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T. S. Eisenberg
Grade 1: Mild ptosis. The nipple is positioned at the
IMC.
Grade 2: Moderate ptosis. The nipple is slightly below
the IMC.
Grade 3: Moderate to severe ptosis. The nipple is well
below the IMC but the nipples are facing anteriorly, or
forward.
Grade 4: Severe ptosis. The nipple is well below the IMC
and facing inferiorly, or down. Moderate to severe ptosis
requires a mastopexy as well and can be nicely adjusted by
the I.D.E.A.L.Breast Lift, staple-rst approach (Eisenberg
2012).
Finally, measure the rib cage circumference under the
breasts. I measure the circumference in inches (not centimeters) and add 4in. This is consistent with how UK and US
bra manufacturers size their bra bands.
Many patients tell me they want to be a full C cup after
surgery, and I use their bra band size to make this point: A
woman with a petite frame (32-in. bra band size) might only
need a B cup to have a “C look,” whereas a larger-framed
woman (38-in. bra band size) may need a D cup to have the
same “C look.” This helps patients understand that their post op size will be more of a “cup-size look” than an actual “cup
size.”
fold (IMF). These marks often correspond to the most
medial edge of each areola.
2. These two reference points (noted in #1) will be a guide
as to the most medial point of the incision line. In general,
it is better to not to extend this point more medially than
the medial edge of the areola.
3. Using the inframammary crease, draw the incision line in
the IMF, extending from the point in #2 laterally approximately 3.5cm. This incision line should be reconrmed
with the patient in the supine position prior to commencing surgery.
4. Determine the lateral border of the sternum marking by
pushing the breast gland medially. No attempt should be
made to go beyond this point in order to bridge any cleavage gap.
5. Likewise, mark the natural limit of the lateral aspect of
the breast gland by pushing the breast laterally.
6. Draw a line approximately 2 nger breadths (roughly
4cm) below the level of the clavicle. This line often correlates with the upper natural limit of a fuller breast.
20.5.4 Intraoperative Preparation andSaline
Breast Augmentation
20.5.3 Preoperative Markings
Preoperative markings should be made with the patient in the
standing or sitting position. The markings represent the natural anatomic limits of the breasts if the glandular tissues were
enlarged (Fig.20.7).
1. Mark the lateral border of the rectus muscles, bilaterally,
several inches or centimeters below the inframammary
Fig. 20.7 Preoperative markings
I have used smooth round Mentor saline-lled implants
ranging in size from 225 to 675cc. Surgeries are performed
in a hospital on an outpatient basis under general anesthesia,
usually by laryngeal mask airway (LMA).
Perioperative antibiotics are used (usually cephalosporin,
or doxycycline if penicillin-allergic) to minimize the chance
of infection. Postoperative nausea and vomiting (PONV)
protocols are administered (Eisenberg 2008).
Place the patient in the supine position with arms at her
sides. This will provide maximum relaxation of the pectoral
muscle.
When prepping the patient, I use a Betadine solution so as
not to lose my markings. Antiseptics that contain alcohol
may cause the skin markings to be lost (see Video 20.1).
20.5.5 Making thePocket
1. Conrm that the preoperative markings you made with
the patient in the sitting position match the proximity to
the IMF in the supine position.
2. Inltrate these markings with a local anesthetic contain-
ing a vasoconstrictor.
3. If the breasts are asymmetric, always start on the smaller
breast. The dimensions of the smaller breast limit the
maximum volume that can be placed. Incise the marked
incision line with a #15 blade scalpel and carry it down to
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subcutaneous tissue. Conrm that adequate hemostasis is
obtained with the use of electrocautery.
4. Perform submuscular blunt dissection—medially near
the lateral border of the sternum, superiorly below the
level of clavicle, and laterally near the anterior axillary
line.
5. Inspect the submuscular space with lighted retractor and
conrm that adequate hemostasis is obtained with the use
of electrocautery.
6. Irrigate the pocket with an antibiotic saline solution and
then pack it with two E-tape sponges. Perform the same
procedure on the other side.
7. Return to the original breast and remove the E-tape
sponges. Reinspect the submuscular space for hemostasis
with the lighted retractor. Now reirrigate the pocket with
an antibiotic saline solution.
8. Reapproximate the deep subcutaneous portion of the incision. This is done with 2–0 Vicryl suture (Ethicon) in an
interrupted fashion. These three sutures are only hemostated— not tied; these sutures will be tied later after the
implant is placed and fully expanded.
20.5.6 Expansion oftheImplant
1. Check the implant for air leaks by submerging it in the
antibiotic irrigant.
2. Insert the ll tube in the anterior diaphragm valve of the
implant and remove all the air.
3. In order to more easily manipulate the implant, insufate
the implant with 25ml of IV normal saline through the
sterile ll system.
4. Place the implant in the submuscular space and further
insufate it to the desired volume with IV normal saline
through a closed ll system.
5. Cut the serratus muscle and the very lateral portion of the
pectoralis major muscle with electrocautery. This will
allow the implant to adequately settle and help prevent a
high-riding implant.
6. Perform this same procedure on the opposite breast.
20.5.7 Symmetry/Closure/Dressings
4. Approximate the subcutaneous tissue with 4–0 Vicryl
suture in an interrupted fashion.
5. Approximate the skin with 5–0 Monocryl in a running
subcuticular suture.
6. Re-evaluate the opposite breast for hemostasis and close
in a similar fashion.
7. Dress the incisions with dry sterile Steri-Strips (1/2×4-in.
Suture Strip Plus from Derma Science).
On average, my surgical time for saline breast augmentation is under 1h. Patients are discharged the same day. I do
not use drains, and they are not recommended.
For those who need surgery for a herniated nipple-areolar
complex, after the implant has been placed, attention is then
turned toward repairing the herniated nipple areola complex
by a circumareolar mastopexy (Fig.20.8).
Follow these steps on rst one breast and then the other.
1. Mark the new nipple areola complex (NAC) with a
methylene blue-dipped nipple areola marker (Figs.20.9
and 20.10).
2. Mark the 12, 3, 6, and 9 o’clock positions of the new
NAC with a methylene blue-dipped 20-gauge needle to
facilitate reapproximation.
3. With a skin scribe, mark the perimeter of the original
NAC of one breast.
4. Inltrate this mark with a local anesthetic containing a
vasoconstrictor.
5. Incise the perimeter of the new NAC with a 10-blade
scalpel, then incise the perimeter of its original NAC.
6. De-epithelialize (or deskin) the skin between these two
incisions and make a relaxing incision with electrocautery in this resected skin area.
7. Close the outer perimeter to a 4 cm diameter with 2–0
PDS suture in a purse string fashion.
8. Further suture the new NAC to the outer perimeter with
3–0 vicryl suture in an interrupted fashion (Fig.20.11).
9. Complete each half of the skin closure with 5–0
Monocryl in a running subcuticular fashion.
10. Dress the incision with a dry sterile Steri-Strip and a
Bacitracin-impregnated Adaptic gauze and then a dry
sterile gauze. Repeat on the other side.
1. With the patient in the supine position, check both breasts
for symmetry by comparing the distance between the
superior aspect of each breast and the clavicle. Adjust if
necessary. I do not sit the patient up to evaluate
symmetry.
2. Remove the ll stems from both breasts.
3. Tie the hemostated 2–0 Vicryl sutures to close the deep
layer.
20.5.8 Post-op Protocol
In the recovery room, patients are placed in a support bra that
clips in the front; they nd this style easier to put on and take
off. They are instructed to wear the bra night and day for
1week in order to minimize swelling and support the tissues
during this early healing phase. The pressure from the band
at the base of the bra helps to re-establish the IMF.
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T. S. Eisenberg
Fig. 20.8 (a) Preoperative view of a 34-year-old woman with bilateral
tuberous breast deformity with ptosis and a herniated nipple areola
complex (NAC). She is 5 foot 3in. tall, 168 pounds and received Mentor
Fig. 20.9 Herniated nipple areola complex
smooth saline moderate prole breast implants—375 cc left breast,
425cc right breast. (b) Postoperative view at 9months
Fig. 20.11 Intraoperative view post NAC reduction
Women who have had children say that the rst 3days
after surgery feel like when their milk came in. Patients are
prescribed Celebrex (400mg 2× a day), gabapentin (300mg
3× a day), hydrocodone (5mg/acetaminophen 325mg every
4h) if needed for pain, and Valium (5mg every 6h) if needed
for muscle relaxation, anxiety, and sleep. Unless there was a
circumareolar mastopexy, ice can be used for discomfort. It
will not increase the chance of vascular compromise to the
skin.
Patients are advised that they may sleep in any position
they desire. It has been my experience that sleep position
does not shift the implants during early healing.
The day after surgery patients may shower—but not
bathe—and can remove their bra to do so. They are told not
to soak in a bathtub or pool for 3weeks; incisions are fully
Fig. 20.10 Markings for NAC reduction
healed at this time.
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They are instructed to apply a thin layer of ointment
directly on top of the Steri-Strips; if desired, they can place
gauze pads on top to protect the bra from the ointment.
Because early ambulation is advisable, patients are told
not to stay in bed, but they are advised to “take it easy” for
1week. That includes refraining from activities like sex that
might raise their blood pressure and promote bleeding.
Mothers can pick up toddlers on the third day after surgery to
transfer them to a high chair, car seat or crib, but should not
carry their child for an extended period of time until 14days
after surgery.
More than 90% of my patients report that they are back to
work in an ofce setting on the fth day after surgery; those
who use their arms a lot (nurses, servers, etc.) are permitted
to return at about 2weeks. Patients are permitted to do activities like running, aerobics, and lower body weights from the
third week on; using upper body weights will be more comfortable at about 5 or 6weeks.
20.5.9 The First Post-op Visit
Patients are generally seen 5–7 days after surgery. At this
time, their Steri-Strips are removed; if the strips came off
sooner it is no problem. I recommend changing from the
ointment to a gentle moisturizer to promote good healing of
the incision. Patients are told that incisions stay reddened
and lumpy for 6weeks. Then they become rm for a minimum of 6months before they start to soften and mature.
Depending upon how high the pectoral muscle has displaced the implant, I might start the patient on a gentle pull up exercise which, as described by Newton’s third law of
motion, displaces the implant in the opposite direction to
facilitate its connection to the existing breast tissue. Patients
are instructed to pull up from the top of their breast toward
the clavicle and hold it for 1min each time, twice a day for a
maximum of 3months (Fig.20.12).
Patients are reminded that it will take 6weeks before their
breast implants even begin to come down, or “drop and uff.”
Their breasts will be 80% settled, soft, and shaped by
3months (roughly 1% a day), and close to 100% settled at
9months. At their initial consultation, patients were informed
about this process and shown pictures of how their breasts
would look at one-week post-op. This is a recommended
practice for patient reassurance.
On average, any increase or decrease in nipple sensation
takes about 6weeks to normalize. In my experience, from
the day of surgery all patients have one side that is more
tender than the other. Unfortunately, there is no rhyme or
reason as to which side it will be. This one-sided tenderness,
which is usually located in the axilla and the side of the
breast, is disconcerting to patients. I explain that they might
experience this on and off for 9months, less and less each
Fig. 20.12 Post-op massage
month. They might have a few months with no discomfort
and then the involved side could zing again. Much reassurance is needed to conrm that this is normal. They are
advised to use anti-inammatories (if they are not allergic)
for any discomfort lasting more than a minute.
20.6 Complications andLimitations
One technique might not satisfy all situations; each case
needs to be evaluated individually.
The technique described in this chapter is not useful for
one-stage submuscular silicone placement. I have tried to
correct TBD with silicone gel implants placed in the dual
plane without radial scoring of the breast parenchyma or
lowering the IMF.I simply tried to stretch the tissues digitally in the hopes that this maneuver would adequately
release the constricted brous tissue of the tubular breast. A
double bubble resulted in each of several efforts.
One patient of mine had a successful result when I placed
the silicone gel implant in the subglandular position. This
approach would need to be studied and evaluated to reveal if
it has merit.
In Zholtikov’s 2019 review of 208 breast augmentation
patients whose TBD was addressed by scoring the breast tissue, the most common complications were as follows: capsular contracture (1.4%), postoperative malposition (1.5%),
“double bubble” (2%), rippling (2%), and areola and nipple
sensitivity disorder (2%). His global complication rate over a
36-month mean follow-up was 8.9% (Zholtikov etal. 2019).
To date, my TBD patients (who underwent a one-stage
saline breast augmentation) had none of the above- mentioned
complications. In addition, there was no bleeding, infection,
deation, seroma, intractable pain, or the need for drains or
reoperation. Those patients who needed a subsequent routine
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T. S. Eisenberg
mammography were able to have one. No patient who chose
to breastfeed after surgery (who was able to breastfeed before
her surgery) reported any problems. Finally, postoperative
surveys revealed that patients were satised with their
esthetic result.
A limitation of my follow-up is the inability to evaluate
every single patient beyond her initial one-week, three-week
and three-month post-op visits due to some women relocating to another city or choosing another doctor for revision
surgery. Most of my patients have a deation warranty for
their implants, which covers some cost of replacement. This
fact, I believe, would incentivize their return to me for follow- up in the event of deation.
The main limitation of this one-stage TBD correction is
that it is only for patients who want saline implants. As stated
above, that is a large majority of the women who come into
my ofce. However, I believe that women who initially ask
for silicone implants would be receptive to learning about the
benets of saline implants to address their tuberous breast
deformity.
20.7 Pearls ofWisdom
• This one-stage correction with saline-inatable breast
implants can be used on any of the four classications of
TBD.
• This technique is useful for any degree of asymmetry.
• It is not necessary to put the patient in the upright position
to determine symmetry because there is distortion from
initial surgical swelling and the implants settle at different
rates over 9months. Use the superior pole of the breast in
relation to the clavicle to reference symmetry.
• Expanding the constricted tissues of tuberous breasts with
the saline implants eliminates the need for the scoring of
the breast parenchyma.
• This one-stage technique also eliminates the need for
lowering the IMF, which decreased the risk of a double-
bubble deformity.
• Because less dissection of breast tissue is needed, there is
a lower chance of hematoma and overall morbidity.
• No drains are used or needed.
• Patients with mild breast ptosis often get enough of an
illusion of a breast lift, obviating the need for a
mastopexy.
• Multiple postoperative visits for serial expansion in the
two-stage approach are not needed.
• The technique might be useful for a subglandular
approach. Further studies need to be done.
• If the patient is unaware that she has TBD, I do not bring
it to her attention. I believe the revelation will create
unnecessary psychic trauma.
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Asymmetric Breasts
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MohanThomas andJamesD’silva
21
Breasts have played a central part in feminine beauty and
have been prominently displayed as art and paintings as very
symmetric in shape which is integral to a beautiful form.
Very few women have perfectly symmetrical breasts. A
slight difference in size up to 20 percent between the right
and left breast is considered normal. But a volume difference
approaching 30% or greater is very difcult to conceal in
normal attire. A young woman with severely asymmetric or
uneven breast development is likely to be profoundly selfconscious. Such marked asymmetry may be caused by
embryological, hormonal, trauma, or idiopathic factors. For
such a woman, surgical intervention to correct this asymmetry can be life changing.
Successful treatment requires compassion, artistry, and
surgical skill.
Understanding asymmetry: An understanding of normal
breast development is important to understand appearance of
breast irregularities. The primordial cells of the human breast
appear between the ventral limb buds as 2 ectodermal ridges
known as mammary ridges or milk lines. The cells of the
upper one-third coalesce to become the future breast, while
the remainder regresses.
Structures of the thoracic region develop at the same time
as a result any abnormal development is demonstrated on
both the breast and the chest wall. Breast development in a
female usually begins between the ages of 8 and 13 due to
the hormonal stimulation of puberty before which the breast
is equivalent in both sexes, consisting of a number of small
ducts in a collagenous stroma. Dissimilar mammary growth
is a common complaint, particularly in the early stages of
breast development. Developmental breast abnormalities
may be part of wider congenital syndromes with a particular
tendency to affect the urinary tract or limb girdles.
M. Thomas (*) · J. D’silva
Aesthetic Surgery, The Cosmetic Surgery Institute
and D. Y. Patil University, Mumbai, India
There are growth disturbances or acquired reasons which
may cause unilateral or bilateral abnormality and may
involve the nipple-areolar complex, the breast mound, or
both. Errors in growth and development in terms of breast
asymmetry include (1) absence of structures, (2) excess
structures, (3) variations in size, and (4) variations in shape
(Reilley 2006).
21.1 Causes ofBreast Asymmetry
1. Developmental asymmetry: The two breast are rarely
symmetric and some asymmetry is seen in all men and
women due to developmental issues which pertain to one
sided preference of upper limbs, sleeping on one side,
breast feeding from one side, etc. (Fig.21.1). Sometimes
the asymmetry is very stark and patient may seek a treatment to correct this.
2. Asymmetric breasts due to infection or burns: Burn injury
to the breast specially before or during the growing phase
can cause marked developmental abnormalities
(Fig.21.2). Infection in the breast (mastitis of pregnancy)
can also cause breast asymmetry (Fig.21.3).
3. Congenital deformity of the NAC: Asymmetry in the
diameter, position, direction of the nipple, etc. which are
not very prominent are very common among humans.
Only when the asymmetry becomes a cause for concern
(Fig. 21.4) does a person consult to address the issue.
Excision of the supernumery element will give a sence of
symmetry to the patient. The NAC which is smaller and
away from its normal position should be considered as
the abnormal one.
4. Asymmetry due to chest/spine deformities:
Kyphoscoliosis of the thoracic spine can push one side of
the rib cage in such a way that the breast on that side may
be more or less prominent. Chest wall deformities such as
pectus carinatum and pectus excavatum (Fig.21.5) may
also reduce or increase the breast prominence making it
look asymmetric.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_21
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Fig. 21.1 Developmental asymmetric breasts where one breast grows more than the other
M. Thomas and J. D’silva
Fig. 21.2 Deformed breast in a 16years old due to burn in childhood.
The scar at the inferior aspect of the breast has pulled the breast tissue
and the NAC inferiorly
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Fig. 21.3 26-year-old patient had mastitis on the right side during breast feeding. Her breasts prior to pregnancy and infection were
symmetrical
317
Fig. 21.4 (a, b) Supernumery breast and NAC on the right side in a 23-year-old lady who also has kyphoscoliosis. (c, d) Supernumery NAC in
an 18-year-old girl who wanted excision of the accessory NAC
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M. Thomas and J. D’silva
Fig. 21.5 (a, b) 27-year- old lady who was operated for pectus excavatum at the age of 15 and is now concerned only about asymmetry of the
breasts. (c, d) 26-year-old lady having a right sided deformity of the rib cage which is reducing the prominence of the breast on the affected side
5. Asymmetry due to tumors: Benign tumors of the breast
specially if present on one side can cause asymmetry
(Fig.21.6).
6. Asymmetry due to deation or removal of breast implant
or secondary to mastectomy (Fig.21.7): Surgical removal
of breast implant from one side either secondary to infection or deation can cause asymmetry which is prominent. Mastectomy secondary to breast cancer also has a
profound inuence on the psychology of the patient.
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