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The inframammary fold is one of the key anatomical features that defines the breast footprint. A sharp, properly located fold is critical to achieving optimal aesthetics in breast augmentation. While the fold position relative to the nipple-areolar complex and breast mound varies anatomically in each patient, there is an ideal distance from the nipple to fold for each implant which should be the target of each breast augmentation surgery.

Understanding the anatomy of the breast is important to ensure positive outcomes in regard to function and aesthetic appeal. Throughout the embryogenesis of the breast, malformations in the anatomy can arise that may require surgical intervention. One of the most crucial tenets of breast anatomy is the blood supply to the nipple-areolar complex. When intervening on possible malformations and/or performing procedures on the breast, maintaining blood flow to the nipple-areolar complex is critical. Using the most robust pedicle increases the reliability of sustaining blood flow to the nipple-areolar complex. In addition to maintaining blood flow, nipple innervation must be maintained to help preserve sensual function and breastfeeding potential. During breast surgery the pectoralis major and minor muscles are normally involved, which requires an understanding of the blood supply, innervation patterns, and functional anatomy of these muscles as well. Additionally, a full comprehension of the position of the inframammary fold is important to produce the most aesthetically pleasing breast possible. The breast is a major part of the plastic surgery realm, and a thorough knowledge of its anatomy allows for the most successful outcomes.

Double-bubble deformity is an uncommon complication after breast augmentation, manifesting as an abnormal crease running across the lower pole to create the appearance of a breast mound on top of a breast mound. Some breasts are predisposed to this phenomenon, such as those with tuberous breast deformity or constricted base width. More commonly, technical malfeasance is the culprit with overdissection of the IMF and concomitant incomplete release of superficial IMF fibers. This chapter discusses the etiology, anatomic considerations, best practices for prevention, and various treatment methods of double-bubble deformity.

The problems following correction of gynecomastia relate to poor healing or treatment that is inadequate or unsatisfactory. Unfavorable healing includes hematoma, seroma, wound separation, or skin loss. Unsatisfactory treatment ranges from incomplete or excessive resection, residual skin laxity to disturbing scars. Proper approach and careful technique are needed. My current approach for gynecomastia contains six options: (1) transareolar excision of offending breast tissue, (2) VASERlipo, (3) radiofrequency tightening, (4) liposculpture of the chest with lipoaugmentation of the pectoralis muscle, (5) a variety of skin excision patterns, and (6) combination therapy. The therapeutic options are arrayed across the modified Simon classification. The aesthetic goal is subtotal glandular reduction, with proper position and shape of the nipples, no inframammary folds, a masculine appearance, and adherent chest skin that reflects the musculoskeleton. The presence of extensive scars detracts. In mild cases, minimal scarring can be achieved by transareolar direct resection or by a wide area of liposuction, depending on spontaneous retraction of the skin envelope. Ultrasonic-assisted lipoplasty is more effective than traditional liposuction for the removal of dense glandular and fibroconnective tissues. Nevertheless, pull-through resection of the fibrous gland is often required. Residual mild to moderate skin laxity should be amenable to subcutaneous bipolar radiofrequency-assisted lipolysis. Over the past 2 years, this author has been reducing skin laxity by the application of BodyTite®. Lipoaugmentation of the pectoralis muscle not only improves masculinity but also reduces tissue laxity. Innovative boomerang pattern for large skin resections for Grade IIIb has been both effective and aesthetic. Clinical cases will demonstrate these multiple approaches and their pitfalls.

Although digital technology increases cancer detection rate, the quality of mammographic images still relies on how the breast is being positioned during the procedure. This study determined the association between type of positioning errors and false negative mammogram found in digital mammography. Methods: Image quality of 17 false negative (FN) digital mammographic cases was independently evaluated by one radiologist using the PGMI criteria. The type of positioning errors made in each mammogram was identified. Chi-square test was used to analyse the association between the type of positioning errors made and FN mammogram. Results: Image quality was significantly different for all mammographic views in digital mammograms, \( \chi^{ 2} \, = \, 2 9. 1 6 8,{\text{ p}}\, 0.05). Errors such as not well demonstrated inframammary fold was the most common positioning errors found in mediolateral oblique view. Contrarily, insufficient projection of pectoral muscles alone was the most common positioning error made in craniocaudal view with 94.1% and 92.9% for left and right side respectively. Conclusion: Image quality of false negative mammogram is appreciably impacted by breast positioning error. Improper positioning could lead to inaccurate and less precision interpretation by radiologists. Thus, improper positioning affecting most of missed breast cancer in screening mammography. A high mammographic technique is crucial for cancer to be early and successfully detected.

The internal mammary artery and vein (IMA and IMV) are commonly utilized as recipient vessels for microsurgical breast reconstruction. While their identification and preparation has been previously described, surgical modifications and technical tips can aid in the reproducibility and ease of dissection.

Hidradenitis suppurativa (HS) is a chronic, progressive inflammatory disease of the apocrine gland-bearing skin that typically affects the axillary, perianal, perineal, and inframammary regions. It causes open comedones (clogged hair follicle), tender subcutaneous papules, inflammatory nodules, abscesses, sinus tracts and scarring. The prevalence of HS is 0.1 to 4% worldwide; the mean age of onset is 20 to 24 years. Cigarette smoking and obesity are risk factors for HS. Dietary triggers include dairy products and highly refined simple carbohydrates. The anal region is the second most commonly involved area after the axilla; 30% to 50% of patients with HS have perianal lesions. A number of comorbid conditions are present in patients with HS including acne, inflammatory bowel diseases, spondyloarthropathy, genetic keratin disorders and squamous cell cancer. Management of the disease includes medical and surgical treatment. Local and small lesions can benefit from medical treatment but recurrence rates are high. Widespread disease is an indication for radical surgical excision with possible need for reconstruction.

Tuberous breast is a rare deformity that can be seen unilateral or bilaterally in women. The complete correction of the deformity can require a variety of procedures and pose a great challenge to plastic surgeons. To make the diagnosis of tuberous breast, one or more of the following findings must be present. These include breast hypoplasia, constricted lower breast parenchyma and skin envelope, superiorly malpositioned inframammary fold, pseudoherniation and or hypertrophy of the NAC (nipple areolar complex). Even with a diagnosis of tuberous breast there are different variations of the deformity and the etiology is still not completely known.

Several groups have published clinical algorithms for the use of various oncoplastic breast conserving surgery techniques. Some favor to select the reconstruction choice primarily based on tumor location by quadrant, others first consider the size and shape of the breast; however, all oncoplastic surgeons use all of these criteria when finalizing their treatment plan. One of the oldest and most commonly used techniques is round block mammoplasty, which works well in most situations. It is technically one of the least demanding procedures when applied to smaller tumors in any location other than the lower pole. However, the level of technical complexity of partial breast reconstruction is increased for peripheral large tumors due to limited exposure. Even though this technique reliably prevents deformities and nipple deviations, the final aesthetic result is limited by the lack of reshaping and loss of projection of the breast. The oncoplastic breast reduction mammoplasty can be used in patients with large breasts for tumors in all quadrants. This technique allows optimal oncological and aesthetic results even for large tumors at the cost of increased duration of surgery and risk of complications. The triangle excision is a straightforward alternative for tumors close to the inframammary fold. For tumors in the lower inner quadrant, the V-mammoplasty allows safe partial breast reconstruction at the expense of longer incisions. Further mastopexy techniques include hemi-batwing mammoplasty, which works well for tumors in the outer quadrants of the breast, and crescent mammoplasty for tumors close to the skin in the supra-areolar region. For retromamillary tumors, Grisotti mammoplasty – also known as the B-technique – can be used in virtually all patients with small adjustments based on the size and shape of the breast.

Implant-based breast reconstruction (IBBR) is the most commonly used surgical technique after mastectomy. The expander-implant (EI) approach may present disadvantages such as pain during the expansion phase and a flat unnatural look of the breast. On the other hand, the direct-to-implant (DTI) single-staged approach leaves the inferior pole of the implant covered by the mastectomy flap only, putting it at risk of exposure in case of flap necrosis or infection. With both approaches, it is hard to control the position of the inframammary fold (IMF), avoid animation deformity and implant displacement, and achieve a natural-looking ptosis of the reconstructed breast.

Although one-step direct form-stable implant breast reconstruction has continued to grow in terms of popularity, immediate one- or two-stage tissue expander (definitive or temporary ones) remains as the preferred approach due to its relative simplicity. More conservative mastectomies, with the preservation of the inframammary fold, skin envelope, and nipple and areola complex, allowed more anatomical reconstructions and better outcomes. In addition, patient’s expectations are greater than when the implants were first used in 1960s [1].

Plastic surgery for breast augmentation is the most common procedure in Brazil and the USA. Despite the different types of access and locations for the silicon implant, this chapter discuss the initial approach to your patient desiring breast augmentation and the aspects regarding the submuscular and subglandular location and the various access points: the inframammary fold, periareolar, and transaxillary. The measurements were made to ensure the best choice in the size of the prosthesis to achieve a better result after breast augmentation.

The author recommends reducing scars after mammaplasties, using the L technique. Their use should be limited, based on resections of skin surplus to the extent of the ptosis. Lines and guides are described that point to any tactic, and anatomically perfect breasts. The “aesthetic pathologies” are dealt with, the ptosis quantified in centimeters, the surgical procedure of L is chosen, and its limitations described. Hypertrophic and ptotic breasts are reduced and shaped as classified. The maneuvers involved in suturing the incisions in a “semicolon” shape are described, starting from the side of the inframammary crease to the medial side, then upward, ending in a vertical suture V–Y or “circular compensation areolar bag” as the skin surplus in the periareolar region, reducing the extent of the horizontal scar, which should be the maximum A–M measurement plus 2 cm. In ptosis of less than 7 cm the results were of a good quality, with no significant residual ptosis, and no distortion of the areola and the cone obtained. The difficulties and advantages of the technique are shown.