Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

72
PART | 3  Breast reshaping
FIG. 9.8  Supraumbilical incision is done first and a tunnel is under­
mined to the xiphoid process, preserving the lateral neurovascular
bundles.
Epigastric tunnel
Scarpa’s fascia
Neurovascular bundle
A
important to preserve the lateral superior flank area and to
avoid damage to the neurovascular bundles that support the
entire flap (Fig. 9.8A, B, C).
FIG 9.8B, C APPEARS ONLINE ONLY
We have already described this27,28 and proposed the
mini-abdominoplasty technique (Fig. 9.9A–F and Fig.
9.10A–H), stressing the importance of preserving the lateral
columns when undermining the long xiphopubic tunnel and
total umbilical stalk section.
Pull-down Approach
The patient is placed in a Fowler position and the flap is
pulled down to reach the inferior suprapubic line delin­
eated previously, and to estimate whether the inferior flap
resection can be done en bloc without problems (Fig.
9.11A–C). This maneuver is critical to determine whether
the defect can be closed without stretching. The inferior
suprapubic line can then be moved up or down, depending
on the laxness and elasticity of the skin and patient bio­
type. Normally it is approximately 7–8 cm from the labia
major vertex.
FIG 9.11B, C APPEARS ONLINE ONLY
Umbilical Stalk Circumcision and Inferior Flap
Block Resection
After confirming the safety of the pull-down approach, the
patient is again placed in the horizontal position and the
umbilical stalk is trimmed in an elliptical shape. The supra­
pubic incision is done superficially to avoid damage to the
lymphatic vessels and the cutaneous muscle nerves that
give the lateral thighs sensibility; this is according to
Guerrero Santos, published in 1980,29 and more recently
by Louarn and Pascal, in 2002.30 We preserve a border of
4–5 cm of the aponeurosis superficialis (Scarpa’s fascia),
then the entire flap is raised en bloc from the abdomen wall
(Fig. 9.12).
Fat Trimming
The excess fat from the upper flap is trimmed, preserv­
ing Scarpa’s fascia and the superior lateral pedicle of
the nerves, veins, and arteries – the branches that supply
the entire abdomen flap that cannot be undermined.
Scarpa’s fascia protects those branches laterally and
maintains a firm structure for the abdomen wall contour
(Fig. 9.13).
Rectus Muscle Aponeorotic Plication
The rectus muscle diastasis is identified and two lines are
drawn from the xiphoid appendix to the suprapubic area. A
3-0 nylon nonabsorbable suture is used; sutures start from
the epigastric area down to and including the umbilicus
stalk in a middle-to-firm fixation. We then have a tunnel of
approximately 6 cm in width and a waist improvement of
approximately 8 cm (Fig. 9.14A, B).
FIG 9.14B APPEARS ONLINE ONLY
Exteriorization of the Umbilicus Stalk
The patient is put in a semi-Fowler position (45°) and the
flap is extended to the pubis area. A 2-0 nylon stitch is
placed to support the flap and, using an Allis forceps, the
umbilicus stalk is grasped and projected to the abdomen
wall. We identify it with blue methylene, marking 1.5 to
2 cm above its new position (Fig. 9.15A, B).
FIG 9.15A APPEARS ONLINE ONLY
This procedure is very important to avoid stretching
or vascular damage to the suprapubic area. With a No.
11 blade, we make a cross-shaped incision approxi­
mately 2 cm long and 1 cm across. We trim the sur­
rounding fat and four tacking stitches are placed to fix
the umbilicus stalk deep into the muscle aponeurotic
plane (Fig. 9.16A, B).

72.e1
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.8  Supraumbilical incision is done first and a tunnel is under­
mined to the xiphoid process, preserving the lateral neurovascular
bundles.
B
C
FIG. 9.11  The patient is in the Fowler position and the superior flap
is pulled down to try to reach the outlined inferior suprapubic inci­
sion. This is a safety measure to prevent stretching and undesirable
vascular complications.
B
C

72.e2
PART | 3  Breast reshaping
FIG. 9.14  Plication of the muscle aponeurosis diastases, fixing the
umbilicus stalk, and preserving the lateral neurovascular bundles.
B
FIG. 9.15  In a semi-Fowler position (45°) we identify the umbilicus
stalk and bring it upward 2 cm to release the suprapubic stretching.
A

73
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.9  Forty-two-year-old patient with rectus muscle diastasis, good skin elasticity and long distance between the umbilicus and the supra­
pubic area. Lipo mini-abdominoplasty was proposed by the author in 1987, with total amputation of the umbilicus stalk and undermining of
a long xiphopubic tunnel, preserving the lateral neurovascular bundles. Waist improvement and new umbilicus fixation.
D
E
A
B
C
F

74
PART | 3  Breast reshaping
FIG. 9.10  Pre- and postoperative pictures of two patients operated by the mini-abdominoplasty technique.
A
B
C
D
E
F

75
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.10  Continued
G
H
Subcutaneous Adhesion Stitches and
Closing Sutures
Approximately 10 to 12 nonabsorbable 4-0 stitches are
made in the subcutaneous level, fixing Scarpa’s fascia to
the muscle aponeurotic tissue. This procedure was described
by Baroudi31 and a posterior approach was described by
Pollock32 to diminish the “dead space” and to avoid flap
sliding, and to prevent hematomas and seromas postopera­
tively. The inferior Scarpa’s fascia border is sutured together
with the muscle aponeurosis and the subcutaneous flap to
protect the lymphatic vessels, the musculocutaneous nerves
and, most important, to pull up the entire crural area and
mons pubis. Even with these stitches, we maintain a suction
drain for 12 hours. Subcutaneous and intradermic sutures
are done with monocryl 4-0, and micropore Steri-strips are
attached to the new scar (Fig. 9.17A–D).
FIG 9.17B, D APPEARS ONLINE ONLY
Mammaplasty
Maintaining the Fowler position we proceed with the breast
surgery. This can take the form of, according to breast size
and degree of ptosis, breast augmentation with silicone
prostheses, mastopexy, or breast reduction.
Breast Augmentation with Silicone Prostheses
Normally we use textured prostheses with a high profile and
we prefer the periareolar incision first (Fig. 9.18A–C, Fig.
9.19A, B, Fig. 9.20A, B, and Fig. 9.21A, B), followed by
an incision in the inframammary sulcus. We use a subglan­
dular or a submuscular approach depending on the amount
of breast tissue the patient already has.
FIG 9.21 APPEARS ONLINE ONLY
Mastopexy with Pitanguy–Ariê approach and
Superior Pedicle Flap
Very often we combine abdominoplasty with this technique.
This is a very simple procedure, described by Pitanguy21
and Ariê22 in the earliest 1960s. For breast ptosis, essentially
this means the removal of a skin ellipse in a vertical or in
an “L” shape design. Excess breast tissue can be removed
like a keel, or a superior dermoglandular pedicle can be
outlined to fulfill the superior pole, to enhance volume and
firmness to the breast. An intradermal suture is used and
Steri-strips applied to protect the suture for 15 days (Fig.
9.22A–D, Fig. 9.23A, B, and Fig. 9.24A, B).
FIG 9.24 APPEARS ONLINE ONLY
Breast Hypertrophy Reduction
The most common breast reduction method used in Brazil
is the technique described by Pitanguy21 in 1967. This tech­
nique removes breast tissue in the shape of a boat keel,
forming two lateral columns. This provides a supportive
structure necessary to support the elevated nipple areola
complex (NAC) in a very natural shape and gives good
physiological function. This technique is especially indi­
cated for small and medium hypertrophic breasts. However,

75.e1
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.17  Several adhesion stitches are done to fix the subcutaneous
“dead space”, and the inferior Scarpa’s fascia is sutured into the flap
and muscle aponeurosis to protect the lymphatic vessels, the muscu­
locutaneus nerves, and most importantly, to pull up the crural area
and mons pubis.
B
D
FIG. 9.21  Same patient in the preoperative and postoperative sitting
position.
A

75.e2
PART | 3  Breast reshaping
A
B
FIG. 9.24  Same patient in sitting position.

76
PART | 3  Breast reshaping
Patient in
Fowler position
Superior flap pulled down
to reach suprapubic area
A
FIG. 9.11  The patient is in the Fowler position and the superior flap is pulled down to try to reach the outlined inferior suprapubic incision.
This is a safety measure to prevent stretching and undesirable vascular complications.
for patients with large breasts, with or without asymmetry,
other techniques work better, and we use the technique
described by Skoog33 in 1971, modified by Netto19 in 1976
and improved by Uebel20 in 1978.
The points ABC are marked in a sitting position as
in the Pitanguy technique and the supralateral flap is
outlined. We use high epidural anesthesia with a continu­
ous infusion catheter. To reduce bleeding we use local
infiltration with saline and epinephrine (adrenaline)
1 : 200 000. The dermoglandular flap is de-epithelialized
and prepared together with the NAC, ready to be trans­
posed up to its new site without stretching and with a good
blood supply. Skoog33 published his nipple areola dermis
flap rotation for large hypertrophy breasts in 1971. This
technique, however, had problems with vascular supply
and lactation problems developed. Silveira Neto19 in 1976,

77
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.12  The inferior flap is raised en bloc, preserving the umbilicus stalk with an inferior border of 4–5 cm of Scarpa’s fascia to protect
the lymphatic vessels and the cutaneus muscle nerves.
FIG. 9.13  The excess abdominal wall fat is trimmed away, preserv­
ing Scarpa’s fascia and the neurovascular bundles.
FIG. 9.14  Plication of the muscle aponeurosis diastases, fixing the
umbilicus stalk, and preserving the lateral neurovascular bundles.
8 cm
Rectus muscle aponeurotic plication
A

78
PART | 3  Breast reshaping
using the same principle as Skoog, modified the technique,
adding glandular tissue in the pedicle and so improving
vascular supply and lactation. Uebel20 in 1978 outlined the
dermoglandular flap in the superioalateral region to achieve
good vascular support and function, along with better con­
touring of the lateral and axillary region (Fig. 9.25A–G,
Fig. 9.26A, B, Fig. 9.27A, B, Fig. 9.28A, B, and Fig.
9.29A–D).
FIG 9.28B APPEARS ONLINE ONLY
In patients with large breast hypertrophy, with or without
asymmetry, there is a challenge to safely elevate the NAC.
In such cases the supralateral dermoglandular flap tech­
nique is indicated to bring it the nipple superiorly without
any tension, preserving neurovascular supply, and improv­
ing lactation ability. Good nipple sensation and an aesthetic
shape of the breast and axillary region are achieved.
POSTOPERATIVE REMARKS AND
OPTIMIZING OUTCOMES
Support undergarments are placed on the patient to rein­
force and maintain pressure on the abdomen wall and
breast. The patient is kept in hospital overnight; the epidu­
ral catheter is maintained for 24 hours connected to the
pump. A solution of sufentanil citrate (100 mg) with saline
solution 0.9% (100 ml) is continuously infused to prevent
pain and no other analgesic drugs are administered. The
patient can (and should) move her legs, beginning immedi­
ately after the surgery; this is important to prevent venous
thromboembolism. Intensive care respiratory procedures
are observed and leg massages given. The next day the
epidural catheter is removed and the patient may start to
walk slowly in a hunched position to avoid stretching the
abdomen. The patient can be released if vital signs are
normal.
FIG. 9.16  A criss-cross incision is done and the umbilicus stalk is
exteriorized and fixed with four stitches deep into the aponeurotic
level.
A
B
FIG. 9.15  In a semi-Fowler position (45°) we identify the umbilicus
stalk and bring it upward 2 cm to release the suprapubic stretching.
Fowler position
± 2cm
upward
B

78.e1
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.28  Two days postoperative with Steri-strips applied.
B

79
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.17  Several adhesion stitches are done to fix the subcutaneous
“dead space”, and the inferior Scarpa’s fascia is sutured into the flap
and muscle aponeurosis to protect the lymphatic vessels, the muscu­
locutaneus nerves, and most importantly, to pull up the crural area
and mons pubis.
A
C
Text continued on page 86
COMPLICATIONS AND THEIR
MANAGEMENT
In a review of the last 8 years we have performed
this procedure on 326 patients. Table 9.1 shows our data
regarding complications. In two patients, suprapubic epi­
dermolyses occurred. Both patients were heavy smokers
and, although they stopped smoking 15 days prior to
surgery, we observed epidermolyses in the suprapubic area
TABLE 9.1  Clinical data and complications
Complications
No. of Patients
%
Suprapubic epidermolyses
2
0.6
Suprapubic necrosis
0
0
Hematoma
0
0
Seroma
3
0.9
Hypertrophic scars
8
2.4
Infections
2
0.6
Dog-ear scar revision
12
3.6
Thromboembolism
0
0
that diminished with administration of buflomedil hydro­
chloride 300 mg twice daily for 7 days, starting 2 days
before the surgery. In three obese patients seromas appeared
5–6 days postoperative. In those patients, we had performed
an intensive lipectomy of the flap and, although we had
used adhesion subcutaneous stitches, seroma resulted.
Hypertrophic scars occurred in eight patients, three with
white skin, and five with black or multiethnic skin. Scar
revision and “dog-ear” correction were required in 12
patients.
Heller et al34 recently published a retrospective cohort
study to evaluate four groups of abdominoplasty patients.
Group I received only abdominal liposuction; group II
received traditional W-pattern incision line abdomino­
plasty; group III had modified transverse incision abdomi­
noplasty; and group IV underwent a combined procedure
of liposuction and short undermined abdominoplasty. They
concluded that group IV had fewer complications than the
other groups. When we compare these data with our group
of lipoabdominoplasty patients, we had similar results with
low rates of complications.
CONCLUSION
Combining abdominal and breast surgery can be very useful
for patients with laxity and excess of skin of the trunk and
esthetic breast deformities, especially in women following
pregnancy and in post-bariatric patients. However, to
benefit the patient and to obtain good results there are many
safety issues to be considered. Patients should have a favor­
able medical profile, excellent surgical facilities, and a well
trained surgical team. We reviewed some surgical breast
techniques for ptosis, micromastia, and large hypertrophies.
We discussed the superior pull-down abdominal flap tech­
nique and introduced some new approaches to make it

80
PART | 3  Breast reshaping
FIG. 9.18  Abdominoplasty combined with 285 ml breast implantation. (A, B) Periareolar incision and submuscular approach; 20 days post­
operative. (C, D) Postoperative of 3 months standing and sitting position.
A
B
C
D

81
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.19  Three months postoperative.
A
B
A
B
FIG. 9.20  Back view showing the body contouring obtained by liposuction.

82
PART | 3  Breast reshaping
FIG. 9.22  Abdominoplasty combined with mastopexy. Vertical incision with a superior pedicle flap to enhance the upper breast pole. Steri-
strips are used for more than 30 days.
A
B
C
D
FIG. 9.23  Another 46-year-old patient who underwent the same lipoabdominoplasty technique, combined with a mastopexy, 2 years
postoperative.
A
B

83
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.25  Fifty-two-year-old patient with large hypertrophy operated by the dermoglandular rotation flap technique. The different surgical
steps.
A
B
C
D
E
F
G

84
PART | 3  Breast reshaping
FIG. 9.26  Three months postoperative showing the new contour, axillary reduction, and nipple areola projection.
A
B
A
B
FIG. 9.27  Forty-two-year-old patient with breast hypertrophy and abdomen flaccidity.

85
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.29  (A) One day after surgery. (B) Two weeks postoperative with Steri-strips. (C) One year in a sitting position.
B
C
A

86
PART | 3  Breast reshaping
easier and safer, including: use of the sitting position to
delineate the inferior curved incision, epidural catheter
anesthesia, suprachondrocostal liposuction to loosen the
inframammary area, undermining the epigastric area only
enough to bring down the flap, keeping Scarpa’s fascia on
the lateral abdomen wall to protect the neurovascular ped­
icles, and in the inferior abdomen to protect the lymphatic
vessels. We also emphasize correction of the mons pubis.
Quilting/adhesion Baroudi stitches in the subcutaneous
tissues are used to prevent seromas. We require early leg
movement and walking to reduce the chance of throm­
boembolism. All of these improvements that have been
successfully introduced and routinely applied in our clinic
help to reduce the surgical time and diminish the risk of
complications such as seroma, vascular flap necrosis, and
venous thromboembolism.
REFERENCES
1. Illouz YG. Une nouvelle technique pour les lipodystrophies locales.
Es Ver Chir Esth France 1980.
2. Callia WEP. Contribuição para o estudo da correção cirúrgica do
abdômen pêndulo e globoso – técnica original. Tese de Doutora­
mento apresentada à Faculdade de Medicina da USP – São Paulo,
1965.
3. Pitanguy I. Abdominal lipectomy: An approach to it through an
analysis of 300 consecutive cases. Plast Reconstr Surg 1967;40(4):
384–91.
4. Psillakis J. Abdominoplasty – some ideas to improve results. Aesth
Plast Surg 1978;2:205.
5. Baroudi R, Keppke EM, Tozzi Neto E. Abdominoplasty. Plast
Reconstr Surg 1974;54:161.
6. Bozola AR, Bozola AC. Addominoplastias. Em Mélega JM. Cirurgia
Plástica, Fundamentos e Arte – Cirurgia Estética. São Paulo: MEDSI;
2003.
7. De Souza Pinto EB, Oliveira RPR. Lipoaspiração superficial.
Revinter Rio de Janeiro 1999;3:11–20.
8. Baroudi R, Moraes M. A “bicycle-handlebar” type of incision for
primary and secondary abdominoplasty. Aesth Plast Surg J
1995;19:307.
9. Uebel CO. Cirurgia do abdomen associada à lipoescultura. In:
Tourniex AAB, editor. Atualização em Cirurgia Plástica Estética.
São Paulo: Robe Editorial; 1994. p. 483–9.
10. Castro CC, Cupello A, Cintra H. Limited incisions in abdomino­
plasty. Ann Plast Surg 1987;19:436.
11. Franco T, Rebello C. Cirur. Estética. Atheneu: Rio de Janeiro, 1977.
12. Hakme F. Technical details in the liposuction associated with lipo­
suction. Rev Bras Cir 1985;75:331.
13. Abramo de Oliveira E, Valera F, Monte AL, et al. Prevention of
seroma in liposuction associated abdominoplasty without active
drainage. Rev Soc Bras Cir Plást 2008;23(1):41–7.
14. Nahas FX, Ishida J, Gemperli R, et al. Abdominal wall closure after
seletive aponeurotic incision and undermining. Ann Plast Surg
1998;41:606.
15. Sinder R, Plastic surgery of the abdomen – personal technique. In:
Abstracts of the 6th International Congress of Plastic and Recon­
structive Surgery. Paris: Masson; 1975. p. 58.
16. Planas J. The “vest over pants” abdominoplasty. Plast Reconstr Surg
1978;61:694.
17. Serson Neto D, Martins LC. Dermolipectomia abdominal. Aborda­
gem geométrica. Ver Lat Am Cir Plast 1972;16:13.
18. Pontes R. Variantes das abdominoplastias em bloco. In: Pontes R,
editor. Abdominoplastia: Ressecção em Bloco e sua Aplicação em
Lifting de Coxa e Torsoplastia. Revinter: Rio de Janeiro; 2004. p.
25–54.
19. Netto ES. Mastoplastia redutora setorial com pedículo areolar
interno. Anais 13th Congresso Brasileiro de Cirurgia Plástica,
p 13–15. Porto Alegre, RS, April 1976.
20. Uebel CO. Mamaplastia redutora com rotação retalho dermo glan­
dular súpero lateral. Anais 15th Congresso Brasileiro Cirurgia
Plástica.São Paulo, SP, Abril 1978.
21. Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg
1967;20:78.
22. Ariê G. Nova técnica em mamaplastia. Rev Latin Amer Cir Plast
1957;3:28.
23. Uebel CO. Lipoabdominoplasty: Revisiting the superior pull-down
abdominal flap and new approaches. Aesth Plast Surg 2009;
33(3):366–76.
24. Minetto ZF, Perez SCM. Anestesia em ortopedia e traumatologia. In:
Manica J, editor. Anestesiologia: Princípios e Técnicas. 3rd ed.
Artmed: Porto Alegre; Chapter 57, 2004. p. 979–1005.
25. Avelar JM. Abdominoplasty without panniculus undermining and
resection: Analysis and 3 years follow up of 97 consecutives. Aesth
Plast Surg J 2002;22(1):16–25.
26. Saldanha OR. Lipoabdominoplasty with selective and safe under­
mining. Aesth Plast Surg 2003;27(4):322–7.
27. Uebel CO. Miniabdominoplasty – A new approach for the body
contouring. Annals of the 9th Congress of the International Society
of Aesthetic Surgeons, New York, 1987.
28. Uebel CO. Minilipoabdominoplasty – its evolution. Lipoabdomino­
plasty. Di Livros: Sao Paulo; 2004. pp. 73–85.
29. Guerrero Santos J, Spaillat L, Morales F, et al. Some problems and
solutions in abdominoplasty. Aesth Plast Surg 1980;4:227–37.
30. Pascal JF, Le Louarn C. Remodeling bodylift with high lateral
tension. Aesth Plast Surg 2002;26(3):223–30.
31. Baroudi R, Ferreira CAAP. Seroma: How to avoid it and how to treat
it. Aesth Surg J 1998;18:439–41.
32. Pollock H, Pollock T. Progressive tension sutures: a technique to
reduce local complications in abdominoplasty. Plas Reconstr Surg
2000;105(7):2583–6.
33. Skoog T. A technique of breast reduction: transposition of the
nipple on a cutaneous vascular pedicle. Acta Chir Scand
1963;453–65.
34. Heller JB, Teng E, Knoll BI, Persing J. Outcome analysis of com­
bined lipoabdominoplasty versus conventional abdominoplasty. Plas
Reconstr Surg 2008;121(5):1821–9.
Fig. 9.2B, 9.4(A–D), 9.5, 9.6, 9.7C, 9.8BC, 9.11BC, 9.14B, 9.15A,
9.17BD, 9.21, 9.24, 9.28B can be found online.
Bonus images for this chapter can be found online at

87
© 2013 Elsevier Inc
Chapter 10 
Key Points
●
Breast shape in patients after massive weight loss
(MWL) often appears as a “pancake” deformity.
●
Conventional techniques of mammaplasty usually fail
to correct breast shape in this specific group of patients.
●
Breast volume deficiency is better addressed using
autologous tissue whenever available.
●
“Spare-parts” and “recycled tissue” concepts are the
fundamental basis of the surgical technique.
●
Redundant tissue over the axillary region, back,
abdomen, or thigh usually provides adequate tissue for
flap transfer, which can be used for autologous breast
augmentation.
Breast reshaping using autologous tissues
after massive weight loss
Moustapha Hamdi and Serhan Tuncer
INTRODUCTION
Breast deformities are the most challenging and variable
part of the massive weight loss (MWL) patient; thus a
thorough definition of the problem and an accordingly
chosen technique determine the success of the surgical
outcome.1–5 Breast deformities of the MWL patient differ
from typically enlarged or ptotic breasts and therefore well-
known techniques usually fail in this group. Significant
breast volume depletion, and loss of upper pole and medial
fullness resulting in the formation of flattened parenchyma
against the chest wall, known as the “pancake” appearance,
are the most common changes.4,5 The majority of patients
present with grade III ptosis and the two breasts are usually
asymmetric because of disproportional volume loss. The
breasts are displaced laterally in continuity with the lateral
chest rolls and the nipple–areola complex is displaced
medially. The skin envelope shows significant laxity and is
covered by stretch marks.
The patients can present with excessive, sufficient, or
insufficient breast volume.1 Although MWL patients rarely
have enlarged breasts, the deformity is treated by one of
the reduction techniques. However, instead of standard
reduction techniques, ligamentous system preservation
combined with retightening procedures provides more
satisfactory and long-lasting results. Therefore, we prefer a
Würinger’s septum-based reduction technique.6 The second
group includes patients who have droopy breasts with
sufficient volume. Existing dermoglandular tissues are
usually adequate to form a natural-looking breast and most
of the patients benefit from one of the mastopexy tech­
niques. Lastly, the majority of patients have saggy breasts
with insufficient volume, so providing extra volume is
mandatory to establish naturally projecting breasts. One
option to correct this type of deformity is to combine mas­
topexy techniques with implant augmentation.1,7 However,
there are certain challenges with implant augmentation–
mastopexy in MWL patients. Due to excessive skin
laxity and loss of dermoglandular suspension, an unnatural
appearance and recurrent ptosis are the most common prob­
lems after implant augmentation.7
On the other hand, most of these patients present with
skin-fat excess, which requires excision and skin tightening
procedures. This redundant skin excess provides excellent
material for breast autoaugmentation.
CLINICAL APPROACH
MWL patients have other redundant parts on their body that
deserve to be removed to achieve a satisfactory result.
However, instead of discarding these parts, they can be used
for autoaugmentation. Parts of the body that can be used to
augment the breast are divided into two main groups. The
first group includes the redundant skin and subcutaneous
tissue near the breast that can be transferred on a reliable
vascular base and the second group includes distant parts
that can only be transferred as free flaps.
Techniques Based on Locoregional Tissue
In most MWL patients, breast deformity is accompanied by
lateral skin redundancy or “side rolls” in the lateral thoracic
area. This axillary extension of the breast can be used to
provide autoaugmentation in patients with insufficient
breast volume, using different surgical techniques.1–5,8,10
Part 3  Breast reshaping

88
PART | 3  Breast reshaping
respectively, to be used for breast augmentation of the
MWL patient.
PREOPERATIVE PREPARATION
After routine preoperative screening tests and assessment
of risk factors, the most important step during the preopera­
tive period is to decide which excess part of the body will
be used for autoaugmentation. If the patient has significant
side rolls and the preoperative evaluation demonstrates
that this excess tissue can provide sufficient volume for the
breast, then we prefer to perform a pedicled flap on the
lateral intercostal or, occasionally, thoracodorsal perfora­
tors. Due to relatively higher rates of complications in
MWL patients, volume enhancement with free flaps is less
preferred. When there is no lateral skin excess, bilateral
abdominal free flaps either on paraumbilical perforators or
as a muscle-sparing TRAM flap to be transferred to the
breast, can be considered in patients carefully selected for
breast augmentation. On the other hand, patients who want
to get rid of redundant skin in the thigh region and also
need to have an augmentation of their deflated breasts can
be good candidates for free transverse musculocutaneous
gracilis flap (TMG) transfer.
Mapping of the vascular anatomy of the chosen flap
before the operation makes the surgery easier and shortens
the operative time.14 Combining two procedures and an addi­
tional free flap transfer lengthens the operative time; hence
any method used to facilitate the surgery is invaluable.
Usually, perforators of the LICAP flap or TDAP flap are
located with a unidirectional hand-held Doppler. Following
the previously described anatomical outlines, it is relatively
straightforward to find a reliable perforator on the back.
However, the surface area of the abdomen is wide and the
number and location of the paraumbilical perforators show
great variability. Therefore more objective and reliable
methods are needed for perforator mapping. Multidetector
computed tomographic (MDCT) angiography and magnetic
resonance angiography are extremely helpful tools to navi­
gate the major perforators to be selected. Both techniques
provide the exact coordinates of the points where the major
perforator pierces the fascia referring to the umblicus.15,16
SURGICAL TECHNIQUE
LICAP Flap (Fig. 10.1)
The largest or “dominant” perforators are found between
the 5th and 7th intercostal spaces in 84% of cases. The
mean distance of these dominant perforators from the ante­
rior border of the latissimus dorsi (LD) muscle varies
between 2.77 and 3.68 cm.11 The flap is designed lateral to
the breast over the axilla and lateral thoracic area. The
anterior border of the flap should include the junction of
the inframammary fold (IMF) with the anterior axillary line
Rubin described a total parenchymal breast reshaping with
dermal suspension mastopexy using the excess tissues
around the breast mound.2,5 A modified Wise pattern with
lateral extension to encompass any significant lateral rolls
was used. The technique was based on de-epithelialization
of the entire region, then lateral and medial dermoglandular
flaps were elevated securing them together with the central
pedicle to the second or third rib periosteum with permanent
sutures. Hurwitz et al described the use of lateral side rolls
as a spiral flap to augment and reshape the breast in MWL
patients.8 In this technique they de-epithelialized fasciocu­
taneous flap extensions of the Wise pattern mastopexy.
We suggested the use of lateral redundant dermoglan­
dular tissue based on lateral intercostal artery perforators
(LICAP) with some personal modifications.3 The technique
evolved from our initial experience with the LICAP flap for
partial breast reconstruction within a clinical algorithm
based on the location of the defect and the availability of
these perforators.9 A case report of pedicled perforator flaps
for breast augmentation was subsequently published.10 We
also reported our clinical experience with ICAP flaps and
addressed the use of pedicled LICAP flaps in MWL
patients.3 In a recent study we described the anatomical
details of the perforators and the flap design.11 As the side
rolls extend more posteriorly to the back of the patient,
perforators based on the thoracodorsal system can also be
used as the main pedicle of the redundant tissue. The tho­
racodorsal artery perforator (TDAP) flap is another valu­
able tool that can be used for reshaping the breast via the
autoaugmentation principle.10,12
Techniques Based on Distant Tissue
Other parts of the body that need to be addressed during
body contouring of the MWL patient are the abdomen,
thighs, and buttocks. Contouring of all three parts is well
described, with several modifications. The main concept in
body reshaping is based on removal of these excess tissues.
However, these skin and subcutaneous tissues can be trans­
ferred as free flaps and used for augmenting the breast in a
single session. Although usage of these tissues is popular
and widely used in postmastectomy breast reconstruction,
there is little experience of augmenting the breast with free
flaps for cosmetic purposes. The whole abdomen can be
raised as two individual deep inferior epigastric perforator
(DIEAP) or muscle sparing TRAM flaps to be transferred
to the breast. Also, during the inner thigh lifting procedure,
transverse skin islands can be prepared as gracilis muscu­
locutaneous flaps and used for bilateral breast augmenta­
tion. Schoeller et al proposed a medial thigh lift free flap
for autologous breast augmentation and presented their
experience with three MWL patients.13 Likewise, upper
gluteal excess and saggy infragluteal parts can be prepared
on superior gluteal or inferior gluteal artery perforator flaps,

89
Chapter | 10  Breast reshaping using autologous tissues after massive weight loss
A
B
C
D
E
F
FIG. 10.1  A 41-year-old patient after 65 kg weight loss. The patient was a candidate for breast pexy/augmentation. The side rolls, which were used
for breast augmentation, were elevated pedicled flaps based on the lateral intercostal perforators. The flaps were placed into the retromammary space
bilaterally. A skin mammaplasty was then performed. (A–C) Preoperative views; (D) the LICAP flap was marked over the side rolls; (E) the flap was
dissected and completely islanded; (F) after placing the flap behind the gland, the mastopexy was done using an L-scar mammaplasty;
Continued

90
PART | 3  Breast reshaping
the flap. The mastopexy is first marked in a vertical scar
mammaplasty pattern. The horizontal extent of the reduc­
tion pattern is determined during surgery, after harvesting
and insetting the flap.
DIEAP Flap (Fig. 10.2)
The abdomen is considered the ideal donor site for auto­
logous breast reconstruction after mastectomy. The morbid­
ity associated with abdominal wall complications has
limited the use of the TRAM flap and a search to minimize
these complications led to the rise of the DIEAP flap.17,18
In the majority of the MWL patients an abdominoplasty
procedure is needed. In carefully selected patients, the
whole abdominal tissue can be raised on DIEAP flaps on
each side of the abdomen to be transferred to the breast as
to allow primary donor site closure. The width of the flap
depends on skin redundancy and varies between 8 and
15 cm. The perforators are located with a Doppler and the
closest and the most anterior perforator to the breast is
chosen for adequate arc of rotation of the flap. The LD
muscle is exposed after incision and the flap is elevated
above the muscle fascia. Once the largest perforator closer
to the pectoralis major muscle is found, it is freed off the
surrounding tissue. The serratus anterior muscle is split and
the perforator is dissected up to its exit above the rib. If a
longer pedicle is required, dissection of the main pedicle
can proceed within the costal groove. Once dissection of
the perforator is complete, the rest of the flap is elevated
easily above the muscle fascia. The inferior incision of the
flap is then extended into the IMF. The breast gland is
dissected and a retroglandular pocket is prepared for
G
H
I
J
(G–I) postoperative views; (J) a lateral view of the breast with the donor site of the augmentation flap (the excised side roll).
FIG. 10.1  Continued

91
Chapter | 10  Breast reshaping using autologous tissues after massive weight loss
A
B
C
FIG. 10.2  A 31-year-old female who had lost a total of 35 kg following bariatric surgery with gastric band insertion and requested an abdomi­
noplasty and mastopexy/augmentation for the contralateral breast. A vertical scar mastopexy was performed together with bilateral breast augmen­
tation using DIEAP free flaps. (A, B) The preoperative views with surgical markings. The bilateral DIEAP flaps were incorporated within the
abdominoplasty marking. (C, D) The preoperative MDCT images showed the dominant perforator on both sides.
Continued

92
PART | 3  Breast reshaping
D
E
F
(E) Bilateral DIEAP flaps were based on the preoperative marked perforators. (F) The DIEAP flap was anastomosed to the
internal mammary vessels through the mastopexy incision.
FIG. 10.2  Continued
a free flap. Preoperative mapping of the perforator anatomy
with MDCT facilitates identification of the dominant per­
forator and the intramuscular course of the vessels.15
Abdominal scars from previous surgeries should also be
considered before the operation. In general, most MWL
patients present with different types of abdominal scars
from bariatric surgery. The majority of these scars are
midline scars and during two hemi-flap transfers they have
no negative impact on flap circulation. Because the tradi­
tional belt lipectomy procedure is less effective in most of
the MWL patients, a fleur-de-lis pattern excision, to achieve
greater improvement above the umbilicus, and resulting in
an extra midline scar, is safely performed by some sur­
geons.19,20 On the other hand, a retrospective study by
Parrett et al demonstrated that donor site morbidities,
including wound breakdown, abdominal laxity and bulging,
were significantly higher compared to DIEAP flap patients
with no previous scars.21
The procedure can be performed by two teams to shorten
the operative time. One team begins by preparing the breast
for reshaping and exposes the internal mammary vessels for
the anastomosis. The other team elevates the two DIEAP
flaps based on the previously identified paraumbilical per­
forators, following meticulous microsurgical dissection
principles. Once the flaps and the recipient sites are ready
each flap is transferred to the contralateral breast for auto­
augmentation. First, the anastomoses are completed and
then the flap skin is de-epithelialized, leaving a small verti­
cal area at the lower pole intact for postoperative monitor­
ing. The flap dermis is tacked into the pectoralis major
fascia. The flap can be folded or gathered inferiorly to
obtain better breast projection or cone. Breast reshaping
with mastopexy and autoaugmentation using DIEAP flap is
finalized by skin closure. It is usually difficult to estimate
the amount of skin to be excised from the breast during
mastopexy and this should be performed after flap insetting

93
Chapter | 10  Breast reshaping using autologous tissues after massive weight loss
Preoperatively, the skin paddle and the gracilis muscle
are marked with the patient in standing position. Occasion­
ally it can be difficult to locate the muscle in an obese or a
MWL patient. The adductor magnus muscle is usually pal­
pated more easily and the gracilis lies just posterior to this
muscle. The upper incision is placed 1–2 cm inferior to the
groin fold in order to prevent distortion of the external
genitalia. The medial margin is located 5 cm ventral to the
adductor muscle and should not be above the great saphe­
nous vein. The posterior margin is extended to the midglu­
teal line and the main volume is achieved from this part of
the flap. The skin paddle is crescent-shaped and the width
of the flap is determined according to the amount of skin
laxity that allows primary closure; this can be predicted
with a simple pinch test.
The operation is performed with the patient in the supine
position with the hips abducted and the knee flexed. One
team prepares the donor site and the recipient vessels, and
the other team harvests the flap. The flap is elevated in an
anterior to posterior fashion. Once the great saphenous vein
is spared and the adductor fascia is incised, dissection pro­
ceeds between the avascular septum between the gracilis
and adductor muscles bluntly. The proximal vascular pedicle
is easily found and dissected to the profunda femoris vessels
to gain a 6–8 cm long pedicle. Next, the flap is raised from
the posterior margin until the posterior border of the gracilis
muscle is reached. Then the gracilis muscle is separated
from adductor longus and adductor magnus muscles and
in order to facilitate tension-free closure over the DIEAP
flap. This complex procedure is long, and prone to the well-
known complications of a long free flap procedure, but it
provides an effective and satisfactory result in patients who
need both breast and abdominal reshaping together and do
not have sufficient volume at the breasts and lateral side
rolls for autoaugmentation.
TMG Flap
The use of a TMG free flap for the reconstruction of various
anatomical regions was described a long time ago, and
Yousif et al demonstrated that this flap could be raised
safely when the skin paddle is designed in a transverse
fashion.22 Historically, the tissue of the upper medial thigh
has received very little attention for the purpose of recon­
structing an esthetically pleasing breast mound. During
the last few years the use of free TMG flaps for breast
reconstruction has been popularized, especially for women
who have inadequate abdominal bulk or who had previous
abdominal surgery.23,24
Excessive skin and soft tissue on the medial thigh after
MWL is a common problem among this patient group and
an appropriate lifting procedure is almost always needed.25
Schoeller et al reported medial thigh lifting combined with
the use of excised tissues as bilateral free gracilis muscu­
locutaneous flaps for breast augmentation in a single-stage
procedure.13
G
H
(G, H) The outcome at 1 year postoperatively.
FIG. 10.2  Continued

94
PART | 3  Breast reshaping
this skin island, which can be removed under local anesthe­
sia after the healing phase is complete.
COMPLICATIONS AND
THEIR MANAGEMENT
MWL patients are susceptible to various complications
after body contouring procedures. In a previous study of
449 post-bariatric surgery patients, 42% of the subjects
developed complications and the rates ranged from 8 to
66% in different series.28–30 Complications in the postop­
erative period include wound healing problems, seromas,
thromboembolic complications, infection, hematoma, and
necrosis.28–31 Patients’ body mass index, overall medical
condition and comorbid factors play an important role in
developing postoperative problems. Both seroma forma­
tion and wound healing problems are seen in the abdo­
minal and thigh regions and the incidence of such
complications is lower in the breast area.28,29 The most
important risk factor for seroma was found to be the
weight of skin excised at the time of surgery.29 In the thigh
region, keeping the anterior border of the excision poste­
rior to the femoral triangle is very important in order to
prevent seroma, lymphatic collection and lymphedema.
Another important determinant for postoperative compli­
cations is combining procedures or more aggressively
applying total body lifting procedures.32 Additional appli­
cation of two free flap transfers for breast autoaugmenta­
tion further lengthens the operative time and might increase
the overall complication rates. However, there are no data
regarding the complication rates after free flap transfer in
MWL patients. On the other hand, perfusion complications
can be expected at the flaps. Previous clinical data demon­
strate that, as the body mass index gets higher, the inci­
dence of venous congestion and fat necrosis increases.33–35
Fat necrosis or partial flap necrosis necessitates debride­
ment, and if a significant amount of flap loss occurs,
volume replacement can be achieved by fat grafting. In
case of total flap loss the situation can be catastrophic both
for the patient and the surgeon and the flap should be
replaced by a silicone implant. Preoperative determination
of the risk factors, careful patient selection for combining
procedures, and appropriate postoperative care are the key
steps to be followed for minimizing major and minor
complications.
CONCLUSION
Breast reshaping after massive weight loss is an effective
procedure and provides high patient satisfaction. The prin­
ciple of using excess tissues for shaping the breast in
patients who have undergone bariatric surgery and also do
not want implant augmentation is a valuable alternative for
dissected distally through the inferior incision with the help
of fingers until its tendinous junction is reached. Finally,
muscle tendon is divided through the subcutaneous tunnel
with the help of long scissors, without the need for a second
incision at the knee level. The pedicle is divided and the
flap is transferred to the subcutaneous pocket on the chest
wall. Usually an inverted-T skin excision followed by
autoaugmentation is performed to achieve a pleasing shape.
After the vascular anastomosis to the internal mammary
vessels is finished, the flap is shaped inside the breast
pocket. Shaping of the TMG flap is different from other
free flaps. Both ends of the skin paddle are brought together
and sutured in order to create a breast cone and give the
flap extra projection. The skin paddle is de-epithelialized
and buried in the subcutaneous pocket; however, a small
elliptic skin island is preserved and located either in the
vertical or in the horizontal scar as a monitor to be removed
later. In order to prevent excessive excision, skin removal
from the ptotic breast is done at the end of the procedure.
POSTOPERATIVE CARE
Postoperative care can sometimes pose a challenge for this
group as MWL patients usually have multiple accompany­
ing comorbidities along with an increased risk for general
postoperative complications.26,27 Especially in cases where
multiple procedures have been carried out, patients should
be observed under ICU conditions in the early postopera­
tive phase (24 hours) or in a so-called semi-ICU where
patients can stay overnight, mainly for free flap monitoring.
Careful monitoring of vital signs, along with urinary output,
is critical and fluid replacement must be administered
accordingly. A control total blood count and biochemistry
panel should be obtained to determine any critical blood
loss or biochemical imbalances and the necessary measures
must be taken according to the results.
Precautions must also be taken to avoid the risk of
thromboembolus, especially in the first hours after surgery
when the patient is immobilized.26 The use of compression
socks or compression devices is advised for all patients.
Pneumatic compression systems for the lower extremity are
quite useful devices and serve well for the purpose. Patients
may also be given low molecular weight heparin during the
immobilized period. It is extremely important to mobilize
patients as early as possible to avoid any complications
related to prolonged immobilization.
Free and pedicled flaps are followed up according to
usual protocol but the follow up of free flaps that are placed
in a tissue pocket can pose a challenge, resulting in diffi­
culty detecting early critical changes in color, temperature
and capillary fill. For this reason, it is important to transfer
free flaps with a skin island that allows monitoring. Changes
in color, temperature and capillary fill can be observed via

95
Chapter | 10  Breast reshaping using autologous tissues after massive weight loss
17. Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing
the functional ımpact of SIEA, DIEP, and muscle-sparing free
TRAM flaps on the abdominal wall: Part II. Bilateral reconstruction.
Plast Reconstr Surg 2010;126:1438–53.
18. Nelson JA, Guo Y, Sonnad SS, et al. A Comparison between DIEP
and muscle-sparing free TRAM flaps in breast reconstruction: a
single surgeon’s recent experience. Plast Reconstr Surg 2010;126:
1428–35.
19. Wallach SG. Abdominal contour surgery for the massive weight loss
patient: the fleur-de-lis approach. Aesth Surg J 2005;25:454–65.
20. Fernando da Costa L, Landecker A, Marinho Manta A. Optimizing
body contour in massive weight loss patients: the modified vertical
abdominoplasty. Plast Reconstr Surg 2004;114:1917–23.
21. Parrett BM, Caterson SA, Tobias AM, et al. DIEP flaps in women
with abdominal scars: are complication rates affected? Plast Recon­
str Surg 2008;121:1527–31.
22. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis
musculocutaneous flap. Ann Plast Surg 1992;29:482.
23. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis
free flap: a valuable tissue source in autologous breast reconstruc­
tion. Plast Reconstr Surg 2004;114:69–73.
24. Arnez ZM, Pogorelec D, Planinsek F, et al. Breast reconstruction
by the free transverse gracilis (TUG) flap. Br J Plast Surg 2004;
57:20–6.
25. Moreno CH, Neto HJG, Helene Junior A, et al. Thighplasty after
bariatric surgery: evaluation of lymphatic drainage in lower extremi­
ties. Obes Surg 2008;18:1160–4.
26. Shermak MA, Chang DC, Heller J. Factors impacting thromboem­
bolism after bariatric body contouring surgery. Plast Reconstr Surg
2007;119:1590–6.
27. Coon D, Michaels VJ, Gusenoff JA, et al. Multiple procedures and
staging in the massive weight loss population. Plast Reconstr Surg
2010;125:691–8.
28. Greco JA 3rd, Castaldo ET, Nanney LB, et al. The effect of weight
loss surgery and body mass index on wound complications after
abdominal contouring operations. Ann Plast Surg 2008;61:235–42.
29. Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development
following body contouring surgery for massive weight loss: patient
risk factors and treatment strategies. Plast Reconstr Surg 2008;
122:280–8.
30. Shermak MA, Chang DC, Heller J. Factors impacting thromboem­
bolism after bariatric body contouring surgery. Plast Reconstr Surg
2007;119:1590–6; discussion 1597–8.
31. Albino FP, Koltz PF, Gusenoff JA. A comparative analysis and sys­
tematic review of the wound-healing milieu: implications for body
contouring after massive weight loss. Plast Reconstr Surg 2009;
124:1675–82, discussion 1683–4.
32. Coon D, Michaels VJ, Gusenoff JA, et al. Multiple procedures and
staging in the massive weight loss population. Plast Reconstr Surg
2010;125:691–8.
33. Seidenstuecker K, Munder B, Mahajan AL, et al. Morbidity of
microsurgical breast reconstruction in patients with comorbid condi­
tions. Plast Reconstr Surg 2011;127:1086–92.
34. Vyas RM, Dickinson BP, Fastekjian JH, et al. Risk factors for
abdominal donor-site morbidity in free flap breast reconstruction.
Plast Reconstr Surg 2008;121:1519–26.
35. Garvey PB, Buchel EW, Pockaj BA, et al. The deep ınferior epigas­
tric perforator flap for breast reconstruction in overweight and obese
patients. Plast Reconstr Surg 2005;115:447–57.
these patients. With the combination of microsurgical skills
and experience in the management of MWL patients, safe
and successful results can be achieved.
REFERENCES
1. Colwell AS, Driscoll D, Breuing KH. Mastopexy techniques after
massive weight loss: An algorithmic approach and review of the
literature. Ann Plast Surg 2009;63:28–33.
2. Rubin JP, Gusenoff JA, Coon D. Dermal suspension and parenchy­
mal reshaping mastopexy after massive weight loss: statistical analy­
sis with concomitant procedures from a prospective registry. Plast
Reconstr Surg 2009;123:782–9.
3. Hamdi M, Van Landuyt K, Blondeel P, et al. Autologous breast
augmentation with the lateral intercostal artery perforator flap in
massive weight loss patients. J Plast Reconstr Aesth Surg 2009;
62:65–70.
4. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmenta­
tion after massive weight loss: the intercostal artery perforator
(ICAP) flap. Ann Plast Surg 2006;57:361–5.
5. Rubin JP, Agha-Mohammadi S, O’Toole JP. Breast reshaping after
massive weight loss. In: Aly A, editor. Body Contouring after
Massive Weight Loss. St. Louis: Quality Medical Publishing; 2006.
p. 361–78.
6. Hamdi M,Van Landuyt K, Tonnard P, et al. Septum-based mamma­
plasty: a surgical technique based on Würinger’s septum for breast
reduction. Plast Reconstr Surg 2009;123:443–54.
7. Spear SL, Boehmler JH, Clemens MW. Augmentation/mastopexy: a
3-year review of a single surgeon’s practice. Plast Reconstr Surg
2006;118:136S–47S; discussion 148S–9S, 150S–1S.
8. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshap­
ing: the spiral flap. Ann Plast Surg 2006;56:481–6; discussion 486.
9. Hamdi M, Van Landuyt K, Monstrey S, et al. Pedicled perforator
flaps in breast reconstruction: a new concept. Br J Plast Surg 2004;
57:531–9.
10. Van Landuyt K, Hamdi M, Blondeel P, et al. Autologous breast
augmentation by pedicled perforator flaps. Ann Plast Surg 2004;53:
322–7.
11. Hamdi M, Spano A, Van Landuyt K, et al. The lateral intercostal
artery perforators: anatomical study and clinical application in breast
surgery. Plast Reconstr Surg 2008;121:389 –96
12. Hamdi M, Van Landuyt M, Hijjawi JB, et al. Surgical technique in
pedicled thoracodorsal artery perforator flaps: a clinical experience
with 99 patients. Plast Reconstr Surg 2008;121:1632–41.
13. Schoeller T, Meirer R, Otto-Schoeller A, et al. Medial thigh lift free
flap for autologous breast augmentation after bariatric surgery.
Obesity Surg 2002;12:831–4.
14. Smit JM, Klein S, Werker PMN. An overview of methods for vas­
cular mapping in the planning of free flaps. J Plast Reconstr Surg
2010;63:e674–82.
15. Gacto-Sanchez P, Sicilia-Castro D, Gomez-Cıa T, et al. Computed
tomographic angiography with VirSSPA three-dimensional software
for perforator navigation ımproves perioperative outcomes in DIEP
flap breast reconstruction. Plast Reconstr Surg 2010;125:24–31.
16. Alonso-Burgos A, Garcıa-Tutor E, Bastarrika G, et al. Preoperative
planning of DIEP and SGAP flaps: Preliminary experience with
magnetic resonance angiography using 3-tesla equipment and blood-
pool contrast medium J Plast Reconstr Aesth Surg 2010;63:
298–304.

96
© 2013 Elsevier Inc
Chapter 11 
Combined abdominoplasty and
breast enlargement by autologous
tissue transfer or transabdominal
implant placement
Reena A. Bhatt, Erik Hoy and Richard Zienowicz
INTRODUCTION
Relative to conventional abdominoplasty, reverse abdomi­
noplasty has been less frequently studied.1–4 This is in part
due to the fact that the reverse abdominoplasty technique
necessitates an upper abdominal scar, and that most patients
present with lower, rather than upper, abdominal laxity. In
patients with relatively normal infraumbilical abdomen
tissues who request that the lax epigastric tissues be
addressed, or patients who are not candidates for conven­
tional abdominoplasty because of previous subcostal inci­
sional scars, reverse abdominoplasty may be the safer,
better, or sole option.5
Using the augmentation mammaplasty by reverse
abdominoplasty (AMBRA) technique, the upper abdominal
pannus is repositioned as dual adipofascial flaps, which
provide autologous tissue for augmentation mammaplasty
by reverse abdominoplasty. The result is a volume increase
of 150– 200 cm3 in the average patient, and greater than
300 cm3 increases in those with a more generous pannus.
Though AMBRA was designed to address a small subset of
patients who also desire breast enhancement, it has proven
similarly valuable for reconstructive purposes in appropri­
ately selected cases.
PREOPERATIVE PLANNING/
PATIENT SELECTION
The key steps in determining a patient’s suitability for
the AMBRA procedure are a careful evaluation of the soft
tissues of the upper epigastrum and performing a “breast
suspension” test (Fig. 11.1). The patient is asked to lift
each breast with a cupped hand. This should restore an
esthetic result to the upper abdomen and umbilicus. Some
patients benefit from suction-assisted lipectomy to the
lower abdomen for contouring. Other patients would be
better served by a mini-abdominoplasty to address moder­
ate skin laxity of the lower abdomen. These adjuncts can
help optimize the final result of AMBRA, without undue
added risk.
SURGICAL TECHNIQUE
Based on the pedicle of the flap, AMBRA is categorized as
either superiorly or inferiorly based. The preoperative
markings do not differ between the two approaches.
These preoperative markings are conducted while the
patient is standing upright, to delineate the inframammary
folds, and breast markings for mastopexy are performed
concurrently. Then the patient is placed supine to allow the
surgeon to retract the excess upper abdominal tissues ceph­
alad, which is an adaptation of the Lockwood technique.6
A.  AUGMENTATION MAMMAPLASTY
BY REVERSE ABDOMINOPLASTY
Key Points
●
Augmentation mammaplasty by reverse
abdominoplasty (AMBRA) may be a viable option for
patients with upper abdominal skin laxity and
adiposity who desire autologous tissue breast
augmentation and/or mastopexy combined with
reverse abdominoplasty.
●
Patients with epigastric or subcostal incisional scars
that exclude them as candidates for conventional
abdominoplasty, can safely undergo AMBRA.
Part 3  Breast reshaping

97
Chapter | 11  Combined abdominoplasty and breast enlargement
The redundant soft tissues of the upper abdomen are then
folded over to mark the “safe” zone of skin excision that
permits tension-free closure with the inframammary fold.
This area can be de-epithelialized without sacrificing a
tension-free closure of the upper abdominal–IMF wound
(Fig. 11.2). This de-epithelialized tissue provides the bulk
for each breast’s augmentation.
Superiorly Based Augmentation
Mammaplasty by Reverse Abdominoplasty
The procedure begins with de-epithelializing the “safe
zone”, taking care to preserve as much dermis as possible.
Dissection is continued, beneath the dermis one centimeter
above the inferior border of the safe zone, and then deep­
ened to the level of Scarpa’s fascia, depending on the
desired thickness of the flap. Dissection proceeds to a level
just cephalad to the umbilicus, where it is directed down to
the rectus abdominis fascia. The de-epithelialized zone is
divided into halves, and a subglandular pocket is under­
mined beneath each breast. The AMBRA flaps are then
FIG. 11.1  Breast suspension test (A, B) to confirm suitability for AMBRA.
A
B
FIG. 11.2  Preoperative markings.

98
PART | 3  Breast reshaping
1. AMBRA is a forgiving technique, if the surgeon pre­
serves the dominant central abdominal perforators and
avoids venous and lymphatic compromise.
2. In patients undergoing AMBRA with concomitant lower
abdominal adiposity, a mini-abdominoplasty or pan­
niculectomy can treat persistent lower abdominal skin
and tissue redundancy without compromising central
abdominal vascularity.
BOX 11.1  Optimizing outcomes pearls
folded into these pockets. The flaps are reflected inferiorly
until plication of the rectus is completed, and the patient is
raised to a seated position on the operating table. The
breasts, once augmented by the AMBRA flaps, can be
assessed for position, projection, and symmetry and adjusted
as necessary.
The patient is returned to a fully supine position, and
with cephalic tension on the flap, the de-epithelialized
border of the skin apron is anchored to the perichondrium,
periosteum, and deep fascia along the lower border of the
breast. A nipple–areola complex located slightly lower on
the breast mound (1 to 2 cm) than ideal, to allow for lower
pole descent, is preferred. The edge of the abdominal skin
flap is then reinforced along its entire length with sutures
to the periosteum. The central midline supraumbilical
abdominal area is then liposuctioned to emphasize the
median raphe. The closure of upper and lower wounds is
the same except that Scarpa’s fascia is approximated in
the lower abdominal closure, followed by dermal closure
(Box 11.1).
PERI- AND POSTOPERATIVE CARE
At the conclusion of the case a thin layer of tissue glue
is applied to the incisions. The wounds are taped vertically
to reduce tension. A 15 cm (6 inch) cotton roll reduced
to half its diameter is placed in the midline to splint the
median raphe and tape is applied across the abdomen for
support and dead space closure. No garment is used for the
first 2 weeks, but the patient is retaped after postoperative
visits.
Case Examples
A 70-year-old patient desired fuller breasts and superior and
central abdominal tightening (Fig. 11.3A, B, C, D).
The case example shown in Fig. 11.4 depicts a patient
who had previous submuscular breast augmentation and
was unhappy with her sagging epigastric soft tissues and
breast appearance.
Key Points
●
Choose patients properly for transabdominal breast
augmentation – patients should be minimally ptotic
and finished with childbirth.
●
Be cautious in the overweight or smoking patient:
postoperative morbidity increases.
COMPLICATIONS AND
THEIR MANAGEMENT
Versus conventional abdominoplasty, the AMBRA scar is
more difficult to conceal, but the normal venous, lymphatic
and periumbilical arterial inflow to the flap are preserved.
Moon and Taylor’s description of the periumbilical perfora­
tor network spurred the evolution of modern microsurgical
breast reconstruction.7 Thus, the reverse abdominoplasty
technique is forgiving, if the surgeon preserves the domi­
nant central abdominal perforators and avoids venous and
lymphatic compromise.
There is no risk for capsular contracture or other device-
related problems with the AMBRA technique, and it pro­
vides a natural-feeling breast. Other techniques for
autologous breast have been suggested to provide these
same benefits versus synthetic implants.8–13 However, aug­
mentation mammaplasty by reverse abdominoplasty also
provides concurrent abdominal contouring. The result can
make for a dramatic improvement in selected patients.
Admittedly, the AMBRA technique requires more operative
time than its implant-based version. A major disadvantage
of AMBRA is the required transverse epigastric scar, which
encompasses both inframammary creases and crosses the
midline in the presternal region. This scar has been surpris­
ingly well tolerated by our patients, who might not other­
wise be abdominoplasty candidates.
CONCLUSION
Augmentation mammaplasty by reverse abdominoplasty
(AMBRA) may be a viable option for patients with
upper abdominal skin laxity and adiposity who desire
autologous tissue breast augmentation and/or mastopexy
combined with reverse abdominoplasty. Those with pre­
vious breast reduction or with a long cholecystectomy
scar may deserve special consideration as candidates for
this procedure. AMBRA may also serve a unique role in
breast reconstruction as an adjunct, alternative, or salvage
procedure.
B.  TRANSABDOMINAL BREAST
AUGMENTATION

99
Chapter | 11  Combined abdominoplasty and breast enlargement
FIG. 11.3  A 70-year-old patient desiring fuller breasts and abdominal tightening. Preoperative (A, C) and postoperative (B, D) photos.
A
B
C
D

100
PART | 3  Breast reshaping
A
B
C
D
FIG. 11.4  Preoperative views (A, B, C) of a patient who had previous submuscular breast augmentation and was unhappy with her sagging
epigastric soft tissues and breast appearance. Postoperative views (D, E, F) of same patient at 1 year are shown.

101
Chapter | 11  Combined abdominoplasty and breast enlargement
PREOPERATIVE PLANNING/
PATIENT SELECTION
Appropriate patients are those who qualify for conventional
abdominoplasty, have no previous breast or superior
abdominal violation, have either minimal ptosis (Grade I)
or pseudoptosis, and are requesting simultaneous abdomi­
noplasty and bilateral breast augmentation. Smoking cessa­
tion should be required longer than 4 weeks preoperatively
and indefinitely post procedure.
MARKING AND ANESTHESIA
Patients are marked in the preoperative holding area for
a low transverse abdominal incision. Surgery is then
preferably performed under monitored anesthesia care
(MAC) with use of a combination of propofol and ket­
amine. Further anesthesia is executed with the patient
placed in the prone position for posterior intercostal nerve
blocks to T4–T12, using a combination of 1% lidocaine
with 1 : 100 000 epinephrine (adrenaline) and 0.5% Mar­
caine. The patient is then rotated to a supine position for
placement of T2–T3 intercostal nerve blocks in the poste­
rior axillary line and bilateral ilioinguinal nerve blocks.
The local anesthetic is then diluted and injected into the
E
F
FIG. 11.4  Continued
INTRODUCTION
A desire for combined cosmetic procedures, particularly
the so-called “mommy makeover” has increased interest
in perfecting techniques that safely and reliably result
in a pleasing esthetic outcome. In our experience, in an
appropriately selected patient population, we have fre­
quently utilized the transabdominal breast augmentation
(TABA) in the pursuit of these goals. Though TABA has
been described before, these published reports have been
limited by short-term follow up and small case series. In
addition, the majority of these surgeons utilized general
anesthesia, which differs from our experience. Often those
patients who desire abdominoplasty are seldom nullipa­
rous and have concomitant involutional breast volume loss
and either resultant ptosis or pseudoptosis. These patients
often request accompanying breast augmentation and we
believe the combined procedure of breast augmentation
via an abdominoplasty incision is a favorable approach
in terms of minimizing incisions and can be safely per­
formed without general anesthesia, thereby limiting post­
operative nausea and vomiting.14–18 The senior surgeon,
R.J.Z., has the largest series to date of this technique and
his procedure and management are illustrated here and
elsewhere.19

102
PART | 3  Breast reshaping
FIG. 11.6  This patient had a significant rectus diastasis after two large pregnancies preoperatively (A). (B) Postoperative results.
A
B
FIG. 11.5  Picture of dissector in patient.
breast periphery and medial intercostal perforators of the
breast mound.
SURGICAL TECHNIQUE
A conventional abdominoplasty flap dissection is per­
formed. Tunnels are created to reach the inframammary
fold, at which point blunt finger dissection is used to create
a subpectoral pocket. The pocket is further defined using a
Snowden Pencer™ balloon dissector (Fig. 11.5). A hockey
stick dissector is frequently used for further pocket
definition.
Following adequate pocket creation, the implants
are positioned. The patient, who has been secured to the
bed, is placed in a sitting position to evaluate for sym­
metry and any further adjustments are made at that time.
After achievement of optimal symmetry, the inframam­
mary tunnels are occasionally partially closed with per­
manent sutures. Additionally, external bolster sutures on
Xeroform pledgets may be used to further define the
inframammary fold. Conventional abdominoplasty then
continues with removal of excess skin and fascial plica­
tion from the xiphoid to the pubic symphysis with inter­
rupted and running permanent sutures. Often, the
supraumbilical flap is judiciously liposuctioned for con­
touring of the midline raphe. The umbilicus is then inset.
For further postoperative pain relief, Marcaine is injected
into bilateral rectus muscles intraoperatively. Two JP
drains are placed and brought out in the mid-suprapubic
region. Finally, the abdominoplasty incision is closed in
multiple layers.
The patient shown in Fig. 11.6 demonstrates significant
preoperative rectus diastasis after two large pregnancies.
The patient in Fig. 11.7 underwent a floating abdominal
technique; note her involutional loss of breast volume
preoperatively.
The patient shown in Fig. 11.8 had significant preopera­
tive lower abdominal adiposity which is improved signifi­
cantly after TABA with a pleasing feminine hourglass
shape.
Box 11.2 gives hints for optimizing outcomes.

103
Chapter | 11  Combined abdominoplasty and breast enlargement
FIG. 11.8  Preoperatively (A), this patient had significant lower abdominal adiposity. Improved contour and hourglass shape is displayed
postoperatively (B).
A
B
FIG. 11.7  This patient (A) underwent a floating umbilical technique; notice the inconspicuous abdominal scars (B).
A
B

104
PART | 3  Breast reshaping
1. Leave inframammary tunnels partially open to aid with
drainage.
2. Inframammary folds can be symmetrically repositioned
to achieve optimal breast appearance with external
suture bolsters or internal sutures.
BOX 11.2  Optimizing outcomes pearls
of the breast pocket and marginal symptomatic capsular
contracture sequelae.
REFERENCES
1. Baroudi R, Keppke EM, Carvalho CG. Mammary reduction com­
bined with reverse abdominoplasty. Ann Plast Surg 1979;2:
368–73.
2. Berrino P, Campora E, Leone S, et al. Correction of type II breast
deformities following conservative cancer surgery. Plast Reconstr
Surg 1992;90:846–53.
3. Dagregorio G, Darsonval V. Aesthetic surgery techniques after exci­
sion of dermatofibrosarcoma protuberans: A case report. Br J Plast
Surg 2005;58:556–60.
4. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast
shaping the spiral flap. Ann Plast Surg 2006;56:481–6.
5. Zienowicz RJ, Karacaoglu E. Augmentation mammaplasty by
reverse abdominoplasty (AMBRA). Plast Reconstr Surg 2009;
124(5):1662–72.
6. Lockwood T. Reduction mammaplasty and mastopexy with superfi­
cial fascial suspension. Plast Reconstr Surg 1999;103:1411–20.
7. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis
musculocutaneous flaps based on the deep superior epigastric
system. Plast Reconstr Surg 1988;2:815–32.
8. Lai YL, Yu YL, Centeno RF, et al. Breast augmentation with bilateral
de-epithelialized TRAM flaps: An alternative approach to breast
augmentation with autologous tissue. Plast Reconstr Surg 2003;112:
302–8; discussion 309–11.
9. Landuyt KL, Hamdi M, Blondeel P, et al. Autologous breast aug­
mentation by pedicled perforator flaps. Ann Plast Surg 2004;
53:322–7.
10. Kwei S, Borud LJ, Lee BT. Mastopexy with augmentation after
massive weight loss. Ann Plast Surg 2006;57:361–5.
11. Hamdi M, Landuyt KV, Frene BD, et al. The versatility of the inter-
costal artery perforator (ICAP) flaps. J Plast Recontstr Aesth Surg
2006;59:644–52.
12. Pulagam SR, Poulton T, Mamounas EP. Long-term clinical and
radiologic results with autologous fat transplantation for breast aug­
mentation: Case reports and review of the literature. Breast J 2006;
12:63–5.
13. Zenn MR, Heitmann C. Extended TRAM flap: Feasibility study on
fresh human cadavers. Ann Plast Surg 2003;50:256–62.
14. Hinderer UT. The dermolipectomy approach for augmentation mam­
maplasty. Clin Plast Surg 1975;2:359–69.
15. Planas J. Introduction of breast implants through the abdominal
route. Plast Reconstr Surg 1976;57:431–7.
16. Barrett BM, Kelly RV. Combined abdominoplasty and augmentation
mammaplasty through a transverse suprapubic incision. Ann Plast
Surg 1980;4:286–91.
17. Wallach SG. Maximizing the use of the abdominoplasty incision.
Plast Reconstr Surg 2004;113:411–7.
18. Rinker B, Jack JM. Subpectoral breast augmentation through the
abdominoplasty incision. Ann Plast Surg 2007;58:241–5.
19. Bhatt RA, Sullivan R, Zienowicz RJ. Transabdominal breast aug­
mentation (TABA). Submitted for publication.
PERI- AND POSTOPERATIVE CARE
At the conclusion of the case, a 15 cm (6 inch) cotton roll
reduced to half its diameter is applied to the supraumbilical
median raphe for further contouring. Pertinent postopera­
tive care is limited to utilizing Medipore™ tape to abdomi­
noplasty incision and for further definition of the breast
mound for 3 months for scar management.
COMPLICATIONS AND THEIR
MANAGEMENT
The greater part of complications are related to the distal
abdominoplasty flap and are managed nonoperatively. The
common complications related to this procedure include:
peri-incisional wound complications, seroma, hematoma,
and cellulitis. Uncommon complications are those related
to breast augmentation, including symptomatic capsule for­
mation and implant malposition.
Further retrospective examination of our patients
revealed the greater majority of adverse events were in
patients who had comorbidities. Many of the complications
in our patient series were in patients who were defined as
overweight, obese, or were smokers.
CONCLUSION
Transabdominal breast augmentation, in the properly
selected candidate, is an excellent choice for patients
requesting both abdominoplasty and breast augmentation.
The procedure is an outpatient procedure and tolerated very
well under MAC anesthesia with nerve blocks. The signifi­
cance of this combined procedure is the addition of the
breast augmentation to the already planned abdominoplasty
with the benefit of eliminating the breast incision. Morbid­
ity is minimal and complication rates parallel those of pub­
lished reports for abdominal contour procedures in females.
There are distinct advantages to the use of this technique
in this re-emerging silicone breast implant era. These
include complete lack of breast incisional scarring, elimina­
tion of implant trauma during placement due to wide access

105
© 2013 Elsevier Inc
Chapter 12 
Key Points
●
The Phi ratio 1/1.618 defines breast aesthetics in a
three dimensional perspective
●
Breast shapes and volume alterations occur
accordingly to specific classifications
●
The L-shaped scar mammaplasty along with
techniques to produce a cone-shaped breast mound is
a versatile technique in breast surgery
Mammaplasty with L-shaped scar
Antonio R. Bozola
INTRODUCTION
It is important to understand why a breast is considered to
be beautiful so we can recognize any esthetic changes and
correct them. Beautiful is an adjective that determines what
the human vision can capture from shapes, volumes, pro­
portions, outlines, lights, glows, shadows, colors, move­
ments, and postures. It is optics, physics, and mathematics;
it is nothing subjective but is purely objective.
Throughout human evolution the limbic brain systems
have been marked out with the attractive features of what
is visually beautiful. One mathematical proportion (Phi) has
been repeatedly stated to be found in beautiful general
forms until the present. “There’s probably a natural connec­
tion between the sense of beauty and efficiency that is
biologically necessary for individual survival. Phi seems to
present single and wonderful properties. It is a quality that
for some reason attracts attention, and it is registered in the
limbic system such as beauty, harmony and balance”.1 Phi
is a universal constant ratio of 1/1.618 (Fig. 12.1).
The Greek philosophers Plato, Aristotle, Pythagoras,
and Euclid studied the proportion Phi (1/1.618) known as
the Phi ratio and felt that beautiful creations respected
certain geometrical laws displaying harmony.2 It is not
known when the Phi ratio was first described or applied
but it has always existed in the fields of mathematics and
physics. Because the Greek sculptor Phidias used that pro­
portion so much, it was called Phi, the Greek letter for the
first part of his name. This proportion was also described
by Leonardo Fibonacci of Pisa, in his development of
mathematical sequences. Leonardo da Vinci called it the
“golden proportion” and used it in Vetruvian Man. It has
been used in the design of such classic edifices as the Par­
thenon. Botanists have found it in phylotaxy.3 In the twen­
tieth century there were psychological studies about
significant preferences for structures containing the Phi
proportion.4
PROPORTIONS AND ANATOMY OF THE
BEAUTIFULLY SHAPED BREAST
Shape and Volume
A beautifully shaped breast can be analyzed from a three-
dimensional point of view (frontal, lateral, and vertical),
from which the possible esthetic distortions are also
reflected.
The shape of the breast contains and molds its volume.
Individual will, period, cultures, and fads have determined
a range of desirable volumes over time. Volume and shape
are different aspects and must be analyzed separately. If a
breast contains or approximates the golden ratio, it is con­
sidered beautiful, even if the volume is not.
We propose three views based on Phi to determine the
three-dimensional beautiful breast: golden ovoid (frontal
view), golden triangle (lateral view), and golden cone (ver­
tical view).
Frontal View
Considering the shape of the breast as an irregular cone, the
horizontal diameter is smaller than the vertical in a ratio of
1 to 1.3. This ratio is the consequence of the application of
Phi to the vertical axis with the shape of the golden oval
(Fig. 12.2A–C). The axis ABCD (Fig. 12.2A). is the breast
meridian line (BML) and it is comprised of two other hori­
zontal lines: the lowest horizontal breast line (LHBL),
which connects the inframammary sulcus where it meets
the breast meridian line (points I); and the highest horizon­
tal breast line (HHBL), which connects the highest point
of the two anterior axillary folds. The vertical measure
between both lines is a single mark for each patient, deter­
mining the vertical extension of the base of the breast.
Applying the ratio of 1 to 1.3 to this, the consequential and
proportional lateral extension is obtained.
Part 3  Breast reshaping

106
PART | 3  Breast reshaping
Lateral View
The normal thoracic skeleton in the anterior external costal
region has an anatomic inclination of approximately 18° in
relation to the vertical axis of the body in the area of the
breast implants. When the golden triangle is inclined over
this angle in relation to the vertical plane, it will resemble
the beautiful breast from the profile (Fig. 12.3A, B).
A normal breast without ptosis, from a lateral view,
is above the horizontal plane A (LHBL). Plane A coin­
cides with points I (the intersection of the breast meridian
line with the inframammary sulcus). The other horizontal
FIG. 12.1  The golden ratio (Phi).
A
C
B
1.6180339887... = Phi
=
=
AB
AC
AC
CB
From the frontal view of the breast, when there is skin
flaccidity, there will be ptosis; the vertical and horizontal
axes tend to invert their proportions – the vertical decreases
and the horizontal increases – and cleavage is diminished.
The points I remain unaltered.
FIG. 12.2  Frontal views of the breast with golden ratio.
LHBL
HHBL
B
C
LHBL
13.5 cm
I
HHBL
MBL
D
C
B
A
I
D
C
B
A
A

107
Chapter | 12  Mammaplasty with L-shaped scar
plane (M) crosses the apex of the mammary cone and
divides the breast into two segments: superior and infe­
rior. Point M is determined from where it crosses the
breast meridian, where in general the nipple is found (this
and the areola may be ectopic – outside the apex of the
cone).
The ideal measurement of the breast from the apex of
the cone to point I is between 7 and 12 cm. These measures
may vary according to country, times, and trends. Smaller
measurements will determine breasts of lesser volume and
projection and vice versa. Smaller breasts are closer to 7 cm
and larger breasts toward 12 cm. The section of the breast
above the apex of the cone to the HHBL measures 1.618
times the size of the section below it. This is the golden
ratio once again.
Vertical View
From the vertical point of view of the individual, when the
patient looks at herself from above, the normal, beautiful
breast is between two vertical lines: the vertical lateral
breast line (VLBL) and the vertical medial breast line
FIG. 12.3  Lateral views of the breast with golden ratio.
Vertical lateral breast line (VLBL)
Vertical medial breast line (VMBL)
Highest horizontal breast line (HHBL)
Lowest horizontal breast line (LHBL)
Meridian breast line (MHBL)
A
I
B
1,618
1
1,618
1
18.0°
C
D
a
A
b
c
Highest horizontal breast line (HHBL)
Plane M
Plane M
Plane A
Point
I Point
1x1,618
1
M
7 - 12 x 1.618
7 - 12 cm
I
Plane A
Lowest horizontal breast line (LHBL)
a
B
b
(VMBL). The former coincides with the anterior axillary
line; the latter is situated 1 to 2 cm laterally to the middle
line of the sternum (Fig. 12.4A, B).
Applying a geometric analysis to the vertical view, it is
observed that four golden triangles are joined by their
closest sides and by their apexes, forming a golden pyramid.
If this pyramid is turned on its vertical axis, a golden cone
is obtained. This presents the relationship of 1 to 1.618
between its height and base and resembles a beautiful breast
as seen from a vertical view. If the lines from the base to
the apex are curved, it resembles a beautiful breast from a
vertical view.
The author believes that the golden ratio must not be
fixed as an exact measure, but rather be considered an
indisputable reference in determining an anatomical stan­
dard for the shape of a beautiful breast, which is mathemati­
cally replicable. A shape of a beautiful breast exists when
it presents at 1 to 1.5. Furthermore, a breast can have a
beautiful shape, though little volume, when the extremes of
the horizontal and vertical diameters do not touch the hori­
zontal and vertical lines described and established at the
thorax as their limits.

108
PART | 3  Breast reshaping
LHBL
HHBL
1-2 cm
Medium sternal line
Vertical lateral breast line
Vertical medial breast line (VMBL)
Vertical medial breast line (VMBL)
Vertical lateral breast line (VLBL) (Anterior axillary line)
Medium sternal line
A
FIG. 12.4  Vertical views of the breast with golden ratio.
a
b
c
B
d

109
Chapter | 12  Mammaplasty with L-shaped scar
One can measure the ptosis, and choose the technique
of skin resection and even predict approximately the length
and final shape of scars.
In lateral view: the thorax is considered to be a vertical
plane and the breasts are placed on it. If we observe no
ptosis, it is like the initial description, above plane A with
no ptosis. The falling breast (where planes A and M coin­
cide) still has no mammary ptosis is still zero (on the breast
borderline). The superior upper pole is partially emptied.
As the ptosis continues, plane M will exceed down the
plane A. Ptosis is installed (Fig. 12.7A).
In the frontal view: the vertical diameter is reduced, and
the horizontal widened; they have reversed themselves. The
upper pole is empty. The distance between points A and M
on the meridian that crosses the two planes will quantify the
ptosis in centimeters, and consequently the amount of skin
to be removed in the mammaplasty. The plane A and point
I remain unchanged throughout life. Now with the reversal
of the increased diameter of the base, the vertical is smaller
and horizontal is greater and the beauty of the breast shape
has been lost. In practice, with the patient standing, one can
get the mammary meridian, and three points: A, projection
of point I over the breast, in plane A (Fig. 12.7B); M, the
apex of the mammary cone on the mammary meridian, and
I (crossing the meridian with the inframammary sulcus).
Point M is not the papilla – it should be, but this may be
“ectopic” in relation to the apex of the breast from irregular
growth of the mammary cone during puberty.
MEASUREMENT
AM (Fig. 12.7C) indicates the method of skin resection to
correct mammary ptosis, and predicts the extension of the
horizontal scar. It is proportional to AM, and not to the
volume removed.
If AM equals 0 to 2 cm, it indicates the skin periareolar
resection. There is no ptosis, only other cosmetic disorders
(volume, shape, areola, papilla). With AM from 3 to 4 cm,
vertical and periareolar resection of the skin is called for.
If AM is 4 to 7 cm, it indicates periareolar, vertical and
lateral resection (L). If AM is greater than 7 cm, periareolar
vertical, lateral, and medial skin resection is needed
(inverted T).
In resection of very large volumes the horizontal
scars will be progressively and slightly more extensive, but
more directly and proportionately related to ptosis (distance
AM).
In symmetrical breasts, the points I and the following
points A and M will have equal positions in both breasts.
In asymmetric breasts, the points I and A will be sym­
metrical, the points M will not, if the asymmetry is ptotic.
In general, the different asymmetries include ptosis, volume,
and shape.
Diagnosis of Breast Shapes and
Volume Alterations
According to the frontal, lateral and vertical views (base
and cone projection without ptosis), it is possible to observe
the various shapes of the breast and to classify hypomastias
and hypertrophies (Fig. 12.5A, B).
Group I: The breast is normal (normomastia). Base,
profile and projection fall within the golden ovoid,
golden triangle and golden cone, respectively. They fit
within the two horizontal lines (HHBL and LHBL) and
the two vertical lines (VMBL and VLBL) previously
referred to. This is the control group described in
“earlier”. The characteristics of Group I are the same
for both hypomastia and hypertrophy classifications.
Group II hypomastia: The diameter of the breast base is
normal or widened, but without an ideal projection.
There is insufficient volume.
Group III hypomastia: This is the opposite of Group II.
The projection of the cone is normal or augmented and
the diameter of the base is reduced. There is insufficient
volume.
Group IV hypomastia: The projection of the cone and
its base are diminished or absent. There is insufficient
volume. Amastias are included in this group.
Group II hypertrophy: The diameter of the base is
widened and the projection is normal. Excess volume is
on the increase of the diameter of the base.
Group III hypertrophy: It is the opposite of Group II,
the projection of the cone is increased and the base
diameter is normal or reduced compared to Group I. The
excess volume is in the projection.
Group IV hypertrophies: This is the sum of both Groups
I and III, the volume in excess is on the base enlarge­
ment and in the projection of the mammary cone.
Flaccidity (Ptosis)
The breast grows, stretching the skin as a skin expander.
The direction of growth is three-dimensional until various
shapes and volumes are achieved, consistent with hormonal
stimulation and the amount of “sprouting”. Only at the end
of the growth process do we observe the final shape and
volume and amount of ptosis.
The anteroposterior growth projects the breast into space
and subjects it to gravitational forces; progressively the
breast falls, except at point I of the inframammary sulcus.
This ptosis starts after puberty and continues throughout
life (Fig. 12.6).
The elastic resistance of skin, shape, and volume will
determine how the ptosis of the breast will be as time
passes, during pregnancy and breastfeeding, after sun expo­
sure and diseases, etc.

110
PART | 3  Breast reshaping
Standard base
GI
GI normal breast
normal breast
GI normal base

normal projection
GII wide or normal base

low projection
GIII narrow base

normal or high

projection
GIV narrow base

low projection
Good volume
Insufficient volume
Standard base
Standard projection
GI
GI normal breast
normal breast
GI normal base

normal projection
GII wide base

normal projection
GIII narrow base

high projection
wide base
high projection
Good volume
Excess volume
Standard base
Standard base
Standard projection
A
Hypomastias Vertical and lateral vision
Hypertrophies Vertical and lateral vision
FIG. 12.5  (A) Diagram of the classified breast forms. (B) Classified breast forms.
Hypomastias
GI normal breast
GII
GIII
GIV
Hypertrophies
GI normal breast
GII
GIII
GIV
B

111
Chapter | 12  Mammaplasty with L-shaped scar
M
I
FIG. 12.6  Growth and evolution of the breast ptosis.
Nipple–Areola Esthetic Disorders
These can be ectopic positions in the vertical and horizontal
axes, or disorders of diameter, shape, projection, and color.
During a complete clinical evaluation of the esthetic
alterations to the breasts, including hypomasties, in addi­
tion to the frontal, lateral and vertical views of their shapes,
it is necessary to consider other elements:
1. The breast itself: breast ptosis, volume, axillary exten­
sion, pectoral pillars.
2. The thorax: the thoracic anatomy with its vertical and
lateral inclination and the curvature of the ribs, and the
presence of pectoral muscles.
3. The nipple–areola complex.
4. The spinal column.
5. Lastly, symmetry must be observed.
SURGICAL TECHNIQUE
Cone Modeling of Group I
Group I has no volume excess. The esthetic changes of the
breast will be in their shape, fostered by ptosis, areola–
papilla; pectoral pillars, axillary extension, etc.
The remodeling is performed with part of the breast that
extends down the inframammary sulcus (plane A). After
periareolar de-epithelialization and the marked skin
removed, an “axial” flap of inferior pedicle is obtained. Its
volume corresponds to a glandular ptosis, and arteriove­
nous pedicle from the fifth or sixth intercostal space, which
will be transposed above the plane A, vertically placed
under the mammary gland detached. The end of the flap
FIG. 12.7  Obtaining the points A and M to quantify the breast ptosis.
A
M
I
A
AM
M
A
C
A
B

112
PART | 3  Breast reshaping
FIG. 12.8  (A) Obtaining the inferior pedicle flap. (B) Under the
breast.
A
B
FIG. 12.9  (A) The inferior pedicle flap with a randomized flap in its
extremity. (B) The mini flap in all cases.
A
B
should reach the upper horizontal mammary line to restore
the upper mammary pole (Fig. 12.8A, B).
Lateral and medial vertents are sutured by themselves,
projecting the cone. If the flap is able to project it enough,
and the diameters are proportional, this suture tactic will be
unnecessary.
The flap can be short, it can be unfolded if it is volumi­
nous, producing a random flap at the end of the axial flap,
following its basic principles (Fig. 12.9A).
In any circumstance of resection of mammary tissue for
breast reduction, this minimum flap has to be left to recon­
figure the lower pole of the mammary cone, keeping it
round (Fig. 12.9B).
Breast Modeling of Group II
– Hypertrophies
In these breasts, the projection of the cone is properly or
little projected, there is a large transverse diameter and
axillary extension is increased. They present less ptosis than
those of Group III and Group IV.
A wedge of mammary tissue is resected from the infra­
mammary sulcus to the top, in the meridian of the breast,
to the extent necessary to reduce the transverse diameter of
the cone (Fig. 12.10A). In general, its top edge does not
reach the upper outline (border) of the gland, but exceeds
the geometric center of the mammary cone.
If there is ptosis, the resection of mammary tissue
can be started, as it has been projected below the
plane A, as in Group I, as a lower pedicle flap, removed
along with the wedge or removed separately (Fig.
12.10B).
If there are large axillary glands, they must be removed
(see Group IV), following the curvature of the ribs. If there
is fat in this place, it has to be liposuctioned. The first point
is on the upper base, above the end of the wedge resection,
fixed along with the aponeurosis of the pectoral muscle and
with many other stitches in the base, and between the ver­
tents as necessary for a proper fitting of the cone. The
diameters are inverted: the vertical increases, while the
horizontal decreases, and the superior pole projects itself.
The proportions are created.
Gland Modeling of Group III
– Hypertrophies
These breasts have a posteroanterior projection higher than
appropriate. The treatment of the gland is base resection
leaving a remnant of the gland, leaving a perfect cone with
the desired proportions (Fig. 12.11A).

113
Chapter | 12  Mammaplasty with L-shaped scar
All resection (“amputation”) must remove only the
glandular tissue, never reaching the subcutaneous tissue
that must remain at the same thickness as the subcutaneous
thorax adjacent to the gland (Fig. 12.11B). Vessels and
nerves pass through this subcutaneous tissue, with their
“epicenter” in the areola–papilla.
The upper outline of the gland is fixed to the aponeuro­
sis of the pectoral muscle, and also along its vertical axis
up to the point I, in order that it does not slide laterally to
where the glandular tissue was removed. Needless to say,
if the skin suture has been well placed in the thorax the skin
resections will result in an L-shaped scar.
Group III breasts present with much ptosis, since the
great posterior–anterior projection projects the breast into
space.
In Group III where the base is further from the desirable
position, to “amputate” the base would not be convenient;
thus the cone is treated, making a flap of the lower pedicle
with an inverted wedge of subareolar base. Suture this verti­
cally to the aponeurosis of the pectoral muscle, and do not
suture the medial and lateral vertents between themselves,
but only the highest point. Only suture subcutaneous,
dermis and skin layers. Keep going from Group III to
Group II.
The vertents “collapse” on the flap, producing a breast
with smaller projection and larger base; take care to keep
the ratio of described proportions.
Gland Modeling of Group IV
– Hypertrophies
The excess volume is on the base diameter beside the four
mammary lines, and the posterior-anterior projection is
increased (Group II + Group III). Usually there is ptosis.
FIG. 12.10  Resectioning the edge and ptosis to reduce Group II breasts.
A
FIG. 12.11  Resectioning the base to reduce Group III breasts.

114
PART | 3  Breast reshaping
1. Demarcation of the skin resection (Fig. 12.12A) and
periareolar de-epithelialization.
2. The volume equal to the ptosis is resected, which cor­
responds to getting a flap of inferior pedicle (Group I)
(Fig. 12.12B), leaving the mini-flap (Figs 12.9B and
12.12D). The wedge is resected (Group II) (Fig. 12.12C).
3. The lateral and medial bases of the cone are resected
(“amputated”) (Group III) (Fig. 12.12E, F). All
resections can be done in a single block (Fig. 12.13B),
or individually when the trial is small.
1. Demarcation the skin resection with L- shaped scar
2. Ptosis resection
3. Edge resection
4. The mini-flap
5. Medial base resection
6. Lateral base resection
FIG. 12.12  (A) Demarcation the skin resection with L-shaped scar. (B) Ptosis resection. (C) Edge resection. (D) The mini-flap. (E) Medial base
resection. (F) Lateral base resection.
A
B
C
D
E
F

115
Chapter | 12  Mammaplasty with L-shaped scar
It is important that at the end of resectioning and glan­
dular suturing the cone must be perfect, and the skin can
recover without any great tension, by removing only the
excess. This is described next.
A mammary cone is not created with the aid of exces­
sive skin traction. It should be ready at the time of the skin
suture.
Modeling Asymmetric Breasts
These breasts require different resections according to
volume and shape. The three-dimensional view, the resec­
tions, modeling and creation of mammary cones and skin
removals are individual and sometimes not transferable
from one to the other breast. Absolute symmetry is difficult
and almost impossible to obtain when operating on asym­
metric breasts. It remains for us to remove the excess skin.
The shape contains and molds an appropriate volume con­
tained between the four mammary lines.
MAMMAPLASTY WITH L-SHAPED SCAR
This tactic of removing skin in an L shape is chosen
when the AM value is 4 to 7 cm. Sometimes, 8 cm can be
achieved with little reduction of volume, good skin, and
experience.
Marking
The patient stands with arms along the thorax (Fig. 12.14A).
This frontal view mark up shows the average external line,
meridians (independent from the areola positions), inframa­
mmary sulcus and mammary lines.
The meridians have to be equidistant from the external
medium line in crossing with the inframammary sulcus
(point I). When the index finger is on point I, and thumb
on the breast in a horizontal posterior–anterior line, on the
meridian mark the points A are projections of points I on
the breasts. In the lateral or oblique view the apex of the
cones on the meridians is marked (points M). The papilla
is not ectopic in its position. In asymmetrical flaccid breasts,
the papillae will also be asymmetric (Fig. 14.14B–D).
The points I will always be symmetrical and, therefore,
also the points A, except in agenesia cases, deformities of
the thorax, spinal column, or one of the breasts.
The meridians, points A (s), M (s), I (s) are key to
marking the resection of skin in mammaplasty.
Now with the patient lying in the horizontal supine
position with arms abducted 90° to the thorax, measure
AM. A flat hand on the lateral side of the breast will dis­
tribute it gently on the thorax leaving the meridian straight
ahead.
From point M to above, passing through A, a semicircle
is marked (Fig. 12.15A). From point I to above in the
meridian, AM is marked, and from this rotation point, an
arch of medial circle slightly closed is marked (Fig. 12.15B).
From point I laterally on the inframammary sulcus, AM
(horizontal) is marked, concave upward, raising the extrem­
ity to 1 to 2 cm, as the base diameter of the breast will be
reduced (Fig. 12.16A). From that point on, a line that goes
up to the point A on mild traction toward the point A, AM
(oblique) is marked, slightly concave to medial, to adjust
on AM horizontal (Fig. 12.16B). The upper to the lower
markings are joined (Fig. 12.16C).
All demarcations of skin resection must be made to
predict the position of the scars on the future cone. If they
FIG. 12.13  (A) Resection diagrams to reduce Group IV breasts and
make a golden ratio breast. (B) Monoblock resection is possible with
an experienced surgeon.
I
X cm
A
C
1
3
1
2
M
X cm x 1,6 cm
A
B