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R. C. Ribeiro et al.
Fig. 23.4 De-epithelialization of the periareolar region
ab
Fig. 23.5 Creation of new inframammary fold and Mandrekas/Ribeiro glandular ap
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Fig. 23.6 Creation of pocket for ap repositioning
This inferior pedicle receives its vascularization through the fourth, fth, and sixth
intercostal arteries. The release of the constriction ring is performed, and the skin
naturally slides over the pedicle, forming the base of the breast to be enlarged
(Fig.23.7).
The nal suture of the areola is made with continuous round block stitches with
non-absorbable 2–0 nylon thread. In certain situations, it may be necessary to suture
with interrupted stitches with 5–0 or 6–0 nylon, and other threads may be used
according to the surgeon’s preference. Rigotomy may be performed to facilitate
skin expansion (Fig.23.8).
It is important to x the breast with hypoallergenic adhesive tape for an approximate period of 15days to model it.
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Fig. 23.7 Transection of constricting ring and reconstruction of breast pillars
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Fig. 23.8 Before and after pictures of a tuberous breast reconstruction with breast implants and
rigotomy for skin expansion
Conclusions
Tuberous breast is a rare entity and difcult to treat, with numerous variations in its
clinical presentation, which requires the individualization of each case to carry out
a precise approach with the correct choice of technique to be used.
Thus, the treatment becomes even more complex in patients with marked breast
asymmetry, which in many cases may require the combination of several surgical
techniques and, sometimes, the performance of more than one surgical time to
obtain better results.
Due to the diversity of clinical ndings, there are different therapeutic possibilities, which can range from the placement of silicone implants, indicated when necessary, to the performance of glandular aps in association with the techniques
described above.
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References
Ribeiro R.C., López L.E.F., Romay S. (2018a) Tuberous Breast. In: Avelar J. (eds) Breast Surgery.
Springer, Cham. https://doi.org/10.1007/978-3-319-54115-0_39
Ribeiro R.C., Valderrama J.B., Mangles M.G.M. (2018b) Poland’s Syndrome. In: Avelar J. (eds)
Breast Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-54115-0_44
Jurado J (1976) Plásticas mamárias de redução baseadas em retalho dérmico vertical monopedicu-
lado. Anais XII Congresso Brasileiro de Cirurgia Plástica, vol 29
Pitanguy I (1984) Mamoplastia reductora con retallo superior em hipertroa mamaria. Rev Bras
Cir 74:265–284
Ribeiro L, Accorsi A Jr, Buss A, Marcal-Pessoa M (2002) Creation and evolution of 30 years of the
inferior pedicle in reduction mammaplasties. Plast Reconstr Surg 110(3):960–970
Robbins TH (1977) A reduction mammaplasty with the areola nipple based on an inferior dermal
pedicle. Plast Reconstr Surg 59(1):64–67
Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B (2004) Current preferences for breast
reduction techniques: a survey of board-certied plastic surgeons 2002. Plast Reconstr Surg
114(7):1724–1736
Wallace WH, Thompson WO, Smith RA, Barraza KR, Davidson SF, Thompson JT II. (1998)
Reduction mammaplasty using the inferior pedicle technique. Ann Plast Surg 40(3):235–240
Ribeiro R.C., de Thuin R., de Figueiredo-e-Silva I.V., Rios M.T. (2018c) Aesthetic Approach
to Breast Reconstruction. In: Avelar J. (eds) Breast Surgery. Springer, Cham. https://doi.
org/10.1007/978-3-319-54115-0_46
Avelar J.M. (2018) Asymmetrical Breasts: A Challenge for Aesthetic Repair. In: Avelar J. (eds)
Breast Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-54115-0_43
von Heimburg D, Exner K, Kruft S, Lemperle G.The tuberous breast deformity: Classication and
treatment. Br J Plast Surg 1996;49:339–45
Longacre JJ.Correction of the hypoplastic breast with special reference to reconstruction of the
“nipple type breast” with local dermofat pedicle ap. Plast Reconstr Surg 1954; 14: 431–41
Goulian D Jr. Dermal mastopexy. Plast Reconstr Surg. 1971 Feb;47(2):105–10. https://doi.
org/10.1097/00006534-197102000-00001. PMID: 4925049.
Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas D, Lambrinaki N, Ioannidou-Mouzaka
L.Aesthetic reconstruction of the tuberous breast deformity. Plast Reconstr Surg. 2003 Sep
15;112(4):1099–108; discussion 1109. https://doi.org/10.1097/01.PRS.0000076502.37081.28.
PMID: 12973230
Meara JG, Kolker A, Bartlett G, Theile R, Mutimer K, Holmes AD. Tuberous breast defor-
mity: principles and practice. Ann Plast Surg. 2000 Dec;45(6):607–11. https://doi.
org/10.1097/00000637-200045060-00006. PMID: 11128758.
Grolleau JL, Lanfrey E, Lavigne B, Chavoin JP, Costagliola M.Breast base anomalies: treatment
strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg. 1999
Dec;104(7):2040–8. https://doi.org/10.1097/00006534-199912000-00014. PMID: 11149766.
Chapter 24
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Aesthetic Approaches forBreast
Reconstruction
RicardoCavalcantiRibeiro, AnaBeatrizArduini,
andLuisFernandezCordova
Abstract Plastic surgery is indivisible, the binomial aesthetic and reconstructive
plastic surgery raises its importance as both seek harmony, well-being and healing.
We cannot dissociate them.
When talking about cosmetic breast surgery, we have many concepts, references,
and techniques that can be applied and that were initially created for reconstructive
purposes, for example oncoplastic surgery. Even though reconstructive surgery may
seem more difcult, sometimes the aesthetic patient´s expectations represent a bigger challenge.
The idea of this chapter is to bring resources from reconstructive surgery to cosmetic surgery and broaden our horizons, always seeking not only the best result, but
also observing the patient in a holistic and ethical way, aiming to balance body
and spirit.
Knowledge of the anatomy of the cutaneous arteries and veins is fundamental to
the design of skin aps and incisions. In the last four decades, with the introduction
R. C. Ribeiro (*)
Plastic and Reconstructive Surgery, Federal University of the State of Rio de Janeiro,
Rio de Janeiro, Brazil
Plastic and Reconstructive Surgery, Carlos Chagas Institute, Rio de Janeiro, Brazil
Division of Plastic and Reconstructive Surgery, Casa de Portugal, Rio de Janeiro, Brazil
e-mail: rribeiro@centroin.net.br
A. B. Arduini
Plastic and Reconstructive Surgery, Carlos Chagas Institute, Rio de Janeiro, Brazil
L. F. Cordova
Plastic and Reconstructive Surgery, Carlos Chagas Institute, Rio de Janeiro, Brazil
Division of Plastic and Reconstructive Surgery, Casa de Portugal, Rio de Janeiro, Brazil
Division of Plastic and Reconstructive Surgery, Global Plastic Surgery, México City, Mexico
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_24
373© The Author(s), under exclusive license to Springer Nature
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of the microsurgical free skin ap (Daniel and Taylor, Plast Reconstr Surg. 52:111,
1973; Taylor and Daniel. Aust N Z J Surg. 43:1, 1973), the revival of the musculo-
cutaneous ap (McCraw etal. Plast Reconstr Surg. 60:341, 1977), the description
of the fasciocutaneous ap (Cormack and Lamberty. The Arterial Anatomy of Skin
Flaps. Church-Livingstone, Edinburgh, 1986; Ponten. Br J Plast Surg. 34:215,
1982), and the use of tissue expansion (Radovan. Plast Reconstr Surg. 69:195,
1982) and ap prefabrication (Baudet et al. Prefabricated free ap transfers.
Presented at the 3rd Annual Meeting of the American Society for Reconstructive
Microsurgery, San Antonio, Texas, September 12–13, 1987), that surgeons and
anatomists have returned to the anatomic dissecting room to search and research the
intricacies of the vascular pathways to and from the skin.
Keywords Breast aesthetics · Capsulectomy · Mammoplasty · Malposition
The concept of aps and its variants become very important in what we seek to explain
here, since they are techniques applied to mostly secondary mammaplasties.
Knowledge of the anatomy of the cutaneous arteries and veins is fundamental to the
design of skin aps and incisions. In the last four decades, with the introduction of the
microsurgical free skin ap (Daniel and Taylor 1973; Taylor and Daniel 1973), the
revival of the musculocutaneous ap (McCraw et al. 1977), the description of the fasciocutaneous ap (Cormack and Lamberty 1986; Ponten 1982), and the use of tissue
expansion (Radovan 1982) and ap prefabrication (Baudet et al. 1987), that surgeons
and anatomists have returned to the anatomic dissecting room to search and research
the intricacies of the vascular pathways to and from the skin. Once the patient has
already undergone one or more aesthetic surgical approaches to the breast, due to surgical manipulation, resources in front of known aps are becoming increasingly scarce.
It is clear that the primary objective of a surgery, whether augmentation or mastopexy, is to prevent complications and reduce reoperation rates, focusing on the
avoidance of complications is an imperative, especially for an elective procedure.
The same decisions and processes that reduce complications also predictably deliver
superior aesthetic results. The modern breast augmentation prioritizes avoiding
complications, reducing reoperations, and minimizing iatrogenic damage to breast
tissue. The success of an operation can only be improved when objective endpoints
are dened before surgery.
Breast implants are one of the top ve procedures in plastic surgery; however,
due to alterations such as capsular contracture, rippling, decrease of subcutaneous
tissue thickness, rupture, malposition, among others, many cases will require plane
and implant exchange (Ribeiro and Arduini n.d.).
Among the alternatives, we can mention our experience with capsule graft, mesh
graft or even free tram.
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Patient Selection
There must be an alignment of expectations towards the patient regarding the possible results, emphasizing that it is often a tertiary surgery onwards. The biggest
challenges present themselves in the face of lack of tissue, thin and accid tissue,
multiple approaches with the change of plans with loss of anatomy domicile, desire
to increase the breast pocket with larger implants or an even greater challenge,
mammoplasty with explant.
After aligning expectations in addition to a systematic assessment of the patient’s
health conditions such as body weight, patient height, and an estimate of breast
volume requirements, we emphasize that the patient must be emotionally stable.
Risk factors such as hypertension, diabetes, smoking, and obesity are not contraindications to reconstruction but may inuence the choice of surgical technique and
predispose a patient to complications in the donor area (Thorne etal. 2013).
Besides that, surgeons and patients tend to focus on the operation itself as the
event that determines the surgical outcome, with preoperative discussion and postoperative management considered to be of secondary importance. Each step of a
breast augmentation is no better than the one that preceded it: planning is dependent
on patient education; the operative procedure is dependent upon the operative plan;
recovery is dependent on the surgical procedure; and nal patient satisfaction is the
cumulative result of all of these steps. Most important of all is how perceptions of
success after surgery were dened at the initial steps of education.
Capsular Contracture
Patients should be educated before surgery that it is normal to feel the capsule
around the implant (Baker grade II), that the capsules on the two sides never develop
equally, and that revision should only be considered for a Baker grade III (rm and
distorted) or Baker grade IV (painful). Surgery is not indicated for a Baker II capsule because there is little likelihood of creating and maintaining a Baker I (no discernable capsule) (Thorne etal. 2013).
Capsular contracture is and has always been a leading cause of revisions
(Thorne etal. 2013). As scar tissue thickens and tightens around the implant, the
breast feels rmer, it looks becomes more spherical, the implant migrates, and the
breast can be painful. Though patients may say, “my implants got hard,” in fact, the
implants are soft but constrained within a tightening envelope of their own tissue.
The main cause of capsular contracture is inammation, which in turn can be
caused by silicone gel bleed, glove talc, blood, tissue trauma, and bacteria. Current
evidence supports Staphylococcus epidermidis biolm as a signicant cause of capsular contracture (Pajkos etal. 2003; Persichetti etal. 2011).
Faced with a scenario of Baker III or IV capsule contracture, when it becomes
imperative to change the implant and often change the plane, we must consider the
need for rearrangement and reinforcement of the breast pouch to receive the new
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Fig. 24.1 Capsule and
implant after total
capsulectomy and breast
implant removal
R. C. Ribeiro et al.
implant. Capsules with these characteristics: thick, brous, calcications, granulomas and identied implant rupture or presence of seroma should be submitted to
total capsulectomy (Fig.24.1).
Malposition
Implant malposition creates some of the most severe deformities following breast
augmentation. The appearance of the breast is determined by the amount and distribution of volume, in a container-content relationship, which in turn is determined
by the position of the breast implant.
Over-dissection allows an implant to move out from its ideal position and incomplete dissection prevents an implant from settling in its ideal position. Even with a
precise pocket, gradual migration from weight, pressure, and gravity can occur,
particularly with chest wall deformities (Thorne etal. 2013) (Fig.24.2). To avoid
migration beyond the inframammary fold, the inferior cut edge of scarpa’s fascia
can be sewn to the muscle fascia, going back to anatomy as a “seat belt,” in this way,
some surgeons will routinely place such sutures with the inframammary incision.
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Fig. 24.2 Asymmetry in
Inframammary fold due to
implant malpostion
Size Exchange
377
Implant size change is usually avoided with proper patient education and selection.
Weight uctuations due to a new lifestyle, with the loss of breast tissue, associated
or not with accidity and even after pregnancy, it is not uncommon for patients after
these changes in the body, together with loss of the result in the breasts, to require
replacement of implants, sometimes larger. We cannot rule out the social pressures
to do so either (Fig.24.3).
There are two major challenges here: the expansion of a store in the face of a
restricted breast pocket, when the desire for a larger implant is desired, or the opposite, the desire to remodel the breast with a smaller implant or explant.
In the rst case, we must educate the patient not to pay attention to a specic
size, but that her desire will be contemplated as closely as her physical characteristics allow. In addition, we must emphasize the importance of tissue elasticity, if
there are striations, sagging, positioning of the inframammary fold, excess medial
detachment with risk of symmastia, or excessive lateral detachment with risk of
lateralization of the breast, larger implants imply enlargement of the areola and
nipple effacement (when not performed associated mastopexia) with displacement
of the areola as well. Thus, often the need to enlarge the pocket to accommodate a
larger prosthesis must be associated with the increase of some structures in order to
reinforce them, as in the case of the pectoralis major, preserving it and allowing
good containment of the implant, either in the submuscular plane or dual plane.
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