Phẫu Thuật Thẩm Mỹ Vòng 1: Các Khái Niệm Và Kỹ Thuật (Aesthetic Breast Surgery)

530
Part II • Technique
This woman, on the other hand, had some parenchyma removed on her right
breast, and her glandular ptosis did not recur. She had a superior pedicle
mastopexy-augmentation with an inferior wedge resection of 75 g on the right
side; 270 cc smooth-walled saline implants were placed in the subglandular lo-
cation. She is shown 1 year postoperatively with complete return of sensation.
Pseudoptosis
Pseudoptosis is usually a secondary problem resulting from a previous breast
reduction procedure in which the nipple was placed too high, and the infra-
mammary fold dropped out below its original level. The vertical footprint has
been elongated, which exaggerates the malposition of the nipple. The nipple
should be about a third to half the distance up the breast mound. With pseudo-
ptosis, the nipple appears too high, with too much volume in the lower pole.
The problem is dropping of the inframammary fold, not glandular ptosis.

531
Chapter 10 • Mastopexy-Augmentation
Pseudoptosis can be challenging to treat. Ideally, an implant can be added
to raise the upper breast border, but the in ramammary old f bers have
been stretched, and the in ramammary old needs weight removed rather
than added. It can be di f cult to place an implant, either above or below
the muscle, and have it stay in the upper pole as desired.
This patient originally had an inverted-T in erior pedicle breast reduction, and
her nipples were placed too high—too close to the upper breast border (ar-
row). The problem could be addressed by augmenting the upper pole o her
breast while reducing lower pole tissue. Un ortunately, an implant can only raise
the upper breast border slightly, and a large implant will instead f ll the lower
pole disproportionately. These problems are di f cult to correct; sometimes an
implant exacerbates the problem. These implants were placed completely sub-
muscularly, but I f nd that there is very little adherence o the muscle in eriorly,
and the implant can almost sel -dissect and drop out.

532
Part II • Technique
For a patient who previously had a breast reduction procedure, it may be better
to create a subglandular pocket conf ned to the upper pole. By leaving the in-
erior breast tissue attached to the chest wall (there is o ten some scar tissue that
can be le t in place in eriorly), this limited pocket dissection may help prevent
descent o the implant.
SU RGICAL PRINCIPLES
Inferior Wedge Resection
I have become convinced that the key to achieving long-lasting aes-
thetic results in mastopexy-augmentation is to understand the dif-
ference between nipple ptosis and glandular ptosis. When the pa-
tient has glandular ptosis, the inferior wedge principle should be
respected.
To avoid burning bridges while per orming mastopexy-augmentation, the im-
plant should be inserted f rst be ore removing any skin; otherwise, the surgeon
may produce undue compression on the nipple when the skin is closed under
too much tension. A mastopexy-augmentation should not rely on the skin or
support, and a tight closure is not necessary. As with a breast reduction and
mastopexy, the f nal result will depend on what is done with the parenchyma.
The breast needs to be shaped, and the skin needs to be redraped.

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Chapter 10 • Mastopexy-Augmentation
This patient has ptosis o both the nipple and the gland. The dotted line marks
the upper breast border, and the new nipple was placed 24 cm rom the
suprasternal notch. The breast meridian is marked in its desired position, not
in its existing position. She had an in erior wedge resection o tissue, with 40 g
removed rom her right breast and 45 g rom the le t breast; Style 115 322 cc
textured responsive gel implants were placed in the sub ascial pockets.
A Doppler examination was per ormed ( or study purposes only); it showed the
artery rom the internal mammary system rom the second interspace (red ar-
rows) entering the areolar opening just medial to the breast meridian. This
artery is usually audible with a pencil Doppler device, because it is only about
1 cm below the skin sur ace. In the intraoperative photo the artery and venae
comitantes that supply an in erior pedicle and an in erior f ap are shown (arrow).
The artery penetrates the intercostals rom the internal mammary artery in the
ourth interspace and then penetrates the pectoralis muscle. It is destroyed when
the implant is inserted, in either the subglandular or the subpectoral location.

534
Part II • Technique
This patient is shown 5 months and 17 months postoperatively. H er supraster-
nal notch-to-nipple distance was 27 cm and 27.5 cm preoperatively, and the
new nipple was marked at 24 cm. Postoperatively it has stretched to 27 cm bi-
laterally. The distance from the lower border of the areola to the inframammary
fold measures 8 cm on the right and 11 cm on the left postoperatively. The
suprasternal notch-to-inframammary fold distance increased by 2 cm. She has
complete return of sensation.

535
Chapter 10 • Mastopexy-Augmentation
Subfascial Sling
Surgeons should be skeptical of claims of good results when the reported
follow-up is less than a full year. I still hear surgeons claiming that the fas-
cia can be used as a sling to hold up the implant. The concept seems log-
ical, and at one time I thought it very appealing. Unfortunately, a care-
ful review of my cases shows that the fascial sling did not support the
implant; it stretched over time, and glandular ptosis recurred.
These photographs show the fascia dissected as an inferior sling. The view on
the left is from below (a superior pedicle was used). In the photo on the right
(shown from above), the fascia is held in the forceps, and it appears to be sub-
stantial enough to support an implant.
The fascia was then sutured up to the medial and lateral pillars and secured to
prevent it from sliding back around the implant. The inferior fascia can be ele-
vated when the implant is placed in either the subglandular pocket or the dual-
plane subpectoral pocket.

536
Part II • Technique
This woman had a mastopexy-augmentation with placement of Style 115 354 cc
textured responsive silicone gel implants and a subfascial sling for support;
25 g of tissue was removed from the lower pole of each breast.
Initially it appeared that the fascial sling worked well to suspend the implants.
She is shown 1 month postoperatively.

537
Chapter 10 • Mastopexy-Augmentation
At 6 months postoperatively, however, it is obvious that the fascial sling was
not effective in maintaining implant elevation.
One year after surgery, her implants have dropped out and the fascia is stretched.
Preoperatively her suprasternal notch-to-nipple distance was 22 cm on both
sides. The new nipple position was marked at 19 cm. Postoperatively the
suprasternal notch-to-nipple distance has stretched to 23 cm on both sides. The
distance from the lower border of the areola to the inframammary fold mea-
sures 10 cm on the right and 8 cm on the left postoperatively. The supraster-
nal notch-to-inframammary fold distance has dropped from 19.5 to 21 cm. She
has complete return of sensation.
Analysis
In judging the results in this patient, it would be tempting to con-
clude that the fascia was too thin and not substantial enough to be used for sup-
port, but I was able to locate good, fairly thick fascia, so that was not the prob-
lem. To prevent the fascia from slipping back under the inferior aspect of the
implant, it was sutured to the pillars, which means that the surgical technique
was acceptable. Nevertheless, despite these efforts, the fascia still stretched.

538
Part II • Technique
This patient also had mastopexy-augmentation. A superior pedicle was used for
the nipple-areola complex, and textured Style 115 203 cc responsive silicone
gel implants were placed on each side. A fascial sling was used; 15 g of tissue
was removed from the right breast and 40 g from the left breast.
She is shown 3 weeks postoperatively with the paper tape still in place. It ini-
tially appeared that the sling was effective.

539
Chapter 10 • Mastopexy-Augmentation
Five months postoperatively, the implant had dropped somewhat.
By 16 months postoperatively, it is obvious that the implant has bottomed out
to some degree despite the use of the fascial sling. H er suprasternal notch-to-
nipple measurement was 22.5 cm on both sides preoperatively, and the nipple
was placed at 20 cm. Postoperatively the suprasternal notch-to-nipple distance
stretched to 21.5 cm on both sides. The distance from the inferior border of
the areola to the inframammary fold measures 9 cm on the right and 8 cm on
the left. The suprasternal notch-to-inframammary fold did not change. She has
complete return of sensation.
Analysis
The fascial sling did not hold in the patients in whom it was used,
even when the implants were small, and their suprasternal notch-to-nipple dis-
tances stretched from their marked positions.

540
Part II • Technique
Fascia stretches and is not effective as a sling to support an implant.
Although some surgical maneuvers may seem promising, it is im-
portant to follow patients for at least 1 year to determine whether
these techniques are worthwhile.
TREATMENT OPTIONS
Staging
Although there are surgeons who pre er to stage the mastopexy-augmentation,
I do not think that it improves the long-term result. Without doubt, staging
will probably reduce the incidence o complications, but I do not think that
it will improve the long-term shape o the breast. Spear and colleagues noted
that the problems encountered with a single-stage mastopexy-augmentation are
not double the complications o a mastopexy and an augmentation, but are in-
stead a potentially higher number. Alternatively, staging has a 100% revision
rate, which I think is not only unnecessary but a burden to the patient.
Tissue Rearrangement
It would be ideal to just rearrange the in erior wedge o tissue rather than to re-
move it. One option would be to place an implant in the upper pole to avoid
damaging the in erior ap blood supply; however, as I have shown, it is di f cult
to prevent the implant rom dropping and to close the pillars without tension.
Another option would be to recruit the in erior wedge by using a superior pedi-
cle extension ap. Again, the problem is tension. It may be di f cult to close the
pillars without compressing the circulation to the nipple-areola complex. I have
tried to use a superior pedicle extension ap along with an implant, but it is
challenging to inset the extension and simultaneously place an implant. It can be
impossible to close the pillars. In my experience, I have ound it necessary to
excise the extension.

541
Chapter 10 • Mastopexy-Augmentation
A sub ascial sling was also used to help keep the 335 g CML cohesive gel im-
plants rom dropping. Only skin was removed rom the right breast and 65 g
o tissue was removed rom the le t breast.
This woman had a mastopexy-augmentation with a superior pedicle extension
f ap. The f ap is shown below deepithelialized, elevated, and turned up under
the pedicle. The implant was inserted, and a ascial sling was pulled up and su-
tured to the pillars.

542
Part II • Technique
She is shown 18 months a ter surgery.
Analysis
The superior pedicle extension ap did not hold well enough to pre-
vent recurrent glandular ptosis. The nipple was placed too low in this patient.
It is important to visualize the f nal breast mound during planning. In a
mastopexy-augmentation, the suprasternal notch-to-nipple distance will stretch
by about 2 cm on average, and the upper breast border will be raised a similar
amount; these changes need to be taken into account. The new nipple position
should be about 8 to 10 cm below the f nal level o the upper breast border.
Because o these two actors, there is no need to lower the new nipple position
to take into account the pendulum e ect o the increased projection (which
makes the nipple look higher.
Preoperative

18 months postoperatively

543
Chapter 10 • Mastopexy-Augmentation
This young woman’s breasts have dropped o a good ootprint. H er upper
breast border is at the upper end o her striae, just below the preaxillary ull-
ness. The upper breast border can easily be seen on the lateral view, where there
is a relatively clear demarcation between the chest wall and the breast.
Further elevation o the nipple and urther removal o in erior parenchyma (78 g
on the right breast and 70 g on the le t) have helped improve both the gladu-
lar and nipple ptosis.
PREFERRED OPERATIVE APPROACH
I have tried di erent procedures to achieve a good result while combining a
mastopexy with a breast implant. A ter a care ul review o my results, I have
concluded that Regnault was correct when she advised us to use a minus-plus
approach. I have not f gured out how to rearrange the in erior wedge o breast
tissue to correct the glandular ptosis that is so common in patients who want
both a li t and some improvement in upper pole ullness. My best results have
been achieved by actually removing the in erior wedge and compensating with
a larger implant.
Markings: Anatomic Considerations
Upper Breast Border
2
10-1 Preoperative
markings

544
Part II • Technique
In some patients the upper breast border may not be obvious; it can be better
def ned by li ting the breast, as shown in this patient. It is always located below
the preaxillary ullness.
Breast Meridian
The breast meridian should be drawn in the desired location, as shown on this
patient’s right breast—not in the existing location. It is marked medial to the
existing nipple position on the right because o the lateralized nipple. On the
le t breast, the meridian is drawn close to the existing meridian. The ideal breast
meridian is usually about 10 cm rom the chest midline at the level o the new
nipple (as drawn through the air, not around the curve o the breast).
2
10-1 Preoperative
markings

545
Chapter 10 • Mastopexy-Augmentation
New Nipple Position
The new nipple position is located on the new breast meridian. The ideal vertical
position o the nipple is determined in relation to the upper breast border. O -
ten the ideal position is at the level o the in ramammary old, but the old level
can be a misleading landmark in many patients. Postoperatively in many C to
D cup patients, the ideal nipple position is about 10 cm below the upper breast
border.
A mastopexy-augmentation will have a signif cant e ect on both the upper breast
border and the new nipple position. Some surgeons try to drop the new nipple
position to accommodate the increased projection achieved by the implant.
H owever, they need to recognize that the upper breast border rises with im-
plant placement, and the suprasternal notch-to-nipple distance lengthens. The
shape o the breast (the third dimension) also changes as the suprasternal notch-
to-nipple distance drops with an implant in place. I now suggest marking the
new nipple position at the same level in both a mastopexy and a mastopexy-
augmentation because o this e ect o the implant.
Low-Breasted Footprint
This 5 oot 7 inch woman is low breasted, and her breasts are also quite low
(the breast shape has signif cantly dropped o the ootprint). Her existing breast
meridian is lateral to her ideal breast meridian. H er upper breast border is
marked with a dotted line. The distance between her clavicle and her upper
breast border is 12 cm (arrow), and the new nipple position is marked at 7 cm.
2
10-1 Preoperative
markings

546
Part II • Technique
When marking the new nipple position, the surgeon must be aware that the
suprasternal notch-to-nipple distance will stretch. The new nipple position was
marked at 21 cm from the suprasternal notch, and postoperatively it stretched
(even as early as 3 months) to 23 cm. The distance from the clavicle to the up-
per breast border measured 12 cm preoperatively and measures 10 cm postop-
eratively (arrow). With time, however, the implant will still likely drop, and in
placing the nipple, it is important to err on the lower side of what would be
ideal.
H igh-Breasted Footprint
This 5 foot 4 inch woman is high breasted. Preoperatively the distance from
her clavicle to her upper breast border was 10 cm (arrow); her new nipple po-
sition was marked at 8 cm below the upper breast border.

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Chapter 10 • Mastopexy-Augmentation
The new nipple position was marked on the new breast meridian at 21 cm from
the suprasternal notch; it has stretched to 23 cm, as seen 11 months postoper-
atively. H er upper breast border was already high; it measures only 8 cm from
the clavicle postoperatively(arrow). The upper edge of the implant is actually
sitting a bit too high, because it is slightly above the preaxillary crease. The
breast footprint should not extend higher than the preaxillary fullness or it will
look odd. There are patients, however, who wish to have such abnormally high
breasts.
Areolar Opening
The upper edge of the areola is marked 2 cm above the new nipple position,
and the areola is drawn freehand. It is important not to have a large areolar skin
circumference, because the areolar tissue will stretch under tension. The im-
plant will add extra pressure. One problem with a mastopexy-augmentation is
widening of the areola. A 4.5 cm diameter areola has a circumference of 14 cm;
it is therefore advisable to try to keep the circumference as small as is practical.
2
10-1 Preoperative
markings

548
Part II • Technique
Sometimes the areolar opening must be de-
signed to make certain that all the pigmented
areolar skin is removed, as was done or this
woman. The areolar opening does not need to
be mosque shaped, but it should be designed
so that there is as little tension as possible on
the areola postoperatively. When the areola is
closed, it should orm a circle.
2
10-2 Intraoperative
review of markings
The skin resection pattern is similar to that used or a breast reduction or a
mastopexy. The design resembles a snowman. A superior pedicle is drawn and
a vertical line ( or the initial incision) is marked. The skin and parenchymal re-
section design is considered tentative and will only be conf rmed once the im-
plant is in place.
Pedicle Design
I have tried di erent pedicles and now think that the superior pedicle is the
sa est and best design or mastopexy-augmentation. Insertion o the implant in
either a subpectoral or subglandular location will damage the blood supply to
Skin Resection Pattern
The skin resection pattern is drawn, but in a mastopexy-augmentation, the skin
should not be excised until the implant is in place to avoid “burning any
bridges” and potentially impeding closure.

549
Chapter 10 • Mastopexy-Augmentation
an in erior pedicle, and dissection laterally can damage the superf cial branch o
the lateral thoracic artery. Dissection medially can damage the per orator rom
the internal mammary system, but it is less likely that the artery rom the sec-
ond interspace that supplies a superior pedicle will be damaged. The medial
pedicle o ten gives a better postoperative shape when the in erior wedge o
parenchyma is removed, because the in erior border o the medial pedicle be-
comes the medial pillar. This is less important in a mastopexy, in which the in-
erior wedge is rearranged, or in a mastopexy-augmentation, in which an im-
plant is inserted.
These photographs depict a lateral pedicle design and a superior pedicle design.
I now use the superior pedicle most requently or mastopexy-augmentation
patients.
Implant Choices
As discussed in Chapter 5, I have ound that the best choice in implants is the
newer-generation smooth-walled silicone gel implant. My experience with saline
implants demonstrated a airly high long-term incidence o capsular contrac-
ture, regardless o whether they were placed above or below the muscle.
Pocket Location
Patients tend to think that implants placed in the subpectoral plane will have a
better chance or remaining elevated. I do not believe that this is true under
normal circumstances. The pectoralis muscle can spasm (usually just the in e-
rior portion that has su ered some surgical trauma), and this can push the im-
plant up into an abnormally high location during the recovery period. I the
implant settles into the desired location, the muscle can sometimes push the
implant down and out. Occasionally the implant will not settle into its desired
location and remains high, requiring a release. This problem can be used to ad-

550
Part II • Technique
vantage in some situations to try to keep the implant behind the upper pole o
the breast, not allowing it to settle into a position centralized behind the breast
mound. This does not always work, and the results can be unpredictable.
I have not ound any di erence in capsular contracture rates with subpectoral
placement, regardless o the implant selected: smooth saline, smooth silicone
gel, or textured silicone gel (see Chapter 5).
I usually choose the subglandular location i a patient has 3 cm o padding in
the upper pole and 1 to 2 cm o padding medially. I o ten let the patient de-
cide which pocket she pre ers, but in a very thin patient I insist on a subpec-
toral location, because she will not have enough padding. H owever, I believe
that the most natural location or the implant is subglandular. A subpectoral
location widens the cleavage and results in the dancing breast syndrome with
pectoralis muscle contraction (see Chapter 5, p. 205).
OPERATIVE TECH NIQU E
Positioning
The patient is marked while standing and is placed supine on the operating table
with her arms extended laterally, slightly less than a ull 90 degrees. I the sur-
geon plans to sit the patient up during the procedure to assess symmetry, her
arms should be appropriately wrapped on the arm boards.
Inf ltration
I the patient requires liposuction along the lateral chest wall, I use a tumescent
type o inf ltration to reduce bleeding (1 L o Ringer’s lactate, 20 ml lidocaine 2%,
1 ml epinephrine 1/ 1000). I do not inf ltrate along the incisions, because the
veins that travel just under the dermis can be damaged. I inf ltrate a lidocaine-
epinephrine mixture in eriorly and laterally, where the in erior wedge o paren-
chyma will be removed (20 ml lidocaine 0.5% with 1/ 400,000 epinephrine).
2
10-3 Infiltration

551
Chapter 10 • Mastopexy-Augmentation
Deepithelialization
2
10-4 Pedicle creation
I the implant is to be placed subglandularly (I no longer use the sub ascial lo-
cation), the breast is elevated superiorly until an adequate pocket is created or
the implant. I the implant is to be placed under the pectoralis muscle, the lat-
eral muscle f bers are elevated and a subpectoral pocket is created. The in erior
border o the muscle is released toward the sternum, and the release is adjusted
so that there is not a sharp junction where the release ends.
The superior pedicle shown here has been deepithelialized in the usual man-
ner, with care taken to avoid damage to the veins just deep to the dermis. A
vertical incision is used or insertion o the implant. It is important not to ex-
cise the skin at this stage.
Implant Insertion
I usually make decisions about implant size preoperatively, but sizers can be
used. The superior pedicle is incised in eriorly, and the vertical incision is made
completely down through the parenchyma until the pectoralis ascia is reached.
2
10-6 Subpectoral
pocket dissection

552
Part II • Technique
The proposed skin resection is marked, but not excised, until the implant is
inserted.
Inferior Wedge Resection
Once the implant is in place, the surgeon can pinch the skin to conf rm that
closure can be achieved without excess tension. The skin is marked and the im-
plant is removed to avoid damage to it during the in erior wedge resection.
Both skin and in erior parenchyma are removed. I there is a minimal amount
o glandular ptosis, a minimal amount o parenchyma should be removed. I
the excess ptotic gland is not removed, it will drop back down postoperatively
as the months go by.
2
10-5 Inferior wedge
excision

553
Chapter 10 • Mastopexy-Augmentation
Care should be taken to keep the implant rom bottoming out. As noted ear-
lier, I have ound that a ascial sling alone (which initially seemed like a good
idea) will not be success ul. I possible, however, it is best not to dissect the
pocket too ar in eriorly. These photographs show that the dissection is not car-
ried caudal to the dotted line o the in erior margins o the Wise pattern. The
f ngers show the in erior margin o the dissection. Liposuction can be used to
contour the in ramammary old be ore f nal insertion o the implant.
A Wise pattern o parenchyma should be le t behind, and all tissue below that
pattern should be directly excised and tailored with liposuction. It is best to
per orm any liposuction without the implant in place; even with appropriate
care, the implant can be damaged with the liposuction cannula.

554
Part II • Technique
The deep dermis is closed with a ew interrupted 3-0 Monocryl sutures (left).
Only enough sutures are used to get dermis-to-dermis apposition; too many
sutures will constrict the blood supply. Usually our deep dermal sutures are
needed around the areola. The skin is then closed (right) with a subcuticular
3-0 Monocryl suture both vertically and around the areola. The vertical closure
is not gathered or cinched.
Pillar Closure
2
10-7 Pillar closure
2
10-8 Skin closure
Once the implant is inserted, it is essential to close the breast parenchyma (not
just the skin) beneath the implant. A good, solid closure is critical, but the pil-
lars should not be closed under excess tension, which is why the design or skin
and parenchymal excision is not made until the implant is in place. I usually use
two or three layers o 3-0 Monocryl, making certain that I suture “white stu to
white stu ” and that f brous tissue is in contact with f brous tissue or solid
healing. Suturing at to at is not likely to provide a secure closure.
Skin Closure

555
Chapter 10 • Mastopexy-Augmentation
Initially it was thought that the vertical scar needed to be shortened, but with ex-
perience it became clear to me that the ull vertical length is needed to accom-
modate the increased projection. It also became obvious that when the vertical
incision was gathered, either it stretched back out or ormed pleated puckers
that needed to be corrected. It is best to leave the vertical incision ull length.
It is ideal i the areolar skin opening can be matched to the areolar circum er-
ence. It is well known that the areola will stretch with an implant in place. I
the circum erence o the skin opening is longer than the circum erence o the
areola, stretching will occur i a mastopexy alone is per ormed. Adding an im-
plant will cause urther stretching. Some surgeons use a deep Gore-Tex suture
around the areola to try to control stretching, but I have not ound this to be
uni ormly success ul.
POSTOPERATIVE CARE
I rarely place drains. The incisions are covered with Micropore paper tape, which
stays in place or 3 to 4 weeks. Patients are placed in a brassiere, mainly to hold
gauze bandages in place and to give the patient a sense o support. Care should
be exercised to ensure that the bra does not compress the nipple.
Patients are encouraged to shower the day a ter surgery. Their activities are not
restricted, unless the implant is placed beneath the muscle. Patients with sub-
pectoral implants are discouraged rom weight-li ting or sports activities or
4 weeks.
PROBLEMS AND COMPLICATIONS
Many o the complications with mastopexy-augmentation are the same as those
that occur a ter breast reduction, mastopexy, and augmentation. Some compli-
cations are implant specif c, pocket specif c, and procedure specif c. Some o the
general complications (such as nipple necrosis) are detailed in other chapters.
2
10-8 Skin closure
2
10-9 Wrap-up
The best way to avoid areolar stretching
and the resultant wound-healing problems
is to ensure that the closure is per ormed
with as little tension as possible. It can be
seen in this photograph that the skin a ter
closure is still relatively loose and can be
pinched. The key to a long-lasting result,
and to avoidance o postoperative compli-
cations, is reliance on the in erior wedge
excision.

556
Part II • Technique
H ematoma
The potential for hematoma development can be reduced with a good
understanding of the blood supply. If the surgeon knows where the ar-
teries can be found, hemostasis can be secured more reliably. I have been
fortunate to have had only one hematoma in a mastopexy-augmentation
patient who required a return to surgery. I have had more hematomas in
mastopexies in which I have placed the inferior wedge under a strip of
pectoralis muscle. One hematoma became obvious at follow-up but did
not require further surgery.
This woman had a superior pedicle vertical mastopexy-augmentation in which
300 cc smooth-walled saline implants placed in subglandular pockets. She re-
turned 3 weeks postoperatively with a resolving hematoma. No surgery was per-
formed until 3 years later to correct some scar contracture. She had a mild
(Baker I) bilateral capsular contracture.

557
Chapter 10 • Mastopexy-Augmentation
The patient is shown be ore scar release on the in erior aspect o her le t breast
and bilateral capsule release, and again 1 month a ter the revision.
Infection
This woman did not have a pure mastopexy-augmentation; previously placed
200 cc saline implants were removed, and 304 cc responsive silicone gel im-
plants were positioned in subglandular pockets. The capsule, which was thick-
ened, edematous, and calcif ed, was removed at surgery, along with the implants.

558
Part II • Technique
She is shown with an in ection; this appeared to be a suture reaction, with the
in ection conf ned to the skin and subcutaneous tissue. The in ection responded
well to antibiotics (oral cephalexin). The patient is shown 11⁄2 years postopera-
tively with a good result.
Wound-H ealing Problems
I am a f rm believer that many wound-healing problems are caused by tension
or low-grade in ection—or both.
This woman had a small dehiscence. There was some redness along the incision
line, suggesting a low-grade in ection. Cephalexin was administered or 1 week
a ter the original surgery. The dehiscence and redness occurred 3 weeks a ter
surgery; she was then given cipro oxacin, with success. She is shown 1 month
(with the in ection cleared but with a residual dehiscence) and 3 months post-
operatively. The dehiscence was allowed to heal secondarily.
Preoperative

1 month postoperatively

3 months postoperatively

559
Chapter 10 • Mastopexy-Augmentation
Nipple Necrosis
A mastopexy-augmentation with a medial pedicle was per ormed on this massive-
weight-loss patient. Saline implants (210 cc) were placed in subglandular pock-
ets. A reduction-augmentation was per ormed and in erior parenchyma removed;
225 g o tissue was removed rom the right breast and 100 g rom the le t breast.
In addition, 50 cc o at was removed by liposuction or contouring around the
in ramammary old. The distal end o the medial pedicle developed necrosis,
and antibiotics were given. She is shown 2 weeks and 6 weeks a ter surgery; no
urther treatment was necessary.
Implant-Specif c Problems
Double Capsules
Late seromas and double capsules seem to be specif c to Biocell textured sur-
ace implants. I had not seen a late seroma until my twenty-third year in practice.
During my career I have used smooth-walled Dow Corning silicone implants,
Preoperative
2 weeks postoperatively
6 weeks postoperatively

560
Part II • Technique
smooth-walled saline implants, some polyurethane implants, Microcell
textured CML and CMH implants, a few Siltex textured saline and gel
implants, and smooth silicone gel Mentor and Allergan implants.
I have now seen 14 cases of double capsules. One mastopexy-augmentation pa-
tient had an expanding seroma well over a year after her original surgery.
Preoperative

9 months postoperatively
Eighteen months after surgery, she called to report the swelling, as shown (left).
She was scheduled for a semi-urgent procedure; 5 days later the swelling had
almost doubled in size (right). There was no history of trauma or any suggestion
of anything that might have caused infection, such as teeth cleaning.
This woman had a superior pedicle vertical mastopexy-augmentation with
378 cc Biocell textured silicone gel implants placed in subglandular pockets.
She is shown 9 months postoperatively.

561
Chapter 10 • Mastopexy-Augmentation
At surgery there was a serosanguineous seroma and a double capsule around
the implant. This capsule was adherent to the implant, and the upper portion
of the implant was adherent to the breast.
4 months after release
The rest of the breast capsule was thin and not contracted. The upper part of
the capsule is shown where the implant was adherent.
The patient is shown 4 months after the evacuation and release. The implants
were replaced with smooth gel implants.

562
Part II • Technique
This woman had a superomedial vertical mastopexy-augmentation with 322 cc
Biocell textured implants placed subfascially. Skin and parenchyma were re-
moved from the lower pole on both sides, with 40 g removed from the right
breast and 45 g removed from the left. She called 11⁄2 years after surgery to re-
port some unexplained swelling on the left breast. H er family physician pre-
scribed antibiotics, but this did not seem to make much difference.
Preoperative

2 years postoperatively at revision
I believe that the Biocell textured implants were a good attempt to repli-
cate the adherence and favorable qualities of the polyurethane implants.
Unfortunately, the adherence is similar to that of Velcro and can be sep-
arated with relative ease; that is, the adherence can be “de-Velcroed.”
Once some separation occurs, there are two rough surfaces that rub
against each other. The resultant shear forces create a seroma.

563
Chapter 10 • Mastopexy-Augmentation
Eventually the swelling settled, but she developed a capsular contracture. She
was taken to the operating room a ull 2 years a ter her initial surgery, and it
was obvious that the capsular contracture was caused by a double capsule. The
inner capsule had tightened around the implant, making it eel f rm. The outer
(usual) capsule was thin and not contracted.
I decided to replace both implants and ound that a partial double capsule had
ormed on the right side (left). The complete double capsule o the le t breast
is shown (right), where it had contracted around the implant but was not ad-
herent on the smooth patch posteriorly.
Shape
I have not ound that shaped implants improve the f nal result. I choose an im-
plant with an appropriate base diameter to produce the desired result. I then
use the di erences in implant prof les to allow some exibility in implant size. I
have rarely used shaped implants, because most mastopexy-augmentation pa-
tients already have most o their volume in the lower pole.

564
Part II • Technique
This woman had a superior pedicle vertical mastopexy-augmentation using
310 g shaped, textured-sur ace implants placed in subglandular pockets. She is
shown just over 1 year a ter surgery. Although this is only one case, I have ound
that the result with shaped implants is less satis actory than with round implants.
Shaped implants add too much volume to the lower third o the breast below
the nipple, where many patients already have excess volume.
Pocket-Specif c Problems
Double Bubble
The term double-bubble deformity is actually used to describe three separate is-
sues (see Chapter 5). The f rst is a water all de ormity caused by the parenchyma
dropping o below the implant. The second is caused by adherence o the pec-
toralis muscle edges to the skin, resulting in olding with contraction. The third

565
Chapter 10 • Mastopexy-Augmentation
de ormity is caused by constricting f bers between the skin and deeper tis-
sues. Each cause needs to be assessed and a correct diagnosis made to suc-
cess ully treat the problem.
This woman had a superior pedicle vertical mastopexy-augmentation with
286 cc smooth-walled responsive silicone gel implants placed in subpectoral
pockets; 20 g o tissue was removed rom the in erior pole o the right breast
and 25 g rom the le t breast. She is shown 3 months a ter surgery with a le t
capsular contracture.
The double-bubble de ormity can be caused by tight f bers that prevent the skin
rom stretching or rom traction o the pectoralis muscle on the dermis. A dou-
ble bubble can clearly be a problem in a tuberous type o breast in which the
constricting f bers have not been completely released and the implant has been
used to lower the in ramammary old. In a nontuberous breast, the old can also
be lowered (either intentionally or otherwise), and a skin-constricting double-
bubble de ormity can occur. In many cases, however, the pectoralis muscle is
the problem, and correction can be di f cult, even with extensive release o the
muscle.

566
Part II • Technique
The contracture became worse, and the implant would slide superiorly with mus-
cle contraction. The left inframammary fold was elevated by the contracture.
The left capsule was released inferiorly; she is shown 1 year after the release with
a resultant double-bubble deformity.

567
Chapter 10 • Mastopexy-Augmentation
Wide Cleavage, Dancing Breast Syndrome
The negative side to a subpectoral pocket location is that wider cleavage
is inevitable i the implant is placed lateral to the muscle insertion on the
sternum. O ten patients do not mind the movement o the implant with
muscle contraction, but athletic patients requently object to this. The
implant usually moves laterally, and visible olds orm over the implant
sur ace with muscle contraction. These “complications” may be worth-
while in very thin patients, because visible rippling is avoided medially and
superiorly.
Despite drawing the desired new cleavage (dotted line) on this patient preoper-
atively, I could not carry (and should not have carried) the dissection that ar
medially. The cleavage could have been narrowed with a subglandular aug-
mentation, but the f nal choice o a subpectoral pocket gave her a better over-
all result because o the increased superior and medial padding o the implant
edges. She had a superior pedicle vertical mastopexy-augmentation with 304 cc
responsive silicone gel implants placed in subpectoral pockets.

568
Part II • Technique
This woman had a mastopexy-augmentation using subpectoral implants, and
the movement o the breasts that results with muscle contraction (dancing breast
syndrome) is obvious. Patients o ten learn how to prevent this, but it can be
di f cult to avoid when opening a jar or li ting weights.
Procedure-Specif c Problems
Capsular Contracture
Capsular contracture can occur with any implant. I reviewed my primary aug-
mentation patients and my primary mastopexy-augmentation patients since the
moratorium on gel implants in 1992. With the primary mastopexy-augmentation
patients, the saline implants did not are well. There was no di erence in inci-
dence, whether the implants were placed subglandularly or subpectorally. The
CML and CMH implants produced the ewest capsular contractures, even in
a longer ollow-up than with the smooth-walled gel implants. There was no
di erence in capsular contracture rates with implants in the subglandular, sub-
ascial, or subpectoral pocket. (See Chapter 5 or the results in primary breast
augmentation in which there was also no di erence in capsular contracture rates
with implants in the subglandular, sub ascial, or subpectoral pockets.)

569
Chapter 10 • Mastopexy-Augmentation
Areolar Spreading
The areola will inevitably stretch when an implant is added, either in a primary
augmentation or in a mastopexy-augmentation. Areolar skin stretches more
than breast skin, so care should be taken to ensure reduced tension on the are-
ola. I do not like the circumvertical approach to breast surgery, because the skin
opening circum erence is longer than the areolar circum erence. Even when a
permanent suture is used, widening can still occur. Adding an implant urther
compounds the problem by adding tension, and correction is unpredictable.
The circum erence o the areolar opening in this patient was excessively long
to completely remove the pigmented skin. The stretching was predictable, be-
cause 600 cc implants were used on both sides. Perhaps a circum erential per-
manent Gore-Tex suture could have prevented this much widening.
Capsular Contracture Prof le: Primary Breast Mastopexy-Augmentation
No. of

Baker II

Baker III

Total
Implant

Patients

(%)

(%)

(%)
Saline

18

2 (11)

4 (22)

6 (33)
CML/ CMH

32

1 (3.1)

1 (3.1)

2 (6.3)
115/ 120

24

0 (0)

3 (12)

3 (12)
15/ 20

11

0 (0)

0 (0)

0 (0)
MPP

4

0 (0)

0 (0)

0 (0)
Saline, 1992-2004: Smooth-walled; both McGhan and Mentor saline implants.
CML/ CMH , 2002-2007: Microcell textured highly cohesive silicone gel implants made by CUI (CML
low pro-
f le; CMH
high prof le).
115/ 120, 2007-2009: Allergan Biocell textured responsive gel implants (115
moderate prof le; 120
high prof le).
15/ 20, 2007-2009: Allergan smooth-walled responsive gel implants (15
moderate prof le; 20
high prof le).
MPP, 2007-2009: Mentor smooth-walled cohesive I gel–f lled implants (moderate plus prof le).

570
Part II • Technique
This woman had a superior pedicle vertical mastopexy-augmentation with CMH
365 g implants placed subfascially. A Gore-Tex permanent suture was used to
prevent stretching of the areolas. The result was somewhat successful, but as
shown 5 months and 1 year after surgery, the areolas had stretched beyond the
Gore-Tex suture. When the areola is contracted (note the left areola in the
20-month photo), the effect is less obvious.
Although a permanent suture can be effective, it has its own problems; there-
fore I try to avoid the circumvertical approach. I would rather match the skin
circumference to the areolar circumference and only add a permanent suture
when widening would inevitably occur because of a mismatch exaggerated by
the tension of an implant.
Preoperative

5 months postoperatively
1 year postoperatively

20 months postoperatively

571
Chapter 10 • Mastopexy-Augmentation
Recurrent Glandular and Nipple Ptosis
Glandular ptosis will recur if the inferior wedge principle is not followed:
adequate lower pole tissue must be excised in a mastopexy-augmentation.
This woman had a superior pedicle mastopexy-augmentation in which Style
410 320 g shaped implants were placed in subglandular pockets. Parenchyma
was removed on both sides, with 50 g removed from the inferior pole of the
right breast and 25 g removed from the left breast. Two years postoperatively
it is obvious that more gland should have been removed from the inferior wedge
on the right breast. The excess parenchyma dropped back, and glandular pto-
sis recurred. The new nipple position had been marked at 21 cm, and it has
stretched to 23 cm postoperatively. The nipple is 11 cm from the new upper
breast border. Both glandular and nipple ptosis recurred to some extent. The
nipples should have been placed higher, and more gland should have been re-
moved from the inferior aspect of the right breast. The shaped implant did not
produce a satisfactory result.

572
Part II • Technique
This woman demonstrates, in a series o operations, that it is important to rec-
ognize that the implant and the gland act separately. Any glandular ptosis will
recur i an insu f cient amount o in erior wedge tissue is removed.
Preoperative
1 month postoperatively
She had a superior pedicle vertical mastopexy-augmentation in which CML
230 g cohesive gel implants were placed with the use o a sub ascial sling. She
had 30 g removed rom the right breast and 20 g rom the le t. She is shown
1 month postoperatively. The upper border o the implant is obvious and both
nipple and glandular ptosis had recurred.

573
Chapter 10 • Mastopexy-Augmentation
Nine months a ter the initial surgery, the problems persisted. The implants were
moved to the subpectoral pocket to better camouf age the implant edges su-
periorly. The nipples were raised and more tissue was removed in eriorly: 21 g
rom the right breast and 20 g rom the le t breast.
9 months postoperatively at revision
3 months after revision
She is shown 3 months a ter the second operation. The glandular ptosis had re-
curred, and her nipples are still somewhat low.

574
Part II • Technique
She had a third operation (second revision) in which the glandular ptosis was
correctly treated with adequate resection. This time 130 g o tissue was removed
rom the right breast, and 155 g was removed rom the le t breast. The photo
on the right shows how separate the parenchyma is rom the implant. The
parenchyma needed to be treated independently o the implant; the mistake in
this case was to not remove enough o the lower wedge o tissue in the f rst op-
eration, because she had signif cant glandular ptosis. At the third operation,
larger silicone gel 354 cc subpectoral implants were used to compensate or the
in erior tissue removal.
At second revision

575
Chapter 10 • Mastopexy-Augmentation
She is shown 1 month and 6 months a ter the third surgery (second revision)
with a better result, except or some bottoming out o the right implant. This
was corrected in a ourth operation.
Analysis
The important message with this case is to treat the breast separately
rom the augmentation. Glandular ptosis needs to be removed i it cannot be
moved. The surgeon must be able to assess the extent o glandular ptosis to re-
move enough tissue to prevent recurrence. I have not f gured out a way to move
the lower pole in a mastopexy-augmentation the way I can in a pure mastopexy.
To better design the markings, the surgeon must also understand the e ect o
the implant on both the upper breast border and on stretching o the supraster-
nal notch-to-nipple distance. This patient’s result was marred by the implant’s
bottoming out, but the principles are obvious, as seen by the “relearning”
process involved in each procedure.
1 month after second revision
6 months after second revision

576
Part II • Technique
Nipples Too H igh or Low
This woman had a superior pedicle mastopexy-augmentation in which CMH
365 g implants were placed in subglandular pockets. Only skin was removed,
and the nipples were not placed correctly. The upper breast border was elevated
about 2 cm with the implant; the nipple was marked as 23 cm rom the
suprasternal notch and stretched to 25 cm.
The nipple position was revised, with a good result seen 11 months a ter the
revision.
Analysis
This patient’s nipples were placed too ar below the anticipated level
o the upper breast border. She had a high in ramammary old and relatively lit-
tle glandular ptosis. The in ramammary old dropped 2 cm. The upper breast
border rose the expected 2 cm. The suprasternal notch-to-nipple distance
stretched rom the marked position at 23 cm to the f nal position at 25 cm.
These postoperative changes should be anticipated and the f nal markings ad-
justed accordingly. It is, however, better to place the new nipple too low rather
than too high.

577
Chapter 10 • Mastopexy-Augmentation
This patient had her nipple placed too close to the upper breast border. The
upper breast border was raised by only 1 cm ( rom 12 to 11 cm rom the clav-
icle). The new nipple position was marked at 6 cm rom the upper breast bor-
der. Style 15 339 cc implants were placed in subglandular pockets on both
sides, with 27 g o tissue removed rom the right side and 26 g rom the le t
side. The suprasternal notch-to-nipple distance stretched rom 20.5 cm to
23 cm; the new upper breast border-to-nipple position measures 9 cm. She has
complete return o sensation.
Analysis
This result is within the desired 8 to 10 cm f nal measurement, but
the nipple would probably have been better placed slightly lower. This was not
a problem or this patient, but some patients will need to wear a ull-coverage
brassiere so that the edge o the areola does not show above the edge o the
brassiere or bathing suit.

578
Part II • Technique
Bottoming Out
There are two types o bottoming out: the f rst is glandular ptosis, which
can be exacerbated by the weight o the implant; the second is dropping
out o the in ramammary old, which can also be exacerbated by the
weight o the implant.
This patient had glandular ptosis (bottoming out) that was aggravated by the
weight o a saline implant.
A mastopexy was per ormed (leaving the implant in place). She is shown 3 years
postoperatively (left). Some ptosis did recur, and when she was seen again
9 years postoperatively (right), she had developed a le t capsular contracture.
Some o the bottoming out had become slightly worse with time.