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

She is shown 1 month and 6 weeks after surgery.
630
Part II • Technique
Three months after surgery, she had healed well, with recovery of half the
areola but with absence of the nipple. It is best to leave necrosis to resolve, as
shown with the remarkable recovery in some of the other cases in this chapter.
Unfortunately, this was not as good a result, but the patient declined further
treatment.
Isolated Nipple Necrosis
It has been my practice to have the assistant pull up on the nipple while I wrap
a laparotomy pad around the base of the breast to compress it for deepithelial-
ization. I did not have a problem with this until recently when two patients de-
veloped isolated nipple necrosis. Although I am uncertain about the actual cause,
I suspect it may be related to direct trauma on the nipple itself.
1 month postoperatively
6 weeks postoperatively
3 months postoperatively

Medial Pedicle Vertical Breast Reduction With Isolated
Nipple Edge Necrosis
631
Chapter 11 • Nipple Necrosis
This patient had a medial pedicle vertical reduction. Although the right nipple
was dark on the f rst postoperative day, the areola had good circulation. It was
di f cult to determine whether the problem was bruising or direct trauma. By
the end o the f rst week it seemed clear that the problem was likely direct
trauma or pressure rom olding over o the nipple in the postoperative brassiere.
The patient is shown 4 months post-
operatively with a good result.
4 months postoperatively
1 day postoperatively

1 week postoperatively
Preoperative

632
Part II • Technique
Medial Pedicle Vertical Breast Reduction With Isolated
Nipple Tip Necrosis
This patient had a medial pedicle vertical breast reduction.
Postoperatively it was not clear whether there was necrosis of the left nipple or
bruising. The areola appeared to have good circulation. She is shown 1 week
and 13 months postoperatively.
It became clear over time that the problem was necrosis, because the patient
lost some projection of the left nipple.
Preoperative
1 week postoperatively

13 months postoperatively

REFLECTIONS
Nipple-areolar necrosis is di f cult to predict, di f cult to diagnose, and di f cult
to treat. Although lawyers may assume this problem is related to surgical neg-
ligence, it has become clear to me that it is o ten associated with variability in
blood supply rather than surgical error. It would be ideal i we could recom-
mend one technique or one pedicle that works better than the others in pre-
venting nipple necrosis, but experience proves otherwise. Nipple necrosis can
occur regardless o the surgeon, the technique, or the pedicle used. We do not
have a method to predict blood supply either preoperatively or intraoperatively.
A diagnosis o nipple necrosis is not straight orward, as these cases have demon-
strated. To act can be a very di f cult decision. There are consequences rom ac-
tion just as there are consequences rom inaction. Both can lead to a bad result,
but no one can know in advance which path will achieve an optimal result.
Lawyers o ten assume that a surgeon should act once a def nite diagnosis o ull
or partial nipple-areolar necrosis is made. It is important not to be pushed to
action by patients, amilies, and other physicians, when in act observation may
be the best choice.
It has become increasingly clear rom previous publications and my own expe-
rience that complete nipple necrosis may occur in 1/ 200 patients. Both partial
necrosis (1/ 140) and edge necrosis (1/ 200) have occurred in similar incidences
in my practice, but these usually result in an acceptable long-term appearance,
even i a minor revision is needed.
The only way to prevent complications is not to operate. Treatment o com-
plications requires judgment and di f cult decision making. There is no right or
wrong answer.
633
Chapter 11 • Nipple Necrosis

Concepts to Recall
• Prevention o nipple necrosis depends on an understanding o the blood
supply.
– Un ortunately only three o the our main arteries may be dominant.
– Nipple necrosis will inevitably occur without surgeon error.
• Diagnosis and evaluation o nipple necrosis are very di f cult.
– The recommendation to convert to ree nipple gra ts in the ace o
questionable blood supply would result in ar too many patients un-
dergoing ree nipple gra ts, which have their own downside.
– Patients with apparently good blood supply may develop necrosis, and
vice versa.
– Venous congestion is the only clear indication or intervention.
• It is best to allow any necrosis to resolve without intervention until clear
demarcation occurs.
• Many patients recover surprisingly well without treatment.
• Early in the postoperative course, it can be impossible to decide what
needs to be debrided.
BIBLIOGRAPH Y
Blondeel PN, H amdi M, Van de Sijpe KA, et al. The latero-central glandular pedicle tech-
nique or breast reduction. Br J Plast Surg 56:348-359, 2003.
Cardenas-Camarena L, Vergara R. Reduction mammaplasty with superior-lateral der-
moglandular pedicle: another alternative. Plast Reconstr Surg 107:693-699, 2001.
Chetboun A, Masquelet AC. Experimental animal model proving the benef t o primary
de atting o ull-thickness random-pattern skin aps by suppressing “per usion steal.”
Plast Reconstr Surg 120:1496-1502, 2007.
Cruz-Korchin N, Korchin L. Vertical versus Wise pattern breast reduction: patient satis-
action, revision rates, and complications. Plast Reconstr Surg 112:1573-1578, 2003.
Daane SP, Rockwell WB. Breast reduction techniques and outcomes: a meta-analysis. Aes-
thet Surg J 19:293-302, 1999.
Dabbah A, Lehman JA Jr, Parker MG, et al. Reduction mammaplasty: an outcome analy-
sis. Ann Plast Surg 35:337-341, 1995.
Lozano DD, Stephenson LL, Zamboni WA. E ect o hyperbaric oxygen and medicinal
leeching on survival o axial skin aps subjected to total venous occlusion. Plast Re-
constr Surg 104:1029-1032, 1999.
Makki AS, Ghanem AA. Long term results and patient satis action with reduction
mammaplasty. Ann Plast Surg 41:370-377, 1998.
Morris SF, Yang D. E ect o vascular delay on viability, vasculature, and per usion o mus-
cle aps in the rabbit. Plast Reconstr Surg 104:1041-1047, 1999.
O’Dey D, Prescher A, Pallua N. Vascular reliability o nipple areola complex-bearing pedi-
cles: an anatomical microdissection study. Plast Reconstr Surg 119:1167-1177, 2007.
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Part II • Technique

Schwartzmann E. Beitrag zur vermeidung von mammillennekrose bei einzeitiger mam-
maplastik schwerer fälle. [Avoidance of nipple necrosis by preservation of corium in
one-stage plastic surgery of the breast] Rev Chir Struct 7:206-209, 1937.
Scott GR. Erratum 2542 to Scott GR, Carson CL, Borah GL. Maximizing outcomes in
breast reduction surgery: a review of 518 consecutive patients. Plast Reconstr Surg
116:1633-1639, 2005.
Seidel SP, Chiari A, Grotting JC. The L-short scar mammaplasty. In Spear SL, ed. Surgery
of the Breast: Principles and Art. Philadelphia: Lippincott, Williams & Wilkins, 2006,
pp 1155-1171.
van Deventer PV. The blood supply to the nipple-areolar complex of the human mammary
gland. Aesthetic Plast Surg 27:393-398, 2004.
van Deventer PV, Page BJ, Graewe FR. The safety of pedicles in breast reduction and
mastopexy. Aesthetic Plast Surg 32:307-312, 2008.
Wallace WH , Thompson WO, Smith RA, et al. Reduction mammaplasty using the infe-
rior pedicle technique. Ann Plast Surg 40:235-240, 1998.
Wong MS, Kim J, Yeung C, et al. Breast necrosis following left internal mammary artery
harvest: a case series and a comprehensive review of the literature. Ann Plast Surg
61:368-374, 2008.
635
Chapter 11 • Nipple Necrosis

(Trang không có chữ)

Breast
Asymmetry
Chapter12
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638
Part II • Technique
B
reast asymmetries are particularly di f cult to treat. I usually warn my pa-
tients that they are unlikely to have a satis actory correction with one operation.
They will ace a li etime o changes and possible corrective procedures. Not only
do the breasts and skin respond di erently to the same level o circulating hor-
mones, but they also respond di erently to surgical manipulations.
Many surgeons discount measurements as being unimportant in breast surgery.
They believe that they understand the “art” o breast surgery and that the as-
sessment and results cannot be properly quantif ed. I disagree. When we un-
derstand that the nipple will drop, on average, 2 cm when an implant is added,
we can better design the mastopexy markings or the opposite side. The new
nipple position measured rom the suprasternal notch will remain unchanged
rom the marked level in a breast reduction, but it will drop 2 cm on the op-
posite breast i a mastopexy-augmentation is per ormed. The surgeon cannot
approach symmetry in these patients i these surgical principles are ignored.
The in ramammary old will drop—o ten unintentionally—when an implant is
added. The old will o ten be elevated with a vertical breast reduction and low-
ered with an in erior pedicle inverted-T breast reduction. It may be better to
choose the latter i an implant is being added to the opposite breast.
Many patients request that surgery be per ormed on one side only. We are ob-
ligated to explain to patients that, o ten, good results cannot be achieved with-
out operating on both sides. A mastopexy alone can give a breast better pro-
jection but will not increase the level o the upper breast border nor increase
upper pole ullness. An implant will do both and may make asymmetry more
pronounced.
This chapter reviews di erent aspects o breast asymmetry and provides exam-
ples o good and bad results. Surgical assessment and principles are reviewed
or each o the ollowing categories o asymmetry:
• Developmental asymmetry
• Other breast abnormalities
– Chest wall de ormities
– Tuberous breast de ormity
– Poland’s syndrome
– Turner’s syndrome
– Lipodystrophy syndrome

Developmental Asymmetry
Developmental breast asymmetries need to be care ully assessed to understand
the problem; the anatomy must be considered, and possible treatment ap-
proaches reviewed with each patient. Some patients may wish to match the
smaller breast, some may wish to match the larger breast, and others may want
both breasts made smaller or larger.
We need to make sure that our patients understand how various choices will
a ect the result. For example, an implant will f ll the upper pole on one side,
but a mastopexy on the other side will not be able to match this upper pole ull-
ness unless an implant is inserted. It is important to explain the e ect an implant
will have on shape and nipple position, compared with the e ect o a mastopexy
or reduction. It is much easier to do the same thing or both sides. Patients also
need to understand how di f cult it can be to achieve—and maintain—symmetry.
Revision surgery is common, and time, gravity, and pregnancy will a ect each
breast di erently.
ASSESSMENT
The surgeon should f rst determine the patient’s wishes. The ollowing issues
are then reviewed with the patient. Breast size is only one aspect o the prob-
lem to be evaluated. All three breast dimensions must be analyzed, starting with
the breast ootprint. Then the shape o the breast mound and the nipple posi-
tion—both lateral and horizontal—need to be evaluated to determine changes
that will be caused by surgery. Finally, areolar size and shape need to be docu-
mented, and the need or improvement noted.
Size
The patient’s eelings about breast size will in uence the treatment plan. Some
patients want only to reduce the larger breast. In this situation it is essential to
explain what can and cannot be done. An implant may be necessary to expand
the breast ootprint borders on the smaller side (even i this is not what the pa-
tient would like). Sometimes e orts to make the nipple position more sym-
metrical will cause scarring.
639
Chapter 12 • Breast Asymmetry

Footprint
As is appropriate or all breast surgery, the our borders o the ootprint
need to be analyzed to determine what changes are possible.
640
Part II • Technique
This patient underwent augmentation o the right breast using a subglandular
280 g implant and reduction o the le t breast with removal o 115 g. Another
100 cc o at was removed with liposuction rom the lateral chest wall on the
le t. Two years later there is a discrepancy in the position o the upper breast
border (arrows); it has been elevated by the implant on the right side, but it has
remained at the same level on the le t.
The upper breast border is inf uenced di erently, depending on the
procedure. A breast implant or mastopexy-augmentation will raise
the upper breast border, and mastopexy or breast reduction will
leave it unchanged. It is lowered with weight loss.
Upper Breast Border
The upper breast border (and upper pole ullness) will be raised with an im-
plant. My measurements have shown that, in most patients, this border is ele-
vated 2 cm on average. Un ortunately, it can be di f cult to predict the exact
amount. The upper breast border can be higher, especially in a subpectoral aug-
mentation in which the implant does not settle into position, and it can be lower
when an implant descends with gravity.

Lower Breast Border (Inframammary Fold)
My measurements have demonstrated that an implant invariably (inten-
tionally or not) lowers the in ramammary old, on average about 2 cm.
The in ramammary old can be raised with a medial pedicle vertical breast
reduction or mastopexy, but it is o ten lowered with an in erior pedicle.
This in ormation acilitates the planning o surgery. Symmetry between
the in ramammary old levels is not as important as it is with the other
breast borders, but a signif cant di erence can be a problem.
641
Chapter 12 • Breast Asymmetry
This patient had a higher in ramammary old on the le t. The dashed lines (top
right) were drawn to show how the old was to be lowered. A smooth-walled
250 cc saline implant was inserted in the subglandular position. The old was
success ully lowered. A medial pedicle vertical mastopexy was per ormed on the
right breast, and that old was elevated.

642
Part II • Technique
A superior pedicle vertical mastopexy was per ormed on this woman’s right
breast using an in erior f ap held up under a pectoralis strip; a subglandular
smooth-walled 250 cc saline implant was placed in the le t breast. Be ore sur-
gery her le t in ramammary old was higher than the right. She is shown 2 years
a ter surgery. The in ramammary old on the le t side has been pushed down
by the implant. It measures 2 cm lower than its preoperative position.

This 17-year-old patient underwent breast reduction using an inferior pedicle
inverted-T on the right side and a subglandular breast augmentation with a
smooth-walled 300 cc saline implant on the left side. She is shown 1 week af-
ter her surgery, with relatively good initial symmetry.
643
Chapter 12 • Breast Asymmetry
Ten years after her original surgery, both inframammary folds have dropped.
Time and weight have also caused the augmented breast and nipple to drop.
In such situations, it may be desirable to use an inferior pedicle inverted-T breast
reduction technique to lower the fold to match the inevitable drop on the aug-
mented side. The fold tends to rise with a medial or superior pedicle, but it will
often drop with time with an inferior pedicle. The surgeon can take advantage
of this difference when planning the ideal procedure. The patient had also gained
weight, which further exaggerated the asymmetry that developed with time.

644
Part II • Technique
Any attempts to tuck up the inframammary fold (especially when it has been
pushed down by an implant) are likely to be only partially successful. I experi-
enced some success in elevating the fold slightly with this patient by changing
her right implant from a 300 cc saline implant to a 150 cc saline implant. The
fold was tucked up and sutured to rib periosteum, which is quite painful for the
patient. Eventually, however, this fold lost some of its initial correction.
The inframammary fold drops with an implant or mastopexy-
augmentation. It can also drop with an inferior pedicle breast re-
duction. It can be raised with a medial or superior pedicle breast
reduction or mastopexy.

This woman needed her medial breast border widened on her right breast. It
would have been a mistake to choose an implant base diameter that f t the ex-
isting breast base diameter. A wider implant base diameter was chosen to f t the
desired breast base diameter. A smooth-walled 350 cc saline implant was used
on the right breast. A superior pedicle vertical mastopexy-augmentation was
used on the le t breast, with a smooth-walled 180 cc saline implant. Both im-
plants were placed in the subglandular position. The implant was needed on
the le t breast to match the upper pole ullness achieved with the implant on
the right side.
645
Chapter 12 • Breast Asymmetry
Medial Breast Border
The medial breast border can be expanded by f lling it with an implant.
Fat or breast tissue can also be used. It can be more di f cult to f ll with
breast tissue, however, and some creative rearrangement o the in erior
ap in a mastopexy may be necessary to achieve this goal. The medial
breast border can be reduced with judicious liposuction.

646
Part II • Technique
This woman needed her right medial breast border f lled out. She had a narrow
breast base. Because an implant was not a choice or this patient, the in erior
ap (Ribeiro-type) was created and placed in a medial pocket, rather than higher
on the chest wall. The patient is shown 18 months a ter a mastopexy on the
right and a medial pedicle vertical reduction on the le t, with removal o 500 g.
The medial aspect o the right breast was f lled out, and the medial aspect o the
le t breast was improved with coning, achieved with a vertical wedge resection.
This patient had a right breast reduction, with removal o 130 g o breast tis-
sue. Nothing was done to the le t breast. The discrepancy in the medial breast
border was easily resolved with a revision per ormed a year later using liposuc-
tion to contour the medial aspect o the le t breast.

A smooth-walled 300 cc saline implant was placed in this woman’s right breast
in a subglandular location. She needed an implant that had a wider base diam-
eter than her existing breast to f ll out both the medial and lateral breast bor-
ders. The le t breast was treated with a superior pedicle vertical mastopexy us-
ing an in erior ap held up under a strip o pectoralis muscle (Gra ). She had
70 g (total) o tissue removed in eriorly and laterally rom the le t breast. The
excess tissue in the lateral breast border on the le t side was urther ref ned with
liposuction. She is shown 1 year a ter surgery. This is a good example o the
importance o care ully assessing the borders to adjust them accordingly.
Shape
A ter the breast ootprint is assessed, the next step is to analyze the shape o the
breast on that ootprint. Ptosis needs to be corrected by removing or rearrang-
ing the in erior pole. The nipple position will also need to be considered, but
the shape and the nipple position need to be analyzed separately. An implant
can be used to alter the shape o the ootprint to better centralize the nipple.
H owever, there are limitations to this strategy, because, a ter an implant is
placed, the breast shape remains much the same as it was preoperatively. I take
photographs at the consultation, because many patients are unaware o what
they look like. An implant will f ll out their breast shape, but they also need to
know that glandular ptosis will be progressive, especially with a large implant.
647
Chapter 12 • Breast Asymmetry
Lateral Breast Border
The lateral breast border can be expanded with an implant. O ten the lat-
eral breast border needs to be reduced, and this is easily achieved with li-
posuction.

648
Part II • Technique
Removing or rearranging an inferior wedge of breast tissue
can help correct breast (glandular) ptosis. Skin is not reliable
as a brassiere.
This young woman had ptosis of her left breast. In this case the easiest
mastopexy to perform was a small breast reduction. She was easily treated with
a medial pedicle vertical breast reduction, with removal of 240 g of tissue. Tai-
lored liposuction was used to remove an extra 25 cc laterally. She is shown
5 months after surgery.

A bilateral asymmetrical breast reduction was performed to treat this patient’s
bilateral ptosis; 130 g were removed from the right breast, and 375 g were re-
moved from the left breast. She is shown 15 months after surgery, when a re-
vision was performed to reduce both areolas.
649
Chapter 12 • Breast Asymmetry

650
Part II • Technique
This woman had a slightly ptotic right breast, but the nipple was in an accept-
able position. The left breast was treated with a medial pedicle vertical breast
reduction, with 315 g of tissue removed from the lower pole. No liposuction
was performed. Note that the new left nipple was placed lower than the right
nipple, but it still was not low enough. The patient was 17 years old at the time
of surgery. She is shown 17 months after surgery. The right nipple did drop on
the mound slightly as she grew older, but the left nipple should have been placed
lower initially. However, the ptosis was corrected, and the shape of both breasts
is fairly symmetrical. The parenchyma was treated correctly.
The shape of the breast needs to be analyzed (and treated) sepa-
rately from the nipple position.

651
Chapter 12 • Breast Asymmetry
This 18-year-old patient had breast augmentation on the left breast with a sub-
glandular responsive gel Style 115 322 cc implant. A mastopexy-augmentation
was performed on the right breast using a medial pedicle vertical approach, with
35 g of tissue removed inferiorly and a Style 115 203 cc implant placed in the
subglandular position. On the left side, the suprasternal notch-to-nipple dis-
tance was 20 cm before surgery; it measured 22.5 cm after surgery.
When an implant is inserted, the new nipple position will drop.
The suprasternal notch-to-nipple distance will usually increase by
2 cm, on average, in both a breast augmentation and a mastopexy-
augmentation. The distance remains as marked preoperatively in
both a mastopexy and a reduction. These numbers are clearly very
important when planning for correction of breast asymmetry. An
implant will also increase the appearance of glandular ptosis, with
the inferior border of the breast dropping to a lower position.

Nipple Position
The changes produced by mastopexy, breast reduction, breast augmentation,
and mastopexy-augmentation are far more critical to understand when plan-
ning a breast asymmetry correction. When the same procedures are performed
on both breasts, the changes will likely be symmetrical. When different proce-
dures are performed on each breast, the surgeon needs to be well aware of what
will happen with each maneuver.
Vertical Nipple Position
The distance between the suprasternal notch and nipple will drop, on average,
2 cm when an implant is used—with or without a mastopexy. The distance be-
tween the suprasternal notch and nipple will remain the same after a mastopexy
or reduction is performed without an implant. When a larger reduction is per-
formed on one side, the nipple on the larger side will end up in a higher posi-
tion. This occurs, in part, because the larger breast is heavier when markings
are made preoperatively, but also because a larger wedge resection of breast tis-
sue causes the nipple to move higher as the wedge of parenchyma is closed (the
length of scar from an elliptical excision is increased more with a wider ellipse).
This effect is not seen with an inferior pedicle inverted-T breast reduction, be-
cause the ellipse is horizontal.
When a different amount of tissue is to be removed from each
breast, the new nipple position should be marked lower on the
larger breast.
652
Part II • Technique

653
Chapter 12 • Breast Asymmetry
This patient had a mastopexy on the right breast and a reduction on the le t. She
had an in erior f ap repositioned on the right breast and 425 g o tissue removed
rom the le t breast. Another 150 cc was removed rom the le t breast with li-
posuction. The new nipple position was marked 1 cm lower on the larger breast,
but it was still higher postoperatively. The right breast also developed recurrent
ptosis. She is shown 14 months a ter surgery, with markings or a revision to
correct these two de ormities. She is also shown 10 months a ter the revision.
Preoperative
Immediate postoperative result
14 months postoperatively

10 months after revision surgery

A mastopexy was performed on this patient’s left breast. The nipple was placed
slightly lower on the surgical side to accommodate the increased projection. In
addition, closure of the vertical ellipse pushes the nipple upward. She is shown
4 weeks after surgery, and again 1 year after surgery. This case shows the im-
portance of understanding the dynamics of nipple elevation with a vertical
mastopexy.
When a mastopexy or a reduction is used on one side and an im-
plant (with or without a mastopexy) is inserted on the other side,
the new nipple position on the mastopexy/ reduction side should be
about 2 cm lower than the existing or marked level of the nipple
on the augmented side.
654
Part II • Technique
Preoperative
4 weeks postoperatively

1 year postoperatively

655
Chapter 12 • Breast Asymmetry
Immediate postoperative result
2 months postoperatively

1 year after revision surgery
This patient had a smooth-walled 300 cc saline implant placed in a subglandu-
lar position on the right breast, and a mastopexy using an in erior ap under a
pectoralis strip on the le t side. The nipple on the mastopexy side was placed at
the same level as the nipple on the smaller breast. A circumareolar incision was
used on the right breast to help reduce some o the protruding areola. The nip-
ple dropped in the augmented breast, leaving the nipple on the mastopexy side
too high. The preoperative suprasternal notch-to-nipple distance on the right
was 21.5 cm, and it stretched to 24 cm postoperatively. The patient is shown
2 months a ter surgery, with prominent stretch marks. These were present be-
ore surgery but were aggravated or a ew months a ter surgery. She is also
shown 1 year postoperatively, with overcorrection on the le t side. Clearly,
I should have realized that both the breast and the nipple drop with an implant.
This is something that I started to understand only a ter care ully reviewing my
results and measurements. (This patient is also shown on p. 647 demonstrat-
ing the need or a larger base diameter implant to f ll out the breast borders.)
Preoperative

656
Part II • Technique
H orizontal Nipple Position
The nipple should be placed on the desired breast meridian and not nec-
essarily through the existing nipple position. Asymmetrical breasts o ten
respond di erently rom normal breasts. When an implant is used on
a poorly developed breast, the medial skin seems to stretch more easily
than the lateral breast skin, even when a proper pocket is created or the
implant.
In this woman the meridian was drawn in its ideal position, not in its existing
position. The nipples were ar too medial, and, even with lateral placement, they
still look a bit too medial because o the excess lateral at. She had a mastopexy
on the right breast, with the in erior ap placed medially and 500 g o tissue
removed rom the le t breast. An additional 200 cc o at was removed with
liposuction. She is shown 2 years a ter surgery. (This patient is also shown on
p. 646, demonstrating the use o an in erior ap to f ll out the medial breast.)

657
Chapter 12 • Breast Asymmetry
This patient demonstrates several errors that I made in attempting to correct
the right breast ptosis without removing or rearranging breast tissue. The nip-
ple was moved to a higher level on a lateral pedicle, and the mastopexy was per-
formed using the skin as a brassiere. It is interesting to note that the breast shape
postoperatively is the same as it was preoperatively. The nipple ptosis was cor-
rected, but not the glandular ptosis. The other error was in nipple position-
ing—both vertical and horizontal. The nipple was placed too high. I should
have recognized that, with time, the implant (smooth-walled 250 cc saline)
would lower the nipple position on the left breast. This further exaggerated the
discrepancy. The nipple was placed too far laterally, because I followed the ex-
isting meridian rather than the desired meridian.

This patient underwent a medial pedicle vertical breast reduction of the left
breast, with removal of 430 g of tissue. Another 125 cc of fat was removed with
liposuction. She is shown at the completion of surgery and again 2 days later.
The last photograph was taken 3 years postoperatively. Even though the nip-
ple was placed 1 cm lower than the nipple on the smaller breast, it is still some-
what higher. I measured the distance from the midline to the areola on each
side and tried to equalize them, but I should have placed the areola slightly
more lateral to better match the right side. The left breast is still a bit too large;
however, she was hoping to lose weight, and the left breast would respond to
weight loss more than the right. Unfortunately, she was unsuccessful in losing
weight.
In patients with breast asymmetry, the nipple should not necessar-
ily be placed on the existing breast meridian, but on the desired
meridian.
658
Part II • Technique
Immediate postoperative result
Preoperative
2 days postoperatively

3 years postoperatively

659
Chapter 12 • Breast Asymmetry
Areolar Size
O ten the nipple and areola on the hypoplastic side are signif cantly smaller
than on the other side. A large areola can be made smaller by ensuring
that the skin circum erence matches the desired areolar diameter. The are-
olar skin will stretch easily. This can be used to one’s advantage by excis-
ing skin around the small areola and purposely stretching it.
A vertical mastopexy-augmentation was per ormed on this patient’s right breast;
20 g o tissue was removed in eriorly, and a smooth-walled responsive gel Style15
371 cc implant was placed subglandularly. On the le t breast, a circumareolar
excision o skin was per ormed to stretch out the slightly protruding areola.
Placement o a Style 20 450 cc implant also helped to stretch the areola.

660
Part II • Technique
When an areola has a tuberous shape, excess areolar skin is removed,
and breast skin is left untouched. When an areola is too small, the
areola is left untouched, but excess skin around the areola is re-
moved to help stretch the areolar skin. Breast skin resists stretch
more than areolar skin, and the surgeon can take advantage of this
characteristic when planning corrective surgery.
One reason that I eel I have better control over breast shape and areolar size
using the vertical approach is that I can match the skin circum erence to the de-
sired areolar circum erence. It is also di f cult through a circumareolar incision
to rearrange or remove the lower pole o the breast i it is ptotic. Circumareo-
lar mastopexies tend to atten the breasts. Although a circumvertical approach
can be used to remove ptotic tissue in the lower pole, the areola tends to stretch
during this maneuver. I will use a Gore-Tex suture i needed, but I would rather
avoid it. I have not ound that the longer vertical scar is a detriment. The ull
length is o ten needed to accommodate the increased projection that results
rom the vertical approaches.
This patient is shown 15 months a ter an asymmetrical breast reduction in which
130 g was removed rom the right breast and 375 g was removed rom the le t
breast. (See p. 649 or photos o this patient be ore her initial surgery.) She was
marked or revision. Note that a vertical wedge o skin was also excised to bet-
ter match the skin circum erence with the desired areolar circum erence. Oth-
erwise, the areola will stretch i the “doughnut” is sewn to the “hole.”

661
Chapter 12 • Breast Asymmetry
This 15-year-old patient underwent a right superior pedicle vertical mastopexy
and a le t breast augmentation with a subglandular 200 cc saline implant. She
is shown 3 weeks a ter surgery.
Revisions
The most common complication is the need or revision surgery. It must be ex-
plained to patients that it is very di f cult to match asymmetrical breasts. The skin
will respond di erently to stretch, with the smaller breast being more resistant
to skin tension. The breast parenchyma will respond di erently with hormonal
and weight changes, and, o course, with time. I always tell my patients that I
never get it right the f rst time, and that they will need revisions during their
li etime. The ollowing examples present good reasons or revision surgery.
Multiple Revisions
Immediate postoperative result

3 weeks postoperatively
Preoperative
PROBLEMS AND COMPLICATIONS
Many complications o breast asymmetry surgery are the same as those
o breast reduction, breast augmentation, mastopexy, and mastopexy-
augmentation. Only complications particular to breast asymmetry are dis-
cussed in this chapter.

662
Part II • Technique
Three months after surgery and again 5 months after surgery her left (aug-
mented) breast had become more ptotic. Initially, the assumption was that the
breast with the larger volume of breast tissue would be more likely to grow with
puberty, but this was not the case.
Eleven months after her initial surgery she underwent a right augmentation.
The left implant was increased in size, and she now had a 270 cc saline implant
on the right side and a 360 cc saline implant on the left side. She is shown be-
fore and 4 days after this second procedure.
3 months postoperatively

5 months postoperatively
11 months postoperatively

4 days after rst revision

663
Chapter 12 • Breast Asymmetry
The problem continued, and 15 months after the second procedure she un-
derwent a revision with an elevation of the right areola and an excision of 25 g
of inferior pole breast tissue. The result was, again, initially overcorrected.
She is shown 3 months after the third procedure, with a good result. She will
probably need more surgery in the future, because she is only 18 years old. She
may still experience some changes with puberty. If she has children, the right
breast is likely to respond more to the hormonal changes. The same would ap-
ply if she gained weight. It is clear that breast asymmetry correction is not a
one-time operation.
Five weeks after surgery the right breast is still too high. It can be hard to man-
age patient expectations through the recovery period. By 5 months postoper-
atively the right breast had already dropped too far. This ptosis only got worse
with time. It was clear that now the right breast was responding to increased
circulating hormones.
5 weeks after rst revision
15 months after rst revision

1 month after second revision

3 months after second revision
5 months after rst revision

664
Part II • Technique
Multiple Revisions, Capsular Contracture, and Impending
Implant Exposure
This woman had a right breast augmentation with elevation o her right areola.
A breast reduction o 145 g was per ormed on her le t breast. The same size
implants, smooth-walled 300 cc saline, were placed in the subglandular posi-
tion on both sides. She is shown 9 months postoperatively. Un ortunately, she
developed capsular contracture on the le t side; a capsular release was per ormed
10 months postoperatively.
Because there was not much subcutaneous tissue to pad the implant, it could
be seen through the skin and dermis. She is shown 4 months a ter capsular re-
lease and be ore the pectoralis f ap correction.

665
Chapter 12 • Breast Asymmetry
Pectoralis major muscle was recruited, and a laterally based f ap o muscle was
used to cover the in erior aspect o the f ap. This resulted in a tight area in the
in erolateral aspect o the le t breast. There was some movement with muscle
contraction. The patient is shown 10 months a ter the f ap correction.
Her right breast became more ptotic over time, and another correction was per-
ormed a year a ter the f ap correction. She is shown 6 years a ter her original
surgery. A total o seven corrective procedures were per ormed.

666
Part II • Technique
Infection/ Dehiscence
This woman had a tuberous-type deformity with large areolas and a constricted
breast base. A mastopexy was performed on her left breast, and a mastopexy-
augmentation with a smooth-walled 300 cc subglandular saline implant was
performed on her right breast. She developed an infection around the superior
aspect of the left areola. This may have been complicated by tension, because
the areolar opening circumference was 17 cm. Dehiscence resulted, and it was
allowed to heal by secondary intention.
SU RGICAL MANAGEMENT OF DEVELOPMENTAL
BREAST ASYMMETRIES
Once a patient’s wishes are fully understood and the deformities in all three di-
mensions are analyzed, the surgeon can develop a surgical plan that addresses
the following basic questions:
• What size does the patient prefer?
• What can and cannot be changed in all four breast footprint borders?

This patient wanted to match her le t breast to her smaller, right breast. No sur-
gery was needed on the right. A medial pedicle vertical reduction was per ormed
on the le t breast in which 125 g was removed. No liposuction was required.
She is shown 1 year postoperatively.
Analysis
It is always di f cult to try to match an existing breast. The amount
o glandular ptosis is relatively similar, but the base o the le t breast is perhaps
a bit too narrow. This might have been best treated with liposuction medially
on the right breast. Note that the nipple position on the le t breast was kept
low. It is better to err on placing the nipple too low, because it can always be
raised. It is almost impossible to lower.
The ollowing examples demonstrate how di erent approaches will produce
di erent results—some success ul and some not.
Breast Reduction on Only One Side
667
Chapter 12 • Breast Asymmetry
• Can the breast shape be matched to the opposite side, or should
both breasts be altered?
• How can the size, ootprint, and shape be matched to the opposite
breast, and when will both sides need surgery?
• What a ect will di erent surgical maneuvers have on each breast,
and how will the breasts change over time?
Results

668
Part II • Technique
Breast Augmentation on Only One Side
This patient underwent augmentation o the right breast with a 150 cc
saline implant. She is shown 1 month and 4 years a ter surgery.
Analysis
In this patient the pocket should have been dissected urther laterally,
and perhaps a wider-base implant should have been used. It is not appropriate
in these cases to choose an implant base diameter that matches the existing
breast base; an implant should be chosen to match the desired breast base di-
ameter. This approach risks more rippling and palpability but should achieve
a better shape. Note that the implant disproportionately f lls the upper pole
compared with the le t side. This is o ten compounded by capsular contracture.
Possible options or expanding the small areola are presented in the ollowing
example.

This patient wanted to match the size of her smaller breast. The right breast
was reduced by 270 g. She agreed to a mastopexy for the left breast, and 40 g
was removed inferiorly, after repositioning the nipple and nipple-areola com-
plex. Another 325 cc of fat was removed with liposuction. She is shown just
over 1 year postoperatively.
Analysis
Note that the new nipple position was placed lower on the larger
breast. This is an important principle to follow. The right nipple did end up
slightly higher. The breasts are relatively symmetrical. The wider wedge exci-
sion on the right breast narrowed that side more. Slightly more liposuction on
the right lateral chest wall might have also helped.
One Side Reduction/One Side Mastopexy
Some patients want to match the larger breast, and some want to match
the smaller breast. Some patients want both breasts to be smaller or larger
than either existing breast. Whether or not both breasts will need surgery
depends not only on size, but also on what shape can be achieved.
669
Chapter 12 • Breast Asymmetry

670
Part II • Technique
One Side Mastopexy/One Side Augmentation
This patient underwent a right mastopexy using an in erior (Ribeiro) f ap.
A le t breast augmentation was also per ormed. The implant was a responsive
gel Style 15 304 cc placed in a subglandular location. She is shown 6 weeks a -
ter surgery.
Analysis
Note that the nipple was placed lower on the right breast. This place-
ment is important, because the implant will, on average, lower the new nipple
position by about 2 cm. The upper breast border was marked with a dotted
line, and the likely implant pocket was also marked. Care was taken to keep the
implant pocket low so that there would not be more upper pole ullness on the
le t. Upper pole ullness can be improved with an implant but not with a
mastopexy.

This patient had a right mastopexy-augmentation, with 32 g removed in eri-
orly, and a responsive gel Biocell textured implant Style 120 400 cc was placed
in a subglandular location. A subglandular augmentation was per ormed on the
le t side with a Style 120 500 cc implant. She is shown 6 months postopera-
tively.
Analysis
The right nipple was placed lower, but its f nal location is slightly
higher than the nipple on the le t. Note that the vertical incision is kept well
above the in ramammary old. She has more upper pole ullness on the mas-
topexy side, so the increased upper pole ullness provided by an implant on the
le t helped achieve symmetry. In addition, the breast meridian was placed lat-
eral to the existing nipple position in an attempt to try to match the le t nipple.
A slightly more lateral position would have been better.
One Side Mastopexy-Augmentation/One Side Augmentation
671
Chapter 12 • Breast Asymmetry

672
Part II • Technique
Bilateral Breast Reduction
A bilateral medial pedicle vertical breast reduction was per ormed on this
woman. She had 565 g o tissue removed rom the right breast and 245 g re-
moved rom the le t breast. An additional 500 cc o at was removed with li-
posuction. She is shown 16 months a ter surgery.
Analysis
The new nipple position was placed lower on the larger breast. This
di erence is not made with the in erior pedicle inverted-T reductions. The heav-
ier breast could def nitely cause some traction on the skin in both approaches,
but I believe that closing a larger vertical ellipse tends to push the nipple up
higher. The in erior pedicle inverted-T procedure results in closure o a hori-
zontal (rather than a vertical) ellipse, and, there ore, the problem does not oc-
cur in those cases. The result is good. Symmetry in the base diameter o the
breasts was achieved by removing a wider in erior wedge on the right breast,
but also by tailoring both sides with liposuction.

673
Chapter 12 • Breast Asymmetry
This patient had asymmetrical breasts. She was well in ormed that her nipple
asymmetry would persist postoperatively. Cohesive gel implants were placed in
the sub ascial location. The right implant was 280 g, and the le t implant was
365 g. She is shown 10 months postoperatively.
Analysis
It is impossible to achieve complete symmetry with this much dis-
parity in nipple position. Di erent implant sizes were used to try to match the
breast base diameters. This patient had a smaller base diameter on the le t side;
there ore, a larger base diameter implant was used. It is important to choose an
implant with the correct desired base diameter rather than match the existing
base diameter. It can be di f cult to avoid bottoming out when the nipples are
higher than hal the distance up the breast mound preoperatively. I have ol-
lowed a series o over 50 sub ascial primary augmentation patients. Based on
these results, I no longer use the sub ascial location, because this placement did
not improve my ability to blunt the upper edge o the implant. In addition, the
sub ascial location sometimes allowed movement o the implant with muscle
contraction.
Bilateral Breast Augmentation

674
Part II • Technique
This patient underwent bilateral breast augmentation. A superior crescent o skin
was excised in an e ort to elevate her le t areola. Smooth-walled responsive sil-
icone gel implants were placed in a sub asical location, Style 20 400 cc each.
Analysis
Despite overcorrection, the crescent excision was unsuccess ul. I have
stopped using a crescent excision to match the level o the areolas. I believe that
this shows that skin will stretch under tension. It is better to reposition the are-
ola without tension. Breast tissue deep to the crescent may also need to be ex-
cised. The other problem with a crescent excision is that it o ten results in a mis-
match o the skin circum erence and areolar circum erence. Areolar skin tends
to stretch to f t the skin opening, and it stretches more easily than breast skin.
Other Breast Abnormalities
CH EST WALL DEFORMITIES
When treating breast asymmetries, it is important to assess any underlying chest
wall abnormalities. Various degrees o scoliosis are o ten associated with chest
wall de ormities. Neither the chest wall nor the breasts are completely sym-
metrical. We need to make sure that patients are aware o these asymmetries
and that they are educated about possibilities or correction.
One o the more di f cult bony abnormalities or surgical correction is the pec-
tus excavatum de ormity. I the problem is severe enough, the bony skeleton
can be corrected. This is o ten very invasive and usually only partially corrects
the problem. I the breast sits on an inwardly sloping chest wall, the breast will
remain inwardly sloping. This is o ten unattractive.

675
Chapter 12 • Breast Asymmetry
This patient’s right chest wall sloped inward. A smooth-walled 200 cc saline
implant was placed through a periareolar incision in a subglandular location.
She is shown 3 months and 6 years postoperatively. The right breast remains
sloped inward.
Preoperative
3 months postoperatively
6 years postoperatively

676
Part II • Technique
This patient had asymmetry o both the chest wall and breasts. An attempt
was made to f ll out the right breast medially, but it had the e ect o widening
the breast ootprint inappropriately. She is shown 3 months and 1 year post-
operatively.
Preoperative
3 months postoperatively
1 year postoperatively

677
Chapter 12 • Breast Asymmetry
An attempt was made at 9 months to
raise the left areola using a crescent exci-
sion. Unfortunately, the areola stretched.
I have found that crescent skin excisions
produce unsatisfactory results. Either the
scar stretches or the areola stretches.
This woman had asymmetry in which the right upper chest wall was concave.
The right breast was smaller than the left, and the footprint borders were dif-
ferent between the breasts. She had a left breast reduction through a vertical
approach. The new nipple was placed too high. Forty grams of tissue was re-
moved, and fat injections were performed on the medial right breast and up-
per chest wall. She is shown 6 months and 2½ years after surgery. Since then,
another set of fat injections was performed in the same areas. The result in breast
shape is good, but the nipple position has detracted from the result.
Preoperative
6 months postoperatively

21⁄2 years postoperatively

678
Part II • Technique
TU BEROU S BREAST DEFORMITY
Tuberous breast de ormity is believed to be caused by a constriction o the as-
cia around the breast, which restricts growth o the breast tissue. The breast
base is kept narrow, the sides are compressed, and any breast tissue that does
develop seems to take the path o least resistance as it pushes out into the are-
ola, causing a typical protruding appearance.
Whether or not a constricting band o ascia exists is controversial, but I am
convinced that it does. During my training, we used a f nger to sweep a pocket
above the pectoralis ascia when creating a subglandular pocket or a standard
breast augmentation. (Today sharp dissection is advised, which is less traumatic.)
In my experience, it was impossible to f nger sweep an implant pocket when
the patient had tuberous breasts. I needed to sharply dissect the breast away
rom the pectoralis ascia to make this sweep. This is an interesting f nding, be-
cause usually there is a clear separation between the deep breast ascia and the
pectoralis ascia. The two layers slide easily over each other. The only attach-
ment seems to be where the deep vascular system penetrates up into the breast
in the ourth interspace.
It is important to remember that the breast is a subcutaneous structure—not a
chest wall structure. It orms in the subcutaneous tissue and is really only at-
tached at the nipple level, and only to the skin. There is a layer o ascia that en-
velops the breast, and a deep artery and vein penetrate through the intercostals
and the pectoralis muscle just above the f th rib to supply the breast. This makes
sense, because we know that the breast is a ourth interspace structure embry-
ologically. This blood supply comes rom the internal mammary system through
the ourth interspace. The rest o the blood supply is superf cial, coming rom
the internal mammary artery rom the second to f th interspaces. These arter-
ies travel above superf cial investing ascia o the breast in the subcutaneous tis-
sue. There is also subcutaneous input rom the superf cial branch o the lateral
thoracic artery, and some input rom the thoracoacromial artery. The veins travel
separately (except or the deep system) just under the dermis, and they mainly
drain superomedially.