Breast Recontouring

The breast is an important structure of the human body in terms of function and esthetics. Derangements in breast mount — breast form/volume/profile/silhouette and nipple-areolar complex — size/shape/nipple projection are all concerns for not only females but also males. Simply esthetic problems of breasts encompass hypoplasia, atrophy, displacement of nipple-areolar complex, widened areola, redundant nipple, breast ptosis, macromastia, etc. Congenital anomalies of breast — Poland syndrome, pectus excavatum, pectus carinatum, etc. — all need to be taken care for restructuring of the body contour. Nowadays, breast cancer of different stages may need different reconstruction modality. Postmastectomy breast reconstruction is another big issue for plastic surgeons. This chapter on breast recontouring will address on every specific kind of breast contour disorders and imperfection, along with individualized strategies of refining, restoring, and reconstruction approaches.


2.
A 38-year-old lady with atrophy of breasts after breast feeding received augmentation of breasts with 300 ml gel implant on each side ( Figure 4).

3.A 26-year-old lady with hypoplasia of breasts; right side is a little smaller.
Dark areola is also complained. After breast augmentation with gel implants, 200 ml in each side, areolar hyperpigmentation was greatly alleviated ( Figures 5 and 6).

2.
A 43-year-old lady with upward displacement of augmented breasts with capsular contracture [2] resulting in ptosis of breasts and displacement of nipple-areolar complex.
She received removal of breast prostheses and surrounding capsules with mastopexy and reduction and reposition of nipple-areolar complex (Figures 10-13).

3.
A 26-year-old young lady suffered from macromastia, which became breast ptosis and asymmetry after weight reduction. She received reduction of breast, mastopexy, and correction of breast asymmetry (Figures 20-22).
Mastopexy with dissecting medial and lateral flaps from the underlying breast tissue was brought together with upward mobilization of the nipple-areolar complex to build up more esthetic and symmetric breasts. The operation was carried out under local anesthesia (Figures 23 and 24).
The patients may suffer from breast deformities, asymmetries, radiation injuries, loss or deformities of nipple-areolar complex, scar contracture, or even lymphedema of the affected side upper extremity.
Breast cancer of different stages may need different reconstruction modality. Postmastectomy breast reconstruction is another big issue for plastic surgeons.
1.This 38-year-old lady had modified radical mastectomy on her right breast. She received postmastectomy breast reconstruction 3 years later. Transverse rectus  abdominis myocutaneous flap [6,9] was harvested from lower abdomen to reconstruct the right breast defect. The photo showed the breast figure 25 years after operation ( Figure 25).
2.Twenty-eight-year-old lady with right side post-modified radical mastectomy received secondary breast reconstruction with free DIEP flap [9], followed by nipple-areolar reconstruction ( Figure 26).
3.This 38-year-old patient received partial mastectomy followed by radiotherapy at left breast for breast cancer, resulted in a contracted and deformed breast [10]. The patient felt embarrassed with the breast asymmetry. Therefore she received differential augmentation of the breasts with gel implant (Mentor Memory gel) (right side 250 ml, left side 300 ml) (Figures 27-29).
4.This 51-year-old lady suffered from breast asymmetry and capsular contractures at both breasts [2], s/p breast cancer surgery and reconstruction with implants. The problems included nipple-areolar complex enlargement at right side, deficient areola at left side, and hardened breast at right side, which were corrected with nipple areolar sharing from right side to left side, change of breast implant size with capsulectomy, and differential augmentation (Figures 30-32).
5.This 37-year-old lady received left side partial mastectomy with irradiation at medial lower quardrant, resulting in significant breast deformity and asymmetry [10]. Her right breast was atrophic and ptotic. Therefore differential mastopexy of right breast and left breasts were performed, intending to achieve symmetricity of the breasts (Figures 33-35).
Intractable funnel chest in this 16-year-old young adult was treated with revascularization of the turnover sternum. The sternum and costal composite tissue were                resected at the outskirt of the depressed area. Special attention was paid to the dissection of the vascular pedicle at both sides of the internal mammary vessels. The recipient vessels at one side were left long, so were the donor vessels at the other side. A segment of the rib at the exit of the recipient internal mammary vessels had to be removed to accommodate the vessels and to facilitate vascular anastomosis. Vascular anastomosis was accomplished with loupes (Keeler, sixfold magnification). Revascularization of the turnover sternum was performed successfully without vascular compromise. The patient recovered well with much improved physical condition. Postoperative three-dimensional computed tomographic (CT) scan revealed increment of thoracic cage volume for 9-17%. A follow-up CT scan 2 years later revealed even more improved thoracic cage expansion (Figures 36-41).

Gynecomastia
1.This 19-year-old young man had bilateral gynecomastia and out-projecting nipple, which made him feel embarrassed. Subcutaneous mastectomy with liposuction via tiny intra-areolar incision approach can achieve flatness of the breasts without leaving conspicuous scar (Figures 42 and 43).

Discussion
Breasts and forechest are important structures in esthetics and function in the human body [16]. Pursuing for a presentable breast and forechest contour has always been a goal for people. Imperfection at these specific areas is a common concern that brought to plastic surgeons.
This chapter introduces many kinds of breast problems, from simple to intriguing, with in-depth solutions. The breast with its unique role in esthetics and function brings about beauty and sorrow in a woman's lifelong journey.
The problems are:   Refinements in breast shape involve thorough evaluation for not only the inherent problem but also the status of the counterpart breast shape and form.
The nipple-areola complex is also an important esthetic unit that should be taken into consideration as a whole, which encompasses the size, form, length, color, etc.
Breast cancer surgery/radiation treatment [10] may create deformity, scar contracture, loss of nipple-areola complex, chest wall tightness, or even recurrence, radiation necrosis, infection, and cardiac tamponade of the severely afflicted individuals [10].
Reconstructions of the breast cancer surgery/treatment-associated problems involve placement of implant, with differential augmentation or reduction mammaplasty/mastopexy at the contralateral side. Nipple-areolar reconstruction can be elaborated with nipple areola sharing from the contralateral side, or by using local flap, followed by full-thickness skin graft and diced cartilage graft to create areola. The implant breast reconstructions are suitable for skin-sparing mastectomy patients.
Transverse rectus abdominis myocutaneous flap and free deep inferior epigastric perforator flap breast reconstruction are options for those with skin deficiencies or secondary reconstructions.
Choice of reconstruction modalities should consider the severity and general condition of the patient, expectation of the patients, and operation times that are desirable to the patients.
Pursuing excellence has been always the ultimate goal for breast surgeries and reconstructions.

Conclusion
Breast recontouring is a common request in the modern era. Introduction of the problems regarding this issue is well described and depicted in this chapter. With the advent of the current plastic and reconstructive surgery modality, almost all the problems can be solved to significantly improve the figure and life quality of the afflicted individuals. Pursuing excellence in plastic surgery and bringing excellence to life have always been our ultimate goals.