49d Wraparound Flap to Restore Nipple Projection
Gl y n Jo n es
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
ANALYSIS O F THE PRO BLEM
The single most troubling problem associated with nipple reconstruction is the
long-term maintenance o nipple projection. The most predictable projection is
achieved using the thick skin o latissimus or gluteal f aps. TRAM f aps are airly
reliable, and expander-implant reconstructions are the most likely to develop atro-
phy and poor projection.
An overgra t o the opposite nipple tissue is one solution or improving nipple pro-
jection. The patient, however, may be reluctant to sacri ce a portion o her normal
nipple to salvage the ailed reconstruction.
This patient had bilateral expander-implant recon-
struction with a C-V f ap nipple reconstruction. Her
skin f aps were extremely thin and almost-complete
atrophy. This is airly typical in thin patients with a
low BMI.
This 60-year-old woman has presented with severe
asymmetry a ter a previous le t latissimus f ap recon-
struction with implant insertion over 20 years pre-
viously. On the right side, she had a subcutaneous
mastectomy with implant reconstruction. She has
developed a grade IV capsular contracture o the le t
breast causing pain and discom ort, together with
complete loss o projection o her nipple reconstruc-
tion. She requests extensive revision o her chest wall
de ormities and revision o her nipple reconstruction.
821
Part VI: Problems Associated With the Nipple-Areola Complex
822
In this instance, the patient had a latissimus f ap with its usually thick skin available
or reconstruction. Un ortunately, her latissimus skin was not particularly thick and
she had undergone atrophy and f attening. She did not want to sacri ce her oppo-
site nipple even though it was an appropriate donor site. A wraparound procedure
incorporating AlloDerm was planned.
RECOMMENDED SOLUTION TO THE PROBLEM
C-V f ap wraparound nipple reconstruction with AlloDerm insertion
Placement o a temporary nipple protector
Bilateral asymmetric implant exchanges with a le t open in erior capsulotomy to
lower the high-riding le t breast implant
TECHNIQ UE
A standard C-V f ap reconstruction was designed and elevated. The donor site was
closed with 4-0 Monocryl subcutaneous sutures, and the f aps were prepared or
transposition on an in erior deepithelialized dermal bed. A 1 by 1 cm AlloDerm
strip was rolled into a cylinder and sutured to itsel with 5-0 chromic catgut to
maintain its shape. The cylinder was placed vertically over the in erior deepitheli-
alized dermal bed and sutured to it with 4-0 Monocryl. The C-V f aps were then
wrapped around the AlloDerm plug and closed with interrupted 4-0 Monocryl and
running 5-0 chromic catgut to complete the closure as usual. The nipple protector
was placed over the area or 10 days to protect the nipple rom external pressure
and trauma.
Chapter 49 • Malposition, Asymmetry, Loss of Projection, Overprojection, and Areolar Spreading
823
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown approximately 9 months postoperatively with much improved
shape and symmetry. Her le t nipple reconstruction with AlloDerm and C-V f ap
wraparound is maintaining good projection and ullness. She is delighted with the
overall improvement in her appearance.
TEACHING PO INTS
Flaps used in nipple reconstruction should always be planned to be longer than the
desired end point, because shrinkage is inevitable both initially and a ter tattooing.
Thin-skinned patients should have a central AlloDerm plug placed to provide addi-
tional volume or maintenance o long-term projection. Placing the f aps on a deep-
ithelialized dermal bed increases deep support and prevents the f aps rom collaps-
ing into the underlying at o a TRAM or latissimus f ap.
Part VI: Problems Associated With the Nipple-Areola Complex
824
The single most troubling problem associated with nipple reconstruction is the
long-term maintenance o nipple projection. The degree o long-term projection
achieved is dependent on the thickness o the dermis available in the reconstructive
f aps used to create a nipple as well as the amount o subcutaneous at attached to
their undersur ace. The most predictable projection is achieved using the thick skin
o latissimus or gluteal f aps. TRAM f aps are airly reliable, and expander-implant
reconstructions are the solution that is most likely to develop atrophy and poor
projection. An overgra t o the opposite nipple tissue is one solution or improving
nipple projection; however, the patient may be reluctant to sacri ce a portion o her
normal nipple to salvage the ailed reconstruction.
BIBLIO GRAPHY
Farhadi J, Maksvytyte GK, Schae er DJ, et al. Reconstruction o the nipple-areola complex: an update.
J Plast Reconstr Aesthet Surg 59:40-53, 2006.
Mohamed SA, Parodi PC. A modi ed technique or nipple-areola complex reconstruction. Indian J
Plast Surg 44:76-80, 2011.
Van Laeken N, Genoway K. Nipple reconstruction using a two-step purse-string suture technique.
Can J Plast Surg 19:56-59, 2011.
A
Acellular dermal matrix (ADM; Strattice)
bene ts, 221
bilateral TRAM f aps, expander-
implants, 600-604
capsulorrhaphy, multidirectional
rein orced with, 310-315
capsulorrhaphy, stable lower pole sling
re-creation with, 197-200
in capsulotomies, a ter radiotherapy,
576-580
complications, 97
double-bubble, synmastia repair, 215-
221
in eccentric periareolar mastopexy
anatomic description, 267-269
outcomes, 273-274
patient history, 267
problem analysis, 269
solutions, 269
surgical technique, 270-273
teaching points, 275
expander implant exchange, capsulor-
rhaphies, at gra ting (nipple malpo-
sition), 807-809
explantation, delayed at gra ting with
implant reinsertion, 92-97
implant exposure a ter nipple recon-
struction: implant replacement,
latissimus dorsi f ap, 659-663
overaugmented breast implant replace-
ment, 306-309
and pectoralis repositioning with (ani-
mation de ormity), 290-294
reconstruction, tissue expander, implant
replacement, 627-634
revision augmentation with total explan-
tation and site change, 77-82
and stable implant ormation, subglan-
dular pockets/revision mastopexy,
201-204
and subglandular to subpectoral pocket
exchange, 103-106
and synmastia repair, subpectoral pocket
conversion, 210-214
Allergan Natrelle implants, 242
Allergan Style 410MF, 154, 156, 233
Allergan Style 410MX, 150, 151
Anaplastic large cell lymphoma (ALCL),
582
Anatomic diagnosis, 9-11
Anatomic implants or upper pole de -
ciency, 259-262
Animation de ormity
neosubpectoral pocket use, 281-285
pectoralis repositioning with, 290-294
subglandular pockets, conversion to,
286-289
Antibiotics
salvage (two-stage), placement o smaller
implants, 84
watch ul waiting/antibiotics, NAC isch-
emia, 496-504
Antiphospholipid syndrome, 723-724
Areolar spreading
circumareolar mastopexy-vertical masto-
pexy, conversion, 423-430
interlocking Gore-Tex permanent purse-
string suture technique, 431-436
secondary mastopexy, 437-440
Asymmetry
asymmetrical mastopexies, unilateral
volume reduction, implant replace-
ment, 359-364
capsule modi cation, site change, 181-
186
capsulorrhaphy, in erior skin recruit-
ment, implant exchange, 678-681
de ormity corrected, local f aps, vertical
mastopexy (skin f aps [compro-
mised]), 399-405
at gra ting, 667-669
implant exchange, capsulotomy, pocket
adjustment, 671-676
lipomodeling, IMF xation, 355-357
lipomodeling and IMF xation, ailed
implant correction, 355-357
overview, 738
repair, latissimus dorsi f ap/adjustable
implant, 769-772
secondary mastopexy, unilateral reduc-
tion mammaplasty, implant replace-
ment (scarring), 415-422
TRAM f ap revision, a ter lumpectomy/
radiotherapy, 773-778
Augmentation-mastopexy
autologous bilateral nipple-areolar
reconstruction, 379-390
challenges in, 376
de ormity corrected, local f aps, vertical
mastopexy (skin f aps [compro-
mised]), 399-405
overview, 14
secondary mastopexy, lower pole reshap-
ing (bariatric patients), 479-484
Autologous bilateral nipple-areolar recon-
struction
anatomic description, 380, 383
outcomes, 388
patient history, 379-380
problem analysis, 383
solutions, 380, 384
surgical technique, 380-382, 384-388
teaching points, 389-390
Autologous tissue
asymmetry repair, latissimus dorsi f ap–
adjustable implant, 769-772
bene ts, 143, 144, 702
bilateral nipple-areolar reconstruction,
379-390
breast reconstruction, SGAP ree tissue
trans er, 719-724
breast reconstruction revision, DIEP ree
tissue trans er, 713-718
DIEP f ap advancement revision (recur-
rent malignancy), 799-801
expander replacement, autologous tissue
trans er, 565-570
at gra ting, implant insertion, TRAM
f ap (volume de ciencies), 727-730
necrosis, latissimus dorsi f ap a ter
TRAM f ap reconstruction, 709-
712
necrosis, salvage, tissue expansion/
bipedicled DIEP f ap, 705-708
overview, 702
recipient vessels, 723-724
salvage, ailed bilateral expander recon-
struction, autologous tissue trans er,
654-658
tissue expansion, TRAM f ap reposi-
tioning, implant insertion (volume
de ciencies), 731-735
B
Bacterial bio lm, 147, 629
Bactrim DS, 393
Bariatric patients
dermal suspension mastopexy technique,
483-484
f attening a ter mastopexy, 460-465
NAC ischemia; see NAC ischemia
reconstruction, tissue expander, implant
replacement, 627-634
secondary mastopexy, lower pole reshap-
ing, 479-484
TRAM f ap revision, a ter lumpectomy/
radiotherapy, 773-778
BCT de ormity
latissimus dorsi myocutaneous f ap/
implants, at trans er, 764-769
Bilateral explantation with delayed implant
reinsertion
anatomic description, 31
outcomes, 34
patient history, 29-31
INDEX
825
826
Index
Bilateral explantation with delayed implant
reinsertion—cont’d
problem analysis, 31
solutions, 32
surgical technique, 32-34
teaching points, 35
Bilateral mastopexies with implant inser-
tion, 135-139
Bilateral TRAM f aps, expander-implants,
600-604
Biocell implants, 469
Bio lm, 629
Biopatch dressings, 126
BodyLogic System, 315
Bottoming out
breast repositioning, nipple malposition,
542-545
excess lower pole volume reduction,
547-550
unilateral old elevation, contralateral
periareolar mastopexy (stretch de-
ormity, bottoming out), 467-472
Brava external expansion
tissue breakdown/ ailed tissue expansion
reconstruction using Rigottomies,
Brava external expansion, serial
lipo lling, 688-694
Breast conservation therapy
complications, 751
latissimus dorsi myocutaneous f ap/
implants, at trans er, 764-769
Breast reconstruction
anatomic diagnosis, 9-11
autologous tissue; see Autologous tissue
cosmetic units, 11
expander, latissimus dorsi f ap, 159-163
at gra ting, a ter lumpectomy, 741-744
ree DIEP f ap, 649-653
implant exposure a ter nipple recon-
struction: implant replacement,
latissimus dorsi f ap, 659-663
local tissue, 610-618
maintenance/restorative procedures, 9
mechanisms o ailure, 8-9
patches, scarring, 11
patient disappointment, 8-9
popularity, 7
recipient vessels, 723-724
reconstruction, ree DIEP f ap, 649-653
reconstruction, tissue expander, implant
replacement, 627-634
reconstruction, tissue expansion, con-
tralateral reduction mammaplasty,
619-626
reconstruction using local tissue, 610-618
revision rates, 7
revision tissue expander–implant re-
construction, latissimus dorsi f ap,
adjustable implant, 639-643
salvage, ailed bilateral expander recon-
struction
and autologous tissue trans er, 654-658
and TRAM f aps, 644-648
salvage, latissimus dorsi f ap, expander,
635-638
symmetry, 11
TRAM f ap revision, a ter lumpectomy/
radiotherapy, 773-778
two-stage, local f aps, 605-609
Breast reconstruction/autologous tissue,
SGAP ree tissue trans er
anatomic description, 720
outcomes, 722
patient history, 719
problem analysis, 720
solutions, 721
surgical technique, 721
teaching points, 723-724
Breast reconstruction revision with autolo-
gous tissue, DIEP ree tissue trans er
anatomic description, 714
outcomes, 716-718
patient history, 713
problem analysis, 714
solutions, 715
surgical technique, 715-716
teaching points, 718
Breast repositioning, nipple malposition
anatomic description, 543
outcomes, 544-545
patient history, 542
problem analysis, 543
solutions, 543
surgical technique, 543-544
teaching points, 545
Breast reshaping, expander-implants
anatomic description, 514
outcomes, 516-517
patient history, 513
problem analysis, 514
solutions, 514
surgical technique, 515-516
teaching points, 517
C
Cancer; see Malignancy
Capsular contracture a ter augmentation
ADM, eccentric periareolar mastopexy,
267-275
capsulorrhaphy, conversion to submam-
mary pocket, 187-191
capsulotomies, ADM a ter radiotherapy,
576-580
circumareolar mastopexy, multiple
de ormities, 339-345
completion o previous lumpectomy,
radiotherapy/nipple-sparing mastec-
tomy, buried TRAM f ap, 779-783
complications o , 370
de ormity corrected, local f aps, vertical
mastopexy (skin f aps [compro-
mised]), 399-405
double-bubble de ormity, subglandular
pocket/capsular f ap conversion,
227-231
explantation, capsulectomies,
conversion to submuscular pockets,
107-110, 120-124
conversion to subpectoral pockets,
115-119
reconstruction a ter silicone implant
rupture, chronic hematoma, 581-
589
tissue expansion, delayed implant
placement, 111-114
hypothetical causes, 147
implant removal, tissue expansion,
replacement with contoured gel
implants, 67-70
intracapsular rupture, gel bleed, 115-119
neopectoral pocket creation, breast
tissue reshaping, implant insertion
with acellular dermal matrix, 71-76
nipple malposition correction, 409-414
overview, 738
periareolar capsulectomy with implant
replacement, 55-59
reconstruction, ree DIEP f ap, 649-653
revision augmentation, total explanta-
tion, site change, insertion o sili-
cone implant with ADM, 77-82
revision tissue expander–implant re-
construction, latissimus dorsi f ap,
adjustable implant, 639-643
Rigottomy and at trans er (RAFT),
571-575
saline implant removal, total capsulec-
tomy, replacement with gel implants,
60-66
secondary expansion, implant replace-
ment (implant malposition), 591-
594
SIEF (simultaneous implant exchange/ at
gra ting), explantation/asymmetry,
365-370
subglandular to subpectoral pocket
exchange, ADM, 103-106
subpectoral pockets, partial, conversion
to with mastopexy (ptosis a ter
augmentation), 317-322
unilateral old elevation, contralateral
periareolar mastopexy (stretch de-
ormity, bottoming out), 467-472
Capsular f aps
partial subpectoral pocket conversion,
bilateral vertical mastopexy (ptosis,
recurrent), 445-453
Capsulectomy; see Explantation
explantation, capsulectomy, reconstruc-
tion a ter silicone implant rupture,
chronic hematoma, 581-589
implant replacement, contralateral re-
duction mammaplasty, 746-751
periareolar, with implant replacement,
56-59
submuscular capsulectomies, replace-
ment/shaped implants (ptosis, recur-
rent), 441-444
surgical drainage with implant exchange,
53
Capsuloplasty, implant conversion to sub-
mammary pocket (double-bubble
de ormity)
anatomic description, 242-243
outcomes, 245-246
827
Index
patient history, 242
problem analysis, 243
solutions, 243
surgical technique, 244-245
teaching points, 247
Capsulorrhaphy
expander implant exchange, capsulor-
rhaphies, at gra ting (nipple malpo-
sition), 807-809
in erior skin recruitment, implant ex-
change/asymmetry, 679-681
multidirectional rein orced/ADM (over-
augmented breast), 310-315
stable lower pole sling re-creation/ADM,
197-200
submammary pocket conversion, 187-
191
Capsulotomy
capsulotomies, ADM a ter radiotherapy,
576-580
implant exchange, capsulotomy, pocket
adjustment/asymmetry, 671-676
unilateral old elevation, contralateral
periareolar mastopexy (stretch
de ormity, bottoming out), 467-
472
Cephalosporin, 384
Chemotherapy
latissimus dorsi f ap reconstruction, con-
tralateral mastopexy, 758-763
reciprocal transposition f aps, nipple
malposition, 815-819
Circulatory compromise
debridement and drainage o in ection
with, 561-564
o nipple-areola complex (NAC), 384-
385, 389-396
Circumareolar mastopexy−vertical masto-
pexy, conversion (areolar spreading)
anatomic description, 426
outcomes, 425, 428-429
patient history, 423-426
problem analysis, 426
solutions, 424, 427
surgical technique, 424, 427-428
teaching points, 429-430
Classic Base implant, 586
Coagulopathy, 723
Contour de ormity; see Shape/contour
issues
Corticosteroids, 384, 396
C-V f ap wraparound, nipple reconstruc-
tion, 821-824
D
Debridement and drainage o in ection
anatomic description, 562
bio lm, 629
outcomes, 563
patient history, 561
problem analysis, 562
solutions, 562
surgical technique, 562-563
teaching points, 564
Dermal suspension mastopexy technique,
483-484
Dermato brosarcoma, 160
DIEP f aps
advancement revision (recurrent malig-
nancy), 799-801
breast reconstruction revision/autologous
tissue, and ree tissue trans er, 713-
718
necrosis, salvage, tissue expansion/
bipedicled f ap, 705-708
reconstruction, ree f ap, 649-653
Double-bubble de ormity
animation de ormity, neosubpectoral
pocket use, 233, 235, 281-285
capsuloplasty, implant conversion to
submammary pocket, 242-247
nipple malposition, a ter augmentation,
409-414
radial capsular scoring, insertion o
wider-base implants, 248-251
site change, capsulectomy, conversion to
subglandular pockets, 232-235
site change to subglandular pockets,
mastopexy, 236-241
subglandular pocket/capsular f ap con-
version, 227-231
subglandular pockets conversion, over-
augmented breast, 301-305
synmastia repair using ADM, 215-221
teaching points, 285
Dupuytren contracture, 694
E
Expanders; see Tissue expanders
Expansion (secondary), implant replacement
(implant malposition), 591-594
Explantation
capsulectomies, conversion to subpecto-
ral pockets, 115-119
capsulectomy, conversion to submuscu-
lar pocket, 107-110
and secondary mastopexy, 121-124
capsulectomy, reconstruction a ter
silicone implant rupture, chronic
hematoma, 581-589
capsulectomy, tissue expansion, delayed
implant placement, 111-114
delayed at gra ting with implant reinser-
tion, 93-97
SIEF (simultaneous implant exchange/ at
gra ting), 365-370
Wise pattern mastopexy, patient with
prior augmentation-mastopexy
(ptosis), 347-353
without replacement (mastopexy), 371-
374
Exposure; see Implant exposure/extrusion
Extracapsular rupture, gel migration, sili-
cone injections
bilateral mastopexies with implant inser-
tion, 135-140
multistage repair with at gra ting, 129-
134
silicone injection correction, bilateral
mastectomies, TRAM f aps, 141-
144
submuscular capsulectomies and implant
exchange, 125-127
F
Failed reconstruction
breast reconstruction revision/autologous
tissue, DIEP ree tissue trans er,
713-718
debridement, 629
implant exposure a ter nipple recon-
struction: implant replacement,
latissimus dorsi f ap, 659-663
reconstruction
ree DIEP f ap, 649-653
tissue expander, implant replacement,
627-634
tissue expansion, contralateral reduc-
tion mammaplasty, 619-626
using local tissue, 610-618
revision tissue expander–implant re-
construction, latissimus dorsi f ap,
adjustable implant, 639-643
salvage
ailed bilateral expander reconstruc-
tion and autologous tissue trans er,
654-658
ailed bilateral expander reconstruc-
tion and TRAM f aps, 644-648
latissimus dorsi f ap, expander, 635-
638
tissue breakdown/ ailed tissue expansion
reconstruction using Rigottomies,
Brava external expansion, serial
lipo lling, 688-694
two-stage reconstruction with local f aps,
605-609
Fat gra ting
asymmetry, 667-669
autologous at trans er, 134
cannulas, 257
e cacy, complications, 257
expander implant exchange, capsulor-
rhaphies, at gra ting (nipple malpo-
sition), 807-809
at gra ting, implant insertion, TRAM
f ap (volume de ciencies), 727-730
f attening (upper pole ullness loss) cor-
rection, 455-458
harvesting procedure, 257
imaging abnormalities, 257
implant exposure/extrusion, impending,
92-97
latissimus dorsi myocutaneous f ap/
implants, at trans er (BCT de or-
mity), 764-769
lipoaspirate preparation, 694
lipostructure technique (Coleman), 257
lumpectomy complications, 741-744
multistage repair with at gra ting, 129-
134
shape/contour issues, 696-699
828
Index
Fat gra ting—cont’d
SIEF (simultaneous implant exchange/ at
gra ting), explantation, 365-370
spaghetti box concept, 669
teaching points, 699
tissue breakdown/ ailed tissue expansion
reconstruction using Rigottomies,
Brava external expansion, serial
lipo lling, 688-694
wrinkling, contour de ormity, 253-257
Fat transplantation, shape/contour issues,
551-554
Flattening (upper pole ullness loss)
at gra ting to correct, 455-458
a ter mastopexy, 460-465
pedicle extension f ap (in erior), 463, 464
G
Gangrene, 396
H
Hammock e ect, 777
Healing by secondary intention, 496-500
Hematoma
explantation, capsulectomy, reconstruc-
tion a ter silicone implant rupture,
chronic hematoma, 581-589
Herniation, 224
High pro le implant, 468
Hyperbaric oxygen, 384, 393, 396
I
Implant exchange, capsulotomy, pocket
adjustment/asymmetry, 671-674
Implant exposure/extrusion
a ter nipple reconstruction: implant
replacement, latissimus dorsi f ap,
661-663
explantation, delayed at gra ting with
implant reinsertion, 92-97
intraluminal steroids, management,
87-91
salvage (two-stage), placement o smaller
implants, 83-86
Implant insertion, skin envelope modi ca-
tion, 519-522
Implant malposition
asymmetrical capsule modi cation, site
change, 181-186
bilateral TRAM f aps, expander-
implants, 600-604
capsulorrhaphy
conversion to submammary pocket,
187-191
stable lower pole sling re-creation
with ADM, 197-200
circumareolar mastopexy, multiple
de ormities, 339-345
di erential diagnosis, 269
double-bubble, synmastia combined
de ormities treatment using ADM,
215-221
mastopexy, conversion to submuscular
pocket (overaugmented breast),
295-300
neosubpectoral pocket conversion, 192-
195
nipple malposition correction, 409-414
pocket modi cation
with pectoralis muscle release, 176-
180
with parenchymal scoring, posterior
capsular f ap, 171-175
secondary expansion, implant replace-
ment, 591-594
stable implant ormation, subglandular
pockets/revision mastopexy and
ADM, 201-204
Implant removal and replacement
anatomic description, 44
bilateral explantation with delayed
implant reinsertion, 29-35
capsulectomy, implant replacement, con-
tralateral reduction mammaplasty,
745-751
capsulorrhaphy
and in erior skin recruitment, implant
exchange/asymmetry, 678-681
multidirectional, rein orced with
ADM (overaugmented breast),
310-315
explantation, capsulectomy
conversion to subpectoral pockets,
115-119
conversion to submuscular pocket,
secondary mastopexy, 120-124
reconstruction a ter silicone implant
rupture, chronic hematoma, 581-
589
at gra ting/asymmetry, 667-669
implant exchange, capsulotomy, pocket
adjustment/asymmetry, 671-676
implant exposure/extrusion, impending,
92-97
implant removal, tissue expansion,
replacement with contoured gel
implants, 67-70
inverted-T mastopexy, conversion to
submuscular silicone gel implants
(in erior pole stretch de ormity),
276-279
outcomes, 46-47
overaugmented breast implant replace-
ment and ADM, 306-309
partial subpectoral pocket conversion,
bilateral vertical mastopexy (ptosis,
recurrent), 445-453
patient history, 43
periareolar capsulectomy with, 55-59
problem analysis, 44-45
revision augmentation, total explanta-
tion, site change, insertion o sili-
cone implant with ADM, 77-82
saline implant removal, total capsulec-
tomy, replacement with gel, 60-66
secondary expansion, implant replace-
ment (implant malposition), 591-
594
secondary mastopexy
areolar spreading, 437-440
unilateral reduction mammaplasty,
implant replacement (scarring),
415-422
seroma a ter augmentation, 43-47
silicone gel implants (high pro le) or
correction o rippling, 263-266
solutions, 45
submuscular capsulectomies
and implant exchange, 125-127
replacement/shaped implants (ptosis,
recurrent), 441-444
subpectoral pockets, partial, conversion
to with mastopexy (ptosis a ter
augmentation), 317-322
surgical drainage with implant exchange,
49-53
surgical technique, 45-46
teaching points, 47
unilateral explantation/delayed implant
reinsertion and mastopexy, 24-28
Implant rotation, shared implants
correction, manual manipulation, 150-153
shaped implant removal, pocket conver-
sion, mastopexy, round implant
insertion, 145-149
shaped implant rotation, 154-158
Implants
base diameter sizing, 338
complications o , 370
diagnosis, 10
patient’s expectations and appearance,
determination o , 262
periprosthetic in ection; see Peripros-
thetic in ection
shaped, bene ts o , 262
sizing systems, 305, 309, 315
tissue expander and secondary implants,
salvage o in ected augmentation,
36-41
and Tyndall e ect, 87
In ection
debridement, bio lm, 629
debridement, drainage, 561-564
expander replacement, autologous tissue
trans er, 565-570
explantation, delayed at gra ting with
implant reinsertion, 93, 97
healing by secondary intention, 496-500
periprosthetic; see Periprosthetic in ec-
tion
periprosthetic f uid collection, 49-50
reconstruction
tissue expansion, contralateral reduc-
tion mammaplasty, 619-626
using local tissue, 610-618
teaching points, 589
watch ul waiting/antibiotics, NAC isch-
emia, 496-504
In erior pole stretch de ormity
and ADM, eccentric periareolar masto-
pexy, 267-275
animation de ormity, neosubpectoral
pocket use, 281-285
829
Index
di erential diagnosis, 269
inverted-T mastopexy, conversion to
submuscular silicone gel implants,
276-279
In erior pole stretch de ormity, bottoming
out
mastopexy, implant site change, 473-477
unilateral old elevation, contralateral
periareolar mastopexy, 467-472
In ormed consent, 76
In ramammary olds (IMFs)
animation de ormity, neosubpectoral
pocket use, 281-285
asymmetry repair, latissimus dorsi f ap/
adjustable implant, 769-772
bilateral TRAM f aps, expander-
implants, 600-604
capsulorrhaphy, in erior skin recruit-
ment, implant exchange/asymmetry,
678-681
completion o previous lumpectomy,
radiotherapy/nipple-sparing mastec-
tomy, buried TRAM f ap, 779-783
correction, expander removal, 595-599
diagnosis, 9-10
di erential diagnosis, 269
double-bubble de ormity with subglan-
dular pocket/capsular f ap conver-
sion, 227-231
double-bubble and synmastia combined
de ormities treated using ADM,
215-221
excess lower pole volume reduction,
547-550
explantation, capsulectomies, conversion
to subpectoral pockets, 115-119
implant exchange, capsulotomy, pocket
adjustment/asymmetry, 671-676
implant removal, tissue expansion,
replacement with contoured gel
implants, 67-70
latissimus dorsi myocutaneous f ap/
implants, at trans er (BCT de or-
mity), 764-769
lipomodeling, IMF xation, 355-357
nipple malposition correction, subpecto-
ral implants, 537-540
overaugmented breast implant replace-
ment, ADM, 306-309
pocket modi cation with parenchymal
scoring, posterior capsular f ap
(implant malposition), 171-175
positioning, xation, 676
reconstruction with expander, latissimus
dorsi f ap, 159-163
re-creation o , 161, 163
salvage, ailed bilateral expander recon-
struction, TRAM f aps, 644-648
secondary expansion, implant replace-
ment (implant malposition), 591-
594
secondary in ramammary old correction
expander removal, 595-599
secondary vertical reduction mamma-
plasty, 529-532
shaped implant removal, pocket conver-
sion, mastopexy, round implant
insertion, 145-149
stable implant ormation, subglandular
pockets/revision mastopexy and
ADM, 201-204
synmastia repair, subpectoral pocket
conversion/ADM, 210-214
tissue expansion, TRAM f ap reposi-
tioning, implant insertion (volume
de ciencies), 731-735
unilateral old elevation, contralateral
periareolar mastopexy (stretch de-
ormity, bottoming out), 467-472
Insurance, 618
Interlocking Gore-Tex permanent purse-
string suture technique
anatomic description, 431
outcomes, 435
patient history, 431
problem analysis, 431
solutions, 432
surgical technique, 432-434
teaching points, 436
Intracapsular rupture, gel bleed
explantation, capsulectomy
conversion to subpectoral pockets,
115-119
conversion to submuscular pocket,
107-110
conversion to submuscular pocket,
secondary mastopexy, 120-124
reconstruction a ter silicone implant
rupture, chronic hematoma, 581-589
explantation, capsulectomy, tissue
expansion, delayed implant place-
ment, 111-114
subglandular to subpectoral pocket
exchange, ADM, 103-106
Intraluminal steroids, implant exposure/
extrusion, management, 87-91
Inverted-T mastopexy, conversion to
submuscular silicone gel implants
(in erior pole stretch de ormity),
276-279
K
Kenalog, 394
L
Latissimus dorsi f aps
asymmetry repair, latissimus dorsi f ap/
adjustable implant, 769-772
autologous tissue correction, latissimus
dorsi f ap a ter TRAM f ap recon-
struction, 709-712
breast reconstruction/autologous tissue,
SGAP ree tissue trans er, 719-724
with expander, 164-168
in implant salvage (recurrent malignancy),
794-796
implant exposure a ter nipple recon-
struction: implant replacement,
latissimus dorsi f ap, 659-663
latissimus dorsi f ap reconstruction,
contralateral mastopexy a ter radio-
therapy, 758-763
latissimus dorsi myocutaneous f ap/
implants, at trans er (BCT de or-
mity), 764-769
lumpectomy de ect correction, 753-757
reconstruction with expander, 159-163,
789-793
revision tissue expander–implant re-
construction, latissimus dorsi f ap,
adjustable implant, 639-643
salvage/ ailed reconstruction, latissimus
dorsi f ap, expander, 635-638
so t tissue distortion/steroids, implant
exposure/extrusion, 87-91
Levof oxacin (Levaquin), 93
Lipomodeling, IMF xation/asymmetry,
355-357
Lipostructure technique (Coleman), 257
Liposuction, circumvertical mastopexy,
533-536
Lower pole de ormities
excess lower pole volume reduction,
547-550
overresection o breast tissue, 523-527
repeat ree nipple gra t/periareolar mas-
topexy, 810-814
secondary mastopexy, lower pole reshap-
ing (bariatric patients), 479-484
volume reduction, 547-550
Lumpectomy
capsulectomy, implant replacement, con-
tralateral reduction mammaplasty,
745-751
completion o previous/nipple-sparing
mastectomy, buried TRAM f ap,
779-783
de ect correction, latissimus dorsi f ap/
implant, 753-757
at gra ting, 741-744
overview, 738
TRAM f ap revision, 773-778
Lupus anticoagulant, 723-724
M
Malignancy, a ter augmentation
debridement, drainage, in ection, 561-
564
latissimus dorsi f ap with expander,
164-168
reconstruction with expander and latis-
simus dorsi f ap, 159-163
Malignancy, recurrent
DIEP f ap advancement revision, 799-
801
latissimus dorsi f ap, implant salvage,
794-796
overview, 786
prognosis, 793
rates, 793
salvage, latissimus dorsi myocutaneous
f ap reconstruction, tissue expander
placement, 789-793
830
Index
Malrotation, 151, 158; see also Implant
malposition; Implant rotation,
shared implants
Massive weight loss (MWL); see Bariatric
patients
Mastectomy
completion o previous lumpectomy,
radiotherapy/nipple-sparing mastec-
tomy, buried TRAM f ap, 779-783
multistage repair with at gra ting, 129-
134
silicone injection correction, bilateral
mastectomies, TRAM f aps, 141-144
Mastectomy f ap necrosis
autologous tissue salvage, tissue
expansion/bipedicled DIEP f ap,
705-708
Mastopexy
ADM in eccentric periareolar, 267-275
asymmetrical mastopexies, unilateral
volume reduction, implant replace-
ment (asymmetry), 359-364
autologous tissue bene ts, 143, 144
bilateral, with implant insertion, 135-
140
challenges in, 376, 389
circumareolar, 275
circumareolar mastopexy−vertical mas-
topexy conversion, 423-430
circumareolar and multiple de ormities,
339-345
complications, avoiding, 353
conversion to submuscular pocket (over-
augmented breast), 295-300
de ormity corrected, local f aps, vertical
mastopexy (skin f aps [compro-
mised]), 399-405
dermal suspension mastopexy technique,
483-484
double-bubble de ormity site change to
subglandular pockets, 236-241
explantation
and capsulectomy, conversion to
submuscular pocket, secondary
mastopexy, 120-124
Wise pattern mastopexy, patient with
prior augmentation-mastopexy
(ptosis), 347-353
without replacement, 371-374
f attening a ter mastopexy, 460-465
implant removal and replacement, se-
roma a ter augmentation, 43-47
implant site change (bottoming out),
473-477
in erior pole stretch de ormity, 267-279
latissimus dorsi f ap reconstruction,
contralateral mastopexy a ter radio-
therapy, 758-763
liposuction, circumvertical mastopexy,
533-536
NAC ischemia, a ter conservative treat-
ment o mastopexy, 391-396
neopectoral pocket creation, breast
tissue reshaping, implant insertion
with acellular dermal matrix, 71-76
neosubpectoral pocket exchange, ptosis
a ter augmentation, 323-328
partial subpectoral pocket conversion,
bilateral vertical mastopexy (ptosis,
recurrent), 445-453
repeat ree nipple gra t/periareolar mas-
topexy, 810-814
secondary, 389
and areolar spreading, 437-440
with lower pole reshaping (bariatric
patients), 479-484
with unilateral reduction mammaplasty,
implant replacement (scarring),
415-422
shaped implant removal, pocket conver-
sion, mastopexy, round implant
insertion, 145-149
stable implant ormation, subglandular
pockets/revision mastopexy and
ADM, 201-204
subglandular pockets, conversion to with
periareolar mastopexy (ptosis a ter
augmentation), 335-338
subpectoral pockets, partial, conver-
sion to (ptosis a ter augmentation),
317-322
teaching points, 429-430
unilateral explantation/delayed implant
reinsertion and mastopexy, 24-28
unilateral old elevation, contralateral
periareolar mastopexy (stretch de-
ormity, bottoming out), 467-472
without implant exchange, ptosis a ter
augmentation, 329-334
McGhan implant, 619
Mechanisms o ailure, 8-9
Medical leeches, 393, 396
Medrol Dosepak, 384
MemoryShape implants, 172
MemoryShape sizers, 126
Mentor Moderate Pro le implants, 310
Mentor Siltex implant, 622
MM MemoryShape implants, 442
Moderate Plus pro le implant, 382
Moderate Pro le implant, 301, 303,
468
Multistage repair with at gra ting, 129-
134
N
NAC ischemia
autologous bilateral nipple-areolar
reconstruction, 379-390
autologous tissue salvage, tissue expan-
sion/bipedicled DIEP f ap, 705-708
complete nipple reconstruction, skate
f aps, 505-509
healing by secondary intention, 496-
500
a ter conservative treatment o masto-
pexy, 391-396
problem analysis, 492-493
watch ul waiting, 491-495
and antibiotics, 496-504
Necrosis
autologous bilateral nipple-areolar
reconstruction, 379-390
autologous tissue correction, latissimus
dorsi f ap a ter TRAM f ap recon-
struction, 709-712
autologous tissue salvage, tissue expan-
sion/bipedicled DIEP f ap, 705-708
complete nipple reconstruction, skate
f aps/NAC ischemia, 505-509
debridement, drainage, in ection, 561-
564
reconstruction with tissue expansion
and implant replacement, 627-634
and contralateral reduction mamma-
plasty, 619-626
secondary mastopexy, unilateral reduc-
tion mammaplasty, implant replace-
ment (scarring), 415-422
two-stage reconstruction, local f aps,
605-609
watch ul waiting
and antibiotics, 496-504
and NAC ischemia, 491-495
Neopectoral pockets
creation, breast tissue reshaping, implant
insertion with ADM, 71-76
Neosubpectoral pockets
animation de ormity, 233, 235, 281-285
conversion, 192-195
exchange, ptosis a ter augmentation,
323-326
synmastia repair, 206-209
Nipple-areola complex (NAC)
ADM, eccentric periareolar mastopexy,
267-275
animation de ormity, neosubpectoral
pocket use, 281-285
asymmetrical mastopexies, unilateral
volume reduction, implant replace-
ment (asymmetry), 359-364
asymmetry repair, latissimus dorsi f ap/
adjustable implant, 769-772
bilateral mastopexies with implant inser-
tion, 135-140
breast reshaping, expander-implants,
513-517
circulatory compromise, 384-385, 389-
396
circumareolar mastopexy, multiple
de ormities (ptosis a ter augmenta-
tion), 339-345
circumareolar mastopexy-vertical masto-
pexy, conversion, 423-430
double-bubble de ormity
site change to subglandular pockets
(mastopexy), 236-241
subglandular pocket/capsular f ap
conversion, 227-231
explantation
with capsulectomy, tissue expan-
sion, delayed implant placement,
111-114
with Wise pattern mastopexy, patient
with prior augmentation-mastopexy
(ptosis), 347-353
831
Index
explantation without replacement (mas-
topexy), 371-374
f attening, at gra ting to correct, 455-
458
implant exposure a ter nipple recon-
struction: implant replacement,
latissimus dorsi f ap, 659-663
implant insertion, skin envelope modi -
cation, 519-522
implant removal, tissue expansion,
replacement with contoured gel
implants, 67-70
intracapsular rupture, gel bleed
explantation, capsulectomy, conver-
sion to submuscular pocket, second-
ary mastopexy, 120-124
subglandular to subpectoral pocket
exchange, ADM, 103-106
intraluminal steroids, management o im-
pending implant exposure/extrusion,
87-91
inverted-T mastopexy, conversion to
submuscular silicone gel implants
(in erior pole stretch de ormity),
276-279
ischemia; see NAC ischemia
latissimus dorsi f ap with expander,
malignancy, a ter augmentation,
164-168
latissimus dorsi myocutaneous f ap/
implants, at trans er (BCT de or-
mity), 764-769
liposuction, circumvertical mastopexy,
533-536
malposition diagnosis, 9-10
mastopexy
conversion to submuscular pocket
(overaugmented breast), 295-300
without implant exchange, ptosis a ter
augmentation, 329-334
with implant site change (bottoming
out), 473-477
neosubpectoral pocket exchange, ptosis
a ter augmentation, 323-328
nipple malposition; see Nipple malposi-
tion, a ter augmentation
overaugmented breast implant replace-
ment, ADM, 306-309
overview, 804
partial subpectoral pocket conversion,
bilateral vertical mastopexy (ptosis,
recurrent), 445-453
periareolar capsulectomy with implant
replacement, 55-59
pocket modi cation, pectoralis muscle
release (implant malposition), 176-
180
pocket modi cation with parenchymal
scoring, posterior capsular f ap
(implant malposition), 171-175
radial capsular scoring, insertion o
wider-base implants (double-bubble
de ormity), 248-251
reconstruction with expander, latissimus
dorsi f ap, 159-163
repeat ree nipple gra t/periareolar mas-
topexy, 810-814
revision augmentation, total explanta-
tion, site change, insertion o sili-
cone implant with ADM, 77-82
secondary mastopexy, areolar spreading,
437-440
seroma a ter augmentation, surgical
drainage with implant exchange,
49-53
shaped implant removal, pocket conver-
sion, mastopexy, round implant
insertion, 145-149
silicone injection correction, bilateral
mastectomies, TRAM f aps, 141-
144
stable implant ormation, subglandular
pockets/revision mastopexy and
ADM, 201-204
subglandular pockets
conversion to, with animation de or-
mity, 286-289
conversion to, with periareolar mas-
topexy (ptosis a ter augmentation),
335-338
submuscular capsulectomies
and implant exchange, 125-127
replacement/shaped implants (ptosis,
recurrent), 441-444
subpectoral pockets, partial, conversion
to with mastopexy (ptosis a ter
augmentation), 317-322
unilateral explantation/delayed implant
reinsertion and mastopexy, 24-28
unilateral old elevation, contralateral
periareolar mastopexy (stretch de-
ormity, bottoming out), 467-472
unilateral synmastia, conversion to sub-
pectoral implants, 222-226
wraparound f ap to restore nipple pro-
jection, 821-824
Nipple malposition
breast repositioning, 542-545
diagnosis, 9-10
expander implant exchange, capsulor-
rhaphies, at gra ting, 807-809
a ter augmentation, 409-414
reciprocal transposition f aps, 815-819
subpectoral breast implants, correction,
537-540
Nipple reconstruction
implant exposure/extrusion a ter nipple
reconstruction: implant replace-
ment, latissimus dorsi f ap, 661-663
skate f aps/NAC ischemia, 505-509
wraparound f ap to restore nipple pro-
jection, 821-824
Nitro-Bid cream, 384
O
Overaugmented breast
capsulorrhaphy, multidirectional
rein orced/ADM, 310-315
implant replacement, ADM, 306-309
mastopexy, conversion to submuscular
pocket, 295-300
secondary mastopexy, unilateral reduc-
tion mammaplasty, implant replace-
ment (scarring), 415-422
subglandular pocket, conversion to,
301-305
Overresection o breast tissue
breast reshaping, expander-implants,
513-517
contour de ormity, 524-527
implant insertion, skin envelope modi -
cation, 519-522
P
Patient disappointment, 8-9
Pectoralis muscle
ull-thickness de ect, 795
pocket modi cation, pectoralis muscle
release (implant malposition), 176-
180
repositioning/ADM (animation de or-
mity), 290-294
stable implant ormation, subglandular
pockets/revision mastopexy and
ADM, 201-204
Pectus excavatum de ormity, 100
Pedicle, pure medial, 499-500, 503-504
Pedicle extension f ap (superior)
f attening a ter mastopexy, 460-465
Pedicle thrombosis, 723
Per usion; see Circulatory compromise
Periareolar capsulectomy with implant
replacement, 56-59
Periprosthetic f uid collection, 49-50
Periprosthetic in ection
anatomic description, 18
bilateral explantation with delayed
implant reinsertion, 29-35
explantation, 22, 23
outcome, 22
patient history, 17-18
problem analysis, 18
rationale, 23
solutions, 18
surgical technique, 19-21
teaching points, 23
tissue expander and secondary implants,
salvage o in ected augmentation,
36-41
POCAR, 134
Pocket conversion
capsuloplasty, implant conversion to
submammary pocket (double-
bubble de ormity), 242-247
double-bubble de ormity, subglandular
pocket/capsular f ap conversion,
227-231
inverted-T mastopexy, conversion to
submuscular silicone gel implants
(in erior pole stretch de ormity),
276-279
mastopexy, conversion to submuscular
pocket (overaugmented breast),
295-300
832
Index
Pocket conversion—cont’d
partial subpectoral pocket conversion,
bilateral vertical mastopexy (ptosis,
recurrent), 445-453
shaped implant removal, pocket conver-
sion, mastopexy, round implant
insertion, 145-149
shaped implant rotation, 154-158
subglandular pockets, conversion to,
or overaugmented breast, 301-305
with periareolar mastopexy (ptosis
a ter augmentation), 335-338
subpectoral pockets, partial, conversion
to with mastopexy (ptosis a ter
augmentation), 317-322
synmastia repair/ADM, 210-214
unilateral synmastia, conversion to sub-
pectoral implants, 222-226
Pocket modi cation
insertion o silicone gel implants, 99-102
parenchymal scoring, posterior capsular
f ap, 171-175
pectoralis muscle release, 176-180
site change, 181-186
anatomic description, 181-182
Pregnancy
mastopexy without implant exchange,
ptosis a ter augmentation, 329-
334
Pseudoptosis, 548
Ptosis (a ter augmentation)
circumareolar mastopexy, multiple
de ormities, 339-345
excess lower pole volume reduction,
547-550
explantation, Wise pattern mastopexy,
patient with prior augmentation-
mastopexy, 347-353
mastopexy, conversion to submuscular
pocket (overaugmented breast),
295-300
mastopexy without implant exchange,
329-334
neosubpectoral pocket exchange, 323-
328
secondary mastopexy
and lower pole reshaping (bariatric
patients), 479-484
and unilateral reduction mammaplasty,
implant replacement (scarring), 415-
422
subglandular pockets
conversion to, or overaugmented
breast, 301-305
conversion to, with periareolar masto-
pexy, 335-338
subpectoral pockets, partial, conversion
to with mastopexy, 317-322
teaching points, 485
Ptosis (recurrent)
partial subpectoral pocket conversion,
bilateral vertical mastopexy, 445-
453
submuscular capsulectomies, replacement/
shaped implants, 441-444
Pure medial pedicle, 499-500, 503-504
R
Radial capsular scoring, insertion o
wider-base implants (double-bubble
de ormity), 248-251
Radiotherapy
capsulectomy, implant replacement, con-
tralateral reduction mammaplasty,
745-751
capsulotomies, ADM a ter, 576-580
completion o previous lumpectomy/
nipple-sparing mastectomy, buried
TRAM f ap, 779-783
at gra ting, implant insertion, TRAM
f ap (volume de ciencies), 727-730
at gra ting a ter lumpectomy, 741-744
implant exchange, capsulotomy, pocket
adjustment/asymmetry, 671-676
latissimus dorsi f ap implant salvage
(recurrent malignancy), 794-796
latissimus dorsi f ap reconstruction, con-
tralateral mastopexy, 758-763
lumpectomy de ect correction, latissimus
dorsi f ap/implant, 753-757
oncoplastic repair, 762-763
overview, 738
partial breast irradiation, 762-763
reciprocal transposition f aps, nipple
malposition, 815-819
salvage, ailed bilateral expander recon-
struction, autologous tissue trans er,
654-658
TRAM f ap revision, 773-778
RAFT procedure, 571-575
Recipient vessels, 723-724
Reciprocal transposition f aps, nipple mal-
position, 815-819
Reconstruction; see Breast reconstruction
Recurrence (cancer); see Malignancy
Reduction mammaplasty
breast reshaping, expander-implants,
513-517
capsulectomy, implant replacement, con-
tralateral reduction mammaplasty,
745-751
complete nipple reconstruction, skate
f aps/NAC ischemia, 505-509
at transplantation, shape/contour issues,
551-554
liposuction, circumvertical mastopexy,
533-536
NAC ischemia; see NAC ischemia
overview, 488
secondary mastopexy, unilateral reduc-
tion mammaplasty, implant replace-
ment (scarring), 415-422
secondary vertical reduction mamma-
plasty, 529-532
watch ul waiting/antibiotics, NAC isch-
emia, 496-504
Re ractory capsular contracture
saline implant removal, total capsulec-
tomy, replacement with gel, 60-66
Revision procedures
circumareolar mastopexy, multiple
de ormities, 339-345
mastopexy, conversion to submuscular
pocket (overaugmented breast),
295-300
neopectoral pocket creation, breast
tissue reshaping, implant insertion
with acellular dermal matrix, 71-76
pectoralis repositioning/ADM (anima-
tion de ormity), 290-294
revision augmentation, total explanta-
tion, site change, insertion o sili-
cone implant with ADM, 77-82
revision tissue expander–implant re-
construction, latissimus dorsi f ap,
adjustable implant, 639-643
Rigottomy
tissue breakdown/ ailed tissue expansion
reconstruction using Rigottomies,
Brava external expansion, serial
lipo lling, 688-694
Rigottomy and at trans er (RAFT), 571-
575
Rippling
inverted-T mastopexy, conversion to
submuscular silicone gel implants
(in erior pole stretch de ormity),
276-279
silicone gel implants (high pro le) or
correction o , 263-266
Rotation; see Implant rotation, shared
implants
S
Saline implant def ation
pocket modi cation, insertion o silicone
gel implants, 99-102
risk actors, 102
Saline implant removal, total capsulectomy,
replacement with gel implants,
61-66
Salvage, ailed bilateral expander recon-
struction
autologous tissue trans er, 654-658
TRAM f aps, 644-648
Salvage (two-stage), placement o smaller
implants, 83-86
Salvage/ ailed reconstruction, latissimus
dorsi f ap, expander, 635-638
Scarring
secondary mastopexy, unilateral reduc-
tion mammaplasty, implant replace-
ment, 415-422
unilateral old elevation, contralateral
periareolar mastopexy (stretch de-
ormity, bottoming out), 467-472
Secondary intention, healing by, 496-500
Secondary mastopexy, lower pole reshaping
(bariatric patients)
anatomic description, 480
dermal suspension mastopexy technique,
483-484
outcomes, 482
patient history, 479-480
problem analysis, 480-481
solutions, 481
surgical technique, 481-482
teaching points, 485
833
Index
Secondary vertical reduction mammaplasty,
529-532
Seroma a ter augmentation
explantation, capsulectomy, reconstruc-
tion a ter silicone implant rupture,
chronic hematoma, 581-589
implant removal and replacement, 43-47
surgical drainage with implant exchange,
49-53
teaching points, 589
SGAP f aps
breast reconstruction/autologous tissue,
SGAP ree tissue trans er, 719-724
Shape/contour issues
at gra ting, 696-699
and implant insertion with TRAM
f ap (volume de ciencies), 727-730
to treat wrinkling, contour de ormity,
253-257
at transplantation, 551-554
latissimus dorsi myocutaneous f ap/
implants, at trans er (BCT de or-
mity), 764-769
overresection o breast tissue, 524-527
overview, 738
repeat ree nipple gra t/periareolar mas-
topexy, 810-814
tissue breakdown/ ailed tissue expansion
reconstruction using Rigottomies,
Brava external expansion, serial
lipo lling, 688-694
tissue expansion, TRAM f ap reposi-
tioning, implant insertion (volume
de ciencies), 731-735
unilateral TRAM f aps, 683-687
Shaped implant removal, pocket conver-
sion, mastopexy, round implant
insertion, 145-149
Shaped implant rotation, 154-158
SIEF (simultaneous implant exchange/ at
gra ting), 365-370
Silicone gel implants (high pro le) or cor-
rection o rippling, 263-266
Silicone injection correction, bilateral mas-
tectomies, TRAM f aps, 141-144
Silvadene cream, 385
Site change
capsulectomy, conversion to subglandu-
lar pockets (double-bubble de or-
mity), 232-235
subglandular pockets, mastopexy
(double-bubble de ormity), 236-241
Skate f aps
complete nipple reconstruction, skate
f aps/NAC ischemia, 505-509
Skin f aps (compromised)
de ormity corrected, local f aps, vertical
mastopexy, 399-403
Skin gra ts
breast reconstruction
autologous tissue, SGAP ree tissue
trans er, 719-724
revision/autologous tissue, DIEP ree
tissue trans er, 713-718
complete nipple reconstruction, skate
f aps/NAC ischemia, 505-509, 593
latissimus dorsi f ap, implant salvage
(recurrent malignancy), 794-796
necrosis, salvage, tissue expansion/
bipedicled DIEP f ap, 705-708
recipient vessels, 723-724
reciprocal transposition f aps, nipple
malposition, 815-819
Smoking
explantation, capsulectomy
conversion to submuscular pocket,
107-110
tissue expansion, delayed implant
placement, 111-114
latissimus dorsi f ap reconstruction, tis-
sue expander placement (recurrent
malignancy), 789-793
salvage/ ailed reconstruction, latissimus
dorsi f ap, expander, 635-638
So t tissue distortion/steroids, implant
exposure/extrusion, 87-91
Spaghetti box concept, 669
Spy angiography, 606
Stable implant ormation, subglandular
pockets/revision mastopexy and
ADM, 201-204
Stem cells, 97
Steroids; see Intraluminal steroids; Implant
exposure/extrusion, management
Strattice; see Acellular dermal matrix
(ADM; Strattice)
Stretch de ormity
areolar spreading; see Areolar spreading
in erior pole; see In erior pole stretch
de ormity
Style 45 implants, 631
Subglandular pockets, conversion to
or animation de ormity, 286-289
double-bubble de ormity, subglandular
pocket/capsular f ap conversion,
227-231
inverted-T mastopexy, conversion to
submuscular silicone gel implants
(in erior pole stretch de ormity),
276-279
or overaugmented breast, 301-305
with periareolar mastopexy (ptosis a ter
augmentation), 335-338
site change, capsulectomy, conversion
to subglandular pockets (double-
bubble de ormity), 232-235
stable implant ormation, subglandular
pockets/revision mastopexy and
ADM, 201-204
Subglandular to subpectoral pocket ex-
change, ADM, 103-107
Submammary implants
capsuloplasty, implant conversion to sub-
mammary pocket (double-bubble
de ormity), 242-247
de ormity corrected, local f aps, vertical
mastopexy (skin f aps [compro-
mised]), 399-405
synmastia repair, subpectoral pocket
conversion/ADM, 210-214
unilateral synmastia, conversion to sub-
pectoral implants, 222-226
Submuscular capsulectomies
and implant exchange, 125-127
replacement/shaped implants (ptosis,
recurrent), 441-444
Submuscular pockets
mastopexy, conversion to submuscular
pocket (overaugmented breast),
295-300
Subpectoral implants
capsulorrhaphy, conversion to submam-
mary pocket, 187-191
mastopexy, implant site change (bottom-
ing out), 473-477
neosubpectoral pocket conversion, 192-
195
nipple malposition correction, 537-540
partial subpectoral pocket conversion,
bilateral vertical mastopexy (ptosis,
recurrent), 445-453
pocket modi cation, pectoralis muscle
release (implant malposition), 176-
180
shaped implant removal, pocket conver-
sion, mastopexy, round implant
insertion, 145-149
silicone gel implants (high pro le) or
correction o rippling, 263-266
site change, capsulectomy, conversion
to subglandular pockets (double-
bubble de ormity), 232-235
stable implant ormation, subglandular
pockets/revision mastopexy and
ADM, 201-204
synmastia repair
neosubpectoral pocket, 205-209
subpectoral pocket conversion/ADM,
210-214
unilateral synmastia, conversion to sub-
pectoral implants, 222-226
Subpectoral pocket conversion (partial),
bilateral vertical mastopexy (ptosis,
recurrent)
anatomic description, 448
outcomes, 452
patient history, 445-448
problem analysis, 448
solutions, 448
surgical technique, 449-451
teaching points, 453
Subpectoral pockets
animation de ormity; see Animation
de ormity
partial, conversion to with mastopexy
ptosis a ter augmentation, 317-322
Superomedial pedicle, 499-500, 503-504
Surgical drainage with implant exchange,
49-53
Synmastia, 206, 209, 226
Synmastia repair
capsulorrhaphy, multidirectional
rein orced/ADM (overaugmented
breast), 310-315
double-bubble, synmastia combined
de ormities treatment using ADM,
215-221
herniation, 224
834
Index
Synmastia repair—cont’d
neosubpectoral pocket, 205-209
subpectoral pocket conversion/ADM,
210-214
unilateral, conversion to subpectoral
implants, 222-226
T
Tailor-tacking, 482
TDAP f aps, 723
Tisseel brin sealant, 587, 589
Tissue breakdown/ ailed tissue expansion
reconstruction using Rigottomies,
Brava external expansion, serial
lipo lling, 688-694
Tissue expander malposition
bilateral TRAM f aps, expander-
implants, 600-604
secondary in ramammary old correction
expander removal, 595-599
Tissue expanders
asymmetry repair, latissimus dorsi f ap/
adjustable implant, 769-772
capsulotomies, ADM a ter radiotherapy,
576-580
central mound incisions, 570
expander implant exchange, capsulor-
rhaphies, at gra ting (nipple malpo-
sition), 807-809
expander replacement, autologous tissue
trans er, 565-570
implant exposure a ter nipple recon-
struction: implant replacement,
latissimus dorsi f ap, 659-663
latissimus dorsi f ap reconstruction, tis-
sue expander placement (recurrent
malignancy), 789-793
overview, 558
reconstruction, tissue expansion,
and contralateral reduction mamma-
plasty, 619-626
with implant replacement, 627-634
reconstruction using local tissue, 610-
618
revision tissue expander–implant re-
construction, latissimus dorsi f ap,
adjustable implant, 639-643
salvage, ailed bilateral expander recon-
struction
and autologous tissue trans er, 654-
658
and TRAM f aps, 644-648
salvage/ ailed reconstruction, latissimus
dorsi f ap, expander, 635-638
secondary implants, salvage o in ected
augmentation, 36-41
tissue expansion, TRAM f ap reposi-
tioning, implant insertion (volume
de ciencies), 731-735
TRAM f ap revision, a ter lumpectomy/
radiotherapy, 773-778
Tissue necrosis, smoking and, 112, 114
TMG f aps, 720, 723
TRAM f aps
autologous tissue bene ts, 143, 144
autologous tissue correction, latissimus
dorsi f ap a ter TRAM f ap recon-
struction, 709-712
bilateral TRAM f aps, expander-
implants, 600-604
completion o previous lumpectomy,
radiotherapy/nipple-sparing mastec-
tomy, buried TRAM f ap, 779-783
at gra ting, implant insertion, TRAM
f ap (volume de ciencies), 727-
730
reconstruction with expander, latissimus
dorsi f ap, 159-163
revision, a ter lumpectomy/radiotherapy,
773-778
salvage, ailed bilateral expander recon-
struction
and autologous tissue trans er, 654-658
and TRAM f aps, 644-648
silicone injection correction, bilateral
mastectomies, TRAM f aps, 141-144
tissue expansion, TRAM f ap reposi-
tioning, implant insertion (volume
de ciencies), 731-735
unilateral, 683-687
Tubular carcinoma, 165, 168
Tyndall e ect, 87
U
Underresection o breast tissue
liposuction, circumvertical mastopexy,
533-536
secondary vertical reduction mamma-
plasty, 529-532
Unilateral explantation/delayed implant
reinsertion and mastopexy, 24-28
Unilateral old elevation, contralateral
periareolar mastopexy (stretch de-
ormity, bottoming out), 467-472
Unilateral synmastia, conversion to subpec-
toral implants, 222-226
Unilateral TRAM f aps, 683-687
Upper pole de ciency, contour de ormity
anatomic implants or upper pole de -
ciency, 259-262
at gra ting to correct, 455-458
at gra ting to treat wrinkling, contour
de ormity, 253-257
overresection o breast tissue, 523-527
silicone gel implants (high pro le) or
correction o rippling, 263-266
subglandular pockets conversion, over-
augmented breast, 301-305
V
Volume de ciencies (persistent)
at gra ting, implant insertion, TRAM
f ap, 727-730
tissue expansion, TRAM f ap reposition-
ing, implant insertion, 731-735
W
Watch ul waiting, NAC ischemia, 491-
495
anatomic description, 496, 502
and antibiotics, 496-504
outcomes, 497-499, 502-503
patient history, 496, 501
problem analysis, 497, 502
solutions, 497, 502
teaching points, 499-500, 503-504
Water all de ormity, circumareolar masto-
pexy, multiple de ormities, 339-
345
Window shading, 93
Wound cultures, 84
Wound separation and dehiscence
salvage (two-stage), placement o smaller
implants, 83-86
Wraparound f ap to restore nipple projec-
tion, 821-824
Wrinkling
at gra ting to treat wrinkling, contour
de ormity, 253-257
inverted-T mastopexy, conversion to
submuscular silicone gel implants
(in erior pole stretch de ormity),
276-279
silicone gel implants (high pro le) or
correction o rippling, 263-266