BREAST DISEASE: DIAGNOSIS AND

CONTEMPORARY MANAGEMENT 0889–8545/02 $15.00
.00

BREAST AUGMENTATION AND

BREAST REDUCTION
Pamela M. Antoniuk, MD

BREAST AUGMENTATION

With the realization that breast implants do not increase a woman’s risk for
breast cancer or connective tissue disease when compared with the general
population, there has been a renewed interest in breast augmentation.27 Women
who desire breast augmentation wish to improve the size, shape, and contour
of their breasts. The reasons for desiring breast augmentation must be deter-
mined before the procedure. Unrealistic expectations or proceeding with breast
augmentation to ‘‘improve a failing relationship’’ will result in frustration and
disappointment for the surgeon and the patient. On the other hand, women
wishing to improve the appearance of their breasts may do so to increase their
self-esteem. Many women who choose augmentation are educated professional
women. With the increased use of the Internet, women come to the initial
consultation well informed, bringing pictures with them obtained from a Web
site. They also may bring in pictures of the look they desire. At this time, the
physician–patient relationship takes on an important role because the patient’s
expectations may or may not be realistic.

Initial Consultation

Although most women desiring breast augmentation are young and healthy,
a full history must be obtained. Women with a family history of breast cancer
may need to be counseled regarding their own risk. Women who are smokers
should be encouraged to quit. Previous breast or chest wall surgeries should be
identified. Medications also are important, and a medication history is informa-

From the Division of Plastic Surgery, Department of Surgery, Women and Infants Hospital,
Providence, Rhode Island

OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA

VOLUME 29 • NUMBER 1 • MARCH 2002 103

104 ANTONIUK

tive. Mood-altering drugs can identify a patient who is depressed and not a
candidate for the procedure. The physician should inquire about herbal remedies
or vitamins because the patient may not consider these medications.
Considerable time is required to understand the final look the patient wishes
to achieve. This appearance will vary according to the woman’s age and whether
she is nulliparous or multiparous. A young nulliparous woman will have small
breasts with little or no ptosis when compared with a woman who has com-
pleted her childbearing and has breasts that have involuted. The latter woman
may present with skin that has been stretched with pregnancy and during
lactation, and there may be stretch marks. Ptosis is more pronounced and the
superior part of the breast flattened.
The breasts must be examined carefully. It is unusual to have symmetrical
breasts; therefore, all asymmetries should be noted and pointed out beforehand
to avoid postoperative accusations.14 The physician should look at the inframam-
mary folds and use a level to identify the fold that is higher, carefully assess the
nipple-areola complexes, and take note of the areolar diameter and projection
because these differences may be accentuated postoperatively. The overall con-
figuration of the breast should be assessed. Is the breast constricted or tubular?
A lack of skin in the inferior pole of the breast will limit breast implant size and
the surgical approach.

Surgical Approach

During the initial consultation, the woman is informed that the implant can
be placed via an axillary, periareolar, inframammary, or transumbilical approach.
The axillary, inframammary, and transumbilical approach can be assisted
endoscopically.6, 10 Based on Bostwick’s experience, the axillary incision line does
not hypertrophy.13 In most instances, the decision can be made based on the
patient’s choice. The woman may wish to avoid incisions on her breasts, or she
may base her decision on previous research or acquaintances. The physician
should recommend the approach that he or she feels is best for the patient,
especially if the woman has ptosis or a constricted breast. Figures 1 to 3 illustrate
breast augmentation results in three patients described in the following case
studies.

Case Studies
Case 1. A 31-year-old woman presented for breast augmentation. She wore
a 34-A brassiere (Fig. 1A). Breast augmentation was performed with Mentor
Siltex (the Mentor Corporation, Santa Barbara, California) textured round im-
plants each filled to 250 mL via an inframammary approach. The final result 7
months later is shown in Figure 1B.

Case 2. A 28-year-old woman presented with bilateral hypoplastic breasts

(Fig. 2A). Her brassiere size was 34-A. Breast augmentation was performed with
Mentor Contour Profile anatomic implants filled to 300 mL each. The final result
1 year later is shown in Figure 2B.

Case 3. A 44-year-old woman who wore an A or small B cup brassiere

presented for breast augmentation (Fig. 3A). Mentor Contour Profile anatomic
implants were placed, each filled to 235 mL. The final result 6 months later is
shown in Figure 3B.
 BREAST AUGMENTATION AND BREAST REDUCTION 105

Figure 1. 31-year-old woman who presented for breast augmentation. She wore a 34-A
brassiere (A, C). She underwent augmentation with Mentor SiltexR textured round implants
each filled to 250 mL via an inframammary approach. Final result 7 months later (B, D).

Figure 2. 28-year-old woman with bilateral hypoplastic breasts (A). Her brassiere size was
34-A. She underwent breast augmentation with Mentor Contour ProfileR anatomic implants
filled to 300 mL each. Final result 1 year later (B).
106 ANTONIUK

Figure 3. 44-year-old woman who wore an A or small B brassiere (A, C). She underwent
augmentation of her breasts with Mentor Contour ProfileR anatomic implants each filled to
235 mL. Final result 6 months later (B, D).

The implant can be placed either subglandular or subpectoral. A woman is

considered a candidate for subglandular placement if she has an adequate
amount of subcutaneous fat to cover the implant at the superior pole or is large
breasted. The implant chosen can be textured or smooth. A smooth implant has
been shown to be associated with a slight increase in capsular contracture.28 The
textured implant is thicker, and, if the patient is thin, the implant will be more
readily palpable. Subpectoral implant placement can be performed with the
textured or smooth implant. Subpectoral implant placement is associated with a
lower risk of capsular contracture.5, 28 Textured implants can be round or anatom-
ical shaped, whereas smooth implants are only round. The anatomic implant is
filled with saline based on the range given by the manufacturer. As suggested
by Hidalgo,14 the round implant should be overfilled by 15% to prevent rippling.
As stated in the manufacturer’s recommendations, the implant should only be
filled within the stated range. The plastic surgeon who wishes to overfill the
round implant needs to inform the patient that he or she is doing so. Adjustable
implants are now available and offer women the ability to have the implant size
changed postoperatively.14 Changes in volume can be made up to 6 months after
placement. The infusion port is then removed. Women need to realize that this
 BREAST AUGMENTATION AND BREAST REDUCTION 107

additional procedure carries a risk, although small, of incisional disruption and

infection.
The final size is dependent on the size of the woman’s breast and chest
wall. A woman who is very thin does much better with a smaller implant, that
is, 225 to 300 mL, when compared with a woman who is larger and has gone
through pregnancy and lactation. The latter patient would be a candidate for an
implant volume of 275 to 400 mL or larger. The larger the implants, the greater
the height, width, and projection. Medially, the implant is restricted by the
sternal edges, and this boundary should never be violated. An implant that is
too large will result in excessive lateral fullness, and when the woman moves
her arm, she will hit the implant. Too much fullness located superiorly will
either result in a cleavage that is considered very flattering or a step-off that is
very undesirable. Implant placement may result in alterations in nipple sensa-
tion.
As described by Schlenz and co-workers,29 the nipple is innervated by
multiple nerves from the anterior and lateral cutaneous branches. The fourth
intercostal nerve is considered the primary nerve that innervates the nipple.
During subglandular placement, there is an increased risk of injury to the nerves.
Subpectoral placement usually results in temporary injury because the nerves
with this approach are stretched, even though when creating the subpectoral
pocket, the muscle fibers are released from the sternal edge and laterally. During
this lateral dissection, nerve fibers can be severed, resulting in numbness that
can be permanent. Hypersensitivity or paresthesias to the nipples or breasts may
develop after augmentation. Although this side effect is usually self-limited,
these new sensations may be distressing to the patient.

Preoperative Preparation

A mammogram, if indicated, should be obtained on all women undergoing

breast surgery. Any suspicious calcifications or lesions should be addressed
before augmentation. Women who smoke should have stopped. Any medica-
tions such as aspirin, aspirin-containing products, and nonsteroidal anti-in-
flammatory medications or herbal treatments should be discontinued to avoid
bleeding. Hematoma formation causes pain, swelling, and the potential for skin
damage and infection requiring a return to the operating room for evacuation.
Because augmentation is a cosmetic procedure, the cost for the operation and
any follow-up treatment may not be covered by insurance. Even when the
hematoma has resolved, there may be an increased risk for capsular
contracture.3, 7 A capsular contracture can develop even when there are no
predisposing events9 and can affect one or both sides. In the most extreme
circumstance, the breast is deformed and painful, resulting in an obvious asym-
metry requiring surgical correction.
In an attempt to prevent infection, perioperative antibiotics are recom-
mended.3, 28 Because staphylococcus is the offending organism in most cases,
antibiotic coverage against this organism is appropriate. The author administers
cephalexin intravenously at surgery and then orally for 3 days following the
procedure. Infection also has been associated with capsular contracture,3, 7, 28
which may lead to removal of the implants if the infection cannot be resolved
with antibiotics.
Other risks include postoperative asymmetries not only in the position of
the nipple-areola complexes but also in how the entire breast appears afterward.
The breasts continue to mature after the implants are placed. This process may
108 ANTONIUK

be accentuated after pregnancy, lactation, and weight fluctuations and may

require further surgery, including replacing the implants or performing a masto-
pexy.
Permanent changes may occur in sensation to the breasts or nipples, some
of which may be welcomed while others may not. These changes include
paresthesias or hypersensitivities or a decrease in sensation. The changes in
sensation may result in a dissatisfied patient, especially if the breasts are an
important part of overall sexual well-being.
The implant may be palpable after it is placed. Visible wrinkling may be
noticed through the skin.13 The implant may deflate.9, 13 This deflation can be
partial or complete. If it occurs on one side, it will cause an obvious asymmetry
in breasts that were once symmetrical. This event would involve yet another
operation to replace the implant.

Postoperative Care

Postoperatively, women are placed in a special garment to prevent implant

movement.3, 23 The patient is seen within 1 week to ensure there are no problems.
Oral analgesics are prescribed. Women who have subpectoral placement usually
are in more pain than women who undergo subglandular placement. The recu-
perative period varies. Most women take off 1 week from work and longer if
necessary. Strenuous activities, including heavy lifting, are restricted for 1 month,
although walking and mild aerobic exercises are permitted. Other forms of
exercise are limited until all healing has occurred.

BREAST REDUCTION

Breast augmentation offers women the potential for increased self-esteem

through breast enhancement. Breast reduction also contributes to the woman’s
overall well-being. A woman seeking breast reduction does so not only for
esthetic reasons but also because of the discomfort caused by the large breasts.24
Such women are truly motivated. Usually, they know someone who has had the
procedure, or they have found the information they seek on the Internet. Many
of the author’s patients have already seen the operation on one of the cable
networks. Although this education aides in the preoperative discussion, it cannot
replace the communication between the patient and physician.

Initial Consultation

Women of all ages may request reduction mammaplasty (although breast

reduction usually is performed when full development has been achieved).
Adolescents with hypertrophy may be considered candidates on a selected
basis. Juvenile hypertrophy is uncommon, usually occurring at menarche with
continued rapid asymmetric growth. As discussed by Kupfer and co-workers,18
juvenile hypertrophy may represent an end-organ hypersensitivity to estrogen
rather than a true endocrine disorder. Other conditions that should be considered
include cystosarcoma phyllodes and juvenile fibroadenoma. The patient and her
parents must understand that the process may continue even after the reduction,
occasionally necessitating revisional surgery years later. For this reason, a period
of watchful waiting is appropriate. Referral for professional counseling for the
 BREAST AUGMENTATION AND BREAST REDUCTION 109

patient and her family often is effective in preventing inappropriate and prema-
ture surgery. Adolescents who are slightly older may find their large breasts
unattractive and the basis for jokes and comments. Psychologically, their self-
esteem is affected not only by this taunting but also by their inability to dress
stylishly and in the latest fashions. Physically, their ability to take part in athletics
and other activities may be limited. Usually, these young women are well
informed; however, appropriate additional medical referral and professional
counseling may clarify the legal issues associated with informed consent and
facilitate reimbursement.
The older woman who presents for breast reduction has lived with her large
breasts for many years. Many of these women wait until their childbearing years
have been completed. At this point, these patients must also cope with the
secondary changes from weight fluctuations, pregnancies, and lactation. The
adolescent and young woman should be counseled regarding the implications
associated with these conditions. The remaining breast tissue will continue to
react to changes in weight and the stimulation of the reproductive hormones,
resulting in yet another breast reduction. Secondary breast reduction should be
performed using the same technique as used in the primary procedure to
maintain blood supply to the nipple-areolar complex.
A full medical history is obtained, including any previous surgeries. Breast
reduction requires many incision lines, and previous healing can assist in de-
termining how the patient may scar. If a smoking history is identified, the
patient is asked to stop prior before surgery because continued smoking may
have deleterious effects on wound healing. Medications, including herbal reme-
dies and vitamins, are discussed. All herbal treatments should be discontinued.
The date of the last mammogram should be documented, and, if necessary, one
is obtained before surgery.
Women who desire a breast reduction present with well-known signs and
symptoms,24 including complaints of upper back, neck, and shoulder pain.
During warm weather, patients may complain of rashes in the inframammary
folds. Bras worn for support also have large shoulder straps, which contribute
to shoulder deformities and skin pigmentation. Infrequently, women complain
of chronic headaches and even symptoms of ulnar nerve paresthesias. They
complain that their breasts are very heavy, resulting in poor posture that contri-
butes to chronic back pain. These symptoms and findings should be documented
by appropriate consultation. This documentation will avoid reimbursement con-
flicts.
Women who request breast reduction should be within their ideal weight
range or slightly above it. Because this operation is an elective procedure, obese
women should lose weight not only to facilitate the surgery but also to avoid
medical complications secondary to the obesity. Because a woman’s breast is
related to her overall size, she may feel she is still too large or even too small
after the surgery. Any significant weight loss after the reduction can result in
breasts that are too small or ptotic. The woman who is the ideal candidate for
breast reduction surgery is comfortable with her size and has been at her present
weight for many years.
During the physical examination, asymmetries are pointed out to the pa-
tient. The degree of ptosis is ascertained; if significant, free nipple grafting is
discussed. In almost all instances, one breast is larger, and it is explained to the
patient that perfect postoperative symmetry is never guaranteed. During this
examination, the patient is also shown where the incisions will be on the breast.
Except for the very small incisions that can be made in women who are candi-
dates for liposuction, incision lines usually include the periareolar area, a verticle
110 ANTONIUK

limb, and, possibly, the inframammary fold (the inverted T incision). The status
of the skin is assessed. Stretch marks present in the superior pole will not be
removed; therefore, even though they may be less noticeable, they will be
present postoperatively. Hidradenitis suppurativa seldom involves the breast;
however, furunculosis is common. Any masses, lumps, or nipple discharge
should be evaluated by the appropriate physician preoperatively.
Although breast reduction is a common and relatively safe procedure, there
are associated risks and complications.20 Young women should be aware that
lactation may not be possible. Changes in breast and nipple sensation can also
occur, and some patients may experience paresthesias or hypersensitivity. Loss
of the nipple-areolar complex and skin slough may occur if the blood supply is
not adequate.

Surgical Approach

The extent of the operation performed is dependent on the estimated

amount of breast tissue to be removed, the quality of the skin, and the degree
of ptosis. Figures 4 and 5 illustrate the results of breast reduction in two patients
described in the following case reports.

Case Studies
Case 1. A 17-year-old girl presented for breast reduction. She wore a 36-DD
brassiere, was 5 feet and 7.5 inches tall, and weighed 131 lbs. She complained
of shoulder and back pain and had stigmation in her shoulders from the bra
straps (Fig. 4A). Breast reduction was performed using the Wise keyhole pattern

Figure 4. 17-year-old girl who presented for breast reduction. She wore a 36DD brassiere.
She is 5⬘71⁄2⬙ tall and weighed 131 lb. She complained of shoulder and back pain. She
also had stigmation in her shoulders from the bra straps (A). She underwent a breast
reduction using the Wise keyhole pattern (B) and the inferior pedicle. The total amount of
breast tissue removed from the right breast was 350 g and 380 g from the left breast. Her
final result 2 years later (C–E).
Illustration continued on opposite page
 BREAST AUGMENTATION AND BREAST REDUCTION 111

(Fig. 4B) and the inferior pedicle. The total amount of breast tissue removed was
350 g from the right breast and 380 g from the left breast. The final result 2
years later is shown in Figure 4C.

Case 2. A 29-year-old woman was 5 feet, 5 inches tall, weighed 140 lbs, and
wore a 32-DDD brassiere (Fig. 5A). She complained of shoulder and back pain.
On the day of surgery, breast markings were placed using the Wise keyhole
pattern (Fig. 5B). The inferior pedicle approach was used. A total of 496 g of
breast tissue was removed from the right breast and 581 g from the left. The
final result 5 months later is shown in Figure 5C.

For the woman who requires a moderate reduction of primarily fatty tissue
and who has good skin quality, minimal ptosis, and optimal nipple-areola
placement, liposuction may be all that is required.21 Ultrasound-assisted liposuc-
tion is not recommended.21 Women with stretch marks or skin laxity are not good
candidates, and the degree of ptosis may actually worsen with this procedure.
Advantages include the small incisions that are located in the inframmamary
fold or periareolar area.14
Vertical mammaplasties are an option if excess skin does not have to be
removed along the inframmamary fold. An incision line around the areola

Figure 4. See legend on opposite page

112 ANTONIUK

Figure 5. 29-year-old woman who is 5⬘5⬙ tall and weighs 140 lbs. Her brassiere size was
32DDD (A). She complained of shoulder and back pain. On the day of her surgery, breast
markings were placed using the Wise keyhole pattern (B). The inferior pedicle approach
was used. 496 g of breast tissue was removed from the right breast and 581 g from the
left. Final result 5 months later (C–E).
Illustration continued on opposite page

extends to the inframmamary fold. Liposuction can also be used. This approach
is considered for moderate reductions. Some women still have postoperative
redundancy of skin at the inframmamary fold, and this redundancy can be
excised at a secondary procedure. As performed by Lejour,19 the incision is
placed and hidden in the true inframmamary fold and is shorter in length than
the inverted T incision.
Women who require a moderate reduction in adipose tissue may or may
not have their surgery covered by insurance. Most insurance companies have
specific criteria for coverage, including height, weight, size of the breasts, and
associated symptoms. The estimated amount of breast tissue that will be re-
moved is given considerable importance. Women who do not meet these criteria
will be denied coverage.
Women who have very large breasts are candidates for a breast reduction
procedure that includes incisions around the areola, the verticle limb, and
inframmamary fold. The nipple-areola complex can be moved to its new position
based on a central, inferior, or superior pedicle. Breast tissue is maintained on
the chest wall in an attempt to preserve sensation to the nipple-areola complex.15
Although multiple sensory nerves have been identified as supplying the nipple,
the fourth lateral intercostal nerve is the most important and should be pre-
served.29
The inferior pedicle technique has been used since 1949 when it was first
described by Aufricht.1 Modifications of this technique have been described.8
Although the inferior pedicle technique is popular with plastic surgeons, long-
term results show that there may be a ‘‘bottoming out’’ inferiorly secondary to
continued descent of tissue.2, 4, 12, 20 As a result, modifications of the inverted T-
breast reduction have been developed.15 The superomedial breast reduction
offers women with moderately large breasts the ability to move the nipple-
areola complex on a pedicle with adequate blood supply and nerve sensation.
The superomedial technique incorporates the vascular supply from the internal
 BREAST AUGMENTATION AND BREAST REDUCTION 113

Figure 5. See legend on opposite page

mammary perforators as well as sensation from the anterior cutaneous

nerves.11, 20 Other pedicles that have been used include the horizontal bipedicle,30
a vertical dermal flap,22 and the central mound technique.2 The ideal technique
has not been developed. All breast tissue removed is submitted for histologic
examination. Breast cancer has been identified in rare instances.22, 25, 26

Postoperative Management

Drains placed at the time of surgery usually are removed the next day and
in all cases within a week. A postsurgical bra is worn for support for 4 weeks.
No heavy lifting is allowed for 4 weeks. Women who have this surgery usually
are pleased with the results. The preoperative symptoms are corrected, and the
women feel much better about themselves. A word of caution is necessary
regarding long-term results. The breasts will continue to change and mature.16
Pregnancy, lactation, and weight fluctuations can make a successful result less
than optimal, and revision may be necessary.20 As noted previously, women who
114 ANTONIUK

have the procedure at a young age may continue to develop and require
a revision.

SUMMARY

Breast enhancement through augmentation improves not only the woman’s

physical appearance but also contributes to her psychologic well-being. With the
current emphasis placed on women’s breasts in the media, it is not surprising
that small-breasted women feel inadequate. Recent US Federal Drug Administra-
tion approval of saline implants has given them a new image, and more women
are seeking breast augmentation.27 As long as the woman understands that this
operation has associated risks, a physician–patient relationship may be devel-
oped resulting in many years of happiness and increased self-esteem.
The shape, contour, and size of a woman’s breasts are permanently altered
by augmentation mammaplasty and breast reduction. Although each case is
unique, the outcome of each procedure should result in a satisfied patient.

References

1. Aufricht G: Mammaplasty for pendulous breasts. Plast Reconstr Surg 4:13–29, 1949
2. Balch CR: The central mound technique for reduction mammaplasty. Plast Reconstr
Surg 67:305–311, 1981
3. Becker H, Springer R: Prevention of capsular contracture. Plast Reconstr Surg 103:
1766–1768, 1999
4. Bostwick J III: Improving safety and aesthetic results in inverted T scar breast reduc-
tion: Discussion. Plast Reconstr Surg 103:888–889, 1999
5. Burkhardt BR: Prevention of capsular contracture: Discussion. Plast Reconstr Surg 103:
1769–1772, 1999
6. Caleel RT: Transumbilical endoscopic breast augmentation: Submammary and subpect-
oral. Plast Reconstr Surg 106:1177–1182, 2000
7. Camirand A, Doucet J, Harris J: Breast augmentation: Compression—a very important
factor in preventing capsular contracture. Plast Reconstr Surg 104:529–538, 1999
8. Courtiss EH, Goldwyn RM: Reduction mammaplasty by the inferior pedicle technique.
Plast Reconstr Surg 59:500–507, 1977
9. Cunningham BL, Lokeh A, Gutowski KA: Saline-filled breast implant safety and
efficacy: A multicenter retrospective review. Plast Reconstr Surg 105:2143–2149, 2000
10. Dowden RV: Transumbilical endoscopic breast augmentation: Submammary and sub-
pectoral, discussion. Plast Reconstr Surg 106:1183–1184, 2000
11. Finger RE, Vasquez B, Drew GS, et al: Superomedial pedicle technique of reduction
mammaplasty. Plast Reconstr Surg 83:471–478, 1989
12. Hammond DC: Short-scar periareolar-inferior pedicle reduction (SPAIR) mammaplasty.
In Operative Techniques in Plastic and Reconstructive Surgery. Philadelphia, WB
Saunders, 1999, pp 106–118
13. Handel N, Jensen JA, Black Q, et al: The fate of breast implants: A critical analysis of
complications and outcomes. Plast Reconstr Surg 96:1521–1533, 1995
14. Hidalgo DA: Breast augmentation: Choosing the optimal incision, implant and pocket
plane. Plast Reconstr Surg 105:2202–2216, 2000
15. Hidalgo DA: Improving safety and aesthetic results in inverted T scar breast reduction.
Plast Reconstr Surg 103:874–886, 1999
16. Hoffman S: Recurrent deformities following reduction mammaplasty and correction
of breast asymmetry. Plast Reconstr Surg 78:55–60, 1986
17. Hudson DA, Skoll PJ: Repeat reduction mammaplasty. Plast Reconstr Surg 104:401–
408, 1999
 BREAST AUGMENTATION AND BREAST REDUCTION 115

18. Kupfer D, Dingman D, Broadbent R: Juvenile breast hypertrophy: Report of a familial

pattern and review of the literature. Plast Reconstr Surg 90:303–309, 1992
19. Lejour M: Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 94:
100–114, 1994
20. Malata CM, Bostwick J III: Breast reduction with the superior parenchymal pedicle: T-
scar approach. In Operative Techniques in Plastic and Reconstructive Surgery. Philadel-
phia, WB Saunders, 1999, pp 126–135
21. Matarasso A: Suction mammaplasty: The use of suction lipectomy to reduce large
breasts. Plast Reconstr Surg 105:2604–2607, 2000
22. McKissock PK: Reduction mammaplasty with a vertical dermal flap. Plast Reconstr
Surg 49:245–252, 1972
23. Mladick RA: Prevention of capsular contracture: Discussion. Plast Reconstr Surg 103:
1773–1774, 1999
24. Netscher DT, Meade RA, Goodman CM, et al: Physical and psychosocial symptoms
among 88 volunteer subjects compared with patients seeking plastic surgery proce-
dures to the breast. Plast Reconstr Surg 105:2366–2373, 2000
25. Pennisi VR, Capozzi A: The incidence of obscure carcinoma in subcutaneous mastec-
tomy. Plast Reconstr Surg 56:9–12, 1975
26. Pitanguy I, Torres ET: Histologic aspects of mammary gland tissue in cases of plastic
surgery of the breast. Br J Plast Surg 17:297–302, 1964
27. Rohrich RJ: The FDA approves saline-filled breast implants: What does this mean for
our patients? Plast Reconstr Surg 106:903–905, 2000
28. Rohrich RJ, Kenkel JM, Adams WP: Preventing capsular contracture in breast augmen-
tation: In search of the holy grail. Plast Reconstr Surg 103:1759–1760, 1999
29. Schlenz I, Kuzbari R, Gruber H, et al: The sensitivity of the nipple-areola complex: An
anatomic study. Plast Reconstr Surg 105:905–909, 2000
30. Strombeck JO: Mammaplasty: Report of a new technique based on the two-pedicle
procedure. Br J Plast Surg 13:79–90, 1960
31. Tang CL, Brown MH, Levine R, et al: Breast cancer found at the time of breast
reduction. Plast Reconstr Surg 103:1682–1686, 1999

Address reprint requests to

Pamela M. Antoniuk, MD
120 Dudley Street
Suite 201
Providence, RI 02905