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J. M. Serra-Mestre et al.
resulting from the broken down fatty acids. We
discard the bottom layer of anesthetic and blood
and then remove the upper part containing the fat
droplets with a small gauze.
Fat Injection
The key issue in fat grafting is to achieve the correct three-dimensional distribution of fat in different planes from depth to surface, creating a
crisscross pattern and avoiding the accumulation
of large quantities of fat. The diameter of the cannula used for the injection should be the same as
the one used to extract the fat, in order to minimize the mechanical damage to the adipocytes.
Microfat is injected via 0.9mm cannulas into
the subcutaneous plane, in contrast to structural
fat grafting.
“Fat injection should be performed in multiple
passes, in multiple tissue planes, and in multiple
directions to avoid large accumulations.”
18.5.3 Surgical Modications
In cases of augmentation or mastopexy, the intermammary distance is sometimes excessive; alternatively, there may be asymmetries in the area of
medial cleavage. However, even using the most
updated surgical techniques, the plastic surgeon
has only a relative control over their correction,
because the space between the breasts is determined by anatomical factors such as the attachment points of the breast tissue to the periosteal
tissue covering the sternum, and also to some
extent by the medial attachments of the pectoralis
major muscle and by the thickness of this muscle
if a retropectoral dissection plane is used.
Recently, we described a procedure in which
we use fat grafting as a complement to the different techniques of breast surgery, not only in cases
of breast augmentation or mastopexy but in breast
reconstruction as well. Using limited amounts of
fat, this technique redenes the cleavage correcting asymmetries and reducing the distance
between the breasts [13].
Fat grafting is always performed once the surgery is nished, and whenever possible, the can-
nula is inserted through the previously made
incisions. The microfat graft is injected into the
subcutaneous layer in the shape of a crescent,
upwards from the inframammary fold to the
upper quadrants. It is important to extend this
crescent to the upper quadrants, creating an
inverted “L” shape to recreate a satisfactory
medial cleavage and to avoid possible irregularities in the upper internal quadrant.
“Fat grafting is extremely useful in the medial
quadrants, and it is also effective for correcting
volume asymmetries in other areas of the breast.”
18.5.4 Technical Tips toImprove
Outcomes andAvoid
Complications
The key issue in fat grafting is to achieve a correct three-dimensional distribution of fat in different planes, avoiding the accumulation of large
quantities. Injection should be performed in multiple passes, in multiple tissue planes, and in multiple directions.
It is very important not to create irregularities
in the donor sites. After liposuction, with a at
3mm cannula without aspiration, we regularize
the whole area where the fat was harvested.
Also the use of a blunt-tip cannula is mandatory in order to avoid any tissue damage.
18.6 Postoperative Care
Each patient requires a specic treatment and
follow-up depending on the techniques that have
been performed. The patient must sleep in the
supine position for 2 or 3 weeks, and prompt
inspection of wounds is important. Stiches are
removed 2weeks after surgery, and a postsurgical bra is mandatory for the rst 2months of follow-up to protect the breast and reduce
discomfort.
At the donor site, in the postoperative period,
we recommend the application of chelating
creams to reduce bruising, and also lymph drainage and massage to help restore the whole area.
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18.7 Outcomes andPrognosis
Fat grafting is not just a complementary technique in breast surgery; in some cases, volume
increase can be achieved with fat grafting alone.
In all events, the patient must be informed of the
procedure’s advantages and limitations. Among
its advantages, it avoids the complications associated with implants such as rupture or contraction,
and also the grafting of autologous fat upholds
one of Converse’s principles of conservative surgery: “replace like with like.” Its main drawback
is that the volume increase that can be achieved
with a single fat grafting session is limited; like
any graft, fat must be injected in a dispersed and
homogeneous way and not delivered in bolus
form. As long as the patient understands these
limitations, satisfactory volume increases can be
obtained in two sessions, thus avoiding the use of
implants.
In cases of mastopexy in medium-sized or
large breasts, fat grafting can avoid the use of
implants since it preserves a sufcient amount of
breast volume for the augmentation.
In small breasts, an intermediate option is
composite breast augmentation. In this technique,
the breast volume is increased with fat, and a
small implant is also inserted. Its main advantage
is that it avoids some of the complications associated with implants and obtains a breast with a
more natural appearance and feel.
In certain situations, then, fat grafting is a safe
alternative to implants in breast surgery, and it
can also serve as a very useful complement to
implants. Fat grafting achieves optimal results in
terms of symmetry and breast shape.
18.8 Complications
Fat injection in breast surgery is a safe technique
with low complication rates. It is important to
consider that fat has become an autologous ller,
completely biocompatible, nonmigratory, and
non-teratogenic.
Despite the low complication rate, the surgeon’s experience with the surgical technique is
important to the success of the procedure, avoiding irregularities or problems of hypo- and hypercorrection of the defects. In any case,
hypocorrection is preferred, as it can be resolved
with subsequent injections.
As in any surgical procedure, inammation or
bruises may appear during the days after the
intervention. In these cases, the use of antiinammatory medication and cold therapy can be
helpful. Infection can also be controlled maintaining correct asepsis of the area, close postsurgical monitoring, and antibiotic prophylaxis
immediately prior to surgery.
Another possible complication is damage to
neighboring structures such as vessels or nerves,
which is not frequent in breast procedures. To
avoid this, we use blunt-tipped cannulas and we
always perform a slight aspiration before injecting the fat to avoid the potential risk of fat
embolization.
In the medium to long term, calcications
may appear, but they are easy to recognize. There
may also be oil droplets or fat cyst, and if the fat
is not injected correctly, areas of steatonecrosis
or hardening may appear. Injections may be done
in multiple passes, in multiple tissue planes, and
in multiple directions, injecting small volumes in
each pass.
18.9 Conclusions
Fat grafting has established itself as a safe technique, which is widely used in breast surgery and
in other parts of the body for increasing volume
and improving tissue quality.
In cosmetic breast surgery, autologous fat
injection has become a routine practice for correcting the inherent limitations of implants and
allows to achieve an ideal breast shape and contour while also increasing the size. It is especially
useful in cases of complicated asymmetries,
chest wall deformities, or tuberous breasts.
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J. M. Serra-Mestre et al.
References
1. Salazar H, Tobon H, Josimovich JB.Developmental
gestational and postgestational modications of the
human breast. Clin Obstet Gynecol. 1975;18:113–37.
2. Vorherr H. Human lactation and breast feeding. In:
Larson BI, editor. Lactation, vol. IV. New York:
Academic; 1978. p.182.
3. Battersby S, Anderson TJ. Histological changes
in breast tissue that characterize recent pregnancy.
Histopathology. 1989;15:415–33.
4. Jindal S, Gao D, Bell P, et al. Postpartum breast
involution reveals regression of secretory lobules
mediated by tissue-remodeling. Breast Cancer Res.
2014;16(2):R31.
5. Serra-Renom J, Garrido MF, Yoon T. Augmentation
mammaplasty with anatomic soft, cohesive silicone
implant using the transaxillary approach at a subfascial level with endoscopic assistance. Plast Reconstr
Surg. 2005;116(2):640–5.
6. Shi Y, Sun H, Fang J, etal. Clinical application of precise composite breast augmentation. Ann Plast Surg.
2019;83(4S Suppl 1):S5–S10.
7. Sarosiek K, Maxwell GP, Unger JG.Getting the most
out of augmentation-mastopexy. Plast Reconstr Surg.
2018;142(5):742e–59e.
8. Serra-Renom JM, Muñoz-Olmo JL, Serra- Mestre
JM.Fat grafting in postmastectomy breast reconstruction with expanders and prostheses in patients who
have received radiotherapy: formation of new subcutaneous tissue. Plast Reconstr Surg. 2010;125(1):12–8.
9. Serra-Renom JM, Muñoz-Olmo J, Serra-Mestre
JM.Breast reconstruction with fat grafting alone. Ann
Plast Surg. 2011;66(6):598–601.
10. Hammond DC, Alfonso D, Khuthaila DK.Mastopexy
using the short scar periareolar inferior pedicle reduction technique. Plast Reconstr Surg.
2008;121(5):1533–9.
11. Serra-Renom JM, Fontdevila J.New marking designs
for vertical scar breast reduction. Aesthet Surg J.
2004;24(2):171–5.
12. Qureshi AA, Myckatyn TM, Tenenbaum
MM. Mastopexy and mastopexy-augmentation.
Aesthet Surg J. 2018;38(4):374–84.
13. Serra-Mestre JM, Fernandez Peñuela R, Foti V,
et al. Breast cleavage remodeling with fat grafting: a safe way to optimize symmetry and to reduce
intermammary distance. Plast Reconstr Surg.
2017;140(5):665e–72e.
14. Serra-Renom JM, Muñoz-Olmo J, Serra-Mestre
JM. Treatment of grade 3 tuberous breasts with
Puckett’s technique (modied) and fat grafting to
correct the constricting ring. Aesthet Plast Surg.
2011;35(5):773–81.
15. Strong AL, Cederna PS, Rubin JP, et al. The current
state of fat grafting: a review of harvesting, processing, and injection techniques. Plast Reconstr Surg.
2015;136(4):897–912.
16. Nguyen PS, Desouches C, Gay AM, et al.
Development of micro-injection as an innovative
autologous fat graft technique: the use of adipose tissue as dermal ller. J Plast Reconstr Aesthet Surg.
2012;65(12):1692–9.
17. Lindenblatt N, van Hulle A, Verpaele AM, etal. The
role of microfat grafting in facial contouring. Aesthet
Surg J. 2015;35(7):763–71.
Nipple-Areola Complex
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Restoration After Breastfeeding
Carlosdel PilarBérnizLaborda
andJesúsOlivas-Menayo
19
Take-Home Points
• Nipple inversion is a frequent condition present since birth or developed later. The main
benign cause for acquired nipple retraction is
inammation associated to mastitis, typical
during breastfeeding.
• Malignant pathology must always be ruled
out.
• Patients’ expectations and degree of retraction
must be assessed before planning any surgical
procedure.
• Plenty of techniques have been described; the
key for the right choice is good preoperative
evaluation.
• For mild degrees of retraction, suture-based
techniques may be successful, but the risk of
recurrence is higher.
• Most effective techniques imply transection of
galactophorous ducts, impairing later breastfeeding. This must be warned to the patients.
• Incisions should always be placed at the areola border or the nipple base to make them as
inconspicuous as possible.
C. del PilarBérnizLaborda (*)
Clínica Universidad de Navarra, Madrid, Spain
e-mail: cberniz@unav.es
J. Olivas-Menayo
Department Plastic Reconstructive and Aesthetic
Surgery, MS Medical Institutes, Lisbon, Portugal
e-mail: doctor@olivasmenayo.com
• The use of traction devices alone or in combination with surgery has proven being effective
reducing recurrence rate.
• The minimal time for traction device placement should be 15days to 1 month, but this
can be longer if it is required.
• Postoperative care of the wounds and traction
device should be taught to the patient.
19.1 Introduction (It Can Include
theAnatomy,
Proportions, etc.)
The ideal nipple-areola complex (NAC) is centered in the point of maximal convexity of the
mound being a visual reference for an attractive
and aesthetically pleasing breast. The ideal
dimensions of the areola are about 4cm diameter
with the nipples slightly upward oriented about
10–15°. The nipple should be 1cm wide and projected over the areola about 1.2cm [1].
Ideal breasts should form an equilateral trian-
gle with the sternal notch and both NACs as the
vertex, with sides between 19 and 21cm. Another
important measure is the distance between the
nipple and the inframammary fold. In a nonptotic breast, the inferior border of the nipple
should be above it.
The blood supply of the NAC depends on both
the parenchymal and subdermal plexus arising
from the external and internal mammary, inter-
© 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_19
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C. del PilarBérnizLaborda and J. O. Menayo
costal, and thoracoacromial arteries [2]. Sensation
of both nipple and areola depends on anteromedial and anterolateral cutaneous branches of the
fourth intercostal nerve [3].
The estimated prevalence of inverted nipple is
between 3 and 5% of the female population, and
in up to 4 out of 5 cases, both nipples are affected.
The main etiology is congenital or acquired after
inammatory processes such as mastitis [4]. The
repercussion is not only aesthetic, considering
that the nipple-areola complex is the key point in
terms of symmetry and aesthetics, but also affects
breastfeeding as well as the sexual and intimate
sphere of the patient. Since it was rst described
in 1840, numerous techniques and methods have
been proposed for its correction [5].
The female breast begins its development in
the fth week of fetal growth with the appearance
of 15–20 breast buds of ectoderm along the mammary crests. These extend from the armpit to the
inguinal region and remit in the seventh week
with the exception of a pair at the fourth or fth
intercostal space level. The persistence of some
of these primitive mammary buttons translates
into disorders such as polymastia or polythelia.
In the fth month, between 15 and 20 invaginations arise from that ectodermal tissue; these penetrate the mesoderm and will give rise to the
galactophorous ducts. At this time, the areolas are
formed, and in the eighth month, the proliferation
of mesenchymal tissue under the pit makes the
nipple protrude [6]. An interruption during the
embryonic development of this mesenchymal
proliferation or the subsequent maturation of the
galactophorous ducts would cause the nipple to
invert in a similar way that secondary brosis
after inammatory or tumoral processes retracts
these structures.
patient’s desires and the degree of retraction as a
guide for the surgeon to choose the most appropriate surgical technique must be taken into consideration in each case. If the patient is not
concerned about breastfeeding in the future,
techniques that do not preserve the ducts are
indicated. On the other hand, when breastfeeding is planned, conservative surgery is indicated
always warning the patient that the recurrence
rate is higher.
19.3 Preoperative Evaluation
During preoperative evaluation, personal and
family history of breast disease or cancer should
be obtained. In those patients where nipple inversion had recently developed, screening mammography must be done and any malignant
pathology ruled out. Pregnancy history, previous
breastfeeding, and specially any wish for breastfeeding if future children are planned must be
asked as previously mentioned.
Areolar diameter is measured, and the grade
of inversion is established according to Han and
Hong (1999) [7] classication, which establishes
3° depending on the severity of the retraction:
Grade I The nipple can be everted manually
easily and maintains projection by itself. In this
case, the presence of brous tissue is minimal
and there are enough soft tissues beneath the nipple-areola complex.
Grade II The nipple can be everted with greater
difculty than grade I and tends to return to the
inverted position. There is a higher degree of
brosis, and the galactophorous ducts may be
shortened.
19.2 Patient Selection
Any patient complaining about nipple retraction
or dissatisfaction with their aspect should be
considered for improvement. During the rst
interview, plans for future children and the wish
to breastfeed should be discussed. Both the
Grade III Severe nipple inversion occurs that
can hardly be corrected manually. It does not
maintain the everted position because of the
brosis, and the galactophorous ducts are
severely shortened. In addition to this, there is a
decit of tissue beneath the nipple-areola
complex.
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The usual breast measures must also be
assessed to detect any asymmetry or ptosis:
• Sternal notch-to-nipple distance
• Nipple-to-IMF distance
• Base width
• Intermammary distance
• Breast triangle
• Breast height
The chosen method for correction will always
be based on the degree of inversion and patients’
maternity wishes.
– For grade I patients, a conservative technique
preferably based on the use of sutures and
traction devices will be preferred. Correction
is possible, and these techniques avoid place-
ment of any visible scar.
– For grade II, the decision will depend on
patient desires. If any future pregnancy and
breastfeeding are planned, conservative tech-
niques should always be used warning the
patient about the risk of recurrence. If there is
no wish for lactation, a duct-non-preserving
technique is preferred.
– For grade III, the preferred option should be
any procedure that cuts all ducts and retraction
to minimize the risk of recurrence and prefer-
ably based on aps instead of sutures. Only if
the patient demands preservation of breast-
feeding, conservative surgery may be offered
always informing the patient of a risk of recur-
rence over 50–60%.
19.4 Anesthetic Considerations
(Local Anesthesia)
The procedure is performed under local anesthesia. Therefore, any allergies or previous reactions
to anesthetics should be ruled out during preoperative evaluation. In our practice, we use a mix
of 50:50 lidocaine:bupivacaine. Lidocaine has a
quick-onset anesthetic effect at the time of injection, and bupivacaine is added for its late effect to
make the immediate postoperative time painless
[8]. No adrenaline is used because there is some
risk of nipple necrosis associated to this proce-
dure. Although some authors advocate the use of
sodium bicarbonate to neutralize the acidity of
both lidocaine and bupivacaine, we prefer the use
of topic lidocaine/prilocaine applied 1 h before
the procedure. In cases of preoperative anxiety or
if the patient demands it, a mild sedation with iv
midazolam is used, achieving greater comfort
and a better experience.
19.5 Surgical Technique
19.5.1 Patient Positioning
The procedure is carried out in supine position
with the arms of the patients slightly abducted.
19.5.2 Procedure Step-by-Step
Once the nipple-areola complex is anesthetized,
the nipple is everted by means of a 3-0 silk stitch
and the incision is made in the nipple-areola transition between the 4 and 8 o’clock (Fig.19.1).
The incision deepens perpendicularly about
1cm. In that plane, dissection is extended in the
cranial direction under the nipple, transecting the
brous tracts that cause the retraction (Fig.19.2).
From the areolar edge of the incision, a ap of
subcutaneous tissue is tailored. This will be interposed under the nipple. This ap is a key element
because it adds projection to the nipple by substituting the absent tissue beneath and preventing
the formation of new brosis that would otherwise make the inversion recur. The interposition
ap is anchored by absorbable sutures to the
opposite nipple wall and then the skin is closed
(Figs.19.3 and 19.4).
To avoid umbilicated scars that may alter the
nal result, 6-0 horizontal mattress stitches are
used. These will be maintained for the rst
15days. Finally, a traction device is applied with
the splinting of the nipple to maintain the projection achieved during the procedure and prevent
inammation of the surrounding tissues. The
base of a 10cc syringe is used for this purpose.
Four notches are carved to anchor two perpendicularly crossed sutures under and over the nipples (Fig.19.5).
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Fig. 19.1 After the NAC is completely anesthetized, it is everted with a 3-0 silk stitch. Once everted, the transition
between the nipple and the areola is incised between 4 and 8 o’clock
C. del PilarBérnizLaborda and J. O. Menayo
Fig. 19.2 Dissection is carried out in a cranial direction beneath the nipple, and under direct visualization, all brous
tracts are transected
Fig. 19.3 Once all brosis is transected, maintained
eversion of the nipple should be observed. Once the ap is
tailored as shown in the drawing, it is sutured to the upper
base of the nipple. This way, it is placed between the two
cut ends of brous tissue
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Fig. 19.4 Once the
nipple is incised,
dissection is deepened
1cm. Then transection
of the ducts is
performed. The ap is
tailored from the inferior
wall of the incision and
interposed between the
two ends of the brous
tissue. An anchor stitch
is used; this way, brosis
is replaced with the
healthy soft tissue, the
nipple base slightly
stretched, and projection
obtained
333
Nipple-Areola TransitionFibrous tracts
A
B
B
A
1 cm
Augmented
projection
Fig. 19.5 Closure of the skin is done with 6-0 monolament horizontal mattress stitches. Traction device is created
with the base of a 10cc syringe and secured with two perpendicular sutures under the nipple
19.5.3 Surgical Modications
We have presented our own surgical repair for
inverted nipple, indicated for most of the cases,
for patients that are not concerned about breast-
feeding and that present a grade II or III of retraction. However, the literature contains plenty of
modications with different degrees of complexity. Some of these are discussed and shown below
and may have their own indication depending on
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the patient. This is divided between techniques
that preserve the ducts and those that do not.
Here, only a small sample is included, those with
a signicant number of cases reported and proved
effectiveness.
19.5.3.1 Duct-Preserving Techniques
Suture Based
Gould DJ (2015): Through an inferior nipple
base incision, blunt dissection of the brous ducts
is carried out preserving them. Two external 4-0
horizontal mattress sutures are placed perpendicularly plus an external 4-0 purse-string suture.
Traction device is maintained for 2 (grades I–II)
or 5days (grade III). A recurrence of 7% out of
191 nipples is reported [9] (Figs.19.6 and 19.7).
Jeong JH (2017): Three slit incisions and a
larger one (5mm) are made in the four cardinal
points of the nipple base. After blunt dissection
of brous ducts, an absorbable monolament
suture is passed through the periphery and center
of the nipple creating a shape of a cross inside a
circle. The traction device is used for 14days.
The reported recurrence rate is 4.30% out of 75
nipples (grades II and III) [10] (Fig.19.8).
Yukun L (2016): Two horizontal and vertical
sutures with 1-0 or 2-0 Mersilk nonabsorbable
sutures are placed crossing the undersurface of
the nipple. The same four ends of the sutures are
used to place the retractor made from a 10 cc
C. del PilarBérnizLaborda and J. O. Menayo
Fig. 19.7 Purse-string suture around the nipple base
Fig. 19.8 Peripheral and crossing sutures with the shape
of a cross inside a circle
Fig. 19.6 Crossed horizontal mattress sutures
syringe base. Traction device is maintained from
3 to 6months depending on patients’ discomfort.
Recurrence rate decreases depending on the
severity of retraction. Out of 257 nipples, 0% rate
is for I, 3.2% for II, and 63.3% for III [11]
(Fig.19.9).
Flap Based
Jeong HS (2015): Two triangular subcutaneous
aps are raised from the areola and passed under
the nipple after blunt dissection to preserve the
ducts. The design of the aps places the scar
crossing the nipple base and the areola. No recurrence has been reported out of 47 nipples (II and
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Fig. 19.9 Crossed sutures with free ends to be anchored
to the traction device
Fig. 19.10 Triangular subcutaneous aps based around
the nipple
III grade), and 5 patients that got pregnant
reported successful breastfeeding. Sensation was
measured with a 100% function eliciting a contraction response [12] (Figs.19.10 and 19.11).
Durgun M (2014): Two triangular subdermal
aps are raised and deepithelialized. After 90°
rotation, these are passed under the tunnels made
by blunt dissection. The two aps are sutured,
and a traction device is placed and maintained for
21days. A 6.25% recurrence has been reported
for 28 grade II and III inverted nipples [13]
(Figs.19.12 and 19.13).
Fig. 19.11 Both aps crossed under the nipple base
Fig. 19.12 Subdermal aps with a curved border reach-
ing half of the areola
Mathur B (2018): This method combines
selective release and transection of the ducts with
a “drawbridge” ap raised from the nipple base to
the areola border to be tunneled under the nipple.
With 97 nipples corrected for all types of inversion, the recurrence reported is 0% with 100%
sensation preserved [14] (Figs.19.14 and 19.15).
19.5.3.2 Duct-Transecting Techniques
Flap Based
Han S (1999): For grade III nipple inversion, the
original technique published by Han advocates
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