Melvin A. Shiffman (Editor)

Breast Augmentation

Melvin A. Shiffman (Editor)

Breast AugmentationPrinciples and Practice

123

ISBN 978-3-540-78947-5 e-ISBN 978-3-540-78948-2

DOI 10.1007/978-3-540-78948-2

Library of Congress Control Number: 2008925097

© 2009 Springer-Verlag Berlin Heidelberg

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Melvin A. Shiffman, MD, JDChairman, Surgery SectionTustin Hospital and Medical Center17501 Chatham DriveTustin, CA 92780-2302USA

It is a great pleasure and privilege to recommend this book on breast augmentation, having spent over 25 years of my life dealing with and operating on breasts. It is still fascinating to understand why breast augmentation has become one of the most com-mon cosmetic operations in the world. The psychology and body image that influence a woman’s decision to have this operation are still a mystery. Many books and articles have been written about various techniques; however, you will find all of this condensed in this book, with the latest information and research to help you understand this rela-tively simple operation. Varying approaches and different implants have puzzled many surgeons and patients alike, and this book provides enlightenment.

Implants and materials used in this operation are discussed and argued in this book and settle the score on which implant should be used in the 21st century. The position-ing of the implants either above or below the muscle is discussed in detail, and the rea-sons behind the authors’ preferences are well demonstrated. Capsule formation has been considered as a sequela of the operation, and many speculations have been put forward as to the likely cause. However, to date, no surgeon or theory has convinced me that the answer has been found as to the likely cause of this condition, and that is why the treat-ment has been toward symptomatic management rather than prevention and cure.

The size of the implants and the final result have depended mostly on the surgeon’s experience and the patient’s psychological state. There is no precise way to accurately determine the size; however, my measurements and ideas have been put forward to help both novice and experienced surgeons alike. New ideas and measurements have also been put forward. Indications and information on where to draw the line between aug-mentation and mastopexy and when to combine the two operations are discussed.

The purpose of this book is to discuss the current thoughts and trends in breast aug-mentation and to detail the current techniques used, as well as to discuss various com-mon complications of this procedure, how to deal with these problems, and how to treat these conditions using the current thoughts and tried and tested methods.

A unique contribution to the gratification of these human needs has been the de-velopment of surgical techniques that are safe, reasonable, and available. These are de-scribed in this book and seem to answer many questions, based on scientific and sound anatomical bases.

Anthony Erian

Foreword

Breast augmentation is one of the most common cosmetic procedures performed. Women who are concerned about the size of their breasts will seek an improved appear-ance with augmentation to conform to their own body image. Despite the prolonged litigation and settlement of lawsuits concerning silicone breast implants and their pos-sible association with autoimmune disease, there has been a resurgence in the frequency of breast augmentation. It has ultimately been shown that silicone is not the cause of the claimed autoimmune disease. Additionally, introduction of a cohesive gel implant that does not contain silicone gel fluid that can “bleed” into the pocket has contributed to a decrease in capsule contracture.

Surgeons performing breast augmentation have to be well informed, not only about the variety of techniques that are available but also about the possible risks and compli-cations of the procedure. The surgeon should be capable of deciding which procedure to use to correct any defect or deformity and of avoiding or treating the variety of possible complications of the surgery. The patient should understand that the possibility exists for a second or even third procedure on the breast after augmentation.

This book is an attempt to bring together, as much as possible, augmentation surgery techniques, the possible complications of each one, and the means of correcting breast imperfections. It also includes chapters on embryology, anatomy, benign and malig-nant breast diseases, mammograms, body dysmorphic disorder, implant choice, breast augmentation principles, the various pockets and incisions, and medical-legal aspects. The international contributors are experts in the field of breast augmentation and have helped put together a much needed textbook to cover the varieties of breast problems and their solutions.

Melvin A. Shiffman

Preface

Part I Anatomy, Benign Breast Disease, Malignant Breast Disease, Mammograms

1 Embryology and Anatomy of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3John E. Skandalakis

2 Nerves, Ligaments, and Vessels of the Chest and Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Elisabeth Würinger

3 Anthropomorphic Measurement of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Melvyn Westreich

4 Anatomy and Clinical Significance of the Pectoral Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Lin Jinde

5 The Inframammary Crease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Brooke R. Seckel, Shawkat A. Sati, W. Thomas McClellan

6 Breast Asymmetries: A Working Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Gianpiero Gravante, Antonino Araco, Valerio Cervelli

7 Benign Disorders of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Melvin A. Shiffman

8 Malignant Breast Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Melvin A. Shiffman

9 Mammograms in Cosmetic Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Melvin A. Shiffman

Part II Preoperative Consultation

10 Initial Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Melvin A. Shiffman

11 Method for Determining Bra Size and Predicting Postaugmentation Breast Size . . . . . . . . 77Edward A. Pechter

12 Breast Assessment and Implant Selection Using the TTM Aesthetic Breast Chart . . . . . . . . 85Toma T. Mugea

13 The Golden Ratios of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Richard Moufarrège

Contents

14 Body Image and Other Psychological Issues in Breast Augmentation . . . . . . . . . . . . . . . . . 117David B. Sarwer, Alison L. Infield

15 Body Dysmorphic Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127Melvin A. Shiffman

16 Use of Decision and Management Algorithms in a Breast Augmentation Practice . . . . . . . . 131Caroline A. Glicksman

Part III Implants

17 Silicone Versus Saline Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165Robert S. Reiffel

18 Choice of Prosthesis Surface: Myth or Necessity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177Richard Moufarrège, Alexandre Dionyssopoulos

19 Enhanced Projection: Adjustable Gel Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185Hilton Becker, Luis A. Picard-Ami, Jr.

20 Betadine and Breast Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191Melvin A. Shiffman

21 Mechanical Analysis of Explanted Silicone Breast Implants . . . . . . . . . . . . . . . . . . . . . . . . . 193Daniel P. Greenwald, Mark Randolph, James W. May

22 Cohesive Gel Silicone Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197Ângelo Rebelo

Part IV Surgical Approaches

23 Principles of Breast Augmentation Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205Melvin A. Shiffman

24 Intraoperative Assessment of Breast Prosthesis Volume Using a Set of Graduated Expanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207Beniamino Palmieri, Pierangelo Bosio, Melvin A. Shiffman

25 Breast Augmentation: Intraareolar Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211Melvin A. Shiffman

26 Breast Augmentation Using the Periareolar Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Asuman Sevin, Kutlu Sevin

27 Inframammary Approach to Subglandular Breast Augmentation . . . . . . . . . . . . . . . . . . . . 221Anthony Erian, Amal Dass

28 Breast Augmentation: Axillary Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231George John Bitar

ContentsX

29 Hydrodissection Axillary Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241Sid J. Mirrafati, Melvin A. Shiffman

30 Nipple or Areolar Reduction with Simultaneous Breast Augmentation . . . . . . . . . . . . . . . . 247Richard A. Baxter

31 Classification of Breast Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251Melvin A. Shiffman

32 Breast Augmentation with Mastopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257Myron M. Persoff

33 Crescent Mastopexy with Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277André Auersvald, Luiz Augusto Auersvald

34 Breast Augmentation with Periareolar Mastopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283Steven P. Davison, Mark W. Clemens

35 Mastopexy/Reduction and Augmentation Without Vertical Scar . . . . . . . . . . . . . . . . . . . . 291Sid J. Mirrafati

36 Classification of the Tuberous Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297Melvin A. Shiffman

37 The Incidence of Tuberous Breast Deformity in Asymmetric and Symmetric Mammaplasty Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301Danielle DeLuca-Pytell, Rocco C. Piazza, Julie C. Holding, Ned Snyder, Lisa M. Hunsicker, Linda G. Phillips

38 Aesthetic Reconstruction of the Tuberous Breast Deformity . . . . . . . . . . . . . . . . . . . . . . . . 307Apostolos D. Mandrekas, George J. Zambacos

39 Periareolar Technique for Correction and Augmentation of the Tuberous Breast . . . . . . . . . 321Bobby Arun Kumar, Darryl J. Hodgkinson

40 The Effect of Breast Parenchymal Maldistribution on Augmentation Mammoplasty Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329Robert R. Brink, Joel B. Beck

41 Management of Anterior Chest Wall Deformity in Breast Augmentation . . . . . . . . . . . . . . 333Darryl J. Hodgkinson

42 Poland’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345Renato da Silva Freitas, André Ricardo Dall’Oglio Tolazzi, Anileda Ribeiro dos Santos, Ruth Maria Graf, Gilvani Azor de Oliveira e Cruz

43 Breast Augmentation in the Transsexual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359Nikolas V. Chugay

44 Anesthetic Drip System to Reduce Pain in Cosmetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . 363Melvin A. Shiffman

Contents XI

Part V Position of Implant

45 Submammary Versus Subpectoral Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371Chin-Ho Wong, Bien-Keem Tan, Colin Song

46 Treatment of the Submammary Fold in Breast Implantation . . . . . . . . . . . . . . . . . . . . . . . 383Adrien Aiache

47 Subfascial Prepectoral Implant Using the Inframammary Approach . . . . . . . . . . . . . . . . . . 389Toma T. Mugea

48 Subfascial Transaxillary Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401Ruth Graf, Daniele Pace

49 Modified Subfascial Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409Richard A. Baxter

50 Submuscular Fascial Dual-Plane Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415Toma T. Mugea

51 “Reverse” Dual-Plane Mammaplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429Gianpiero Gravante, Gaetano Esposito

Part VI Breast Augmentation with Autologous Tissue

52 History of Breast Augmentation with Autologous Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437Melvin A. Shiffman

53 Breast Augmentation with Autologous Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443Tetsuo Shu

54 Fat Transfer with Platelet-Rich Plasma for Breast Augmentation . . . . . . . . . . . . . . . . . . . . 451Robert W. Alexander

55 Fat Transfer and Implant Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471Katsuya Takasu, Shizu Takasu

56 Breast Augmentation with the Brava® External Tissue Expander . . . . . . . . . . . . . . . . . . . . 477Ingrid Schlenz

57 Autogenous Augmentation Mammaplasty with Microsurgical Tissue Transfer . . . . . . . . . . 485Mary E. Lester, Robert J. Allen

Part VII Complications

58 Complications of Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495Anthony Erian, Amal Dass

59 Less Common Complications of Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505Melvin A. Shiffman

ContentsXII

60 Capsular Contracture Following Augmentation Mammaplasty: Etiology and Pathogenesis 525John A. McCurdy, Jr.

61 Complications Related to the Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541Felix-Rüdiger G. Giebler

62 Imaging Evaluation of Silicone Within the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547R. James Brenner

63 Treatment of Capsule Contracture with Endoscopic CO2 Laser . . . . . . . . . . . . . . . . . . . . . . . 563Franck Landat

64 Hammock Capsulorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569Richard Moufarrège

65 Breast Implant Malposition: Prevention and Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . 573Christine A. DiEdwardo, Shawkat A. Sati

66 Aesthetic Outcome of Breast Implant Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583David T. Netscher, Asaad Samra

67 Inframammary Fold Elevation and External Synmastia Repair: Morgan–Metcalf Method . . 601Robert Yoho

68 Intracapsular Allogenic Dermal Grafts for Periprosthetic Breast Implant Problems . . . . . . . 605Richard A. Baxter

69 Submammary Flap for Correction of Severe Sequelae from Augmentation Mammaplasty 609José Juri, Maria Fernanda Valotta, Susana Létiz

70 Idiosyncratic Allergic Reaction: A Rare Complication of Augmentation Mammoplasty . . . . 617Robert X. Murphy, Jr.

71 Complications of Silicone Gel Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623Antonino Araco

72 Aesthetic Management of the Breast Capsule After Explantation . . . . . . . . . . . . . . . . . . . . 631Greg Chernoff

73 Complications of the Transumbilical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635Melvin A. Shiffman

74 Subfascial Breast Augmentations: Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637Melvin A. Shiffman

75 Complications of Autologous Fat Transfer to the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . 639Melvin A. Shiffman

Part VIII Miscellaneous

76 Breast Conservation Therapy After Augmentation Mammaplasty . . . . . . . . . . . . . . . . . . . . 643J. Arthur Jensen

Contents XIII

77 Serologic and Histologic Findings in Capsule Contracture Patients with Silicone Gel Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649Lukas Prantl

78 Medical-Legal Aspects of Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655Melvin A. Shiffman

79 Editor’s Commentary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661Melvin A. Shiffman

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665

ContentsXIV

Adrien Aiache, MD9884 Santa Monica Blvd., Apt BH310Beverly Hills, California 90212-1622USAE-mail: aaiachemd@sbcglobal.net

Robert W. Alexander, MD, DMD, FICSAssistant Professor (Clinical), University of Texas, Health Science Center at San Antonio, Department of SurgeryAffiliate Associate Professor, University of Washington, Department of Surgery3500 188th St. SW, Suite 670Lynnwood, Washington 98037USAE-mail: rwamd@cybernet1.com

Robert J. Allen, MDMedical University of South Carolina125 Doughty Street, Suite 480Charleston, South Carolina 29403USAE-mail: boballen@diepaslap.com

Antonino Araco, MDAttending SurgeonDolan Park HospitalStoney Lane Tardebigge, Bromsgrove B60 1LYUKE-mail: araco@libero.it

Andre Auersvald, MDClinica AuersvaldAlameda Presidente Taunay 1765Curitiba, Parana 80430-000BrazilE-mail: andreauersvald@uol.com.br

Luiz Augusto Auersvald, MDClinica AuersvaldAlameda Presidente Taunay 1765Curitiba, Parana 80430-000BrazilE-mail: andreauersvald@uol.com.br

List of Contributors

Richard A. Baxter, MD, FACSClinical InstructorUniversity of Washington School of Medicine, Seattle6100 219th Street, SW, Suite 290Mountlake Terrace, Washington 98043USAE-mail: drbaxter@baxterplasticsurgery.com

Joel Beck, MD, FACS66 Bovet RoadSan Mateo, California 94402-3125USAE-mail: jbeck@baysurgery.com

Hilton Becker, MD 5458 Town Center Road, Suite 101Boca Raton, Florida 33486USAE-mail: hbeckermd@msn.com

George John Bitar, MD Medical Director, Bitar Cosmetic Surgery InstituteVisiting Lecturer, Department of Plastic Surgery, University of Virginia8650 Sudley Road, #203Manassas, Virginia 20110USAE-mail: georgebitar@drbitar.com

Pierangelo Bosio, MD Department of General SurgeryUniversity of Modena Medical SchoolPoliclinico Di Modena, via Del Pozzo 7141100, ModenaItaly E-mail: pierangelo.bosio@libero.it

R. James Brenner, MD, JD, FACR, FCLM Chief of Breast Imaging, Professor of RadiologyUniversity of CaliforniaUCSF-Mt. Zion Hospital, Radiology H28041600 Divisadero StreetSan Francisco, California 94115-1667Bay Imaging ConsultantsWalnut Creek, CA 94598USAE-mail: james.brenner@radiology.ucsf.edu

Robert R. Brink, MD66 Bovet RoadSan Mateo, California 94402-3125USAE-mail: moonsheyn@yahoo.com

List of ContributorsXVI

Valerio Cervelli, MD, PhDProfessor of Plastic SurgeryUniversity of Tor VergataVia Montpellier00133 RomeItaly

Greg Chernoff, BSc, MD, FRCSC 9002 N. Meridian Street, Suite 205Indianapolis, Indiana 46260USAE-mail: greg@drchernoff.com

Nicholas V. Chugay, DO 4210 Atlantic AvenueLong Beach, California 90807USA

Mark W. Clemens, MD Resident, Department of Plastic SurgeryGeorgetown University Medical Center3800 Reservoir Road NWWashington, DC 20007USAE-mail: clemensmd@gmail.com

Andre Ricardo Dall’Oglio Tolazzi, MD Volunteer Assistant Plastic SurgeonFederal University of ParanaRua Brigadeiro Franco, 2507, Ap.102Curitiba-PR, 80250-030BrazilE-mail: artolazzi@yahoo.com.br

Amal Dass, MD, MBChB, BAO (Ire), LRCP & SI, MRCS (Edin)Fellow in Cosmetic SurgeryBlk 10B, Braddell View, #02-06, S579721 SingaporeE-mail: amaldass_2000@yahoo.com

Steven P. Davison, DDS, MD, FACS Associate Professor of SurgeryDepartment of Plastic SurgeryGeorgetown University Medical Center 3800 Reservoir Road, NWWashington, DC 20007USAE-mail: spd2@georgetown.edu

Danielle M. Deluca-Pytell, MD 400 E. Main Street, 2nd Floor North BuildingMount Kiscoe, New York 10549USAE-mail: delucapytell@verizon.net

List of Contributors XVII

Christine Anne Diedwardo, MDLahey Clinic, 41 Mall RoadBurlington, Massachusetts 01805-0002 USAE-mail: christine.a.diedwardo@lahey.org

Alexandre Dionyssopoulos, MDAssistant ProfessorAristotle University of TessalonikiTessalonikiGreece

Anthony Erian, MD, MBBCH, Bs (Lon), LRCP, FRCS (Eng) FRCS (Edin)Orwell Grange, 43 Cambridge RoadWimpole, CambridgeUKE-mail: erian@erian.demon.co.uk

Gaetano Esposito, MDProfessor of Plastic Surgery, University of Tor Vergata, Rome Centro Ustioni OspedaleS.Eugenio Piazzale Umanesimo, n.10 00143 RomaItalyE-mail: gaetanoesposito@fastwebnet.it

Renato Da Silva Freitas, MD Assistant Professor of Plastic Surgery, Federal University of Parana Plastic and Reconstructive Surgery UnitHospital de Clinicas of Federal University of ParanaR. General Carneiro, 181, 9˚ andarCuritibas-PR 80060-900BrazilE-mail: dr.renato.freitas@gmail.com

Felix-Rüdiger G. Giebler, MDVincemus-KlinikBrückenstrasse 1-A25840 Friedrichstadt/EiderGermanyE-mail: info@vincemus-klinik.de

Caroline Glicksman, MDJersey Shore University Medical Center, Neptune, New JerseyCenter for Special Surgery, Wall, New JerseyOcean County Medical Center, Brick, New Jersey 2164 Highway 35Sea Girt, New Jersey 08750-1013USAE-mail: docglicksman@aol.com

List of ContributorsXVIII

Ruth M. Graf, MD, PhDProfessor of Plastic Surgery, Federal University of Paraná Rua Solimões, 1175Mercês, Curitiba – ParanáCep: 80810-070BrazilE-mail: ruthgraf@bighost.com.br, ruthgraf@bsi.com.br

Gianpiero Gravante, MD, PhDClinical Fellow in Hepatobiliary and Pancreatic SurgeryUniversity Hospitals of LeicesterResearch Fellow of Physiology, University of Tor Vergata, Rome Via Umberto Maddalena 40/a00043 Ciampino, RomaItalyE-mail: ggravante@hotmail.com

Daniel P. Greenwald, MD1208 East Kennedy Boulevard, Suite 221Tampa, Florida 33606USAE-mail: docdan@bs-ps.com

Darryl J. Hodgkinson, MD, MBBS (Hons), FRCS (C), FACS FACCS The Cosmetic and Restorative Surgery Clinic20 Manning RoadDouble Bay, New South Wales 2028AustraliaE-mail: dr_hodgkinson@bigpond.com

Julie C. Holding, MD 6.124 McCullough Building, 301 University BoulevardGalveston, Texas 77555-0724USAE-mail: jcholdin@utmb.edu

Lisa M. Hunsicker, MD Revalla Plastic Surgery7720 S Broadway, Suite 380Littleton, Colorado 80122 USA

Ali Infield, BADepartment of Psychiatry Research Assistant, Center for Weight and Eating DisordersUniversity of Pennsylvania School of Medicine3535 Market StreetPhiladelphia, Pennsylvania 19104USAE-mail: infieldl@mail.med.upenn.edu

List of Contributors XIX

J. Arthur Jensen, MD, FACSAssistant Professor of Plastic Surgery, Geffen School of Medicine at UCLAAdjunct Assistant Professor, John Wayne Cancer Center2001 Santa Monica Boulevard, Suite 790WSanta Monica, California 90404USAE-mail: Dr.J.Jensen@gmail.comJAJCA@aol.com

Lin Jinde, MDHangzhou Municipal Plastic Surgery Hospital168, Shangtang RoadHangzhou, Zhejiang Province, 310014ChinaE-mail: hzljd@sohu.com

José Juri, MDClínica Juri Cirugía PlásticaCerviño 32521425 Capital Federal, Buenos AiresArgentinaE-mail: info@clinicajuri.com.ar, clinicajuri@bcnsite.com

Bobby Arun Kumar, MD, MB BS (UNSW) BSc (UNSW) P.O. Box 155Pyrmont, New South Wales 2009AustraliaE-mail: getbare@hotmail.com

Franck Landat, MD2, rue Glesener, L.1630 Luxembourg LuxembourgE-mail: drlandat@pt.lu

Mary E. Lester, MDMedical University of South Carolina96 Jonathan Lucas Street, 426 CSBCharleston, South Carolina 29425USAE-mail: lesterma@musc.edu

Susana Létiz, MDJuramento 44621430 Capital Federal, Buenos AiresArgentinaE-mail: suletiz@hotmail.com

Apostolos D. Mandrekas, MD, PhDDirector, Artion Plastic Surgery Centre11 D. Vassilious Sreet, N. PsyhikoAthens 15451GreeceE-mail: amandrekas@artion-plasticsurgery.com

List of ContributorsXX

James W. May, Jr., MD Chair, Division of Plastic & Reconstructive SurgeryMassachusetts General Hospital, 15 Parkman Street, WACC 435Boston, Massachusetts 02114USAE-mail: jwmay@partners.org

W. Thomas McClellan, MDDepartment of Plastic & Reconstructive SurgeryLahey Clinic, Burlington, MassachusettsMorgantown Plastic Surgery Associates1085 Van Voorhis Road, Suite 350Morgantown, West Virginia 26505USAE-mail: wtmcclellan@gmail.com

John McCurdy, Jr., MDFormerly Assistant Clinical Professor of SurgeryUniversity of Hawaii John A. Burns School of Medicine1188 Bishop Street, Suite 2402Honolulu, Hawaii 96813USAE-mail: johnmccurdy@hotmail.com

Sid J. Mirrafati, MDMira Aesthetics 1101 Bryan Avenue, Suite GTustin, California 92780-4401USAE-mail: drmirrafati@youngerlook.com

Richard Moufarrège, MD, FRCS(C)Assistant ProfessorUniversity of MontrealPrivate practice: 1111, rue St-Urbain, Suite 106Montreal (Quebec), H2Z 1Y6Canada E-mail: plasticsurg_moufar@hotmail.com

Toma T. Mugea, MD, PhD Professor, Plastic and Aesthetic SurgeryOradea Medical UniversityDirector Medestet Clinic9/7 Cipariu SquareCluj-NapocaRomaniaE-mail: drmugea@medestet.ro

List of Contributors XXI

Robert X. Murphy, Jr., MD, MSDepartment of Surgery, Division of Plastic SurgeryLehigh Valley HospitalCedar Crest & I-78, P.O. Box 689Allentown, Pennsylvania 18105-1556USAE-mail: sally.lutz@lvh.com, robert.murphy@lvh.com

David T. Netscher, MDClinical Professor, Division of Plastic SurgeryBaylor College of MedicineAdjunct Professor of Surgery, Cornell University, Houston, TexasChief of Plastic Surgery, Veterans Affairs Medical Center, Houston, TexasPrivate practice: 6624 Fannin Street, Suite 2730Houston, Texas 77030-2339USAE-mail: netscher@bcm.tmc.edu

Gilvani Azor De Oliveira e Cruz, MDChief Professor, Plastic Surgery UnitFederal University of ParanaRua Saint´ Hilaire, 717, Aptº 2002, Agua VerdeCEP: 80254-140Curitiba, PRBrazilE-mail: gilvani@ufpr.br

Daniele Pace, MD, MsCRua Solimões, 1175 Mercês, Curitiba, Paraná BrasilCep 80810-070BrazilE-mail: danielepace@hotmail.com

Beniamino Palmieri, MDDepartment of SurgeryUniversity of Modena Medical School and Reggio EmiliaPoliclinico IV floor Via del Pozzo, 7141100 ModenaItaly E-mail: palmieri@unimo.it

Edward A. Pechter, MD, FACSAssistant Clinical Professor of Plastic SurgeryUniversity of California, Los Angeles25880 Tournament Road, Suite 217Valencia, California 91355-2844USAE-mail: drpechter@aol.com

Myron M. Persoff, MD3659 South Miami AvenueMiami, Florida 33133-4227USAE-mail: drpersoff@drpersoff.com

List of ContributorsXXII

Linda G. Phillips, MDDistinguished Truman G. Blocker, Jr., MD, ProfessorChief, Division of Plastic SurgeryProgram Director, Plastic Surgery Residency ProgramUniversity of Texas Medical Branch, Galveston6.124 McCullough Bldg., 301 University BoulevardGalveston, Texas 77555-0724USAE-mail: lphillip@utmb.edu

Rocco C. Piazza, MD53 Campau Circle, NWGrand Rapids, Michigan 49503USAE-mail: rpiazzamd@gmail.com

Luis A. Picard-Ami, Jr., MDPTY 8016, 1601 N.W. 97th AvenueMiami, Florida 33102USAConsultorios Médicos Paitilla #513Panamá CityPanamáE-mail: picardami@psi.net.pa

Lukas Prantl, MD, PhDDirector, Department of Plastic SurgeryUniversity of RegensburgFranz-Josef-Strauss-Allee 1193042 RegensburgGermanyE-mail: lukas.prantl@klinik.uni-regensburg.de

Mark A. Randolph, MSMassachusetts General HospitalDivision of Plastic Surgery Research Lab 15 Parkman Street, WACC 457Boston, Massachusetts 02114USAE-mail: marandolph@partners.org

Angelo Rebelo, MDClinica MilenioRua Manual Silva Leal, 7A, 11C1600-166 LisboaPortugalE-mail: clinicamilenio@netcabo.pt

Robert S. Reiffel, MD12 Greenridge Avenue, Suite 203White Plains, New York 10605-1238USAE-mail: r.reiffel@verizon.net

List of Contributors XXIII

Anileda Ribeiro Dos Santos, MDVolunteer Assistant Plastic SurgeonFederal University of ParanaRua Pe. Anchieta, 640, Aptº 501, ChampagnatCEP: 80430-060, Curitiba, PRBrazilE-mail: aniledaribeiro@yahoo.com.br

Asaad Samra, MDFormer Resident, Division of Plastic Surgery, Baylor College of MedicineThe Samra Group733 North Beers Street, Suite U1Holmdel, New Jersey 07733USAE-mail: asamramd@aol.com

David B. Sarwer, PhDDepartments of Psychiatry and SurgeryThe Edwin and Fannie Gray Hall Center for Human AppearanceCenter for Weight and Eating DisordersUniversity of Pennsylvania School of Medicine10 Penn Tower3400 Spruce StreetPhiladelphia, Pennsylvania 19104USAE-mail: dsarwer@mail.med.upenn.edu

Shawkat A. Sati, MDClinical Instructor, Tufts University Lahey Clinic, Department of Plastic & Reconstructive Surgery41 Mall RoadBurlington, Massachusetts 01805USAE-mail: shawkat.sati@lahey.org

Ingrid Schlenz, MDConsultant, Department of Plastic and Reconstructive SurgeryWilhelminenspitalMontleartstrasse 371160 ViennaAustriaE-mail: ingrid.schlenz@wienkav.at

Brooke R. Seckel, MDLahey Clinic, Department of Plastic & Reconstructive Surgery, Burlington, MassachusettsBoston Plastic Surgery AssociatesEmerson HospitalJohn Cuming Building, Suite 700, 131 ORNACConcord, Massachusetts 01742USAE-mail: drseckel@gmail.com

List of ContributorsXXIV

Asuman Sevin, MDPlastic and Reconstructive Surgery DepartmentAnkara Numune Training and Research HospitalZirvekent 2. Etap Sitesi C-1/43Cankaya, 06550 AnkaraTurkeyE-mail: basevin@gmail.com

Kutlu Sevin, MDProfessor, Plastic and Reconstructive Surgery DepartmentAnkara University Faculty of MedicineZirvekent 2. Etap Sitesi C-1/43Cankaya, 06550 AnkaraTurkey

Melvin A. Shiffman, MD, JDChairman, Section of SurgeryTustin Hospital and Medical Center 17501 Chatham DriveTustin, California 92780-2302USAE-mail: shiffmanmdjd@yahoo.com

Tetsuo Shu, MDDaikanyama Clinic4F, 1-10-2 Ebisu-Minami, Shibuya-kuTokyo, 150-0022Japan E-mail: shu@mpint.co.jp

John E. Skandalakis, MD, PhDChris Carlos Distinguished Professor of Surgical Anatomy and TechniqueDirector, Centers for Surgical Anatomy & Technique Professor of Surgery, Department of SurgeryEmory University School of MedicineClinical Professor of Surgery, The Medical College of Georgia, Augusta, GeorgiaClinical Professor of Surgery, Mercer University School of Medicine, Macon, Georgia1462 Clifton Road, NE, Suite 303Atlanta, Georgia 30322USAE-mail: cfroman@emory.edu, cpainte@emory.edu

Ned Snyder IV, MD901 W. 38th Street, Suite 410Austin, Texas 78705USA

List of Contributors XXV

Colin Song, MD, MBBCh, FRCS, FAMSHead and Senior ConsultantDepartment of Plastic Reconstructive and Aesthetic SurgeryDirector, Post Graduate Medical InstituteSingapore General HospitalOutram Road169608 SingaporeE-mail: colin.song@sgh.com.sg

Katsuya Takasu, MD, PhDTakasu Clinic Building 8F16-23 Tuabaki-cho, Nakamura-kuNagoya, 453-0015JapanE-mail: tomoko@takasu.co.jp, info@takasu.co.jp

Shizu Takasu, MDTakasu Clinic Building 8F16-23 Tuabaki-cho, Nakamura-kuNagoya, 453-0015JapanE-mail: tomoko@takasu.co.jp, info@takasu.co.jp

Bien-Keem Tan, MD, MBBS, FRCS, FAMS Senior Consultant, Department of Plastic Reconstructive and Aesthetic SurgerySingapore General HospitalOutram Road169608 SingaporeE-mail: bienkeem@singnet.com.sg

Maria Fernanda Valotta, MD3 de Febrero 9861426 Capital Federal, Buenos AiresArgentinaE-mail: cplastica@doctoravalotta.com.ar

Melvyn Westreich, MDDepartment of Plastic SurgeryAssaf HaRofeh Medical CenterTzrifin, 70-33IsraelE-mail: mwestreich@hotmail.com

Chin-Ho Wong, MBBS, MRCS (Ed), M Med (Surgery) Chief Resident, Department of Plastic, Reconstructive and Aesthetic SurgerySingapore General HospitalOutram Road169608 Singapore E-mail: wchinho@hotmail.com

List of ContributorsXXVI

Elisabeth Würinger, MDDepartment of Plastic and Reconstructive SurgeryWilhelminenspitalMontleartstrasse 371160 ViennaAustriaE-mail: dr.elisabeth.wueringer@utanet.at

Robert Yoho, MD797 S. Arroyo ParkwayPasadena, California 91105 USAE-mail: ryrobert@pacbell.net

George J. Zambacos, MDAssociateUniversity of Athens27 Skoufa StreetKolonaki, Athens 10673GreeceE-mail: gzambacos@aestheticsurgery.gr

List of Contributors XXVII

Part I Anatomy, Benign Breast Disease, Malignant Breast Disease, Mammograms

Chapter

1.1 Introduction

In the middle and fore-part of each side of the Chest, there rise two fleshy Eminences, called the Breasts, which are a good deal larger in Women than in Men. The Breasts of Women are composed of Glandular Bod-ies, interspersed with an infinite Number of Vessels, which serve for the Secretion of Milk. Those of Men are only composed of Skin, Flesh, and Fat … In general, the Breasts of Men ought to be small, and a little plain. Those of Women ought to be round, high, and have the Figure of two Hemispheres, separated from one another by a middle Interstice.Nicolas Andry de Bois-Regard, Orthopaedia (1743) [1]

1.2 Embryogenesis

The ectoderm and the mesenchyme are responsible for the genesis of the male and female breast. The ectoderm is responsible for the formation of the ducts and alveoli, and the mesenchyme is responsible for the connective tissue and its vessels.

In the ventral area of the body, the milk line (ridge) develops (Fig. 1.1). Usually, it extends from the axilla to the inguinal area. However, occasionally the milk ridge extends down into the triangle of Scarpa. The pectoral part of the milk ridge produces the right and left mam-mary primordia. The proximal and distal part of the ex-trapectoral ridge disappears.

Kopans [2] stated that the breasts have the same ecto-dermal origin as skin glands (Fig. 1.2). The ectodermal thickening of the mammary primordium grows into the dermis [3]. This produces 16–24 solid cords of ecto-dermal cells growing within the underlying mesoderm (dermis). Later, these buds will become canalized and form the lactiferous ducts and alveoli. The epidermal surface of the future nipple is at first a shallow depres-sion during the final trimester; near term it becomes everted and ready to accept the lactiferous ducts.

Howard and Gusterson [4] stated that very little is known about the molecular mechanisms that initiate breast formation. A small part of the ridges remains in

the pectoral area, which is responsible for the genesis of the right and left breasts as well as for the embryological mammary anomalies. The typical developmental har-mony between ectoderm (epithelial ductal lining and acini) and mesenchyme (the skin and the supporting elements) occasionally goes awry, producing congenital anomalies of the breast.

Each mammary lobe has one lactiferous duct, which terminates at the nipple of the mammary gland. The pathway of the lobes is from the nipple to the connective and fatty tissue of the superficial fascia. Thus, the breast can be conceptualized as a grouping of large glands that originate from the epidermis. Langebartel [5] termed

1

Fig. 1.1 The milk line. Mammary glands usually develop in humans from the pectoral portion of the line. Supernumerary mammary structures may develop from other positions along the line (From Skandalakis et al. [58], with permission)

1Embryology and Anatomy of the BreastJohn E. Skandalakis

the female breast “mostly a mound of fat, with fascias and fibrous strands and the mammary gland (active or inactive).”

Kopans [2] analyzed breast development: “The breast develops in the superficial layer of fascia that lies just beneath the skin. It is not clear whether the superficial layer splits into a deep and superficial layer to form an incomplete envelope around the gland, or whether the elongating ducts invaginate the fascia, which then ends up enveloping the gland” (Fig 1.3).

The chronology of breast development is presented in Table 1.1.

The breast characteristically presents changes when still in utero as well as during the extrauterine period. Russo and Russo [6] divide these changes into two phases:• Developmental phase: Early stages of gland morpho-

genesis from nipple epithelium to lobule formation• Differentiation phase: Differentiation of mammary

epithelium

Remember: The ridges disappear early, but a small por-tion remains in the pectoral region. This is responsible for the genesis of “a single pair of glands,” according to Bland and Romrell [7].

Neville et al. [8, 9] have summarized the stages of hu-man mammary development (Table 1.2), noting the role of the mammary fat pad in the development of the mam-mary epithelium. The fat pad provides signals that me-diate ductal morphogenesis and alveolar differentiation.

The genesis of the breast is an enigma. Sakakura [10] and Robinson et al. [11] have discussed mesenchymal interactions.

1.3 Congenital Anomalies

The axilla is the most common area in which accessory breast tissue can be found [2]. The multiple but rare congenital anomalies of the breast may be associated with various other syndromes. It is not within the scope of this chapter to study these syndromes or their associ-ated anomalies.

1.3.1 Amastia

By definition, amastia is the absence of one or both breasts. This congenital phenomenon is very rare. The first reports of unilateral amastia [12], bilateral amastia

Fig. 1.2 Development of the breast. a–d Stages in the formation of the duct system and potential glandular tissue from the epi-dermis. Connective tissue septa are derived from mesenchyme of the dermis. e Eversion of the nipple near birth. (From Skan-dalakis et al. [58], with permission)

Table 1.1 Timeline of breast development

4th–6th fetal week Development of milk lines or mammary (ectodermal) ridges

10th fetal week Atrophy of the proximal and distal part of the milk lines; the mid-dle (pectoral) part is responsible for the genesis of the breast

5th fetal month Development of the areola and 15–20 solid cords

Later Lactiferous ducts; mammary glands develop from the milk lines

After birth Nipple is visible

Puberty Ducts develop acini at their ends

1 Embryology and Anatomy of the Breast4

Fig. 1.3 It is unclear how the breast devel-ops with respect to the superficial fascia, which runs just under the skin. a The fascia may split, forming a deep and superficial layer with the breast in between (insinua-tion). b–d The other possibility is that as the ducts elongate and grow back into the soft tissues, they may be enveloped by the fascia (invagination; e, f). (From Kopans [2], with permission)

[13], and amastia (with or without athelia) associated with Poland syndrome [14] were all published in the 1800s. In 1917, Deaver and McFarland [15] reported other congenital anomalies in association with amastia.

In females, unilateral breast absence is the most common form of amastia. Bilateral amastia has been reported in male and female patients [16].

Trier [17] divided his presentation of 43 cases of amastia into three categories:

• Bilateral amastia • Unilateral amastia• Bilateral amastia with congenital ectodermal defects According to Merlob [18], 40% of all cases of amastia are associated with other congenital malformations (skeletal, facial, renal, genital). Several syndromes are associated with this condition [19–22]. Familial oc-currence has been observed by various investigators

1.3 Congenital Anomalies 5

[23–24], and complete absence of a breast in siblings has been reported [25].

Greydanus and colleagues [26] state that amastia is the result of “complete mammary ridge involution, in-cluding the pectoral ridge on the affected side.”

1.3.2 Athelia

Athelia, from the Greek word ΘΗΛΗ, is the congenital absence of one or both nipples and areolas of the breast. Athelia, which may be the rarest of all breast anoma-lies [27], may result from a developmental failure of the lower cervical and upper thoracic somites [28]. The fatty stroma is the precursor of the mammary fat pad [29], and without a good stroma, the overlying breast tissue cannot grow.

Ishida et al. [29] reported that athelia “is always asso-ciated with other anomalies… but [is] usually associated with amastia.” These authors stated that “individuals

generally present absence of the nipple–areola complex inside a constellation of other alteration. So, athelia can-not be classified in distinct groups.” Latham et al. [30] cautioned that athelia, which is “uniformly described in the literature as being associated with a syndrome or a cluster of syndromes,” should be differentiated from amastia (absence of breast tissue and nipple–areolar complex) and amazia (absence of breast tissue).

The inverted nipple is not an athelic phenomenon. According to Lawrence and Lawrence [28], it is the re-sult of the persistence of fibers from the original invagi-nation of the mammary pit (dimple).

1.3.3 Polythelia

More than two nipples, each with an areola, are present in polythelia. Schmidt [31] stated, “Not every supernu-merary areola has a nipple, but every supernumerary nipple has an areola. The term ‘polythelia’ means a de-

Table 1.2 Stages of mammary development (GH growth hormone, IGF-1 insulin-like growth factor-1, HGF human growth factor, TGF-ß transforming growth factor-ß, PRL prolactin, HER heregulin, FIL feedback inhibitor of lactation)

Developmental stage Hormonal regulation Local factors Description

Embryogenesis ??? Fat pad necessary for ductal extension

Epithelial bud develops in 18–19-week fetus, extending a short distance into mammary fat pad with blind ducts that become canalized; some milk secretion may be present at birth

Pubertal development — — —

Before onset of menses

Estrogen, GH IGF-1, HGF, TGF-ß, ???

Ductal extension into the mammary fat pad; branching morphogenesis

After onset of menses Estrogen, proges-terone, PRL?

— Lobular development with forma-tion of terminal duct lobular unit

Development in pregnancy

Progesterone, PRL, placental lactogen

HER, ??? Alveolus formation; partial cel-lular differentiation

Transition: lactogenesis Progesterone withdrawal, PRL, glucocorticoid

Unknown Onset of milk secretion:Stage I: midpregnancyStage II: parturition

Lactation PRL, oxytocin FIL, stretch Ongoing milk secretion, milk ejection

Involution Withdrawal of prolactin Milk stasis (FIL??)

Alveolar epithelium undergoes apoptosis and remodeling; gland reverts to prepregnant state

From Neville [8], with permission

1 Embryology and Anatomy of the Breast6

veloped areola with a nipple.” Supernumerary nipples may be found anywhere along the embryonic milk line [32]. Merlob [18] reported the prevalence of supernu-merary nipples in various ethnic population studies as ranging from 0.22% to 11–16%. He stated that polythe-lia may be sporadic, familial, or syndromic.

Table 1.3 presents congenital malformations and dis-eases associated with polythelia.

1.3.4 Polymastia

The presence of more than two breasts, which are usu-ally located at the mammary ridge, is called polymastia. The terms “ectopic breast” and “supernumerary breast” also appear in the literature. Darwin [33] viewed both polymastia and polythelia as atavistic traits, represent-ing human phylogeny.

Supernumerary breasts and nipples have a 1–2% in-cidence of all live births [7, 34].

What embryogenetic explanation can be found for the reported cases of supernumerary mammary organs on the vulva, legs, or dorsal trunk? Dixon and Mansel [35] stated that the cause is unknown. Ectopic and nor-mally located breasts may be equally subject to pathol-ogy (mastitis, cancer, etc.).

Polymastia is associated with other anomalies, both obvious and more hidden. Mehes and colleagues [36–38] and Goeminne [39] advise complete evaluation of the patient with ectopic breast(s) to rule out other prob-lems, such as renal anomalies.

1.3.5 Breast Asymmetry

Araco et al. [40] defined breast asymmetry as “an asym-metric morphology of the shape, volume, or position of the breast, the nipple–areola complex, or both.” Tu-

berous breast deformity (an aberration of breast shape) includes a spectrum of symmetrical and asymmetrical defects, both unilateral and bilateral [41].

In megalomastia, the breast is extremely enlarged. Unilateral megalomastia is extremely rare [42].

Micromastia is a congenital condition in which the breast fails to develop beyond its prepubertal state, de-spite the presence of mammary gland tissue [27]. The condition may be unilateral or bilateral. The etiology of micromastia (hypoplasia, aplasia) is unknown; however, unilateral hypoplasia may be associated with several syndromes, such as congenital renal hyperplasia and other autosomal dominant inherited conditions.

1.3.6 Gynecomastia

Gynecomastia refers to enlargement of the male breast. The development and then spontaneous regression of mild gynecomastia is common and usually asymptom-atic in young men. Gynecomastia is also relatively com-mon in older men; it is usually idiopathic and commonly regresses spontaneously [3].

1.4 Anatomy

The female breast is practically enveloped by the su-perficial fascia of the anterior chest wall (Fig 1.4). The superficial fascia is continuous with the superficial abdominal fascia of Camper below and the superficial fascia of the neck above, merging anteriorly with the dermis of the skin.

The base of the breast has the following extensions:• From the 2nd rib (above) to the 6th or 7th rib (be-

low)• From the sternal border (medial) to the midaxillary

line (lateral)

Table 1.3 Polythelia and associated conditions

Urinary tract abnormalities Cardiac abnormalities Miscellaneous abnormalities

Renal agenesisRenal cell carcinomaObstructive diseaseSupernumerary kidney(s)

Cardiac conduction disturbances (especially left bundle branch block)HypertensionCongenital heart anomalies

Pyloric stenosisEpilepsyEar abnormalitiesArthrogryposis multiplex congenita

From Pellegrini and Wagner [32], with permission

1.4 Anatomy 7