Patients who have undergone significant breast involution or who do not have sufficient lateral skin folds to provide sufficient tissue for autoaugmentation of the breast will require breast implants if they desire larger breasts. Most of the patients that fall into this category are young women with good skin tone. These patients can be considered for an isolated breast augmentation if there is minimal ptosis and skin redundancy. Our preferred approach to breast augmentation is with an inframammary fold (IMF) incision. Patients falling into this category represent less than 2% of the breast deformities we have corrected. Description of this technique can be found in the chapters of this text dealing with augmentation mammaplasty.

Patients with inadequate volume associated with grade 2 or 3 ptosis, significant skin redundancy, an enlarged nipple-areolar complex (NAC), and/or an inadequate lateral skin fold on physical examination will require a mastopexy in addition to augmentation mammaplasty. In select patients we perform a mastopexy-augmentation through a vertical access incision made beneath the NAC. After submuscular placement of the implant, we tailor-tack the skin envelope to the correct nipple position and control the redundant skin envelope. It is not uncommon to require a significant inframammary extension to control the redundant skin. The patient must be made aware of this potential scar burden preoperatively. In complicated cases in which there is significant asymmetry or a loose IMF, we prefer to perform a staged mastopexy-augmentation to optimize the aesthetic outcome. In some cases, the patients have been satisfied with their breast size following the mastopexy, obviating the need for later augmentation.

Approximately 20% of patients presenting for breast surgery have excessive breast volume necessitating a breast reduction. Our preferred technique is a Wise-pattern reduction mammaplasty using either a medial or inferior pedicle. The decision as to which pedicle is used will depend in part on the nipple-to-fold distance and on the experience of the surgeon. These techniques are described in detail in chapters dealing with reduction mammaplasty and mastopexy. Although the procedure is performed in a similar manner as for non-MWL patients, there are special preoperative considerations and modification to the markings that may need to be addressed. Some patients have significant medialization of the NAC. In these patients, it may be difficult to adequately rotate the pedicle to its new position on the breast meridian. If we believe that this might be an issue, then we choose an inferior pedicle. Since these patients may also have a considerable lateral skin fold, the posterior extension and width of the lateral excision can be significantly larger than for non-MWL patients. It is important to come out of the breast crease laterally when performing the markings to prevent a “boxy” appearance to the breast. The width of the lateral excision can be estimated with a pinch test. Liposuction of the lateral skin fold may be useful to further contour the lateral fold of the breast. This is best performed after the skin resection has been performed and the skin has been temporarily closed with staples.

Short-scar techniques in the MWL may result in a large inferior dog-ear due to the excessive skin redundancy and poor skin tone. This dog-ear will require a horizontal excision to remove the redundancy. A pitfall of the short-scar technique would be to chase the dog-ear inferiorly, which would leave an unsightly scar below the IMF. In addition, short-scar techniques
will have minimal impact on the lateral skin fold that is present in the majority of MWL patients.

Although many of the women presenting after MWL feel that they need a breast reduction, the majority of these woman have adequate volume to give them the size and shape they desire. Careful examination of the breast parenchyma will determine whether there is sufficient parenchymal volume. The lateral skin fold is also evaluated to assess how much tissue can be recruited into the breast for autoaugmentation. In patients who have adequate parenchymal volume, severe ptosis, and an adequate lateral skin fold, our preferred technique is dermal suspension with total parenchymal reshaping and autologous augmentation from the lateral chest wall (2,3,4). This technique provides reliable results with the ability to intraoperatively individualize the size and shape of the breast. Since the parenchymal reshaping and the amount of tissue recruited for autologous augmentation can be customized for each breast, this technique allows for the correction of difficult breast asymmetries often encountered in these patients.

As with all of our MWL patients desiring body contouring procedures, a thorough history and physical examination is performed (10). Specific questions about a personal and family history of breast cancer are asked, and all patients undergo mammography in accordance with the American Cancer Society guidelines (11). A nutritional assessment is also performed to ensure that the patient is optimized prior to surgery.