Breast Deformities and Mastopexy

CME

Maurice Y. Nahabedian, Learning Objections: After reviewing this article, the participant should be able M.D. to: 1. Appreciate the diversity of approaches for the correction of breast de- Washington, D.C. formities and mastopexy. 2. Review the salient literature. 3. Understand patient selection criteria and indications. Summary: Breast deformities and mastopexy continue to challenge plastic surgeons. Deformities such as Poland syndrome, tuberous breast, gynecomastia, and other congenital conditions are uncommon; therefore, management experience is often limited. Various techniques have been described, with no general consensus regarding optimal management. Mastopexy has become more common and is performed both with and without augmentation mammaplasty. However, a variety of techniques are available, and a thorough understanding of the indications, patient selection criteria, and techniques is important to optimize outcomes. This article will review these and other conditions to provide a better understanding of the current available data and evidence for these operations. (Plast. Reconstr. Surg. 127: 91e, 2011.)

hen considering all types of breast sur- TUBEROUS BREAST DEFORMITY gery, the category of breast deformity is There are several features of the tuberous Wperhaps the least prevalent and in some breast that are important to identify before man- ways the most challenging. The conditions that agement. These include a constricted base, con- make up this category include tuberous breast, traction of the skin envelope, relative micromastia, Poland syndrome, and gynecomastia, as well as enlarged diameter of the nipple-areola complex, congenital and developmental breast asymme- and herniation of breast parenchyma through the tries. Many of these anomalies have embryologic nipple-areola complex2 (Fig. 1). Although the ex- origins and manifest during puberty.1 These con- act etiology has not been elucidated, it is generally ditions have all been described in variable detail accepted that this disorder has an embryologic both in textbooks and in the scientific literature; origin.3 Most reports have speculated that the su- however, because these conditions are less com- perficial investing fascia of the breast is abnormal mon, associated with variable degrees of complex- and constricted at the base of the breast. This ity, and are sometimes difficult to treat, there is a constriction at the base and deficiency at the are- lack of consensus on optimal management. This ola is responsible for the reduced base diameter section will focus on and emphasize the various and areolar herniation.3 A competing theory states evaluation and management strategies that have that there is no constrictive band at the base of the been described. breast and that the only abnormality is a deficiency A separate topic in this category is mastopexy. of areolar support, giving rise to the herniation.4 Although mastopexy is used to correct an overly ptotic breast and may be unrelated to the correction of a classic breast deformity, the principles and concepts of repair are best suited for this Disclosure: The author has no financial interest to section, as there is some degree of overlap with the declare in relation to the content of this article. correction of breast deformities. The subcategory of augmentation mastopexy will also be covered in this section.

From the Department of Plastic Surgery, Georgetown Uni- Related Video content is available for this ar- versity Hospital. ticle. The videos can be found under the “Re- Received for publication April 27, 2010; accepted September lated Videos” section of the full-text article, or, 14, 2010. for Ovid users, using the URL citations Copyright ©2011 by the American Society of Plastic Surgeons printed in the article. DOI: 10.1097/PRS.0b013e31820a7fa7

www.PRSJournal.com 91e Plastic and Reconstructive Surgery • April 2011

Fig. 1. Preoperative and postoperative views of a patient with tuberous breast deformity. (Left) The nipple-areola complex is enlarged with a herniated appearance, and the base diameter of the breast is constricted. In this case, the breast was corrected with autologous fat grafting. (Center) Results following first session of fat grafting. (Right) Results following second session of fat grafting. (Reprinted from Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: Safety and efficacy. Plast Reconstr Surg. 2007;119: 775–785.)

Several surgical approaches have been described undermining, and subglandular implant place- to correct the tuberous breast deformity.2–11 Rees ment are used.4 Their belief is that the deformity and Aston first described the correction of the is due solely to an areolar abnormality and not to tuberous breast in 1976 and advocated expanding a constrictive band at the base. Coleman and Sa- the base diameter of the breast with radial boeiro have reported on the benefits of lipoaug- scoring.2 Dinner and Dowden believed that the mentation by injecting autologous fat into the sub- constriction was the result of a cutaneous band cutaneous tissues and pectoral muscle.8 In a single and advocated a skin incision.5 Ribeiro et al. iden- patient, two sessions were required, with injection tified a constrictive ring and advocated dividing it volumes of 370 cc on the right and 380 cc on the horizontally.6,7 Mandrekas et al. have performed a left. This was followed 4 years later with 300 cc on similar operation to Ribeiro, except that the con- the left and 340 cc on the right (Fig. 1). strictive band was divided vertically3 (Fig. 2). Pa- It is generally believed that correction of tu- cifico and Kang have described an alternative ap- berous breast deformity requires attention to sev- proach in which areola reduction, subdermal eral salient points. The approach that is advocated

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Fig. 2. The Mandrekas technique is illustrated. (Above, left) A periareolar approach is advocated. (Above, center) The dissection proceeds in the subcutaneous plane to the pectoral fascia. (Above, right) The dissection continues to the desired inframammary fold. (Below, left) The inferior pole of the breast is exteriorized, and the constrictive band is divided vertically. (Below, right) Finally, the areola is reduced, and the breast is recontoured. (Reprinted from Mandrekas AD, Zambacos GJ, Anastasopoulos A, et al. Aesthetic reconstruction of the tuberous breast deformity. Plast Reconstr Surg. 2003; 112:1099–1108.) by most is to outline a circumareolar pattern their review of eight patients, reported no around the perimeter of the desired nipple-areola complications.3,4 Reported outcomes have ranged complex. A donut-type mastopexy pattern is out- from good to excellent. Mandrekas et al. reported lined. After skin excision, the circumference of 100 percent patient satisfaction and 100 percent sur- the surrounding tissues is undermined; however, geon satisfaction.3 Pacifico and Kang reported the inferior subcutaneous plane is undermined outcomes on eight patients and 13 breasts follow- to the level of the inframammary fold and chest ing areola reduction and subglandular augmenta- wall. The inferior breast parenchyma is under- tion.4 An independent panel graded the outcomes mined and ultimately divided centrally or scored as excellent in 75 percent and good in 25 percent; to disrupt or divide the fibrous constrictive ring. however, all patients reported that they were very The lower pole of the breast can be contoured by satisfied with the outcome. utilizing an inferiorly based flap or the medial and lateral lower breast pillars to provide the paren- MASTOPEXY chymal tissue needed to reconstruct the lower See Video 1, in which Dr. Elizabeth Hall- pole. A prosthetic device is usually inserted in the Findlay shows the marking of the breast for prepectoral plane and covered entirely by paren- mastopexy and reduction, available in the “Re- chymal tissue. In rare circumstances, a prosthetic lated Videos” section of the full-text article on device may not be necessary if there is enough PRSJournal.com. Video for Ovid users is avail- parenchymal tissue to create a flap of tissue to able at http://links.lww.com/PRS/A309. enhance projection and contour. See Video 2, in which Dr. Hall-Findlay shows Complications include recurrence, loss of sen- the dissection for mastopexy, including inferior sation, asymmetry, scar, delayed healing, and im- flap rearrangement, the superior pedicle, and ver- plant-related complications. Mandrekas et al., in tical skin resection, available in the “Related Vid- their review of 11 patients, and Pacifico and Kang, in eos” section of the full-text article on PRSJournal.

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Video 1. Video 1, in which Dr. Elizabeth Hall-Findlay shows the Video3. Video3,inwhichDr.Hall-Findlayshowstheskinclosure markingofthebreastformastopexyandreduction,isavailablein and liposuction for mastopexy, is available in the “Related Vid- the “Related Videos” section of the full-text article on PRSJournal. eos” section of the full-text article on PRSJournal.com. Video for com. Video for Ovid users is available at http://links.lww.com/ Ovid users is available at http://links.lww.com/PRS/A311. Pre- PRS/A309. Presented with permission from Elizabeth Hall-Find- sented with permission from Elizabeth Hall-Findlay, M.D., and lay, M.D., and Tracker Productions, Banff, Alberta, Canada. Tracker Productions, Banff, Alberta, Canada.

Mastopexy is indicated in women who desire an improvement in breast contour without a volume change. Traditionally, mastopexy has been performed using primarily skin excision techniques; however, since the mid-1990s, there has been an emphasis on internal shaping of the parenchymal tissue as well. The classic skin excision patterns for mastopexy have included crescent, periareolar, circumvertical, and inverted-T de- signs. Internal shaping can be performed using various supportive materials or parenchymal pillars. This section will review the indications as well as various methods and techniques described. The type of mastopexy performed will depend on the degree of breast ptosis. Breast ptosis is Video 2. Video 2, in which Dr. Hall-Findlay shows the dissection graded using Regnault’s classification (Table 1). for mastopexy, including inferior flap rearrangement, the supe- An excellent review of the standard mastopexy riorpedicle,andverticalskinresection,isavailableinthe“Related techniques was compiled by Rohrich et al.12 A Videos” section of the full-text article on PRSJournal.com. Video crescent mastopexy can be considered when the for Ovid users is available at http://links.lww.com/PRS/A310. degree of nipple-areola complex elevation does Presented with permission from Elizabeth Hall-Findlay, M.D., and not exceed 1 cm. A periareolar mastopexy can be Tracker Productions, Banff, Alberta, Canada. Table 1. Regnault’s Classification of Breast Ptosis Based on the Position of the Nipple-Areola Complex com. Video for Ovid users is available at http:// Relative to the Inframammary Fold links.lww.com/PRS/A310. See Video 3, in which Dr. Hall-Findlay shows Scale Criteria the skin closure and liposuction for mastopexy, Pseudoptosis NAC is above the IMF available in the “Related Videos” section of the Type I (mild) NAC is at or 1 cm below the IMF Type II (moderate) NAC is 1–3 cm below the IMF full-text article on PRSJournal.com. Video for Type III (severe) NAC is at the lowest portion of Ovid users is available at http://links.lww.com/ the breast PRS/A311. NAC, nipple-areola complex; IMF, inframammary fold.

94e Volume 127, Number 4 • Breast Deformities and Mastopexy considered when the distance of nipple-areola proaches for mastopexy have emphasized modi- complex elevation ranges from 1 to 2 cm, which fication of the skin envelope only with minimal would be classified as a Regnault I or II. After the parenchymal manipulation. Goes was the first to skin excision, the outer perimeter of the dermis is demonstrate that skin-only excisions were not suf- scored, and the subcutaneous plane is under- ficient to maintain long-term benefits.13,14 He mined circumferentially to allow for adequate re- emphasized using a periareolar dermal flap in draping of the skin envelope over the paren- conjunction with mixed mesh to support the glan- chyma. The periareolar mastopexy can be dular structures. As these concepts have evolved, performed as a “donut” and in an eccentric pat- the benefits of internal parenchymal reshaping tern (Fig. 3). A circumvertical mastopexy will lift have been demonstrated. Foustanos and Zavrides the base of the breast as well as reposition the have described the double-flap technique.15 The nipple-areola complex and is usually used for a mastopexy outline utilizes the inverted-T pattern. Regnault II (Fig. 4). The inverted-T technique is An inferiorly based parenchymal flap based on useful for the moderate to severely ptotic breast chest wall perforating vessels is created, as well as classified as a Regnault II or III (Fig. 5). The hor- a medial and lateral pillar. The upper breast is izontal incision will reduce the distance from the partially undermined off the pectoral fascia. The nipple-areola complex to the inframammary fold, inferior parenchymal flap is sutured to the pec- while the vertical incision will reduce the base toral fascia, and the medial and lateral pillars are diameter. The L-shaped mastopexy will eliminate sutured together. Boehm et al. prefer the same the medial portion of the inverted-T incision and operation, except that it is performed through a is indicated for women with grade I to II breast vertical incision.16 Ritz et al. have described the ptosis (Fig. 6). fascial suspension mastopexy in which a vertical or Recent innovations have expanded the op- inverted-T pattern is delineated.17 The technique tions for traditional mastopexy. Traditional ap- is similar to the Foustanos and Zavrides technique, except that the inferior parenchymal pedicle is tunneled under a 3 ϫ 5-cm band of pectoralis fascia. The medial and lateral pillars are approx- imated. Graf and Biggs have popularized the pectoral loop technique in which the inferior parenchymal flap is passed through a loop of pectoral muscle to maintain the position of the flap.18 This operation can be performed though various incisional patterns that include J, inverted-T, vertical, and horizontal patterns. The use of an interlock- ing Gore-Tex suture to maintain the diameter of Fig. 3. Illustrations of (left) an eccentric mastopexy pattern and the nipple-areola complex can be considered. (right)aperiareolarordonutmastopexypattern.(Reprintedfrom Complications include delayed healing, skin Rohrich RJ, Thornton JF, Jakubietz RG, Jakubietz MG, Gru¨nert JG. necrosis, nipple necrosis, nipple asymmetry, fat Thelimitedscarmastopexy:Currentconceptsandapproachesto necrosis, and unattractive scars.18 Mammographic correct breast ptosis. Plast Reconstr Surg. 2004;114:1622–1630.) changes can occur following glandular reshaping

Fig. 4. The pattern for a circumvertical mastopexy is illustrated. (Reprinted from Rohrich RJ, Thornton JF, Jakubietz RG, Jakubietz MG, Gru¨nert JG. The limited scar mastopexy: Current concepts and approaches to correct breast ptosis. Plast Reconstr Surg. 2004;114:1622–1630.)

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Fig. 5. The pattern for the inverted-T mastopexy is illustrated. (Reprinted from Rohrich RJ, Thornton JF, Jakubietz RG,JakubietzMG,Gru¨nertJG.Thelimitedscarmastopexy:Currentconceptsandapproachestocorrectbreastptosis. Plast Reconstr Surg. 2004;114:1622–1630.)

AUGMENTATION MASTOPEXY Augmentation mastopexy is a complex operation that incorporates all of the elements of augmentation mammaplasty and mastopexy. Proper assessment includes the degree of nipple ptosis, degree of breast ptosis, distance from the nipple- areola complex to the inframammary fold, location of the nipple-areola complex relative to the breast, and the quality of the skin envelope and Fig.6. ThepatternfortheL-shapedmastopexyisillustrated.(Re- parenchymal tissue. Indications for an augmenta- printedfromRohrichRJ,ThorntonJF,JakubietzRG,JakubietzMG, tion and mastopexy include a nipple-areola com- Gru¨nert JG. The limited scar mastopexy: Current concepts and plex that is below the inframammary fold, Reg- approachestocorrectbreastptosis.PlastReconstrSurg.2004;114: nault’s grade II to III ptosis, excess breast skin 1622–1630.) relative to breast parenchyma, and breast ptosis that is more than 2 cm below the inframammary fold. The goals of this procedure are to elevate the position of the nipple-areola complex, enhance and include microcalcifications. These can usually breast volume, and tighten the skin envelope to be distinguished from malignant transformation. improve breast contour and position. In a recent survey of U.S. plastic surgeons, the The decision making with regard to mas- skin excision pattern utilizing the inverted-T incision topexy alone, augmentation alone, and augmen- was found to be the most common type of mastopexy tation mastopexy can be complicated. The ideal performed.19 Physician satisfaction was highest with position of the nipple-areola complex should be short-scar circumvertical techniques and lowest with determined based on the inframammary fold and periareolar techniques. Morbidities were assessed the midhumeral location (Fig. 7). If nipple eleva- based on procedure type. Revisions were highest tion is not required, then augmentation alone in the periareolar group (p Ͻ 0.002), bottoming should suffice. However, if there is some degree of out was greatest in the inverted-T group (p Ͻ breast ptosis, augmentation mastopexy may be 0.043), and asymmetry was highest in the short- considered. Mastopexy types include the crescent, scar group (p Ͻ 0.008). circumareolar, circumvertical, and Wise pattern.

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eral technical points that should be considered to keep the operation safe and effective. Spear has reviewed the complexities associated with this operation when the mastopexy is performed following augmentation, including infection, implant exposure, loss of nipple-areola sensation, malposition of the nipple-areola complex, and malposition of the implant relative to the overlying breast.20 The complexities are compounded when simultaneous augmentation and mastopexy are planned, because of apposing vectors. Risks include devascularization of the central breast mound, skin necrosis, loss of nipple sensation, and nipple malposition. Friedman has outlined several preventative measures when considering simultaneous augmentation and mastopexy.21 These include subpectoral device placement, augmentation before mastopexy, tailor-tacking the skin envelope, avoidance of inverted-T incisions, and parenchymal resection as needed. Clinical experience with augmentation/mastopexy has been generally favorable. Stevens et al. have reported a 10.9 percent implant revision rate and a 3.7 percent tissue revision rate.22 Compli- cations included saline implant deflation, recur- rent ptosis, poor scaring, and areolar asymmetry. The majority of women had silicone gel implants Fig. 7. The position of the nipple-areola complex is based on the (69 percent) placed in the submuscular position relationship to the inframammary fold, as depicted. (Reprinted (87 percent). The type of mastopexy included the from Spear SL, Boehmler JH, Clemens MW. Augmentation/mas- inverted-T (60 percent), periareolar (21 percent), topexy: A 3-year review of a single surgeon’s practice. Plast Re- circumvertical (15 percent), and crescent (4 per- constr Surg. 2006;118(Suppl.):136S–147S.) cent). Spear et al. have reported on 166 women who had various combinations of augmentation, mastopexy, and augmentation mastopexy.23 There For mild ptosis, a crescent or periareolar approach were 97 primary procedures and 69 secondary is considered. For moderate ptosis, a circumver- procedures. Complications following primary aug- tical approach is considered. For severe ptosis, an mentation occurred in 1.7 percent compared with inverted-T incisional pattern is often performed. 17.4 percent following primary augmentation All of these options will depend on the desires mastopexy. The revision rate following primary and expectations of the patient. If a woman is augmentation was 1.7 percent compared with 8.7 interested in mastopexy alone or augmentation percent following primary augmentation mas- alone, this should take priority, assuming that the topexy. Comparing the complication and revision patient understands the shortcomings, risks, and rate in women following secondary augmentation benefits. In a woman with mild to moderate breast and augmentation/mastopexy procedures dem- ptosis, simultaneous augmentation and mas- onstrated no difference. topexy can be considered. In a woman with severe breast ptosis, a staged procedure can be consid- POLAND SYNDROME ered. In these patients, either mastopexy or aug- Poland syndrome is an uncommon condition mentation can be performed first followed by the with a reported incidence that is less than 0.1 other. Prosthetic devices can be placed in the sub- percent.1 It is characterized by hypoplasia or apla- pectoral or subglandular plane. These planes are sia of the breast and nipple-areola complex, ab- usually accessed through the mastopexy incisions sence of the pectoralis minor muscle, absence of and do not require remote access. the sternal head of the pectoralis major muscle, When either a staged or simultaneous aug- and a subcutaneous soft-tissue deficiency. The mentation/mastopexy is planned, there are sev- typical appearance of a patient with Poland syn-

97e Plastic and Reconstructive Surgery • April 2011 drome includes severe asymmetry of the af- Complications following correction of Poland fected and nonaffected chest wall, with a breast deformity are primarily related to the re- pathognemonic groove at the junction of the construction itself. Prosthetic devices may be superior anterior axillary line and chest wall compromised because of capsular contracture, because of the absent sternal head of the pec- implant rupture, implant distortion, implant mi- toralis major. Brachydactyly and syndactyly are gration, and seroma formation.26,30,31 Flap recon- sometimes associated with this syndrome. struction may fail due to perfusion problems, re- The goals of treatment are to correct the bone sulting in partial or total flap failure. Breast deformity when necessary, address the soft-tissue asymmetry is almost always a certainty following deficiency, and to reconstruct the breast. Correc- unilateral reconstruction; however, secondary tion of Poland deformity may require stages. In procedures may improve the imbalance. Rocha et young children with a severe chest wall deformity, al. have described the phenomena of costal re- early reconstruction of the thoracic cage may be sorption and mediastinal shift following pros- 31 necessary before breast reconstruction, which thetic reconstruction. would be considered in late adolescence or adult- Outcomes following correction have generally hood when breast development is complete.24 been good. Seyfer et al. reported long-term results 30 Reconstructive options include remodeling of following correction in 27 patients. The majority the thoracic cage, use of autologous tissue with of women had soft prosthetic devices with or with- free or pedicled flaps, prosthetic devices, and au- out a latissimus dorsi flap and did well. Custom- tologous fat transfer using injection techniques. made devices fared worse requiring premature Fokin and Robicsek have described an option for removal in 75 percent. Contralateral procedures chest wall reconstruction utilizing contralateral for balance and symmetry were necessary in 13 of split-rib grafts that are secured to the defective rib 21 women (62 percent). margins and sternal edge.24 This is resurfaced with prosthetic mesh for support. During the second GYNECOMASTIA stage, latissimus dorsi flap reconstruction is con- See Video 4, in which Dr. Hall-Findlay shows sidered. Dingeldein et al. have described a similar the reduction surgery, including inferior wedge procedure that spares the costal cartilage and uti- excision, medial pedicle, and vertical skin re- lizes the latissimus dorsi muscle immediately 25 section, available in the “Related Videos” section rather than prosthetic mesh. Borschel et al. had of the full-text article on PRSJournal.com. Video stratified the various types of Poland deformities reconstructed with prosthetic devices with and without the addition of a latissimus dorsi flaps.26 The prosthetic devices included tissue expanders, customized solid silicone implants, and standard saline and silicone gel implants. In men, a custom silicone implant is preferred rather than a latissimus dorsi flap. In women, a two-stage reconstruction is preferred, starting with a tissue expander and followed by either a latissimus dorsi flap with or without an implant or a prosthetic device without flap coverage. Kelly et al.27 have successfully used the contralateral latissimus dorsi free flap in a 2-year-old girl, and Laio et al.28 have used the deep inferior epigastric perforator flap in a 52- year-old woman with severe ipsilateral chest wall abnormalities associated with Poland syndrome. Coleman and Saboeiro have described and pop- Video 4. Video 4, in which Dr. Hall-Findlay shows the reduction ularized lipoaugmentation for breast deformi- surgery, including inferior wedge excision, medial pedicle, and ties, including Poland breast.8 Pinsolle et al. vertical skin resection, is available in the “Related Videos” section have used lipoaugmentation alone in one pa- of the full-text article on PRSJournal.com. Video for Ovid users is tient and in combination with prosthetic devices available at http://links.lww.com/PRS/A312. Presented with and/or autologous tissue in seven patients with permissionfromElizabethHall-Findlay,M.D.andTrackerProduc- Poland syndrome.29 tions, Banff, Alberta, Canada.

98e Volume 127, Number 4 • Breast Deformities and Mastopexy for Ovid users is available at http://links.lww. using direct excision or suction lipectomy. Various com/PRS/A312. modalities to assist with these techniques have been See Video 5, in which Dr. Hall-Findlay shows recently described. the summary and result for mastopexy and re- The goals of treatment are to determine the duction, available in the “Related Videos” sec- etiology of this condition and to control or reverse tion of the full-text article on PRSJournal.com. the process (Fig. 8). Gynecomastia may be due to Video for Ovid users is available at http://links. the ingestion of certain medications, systemic dis- lww.com/PRS/A313. ease, body habitus, or genetic predisposition. Gynecomastia is a condition of benign prolif- Medications that have been implicated in causing eration of breast tissue in men. Although not com- gynecomastia include, but are not limited to, anti- monly reported, it is present in 40 to 50 percent androgens, exogenous hormones, and cardiovas- of men over 40 years of age.32 It can manifest in cular medications, such as digoxin and spirono- pubertal boys and in men of advanced years. The lactone, as well as antiulcer medications, such as etiology is variable and may be due to excess cir- cimetidine and ranitidine.32,33 Systemic conditions culating estrogen, decreased circulating andro- include thyroid abnormalities, renal failure, and gens, or a deficiency of androgen receptors.32,33 In liver disorders. Control of the underlying condi- middle-aged and older men, it is thought to be due tion or cessation of medication may improve the to the excessive aromatization of androgens to condition; however, if not, then surgical options estrogens.32 Initial evaluation requires differenti- are considered. The goal of surgery is to remove ation between fatty tissue, parenchymal enlarge- the excess breast tissue and skin, ensure adequate ment, and tumor. Imaging studies, such as mam- positioning of the nipple-areola complex, ensure mography, are useful. Biopsy may be indicated in symmetry between the breasts and chest wall, and some cases. to avoid significant scarring.35 Classification of the gynecomastia will assist with There have been several methods by which treatment planning. Rohrich et al. have classified excess breast tissue is removed that range from gynecomastia based on breast size and degree of direct excision to suction-assisted lipectomy. Cur- ptosis.34 Grade I is minimal hypertrophy without pto- rent standards are to use liposuction and its de- sis. Grade II is moderate hypertrophy without ptosis. rivatives unless the condition is so severe that di- Grade III is severe hypertrophy with grade I ptosis. rect skin excision is required. For when skin Grade IV is severe hypertrophy with grade II or III excision and free nipple grafting are necessary, ptosis. Surgical management consists of removal of Murphy et al. have described a method by which the excess fat and glandular tissue. This is achieved nipple-areola placement is optimized.36 Based on preoperative measurements, the vertical axis is lo- cated 0.33 times the distance of the sternal notch and pubis, and the horizontal axis or internipple distance is 0.21 times the chest circumference. An alternative to free-nipple grafting in cases of severe hypertrophy is described by Tashkandi et al.37 In these cases, a single-stage subcutaneous mastectomy and circumareolar concentric skin reduction is performed. Traditional suction-assisted liposuction can be effective in mild cases of gynecomastia; however, in more advanced cases, enhancing the efficacy and strength of liposuction may be necessary. Hodgson has reported on the use of ultrasonic- assisted liposuction in conjunction with suction- assisted liposuction for gynecomastia.38 Thirteen patients with gynecomastia that ranged from Video 5. Video 5, in which Dr. Hall-Findlay shows the summary grade I to III had successful treatment with aspi- and result for mastopexy and reduction, is available in the “Re- rates that ranged from 100 to 300 cc using ultra- lated Videos” section of the full-text article on PRSJournal.com. sonic-assisted liposuction and 100 to 600 cc using Video for Ovid users is available at http://links.lww.com/PRS/ suction-assisted liposuction. Lista and Ahmad A313. Presented with permission from Elizabeth Hall-Findlay, have utilized power-assisted liposuction in con- M.D., and Tracker Productions, Banff, Alberta, Canada. junction with a pull-through technique to sever

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Fig. 8. A preoperative algorithm for gynecomastia is illustrated based on the possible etiologies. (Reprinted from Rohrich RJ, Ha RY, Kenkel JM, Adams W. Classification and management of gynecomastia: Defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111:909–923.) the subdermal attachments of the fibroglandular toma, seroma, partial nipple necrosis, suture line breast tissue.39 The mean aspirate from the power- dehiscence, pain, loss of nipple sensation, and assisted liposuction was 459 cc (range, 25 to 1400 infection. Lanitis et al. have demonstrated that cc), and the amount of additional tissue extracted patient age, resection volume, grade of gyneco- with the pull-through technique ranged from 5 to mastia, and surgical approach was not predictive 70 cc per breast. An alternative to the pull-through of a minor or major complication using direst technique is to use a power-assisted arthroscopic- excisional techniques.41 They reported an overall endoscopic cartilage shaver as described by Prado complication rate of 15.5 percent, with the ma- and Castillo.40 This was demonstrated to be effec- jority of complications due to underresection tive in 20 patients in whom the fibrofatty and (21.9 percent), overresection (18.7 percent), com- glandular tissues were removed without areolar plex scars (18.7 percent), hematoma (16.1 per- incisions (Fig. 9). cent), and seroma (9.1 percent). Gingrass and Complications include inadequate resection, Shermak have reported no serious complications overresection, excess skin, complex scars, hema- using ultrasound-assisted liposuction.42 Potential

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Fig. 9. Preoperative and postoperative views following gynecomastia surgery using the endoscopic cartilage shaving device. (Re- printed from Prado AC, Castillo PF. Minimal surgical access to treat gynecomastia with the use of a power-assisted arthroscopic- endoscopic cartilage shaver. Plast Reconstr Surg. 2005115:939–942.) risks of ultrasonic liposuction include thermal Table 2. CPT Codes Commonly Used in burns and skin necrosis, because one of the by- Reconstruction of Breast Deformities and products of ultrasonic energy is heat. This is Mastopexy* avoided by using cool towels over the skin and CPT avoiding superficial planes near the skin surface.38 Code Descriptor Outcomes following gynecomastia treatment 14040 Adjacent tissue transfer or rearrangement, have been generally regarded as good to excellent, trunk; defect 10 cm2 or less 14041 Adjacent tissue transfer or rearrangement, regardless of the technique used. After ultrasound- trunk; defect 10.1 cm2 to 30.0 cm2 assisted liposuction for gynecomastia, Hodgson et 15734 Muscle, myocutaneous, or fasciocutaneous flap; al. used a visual analogue score to assess patient trunk 38 19300 Mastectomy for gynecomastia satisfaction. Based on a scale of one to 10, the 19316 Mastopexy mean score for overall satisfaction, shape, appear- 19325 Mammaplasty, augmentation; with prosthetic ance of scars, and self-confidence was nine. implant Rohrich et al. have demonstrated that no addi- *This information prepared by Dr. Raymond Janevicius is intended to provide coding guidance. tional procedures were necessary in 86.9 percent (53 of 61) of men following ultrasound-assisted liposuction for gynecomastia.34 In eight men with were satisfied to very satisfied. Based on the vari- grade III and IV gynecomastia, staged excision of ability of outcomes, patients must be carefully skin and breast was necessary to achieve the de- counseled regarding the risks and benefits of gy- sired outcome. Ridha et al. have recently reported necomastia surgery. on gynecomastia outcomes following a question- Table 2 lists CPT codes commonly used in re- naire evaluation in 72 men following gynecomas- construction of breast deformities and mastopexy. tia surgery.43 Although postoperative scores were increased using a Likert score from zero to five Maurice Y. Nahabedian, M.D. Georgetown University Hospital following either liposuction alone, surgical exci- 3800 Reservoir Road, NW sion alone, or a combination, the degree of in- Washington, D.C. 20007 crease was moderate. Only 62.5 percent of men [email protected]

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