**10. Complications**

 As with even simple breast surgery, there is a notable complication rate. Consistently, studies have shown 15–25% reoperation rates post primary augmentation, and clinical experience shows that this rate is consistent when augmentation is combined with mastopexy [10]. Interestingly, these studies have shown the complication rates to not be exponential or even additive when combined surgery is performed versus a two stage approach [11, 12]. This is likely explained by the occasional patient specific intrinsic difficulties associated with either mastopexy and augmentation alone along with more careful patient selection when combining procedures. And fortunately, significant complications like implant extrusion, infection and nipple necrosis are very uncommon. Should nipple ischemia be noted intraoperatively, several maneuvers may reverse the impending danger. Evacuation of periareolar hematoma and strict hemostasis is the simplest step, otherwise nitroglycerin paste or spray immediately postoperatively to the NAC for minor ischemia is beneficial by improving venous congestion. However, should the ischemia be more profound, early removal of sutures and/or the implant will likely improve blood supply and venous drainage. Lastly, consideration of hyperbaric therapy in the early postoperative period, although cumbersome and not well defined in the literature, has shown evidence of dramatic reversal in impending necrosis [13]. Fortunately, the most significant reasons for reoperation are typically unfavorable scarring, capsular contracture, hematoma and implant malposition [14]. Excising entire capsules because of capsular contracture increases risk of hematoma especially when combined with ptosis correction (**Figure 23**). These are managed in a similar manner for either augmentation or mastopexy alone and methods to minimize these complications and the need for subsequent revisions are not very different than for either mastopexy or augmentation alone. For instance, the authors do not perform mastopexy surgery on current smokers for well-defined reasons, and of course this

#### **Figure 23.**

*Simultaneous correction of ptosis and capsular contracture adds to an already high revision rate and complication rate of simultaneous mastopexy/augmentation. The patients shown are even higher risk because of thin tissue and large implant size.* 

 includes candidates for simultaneous surgery as well. As previously mentioned, a more conservative methodology for implant size selection is recommended in combined surgery in order to minimize wound tension and ischemic stress on the NAC. Otherwise, simultaneous mastopexy and augmentation is planned with a similar risk stratification to other cosmetic breast procedures, albeit with more regard for the rarer more devastating complications discussed above [15].
