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

30
Part I • Concepts and Principles
Inframammary fold
Nipple
Inframammary fold
Nipple
Both o these breast shapes are acceptable and attractive. The shape on the le t,
shown a ter breast augmentation, is rarely achieved with a mastopexy or re-
duction, and or breast augmentation, it is only attained in patients who already
have a breast shape with the nipple located well above the in ramammary old.
Two acceptable, but di erent, breast shapes are shown. In the f rst, the nipple
is well above the in ramammary old, with no glandular ptosis. In the second,
the nipple is at the level o the in ramammary old with some (acceptable) glan-
dular ptosis. Both still have nipples centralized on the breast mound.

The patient on the right, shown a ter a medial pedicle vertical breast reduction,
has a more typical breast reduction shape with a similar breast ootprint; her
right breast hangs down o the ootprint itsel , more like an awning. In both
cases, the nipple is centralized on the breast mound, but the breast mound sits
a bit lower on the ootprint in a reduction or mastopexy patient.
The shape o the breast (the third dimension) needs to be analyzed much the
same way one would analyze the ootprint. It is important to look at all our
breast quadrants to see what can and cannot be altered, to assess the projec-
tion, and then to determine where the nipple should be positioned. Unaccept-
able breast shapes should also be analyzed to learn how they can be avoided
and corrected.
Decision making is inf uenced by all three dimensions and how they can be
changed to create an ideal result.
U PPER POLE FU LLNESS
Analysis
The upper pole o the breast may be ull or empty. Many patients desire a
rounded, ull upper breast area. Some patients are naturally endowed with up-
per pole ullness, whereas in others this shape can only be achieved surgically
with an implant. A naturally ull upper pole gives the surgeon more f exibility
in designing a breast reduction or a mastopexy.
Patients in North America o ten request a breast shape with a very ull upper
pole, which they consider an ideal look. Surgeons, however, o ten view a slop-
ing upper pole as the most attractive shape. In Europe and South America, a
sloping upper pole is more acceptable, and until recently, smaller breasts were
considered attractive. In past years, patients in North America were more likely
to ask or larger breasts than patients in South America, but this di erence seems
to be narrowing to some degree, with patients in South America now also ask-
ing or larger breasts.
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Chapter 1 • Breast Analysis and Clinical Concepts

The woman on the left has good upper pole fullness, whereas the woman on
the right has poor upper pole fullness. The surgeon can achieve a better aes-
thetic result after breast reduction in the patient on the left. Insertion of a breast
implant can improve upper pole fullness and elevation of the upper breast bor-
der, but often not as much as a patient wishes.
The surgeon should evaluate upper pole ullness in every patient.
This will not be altered with a standard reduction or mastopexy. It
can only be increased to any signif cant degree with a breast implant
or at injections.
Patients need to understand that the amount of upper pole fullness in their
breasts before a reduction or mastopexy will not change. H owever, when pa-
tients gain or lose weight, the upper pole is one of the areas that tends to change.
32
Part I • Concepts and Principles
This breast reduction patient had good upper pole fullness following surgery, but
as she lost 23 kg (50 pounds), she lost breast tissue mainly in the upper pole.

This patient lost 23 kg (50 pounds) preoperatively. Most o the volume loss
was in the upper pole. The lower border o the breast was actually higher a ter
the weight loss, but the upper breast border was lower, and all our quadrants
o the breast lost volume. The patient gained some weight a ter surgery, which
helped ll her upper pole and raise her upper breast border.
Effecting Change
There are numerous claims that the upper pole can be improved and the upper
breast border elevated by suturing the breast tissue up to the chest wall. A re-
view o the literature shows that this is rarely possible. Initially many o these
suture techniques appear to work, and the initial ollow-up photographs are en-
couraging. Un ortunately, this improvement drops out with time, and the up-
per breast contours return to the original position and shape.
My own experience conf rms this conclusion. In a series o 77 patients, I ele-
vated the upper breast o the chest wall and sutured the breast tissue in a higher
position onto the pectoralis ascia in an attempt to improve upper breast ull-
ness. I used absorbable 3-0 PDS in 43 breast reduction patients and nonab-
sorbable 3-0 Ti-cron in another 34 patients. Although it appeared initially that
upper pole ullness had increased, this apparent improvement had all but dis-
33
Chapter 1 • Breast Analysis and Clinical Concepts

appeared in the 72 patients who returned or ollow-up a ew months later. It is
not acceptable to judge f nal results in breast surgery rom photographs o the
patient on the operating table or a ter a ew weeks’ time. The f nal result should
not be evaluated until at least 1 year has passed.
34
Part I • Concepts and Principles
In this breast, the arrows mark the in erior border o the pillars in a medial pedi-
cle vertical breast reduction. The upper breast tissue has been elevated o the
chest wall, and the suture is shown be ore tying to secure the breast tissue higher
up on the chest wall.
In this patient, the sutures appear to have increased upper pole ullness.

Unfortunately, this fullness dissipates over time. The early postoperative view
at 9 days (middle) shows a temporary increase in upper pole fullness that has
disappeared by 4 months (right), although the patient still has good projection.
35
Chapter 1 • Breast Analysis and Clinical Concepts
This patient is shown at 3 weeks and 7 months postoperatively. The sutures that
were used to move the breast tissue up higher on the chest wall appeared to raise
the upper breast border and increase upper pole fullness, but the gain was tem-
porary. Both settled down to their original position, best seen in the lateral views.
Preoperative
Preoperative

3 weeks postoperatively

7 months postoperatively
9 days postoperatively

4 months postoperatively

The only procedures in the literature that appear to increase upper pole ullness
are those in which an in erior (Ribeiro) ap is held up with a sling o pectoralis
muscle or those in which breast tissue is secured to the second rib (Rubin) rather
than to pectoralis ascia. In act, i suturing breast tissue to pectoralis ascia ac-
tually held over the long term, the breast tissue would move with contraction
o the pectoralis muscle. When scar contracture o the breast to the chest wall in-
advertently results rom surgery, patients complain that the breast moves when
they contract their chest or arm muscles.
The breast is not attached to the chest wall but reely slides over it unless held
back by skin zones o adherence (the in ramammary old and medial breast bor-
der). Rarely, some upper pole ullness might be achieved, but even in these pa-
tients the upper border o the breast does not change.
Although we do not seem to be able to increase upper pole ullness by using
breast parenchyma, we can increase it by using exogenous material. Breast im-
plants e ectively increase upper pole ullness, and the judicious use o at in-
jections holds def nite promise.
In most breast reductions and mastopexies it is very di f cult to in-
crease upper pole ullness. The upper breast border lies below the
preaxillary ullness and will not change. Projection can be main-
tained over the long term, but upper pole ullness cannot.
36
Part I • Concepts and Principles
This patient is seen 2 weeks a ter a mastopexy. It appears that not only has upper
pole ullness been improved, but the upper breast border has been raised. Un or-
tunately, 15 months postoperatively she has better projection than she did preop-
eratively, but no actual increase in upper pole ullness. The upper breast border is
not elevated. The initial good result can be misleading to surgeons, and it is no-
toriously di f cult to get patients to come back or reassessment postoperatively.
Preoperative

2 weeks postoperatively

15 months postoperatively

37
Chapter 1 • Breast Analysis and Clinical Concepts
Upper pole fullness
Projection
Upper breast border
Inframammary fold
U pper pole fullness and projection are not the same.
LOWER POLE FU LLNESS
Analysis
Most augmentation patients want to f ll the breast mound and increase both
upper and lower pole ullness. Some patients want to increase the upper pole
more than the lower pole, whereas others, such as patients with tuberous breasts,
actually request more lower pole ullness. Most breast reduction and mastopexy
patients seek to reduce lower pole ullness with removal o the excess, ptotic
breast tissue.
Effecting Change
When a breast reduction is per ormed, the lower pole excess can be removed.
When a mastopexy is per ormed, the lower pole excess should be moved to pre-
vent bottoming out.
Skin (and dermis) stretch when tension is applied. This is the principle behind
skin expansion. Skin is not as reliable as a brassiere or supporting the weight
o a ull in erior pole. Many breast reduction patients, especially younger pa-
tients, exhibit good skin quality and elasticity; their skin can withstand tension
to a signif cant degree, and it is ar more e ective as a brassiere than the skin o

mastopexy patients. Most mastopexy patients have already shown that their skin
stretches with tension. The tissue that is removed in a breast reduction needs
to be surgically rearranged in a mastopexy, and the skin and dermis should not
be relied on to support the breast shape. The rearranged breast tissue needs to
heal in its new position.
38
Part I • Concepts and Principles
This woman is shown 6 years ollowing breast reduction on her le t breast and
a mastopexy on her right. The breast tissue was invaginated, and dermal aps
were created on the patient’s right breast. An initially good result deteriorated
over time. This patient example demonstrates that breast reduction with tissue
removal is an easier method or breast reshaping than trying to use skin to push
up and hold the breast tissue.
The upper pole cannot be augmented, and the lower pole cannot be reduced
by tightening the skin and dermis. We need to remember that skin and dermis
are the same thing and that dermal aps are unlikely to be reliable because skin
(and dermis) stretches under tension.
The tissue that is removed in a breast reduction needs to be moved
in a mastopexy.
Di f culty arises when a patient wishes to reduce lower pole ullness and improve
upper pole ullness. A mastopexy alone can improve projection, but upper pole
ullness is elusive without an implant. Un ortunately, it is almost impossible to
rearrange the excess in erior breast tissue with a mastopexy-augmentation. In
my experience, this tissue needs to be removed or else the breast tissue will drop
down again.
Some surgeons think that when an implant is combined with a mastopexy, the
implant can help hold up the ptotic breast tissue. This will only happen with

capsular contracture, when the capsule, being attached to the breast tissue, has
tightened and elevated the tissue. When a soft capsule forms, the breast tissue
acts independently of the implant, and because it is not attached deeply, it will
descend. Mastopexy patients have already demonstrated that their skin elastic-
ity is poor and cannot be relied on to hold the breast tissue up.
39
Chapter 1 • Breast Analysis and Clinical Concepts
This woman had bilateral capsular contracture and a ruptured saline implant on
the right. H er breast tissue is attached to the contracted capsule on the left,
which is holding up the breast tissue. On the right side, where the capsule is no
longer acting as a force on the parenchyma, the breast has dropped back down
to its original position. Normally implants and breast parenchyma are inde-
pendent of each other.
In this patient, it is clear that a circumareolar mastopexy-augmentation was not
successful, because there is too much parenchyma in the lower pole. The im-
plant and breast tissue are independent of each other, as seen when the patient
contracts her pectoralis muscle.

With a mastopexy-augmentation it is di f cult to rearrange the lower pole, and
it is o ten better to remove it and use a larger implant to compensate or the
tissue removal. Although a reduction-augmentation seems to be counterintu-
itive, it may be the best choice or a long-lasting result.
40
Part I • Concepts and Principles
This mastopexy-augmentation patient shows how the parenchyma slides easily
o the implant. The lower pole needs to be removed in a breast reduction,
moved in a mastopexy, and removed in a mastopexy-augmentation.
LATERAL BREAST QU ADRANT
Analysis
The lateral breast quadrant can be augmented or reduced. Because the breast
is not f xed laterally, both the lateral breast quadrant and breast border tend to
be similar.
Effecting Change
In some patients the lateral quadrant needs to be augmented. This includes pa-
tients with narrow breasts that do not extend to the lateral chest wall, where
the lateral breast border needs to be widened. The quadrant itsel may need to
be f lled i the problem is lack o volume as well as a narrow base dimension, as
in patients with tuberous breast de ormities.
The lateral breast quadrant o ten needs to be reduced in breast reduction pa-
tients. Reducing the lateral aspect o the breast will o ten reduce the extent o
the lateral breast border as well. This is usually done by excising breast tissue

directly or by tailoring it laterally with liposuction. The lateral quadrant is ur-
ther reduced in many breast reduction patients by removing excess breast tis-
sue parallel to the chest wall to reduce the ullness as well as the lateral extent
o the breast.
MEDIAL BREAST QUADRANT
Analysis
The medial breast quadrant can be augmented with an implant. Frequently the
patient also wants the medial breast border moved and the cleavage narrowed.
The medial quadrant can be augmented with an implant or with at injections.
It rarely needs to be signif cantly reduced, because in most breast reductions,
the excess is located in the lateral quadrant rather than the medial. A vertical
wedge excision brings the medial and lateral pillars together, which narrows the
breast base and improves the medial breast curvature.
Effecting Change
The amount o breast tissue that olds over the medial breast border is o ten in-
creased with a standard inverted-T type o reduction, whereas it is reduced with
a vertical type o reduction.
41
Chapter 1 • Breast Analysis and Clinical Concepts
As seen above, an inverted-T breast reduction sometimes pushes ullness me-
dially, especially at the level o the in ramammary old, where the medial dog-ear
results. The cleavage narrows, not because o medial breast border movement,
but more as an indication o breast tissue olding over the border.

With vertical breast reduction or mastopexy, the cleavage is sometimes widened
as a result o the breast coning and its base narrowing. In this patient, shown
4 years a ter medial pedicle vertical breast reduction, excision o a vertical wedge
o skin and parenchyma has coned and narrowed the breast. The cleavage is
widened and improved; the medial breast border is moved and the medial quad-
rant is reduced.
PROJECTION
Analysis
Good projection is important to good breast shape. We know that patients want
good projection, and we can o ten achieve this with an implant. I the distance
between the lower border o the areola and the in ramammary old is measured,
a nicely projecting B to D cup breast will have a distance o 7 to 11 cm. This
distance increases as projection increases.
Effecting Change
The idea that the breast’s vertical distance should only be 5 cm rom the in ra-
mammary old to the lower border o the areola ignores the natural ideal breast
shape that results in a nicely projecting breast a ter reduction. Mastopexy and
reduction patients o ten do not want the skin-on-skin look, with the lower pole
o the breast hanging down below the in ramammary old. Surgeons have not
been able to shorten this distance without f attening the breast.
The distance between the lower border o the areola and the in ramammary
old is o ten 7 cm in a B cup breast, 9 cm in a C cup breast, and 11 cm in a
D cup breast. Obviously, this distance is quite variable and is shorter in patients
who do not have a large lower pole. H owever, a longer curve is not only at-
tractive, but can also be necessary to promote good breast projection.
42
Part I • Concepts and Principles

43
Chapter 1 • Breast Analysis and Clinical Concepts
The 5 cm vertical distance advocated or an inverted-T in erior pedicle breast
reduction is used in an attempt to prevent stretching and bottoming out. Un-
ortunately it sometimes f attens the breast instead. A vertical reduction cones
the breast tissue, thereby producing better projection. A long vertical distance
between the in erior border o the areola and the in ramammary old is needed
to accommodate this increased projection.
The lower pole of the breast may curve below the level of the in-
framammary fold. This is not unattractive, and a longer distance is
needed with larger breasts, especially with increased projection.

Both o these patients show that a good result o ten includes a long lower pole
length when good projection is achieved. A 5 cm distance rom the lower bor-
der o the areola to the in ramammary old would f atten the breast.
REEVALUATING TH E WISE PATTERN
FOR PLANNING BREAST SH APE
Analysis
Robert Wise designed a breast pattern based on a brassiere design. Over time,
this pattern came to be used only or the keyhole opening, with many surgeons
not realizing that the pattern actually covers the ideal breast shape in its en-
tirety. The Wise pattern, when closed, provides good breast projection.
Effecting Change
44
Part I • Concepts and Principles
This pattern is an ideal method or deciding what tissue should be le t behind,
rather than or determining what to remove. To create a Wise pattern breast
shape, a vertical wedge o breast tissue needs to be removed and the vertical
limbs closed.

45
Chapter 1 • Breast Analysis and Clinical Concepts
7 cm
14 -16 cm
Before
After
The crosshatched areas have had the subcutaneous tissue removed with direct
excision and liposuction. Liposuction is performed peripherally; this can make
the skin contract to some degree. When the Wise pattern is superimposed over
the breast tissue and closed, it provides a nicely coned shape. All the tissue pe-
ripheral to the pattern should be removed.
The breast is narrowed and elevated. The remaining tissue, both vertically and
horizontally, is then removed with a combination of direct excision and lipo-
suction tailoring.

The Wise pattern is good for determining what to leave behind. The
key is to remove all tissue beyond the Wise pattern and to close both
the parenchyma and the skin without tension.
46
Part I • Concepts and Principles
As the Wise pattern is closed, the base o the breast narrows and the in erior
portions rise.
Ideal Nipple Position
Once the surgeon understands what can and cannot be achieved with the breast
ootprint and the breast shape, then f nal decisions about nipple position are
easier to determine.
CENTRALIZATION OF NIPPLE POSITION VERTICALLY
Analysis
The nipple needs to be centralized, both vertically and horizontally. This does
not necessarily mean centered, because the ideal breast shape has the nipple po-
sitioned a third to hal the distance up the breast mound and slightly lateral to
center. When the breast hangs o the breast ootprint, the nipple can still be
centralized, but it may be closer to the level o the in ramammary old.
Many beauti ul breasts have some glandular ptosis, but the nipple is at the level
o the in ramammary old, with the breast curving downward so that some breast
skin is lying on chest wall skin. The breast is lower on the chest wall than in
most o the “ideal” augmentation patients.

Effecting Change
With a breast augmentation, the mound is adapted to the existing nipple posi-
tion, and the breast implant size and dimensions are chosen with that position
in mind. This is in contrast to a mastopexy or breast reduction, in which the
nipple is moved up and adapted to the new breast shape.
With breast augmentation I look or a patient whose nipple and breast tissue are
both above the level o the in ramammary old. With an ideal breast augmenta-
tion patient, the landmarks o the breast ootprint do not need to be altered.
47
Chapter 1 • Breast Analysis and Clinical Concepts
In this patient, all our landmarks o the breast ootprint—the upper breast bor-
der, the in ramammary old, the medial breast border, and the lateral breast
border—are slightly increased. The nipple was already nearly centralized pre-
operatively, so none o the landmarks needed to be signif cantly altered.

For this patient, the inframammary fold needed to be lowered on both sides,
but more on the patient’s left. Some inevitable asymmetry remains, because the
left nipple was higher preoperatively. It is clear that an understanding of the
landmarks and what can be changed is essential to provide good shape and cen-
tralize the nipple on the breast mound.
48
Part I • Concepts and Principles

This woman also demonstrates the importance o assessing the existing breast
ootprint with its landmarks and determining what needs to be changed to cen-
tralize the nipple. The implant is used to augment all our quadrants, but in this
case, signif cantly more augmentation was required in the lower quadrant.
With a breast augmentation we can alter the borders o the breast
ootprint to best shape the breast. The implant is used to shape the
mound so that it is centralized behind the existing nipple position,
whereas with a breast reduction or mastopexy, the mound is altered
and the nipple is repositioned to f t that new mound.
49
Chapter 1 • Breast Analysis and Clinical Concepts

This breast reduction patient’s nipple is centralized on the breast mound, but
the nipple is closer to the inframammary fold, with the mound hanging off the
breast footprint. Her breasts have good projection, and this means that the ver-
tical distance between the bottom of the areola and the inframammary fold is
not short. A longer distance is needed to accommodate the increased projec-
tion that results from a vertical reduction.
50
Part I • Concepts and Principles

Although this patient had a breast reduction, the shape that resulted is similar to
that of a breast augmentation, with the nipple well above the inframammary
fold. This happens only rarely, when the inframammary fold is quite low and
the vertical breast footprint is quite large. The preoperative markings show that
she has a relatively high upper breast border and a low inframammary fold. The
new nipple position was appropriately located below the upper breast border
but well above the inframammary fold. In this position, the nipple sits higher
than usual postoperatively but without appearing to be too high, because it was
still centralized on the breast mound.
CENTRALIZING TH E NIPPLE POSITION
H ORIZONTALLY
Analysis
Some surgeons suggest drawing the breast meridian from the clavicle down to
the existing nipple position. Unfortunately in some individuals this will result
in a nipple that is positioned either too medially or too laterally. Instead, the
surgeon should visualize the desired breast meridian by estimating how much
breast narrowing can be achieved. It is often easier to excise excess lateral breast
tissue using vertical techniques than it is using inverted-T techniques; therefore
the new meridian can be placed more medially with the vertical approach. With
many of the inverted-T techniques the breast still remains fairly wide; a more
lateral breast meridian would be desired.
51
Chapter 1 • Breast Analysis and Clinical Concepts

In this patient, the new breast meridian (dashed line) is marked at the same po-
sition as the existing nipple.
52
Part I • Concepts and Principles
Conversely, in this woman the nipples are too medial, and the desired merid-
ian (dashed line) must be drawn lateral to the existing nipple position.
In this patient, however, the new meridian (dashed line) would be too lateral if
the line were drawn through the position of the existing nipple.

The proposed breast meridian should be marked in its ideal position, regard-
less o where the nipple exists preoperatively. The new nipple position is then
drawn at the intersection o the vertical position (as determined by the level o
the upper breast border) and the horizontal position (as determined by the new
breast meridian). On average, this is 10 cm below the upper breast border and
10 cm rom the middle o the chest wall. The upper border o the areola is then
marked about 2 cm above the new nipple position.
The new breast meridian should not be drawn through the exist-
ing nipple position. It should be drawn in its ideal position, with
the new breast mound visualized by the surgeon.
BREAST PTOSIS
A discussion about the breast ootprint and breast shape would be incomplete
without also considering breast ptosis. We all use the Regnault ptosis classif -
cation, but it is limiting because it def nes ptosis based on the location o the
in ramammary old. The in ramammary old level varies rom patient to patient
and is sometimes not located in the ideal position. It is o ten stated that a
mastopexy is needed i the nipple sits well below the in ramammary old. This is
not always true, because in some situations the nipple and/ or the old needs to
be moved. Breast ptosis is not just a problem o nipple position. Ptosis needs
to be evaluated to determine whether the problem is nipple ptosis, glandular
ptosis, a combination o the two, or pseudoptosis.
Preoperatively the surgeon needs to assess the nipple position, glan-
dular position, and inframammary fold position to determine the
best surgical approach for the patient.
Analysis
It is better to def ne ptosis in terms o the relation o each quadrant to the desired
nipple position, rather than the relation o the nipple position to the in ramam-
mary old. Both the nipple and the in ramammary old are too high in a tuberous
breast, and ptosis should not be classif ed by how they relate to each other.
The ideal nipple position should be def ned in relation to the upper breast bor-
der rather than in relation to the in ramammary old. Ptosis should then be de-
termined by the volume o the tissue in the upper and lower quadrants, with
respect to the ideal nipple position.
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Chapter 1 • Breast Analysis and Clinical Concepts

54
Part I • Concepts and Principles
Nipple Ptosis
In patients with nipple ptosis, the nipple is not centered on the breast mound.
In some situations it may be helpful to determine the relation of the nipple
position and the inframammary fold. It is also important to evaluate the rela-
tion of the nipple position and the existing breast mound as well as the desired
(and possible) result. Sometimes the nipple is not actually ptotic, but the infra-
mammary fold is too high. At other times the nipple appears to be too low, be-
cause there is very little parenchyma in the lower pole, as in a tuberous breast
deformity.
NORMAL
Normal with no ptosis Normal with ptosis
Nipple below
inframammary fold
Tuberous breast
ANALYSIS
EFFECTING CHANGE
Lower the
inframammary fold
Raise the nipple

55
Chapter 1 • Breast Analysis and Clinical Concepts
NORMAL
Normal with no ptosis

Normal with ptosis
Gland below
inframammary fold
ANALYSIS

EFFECTING CHANGE
Reduce lower pole
Glandular Ptosis
In patients with glandular ptosis, the lower pole is ptotic, and the nipple ap-
pears too high because o a preponderance o tissue in the lower pole. When
the breast tissue hangs below the level o the in ramammary old, the breast is
def ned as ptotic. H owever, it can be quite acceptable or the lower pole o the
breast to hang below the level o the in ramammary old and exhibit some pto-
sis as long as the nipple is centered on the breast mound. The nipple looks best
when it is positioned about a third to hal the distance up the breast mound
and slightly lateral to the breast meridian (centralized). Sometimes the gland is
not actually ptotic, but the in ramammary old is too high; there ore it would
be unwise to use the old to def ne ptosis in this circumstance. Unacceptable
glandular ptosis occurs when the lower pole o the breast bottoms out and the
nipple is no longer centered on the breast mound; it appears too high, because
there is too much gland in the lower pole.

56
Part I • Concepts and Principles
NORMAL
Normal with no ptosis Normal with ptosis
Gland and nipple below
inframammary fold
ANALYSIS

EFFECTING CHANGE
Raise nipple and
reduce lower pole
Combination of Nipple Ptosis and Glandular Ptosis
Most patients who present for a mastopexy have both nipple ptosis and glan-
dular ptosis. The surgeon needs to evaluate each independently. It can be rela-
tively simple to correct nipple ptosis by moving the nipple. If there is true glan-
dular ptosis as well, the surgeon needs to either “remove” lower pole tissue or
“move” it by rearranging the parenchyma. Moving the nipple alone (as in most
circumareolar mastopexies) or moving the nipple and tightening the skin will
not correct glandular ptosis. The lower pole parenchymal excess needs to be
addressed separately, and both nipple ptosis and glandular ptosis need to be
treated independently.
Pseudoptosis
In patients with pseudoptosis, the inframammary fold has dropped. When this
happens the nipple appears to be too high, because there appears to be too
much tissue in the lower pole of the breast. This type of bottoming out is not
glandular ptosis, because much of the lower pole is sitting above the infra-

57
Chapter 1 • Breast Analysis and Clinical Concepts
Effecting Change
Nipple ptosis is not necessarily corrected with a mastopexy. Sometimes the nip-
ple needs to be moved, and sometimes the mound needs to be adjusted to the
existing nipple position. I the nipple and breast tissue are low, then a mastopexy
may be indicated. I the problem is a high in ramammary old, then the old
can be lowered with an implant. I the lower pole is empty, making the nipple
look too low, an implant can be used to f ll out the lower pole.
Some glandular ptosis is normal and acceptable. Unacceptable glandular pto-
sis results a ter breast reduction or mastopexy, when the surgeon mistakenly
tries to push tissue into the upper pole o the breast. Projection can be increased
by removing or moving a vertical wedge o tissue rom the lower pole, but up-
per pole ullness cannot be increased by pushing tissue upward into the upper
pole. When a breast reduction is per ormed, the key is to remove su f cient tis-
sue rom the lower pole.
mammary old. The breast tissue drops out, pushing the in ramammary old
into a more in erior position. The nipple appears to be too high, because the
breast ootprint has been increased in a vertical direction, with the in ramam-
mary old dropping, o ten several centimeters below an inverted-T scar.
NORMAL
Normal

Inframammary drops
making nipple look too high
ANALYSIS

EFFECTING CHANGE
Raise inframammary
and reduce lower pole

58
Part I • Concepts and Principles
I the surgeon attempts to increase upper pole ullness rom AB to AC, the tis-
sue will all over time and revert to AB. The excess tissue will descend and cause
bottoming out or glandular ptosis.
a

b c

a

b c
a

b
Good upper
pole fullness
Poor upper

pole fullness
The tissue below the ideal breast shape needs to be removed. When the breast
has a ski-jump slope, the f nal shape in the upper pole will remain unchanged.

59
Chapter 1 • Breast Analysis and Clinical Concepts
Not enough breast tissue was removed inferiorly in this patient; the extra tis-
sue that was initially pushed up into the upper pole has dropped out over time.
H er bottoming out is caused by glandular ptosis. Excess tissue in the inferior
aspect of her breast makes the nipple no longer look centralized on the breast
mound. She is shown 1 year postoperatively. H er upper pole fullness has not
increased; I performed this procedure before I understood that I could not push
tissue into the upper pole and hold it with either sutures to the chest wall or a
skin-dermal sling. I should have determined the amount of tissue to be removed,
understanding that the empty upper pole would remain empty. This bottom-
ing out is the result of a planning error, not a procedural one. In this case the
nipple positioning was not as much in error as the mound creation was.
Pushing tissue into the upper pole of the breast will only cause bot-
toming out with too much tissue in the lower pole (glandular pto-
sis). The nipple appears to be too high, because it is no longer cen-
tralized on the breast mound.

60
Part I • Concepts and Principles
Nipple ptosis and glandular ptosis usually occur together as a result of aging,
weight gain, and/ or pregnancy. The nipple tends to stay relatively centered on
the breast mound. The changes subsequent to surgery do not occur in the same
manner. The skin above the nipple does not usually stretch very much in a breast
reduction or mastopexy, and the suprasternal notch-to-nipple distance does not
change much with time. H owever, the lower pole of the breast stretches over
time, leading to glandular ptosis. Sometimes the inframammary fold also drops,
leading to pseudoptosis.
Glandular ptosis alone can occur postoperatively when the breast tissue stretches
and the skin follows or with weight gain or pregnancy.
This woman initially had a good result after her inverted-T inferior pedicle breast
reduction, but two pregnancies resulted in a typical pattern of stretching and
bottoming out.

61
Chapter 1 • Breast Analysis and Clinical Concepts
Inframammary
fold
Inframammary
fold
This woman’s nipples are actually too high, but all the breast tissue is in the
lower pole and the in ramammary old has dropped out, making the nipples
seem much higher than they are. Because lowering the nipples is almost im-
possible to achieve, the solution is to remove the excess tissue in the lower pole
and to raise the in ramammary old back up into the scar. See Chapter 8 or a
discussion o re-reduction.
Most o the glandular breast tissue in a normal breast is lateral, with very little
true breast tissue medially. As the breast tissue expands with pregnancy, the lat-
eral breast expands and drags the skin with it. This makes the nipples look as i
the surgeon had poor judgment and misplaced them. Skin will stretch; there-
ore relying on the skin as a brassiere is not a good strategy, because it will not
hold under signif cant tension. Skin elasticity varies, as does the damage caused
by tension and stretching.
Pseudoptosis is characterized by dropping o the in ramammary old with sub-
sequent bottoming out. As a result, the nipple appears to be placed too high.

62
Part I • Concepts and Principles
In this woman, the nipple position looked too high because of a combination of
too much tissue in the lower pole of the breast and dropping out of the infra-
mammary fold from the previous inverted-T inferior breast reduction (both
glandular ptosis and pseudoptosis). The solution was to remove the heavy in-
ferior breast tissue and to elevate the inframammary fold. This tissue can be re-
moved directly and then tailored using liposuction.
REFLECTIONS
A better understanding of what we can (and should) achieve with surgery comes
with a better understanding and appreciation of the breast footprint and the
breast shape (all three breast dimensions). When we evaluate each of the breast
borders, and when we know what changes can—and cannot—be effected, we
can provide our patients with better results. Surgeons need to appreciate (and
educate their patients) that different breast shapes are acceptable and desirable.
Breast ptosis should not be de ned in relation to the inframammary fold, but
instead should be understood in relation to the upper breast border. Nipple
ptosis is relatively simple to correct, but a true understanding of glandular pto-
sis and the best approach to treatment is necessary. Pseudoptosis is a dropping
of the inframammary fold; surgical correction can be dif cult.

63
Chapter 1 • Breast Analysis and Clinical Concepts
Concepts to Recall
• Analysis o the breast ootprint and all its landmarks, and o the breast
shape and all its landmarks, is the basis or patient evaluation.
• The landmarks o the breast ootprint are: the upper breast border, lower
breast border (in ramammary old), medial breast border, and lateral
breast border.
• The breast is a subcutaneous structure that is not attached to the chest
wall. The skin zones o adherence (in ramammary old and medial breast
border) keep the breast in place. The breast can easily slide superiorly and
laterally, but it tends to old over the in ramammary old and the medial
breast border.
• The base o the breast ( ootprint) constitutes the f rst two breast dimen-
sions.
• The third dimension is the shape o the breast that sits on that ootprint.
• The breast shape can only be modif ed to some degree. The breast mound
needs to be adapted to the existing nipple position when per orming a
breast augmentation.
• Surgeons must understand the limits o what can be done with the bor-
ders o the breast ootprint and with the breast shape to centralize the
nipple and to maintain that shape. Without an understanding o these
concepts, initial good results will be degraded over time because o glan-
dular ptosis (an excess o parenchyma in the lower pole) or pseudoptosis
(a dropping o the lower hal o the breast ootprint).
• The upper breast border can be lowered with parenchymal resection, but
can only be elevated to some degree with exogenous material, such as
implants or at injections.
• The lower breast border (in ramammary old) can be lowered with im-
plants and raised to some degree with parenchymal resection.
• The medial breast border can be moved laterally with parenchymal re-
section and medially to some degree with an implant.
• The lateral breast border can be moved medially with parenchymal re-
section and laterally with an implant.
• The upper breast quadrant can be f lled with an implant, but not with
parenchyma.
• The lower breast quadrant can be f lled with an implant, but excess tis-
sue needs to be removed or moved to reduce lower pole ullness.
• The medial and lateral breast quadrants can be f lled with an implant or
reduced with resection.
• Projection is an important aspect o shape that tends to be augmented
with vertical parenchymal approaches, but can be reduced with inverted-T
approaches.

64
Part I • Concepts and Principles
• The ideal shape o the breast parenchyma ollows the Wise pattern.
• The nipple position needs to be centralized, not centered, on the breast
mound, both vertically and horizontally. A good understanding o ac-
ceptable mound positions and consequences o surgical maneuvers is es-
sential or proper nipple positioning.
• The ideal nipple position should not be determined in relation to the in-
ramammary old, but in relation to the upper breast border.
• Ptosis should not be classif ed by relating the nipple position and the in-
ramammary old, because the old can be so variable. Ptosis should in-
stead be determined by looking at the upper and lower breast quadrants
in relation to the ideal nipple position.
• There are three main types o ptosis: nipple ptosis, glandular ptosis, and
pseudoptosis.
• Surgeons need to understand the natural history o the di erent types o
ptosis and how to evaluate and treat them.
BIBLIOGRAPH Y
Breast Aesthetics
Avsar DK, Aygit AC, Benlier E, et al. Anthropomorphic breast measurement: a study o
385 Turkish emale students. Aesthet Surg J 30:44-50, 2009.
Brink RR. Evaluating breast parenchymal maldistribution with regard to mastopexy and
augmentation mammaplasty. Plast Reconstr Surg 86:715-719, 1990.
Brink RR. Evaluating breast parenchymal maldistribution with regard to mastopexy and
augmentation mammaplasty. Plast Reconstr Surg 106:491-496, 2000.
Blondeel P H ijjawi J, Depypere H, et al. Shaping the breast in aesthetic and reconstructive
breast surgery: an easy three-step principle. Plast Reconstr Surg 123:455-462, 2009.
Ferreira MC. Evaluation o results in aesthetic plastic surgery: preliminary observations on
mammaplasty. Plast Reconstr Surg 106:1630-1635, 2000.
H irsch EM, Brody GS. Anatomic variation and asymmetry in emale anterior thoracic
contour: an analysis o 50 consecutive computed tomography scans. Ann Plast Surg 59:73-
77, 2007.
H sia H C, Thomson JG. Di erences in breast shape pre erences between plastic surgeons
and patients seeking breast augmentation. Plast Reconstr Surg 112:312-320, 2003.
Kim MS, Sbalchiero JC, Reece GP, et al. Assessment o breast aesthetics. Plast Reconstr
Surg 121:186e-194e, 2008.
Penn J. Breast reduction. Br J Plast Surg 7:357-371, 1955.
Regnault P, Daniel RK, Tirkanits B. The minus-plus mastopexy. Clin Plast Surg 15:595-
600, 1988.
Rohrich RJ, Smith PD, Marcantonio DR, et al. The zones o adherence: role in minimiz-
ing and preventing contour de ormities in liposuction. Plast Reconstr Surg 107:1562-
1569, 2001.

65
Chapter 1 • Breast Analysis and Clinical Concepts
Smith DJ, Palin WE Jr, Katch VL, et al. Breast volume and anthropomorphic measure-
ments: normal values. Plast Reconstr Surg 78:331-335, 1986.
Tepper OM, Choi M, Small K, et al. An innovative three-dimensional approach to def n-
ing the anatomical changes occurring a ter short scar medial pedicle reduction
mammaplasty. Plast Reconstr Surg 121:1875-1884, 2008.
Tepper OM, Unger JG, Small KH , et al. Mammometrics: the standardization o aesthetic
and reconstructive breast surgery. Plast Reconstr Surg 125:393-400, 2010.
Thomsen JG, Liu YJ, Resti o RJ, et al. Sur ace area measurement o the emale breast:
phase I: validation o a novel optical technique. Plast Reconstr Surg 123:1588-1596,
2009.
Westreich M. Anthropomorphic breast measurement: protocol and results in 50 women
with aesthetically per ect breasts and clinical application. Plast Reconstr Surg 100:468-
479, 1997.
Wise RJ. A preliminary report on a method o planning the mammaplasty. Plast Reconstr
Surg 17:367-375, 1956.

(Trang không có chữ)

Applied Anatomy:
Key Concepts for
Modern Breast Surgery
Chapter2
67
F
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e
P
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n
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n
g
0
4
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3
3
4
7
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e
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T
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s

68
Part I • Concepts and Principles
M

y understanding o breast anatomy developed rom several important
sources. Conversations over a 30-year riendship with Ian Taylor provided
unique insights that helped me to think about anatomy in a new way. With Ian’s
guidance, I have tried to really see what I am looking at. My sta have been pa-
tient with me as I make them all stop and “admire” blood vessels and wait while
I take photographs to record and study what I am observing.
The work o Elisabeth Würinger has also impressed and in uenced me. I f rst
observed her in her operating room in Vienna, where I was surprised by her
ability to success ully isolate the nipple and areola on a imsy portion o tissue
that she called the septum. H er dissections and her operative approaches have
clarif ed the role o this septum in breast surgery. Cadaver dissections by one o
Ian Taylor’s students, Linda H uang, have urther demonstrated the medial-to-
lateral condensation that is consistent with Würinger’s medial-to-lateral “liga-
ment.” Another o Ian’s trainees, Niamh Cordu , has studied the venous
drainage o the breast. With Niamh’s assistance, Ian Taylor, Elizabeth Würinger,
and I were able to collaborate to clari y important anatomic concepts and rela-
tionships. This chapter re ects my interpretation o our combined thinking, but
these are certain to be continued controversies.
TOPOGRAPH Y
The breast is a skin “appendage.” It develops in the subcutaneous tissue and is
held in place by skin structures. It is only very loosely attached to the chest wall.

The skin is prevented rom descending by various attachments to its deeper lay-
ers. I these attachments did not exist, the skin would end up in olds much as
a sock might drop into layers around the ankle. The breast is attached to the
skin at the nipple and is held in place peripherally by skin attachments at the in-
ramammary old and the sternum or medial breast border—the zones of ad-
herence. The in ramammary old constitutes the lower breast border. It is not a
ligament, but there are multiple crisscrossing f bers that hold the skin in place
in a manner similar to that o the gluteal old. The medial breast border is
ormed by the skin attachments to the sternum. These attachments are looser
than those at the in ramammary old but are similar to those over the sacrum.
69
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
Zones of adherence
There are no def nite zones o adherence superiorly or laterally. When a woman
lies on her side, the upper breast olds over at the medial breast border, where
there are skin attachments, and the lower breast slides out laterally, because
there are no skin attachments. When she stands up, the breast olds over at the
in ramammary old, where there are skin attachments. I she is placed in the
Trendelenburg position, her breast slides upward, because there are no skin at-
tachments superiorly.

These photos show that in ramammary old f bers do exist. They are skin struc-
tures—not breast structures—that consist o crisscrossing f bers. These f bers
do not constitute a ligament, but cover a wider area than is normally appreci-
ated. The f gure on the top shows the f bers in situ. The f gure on the bottom
shows the f bers being pulled upward by the orceps. The in ramammary old, in
turn, is also pulled upward.
The breast is contained within a superf cial and a deep ascia. The ascia can be
poorly def ned in some patients, but it is loosely attached to the skin and at o
the subcutaneous layer. The deep layer o ascia is easily separated with f nger
dissection rom the pectoralis ascia. The breast is not held in place by any sig-
nif cant attachments between the deep ascia and the chest wall.
70
Part I • Concepts and Principles

71
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
The photo on the top shows how loosely the skin and subcutaneous tissue can
be attached to the superf cial breast ascia. The breast is attached to the skin at
the nipple. The photo on the bottom shows the deep ascia o the breast held
up by the retractor. The pectoralis ascia can be easily seen, with no signif cant
attachments between the pectoralis ascia and the deep ascia o the breast. Al-
though many books show a layer o at between the deep breast ascia and the
pectoralis ascia, it is not present in this patient. There is some at contained
within the breast parenchyma, but it is not a separate layer.
The breast is held in place by the medial and inferior skin (not
breast) zones of adherence and is very loosely attached to the chest
wall.

Blood Supply to the Breast
The breast develops at the level o the ourth interspace. The blood and nerve
supplies originate rom the same level.
72
Part I • Concepts and Principles
2
3
4
5
6
Duct
Gland
Cooper’s ligaments
Pectoralis major muscle
Pectoralis minor muscle
Second superficial branch of
internal mammary artery
Rib
Deep layer of enveloping breast fascia
Superficial layer of enveloping breast fascia
Internal intercostal muscle
External intercostal muscle
Würinger’s septum
Fifth superficial branch of
internal mammary artery
Fourth deep branches of
internal mammary vein and artery
Deep fascia
The breast has both a deep and a superf cial blood supply. The deep vessels pen-
etrate the breast rom its undersur ace (contained within Würinger’s septum)
and spread out through the breast. The superf cial vessels are pushed upward
as the breast develops; they travel over the top o the breast in the subcutaneous
tissue and supply the breast rom the periphery.

73
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
Superficial branches of the
internal mammary artery
Superficial branch of
the lateral thoracic artery
Thoracoacromial artery
2nd
3rd
Fourth deep branch of the
internal mammary artery
5th
6th
5
4
3
2
6
Lateral thoracic artery
(external mammary artery)
4th
Internal mammary artery
Superficial branch of
the lateral thoracic artery
2nd
3rd
4th
(deep)
5th
Superficial branches
of the internal
mammary artery
As the breast develops and expands, the superf cial vessels are stretched out in the
subcutaneous tissue over the breast and extend toward the center o the breast.
The deep vessels enter the deep portion o the breast and penetrate the breast
tissue as it develops and expands. The nerves ollow a similar pattern. Once a
surgeon understands this pattern, he or she can more easily design aps and
pedicles or primary and secondary procedures.

The breast has a deep and a superf cial blood supply. The deep sys-
tem contains both arterial input and venous drainage rom the in-
ternal mammary system. It per orates the intercostal muscles and
the pectoralis muscle, entering the breast just above the f th rib.
The superf cial system is contained within the subcutaneous tissue
and is pushed outward as the breast develops and expands.
DEEP VASCU LAR SYSTEM
The main arteries and veins are derived rom the internal mammary system.
Other branches come rom the lateral thoracic artery and the thoracoacromial
artery.
The deep (internal mammary) system enters the breast at the ourth interspace,
where the breast originates. These arteries and veins are contained within the
septum described by Würinger. This septum has an in erior and a superior lea
o thin tissue that contain these vessels. The septum thickens laterally and me-
dially and orms a type o ligament. This condensation o tissue has been ound
both in Würinger’s dissections and in Taylor’s and H uang’s histologic prepa-
rations. When per orming a breast reduction, the surgeon can see this septum
a ter the in ramammary old has been incised by pushing up bluntly on the tis-
sue separating it rom its in erior attachments. Blood vessels can be observed
travelling toward the center o the breast; these are located beneath a very thin
layer o tissue that composes the in erior lea o the septum.
The breast can be separated rom all o its superf cial attachments and remain
intact, attached only to this septum and the vessels contained within it. When
Würinger dissects away the extra breast tissue rom this septum in a breast re-
duction procedure, not only can the nipple be isolated and receive blood rom
this septum, but also the lateral and medial attachments o this “ligament” can
be visualized.
74
Part I • Concepts and Principles

75
Chapter 2 • Applied Anatomy: Key Concepts for Modern Breast Surgery
Pectoralis major muscle
Würinger’s septum
Breast tissue
Fifth rib
Perforating branch of the fourth
deep branch of the internal
mammary artery and vein
This patient’s right breast is shown. The surgeon’s thumb is holding up the su-
peromedially based pedicle, showing the vessels through the thin inferior layer
of the septum. The septum has a superior and inferior leaf that contain the deep
arterial and venous system, which comes through the fourth interspace.

SU PERFICIAL VASCU LAR SYSTEM
As the breast grows, the separation between the deep and superf cial systems
becomes more obvious. The breast pushes the subcutaneous tissue outward as
it grows. This subcutaneous tissue carries the arteries and veins that supply the
skin and the nipple and areola. The main arterial system is derived rom branches
o the internal mammary artery. The veins course just below the dermis and can
be seen through the skin as they travel superomedially, with a ew travelling su-
perolaterally. When the patient is supine, the medial direction o the drainage
and arterial supply becomes more obvious.
I the surgeon understands the deep and superf cial vascular sup-
ply, the design o pedicles and aps becomes more predictable in
both primary and secondary breast surgery.
ARTERIAL SU PPLY
The main blood supply to the breast, both superf cial and deep, comes rom
the internal mammary system. The main arterial supply comes rom the ourth
interspace and enters the breast just above the f th rib, usually just medial to
the breast meridian. This makes sense i one considers the breast origin and its
development a ter puberty.
Internal Mammary System
All o the branches rom the internal mammary system emerge rom around the
edge o the sternum. They then pass to varying degrees under the pectoralis
muscle insertion be ore they move toward the sur ace.
Fourth Interspace Perforator
The ourth branch penetrates the pectoralis muscle just medial to the breast
meridian and then travels upward into the center o the breast. Similar to many
deep vessels, it has accompanying venae comitantes. This system supplies an in-
erior and central pedicle.
76
Part I • Concepts and Principles

Pectoralis major muscle
Fourth deep branch of the internal
mammary artery
Internal mammary artery and vein
Breast tissue
Fifth rib
Deepithelialized pedicle
77
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
This patient is undergoing a subglandular breast augmentation. The in ra-
mammary old is marked, and the retractor is held medially. The deep system
rom the internal mammary artery (arrow) per orates the pectoralis muscle as
it enters the deep sur ace o the breast. The deep artery and vein also per orate
the intercostal muscles just above the f th rib be ore they per orate the pec-
toralis muscle. In the photo o the patient’s le t breast (bottom right), the rib is
just above the lower skin border.
SUPERIOR

78
Part I • Concepts and Principles
In this patient’s right breast, a hemostat points toward the per orator, which has
penetrated the ourth interspace and the pectoralis muscle. A medially based
pedicle is suspended in a cephalad direction. The artery comes up just above the
f th rib and just medial to the breast meridian. This constitutes the deep system.
Pectoralis major
muscle
Breast tissue
Perforating branch
and venae comitantes
of the fourth deep
branch of the internal
mammary artery
The deep per orating artery and its venae comitantes are held in the tip o the
hemostat. This is the deep branch that originates rom the ourth interspace o
the internal mammary system. It per orates the pectoralis muscle just above the
f th rib and enters the undersur ace o the breast. It is the system that supplies
an in erior or central pedicle.
Pectoralis major muscle
Fifth rib
Breast tissue
Fourth deep branch
of the internal
mammary artery