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C. G. M. de Lecea et al.
Fig. 15.10 Preoperative (left) and postoperative (right) pictures of a 45-year-old woman after inverted T breast reduction. A total of 1.8kg was resected
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Fig. 15.11 Preoperative (left) and postoperative (right) pictures of a 38-year-old woman after inverted T breast reduction. A total of 860g was resected
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C. G. M. de Lecea et al.
nancy [53]. After a physical examination and in
the absence of an acute phenomenon such as a
wound infection, evaluation should consist of
mammography and ultrasonography of the
affected breast. Combining the radiographic ndings with echographic appearance of the mass
will help to differentiate fat necrosis and other
benign conditions from the more ominous malig-
needle or open biopsy of the mass. Injection of
any agent into the mass before it is denitively
diagnosed is contraindicated, as is surgical
removal or observation without obtaining a condent exclusion of malignancy. Referral to an
oncologist would be premature in this instance
and would provoke an unnecessary level of
patient anxiety.
nant etiology. The mammographic appearance of
fat necrosis ranges from completely undetectable
to a spiculated density and clustered microcalci-
15.8 Complications
cations. Many authors believe that the calcications of fat necrosis can be distinguished from
those seen with breast malignancies [54].
Ultrasonographic ndings include a solitary cyst,
heterogenous echogenicity, and microcalcications. Any remaining doubt as to the biologic
nature of the mass should then be pursued with
Table 15.1
Postoperative complications Risk factors Treatment
1. Delayed wound healing (most common)
Dehiscence Big preoperative breast volume A. Conservative
Skin loss Large breast resection weight Wound care
Hypertrophic scars Active smoking Infection avoidance
Older patients
2. Fat necrosis (2–10%)
High BMI A. Conservative (if asymptomatic)
Large breast resection weight B. Surgical (if pain/big size)
Suprasternal notch to the nipple
>37cm
3. Nipple-areola necrosis
Pedicle compression A. Intraoperatively:
Tight sutures Suture withdrawal
Internal hematoma Nipple-areola graft
4. Hematoma/seroma
Hematological diseases A. Conservative (if stable or small)
Drugs/herbal therapies BMI
>35Kg/m
5. Infection (4–26%)
Smoking Conservative
2
The average complication rate derived from
the literature runs within 14–53% [22, 49–51].
The most common complications include
seroma, hematoma, nipple necrosis, fat necrosis, infection, and wound healing problems
(Table15.1).
B. Surgical: Debridement and closure
B. Postoperatively:
Partial loss: wound care
Total/subtotal loss: debridement and
reconstruction
B. Surgical (if unstable or big)
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15.8.1 Delayed Wound Healing
Delayed wound healing is the most common
complication in breast reduction surgery. It contemplates wound partial or complete dehiscence
(Fig.15.12), skin loss, and hypertrophic scars. It
is correlated directly with the average preoperative breast volume, average resection weight per
breast [18, 50], and active smoking [52] and
inversely with patient age [22, 49]. The typical
areas affected are the points of greater skin tension or the most remote from blood supply.
Patients with delayed wound healing should
be followed up closely in the ofce to ensure the
most appropriate wound care and to avoid the
development of infection. Wet wound care is frequently used in our institution, except for very
contaminated and exudative lesions which may
be beneted from dry dressings or even from
negative-pressure wound healing.
15.8.2 Fat Necrosis
Fat necrosis is one of the most common complications associated with reduction mammoplasty.
Regardless of the technique, the rates of fat
necrosis have been reported in the 2–10% range
[50]. Its main etiology is the lack of blood supply
secondary to large suture bites in the breast
parenchyma or a diminished blood supply at the
distal end of the pedicle [11]. Fat necrosis commonly presents as a rm, soft-tissue mass that
usually resolves spontaneously. It can be associated with redness and mild discomfort and may
be confused with an infectious process. The literature is inconsistent with respect to detailed
cause and effect or denitive correlations between
fat necrosis and risk factors. However, some of
these risk factors include greater BMI [11, 22,
55–57], larger resection weights (greater than
1300g) [23, 49], and long suprasternal notch-tonipple distance (especially over 37 cm) [58].
Conservative treatment is the best approach in
asymptomatic patients, whereas a second review
surgery must be recommended in painful or in
large fat necrosis.
Fig. 15.12 Skin dehiscence in the union of the vertical
and the horizontal incisions of an inverted T pattern
15.8.3 Nipple-Areolar Necrosis
Nipple necrosis can occur when there is constriction, kinking, or compression of the pedicle
obstructing venous return. The main reasons for
this venous compression may come from a too
tight closure of the skin incisions or from an
internal hematoma.
If a nipple and areola look congested, removal
of sutures and release of compression are rst
indicated. If there is still no improvement of the
nipple-areola venous drainage intraoperatively,
an immediate nipple-areola complex graft should
be performed.
A conservative treatment with wound care
should be followed if the nipple-areola congestion has developed during the immediate postoperative period. Sometimes, some early blistering
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Fig. 15.13 A partial nipple-areola complex loss in an
inverted T pattern, treated conservatively, healing by
secondary intention and with a subsequent loss of
pigmentation and slight deformity
can occur with complete recovery or with some
irregular pigmentation. Other times, only a partial loss occurs, and it is often best to leave this to
heal by secondary intention because the outcome
can be excellent or acceptable (Fig. 15.13).
However, a total or subtotal well-delimited nipple necrosis should undergo debridement and a
second-stage reconstruction (Fig.15.14).
15.8.4 Hematoma andSeroma
Hematoma risk increases with patients with
hematological pathologies as well as patients
under some medications or herbal therapies (acetylsalicylic acid, nonsteroidal anti- inammatory
drugs, ginger, garlic, among others). Higher risk
of developing seroma has been associated with
higher BMI or equal to 35 kg/m2 [57].
Hemodynamically stable patients with small liquid accumulation must be treated conservatively.
An acute active hematoma should be urgently
Fig. 15.14 Picture after complete debridement of a total
nipple-areola complex necrosis in an inverted T pattern
breast reduction mammoplasty
ruled out and treated surgically if the patient
starts with sudden changes in breast volume,
pain, consistency, and vital constants.
15.8.5 Infection
The rate of infection after breast surgery ranges
from 4 to 26% [33]. The microorganism most
commonly found comes from the skin microbiota. Culture specimens should be taken if there is
any type of wound discharge to optimize the antibiotic therapy in accordance with the sensitivity
of the microorganism involved and the hospital’s
infection disease protocols.
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15.9 Conclusions
Breast reduction is a reliable surgery in postmaternity patients. Considerations on further pregnancies or patients’ expectations should always
be claried in the rst medical consultation for
the optimization of the surgical preparation.
Different skin approaches, glandular resections,
and breast remolding may be assessed depending
on the patients’ breast morphology, desires, and
surgeon’s preferences. Finally, patients must be
explained and aware of the possible complications and the surgical outcomes before undergoing breast reduction.
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Postpartum Breast Lift
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withandWithout Implants
RichardJ.Zienowicz andErcanKaracaoglu
16
Take-Home Points
• The discussion of breast rejuvenation should
include whether breast implants should be
recommended. Most experienced aesthetic
breast surgeons feel that the addition of an
implant to the sagging breast results in a more
predictable breast mound elevation and longer
lasting result.
• The patient is marked in the standing position.
The lower pole tissues are gently pinched, and
marks are made on both sides of the pinched
skin. Depending on the size of the implant
chosen (or not), the markings can be adjusted
accordingly.
• These markings are only provisional and serve
as a guide to begin the tailor-tack method of
reshaping the gland.
• The base of the NAC marking is incised on the
junction of circular and vertical marking, and
a single 3-0 Monocryl is subcuticularly placed
to secure this important landmark.
• Circumvertical mastopexy by design re-creates an ideal breast shape. The technique
involves tightening in a vertical direction that
maximally elevates the glandular tissues and
R. J. Zienowicz (*)
Division of Plastic Surgery, Brown University, School
of Medicine, Alpert Medical School,
Providence, RI, USA
E. Karacaoglu
Department of Plastic Surgery, Bahcesehir University,
School of Medicine, Istanbul, Turkey
restores projection more than any other
method.
• Limitations of this technique are seen with
massive ptosis and where Weiss pattern excision of redundant lower pole tissues is sometimes a preferable option.
16.1 Introduction
The postpartum patient after dealing with the exigencies of childcare is left to deal with an often
drastically altered physique. Fortunate individuals
will lose their pregnancy weight expeditiously,
and this is often hastened by the act of nursing
with the enormous calorie expenditure that it
involves. The maternal infant bonding that results
as well as enhanced immune competence and
intelligence seen in infants nursed for a signicant
time frame suggests that most physicians including plastic surgeons should recommend breastfeeding to their prospective patients. A few
months of discontinuation of nursing is generally
recommended before entertaining breast surgery.
The discussion of breast rejuvenation should
include whether breast implants should be recommended. Most experienced aesthetic breast surgeons feel that the addition of an implant to the
sagging breast results in a more predictable breast
mound elevation and longer lasting result due to
the inherent structure of the implants, which confer immediate shape enhancement to the breast.
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_16
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R. J. Zienowicz and E. Karacaoglu
Regnault published a classication of breast
ptosis in 1976 that continues to be a common system of classifying ptosis [1]. Although variations
of this classication exist, key elements from
Regnault’s classication predominate when surgeons discuss and describe degrees of breast
ptosis:
Grade 1: Mild ptosis—nipple just below the
inframammary fold but still above the lower
pole of the breast
Grade 2: Moderate ptosis—nipple further below
the inframammary fold but still with some
lower pole tissue below the nipple
Grade 3: Severe ptosis—Nipple well below the
inframammary fold and no lower pole tissue
below nipple
Pseudoptosis—Inferior pole ptosis with nipple at or above the inframammary fold.
Circumvertical mastopexy (CVM) by design
re-creates an ideal breast shape. It is the author’s
preferred technique because of the limited scarring that results. Indeed, compared to Wise pattern techniques, scarring is generally halved. The
CVM technique involves tightening in a vertical
direction that maximally elevates the glandular
tissues and restores projection more than any
other method. Limitations of this technique are
seen with massive ptosis and where Weiss pattern
excision of redundant lower pole tissues is sometimes a preferable option. The decision of
whether it is safe to perform augmentation concurrent with mastopexy has been addressed by
several large studies [2, 3] and has been safely
practiced by the authors for over 25years.
Contraindications
• Active galactorrhea
• Active breast acne
• Previous trauma or surgery that may have
compromised nipple-areolar complex
vascularity
16.3 Preoperative Evaluation
16.3.1 Physical Examination
The patient should be able to give the surgeon an
estimate of her expectations with respect to the
size of the resulting breasts, degree of lifting, size
of areolae, and scarring. Her body habitus, i.e.,
natural breast size, shoulders, hips, derriere, and
ectomorphic, endomorphic, or mesomorphic
build, should be considered in recommending a
size that complements her frame ideally and
coincides with her individual preferences. We
typically then place the patient in an appropriate
sized bra and choose silicone sizers (Allergan,
Inc., Mentor, Inc.) to place within each cup and
have the patient put on her blouse or shirt to view
in a full-length mirror. We can upsize or downsize until she is comfortable with a particular
size. We then perform three-dimensional imaging
with VECTRA imaging system to demonstrate
landmarks, symmetry, or lack of CVM markings
and implant type and size and utilize morphing
software to simulate post-op result. If the patient
wishes to see a variety of sizes, these can be visually compared side to side facilitating accurate
choices that have been validated in several
studies.
16.2 Patient Selection
All grade 3 and most grade 2 ptotic patients
require mastopexy for proper breast rejuvenation.
Occasionally, a circumareolar (Benelli, donut)
mastopexy will sufce for some grade 2 patients,
and very large implants can sometimes adequately correct intermediate ptosis. For discussion of the nuances of these scenarios, the reader
is encouraged to refer to more comprehensive
sources.
16.3.2 Preoperative Markings
The patient is marked in the standing position. A
vertical line is drawn with a methylene blue
marker from the apex of the nipple upwards in a
direction that corresponds to the desired direction
of glandular correction. A breast that hangs in a
medial to lateral direction will require obliquity
of the line in a lateral to medial direction to move
the displaced tissues from lateral to medial. Next,
the lower pole tissues are gently pinched with the
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surgeon’s index and thumb until they are touching together and marks are made on both sides of
the pinched skin along the lower pole stopping a
few centimeters short of the inframammary fold
(IMF). The skin of the lower pole of an individual’s breast can vary enormously. If the skin thickness and quality are optimal, then the markings
should be immediately adjacent to the surgeon’s
ngers. If the skin is thin and stretchable, then the
markings should be commensurately wider.
Depending on the size of the implant chosen (or
not), the markings can also be adjusted accordingly. These are only provisional and serve as a
guide to begin the tailor-tack method of reshaping the gland described below.
16.4 Anesthetic Considerations
This operation can be performed comfortably
with general endotracheal (GET), laryngeal mask
airway (LMA), or deep monitored anesthesia
care (MAC). My preference having done it for
many years with MAC, which required intercostal nerve blocks to accomplish satisfactorily, is
for general anesthesia with LMA.The operation
should take on average 2h for a single surgeon
and only half with a competent assistant who can
suture adequately. This is within the safety window of time for LMA anesthesia. My strong preference is to avoid epinephrine anywhere near the
nipple-areolar complex (NAC) to prevent unintentional restriction of blood ow to that structure, which is the most concerning complication
of this combined procedure.
16.5.2 Approaches
Occasionally, in a narrow breast with marked
ptosis and planned large implant placement during which it is anticipated that there will be strain
on the NAC closure due to increased tension
from the indwelling implant, I will opt to place
the implants through a transaxillary approach.
This portal maximally preserves vascularity to
the NAC but adds another step and incision. The
resulting axillary scar is invariably of little cosmetic concern to the patient for the added safety
it provides.
16.5.3 Procedure Step-by-Step
Prior to prepping, xylocaine 1% with epinephrine
is injected into the central lower pole (where the
implant insertion will be performed) in the center
of the zone that has been marked for excision.
For postoperative comfort, 0.25% Marcaine and
0.5% xylocaine intercostal nerve blocks may be
performed from T2–T7 as well. The patient is
prepped with ChloraPrep and Tegaderm applied
to the NAC bilaterally until implants are placed.
Depending on the chosen implant size, a vertical
incision is made in the lower pole between 3.5
and 5 cm in length and carried down through
breast parenchyma until the pectoralis major
muscle is encountered (Fig. 16.1). A narrow
Deaver retractor is then inserted, and traction in
the direction of the ceiling is applied which pulls
16.5 Surgical Technique
16.5.1 Patient Positioning
The patient is placed supine on the OR table with
arm boards superiorly positioned at right angles
and arms xed to the arm boards with Webril and
Velcro to permit a full sitting position to assess
breast shape and properly judge intraoperative
NAC markings. Additionally, the head should be
secured with tape to the headrest in a straight
neutral position.
Fig. 16.1 Depending on the chosen implant size, a vertical incision is made in the lower pole between 3.5 and
5 cm in length and carried down through breast
parenchyma until the pectoralis major muscle is
encountered
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