A recent article studied 100 consecutive breast aug patients to try and determine what pre-existing conditions will affect the final outcome.  Recognizing these pre-op conditions are essential to develop a sound surgical approach.  In this study 18% of patients were considered to be challenging cases.  Major complicating factors included pectus excavation or pectus carinatum, tuberous breast, Poland syndrome or scoliosis.  Minor complicating factors were such things as volume asymmetry, verticle nipple asymmetry, constricted breast base, pseudo ptosis, IMF/intra mammary fold & asymmetry.  If a patient had more than 4 minor complicating factors they considered it a challenging case.