Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

C H A P T E R 5 5
mebooksfree.net

Augmentation Mammoplasty, Mastopexy, and
Mastopexy-Augmentation
Ali A. Qureshi and Terence M. Myckatyn
Key Points
Breast augmentation can be performed with implants in the subglandular, subfascial, and
submuscular planes with the primary goal to increase the size of the breast. Fat grafting can be used
alone or as an adjunct procedure for breast augmentation.
Breast implants can be saline or silicone, smooth or textured, round or anatomic. These devices can
rupture or form capsules that lead to capsule contracture and distortion of the breast.
Mastopexy aims to change the shape of a breast that has become ptotic or involuted as result of age,
hormonal changes, or weight loss by altering the skin and parenchyma of the breast.
Management of capsular contracture or rupture of a prosthetic device can present a unique set of
challenges and often requires operative intervention. A new pocket may need to be created or
adjunct materials like acellular dermal matrices may be helpful.
Mastopexy-augmentation can be performed as a single-stage procedure to alter both the size and
shape of the breast at the same operation and presents a unique set of challenges.
mebooksfree.net

Augmentation Mammoplasty
Augmentation mammoplasty or breast augmentation (BA) continues to be one of the most commonly
performed aesthetic breast procedures in the United States. 1 The primary goal of the surgery is to
increase the size of the breast, but there are simultaneous changes to the shape of the gland and nipple-
areola complex (NAC) position. Thoughtful planning and use of devices individualized for the patient
help the surgeon to achieve a patient’s goals. Although historically BA has been performed with a
prosthetic device, advances in flap design and fat grafting have led to a paradigm shift where now BA
can be performed almost exclusively with a patient’s own tissue if desired.
mebooksfree.net

Preoperative Assessment
The consultation for BA, like that for any aesthetic procedure, is an art and a science. It requires a
thoughtful assessment and understanding of a woman’s goals for the size and shape of her breasts. This
must be complemented by the surgeon’s evaluation of objective parameters of anatomy and tissue
dynamics. Together, the subjective assessment of expectations and objective physical examination creates
an individualized plan for a patient seeking BA. The astute surgeon is aware, and communicates to the
patient, that not only will BA affect the size of the breast, but also the overall gland shape and position of
the NAC. After any aesthetic breast procedure, the breast will continue to age and patients should be
warned that further procedures may be necessary in the future if they desire restoration of a youthful
breast.
Patient’s seeking BA have often invested a large amount of time in thinking about their ideal breast size
and shape. They have researched implants, planes of implant placement, and incisions, and have
explored the experiences of friends, family, and internet bloggers before seeing a plastic surgeon in
consultation. It is not uncommon for a BA candidate to have met with other plastic surgeons in
consultation and continue to search until she finds the “right” surgeon who has the skill, results,
reputation, or price point that fits with her expectations. The artful history taker will be able to elicit this
and tailor a unique surgical plan using all the information available. Clinical intuition and experience of
the surgeon cannot be underestimated. Unrealistic expectations or indications of psychologic instability
should raise a red flag to the provider; surgeons should have a low threshold for a second or even third
consultation prior to offering surgery, if at all.
The main goal is to increase the volume of the breast and centralize the nipple on the breast mound. The
breast mound should reside completely or largely above the inframammary fold (IMF) although this can
vary with age. Upper pole fullness and specifically superomedial fullness is generally desired. Asking a
patient to bring photographs of augmented breasts that she finds desirable and undesirable can help the
surgeon understand the patient’s aesthetic expectation for her own breasts. When a potential BA
candidate mentions a “natural look,” it is important to inquire further and clarify what characteristics of
the breast create a “natural look” in the eyes of the patient. Often, but not always, it is equated with a
sloped upper pole that transition to the curve of the lower two-thirds of the breast. Some women may
desire a convex upper pole and have an “augmented” look that is “natural” to them. Clear
communication of expectations of outcomes in and out of clothes is also important.
A thorough medical and surgical history should be obtained. Candidates should be asked about their
current bra size and desired cup size. Patients with a history of prior BA and complications necessitating
a revision are different than those seeking a primary BA. For example, it would be useful to know if a
patient has had a previous breast reduction surgery or radiation because of breast cancer. Additionally, it
is important for a surgeon to understand a patient’s hobbies and interests. Patients who are highly
athletic and perform weight training or yoga for example may be less amenable to submuscular
placement of an implant because of animation deformity or changes to the pectoralis muscle.
Physical examination before BA should be systematic and include an assessment of the chest wall. The
chest wall is the foundation upon which a prosthetic device will sit, and chest wall asymmetries or
abnormalities recognized preoperatively can allow for better operative correction. This is especially true
in women who have a history of congenital chest wall abnormalities or scoliosis. Standard measurements
before BA include base width (BW), sternal notch to nipple distance (SN-N), nipple to inframammary
fold (N-IMF), NAC diameter, and internipple distance (Figure 55.1). Base width can be measured from
the medial aspect of the breast footprint to the anterior axillary fold. Tissue quality should also be
assessed. This can be done by measuring the pinch thickness of the breast, particularly in the upper pole
where involution can be easily appreciated. Generally, 2 cm of pinch thickness is considered the
mebooksfree.net

minimum necessary for placement of an implant in the subglandular or subfacial plane. Patients with less
than 2 cm of pinch thickness may be better candidates for implant placement behind the pectoralis
muscle. The interface between the skin and the breast parenchyma should also be evaluated, as
postpartum women or patients with poor dermis due to massive weight loss may have skin that very
easily glides over the underlying breast parenchyma. The lower pole of the breast can be constricted in
patients with micromastia or mild tuberous breast deformity. Lowering of the IMF and recruitment of
upper abdominal skin may be warranted in these patients and should be considered during the
evaluation. An assessment of the width of the sternum is a nuance that can help the surgeon talk to a
patient about expected superomedial fullness and interbreast distance that will likely persist after
augmentation. This distance can be decreased and even lead to symmastia when the implant is placed
subglandularly, but is less likely with submuscular placement because the medial pectoralis muscle
attachments are left intact and prevent medial migration.
FIGURE 55.1 Key landmarks and measurements for breast augmentation and mastopexy. For both breasts, the sternal notch
(SN), nipple (N), and inframammary fold (IMF) are marked. The sternal notch to nipple (SN-N) distance and the nipple to
inframammary fold (N-IMF), and internipple distance are key metrics for analyzing nipple position and assessing symmetry
between sides. The BW is a key measure for determining the appropriate transverse dimension of a breast implant and chest
wall diameter. The nipple-areola complex (NAC) dimensions can affect incision design, particularly for a periareolar or
circumvertical mastopexy and may contribute to asymmetry between sides.
According to current epidemiologic studies, one in eight women will get breast cancer. Women with
augmented breasts are at no increased risk of breast cancer compared to women with nonaugmented
breasts. There is no difference in breast cancer survival rates among women with and without augmented
breasts. 2 Women with a history of breast augmentation undergo screening mammography with special
implant-displaced or Eklund views to better assess the tissue anterior to the implant. 3 The sensitivity is
increased with ultrasound (US) or magnetic resonance imaging (MRI). When silicone implants were
mebooksfree.net

reintroduced into the market in 2006, the Food and Drug Administration (FDA) recommended screening
with MRI for silent ruptures 3 years after placement and then every 2 years thereafter. For women
desiring breast augmentation, routine mammographic screening should be performed or reviewed if
indicated preoperatively using the US Preventative Services Task Force guidelines based on age over 40
and risk. 4
Assessment of the NAC relative to the IMF is a common way to assess breast ptosis (Figure 55.2). In
general, patients who have visible breast skin below the NAC (pseudoptosis or grade I and II ptosis) on a
frontal view may be candidates for BA alone. Patients who seek BA who have no visible breast skin
below the NAC on a frontal view (grade III ptosis) likely need a mastopexy as well to reposition the NAC
on the breast mound.
FIGURE 55.2 Grades of breast ptosis based on the position of the gland and nipple relative to the inframammary fold.
(From Qureshi AA, Myckatyn TM, Tenenbaum MM. Madtopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38:374-384.)
The location of the breast and its footprint on the chest should be evaluated preoperatively during the
consultation. There are several ways to make this assessment. Hall-Findlay describes that a patient can be
“high” or “low” breasted based on the location of the breast on the chest wall relative to the clavicle
and/or humerus. 5 For example, a patient with an IMF at the junction of the middle and distal thirds of the
humerus may be considered “low” breasted whereas another with the IMF at the middle of the humerus
may be considered “high” breasted.
The location of the pectoralis muscle relative to the breast mound and the IMF should also be assessed. In
some women, the pectoralis major muscle and anterior axillary fold are well defined. The pectoralis
major’s inferior attachments can be above or below the NAC and at or above the IMF. This can be
particularly meaningful when thinking about how a prosthetic device will affect the upper breast border
if the implant is placed submuscularly versus subglandularly. For example, a low breasted patient with a
pectoralis major muscle attachment that is higher than the NAC may not benefit from subpectoral
placement of the breast because the implant will ride high behind the pectoral muscle whereas the NAC
will remain in a lower position and not be centered on the implant and augmented breast mound.
Patients being evaluated for BA with fat alone or composite BA with fat and an implant should be
evaluated for potential donor sites for fat grafting. Common areas include the abdomen, flanks and
medial thighs. Finding suitable donor sites and adequate fat can be challenging in women with a low
body mass index (BMI) who also have micromastia.
Standardized preoperative photographs should be obtained as a way to document and review anatomy
mebooksfree.net

and asymmetries with the patient. Many times, differences between breasts that are not visible to the
patient in the mirror can be more apparent in a photograph. Asymmetries noted preoperatively may
require correction, can persist, or become more noticeable after a BA. The impact of asymmetries on the
operative plan should be discussed with the patient. Three-dimensional imaging has emerged as a newer
technology that can also aid with educating patients. 6 Newer virtual reality simulation technologies have
also enhanced the preoperative consultation.
mebooksfree.net

Augmentation With Implants
Breast implants for augmentation vary in composition, shape, and shell texturing. Implants are filled with
either saline or silicone. However, even saline filled implants have a silicone outer shell. During the FDA
moratorium on silicone implants in the 1990s, saline implants were the only implants available for use.
This was reversed in 2002 when silicone implants again became available for use in BA and breast
reconstruction largely from combine efforts of plastic surgeons and industry. Silicone implants are
considered “off label” when used in women less than 22 years old per the FDA.
Just how different saline and silicone implants feel is subjective. A major difference besides cost and feel
is that saline and silicone implants differ in how a device rupture is detected. Regardless of type or
manufacturer, implant rupture is inevitable. Detection of a rupture in saline implants is fairly
straightforward as deflation of the implant and an obvious decrease in an augmented breast indicates a
rupture. Silicone implants, including the modern fifth generation cohesive gel implants, differ from the
first silicone implants in the 1960s in that the amount of cross-linking of the silicone has increased. First
and second generation silicone ruptures led to free floating silicone in the pocket leading to inflammation
and silicone granuloma formation. Ruptures of the current fifth generation implants are very different.
Silicone ruptures with cohesive gel implants can be detected on mammogram but more often require MRI
to confirm a suspected rupture. Often delayed capsular contracture can be due to a silent rupture of a
highly cohesive gel implant.
Implants can be anatomically shaped or round devices. Different manufacturers have implants of both
types with variable dimensions including height, width, projection, and volume. For a round device,
height and width will be the same. Therefore, for a given base width with a round device, an implant can
vary in volume and projection. Anatomic implants will have variable height, width, volume, and
projection and hence, they have many more permutations. This variability and plethora of implant
options help the plastic surgeon to customize the BA and even choose different devices for each breast to
correct asymmetries.
Whether shaped or round implants have a different look is controversial. Some studies have shown that it
is not possible to accurately detect a shaped versus round implant in the submuscular plan
intraoperatively. 7 Proponents of each type of implant may argue that a round implant has a more round
superomedial curve whereas an anatomic implant has a more teardrop look when placed in the
subglandular or subfascial plan. Additionally, anatomic implants have been argued to have unique uses
in breast reconstruction and tuberous breast deformity, though this is debated.
The outer shell of an implant can be either smooth or textured. Textured devices offered by the various
implant manufacturers are differentiated by the proprietary methods used to texture the device and
surface texture characteristics. Macrotextured devices are characterized by heterogeneously arranged
pores with a diameter of 600 to 800 µm and a depth of 150 to 200 µm. Microtextured devices possess a
more uniform pore distribution whose diameters range from 70 to 150 µm with a depth of 40 to 100 µm.
Pore size and distribution of other textured implant brands run intermediate to the micro- and
macrotextured devices. Surface area, pore size, and distribution may play a role in soft tissue integration
with the breast implant surface, the organization of myofibroblasts and matrix proteins, and potential for
accumulation of bacterial biofilms. 8–10 Textured devices increase friction between the implant and the
surrounding tissues that encompass an implant. Anytime a foreign body is placed into a cavity, whether a
prosthetic hip in a hip joint or a chin implant in the face, a capsule forms around the device and it
happens in the breast around a breast implant. Textured devices have lower rates of capsular contracture,
or the formation of a capsule that leads to deformity and/or pain in the breast following BA. This is
particularly true when a textured implant is placed in a subglandular or subfascial plane. Textured
devices are thought to be less likely to migrate beyond the dissected pocket, but recent data with
mebooksfree.net

anatomic, textured devices have demonstrated that even these implants can have rotation and
malposition necessitating reoperation. 11 Currently, anatomic implants are all textured devices. Round
devices can come as either textured or smooth.
mebooksfree.net

Incisions and Planes for Implant Placement
The implant in BA can be placed in different planes using a number of incisions for exposure. Options for
planes of implant placement include subglandular, subfascial, submuscular, and dual-plane (Figure 55.3).
The subglandular plane is below the breast parenchyma but above the fascia of the pectoralis major
muscle. The subfascial plane is below the fascia of the pectoralis muscle and above the muscle itself and is
the same plane used by the breast surgeons when they perform mastectomies. The submuscular plane is
below the pectoralis muscle superiorly and inferiorly below the pectoralis muscle fascia as it
interdigitates with the rectus muscle fascia (Figure 55.4). This is also sometimes referred to as a
retropectoral pocket. Dual-plane breast augmentations take advantage of having superior pole coverage
with muscle with variable lower pole coverage with breast parenchyma. Dual-plane breast
augmentations, as graded I, II, and III, vary by the amount of pectoralis muscle release inferiorly and
subsequent amount of contact between the implant and breast parenchyma inferiorly.
FIGURE 55.3 Options for planes of placement of the breast implant include subglandular, subfascial, subpectoral, and dual-
plane.
mebooksfree.net

FIGURE 55.4 A–C. Preoperative photographs of a 29-year-old woman with micromastia, and minimal asymmetry in good
health for breast augmentation. Three-dimensional image simulation in addition to tissue-based planning was performed to
facilitate implant selection. Bilateral 330 cc moderate profile smooth round silicone breast implants were placed using a
submuscular approach with inferior release of the pectoralis muscle but fascial preservation. D–F. Two-year postoperative
results.
Incision options for BA include IMF, periareolar, and transaxillary approaches. The IMF incision is placed
in the desired IMF crease, which may be below the native IMF if the IMF is going to be lowered in a BA.
Periareolar incisions are made along the junction of the areola and the breast skin. Transaxillary incisions
are made in the hair-bearing region of the axilla.
mebooksfree.net

Complications
Delayed seromas with or without an associated mass should raise suspicion for breast implant-associated
anaplastic large cell lymphoma (BIA-ALCL). In line with current National Comprehensive Cancer
Network Guidelines, suspicious fluid should be sent with fine needle aspiration and tested as BIA-ALCL
fluid is CD30 positive and anaplastic large cell lymphoma kinase (ALK) negative prior to surgical
intervention. 12 A PET-CT scan is recommended to visualize a suspicious seroma or mass. Treatment
always requires complete capsulectomy, and depending on stage of disease, it may also need adjuvant
chemotherapy or immunotherapy. This is a rare disease process, and the understanding of its etiology is
rapidly evolving.
Revisions rates for BA are largely surgeon dependent. The threshold to perform a revision because of
patient complaints or dissatisfaction varies by surgeon. Database studies of complications after BA have
shown rates of less than 1% to 2% for hematoma and less than 1% for infection and deep vein
thrombosis/pulmonary embolism (DVT/PE). 13 Capsular contracture rates from long-term studies
demonstrate variability based on implant manufacturer.
mebooksfree.net

Capsular Contracture
Capsule formation around an implant in any part of the body is a reaction to a foreign body. When the
body forms a capsule that distorts the breast and/or causes pain in the breast following BA, this is known
as capsular contracture. The Baker classification system is a routine method of categorizing capsular
contracture in patients with BA (Table 55.1). It relies on physical examination to assess how soft the
augmented breast and whether or not the patient reports pain. Applanation tonometry, adopted for
measuring intramammary compliance, and ultrasound elastography represent more modern and
quantitative, but less widely adopted techniques for assessing capsular contracture. 14,15
TABLE 55.1
Baker Classification System for Capsular Contracture
Baker Grade
Physical Examination
Patient Report of Pain
I
Soft
No pain
II
Palpable, minimal firmness
No pain
III
Easily palpable, moderate firmness
Pain
IV
Firm, distorted
Painful
The etiology of capsular contracture is multifactorial and may differ based on whether capsule
contracture occurs early or late. Capsular contractures can occur “early” within 1 year of placement or in
a delayed fashion several years later. Historically, smooth devices placed in the subglandular plane have
had the highest rates of capsular contracture.
Patients with grade III or IV capsular contracture with or without concomitant silicone rupture or silicone
granulomas, and those with asymmetry requesting a revision procedure will require operative
management. Treatment involves either open capsulectomy or capsulotomy. These can be challenging
operations due to silicone rupture, scar formation, thin tissues, and highly vascularized tissue from
chronic inflammation. Depending on the plane of the BA, removal of the capsule off the breast
parenchyma and/or chest wall can be difficult and techniques including tumescence of the capsule can
aid in identifying the correct plane of dissection. Posterior capsulectomy or removal of the capsule of the
chest wall should be done with caution as the tissue can be thin and can lead to inadvertent penetration
into the thoracic cavity leading to a pneumothorax. Some advocate partial removal or curettage of the
posterior capsule for this reason. Closed capsulotomy that involved external, manual compression to
break through the capsule is no longer recommended due to risk of implant rupture or possible
hematoma formation and incomplete management of the problematic capsule. Medical therapy with
leukotriene inhibitors has shown some benefit in preventing and improving capsular contracture. 16
Intraluminal steroids and pocket irrigation with steroids were once performed, but no longer are
common practice due to risk of implant rupture, wound dehiscence, and atrophy of tissues. Recurrent
capsular contracture often requires placement in an alternative plane or neosubpectoral pocket after a
capsulectomy. 17 Acellular dermal matrices (ADM) have also been used in recalcitrant cases of capsular
contracture to create an interface between implant and breast tissue. 18
mebooksfree.net

Implant Rupture
Implant rupture can occur regardless of implant fill material. Saline rupture can easily be identified by
unilateral deflation and breast asymmetry that occurs suddenly. This can sometimes be preceded by
trauma. Silicone rupture can present with the presence of silicone granulomas or can be silent and
diagnosed on mammography or MRI. Rupture can be intracapsular or extracapsular. Treatment of
rupture often requires removal of one or both implants and any ruptured material in the case of silicone
rupture with or without capsulectomy or capsulotomy. This is can be followed by replacement with a
new implant.
mebooksfree.net

Augmentation With Fat and Flaps
BA can be performed with fat grafting or autologous tissue. Fat grafting alone can be used to augment a
breast. However, with unpredictable rates of long-term fat graft survival, it may be difficult to reliably
augment a breast to a desired cup size. More than one surgery or round of fat grafting may be required to
achieve a patient’s goals. Composite BA is a procedure in which implant-based BA is combined with fat
grafting, often placed in the superior pole to blunt the transition between native tissue and the implant.
Fat can be placed laterally and inferiorly when the soft tissue envelope is thin to reduce visible rippling or
mask implant palpability. Autologous BA with flaps are common in patients who have had a massive
weight loss because they have a paucity of breast tissue, which is often atrophic because of major
fluctuations in weight. A number of perforator flaps based on intercostals have been used for this
purpose.
mebooksfree.net

Mastopexy
Mastopexy focuses on changing the shape of the breast to one that appears youthful and beautiful; it also
addresses descent of the NAC relative to the IMF. 19 Aging, hormonal changes associated with pregnancy,
and weight loss can all affect the skin envelope and breast parenchyma. By addressing the outer lamella
of the breast (the skin) and/or the inner lamella of the breast (the parenchyma), the discrepancy between
the skin and breast tissue can be reduced. Similar to BA, mastopexy is a very common aesthetic breast
surgery and can often be combined with augmentation as a single or two-staged procedure. One of the
most litigated plastic surgery operations, mastopexy-
 augmentation, has increasingly become safer and
more acceptable to well-informed patients.
mebooksfree.net

Preoperative Assessment
Analysis of the breasts and chest wall for mastopexy is similar to that described earlier for BA. An
assessment and documentation of breast ptosis is essential. The density of the breasts and superior pole
involution should be assessed. Additionally, the interaction between skin and breast parenchyma must be
critically evaluated as this may help the surgeon counsel the patient on whether mastopexy alone will
help achieve the patient’s results or whether the addition of an implant will also help restore shape,
structure, and volume to the breast.
If the planned procedure is a secondary mastopexy or mastopexy-augmentation, an attempt to obtain
previous operative reports should be made. Scars and examination can provide a roadmap, but operative
notes can help provide information to reduce the risk of complications from compromised blood supply
to the NAC or parenchyma.
mebooksfree.net

Surgical Approaches
Three major categories of surgical approaches for mastopexy have been described: periareolar, vertical,
and Wise pattern. 19 A paradigm shift in mastopexy took place when Benelli demonstrated that skin only
mastopexies were not as durable as mastopexies that address the skin and parenchyma by redistributing
the parenchyma. 20 Plastic surgeons now understand that by addressing both the outer lamella (skin) and
inner lamella (parenchyma), more durable and predictable changes can be achieved in the ptotic,
involuted breast.
Periareolar mastopexies can be used in patients who have grade I or II ptosis, nipple asymmetry, or
widened areola (Figure 55.5). This technique can be used to elevate the nipple no more than 2 cm with an
eccentrically designed oval. A variation of the periareolar mastopexy is the crescentic mastopexy in which
a crescent is designed only superior to the existing areola. The periareolar mastopexy hides the scar along
the areolar-breast junction. Removing skin in a concentric pattern can, however, flatten and reduce breast
projection. Scar widening and eventual widening of the areola can occur, but some have advocated the
use of a barbed or permanent suture to control this. If there is circumferential full thickness violation of
the dermis, decreased nipple sensitivity may occur.
mebooksfree.net

FIGURE 55.5 Periareolar mastopexy incision placement and final scar location.
(From Qureshi AA, Myckatyn TM, Tenenbaum MM. Madtopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38:374-384.)
Vertical mastopexies have evolved from reduction mammoplasty techniques described by Lassus,
Peixoto, Pitanguy, and Lejour to mention a few. 19 The underlying premise of vertical techniques is to
both incorporate ptosis correction with excision of glandular material using a periareolar approach with a
vertical component in line with the breast meridian (Figure 55.6). This technique can be used for all
grades of breast ptosis. The short-scar periareolar inferior-pedicle reduction (SPAIR) and Hall-Findlay
mastopexy techniques are the two vertical mastopexies with the highest surgeon satisfaction. 21
mebooksfree.net

FIGURE 55.6 Vertical mastopexy incision placement and final scar location.
(From Qureshi AA, Myckatyn TM, Tenenbaum MM. Madtopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38:374-384.)
Hammond popularized the SPAIR mastopexy that relies on the fourth intercostal perforator or inferior
pedicle for blood supply to the nipple. 22 It involves a periareolar closure in a pin-wheel or interlocking
pattern, sometimes with a permanent suture. Suspension sutures to the pectoralis fascia can be used to
elevate the breast onto a higher position on the chest wall, though the durability of such techniques is
hotly debated. The redundant skin inferiorly can be excised in a “J” or “T” pattern. Because weight
remains in the inferior portion of the breast, bottoming out remains a shortcoming. The periareolar
closure can widen or have pleating that persists. This technique is not typically complemented with
implant placement.
The Hall-Findlay vertical mastopexy most commonly uses the superomedial or medial pedicles for the
NAC based on the second and third intercostal perforators, respectively (Figure 55.7). 23 Different from
the SPAIR technique that preserves the inferior pedicle, the inferior pole of breast tissue is excised in the
Hall-Findlay technique. The medial and lateral pillars are then sutured together, and this provides
mebooksfree.net

structural support and buttresses the elevated NAC. By removing weight from the inferior pole of the
breast, less gravitational pull will be exerted on the raised NAC and breast. Similar to the SPAIR
technique, inferior skin redundancy can be excised as a “J” or “T.” An implant can be placed in the
subglandular, subfascial or submuscular planes without concern for blood supply to the NAC as the
second and/or third intercoastal perforators travel superficially in the gland and remain undisturbed by
an augmentation.
FIGURE 55.7 A–C. Preoperative photographs of a nonsmoking, healthy 51-year-old woman with ptosis and moderate
asymmetry in which the right breast was more ptotic, had a lower inframammary fold, and was slightly larger than the left. She
was interested in improving breast symmetry, shape, and nipple-areolar positioning. A Hall-Findlay vertical mastopexy was
performed with a slight parenchymal reduction and more aggressive nipple-areolar elevation on the right. D–F. Six-month
postoperative results.
In general, vertical mastopexies create an inverted breast shape at the end of the procedure with
exaggerated upper pole fullness and a sloped inferior pole. Patients should be counseled that it can take
weeks to months for the breast and/or implant to settle and for the breast to take on its final appearance.
The Wise-pattern or inverted-T mastopexy has been a powerful, traditional method for reducing the
discrepancy between skin and breast parenchyma. It can be used for all types of ptosis but carries a large
scar burden. It was first described in the 1950s by Wise when he developed templates for a skin only
mastopexy. Since that time, the technique has evolved to include parenchymal redistribution and can be
used with practically any pedicle for blood supply to the NAC. This versatility makes it popular among
surgeons, as it is easily adapted from traditional Wise-pattern inferior-pedicle reduction mammoplasty
techniques. Final scars are along the areola, the vertical meridian of the breast, and along the IMF ending
up as an inverted-T or anchor pattern (Figure 55.8). This technique has the largest scar burden of any
mastopexy method and can experience bottoming out when combined with an inferior pedicle. 21 An
implant can be placed in the subglandular, subfascial, or submuscular plane depending on where the
blood supply to the NAC is coming from.
mebooksfree.net

FIGURE 55.8 Wise-pattern or inverted-T mastopexy incision placement and final scar location.
(From Qureshi AA, Myckatyn TM, Tenenbaum MM. Madtopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38:374-384.)
mebooksfree.net

Complications
Complications in mastopexy have been found to be around 1% in large database studies, with less than
1% rates for hematoma, infection, and DVT/PE. 13 Survey studies of plastic surgeons reporting
complications found suture spitting, excess scarring, and bottoming out to be the most commonly
reported complications. 21 Specifically, excess scarring was noted with the periareolar technique, suture
spitting with the SPAIR technique, persistent asymmetry with the vertical technique, and bottoming out
with the inverted-T or Wise-pattern mastopexy. Revision rates have been reported to be as high as 50% in
periareolar approaches.
mebooksfree.net

Mastopexy-augmentation
Single or two-staged mastopexy-augmentation is a powerful way to reshape and add volume to a breast
(Figure 55.9). The surgeon must be mindful that there are competing forces at play during this procedure.
Mastopexy addresses the skin envelope and shape and often requires removal of skin and parenchyma.
In an augmentation, volume is being added or redistributed either with autologous breast tissue,
implants, or fat. Caution and planning must be applied as the surgeon keeps in mind the blood supply to
the NAC and plane of augmentation. Tension-free closure increases the likelihood of a well-appearing
scar.
FIGURE 55.9 A–C. Preoperative photographs of a nonsmoking, healthy 43-year-old woman with grade 1 ptosis who desired
increased upper pole fullness, overall breast volume, and elevation of the nipple-areola complex. The patient had reasonable
expectations and understood that simultaneous breast augmentation-mastopexy is associated with a higher revision rate than
when either procedure is performed alone. She underwent a simultaneous augmentation-mastopexy with bilateral 385 cc
moderate profile round textured breast implants placed using a type 2 biplanar approach. D–F. One-year postoperative results.
Single-stage mastopexy-augmentation with implants was once considered a controversial and risky
procedure, highlighted in 2003 when Spear published “Augmentation/Mastopexy: Surgeon, Beware.”
Although first described in the 1970s, the safety of single-stage mastopexy-augmentation gained traction
with large experiences by Stevens and Calobrace et al. who reported revision rates between 8.6% and
23.2%, which was less than the 100% two-operation rate when mastopexy-augmentation was not
performed as a single-stage procedure. 24,25 Other studies demonstrated the safety of blood supply and
perfusion to the NAC when mastopexy-augmentation was performed with an implant. 26 Meta-analyses
of reports of single-stage mastopexy-augmentation have found an overall complication rate of 13% with a
reoperation rate of 11%. 27
Two-stage mastopexy-augmentation can also be performed. Some surgeons prefer this method because it
allows them to address one issue in the first stage, namely shape or volume and then address the other at
a second operation, if even necessary. However, a staged approach commits a patient to two operations
and recoveries. There is no consensus of whether augmentation or mastopexy should be performed in a
mebooksfree.net

two-staged plan.
Mastopexy-augmentation has been found to have a complication rate of less than 2% in large database
studies with rates of less than 1% for hematoma, infection, and DVT/PE.28
mebooksfree.net

Questions
1. A 45-year-old woman with whom had a gastric bypass performed 3 years ago has lost 125 lb and
currently has a BMI of 29, which has been stable for a year. She is bothered by her grade III ptosis
and involuted breasts. She presented for single-stage mastopexy-augmentation and a decision is
made to perform a Wise-pattern mastopexy with retropectoral placement of a smooth, round silicone
device. Which of the following is the most likely sequela of the procedure?
a. Complete nipple necrosis
b. Delayed seroma
c. Implant rupture and silicone leak
d. Lateral malpositioning of the implant
e. Symmastia
2. A 33-year-old woman presents for evaluation of nipple asymmetry. She is bothered by the
discrepancy between her NAC as the right is 4 cm and the left is 6 cm in width. The left nipple is also
1 cm lower than the right. Which of the following techniques is most suited to correct her
asymmetry?
a. Breast augmentation with implants
b. Circumvertical mastopexy
c. Free nipple grafting
d. Inverted T-mastopexy
e. Periareolar mastopexy
3. A 25-year-old woman presents for evaluation of bilateral breast augmentation. She is interested in
a smooth, silicone round device and wants the implant to be placed underneath the breast but not
the muscle. Which of the following is she at greatest risk based on the implant type and plane of
placement?
a. Animation deformity from the pectoralis muscle
b. Capsular contracture
c. Deflation and subsequent loss of volume
d. Superior implant migration
e. Widening of the areola
4. A 39-year-old woman with a history of bilateral breast augmentation with textured, silicone
anatomic implants 7 years ago presents with asymmetric breast swelling of the left breast with no
antecedent trauma. Ultrasound demonstrates a capsule with fluid in the periprosthetic space. Which
of the following is the next appropriate step in management?
a. Observation
b. MRI study of both breasts
c. Compression garment with repeat evaluation in 2 weeks
d. Ultrasound guided aspiration of fluid and cytology tests for ALK and CD30
e. Surgical exploration with explant and capsulectomy
5. A 62-year-old woman is dissatisfied with the appearance of the size and shape of her breasts. She
currently wears a 32B bra and has grade III ptosis. A decision is made to perform a single-stage
mastopexy-augmentation. Which of the following is the most likely complication after single-stage
mastopexy-augmentation?
a. Asymmetry
b. Capsular contracture
c. Poor scarring
mebooksfree.net

d. Recurrent ptosis
e. Seroma
6. Which of the following best represents the existing Food and Drug Administration
recommendation on screening for silent ruptures in silicone implants used for breast augmentation
and/or reconstruction?
a. MRI annually after placement
b. MRI 2 years after placement and then every 2 years thereafter
c. MRI 3 years after placement and then every 2 years thereafter
d. MRI at 5 years and then as needed
e. MRI only if palpable changes in silicone
1. Answer: d. Lateral malposition is a common problem seen in mastopexy-augmentation in the
massive weight loss patient population. These patients have attenuated tissues and with placement
under the muscle the implant can migrate laterally. Some have advocated the use of acellular dermal
matrix or mesh support of the lateral buttress of the augmented breast. Complete nipple necrosis is a
devastating and exceedingly rare complication. Delayed seroma can occur but its less likely than
implant malposition. Implant rupture and silicone leaks can also occur but it is not higher in massive
weight loss patients. Symmastia is unlikely with retropectoral implant placement because the medial
pectoralis muscle fibers prevent medial migration of the implants.
2. Answer: e. This is a young woman with NAC asymmetry with regards to diameter as well as
nipple position. A periareolar mastopexy can correct the NAC diameter discrepancy and also help
elevate a nipple up to 2 cm. Breast augmentation is unlikely to address the underlying problem. The
other mastopexy techniques can also correct the nipple asymmetry but are likely to carry a larger
scar burden and alter the shape of the breast. Free nipple grafting involves completely removing the
NAC and is not appropriate for correction of isolated nipple asymmetry.
3. Answer: b. Subglandularly placed smooth devices are at greatest risk for capsular contracture.
This rate can be decreased by using a textured device or placing the implant partially or completely
behind the muscle as in a dual-plane or retropectoral augmentation. Animation deformity can occur
after placement of an implant placement behind, not in front of, the pectoralis muscle. Deflation is
possible and common with saline not silicone implants. Superior implant migration is not a common
complication. Areola can widen after an augmentation but that is not the greatest risk associated
with this augmentation.
4. Answer: d. A delayed seroma after placement of a texture implant should raise suspicion for BIA-
ALCL. The fluid should be aspirated and sent specifically for ALK and CD30 as the fluid will be ALK
negative and CD30 positive. This is the first test that is done in the diagnostic work-up of BIA-ALCL
and precedes surgical intervention. If a diagnosis of BIA-ALCL is made (CD30+/ALK-), then a PET-
CT scan of the chest is indicated to further characterize the mass and fluid collection associated with
the implant capsule and breast tissue. The case should be reported to the PROFILE Registry,
sponsored by the Plastic Surgery Foundation, which tracks BIA-ALCL cases. Treatment will be
dictated based on staging thereafter and will require surgical exploration with explant and complete
capsulectomy. The capsule should be sent for pathology. Observation, further imaging, and
compression garment placement are not appropriate next steps.
5. Answer: d. In a meta-analysis by Khavinin et al., pooled complication rates in aesthetic breast
surgery were examined. Recurrent ptosis was the most commonly encountered complication after
single stage mastopexy augmentation at 5.2%. This was followed by poor scarring (3.74%), capsular
contracture (2.97%), asymmetry (2.94%), and seroma (1.42%).
6. Answer: c. The current FDA recommendation is for an MRI to be performed 3 years after
placement and then every 2 years thereafter. The purpose of this is to identify silent ruptures of the
mebooksfree.net

implant that would otherwise go unnoticed.
mebooksfree.net

Acknowledgments
The authors thank Drs. W. Grant Stevens, Andrea E. Van Pelt, and Adrian M. Przybyla, who wrote the
chapter on mastopexy and mastopexy-augmentation and Dr. Steven A. Teitelbaum who wrote the
chapter on breast augmentation in the 7th edition of this book.
mebooksfree.net

References
American Society of Plastic Surgeons. Cosmetic Surgery National Data Bank Statistics. 2016:1-26.
Bryant, H, Brasher, P. Breast implants and breast cancer—reanalysis of a linkage study. N Engl J Med. 1995;332(23):1535-1539.
Eklund, GW, Busby, RC, Miller, SH, Job, JS. Improved imaging of the augmented breast. AJR Am J Roentgenol 1988;151(3):469-473.
Siu, AL; US Preventive Services Task Force . Screening for breast cancer: U.S. Preventive Services Task force recommendation statement. Ann
Intern Med. 2016;164(4):279-296.
Hall-Findlay, EJ. The three breast dimensions: analysis and effecting change. Plast Reconstr Surg. 2010;125(6):1632-1642.This is an important
article on understanding the dimensions of the breast. It describes whether different parameters of the breast can be changed and how.
Overschmidt, B, Qureshi, A, Parikh, RP, et al. A prospective evaluation of three dimensional image simulation: patient-reported outcomes
and mammometrics in primary breast augmentation. Plast Reconstr Surg. 2018;142(2):133e-144e.
Hidalgo, DA, Weinstein, AL. Intraoperative comparison of anatomical versus round implants in breast augmentation: a randomized
controlled trial. Plast Reconstr Surg. 2017;139(3):587-596.
Wolfram, D, Rainer, C, Niederegger, H, et al. Cellular and molecular composition of fibrous capsules formed around silicone breast implants
with special focus on local immune reactions. J Autoimmun. 2004;23(1):81-91.
Maxwell, GP, Scheflan, M, Spear, S, et al. Benefits and limitations of macrotextured breast implants and consensus recommendations for
optimizing their effectiveness. Aesthet Surg J. 2014;34(6):876-881.
Brown, T. Breast implant-associated anaplastic large cell lymphoma in Australia and New Zealand: high-surface-area textured implants are
associated with increased risk. Plast Reconstr Surg. 2018;141(1):176e-177e.
Sieber, DA, Stark, RY, Chase, S, et al. Clinical evaluation of shaped gel breast implant rotation using high-resolution ultrasound. Aesthet Surg
J. 2017;37(3):290-296.
Clemens, MW, Horwitz, SM. NCCN Consensus Guidelines for the diagnosis and management of breast implant-associated anaplastic large
cell lymphoma. Aesthet Surg J. 2017;37(3):285-289.
Gupta, V, Yeslev, M, Winocour, J, et al. Aesthetic breast surgery and concomitant procedures: incidence and risk factors for major
complications in 73,608 cases. Aesthet Surg J. 2017;37(5):515-527.This large database study provides invaluable information about complications in
aesthetic breast surgery.
Prantl, L, Englbrecht, MA, Schoeneich, M, et al. Semiquantitative measurements of capsular contracture with elastography: first results in
correlation to Baker Score. Clin Hemorheol Microcirc. 2014;58(4):521-528.
Moore, JR. Applanation tonometry of breasts. Plast Reconstr Surg. 1979;63(1):9-12.
Graf, R, Ascenco, AS, Freitas Rda, S, et al. Prevention of capsular contracture using leukotriene antagonists. Plast Reconstr Surg.
2015;136(5):592e-596e.
Maxwell, GP, Gabriel, A. The neopectoral pocket in revisionary breast surgery. Aesthet Surg J. 2008;28(4):463-467.This is a seminal article for
understanding operative management of capsular contracture and/or implant rupture. It describes a reproducible technique of managing the diseased
capsular and creation of a new pocket for implant replacement.
Maxwell, GP, Gabriel, A. Acellular dermal matrix for reoperative breast augmentation. Plast Reconstr Surg. 2014;134(5):932-938.
Qureshi, AA, Myckatyn, TM, Tenenbaum, MM. Mastopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38(4):374-384.This recent review
covers surgical steps and approaches for mastopexy and mastopexy-augmentation.
Benelli, L. A new periareolar mammoplasty: the “round block” technique. Aesthet Plast Surg. 1990;14(2):93-100.
Rohrich, RJ, Gosman, AA, Brown, SA, Reisch, J. Mastopexy preferences: a survey of board-certified plastic surgeons. Plast Reconstr Surg.
2006;118(7):1631-1638.
Hammond, DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammoplasty. Plast Reconstr Surg. 1999;103(3):890-901.This
landmark article describes the technique of Hammond in the SPAIR procedure.
Hall-Findlay, EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg. 2002;29(3):379-391.This seminal article describes various
pedicles and the technique used in a vertical mastopexy by Hall-Findlay.
Stevens, WG, Macias, LH, Spring, M, et al. One-stage augmentation mastopexy: a review of 1192 simultaneous breast augmentation and
mastopexy procedures in 615 consecutive patients. Aesthet Surg J. 2014;34(5):723-732.This article describes a large series of single-stage
mastopexy-augmentation and describes complications and safety profiles.
Calobrace, MB, Herdt, DR, Cothron, KJ. Simultaneous augmentation/mastopexy: a retrospective 5-year review of 332 consecutive cases. Plast
Reconstr Surg. 2013;131(1):145-156.This article describes a large series of single stage mastopexy-augmentation and describes complications and safety
profiles.
Swanson, E. Safety of vertical augmentation-mastopexy: prospective evaluation of breast perfusion using laser fluorescence imaging. Aesthet
Surg J. 2015;35(8):938-949.
Khavanin, N, Jordan, SW, Rambachan, A, Kim, JY. A systematic review of single-stage augmentation-mastopexy. Plast Reconstr Surg.
2014;134(5):922-931.
Winocour, J, Gupta, V, Kaoutzanis, C, et al. Venous thromboembolism in the cosmetic patient: analysis of 129,007 patients. Aesthet Surg J.
2017;37(3):337-349.
mebooksfree.net

C H A P T E R 5 6
mebooksfree.net

Breast Reduction
Paul H. Izenberg and Nicholas L. Berlin
Key Points
Integrate anatomic, functional, and aesthetic principles of plastic surgery.
Perform thorough physical examination and document findings related to macromastia.
Each technique has its own indications and limitations.
Preoperative markings and planned resection are essential to achieve consistently good results.
Appreciate the desired three-dimensional shape of the breast and underlying neurovascular
structures throughout the operation.
Counsel patients regarding risks for short-term and long-term complications.
Address acute postoperative issues promptly to avoid long-term sequela.
The breast reduction procedure demands that the surgeon integrates anatomic, functional, and aesthetic
principles into the design and execution of the operation. This chapter will emphasize principles and
techniques for surgeons to achieve aesthetically and functionally pleasing results on a routine basis. There
have been numerous techniques for breast reduction described in the literature over the past decades,
each adding improvements in the reliability, perioperative risk reduction, and the enhancement of the
final appearance. This chapter will not attempt to review all of the previously published data. Instead, we
will emphasize techniques that have worked well for the senior author in the majority of clinical cases
over 40 years of practicing plastic surgery.
mebooksfree.net

Relevant Anatomy and Physiology
The breast is a subcutaneous structure with the strongest attachments to the chest wall medially along the
sternum and at the inframammary (IM) fold. The primary blood supply originates from the internal
mammary system and its arteries perforate the breast from deep to superficial. The venous drainage is
located more superficially. Pedicle design should be based on dominant blood vessels for each specific
technique for perfusion and sensation to the nipple-areolar complex (NAC) without compromising the
intended shape and underlying breast parenchyma. The superior pedicle approach relies on internal
mammary perforators from the second rib intercostal space, whereas the blood supply to the
superomedial pedicle originates from both the second and third rib intercostal space. The blood supply to
the inferior pedicle is based upon the fourth rib intercostal space. All skin and subcutaneous flaps rely on
a network of subdermal venous drainage.
Lymphatic pathways parallel the venous drainage and include cutaneous, internal mammary, posterior
intercostal, and axillary routes.
The lateral branches of the fourth, fifth, and sixth intercostal nerve supply the primary sensation to the
NAC. 1,2 Deep and superficial sensory nerve branches allow any full thickness pedicle described to supply
sensibility to the NAC without much impact, provided there is careful dissection, limited undermining,
and the muscle fascia remains intact.
mebooksfree.net

Patient History
The surgeon must carefully document any symptoms associated with enlarged breasts and attempted
nonsurgical approaches to resolve these issues (physical therapy, pain medications, weight loss). Some
findings that have been associated with macromastia include occipital headaches, neck pain, shoulder
pain, midback and lower back issues, shoulder grooving, intertrigo or skin rashes, sensory changes
including upper extremity paresthesias, difficulty participating in recreational activities, work, sleep, ill-
fitting clothes, and anything else that may be attributed to breast hypertrophy. In addition, changes in
breast size, as well as previous breast surgery, biopsies, scars, and asymmetries as noted by the patient
should be recognized. Document skin lesions, changes with pregnancy, and a personal or family history
of cancer (particularly if the family history includes members with breast, colon, prostate cancer or
melanoma). If there is any concern for a genetic predisposition for breast cancer, it is recommended that
the patient obtain a genetic consultation preoperatively. Consider the potential role of medications that
may increase breast size (e.g., hormones, oral contraceptives, and steroids). Additionally, some systemic
diseases may affect wound healing, especially related to skin vascularity (e.g., scleroderma, lupus,
Raynaud disease, or other connective tissue disorders).
Preoperative mammography is not necessary for elective breast reduction before the age at which
screening mammography is generally recommended. Unless there are concerning aspects of the patient’s
history or examination that call for further investigation, patients should follow the existing clinical
practice guidelines that recommend annual screening for patients of certain age groups. 3
mebooksfree.net

Physical Examination
There are multiple aspects of the physical examination that need to be documented for patient selection
and surgical planning (Figure 56.1). Furthermore, specific findings in the physical examination may
anticipate potential limitations of the procedure in achieving the desired aesthetic result. Therefore, it can
be helpful to integrate a standardized checklist into the clinical encounter.
Stature: Height and weight are used to calculate total body surface area, which determines the
amount of tissue that must be resected based on the Schnur or other scales required for insurance
coverage. 4
Shoulder grooving and hyperpigmentation: These findings are typically minimal in younger patients
with excellent skin.
Scoliosis and chest wall asymmetries: These findings may disguise breast volume or width differences
that become more apparent postoperatively and should be discussed with the patient in the
preoperative setting.
Manubrial projection, pectus excavatum, and pectus carinatum: Breast reduction will not change these
abnormalities and may even make them more apparent postoperatively.
Soft tissue fullness of the anterior axillary folds and lateral chest: Suction-assisted lipectomy (SAL) may
reshape these areas. The effects may be limited in obese patients, especially in those patients with
fullness extending posteriorly.
Deficient cephalic and medial breast: Emphasize the challenges involved in filling these areas and limit
the resection of breast parenchyma in these areas if already deficient.
Skin quality: Document scars, skin lesions, striae, or dimpling with motion. Youthful and elastic skin
appears to have a greater risk for hypertrophic scarring postoperatively. A vertical approach may
reduce this risk.
IM fold asymmetries: These may become more apparent to the patient once volume is removed.
Intertrigo: Document open wounds, acne, hidradenitis suppurativa, or hyperpigmentation.
NAC position: Wide, narrow, or asymmetric nipple positioning can be corrected to a limited degree.
Note the position of the NAC relative to:
The breast mound
The IM fold
Current and intended breast meridian
Sternal notch
Contralateral NAC
Papule: Note the size and shape of the papule, including continuous or episodic inversion. It may not
improve postoperatively. Complete nipple inversion may be dealt with at the time of the breast
reduction if needed.
Areola: Document abnormal size, shape, color, and symmetry relative to the contralateral side.
Costal margins: Note any abnormal projection and asymmetries, because this may become more
noticeable postoperatively.
Breast parenchyma: Estimate any volume discrepancies, density (e.g., fatty versus fibrous), estimated
volume to be removed, and presence or absence of masses.
mebooksfree.net

FIGURE 56.1 Key aspects of the physical examination for patients with macromastia. AAL, anterior axillary line; IM,
inframammary; NAC, nipple-areolar complex.
mebooksfree.net

Preoperative Photography
Standardized photography of women considering breast reduction is essential for insurance approval, for
operative planning, and to identify preoperative asymmetries that may affect the final result (Figure 56.2).
Anterior views with arms elevated and at the sides
Lateral views with arms elevated and at the sides
Optional: oblique views
Posterior view (useful for documenting the presence of scoliosis, shoulder grooving, and chest wall
asymmetries)
mebooksfree.net

FIGURE 56.2 Suggested preoperative photography.
mebooksfree.net

Preoperative Markings
Each breast reduction technique is unique and requires variations in markings. We will review a general
approach to initial markings. Surgeons generally have two decisions to make: the pedicle type and the
pattern of skin resection.
Preoperative markings for keyhole pattern technique:
1. Ask patient to stand with arms at her sides.
2. Mark the IM fold and extend this marking medially to a point that is still hidden in the fold. In the
midline (at a point corresponding approximately to the breast meridian that will be marked in the
next step), make a small peak or upswing of about 1 cm, which may take some tension off the flaps
(Figure 56.3). Curve the medial marking cephalically, as this incision tends to straighten
postoperatively potentially resulting in visible scarring. Extend the IM fold markings laterally to a
point that corresponds with the anterior axillary line, approximately where the breast ends. Avoid
extending this mark toward the back chasing skin folds laterally.
3. With a measuring tape hung around the neck or using the midclavicle, mark out the intended breast
meridian bilaterally (this may not align with the current nipple position) (Figure 56.4). Carry this line
down under the breast crossing the IM fold at the central peak.
4. Mark the new nipple position: This is critical and can be done using a number of techniques (Figure
56.5). The distance from the sternal notch to nipple can vary with height, but an example is that a 5′6″
woman who is a 34/36 C will be about 23 to 24 cm (Table 56.1). This mark should be very close to a
hypothetical line that connects laterally to ∼2 cm below the midpoint of the upper arm. And finally,
it should be ∼2 cm above the projected IM fold onto the anterior breast. Be sure to compensate
modestly for skin elasticity which can cause some postoperative retraction cephalically. All three
marks should be very close, and most importantly, the appearance of the final NAC position should
appear reasonable.
5. Measure the length of the medial and lateral limbs of the IM fold from the midline peak. Add 1 to
1.5 cm to each distance and transpose this point to the planned corresponding inferior margins of the
upper flaps, ∼8 to 9 cm below the new papule position (see Figure 56.3). Adding this horizontal
length to the upper flaps reduces tension and may help to avoid wound healing issues at the
trifurcation.
6. With a flexible wire keyhole template, place the areolar opening over the new nipple position and
open to the previously marked upper flap lengths. Draw the new NAC position and the vertical
limbs. The limbs will be ∼5 cm for a small breast and ∼6 to 7 cm for a larger final breast. Extend the
upper flap incisions from these points to join the IM fold incision medially and laterally with a gentle
S-shaped curve.
7. Finally, mark topographically areas for planned liposuction as needed (lateral chest, anterior axillary
fold) and estimate the amount to be removed with suction.
mebooksfree.net

FIGURE 56.3 How to mark the inframammary (IM) fold and determine lengths of upper flap incisions. Extend mark medially
and laterally to points that are still hidden in fold and curve cephalically. At the breast meridian, make a small peak of about
1 cm to reduce tension on the final closure. Measure the length of the medial and lateral limbs of the IM fold. Add 1 to 1.5 cm to
each distance and transpose to the corresponding inferior margins of the upper flaps, 8 to 9 cm below the new papule position.
mebooksfree.net

FIGURE 56.4 How to find the intended breast meridian with a measuring tape hung around the neck. IMF, inframammary fold;
NAC, nipple-areolar complex.
mebooksfree.net

FIGURE 56.5 Three approaches to marking the new papule location. (1) Mark about 2 cm below the midpoint of the upper arm
on the meridian. (2) Mark about 2 cm above the transposed position of the inframammary (IM) fold. (3) Refer to Table 56.1 for
example sternal notch-to-nipple distances based on desired brasserie size. Remember to compensate for skin elasticity.
TABLE 56.1
Normative Values of Common Preoperative Breast Measurements [Reported in Inches (centimeters)]
Measurement
32
34
36
38
B
C
D
B
C
D
B
C
D
B
C
D
Sternal notch to nipple (left)
7.8 (19.9)
8.2 (20.8)
9.6
(24.4)
8.3
(21.0)
8.8
(22.4)
9.9
(25.1)
8.7
(22.1)
9.4
(24.0)
10.2
(25.9)
9.1
(23.1)
10.1
(25.6)
10.5
(26.6)
Sternal notch to nipple (right)
8.1 (20.4)
8.3 (21.1)
9.5
(24.1)
8.3
(21.1)
8.9
(22.5)
9.8
(25.0)
8.6
(21.8)
9.4
(23.9)
10.2
(25.9)
9.1
(22.5)
9.9
(25.2)
10.6
(26.8)
Nipple to nipple
7.9 (20.0)
8.0 (20.3)
8.4
(21.4)
8.1
(20.7)
8.3
(21.0)
8.6
(21.8)
8.4
(21.3)
8.6
(21.7)
8.7
(22.2)
8.6
(21.9)
8.8
(22.4)
8.9
(22.5)
IMF to nipple
3.3 (8.4)
3.8 (9.7)
4.0
(10.2)
3.5
(8.9)
4.0
(10.2)
4.3
(10.9)
3.8
(9.7)
4.3
(10.9)
4.5
(11.4)
4.0
(10.2)
4.5
(11.4)
4.8
(12.2)
mebooksfree.net

Areolar width
1.8 (4.6)
2.0 (5.2)
2.1
(5.3)
1.9
(4.7)
2.0
(5.3)
2.1
(5.3)
1.9
(4.9)
2.0
(5.1)
2.1
(5.3)
2.0
(5.0)
2.1
(5.2)
2.1
(5.4)
Breast width
5.8 (14.7)
5.8 (14.7)
6.2
(15.7)
5.9
(15.0)
6.0
(15.2)
6.4
(16.3)
5.9
(15.0)
6.2
(15.7)
6.6
(16.8)
6.0
(15.2)
6.4
(16.3)
6.8
(17.3)
Values obtained from a study of 30 women for each breast
size by Robert Oneal, MD, Denis Lee, and Art Rathjen.
IMF, inframammary fold.
mebooksfree.net

Inferior Pedicle Technique
This technique may be considered for breasts in which the NAC falls significantly below the triangle
formed by the planned vertical flaps. It can be done in very large breasts, but size can be a limiting factor
and the amputation/free nipple graft technique may be considered.
After prepping and draping the patient in the usual manner, reinforce your markings at the IM fold.
Mark out the new areolar size (3.0–5.0 cm depending on final breast size) with the breast under some
mild tension. Design the inferior pedicle from about 1 cm above and around the NAC and flare down
toward the IM fold medially and laterally. This pedicle base is generally ∼8 to 10 cm or wider.
Remeasure and then join the vertical flap incisions in the center of the planned location of the NAC, not
fully committing to the final NAC location (Figure 56.6). Tattoo key points for closure with a needle and
marking ink including NAC orientation to avoid inadvertent rotation during insetting.
mebooksfree.net

FIGURE 56.6 The preoperative markings for an inferior pedicle technique with a keyhole pattern skin resection. Note the
anticipated flaring of the pedicle shape and tapering of the soft tissues.
If planning to perform SAL laterally, infiltrate with tumescent solution in the intended areas at this time.
Placing the breast base under tension, make all planned incisions and deepithelialize the inferior pedicle
mebooksfree.net

with knife or scissors. Proceed with the SAL.
Some surgeons prefer to elevate the upper flaps first. We have found that elevating the inferior pedicle
initially works best for us. Make the dermal incisions medially and laterally on the IM fold carrying them
about about halfway up the pedicle. Flare this dissection at the IM fold away from the pedicle to leave
some added volume and to preserve NAC sensation. Now complete the incision around top of the
pedicle and dissect toward the chest wall following natural tissue planes of the breast parenchyma
(Wuringer’s Planes) and avoiding larger vessels at the pedicle base. 5,6 Carry this dissection to the chest
wall without injury to the muscle fascia.
Proceed to elevate the medial and lateral flaps. Incise down to the breast capsule along the flap margins,
and at the flap corners, tack the capsule to the dermis to assist in avoiding stripping the soft tissues from
the overlying dermis, thus protecting blood supply to the skin edges (Figure 56.7). Trim and taper the
flaps as needed for shaping the breast and removing the needed volume. Try to limit the resection from
the medial flap, as this area is frequently already deficient. Once the flaps are elevated, remove the breast
from the chest wall en bloc leaving the pectoralis fascia intact and avoiding injury to the blood supply of
the pedicle. Weigh the specimen. Consider dividing and labeling as central, medial, and lateral so as to be
able to help localize any pathology if inadvertently found.
mebooksfree.net

FIGURE 56.7 Elevation of the upper flaps and suturing the breast capsule to the dermis at the corners to prevent stripping the
soft tissues from the overlying dermis.
Divide the dermis at the base of the inferior pedicle to assist in closure. After hemostasis, staple the flaps
into position, sit the patient up, and if available, hold a sterilized bra of the planned postoperative breast
mebooksfree.net

cup size in position to assess the size and to determine asymmetries (Figure 56.8). Return the patient to
supine position, and if necessary, release staples and resect additional tissue as indicated. Once both sides
are symmetric volumes, restaple, sit up, and mark the new NAC position measuring from the sternal
notch with a suture with patient as vertical as possible. They should be symmetric. Modify the NAC
position if needed. Excise the skin for the new NAC position, bring the NAC to the skin surface, and
confirm that the NAC is not rotated. You can remove some additional volume from the NAC defect if
needed. Drains are placed prior to closure for 24 hours only if large amounts of tumescent fluid were used
for lateral SAL or if a large potential dead space persists. This is usually not necessary.
mebooksfree.net

FIGURE 56.8 The inferior pedicle is then brought into position and the upper flaps are brought down and stapled at the
meridian. Confirm the correct orientation of the nipple-areolar complex based upon preoperative markings.
mebooksfree.net