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

680
Part II • Technique
This woman had a tuberous breast correction with release o the constriction
and a mastopexy-augmentation. Smooth-walled 200 cc saline implants were
placed subglandularly. Three years postoperatively her scars were corrected, and
the right breast capsule was released. She is shown 2 years and 9 years a ter her
initial surgery. Note that the breast ootprint has been expanded superiorly, in-
eriorly, and medially. This was accomplished with the implant. The breast shape
was corrected by releasing the constricting f bers and allowing the skin to ex-
pand to reshape around the breast implant. The areolas were made smaller and
elevated into an appropriate position on the new mound.
Preoperative
2 years postoperatively
9 years postoperatively

681
Chapter 12 • Breast Asymmetry
This patient’s tuberous breasts were corrected using smooth-walled 275 cc saline
implants. The constricting bands were released, but the areolas protruded again.
Initially, a circumareolar incision was made and closed with a purse-string PDS
suture. It did not work. Four years later, the capsular contracture was released
and a superior pedicle vertical approach was used on each breast so that the skin
circumference could be matched with the areolar circumference. Areolar skin
stretches easily, and matching the skin and areolar circumferences helps prevent
areolar widening by avoiding tension on the areolar closure.
Breast skin will undoubtedly stretch, and, unfortunately, so will the
areola. After release of the fascial constriction, the skin circumfer-
ence should match the areolar circumference. With tuberous breasts,
this usually means excision of redundant areola. In hypoplastic
breasts, this usually means excision of surrounding skin to try to
stretch the areola.

682
Part II • Technique
This patient had a circumareolar incision on the le t breast, with reduction o the
areola and creation o an in erior turndown Ribeiro-type ap. A smooth-walled
saline 275 cc implant was placed in the subglandular position. She had a right me-
dial pedicle vertical breast reduction with removal o 225 g o breast tissue. An ad-
ditional 100 cc was removed with tailored liposuction. She is shown 5 months and
2 years a ter surgery, with le t capsular contracture and stretching o the areola.
Analysis
This patient example shows how di f cult it can be to achieve long-
lasting symmetry. The initial result was good, but the le t nipple stretched down
more than expected. The result was also complicated by capsular contracture.
I have stopped using saline implants or breast asymmetries, as well as or my
other augmentation patients, because I had a much higher capsular contracture
rate with saline implants. It is important that all patients realize that their skin is
not the same on both sides and that we cannot always predict what will hap-
pen. The need or revision is to be expected.
5 months postoperatively
Markings and immediate postoperative result

683
Chapter 12 • Breast Asymmetry
It is important to assess the footprint before deciding how best to
expand the borders. This will usually involve an implant. The
amount of breast ptosis on the desired footprint (not the existing
footprint) needs to be assessed. The ideal position of the nipple on
the desired breast mound (not the existing mound) must be deter-
mined. The size and protrusion of the areola need to be treated.
The key maneuver is to release the constricting bands to achieve and
maintain a good result.
5 months postoperatively
2 years postoperatively

684
Part II • Technique
This patient example demonstrates how relapse of the nipple-areolar deformity
can occur after a circumareolar purse-string suture has been placed. Smooth-
walled saline implants were placed in the subglandular position—175 cc on the
right and 225 cc on the left. She is shown 1 year postoperatively.
It was thought in the past that individuals with tuberous breasts
lacked breast skin inferiorly. There is no question that this is true,
but the skin will usually stretch quite easily when tension is applied.
A tuberous breast deformity is not a matter of tight skin as much
as it is a result of a tight fascial envelope around the breast that has
forced the constricted breast tissue to protrude into the softest part
of the breast—the areola.
Preoperative
1 year postoperatively

685
Chapter 12 • Breast Asymmetry
When I thought that the problem with tuberous breasts included a lack o skin
in the lower pole (as we were taught), I used the ap shown above, which was
described by Dinner, to f ll out the lower pole. It worked, but it added extra
scars that proved to be unnecessary when we realized how easily the lower pole
skin will stretch. This patient is shown with the ap designed or the right breast.
A smooth-walled 300 cc saline implant was placed in the subpectoral position.
A vertical mastopexy was per ormed on the le t breast, with a smooth-walled
200 cc saline implant in the subpectoral position.

686
Part II • Technique
She is shown 1 year a ter surgery. Interestingly, she was very disappointed—
not with the scar, but with the eel o di erent-sized implants.
Operative Technique for Tuberous Breast Deformities
The key to managing tuberous breast de ormities is to f rst understand the de-
ormity, specif cally, the ootprint (all our borders) and the shape (a tight con-
striction band restricting breast growth and creating protrusion into and widen-
ing o the areola).
There are several ways to help f ll out the lower pole and stretch the skin. First,
the constricting bands need to be released. The easiest way to stretch the skin
(and expand the ootprint) is to add an implant. But the implant only works
well i the constriction is adequately released. Another way o adding tissue to
the lower pole (and removing tissue rom under the areola) is to use the ap
described by Ribeiro or tuberous breasts.

687
Chapter 12 • Breast Asymmetry
The in eriorly based tuberous ap is dissected rom under the areola. The ap is
then turned downward, either deep to the parenchyma, as shown above, or re-
versed and tucked under the skin. This ap is small, but it can help f ll out the
lower pole and also reduce the areolar excess. This is especially use ul when an
implant is not going to be used. It is di f cult to stretch out the lower pole with-
out adding something (an implant) to apply tension to the skin a ter release o
the constricting bands.
When the skin circum erence is larger than the desired areolar circum erence,
the areola will stretch unless a permanent purse-string suture is used. Ideally,
the areolar skin can be reduced and matched to the skin circum erence.

688
Part II • Technique
This is a di erent patient. The Gore-Tex purse-string suture described by Den-
nis H ammond does work, although sometimes the areola stretches beyond the
Gore-Tex edges, as shown here. It is best (i at all possible) to avoid this prob-
lem by trying to match the areolar circum erence to the areolar skin opening
circum erence. For this reason, I try not to use a circumvertical technique in
breast surgery; instead, I accept a longer vertical length and a longer curve to
the lower pole o the breast to try to prevent areolar widening. This problem is
more obvious in the tuberous breast.
Problems and Complications
Complications specif c to correction o the tuberous breast include the ollowing:
• Inability to expand the ootprint su f ciently
• Recurrence o the areolar protrusion, with widening o the areola
• Inadequate release o the bands, resulting in a tight lower pole
The areola stretches more easily than the breast skin, and the areola will in-
evitably widen. I tried absorbable sutures, but they ailed.

689
Chapter 12 • Breast Asymmetry
This woman’s tuberous deformity was corrected with circumareolar reduction of
the areola, release of the constricting bands, and bilateral subglandular breast aug-
mentation with smooth-walled saline implants. A 240 cc implant was placed on
the right side, and a 230 cc implant was placed on the left side. There was inad-
equate release of the constriction compounded by bilateral capsular contracture.
She is shown 3 weeks postoperatively and 21⁄2 years later, just before a revision.
The lower pole skin remained tight, because the constriction was not adequately
released. Note that the medial skin stretched more than the lateral skin. The cap-
sules were released and an attempt was made to move the areolas more medially.
3 weeks postoperatively
Preoperative
2 1⁄2 years postoperatively

690
Part II • Technique
It has been reported that highly cohesive, shaped gel implants should help
relieve some of the tightness of lower pole skin. This was not the case in
the following patient example; inadequate release of the constricting band
was still a problem.
This patient had a Style 410MM 450 cc implant placed in the subglandular
position on both sides. She is shown at 6 weeks and 5 months after surgery.
The shaped implant was chosen, because she had a bony prominence in her up-
per chest, and it was hoped that the full lower pole of the implant would help
stretch out the lower pole skin. The patient is quite happy with the shape, al-
though the constricting bands are not adequately released.
6 weeks postoperatively
Preoperative
5 months postoperatively

691
Chapter 12 • Breast Asymmetry
Bilateral breast augmentation with smooth-walled 350 cc saline implants was
performed on this patient. The constricting fascia was released, and redundant
areolar skin was excised to match a good skin circumference. She is shown
1 week and 7½ years after surgery.
Results
Bilateral Breast Augmentation
1 week postoperatively
Preoperative
7 1⁄2 years postoperatively

692
Part II • Technique
Bilateral Mastopexy-Augmentation
This patient underwent a bilateral mastopexy-augmentation, with movement
o the nipple and areola higher on the breast mound. The implant f lled out all
our breast borders, but it also stretched out the skin. The nipple was later re-
elevated to a better position on the mound. She is shown 16 months a ter the
original surgery, be ore the revision, and again 16 months a ter the revision.
16 months postoperatively
Preoperative
16 months following revision surgery

693
Chapter 12 • Breast Asymmetry
This patient had a right medial pedicle vertical breast reduction and a left su-
perior pedicle mastopexy. She had 270 g removed from the right breast, and
skin only was removed from the left breast. She is shown 9 months after the
original surgery, before a revision in which an additional 50 g was removed from
the right breast, and the areola was further elevated on the left breast. Note that
the new nipple position was marked lower on the larger breast.
One Side Reduction/One Side Mastopexy
9 months postoperatively
Preoperative
3 months postoperatively

694
Part II • Technique
One Side Augmentation/One Side Mastopexy-Augmentation
This woman had a smooth-walled saline implant placed subglandularly through
a circumareolar incision on the left breast. A mastopexy-augmentation was per-
formed on the right breast. The right implant was 300 cc, and the left implant was
330 cc. She is shown 3 months and 21 months postoperatively. She subsequently
had a small amount of tissue removed from the lower pole of the right breast.
Analysis
Because implants were being used on both sides and both sides had
tight skin, the new nipple position could be matched so that its measurements
were close to those on the left breast. It is clear in retrospect, however, that the
skin above the areola on the right breast was not as tight as the skin on the left,
and it stretched a bit more postoperatively. Even with tuberous breasts, any
glandular ptosis needs to be assessed—and probably treated—at the initial op-
eration to try to help prevent subsequent dropping.
3 months postoperatively
Preoperative
21 months postoperatively

695
Chapter 12 • Breast Asymmetry
An augmentation was performed on this patient’s right breast, with subglan-
dular placement of a smooth-walled 200 cc saline implant. A mastopexy was
performed on her left breast. She is shown 2 years and 8 years postoperatively,
when the implant collapsed. She was marked for a revision with removal of the
envelope and insertion of a cohesive gel 150 cc implant.
Analysis
Nipple repositioning was successful on this patient, but it was im-
portant to place it slightly lower than the augmented side, because the left breast
was treated with a vertical mastopexy. A circumareolar mastopexy would likely
have stretched downward, whereas with the vertical approach, there is less ten-
sion on the superior aspect of the areola.
One Side Augmentation/One Side Mastopexy
2 years postoperatively
Preoperative
8 years postoperatively

696
Part II • Technique
One Side Reduction
This woman wanted to match her larger breast to the smaller one. This was
only possible because she had a relatively good footprint on the small side, and
the tuberous deformity was mainly subareolar. She had a medial pedicle verti-
cal breast reduction on her right breast and an areolar skin reduction and re-
lease of the constricting bands through a circumareolar incision. She is shown
6 weeks and 5 years after surgery.
Analysis
It is much harder to match a smaller breast than it is to match a larger
breast. Note that although the new nipple position was placed lower on this pa-
tient’s right breast, it was not low enough.
6 weeks postoperatively
Preoperative
5 years postoperatively

697
Chapter 12 • Breast Asymmetry
This patient had a lateral pedicle vertical breast reduction and a le t mastopexy-
augmentation using a subglandular smooth-walled 175 cc saline implant. She
is shown 1 month and 7 months postoperatively.
Analysis
Note that without an implant the ootprint on the right side is still
def cient in the medial breast border and the lower breast border (in ramam-
mary old).
One Side Reduction/One Side Mastopexy-Augmentation
1 month postoperatively
Preoperative
7 months postoperatively

698
Part II • Technique
POLAND’S SYNDROME
Poland’s syndrome was described by Al red Poland in 1841. It is characterized
by hypoplasia or aplasia o one breast, along with an underlying absence o the
sternal head o the pectoralis muscle, resulting in a classic inward-curving old in
the preaxillary area. Complete or partial absence o the pectoralis major and mi-
nor muscles can occur with various skeletal abnormalities such as brachydactyly
and syndactyly.
There are many ways o approaching the pectoralis de ormity, but I have not
tried any o them. I am including this section to be complete in my description
o breast asymmetry issues. I do not have enough experience to use a latissimus
ap, and I would re er any patient who considers this an important part o the
de ormity. Fat injections have provided a less invasive solution and appear to
have signif cant potential.
This patient had Poland’s syndrome. No attempt was made to treat the missing
pectoralis major muscle and preaxillary old (arrow) on the le t side. She had a
le t breast augmentation using a subglandular 200 cc implant. (There was no
pectoralis muscle to place the implant in a subpectoral position.) She also had a
vertical mastopexy on the right breast to reduce the areolar circum erence.

699
Chapter 12 • Breast Asymmetry
She is shown 6 weeks and 1 year a ter surgery.
She is shown 9 years postoperatively. The scars were rom a rib resection per-
ormed elsewhere to treat thoracic outlet syndrome.
Analysis
Weight gain has helped provide padding or the implant, but her
right breast has also enlarged and stretched the areola. The initial appearance
would have been improved with subpectoral placement o the implant or
padding; however, there was no muscle available. These cases are very di f cult;
there is a def nite place or at injections. I have very little experience with at
injections, but they are a good choice to help blunt the implant edges and f ll
out and create the preaxillary old without using the latissimus.

700
Part II • Technique
This patient had classic Poland’s syndrome on the right with a lack of pectoralis
muscle and an inward-curving preaxillary fold, indicated by the arrow (top left).
She had a subglandular (no pectoralis muscle) smooth-walled 275 cc saline im-
plant placed. She is shown 1 month postoperatively.
Analysis
The areola stretched fairly well without using a circumareolar inci-
sion. The breast shape could have easily become rounded, but, fortunately, it
bottomed out a bit and matched the left breast better than expected.
She is shown 18 months after sur-
gery, when she underwent a right
capsular release.
1 month postoperatively
Preoperative

701
Chapter 12 • Breast Asymmetry
This patient had less development and underwent a bilateral subglandular breast
augmentation with CML 170 g implants. Note the webbed neck and widely
spaced nipples.
Patients with Turner’s syndrome are not likely to develop much breast tissue.
It was interesting that the f rst patient shown above also had a tuberous-type
de ormity. These patients need to be managed by an endocrinologist. When
treating these patients, it is essential to maintain a close working relationship
among specialists.
Bilateral subglandular breast augmentation was per ormed on this patient with
Turner’s syndrome. Both (tuberous) areolas were released. The patient was lost
to ollow-up.
TU RNER’S SYNDROME
Turner’s syndrome is a chromosomal abnormality XO gonadal dysgenesis. Pa-
tients are usually short and have a classic webbed neck and low hairline. They
have nonworking ovaries, which results in breast hypoplasia. The chest is broad
and shield-shaped, with widely placed nipples. The presentation is somewhat
variable, as shown by the ollowing two patients.

702
Part II • Technique
LIPODYSTROPH Y SYNDROME
The patient presented above is the only patient I have seen with lipodystrophy
syndrome. This was a rare orm o lipodystrophy that resulted in an absence o
subcutaneous at in her extremities. Although her muscles were hypertrophied,
she did have at in the neck, ace, upper back, and lower abdominal wall. It did
not suction well, and, there ore, very little at was available or at injections.
H er chest wall was broad, and her nipples widely spaced. There was very little
at in the breasts. The breasts had a tuberous-type de ormity that was managed
well with mastopexy alone, but implants were def nitely needed or size. She
underwent a vertical mastopexy, but her breasts remained small.
She is shown 4 years a ter the mastopexy. In an e ort to expand her breast oot-
print in eriorly, medially, and superiorly, she had a subglandular breast augmen-
tation using Biocell textured responsive silicone gel Style 115 354 cc implants.

703
Chapter 12 • Breast Asymmetry
She is shown 3 months a ter the breast augmentation. Her breasts remain widely
spaced; however, the shape is still good and the ootprint is expanded.
REFLECTIONS
Breast asymmetries present plastic surgeons with signif cant challenges to over-
come. These can be some o the most di f cult cases we manage. The surgeon
needs to care ully assess the problem in all three dimensions to better plan the
surgical approach. An understanding o what needs to be addressed and what
change would be e ected with each surgical maneuver is essential. Even with
the best planning, the results can be unpredictable.
One o the most common complications is the need or surgical revision. The
asymmetry that results a ter the f rst procedure can develop, in part, because
the breasts respond unpredictably. Patient requests can make surgical planning
di f cult. Each breast responds di erently to gravity, pregnancy, and weight gain
and loss. Revisions are inevitable as time passes.

704
Part II • Technique
Concepts to Recall
• The patient’s wishes will guide the surgeon in planning and patient ed-
ucation.
• An understanding o what can and cannot be changed in combination
with a care ul analysis o critical breast landmarks is essential to determine
what needs to be changed.
• The breast shape must be assessed relative to its position on the desired
ootprint—not on the existing ootprint.
• The upper breast border can be elevated with an implant. It remains un-
changed with a mastopexy or breast reduction.
• The lower breast border (in ramammary old) can be lowered with an im-
plant. It can be raised with a superior or medial mastopexy or reduction.
• An in erior pedicle approach can lower the in ramammary old, which is
an advantage i a lower old is needed when an implant is not going to
be used.
• Widening the medial breast border usually requires an implant. An im-
plant with a wider base diameter should be chosen to f t the desired breast
base diameter rather than an implant that f ts the existing breast base di-
ameter. Fat injections and liposuction can help contour the old.
• The lateral breast border can be expanded with an implant and narrowed
with tissue removal and liposuction.
• Ptosis should be def ned relative to the desired and achievable result, not
relative to the existing in ramammary old.
• The existing and new nipple position should be assessed in the vertical
and horizontal directions, with attention to the desired and achievable
result, and not in relation to the current de ormity. The breast meridian
should be drawn in its ideal position. The new nipple position should be
about a third to hal the distance up the breast mound.
• The suprasternal notch-to-nipple distance will not change a ter a masto-
pexy and reduction. It will elongate, on average, 2 cm a ter a breast aug-
mentation or mastopexy-augmentation. Awareness o this di erence in
f nal nipple position is especially important in breast asymmetry cases in
which di erent surgical maneuvers are used or each breast.
• Areolar skin stretches more easily than breast skin. The areolar skin cir-
cum erence should be matched to the desired areolar circum erence to
prevent widening. Implants also cause areolar widening. A circumverti-
cal approach is advised to prevent areolar widening, even when a perma-
nent purse-string suture is to be used.

705
Chapter 12 • Breast Asymmetry
BIBLIOGRAPH Y
Asymmetry
H o man S. Recurrent de ormities ollowing reduction mammaplasty and correction o
breast asymmetry. Plast Reconstr Surg 78:55-62, 1986.
Sojitra NM, Ion L, Jain A, et al. Unilateral vertical scar breast reduction with glandular
transposition o the nipple-areola in breast asymmetry. Plast Reconstr Surg 116:114-
123, 2005.
Fat Injections
Coleman SR. Structural at gra ting: more than just a permanent f ller. Plast Reconstr Surg
118(3 Suppl):S108-S120, 2006.
Coleman SR, Saboeiro AP. Fat gra ting to the breast revisited: sa ety and e f cacy. Plast Re-
constr Surg 119:775-785, 2007.
Delay E, Garson S, Tousson G, et al. Fat injection to the breast: technique, results, and
indications based on 880 procedures over 10 years. Aesthet Surg J 29:360-378, 2009.
H yakusoku H, Ogawa R, Ono S, et al. Complications a ter autologous at injection to the
breast. Plast Reconstr Surg 123:360-370, 2009.
Pu LL, Coleman SR, Cui X, et al. Autologous at gra ts harvested and ref ned by the Coleman
technique: a comparative study. Plast Reconstr Surg 122:932-937, 2008.
Spear SL. Fat or breast: where are we? Plast Reconstr Surg 122:983-984, 2008.
Tuberous
DeLuca-Pytell DM, Piazza RC, H olding JC, et al. The incidence o tuberous breast de-
ormity in asymmetric and symmetric mammaplasty patients. Plast Reconstr Surg
116:1894-1901, 2005.
Dinner ML. The tubular/ tuberous breast syndrome. Ann Plast Surg 19:414-420, 1987.
Gallegos ML, Casas LA. A systematic, one-stage approach in the treatment o tuberous
breast de ormity. Aesthet Surg J 18:431-438, 1998.
H ammond DC. The interlocking Gore-Tex suture or control o areolar diameter and
shape: P73. Plast Reconstr Surg 116:214, 2005.
H ammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture or control o
areolar diameter and shape. Plast Reconstr Surg 119:804-809, 2007.
Lockwood TE. Superf cial ascial system (SFS) o the trunk and extremities: a new con-
cept. Plast Reconstr Surg 87:1009-1018, 1991.
Mandrekas AD, Zambacos GJ, Anastasopoulos A, et al. Aesthetic reconstruction o the
tuberous breast de ormity. Plast Reconstr Surg 112:1099-1108, 2003.
Muti E. Personal approach to surgical correction o the extremely hypoplastic tuberous
breast. Aesthetic Plast Surg 20:385-390, 1996.
Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg 3:339-347, 1976.
Ribeiro L, Canzi W, Buss A Jr, et al. Tuberous breast: a new approach. Plast Reconstr Surg
101:42-50, 1998.
Teimourian B, Adham NM. Surgical correction o the tuberous breast. Ann Plast Surg
10:190-193, 1983.
Toranto IR. Two-stage correction o tuberous breast. Plast Reconstr Surg 67:642-646,
1981.
Vecchione TR. A method or recontouring the domed nipple. Plast Reconstr Surg 57:30-
32, 1976.

Poland’s Syndrome
Borschel GH , Costantino DA, Cederna PS. Individualized implant-based reconstruction
o Poland syndrome breast and so t tissue de ormities. Ann Plast Surg 59:507-514,
2007.
Delay E, Sinna R, Chekaroua K, et al. Lipomodelling o Poland’s syndrome: a new treat-
ment o the thoracic de ormity. Aesthetic Plast Surg 34:218-225, 2010.
Fabian MC, Fischer JD. A variant o Poland’s syndrome. Can J Surg 37:67-69, 1994.
Freitas Rda S, o Tolazzi AR, Martins VD, et al. Poland’s syndrome: di erent clinical pre-
sentations and surgical reconstructions in 18 cases. Aesthetic Plast Surg 31:140-146,
2007.
Longaker MT, Glat PM, Colen LB, et al. Reconstruction o breast asymmetry in Poland’s
chest wall de ormity using microvascular ree aps. Plast Reconstr Surg 99:429-436,
1997.
Pereira LH, Sterodimas A. Poland syndrome: aesthetic result a ter late seroma and implant
removal without replacement. Aesthet Surg J 28:101-103, 2008.
Poland A. Def ciency o the pectoral muscles. Guy’s H ospital Rep 6:191, 1841.
Ram AN, Chung KC. Poland’s syndrome: current thoughts in the setting o a controversy.
Plast Reconstr Surg 123:949-953, 2009.
Ravitch MM. Poland syndrome: a study o an eponym. Plast Reconstr Surg 59:508-512,
1977.
706
Part II • Technique

I-1
A
Anesthesia
for augmentation, 180
for liposuction-only breast reduction,
391
for pucker correction, 293, 295,
310
for vertical breast reduction, 281
Antibiotics
in breast augmentation, 185, 194
in vertical breast reduction, 298-299
Areola
depigmentation of, 322
necrosis of, after breast re-reduction,
410-412
opening
in mastopexy, 474-475
in mastopexy-augmentation, 547-
548
in vertical breast reduction, 276,
288
size of, 659-661
spreading of, 229, 569-570
tuberous breast deformity correction,
681
Arterial supply
description of, 76
internal mammary system; see Internal
mammary system
lateral thoracic artery, 82
thoracoacromial artery, 83
Asymmetry
chest wall deformities, 674-677
developmental; see Developmental
asymmetry
laterally sloping chest wall as cause
of, 161-162
lipodystrophy syndrome as cause of,
702-703
overview of, 638
patient discussions about, 141
Poland’s syndrome as cause of, 698-
700
reduction as cause of, 306-308
sternal prominence as cause of, 163,
179
surgical correction of
areolar size considerations, 659-
661
augmentation, 159-163, 668,
670, 673-674
breast shape evaluations, 647-
651
breast size considerations, 639-
661
capsular contracture after, 664-
665
footprint evaluations, 640-646
infection after, 666
mastopexy, 669-670
mastopexy-augmentation, 671
nipple position considerations,
652-658
problems and complications asso-
ciated with, 661-666
reduction, 667, 669, 672
results, 666-674
revision surgery, 661-665, 703
surgical decision making for, 141
tuberous breast deformity; see
Tuberous breast deformity
Turner’s syndrome as cause of, 701
vertical breast reduction as cause of,
306-308
Augmentation
anesthesia for, 180
antibiotics, 185, 194
asymmetry corrections with, 159-
163, 668, 670, 673-674
bandaging used in, 186-187
bilateral, 691
breast shape changes, 155-158
case studies of, 230-240
clinical outcomes of, 148-163
considerations for, 118
dissection, 182
drains, 186
follow-up after, 188
footprint affected by, 149-154
hemostasis during, 189
in high-breasted patients, 148
implants
bottoming out of, 221-222, 579
choices, 164-166
complications and problems asso-
ciated with, 194-204, 215-217
displacement of, 222-228
double capsules, 200-204
edge visibility, 195
exposure of, 220
extrusion of, 194
federal limitations on choice of,
164
folds in, 196-198
fracture of, 171, 198
malposition of, 221-228
padding of, 195
placement of, 174-176, 195
povidone-iodine soaking of, 184
problems associated with, 194-204
rippling of, 195
rugae formation, 199
rupture of, 192, 215-217
saline, 171, 215-217
silicone, 164-166, 217
size of, 167-168
subfascial placement of, 174
subglandular placement of, 174-
176
subpectoral placement of, 174-176
tissue adherence to, 198-199
tissue ingrowth, 198
incisions
crescent, 172-173
infraareolar, 170
inframammary, 168-170, 176
marking of, 177
periareolar, 170-171
transaxillary, 171-172
inframammary fold changes, 24,
151, 222, 237, 522
lateral breast border changes, 152
in low-breasted patients, 148, 234
markings and design for, 176-178
mastopexy and; see Mastopexy-
augmentation
Index

Index
Augmentation—cont’d
measurements be ore, 176
medial breast border changes, 153-
154
medial breast quadrant, 41
mound adaptations to existing
nipple position, 101-102
nipple positioning, 49
patients
evaluation o , 163-164
positioning o , 179
photograph review be ore, 139, 164
planning or, 164-176
pocket
ormation o , 183
problems associated with, 205-
206
postoperative care, 186-188
principles o , 148-163
problems and complications
associated with
capsular contracture; see Capsular
contracture
dancing breast syndrome, 205
double bubble, 206-209
double capsules, 200-204
hematoma, 188-193
implant-related, 194-204, 215-
217
in ection, 194
Mondor’s disease, 210
pocket-specif c, 205-206
scar contracture, 218-219
seromas, 200-204
tension bands, 210
reduction and; see Reduction-
augmentation
results o , 230-240
suprasternal notch-to-nipple
changes, 121-122
surgical decision making or, 139
technique or, 180-186
tuberous breast de ormity correction
with, 102, 681, 690-692
upper breast border changes, 149-
150
B
Bakamjian ap, 88
Baker classif cation system, 211
Blood supply, 72-74
Bottoming out, o in ramammary old,
111, 159, 319-322, 407, 427,
443, 579; see also Pseudoptosis
Breast
anatomy o , 67-95
arterial supply to, 76-84, 93
blood supply to, 72-74, 93, 597-
598, 678
innervation o , 84-85
topography o , 68-74
vascular system o , 74-76
venous drainage o , 84
Breast augmentation classif cation, 211
Breast base width, 28, 327
Breast mound
augmentation considerations,
101-102
at injections to change, 102
liposuction used to change, 102
nipple movement with modif cation
o , 102-111
shaping o , 112-116
Breast ptosis; see also Ptosis
analysis o , 53-57
changes in, 57-62
illustration o , 648
Breast shape
augmentation e ects on, 155-158
description o , 29-31
evaluation o , 441-443, 446, 647-
651
implant e ects on, 155-158
lateral breast quadrant, 40-41
lower pole ullness, 37-40
mastopexy evaluations o , 441-443,
446
mastopexy-augmentation e ects on,
524-532
medial breast quadrant, 41-42
projection, 42-44, 394
upper pole ullness, 31-37
vertical breast reduction e ects on,
255-256
Wise pattern or planning, 44-46
Breast- eeding, 95, 136
C
Capsular contracture
a ter asymmetry surgery, 664-665
bilateral, 517
capsule removal, 213-215
classif cation systems or, 211
description o , 39, 165, 187, 190
illustration o , 211, 516-517, 664-
665
implant rippling caused by, 196
mastopexy-augmentation, 568-569
onset o , 212
release o , 212-213
rugae ormation caused by, 199
vitamin E or, 187
Capsulectomy, 212-215
Central pedicle
arterial supply to, 86-91
mastopexy uses o , 116
Chest wall
de ormities o , 674-677
laterally sloping, 161-162
Circumareolar mastopexy, 438, 518
Cleavage
mastopexy e ects on, 42
subpectoral implant placement e -
ects on, 567-568
Communication, 135
Congenital de ormities
patient discussions about, 141
Poland’s syndrome, 698-700
Turner’s syndrome, 701
Consultation
group seminars, 132-133
individual, 133-134
in ormational binders, 134-135
nurse assessments, 133
patient coordinator, 134-135
patient in ormation DVDs and
handouts, 131
photographs, 133-134, 136
preconsultation assessments, 130-
131
vertical breast reduction, 265-268
Cooper’s ligaments, 5, 9
Cordu method, 459-460
Crescent incision, 172-173
D
Dancing breast syndrome, 174, 195,
205, 218, 550, 567-568
Daniel/ Gra in erior ap method,
451-452, 479
Deep ascia, 70, 679
Depigmentation
o areola, 322
o ree nipple gra ts, 262, 607-
608
Developmental asymmetry
areolar size considerations, 659-
661
assessment o , 639-661
breast shape evaluations, 647-651
breast size considerations, 639-661
description o , 639
ootprint evaluations
lateral breast border, 647
lower breast border, 641-644
medial breast border, 645-646
upper breast border, 640
nipple position considerations
horizontal, 656-658
vertical, 652-655
ptosis evaluations, 647-651
Double bubble, 206-209, 564-566
Double capsules, 200-204, 559-563
Drains
breast augmentation, 186
mastopexy, 482
vertical breast reduction, 295
DVDs, 131
I-2

Index
E
Edge necrosis, 602-604, 610-611,
615-616
F
Fascia
deep, 70, 679
superf cial, 70
Fat injections, 102
Fat necrosis, 297
Flap; see specif c ap
Footprint
assessment o , 519-520
asymmetry in; see Asymmetry
high-breasted; see H igh-breasted
patients
implant e ects on, 149-154
individual variations in, 28
landmarks, 4-8, 439, 520
lateral breast border; see Lateral
breast border
low-breasted; see Low-breasted
patients
lower breast border; see Lower
breast border
mastopexy evaluation o , 439-440
medial breast border; see Medial
breast border
in tuberous breast de ormity analysis,
679, 683
upper breast border; see Upper breast
border
vertical breast reduction evaluation
o , 252-255
zones o adherence, 9-10, 69
Fourth intercostal nerve, 85, 94-95
Fourth interspace per orator, 76-79
Free nipple gra ts
considerations be ore using, 608
illustration o , 263
indications or, 103, 410
G
Gore-Tex sutures, 173, 555, 688
Group seminars, 132-133
H
H ematoma
breast augmentation and, 188-193
late-onset o , 190-193
mastopexy and, 484-485
mastopexy-augmentation and, 556-
557
vertical breast reduction and, 300-
301
H igh-breasted patients
augmentation in, 148
illustration o , 6-7, 253
mastopexy in, 439
mastopexy-augmentation in, 546-547
vertical breast reduction in, 253-254
H ypertrophic scars, 304-305
I
Implants
augmentation uses o ; see Augmen-
tation, implants
in ramammary old a ected by, 151,
522, 641, 644
mastopexy and, 39, 115
mastopexy-augmentation; see
Mastopexy-augmentation, im-
plants
new nipple position a ected by, 651
saline, 171, 215-217
shaped, 563-564
silicone
ederal regulations, 164-166
rupture o , 217
Incisions
augmentation, 168-173
crescent, 172-173
in raareolar, 170
in ramammary, 168-170, 176
liposuction-only breast reduction,
389
periareolar, 170-171
transaxillary, 171-172
Individual consultations, 133-134
In ection
a ter asymmetry corrective surgery,
666
a ter augmentation, 194
a ter mastopexy-augmentation, 557-
558
a ter vertical breast reduction, 297-
300
In erior ap
blood supply or, 599
medially based, 453-454
pectoralis strip with, 451-452, 479,
499-511
results o , 499-511
retraction o , 486
Ribeiro, 449-451, 478
technique or, 472-482
In erior pedicle
advantages o , 103
arterial supply to, 86
inverted-T procedure, 110-111
nipple movement uses o , 110-111
re-creation o , in breast re-reduction,
411, 424-426
vertical breast reduction use o , 258
In erior wedge resection principle
mastopexy application o , 408, 427
mastopexy-augmentation application
o , 518, 532-534, 552-554
In ormational binders, 134-135
In raareolar incision, 170
In ramammary old
analysis o , 16-18, 443
anatomy o , 70
asymmetry o , 17
augmentation changes to, 151, 522,
641
bottoming out o , 111, 159, 319-
322, 407, 427, 443, 579; see
also Pseudoptosis
changes in, 19-24
constrictions in, 208-209
description o , 8-10
dropping o , 22, 56-57, 405, 638,
643
elevating o , 19-20, 408-410
f bers o , 70
implant e ects on, 151, 522, 641,
644
level o , 16-24
lowering o , 21-24, 160, 222, 237,
640
mastopexy-augmentation e ects on,
24, 446, 644
nipple position relative to, 469
raising o , 408-410, 427, 641
in vertical breast reduction; see
Vertical breast reduction,
in ramammary old
weight loss e ects on, 18
Intercostal arteries, 81
Internal mammary system
branches o , 80-81, 598
descending branch rom the second
interspace, 80
Doppler examination o , 90-91
ourth interspace per orator, 76-
79
Inverted-T procedure
design o , 111
in ramammary old
bottoming out o , 407
elevation o , 19
medial pedicle, with nipple necrosis,
619-620
parenchymal resection, 112
pseudoptosis a ter, 445
puckers with, 309
re-reduction a ter, 604-605, 609
L
Landmarks, 5-8
Lateral breast border
analysis o , 26
augmentation changes to, 152
changes in, 26-28
description o , 9
implant or expanding o , 647
I-3

Index
Lateral breast border—cont’d
mastopexy-augmentation changes
to, 523-524
vertical breast reduction considera-
tions, 255
Lateral breast quadrant, 40-41
Lateral pedicle
arterial damage as contraindication
to use o , 600
arterial supply to, 92
innervation o , 109
mastopexy uses o , 102-103, 109
nipple movement uses o , 108-109
vertical breast reduction use o , 251,
321
Lateral thoracic artery, 82, 85, 92
Laterally based rotation ap, 460-463
Laterally sloping chest wall, 161-162
Lipodystrophy syndrome, 702-703
Liposuction
description o , 102, 386
in ramammary old elevation by, 410
in mastopexy, 481
Liposuction-only breast reduction
activity restrictions a ter, 393
advantages o , 386
anesthesia or, 391
candidates or, 263-264, 387
case studies o , 395-401
contraindications or, 387-388
disadvantages o , 386
incisions, 389
indications or, 263, 387-388
in ramammary old marking be ore,
390
markings or, 390-391
nerve damage concerns a ter, 388
nipple necrosis risks with, 386
operative technique or, 391-393
outcomes o , 395
patient positioning or, 391
patient selection or, 263-264, 387
perimenopausal women as candi-
dates or, 387
planning o , 389-391
postoperative care, 393
postoperative imaging concerns, 394
preoperative assessment, 388-389
problems and complications with,
394
ptosis and, 388
results o , 395-401
symmetry issues with, 394
upper pole ullness losses secondary
to, 392, 397
volume monitoring during, 392
in young patients, 264
Loss o sensation, 136
Low-breasted patients
illustration o , 6, 8, 253
mastopexy in, 440
mastopexy-augmentation in, 522,
545-546
vertical breast reduction in, 253-254
Lower breast border; see also In ra-
mammary old
description o , 100-101, 113
mastopexy-augmentation changes
in, 522
Lower pole ullness
analysis o , 37
changes in, 37-40, 140
M
Mammogram, 135
Mastopexy
areolar opening in, 474-475
asymmetry corrected with, 669-670
bandages or, 482
breast shape evaluations, 441-443,
446
breast size evaluations be ore, 468
case studies o , 434-435
central pedicle or, 116
circumareolar, 438, 518
cleavage a ected by, 42
complications and problems associ-
ated with
hematoma, 484-485
in erior vertical ap retraction, 486
nipple necrosis, 482-483, 599-600
puckers, 486-489
scar de ormity, 491
skin tension, 490
considerations or, 118
dermal closure in, 480-481
drains or, 482
ollow-up a ter, 434-437
ootprint evaluations, 439-440
goals o , 448
in high-breasted patients, 439
implants combined with, 39, 115
indications or, 441, 446
in erior vertical ap
blood supply or, 599
results o , 499-511
retraction o , 486
technique or, 472-482
inf ltration, 476
lateral pedicle or, 102-103, 109
lipodystrophy syndrome–related
asymmetry correction with,
702-703
liposuction in, 481
in low-breasted patients, 440
markings and design or, 472-476
medial pedicle or, 612, 617-618
nipple position with, 49, 464-465,
473, 654
operative approach or, 472-476
overview o , 430-438
parenchymal rearrangement in
Cordu method or, 459-460
Daniel/ Gra method or, 451-
452, 479
description o , 113, 115, 432-433,
438
laterally based rotation ap, 460-
463
medial pedicle extension ap or,
457-458
medially based in erior ap or,
453-454
medially based rotation ap, 459-
460
overview o , 448
pedicle extension aps or, 454-
458
Ribeiro ap or, 449-451, 478
rotation aps or, 459-463
superior pedicle extension ap or,
454-456
patients
positioning o , 476
selection and evaluation o , 468-
471
pedicle
creation o , 476-477
design o , 466, 476
pillar closure in, 480
planning or, 464-468
postoperative care, 482
principles or, 438-439
ptosis
evaluation o , 441-446
patient discussions about, 469
reduction versus, 430
results o , 434-437, 492-511
skin closure a ter, 482
skin resection pattern or, 465, 475-
476
small breast reductions with, 492-498
superior pedicle or, 102, 106
suprasternal notch-to-nipple changes
with, 125
surgical decision making or, 139-
140
suturing or, 480-482
taping o incisions or, 482
technique or, 476-482
tuberous breast de ormity correction
with, 693, 695
upper breast border and, 442, 472,
502, 640
I-4

Index
upper pole ullness and, 36, 139-
140, 468-469
vertical wedge resection principle,
447-448
Wise pattern or, 465-466
Mastopexy-augmentation
areolar opening in, 547-548
asymmetry correction with, 671
breast shape changes and, 524-532
case studies o , 582-588
challenges associated with, 516
complications and problems associ-
ated with
areolar spreading, 569-570
bottoming out, 578-580
capsular contracture, 568-569
dancing breast syndrome, 567-
568
description o , 555
double-bubble de ormity, 564-566
double capsules, 559-563
glandular ptosis recurrence, 571-
575
hematoma, 556-557
implant-specif c, 559-563
in ection, 557-558
nipple necrosis, 559, 599-600,
613-614
nipple placement too high or too
low, 576-577
nipple ptosis recurrence, 571-575
puckers, 580-581
wide cleavage, 567-568
wound healing, 558
considerations or, 118
deepithelialization or, 551
ootprint
alterations to, 521-524
assessment o , 519-520
glandular ptosis corrected with,
525-526, 529-530
in high-breasted patients, 546-547
implants
double capsules, 559-563
in ramammary old bottoming out
caused by, 579-580
insertion o , 551-552
pocket location or, 549-550
problems associated with, 559-
564
selection o , 549
shaped, 563-564
subglandular placement o , 551
in erior wedge resection principle,
518, 532-534, 552-554
inf ltration or, 550
in ramammary old level a ected by,
24, 446, 644
lateral breast border changes with,
523-524
in low-breasted patients, 522, 545-
546
lower breast border changes with,
522
markings or, 543-550
medial breast border changes with,
523-524
meridians and, 544
new nipple position and, 545
operative approach and technique
or, 543-555
parenchymal rearrangement in, 116,
516
patient positioning or, 550
pedicle design or, 548-549
pillar closure in, 554
pocket
double bubble de ormity, 564-566
location o , 549-550
problems associated with, 564-566
postoperative care, 555
principles o , 532-540
results o , 582-588
skin closure a ter, 554-555
skin resection pattern in, 548
staging o , 540
sub ascial sling and, 535-539
superior pedicle and, 548-549, 605-
606
superior pedicle extension ap and,
540-542
suprasternal notch-to-nipple changes
with, 126-127, 519
surgical decision making or, 140
suturing o , 554-555
tissue rearrangement with, 540-543
tuberous breast de ormity correction
with, 692, 694, 697
upper breast border changes with,
521, 543-545, 640
Medial breast border
analysis o , 24
changes in, 24-25
description o , 9-10
mastopexy-augmentation changes
to, 523-524
vertical breast reduction considera-
tions, 255
widening o , 645
Medial breast quadrant, 41-42
Medial pedicle
advantages o , 103-104, 251
arterial damage as contraindication
to use o , 600
arterial supply to, 85, 91, 103
blood supply to, 103, 251, 258
creation o , 283
design o , 279-281
ull-thickness, 104, 283
in erior parenchymal resection with,
117
innervation o , 95, 103
mastopexy use o , 612
mound shaping uses o , 116
nipple movement uses o , 103-104
vertical breast reduction uses o ,
102, 137-138, 250-251, 258,
279-281, 285, 326-347, 374,
601-603, 607-608, 610-611,
615-616, 621-630, 658, 693
Medial pedicle extension ap, 457-458
Medially based in erior ap, 453-454
Medially based rotation ap, 459-460
Meridians
description o , 52-53
marking o
or mastopexy-augmentation, 544
or vertical breast reduction, 270-
272
Minus-plus technique, 516, 519
Mondor’s disease, 210
N
Necrosis; see Fat necrosis; Nipple
necrosis; Nipple-areolar necrosis
Nipple
innervation o , 95
inversion o , 324
laterally sloping chest wall e ects on
appearance o , 161
ptosis o , 28, 54, 56-57, 155, 443-
445, 492, 503-504, 528, 533,
571-575
sensation in, 384
Nipple movement
in erior pedicle or, 110-111
lateral pedicle or, 108-109
medial pedicle or, 103-104
superior pedicle or, 105-106
superomedial pedicle or, 106-107
Nipple necrosis
anatomic considerations, 597-598
bilateral, 617-618
description o , 83, 592-593
diagnosis o , 601-622, 633-634
edge, 602-604, 610-611, 615-616,
631
illustration o , 593
incidence o , 594-597, 633
isolated, 630-632
liposuction-only breast reduction,
386
literature review regarding, 595-597
litigation risks and, 592, 633
I-5

Index
Nipple necrosis—cont’d
mastopexy and, 482-483, 599-600
mastopexy-augmentation and, 559,
599-600, 613-614
medial pedicle inverted-T reduction
with, 619-620
medial pedicle mastopexy and, 612,
617-618
prevention o , 599-600
re-reduction and, 410-412
tip, 632
treatment o , 622-630
venous congestion, 629
vertical breast reduction, 297, 599,
615-616, 621-622, 624-632
Nipple position
centralization o
horizontal, 51-53, 473
vertical, 46-51, 473
ideal, 14-16, 254, 443, 465
implants and, 100
lateral, 101
new
horizontal, 656-658
implant e ects on, 651
mastopexy determinations, 464-
465, 473, 654
mastopexy-augmentation determi-
nations, 545
vertical, 652-655
vertical breast reduction markings
or, 272-275
problems associated with, 404-406,
426, 576-577
upper breast border or determining,
14-16, 254
Nipple-areola complex
breast re-reduction considerations,
426-427
movement o , 102-103
Nipple-areolar necrosis
diagnosis o , 601-622
edge, 602-604, 610-611, 615-616
re-reduction and, 410-412, 604-605
Nurse assessments, 133
P
Parenchymal rearrangement
Cordu method or, 459-460
Daniel/ Gra method or, 451-452,
479
description o , 113-116, 432-433,
438
laterally based rotation ap or, 460-
463
medial pedicle extension ap or,
457-458
medially based in erior ap or, 453-
454
medially based rotation ap or,
459-460
overview o , 448
pedicle extension aps or, 454-458
Ribeiro ap or, 449-451, 478
rotation aps or, 459-463
superior pedicle extension ap or,
454-456
Parenchymal resection
description o , 112-113, 138, 257
in erior, 287-288
lateral, 285-287
in vertical breast reduction, 284-288
Patient coordinator, 134-135
Patient education, 136-137
Patient in ormation DVDs and hand-
outs, 131
Pectoralis ascia, 71
Pectus excavatum, 27, 674-677
Pedicle(s)
arterial supply to, 85-92
breast- eeding considerations, 95
central; see Central pedicle
ull-thickness, 93
innervation o , 94-95
lateral; see Lateral pedicle
mastopexy and, 466, 476
medial; see Medial pedicle
re-creation o , 411, 424-426
superior; see Superior pedicle
venous drainage o , 93
Pedicle extension aps, 454-458
Periareolar incision, 170-171
Photographs, 133-134, 136
Pillar closure
in mastopexy, 480
in mastopexy-augmentation, 554
in vertical breast reduction, 289-291
Pocket
or augmentation
ormation o , 183
problems associated with, 205-
206
or mastopexy-augmentation, 549-
550
Poland’s syndrome, 698-700
Preconsultation assessments, 130-131
Preoperative preparation
description o , 135-136
vertical breast reduction and, 268
Projection, 42-44, 394
Pseudoptosis, 23, 28, 56-57, 61-62,
155, 443, 445, 530-532
Ptosis
actors associated with, 60
glandular, 28, 55-57, 59-60, 115,
155, 431, 438, 442-446, 469,
492, 503-504, 525-526, 529-
530, 533, 571-575, 578-579
liposuction-only breast reduction
e ects, 394
nipple, 28, 54, 56-57, 155, 443-
445, 492, 503-504, 528, 533,
571-575
pseudoptosis, 23, 28, 56-57, 61-62,
155, 443, 445, 530-532
Regnault classif cation o , 53, 441
Puckers
mastopexy and, 486-489
mastopexy-augmentation and, 580-
581
vertical breast reduction and, 309-
318, 333
R
Reduction; see also Vertical breast
reduction
asymmetry corrected with, 667,
669, 672
breast- eeding a ter, 136
consultation about, 134
inverted-T; see Inverted-T procedure
liposuction-only; see Liposuction-
only breast reduction
mastopexy versus, 430
medial pedicle approach or, 137-
138
parenchymal resection in, 138
patient education about, 136-137
ptosis correction with, 649
revision o ; see Re-reduction
skin resection in, 138-139
small, 492-498
suprasternal notch-to-nipple changes
with, 123-124
surgical decision making or, 137-
139
tuberous breast de ormity correction
with, 693, 696-697
vertical; see Vertical breast reduction
Reduction-augmentation
indications or, 116, 140, 469, 516,
519
lower pole changes with, 40
Regnault ptosis classif cation, 53, 441
Re-reduction
complications and problems associ-
ated with
excess skin removal, 412-413
nipple-areolar necrosis, 410-412,
604-605
in erior wedge resection principle
or, 408, 427
in ramammary old
bottoming out o , 407
raising o , 408-410, 427
a ter inverted-T procedure, 604-
605, 609
I-6

Index
nipple-areola complex considera-
tions, 426-427
overview o , 404-405
pedicle re-creation, 411, 424-426
reasons or
bottoming out o in ramammary
old, 407, 427
nipple position too high, 404-406,
426
results o , 414-424
wedge resection principle or, 408,
427
Ribeiro ap, 36, 87, 114, 447, 449-
451, 478, 682, 686
Rippling, o implants, 195
Rotation aps, 459-463
S
Saline implants, 171, 215-217
Scar/ scarring
contracture o , 218-219, 447
hypertrophic, 304-305
mastopexy and, 491
vertical breast reduction and, 304-
305
Seroma
a ter augmentation, 200-204
a ter vertical breast reduction, 301-
303
Silicone implants
ederal regulations or, 164-166
rupture o , 217
Skin resection
description o , 116-117
excessive, 412-413
inverted-T pattern o , 465
mastopexy and, 465, 475-476
mastopexy-augmentation and, 548
vertical breast reduction and, 138-
139, 256-257, 277-278, 325
Skin tension, 433, 490, 684
Starburst wrinkling, 438
Sternal prominence, 163, 179
Subcuticular suture, 293
Sub ascial sling, 535-539
Subpectoral augmentation, 85
Superf cial ascia, 70
Superior pedicle
blood supply to, 88, 105
long, 105
mastopexy and, 102, 106
mastopexy-augmentation use o ,
548-549, 605-606
thinning o , 94
vertical breast reduction and, 258
Superior pedicle extension ap
mastopexy and, 454-456
mastopexy-augmentation and, 540-
542
Superomedial pedicle
blood supply to, 281
description o , 90, 106-107
vertical breast reduction and, 279
Suprasternal notch-to-nipple measure-
ments, 121-127, 519, 651
Suturing
mastopexy and, 480-482
mastopexy-augmentation and, 554-
555
vertical breast reduction and, 293-
295
Swartzmann maneuver, 279
T
Tension bands, 210
Thoracoacromial artery, 83
Transaxillary incision, 171-172
Tuberous breast de ormity
areola skin excision in, 681
assessment o , 679-686
causes o , 678
ootprint analysis in, 679, 683
operative technique or
augmentation, 102, 681, 690-
692
description o , 686-688
implants, 102, 681, 690-692
mastopexy, 693, 695
mastopexy-augmentation, 692,
694, 697
problems and complications asso-
ciated with, 688-690
reduction, 693, 696-697
results, 691-697
Ribeiro ap, 686
skin tension or, 684
Turner’s syndrome, 701
U
Upper breast border
analysis o , 10-11
augmentation e ects on, 149-150,
640
changes in, 11-16, 100
def nition o , 443
deviation in, 11
high, 14, 17
low, 17
marking o
or mastopexy-augmentation,
543-544
or vertical breast reduction, 269-
270
mastopexy and, 442, 472, 502, 640
mastopexy-augmentation e ects,
521, 545, 640
nipple position and, 14-16, 254,
404-406, 426
Upper pole ullness
analysis o , 31-33
changes in, 33-37
evaluation o , be ore mastopexy,
468-469
liposuction-only breast reduction
e ects on, 392, 397
patient consultation about, 139-
140
regional di erences in, 31
V
Vascular system, 74-76
Vertical breast ootprint, 6-8
Vertical breast reduction; see also
Reduction
antibiotics, 298-299
areolar opening or, 276, 288
asymmetry corrected with, 667,
669, 672
breast shape considerations, 30-31,
255-256
case studies o , 348-373
complications and problems associ-
ated with
areola depigmentation, 322
asymmetry, 306-308
bottoming out, 319-322
description o , 265
at necrosis, 297
hematoma, 300-301
indentations, 323-325
in ection, 297-300
nipple inversion, 324
nipple necrosis, 297, 599, 615-
616, 621-622, 624-632
puckers, 309-318, 333
scarring, 304-305
seroma, 301-303
skin overresection, 325
underresection, 319-322
wound-healing, 297-300
considerations or, 118
consultation be ore, 265-268
deepithelialization with, 282-283
dermal closure, 292
description o , 250
drains used with, 295
in high-breasted patients, 253-
254
in erior pedicle or, 258
inf ltration or, 282
in ramammary old
elevation o , 19-20, 440
preoperative marking o , 281
lateral pedicle or, 251, 321
liposuction tailoring with, 292
in low-breasted patients, 253-254
lower pole ullness a ter, 37
I-7

Index
Vertical breast reduction; see also
Reduction—cont’d
markings and design
areolar opening, 276
meridians, 270-272
new nipple position, 272-275
skin resection pattern, 277-278
upper breast border, 269-270
medial pedicle or, 102, 250-251,
258, 279-281, 285, 326-347,
374, 601-603, 607-608, 610-
611, 615-616, 621-632, 658,
693
nipple position
description o , 49
new, marking o , 272-275, 308
nipple sensation a ter, 384
operative technique or, 281-296
parenchymal resection with, 284-288
patients
evaluation o , 265-268
positioning o , 281
selection o , 259-264
pedicle
creation o , 283
design o , 258, 279-281
lateral, 251, 321
medial, 102, 250-251, 258, 279-
281, 285, 326-347, 374
superior, 258
superomedial, 279
pillar closure or, 289-291
planning or, 268
postoperative care, 296
preoperative preparation or, 268
principles o , 252-258
results o , 326-347
revision rates or, 325; see also
Re-reduction
skin closure a ter, 293-295
skin resection in
description o , 256-257, 277-278
overresection, 325
superior pedicle or, 258
superomedial pedicle or, 279
suturing with, 293-295
taping of ncision, 296
tuberous breast de ormity correction
with, 693, 696-697
upper pole ullness a ter, 36
vertical length measurements with,
382-383
vertical wedge resection and, 256,
260, 284-285
wide breast base corrected with,
327
Wise patterns, 257, 287, 290, 331
Vertical wedge resection principle
breast re-reduction use o , 408
mastopexy use o , 447-448
vertical breast reduction use o , 256,
260, 284-285
Vitamin E, 187
W
Water all e ect, 206, 517
Wedge resection principle
in erior
mastopexy application o , 408,
427
mastopexy-augmentation
application o , 518, 532-534,
552-554
vertical
breast re-reduction and, 408, 427
mastopexy and, 447-448
vertical breast reduction and, 256,
260, 284-285
Weight loss
glandular ptosis secondary to, 60
in ramammary old a ected by, 18
skin excess secondary to, 261
upper pole ullness a ected by,
32-33
Wise pattern
description o , 44-46
mastopexy and, 466-467
mastopexy-augmentation and, 553
parenchyma removal beyond, 112
vertical breast reduction and, 257,
287, 290, 331
Wound-healing problems
mastopexy-augmentation and, 558
vertical breast reduction and, 297-
300
Würinger’s septum, 72, 75, 477, 598
Y
Young patients
consultation with, 130-131
liposuction-only breast reduction
or, 388
Z
Zones o adherence, 9-10, 69
I-8