The safety in breast surgery depends on several factors, as it begins with the knowledge
of specific details, which will determine the limitations and allow a safe surgical
schedule with the techniques currently available, clarifying to patients about all
the factors inherent to this procedure1. Thus, expectations are closer to reality when patients understand the benefits and
limitations of breast surgery2.
Following the good practice of medicine, which starts with an adequate preoperative
evaluation, anatomical and anthropometric points were created on the chest to study
the breast objectively3,4.
An important factor in evaluating the breasts is how it is done since the measurement
obtained directly from the patient is different in that collected through a photographic
image, which can directly interfere in the surgical programming4-6.
Several complications may occur after an adequate evaluation, followed by surgical
programming, regardless of the technique used7.
Several authors have sought to describe studies that evidence evaluations related
to complications in breast reduction surgery. The most common complications found
in the literature related to blood perfusion of the nipple-areola complex (NAC), surgical
site infection, dehiscences, asymmetries, and changes in sensitivity secondary to
the surgical procedure have been described8-12.
Given the prevalence of complications in breast surgery and a lack of protocol for
the treatment and conduction of these alterations, the Sociedade Brasileira de Cirurgia Plástica (SBCP) mobilized to evaluate which complications are more frequent and which studies
exist in the literature that cites these changes with reports of ways to avoid them.
This study aims to discuss controversial issues and complications in breast surgery
with its main treatments.
During research at PubMed on breast surgery x complications x treatment of complications,
topics that would be discussed were elected.
Articles evaluating breast reconstruction surgery and augmentation mammoplasty surgeries
without mastopexy or reducing mammoplasty were excluded, with priority for English,
Spanish, Italian and French articles.
Based on articles referring to evidence-based medicine and selection of the most frequent
complications, they were listed and taken to the discussion in a roundtable with four
plastic surgeons with experience in breast plastic surgery and full members of the
SBCP in which, based on scientific articles, discussed the behaviors relevant to each
complication listed, during the class of the distance learning program (PED) of the
referred society (SBCP).
The articles chosen to serve as the basis for the discussion were the studies by Kerrigan
and Slezak (2013)11, which was based on the American Board of Plastic Surgery, where 606 plastic surgeons who performed 6,461 breast reduction procedures were heard.
Also, the Greco and Noone study (2017)8, where 1,343 plastic surgeons performed 59,883 breast reduction procedures. The studies
were classified as level 1 of scientific evidence.
The points that were defined for discussion were:
Antibiotic therapy in mammoplasties;
Mammoplasty with prosthesis;
Large mammary ptoses;
Use of drain;
Dressings in mammoplasty;
Fat graft in breasts.
1. Antibiotic therapy in mammoplasties
The questioning involving the use of antibiotics in reducing mammoplasties involves
the use or not of the antibiotic, in what period and how long it will be used.
Ahmadi et al. (2005)13 conducted a randomized clinical trial with 50 women submitted to reduction mammoplasty,
distributed in three groups. One group did not receive antibiotics, another received
only perioperative, and the third received antibiotics in the perioperative period
and for another six days. There was no statistical difference between the groups regarding
the occurrence of infection.
Veiga Filho et al. (2010)14 published a study with 100 reduction mammoplasty patients divided into two groups,
without antibiotics and with antibiotics in the perioperative period and for another
six days. They found a significant difference in surgical site infection rates (14%
in the group without antibiotics versus 2% in the group that received antibiotics,
p=0.03). However, other studies that evaluated the use of antibiotics concluded that,
when used for seven days, it is not superior to that used only perioperatively, in
terms of decreasing infection rates 15,16.
A recent, triple-blind randomized clinical trial evaluated 124 patients undergoing
reduction mammoplasty. One group received perioperative antibiotics for another seven
days, and the other received only perioperative antibiotics and a placebo for seven
days. There was no difference in infection rates, concluding that maintaining antibiotics
in the postoperative period did not bring benefits17.
2. Intraoperative infiltration
Noone et al. (2010) 18 surveyed 296 American plastic surgeons, referring to breast infiltration with vasoconstrictive
solutions before the surgical procedure. Of this total, 49% did not use infiltration,
17% used it sporadically, and 34% used infiltration in all patients. However, evaluating
the occurrence of hematomas, they did not observe a relationship with the use or not
3. Mammoplasty with prosthesis
Mammoplasty/mastopexy associated with the use of implants was evaluated in different
aspects: indication, implant plan, the texture used and association with fatty breasts.
No article was found in the literature that contemplates all these factors together.
Thus, the discussion was based on the literature involving each of these items in
isolation and on the participants’ experience.
4. Large mammary ptoses
The safety regarding the good perfusion of the flaps for the ascension of the NAC
5. Masculinizing mammoplasty
Masculinizing mammoplasty has some particularities, mainly related to the large volume
of detachment, resection and thin-thickness flaps.
The techniques are based on previous breast volume, resulting in periareolar, concentric
periareolar scars or even mastectomy scarring with NAC graft21,22.
The main complications refer to a hematoma, followed by the suffering of the NAC,
suffering or loss of the areolar graft with depigmentation, total or partial necrosis
of the NAC, changes in sensitivity and hypertrophic scars21,22.
6. Suffering of the nipple-areola complex (NAC)
No conclusive clinical studies on the viability of NAC after mammoplasties were found
in the literature, indicating effective conduct for the treatment of its suffering.
However, oxygen therapy through the hyperbaric chamber is effective in studies evaluating
NAC perfusion in patients undergoing mammary reconstruction23.
Studies in rats showed greater permeability of red blood cells when using pentoxifylline
before the procedure24.
7. Use of drain
Studies evaluating the use of a drain in mammoplasty consider the type of drain used,
its efficacy and time of use.
Studies with levels of evidence I and II show no difference in the prevention of hematomas
and the improvement of tissue healing25-27.
8. Mammoplasty dressing
Veiga Filho et al. (2012) 28 performed a randomized clinical trial with 70 patients submitted to reduction mammoplasty.
Of these, 35 had the dressing removed on the first postoperative day (DPO) and 35
on the sixth day. They did not find a statistical difference in infection rates but
found lower skin colonization, with significance, when the dressing is maintained
for six days. They also found a statistical significance that the patients preferred
to keep the dressing for six days and considered this a safer option28.
9. Fat graft in breasts
A systematic review on breast fat grafting demonstrated 2% of palpable cysts, 0.6%
of infection, 0.5% of hematoma and 0.1% of seroma29. Mammography images demonstrated 6.5% of oily cysts, 4.5% of calcifications, and
1.2% of fatty necrosis. Of these alterations, 81.5% presented BIRADS 2 images, 16.4%
had BIRADS 3, and 3.2% had BIRADS 4, which required a biopsy of the lesions related
to the image found. The amount of infiltrated fat or the resorption rate of this fatty
graft in breasts.29
The constant study of different tactics and approaches in mammoplasty is important
in the relationship between clinical practice and the literature, especially with
articles that address evidence-based medicine or systematic reviews. Discussions about
these articles enhance the specialty, as they add the base of the literature with
the experience of specialists in the area, prioritizing the safety of the patient
and the professional who performs the surgical procedure.
The use of antibiotics in breast surgeries has its importance described by several
authors. However, there is still no consensus on the time and ideal dose of antibiotic
use. The literature indicates safety in using the antibiotic only in the perioperative
period and may extend for up to 24 hours after the procedure 13,14,16,17. It was clear from the discussions that the important thing is the patient’s follow-up
in the postoperative period. The surgeon should institute antibiotic therapy for as
long as he deems necessary from any sign of infectious process. Breast solution infiltration
has no standardization and consensus among surgeons, related to the amount of solution
used, type of dilution of the solution, place where the solution is infiltrated, and
the benefits and risks involving such procedure.
There is consensus in the literature that breast infiltration did not significantly
affect the occurrence of hematomas but did not interfere in the healing process. However,
the only reports involving infiltrated solution were in experimental studies in rats.
A reduction in the release of vasodilator neuropeptides was observed after using ropivacaine,
which could reduce the local inflammatory process and consequently a better quality
Mastopexy surgery with breast implants remains a challenge among plastic surgeons.
It is a safe surgery with the greatest complications related to great weight loss,
smoking, and diabetes31. Body awareness is important in indicating this procedure, since the breast implant
aims to provide a filling of the breast, having no action on the evolution of the
breast to future breast ptosis, regardless of the surface of the implant as well as
the plane in which is introduced because the action of gravity ends up acting on the
breast and the implants 32. No articles were found in the literature that defines the best plan of breast implant
or at least the type of texture of the implants.
One factor that cannot be forgotten is the fact that there is a suspicion in the correlation
between more aggressive texturing according to the classification of Jones et al.
(2018) 33 and the onset of giant cell lymphoma (BIA-ALCL)34, even though it is an uncommon disease can occur in 1:2,832 to 1:86,029 according
to texturization35. Furthermore, in a more recent study by Cordeiro et al. (2020), 36 occurred in 1:354 of breast cancer patients submitted to reconstruction with grade
3 textured implants. Therefore, the choice of implant plan in mastopexy with prosthesis
should also observe the type of implant selected, whether smooth or textured and in
the future could create a standardization related to the plane and surface of the
implants used, aiming at patient safety and a lower rate of complications.
There is no unanimity among plastic surgeons regarding the best flap for NAC rise
in large-volume breasts and marked degree of breast ptosis. The factors that may interfere
with this decision are the patient’s age, comorbidities, degree of ptosis and experience
of the surgeon with the technique used. The most used techniques are areola graft,
use of lower pedicle and medial supper pedicle. Unfortunately, no studies have been
found in the literature comparing these different techniques between them19,20.
Masculinizing mammoplasty aims to perform a mastectomy in male transgender patients,
and the techniques used vary according to breast volume and skin to be removed. Several
techniques are available, resulting in periareolar, concentric periareolar scars and
resulting from classical reduction mammoplasty. Complications in this type of specific
surgery are similar to those found in reducing mammoplasty, emphasizing the presence
of hematomas with a higher prevalence. The occurrence of hypertrophic scars could
be explained by an increase in hair on the chest and an increase in testosterone.
Currently, in Brazil, there are two ordinances of the Ministry of Health that authorize
this type of procedure, and the Federal Council of Medicine, as of 2020, authorizes
the transsexualizing surgical process in patients over 18 years old, who have a minimum
follow-up of two years by multidisciplinary team 21,22,37-40.
Blood perfusion of NAC is always a concern in mammoplasties. In case of alteration
in the NAC circulation, either due to decreased perfusion or congestion in the flap,
few studies in humans address this issue with treatment suggestions effectively. Oxygen
therapy, through the hyperbaric chamber, has its role, but with a technical difficulty
of using it in our environment23. Pentoxifycin had its use evaluated in studies in rats, bringing benefit in its use24. Studies involving suction cup, laser, heparin or other medication are necessary
to prove its efficacy and safety in its use41,42.
Studies evaluating the use of drain in mammoplasty surgeries, with evidence levels
I and II, have shown no difference in the healing and prevention of hematomas. The
question in these studies was about the need for plastic surgeons to use drains in
mammoplasty surgeries, and the indication was based on the prevention of hematomas
or excessive bleeding. However, there was no correlation between the use of drains
and the prevention of hematoma25-27.
The length of stay of dressings in reduction mammoplasty was evaluated in a randomized
study with 70 women divided into two groups: group 1 - dressing removed in 1 day and
7 cases of infection (increased levels of Staphylococcus colonization); group 2 -
dressing removed after 6 days and presenting 2 cases of infection, p=0.09. The study
concluded that there was no difference in maintaining or removing dressing after 1
day but presenting an increase in bacterial colonization in group 1. The questioning
of this study also refers to the concept of infection because no patient developed
an infectious process in surgery. Another conclusion of the study was that patients
feel safer using the dressing in the operated region28.
Breast fat grafting has wide use, but some care related to images resulting from this
mammography procedure cannot be ignored. In addition, the amount of grafted fat and
this fat is prepared to be grafted is not established to promote uniformity in the
amount of absorption and stabilization of the graft29,43,44.
The present study, based on studies of the literature and experience of the professionals
involved, concluded that:
Perioperative antibiotic is sufficient in antibacterial prophylaxis;
Removing dressing in DPO 1 does not alter the outcome of bacterial infection;
Breast infiltration solution containing epinephrine and anesthetic reduces postoperative
pain and does not increase hematoma
Fat injection, when performed in the breasts, should be thrifty;
Pentoxifyphiline has good results in the prevention of necrosis in flaps with suffering
Drain does not alter healing or bruising in mammoplasties.
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1. Federal University of São Paulo, São Paulo, SP, Brazil.
2. Brazilian Society of Plastic Surgery, Mammoplasty Chapter, São Paulo, SP, Brazil.
Paulo Rogério Quieregatto Do Espirito Santo Rua Coelho Lisboa, 442 - cj 13, Tatuapé, São Paulo, SP, Brazil Zip Code 03323-040
Article received: April 19, 2020.
Article accepted: May 18, 2021.
Conflicts of interest: none.