Operative Technique in Plastic Surgery – Kevin C.Chung

volume and the patient has reached his or her full developmental maturity.7
■ Performed in the lateral decubitus position.
■ The same 5- to 6-cm incision is used for the harvest of the latissimus dorsi
muscle.
■ The 10-mm, 30-degree endoscope is inserted to complete the superficial
and deep dissection of the latissimus dorsi muscle as previously described
(TECH FIG 3).
■ With the thoracodorsal neurovascular pedicle directly visualized, the origin
and insertion of the muscle are divided.
■ The patient is then repositioned supine, and the anterior dissection is
performed to regain access to the tissue expander.
■ The tissue expander is removed and the latissimus dorsi muscle is
transferred into the anterior pocket and sutured into place.
• The lumbosacral fascia is affixed to the sternum and along the new
position of the inframammary fold.
• The former lateral border of the latissimus dorsi muscle is secured to the
inferior border of the clavicular head of the pectoralis major muscle.

TECH FIG 3 • Two-stage endoscopic approach using
a 5-cm axillary incision. The initial dissection is
performed under direct, open, visualization. The
subsequent dissection is performed under endoscopic
visualization for muscle harvest.
• The insertion of the latissimus dorsi muscle is attached anteriorly to the
bicipital groove of the humerus.
■ A breast implant can then be positioned deep to the latissimus dorsi muscle.

PEARLS AND PITFALLS
Hemostasis
■ Maintain adequate hemostasis to avoid hematomas that may
subsequently become infected causing removal of implants.
Latissimus
dorsi muscle
transfer
■ Avoid dissecting under the teres major at the inferior angle of the
scapula.
■ Maintain visualization of the thoracodorsal pedicle during the
endoscopic harvest of the latissimus dorsi muscle to avoid injury
to the pedicle.
■ Perform dissection of the vascular pedicle under direct
visualization in the axilla to permit safe mobilization of the
latissimus dorsi muscle.
Tissue
expander and
implant
■ Score the deep surface of the breast parenchyma to allow
complete expansion of the breast.
Customized
chest
implants
■ Paying special attention to “feathering” of the implant’s border
during design and fabrication of the implant can hide visible,
palpable edges (FIG 4).
■ Fat grafting during implantation can also help reduce visible and
palpable edges.
■ Fat grafting can also be done secondarily to correct visible and
palpable edges noted postimplantation.
Secondary
procedures
■ Often contralateral mammoplasty is needed to maintain
symmetry.
■ Nipple-areolar complex reconstruction is occasionally needed.
■ Translocation of the nipple-areolar complex to create symmetry
with the contralateral side may be indicated.
POSTOPERATIVE CARE
■ Following Poland syndrome reconstruction, standard incisional postoperative
care is required.
■ For patients who require an implant-based reconstruction, postoperative
protocols apply.
■ Perioperative oral antibiotics are commonly given.
■ Closed-suction drains, when placed, are not removed until the output from
each drain is less than 30 cc for 2 consecutive days.

OUTCOMES
■ The goals for reconstruction of the female patient are to achieve breast
symmetry, recreate the anterior axillary fold, and provide adequate
infraclavicular fullness.
■ These goals are successfully achieved with any of the aforementioned
reconstructive options.
■ To optimize breast symmetry, female patients most often request a
contralateral mastopexy and/or reduction.
■ Seyfer et al.14 performed 57 operations on 29 women and incurred no
revision operations when they performed the latissimus dorsi transfer in
conjunction with breast implant. Most complications seen were due to the
breast implant itself. Capsular contractures were revised using open
capsulotomies.14
■ The general goal for reconstruction of the male patient is to achieve symmetric
chest wall contour (FIG 4).
■ As in their female counterpart, the latissimus dorsi transfer had better overall
outcomes.3
■ When performed as an isolated procedure, the latissimus dorsi muscle
transfer is prone to undercorrect the deformity; however, fat grafting can be
used as an adjunctive procedure to improve symmetry over time.
■ The reconstructive results for Poland syndrome tend to be long-lasting,
accompanied by high patient satisfaction.3
COMPLICATIONS
■ Complications of Poland syndrome reconstruction include seroma, hematoma,
infection, scar, delayed wound healing, and pain/paresthesias.
■ Seroma formation was most often seen after the removal of the closed-
suction drains in the latissimus dorsi transfer donor site.14
■ However, as in the Seyfer et al.14 study, these seromas are typically small
and treated conservatively until they resolve on their own.
■ Long-term complications can occur with implant-based reconstruction and are
manifested predominantly by capsular contracture and implant rupture.3,14
■ Progressive asymmetries can also become apparent over time due to
discordant amount of breast tissue and differences in the skin envelope.
■ Implant infection and malposition may also occur.

FIG 4 • Left Poland Syndrome. A. Preoperative. B. Four
years postoperative using a customized chest wall
implant reconstruction with a “feathering” technique to
camouflage the edges of the implant.
REFERENCES
1. Buchanan P, Leyngold M, Mast BA. Bipolar latissimus dorsi transfer for
restoration of pectoralis major function in Poland syndrome. Ann Plast Surg.
2016;77(1):85-89.
2. Ram AN, Chung KC. Poland’s syndrome: current thoughts in the setting of a
controversy. Plast Reconstr Surg. 2009;123(3):949-953.
3. Seyfer AE, Icochea R, Graeber GM. Poland’s anomaly. Natural history and
long-term results of chest wall reconstruction in 33 patients. Ann Surg.
1988;208(6):776-782.
4. Hurwitz DJ, Stofman G, Curtin H. Three-dimensional imaging of Poland’s
syndrome. Plast Reconstr Surg. 1994;94(5):719-723.
5. Wright AR, et al. MR and CT in the assessment of Poland syndrome. J
Comput Assist Tomogr. 1992;16(3):442-447.
6. Gatti JE. Poland’s deformity reconstructions with a customized, extrasoft
silicone prosthesis. Ann Plast Surg. 1997;39(2):122-130.
7. Borschel GH, Izenberg PH, Cederna PS. Endoscopically assisted
reconstruction of male and female Poland syndrome. Plast Reconstr Surg.
2002;109(5):1536-1543.
8. Fokin AA, Robicsek F. Poland’s syndrome revisited. Ann Thorac Surg.
2002;74(6):2218-2225.
9. Haller JA Jr, et al. Early reconstruction of Poland’s syndrome using

autologous rib grafts combined with a latissimus muscle flap. J Pediatr Surg.
1984;19(4):423-429.
10. Longaker MT, et al. Reconstruction of breast asymmetry in Poland’s chest-
wall deformity using microvascular free flaps. Plast Reconstr Surg.
1997;99(2):429-436.
11. Borschel GH, Costantino DA, Cederna PS. Individualized implant-based
reconstruction of Poland syndrome breast and soft tissue deformities. Ann
Plast Surg. 2007;59(5):507-514.
12. Santi P, et al. Anterior transposition of the latissimus dorsi muscle through
minimal incisions. Scand J Plast Reconstr Surg. 1986;20(1):89-92.
13. Santi P, Berrino P, Galli A. Poland’s syndrome: correction of thoracic
anomaly through minimal incisions. Plast Reconstr Surg. 1985;76(4):639-641.
14. Seyfer AE, Fox JP, Hamilton CG. Poland syndrome: evaluation and treatment
of the chest wall in 63 patients. Plast Reconstr Surg. 2010;126(3):902-911.

58
CHAPTERGynecomastia
Dennis Hammond and Eric Yu Kit Li
DEFINITION
■ Gynecomastia involves the abnormal proliferation of glandular breast tissue in
men, resulting in breast enlargement.1,2
■ It is distinguished from pseudogynecomastia or lipomastia, which is
characterized by fatty deposition without glandular development.
ANATOMY
■ In healthy patients, the male breast resembles that of a prepubescent female.
■ Fat is the predominant tissue and lobules are absent, in contrast to ductal and
lobular development in females (FIG 1).
■ The ideal male breast is also flat, to accentuate the contour of the underlying
pectoralis major muscle.
■ The arterial supply, venous drainage, lymphatic drainage, and sensory supply
mimic those of the female breast.
■ Although there is general consensus on the ideal size, shape, and location of
the nipple-areolar complex (NAC) in women, this subject has been less
extensively studied in men.
■ Various authors have published equations to calculate the ideal NAC on the
male torso, often as a function of measurements such as patient height and
chest circumference.3–8
■ Some general themes exist among the various formulas, in that the ideal male
NAC is
• Slightly oval (horizontal greater than vertical)
• Smaller (with diameter lesser than 3 cm)

• Positioned around the 4th or 5th intercostal space
■ Recent studies have characterized the shape of gynecomastia specimens as
having a head, body, and tail9,10 (FIG 2).
■ The head is semicircular in shape and extends toward the midline.
■ The body is located directly underneath the NAC and intimately attached to
it.
■ The tail tapers off and extends toward the axilla.
■ Awareness of this shape may help guide intraoperative dissection.
PATHOGENESIS
■ Gynecomastia occurs due to a hormonal imbalance between the level or action
of estrogens and androgens.1,2
■ Estrogens stimulate breast development, whereas androgens inhibit it.
■ Causes of this imbalance may be idiopathic, physiologic, pharmacologic, or
pathologic.11
FIG 1 • In the normal male breast, fat is the
predominant tissue and lobules are absent. This is in
contrast to the developed female breast, which features
lobules and ducts.

FIG 2 • A typical gynecomastia specimen with head,
body, and tail sections.
■ Obesity is also strongly associated with gynecomastia, due to increased levels
of circulating estrogens from peripheral aromatization of androgens in adipose
tissue.1
■ Histopathologically, early-stage gynecomastia is characterized by ductal
proliferation with loose stromal tissue (florid type).12
■ Over time, generally over the course of a year, the stromal tissue undergoes
fibrosis (fibrotic type).12
■ Gynecomastia that has undergone fibrosis is unlikely to be responsive to
medical treatment.
NATURAL HISTORY1,2
■ Physiologic gynecomastia (FIG 3A–C)

■ Often seen in newborns, adolescents, and older men
■ Adolescent gynecomastia:
• May begin as early as age 12
• Can occur in up to 65% of adolescent boys13
• Breast enlargement typically lasts 6 to 12 months.
• Ninety percent of cases spontaneously resolve without treatment.14
• Generally, presents as a subareolar, firm, concentric, fibrous mass with
surrounding fibrofatty tissue that is proportional to the body habitus of the
patient
■ Senescent gynecomastia (FIG 3D):
• Can occur in up to 65% of men over 65 years of age15
• Generally presents as diffuse fibrofatty tissue that gradually enlarges over
time
■ Pathologic gynecomastia
■ Can occur at any age, related to a tumor or medical condition (eg, liver or
kidney disease)
■ There may be a history of rapid eccentric growth, nipple discharge, skin
changes, or constitutional symptoms.12
■ Pharmacologic gynecomastia
■ Can occur at any age, related to a drug exposure.
■ Generally presents as a subareolar, firm, concentric, mass.
■ If the mass is not fibrotic, stopping the offending medication may resolve the
condition.
■ If the mass is fibrotic, stopping the offending medication may halt
progression of gynecomastia, but it is unlikely to reduce the breast
enlargement already present.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients with the suspected diagnosis should be evaluated for both signs and
symptoms related to the abnormal breast growth.
■ A detailed history should inquire about:
■ The onset and velocity of breast growth
■ The onset of puberty and ongoing pubertal development (if applicable)
■ Any tendency for spontaneous resolution of the breast hypertrophy
■ Associated symptoms, including pain, tenderness, weight loss, night sweats,
and general malaise

FIG 3 • A–C. Frontal and lateral views of a 24-year-old
man who presented with bilateral physiologic
gynecomastia. Both sides were characterized by a
subareolar fibrous mass and surrounding fibrofatty
tissues. D. Frontal view of a 52-year-old man who
presented with bilateral senescent gynecomastia with
skin excess and NAC ptosis. Both sides were
characterized by diffuse fibrofatty tissues.
■ Any social, vocational, or avocational dysfunction due to the breast
enlargement
■ The effect of the breasts on the patient’s psychological well-being and self-
esteem
■ Any personal or family history of breast cancer or disorders
■ Medication history, especially recreational and off-the-counter drugs (eg,
marijuana and exogenous steroids)
■ Symptoms suggestive of underlying thyroid, liver, or kidney disease
■ A detailed physical should examine
■ The patient’s height, weight, and body mass index
■ For the development of secondary sexual characteristics (if applicable)
■ For the presence of a subareolar mass and its area of involvement
■ For the presence of fibrofatty tissue and its area of involvement

■ For other masses, irregularities, or deformities involving the breasts or chest
wall
■ Overall breast aesthetics, including the shape, size, and symmetry of the
breasts and NACs, the degree of ptosis, excess skin, and the position and
symmetry of the inframammary folds (IMFs)
■ Standard breast measurements to highlight asymmetries, including the sternal
notch to nipple, midclavicular to nipple, nipple to midline, and nipple to IMF
distances
■ The patient’s neck, abdomen, and testicles for any masses or irregularities
IMAGING
■ Imaging is not typically required if the history and physical examination are
consistent with physiologic gynecomastia.
■ In suspected cases of pathologic gynecomastia, appropriate imaging
(mammogram, ultrasound, etc.) should be carried out based on the identified or
suspected abnormalities.
DIFFERENTIAL DIAGNOSIS
■ Idiopathic gynecomastia
■ Physiologic gynecomastia
■ Pseudogynecomastia or lipomastia
■ Benign breast tumors (eg, fibroadenoma, giant fibroadenoma, phyllodes
tumor, lipoma, or cysts)
■ Malignant breast tumors (eg, ductal or lobular carcinoma, lymphoma, or
metastases)
NONOPERATIVE MANAGEMENT
■ Patient reassurance is the foremost treatment in adolescent gynecomastia.
■ About 90% of adolescent cases spontaneously resolve, so no treatment may
be needed at all.14
■ Treatment is indicated when gynecomastia has persisted for more than 2
years, or if there are overriding functional, medical, or psychosocial concerns
that warrant earlier intervention.16
■ In gynecomastia related to reversible etiologies, the offending medication
should be stopped or the underlying condition treated as soon as possible.
■ Weight loss through dietary restriction and exercise are important first-line
treatments in any gynecomastia related to obesity.

■ Pharmacologic therapies, including danazol, tamoxifen, and anastrozole, may
be effective in preventing or treating early-stage gynecomastia but are less
effective once breast tissues undergo fibrosis.2
■ Of these medications, tamoxifen is most widely used, but there are no clear
guidelines on the ideal dose or duration.
■ All medications also have unfavorable side effects that must be considered.
■ If pathologic gynecomastia is suspected, patients should be urgently referred
to the appropriate specialist(s).
SURGICAL MANAGEMENT
■ Surgical treatment is indicated when gynecomastia is persistent or causes
functional or aesthetic concerns.
■ Options include liposuction, excision of the subareolar fibrous tissue, or a
combination of the two.
■ In patients with significant breast enlargement with skin excess and ptosis,
mastopexy may be incorporated as well.
■ Although weight loss should be the first-line strategy in any obese patient with
gynecomastia, it is still reasonable to proceed with surgery in obese patients
since normalizing the chest wall contour may allow the patient to lead a more
active lifestyle.16
■ Whether resected gynecomastia tissues should be routinely sent for
histopathological examination is debatable.
■ The likely risk of finding occult malignancy in gynecomastia specimens is
less than 0.01%.12,17
■ Of note, the College of American Pathologists does not specifically require
the use of cancer protocols for gynecomastia, nor do they offer any formal
guidelines for the examination of gynecomastia tissue.
Preoperative Planning
■ The patient is seen preoperatively 1 to 3 days before surgery to achieve several
objectives:
■ To review the procedure in detail, and revisit goals and expectations of
surgery with the patient
■ To complete all perioperative paperwork, including orders, prescriptions, and
instruction sheets
■ To mark the patient in an unrushed, quiet, and controlled environment
■ To obtain preoperative photographs of the marked patient

■ For all procedures, the patient is marked in a standing position with arms at the
sides.
■ Preoperative markings are done with a variety of colored markers.
■ A laser leveler can be used to confirm the horizontal plane across the chest.
■ Preoperative photographs serve several functions:
■ They document the surgical plan electronically.
■ They can be brought to the operating room to guide intraoperative decision-
making.
■ They can be compared to postoperative photographs to critically appraise
surgical technique and final results.
■ They can be used to educate patients in the preoperative and postoperative
settings.
■ Photographs, at the minimum, should capture three standard views of the
breasts including the front and each side.
■ Supplemental views, including ¾s, hands over head, and with breasts lifted
by the patient, can also be taken.
■ Patients should be framed from the top of the shoulders to midway between
the breast and umbilicus, with the width extending just outside the arms.
Positioning
■ The patient is positioned supine on an operating room table that is capable of
sitting up 90 degrees.
■ This positioning will allow the patient to be placed upright intraoperatively
and the chest to be evaluated in the sitting position, which may guide
intraoperative decision-making.
■ The patient’s head is positioned at the top of the table, supported by a foam
headrest.
■ The patient’s arms are placed on arm boards and secured to allow safe upright
positioning of the patient.
■ Arm boards are placed at the shoulder level.
■ Foam pads are placed between the arm and arm boards.
■ The arm is then secured to both with a soft towel followed by a gentle
circumferential wrap of gauze, which runs from the axilla to the hand to
provide a uniform layer of support.
■ The patient’s knees are elevated with a pillow to relieve pressure on the back
while the patient is upright, and the patient’s heels are supported with foam

pads.
■ A heated air-warming device is placed on the lower body.
■ The area from the top of the shoulders to midway between the inferior pole of
the breast and umbilicus is prepped and draped to allow full visualization of the
shoulders, chest, and breasts during surgery.
Approach
■ All surgical techniques can be performed under local anesthesia, intravenous
sedation, or general anesthesia.
■ Development of a surgical plan is based on the need to address two issues.16
■ How to best remove the excess volume
■ When and how to best remove the excess skin
■ Volume reduction techniques:
■ Direct glandular excision is performed when gynecomastia presents as an
isolated subareolar fibrous mass.
■ Liposuction is performed when gynecomastia presents largely as a diffuse
accumulation of fibrofatty tissue.
■ When both a subareolar fibrous mass and diffuse fibrofatty tissue are present,
both direct excision and liposuction techniques are used to effectively
recontour the chest wall.
■ Skin reduction techniques:
■ In general, most patients do not require skin envelope excision after volume
reduction, because the propensity of the chest wall skin to retract is
significant, especially in younger patients.
■ Only in cases of significant skin excess or laxity is a skin-reducing procedure
required.
■ Small localized areas of skin excess can be directly treated with skin
excision.
■ Small reductions in the skin envelope or ptotic NACs can be treated with
periareolar mastopexies.
■ Large reductions in the skin envelope or extremely ptotic NACs can be
treated with circumvertical mastopexies.
T E C H N I Q U E S

■ Direct Excision
■ Landmarks:
■ The patient is marked in a standing position with arms at the sides.
■ The subareolar mass underneath the NAC is palpated and outlined with a
surgical marker.
■ The planned incision on the inferior areolar border is marked.
■ The planned incision on the inferior areolar border is first infiltrated with
local anesthetic.
■ Local anesthetic is also injected deep to the NAC and in the subcutaneous
tissues overlying the fibrous mass.
■ In this fashion, the plane between the subcutaneous and glandular tissues is
intentionally hydrodissected to facilitate later dissection with cautery.
■ Using a no. 15 blade, the periareolar incision is made through the deep
dermis.
■ A Senn retractor is then placed on the dermal edge, upward traction is
applied, and the plane between the deep dermis and glandular tissue is
carefully dissected with monopolar cautery (TECH FIG 1A).
■ The dissection is performed both medial and lateral to the area underneath
the nipple first (where a true plane exists) and then joined in the middle
transecting the ducts (where no true plane exists).
■ Care is taken to ensure that the NAC maintains a uniform thickness of 5 to
10 mm.
■ Once beyond the boundaries of the NAC, the dissection is continued with
monopolar cautery in the plane between the subcutaneous and glandular
tissues, peripherally in all directions.
■ It is important to stay in this plane to preserve the overlying subcutaneous
fat and maintain an even contour to the breast skin flaps.
■ Once the fibrous mass is freed to its peripheral margins, it is elevated from
the pectoralis major fascia.
■ Extra care is taken to avoid violating the fascia.
■ If possible, leave a bed of fat above the fascia to avoid a “saucer” contour
deformity deep to the NAC.

TECH FIG 1 • A. The plane between the dermis and
glandular tissues. B. The completed inferior areolar
closure. The gynecomastia specimen is shown above.
■ After the fibrous tissue is removed, the chest wall is carefully palpated and
inspected for any remaining contour irregularities.
■ Further scissor dissection or cautery excision can be done at this point to
feather the peripheral contours and excise any remaining glandular tissue.
■ The dissected space is irrigated with normal saline and hemostasis checked.
■ The wound layers are closed with 4-0 Monocryl (Ethicon Inc., Somerville,
NJ, USA) or equivalent absorbable monofilament dermal interrupted suture,
followed by a 3-0 Stratafix (Ethicon Inc., Somerville, NJ, USA) or equivalent
absorbable barbed subcuticular suture (TECH FIG 1B).
■ Dermabond (Ethicon Inc., Somerville, NJ, USA) is lastly applied to the skin
incision.
■ Liposuction
■ Landmarks:
■ The patient is marked in a standing position with arms at the sides.
■ The fibrofatty issues surrounding the breast are palpated and outlined for
liposuction (TECH FIG 2A).
■ The planned access incisions for liposuction are marked at the lower border
of the NAC and/or along the lateral aspect of the IMF.
■ The planned incisions are infiltrated with local anesthetic.
■ Wetting solution is next infiltrated deep to the NAC and in the surrounding

areas of fibrofatty tissue.
• Typical wetting solution consists of 40 to 60 mL of 1% lidocaine with 1
amp of Epi added to 1 L of NS.
• Fluid is added to each breast until the tissue consistency is firm.
■ After allowing time for the wetting solution to take effect, standard
liposuction is performed (TECH FIG 2B).
• A 3- to 4-mm cannula is used by the author.
• Care is taken to feather the boundaries of the marked areas.
• In bilateral cases, the access incision on the opposite NAC can be used
and the cannula passed across the midline to liposuction the subareolar
area (TECH FIG 2C).
• Underneath the NAC, external pinching compression with the opposite
hand is used to drive the dense subareolar fat into the cannula.
■ In breasts with a well-defined IMF, the cannula can be used to
discontinuously undermine it and soften it.
■ All wounds are closed with dermal 4-0 Monocryl (Ethicon Inc.,
Somerville, NJ, USA) or equivalent absorbable monofilament dermal
interrupted suture, and Dermabond (Ethicon Inc., Somerville, NJ, USA) is
applied to the skin.
TECH FIG 2 • A. Preoperative markings of the

fibrofatty tissue surrounding the breast and the
planned area of liposuction. B. The path of the
liposuction cannula to reach all areas of the breast. In
bilateral cases, the NAC access incision can be used
to pass the cannula across the midline to liposuction
the opposite subareolar area. C. The liposuction
cannula is shown passing through the NAC access
incision and across the midline to reach the opposite
subareolar area.
■ Combination Technique
■ Landmarks:
■ The patient is marked in a standing position with arms at the sides.
■ The subareolar mass underneath the NAC is palpated and outlined with a
surgical marker.
■ The fibrofatty issues surrounding the breast are palpated and outlined for
liposuction.
■ The planned incisions on the inferior areolar border and/or the lateral
aspect of the IMF are marked.
■ The planned incisions on the inferior areolar border and lateral IMF are first
infiltrated with local anesthetic.
■ Local anesthetic is also injected deep to the NAC and in the subcutaneous
tissue overlying the fibrous mass.
■ Wetting solution is then infiltrated into the surrounding areas of the
fibrofatty tissue until the breast is firm.
■ After allowing time for the wetting solution to take effect, liposuction is then
performed using a 3- to 4-mm cannula, as described above.
■ Once no further liposuction can be performed, the mass effect of the
remaining fibrous portion is assessed.
■ If there remains a persistent and protuberant fibrous mass, the inferior
areolar border is incised and the glandular tissue excised via direct excision,
based on the technique as described above.

■ Periareolar Skin Reduction
■ Landmarks:
■ The patient is marked in a standing position with arms at the sides.
■ The midsternal line, IMF, and lateral breast contour are marked.
■ The top of the periareolar incision is drawn, and symmetry on both sides is
confirmed with a laser leveler.
• The author typically positions the new NAC 2 to 3 cm above the existing
IMF.
■ A circular pattern is next drawn around the NAC (TECH FIG 3A).
■ Under maximum stretch, the NAC is outlined with a nipple marker with a
maximum diameter of 3 cm.
■ Local anesthetic is injected in the deep dermis of the periareolar pattern.
■ Wetting solution is also infiltrated deep to the NAC and in the surrounding
areas of fibrofatty tissue.
■ Liposuction and/or direct excision is first carried out, as described above.
■ The breast is accessed through an incision on the caudal portion of the
periareolar pattern.
■ The NAC is incised to the deep dermis, and the previously marked
periareolar pattern preliminarily stapled.
■ The patient is then placed upright to visualize the resultant breast shape, and
the staple line is adjusted as needed to create the desired chest contour and
NAC elevation.
■ After the staple line is deemed satisfactory, the patient is returned supine.
■ The staple line is marked with a surgical marker, and the staples are
removed.
■ The intervening skin within the periareolar pattern is then de-epithelialized.
■ Typically, the periareolar dermis is minimally incised or not incised at all to
maintain the subdermal plexus that supplies the NAC.
■ The dermis may be incised, however, in staged scenarios in which the NAC
has secondarily revascularized via its wound base.
■ The periareolar defect is lastly closed using a periareolar purse-string
technique.18
■ Eight evenly spaced cardinal points are marked on the areola and
periareolar incision.
■ A 2-0 Cytoplast (Surgiform Technologies Ltd., Columbia, SC, USA) or

equivalent polytetrafluoroethylene (PTFE) suture on a straight needle is
selected.
TECH FIG 3 • A. A circular pattern is drawn around
the NAC to outline the periareolar pattern. B.
Appearance of the periareolar pattern after weaving of
the purse-string suture. C. The completed periareolar
closure.
■ The suture is then passed, from deep to superficial, starting on the medial
dermal shelf of the periareolar incision, through the corresponding cardinal
point on the dermis of the areola, inserted back into the outer dermal shelf,
and then passed through the periareolar dermis to the next cardinal point.
■ This weaving is continued until the suture has weaved completely around the
periareolar defect, culminating in the appearance of a wagon wheel (TECH
FIG 3B).
■ The free suture ends are then tightened to cinch the periareolar incision
down to match the diameter of the areola, followed by placement of 8 to 10
square knots to secure the suture.

■ The knot complex is placed underneath the medial dermal shelf, and the
periareolar closure is completed with 3-0 Stratafix or equivalent absorbable
barbed suture (Ethicon Inc., Somerville, NJ, USA) (TECH FIG 3C).
■ Circumvertical Skin Reduction
■ Landmarks:
■ The patient is marked in a standing position with arms at the sides.
■ The midsternal line, IMF, and lateral breast contour are marked.
■ The top of the periareolar incision is drawn, and symmetry on both sides is
confirmed with a laser leveler.
• The author typically positions the new NAC 2 to 3 cm above the existing
IMF.
■ A circular pattern is next drawn around the NAC, followed by a vertical
pattern below the NAC extending in a curvilinear fashion toward the IMF
(TECH FIG 4).
■ Under maximum stretch, the NAC is outlined with a nipple marker with a
maximum diameter of 3 cm.
■ Local anesthetic is injected in the deep dermis of the periareolar pattern.
■ Wetting solution is also infiltrated deep to the NAC and in the surrounding
areas of fibrofatty tissue.
■ Liposuction and/or direct excision is first carried out, as described above.
■ The breast is accessed through an incision on the caudal portion of the
periareolar pattern.
■ The NAC is incised to the deep dermis, and the previously marked
circumvertical pattern preliminarily stapled.
■ The patient is then placed upright to visualize the resultant breast shape, and
the staple line is adjusted as needed to create the desired chest contour and
NAC elevation.
■ After the staple line is deemed satisfactory, the patient is returned supine.
■ The staple line is marked with a surgical marker, and the staples are
removed.
■ The intervening skin within the periareolar pattern is de-epithelialized, while
the intervening skin within the vertical pattern may be de-epithelialized or
removed altogether.
■ Typically, the periareolar dermis is minimally incised or not incised at all

to maintain the subdermal plexus that supplies the NAC, but the dermis of
the vertical pattern may be incised to gain further access to the breast
and/or facilitate flap advancement and closure.16
■ The vertical pattern is closed with 4-0 Monocryl (Ethicon Inc., Somerville,
NJ, USA) or equivalent interrupted deep dermal sutures followed by
subcuticular closure with 3-0 Stratafix (Ethicon Inc., Somerville, NJ, USA)
or equivalent absorbable barbed suture.
■ The periareolar defect is closed using the periareolar purse-string
technique,18 as described earlier.
TECH FIG 4 • A-C. Preoperative markings of the
planned circumvertical pattern skin reduction.
PEARLS AND PITFALLS
Landmarks
■ The top of the NAC is typically positioned 2 to 3 cm above the
IMF by the authors. Although other techniques can be used to

calculate the ideal position of the NAC,3–8 it is ultimately the
surgeon’s artistic judgment that should prevail. To this end, sitting
the patient up intraoperatively and tailor-tacking the periareolar or
circumvertical patterns will preview the desired result and NAC
position before irreversible incisions are made.
Technique
■ Patients with hairy chests are advised to shave preoperatively. This
will save time the day of surgery and also allow easier
identification of the inferior areolar border for incision placement.
■ If there is any doubt whether skin resection is required after
volume reduction techniques, stage the mastopexy. Even when
skin retraction is insufficient and a second-stage procedure is
required, the amount of skin reduction required is usually less than
originally thought, and it may be possible to reduce the amount of
cutaneous scarring.16
■ In cases of delayed skin envelope reduction, no additional internal
dissection is required. As well, the dermal edges of the periareolar
and circumvertical patterns can be safely incised at this point to
facilitate tension-free closure since the NAC will have adequate
secondary revascularization from its wound base.16
■ A common area for persistent skin excess and fatty accumulation,
particularly in obese patients, is under the arm along the lateral
chest wall. The extra skin in this area can be directly excised to
achieve the appropriate chest contour (FIG 4).
■ In breasts with significant fibrofatty tissue, liposuctioning the
breast tissue via various access incisions can be of mechanical
advantage and help achieve a more uniform reduction in breast
volume. In bilateral cases, it is helpful to use the contralateral
breast incisions to liposuction the ipsilateral subareolar area (see
TECH FIG 2C).
■ When elevating the fibrous mass off the chest wall, avoid violating
the pectoralis major fascia to minimize postoperative pain,
bleeding, and scar tethering deep to the NAC. If possible, leave a
thin layer of fat above the fascia to maintain a natural gliding plane
and to avoid a “saucer” concave deformity involving the NAC.
■ In patients presenting for revision gynecomastia surgery, use small
liposuction cannulas to carefully control the amount of liposuction
performed and avoid contour irregularities. Particularly in patients
who have had only liposuction performed as the primary
procedure, it is wise to perform direct excision in revision surgery
to eliminate any residual breast bud and avoid further patient
dissatisfaction.

Postoperative
care
■ It may be difficult to find compression dressings designed
specifically for men. In our practice, we recommend that patients
purchase a sports compression shirt that is a size smaller than the
patient’s normal size. If the shirt is too uncomfortable for the
patient for prolonged use, the arms and bottom portion of the shirt
may be trimmed so that the compression is isolated to the chest.
FIG 4 • A common area for persistent skin excess and
fatty accumulation is the lateral chest wall.
POSTOPERATIVE CARE
■ All incisions are covered with Dermabond; no additional external dressings are
required.
■ Patients are typically discharged the same day after surgery.
■ Drains are usually unnecessary but, if placed, are typically removed at the first

follow-up visit.
■ Routine follow-up visits are scheduled at 1 week, 6 weeks, 6 months, and
yearly thereafter.
■ A sports compression shirt is worn for the first 2 weeks.
■ Patient may resume full activities generally 4 to 6 weeks after surgery.
OUTCOMES
■ Gynecomastia surgery is generally well tolerated with patient satisfaction rates
over 90%19–21 (FIG 5).
■ Most patients benefit from improved emotional comfort, functional capacity,
and social acceptance.22,23
■ Overall surgical complication rates vary from 5% to 30%, depending on the
technique used.11,20,23–26.
■ Recurrence is possible in incomplete resections or if the offending
medication(s) is continued after surgery.
■ Recurrence is also more likely in patients with glandular vs fibrofatty
gynecomastia.21
FIG 5 • A–C. 1 year postoperative frontal and lateral

views of the patient in FIG 3A–C after combined
approach with direct excision and liposuction
techniques. Note the improved and more masculine
chest contour after surgery, as well as the natural
reduction in the size of the NACs after removal of the
underlying subareolar masses. D. 1 year postoperative
frontal view of the patient in FIG 3D after liposuction for
volume reduction and circumvertical mastopexy for skin
reduction. Note the elevated position of the NAC and
improved and more masculine chest contour after
surgery.
COMPLICATIONS
■ Early
■ Hematoma
■ Seroma
■ Infection
■ Delayed wound healing or wound dehiscence
■ NAC necrosis
■ Late
■ Adverse scarring
■ Shape change
■ Loss of nipple-areolar complex function (sensation or lactation)
■ Fat necrosis
■ “Saucer” contour deformity to the NAC
REFERENCES
1. Thiruchelvam P, Walker JN, Rose K, et al. Gynaecomastia. BMJ.
2016;354:i4833.
2. Narula HS, Carlson HE. Gynaecomastia: pathophysiology, diagnosis and
treatment. Nat Rev Endocrinol. 2014;10(11):684-698.
3. Atiyeh BS, Dibo SA, El Chafic AH. Vertical and horizontal coordinates of the
nipple-areola complex position in males. Ann Plast Surg. 2009;63(5):499-502.
4. Murphy TP, Ehrlichman RJ, Seckel BR. Nipple placement in simple
mastectomy with free nipple grafting for severe gynecomastia. Plast Reconstr

Surg. 1994;94(6):818-823.
5. Kasai S, Shimizu Y, Nagasao T, et al. An anatomic study of nipple position
and areola size in Asian men. Aesthet Surg J. 2015;35(2):NP20-NP27.
6. Shulman O, Badani E, Wolf Y, Hauben DJ. Appropriate location of the nipple-
areola complex in males. Plast Reconstr Surg. 2001;108(2):348-351.
7. Beckenstein MS, Windle BH, Stroup RT Jr. Anatomical parameters for nipple
position and areolar diameter in males. Ann Plast Surg. 1996;36(1):33-36.
8. Beer GM, Budi S, Seifert B, et al. Configuration and localization of the
nipple-areola complex in men. Plast Reconstr Surg. 2001;108(7):1947-1952.
9. Blau M, Hazani R, Hekmat D. Anatomy of the gynecomastia tissue and its
clinical significance. Plast Reconstr Surg Glob Open. 2016;4(8):e854.
10. Blau M, Hazani R. Correction of gynecomastia in body builders and patients
with good physique. Plast Reconstr Surg. 2015;135(2):425-432.
11. Bailey SH, Guenther D, Constantine F, Rohrich RJ. Gynecomastia
management: an evolution and refinement in technique at UT Southwestern
Medical Center. Plast Reconstr Surg Glob Open. 2016;4(6):e734.
12. Senger JL, Chandran G, Kanthan R. Is routine pathological evaluation of
tissue from gynecomastia necessary? A 15-year retrospective pathological and
literature review. Plast Surg (Oakv). 2014;22(2):112-116.
13. Nydick M, Bustos J, Dale JH Jr, Rawson RW. Gynecomastia in adolescent
boys. JAMA. 1961;178:449-454.
14. Akgul S, Kanbur N, Derman O. Pubertal gynecomastia: what about the
remaining 10%? J Pediatr Endocrinol Metab. 2014;27(9-10):1027-1028.
15. Niewoehner CB, Nuttal FQ. Gynecomastia in a hospitalized male population.
Am J Med. 1984;77(4):633-638.
16. Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg.
2009;124(1 Suppl):61e-68e.
17. Koshy JC, Goldberg JS, Wolfswinkel EM, et al. Breast cancer incidence in
adolescent males undergoing subcutaneous mastectomy for gynecomastia: is
pathologic examination justified? A retrospective and literature review. Plast
Reconstr Surg. 2011;127(1):1-7.
18. Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture for
control of areolar diameter and shape. Plast Reconstr Surg. 2007;119(3):804-
809.
19. Colombo-Benkmann M, Buse B, Stern J, Herfarth C. Indications for and
results of surgical therapy for male gynecomastia. Am J Surg. 1999;178(1):60-
63.

20. Li CC, Fu JP, Chang SC, et al. Surgical treatment of gynecomastia:
complications and outcomes. Ann Plast Surg. 2012;69(5):510-515.
21. Fricke A, Lehner GM, Stark GB, Penna V. Long-term follow-up of
recurrence and patient satisfaction after surgical treatment of gynecomastia.
Aesthetic Plast Surg. 2017;41:491-498.
22. Davanço RA, Sabino Neto M, Garcia EB, et al. Quality of life in the surgical
treatment of gynecomastia. Aesthetic Plast Surg. 2009;33(4):514-517.
23. Kasielska A, Antoszewski B. Surgical management of gynecomastia: an
outcome analysis. Ann Plast Surg. 2013;71(5):471-475.
24. Fagerlund A, Lewin R, Rufolo G, et al. Gynecomastia: a systematic review. J
Plast Surg Hand Surg. 2015;49(6):311-318.
25. Hammond DC, Arnold JF, Simon AM, Capraro PA. Combined use of
ultrasonic liposuction with the pull-through technique for the treatment of
gynecomastia. Plast Reconstr Surg. 2003;112(3):891-895.
26. Zavlin D, Jubbal KT, Friedman JD, Echo A. Complications and outcomes
after gynecomastia surgery: analysis of 204 pediatric and 1583 adult cases
from a national multi-center database. Aesthetic Plast Surg. 2017;41:761-767.

59
CHAPTERJuvenile Hypertrophy
Dennis Hammond and Eric Yu Kit Li
DEFINITION
■ Juvenile or virginal breast hypertrophy is a rare condition characterized by
atypical and pronounced breast growth during puberty in the absence of a
discrete mass or nodularity.1,2
■ The term gigantomastia may be used to describe extreme cases.1
ANATOMY
■ At thelarche, the breast develops into glandular tissue composed of lobules
and ducts and supporting stromal tissue.
■ Breast development continues until the age of 18 to 20, at which point growth
is complete.
■ The arterial supply of the breast is derived from numerous sources, including
perforators from the internal thoracic, external thoracic, thoracoacromial, and
anterior and posterior branches of intercostal arteries.
■ The internal thoracic artery is the dominant source.
■ The blood supply to the nipple-areolar complex (NAC), in particular, is
augmented by a rich vascular arcade that travels in a distinct fascial septum
known as Wuringer septum3 (FIG 1A).
• The arcade takes origin from the thoracoacromial, external thoracic, and
intercostal arteries.
• The septum arises approximately at the level of the 5th rib, dividing the
breast into a superior two-thirds and inferior one-third, and courses from the
pectoralis major fascia to the NAC (FIG 1B,C).
• Preservation of the septum and its vascular arcade is key to maintaining a
robust NAC during pedicle dissection in breast surgery.

■ The venous drainage of the breast parallels the arterial supply.
■ The lymphatic drainage of the breast is generally to the axillary and internal
mammary lymph nodes.
■ A variety of sensory nerves innervate the breast, including the anterior and
lateral branches of the 2nd through 6th intercostal nerves and supraclavicular
nerves.
■ The NAC is predominantly innervated by the lateral branch of the 4th
intercostal nerve.
■ The breast is enveloped by the Scarpa fascia, which forms anterior and
posterior lamellae.
■ Cooper ligaments are intraparenchymal fibers, which span both lamellae and
confer structural support to the breast.
■ The inframammary fold (IMF) is the foundation of the breast and is the point
of convergence of the Scarpa fascia of the abdomen inferiorly with the anterior
and posterior lamellae of the breast superiorly.4
■ The fat layer above the Scarpa fascia is thicker, denser, and more compact
than the fat layer below it.
■ Avoidance of downward deforming pressures on the subscarpal fatty
layer/space, whether by an implant or parenchyma, is key to preventing
“bottoming out” of the breast and undesired lowering of the IMF.
PATHOGENESIS
■ The exact cause of juvenile hypertrophy is unknown.1,2
■ Theories include either increased end-organ sensitivity to normal levels of
gonadal hormones or increased levels of gonadal hormones, although previous
studies have identified normal hormone levels in juveniles diagnosed with this
disease.
NATURAL HISTORY
■ Juvenile hypertrophy is characterized by rapid and atypical breast growth
during puberty.
■ Initial growth over the first 6 months may be extreme, followed by a longer
period of slower growth.
■ Disease onset can be anytime during puberty, but in most cases, it is shortly
after thelarche (ages 9 to 13).
■ Involvement can be either unilateral, which is more common, or bilateral.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ Juveniles with the suspected diagnosis should be evaluated for both signs and
symptoms related to rapid breast growth.
■ A detailed history should inquire about:
■ The onset and velocity of breast growth
■ The onset of puberty and ongoing pubertal development
■ Associated symptoms, including headaches; neck, shoulder, or back pain;
shoulder grooving from brassiere straps; and skin irritation or intertrigo along
the IMF
■ Any social, vocational, or avocational dysfunction due to the hypertrophied
breasts
■ The effect of the breasts on the patient’s psychological well-being and self-
esteem
■ Any personal or family history of breast cancer or disorders
■ A detailed physical should examine
■ The patient’s height, weight, and body mass index
■ For signs related to hypertrophied breasts, including skin striae or hyperemia,
peau d’orange skin, dilated subcutaneous veins, or, in severe cases, tissue
necrosis involving the breast
■ For specific masses, irregularities, or deformities involving the breasts or
chest wall

FIG 1 • A. Intraoperative appearance of the Wuringer
septum, which is seen as a distinct white fascial layer

during pedicle dissection. B. The Wuringer septum is a
horizontally oriented fascial condensation that spans
from the pectoralis major fascia, at the level of the 5th
rib, to the nipple-areolar complex. The septum contains
a rich vascular arcade, which receives contributions
from thoracoacromial, external thoracic, and intercostal
arteries. The septum divides the breast into a superior
2/3rd and inferior 1/3rd. C. The IMF is the point of
convergence of the Scarpa fascia of the abdomen
inferiorly with the anterior and posterior lamellae of the
breast superiorly. Wuringer septum is illustrated in the
middle of the breast.
■ Overall breast aesthetics, including the shape and size of the breasts and
NACs, the degree of ptosis, and the position and symmetry of the IMFs
■ Standard breast measurements to highlight asymmetries, including the sternal
notch to nipple, midclavicular to nipple, nipple to midline, and nipple to IMF
distances
IMAGING
■ Mammography tends to be of limited value because of the density of the breast
tissues in juvenile hypertrophy.
■ Ultrasonography or magnetic resonance imaging may be useful in select
situations, especially if masses or irregularities are identified on examination
and the diagnosis is in question.
■ Ultimately, diagnosis of juvenile hypertrophy is often clinical and based on
history and examination.2
DIFFERENTIAL DIAGNOSIS5
■ Physiologic breast hypertrophy (including normal growth or pregnancy-related
growth)
■ Benign breast tumors (eg, fibroadenoma, giant fibroadenoma, phyllodes
tumor, or cysts)
■ Malignant breast tumors (eg, ductal or lobular carcinoma, lymphoma, or
metastases)

NONOPERATIVE MANAGEMENT
■ Pharmacologic therapies, including tamoxifen, dydrogesterone, danazol, and
bromocriptine, have been used as both primary treatment options or in
combination with surgery, in either a neoadjuvant or adjuvant fashion.6
■ The safety and efficacy of these therapies are not well established, however,
due to the scarcity of reported cases.
SURGICAL MANAGEMENT
■ Surgical treatment of juvenile hypertrophy is reduction mammoplasty.
■ Surgery is ideally performed once breast size has stabilized for 6 to 12 months,
but earlier intervention may be necessary if there are overriding functional,
medical, or psychosocial concerns.2,7
■ All resected breast tissues should be sent for histopathological examination to
rule out breast pathologies.
■ Reduction mammoplasties are completed using the short scar periareolar
inferior pedicle (SPAIR) technique.8,9
■ The SPAIR technique is advantageous over other techniques for numerous
reasons:
■ It is versatile and can be used for breast reductions of varying size.
■ Most plastic surgeons have been trained and are comfortable using the inferior
pedicle.
■ The circumvertical skin resection pattern minimizes scar burden, creates a
more rounded breast shape, and improves breast projection while avoiding
wound healing difficulties at the T junction or vertical segments associated
with other breast reduction techniques.
■ Lessening the scar burden is a significant priority in young female patients.
■ The breast can be actively shaped with various intraoperative maneuvers to
achieve the final desired contour.
■ The IMF is preserved, thus minimizing the risk of long-term “bottoming out”
of the breast.
Preoperative Planning
■ The patient should be seen preoperatively 1 to 3 days before surgery to
achieve several objectives:
■ To review the procedure in detail and revisit goals and expectations of
surgery with the patient

■ To complete all perioperative paperwork, including orders, prescriptions, and
instruction sheets
■ To mark the patient in an unrushed, quiet, and controlled environment
■ To obtain preoperative photographs of the marked patient
■ Preoperative markings can be done with a variety of colored markers, each
representing a specific surgical step.
■ The patient is marked in a standing position with arms at the sides.
• A laser leveler can be used to confirm the horizontal plane across the chest.
■ The midsternal line, IMF, lateral breast contour, and breast meridian are first
marked (FIG 2A).
• The IMF is drawn across the chest so that it can be visualized with the
breasts at rest (FIG 2B).
■ The periareolar pattern is outlined next:
• The top point is the intersection of a line 2 to 4 cm above the IMF with the
breast meridian (FIG 2C).
• The bottom points are the top points of a rectangle, which is drawn 8 cm
wide, centered on the breast meridian and arising from the IMF, with a
height of 8 to 10 cm (FIG 2D).
• The lateral and medial points are identified by lifting the breast up and
outward and up and inward with just enough tension to create a rounded
contour and transposing the breast meridian onto the breast (FIG 2E,F).
• The above points are then joined together to create an elongated oval, which
outlines the periareolar pattern (FIG 2G).
■ The superior aspect of the inferior pedicle is outlined last within the
periareolar pattern:
• The top points of the rectangle are joined with a curved line skirting the
areola by 2 cm (FIG 2H).
• The final design of the inferior pedicle thus comprises the area encompassed
by the rectangle and the curved line.

FIG 2 • A. The midsternal line, IMF, lateral breast
contour, and breast meridian are marked. B. The IMF is
drawn across the chest. C. The top point is the

intersection of a line 2 to 4 cm above the IMF with the
breast meridian. D. The bottom points are the top points
of an 8- × 8- to 8- × 10-cm rectangle, centered on the
breast meridian, arising from the IMF. E,F. The lateral
and medial points are identified by manipulating the
breast and transposing the breast meridian. G. The
periareolar pattern is outlined. H. The top points of the
rectangle are joined with a curved line skirting the
areola by 2 cm.
■ Preoperative photographs serve several functions:
■ They document the surgical plan electronically.
■ They can be brought to the operating room to guide intraoperative decision-
making.
■ They can be compared to postoperative photographs to critically appraise
surgical technique and final results.
■ They can be used to educate patients at both the pre- and postoperative
settings.
■ Photographs, at the minimum, should capture three standard views of the
breasts including the front and each side.
■ Supplemental views, including ¾s, hands over head, and with breasts lifted
by the patient, can also be taken.
■ Patients should be framed from the top of the shoulders to midway between
the breast and umbilicus, with the width extending just outside the arms.
Positioning
■ The SPAIR technique is performed under general anesthesia.
■ The patient is positioned supine, on an operating room table that is capable of
sitting up 90 degrees.
■ This will allow the patient to be placed upright intraoperatively and the
breasts to be evaluated in the sitting position, which may guide intraoperative
decision-making.
■ The patient’s head is positioned at the top of the table, supported by a foam
headrest (FIG 3A).
■ The patient’s arms are placed on arm boards and secured to allow safe upright

positioning of the patient.
■ Arm boards are placed at the shoulder level.
■ Foam pads are placed between the arm and arm boards (FIG 3B).
FIG 3 • A. The patient’s head is positioned at the top of
the table, supported by a foam headrest. B. Foam pads
are placed between the arm and arm boards. C. The
arm is secured with a soft towel followed by a gentle
circumferential wrap of gauze. D. The patient’s knees
are elevated with a pillow, and the patient’s heels are
supported with foam pads. E. A heated air-warming
device is placed on the lower body.
■ The arm is then secured to both with a soft towel followed by a gentle
circumferential wrap of gauze, which runs from the axilla to the hand to
provide a uniform layer of support (FIG 3C).
■ The patient’s knees are elevated with a pillow to relieve pressure on the back
while the patient is upright, and the patient’s heels are supported with foam
pads (FIG 3D).
■ A heated air-warming device is placed on the lower body (FIG 3E).
■ The area from the top of the shoulders to midway between the inferior pole of
the breast and umbilicus is prepped and draped to allow full visualization of
the shoulders, chest, and breasts during surgery.

T E C H N I Q U E S
■ Short Scar Periareolar Inferior Pedicle (SPAIR)
Technique8,9
Incisions
■ With the breast under stretch using a tourniquet, a 40- to 52-mm areolar
mark is made on the breast (TECH FIG 1A).
■ Local anesthetic is injected into all the planned incisional areas and in the
dermis of the area encompassed by the inferior pedicle.
■ The areolar and periareolar incisions are made to the deep dermis, and the
periareolar area de-epithelialized, except in the planned crescentric resection
area above the NAC (TECH FIG 1B).
■ The periareolar area is incised through the dermis leaving a 5-mm dermal
cuff from the skin edge (TECH FIG 1C).
■ This dermal edge will be used ultimately for placement of the periareolar
purse-string suture.
Flap Creation
■ Breast flaps are then developed medially, superiorly, and laterally from the
periareolar incision (TECH FIG 2A,B).
■ The medial and superior breast flaps are dissected thicker, aiming for 4 to 6
cm thickness (TECH FIG 2C,D).
■ The lateral breast flap is dissected thinner, along the plane of the outer
lamina (TECH FIG 2E).
■ At the base of the superior breast flap dissection, the cephalic aspect of the
breast septum is identified and preserved, while medially and laterally the
septum is incised/released (TECH FIG 2F).
■ The curved line skirting the areola is incised. and dissection proceeds to the
pectoralis fascia to define the segment of breast tissue to be removed and free
the inferior pedicle.
■ The final specimen resembles a horseshoe, with the lateral segment being
larger (TECH FIG 2G).
■ Care is taken to avoid inadvertent undermining of the pedicle and preserve
the septum.

Shaping
■ Various maneuvers are now used to further shape the breast as needed.
■ If the upper pole is concave, the leading edge of the superior breast flap can
be advanced superiorly and fixated to the pectoralis fascia using 3-0 PDS
(Ethicon Inc., Somerville, NJ, USA) or equivalent absorbable interrupted
sutures to autoaugment the upper pole (TECH FIG 3A,B).
■ If the medial pole is deficient, the medial breast flap can be imbricated upon
itself on its deep surface using 3-0 PDS (Ethicon Inc., Somerville, NJ, USA)
or equivalent absorbable interrupted sutures to create a more rounded contour
(TECH FIG 3C,D).
■ If either contour is excessive, the breast flaps can be further debulked as
needed.
■ To centralize the pedicle, the superior aspect of the inferior pedicle is sutured
to the pectoralis fascia (TECH FIG 3E,F).
TECH FIG 1 • A. A 40- to 52-mm areolar mark is made
on the breast. B. The areolar and periareolar incisions
are made to the deep dermis, and the periareolar area
de-epithelialized. C. The periareolar area is incised

through the dermis, leaving a 5-mm dermal cuff.

TECH FIG 2 • A,B. Breast flaps are developed from
the periareolar incision. C. Medial breast flap. D.
Superior breast flap. E. Lateral breast flap. F. The

cephalic aspect of the breast septum, after dissection
of the superior breast flap. G. The horseshoe-shaped
breast reduction specimen.
TECH FIG 3 • A,B. Autoaugmentation of the upper
pole with sutures. C,D. Autoaugmentation of the
medial pole with sutures. E,F. Suture suspension of
the inferior pedicle to the pectoralis fascia.

TECH FIG 4 • A,B. Two lateral buckle points are
identified, which are the starting points of the inferior
pole skin plication. C–E. The inferior pole skin is

progressively stapled from superior to inferior, curving
inferolaterally toward the IMF. F,G. The plication line is
marked with a surgical marker. H. The outlined
resection area is de-epithelialized, and the redundant
medial and lateral wedges of tissue are removed.
Skin Plication
■ The vertical pattern to manage the excessive skin enveloped is next created.
■ A hemostat is applied to the superior pedicle and cephalic traction applied in
line with the breast meridian to reveal two lateral buckle points, which are
stapled together and represent the starting point of the inferior pole skin
plication (TECH FIG 4A,B).
■ With two hemostats applied to the dermal edge of the buckle points and
upward traction (away from patient) in line with the breast meridian, the
inferior pole skin is progressively stapled from superior to inferior, curving
inferolaterally toward the IMF to achieve a smooth and contoured breast
shape (TECH FIG 4C–E).
■ After preliminary staple closure, the patient is placed upright to visualize the
resultant breast shape and make adjustments to the staple line as needed.
■ After the staple line is deemed satisfactory, the patient is returned supine, the
plication line is marked with a surgical marker with hash marks to guide
closure, and the staples are remove (TECH FIG 4F,G).
■ The outlined resection area, which typically resembles a “slanted V,” is de-
epithelialized, and the redundant medial and lateral wedges of tissue adjacent
to the pedicle are removed en bloc (TECH FIG 4H).
Closure
■ A drain is placed as desired, coursing around the pedicle, and brought out
through the lateral breast.
■ The vertical incision is closed with 4-0 Monocryl (Ethicon Inc., Somerville,
NJ) or equivalent interrupted deep dermal sutures followed by subcuticular
closure with 3-0 Stratafix (Ethicon Inc., Somerville, NJ) or equivalent
absorbable barbed suture.
■ The periareolar defect is closed last using the periareolar purse-string
technique.10

■ Eight evenly spaced cardinal points are marked on the areola and
periareolar incision (TECH FIG 5A).
■ A 2-0 Cytoplast (Surgiform Technologies Ltd., Columbia, SC) or
equivalent PTFE suture on a straight needle is selected.
■ The suture is then passed, from deep to superficial, starting on the medial
dermal shelf of the periareolar incision, through the corresponding cardinal
point on the dermis of the areola, inserted back into the outer dermal shelf,
and then passed through the periareolar dermis to the next cardinal point.
■ This weaving is continued until the suture has weaved completely around
the periareolar defect, culminating in the appearance of a wagon wheel
(TECH FIG 5B).
■ The free suture ends are then tightened to cinch the periareolar incision
down to match the diameter of the areola (TECH FIG 5C), followed by
placement of 8 to 10 square knots to secure the suture.
■ The knot complex is placed underneath the medial dermal shelf, and the
periareolar closure is completed with 3-0 Stratafix or equivalent absorbable
barbed suture (Ethicon Inc., Somerville, NJ, USA) (TECH FIG 5D).
TECH FIG 5 • A. Eight evenly spaced cardinal points
are marked on the areola and periareolar incision. B.

Intraoperative appearance of the periareolar pattern
after weaving of the purse-string suture. C. The
periareolar incision is cinched down to match the size
of the areola. D. Completed periareolar closure.
PEARLS AND PITFALLS
Landmarks
■ Place the top of the periareolar pattern 4 cm above the IMF for
smaller reductions and 2 cm above the IMF for larger reductions
because the vertical skin resection is more significant in larger
breasts, which tends to create a more pronounced lifting effect.
■ Draw the rectangle below the periareolar pattern with a height of 8
cm for smaller breasts and 10 cm for larger breasts to preserve
more breast skin for redraping in larger reductions.
■ Push the breasts medially after all markings are completed to
confirm symmetry (FIG 4A).
■ To ensure that there is sufficient skin medially to allow tension-
free redraping of the breast, the distance from the midsternal line
to the medial mark of the periareolar pattern should be at least 12
cm (FIG 4B).
Technique
■ Periareolar patterns greater than 20 cm and reductions greater than
1000 g tend to be more difficult; they require more tedious
dissection and greater operator skill and culminate in more
pleating and scalloping around the periareolar closure.
■ The thickness of the superior and medial breasts flaps can be
directly controlled by adjusting the path of dissection toward the
chest wall; bevel inward for lesser thickness and vice versa.
■ With upward traction of the two hemostats applied to the dermal
edge of the buckle points, and gentle inward pressure on the
inferior pedicle along the breast meridian, the inferior breast
tissues will imbricate and reveal a curvilinear path toward the IMF,
which guides preliminary staple closure of the breast.
■ Instead of being resected, the medial wedge of tissue adjacent to
the pedicle may be de-epithelialized and preserved for more
medial fullness to the reduced breast.
■ If the nipple to IMF distance of the inferior pedicle is long,
plication sutures can be placed on the dermis of the pedicle to

shorten the distance and improve the lower pole contour of the
pedicle (FIG 5A,B).
■ If the resultant periareolar defect after closure of the vertical
segment is not circular, it can be resected again and de-
epithelialized to create a circular defect that matches the areola;
this will better approximate the wound edges using the periareolar
purse-string technique (FIG 5C).
Postoperative
care
■ If there is any concern about the vascularity of the NAC,
especially in cases in which the inferior pedicle is long, a support
bra should not be worn postoperatively to avoid compression on
the pedicle, and patients should be specifically educated about this
to avoid unnecessary anxiety about not wearing a bra.
FIG 4 • A. The breasts are pushed medially to check
that the markings are symmetrical. B. The minimum
distance from the midsternal line to the medial
periareolar pattern is 12 cm.