Revisions Related to Skin Excess

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Persistent skin excess, usually the most frequent complication, occurs at the inferior pole of the breast and is reported in approximately 10 % of cases of vertical scar mammaplasty. It may be caused by various factors:

1. Excessively high positioning of the pedicle, producing a dead space in the inferior pole and subsequent skin excess.

2. Insufficient excision of skin at the inferior end of the vertical incision (Figs. 14.2,14.3). It is absolutely essential to look for potential dog ears at this point during surgery and to correct them immediately.

3. In larger reductions of more than 1000 g, postoperative resolution of swelling can sometimes result in a lax skin envelope in the lower pole. Simple excision of the redundant skin along the previous vertical incision reshapes the lower pole of the breast and restores a pleasing contour without additional scarring. Also, tightening of the lower skin enve-

Fig. 14.2 a-d. A middle-aged patient with breast hypertrophy and marked ptosis who had reduction of 300 g on the right and 330 g on the left breast using the inferocentral pedicle technique (Dr. Wueringer). a,b Preoperative and postoperative views. c Bilateral dog ears at the level of the IMF, which are noticeable when the patient raises her arms. d Marking of a crescent excision

Fig. 14.3 a,b. Immediate postoperative results after the secondary revision of the scar
Fig. 14.4. a Preoperative view of a patient with large and ptotic breasts. b The patient underwent breast reduction using the lozenge technique (Dr. Ribeiro); a postoperative view demonstrates the excess of skin at the inferior pole of the left breast

Fig. 14.5. a The area of skin resection is marked in the form of an ellipse not extending beyond the inframammary sulcus. An inverted T-shaped marking is designed in case extra skin resection is needed. b In this case only the vertical excision was per formed, including skin, fat, and glandular tissue. The final result was a vertical scar not extending beyond the inframammary fold

Fig. 14.5. a The area of skin resection is marked in the form of an ellipse not extending beyond the inframammary sulcus. An inverted T-shaped marking is designed in case extra skin resection is needed. b In this case only the vertical excision was per formed, including skin, fat, and glandular tissue. The final result was a vertical scar not extending beyond the inframammary fold

Revisions Related to Breast Shape

Fig. 14.6. Result after correction

Fig. 14.6. Result after correction lope increases the projection of the breast and often improves the overall aesthetic result. When necessary, additional tissue can also be removed via this approach (Fig. 14.4-14.6). If such a maneuver is not sufficient to correct the excess, a short T- or L-shaped resection is performed to permit correction without extending the scar below the IMF and adversely compromising the aesthetic result.

Revisions Related to Breast Shape

Unsatisfactory aesthetic results may be the result of final breast asymmetry; this may be due to insufficient gland resection on one side or to different closure methods where one breast envelope is tightened more than the other. Usually this happens if separate

Fig. 14.7 a-e. A 35-year-old woman in preparation for SPAIR mammaplasty (Dr. Hammond). a Preoperative appearance. b Preoperative markings demonstrating the medial malposition of the nipple-areola complex. c The breast reduction removed 670 g from the right and 738 g from the left breast; however, at 4 months, internal scarring from a resolving bilateral seroma cavity has tethered the breast flaps and pedicle, causing shape distortion and asymmetry. d Preoperative marks outline the planned periareolar scar revision along with further plication of the vertical skin segment.Additional reduction of 241 g on the right and 186 g on the left breast is performed. The scarred seroma cavity is removed, restoring a pleasing shape to the breast. e The final result seen at 2 months after the correction shows correction of the shape distortion along with a better overall aesthetic appearance

Fig. 14.7 a-e. A 35-year-old woman in preparation for SPAIR mammaplasty (Dr. Hammond). a Preoperative appearance. b Preoperative markings demonstrating the medial malposition of the nipple-areola complex. c The breast reduction removed 670 g from the right and 738 g from the left breast; however, at 4 months, internal scarring from a resolving bilateral seroma cavity has tethered the breast flaps and pedicle, causing shape distortion and asymmetry. d Preoperative marks outline the planned periareolar scar revision along with further plication of the vertical skin segment.Additional reduction of 241 g on the right and 186 g on the left breast is performed. The scarred seroma cavity is removed, restoring a pleasing shape to the breast. e The final result seen at 2 months after the correction shows correction of the shape distortion along with a better overall aesthetic appearance surgeons are working on each breast with little communication or if many sutures were used to shape the breast gland. We do not therefore advise the use of many fixation stitches either on the thoracic wall or between the breast pillars. Closure of the two vertical pillars is performed with stitches in the superficial fascia followed by a second layer in the dermis. Few or no stitches on the gland are recommended in order to avoid fat necrosis, which may contribute to breast asymmetry later on. Another reason for breast asymmetry is internal scarring due to seroma or hematoma formation deep within the breast. As the seroma resolves, the scar cavity that has developed pulls on the pedicle, flattening of the breast mound. If this shape distortion does not resolve satisfactorily after 1 year, it is necessary to surgically excise the scarred cavity through the previous periareolar and vertical incisions (Fig. 14.7). After removal of the scar cavity, the breast shape is restored. No instances of recurrence have been reported.

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