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

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Part II • Technique
RESU LTS
The following case examples were chosen to illustrate various issues in de-
cision making, planning, and surgical results. Preoperative and postoper-
ative photographs are shown with surgical details included. An analysis is
then presented with each case to show where decision making might have
been improved.
This patient had 225 cc smooth-walled saline implants placed in the subglan-
dular position through an inframammary fold incision. She is shown 16 months
postoperatively.

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Chapter 5 • Breast Augmentation
She did well until the right implant leaked 7 1⁄2 years a ter her initial augmenta-
tion. She was relatively symmetrical both be ore and a ter her initial surgery un-
til the right implant collapsed. It is important to note that on the implanted
side the upper breast border (dotted lines) is elevated, as shown by the black ar-
rows. The weight o the implant has lowered the nipple position, the lower pole,
and the in ramammary old to some degree. The breast on the side with the
collapsed implant has returned to its original size and shape.
Analysis
This patient shows the e ect that an implant has on the breast bor-
ders, as well as on the breast shape and nipple position. Patients o ten want
larger and larger implants to f ll the upper pole. Some elevation has occurred,
as shown by the dotted lines marking the upper breast border. This patient also
demonstrates that, even with a relatively small implant, the in ramammary old
is lowered, the breast becomes more ptotic on the breast ootprint, and the nip-
ple is lowered. My measurements have shown that the suprasternal notch-to-
nipple distance is, on average, lengthened 2 cm with a breast augmentation,
which means that the breast will appear to be lower on the chest wall postop-
eratively. The upper breast border is elevated an average o 2 cm, and the lower
breast border (in ramammary old) is lowered about 2 cm. The distance rom
the in erior border o the areola to the in ramammary old is lengthened sev-
eral centimeters. This distance tends to increase with time in some patients when
the implant bottoms out.

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Part II • Technique
This patient had 390 cc (360 cc 30 cc each) smooth-walled saline implants
placed above the muscle through a transaxillary incision. The left inframam-
mary fold was purposely lowered. She is shown 2 years after surgery.
Analysis
This was a challenging patient to operate on, because both the in-
framammary fold and the nipple were higher on the left breast. It appeared that
the left breast was smaller, but it had more upper pole fullness; a larger implant
on this side might have caused too much fullness, especially if the fold was not
lowered completely. Any attempt to lower the fold would tend to make the nip-
ple look higher on the breast mound. Some compromise needs to be accepted,
because correcting one form of asymmetry can exaggerate another.

This woman had 325 cc cohesive gel implants placed above the muscle through
an inframammary incision. She is shown 7 months after surgery.
Analysis
Both folds were lowered in this patient. She has a narrow breast foot-
print with an average upper breast border and a relatively high inframammary
fold, especially on her left. H er left nipple remained higher—as expected. This
difference is exaggerated the more her inframammary fold is lowered on the left.
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Chapter 5 • Breast Augmentation

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Part II • Technique
This woman was low breasted and had 325 cc smooth-walled silicone cohesive
I gel implants placed above the muscle through an in ramammary incision. She
is shown 6 months a ter surgery.
Analysis
This patient has a very low breast ootprint with a very low upper
breast border. The in ramammary old was lowered slightly to better centralize
the nipple on the breast mound. A mastopexy was not indicated, because the
breast ootprint itsel cannot be raised. The breasts look ptotic, because the in-
ramammary old is quite high (leaving a very narrow but low ootprint). Al-
though the old can be lowered slightly to make the nipple look higher and,
there ore, more centralized on the breast mound, the breast will remain low on
the chest wall. An implant can only raise the upper breast border slightly. A
mastopexy will not elevate the position o the breasts on the chest wall (the
ootprint). This case demonstrates that a preoperatively in ormed patient will
be ar more accepting o the f nal result.

This woman had smooth-walled 350 cc saline implants (325 cc 25 cc each)
placed below the muscle through an in raareolar incision. She did not have
enough padding or a subglandular implant. She is shown 3 years a ter surgery.
Analysis
This patient looks as i she is low breasted, because her breasts are
sagging. Her nipples and breasts are hanging o the breast ootprint (combined
glandular and nipple ptosis). She pre erred the appearance o sagging breasts
over the scars o a mastopexy. She knew that her right breast would still sag
more than the le t i just an implant were used. Glandular ptosis is increased (as
seen on the lateral views by comparing the moles on her arm relative to the
breast), but the nipple appears to be better centered on the breast mound. The
upper breast border was not elevated as much as the patient wished, but a larger
implant would likely only f ll the lower pole more, which would exaggerate the
di erence. The arrows show the lateral edge o the pectoralis muscle. Most o
the implant actually sits below the edge o the muscle; contraction o the mus-
cle will lower the implant, not support it.
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Chapter 5 • Breast Augmentation

This woman had a smooth-walled 300 cc saline implant on the right (275 cc
25 cc) and a 275 cc saline implant on the le t (275 cc 0 cc). Both implants
were placed through an in ramammary incision into a subpectoral pocket. She
is shown 19 months postoperatively.
Analysis
This patient is too thin to achieve an ideal result in many aspects,
but she has a good vertical breast ootprint with a slightly narrow horizontal
breast ootprint. She would need an implant with a large enough base diame-
ter to widen the breast and f ll the lateral chest wall. The implants needed to be
placed in the subpectoral position because o a lack o padding. She has wider
cleavage, but this needs to be accepted as a compromise to achieving better up-
per pole padding. Saline implants tend to show rippling more than cohesive gel
implants, but all implants can ripple. The nipple is nicely centralized on the
breast mound without having to intentionally lower the in ramammary old.
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Part II • Technique

This woman had responsive silicone gel implants placed through an in ramam-
mary incision in the subpectoral plane. The implants were Style 15, 286 cc
in the right breast and 265 cc in the le t breast. She is shown 2 months a ter
surgery.
Analysis
This patient is high breasted with an already high upper breast bor-
der; there ore a good result is achieved by lowering the in ramammary old and
f lling the lower pole.
Sometimes the old needs to be lowered because the nipple is too
low on the breast, but a mastopexy is not indicated. The lower
quadrant o the breast needs to be f lled out by adapting the im-
plant to shape the breast mound.
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Chapter 5 • Breast Augmentation

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Part II • Technique
This woman had smooth-walled saline implants placed through an inframam-
mary incision in the subglandular position. The right implant was 325 cc and
the left was 300 cc. She is shown 10 days, 3 years, and 9 years postoperatively.
She subsequently underwent a vertical mastopexy-augmentation with exchange
of the implants for smooth-walled responsive gel implants Style 15 194 cc each
placed behind the posterior leaf of the capsule, but still in the subglandular lo-
cation. She is shown 2 1⁄2 years after the mastopexy-augmentation.
Preoperative

10 days postoperatively

Analysis
This patient is very low breasted. Although the result initially im-
proved the low appearance o the breasts, the implants settled with time into
the original position and pushed the gland even lower. Patients with this result
o ten ask or a larger implant, but the result will not improve. The upper pole o
the breast will not f ll out more; instead, the bottom o the breast will drop even
urther. Larger implants do not solve the problem and o ten make the breasts
look worse. This patient is still low breasted but the shape was improved by a
mastopexy-augmentation, using a smaller (rather than a larger) implant.
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Chapter 5 • Breast Augmentation
3 years postoperatively

9 years postoperatively

2 1⁄2 years after revision

This woman had breast augmentation using Biocell textured silicone gel im-
plants placed in the subglandular position through an in ramammary incision.
Style 115 401 cc implants were placed on each side. Some liposuction was per-
ormed in the area o preaxillary ullness. She is shown 1 year a ter surgery.
Analysis
This patient had a small amount o nipple ptosis but no real glan-
dular ptosis. The in ramammary old was relatively high, but the breast mound
was acceptable. The breast mound needed to be shaped to f t the existing nip-
ple position. This meant that the in ramammary old needed to be lowered and
the lower pole f lled out to better centralize the nipple. The suprasternal notch-
to-nipple distance preoperatively was 24.5 cm on the right and 25 cm on
the le t. Postoperatively this distance has lengthened to 27 cm on the right and
26.5 cm on the le t. H er nipple-to-in ramammary old distance stretched rom
8.5 cm preoperatively to 13 cm postoperatively on both sides. The supraster-
nal notch-to-in ramammary old distance has lengthened rom 22 cm to 25 cm.
The upper breast border is elevated by the implant, but the in ramammary old
is lowered. The breast shape is improved, with the nipple better centralized, but
the implant added some glandular ptosis to the breast shape.
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Part II • Technique

REFLECTIONS
Breast augmentation surgery is ar rom straight orward. It is important to un-
derstand the breast ootprint and what will happen to each o the borders. The
upper breast border will be elevated by 2 cm, on average, but a larger implant
will not f ll the chest wall any urther. The lower breast border will inevitably
drop. A larger implant will have a disproportionate e ect on the in ramammary
old.
The implant base diameter should be chosen to achieve the desired breast base
diameter—both medially and laterally—not based on the existing breast base
diameter. It is di f cult to narrow normal cleavage. Patients need to be aware
that their preoperative cleavage will determine their postoperative cleavage.
They also need to be instructed that placing the implant under the muscle will
widen the cleavage.
I do not believe that the subpectoral location con ers any benef t with regard
to capsular contracture. I use a subpectoral pocket only to camou age the im-
plant when a patient does not have enough padding.
I do not believe that the current textured-sur ace breast implants have a lower
capsular contracture rate. In my experience, it has actually been higher because
o the incidence o late seromas and double capsules.
Complications in breast implant surgery are di f cult to prevent and can be di -
f cult to treat. There are general complications, implant-specif c complications,
and procedure-specif c complications.
One o the most di f cult aspects o breast augmentation surgery is management
o patient expectations. There is so much con using in ormation given to pa-
tients by other surgeons, their riends, and the Internet. Surgeons really do not
know the best answer to many questions about breast augmentation surgery.
There are many opinions on what might be the best approach to various issues.
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Chapter 5 • Breast Augmentation

Concepts to Recall
• All our borders o the breast base ( ootprint) need to be assessed.
• The base o the breast sits on a variably sloping chest wall.
• Asymmetries can involve any o the above landmarks.
• The upper breast border is elevated with an implant, but the lower breast
border descends.
• The nipple position (as measured rom the suprasternal notch) drops, on
average, 2 cm when an implant is in place.
• The breast shape on the ootprint becomes more ptotic.
• The di erences between glandular ptosis and nipple ptosis need to be
understood.
• The implant is used to adapt the breast mound to the existing nipple
position.
• Sometimes it is necessary to purposely lower the in ramammary old to
better centralize the nipple position on the mound.
• Occasionally it is important to use an implant with a base diameter that
is wider than the breast to improve the medial and lateral dimensions o
the breast ootprint.
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McCarthy CM, Pusic AL, Kerrigan CL. Silicone breast implants and magnetic resonance
imaging screening or rupture: do U.S. Food and Drug Administration Recommen-
dations ref ect an evidence-based practice approach to patient care? Plast Reconstr Surg
121:1127-1134, 2008.
Cancer
Brinton LA. The relationship o silicone breast implants and cancer at other sites. Plast Re-
constr Surg 120(7 Suppl 1):S94-S102, 2007.
Deapen D. Breast implants and breast cancer: a review o incidence, detection, mortality,
and survival. Plast Reconstr Surg 120(7 Suppl 1):S70-S80, 2007.
H andel N. The e ect o silicone implants on the diagnosis, prognosis, and treatment o
breast cancer. Plast Reconstr Surg 120(7 Suppl 1):S81-S93, 2007.
H oshaw SJ, Klein PJ, Clark BD, et al. Breast implants and cancer: causation, delayed de-
tection, and survival. Plast Reconstr Surg 107:1393-1406, 2001.
Lipworth L, Tarone RE, McLaughlin JK. Breast implants and lymphoma risk: a review o
the epidemiologic evidence through 2008. Plast Reconstr Surg 123:790-793, 2009.
247
Chapter 5 • Breast Augmentation

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Vertical Breast
Reduction
Chapter6
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250
Part II • Technique
T
he best breast reduction operation is the one that the surgeon is most com-
ortable with and per orms most sa ely and success ully. There is no one ideal
method or all patients. We need to understand the basic surgical principles so
that we can adapt di erent techniques to di erent situations.
When discussing vertical breast reduction, there is some con usion as to what
“vertical” actually means, because there are multiple vertical approaches and
pedicles to choose rom. The technique described here relies less on shorten-
ing the scars and more on understanding the undamental concepts that guide
the planning process. In my judgment, the key component to a vertical proce-
dure is a central vertical wedge resection o the parenchyma that narrows and
cones the breast, thereby removing the heavy in erior breast tissue and improving
projection and shape. Di erent pedicles and di erent skin resection patterns
can be used to accomplish this goal.
I pre er the medial pedicle or its obvious advantages. The belie that surgeons
must choose between scars and shape is not true. The medical pedicle vertical
breast reduction not only results in shorter scars but also maintains an aesthetic,
long-lasting breast shape. It has a robust blood supply and a pedicle that ro-
tates easily into position without kinking or compression. Sensation recovery is
comparable to that o other pedicle approaches (see Appendix B). In addition,
the surgery takes less time, blood loss is reduced, and recovery is quicker. In
my experience, the incidence o complications is also dramatically reduced with
this approach because o the lack o tension on the skin closure and on the pil-
lar closure.
MY EVOLU TION
I was ortunate to be exposed to many di erent breast reduction techniques
during my training. Originally I learned the lateral wedge resection o Du our-
mentel, but the breasts tended to point in a medial direction. I ound the older
Biesenberger technique to be damaging to the blood supply, resulting in necro-
sis o the skin aps. With Strombeck’s horizontal bipedicled technique, closure
was di f cult and nipple necrosis occurred requently.
The vertical bipedicle technique described by McKissock was a landmark de-
velopment. This advance made breast reduction procedures sa er and more re-
liable. It is interesting that many surgeons who per ormed this operation in
North America dropped the superior portion o the vertical bipedicle, whereas
the Europeans avoided the in erior portion and kept a superior pedicle. Clo-

sure o the breast parenchyma became easier with a single in erior pedicle. The
in erior pedicle inverted-T became the standard breast reduction in the 1980s
and 1990s.
For the f rst 10 years o my practice I primarily used an in erior pedicle inverted-
T approach to breast reduction. Occasionally I used a superior pedicle, but the
in erior pedicle was easier and more predictable. I was not unhappy with the
results, but sometimes the in ramammary scars were unsightly, and some bot-
toming out occurred. Some o the breasts had a boxier shape than I desired. I
used liposuction laterally to improve breast shape, but I still had problems with
the lateral and medial dog-ears. I would explain to patients that these dog-ears
could not be corrected. (Now I can correct a persistent in erior pucker in the
vertical approach.) Interestingly, my revision rate is higher with the vertical ap-
proach, but only because I have an option or dog-ear correction. When I was
doing inverted-T procedures, I had no solution or this problem and, there ore,
I per ormed ewer revisions.
A ter meeting Madeleine Lejour, I decided to try the vertical approach. I real-
ized that the shape was better, but I had problems insetting some o the longer
superior pedicles. Initially I thought that the blood supply was deep (it is not),
so I tried to keep the pedicle ull thickness. With more experience, I realized
that it is easier—and sa er—to thin out the pedicle so that it can be inset with
ease and without compression.
I tried the lateral pedicle next, because we have been taught that the innerva-
tion to the nipple comes rom the lateral ourth intercostal nerve. The design
o the lateral pedicle prevented adequate lateral resection o the parenchyma,
and the result was o ten too ull laterally. I would try to pull the lateral pedicle
medially and suture it under tension, but it almost always settled back out lat-
erally, resulting in an unacceptable shape.
With the medial pedicle, I was impressed with the sensation and much happier
with the shape (see Appendix B).
The medial pedicle has a good blood supply and gives an elegant
curve to the lower pole of the breast. With a superior pedicle the
area centrally and inferiorly can be empty, resulting in a postoper-
ative shape that is concave inferiorly. The inferior border of the me-
dial pedicle becomes the medial pillar, and the whole base of the
pedicle rotates as the pedicle is rotated into position.
251
Chapter 6 • Vertical Breast Reduction

My analysis o sensation using the superior, lateral, and medial pedicles showed
that the medial pedicle outper ormed the lateral and superior pedicles.
My current understanding o the blood supply has encouraged me to use a true
superomedial pedicle in larger breast reductions. I o ten cut across the artery
(descending branch rom the second interspace) that supplies a superior pedicle.
This artery almost always enters the breast about a centimeter deep to the skin
sur ace just medial to the breast meridian. It bleeds pro usely when it is tran-
sected during a purely medial pedicle procedure. It may be advisable to try to
preserve this artery in the longer pedicles i possible. Because the artery is quite
superf cial, the pedicle can be inset more easily i some o the deeper restricting
parenchyma is removed.
SU RGICAL PRINCIPLES
Although the f rst our chapters o this book discuss surgical principles in some
detail, a brie review is in order when planning breast reduction. Adherence to
these principles is key to achieving optimal results. The ollowing principles
merit attention.
Analysis of Breast Dimensions
During the surgical planning process, it is important to evaluate all three breast
dimensions and to train our eyes to really “see what we are looking at.” This
helps the surgeon understand what can and cannot be changed with the our
breast borders and the breast shape.
Breast Footprint
The surgical plan must be adapted to the patient’s individual ootprint. The sur-
geon needs to recognize that the base o the breast on the chest wall cannot be
changed to any signif cant degree and that the patient’s high- or low-breasted
status will in uence the f nal result.
252
Part II • Technique

253
Chapter 6 • Vertical Breast Reduction
The high-breasted woman shown above, has a high upper breast border (ar-
row). The low-breasted woman shown in the photos below, has a low upper
breast border (arrow). Breast reduction surgery will produce very different
results in each patient. The nipple could be easily placed too high in the sec-
ond patient.

254
Part II • Technique
The upper breast border is unchanged in both patients; it remains 14 cm from
the clavicle in the low-breasted patient and 12.5 cm from the clavicle in the
high-breasted patient. H owever, the lower breast border (inframammary fold)
is elevated in both patients. It is marked between the breasts on the midline of
the chest preoperatively (at the level of the elbow crease in the low-breasted
woman and just above the elbow crease in the high-breasted woman).
The upper breast border is a stable landmark that does not change
with surgery; it is the best landmark for determining the new nip-
ple position. I have taken measurements from the clavicle to the up-
per breast border both before and after surgery and found that this
measurement remains unchanged.
The low-breasted patient above has a very different result from the high-breasted
patient shown below. The high-breasted patient’s result is usually more satis-
fying to the patient than that of the low-breasted patient, who needs to under-
stand that the position of her breast on the chest wall will remain unchanged,
despite efforts to elevate her inframammary fold and reduce her breasts.

The medial breast border remains unchanged in this patient. H owever, it can be
tailored with both direct excision and liposuction.
255
Chapter 6 • Vertical Breast Reduction
The lateral breast border is often narrowed with the vertical wedge resection and
contoured with direct excision and liposuction.
Breast Shape: The Third Dimension
The breast shape (the third dimension) will have good projection with the me-
dial pedicle vertical breast reduction, but it will still be slightly ptotic. Some of
the shape will drop off the breast base. Some breast skin will still descend onto
chest wall skin. Increased upper pole fullness may be attained with implants or
fat injections, but sutures do not provide a long-term correction.

256
Part II • Technique
The shape on the le t, with the breast mound positioned high on the breast
base, is rarely achieved in a breast reduction or mastopexy. It can only be at-
tained i the patient presents without any ptosis. Both breast shapes are quite
acceptable; the more ptotic shape is common with a breast reduction or mas-
topexy. A long vertical length is needed between the areola and the in ramam-
mary old to accommodate the increased projection that results rom coning
the breast with the vertical wedge resection technique.
The lower pole can be augmented with an implant and reduced with a breast re-
duction. It cannot be elevated by suturing tissue up to the chest wall. It is im-
portant to either remove or move ptotic breast tissue. Moving an in erior ap
(Ribeiro) and closing the pillars around the ap can be benef cial. Passing the in-
erior ap under a strip o pectoralis muscle (Gra ) can help suspend the ap. The
in ramammary old is o ten inadvertently lowered with an in erior pedicle inverted-
T reduction, and the breast base is lowered. This is not usually an ideal situation.
Vertical Wedge Resection Principle
Many o the inverted-T approaches to breast reduction involve a horizontal
wedge resection o both skin and parenchyma, resulting in a lateral and medial
dog-ear. This resection tends to produce a wider breast base with a boxy shape,
even when per ormed by the most experienced surgeons.
The central vertical wedge resection cones and narrows the breast. It also re-
sults in two dog-ears: one into the nipple and the other at the bottom o the
vertical incision at the level o the in ramammary old.
Skin Resection Pattern
Sometimes there is too much skin (or skin o poor quality), and an inverted-
T skin resection pattern may be necessary. This can be combined with the ver-
tical approach using a medial or vertical pedicle.
Upper pole fullness
Projection
Upper breast border
Inframammary fold

The Wise pattern is better used for the parenchymal resection pattern. The skin
can then adapt to the breast shape rather than vice versa. The pattern itself is de-
signed for removing a vertical wedge. When the pattern is brought together, the
result is a cone. Good results are easily obtained on a consistent basis if the Wise
pattern is used and if the parenchyma (and the skin) is closed without tension.
The surgeon is advised to leave behind a Wise pattern of paren-
chyma and remove all tissue beyond the pattern.
Liposuction is used for peripheral tailoring. Removal of tissue outside the pat-
tern is better than trying to force parenchyma into the pattern under tension.
Tension on the parenchymal closure can result in some relapse.
257
Chapter 6 • Vertical Breast Reduction
The skin resection pattern does not need to be vertical to take
advantage of the improved shape of the central vertical wedge
resection of parenchyma.
Wise Brassiere Pattern
Robert Wise designed a breast reduction pattern based on a brassiere design.
This design has been used to create a skin brassiere. Many surgeons now believe
that the skin brassiere is unreliable as a handle to hold up breast tissue, particu-
larly in breast reduction and mastopexy patients whose skin is of poor quality.

Pedicle Design
Although the inferior pedicle is an excellent one, it forces the re-
section to be performed in the superior pole, leaving behind the
heavy inferior breast tissue, which can eventually descend in re-
sponse to gravitational forces.
The in erior pedicle is based on the artery and venae comitantes that enter its
deep sur ace at the ourth interspace. (It is supplemented by some lower inter-
costal branches superf cially rom just above the in ramammary old.) The skin
and parenchyma are detached superiorly when an in erior pedicle is used. The
vascular supply to a lateral pedicle can be somewhat less reliable, and adequate
resection is o ten restricted by the base o this pedicle.
A more superiorly based pedicle permits removal o the heavy in erior breast
tissue, while leaving a Wise pattern o parenchyma attached to the superior skin.
The vascular supply to the superior, medial, and lateral pedicles is superf cial,
lying in the subcutaneous tissue superf cial to the parenchyma. These vessels
get pushed outward as the breast develops.
The superior pedicle has an excellent blood supply but can be di f cult to inset.
The purely medial pedicle also has an excellent blood supply. Longer, true su-
peromedial pedicles can combine the advantages o both. Because the veins lie
just under the dermis and most o them drain superomedially, a medial or su-
peromedial pedicle that incorporates any visible veins is likely to have good
drainage.
258
Part II • Technique
The veins are easily seen just under the skin in the patient on the le t. In the pa-
tient on the right, the medially based pedicle is designed to include a very ob-
vious vein. It is important to preserve—and not damage—these veins.

PATIENT SELECTION
A medial pedicle vertical breast reduction is an elegant operation or pa-
tients with small to moderate hypertrophy. I the reduction involves much
more than 800 g on each breast, it may be necessary to add a short hor-
izontal scar to the skin resection pattern. There are no exact guidelines
indicating when this addition should be made, because so much o the
decision making will depend on the f nal breast size and the quality and
elasticity o the skin.
259
This woman was a good candidate or a medial pedicle vertical breast reduction.
She had 460 g removed rom the right breast and 435 g rom the le t breast.
Another 600 cc o at was removed rom the periphery using liposuction.
Chapter 6 • Vertical Breast Reduction

260
Part II • Technique
The vertical wedge resection principle can be used in both large and
smaller breast reductions. This approach preserves the principle of re-
moving the heavy inferior pole and leaving the remaining breast tissue in
the upper pole.
Many large-breasted patients are good candidates for a vertical breast
reduction.
This patient had 1275 g removed from the right breast and 1200 g removed
from the left breast using a medial pedicle vertical breast reduction. Liposuc-
tion was also used to remove 400 cc of fat. The vertical incision was not curved
outward, and a T was not added. Only small puckers resulted. Extra skin does
not always need to be removed, but sometimes a T, J, or L needs to be added.

This large-breasted woman had a medial pedi-
cle vertical reduction, with a T added to remove
extra skin. She had 2125 g removed rom the
right breast and 2575 g removed rom the le t
breast. An additional 600 cc o at was removed
using liposuction.
261
Chapter 6 • Vertical Breast Reduction
Patients who have lost signif cant amounts o weight o ten have very poor quality
skin that is less adaptable. They may not need a large parenchymal reduction, but
they need more aggressive skin resection. It may be advisable in these situations
to convert to an inverted-T skin resection pattern i the skin is loose and inelastic.
This massive-weight-loss patient had too much skin to be excised to avoid adding
a T. She had 545 g removed rom the right breast and 395 g removed rom the
le t breast. The upper pole was f lled with 304 cc implants.

This woman had free nipple grafts. Sometimes the pedicle distance is too long,
and there may be a problem with the blood supply. In addition, a very long
pedicle has too much bulk, which prevents adequate resection and may even-
tually lead to bottoming out. Free nipple grafts occasionally develop depig-
mentation, even when carefully performed. This woman had 2025 g removed
from the right breast and 1770 g removed from the left breast. Another 775 cc
of fat was removed using liposuction. She is shown 1 week (after removal of the
bolster), 1 month, and 1 year after surgery, with a less than satisfactory result.
I usually try a pedicle but warn the patient preoperatively that I may need to
convert to free nipple grafts.
262
Part II • Technique
Preoperative

1 week postoperatively
1 month postoperatively

1 year postoperatively

263
Chapter 6 • Vertical Breast Reduction
This woman had free nipple grafts, with 760 g removed from the right breast
and 1030 g removed from the left breast. She had 300 cc of fat removed using
liposuction. She is shown 10 days and 19 months postoperatively. She required
a later revision to correct some of the bottoming out. Free nipple grafts are not
an ideal solution for overly large breasts.
Liposuction-only breast reduction is an option for some patients (see Chapter 7).
The best candidates are high breasted with good upper pole fullness. To get a
good result with liposuction only, the breasts need to be composed of a large
proportion of fat versus glandular tissue, and the nipples need to be in a rela-
tively high position. Although it would be ideal to avoid extensive scars in
teenagers, liposuction-only reduction is rarely indicated, because many of these
patients have very little fatty tissue in the breasts—especially young patients who
are close to their ideal body weight.
Preoperative
10 days postoperatively

19 months postoperatively

This perimenopausal woman had liposuction-only breast reduction with 650 cc
removed from the right breast and 600 cc removed from the left breast. She
lost projection, but both the nipple and the breast are elevated, compared with
the level of the elbow crease.
264
Part II • Technique
This intraoperative photo of a teenage patient shows that she is not a good can-
didate for liposuction-only breast reduction. The parenchyma is more glandu-
lar than fatty. There is very little fat to remove. When a young woman is not
overweight, liposuction-only is unlikely to be a good choice.

265
Chapter 6 • Vertical Breast Reduction
PATIENT EVALU ATION
It is important or the surgeon to stand back and assess the patient’s ootprint and
breast shape. I take photographs o my patients at the time o consultation so that
they can better understand the issues. Patients o ten see asymmetries and other
problems better in a photograph than they do looking in a mirror. I mark on the
rontal photograph to show whether they are high or low breasted. I mark on the
lateral photograph to show whether they have good or poor upper pole ullness. I
then give them the photographs to take home a ter I make a copy or the chart.
Patients o ten wish to have their breasts higher on the chest wall—a reasonable
request but not possible to achieve. I explain that the upper breast border will
not change with a breast reduction. Patients o ten hope that somehow we can
move some o the in erior pole excess into the upper pole. They interpret up-
per pole ullness and projection as equivalent. I explain that we can def nitely
increase projection. I draw a new breast with increased projection, i needed,
but I emphasize that they will still have a ski-jump–shaped upper pole i that is
their shape preoperatively.
These consultation photographs have not only allowed me to better understand
my own results—and limitations—but they have been o immeasurable value
in helping manage patient expectations.
I warn patients that I do not have as much control over size as they might like,
and that I may not be able to make their breasts as small as they wish. (It is
more di f cult to achieve as small a breast size with the vertical approach as with
an in erior pedicle inverted-T approach.) I also in orm larger-breasted patients
o the possibility that they may need a short T or a “hockey stick” extension
added to their vertical scar.
I explain that the three problems to be expected with breast reduction are scar-
ring, potential loss o sensation, and possible inability to breast- eed. I show pa-
tients various scar examples, and tell them that about 85% o patients recover
normal to near-normal sensation in the nipples and breast skin. Although I warn
them that the resultant ability to breast- eed is about 50/ 50, I discuss Norma
Cruz-Korchin’s study that shows that about 60% o large-breasted patients are
able to breast eed—with or without having had a breast reduction. In both
groups, about 25% o patients needed to add some supplementation. I also ex-
plain potential unexpected complications, both minor and major.
H eavy patients are in ormed that the cosmetic result is optimal when they are
at their ideal weight. I per orm liposuction on the lateral chest wall and preax-
illary areas, but there are limits to what can be achieved. Overweight patients
are also told that they will tend to lose volume in the upper pole i they lose
weight, either be ore or a ter breast reduction surgery.

266
Part II • Technique
Preoperative
After medial pedicle vertical reduction

18 months postoperatively
after losing 50 pounds
This woman had a medial pedicle vertical breast reduction with a good result.
She then lost 23 kg (50 pounds). The breast shape did not change except for
the loss of volume, mainly in the upper pole. When patients lose weight, a dis-
proportionate amount of tissue is lost in the upper portions of the breast.

267
Chapter 6 • Vertical Breast Reduction
Preoperative

2 weeks postoperatively

5 years postoperatively
This woman had a small breast reduction with a lateral pedicle. She is shown
2 weeks a ter surgery. Some settling is to be expected. She returned 5 years later,
a ter a signif cant weight gain. Note the increase in upper pole ullness. Weight
gain and weight loss make a def nite di erence in the upper pole.

This patient lost 9 kg (20 pounds) between her initial consultation and her sur-
gery. H er breasts have dropped somewhat, compared with the elbow crease
level, and much o the volume is lost in the upper pole. Some o this e ect may
be related to her weight loss in the upper abdomen, which resulted in her breasts
not being pushed outward as much.
PLANNING
Preoperative Preparation
Patients are instructed to stop taking aspirin, other antiin ammatories, and all
herbal preparations 2 weeks be ore surgery. They are also told to note which
breast is bigger; sometimes this di erence is obvious, but when the shape is
quite di erent rom one side to the other, it may be more di f cult to identi y.
Un ortunately, they rarely pay attention to this request.
268
Part II • Technique
Initial consultation

Preoperatively after losing 20 pounds

MARKINGS AND DESIGN
There are only a ew key markings; these include the upper breast border, breast
meridian, new nipple position, areolar opening, skin resection pattern, and in-
ramammary old level.
The U pper Breast Border
I begin by marking the upper breast border at the junction o the chest wall
and the breast. It is easily def ned when there is a relatively sharp demarcation
between the two. It is usually just at the top o any striae that may be present.
Because this is a static landmark, determining the new nipple position becomes
straight orward.
269
Chapter 6 • Vertical Breast Reduction
This patient’s upper breast border (dotted line) was airly clear, because there
was a def nite demarcation between the chest wall and the breast itsel . When
she raised her breasts or a photo o the in ramammary olds, the dotted line
was drawn at the correct level. Breast reconstructive surgeons o ten push the
breast upward to demarcate the upper breast border. This is a good maneuver
or breast surgery o all types. The distance between the clavicle and the upper
breast border measured 14 cm. H er new nipple position was marked 25 cm
rom the suprasternal notch. She was 5 eet 4 inches tall.
The most important landmark is the upper breast border.
1
6-1 Preoperative
markings

270
Part II • Technique
This woman did not have an easily visualized boundary between her breast and
the chest wall. The breast was pushed upward to help identi y and mark this
boundary. The upper breast border is always below the preaxillary crease. The
distance between the clavicle and the upper breast border measured 10.5 cm.
H er new nipple position was placed 21 cm rom the suprasternal notch. She
was 5 eet 2 inches tall.
The Breast Meridian
The surgeon should be able to visualize the f nal result to determine where the
ideal breast meridian lies. The existing nipple position is ignored; it can be too
lateral or too medial. The ideal breast meridian is usually about 10 cm rom the
chest midline, as measured in the air, not ollowing the curve o the breast. It
is always better to err in drawing the meridian too lateral, because nipples that
are too medial are ar more unsightly. It is easiest to draw the new meridian
down rom the clavicles. The starting point on the clavicle does not matter (most
surgeons say 7 cm rom the suprasternal notch); what is important is the loca-
tion o the meridian at the new nipple level.
The breast meridian is marked where it should be—not where it is.
1
6-1 Preoperative
markings

271
Chapter 6 • Vertical Breast Reduction
The patient on the left had laterally positioned nipples. The meridian was drawn
medial to this position. The patient on the right had medially positioned nip-
ples. The meridian was drawn lateral to them. These patients represent oppo-
site extremes, but they both illustrate why it is important to draw the breast
meridian in its ideal position.
This woman’s right nipple was located further laterally, and her left nipple was
closer to the postoperative (ideal) breast meridian. If the surgeon does not rec-
ognize the difference from one side to the other, the postoperative result will
be asymmetrical.
1
6-1 Preoperative
markings

272
Part II • Technique
In this patient, the measurement in the air from the chest midline to the new
meridian was 10 cm. The new nipple position was not only 10 cm from the
midline, but also 10 cm from the upper breast border. These measurements
provide good starting points for most surgeons. Adjustments can then be made
depending on the patient’s anatomy and the surgeon’s experience.
New Nipple Position
Upper breast
border
Areolar opening
New nipple position
8-10 cm
2 cm
The new nipple position should be on the new breast meridian, approximately
8 to 10 cm below the upper breast border. Most C to D cup breasts have the
nipple positioned about 10 cm from the upper breast border. When a patient
has poor upper pole fullness, it is advisable to err in placing the nipple too low
rather than too high. The nipple should be at the most projecting part of the
breast and not sitting on the upper slope of the breast. The nipple should not be
1
6-1 Preoperative
markings

placed at some arbitrary measurement from either the suprasternal notch or the
clavicles. It is far more reliable to determine the new nipple position with the
patient standing than when the breast slides up on the chest wall during surgery.
Because the upper breast border remains unchanged a ter breast re-
duction (or mastopexy), it is easier to visualize the f nal result and
thereby determine the new nipple position.
273
Chapter 6 • Vertical Breast Reduction
This woman’s new nipple position was 9 cm below the upper breast border.
The meridian measures 9 cm from the chest midline, as measured in the air.
The nipple was placed at what will be the most projecting part of the breast.
This patient has good upper pole fullness. A lower nipple position would have
been chosen on this same patient if she had had a ski-jump type of slope to her
upper pole.
I no longer use the in ramammary old as my landmark or the new
nipple position.
I used to think that the inframammary fold was the ideal location for the new
nipple. I found, however, that in some patients this did not make sense and I
either raised the position or lowered it to avoid placing the nipple in the wrong
place. I could not initially explain why I made those changes until I spent time
analyzing my preoperative markings and my postoperative results. When I be-
gan to understand the breast footprint and which of the borders could be al-
tered with different maneuvers, it became more obvious.
1
6-1 Preoperative
markings

274
Part II • Technique
If the new nipple position had been placed at the inframammary fold in this pa-
tient (the fold is marked on the chest midline between the breasts), the nipples
would have been too high.
This woman’s inframammary fold is actually below her preoperative nipple po-
sition. H er new nipple position has been marked several centimeters above the
inframammary fold, on the chest midline between her breasts. H er inframam-
mary fold is below her elbow crease preoperatively, and it has been raised
slightly. (This is the same patient preoperatively and postoperatively. I removed
her suprasternal mole.)

275
Chapter 6 • Vertical Breast Reduction
Although the nipple was placed 1 cm lower on this woman’s right breast (25 cm
on the le t versus 26 cm on the right), the f nal result is asymmetrical. The nip-
ple is still too high on the right breast, and the in erior pole was inadequately
resected. When there is breast asymmetry, a wider vertical ellipse o skin and
breast tissue is removed rom the larger side, and the incision will lengthen more
with a wider excision. This ellipse e ect, as well as underresection o the lower
pole, makes it important to mark the new nipple position lower on the larger
breast.
When there is signif cant breast asymmetry, the new nipple position
should be marked slightly lower on the larger side.
This is not a problem with the horizontal parenchymal resection patterns, but,
when a larger vertical ellipse is closed, the new nipple position is pushed up
more than when a narrower wedge excision is closed.

276
Part II • Technique
Areolar Opening
Most o my breast reductions have postoperative areolar diameter measurements
o 4.5 to 5 cm. I mark the upper border o the areola 2 cm above the new nip-
ple position and draw reehand an areolar opening that measures about 16 cm.
(An areola with a 16 cm circum erence has a 5 cm diameter; an areola with a
14 cm circum erence has a 4.5 cm diameter.)
Surgeons who pre er to have a pattern can open a large paperclip (16 cm) and
close it to orm a “per ect” circle. The areolar opening can be adjusted just be-
ore f nal closure i it is not completely circular. This template can be opened
up widely or patients with larger breasts i needed (above, left). I the areola is
not a complete circle be ore closure, extra skin can be removed (above, right).
It is important not to have any tension on the f nal closure. Because this is not
a skin brassiere operation, the opening should not be too wide. Care should be
taken to ensure that the markings or the areolar opening are symmetrical.
I do not like the circumareolar approaches to vertical breast reduction in which
some o the excess skin is taken up around the areola. The tension that results
on the areolar skin tends to widen the f nal areolar diameter. Areolar skin
stretches more easily than breast skin, and widening is inevitable. Stretching can
be reduced with a permanent Gore-Tex type o suture, but this adds an extra
variable to the result. I pre er to match the skin-opening length to the areolar
circum erence to avoid stretching. I would rather not remove extra skin around
the areola. The longer vertical length is actually needed to accommodate the
increased projection that results.
1
6-1 Preoperative
markings

Skin Resection Pattern
The skin resection pattern is not important or parenchymal shap-
ing. The excess skin needs to be removed or a good closure around
the parenchyma, not vice versa. The surgeon should shape the
parenchyma a ter the vertical wedge resection and then excise the
excess skin to f t, with care taken not to take too much skin and not
to close the skin under tension.
Skin stretches under tension, and only highly elastic skin can serve as a brassiere.
It is better to excise and shape the parenchyma and then allow the skin to adapt
to the new breast shape.
The skin resection pattern resembles a snowman shape, with the areolar open-
ing being the head and the body rounded. Some surgeons pre er to make the
skin resection in the orm o a V, because they believe that it will be easier to
avoid a pucker in eriorly. I believe that it is best to make the resection U shaped,
because it is di f cult to remove enough in erior subcutaneous tissue with a V
resection, and a pucker is inevitable. In erior puckers are actually a problem o
excess subcutaneous tissue rather than excess skin.
The skin excision should leave at least 2 to 4 cm o intact skin above the in ra-
mammary old. This can be di f cult or surgeons to accept initially, but it is im-
portant to avoid the temptation to excise the skin urther in eriorly. There are
two reasons the scar will end up on the chest wall i this rule is not ollowed.
First, an elliptical incision lengthens when it is closed. Second, surgeons are
o ten unaware that the in ramammary old usually rises a ter a medial pedicle
vertical breast reduction. Some o the in erior breast skin becomes chest wall
skin. The in ramammary old can be purposely elevated, but it o ten occurs
unintentionally.
The skin resection pattern should not be brought down to the in-
ramammary old, or the scar will extend onto the chest wall.
277
Chapter 6 • Vertical Breast Reduction
1
6-1 Preoperative
markings

The inverted-T markings, as well as the vertical snowman markings, are shown
on this patient. Instead o extending the vertical lines medially and laterally,
they are joined together in a U-shaped curve well above the in ramammary old.
It is help ul to pinch the skin together to make sure that the lower pole will
maintain a nice curve and that there will be no tension on the skin closure. Some
surgeons rotate the breast medially and laterally to ensure that these vertical
markings line up with the breast meridian.
A ter the markings are made, I stand back and visualize the Wise pattern to con-
f rm that the markings are symmetrical.
278
Part II • Technique
This patient has a snowman-type design or her skin resection pattern with a
medial pedicle. I the markings do not stay well above the in ramammary old,
the scar will extend onto the chest wall.