Video Atlas Phẫu Thuật Tạo Hình Thẩm Mỹ (Aesthetic Plastic Surgery Video Atlas)

Operative Approach
187
A wide saw blade is used to initiate the osteotomy in the central
portion of the chin (Fig. 13.30). The saw blade is changed to a nar-
rower one to complete the osteotomies laterally (Fig. 13.31). The
osteotomy site is continuously irrigated during the course of the
osteotomy. Malleable retractors protect the nerves and the other soft
tissues throughout the osteotomy. After the caudal segment is freed it
is advanced or retracted to the desired position (Fig. 13.32). A pre-
fabricated step plate is contoured and placed in position to fi t the
anterior symphysial surface on both sides of the osteotomy (Fig.
13.33). Four screws, two on each side of the osteotomy, are placed
(Fig. 13.34). Two osteotomies with removal of an intervening segment
are used when a reduction in height is desired (Fig. 13.35). If setback
is performed two screws should be suffi cient for fi xation after which
a burr is used to the contour the lateral chin-mandible junctions
bilaterally. The wound is then repaired as previously described (Fig.
13.36).
Genioplasty using augmentation
techniques
In current parlance, augmentation genioplasty usually refers to the
implantation of alloplastic implants. Autogenous augmentation using
bone or cartilage grafts is highly successful. However, unless the graft
material is readily available because of a concomitant procedure
being performed, one has to forego autogenous augmentation in favor
of an osteotomy, which is often simpler. In extreme craniofacial cases,
A
B
C
Combined horizontal macrogenia and vertical microgenia
Fig. 13.19 Combined horizontal macrogenia and vertical microgenia.
In the upper diagram the broken line outlines the normal chin bone
profi le. An oblique horizontal osteotomy is shown in the middle
diagram. In the lower diagram the caudal segment is moved
caudally and inferiorly. Bone graft is used depending on the size of
the gap.
A
B
C
Combined vertical macrogenia and horizontal microgenia
Fig. 13.20 Combined vertical macrogenia and horizontal
microgenia. In the upper diagram the broken line illustrates normal
chin bone outline. Two osteotomies with a wedge ostectomy are
demonstrated in the middle diagram. The lower diagram
demonstrates cephalic and anterior positioning of the caudal chin
segement with fi xation.

13
GENIOPLASTY
188
A
Chin asymmetry
B
Deficient anterior facial height
C
Asymmetric chin with excess lower facial height
Fig. 13.21 Chin asymmetry. A, Chin asymmetry with normal anterior
lower facial height. A segment is removed and reversed to obtain
symmetry. B, An asymmetric chin with defi cient overall anterior
facial height. A horizontal osteotomy is made and differentially
repositioned in a caudal direction. The resulting gap is grafted. C,
Asymmetric chin with excess lower facial height. Two osteotomies
are performed resulting in a wedge. The wedge is removed and the
caudal segment is differentially positioned and fi xed in a caudal
direction to close the gap.

Operative Approach
189
however, where the chin bone defi ciency is too severe to reach the
intended goals with an osteotomy, one may use bone or cartilage graft.
The two most common alloplastic materials used in augmentation
genioplasty are silicone and porous polyethylene. While some litera-
ture suggests that silicone implants should be placed supraperiostially
to diminish bone resorption, the senior author holds that a subper-
osteal plane should be considered for all implant types. Placing the
implant in this plane and over the symphysis would minimize the soft
tissue injury, dimpling and migration of the implant. Bone erosion will
be also minimized if the implant is placed over the denser portion
of the bone. Furthermore, if contracture should occur, the deeper
location of the implant limits the deleterious affects on the soft tissue
contour. The soft tissue response to augmentation genioplasty is
0.8 : 1.0 (Table 13.2).
Augmentation genioplasty can be performed under local anesthe-
sia with sedation. A submental incision is favored over an intraoral
approach because of the reduced risk of cephalad migration of the
implant, dehiscence and infection. This incision also permits access to
the anterior submental/cervical structures for lipectomy and platysma
modifi cation, which is commonly indicated in senescent patients
requiring genioplasty.
The submental incision is placed 0.5 cm anterior to the natural
submental crease. Prior to making an incision, the midline of the
anterior chin is marked and extended across the incision. The area is
infi ltrated with xylocaine containing 1 : 200 000 epinephrine. The inci-
sion is made with a scalpel and carried through the soft tissues with
electrocautery to the periosteum. The periosteum is incised and ele-
vated. The midline mark on the skin is used to mark the underlying
bone. A symmetric pocket is created just large enough to accommodate
the implant using an Obwegeser elevator. The implant is inserted one
side at a time and is positioned such that its midline is aligned with
the midline of the chin as marked previously (Fig. 13.37). The wound
is irrigated and the periosteum is closed using 5-0 monocryl for the
periosteum and dermis and 6-0 fast-absorbable catgut for the skin.
The soft tissue and skin are closed in layers. A tape dressing is applied.
The patient will receive antibiotics perioperatively. An intraoral inci-
sion is employed when extended implants or mandibular angle implants
are used. These are placed in the subperiosteal plane as well.
Fig. 13.22 Burr reduction genioplasty.
Fig. 13.23 Local injection of anesthesia and vasoconstricting agent
in labial mucosa.
Fig. 13.24 Administration of local anesthesia to soft tissues
posterior to mandibular symphysis.
Fig. 13.25 The intraoral incision is marked 1 cm from the sulcus on
the labial mucosa.

13
GENIOPLASTY
190
Optimizing outcomes
Outcomes are generally pleasing and improve chin appearance and
overall facial harmony (Figs 13.38–13.41). Outcomes can be
optimized as follows:
●
Scrupulous preoperative evaluation: history, physical exam and
soft-tissue cephalometric analysis of life-size photographs.
●
Digital life-size photography to precisely plan the chin
alterations.
●
Utilization of osteotomy as often as possible to provide versatility
to the technique and improve the cervico-mental angle.
●
Leaving suffi cient soft tissue on the gingival side of the
incision to minimize lip ptosis and wound dehiscence.
●
Placement of the implant in the subperiosteal plane when an
implant is used.
●
Protection of the soft tissue with malleable retractors to avoid
nerve and soft tissue damage.
●
Use of additional grafts under the labiomental groove, when an
advancement over 10 mm is necessary, to avoid excessive
deepening of in the labiomental groove.
COMPLICATIONS AND SIDE EFFECTS
Complications are rare. Nevertheless, the surgeon must understand
their potential causes and management (Table 13.3).27
Fig. 13.26 A scalpel is used to make the initial incision.
Fig. 13.27 Electrocautery is used to incise through the remaining
soft tissues (mentalis muscle and periosteum) to reach the surface of
the osseous chin. A cuff of mentalis muscle and mucosa is left on
the cephalic aspect of the mandiblular symphysis to be used later
for closure.
Fig. 13.28 A periosteal elevator is used to dissect in a subperiosteal
plane taking care not to injure the mental nerves.
Fig. 13.29 A retractor is placed to retract the soft tissues and to
protect the mental nerve. A vertical notch is placed to mark the
midline of the symphysis to facilitate subsequent identifi cation of
midline and attainment of desired caudal segment alignment.

191
Complications and Side Effects
Complications of osseous genioplasty
Wound dehiscence and infection
Wound dehiscence and infection are rare after osseous genioplasty. As
long as there is no loose or exposed hardware, most wound dehiscences
will close spontaneously. Conservative debridement and irrigation, and
intravenous followed by oral antibiotics are indicated. In most inci-
dences, this regimen protects the osteotomy site and may avoid
removal of the screws and plates.
Hematoma
Hematomas must be drained to prevent abscess formation, which will
place the caudal bone segment in peril of resorption. Use of antibiotics
will reduce the potential for an infection. This can be done under local
anesthesia. The hematoma is evacuated and the wound is irrigated
and repaired.
Tooth devitalization
Tooth devitalization is one of the most serious complications associ-
ated with genioplasty. All precautions must be enacted to obviate this
Fig. 13.30 A reciprocating saw with a wide blade is used to make
the central component of the horizontal osteotomy.
Fig. 13.31 The saw blade is changed to a narrower one to complete
the lateral components of the osteotomy.
Fig. 13.32 The caudal segment is advanced.
Fig. 13.33 The fi xation plates have a step conformation to match the
new contour of the anterior bone surface.
complication. This includes placing the osteotomy at least 30.5 mm
caudal to the occlusal edge of the mandibular canines.
Dental root exposure
This complication manifests itself as caudal retraction of the gingiva
resulting in painful exposure of the sensitive portion of the teeth. This
is usually the consequence of placement of the incision too close to
the gingiva, although poor dental hygiene and infection can be the
cause of this complication as well. Gingival grafting would be required
to treat the associated pain and root exposure.
Neurosensory loss
Some degree of lip paresthesia occurs in more than one half of the
patients treated with osteotomy of the chin bone. Sensory loss or
reduction is often a temporary condition in almost all patients.28 When
numbness persists, it is generally characterized as hyposthesia, not
anesthesia. When traction is the etiology, sensation generally returns
within days to weeks. However, avulsion or transection injury during
an osteotomy can occur if the osteotomy is too close to the mental

13
GENIOPLASTY
192
Overcorrection or undercorrection
Like asymmetry, overcorrection and undercorrection is the result of
faulty surgical planning and/or imprecise surgical enactment. If in
doubt, one should alter the chin conservatively. Either condition can
be corrected through a revision osteotomy.
Irregularities and step-type deformities
A step-type deformity, if present, is most often seen along the posterior
limits of the osteotomy. It is more common after a set-back technique
when the mandibular border is not aligned perfectly. This should be
noted and corrected by contouring the caudal segment. However, if
such a fl aw is discovered post-operatively, it should be observed for 6
months, during which time some bone remodeling may occur. If sat-
isfactory improvement is not observed, an oval burr can be used to
re-contour the mandibular border through a submental or an intraoral
incision.
Lower lip retraction
Lower lip retraction is a manifestation of a loss of lower lip support.
It results in descent of the lower lip position and an increase in lower
incisor show. This complication is generally the consequence of incom-
plete or improper mentalis muscle repair.29,30 This deformity can be
corrected through an intra-oral incision, extensive subperiosteal dis-
section and suspension of the periosteum cephalically.
Complications of augmentation
genioplasty
The fi rst three complications of alloplastic chin augmentation, dehis-
cence, extrusion and infection are all potentially related to inadequate
soft tissue closure and coverage following the use of intraoral incisions.
The common error is placing the access incision too close to the sulcus
and not leaving enough soft tissue over the gingival side.
Dehiscence
Dehiscence results in an exposed implant. One etiology is a tight
pocket, which can also lead to wound tension and breakdown. The
implant should be removed, the wound is irrigated and either loosely
approximated or left to heal. Oral antibiotics are used for 5–7 days.
Fig. 13.34 The fi xation plate is further contoured and fastened in
place with four screws, two on either side of the osteotomy.
Fig. 13.35 A segment of bone can be removed to achieve reduction
of anterior lower facial height.
Fig. 13.36 The wound is closed carefully incorporating both
mucosa and mentalis muscle in each suture bite in order to assure
proper alignment. Multiple interrupted chromic gut sutures are
used.
foramen due to the fact that the nerve has a brief caudal course prior to
emerging from the mental foramen (Fig. 13.6). Complete sensory loss
with no recovery after 1 year may require exploration and neurorraphy.
Soft tissue ptosis
Soft tissue ptosis results in a displeasing chin form, a ‘witch’s chin’,
and is more common after reduction genioplasty. This complication
is observed more frequently following chin ostectomy with burr rather
than setback procedures. It can also occur following removal of a chin
implant. Soft tissue excision through an elliptical incision in the sub-
mental area can correct this imperfection.
Asymmetry
Commonly, post-surgical asymmetry is the result of the failure to
detect the pre-existing asymmetry, although the failure to correct
unevenness or improper bone repositioning can also cause misalign-
ment. Mild asymmetries can be managed expectantly as they may
improve overtime with bone remodeling. Signifi cant asymmetry should
be corrected early, preferably prior to osseous union.

193
Complications and Side Effects
A
B
C
D
E
F
Fig. 13.37 Submental approach for augmentation genioplasty.

13
GENIOPLASTY
194
Fig. 13.38 A patient with horizontal microgenia before (left) and
following advancement genioplasty, secondary rhinoplasty, and
submental lipectomy (right) on front view (above) and profi le
(below).
Fig. 13.39 A patient with combined horizontal and vertical
microgenia before (left) and following osseous genioplasty and
submental lipectomy (right) on front view (above) and profi le (below).
Table 13.3 Complications of genioplasty and their management
Complication
Management
Osteotomy
Dehiscence and infection
Hematoma
Tooth devitalization
Dental root exposure
Neurosensory loss
Soft tissue ptosis
Asymmetry
Overcorrection/undercorrection
Irregularities and step-type deformities
Lower lip retraction
Irrigation, debridement and closure of wound if hardware is stable, systemic antibiotics
Drainage
Root canal by a dentist
Gingival grafting
Conservative/expectant initially; neurorraphy if anesthesia persists
Submental incision with skin excision
Early re-operation prior to osseous healing
Early re-operation prior to osseous healing
Observe 6 months. If no improvement is noted recontour with oval burr
Lip advancement
Augmentation
Dehiscence/extrusion
Infection
Malposition
Bone resorption
Capsular contracture
Lower lip retraction
Removal of implant, irrigation, closure, use of antibiotics
Explantation, irrigation, antibiotics and delayed osteoplastic genioplasty
Re-operation with re-positioning
Explantation and osteoplastic genioplasty if the impant is endangering the tooth root
Explantation and osteoplastic genioplasty
Repair of mentalis muscle, lip advancement

195
Complications and Side Effects
Extrusion
Extrusion presents in a similar fashion as dehiscence, although dehis-
cence does not necessarily always expose the implant. When a chin
implant is exposed, it is removed, the wound is irrigated and the
wound edges are loosely approximated, and oral antibiotics are pre-
scribed for 5–7 days. The residual or resultant deformity is best
managed by osteoplastic genioplasty.
Infection
Infection involving chin implants in the absence of exposure is rare.
When infection occurs, removal of the implant is usually inevitable.
Delayed osseous genioplasty can often be performed with satisfactory
results.
Malposition/dislodgment
Malposition is the placement of an implant in an inappropriate
location. Re-operation with proper positioning or conversion to an
osteotomy is indicated. Dislodgment refers to a change in location
of the implant after correct initial placement. This occurs most
often with silicone prostheses. Cephalic migration of an implant
placed trans orally is the most common presentation. Blunting of the
labiomental groove is seen with this type of displacement. Removal
of the implant and osseous genioplasty often provides the best
outcome.
Bone resorption
Almost all augmentation genioplasties will result in some degree of
bone resorption under the implant.31,32 This complication is more
common with non-porous implants such as silicone or acrylic. As
resorption is essentially inevitable, care must be taken to place the
implant caudally enough so that when bone erosion occurs, dental
roots are not placed in peril. Additionally, the magnitude of resorption
is less caudally due the higher bone density and decreased activity of
the muscle overlying the implant. In case of pending erosion of the
tooth roots, the implant should be removed and an osteotomy should
be performed.
Capsular contracture
Capsule contracture is almost exclusively seen when a smooth implant
is utilized, in particular silicone implants. This type of contracture
distorts the implant and generates an unnatural soft tissue contours
punctuated by a central bulge. Explantation, removal of the capsule
Fig. 13.40 A patient with microgenia and aging face before (left)
and following facial rejuvenation, submental lipectomy and osseous
genioplasty (right) on front view (above) and profi le (below).
Fig. 13.41 A patient before (left) and following reduction
genioplasty with osteotomy (right) on front view (above) and profi le
(below).

13
GENIOPLASTY
196
anteriorly, and osseous genioplasty are indicated; however, these inter-
ventions are not universally successful due to residual soft tissue
distortion.
Lower lip retraction
Lip retraction presents with less frequency when submental access is
used compared to the intra-oral incision. When it occurs, surgical
elevation of the soft tissues with a subperiosteal dissection and cephalic
fi xation with bone tunneling or anchor suture may prove successful.33
POSTOPERATIVE CARE
The patient resumes eating the day of surgery. Liquids are advanced
to a soft diet and then a regular diet according to the patient’s general
tolerance of food within 24–48 hours. The patient is instructed to rinse
with antiseptic mouthwash after eating and three times daily. Tooth
brushing can be resumed the day of surgery, but the patient should be
instructed to exercise caution when cleaning the area close to the inci-
sion. Oral antibiotics are prescribed for 5–7 days. The patient should
avoid heavy exercise for 3 weeks following osteotomy. Foam type com-
pressive tape dressing is removed in 2–3 days (Table 13.4).
CONCLUSION
1.
Precise closure of mentalis muscle and mucosa is important to
avoid lip ptosis and wound dehiscence when intraoral
incisions are used.
2.
Augmentation genioplasty performed through a submental
incision is prone to fewer complications than through an
intraoral incision.
3.
Exposure and judicious protection of the mental nerves can
reduce the incidence of lip anesthesia.
4.
Chin advancement should be done conservatively on patients
with a long face deformity who decline orthognathic surgery.
5.
When a set back genioplasty is performed, the posterior
portion of the repositioned segment may require contouring to
prevent palpable step deformities.
Genioplasty is a relatively straightforward procedure with low morbid-
ity and highly gratifying results. The use of digital life-size photographs
with soft tissue cephalometrics facilitates precise surgical planning and
execution. Understanding of the nature of the deformity and proper
selection of the procedure are the keys to a successful outcome. Geni-
oplasty also plays a pivotal role in achieving superior results when
other disharmonies are being addressed with rhinoplasty, submental
lipectomy or facial rejuvenation.
Table 13.4 Postoperative care
Short term
Liquid/soft diet initial – advances as tolerated following surgery
Compressive foam tape dressing – 2–3 days
Anti-septic mouthwash rinse (minimum: three times daily) – 5
days
Gentle tooth brushing labial surface mandibular teeth for 7 days
Oral antibiotics – 5–7 days
Resome heavy exercise – 21 days
Long term
Routine oral hygiene/prevention of periodontal disease
Avoidance of direct blunt trauma to chin
Pitfalls
1.
Use of a chin implant will not alter the cervico-mental angle as
much as an osseous genioplasty.
2.
Placement of the implant above the periosteum may cause
dimpling of the skin.
3.
Genioplasty alone will fail to provide a satisfactory outcome on
patients with signifi cant class II or III maxillary/mandibular
deformity.
4.
Alloplastic genioplasty will not correct the pre-existing chin
asymmetry.
5.
Signifi cant chin advancement without augmentation of the B
point may result in a deep labiomental crease, which can be
very displeasing.
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199
CHAPTER 14
Aesthetic Contouring of the
Craniofacial Skeleton
Michael J Yaremchuk
●
Craniofacial deformities which are disfi guring and are of
functional consequence to vision, breathing, and mastication,
usually require skeletal osteotomies and rearrangement as
treatment. In patients with less severe midface or mandibular
hypoplasia, occlusion is normal or has been compensated by
orthodontics. These patients have neither respiratory nor
ocular compromise. In these patients, the appearance of
skeletal osteotomies and rearrangements can be simulated
through the use of facial implants. Diagrammatic
representations of how implant surgery can mimic the
appearance of skeletal osteotomies are shown in Figs 14.2
and 14.3.
PREOPERATIVE EVALUATION
Physical examination
Physical examination is the most important element of preoperative
assessment and planning. Reviewing life-size photographs with the
patient can be helpful when discussing aesthetic concerns and goals.
It also allows demonstration of the asymmetries common to all faces.
Their recognition preoperatively is important to the surgeon in plan-
ning and to the patient in anticipating the postoperative result.
As asymmetries become more obvious, it is important to recognize
that they are more complex than relative skeletal defi ciencies or
excesses. Rather, they refl ect three-dimensional differences that are
most easily conceptualized as twists of the facial skeleton.
Facial asymmetries should be identifi ed on patients who seek
facial augmentation and notifi ed during the preoperative
evaluation.
Radiology
Most aesthetic procedures are done without preoperative radiology
assessment. In general, the size and position of the implant are largely
aesthetic judgments. Cephalometric X-rays are most often used for
planning chin and mandible augmentation surgery. These studies
defi ne skeletal dimensions and asymmetries as well as the thickness
of the chin pad. Computerized tomographic (CT) scans provide the
ability to view the skeleton in different planes and, through computer
manipulation, in three dimensions. CT imaging provides digitized
information that can be transferred to design software. This can
be used to create life-sized models and custom implants, which are
Summary
1. Most aesthetic augmentation of the facial skeleton is done
with alloplastic implants.
2. Implant surgery can mimic the appearance obtained after
skeletal osteotomies.
3. Solid silicone and porous polyethylene are the most commonly
used materials for facial skeletal augmentation.
4. Incisions should be placed remote from implant placement.
5. The subperiosteal plane is preferred for implant placement.
6. Avoid large implants with poor transitions.
7. Gaps between the implant and the skeleton result in
unanticipated increases in augmentation.
8. Screw fi xation of the implant eliminates gaps between the
implant and the skeleton as long as the implant is malleable.
9. Screw fi xation of the implant prevents implant movement.
10. All faces are asymmetric. Facial asymmetries should be
identifi ed and discussed with the patients preoperatively.
INTRODUCTION
Augmentation is the predominant means of aesthetic contouring of
the facial skeleton in non-Asian populations. Conceptually, autoge-
nous bone would be the best material for augmentation, because it has
the potential to be revascularized and, then, incorporated into the
facial skeleton. In time, it could be biologically indistinguishable from
the adjacent native skeleton. Practically, the use of autogenous bone
is limited. The morbidity, time and hospital costs associated with
autogenous bone graft harvest can be signifi cant. Furthermore, the
inevitable resorption and the poor handling characteristics of autoge-
nous bone grafts also limit the quality and predictability of the aes-
thetic result. For these reasons, almost all facial skeletal augmentation
is done with alloplastic implants. A diagrammatic survey of the facial
skeletal areas amenable to augmentation with alloplastic implants is
presented in Fig. 14.1.
INDICATIONS
●
Facial skeletal augmentation is most often done to enhance
facial appearance in patients whose skeletal relationships are
ostensibly within the normal range. These patients want more
defi nition and angularity to their appearance. Other patients
desire to “balance” their facial dimensions.

14
AESTHETIC CONTOURING OF THE CRANIOFACIAL SKELETON
200
particularly helpful when augmenting facial skeletons with signifi cant
asymmetries.
SURGICAL PLANNING
For most reconstructive problems, surgery is performed to return the
involved area to its original appearance, or, if that is not possible, to
one that is symmetric and accepted as normal. When alloplastic
implants are used to make the face more attractive, the aesthetic goal
is more arbitrary. Because implant augmentation of the facial skeleton
results in measurable changes in facial dimensions and proportions, it
is intuitively advisable and appropriate to use facial measurements to
evaluate the face and to guide surgery.
Facial anthropometries and
neoclassical canons
For purposes of painting and sculpture, Renaissance scholars and
artists formulated ideal proportions and relations of the head and face.
These were largely based on classical Greek canons. Although usually
referenced in texts discussing facial skeletal augmentation, neoclassi-
cal canons have a limited role in surgical evaluation and planning,
because they are based on idealizations. When the dimensions of
normal males and females were evaluated and compared to these
artistic ideals, it was found that some theoretic proportions are never
found, and others are one of many variations found in healthy normals,
or those determined more attractive than normals.1,2 The neoclassical
canons do not allow for the facial dimensions that are known to differ
with sex and age. Most of these canons of proportion (e.g. the width
of the upper face is equal to fi ve eye widths), are interesting but hold
for few individuals and cannot be obtained surgically or, if obtainable,
only with extremely sophisticated craniofacial procedures. For these
reasons, we have found it more useful to use the anthropometric mea-
surements of normal individuals to guide our Gestalt in the selection
of implants for facial skeletal augmentation (Fig. 14.4).3 Normal
dimensioned faces are intrinsically balanced. That is, the relations
between the various areas of the face relate to one another in a way
that is not distracting to the observer. By comparing a patient’s dimen-
sions to the average, the surgeon has some objective basis as to what
anatomic area may be amenable to augmentation, and by how
much.
Anesthesia and preparation
Facial skeletal augmentation can be performed under local anesthesia
with sedation or general anesthesia. It is routinely performed on an
outpatient basis. When implants are placed through intrasoral
approaches, general anesthesia with nasotracheal or endotracheal intu-
bation assures protection of the airway and the best possible antiseptic
preparation of the oral cavity. Patient positioning and exposure for
implant placement are also optimized when the airway is controlled.
Prior to preparation and draping a dilute solution of Marcaine with
epinephrine is infi ltrated into the operative site for postoperative pain
control and intaoperative hemostasis. Cephalosporins are adminis-
tered perioperatively.
Incisions
Incisions are borrowed from craniofacial and aesthetic surgery.
Coronal incisions are used to place implants in the frontal and
temporal areas. Transconjunctival retroseptal incisions are used to
access the infraorbital rim and internal orbit. The lateral extent of the
lower-lid blepharoplasty incision provides access to the lateral orbit
and zygomatic arch. This small cutaneous incision leaves an incon-
spicuous scar. (I avoid skin or skin muscle-fl ap lower-lid approaches
which not uncommonly heal with lower-lid malposition.) Intraoral
sulcus incisions are used to augment the midface as well as the man-
dibular body and ramus. These incisions are made with a generous
labial cuff to allow watertight mucosal closure. Chin area augmenta-
tion is performed through submental incisions. Placement of incisions
directly over implants is avoided.
Fig. 14.1 A diagrammatic survey of the
alloplastic implants used for facial skeletal
enhancement. Anatomic areas include the
infraorbital rim, malar, pyriform aperture, chin
as well as the mandibular body and ramus.
Alloplastic implants used for facial skeletal enhancement

Surgical Planning
201
Multiple implant augmentation of the midface skeleton
A
B
C
D
Fig. 14.2 Diagrams show how multiple implant augmentation of the midface skeleton can simulate the visual appearance of LeFort III
osteotomy and advancement without altering dental occlusion. A, Illustration of midface concavity and Class III malocclusion. B, Osteotomy
and advancement at the LeFort III level provides midface projection and Class I occlusion. C, Illustration of midface concavity and Class I
occlusion. D, Multiple midface implants provide visual effect of LeFort III osteotomy and advancement but does not alter occlusion.

14
AESTHETIC CONTOURING OF THE CRANIOFACIAL SKELETON
202
Multiple implant augmentation of the mandible
A
B
C
D
Fig. 14.3 Diagrams show how multiple implant augmentation of the mandible can simulate the visual appearance of of sagittal split
osteotomy and horizontal osteotomy of the chin without altering dental occlusion. A, Mandibular defi ciency with Class II occlusion. B, After
sagittal split osteotomy with horizontal osteotomy and advancement of the chin to increase chin projection. Note that the occlusion has been
corrected from Class II to Class I. C, Mandibular defi ciency with Class I occlusion. D, The visual effect of sagittal split osteotomy and
horizontal osteotomy of the chin with advancement has been simulated with mandible and chin implants. Note that the Class I occlusion is
unchanged. Notice also that the border regularities inherent with skeletal osteotomies are avoided when implants are used.

Surgical Planning
203
Frontal and lateral views of female and male faces
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64
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Fig. 14.4 Frontal and lateral views of female and male faces drawn from average anthropometric measurements for 21 year old North
American Caucasians. Measurements are in millimeters. A, Frontal view female. B, Frontal view male. C, Lateral view female. D, Lateral
view male.

14
AESTHETIC CONTOURING OF THE CRANIOFACIAL SKELETON
204
ALLOPLASTIC MATERIALS
Implant materials used for facial skeletal augmentation are biocompat-
ible – that is, there is an acceptable reaction between the material and
the host. In general, the host has little or no enzymatic ability to
degrade the implant with the result that the implant tends to maintain
its volume and shape. Likewise, the implant has a small and predict-
able effect on the host tissues that surround it. This type of relation-
ship is an advantage over the use of autogenous bone or cartilage
which, when revascularized, will be remodeled to varying degrees,
thereby changing volume and shape.
The presently used alloplastic implants used for facial reconstruc-
tion have not been shown to have any toxic effects on the host.4 The
host responds to these materials by forming a fi brous capsule around
the implant, which is the body’s way of isolating the implant from the
host. The most important implant characteristic that determines the
nature of the encapsulation is the implant’s surface characteristics.
Smooth implants result in the formation of smooth-walled capsules.
Porous implants allow varying degrees of soft tissue ingrowth that
results in a less dense and defi ned capsule. It is a clinical impression that
porous implants, as a result of fi brous incorporation rather than encap-
sulation, have a lower tendency to erode underlying bone or migrate due
to soft tissue mechanical forces and, perhaps, are less susceptible to
infection when challenged with an inoculum of bacteria. The most com-
monly used, commercially available materials today for facial skeletal
augmentation are solid silicone, and porous polyethylene –Medpor
(Porex, Fairborn, GA). Eppley5 has summarized the attributes of these
materials.
The surface characteristics of an implant infl uence the surrounding
soft tissue’s response to the implant. Smooth-surfaced implants
induce denser capsule formation than porous implants.
Polysiloxane (silicone)
Solid silicone or the silicone rubber used for facial implants is a vul-
canized form of polysiloxane. Polysiloxane is a polymer created from
interlinking silicone and oxygen with methyl side groups and, as such,
is the only non-carbon chain polymer used in medical implantation.
Solid silicone has the following advantages: it is easily sterilizable by
steam or irradiation, it can be carved easily with either a scissors or
scalpel, and it can be stabilized with a screw or suture. There are no
known clinical or allergic reactions. Because it is smooth, it can be
removed quite easily. Disadvantages include the tendency to cause
resorption of underlying bone (particularly when used to augment the
chin), the potential to migrate if not fi xed, and the potential for its
fi brous capsule to be visible when placed under thin soft tissue
cover.
Porous polyethylene
Porous polyethylene – Medpor (Porex, Fairborn, GA) – is a simple
carbon chain of ethylene monomer. Porous polyethylene is fi rm but
fl exible. Its intramaterial porosity is between 125 and 250 μm, allows
fi brous tissue growth into the surface of the implant. The porosity of
this implant has both advantages and disadvantages. Soft tissue growth
into the implant lessens the tendency to migrate and to erode under-
lying bone. Its fi rm consistency allows it to be easily fi xed with screws
and contoured with a scalpel or power equipment without fragmenting.
However, its porosity causes its soft tissue to adhere to it, making
placement more diffi cult and requiring a larger pocket to be made than
with smoother implants. The soft tissue ingrowth also makes implant
removal more diffi cult.
REQUISITES OF IMPLANT SHAPE,
POSITIONING, AND IMMOBILIZATION
Shape
The external shape of the implant should mimic the shape of the bone
it is augmenting. Its posterior surface should be one that molds to the
bone to which it is applied. The implant margins must taper imper-
ceptibly into the bone they are augmenting so that they are neither
visible nor palpable.
Positioning
Although some surgeons prefer to place implants in a soft tissue
pocket, clinical experience has led this surgeon to adopt a policy of
strict subperiosteal placement. Placement in a subperiosteal pocket
involves a dissection that is safe to peripheral nerves and relatively
bloodless. It allows visualization and, therefore, more precise augmen-
tation of the skeletal contour desired for augmentation.
The size of the pocket will be determined by the type of implant
used and its method of immobilization. The long-standing teaching
using smooth silicone implants is to make a pocket just large enough
to accommodate the implant and, therefore, guarantee its position.
Porous implants require a larger pocket, because they adhere to the
soft tissues during their placement. This author, whether using smooth
or porous implants, dissects widely enough to have a perspective of
the skeletal anatomy being augmented, which allows more precise,
symmetric implant positioning.
Wide subperiosteal exposure of the area to be augmented
optimizes accuracy of implant placement.
Immobilization
Facial implants should be immobilized. Many surgeons stabilize the
position of the implant by suturing it to surrounding soft tissues or by
using temporary transcutaneous pull-out sutures. Screw fi xation of the
implant to the skeleton is preferred. Screw fi xation prevents any move-
ment of the implant and also assures application of the implant to the
surface of the bone. Because each facial skeleton has a unique and
varying surface topography, a non-conforming implant will leave gaps
between the implants and the skeleton. These gaps between the
implant and the skeleton are problematic for two reasons. The space
between the implant and the skeleton is equivalent to an additional
augmentation. This can lead to over-augmentation and asymmetries.
Gaps are also potential spaces for hematoma and seroma formation
(Fig. 14.5). Finally, screw fi xation allows for fi nal contouring with the
implant in position. This fi nal contouring is particularly important
where the implant interfaces with the skeleton. Any step-off between
the implant and the skeleton will be palpable and possibly visible in
patients with thin soft tissue cover.
Screw fi xation not only prevents implant movement but also
obliterates gaps between the implant and the native skeleton.
Gaps result in unanticipated increase in implant augmentation.
MIDFACE IMPLANTS
Virtually all aesthetic augmentation is performed on the middle and
lower thirds of the facial skeleton. The midface is best conceptualized
as having three zones, alone, or in combination, appropriate for aug-

Midface Implants
205
Screw fixation
Fig. 14.5 Screw fi xation applies the implant
to the skeleton and obliterates the gaps
which are equivalent to an increase in
augmentation. A, Without screw fi xation
there are gaps between the posterior surface
of the implant and the anterior surface of the
mandible. B, The screw at the upper border
applies the implant to the skeleton. C, The
lower screw now obliterates all gaps. The
posterior surface of the implant is congruent
with the anterior surface of the mandible.
The amount of augmentation is equivalent to
the thickness of the implant only.
mentation. Implants are designed to augment the infraorbital rim, the
malar area, and the pyriform aperture.
Infraorbital rim
Because the infraorbital rim and upper midface skeleton support the
lower eyelids and the cheek soft tissues, their projection impacts on
lid and cheek position. Patients with retrusive skeletons are more
likely to undergo premature lower lid and cheek descent with aging.
This lack of skeletal support predisposes to lower-lid malposition after
blepharoplasty and limits the effi cacy and longevity of midface lifting.
Defi cient infraorbital rim projection predisposes to lower-lid
descent with aging.
Defi cient infraorbital rim projection predisposes to lower-lid
descent after blepharoplasty.
Jelks and Jelks6 categorized globe–orbital rim relationships and the
tendency for the development of lower-lid malposition after blepharo-
plasty. On sagittal view, they placed a line or “vector” between the
most anterior projection of the globe and the malar eminence and lid
margin. A “positive” vector relationship exists when the most anterior
projection of the globe is posterior to the lid margin and the malar
eminence. A “negative” vector relationship exists when the most ante-
rior projection of the globe lies anterior to the lower lid and the malar
eminence. See Fig. 14.6. They warned that, patients whose orbital
morphology has a negative vector relationship are prone to lid malpo-
sition after lower blepharoplasty.
Augmentation of the infraorbital rim in patients with a retruded
infraorbital rim can bring it into a better relationship with the globe,
thereby “reversing the negative vector”.7 See Fig. 14.6.
Infraorbital rim augmentation is part of the strategy for normal-
izing the appearance in patients who are “morphologically prone”. It
can be adapted for morphologically prone patients who are fi rst seeking
improvement in their periorbital appearance or for those whose lid
malposition and round-eye appearance that has been exaggerated by
previous lower blepharoplasty.8
Infraorbital rim augmentation can provide support for the
resuspended lower lid and cheek in patients with midface skeletal
defi ciency.
Surgical technique
The infraorbital rim and adjacent anatomy must be exposed suffi -
ciently to assure ideal implant placement, smooth implant facial skel-
eton transition, and screw fi xation. Direct, subciliary skin or skin
muscle-fl ap incisions can provide this exposure. A transconjunctival
incision alone is inadequate for implant placement or screw stabiliza-
tion. Use of a transconjunctival retroseptal incision requires lengthen-
ing with a lateral canthotomy or combination with intraoral and
coronal incision. It is important to identify the infraorbital nerve that
exits from the infraorbital foramen about 1 cm below the margin of
the orbit. This may be 3–6 mm in patients with signifi cant maxillary
hypoplasia – usual candidates for this surgery. The orbicularis oculi
and the origins of the lip elevators are separated from the underlying
skeleton in a subperiosteal plane to expose the infraorbital rim. The
implant is carved to fi t the specifi c needs of the patient. Segmenting
the implant may facilitate placement of the implant through limited
skeletal access. The implant is fi xed to the skeleton with titanium screw.
This technique is summarized in Fig. 14.7. A clinical example is shown
in Fig. 14.8.
Pyriform aperture
The average North American Caucasian face is convex (Figs 14.4). A
relative defi ciency in lower midface projection may be congenital or

14
AESTHETIC CONTOURING OF THE CRANIOFACIAL SKELETON
206
may be acquired, particularly after cleft surgery and trauma. Patients
with satisfactory occlusion and lower midface concavity can have their
aesthetic desires satisfi ed with skeletal augmentation. Implantation of
alloplastic material in the paranasal area can simulate the visual effect
of LeFort I advancement and other skeletal manipulations.9
Pyriform aperture augmentation increases the projection of the
nasal base and, therefore, opens the nasolabial angle.
Surgical technique
Paranasal augmentation is done through an upper gingivobuccal
sulcus incision made just lateral to the piriform aperture to avoid
placing incisions directly over the implant. An adequate cuff of mucosa
is left to allow layered closure. Subperiosteal dissection exposes the
area to be augmented. The infraorbital nerve is identifi ed and pre-
served. The patient’s anatomy will determine whether the entire cres-
cent or just the horizontal or vertical limb of the crescent will be
utilized. The root of the canine usually lies in the fi eld to be augmented
and should be avoided if the implant is immobilized with screws. A
patient who underwent aesthetic rhinoplasty and augmentation of the
pyriform aperture area is shown in Fig. 14.9.
The implant may compromise the nasal airway if malpositioned.
Malar
Prominent malar bones are considered attractive. Hence, the malar
area is frequently augmented with implants.
The lack of anthropometric and cephalometric landmarks precludes
the availability of normative data making analysis and augmentation
of the malar area largely subjective. Malar defi ciency is often part of a
generalized midface defi ciency for which malar augmentation alone
may be inadequate or, even, inappropriate. Clinical experience has
shown that when malar projection is deemed inadequate, malar aug-
mentation is most effective when it recreates the contours of a normal
skeleton with prominent anterior projection. Malar skeletal augmenta-
tion is not a substitute for soft tissue augmentation or repositioning.
Since full cheeks are associated with youth, malar augmentation
is often performed to provide a youthful appearance. This may provide
an aesthetic benefi t if there is a relative malar hypoplasia or if the
implants are of modest size and projection. This skeletal augmentation
is not equivalent to a soft tissue augmentation or resuspension. Simi-
larly, malar implants are often advocated as a means to obliterate
lower-eyelid wrinkles or secondary bags. Malar augmentation impacts
poorly on these surface irregularities. More often, they detract from
periorbital aesthetics by contributing to lower-lid malposition, particu-
larly when placed through an eyelid approach.10
Skeletal augmentation is not a substitute for soft tissue
augmentation or resuspension.
Surgical technique
Malar augmentation can be performed through intraoral, coronal, or
eyelid incisions. It is the author’s preference to access the malar
midface through an intraoral approach.
An upper buccal sulcus incision is mad e far enough from the apex
of the sulcus so that suffi cient labial tissue is available on either side
for a secure two-layer closure. Taking care to identify the infraorbital
nerve, subperiosteal dissection is carried over the malar eminence and
onto the zygomatic arch almost up to the zygomaticotemporal suture.
The pocket size should allow precise insertion of the implant to the
area of the skeleton desired for augmentation.
Extending a malar implant onto the zygomatic arch has a profound
impact on midfacial width.
Although implants with greater projection are available, I rarely
provide more than 3 mm of augmentation at the point of maximum
projection. Larger implants will become obvious with time as the
Positive vector
Negative vector
‘Reversed’ negative vector
Implant
Jelks and Jelks
Fig. 14.6 Jelks and Jelks118-6 categorized globe-orbital rim relationships by placing a line or “vector” between the most anterior projection of
the globe and the malar eminence and lid margin. (Left) Positive vector relationship. In the youthful face with normal globe-to-skeletal rim
relations, the cheek mass supported by the infraorbital rim lies anterior to the surface of the cornea. The position of the cheek prominence
beyond the anterior surface of the cornea is termed a positive vector. (Center) Negative vector relationship: In patients with maxillary
hypoplasia, the cheek mass lies posterior to the surface of the cornea. The position of the cheek prominence beyond the anterior surface of
the cornea is termed a negative vector. (Right) ‘Reversed’-negative vector relationship: Alloplastic augmentation of the infraorbital rim can
reverse the negative vector. After Yaremchuk, M.J. Restoring palpebral fi ssure shape after previous lower blepharoplasty. Plast. Reconst.
Surg. 111:441-450.

Mandible Implants
207
overlying soft tissues atrophy and sag. The capsule formation that
accompanies smooth-surfaced implants further exaggerates the ten-
dency towards implant visibility.
Large malar implants will become visible with time.
In my experience, implants with large surface areas do not mimic
natural skeletal topography and cause unnatural implant-dictated
contours. The intraoperative position of both smooth and porous
implants can be guaranteed with screw fi xation of the implant to the
skeleton. See Figs 14.10 and 14.11.
MANDIBLE IMPLANTS
Each of the anatomic areas of the mandible – chin, body, angle and
ramus – may be defi cient and are amenable to augmentation with
alloplastic materials. For further information on the chin please see
Chapter 13, Genioplasty.
Ramus, angle, and body
Alloplastic augmentation of the mandibular ramus and body can have
a dramatic impact on the appearance of the lower third of the face.
Two patient populations have had their aesthetic concerns satisfi ed
with mandibular augmentation procedures. One group has mandibular
dimensions that relate to the upper and middle thirds of the face
within the normal range. These patients perceive a wider lower face
as an enhancement to their appearance. Patients in this treatment
group often present with a desire to emulate the appearance of models
and actors who have a defi ned, angular lower face. This patient group
benefi ts from implants designed to augment the ramus and posterior
body of the mandible and, in so doing, increase the bigonial distance
(Fig. 14.4 and 14.5).
The other major group of patients who benefi t from augmentation
of the mandibular ramus and body are those patients with skeletal
mandibular defi ciency who have their malocclusion treated with ortho-
dontics. The skeletal anatomy associated with mandibular defi ciency,
which can be camoufl aged with implants designed to augment the
ramus and body of the mandible include the obtuse mandibular angle
Increasing projection of infraorbital rim
Fig. 14.7 Overview of operation to increase projection of infraorbital
rim and “reverse the negative vector” in patients with upper
midface skeletal defi ciency. I prefer a transconjunctival retroseptal
incision (broken line) with the lateral extent of a lower-lid
blepharoplasty incision (solid line) to expose the infraorbital rim.
This approach preserves the integrity of the lateral canthus, and
hence, the palpebral fi ssure. Transcutaneous blepharoplasty or
transconjunctival with lateral canthotomy incisions are alternative
approaches which provide greater exposure but are accompanied by
a greater risk of palpebral fi ssure distortion. An intraoral incision
(broken line) is use to access the lower midface skeleton and to
identify and protect the infraorbital nerve. The lower-lid and midface
soft tissues are freed by subperiosteal dissection. The implant is
immobilized with titanium screws.
A1
A2
Fig. 14.8 Clinical example of a patient who underwent augmentation of the infraorbital rim with an alloplastic implant, subperiosteal
midface lift, and lateral canthopexy. A, Pre and postoperative frontal views. B, Pre and postoperative lateral views.
B1
B2

14
AESTHETIC CONTOURING OF THE CRANIOFACIAL SKELETON
208
A1
A2
B1
B2
Fig. 14.9 A 20-year-old woman underwent rhinoplasty and pyriform aperture augmentation. Note how augmentation of the pyriform
aperture has changed the lower midface shape from concave to convex. A, Pre and postoperative frontal views. B, Pre and postoperative
lateral views.

Mandible Implants
209
with steep mandibular plane, as well as the decreased vertical and
transverse ramus dimensions. The addition of an extended chin
implant will camoufl age the poorly projecting chin.14
Surgical technique
A generous intraoral mucosal incision is made to expose the ramus and
body of the mandible. It is made at least 1 cm above the sulcus on its
labial side. The anterior ramus and body of the mandible are freed from
their soft tissues. If the mental area is also being augmented, a submen-
tal incision is made for access and exposure of the anterior mandible.
The mental nerve is visualized as it exits its foramen to avoid its injury.
It is important to free both the inferior and pos-terior borders of the
mandible of soft tissue attachments to allow placement.
To assure the desired placement of the implant and its application
to the surface of the mandible, the implant is fi xed to the mandible
with titanium screws. With vigorous retaction, this is performed
intraorally (Fig. 14.12). This allows strategic unicortical screw fi xa-
tion of the implant to the mandible. Usually two or three screws are
used to obliterate any gaps between the mandible and the implant.
Screws are placed to avoid the anticipated path of the inferior alveo-
lar nerve prior to its exit from the mental foramen.
It is crucial to soften any transitions between the implant and the
mandible, particularly where the implant extends beyond the anterior
mandibular border’s inferior edge. Any step-offs between the implant
and the mandible in this area may be visible in thin patients. Screw
fi xation of the implants allows scalpel or mechanical burr fi nal con-
touring with the implants in place. A small suction drain may be placed
at the operative site that exits through the skin behind the ear. The
incision is closed in two layers with absorbable sutures.
Make the intraoral incision at least 1 cm above the sulcus on the
labial side to provide adequate soft tissue for two-layer closure and
to avoid saliva pooling over the suture line in the early
postoperative period.
A clinical example is shown in fi gure 14.13.
Operative technique for malar augmentation
Fig. 14.10 Overview of the operative technique for malar augmentation.
The upper buccal sulcus incision is at least 1 cm above the apex so
that suffi cient tissue is available for closure. Taking care to identify
the infraorbital nerve, the subperiosteal dissection is carried over
the malar eminence and onto the zygomatic arch just beyond the
zygomaticotemporal suture. Implants are fi xed with titanium screws.
A trochar attached suction drain is placed. It exits through temporal
hair bearing scalp. The broken line indicates the buccal sulcus
incision. The dotted area denotes the area of subperiosteal dissection.
The implant usually extends from the temperozygomatic suture on
the zygomatic arch to just below the foramen of the infraorbital nerve.
It does not extend beyond the malar bone into the submalar area.
A1
A2
Fig. 14.11 A 24-year-old woman underwent
malar augmentation, chin augmentation, and
submental lipectomy. A, Pre and
postoperative frontal views. B, Pre and
postoperative oblique views.
B1
B2

14
AESTHETIC CONTOURING OF THE CRANIOFACIAL SKELETON
210
make the cheek project more; however, the face will appear increas-
ingly round and, therefore, less defi ned and less angular.
Soft tissue augmentation does not provide the same visual effect
as skeletal augmentation and vice versa.
COMPLICATIONS
The best available data support the biocompatibility of the currently
used implant materials. No cases of cancer have been reported in
association with a polymer craniofacial implant. True hypersensitivity
reactions to prefabricated polymer implants are extremely rare.
There are no truly scientifi c data to document the surgical compli-
cation rate related to facial skeletal augmentation. Prospective studies
that control for surgical technique, implant site, patient selection, and
follow-up time do not exist. We reviewed almost 200 reports in the
literature that provided suffi cient data to compare complication rates
related both to implant material and implant site.4 The accumulation
of these clinical data can provide some useful information about factors
that can contribute to morbidity with implants. For example, the
quality of the soft tissue coverage is clearly related to morbidity. Com-
plication rates are lowest in the chin and malar region, where the soft
tissue cover is relatively thick, and highest in the nose and ear, where
the soft tissue cover is thin and often under tension from the underly-
ing device. The surface characteristic of an implant may also be impor-
tant. Porous implants allow a certain ingrowth of tissue which may
allow the presence of host defenses within the implant to decrease the
risk of infection. Given that several biomaterials are well tolerated in
the human body, the actual chemical structure of an implant is impor-
tant only to the degree that it infl uences the consistency and surface
characteristics of the device.
In 2003, I reported my personal experience with porous implants
used for facial skeletal reconstruction.8 This report was based on expe-
riences with 162 patients who were operated on over an 11-year period
(1990–2001). In this series no implants migrated or were extruded,
formed clinically apparent capsules, or caused symptoms attributable
to bio-incompatibility. The overall reoperation was 10% (n = 16), which
included operations to remove implants because of acute infection (2%
– n = 3) or late infection (1% – n = 1), or to remove implants causing
displeasing contours (2% – n = 3). The rate of complications has not
changed in facial implant procedures in the subsequent 100 patients.
The presence of a foreign body decreases the minimal infecting
dose of Staphylococcus aureus in an animal model due to impaired
bacterial clearance.19 If microorganisms are not eliminated rapidly
from an implant surface they will adhere to the implant initially by
non-specifi c physical forces and then by the formation of biofi lms
characterized by clustering together in an extracellular matrix attached
to the implant.20 Biofi lms protect bacteria from host defenses and
antibiotics. Only aggressive debridement and long-term suppressive
therapy have been effective in treating orthopedic implant-related
infections. This approach is usually not appropriate in facial implant
patients since both debridement and chronic infection may be deform-
ing in this appearance conscious population. Since antibiotic treat-
ment alone is usually not successful, facial implant-related infections
are treated by implant removal and appropriate wound care. Implants
may be replaced in 6 to 12 months.
CONCLUSION
Augmentation of the facial skeleton with alloplastic materials can be a
safe and effective way to alter facial appearance. Virtually any area of the
facial skeleton can be augmented. A satisfactory result requires avoid-
ing morbidity in the facial sensory and neuromuscular apparatus during
surgical exposure, selecting sites with adequate soft tissue cover and
using implants that merge imperceptibly with the adjacent skeleton.
Screw fixation of the implant.
Fig. 14.12 Screw fi xation of the implant to the mandible through an
intraoral approach.
Implants used to camoufl age soft
tissue depressions
The implants discussed in this chapter are designed to increase the
surface projection of the facial skeleton. Some surgeons have used
implants placed on the facial skeleton to disguise overlying soft tissue
volume inadequacy, usually due to involutional changes brought on by
age. Submalar implants are used to expand midfacial depression and,
in so doing, may reduce the prominence of the nasolabial fold.15 Mittle-
man designed an extended chin implant shaped to camoufl age the prejowl
sulcus.16 The sulcus develops due to some bone resorption along the
border of the mandible and soft tissue atrophy directly over it. This
depression exaggerates the jowl. Flowers designed an implant to fi ll out
the “tear trough”, the area that develops in some individuals medial to the
infraorbital foramen between the thick cheek skin and thin eyelid skin.17
Skeletal versus soft tissue augmentation
The value of soft tissue repositioning and augmentation has been
recognized and exploited during the last decade. Unfortunately, since
the ultimate expression of skeletal or soft tissue structure is refl ected
on the skin’s surface, some surgeons have used this as a justifi cation
for the equivalence and interchangeability of soft and hard tissue aug-
mentation. For example, malar skeletal implants are used to restore
cheek fullness while fat grafts are used to create malar prominence.
Up to 1 mm or so, the visual effect of either augmentation modality
may be equivalent depending on the thickness of the overlying soft
tissue envelope. However, beyond a minimal augmentation, the visual
effects of these modalities are markedly different. This is easily con-
ceptualized when envisioning large augmentations. A large implant
placed on the malar bone will make the cheek project more, making
the face more defi ned, angular and, therefore, make the face appear
thinner and more skeletal. Implanting fat into the cheeks will also

References
211
A1
A2
B1
Fig. 14.13 A 30-year-old with mandibular defi ciency and
orthodontically corrected occlusion underwent chin and mandibular
augmentation with alloplastic implants. A, Pre and postoperative
frontal views. B, Pre and postoperative lateral views. C, Artist’s
rendition of surgery.
B2
Chin and mandibular augmentation with alloplastic implants
C
REFERENCES
1. Farkas L, Hreczko TA, Kolar JC, Munro IR. Vertical and horizontal
proportions of the face in young adult North American Caucasians:
revision of neoclassical canons. Plast Reconstr Surg 1985; 75:328.
2. Farkas LG, Kolar JC. Anthropometries and art in the aesthetics of
women’s faces. Clin Plast Surg 1987; 14:599.
3. Farkas LG, Hreczko TA, Katie MJ. Craniofacial norms in North
American Caucasians from birth (one year) to adulthood. Appendix A.
In: Farkas LG (ed.). Anthropometry of the Head and Face. 2nd edn.
New York: Raven Press; 1994.
4. Rubin JP, Yaremchuk MJ. Complications and toxicities of implantable
biomaterials used in facial reconstructive and aesthetic surgery: a
comprehensive review of the literature. Plast Reconstr Surg 1997; 100:1336.
5. Eppley BL. Alloplastic implantation. Plast Reconstr Surg 1999; 104:1761.

14
AESTHETIC CONTOURING OF THE CRANIOFACIAL SKELETON
212
6. Jelks GW, Jelks EB. The infl uence of orbital and eyelid anatomy on the
palpebral aperture. Clin Plast Surg 1991; 18:193.
7. Yaremchuk MJ. Infraorbital rim augmentation. Plast Reconst Surg 2001;
107:1585.
8. Yaremchuk MJ. Restoring palpebral fi ssure shape after previous lower
blepharoplasty. Plast Reconst Surg 2003; 111:441.
9. Yaremchuk MJ, Israeli D. Paranasal implants for correction of midface
concavity. Plast Reconst Surg 1998; 102:1676.
10. Yaremchuk MJ. Malar implants. In: Atlas of Facial Implants.
Philadelphia: Elsevier-Saunders; 2007: Ch. 7.
11. McCarthy JG, Ruff JG. The chin. Clin Plast Surg 1988; 15:125.
12. Yaremchuk MJ. Improving aesthetic outcomes after alloplastic chin
augmentation. Plast Reconst Surg 2003; 112:1422–1432.
13. Zide BM. The mentalis muscle: An essential component of chin and
lower lip position. Plast Reconst Surg 1989; 83:413.
14. Yaremchuk MJ. Mandibular augmentation. Plast Reconstr Surg 2000;
106:697.
15. Binder W. Submalar augmentation: an alternative to facelift surgery.
Arch Otolaryngol 1989; 115:797.
16. Mittleman H. The anatomy of the aging mandible and its importance
to facelift surgery. Facial Plast Surg Clin North Am 1994; 2:301.
17. Flowers RS. Tear trough implants for correction of tear trough
deformity. Clin Plast Surg 1993; 20:403.
18. Yaremchuk MJ. Facial skeletal reconstruction using porous polyethylene
implants. Plast Reconstr Surg 2003; 111:1818.
19. Zimmerli, W. Waldvogel FA, Vaudaux P and Nydegger UE. Pathogenesis
of foreign body infection: description and characteristics of an animal
model. J Infect Dis 1982; 146: 487–497.
20. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofi lms: a common
cause of persistent infections. Science 1999; 284:1318–1322.

213
CHAPTER 15
Augmentation of Facial Structures with
Autologous Fat
Sydney R Coleman and Alesia P Saboeiro
INDICATIONS AND CONTRAINDICATIONS
Indications
1.
Facial rejuvenation – addresses hollowing, wrinkling and mild
skin laxity.
2.
Change in facial proportion – cheek, chin and mandibular
augmentation.
3.
Reconstruction – hemifacial microsomia, facial atrophy, trauma
and post-surgical tissue defects (including facelifts).
4.
Lipoatrophy secondary to disease – HIV related lipoatrophy.
Contraindications
1.
Poor health prohibiting anesthesia.
2.
Extreme lack of body fat suffi cient for transfer.
3.
Unrealistic patient.
FAT GRAFTING FOR FACIAL
REJUVENATION
The face of youth is full, soft and well defi ned. While traditional aes-
thetic facial procedures that involve cutting and pulling of the skin are
sometimes benefi cial, they do not replace the facial volume that dimin-
ishes with age. Fat grafting offers a permanent correction of the loss
of volume that occurs over time. The idea of what is attractive will
vary from culture to culture and person to person, but facial fullness
is generally associated with youth. The attractive face, therefore, has
a smooth brow and temples, full upper eyelids without excess skin,
smooth lower eyelids, round but angular cheeks, minimal nasolabial
folds, full lips, and a well defi ned chin and jaw line. The aging process
results in predictable changes. With time, the temples begin to hollow
and the upper and lower eyelids defl ate, leaving behind either excess
skin or hollowing of the orbit. A break occurs in the anterior cheek,
fl attening this area and accentuating the nasolabial folds, and the lips
begin to invert. The anterior chin fl attens and the jaw line becomes
less defi ned and angular. The overall result appears as descent of the
skin, but often by restoring the underlying volume alone, an apparent
repositioning of the skin can be achieved. The use of photographs of
patients at a younger age is extremely helpful in understanding the
aging process and what is needed to restore a youthful face.
The cheek is a relatively easy area to visualize in three dimensions.
The immediate, intraoperative results of cheek augmentation with fat
are the most similar to what will be seen as the fi nal result.17 This is
a good area to begin learning and practicing making three-dimensional
changes in the face. On the other hand, the lower eyelid is one of the
most diffi cult areas for structural fat grafting. Irregularities, lumps, and
excess fat can easily be seen through the thin eyelid skin when the
Summary
1. Fat can be grafted successfully to yield long-lasting, natural
contour changes.
2. A variety of aesthetic and reconstructive issues can be
addressed with structural fat grafting.
3. The addition of volume to the face can reverse many signs of
aging that were previously addressed with procedures
involving cutting and pulling of the skin.
4. Fat to be grafted must be harvested gently to preserve the
natural architecture.
5. Fat should be refi ned by centrifugation and decanting to
provide predictable volume changes.
6. Fat should not be stored or frozen for future use.
7. Grafted fat should be placed in very small aliquots using
multiple passes.
8. Strict sterile technique should be maintained during the fat
grafting procedure.
9. Grafted fat should not be molded after placement.
10. Structural fat grafting results in signifi cant bruising and tissue
edema.
INTRODUCTION
With renewed interest in volumetric enhancement for facial rejuvena-
tion, fat grafting is once again gaining popularity. It has been used
successfully for soft tissue augmentation since 18931 and in 1909
Eugene Hollander described a technique to transplant fat using a
needle and syringe.2 In 1926 Miller claimed that grafting fat through
hollow metal cannulas gave a more natural and longer lasting correc-
tion than paraffi n.3 Soon after the introduction of suction curettage of
body fat for contouring, Teimourian and Illouz described the injection
of semi-liquid fat into liposuction deformities4,5 and Chajchir described
injecting suctioned fat into the face.6 Although some of the initial
results were positive7,8 many were not.9,10 Illouz compared the longev-
ity of grafted fat in the face to that of collagen.4 In the 1980s, many
well-respected plastic surgeons denounced fat grafting based on nega-
tive results.11,12 As techniques changed, more positive results were
obtained and surgeons began to realize that grafted fat could result in
long-lasting contour changes.13–16 The technique developed by Coleman
began in 1987 and evolved over the next few years to become a stan-
dard for fat grafting. It emphasizes basic sound surgical techniques
with the gentle handling of tissues to make fat grafting predictable and
reliable.

15
AUGMENTATION OF FACIAL STRUCTURES WITH AUTOLOGOUS FAT
214
swelling resolves. The lower eyelid should be approached with caution
and only after gaining confi dence in other more forgiving areas of the
face.
Augmentation of the lips is a relatively simple procedure, but the
anatomy of an attractive lip is often ignored and the lips are fi lled like
tubes or sausages. A youthful, attractive upper lip has a distinctly
protuberant white roll that tapers off from the Cupid’s bow and
becomes less obvious laterally. Under the Cupid’s bow, the vermillion
of the lip has a well-centered, distinct tubercle. The width of the upper
lip comes from the less-distinct fullness laterally. Between the central
tubercle and the lateral fullness, there is often a concavity or slight
depression.
The lower lip has a slightly protuberant rim, which is less distinc-
tive than the white roll of the upper lip. The fullness and depressions
of an attractive lower lip are opposite to those of the upper lip, with a
central cleft and more fullness laterally. The amount of vermilion
visible is much greater in the lower lip than in the upper lip
(Fig. 15.1).18,19
FAT GRAFTING FOR CHANGE IN FACIAL
PROPORTION
The younger patient will present not with the typical signs of aging,
but requesting a change in the contours of the face. The most com-
monly requested changes in facial proportion are for cheeks that are
more prominent, full and angular; a chin that is more prominent
anteriorly; and a mandibular border that is more angular and well
defi ned. Again, the cheek is an easier place to start learning fat grafting.
The natural cheek prominence should be identifi ed as the malar prom-
inence and the fullness should extend laterally toward the base of the
helix. Some fullness should also be placed over the anterior cheek,
creating a slight ‘apple’ effect.
Augmentation of the chin is accomplished by fi rst placing fat over
the entire anterior prominence of the mandible.20 The shape of the
chin is then sculpted by placing additional fat in two small balls,
leaving a slight central cleft between them. This creates not only a
more prominent chin, but also a shapelier chin.
Mandibular augmentation creates a defi ned border separating the
face from the neck. This is generally considered an attractive look and
can be created by placing fat deep along the periosteum of the man-
dible as well as more superfi cially beneath the skin. The angle of the
mandible should be identifi ed and emphasized if it is not visible. A
continuous line should then be developed from the angle to the chin
(Fig. 15.2).
FAT GRAFTING FOR RECONSTRUCTION
Fat can be placed deep along the facial bones as well as more superfi -
cially beneath the skin to correct many apparent defi ciencies of both
bone and soft tissue. It has been used successfully to correct defects
such as hemifacial microsomia and atrophy, post-traumatic defects,
and post-surgical defects.21 Tissue lost after radical neck dissections
can be supplemented with fat grafting to restore a normal facial appear-
ance. In addition, the fl attening of the posterior jaw line created by
most facelift procedures can be corrected using fat grafts (Fig. 15.3).
Fig. 15.1 Facial aging example
33 year old woman who presented complaining that her lower eyelids were no longer smooth and that her right cheek was indented. Fat
was placed into the lower eyelids and cheeks bilaterally. Preoperative photo (upper) and post-operative photo (lower) 2 years and 9 months
after the procedure.
A
B
A
B
Fig. 15.2 Facial proportion example
40 year old woman who presented complaining about a lack of
pleasing facial contours, asymmetry, small lip, and a weak jaw line.
Fat was placed throughout the face during four surgical procedures.
Preoperative photo (left) and post-operative photo (right) 11 months
after the last procedure.

215
Preoperative History and Considerations
Other patients that are poor candidates are those with an extreme lack
of body fat, such as the serious body builder, or those with anorexia.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
The primary unique consideration for the patient undergoing a fat
grafting procedure is the present and future weight of the patient.
Patients are ideally at their optimal weight and will not fl uctuate sig-
nifi cantly from that weight. Since the transferred/grafted fat remains
viable, it will respond to weight changes as if it were still in its native
site. Patients should understand that if they lose a signifi cant amount
of weight they can lose the correction obtained. Alternatively, if they
gain a signifi cant amount of weight, the fat placed may increase in
A
B
Fig. 15.3 Reconstruction example
26 year old woman who presented with left
hemifacial microsomia secondary to 1st and
2nd branchial arch syndrome. She had
multiple previous reconstructions, including
rib and cranial bone grafts to the mandible, a
silastic chin implant, and a rectus abdominus
free fl ap, but she was still left with a
signifi cant defi ciency on the left side and
noticeable asymmetry. Fat was grafted along
the left cheek and jaw line during two
surgical procedures. Preoperative photo (left)
and Post-operative photo (right) 3 years and 8
months after the second procedure.
A
B
Fig. 15.4 Lipoatrophy example
A 45 year old woman who presented with lipoatrophy of her lower face. Fat was grafted to her nasolabial folds and anterior cheeks.
Preoperative photo (upper) and post-operative photo (lower) 1 year and 2 months after the procedure.
FAT GRAFTING FOR LIPOATROPHY
There is a typical pattern of facial fat loss that occurs in patients who
are HIV positive and who receive certain anti-retroviral medications.
Unlike generalized aging, this loss of fat generally occurs in the buccal
cheeks and is a characteristic of the disease. In addition, these patients
may have loss of fat in the temples and in the periorbital region. All
of these areas can be addressed with fat grafting to restore a healthier
appearance to the patient. (Fig. 15.4)22,23
CONTRAINDICATIONS TO FAT GRAFTING
Like all elective procedures, patients in poor health and those with
unrealistic expectations are not candidates for structural fat grafting.

15
AUGMENTATION OF FACIAL STRUCTURES WITH AUTOLOGOUS FAT
216
volume. Additionally, volume increases have been noted in some
patients treated with anti-retroviral medications.
TECHNIQUE OF FAT GRAFTING
Harvesting
The detailed steps regarding harvesting of tissues have been previ-
ously described in the literature.24–26 The main objective of the harvest-
ing portion of the procedure is to gently obtain intact tissue parcels
that will remain viable during the grafting process. The choice of
harvesting sites is based only on the area of desired contour change,
as no clear correlation has been made between the harvest site and
longevity of grafted fat.27,28 Small incisions are made adjacent to the
harvest site and using a blunt lamis infi ltrator, the tissue is infi ltrated
with 0.2% lidocaine with 1 : 200 000 epinephrine. Even when the
patient is under general anesthesia, the local infi ltration is performed
for hemostatic purposes. Approximately 1 cc of anesthetic is infi ltrated
for each 1 cc of fat to be harvested. Superwet techniques should be
avoided to maintain the architecture of the harvested fat. Fat is then
harvested using a 10 cc syringe attached to a blunt, two-holed Coleman
harvesting cannula. Syringes larger than 10 cc and plunger-locking
devices are not used as these may create too much negative pressure
and damage the parcels of fat. Instead, minimal negative pressure is
created with the 10 cc syringe and the curetting action of the cannula.
The most important consideration regarding harvesting of fat is main-
taining the integrity of the fat cells and the normal architecture of the
tissue. Any mechanical or chemical insult (straining, chopping,
beating, washing) that damages this fragile tissue will result in even-
tual necrosis of the injected fat.
Refi nement
After the fat has been harvested, the cannula is replaced with a Luer-
Lok plug and the plunger is removed. The syringe is then centrifuged
for 3 minutes at 3000 rpm. Centrifugation separates the almost pure
fat from ruptured fat cells that present as an oil layer and the local
anesthetic and blood that present as an aqueous layer. The oil layer
is then carefully decanted off the top and the Luer-Lok is released to
evacuate the lower aqueous layer. Neuropads are used to wick off any
remaining oil and then the fat is transferred into 1 cc Luer-Lok syringes
for placement into the face. This process of gentle refi nement and
removal of oil, blood and local anesthetic allows for more predictable
results, as the volume change is, therefore, secondary only to the
grafted fat. Fat should not be stored or frozen for future use. The
necrosis of the fatty tissue that occurs with freezing will result in
considerable resorption of the fat and the development of surface
irregularities.
Placement
Depending on the extent of surgery, general, regional or local anes-
thesia may be used when fat is grafted. For larger body fat grafting
cases, general anesthesia is preferred. Incisions for grafting the fat
are positioned such that fat can be placed from at least two different
directions. A blunt Type I Coleman cannula is used for the placement
of the local anesthetic as well as the fat. Sharp needles should be used
with extreme care in the subcutaneous planes for injection of local
anesthetic and fat due to the risk of intravascular injection.29 The
infi ltration cannula is attached to a 1 cc Luer-Lok syringe fi lled with
refi ned tissue and the fat is distributed into the tissue planes only as
the cannula is withdrawn. Very small aliquots of fat (0.02–0.1 cc) are
placed with each pass of the cannula such that each parcel of fat is
surrounded by native tissue to ensure access to a blood supply and
stability of the transplanted tissue. The fat should be grafted such that
the desired shapes are formed during the infi ltration of the fat. Because
the fat is integrated into the host tissue, attempts at signifi cant molding
of the fat after placement are usually futile and can cause undesirable
irregularities.
With experience, the surgeon can predict the changes that will
result when refi ned fat is placed in a certain area. However, even with
a preconceived idea of the amount of fat to be placed in any area, the
immediate appearance after grafting is an important indicator of the
fi nal result.
Unfortunately, many variables can alter the appearance immedi-
ately after grafting. The edema caused by the trauma of the blunt
cannula can differ from person to person as well as from area to area.
A hematoma, or even excessive bruising, can also mislead the surgeon.
Muscle movement in the immediate postoperative period also may
affect the stability or longevity of the grafted fat.
Fat grafting in the subcutaneous plane, as well as along the peri-
osteum and into the muscle, has been described. The Coleman tech-
nique of structural fat grafting, however, does not promote the
intentional placement of fat into the muscle, as it appears to cause
a thickening of the muscle that is undesirable, especially in the
lip. When correcting signifi cant bony or structural defi ciencies, it
is usually essential to place fat deep along the periosteum and gra-
dually add additional fat more superfi cially. Placement of fat in the
subcutaneous plane gives a more signifi cant volume change than
the deeper, supraperiosteal grafts, and placement of fat just beneath
the skin can result in an improvement in skin texture over time. Intra-
dermal placement has been discouraged in the past, but has
been revisited recently.30 Using a sharp 22-gauge needle attached to
a 1 cc syringe of refi ned fat, small amounts of fat can be placed intra-
dermally into scars and deep wrinkles. The long-term effect of this
method of placement does not appear to be as reliable as the subcu-
taneous placement with a larger bore cannula, however, and is differ-
ent from the subcision technique described by Carraway.7 Instead of
undermining the area fi rst with a sharp needle and then injecting the
fat, it is recommended that the fat be placed fi rst, followed by the
release of any remaining adhesions or scar tissue using a ‘v-dissector’
or sharp needle afterward.31 This maneuver, however, is traumatic
and may destabilize the fat. It should be used with caution and should
be delayed until the intradermal and subcutaneous placement is
completed.
Optimizing outcomes
●
Harvest fat gently with a 10 cc syringe to maintain intact
tissue parcels.
●
Avoid tumescent techniques.
●
Refi ne the fat using centrifugation and decanting to increase
predictability of results.
●
Place very small (0.02–0.1 cc) aliquots of fat with each
withdrawal of the cannula.
●
Do not attempt to mold the grafted fat, but do ensure that it is
smooth.
COMPLICATIONS OF FAT GRAFTING
Complications of fat grafting can be classifi ed as acute or late. Acute
complications include bleeding/hematoma, the frequency of which can
be lessened with the use of a blunt cannula, and temporary injury to
an underlying nerve or muscle. Fat is not intentionally placed into
muscles, but occasionally edema in the area can inhibit or alter normal
muscle movement. As the edema resolves, patients generally recover
completely.
The most devastating and fortunately rare complication is an
intravascular embolization.29 This has never occurred when using a

References
217
blunt cannula. Therefore, sharp needles are discouraged, except when
placing fat directly into the dermis. In addition, large boluses of fat
should not be injected and injection guns should not be used when
grafting fat.
Late complications include infections, which can result in resorp-
tion of the grafted fat. Strict sterile technique must be employed and
cannulas that penetrate the oral mucosa should be considered con-
taminated and replaced. If lip augmentation is performed as part of a
total facial rejuvenation procedure, it should be performed last. As
previously mentioned, an increase or decrease in the size of the grafted
area secondary to weight gain or loss can occur. Cosmetic concerns
resulting from either too much or too little fat placed in an area as
well as lumps and irregularities can occur. With experience, more
accurate estimations of the correct volume and more precise placement
techniques will be possible. In addition, contour deformities can occur
in the donor site areas and incisions can remain visible for a prolonged
period. Fat must be harvested carefully to avoid irregularities. Incisions
can be lubricated with the oil obtained after centrifugation and/or
revised later. This is not a complete list of complications and more
exhaustive descriptions of potential complications32 and untoward
effects are available.
POSTOPERATIVE CARE
The tissue trauma that occurs with the placement of fat in the manner
described results in a signifi cant amount of bruising and tissue edema.
To help minimize the bruising and swelling, Tegaderm® is placed over
the infi ltrated areas immediately after the procedure and this remains
in place for 3 or 4 days. In addition, cold therapy is employed for 72
hours postoperatively.
Light touch can be instrumental in reducing swelling by encourag-
ing lymphatic drainage. Deep massage, however, should be avoided in
the fi rst weeks after fat grafting. Although it is diffi cult to move the
recently infi ltrated fat, strong directed pressure could displace the fat
and force it into an undesirable area. Recovery from this procedure
usually requires a minimum of 2 weeks and sometimes as long as 6
weeks.32
CONCLUSION
Fat grafting using a blunt cannula has been used by plastic surgeons
for altering the appearance of the face for almost 100 years. This
autologous tissue is completely biocompatible and, therefore, is usually
the safest choice for altering facial volume or contours. Furthermore,
fat grafts can be placed such that they are long lasting, completely
integrated and natural appearing. Concurrent with the development of
fat grafting, our understanding of aging and methods of rejuvenation
have also developed. We now approach facial rejuvenation and facial
proportion with a better understanding of the need for volume to
accomplish the desired changes.
Fat is fragile tissue that may not survive the trauma of harvesting,
refi nement or placement into a recipient site. Each step in the process
has the potential to injure the fat cell or destroy the fatty tissue archi-
tecture. Gentle handling of the tissues and placement of tiny aliquots
of fat is fundamental to the success of this technique. Grafting of fat
in this manner allows for signifi cant contour changes and longevity of
the correction. It also, unfortunately, causes a tremendous amount
of bruising and swelling, which must be emphasized prior to the
procedure.
The outcome of fat grafting is not only surgeon dependent, but also
dependent on the technique used to harvest, refi ne and place the fat.
In addition, the effects of grafted fat differ between recipient sites and
from patient to patient. Because of this variability, the results of fat
grafting can be unpredictable. Directed research will help us to better
understand this variability so that the most consistent results may be
obtained.
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3. Miller C. Cannula implants and review of implantation techniques in
esthetic surgery. Chicago: The Oak Press; 1926.
4. Illouz YG. The fat cell ‘graft’: a new technique to fi ll depressions. Plast
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5. Teimourian B. Repair of soft-tissue contour defi cit by means of
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6. Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and
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11. Goldwyn RM. Unproven treatment: whose benefi t, whose
responsibility? Plast Reconstr Surg 1988; 81(6):946–947.
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14. Coleman SR. Long-term survival of fat transplants: controlled
demonstrations. Aesthetic Plast Surg 1995; 19(5):421–425.
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in aesthetic facial recontouring: sixteen years of experience with 1936
cases. Clin Plast Surg 2000; 27(4):515–543.
16. Trepsat F. Periorbital rejuvenation combining fat grafting and
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Louis, MO: Quality Medical Pub; 2004:237–270.
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1220–1224.
23. Coleman SR. Discussion of treatment of facial fat atrophy related to
treatment with protease inhibitors by autologous fat injection in
patients with human immunodefi ciency virus infection. Plast Reconstr
Surg 2004; 114(2).
24. Coleman S. Hand rejuvenation with structural fat grafting. Plast
Reconstr Surg 2002; 110(7):1731–1743.
25. Coleman S. Structural fat grafting. St. Louis, MO: Quality Medical Pub;
2004.
26. Coleman SR. Structural fat grafting. In: Nahai F ed. The art of aesthetic
surgery: principles & techniques. St. Louis, MO: Quality Medical Pub;
2005:289–363.
27. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer
viability: a quantitative analysis of the role of centrifugation and harvest
site. Plast Reconstr Surg 2004; 113(1):391–395.

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AUGMENTATION OF FACIAL STRUCTURES WITH AUTOLOGOUS FAT
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28. Ullmann Y, Shoshani O, Fodor A et al. Searching for the favorable
donor site for fat injection: in vivo study using the nude mice model.
Dermatol Surg 2005; 31(10):1304–1307.
29. Coleman SR. Avoidance of arterial occlusion from injection of soft
tissue fi llers. Aesthetic Surg J 2002; 22(6):555–557.
30. Coleman S. Facial augmentation with structural fat grafting. Clin Plast
Surg 2006; 33(4).
31. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision)
surgery for the correction of depressed scars and wrinkles. Dermatol
Surg 1995; 21(6):543–549.
32. Coleman SR. Problems, complications and postprocedure care: chapter
4. Structural fat grafting. St. Louis, MO: Quality Medical Pub; 2004:75–
102.

219
CHAPTER 16
Breast Augmentation
Per Hedén
PATIENT AND IMPLANT SELECTION,
INDICATIONS AND CONTRAINDICATIONS
Indications
1.
Developmental breast hypoplasia or asymmetry
2.
Involutional breast deformity as a result of:
a. weight loss
b. pregnancy and breast feeding
3.
Patients with normal breast volume who desire a more
youthful appearance.
Contraindications
1.
Patients with unrealistic expectations or abnormal desires
2.
Psychiatrically or psychologically unfi t patients.
Implant selection should be based on:
1.
patient desires
2.
width of existing glandular tissue and desired breast width
3.
thorax shape
4.
envelope characteristics
5.
amount and shape of glandular tissue.
The reason why a patient seeks breast enhancement may be inborn or
acquired. Indication is frequently divided into the following:
A. Developmental breast hypoplasia or asymmetry;
B. Involutional breast deformity due to weight loss or following
pregnancy and breast feeding.
The third indication may be patients with relatively normal breast volume
who wish to have larger, more youthful breasts. In this group, patients
who are psychologically unsuitable for surgery are more common.
The general public and even the media have many misconceptions
about the typical patient. The stereotype is a young woman who wants
to have bigger breasts. Instead, the typical patient is a professional
woman with children, 30–40 years of age, who does not wish to have
big breasts, but larger, more youthful ones that are in harmony with
her appearance. Mastopexy procedures are common to rejuvenate the
female breast, but do have limitations in achieving the most youthful
appearance in the upper pole. Breast implants can produce a more
long-term and stable youthful upper pole.
CONTRAINDICATIONS
The main contraindications are psychological. Patients must have
realistic expectations of the procedure and understand benefi ts and
risks. Those who do not understand, or are psychiatrically unstable
and have unrealistic expectations are contraindicated. Clearly, a
Summary
To achieve successful breast augmentation results, it is crucial to:
1. understand patient desire and establish realistic patient
expectations
2. not select an arbitrary implant volume
3. measure and analyze dimensions and proportions of existing
breast and thorax
4. select implant width in relation to current and desired breast
width
5. use dimensional analysis during preoperative markings.
Calculate vertical implant position in relation to implants’ base
plate dimensions
6. calculate and mark new nipple to inframammary fold distance
in relation to:

a. base width and projection of the implant

b. amount of glandular tissue

c. envelope characteristics
7. select sub-muscular or sub-glandular implant position
depending on the amount of covering glandular tissue. Use
some type of dual plan submuscular positioning with release
of inferior medial origin in majority of cases
8. commonly use sub-mammary fold approach
9. use local anaesthesia even under general anaesthesia
10. use cutting cautery, avoid blunt implant pocket dissection and
leave loose connective tissue on ribs if sub-muscular position
is selected.
INTRODUCTION
The female breast is a universal symbol of sexuality, motherhood and
femininity today, dating back even to the time of ancient cave paint-
ings. In the 1940s Alfred Kinsey observed that the female breast could
inspire more sexual arousal in men than the sex organ.1 Since its
introduction in 1962, modern breast augmentation with implants has
become one of the most common aesthetic procedures, receiving more
media attention than any other. However, much reporting, especially
in the non-professional literature, has been faulty. More than one
million breast implants are now inserted every year, 250 000 in the
US. Most patients are very satisfi ed with the results.2 Most experience
better psychological functioning and body image; many experience less
anxiety and depression3 and even have better sexual relations with
their partners. However, most women do not seriously contemplate
the possibility of unfavourable results.4 Various complications are pos-
sible and should be seriously considered before undergoing a procedure.
The risk should be minimized by a meticulous preoperative evaluation
and surgical procedure. Selecting the ideal dimensions for implants,
based on biological prerequisites, is crucial.

16
BREAST AUGMENTATION
220
medical history and physical examination have to be undertaken to
rule out health problems that may be contraindications. Older patients
and patients with a genetic disposition for breast cancer should undergo
a preoperative mammogram. General medical conditions such as dia-
betes mellitus and heavy smoking are only relative contraindications.
Radiation therapy is a relative contraindication as it signifi cantly
increases the rate of capsular contraction.
PATIENT AND IMPLANT SELECTION
Patient communication
Previously, decision-making has been relatively arbitrary and based
mainly on the surgeon’s experience without detailed measurements
and analysis. In the last decade this has changed dramatically. Today,
breast augmentation is no longer a ‘volumetric’ procedure, but a
dimensional planning process. With the introduction of form-stable,
high-cohesive silicone gel implants, dimensional planning has become
crucial (Fig.16.1B). A low cohesive or liquid implant fi ller (Fig. 16.1A)
can be deformed and made to fi t in a poorly planned implant pocket,
but with form-stable devices this is no longer the case.
The fi rst step in implant selection is the understanding of the
patients’ expectations and desires. They must be told what the tissue
limitations are and the drawbacks in selecting large implants should
be clearly explained. During patient consultation, a full size mirror is
useful to show the patient present and expected breast dimensions.
Displacing the breast medial and lateral can easily demonstrate width
limitations and the projection can be demonstrated with a calliper and
by cupping the hand at the expected projection of the new breast. To
use sizers in a tight-fi tting sports bra may give the patient a certain
feeling for the expected volume, but unless the patient is completely
fl at, this is of limited use in describing dimensions. The patient must
understand that a condition for achieving the demonstrated breast
dimensions is that no capsular contraction occurs in the postoperative
phase (Fig. 16.2A–D). A severe capsular contraction could alter dimen-
sions considerably, especially if low cohesive fi llers are used (Fig.
16.3A–C & Fig. 16.4A & B).
Selection of implant fi ller,
shape and surface
Only silicone gel and saline have been used long term and can be
regarded as safe and proven. All implants consist of a solid silicone
envelope. The surface may be textured or smooth. In the sub-glandu-
lar position, textured implants are favoured, whereas with sub-muscu-
lar placement, implants can be either smooth or textured (Fig. 16.1A
& B). The benefi t of silicone as a fi lling material is its softer, more
‘natural’ consistency and form (Fig. 16.5A–D). Saline implants have a
Fig. 16.1 A, A responsive, smooth silicone gel
implant. The so-called ‘tilt-test’, moving the
implant in vertical position shows the
instability of the upper pole of the implant.
This results in deformation and irregularities
of the implant. It is likely that this results in
increased envelop wear and possible supture
long-term. B, A high cohesive, form-stable
implant will retain the shape of the upper
pole during a tilt-test.
A
B
A
B
C
D
Fig. 16.2 Patient with a right sided capsular
fi brosis and soft left breast. Note that the
circumferential shrinking of the capsule
shifts the implant in a cranial direction.
A, B and C, 1 year after the augmentation.
D, 6 months after the augmentation. Compare
fi gure D to fi gure C and note how the implant
has shifted in a cranial direction due to the
capsular fi brosis.

221
Patient and Implant Selection
higher rupture-risk, especially if these are not overfi lled. However, the
latter increases breast fi rmness. Silicone gel is available in a form-
stable version; the round implant will retain its shape in standing
position, as opposed to saline or standard responsive silicone gel
implants, which become more position dependent. An anatomical
high cohesive form-stable silicone implant will also maintain its
anatomical shape in all positions. Form-stable silicone implants
have a very low incidence of rupture.5
Selections of implant dimensions
Regardless of implant type, a dimensional analysis should be under-
taken. If high cohesive form-stable devices are used this is crucial, as
these implants cannot be deformed. The most important dimension to
defi ne is the ideal implant-base width, which should be measured with
a calliper. Existing glandular tissue width should also be measured. If
an implant with a base width exceeding the existing breast width is
selected, the risk of implant edge palpability and visibility is increased
(Fig. 16.6A–D). However, with a very narrow breast base width, like
that in tuberous and contracted breasts, the existing width must be
exceeded for a natural appearance. The new desired inter-mammary
distance is usually about 2–3 cm and laterally the anterior axillary line
should be respected. Measuring the ideal width of the desired new
breast provides information on ideal implant width if the tissue-cover
is subtracted (Fig. 16.7). The covering tissue should be measured with
a pinch-test at the expected inner border and at the lateral border of the
new breast. These measurements should then be added together and
divided by two, as a pinch is a double-fold of tissue. Subtracting the tissue
cover from the ideal breast width provides the ideal implant width.
From the implant manufacturers’ charts the implant dimensions are
found and the upper border of the implant can also be calculated. This
is done by elevating the arms 45º above the horizontal plane, simulat-
ing the expected, ideal nipple position after a correctly performed aug-
mentation (Fig. 16.8A–D). This maneuver can be used to estimate
where the upper border of the new implant will be, as half should be
located above the nipple areola complex. This can be a useful guide in
selecting the ideal implant shape and estimating the upper pole appear-
ance of the augmented breast. When selecting implant projection, this
is highly related to the tissue characteristics and to the patient’s desires.
The selected projection together with the base dimensions of the
implant supplies the implant volume. Implants are thus selected as a
result of the dimensions of the ideal new breast and implant.
Preoperative history and
psychological considerations
Patients who are unsuitable for surgery must be identifi ed preopera-
tively. Andersson has proposed a number of questions that, if answered
positively, should result in a further appointment before surgery as
A
B
C
Fig. 16.3 A, After subglandular implantation in thin patients breasts have an unnatural appearance compared to sub-muscular implantation.
B, Illustrates the implant with capsule on the left side and without on the right side. Only limited degree of capsular activity is noted in
spite of the unnatural appearance in Figure 16.3A. C, After exchanging to implants in a new submuscular pocket.
A
B
Size of implant pockets
Fig. 16.4 A, an anatomical high cohesive form-stable implant
should have a snug implant pocket (illustrated on the left breast of
A). B, shows the larger size of the implant pocket to allow free
movement of the implant. When these breasts develop capsular
contraction the implant pocket shrinks circumferentially, which
means more cranial movement of the implant. Low cohesive fi llers
will also deform more to a round spherical shape, reducing the
width of the breast, but increasing the projection (illustrated on the
left side of B).

16
BREAST AUGMENTATION
222
outlined in Table 16.1.6 During the evaluation, it must be stressed that
breast augmentation complexity varies greatly. Tuberous breasts, severe
ptosis, secondary augmentation cases and pronounced asymmetries
are more diffi cult to correct.
OPERATIVE TECHNIQUE
Relevant surgical anatomy
The appearance of the female breast is greatly affected by various
factors, particularly heredity. Glandular tissue is covered with a fat
layer above the Scarp’s fascia and the amount of fat interspersed in the
glandular tissue varies greatly. This part of the breast is relatively
unimportant from an anatomical standpoint when it comes to per-
forming breast augmentation surgery, as implants are always placed
under the glandular tissue. The most important structure germane to
breast augmentation is the pectoralis major muscle. This is a strong,
predominant fl eshy muscle, tendinous only at its insertion into the
crista tubercule of the humerus. The pectoralis major has a fairly thin
fascia, stronger and more distinct in the upper pole of the muscle. This
is relevant to a sub-fascial breast augmentation. The pectoralis major
muscle origins in three distinct parts, fi rst along the sternal half of the
clavicle, second on the ventral surface of the sternum and costal
A
B
C
D
Fig. 16.5 A and B, Preoperatively, before
secondary breast augmentation; note
unnatural appearance with round saline
implants. Inappropriate implant dimensions
to chest width selected; implant base is too
narrow with too large intramammary
distance. C and D, After exchanging to
form-stable anatomical implants of adequate
base dimension.
A
B
C
D
Fig. 16.6 Patient after breast augmentation
with oversized round saline implants. The
implant is too wide with apparent implant
edges (A) and clear visibility in side view (D)
with prominent rippling when patient bends
forward (B). Also with excessive implant
width the appearance of the covering
pectoralis muscle is artifi cial and deformed
during muscle contraction (C).

Operative Technique
223
The width of the desired breast
Desired breast width
Tissue cover
Desired breast width
- Tissue cover
= implant width
Fig.16.7 The width of the desired breast should be measured
with a calliper usually leaving an inframammary distance of
approximately 2–3 cm. The tissue cover should be measured with a
pinch test in the medial and lateral pole of the estimated breast
implant border.
Table 16.1 List of questions that, if answered affi rmatively,
warrants additional patient assessment
Does the patient have diffi culty describing the desired change?
Does the patient have only a minimal deformity?
Is the patient’s support system (family and friends) opposed to
the procedure?
Does the patient display bizarre behaviour suggestive of possible
schizophrenia or psychosis?
Does the patient have unreasonable expectations, make frequent
demands of surgeon and/or staff and displace a sense of
urgency?
Does the patient appear extremely depressed or anxious?
Is the patient in the midst of a major life-crisis or change?
Has the patient had a history of dissatisfaction with cosmetic
surgery or frequent cosmetic procedures?
Does the patient have concerns regarding gender sexual identity
issues?
A
B
C
D
E
Fig. 16.8 A–E, Before and after breast augmentation with form-stable anatomical implants. Dual plane III submuscular implantation was
performed and due to contracted lower pole of the breast the gland was divided radially in the lower pole to permit good shape of the lower
pole of the breast. A higher projection (moderate height and extraprojection implant – MX model) implant was also used to minimize the risk
for ‘double bubble deformation’ of the lower pole of the breast. With arm elevation 45° (B) a line drawn from the nipple to the sternum
(NS–line). This simulates accurate nipple position after the augmentation. In the midline measured distally form the NS line the lower ideal
border of the implant calculated in relation to base plate dimensions of the implant (half the implants height)
cartilage numbers II–VI, and thirdly with a slip on the aponeurosis of
the external oblique abdominal muscles. It is of importance to note
that the width and length of the muscle has a great interindividual
variation. The innervations come from the brachial plexus in the
axilla. The muscle is a powerful adductor, which fl exes, adducts and
rotates the arm medially. The pectoralis minor muscle originates from
ribs II–V, near the cartilage–bone junction, so the muscle is more
lateral in its origin than the pectoralis major. This is important when
performing a sub-muscular breast augmentation where the dissection
plane should be between the pectoralis major and minor, making it

16
BREAST AUGMENTATION
224
easiest to dissect from medial to lateral between them. The innerva-
tions to the breast come from thoracic segments III–VI. Sensory reduc-
tion in the breast after augmentation is a common initial complaint.
Most patients do not suffer from this after the initial 6 months of
healing, but they should be informed of the possibility of chronic
sensory reduction, most commonly related to the lateral intercostal
branches coming from the upper lateral quadrant. To minimize risk,
large implants should not be selected and the sharp dissection in the
direction of the axilla should be minimized. This is the only part of
the dissection that should be blunt.
Preoperative markings
Accurate and detailed preoperative marking is essential. Two impor-
tant questions should be addressed. The fi rst is the vertical location
of the implant on the chest wall. If implants are too high the nipple
areola complex will point downwards and the upper pole will be too
full. If implants are placed too low the breast will be too full in the
lower pole. Ideal nipple projection is centrally on the implant, thus the
base dimension of the implant is important. Usually, half should be
located above the nipple areola complex in the augmented breast and
half below it. The ideal postoperative position of the nipple areola
complex can be simulated with the arms elevated 45º above the hori-
zontal plane; in this position, a line from the nipple to the sternum
can be drawn (NS-line) (Figs 16.8A–E & 16.9). As the tissues in the
midlines are relatively fi xed, measurements of ideal implant height are
better done along the sternum. With arms lowered, half of the implant
height, or for round implants half the diameter of the implant, is
measured distally, and at the distal point a horizontal line is drawn
laterally, representing the implants’ lower pole (ILP-line; Fig. 16.10).
In patients with asymmetric nipple heights, this will result in different
heights of the ILP-line, but the implant will be adequately positioned
in relation to the nipple areola complex.
Secondly, the ideal amount of skin in the lower pole of the aug-
mented breast should be calculated; how long should the nipple-infra
mammary fold distance be and, if a sub-mammary fold incision should
be utilized, where should this incision be placed? Unfortunately, it is
seldom recognized that the amount of skin in the lower pole of the
breast is greatly affected by the three factors: the width and projection
of the implant; the amount of glandular tissue and the characteristics
of the envelope. Higher projecting implants with larger base circumfer-
ence necessitate longer nipple inframammary fold distance. The ideal
nipple to inframammary fold distance in the augmented breast is equal
to the distance between the ideal nipple projection point on the ventral
surface of the implant measured down to the implant’s lower pole
(LVC), plus the added distance for the amount of glandular tissue that
the patient has preoperatively (Fig. 16.11A & B). The ideal amount of
skin between the nipple and the new inframammary fold is calculated
by adding the implant’s lower ventral curvature (LVC) and the distance
between the nipple and the ILP-line with arms elevated 45º above the
horizontal plane. Subtracted from this addition is half the implant
height. The implant’s lower ventral curvature is today only available
from some manufacturers, but can also easily be calculated with a tape
ruler measuring the curvature between a vertical (implants projection)
and horizontal axis (implants half baseplate of height for anatomical
ones) marked on a piece of paper. Added to this the second number is
obtained by elevating the arms 45º, measuring between the nipple and
the previously marked ILP-line, and simultaneously compressing the
glandular tissue to simulate the effect of the implant on the glandular
tissue. Adding this N-ILP-measurement with the LVC (lower ventral
curvature) of the implant, and subtracting half implant height provides
the ideal distance between the nipple and the inframammary fold.
When marking this distance on the breast tissues should be stretched
maximally, simulating a tissue stretch and considering envelope char-
Elevation of the nipple areola complex
Fig. 16.9 A correctly performed breast augmentation creates an
elevation of the nipple areola complex.
Vertical location of the implant on the chest wall
Example NS-ILP measurements
Style 410 MM 280
Height of implant 11.1 cm
Mark nipple-sternum line (NS) with arms elevated
1/2 height 5.6 cm
Measure distally implant half height
(or radius for round implants) 5.6 cm
Mark lower pole of the implant (ILP)
Fig. 16.10 To plan the vertical location of the implant on the chest
wall should be calculated based on the dimensions of the implant.
The way to do this is to elevate the arms 45° above the horizontal
plane and draw a line between the nipple and the sternum (NS).
This arm elevation simulates the nipple position after the
augmentation. By lowering the arms and measuring distally along
the sternum (where the tissues are fi xed) half the height of the
implant or the radius for round implants defi nes the vertical position
of the lower pole of the implant. From this distal marking in the
midline a horizontal line is marked to illustrate the lower pole of the
implant (ILP line).

Operative Technique
225
acteristics. The fi nal step is to mark the location of the upper pole of
the implant and measure tissue covered here. A pinch-test is done and
if the pinch is below 2–3 cm (equal to a tissue cover of 1–1.5 cm) muscle
cover in the upper pole of the implant is recommended (Fig. 16.8A–E).
These markings and measurements7 (the Akademikliniken or AK
method) by the author is a more detailed preoperative planning than
traditionally used in breast augmentations. This has been developed for
form stable anatomical implants but the basic principles of this method
is equally applicable for smooth, non form stable and round implants.
Sub-muscular versus sub-glandular
implant placement
Indications for both sub-muscular and sub-glandular implant positions
exist and the decision should mainly be based on the tissue cover.
With the preoperative marking described above, it is easy to measure
where the upper implant pole will be located. A pinch and measure-
ment of the tissue with a calliper provides information for implant
positioning. If the pinch is below 2–3 cm, this is equal to a tissue cover
of 1–1.5 cm and a sub-muscular placement is recommended. With a
pinch thickness of more than 4 cm, sub-glandular placement may
produce favourable results as such breasts usually are large and a sub-
glandular position of the implant may provide more natural aging with
gradual ptotis of the breast. Benefi ts of sub-muscular implant position
are that the implant edges are better covered, resulting in less implant
edge visibility. It is also less likely that the tissues will become atro-
phied due to the pressure of the implant. It appears that sub-muscular
placement has better long-term aging compared to sub-glandular
implants, especially in smaller breasts. Advantages of sub-glandular
placements are that the breasts will have no movement during pecto-
ralis muscle activity and a more natural appearance is produced in the
ptotic breast. In the tuberous, contracted breast the risk for double
bubble deformity in the lower pole is minimized. Sub-glandular implan-
tation is less painful during the initial hours after surgery. The draw-
backs of sub-glandular implant positioning can be minimized if the
thin pectoralis major fascia is included in the elevated gland. Subfacial
implantation is commonly favoured above sub-glandular.8
With the modifi cations of sub-muscular implant techniques, this
implant position is more common than sub-glandular/sub-facial. By
placing the implant in dual plane position (Fig. 16.12A–D), where only
the upper pole of the implant is covered with the muscle, the draw-
backs of sub-glandular implantation, such as animation during pecto-
ralis muscle activity, can be minimized.9,10
Incisional approach
The length of the incision depends on the type and size of implant
used. Saline fi lled ones can be inserted through a 3–4 cm incision,
whereas form-stable silicone implants necessitate a 4.5–6 cm incision.
Four different approaches have been described. Sub-mammary fold
incision was fi rst used in the 1970s, this was followed by a periareolar
and transareolar incision.11 In the 1970s transaxillary implantation
was also popularized.12 This was followed by the description of trans-
umbilical approach for implant insertion.13 Saline implants must be
used through the transumbilical route and smooth implants are easier
to implant through the axilla. According to the preoperative markings
described above, the sub-mammary fold incision has been modifi ed
and this ‘new’ sub-mammary fold incision has several advantages.
The new sub-mammary fold incision
By the exact calculation of the ideal distance between the nipple and
the new inframammary fold, the ideal position of the sub-mammary
Lower ventral curvature (LVC)
Posterior surface
of the breast (X)
Convex surface
of the breast (Y)
Implants lower pole (ILP)
In an augmented breast the nipple to inframammary fold distance (N-IMF) = LCV + N-ILP−½ implant height
N-IMF
A
B
+
Distance between the nipple and the new inframammary fold
Fig. 16.11 The ideal distance (= amount
of skin) between the nipple and the new
inframammary fold should be calculated
based on the lower ventral curvature (LVC)
of the implant, measured from ideal nipple
projection point on the ventral surface of the
implant to its lower pole, plus the difference
between the posterior surface of the breast
(X) (this is equal to half the height of the
implants) and the convex surface on the
breast (Y) measured between the nipple and
the implant’s lower pole (previously marked
ILP line) with the arms elevated 45° above
the horizontal plane.

16
BREAST AUGMENTATION
226
fold incision can be calculated (see markings above). A major reason
for the previously bad reputation of the sub-mammary fold incision
was that resulting scars were not exactly calculated and not placed
in the new position of the sub-mammary fold. Arbitrary location
of the incision results in worse sub-mammary scarring. The sub-
mammary fold incision offers several advantages: less risk for sensory
disturbances that may be pronounced in the periareolar and the axil-
lary approach; less contamination of the implant through the sub-
mammary fold incisions; and easy inspection and palpation of the
implant pocket. The latter is very important if form-stable devices
are used, where it is crucial to position the implant correctly and to
avoid buckling and irregularities of the implant edges. It is easy to
control the exact position of the implant through the sub-mammary
fold. Dual plane dissection and the division of the pectoralis origin of
the pectoralis muscle is also easier to divide than through the axillary
and the periareolar incision (Fig. 16.13A & B), giving superior control
of the sub-mammary fold, especially if the scarpas fascia is fi xed to the
thoracic wall when creating the new fold (Fig. 16.14A–C).
The incision is made with a scalpel and dissection is carried on
with cutting cautery (Colorado® Tungsten tip and the Valley lab Force
FX® cautery in spray and blend mode facilitates a bloodless dissec-
tion). The dissection is vertical, exposing the thoracic fascia. Dissec-
tion proximal along this fascia creates a lower sub-glandular pocket.
In sub-muscular positioning the pectoralis major muscle’s lower origin
is exposed and in dual plane I technique the muscle is elevated together
with the gland. More commonly used is the dual plane II, where the
Dual plane I
Dual plane II
Dual plane III
Dual plane IV
Sub-muscular dissection
Fig. 16.12 Sub-muscular dual plane implant positioning. In dual plane I dissection, the origin of the pectoralis muscle is elevated together
with the breast without sub-glandular dissection proximal to the muscle division. This does not permit lateral retraction of the muscle and
produce less favourable animation during pectoralis activity. In dual plane II dissection a subglandular pocket is created in the lower pole of
the breast up to the level of the nipple areola complex. The origin of the pectoralis muscle is detached distal to this area creating a weaker
fl ap of the pectoralis muscle in its inferior pole. In dual plane III dissection the subglandular plane goes above the nipple areola complex and
the muscle is divided as in dual plane II. This procedure is favored in slightly ptotic breasts. In dual plane IV dissection the subglandular
dissection is somewhat more extensive than in dual plane III, and the muscle division is higher and more parallel to the fi bres of the
pectoralis major muscle. Note that the medial part of the muscle dissection still should stay well below the nipple plane. The solid red line
indicates the muscle division, the dotted red line extent of sub-glandular dissection and the black dotted line the nipple sternum line with
arms elevated 45° above horizontal plane (NS).

Operative Technique
227
sub-glandular pocket is created up to the areola plane. The muscle is
then divided distally from its lateral border, cutting it horizontally
towards the sternum. The muscle is elevated with a cutting cautery.
The muscle is divided obliquely, parallel to the chest wall, to minimize
the risk of entering between the ribs and intercostal muscles. When
entering the sub-muscular plane, the loose connecting tissue on top
of the ribs is exposed and this tissue should be left intact on the ribs,
minimizing seroma formation and pain, and facilitating postoperative
mobilization. The whole dissection is carried out with a cutting
cautery. Blunt dissection should be avoided as this increases trauma,
pain and seroma. The dissection is fi rst done in the proximal and
medial part of the pocket, and from this medial dissection the lateral
extent of the pocket is made, minimizing the risk of entering under-
neath the pectoralis minor muscle. The only part of the implant pocket
that could be blunt is in the direction of the axilla, minimizing trauma
to the sensory innervations of the nipple areola complex. The size of
the pocket depends on implant type; form-stable textured implants
should have an implant pocket that fi ts snugly, approximately 0.5 cm
wider on each side than the implant base width and 1–2 cm in the
proximal direction. Smooth implants move more freely in the implant
pocket and the implant pocket can be bigger. The medial inferior origin
of the pectoralis muscle is released, curved in a proximal direction to
the level of the nipple areola complex.
In dual plane III dissection, the sub-glandular pocket is more
extensive, passing the level of the nipple areola complex followed by
similar muscle dissection as described for dual plane II dissection,
above. In dual plane IV dissection,7 the extent of the sub-glandular
part of the pocket is similar to the dissection in dual plane III, but the
muscle is divided from the lateral border at the level of the nipple
areola complex, more parallel to the fi bres (Fig. 16.12A–D). It is impor-
tant not to divide the medial origin of the pectoralis muscle higher
than the NS-line. Muscle division, inferior-medially, should stay
1–2 cm below the NS-line (see markings above). In sub-glandular dis-
section, elevation of the pectoralis major fascia, together with the
elevated breast, minimizes implant edge palpability and visibility in
the upper pole.
Axillary approach
The incision in the axilla should be planned at the vertex or possibly
1 or 2 cm medial to it. The incision is made along the skin creases,
perpendicular to the length of the axilla. The axillary approach can be
used for sub-glandular placement or sub-muscular positioning. No scar
A
B
Fig. 16.13 A, Oblique view after
submuscular implantation via axillary
incision. B, During pectoralis muscle
contraction irregularity in the lower pole is
seen due to inadequate muscle release,
which is much more common via the axillary
approach than via the submammary fold,
where more control of the muscle division is
possible. All the different muscle divisions
described in Figure 16.13 are not possible to
perform via the axilla.
A
B
C
Fig. 16.14 A, B and C, A patient with a well healed axillary scar and also submammary scar after a secondary breast augmentation. Note
that the submammary scar is relatively fi xed to the inframammary fold even during arm elevation (C).

16
BREAST AUGMENTATION
228
is present on the breast; usually it is well hidden and fairly incon-
spicuous in the axilla. Disadvantages include that the dissection is
blind during the most important part and the view of the inferior-
medial muscle division is more technically demanding. Use of an
endoscope facilitates the muscle division, but the detailed different.
Dual plane dissection, as described above, is not possible. It is also
diffi cult to control implant folds and rotations, if form-stable devices
are used. Implants are more contaminated through the sweat glands
in the axilla and sensory nerve (the lateral thoracic) or sentinel node
affection is possible. The surgeon does not have the same control of
the shape of the lower pole of the breast as in sub-mammary fold
approaches (Figs 16.13A & B &16.14A–C).
After scalpel incision, dissection is carried out with a cutting
cautery as described for the sub-mammary fold approach, above. The
lateral border of the pectoralis minor is palpated and easily identifi ed.
The dissection is carried out immediately under the muscle in a
medial-inferior direction. The plane between the pectoralis minor and
major is identifi ed and dissection is carried out between them. Sharp
dissection under inspection is diffi cult for the rest of the dissection
plane and this is often done bluntly, creating more traumas and bleed-
ing. Endoscopic assisted dissection improves the quality and control
of the division of the inferior-medial origin of the muscle, but is less
controlled as under dissection via the sub-mammary fold.
Transareolar/periareolar approach
This incision has been widely used. It creates a well-hidden scar and
gives better access to the sub-glandular and sub-muscular plane. The
origin of the pectoralis muscle can be visualized and divided. Disad-
vantages include more contamination and sensory nerve affection than
the sub-mammary fold incision and it is harder to inspect the whole
implant pocket. The size of the areola also has to be at least 3 cm in
diameter to insert a medium-sized implant. Many patients and sur-
geons feel that the periareolar scar is more obvious than a well-hidden
scar in the sub-mammary fold.
Incision is made with the scalpel and then continued with a cutting
cautery and a Colorado tip, either in the Scarpas fascia plane passing
around the gland and retracting in a proximal fashion or straight
through the gland.
Implant insertion
After careful control of the haemostasis, the implant can be inserted.
Prior to this, drains can be placed; usually through the axilla. However,
with the dissection technique described above for the new sub-
mammary fold incision, bleeding is usually minimal and no discharge
is seen in the drains. The author has, therefore, abandoned the usage
of drains in almost all primary augmentation cases. A ‘no touch tech-
nique’ is recommended, where the surgeon changes the gloves and is
the only one to touch the implant during insertion. The assistant
retracts the gland with a long retractor during insertion. When using
textured implants lubrication may be recommended. In most cases
soaking the implant in saline solution is suffi cient. An anatomical
form-stable device is easier to insert at 90º, where the tip is rotated in
and then right and left sides are wriggled into the pocket. When the
implant has been placed into the pocket the edges should be palpated
and controlled so there are no bucklings and irregularities. This is
especially important if form-stable devices are used. An anatomical
device should also be controlled regarding position. Marking dots indi-
cating the vertical axis of the implants are present in most anatomical
devices.
Incision closure
The pectoralis fascia is usually closed with an absorbable suture in the
axillary approach, followed by sub-cuticular stitching. In the periareo-
lar approach the dissected gland is usually left open, but can be closed
with an absorbable stitch. The new sub-mammary fold incision can
be utilized to mark the new sub-mammary fold, resulting in a less
conspicuous scar and a better shaped lower pole (Figs 16.14B & C &
16.15). A good grip in the thoracic fascia is taken along the ILP line
with an absorbable suture (Monocryl or Monocyn 3/0), passed through
the tissues on top of the Scarpas fascia below and above the incision.
Usually, three stitches are inserted, one in the midline left untied,
while the two lateral ones are tightened. This is followed by a deep
dermal ridge suturing with good strong bites of the dermis far away
from the wound edge and deeper at the immediate wound edge. This
creates a ridging effect and a more relaxed incision line, creating more
inconspicuous scars. A sub-cuticular suture is then inserted. Absorb-
able monofi lament sutures are favoured in all layers.
Optimizing outcomes
One has to:
1. create realistic patient expectations:
a. avoid oversized implants
b. respect limits of existing thorax and breast
c.
select adequate implant width
2. plan the surgery carefully:
a. calculate ideal vertical implant position
b. calculate ideal amount of nipple inframammary fold skin,
by adding implants at the lower ventral surface curvature
(LVC) and the distance needed for the amount of
glandular tissue (usually between 1 and 3 cm)
3. favour sub-mammary fold incision in majority of cases
4. always use local anaesthetics circumferential along implant
border limits
5. use dual plane implant position in most cases
6. use sub-facial implantation, which is preferred over sub-
glandular if tissue pinch in upper pole of implant is more than
4 cm
7. use cutting cautery with sharp tungsten needle
8. preserve loose connective tissue on ribs in sub-muscular
implant positioning
Fig. 16.15 Right breast closed with suture between Scarpas fascia
and thoracic wall to fi x the incision to the new inframammary fold.
Compare to the left side where only Scarpas fascia has been closed,
this side moves much more when the breasts are pulled in a cranial
direction.

229
Complications and Side Effects
9. avoid blunt fi nger dissection with possible exception of lateral
in the direction of the axillary
10. engage in careful control of hemostasis and make sure that the
patient is normotensive before the wounds are closed
11. in sub-muscular placement, divide inferior-medial origin of
pectoralis major muscle
12. plan carefully medial muscle division, always well below
nipple plane.
13. use a ‘no touch’ technique during insertion
14. check implant’s position on thoracic wall, palpate around
edges, avoid creases and buckles
15. in submammary fold incisions, emphasize the fold by suturing
of Scarpas fascia to thoracic wall
16. use deep dermal ridge suturing in two layers to maximize fi nal
scar appearance
17. encourage early mobilization with arm elevation above head
directly after surgery
18. recommend long time surgical taping of scar (up to 6 months
3 M micropore tape).
COMPLICATIONS AND SIDE EFFECTS
Oversized breast augmentation adds to the frequency of complica-
tions14,15 (Fig. 16.6A–D). One has to avoid operating on patients who
expect exact results and be careful in planning breast augmentation in
tuberous breasts, where large asymmetries are present and if the breast
is ptotic with poor tissue quality. Surgical complications with bleeding,
pneumothorax and nerve damage could be minimized with careful
planning and a meticulous surgical technique.
Early and late postoperative complications
Hematoma
This is an uncommon complication if a meticulous technique is used,
but occurs in approximately 0.5–2% of cases.16–18 Hematomas should
be evacuated, as even small hematomas may contribute to capsular
contraction and wound dehiscence.
Seroma
Blunt dissection adds to the risk of seroma formation. With sharp
dissection and by leaving the loose connective tissue on the ribs this
problem can generally be avoided.14 Seromas may also occur late and
be related to a sub-clinical infection (Fig. 16.16B). These should be
drained and cultures taken before antibiotics are administered.
Infections and septic shocks
Patients receiving implantations should receive prophylactic antibiot-
ics. For non-allergic patients the antibiotic of choice is fl ucloxacillin,
ideally by IV, 20 minutes preoperatively. Giving antibiotics days before
surgery or for longer periods post operatively is not indicated. One dose
of fl ucloxacillin is suffi cient. For patients with penicillin allergy, clinda-
mycin is the preferred drug. This regime almost entirely eliminates
the risk for infections. If these occur, it is usually because of poor
surgical techniques during wound closure. Infections should normally
be treated with implant removal and a longer healing period before
new implants are inserted.19
Asymmetries and implant malposition
Meticulous planning and surgical technique minimizes risk, but cap-
sular contraction or poor tissue adhesion of anatomical textured
implants may result in malposition or rotation. To minimize this risk,
the pore size of the textured surface should be larger than 300 μm20,21
(Figs 16.16A & B & 16.17A–D).
Implant visibility, rippling, synmastia, perforation
and implant extrusion
These are uncommon, but if implants are placed in the wrong position
in relation to the covering muscle, with too poor tissue cover and/or
are excessively large, they may be seen (Fig. 16.6A–D).
Double bubble deformity
This type of deformity of the lower pole of the breast may occur if
the implant has to be placed signifi cantly lower than the inframam-
mary fold and the glandular tissue is contracted or tuberous. In a
contracted breast with a short nipple inframammary fold distance,
an implant with a dimension that exceeds the natural boundaries
of the breast is usually necessary. To minimize the risk for double
bubble deformity the gland has to be modifi ed via radial incision or
a creation of a glandular fl ap, to optimize the transition between
implant and gland. Higher projecting and form-stable implants (e.g.
A
B
Fig. 16.16 A, In-growth of fi brous capsule into the surface of textured implant with pore size larger than 300 μm. Note the Velcro-like
adhesion between the capsule and implant. B, Non-adhesion of an implant capsule to a textured implant surface. A mucus-like fi lm is
present on the implant surface and this is a prerequisite for rotation of the implant.

16
BREAST AUGMENTATION
230
Inamed Style 510 implants) also minimize the risk of double bubble
deformity.
Deformations during pectoralis muscle contraction
For a natural-looking lower pole of the breast it is important to divide
the origin of the pectoralis muscle, as above (Fig. 16.18A–E). By dual
plane dissection II–IV, deformations of the breast during muscle con-
tractions are minimized. It is important not to divide the pectoralis
muscle too high along the sternum. The medial division should always
end well below the height of the nipple areola complex. Especially in
ptotic breasts, it is easy to over-dissect the inferior medial origin of the
muscle. The preoperative markings of the nipple sternum lines (NS)
are a valuable guideline.
Interference with the postoperative investigations
Breast implants always make mammograms more diffi cult to inter-
pret, but by using, for example, Eklund’s examination, glandular tissue
can be examined accurately. Magnetic resonance imaging (MRI) is the
most reliable way of investigating both the implant and the glandular
tissue.22,23
Capsular contraction
This is the most common late complication.16,18 The frequency varies
depending on the implant’s position. Most studies confi rm that sub-
muscular positioning minimizes capsular contractions, as do textured
surfaces, especially in the sub-glandular plane. With modern techniques
the frequency of capsular contraction is approximately 5–10%. This may
vary from a slight fi rmness to a very hard, deformed and cold breast.24
Implant rupture
All implants may rupture, but the risk for this is greatly related to the
generation of implant used and the duration of implantation. Genera-
tion two implants, mainly used in the 1970s, have a relatively high
risk for rupture after more than 10 years.25,26 Third generation implants
with a mean age of 11 years have been found to have a worst-case
rupture prevalence of 8%27 (Fig. 16.19A). It appears that form-stable
implants with high cohesive silicone gel have a very low rupture fre-
quency, but these have only been used since 1994 and long-term risks
are not fi nally proven. Implantation times between 5 and 9 years show
risks of approximately 1%5 (Fig. 16.19B). Extravasation of silicone gel
is uncommon and highly related to closed capsulotomy.23,24 This
manoeuvre should be avoided.
POSTOPERATIVE CARE
Antibiotics
These are not needed postoperatively if signs of infections are not
present.
Drains
With meticulous technique and sharp dissection with a cutting cautery
drains can be avoided without negative effects in most cases. If drains
are inserted they are taken out through the axilla and vacuum is
applied. Most patients do not need drains after 24 hours, as drainage
is normally less than 50 ml per 24 hours.
Dressings
Surgical tape, Micropore® or Steristrip®, is placed directly on the wound
and no other dressing is usually needed. A sport bra may be useful to
minimize implant movement, especially if form-stable implants are
used. Smooth-walled saline implants should be moved around with
massage. For patients with large natural breasts, a bra should be used
after the initial 3 weeks of healing, whereas patients with small natural
breasts do not need a supportive bra after 3 weeks.
A
B
C
D
E
Fig. 16.17 A–D, Preoperative planning according to the ‘Akademikliniken-method’ (see description of Figures 16.9, 16.10 & 16.11). Note that
arm elevation 45° over the head and drawing of a line from the nipple to the sternum simulates nipple position after the augmentation (B).
C, 3 months later the implants have settled moderately, but 6 months later due to non-adhesion of the textured implants, too much descent
of the implant is noted (D). Compare to opposite reaction due to capsular contraction in Figure 16.2. E, After implant exchange and insertion
into new sub-muscular implant pocket, drainage and long-term fi xation, a good long-term stable result has been achieved 1 year after the
secondary correction.

Conclusions
231
Physical activity and exercise
Arm elevation is recommended directly after the procedure. Stretching
the pectoralis muscle once every hour during the fi rst 24 hours after
the procedure minimizes postoperative pain in sub-muscular implan-
tation. With proper surgical technique and infi ltration of local anaes-
thesia around the breast, postoperative pain is normally minimal.
With mild analgesic medication patients should be able to go home
within 4–6 hours. Sports and vigorous physical activity should be
avoided for approximately 3 weeks. Following this initial healing phase
the patient can resume sports, but all sports that exert tension on the
scar, or to much implant movement, such as serving in tennis or
trampoline bouncing, should be avoided for 3 months. Vigorous
stretching perpendicular to the scar may widen it during this period.
To improve the fi nal scar appearance, scars should be taped with paper
tape (Micropore®) for up to 6 months. This helps the scar to mature
and reminds the patient not to exert excessive tension.
Shower and bath
With surgical tape on the wound patients are allowed to shower the
fi rst postoperative day, but baths should be avoided for 1 week.
A
B
C
D
E
Fig. 16.18 A, Patient seeking for secondary breast augmentation where surgeon neglected to address the ptosis of the breast. The
deformation is more noticeable during pectoralis muscle activity (B). Preoperative planning for implant exchange and simultaneous
mastopexy (C). After secondary procedure in relaxed (D) and tightened pectoralis muscle situation (E).
Long-term follow-up
Self-examination on a weekly basis is recommended. This can be done
with circular movements of the hand around the breast during showers.
If patients experience changes and alterations in the fi rmness or
appearance or notice nodules and irregularities, a follow-up visit is
recommended. Otherwise, patients are recommended to call in for a
check up 10 years after surgery. MRI investigations of the breasts may
be indicated after long-term implantation. No absolute recommenda-
tion of when implants should be exchanged can be given, but all
patients should be informed that it is likely at some point. Modern
implants will probably stay intact for 10 or even 20 or more years.
CONCLUSIONS
In breast augmentation surgery there are many alternative techniques
and materials. Different implant shapes with surface variability are
available and access to the surgical pocket can be through several dif-
ferent routes. All have advantages and drawbacks, but accurate plan-
ning is always essential (Fig. 16.20A & B). Implant selection and
preoperative planning should not be arbitrary, but based on a meticu-
A
B
Fig. 16.19 A, Explantation of low-cohesive
ruptured silicone gel is more diffi cult than
explantation of a ruptured form-stable
silicone implant (B).

16
BREAST AUGMENTATION
232
lous analysis of biological prerequisites and implant dimensions. Good
patient communication and meticulous planning minimizes the risk
for re-operation and dissatisfaction and is the foundation for a long-
term, stable result.
REFERENCES
1. Kinsey AC, Pomeroy WB, Martin CE. Sexual behavior in the human
male. Philadelphia: WB Saunders, 1948.
2. Beale S, Hambert G, Lisper Ho et al Augmentation mammoplasty: the
surgical and psychological effect of the operation and prediction of the
result. Ann Plast Surg 1984; 13:279–297.
3. Cash T, Duel L, Perkins L. Women psychosocial outcome of breast
augmentation with silicone gel fi lled implants: a two year prospective
study. Plast Recontruc Surg 2002; 109:2112.
4. Schlebusch L, Mahrt I. Long term psychological sequele of augmentation
mammoplasty. S Afr Med J 1993; 83:267–271.
5. Hedén P, Boné B, Murphy DK, Slitcom A, Walker PS. Style 410 cohesive
silicone breast implants. Safety and effectiveness at 5 to 9 years after
implantation. Plast Reconst Surg 2006; 118:1281–1287.
6. Andersson RC. Aesthetic surgery and psychosocial issues. Aesthetic
Surgery Q 1996; 16(4):227–229.
7. Hedén P. Breast augmentation with anatomic, high-cohesiveness silicone
gel implants. In: Spear SL, ed. Surgery of the breast. Lippincott Williams
& Wilkins; 2006:1344–1366.
8. Graf RM, Bernardes A, Rippel R, Araujo LR, Damasio RC, Auersvald A.
Subfascial breast implant: a new procedure. Plast Reconstr Surg 2003;
111(2):904–908.
9. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-
tissue relationships in a wide range of breast types. Plast Reconstr Surg
2001; 107(5):1255–1272.
10. Spear SL, Carter ME, Ganz JC. The correction of capsular contracture
by conversion to “Dual-Plane” positioning: technique and outcomes.
Plast Reconstr Surg 2003; 112(2):456–466.
11. Jones FR, Tauras AP. A periareolar incision for augmentation
mammoplasty. Plast Reconst Surg 1973; 51:641.
12. Hoehler H. Breast augmentation: the axillary approach. Br J Plast Surg
1973; 26:373.
13. Johnson GW, Christ JE. The endoscopic breast augmentation: the
transumbillical insertion of saline fi lled breast implants. Plast Reconstr
Surg 1993; 92(5):801–808.
14. Tebbetts JB. A system for breast implant selection based on patient
tissue characteristics and implant-soft tissue dynamics. Plast Reconstr
Surg 2002; 109(4):1396–411.
15. Tebbetts JB. Patient evaluation, operative planning, and surgical
techniques to increase control and reduce morbidity and
reoperations in breast augmentation. Clin Plast Surg 2001; 28(3):501–
521.
16. Heden P, Jernbeck J, Hober M. Breast augmentation with anatomical
cohesive gel implants: the world’s largest current experience. Clin Plast
Surg 2001; 28(3):531–552.
17. Rheingold LM, Yoo RP, Courtiss EH. Experience with 326 infl atable
beast implants. Plast Reconstr Surg 1994; 93(1):118–112.
18. Kjoller K, Holmich LR, Jacobsen PH et al. Capsular contracture after
cosmetic breast implant surgery in Denmark. Ann Plast Surg 2001;
47(4):359–366.
19. Pittet B, Montandon D, Pittet D. Infection in breast implants. Lancet
Infect Dis 2005; 5(2):94–106.
20. Danino A, Rocher F, Blanchet-Bardon C, Revol M, Servant JM. A
scanning electron microscopy study of the surface of porous-textured
breast implants and their capsules. Description of the ‘velcro’ effect of
porous-textured breast prostheses. Ann Chir Plast Esthet 2001;
46(1):23–30.
21. Danino AM, Basmacioglu P, Saito S, Rocher F, Blanchet-Bardon C, Revol
M, Servant JM. Comparison of the capsular response to the biocell rtv
and mentor 1600 siltex breast implant surface texturing: a scanning
electron microscopic study. Plast Reconstr Surg 2001; 108(7):2047–
2052.
22. Brown SL, Silverman BG, Berg WA. Rupture of silicone-gel breast
implants: causes, sequelae, and diagnosis. Lancet 1997;
350(9090):1531–1537.
23. Belli P, Romani M, Magistrelli A, Masetti R, Pastore G, Costantini M.
Diagnostic imaging of breast implants: role of MRI. Rays 2002;
27(4):259–277.
24. Baker J. Classifi cation of spherical contractures. Paper presented at the
Aesthetic Breast Symposium in Scottsdate, Arizona, 1975.
25. Holmich LR, Kjoller K, Vejborg I et al. Prevalence of silicone breast
implant rupture among Danish women. Plast Reconstr Surg 2001;
108(4):848–858.
26. Holmich LR, Kjoller K, Vejborg I et al. Prevalence of silicone breast
implant rupture among Danish women. Plast Reconstr Surg 2001;
108(4): 859–863.
27. Heden P, Nava MB, van Tetering JP et al. Prevalence of rupture in
INAMED silicone breast implants. Plast Reconstr Surg 2006;
118(2):303–308; discussion 309–312.
A
B
Fig. 16.20 A, Dissatisfi ed patient after breast
augmentation where a surgeon failed to
address the characteristics of the envelope.
The envelope is too big for the selected
implant; more fi lling or preferably a
mastopexy is needed for a natural
appearance.

233
CHAPTER 17
Breast Reduction
Elizabeth J Hall-Findlay
When it was discovered that either of McKissock’s pedicles could be
severed, the inferior pedicle with an inverted T skin resection pattern
became the favored method.6–8 It has a reliable blood supply to the
nipple and areolar complex and the skin fl aps close easily over the
pedicle. The skin brassiere was tightened to control the breast shape.
Although most surgeons around the world now use an inferior pedicle
alone for the nipple and the Wise skin resection pattern9 for the skin,
some still prefer the vertical bipedicle of McKissock, especially for
larger reductions.
Meanwhile, the South Americans10–13 and the Europeans14–18 devel-
oped expertise with a vertical skin resection pattern and a vertical
wedge resection of parenchyma. These techniques were used mainly
for small reductions, with an inverted T skin resection pattern used
for the larger reductions. Many of these surgeons used the superior
pedicle19 for the nipple–areolar complex rather than the inferior pedicle,
even when they chose an inverted T skin resection pattern. Many
European and South American surgeons continue to use a superior
pedicle, but often combine it with a Wise skin resection pattern.
Principles behind the techniques
The three main problems with breast reduction are:
● moving the nipple–areolar complex to a higher position while
maintaining blood supply – if possible, it would be ideal to preserve
both sensation and breast feeding potential as well as circulation;
● resecting enough parenchyma without damaging the blood supply
to the pedicle or resultant skin fl aps;
● designing the skin fl aps to preserve blood supply while at the same
time excising the redundant skin.
Maintaining the blood supply
The breast is a superfi cial ectodermal structure that develops from the
fourth interspace and its blood supply is superfi cial,20 except for the
perforator through the pectoralis muscle. The perforator:
● comes from the fourth or fi fth interspace from the internal
mammary artery;
● is accompanied by venae comitantes;
● can have several branches as it passes through the pectoralis
muscle.
The superfi cial arteries comprise:
● one from the second or third interspace from the internal mammary
system (which is a robust artery supplying a superior pedicle);
● the medial branches of the internal mammary system;
● the superfi cial thoracic vessel (a branch of the lateral thoracic
system).
The veins do not accompany the arteries and are found separately (and
seen) just beneath the dermis.
Summary
1. Skin resection patterns are the inverted T, vertical, horizontal,
and liposuction-only.
2. Pedicles for nipple and areola may be inferior, central, superior,
medial or lateral.
3. Resection can be direct, liposuction or a combination of direct
and liposuction.
4. The inferior pedicle has become the workhorse for maintaining
blood supply, sensation and breastfeeding potential for the
nipple–areolar complex. Long scars and bottoming out over
time are accepted as minor problems compared with the ease
and safety of creating an inferior pedicle.
5. An inverted T skin resection pattern with an inferior pedicle
uses a horizontal excision with medial and lateral dog-ears.
6. A vertical skin resection pattern with a medial pedicle uses a
vertical excision with superior and inferior dog-ears.
7. An inverted T skin resection pattern with an inferior pedicle
uses the skin to shape the breast.
8. A vertical skin resection pattern with a medial or superior
pedicle uses the breast to shape the skin.
9. Redundant poor quality skin needs to be excised.
10. Periareolar, no vertical scar, and liposuction-only procedures
have specifi c indications.
INTRODUCTION
This chapter describes in detail two main approaches to breast reduc-
tion – the inferior pedicle with an inverted T skin resection pattern
and the medial pedicle with a vertical skin resection pattern. There
are, however, many ways to combine skin resection patterns, paren-
chymal resection patterns and pedicle design.
History of development of
different techniques
In the 1970s McKissock1 introduced the vertical bipedicle breast reduc-
tion technique, which was the fi rst procedure for breast reduction
surgery that was both reliable and reproducible. Before then:
● a popular breast reduction procedure was the Biesenberger2 method,
but this often ended up with problems with skin fl ap necrosis;
● Strombeck’s3 horizontal bipedicle was not easy and it was diffi cult
to close the skin fl aps over the pedicles without compression;
● the lateral wedge of Dufourmentel4 was relatively easy to perform,
but left the breasts with a ‘snoopy’ shape and medialized nipples;
● Skoog’s5 lateral and medial pedicles were not widely known.

17
BREAST REDUCTION
234
Types of pedicle
The blood supply of the different pedicles (Fig. 17.1A–E) is as
follows:
● the inferior pedicle relies on the perforator and its venae
comitantes;
● a superior pedicle is well supplied by the long branch of the inter-
nal mammary system from the second or third interspace;
● medial vessels supply a medial pedicle;
● the superfi cial thoracic artery supplies a lateral pedicle.
The inferior pedicle must therefore be a full thickness dermoglandular
pedicle to survive. In contrast, the superior, medial and lateral pedicles
can all be dermal because both their venous and arterial blood supply
is superfi cial. The innervation and the ductal system, however, will
only be preserved with a full thickness pedicle.
The choice of pedicle is often a personal preference for the surgeon.
All seem to have comparable postoperative sensibility. Although the
lateral fourth intercostal nerve provides the main sensation to the
nipple and areola, several other nerves (medial, supraclavicular) are
also important. Many of the pedicles preserve the deep branch of the
lateral fourth intercostal as it runs just above the pectoralis fascia. It
is important to leave tissue on the fascia to preserve this nerve and
protect sensation.
Inferior pedicle The inferior pedicle is safe and reliable, maintaining
blood supply, sensation and breastfeeding potential for the nipple–areolar
complex; this mandates that the skin is then used as a brassiere. Long
scars and bottoming out over time are accepted as minor problems
compared with the ease and safety of creating an inferior pedicle.
The inferior pedicle is supplied by an arterial perforator through
the pectoralis muscle that usually comes from the internal mammary
system at the level of the fourth intercostal space and is accompanied
by venae comitantes. There can be several branches, but it enters the
breast usually just medial to the breast meridian about 4–6 cm above
the IMF.
Central pedicle The central pedicle may not be quite as reliable as
an inferior pedicle because there are many small but powerful blood
Fig. 17.1 Skin resection patterns and pedicles for breast reduction. A, Inverted T with inferior pedicle. B, Vertical with medial pedicle.
C, Vertical with superior pedicle. D, Circumvertical with superior pedicle. E, Circumvertical with inferior pedicle (short scar periareolar
inferior pedicle reduction [SPAIR] technique). F, Periareolar with central pedicle. G, Horizontal with wide-based inferior pedicle.
Various skin resection patterns and pedicles for breast reduction
B
A
C
D
F
E
G
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Vertical (superior pedicle)
Circumvertical
Circumvertical (Spair technique) inferior pedicle
Peri-areolar
Horizontal
Scar around areola
Scar in inframammary fold

Introduction
235
vessels that enter the breast superfi cially from the level of the IMF. These
are cut when a central pedicle is created. Creation of a central pedicle
also severs the superfi cial veins, which supply most of the breast.
A central pedicle relies on the same arterial perforator and its venae
comitantes as supply an inferior pedicle, and is therefore, by defi nition,
full thickness.21,22
Superior pedicle The superior pedicle has a very robust artery sup-
plying it from the internal mammary system at the level of the second
or third interspace. This strong artery usually enters the pedicle very
superfi cially just medial to the breast meridian. If there is some concern
about the vessel it can be easily picked up by Doppler preoperatively.
The veins are separate from the artery, lie just beneath the dermis,
and can usually be seen through the skin when performing the preop-
erative markings. The superior pedicle may need to be thinned to inset
it without compression or kinking. Thinning will not damage its
(superfi cial) blood supply.
Although the superior pedicle remains a good choice for a
mastopexy, it often needs to be signifi cantly thinned to inset
correctly. This thinning leaves an empty space inferiorly and can
leave an odd shape at the end of the procedure.
Lateral pedicle The lateral pedicle is supplied via the superfi cial
thoracic artery (a branch of the lateral thoracic artery, which runs just
deep to the edge of the pectoralis muscle). The lateral pedicle is reli-
able, but can be a problem in breast reduction surgery because the base
of the pedicle is the tissue that needs to be removed to achieve a good
reduction.
Medial pedicle The medial pedicle has surprisingly good sensation,
especially when created as a full thickness pedicle where the deep
branch of the fourth intercostal nerve is preserved by leaving tissue
over the pectoralis fascia.
The vascular supply of the medial pedicle is from the medial
branches of the internal mammary system (probably the third and
fourth interspaces) and the orientation of the pedicle is best viewed
when the patient is lying down. The surgeon can then visualize where
the breast began before it grew large and ptotic.
Some surgeons prefer to call this pedicle ‘superomedial’ because of
its orientation when the patient is standing. But pedicles are usually
named according to their blood supply and the arteries and veins are
both ‘medial’.
Because the base of the medial pedicle rotates and the inferior
border of the medial pedicle becomes the medial pillar, the use of
the medial pedicle gives an elegant curve to the lower pole of the
breast.
To allow the medial pedicle to rotate easily into position, the vessel
that supplies a superior pedicle is usually transected when creating it.
Free nipple grafts Free nipple grafts are an important consideration
especially if any of the other pedicles have an unpredictable blood
supply,23,24 especially for the larger reductions. There is a loss of sensa-
tion, a loss of projection to the nipple, and a loss of breastfeeding
potential. There is also a chance of irregular pigmentation.
Minimizing the risk of nipple necrosis
Although breast reduction is predictable and safe, there is a risk of
complete nipple necrosis in around 1 in 300 patients. Some surgeons
routinely use free nipple grafts, whereas many reserve these for the
large reductions. The nipple is preserved with the Passot25 technique
(or when a similar pedicle is used in a variation of the Robertson26
technique) where the complete inferior breast is used as a broad pedicle,
and this is occasionally selected for extremely large reductions.
Skin resection pattern
The skin resection pattern (Fig. 17.2A–G) is determined mainly by the
amount and quality of the excess skin.
● A full inverted T pattern is needed if there is a signifi cant amount
of excess skin, especially when it is poor quality (as in patients who
have undergone massive weight loss). There is too much skin and
the redundant skin cannot adapt to the new breast shape without
further resection. It is the most commonly used breast reduction
resection pattern, especially for the larger breast.
● The horizontal (often called no-vertical scar technique) usually
involves a very widely based inferior pedicle with a horizontal skin
resection pattern. A cutout is made for the nipple and areola, and
the longer superior fl ap is gathered to fi t the skin along the IMF.
There is no vertical resection of breast tissue or skin.
● The vertical approaches are best used for small and medium-sized
breast reductions. Pedicle choice depends mainly on surgeon
preference.
● The periareolar approach should be confi ned to small breast
reductions and may be indicated if there is little excess skin or a
constricted lower pole.
Approaches to minimize scarring and maximize breast
shape
Surgeons around the world are becoming more interested in the verti-
cal approach, which involves the use of different pedicles with a verti-
cal wedge resection of breast tissue. Proponents of this technique
note:
● shorter scars;
● an improved shape with more projection;27–34
● shape that lasts longer and does not bottom out as easily as with
the inferior pedicle, inverted T techniques.
The aim of further reducing scars is evident in the techniques that
attempt to confi ne the scar to the area around the areola. The peri-
areolar method is best suited for small breast reductions and some
mastopexies.35,36 These are diffi cult procedures with a long learning
curve. Separation of the skin fl aps from the parenchyma is an essential
component to achieve a good outcome.
The controversy continues between using the skin brassiere to
shape the breast versus reshaping the breast and allowing the skin to
redrape. Many methods rely on the skin brassiere to shape the breast
and hold it in position:
● inverted T techniques tend to resect tissue around an inferior
pedicle and then rely on the skin pattern to hold the breast up;
● the vertical component of the Wise skin pattern is kept short to
accommodate for expected stretching in the healing period, but this
shortening tends to fl atten the breast and prevent projection;
● vertical approaches rely on the vertical wedge resection and subse-
quent coning of the breast tissue to shape the skin and do not rely
on the skin to hold the shape.
Unanswered questions
Many questions are still debated by surgeons and include:
● How important is the skin brassiere in shaping the breast? Does
it depend on the quality of the patient’s skin?
● How important is the nature of the breast resection in shaping the
breast?
● How important are breast parenchymal sutures?
● Does the pedicle have any infl uence over the resultant shape or is
it just a means of maintaining blood supply to the nipple?