Book Review: Aesthetic Breast Surgery: Concepts & Techniques

This text is a single author's publication based upon her recollection and analysis of her 27 years of solo private practice as a well-recognized and successful breast surgeon. The book is divided into two parts, Part I: Concepts and Principles, and Part II: Technique. Part I includes 4 chapters with the following titles: 1. Breast Analysis and Clinical Concepts, 2. Applied Anatomy: Key Concepts for Modern Breast Surgery, 3. Surgical Principles, 4. Patient Selection, Education, and Surgical Decision-Making. The remaining chapters comprise Part II: Breast Augmentation, Vertical Breast Reduction, Liposuction-only Breast Reduction, Breast Re-reduction, Mastopexy, Mastopexy-Augmentation, Nipple Necrosis, and finally a chapter on Breast Asymmetry.

As opposed to the wide coverage of different techniques offered in most multi-author publications, unique to the structure of this text is coverage of only the relevant techniques that the author has come to use most frequently in personal practice, making a thorough description and upfront analysis of the results possible. Many photographic examples of even the suboptimal results have been employed without hesitation to facilitate the readers' understanding. Important points that are not to be missed are recapitulated and highlighted in between bold lines.

The author starts by describing various new concepts such as the breast footprint, zone of adherence, and breast borders, which aid in the preoperative analysis of the patient and in assessing what can and cannot be altered with surgery. I have come to agree on the author's unique way of determining the new nipple position, based upon the distance from the upper breast border, which is both appealing and logical, whereas the most commonly described method that relies on the inframammary fold may, in fact, be misleading in many cases.

The pertinent anatomy of the breast is well described in terms of our interest in its surgical relevance. Understanding the superficial and deep supply of the breast remains a sound foundation for the design and performance of the various breast reduction surgeries described in the textbook. The author also measured the suprasternal notch-to-nipple distance in samples of 50 patients in breast augmentation, reduction, mastopexy, and mastopexy-augmentation. How these values changed or did not change with subsequent surgery was a useful and interesting guideline of which the surgeon should be aware.

In the breast augmentation chapter, the author gives a detailed description of her inframammary approach, both subglandular and submuscular. Her preference for smooth types of cohesive gel implants and the problems associated with late seroma, and double capsule associated with the Biocell textured implants are mentioned. Although the choice of implant and personal preference for the technique may differ among different countries and geographic regions in which they are practiced, the author's evolution in her choice of implants and the rationale for the changes over the years are well documented. Postoperative complications after augmentation procedures and their management are shown with accompanying photographic examples. The description of the double bubble and its three different causes justifies different approaches to solving what appears to be the same deformity based on a thorough understanding of the pathogenesis behind it.

A significant number of pages are devoted to the author's description of the vertical breast reduction, mainly the superomedially based vertical reduction procedure, which is the author's preferred method. Step by step guidelines in determining the primary landmarks for the design and execution of breast reduction are well described and depicted in the accompanying DVD. The part describing lateral resection and inferior resection could have been better depicted by schematic illustrations, especially where the author employs the terminology of "directly excising the glandular and fibrous tissue under the lateral skin flap", "carved out as if it were made of soapstone", and that the "excess tissue and resulting edges should be carefully carved into a good shape". The author emphasizes the need for exact tension-free parenchymal closure as well as skin closure to ensure the desired postoperative outcome. At the end of the chapter, photographic data of about 25 cases are presented along with variables such as age, weight, height, brassiere size, estimated blood loss, operation time, pedicle-type on each side, removed tissue weight, ancillary liposuction area, length of follow-up care, sensation changes pre- and postoperatively, vertical scar length, and the presence of any complications.

For mastopexy to be successful, the author emphasized the "vertical wedge resection principle," in which glandular tissue rearrangement is taken to be a prerequisite for a long-lasting result. A small inferior breast reduction is proposed to be the most effective way to achieve this. The goals of mastopexy are described to be the rearrangement of the breast mound, reduction of lower pole glandular ptosis, repositioning of the nipple to a more centralized position on the breast mound, elevation of the breast footprint, and improved upper pole fullness. The author points out that only the first three goals can be achieved with a "pure" mastopexy, whereas the latter two require a breast implant.

The next chapter on breast mastopexy-augmentation addresses the difference between nipple ptosis and glandular ptosis, where the ptotic lower pole parenchyme needs to be removed, rather than pushed up and affixed with skin or dermis. Important points are outlined, such as the superior pedicle being the best choice in a mastopexy-augmentation patient, because an implant may damage the blood supply to the other pedicles. A maximum elevation of 2 cm is proposed as the limit for a change in the upper border of the breast that is obtainable with an implant.

The cause and incidence of an inevitable complication from breast surgery, namely, nipple necrosis, is well analyzed, and insights into its management are provided in a separate chapter. Problems with breast asymmetry and tuberous breast deformities are briefly explained along with the example cases in the following chapter.

This textbook tells a years-long story of a competent and well-experienced breast surgeon. Its strength is that it is a detailed retrospective analysis of the experience, as well as a review of the relevant and current literature, supported by evidence behind the story telling in all. Understanding and absorbing the author's unrivaled experience is a task left to the shrewd reader.