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

Part II: Problems in Augmentation Mammaplasty
372
ANALYSIS O F THE PRO BLEM
The alterations in this patient’s breasts are typical o women who had breast aug-
mentation in their twenties, ollowed by multiple pregnancies, weight gain, and
changes in breast volume. It can be seen that at age 22 she had relatively small
breasts; however, the right NAC was lower even at that time. Her immediate post-
operative appearance demonstrated a slightly lower NAC on the right; when she
was seen 10 years later, she had gained weight and had the beginning o ptosis. By
age 42, a ter urther weight gain, the ptosis had progressed and the implants had
migrated superiorly.
Because the patient had requested implant removal, the nal result will depend on
her residual breast tissue. Such patients can present a problem, because the surgeon
does not have an accurate estimate o the remaining breast tissue or re-creation o
the new breast mound until the implants are removed in the operating room. Even
i the size o the implants is known, it can be di cult preoperatively to accurately
predict nal breast contour, shape, and volume. An appropriate mastopexy is criti-
cal in attempting to resolve these problems.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the implants
Intraoperative sequencing o the mastopexy pattern
(This re ers to the ability to tailor-tack tissue based on preoperative markings
once the implant is removed. Because the exact remaining volume o breast tis-
sue is unpredictable, the surgeon should not commit to the nal skin excision
until the implants have been removed. I an aggressive skin excision is per-
ormed at too early a stage in the procedure, the result can be compromised.)
TECHNIQ UE
In this patient I used a method I call intraoperative sequencing. This method is
based on the preoperative markings, which consist o both a vertical and a tradi-
tional T-pattern.

Chapter 21 • Explantation

373
This method allows me to maintain multiple options once the implant is removed.
Typically in these patients the nal closure is vertical, with a short horizontal IMF
component. At each step tailor-tacking o the skin is per ormed to assess the intra-
operative contour and shape. Once the nal amount o excision is determined, in
the majority o these patients, the nipple can be based on an in erior and superior
pedicle. Because the patient has already had an implant, there has been some com-
promise to the blood supply o the breast tissue, and maintaining as much o the
pedicle sur ace area ensures NAC viability. The intraoperative photos demonstrate
the pedicle being divided and released until there is adequate mobilization o the
nipple. Finally, the skin pattern is closed in primarily a vertical pattern with a short
horizontal T.

Part II: Problems in Augmentation Mammaplasty
374
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 5 years a ter removal o her implants with the previously
described mastopexy. It is also obvious that she has lost a signi cant amount o
weight a ter the procedure. Her breasts have maintained airly good shape and con-
tour, and there is a slight recurrence o ptosis, which is inevitable in this group o
patients when they lose a signi cant amount o weight postoperatively. However,
even with the weight loss and typical tissue relaxation, she has maintained a good
result.
TEACHING PO INTS
Preoperatively it can be di cult to predict or patients exactly how much remain-
ing breast tissue will be available or recreating the breast mound. Leaving options
open by doing intraoperative sequencing and not committing to the nal excision
until a ter implant removal can bene t this group o patients. Maintaining the NAC
on as broad a pedicle as possible ensures viability.
BIBLIO GRAPHY
Gurunluoglu R, Sacak B, Arton J. Outcomes analysis o patients undergoing autoaugmentation a ter
breast implant removal. Plast Reconstr Surg 132:304-315, 2013.
Paydar KZ, Kohan E, Hansen SL, Roostaeian J, Gradinger GP. Long-term e ects o breast aging in
patients undergoing explantation: analysis o breast aesthetics rom be ore augmentation to a ter
explantation. Ann Plast Surg. 2013 Mar 11. [Epub ahead o print]

Pa r t III
Problems in Mastopexy
and Augmentation-
Mastopexy

The problems associated with mastopexy and augmentation-mastopexy are very similar to those
seen in breast reduction and augmentation patients. In mastopexy procedures, issues such as
NAC ischemia, ap ischemia, asymmetry, scarring, shape problems, in ection, and recurrent
ptosis all can occur.
When adding an implant, all o these problems can be exacerbated. New challenges include
capsular contracture, implant malposition, animation de ormities, implant visibility, and palpa-
bility. Adding an implant with a mastopexy may even ampli y di f culties aced when per orm-
ing revision surgery. Additionally, in any type o breast implant surgery, the risk o in ection is
increased when implants are replaced. This increased risk is likely secondary to the phenom-
enon o biof lm ormation at the time o the original surgery. Another increased risk actor in a
previous augmentation or mastopexy patient is the increased incidence o NAC ischemia.
Mastopexy and augmentation-mastopexy remain challenging operations as primary procedures,
and revision operations signif cantly increase the possibility o any o the scenarios discussed.
When revising the breast surgery result in a mastopexy or augmentation-mastopexy patient,
it is help ul to obtain as much in ormation as possible concerning the original operation. For
example, what was the pedicle used to move the nipple in the original procedure? Also, i an
implant was used, what pocket is it in? What is the status o the overlying so t tissues? Because
these tissues have previously been rearranged, the possibility o ischemia is an important con-
sideration when planning a revision. For example, one scenario in which the risk o ischemia is
magnif ed is in the patient who has had the NAC repositioned one or more times in the past. In
this setting, it may be necessary to reposition the NAC as a ree skin gra t. This is an example
in which knowledge o the previous surgery is crucial. A series o cases will be presented in this
section that demonstrates reoperative issues a ter mastopexy and augmentation-mastopexy.

Se c t Io n o n e
Postoperative Complications
Chapter 22 Ischemia of the Nipple-Areola Complex
22a Autologous Bilateral Nipple-Areolar Reconstruction
22b Conservative Treatment o Nipple-Areolar Ischemia Following Mastopexy
Chapter 23 Compromised Skin Flaps
23a De ormity Following Failed Augmentation-Mastopexy Corrected With Local Flaps Using
a Vertical Mastopexy
377

(Trang không có chữ)

C h a p t e r 2 2
ISCHEMIA OF THE NIPPLE-
AREOLA COMPLEX
22a Autologous Bilateral Nipple-Areolar Reconstruction
Nea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 27-year-old woman was referred by another plastic surgeon for possible re-
vision of an unsatisfactory augmentation-mastopexy result. Two years earlier the
patient had undergone breast enlargement with 400 cc saline implants placed in the
subpectoral position. This was done in conjunction with a circumareolar mastopexy.
379

Part III: Problems in Mastopexy and Augmentation-Mastopexy
380
She was unhappy with the cosmetic result, because her areolae were too large, the
circumareolar scars were too wide and uneven, and her breasts were asymmetri-
cal and ptotic. The patient then became pregnant with her rst child. During preg-
nancy the appearance o her breasts deteriorated urther. She presented or revision
6 months a ter the birth o her daughter.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Physical examination con rmed the presence o high-riding subpectoral saline im-
plants; a Snoopy dog de ormity; large, irregularly shaped areolae; and widened cir-
cumareolar scars. The patient had grade 3 ptosis bilaterally and slight asymmetry
(the le t breast was larger). Both breasts were so t (Baker grade I). She was a suit-
able candidate or revision.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the saline implants
Conversion o the circumareolar mastopexy to a vertical mastopexy
Insertion o submammary silicone gel implants
TECHNIQ UE
The patient’s operative report rom her original augmentation-mastopexy was un-
available. We thought that the implants had been inserted through the in erior por-
tion o her circumareolar incision, thereby preserving the blood supply to the NAC
through the superior pedicle. Markings were made or a vertical mastopexy incor-
porating a superiorly based pedicle to the nipple. The pedicle was deepithelialized,
and the incisions were carried down into the breast parenchyma.

Chapter 22 • Ischemia of the Nipple-Areola Complex

381
The patient had a very abundant layer o breast tissue, and we elected to convert
the implant to the submammary plane, to enhance the correction o ptosis. A new
retromammary pocket was dissected and the subpectoral saline implant removed.
The muscle was sutured to the underlying chest wall to permanently eradicate
the old submuscular pocket. The vertical wedge o skin and breast tissue rom the
lower pole o the breast was resected, to create medial and lateral pillars. The nip-
ple was elevated approximately 4 cm on a superiorly based dermal/parenchymal
pedicle that was more than 2 cm in thickness over its entire length.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
382
A 400 cc smooth, round Moderate Plus pro le silicone gel implant (Mentor, Santa
Barbara, CA) was rinsed in Betadine and inserted into the submammary pocket.
The medial and lateral parenchymal pillars were approximated and sutured to one
another in layers, rom deep to super cial. The resulting dog-ear at the in erior
end o the vertical closure was debulked, with resection o the triangular-shaped
segments o breast parenchyma rom the in erior undersur ace o the medial and
lateral pillars. The in eromedial corners o the pillars were then sutured to one
another and to the underlying capsule and chest wall with a buried 2-0 PDS suture
that incorporated all three points; this ensured a secure deep-layer closure to pre-
vent implant exposure in the event o wound breakdown. The excess skin at
the in eriormost extent o the vertical skin excision was trimmed and the resulting
de ect closed in layers with buried purse-string sutures. At the completion o the
procedure, the viability o the NACs and skin f aps on both sides appeared uncom-
promised.

Chapter 22 • Ischemia of the Nipple-Areola Complex

383
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient was seen or her rst postoperative visit 48 hours a ter surgery. The
dressings were removed, and signi cant venous congestion o the NACs bilaterally
was evident. The problem was worse on the right side. Patches o pink areolar skin
were present on both sides, and the NACs were not cool to the touch. There was no
evidence o a hematoma or in ection, and the breast skin f aps appeared viable bi-
laterally.
ANALYSIS O F THE PRO BLEM
This patient had bilateral venous congestion o her nipples a ter a secondary mas-
topexy and implant exchange. This is a serious and not in requent complication in
patients who have had previous breast implant surgery and require correction o
ptosis. Despite care ully planned, minimally traumatic surgery, some patients will
develop circulatory compromise o the nipple and/or skin f aps. In this case, the
length o the superior pedicle was not excessive, and the pedicle was thick and ap-
peared to provide su cient circulation to the nipple. However, it was impossible
to know the depth o the dissection rom the previous surgery. Scarring and inter-
rupted circulation rom the patient’s previous surgery may have contributed to the
postoperative congestion. Although the right NAC appeared to be more compro-
mised, there were areas o pink areolar skin bilaterally, and the NACs were not
cool to the touch. The breasts were so t, there was no evidence o a hematoma or
f uid accumulation, and the mastopexy skin f aps did not appear to be under exces-
sive tension. For these reasons, we proceeded conservatively to ensure survival o
the maximum amount o tissue, and responded in timely ashion as the clinical situ-
ation evolved.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
384
RECOMMENDED SOLUTION TO THE PROBLEM
Application o Nitro-Bid cream to promote venous drainage o the NACs
Administration o oral corticosteroids to reduce edema
Continued prophylactic antibiotics
Frequent observation o the patient
Appropriate surgical interventions as indicated by the patient’s evolving clinical
condition
TECHNIQ UE
At the rst dressing change, on postoperative day 2, the problem was identi ed,
and measures were immediately taken to try to reverse the process. The patient was
started on a course o oral corticosteroids (Medrol Dosepak); Nitro-Bid cream 2%
was applied to the NACs three times daily; and oral cephalosporin was continued.
Based on the nding o interspersed patches o warm, pink areolar skin on both
sides, we were guardedly optimistic.
The patient was seen at 48-hour intervals. By postoperative day 4, the viability o
her NACs appeared to be deteriorating. The areolar skin was becoming darker and
was cooler to the touch. The circumareolar dermal sutures were cut to reduce ten-
sion on the NACs, and hyperbaric oxygen treatments were initiated (60 minutes
daily or 5 days).

Chapter 22 • Ischemia of the Nipple-Areola Complex

385
By the end o oxygen treatment on postoperative day 9, the patient’s status ap-
peared to be stable, and slight improvement was noted. The tissues were beginning
to demarcate. At least 50% o the le t NAC and 30% to 40% o the right NAC was
viable. There was no sign o in ection. The patient was instructed to apply Silvad-
ene cream to her NACs twice daily and continue oral antibiotics.
Because there were no signs o in ection and the patient was compliant with her
dressing changes, a conservative course was maintained. She continued to apply
Silvadene cream twice daily. Repeat cultures o the open wounds grew only skin
f ora. Drainage increased on the right side, and a ter consultation with an in ec-
tious disease specialist, double antibiotic coverage was started with oral Augmentin
500 mg three times daily and oral Bactrim DS twice daily. By the end o the third
week (postoperative day 23), complete demarcation o viable and nonviable tis-
sue was evident. On the le t side, the nipple and approximately 50% o the areola
survived. The right side had considerably greater tissue loss, with survival o only
a tiny remnant o the nipple. As the nonviable tissues progressed to ull-thickness
necrosis, mature eschars ormed, the circumareolar incisions separated, and open
wounds developed, mostly characterized by healthy-appearing granulation tissue.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
386
To remove all necrotic debris, saline wet to dry dressings were applied. The patient
changed these at home three times daily. She was seen requently in the o ce or
sharp debridement o necrotic eschar and small areas o at necrosis. By week 6,
wounds were clean bilaterally, and all open areas were covered with granulation
tissue that appeared healthy. The wound on the le t side was beginning to contract.
The wound edges on the right were still gaping.
Delayed wound closure was per ormed. On an outpatient basis and under local
anesthesia the wounds were debrided, skin f aps conservatively undermined, and
the open de ects repaired with a layered closure. Both sides healed. The patient is
shown 10 days later, approximately 2 months a ter her original operation. She was
encouraged to wait a su cient amount o time or the tissues to so ten and the
scars to mature be ore proceeding with any urther attempts at reconstruction.

Chapter 22 • Ischemia of the Nipple-Areola Complex

387
She was very compliant with this regimen and is shown approximately 3 months
a ter delayed closure o the wounds.
The patient waited a total o 6 months a ter delayed primary closure be ore pro-
ceeding with the nal revision. By this time, all open areas were solidly healed, all
residual at necrosis had resolved, the scars were so t, and the tissues were supple.
Her right breast had become slightly rmer rom capsular contracture (Baker grade
II). She is shown shortly be ore her nal revision.
The patient requested restoration o the most normal-appearing nipples and are-
olae possible, improved breast shape and symmetry, and eradication o dog-ears on
both sides by whatever means was necessary. Her nal surgical procedure consisted
o a right open capsulotomy (reinsertion o same implant), liposuction o the lateral

Part III: Problems in Mastopexy and Augmentation-Mastopexy
388
breast mounds or improved contour, excision o dog-ears, and bilateral nipple-are-
olar reconstruction. We elected to use the residual pigmented skin on each side or
nipple reconstruction (with a modi ed skate f ap), and to create new areolae using
ull-thickness skin gra ts rom her upper inner thigh area. The surgical procedure
was unevent ul.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had a satis actory recovery. She is shown 4 months postoperatively,
which was almost exactly 1 year a ter the rst revision o her unsatis actory pri-
mary augmentation-mastopexy. Considering her signi cant complications, the nal
result is acceptable. The patient understands that her reconstructed nipples will not
be unctional or breast- eeding. They have no sensitivity and do not become erect
when stimulated.

Chapter 22 • Ischemia of the Nipple-Areola Complex

389
TEACHING PO INTS
It is o ten said that we learn more rom our ailures than rom our successes. This
may be a case in point. This patient presented with an unsatis actory outcome a -
ter a primary augmentation-mastopexy. She requested a revision, and the operative
plan called or implant removal and replacement, along with conversion o her ex-
isting circumareolar mastopexy to a vertical mastopexy. It was thought that the use
o a vertical mastopexy template would allow better control o the diameter o the
NAC, prevent unsightly spreading o the areola, and avert widening o the circum-
areolar scar. Vertical mastopexy is also an excellent technique or correcting mod-
erate degrees o ptosis, improving breast projection, and achieving relatively long-
lasting upper pole ullness.
Secondary mastopexy in previously augmented patients is always a risky proposi-
tion. These patients have prior skin incisions, and their breast tissue has been un-
dermined o o underlying structures. They have some degree o stretching, thin-
ning, and atrophy o the so t tissue envelope surrounding the implant. These actors
contribute to diminished circulation to the nipple and skin. A thorough under-
standing o the remaining blood supply to the nipple and potential skin f aps, care-
ul surgical planning, and cautious operative technique contribute to the likelihood
o a success ul outcome. In this particular case, because the distance that the nipple
was to be raised was short (approximately 4 cm) and the patient had a thick layer
o glandular tissue (more than 2 cm), a superiorly based pedicle was thought to be
a sa e way to transpose the NACs. Her native breast tissue was relatively abundant;
there ore the implants were converted rom the subpectoral plane to a new sub-
mammary pocket to achieve a better result with improved and longer-lasting cor-
rection o ptosis (and reduced risk o recurrent Snoopy dog de ormity). The series
o un oreseen complications that occurred postoperatively suggests that the surgical
planning was de cient. There may have been more damage to the superiorly based
nipple blood supply rom the rst operation than anticipated. It is also possible that
conversion o the implant rom the subpectoral pocket to a submammary plane ur-
ther compromised blood supply to the nipple (in particular, venous drainage).
Circulatory compromise to the nipple is a plastic surgery emergency. All reasonable
steps should be taken to try to reverse the process and salvage as much tissue as
possible. Typically (as in this case), the problem results rom compromised venous
drainage, resulting in a congested, poorly per used NAC. The remedial steps include
application o Nitro-Bid cream, corticosteroids, the use o leeches, removal o su-
tures (to reduce skin tension), explantation (to reduce compression o the pedicle),
and hyperbaric oxygen therapy. Prophylactic antibiotics should be given to protect
compromised tissues rom secondary in ection. The speci c modalities to employ
and when they should be initiated are clinical decisions tailored or each patient.
It is always best to avoid debridement o tissues, because questionable-appearing
tissue o ten will prove viable, and it is especially di cult to replace structures such
as the nipple and areola. It is pre erable to allow natural demarcation to occur be-
ore proceeding with surgical debridement (except in cases o in ection). Once all
Continued

Part III: Problems in Mastopexy and Augmentation-Mastopexy
390
necrotic tissue has separated, adequate time should be allowed or healthy granu-
lation tissue to orm. It is best at this point to proceed with the simplest possible
surgical closure. Complex reconstructive procedures should be delayed until the
wound is closed and skin coverage is stable. Once all open areas have healed, a
suitable period o time should be allowed to elapse (3 to 6 months) to ensure com-
plete eradication o residual bacterial contamination, enhancement o blood supply,
so tening o the skin and subcutaneous tissues, and maturation o the scars. At the
appropriate time, necessary reconstructive procedures can be per ormed. As dem-
onstrated in this case, even in dire situations it is usually possible to salvage an ac-
ceptable outcome.
Obviously, unanticipated complications lead to disappointed patients and o ten
cause signi cant stress to surgeons. It is critical to obtain thorough in ormed con-
sent be ore undertaking breast revision surgery. In augmented patients undergoing
secondary procedures, especially procedures involving mastopexy, capsulotomy,
or capsulectomy and implant exchange, the potential or compromised circulation
to the skin f aps and to the nipple and areola must be explicitly discussed. Patients
should be in ormed that in the event o an untoward outcome, additional corrective
procedures may be required to achieve the best result. Once a signi cant complica-
tion has occurred, patients need to be ully in ormed about what has transpired; the
proposed treatment plan should be outlined in detail. Patients who have complica-
tions should be seen at requent intervals and have ready access to their surgeon at
all times. It is critical to maintain a patient’s con dence and cooperation to achieve
the best outcome.
BIBLIO GRAPHY
Berthe JV, Massaut J, Greuse M, et al. The vertical mammaplasty: a reappraisal o the technique and
its complications. Plast Reconstr Surg 111:2192-2199, 2003.
Di Benedetto G, Sperti V, Pierangeli M, et al. A simple and reliable method o nipple reconstruction
using a spiral f ap made o residual scar tissue. Plast Reconstr Surg 114:158-161, 2004.
Hammond DC, Hidalgo D, Slavin S, et al. Revising the unsatis actory breast augmentation. Plast
Reconstr Surg 104:277-283, 1999.
Handel N. Secondary mastopexy in the augmented patient: a recipe or disaster. Plast Reconstr Surg
118(7 Suppl):S152-S163, 2006.
Kroll SS, Reece GP, Miller MJ, et al. Comparison o nipple projection with the modi ed double-
opposing tab and star f aps. Plast Reconstr Surg 99:1602-1605, 1997.
Little JW III. Nipple-areola reconstruction. Clin Plast Surg 11:351-364, 1984.
Nahabedian MY. Nipple reconstruction. Clin Plast Surg 34:131-137, 2007.
Shestak KC, Nguyen TD. The double opposing periareola f ap: a novel concept or nipple-areola re-
construction. Plast Reconstr Surg 119:473-480, 2007.
Spear S. Augmentation/mastopexy: “surgeon beware.” Plast Reconstr Surg 112:905-906, 2003.
Tebbetts JB. The greatest myths in breast augmentation. Plast Reconstr Surg 107:1895-1903, 2001.

22b Conservative Treatment of Nipple-Areolar Ischemia
Following Mastopexy
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 59-year-old woman had silicone implants inserted more than 25 years ago.
Over time, her breasts became larger and progressively more ptotic. At presenta-
tion she requested explantation. She was concerned about possible rupture o her
second-generation silicone implants and thought that her breasts were too large
and pendulous. She did not wish to have new implants inserted.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
At her initial presentation, the patient’s breasts were large, asymmetrical, and pen-
dulous. Her subglandular implants had been inserted through IMF incisions. The
le t breast was more ptotic than the right breast, and the le t nipple was approxi-
mately 1.5 cm lower than the right nipple. Palpation revealed modest capsular
contracture (Baker grade II) and con rmed the presence o substantial amounts o
breast tissue on both sides. She was a suitable candidate or explantation, capsulec-
tomy, and bilateral mastopexy.
391

Part III: Problems in Mastopexy and Augmentation-Mastopexy
392
TECHNIQ UE
Bilateral Wise skin pattern mastopexies were per ormed. The periprosthetic space
was approached through a radial incision in erior and lateral to the nipple. Both
implants were removed and noted to be grossly intact. However, signi cant gel
bleed had occurred on the le t side. Complete capsulectomies were per ormed bi-
laterally. The superior and in erior pedicles to the nipple were maintained on both
sides (no breast tissue was resected), and the skin f aps were widely undermined o
the underlying parenchyma to acilitate closure. The operation was unremarkable,
with no intraoperative complications.
The patient’s rst postoperative visit and dressing change was at 48 hours. She had
severe venous congestion o her right NAC.
ANALYSIS O F THE PRO BLEM
The patient presented with compromised venous drainage o her right NAC. The
le t NAC had ecchymoses, but circulation was not impaired. The mastopexy skin
f aps on both sides were completely viable. At the initial postoperative visit, the
breast was assessed or signs o f uid accumulation (hematoma or seroma) or exces-
sive tightness o the skin closure; neither was identi ed. She was in ormed that cir-
culation to her right nipple and areola was compromised and appropriate measures
would be initiated to salvage the threatened tissues to the greatest extent possible.
RECOMMENDED SOLUTION TO THE PROBLEM
Immediate removal o all periareolar sutures
Application o Nitro-Bid cream to the congested areolar skin three times daily
A course o oral corticosteroids
A course o oral antibiotics
Hyperbaric oxygen treatments
Possible application o medical leeches

Chapter 22 • Ischemia of the Nipple-Areola Complex

393
TECHNIQ UE
The running subcuticular and interrupted dermal sutures were removed to release
tension on the areola and promote venous drainage. Nitro-Bid paste was applied to
the entire areolar sur ace, and the patient was instructed to apply Nitro-Bid cream
three times daily. She was started on a short course o oral corticosteroids (Medrol
Dosepak) and was given Bactrim DS twice daily. She had hyperbaric oxygen treat-
ments daily or 5 days, beginning that day. The use o medical leeches was sug-
gested to the patient, but she declined this option.
The patient was ollowed requently. On postoperative day 4, improvement was
subtle. Her areolar skin was still congested, but appeared a little more pink. The
NAC was still cool to the touch. There was no sign o in ection. Treatment was
continued with hyperbaric oxygen, Nitro-Bid, oral antibiotics, and a tapering dose
o oral corticosteroids.
By her next visit on postoperative day 6, improved circulation o the right NAC
was evident. Her entire nipple appeared viable, and at least 80% o the areola
looked as i it would survive. Nitro-Bid applications were discontinued. The patient
continued to take antibiotics, and moist saline gauze dressing changes three times
daily were initiated.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
394
By 3 weeks postoperatively, her right NAC appeared very healthy. The mastopexy
incisions were healing well on both sides. The patient was returned shortly therea -
ter to surgery, and under local anesthesia the wound edges were debrided and de-
layed closure accomplished. A small open area at the 6 o’clock position on the le t
side was also closed.
Her wounds were completely healed by 6 months, although the right NAC was
mildly distorted. The patient complained o rm, tender nodules within the breast
parenchyma. These were thought to be secondary to at necrosis. These areas were
injected with small doses (2 to 5 mg) o Kenalog at bimonthly intervals, and her
symptoms gradually subsided. She was o ered urther revision but declined addi-
tional surgical intervention.

Chapter 22 • Ischemia of the Nipple-Areola Complex

395
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 21⁄2 years a ter
explantation and mastopexy. Her
overall result is acceptable. The ap-
pearance o her breasts could have
been enhanced by urther revision
consisting o bilateral periareo-
lar mastopexies to improve areolar
symmetry and centralize the nipple
within the areolar complex.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
396
TEACHING PO INTS
Circulatory compromise o the nipple and/or skin f aps is always a risk o masto-
pexy or breast reduction surgery and is even more o a threat in patients who have
had breast implants placed previously. The reason patients with implants are at
higher risk or ischemic complications is because insertion o the prosthesis divides
many o the per orating vessels that supply the overlying tissues. In addition, the
long-term presence o implants causes gradual atrophy and thinning o tissues.
When mastopexy f aps and nipple pedicles are dissected within these thinned, atro-
phic tissues, blood supply to the skin and nipple is urther compromised.
When circulation to the nipple is threatened, it is usually caused by venous conges-
tion. As soon as diminished circulation is observed, steps should be taken to re-
store per usion. Removal o skin sutures may reduce skin tension and promote ve-
nous drainage. Oral or parenteral steroids can reduce edema. Hyperbaric oxygen
treatments may promote healing by reducing ree radicals in the zone o ischemia.
Leeches can prove use ul in salvaging congested tissues. The key principle in treat-
ing patients with nipple-areolar ischemia (whether o arterial or venous cause) is to
give the tissues time to heal. The nipple and areola are very resilient and o ten, as
in this case, will prove salvageable i given adequate time to recover. Antibiotics are
important to prevent secondary in ection o the compromised tissues. Surgical de-
bridement o any o the NAC should be avoided until it is evident that irreversible
changes are present (dry gangrene).
Undermining can
disrupt blood
supply to NAC

Chapter 22 • Ischemia of the Nipple-Areola Complex

397
BIBLIO GRAPHY
Calderon W, Eulu A, Borel C, et al. Total nipple-areola complex necrosis in in erior pedicle breast re-
duction. Plast Reconstr Surg 118:292-293, 2006.
Daane S, Zamora S, Rockwell WB. Clinical use o leeches in reconstructive surgery. Am J Orthop
(Belle Mead NJ) 26:528-532, 1997.
Friedman HI, Fitzmaurice M, Le aivre JF, et al. An evidence-based appraisal o the use o hyperbaric
oxygen on f aps and gra ts. Plast Reconstr Surg 117(7 Suppl):S175-S190, 2006.
Handel N. Secondary mastopexy in the augmented patient: a recipe or disaster. Plast Reconstr Surg
118(7 Suppl):S152-S163, 2006.
Thom SR. Hyperbaric oxygen: its mechanisms and e cacy. Plast Reconstr Surg 127 Suppl 1:S131-
S141, 2011.
Woods JE, Meland NB. Conservative management in ull-thickness nipple-areolar necrosis a ter sub-
cutaneous mastectomy. Plast Reconstr Surg 84:258-264, 1989.
Wray RC, Luce EA. Treatment o impending nipple necrosis ollowing reduction mammaplasty. Plast
Reconstr Surg 68:242-244, 1981.

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23a Deformity Following Failed Augmentation-
Mastopexy Corrected With Local Flaps Using a
Vertical Mastopexy
Nea l Ha n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 33-year-old woman was re erred by her plastic surgeon or evaluation and
possible treatment o breast de ormity and asymmetry. Approximately 1 year ear-
lier, she underwent bilateral submuscular augmentation with saline implants in con-
junction with circumareolar mastopexy. Intraoperatively, there was an inadvertent
cautery burn, resulting in a through-and-through buttonhole injury o the in erior
pole o the right breast. The surgeon excised the buttonhole and closed the resulting
de ect in layers; implants were inserted bilaterally.
c H a Pt e r 2 3
COMPROMISED SKIN FLAPS
399

Part III: Problems in Mastopexy and Augmentation-Mastopexy
400
Several weeks a ter the surgery, the patient developed an in ection o the right
breast, necessitating explantation. The area healed, and 3 months later, a new sa-
line implant was inserted. The breast healed, but the patient was dissatis ed with
her result. On the right side, she had a large notch or cle t o the in erior pole o the
breast as well as excessive rmness and spherical de ormity. Her le t breast had an
unaesthetic, f at appearance.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is seen at the time o re erral, approximately 6 months a ter her previ-
ous procedure involving reinsertion o the right saline implant. Examination reveals
the presence o saline implants bilaterally, with Baker grade III contracture on the
right side; as a result o contracture, the right breast has a spherical con guration
and excessive upper pole projection. The right breast is truncated compared with
the le t breast, and there is a large cle t o the central in erior pole. The Benelli mas-
topexy scars are well healed. On the le t side, the patient has a slightly contracted
Baker grade II capsule, and the mastopexy scars have healed well. The le t breast
lacks projection and has an unaesthetic, f at pancake-like pro le.
ANALYSIS O F THE PRO BLEM
The patient had breast asymmetry, breast de ormity, and capsular contracture. As a
result o surgical resection o tissue, in ection, and scarring, there was a signi cant
de ciency o so t tissue o the central lower pole o the right breast. The patient
also had Baker grade III capsular contracture on the right side, causing a rm, dis-
torted breast. On the le t side, the patient eels that despite her upli t, her breast still
“sags” and has an unattractive, f attened appearance.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the subpectoral saline implants
Capsulectomy
Insertion o silicone gel implants in submammary pockets
Bilateral vertical mastopexy

Chapter 23 • Compromised Skin Flaps

401
TECHNIQ UE
Measurements and skin markings or the bilateral vertical mastopexy were made
on both breasts. Surgery was started on the le t side, where the appropriate areas
were deepithelialized. A ull-thickness segment o the in erior pole o the breast was
resected. The saline implant was removed, and a virgin submammary pocket was
created by dissecting the pectoral muscle away rom the overlying breast paren-
chyma. The pectoral muscle was brought into approximation with the chest wall
and sutured into anatomic position. A new silicone gel implant was inserted into
the submammary pocket, and the medial and lateral pillars were approximated in
the midline; the skin was temporarily aligned with skin staples.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
402
Attention was then directed to the right side, where similar steps were per ormed.
The segment o skin and breast tissue resected was considerably thinner on the
right side than on the le t. The implant, surrounded by a thickened and contracted
capsule, was easily accessed and removed en bloc.

Chapter 23 • Compromised Skin Flaps

403
Once again, a new submammary pocket was created by dissecting the pectoral
muscle o the overlying parenchyma; the muscle was securely sutured to the ad-
jacent chest wall. A new silicone gel implant was inserted into the submammary
pocket, and the medial and lateral pillars were sutured together in layers. The skin
f aps were approximated with skin staples, a ter which the redundant “dog-ear”
skin was marked and excised.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
404
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 2 years a ter the cor-
rective surgery. She is pleased with the re-
sult. The cle t o the lower pole o the right
breast has been completely eradicated, the
capsular contracture has been corrected,
and the breasts have a more attractive con-
tour, with greatly improved projection and
better overall symmetry.

Chapter 23 • Compromised Skin Flaps

405
TEACHING PO INTS
This patient developed complications a ter an augmentation-mastopexy, which led
to a signi cant so t tissue de ciency o the lower pole o her right breast. She also
developed symptomatic capsular contracture o the right breast, and she was dissat-
is ed with the shape and projection o her le t breast. This constellation o ndings
was ideally suited to surgical revision incorporating a mastopexy. When patients
have insu cient tissues o the lower pole o the breast— rom in ection, surgical
misadventure, atrophy, or repeated capsulectomy—it is o ten possible to recruit
healthy, well-vascularized so t tissues rom adjacent areas. In such cases, mastopexy
f aps are used as advancement or rotation f aps to ll the de ect. In this case, either
a conventional Wise pattern or vertical mastopexy could have been used. Vertical
mastopexy was selected, because advancement o the ull-thickness parenchymal
pillars rom the lower outer and lower inner quadrants provides ample tissue to ll
the midline cle t. At the same time, it was decided to convert the implant type rom
saline to silicone and to reposition them rom subpectoral to submammary. The
implants were placed in the submammary plane or two reasons: submammary or
dual plane positioning may con er improved shape in patients with breast ptosis,
and has the advantage o enabling placement o the new implants into virgin pock-
ets. The use o the submammary position, along with aggressive capsulectomy and
the use o new sterile prostheses, is consistent with the tenets o the bacterial bio-
lm hypothesis o capsular contracture.
The use o a vertical mastopexy in this instance resulted in a very nice improvement
in breast contour. Vertical mastopexy increases nipple projection by reversing the
f attening caused by the prior Benelli mastopexy, and it yields more lasting upper
pole ullness. Other options that might have been considered in this case include
autologous at gra ting or a superiorly based rectus muscle turnover f ap. These
methods might have provided the needed so t tissue to ll the cle t, but neither
method would have corrected the breast ptosis or the f attening and lack o upper
pole ullness, all o which were success ully addressed by vertical mastopexy.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
406
BIBLIO GRAPHY
Adams WP Jr. Capsular contracture: what is it? What causes it? How can it be prevented and man-
aged? Clin Plast Surg 36:119-126, 2009.
Dickinson BP, Handel N. Approaching revisional surgery in augmentation and mastopexy/augmenta-
tion patients. Ann Plast Surg 68:12-16, 2012.
Rieger UM, Mesina J, Kalbermatten DF, et al. Bacterial bio lms and capsular contracture in patients
with breast implants. Br J Surg 100:768-774, 2013.
Spear SL, Boehmler JH IV, Clemens MW. Augmentation/mastopexy: a 3-year review o a single sur-
geon’s practice. Plast Reconstr Surg 118(7 Suppl):136S-147S, 2006.
Spear SL, Low M, Ducic I. Revision augmentation mastopexy: indications, operations, and outcomes.
Ann Plast Surg 51:540-546, 2003.
Spear SL, Pelletiere CV, Menon N. One-stage augmentation combined with mastopexy: aesthetic re-
sults and patient satis action. Aesthetic Plast Surg 28:259-267, 2004.
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.
Tamboto H, Vickery K, Deva AK. Subclinical (bio lm) in ection causes capsular contracture in a por-
cine model ollowing augmentation mammaplasty. Plast Reconstr Surg 126:835-842, 2010.

SEC T IO N T WO
Unsatisfactory Aesthetic Outcomes
Chapter 24 Nipple Malposition
24a Correction o Nipple Malposition in a Patient With Previously Augmented Breasts
Chapter 25 Unsatisfactory Scarring
25a Secondary Mastopexy, Unilateral Reduction Mammaplasty, and Implant Replacement
Chapter 26 Spreading of the Areolae
26a Conversion o Circumareolar Mastopexy to Vertical Mastopexy
26b Interlocking Gore-Tex Permanent Purse-String Suture Technique
26c Secondary Mastopexy
Chapter 27 Recurrent Ptosis
27a Total Submuscular Capsulectomies and Replacement With Shaped Implants
27b Conversion to Partial Subpectoral Pocket and Bilateral Vertical Mastopexy
Chapter 28 Flattening or Loss of Upper Pole Fullness
28a Fat Gra ting to Correct Flattening or Loss o Upper Pole Fullness
28b Loss o Upper Pole Fullness A ter Mastopexy
Chapter 29 Inferior Stretch Deformity and Bottoming Out
29a Correction o Bottoming Out With Unilateral Fold Elevation and Contralateral Periareolar Mas-
topexy
29b Correction o In erior Stretch De ormity With Mastopexy and Implant Site Change
Chapter 30 Revision in Bariatric Patients of Unsuccessful Outcome After
Mastopexy or Augmentation-Mastopexy
30a Secondary Mastopexy With Lower Pole Reshaping
407

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24a Correction of Nipple Malposition in a Patient With
Previously Augmented Breasts
Nea l Ha n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 61-year-old woman initially had bilateral breast augmentation in her early
30s. Over the years, she underwent several revisions or size change and or cor-
rection o capsular contracture. At the time o presentation, she had subpectoral
225 cc Moderate Plus pro le Siltex gel- lled implants (Mentor, Santa Barbara, CA).
She was dissatis ed with the cosmetic appearance o her breasts and the position
o her nipples, and thought her breasts were too rm.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient was a middle-aged woman with bilateral breast implants. Both breasts
had a very unnatural and unaesthetic appearance. They were rm and spherically
de ormed (Baker grade III contracture), and the cleavage was ar too wide. Both
breasts had excessive upper pole ullness and an unattractive, convex silhouette,
with a mild double-bubble de ormity on the right side. The NACs were laterally
displaced. The right nipple was actually positioned lateral to the anterior axillary
line. The patient had well-healed, slightly depressed in erior periareolar scars.
409
409
C H a PT Er 24
NIPPLE MALPOSITION

Part III: Problems in Mastopexy and Augmentation-Mastopexy
410
ANALYSIS O F THE PRO BLEM
This patient presented with bilateral capsular contracture, implant malposition,
lateral nipple malposition, and a unilateral double-bubble. Each o her anatomic
problems required a speci c solution, and her treatment plan was developed to co-
ordinate all interventions or a harmonious result. O tentimes, lateral displacement
o the NAC is more apparent than real and is a consequence o medial malposition
o the implant. However, in this case the implants were displaced very ar laterally,
as evidenced by the patient’s very wide cleavage; her extreme lateral nipple position
was there ore a true anatomic anomaly. Movement o the implants closer to the
midline would exacerbate the lateralized nipple position. The nipple and areolae
actually needed to be repositioned with respect to the breast meridian. At the same
time, capsular contracture and unilateral double-bubble required correction and
creation o more attractive cleavage was needed.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the implants ollowed by an aggressive capsulectomy
Enlargement o the pockets medially to improve cleavage
Use o eccentrically designed circumareolar mastopexies to reposition the nip-
ples and areolae closer to the breast meridian
Radial scoring o the in erior breast f ap to correct the right-sided double-bubble
Insertion o a new pair o wider base diameter silicone gel implants
TECHNIQ UE
With the patient in the standing position, her breasts were inspected and measured,
and her skin was marked. The new nipple location was marked 21 cm rom the
sternal notch, and the breast meridian was marked on each side to relocate the nip-
ples 11.5 cm rom the midline. The goal was to create a roughly equilateral triangle
ormed by lines marking the internipple distance and the sternal notch-to-nipple
distance. Both nipples were moved superiorly and medially, with the right nipple
moved considerably arther medially than the le t nipple.

Chapter 24 • Nipple Malposition

411
The patient was placed in a supine position in the operating room. A 2 cm side
strip was outlined centered on the sternum, designating the desired medial borders
o the new pockets. Two eccentric circles were inscribed around the nipple, indi-
cating the skin incisions or the asymmetrical periareolar mastopexies. The area
between the circles was deepithelialized, with care taken to preserve the thickest
possible layer o dermis. A circle was marked 1 cm within the border o the larger
outer circle, representing a cu o dermis to preserve or placement o the periareo-
lar purse-sting suture. The dermis was incised with cautery. The breast skin superi-
orly and medially was undermined in the subdermal plane to acilitate reposition-
ing o the NAC upward and medially. The breast parenchyma was divided in erior
to the NAC to access the implant; this preserved blood supply to the NAC through
the superior pedicle.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
412
The wound was deepened to the level o the anterior capsule around the prosthe-
sis. The breast parenchyma was dissected o the capsule with the implant in place;
leaving the implant in situ acilitated this dissection. The anterior capsule was in-
cised and the silicone implant removed. A total capsulectomy was per ormed. A
sizer was inserted and the skin incision temporarily approximated with staples to
simulate a periareolar mastopexy.
Comparison o the breasts demonstrated that the le t nipple had been satis actorily
repositioned relative to the breast mound.

Chapter 24 • Nipple Malposition

413
A new, wider-based (Moderate Pro le 225 cc) Siltex implant was inserted into the
subglandular pocket, and the deep layer was closed. Markings were made or place-
ment o a periareolar pinwheel purse-string suture. Suture (0 Prolene) was placed
and tightened to reduce the areola to the desired diameter (3.5 cm). The knot was
tied and buried and the nal skin closure completed. Similar steps were carried out
on the right side, with the addition o radial scoring o the in erior breast f ap to re-
lease the double-bubble.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 18 months a ter corrective surgery. Capsular contracture is al-
leviated and cleavage signi cantly narrowed.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
414
Her nipples are more superior and medial on both sides, and the double-bubble is
eliminated.
TEACHING PO INTS
This patient presented with a constellation o abnormalities, including capsular
contracture, implant malposition, a unilateral double-bubble, and nipple-areolar
malposition. The strategies selected to correct these de ormities were chosen to
work in harmony with one another to achieve the best overall result. Total cap-
sulectomy reduces the chance o recurrent contracture; medial enlargement o the
pocket in conjunction with selection o a wider base diameter implant helps to re-
store attractive cleavage. In this case, lateral malposition o the patient’s nipples
was not simply the result o medial implant malposition, but rather it was caused
by a true anatomic displacement o her nipples o the breast midline. Asymmetri-
cal, eccentric periareolar mastopexies were used to reposition the nipples both su-
periorly and medially with respect to the breast meridian. This was done at the
same time that new implants were placed closer together (which by itsel would
have exacerbated lateral nipple malposition). The double-bubble de ormity on the
right side was released by radial scoring o the in erior breast f ap. Although the pa-
tient’s nal result is imper ect, it is a signi cant improvement over her preoperative
appearance.
BIBLIO GRAPHY
Colwell AS, May JW Jr, Slavin SA. Lowering the postoperative high-riding nipple. Plast Reconstr Surg
120:596-599, 2007.
Frenkiel BA, Paci co MD, Ritz M, et al. A solution to the high-riding nipple-areola complex. Aesthetic
Plast Surg 34:525-527, 2010.
Ra el B. Technique or correction o areola misplacement with no new scars. Plast Reconstr Surg
88:895-897, 1991.
Spear SL, Ho man S. Relocation o the displaced nipple-areola by reciprocal skin gra ts. Plast Recon-
str Surg 101:1355-1358, 1998.
Spear SL, Albino FP, Al-Attar A. Classi cation and management o the post-operative, high-riding
nipple. Plast Reconstr Surg 131:1413-1421, 2013.

C h a p t e r 2 5
UNSATISFACTORY SCARRING
25a Secondary Mastopexy, Unilateral Reduction
Mammaplasty, and Implant Replacement
Nea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 34-year-old woman lost 120 pounds a ter undergoing success ul bariatric
surgery. This resulted in severely ptotic, de ated breasts. There ore the patient un-
derwent simultaneous augmentation with subpectoral saline implants and Benelli
circumareolar mastopexy approximately 1 year a ter her bariatric surgery. Shortly
a ter surgery, she developed wound-healing problems, including in ection and
wound dehiscence. The patient was treated conservatively, with oral antibiotics and
dressing changes, and her circumareolar wounds slowly closed by secondary inten-
tion. Approximately 6 months a ter all areas healed, she was told that additional
surgery to improve breast shape and reduce residual scarring should be considered.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a tall, mildly obese, pale-skinned woman. She had undergone bilat-
eral subpectoral breast augmentation and circumareolar mastopexy. Both breasts
are so t (Baker grade I). The breasts are signif cantly asymmetrical, with the right
side considerably larger than the le t. The breasts are ptotic and have an unaes-
thetic, boxy shape. The areolae have a stellate appearance and are stretched out.
415

Part III: Problems in Mastopexy and Augmentation-Mastopexy
416
The circumareolar scars are irregular and extremely wide, especially around the
superior and medial borders o the areolae; the scars measure up to 5 cm wide in
some areas.
ANALYSIS O F THE PRO BLEM
This patient presented with a poor aesthetic result a ter she underwent augmenta-
tion mastopexy. Her chie problems were breast asymmetry, persistent ptosis, and
excessively wide scars. The most logical approach to improving her breast symme-
try was to urther reduce the volume o her right breast. The patient liked “large
breasts” but was persuaded that a better shape and more reliable long-term im-
provement o the scars could be achieved by reducing the size o her right breast.
Although another attempt at circumareolar mastopexy could be considered, it
would be unlikely to provide signif cant long-lasting improvement in either breast
shape or scarring. Improved upper pole ullness and a more conical shape could
best be achieved with either a vertical or Wise pattern mastopexy. Either o these
techniques is the most reliable way to permanently reduce the diameter o the are-
olae and to minimize tension on the circumareolar closure, thus reducing the risk o
recurrent spreading o the areolae and widening o the circumareolar scar.
Because it was desirable to resect as much scarred skin as possible in this patient,
the Wise pattern was selected. She was advised that it would be impossible to com-
pletely excise all o the widened scars, because they extended quite high on the
breast and very ar medially. It was not possible to obtain the patient’s previous op-
erative report, and she did not know the exact size o her saline implants. However,
preoperatively we thought that acceptable symmetry could be achieved solely by
removing tissue rom the right breast with both saline implants remaining in situ.
RECOMMENDED SOLUTION TO THE PROBLEM
Wise pattern mastopexy o the le t breast
Wise pattern reduction mammaplasty o the right breast
Leaving both subpectoral saline implants in situ
Insertion o a new, smaller saline implant on the right side, because it was deter-
mined intraoperatively that parenchymal resection alone could not achieve ad-
equate reduction o the right breast to achieve symmetry

Chapter 25 • Unsatisfactory Scarring

417
TECHNIQ UE
The patient’s breasts were marked in the standing position. The new nipple location
was tentatively located on the midaxis o the breast 26 cm rom the sternal notch.
The f nal desired diameter o the areolae was 4 cm each. We thought that the ver-
tical limb o the inverted-T scar should be at least 8 cm in length to accommodate
the large proportions o this patient’s breasts; there ore aps measuring 10 cm in
length—a 2 cm radius o each areola plus vertical scars 8 cm long—were marked.
The markings were lightly scratched into the skin a ter anesthesia was induced.
Surgery was per ormed f rst on the le t side, with the goal o f nishing breast mound
reconf guration on the smaller side, then on the right breast, which would then be
reduced and li ted to match both the size and level o the le t side. Immediately
be ore making the skin incisions, the mastopexy aps were approximated by tailor-
tacking with a skin stapler. Based on the amount o tension, we decided to remark
the skin excision more conservatively by adding 1 cm in width and 1 cm in length
to the medial and lateral mastopexy skin aps. Skin incisions were then made along
the new, more conservative markings. A broad in erior pedicle was deepithelialized.
The skin aps were widely undermined to allow adequate mobilization. The aps
were then approximated with skin staples to simulate the closure and attention di-
rected to the right side.

Part III: Problems in Mastopexy and Augmentation-Mastopexy
418
The skin aps on the right breast were remarked to match the incisions made on
the le t. A wide in erior pedicle was deepithelialized and the mastopexy skin aps
were widely undermined in the superf cial subcutaneous plane. Breast parenchyma
was then resected rom the lower outer quadrant o the breast, maintaining a
broad-based in erior pedicle. The resection o breast tissue was carried down to the
level o the muscle and ascia covering the subpectoral saline implant. The wound
edges were temporarily approximated with key sutures and staples, and the patient
was placed in the sitting position. It was evident that the right breast was still much
larger than the le t breast. The wounds were reopened and additional tissue was
resected rom the lower inner quadrant o the right breast. Once again the wound
edges were temporarily closed with sutures and staples, and the patient was placed
in the sitting position. The right breast was still much larger than the le t breast.

Chapter 25 • Unsatisfactory Scarring

419
Because it was eared that urther resection o parenchyma rom the right breast
could compromise circulation to the nipple, we decided to remove and replace the
right breast implant. A capsulotomy incision was made lateral to the pedicle and an
intact saline implant was removed and weighed to determine its volume, which was
550 cc. An in atable sizer was inserted into the subpectoral pocket and the incision
stapled. With the patient in the sitting position, the sizer was gradually in ated un-
til the desired degree o symmetry was achieved. A moderate prof le in atable im-
plant was f lled with 375 cc o saline and inserted into the pocket. The aps were
then approximated and closed, and the desired symmetry was achieved. On both
sides circular skin excisions were completed to allow the NAC to sit in its new loca-

Part III: Problems in Mastopexy and Augmentation-Mastopexy
420
tion, and the incisions were closed in layers. The right breast is shown immediately
a ter completion o the procedure.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had an unevent ul postoperative course; all surgical incisions healed
primarily. Her result is shown 4 months a ter surgery. The patient has greatly im-
proved breast symmetry, although the right breast may still be marginally larger
than the le t. Breast shape has been considerably improved, with correction o pto-