Cosmetic and Reconstructive Breast Surgery

Cosmetic and Reconstructive Breast Surgery
150
ascertain the importance of future breastfeeding, nipple
sensation, hypopigmentation of the nipple, hypertrophic
and keloid scars. Incidences differ in the literature with
respect to which pedicle was utilized. Revision rate is a very
important marker of a reduction technique. At our institu-
tion, for 133 Wise pattern superomedial-based pedicles and
nine free nipples, results were an overall 4.6% revision rate,
for hematomas (1.4%), contour improvements (1.4%), and
revision of the surgical scar (1.8%).9 No nipple losses were
observed. We have found immediate treatment with
hyperbaric oxygen to be benefi cial in selected patients when
nipple ischemia is suspected early; however, large prospec-
tive studies are still required to completely elucidate its role.
At our institution we have observed a link between sickle
cell trait and fl ap necrosis in a breast reduction patient.21
Risk factors associated with fl ap survival, such as smoking,
obesity, radiation, and diabetes, should be well addressed
preoperatively.
POSTOPERATIVE CARE
The postoperative care following reduction mammaplasty
is generally routine. Steri-strips are usually placed along
the incisions and women are instructed to wear a compres-
sive breast garment. The compressive garment or bra is
worn 23 hours a day for 4–6 weeks. Drains are usually
inserted and removed after 24 hours. Sometimes the drains
will remain in place for 2–3 days if the output is elevated.
Women are instructed to shower on postoperative day 2 or
3. Activity restrictions are necessary for the fi rst 6 weeks
following the operation. Women are encouraged to refrain
from any strenuous or bouncing activities, such as aerobic
exercise, jogging, or running. After 6 weeks they can resume
all normal activities.
CONCLUSIONS: WISE PATTERN
The key advantages of a Wise pattern, and specifi cally when
combined with a superomedial pedicle, are:
● Adaptability. The Wise pattern as a skin excision scar
can be applied to a variety of pedicle or free nipple
reductions.
● Shape. The skin pattern can be used to cone and shape
the breast.
● Reproducibility and predictability. This pattern features
an advantage in the learning curve and ability to
teach.
● Progressive. The Wise pattern can be used with increas-
ing degrees of ptosis, skin excess, and breast volume.
CASE 11.1 Surgical procedure. Photo of surgical excision of
skin fl aps with a superomedial pedicle pattern. Excision of
an arc of tissue above the areola to create space for the new
position of the nipple–areolar complex. Note that the bulk
of the tissue is removed laterally.
CASE 11.2 Surgical procedure. Photo of the superomedial
pedicle. Width of the superomedial pedicle prior to excision
of breast parenchyma.
CASE 11.3 Preoperative markings on a 34-year-old woman
with macromastia.

Breast Reduction: Wise Pattern Techniques
151
CASE 11.4 A, B The 34-year-old woman with macromastia
from Case 11.3. C, D 7 months post superomedial pedicle
Wise pattern breast reduction. Right and left breasts were
reduced 950 g and 1100 g, respectively. Patient demon-
strates no settling period or tissue adaptation.
A
B
C
D

Cosmetic and Reconstructive Breast Surgery
152
CASE 11.5 A, B A 24-year-old woman with macromastia.
C, D 6 months post 800 g breast reduction, and E, F 14
months post-reduction.
A
B
C
D
E
F

Breast Reduction: Wise Pattern Techniques
153
CASE 11.6 A, B A 19-year-old woman with macromastia,
and C, D 1 year after 740 g reduction right breast and 680 g
reduction left breast.
A
B
C
D

Cosmetic and Reconstructive Breast Surgery
154
CASE 11.7 A 47-year-old woman with macromastia. A, B
Preoperative views, and C, D 10 months after 1770 g reduc-
tion right breast and 1840 g left breast.
A
B
C
D

Breast Reduction: Wise Pattern Techniques
155
CASE 11.8 A 44-year-old woman with macromastia. A, B
Preoperative views, and C, D 10 months after 565 g reduc-
tion right breast and 725 g reduction left breast.
A
B
C
D
REFERENCES
1. American Society of Plastic Surgeons.
2. Rohrich RJ, Gosman AA, Brown SA, et al. Current preferences for
breast reduction techniques: a survey of board certifi ed plastic
surgeons. Plast Reconstruct Surg 2004; 114: 1724–1733.
3. Hammond DC. Short scar periareolar-inferior pedicle reduction
(SPAIR) mammaplasty. Op Tech Plast Reconstruct Surg 1999; 6:
106.
4. Hammond DC. Short scar periareolar–inferior pedicle reduction
(SPAIR) mammaplasty. Plast Reconstruct Surg 1999; 103:
890–901.
5. Hall-Findlay EJ. Discussion. Plast Reconstruct Surg 2005; 115:
1278.
6. Lexer E. Zur Operation der mammahypertrophie und der
Hangebrust. Dtsh Med Wochenschr 1925; 51: 26.
7. Wise RJ. A preliminary report on a method of planning the
mammaplasty. Plast Reconstruct Surg 1956; 17: 367.
8. Cruz-Korchin N, Korchin L. Vertical versus Wise pattern breast
reduction: patient satisfaction, revision rates, and complications.
Plast Reconstruct Surg 2003; 112: 1573–1578.
9. Davison SP, Mesbahi AN, Ducic I, et al. The versatility of the
superomedial pedicle with various skin reduction patterns. Plast
Reconstruct Surg In press.
10. Strombeck JO. Report of a new technique based on the two pedicle
procedure. Br J Plast Surg 1960; 13: 79.
11. Weiner DL, Aiache AI, Silver L, Tittiranonda T. A single dermal
pedicle for nipple transposition in subcutaneous mastectomy,
reduction mammaplasty, or mastopexy. Plast Reconstruct Surg
1973; 51: 115–120.
12. Orlando JC, Guthrie RH Jr. The superomedial dermal pedicle for
nipple transposition. Br J Plast Surg 1975; 28: 42–45.
13. Hauben DJ. Experience and refi nements with the superomedial
dermal pedicle for nipple–areola transposition in reduction
mammaplasty. Aesthet Plast Surg 1984; 8: 189–194.
14. Hauben DJ. Superomedial pedicle technique of reduction
mammaplasty. Discussion. Plast Reconstruct Surg 1989; 83:
479.
15. McKissock PK. Reduction mammoplasty with a vertical dermal
fl ap. Plast Reconstruct Surg 1972; 49: 245.
16. Johnson CM Jr, To WC. A case approach to open structure
rhinoplasty. Philadelphia: WB Saunders, 2004.
17. Farina MA, Newby BG, Alani HM. Innervation of the
nipple–areola complex. Plast Reconstruct Surg 1980; 66:
497–501.
18. Finger RE, Vasquez B, Drew GS, Given KS. Superomedial pedicle
technique of reduction mammaplasty. Plast Reconstruct Surg
1989; 83: 471–478.
19. Hsia H, Thomson JG. Differences in breast shape preferences
between plastic surgeons and patients seeking breast
augmentation. Plast Reconstruct Surg 2003; 112: 312–320.
20. Mustoe TA, Cooter R, Gold M, et al. International clinical
guidelines for scar management. Plast Reconstruct Surg 2002; 110:
560–572.
21. Spear SL, Carter ME, Low M, et al. Sickle cell trait: a risk factor
for fl ap necrosis. Plast Reconstruct Surg 2003; 112: 697–698.

157
C H A P T E R
12
Breast Reduction: Short Scar
(Vertical) Techniques
Elizabeth J. Hall-Findlay
INTRODUCTION
Breast reduction techniques have tried to balance the
removal of excess tissue with preservation of circulation
to the nipple–areolar complex. In the 1970s the introduc-
tion of the vertical bipedicle technique as described by
McKissock1 made breast reduction safe, reproducible, and
reliable. Once surgeons realized that the nipple could
survive on either pedicle the procedure was further simpli-
fi ed. The inferior pedicle2–4 became the standard in North
America, whereas in South America and Europe both supe-
rior and inferior pedicles were used.
The vertical bipedicle technique relied on a horizontal
excision of skin and breast tissue with removal of the skin
in the Wise5 pattern. These techniques were applicable to
every breast size, with free nipple grafts6 being usually
reserved for the extremely large breast.
There was, however, some dissatisfaction with the
often unsightly scar along the inframammary fold. South
American7–10 and European11–15 surgeons tried various
shorter scar techniques which often relied instead on a
vertical resection of breast tissue. Not only were the scars
shortened, but often the breast had a better shape because
of the coning effect, which resulted in narrowing of the
breast and better projection. Unfortunately, the learning
curve was somewhat diffi cult and surgeons the world over
felt more comfortable with the inverted-T techniques.
Surgeons need to realize that these procedures are not
limiting. They can apply the vertical wedge resection
principles in the breast tissue while still using an inverted
T skin resection pattern when needed. The choice of pedicle
is not limited. Different pedicles can be used with different
parenchymal resection patterns, and both can be used with
different skin resection patterns.16–20
INDICATIONS AND CONTRAINDICATIONS
Short scar breast reduction techniques which rely on a verti-
cal skin scar rather than incorporating a full inverted T
pattern are usually best reserved for small to moderate-sized
breasts.21–23 Extremely large breasts, or those with lots of
poor-quality skin, will still need an inverted T to take care
of the skin excess. But the same principles discussed below
can be used for the parenchyma even in the larger breast.
The very short circumareolar techniques are best con-
fi ned to reductions or mastopexies where there is only a
very small amount of excess skin.24,25
The vertical wedge resection of skin and parenchyma
results in two dog-ears: one superior, which disappears into
the nipple, and one inferiorly, which usually disappears but
which may need revision either at the time of the surgery
with a small T or J or L, or a later revision in the offi ce.
The inverted-T techniques also have two dog-ears.
Because the resection of breast tissue and skin is performed
mainly in a horizontal direction in inverted-T cases, there
is a dog-ear both medially and laterally. These are often
more diffi cult to correct than the vertical dog-ears. This
then results in an artifi cially low revision rate than with
the vertical techniques. Each surgeon needs to take these
different factors into consideration.
Breast size
● Very small – short circumareolar techniques
● Small to medium – vertical techniques as described in
this chapter
● Large – various pedicles and parenchymal resection pat-
terns with inverted T skin incision
● Extremely large – amputation techniques with consid-
eration of free nipple grafts.
Liposuction-only breast reduction techniques26,27 can
also be considered for fatty breasts. Liposuction will not
work in very young patients who are close to their ideal
body weight. It is best reserved for older women with fatty
breasts and relatively high nipples. The nipples can rise to
some degree, but often at the expense of losing some upper
pole fullness. Some patients are less concerned about shape,

Cosmetic and Reconstructive Breast Surgery
158
and liposuction-only may be a good choice. The same rea-
soning could be applied to patients who are more concerned
about nipple sensation, or those who are not willing to
accept some risk of nipple necrosis.
PREOPERATIVE HISTORY
AND CONSIDERATIONS
Breast size and surgeon experience will be the main deter-
minants in the choice of breast reduction procedure. Other
factors to be taken into consideration are the nature of the
skin excess and elasticity, previous biopsies (which might
limit pedicle choices), and concerns about nipple sensation
and blood supply. This chapter concentrates on a medial
pedicle vertical approach, but many of the principles can
apply from small to large reductions by using the same type
of pedicle with a mainly vertical skin resection pattern, and
then deciding on the fi nal skin resection pattern.
There is no one ‘vertical’ or ‘short scar’ technique, just
as there is no one ‘inverted-T’ technique. Each surgeon will
have his or her own preferences, depending on the results
they can achieve in their hands. The vertical approaches
that have come into more common acceptance are as
follows:
Vertical skin resection pattern using
a superior pedicle7–15
In the technique as described by Lassus11,12 a superior
pedicle is used for the smaller breast reductions and a
medial pedicle is used when the nipple has a greater dis-
tance to travel. He performs a vertical wedge resection of
breast tissue with no horizontal resection of parenchyma.
The inframammary fold stays at the original level.
In the technique as described by Marchac and de Olarte13
a superior pedicle is used. For larger reductions a small T
skin resection was added.
In the technique as described by Lejour and colleagues14,15
a superior pedicle is used. For larger reductions liposuction
was performed initially to reduce breast size and make the
pedicle more pliable and easier to inset. Lejour directly
excised both a vertical wedge of breast tissue and a horizon-
tal wedge just above the inframammary fold, where she
undermined the skin. This resulted in an elevation of the
inframammary fold.
Vertical skin resection pattern using a medial or
lateral pedicle16,17,19,23
This chapter describes a vertical skin resection pattern
using a medial pedicle.21,22 The lateral pedicle was used
initially by the author because it was thought that it would
result in better sensation. Studies have shown that fi nal
sensation was the same with the superior, medial, and
lateral pedicles. The lateral pedicle unfortunately restricted
the ability to excise the excess lateral breast tissue because
that excess formed the base of the pedicle. The medial
pedicle, on the other hand, has excellent sensation and
allows resection of all the excess breast tissue both laterally
and inferiorly. The parenchymal resection pattern relies on
a vertical wedge excision, with the horizontal excess along
the inframammary fold being removed both directly and
with liposuction. The Wise pattern is used to determine
what breast tissue should remain rather than what should
be excised. The inframammary fold rises.
Vertical skin resection pattern using an
inferior pedicle20
In the technique described by Hammond20 an inferior
pedicle is used along with a circumvertical skin resection
pattern. To reduce the length of the vertical scar many
surgeons use a circumvertical skin resection pattern,28,29
where much of the excess vertical distance is taken up
around the areola instead. The surgeon must be comfort-
able with the techniques used to prevent areolar widening,
fl attening, and wrinkling when there is a signifi cant dis-
crepancy between the skin circumference and the areolar
circumference. The inframammary fold does not rise, and
it is important not to violate the fold in order to prevent
descent. Descent and bottoming-out is less of a problem
with the procedures that use a more superiorly based pedicle
and which rely on removal of all the excess inferior breast
tissue.
OPERATIVE APPROACH USING A MEDIAL
PEDICLE VERTICAL SKIN RESECTION PATTERN
Surgical anatomy
Blood supply
The arterial input for the breast comes mainly from the
medial branches of the internal mammary system.30–33
These vessels are the main source of blood supply for the
superior, medial, and inferior pedicles. The lateral pedicle
is supplied by the superfi cial branch of the lateral thoracic
artery. The superior and medial pedicles are supplied
directly by branches of the internal mammary system, and
these vessels are superfi cial when they reach the areola. The
inferior pedicle is supplied by a perforator through the pec-
toralis muscle, which also originates from the internal
mammary system.
The veins do not accompany the arteries (except for the
venae comitantes, which accompany the perforator that
supplies an inferior or central pedicle). The veins are just
beneath the dermis and are often easily visible through the
skin. It is a good idea to try to incorporate a visible vein in
the base of the pedicle.
Innervation
Although the main innervation to the nipple is described
as coming from the lateral branch of the fourth intercostal
nerve, there are also signifi cant medial branches34 as well
as superior branches. When the pectoralis fascia is not vio-
lated, and when a medial pedicle is kept full thickness,
there is a good chance that the deep branch of the lateral
fourth intercostal nerve will be preserved.34

Breast Reduction: Short Scar (Vertical) Techniques
159
Ductal anatomy
Breast reduction removes many of the ducts needed for
breastfeeding, but because the breast usually comprises
20–25 separate lobules, many of these will be preserved
with a full-thickness pedicle.35 Inferior, lateral, and medial
pedicles can easily be kept full thickness, but often a
superior pedicle needs to be thinned to allow it to be inset.
Full-thickness pedicles are therefore not needed for either
arterial or venous input (except for the inferior and central
pedicles), but they are more likely to contain both nerves
and ducts when they are kept full thickness. If a pedicle is
thinned it does need to be thicker as it approaches the
source of its blood supply. Thinning a medial pedicle right
to the sternal border could be a problem. A medial pedicle
may have had its blood supply damaged during the pocket
dissection for a prior augmentation. A superior pedicle
might be more reliable in such cases.
Markings
New nipple position (Figs 12.1, 12.2)
Determining the new nipple level is often confusing and a
source of concern. Although the inframammary fold
is a good guideline, the best indication is to actually
‘see’ where the breast mound starts and to keep the nipple
position somewhere between the lower third and the middle
of the imagined fi nal breast. Once the surgeon realizes
that it is almost impossible to raise the breast on the chest
wall, the upper border of the breast is a very important
landmark. Suturing the breast to the pectoralis fascia to
raise the breast or increase upper pole fullness does not
work.
Upper border of the breast
This will not change with a breast reduction and is best
marked by starting with the indentation just below the pre-
axillary fullness. A dotted line (see Figs 12.1B, 12.2A) is
then drawn from this area up and across the breast, where
it is usually fairly clear where the demarcation between the
breast and the upper chest wall occurs. Placing the new
nipple position anywhere close to this demarcation line will
cause problems with nipples that are too high.
Inframammary fold
It is important to mark the level of the inframammary fold,
as this is a good guideline to help determine the level of the
new nipple. When a patient has a lot of upper pole fullness
then the new nipple can be positioned higher than the level
of the fold (see Figs 12.2B, 12.4A). When the patient has
very little upper pole fullness the new nipple position may
actually need to be lower than the inframammary fold (see
Figs 12.1B, 12.10B, 12.11A). The best guideline is to visual-
ize the fi nal breast, realizing that the demarcation between
the upper level of the breast mound and the chest wall will
not change. The level of the inframammary fold provides a
second checkpoint.
Breast meridian
A line is drawn down the breast meridian – not through the
nipple, but where the surgeon wants the fi nal meridian to
be (Fig. 12.2B). In an inverted-T reduction the meridian
A
B
FIGURE 12.1 This patient has breasts which are low on the chest wall. The best way to determine the new nipple position is to mark the upper
border of the breast mound where it meets the chest wall. Suturing the breast tissue to the chest wall will only temporarily increase upper pole
fullness, and eventually the breast will settle down to its original position. On the other hand, the inframammary fold can be raised slightly by
using the vertical techniques, which remove the heavy inferior breast tissue. A The breasts are low on the chest wall. B The junction of the
upper border of the breast where it meets the chest wall is marked with a dotted line. It is important not to mark the new nipple position too
close to this border. The nipple is ideally about one-third to halfway up from the lower border of the breast mound. In this case the new nipple
position is marked at the level of the inframammary fold, which is shown by a horizontal mark between the breasts.

Cosmetic and Reconstructive Breast Surgery
160
will be somewhat more lateral than in a vertical reduction,
because the inverted-T techniques do not usually result in
as much breast narrowing. At the level of the inframam-
mary fold medially the measurement to the desired breast
meridian is usually around 9–11 cm.
The new nipple position is then marked at the intersec-
tion of the vertical position (as determined by the top of
the breast mound and the inframammary fold; Fig. 12.2B)
and the breast meridian. The top of the new areola is
then marked about 2 cm above the nipple position (Fig.
12.3A).
It is important in a vertical reduction to mark the new
nipple position slightly lower on the larger breast (Fig.
12.10B), because the weight of the larger breast stretches
the skin and a larger vertical wedge resection will push the
nipple up higher.
Areolar opening (Fig. 12.3B)
A pattern can be used to determine the areolar opening, or
it can be drawn freehand. It will need to be wider if the
areola is large and placed laterally, because it is important
to remove all the pigmented skin from the fl aps that will
remain. A large paperclip has a distance of 16 cm – a 5 cm
diameter areola has a 16 cm circumference. The original
Wise pattern had a 14 cm circumference, which matches a
4.5 cm diameter areola.
An areolar opening that is much larger than 18–20 cm
will require knowledge of the circumareolar skin closure
techniques to prevent widening of the areola. A large dis-
crepancy between the skin and areolar circumferences will
not only cause the areola to stretch, but will also lead to
some fl attening and loss of projection and could result in
permanent wrinkling.
Lejour and colleagues14,15 would carry the areolar opening
out in a mosque dome shape, but it is probably better to
try to take out any excess vertically. As long as the fi nal
skin shape is circular once it is closed, the original shape
is somewhat irrelevant.
Skin resection pattern
The vertical lines that are drawn in a Wise pattern are
much the same as those used in a vertical resection pattern.
Instead of drawing the vertical limbs for 5 cm and then
carrying the lines medially and laterally, the vertical limbs
are joined together about 2–4 cm above the level of the
inframammary fold (Fig. 12.3E). It is important not to take
too much skin. The fi nal closure should be loose and under
no tension. It is important to realize that the inverted-T
patterns often rely on the skin closure to act as a brassiere,
whereas the vertical approaches rely on the parenchymal
resection and just allow the skin to redrape.
It is important not to carry the skin resection pattern
down to the inframammary fold or the vertical scar will end
up below the fold. There are two reasons for this: one is
that closure of the skin ellipse will end up longer vertically;
the second is that the inframammary fold often rises, and
it is important to take this into account. It is also better to
keep the skin resection pattern as a ‘U’ rather than as a ‘V,’
so that enough skin and subcutaneous tissue is removed.
A persistent skin pucker is often more of a problem of
residual subcutaneous tissue than of excess skin.
Medial pedicle design
The best way to allow for easy inset of the pedicle is to put
half of the base in the areolar opening and half into the
vertical skin resection pattern (see Figs 12.3D, 12.4B,
12.7B, 12.10B, 12.11A). If the pedicle is left too low, not
enough tissue will be removed inferiorly and there will be
A
B
FIGURE 12.2 This patient has breasts which are high on the chest
wall. Note the high position of the junction between the upper
border of the breast and the chest wall. A The dotted line marks the
border by starting laterally with x’s at the depression just below the
pre-axillary fullness and then following the depression medially. B In
this case the new nipple position is marked higher than the
inframammary fold because the patient has so much upper pole
fullness. It is best to use the upper border of the breast as the
defi nitive guideline and to use the inframammary fold as a
supplementary guide.

Breast Reduction: Short Scar (Vertical) Techniques
161
A
B
C
D
FIGURE 12.3 This series of photos shows the markings for a medial pedicle vertical breast reduction. A The initial markings are shown in Fig.
12.2B. Note that the breast meridian is drawn where it should be, not where it currently is. The actual position of the nipple is ignored because
drawing the meridian through the current nipple can be misleading and may result in a new nipple that is too medial or too lateral. The new
nipple position has been marked in relation to the upper border of the breast rather than directly at the level of the inframammary fold. The
top of the areola is marked 2 cm above the new nipple position. B The areolar opening is drawn freehand. A large paperclip can be used as a
marker because it measures 16 cm, which is the circumference of a 5 cm diameter areola. Care must be taken (as in this case) to draw out the
areolar opening to be sure to remove any pigmented skin. The fi nal shape should end up as a circle. C Any visible veins should be marked and
included in the base of the pedicle if at all possible. D A superior pedicle could easily be used in this case, but the medial pedicle still allows
easy access to remove the excess breast tissue laterally. The base of the pedicle is usually 6–10 cm. When the pedicle is rotated into position,
the inferior border of the medial pedicle becomes the medial pillar.
pseudoptosis and bottoming-out due to inadequate inferior
tissue resection.
The base of the pedicle is usually designed from 6 to
10 cm. It is important to try to visualize any veins (see Figs
12.3C, 12.7B, 12.10B) directly under the skin. They are
just under the dermis and can often be included in the base
of the pedicle. Some surgeons term this a ‘superomedial’
pedicle,23 but the blood supply is medial. When the patient
is lying down the medial orientation of the pedicle is more
obvious. The superomedial direction is somewhat artifi cial
because it results from ptosis as the patient stands, but the
vessels stretch with the skin and breast as they descend and
the origin of the vascular supply is medial.
A centimeter of dermis and tissue is left around the new
areola, as described by Schwartzmann36 (Fig. 12.4C) in
order to provide some safety margin for the blood supply.

Cosmetic and Reconstructive Breast Surgery
162
E
F
FIGURE 12.3, cont’d E With the breasts pulled up the skin resection pattern is shown. It lies usually 2–4 cm above the level of the
inframammary fold and is drawn in the shape of a ‘U’ rather than a ‘V’ in order to remove all the redundant skin and subcutaneous tissue.
F Intraoperative view. The pucker will eventually tuck in without help.
A
B
C
D
FIGURE 12.4 Operative technique: medial pedicle vertical breast reduction. A Preoperative markings for vertical breast reduction with medial
pedicle. B Intraoperative markings showing base of medial pedicle halfway into the areolar opening and halfway into vertical skin resection
pattern. C De-epithelialization with skin resection pattern incision made. D Resection specimen showing very little skin removal with resection
beveled out laterally, medially, and inferiorly.

Breast Reduction: Short Scar (Vertical) Techniques
163
Full thickness
Resected breast tissue
E
F
G
Medial pedicle
rotated superiorly
H
I
FIGURE 12.4, cont’d E Drawing shows the full-thickness medially based pedicle and the shape of the skin and parenchyma excised. F The
inferior border of the pillars is marked by the arrows. The pillars are only about 5–7 cm long and do not extend down to the inframammary fold.
The inferior border of the medial pedicle becomes the medial pillar. G The medial pedicle is full thickness – this is not needed for blood supply
but for improved sensation and breastfeeding potential. H The base of the areola is closed and the medial pedicle rotates easily into parition. I
A superior platform is left for the areola to sit on. The medial pedicle will appear to be undermined, much like an inferior pedicle. This superior
platform cannot be used to increase upper pole fullness but can be used to help prevent nipple retraction.

J
K
L
M
N
O
FIGURE 12.4, cont’d J The parenchymal excision is beveled out laterally. K The Kocher clamp is useful to help undermine the tissue down to
the inframammary fold. It is important to leave some fat on the skin to prevent scar contracture. L The forceps point to the area where more
tissue can be removed directly. Further tapering will be performed with liposuction. M Area for further resection laterally. It is important to
leave tissue to form a lateral pillar, which should be a couple of centimeters thick. Further tissue should be removed inferior to the lateral pillar
and under the pillar parallel to the chest wall. It is diffi cult to remove enough tissue with the vertical approach, and the tissue under the lateral
fl ap can be excised. Any thick fi brous tissue will need to be directly excised because liposuction is ineff ective. N Resection is completed. It is
important to leave tissue on the pectoralis major muscle to preserve nerves and to help prevent bleeding. O The fi rst pillar suture is placed at
the inferior border of the pillars. This suture is only a centimeter or so below the surface. It is both unnecessary and unwise to try to pull tissue
from deep and lateral. Putting tension on the tissue will not hold in the long term.

P
Medial and lateral pillars
sutured together
Resected
breast tissue
Q
R
S
T
U
FIGURE 12.4, cont’d P The fi rst pillar suture is closed. Usually only 3–4 sutures are used. Only superfi cial bites of fi brous tissue are taken, not
deep bites of fat. Q The red dotted lines show where breast tissue needs to be removed below the pillars by direct excision and tailored out by
liposuction. R Deep dermal sutures are used just to approximate the skin edges. It is important not to use too many sutures. The dermis is not
sutured to the breast tissue. The areas for liposuction are marked. Liposuction is designed to leave a Wise pattern of tissue behind to give the
breast a good shape. The lateral chest wall and pre-axillary areas are also suctioned. S Care must be taken to remove subcutaneous tissue
below the pucker, both laterally and medially, without removing all the fat under the skin. The pucker will then tuck in without being sutured
down. T Liposuction is completed and the areolar stay sutures placed in the dermis. U The areolar and vertical incisions are closed with a
subcuticular absorbable suture. Note that the closure is loose so that the circulation to the skin edges is not constricted and the vertical incision
is left at its full length and not gathered. The gathering interferes with wound healing and either lengthens over time or stays and leaves
permanent pleats in the skin that require revision.

Cosmetic and Reconstructive Breast Surgery
166
FIGURE 12.4, cont’d V Final closure. A good breast shape is left on the table at the end of the procedure. W Paper tape is applied to the
incisions and left on for 3 weeks. Patients are allowed to shower the next day and a brassiere is only used to hold the bandages in place.
Operative technique (Fig. 12.4)
Infi ltration
It is important not to infi ltrate along the incision lines so
that the veins are not damaged. Infi ltration can be used in
the breast tissue itself, but is usually reserved for those
areas where liposuction will be performed. Either direct
infi ltration or a tumescent-type solution can be used. Lipo-
suction is usually performed in the pre-axillary areas as well
as the lateral chest wall and along the inframammary
fold.
Creation of the pedicle (Fig. 12.4C)
The pedicle is created full thickness after de-epithelializa-
tion (Fig. 12.4G). Either a scalpel or cutting cautery is used
to cut the pedicle directly down towards the pectoralis
fascia. It is important at this stage to make sure the assis-
tant does not pull on the pedicle so that it is not inadver-
tently undermined. Undermining is not likely to damage
the blood supply, but could interfere with sensation and
breastfeeding potential. Most of the bleeding that is encoun-
tered is superfi cial.
Parenchymal resection (Fig. 12.4D)
The breast parenchyma is resected en bloc using either
a scalpel or cutting cautery. The resection can be
beveled out laterally, medially, and inferiorly. It is
often diffi cult to reduce the breasts adequately using
the vertical technique, and more tissue can be removed
parallel to the chest wall laterally in order to remove more
tissue.
It is a good idea to leave a superior platform (Fig. 12.4I)
of tissue so that the areola can sit with some support
from below. The pedicle will tend to look undermined
and be thinned (much as happens with creation of an
inferior pedicle), and this platform can help prevent nipple
retraction.
It is important to leave about 1–2 cm of tissue attached
to the skin laterally to create a lateral pillar (Fig. 12.4M).
This tissue should be about 7 cm long and the resection
can be more aggressive inferiorly (below the Wise pattern).
Further tissue can be removed laterally under the lateral
pillar and parallel to the chest wall in order to achieve an
adequate parenchymal resection.
It is important to avoid resecting tissue superiorly unless
the patient has a great deal of upper pole fullness. The breast
tissue below a Wise pattern (Fig. 12.5) is removed either by
direct excision under the skin fl aps or by liposuction. A
combination of beveled resection (rather than undermining)
and liposuction for the more distal (and usually fatty) areas
works best (Fig. 12.4R). This type of resection is much like
that used for gynecomastia, where the glandular tissue is
excised directly and the resection tailored distally with lipo-
suction. Partial closure is often completed before the fi nal
liposuction is performed (Fig. 12.4R).
It is important to look at what is being removed
and what is being left behind. The Wise pattern5 was devel-
oped from a brassiere design and is a good design to guide
the surgeon on what to leave behind (Fig. 12.4R). The
medial pedicle vertical breast reduction leaves the breast
parenchyma attached to the upper skin fl aps, and the excess
breast tissue inferiorly is removed. The breast will descend
to its original position on the chest wall. The inframam-
mary fold may rise slightly, but the upper border of the
breast will remain the same unless tissue has been removed
there. Suturing breast tissue up to the pectoralis fascia will
not raise the breast on the chest wall or increase upper pole
fullness. Breast tissue which has been pushed up will just
drop with gravity and end up bottoming-out.
Skin resection
The skin that is removed mirrors the vertical wedge paren-
chymal resection. If the patient has good-quality skin and
V
W

Breast Reduction: Short Scar (Vertical) Techniques
167
A
B
C
FIGURE 12.5 The Wise pattern was developed from a brassiere
design. It is often used now for designing the keyhole opening, but
in fact the whole pattern is good for deciding what breast tissue to
leave behind. A The Wise pattern superimposed on the supine
patient preoperatively. B The patient at the end of surgery. C The Wise
pattern superimposed on the breast at the end of surgery. The
pattern can be used to help determine what tissue to remove, either
by direct excision or by liposuction. The remaining breast is left
attached to the skin fl aps superiorly, medially, and laterally. The
breast tissue is removed inferiorly and laterally and liposuction is
used to tailor the breast peripherally.
there is not too much excess, the skin will redrape. Sur-
geons are often surprised by how much of the extra skin
will redrape. Puckers are deliberately left behind (Figs 12.6,
12.8, and 12.9) and they tuck in toward the inframammary
fold quite well (Fig. 12.8C). It is often quite diffi cult to
design a further ‘T,’ ‘J’ or ‘L’ resection properly (Fig. 12.10).
The surgeon does not know exactly where the new infra-
mammary fold will lie, and any horizontal scar may end up
below the fold.
Closure
The closure is started by placing a suture at the base of the
areolar opening (Fig. 12.4O). This allows the surgeon to see
what has been removed and what is left behind.
The inferior border of the medial pedicle now becomes
the medial pillar. The pedicle is rotated up into position
and the pillar suturing starts inferiorly with the base of the
pedicle inferiorly being sutured to a matching position on
the lateral side. This is usually about 7 cm below the areola,
where the de-epithelialized pedicle base meets the skin and
about 1 or 2 cm below the skin surface (Fig. 12.4O,P). Deep
sutures pulling tissue from laterally are not only unneces-
sary but can delay healing. Any tension placed on the
parenchymal closure will just stretch out to some degree.
Any tension on the skin closure will not only cause wound
healing problems but will also stretch out.
Only about two to four sutures are usually needed to
close the pillars, and it is important to keep the medial
pedicle rotated up into position during closure. Absorbable
sutures such as 3/0 Monocryl are used. The dermis is then
closed with deep interrupted absorbable sutures (Fig. 12.4R).
Here it becomes obvious that too much skin resection will
lead to too tight a closure. Wound-healing problems can
result. The dermis is usually closed vertically, but a slight
hockey stick going out laterally may be indicated (see Figs
12.8C, 12.10D). It is important to do this after the paren-
chymal resection. A hockey stick-type resection should be
confi ned to skin only, because a similar resection or closure
of the parenchyma itself will end up with a medialized
breast (much like the Dufourmentel37 lateral resection).
The skin is then closed with a running subcuticular
suture (Fig. 12.4T). Originally surgeons (including the
author) thought that this skin needed to be gathered to
keep the vertical length as short as possible, but with it

Cosmetic and Reconstructive Breast Surgery
168
has been realized that gathering is not only unnecessary
but is actually contraindicated.38,39 Measurements have
shown that the vertical length stretches out with time, and
gathering not only leads to a temporary teardrop-shaped
areola but also results in delayed healing, because the gath-
ering constricts the blood supply to the skin margins. The
pucker at the inferior end of the vertical incision may look
better on the table when it is gathered, but in fact it can
cause delayed resolution of the inferior aspect of the
breast.39
The areola is closed with four interrupted deep dermal
sutures and a subcuticular suture (Fig. 12.4T,U). The
pedicle is not rotated into position any set number of
degrees, but usually sits at about 90º compared to its origi-
nal position. It is allowed to settle into its own position at
FIGURE 12.6 A 38-year-old woman, 5 feet 4 inches tall, 145 lb, 38C. She had 300 g taken from the right side and 290 g from the left, with
150 mL liposuction peripherally. She had almost complete return of sensation in 3 months. A Preoperative frontal. B Preoperative lateral.
C intraoperative view showing initial puckers. D 10 days postoperative frontal.
the areolar level, but is defi nitely rotated up in order to close
the pillars properly.
It is not necessary to suture dermis to breast tissue or
to suture the pucker down to the chest wall. The shape will
actually resolve better and faster if the skin is allowed to
fi nd its own position.
There are surgeons who believe that they can increase
upper pole fullness by undermining superiorly and suturing
breast tissue up to the pectoralis fascia. The author has
tried this using 3/0 PDS in 30 patients and 3/0 Ticron in
another 30 patients, and it has not lasted. Initially it looks
as if some increase in upper pole fullness is achieved, but
this drops out with time. For this reason, determining the
upper border of the breast is a key component in determin-
ing the new nipple position.
B
C
D
A

Breast Reduction: Short Scar (Vertical) Techniques
169
Drains and antibiotics
Drains are rarely used. They do not prevent hematomas,
and seromas in the breast will disappear fairly quickly
without treatment. The author has performed over 1600
breast reductions and has only had two cases of hematoma.
The key is to search for known vessels (especially the per-
forator that supplies an inferior or central pedicle) and
make sure that hemostasis is secured (especially when
tumescent-type infi ltration has been used).
Antibiotics are used routinely at induction and then for
several days postoperatively. Not only did they improve the
author’s infection rate in larger breast reductions, but
wound-healing problems in the vertical incision almost
disappeared. This was observed before the author stopped
gathering the vertical incision, and nothing other than the
routine use of antibiotics was changed. Absorbable suture
spitting (PDS and Monocryl) cleared up dramatically.
Dressings
The incisions are all covered with paper tape (Fig. 12.4W),
which stays in place for 3 weeks and provides an excellent
bandage. Patients are encouraged to shower the day after
surgery. A surgical brassiere is used mainly to hold the
bandages in place, and is usually used for a couple of weeks
day and night. Patients are restricted in their activities only
as discomfort dictates.
OPTIMIZING OUTCOMES
● Patient selection: small to medium-sized breast
reductions
● Markings: nipple position is key
● Base of pedicle halfway into areolar opening, half verti-
cal; incorporate a vein into pedicle
● Do not take too much skin: tension causes healing
problems
● Leave 2–4 cm of skin above inframammary fold
● Technical: full-thickness, medially based pedicle
● Excise tissue to leave behind a Wise pattern
● Liposuction for tailoring peripherally
● Leave tissue over pectoralis fascia
● Do not suture breast to pectoralis fascia
● Do not suture dermis to breast
● Do not gather the skin
● Do not put tension on the pillar closure
● Do not put tension on the skin
● Do not suture the pucker down
● Drains are usually unnecessary
● Antibiotic coverage helps wound healing
● Postoperatively: puckers can take months to settle in
larger breasts
● A preoperatively informed patient is the surgeon’s best
ally.
The key to a good result is fi rst to educate the patient.
It is not simple to convert a vertical scar with a small T,
and seemingly large puckers will disappear with time,
leaving a more acceptable result in the long term. Correct-
ing a pucker 1 year postoperatively is usually easy through
FIGURE 12.6, cont’d E 10 days postoperative lateral. F 4 years
postoperative frontal. G 4 years postoperative lateral. The vertical
scars are 11 cm on the right and 10 cm on the left.
F
E
G

Cosmetic and Reconstructive Breast Surgery
170
FIGURE 12.7 A 45-year-old woman, 5 feet 3 inches tall, 200 lb, 36DD. She had 625 g removed from the right breast and 740 g from the left
breast. Liposuction peripherally totaled 850 mL. The patient had complete return of sensation. A Preoperative frontal. B Preoperative frontal
with markings. Many of the numbers are there only for follow-up statistics. C Preoperative lateral. D One month postoperative frontal.
a vertical incision in the offi ce under local anesthesia,
and is often more a question of excising excess subcutane-
ous tissue than excess skin. Revision rates depend on
the surgeon’s threshold for revision as well as getting
past the learning curve. Plastic surgeons accept a small
revision rate in most other procedures, and a small revis -
ion rate should be accepted for breast reduction as well.
It is fortunate that in a vertical reduction the puckers
can be revised – it is much more diffi cult to revise the
puckers at either end of a horizontal inframammary fold
incision.
It is important not to excise too much skin in order to
allow the closure to be slightly loose. Tension created on
the breast tissue itself by taking deep bites to close the
pillars will just stretch out with time and leave a less sat-
isfactory shape. Excision, not tension, is the key to a good
shape. Tension on the skin will just lead to wound healing
problems. Skin under tension (the principle behind tissue
expansion) will eventually stretch and should not be relied
upon to hold shape.
It is important not to gather the skin during closure.
Excessive gathering just constricts blood supply to the
A
B
C
D

Breast Reduction: Short Scar (Vertical) Techniques
171
FIGURE 12.7, cont’d E One month postoperative lateral. F 4 years
postoperative frontal. G 4 years postoperative lateral.
wound edges and the vertical length eventually stretches. A
long vertical length is not a problem. Most surgeons have
trouble switching their thinking from keeping a 5 cm verti-
cal length – which is needed in an inverted-T inferior pedicle
breast reduction – to allowing a vertical length of 7–11 cm.
An elegant curve to the breast is quite acceptable, a B cup
being about 7 cm from areola to inframammary fold, a C
cup being about 9 cm, and a D cup being about 11 cm.
Surgeons need to alter their concept of trying to push
the breast above the inframammary fold to allowing a nice
curve to fall slightly below the fold (see Figs 12.6G, 12.7G,
12.8H, 12.9H). Not only do larger breasts look good with
this curve, but the vertical length also allows for better
projection because the breast is not compressed by a tight
skin brassiere. With an inverted-T inferior pedicle reduc-
tion the skin eventually stretches anyway, and the result is
some bottoming-out below the scar (which makes the
nipples look as if they were placed too high).
Bottoming-out can be avoided by removing enough
breast tissue inferiorly. Trying to push breast tissue up into
the upper pole will only result in that same tissue settling
back inferiorly and bottoming-out. The key to a good fi nal
breast shape is to remove all tissue, with the residual paren-
chyma falling into a Wise pattern. The remaining tissue is
left attached to the overlying skin, and all tissue external
to a Wise pattern is either directly excised or tailored with
liposuction.
COMPLICATIONS (Figs 12.11–12.14)
All complications will occur eventually, especially in a large-
volume practice.40 They cannot be completely avoided. For
example, nipple necrosis is probably more likely to occur
because of a variation in vascular anatomy that cannot be
predicted, and less likely to be a problem of surgical error.
● Hematoma: good hemostasis, especially with tumes-
cent-type infi ltration
● Seroma: drains do not help – seromas disappear with
time
● Infection: no tension on skin, antibiotic coverage
● Nipple necrosis: care in design and execution of
pedicle
● Fat necrosis: avoid large sutures in fat
● Wound healing: no tension on repairs
● Asymmetry: design nipple lower on larger breast
● Under-resection: patient education, remove tissue
laterally
● Scarring: avoid tension on skin closure, no gathering
● Indentations: avoid tension on pillar closure
● Bottoming-out: adequate inferior resection is essential
● Shape: leave behind a Wise pattern
POSTOPERATIVE CARE
Paper tape is placed on the incisions and patients
may shower daily and pat the tape dry. This forms an
excellent bandage and is applied directly from the roll. The
fi rst piece is thrown away and the remaining tape is as
sterile as needed. 3M Micropore paper tape appears to
E
F
G

Cosmetic and Reconstructive Breast Surgery
172
FIGURE 12.8 A 37-year-old woman, 5 feet 8 inches tall, 175 lb, 38F. 560 g removed from right breast and 440 g from left breast; 300 mL
liposuction peripherally. She had complete return of sensation at 6 weeks postoperatively. A Intraoperative view shows puckers, which are hard
for many surgeons to accept. The temptation is strong to convert to a short ‘T.’ The problem with the T is that it is often not clear where to put
it. The inframammary fold rises with the medial pedicle vertical breast reduction. Instead, a small ‘J’ curve was allowed to settle on the right
breast without further skin excision. B The new inframammary fold is not at the level when the breast is just pushed down as shown. C The
actual level of the new fold is better demonstrated when the breast is elevated and pushed down in the manner shown. D 6 weeks
postoperatively showing the area pulled up. There is a small ‘J’ curve on the right.
A
B
C
D

Breast Reduction: Short Scar (Vertical) Techniques
173
FIGURE 12.8, cont’d E Preoperative frontal view. F Preoperative lateral view. G 6 weeks postoperative frontal view. H 6 weeks postoperative
lateral view. The vertical scar length on the left breast is 10 cm and on the right is 13 cm.
E
F
G
H

A
B
C
D
E
F
FIGURE 12.9 A 42-year-old woman, 5 feet 5 inches tall, 185 lb, 38DD. 540g removed from right breast and 585 g removed from left breast.
475 mL liposuction peripherally. This series of photos shows how the pucker at the end of the procedure looks as if it should be converted to a
‘T’ but how it does settle. She had almost complete return of sensation by 2.5 months. A Preoperative frontal view. B Preoperative lateral view.
C Preoperative marked with breasts pulled up. D Intraoperative view at end of procedure, showing puckers. E 3 weeks postoperative frontal
view. F 3 weeks postoperative view lying down, showing how much the puckers have already tucked in and settled.

G
H
I
J
FIGURE 12.9, cont’d G 2.5 months postoperatively, showing a good frontal result. H 2.5 months postoperatively, showing good lateral
projection and shape. The vertical scar now measures 10 cm. I 2.5 months postoperatively with the breasts pulled up. J 2.5 months
postoperatively with the arms up, showing resolution of left pucker but persistent right pucker. The right will still take some time to settle.
Breast Reduction: Short Scar (Vertical) Techniques
175

Cosmetic and Reconstructive Breast Surgery
176
A
B
C
D
FIGURE 12.10 A 36-year-old patient, 5 feet 3 inches tall, 135 lb, 34DD. 760 g removed from right breast and 530 g from left breast. 300 mL
liposuction peripherally. She had partial return of sensation at 2 months but no documentation at 8 months. A Preoperative frontal view.
B Preoperative frontal view with markings. Note that new nipple position on the right (larger) breast is marked lower. Note that veins are
marked and preserved in the pedicles. The pedicle may look ‘superomedial’ with the patient standing, but the blood supply is medial and the
orientation of the pedicle is more obviously medial when the patient is lying down. C Preoperative lateral view. D Intraoperative view
showing the vertical scar on the left breast but the scar on the right breast angled out laterally as a ‘J.’ Note that the ‘J’ is kept above the original
inframammary fold and curved upwards.
stay in place better and last longer than generic tape
(Fig. 12.4T).
A surgical brassiere is applied mainly to hold the initial
bandages in place and then to give the patient a sense of
support. Although it would be ideal to apply pressure to
the areas where liposuction has been performed, it would
not be appropriate to apply too much pressure to the
nipple–areolar complex. Patients are warned that the lipo-
suction areas will be bruised and will remain swollen and
fi rm for several weeks. Patients are allowed to change bras-
sieres or go without completely. Most prefer some
support.
Although seromas do occur, they usually do not need to
be aspirated. They tend to disappear fairly quickly.
Patients are informed preoperatively that they will not
achieve as small a size as they often would like, and the
fi nal size will depend on the size of the pedicle needed. The
pedicle will be larger in a larger breast and these patients
cannot expect a ‘B’ cup.
Patients are also informed preoperatively that puckers
are to be expected. They realize that it may take a full year
for the puckers to disappear. They are also informed that
if a pucker remains it can usually be corrected in the offi ce
under local anesthesia, but they must realize that this will
not be performed for a full year. Sometimes it takes that
long for a pucker to settle down, but most puckers – espe-
cially in the smaller breasts – will take only a few weeks to
months to settle.

Breast Reduction: Short Scar (Vertical) Techniques
177
FIGURE 12.10, cont’d E Postoperative frontal view at 8 months. F Postoperative lateral view at 8 months. G Postoperative view, arms up, at 8
months. H Postoperative pulled-up view at 8 months to show how the scar could end up too low – the inframammary fold rises with this
procedure.
CONCLUSIONS
Shorter scar reduction techniques are best used for the
smaller and medium-sized breast reductions. The circum-
areolar techniques can be used for very small reductions,
but small to moderate-sized breasts can easily be reduced
with some of the many vertical approaches. Several pedicles
can be used with different skin resection patterns, but the
medial pedicle combined with a vertical skin pattern has
proved to be a reliable easy-to-learn technique which gives
good results. The medial pedicle principles can also be
applied to larger reductions or patients with poor-quality
skin where a horizontal excision (T, J, or L) is added.
The principles involved are to use as short a scar as
possible but at the same time give the patient an excellent
shape with a narrowed breast base and good projection.
Removing the heavy inferior breast tissue and leaving the
skin attached superiorly, medially, and laterally helps
prevent bottoming-out with time. Leaving behind a Wise
pattern of tissue and excising or suctioning all excess
peripherally will give a good, long-lasting shape. It is impor-
tant to realize that the skin is not used as a brassiere and
needs to be looser to accommodate the increased projection
that results with the medial pedicle vertical breast
reduction.
E
F
G
H

Cosmetic and Reconstructive Breast Surgery
178
A
B
C
D
FIGURE 12.11 A–D A 56-year-old woman who had a vertical breast reduction using a medial pedicle. She was 5 feet 4 inches tall, wore a 40DD
brassiere and weighed 155 lb. She had 715 g removed from the right breast and 550 g from the left. She also had multiple seborrheic keratoses
on the chest wall removed at the same time. She was placed on perioperative cephalosporin but developed an infection in the right breast at 3
weeks. This was successfully treated with ciprofl oxacin and healed well without any further treatment. She had full recovery of sensation in her
nipples and areolas.

Breast Reduction: Short Scar (Vertical) Techniques
179
A
B
C
D
FIGURE 12.12 Nipple necrosis can occur from a lack of arterial input or venous congestion. It is often unpredictable and diffi cult to assess and
treat. This case, shown at 2 weeks, 6 weeks, and 3 months, shows that it can be best to leave the areola to declare itself and heal by secondary
intention.
A
B
FIGURE 12.13 A, B Dehiscence of the areola at 3 weeks which healed in a few months by secondary intention. The fi nal result is shown at 18
months.

Cosmetic and Reconstructive Breast Surgery
180
A
B
C
D
FIGURE 12.14 A Preoperative markings for vertical breast reduction using a medial pedicle. B Intraoperative photo with 740 g removed from
the right breast and 700 g removed from the left. C Hematoma developed postoperative. Tumescent infi ltration had been used and the
perforator that would normally supply an inferior pedicle was bleeding. It had probably been in a constricted state because of the tumescent
infi ltration and had not been properly cauterized. D Patient seen 2 months postoperatively.
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35. Cruz-Korchin N, Korchin L. Breast-feeding after vertical
mammaplasty with medial pedicle. Plast Reconstruct Surg 2004;
114: 890–894.
36. Schwartzmann E. Beitrag zur Vermeidung von Mammillennekrose
bei einzeitiger Mammaplastik schwerer Fälle. (Avoidance of nipple
necrosis by preservation of corium in one-stage plastic surgery of
the breast.) Rev Chir Struct 1937; 7: 206–209.
37. Dufourmentel C, Mouly R. Plastie mammaire par la méthode
oblique. Ann Chir Plast 1961; 6: 45.
38. Spector JA et al. The vertical reduction mammaplasty: a
prospective analysis of patient outcomes. Plast Reconstruct Surg
2006; 117: 374–381.
39. Hall-Findlay EJ. Discussion: vertical reduction mammaplasty. Plast
Reconstruct Surg 2006; 117: 382–383.
40. Berthe J-V, Massaut J, Greuse M, et al. The vertical
mammaplasty: a reappraisal of the technique and its
complications. Plast Reconstruct Surg 2003; 111: 2192–2199.

183
C H A P T E R
13
Breast Surgery in the Massive
Weight-Loss Patient
Dennis J. Hurwitz and Siamak Agha-Mohammadi
INTRODUCTION
After massive weight loss, obese women experience laxity
of the skin proportional to the excess localized adiposity.
The change in the breast is profound but unpredictable,
owing to the variable gland to fat ratio, genetics, and prior
pregnancies. Smaller breasts defl ate; larger breasts fl atten.
For many, a singularly proud and voluptuous feature has
been ruined. Further distorted by neighboring rolls of upper
torso skin, these breasts conform poorly to brassieres. These
women are resigned to concealing their breasts. Hence,
among their many aesthetic concerns, breast reshaping is
a priority. When given a choice, most weight-loss patients
prefer mastopexy with autogenous tissue augmentation
rather than augmentation with a silicone implant.
Nevertheless, skin reduction pattern mastopexy with
silicone implant augmentation for volume is commonly
presented in plastic surgery meetings. When the senior
author became active in post-bariatric surgery body in the
late 1990s, he favored that approach, and both authors still
use it when there is inadequate neighboring discard tissue
available for augmentation. Mastopexy with an implant is
expeditious, resulting in dramatically improved breast
contour, symmetry, and position of the nipple–areolar
complex (NAC). Nevertheless, it is a complicated procedure
that fails to address chest deformity and suffers from dete-
riorating aesthetics. The many solutions suggested for pre-
venting recurrent ptosis after mastopexy or breast reduction
in the general population attest to its high frequency and
diffi culty.1–7
Not only is there glandular ptosis, enhanced by the
weight of the implants, but the breast loose skin conforms
poorly to implants (Fig. 13.1). The upper pole of the breast
empties and the lower pole fi lls excessively, resulting in
descent of the inframammary fold (IMF), an excessive dis-
tance between the IMF and the NAC, and an upward rise
to the NAC. This deformity is treated with an upper body
lift and repositioning of the implant (Fig. 13.1). With mild
skin laxity of the mid-torso one may pre-empt this unfavor-
able cascade of poor aesthetics with a secure permanent
suture advancement of the IMF along the inferior implant
space (Fig. 13.2). When there is adequate breast volume and
minimal mid-torso laxity and breast descent, we advocate
a mastopexy with dermal to rib suspension and internal
shaping technique similar to that proposed by Rubin et al.8
In addition we secure the IMF during the mastopexy.
Massive weight-loss patients usually accept increased
risk and operative time of autogenous fl aps for a more aes-
thetic, long-lasting outcome. Use of neighboring excess
tissue for breast reshaping was proposed by Zook in the
1970s.9 He placed de-epithelialized discard epigastric fl aps
beneath Pitanguy mastopexies. The inferior incision was
carried around the trunk to correct undesirable rolls and
bulk. Others used the Wise pattern and recruited skin folds
below and lateral to the breasts to rebuild the breast.9–13
Successful use of a lateral thoracic fasciocutaneous fl ap
for breast reconstruction by Holstrom has ignited consider-
able interest in this trans-serratus perforator fl ap for post-
mastectomy,
cosmetic
augmentation,
and
massive
weight loss.14–18
Spiral fl ap breast reshaping with an upper body lift
evolved to correct glandular ptosis (bottoming-out), poor
breast projection, and inadequate lateral and superior pole
fi ll with neighboring excess tissue.19,20 The descended IMF
is raised. The inferior pole of the breast is supported and
augmented by the superior rotation of excess epigastric skin
and fat. The lateral thoracic fl ap is tunneled under the
superior breast to impart upper pole and lateral breast full-
ness and curvature. The operation combines well with the
L brachioplasty21 (Figs 13.3–13.5). Spiral fl ap refers to the
invariable twisting and advancement under and around
the breast of this compound superior epigastric and lateral
thoracic fl ap. Previously presented in technical detail,22 the

A
B
C
FIGURE 13.1 A Oblique anterior view show a 32-year-old 137-lb, 5 ft
4 in woman who lost 170 lb and is marked for total body lift surgery,
including lower body lift, abdominoplasty, vertical thighplasty and
Wise pattern mastopexy with 350 mL saline-fi lled silicone implant
augmentation. B Six months later she is pleased with her lower body
and thighs, but her breasts bottomed out with descent of her
inframammary fold (IMF). Markings are drawn for revision of her
mastopexy with a reverse abdominoplasty and an upper body lift,
including raising her IMF. C The result 2 years after her breast revision
with an upper body lift, showing an excellent breast shape, nipple
position, and maintenance of her IMF suspension.
Cosmetic and Reconstructive Breast Surgery
184

A
B
C
D
FIGURE 13.2 These are the anterior and left oblique views before and 6 months after an abdominoplasty and augmentation mastopexy
with 325 mL on the right and 390 mL on the left. Suture stabilization of her inframammary folds (IMFs) was performed through the inferior
portion of her implant dissection. She was 40 years old, 5 ft 6 in and 135 pounds, having lost 130 lb after gastric bypass surgery. Her breast
shape and IMF have maintained position.

A
B
C
FIGURE 13.3–FIGURE 13.5 These are the preoperative and 1-year
postoperative views of a 5 ft 4 in, 160 lb 42-year-old massive weight
loss patient who had a single-stage total body lift followed
by revisions of her right medial breast and central abdominal scars
and vertical thighplasties. There is long-lasting correction of all her
sagging skin and contour issues, with acceptably maturing scars. The
considerable inferior extension of her breast fl ap onto the
epigastrium is evident, as well as the lateral thoracic fl aps. Both
contributed volume and shaping to her breasts, which are
symmetrical and fi rmly supported by inframammary folds (IMFs). Her
convex lateral breast transitions into a concave but rounded anterior
axillary fold. The hanging arm skin is corrected with reduction of the
hyperaxilla and no constricting bands.
Cosmetic and Reconstructive Breast Surgery
186

A
B
C
FIGURE 13.4
D

Cosmetic and Reconstructive Breast Surgery
188
A
B
C
D
FIGURE 13.5

Breast Surgery in the Massive Weight-Loss Patient
189
spiral fl ap description in this chapter focuses on the increas-
ingly used modifi ed sickle version harvested from a verti-
cally oriented lateral thoracoplasty.
INDICATIONS AND CONTRAINDICATIONS FOR
SPIRAL FLAP RESHAPING (Boxes 13.1–13.3)
Spiral fl ap breast reshaping with an upper body lift is indi-
cated in patients with suitable torso anatomy who are in
good health and have a good understanding of the proce-
dure. We give our patient-oriented book, Total Body Lift, to
facilitate their comprehension and preparation for surgery.23
The patient needs to appreciate the value and diffi culty of
breast reshaping with upper body tissue discard. The patient
accepts fl ap donor site and mastopexy scars that may extend
around the back. Accompanying brachioplasty scars lie
along the medial arm, across the axilla, and down the mid-
lateral chest.
tissue is left attached inferiorly to the breast mound to be de-
epithelialized and fl ipped over the inferior pole. The roll of
lateral chest and back tissue is left contiguous to the central
breast mound as a transverse lateral thoracic extension.
For lesser back laxity without rolls of skin, the lateral
fl ap extension is modifi ed to ascend superiorly along the
mid-lateral chest to the axilla, which is the subject of the
accompanying video demonstration.
OPERATIVE APPROACH
Spiral fl ap reshaping depends on an understanding of the
above-described geometric interplay of upper body lift and
breast anatomy and aesthetics. One must preserve blood
supply to both the breast and this complex fl ap, and be
technically facile in de-epithelialization, harvesting, moving,
and shaping these fl aps using an appropriate mastopexy
technique.
Our clinical and cadaveric laboratory experience proves
that the vasculature of the breast, axial pattern and perfora-
tors of the lateral thoracic, thoracoacromial, internal
mammary and intercostal vessels emanates through sus-
pending fascia from the third to the fi fth ribs24 (Fig. 13.6).
Accordingly, the elevation of the descended breast from the
eighth to the sixth ribs does not disrupt this critical mid-
thoracic blood supply. Likewise, the creation of a lateral
suprapectoral opening and superior tunnel over the third
rib avoids critical axial vasculature. The mastopexy pattern
varies from circumareolar to Wise. Because undermining is
in the deep subcutaneous plane, the vascularity of the NAC
and parenchyma is preserved. Our experience with limited
skin necrosis is related to excessive tension at closure.
The spiral fl ap consists of both a broad-based inferior
fl ap extension of the central breast mound and a narrow-
based lateral thoracic fasciocutaneous fl ap supplied by
trans-serratus fascial intercostal perforators. The patient
with massive weight loss has large subcutaneous tissue
vessels which are readily identifi ed and supply these fl aps
to the tip of the scapula.
Finally, the breast reshaping depends on a complex
interplay of mastopexy and autogenous tissue fi lling, with
fl ip-up of an inferior fl ap of epigastric tissue and turning,
twisting, and advancement of a large fl ap of lateral chest
tissue tunneled under the upper pole of the breast. Persis-
tent projection and natural contour without bottoming-out
depend on secure suturing of the fl aps and the reverse
abdominoplasty to the costal cartilages and fascia.
Preoperative planning for the breast reshaping and upper
body lift begins with a fi nal assessment. Some patients lose
or gain substantial amounts of weight, or may have altered
their priorities and expectations. If a single-stage total body
lift is planned, the lower body lift and abdominoplasty are
drawn fi rst, which is taken into consideration for the upper
body lift.25
Severe skin laxity of the upper torso is optimally treated
with a complete upper body lift, a transversely oriented de-
epithelialized back fl ap, and a Wise pattern mastopexy (see
Figs 13.3–13.5. The upper body lift combines a reverse
abdominoplasty with removal of the back rolls, elevation
BOX 13.1 Indications
●
Patient aversion to silicone implants
●
Acceptance of risks and scars of fl ap reconstruction
●
Severe excess skin and fat in the mid-torso
●
Signifi cant breast ptosis
●
Inadequate breast volume
BOX 13.2 Contraindications
●
Smokers
●
Unreasonable expectations
●
Obese
●
Underweight
●
Minimal deformity
Obese patients with relatively poor vasculature and
thick immobile fl aps are generally poor candidates. Thin
patients offer insuffi cient tissue. Patients who are medically
and psychologically unstable, non-compliant, unreason-
able, and using tobacco products are also generally poor
candidates for these procedures.
Spiral fl ap reshaping successfully treats the empty breast
that is associated with extreme NAC ptosis and glandular
descent following massive weight loss. A variety of breast
shapes, ranging from broad and fl at to constricted, are ame-
nable to these operations. Patients who have had prior
breast reduction and implant augmentation are also treat-
able. In women with excess skin and fat in the upper torso
in which the lateral volume is greater than the medial
volume, the operation can be accompanied by a simultane-
ous upper body lift. Upper body lift consists of a reverse
abdominoplasty, excision of back skin excess, and creation
of a raised IMF. The anticipated upper abdominal excess

Cosmetic and Reconstructive Breast Surgery
190
and fi xation of the inframammary fold, and breast reshap-
ing. For severe deformity a Wise pattern mastopexy is
needed for elevation of the NAC, removal of excess breast
skin, and the inclusion of de-epithelialized discard from the
mid-torso.
In patients with mild to moderate upper body skin
laxity, the upper lift is modifi ed to give fewer and less con-
spicuous scars. Moderate breast ptosis may only need a
circumareolar or vertical pattern mastopexy. Isolated lateral
IMF descent responds to elevation only along the lateral
chest wall. The transverse back excision for the lateral
thoracic fl ap harvest can be exchanged for a wide
lateral chest de-epithelialized sickle shape. The back and
lateral chest skin is then advanced to the mid-axillary line,
with suture fi xation to the serratus fascia. The sickle shape
extends from the lateral breast to the short limb of the left
brachioplasty.
For the following operation description refer to the
accompanying video. Figures 13.6–13.8 show the preopera-
tive surgical markings and the result at 4 months of the
fi lmed patient.
Markings for the upper body lift begin with the patient
standing, which allows the torso skin and breasts to descend.
After the usual grid pattern is drawn, the ptotic breast is
elevated off the chest wall to site and mark the current IMF
along the nipple line. This level is registered across to the
lower sternum. The low breast is pushed up to the sixth
rib, and if the patient concurs that is the desired level this
higher IMF level is sited and marked over the sternum.
There will be a several but well-appreciated centimeter rise
from the old IMF.
Because raising the IMF lowers the NAC, the new NAC
is positioned several centimeters higher than the new IMF
along the nipple line. This point is also registered over the
sternum. If there is excess skin and the breast needs to be
narrowed, a Wise ‘keyhole’ pattern is drawn. To accom-
modate anticipated tissue fi ll, the descending vertical limbs
are kept narrow and long.
The inferior incision line of the Wise pattern, which is
usually placed about the current IMF, is positioned inferi-
orly onto the lower chest to include anticipated discard skin
from the reverse abdominoplasty. To determine this addi-
tional area of skin, the patient should lift her breast mound
to the anticipated higher level, then push the epigastric skin
upward and laterally until the umbilicus moves slightly
superior. The raised lower chest skin along the convergence
of the nipple line and an imaginary horizontal extension of
the new IMF are marked on the sternum with an ink dot.
From the ink dot a rising line sweeps medially to the medial
incision line of the Wise pattern near the sternum. From
the nipple line inferior incision junction the line continues
laterally and parallel to the lateral incision line of the Wise
pattern. The advanced reverse abdominoplasty fl ap estab-
lishes the new IMF. Unless there is synmastia these upper
reverse abdominoplasty incisions do not cross the anterior
midline.
The next step involves determining the breadth and
length of the transverse lateral chest and back skin roll to
be removed, which was not performed in the patient in the
video (Figs 13.1–13.3). This excess tissue provides fi ll and
shape as a de-epithelialized, laterally based fasciocutaneous
fl ap. The width of the tissue to be removed is determined
by gathering the local redundant skin. The shape of fl ap
resembles a hemiellipse rather than an equal-sided ellipse,
with the longer inferior line advanced laterally during
closure, which slightly reduces transverse width to narrow
the waist. The placement of this excision pattern results in
a closure along the brassiere line.
Alternatively, when there is only mild to moderate skin
excess in the mid-torso and back, and the patient objects
to a back scar, a sickle-shaped excision is drawn by pushing
this excess skin superior and lateral to the breast and gath-
ering the excess along the lateral chest, as seen in the video.
The lateral chest excision continues into the axilla as the
short limb of the L brachioplasty. For most patients, the
upper body lift is completed with an L brachioplasty.21 This
complements the breast reshaping as it treats four inter-
twined deformities of the upper arm, axilla, and lateral
chest. The brachioplasty corrects the canopy-like hanging
skin, ptosis of the posterior axillary fold, oversized axilla,
and lax lateral chest skin.
The L brachioplasty consists of a long-limbed hemi-
elliptical excision of the inferior medial upper arm skin and
a short-limbed vertical elliptical excision of the lateral chest
connected by an inverted V excision through the axilla (see
Figs 13.3, 13.4, 13.7 and 13.8, and video for details of the
L brachioplasty markings). The superior incision line of the
arm ellipse rises from the medial elbow along the bicipital
groove to the deltopectoral groove. By gathering and pinch-
ing the excess skin of the arm, the inferior incision line
extends from the medial elbow along the posterior margin
of the arm to rise towards the deltopectoral groove. The
FIGURE 13.6 This right breast anatomical specimen was prepared
with Microfi l intravascular injections. Previous anatomical dissections
have confi rmed a mid-breast suspensory ligament containing a ring
of dominant blood supply from internal mammary perforators to
lateral intercostal and lateral thoracic vessels from the third to the
fi fth ribs. The NAC is being held with a hook. The spiral fl ap reshaping
technique preserves these transverse dominant third to fi fth rib
vascular arcades.

Breast Surgery in the Massive Weight-Loss Patient
191
A
B
C
FIGURE 13.7–FIGURE 13.9 These are the preoperative and 27-
month postoperative views of a 5 ft 6 in 175 lb, 37-year-old massive
weight loss patient who had a single-stage total body lift. The upper
body lift, spiral fl ap breast reshaping and L brachioplasty are
demonstrated in the accompanying video. There is correction of all
her sagging skin and contour issues, with acceptably maturing scars.
Her breasts are symmetrical with adequate superior pole fullness
and no glandular ptosis. Her convex lateral breast transitions into a
concave but rounded anterior axillary fold. The hanging arm skin is
corrected with reduction of the hyperaxilla and no constricting
bands.

B
C
D
FIGURE 13.8
A

second ellipse drops vertically from the deltopectoral groove
to include approximately the lateral half of the axilla and
excess lateral chest wall skin. The chest portion of this
ellipse is coordinated with the removal of a back roll per-
formed during an upper body lift, and expansion of the
breast by auto-augmentation.
An inferiorly based triangular fl ap is formed as the infe-
rior arm incision meets the lateral incision of the vertically
oriented lateral chest ellipse. The ability to advance this
triangular fl ap to the deltopectoral groove is established by
pinch approximation. This maneuver elevates the ptotic
posterior axillary fold, tapering the arm into the axilla.
For the severe deformity, the upper body lift with spiral
fl ap reshaping begins in the prone position with the
harvesting of a lateral chest fl ap from mid-back excess. In
mild to moderate situations the sickle fl ap modifi cation is
prepared in the supine position. In either case, the fl ap is
de-epithelialized before elevation. As these fl aps and the
epigastric fl aps are large areas, removal of thick, split-
thickness grafts with an electric dermatome is preferred. A
subsequent careful search for and removal of retained epi-
thelium is essential to minimize cyst formation. The de-
epithelialization commits the width of resection, so the
surgeon must be accurate in preoperative marking. While
the patient is prone in the severe cases, the perimeter inci-
sions are made through the subcutaneous fat to the latissi-
mus dorsi muscle. After undermining for several centimeters,
the fl ap is elevated from the muscular fascia extending
medial to lateral. The muscular fascia is included with the
fl ap near the lateral border of the latissimus dorsi, as when
the serratus anterior muscle is reached the dissection stops.
Prior infi ltration with epinephrine-containing solutions is
recommended to reduce blood loss. The edges of the exci-
sion are aligned with towel clips for the two-layer closure.
The patient is wrapped in a surgeon’s gown and turned
supine. The de-epithelialized lateral chest fl aps remain
attached to the serratus anterior and the central breast
pedicle. When the width of the reverse abdominoplasty skin
excision is confi rmed, the extended Wise pattern is de-
epithelialized. After marking the NAC with a 45 mm diam-
eter cookie cutter, the Wise pattern mastopexy with its
epigastric extension is de-epithelialized and extends to the
previously raised lateral thoracic fl ap extension. This tedious
process is expedited with the use of an electric dermatome
set at 32 thousands of an inch. The medial, superior and
lateral skin fl aps of the Wise pattern are incised and under-
mined superfi cially as needed.
If the sickle-shaped modifi cation of the spiral fl ap is
chosen, the de-epithelialized fl ap perimeter incisions are
made and the fl ap is raised from the serratus fascia, starting
A
B
FIGURE 13.9
Breast Surgery in the Massive Weight-Loss Patient
193

Cosmetic and Reconstructive Breast Surgery
194
from the axilla. The fl ap’s anterior limb incision is com-
pleted fi rst. With identifi cation of the lateral border of the
pectoralis major muscle near the fourth rib, dissection of a
tunnel for the fl ap continues across the muscle. Because
the muscle is adherent to the skin, in thin patients it can
be easily palpated along the anterior axillary line. The
search for this junction is aided in heavier patients by incis-
ing to the anticipated level of the muscle and then retract-
ing away. A dissection that is too deep tends to be associated
with increased blood loss and may result in damage to
major blood supply to the breast. Once the lateral border is
identifi ed, the dissection proceeds broadly over the anterior
surface over the third and fourth ribs. A path from the base
of the lateral thoracic fl ap to the window over the pectoralis
muscle is created without injuring the large vessels overly-
ing the serratus fascia. The pocket for the spiral fl ap
is developed towards the parasternal region. The space is
crescent-shaped, extending under the superior pole of the
breast from lateral border of the pectoralis muscle near the
fourth rib to the sixth sternochondral junction. The tunnel
is widened enough to accept the lateral thoracic fl ap.
The next step includes the posterior incision and com-
pletion of fl ap elevation. The fi fth, sixth, and perhaps the
fourth intercostal trans-serratus perforators are protected
by awareness of the lateral border of the latissimus dorsi
muscle and the ribs. These vessels can be located by Doppler
or direct visualization to the mid-axillary line. The lateral
thoracic portion of the fl ap is nearly raised, but not until
the entire breast is suspended, so the reverse abdomino-
plasty begins.
The
long
junction
between
the
extended
de-
epithelialized fl ap and upper abdomen is incised from the
parasternal region to the raised lateral thoracic fl ap. The
breast with its epigastric fl ap extension is undercut along
the rectus muscle fascia from the lower ribs to the sixth rib.
The new IMF position, which has been registered over the
sternum, guides this movement of the central breast pedicle.
The termination of the tunnel for the lateral thoracic fl ap
is completed under the medial fl ap of the Wise pattern
parasternally about the sixth rib.
With the breast mobilized and the submammary tunnel
completed, the lateral thoracic fl ap is prepared for augmen-
tation by trimming back the distal tip until bright red
bleeding is appreciated. A suture is placed through the distal
end of the fl ap, followed by the insertion of a long clamp
through the parasternal site. This is grasped and the back
fl ap rotated along the lateral border of the pectoralis muscle,
into the submammary space. This pulling suture is then
stitched to the sixth costochondral junction, which holds
the medial position of the fl ap. While in situ, the fl ap is
tailored to optimally augment and reshape the breast. Gen-
erally the fl ap lies fl at, but it may be rolled or further
advanced on itself. The spiral fl ap is stitched to the lateral
border entrance of the pectoralis major muscle. The breast
usually slopes laterally with inadequate projection. Central-
izing the breast requires suture suspension of the de-epi-
thelialized fl ap, catching mid-epigastric fl ap dermis and
pulling it medially by approximating it to the sixth rib
cartilage.
The next step is to align the NAC and superior portion
of the Wise pattern vertical fl aps. The inferior epigastric
extension is rotated upward and sutured to shape and
project the mound.
Attention is again directed to the reverse abdomino-
plasty component. The inferior pedicle abdominal skin
fl ap is directly undermined for several centimeters, and
with the aid of graduated Brazilian dissector dilators the
fl ap is discontinuously undermined over the rectus abdomi-
nis fascia beyond the costal margins. The breast pedicle is
repositioned superiorly and the inferiorly based abdominal
fl ap is advanced to the new IMF, which is usually at the
fi fth and sixth ribs. Approximately 12 interrupted 0 braided
polyester sutures are placed in the subcutaneous fascial
portion of the fl ap and along the sixth rib cartilage and
periosteum. With the modifi ed upper body lift and sickle
fl ap, the advancement of the reverse abdominoplasty is in
continuity with the lateral chest skin fl ap.
With the abdominal fl ap pushed fi rmly upwards, the
sutures are sequentially tied. The closure of the reverse
abdominoplasty forms the new inframammary fold, hidden
under the breast.
The medial and lateral Wise pattern breast fl aps are
advanced over the breast mound and sutured together and
along the IMF to complete the restoration of the breast.
The added fl ap volume creates additional tension on the
closure of the Wise pattern fl aps. A high-tension closure of
the lateral thoracic fl ap donor site from the axilla to the
IMF appropriately fl attens this area, emphasizing the newly
created lateral breast fullness and projection. The lateral
chest donor site closure is continuous with the advanced
and stabilized new IMF. A fi rm fold also improves breast
projection and eliminates bottoming-out. A matching pro-
cedure is performed on the contralateral breast.
The reverse abdominoplasty is closed in three layers.
After the interrupted large braided permanent sutures, there
are running absorbable sutures placed in the subdermal
region and monofi lament sutures placed in the dermis.
During this closure, the L brachioplasty begins with thor-
ough liposuction under the skin destined for resection.
Ultrasound-assisted lipoplasty (UAL) with additional UAL
of the arm is preferred and performed as needed. The pos-
terior incision is followed by the anterior incision. The L-
shaped strip of skin with very little fat is excised, leaving
denuded vasculature and sensory nerves. Closure of the
brachioplasty begins with deep suture advancement of the
posterior axillary fold triangular fl ap across the axilla to
the deltopectoral groove with 2/0 braided suture. Towel
clips are used to align the skin closure. Closure is performed
in two layers using an absorbable suture. Our experience
with the speed, ease, and holding power of the Quill 0
double-armed barbed suture has been favorable. Quill 2/0
sutures can also be used for the dermal closure. The ipsi-
lateral breast can be closed concurrently with the de-epithe-
lialization on the contralateral breast.
The fi nal intraoperative video and the results 2 weeks
postoperatively are shown in the video. As the skin tension
begins to equilibrate, the brachioplasty scar courses from
the medial epicondyle along the medial arm, just inferior

Breast Surgery in the Massive Weight-Loss Patient
195
Some patients have experienced a diminution of supe-
rior pole fullness over time. Others have developed lateral
breast fullness at the base of the lateral thoracic fl ap. In two
patients the lateral breast was further advanced along the
serratus fascia to correct this malposition. In the occasional
case of breast size asymmetry, the fault lay in failing to
consider the preoperative size discrepancies. Lateral IMF
descent was signifi cant in fi ve breasts, probably owing to
the large size of the fl aps. This descent was corrected with
readvancement of the lateral breast.
The L brachioplasty triangular fl ap across the axilla has
a tenuous blood supply and may suffer necrosis, particularly
if there is direct pressure. A small area of skin loss may
lead to a large wound that may need to heal by secondary
intention.
POSTOPERATIVE CARE
The incisions are usually covered with a skin glue together
with a light gauze dressing and a surgical bra. No constrict-
ing binder is place across the mid-abdomen, although a
long-leg elastic lower body garment is used. Patients are
admitted for a single night’s observation and care. The
brachioplasty incisions are covered with large gauze pads
and placed in an ACE wrap. These are replaced by elastic
sleeves several days later. No direct pressure is placed on
the triangular fl ap in the axilla as it is vulnerable to isch-
emic necrosis. As previously stated, considerable incisional
pain may linger along the IMF, which may require and
responds well to intercostal nerve blocks.
The scars may take years to mature, especially along the
distal arm. Minor contour deformities of the breast are suc-
cessfully treated with lipoaugmentation in the subcutane-
ous plane.
CONCLUSION
There are a variety of operations to reshape the breast after
massive weight loss. It is the primary author’s feeling that
options using autologous tissue are preferable to those that
use prosthetic devices, and therefore these fl aps have
become the treatment of choice A compound fl ap that
includes an epigastric and a lateral thoracic extension to
the central breast mound has been designed and termed a
spiral fl ap based on the manner of usage. The spiral fl ap
has been successfully combined with an upper body lift and
L brachioplasty in over 100 patients. The sickle-shaped
modifi cation is demonstrated on video for this atlas.
REFERENCES
1. Regnault P. Breast ptosis. Clin Plast Surg 1976; 3: 193–203.
2. Spear SL, Majidian A. Mastopexy. In: Spear SL, ed. Breast surgery:
principles and art. Philadelphia: Lippincott Williams & Wilkins,
1998: 673–684.
3. De Pina DP. Technical refi nements in mammaplasty. Plast
Reconstruct Surg 1983; 71: 50.
4. Exner K, Scheufl er O. Dermal suspension fl ap in vertical-scar
reduction mammoplasty. Plast Reconstruct Surg 2002; 109:
2289.
BOX 13.3 Optimizing outcomes
●
Properly analyze the deformity and the volume of tissue
available for auto-augmentation
●
Select the appropriate mastopexy pattern and anticipate the
extra skin to accommodate added breast volume
●
Consider the sickle pattern modifi cation of the spiral fl ap for
less severe deformity or to avoid a back scar
●
Master each of the component operations and their complex
interplay
●
Develop an obsessive marking technique that leads to
confi dence to commit full inclusion into fl aps, pre-excision
defatting, or expeditious excision
●
Learn a rapid means of de-epithelialization, such as the use
of an electric dermatome
●
Minimize the use of electrocautery to make incisions that
will be closed under tension
●
Secure the IMF as fi rmly as possible
●
Expect the closure tension of the reverse abdominoplasty
and the breast mound to be high
●
Further undermine the Wise pattern fl aps, or remove some
of the spiral fl ap if the closure tension is too high
●
Develop a team of operators with confi dence in each other
to the bicipital groove, coursing to the axillary dome before
descending vertically and terminating on the chest, forming
an inverted L. The inferior contour of the arm drops slightly
at the mid-humerus and then rises distinctly to a superiorly
positioned posterior axillary fold. The suspended posterior
axillary fold skin conforms well to the axillary hollow. The
brachioplasty scar zigzags through the axilla, descending
and curving around the lateral breast, similar to the lateral
brachiothoracoplasty of Pitanguy.26 The mid-torso laxity
has been corrected, and the breasts are raised, with improved
fullness and shape.
COMPLICATIONS AND SIDE EFFECTS
Moderate incisional pain may linger for several weeks along
the reconstructed IMF. Oral medication with narcotics is
usually adequate. In cases where pain is protracted, an
intercostal nerve block may be useful. Breasts in which the
swelling and edema are moderate to severe generally relax
and become ptotic, usually over the course of 1 month.
Diffusely swollen upper extremities require higher elevation
and more complete elastic wrapping.
The most common complication is distal fl ap necrosis
of the lateral thoracic extension. Experience has demon-
strated that some fi rmness may be palpable in about 20%
of cases. This will generally resolve without treatment.
From over 100 cases, inclusion cysts necessitating a biopsy
or aspiration have been performed in only four. One patient
suffered skin edge necrosis of the reverse abdominoplasty
fl ap and cellulitis 1 week after an upper body lift. She had
resumed cigarette smoking immediately after her surgery.
Healing was by secondary intention. Scar revision restored
an aesthetic result.

5. Frey M. A new technique of reduction mammoplasty: Dermis
suspension and elimination of medial scars. Br J Plast Surg 1999;
52: 45.
6. Goes J. Periareolar mammoplasty with mixed mesh support: The
double skin technique. Op Tech Plast Reconstruct Surg 1996; 3:
197.
7. Graf R, Biggs T. In search of better shape in mastopexy and
reduction mammoplasty. Plast Reconstruct Surg 2002; 110: 309.
8. Rubin JP, O’Toole J, Agha-Mohammadi S. Approach to the breast
after weight loss. In: Rubin JP, Matarasso A, eds. Aesthetic surgery
after massive weight loss. Philadelphia: Saunders Elsevier, 2007;
37–38.
9. Zook EG. The massive weight loss patient. Clin Plast Surg 1975;
2: 457–466.
10. Wise RJ. A preliminary report on a method of planning the
mammaplasty. Plast Reconstruct 1956; 17: 367–369.
11. Palmer B, Hallberg D, Backman L. Skin reduction plasties
following intestinal shunt operations for treatment of obesity.
Scand J Plast Reconstruct Surg 1975; 9: 47–52.
12. Shons AR. Plastic reconstruction after bypass surgery and massive
weight loss. Surg Clin North Am 1979; 59: 1139–1152.
13. Holstrom H, Lossing C. The lateral thoracodorsal fl ap in breast
reconstruction. Plast Reconstruct Surg 1986; 577: 933.
14. Heitmann C, Guerra A, Metzinger SW, et al. The thoracodorsal
artery perforator fl ap: anatomical basis and clinical application.
Ann Plast Surg 2003; 51: 23–29.
15. Levine JI, Soucid NE, Allen RJ. Algorithm for autologous breast
reconstruction for partial mastectomy defects. Plast Reconstruct
Surg 2005; 116: 762.
16. Van Landuyt K, Hamdi M, Blondeel P, Monstrey S. Autologous
augmentation of pedicled perforator fl aps. Ann Plast Surg 2004;
53: 322–327.
17. Pittet B, Mahajan AL, Alizadeh N, et al. The free serratus anterior
fl ap and its cutaneous component. Plast Reconstruct Surg 2006;
117: 1277.
18. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous
augmentation after MWL: The intercostal artery perforator (ICAP)
fl ap. Ann Plast Surg 2006; 57: 361.
19. Hurwitz DJ, Golla D. Breast reshaping after massive weight loss.
In: Shenaq S, Spear SL, Davison S, eds. New trends in breast
reduction and mastopexy. Semin Plast Surg 2004; 18: 179–187.
20. Hurwitz DJ, Agha-Mohammadi S. Post bariatric surgery breast
reshaping: the spiral fl ap. Ann Plast Surg 2006; 56: 481–486.
21. Hurwitz DJ, Holland SW. The L brachioplasty: An innovative
approach to correct excess tissue of the upper arm, axilla and
lateral chest. Plast Reconstruct Surg 2006; 117: 403–411.
22. Hurwitz D. Breast reduction and mastopexy after massive weight
loss. In: Spear S, ed. Surgery of the breast. Philadelphia: JB
Lippincott, 2005; 1193–1209.
23. Hurwitz DJ. Total body lift: reshaping the breast, chest, arms,
thighs, hips, waist, abdomen and knees after weight loss, aging
and pregnancies. New York: MDPublish, 2005.
24. Wuringer E, Mader N, Posch E, et al. Nerve and vessel supplying
ligamentous suspension of the mammary gland. Plast Reconstruct
Surg 1998; 101: 1486.
25. Hurwitz DJ. Single stage total body lift after massive weight loss.
Ann Plast Surg 2004; 52: 435–441.
26. Pitanguy I. Correction of lipodystrophy of the lateral thoracic
aspect and inner side of the arm and elbow. Clin Plast Surg 1975;
2: 477.
Cosmetic and Reconstructive Breast Surgery
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197
C H A P T E R
14
Gynecomastia
Michael Zenn
INTRODUCTION
Gynecomastia is a benign enlargement of the male breasts.
This may be due to proliferation of the glandular compo-
nent or to an increase in the adipose component of the
breast. Both etiologies are quite common. There is a bimodal
distribution to the occurrence of gynecomastia. The fi rst
peak occurs during puberty, around the ages of 13 and 14
years; this trend declines through the late teenage years.
The second peak is found in the adult population between
50 and 80 years. There is no racial difference in the preva-
lence of gynecomastia.1,2
Many medical conditions are associated with gyneco-
mastia (Table 14.1), but it is beyond the scope of this
chapter to go into each of these. The etiology should be
diagnosed prior to treatment.1–3
INDICATIONS AND CONTRAINDICATIONS
Evaluation
Gynecomastia, due either to fatty enlargement or to glan-
dular proliferation, can usually be discriminated by physical
examination. Although some may consider gynecomastia
due to fatty enlargement to be ‘pseudogynecomastia,’ both
conditions are of concern to the patient and are treated by
plastic surgery. The degree of fatty infi ltration versus glan-
dular breast tissue will ultimately dictate the course of
action to be taken.
Any breast mass found on examination should not be
assumed to be breast tissue, as other disorders, such as
neurofi bromas, lymphangiomas, lipomas, and dermoid
cysts, can account for such masses. Breast cancer in men
accounts for 1% of all breast cancers and should also always
be in the differential diagnosis, especially if the mass has
been enlarging and is asymmetric with the contralateral
side.1
PREOPERATIVE HISTORY AND
CONSIDERATIONS
Painful, tender gynecomastia appearing during puberty
requires only history, physical examination, palpation, and
examination of the testicles by palpation or ultrasound. If
these are normal, reassurance and periodic follow-up are
prescribed. In the majority of patients with this condition,
spontaneous resolution will occur within 1–2 years. Evi-
dence of feminization, such as small testicular size, lack of
male hair distribution, or a eunuchoid body habitus, sug-
gests a feminizing tumor and endocrine work-up is indi-
cated, starting with serum testosterone, estradiol, lutein-
izing hormone, and dehydroepiandrosterone levels.1,3,4
Gynecomastia in men is quite common. Work-up should
include a careful history, including medication use, social
history, questions about hepatic dysfunction, testicular
insuffi ciency, pulmonary symptoms, and hyperthyroidism.
These questions will uncover most conditions associated
with gynecomastia. If physical examination is normal, and
if liver function, renal function, and thyroid function are all
normal on laboratory examination, further examination is
unwarranted. Drugs that may be causing gynecomastia
(Table 14.2) should be discontinued if possible, and the
patient should be re-evaluated in 1 month. If gynecomastia
is progressive or new in onset and there are no abnormalities
in physical examination or basic laboratory screening, mea-
surements of chorionic gonadotropin, testosterone, estra-
diol, and luteinizing hormone are indicated.1,3,4
OPERATIVE APPROACH
Treatment
Treatment of the enlarged breast is indicated if gynecomas-
tia causes pain, embarrassment, or emotional discomfort
that interferes with the patient’s daily life. The remainder

Cosmetic and Reconstructive Breast Surgery
198
of this chapter will deal with the surgical treatment of
gynecomastia when no other medical interventions are
required for diagnosis or treatment.
Treatment will depend on the degree of gynecomastia and
its composition. Patients who are smaller-breasted and have
a large component of fatty tissue can be managed with lipo-
suction alone. Patients with signifi cant breast tissue which
is not amenable to liposuction will require direct excision.
Patients having a large breast with excessive skin as well as
underlying breast tissue will require a procedure to reduce
the volume of the breast as well as the skin envelope.
The ultimate goal of gynecomastia repair is a fl at chest
in line with the patient’s body habitus, minimal scarring,
and appropriately positioned and shaped nipple complexes.
It is obvious to those of us who treat this condition com-
monly that patients may be treated in a variety of ways for
a similar condition, and there are those who feel strongly
that their way is the best. It is the goal of this chapter to
lay out all possible treatments for gynecomastia and leave
it to the clinician to decide which would be the most appro-
priate in any particular case. It is helpful, when deciding
which procedure should be performed, to involve the patient
as much as possible and help him make decisions regard -
ing scar placement, morbidity, and downtime from the
different surgical procedures, and ultimately, the fi nal
outcome.
Liposuction
In cases of minor gynecomastia with minimal skin excess
and a majority of fatty tissue excess, liposuction alone can
TABLE 14. 1 Conditions associated with gynecomastia
Neoplasms
Testicular (germ cell, Leydig cell or Sertoli cell)
Adrenal (adenoma or carcinoma)
Atopic production of HCG (lung, liver and kidney cancer)
Primary gonadal failure
Acquired (trauma, infection, torsion, radiation, chemotherapy)
Congenital
Secondary hypogonadism
Defects of testosterone production
Androgen-insensitivity syndromes
True hermaphroditism
Liver disease
Starvation
Renal disease
Hypothyroidism/thyrotoxicosis
Excessive extraglandular aromatase activity
Drugs (see Table 14.2)
Idiopathic gynecomastia
TABLE 14.2 Drugs associated with gynecomastia
Category
Drug
Hormones
Androgens
Anabolic steroids
Chorionic gonadotropin estrogens
Antiandrogens or inhibitors
of androgen synthesis
Cyproterone
Flutamide
Estrogen-binding blockers
Clomid
Antibiotics
Isoniazid
Ketoconazole
Metronidazole
Anti-ulcer medicines
Cimetidine
Omeprazole
Ranitidine
Cancer agents (anchorin
agents)
Cardiovascular
Amiodarone
Captopril
Digitoxin
Enalapril
Methyldopa
Nifedipine
Reserpine
Verapamil
Spironolactone
Psychoactive agents
Diazepam
Haloperidol
Phenothiazines
Tricyclic antidepressants
Drugs of abuse
Alcohol
Amphetamines
Heroin/opiates
Marijuana
Other
Phenytoin
Penicillamine
Auranofi n
Sulindac
Theophylline
be successful.5,6 This can be done through a remote-access
incision in the axillae, or in the periareolar area. Some cases
can be done in a stepwise fashion, performing liposuction
fi rst and determining whether any direction excision is
required secondarily. Some people advocate performing
gynecomastia in two separate stages when there is skin
excess.2 In such cases liposuction is performed to removed
the fatty component and allow the skin to retract. Second-
ary resection of skin and breast is then performed when the
requirements for resection have diminished. This may limit
the ultimate quantity of scar, but the patient must agree to
a two-stage procedure. Most recently, ultrasonic liposuction
has been championed as the treatment for the majority of
cases of gynecomastia, even where there is signifi cant glan-
dular tissue.4,7

Gynecomastia
199
Direct excision
Before liposuction, the gold standard for gynecomastia
repair was direct excision. In minimal and some moderate
cases, reduction can be carried out through a periareolar
excision only, excising both skin and fatty tissue. The more
modern version of this procedure involves central resection
of breast tissue only and peripheral liposuction at the same
time. Most cases can be managed by this technique.8 The
disadvantages of this procedure include insensitivity of the
nipple, as direct breast tissue excision will, by defi nition,
divide the innervation to the nipple–areolar complex. Spon-
taneous reinnervation may occur to varying degrees, but
this cannot be guaranteed.
There is also an art to the excision procedure to ensure
that enough tissue remains under the nipple so that the
contour with the surrounding skin and subcutaneous tissue
is seamless. One must remember in these cases that
removal of all breast tissue is not the goal. This is a con-
touring procedure, and thinking about it as such will avoid
contour-related problems later.
Limited skin resection procedures
In cases of moderate to severe gynecomastia where excess
skin, breast ptosis, and an enlarged areola are characteristi-
cally seen, limited procedures will not suffi ce. In addition
to removing volume via liposuction or direct excision, skin
must also be removed. The most common mistake made
in skin removal procedures is to treat the male breast like
the female breast and perform skin resection with an
inverted T or ‘Wise pattern’ excision. Performance of a T
excision in the male shows a lack of understanding of its
design. In a female breast, T excision is largely hidden by
the breast mound itself. In a male gynecomastia repair,
where the goal is a fl at chest and limited scar, a T incision
becomes quite conspicuous.
The goal of limiting scarring from skin excision in gyne-
comastia would be best met if it were possible to hide the
scar in the periareolar area only. This is possible if only
moderate ptosis exists.9,10 Examples of signifi cant skin
reduction in cases of signifi cant ptosis using only a peri-
areolar scar have been reported, but have limited applicabil-
ity.11 The fi nal skin contour must be smooth without
wrinkling, and this is the limiting factor in using the peri-
areolar approach.
Historically, many limited skin incision designs have
been performed12–20 (Fig. 14.1). Common to many of these
procedures is the maintenance of a periareolar scar and
limiting the length and locations of any additional scars.
The optimal skin incision design used would be patient-
dependent and based on clinical judgment at the time of the
procedure. In general, scars that extend laterally and inferiorly
from the periareolar area are perhaps best hidden. One should
try to avoid medial or superior extension when possible.
Maximal skin removal procedures
Many patients presenting with gynecomastia, especially
those presenting after bariatric surgery, have large skin
envelopes which are essentially empty. Nipples can be mal-
positioned quite distant from their normal location. Large
skin excisions need to be performed in these cases and, as
with much post-bariatric surgery, contour is the primary
concern and the length of the scars secondary. Patients will
accept large scars so that they may wear clothes comfortably
and not have any hanging skin. Although small nipple
movements can retain a nipple on a small dermal pedicle
and still maintain its viability, larger nipple movements are
best treated with free nipple grafting.21 The goal in these
procedures is to maximally remove skin symmetrically so
that a fl at contour is left. In most cases of skin excision,
whether maintaining the nipple on a pedicle or free grafting
it, nipple sensation will probably be absent and there is the
added increase risk of necrosis or graft loss.
Nipple positioning
Important considerations in gynecomastia repair is the ulti-
mate location, size, and shape of the nipple–areolar complex
once the reduction is performed.22–24 In cases of volume
reduction without skin excision, one can expect a larger
areola to contract signifi cantly once there is no volume
underneath it. The degree of reduction is variable but should
be symmetric. Although the fi nal areola may still be large, it
is desirable to avoid complete periareolar scars when possi-
ble. A slightly enlarged areola has a more natural appearance
out of clothes than one with a concentric scar.
In cases where skin excision is planned, one must pay
close attention to locating the nipple–areolar complex and
making it the appropriate size. Although there is natural
variation, the appropriate-size nipple–areolar complex in a
male is smaller than that of a female. Whereas the female
nipple–areolar complex tends to be round, with an average
diameter of 40 mm, the male complex is oval in shape, with
an average horizontal diameter of 27 mm and an average
vertical diameter of 20 mm. Many papers have been written
on localization of the nipple–areolar complex.22–24 In general,
most nipples are located in the fourth or fi fth intercostal
space over the inferior margin of the pectoralis muscle.
Although some publications recommend reliance on ana-
tomic and soft tissue landmarks such as the acromioclavicu-
lar joint and the anterior superior iliac spine, others use
more sophisticated calculations. One such method reported
by Beer et al.24 uses measurements of the circumference of
the chest and length of the sternum to help localize the new
nipple–areolar complex. Clinically, it is helpful to compare
clinical judgment to these formulas for placement as a check
prior to fi nal nipple placement. Bear in mind that in all
techniques some settling may occur. This will vary depend-
ing on the patient’s anatomy and tissue characteristics.
Complications
As with other breast procedures, common complications of
gynecomastia repair include bleeding, infection, seroma,
asymmetry, bad scarring, pain, and a poor cosmetic result.
The most common reasons for patient dissatisfaction
include the appearance of scars, persisting fullness in the
chest, irregularity of the skin, nipple and skin insensitivity,
and chronic pain.

Cosmetic and Reconstructive Breast Surgery
200
A
B
C
D
E
F
G
H
FIGURE 14.1 Examples of incision patterns for gynecomastia repair (‘striped’ areas are de-epithelialized; ‘fatty’ areas are resected). A. Lower
periareolar (Webster12) B Omega (Barsky13). C Transareolar (Pitanguy14). D Superior areolar (Letterman and Schurter15). E Nipple transposition
with lateral excision (Letterman and Schurter16). F Bipedicle (Pers17, Peters18). G Mastectomy with free nipple graft (Wray19). H Periareolar excision
with purse-string closure (Huang20, Colic11, Persichette10).