Phẫu Thuật Tạo Hình (Tập 5): Tuyến Vú – Neligan (Ấn bản 4)

60
SECTION I
CHAPTER 4 • Breast augmentation
Surgical prep and sterile
After local infiltration, nipple shields (created by placing
a small piece of Tegaderm over each nipple areolar
complex) provide a barrier against potential bacterial
contamination52 (Fig. 4.9). The patient is prepped with
chlorhexidine or other alternatives and draped to
provide a sterile field with the entire chest and bilateral
breasts visible for assessment during the procedure. The
sterile dressings must be secured to prevent disruption
in the sterile field while placing the patient in the upright
positon.
Inframammary approach
The inframammary incision is the most commonly used
due to its direct access and visualization of the pocket
with the least injury to surrounding structures.55 After
determining the inframammary fold position (either the
native true fold position or the planned lowered posi­
tion), a paramedian line is drawn through the center of
the breast and bisects the newly drawn inframammary
fold. The incision’s medial extent begins 1 cm medial to
the paramedian line and extends laterally for the appro­
priate distance as previously described (Fig. 4.10). A
fiberoptic headlight is worn for visualization or a lighted
retractor is used based on surgeon preference. The inci­
sion is made with a 15 blade through the skin to the
mid-dermis. Dissection is then carried out with electro­
cautery through the skin and subcutaneous tissue bevel­
ing upward while rotating the breast off of the chest
wall. Once dissection has been carried superiorly for
1 cm, the dissection is carried through the superficial
Scarpa’s fascia and towards the lateral pectoral border
deep on the chest wall. This beveling maneuver pre­
serves a small cuff of superficial fascia at the incision
Table 4.2  Breast local anesthetic formula
0.5% lidocaine plain
25 mL
0.5% lidocaine/1 : 200 000 epinephrine
25 mL
0.5% bupivacaine/1 : 200 000 epinephrine
25 mL
Injectable saline
25 mL
0.25% lidocaine, 0.125% bupivacaine, 1 : 400 000
epinephrine
100 mL
Fig. 4.8  Infiltration of local anesthetic
Fig. 4.9  Nipple shields are placed to provide a barrier against potential bacterial
contamination.
the arms by the patient’s side is a useful alternative.
Some surgeons position the patient with the arms out­
stretched at 90°, but this position can lead to misinter­
pretation of the breast–implant relationship due to
breast elevation when placed in this position.
Infiltration of local anesthetic
Prior to surgical preparation, 50 mL of a local field block
is injected of 0.25% lidocaine, 0.125% bupivacaine,
1 : 400 000 epinephrine (Table 4.2). The injection is placed
in the dermis along the planned incision line, deep to
the dermis along the inframammary fold, the medial
pectoral border, the anterior axillary line and finally
deep to the breast parenchyma in a fanning fashion
throughout the area of planned pocket creation (Fig.
4.8). These injections provide not only assistance in
operative hemostasis, but also in the management of
postoperative pain. Alternatively, many surgeons opt
not to inject any anesthetic agents prior to surgery.

61
Treatment and surgical technique
If the subpectoral or dual plane pocket is selected, the
dissection initially proceeds to the lateral edge of the
pectoralis major muscle. The lateral pectoral border is
identified and fascia incised to expose the underlying
muscle. Upward retraction of the breast tissue will
usually elevate the lateral border allowing further dis­
section and placement of the retractor beneath the
overlying pectoralis muscle (Fig. 4.12). It is an extremely
important principle to never cut through the muscle if
you cannot tent the muscle upward. Inability to elevate
the muscle may indicate that the muscle fascia is
extremely adherent, or more likely that the identified
muscle is actually not the pectoralis, but rather the ser­
ratus, rectus or an intercostal muscle. Continuing the
dissection through an intercostal could inadvertently
penetrate the pleural space with a resultant pneumotho­
rax. Once the edge of the pectoralis is safely elevated
and the subpectoral space is identified, dissection is
carried upward centrally to the superior extent of the
pocket. Dissection is then carried laterally to identify
the pectoralis minor and continued superficial to it until
the lateral border of the pocket is reached. Dissection
is then continued along the lateral border of the pocket,
identifying and staying superficial to the serratus muscle
until the inferior extent of the pocket at the inframam­
mary fold is reached. Dissection should be performed
bluntly along the lateral border to avoid injury to the
lateral intercostal cutaneous nerves, especially the
fourth intercostal which provides the primary innerva­
tion to the nipple areolar complex.
The muscle is then released along the planned infra­
mammary fold, staying 1 cm superior to the fold to
account for caudal muscle descent (Fig. 4.13). Dissection
which insures the fold is not inadvertently lowered and
also provides a cuff of fascia that will prove useful
during closure (Fig. 4.11).
For subglandular pocket creation, dissection is carried
out below the breast parenchyma but superficial to the
pectoralis fascia and muscle. The pocket size is created
to accommodate the implant selected for augmentation.
If the implant is to be placed in the subfascial plane, the
pocket is created deep to the pectoralis fascia and breast
tissue, but superficial to the pectoralis muscle. This
fascia becomes thicker and more obvious as dissection
proceeds cephalad towards the clavicle. Medial inter­
costal vessels may be present and should be avoided or
coagulated with insulated forceps in a prospective
manner.
Fig. 4.10  The incision is made starting one centimeter medial to the paramedian
line of the breast and extending laterally for the appropriate distance.
Fig. 4.11  Preservation of a small cuff of Scarpa’s fascia during initial dissection
avoids inadvertent lowering of the inframammary fold and assists in anchoring the
fold during closure.
Fig. 4.12  Upward retraction on the breast tissue elevates the lateral border of the
pectoralis muscle allowing further dissection and placement of the retractor under
the muscle.

62
SECTION I
CHAPTER 4 • Breast augmentation
tuberous or constricted breast. The levels of dual plane
are a continuum and not fixed points. The release of the
caudal edge of the muscle is performed incrementally,
creating the least amount of release that will adequately
address the lower pole (Fig. 4.14). When creating a dual
plane to address the laxity of the lower pole, placement
of a retractor into the breast pocket and elevating supe­
riorly while rocking the breast tissue over the retractor
will assist in assessing the effects of the implant on the
skin and breast tissue once placed in the pocket. When
a dual plane is created for expansion and exposure, the
level will depend on the need to access the parenchyma
for radial scoring. This usually requires at least a level
2 for complete access to the lower pole and often even
a level 3 to expose the retro-areolar tissue.
If required, inframammary fold lowering must occur
in the subglandular pocket as the attachments creating
the fold are superficial to the deep pectoral fascia.53
Thus, a subglandular/subfascial or dual-plane approach
provide the necessary subglandular plane in the lower
pole of the breast. Dissection deep to the deep pectoral
fascia will likely result in maintenance of the fold struc­
ture resulting in a double bubble deformity.
Periareolar approach
Although used less often in the past few years, this
incision initially described by Jenny in 1972 can be
very useful for someone wanting to avoid a scar in the
fold of the breast.54,55 It is most inconspicuous when
there is a distinct border and a marked color contrast
between the areolar skin and surrounding breast skin.
directly at the fold will often lead to a fold that is lower
than planned as the muscle retracts inferiorly. In per­
forming a dual-plane approach, great care should be
taken to stop the dissection along the fold at the most
medial extent along the sternum. Dissection should
absolutely not be continued superiorly along the
sternum as has been previously described. Preservation
of the most caudal attachment of the pectoralis muscle
along the sternum in a dual-plane approach is critical to
minimize the chance of window-shading of the pecto­
ralis, a phenomenon which often leads to medial implant
exposure and unsightly animation deformities. The
extent of the pocket is completed by defining the medial
pectoral border by dividing the accessory slips of pec­
toralis muscle that insert along the ribs, preserving the
main body of the muscle as it inserts along the sternum.
Dividing these muscles with electrocautery and not
depending on blunt dissection improves postoperative
cleavage and maintains prospective hemostasis.
The final maneuver in the dual-plane approach is
creating the subglandular pocket inferiorly. The levels
of dual plane represent the amount of muscle released
from the inferior breast tissue and resultant inferior
subglandular pocket. Division of the inferior pectoralis
muscle just above the inframammary fold during initial
pocket dissection as was just described creates a dual
plane level 1. The level of dual plane required varies and
each surgery can be tailored to provide the optimal level
based on soft-tissue requirements and implant selection.
In general, creating a subglandular pocket inferiorly is
required to either redrape relaxed or ptotic skin and
breast tissue more accurately over the implant or for
expansion and exposure of the lower pole, such as in a
Fig. 4.13  The pectoralis muscle is released along the inframammary fold staying
1 cm superior to the fold to account for caudal muscle descent. Muscle release
should end at the most caudal aspect of the medial muscle attachments and not
extend superiorly along the sternum.
Fig. 4.14  The dual plane is created by exposing the caudal edge of the pectoralis
muscle and incrementally releasing off the overlying breast tissue creating a
subglandular pocket inferiorly. The dual plane levels are a continuum but a general
guideline would include: level 1, the caudal edge of the muscle is present in the
lower pole below the areola; level 2, the caudal edge is at the inferior areola; and
level 3, the caudal edge is at the superior areola.

63
Treatment and surgical technique
funnel57 (Fig. 4.15). The opening of the funnel should be
cut large enough to allow easy egress of the implant
through the funnel. This can be easily confirmed by
passing the implant with irrigation solution through the
funnel prior to insertion. The implant orientation is then
confirmed in the funnel and a maneuver of squeezing
the implant through the funnel with pressure exerted
on the back of the funnel allows the implant to slip into
the breast pocket. These maneuvers provide a “no-touch”
technique that has been associated with lower capsular
contracture rates.58 The funnel allows for easier implant
placement with potentially smaller incision require­
ments compared to manual placement. It has proven
especially helpful with textured implants, which can be
much more challenging and require larger incisions
compared to smooth implants.31 Whereas many of the
shaped implants can be placed with the funnel, the
firmer and larger cohesive shaped implants may pose a
challenge due to the lack of implant and gel flexibility
and may not be appropriate for the funnel. Once the
implant is in the pocket, a finger-assisted assessment
and manipulation of the implant within the pocket is
necessary to confirm its proper placement and assure
appropriate redraping of the breast parenchyma over
the implant. This maneuver is especially important with
textured devices as these implants are less mobile and
less likely to stretch the pocket and thus a distortion or
wrinkling of the implant in a tight pocket may be per­
manent if not resolved prior to closure. Repeated
removal and insertions of the implant should be avoided
to minimize implant or incision damage, potential
contamination and pocket overdissection. This is espe­
cially important with shaped implants as a stretched
The periareolar incision can also allow for easy adjust­
ments of the IMF and direct access to the parenchyma
for scoring and release in constricted lower poles.
Patients with smaller areolar complexes (<3 cm) also
may be inappropriate due to difficulty in implant place­
ment, especially with larger, textured or shaped implants
as injury to the implant can occur while trying to place
an implant through the longer breast tunnel associated
with these incisions. There has also been concern with
the potential contamination of the implant and breast
pocket from transected lactiferous ducts, increased risk
of nipple sensitivity changes, and the risk of hypopig­
mented scars in patients with darkly pigmented areola.
The incision is made between 3 o’clock and 9 o’clock
through the skin with a no. 15 blade precisely on the
border between areola and adjacent breast skin. Dissec­
tion is carried through the inferior aspect of the breast
directly through the breast tissue (transparenchymal) to
the retroglandular plane until the lateral pectoralis
border is identified. Care should be taken not to carry
the dissection superiorly and inadvertently devascular­
ize the nipple areolar complex. Dissection inferiorly in
the subcutaneous plane down to the inframammary
fold is preferred by some surgeons but may not be
optimal in some patients as it can create significant
distortion and stretch deformities in the lower pole of
the breast. The lateral pectoral border is identified and
the remainder of the dissection proceeds as described
for the inframammary incision. If a constricted lower
pole is present, the exposed parenchyma inferior to
the dissection can be radial scored to allow for expan­
sion and proper redraping of the tissue over the implant.
A final check for hemostasis and pocket irrigation
with antibiotic solution prior to implant placement is
performed.
Implant placement
Once dissection is complete, the pocket is prepared for
the implant. The pocket is irrigated with the Adam’s
solution of triple antibiotic solution (1 g cefazolin
sodium, 50 000 units of bacitracin mixed in 500 mL of
normal saline) or the modified Adam’s solution which
includes 50 cc of betadine (povidone-iodine) added to
the formula.56 It is the goal during the operation to
achieve prospective hemostasis with minimal blood
staining, however a final assessment is mandatory prior
to implant placement. The implants are soaked in the
irrigation solution prior to insertion. Gloves are changed
and rinsed with the irrigation solution to remove any
lint or powder.
The implant is then placed either manually or with
the assistance of an insertion sleeve such as the Keller
Fig. 4.15  An insertion sleeve such as the Keller funnel can facilitate implant
placement. The implant should be oriented appropriately in the funnel prior to
placement and the funnel opening must be adequate to allow a smooth and gentle
passage of the implant.

64
SECTION I
CHAPTER 4 • Breast augmentation
stabilization of the fold structure. This is accomplished
by securing the caudal edge of the Scarpa’s fascia present
on the lower incisional edge to the underlying deep
fascial structures with an absorbable suture such as 2-0
Vicryl or permanent suture (Fig. 4.17). This is usually
done by simply incorporating the superficial and deep
fascia together during closure, but can be also performed
by first placing three sutures on the lower flap securing
Scarpa’s fascia to the underlying deep fascia followed
by closure of the incision. Unique to both round and
shaped textured devices, the implant must be seated
accurately at the base of the breast pocket as it is less
likely to settle in the breast pocket postoperatively as
compared to smooth breast implants. Thus, special care
must be taken during closure not to inadvertently injure
the breast implants. The incision is closed in three
layers: Scarpa’s fascia superiorly to Scarpa’s fascia (with
or without deep fascia) inferiorly, deep dermis and
subcuticular.
The periareolar incision lacks the ability to control the
fold structure during closure. Closure includes closing
the breast parenchyma deep to the incision, followed by
deep dermal interrupted and a running subcuticular
with absorbable sutures. A precise closure is required to
achieve a well-healed camouflaged scar.
Transaxillary approach
Initially described by Hoehler in 1973 and later popular­
ized by Bostwick and others, the transaxillary approach
places the incision in the deep axilla and avoids a scar
directly on the breast.59 This dissection can be performed
bluntly but visualization with the endoscope is preferred
for controlled pocket dissection, precise muscle division
pocket from overmanipulation could lead to implant
rotation postoperatively.
Closure
Prior to incision closure, the patient should be placed in
the upright position to assess implant position, fold
position, symmetry and the adequacy of the dual plane
(Fig. 4.16). Any additional adjustments of the dual plane
can be accomplished after being placed back in the
recumbent position by simply retracting the breast
tissue superiorly off the implant, identifying the caudal
edge of the muscle, and releasing it incrementally off
the overlying breast tissue to the desired level. Reassess­
ment in the upright position after appropriate adjust­
ments is advisable to confirm position of implants and
optimal relationship between the implant and the over­
lying breast tissue.
A significant advantage of the inframammary
approach which is often underappreciated is the ability
to accurately and effectively control the fold position
during closure of the incision. The cuff of superficial
Scarpa’s fascia that was preserved during the initial
incision is utilized to secure the fold during closure. In
general, if the inframammary fold structure is well-
developed and stable and has not been violated or
lowered during the procedure, then re-approximation
of the superficial fascia during closure is usually ade­
quate. However, when the fold is unstable due to either
inherent weakness in the fold structure or from disrupt­
ing it with fold lowering, closure should include
Fig. 4.16  The patient is placed in the upright position to assess implant position,
fold position, symmetry and the adequacy of the dual plane and redraping of the
breast tissue over the implant.
Fig. 4.17  When stabilization of the inframammary fold is required due to inherent
weakness in the fold structure or secondary to fold lowering, closure requires
incorporating deep fascial structures into the Scarpa’s fascia closure to secure the
fold position.

65
Postoperative management
placing upward pressure away from the abdominal
and thoracic cavity. If the implant is being placed sub­
glandular, then pressure is exerted upward at the IMF
to stay in the subglandular plane. The tunnel ends up
just cephalad to the nipple. Placement of the implant
submuscular is possible with the use of special instru­
mentation to enter the fascial plane in a high lateral
position. The tube can then be removed and an endo­
scope utilized to verify the correct pocket. Instrumen­
tation is then removed from the tunnel and an expander
is rolled up, placed through the incision and advanced
up the tunnel through a subcutaneous “milking” tech­
nique with manual external pressure. The expander is
filled with saline to 150% of the final volume of the
planned implant. Some final pocket adjustments are
made and the expander is removed through simple
backward traction on the filler tube. The saline implant
is then advanced into the breast pocket similar to the
expander placement and filled to the desired final
volume. The endoscope can then be reintroduced to
confirm hemostats, valve patency and implant posi­
tion. The patient is placed in the upright position to
verify optimal implant positioning. The incision is
closed with a single layer of absorbable suture and
an abdominal binder placed for compression of the
abdominal tunnels.
Postoperative management
The management of breast augmentation is quite vari­
able amongst surgeons, but the type of device used
can alter the postoperative protocols. In our practice,
patients are given analgesics, muscle relaxant and
antibiotics. Some surgeons advocate no narcotics
and only anti-inflammatories postoperatively. The first
postoperative appointment is usually 3–4 days after
surgery. All patients are wrapped in an ace wrap for
the first 24 hours followed by a sports bra to be worn
23 hours a day for the next 4 weeks. Early range of
motion beginning in the recovery room is initiated for
all patients that includes shoulder rolls in both direc­
tions as well as elevation of the arms outward to the
sides and over the head. With smooth devices, implant
massage begins postoperative day 4 and includes dis­
placing the implant upward and downward in the
pocket, crossing the arms and pulling the implants
inward to create cleavage and downward pressure on
the implants to stretch the lower pole. With textured
implants, both round and shaped, limited arm move­
ment other than range of motion is recommended for
the first week. Implant massage is contraindicated as
the textured surface can irritate the pocket and poten­
tially create serous fluid around the implant. Likewise,
and prospective hemostasis. Any implant can be placed,
but larger silicone implants and anatomically shaped
implants can prove more difficult due to the long tunnel
and limited access. An insertion sleeve can be very
helpful in implant placement. With the patient’s arms
down to her side, the most anterior part of the axilla is
marked and the incision should not extend anteriorly
beyond this. The arm is then abducted 45° and a promi­
nent axillary crease is identified, preferably high in the
axilla. The incision length is the same as other approaches.
The patient should be placed on the operating room
table with the arms abducted 90°, but secured so that
they can be adducted somewhat when the patient is
placed in the upright position to check implant place­
ment. The incision is made and the medial aspect of the
incision is elevated. Superficial subcutaneous dissection
carried out to the lateral border of the pectoralis major
to prevent injury to the intercostobrachial nerve (sensa­
tion to the inner portion of the arm). The dissection is
then carried under the pectoralis fascia (subfascial) or
deep to the muscle (subpectoral) to create the implant
pocket. It is very important to confirm the correct plane
is entered before proceeding further.
When an endoscopically assisted transaxillary dissec­
tion is carried out, the endoscope is placed through the
tunnel into the correct plane and the dissection contin­
ues under direct visualization with the use of a long
insulated electrocautery instrument. Implant sizers are
used after completion of the dissection to identify any
areas that need final adjustments. After final confirma­
tion in the upright position and pocket irrigation, the
closure includes pectoralis fascia closure followed by a
layered incisional closure.
Transumbilical
The transumbilical approach has the significant limita­
tion of only allowing for augmentation with saline
implants. During the moratorium when silicone
implant use was significantly limited, saline augmen­
tation was the predominant procedure and this
approach was a viable option for patients. With the
increased use of prefilled silicone implants and now
anatomically shaped devices, this approach has much
more limited applicability. Positioning and markings
are identical to inframammary approach with an addi­
tional mark made from the umbilicus to the medial
border of the areola bilaterally. An incision is made in
the upper half of the umbilicus and an opening is
made large enough to accommodate an index finger.
An endotube is then passed along the rectus fascia
along the drawn line up to the medial areola. The
endotube should be carefully advanced in the subcuta­
neous tunnel continually palpating the tube and

66
SECTION I
CHAPTER 4 • Breast augmentation
Blind or blunt pocket dissection without surgery for
hemostasis after should be avoided to limit the incidence
of hematoma. Patients should likewise be counseled to
avoid medications that increase bleeding or interfere
with platelet function for at least two weeks prior to
surgery (see Table 3.1). A hematoma is easily recogniz­
able with a breast that is swollen, painful, bruised and
exquisitely painful to palpation or often arm movement.
Treatment includes reoperation with evacuation of the
hematoma, hemostasis, pocket washout and drainage.
Implant replacement is usually not necessary. A hema­
toma left untreated is discouraged as it can lead to
prolonged healing, wound problems, delayed healing,
infection and possible long-term issues of asymmetry
and possible capsular contracture.61
Infection
Infection rates for primary breast augmentation can
approach 2%.62–64 It is well known the breast parenchyma
and associated breast ducts harbor bacteria that can be
introduced into the operative field or breast pocket.52,65
Prevention is key and many operative maneuvers can
assist in minimizing this possibility. Current recom­
mendations are for skin preparation with chlorhexidine
that covers most organisms including methicillin-
resistant staphylococcus aureus (MRSA). Likewise,
perioperative antibiotics and antibiotic pocket irrigation
reduce implant contamination and possible infection.
The standard treatment includes operative exploration,
irrigation and debridement of the pocket with drainage.
In most incidences, the implant is removed during this
procedure and re-augmented six months later. There is
the possibility of implant salvage with prolonged anti­
biotic therapy if the patient is clinically stable and the
infection is limited, but failure of a salvage procedure
would mandate implant removal.66–68
Sensation changes
Alterations in nipple sensitivity can manifest as either
hypoesthesia or hyperesthesia and are often the result
of traction injury, bruising, inflammation or possibly
even injury to the lateral intercostal cutaneous nerve
that enters the breast laterally on the deep surface just
above the pectoral fascia. Although the major innerva­
tion is the fourth, there is some overlap from the anterior
and lateral branches of the third and fifth intercostal
nerves. There is evidence that nipple sensitivity changes
are no more likely with a periareolar incision when
compared to an inframammary incision.69,70 The most
common cause is aggressive pocket dissection laterally,
especially with sharp dissection, with injury to the
intercostal nerves.
the implants are placed in a controlled pocket with the
implant positioned appropriately at the base of the
pocket and displacement could lead to implant malpo­
sition or, in the case of shaped devices, rotation of the
implant (see Fig. 3.13). The different types of texture
available vary considerably in terms of texture aggres­
siveness and implant adherence, and the exact postop­
erative protocol and decision on drain placement
should be based on those considerations. In primary
breast augmentation, drains seem to offer very little
benefit.
Patients are allowed to resume regular bras after 4
weeks, but should continue with a sports bra during
bedtime for an additional 2–4 weeks to limit lateral
implant movement during pocket formation. Normal
activity resumes within a few days after surgery, but
exercise and high impact activity should be delayed for
3–4 weeks. Whereas smooth implants often seem high
initially and often require downward massage and/or
the use of breast bands or bandeaus, textured devices
that are appropriately seated in the base of the breast
pocket should only occasionally require such maneu­
vers. Whereas smooth implants will seem more mobile
and softer in the first few weeks after surgery compared
to textured devices, the textured implants will soften
with modest movement often present after 4–6 weeks.
If a variety of smooth and textured (round and/or
shaped) breast implants are being utilized within a
practice, it is extremely important to communicate to
ancillary staff the type of device placed with each patient
in order to initiate the appropriate postoperative proto­
col as inappropriate instructions can lead to postopera­
tive problems such as seromas, malposition and
rotational deformities.
Postoperative follow-ups occur approximately at 3
days, 3 weeks, 3 months and one year postoperatively.
Photographic documentation and critical evaluation
of surgical outcomes is imperative. In our practice,
every breast implant patient is placed on 400 IU of
vitamin E to potentially reduce the incidence of cap­
sular contracture. Whereas there is no evidence to the
benefit of vitamin E in breast augmentation, there is
encouraging data on the reduction of radiation-induced
scarring in the treatment of radiation-induced fibrosis
(RIF).60
Perioperative complications
Hematoma
The incidence of hematoma after a primary breast aug­
mentation has ranged from 0.5–2.0%. The best preven­
tion is achieving meticulous hemostasis intraoperatively.

67
Perioperative complications
Enterobacter, Bacillus and other organisms have been
implicated in this process.
Many techniques have been proposed to reduce
the incidence of capsular contracture. With smooth
implants, the concept of creating a large pocket with
displacement exercises has been used to try and
impede the development of a tightening capsule. The
use of textured implants may have some protective
properties as has been previously discussed in this
chapter. Maneuvers to minimize tissue trauma, blood
staining and seroma formation during pocket dissec­
tion have been employed as these may all contribute
to capsular contracture formation. Periprosthetic fluid
pockets generally resorb within the first week, and the
use of topical antibiotic irrigation has been shown to
decrease this rate.86 Additionally, the use of an inser­
tion sleeve (e.g., Keller funnel) for implant placement
and placement of Tegaderm (nipple shield) over the
nipple areolar complex have been employed to reduce
bacterial contamination of the implant and potentially
biofilm formation.52,57 Pocket irrigation with antibiotic
solutions has proven beneficial in reducing the inci­
dence of capsular contracture. Whereas the original
irrigation solutions contained betadine, some concerns
over the use of betadine in the implant pocket and
regulations imposed by the FDA led to the evaluation
and popularization of a few different antibiotic combi­
nations, including the “Adam’s solution” of gentamy­
cin 80 mg, bacitracin 50 000 units and cefazolin 1 g in
500 cc of normal saline, which have proved effective in
reducing capsular contracture incidence.56 Leukotriene
receptor antagonists which are used to treat asthma,
such as zafirlukast (Accolate) and montelukast (Singu­
lair), have shown some benefit in reversing the clinical
signs of capsular contracture but should be used with
caution due to potentials side effects.87,88 Box 4.2 sum­
marizes some of the implant and surgical technique
options that have been associated with lower capsular
contractures.32–36,43,45,46,52,56,57,89–94
Deflation and implant rupture
It is important to inform breast augmentation patients
that breast implants do not last a lifetime. Implant
rupture and failure of the shell is implant-style depen­
dent. Any disruption of the outer shell of a saline
implant leads to complete failure of the implant with
the saline leaking out into surrounding tissue and is
harmless. Saline implant failure can be associated
trauma or a spontaneous leak that involves either fold
fatigue on the shell of the implant or valve incompe­
tence. Silicone implant rupture rates have been quite
variable between devices and failures increase with the
age of the implant. The fifth generation silicone gel
implants have more cohesive gels and the silicone is
less likely to egress from the implant shell leading to a
much lower rupture rate than early fourth generation
devices.24,33,34,71,72 MRI imaging is currently the diagnos­
tic technique of choice to discern a silicone implant
rupture.
Capsular contracture
Capsular contracture remains the number one compli­
cations of breast augmentation with incidence ranging
as high as 15–30% with the development of palpable
and/or visible deformation of the periprosthetic
capsule around the implant.71–75 The development of a
capsule around an implant is always present due to
the unique foreign body reaction by the surrounding
breast tissue. A periprosthetic capsular contracture that
is clinically significant is characterized by excessive
scar formation with shrinkage and often thickening of
the capsule leading to firmness, distortion and dis­
placement of the breast implant. Baker proposed a
clinical classification system for capsular contractures
that is still widely used today76 (see Table 3.2). While
there are many factors identified that seem to contrib­
ute to the incidence of capsular contracture, the exact
etiology is not known. The hypertrophic scar theory
proposes that myofibroblasts are stimulated in the
capsule creating scar and contracture.77 Irritants such
as silicone gel, blood or seroma in the pocket may
incite a contracture.78–80 Also, stimulation and irritation
from foreign body particles such as powder, lint or
dust may also contribute.81 The infection theory has
been studied and appears currently to be the most
cited explanation for capsular contracture develop­
ment.82–85 This theory entails a chronic subclinical
infectious process located adjacent to the implant shell
within a microscopic biofilm that is protective of the
infectious process and inaccessible to cellular and
humoral immune function to combat the inflammatory
process. Staphylococcus epidermidis, Propionibacterium,
BOX 4.2  Items associated with reduced capsular contracture
incidence
No-touch technique
Nipple shields
Pocket irrigation with triple antibiotics
Insertion sleeve
Submuscular implant pocket
Textured implants
Inframammary incision
Cohesive shaped implants

68
SECTION I
CHAPTER 4 • Breast augmentation
include implant exchange to the retropectoral position,
implant exchange to an appropriate device with less
wrinkling (e.g. saline to silicone, textured surface to
smooth surface), fat grafting, and/or placement of a
soft-tissue matrix.
Animation deformity
Implant distortion on muscular contracture is a phe­
nomenon unique to implants placed in the submuscu­
lar position. It can be very noticeable and especially
bothersome for patients who exercise or lift weights
frequently. In one study, although mostly mild, 15% of
patients were noted to have moderate or severe distor­
tion on animation.95 Placement of the implant in the
subglandular/subfascial or subpectoral pocket is pre­
ventative and may be a preferable pocket for those
patients at risk, but must be weighed against the ben­
efits of subpectoral placement. If a severe animation
deformity is present, correction may include conver­
sion to preferably a subglandular/subfascial pocket or
to a dual plane with or without acellular dermal matrix
in patients who are not candidates for subglandular or
subfascial placement.
Anaplastic large cell lymphoma
There has been over the past few years an increasing
awareness and questions raised concerning reported
cases of ALCL in women with breast implants (see also
Chapter 12). To date, there have been nearly 200 cases,
but this number continues to grow.50 Initial presentation
has included the development of a late periprosthetic
fluid collection, a mass attached to the capsule, tumor
erosion through the skin, lymph node involvement, or
discovered during a revisional procedure. These have
been associated with saline and silicone implants. Where
the history of implants is known, most if not all are
associated with having at least one textured implant in
place as part of their history, the majority of these being
of the “salt-loss” type of texturing. This observation
suggests a probable chronic inflammatory cause,
although the rarity of this lesion precludes any statisti­
cally certain causal relationship and is suggestive of a
multifactorial inflammatory cause. As previously dis­
cussed, there is some early evidence that texture may be
merely a passive potentiator and the real culprit may be
a chronic immune response to a certain variety of
bacteria.51
Conclusion
In any patient presenting with a late seroma one year or
greater after implant surgery, evaluation should include
Implant malposition/rotation
Implant malposition is the second most common com­
plication in most studies and is a rather broad category
encompassing a wide range of complications. Malposi­
tions include inferior malposition with disruption of
the inframammary fold (double bubble) or inferior
stretch deformity (bottoming out), lateral malposition,
medial malposition (symmastia) and superior malposi­
tion which can often be associated with ptosis of the
breast tissue off the implant (snoopy deformity). Most
malpositions are preventable. Medial and lateral mal­
positions are most often the result of overdissection of
the lateral pocket or over-release of the pectoralis
sternal attachments, respectively. Inferior malposition
is often due to mismanagement of the inframammary
fold during lowering or use of implants larger than the
lower pole can tolerate leading to stretch deformities.
Superior malpositions are usually due to underdissec­
tion of the lower pole, inadequate dual plane if sub­
muscular, inadequate lowering of the inframammary
fold or the development of a capsular contracture.
Another contributing factor to malposition is the effect
of abnormal and/or asymmetric chest walls on the
migration of the implants on the chest wall. The use of
textured implants in this situation may help to reduce
implant movement over time. Implant rotation is a
complication only applicable to shaped devices and
refers to the implant orientation becoming altered in
the breast pocket. Because of this possibility, all shaped
devices are textured to help maintain spatial orienta­
tion in the pocket. Creation of a controlled implant
pocket that fits the implant accurately (hand-in-glove)
is critical in minimizing this risk. Whereas it has been
postulated that adherence of the textured implant to
the surrounding capsule is required to prevent rota­
tion, it appears that the frictional component of the
textured devices positioned in a controlled pocket is
adequate to minimize the risk of rotation.
Wrinkling/rippling
Adequate soft-tissue coverage takes priority in deter­
mining implant pocket location and minimizing the
risk of wrinkling, rippling, visibility and/or palpability
of the implant. Placement of the implant in the sub­
muscular or dual-plane pocket provides the greatest
coverage. Placement of an implant above the muscle
requires at least a 2 cm upper pole pinch thickness.
Even with adequate coverage, soft-tissue atrophy
and lower pole thinning and stretching is possible.
Wrinkling is more likely with inadequate or thin soft-
tissue coverage, saline implants, textured implants and
underfilled gel devices. Treatment of wrinkling may

69
Conclusion
image-guided fluid aspiration and appropriate fluid
evaluation for culture, cell count and cytology.96 All late
seromas or capsular contractures associated with a mass
should be evaluated and ALCL should be considered
and ruled out. Even if idiopathic and not associated
with infection or neoplastic process, surgical interven­
tion is usually indicated and includes total capsulectomy
with or without implant exchange. Appropriate staging
is mandatory and dictates adjuvant treatment, includ­
ing possibly chemotherapy, radiation therapy and/or
high-dose stem cell infusion for local extracapsular
involvement.
Bonus content for this chapter can be found online at

Table 4.1 Current approval status of gel breast implants in the United States.
Disclosure
Dr. Calobrace has been a speaker for Mentor, Allergan and Sientra with
no financial disclosure. He is also a stockowner and general partner of
Strathspey Crown Advisory Board of which Alphaeon Corporation is a
wholly-owned subsidiary.
28. Tebbetts JB, Adams WP. Five critical decisions in breast
augmentation using five measurements in 5 minutes: the high five
decision support process. Plast Reconstr Surg. 2005;116:2005–2016.
The authors describe their process of decision-making in breast
augmentation that has evolved from the biodimensional and TEPID
approach to breast assessment. This third generation is a process of breast
assessment that prioritizes five critical decisions, identifies five key
measurements, and completes all preoperative assessment and operative
planning decisions in breast augmentation in 5 minutes or less.
29. Adams WP. The process of breast augmentation: four sequential
steps for optimizing outcomes for patients. Plast Reconstr Surg.
2008;122:1892–1900. Optimizing patient outcomes in breast
augmentation requires defining the overall process to allow for enhanced
patient outcomes. The author describes a defined process of breast
augmentation including structured patient education and informed
consent; tissue-based preoperative planning consultation; refined surgical
technique; and structured postoperative instructions, management, and
follow-up.
31. Calobrace MB, Kaufman DL, Gordon AE, et al. Evolving practices
in augmentation operative techniques with Sientra HSC round
implants. Plast Reconstr Surg. 2014;134(suppl 1):57S–67S.
34. Maxwell GP, Van Natta BW, Murphy DK, et al. Natrelle style 410
form-stable silicone breast implants: core study results at 6 years.
Aesthet Surg J. 2012;32:709–717.
43. Stevens WG, Nahabedian MY, Calobrace MB, et al. Risk factor
analysis for capsular contracture: a 5-year Sientra study analysis
using round, smooth and textured implants for breast
augmentation. Plast Reconstr Surg. 2013;132:1115–1123.
47. Tebbetts JB. Dual plane breast augmentation: optimizing implant-
soft-tissue relationships in a wide range of breast types. Plast
Reconstr Surg. 2001;107:1255–1272. The author describes the indications
and techniques for utilizing a dual-plane approach in breast augmentation.
The submuscular pocket is adjusted to create variable amounts of
subglandular only coverage in the lower pole. This dual-plane approach
adjusts implant and soft-tissue relationships to optimize coverage and
implant–soft tissue dynamics. Indications, operative techniques, results,
and complications are reviewed for a series of patients.
56. Adams WP, Rios JL, Smith S. Enhancing patient outcomes in
aesthetic and reconstructive breast surgery using triple antibiotic
breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg. 2006;118(suppl 7):46S–52S. The authors demonstrate the clinical
importance of incorporating triple antibiotic irrigation in breast
augmentation procedures. This shows the incorporation of triple antibiotic
solution irrigation is associated with a low capsular contracture rate
compared to previously published reports, and its clinical efficacy supports
previously published in vitro studies. The use of triple antibiotic irrigation
is recommended in all aesthetic and reconstructive breast implant
procedures and is cost effective.
71. Spears S, Murphy D, Slicton A. Inamed silicone breast implant core
study results at 6 years. Plast Reconstr Surg. 2007;120:8S–16S.
72. Cunningham B. The Mentor Core Study on silicone MemoryGel
breast implants. Plast Reconstr Surg. 2007;120:19S–29S. The authors
provide an update on the post-approval study for Allergan’s breast
implants. The ongoing core study results demonstrate safety and
effectiveness of the Natrelle smooth and textured silicone-filled round
breast implants through six years of the 10 year study. The results reveal
low rupture rates and significantly high patient satisfaction.
96. Bengtson B, Brody GS, Brown MH, et al. Managing late
periprosthetic fluid collections (seroma) in patients with breast
implants: a consensus panel recommendation and review of the
literature. Plast Reconstr Surg. 2011;128:1–7. The authors review
the development of late or delayed periprosthetic fluid collections post
breast augmentation. A consensus report was created from a group of
practicing plastic surgeons and device industry physicians concerning
the management of this complication. Based on this collaboration,
treatment recommendations and treatment algorithms were created to
guide the management of these late-onset periprosthetic fluid
collections.
Access the complete reference list online at

69.e1
References
References
1. Goin JM, Goin MK. Augmentation mammaplasty. In: Goin J, Goin
M, eds. Changing the Body: Psychological Effects of Plastic Surgery.
Baltimore: Williams & Wilkins; 1981:191–202.
2. Edgerton MT, McClary AR. Augmentation mammoplasty. Plast
Reconstr Surg. 1958;21:279.
3. Edgerton MT, Meyer E, Jacobson WE. Augmentation mammoplasty.
II. Further surgical and psychiatric evaluation. Plast Reconstr Surg.
1961;27:279.
4. Druss R. Changes in body image following augmentation breast
surgery. Int J Psychoanal Psychother. 1973;2:248.
5. Shipley RH, O’Donnell JM, Bader KF. Personality characteristics of
women seeking breast augmentation. Comparison to small-busted
and average-busted controls. Plast Reconstr Surg. 1977;60:369–376.
6. Baker JL Jr, Kolin IS, Bartlett ES. Psychosexual dynamics of patients
undergoing mammary augmentation. Plast Reconstr Surg.
1974;53:652–659.
7. Maxwell GP, Gabriel A. The evolution of breast implants. Clin Plast
Surg. 2009;36:1–13.
8. Regnault P, Baker TJ, Gleason MC, et al. Clinical trial and
evaluation of a proposed new inflatable mammary prosthesis. Plast
Reconstr Surg. 1972;50:220–226.
9. Rees TD, Guy CL, Coburn RJ. The use of inflatable breast implants.
Plast Reconstr Surg. 1973;52:609–615.
10. Williams JE. Experience with a large series of breast implants. Plast
Reconstr Surg. 1972;49:253–258.
11. Grossman AR. The current status of augmentation mammaplasty.
Plast Reconstr Surg. 1973;52:1–7.
12. McKinney P, Tresley G. Long term comparison of patients with gel
and saline mammary implants. Plast Reconstr Surg. 1983;72:27–29.
13. Capozzi A. Clinical experience with Heyer-Schulte inflatable
implants in breast augmentation. Plast Reconstr Surg.
1986;77:772–778.
14. Cronin TD, Gerow FJ. Augmentation mammoplasty: A new “natural
feel” prosthesis. Transactions of the Third International Congress of
Plastic Surgery, October 13–18, 1963. Amsterdam: Excerpta Medica
Foundation; 1963:41–49.
15. Peters W, Smith D, Fornasier V, et al. An outcome analysis of 100
women after explantation of silicone gel breast implants. Ann Plast
Surg. 1997;39:9–19.
16. Maxwell GP, Baker MR. Augmentation mammaplasty: general
considerations. In: Spear SL, ed. Surgery of the Breast: Principles and
Art. Vol. 1. 2nd ed. Baltimore: Lippincott Williams & Wilkins;
2006:1237.
17. Young LV, Watson ME. Breast implant research: where we have
been, where we are, where we need to go. Clin Plast Surg.
2001;28:451–483.
18. Maxwell GP, Gabriel A. The evolution of breast implants. Clin Plast
Surg. 2009;36:1–13.
19. Jackson IT. Evolutionary development of cohesive gel implants: A
new era in implant technology. In: Jackson IT, ed. Innovations in
Plastic Surgery: Cohesive Gel Implants. Vol. 1, No. 3. St. Louis: Quality
Medical Publishing, Inc.; 2007:9A–12A.
20. Tebbetts JB. Dimensional Augmentation Mammaplasty Using the
Biodimensional System. Santa Barbara: McGhan Medical Corporation;
1994:1–90.
21. Tebbetts JB. Form stability of the style 410 implant: definitions,
conjectures, and the rest of the story. Plast Reconstr Surg.
2011;128:825–826.
22. Heden P, Bone B, Murphy DK, et al. Style 410 cohesive silicone
breast implants: safety and effectiveness at 5 to 9 years after
implantation. Plast Reconstr Surg. 2006;118:1281–1287.
23. Brown MH, Shenker R, Silver SA. Cohesive silicone gel breast
implants in aesthetic and reconstructive breast surgery. Plast
Reconstr Surg. 2005;116:768–779.
24. Bengtson BP, Van Natta BW, Murphy DK, et al. Style 410 highly
cohesive silicone breast implant core study results at 3 years. Plast
Reconstr Surg. 2007;120:40S–48S.
25. Gabriel A, Fritzsche S, Creasman C, et al. Incidence of breast and
chest wall asymmetries: 4D photography. Aesthet Surg J. 2011;31:
506–510.
26. Muntan CD, Sundine MJ, Rink RD, et al. Inframammary fold: a
histological reappraisal. Plast Reconstr Surg. 2000;105:549–556.
27. Teitelbaum S. The inframammary approach to breast augmentation.
Clin Plast Surg. 2009;36:33–43.
28. Tebbetts JB, Adams WP. Five critical decisions in breast
augmentation using five measurements in 5 minutes: the high five
decision support process. Plast Reconstr Surg. 2005;116:2005–2016.
The authors describe their process of decision-making in breast
augmentation that has evolved from the biodimensional and TEPID
approach to breast assessment. This third generation is a process of breast
assessment that prioritizes five critical decisions, identifies five key
measurements, and completes all preoperative assessment and operative
planning decisions in breast augmentation in 5 minutes or less.
29. Adams WP. The process of breast augmentation: four sequential
steps for optimizing outcomes for patients. Plast Reconstr Surg.
2008;122:1892–1900. Optimizing patient outcomes in breast augmentation
requires defining the overall process to allow for enhanced patient outcomes.
The author describes a defined process of breast augmentation including
structured patient education and informed consent; tissue-based
preoperative planning consultation; refined surgical technique; and
structured postoperative instructions, management, and follow-up.
30. Tebbetts JB, Teitelbaum S. High- and extra-high-projection breast
implants: potential consequences for patients. Plast Reconstr Surg.
2010;126:2150–2159.
31. Calobrace MB, Kaufman DL, Gordon AE, et al. Evolving practices
in augmentation operative techniques with Sientra HSC round
implants. Plast Reconstr Surg. 2014;134(suppl 1):57S–67S.
32. Namnoum JD, Largent J, Kaplan HM, et al. Primary breast
augmentation clinical trial outcomes stratified by surgical incision,
anatomical placement and implant device type. J Plast Reconstr
Aesthet Surg. 2013;66:1165–1172.
33. Hammond DC, Migliori MM, Caplin DA, et al. Mentor Contour
Profile Gel implants: clinical outcomes at 6 years. Plast Reconstr
Surg. 2012;129:1381–1391.
34. Maxwell GP, Van Natta BW, Murphy DK, et al. Natrelle style 410
form-stable silicone breast implants: core study results at 6 years.
Aesthet Surg J. 2012;32:709–717.
35. Jewell ML, Jewell JL. A comparison of outcomes involving highly
cohesive, form-stable breast implants from two manufacturers in
patients undergoing primary breast augmentation. Aesthet Surg J.
2010;30:51–65.
36. Caplin DA. Indications for the use of MemoryShape breast implants
in aesthetic and reconstructive breast surgery: long-term clinical
outcomes of shaped versus round silicone breast implants. Plast
Reconstr Surg. 2014;134:27S–37S.
37. Hammond DC. Technique and results using MemoryShape
implants in aesthetic and reconstructive breast surgery. Plast
Reconstr Surg. 2014;134(suppl 3):16S–26S.
38. Schwartz MR. Algorithm and techniques for using Sientra’s silicone
gel shaped implants in primary and revision breast augmentation.
Plast Reconstr Surg. 2014;134(suppl 1):18S–27S.
39. Strasser EJ. Results of subglandular versus subpectoral
augmentation over time: one surgeon’s observations. Aesthet Surg J.
2006;26:45–50.
40. Goes JCS, Landecker A. Optimizing outcomes in breast
augmentation: seven years of experience with the subfascial plane.
Aesthetic Plast Surg. 2003;27:178–184.
41. Serra-Renom J, Garrido MF, Yoon T. Augmentation mammoplasty
with anatomic soft, cohesive silicone implant using the transaxillary
approach at a subfascial level with endoscopic assistance. Plast
Reconstr Surg. 2005;116:640–645.
42. Graf R, Pace DT, Damasio RC, et al. Subfascial breast augmentation.
In: Innovations in Plastic and Aesthetic Surgery. New York: Springer;
2008:406–413.
43. Stevens WG, Nahabedian MY, Calobrace MB, et al. Risk factor
analysis for capsular contracture: a 5-year Sientra study analysis
using round, smooth and textured implants for breast
augmentation. Plast Reconstr Surg. 2013;132:1115–1123.

69.e2
SECTION I
CHAPTER 4 • Breast augmentation
44. Wong CH, Samuel M, Tan BK, Song C. Capsular contracture in
subglandular breast augmentation with textured versus smooth
breast implants: a systematic review. Plast Reconstr Surg.
2006;118:1224–1236.
45. Barnsley GP, Siigurdson LJ, Barnsley SE. Textured surface breast
implants in the prevention of capsular contracture among breast
augmentation patients: a meta-analysis of randomized controlled
trials. Plast Reconstr Surg. 2006;117:2182–2190.
46. Schaub TA, Ahmad J, Rohrich RJ. Capsular contracture with breast
implants in the cosmetic patient: saline versus silicone. A systematic
review of the literature. Plast Reconstr Surg. 2010;126:2140–2149.
47. Tebbetts JB. Dual plane breast augmentation: optimizing implant-
soft-tissue relationships in a wide range of breast types. Plast
Reconstr Surg. 2001;107:1255–1272. The author describes the indications
and techniques for utilizing a dual-plane approach in breast augmentation.
The submuscular pocket is adjusted to create variable amounts of
subglandular only coverage in the lower pole. This dual-plane approach
adjusts implant and soft-tissue relationships to optimize coverage and
implant–soft tissue dynamics. Indications, operative techniques, results,
and complications are reviewed for a series of patients.
48. Hall-Findlay EJ. Breast implant complication review: double
capsules and late seromas. Plast Reconstr Surg. 2011;127:56–66.
49. Spears SL, Rottman S, Glicksman C, et al. Late seromas after
breast implants: theory and practice. Plast Reconstr Surg.
2012;130:423–435.
50. Brody GS, Deapen D, Taylor CR, et al. Anaplastic large cell
lymphoma occurring in women with breast implants: analysis of
173 cases. Plast Reconstr Surg. 2015;135:695–705.
51. Adams WP. Discussion: anaplastic large cell lymphoma occurring
in women with breast implants: analysis of 173 cases. Plast Reconstr
Surg. 2015;135:709–712.
52. Wixtrom RN, Stutman RL, Burke RM, et al. Risk of breast implant
bacterial contamination from endogenous breast flora, prevention
with nipple shields, and implications for biofilm formation. Aesthet
Surg J. 2012;32:956–963.
53. Schusterman MA. Lowering the inframammary fold. Aesthet Surg J.
2004;24:482–485.
54. Jenny H. The areolar approach to augmentation mammoplasty. Int J
Aesthetic Plast Surg. 1972;F:1972.
55. Pinsky MA. Breast augmentation: incision selection. In: Bucky LP,
Mottura AA, eds. Techniques in Aesthetic Breast Surgery. Philadelphia:
Saunders Elsevier; 2009:15–26.
56. Adams WP, Rios JL, Smith S. Enhancing patient outcomes in
aesthetic and reconstructive breast surgery using triple antibiotic
breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg. 2006;118(suppl 7):46S–52S. The authors demonstrate the clinical
importance of incorporating triple antibiotic irrigation in breast
augmentation procedures. This shows the incorporation of triple antibiotic
solution irrigation is associated with a low capsular contracture rate
compared to previously published reports, and its clinical efficacy supports
previously published in vitro studies. The use of triple antibiotic
irrigation is recommended in all aesthetic and reconstructive breast
implant procedures and is cost effective.
57. Moyer HR, Ghazi B, Saunders N, Losken A. Contamination in
smooth gel breast implant placement: testing a funnel versus digital
insertion technique in a cadaver model. Aesthet Surg J.
2012;32:194–199.
58. Mladick RA. “No-touch” submuscular saline breast augmentation
technique. Aesthetic Plast Surg. 1993;17:183–192.
59. Hoehler H. Breast augmentation: the axillary approach. Br J Plast
Surg. 1973;26:373–376.
60. Magnusson M, Hoglund P, Johansson K, et al. Pentoxifylline and
vitamin E treatment for prevention of radiation-induced side-effects
in women with breast cancer: a phase two, double-blind, placebo-
controlled randomized clinical trial (Ptx-5). Eur J Cancer.
2009;45:2488–2495.
61. Williams C, Aston S, Rees TD. The effect of hematoma on the
thickness of pseudosheaths around silicone implants. Plast Reconstr
Surg. 1975;56:194–198.
62. Cunningham B. The Mentor Study on Contour Profile Gel silicone
MemoryGel Breast Implants. Plast Reconstr Surg. 2007;120:33S–39S.
63. Hvilsom GB, Hölmich LR, Henriksen TF, et al. Local complications
after cosmetic breast augmentation: results from the Danish
Registry for Plastic Surgery of the breast. Plast Reconstr Surg.
2009;124:919–925.
64. Codner MA, Mejia JD, Locke MB, et al. A 15-Year Experience with
Primary Breast Augmentation. Plast Reconstr Surg.
2011;127:1300–1310.
65. Ransjo U, Asplund O, Gulbert L, et al. Bacteria in the female breast.
Scand J Plast Reconstr Surg. 1985;19:87–89.
66. Spears SL, Howard MA, Boehmler JH, et al. The infected or
exposed breast implant: management and treatment strategies. Plast
Reconstr Surg. 2004;113:1634–1644.
67. Spears SL, Seruya M. Management of the infected or exposed breast
prosthesis: a single surgeon’s 15-year experience with 69 patients.
Plast Reconstr Surg. 2010;125:1074–1084.
68. Sforza M, Andjelkov K, Husein R, et al. Will 1-stage implant
salvage after periprosthetic breast infection ever be routine? A
6-year successful experience. Aesthet Surg J. 2014;34:1172–1178.
69. Mofid MM, Klatsky SA, Singh NK, et al. Nipple-areola complex
sensitivity after primary breast augmentation: a comparison of
periareolar and inframammary incision approaches. Plast Reconstr
Surg. 2006;117:1694–1698.
70. Okwueze MI, Spear ME, Zwyghuizen AM, et al. Effect of
augmentation mammoplasty on breast sensation. Plast Reconstr
Surg. 2006;117:73–83.
71. Spears S, Murphy D, Slicton A. Inamed silicone breast implant core
study results at 6 years. Plast Reconstr Surg. 2007;120:8S–16S.
72. Cunningham B. The Mentor Core Study on silicone MemoryGel
breast implants. Plast Reconstr Surg. 2007;120:19S–29S. The authors
provide an update on the post-approval study for Allergan’s breast
implants. The ongoing core study results demonstrate safety and
effectiveness of the Natrelle smooth and textured silicone-filled round
breast implants through six years of the 10 year study. The results reveal
low rupture rates and significantly high patient satisfaction.
73. Wong C, Samuel M, Tan B, et al. Capsular contracture in
subglandular breast augmentation with textured versus smooth
breast implants: a systematic review. Plast Reconstr Surg.
2006;118:1224–1236.
74. Pollock H. Breast capsular contracture: a retrospective study of
textured versus smooth silicone implants. Plast Reconstr Surg.
1993;91:123–130.
75. Henriksen T, Holmich L, Fryzek J, et al. Incidence and severity of
short term complications after breast augmentation: results from a
nationwide breast implant registry. Ann Plast Surg. 2005;54:343–350.
76. Spear SL, Baker JL Jr. Classification of capsular contracture after
prosthetic breast reconstruction. Plast Reconstr Surg.
1995;96:1119–1124.
77. Baker J, Chandler M, Levier R, et al. Occurrence and activity of
myofibroblasts in human capsular tissue surrounding mammary
implants. Plast Reconstr Surg. 1981;68:913–914.
78. Handel N, Cordray T, Gutierrez J, et al. A long-term study of
outcomes, complications, and patient satisfaction with breast
implants. Plast Reconstr Surg. 2006;117:757–767.
79. Brandon H, Young V, Jerina K, et al. Mechanical analysis of
explanted saline-filled breast implants exposed to betadine pocket
irrigation. Aesthet Surg J. 2002;22:438–444.
80. Pranti L, Schreml S, Fichtner S, et al. Clinical and morphological
conditions in capsular contracture formed around silicone breast
implants. Plast Reconstr Surg. 2007;120:275–284.
81. Adams WP Jr. Capsular contracture: what is it? What causes it?
How can it be prevented and managed? Clin Plast Surg.
2009;36:119–126.
82. Pajkos A, Deva AK, Vicery K, et al. Detection of subclinical
infection in significant breast implant capsules. Plast Reconstr Surg.
2003;111:1605–1611.
83. Weiner T. The role of betadine irrigation in breast augmentation.
Plast Reconstr Surg. 2007;119:12–15.
84. Adams W, Conner W, Chad H, et al. Optimizing breast pocket
irrigation: an in vitro study Burkhardt and clinical implications.
Plast Reconstr Surg. 2000;105:334–342.

69.e3
References
85. Burkhardt B, Dempsey P, Schnur P, et al. Capsular contracture: a
prospective study of the effects of local antibacterial agents. Plast
Reconstr Surg. 1986;77:919–928.
86. Pfeiffer P, Jorgensen S, Kristiansen TB, et al. Protective effect of
topical antibiotics in breast augmentation. Plast Reconstr Surg.
2009;124:629–634.
87. Gryskiewicz JM. Investigation of accolate and singulair for
treatment of capsular contracture yields safety concerns. Aesthet
Surg J. 2003;23:98–101.
88. Riccioni G, Bucciarelli T, Mancini B, et al. Antileukotriene drugs:
clinical application, effectiveness and safety. Curr Med Chem.
2007;14:1966–1977.
89. Mladick RA. “No-touch” submuscular saline breast augmentation
technique. Aesthetic Plast Surg. 1993;17:183–192.
90. Hakelius L, Ohlsen L. Tendency to capsule contracture around
smooth and textured gel-filled silicone mammary implants: a 5-year
follow-up. Plast Reconstr Surg. 1997;100:1566–1569.
91. Burkhardt B, Eades E. The effect of biocell texturizing and
povidione-iodine irrigation on capsule contracture around
saline-inflatable breast implants. Plast Reconstr Surg. 1995;96:
1317–1325.
92. Coleman DJ, Foo IT, Sharpe DT. Textured or smooth implants for
breast augmentation? A prospective controlled trial. Br J Plast Surg.
1991;44:444–448.
93. Malata CM, Felderg L, Coleman DJ, et al. Textured or smooth
implants for breast augmentation? Three year followup of a
prospective randomized controlled trial. Br J Plast Surg.
1997;50:99–105.
94. Weiner RC. Relationship of incision choice to capsular contracture.
Aesthetic Plast Surg. 2008;32:303–306.
95. Spears SL, Schwartz J, Dayan JH, et al. Outcome assessment of
breast distortion following submuscular breast augmentation.
Aesthetic Plast Surg. 2009;33:44–48.
96. Bengtson B, Brody GS, Brown MH, et al. Managing late
periprosthetic fluid collections (seroma) in patients with breast
implants: a consensus panel recommendation and review of the
literature. Plast Reconstr Surg. 2011;128:1–7. The authors review the
development of late or delayed periprosthetic fluid collections post breast
augmentation. A consensus report was created from a group of practicing
plastic surgeons and device industry physicians concerning the
management of this complication. Based on this collaboration, treatment
recommendations and treatment algorithms were created to guide the
management of these late-onset periprosthetic fluid collections.

SECTION I • Aesthetic Breast Surgery
5 
Breast augmentation with autologous
fat grafting
Emmanuel Delay and Samia Guerid
SYNOPSIS
■ Breast augmentation with autologous fat grafting has been
a controversial topic for the last thirty years. Based on our
clinical and radiologic experience since 1998, we developed
an efficient new technique to realize breast augmentation:
lipomodeling.
■ Our technique is efficient and safe and has become a
standard procedure during breast reconstruction after cancer,
correction of breast conservative treatment sequelae, breast
and thorax malformations treatment, and aesthetic breast
augmentation.
■ Prior evaluation and accurate patient selection are mandatory.
Ultrasound of the breast is performed on patients under 30 years
of age, ultrasound and one mammography incidence between
30 and 40 years of age, and standard mammography and ultrasound
over 40 years.
■ In case of ACR 3, biopsy has to downstage the lesion to ACR 1 or 2,
otherwise the procedure is contraindicated. Breast lipo-augmentation is
only moderate unless done in multiple sessions, which is difficult in
pure aesthetic surgery.
■ Fat is harvested by means of a 3.5 mm cannula adapted to a syringe
and centrifuged during 20 seconds at 3000 rpm. Fat transfer has then
to be very accurate.
■ Patient follow-up is done at 15 days, 3 months, and one year.
At one year, a new radiologic evaluation is done by means
of the same radiologic tools as preoperative work-up. In case
of a new suspect lesion, biopsy is performed to obtain
accurate diagnosis. No hematoma has been reported in our
experience. Infection rate is very low (0.6%) and easily handled
by pulling out some stitches, ice application, and antibiotic
treatment.
■ At the beginning of practice, some fat necrosis can be seen that
becomes very rare through clinical experience. In 10% of cases, oil
cysts are seen that can easily be managed by puncture at the
follow-up visit.
Introduction
Transferring fat from areas where it is present in excess
(abdomen, thighs) to the breast for aesthetic and recon­
structive purposes is a surgical renewal. This approach
has been considered since the very beginning of liposuc­
tion, particularly after the publication of Illouz’s1 and
Fournier’s2 works. However, it remained controversial
and never became widely used until the development
of more precise tools and techniques. It was feared that
autologous fat transfer would generate fat necrosis and
calcifications which, at that time, were not readily
assessable because of the limitations of available imaging
modalities.
The American Society of Plastic and Reconstruc­
tive Surgeons had, in 1987 after a case presented by
Bircoll,3 advised to discontinue fat transfer surgery.
Fat grafting procedures diminished significantly fol­
lowing this opinion (see Historical Perspective). In
1998, given the proven efficacy of fat transfer to the
face demonstrated by Coleman4,5 for facial rejuvena­
tion or post-surgery reconstruction, we developed
a research program aiming to evaluate the efficacy
and safety of the procedure for thoraco-mammary
reconstructions.
We adapted the technique for breast procedures, and
we chose to name it “lipomodeling”.6,7 We assessed its
efficacy and tolerance in patients and demonstrated the
absence of significant clinical or radiological signs of
adverse effects. Obtained results went largely beyond
our hopes, and this technique has now a major role in
breast plastic and aesthetic surgery.
  Access video lecture content for this chapter online at expertconsult.com

71
Patient presentation
The purpose of the present chapter is to present the
evolution of ideas and the progress of knowledge about
fat grafting to the breast, its applications, and to describe
its indications and contraindications and precise tech­
nique. We will finally present clinical outcomes and
results obtained with this technique for each clinical
situation.
Access the Historical Perspective section online at

Basic science
Fat grafting technique is now very well described. Sci­
entific research and surgical practice were able to show
that each fat lobule has to be surrounded by vascular­
ized tissue at a distance of 2 mm or less. The conse­
quence of this observation is the grafting of fat
spaghettis in a 3D grid where each tunnel has to be
surrounded by recipient tissue with spaghetti of a
diameter less than two millimeters. Spaghetti box
concept is essential to understand to handle lipomod­
eling technique. It is actually possible to graft as much
volume as can accept recipient tissue: while sticking
to that rule, it is then possible to anticipate quantity of
fat to be transferred and the number of sessions needed
to achieve the planned result. With experience, it is
important to learn how to scan the patient with hands
and eyes and evaluate recipient tissues, which eases
transfer precision.
Patient presentation
Lipomodeling of the breast and chest wall is a technique
that nowadays has many indications. It has been of
great help in reconstructive breast surgery. In aesthetic
breast surgery and in selected cases, fat transfer can be
used instead of implants (augmentation, mastopexy
with a slight lack of fullness in the upper pole), and it
can correct some defects of implant augmentations. The
procedure is becoming a new gold standard to enhance
breast aesthetic outcomes.
Poland syndrome
Correction of the breast and chest wall deformities of
Poland syndrome is still today a challenge for plastic
surgeons. Lipomodeling appears to be very useful in
these cases. Breast rehabilitation with exclusive fat
grafting leads to excellent outcomes with simple but
repeated procedures15,16,23,31,32 and very limited scarring
and donor site morbidity. The results are very interest­
ing, and a breast almost identical to the opposite side
can be achieved (Fig. 5.1). This technique appears to
revolutionize the management of breast and chest wall
deformities in Poland syndrome15,16,23,24,31,32.
Pectus excavatum
Pectus excavatum is a complex deformity with hollow­
ing of the anterior sternocostal wall. It usually has little
or no impact on the respiratory function. In most cases
the complaint is mainly morphological and aesthetic,
with considerable deformity of the thorax, especially in
severe or lateralized forms. Procedures involving modi­
fications of bony and cartilaginous structures can be
very invasive when done for aesthetic purpose. Fat
transfer techniques give satisfactory correction for mild
to moderate forms (Fig. 5.2),15,16,23,24,33 or in association
with a custom-made rigid implant (based on a 3D CT
scan) in major forms.
Tuberous breasts
Tuberous breast is a deformity of the breast footprint,
with onset at puberty when breast development begins.
Various surgical approaches have been described, and
a wide range of techniques has been published to obtain
optimal results. Among them, lipomodeling15,16,23,24,34 can
correct the lack of volume (especially in unilateral cases)
and improve base and shape of the breast (Fig. 5.3). It
is a very useful adjunct in the treatment of tuberous
breasts. The ideal indication is the unilateral hypoplastic
tuberous breast (which usually requires two fat transfer
sessions), associated with the lack of fullness of the
upper pole. In cases of bilateral breast hypoplasia asso­
ciated with tuberous deformity, implants remain the
gold standard unless the clinical condition is associated
with a lower body adiposity large enough to augment
the two breasts efficiently. Lipomodeling can drastically
enhance the results of these corrections by improving
the décolleté area.
Asymmetric breasts
Asymmetry is a difficult problem, mostly when one
breast has satisfactory fullness and perfect shape and
the other is hypoplastic. Conventionally, implant aug­
mentation in the underdeveloped breast is the standard
procedure. While the initial result is usually good,
asymmetry of shape and volume often reappears several
years later, due to aging of the breasts. In this indication,
lipomodeling yields a breast very similar to the normal
breast,15,16,23,24 and change over time is natural, in par­
ticular regarding ptosis. Depending on the degree of

71.e1
Historical perspective
Historical perspective
First attempts
In 1895, Czerny described the first clinical case of breast
reconstruction by transplantation of a giant lipoma of
the lumbar region to the breast on the same patient.
Adipose cells were used to fill the defect left in the
breast after tumor resection in a patient with a fibroad­
enoma8,9. After that, some authors performed breast
reconstruction or augmentation using fasciocutaneous
flaps10, gluteus fat implants11, or local pedicled flaps12.
Injections of fat either directly into the breast1,2,13 or into
previously inserted implants14 have also been reported.
Authors even described cases of augmentation mam­
maplasty by cadaver fat allografts15–17.
The development of liposuction with its efficiency1
contributed to the rise of body contouring and to the
worldwide generalization of the concept. It became
tempting to use autologous fat tissue harvested by
liposuction for breast augmentation, as primarily done
by Illouz. Similarly, in 1991, Fournier described the fat-
grafting technique which he used in patients who
refused implants and desired moderate breast augmen­
tation2. The quantity of grafted fat was between 100 and
250 cc in each breast, injected in the retroglandular
space.
At that time, many surgeons were skeptic about the
procedure. The technique was not standardized, and it
was not possible to guarantee the absence of fat necrosis
following fat transfer. Moreover, breast imaging tech­
niques were not as accurate as today; any mammary
tumefaction could cause mammographic changes and
give rise to diagnostic confusion. The scientific com­
munity feared that areas of fat necrosis might interfere
with breast cancer detection.
The controversy
Fat grafting to the breasts became highly controversial
since Bircoll’s first presentation of a patient undergoing
breast augmentation by injection of fat cells obtained by
liposuction, in Bangkok in 1984, then at the Californian
Society of Plastic Surgeons in 1985. The patient was a
20-year-old woman who requested a moderate augmen­
tation of her breasts while undergoing fat grafting to
repair damages caused by a dog bite. Bircoll considered
that the technique should only be used for women
requesting moderate augmentation because of the
potential risk of necrosis when grafting large quantities.
His paper published in The Plastic and Reconstructive
Surgery journal in February 19873 reported the main
advantages of the procedure: simplicity, absence of scar,
early recovery, avoidance of implant use and implant-
related complications, and impact at the site of fat
removal.
In April 198718, Bircoll reported the case of a patient
undergoing bilateral fat grafting after unilateral recon­
struction by transverse rectus abdominus myocutane­
ous (TRAM) flap to improve aesthetic results and
symmetry. These two papers triggered controversial
reactions from the medical community18–21, who stated
that autologous fat injections in the breasts could
generate microcalcifications and cysts and possibly
interfere with detection of early breast carcinoma. Bircoll
claimed22,23 that cancer-related calcifications and those
consecutive to fat transplantation occurred in different
sites and had different radiological aspects that could
not be mistaken. Moreover, breast reduction surgery
was also a cause of microcalcifications, but the proce­
dure was still performed every day. But the American
Society of Plastic and Reconstructive Surgeons (ASPRS)
stated the following: “The committee is unanimous in
deploring the use of autologous fat injection in breast
augmentation, much of the injected fat will not survive,
and the known physiological response to necrosis of this
tissue is scarring and calcification. As a result, detection
of early breast carcinoma through xerography and
mammography will become difficult and the presence
of disease may go undiscovered.”
There was no explicit reference to scientific findings,
and the report only expressed the opinion of the
members of the committee. Despite the paucity of sci­
entific information, and although it had long been rec­
ognized that any mammary surgery could be responsible
for the occurrence of fatty cysts or mammographic
changes, the injection of fat into the breasts became a
strong taboo among plastic surgeons. The ASPRS ban
put an end to any research or experimentation on the
subject.
Ironically, in 1987, a retrospective study of the mam­
mographic changes after breast reduction published in
the same journal24 reported that calcifications were
detectable in 50% of all mammograms 2 years after the
surgery. The author insisted that in most cases these
benign calcifications were easily distinguishable from
cancer. Despite this high incidence and the risk for
mammography abnormalities to interfere with cancer
detection, there was no discussion of discontinuing
breast reduction surgery.
Lifting of the taboo
Fat grafting regained popularity after Coleman’s work
demonstrating4,5 that fat tissue could be transplanted
safely provided that adequate care is given to the

71.e2
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CHAPTER 5 • Breast augmentation with autologous fat grafting
preparation and transfer of fat cells. The preliminary
work of Coleman was mainly on facial rejuvenation, but
his demonstration of fat transfer efficacy, based on
atraumatic fat harvesting and injection,4,5 prompted us
to adapt the technique to breast reconstruction.
Breast and thorax fat grafting contribution in the
setting of breast reconstruction has been one of our
principal research topics over the past fifteen years. We
used first fat grafting along with extended autologous
latissimus dorsi flap reconstruction. This technique,
developed in our department,25–27 gave satisfactory
results in 70% of the cases. However, the other 30%
resulted in insufficient breast volume, needing the
insertion of an implant and a systematic reduction of
the contralateral breast. By adding an implant, the
procedure was no longer autologous and the patients
suffered the drawbacks of prostheses (unnatural shape
and texture, implant-related complications, and neces­
sity to change the prosthesis after a while).
We started then to use fat grafting in breast cancer
patients undergoing autologous latissimus dorsi flap
reconstruction who were at low risk of local recurrence.
We named the technique “lipomodeling”, from the
Greek root “lipo” for fat, and the Latin word “modello”,
which means to give shape or volume, which was
exactly the purpose of this procedure. At first, only
volunteer patients who agreed to undergo strict
follow-up were chosen. Then, after our demonstration
of the technique efficacy, it became a standard in almost
all patients treated by latissimus dorsi flap reconstruc­
tion in our department. Fat grafting guaranteed optimal
breast shape and texture as well as a natural décolleté.
A study of mammography, CT-scan, and MRI findings
on these patients, conducted at the same time,28 demon­
strated that the impact of lipomodeling on the patient’s
imaging did not result in any significant change in the
follow-up. Breast radiologists were able to note any
difference between normal findings after the procedure
and cancer recurrence. It was thus progressively
extended to other indications of breast reconstruction,
then to the correction of breast deformities, to the treat­
ment of conservative breast surgery sequelae and, more
recently, to breast cosmetic surgery. This evaluation
work had also been a creative work while adapting the
technique to the vast majority of clinical situations of
breast plastic and aesthetic surgery. Lipomodeling has
nowadays dramatically changed indications, technique,
and results of breast aesthetic and reconstructive inter­
ventions. Many original applications of this technique
were described by our team in publications made by our
residents.
Our first presentations at the Société Française de
Chirurgie Plastique et Reconstructrice28 and the Interna­
tional Confederation for Plastic Reconstructive and
Aesthetic Surgery29 raised the 1987 controversy. We
answered point-by-point to every argument until scien­
tific evidences gradually won over the hostility of the
clinical community. Fat grafting has now become a
standard procedure in breast reconstruction7,30,31. Since
then, breast fat grafting has gained significant interest
and indications and is today one of the challenging
topics in plastic surgery. Fat grafting technique has
broadened its indications, and we have been using it for
breast asymmetries and tuberous breasts since 2000 and
for conservative breast treatment sequelae since 2002.
Most important development of the technique in very
safe conditions is the strong collaboration with a breast
radiologist team that has an education and an experi­
ence in pre- and post-lipomodeling evaluation. In this
setting, once a year we lead a specific course for
breast radiologists in Lyon (“Breast imaging and plastic
surgery”).

72
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CHAPTER 5 • Breast augmentation with autologous fat grafting
A
B
C
D
Fig. 5.1  Patient aged 16 years with Poland syndrome. Treatment of the deformity by 4 sessions of lipomodeling (157 mL, 286 mL, 272 mL during the 3rd session right
breast lipomodeling 140 mL, 227 mL) at 3 to 6 months of interval. Result at 24 months after last session. (A) Preoperative view. (B) Preoperative oblique view.
(C) Preoperative oblique view. (D) Postoperative view. (E) Postoperative oblique view. (F) Postoperative oblique view.
E
F

73
Patient presentation
asymmetry and hypoplasia, one or two fat transfer ses­
sions will be needed for an optimal result (Fig. 5.4).
Bilateral breast augmentation
Lipomodeling in aesthetic surgery is developing fast.
Our studies have shown that if lipomodeling is carried
out according to the technique we described in this
chapter, it does not generate any radiological images
with differential diagnosis of breast malignancy or
radiological follow-up problems, for breast imaging
specialized radiologists. It is now accepted as a
standard procedure for moderate or very moderate
augmentation.
The indications of breast augmentation with fat
grafting (lipoaugmentation) differ from those of
implant augmentations. Lipoaugmentation is suitable
for patients looking for a moderate or even very mod­
erate increase of breast volume,35 or who desire to
recover the upper pole fullness they had before weight
loss or pregnancy. The ideal patient is a young woman
with a slim upper body and moderately small breasts,
and with sufficient localized adiposity of the lower
body to allow for one or even two lipomodeling ses­
sions (Fig. 5.5). In this indication, fat harvesting
enhances the lower body contour and can be associ­
ated to standard liposuction to improve final result.
After this procedure, we recommend a strict stability
of patient’s weight. Any change in weight might affect
the breast volume and shape.
Composite breast augmentation
The first application of lipomodeling is primary breast
augmentation in cases where the patient wishes to have
a natural transition between thorax and implant or
in skinny patients where an implant will inevitably
be visible. The technique is the ideal complement to
volume augmentation by implant as it allows for a
perfect shape. Second application is as an option for
correction, in secondary cases, of the imperfections due
to implant augmentation. It enhances the décolleté
area, improves tissue coverage of the implant, espe­
cially in the lower pole, reduces rippling in thin patients,
Fig. 5.2  Patient aged 16 years with severe lateralized pectus excavatum, treated by two lipomodeling sessions of the right breast (320 mL, 500 mL) at 2 years of interval.
Result 1 year after second procedure. (A) Preoperative view. (B) Preoperative oblique view. (C) Postoperative view. (D) Postoperative oblique view.
A
B
C
D

74
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CHAPTER 5 • Breast augmentation with autologous fat grafting
Fig. 5.3  Patient aged 17 years with tuberous breasts, treated by two lipomodeling sessions of the left breast (340 mL, 230 mL) and right lipomodeling (320 mL, 230 mL).
Result 12 months after second procedure. (A) Preoperative view. (B) Preoperative oblique view. (C) Preoperative oblique view. (D) Postoperative view. (E) Postoperative
oblique view. (F) Postoperative oblique view.
A
B
C
D
E
F

75
Patient presentation
for the patient and the surgeon. In rare cases, complica­
tions can occur. In thin patients with smoking habits,
exposure of an implant can result in implant withdrawal.
Large breast reduction can result in fat and skin necrosis
with subsequent breast deformity. Some of these patients
are referred to our clinic for revision and secondary
procedures. We find lipomodeling to be very useful in
these cases. It efficiently enhances tissue thickness and
improves tissue quality.
After implant complications with withdrawal, lipo­
modeling prepares the tissues to render the secondary
augmentation safer. After complicated breast reduc­
tions, fat transfer can restore the suppleness of the breast
while improving the quality of the suffering skin.
These complementary fat grafting procedures have
reduced donor site morbidity while improving breast
sequelae. We find them very useful in the management
of these difficult patients with high expectations and
risk of medico-legal issues for the previous surgeon.
and reduces demarcation of the implant in the upper
pole (Fig. 5.6). We also have a clinical impression that
requires further scientific data, that complementary fat
grafting might improve capsular contractures in mod­
erate cases. In secondary implant changing, we usually
recommend fat transfer with the previous implant in
place. Once all the deformities are corrected, the implant
is replaced, thus avoiding any risk of leaving a punc­
tured implant.
The clinical results obtained with composite augmen­
tation are so interesting that it seems to us that the
technique could be, in the future, the new gold standard
in breast implant augmentation.
Management of severe complications of
breast aesthetic surgery
Breast reduction, breast augmentation, and mastopexy
are commonly performed procedures in breast aesthetic
surgery. The outcomes are most of the time satisfactory
Fig. 5.4  Patient aged 19 years with breast asymmetry. Treatment by one lipomodeling session of the left breast (210 mL). Result at 12 months. (A) Preoperative view.
(B) Preoperative oblique view. (C) Postoperative view. (D) Postoperative oblique view.
A
B
C
D

76
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CHAPTER 5 • Breast augmentation with autologous fat grafting
Fig. 5.5  Patient aged 30 years. Bilateral breast augmentation by one lipomodeling session: left breast (390 mL), right breast (410 mL). Result at 12 months.
(A) Preoperative view. (B) Preoperative oblique view. (C) Postoperative view. (D) Postoperative oblique view.
A
B
C
D
Breast conservative treatment sequelae
Breast conservative treatment is an ideal indication for
lipomodeling. Comprehensive examination of the breast
is mandatory in order to determine which zones are to
be fat grafted in order to obtain symmetry with the
contralateral breast. Fasciotomies are necessary in this
indication to allow for skin expansion under the scar.
However, one has to be aware that irradiated breast is
more prone to skin necrosis and fasciotomies have to be
done sparingly. Patient information is very important in
this setting because one has to exclude the risk of confu­
sion with cancer recurrence and the patient has to be
aware that at least two sessions are mandatory to achieve
good results. The first session aims to enhance skin
vascularization, and the second session allows volume
gain and complete correction of the deformity (Fig. 5.7).
Patient selection
Very careful explanations of the procedure have to
be given to the patients. The possibility of multiple
fat grafting sessions has to be mentioned as well as
strict radiologic surveillance. In aesthetic indications, the
information given to the patient is particularly thorough
and extensive with especially elaborated comprehensive
leaflets provided during preoperative consultations.35,36
We have four different information leaflets: lipomodel­
ing in breast reconstruction, lipomodeling for the
correction of breast conservative treatment sequelae,
lipomodeling for the correction of breast deformities,
and aesthetic breast lipomodeling. The main feared risk
is that a breast cancer may occur coincidentally with
lipomodeling. In order to reduce this risk, imaging inves­
tigation (mammography and ultrasound) is carried out
before lipomodeling by a specialized radiologist in order
to ascertain the absence of any suspicious lesion. If there
is any doubt, lipomodeling is delayed or contraindicated.
The radiologist must give his agreement before the lipo­
modeling procedure and thereby becomes co-responsible
of the follow-up.37–40 The patient gives written consent to
undergo the same investigations by the same radiologist
one year after the procedure. If the radiologist observes
a suspicious lesion on imaging at one year, micro-biopsy
is systematically performed in order to establish a defini­
tive diagnosis. Ultrasound is done under the age of 30,

77
Surgical technique
The various adipose areas of the body are examined
to identify fat deposits to be harvested. Generally, for
reconstruction purposes, abdominal fat is used, as it is
appreciated by the patients and harvesting in this area
does not require a position change from the patient
during the procedure. In breast aesthetic surgery, the
trochanteric region (saddle bags) and the inside of the
thighs and knees are preferred, according to patient
choice. Future harvesting areas are outlined with a skin
marker (Fig. 5.8B).
Anesthesia
Because of the important amounts of harvested fat,
lipomodeling is performed under general anesthesia in
the majority of patients. Conventional prophylactic
antibiotics are usually given perioperatively, as we
usually do in various plastic surgery procedures. No
specific antibiotics are prescribed in the case of lipomod­
eling. Local anesthesia can only be used for minor
revisions to correct any residual defect.
ultrasound and one mammography incidence between
30 and 40 years of age, and mammography and ultra­
sound over 40 years. In case of ACR 3, biopsy has to
downstage the lesion to ACR 1 or 2, otherwise the proce­
dure is contraindicated.
Surgical technique
Preparation
Patients are informed of the operative technique and its
potential risks and complications, and provided with an
information leaflet with an information consent form to
sign. The patient’s weight should be stable at the time
of the procedure, as the transferred fat retains the
memory of its origins (if the patient loses weight after
lipomodeling, she will lose some of the benefits of the
procedure). Areas of the breast that require correction
are identified and marked out on the upright standing
patient (Fig. 5.8A).
Fig. 5.6  Patient aged 47 years. Secondary case: bad result after previous breast implant augmentation. Treatment by composite augmentation: one lipomodeling session on
the left breast (150 mL), right breast (165 mL), and bilateral implant changing during the same procedure. Result at 12 months. (A) Preoperative view. (B) Preoperative
oblique view. (C) Postoperative view. (D) Postoperative oblique view.
A
B
C
D

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CHAPTER 5 • Breast augmentation with autologous fat grafting
Fig. 5.7  Patient aged 58 years with severe breast conservative treatment sequelae and pectus excavatum, treated by two lipomodeling sessions of the left breast (324 mL,
270 mL) and right lipomodeling during the second session (130 mL). Result 12 months after second procedure. (A) Preoperative view. (B) Preoperative oblique view.
(C) Preoperative oblique view. (D) Postoperative view. (E) Postoperative oblique view. (F) Postoperative oblique view.
A
B
C
D
E
F

79
Surgical technique
A
B
C
D
Fig. 5.8  Fat harvesting and preparation. (A) Marking of the recipient site (breast conservative treatment sequelae). (B) Marking of the donor site area. (C) Fat harvest with
the harvesting cannula fitted directly on to the 10 mL Luer Lock syringe. (D) Infiltration with saline and epinephrine solution. (E) Infiltration of the donor site with
ropivacaine. (F) Centrifugation of the syringes in batches of 6.
E
F

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CHAPTER 5 • Breast augmentation with autologous fat grafting
G
H
I
(G) Centrifugation separates the fat into 3 layers. Only the middle layer of purified fat will be retained. (H) The bottom layer (serous fluid) is discarded by
removing the cap. (I) The oily top layer is removed. (J) We prepare many 10 mL syringes containing pure fat.
J
Incisions
In the harvesting areas, incisions are made using a no.
15 blade. For abdominal harvesting, four incisions are
made around the umbilicus, and a lateral incision on
each side when lateral abdominal and supra-iliac fat is
to be harvested. For the thighs, the patient is positioned
in a ventral decubitus and an incision is made in each
subgluteal fold. A complementary incision on the inside
of the knees can be made for fat harvesting of this area.
At the recipient site on the breast, punctiform incisions
are done with an 18 G needle in previous scars when
possible. In order to create a network of transfer tunnels,
at least three incisions are needed, two of which are in
the inframammary fold and one into the areola.
Fat harvesting
Recent studies on fat transfer have contributed to stan­
dardization of the technique of harvesting and injection
and the reduction of any pitfalls at each stage. Meticu­
lous work at each step enhances fat survival in the short,
medium, and long term. A five holes cannula is used for
harvesting. These cannulas have a blunt tip which can
be inserted in a 4 mm incision made with a no. 15 blade.
Harvesting is done with a 10 cc syringe, directly adapted
to the cannula by means of a Luer Lock system (Fig.
5.8C). Subcutaneous infiltration with 500 cc of normal
saline at 9% and 0.5 mg of epinephrine is done (Fig.
5.8D). Suction depression is moderate to minimize
damage to the adipocytes. Too strong mechanical suction
might have a harmful effect on adipocyte survival. Suf­
ficient fat must be harvested to anticipate for the loss
during centrifugation and the expected resorption after
transfer.
If necessary, in order to obtain a perfect result at the
donor sites, harvesting areas are finally smoothed with
conventional liposuction using a 4 mm cannula. A solu­
tion of saline and ropivacaine is then infiltrated in the
Fig. 5.8, cont’d

81
Surgical technique
■ A middle layer of purified fat. This is the useful
part which will be transferred. The other two layers
are discarded, the lower layer simply by removing
the cap (Fig. 5.8H) and the upper layer by pouring
off the oil which covers the middle layer (Fig. 5.8I).
The team must be well organized so that fat preparation
is carried out efficiently and rapidly. Using a three-way
tap, the purified fat is grouped into 10 mL syringes, by
transfer from one syringe to another, in order to obtain
the required number of 10 cc syringes of pure fat (Fig.
5.8J).
Fat transfer
After fat preparation, 10 mL syringes of purified fat are
ready for transfer. Fat is transferred directly to breast
areas with the 10 mL syringes fitted with special dispos­
able transfer cannulas of 2 mm diameter (Fig. 5.9A).
These cannulas are longer and stronger than the ones
donor sites at the end of the harvesting in order to
reduce pain after the procedure (Fig. 5.8E). The cutane­
ous incisions are closed with fine, fast absorbable
sutures.
Fat preparation
During the harvesting process, the assistant prepares
the syringes for centrifugation. They are sealed with a
screw top and centrifuged in batches of six for 20 seconds
at 3200 rpm (Fig. 5.8F).
Centrifugation separates the harvested fat into three
layers (Fig. 5.8G):
■ A layer at the top (oily fluid) containing
chylomicrons and triglycerides resulting from cell
lysis.
■ A lower layer of blood remnants and serum, as well
as the infiltration fluid especially if harvesting was
done under local anesthesia.
Fig. 5.9  Fat transfer. (A) Cannula designed for fat transfer in lipomodeling. (B) Incision in the breast with an 18-gauge trocar. (C) Demonstration of the principle of fat
transfer: fat is transferred while the cannula is gently withdrawn, leaving a fine cylinder of fat resembling spaghetti. (D) Fat transfer into the breast.
A
B
C
D

82
SECTION I
CHAPTER 5 • Breast augmentation with autologous fat grafting
result the day after the procedure when the breast is
already swollen.
Outcomes, prognosis, complications
Based on the first author’s personal experience of 2500
procedures of reconstructive and aesthetic breast surgery,
and with a 17-year follow-up for the first patients, reli­
able indications on long-term follow-up can be given.
Long-term clinical follow-up
All patients were clinically followed up and seen in
consultation after 15 days, 3 months, and 1 year. Photo­
graphs were taken at each visit. A detailed follow-up
protocol aimed to assess the quality of the result from
the patient’s and the surgeon’s viewpoint, patient satis­
faction, and any adverse effects or complications.
Results were considered very good or good in the
majority of cases. Very few results were considered as
moderately good and none as poor. As a matter of fact,
if the result is insufficient, an extra lipomodeling session
can be planned until optimal results are achieved. The
percentage of good or very good results depends on the
subpopulation studied in relation to the indication.
Long-term radiological follow-up
In 1998, when we developed this theme of research, the
main fear concerning fat transfer in the breast was the
risk that it would compromise imaging investigations.
This fear had in fact led to the controversy of 1987 and
its consequences, which we mentioned in the history
part of this chapter. For this reason, we undertook to
analyze the effect of fat transfer on breast imaging. We
carried out three studies with imaging of breasts recon­
structed by autologous latissimus dorsi flap and lipo­
modeling (mammography, ultrasound, MRI),20 imaging
of conserved breasts after lipomodeling (mammogra­
phy, ultrasound, MRI),30 and imaging of breasts with
defects corrected by lipomodeling (asymmetry, tuber­
ous breasts, Poland syndrome).
Our findings showed that if lipomodeling was carried
out according to modern and standardized principles,
it does not hinder correct breast imaging and follow up.
It is noteworthy that all the procedures were per­
formed in a surgical team that has completed its learning
curve and with specialized radiologists who are familiar
with images potentially induced by fat transfer. These
conditions are of fundamental importance to allow the
use of fat transfer in aesthetic surgery. Imaging in
the majority of reconstructed breasts was normal, with
some images of oily cysts and fat necrosis. All the
images observed were in favor of benign lesions easily
used for facial fat grafting procedures because the recipi­
ent tissue is firmer and more fibrous. Incisions are made
using an 18G trocar (Fig. 5.9B). This makes an adequate
incision while limiting scarring. Several incisions are
made in order to create a honeycomb of multiple micro­
tunnels for fat transfer. Fat is grafted in small amounts,
in the form of fine cylinders resembling spaghetti (Fig.
5.9C). Microtunnels must be created in many directions.
Transfer is done from the deep to the superficial layer.
Good spatial visualization is necessary to form a three-
dimensional matrix and to avoid areas of fatty collections
that would lead to fat necrosis. Each microtunnel must
be designed to be surrounded by well-vascularized
tissue (Fig. 5.9D). Fat is transferred under light pressure
while gently withdrawing the cannula. It is necessary
to overestimate the quantity of fat to be transferred
when possible, anticipating the 20–30% expected fat
resorption.
When the recipient tissues are saturated and cannot
absorb further fat, it is useless to persist because of the
risk of inducing areas of fat necrosis. Over-saturation of
the recipient site with fat grafting must be avoided.
Planning a supplementary session in a few months is
preferred and leads to more steady results. Sutures are
placed using very fine, fast absorbable suture material,
and the breast is covered with an ordinary dry dressing
for a few days.
Postoperative care
Harvesting sites
Pain in the harvested areas is the same as for standard
liposuction procedures. Patients complain of moderate
pain for 48 hours and can be treated with level 1 anal­
gesics. We use an infiltration of diluted ropivacaine at
the end of harvesting to control pain in these sites during
the first 24 hours. At the end of the procedure, a com­
pressive and elastic dressing is left in place for five days.
Level 1 analgesics are prescribed for two weeks.
Bruising is very important and persists for three
weeks. Postoperative edema resolves totally or almost
totally in three months. To hasten resorption, we ask
patients to massage their harvesting areas in a circular
motion.
Breast
Bruising resolves in two weeks. Edema resulting from
the procedure resolves in one month. During the first
three postoperative months, 20–30% of the added
volume is gradually lost. But because of the initial
edema, the patient may have the impression that she
has lost about 50% of her breast volume, as she sees the

83
Outcomes, prognosis, complications
scars in a harvesting site. We had one case of irregularity
in the supra-iliac region that required secondary correc­
tion by lipomodeling. The majority of patients are satis­
fied with the improvement of the donor sites. This
secondary benefit probably contributes to the very high
rate of satisfaction of the technique.25 Irregularities at
the donor sites may be due to uneven harvesting of the
fat grafts, so harvesting is sometimes completed by
standard liposuction to further improve the result and
for greater patient satisfaction.
It is essential that this procedure should be carried
out by experienced plastic surgeons who have com­
pleted their learning curve, as previous experience of
cosmetic liposuction is valuable in these circumstances
in order to limit the risk of complication and to give the
patient the best possible cosmetic result. Local infection
occurred in only one of the 2500. This was seen as
redness around the umbilicus and was treated without
difficulty by antibiotics and local application of ice, with
no long-term consequences.
On the breasts, scars must be located in the submam­
mary fold or in its axillary prolongation, or in the areolar
region where scars are always of good quality. The
presternal area should be avoided as there is increased
risk of hypertrophic scarring, presenting as small red
hypertrophic punctate scars. Incisions are usually invis­
ible, since they are made with a trocar; they only measure
1.5 mm. Twelve infections occurred at the recipient site
among the 2500 lipomodeling procedures of the breast
and chest wall. They presented as redness of the breast.
The suture at the recipient site was removed. An effu­
sion of fat and pus was evacuated. Topical treatment,
antibiotics, and the application of ice completely
resolved the problem with no impact on the final result.
It should be noted that we had one case of intraoperative
pneumothorax (1 case in 2500 procedures), probably
due to the transfer cannula piercing the pleura. Pneu­
mothorax was revealed by oxygen desaturation during
the procedure. A pleural drain was set, and oxygen satu­
ration returned to normal with total recovery and no
later consequences. To avoid this complication, projec­
tion of the areolar region should be improved via two
incisions in the submammary fold, and not via the
areolar region itself. We have had no case of fat embo­
lism. There is a potential risk if fat is injected in a large
vessel. Extreme caution is then mandatory in the sub­
clavian area, in particular in the breast and chest wall
deformities of Poland syndrome where subclavian
vessels may lie lower than in normal anatomy. In 3% of
cases, we observed focal clinical fat necrosis. The risk is
higher during the surgeon’s early experience (15% in
the first 50 cases). In these cases, fat necrosis occurred
in overtreated areas. When the recipient tissue is
distinguished from suspicious ones. Abnormal images
were essentially oily cysts, occurring in 10–15% of cases.
The most complex situation concerned lipomodeling
for the sequelae of conservative treatment. In this popu­
lation, the fat necrosis aspect already develops in about
20% of patients following conservative partial mastec­
tomy. Lipomodeling doubles this occurrence. It gener­
ates mainly oily cysts but sometimes more complex
lesions of fat necrosis. Due to the spontaneous local car­
cinoma recurrence rate of about 1.5% per year, follow-up
must be rigorous. We believe that this indication should
be restricted to multidisciplinary teams working with
radiologists who have perfect mastery of the subject.
Long-term oncological follow-up
Seventeen years of oncological follow-up have not
revealed an increased risk of local recurrence after mas­
tectomy or after conservative treatment. Further studies
are needed to assess if, due to strict radiologic sur­
veillance, the recurrence rate is even lower or any
malignancy sooner discovered by these patients.
Clinical evaluation
The success rate is easy to evaluate by clinical examina­
tion, patient opinion, and comparison of the photographs
taken at each consultation with earlier photographs.
Twenty to 30% of the volume obtained with fat transfer
is gradually lost. Volume is stable after 3 to 4 months
and remains so if the patient maintains a steady weight.
If the fat harvested is very oily, resorption may be higher,
up to 40–50%, and may continue over a longer period
of 5 to 6 months. If the patient loses weight, the volume
of the transferred fat decreases and the result is a smaller
breast with possible asymmetry. Therefore, it is impor­
tant for the patient to understand that she must maintain
a stable weight. Inversely, if she gains weight, breast
volume increases. Very long-term evaluation (more than
10 years) confirms that volume remains stable. If breast
asymmetry appears after weight loss or gain (for
example after discontinuation of anti-hormonal treat­
ments in adjuvant therapy of breast cancer), a comple­
mentary lipomodeling session can easily be performed
at a later date. The technique can also be used in the
other breast if asymmetry develops over time. This
technique therefore offers flexibility and precision for
long-term revision that is well appreciated by the
patients.
Complications
At the harvesting sites, scars must be concealed as much
as possible, generally in a fold or in the peri-umbilical
region. No patients have complained of unaesthetic

84
SECTION I
CHAPTER 5 • Breast augmentation with autologous fat grafting
the inframammary fold, we use a technique derived
from our reconstructive experience in cases of latissimus
dorsi with a low situated inframammary fold. We locate
the desired level of the inframammary fold and mark it
with a horizontal line on the midclavicular line. We
draw a horizontal ellipse under this desired inframam­
mary fold (5–6 cm width, and 2–3 cm height). The
ellipse is de-epithelialized and the upper border of the
ellipse is incised with the cautery to the thoracic wall.
Then the de-epithelialized flap is kept attached to the
thoracic skin while undermining in the deep plane for
5 to 6 cm. This de-epithelialized flap is pulled up under
the breast and fixed to the thoracic wall with no. 1 Vicryl
sutures at the predefined position of the inframammary
fold. The lower pole of the breast is undermined at the
level of the pectoralis muscle, and then rolled to define
the lower pole contour and sutured to the fixed infra­
mammary fold. The main drawback of this technique is
the resulting scar that is 6 cm long but most of the time
hidden in the inframammary fold. The main advantage
is the enhancement and efficient correction of the infra­
mammary fold. In rare cases when this technique is
associated to aesthetic lipomodeling augmentation of
the breast, we start by fixating the inframammary fold
then we do the fat transfer.
Fasciotomies
While transferring fat to the breasts, the plastic surgeon
is often faced with fibrous strings or adhesion areas
making the lipomodeling procedure difficult. The
inferomedial area in tuberous breasts is the typical
illustration. We developed the fasciotomy technique
and had it published by one of our residents.41,42 We
recommend in these cases the use of an 18G trocard’s
tip to selectively rupture these strings and adhesions
under local tension held on the skin by a double hook
(Fig. 5.10A–C). Fasciotomies have to be done in different
levels in order to obtain a mesh of fibrous tissue to allow
for a full expansion of the skin envelope.41,42 After mesh
creation, a new moderate fat transfer is done to fill the
newly created holes. Care must be taken not to under­
mine the area because fat grafting will not take if not in
proper contact with the recipient site. Great care must
also be taken, especially in young patients, not to do
fasciotomies in the presternal region in order to avoid
the formation of hypertrophic scars. Fasciotomies are a
very powerful means to modify the shape of the breast
and irregularities.
Thumb blocking technique
In order to lower the inframammary fold and to fix
it in the right position, this maneuver is of utmost
saturated with fat, the surgeon should not persist, as
areas of fat necrosis may develop. Clinical signs of fat
necrosis are typical: tender nodule, slightly sensitive but
stable over time, then gradually decreasing. Any
increase in size of a hard swelling, even in a recon­
structed breast, should undergo micro-biopsy by a
radiologist in order to rule out a malignant change.
Fat necrosis nodules are mainly seen in the early
stages of the surgeons’ learning curve and decrease as
the experience increases, if they respect the principle of
the 3D network and avoid fat oversaturation of the
recipient site.
Secondary procedures
Multiple fat grafting sessions
As previously stated, another fat grafting session can be
planned if the result is unsatisfactory. Ease of recovery
and improvement of donor sites are strong positive
arguments for the patient. Some associated procedures
can also be done to enhance the results.
Liposuction of the inframammary area
In patients with a bulky inframammary area anterior to
the inferior ribs, we perform a heavy liposuction (7–8 cm
under the inframammary fold). This liposuction seems
to enhance breast projection. It also enhances the infra­
mammary fold definition while giving the impression
of a complementary breast augmentation.
We use this tip in the setting of major breast reduction
in overweight patients to improve the definition of the
breast. It can also be used in tuberous breasts if possible
and in exclusive lipomodeling breast augmentation to
improve the final outcome.
The technique consists of a heavy liposuction, going
from the deep to the superficial layers of the skin in the
predefined area while insisting on the restoration of the
inverted V resulting from the junction of the two inframa­
mmary folds and the intermammary valley. Because
liposuction of this area is painful, we systematically infil­
trate diluted ropivacaine at the end of the procedure.
Inframammary fold definition
In some cases of breast aesthetic surgery, the inframam­
mary fold is ill defined or has been damaged by previous
surgery. The wearing of a push-up bra enhances
the fullness of the upper pole by displacing the
mammary gland to the upper region while removing
the necessary gland to define the inframammary fold
from the lower pole. We consider the inframammary
fold as the foundation of the breast. To create or recreate

85
Secondary procedures
C
D
E
A
B
Fig. 5.10  Complementary procedures. (A) The “fasciotomies”. (B) Complement of
lipomodeling after fasciotomies. (C) Immediate result at the end of the procedure.
(D) The “thumb blocking technique”. (E) The “thumb blocking technique”: the
cannula is blocked by the upper part of the thumb.

86
SECTION I
CHAPTER 5 • Breast augmentation with autologous fat grafting
1. Illouz YG. Body Sculpting by Lipoplasty. Churchill Livingstone;
1989:504. First comprehensive description of liposuction technique,
representing a major step toward silhouette remodeling.
13. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg.
1997;24:347–367. Description of lipostructure technique allowing for
long-term survival of fat grafting. This article was the new starting point
of the fat grafting technique.
16. Delay E. Lipomodeling of the reconstructed breast. In: Spear SE, ed.
Surgery of the Breast: Principles and Art. 2nd ed. Philadelphia:
Lippincott Williams and Wilkins; 2006:930–946. A comprehensive
chapter describing fat grafting technique and an important single operator
series.
20. Pierrefeu-Lagrange AC, Delay E, Guerin N, et al. Radiological
evaluation of breasts reconstructed with lipomodeling [Article in
French]. Ann Chir Plast Esthet. 2006;51:18–28. This article reports a
large series of follow-up patients after breast lipomodeling. Its conclusions
show that breast lipomodeling does not hinder radiologic surveillance.
31. Delay E, Sinna R, Chekaroua K, et al. Lipomodeling of Poland’s
syndrome: a new treatment of the thoracic deformity. Aesthetic Plast
Surg. 2010;34:218–225. Description of the technique in the setting of
thoracic deformity. The article shows the method and gives precise
information and preoperative evaluation to safely realize the procedure.
34. Delay E, Sinna R, Ho Quoc C. Tuberous breast correction by fat
grafting. Aesthet Surg J. 2013;33:522–528. Article showing the
evaluation and planning of fat grafting to correct tuberous breast
deformity.
35. Delay E, Sinna R, Delaporte T, et al. Patient information before
aesthetic lipomodeling (lipoaugmentation): a French plastic
surgeon’s perspective. Aesthet Surg J. 2009;29:386–395. Precise
information given to the patient before undergoing breast
lipoaugmentation. Might help plastic surgeons in writing their proper
informed consent before the procedure.
36. Delay E, Garson S, Tousssoun G, Sinna R. Fat injection to the breast:
technique, results and indications based on 880 procedures over 10
years. Aesthet Surg J. 2009;29:360–376. A single operator large
retrospective study of fat injection to the breast in its different indications:
reconstructive and aesthetic. Discussion of the techniques and its
combination, the expected results, and the necessary follow-up of the
patients.
40. Veber M, Tourasse C, Toussoun G, et al. Radiographic findings after
breast augmentation by autologous fat transfer. Plast Reconstr Surg.
2011;127:1289–1299. A thorough description of the radiological imaging
of breasts treated with fat grafting with typical benign calcifications and
cysts. Any doubt on the images must be solved with complementary
documentation, namely biopsy.
41. Ho Quoc C, Sinna R, Gourari A, et al. Percutaneous fasciotomies
and fat grafting: indications for breast surgery. Aesthet Surg J.
2013;33:995–1001. Percutaneous fasciotomies are very important to
enhance breast shape while performing fat grafting. Its indications and
realization are described in this article.
Access the complete references list online at

importance. The surgeon has to open the first commis­
sure of his hand at the exact place of the inframammary
fold for the thumb and intermammary valley for the
index. We call this technique the “thumb blocking tech­
nique” (TBT). Fat is then transferred with the tip of
cannula coming up against the thumb or index finger
(Fig. 5.10D,E). This technique will fix the boundaries of
the breast while transferring fat only into the chosen
breast base.
Conclusion
Lipomodeling is a huge step in plastic, reconstructive,
and aesthetic surgery of the breast and represents one
of the main surgical advances of the last twenty years.
In the setting of breast asymmetries and malforma­
tions, lipomodeling represents the ideal technique.
Nowadays, it seems not desirable to treat an asymmetry
by unilateral implant positioning. The vast majority of
breast asymmetries should be treated by lipomodeling
alone. Symmetry is then noteworthy and definitive if
the patient stays weight stable. Application of lipomod­
eling to other thoraco-mammary malformations is now
well described. In Poland syndrome, lipomodeling is a
significant contribution and allows for a reconstruction
of an unprecedented quality at the expense of interven­
tions, with simple follow-ups and very little scar burden.
Lipomodeling is also indicated to correct thoraco-
mammary deformations of numerous unilateral and
symmetric pectus excavatum. Fat grafting is a new
therapeutic alternative for tuberous breasts correction,
without implant, of associated breast asymmetries,
especially when hypotrophy is unilateral. The technique
can also be used for breast augmentation when desired
augmentation is moderate. Our work has shown that
radiologic breast surveillance can be safely performed
after lipomodeling. Lastly, fat grafting has drastically
changed the correction of breast conservative treatment
corrections. The procedure can restore perfect symmetry
in two sessions without the need of an implant or a flap.

86.e1
References
References
1. Illouz YG. Body Sculpting by Lipoplasty. Churchill Livingstone;
1989:504. First comprehensive description of liposuction technique,
representing a major step toward silhouette remodeling.
2. Fournier PF. The breast fill. In: Fournier PF, ed. Liposculpture: The
Syringe Technique. Paris: Arnette Blackwell; 1991:357–367.
3. Bircoll M. Cosmetic breast augmentation utilizing autologous fat
and liposuction techniques. Plast Reconstr Surg. 1987;79:267–271.
4. Bircoll M, Novack BH. Autologous fat transplantation employing
liposuction techniques. Ann Plast Surg. 1987;18:327–329.
5. Hartrampf CR Jr, Bennett GK. Autologous fat from liposuction for
breast augmentation (letter to the editor). Plast Reconstr Surg.
1987;80:646.
6. Ettelson CD. Fat autografting (letter to the editor). Plast Reconstr
Surg. 1987;80:646.
7. Linder RM. Fat autografting (letter to the editor). Plast Reconstr
Surg. 1987;80:646.
8. Oustehout DK. Breast augmentation by autologous fat injection
(letter to the editor). Plast Reconstr Surg. 1987;80:868.
9. Bircoll M. Reply (correspondence). Plast Reconstr Surg. 1987;80:647.
10. Bircoll M. Autologous fat transplantation to the breast. Plast
Reconstr Surg. 1988;82:361–362.
11. Brown FE, Sargent SK, Cohen SR, Morain WD. Mammographic
changes following reduction mammaplasty. Plast Reconstr Surg.
1987;80:691–698.
12. Coleman SR. Long-term survival of fat transplants: controlled
demonstrations. Aesthetic Plast Surg. 1995;19:421–425.
13. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg.
1997;24:347–367. Description of lipostructure technique allowing for
long-term survival of fat grafting. This article was the new starting point
of the fat grafting technique.
14. Sinna R, Delay E, Garson S, Mojallal A. Scientific bases of fat
transfer. Critical review of the literature [Article in French]. Ann
Chir Plast Esthet. 2006;51:223–230.
15. Delay E, Delaporte T, Sinna R. Breast implant alternatives [Article
in French.]. Ann Chir Plast Esthet. 2005;50:652–672.
16. Delay E. Lipomodeling of the reconstructed breast. In: Spear SE, ed.
Surgery of the Breast: Principles and Art. 2nd ed. Philadelphia:
Lippincott Williams and Wilkins; 2006:930–946. A comprehensive
chapter describing fat grafting technique and an important single operator
series.
17. Delay E, Gounot N, Bouillot A, et al. Breast reconstruction with the
autologous latissimus dorsi flap. Preliminary report of 60
consecutive reconstructions [Article in French]. Ann Chir Plast
Esthet. 1997;42:118–130.
18. Delay E, Gounot N, Bouillot A, et al. Autologous latissimus breast
reconstruction. A 3-year clinical experience with 100 patients. Plast
Reconstr Surg. 1998;102:1461–1478.
19. Delay E. Breast reconstruction with an autologous latissimus flap
with and without immediate nipple reconstruction. In: Spear SE,
ed. Surgery of the Breast: Principles and Art. 2nd ed. Philadelphia:
Lippincott Williams and Wilkins; 2006:631–655.
20. Pierrefeu-Lagrange AC, Delay E, Guerin N, et al. Radiological
evaluation of breasts reconstructed with lipomodeling [Article in
French]. Ann Chir Plast Esthet. 2006;51:18–28. This article reports a
large series of follow-up patients after breast lipomodeling. Its conclusions
show that breast lipomodeling does not hinder radiologic surveillance.
21. Delay E, Delaporte T, Jorquera F, et al. Lipomodelage du sein
reconstruit par lambeau de grand dorsal sans prothèse. 46th
Congress of the Société Française de Chirurgie Plastique, Esthétique et
Reconstructrice. Paris, 17–19 October 2001.
22. Delay E, Chekaroua K, Mojallal A, Garson S. Lipomodeling of the
autologous latissimus reconstructed breast. 13th International
Congress of the International Confederation for Plastic
Reconstructive and Aesthetic Surgery. Sydney, 10–15 August 2003.
ANZ J Surg. 2003;73:A170.
23. Delay E. Breast deformities. In: Coleman SR, Mazzola RF, eds. Fat
Injection: From Filling to Regeneration. St Louis: Quality Medical
Publishing; 2009:545–586.
24. Delay E, Moutran M. Fat grafting to the breast. In: Nahai F, ed. The
Art of Aesthetic Surgery, Principles and Techniques. 2nd ed. St Louis:
Quality Medical Publishing; 2011:2279–2307.
25. Delay E, Gosset J, Toussoun G, et al. Efficacy of lipomodelling for
the management of sequelae of breast cancer conservative treatment
[Article in French]. Ann Chir Plast Esthet. 2008;53:153–168.
26. Delay E, Delpierre J, Sinna R, Chekaroua K. How to improve breast
implant reconstructions? [Article in French]. Ann Chir Plast Esthet.
2005;50:582–594.
27. Sinna R, Garson S, Delay E. Three-dimensional imaging. Ann Plast
Surg. 2005;55:696–697.
28. Garson S, Delay E, Sinna R, et al. 3D evaluation and breast plastic
surgery: preliminary study [Article in French]. Ann Chir Plast Esthet.
2005;50:296–308.
29. Garson S, Delay E, Sinna R, et al. 3D evaluation and mammary
augmentation surgery [Article in French]. Ann Chir Plast Esthet.
2005;50:643–651.
30. Gosset J, Guerin N, Toussoun G, et al. Radiological evaluation after
lipomodelling for correction of breast conservative treatment
sequelae [Article in French]. Ann Chir Plast Esthet. 2008;53:178–189.
31. Delay E, Sinna R, Chekaroua K, et al. Lipomodeling of Poland’s
syndrome: a new treatment of the thoracic deformity. Aesthetic Plast
Surg. 2010;34:218–225. Description of the technique in the setting of
thoracic deformity. The article shows the method and gives precise
information and preoperative evaluation to safely realize the procedure.
32. La Marca S, Delay E, Toussoun G, et al. Treatment of Poland
syndrome thorax deformity with the lipomodeling technique: about
ten cases [Article in French]. Ann Chir Plast Esthet. 2013;58:60–68.
33. Ho Quoc C, Delaporte T, Meruta A, et al. Breast asymmetry and
pectus excavatum improvement with fat grafting. Aesthet Surg J.
2013;33:822–829.
34. Delay E, Sinna R, Ho Quoc C. Tuberous breast correction by fat
grafting. Aesthet Surg J. 2013;33:522–528. Article showing the
evaluation and planning of fat grafting to correct tuberous breast
deformity.
35. Delay E, Sinna R, Delaporte T, et al. Patient information before
aesthetic lipomodeling (lipoaugmentation): a French plastic
surgeon’s perspective. Aesthet Surg J. 2009;29:386–395. Precise
information given to the patient before undergoing breast
lipoaugmentation. Might help plastic surgeons in writing their proper
informed consent before the procedure.
36. Delay E, Garson S, Tousssoun G, Sinna R. Fat injection to the breast:
technique, results and indications based on 880 procedures over 10
years. Aesthet Surg J. 2009;29:360–376. A single operator large
retrospective study of fat injection to the breast in its different indications:
reconstructive and aesthetic. Discussion of the techniques and its
combination, the expected results, and the necessary follow-up of the
patients.
37. Gosset J, Flageul G, Toussoun G, et al. Lipomodelling for correction
of breast conservative treatment sequelae. Medicolegal aspects.
Expert opinion on five problematic clinical cases [Article in French].
Ann Chir Plast Esthet. 2008;53:190–198.
38. Delay E. Correction of partial breast deformities with the
lipomodeling technique. In: Kuerer H, ed. Kuerer’s Breast Surgical
Oncology. New York: McGraw-Hill; 2010:815–825.
39. Delay E, Gosset J, Toussoun G, et al. Post-treatment sequelae after
breast cancer conservative surgery [Article in French]. Ann Chir
Plast Esthet. 2008;53:135–152.
40. Veber M, Tourasse C, Toussoun G, et al. Radiographic findings after
breast augmentation by autologous fat transfer. Plast Reconstr Surg.
2011;127:1289–1299. A thorough description of the radiological imaging
of breasts treated with fat grafting with typical benign calcifications and
cysts. Any doubt on the images must be solved with complementary
documentation, namely biopsy.
41. Ho Quoc C, Sinna R, Gourari A, et al. Percutaneous fasciotomies
and fat grafting: indications for breast surgery. Aesthet Surg J.
2013;33:995–1001. Percutaneous fasciotomies are very important to
enhance breast shape while performing fat grafting. Its indications and
realization are described in this article.
42. Ho Quoc C, Michel G, Dlimi C, et al. Percutaneous fasciotomies to
improve fat grafting into the breast [Article in French]. Ann Chir
Plast Esthet. 2014;59:130–135.

SECTION I • Aesthetic Breast Surgery
6 
Mastopexy options and techniques
Robert Cohen
SYNOPSIS
■ Breast ptosis presents in many forms and can be congenital in nature,
or acquired due to causes such as aging, weight changes, and
pregnancy.
■ Patients with ptosis generally desire the same result – youthful and
“perky” breasts. However, due to wide variations in breast volume and
tissue quality, ultimate results vary with each patient, and as a result,
preoperative management of expectations is critical.
■ There are many surgical options that can be customized to patients’
needs, but these generally address repositioning of the glandular tissue
and nipple areolar complex and management of skin excess.
■ Scar patterns include circumareolar, circumvertical (including J or L
scar variations), and inverted-T patterns. Pedicles can be designed
from all directions and are independent of the scar pattern.
■ Ancillary procedures such as fat grafting, small volume tissue removal
(direct or with liposuction), and mesh placement can be used to
further improve aesthetic results.
■ Complications can occur but can be minimized with careful patient
selection, preoperative planning, and execution of surgery.
Introduction
Breast ptosis is one of the more common issues seen in
plastic surgeons’ offices, particularly those performing
a significant amount of aesthetic breast surgery.
Although ptotic breasts can be developmental and occur
during breast growth at puberty, the image of drooping
breasts elicits a sense of aging and loss of femininity for
most patients. Beautifully shaped, “perky” breasts –
regardless of size – are a symbol of youth and sexuality,
and the lack of this trait can cause insecurity and self-
esteem issues for many women.
It is important to keep the concept of ptosis sepa­
rate from the issue of volume. Women can experience
ptosis with breasts that (1) have volume deficiency;
(2) have ideal volume for their personal sense of
proportion; or (3) have volume excess as in the case
of symptomatic macromastia. In the cases of volume
deficiency, augmentation mastopexy is generally the
best option, while in situations of symptomatic mac­
romastia, breast reduction surgery offers the definitive
correction.
The concept of augmentation mastopexy and breast
reduction is addressed in other chapters, so this discus­
sion will focus on the relatively narrow spectrum of
women who have a relatively appropriate amount of
breast volume, but are lacking the shape and position
associated with a youthful and aesthetic breast. In these
women, the primary treatment is rearrangement of the
breast parenchyma combined with skin excision and
re-draping. Possible small volume addition (via fat
grafting) or small volume reduction (via direct tissue
resection and/or liposuction) will also be discussed
within the context of creating the best possible final
breast shape and correcting preoperative asymmetry in
women who otherwise have adequate volume. Aug­
mentation mastopexy is only discussed in this chapter
as it relates to correction ptosis due to tuberous breasts.
The focus of this chapter is on a practical overview of
managing the patient who presents with breast ptosis
(as opposed to breast volume issues) as the primary
driver for surgery. This will include understanding the
pathophysiology of ptosis, assessing the multiple varia­
tions of ptosis (including tuberous breasts), managing
patient expectations based on their anatomic limitations,
understanding and applying the appropriate surgical
techniques, and preventing and/or managing possible
  Access video and video lecture content for this chapter online at expertconsult.com

88
SECTION I
CHAPTER 6 • Mastopexy options and techniques
direct reshaping with sutures can be ineffective. As
some degree of natural upper pole fullness is critical in
creating a youthful and “perky” breast, patients with
low density breasts should be advised of these ana­
tomic issues before surgery and may need to consider
upper pole volume augmentation with implants or fat
grafting.
Breast glandular tissue, like breast fat, can vary widely
in density and quality. Generally speaking, glandular
tissue is firmer than fat and has more potential for
reshaping and maintaining its shape over time. Masto­
pexy patients with a high proportion of dense glandular
tissue can sometimes achieve a result that is comparable
in appearance to an augmentation mastopexy. On the
other extreme of the spectrum, it is also important to
assess patients for fibrocystic changes, as these tissues
can be more difficult to work with and can, in severe
complications. All patient photographs in this chapter
are presented from the author’s personal cases.
Breast tissue assessment
When assessing ptotic breasts, multiple tissue categories
need to be evaluated and addressed. Thinking of the
breast from superficial to deeper tissues, the surgeon
must assess the skin thickness and elasticity; the thick­
ness and relative proportion of subcutaneous fat; the
density and consistency of breast parenchyma; the state
of Cooper’s ligaments; the prominence of the pectoralis
major muscle and other chest wall musculature; and the
nature of the bony base of the chest, including the
sternum and ribcage. All of these tissue layers interact
to create the final breast appearance, and each compo­
nent and their interactions with one another must be
assessed in order to provide each patient with the best
surgical plan (Fig. 6.1).
The skin envelope can vary dramatically between
patients. On one end of the spectrum are patients with
thick, elastic skin with no evidence of striae. This skin
type would more typically be seen in younger patients
with developmental ptosis. On the other end of the
spectrum are patients with thin skin, severe striae, and
minimal elasticity; more commonly seen in multiparous
patients and those who have undergone massive weight
fluctuations. Loss of skin thickness and elasticity can
be a significant contributor to breast ptosis. While the
skin is only one part of what will ultimately support
the results of a mastopexy, the thicker and more elastic
the skin, the more favorable the ultimate outcome will
be. This is something that must be addressed with
patients preoperatively in order to manage expectations
appropriately.
The amount and relative proportion of subcutaneous
breast fat can vary dramatically between patients, and
density of fat can also vary. These variables can have a
significant impact on the ultimate result. In general,
higher density of the soft tissues allows for a greater
degree of control when reshaping the breast mound, as
the tissues are less susceptible to gravitational distor­
tion. A layer of fat padding under the skin can be very
helpful in creating a smooth and natural final result, and
can camouflage pre-existing irregularities in breast
tissue, particularly in the case of fibrocystic breasts.
In many patients with a very high percentage of fat
in the breasts (particularly soft, low density fat), it can
be very difficult to maintain upper pole fullness, as the
fat will tend to settle with gravity to the lower pole of
the breast, creating a volume depleted or “scooped out”
appearance of the upper breast. Additionally, softer fat
has few fibrous elements that will hold a suture, so
Fig. 6.1  Profile anatomic view of the hemisected human breast. The ligaments
described by Sir Astley Cooper are clearly demonstrated to run from the posterior,
or deep, breast fascia, which is intimately associated with the pectoralis major
muscle fascia, to the anterior, or superficial, breast fascia, and insert into the
dermis. The parenchyma, which is encapsulated within these fascial borders,
changes with aging, implants, weight changes, and pregnancy. These types of
parenchymal changes result in alterations to the integrity of Cooper’s ligaments, the
breast’s fascial components, and the overlying skin and fat.
Rib 2
Pectoralis
major
Pectoralis
minor
Deep fascia
Second superficial branch
internal mammary artery
Fifth superficial branch
internal mammary artery
Cooper’s
ligaments
Duct
Gland
Internal intercostal
External intercostal
Fourth deep
branches of
mammary vein
and artery
Würinger’s septum

89
Pathophysiology and classification of breast ptosis
to the breasts, as well as women who rarely use bras or
engage in frequent high impact exercise can accumulate
more damage to the soft tissues of their breasts.
Once detailed tissue analysis of the breast tissues is
completed by the surgeon, a classification of the type
and degree of breast ptosis can be helpful in determin­
ing the best surgical course. Articles by Regnault and
Brink help to divide ptotic breasts into predictable cat­
egories. Regnault1 created the classification of breast
ptosis used by most plastic surgeons today. His system
is predicated on the relationship of the nipple to the
inframammary fold (IMF). In mild, or Grade I ptosis,
the nipple is situated within 1 cm of the inframammary
fold and is above the lower pole of the breast. In moder­
ate, or Grade II ptosis, the nipple is 1–3 cm below the
inframammary fold but is still located above the lowest
point of the breast. In severe, or grade III ptosis, the
nipple is more than 3 cm below the inframammary fold
and is situated at the lowest part of the breast (Fig. 6.2).
Brink2 further included the categories of glandular
ptosis, pseudoptosis, and parenchymal misdistribution
(Table 6.1 & Fig. 6.3). Glandular ptosis is a specific varia­
tion of ptosis where the nipple remains situated above
the lower pole of the breast, but the glandular tissue and
nipple areolar complex begin to settle below the infra­
mammary fold, creating a ptotic appearance. Pseudo­
ptosis also involves glandular tissue descending below
the inframammary fold; however, in this case, the nipple
stays in a fixed position, leading to a progressively
Fig. 6.2  Breast ptosis classification as described by Regnault. (A) Minimal ptosis:
the nipple is at the level of, or just inferior to, the inframammary crease.
(B) Moderate ptosis: the nipple is 1–3 cm below the inframammary crease.
(C) Severe ptosis: the nipple is >3 cm below the inframammary crease. (Redrawn
from: Georgiade GS, Georgiade NG, Riefkohl R. Esthetic breast surgery. In: McCarthy
JG, ed. Plastic Surgery. Philadelphia: WB Saunders; 1991:3839.)
A
B
C
cases, result in irregular or “lumpy” appearing breasts
if there is insufficient fat coverage to hide these
irregularities.
Cooper’s ligaments were discovered by Sir Astley
Cooper and are ligaments that originate from the pec­
toralis fascia and penetrate through the breast paren­
chyma to the dermal layer. These ligaments can be very
helpful in supporting the breasts in a youthful position.
With time, gravity, changes from childbearing, and
weight fluctuations, these ligaments can become attenu­
ated and the breast as a whole can descend on the
patient’s chest. Although not much can be done directly
by the surgeon to improve the strength of Cooper’s liga­
ments, this discussion can further help patients under­
stand why their breasts have changed over time and
what the limitations of surgery are relative to these
changes.
The size and shape of the pectoralis major muscles
and bony architecture of the ribcage and sternum are
not part of the breast anatomy per se, but these structures
do have an indirect impact on the breast appearance and
position. Ribcage asymmetry can affect breast projection
and symmetry. The presence of a pectus excavatum or
pectus carinatum can also impact the appearance of the
intermammary region and affects the likelihood of
medial or lateral migration of breast tissue, particularly
in the supine position. Once again, these bony and
muscular anatomic features are difficult to adjust
without more aggressive surgery such as sternal remod­
eling; however, pointing these features out to patients
preoperatively can be very helpful in managing patient’s
ultimate expectations.
Pathophysiology and classification of
breast ptosis
As partially addressed in the above section on breast
tissue considerations, there are multiple factors which
can affect breast ptosis. In certain cases, ptosis of the
breasts can be developmental due to naturally poor skin
elasticity and weak Cooper’s ligaments, often in con­
junction with heavier, denser breast tissue. This can be
further exacerbated in patients with naturally high
inframammary folds, creating a pivot point around
which the breast tissue can rotate. Other causes for
ptosis can be situational, as in patients whose breast size
has fluctuated due to pregnancies or weight changes,
wherein the skin elasticity and ligamentous support
becomes attenuated. Aging is also a significant issue, as
the skin and soft tissue support naturally weakens over
time. Finally, lifestyle choices can also affect the breasts.
Patients who smoke or sustain significant sun damage

90
SECTION I
CHAPTER 6 • Mastopexy options and techniques
Fig. 6.3  (A–D) Different types of breast ptosis. IMF,
inframammary fold. (Redrawn after: Brink RR. Management
of true ptosis of the breast. Plast Reconstr Surg. 1993;
91:657–662.)
A
B
C
D
*ODQGXODUSWRVLV
7UXHSWRVLV
3DUHQFK\PDOPDOGLVWULEXWLRQ
KLJK,0)
3VHXGRSWRVLV
Table 6.1  Procedural specifics for forms of breast ptosis
Inframammary
fold position
Parenchymal
position
Nipple areolar
position
Nipple to
fold distance
Clavicle to
nipple distance
Clavicle to
fold distance
True ptosis
Fixed normal
Fixed rotated
Low downward
pointing
Unchanged
normal
Elongated
Unchanged
normal
Glandular ptosis
  Common
Mobile descended
Mobile descended
Low forward
pointing
Elongated
Elongated
Elongated
  Uncommon
Fixed normal
Mobile descended
Low relative to
fold
Elongated
Normal to
elongated
Unchanged
Normal
Normal
Parenchymal
Fixed high
Fixed high
maldistribution
Normal downward
pointing
Short
Normal
Short
Pseudoptosisa
Variable, usually
lowa
Mobile
re-descended
Surgically fixed
Elongated
Surgically fixed
Variable,
usually
elongateda
aPseudoptosis is most common after corrective procedures for glandular ptosis where the fold has descended preoperatively.
(From Brink RR. Management of true ptosis of the breast. Plast Reconstr Surg. 1993;91:657.)

91
Initial patient assessment and management of expectations
oversized and protruding areolas (due to herniation of
breast tissue), and conical or tubular breast shapes.
Tuberous breasts occur on a spectrum and can also be
very asymmetrical in nature.
The classification of tuberous breasts was further
expanded by Grolleau3 and von Heimburg.4 Much
crossover can be seen within these two classification
systems (Figs. 6.4 & 6.5 and Table 6.2).
Initial patient assessment and
management of expectations
Patients seeking mastopexy surgery will often present
with an idea of how they wish to look after surgery.
Many patients will bring in younger photos of them­
selves, show photos from plastic surgery website galler­
ies, or present magazines with images of celebrities or
models. Unfortunately, many of these patients do not
fully understand the anatomic limitations they have,
which can include weak and damaged skin, poor quality
Fig. 6.4  (A–C) Normal breast development with forward and peripheral expansion.
(D, E) Development of a tuberous breast, with limited peripheral expansion and
exaggerated forward expansion. (Redrawn from: Grolleau JL, Lanfrey E, Lavigne B,
et al. Breast base anomalies: treatment strategy for tuberous breasts, minor
deformities, and asymmetry. Plast Reconstr Surg. 1999; 104(7):2040–2048.)
A
B
C
D
E
1RUPDOEUHDVW
JURZWK
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
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7XEHURXVEUHDVW
JURZWK
Fig. 6.5  Classification system for breast base anomalies. Type I breasts have hypoplasia of the lower medial quadrant. Type II breasts have hypoplasia of both lower
quadrants. Type III breasts have hypoplasia of all four quadrants. (Redrawn from: Grolleau JL, Lanfrey E, Lavigne B, et al. Breast base anomalies: treatment strategy for
tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg. 1999; 104(7):2040–2048.)
7\SH,
7\SH,,
7\SH,,,
Table 6.2  von Heimburg’s tuberous breast classification
Class
Anatomic features
von Heimburg class I
Hypoplasia of lower medial quadrant
von Heimburg class II
Hypoplasia of both lower quadrants
with adequate areolar skin
von Heimburg class III
Hypoplasia of both lower quadrants
with limited areolar skin
von Heimburg class IV
Hypoplasia of all quadrants
(From von Heimburg D, et al. The tuberous breast deformity: classification and
treatment. Br J Plast Surg. 1996;49:339–345. Reprinted with permission from The
British Association of Plastic Surgeons.)
longer nipple to IMF distance. Breasts with pseudopto­
sis are commonly referred to by surgeons as breasts that
have “bottomed out”.
The concept of parenchymal maldistribution in
Brink’s classification system refers to what is more
commonly known as tuberous or constricted breasts,
wherein abnormally tight tissues do not allow proper
expansion of the breast during development, resulting
in high inframammary folds, widely spaced cleavage,

92
SECTION I
CHAPTER 6 • Mastopexy options and techniques
achieve a reasonable aesthetic appearance without
volume around which the skin can be tightened, and
these patients will usually need a breast augmentation.
Patients in the middle of the spectrum are the ones who
can be appropriate candidates for mastopexy only, but
these patients can also be the most complicated with
regard to preoperative discussions and choices.
As a general rule, performing a mastopexy without
some type of augmentation creates the illusion of a
smaller breast even if minimal tissue is removed. This
is due to the fact that the breast tissue is compacted into
a smaller area, and this compression effect will be more
significant in patients with softer, lower density breast
tissue. Furthermore, patients with a naturally wider
breast base width diameter (BWD) or lower inframam­
mary fold will also appear smaller than expected as the
redistributed breast tissue will spread out over a larger
surface area, providing less central projection and cleav­
age. The concept of the breast potentially appearing
smaller must be addressed preoperatively, as for some
patients this will be an unacceptable outcome. These
patients will need to consider augmentation (for rela­
tively larger volume increases) or possibly fat grafting
(for relatively smaller volume increases).
Adding implants clearly adds additional risks and
maintenance to breast surgery, although as demon­
strated in recent studies,5,6 the risks of adding augmen­
tation to mastopexy are additive, not multiplicative.
Regardless, patients need to weigh their final desired
breast aesthetics with the ease and maintenance of their
breasts over time. Once again, certain cases have more
obvious courses of action than others.
An example of this can be derived from two of the
author’s patients. Both patients actively wished to avoid
the use of breast implants, and both wished to have
“perky” breasts. The first patient (Fig. 6.6A,B) had thick
elastic skin and a large volume of firm glandular tissue.
In this case, due to favorable volume and anatomy, a
significant improvement with good upper pole aesthet­
ics was expected, and the recommendation for masto­
pexy only was straightforward to make. A typical
preoperative discussion regarding risks and expecta­
tions occurred.
In the second case (Fig. 6.6C,D), the patient had less
favorable skin elasticity, lower density parenchyma, and
less breast volume overall. There was potential for a fair
degree of improvement with regard to ptosis; however,
it was clear based on the preoperative anatomy that
upper pole fullness would be suboptimal and the overall
degree of change and improvement would be less dra­
matic than in the case of the first patient.
With this patient, a much longer preoperative discus­
sion occurred, with a blunt explanation of what the
or low density breast tissue, and pre-existing asymme­
tries. Aligning each patient’s mental image of their ideal
final result with a realistic and achievable result based
on their actual anatomy is critical for surgical success.
Additionally, patients need to understand that the
forces (such as gravity) and anatomic features (such as
weak skin) that lead to ptosis in the first place will still
be present, and that future maintenance with more
surgery is highly likely. Frank discussions indicating
that recurrent ptosis is “more a matter of when than
if…” can be helpful to place patients in the right frame
of mind. If they cannot accept the idea that mastopexy
surgery is rarely a permanent correction, they should
not be considered an appropriate candidate for surgery.
When assessing a patient for potential mastopexy
surgery, one of the most important initial steps is to
separate and analyze the components of ptosis and
volume. Clearly, the ptotic component of the breast
should be addressed surgically to create a more youth­
ful and aesthetic shape. Breast volume needs to be
assessed both as a distinct issue, and as it relates to the
correction of ptosis. Specifically, most patients will have
a sense of whether they have too little, too much, or the
right amount of volume. If they are happy with their
volume in bras, but do not like the shape of their breasts
or skin laxity, they may be a good candidate for masto­
pexy only. If they are experiencing symptoms such as
back or neck pain and feel that they are too large, they
are likely candidates for a formal breast reduction, while
other patients that desire more fullness may require
simultaneous or staged breast augmentation or fat
grafting.
Some of this evaluation can occur in the initial discus­
sion, prior to the physical examination. Once the surgeon
has a sense of a patient’s satisfaction with their breast
volume in bras, this must be reconciled with their actual
anatomy during the physical exam. It is at this time
that further recommendations based on the surgeon’s
understanding of each patient’s unique anatomy should
be made, to give the patient a realistic idea of what may
be achieved with surgery. In many cases, what a patient
wants with regard to size and shape may not be com­
pletely realistic. Their decisions need to be guided by a
surgeon who can evaluate the many breast tissue vari­
ables and can synthesize options that will achieve the
closest match between the patient’s ideal result and a
realistic result.
Decisions on the more extreme ends of the spectrum
are generally easier to make. Patients with large, symp­
tomatic breasts need a reduction in order to improve
their physical symptoms and achieve a breast that is
proportionate to their overall physique. Conversely,
patients with significantly involuted breasts cannot

93
Initial patient assessment and management of expectations
Fig. 6.6  (A–D) Pre- and postoperative photos of
patients with (A,B) more favorable anatomy and
(C,D) less favorable anatomy with regard to
postoperative upper pole projection. Preoperative
management of expectations should be customized
to each patient’s anatomic limitations.
A
B
C
D
be happy with the relatively under-filled upper poles
and would need to be steered towards implants prior to
surgery. Of course, implants can be added or removed
later, but no patient should be subjected to additional
surgeries that could have been avoided with an appro­
priate preoperative discussion.
Once it is determined that a mastopexy, as opposed
to a breast reduction or an augmentation mastopexy,
is appropriate, further analysis and patient discussion
regarding surgical technique, scar patterns, and ancil­
lary procedures (such as lateral chest liposuction, small
volume fat grafting, or small volume tissue removal
for breast shaping and asymmetry correction) can be
expected upper pole shortcomings would be without
simultaneous augmentation. Additionally, this patient
was shown multiple examples of other patients with
similar anatomy who underwent mastopexy only, so
she could have a realistic idea of what to expect after
her procedure. This in-depth process allowed her to
weigh out the pros and cons of mastopexy only versus
augmentation with mastopexy in her ultimate decision,
thus enabling her to select which surgical route would
best fit her lifestyle and sense of aesthetics.
This patient was very satisfied with her final results
because they matched up with what she expected based
on the presurgical discussions. Other patients might not

94
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CHAPTER 6 • Mastopexy options and techniques
potential mastopexy patient. Management of expecta­
tions has been discussed at length, but it is also important
to know if the patient has any history of body dysmor­
phia, eating disorders, or any other mental health issue
that could affect ultimate satisfaction. A breast-specific
history should also be taken to understand if the patient
has a family or personal history of breast cancer or a
history of surgery, injury, or radiation to the breasts.
Patients should also be asked if their weight is stable or
if they plan to have future pregnancies, as these changes
could have a negative effect on the results. If they have
had a recent pregnancy, especially in conjunction with
breast feeding, they should wait until the breast size has
stabilized and milk production has ceased. The spine
and shoulders should be examined for scoliosis or other
asymmetries, as these irregularities can impact postop­
erative breast asymmetry and should be pointed out
to the patient. With regard to mammography, there is
some variation in recommendations, but a preoperative
screening at age 40 (or age 35 if there is a positive family
history of breast cancer) is this author’s practice.
Scars, pedicles, and
ancillary procedures
There have been many techniques described to correct
ptotic breasts, which differ in regard to final scar place­
ment, pedicle orientation, management of the paren­
chyma, and the use of ancillary procedures. Scars include
circumareolar techniques (popularized by Benelli,7,8 and
later modified by Spear and colleagues 9,10); circumverti­
cal techniques (popularized by Lassus,11–14 Lejour,15–18
and later modified by Hall-Findlay,19,20 and Higdon and
Grotting21); and inverted-T scar techniques (popular­
ized by Wise and colleagues,22,23 and later modified by
McKissock,24 Courtiss and Goldwyn,25 and Marchac and
Olarte).26 Pedicles can come from any direction but are
most commonly inferior, superomedial, superior, lateral,
and central pedicles. Parenchymal management can
include autoaugmentation and internal suturing (Rubin
and Khachi27), internal mesh (Góes28–30), or a pectoralis
muscle sling (Graf and Biggs31). Ancillary procedures
include liposuction of the peripheral breast/chest to
improve contouring, and fat grafting to the upper pole
to improve volume in this region without the risks and
maintenance of implants.
Many surgeons will incorporate components of dif­
ferent techniques to suit each patient’s unique needs. It
is important to note that the skin resection pattern and
the vascular pedicle are generally independent of one
another. The skin resection pattern should be chosen
based on the degree of skin excess, while the pedicle can
discussed. These discussions can be integrated into the
larger discussion about general risks and complications.
Surgical decision-making
After the initial discussion and physical examination
of the patient is completed, the surgeon can decide on
the specific techniques that will be most appropriate for
the patient. Some of these decisions will be extremely
important to the patient (e.g., scar pattern), while
others will seem less important to the patient but will
be of major significance to the surgeon (e.g., pedicle
orientation).
With regard to scars, many things that seem obvious
to the surgeon may not be as clear to the patient. As an
example, some patients will ask whether there will be
any scar after surgery. They may think that plastic sur­
geons can perform scarless surgery or that scars will
vanish over time. It is critical for patients to understand
that there will be some type of permanent scar as a
trade-off for the mastopexy. Furthermore, every patient
needs to realize that while surgical technique and post­
surgical management (such as massage, silicone sheet­
ing, and other modalities) can directly affect the nature
of the scars, a significant portion of how they heal will
be based on their genetics.
With regard to the scar pattern, every patient wants
the minimal amount of scars; however, it is important
for them to understand that less scar is not a fair trade-
off for residual ptosis or an unacceptable final breast
shape. Therefore, it is necessary to explain that the type
of scar pattern is largely determined by each patient’s
anatomy and the degree of ptosis. In some cases, a
patient may be in a “gray area” between techniques
(e.g., between a circumvertical and an inverted-T scar
pattern). In these cases, the patient should go into
surgery knowing that the larger scar pattern is a possi­
bility, so they are not surprised or disappointed after­
wards if that scar pattern is used. This will also allow
the surgeon the greatest amount of flexibility in order
to achieve the best overall result. Which specific tech­
nique should be applied to a given situation is discussed
in detail later in the chapter.
Other presurgical considerations
As with any other aesthetic surgery, a thorough overall
evaluation of the patient’s mental and physical health
should be completed prior to entering the operating
room. Besides the standard general medical history,
physical examination, and assessment for risks such as
bleeding or clotting disorders, cardiopulmonary issues,
etc., a few specific considerations should be given to the

95
Marking technique
without distorting the areolas or lower breasts. (The
exception to this would be patients with large, dense,
conical breasts with mild ptosis, wherein a flattening
effect would be aesthetically beneficial. [Video 6.1
]).
Bearing the above in mind, the majority of patients
appropriate for mastopexy without augmentation will
have grade II or III ptosis, which will benefit from cir­
cumvertical skin resection, which tightens the lower
pole, raises the IMF, and increases breast projection. An
inframammary skin resection (inverted-T scar) can be
added in patients with significant lower pole skin excess
and poor skin elasticity, where lower pole skin overlap
would still be present after a circumvertical resection.
In “gray area” cases, a circumvertical skin resection is
planned and tailor-tacked during surgery, and if excess
lower pole skin is still present, the patient can easily be
converted to an inverted-T scar, on the table.
In terms of pedicle orientation, the author has found
the superomedial and superior pedicles to be most
useful. In the majority of patients, a superomedial
pedicle represents a shorter distance to the nipple than
an inferior pedicle. Additionally, this leaves the base of
the pedicle in the area of the breast where fullness is
most needed, and allows the pedicle to be suspended
from above as opposed to being pushed up from below,
which is the case with inferior pedicles. If the distance
from the skin resection to the nipple is very short –
making any rotation of the pedicle difficult – a superiorly
based pedicle is used by the author.
With regard to ancillary procedures, in cases where
patients wish to be modestly fuller in the upper pole,
but do not wish to have implants, the author offers fat
grafting (if appropriate harvest sites are available).
Biologic materials such as resorbable mesh or ADM can
also be offered in patients with particularly soft breast
tissue and weak skin. These reinforcement materials can
act as an internal support bra and be sutured to the
pectoralis fascia. In patients with wide, poorly-defined
breasts, lateral chest liposuction is offered as a means of
sculpting the outer curve of the breast and providing
more definition between the breast and the lateral chest.
Marking technique
Proper preoperative breast markings are critical in
performing mastopexy surgery. The markings guide the
surgeon with regard to symmetry and nipple placement,
and allow for intraoperative adjustment as needed,
without losing sight of important anatomic landmarks.
Appropriate markings will also alert surgeons to pos­
sible tilting of the torso and reduce the risk of asym­
metrical nipple placement when the patient is examined
in the seated position.
be chosen based on the location of the nipple on the
breast.
In the previous edition of this textbook, Drs Higdon
and Grotting wrote a beautiful and comprehensive
chapter on mastopexy and the various historical and
current techniques. Review of this chapter and reading
the original journal articles referenced above is essential
for the plastic surgeon who wishes to have in-depth
knowledge of mastopexy techniques. Some of the more
complex techniques (such as those involving multiple
internal flaps or the use of mesh) have a relatively steep
learning curve, and a step-by-step review of each one is
beyond the scope of this current chapter.
For this volume, this author presents a relatively
straightforward and somewhat universal marking, dis­
section, and reassembly process that uses concepts and
techniques familiar to most surgeons currently perform­
ing some form of breast reduction and mastopexy
surgery. The learning curve is relatively mild, and com­
plications such as nipple necrosis, areolar distortion,
and nipple areolar complex malposition are low.
Algorithm for technique selection
In the author’s practice, in comparison to augmentation
mastopexies and reduction mammoplasties (totaling
>150 cases per year), mastopexy without augmentation
or significant reduction is much less common, as the
patient’s aesthetic goals and anatomy must align closely
for an acceptable final result that provides reasonable
volume and a pleasing overall breast shape. Most
patients in this category fit the profile of having a fairly
significant amount of natural breast tissue (usually at
least a C cup) and enough ptosis (generally Regnault
grade II or III) to warrant the surgery and the resulting
scars. Most patients who are candidates for mastopexy
only have enough breast density to create aesthetic
upper breast fullness. However, patients with less firm
tissues are still candidates, as long as they understand
that their tissues will limit the degree of upper poles
fullness despite the correction of their nipple position
and lower pole ptosis. Skin elasticity and thickness for
mastopexy patients can vary widely, and once again,
these variations must be discussed with patients for the
best management of expectations.
Although the author frequently uses a version of
circumareolar tightening in appropriate augmentation
mastopexy and tuberous breast correction patients
(discussed in more detail later in this chapter), this
technique is rarely used in pure mastopexy patients due
to the flattening effect of this technique and the inherent
limitations with regard to superior repositioning of the
nipples and tightening the skin of the lower poles

96
SECTION I
CHAPTER 6 • Mastopexy options and techniques
The inframammary folds (IMF) are marked (Fig.
6.7C), and if a significant fold asymmetry is present, it
should be noted for adjustment during surgery. A large
caliper is then used to transpose the inframammary fold
onto the breast on each side, and these marks are
re-measured from the low point of the sternal “V”
marking to ensure symmetry (Fig. 6.7D,E).
Each breast is rotated medially and laterally, and with
each rotation, a line is drawn as a plumb line from the
transposed IMF mark on the breast to the meridian line
which had previously been drawn on the abdomen (Fig.
6.7F,G). These two new lines represent the extent of safe
The following is a description of the author’s pre­
ferred marking technique. The patient is marked in the
standing position with shoulders relaxed. The sternal
notch is marked with a “V”, and a midline is drawn
down to the umbilicus (Fig. 6.7A). After this, a measur­
ing tape is draped around the patient’s neck to assist
marking the patient’s breast meridians (Fig. 6.7B). Keep
in mind, these lines bisect the breast, but they may not
intersect the nipples if the nipples are medially or later­
ally situated. These marks are continued down the
breasts to include the lower poles, and then continued
down on to the abdomen.
A
B
C
D
E
F
Fig. 6.7  (A–L) Author’s preferred method of marking for mastopexy. The midline, breast meridians, and inframammary folds (IMF) are marked. The IMF is transposed on
the breast, and the breast is rotated medially and laterally to determine the amount of skin resection. The vertical limbs are measured at 7 cm, and the areas for skin
undermining (in the case of vertical mastopexy) or skin resection (for inverted-T scar mastopexy) are marked, leaving approximately 3 cm of skin from the bottom of the skin
resection to the IMF.

97
Marking technique
G
H
I
J
K
L
Fig. 6.7, cont’d
skin resection. Marks at 5 cm increments are drawn up
the meridian lines from the transposed IMF marking to
allow other points of reference in case intraoperative
adjustments are made (Fig. 6.7H). A pre-made template
with a keyhole of 42 mm (or 38–40 mm in patients with
smaller areolas) is centered on the transposed IMF mark.
The template is opened and matched to the medial and
lateral rotation plumb lines (Fig. 6.7I,J). This template
can be easily created using two layers of foam tape on
top of each other and then placed sticky side to sticky
side for a total of four layers, with a 42 mm hole cut in
the center, split up the 6 o’clock position and with cross-
hatches drawn at the 3 o’clock, 12 o’clock, and 9 o’clock
positions.
Marks are made 7 cm below the bottom of the keyhole
(Fig. 6.7K). In cases where a circumvertical is planned
(Grade I, most Grade II, and rarely Grade III ptosis),
dashed lines are extended medially and laterally and
connected with the IMF markings. Another mark is
made 2 finger-widths (approximately 3 cm) up from the
IMF, which becomes the lowest point of skin resection
(Fig. 6.7L). The parenchyma between the IMF and the
marks 7 cm down from the keyhole is later undermined
and either resected or, more commonly, sutured up
to the pedicle to create more fullness. In cases where
an inverted-T scar skin resection is planned, the skin
between these markings is removed, and the underlying
parenchyma handled in the same way as noted above.

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CHAPTER 6 • Mastopexy options and techniques
Finally, the pedicle is marked. Generally, this is a
superomedial or superior pedicle, although in many
cases, the entire area within the skin resection pattern
with the exception of the nipple areolar complex is
simply de-epithelialized to maximize volume and blood
supply.
Circumvertical mastopexy with the
option of inverted-T scar conversion
After administering preoperative intravenous antibiot­
ics, the patient is brought to the operating room and the
following is the author’s preferred procedure. With the
patient prepped and draped in the supine position
under general anesthesia, one or both breasts can be
quickly tailor-tacked at the proposed incisions, and the
patient examined in the seated position to ensure proper
skin resection. There will be mild lower breast distortion
given that no dissection has yet occurred, but this
maneuver will confirm that the markings are not exces­
sively aggressive. With more experience, this maneuver
can quickly be done by pinching the skin together
manually, or skipped altogether, depending on the
surgeon’s confidence in the markings.
Next, the central breast is placed on maximum stretch
by the surgical assistant, and the areola is marked
(usually with a 42 mm cookie-cutter) and scored with a
15-blade scalpel. The previously made markings for the
mastopexy are scored with a scalpel (Fig. 6.8A). If a
circumvertical skin resection is planned, the medial and
lateral areas of skin undermining (marked with a “U”
in the photos) are injected with approximately 10 cc per
breast of local anesthetic containing epinephrine to
minimize bleeding (Fig. 6.8B). Then the pedicle (in large
breasts), or the entire area within the markings (in
smaller breasts), is de-epithelialized with a 10-blade
scalpel (Fig. 6.8C). Electrocautery is then used for hemo­
stasis and to contract the dermis (Fig. 6.8D).
The lower dermis is released (Fig. 6.8E), and a 10-blade
scalpel on a flat handle is placed parallel to the skin and
used in progressively advancing circular movements to
undermine the skin in the inferomedial and inferolateral
breast areas, leaving a few millimeters of subcutaneous
fat to maintain blood supply and smoothness (Fig. 6.8F).
After this, electrocautery is carefully used for hemostasis
of this undermined skin.
Next, a lateral flap of 1.5–2 cm thickness is developed
down to the level of the chest wall, and the areas of
parenchyma below the undermined inferomedial and
inferolateral skin flaps skin are dissected off the chest
wall leaving a thin layer of fat down on the fascia to
maximize lymphatic drainage and create a gliding plane
after healing (Fig. 6.8G). The parenchyma from the
undermined areas is usually maintained for maximum
volume and sutured to the main pedicle with 3.0 Vicryl
suture (Fig. 6.8H). In cases where a small reduction is
preferred, this undermined tissue is resected and sent
to pathology for evaluation. Regardless, the tissue
should be dissected out from the lower breast in order
to re-establish a sharp, higher inframammary fold.
At this point in the surgery, the pedicle is superome­
dially or superiorly based, but unlike a breast reduction,
this “pedicle” essentially represents all of the breast
tissue besides the tissue connected to the lateral skin
flap. If dense, white glandular tissue is present, the
author usually leaves a thin (0.5–1 cm thick) layer of this
as part of the lateral flap, to help maintain a smooth,
firm contour of the lateral breast and to provide extra
soft tissue support.
The lower half of the pedicle is undermined at the
level of the chest wall, and the pedicle (again, represent­
ing the majority of the breast tissue) is rotated in a
superomedial direction or shifted in a superior direc­
tion, and sutured at its deep lateral and inferior border
to the chest wall using 3.0 PDS suture (polydioxanone
suture) (Fig. 6.8I). This stabilizes the tissue in a higher
position during the healing process and elevates the
new inframammary fold. Care must be taken not to
over elevate the tissue as this can cause a distortion
and over-rotation of the lower pole of the breast.
The suture points are usually 1–1.5 cm above the
original IMF.
Once the dissection and stabilization of the paren­
chyma in its new position is completed, the skin is
temporarily tailor-tacked with a stapler (Fig. 6.8J)
and checked with the patient in the seated position.
Based on the appearance of the breast, small adjust­
ments in the pedicle position and the amount of skin
resection can be made. Also, the lower breast skin
excess can be evaluated, and if significant skin-on-skin
contact is still present, the patient can be converted
to an inverted-T scar pattern by simply resecting the
undermined skin of the inferomedial and inferolateral
breasts.
This is also an excellent time for the circulator to take
a front view photo, which shows one breast essentially
completed (except for final suturing), while the other
breast is in its original state (Fig. 6.8K). This photo can
be a very dramatic visual tool for patients to understand
the true degree of correction the surgery created.
The patient is returned to the supine position, and
attention is turned to the left breast where the same
procedure is performed with considerations made for
asymmetry correction. If an inverted-T scar pattern was
necessary on the right breast, this type of skin resection

99
Circumvertical mastopexy with the option of inverted-T scar conversion
A
B
C
D
E
F
Fig. 6.8  (A–K) Author’s preferred surgical technique for mastopexy. The areola is marked on stretch and scored, and the mastopexy pattern is scored and de-epithelialized.
The skin is cauterized and released, leaving a superomedial or superior pedicle. Inferomedial and inferolateral flap undermining is performed, and a lateral flap of
approximately 1.5–2 cm thickness is developed to the chest wall. The pedicle is consolidated with 3.0 Vicryl and then elevated and sutured approximately 1–1.5 cm above
the original inframammory fold with 3.0 PDS. Layered closure is performed, and a photograph is taken to compare the repaired breast with the original anatomy.
Continued

100
SECTION I
CHAPTER 6 • Mastopexy options and techniques
G
H
I
J
K
Fig. 6.8, cont’d

101
Tuberous breast correction
Although there were concerns in the 1980s with
oncologic issues after fat grafting to the breasts,32 these
issues have since been re-examined, and the technique
of fat grafting to breasts is now a common adjunctive
procedure in both aesthetic and reconstructive surgery.33
With the technique of fat grafting, a volume deficient
upper breast pole can generally be filled in a more direct
and effective way than can be achieved with a masto­
pexy alone (Fig. 6.9). Additionally, this provides a lower
maintenance option than breast augmentation with
implants, and is particularly beneficial in larger breasted
patients where only a modest amount of volume
(approximately 100–300 cc) per breast is needed.
The primary limitation for fat grafting is the presence
of sufficient donor site fat and the patient’s willingness
to accept additional surgical sites. Patients must under­
stand that there is somewhat less predictability with
regard to volume increase than there would be with an
implant; however, this is the trade-off for lower mainte­
nance associated with a totally autologous procedure.
Besides eliminating implant complications such as
capsular contracture and implant malposition, fat graft­
ing allows preferential volumetric filling in the areas
where that volume is needed most. Additionally, by
embedding fat in the subcutaneous tissues of the upper
breast, there is less direct force on the lower pole of the
breast than there would be with an implant, potentially
reducing the risk of a lower pole stretch deformity.
In other patients who need removal of lateral chest
fat for reshaping purposes, tumescent can be placed and
careful deep lateral chest liposuction can be performed
to better contour the breasts.
Once closure is completed, the incisions are cleaned
and dried, and mastisol and Steri-Strips are applied. The
patient is placed in a gently compressive surgical bra,
extubated, and sent to the post-anesthesia care unit
(PACU) for recovery. Patients are sent home the same
day of surgery, and pain is usually mild and easily
controlled with oral medications.
Tuberous breast correction
Tuberous breasts, as noted in the section on breast
anatomy, are generally defined by constricted lower
poles, a wide intermammary distance, conical breast
shapes, oversized and protruding areolas, and an excess
of herniated, retroareolar breast tissue combined with a
general paucity of breast tissue. In order to create an
aesthetic breast in a tuberous breast patient, a reversal
of all these problems must be achieved. In essence: high
inframammary folds with constricted lower breast
tissue need to be released and expanded. Oversized and
protruding areolas with herniated breast tissue need to
can be performed immediately on the left, skipping the
skin-undermining maneuvers.
Once the left breast dissection is completed, it is
tailor-tacked as well, and the patient is carefully checked
in the supine and seated position for good shape, size,
and symmetry. Staples are then removed after a marking
pen is used to make cross-hatches on the vertical to
ensure that proper orientation between the medial and
lateral flaps is maintained during closure.
If reasonably strong breast tissue or superficial fascia
is present, parenchymal pillar sutures can be placed
with 3.0 PDS in interrupted fashion for additional deep
support. If a more extensive circumvertical resection
was performed, a single 10-French hubless Blake drain
on each side is an option to help the undermined
tissue adhere down to the chest wall. If a smaller cir­
cumvertical resection or an inverted-T scar resection
was performed, no drains are used. Prior to closure,
the wounds are irrigated with saline, final hemosta­
sis is ensured, and quarter-percent bupivacaine with
epinephrine is generally infiltrated for early postopera­
tive analgesia. In appropriate patients with very weak
tissues, additional support such as a re-absorbable
mesh can be used as an internal bra to offload weight
from the skin. The support mesh is used in a similar
orientation to a real bra and is sutured just below and
lateral to where the parenchyma was sutured to the
pectoralis fascia.
Final closure is performed in layers of running suture
to minimize knots and the risk of spitting sutures. First,
a 3.0 PDS suture is used at the bottom of the areolar
keyhole with the knot and suture tail buried deeply.
This suture is used in running whip-stitch fashion to
reapproximate the deep dermis down to the inframam­
mary crease and is run back up the vertical incision and
then around the areola for deep dermal support. The
same technique is applied to the inframammary incision
if such an incision was used. Any de-epithelialized
dermis between the suture bites is invaginated and
fuses to itself over time. An equivalent strength barbed
suture (2.0 PDO) can also serve this purpose. The areolas
are checked for good shape and symmetry, and a cookie-
cutter can be used at this point for further areolar shape
and diameter refinements. After the deep closure, the
skin is run closed with a 4.0 Monocryl in subcuticular
fashion.
In appropriate patients where increased upper pole
fullness without implants is desired and recommended,
fat grafting is performed. Liposuction of areas such as
the flanks and thighs can be performed, the fat pro­
cessed, and then re-injected into the subcutaneous space
of the upper poles with a small, blunt fat grafting
cannula.

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CHAPTER 6 • Mastopexy options and techniques
greater resistance against implant compression. When
form stable anatomic implants are an option, these can
potentially provide other benefits due to their resistance
to compression and ability to create preferential lower
pole expansion.
For most of these cases, the author performs a peri­
areolar approach, as this allows the minimum amount
of scarring in the lower pole of the breast where expan­
sion is needed the most. This also eliminates concerns
about IMF incision placement, where less lower pole
expansion than expected preoperatively may be an
issue. Although IMF approaches have shown lower
rates of capsular contracture, this benefit is reduced for
tuberous breast patients because aggressive scoring of
the lower breast and tissue resection is often necessary,
which exposes the implant to glandular tissue and
be corrected by reducing the areolar diameter, forcing
the retroareolar tissue back into the main breast mound
(sometimes requiring tissue resection). Finally, under­
sized and widely-spaced breasts generally require cor­
rection with augmentation.
For correction of tuberous breasts, the author’s pro­
cedure starts with a thorough evaluation of the breast
anatomy as noted above. Of key importance is the
patient’s ideal breast base width diameter, as this will
determine the proper width of the implants. The true
base width of the chest in a tuberous breast patient is
almost always wider than the breast base width of the
constricted breast, and it is on the true chest width that
the implant width is selected. The author also generally
prefers highly cohesive textured implants to allow for
greater stability, lower capsular contracture rates,34 and
Fig. 6.9  (A–C) Before and (D–F) after, a 39-year-old woman with vertical mastopexy and upper pole fat grafting (300 cc right breast; 200 cc left breast due to preoperative
asymmetry), liposuction of flanks, and full abdominoplasty.
A
B
C
D
E
F