Wise pattern.
Patients who present with mild ptosis require alloplastic augmentation only. For
those with moderate ptosis, a combination o skin mastopexy and alloplastic aug-
mentation is usually su f cient to correct the breast shape. For patients who have
severe ptosis and particularly excessive skin laxity secondary to poor skin tone, a
dermal suspension mastopexy and parenchymal reshaping using only autologous
tissue is the procedure o choice i they will be satisf ed with the resultant volume.
Staging o the mastopexy and augmentation is always an option in di f cult cases.
However, many patients are reluctant to bear the expense and recovery period re-
quired or two planned procedures.
An important caveat or surgeons who attempt secondary correction o ptotic
breasts that were previously augmented is that explantation plus mastopexy and
signif cant dissection in multiple planes can place patients at a higher risk or vascu-
lar compromise to the skin and NAC.
BIBLIO GRAPHY
Guseno JA, Rubin JP. Plastic surgery a ter weight loss: current concepts in massive weight loss sur-
gery. Aesthet Surg J 28:452-455, 2008.
Rubin JP. Mastopexy a ter massive weight loss: dermal suspension and total parenchymal reshaping.
Aesthet Surg J 26:214-222, 2006.
Rubin JP, Guseno JA, Coon D. Dermal suspension and parenchymal reshaping mastopexy a ter mas-
sive weight loss: statistical analysis with concomitant procedures rom a prospective registry.
Plast Reconstr Surg 123:782-789, 2009.
Rubin JP, Khachi G. Mastopexy a ter massive weight loss: dermal suspension and selective
auto-augmentation. Clin Plast Surg 35:123-129, 2008.
Spear S. Augmentation/mastopexy: “surgeon, beware.” Plast Reconstr Surg 112:905-906, 2003.
Stevens WG, Stoker DA, Freeman ME, et al. Mastopexy revisited: a review o 150 consecutive cases
or complication and revision rates. Aesthet Surg J 27:150-154, 2007.

(Trang không có chữ)

Pa r t IV
Problems in Reduction
Mammaplasty

Breast reduction is a commonly per ormed operation and one that has a very high rate o pa-
tient satis action. The primary goal o breast reduction is unctional: to alleviate the physical
symptoms and prevent the musculoskeletal damage that can result rom macromastia. At the
same time, breast reduction is an aesthetic procedure. Most women who present or reduction
mammaplasty eel their breasts are out o proportion to the rest o their body. Restoration o
desirable aesthetic balance—creating a breast that is harmonious with the patient’s overall body
habitus—is a critical goal o breast reduction surgery. W hile patients with macromastia want a
reduction in overall breast size, they de nitely do not want this at the expense o an attractive-
appearing breast. Plastic surgeons are thus charged with the obligation to reduce the size o the
breast and at the same time maintain a pleasing aesthetic appearance. In addition to such aes-
thetic concerns, the plastic surgeon must also be mind ul o the unctional aspects o the emale
breast—primarily sensibility and lactation. The act that success ul breast reduction surgery
must achieve so many disparate objectives simultaneously makes this a challenging procedure.
During the past decade, there has been a paradigm shi t in the approach to breast reduction
surgery. “Short scar” breast reduction has become increasingly popular. Patients expect, and
plastic surgeons endeavor to provide, improved aesthetic results with diminished scarring and
decreased morbidity. However, despite the technical advances in recent years, breast reduction
remains challenging and can be raught with complications and poor aesthetic outcomes. Most
complications a ter reduction mammaplasty are related to circulatory compromise o the skin or
gland and can mani est in a variety o ways, including at necrosis, wound separation, skin f ap
necrosis, and nipple ischemia with partial or even total nipple loss. Other problems may include
asymmetry, poor shape, and unsatis actory scarring. W hile the aim o the plastic surgeon is al-
ways to prevent complications and suboptimal outcomes, a certain number o patients inevita-
bly will experience unsatis actory results. In this section, our contributors present a wide range
o surgical options designed to correct the complications and suboptimal aesthetic outcomes that
occasionally occur a ter reduction mammaplasty. Fortunately, most o these cases can be e ec-
tively remedied, and the majority o patients will ultimately achieve a success ul outcome.

Se c t Io n o n e
Postoperative Complications
Chapter 31 Ischemia of the Nipple, Areola, and/or Skin Flaps
31a Watch ul Waiting
31b Healing by Secondary Intention
31c Watch ul Waiting With Antibiotics
31d Complete Nipple Reconstruction With Skate Flaps
489

(Trang không có chữ)

491
31a Watchful Waiting
el iz a bet h J. Ha l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 24-year-old woman wanted a breast reduction. She was 5 eet 4 inches tall,
weighed 148 pounds, and wore a size 38G bra. She underwent a medial pedicle
vertical breast reduction with 330 g removed rom her right breast and 320 g rom
her le t breast. Using liposuction, an additional 225 cc o at was removed rom her
lateral chest wall and preaxillary areas. No problems arose during the surgical pro-
cedure or early recovery.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Soon a ter surgery, the patient’s right
nipple and areola were dusky. No vis-
ible swelling was present to indicate
venous congestion.
c H a Pt e r 31
ISCHEMIA OF THE NIPPLE,
AREOLA, AND/OR SKIN FLAPS
491

Part IV: Problems in Reduction Mammaplasty
492
ANALYSIS O F THE PRO BLEM
The remainder o this case presents di erent patient examples to help with the
analysis o patients with ischemia o the nipple, areola, and/or skin aps.
The decision to intervene when the nipple and areola are dusky is a di f cult one.
Some NACs look even worse than this, yet do well. For example, this patient had
calcif ed capsules removed, a vertical mastopexy, and implant replacement. Her
right nipple and areola looked quite dusky and remained so during the postopera-
tive period. However, when seen at 8 months postoperatively, she had no tissue loss
or other sequelae o ischemia.
This patient had a medial pedicle vertical breast reduction, and both NACs ap-
peared compromised at the end o the procedure. Yet both settled and healed well
without intervention.
Accurate assessment o circulation can be di f cult. Sophisticated equipment is
available or this purpose. However, it is expensive and not always e ective. I the
problem is compression, surgery may be indicated. I , however, the problem is de-
creased arterial input, there is no readily available solution. A ree nipple gra t has
its own complications and limitations (unpredictable take, depigmentation, irregu-
lar scarring, and loss o sensation). I venous congestion is clearly the problem, su-
tures need to be removed.

Chapter 31 • Ischemia of the Nipple, Areola, and/or Skin Flaps

493
This patient’s mastopexy-augmentation was per ormed on her le t nipple and NAC
as an outpatient procedure. Eighteen hours postoperatively, considerable venous
congestion was noted, with swelling and purplish discoloration. Sutures were re-
moved to decrease tension on her areola. In retrospect, removal o the implant and
closure o the incision may have been an appropriate choice.
She is shown at 5 days, 5 weeks, and 6 months. One year postoperatively, she un-
derwent revision o her le t areola. This would have been necessary regardless o
whether or not the implant had been removed. However, i the implant had been
removed earlier, with success ul closure o her incision, she would not have re-
quired treatment o this open wound.
She is shown 3 years postoperatively.

Part IV: Problems in Reduction Mammaplasty
494
RECOMMENDED SOLUTION TO THE PROBLEM
Continued watch ul waiting
TECHNIQ UE
Three weeks postoperatively, the breast reduction patient who was presented at the
beginning o this case had nearly complete necrosis o her right NAC; only a small
amount o the upper medial areola appeared viable. The decision was made to con-
tinue watch ul waiting, with no other intervention.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown preoperatively and 9 months postoperatively, with surpris-
ingly good healing o her nipples and areolae. Revision can now be per ormed with
almost complete preservation o her NACs. Although intervention at 4 weeks was
tempting, debridement might have damaged some o the tissues that survived.

Chapter 31 • Ischemia of the Nipple, Areola, and/or Skin Flaps

495
TEACHING PO INTS
When is intervention a good idea? It may be the correct choice when in ection or
signif cant necrosis o the parenchyma itsel is present. A ew weeks postoperatively,
however, it may be best not to intervene and to allow the area to heal secondarily.
The nipple and areola appear to be somewhat privileged in terms o their blood
supply. Unless it is necessary to intervene, it may be best to wait.
There are consequences o action and consequences o inaction when treating nip-
ple and areolar necrosis. It can be di f cult to make the right decision both at the
time o surgery and in the postoperative period. As the cases presented in this chap-
ter show, we do not have a precise way to determine when intervention will help
circulation in the postoperative period, nor can we accurately determine a patient’s
f nal outcome with or without intervention.
BIBLIO GRAPHY
Daane SP, Rockwell WB. Breast reduction techniques and outcomes: a meta-analysis. Aesthet Surg J
19:293-302, 1999.
Dabbah A, Lehman JA II, Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast
Surg 35:337-341, 1995.
Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts & Techniques. St Louis: Quality Medical Publish-
ing, 2010.
O’Dey DM, Prescher A, Pallua N. Vascular reliability o nipple-areola complex-bearing pedicles: an
anatomical microdissection study. Plast Reconstr Surg 119:1167-1177, 2007.
Schwartzmann E. [Avoidance o nipple necrosis by preservation o corium in one-stage plastic surgery
o the breast] Rev Chir Struct 7:206-209, 1937.
Scott GR, Carson CL, Borah GL. Maximizing outcomes in breast reduction surgery: a review o 518
consecutive patients. Plast Reconstr Surg 116:1633-1639, 2005.
Scott GS, Scott GR, Carson CL, et al. Maximizing outcomes in breast reduction surgery: a review o
518 consecutive patients. Plast Reconstr Surg 116:1633-1639, 2005. Erratum June 2006, 2542.
Van Deventer PV, Page BJ, Graewe FR. The sa ety o pedicles in breast reduction and mastopexy. Aes-
thetic Plast Surg 32:307-312, 2008.

31b Healing by Secondary Intention
el iz a bet h J. Ha l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 31-year-old woman desired a breast reduction. She was 5 eet 6 inches tall,
weighed 158 pounds, and wore a size 38DD bra. Breast reduction was per ormed
using the medial pedicle vertical approach with 415 g removed rom her right
breast and 425 g rom her le t breast. With liposuction, 100 cc was removed rom
the lateral chest wall, preaxillary areas, and along the IMFs. The surgery was per-
ormed as an outpatient procedure under general anesthetic. It lasted 95 minutes,
and both the surgery and recovery were unevent ul. The patient was contacted
postoperatively and seemed to be doing well, without complaints.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Seventeen days postoperatively, at a routine ollow-up, she has signif cant necrosis
o her right NAC with bruising and di use but ill-def ned induration. Her areola is
dry and shows no signs o in ection.
496

Chapter 31 • Ischemia of the Nipple, Areola, and/or Skin Flaps

497
ANALYSIS O F THE PRO BLEM
The area o necrosis was well demarcated. Signif cant necrosis deep to the areola
was not evident. There was no need to intervene at this stage. The patient was con-
tent to wait and allow the wound to heal. She did not return or assessment or sev-
eral months. During this time, the necrotic area separated, and the open area healed
secondarily. She had no residual induration; there ore persistent deep necrosis was
not a concern.
Some surgeons recommend debridement at this stage. However, this can remove tis-
sue that would otherwise heal. Some patients would demand intervention. There is
no single solution to the problem. The consequences o action and o inaction need
to be considered. I there is evidence o in ection, then antibiotics should be given
(and perhaps should be used whenever areas o decreased circulation are obvious
to help prevent bacteria rom gaining the upper hand). I signif cant deep necrosis
becomes evident either at this stage or at later ollow-up visits, then debridement
can be per ormed once the areas o demarcation are clear. Sometimes it is better to
allow an area o necrosis to declare itsel urther. The NAC seems to be a privileged
area o the breast, and watch ul waiting can be the best approach or some patients.
RECOMMENDED SOLUTION TO THE PROBLEM
Healing by secondary intention
TECHNIQ UE
No treatment was per ormed.
The patient is shown 11 months postoperatively.

Part IV: Problems in Reduction Mammaplasty
498
She is shown 5 years postoperatively just be ore revision. She had decreased sen-
sation on her right nipple and areola. Her right areola measured 5 cm in diam-
eter and her le t areola was 4 cm. Revision o her right areola involved removal o
the outer depigmented area and a vertical rereduction o some o the ptotic gland.
Ninety grams was removed rom the in erior aspect o her right breast, and 80 g
was removed rom her le t breast.
She is shown 5 weeks a ter her revision.

Chapter 31 • Ischemia of the Nipple, Areola, and/or Skin Flaps

499
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown with obvious areolar necrosis a ter the initial breast reduc-
tion. She did nothing or more than 5 years. The f nal photo is her result shown
31/2 years a ter the revision and a small re-reduction to correct some o the residual
glandular ptosis. These results show how important it is to leave the necrotic area
to demarcate, and it o ten does not need to be debrided. The f nal result is better as
a result o choosing not to intervene. The NAC exhibits a privileged status with ex-
cellent healing that cannot be replicated by reconstructive attempts.
TEACHING PO INTS
Don’t rush to act. With patients who have impending necrosis or evident necrosis, it
can be help ul to show photos o other patients’ results to reassure them that reop-
eration may not be in their best interest. On the other hand, any evidence o in ec-
tion or deep necrosis may necessitate earlier intervention. Antibiotics are probably
a good choice whenever there is decreased circulation to help prevent bacteria rom
worsening the problem.
A pure medial pedicle (as shown in the drawings on the patient) has blood supply
rom the internal mammary system rom the third interspace. The veins drain su-
peromedially. Alternatively, a true superomedial pedicle carries arteries rom both
the second and the third interspace. The descending artery rom the second in-
terspace enters the areolar opening usually just medial to the breast meridian. A
pedicle that is based across the top o the areolar opening probably has a better
blood supply. It can be somewhat more di f cult to inset a true superomedial pedicle
rather than a pure medial pedicle. However, the arteries are superf cial in the sub-
cutaneous tissue overlying the parenchyma, and the veins are just beneath the der-
mis; there ore any restrictive deep tissue can be removed without inter erence with
blood supply.

Part IV: Problems in Reduction Mammaplasty
500
The pure medial pedicle (as shown on the le t) has a single axial artery. The true su-
peromedial pedicle (as shown on the right) has two axial arteries. The veins in both
cases drain superomedially and can o ten be seen just beneath the skin.
The pure medial pedicle is o ten inaccurately called a “superomedial” pedicle, be-
cause it can have a superomedial orientation when the patient is standing. The
blood supply, however, is medial mainly rom the branch rom the internal mam-
mary artery at the third interspace. The occurrence o nipple and areolar necrosis
can also be signif cantly reduced by per orming a true superomedial pedicle that
incorporates the strong artery rom the second interspace; this is achieved by bring-
ing the base o the pedicle just lateral to the breast meridian. The pedicle can be a
bit more di f cult to inset when the base is extended in this way; however, because
these arteries (and the veins) are in the subcutaneous tissue, any deep constricting
parenchyma that prevents an easy inset can be sa ely removed. A true superomedial
pedicle has a dual axial arterial blood supply, whereas a pure medial pedicle has
only a single axial arterial blood supply.
BIBLIO GRAPHY
Daane SP, Rockwell WB. Breast reduction techniques and outcomes: a meta-analysis. Aesthet Surg J
19:293-302, 1999.
Dabbah A, Lehman JA, Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast
Surg 35:337-341, 1995.
Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts & Techniques. St Louis: Quality Medical Publish-
ing, 2010.
O’Dey DM, Prescher A, Pallua N. Vascular reliability o nipple areola complex-bearing pedicles: an
anatomical microdissection study. Plast Reconstr Surg 119:1167-1177, 2007.
Schwartzmann E. [Avoidance o nipple necrosis by preservation o corium in one-stage plastic surgery
o the breast] Rev Chir Struct 7:206-209, 1937.
Scott GS, Scott GR, Carson CL, et al. Maximizing outcomes in breast reduction surgery: a review o
518 consecutive patients. Plast Reconstr Surg 116:1633-1639, 2005. Erratum June 2006, 2542.
Van Deventer PV, Page BJ, Graewe FR. The sa ety o pedicles in breast reduction and mastopexy. Aes-
thetic Plast Surg 32:307-312, 2008.
Internal
mammary
artery
Medial
pedicle
Third internal
mammary
perforator
Internal
mammary
artery
2
3
Superomedial
pedicle
Internal
mammary
perforators

31c Watchful Waiting With Antibiotics
el iz a bet h J. Ha l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 34-year-old woman desired a breast reduction. She was 5 eet 8 inches tall,
weighed 187 pounds, and wore a size 40DD bra. A medial pedicle vertical breast
reduction was per ormed under general anesthesia. She had 650 g removed rom
her right breast and 630 g removed rom her le t breast. Using liposuction o her
lateral chest wall and preaxillary areas, 100 cc was rom her right breast and 175
cc rom her le t breast. The surgery lasted 2 hours. There were no apparent prob-
lems during the procedure, and her recovery was unevent ul.
One week later the patient called with concerns about dark areas on her right
areola. She did not want to drive the 3 hours to the o f ce. The ollowing day she
reported that she was better. Two weeks a ter surgery, she went to the local emer-
gency department, where the ER physician “ reaked out.” No treatment was pro-
vided and it was le t to the patient to contact us the ollowing day.
Both NACs were somewhat dusky at the end o
the procedure, but there was no evidence o com-
pression or constriction. The decision not to inter-
vene was di f cult, because circulation o ten returns
when there is duskiness o one or both areolae.
There are no clear rules or f ndings to help with
decision-making in these cases. Removal o sutures
is indicated only i there is obvious congestion. In-
terventions such as converting to ree nipple gra ts
have their own negative consequences.
501

Part IV: Problems in Reduction Mammaplasty
502
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
She is shown at her 4-week ollow-up. Her right NAC has areas o necrosis. Some
parts o the nipple itsel appear viable. The area is dry with no evidence o in ec-
tion. Induration is present below the area o necrosis.
ANALYSIS O F THE PRO BLEM
There is not necessarily one correct treatment or this patient’s problem. Debride-
ment can remove areas o necrosis that may heal. Sometimes it is better to allow ne-
crotic tissue to declare itsel urther. The NAC is a privileged area o the breast, and
watch ul waiting can be the best course o action.
RECOMMENDED SOLUTION TO THE PROBLEM
Watch ul waiting to allow the wound to heal by secondary intention
TECHNIQ UE
No intervention was per ormed.
Six weeks postoperatively, the necrotic part o her areola had better demarcation.
The area was dry, but the tissue beneath it was indurated, indicating ull-thickness
necrosis. At this stage, debridement might have resulted in removal o viable tissue.
The patient agreed to continue to wait.

Chapter 31 • Ischemia of the Nipple, Areola, and/or Skin Flaps

503
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Four months postoperatively, the area o necrosis is well healed.
Approximately 10 months later, she developed some redness around the area. A
small area o induration persisted. The patient was given antibiotics. She did not
return or urther ollow-up. Antibiotics (usually either cephalexin or cipro oxa-
cin) are used whenever there is a possibility that bacteria are causing in ammation.
They can also be used to prevent bacteria rom taking hold whenever there is tissue
that has poor blood supply (necrosis or impending necrosis).
TEACHING PO INTS
Don’t rush to act. In this case, waiting probably achieved a better result than i the
area had been debrided. With patients who have impending necrosis or evident ne-
crosis, it can be help ul to show photos o other patients’ results to reassure them
that reoperation may not be in their best interest. On the other hand, any evidence
o in ection or deep necrosis may necessitate earlier intervention. Antibiotics are
probably a good choice whenever there is decreased circulation to help prevent bac-
teria rom worsening the problem.
A pure medial pedicle (as shown in the drawings on the patient) has blood supply
rom the internal mammary system rom the third interspace. The veins drain su-
peromedially. Alternatively, a true superomedial pedicle carries arteries rom both
the second and the third interspace. The descending artery rom the second in-
terspace enters the areolar opening usually just medial to the breast meridian. A
pedicle that is based across the top o the areolar opening probably has a better
blood supply. It can be somewhat more di f cult to inset a true superomedial pedicle
rather than a pure medial pedicle. However, the arteries are superf cial in the sub-
cutaneous tissue overlying the parenchyma, and the veins are just beneath the der-
mis; there ore any restrictive deep tissue can be removed without inter erence with
blood supply.

Part IV: Problems in Reduction Mammaplasty
504
The pure medial pedicle (as shown on the le t) has a single axial artery. The true su-
peromedial pedicle (as shown on the right) has two axial arteries. The veins in both
cases drain superomedially and can o ten be seen just beneath the skin.
The pure medial pedicle is o ten inaccurately called a “superomedial” pedicle, be-
cause it can have a superomedial orientation when the patient is standing. The
blood supply, however, is medial mainly rom the branch rom the internal mam-
mary artery at the third interspace. The occurrence o nipple and areolar necrosis
can also be signif cantly reduced by per orming a true superomedial pedicle that
incorporates the strong artery rom the second interspace; this is achieved by bring-
ing the base o the pedicle just lateral to the breast meridian. The pedicle can be a
bit more di f cult to inset when the base is extended in this way; however, because
these arteries (and the veins) are in the subcutaneous tissue, any deep constricting
parenchyma that prevents an easy inset can be sa ely removed. A true superomedial
pedicle has a dual axial arterial blood supply, whereas a pure medial pedicle has
only a single axial arterial blood supply.
BIBLIO GRAPHY
Daane SP, Rockwell WB. Breast reduction techniques and outcomes: a meta-analysis. Aesthet Surg J
19:293-302, 1999.
Dabbah A, Lehman JA II, Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast
Surg 35:337-341, 1995.
Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts & Techniques. St Louis: Quality Medical Publish-
ing, 2010.
O’Dey DM, Prescher A, Pallua N. Vascular reliability o nipple-areola complex-bearing pedicles: an
anatomical microdissection study. Plast Reconstr Surg 119:1167-1177, 2007.
Schwartzmann E. [Avoidance o nipple necrosis by preservation o corium in one-stage plastic surgery
o the breast] Rev Chir Struct 7:206-209, 1937.
Scott GS, Scott GR, Carson CL, et al. Maximizing outcomes in breast reduction surgery: a review o
518 consecutive patients. Plast Reconstr Surg 116:1633-1639, 2005. Erratum June 2006, 2542.
Van Deventer PV, Page BJ, Graewe FR. The sa ety o pedicles in breast reduction and mastopexy. Aes-
thetic Plast Surg 32:307-312, 2008.
Internal
mammary
artery
Medial
pedicle
Third internal
mammary
perforator
Internal
mammary
artery
2
3
Superomedial
pedicle
Internal
mammary
perforators

31d Complete Nipple Reconstruction With Skate Flaps
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 19-year-old woman had bilateral breast reduction with an in erior pedicle
technique. She developed bilateral nipple-areolar necrosis. A ter the areas involved
had healed, she underwent multiple attempts to create nipples using local aps.
These procedures were unsuccess ul and resulted in multiple scars that traversed
the area at di erent angles.
The patient is shown at her initial consultation. Her le t breast was marked to indi-
cate the location or the uture NAC reconstruction.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s breasts are symmetrical in volume and contour. Several intersecting
scars cross the areas o her previous NACs. They are thought to be the result o
necrosis o the original NAC and two ailed attempts at reconstruction using local
aps. Neither breast shows signs o at necrosis clinically. Within the breast paren-
chyma, the tissue is so t and symmetrical.
ANALYSIS O F THE PRO BLEM
Based on the patient’s history, her scars resulted rom a postoperative in ection, and
not rom loss o pedicle blood supply, which is a more typical cause that compro-
mises blood ow to the NAC and usually leads to secondary loss. When this occurs
a ter an in erior pedicle technique, breast tissue is destroyed underneath the NAC,
505

Part IV: Problems in Reduction Mammaplasty
506
but this did not occur. In a consultation, the patient’s original doctor conf rmed that
a necrotizing in ection developed postoperatively, primarily a ecting her NAC. This
explained the absence o at necrosis within the breast mound itsel .
The diagnosis was complete bilateral NAC necrosis a ter reduction mammaplasty
with multiple ailed attempts at NAC reconstruction using local aps. Because o
the multiple intersecting scars in the area o her original NACs, it was thought that
urther attempts using local tissue or local aps would be unsuccess ul.
RECOMMENDED SOLUTION TO THE PROBLEM
First stage: Areolar reconstruction with a ull-thickness skin gra t harvested
rom the patient’s lateral transverse scar on both sides to create bilateral areolae
Second stage: Nipple reconstruction in which the previously inset ull-thickness
skin gra t is raised as a traditional skate ap and tubed on itsel , ollowed by
skin gra ting to the deepithelialized area
TECHNIQ UE
The patient was ollowed or approximately 2 months. By this time, the areas
around her NACs showed some resolution o in ammation and active healing, and
were signif cantly improved. Breast volume was maintained, supporting the hy-
pothesis that a local phenomenon, rather than ischemia o the in erior pedicle, had
caused NAC necrosis. On the patient’s le t side, the proposed site or NAC recon-
struction was marked.

Chapter 31 • Ischemia of the Nipple, Areola, and/or Skin Flaps

507
In the f rst stage, ull-thickness skin gra ts were harvested rom the patient’s lateral
transverse scars bilaterally and trans erred to the area o her previous NACs. No
attempt to create a new nipple was made at this procedure; the goal was to replace
the scarred area with healthy tissues.
The patient is shown two months a ter ull-thickness skin gra ts were applied.
First graft replaces
scarred area
(will become skate flap)
Second graft
becomes areola
in final procedure

Part IV: Problems in Reduction Mammaplasty
508
In stage 2, a traditional skate ap was marked over the gra t. The wings o the
skate were elevated and tubed on themselves. The remaining deepithelialized area
was then covered with a skin gra t in the traditional manner. There ore, in this pa-
tient, the lateral margins o the previous in ramammary incision were used twice on
each side to achieve the appropriate ull-thickness skin gra ts.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Compared to her preoperative view, the patient is shown 2 months a ter the second
stage o the procedure. Her new nipples are viable. The tissues are healing appro-
priately in areas that had previous necrosis and scarring, and probably diminished
blood supply.
C
D
A

C
D
A
B

Chapter 31 • Ischemia of the Nipple, Areola, and/or Skin Flaps

509
TEACHING PO INTS
The use o ull-thickness skin gra ts in this area allowed resur acing o the damaged
area and coverage o some o the noticeable de ormities rom previous local aps.
Because the blood supply was compromised in the area o the patient’s original
NAC, the use o local tissue was no longer a potential solution. The downside to
the solution was the need to per orm two stages; however, in this particular clinical
setting, this technique has a higher chance o success.
This technique is use ul in patients who have had tissue expansion or other breast
reconstruction techniques ollowed by unsuccess ul attempts at creating NACs that
have resulted in limited local tissue or minimal tissue immediately underneath the
area o the NAC. A ter tissue expansion, o ten the layer o tissue underneath the
reconstructed NAC is very thin, and reconstruction with local aps can be di f cult.
By using this two-stage gra ting technique, surgeons are less dependent on tissue in
the immediate area, and minimal blood supply is required or adequate resolution
o this challenging problem.
BIBLIO GRAPHY
Al ano C, Tenna S, Caggiati A, et al. Nipple reconstruction by local aps: a long-term comparative
study between star and skate techniques. Acta Chir Plast 46:127-131, 2004.
Hammond DC, Khuthaila D, Kim J. The skate ap purse-string technique or nipple-areola complex
reconstruction. Plast Reconstr Surg 120:399-406, 2007.
Katsuragi Y, Kayano S, Koizumi T, et al. How long does the nipple projection last a ter reconstruction
using the skate ap purse-string technique? Plast Reconstr Surg 127:149e-151e, 2011.
Shestak KC, Nguyen TD. The double opposing periareola ap: a novel concept or nipple-areola re-
construction. Plast Reconstr Surg 119:473-480, 2007.
Zhong T, Antony A, Cordeiro P. Surgical outcomes and nipple projection using the modif ed skate
ap or nipple-areolar reconstruction in a series o 422 implant reconstructions. Ann Plast Surg
62:591-595, 2009.

(Trang không có chữ)

SEC T IO N T WO
Suboptimal Aesthetic Outcomes
Chapter 32 Overresection of Breast Tissue
32a Breast Reshaping With Expander-Implants
32b Implant Insertion With Skin Envelope Modi cation
32c Overresection o Breast Tissue
Chapter 33 Underresection of Breast Tissue
33a Secondary Vertical Reduction Mammaplasty
33b Liposuction With Circumvertical Mastopexy
Chapter 34 Nipple Malposition
34a Correction With Subpectoral Breast Implants
34b Correction With Breast Repositioning
Chapter 35 Bottoming Out
35a Reduction o Excess Lower Pole Volume
Chapter 36 Unsatisfactory Shape or Contour
36a Fat Transplantation
511

(Trang không có chữ)

513
C h a PT Er 32
OVERRESECTION OF BREAST
TISSUE
32a Breast Reshaping With Expander-Implants
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 42-year-old woman had undergone a reduction mammaplasty 5 years previ-
ously. The patient elt that her breast volume had been overreduced. She also com-
plained o volume asymmetry and nipple location. She said the le t nipple was
sitting too high and along the outer edge o the breast; the right nipple was also sit-
ting too high. She noted that it was di cult to wear clothing and had trouble nd-
ing a bra that t. Her goal was to increase volume, improve shape, and reposition
both NACs. She was a healthy nonsmoker with no other medical issues.
513

Part IV: Problems in Reduction Mammaplasty
514
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient has multiple problems as a result o her previous mammaplasty. Her
le t NAC lies along the anterior axillary old as a result o marked lateral displace-
ment and sits too high. The right NAC sits too high on the breast mound but lies
within the midclavicular line. The le t in ramammary old is higher than the right
in ramammary old. The breasts have lost projection, and there is minimal breast
tissue in the superior pole.
ANALYSIS O F THE PRO BLEM
One o the most di cult components o this patient’s revision was repositioning o
the NACs. The question was whether to do ree nipple trans ers or pedicle trans-
ers. The le t NAC, which was positioned more laterally, would be the more di -
cult to correct based on a pedicle. In addition, whether the NACs were lowered as
gra ts or on a pedicle, there would be a scar above the NACs. Volume correction
could be accomplished by an implant or an expander. The logic o the use o ex-
pander is two old: rst, it allows or better adjustment o the patient’s asymmetry
correction, and second, by expanding the breast, it is o ten possible to lower the
NAC without leaving a scar above it.
It was explained to the patient that correction would require at least two stages.
The rst would involve insertion o bilateral expander-implants with selective ex-
pansion or volume and asymmetry correction, and the NACs would be lowered. In
the second stage permanent implants would be placed, and her NACs repositioned
on pedicles. The inverted-T incisions would be modi ed once the expansion was
completed.
RECOMMENDED SOLUTION TO THE PROBLEM
Insertion o tissue expanders
Asymmetrical expansion
Placement o permanent implants
Repositioning o NACs on pedicles

Chapter 32 • Overresection of Breast Tissue

515
TECHNIQ UE
The rst step o the revision surgery was insertion o 600 cc tissue expanders
through the lateral portion o the original reduction in ramammary scars. The de-
vices were placed in the subglandular space and expansion was begun. Over the
next 7 months, both volume and symmetry were corrected by selective expansion.
A total o 520 cc was placed on the le t side and 720 cc on the right side.
Seven months a ter expander insertion, the patient underwent the second-stage pro-
cedure.

Part IV: Problems in Reduction Mammaplasty
516
The expanders were removed through the lateral in ramammary incision. The di -
erence in expansion volume was done primarily or nipple repositioning. A ter the
external ports o the adjustable expander-implants were isolated, the volumes were
decreased to con rm NAC location. It was determined that 300 cc gel implants
on both sides would provide the shape and volume desired. Rather than using
di erent-sized implants, breast tissue was removed selectively to create volume
symmetry so equal size implants could be used. Next the NACs were repositioned.
On the le t side, the NAC was moved medially based on a medical pedicle and then
closed with an oblique in erolateral closure. The right NAC was repositioned with
a periareolar mastopexy.

Chapter 32 • Overresection of Breast Tissue

517
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The early postoperative photo shows improved volume and symmetry, as well as
better location o the NACs. The patient is also seen at 1 year postoperatively dem-
onstrating good correction o volume de ciency and improved contour. The in ra-
mammary olds are more symmetrical. The most di cult part o this revision was
relocation o the NACs. The right side, which only needed to be lowered, is in a
better location but is still slightly high. The le t NAC also was moved medially but
still is not sitting in the midclavicular line. Moving the NAC on pedicles has limited
the degree o correction, and doing ree nipple gra ts may have been more success-
ul or ideal repositioning. The le t medial in ramammary scar extends higher than
the right, which creates medial old asymmetry. However, this scar extended more
superiorly originally.

Part IV: Problems in Reduction Mammaplasty
518
TEACHING PO INTS
The use o adjustable expander-implants allows control o volume and enables low-
ering o the nipple-areolar complexes. Placing the devices subglandularly in this
patient acilitated better control o shape. The expansion process minimized the
distance the nipples needed to be moved. Although the adjustable saline implants
could have been le t in permanently, it was decided to replace them with permanent
300 cc gel implants.
BIBLIO GRAPHY
Amini P, Stasch T, Theodorou P, et al. Vertical reduction mammaplasty combined with a superomedial
pedicle in gigantomastia. Ann Plast Surg 64:279-285, 2010.
Eisenberg T. Simultaneous augmentation mastopexy: a technique or maximum en bloc skin resection
using the inverted-T pattern regardless o implant size, asymmetry, or ptosis. Aesthetic Plast Surg
36:349-354, 2012.
Mayo F, Vecino MG. Aesthetic remodeling o the healthy breast in breast reconstruction using ex-
panders and implants. Aesthetic Plast Surg 33:220-227, 2009.
Michelle le Roux C, Kiil BJ, Pan WR, Rozen WM, Ashton MW. Preserving the neurovascular supply
in the Hall-Findlay superomedial pedicle breast reduction: an anatomical study. J Plast Reconstr
Aesthet Surg 63:655-662, 2010.
Neaman KC, Armstrong SD, Mendonca SJ, et al. Vertical reduction mammaplasty utilizing the supero-
medial pedicle: is it really or everyone? Aesthet Surg J 32:718-725, 2012.
Swanson E. Prospective outcome study o 106 cases o vertical mastopexy, augmentation/mastopexy,
and breast reduction. J Plast Reconstr Aesthet Surg 66:937-949, 2013.

32b Implant Insertion With Skin Envelope Modif cation
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
The 25-year-old patient in this case had undergone a bilateral breast reduction with
an inverted-T technique 3 years previously. At her initial consultation she stated
that she was dissatis ed with the shape o her breasts and thought they had been
overreduced. She also elt that her nipples appeared too high on the breast mounds
and was dissatis ed with the lack o upper pole ullness and the excessive amount
o breast tissue in the lower pole.
519

Part IV: Problems in Reduction Mammaplasty
520
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
On examination, the majority o the patient’s breast tissue is below the NACs. On
the right side the distance o the NAC to the clavicle is 17 cm, and on the le t it is
18 cm. There is minimal breast tissue above the areolae, and there is a lack o pro-
jection o the breast mounds. The incisions are well healed, with minimal scarring.
ANALYSIS O F THE PRO BLEM
It was apparent that this patient had an excessive amount o breast tissue removed
during the original procedure. The nipples appeared to have been placed too high,
and probably over time the breast tissue had allen in eriorly, creating bottom-
ing out and superior rotation o the NACs. There was no projection o the breast
mounds, and the superior poles o the breasts were completely f at. The breasts had
a boxy appearance, probably rom the lack o breast tissue centrally.
RECOMMENDED SOLUTION TO THE PROBLEM
Two options or treating this patient: implants or at injection
Removal o skin in the vertical dimension to enhance skin contour
Placement o high pro le implants to enhance central mound projection
TECHNIQ UE
Initially, the lateral portion o the original in ramammary incision was opened.
Next a subglandular pocket was created or implant insertion. With a 400 cc sizer
in place, the skin envelope was tailor-tacked. It was determined that skin needed to
be removed in the vertical dimension as well as in the original transverse scar. How-
ever, the NACs now appeared to be in a reasonable location, and it was elected not
to reposition them. The nal implant that was placed in the subglandular space was
400 cc. The skin was resected in a modi ed T-pattern without nipple repositioning,
and the skin envelope was closed.
Deepithelialized
skin
Implant in place