Aesthetic Breast Surgery into Next Millenium II
Whenever we talk of female beauty, breast is invariably associated as one of its attributes. Why? Our first food after birth comes from the breast, raises an eternal bondage according to the Freudian philosophy.
The idea of the beauty has changed over ages, in different cultures and at various stages of civilisation, along with its individual perception. This is mainly related to facial aesthetics and body contour. Seldom much is talked about breast- except that it is ornamental in a female, as much as it is the first contact between a mother and a child after birth.
Figure 1: Over-augmented Breast
We know that the breast extends from 2nd to the 6th rib, from mid-axillary line to the sternum and it develops on the mammary line. This is as far as the anatomy is concerned. But what about the aesthetics?
Figure 2: Correctly Augmented Breast
Figure 3: Venus of Palaeolithic Age
In recent years I have endeavoured to project the aesthetics of the female breast to the international community. Though Pamela Anderson or Dolly Parton may have an attraction(?) to the male eye, yet no artist or sculptor would attribute those breasts as the epitome of beauty. If we look at two augmented breasts, which looks normal? In Figure 1 the breasts have been over-augmented and also it shows sagging of traditional prosthesis with gravity. In Figure 2 the augmentation is balanced with the natural drop. Also it's ‘proportions to the body’ (Figure 3) of the individual ( i.e., height, structure, girth etc.) has to be considered, when visualising the outcome.
Figure 6: Bronze Figurine
The first and foremost is a philosophy, that there is a gradual droop of the breasts with age. The breast of an eighteen year girl and that of a fifty-five year old lady is not the same. This natural droop with age forms the aesthetic basis of performing breast surgery.
Figure 4: Indian Sculpture
On the lateral profile the line from clavicle to the nipple must be straight line, rather than an obvious convex curve. This fact is substantiated by the painting of Radha (Figure 5) or an extract from Indian sculpture (Figure 4) or from a bronze figurine (Figure 6)
Figure 5: Radha
Aesthetic Surgery is an art and the success of the cosmetic surgeon lies in the fact that the profile is enhanced, yet nobody can recognize that the lady underwent cosmetic surgery. This is where the natural aesthetics of the breast should be taken into account. The other factor, while performing this surgical art- is not only the immediate result, but also its long term aesthetics. Gravitational changes with aging do play an important role together with the intrinsic changes as skin elasticity, fine epidermal lines, ultra-violet changes (if one happens to be a topless sun worshipper!) and pigmentary changes specially in a person with dark skin, also cannot be ignored.
That the fashions of performing breast surgery are changing, is reflected in our human beings’ eternal quest for a change due to our inherent dissatisfaction with what is present. But it is good to remember the golden words of Euripedes (484-406 B.C.) that moderation is the noblest gift of heaven.
This forms the aesthetic framework of the art of breast surgery into the next millennium. Aesthetic breast surgery consists of:
- Breast Augmentation
- Breast Reduction & Mastopexy
- Correction of Unequal Breasts
- Correction of Accessory Breasts
- Correction of Inverted nipple
- Correction of Gynaecomastia
1. Breast Augmentation
When analyzing this popular procedure the key issues that come to one’s mind is “What do we insert?” and “Where?”
Czerny from Heidelberg is generally accepted to have performed the first
augmentation mammoplasty in 1895. Since then, a variety of nonsilicone materials have been injected or implanted to augment or to reconstruct the hypoplastic female breast, including autologous tissues, intramammary- or submammary-injected alloplastic materials, and preformed alloplastic materials other than silicone. For various reasons, none was fully acceptable. The introduction of the medical-grade silicone bag prosthesis in the early 1960s improved the results of mammary augmentation dramatically and reduced the incidence of fibrous contracture and implant extrusion. Other methods of breast augmentation became obsolescent.
Silicone has been a long stay as the only safe, inert material. What actually is it? Silicone is a family of chemical compounds with many common uses. We use items containing silicones every day without even realizing it. The special qualities of silicones make them ideal for many items, from medical implants and instruments, to hand lotions and lipstick. Even some of the foods we eat contain silicones.
Silicones are made from silicon, found naturally in sand, quartz and rocks. Next to oxygen, silicon is the most common element in the earth’s crust, and like oxygen, both animal and plant life depend on silicon. Silicon becomes silicone when it is combined with oxygen, carbon and hydrogen. Depending on how the silicone molecules are arranged, silicone can be manufactured into a variety of forms, including powders, gels, oils, and elastomers. Silicon elastomers are conversion of the natural silicon into a semi-solid gel form, which gives the particular ‘feel’ of the breast.
Breast prosthesis comprises of an outer shell of silicone sheet and an inner filling of silicone elastomer. It has sustained so many modifications in its shape and form, right from a circular umbrella like cone to the anatomical variety of today. First and foremost was the shell - which initially had a smooth surface ( still unfortunately used by many of the plastic surgeons here). This gave rise to a high degree of capsular contracture rate amounting to 45% - and we saw a jump from 80’s to 90’s to the textured (rough surface) shell, where the capsular contracture dramatically fell to 5-9%.       In between we saw an upsurge of polyuerthrane coated     ones to decrease capsular contracture. Later on it proved to be carcinogenic and was abandoned. This was replaced with MISTI Gold prosthesis, which again fell out of repute.
The next came the filling. Silicone was performing well until in early 90’s the famous litigation in USA with Dow Corning -the main supplier of the elastomer, where the American Court awarded seven million dollars to a lady affected by auto-immune disease, which was attributed to silicone seepage. At that stage, there was no medical evidence to prove or disprove this and FDA banned  silicone filled prosthesis only in USA, though the shell was still of silicone. However in other parts of the world including United Kingdom, silicone was still routinely used without any adverse effects.
To compensate for this ‘silicone bar’ in USA, saline filled varieties as Becker to 133, 163, 363 came in market. In the midst of the ‘silicon controversy’ another group started filling the prosthesis with soya bean oil and Trilucent implant was born. One problem with these new varieties was that the ‘feel’ was not normal, as it was with silicone and the shell fracture was significant.
Figure 7: McGhan's Different Varieties of Anatomical Implants
Another big problem with all these -- be it silicone, saline or Trilucent were the fluid nature of the filling. Under gravity they all gravitated inferiorly resulting in total distortion of the superior pole. This also resulted in loss of projection, which is of prime importance in augmentation. To compensate these drawbacks a new silicone hydro-colloid semi-solid gel came into market. The shape of outer covering changed from moderate to low profile and ultimately merged into an anatomical shaped one, combined with a hydro-colloid filled semi-solid gel -- which is the best available in market today. In the meantime a study on a huge section from USA in 1996, proved silicone had no relation to auto-immune disease and further studies are going on.
Figure 8: Breast Prosthesis Placement
The other question was where to insert? This was to do with capsular contracture. Sub-mammary to sub-pectoral are both accepted methods of treatment. My personal preference would be for the sub-mammary one as to sub-pectoral insertion, to give it proper natural aesthetics. Moreover sub-pectoral includes detachment of medial fibres of pectoralis, which causes more bleeding and hence increased risk of contracture.
Having performed significant number of endoscopic breast augmentations          via umbilicus or trans-axial route- I would say, it may be a new method, but not the best one. Firstly you have to introduce a saline filled prosthesis and the ‘feel’ is not just good. Secondly the pocket is not adequate to ensure the normal aesthetics and thirdly the infra-mammary fold is distorted specially by trans-umbilical route.
Today the philosophy of breast augmentation -- is not a volumetric expansion, but an increased projection at the right level on a correct base: to give the desired cleavage.
2. Breast Reduction & Mastopexy
Figure 9: Breast Reduction - An Artistic Concept
Large breasts may be attractive to some male eye, but it causes enormous inconvenience to the victimized female. In addition to breast pain it also causes shoulder, neck and back pain. Getting the right cosmetic clothing (bra etc.) to turning from one side to the other or carrying out gymnastics, it is a nuisance to the person who develops this hypersensitivity of the estrogen receptors during puberty. The social comments to the downward fixation of a male vision in a discourse - shatters the identity.
To alleviate this problem though amputation of the breast may have started the reduction technique, yet it was RS Wise in 1956 who suggested the key-hole pattern of reduction.- to give it the cone shape. Breast is a cone and its reduction must be in a three-dimensional plane. The other issue was preserving the blood-supply to the nipple-areolar complex, which is supplied from all sides. In came techniques of Duformental,b-Reduction, McKissock, Pitanguy, Skoog , Strombeck, Robbins etc. and all breasts landed with a standard Wise pattern of inverted T-shaped scar.
Breast reduction entails reduction of the breast and correction of skin envelope, whereas mastopexy is correction of the skin envelope only. That in breast reduction two different entities play a role individually and each must be addressed in its own merit brought a new dimension to the philosophy of breast reduction.
Reducing the scarring was the next phase in the agenda and Mouly aimed at an oblique scar, while Rudolf Myer aimed at an L-scar. Several others gave their own ways   to this concept. It was Daniel Marchac who proposed reducing the infra-mammary scar at the cost of compensation at nipple-areolar complex level. The ideas of Mouley and Marchac were further modified by Lassaus   into a vertical scar, which was popularized by Lejour   .
Several other techniques as axillary approach, Erich Lexter’s Mammoplasty attempted by Hinderer were born and pedicles were switched, sometimes keeping the vertical scar  or converting Marchac’s superior pedicle to an inferior one and in came the SPAIR technique to play its harmony in the symphony of breast reduction orchestra. Some other techniques as horizontal scar and liposuction  of the breast were tried and died even before they were born. Breast is a fibro-fatty-glandular organ - and liposuction can only remove the fatty element, but not the other two.
With the establishment of the evidence that nipple areolar complex is supported by a central posterior core of blood vessel (Levet ) and the fact that the breast is a combination of two key issues- the breast tissue itself and its skin envelope,  Savaci proposed a peri-areolar reduction which was later modified by others  . These secondary concepts were essentially an admixture of Marchac’s concept adapted to a peri-areolar route. In my experience, the problem is when there is no dermal support following peri-areolar reduction, under the influence of gravity and the lateral pillars falling apart as stitches dissolve or give way, the breast in no time loses its projection and assumes a male form. Savaci’s idea was further developed by Wuringer  to hold up the breast against gravity. Later other techniques as trap-doors under pectoralis were tried to achieve this goal. Trap dooring the pedicle in-between pectoralis is a dangerous proposition and may put the vascularity of the nipple-areolar complex unnecessarily to risk. Other methods to hold the breast up are being experimented. Though the idea of superficial fascial system (SFS)  suspension looks great, theoretically, it does not have enough strength against gravity. On the other hand Frey’s idea looks more promising , but in breasts where reduction is minimal, getting enough length of the skin for suspension can be a problem. Moreover whatever stitch is applied to pectoral fascia or periosteum , under the influence of gravity it tends to give way. The only secure place is a wrap around with the rib and costal cartilage. Lindquivist’s bio-absorbable screws to secure this with rib may be the answer.
I remember Carlos in the International Society of Aesthetic Plastic Surgeons meet propose in presence of Levet the first concept of peri-areolar reduction on a central pedicle wrapped with a vikryl mesh, though while writing this resume I could not see any publications to that effect.
The question is how long does this lift last against gravity? In the long run will it stay as you have raised it with surgery? This is the key question into the next millennium. A reduced scar, i.e. peri-areolar, with either sling, mesh or a fascia to hold it up is the way forward into the 21st century. Has anyone thought about a free fascial transfer?
3. Correction of Unequal Breasts
Unequal breasts  may be due to an underdevelopment of one breast or over-development of the other. Basically the decision is of matching the two. Depending on the size the patient wants, one breast can be reduced or the other augmented, - in most cases, it is the combination of the two to give it the right size and aesthetic shape. In most cases, where a reduction is deemed, I tend to carry out a peri-areolar reduction which gives the best cosmetic results.
Usually the hypoplastic breast is often associated with a condition called tubular  breast. Here not only is the breast hypoplastic, but also the base diameter is very narrow. Though there are some one stage operations  to correct this primarily, the results are not very good. In these cases volumetric increase of the size would not give best aesthetic result. The aim is to increase the base diameter. This can be achieved by a expander-prosthesis as a Becker or expand the breast     in the first instance and later insert the right sized prosthesis to balance the contralateral side
4. Correction of Accessory Breasts
Figure 10 : Accessory Breasts
Though there is a theoretical possibility of accessory breasts developing anywhere on the milk ridge, in reality it is usually a single or a pair that is mostly found in the axilla. Sometimes it may be mistaken for a lymphangioma or even a part of the breast. Liposuction has been tried. However where the fibroglandular component is predominant, excision either open or endoscopic remains the only alternative.
5. Correction of Inverted Nipple
Nipple has two important roles in a female. As much as it is sensory to the sexuality of the female, it is the vehicle of transport of the breast milk to the hungry infant. Understanding inverted nipple associated with an underlying pathology needs correction of the underlying condition. In idiopathic cases initially different operations         were described. All operations of correction of this condition caused so much scarring, that it interfered with lactation.
While I was in training, my Consultant Mike Gipson gave us the idea that this could be corrected by a constant vacuum suction and made an ingenuous device with a syringe to achieve this. Later on my colleague Douglas McGeorge marketed it as a commercial device called ‘Nipellete’.
Though most of these are curable by Nipelllete alone , still in severe refractory cases surgery       might be the only alternative.
One of the serious malaise that has effected modern western world is the mania of publications. Before one has any clue of the subject, a publication is born. In most cases the thought process is blocked and there is a compulsive socio-career oriented compulsion to publish. Invariably this lands up with lot of junk or the repetition of same idea again and again and again.
In case of gynaecomastia the number of publications  reflects this fact. The original operation of removing breast by a subcutaneous mastectomy underwent several modifications of approaching the breast tissue either by an infra-mammary route or axillary route  or through or around the nipple. All these techniques    were basically aiming at a position of hiding the scar.
There are few basic questions to be answered before we step in to manage gynaecomastia:
- What is the grade of gynaecomastia?
- Do we remove breast tissue only, or adjust the skin with it?
- Is the breast predominantly of fatty tissue or fibro-glandular tissue?
- What is the best way to avoid scars?
- How to prevent the saucerisation to give cosmetically good results?
Before contemplating surgery, these questions have to be answered. Grade I gynaecomastia can be treated with reduction of breast tissue, but Grade II (sometimes) and Grade III (always) requires skin excision alongside.
Liposuction     , as the only treatment is applicable to fatty breasts in Grade I and early Grade II gynaecomastia.
In other cases excision must be performed. The choice of approach is individual. I tend to use a superior pedicle based peri-areolar   approach and reduce the skin  if needed. The removal of breast is an art. Anterior approach to the breast invariably results in saucerisation. Sometimes this can be masked by adjuvant peripheral liposuction. Over-reduction at nipple-areolar complex can cause severe nipple retraction. I use a posterior approach, my own technique, which has uptil now produced consistent cosmetic results.
In Grade III ‘giganto-gynaecomastia’    an inferior or superior pedicle technique or bipedicled technique  or even a free nipple transfer may be necessary.
In fibro-glandular breast which does not need skin excision, I use the endoscopic technique.
Fashions will change. The process of describing yet another technique will go on   .
Figure 11: Rene Margaritte’s 'The Rape'
Breast is an intensely personal organ of a lady - and there is a relationship of this femininity to her soul. So whenever a surgeon attempts to perform this surgery, let us remember that we are playing with her femininity - and surgery done in the wrong way, is a monstrous abuse of her femininity. Changes may come and go, fashions of performing breast surgery may change further in the next millennium, but the eternal philosophy of human psychology in relation to this organ will not change. Even before attempting to put a knife in it, one must always remember, they are delicate and must be dealt with expertise, professionalism, aesthetics and art. Maybe Rene Margaritte’s concept of ‘The Rape’(Figure 7) will emerge as the epitome of normality one day and challenge the present concept. Until that time the patterns of performing aesthetic breast surgery will re-fashion, re-model and re-vibrate around the rhythms of the present philosophy.
 Sartre DB, et al
Bigger is not always better: body image dissatisfaction in breast reduction and breast augmentation patients.
Plast Reconstr Surg. 1998 Jun;101(7):1956-61; discussion 1962-3.
Beekman WH, Hage JJ, Jorna LB, Mulder JW
Augmentation mammaplasty: the story before the silicone bag prosthesis.
Department of Plastic and Reconstructive Surgery, Academisch Ziekenhuis Vrije Universiteit, Amsterdam, The Netherlands Ann Plast Surg 1999 Oct;43(4):446-51
 Glatt BS, et al.
Long-term follow-up of a sponge breast implant and review of the literature.
Ann Plast Surg. 1999 Feb;42(2):196-201. Review.
 Hadden WE.
Silicone breast implants: a review.
Australas Radiol. 1998 Nov;42(4):296-302. Review.
 Wyatt LE, et al.
The influence of time on human breast capsule histology: smooth and textured silicone-surfaced implants.
Plast Reconstr Surg. 1998 Nov;102(6):1922-31.
 Hakelius L, et al
Tendency to capsular contracture around smooth and textured gel-filled silicone mammary implants: a five-year follow-up.
Plast Reconstr Surg. 1997 Nov;100(6):1566-9.
 Malata CM, et al
Textured or smooth implants for breast augmentation? Three year follow-up of a prospective randomised controlled trial.
Br J Plast Surg. 1997 Feb;50(2):99-105.
 Asplund O, et al.
Textured or smooth implants for submuscular breast augmentation: a controlled study.
Plast Reconstr Surg. 1996 May;97(6):1200-6.
 Coleman DJ, et al.
Textured or smooth implants for breast augmentation? A prospective controlled trial. Br J Plast Surg. 1991 Aug-Sep;44(6):444-8
 Hoffman S.
Correction of established capsular contractures with polyurethane implants.
Aesthetic Plast Surg. 1989 Winter;13(1):33-40.
 Cohney BC, et al.
Augmentation mammaplasty--a further review of 20 years using the polyurethane-covered prosthesis.
J Long Term Eff Med Implants. 1992;1(3):269-79.
 Bruck HG.
Long-term results following implantation of breast prosthesis with a polyurethane coating.
Handchir Mikrochir Plast Chir. 1990 Sep;22(5):274-6. German.
 Hester TR Jr, et al.
A 5-year experience with polyurethane-covered mammary prostheses for treatment of capsular contracture, primary augmentation mammoplasty, and breast reconstruction.
Clin Plast Surg. 1988 Oct;15(4):569-85.
 Melmed EP.
Polyurethane implants: a 6-year review of 416 patients.
Plast Reconstr Surg. 1988 Aug;82(2):285-90
 Ersek RA.
Molecular impact surface textured implants (MISTI) alter beneficially breast capsule formation at 36 months.
J Long Term Eff Med Implants.
 Guerette PH.
The silicone breast implant controversy.
Can Nurse. 1995 Feb;91(2):31-7.
 Palley HA
The evolution of FDA policy on silicone breast implants: a case study of politics, bureaucracy, and business in the process of decision-making.
Int J Health Serv. 1995;25(4):573-91. Review.
 Moran T. Battle scars.
For plastic surgeons, psychological effects linger from silicone breast implant controversy.
Tex Med. 1995 Jan;91(1):30-4.
 Lack of association between augmentation mammoplasty and systemic sclerosis (scleroderma). Arthritis Rheum. 1996
 Ersek RA, et al.
Textured surface, nonsilicone gel breast implants: four years' clinical outcome.
Plast Reconstr Surg. 1997 Dec;100(7):1729-39.
 Brown SL, et al.
Rupture of silicone-gel breast implants: causes, sequelae, and diagnosis. Lancet. 1997 Nov 22;350(9090):1531-7
 Hochberg MC, et al.
The association of augmentation mammoplasty with connective tissue disease, including systematic sclerosis (scleroderma): a meta-analysis.
Curr Top Microbiol Immunol. 1996;210:411-7.
 Shrotria S, et al.
Breast haematomas: same appearance, different diagnosis.
Br J Clin Pract. 1994 Jul-Aug;48(4):214-5.
R Breast augmentation by an umbilical approach.
Aesthetic Plast Surg. 1999 Sep-Oct;23(5):323-30.
 Ho LC
Endoscopic-assisted augmentation mammaplasty.
Br J Plast Surg. 1996 Dec;49(8):576-7.
 Beer GM, et al.
Endoscopic plastic surgery: the endoscopic evaluation of implants after breast augmentation.
Aesthetic Plast Surg. 1995 Jul-Aug;19(4):353-9.
 Price CI, et al.
Endoscopic transaxillary subpectoral breast augmentation.
Plast Reconstr Surg. 1994 Oct;94(5):612-9.
 Tebbetts JB
Transumbilical approach to breast augmentation.
Plast Reconstr Surg. 1994 Jul;94(1):215-6
 Benmeir P, et al.
Laparoscopic breast augmentation.
Plast Reconstr Surg. 1994 Jul;94(1):215.
 Chajchir A, et al
Endoscopic augmentation mastoplasty.
Aesthetic Plast Surg. 1994 Fall;18(4):377-82.
 Simler AG.
Endoscopic augmentation mammoplasty: the umbilical approach.
Plast Surg Nurs. 1994 Fall;14(3):149-53.
 Johnson GW, et al.
The endoscopic breast augmentation: the transumbilical insertion of saline-filled breast implants.
Plast Reconstr Surg. 1993 Oct;92(5):801-8.
 Ho LC.
Endoscopic assisted transaxillary augmentation mammaplasty.
Br J Plast Surg. 1993 Jun;46(4):332-6.
 Pechter EA.
A new method for determining bra size and predicting postaugmentation breast size. Plast Reconstr Surg. 1998 Sep;102(4):1259-65.
 Bruhlmann Y, et al
Breast reduction improves symptoms of macromastia and has a long-lasting effect. Ann Plast Surg. 1998 Sep;41(3):240-5.
 Wise RJ.
A preliminary report on method of planning the mammoplasty.
Plasr Reconstrr Surg 1956;17: 367-75
 Douformentel c, Mouly R.
Mammoplasty by the oblique technique.
Ann Chir Plast 1961;6:45-48
 Regnault P Reduction mammaplasty by the "B" technique.
Plast Reconstr Surg. 1974 Jan;53(1):19-24
 Mckissock PK. reduction mammoplasty with a vertical dermal flap. Plastic and Reconstructive Surgery 1972;49:245-52
 Skoog T.
A technique of breast reduction; transposition of the nipple on a cutaneous vascular pedicle.
Act Chir Scand 1963;126:453-65
 Strombeck JO.
Mammaplasty: report of new technique based on the two pedicle procedure.
Br J Plast Surg 1960;13:79-90
 Robbins TH
A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg. 1977 Jan;59(1):64-7.
 Douformentel c, Mouly R.
Mammoplasty by the oblique technique.
Ann Chir Plast 1961;6:45-48
 Meyer R.
"L" technique compared with others in mammaplasty reduction.
Aesthetic Plast Surg 1995 Nov-Dec;19(6):541-8 Centre de Chirurgie Plastique, Lausanne, Switzerland.
Richard L, Delay E, Payement G, Cresseaux P, Cantaloube D
[Mammaplasty with an L-shaped scar and a pre-established design. Apropos of 80 cases].[Article in French]
Service de Chirurgie Plastique, Chirurgie Maxillo-Faciale et Stomatologie, Hopital d'Instruction des Armees Desgenettes, Lyon, France
Plast Reconstr Surg 1991 Mar;87(3):583 Correction in description of breast reduction with short L scar.
 Born G The "L" reduction mammoplasty Ann Plast Surg 1994 Apr;32(4):383-7
Reduction mammaplasty with short inframammary scar.
Plast Reconstr Surg 1986 May;77(5):859-60
 Evolution of the vertical scar in Lejour's mastoplasty technique.
Aesthetic Plast Surg. 1996 Sep-Oct;20(5):377-84.
 Lassus C An "all-season" mammoplasty. Aesthetic Plast Surg 1986;10(1):9-15
 Lassus C Breast reduction: evolution of a technique--a single vertical scar. Aesthetic Plast Surg 1987;11(2):107-12
 Lassus C
A 30-year experience with vertical mammaplasty
Plast Reconstr Surg 1996 Feb;97(2):373-80
 Lejour-M :
Vertical mammaplasty and liposuction of the breast.
Plast-Reconstr-Surg. 1994 Jul; 94(1): 100-14
 Lejour-M; Abboud-M; Declety-A; Kertesz-P.
[Reduction of mammaplasty scars: from a short inframammary scar to a vertical scar] .
Ann-Chir-Plast-Esthet. 1990; 35(5): 369-79
 Lejour M
Vertical mammaplasty: early complications after 250 personal consecutive cases.
Plast Reconstr Surg 1999 Sep;104(3):764-70
 Lejour M
Vertical mammaplasty as secondary surgery after other techniques.
Aesthetic Plast Surg 1997 Nov-Dec;21(6):403-7
Y Axillary reduction mammaplasty--Yhelda Felicio's technique.
Aesthetic Plast Surg 1997 Jul-Aug;21(4):270-5
 Hinderer UT, del Rio JL
Erich Lexer's mammaplasty
Aesthetic Plast Surg 1992 Spring;16(2):101-7
 Asplund OA, Davies DM
Vertical scar breast reduction with medial flap or glandular transposition of the nipple-areola.
Br J Plast Surg 1996 Dec;49(8):507-14
 Chen TH, Wei FC
Evolution of the vertical reduction mammaplasty: the S approach.
Aesthetic Plast Surg 1997 Mar-Apr;21(2):97-104
 Hammond DC
Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty.
Plast Reconstr Surg 1999 Mar;103(3):890-901; discussion 902
 Schmidt GH
Design-enhanced breast reduction: an approach for very large, very ptotic breasts without a vertical incision.
Ann Plast Surg. 1998 Sep;41(3):335.
 Courtiss EH
Reduction mammaplasty by suction alone.
Plast Reconstr Surg 1993 Dec;92(7):1276-84; discussion 1285-9
 Gray LN
Liposuction breast reduction.
Aesthetic Plast Surg. 1998 May-Jun;22(3):159-62
 Levet Y
Posterior pedicle: anatomoclinical concept of mammaplasty].
Ann Chir Plast Esthet 1993 Aug;38(4):463-8 [Article in French]
 Levet Y
The pure posterior pedicle procedure for breast reduction.
Plast Reconstr Surg 1990 Jul;86(1):67-75
 Luan J, Yang P, Ling Y Chung Hua Cheng Hsing Shao Shang Wai Ko Tsa Chih 1995 Jan;11(1):20-2
[Reduction mammaplasty using glandular pedicle]. [Article in Chinese]
 Savaci N Reduction mammoplasty by the central pedicle, avoiding a vertical scar.
Aesthetic Plast Surg 1996 Mar-Apr;20(2):171-5
 Aiache AE
Arch reduction mammaplasty.
Plast Reconstr Surg 1999 Mar;103(3):862-8
 Flowers RS, Smith EM Jr "Flip-flap" mastopexy. Aesthetic Plast Surg 1998 Nov-Dec;22(6):425-9
 Caldeira AM, Lucas A
[Mammaplasty with triple interposition of glandular flaps. Technical note].
[Article in French]
Ann Chir Plast Esthet 1997 Jun;42(3):238-46
 Wuringer E
Refinement of the central pedicle breast reduction by application of the
Plast Reconstr Surg 1999 Apr;103(5):1400-10
 de Araujo Cerqueira
A Mammoplasty: breast fixation with dermoglandular mono upper pedicle flap under
the pectoralis muscle.
Aesthetic Plast Surg 1998 Jul-Aug;22(4):276-83
 Lockwood T
Reduction mammaplasty and mastopexy with superficial fascial system suspension. Plast Reconstr Surg 1999 Apr;103(5):1411-20
 Frey M
A new technique of reduction mammaplasty: dermis suspension and elimination of medial scars.
Br J Plast Surg 1999 Jan;52(1):45-51
 Wieslander JB
[Congenital breast deformity is a serious handicap. An important indication for breast reconstruction with silicone implants].
Lakartidningen. 1999 Apr 7;96(14):1703-5, 1708-10. Swedish.
 Gasperoni C, et al
Breast shape malformations.
Aesthetic Plast Surg. 1997 Nov-Dec;21(6):412-6.
 von Heimburg D, et al.
The tuberous breast deformity: classification and treatment.
Br J Plast Surg. 1996 Sep;49(6):339-45.
 Dinner MI, et al
The tubular/tuberous breast syndrome.
Ann Plast Surg. 1987 Nov;19(5):414-20.
 Atiyeh BS, et al
Perinipple round-block technique for correction of tuberous/tubular breast deformity. Aesthetic Plast Surg. 1998 Jul-Aug;22(4):284-8.
 Williams G, et al
Mammoplasty for tubular breasts.
Aesthetic Plast Surg. 1981;5(1):51-6.
 Budner M, et al.
[Breast asymmetry--differential diagnosis and surgical correction].
Zentralbl Gynakol. 1993;115(9):410-5. German
 Becker H.
Clin Plast Surg. 1988 Oct;15(4):587-93.
 Persoff MM. Expansion-augmentation of the breast.
Plast Reconstr Surg. 1993 Mar;91(3):393-403.
 Wilk A, et al
[Tissue expansion in mammary reconstruction and asymmetry. Apropos of 24 prostheses].
Ann Chir Plast Esthet. 1994 Apr;39(2):221-32. French.
 Scheepers JH, et al
Tissue expansion in the treatment of tubular breast deformity.
Br J Plast Surg. 1992 Oct;45(7):529-32.
 Leone MS, et al
[Permanent expanders in esthetic, corrective and reconstructive surgery of the breast].
Minerva Chir. 1992 Sep 30;47(18):1461-6. Italian
 Versaci AD, et al
Treatment of tuberous breasts utilizing tissue expansion.
Aesthetic Plast Surg. 1991 Fall;15(4):307-12
 Aiache A
Surgical repair of the inverted nipple.
 Kurihara K, et al
Surgical correction of the inverted nipple with a tendon graft: hammock procedure. Plast Reconstr Surg. 1990 Nov;86(5):999-1003.
 Crestinu JM
Inverted nipple: the new method of correction.
Aesthetic Plast Surg. 1989 Summer;13(3):189-97
 Hauben DJ
Correction of the inverted nipple.
Plast Reconstr Surg. 1987 Sep;80(3):470-1
 Crestinu JM
The inverted nipple: a blind method of correction.
Plast Reconstr Surg. 1987 Jan;79(1):127-30.
 Yanai A, et al
Correction of the inverted nipple.
Aesthetic Plast Surg. 1986;10(1):51-3.
 Teimourian B, et al
Simple technique for correction of inverted nipple.
Plast Reconstr Surg. 1980 Apr;65(4):504-6.
 Wolfort FG, et al
Correction of the inverted nipple.
Ann Plast Surg. 1978 May;1(3):294-7.
 Broadbent TR, et al
Benign inverted nipple: trans-nipple-areolar correction.
Plast Reconstr Surg. 1976 Dec;58(6):673-7.
 Terrill PJ, et al
The inverted nipple: to cut the ducts or not?
Br J Plast Surg. 1991 Jul;44(5):372-7.
 Trademark Boots Chemists
 Pompei S, et al
A new surgical technique for the correction of the inverted nipple.
Aesthetic Plast Surg. 1999 Sep-Oct;23(5):371-4
 Sakai S, et al
A new surgical procedure for the very severe inverted nipple.
Aesthetic Plast Surg. 1999 Mar-Apr;23(2):139-43
 Lee HB, et al.
Correction of inverted nipple using strut reinforcement with deepithelialized triangular flaps.
Plast Reconstr Surg. 1998 Sep;102(4):1253-8.
 Yamamoto Y, et al
Correction of inverted nipple with modified star flap technique.
Aesthetic Plast Surg. 1997 May-Jun;21(3):193-5.
 el Sharkawy AG
A method for correction of congenitally inverted nipple with preservation of the ducts.
Plast Reconstr Surg. 1995 May;95(6):1111-4.
 Panchal J
Correction of inverted nipple with periductal fibrous flaps.
Plast Reconstr Surg. 1992 Jun;89(6):1185-6
 Megumi Y
Correction of inverted nipple with periductal fibrous flaps.
Plast Reconstr Surg. 1991 Aug;88(2):342-6.
 Donati L, et al.
[Surgical treatment of gynecomastia. Indications and methods].
Minerva Chir. 1993 Jul;48(13-14):743-7. Italian.
 Luckey RC
Modified technique for correction of gynecomastia.
Plast Reconstr Surg. 1992 Apr;89(4):767.
 Beraka GJ
Correction of gynecomastia with an inframammary incision and subsequent scar. Plast Reconstr Surg. 1995 Dec;96(7):1753-4.
 Dolsky RL.
Gynecomastia. Treatment by liposuction subcutaneous mastectomy.
Dermatol Clin. 1990 Jul;8(3):469-78. Review.
 Balch CR A transaxillary incision for gynecomastia.
Plast Reconstr Surg. 1978 Jan;61(1):13-6.
 Pitanguy I, et al.
Treatment of gynecomastia using a trans-areolar incision].
Minerva Chir. 1989 Sep 15;44(17):1941-8. Italian.
 Letterman G, et al.
Surgical correction of massive gynecomastia.
Plast Reconstr Surg. 1972 Mar;49(3):259-62
 Webster MH.
Plastic surgery of the breast. Practitioner. 1980 Apr;224(1342):406-8
 Freiberg A, et al
Apple-coring technique for severe gynecomastia.
Can J Surg. 1987 Jan;30(1):57-60.
 Babayan R
[Transareomamillary incision in gynecomastia].
Zentralbl Chir. 1989;114(1):49-54. German.
 Simon BE, et al.
Classification and surgical correction of gynecomastia.
Plast Reconstr Surg. 1973 Jan;51(1):48-52.
 Samdal F, et al Surgical treatment of gynaecomastia. Five years' experience with liposuction.
Scand J Plast Reconstr Surg Hand Surg. 1994 Jun;28(2):123-30.
 Abramo AC
Axillary approach for gynecomastia liposuction.
Aesthetic Plast Surg. 1994 Summer;18(3):265-8.
 Xuan QY
[Suction lipectomy for male gynecomastia].
Chung Hua Cheng Hsing Shao Shang Wai Ko Tsa Chih. 1993 Jul;9(4):243-4, 317. Chinese.
 Mladick RA.
Gynecomastia. Liposuction and excision.
Clin Plast Surg. 1991 Oct;18(4):815-22. Review.
 Rosenberg GJ.
Gynecomastia: suction lipectomy as a contemporary solution.
Plast Reconstr Surg. 1987 Sep;80(3):379-86.
 Becker H
The treatment of gynecomastia without sharp excision.
Ann Plast Surg. 1990 Apr;24(4):380-3.
 Fara M, et al
[Reduction surgery of the breasts in severe gynecomastia using a surgical flap with a single pedicle at the top].
Rozhl Chir. 1981 Nov;60(11):723-5. Czech.
 Saad MN.
An extended circumareolar incision for breast augmentation and gynecomastia. Aesthetic Plast Surg. 1983;7(2):127-8.
 Chiu DT, et al
The pinwheel technique: an adjunct to the periareolar approach in gynecomastia resection.
Ann Plast Surg. 1999 May;42(5):465-9.
 Huang TT, et al
A circumareolar approach in surgical management of gynecomastia.
Plast Reconstr Surg. 1982 Jan;69(1):35-40
 Botta SA.
Re: Eccentric skin resection and purse-string closure for skin reduction with mastectomy for gynecomastia.
Ann Plast Surg. 1999 May;42(5):571-2.
 Smoot EC 3rd.
Eccentric skin resection and purse-string closure for skin reduction with mastectomy for gynecomastia.
Ann Plast Surg. 1998 Oct;41(4):378-83.
 Gundersen J
[Circular skin reduction in surgery of gynecomastia].
Ugeskr Laeger. 1991 Apr 8;153(15):1070. Danish.
 Pasta V, et al [Advantages of liposuction in the surgical treatment of gynecomastia].
G Chir. 1988 Dec;9(12):906-9. Italian.
 Hall WW, et al
Correction of areolar depression in postsurgically treated gynecomastic patients. Ann Plast Surg. 1999 Apr;42(4):452-4.
 Bose, A.
Gynaecomastia Revisited in Indian Journal of Plastic Surgery October 1997
 Melmed EP.
Surgical treatment of grade III gynaecomastia.
Ann R Coll Surg Engl. 1990 Jan;72(1):68-9.
 Botta SA.
Alternatives for the surgical correction of severe gynecomastia.
Aesthetic Plast Surg. 1998 Jan-Feb;22(1):65-70.
 Ward CM, et al. Surgical treatment of grade III gynaecomastia.
Ann R Coll Surg Engl. 1989 Jul;71(4):226-8.
 Kornstein AN, et al.
Inferior pedicle reduction technique for larger forms of gynecomastia.
Aesthetic Plast Surg. 1992 Fall;16(4):331-5
 Peters MH, et al.
Treatment of adolescent gynecomastia using a bipedicle technique.
Ann Plast Surg. 1998 Mar;40(3):241-5.
 Murphy TP, et al.
Nipple placement in simple mastectomy with free nipple grafting for severe gynecomastia.
Plast Reconstr Surg. 1994 Nov;94(6):818-23.
 Ohyama T, et al.
Endoscope-assisted transaxillary removal of glandular tissue in gynecomastia. Ann Plast Surg. 1998 Jan;40(1):62-4.
 Casanova D, et al.
[Surgical treatment of gynecomastia].
J Chir (Paris). 1997 Jul;134(2):76-9. French.
 Morselli PG.
"Pull-through": a new technique for breast reduction in gynecomastia.
Plast Reconstr Surg. 1996 Feb;97(2):450-4.