AESTHETIC BREAST SURGERY CONCEPTS & TECHNIQUES ELIZABETH J. HALL-FINDLAY MediaCenter.thieme.com plus e-content online Thieme
Operative videos complement the text
on MediaCenter.Thieme.com!
Simply visit MediaCenter.Thieme.com and, when prompted during the
registration process, enter the code below to get started today.
3242-Y8FZ-89Q3-MH46
Connect with us on social media
AESTHETIC
BREAST SURGERY
Concepts &Techniques
Terry McCue, Gift of the Dance
Canada House Gallery
AESTHETIC BREAST SURGERY Concepts & Techniques Elizabeth J. Hall-Findlay, MD, FRCSC PRIVATE PRACTICE, BANFE, ALBERTA, CANADA Illustrated by JENNIFER N. GENTRY, MA, CMI Thieme
Director, Editorial Services: Mary Jo Casey
International Production Director: Andreas Schabert
International Marketing Director: Fiona Henderson
International Sales Director: Louisa Turrell
Director of Sales, North America: Mike Roseman
President: Brian D. Scanlan
Library of Congress Cataloging-in-Publication Data
is available from the publisher upon request.
© 201 Thiem e Medical Publishers, Inc.
Thiem e Publishers New York
333 Seventh Avenue, New York, NY 10001 USA
+1 800 782 3488, custom erservice@thieme.com
Thiem e Publishers Stuttgart
Rüdigerstrasse 14, 70469 Stuttgart, Germ any
+49 [0]711 8931 421, customerservice@thieme.de
Thiem e Publishers Delhi
A-12, Second Floor, Sector-2, Noida-201301
Uttar Pradesh, India
+91 120 45 566 00, customerservice@thieme.in
Thiem e Publishers Rio de Janeiro, Thiem e Publicações Ltda.
Edifício Rodolpho de Paoli, 25º andar
Av. Nilo Peçanha, 50 – Sala 2508
Rio de Janeiro 20020-906, Brasil
+55 21 3172 2297
eISBN
This book, including all parts thereof, is legally protected by co-
pyright. Any use, exploitation, or commercialization outside the
narrow limits set by copyright legislation without the publisher’s
consent is illegal and liable to prosecution. This applies in par-
ticular to photostat reproduction, copying, mimeographing or
and electronic data processing and storage.
Im portant note: Medicine is an ever-changing science undergoing
continual development. Research and clinical experience are con-
tinually expanding our knowledge, in particular our knowledge of
proper treatment and drug therapy. Insofar as this book m entions
any dosage or application, readers may rest assured that the au-
thors, editors, and publishers have m ade every effort to ensure that
such references are in accordance with the state of knowledge at
the tim e of production of the book.
Nevertheless, this does not involve, imply, or express any
guarantee or responsibility on the part of the publishers in respect
to any dosage instructions and forms of applications stated in the
book. Every user is requested to exam ine carefully the manufac-
in consultation with a physician or specialist, whether the dosage
schedules mentioned therein or the contraindications stated by
the m anufacturers differ from the statem ents made in the present
book. Such examination is particularly important with drugs that
are either rarely used or have been newly released on the m arket.
Every dosage schedule or every form of application used is enti-
rely at the user’s own risk and responsibility. The authors and
publishers request every user to report to the publishers any di-
screpancies or inaccuracies noticed. If errors in this work are found
after publication, errata will be posted at on the
product description page.
Some of the product names, patents, and registered designs
referred to in this book are in fact registered trademarks or proprie-
made in the text. Therefore, the appearance of a name without de-
signation as proprietary is not to be construed as a representation
by the publisher that it is in the public domain.
D ED ICATIO N
To my mother, Betty Hall, a true inspiration to all six o her children.
She made us believe that we could achieve whatever we set as goals.
She never liked attention, and we were all so proud o her
when she stood up or what she elt was right when it was most dif cult.
For all her sacri ces or us—both personally and nancially—
I wish to dedicate this book to her.
•
(Trang không có chữ)
vii
The Art Featured in This Book
Many o the works o art that appear in this book—on the cover and on the f rst
pages o each part and chapter—were created by the talented Canadian artists o
Canada House Gallery o Ban , Alberta. Established in 1974, Canada House Gallery
is one o Canada’s most vibrant commercial art galleries. The unique and distinc-
tive collection ocuses on contemporary paintings, sculpture, and jewelry by re-
nowned and respected Canadian artists. Recognized in 2002 by their peers, the
gallery was accepted into the Art Dealers Association o Canada. Over the years,
Canada H ouse Gallery has earned a reputation or excellence in the Canadian art
community. They have become a destination or art lovers throughout Alberta,
Canada, and abroad. (1-800-419-1298; 1-403-762-3757; info@canadahouse.com)
TERRY MCCU E
Born 1945 in southeastern Ontario.
Cover, Part I, Part II: “Gi t o the Dance”
Terry McCue is an Ojibway Indian rom the Curve Lake First Nation, in southeastern
Ontario. Terry moved to Alberta in 1976 and continues to call it home. For 19 years,
Terry worked as a acilitator, conducting workshops across Canada to train substance
abuse workers in Native communities. During that time he worked as a reelance il-
lustrator, producing a variety o works, including posters, book covers, and illustra-
tions or addiction manuals. H e used this work to continually develop his skills as an artist. Terry’s work
can be ound in private and corporate collections in Canada and the United States.
Terry is a sel -taught painter, who spent time in his youth watching his cousin Arthur Schilling and
learning rom him. Arthur still in uences Terry’s paintings. Terry’s paintings re ect the our principles
that sum up his philosophy: “H umanity is an integral part o creation. H umor is spiritual sustenance. Re-
spect or the natural world, and our place in it, is the key to personal understanding. We are magical be-
ings living in a magical world.”
SU SAN ELKINS
Born in Banff, Alberta.
Chapter 1: “Shape and Colour”
Susan Elkins loves color. “It would be easy to describe the work o Ban impressionist
painter Susan Elkins as surreal, dreamlike, and otherworldly. But in act, her vision
and her work are grounded in truth: true colors ound within a scene or landscape,”
wrote Rob Alexander. “It’s an abstract approach,” says Susan. “I’m looking at
patterns and colors coming together. In nature there is no outline. It’s to achieve
the eeling o the natural light or the richness o an indoor still li e. It’s a great way to study colors com-
ing together; it’s like music, with notes coming together.” Susan studied with American painter H enry
H ensche, who taught his students at The Cape School o Art in Provincetown, Massachusetts, that
shadows have color, a lesson Susan Elkins has not orgotten.
viii
The Art Featured in This Book
LES TH OMAS
Born 1962 in British Columbia.
Chapter 2: “Figure Painting 04-3347”
Les Thomas, a highly accomplished artist, has received many awards or his work and
has been eatured in several publications; his paintings are in public and private col-
lections in Canada, the United States, the United Kingdom, and Germany. Thomas’s
paintings tend to play with the relationship between culture and nature. The special
encaustic wax f nish that he applies, he explains, “may very well pertain to memory,
and the manner in which we hold visual experiences within the capacities or recollection. Think o the
last time you encountered a bear on the roadside, or craned your neck to watch a mountain goat or sheep
on a steep and rocky slope.”
ELISE FINDLAY
Born 1987 in Banff, Alberta.
Chapter 3: “Perspective”
Elise is the daughter o author Elizabeth Hall-Findlay. Her mother reports: “She could
never sit still and was always creating sculptures and paintings, even as a young child.
She would imbue her art with a sense o humor and creativity that surprised me. I al-
ways tend to do the same thing (as evident in my surgery), but she was always making
something new and di erent. This sculpture was created on the ASPS/ ASAPS Baltic
Cruise in 2007. One o the tours o ered was to visit a sculpture studio in Talinn, Estonia. While Jack
Fisher and I struggled to ollow the model’s curves with our clay, Elise immediately struck out, creat-
ing a work o art instead. She has now completed her degree at Dalhousie University in H ali ax, Nova
Scotia, with a double major in sociology and comparative religion. She is currently contemplating urther
study in the visual and creative arts.”
LESLIE ROWE-ISRAELSON
Born 1954 in Vancouver, British Columbia.
Chapter 4: “Looking Down From H eaven”
Leslie Rowe-Israelson and her twin sister, Melanie Rowe-Prosser, spent their child-
hood in Victoria, British Columbia. For the past 20 years, the twins have lived and
worked in the heart o the Canadian Rockies. The beauty o the mountains, particu-
larly in Ban National Park and Jasper National Park, is their passion and inspiration.
It was in the mountains that they discovered their other shared passion: glass would
come to consume their thoughts and dreams. Through dedication, this passion became their visual lan-
guage. Part o the dedication has been through training and dialog with other glass artists. From 1985
to 1994, Leslie and Melanie attended the world-renowned Pilchuck Glass School in Stanwood, Wash-
ington. To express their artistic “voice,” their visual language has required the development o unusual
techniques involving sand-casting, mosaics, and pˆate de verre. Because o the time-consuming nature o
the creation o each piece, it becomes a contemplative process that both Melanie and Leslie f nd reward-
ing. Leslie’s work had ound a home in national and international collections such as that o a previous
Canadian Prime Minister, the Fairmont H otels, and the King o Jordan.
ROSE-AIMÉE BÉLANGER
Born 1923 in Témiscaming, Quebec.
Chapter 5: “I Am Woman”; Chapter 8: “Camille”
Rose-Aimée Bélanger creates wonder ul f gures, ull o li e and humor, in sandstone
and bronze. H er subjects come rom the people around her: her amily, riends, and
local characters she has met over her li etime. They are shown in amiliar attitudes, in
repose and at work: women holding bouquets, dreaming, relaxing, reading, picking
berries or mushrooms, and coddling their children; men at work, or taking a lunch
break. She sculpts people with realism and candor, people o her own milieu. All her
f gures seem to be alive and not posed. They are tender and understanding, exuding
an aura o calm and serenity. Shapes have become in ated, giving her f gures gracious
yet heavy orms. Almost a paradox, she exploits this with much style and success. H er
extraordinary aesthetics give the impression o lightness. Shortly a ter graduating rom
École des Beaux-Arts in Montréal, Rose-Aimée put her career on hold to devote her
ix
The Art Featured in This Book
KATE H ANSEN
Born 1977 in Saskatoon, Saskatchewan.
Chapter 6: “Krista and Colum”
Kate H ansen graduated in 2001 rom the University o Regina in Saskatchewan with a
BFA in f ne arts, with a ocus on painting. “I have been interested in painting people or
as long as I can remember,” she says. “I am ascinated by expressions, the dynamism
o the f gure, and the undertones o skin.” H er grad show, a series o f gurative oil
paintings, was at the Mackenzie Art Gallery in Regina. She was married in 2002 and
moved to Crowsnest Pass in the Rocky Mountains o Alberta. She continued to paint, exhibiting several
times with group shows at the Crowsnest Pass Art Gallery. In 2007 she gave birth to her f rst child and
began to work with conté crayons instead o oil paints. H er series, “Madonna and Child,” was inspired
by the birth o her son. In 2008 the amily moved to Courtenay on Vancouver Island in British Colum-
bia, and their second child was born shortly therea ter. Kate continues to create and exhibit artwork while
caring or her amily. This particular image, “Krista and Colum,” was repeatedly removed by Facebook
rom her website or being pornographic.
JOH N MACDONALD
Born 1964 in Prince George, British Columbia.
Chapter 7: “Video Stills, Shower II”
John Macdonald is an accomplished artist rom British Columbia whose large-scale
oil-on-canvas works have been collected and exhibited nationally or more than a
decade. In ormed by the traditional as well as the avant-garde, his work depicts f gu-
rative subjects engaged in an instinctual response to their environment, rein orced by
the materiality o the painted sur ace. Macdonald’s paintings are landscapes and f g-
ures in landscapes, implying our alienation and isolation in relation to our cultural environment and the
displacement experienced. Other paintings deal with the encompassing nature o our environment, its
materialism, and the unresolved con icts that emerge. These paintings are metaphors or common expe-
rience, re ecting certain aspects o the anxieties o our times. The work is enigmatic and open ended, en-
couraging dialog with the viewer that evokes a mix o responses.
JEAN SMITH
Born 1918 in Hythe, England. Died 1999.
Chapter 9: “Sel Conf dence”
Jean Smith lived in Toronto most o her li e. She was primarily known or her land-
scapes o the Georgian Bay in the Great Lakes. She captured the magnif cent scenery o
Precambrian shield and white pine in her watercolors. Jean loved to draw f gures, mainly
o women. She combined a realistic impression o their physical shape while capturing
their mood and inner sense o sel , yet always maintaining a sense o humor.
ARNAQU ASH EVAK
Born 1956 near Cape Dorset on Ba f n Island,
N unavut. Died 2009.
Chapter 10: “Tattooed Women (Cape Dorset)”
Arnaqu, an Inuit, was the adopted son o Kenojuak and Johnniebo Ashevak. Arnaqu
began carving in the early 1980s and is perhaps best known or his three-dimensional
work. H e did not make simple carvings, but rather constructions o various and o ten
unconventional materials. Arnaqu began working as an assistant printmaker or the co-
operative in 1990 and has been represented as a printmaker in annual collections since that time. Arnaqu’s
inspiration came rom the sculptural work o a First Nation artist he met while in residency at the Ban
Centre in 1991.
Also known as Arnaquq, Annaco, Annago.
time to being a wi e and mother. Some 30 years later, she resumed her sculpting patiently and gradually,
with great determination. To begin again in your late f ties a ter a lapse o many years is rare. H owever,
she has done so with panache. Still burning with zeal and energy, she is now into her eighties, looking
orward to her next project, her next show. She is def nitely a master o bronze f gures.
x
The Art Featured in This Book
N IKOL H ASKOVA
Born 1972 in Litomerice, Czechoslovakia.
Chapter 11: “Grace”
A ascination with the world o art began at an early age or Nikol. Born in the ormer
Czechoslovakia, she remembers sketching on the edges o newspapers when no other
material was available. Sketching, painting, poetry, and acting were her interests rom
young childhood. Nikol and her amily escaped the ormerly oppressed Czechoslova-
kia in 1987 with the intent o emigrating to Canada. A ter a long and o ten trying
process, they were f nally allowed to resettle in Vancouver. This dramatic change had an incredible im-
pact on Nikol. Although this experience was o ten challenging, it provided urther observation not only o
the art world, but also o politics, spirituality, and the strength o the human spirit. Currently, Nikol paints
in her studio in the Vancouver area. She participates in several exhibitions each year and enjoys an active
li estyle with her amily. “For me,” she says, “painting is about con ronting the plastic o modern exis-
tence. I am ascinated by contrasts, literally and metaphorically. Whether I am recording the tension o
human relationships, the con ict between environment and ‘sprawl,’ or the collision o black silk and pale
skin, I am constantly drawn to opposing elements.”
OVILOO TU NNILLIE
Born 1949 in Cape Dorset, Ba f n Island, N unavut.
Chapter 12: “Torso”
Oviloo, an Inuit, comes rom a very artistic amily in the community o Cape Dorset.
H er parents, Toonoo and Sheojuke, were artists, as are her brother, Koperqualuk, and
her sister, Napatchie. Says Orviloo, “I started carving seriously in 1973, but my f rst
carving was actually done in 1965, a ter the birth o my f rst child. I like to carve
using di erent types o stone, and I allow mysel to be exible, exploring di erent
subject matter in my carvings. I like to carve things that are di erent rom what many would perceive as
typical Inuit art, and or that reason I f nd that my work is well received.
Also known as Toonoo, Ovilu, Ooveelook, Ovelook, Tunillie.
xi
When Karen Berger rom Quality Medical Publishing f rst contacted me about
writing a book on breast surgery, I questioned whether I had enough to o er.
I was busy raising my children and running a practice, and I almost didn’t take
the time to publish my approach to vertical breast reduction surgery (A sim-
plif ed vertical reduction mammaplasty: shortening the learning curve. Plast
Reconstr Surg 104:748-759, 1999).
Since then, my experience has deepened, my children have grown, and my prac-
tice has matured. This has allowed me the perspective and the opportunity to
analyze various aspects o breast surgery and to reach some conclusions. Dur-
ing this time, I have been stimulated and challenged by colleagues and students,
both directly and in teaching courses. As a result o these in uences, I have be-
come a better surgeon.
This book is a review o my thoughts and experience rom a solo practice that
has spanned 27 years. It is intended as a comprehensive (but personal) approach
to aesthetic breast surgery, covering breast reduction, breast augmentation,
mastopexy, mastopexy-augmentation, and breast asymmetry.
I have care ully reviewed all my charts with patients’ preoperative and postoper-
ative photographs since I began practice in 1983. It has been an enlightening—
and very humbling—experience. It has taught me that my memory has played
tricks to prevent me rom being too hard on mysel . As I look back, I am amazed
at how many complications and problems I have “blocked out.” I realize that
relying on memory is not good enough: we need to document our results be-
ore we make any claims.
I started taking measurements o my results to more realistically assess the
changes that were being produced. This process has been very educational and
has helped me to “see” and analyze patient results in a new way. I do not believe
that we need measurements to per orm good surgery; however, they are essen-
tial i we are to truly comprehend the principles o what we are doing. I keep see-
ing more things that I would like to measure to discover whether my impres-
sions are right or wrong.
Preface
Plastic surgery has been a ascinating and rewarding career or me. I owe some
o this to Robert Goldwyn, who warned us to never let a procedure become
routine, because “routine” leads to mistakes. Li e (and work) are also ar more
interesting i we continue to be curious and observe what we are seeing. This
is especially true o anatomy: I didn’t “see” the blood vessels until I started
“looking.” The result has been a clearer understanding o pedicle and f ap blood
supply and a better comprehension o nipple necrosis. Several years ago I met
with Ian Taylor, Niamh Cordu , and Elisabeth Würinger or a rank discussion
about anatomy. I hope that I have been able to accurately represent some o
their thoughts in this book. We still don’t completely agree, but that is what
makes it all so ascinating!
As my anatomic insights have grown, I have applied that knowledge to im-
proving my results. I ocused initially on my breast reduction outcomes. I have
been very pleased with the medial and superomedial pedicles, because they al-
low an in erior vertical wedge excision with any type o skin resection pattern. I
was able to extend these principles to mastopexies as well when my results showed
that what is “removed” in a breast reduction needs to be “moved” in a mastopexy.
The in erior wedge principle is the key to success in breast reduction, mastopexy,
and mastopexy-augmentation. Un ortunately, I have not determined how to
move that in erior wedge o parenchyma with a mastopexy-augmentation, and I
believe that the best choice in this situation is a “reduction-augmentation.”
Measurements and an understanding o the changes produced by the di erent
procedures are invaluable when treating a patient with breast asymmetry. It is
important to recognize that the nipple, or example, will drop 2 cm in a breast
augmentation or a mastopexy-augmentation, but will stay close to its marked
position in a mastopexy or reduction. Achieving symmetry is an elusive goal,
but it is much easier when the principles are better understood.
My measurements have shown that or most procedures, a ull year’s ollow-
up is needed be ore results are relatively stable. We are deluding ourselves into
believing that we have ound solutions i we only ollow our patients or a ew
months; this is just not enough time. Long-term ollow-up ensures that any
statements made are supported by acts—both measurements and photographs.
I have also presented my experience with complications through a discussion
o avoidance and treatment. I don’t have all the answers; I am still looking. Un-
ortunately, I have had more experience with nipple necrosis than I would like
to admit, although my numbers are in line with those reported in the literature.
We would all like to understand how to prevent it, how to diagnose it, and how
xii
Pre ace
to treat it. Fortunately, I documented these cases with numerous photographs,
and many are presented in a chapter dedicated entirely to this topic. A review
o these photographs, along with the current understanding o the blood sup-
ply presented in the anatomy chapter, demonstrate the di f culty in assessing
and treating nipple necrosis. Watch ul waiting may be the best choice, unless
there is clear evidence o venous compression.
The principles and concepts presented in these pages have all been articulated
elsewhere. It has been a revelation or me to reread papers and chapters, and
recognize what I missed the f rst time. Skoog realized that the principle o the
wedge excision was the key to good breast surgery. McKissock made breast re-
duction sa er. H e also understood how seductive it is to keep reinventing the
wheel when he wrote:
The thought that suturing the in erior pedicle to the chest wall will suspend the
breast or a prolonged period o time is naive. It is a continuously recurring con-
cept perpetuated by wish ul thinking rather than unbiased observation. It is not a
new idea. It has lured generations o surgeons as intelligent as ours into a period
o trial and acceptance that will take another generation to undo. Perhaps its in-
trinsic seductiveness is so great that plastic surgery is doomed orever to repeated
cycles o this idea being rediscovered and rediscarded. (PRS 66:69-70, 1980)
This book is a personal view o aesthetic breast surgery; there are bound to be
di ering opinions. I hope, however, that I have provided enough long-term
evidence to support my opinions, to help other surgeons avoid some o my mis-
takes, and to provide a oundation or urther investigation.
Elizabeth J. H all-Findlay
xiii
Pre ace
(Trang không có chữ)
xv
Once I was assigned to a rotation in plastic surgery, I no longer had any doubts
about what type o career path to pursue. I had known that I wanted to be a
surgeon, but I quickly realized the scope o the specialty, and the act that we
were able to not only put the puzzle pieces together, but also to design the puz-
zle itsel . I have never looked back.
Obviously, there were several mentors along the way who encouraged me and
provided guidance in all sorts o ways. Robert McFarlane opened the door to
plastic surgery or me when so many others told me surgery wasn’t a good
choice or a woman. Rollin Daniel showed me the possibilities. Rollin taught
me critical thinking and an appreciation or the history o plastic surgery, as well
as its unlimited potential.
The 1970s were an exciting time. Microsurgery was in its in ancy, and then
muscle and musculocutaneous aps came on the scene. I was privileged to have
been taught by the best. Luis Vasconez was so ull o ideas that none o us could
keep up. H e restored my temporarily destroyed aith in plastic surgery. That
year (1979-1980), I completed a ellowship with H arry Buncke; both he and
Luis Vasconez taught me to value amily and career. They seemed to be able
to juggle both—with sacrif ces along the way, o course—but they convinced
me that I could have it all, too. My other mentor was another li elong riend,
Paul Weiss. Paul taught me how to operate, but he also taught me how to treat
patients. He made sure that I did not lose sight o the reason we went into med-
icine, despite all the rustrations and roadblocks.
O course, I have many others to thank: Berish Strauch accepted me into his
residency program and provided me with a good oundation. I thank all the at-
tendings at Montef ore and Einstein. Over the years, Ian Taylor, a long-time
riend, has made me stop and think—and then observe the blood supply to the
breast. My associate, Tom Sinclair, has helped out when I got “stuck” and allowed
me to pursue my interest in breast surgery. My sta over 27 years have tolerated
a lot. They have helped me with patient care, documentation, and photographic
ollow-up. Leslie H o man, Debbie Myson, H eather Tennant, Judy Tennant,
Acknowledgments
Marie Whiting, Patsy Fisher, Cari Kaiser, Tracey McLean, Mike Ox ord, Colleen
Weatherhog, Linda H anna, Amanda Araujo, Maria Neish, and Kristene Brager
are only a ew who have helped. Dr. Sandra Mergler and Dr. Patty Edgar have
assisted me in many ways and have listened patiently to my rambling discus-
sions on what I see and what I think is happening.
Special thanks go to Julita de la Cruz, who began as my nanny and continues
as an invaluable o f ce assistant. She oversees all my operating room inventory
and takes and catalogs all my photographs. I couldn’t work—or play—without
her help.
I have three wonder ul children who have made my li e complete. Jamie, David,
and Elise have put up with my never getting home when I said I would and
have given up time with me when I seemed to be endlessly working. They have
all three become wonder ul young adults, and I could not be more proud o
them. I would like to thank their ather, Don Findlay, or accepting that I some-
times had to put work ahead o amily. H e was a good husband and ather.
My “other” amily is no less important. My mother, Betty H all, set high stan-
dards or all six o her children. She and my ather, H ugh H all, made sure that
we had the important things in li e. A good sense o right and wrong, along
with an emphasis on education, set us all on the right oot. My mother believed
that we could accomplish what we set our sights on.
Last, but not least, o course, I want to thank Karen Berger at Quality Medical
Publishing or believing that I had something to o er—and then pushing me
relentlessly to spend more evening and weekend time writing and sorting
through patient charts and photographs. It has been almost a 10-year project.
All the sta at QMP have been so good to work with. They all believe in pro-
ducing a pro essional product without compromise. Becky Sweeney, Carolyn
Reich, Amy Debrecht, Michelle Berger, Olivia Ayes, Taira Keele, and Andrew
Berger are only a ew o the sta dedicated to a high-quality product. Amanda
Behr, Brenda Bunch, and Jenni er Gentry are all medical artists who contributed
to the book. There are many others at Quality Medical Publishing working be-
hind the scenes who I should also thank and, even though I may not know their
names, I do not want them to go unacknowledged. I wish I had their talent.
xvi
Acknowledgments
xvii
PART I Concepts and Principles
1
Breast Analysis and Clinical Concepts, 3
2
Applied Anatomy: Key Concepts or Modern Breast
Surgery, 67
3
Surgical Principles, 99
4
Patient Selection, Education, and Surgical Decision
Making, 129
PART II Technique
5
Breast Augmentation, 147
5A-1
Preoperative markings or subglandular breast
augmentation, 176, 179
5A-2
Intraoperative review o markings or subglandular breast
augmentation, 179
5A-3
Inf ltration or subglandular breast augmentation, 180
5A-4
Pocket dissection or subglandular breast augmentation, 181, 182
5A-5
Implant insertion or subglandular breast augmentation, 183
5A-6
Incision closure or subglandular breast augmentation, 185
5A-7
Wrap-up or subglandular breast augmentation, 186
5B-1
Preoperative markings or subpectoral breast
augmentation, 176, 179
5B-2
Intraoperative review o markings or subpectoral breast
augmentation, 179
5B-3
Inf ltration or subpectoral breast augmentation, 180
5B-4
Pocket dissection or subpectoral breast augmentation, 181, 182
5B-5
Implant insertion or subpectoral breast augmentation, 183
5B-6
Incision closure or subpectoral breast augmentation, 185
5B-7
Wrap-up or subpectoral breast augmentation, 186
Contents
1
xviii
Contents
6
Vertical Breast Reduction, 249
6-1
Preoperative markings, 269, 270, 271, 272, 273, 276, 277, 279,
280, 281
6-2
Intraoperative review o markings, 281
6-3
Inf ltration, 282
6-4
Pedicle creation, 283
6-5
Parenchymal resection, 223, 284, 285, 286, 287
6-6
Pillar closure, 289
6-7
Closure o dermis, 292
6-8
Liposuction or contouring, 292
6-9
Skin closure, 293
6-10
Wrap-up, 296
7
Liposuction-Only Breast Reduction, 385
8
Breast Re-reduction, 403
8A
Re-reduction o previous vertical breast reduction, 404
8B
Re-reduction o previous inverted-T breast reduction, 404
9
Mastopexy, 429
9-1
Preoperative markings, 472, 473, 474, 475
9-2
Intraoperative review o markings, 476
9-3
Inf ltration, 476
9-4
Deepithelialization, 476
9-5
Creation o in erior wedge, 477, 478
9-6
Elevation o pectoralis strip, 479
9-7
Closure o pillars, 480
9-8
Closure o dermis, 480
9-9
Skin closure, 482
9-10
Wrap-up, 482
1
2
2
10
Mastopexy-Augmentation, 515
10-1
Preoperative markings, 543, 544, 545, 547
10-2
Intraoperative review o markings, 548
10-3
Inf ltration, 550
10-4
Pedicle creation, 551
10-5
In erior wedge excision, 552
10-6
Subpectoral pocket dissection, 551
10-7
Pillar closure, 554
10-8
Skin closure, 554, 555
10-9
Wrap-up, 555
11
Nipple Necrosis, 591
12
Breast Asymmetry, 637
Index, I-1
xix
Contents
2
(Trang không có chữ)
Concepts
and Principles
Part I
G
I
f
t
o
f
t
h
e
D
a
n
c
e
,
T
e
r
r
y
M
c
C
u
e
(Trang không có chữ)
Breast Analysis
and
Clinical Concepts
Chapter1
3
S
h
a
p
e
a
n
d
C
o
l
o
u
r
,
S
u
s
a
n
E
l
k
i
n
s
A
s surgeons we naturally tend to seek solutions to our patients’ breast prob-
lems in the operating room. H owever, be ore we undertake a surgical proce-
dure, it is essential to f rst care ully evaluate the patient’s breast appearance and
to visualize the potential aesthetic result ollowing surgery. To accomplish this
goal, we need a good understanding o the landmarks that in uence breast ap-
pearance and how these can be altered. Two separate issues must be assessed
be ore the appropriate surgical technique is chosen: (1) the breast position on
the chest wall or breast footprint and (2) the breast shape. The key to planning
the best surgical approach or each patient is to determine what can and can-
not be achieved with a particular shape and ootprint. Sometimes our desires
(and those o our patients) do not match our abilities to e ect change because
o existing anatomic limitations; these limitations must be ully explained to the
patient so that her expectations are realistic.
4
Part I • Concepts and Principles
The breast is a subcutaneous structure attached to the skin at the ourth inter-
space level. The only real skin attachment is at the nipple. The breast is not at-
tached to the pectoralis ascia or the chest wall. As the breast develops it pushes
the subcutaneous tissue outward. The breast ootprint is determined by the
Upper breast border
Lateral breast border
Medial breast border
(fixed over sternum)
Inferior breast border
(fixed inframammary fold)
zones o adherence to the skin (not to the breast) medially and in eriorly. The
shape o the breast on that ootprint is determined by the volume o tissue in
the upper, outer, inner, and in erior quadrants. The skin envelope plays a rela-
tively minor role in shaping the breast. Cooper’s ligaments hold the breast
parenchyma together but do not hold the breast to the skin, chest wall, or pec-
toralis ascia.
Breast Footprint
5
Chapter 1 • Breast Analysis and Clinical Concepts
The breast ootprint on the chest wall consists o our landmarks:
1. Upper breast border
2. In ramammary old
3. Medial breast border
4. Lateral breast border
A surgeon must f rst assess each o these landmarks on each patient be ore de-
ciding what surgical procedure is appropriate. Choosing a course o action de-
pends on an understanding o what can and cannot be done to change any o
these parameters. It is also important to recognize that the chest wall is not
completely at, allowing this ootprint to be positioned on each side o the chest
as i it were sitting on the sides o a sloping house roo .
U nderstanding the breast footprint on the chest wall is key to un-
derstanding what can and cannot be achieved in aesthetic breast
surgery.
The breast ootprint has both a vertical and a horizontal dimension. The hori-
zontal dimension can be widened with a breast augmentation, and it can be
narrowed with breast reduction.
An easier concept or patients to understand is that some patients are high
breasted and some are low breasted. This relates to the position o the breast
on the chest wall, which varies rom patient to patient. Some patients have a
high vertical breast ootprint (high breasted) and some have a low vertical breast
ootprint (low breasted). But the ootprint itsel can be either short or long.
6
Part I • Concepts and Principles
The patient on the le t is high breasted, whereas the patient on the right is low
breasted. It is not just that the patient on the right has breasts that hang lower;
the distance between the clavicle and the upper breast border (dashed line) is
much shorter in the patient on the le t. I one ignores the breasts, it is evident
that there is a much larger area o “f at” chest wall in the patient on the right
and much less in the patient on the le t. Patients need to understand that this
characteristic will not change.
The junction o the chest wall and the breast (the upper breast border) is marked
with a dashed line in both o these high-breasted patients. The in ramammary
old level is also marked on their chest walls between their breasts. The vertical
ootprint in the f rst patient (top) is very long, whereas the ootprint in the sec-
ond patient (bottom) is quite short. This has signif cant implications or the plan-
ning o surgical procedures.
7
Chapter 1 • Breast Analysis and Clinical Concepts
Both of these patients are low breasted, but the footprint spans a long vertical
distance in the rst patient (top) and a very short vertical distance in the second
patient (bottom). The upper breast border, where the chest wall meets the breast,
can be easily seen. The inframammary fold on both patients is marked with a
horizontal line on the chest wall between the breasts. The inframammary fold is
very low (below the elbow crease) in the rst patient but quite high (well above
the elbow crease) in the second patient. These footprint borders need to be
evaluated; they will determine what can be explained to the patient and will help
the surgeon determine key landmarks, such as the new nipple position.
H igh-breasted patients and low-breasted patients can have either a
long vertical breast footprint or a short vertical breast footprint.
8
Part I • Concepts and Principles
ZONES OF ADH ERENCE
The breast is a subcutaneous structure attached to the skin, not to the chest
wall. Cooper’s ligaments hold the breast parenchyma together but do not at-
tach to the skin, chest wall, or pectoralis ascia. The breast moves reely on the
chest wall, except where it is limited by the zones o skin adherence (skin at-
tachments). The breast ootprint is de ned by two zones o adherence between
the skin and the chest wall:
• In ramammary old
• Medial breast border
The in ramammary old zone o adherence supports the breast; it is located
where the skin attaches to the chest wall, approximately at the level o the sixth
rib. There is no de nable in ramammary old ligament, but there are clearly vis-
ible crisscrossing bers that secure the dermis to the deep ascia; these are di -
cult to reconstruct. The bers holding the skin in place orm a de nite con-
densation at the level o the in ramammary old and cover a variable distance
vertically. Traction can be applied on the bers to permit clear visualization o
the attachment to the dermis. These bers need to be maintained or reconsti-
tuted i there is to be any weight (breast or implant) pressing downward.
9
Chapter 1 • Breast Analysis and Clinical Concepts
The second zone o adherence is the medial border o the breast ootprint. This
zone o adherence is more di use over the sternum and allows only a minor
amount o mobility. The in ramammary old resembles the gluteal crease,
whereas the medial border over the sternum resembles the zone o adherence
over the sacrum.
Both the lateral breast border and the upper breast border are more mobile and
have no well-def ned zones o adherence. When a woman lies on her side, the
breast olds over the zone o adherence medially, but the opposite breast slides
out laterally, where there are minimal attachments. The breast slides superiorly
when she lies down, because there are no real attachments at the upper breast
border to prevent breast displacement. But when she stands up, the breast olds
over the in ramammary old because o the well-def ned zone o adherence.
The breast ootprint is def ned by two zones o adherence between
the skin and the chest wall: the in ramammary old and the medial
breast border.
U PPER BREAST BORDER
Analysis
The upper breast border is located where the chest wall and breast meet. The
border is o ten clearly demarcated and is the most important landmark or plan-
ning aesthetic breast surgery. Some women’s breasts are located close to the
clavicle, whereas others’ breasts are situated ar down on the chest wall and dis-
tant rom the clavicle. Individuals with a high upper breast border o ten have
very good upper pole ullness, while those with a lower upper breast border o -
ten exhibit little upper breast ullness. The ideal nipple position in these latter
individuals will also be much lower than in patients with a high border.
10
Part I • Concepts and Principles
The upper breast border is a curved line that lies just below the preaxillary ull-
ness. In the patient on the le t, the border sits below the preaxillary indenta-
tion. In the patient on the right, it sits just above the anterior edge o the preax-
illary indentation.
A surgeon can push the breast upward to delineate the junction between the
chest wall and the breast, but it drops back down to its original position post-
operatively. This upper breast border is often indicated by the upper limit of
the striae.
When the real (or apparent) upper breast border deviates greatly from its posi-
tion near the preaxillary crease, the breasts look abnormal.
11
Chapter 1 • Breast Analysis and Clinical Concepts
In both of these breast augmentation patients, the upper breast border (dashed
line) has deviated from its ideal position. This is much more evident in the pa-
tient on the left, where abnormally high-riding implants have raised the upper
breast border to a position that is well above the preaxillary indentation. Even
if the surgeon were able to elevate the breast tissue, it would look abnormal to
have breasts that high. Patients often ask that the implant be positioned higher
on the chest wall, but it is part of our role as surgeons to explain that this im-
plant placement would appear unnatural and unaesthetic.
Effecting Change
Realization that the upper breast border is a landmark that is peculiar to each
patient makes the planning process easier. It is not a zone of adherence. The
border can be elevated with implants and fat injections, but it is almost impos-
sible to elevate with sutures. It can be lowered by removing parenchyma.
Both the surgeon and patient need to be realistic about how much an implant
can (and should) raise the upper breast border. Usually the implant will alter
the vertical breast footprint in both an upward and downward direction.
This woman presented a ew years a ter breast augmentation with saline im-
plants (left). One implant had ruptured. Her breasts were symmetrical be ore and
a ter the augmentation. She is shown 4 months a ter the rupture (right). The up-
per breast border is marked with a dashed line. It should always lie close to the
level o the anterior edge o the indentation below the preaxillary ullness. Even
with an implant in place, the upper breast border is only raised a ew centimeters.
The in ramammary old was also unintentionally lowered with the implant, and
in this case it reverted to its normal position a ter the implant ruptured.
The upper border is delineated by marking the indentation just below the preax-
illary ullness. I this indentation is ollowed medially, the position o the upper
border o the breast becomes obvious and is marked with a dashed line.
12
Part I • Concepts and Principles
The patient on the le t is high breasted, with a short distance between her clav-
icles and her upper border (dashed line). The patient on the right, however, is
low breasted, and the distance between her clavicles and upper breast border is
signif cantly longer.
This woman has a low and well-de ned upper breast border (indicated by a
dashed line in the top photos and by an arrow in the bottom photos). H er
breasts start fairly far down the chest wall, away from the clavicle, just at the
level of the anterior edge of the indentation below the preaxillary fullness. Post-
operatively the lower pole is reduced and the breast has better projection, but the
upper breast border remains unchanged.
13
Chapter 1 • Breast Analysis and Clinical Concepts
This patient has a very high upper breast border (indicated by a dashed line in
the top photos and by an arrow in the bottom photos) that is close to the clav-
icle. Postoperatively this border is unchanged and remains at the level of the
anterior edge of the indentation, just below the preaxillary fullness.
The upper breast border is a far better determinant of the new nipple position
than the level of the inframammary fold or some arbitrary measurement from
the suprasternal notch. If the surgeon marks this upper border and then visu-
alizes the nal result, the ideal new nipple position will become obvious. This
position is a third to half the distance up the breast mound.
14
Part I • Concepts and Principles
The new nipple position for most C cup breasts should be about 8 to 10 cm
below the upper breast border. In the past I suggested placing the nipple at the
level of the inframammary fold, and this was good advice for most patients. In
the patients pictured above, however, this advice would be misleading. The nip-
ples are already at the level of the inframammary fold. The upper breast border
is clearly a better landmark.
15
Chapter 1 • Breast Analysis and Clinical Concepts
In the patient on the left, the new nipple position and the inframammary fold
level coincide well. In the patient on the right, however, the new nipple posi-
tion is placed lower than the inframammary fold (and was still placed too high),
because the inframammary fold is quite close to the upper breast border (dashed
line). These patients show that an arbitrary distance for a new nipple position
from the suprasternal notch could be misleading. All of these patients demon-
strate that the upper breast border is a consistently good landmark for deter-
mining the new nipple position vertically.
The in ramammary old is a good guideline or understanding the
existing breast ootprint on the chest wall, but the upper breast bor-
der is a better landmark or determining the ideal nipple position.
The new nipple position should be determined preoperatively while the patient
is standing, because the landmarks will not change. When a patient is lying
down, especially a ter some o the closure has been completed, some o the
landmarks are distorted, and it is more di f cult to accurately position the new
nipple.
INFRAMAMMARY FOLD LEVEL
Analysis
I one critically evaluates patients preoperatively, it becomes evident that their in-
ramammary old levels di er. In some patients the in ramammary old is at the
level o the elbow crease, whereas in others it is at a level hal way up the arm.
The arm position by itsel is not important, but it can serve as a landmark to
use in discussions with the patient. Many patients show what they want by
pulling upward on their breasts, elevating the in ramammary old. The surgeon
needs to explain that the position o the breast on the chest wall cannot be
changed, and it cannot be elevated the way that they ask. It is also important
to explain that the position at which the brassiere underwire will rest can only be
minimally changed, which may limit clothing choices.
The surgeon needs to assess and evaluate the in ramammary old
level to decide how to approach any potential changes in the level
itsel . It can only be changed slightly, but its original position on
the chest wall will ultimately determine the f nal result.
Although one would assume that patients with a high upper breast border would
have a high in ramammary old and vice versa, this is not always the case. Some
high-breasted patients actually have very large breast ootprints with low in ra-
mammary olds. Conversely, some low-breasted patients have relatively high in-
ramammary olds and very small breast ootprints.
16
Part I • Concepts and Principles
Both of these women have relatively high upper breast borders. The patient on
the right has a high inframammary fold (well above the elbow crease), and the
patient on the left has a low fold (at the level of the elbow crease). The infra-
mammary fold is marked on the chest wall between the breasts.
17
Chapter 1 • Breast Analysis and Clinical Concepts
Both of these women have relatively low upper breast borders (dashed line).
The inframammary fold of the patient on the left is quite high (well above the
elbow crease), and the inframammary fold of the patient on the right is quite
low (close to the elbow crease).
Often the inframammary fold levels are asymmetrical, with one higher than the
other. The fold is elevated when a woman raises her arms and when she is
supine. Interestingly, the breast with a higher inframammary fold tends to rise
higher with arm elevation than the breast with the lower fold; this is also true
of the nipple, which appears to rise higher with arm elevation on the side with
the higher fold. It is helpful postoperatively—especially in a breast augmenta-
tion patient—to be aware of this dynamic asymmetry before surgery and to
point it out to the patient.
This woman has in ramammary olds at di erent levels. Measurements can be
made both be ore and a ter surgery to see what changes in the in ramammary
old position can be e ected with di erent surgical techniques. Surgery is an art,
but a better understanding comes with science, measurement, and evaluation.
18
Part I • Concepts and Principles
When a patient has lost massive amounts o weight, the in ramammary old f bers
are o ten stretched so extensively that the zone o adherence is lost, and the old
itsel loses its def nition and drops. This makes any kind o body-contouring
correction quite di f cult, because the old can be easily pulled downward with
an abdominoplasty; the surgeon should be aware o this potential problem.
Normally we can pull upward on the breast and elevate the in ramammary old
during the physical examination, but the old is at its lowest level when the pa-
tient is standing. It o ten rides up to some degree when the patient lies down.
H owever, in massive-weight-loss patients, the old seems to oat easily in both
directions vertically.
The in ramammary old can “ oat” a ter massive weight loss, be-
cause the in ramammary old f bers have been stretched. Normally
the old is mobile upward on physical examination but cannot be
pulled downward when a patient is standing.
Effecting Change
Elevating the Fold
The in ramammary old can be raised slightly with some methods o breast re-
duction when the bulk o the breast tissue is removed in eriorly and the pedi-
cle and remaining breast tissue are le t superiorly. Direct excision o some in-
ramammary old f bers, combined with liposuction, is help ul or tailoring the
old, especially medially and laterally, to allow it to develop a nice upward curve.
This change can be e ected only i there is no pressure (weight) pushing down-
ward on the old. Removal o old f bers would be contraindicated i tissue or
an implant were le t in eriorly to push downward on the old. When an in erior
pedicle technique is used, the old cannot be raised.
Most inverted-T techniques rely mainly on a horizontal elliptical excision o
breast tissue and skin, and most vertical techniques rely on a vertical elliptical
excision o breast tissue and skin. The vertical techniques tend to narrow and
cone the breast, resulting in more projection. In the inverted-T techniques, a
dog-ear is created at each end, medially and laterally. In the vertical techniques,
two dog-ears result at either end—one into the areola (which disappears) and
one that creates a pucker at the level o the in ramammary old. In vertical tech-
niques that only remove a vertical wedge or in those that use an in erior pedicle,
the in ramammary old will not rise.
19
Chapter 1 • Breast Analysis and Clinical Concepts
A comparison o the location o this patient’s abdominal scar relative to the in-
ramammary old shows that the old has been raised a ter a vertical breast re-
duction. This can only occur with removal o tissue (not skin) along the in ra-
mammary old.
This patient shows the amount o in ramammary old elevation that can be
achieved with removal o tissue above the existing in ramammary old. A ter
undergoing lumpectomy and radiation therapy on her le t breast, she asked or
a matching procedure on her right breast. Preoperatively her right in ramam-
mary old was signif cantly lower than the le t. A ter corrective surgery with
breast reduction on the right side, her old is clearly elevated and matched to
the opposite side. It is not always desirable to elevate the old, but these pho-
tos show the power o in ramammary old elevation.
The inframammary fold can rise with some vertical breast reduc-
tion techniques. This can only occur if the inferior weight of the
breast tissue is removed.
20
Part I • Concepts and Principles
Lowering the Fold
When a breast augmentation is per ormed, the breast mound is adapted to the
existing nipple position, and the in ramammary old is o ten purposely lowered.
This is particularly true or a tuberous breast de ormity.
21
Chapter 1 • Breast Analysis and Clinical Concepts
The in ramammary old on this woman’s le t breast was lowered to some de-
gree but not excessively. The problem with lowering the old is that the in ra-
mammary old f bers are released, and the weight o an implant can push the
old even lower. In my experience, this lowering is more likely to occur with
saline implants. My theory is that the piston or “water hammer” e ect o the
saline against the implant envelope can aggravate this problem.
This woman had subpectoral saline implants. The right in ramammary old was
purposely lowered to center the implant under the breast mound. However, the
old continued to drop, as seen at 5 weeks and then at 4 months postoperatively.
The inframammary fold can drop, either intentionally with surgery
or from pressure. This can occur with inferior pedicle inverted-T
breast reductions, with augmentation mammaplasty, and with
mastopexy-augmentation procedures.
Sometimes patients who have had previous breast reduction surgery present
with nipples that appear to be too high. Although in some cases the surgeon
positioned the nipples too high, o ten the problem is that the in ramammary
old has dropped. This can be conf rmed by observing the position o the in-
ramammary old relative to the in ramammary scar.
22
Part I • Concepts and Principles
Preoperative
5 weeks postoperatively
4 months postoperatively
This patient has two problems. The nipples were placed too high relative to the
upper breast border, which is at the level of the indentation just below the preax-
illary fullness, and her inframammary fold has dropped out (pseudoptosis). The
nipple position cannot be corrected, but the inframammary fold can be elevated.
Direct excision of the skin along the inframammary scar with pushing up of the
breast tissue will prove unsuccessful, with repeat dropping out. The key to cor-
rection is to remove a vertical wedge of breast tissue and to excise, directly or
with liposuction, the tissue (not the skin) between the dropped out inframam-
mary fold and the scar. This maneuver will create the illusion of lower nipples
(see Chapter 8).
23
Chapter 1 • Breast Analysis and Clinical Concepts
The inframammary fold has dropped below the scar in both of these previous
inverted-T inferior pedicle breast reduction patients. On the right, the scar is
marked with a dashed line.
Although some surgeons purposely place the inframammary scar above the level
of the fold, the scar often ends up several centimeters above the fold. I believe
that many inverted-T procedures compress the parenchyma, and, as the skin
stretches, the breast tissue is forced inferiorly. This is likely to be made worse
by methods that resect tissue superiorly and leave a heavy inferior pedicle. Some
surgeons emphasize that it is important not to violate the inframammary fold
itself, but bottoming out of the inframammary fold occurs across the base of
the inferior pedicle, which is clearly not disturbed by the surgery.
The inframammary fold level can be elevated with some vertical
breast reductions and lowered with breast augmentation or with a
mastopexy-augmentation procedure, sometimes unintentionally.
MEDIAL BREAST BORDER
Analysis
The medial breast border is limited by the fascial attachments to the lateral bor-
der of the sternum and can rarely be moved medially. Attempts to alter this bor-
der should be approached with some trepidation; too much narrowing of the
cleavage can result in implant edge visibility or even synmastia. Care must be
taken not to damage the vessels from the internal mammary system that perfo-
rate the pectoralis muscle as they appear from around the edge of the sternum.
Effecting Change
24
Part I • Concepts and Principles
For this woman with asymmetrical breasts, the planned widening of the medial
breast border is marked with a crosshatched line. In this situation the border
can be moved with an implant. In pure augmentation patients, it is hard to move
the border medially without risking visibility of the implant edge.
The medial breast border determines breast cleavage. This can be quite variable
and challenging to alter.
A woman’s cleavage cannot be narrowed to any signif cant degree, even with a
breast implant. This woman’s medial breast borders (dashed lines) are close to
each other, creating cleavage that can usually be maintained with a breast aug-
mentation.
25
Chapter 1 • Breast Analysis and Clinical Concepts
In this patient, both medial breast borders (dashed lines) are widely spaced, mak-
ing it di f cult to narrow her cleavage with a breast augmentation. It is important
or patients to understand that the medial border is one o the most di f cult to
alter.
In very muscular patients, as shown here, placing the implant below the mus-
cle can result in lateral movement o the medial breast border with widening o
the cleavage.
LATERAL BREAST BORDER
Analysis
The lateral breast border is ideal when it is f ush with the lateral chest wall. I it
is too narrow, it can be widened with an implant. The ootprint itsel rarely ex-
tends beyond the lateral chest wall, but o ten the surgeon will want to remove
some o the at in this area or better contouring.
Effecting Change
When breast augmentation is planned, it is important that the surgeon match
the implant base diameter to the ideal breast diameter rather than to the exist-
ing breast diameter. I the lateral breast border is too narrow, it is o ten easily
corrected with an implant when a patient desires an augmentation. The surgeon
should not be restricted to ollowing the existing breast diameter and should
instead use a wide enough implant base to widen the lateral breast border.
26
Part I • Concepts and Principles
In this patient, the base diameter o the right breast should be ignored so that
the ootprint can be increased in all our dimensions. In the vertical dimension,
it is necessary to lower the in ramammary old slightly and to center the implant
behind the nipple. To achieve better symmetry, an implant with a larger base
diameter than the base diameter o the right breast is indicated.
This young woman has pectus excavatum with a signif cant lateral slope to the
chest wall. This slope makes her nipples look quite lateral. To correct this prob-
lem, the lateral breast border needs to be moved laterally to permit the implant
to be centralized behind the nipple. Without this correction, her nipples would
have appeared too lateral on the breast mound. This correction is more di f -
cult to achieve on a sloping chest wall. In this woman, the upper breast border
is low and has not been raised signif cantly. It is now slightly above the inden-
tation just below the preaxillary ullness.
27
Chapter 1 • Breast Analysis and Clinical Concepts
Normal
Sloped chest wall
In a patient whose breast base is too wide, the excess lateral fullness can be re-
duced with a combination of direct excision and peripheral liposuction for tai-
loring. Although some augmentation patients exhibit too much fullness in the
lateral chest wall, it is typically breast reduction or mastopexy patients who re-
quire lateral tailoring. Liposuction can be performed to contour three distinct
areas in the lateral breast: the lateral chest wall, the lateral breast beyond an ideal
inframammary fold, and the preaxillary fullness.
28
Part I • Concepts and Principles
This patient needed reduction of her lateral breast border. This was achieved by
narrowing the breast using a vertical wedge excision in combination with direct
excision and liposuction, as shown in the crosshatched areas. The lateral breast
border is better delineated when the patient is lying down. It is important to
remove the excess tissue (usually by liposuction) in the crosshatched areas.
The breast footprint (base) on the chest wall varies from patient to
patient. The vertical and horizontal dimensions of this footprint
should be noted preoperatively to understand what can and cannot
be changed. The actual shape and slope of each side of the chest
wall must also be taken into account.