Plastic Surgery, Volume Five: Breast (Fourth Edition): Cẩm nang Toàn diện Phẫu thuật Thẩm mỹ và Tái tạo Vú – Maurice Y. Nahabedian & Peter C. Neligan

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SECTION I
CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
positioned to approximately 60° to assess breast sym­
metry, fullness, and nipple position. The nipple areolar
complex is exteriorized such that the length from the
inferior aspect of the nipple areolar complex is 5–6 cm
from the horizontal incision. A single drain is placed,
and the incisions are closed with interrupted dermal
and continuous subcuticular sutures. Fig. 9.12 illustrates
a patient following reduction mammaplasty using an
inverted-T pattern and a medial pedicle.
Outcomes
Patient outcomes following inverted-T reduction mam­
maplasty using a medial pedicle have been favor­
able.16,20,21,22 Nahabedian et al. studied a series of 45
breasts with severe mammary hypertrophy and demon­
strated viability of the nipple areolar complex in 44/44
breasts and retained sensation in 42/44 breasts.15 Loss
of sensation was related to pedicle length rather than
the weight of tissue excised, as resections of 2500 g did
not result in sensory loss. Mean resection volume was
1627 g on the left and 1580 g on the right. One woman
required a free nipple graft that had a resection volume
of 2530 g and a pedicle length of 18 cm. Patient satisfac­
tion was assessed using a non-validated questionnaire
demonstrating 100% satisfaction with nipple projection
and 22/23 patients satisfied with breast shape.
Abramson et al. reviewed a series of 88 consecutive
patients that had reduction mammaplasty using an
inverted-T approach and a medial pedicle.16 The overall
complication rate was 6.8% and included hematoma,
partial nipple necrosis, incisional dehiscence, and fat
necrosis. Bottoming out of the breast was minimized
using this technique. At the 1-year follow-up, the nipple
to inframammary fold distance increased 11% when the
resection volume was between 500 and 1200 g/breast
and 34% when greater than 1200 g/breast.
Sensation and viability studies of the nipple areolar
complex have also demonstrated favorable results using
the inverted-T approach and the medial pedicle.21,22 In a
study comparing 41 medial and 31 inferior pedicle
techniques, sensory retention was demonstrated in 68
of 79 breasts (86%) using a medial pedicle and in 50 of
54 breasts (92%) using an inferior pedicle. Viability of
the nipple areolar complex was demonstrated in 74
of 79 breasts (94%) using a medial pedicle and in 53 of
54 breasts (98%) using an inferior pedicle. Mean resec­
tion volume for the medial pedicle cohort was 1490 g
(range, 930–2910 g) and 720 g (range, 400–1580 g) for
the inferior pedicle cohort. Nipple areolar sensation
using a pressure specified sensory device was studied
in eight women following inferior pedicle reduction
mammaplasty and in nine women following medial
to reduce bulk. Distal pedicle bleeding is assessed to
ensure perfusion of the nipple areolar complex. Absence
of bleeding usually dictates conversion to a free nipple
graft. The breast skin flaps are elevated with a thickness
that correlates to the interface of the parenchyma and the
subcutaneous tissue. A temporary trifurcation suture is
placed approximating the inferior corner of the medial
and lateral vertical limbs of the inverted-T pattern to a
predetermined point on the inferior horizontal incision
(Fig. 9.11). A dog-ear is avoided medially by ensuring
equal length. Skin adjustments are made laterally using
a tailor-tack approach. The nipple areolar complex is
rotated superiorly towards the apex of the vertical
limbs. Twisting or kinking of the pedicle is avoided.
The skin edges are temporarily stapled and the patient
Fig. 9.11  Schematic illustrations following glandular excision and the trifurcation
suture. (Redrawn after Nahabedian MY, McGibbon BM, and Manson PN. Medial
pedicle reduction mammaplasty for severe mammary hypertrophy. Plastic and
Reconstructive Surgery. 2000;105:896–904.)
Initial trifurcation suture
Dermal pedicle flap rotated upward
Positioned dermal pedicle flap
A
B
C

147
Treatment/surgical technique
A
B
C
D
E
F
Fig. 9.12  (A) Preoperative photograph of a patient scheduled for a reduction mammaplasty using the inverted-T technique and a medial pedicle is shown. (B) A right
lateral view is depicted. (C) The inverted-T is delineated. (D) The medial pedicle is delineated and de-epithelialized. (E) The glandular resection is completed and the
medial pedicle is isolated. (F) The bilateral medial pedicles are depicted.
Continued

148
SECTION I
CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
of patients. The length of nipple transposition ranged
from 4 to 15 cm, with a median of 8 cm. The weight of
breast tissue excised ranged from 210–1850 g per breast.
It was subsequently opined that the superomedial
pedicle technique was suitable for breasts of moderate
volume rather than large volume. Fig. 9.13 illustrates
the basic markings and technique of the superomedial
pedicle.
Markings
With the patient standing, an inverted-T pattern is
delineated as previously described. The desired posi­
tion of the nipple areolar complex serves as the focal
point of the pattern. With the patient in the supine
pedicle reduction mammaplasty. When comparing the
two techniques, there were no significant differences in
postoperative sensory outcomes, despite significantly
greater reduction volumes using the medial pedicle
technique (mean of 1.7 kg vs 1.1 kg). In addition, the
amount of breast tissue removed did not correlate with
postoperative sensory outcomes.
Superomedial pedicle technique
Orlando and Guthrie originally described the supero­
medial reduction mammaplasty technique using the
inverted-T in 1975.23,24,25 Early studies focused on the
nipple areolar complex and demonstrated viability in
100% of patients and retention of sensitivity in 83–92%
G
H
I
(G) The medial pedicle is rotated towards the apex of the breast.
(H) A postoperative photograph at 3 months is depicted following a reduction
mammaplasty using an inverted-T pattern and a medial pedicle. (I) A right lateral
view is shown.
Fig. 9.12, cont’d

149
Treatment/surgical technique
Outcomes
Davison et al. have reviewed their 6-year experience
with the superomedial pedicle in 215 patients.26 The
incisional patterns included 30 circumvertical; 43 cir­
cumvertical with short transverse scar; 133 inverted-T;
and nine free nipple grafts with an inverted-T. The
selected incisional pattern correlated with resection
volume. The mean weights were 688 g/breast following
circumvertical reduction; 1137 g/breast following cir­
cumvertical reduction with a short transverse scar;
1184 g/breast following inverted-T reduction; and
1929 g/breast following free nipple graft using an
inverted-T pattern. The overall complication rate using
an inverted-T approach was 18% and included seroma
(3.7%); hematoma (3.7%); delayed healing (0.75%); cel­
lulitis (1.5%); altered nipple sensation (0.75%); superfi­
cial necrosis (1.5%); and complex scar (1.5%). There
were no cases of total nipple loss. The advantages of the
superomedial pedicle included superior vascularity;
shorter pedicle length; less de-epithelialization; favor­
able arc of rotation; no need to use parenchymal sutur­
ing techniques; providing superomedial fullness; and
reduced incidence of bottoming-out.
Lugo et al. studied the efficacy of the superomedial
medical technique for women with severe mammary
hypertrophy defined as greater than 1000 g per breast.
A total of 200 patients met the criteria for analysis.
Mean resection volume was 1277 g on the right and
1283 g on the left. Mean nipple areolar transposition
was 11.25 cm on the right and 11.4 cm on the left.
Partial nipple necrosis occurred in 10.5%, and 98% of
patients reported normal sensation of the nipple areolar
complex.27 Altuntas et al. have demonstrated that the
position of the nipple areolar complex did change over
time following superomedial reduction mammaplasty
using an inverted-T pattern with a descent of 1.61 cm
position, the superomedial pedicle is delineated.
Although similar in design to the medial pedicle, there
are differences in orientation. The superior limb of the
pedicle is oriented in a true vertical position, whereas
the medial limb is oriented approximately 45° off the
vertical. The pattern extends around the nipple areolar
complex with a 5–10 mm peripheral zone to preserve
the integrity of the subdermal plexus.
Surgical technique
Local anesthetic agents with epinephrine are considered
prior to the incisions for improved hemostasis. A
42–45 mm cookie-cutter is used to inscribe the nipple
areolar complex. The epidermis is incised to the level
of the mid-dermal layer. The superomedial pedicle is
de-epithelialized. The inverted-T markings are incised.
Dermoglandular wedge excisions are performed and
based inferiorly and laterally. The superomedial pedicle
is usually maintained on its dermo-parenchymal attach­
ments such that the chest wall perforators are included.
This maneuver increases the likelihood of adequate
perfusion to the nipple areolar complex. The superome­
dial pedicle is then repositioned such that the nipple
areolar complex is at the apex of the vertical limbs.
Because of the vertical limb, rotation may be compro­
mised and some degree of folding of the de-epithelialized
pedicle may occur. A back-cut on the inferior limb may
augment the degree of rotation to minimize any tension
on the pedicle. Parenchymal suturing can be considered
for optimal shaping and contour but may not be neces­
sary. A trifurcation suture is placed to ensure tension
free closure of the inverted-T incision. Irrigation is
performed, and hemostasis is ensured followed by
closed suction drain placement. The skin is closed in
layers with absorbable sutures. Fig. 9.14 illustrates a
patient following superomedial reduction mamma­
plasty using an inverted-T technique.
Fig. 9.13  (A–D) Superomedial pedicle with Wise-pattern skin closure. (A) Skin markings; (B) inferior parenchymal resection; (C) lateral parenchymal resection and
trifurcation suture; (D) skin closure.
A
a
b
c
d
B
Back cut
C
a
b
c
d
D
b
c
d

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SECTION I
CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
on the right breast and 1.79 cm on left breast at a mean
follow-up of 15 months. The length from the nipple
areolar complex to the inframammary fold increased by
3.31 cm and 3.59 cm on the right and left breast, respec­
tively. These changes were related more to descent of
the lower pole rather than upward migration of the
nipple areolar complex.28
Central mound technique
Balch described the central mound technique for reduc­
tion mammaplasty in 1981.29 The rationale for this
technique was that the vascularity of the nipple areolar
complex would not depend on a dermal pedicle but
instead on the deep parenchymal vascularity. The origi­
nal description included resection of medial and lateral
pillars with the benefit of less bottoming out that was
sometimes seen with inferior pedicle techniques. Hester
reported his experience with the central mound tech­
nique in 65 patients. The vascularity was predominantly
from the perforating branches from the lateral thoracic
artery, intercostal, internal mammary, and thoracoacro­
mial vessels with the pectoralis major muscle as the
foundation. The benefit of this technique was that it
could be used for small and large reductions, pedicle
length issues were avoided, and postoperative breast
A
B
C
D
Fig. 9.14  (A) A preoperative image of a patient scheduled for reduction mammaplasty using an inverted-T and a superomedial pedicle. (B) A preoperative left lateral view
is depicted. (C) A preoperative right lateral view is depicted. (D) A postoperative photograph at 6 months is depicted following reduction mammaplasty using the inverted-T
technique and a superomedial pedicle.

151
Treatment/surgical technique
Markings
The usual breast landmarks including the sternal notch,
midclavicular point, sternal midline, breast meridian,
nipple areolar complex, and inframammary fold are
marked and delineated with the patient in the upright
position. The inverted-T pattern is drawn as previously
described. The central mound is marked with the patient
supine. In the majority of cases, the actual position of
the nipple areolar complex lies within the boundaries
of the vertical limbs or just below it. The inferior border
of the central mound extends around the nipple areolar
complex forming a triangle with the inferior point of the
vertical limbs.
Surgical technique
Following transport to the operating room, the patient
is placed under general anesthesia; however, sedation
and local anesthesia can also be considered. Pneumatic
compression devices are applied, and intravenous anti­
biotics are administered. Local anesthetics agents are
sometimes used. The nipple areolar complex is delin­
eated with a 42–45 mm cookie-cutter then incised. The
central mound outline is incised then de-epithelialized
using heavy surgical scissors or a scalpel. The inverted-T
pattern is incised. Dermoglandular wedge excisions
are performed inferiorly and laterally. Inferiorly, it
is important not to undermine the breast because of
projection and contour was optimized. Fig. 9.15 illus­
trates the central mound technique.
The central mound technique is very different than
the traditional pedicle orientations for transposition of
the nipple areolar complex. The primary vascularity
of the central mound is derived from the intercostal
perforators and secondarily through the vessels supply­
ing the breast. Wuringer in 1998 described the horizontal
fibrous septum of the breast.5 The significance of this
septum is that it essentially bisects the breast into a
cephalad and caudal half and includes a significant
contribution of the vascularity and innervation to the
breast parenchyma and nipple areolar complex. It
includes dominant vascular contributions from the
thoracoacromial, internal mammary, lateral mammary,
and intercostal vessels, as well as innervation from the
anterior and lateral divisions of the 2nd–4th intercostal
nerves. The central mound technique preserves this
septum and provides excellent vascularity and innerva­
tion to the nipple areolar complex.
The central mound is typically performed in women
in need of small to moderate reduction mammaplasty,
with resection volumes ranging from 200–600 g with
nipple elevation less than 6 cm. The central mound
becomes less effective for severe mammary hypertrophy
or when the nipple areolar complex requires more eleva­
tion because of the potential risk to the horizontal
septum and vascularity.
(E) A postoperative left lateral view. (F) A postoperative right lateral view.
E
F
Fig. 9.14, cont’d

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CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
are temporarily stapled. The patient is sat upright
to approximately 45° to assess volume and contour
symmetry. Lateral adjustments using a tailor-tacking
approach are sometimes necessary. A closed suction
drain is placed along the inferior aspect of the breast.
The ideal location for the nipple areolar complex is
determined and delineated with the appropriate cookie-
cutter. The incision is created, and the nipple areolar
complex is exteriorized and sutured using absorbable
dermal and subcuticular placement. The remaining
incisions are closed in the same fashion. Surgical dress­
ings and a soft compression bra are applied. Fig. 9.16
illustrates a patient having a central mound reduction
mammaplasty using an inverted-T pattern.
possible damage to the horizontal septum. Sometimes
this septum and intercostal vessels can be visualized
and protected. The excision should always be directed
toward the inframammary fold. An inferior wedge is
excised extending from the inferomedial to inferolateral
breast. The lateral resection can be more aggressive
because the vascularity to the nipple areolar complex is
based on the chest wall perforators. The parenchymal
resection extends to the level of the subcutaneous fat.
The subdermal plexus is preserved and protected. This
dissection is sometimes performed using sharp dissec­
tion techniques to avoid thermal injury. The wound is
irrigated, and hemostasis is ensured. A temporary tri­
furcation suture is placed, and the remaining incisions
Fig. 9.15  Central mound technique popularized by Hester. (Redrawn from Hester TR Jr, Bostwick J III, Miller L. Breast reduction utilizing the maximally vascularized central
pedicle. Plast Reconstr Surg. 1985;76:890–900.)
Closure of horizontal limb from
periphery towards center to eliminate
dog ears
Excision of excess skin from vertical
limb and nipple placement
De-epithelialization
Superior
skin flap
Lateral
skin flap
Medial
skin flap
Central
breast pedicle
Tissue to be
resected
Temporary
closure of
vertical limb
Measurement
and excision of
medial and
lateral dog ears

153
Treatment/surgical technique
A
B
C
D
E
F
Fig. 9.16  (A) Preoperative image of a patient scheduled for reduction mammaplasty using an inverted-T and a central mound. (B) Inverted-T markings with measurements.
(C) Central mound markings. (D) Central mound de-epithelialized. (E) Central mound created with elevated skin flaps. (F) Central mound with lateral excision.
Continued

154
SECTION I
CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
Patients that present with a mild to moderate degree
of radiation damage are usually considered for reduc­
tion mammaplasty when indicated; however, patients
with severe radiation damage are usually discouraged
from proceeding because of the increased likelihood of
complications. Tobacco use and poorly-controlled dia­
betes mellitus should be considered absolute contrain­
dications for reduction mammaplasty, regardless of the
degree of radiation damage. Specific maneuvers for
reduction in this setting include designing skin flaps
with shorter, wider, and broader pedicles. Undermining
of the breast parenchyma is usually avoided in favor of
wedge resections. Pedicle selection should be based on
the previous incision location. If the previous lumpec­
tomy was performed in the lower pole of the breast,
then an inferior pedicle should not be used in the breast
reduction. The pedicle should be remote from the
lumpectomy site. Breast amputation techniques with
free nipple grafting are also considered for these patients.
Special circumstances
Reduction mammaplasty and radiation therapy
The management of localized breast cancer is often per­
formed with lumpectomy and postoperative radiation
therapy. This is sometimes performed in the setting of
moderate to severe mammary hypertrophy. Performing
a reduction mammaplasty following radiation therapy
can pose additional challenges because of the soft tissue
changes following radiation.30 Complications such as
delayed healing, fat necrosis, incisional dehiscence, and
nipple necrosis may be more common because of dimin­
ished fibroblast activity, decreased soft-tissue elasticity,
fat atrophy, and changes to the microcirculation. Modi­
fication in patient selection and surgical technique are
therefore necessary to minimize the occurrence of these
adverse events.
G
H
I
(G) The inferior and lateral excisions are depicted. (H) Immediate
closure following central mound reduction mammoplasty. (I) A 1-year postoperative
photograph following central mound reduction mammoplasty.
Fig. 9.16, cont’d

155
Special circumstances
Fig. 9.17 illustrates a patient following medial pedicle
reduction mammaplasty using an inverted-T pattern.
Outcomes following reduction mammaplasty in the
setting of prior radiation are mixed, but all demonstrate
increased complications compared with the non-
radiated patients. In the author’s series of 12 patients,
mean age was 49.5 years and the mean BMI was 29.
Most women were a D to a DD cup. There was one
smoker in the cohort and 11 non-smokers. The mean
time from completion of radiation therapy and reduc­
tion mammaplasty was 2.5 years. All women had an
inverted-T pattern using a variety of pedicles that
included the inferior, medial, central mound, superome­
dial, superolateral, and McKissock. Mean resection
weight was 623 g (range, 141–1139 g). Minor complica­
tions included delayed healing at the trifurcation junc­
tion in three patients, infection in one patient, and breast
skin necrosis in one patient. All were managed with
local wound care. Major complications occurred in one
patient and included infection, delayed healing, as well
as skin and fat necrosis. This patient required surgical
debridement and a latissimus dorsi flap.
Reduction mammaplasty and breast asymmetry
Breast asymmetry can manifest in a variety of ways in
women with mammary hypertrophy and includes
unilateral or bilateral enlargement, nipple areolar asym­
metry, asymmetries in the breast footprint, or following
breast biopsy or excision procedures. Reduction mam­
maplasty in women with breast asymmetry is managed
using a combination of variables including measuring
the differences, assessing the contour and position of the
nipple areolar complex, planning the correction, and
differentially excising skin and parenchyma. This is
commonly performed using the inverted-T skin pattern
with transposition of the nipple areolar complex on a
vascularized pedicle or as a graft.
One of the more challenging asymmetry situations to
manage is when the breast footprint dramatically differ­
ent. A patient with breast asymmetry due to a significant
difference in the position of the inframammary fold is
shown in Fig. 9.18. On examination, the distance from
the sternal notch to nipple areolar complex was similar
at 30 and 32 cm; however, there was a 5 cm difference
in the position of the inframammary fold. This made
fitting into a brassiere difficult and uncomfortable. Cor­
rection of this type of deformity is facilitated using the
inverted-T technique because the right and left patterns
can be delineated to accommodate the difference. On
the right breast, the horizontal limb of the inverted-T
pattern was positioned 5 cm above the inframammary
fold. Following the glandular resection, the soft tissues
between the inframammary fold and the incisional edge
are defatted and the skin flap is repositioned on the
chest wall such that the cut edge will form the new
inframammary fold. Following parenchymal rearrange­
ment and temporary skin closure, the patient is sat up
to approximately 45° to assess symmetry.
The management of parenchymal and nipple areolar
complex asymmetry is simplified using an inverted-T
pattern. With parenchymal asymmetry, differences in
shape and contour are analyzed. Most patients will be
larger on one side versus the other. With severe
mammary hypertrophy, pedicle selection is based on
length and arc of rotation. Medial pedicles are usually
selected because of their relatively short length and
favorable arc of rotation. However, inferior pedicles are
selected when the nipple areolar complex is at the lowest
point of the breast because its short length will minimize
the bottoming out phenomena. Parenchymal resection
is performed systematically but focused on the inferior
and lateral aspects of the breast. The specimens are
accurately weighed for both breasts. Adjustments are
made based on the visual assessment of breast contour
and symmetry as well as the difference in weight. When
there are asymmetries of the nipple areolar complex,
adjustments are made by equalizing the distance from
the sternal notch to the desired position. The breast
meridian is delineated based on the width of the breast
and desired location of the nipple areolar complex.
Symmetry is confirmed by ensuring equal distance from
the midsternum to the desired nipple areolar complex.
Secondary reduction mammaplasty
Some patients following reduction mammaplasty
may require a second reduction mammaplasty, usually
because of weight gain.31 Secondary reduction mam­
maplasty can pose challenges because of the scars, dis­
ruption of the primary blood supply, and uncertainty
regarding the previous reduction mammaplasty tech­
nique. The primary concern with secondary reduction
mammaplasty is nipple areolar necrosis and fat necrosis.
Questions regarding whether it is safe to use the same
pedicle or another pedicle as well as the optimal timing
for secondary reduction have generated discussion.
Many surgeons have opined that both options are viable
because of the revascularization of the breast paren­
chyma, skin, and the nipple areolar complex. However,
the predictability of the revascularization pattern is
compromised. It is therefore important to have an
understanding of the normal, and to some extent the
reconfigured, vascularity of the breast. It is also impor­
tant to ensure that adequate time has elapsed before
embarking on the secondary procedure.

Fig. 9.17  (A) Preoperative photograph of a woman with mammary hypertrophy and
right breast radiation. (B) Inverted-T markings and breast measurements. (C) A
3-year postoperative image following reduction mammoplasty. (D) Left lateral view.
(E) Right lateral view.
A
B
C
D
E

157
Postoperative care
event of no blood flow to the nipple areolar complex,
free graft techniques are recommended.
Postoperative care
The postoperative care following reduction mamma­
plasty using the inverted-T pattern is routine. Immedi­
ately following completion of the procedure, the
incisions are infiltrated with a longer acting local anes­
thetic. Steri-Strips, Xeroform strips, dry gauze, and a
clear adhesive are applied. The nipple areolar complex
is visible through the clear adhesive. A chlorhexidine
patch is placed over the drain site until the drain is
removed. A soft compressive surgical brassiere is
applied making sure that excessive pressure is avoided.
In the event that the nipple areolar complex becomes
mottled or congested, it is recommended that sutures be
removed and the patient return to the operating room
for exploration. Patients are usually discharged home
on the day of surgery with narcotics and a few days of
oral antibiotics.
Perhaps the safest method for secondary reduction
mammaplasty would be liposuction. This technique can
be safely performed without any detailed knowledge of
the vascularity. Although effective for volume reduc­
tion, there may be minimal effect in skin envelope
change. Some degree of skin tightening and contracture
may occur, but this is unpredictable. A second option
would be a wedge excision of the previous scars and
underlying parenchyma. Parenchymal undermining is
avoided; therefore, there is minimal disruption of the
underlying vascularity to the nipple areolar complex.
When the surgeon has knowledge of the prior type of
pedicle technique, then the reduction can proceed using
that same pedicle with greater certainty that the vascu­
larity will be maintained. However, a new pedicle can
also be considered. In these situations, it may be prudent
to use a dermoparenchymal pedicle and incorporate
the dominant intercostal perforators that have been
described. In the event that there are questions regard­
ing the tissue or nipple areolar complex perfusion, fluo­
rescent angiography techniques can be used. In the
Fig. 9.18  (A) Preoperative photograph of a woman with breast asymmetry. (B) Footprint
asymmetry is noted with discrepancy of the right inframammary fold. (C) A 1-year
postoperative photograph following correction of asymmetry and reduction mammaplasty.
A
B
C

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CHAPTER 9 • Reduction mammaplasty with inverted-T techniques
The patients usually return to the office on either
postoperative day 1 or 2 to remove the dressings and
usually to remove the drain. It is unusual to require
prolonged drain care unless the output is unusually
high, exceeding 50 cc/24 h, without a progressively
diminishing output. The patients are permitted to
shower 24 h following drain removal or on postopera­
tive day 3 if the drain is still in place. The patients are
instructed to wear the soft bra continuously and to
avoid wearing any underwired bra for 2 months. When
everything is proceeding as expected, patients are
usually seen 7–10 days later for re-evaluation. In the
event that there is any incisional dehiscence or small
ulceration, local wound care measures are implemented
using a silver sulfadiazine ointment. Patients are
instructed to avoid strenuous activities such as heavy
lifting or running for 1 month. Subsequent follow-up
appointments are scheduled for 6 weeks and 6 months.
All patients are instructed to obtain a mammogram 6
months following the operation, as this will be the new
baseline for future mammograms.
Complications
The complications following mastectomy with the
inverted-T technique have been discussed throughout
the chapter. They include, but are not limited to, bleed­
ing; infection; scar; asymmetry; hematoma; seroma;
delayed healing; nipple areolar necrosis; T-junction
necrosis/delayed healing; inability to breast-feed; loss
of nipple sensitivity; fat necrosis; contour abnormality;
asymmetry; and further surgery.32 Despite these untow­
ard events, reduction mammaplasty remains an opera­
tion that is commonly performed with high patient
satisfaction. Complications rates vary and range from
10% to 20%. Complications have been correlated with
increasing breast size and volume of resection. Figs.
9.19–9.23 illustrate some of the common complications
following reduction mammaplasty.
Conclusion
The inverted-T method has proven to be a diverse and
versatile method for achieving excellent outcomes with
reduction mammaplasty. Its diversity is exemplified by
the variety of orientations that the pedicles can assume.
Outcomes have been consistent and reliable for a wide
variety of breast shapes, volumes, and contours. The
inverted-T has a strong safety profile with a complica­
tion profile that is similar to all methods of performing
reduction mammaplasty. It is easy to teach and to learn
and should be in the armamentarium of all plastic
surgeons.
Fig. 9.19  Delayed healing of the nipple areolar complex.
Fig. 9.20  Depigmentation of the nipple areolar complex.
Fig. 9.21  Mammographic evidence of fat necrosis following reduction
mammaplasty.

159
Conclusion
Fig. 9.22  Right breast hematoma following reduction mammaplasty immediately
postoperative.
Fig. 9.23  Delayed healing at the T-junction.
5. Wuringer E, Mader N, Posch E, et al. Nerves and vessels supplying
ligamentous suspension of the mammary gland. Plast Reconstr Surg.
1998;101:1486–1493. This cadaveric study of 28 breasts demonstrated two
structures, the fibrous sling and the vascular and nervous membranes
attached to it. These were consistent anatomic findings and determined to
be the principal source of vascularity and innervation to the nipple areolar
complex.
7. Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the
nipple-areola complex: an anatomic study. Plast Reconstr Surg.
2000;105:905–909. This cadaveric study of 28 female breasts demonstrated
that the lateral and anterior cutaneous branches of the 3rd, 4th, and 5th
intercostal nerves innervated the nipple areolar complex. The anterior
cutaneous branches coursed superficially within the subcutaneous tissue
terminating at the medial areolar border.
15. Nahabedian MY, McGibbon BM, Manson PN. Medial pedicle
reduction mammaplasty for severe mammary hypertrophy. Plast
Reconstr Surg. 2000;105:896–904. The use of a medial pedicle for severe
mammary hypertrophy was studied in 23 women. The medial pedicle
successfully transposed the nipple areola complex in 44 of 45 breasts
(98%). Mean change in nipple position was 17.1 cm, and mean weight of
tissue removed was 1604 g per breast.
21. Mofid MM, Dellon AL, Elias JJ, et al. Quantitation of breast
sensibility following reduction mammaplasty: a comparison of
inferior and medial pedicle techniques. Plast Reconstr Surg.
2002;109:2283–2288. A total of 34 women following inferior and medial
pedicle reduction mammaplasty were studied using computer-assisted
neurosensory testing to generate normal breast sensation data and to
compare sensory outcomes between the two pedicles. No significant
differences in postoperative sensory outcomes were demonstrated. In
addition, the amount of breast tissue removed did not correlate with
postoperative sensory outcomes.
26. Davison SP, Mesbahi AN, Ducic I, et al. The versatility of the
superomedial pedicle with various skin reduction patterns. Plast
Reconstr Surg. 2007;120:1466–1476. This study reviewed 279 breast
reductions using the superomedial pedicle. No patient had nipple loss, and
the overall complication rate was 18%. The authors concluded that the
superomedial dermoglandular pedicle is a safe and reliable technique for
reduction mammaplasty.
28. Altuntas ZK, Kamburoglu HO, Yavuz N, et al. Long-term changes
in nipple-areolar complex position and inferior pole length in
superomedial pedicle inverted T scar reduction mammaplasty.
Aesthetic Plast Surg. 2015;39:325–330. This retrospective study reviewed
48 women following superomedial reduction mammaplasty. The authors
demonstrated that the new nipple areolar complex position descends over
time. The authors advocate that the NAC be placed 1.5–1.75 cm below the
most projected area of the breast after final shaping so that in the long
term, the nipple areolar complex would be at the proper position.
30. Spear SL, Rao S, Patel KM, et al. Reduction mammaplasty and
mastopexy in previously irradiated breasts. Aesthet Surg J.
2014;34:74–78. The authors review their experience with 12 reduction
mammaplasty operations in patients that had been previously radiated.
Average specimen weight was 623 g. Four patients (22%) experienced
five minor complications, and one patient had a major complication
requiring flap reconstruction. Proper patient selection is critical
when considering reduction mammaplasty in previously radiated
patients.
32. Cunningham BL, Gear AJ, Kerrigan CL, et al. Analysis of breast
reduction complications derived from the BRAVO study. Plast
Reconstr Surg. 2005;115:1597–1604. Data from 179 patients was
reviewed from the Breast Reduction Assessment: Value and Outcomes
(BRAVO) study. The overall complication rate was 43% (77 patients).
Conclusions included resection weight correlated with increased risk of
complications; delayed healing correlated with resection weight and
inversely with increasing age and anesthesia times; vertical incisions may
be associated with higher complications; and complications had no
negative effect on improvement in Short Form-36.
Access the complete reference list online at

159.e1
References
References
1. Goldwyn RM. Plastic and Reconstructive Surgery of the Breast. Boston:
Little, Brown and Company; 1976.
2. Wise RJ. A preliminary report on a method of planning the
mammaplasty. Plast Reconstr Surg. 1956;17:367–375.
3. Wise RJ, Gannon JP, Hill JR. Further experience with reduction
mammaplasty. Plast Reconstr Surg. 1963;32:12–20.
4. Nahabedian MY. Scar Wars: optimizing outcomes with reduction
mammaplasty. Plast Reconstr Surg. 2005;116:2026–2029.
5. Wuringer E, Mader N, Posch E, et al. Nerves and vessels supplying
ligamentous suspension of the mammary gland. Plast Reconstr Surg.
1998;101:1486–1493. This cadaveric study of 28 breasts demonstrated two
structures, the fibrous sling and the vascular and nervous membranes
attached to it. These were consistent anatomic findings and determined to
be the principal source of vascularity and innervation to the nipple areolar
complex.
6. Hamdi M, Van Landuyt K, Tonnard P, et al. Septum-based
mammaplasty: a surgical technique based on Wuringer’s septum
for breast reduction. Plast Reconstr Surg. 2009;123:443–454.
7. Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the
nipple-areola complex: an anatomic study. Plast Reconstr Surg.
2000;105:905–909. This cadaveric study of 28 female breasts demonstrated
that the lateral and anterior cutaneous branches of the 3rd, 4th, and 5th
intercostal nerves innervated the nipple areolar complex. The anterior
cutaneous branches coursed superficially within the subcutaneous tissue
terminating at the medial areolar border.
8. McKissock PK. Reduction mammaplasty with a vertical dermal
flap. Plast Reconstr Surg. 1972;49:245–252.
9. Strombeck JO. Reduction mammoplasty: some observations and
reflections. Aesthetic Plast Surg. 1983;7:249–251.
10. Muller FE. Late results of Strombeck’s mammaplasty: a follow-up
study of 100 patients. Plast Reconstr Surg. 1974;56:664–666.
11. Robbins TH. A reduction mammaplasty with the areola-nipple
based on an inferior dermal pedicle. Plast Reconstr Surg.
1977;59:64–67.
12. Ramon Y, Sharony Z, Moscona RA, et al. Evaluation and
comparison of aesthetic results and patient satisfaction with
bilateral breast reduction using the inferior pedicle and McKissock’s
vertical bipedicle dermal flap techniques. Plast Reconstr Surg.
2000;106:289–297.
13. Georgiade NG, Serafin D, Morris R, et al. Reduction mammaplasty
utilizing an inferior pedicle nipple-areolar flap. Ann Plast Surg.
1979;3:211–218.
14. Courtiss EH, Goldwyn RM. Reduction mammaplasty by the
inferior pedicle technique. Plast Reconstr Surg. 1977;59:500–507.
15. Nahabedian MY, McGibbon BM, Manson PN. Medial pedicle
reduction mammaplasty for severe mammary hypertrophy. Plast
Reconstr Surg. 2000;105:896–904. The use of a medial pedicle for severe
mammary hypertrophy was studied in 23 women. The medial pedicle
successfully transposed the nipple areola complex in 44 of 45 breasts
(98%). Mean change in nipple position was 17.1 cm, and mean weight of
tissue removed was 1604 g per breast.
16. Abramson DL, Pap S, Shifteh S, et al. Improving long-term breast
shape with the medial pedicle Wise pattern breast reduction. Plast
Reconstr Surg. 2005;115:1937–1943.
17. Palmer JH, Taylor GI. The vascular territories of the anterior chest
wall. Br J Plast Surg. 1986;39:287–299.
18. Jaspars JJ, Posma AN, van Immerseel AA, et al. The cutaneous
innervation of the female breast and nipple-areola complex:
implications for surgery. Br J Plast Surg. 1997;50:249–259.
19. Sarhadi NS, Dunn JS, Lee FD, et al. An anatomical study of the
nerve supply of the breast, including the nipple and areola. Br J
Plast Surg. 1996;49:156–164.
20. Nahabedian MY, Mofid MM. Viability and sensation of the
nipple-areolar complex after reduction mammaplasty. Ann Plast
Surg. 2002;49:24–32.
21. Mofid MM, Dellon AL, Elias JJ, et al. Quantitation of breast
sensibility following reduction mammaplasty: a comparison of
inferior and medial pedicle techniques. Plast Reconstr Surg.
2002;109:2283–2288. A total of 34 women following inferior and medial
pedicle reduction mammaplasty were studied using computer-assisted
neurosensory testing to generate normal breast sensation data and to
compare sensory outcomes between the two pedicles. No significant
differences in postoperative sensory outcomes were demonstrated. In
addition, the amount of breast tissue removed did not correlate with
postoperative sensory outcomes.
22. Schreiber JE, Girotto JA, Mofid MM, et al. Comparison study of
nipple-areolar sensation after reduction mammaplasty. Aesthet Surg
J. 2004;24:320–323.
23. Orlando JC, Guthrie RH. The superomedial dermal pedicle for
nipple transposition. Br J Plast Surg. 1975;28:42–45.
24. Hauben DJ. Experience and refinements with the supero-medial
dermal pedicle for nipple-areola transposition in reduction
mammaplasty. Aesthetic Plast Surg. 1984;8:189–194.
25. Finger RE, Vasquez B, Drew GS, et al. Superomedial pedicle
technique of reduction mammaplasty. Plast Reconstr Surg.
1989;83:471–480.
26. Davison SP, Mesbahi AN, Ducic I, et al. The versatility of the
superomedial pedicle with various skin reduction patterns. Plast
Reconstr Surg. 2007;120:1466–1476. This study reviewed 279 breast
reductions using the superomedial pedicle. No patient had nipple loss, and
the overall complication rate was 18%. The authors concluded that the
superomedial dermoglandular pedicle is a safe and reliable technique for
reduction mammaplasty.
27. Lugo LM, Prada M, Kohanzadeh S, et al. Surgical outcomes of
gigantomastia breast reduction superomedial pedicle technique: a
12-year retrospective study. Ann Plast Surg. 2013;70:533–537.
28. Altuntas ZK, Kamburoglu HO, Yavuz N, et al. Long-term changes
in nipple-areolar complex position and inferior pole length in
superomedial pedicle inverted T scar reduction mammaplasty.
Aesthetic Plast Surg. 2015;39:325–330. This retrospective study reviewed
48 women following superomedial reduction mammaplasty. The authors
demonstrated that the new nipple areolar complex position descends over
time. The authors advocate that the NAC be placed 1.5–1.75 cm below the
most projected area of the breast after final shaping so that in the long
term, the nipple areolar complex would be at the proper position.
29. Balch CR. The central mound technique for reduction
mammaplasty. Plast Reconstr Surg. 1981;67:305–311.
30. Spear SL, Rao S, Patel KM, et al. Reduction mammaplasty and
mastopexy in previously irradiated breasts. Aesthet Surg J.
2014;34:74–78. The authors review their experience with 12 reduction
mammaplasty operations in patients that had been previously radiated.
Average specimen weight was 623 g. Four patients (22%) experienced five
minor complications, and one patient had a major complication requiring
flap reconstruction. Proper patient selection is critical when considering
reduction mammaplasty in previously radiated patients.
31. Losee JE, Caldwell EH, Serletti JM. Secondary reduction
mammaplasty: is using a different pedicle safe? Plast Reconstr Surg.
2000;106:1004–1010.
32. Cunningham BL, Gear AJ, Kerrigan CL, et al. Analysis of breast
reduction complications derived from the BRAVO study. Plast
Reconstr Surg. 2005;115:1597–1604. Data from 179 patients was
reviewed from the Breast Reduction Assessment: Value and Outcomes
(BRAVO) study. The overall complication rate was 43% (77 patients).
Conclusions included resection weight correlated with increased risk of
complications; delayed healing correlated with resection weight and
inversely with increasing age and anesthesia times; vertical incisions may
be associated with higher complications; and complications had no
negative effect on improvement in Short Form-36.

SECTION I • Aesthetic Breast Surgery
10 
Reduction mammaplasty with short
scar techniques
Frank Lista, Ryan E. Austin, and Jamil Ahmad
SYNOPSIS
■ Reduction mammaplasty is one of the most commonly performed
plastic surgery procedures.
■ Short scar techniques aim to improve symptomatic mammary
hypertrophy while enhancing the long-term shape of the breasts with
minimal scarring.
■ Commonly described short scar techniques include periareolar scar,
short scar periareolar inferior pedicle reduction (SPAIR), vertical scar,
L-short scar, and no vertical (horizontal only) scar.
Access the Historical Perspective section online at

Introduction
Reduction mammaplasty continues to be one of the
most commonly performed procedures in plastic
surgery. In 2014, the American Society for Aesthetic
Plastic Surgery reported that over 114 000 breast reduc­
tions were performed, and these figures remain rela­
tively constant year-to-year.1 The goals of reduction
mammaplasty are three-fold: (i) improvement in the
physical symptoms associated with mammary hyper­
trophy, (ii) improvement in the appearance of the breast,
and (iii) long-lasting results. However, traditional
reduction mammaplasty techniques (i.e., inverted-T or
Wise pattern scar) add significant scar burden to the
breast.
Short scar reduction mammaplasty techniques were
developed to improve long-term projection of the
breasts while minimizing the scar burden associated
with other breast reduction techniques. In recent years,
short scar reduction techniques have become increas­
ingly popular, as reflected in the surveys of board-
certified plastic surgeons from the American Society for
Aesthetic Plastic Surgery (2002),2 the American Society
of Plastic Surgeons (2006),3 and the Canadian Society of
Plastic Surgeons (2008).4 As more plastic surgeons are
trained in the use of short scar techniques, adoption of
such procedures into clinical practice will likely continue
to grow.
Since 1989, we have exclusively performed our modi­
fied vertical scar reduction mammoplasty technique for
patients requiring breast reduction. As our practice
demographic evolved, we saw younger women pre­
senting for reduction mammaplasty who were not only
interested in relief of their symptoms secondary to
mammary hypertrophy, but were also concerned with
the amount of scarring that resulted from the procedure
and the long-term appearance of their breasts.
Many variations of short scar reduction mammaplasty
techniques have been described. This chapter will
present an overview of some of the commonly described
short scar techniques, with a focus on our vertical scar
reduction mammaplasty technique.
Key points
■ Patients presenting with ≥2 symptoms of mammary
hypertrophy (upper back, neck, shoulder, or arm
pain; arm numbness; rashes; and bra strap grooves)
are more likely to significantly improve following
reduction mammoplasty.
■ Postoperative breast size will likely remain larger
using short scar techniques in comparison to
  Access video content for this chapter online at expertconsult.com

161
Basic science/disease process
pedicle, the blood supply coursed through the pedicle
in a superficial plane. They concluded that thinning
of the superficial aspect of the superomedial pedicle
could lead to vascular compromise or denervation
of the NAC, and instead recommended resection be
done from the deep surface or the base of the pedicle
if needed.
Based on these studies, we believe that a superior
pedicle may have either an axial or random blood
supply while a superomedial pedicle is more likely to
have an axial blood supply, which further supports the
safety of the partial thickness superior or superomedial
pedicle design that we use in our technique.
Reducing and reshaping the breast
The goals of reduction mammaplasty procedures
include the ability to effectively reduce breast size to
achieve symptomatic relief, while transposing the NAC
to a more aesthetically pleasing position on the breast
and reshaping the remaining breast parenchyma. One
common criticism of vertical scar techniques is that at
the completion of the procedure, the breast mound has
a distorted appearance with characteristic flattening of
the inferior pole and exaggerated superior pole fullness.
However, in the early postoperative period, the breast
settles into the shape that resembles the long-term
appearance.55–57
Three-dimensional imaging of breasts following
vertical scar reduction mammaplasty has given us a
better understanding of how the breast changes over
time. Eder et al.55 showed that edema following vertical
scar reduction mammaplasty is resolved by 3 months
postoperatively, and that further contour changes in the
breast are complete by 9 months postoperatively. In
2008 we reported our results at long-term follow-up,
showing that pseudoptosis does not occur, attesting to
the maintenance of breast shape and projection follow­
ing this procedure (Fig. 10.1).58 We also found that,
compared with preoperative skin markings, the NAC
was located significantly higher (approximately 1.3 cm)
at both early and long-term follow-up (Fig. 10.2).58 We
attribute the superior movement of the NAC to excision
of central and inferior pole breast tissue, which
unweights the remaining breast tissue including the
NAC, allowing for elastic recoil of the superior pole
skin. The excision of the inferior pole parenchyma also
directly helps to prevent pseudoptosis by removing this
weight from the inferior pole. Further, suturing of the
medial and lateral pillars produces coning of the breast,
which not only pushes the NAC superiorly but also
redistributes skin laxity in the breast to avoid inferior
displacement of the NAC.58 At 4 years, the distance from
inverted-T scar techniques, and may be unsuitable
for patients who desire a small postoperative breast
size but have significant mammary hypertrophy.
■ A higher rate of complication has consistently been
reported in active smokers and obese individuals.
Consideration must be given before performing an
elective operation on these higher-risk patients.
■ Markings for vertical scar reduction mammaplasty,
particularly the new position of the nipple areolar
complex (NAC), are different from inverted-T scar
reduction mammaplasty techniques.
Basic science/disease process
Blood supply of the nipple areolar complex
The most critical aspect of repositioning the NAC is
ensuring adequate blood supply. While nearly any
pedicle can and has been employed in short scar reduc­
tion techniques, the two most commonly utilized pedi­
cles are superior and superomedial. A closer study of
the blood supply to the NAC provides a better under­
standing of why the selection of a superior or supero­
medial pedicle provides a reliable blood supply for
transposition of the NAC.
Since Manchot (1889)51 first described the blood
supply to the breast, many varying observations of the
vascular anatomy have been made. More recently, van
Deventer52 performed anatomical studies on 15 female
cadavers in an attempt to further clarify the blood
supply to the NAC. This study found that in all breasts,
the NAC received a blood supply medially or superiorly
from one or more branches of the internal thoracic
artery, most commonly the third (47.5%) or second
(25.0%) intercostal perforators.52 In 13 of 27 breasts, the
NAC did not receive any blood supply from superiorly.
Contributions from the lateral thoracic artery, posterior
intercostal arteries, and axillary artery were variable;
however, there were abundant anastomoses between
these varying blood supplies around the NAC. From
this study, van Deventer et al.53 concluded that the NAC
generally has a dual blood supply, inferomedially from
the internal thoracic intercostal artery system and
superolaterally from the lateral thoracic artery and other
minor contributors, with the most reliable blood supply
arising from the internal thoracic artery.
Michelle le Roux et al.54 examining the neurovascular
anatomy in 11 female cadaveric breasts reported that
the arterial supply to the superomedial pedicle origi­
nated from a single dominant vessel while the venous
drainage was through an extensive branching network.
Along with intercostal nerve branches innervating the

161.e1
Historical perspective
Historical perspective
Short scar reduction mammaplasty techniques have
recently seen resurgence in popularity in the plastic
surgery community. However, many of the techniques
in use today are actually refinements or modifications
of techniques developed throughout the 20th century. An
entire chapter could be written on the history of reduc­
tion mammaplasty, and the technical nuances and varia­
tions. Below, we present an overview of some of the
major contributions to short scar reduction mamma­
plasty over the past century.
Periareolar scar
Searching for a way to perform a reduction mamma­
plasty without the introduction of visible scars onto the
skin of the breast, Andrews et al.5 (1975) first described
a technique that camouflaged the incision at the junc­
tion of the breast skin and pigmented areola. Since then,
multiple authors have described techniques for reduc­
ing, shaping, and anchoring the breast parenchyma to
achieve an aesthetic breast shape.6–10
Unfortunately, one of the major problems associated
with periareolar scar reduction techniques remained the
tendency for the areola to widen postoperatively. In
response, Peled et al. (1985)11 described a purse-string
suture for closure of the areola, which was quickly fol­
lowed by Benelli’s “round-block” technique, which
utilized a running non-absorbable suture around the
areola to create a dense scar layer and thus prevent
areolar widening (1987).8 Modifications of this technique
are still used to this day in periareolar reduction mam­
maplasty and mastopexy.12
Another problem of periareolar scar techniques was
the tendency to develop postoperative ptosis. To address
this, Bustos (1990)9 described his use of a silicone sheet to
act as an internal support layer for the breast parenchyma.
Not only did this allow for offloading of tension from
the incision, but also minimized postoperative ptosis by
reducing the weight of the breast parenchyma from the
inferior pole of the breast. However, concerns were raised
regarding artifacts from the permanent silicone sheet
that were seen on mammography.13 Góes modified this
concept of the “internal brassier” and advocated use of
a partially absorbable mesh to prevent late ptosis,14 later
demonstrating the safety and efficacy of this technique.15
Short scar periareolar inferior
pedicle reduction
The SPAIR technique was described by Hammond.16,17
Combining concepts of the periareolar and vertical scar
skin reductions with an inferior dermoglandular pedicle,
this technique was developed to make short scar
reduction mammaplasty more appealing to surgeons
unfamiliar with the superior dermoglandular pedicle
and the typical immediate postoperative, on-table
appearance following vertical scar reduction mamma­
plasty.16 In conjunction with the SPAIR technique,
Hammond et al.12 developed a novel interlocking peri­
areolar suture technique, which has helped manage skin
tension in periareolar closure (see Video 10.1
).18
L-short scar
In 1924, Holländer described an inferolateral oblique
incision that allowed preservation of the medial portion
of the inframammary fold.19 In subsequent years, several
authors described laterally based L-shaped incisions
that prevent the introduction of scars to the visible
décolletage region of the female chest.20,21
Meyer and Kesselring (1971)22 were the first to describe
the modern L-short scar, with the horizontal limb of
the excision “hidden” by placing it at the level of the
new inframammary fold. Other techniques such as Reg­
nault’s B-mammaplasty,23 Maillard’s Z-mammaplasty,24
Lassus’ “all-season” mammaplasty,25 and Gasperoni’s
J-mammaplasty26 have slight variations in the design of
the skin pattern; however, they all result in an L-shaped
or limited T-shaped scar.27 Most recently, Chiari Jr. has
continued to describe his use of and experience with the
L short scar technique.28–30
No vertical (horizontal only) scar
The no vertical scar technique was first described by
Passot (1925),31 though, in subsequent years, several
authors described a similar approach with the use of a
free nipple graft.32–34 Ribeiro (1975)35 was the first to
describe transposition of the NAC on a dermoglandular
pedicle in association with the no vertical scar technique.
Little was written on the technique until it was resur­
rected in the 1990s by Yousif et al.,36 and, more recently,
Lalonde et al.37
Vertical scar
Reduction mammaplasty finishing with a vertical scar
was first described by Arie in 1957.38 However, this tech­
nique did not gain popularity because the vertical scar
often extended below the inframammary crease leaving
an unsightly scar on the chest wall. Years later, Lassus
(1969)39–41 and Lejour (1994)42–44 renewed interest in verti­
cal scar techniques and are responsible for much of the
pioneering work. In 1999, Hall-Findlay45–48 described a
modification of Lejour’s technique that has since become
the most commonly performed short scar breast reduc­
tion technique. In 2006, we first described our technique
for vertical scar reduction mammaplasty and have since
made several modifications (Table 10.1).49,50

161.e2
SECTION I
CHAPTER 10 • Reduction mammaplasty with short scar techniques
Table 10.1  Comparison of different techniques for vertical scar reduction mammaplasty
Lassus
Lejour
Hall-Findlay
Lista
Skin markings
Elliptical pattern
Mosque dome pattern,
rounded inferiorly
Mosque dome pattern,
rounded inferiorly
Mosque dome pattern,
pointed inferiorly
Pedicle selection
Superior (or lateral)
Superior
Superomedial
Superior or superomedial
Pedicle thickness
5 mm
2–3 cm
Full-thickness
2.5 cm
Design of
excision
Central with superior and
inferior extensions
Central with superior,
inferomedial and
inferolateral extensions
Central with superior,
lateral and inferior
extensions
Central with superior,
lateral, and inferior
extensions
Liposuction
Limited
Extensive pre-excision
Limited
Extensive postexcision
Skin undermining
No
Yes
No
No
Pedicle sutured to
chest wall
No
Yes
No
No
Breast shaping
Only skin of medial and
lateral pillars sutured
together
Skin and parenchyma of
medial and lateral pillars
sutured together
Skin and parenchyma of
medial and lateral pillars
sutured together
Skin and parenchyma of
medial and lateral
pillars sutured together
(Adapted from Lista F, Ahmad J. Vertical scar reduction mammaplasty: 15-year experience including a review of 250 consecutive cases. Plast Reconstr Surg. 2006
Jun;117(7):2152–2165.)

162
SECTION I
CHAPTER 10 • Reduction mammaplasty with short scar techniques
Fig. 10.1  Studying the fate of nipple areolar complex (NAC) position and inferior
pole length following vertical scar reduction mammaplasty. (A) The shortest
distance between the inferior edge of the clavicle and planned postoperative
position of the superior border of the NAC. (B) The shortest distance between the
inferior edge of the clavicle and the nipple. (C) The distance between the
inframammary crease and the inferior border of the NAC. (Adapted with permission
from: Ahmad J, Lista F. Vertical scar reduction mammaplasty: the fate of NAC
position and inferior pole length. Plast Reconstr Surg. Apr
2008;121(4):1084–1091.)
A
B
C
the inframammary crease to the inferior border of the
NAC was significantly shorter, confirming that pseudo­
ptosis does not occur after our technique for vertical
scar reduction mammaplasty.58
Diagnosis/patient presentation
Women presenting for reduction mammaplasty are a
diverse patient population, ranging greatly in age, body
habitus, and breast size. Patient goals in seeking reduc­
tion mammaplasty range from purely functional to
purely aesthetic, with most patients falling on a spec­
trum between the two. However, this remains an
important distinction to make preoperatively, given that
in our healthcare system, reduction mammaplasty is an
insurance-covered procedure that requires preapproval
to ensure medical necessity.
With mammary hypertrophy, breast size or body
mass index (BMI) does not correlate with subjective
physical symptoms. Studies have not found a direct
correlation between preoperative breast size and the
severity of preoperative symptoms.59,60 Symptomatic
mammary hypertrophy can have a detrimental effect on
quality-of-life. Studies have shown that the impact of
symptomatic mammary hypertrophy on a woman’s
quality-of-life is similar to individuals living with mod­
erate angina, renal transplant, or osteoarthritis of the
knee.60–62
Kerrigan et al.63 reported an evidence-based defini­
tion of medical necessity for breast reduction in an effort
to establish clear, practical, and objective criteria that
could be applied by physicians to help differentiate
women seeking breast reduction primarily for symptom
relief vs. aesthetic improvement. They identified seven
symptoms specific to breast hypertrophy: upper back
pain, neck pain, shoulder pain, arm pain, arm numb­
ness, rashes, and bra strap grooves. Results of this study
established that women reporting at least two of seven
physical symptoms all or most of the time improved to
a significantly greater extent than women reporting less
than two symptoms all or most of the time. Their data
suggested that women reporting at least one of seven
physical symptoms might also report greater improve­
ment than those with no symptoms all or most of the
time. We have found this definition of medical necessity
useful in evaluating patients that will benefit most from
breast reduction.
Patient selection
Selecting individuals who are suitable candidates for
short scar reduction mammaplasty techniques is impor­
tant, as these procedures are not suitable for all patients
or breast shapes. However, in our experience, short scar
techniques are versatile procedures that can be widely
adapted to the majority of patients seeking reduction
mammaplasty.
The major criticism of short scar reduction mamma­
plasty techniques is that these procedures limit the
amount of breast volume reduction that can be achieved.
However, when thinking about short scar reduction
mammaplasty, we suggest physicians conceptually
separate the two main aspects of the procedure: skin
excision and parenchymal resection. Short scar reduc­
tion techniques, by their nature, limit the amount of skin
excision possible when compared to traditional tech­
niques. Much more skin excision will be possible with
an L-short scar than with a periareolar scar.
However, we believe that the amount of parenchymal
resection possible with short scar techniques, the verti­
cal scar in particular, is greater than previously sug­
gested.64 In our 2006 review of 250 consecutive patients
who underwent vertical scar reduction mammaplasty,
the average weight of tissue excised was 526 g, with the
largest excision exceeding 2000 g.49 The safety and fea­
sibility of larger volume reductions using the vertical
scar,65–68 SPAIR,69 and L-short scar29 techniques have all
been well documented in the literature.

Fig. 10.2  (A) A 38-year-old woman underwent vertical scar reduction by mammaplasty using bilateral superior pedicles. From the right breast, 375 g was excised and
325 g from the left. (B) Preoperatively, the distance from the inferior edge of the clavicle to the level of the planned postoperative position of the superior border of the
nipple aveolar complex (NAC) was 21 cm. (C) At 5 days postoperatively, the distance from the inferior edge of the clavicle to the superior border of the NAC is 20 cm,
resulting in a difference of 1 cm. (D,E,F) At 4 years follow-up, the distance from the inframammary crease to the inferior border of the NAC was unchanged. (From: Ahmad
J, Lista F. Vertical scar reduction mammaplasty: the fate of NAC position and inferior pole length. Plast Reconstr Surg. 2008 Apr;121(4):1084–1091.)
A
B
C
D
E
F

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CHAPTER 10 • Reduction mammaplasty with short scar techniques
While it is possible to perform this technique on
patients with extremely large breasts, it is important for
these patients to realize that their postoperative breast
size will likely remain larger when compared to other
traditional techniques because of the amount of skin
preserved with a vertical scar technique. In patients
with severe mammary hypertrophy desiring a very
small postoperative breast size, this technique is not
suitable. Along with other authors,40,45 we recommend
learning this technique by initially operating on patients
with mild to moderate hypertrophy and good skin
quality. As more experience is gained, one can progress
to performing this technique on patients with greater
degrees of mammary hypertrophy and poorer skin
quality.
Patient characteristics and complications
Patient selection plays an important role in preventing
and minimizing postoperative complications. In our
2006 review of complications in 250 consecutive breast
reductions, there was a statistically significant differ­
ence between groups for BMI, with complications
occurring less frequently in patients of normal weight
(BMI: 18.5–25.0 kg/m2),49 a finding which is supported
by other studies.70–78 Associations between smoking and
complications in reduction mammaplasty have also
been reported, in particular, wound healing/dehiscence
and wound infection.75,77–80 A study by Bikhchandani
et al.81 found that wound related complications occurred
in 35% of smokers and that smokers had a 2–3 times
higher risk of developing a complication.
In our practice, we do not perform this procedure
on patients with a BMI >35.0 kg/m2 or on active
smokers. Patients presenting for breast reduction with
a BMI >35 kg/m2 are advised to lose weight prior to
undergoing this procedure. Smokers are instructed
to quit smoking for at least 4 weeks preoperatively
and 4 weeks postoperatively to decrease their risk for
complications.82,83
Treatment/surgical technique
Vertical scar reduction mammaplasty
We routinely perform vertical scar reduction mamma­
plasty as a day surgery procedure. The average operat­
ing time is less than 70 min.49 Multiple authors have
shown that there is no increased risk of complications
following breast reduction as a day surgery proce­
dure.72,84–87 In addition, Buenaventura et al.86 estimated
between $1500 and $2500 US dollars were saved when
breast reduction surgery was performed as a day surgery
procedure as opposed to requiring inpatient admission,
while Nelson et al.4 reported an estimated cost savings
of $873 Canadian dollars.
The American Society of Plastic Surgeons’ Patient
Safety Committee provides an overview of periopera­
tive steps that should be completed to ensure appropri­
ate patient selection for the ambulatory surgery setting.88
In addition, guidelines for perioperative cardiovascular
evaluation,89,90 prevention of pulmonary complica­
tions91,92 and venous thromboembolism prophylaxis93,94
are also available.
Below is a description of the planning and surgical
technique for our vertical scar reduction mammaplasty.
Skin marking
The patient is marked preoperatively in a standing posi­
tion, with arms relaxed at the sides. The midline of the
chest and the inframammary creases are marked (Fig.
10.3). The central axis of the breast is drawn by extend­
ing a straight line from the midpoint of the clavicle,
typically located 7–8 cm from the midline, through the
nipple to intersect with the inframammary crease. One
hand is inserted behind the breast to the level of the
inframammary crease, and this point is projected ante­
riorly onto the breast and marked (point A). Point A
represents the superior border of the new NAC. This
point is transposed onto the contralateral breast instead
of using the contralateral inframammary crease, as
asymmetry in inframammary crease height can result in
asymmetry of the NAC position postoperatively.
The inferior limit of the planned skin excision is
marked (point B) 2–4 cm above the inframammary
crease, depending on the size of the reduction. This
distance is shorter in smaller reductions (less inframam­
mary crease movement) and longer in larger reductions
(greater inframammary crease movement). The infra­
mammary crease moves superiorly after vertical scar
breast reduction, which accounts for the extension of the
vertical scar onto the chest wall in earlier techniques.
Limiting the inferior end of the vertical scar to a point
above the inframammary crease prevents this problem.
A mosque dome pattern is used in this technique. The
roof of the mosque dome is drawn by extending curved
lines from point A to points C and D, which form the
border of the new NAC. The roof is drawn such that
when points C and D are brought together and the
breast is coned, the roof will form a circle. The vertical
limbs of the mosque dome pattern are drawn by extend­
ing curved lines from point B to points C and D, thus
forming the margins of the planned skin excision. Block­
ing triangles should be drawn at points C and D, toward
the central axis of the breast, to prevent a teardrop

165
Treatment/surgical technique
breast. We achieve shaping of the breast using other
techniques.
Infiltration
A small incision is made superior to point B, between
the vertical limbs, through the skin that will later be
excised. Infiltration is performed just deep to the skin
vertical limb incision lines, as well as within the breast
parenchyma. Each breast is infiltrated with 500 mL of a
solution composed of 1000 mL of Ringer’s lactate solu­
tion, 40 mL of 2% lidocaine, and 1 mL of 1 : 1000 epi­
nephrine. The lateral chest wall is also infiltrated at this
time in preparation for later liposuction.
Selection of the pedicle
In the supine position, a tourniquet is applied to the
breast to keep the skin taut. The NAC is outlined using
a metal washer, 45 mm in diameter, centered over the
nipple. At this point we select the type of pedicle to be
used to transpose the new NAC (Fig. 10.4). If any part
of the new areola lies superior to a line joining the block­
ing triangles (points C and D), a superior dermoglandu­
lar pedicle is used; if all of the new areola lies inferior
to this line, a superomedial dermoglandular pedicle is
used (Fig. 10.5). This rule limits pedicle length and helps
to avoid vascular compromise of the NAC. The superior
pedicle is drawn from the blocking triangles inferiorly,
leaving a 2.5 cm border around the NAC. The supero­
medial pedicle is drawn with a base extending from the
midpoint of the mosque dome roof to the medial block­
ing triangle. A 2.5 cm border is left around the NAC.
The base of the superomedial pedicle should be wide
deformity of the areola. The inferior extent of the skin
resection is marked in the shape of a ‘V’ instead of a ‘U’
as described in other techniques, as we feel that this
allows for easier skin closure and helps to prevent
dog-ear formation at the inferior extent of the vertical
scar.45,49
The areas where liposuction will be performed at the
axillary area and along the lateral chest wall are marked.
The new NAC and pedicle selection and marking are
performed after induction of anesthesia.
Fig. 10.3  Mosque dome skin marking pattern. Point A is at
the level of the anterior projection of the inframammary crease
on the breast. Point A will be the new location of the superior
border of the areola. Point B is the inferior limit of the skin
excision. Point B is 2–4 cm above the inframammary crease
along the central axis of the breast. Blocking triangles are
extended from points C and D. (Adapted with permission from:
Lista F, Ahmad J. Vertical scar reduction mammaplasty: 15-year
experience including a review of 250 consecutive cases. Plast
Reconstr Surg. 2006 Jun;117(7):2152–2165.)
A
A
B
C
C
D
D
Roof
Blocking triangle
Vertical limb
Tips
In cases of asymmetric vertical scar breast reduction (>100 g
difference), Point A on the larger side should be marked
1–2 cm lower than on the smaller side to account for
differential unweighting of the breasts.
Anesthesia and positioning
We perform breast reduction surgery under general
anesthesia. The patient is in the supine position with
both shoulders abducted to 90° to allow for liposuction
of the tail of the breast and lateral chest wall. We do not
sit the patient up during surgery with this technique, as
the breast mound has a distorted appearance with
characteristic flattening of the inferior pole and exagger­
ated superior pole fullness. Instead, we assess the
patient for symmetry of shape and volume in the supine
position. In addition, we do not utilize tacking sutures
from the breast parenchyma to the pectoralis fascia, as
these sutures can cause unwanted tethering of the

166
SECTION I
CHAPTER 10 • Reduction mammaplasty with short scar techniques
De-epithelialization
Leaving the breast tourniquet in place will facilitate
de-epithelialization of the dermoglandular pedicle by
increasing skin tension over the breast. Prior to
de-epithelialization, the NAC and the pedicle are
marked, as explained previously. To prevent damage to
the blood vessels travelling superficial through the
pedicle, it is important to leave the deep dermis intact
when de-epithelializing as opposed to removing the
skin full thickness (Fig. 10.6).
Excision of breast tissue
Surgical excision of skin, fat, and breast parenchyma
is performed en bloc, as outlined by the preoperative
skin markings. Modification of these markings intra­
operatively is not necessary. We find that the following
sequence of steps is helpful in maximizing the effi­
ciency of the excision while ensuring adequate volume
reduction. Begin by incising around the borders of the
dermoglandular pedicle to a depth of 2.5 cm. A der­
moglandular flap containing the NAC is then raised at
a thickness of 2.5 cm. It is important to maintain this
2.5 cm thickness under the NAC so as not to disrupt its
neurovascular supply.
The medial parenchymal pillar is developed by incis­
ing the medial vertical limb straight down through skin,
fat, and breast parenchyma to a level just superficial to
the pectoralis fascia. This will leave move breast paren­
chyma medially, which contributes to more medial
breast fullness and a better final breast shape (Fig. 10.7).
The lateral parenchymal pillar is developed in a manner
similar to the dermoglandular pedicle. An incision
through the lateral vertical limb is carried through skin,
fat, and parenchyma to a depth of 2.5 cm. Dissection is
enough to maintain a pedicle width-to-length ratio of
no less than 1 : 2 to preserve its blood supply but should
be narrow enough to allow easy rotation and insetting
of the NAC into the roof of the mosque dome.
In our experience, the superior pedicle is the most
commonly employed, while the superomedial pedicle
is reserved for cases of mammary hypertrophy with
greater degrees of ptosis when the NAC must be trans­
posed a greater distance. The axial blood supply to the
superomedial pedicle is more reliable in these cases. In
cases where the NAC is situated too medially, a supero­
lateral pedicle may be required to allow for adequate
rotation and insetting.
Fig. 10.4  Approach for pedicle selection. A superior pedicle is used if any part of
the new areola lies superior to a line joining the blocking triangles (A), and a
superomedial pedicle if all of the areola lies inferior to this line (B).
Superior pedicle
Superomedial pedicle
A
B
Fig. 10.5  Mosque dome skin marking pattern with superomedial pedicle.
Tips
If any part of the new areola lies superior to a line joining the
blocking triangles, a superior dermoglandular pedicle is used;
if all of the new areola lies inferior to this line, a superomedial
dermoglandular pedicle is used
Fig. 10.6  Superomedial pedicle de-epithelialized.

167
Treatment/surgical technique
resection of breast tissue, particularly in the superolat­
eral quadrant. While maintaining inferiorly directed
tension on the tissue to be excised, the superior flap is
developed by continuing the 2.5 cm thick flap from
under the dermoglandular pedicle (Fig. 10.9). The dis­
section is completed by curving deep, towards the
pectoralis fascia, at the superior margin of the breast
(Fig. 10.10). After excision is complete, the medial,
superior, and lateral skin flaps should feel even in thick­
ness and smooth (Fig. 10.11).
The tissue between the inferior edge of the vertical
wound and the inframammary crease is thinned to
prevent a dog-ear from forming (Fig. 10.12). The skin is
typically left about 0.5 mm thick, and a layer of fat
should be left on the deep fascia to prevent the skin
tethering down to the fascia. We have not found it
necessary to perform any excisional modification of the
skin in this region to control dog-ear formation.
then carried laterally while maintaining this 2.5 cm
depth. The lateral dissection will not be completed at
this point.
At the inferior extent of the skin excision, the lateral
and medial vertical limbs are joined in the shape of a
‘V’ as previously explained. At this point the lateral and
medial parenchymal dissections can be joined and
carried down to the chest wall. The inferior extent of the
resection specimen should be lifted off the pectoralis
fascia from inferior to superior, taking care to leave a
layer of breast tissue over the pectoralis fascia to prevent
bleeding and postoperative pain. At this time the lateral
flap dissection can be completed by continuing to
develop the 2.5 cm thick flap until the lateral border of
the breast is reached (Fig. 10.8).
Once the parenchyma is incised and freed from its
deeper attachments, inferiorly directed retraction on the
tissue to be excised will allow for a more extensive
Fig. 10.7  Medial breast tissue is left intact preserving medial fullness.
Fig. 10.8  Extent of lateral excision.
Fig. 10.9  Partial thickness superomedial pedicle is 2.5 cm thick.
Fig. 10.10  Extent of superior excision.

168
SECTION I
CHAPTER 10 • Reduction mammaplasty with short scar techniques
Fig. 10.11  Extent of breast tissue excision using a
superior pedicle (A) and superomedial pedicle (B) shown
in sagittal (SS) and transverse sections (TS)
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Fig. 10.12  Excision of breast tissue between the end of the vertical wound and the
inframammary crease to prevent a dog-ear from forming.
Tips
Maintaining a 2.5 cm flap thickness throughout the superior
and lateral flaps is important, as over-resection can lead to
contour irregularities while under-resection can result in an
inadequate volume reduction of the breast, by as much as
100–300 g per side.
Liposuction
Given the utility of liposuction for both breast volume
reduction and contouring of the lateral chest wall, we
now use liposuction in all cases. In particular, liposuc­
tion of the lateral thoracic compartment helps to shape
the lateral breast border.
Liposuction is performed using a 4 mm, three-hole,
blunt cannula for volume reduction of the axillary area
of the breast and contouring of the lateral chest wall.
Liposuction is performed following parenchymal exci­
sion because it is very difficult to accurately assess the
composition of the breast preoperatively by clinical

169
Treatment/surgical technique
Tips
In the vertical scar reduction technique, the tissue of the lateral
chest wall will be advanced onto the lateral breast, so
overaggressive liposuction in this transition area between the
lateral breast and anterior lateral chest wall must be avoided
to prevent contour deformities of the inferolateral breast
postoperatively.
Fig. 10.13  Parenchymal pillar sutures.
Tips
The inferior pillar suture should be placed no closer than 4 cm
from the inferior end of the incision to prevent creating a
dog-ear deformity. Placement of this suture too close to the
inframammary crease will prevent adequate gathering of the
skin later in the procedure. The superior pillar suture should
be no closer than 2 cm from the NAC to avoid deforming the
NAC.
Fig. 10.14  A four-point box stitch is used to gather the skin of the vertical wound.
examination. In excessively fatty breasts, liposuction
can also be performed on the superior half of the breast
for volume reduction. Access to these areas is through
the medial and lateral pillars created by the surgical
excision.
Breast shaping
Shaping of the breast in the vertical scar reduction is
largely achieved by reapproximating the medial and
lateral parenchymal pillars using inverted #1 Vicryl
sutures (Ethicon, Inc., Somerville, NJ) placed through
the breast capsule (Fig. 10.13). These parenchymal pillar
sutures may contribute to improved long-term projection
of the breasts by preventing pseudoptosis or “bottoming
out” of the breast. Typically, two parenchymal pillar
sutures are required. Temporary skin staples are used to
close the vertical wound while suturing the skin.
Wound closure
All layers of wound closure are performed using a 3-0
Monocryl plus suture (Ethicon, Inc., Somerville, NJ). To
begin, the NAC is advanced or rotated into position,
depending on the pedicle orientation, and inset prior to
closure of the vertical scar. If there is any tension during
insetting of the NAC, a small superficial incision through
the dermis may be required extending superiorly from
the blocking triangles to facilitate insetting. The NAC is
inset with inverted deep dermal sutures at the 3, 6, 9,
and 12 o’clock positions and closed using a running
subcuticular suture.
Next, a four-point box suture is used to gather the
skin of the vertical wound (Fig. 10.14). Starting at the
inferior apex of the vertical scar and working towards
the areola, sequential box sutures allow for selective
gathering of the vertical wound, thereby preventing
dog-ear formation and providing control over the length
of the vertical scar. The distance between the box suture
points on the same side of the vertical wound should be
15–25 mm to create a powerful gathering effect, and all
of these sutures should be buried. It is important to
begin each additional four-point box suture immedi­
ately adjacent to the previous one to avoid gaping. Skin
within 2 cm of the areola is not gathered to prevent
distortion of the areola. The remainder of the wound is
closed with simple inverted deep dermal sutures.
After gathering of the skin, there may be gaping of
the horizontal pleats caused by the box sutures along
the vertical wound (Fig. 10.15). These are corrected

170
SECTION I
CHAPTER 10 • Reduction mammaplasty with short scar techniques
using an inverted deep dermal suture. Correction of
horizontal pleats is essential because they do not settle
with time and lead to small horizontal scars within the
larger vertical scar. Skin staples are used along the verti­
cal wound for final closure along the length of the verti­
cal scar (Fig. 10.16).
Using box sutures, the skin can be gathered several
centimeters so that the vertical scar measures 8 cm or
less. However, in some cases a longer vertical scar is
acceptable. Cutaneous wrinkling of the vertical scar
associated with gathering of the skin will disappear by
6 months postoperatively.95
We do not routinely use drains in conjunction with
reduction mammaplasty procedures, a practice sup­
ported by evidence in the literature.96–99 Wrye et al.97
reported that performing reduction mammaplasty
Fig. 10.15  The vertical wound has been gathered using four-point box stitches resulting in gaping of the gathered wound edges. The gaping of the horizontal pleats has
been corrected using inverted deep dermal sutures.
Fig. 10.16  The nipple areolar complex has been inset and skin staples are used
along the vertical wound for final closure.
Tips
Lassus39 measured the distance between the inferior border of
the areola and the inframammary crease in young women with
aesthetically pleasing breasts and found measurements
ranging from 4.5 to 10 cm. Hall-Findlay45 has shown results
where this distance postoperatively was up to 12 cm. Along
with other authors,44 in our experience the length of the vertical
scar does not increase over time after vertical scar reduction
mammaplasty.58 Though some suggest gathering of the
vertical incision does not impact the long-term length of the
vertical scar,100 we feel this is a critical step in our vertical scar
reduction mammaplasty technique.
Dressings and wound care
Each breast is injected with 10 mL of 0.5% bupivacaine
with 1 : 200 000 epinephrine for postoperative pain relief.
The wounds are dressed with paraffin gauze, followed
by dry gauze, and finally by abdominal pads. These are
held in place by a surgical bra.
Postoperative care
Patients should wear a bra at all times for 4 weeks fol­
lowing surgery. On postoperative day 1, they are
instructed to shower and wash their wounds with soap
and water and dress them with dry gauze. Patients are
seen on postoperative day 5, at which point skin staples
are removed and replaced with Steri-Strips (3M, St.
Paul, MN). We typically see patients again at 1 month
and 3 months postoperatively. Patients may return to
their normal level of activity 3 weeks postoperatively
and can begin physically demanding activity 1 month
following surgery.
without the use of closed suction drainage does not
increase complications and is preferred by patients.

171
Outcomes, prognosis, and complications
With younger patients presenting for reduction mam­
maplasty, the ability to breast-feed following surgery
may be an increasing concern. Rates of lactation reported
in the literature are 60–80% for superior pedicle
techniques105–108 and 48–65% for medial pedicle tech­
niques,105,106,109 which are not significantly different from
breast-feeding rates in patients who have not had breast
surgery. In our practice, we emphasize to patients pre­
operatively that breast-feeding is a complex process,
and that even patients who have not have breast reduc­
tion surgery can have difficulty breast-feeding.
Reported complication rates for short scar reduction
mammaplasty procedures are highly variable, ranging
from 3% to 25%.59,66,67,110,111 Commonly reported compli­
cations include superficial wound dehiscence (0–14.3%),
hypertrophic scarring (0–8.8%), seroma (0–17%), hema­
Outcomes, prognosis,
and complications
As previously mentioned, the primary goals of reduc­
tion mammaplasty are three fold: (i) improvement
in the physical symptoms associated with mammary
hypertrophy, (ii) improvement in the appearance of the
breast, and (iii) long-lasting results. Short scar reduction
mammaplasty techniques, vertical scar procedures in
particular, meet all of these criteria (Fig. 10.17). Several
studies have shown that following short scar reduction
procedures, patients have high levels of satisfaction101–103
and significant improvements in both macromastia-
related symptoms and quality-of-life.59,66,104 These results
have been shown to persist over time.58,103
Fig. 10.17  A 19-year-old woman who underwent vertical scar reduction mammaplasty using bilateral superior pedicles. A total of 420 g was excised from the right breast
and 400 g from the left; 50 mL was liposuctioned from the right breast and 100 mL from the left. Results 3 months postoperatively are shown.
A
B
C
D

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CHAPTER 10 • Reduction mammaplasty with short scar techniques
authors42,45 have described using a continuous intrader­
mal suture to gather the skin of the vertical wound, this
may be a source of wound healing problems due to
constriction of the blood supply to the skin edges. To
mitigate these factors, our use of the four-point box
suture gathers the skin of the vertical wound effectively
while causing less skin edge ischemia. Staples provide
further approximation of the skin edges without causing
additional ischemia.
Under-resection
Short scar reduction mammaplasty techniques have
been criticized because it can be difficult, for those
who normally perform inferior pedicle/inverted-T scar
reduction mammaplasty techniques, to assess the ade­
quacy of the reduction.116 At the end of the operation,
there is exaggerated superior pole fullness, inferior pole
flatness, and indrawing of the nipple with which one
must become familiar. Although vertical scar techniques
have a characteristically unusual appearance on the
operating room table at the end of the procedure, they
invariably give a much more aesthetically pleasing
result postoperatively.
While learning this technique, there is a tendency for
under-resection due to inadequate tissue resection later­
ally and superiorly. However, with the straightforward
design of the excision in our technique, increased reduc­
tion can be safely achieved by excising breast tissue
laterally to the anterior axillary line and superiorly deep
to the pedicle, if necessary. Provided that the thickness
of the pedicle and skin flaps is 2.5 cm, it is possible to
resect more tissue without compromising the blood
supply of the pedicle or breast skin.
Secondary procedures
Patients may present for consideration of repeated breast
reduction for many reasons including inadequate breast
volume reduction, breast and NAC asymmetries, and
recurrent symptomatic mammary hypertrophy. These
patients should be assessed in a manner similar to
patients presenting for primary reduction mammaplasty
consultation; however, additional attention must be
given to (i) scars on the breast, (ii) areas of parenchymal
excess, and (iii) the patient’s goals for the procedure.
One of the major concerns regarding repeated breast
reduction is the blood supply of the NAC, particularly
in cases where the original dermoglandular pedicle
design is unknown. To date, there have been 3 reported
cases of complete NAC necrosis, 2 cases of partial necro­
sis, and 2 cases of ischemia/epidermolysis.117 In 2012,
we reported our experience performing a modified
technique for vertical scar breast reduction in 25 patients
toma (0–8.6%), infection (0–8.3%), altered nipple
sensation (0–11%), and fat necrosis (0.8–6.2%) (Table
10.2).49,66,67,110,112,113 Though instances of NAC necrosis
have been reported, we have not experienced any cases
of partial or total nipple necrosis using our vertical scar
technique. Rates of revision surgery following vertical
scar reduction mammaplasty range from 2% to 8%, with
the most common indication being scar revision.67,112,114
Studies comparing complication rates in vertical scar
and inverted-T scar pattern reduction mammaplasty
have not demonstrated consistent results on the relative
rate of complications between these procedures.110,112,115
In 2006, we reviewed 250 consecutive cases of vertical
scar reduction mammaplasty and found our complica­
tion rate was 5.6%.49 The most common complications
were superficial wound dehiscence (2.2%), hematoma
(1.2%), fat necrosis (0.8%), and seroma (0.4%).49 Our
analysis found no statistically significant difference
between groups (i.e., complication vs. no complication)
in regard to pedicle selection (p=0.662) and use of
liposuction (p=0.831).49 Although our review found
no association between complications and amount of
reduction (p=0.107), other studies have reported higher
complication rates with larger resection specimens.78,79
The following are some problems encountered after
vertical scar reduction mammaplasty and how they can
be prevented.
Wound dehiscence
Superficial wound dehiscence was the most frequent
complication in our review of 250 consecutive cases,
occurring in 2.2% of breasts. The area where this occurs
is typically in the middle portion of the vertical wound,
as this is the area under greatest tension. Although other
Table 10.2  Complications following short scar reduction
mammaplasty
Early complications
Late complications
Bleeding/hematoma
Over-resection/under-resection
Seroma
Asymmetry
Infection (cellulitis, abscess)
Contour irregularities
Wound dehiscence
Pseudoptosis
Fat necrosis
Hypertrophic scar
NAC vascular compromise/
necrosis
NAC malposition/shape
Skin vascular compromise/
necrosis
NAC widening (periareolar
scar/SPAIR)
Altered nipple sensation
Permanent suture infection/
extrusion
Inability to lactate
NAC, nipple areolar complex; SPAIR, short scar periareolar inferior pedicle
reduction.

173
Conclusion
mammaplasty to be a versatile technique that can
produce reliable results in most patients. While it is
possible to perform this technique on patients with
large breasts, it must be noted that the postoperative
breast size will likely remain larger in comparison to
other traditional breast reduction techniques. In patients
with significant mammary hypertrophy desiring a small
postoperative breast size, this technique may be unsuit­
able. Overall, vertical scar reduction mammaplasty
results in a more projected breast with a narrower base,
preservation of superomedial breast fullness, minimal
scar burden, and long-lasting breast shape, which are
the sine quibus non of aesthetic breast surgery.
who had undergone previous breast reduction; since
then, we have used this approach in over 40 patients.
To date, we have had no cases of either partial or total
necrosis of the NAC. In our experience, repeated breast
reduction using our modified technique for vertical scar
breast reduction technique is a safe procedure even
when the initial breast reduction technique is
unknown.50,117
In cases of repeated breast reduction, our technique
is similar to that outlined above; however, the following
modifications are used when determining the optimal
pedicle selection:
1. If the NAC is in an ideal position preoperatively:
only a vertically oriented, inferior wedge excision
is performed; or
2. If superior transposition of the NAC is required: a
partial-thickness, superior pedicle with careful
de-epithelialization preserving the deep dermis is
performed (Fig. 10.18).
This strategy for pedicle selection combined with a
vertically oriented, inferior wedge excision limiting the
amount of undermining of breast tissue helps to maintain
blood supply to the remaining breast tissue. Additionally,
liposuction is an important adjunct to achieve volume
reduction while limiting the amount of dissection during
repeated breast reduction and is used in all cases.
Conclusion
In over 20 years experience of more than 3000 patients,
we have found our method of vertical scar reduction
Fig. 10.18  Approach for pedicle selection in repeated breast reduction. (A) If
nipple areolar complex (NAC) is in an adequate position, an inferior wedge
resection with no pedicle is selected. (B) If the NAC is low and requires
transposition, a superior pedicle is used. (Adapted with permission from: Ahmad J,
McIsaac SM, Lista F. Does knowledge of the initial technique affect outcomes after
repeated breast reduction? Plast Reconstr Surg. 2012 Jan;129(1):11–8.)
Ideal NAC position
No pedicle
Low NAC position
Superior pedicle
A
B
12. Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex
suture for control of areolar diameter and shape. Plast Reconstr
Surg. 2007;119(3):804–809.
17. Hammond DC. The short scar periareolar inferior pedicle
reduction (SPAIR) mammaplasty. Semin Plast Surg. 2004;18(3):
231–243.
30. Chiari Júnior A. The L short-scar mammaplasty: a new approach.
Plast Reconstr Surg. 1992;90(2):233–246.
37. Lalonde DH, Lalonde J, French R. The no vertical scar breast
reduction: a minor variation that allows you to remove vertical
scar portion of the inferior pedicle wise pattern T scar. Aesthetic
Plast Surg. 2003;27(5):335–344.
47. Hall-Findlay EJ. Pedicles in vertical breast reduction and
mastopexy. Clin Plast Surg. 2002;29(3):379–391. A succinct review of
various breast reduction techniques and the pedicles that are used to
transpose the NAC. Dr. Hall-Findlay describes in detail her technique for
vertical scar reduction mammaplasty.
49. Lista F, Ahmad J. Vertical scar reduction mammaplasty: 15-year
experience including a review of 250 consecutive cases. Plast
Reconstr Surg. 2006;117(7):2152–2165. We describe our technique for
vertical scar reduction mammaplasty using a superior or medial pedicle.
We performed a review of 250 consecutive patients including an analysis
of complications. Technical considerations are discussed in detail, and a
review of previously described techniques of vertical scar reduction
mammaplasty is included.
53. van Deventer PV, Page BJ, Graewe FR. The safety of pedicles in
breast reduction and mastopexy procedures. Aesthetic Plast Surg.
2008;32(2):307–312.
58. Ahmad J, Lista F. Vertical scar reduction mammaplasty: the fate of
nipple–areola complex position and inferior pole length. Plast
Reconstr Surg. 2008;121(4):1084–1091. We report on the early and
long-term fate of the NAC position and inferior pole length. Compared
with preoperative skin markings, the NAC was located significantly
higher at both early and long-term follow-up. Based on these findings, we
adjusted their skin marking technique so that the superior border of the
NAC is marked at the level of the inframammary crease. We also
observed that at 4 years, the distance from the inframammary crease to
the inferior border of the NAC was significantly shorter, and
pseudoptosis did not occur after vertical scar reduction mammaplasty.
63. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty:
defining medical necessity. Med Decis Making. 2002;22(3):208–217.
An evidence-based definition of the medical necessity for breast reduction
is described in an effort to establish clear, practical, objective, and fair
criteria that could be applied by physicians to help differentiate women
seeking breast reduction for symptom relief versus aesthetic improvement.
117. Ahmad J, McIsaac SM, Lista F. Does knowledge of the initial
technique affect outcomes after repeated breast reduction? Plast
Reconstr Surg. 2012;129(1):11–18. We report our modified technique for
vertical scar reduction mammaplasty used in patients presenting for
repeated breast reduction. This approach was used safely in patients
regardless of whether or not the previous pedicle was known.
Access the complete reference list online at

173.e1
References
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2008;32(2):307–312.

173.e2
SECTION I
CHAPTER 10 • Reduction mammaplasty with short scar techniques
54. Michelle le Roux C, Kiil BJ, Pan W-R, et al. Preserving the
neurovascular supply in the Hall-Findlay superomedial pedicle
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55. Eder M, Klöppel M, Müller D, et al. 3-D analysis of breast
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56. Quan M, Fadl A, Small K, et al. Defining pseudoptosis (bottoming
out) 3 years after short-scar medial pedicle breast reduction.
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57. Small KH, Tepper OM, Unger JG, et al. Re-defining pseudoptosis
from a 3D perspective after short scar-medial pedicle reduction
mammaplasty. J Plast Reconstr Aesthet Surg. 2010;63(2):346–353.
58. Ahmad J, Lista F. Vertical scar reduction mammaplasty: the fate of
nipple–areola complex position and inferior pole length. Plast
Reconstr Surg. 2008;121(4):1084–1091. We report on the early and
long-term fate of the NAC position and inferior pole length. Compared
with preoperative skin markings, the NAC was located significantly
higher at both early and long-term follow-up. Based on these findings, we
adjusted their skin marking technique so that the superior border of the
NAC is marked at the level of the inframammary crease. We also
observed that at 4 years, the distance from the inframammary crease to
the inferior border of the NAC was significantly shorter, and
pseudoptosis did not occur after vertical scar reduction mammaplasty.
59. Spector JA, Kleinerman R, Culliford AT 4th, Karp NS. The vertical
reduction mammaplasty: a prospective analysis of patient
outcomes. Plast Reconstr Surg. 2006;117(2):374–381.
60. Kerrigan CL, Collins ED, Striplin D, et al. The health burden of
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61. Thoma A, Sprague S, Veltri K, et al. A prospective study of
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quality of life and clinical outcomes. Plast Reconstr Surg.
2007;120(1):13–26.
62. Kerrigan CL, Collins ED, Kneeland TS, et al. Measuring health
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63. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty:
defining medical necessity. Med Decis Making. 2002;22(3):208–217.
An evidence-based definition of the medical necessity for breast reduction
is described in an effort to establish clear, practical, objective, and
fair criteria that could be applied by physicians to help differentiate
women seeking breast reduction for symptom relief versus aesthetic
improvement.
64. Hammond DC, Loffredo M. Breast reduction. Plast Reconstr Surg.
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66. Antony AK, Yegiyants SS, Danielson KK, et al. A matched cohort
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67. Neaman KC, Armstrong SD, Mendonca SJ, et al. Vertical reduction
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68. Akyurek M. Contouring the inferior pole of the breast in vertical
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Plast Reconstr Surg. 2011;127(3):1314–1322.
69. Hammond DC, O’Connor EA, Knoll GM. The short-scar
periareolar inferior pedicle reduction technique in severe
mammary hypertrophy. Plast Reconstr Surg. 2015;135(1):
34–40.
70. Nelson JA, Fischer JP, Chung CU, et al. Obesity and early
complications following reduction mammaplasty: an analysis of
4545 patients from the 2005–2011 NSQIP datasets. J Plast Surg
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71. Imahiyerobo TA, Pharmer LA, Swistel AJ, Talmor M. A
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72. Stevens WG, Gear AJL, Stoker DA, et al. Outpatient reduction
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73. O’Grady KF, Thoma A, Dal Cin A. A comparison of complication
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74. Gust MJ, Smetona JT, Persing JS, et al. The impact of body mass
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patients. Aesthet Surg J. 2013;33(8):1140–1147.
75. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a
study of complications following breast reduction. J Plast Reconstr
Aesthet Surg. 2011;64(4):508–514.
76. Villani F, Caviggioli F, Banzatti B, et al. Correlation between
complication rate and perioperative risk-factors in superior pedicle
reduction mammaplasty: our experience in 127 patients. Acta Chir
Plast. 2009;51(3–4):65–68.
77. Manahan MA, Buretta KJ, Chang D, et al. An outcomes analysis of
2142 breast reduction procedures. Ann Plast Surg. 2015;74(3):
289–292.
78. Srinivasaiah N, Iwuchukwu OC, Stanley PRW, et al. Risk factors
for complications following breast reduction: results from a
randomized control trial. Breast J. 2014;20(3):274–278.
79. Robert G, Duhamel A, Alet J-M, et al. Complications of breast
reduction about 715 breasts. Ann Chir Plast Esthet.
2014;59(2):97–102.
80. Lewin R, Goransson M, Elander A, et al. Risk factors for
complications after breast reduction surgery. J Plast Surg Hand
Surg. 2014;48(1):10–14.
81. Bikhchandani J, Varma SK, Henderson HP. Is it justified to refuse
breast reduction to smokers? J Plast Reconstr Aesthet Surg.
2007;60(9):1050–1054.
82. Pluvy I, Garrido I, Pauchot J, et al. Smoking and plastic surgery,
part I. Pathophysiological aspects: update and proposed
recommendations. Ann Chir Plast Esthet. 2015;60(1):e3–e13.
83. Rinker B. The evils of nicotine: an evidence-based guide
to smoking and plastic surgery. Ann Plast Surg. 2013;70(5):
599–605.
84. Short KK, Ringler SL, Bengtson BP, et al. Reduction mammaplasty:
a safe and effective outpatient procedure. Aesthetic Plast Surg.
1996;20(6):513–518.
85. Davies BW, Lewis RD, Pennington GA. Reduction mammaplasty:
a comparison of outpatient and inpatient procedures. Aesthetic
Plast Surg. 1996;20(1):77–80.
86. Buenaventura S, Severinac R, Mullis W, et al. Outpatient reduction
mammaplasty: a review of 338 consecutive cases. Ann Plast Surg.
1996;36(2):162–166.
87. Carpelan A, Kauhanen S, Mattila K, et al. Reduction mammaplasty
as an outpatient procedure: a retrospective analysis of outcome
and success rate. Scand J Surg. 2015;104(2):96–102.
88. Haeck PC, Swanson JA, Iverson RE, et al. Evidence-based patient
safety advisory: patient selection and procedures in ambulatory
surgery. Plast Reconstr Surg. 2009;124(4 suppl):6S–27S.
89. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007
guidelines on perioperative cardiovascular evaluation and care for
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Cardiology/American Heart Association task force on practice
guidelines (writing committee to revise the 2002 guidelines on
perioperative cardiovascular evaluation for noncardiac surgery):
developed in collaboration with the American Society of
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90. Chopra V, Flanders SA, Froehlich JB, et al. Perioperative practice:
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91. Haeck PC, Swanson JA, Iverson RE, Lynch DJ. Evidence-based
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References
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92. Haeck PC, Swanson JA, Iverson RE, Lynch DJ. Evidence-based
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risk factors. Plast Reconstr Surg. 2009;124(4 suppl):57S–67S.
93. Seruya M, Baker SB. MOC-PS(SM) CME article: venous
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94. Venturi ML, Davison SP, Caprini JA. Prevention of venous
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and recommendations. Aesthet Surg J. 2009;29(5):421–428.
95. Tapia A, Blanch A, Salvador J, et al. Evolution of the vertical scar
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96. Vandeweyer E. Breast reduction mammaplasty. Shall we drain?
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97. Wrye SW, Banducci DR, Mackay D, et al. Routine drainage is not
required in reduction mammaplasty. Plast Reconstr Surg.
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98. Kosins AM, Scholz T, Cetinkaya M, Evans GRD. Evidence-based
value of subcutaneous surgical wound drainage: the largest
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99. Stojkovic CA, Smeulders MJC, Van der Horst CM, Khan SM.
Wound drainage after plastic and reconstructive surgery of the
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100. Matthews JLK, Oddone-Paolucci E, Lawson DM, Hall-Findlay EJ.
Vertical scar breast reduction: does gathering the incision matter?
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2014, July 4].
101. Swanson E. Prospective outcome study of 106 cases of vertical
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102. Adham M, Sawan K, Lovelace C, et al. Patient satisfaction with
vertical reduction mammaplasty: part I. Aesthet Surg J.
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103. Bouwer LR, van der Biezen JJ, Spronk CA, van der Lei B. Vertical
scar versus the inverted-T scar reduction mammaplasty: a 10-year
follow-up. J Plast Reconstr Aesthet Surg. 2012;65(10):1298–1304.
104. Thoma A, Ignacy TA, Duku EK, et al. Randomized controlled trial
comparing health-related quality of life in patients undergoing
vertical scar versus inverted T-shaped reduction mammaplasty.
Plast Reconstr Surg. 2013;132(1):48e–60e.
105. Cruz NI, Korchin L. Lactational performance after breast reduction
with different pedicles. Plast Reconstr Surg. 2007;120(1):35–40.
106. Chiummariello S, Cigna E, Buccheri EM, et al. Breastfeeding after
reduction mammaplasty using different techniques. Aesthetic Plast
Surg. 2008;32(2):294–297.
107. Cherchel A, Azzam C, De Mey A. Breastfeeding after vertical
reduction mammaplasty using a superior pedicle. J Plast Reconstr
Aesthet Surg. 2007;60(5):465–470.
108. Kakagia D, Tripsiannis G, Tsoutsos D. Breastfeeding after
reduction mammaplasty: a comparison of 3 techniques. Ann Plast
Surg. 2005;55(4):343–345.
109. Cruz-Korchin N, Korchin L. Breast-feeding after vertical
mammaplasty with medial pedicle. Plast Reconstr Surg. 2004;114(4):
890–894.
110. Zoumaras J, Lawrence J. Inverted-T versus vertical scar breast
reduction: one surgeon’s 5-year experience with consecutive
patients. Aesthet Surg J. 2008;28(5):521–526.
111. Nadeau MH, Gould DJ, Macias LH, et al. Superior pedicle
technique of reduction mammaplasty: a stepwise approach. Aesthet
Surg J. 2015;35(1):94–104.
112. James A, Verheyden C. A retrospective study comparing patient
outcomes of wise pattern-inferior pedicle and vertical pattern-
medial pedicle reduction mammoplasty. Ann Plast Surg.
2011;67(5):481–483.
113. Beer GM, Spicher I, Cierpka KA, Meyer VE. Benefits and pitfalls of
vertical scar breast reduction. Br J Plast Surg. 2004;57(1):12–19.
114. Rinker B. Lowering revision rates in medial pedicle breast
reduction by the selective addition of “inverted-T” technique.
Aesthetic Plast Surg. 2013;37(2):341–348.
115. Cunningham BL, Gear AJL, Kerrigan CL, Collins ED. Analysis of
breast reduction complications derived from the BRAVO study.
Plast Reconstr Surg. 2005;115(6):1597–1604.
116. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast
reduction. Plast Reconstr Surg. 1999;104(3):806–815.
117. Ahmad J, McIsaac SM, Lista F. Does knowledge of the initial
technique affect outcomes after repeated breast reduction? Plast
Reconstr Surg. 2012;129(1):11–18. We report our modified technique for
vertical scar reduction mammaplasty used in patients presenting for
repeated breast reduction. This approach was used safely in patients
regardless of whether or not the previous pedicle was known.

SECTION I • Aesthetic Breast Surgery
11 
Gynecomastia surgery
Charles M. Malata and Kai Yuen Wong
SYNOPSIS
■ Gynecomastia is the benign enlargement of male breast tissue. It is a
common condition and can be associated with significant
psychological morbidity. The mainstay of treatment is surgery.
■ When surgery is indicated, the aim is to restore a normal looking male
chest contour with minimal scarring whilst maintaining the viability of
the nipple areolar complex.
■ A wide range of surgical techniques have been described for
gynecomastia treatment including various forms of liposuction, open
glandular excision, skin reduction, and combinations of these.
■ Liposuction has now become established as the prime modality in the
surgical treatment of gynecomastia, either alone or in combination with
other techniques.
■ This chapter outlines the salient features and principles of the main
surgical techniques. We propose an evidence-based approach to
achieving predictable and safe results. An algorithm to facilitate
surgical success is presented.
Access the Historical Perspective section online at

Introduction
Gynecomastia, or abnormal breast tissue enlargement in
men, is the most common breast pathology amongst
males. It has a reported prevalence of 30–70% depend­
ing on age group,1–3 and the condition can pose a sig­
nificant psychological challenge to the patients.4,5 Most
cases, especially those occurring during adolescence,
are benign and self-limiting. The majority of patients
presenting for surgical treatment have already had a
medical cause excluded by the referring physician or
have not responded to drug therapy. Severe breast
enlargement or lesser degrees of gynecomastia may be
directly referred for surgery on account of severe emo­
tional or psychological distress. The aim of treatment is
restoration of a normal male chest contour while mini­
mizing the evidence of surgery and protecting the nipple
areolar complex.
There is a plethora of described techniques for the
surgical management of enlarged male breasts. In con­
trast there are few reports on an integrated surgical
approach in general and the roles of different treatment
modalities in particular.6–9 Although excisional tech­
niques have traditionally been the accepted standard,
liposuction has now become established as the prime
surgical modality either alone or in combination with
more invasive methods. More recently, other minimally
invasive surgical techniques have been described, but
their roles have yet to be established. Gynecomastia
patients may constitute a challenging group with respect
to satisfaction postoperatively.10 The many surgical
options and their inter-relationship are therefore out­
lined here with a guide to technique selection and
optimization of outcomes.
Basic science
Gynecomastia is thought to primarily result from an
increased estrogen to androgen ratio since estrogens
stimulate breast tissue while androgens antagonize its
effects.16,17 This hormonal imbalance may therefore arise
from an absolute or relative excess of estrogens, or an
absolute decrease of androgen levels or their action
(Table 11.1). Interestingly, a recent review identified 49
  Access video content for this chapter online at expertconsult.com

174.e1
Historical perspective
Historical perspective
The key dates in this timeline are:
■ Seventh century: the first surgical treatment of
gynecomastia dates to Paulus Aegineta (625–690
ad).
■ 1946: modern treatment started with the time-
honored Webster’s technique of a periareolar
approach to open excision.11
■ 1972: Illouz introduces liposuction as a non-invasive
modality for body contouring.12
■ 1983: Teimourian and Perlman describe
gynecomastia treatment with an innovative
combination of open excision and liposuction.13
■ 1992: ultrasonic liposuction for the treatment of
gynecomastia is pioneered by Zocchi.14
■ 1996: the “pull-through” technique is reported by
Morselli as an adjunct to liposuction.15
■ 2003: Fruhstorfer and Malata present the first
comprehensive algorithmic approach to the surgical
management of gynecomastia.6

175
Diagnosis/patient presentation
common presenting complaint in those seeking surgical
treatment.
On physical examination, gynecomastia is usually
bilateral and felt as glandular tissue under the nipple
areolar complex and extends to a variable size in all
directions. It needs to be differentiated from pseudogy­
necomastia or lipomastia, which is adipose tissue
hypertrophy without glandular proliferation. Breast
cancer is uncommon and accounts for less than 1% of
malignancies in men in the UK and USA.26,27 It typically
presents unilaterally and is felt as a hard mass located
outside the nipple areolar complex. As part of the
systems review, physical examination should include
assessment of secondary sexual development and the
thyroid, as well as looking for signs of chronic kidney
or liver disease. When examining the genitalia, it is also
important to look for any testicular masses or atrophy.
Liver enlargement may sometimes be encountered.
Laboratory tests (Box 11.1) are tailored according to
the clinical findings. Extensive work-up is rarely indi­
cated and often does not influence treatment.28 Bio­
chemical assessment includes tests for liver, kidney,
and thyroid function; and serum levels of testosterone,
prolactin, follicle-stimulating hormone, and luteinizing
hormone. Additional tests may be necessary in cases of
recent or symptomatic gynecomastia to rule out tumors.2
For example, serum levels of estrogens, human chori­
onic gonadotrophin (hCG), dehydroepiandrosterone
(DHEA), and urinary 17-ketosteroids.
Routine mammography and breast ultrasonography
with or without biopsy is not routinely recommended
unless breast cancer is suspected29–33 or the patient
presents with unilateral breast enlargement. Similarly,
testicular ultrasonography or abdominal computer
tomography may be performed if a testicular or adrenal
medications reported to be associated with gynecomas­
tia where, in the majority of cases, hormonal imbalance
could not explain the breast enlargement.18
Etiologically gynecomastia can be physiological or
pathological in nature. The former may occur during
three different age groups. In the neonate, gynecomastia
is attributed to high levels of maternal estrogen during
pregnancy. During puberty, up to 65% of boys may have
gynecomastia, but this usually resolves in 75% of cases
within 2 years of onset.19 Gynecomastia is also very
common in older men with a reported prevalence of
72% in the hospitalized male population aged 50–69
years.20 Proposed mechanisms for this include enhanced
peripheral aromatization secondary to increased total
body fat, and decreased levels of androgens associated
with aging.16,21–23 Older men are also more likely to
be taking medications, which may themselves cause
gynecomastia.18
Diagnosis/patient presentation
A thorough history is important to determine the
underlying cause of gynecomastia (Table 11.1) and rule
out breast cancer and other tumors. On the other hand,
it should be noted that around 25% of gynecomastia
cases may be idiopathic.24 Salient points include patient
age, onset and duration of breast enlargement, symp­
toms of associated pain, recent weight change, and a
systems review with particular attention to possible
endocrine and liver abnormalities. Medications and
recreational drug use need to ascertained as they may
cause 10–20% of gynecomastia cases.18,24,25 It is also
important to explore the psychological and social effects
of gynecomastia as social embarrassment is the most
Table 11.1  Classification of the causes of gynecomastia
Idiopathic
Physiological
Neonatal, pubertal, aging
Pathological
Congenital
Klinefelter’s, anorchia, hermaphroditism, androgen resistance syndromes, enzyme defects of testosterone
synthesis, increased peripheral tissue aromatase
Endocrine
Castration, mumps, Cushing’s syndrome, congenital adrenal hyperplasia, adrenocorticotropic hormone
deficiency, hyperthyroidism, hypothyroidism, panhypopituitarism, hyperprolactinemia
Tumors
Testicular (choriocarcinoma, Sertoli and Leydig cell tumors); adrenal (adenoma, carcinoma); pituitary
adenoma; breast carcinoma; tumors that secrete human chorionic gonadotrophin (lung, liver, kidney,
stomach, and lymphopoietic)
Drugs
Hormones (estrogens, androgens, gonadotrophins); anti-androgens (cimetidine, spironolactone, digitalis,
progesterone, cyproterone, flutamide); stimulators of prolactin (phenothiazines, reserpine, hydroxyzine);
drugs of abuse (marijuana, heroin, methadone, amphetamines); anti-tuberculosis drugs (isoniazid,
ethionamide, thiacetazone)
Metabolic
Thyrotoxicosis (altered testosterone/estrogen binding); renal failure (acquired testes failure); cirrhosis
(increased substrate for peripheral aromatization); starvation (same as cirrhosis); alcoholism
Other
Human immunodeficiency virus, chest wall trauma, cystic fibrosis, physiological stress

176
SECTION I
CHAPTER 11 • Gynecomastia surgery
Treatment/surgical technique
Medical management
Most cases of gynecomastia do not require treatment
as they are benign and self-limiting.19,37,38 Weight loss
should be recommended for male patients with pseu­
dogynecomastia in the first instance. Specific treatment
should be directed at addressing any identified underly­
ing cause (see Table 11.1).
Medical therapies essentially focus on correcting
the imbalance of androgens and estrogens.28,39,40 Anti-
estrogens such as tamoxifen are often used as a first-line
medication, including men with prostate cancer41–44 and
persistent pubertal gynecomastia.45–47 Other medications
include testosterone, danazol (gonadotrophin inhibi­
tor), and aromatase inhibitors such as testolactone. The
evidence base for medical therapies is limited by the
difficulty in differentiating treatment effects from spon­
taneous resolution of gynecomastia.48,49 Furthermore,
medications are probably most effective during the
active, proliferative phase of gynecomastia. In patients
with long-standing gynecomastia of over 1 year, medical
treatment is often ineffective as the breast glandular
tissue progresses to irreversible dense fibrosis and hya­
linization.2,24,35,38 Such cases should be considered for
surgical treatment.
Radiation treatment has been used prophylactically
in older men with prostate cancer treated by anti-
androgens.50–52 Conversely, it is not recommended for
the treatment of pubertal gynecomastia due to the
increased lifetime risk of breast cancer, albeit very small.
When treatment is indicated, most patients do not
need a trial of medical therapies and are best managed
with surgery, which is the mainstay modality (see
Table 11.2).
BOX 11.1  Diagnostic evaluation of gynecomastia
• Laboratory tests:
•
Testosterone
•
Estrogen ± β-human chorionic gonadotrophin
•
Prolactin, follicle-stimulating hormone, and luteinizing
hormone
•
Urea and electrolytes
•
Liver function tests
•
Thyroid function tests (thyroxine and thyroid-stimulating
hormone)
•
± Dehydroepiandrosterone or urinary 17-ketosteroids
• Radiological examination:
•
Breast ultrasound scan
•
Mammogram
•
± Abdominal computer tomography scan
•
± Testicular ultrasound scan
• ± Core or fine-needle biopsy
Table 11.2  Simon et al.’s classification of gynecomastia
Breast enlargement
Skin excess
I
Small
No
II
A
Moderate
No
B
Yes
III
Marked
Yes
(Adapted from Simon BE, Hoffman S, Kahn S. Classification and surgical
correction of gynecomastia. Plast Reconstr Surg. 1973;51:48–52.)
BOX 11.2  Indications for gynecomastia surgery
• Persistent enlargement after puberty (>2 years) and exclusion of
medical causes
• Ιnadequate response to medical treatment
• Severe breast enlargement
• Significant asymmetry or unilateral condition
• Severe psychosocial effects or morbidity
• Patient request
• Post massive weight loss
• Specific clinical conditions:
•
Drug induced – prostate cancer treatment
•
Drug induced – anabolic steroid use or cannabis use (as
unlikely to respond to medical therapy or resolve
spontaneously)
mass is suspected based on clinical findings and
investigations.
Patient selection
Various clinical and histological classifications have
been suggested for gynecomastia.6,7,34,35 Simon et al.’s
classification36 is the most practical as it takes into
account not only the size of the breast but also the
amount of redundant skin (Table 11.2). The boundaries
between the categories are, however, not well defined,
leading to subjectivity and interobserver variability.
Therefore, in our practice we classify gynecomastia into
two clinical groups:6 small to moderate size with no or
minimal skin excess (Simon’s grades I and IIA), and
moderate to large size with moderate to marked skin
excess (Simon’s grades IIB and III). This facilitates choice
of treatment modality as will be discussed in the follow­
ing section. The indications for gynecomastia surgery
are summarized in Box 11.2.

177
Treatment/surgical technique
and can be associated with intraoperative conversion to
open excision in up to 39% of cases.54 It can be effective
in soft breasts even if large, but good skin quality is
important for later contraction and avoiding the need
for skin resection. Liposuction allows the achievement
of better breast contours with minimal scarring.
Special liposuction cannulas specifically designed for
the treatment of gynecomastia (Fig. 11.3) have been
successfully used for the treatment of more difficult or
firmer breasts.56,58–61 Cross-tunnel suctioning for larger
breasts, ptotic breasts, and those with excess skin or
well-defined inframammary folds makes SAL more
effective. Such extensive cross-suctioning enables more
consistent contraction of the skin and allows it to redrape
with less waviness and irregularity. The inframammary
crease can be obliterated by sharp dissection62 or by
suction cannulas.61 In our practice we do not employ
special sharp cannulas due to the potential risk of intra-
and postoperative bleeding.
After infiltration, a suction cannula is inserted
through the same access incision used for infiltration.
The laterally placed incision in the inframammary fold
allows better access for the liposuction to the whole
breast laterally and medially. This contrasts with the
axillary and transareolar incisions preferred by others,
but provides less access and greater risk of accidental
penetration of the chest wall. A 4.6 mm or 5.2 mm Mer­
cedes cannula is used for the initial suction employing
the palm down and pinch techniques. The refinement
and final contouring is performed with a 3 mm or
Surgical management
Well-established surgical techniques for gynecomastia
treatment include various forms of liposuction, open
glandular excision, skin reduction, and combinations of
these. Liposuction is now the prime surgical technique
as it is minimally invasive, improves contouring by
feathering the peripheries, and is frequently successful
as a single modality.6,9,53,54
Various forms of liposuction have been described
including conventional, power-assisted, ultrasound-
assisted, laser-assisted, and vibration amplification
of sound energy at resonance (VASER)-assisted.32–36
The most common types used are conventional and
ultrasound-assisted liposuction. The salient features of
the main available surgical modalities are outlined
below.
Anesthesia and infiltration
We perform all surgery under general anesthesia as day
cases (ambulatory care setting) except when skin reduc­
tion is planned, in elderly prostate cancer patients, when
it is envisaged that a drain may be required (which is
rare except for very large gynecomastia), and in patients
with underlying medical problems or those travelling
from a long distance away. All have preoperative pho­
tographic documentation of their breasts by professional
medical photographers. All patients receive periopera­
tive broad-spectrum antibiotic prophylaxis at general
anesthetic induction (see Table 11.2).
Patients are marked preoperatively in the upright
sitting position highlighting the inframammary fold,
breast boundaries, planned stab-incision sites, and con­
centric topography-type marks centered on the most
prominent portion of the breast (Fig. 11.1). The breast
tissue is infiltrated through a stab incision in the lateral
inframammary crease using a superwet (near-tumescent)
technique. The wetting solution consists of Ringer’s
lactate containing 1 mL of 1 in 1000 solution of adrena­
line (1 mg) and 30 mL of 1% lignocaine (300 mg) per liter.
Conventional liposuction
Conventional liposuction, also referred to as “traditional
liposuction” or “suction-assisted lipectomy” (SAL) was
introduced by Yves Illouz in the 1970s with a series of
over 3000 cases12 of body contouring at different sites. It
is useful for diffuse breast enlargement of soft to mod­
erately firm consistency28,53,55–57 (Fig. 11.2). However,
residual subareolar tissue is a frequently encountered
complication with this technique.6,8,54 This persistent
tissue is often uncomfortable leading to patient requests
for further surgery. Additionally, SAL is not suitable for
severe cases or in breasts with primarily fibrous tissue7
Fig. 11.1  Preoperative marking of gynecomastia patient in upright position.
Concentric topography-type marks are centered on the most prominent portion of
the breast. The dots around the nipple areolar complex mark the inferior periareolar
incision for potential intraoperative conversion to open excision. The straight lines
indicate areas of tapering of the liposuction in the areas adjacent to the breast
tissue while the crosses mark the areas not to be “violated” during the liposuction
procedure. The interrupted lines illustrate the inferior extent of the liposuction to
allow successful skin redraping.

178
SECTION I
CHAPTER 11 • Gynecomastia surgery
a satisfactory contour is obtained, the surrounding fat
is feathered to avoid a noticeable saucer deformity, and
any well-defined inframammary fold as determined
preoperatively is deliberately disrupted in order to
avoid the gynecoid (female) contour of the breast. This
also enables the liposuction to extend well beyond the
confines of the breast in order to facilitate postoperative
redraping of the skin as popularized by Rosenberg.55,58,61
3.7 mm Mercedes cannula. It is important to make a
concentrated effort to suction the breast tissue and not
just the subcutaneous tissue. During suction, contour
changes are constantly assessed by direct observation,
while the thickness of the breast is evaluated intermit­
tently with the contralateral hand by palpation between
the fingers and thumb. A close watch is also kept on the
color (blood-staining) and volume of the aspirate. Once
Fig. 11.2  A 25-year-old patient with gynaecomastia of moderate size and consistency treated by conventional liposuction only. (A–C) Preoperative appearance and (D–F)
postoperative result 6 months later. (From: Wong KY, Malata CM. Conventional versus ultrasound-assisted liposuction in gynaecomastia surgery: a 13-year review. J Plast
Reconstr Aesthet Surg. 2014;67:921–926.)
A
B
C
D
E
F

179
Treatment/surgical technique
addition to the better mechanical leverage of the liposuc­
tion, the laterally placed incisions avoid trauma and
thermal burns to the nipple areolar complex.6,7,57 UAL is
technically demanding and a number of precautions
have to be undertaken to prevent morbidity (Box 11.3).68–72
Routine safety measures to avoid thermal injuries6,7,57 are
taken including continuous saline irrigation through the
sheath system (40 mL/h for the Mentor based machines
listed above), use of a probe sheath, skin guard, wet
towels around the entry site, and avoidance of “end
hits”. The cannula is continuously moved in fan-like long
strokes, starting deep and working superficially. The
strokes should go beyond the marked boundaries of the
breast enlargement, and, as with SAL, a special effort is
made to disrupt the inframammary fold where this is
well formed. The well described UAL endpoints73 are
determined by loss of tissue resistance, aspirate volume,
blood-tinged appearance of the aspirate, and planned
treatment time. Final fat evacuation and contouring is
performed using conventional liposuction (3.7 mm
Mercedes cannulas) with the suction set at the machine’s
maximum (see Video 11.1
).74
Other minimally invasive techniques
An increasing number of minimally invasive techniques
have also been described including endoscopically-
assisted,75,76 pull-through,15,77–79 arthroscopic shavers,8,15,80
and mammatome excision.81,82 Their exact roles remain to
be established. The most promising is the arthroscopic
shaver which provides a less invasive alternative to open
excision with no visible periareolar scar, and can be
combined effectively with liposuction.8 Additionally,
it is readily available in most hospitals in the UK and
USA. These minimally invasive techniques have been
Conventional liposuction can be used in the tradi­
tional manner (as in our practice) and employ power
assistance alone or in combination with open glandular
excision.63 We have a low threshold for conversion to
open excision based on the contour, lump palpability,
and pinch test. Therefore, if unsuccessful based on the
contour, palpation, and pinch, a semicircular inferior
periareolar incision should be made and the disc resected
by open excision. This is easily accomplished within a
few minutes because of the prior liposuction.
Ultrasound-assisted liposuction
Ultrasound-assisted liposuction (UAL) was developed
by Zocchi in the 1980s based on selective destruction of
adipose tissue while protecting other tissues from
damage.14 UAL is far more effective for firmer breasts
than SAL (Fig. 11.4, UAL). By emulsifying breast fat, it
is particularly useful for addressing dense, fibrous
gynecomastia.7,14,54,57,64 It has also been suggested that
UAL results in less postoperative bruising, a smoother
breast contour, better postoperative skin contraction,
and less surgeon fatigue.7,54,57,65–67 Furthermore, in our
study of 219 consecutive patients over a 13-year period,
compared to conventional liposuction, UAL had signifi­
cantly lower rates of intraoperative conversion to open
excision (25% vs. 39%) and postoperative revision (2%
vs. 19%).54 Patients treated with UAL were therefore 8.5
times less likely to undergo subsequent revision surgery
and 1.5 times less likely to have intraoperative conver­
sion to open excision. As a result, when available, UAL
has become our preferred modality of treatment.
UAL employs either solid or hollow cannulas. After
infiltration with the wetting solution (at a rate of 400 mL/
min for the Mentor Contour Genesis or Mentor Lysonix
3000 machines; Mentor Medical Systems, Santa Barbara,
California), a hollow UAL cannula with or without a
skin-protective port is inserted through the same stab
incisions as those used for conventional liposuction. In
Fig. 11.3  Examples of different liposuction cannulas. (Top) Mercedes tip, (middle)
spatula tip, and (bottom) V-shaped tip.
BOX 11.3  Disadvantages of ultrasonic liposuction
• Limited availability and expensive equipment
• Increased operating time
• Labor intensive for the nurses
• Specific risks of:
•
Thermal injury
•
Skin necrosis
•
Demyelination of peripheral nerves
• Cavitation and potential DNA changes
• Meticulous precautions are needed including:
•
Skin guard
•
Ultrasonic liposuction probe sheath
•
± Continuous fluid irrigation
•
Wet towel around the skin
•
Continuous movement technique of the probe
•
Avoidance of end hits

180
SECTION I
CHAPTER 11 • Gynecomastia surgery
transareolar, and circumthelial.11,83–94 Liposuction is
frequently not effective for very glandular tissue, small
discrete breast buds, and body builders as the latter
have large amounts of glandular tissue with little fat.95,96
Excisional techniques are effective for these groups
of patients, although they are associated with a high
complication rate with potential for adverse scars and
contour abnormalities.97,98 Open excision is currently
used in combination with liposuction, as pioneered by
advocated in an attempt to reduce unsightly scarring and
the risk of nipple deformities. However, it remains to be
seen whether they will be efficacious or widely adopted.
Open excision
Open excision via an inferior periareolar approach11
is the traditional approach. Various other incisions
have been described such as circumareolar, periareolar,
Fig. 11.4  A 46-year-old patient with bilateral gynecomastia of moderate size and firm consistency treated by ultrasound-assisted liposuction only. (A–C) Preoperative
appearance and (D–F) postoperative result 5 months later.
A
B
C
D
E
F

181
Treatment/surgical technique
semicircular incision along the inferior margin of the
nipple areolar complex. To excise the excess tissue,
Bostwick scissors are used to dissect inferiorly to the
lower border of the breast before proceeding in a deep
plane above the pectoralis major muscle to the superior
border of the breast. At least a 1 cm disc of breast tissue
is left under the areola to prevent a depression of the
nipple areolar complex6 (Figs. 11.5 & 11.6). Open excision
Teimourian and Perlman.13 The liposuction serves a
number of purposes such as pretunneling to facilitate
resection, reducing bleeding and bruising, and par­
tially breaking down the breast tissue. After liposuc­
tion the tissue can be resected via a number of access
incisions.
We prefer the time-honored Webster’s technique
for open excision where breast tissue is excised via a
Fig. 11.5  A 20-year-old patient with left-sided gynecomastia of large size and moderate consistency, treated by conventional liposuction and open excision.
(A–C) Preoperative appearance and (D–F) postoperative result 6 months later showing excellent symmetry.
A
B
C
D
E
F

182
SECTION I
CHAPTER 11 • Gynecomastia surgery
such as cost, a single operation, and reduced time away
from work.
Skin reduction
There are a number of procedures used to reduce
excess skin in gynecomastia. Although most of these
techniques are similar to those used in females, it is
even when combined with liposuction sometimes does
not fully correct large and ptotic breasts for which
skin reduction is indicated. Some authors recommend
eschewing skin resection leaving the skin to contract on
its own over a 6–8 month period. We prefer to address
the skin excess at the first operation if the patient is
willing to accept the scars. This has practical benefits
Fig. 11.6  A 30-year-old patient with right-sided gynecomastia of moderate size and firm consistency, treated by ultrasound-assisted liposuction and open excision.
(A–C) Preoperative appearance and (D–F) postoperative result 6 months later showing excellent symmetry.
A
B
C
D
E
F

183
Treatment/surgical technique
associated with excessive puckering of the periareolar
skin, persistent discharge, and suture palpability. In
patients with true ptosis, those aiming for complete
resolution (flat breasts) or best possible cosmesis, skin
reduction can be undertaken using the LeJour vertical
mammaplasty skin pattern.
LeJour pattern
In patients with true ptosis or very large breasts, skin
reduction and tissue resection can be undertaken using
the LeJour vertical mammaplasty skin pattern. The skin
and underlying breast tissue is resected in a vertical
ellipse and then the pillars are approximated. However,
the final vertical scar is very noticeable. This technique
should be used as a last resort, especially in those who
wish to avoid a T-scar (Figs. 11.9 & 11.10).
Other skin reduction techniques
Others resort to lateral wedge, elliptical, and inverted-T
excisions (Fig. 11.11). All these scars are more noticeable
even after 12–18 months. Patients with very large or
ptotic breasts are suitable candidates for elliptical mas­
tectomy and free nipple grafting or superior nipple
transposition (Figs. 11.12 & 11.13). This also avoids the
telltale features of female-type breast reduction scars. It
should however be avoided in dark-colored skin because
of nipple depigmentation. In an attempt to reduce
unsightly scarring and risk of nipple deformities, less
invasive excisional techniques have recently been advo­
cated, but their role remains to be established. In patients
with a high potential for keloid or hypertrophic scarring
we frequently employ a Lalonde-type breast reduction
no-vertical scar technique (Figs. 11.12 & 11.13). After
de-epithelialization, liposuction is performed prior to
open glandular excision and via the horizontal incision.
After achieving hemostasis the nipple areolar complex
is transposed superiorly and brought out through the
predetermined “button-hole”. The long inframammary
incision is then closed over a suction drain.
Staged skin reduction
Skin reduction, with its resultant large visible scars, is
sometimes resisted by patients, and thus another
approach is to stage the surgery. Specifically, starting
with liposuction followed by subsequent skin resection
a minimum of 4–6 months later. This potentially reduces
the incidence of skin resection and hence minimizes
scarring. Occasionally patients planned for two-stage
surgery accept the initial results and decline the second
skin reduction procedure. The staged skin reduction
is also likely to be smaller following some skin
important to reduce the resemblance to the female
breast reduction pattern and (try as much as possible
to) minimize the scars. Although skin reduction tech­
niques can result in large scars as compared to liposuc­
tion and Webster’s incision, they are well tolerated by
patients with large breasts, significant ptosis, or poor
skin quality.
In patients with obvious skin excess or very large
breasts, skin reduction techniques should also be
planned usually at the same time as the open excision
of the breast tissue or as a second stage, a minimum of
4–6 months later. There is, however, no consensus on
when and how to undertake skin resection. We base
this decision on skin elasticity, presence of ptosis, skin
excess, skin type, and the patient’s willingness to accept
a potential two-stage procedure. The surgeon’s prefer­
ence also plays a role in choosing the technique.
In patients in whom open excision is not mandated
by the gynecomastia appearance and consistency, we
always consent them for open excision in case the lipo­
suction leaves significant residual stromal tissue. When­
ever there is skin excess or ptosis, we prefer to address
the skin excess at the original operation, especially in
cases of poor or borderline skin elasticity. The choice of
skin reduction technique (Box 11.4) also depends to a
large extent on the surgeon’s preference.
Concentric mastopexy pattern
The periareolar concentric mastopexy-type skin reduc­
tion is preferable to other skin reduction techniques
principally because it avoids extra-areolar scars. We
prefer to use the concentric periareolar technique13,99
because of the less noticeable scarring (Figs. 11.7 & 11.8).
There is still a risk of adverse scarring (widely stretched,
hypertrophic, or keloid), particularly in dark skinned
patients. In very large breasts this technique is
BOX 11.4  Salient features of skin reduction surgery
for gynecomastia
• Indications:
•
Large gynecomastia (Simon’s grade IIb or III)
•
Ptotic breasts
•
Poor skin quality
•
Post massive weight loss
• Options for skin reduction:
•
Concentric
•
Vertical scar (LeJour type)
•
Elliptical
•
T-scar (Wise pattern)
•
Lateral wedge
•
No vertical scar with nipple transposition (Lalonde type)
Text continued on p. 191

184
SECTION I
CHAPTER 11 • Gynecomastia surgery
A
B
C
Fig. 11.7  A 30-year-old patient with bilateral gynecomastia of large size and moderate consistency, treated by conventional liposuction and concentric skin reduction.
(A–C) Preoperative appearance, (D–F) markings, and (G–I) postoperative result 7 months later.
G
H
I

185
Treatment/surgical technique
A
B
Fig. 11.8  Intraoperative images of conventional liposuction, glandular resection, and concentric skin excision. (A,B) The markings are similar to the Benelli periareolar
mastopexy technique with the solid lines outlining the extent of skin resection. The doughnut is de-epithelialized.
Continued
E
F
Fig. 11.7, cont’d
D

186
SECTION I
CHAPTER 11 • Gynecomastia surgery
G
E
F
C
D
Fig. 11.8, cont’d (C,D) Conventional liposuction is subsequently performed, and
the residual breast tissue then excised, leaving the nipple areolar complex
vascularized on a superior pedicle. (E–G) Following tissue resection, a periareolar
purse-string suture is placed with subsequent skin closure using 4/0 vicryl deep
dermal and 4/0 monocryl subcuticular sutures. A suction drain is placed following
extensive tissue resections.

A
B
C
D
Fig. 11.9  A 17-year-old patient with bilateral gynecomastia of large size, firm consistency, and grade 1 ptosis treated by conventional liposuction, glandular resection, and
LeJour skin pattern excision. (A–D) Preoperative appearance with markings and (E,F) postoperative results 1 week (top 2) and 2 months later (G,H). Note the flat chest
contour in the lateral and oblique views.
E
F
G
H