Chẩn Đoán Và Điều Trị Phẫu Thuật Tái Tạo Hiện Đại (CURRENT Reconstructive Surgery)

ADVANCES IN MASTOPEXY • 533
A single-stage procedure may seem attractive to both
surgeon and patient, but its successful execution is con-
tingent upon careful preoperative planning and attentive
implementation to reduce the severity and frequency of
complications. If the primary goal is to correct signifi -
cant asymmetries, particularly if this involves a signifi cant
reduction or a reduction/mastopexy procedure on one
side, the safest plan may be to perform the mastopexies
fi rst followed by breast augmentation at a second stage.
Attempting to account for too many variables in one set-
ting may lead to unpredictable and disappointing results.
Our approach to augmentation mastopexy is focused
around several principles: placing the implants fi rst and
then tailoring the skin envelope to accommodate the larger
breast volume, addressing breast asymmetries by employ-
ing different mastopexy patterns when appropriate, tailor-
tacking the skin with the patient in the upright position
in the operating room prior to committing to the planned
mastopexy pattern, and conservative superfi cial undermin-
ing of the skin to preserve perfusion to the nipple-areola
complex and to reduce wound healing complications.
Patient Preparation
When evaluating a patient for augmentation/mastopexy,
several key factors should be taken into account. An
implant alone may be suffi cient to address some mild
forms of ptosis. However, the more the skin and glandular
tissue overhangs the inframammary fold, the less likely an
implant will be able to completely fi ll out the breast in
a cosmetically acceptable fashion unless skin is excised. 15
Similarly, the lower the nipple, the less likely a prosthesis
will raise the nipple adequately onto the surface of the
breast. In these cases, the circumareola or vertical tech-
nique are most helpful for addressing a greater degree of
ptosis. 16
After evaluating the degree of breast and nipple
ptosis and forming an operative plan, measurements
for the implant are made. The base width of the breast
is measured as well as the superior pole pinch thick-
ness. The difference between these values is used as a
guide to determine the upper limit for the diameter of
the implant. Using the implant diameter measurement,
the height of anticipated breast is marked from the
inframammary fold. Markings are made to visualize the
implant position on the chest wall and predict appropri-
ate nipple placement.
Unlike breast reduction procedures, the nipple-areola
complex is invariably marked to lie somewhere above the
inframammary fold in augmentation/mastopexy. While the
most serious error is to place the nipple too high, the most
common error is inadequate elevation of the nipple. It is
important to note the presence of tan lines. Citing the
upper border of the areola needs to take these borders into
consideration. It is also useful to have the patient wear a
bra and mark the upper boundaries of the breast that the
bra covers. These maneuvers can serve as important guides
to avoid placing the nipple too high. As a general principle,
the fi nal extent and pattern of the excision should not
be committed to until the implants are placed. The skin
envelope and nipple position are then tailor-tacked with
the patient sitting upright and then adjusted to the dimen-
sions of the newly augmented breast. Only then is the fi nal
nipple position determined.
The decision-making process in selecting the appro-
priately sized implant is more complex in one-stage aug-
mentation mastopexy than staged augmentation after
mastopexy alone. Because the skin envelope will be
reduced, it is important to measure not only the base
width of the breast in its native state, but also the base
width while tailor-tacking the skin to simulate the breast
dimensions after mastopexy. This will effectively narrow
the base width and provides a closer approximation of
what the outer limits of the implant diameter should be.
For example, if the breast is 14 cm wide with a 2 cm pinch
thickness and has a base width of 13 cm when simulating
the mastopexy, then an implant diameter of 11 cm might
be more appropriate than one with a diameter of 12 cm. In
terms of implant projection, for defl ated breasts, we prefer
the higher profi le models to fi ll out the loose skin enve-
lope. Once these parameters are defi ned, a discussion with
the patient regarding her ideal breast size refi nes the fi nal
choice of implant.
Augmentation/Mastopexy Technique
A concentric mastopexy for augmentation/mastopexy
works well for a patient where the nipple lies near or just
below the inframammary fold with the inferior border of
the areola no lower than the inferior curve of the breast
on frontal view, and where there is less than 4 cm of breast
overhanging the inframammary fold, leaving an initial
nipple to inframammary fold distance of no more than
9 cm ( Figures 45-9 and 45-10 ). In planning a circumare-
ola mastopexy, as a guideline, the ratio of the outer to the
inner diameter of the circumareola markings should ide-
ally be no greater than 2:1 and certainly no greater than
3:1. A periareola augmentation/mastopexy must take into
account the implant’s tendency to dilate the areola while
fi lling out the native breast skin and increasing breast vol-
ume. The ideal scenarios for periareola mastopexy and
augmentation are (1) the areola being too large preop-
eratively, (2) the nipple and/or breast being too ptotic for
correction with an implant alone, and (3) the breast(s)
being tuberous. 17
The short scar technique is appropriate for the
majority of patients with a moderate amount of ptosis
( Figure 45-11 ). 18 – 21 In patients where it is unclear whether
any mastopexy procedure will be necessary, the proce-
dure begins with a periareola incision for placement of
the implant without any de-epithelialization. 22 The inci-
sion is usually made along the inferior border of the are-
ola and dissection is carried down to the pectoralis major
muscle. If the ptosis is severe and the surgeon is confi -
dent that a vertical technique is required, then the safest

534 • CHAPTER 45
way to enter the breast is in a vertical manner within the
planned area of de-epithelialization. Theoretically, this
dissection would be parallel to the neurovascular supply
to the nipple. However, if there is any question regard-
ing the need for a vertical excision, then a periareola
approach is used.
At our institution, we prefer a dual-plane approach
when placing the implant partially retropectorally. 23 The
inferior third of the pocket is dissected in the subglandu-
lar plane while the upper two thirds or so of the pocket
lies in the subpectoral plane. Meticulous hemostasis and
irrigation with a triple-antibiotic solution are routinely
performed to minimize the risk of capsular contracture or
infection. 24 After completing the dissection, the implant
is soaked in antibiotic solution, the fi eld is re-prepped
with a Betadine paint stick, and gloves are changed prior
to implant placement. After the insertion of the implant,
the incision is stapled closed and the patient is positioned
sitting fully upright.
The design is tailor-tacked with the patient sit-
ting upright once the implant is in place. Only then is
de-epithelialization performed as necessary. The strategy
should be to avoid making unnecessary scars on the breast
in borderline cases. 25 , 26 Minimal undermining in the sub-
cutaneous plane is performed to re-drape the skin. Care
is taken not to dissect deep and violate the breast paren-
chyma in order to preserve blood supply to the nipple.
Usually only 1 to 2 cm of undermining is required. The
amount of excess skin that can safely be removed is now
more accurately determined. These areas are de-epithe-
lialized and then minimal subcutaneous undermining is
performed around the areola after incising the dermis
leaving a 5 to 7 mm dermal cuff. The vertical closure is
usually 6 to 8 cm in length, depending on the implant
and fi nal total breast size. Greater vertical lengths are
addressed with small transverse triangular excisions based
at the inframammary fold. Sometimes, a small amount
of excision of breast tissue is required both in the verti-
cal and transverse components of the design. Note that
these maneuvers should be conservative as they increase
the risk of implant exposure and vascular compromise.
All incisions are then closed using buried interrupted
FIGURE 45-9. (Left) Preoperative view of a 37-year-old woman with second-
degree ptosis and breast asymmetry. (Right) Postoperative view, 14 months after
undergoing bilateral augmentation with 265-cc silicone implants and bilateral concentric
mastopexies.

ADVANCES IN MASTOPEXY • 535
FIGURE 45-10. (A,B) Preoperative view of a 37-year-old woman with second-
degree ptosis and breast asymmetry. (C) Preoperative markings. (D–F) Postoperative
view, 9 months after undergoing bilateral augmentation with 240-cc silicone implants and
bilateral concentric mastopexies.
A
B
C
D
E
F

536 • CHAPTER 45
and running Monocryl suture. The nipple position is
then reassessed and remeasured and may be fi ne-tuned as
required. Finally, the skin is closed with interrupted and
running buried Monocryl suture. All patients are placed
in a soft bra and followed closely in the fi rst few days to
monitor the nipple and fl aps.
COMPLICATIONS
Regardless of the pattern used, each can be associated with
potential complications. Inappropriate use of the concen-
tric excision can lead to poor scarring, areola distortion,
and fl attening of the breast may occur. Lejour found that
FIGURE 45-11. (A, B) Preoperative view of a 49-year-old woman with third-degree
ptosis and breast asymmetry. Patient had previously received a left 180-cc saline implant
25 years earlier from breast asymmetry. (C) Preoperative markings. (D–F) Postoperative
view, 3.5 years after undergoing bilateral augmentation with a left 286-cc and right
234-cc silicone implants and bilateral vertical mastopexies.
A
B
C
D
E
F

ADVANCES IN MASTOPEXY • 537
FIGURE 45-12. Examples of poor mastopexy outcomes:
(A) over-elevation of the nipple; and (B) unacceptable scarring.
A
B
FIGURE 45-13. (A,B) Examples of nipple loss after
mastopexy or augmentation/mastopexy.
A
B
in her experience of 152 consecutive circumvertical mas-
topexy patients, complications included four seromas, six
hematomas, and one infection. 27
A malpositioned nipple-areola complex is usually the
result of unsuccessful preoperative planning and/or com-
mitting to the planned excision without intraoperative
tailor-tacking. These maneuvers are critical because it is
not always possible to accurately predict the new dimen-
sions of the breast once the implant is placed. Most com-
monly, the nipple is inadequately raised, which can be
addressed with a simple revision. However, a nipple-are-
ola that is too high is a more diffi cult problem because
surgical correction is diffi cult and may leave the patient
with a visible scar in the superior pole of the breast—a
scar that may be visible in a swimsuit or low-cut dress
( Figure 45-12 ). More dreaded than the malpositioned
nipple is frank nipple necrosis ( Figure 45-13 ). In patients
who have previously undergone breast reduction, the
risks may be signifi cant. In secondary cases, when in
doubt, the mastopexy may be performed using de-
epithelialization only, without undermining the skin. If
re-draping is necessary, undermining should always be
performed conservatively (1–2 cm) in a superfi cial sub-
cutaneous plane.
Specifi cally, with regard to the augmentation/mas-
topexy patient, these procedures have a higher rate of
complication. A review from 1993 to 2001 yielded 34
consecutive revision augmentation/mastopexies with the
most common problems being recurrent ptosis (55%),

538 • CHAPTER 45
FIGURE 45-14. (A,B) Preoperative view of a 42-year-old woman who presented
11 years after breast augmentation with subglandular saline implants complaining of
droopiness and upper pole emptiness. She has 36C cup breasts and second-degree
ptosis with asymmetry. (C) Preoperative markings for a circumvertical mastopexy
with augmentation. (D) Intraoperative view of initial de-epithelialization of design.
(E) Placement of strattice as an interpositional graft by parachuting. (F) Strattice
in place with no ripples.
A
B
C
D
E
F

ADVANCES IN MASTOPEXY • 539
G
FIGURE 45-14. (continued ) (G–I) Postoperative view,
13 months after undergoing bilateral augmentation/mastopexy
with 457-cc silicone implants placed subpectorally with
bilateral vertical mastopexies.
I
H
capsular contracture (55%), implant malposition (35%),
size change (30%), poor scars (25%), and nipple malposi-
tion (10%), and an average interval to revision of 7 years.
If these complications occur, revision surgery can often be
very challenging and may require incorporating acellular
dermal matrix into revisionary augmentation/mastopexy
for capsular contracture, rippling, implant malposition,
and reinforcing thinned breast tissues from large breast
implants ( Figure 45-14 ). The benefi ts of acellular dermal
matrix include improved control and support of implant
position, and better implant coverage. In cases of diffi -
cult and recurrent capsular contracture, acellular dermal
matrix may be inset as a large interpositional graft.
CONCLUSION
Mastopexy can be a safe and gratifying procedure for
both patient and surgeon when performed with thought-
ful planning and careful execution. Patients should be
well-informed preoperatively that breast asymmetries
may be improved upon but is rarely completely corrected.
A symmetric approach is preferred for mild asymmetries
while different excision patterns may be required for sig-
nifi cant asymmetries. Nipple-areola malposition may be
avoided by careful intraoperative tailor tacking. Safe and
successful surgeries can be reliably achieved for both mas-
topexy and augmentation/mastopexy with adherence to
these principles.
REFERENCES
1. Regnault P. The hypoplastic and ptotic breast: a combined
operation with prosthetic augmentation. Plast Reconstr Surg.
1966;37:31–37.
2. Lassus C. Breast reduction: evolution of a technique—a
single vertical scar. Aesthetic Plast Surg . 1987;11:107.
3. Lejour M. Vertical mammaplasty: update and appraisal of
late results. Plast Reconstr Surg . 1999;104:771–781.
4. Berthe JV, Massaut J, Greuse M, et al. The vertical mamma-
plasty: A reappraisal of the technique and its complications.
Plast Reconstr Surg . 2003;111(7):2192–21929; discussion
2200–21922.
5. Graf R, Biggs TM. In search of better shape in mas-
topexy and reduction mammoplasty. Plast Reconstr Surg.
2002;110(1):309–317; discussion 318–322.
6. Ritz M, Silfen R, Southwick G. Fascial suspension mastopexy.
Plast Reconstr Surg . 2006;117:86.
7. Hidalgo DA. Vertical mammaplasty. Plast Reconstr Surg .
2005;4:1179–1197.

540 • CHAPTER 45
8. Benelli L. A new periareolar mammaplasty: the “round
block” technique. Aesthetic Plast Surg. 1990;14: 93–100.
9. Rohrich RJ, Beran SJ, Restifo RJ, Copit SE. Aesthetic
management of the breast following explantation: Eval-
uation and mastopexy options. Plast Reconstr Surg .
1998;101(3):827–837.
10. Baran CN, Peker F, Ortak T, Sensöz O, Baran NK. Unsat-
isfactory results of periareolar mastopexy with or without
augmentation and reduction mammoplasty: enlarged are-
ola with fl attened nipple. Aesthetic Plast Surg . 2001;25(4):
286–289.
11. Spear SL, Boehmler JH 4th, Clemens MW. Augmentation/
mastopexy: a 3-year review of a single surgeon’s practice.
Plast Reconstr Surg . 2006;118(7 Suppl):136S-147S; discus-
sion 148S-149S, 150S-151S.
12. American Society for Aesthetic Plastic Surgery Website.
. Accessed January
10, 2010.
13. Spear SL, Venturi ML. Augmentation with periareolar mas-
topexy. In: Spear SL, ed. Surgery of the Breast: Principles and Art .
Vol 2. 2nd ed. Philadelphia: Lippincott Williams & Wilkins;
2006:1393–1402.
14. Spear, SL. Augmentation/mastopexy: “Surgeon, beware”.
Plast Reconstr Surg . 2003;112(3):905–906.
15. Brink RR. Evaluating breast parenchymal maldistribution
with regard to mastopexy and augmentation mammaplasty.
Plast Reconstr Surg. 2000;106:491–496.
16. Cardenas-Camarena L, Ramirez-Macias R. Augmentation/
mastopexy: how to select and perform the proper technique.
Aesthetic Plast Surg. 2006;30:21–33.
17. Spear SL, Giese SY, Ducic I. Concentric mastopexy revis-
ited. P last Reconstr Surg . 2001;107(5):1294–1299.
18. Ceydeli A, Freund RM. “Tear-drop augmentation mas-
topexy”: a technique to augment superior pole hollow.
Aesthetic Plast Surg. 2003;27:425–432; discussion 433.
19. Gruber R, Denkler K, Hvistendahl Y. Extended crescent
mastopexy with augmentation. Aesthetic Plast Surg. 2006;
30:269–274; discussion 275–266.
20. Nigro DM. Crescent mastopexy and augmentation. Plast
Reconstr Surg. 1985;76:802–803.
21. Persoff MM. Vertical mastopexy with expansion augmenta-
tion. Aesthetic Plast Surg. 2003;27:13–19.
22. de la Fuente A, Martin del Yerro JL. Periareolar mastopexy
with mammary implants. Aesthetic Plast Surg. 1992;16:
337–341.
23. Tebbets JB. Dual plane breast augmentation: Optimizing
implant-soft-tissue relationships in a wide range of breast
types. Plast Reconstr Surg. 2001;107(5):1255–1272.
24. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient out-
comes in aesthetic and reconstructive breast surgery using
triple antibiotic breast irrigation: six-year prospective clini-
cal study. Plast Reconstr Surg. 2006;118(7 Suppl):46S–52S.
25. Elliott LF. Circumareolar mastopexy with augmentation.
Clin Plast Surg. 2002;29:337–347, v.
26. Gasperoni C, Salgarello M, Gargani G. Experience and tech-
nical refi nements in the “donut” mastopexy with augmenta-
tion mammaplasty. Aesthetic Plast Surg. 1988;12:111–114.
27. Lejour M. Vertical mammaplasty: early complications
after 250 consecutive cases. Plast Reconstr Surg . 1999;104:
764–770.

46
Breast Augmentation
Vu T. Nguyen, MD
INTRODUCTION
Augmentation mammaplasty is currently the most pop-
ular cosmetic surgical procedure in the United States,
and has consistently been so since 2006. Data from the
2010 American Society of Plastic Surgeons’ national
clearinghouse of plastic surgery statistics show that some
289,000 women underwent augmentation in 2009,
a 36% increase since the year 2000. 1 These statistics
clearly indicate that augmentation mammaplasty is an
integral part of the practice of many plastic surgeons,
and will remain so for years to come. However, these
statistics should not give surgeons the impression that
this procedure is altogether straightforward in regard
to its preparation, execution, outcomes, and potential
complications. In fact, no plastic surgery procedure has
provoked as much controversy and scrutiny, both in the
medical literature as well as in the lay public, than that
of breast augmentation. The lessons learned from this
unique history have taught us how to better approach
and inform our patients of the risks and benefi ts of this
popular procedure. Therefore, as we continue in the
practice of breast augmentation, it is inherent upon us to
minimize complications and unnecessary reoperations,
as well as ensure its safe and reliable practice, particu-
larly in light of its known intrinsic issues and somewhat
checkered past.
PATIENT EVALUATION AND SELECTION
A wide variety of body and breast types present for aug-
mentation mammaplasty. Furthermore, there exists a
dizzying array of options in regard to incision placement,
implant location, and implant types, including choice
of fi ller material, surface texture, shape, and size. Given
these various options, it should become apparent that
no one technique or approach can possibly suffi ce for all
patients and all situations. Instead, practitioners need to
become facile with a number of available options; and
in conjunction with the patient, make decisions based
on a careful evaluation of the patient’s specifi c breast
characteristics; noting to the patient the particular
benefi ts and trade-offs of each. It bears repeating that
each patient be approached individually, based on not
only their physical characteristics but also their desired
outcome. Some patient profi les do, however, become
apparent. Younger patients in their 20s who present for
augmentation are oftentimes single and nulliparous. The
body habitus is a relatively thin, athletic, or even mus-
cular physique. Expectations are therefore usually high,
and aesthetic concerns are yet unconstrained by more
long-term or oncologic issues. This is in contrast to the
30- to 40 year-old age group, who are often seeking aug-
mentation following age-related changes or postpartum-
related involution. While expectations are oftentimes
more reasonable, concerns regarding cancer surveillance
and detection come into play. Additionally, secondary
agendas for breast augmentation may play a role, includ-
ing marital diffi culties, issues with social insecurity, and
professional career advancement. Beginning the patient
evaluation with a frank discussion regarding the moti-
vation behind augmentation can only assist in building
rapport between physician and patient, and potentially
minimize complications due to unreasonable expecta-
tions or other psychosocial issues.
While many patients presenting for consulta-
tion regarding breast augmentation appear young and
healthy, a complete medical history is a requisite for all
patients. Beyond the routine evaluation of a patient’s
age, past medical/surgical history, list of medications, and
allergies, a thorough investigation into potential factors
that could contribute to acute postoperative problems
should occur (eg, bleeding, infection, delayed wound
c h a p t e r

542 • CHAPTER 46
healing, etc). This includes but is not limited to their his-
tory of smoking, diabetes, and possible coagulopathies.
A history specifi c to breast-related illness should also be
elucidated; focusing on prior breast-related symptoms,
diagnoses, imaging, and procedures. A personal or family
history of breast cancer must be noted and if appropri-
ate should prompt a discussion regarding the necessity
of genetic testing. In regards to presurgical mammog-
raphy, screening recommendations are available via the
American Cancer Society and the American College of
Radiology. Additionally, a discussion regarding the effect
of breast implants on breast imaging and cancer surveil-
lance should take place. Patients should be aware that all
breast implants interfere with mammography, and that
additional views are necessary in order to increase the
amount of visualized tissue. Using Eklund views, up to
85% of breast tissue may be imaged with implants in the
submuscular position, as compared to up to 64% of breast
tissue in the subglandular position. 2 Despite these limi-
tations, current evidence indicates that breast implants
do not adversely affect the surveillance of breast cancer,
stage at diagnosis, or survival rate.
A discussion regarding the more frequent complications
associated with the use of breast implants must include
the issues of capsular contracture, implant failure/rupture/
defl ation, device palpability, rippling, scalloping, deforma-
tion, malposition, and asymmetry. The potential for these
complications must be addressed on an individual basis
and in relation to the type of implant, the patient’s anat-
omy, and their individual breast characteristics. An honest
discussion regarding the impact of implants on a particular
patient and their breasts is important to mitigate potential
problems that arise only after the surgery is performed.
Tebbetts, for example, includes a comprehensive list of
potential complication unique to implant-based breast
augmentation as part of his documentation and informed
consent process. 3
Additional unique complications may include widening
and other associated changes of the nipple-areola complex.
While sensation is usually not permanently affected, there
is some indication that increasing implant size has some
effect on diminished sensation. Similarly, lactation is not
usually impaired, especially when extensive dissection
through breast parenchyma is avoided. However, patients
should be advised to refrain from undergoing breast aug-
mentation within 6 months of lactation to prevent the
possibility of milk pooling within the breast pocket. Lastly,
studies have shown that silicone implants do not increase
silicone levels in breast milk above baseline levels, which
are in fact lower than those found in infant formula and
cow’s milk.
While some surgeons may advocate a more cursory or
gestalt approach to the physical examination, measuring
and documenting these physical fi ndings allows for deci-
sion making based on objective parameters. Beginning with
height, weight, chest, and bra size; the recording of these
values assists in the important practice of reviewing one’s
own experience, and over time in making adjustments to
technique and approach. Moreover, documenting and con-
veying these fi ndings to the patient allows the physician
the opportunity to point out areas of potential concern.
Inherent, yet often unnoticed, asymmetries in regard to
breast size, nipple location, breast diameter, and inframam-
mary fold position are the rule and not the exception; and
should be highlighted to the patient and trigger a discus-
sion regarding their impact on the fi nal outcome.
Tebbetts, again, has been an advocate for the objective
measurement and analysis of breast characteristics. His
High Five decision support process uses fi ve measurement
and fi ve critical decisions, in order to consolidate the pre-
operative planning process. 4 Even this method, however,
is likely too cumbersome for the vast majority of sur-
geons to embrace in their everyday practices. Therefore,
each individual surgeon must over time develop their
own practical system of examination; encompassing at
the minimum, assessment of the dimensions of the breast,
native breast volume, nipple and inframammary fold
position, and the presence of any breast mass. Additional
important elements may include the amount of breast
skin laxity, overall skin quality, amount of postpartum
involution, presence of striae, and other characteristics
of the skin envelope. Many advocate measurement of the
breast diameter, sternal notch-to-nipple distance, nipple
to inframammary fold distance, medial and lateral pinch,
and upper pole pinch tests. The chosen implants can
then be narrowed in on using a combination of these
measurements (ie, breast diameter: one half medial and
one half lateral pinch amounts) and the desired outcome
of the patient. In regard to the latter parameter, this is
of critical importance as it is a major source of patient
dissatisfaction. Size, or more accurately inadequate or
unwanted size, is viewed as one of the most common
reason for early reoperation following breast augmenta-
tion. Efforts to estimate a patient’s desired amount of
augmentation have resulted in a multitude of systems,
including custom digital imaging and the use of vari-
ous spacers (eg, rice bags) and implants placed within
a bra to simulate the augmentation. No system is ideal;
however, a component of the Bodylogic system uses a
four-part visual scale accompanied by descriptive text in
order to defi ne the patient’s desired outcome. 5
Type 1—I desire a gentle fi lling out of my breast in a
way that is completely natural with no excess full-
ness in the upper pole of my breast. I understand
that perhaps a bigger implant could potentially be
used but my wishes are more for a conservative
augmentation.
Type 2—I would like the biggest implant that can be
used without creating a breast which has an unnat-
ural look, ie, an excess rounded appearance in the
upper pole of the breast. I do not want it to be obvi-
ous that I have had a breast augmentation.
Type 3—I desire a large breast augmentation and do not
mind if it has a mildly unnatural look, ie, a noticeably
rounded contour in the upper pole of the breast.

BREAST AUGMENTATION • 543
Type 4—I want to use the biggest implant possible
knowing that it will create a distorted unnatural
look and it will be obvious that I have had a breast
augmentation.
Additional adjuncts for size determination include the
use of magazine/internet photographs, the amount of
padding if any used by the patient, and their size during
pregnancy, including any relevant photographs. Regardless,
despite the fact that no guarantees can or should be made
regarding the fi nal outcome; all efforts need to be made to
ensure that decisions made intraoperatively are consistent
with the patient’s overall desired outcome.
PATIENT PREPARATION
Similar to virtually all plastic surgery procedures, the
preoperative preparation and patient education prior to
embarking on surgery far outweighs what occurs within
the operating room. This process is only further obfuscated
by the myriad of surgical options available in augmenta-
tion; including incision placement, pocket location, implant
type, and size. Moreover, each of these variables must be
assessed within the context of the patient’s own desires, the
potential benefi ts, and the possible trade-offs. Key amongst
these is recognizing the particular consequence of choices
made, especially regarding their inevitable long-term effect
upon the patient’s native breast dimensions and tissue
characteristics. The general rule being that the choice of
implant, incision, and pocket position must be tailored to
the individual characteristics and anatomy of the patient
and their breasts. Pushing beyond those anatomical limits
can risk serious consequences in terms of short-term com-
plications and long-term outcomes. In the end, the goal
must be to provide the most optimal long-term soft tissue
coverage of the implant, while at the same time fulfi lling
the objectives and desires of the patient.
Incision Placement
Options for incision placement include inframammary,
periareola, axillary, and transumbilical approaches, with
the latter two most often requiring endoscopic assistance.
Choice depends on the surgeon’s training and experience
in a given technique coupled with individual patient’s
desires, anatomical limitations, and surgical demands.
In particular, the patient’s particular breast habitus may
facilitate, or limit, the use of one or more approaches
to the breast. Similarly, the need for more direct access
and/or additional adjustments to the implant pocket and
breast assists in determining what is ideal for a given
situation.
Inframammary. The most direct approach, inframam-
mary, takes advantage of the fact that many patients
present for augmentation with a demonstrable inframam-
mary fold and some degree of breast ptosis. This incision
provides the most direct visual access to both the sub-
mammary, as well as the subpectoral, spaces without the
excessive dissection of breast parenchyma. Therefore,
hemostasis and precise pocket dissection are facilitated;
as is the incremental release of the pectoralis muscle
needed in dual-plane–type augmentations. The location
also allows for a generous incision length. When com-
bined, these factors make the inframammary approach
amenable to virtually any type or size of implant, includ-
ing textured, anatomic, cohesive gel, and even form-stable
silicone implants. The scar itself, when placed at the infra-
mammary fold or just above, is usually imperceptible;
seen only when the patient is supine or recumbent and
one is looking from below. Finally, it can be used in a wide
variety of patients, especially those with a well-defi ned
fold and/or small areola size. Caution, however, should
be exhibited in patients with severely hypoplastic breast
and in constricted or tuberous breast patients, as the new
position of the inframammary fold may be diffi cult to
discern (and therefore risking a more visible scar on the
breast), and due to the extensive amount of parenchymal
adjustment sometimes necessary in these cases.
Periareola. While the inframammary approach is more
straightforward, the periareola incision is likely the most
versatile. It can be used in a large variety of patients,
including those presenting with thin native breast tis-
sue and minimal ptosis, ill-defi ned or asymmetric infra-
mammary folds, and those requiring more extensive
parenchymal alterations (eg, tuberous breasts, revisions,
capsulorrhaphies, capsulectomies, etc). The exception
to this being those individuals with smaller areola sizes
(eg, 3.0 cm diameter areola roughly equates to a 4.5 cm
hemi-incision) and with light or indistinct areola margins.
Otherwise, it provides for a well-concealed scar when
placed exactly at the margin of the areola and breast
skin. Incisions placed just within the margin risk hypop-
igmentation, while those just outside the areola may be
complicated by a hyperpigmented and more visible scar.
Through this incision, a wide variety of parenchymal
adjustments can be made, in addition to alterations to the
height of the inframammary fold. Furthermore, the peri-
areola approach can be incorporated into various mas-
topexy-type incisions and facilitates revisional surgery
due to its central location within the breast. Concerns
regarding this technique mainly include its proximity to
the nipple. This includes the possibility for diminished
sensation and the inability for lactation. More pressing
may be its implication toward higher capsular contrac-
tion rates due to the adjacent nipple and/or the need
for parenchymal division, and subsequent bacterial con-
tamination during insertion of the implant. Additionally,
advocates of the dual-plane technique warn against the
possibility of “upstaging” of the procedure due to the
necessary release of parenchymal attachments between
the pectoralis muscle and the overlying breast tissue.
Depending on the plane of dissection, this may result in
a greater than expected cephaled retraction of the pec-
toralis, and therefore a lesser amount of soft tissue cover-
age of the implant inferiorly.

544 • CHAPTER 46
Axillary. The axillary approach was developed in the
1970s, and gained more widespread popularity during
the 1990s following the introduction of the endoscopic-
assisted method. Originally, this technique necessitated
a somewhat blind and blunt approach to pocket dissec-
tion. Detractors complained of an inability to precisely
control the pocket dissection and an increased concern
over acute postoperative complications, including bleed-
ing, pain, edema, and ecchymosis. Limitations in surgical
control also led to complaints of implants positioned too
high secondary to inadequate pectoralis division, or too
low due to overdissection of the pocket and inadvertent
lowering of the inframammary fold. With the addition of
endoscopic assistance, advocates of the approach argue
that what was once a blind and blunt type of procedure
has been converted to a more direct and precise form of
dissection, while still retaining the benefi ts of the original
approach. This includes the absence of any scar on the
breast, the lack of violation of any breast parenchyma,
and the ability to place the implant in either a subpec-
toral or subglandular pocket. At the same time, use of
the endoscope allows more direct visualization, critical
for the accurate dissection of the pocket and division of
the pectoralis fi bers, control of the fold position, and of
course hemostasis. These benefi ts are balanced by a num-
ber of limitations of this approach. While it can be used
in a wide variety of breast types, the axillary approach
is not recommended when extensive alterations to the
breast parenchyma are necessary (eg, tuberous breasts,
revisions requiring capsulectomy or capsulorrhaphy).
Additionally, this approach is not amenable to perform-
ing either a dual-plane type II or III dissection. Due to
the remote site and incision size limitations within the
boundaries of the axilla, certain implants are not rec-
ommend with this approach, including larger silicone
(.500 cc), textured, anatomic, and form-stable implants.
During the initial portion of the dissection, there is a
risk of injury to the intercostobrachial cutaneous nerve,
resulting in anesthesia over the upper, inner aspect of
the arm. Furthermore, even advocates of this approach
recognize that patients should be informed that there is
always the possibility that a conversion to a more direct
approach may be necessary during the operation and that
they will likely require a secondary incision for any sub-
sequent revisional procedure. Finally, logistical issues are
present, including the need for specialized surgical train-
ing, the fi xed-cost investment in equipment, additional
staff training in order to troubleshoot potential intraop-
erative technical problems, and the distinct potential for
greater operative and anesthetic times.
Transumbilical. Lastly, the most recent advent in inci-
sion type is the transumbilical approach to breast aug-
mentation, introduced in 1993. Since its introduction,
refi nements in technique and instrumentation have made
it an option for surgeons seeking a remote site of access
that does not have the same potential for exposure of the
incision site during certain social or sporting activities,
as in the axillary approach. However, it shares some of
the same limitations as its similarly endoscopic-assisted
cousin. This includes restrictions on implant type, lim-
ited to essentially saline implants; the overall decrease
in pocket control, leading to issues with asymmetry and
possibly increased revision rates; and the inability to
perform additional adjunctive measures to the breast.
Patients should again be informed of the risk of conver-
sion to a more direct approach, and the need for a sec-
ondary incision for revisional operations. Finally, while
technically possible, there is noted diffi culty in creating a
subpectoral pocket. This factor, when combined with the
need for saline implants, potentially limits the popula-
tion of patients to those with adequate native soft tissue
coverage; in order to limit the issues of implant palpabil-
ity or visibility.
In the end, the choice of incision type must again be
individualized taking to account the surgeon’s level of
comfort and experience and weighing the benefi ts and
trade-offs of each approach. All are acceptable methods
when taking into account a particular patient’s breast
habitus and desires. In regards to patient choice in the
matter, an interesting and revealing practice is to inquire
as to which incision would be most desired, not if the
incision healed well and resulted in an almost impercep-
tible scar, but instead if due to differences in patient biol-
ogy, the incision healed poorly. The answer often comes
as a surprise to not only the practitioner, but also the
patients themselves.
Implant Position
Choices regarding the position of the implant relative to
the surrounding soft tissues are best made in regard to
optimizing coverage of the implant. Doing so reduces the
potential trade-offs of implant palpability and/or visibil-
ity, and respects the character of the tissues in regard to
their inevitable evolution over time. Options for implant
pocket location include subglandular, subfascial, sub-
pectoral, total submuscular, and dual-plane techniques.
Of these, only subglandular, subpectoral, and dual-plane
techniques are widely practiced. Subfascial positioning
represents a modifi cation of the subglandular technique,
adding a thin amount of additional tissue coverage. The
total submuscular technique was developed as a method
of providing increased lateral coverage of the implant,
utilizing a portion of the serratus anterior muscle, in
addition to the pectoralis, to provide total muscular cov-
erage. Due to trade-offs of increased technical diffi culty,
inadequate lower pole projection and inframammary
fold defi nition, and late superior displacement over time,
in addition to a lack of signifi cant benefi ts; this method is
less frequently used.
Subglandular. Initial attempts at augmentation placed
implants in the subglandular, also known as the retro-
mammary, plane. This technique is still widely practiced,
and is ideal in situations of breasts with adequate soft

BREAST AUGMENTATION • 545
tissue coverage; as evidenced by a 2.0 cm or greater pinch
test of the upper pole. This provides adequate coverage
for the implant and reduces the risk of implant palpabil-
ity and visible irregularities often seen in thin-breasted
individuals. Potential benefi ts include less postoperative
pain and therefore more rapid recovery, and the avoid-
ance of implant distortion seen sometimes with pectora-
lis muscle contraction. Trade-offs include the increased
risk of implant edge palpability/visibility (particularly
with saline-fi lled and/or textured implants), increased
interference with screening mammography, and poten-
tially increased rates of capsular contracture. In addition,
caudal migration of the implant over time may place
additional pressure on the overlying tissues increasing
the amount of ptosis, and in extreme cases result in a
“rocks in a sock” type of deformity.
Subpectoral. In order to address these issues, the sub-
pectoral, or retropectoral, technique was developed.
Overall, the subpectoral position affords a softer, more
natural appearing augmentation. While this technique
does provide more soft tissue coverage, particularly in
those patients with thin breast tissue and inadequate
upper pole pinch tests, it too has its own host of benefi ts
and trade-offs. Studies have reported a lower incidence of
capsular contracture; however, it is not known whether
this is due to a true reduction in capsule formation or
simply a situation of decreased detection. And as pre-
viously indicated, the subpectoral position facilitates a
greater amount of breast tissue being visible during mam-
mography. Potential trade-offs relate directly to the rela-
tionship between the pectoralis muscle and the implant.
Primary among these is the sometimes visible distortion
of the implant and breast shape with pectoralis muscle
contraction. Ironically, this is most often seen in those
women with thin breast tissue coverage, for which sub-
glandular placement would risk increased implant pal-
pability/visibility. In contrast, in patients with increased
amounts of glandular tissue, particularly those with a
moderate amount of breast ptosis or postpartum atrophy,
the support added by subpectoral placement may result
in increased separation of the implant from the overlying
ptotic breast tissue and risk development of a “Snoopy”
deformity. Finally, in situations where division of the ori-
gins of the pectoralis muscle is not performed; lateral
and superior displacement of the implant can occur over
time, widening the intermammary space between the
breasts and reducing the appearance of cleavage. In order
to address this issue, various amounts of pectoralis mus-
cle release have been advocated, except in cases of thin
soft tissue coverage at the inframammary fold (inferior
pinch test ,0.5 cm). This likely represented the impetus
for the development of the dual-plane technique.
Dual Plane. This latest method of implant placement
reports to offer many of the benefi ts of the above men-
tioned techniques, while minimizing the potential trade-
offs. Elements of the dual-plane technique include
(1) the division of selective origins of the pectoralis
muscle, (2) a varying amount of dissection between the
pectoralis muscle and the breast parenchyma in order
to adjust the amount of muscle retraction and thereby
the breast’s relationship to the implant, and therefore
(3) the placement of the implant partially behind the
pectoralis muscle and partially behind the breast paren-
chyma. The main purpose of the technique is to allow
a maximal amount of implant coverage via its partial
subpectoral placement, while at the same time allow-
ing varying degrees of interface between the implant and
the breast parenchyma; as determined by the amount of
native breast ptosis and/or laxity. Type I dual plane refers
to a complete division of the pectoralis origins across
the inframammary fold, without any dissection within
the subglandular plane ( Figure 46-1 ). This technique
is applicable to the majority of augmentation patients
who present with all of their native breast tissue situated
above the inframammary fold and a relatively tight breast
skin envelope (eg, areola to inframammary fold distance
of 4.0–6.0 cm). Type II dual plane is recommended in
conditions where the majority of the breast exists above
the inframammary fold and the tissues are more mobile
with looser attachments (eg, areola to inframammary
fold distance of 5.5–6.5 cm). While the same pectoralis
origins are released, dissection is also performed at the
subglandular plane up to the inferior level of the areola,
allowing for a controlled amount of pectoralis retraction
and increased amount of parenchymal-implant interac-
tion. Finally, type III dual-plane techniques are applica-
ble in situations of ptotic breasts where up to a third of
the tissue is situated below the inframammary fold and
the breast envelope is markedly stretched (eg, areola to
inframammary fold distances of 7.0–8.0 cm), or in cases
of constricted or tuberous breasts with corresponding
short areola to inframammary fold distances of only 2.0
to 5.0 cm. Subglandular dissection is performed to the
level of the superior aspect of the areola, allowing for an
even greater amount of implant projection and interface
with the overlying breast parenchyma. Regardless, shared
amongst the different levels of the dual-plane technique
is the strict preservation of the pectoralis origins along the
sternal edge. Doing so does limit the amount of cleavage
attainable, but does so at the benefi t of providing maxi-
mal medial implant coverage, minimizing the possibil-
ity of medial implant show, limiting the window shading
of the pectoralis muscle following its release along the
inframammary fold, and preventing symmastia.
In summary, the choice of implant placement must be
made with the goal of optimizing long-term soft tissue
coverage, while appreciating the trade-offs of particular
techniques. Paramount is the recognition that areas of
overdissection or thinning of the breast parenchyma have
long-term consequences as the implant inevitably exerts
continued pressure on the overlying tissues, and that the
correction of these problems may be diffi cult to poten-
tially impossible. Therefore, the patient’s desired outcome
must be tempered by what their tissue characteristics

546 • CHAPTER 46
FIGURE 46-1. Dual-plane technique. (Reprinted with
permission from Adams WP Jr. Breast Augmentation. New York:
McGraw-Hill; 2011.)
Dual-plane I
A
Dual-plane II
B
Dual-plane III
C
and dimensions will allow, via the process of adequate
preoperative planning and patient education.
Implant Selection
Implant selection from the patient’s point of view is
driven by several factors, including aesthetics, size, and
safety. From the practitioner’s viewpoint, much of implant
choice and development has been based upon the inci-
dence of capsular contracture. And with the return of
silicone implants to the market in 2006, there again is a
somewhat perplexing amount of implant choices avail-
able. Currently, the majority of implants placed within
the United States are round, smooth-walled implants,
with an equal distribution between silicone and saline-
fi lled devices. Options due exist, however, in regard to
choice of fi ller material, shell design, implant shape, and
of course size.
Silicone vs Saline. While there are obvious differences
between the two types of implants, patients tend to fall
into one of two categories: those who are comfortable
with using silicone and those who are not. Patient edu-
cation into the history and safety of silicone implants is
of vital importance in order to allow patients the option
of an informed choice regarding what they choose to
put into their bodies. That being said, neither implant is
inherently “safer” or “better” than the other. Benefi ts and
trade-offs exist that must be taken into account, along
with the patient’s particular breast characteristics.
In some aspects, silicone represents the ideal fi ller
material—inert and similar in consistency and weight
to breast tissue. While its early history was plagued with
high rates of capsular contracture, the current fourth
generation of silicone implant has demonstrated relative
low rates, likely due to its low-bleed polymer shell and
cohesive gel fi ller material. Trade-offs include a slightly
higher cost, the phenomenon of silent implant rupture,
and the need for larger access incisions limiting its use in
the majority of axillary and transumbilical cases.
In direct contrast, saline implants enjoy the abil-
ity to be placed via smaller incisions and through the
full array of access sites. Improved design has corrected
early problems associated with valve failure and sub-
sequent defl ation. Trade-offs exist, however, due to the
inherent nature of a liquid-fi lled device. Underfi lling of
the implant, while providing some aspect of softness,
is associated with wrinkling and folding of the device,
and likely contributes to an increased rate of rupture. In
contrast, overfi lling can create a scalloping effect along

BREAST AUGMENTATION • 547
the edge of the device as the shell stretches to accom-
modate the increased volume. These issues contribute
to an overall increased rate of implant palpability and
visibility, particularly when using a subglandular pocket.
In addition, when appropriately fi lled, saline devices are
again noticeably fi rmer and slightly heavier than their
silicone counterparts.
Smooth vs Textured. Texturing was originally designed
in an effort to mimic the decrease capsular contracture
rate seen with polyurethane foam-coated implants used
during the 1980s. Due to questions of safety regarding
their degradation, these devices were removed from the
US market in 1991. Regardless, evidence does exist that
the textured surface may decrease the rate of capsule for-
mation; however, its benefi ts appear to be lost when the
implant is placed in a submuscular position. Additional
attributes include a reduced propensity for migration and/
or rotation, explaining its frequent association with ana-
tomic or shaped implants. Downsides include the poten-
tial for increased rippling and palpability, particularly in
the subglandular position.
Round vs Shaped. While the original Cronin and
Gerow implants were both anatomic in shape and tex-
tured, issues with high capsular contracture drove manu-
facturers to create round, smooth-walled implants that
could move within their pockets in an effort to reduce
capsule formation. With the exception of the previ-
ously mentioned polyurethane-coated implants, this
type of implant has dominated the US market ever since.
Advocates of shaped or anatomic implants purport the
benefi ts of a more “customized” device in certain ana-
tomical situations, such as reduced upper pole fullness in
women with thin superior tissues and greater lower pole
projection in cases of mammary ptosis. This is, however,
at the cost of contour irregularities due to rotation of
the implant and therefore the need for exacting pocket
dissection. Additionally, arguments exist whether round
implants assume an anatomic shape regardless when ver-
tical and in vitro.
Size. It bears mentioning again the critical nature of size
in implant selection. In general, the implant most often
should fi t within the limits of the native breast dimen-
sions. To do otherwise risks issues of contour irregulari-
ties, including lowered inframammary folds, lateral arm
impingement, high and/or excessively full upper poles,
and symmastia. Regardless, the bigger the implant, the
more likely that issues of edge palpability and visibility
are to occur. Furthermore, over time, the native breast
tissue invariably undergoes progressive thinning due to
the constant forces of the implant and gravity, which
are only exacerbated in situations of larger implants.
Therefore, the demands of the patient must always be
weighed against the potential short and long-term trade-
offs inherent in choosing an implant for augmentation.
With careful patient preparation and thorough education
on the potential risks and trade-offs, patients most often
accept limitations in exchange for minimizing implant
palpability/visibility in the short term, and providing the
best possible soft tissue coverage in the long term.
TECHNIQUE
Safe surgical technique begins outside of the operating
room. The operative plan, including choices made regard-
ing incision location, pocket position, and implant type,
must be documented and reviewed well before embark-
ing on the operation. It is recommended that the choice
of implant be “bracketed” by ordering an implant size/
type above and below the optimal designated implant.
It is also prudent that a third implant be available in
the sizes selected, in the rare case of implant rupture or
contamination.
Preoperative markings may be done either the day
before or the day of surgery. These should be performed
in an upright fashion, marking the sternal midline, level of
the existing and desired inframammary folds, medial and
lateral extents of the implant pocket, any key anatomical
landmarks, and the proposed incisions. Any adjustments
to the native breast contour should be marked, and may
prompt a fi nal discussion regarding the benefi ts and trade-
offs of the proposed operative plan.
Perioperative
antibiotic
prophylaxis
is
recom-
mended due to the correlation between bacteria (mainly
Staphylococcus epidermidis ) within the lactiferous ducts of
the breast, subclinical infection, and capsular contracture.
If utilizing general anesthesia, lower extremity compres-
sion devices or pharmacoprophylaxis for deep vein throm-
bosis is highly recommended. Arms should be securely
fastened onto the operative armboards in order to allow
sitting up during the operation to assess for symmetry.
Inframammary .
When
using
the
inframammary
approach, location of the incision relative to the exist-
ing inframammary fold is a key factor. In patients with
a defi ned, symmetric, and ideally located inframammary
fold, the incision can be placed directly within the fold.
However, most situations have some degree of variabil-
ity. A fact which must be taken into account is that aug-
mentations frequently have a slight lowering effect on
the inframammary fold. This situates the fi nal location
of the incision usually up onto the dependent portion
of the breast, which is much more preferable and less
visible than an incision on the chest wall. If planning to
adjust the location of the fold, then the incision should
be placed in the new, proposed inframammary fold loca-
tion, taking into account the factors stated above. Incision
length is mainly determined by the type of implant, with
saline implants requiring a smaller (eg, 3 cm) incision
versus larger incisions for silicone and textured implants.
Finally, the medial aspect of the incision should not
extend beyond the medial border of the areola, in order
to prevent its visibility with certain articles of clothing
( Figure 46-2 ).

548 • CHAPTER 46
FIGURE 46-2. Inframammary incision. Generally, the
most medial extent of the incision is no greater than 1 cm
medial to the nipple, with the remaining incision lateral to
the nipple. (Reprinted with permission from Adams WP Jr. Breast
Augmentation. New York: McGraw-Hill; 2011.)
1 cm
If plans are to maintain the current position of the
inframammary fold, dissection must then be directed
perpendicularly or cephalad in order to prevent inadver-
tent undercutting and lowering of the fold ( Figure 46-3 ).
With upward retraction using an army-navy–type retrac-
tor, access to the subglandular pocket is relatively
straightforward. Following division of the fascia, upward
retraction also tents up the inferior border of the pec-
toralis muscle, aiding in its identifi cation. Access to the
subpectoral pocket is usually achieved just lateral to
the medial costal origins, with further superior pocket
dissection greatly facilitated using a lighted retractor.
Verifi cation of the pectoralis can be done by lightly
touching the muscle in question with the electrocau-
tery, and confi rming the proper location and direction
of muscular contraction. Additionally, when in question,
a small amount of cephalad submuscular dissection can
be performed, verifying the subpectoral location via its
loose areola tissue, relatively avascular plane of dissec-
tion, and the visible rib cartilages and intercostal spaces
( Figure 46-4 ). Further medial and judicious lateral dis-
section may be performed bluntly at this point, but sharp
dissection using the cautery is preferred for hemostasis.
Once a precise pocket is created, decisions regarding pec-
toral division plus/minus dual-plane dissection are per-
formed. Complete division of the inferomedial origins
of the pectoralis is carried out using the cautery and at a
location 0.5 to 1.0 cm off of the chest wall ( Figure 46-5 ).
This helps to prevent inadvertent lowering of the infra-
mammary fold medially, and assists in identifi cation
and ligation of bleeding vessels. More medial division
or attenuation of the sternal origins of the muscle is
up to the discretion of the surgeon, but does place the
patient at risk for increased implant palpability/visibil-
ity and symmastia. Once subpectoral dissection is com-
plete, dual-plane techniques may be then performed. It
is worth noting that although defi nitions do exist for the
differing levels of this technique, the actual release of
the overlying parenchymal attachments to the pectoralis
muscle are done in an incremental fashion, with small
amounts of dissection resulting in signifi cant retraction
of the pectoralis muscle superiorly. In any of the above
stated techniques, one can always dissect further; how-
ever, reversing the result is technically diffi cult to impos-
sible. After pocket dissection is complete on both sides,
they should be manually palpated for symmetry and any
areas of focal constriction. The use of implant sizers is
often helpful to defi ne the optimal implant.
Following confi rmation of adequate hemostasis, gen-
erous irrigation of the pockets should be performed.
While previous studies have demonstrated the benefi ts
of povidone-iodine–containing solutions, the FDA in
2000 restricted their use despite the lack of any data
linking extraluminal contact with implant shell failure.
Regardless, if povidone-iodine solution is utilized, the
off-label indication should be documented and discussed
with the patient. More commonly, irrigation is performed
with approximately 250 cc of a solution consisting of
bacitracin, cefazolin, and gentamicin. Insertion of the
prosthesis should be performed with a minimal amount
of contamination and contact. These methods include
the use of talc-free gloves, exchanging of gloves prior to
implant handling, wiping the incision site with povidone-
iodine or antibiotic solution-soaked sponges, and/or the
application of an occlusive dressing around the incision
site. Once placed and/or infl ated, the implant should be
confi rmed of its correct anterior-posterior orientation.
Symmetry should be assessed with the patient upright.
Any fi nal adjustments to the pocket are made, and the
incision is closed in layers. Postoperative dressings run
the gamut from simple surgical bras to complex dressings
and wrapping schemes. While no postoperative dressing
regimen is a replacement for accurate, on-table surgical
technique; in certain situations, they can assist in main-
taining the results achieved within the operating room.
Periareola. Periareola incisions have the benefi t of
healing almost imperceptively when placed exactly at
the inferior areola margin, with likely the lowest rate
of hypertrophic scarring. Limitations are based on the
size of the areola and the corresponding type and size
of the implant. Following skin incision, two approaches
exist for parenchymal access—trans- and peri-paren-
chymal. In the former, dissection is performed directly

BREAST AUGMENTATION • 549
FIGURE 46-3. Inframammary approach. (A, B) After
the initial incision is made, cautery dissection is immediately
performed in a cephalad direction to avoid inadvertent
lowering of the inframammary fold. (C) If performing a
subpectoral pocket dissection, the inferolateral edge of
the pectoralis muscle is identifi ed and dissection proceeds
cephalically beneath the muscle. (Reprinted with permission from
Adams WP Jr. Breast Augmentation. New York: McGraw-Hill; 2011.)
Lateral
Medial
A
B
C

550 • CHAPTER 46
FIGURE 46-4. Subpectoral pocket dissection. With
anterior retraction of the pectoralis muscle, note the relatively
avascular plane between the pectoralis major muscle and the
underlying chest wall. (Reprinted with permission from Adams WP
Jr. Breast Augmentation. New York: McGraw-Hill; 2011.)
Pectoralis major m.
Direction of
dissection
End of muscle
division
FIGURE 46-5. Pectoralis major muscle division. Note
the preservation of 0.5 to 1.0 cm of pectoralis along the
inferomedial origin of the muscle, as well as preserving all of
the muscle attachments to the sternal edge. (Reprinted with
permission from Adams WP Jr. Breast Augmentation. New York:
McGraw-Hill; 2011.)
perpendicular toward the pectoralis muscle, with further
dissection within the subglandular space. With the lat-
ter, dissection is performed inferiorly along a subcuta-
neous plane in order to reach the inferior aspect of the
breast. Both approaches allow varying degrees of access
for parenchymal alteration or inframammary fold adjust-
ment. Care must be taken, however, in that both also
create potential spaces within the breast that can lead to
malposition of the implant. Additionally, transparenchy-
mal dissection automatically creates as type II dual-plane
dissection and may be too aggressive in circumstances
of thin soft tissue coverage. Finally, this route of access
exposes the implant to greater amounts of contamina-
tion or seeding, due to the adjacent nipple and parenchy-
mal division; and has been theorized to lead to increasing
rates of capsular contracture.
Axillary. Initially, a greater amount of preparation, plan-
ning, equipment, and technique are necessary when
using the axillary approach. An early decision must be
made whether to perform this technique with or with-
out the aid of endoscopy. Traditional techniques neces-
sitated blunt dissection and stretching of the pocket
and associated muscular attachments. Complications
included higher rates of bleeding, hematoma, asymmetry,
and malposition. Advocates of the endocopic technique
note its similarity with more conventional approaches
to breast augmentation—eg, direct visualization, sharp
dissection of tissue, and overall control of hemostasis
and pocket dissection. Limitations of this technique may
include the choice of implant type and pocket location,
with most practitioners utilizing smooth-walled, saline
implants (due to the limited incision size and remote
location) and correspondingly a subpectoral placement.
Silicone implants may be used, but often must be limited
in size (,500 cc).
Initial preparation includes marking of the axillary
incision while standing. The incision should be horizon-
tally oriented and high within the axilla, with its ante-
rior limit at the posterior margin of the pectoralis muscle
( Figure 46-6 ). Intraoperative positioning of the patient
should be with arms extended 90 degrees, with access
to the axilla and adequate space above both arms for
positioning of the surgeon. Correspondingly, the endo-
scopic monitor should be situated at the foot of the bed
to facilitate direct line of sight and dissection. Additional
key instrumentation includes a short 10 mm diameter/30
degree-angle endoscope, light source, suction, digital
camera, and ideally a composite retractor that incorpo-
rates all of these elements.
Following incision and cautery dissection of the sub-
cutaneous tissue, scissors can be used to dissect a space
toward the posterior aspect of the pectoralis muscle. Of
note, maintaining dissection anteriorly limits disruption
of the intercostobrachial cutaneous nerve. Division of
the perctoralis fascia should occur on a line a parallel
to the posterior border of the muscle, and the subpec-
toral space confi rmed with digital palpation of the loose
areola tissue and relatively avascular plane. Again, at
this point, further dissection may be performed bluntly

BREAST AUGMENTATION • 551
FIGURE 46-6. Axillary incision with saline implant. The
preferred method is a 2.5 to 3.0 cm incision marked within
crease in axillary apex. (Reprinted with permission from Adams WP
Jr. Breast Augmentation. New York: McGraw-Hill; 2011.)
(using a curved Emory or Agris-Dingman dissector) and/
or more sharply under direct endoscopic visualization.
Division of pectoralis muscular origins proceeds as previ-
ously stated, with the axillary technique limited to type I
dual-plane dissections, followed by confi rmation of ade-
quate hemostasis and pocket irrigation. It is worth noting
that exchanging instrumentation is greatly facilitated by
the removal and replacement of an instrument prior to
withdrawing the retractor or other device from the plane
of dissection. This limits the amount of time spent re-
manipulating the soft tissues in order to regain access to
the pocket. Insertion of a saline prosthesis is also aided
by double-rolling the implant around the central valve
into a cigar-shape device. Any issues regarding control of
the operation (eg, hemostasis) necessitates conversion to
a more open approach.
COMPLICATIONS
Any surgical procedure that carries with it an approxi-
mate 50% complication rate and/or a 30% reoperation
rate would likely be construed by many as ill advised,
notwithstanding it being an operation that is both elec-
tive and cosmetic. These numbers outline the current
statistics associated with breast augmentation; again
highlighting the fact that this is anything but a simple and
straightforward procedure. A look at the list of adverse
events included in the product data sheet associated with
breast implants include implant rupture, capsular con-
tracture, reoperation, implant removal, pain, changes in
nipple and breast sensation, infection, scarring, asymme-
try, wrinkling, implant displacement/migration, implant
palpability/visibility, breastfeeding complications, hema-
toma/seroma, implant extrusion, necrosis, delayed
wound healing, breast tissue atrophy/chest wall defor-
mity, calcium deposits, and lymphadenopathy. Review
of the Mentor and Allergan 10-year Core Studies reveal
that the risk of any complication following primary aug-
mentation was 36.6% at 3 years (Mentor) and 45% at
7 years (Allergan), with the most frequent being reopera-
tion (15.4% and 30.1%, respectively), followed by grade
III/IV capsular contracture (8.1% and 15.5%). 6 , 7 Within
the above stated list exist both unavoidable and avoid-
able complications. An obvious goal, therefore, must be
to reduce and/or eliminate those avoidable occurrences
that may lead to later reoperation.
Reoperation for these avoidable complications (eg,
change in size) most likely represents a failure of plan-
ning and/or education on the part of the surgeon. During
the preoperative evaluation, the clinician must recognize
what is achievable in regards to the patient’s own tis-
sues. The patient must then understand and accept the
limitations, risks, and trade-offs of the choices made.
Otherwise, pushing beyond those physical limitations
increases the risk of complications. This process of dis-
covery and subsequent discussion then assists both the
patient and the surgeon in anticipating long-term conse-
quences of those choices.
Broadly speaking, there is nothing done in the process
of breast augmentation that improves the tissue qual-
ity of the patient’s breasts. Additionally, the placement
of an implant, particularly a large implant (.350 cc)
in conjunction with age-related changes in the breast,
will likely diminish the quality of those tissues over the
long term.
Implant Rupture
While not the most common complication associated
with augmentation mammaplasty, it is often the one
that concerns the patient most; in addition to being one
that is frequently misunderstood by the patient. Likely
due to the history and misinformation surround sili-
cone implants, patients often arrive with preconceived
notions regarding both the incidence and consequences
of implant rupture. Based on the manufacturers’ core
study data, including an MRI-evaluated cohort, rup-
ture in silicone implants occurred in 0.5% of patients at
3 years and 8.6% at 7 years, underscoring the fact that
rupture is an intrinsic component of implants. Patients
should be educated that implants are not lifetime devices,
particularly when viewed with the fact that 36% are
placed in women age 30 to 39 years, followed by the 20-
to 29-year-old cohort (30%) and the 40 to 54 age group
(28%). The longer the interval from surgery, the greater
the risk of rupture. Consequences of implant rupture
are for the most part local (ie, defl ation in the context
of saline implants) or silent (ie, silicone implants). In
regard to the former, it is recommended that removal or
replacement of the device occur within 1 month to avoid
contraction of the pocket. In regard to the latter, it is rec-
ommended that women with silicone implants undergo
screening MRIs at 3 years following primary surgery, and
then every 2 years thereafter in order to detect silent
rupture. At this point, it is uncertain who will bear the

552 • CHAPTER 46
burden for the cost of these MRIs. Regardless, when rup-
ture has been detected (via characteristic radiographic
fi ndings such as the linguini sign, subcapsular lines, tear-
drop sign, keyhole sign, noose sign), the implant should
be removed and/or replaced. Consequences of silicone
rupture are mainly local in nature, due to the fact that the
majority of ruptures are intracapsular (ie, remain within
the boundaries of the scar tissue capsule surrounding the
implant). Local breast complications may include breast
hardness, change in shape or size, and breast pain. Rare
but reported symptoms due to extracapsular rupture
have included granuloma formation, nerve injury, tissue
breakdown, and lymphadenopathy. Currently, the scien-
tifi c data, including several large epidemiologic studies,
fails to fi nd any connection between silicone implants
and connective tissue, rheumatologic diseases, or cancer.
Capsular Contracture
The formation of scar tissue encapsulating a breast
implant is a normal physiologic process. However, when
that capsule becomes excessively thickened and/or con-
tractile in nature, and adversely affects the breast shape
and/or is symptomatic; it then becomes pathologic (ie,
Baker grade III/IV). The incidence of capsular contrac-
ture represents the largest single complication associ-
ated with breast augmentation, and constitutes the
most frequent cause for reoperation. Its incidence has
been as high as 50% in some series, depending on the
grade and severity of symptoms as outlined by the Baker
classifi cation.
Class I—Breast is soft and looks natural (ie, none)
Class II—Breast looks normal, but is fi rm to palpation
(ie, mild)
Class III—Breast both feels looks and feels abnormal (ie,
moderate)
Class IV—Breast is hard, painful, and looks distorted
(ie, severe)
The onset of capsular contracture is usually within the
fi rst year; however, it may occur at any time. There exist
a myriad of inciting factors implicated in causing capsular
contracture; however, the majority of them can be grouped
into one of two categories: infectious or due to hypertro-
phic scar formation.
Infectious theories are supported by the fact that
S epidermidis has been shown to be signifi cantly associ-
ated with capsular contracture, and in a prospective study
found to be present in 90% of implants removed for this
reason. 8 Additionally, numerous other bacterial agents
have been implicated, indicating a possible polymicrobial
cause. Low-level colonization is thought to occur second-
ary to skin level contact (especially at the nipple) or via
insertion of the implant through transected glandular tis-
sue. These concerns have led to the widespread usage of
antibiotic irrigation (eg, bacitracin/cefazolin/gentamicin
solution) of the implant pocket and an emphasis on strict
sterile technique. 9
A second leading hypothesis deals with the introduc-
tion of non-infectious material as a nidus for capsule
formation; with subsequent infl ammation and fi broblast
proliferation, leading to collagen deposition and contrac-
ture formation. Inciting agents include blood, seroma,
and powdered glove residue. This hypothesis is supported
by early evidence showing a high rate of capsular contrac-
ture following complications of hematoma.
Efforts to combat capsular contracture have driven
both refi nements in surgical technique, as well as implant
design. For example, while early silicone implants were
notorious for their high rate of capsule formation attrib-
uted to gel bleed, successive generations of both silicone
and saline implants have demonstrated progressively
lower rates. Accordingly, a host of additional factors have
been thought to be benefi cial in regards to inhibiting
capsule formation. Following the low rates found with
polyurethane-coated implants, textured implants have
been reported to reduce capsular contracture; although
this benefi t appears to be negated when implants are
placed in a submuscular position. There is some evidence
that smaller implant sizes (,350 cc) have a reduced
incidence of contracture. Additionally, many surgeons
recommend postoperative pocket massage and displace-
ment exercises. Finally, as a general recommendation,
atraumatic tissue dissection, combined with meticulous
hemostasis, has been advocated in contrast to more blunt
techniques. Modalities that have not been found to have
a signifi cant effect regarding capsule formation include
the use of prolonged systemic antibiotics nor the use of
surgical drains within the implant pocket.
While prevention is the best method of treatment,
techniques for dealing with capsular contracture ini-
tially consisted of closed capsulotomy. This method
was frequently complicated by uncontrolled capsular
tears, resulting in asymmetry and hematoma formation.
Additional complications included implant rupture with
possible silicone extrusion into surround tissues, resultant
chronic infl ammation, and siliconomas. This technique
has been largely replaced by open capsulotomy/cap-
sulectomy, with the goal of total capsulectomy. Further
adjuncts include implant exchange due to concerns of
biofi lm development and repositioning of the implant
to a new surgical site (ie, subglandular to subpectoral or
dual plane). Unfortunately, no medical modality (eg, leu-
kotriene inhibitors, NSAIDs, steroids) has been proven
to be of any benefi t in the prevention or treatment of
capsular contracture.
Aesthetic Complications
Aesthetic complications consist of issues regarding size,
malposition, asymmetry, and contour irregularities (both
dynamic and static). Other than capsular contracture,
this category of complications accounts for the highest
rates of reoperation following augmentation. According
to manufacturers’ core study data, implant malposi-
tion alone was responsible for 13.6% of reoperations

BREAST AUGMENTATION • 553
(Allergan); while in a separate study, request for size/
style change accounted for 14.7% (Mentor). When all
combined, these various issues are not only a major
source for reoperation, but are also likely preventable;
and therefore represent a failure in preoperative plan-
ning and education. This is most likely due to mismatches
in patient physical characteristics and/or patient desires
with the overall surgical plan. It cannot be overempha-
sized that implant augmentation beyond the physi-
cal limitations of the patient’s breast habitus place the
patient at signifi cant risk for these complications.
Malposition and asymmetry are again often due to
ignoring the specifi c limitations of the patient’s breast.
This may include violation of the native inframammary
fold, resulting in inferior displacement of the implant;
overdissection of the lateral pocket, resulting in lateral
displacement; division of the sternal origins of the pecto-
ralis muscle, resulting in symmastia; and an overall mis-
match between the native breast and underlying implant,
resulting in a double-bubble deformity. This latter prob-
lem is commonly seen following disruption of the infra-
mammary fold with inferior displacement of the implant,
often in conjunction with situations of constricted or
tuberous breasts. Additional contour issues include the
so-called “Snoopy” deformity, occurring when recurrent,
ptotic, native breast tissues hangs over the end of a supe-
riorly displaced implant. In regard to issues of wrinkling
and rippling deformities transmitted through the skin,
this is most often due to volume underfi ll associated
with saline and textured implants. The opposite is true
of “scalloping” along the implant edge, which is indica-
tive of saline implant overfi ll. Finally, implant placement
in a thin and/or athletic individual, in a submuscular
position in order to prevent particular aesthetic compli-
cations, may instead result in implant deformities asso-
ciated with pectoralis muscle contraction. Correction
of these various issues revolves around recognizing the
anatomical basis for the deformity; correcting the surgi-
cal error; and/or implementing changes in implant size,
pocket dimensions, and/or location using a combination
of techniques. A fi nal word needs to be said regarding
reoperation for size change following primary augmen-
tation. As previously stated, every effort must be made
to accurately assess the patient’s desires for fi nal breast
size, within the context of what their native tissues
can accommodate. This complication should clearly be
viewed as avoidable in nature and therefore represents
inadequate patient preparation and education or a lack
of rapport between patient and surgeon. Regardless, this
should prompt a review of one’s approach to patient
consultation and preoperative preparation.
Local Complications
Local issues include nipple complications (10.4%), hyper-
trophic scarring (6.7%), hematoma (2.6%), changes
in breast sensation (2.2%), seroma (1.6%), and infec-
tion (,1%). Additionally, depending on the study, there
appears to be variable amount of what is labeled “chronic
breast pain” following augmentation, ranging from
1.7% to 11.4%.
While it is tempting to treat issues of postoperative
fl uid collections conservatively, hematomas and seromas
predispose the patient to more complex issues of infection,
capsular contracture, and asymmetry; and should therefore
be treated immediately upon diagnosis.
In regard to infection, while rates are low, the impact
on the patient can be severe due to the possibility of
reoperation and/or implant removal. While S epidermidis
species are ubiquitous within the breast due to the pres-
ence of the lactiferous ducts, Staphylococcus aureus spe-
cies are responsible for the majority of implant related
infections. Attempts to prevent infection have been out-
lined previously, but also include the use of closed fi lling
systems when using saline implants. Treatment of associ-
ated infections is geared toward aggressive and prompt
management, using a combination if intravenous antibi-
otics, surgical irrigation and debridement, capsulectomy,
and implant exchange. Explantation, healing, and delayed
reimplantation is the most conservative approach and is
always an option in cases of severe infection, implant
exposure, and/or abscess.
Uncommon Complications
Uncommon complications associated with breast aug-
mentation include galactorrhea, late hematoma, Mondor
disease, and neoplasm. Mondor disease represents infl am-
mation and subsequent upper abdominal wall venous
thrombosis, presenting as a tender, palpable cord, usually
located inferior to the inframammary fold. Treatment
includes anti-infl ammatories, with self-resolution over a
few weeks.
While several large, epidemiologic studies have failed
to show any increased risk of breast cancer following aug-
mentation, it must be recognized that the development
and diagnosis of masses within the breast will become
an ever-increasing issue. Inherent within this problem are
the limitations of breast imaging associated with implants
and the evolving strategies currently available for diag-
nosis and treatment. Current recommendations include
the use of open biopsy versus fi ne-needle or core biopsy,
due to the presence of the implant. Treatment following
a diagnosis of breast cancer usually involves mastectomy.
Breast conservation therapy is currently not recom-
mended due to several issues. Intrinsically, most patients
have limited native breast tissue to begin with. Therefore,
obtaining clear margins may be diffi cult, and the result-
ing defect following lumpectomy can be substantial and
often associated with signifi cant asymmetries. Adjuvant
radiation therapy, as a component of breast conservation
therapy, has been shown to incur a high rate of complica-
tions, foremost among them being capsular contracture
(up to 65%). And surveillance and imaging following
conservation therapy is even further hampered by the
presence of capsule formation around the implant.

554 • CHAPTER 46
OUTCOMES ASSESSMENT
Despite the plethora of issues surrounding breast augmen-
tation, including patient desires, education, preoperative
planning, and potential complications; patient satisfac-
tion following augmentation mammaplasty remains high,
averaging 95%. Psychosocial and quality of life assessments
have shown mixed results. Similar to other cosmetic sur-
gery patients, women seeking breast augmentation report
a higher rate of body image issues, psychiatric disease, and
suicide than the general population. However, quantitative
improvements following augmentation have been found in
the areas of body image, concern over weight, and sexual
attractiveness.
REFERENCES
1. American Society of Plastic Surgeons. Report of the 2010
Plastic Surgery Statistics . APS National Clearinghouse of
Plastic Surgery Procedural Statistics.
gery.org/Media/Statistics.html .
2. Miglioretti DL, Rutter CM, Geller BM, et al. Effect of breast
augmentation on the accuracy of mammography and cancer
characteristics. JAMA. 2004;291:442.
3. Tebbetts JB. Dual plane breast augmentation: Optimizing
implant-soft-tissue relationships in a wide range of breast
types. Plast Reconstr Surg. 2006;118(7 Suppl):81S.
4. Tebbetts JB, Adams WP. Five critical decisions in breast
augmentation using fi ve measurements in 5 minutes: The
high fi ve decision support process. Plast Reconstr Surg.
2006;118(7 Suppl):35S.
5. Mentor Corporation. Bodylogic System.
wwllc.com/global/physician-information/bodylogic.htm .
6. Cunningham B. The Mentor Core Study on silicone Mem-
oryGelb breast pmplants. Plast Reconstr Surg. 2007;120
(7 Suppl 1):19S.
7. Spear SL, Murphy DK, Slicton A, et al. Inamed silicone breast
implant core study results at 6 years. Plast Reconstr Surg.
2007;120(7 Suppl 1):8S.
8. Pajkos A, Deva AK, Vickery K, et al. Detection of subclinical
infection in signifi cant breast implant capsules. Plast Reconstr
Surg. 2003;111:1605.
9. Adams WP, Rios JL, Smith SJ. Enhancing patient outcomes
in aesthetic and reconstructive breast surgery using triple
antibiotic breast irrigation: Six-year prospective clinical
Study. Plast Reconstr Surg. 2006;118(7 Suppl):46S.

c h a p t e r47
Congenital Breast Deformities
S. Alex Rottgers, MD / Derek Fletcher, MD / Angela Song Landfair, MD / Kenneth C. Shestak, MD
INTRODUCTION
Aesthetically “normal” breasts are of great importance
for young women because their perception of feminin-
ity and sexual identity. Morphological deformities of the
breast can cause issues with wearing clothes, psychologi-
cal stress, depression, peer rejection, and psychosexual
dysfunction, particularly in adolescent females. Many of
these deformities lend themselves to reconstruction dur-
ing or after breast development is complete.
In addition, abnormalities of breast development can
carry with them serious implications for the medical,
functional, and psychological well-being of the patient.
Congenital breast deformities may be associated with
abnormalities of other organ systems (genito-urinary)
which should be sought out for treatment.
As the breast constantly evolves over time and revi-
sions may be required in the future following initial sur-
gery, the timing and method of reconstruction should
be determined only after a detailed discussion with the
young patient and her family to understand her expecta-
tions and to best ensure that they together understand
the realities and limitations of a proposed procedure.
This is central to the process of informed consent and is
the foundation of the doctor–patient relationship.
Pediatric breast deformities can be divided into hyper-
plastic, hypoplastic, and post-traumatic defects. Each
represents various pathologies and a spectrum of dis-
ease which warrant consideration on a case-by-case basis.
Treatment goals should focus on accurate diagnosis and
appropriate timing and technique selection that will opti-
mize the cosmetic outcome and best satisfy the psycho-
logical needs of the patient.
EMBRYOLOGY AND DEVELOPMENT
Breast development is initiated between the 5th and
7th week of gestation. At this time, the mammary
lines form as bilateral linear condensations of ectoderm
extending from the axillary areas to the groin region,
which invaginate and come to lie below the ectodermal
surface forming the mammary ridges. In most instances,
only a small focus of mammary tissue overlying the tho-
racic region in the area of the fourth intercostal space
persists and will go on to form the true breast, while
those foci in the other areas promptly regress. This tis-
sue continues to divide and thicken; and by the 8th
gestational week, ectoderm has invaded into the under-
lying mesenchyme in a branching patter. At 16 weeks
of gestation, 15 to 25 epithelial branches have formed,
but canalization has not begun. It is during the third tri-
mester, under the infl uence of placental sex hormones
(mainly estrogen and progesterone) that these epithe-
lial branches are canalized, and primitive breast ducts
begin to form. At 32 weeks, differentiation of the paren-
chyma into lobules begins. The nipple-areola complex
begins to form and is completed in the early postnatal
period. Branching and canalization continue after birth
and through early childhood. 1 , 2
Breast development is relatively quiescent through-
out childhood. Further breast growth and maturation
is subsequently initiated at the time of thelarche. With
the increased growth at thelarche, the breast progresses
through a series of morphological stages, as described
by the Tanner classifi cation. A Tanner stage 1 breast is
prepubertal, with no appreciable breast parenchyma
and slight nipple elevation. At thelarche, the breast

556 • CHAPTER 47
progresses toward Tanner stage 2 with enlargement of
the nipple-areola complex and elevation of the breast/
nipple as a small mound. Tanner stage 3 describes a
breast with further enlargement and a smooth transi-
tion between the breast and areola without separation of
their contours. As the breast continues to enlarge toward
Tanner stage 4, the nipple and areola enlarge more and
project as a secondary mound above the breast contour.
Finally, at the fi nal Tanner stage 5, the breast achieves its
mature size and form. The areola has receded and forms
a continuous contour with the surrounding breast. 3 Most
females have achieved full breast maturity by age 16
to 18 years; however, the evolution of the breast form
continues as a lifelong process based on changes in body
habitus, pregnancy, and other factors.
HYPOPLASTIC DISORDERS
Various conditions result in hypoplasia or aplasia of the
breast. Hypoplasia in the form of mild asymmetry, con-
stricted breast deformities, and mild presents of Poland
syndrome is much more common than aplasia of the
breast. Both the constricted breast deformity and Poland
syndrome will be discussed in detail below.
Terms used to describe breast aplasia include athelia
(isolated absence of the nipple-areola complex), amasia
(absence of breast parenchyma), and amastia (absence
of both breast tissue and the nipple-areola complex). 1
Although this nomenclature would suggest otherwise,
athelia and amasia do not seem to occur without the other.
For a comprehensive description of amastia, the reader is
referred to description by Trier. 4
HYPERPLASTIC DISORDERS
Hyperplastic disorders include the excess development of
mammary tissue in its normal anatomic location as well as
the development of breast tissue or nipple-areola struc-
tures in locations remote from the normal thoracic distri-
bution. Treatments require simple observation, excision,
or breast reduction techniques. Accurately diagnosing and
assessing the degree of deformity is essential, along with
counseling the patient and family.
Virginal Hypertrophy
Virginal hypertrophy of the breast is a rare condition
that results in excessive, rapid, and often nonyielding
proliferation of breast tissue. The etiology is unclear, but
pathologic evaluation seems to suggest an abnormal sen-
sitivity of the glandular tissue to circulating estrogen is
the cause in the setting of normal levels of this hormone.
The condition may be unilateral or bilateral. Patients
often exhibit a rapid onset of breast hypertrophy only
months after the initiation of breast growth that quickly
becomes symptomatic with the typical signs of macro-
mastia (shoulder and neck pain, bra strap grooving, and
rashes) along with tender breast parenchyma, thinned
skin, striae, and dilated veins. They will generally present
because of the rapid progression.
Treatment is ultimately surgical. Breast reduction
techniques are standard as a fi rst-line therapy, and goals
should be to fi rst achieve an improved breast size and
symptom relief. Improved symmetry in asymmetric
cases of hypertrophy is also important. Some patients
still require repeated breast reduction operations, and
mastectomy may be considered in refractory cases. 5
Pharmacologic therapy in the form of medroxyproges-
terone acetate, dydrogesterone, tamoxifen, and bro-
mocriptine has been used but side effects have limited
their use. 1 , 5
Giant Fibroadenoma
Like virginal hypertrophy, giant fi broadenomas results
from abnormal sensitivity of the breast tissue to normal
hormonal levels. This entity is a discrete benign tumor
which enlarges rapidly and causes asymmetric enlarge-
ment of the breast. 5 Treatment is also surgical excision.
This is accomplished through breast reduction techniques
with a pedicle design and excision pattern that incorpo-
rates the mass into the resection specimen and positions
the pedicle in the location of the greatest amount of nor-
mal breast tissue to preserve breast fullness. Concurrent
matching procedures on the contralateral breast or
delayed revision mastopexy/augmentative procedures
may be needed to achieve symmetry. Timing for surgery
is driven by the rate of tumor growth. Excision may be
necessitated prior to completion of breast development
to limit the distortion of the breast and better achieve an
aesthetic result.
The differential diagnosis for fi broadenoma includes
cystosarcoma phyllodes, which can be diffi cult to differ-
entiate on pathology preoperatively or even on frozen sec-
tions. Because the incidence of phyllodes tumor is less than
1.3%, treatment should include simple excision of the
mass followed by consideration for mastectomy or adju-
vant therapy if the diagnosis of phyllodes tumor is made
with consultation of surgical oncology or pediatric surgery
is recommended.
Polythelia and Polymastia
Polythelia, presence of accessory nipples, is a common
pediatric abnormality and has reported incidence as high
as 5.6%. 1,4 Polymastia, the development of supernumerary
breast tissue, with or without a nipple or areola is much less
common. Both are presumed to arise from an incomplete
regression of the mammary ridge during embryonic devel-
opment, leaving residual mammary tissue along the “milk
line” between the axilla and pubic region. Polymastia most
often occurs with axillary breast tissue. 1 Supernumerary
breast tissue may also be removed surgically with place-
ment of closed suction drains.

CONGENITAL BREAST DEFORMITIES • 557
Gynecomastia
Although usually seen by plastic surgeons in its most
severe form, gynecomastia is by far the most common
pediatric breast deformity occurring in up to 65% of
pubescent males. 1 Gynecomastia is a clinical term denot-
ing enlargement of the male breast such that it is female
like. It is most often related to proliferation of ductal
epithelium, as no true acnicar development occurs. Most
often, it is idiopathic in its etiology, but the prolifera-
tion can be a symptom of an underlying pathologic pro-
cess. “Physiologic” gynecomastia is common during three
periods of a male’s lifespan. Neonates often exhibit small
enlargement of the breast bud and may secrete colos-
trum transiently as a response to maternal estrogens. As
stated above, the fl uctuating hormonal milieu of early
puberty produces gynecomastia in up to 65% of males
between age 14 to 16 years, and declining androgen pro-
duction seen in later life can lead to a relative estrogen
excess and to the development of gynecomastia. If other
signs of pubertal development are present, a normal his-
tory and physical should suffi ce for evaluation; but in
the absence of normal pubertal development, a more
extensive evaluation is needed to elucidate the etiol-
ogy. In most males, pubertal gynecomastia is mild and
transient. 1
While gynecomastia may be considered normal in these
age groups, a history and physical examination should be
performed to look for common causes such as testicu-
lar cancer, pituitary tumors, adrenal tumors, liver disease,
paraneoplastic syndromes, Klinefelter syndrome, thyroid
disease, renal failure, myotonic dystrophy, HIV, and the
use of marijuana, alcohol, anabolic steroids, and medica-
tions known to cause gynecomastia. 1 The most common
etiology of gynecomastia in patients older than age 40
years is drug induced.
When signifi cant gynecomastia persists for 2 years
beyond puberty, surgery is often indicated to re-create
a more normal chest contour and nipple location with
limited scaring. The fi rst procedures described for gyne-
comastia focused on subcutaneous mastectomy through
periareola or various other incisions. 6,7 This likely is still
the best approach in cases of dense fi brous tissue that
is located in a subareola plane. Others have advocated
the use of ultrasound-assisted liposuction as the standard
fi rst-line approach, followed by secondary excision only
for a marked residual deformity. The ideal approach in
most cases is a combination of these, with direct periare-
ola excision of the central, fi brous breast buds followed
by liposuction to contour the periphery. Severely redun-
dant skin may be excised primarily with a periareola or
vertical skin excision, but we believe that the signifi cant
elasticity of youthful skin often allows and produces
adequate retraction of skin excess, such that in most
cases primary skin excision is not warranted. If the skin
envelope redundancy persists beyond 6 to 12 months
postoperatively, excision can then be undertaken. 6,7 Care
must be taken during resection, not to over-resect tis-
sue to avoid a contour indentation “dishing” or nipple
retraction. Regardless of technique used, postopera-
tive care involves use of closed suction drains follow-
ing excision, prolonged compressive garment application
(for at least 6 weeks), twice daily deep tissue massage
instituted at 1 week postoperative, and abstinence from
heavy exercise for 1 month. These adjuncts aid in tissue
re- draping, reduce edema, and limit formation of seroma
and hematomas.
AN APPROACH TO CONGENITAL
AND DEVELOPMENTAL
BREAST ASYMMETRIES
Both hypoplastic and hyperplastic breast disorders rep-
resent a spectrum of disease. Often patients present with
bilateral manifestations of breast hypoplasia, breast con-
striction, and hyperplasia. Signifi cant breast asymmetries
can result from variable expressions of these. The key to
achieving an outcome that both the patient and surgeon
are pleased with is to fi rst identify these bilateral and
asymmetric abnormalities preoperatively. The surgeon
must understand what the patient perceives as abnor-
mal about her breasts, which breast she like better, and
what their goals of treatment are. The key is to educate
the patient that the goal is improvement of her breast
symmetry and contour, rather than perfection. Perfection
is always striven for, but in reality is never achieved.
Managing patient expectations preoperatively is a key to
success in this area of surgery. Signifi cant improvements
almost always occur, and if patients understand the lim-
its of surgery before the procedure, they are generally
pleased with their result.
If the surgeon can accurately identify which breast
bothers the patient or if both are problematic, then he
or she can begin to formulate an operative treatment
plan. In our experience, the best results in cases of breast
asymmetry are achieved in cases where a patient has a
smaller, but aesthetically pleasing breast, which they
want the larger breast to match. A single-staged reduc-
tion or mastopexy can improve symmetry, correct ptosis
in the larger breast, and avoid the potential problems of
implant-based reconstruction/augmentation. This limits
the number of variables at play (eg, issues inherent with
implant placement) and increases the predictability of
the fi nal outcome.
The operation should be designed based on the amount
of resection needed to match the contralateral breast vol-
ume, the distance which the nipple must be transposed
to achieve symmetry, the degree of ptosis, and the expe-
rience/comfort the surgeon has with various pedicle
techniques. This is illustrated by the patient in case 1
( Figure 47-1 ). She presented at age 17 with unilateral
right breast hypertrophy. She liked the size of her oppo-
site left breast and did not wish to have surgery on it.

558 • CHAPTER 47
FIGURE 47-1. An 18-year-old patient with
developmental breast asymmetry with unilateral right breast
hyperplasia. The plan is for unilateral right breast reduction
with 5-cm nipple transposition. A total of 365 g of tissue was
resected from the right breast.
FIGURE 47-2. (A) Preoperative and (B) 5-year postoperative anteroposterior view
showing maintenance of symmetry.
A
B
She underwent an inferior pedicle breast reduction with
a Wise pattern skin excision. She is shown 5 years post-
operatively ( Figures 47-2 and 47-3A,B ) with excellent
shape and symmetry of the breasts.
In most cases, the clinical scenario is not so straightfor-
ward or simple however. In our experience, most surgical
corrections involve bilateral surgery. Differential reduc-
tions, mastopexies, augmentations, and most frequently
combinations of these must be employed to achieve the
most harmonious balance between the breasts when
combinations of hypoplasia and hyperplasia coexist.
Careful consideration of each breast and each breast
abnormality within the context of the patient’s expecta-
tions is paramount. This includes explaining the details
of surgery, such as incision placement, anticipated recov-
ery and the potential surgical, cosmetic complications
that may occur including the inherent risks of breast
implants specifi cally focusing on capsular contracture,
implant failure, and unplanned additional surgery. It
must also be mentioned that the breast appearance will
most likely change with weight fl uctuation, pregnancy,
and aging; regardless of what procedures are undertaken,
all are important elements of an informed consent that
centrally involves the patient and her parents.
Timing for reconstruction must also be addressed
with the patient and her family. As the breast is con-
stantly developing and evolving in form, it is best to delay

CONGENITAL BREAST DEFORMITIES • 559
FIGURE 47-3. (A) Preoperative and (B) 5-year postoperative oblique view.
A
B
treatment in very young patient. It is most often ideal to
delay reconstruction until the patient has fi nished grow-
ing and her breasts are mature (patients who are older
than 16 years of age).
We employed this strategy in the patient shown in
case 2 ( Figure 47-4A,B ). She was seen at age 15 with a
combination of right breast hypoplasia with breast con-
striction and left breast hypertrophy. The best approach
FIGURE 47-4. (A,B) A 16-year-old patient with right breast hypoplasia and
left breast hyperplasia. The plan is for a partial retropectoral placement of a 360-cc,
moderate profi le, saline implant and left vertical reduction of 335 g.
A
B

560 • CHAPTER 47
FIGURE 47-5. (A,B) Preoperative and (C,D) 4-month postoperative views showing
improved breast symmetry with bilateral breast surgery.
A
B
D
C
was to wait until the summer prior to her senior year in
high school, at which time she underwent a periareola
augmentation/mastopexy on the right side with the par-
tial subpectoral placement of a saline implant and a left
vertical mastopexy. She is shown at 4 months follow-
ing surgery ( Figure 47-5 ) with much improved overall
breast symmetry.
In cases of more severe deformities in a setting of a
patient who appears to be mature (physically and psy-
chologically) at an age younger than 16 years, earlier
surgical intervention can be considered. When surgical
procedures are undertaken in these younger patients,
future revisions are likely to be more common.
Another approach to this problem is placement of a
standard tissue expander followed by immediate expan-
sion to correct for the current asymmetry. If patients
are young and likely to have continued maturation
of their breasts, this expander can be left with subse-
quent adjustments made to the volume over a period
of months to years. The ultimate exchange for a per-
manent prosthetic can be made when the patient has
fully matured, and she desires the completion of her
reconstruction. The senior author (KCS) fi rst encoun-
tered this strategy when two postmastectomy patients
were lost to follow-up after placement of their tissue
expander and subsequent expansion. The patients did
not return for placement of their permanent prosthe-
sis until years later. In the interim, they had no com-
plications and exhibited an aesthetic breast contour
that was appealing. In the past, we have considered the
use of Becker adjustable breast implants (currently no
longer available) but experienced diffi culty fi nding the
expander port, and fear of implant injury has lead us to
favor the use of expanders with magnetized injection
ports and robust metallic backstops.
Placement of a breast reconstruction tissue expander
should not be considered defi nitive reconstruction, but it
offers a means for a young patient to have her emotional
and social concerns centered around a signifi cant breast
asymmetry addressed in a timely manner in a way that
can be adjusted as she continues to grow and limits the
risks of compromising her ultimate outcome once she
has reached maturity.
TUBEROUS BREAST DEFORMITIES
Tuberous breast deformity describes a spectrum of aber-
rant breast morphology fi rst reported by Rees and Aston. 8
The term “tuberous breast” refers to the similarity in
shape of affected breasts to a tuberous plant root. Since

CONGENITAL BREAST DEFORMITIES • 561
its original description in 1976, multiple authors have
reported similar anomalous breast deformities under
various monikers, including “Snoopy” breast, constricted
breast, tubular breast deformity, lower pole hypoplastic
breast, narrow-based breast, herniated areola complex,
domed nipple, and nipple breast.
Clinical Features
Tuberous breast deformity describes a broad spectrum
of aberrant breast shape that presents during adolescent
breast development. The degree of deformity varies on a
continuum from mild to severe. Affected breasts demon-
strate a constellation of fi ndings, each with variable degrees
of contribution to the deformity as a whole. These fi ndings
are listed above.
The key features of tuberous deformity are lower pole
skin envelope defi ciency in the vertical and horizontal
dimensions, parenchymal hypoplasia, and constriction of
breast development in the lower pole. Pseudo-herniation
of the nipple-areola complex is a common but not constant
feature of tuberous breast deformity, occurring in 40% to
50% of cases. However, breasts that are more severely
affected and/or asymmetric tend to demonstrate greater
degrees of nipple-areola complex involvement, including
enlargement of the areola and herniation of underlying
parenchyma into the nipple-areola complex.
There is no consensus in the literature regarding what
degree of deformity predominates. Either unilateral or
bilateral breast involvement may occur, although reports
in the literature vary as to which presentation is more
common . While the incidence of tuberous breast defor-
mity among the general population is not known, it is
much more common than previously anticipated.
Etiology
The defi nitive etiology of tuberous breast deformity is
unknown; however, the theory proposed by Grolleau
et al. seems to most aptly fi t the clinical picture.9
They proposed anomalous superfi cial fascial adhesions
between the dermis and the underlying muscular plane.
The adhesions restrict normal development of the breast
parenchyma and overlying skin envelope in the lower
pole. The restriction favors, instead, growth of the breast
away from the chest wall, leading to formation of tuber-
ous shape and enlargement of the areola as the breast
develops during adolescence. Mandrekas et al. hypoth-
esized that the deformity results from a combination of
an abnormal constricting fi brous ring surrounding the
periphery of the nipple-areola complex and a normal
superfi cial fascial window beneath the areola. 10 Because
the ring density is highest in the lower pole, the develop-
ing adolescent breast is unable to expand inferiorly and
is forced to grow away from the chest wall toward the
superfi cial fascial window beneath the areola. It is the
degree of superfi cial fascial aberrancy that determines
the degree of severity of the deformity.
Classifi cation
The broad spectrum of deformity and inconsistent
nomenclature used to describe tuberous breasts lead to
the formation of several classifi cation systems. Grolleau
classifi ed the deformity into three subtypes based on the
degree and location of the breast base constriction and
subareola skin defi ciency. 9
Type I: lower medial quadrant defi ciency
Type II: lower medial and lateral quadrant defi ciency
Type III: defi ciency of all four quadrants
Aesthetic reconstruction of the tuberous breast poses
a challenge to the plastic surgeon. The broad spectrum
in aberrant breast shapes requires a systematic approach
to consistently achieve satisfactory outcomes. Once the
diagnosis is established, every effort must be made to
accurately analyze the deformity. Careful consideration
as to the severity of deformity, presence or absence of
asymmetry, and the quantifi cation of the various mor-
phological elements contributing to the deformity
should be measured and noted. This includes discrep-
ancies in inframammary fold level, the nipple to fold
distance, the suprasternal notch to nipple distance, the
breast and chest base width dimensions, the patient’s
torso dimensions and an estimate of her native breast
tissue, and any asymmetries of the parenchyma. Once
the deformity has been accurately classifi ed, the patient
(and her parents) should be engaged in a thorough dis-
cussion regarding the various elements of her deformity,
the challenges and limitations of operative intervention,
possible complications, and appropriate expectations
regarding outcome.
The goals of surgery are to restore volume to the hyp-
oplastic breast(s), expand the lower pole by releasing
the tethering fi brous attachments or bands between the
breast parenchyma and deep fascial and pectoralis mus-
cle and also between the breast parenchyma and skin,
and where necessary, reduce the areola size and recess
the herniated breast tissue. This is best accomplished
with an infra-areola incision which provides direct access
for the release of the constricting fi brous bands and for
placement of an implant into the subpectoral space. The
incision can be easily converted to a periareola incision
when needed. Saline implants are currently mandated for
reconstruction in the United States for patients younger
than 22 years. They offer the advantage of mild adju-
stability in this population where native breast volume
asymmetry is so prevalent. There must be an increase in
the base dimensions of the breast in terms of both width
and height.9,10,11 In the vast majority of cases, the proce-
dure can be carried out in a single stage with a period of
preliminary tissue expansion (a two-staged procedure is
reserved for only the most severe cases).
A typical patient is illustrated in case 3 ( Figure 47-6 ).
This adolescent female presented at age 17 with
severe bilateral breast hypoplasia and a Grolleau type
3 constriction of both breasts with signifi cant hypoplasia

562 • CHAPTER 47
FIGURE 47-6. (A–C) Preoperative view of 18-year-old female with Grolleau type III
bilateral breast constriction.
A
B
C
and pseudo-herniation of breast tissue through the areola.
The surgical plan entailed the partial retropectoral place-
ment of 330 cc of moderate profi le, smooth-surfaced,
saline implants, using a dual plane approach incorporated
with a periareola mastopexy with Gore-Tex sutures.
The 24-month, postoperative, follow-up evaluation dem-
onstrates ( Figure 47-7 ) the patient to have an excellent
improvement in breast appearance from the standpoint
of volume, contour, and nipple- areola appearance.
In summary, key features of treatment include:
• Assessment of unique features associated with each
individual deformity
• Restore mammary base dimensions and re-position
inframammary fold
• Release of constricting bands between the breast
parenchyma and the deep fascial/muscle tissue and
bands between the parenchyma and overlying skin
A
B
C
FIGURE 47-7. (A) Preoperative and (B,C) 2-year postoperative oblique view.

CONGENITAL BREAST DEFORMITIES • 563
• Placement on a prosthetic implant in the subpectoral
space using dual plane approach
• Reduce herniated breast tissue and reduce and con-
trol the size of the areola through a periareola mas-
topexy incision
• Balance breast asymmetry with bilateral procedures
POLAND SYNDROME
Pathognomonic of Poland syndrome is the agenesis of the
sternocostal head of the pectoralis major muscle. In addi-
tion, there are varying degrees of accompanying anoma-
lies of the upper limb and ipsilateral thorax prominently
including various degrees of ipsilateral breast hypoplasia
in women. Although named after the anatomist Alfred
Poland, the thoracic component of the disease was origi-
nally described by Lallemand in 1826, and the association
with complex syndactyly was made by Floriep in 1839.
These initial fi ndings were later reiterated by Poland in
1841 at Guys Hospital in London.12
The incidence of Poland syndrome is estimated at
1:30,000 to 1:100,000 live births, with the majority
of cases being of sporadic inheritance. The incidence
is higher in men than for women at 3:1, and the right
side is often more affected than the left by 3:1. The
most common presenting deformities seen by the clini-
cian are limb anomalies in both females and males and
ipsilateral hypomastia in females. However, many men
remain undiagnosed unless they seek treatment for hand
anomalies which are most commonly a shortened upper
arm, forearm, or fi ngers, termed brachysymphalangism
along with ebbing of the ipsilateral fi ngers in the form
of syndactyly. The frequency of hand abnormalities in
the Poland syndrome patient ranges between 13.5% and
56%.13,14
Breast deformity in the female is highly variable, rang-
ing from mild hypoplasia to aplasia. The typical breast
deformity is marked by defi cient parenchyma, a high
inframammary fold, and a malpositioned and underde-
veloped nipple-areola complex. Indeed 14% of breast
aplasia may be accounted for by Poland syndrome. It is
important to note that in 20% of cases, there are asso-
ciated skeletal deformities leading to contour and rota-
tional anomalies of the chest wall. Ribs can be deformed
and/or hypoplastic, particularly second through fi fth ribs.
Poland syndrome is sometimes referred to as “acropec-
toral renal fi eld defect” due to a high incidence of renal
anomalies. The most common anomalies include duplica-
tion of the collecting system of unilateral renal agenesis.
In very atypical cases, the patient can present with uni-
lateral renal agenesis or dextrocardia in left-sided Poland
syndrome. Associations between Poland syndrome and
malignancy have been documented. Breast hypoplasia
does not preclude development of breast carcinoma. The
most commonly associated syndromes are Mobius and
Klippel-Feil syndromes. 13,14
Etiology
The etiology of Poland syndrome remains unknown. The
most popular current theory is the subclavian artery sup-
ply disruption sequence, a vascular compromise event that
occurs during critical 6th and 7th weeks of pregnancy.
This event would coincide with fetal breast development
between weeks 5 to 7 of gestation, which begins as bilateral
thickening of the ectoderm along the mammary line, then
partially involutes shortly thereafter. The remaining thick-
ened mammary line forms the mammary ridge. Reduction
in blood fl ow at crucial periods or hypoplasia of internal
thoracic artery could lead to disruption in pectoralis major
development, where hypoplasia of the branches of brachial
artery during development could lead to symbrachydactyly.
Clinical Classifi cation
The Foucras classifi cation, which classifi es the Poland syn-
drome patient into mild, moderate, and severe categories,
adequately describes clinical fi ndings based on degrees of
thoracic deformity. 13
Grade I is a minor deformity consisting of pectoralis
major hypoplasia and moderate breast hypoplasia, result-
ing in breast asymmetry in women but only slight chest
wall asymmetry in men. Nipple-areola is present, but often
smaller and elated. No skeletal abnormalities should be
found in a grade I patient.
Grade II is a moderate deformity with marked pectora-
lis major aplasia, hypoplasia of other chest wall muscles,
moderate rib deformity, and marked chest wall deformity
in men and women. Breast tissue is severely hypoplastic
or absent and the nipple-areola is hypoplastic or absent.
In men, grade II is best addressed with a customized chest
wall implant or a latissimus dorsi fl ap, with or without
autologous fat injections. In women, a latissimus dorsi
fl ap with tissue expansion and implant may be effective.
Adjunct autologous fat transfers can improve symmetry.
Chest wall muscles affected may include the adjacent
muscles to the pectoralis major, including the serratus
latissimus dorsi and external oblique.
Grade III is a severe deformity with aplasia of breast and
pectoralis major as well as aplasia of other chest wall mus-
cles, major bone and cartilage anomalies with rib aplasia
and sternal deformity, and major chest wall deformity in
men and women. In both men and women, the treatment
often involves several stages. Complicating the reconstruc-
tive ladder, grade III patients also often have absent or
severely hypoplastic latissimus dorsi muscles. Free fl aps
may be the best options, such as contralateral free latis-
simus dorsi with an implant or abdominal tissue-based
reconstructions. Primary skin expansion may often be nec-
essary. Outcomes are often less than satisfactory and serial
fat injections can help balance the soft tissue defect.
Treatment
Surgical therapy of Poland syndrome focuses on improv-
ing function of the affected limb and improving chest

564 • CHAPTER 47
FIGURE 47-8. A 19-year-old patient with unilateral
Poland syndrome with severe breast hypoplasia, skin
envelope defi ciency, and superior nipple malposition.
(Used with permission of Julian J. Pribaz, MD.)
wall appearance. The chest deformities of Poland syn-
drome rarely cause functional problems, except in the
most severe cases. Indications for reconstruction of the
thorax include chest wall depression, inadequate protec-
tion of the mediastinum, or paradoxical movement of
chest walls during respiration. Hand anomalies should be
corrected prior to 1 year of age to maximize functional
outcomes.
In most cases, surgery for Poland syndrome is for the
correction of breast aplasia or hypoplasia in females. In the
absence of severe chest wall anomalies, waiting until after
puberty affords the best chance of balancing asymmetry.
The challenges to aesthetic breast reconstructions in
the patient with Poland syndrome include tight and unfor-
giving skin envelope, defi cient subcutaneous tissue, high
inframammary fold, nipple-areola complex malposition
or absence, and adequacy of recipient vessels if free fl ap
reconstruction is desired. Often, a variety of treatment of
modalities described below must be combined to produce
optimal results.
Expander and Implant Reconstruction
Grade I and many grade II patients may be treated with
implants. A single-stage correction with a submuscular
implant can produce suitable results. For implant recon-
struction to be successful, the patient must have adequate
soft tissue thickness on the affected side to cover and
camoufl age the implant. The tight skin envelope, high and
tight inframammary fold, and soft tissue defi ciency can
prove challenging for reconstruction with implant alone.
A tissue expander may be utilized in a subpectoral posi-
tion if there is enough pectoralis major muscle present
in the superior and medial position. With expansion of
the superior pole of the chest, the nipple-areola complex
will descend to a more symmetric position14 (see below).
Implants are frequently used in Poland syndrome but, as
with their use in other locations, they are not without
drawbacks and morbidity.
Autologous Tissue Transfer
Pedicled latissimus dorsi myocutaneous fl ap reconstruc-
tion, with or without an accompanying implant, has
been considered a mainstay of treatment in patients
with moderate to severe chest wall defi ciency and breast
agenesis or hypomastia. The potential benefi ts are ease
of harvest, replacement of pectoralis major with simi-
lar tissue, and relative ease compared with microsurgical
reconstruction. 15
This strategy was used in the patient depicted in case 4
( Figure 47-8 ). She presented at age 19 with a right uni-
lateral Poland syndrome with severe breast hypoplasia,
including a superiorly malpositioned nipple-areola com-
plex and absence of the anterolateral axillary fold. There
was a defi ciency of anterior chest wall and breast skin. The
plan was for a two-stage reconstruction with the initial step
being slow, gradual expansion of the breast and chest wall
FIGURE 47-9. The reconstruction begun with
subcutaneous tissue expansion of the upper and lower aspect
of the skin envelope to increase quantitative dimension of skin
envelope in an attempt to lower nipple-areola position. (Used
with permission of Julian J. Pribaz, MD.)
skin ( Figure 47-9 ). Subsequent to this, the patient under-
went removal of the expender along with harvest of the
right latissimus dorsi muscle fl ap through limited back and
high axillary incisions. The latissimus dorsi fl ap was inset
( Figure 47-10 ) to the parasternal area and to the infra-
mammary region through inframammary incision used for
the tissue expander placement. A 260-cc saline implant
was placed beneath the latissimus dorsi fl ap. The patient
is shown 3 years following the second stage of the recon-
struction ( Figure 47-11 ) with a marked improvement in
the appearance of her breasts.
The greatest potential limitation of this operation is
that the latissimus dorsi can be defi cient or absent in
the more severe forms of Poland syndrome, leading to

CONGENITAL BREAST DEFORMITIES • 565
inadequate tissue bulk or defi cient vascular supply. In
addition, the harvest of latissimus dorsi fl ap may decrease
function in an upper extremity that may already have
decreased function compared with the contralateral
extremity. The plastic surgeon must carefully examine
the status of the latissimus dorsi muscle in every patient.
Transverse rectus abdominis myocutaneous (TRAM)
fl aps have been used frequently in patients with Poland
syndrome. Pedicled TRAM fl aps may encumber the
young, active patient by virtue of possible abdominal mor-
bidity. Free TRAM fl aps have been utilized successfully.
FIGURE 47-10. The subcutaneous tissue defi cit
and anterior axillary fold was reconstructed with the right
latissimus dorsi muscle fi xed to skin of the lower breast and
parasternal region. A 260-cc, moderate profi le, smooth saline
implant was placed beneath the latissimus dorsi muscle.
(Used with permission of Julian J. Pribaz, MD.)
In addition, other free tissue transfer options include
the deep inferior epigastric artery perforator (DIEP),
the superior gluteal artery (SGAP), and superfi cial infe-
rior epigastric artery (SIEA) fl ap for the treatment of
moderate-to-severe Poland syndrome with breast hyp-
oplasia or aplasia. Longaker published a series of nine
patients who underwent free tissue transfer for Poland
syndrome chest wall reconstruction.16
There is a high incidence of anomalies in vasculature
arising from the subclavian vessels in Poland syndrome.
Preoperative imaging such as ultrasound or CT angio-
gram is recommended to determine patency and fl ow in
the thoracic vasculature, particularly the internal mam-
mary vessels.
Autologous Fat Transfer by Injection
Coleman’s technique of lipostructure is desirable due to
low invasiveness and mobility. Pinsolle and colleagues 17
used autologous fat injections in a series of eight patients
(mean age, 25 years), using fat harvested from abdomi-
nal or trochanteric areas, with fat necrosis occurring in
one patient. They noted that fat injection can be used in
conjunction with other procedures, and is especially use-
ful in fi lling the subclavicular hollowing seen in even the
mildest cases of patients with Poland syndrome.17
At this particular time, serial fat transfers can opti-
mize outcome when used as a touch-up procedure after
the defi nitive reconstruction. Fat transfers can deliver a
modest amount of tissue and are best used as adjuncts
to tissue expander, implant, and autologous tissue recon-
structions. However, we would predict and anticipate
that autologous adipose injections will play a substan-
tially larger role in the breast reconstructions performed
in patients with breast hypoplasia accompanying Poland
syndrome and also in the correction of other congenital
and developmental breast deformities in the years and
decades ahead.
A
B
FIGURE 47-11. (A) The preoperative and (B) 3-year postoperative appearance of the
patient is illustrated. (Used with permission of Julian J. Pribaz, MD.)

566 • CHAPTER 47
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c h a p t e r48
Acellular Dermal Matrix in Aesthetic
Revisionary Breast Surgery
G. Patrick Maxwell, MD, FACS / Allen Gabriel, MD, FACS
INTRODUCTION
Breast augmentation is the most common aesthetic pro-
cedure performed in the United States and perhaps in
the world. As plastic surgeons, we strive to achieve per-
fection and continue to improve our surgical techniques
to achieve the aesthetic breast form. Despite advances in
implant technology and surgical techniques, undesired
outcomes are encountered, leading to revisionary surger-
ies. In preparing for a revisionary breast augmentation,
one must understand patients’ goals and expectations and
evaluate the probability of their accomplishment, as well
as the risk/benefi t ratio. When a decision is made to move
forward, the goal should be to plan and execute the most
precise and effi cient surgical correction. To achieve this
goal, one must understand the problem(s) and variables
involved, and then look for new solutions.
In the past, our options were limited to working with
only native tissues that were available to us for these pro-
cedures. With the advent of acellular dermal matrices
(ADM), the indications and the spectrum of correcting
secondary deformities has improved.
It is estimated that over 300,000 primary breast aug-
mentations were performed in the United States in 2009,
and therefore there are now over 3 million women with
augmented breasts in this country. 1– 3 Based on current
data, between 15% and 30 % of these women, will have
a reoperation within 5 years of their initial procedure. 1– 3
Unfortunately, this rate climbs to 35% in patients with
prior history of revisionary breast augmentation. 4 As pro-
cedures become more complex in nature and number,
new techniques and solutions are required of surgeons
who perform these challenging operations to improve long
term patient outcomes.
Capsular contracture has historically been the most com-
mon complication of aesthetic and reconstructive breast
surgery and remains the primary reason for most revision-
ary surgeries. 2 , 3 , 5 , 6 While increasing data suggest capsular
contracture can be minimized in primary augmentation
by technical detail, including precise, atraumatic, bloodless
dissection, appropriate antibiotic breast pocket irrigation,
and minimizing any points of contamination during the
procedure, 4 , 7 treatment of an established capsule remains
even more challenging than the application of these tech-
niques alone.
With the enforcement of FDA restrictions on silicone gel
implants in the early 1990s, American surgeons were forced
to use saline implants. 1 Prior to the 1992 “moratorium,” the
majority of silicone gel implants were placed in the subg-
landular position; saline implants (due to their palpability)
began to be placed under the muscle in an effort to con-
ceal the untoward contour irregularities of these implants. 8
As the number of these implants were of larger volumes,
many patients experienced thinning of breast parenchyma
and the overlying soft tissue, whether the implants were
in subglandular or subpectoral positions. The thinned tis-
sues in turn can lead to long-term complications, such as
palpability, rippling, implant extrusion, double bubble,
“Snoopy” deformity, symmastia, “bottoming out,” and
implant malposition. 1 , 8 , 9
Hence, implant malposition and concerns with ptosis
or skin stretch are the next most common causes for aes-
thetic revisionary surgery following capsular contracture.

568 • CHAPTER 48
These are more frequently associated with larger volume
saline implants, but can be a result of planning decisions,
surgical technique, or effects of time (gravity) with silicone
gel implants as well. Historically, our options for revision and
improvement have included replacing saline implants with
gel implants, capsulorrhaphy, use of capsular fl aps, or per-
forming a site change operations. The site change principle,
described in the mid-1980s, combined total or partial cap-
sulectomy with conversion to a different pocket (generally
a subglandular to subpectoral site change) for the replace-
ment implant. 10 While site change procedures have been
successful, none of these procedures alone have resulted in
complete resolution of the described complaints.
As change was necessary to improve clinical outcomes
in this population of breast revision patients, application
and development of newer techniques and technologies
were pursued. Many breast revisions require creation of
a new pocket for the new implant. Because many patients
have had implants in multiple pockets, and as the major-
ity of implants in revisionary patients today are already
in the subpectoral position, we developed (in 1991) the
“neopectoral pocket” concept to create a new pocket in
the subpectoral-precapsular space. 11 Initially developed
for double-bubble problems (inferior malposition), this
concept was also applied to symmastia (medial malposi-
tion), capsular contracture, ptosis, and conversion of round
to anatomical-shaped implants (demanding a snug, hand-
in-glove fi t). The detailed operative technique of creation
of the neopectoral pocket has been described in a previ-
ous publication. 8 For patients presenting with implants
in the subglandular position, a subpectoral site change is
utilized.
Notwithstanding the importance of the site change
concept, the most important addition to our clinical arma-
mentarium has been the utilization of acellular dermal
matrix (ADM), as a regenerative construct, to help solve
these challenging clinical presentations. 12 The successful
use of ADMs has been reported in a range of clinical set-
tings, including abdominal wall repair, hernia repair, facial
and eyelid surgery, cleft palate repair, soft tissue augmen-
tation, tendon repair, ulcer repair, vaginal sling repair, and
breast reconstruction. 13 – 23 While its use in reconstructive
expander and implant breast surgery has become a stan-
dard of care, its use in aesthetic revisionary breast surgery
has evolved more slowly, 24– 26 and has only recently gained
widespread adaption. 24
PATIENT SELECTION
The use of ADM can be categorized into four distinct
indications based on the underlying clinical presentation:
(1) coverage of implant lower pole (usually for revision
mastopexy), (2) implant stabilizer (usually for malposition
correction), (3) tissue thickener (usually superomedially
or inferiorly), and (4) treatment of capsular contracture
(which may be technically similar to lower pole cover or
superior-medial thickening) ( Figure 48-1 ).
The important concept and technique of lower pole
coverage is perhaps the most frequently used role for
ADM. It is employed when performing soft tissue and
skin envelope alterations in reoperative surgery (revision
mastopexy with augmentation). As many patients with
previously placed implants develop laxity, sag, or tissue
thinning over time, mastopexy or revision mastopexy over
the replacement implant is required to achieve the aes-
thetic breast form. If the existing implant is subglandular,
a subpectoral (subpectoral-fascial) pocket is created (after
capsule treatment), the new implant inserted in the newly
created subpectoral pocket, and the lower portion of the
implant covered with ADM. This allows a circumvertical
or inverted T mastopexy to be safely performed without
underlying muscle, as the ADM separates the skin clo-
sure from the implant. If the existing implant is already
subpectoral, a neopectoral site change is carried out, and
the ADM utilized similarly. If there has been a previous
implant in both the subglandular and subpectoral pockets,
lamellar separation (dissecting the pectoralis muscle from
its superfi cial and deep scarred attachments) may be nec-
essary ( Figure 48-2 ). ADM is considered to be the outer
layer of the underling implant (to which it is intimately
engaged by proximity of placement), and may also require
suture stabilization. Thus, the ADM may be tacked to the
inferior border of the pectoralis major above and to Scarpa
fascia or deep fascia below (at the level of the inframam-
mary fold). Parachute pull-out sutures may alternatively
be used to re-drape the ADM. When there is lamellar scar-
ring requiring lamellar separation, the remaining pectoralis
muscle may be “window shaded” up in the pocket, requir-
ing lower muscle inferior pull following its release. This
lower pole coverage situation is best achieved by suturing
of the ADM along the entire length of the lower pectoral
border, draping it over the implant inferiorly, and securing
it (under more tautness) at or near the inframammary fold.
This application is similar to the reconstructive model, as
a pectoral muscle extension ( Figure 48-3 ). In all instances,
an adequate environment, cover and stability over the
nonmuscle-covered portion of the implant (lower pole) by
the ADM, allows the skin envelope to be safely lifted and
tightened (mastopexy), assuming adequate respect for the
vascularity to the re-draped tissue, as well as compliance
with all sound surgical principles ( Figures 48-4 , 48-5 , and
48-6 ).
Regarding the desired biomechanical properties of the
desired ADM, rapid revascularization is required to con-
formability of the ADM to re-drape over the surface of the
implant (intimate engagement of surface contours). If the
patient had capsular contracture a more compliant mate-
rial may be desired. If the patient had more laxity or stretch
deformity, a more taut material might be preferable.
ADM also allows the surgeon an enhanced control in
maintaining implant position in a newly created “neo”
pocket or for reinforcement after capsulorrhaphy in various
forms of implant malposition correction. Inferior malposi-
tion (double bubble), medial malposition (symmastia), or

ACELLULAR DERMAL MATRIX IN AESTHETIC REVISIONARY BREAST SURGERY • 569
lateral malposition are generally treated by capsulorrhaphy
or site change (the authors’ preference). In a certain per-
centage of patients, the tissue is strong enough to support
this correction with a new pocket and appropriate sutur-
ing alone. A number of these patients, however, will have
thin tissue, previous scar, or problematic bony contour
slopes, such that reinforcement of the site change (ie, neo-
pectoral pocket of appropriate dimensions in the correct
location with old pocket obliteration) with ADM is highly
advised to reinforce or buttress the corrected implant posi-
tion ( Figures 48-6 , 48-7 , and 48-8 ). These materials are
sutured in appropriate position with proper purchase to
achieve support. The biomechanical properties of ADM
for this indication are strength and tautness to maintain
implant stabilization.
The concept of ADM as a tissue thickener is an exten-
sion of second-stage breast reconstruction where expander-
FIGURE 48-2. Intraoperative view of lamellar separation.
Center placement
Lower lateral
placement
Medial placement
Upper medial
placement
FIGURE 48-1. Placement of ADM at various anatomical locations during
revisionary surgery based on distinct indications with underlying clinical presentation.
A
B
C
D

570 • CHAPTER 48
to-implant conversion is facilitated by a superomedial
placement of an extra-thick ADM, to enhance soft tissue
cover of the implant and give a better visual and palpable
confl uence of chest to breast form. 27 In aesthetic revi-
sions, this is also most frequently applied to upper pole (or
superomedial area) to thicken tissue, minimize visibility of
traction rippling, camoufl age implant edges, and enhance
cleavage. An extra-thick allograft material is generally used
and appropriately trimmed. It is draped over the implant
(intimate engagement on its deep surface) and in contact
with existing capsule or new/neo pocket on its superfi cial
surface. Parachute 2-0 Prolene sutures with Keith needles
are used in the ADM corners, and interspersed on the
medial side to facilitate placement and re-draping. The
suture ends are tied to themselves externally, under no ten-
sion, and covered with a Tegaderm for 7 to 10 days. This
same application is occasionally used laterally or inferolat-
erally for implant visibility or palpability, and inferiorly to
“thicken” a very thin cutaneous cover ( Figures 48-7 and
48-8 ). The key to success is proper pocket alteration with
incorporation of the extra-thick ADM providing bulk, yet
revascularization and cellular repopulation.
Even though the presenting problem may be capsular
contracture, additional deformities may be identifi ed fol-
lowing detailed analysis from skin envelope to chest wall
as noted above. This can include thinned tissue over an
encapsulated implant, malposition of the encapsulated
implant, or stretched deformity, “Snoopy” deformity, or
ptosis over an encapsulated implant. If the encapsula-
tion is in the subglandular position, a total capsulectomy
with site change to the subpectoral position is usually per-
formed. If the encapsulation is in the subpectoral position,
a neopectoral pocket with partial anterior capsule excision
and residual capsule obliteration, or total (perhaps partial)
capsulectomy is performed. In these cases, the ADM is
again selected for rapid revascularization, conformability
to the implant, and performance. The technique is most
frequently similar to the lower pole cover concept, but
may be closer to a medial thickener, or malposition rein-
force, depending on the presenting problem ( Figures 48-9
and 48-10 ). There is an increasing body of documentation
that the coupling of the ADM to the implant will further
reduce the incidence of capsular contracture. 12 , 24 If capsu-
lar contracture is the only clinical diagnosis, then we rec-
ommend for the placement of the ADM at the lower or
middle poles.
PATIENT PREPARATION
ADM is utilized as an adjunct to the sound surgical
principles necessary to diagnose and treat the underly-
ing cause(s) necessitating the revisionary aesthetic breast
surgery. Clinical data shows the four main indications
(drivers) for revisionary surgery are capsular contrac-
ture, implant malposition, ptosis, and implant visibility or
palpability. 24 – 26 Each patient must be individually evalu-
ated regarding concerns, goals, knowledge of previous
surgical and implant specifi cs, and careful evaluation of
her breasts—dimensions, quality/quantity of overlying
soft tissue, and scarring (critical in planning surgery and
ADM
FIGURE 48-3. Interposition of regenerative matrix between implant and skin
closure. This is similar to the “reconstructive model.”
A
B

ACELLULAR DERMAL MATRIX IN AESTHETIC REVISIONARY BREAST SURGERY • 571
FIGURE 48-4. (A–C) Preoperative views of a 37-year-old woman who had
undergone breast augmentation. (D–F) Thirty-two months after revision augmentation/
mastopexy (inverted T), which included the development of neopectoral pocket, lower
pole coverage with ADM, and replacement of implants with form stable, highly cohesive
gel anatomic implants.
A
C
E
B
D
F

572 • CHAPTER 48
FIGURE 48-5. Patient as seen in Figure 48-4
demonstrating the softness of implants 32 months following
the treatment of her capsular contracture and ptosis.
maintaining necessary vascularity to manipulated tissues).
As always, appropriate candidate selection is important for
achieving successful outcome, and high-risk patients (eg,
smoker and those with body mass index .35) should be
discouraged to have elective surgery.
Despite the apparent complexity of a given clinical
presentation, there are fi ve underlying basic components,
which may be the cause, or contribute to the cause, of the
problem: the skin, soft tissue, capsule, implant, and chest
wall. These underlying components must be carefully and
systematically analyzed from outside in, or inside out,
until all layers involved are evaluated. The main drivers
for reoperative surgery mentioned above should always
be kept in mind as these fi ve components are evaluated.
We have learned from our revisionary and reconstructive
breast experience that one or more of these components
and layers may need to be addressed, in addition to the use
of ADM. Such surgical manipulations may include skin
envelope reduction, fat injection, lamellar separation, cap-
sulectomy. Capsulotomy and site change of the replace-
ment implant. In order to help plan for the surgery, some
general principles can be followed.
TECHNIQUE
For patients whose original implants were subglandular, a
pocket change to a subpectoral plane and lower pole cov-
erage with ADM is generally performed. For those patients
whose original implants were subpectoral, a neopectoral
pocket with the addition of ADM is generally performed.
For patients who do have adequate breast tissue, a subfas-
cial pocket may be utilized with ADM coverage or support
as indicated.
The surgical techniques used are based on the preopera-
tive fi ndings and the indications as described above. The
ADM should be conformed to, and in intimate contact
with, the outer surface of the implant (like a hand in a
glove). The appropriate pocket is created whether it is a
neopectoral, subpectoral, or subfascial. 8 , 11 Three to fi ve
half-mattress, stabilizing “parachute” sutures are placed
between the skin and ADM to stabilize the tissue and place
it in the desired location. Sizes selected are normally in the
6 to 8 × 10 to 16 cm range (depending on size of implant),
rectangle or contour shapes, and trimmed as needed.
Seroma formation should be prevented in all breast revi-
sions, to further revascularization and cellular repopula-
tion of the ADM, so drains are always recommended.
The use of acellular dermal products have been popular-
ized in both breast and abdominal wall reconstructions. 13– 23
In reconstruction cases, ADMs have been used to replace
tissue, extend existing tissue, or act as a supplement. In
aesthetic revisions, the ADM essentially becomes an outer
conforming, regenerative layer around the implant. They
have been used to correct implant rippling and displace-
ment, ptosis, and capsular contracture. 25 , 26 , 28 ADMs are
used as an alternative to other autologous tissue methods
of coverage and provides camoufl age, thus decreasing rip-
pling, and increasing soft tissue padding. 29 In addition to
all the indications described previously, we have also used
ADMs as a mode of treatment for capsular contracture. 24
Breast capsular contracture is similar to lamellar scar-
ring in the eyelids. At the cellular level, capsular contrac-
ture is most likely caused by any process that produces
increased infl ammation, which in turn leads to the for-
mation of deleterious cytokines within the periprosthetic
pocket. Consequently, in addition to the many techniques
described for treating and preventing capsular contrac-
ture, 4 , 5 , 8 , 30 – 36 the addition of ADM is believed to be another
modality in fi ghting the evolution of the capsule. An ADM
can counteract the infl ammatory process, adding more
tissue in-growth availability and controlling the interface
of the pocket by providing a regenerative layer between
device and native tissue.
The rising demand for the use of ADM coupled with
good outcomes in breast reconstructions has spurred tre-
mendous interest in its use for aesthetic breast surgery
patients. In the past, revisionary surgeries were gener-
ally performed with a total capsulectomy, removal of the
implant from the subglandular plane, and placement of a
new implant in the subpectoral position. 5 , 8 , 10 This is a fairly
simple procedure, involving a change in implant placement
from over the muscle to under the muscle. More recently,
it has become necessary to perform revisionary surgery on
volume-depleted or severely scarred breasts. In correcting
these deformities as described in the indication section, in
addition to the site change operation, ADMs can provide
additional coverage where the repair is performed.
COMPLICATIONS
Numerous complications are possible with revisional breast
surgery, including malposition and recurrent rippling and
capsular contracture—the same complications which

ACELLULAR DERMAL MATRIX IN AESTHETIC REVISIONARY BREAST SURGERY • 573
FIGURE 48-6. (A–C) Preoperative views of a 49-year-old woman who had
undergone augmentation/mastopexy. (D–F) Thirty months after revision augmentation/
mastopexy (inverted T), which included the development of neopectoral pocket, lower
pole coverage and reinforcement of inferior and lateral walls with ADM and replacement
of implants form stable, highly cohesive gel anatomic implants. Successful correction of
inferior and lateral malposition was achieved.
A
C
E
B
D
F

574 • CHAPTER 48
FIGURE 48-7. (A–C) Preoperative views of a 38-year-old woman who had
undergone multiple previous revision augmentations. (D–F) Twenty-six months after
revision augmentation through inframammary fold incision, which included the
development of neopectoral pocket, lamellar separation, lower pole coverage with ADM,
and replacement of implants with textured gel implants.
A
C
E
B
D
F

ACELLULAR DERMAL MATRIX IN AESTHETIC REVISIONARY BREAST SURGERY • 575
FIGURE 48-8. Patient as seen in Figure 48-7
demonstrating the softness of implants 26 months following
the treatment of her implant malposition, lamellar scarring,
and tissue thinning.
necessitated the original reoperation. The use of ADM may
add a potentially higher rate of infection and/or seroma for-
mation. 37 The dermis takes time to revascularize and may
not ward off infection as well as the body’s own tissues.
Scientifi c review will determine whether this is true or not.
A challenge that is continually faced in aesthetic revi-
sionary surgery is the cost of these products and their
affordability by the patient. This should be balanced
against the possible cost of performing another surgical
revision due to failure of the planned procedure. Therefore,
as surgeons continue to report outcome data using ADMs
in revisionary aesthetic breast surgery and compare it to
the outcomes without use of ADMs, a new picture may
emerge. No doubt, the coming years will be exciting as
we further defi ne the issues, advance the science, and our
understanding of it via evidence-based medicine, for the
benefi t of our patient population.
FIGURE 48-9. (A-C) Preoperative views of a 45-year-
old woman who had undergone multiple previous attempts at
correction of capsular contracture.
C
A
B

576 • CHAPTER 48
FIGURE 48-9. (continued) (D-F) Twenty-two months
after revision augmentation through inframammary fold
incision which included the development of neopectoral
pocket, lower pole coverage with ADM, and replacement
of implants with higher-profi le, lower-volume textured
gel implants.
E
D
F
FIGURE 48-10. Patient as seen in Figure 48-9
demonstrating the softness of implants 22 months following
the treatment of her capsular contracture.
OUTOMES ASSESSMENT
A recent published series of 78 consecutive patients who
underwent revisionary breast augmentation/mastopexies
with ADMs was one of the largest series to date to address
the use of ADM in revisionary aesthetic breast surgery. 12
Of the 78 patients, 56 patients had their original implants
in the subpectoral position, and 22 had them in the sub-
glandular position. Complications included two patients
(2.5%) requiring reoperation, one for a hematoma and the
other for an implant malposition ( Table 48-1 ). Presenting
clinical signs are listed in Table 48-2 and the type of opera-
tion performed is listed in Table 48-3 . As expected, the
majority of complaints were due to “implant hardening.”
Of 78 patients, 77 (99%) were assessed as having soft
implants with a Baker I level of capsule contracture at fi nal
follow-up; one patient (1%) had a Baker II contracture. No
patient had a Baker III or Baker IV classifi cation postopera-
tively ( Table 48-4 ).

ACELLULAR DERMAL MATRIX IN AESTHETIC REVISIONARY BREAST SURGERY • 577
TABLE 48-1. Complications
Complication
No. of Patients
Hematoma
1
Seroma
0
Implant malposition
1
Implant rupture
0
Infection
0
Total
2
TABLE 48-2. Presenting Clinical Signs
Clinical Signs
No. of Patients
Capsular contracture
56
Implant exposure
2
Rippling
7
Implant malposition
5
Bottoming out
4
Symmastia
4
Total
78
TABLE 48-3. Augmentation vs
Augmentation/Mastopexy
No. of Patients
Augmentation
49
Augmentation/mastopexy
29
Total
78
TABLE 48-4. Preoperative and
Postoperative Baker Classifi cation in
All Patients
% of Patients
Preoperative
Postoperative
Baker I
6.4
97.4
Baker II
20.5
2.6
Baker III
64.1
0
Baker IV
9.0
0
Currently, we have performed over 200 revisionary
augmentations with ADM. As the results continue to be
satisfactory both to surgeon and patient, we continue to
exploit new concepts and new techniques to improve
outcomes, minimize risks while enhancing patient safety,
purse effi ciency, and lower costs. We are now seeing prod-
uct differentiation in outcome assessment, thus we are
carefully documenting these fi ndings to report in peer-
reviewed literature.
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49
Physical and Radiologic
Evaluation of the Hand
Bradley A. Hubbard, MD / Matthew J. Concannon, MD
INTRODUCTION
A consistent and thorough hand examination is an essen-
tial tool for hand surgeons, emergency room physicians,
and primary care physicians alike. In every situation
and with every patient, a complete hand examination
should be performed. This will prevent missed inju-
ries and guide therapeutic intervention if other abnor-
malities exist. To the well-practiced physician, this can
be performed swiftly, usually under 5 minutes, thus
there is no advantage in performing a more limited
examination.
HISTORY
A critical component in the evaluation of the patient
with a hand problem or injury is their history. Issues
such as the patient’s age, sex, hand dominance, and the
presence of other medical problems are important to
note. In addition, it is important to specifi cally inquire
about issues that are particularly germane to hand prob-
lems: Is the patient a diabetic? Is he a smoker? Does
she have arthritis? Has he previously been injured or
had problems with his hand in the past? When evaluat-
ing injuries, have the patient describe exactly how the
injury occurred. Have the patient characterize the pain
or problem and how long it has troubled them. This
type of information can provide understanding into the
etiology of the problem and furnish clues as to their
solution.
Knowledge of the patient’s occupation and hobbies can
give a sense of how they use their hand. For example, a
construction worker uses his hands in a different way than
a touch typist, and has different needs that must be con-
sidered. Hobbies that are an important part of the patient’s
life (such as playing musical instruments) can give insight
into the impact of the injury and the most appropriate
treatment options.
OBSERVATION
Spend a moment looking at the hand. Remove all dress-
ings, splints, or packing. Practice this skill with all patients
as it can be especially valuable in the unconscious, men-
tally challenged, or pediatric populations, where commu-
nication is diffi cult or impossible.
Notice whether the skin is calloused, indicating some-
one involved in manual labor, or if it is soft. In a trauma
situation, examine the wounds. Are they “sharp” or is it a
stellate “crush type” of injury, which would imply much
deeper and widespread tissue damage. Evaluate the color
of the hand. This can give clues to vascular status, force
of injury, and potential occult damage to the underlying
tissue.
Examine the resting fi nger and hand position; at rest,
the fi ngers fall into a normal “cascade” ( Figure 49-1A ).
Division of the fl exor tendons will result in an abnormal
posture at rest ( Figure 49-1B ). Fractures of the phalanges
may result in fi nger rotation or produce an angular devia-
tion ( Figure 49-1C ).
Examine the musculature of the hand, particularly at
the fi rst web space and the thenar eminence. Is there evi-
dence of muscle atrophy? The elderly have a certain degree
of muscular atrophy as a natural result of aging, but atro-
phy can also be evidence of an underlying neural problem,
c h a p t e r

580 • CHAPTER 49
such as longstanding nerve compression (eg, carpal tunnel
or cubital tunnel syndrome).
VASCULAR EXAMINATION
There are many ways to assess the vascular status of
the hand or digit. A word of caution should be inter-
jected about severely angulated fractures, dislocations,
or fi nger torsion. These misalignments can often cause
ischemia or venous congestion without true vascular
injury and should be reduced prior to formal vascular
examination.
After assessment of its color, the radial and ulnar
arteries can often be palpated at the volar wrist. If too
swollen for adequate palpation, a Doppler probe can be
used to analyze the blood fl ow not only in these arter-
ies, but also as far distally as the volar pulp at the distal
phalanx.
If (after visual inspection and Doppler exam) there is
some question as to the vascular status, pinprick of the
affected part with a 22-gauge needle may be helpful. After
pinprick of the fi nger, both the color and the quality of
the blood expressed can help determine if a vascular prob-
lem exists. A completely ischemic part will not bleed at
all, whereas one with venous congestion will bleed quite
briskly with very dark (almost black) colored blood.
Normal perfusion is indicated by moderately brisk bleed-
ing of bright red blood.
The Allen test is used to confi rm the adequacy of per-
fusion to the hand by either the radial or ulnar arter-
ies alone. This is performed by compressing both the
radial and ulnar arteries at the wrist and then asking the
patient to repetitively make a fi st until the hand is exsan-
guinated. The radial artery is released while maintaining
compression on the ulnar artery and the perfusion to the
fi ngers is assessed. The test is repeated except this time
the ulnar artery is released and the radial artery is com-
pressed. In a normal test, the fi ngers should be perfused
and pink within 6 seconds. The clinical observation of
inadequate or absent revascularization correlates with
reduced digit blood pressure. 1
The Allen test should always be performed prior to
any planned manipulation of these vessels (such as radial
artery line placement) to avoid the potentially devastating
FIGURE 49-1. Observation of fi nger position at rest. (A) Normal cascade. (B) Middle
fi nger tendon disruption. (C) Osseous injury causing rotational deformity.
B
A
C

PHYSICAL AND RADIOLOGIC EVALUATION OF THE HAND • 581
consequences of distal ischemia if the artery becomes
injured or thrombosed. If the thumb and index fi nger do
not show a good blush of reperfusion after release of the
ulnar artery (while still occluding the radial artery), it is
likely that inadequate crossover perfusion from the ulnar
side of the hand exists, and any cannulation or manipula-
tion of the radial artery should be avoided to prevent pos-
sible ischemic loss.
SENSORY EXAMINATION
The major nerves to the hand and forearm provide sen-
sory information as well as transmitting motor impulses,
and therefore nerve function can be analyzed using both
sensory and motor tests. This can be very useful to exploit,
because it can help distinguish a tendon injury from a
nerve injury if a patient is unable to perform a particular
action. Unfortunately, a proper motor examination can
be diffi cult to perform in the acute setting due to pain.
Patients will often be unwilling to move or claim they
are unable to move the affected part, but after proper
anesthesia no underlying injury is found. Therefore, it is
standard in our practice to perform the sensory examina-
tion, then anesthetize the area prior to testing the motor
function.
Testing for sensation is relatively straightforward;
however, it is important to realize that the border areas
between nerve distributions are not precisely consistent
from individual to individual, with extensive crossover.
Therefore, it is helpful to know which areas are purely
innervated by only the ulnar nerve, median nerve, or
radial nerve. The autonomous sensory zones include the
following: the volar aspect of the small fi nger—ulnar
nerve; the volar aspect of the index fi nger—median nerve;
the dorsal aspect of the fi rst web space—radial sensory
nerve ( Figure 49-2 ).
A
B
C
FIGURE 49-2. Areas without sensory nerve overlap.
(A) Ulnar nerve—small fi ngertip; median—index fi nger
tip. (B) Radial nerve—fi rst web space. (C) Digital nerve—
lateral aspect of fi nger tip (index fi nger radial digital nerve
distribution pictured).