Operative Technique in Plastic Surgery – Kevin C.Chung

assessment and adjustments.
■ Incision closure is performed in the standard fashion with buried
monofilament absorbable sutures.
■ A closed suction drain may be left in place and removed at or after the first
postoperative visit.
TECH FIG 6 • A. The nipple incision is carried out
after measurement with a 38- to 45-mm cookie cutter.
In contrast to a breast reduction, all the skin within the
Wise pattern is de-epithelialized. B. The breast are
retracted superiorly with skin hooks to allow de-
epithelialization of the inferior Wise pattern skin. C.
After the lower pole skin has been removed, incisions
are carried through the breast tissue to chest wall.
This develops lateral and medial pillars. (The later
pillar is shown here in the retractor.) D. The medial
and lateral pillars are displayed here. E. The medial
and lateral pillars are tucked under the
dermoglandular pedicle supporting the nipple to
provide autoaugmentation.

PEARLS AND PITFALLS
Periareolar
mastopexy10
■ Do not attempt to move the nipple-areolar complex more than 2
cm as it will flatten the breast.
■ Use the three concentric mastopexy rules described by Spear et
al. to avoid complications.
■ Superficially undermine surrounding breast skin flaps for
tension-free closure.
■ Mastopexy should be performed after augmentation in a
combined procedure, as augmentation will decrease the amount
of skin resection necessary.
Vertical
mastopexy8,11,12
■ This technique may be combined with augmentation. If
augmentation mastopexy is planned, augmentation should be
performed first. The subpectoral or subglandular plane may be
initially accessed through the vertical incision or the
inframammary incision.
■ The vertical incision should stop 2 cm above the IMF to avoid
disrupting the fold. The excess gathered skin will settle in 2–3
months or the excess can be trimmed with a dog ear correction
in the IMF.
■ Tailor tacking the vertical incision closed and sitting the patient
supine are useful in assessing the initial result and symmetry.
■ If the outer marked areolar diameter is significantly larger than
the inner areolar diameter, a blocking suture is useful to prevent
areolar enlargement or scar widening.
■ More aggressive mastopexy with a planned excision in the fold
can be performed in patients with excessive skin laxity or cases
without simultaneous augmentation.
Wise pattern
mastopexy
■ Reserved for grade 3 ptosis or breast requiring significant skin
redundancy.
■ Medial and lateral de-epithelialized skin flaps may be used to
provide upper pole autoaugmentation.
■ Use the inframammary fold or most projected point of the
breast for ideal nipple placement to avoid malposition,
particularly a high-riding nipple.
■ Maintain an adequate dermoglandular pedicle in high-grade
ptosis to prevent nipple-areolar necrosis.
POSTOPERATIVE CARE

■ Compressive surgical bra
■ No strenuous upper body exercise activity for 4 to 6 weeks
■ Surgical drains typically not needed
■ 24 hours or less of perioperative antibiotics
■ Occlusive dressing for 48 hours
OUTCOMES
■ Mastopexy is an operation with a steep learning curve, and special attention
should be paid to preoperative planning and patient selection (FIG 3).
■ Patient and surgeon expectations should be discussed to ensure agreement on a
realistic result.
■ When properly planned and executed, mastopexy has high satisfaction rates.
■ However, patients with significant ptosis, diabetes, obesity, tobacco use, or
prior radiation should be approached with caution.
COMPLICATIONS
■ Bleeding, infection, dehiscence, delayed wound healing
■ Nipple-areolar necrosis in the previously irradiated or augmented breast
■ Areolar widening, hypertrophic or widened scar
■ Asymmetry
■ Nipple malposition

FIG 3 • A,B. Postoperative photos of the patient in FIG
2A,B after periareolar mastopexy show an improved
upper pole breast slope and skin envelope with

resolution of ptosis. C,D. Postoperative photos of the
patient in FIG 2C,D after vertical mastopexy and
augmentation. E,F. Postoperative photos of the patient
in FIG 2E,F after revision vertical mastopexy using
acellular dermal matrix for treatment of pseudoptosis.
G,H. Postoperative photos of the patient in FIG 2G,H
about 6 months after Wise pattern mastopexy.
ACKNOWLEDGMENT
Dr Ter Louw dedicates this chapter to the memory of Scott L. Spear,
MD, FACS, who passed away during its preparation. Founding Chair
of the Georgetown University Hospital Department of Plastic Surgery,
Washington, DC, Dr Spear was an innovator, a skilled and thoughtful
surgeon, a mentor to many, and a dedicated husband, father, and
friend.
REFERENCES
1. De Mey A, Greuse M, Azzam C. The evolution of mammaplasty. Eur J Plast
Surg. 2005;28:213-217.
2. Lassus C. New refinements in vertical mammaplasty. Chir Plast. 1981;6:81-
86.
3. Lejour M. Vertical mammaplasty: update and appraisal of late results. Plast
Reconstr Surg. 1999;104:771.
4. Benelli L. A new periareolar mammaplasty: the “round block” technique.
Aesthetic Plast Surg 1990;14:93-100.
5. Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy. Plast
Reconstr Surg. 1990;85(6):961-966.
6. Rohrich RJ, Thornton JF, Jakubietz RG, et al. The limited scar mastopexy:
current concepts and approaches to correct breast ptosis. PlastReconstr Surg.
2004;114(6):1622-1630.
7. Lai HMJ, Lam T. A mathematical design in creating the new nipple-areolar
complex in vertical mammaplasty. Plast Reconstr Surg Glob Open.
2014;2:e177.
8. Lejour M. Vertical mammaplasty early complications after 250 personal
consecutive cases. Plast Reconstr Surg. 1999;104:764.

9. Graf R, Ricardo Dall Oglio Tolazzi A, Balbinot P, et al. Influence of the
pectoralis major muscle sling in chest wall-based flap suspension after vertical
mammaplasty: ten-year follow-up. Aesthet Surg J. 2016;36(10):1113-1121.
10. Gruber RP, Jones HW Jr. The “donut” mastopexy: indications and
complications.Plast Reconstr Surg. 1980;65(1):34-38.
11. Berthe JV, Massaut J, Greuse M, et al. The vertical mammaplasty: a
reappraisal of the technique and its complications. Plast Reconstr Surg.
2003;111:2192.
12. Beer GM, Spicher I, Cierpka KA, et al. Benefits and pitfalls of vertical breast
reduction. Br J Plast Surg. 2004;57:12.

7
CHAPTER
Section III: Reduction
Mammaplasty
Reduction Mammaplasty
Peter Henderson and Joseph J. Disa
DEFINITION
■ Breast hypertrophy can be a physically and socially debilitating condition that
frequently leads women to seek surgical intervention. Macromastia is defined
as symptomatic breast tissue less than 1500 g, and gigantomastia is defined as
symptomatic breast tissue greater than 1500 g.
■ Reduction mammoplasty has two elements: skin excision pattern and
parenchymal excision/pedicle design. With few exceptions, these two elements
are independent variables that can be combined in any manner. The vertical-
only skin excision pattern and the superomedial pedicle design are increasingly
commonly used, and are often combined, especially in patients in whom the
maintenance of upper pole projection is important, and the degree of
ptosis/excess skin is not excessive.
ANATOMY
■ The boundaries of the breast are commonly considered to be the clavicle
cranially, the inframammary fold caudally, the sternum medially, and the
lateral/anterior aspect of the latissimus muscle laterally. The tail of Spence
extends from the upper outer quadrant into the axilla (FIG 1).
■ The blood supply to the breast is from perforators from the internal mammary
(thoracic) artery and vein, as well as the thoracoacromial and lateral thoracic
vessels.
■ The breast is innervated by the 4th through 6th intercostal nerves.
■ In females, the areola is usually round and 38 to 40 mm.

■ Breast ptosis is most commonly graded on the Regnault scale (FIG 2). Grade
0 (no ptosis) indicates that the nipple sits cranially to the IMF. Grade 1
indicates that the nipple sits at the level of the IMF. Grade 2 indicates that the
nipple sits caudal to the IMF but not at the caudal-most point of the breast.
Grade 3 indicates that the nipple sits at the caudal-most point of the breast.
Pseudoptosis is when the nipple sits at or above the IMF, but there is excessive
breast tissue below the IMF (this has a characteristic “bottomed out”
appearance).
■ Common, clinically relevant breast measurements include nipple-sternal notch
and nipple-IMF distances.
■ Bra sizes are an imperfect way to gauge breast size (not in the least because
most women do not wear the correct size bra). The convention is that the
“number” in the breast size is the circumference of the chest wall (measured
just caudal to the breast). The “cup” size is indicated by a letter, with each
letter’s position in the alphabet indicating the increased number of inches that
are measured when the circumference around the breasts is measured (eg,
“32B” means that the chest wall circumference is 32 in., and the circumference
around the breasts is 34 in.).
PATHOGENESIS
■ Breast hypertrophy is a congenital disorder that frequently is exacerbated by
weight gain. Especially in young patients, it can be due to increased end-organ
responsiveness to estrogen.
NATURAL HISTORY
■ In addition to being socially debilitating in young patients, breast hypertrophy
can progress to physical ailments, including “notching” of the shoulders due to
the bra straps, neck and upper back pain, and intertriginous infections.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Detailed patient and family history of breast disease is crucial (including
benign tumors, malignancy, screening, etc.), and information regarding any
prior radiation treatment and the operative reports from any prior breast
procedures (most notably partial mastectomy/“lumpectomy” or prior breast
reduction) should be obtained.

FIG 1 • Breast anatomy.

FIG 2 • Regnault scale for breast ptosis.
■ Factors relevant to lifetime estrogen exposure, such as age at menarche,
menopause (if applicable), number of pregnancies, and use of birth control
medications, are also important.
■ Breast-feeding history (including plans for future childrearing) is mandatory.
■ Nicotine use should be carefully investigated; most surgeons will not perform
this elective procedure on anyone who has smoked in the past 2 to 4 weeks.
■ Personal importance of erogenous breast sensitivity should be discussed, as
decreased or complete absence of nipple sensation is a possible consequence.
■ Symptoms related to breast hypertrophy (should notching, back pain,
intertriginous infections, and difficulties with personal hygiene) should be
noted.
■ Physical exam should note any asymmetry between breasts, complete
bimanual examination for masses in both breasts and bilateral axillae, and
appropriate breast measurements (nipple-sternal notch, nipple-IMF).
IMAGING
■ In patients who are of an age when standard, surveillance breast imaging is
recommended (40–50 years, depending on the recommending agency), and
mammography should always be performed prior to any breast reduction
procedure. Many surgeons will obtain surveillance imaging prior to reduction
regardless of age, though this practice is not formally endorsed.
DIFFERENTIAL DIAGNOSIS
■ Though unlikely, the possibility of a large breast mass must be considered
when a patient is evaluated for presumed breast hypertrophy.
NONOPERATIVE MANAGEMENT
■ Weight loss may lead to a small incremental improvement in symptoms but
rarely is significant enough to sufficiently alleviate symptoms.
■ Liposuction is a reasonable approach in a very small subset of patients
(namely those with excessive breast volume without ptosis).
SURGICAL MANAGEMENT
Preoperative Planning

■ It is important that a frank discussion occur between surgeon and patient
regarding each patient’s wishes for postoperative breast size. This will rarely
have a significant impact on the type of procedure performed but will impact
the amount of breast tissue excised.
Positioning
■ Patient should be positioned supine on the operating room table.
■ Because the patient will be flexed at the waist in order to “sit upright” during
the procedure, secure the arms (usually out, on arm boards) and head, and
ensure that the patient’s waist is appropriately positioned relative to the break
in the table.
Approach
■ Options for skin excision patterns include the “Wise pattern” (“anchor” or
“inverted T”) and vertical-only (“mosque”). Options for parenchymal
excision/pedicle design include superior, superomedial, medial, inferior, central
mound, lateral, and bipedicle (among others).1
T E C H N I Q U E S
■ Vertical, Superomedial Pedicle Reduction
Mammaplasty
■ Inject wetting solution into the inferomedial and inferolateral portions of the
resection specimen (what would be the medial and lateral parts of the
“anchor” in the traditional Wise pattern excision).
■ Mark the neo-areola with a nipple sizer (“cookie cutter”); most surgeons use
42 mm.
■ Incise partial-thickness dermis of the pedicle and the circumareolar incision.
■ Place the breast tourniquet.
■ De-epithelialize the pedicle (taking care not to inadvertently undermine the
nipple-areola complex).
■ Incise full-thickness dermis around the pedicle.
■ Remove the breast tourniquet.
■ Incise the breast parenchyma straight down to the chest wall, taking care not

to undermine the pedicle.
■ Incise full-thickness dermis to the rest of the skin incisions.
■ Undermine the inferomedial and inferolateral corners just below the dermis
(many surgeons will use curved Mayo scissors, especially if wetting solution
has been injected).
■ Remove the skin/fat/breast parenchyma specimen as one single piece.
■ Irrigate and ensure hemostasis.
■ Weigh specimens.
■ Rotate the pedicles (clockwise on the right breast and counterclockwise on
the left breast) to ensure that they rest comfortably in a tension-free manner.
■ Place “pillar stitches” between the resulting medial and lateral pillars
through the breast parenchyma (with or without the overlying dermis).
■ Assess for symmetry, with potential interventions for insufficient symmetry
being the excision of additional tissue and altering the pillar stitches.
■ Use of closed-suction drains is typically unnecessary.
■ Close the skin in the deep dermal and subcuticular positions.2–4
■ Central Mound Reduction Mammaplasty
Markings
■ Preoperative markings should be done in the upright or sitting position
(TECH FIG 1A-C).
■ The most reliable location for the nipple-areola complex is with the
superior border at the level of the inframammary fold (this provides better
results than a predetermined nipple-sternal notch distance, or the
midhumeral point).
■ It is advisable to initially mark a vertical-only skin excision pattern (later a
horizontal component can be excised if needed).
■ Nipple sizers (usually 42 mm) are used to define the new borders of the
areola (if at all possible, remove all additional areolar tissue to prevent
unsightly pigmented skin at closure lines).
Excision of Parenchyma
■ Incise the circumareolar and vertical-only skin excision markings, and de-
epithelialize all tissue besides the newly defined nipple-areola complex.

■ Excise as much breast parenchyma inferior to the nipple-areola complex as
necessary in order to achieve the desired breast size (TECH FIG 2A-C).
■ The central tenet of the central mound technique is to maintain a pedicle
directly from the nipple-areola complex to the underlying pectoralis major
muscle; therefore, do not undermine the nipple-areola complex in the
course of removing excess breast parenchyma (TECH FIG 2D-F).
TECH FIG 1 • Markings for central mound breast
reduction using the Wise pattern.

TECH FIG 2 • A–C. Skin flaps of appropriate thickness
to maintain adequate vascularity are elevated off the
gland laterally, medially, and superiorly. D–F. The
footprint of the breast is left attached to the muscle
and is not undermined.
■ If necessary, skin flaps medial, superior, and lateral to the nipple-areola
complex can be created in order to allow for the necessary mobility to
transpose the nipple-areola complex into its final position near the level of
the inframammary fold. This is done in a manner angling away from the
nipple-areola complex (thereby creating a “cone” with the nipple-areola

complex at the apex). The parenchyma of the skin flaps should be at least 2
cm thick to maximize vascularity.
■ Excision of the breast parenchyma leads to the creation of medial and lateral
“pillars,” which are sutured together with deeply placed, heavy, slowly
absorbable sutures.
Completion
■ The patient is flexed at the waist to “sit up.”
■ At this point, the breast is examined to determine whether there is sufficient
excess skin and/or breast parenchyma to warrant the excision of a horizontal
wedge of tissue. If so, the markings should be made such that the closure will
fall at the level of the inframammary fold. If no further breast parenchymal
excision is warranted, the skin can be removed by de-epithelialization alone.
If the patient would benefit from the excision of additional breast
parenchyma, then the horizontal wedge can be taken as a full-thickness
segment.
■ The tissue is irrigated and hemostasis is ensured.
■ Closed-suction drains can be placed, depending on surgeon preference.
■ The areola is inset to its new location, and the skin is closed (TECH FIG 3).
TECH FIG 3 • Intraoperative appearance after gland
and nipple-areola repositioning.
PEARLS AND PITFALLS

Skin
excision
pattern
■ When the vertical-only skin excision pattern is attempted, the
amount of excess skin at the inferior portion of the vertical wound
should be examined. A mild amount of “bunching” can be tolerated,
as it usually “settles out” over the first 6 months. A moderate or
significant amount of excess skin should be excised in a transverse
direction, essentially converting the “vertical-only” skin excision
pattern into a Wise pattern.
Nicotine use
■ Nicotine use (either in cigarettes or in nicotine patches)
significantly increases the risk of NAC ischemia, fat necrosis, and
other wound healing complications. The nicotine metabolite
cotinine can be detected in the urine, and a point-of-care test can be
performed in the preoperative area immediately prior to the
scheduled operation if concern exists.
Parenchymal
excision
■ Efforts should be made to minimize the amount of parenchymal
tissue removed underlying the final location of the NAC (superior
and lateral to the pedicle); overresection can lead to poor NAC
projection.
POSTOPERATIVE CARE
■ Bras that provide maximal support (and do not contain any rigid components
like underwire) should be worn for the first 2 to 4 weeks.
■ If closed-suction drains were used, they will likely be able to be removed in 1
to 7 days.
■ Nipple-areola complex ischemia/necrosis is a rare but dreaded complication
that should be checked for regularly in the immediate to early postoperative
period (creation of a pedicle that is sufficiently wide and thick can significantly
reduce the risk of this happening). If NAC ischemia is thought to present in the
early postoperative period, periareolar sutures can be removed, undoing the
inset and potentially releasing any ischemia-inducing configuration.
OUTCOMES
■ Most patients are satisfied following breast reduction procedures (FIG 3).
■ Use of superomedial pedicle is thought to maximize upper pole fullness and
reduce the likelihood of pseudoptosis (“bottoming out”) that is thought to occur
more frequently with an inferior pedicle design.
■ Nipple sensation is rarely absent, but usually decreased relative to the
preoperative baseline. Occasionally, nipple sensation is increased

postoperatively due to decrease stretch/tension once the excess weight/volume
has been removed.
■ Ability to breast-feed is impaired in approximately 40% of patients.
COMPLICATIONS
■ Hematoma can occur, but risk can be minimized if hemostasis is diligently
attempted.
■ Seroma can occur and can usually be addressed with percutaneous drainage.
■ Fat necrosis can be a consequence of parenchymal ischemia. It usually softens
(if not completely resolves) in a matter of months, but sometimes requires
surgical excision.
FIG 3 • A. Patient preoperatively. B. Three years after
breast reduction.
■ NAC ischemia is rare but can potentially lead to necrosis and complete loss of
the NAC.

■ Alterations in nipple sensation or breast-feeding ability are not uncommon,
and the patient should be counseled in the preoperative period as to the
possibility of this occurring.
REFERENCES
1. Antony AK, Yegiyants SS, Danielson KK, et al. A matched cohort study of
superomedial pedicle vertical scar breast reduction (100 breasts) and traditional
inferior pedicle Wise-pattern reduction (100 breasts): an outcomes study over 3
years. Plast Reconstr Surg 2013;132:1068-1076.
2. Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin
Plast Surg. 2002;29(3):379-391.
3. Spear SL, Davison SP, Ducic I. Superomedial pedicle reduction with short
scar. Semin Plast Surg. 2004;18(3):203-210.
4. Van Deventer PV, Graewe FR. The blood supply of the breast revisited. Plast
Reconstr Surg. 2016;137(5):1388-1397.

8
CHAPTERInferior Pedicle
Paul A. Ghareeb and Albert Losken
DEFINITION
■ Reduction mammaplasty remains one of the most commonly performed
operations by plastic surgeons.
■ Inferior pedicle reduction mammaplasty is one of the most widely used
reduction techniques because it is easy to learn, is safe, and has reproducible
outcomes.1
■ This technique was described and refined in the 1970s by Ribiero, Robbins,
Georgiade, and Courtiss and Goldwyn.2,3
■ Is most commonly utilized with a Wise pattern (inverted T) skin excision.
■ The inferior pedicle reduction technique is extremely versatile and can be used
in almost any reduction procedure. We have found it to be useful in patients
with long nipple to notch distances and those with large anticipated reduction
specimens.
■ The complication rates for inferior pedicle reductions have been shown to be
equivalent for small and large (greater than 1000 g) reductions, making this
technique particularly useful when treating gigantomastia.4
ANATOMY
■ Borders of the breast
■ Superiorly: clavicle
■ Medially: sternum
■ Inferiorly: superior border of rectus fascia
■ Laterally: anterior border of latissimus
■ Blood supply
■ Intercostal perforators

• Primary blood supply to the inferior pedicle
■ Internal mammary perforators
■ Lateral thoracic artery
■ Thoracoacromial artery
■ Innervation
■ Intercostal sensory branches
• The fourth intercostal sensory nerve provides the majority of sensation to
the nipple-areolar complex (NAC).
• The sensory branches course just above pectoralis fascia before piercing the
breast parenchyma to supply the overlying skin and nipple. It is important to
maintain a layer of breast tissue over the pectoralis when performing
reduction mammaplasty to prevent damage to these nerves.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Focused history
■ Current brassiere size and desired size after mammaplasty is important to
determine with the patient preoperatively in order to guide goals and
expectations.
■ Symptoms of macromastia and any interventions attempted must be
elucidated and recorded preoperatively.
■ History of childbirth, breast-feeding, and desire to have further children are
important to discuss. With the inferior pedicle technique, most women
maintain the ability to breast-feed postoperatively but should be counseled on
this during the consultation.
■ Mammographic history if applicable, as well as family history of breast
disease or cancer.
■ A history of smoking should be discussed prior to any reduction, and patients
should be counseled to stop smoking at least 1 month prior to reduction
mammaplasty due to the significantly increased risk of wound healing
complications.
■ Physical exam
■ Examine the overall breast shape, asymmetries, previous scars, and estimate
breast size in grams. Always examine for breast masses and nipple sensation.
Record breast measurements including sternal-notch-to-nipple and nipple-to-
inframammary fold distances.
• Patients considered to be good candidates for an inferior pedicle reduction

often times have long nipple to notch and nipple to IMF distances, which
can both be easily addressed with this technique. Furthermore, patients with
boxy-appearing breasts can be shaped effectively with the skin excision.
■ Evaluate existing ptosis utilizing the Regnault classification.
■ Note any additional axillary tissue laterally that would not be resected with
standard reduction mammaplasty. This is often an area that the patient
assumes will be treated with standard reduction procedures but must be
counseled that this is an additional area that must be treated.
IMAGING
■ Mammography is recommended for women who meet screening criteria.
■ No other routine imaging is required preoperatively.
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative markings are critical to the success of any breast reduction.
■ The patient is examined in the standing position, with her arms resting to
either side.
■ The midline is marked first from sternal notch to the umbilicus.
■ The true breast meridian is then marked on each side from the midclavicular
line down onto the abdominal wall. Note that this may not always align with
the position of the NAC.
■ Pitanguy point is then identified and marked by placing one’s fingers
underneath the breast at the inframammary fold and curling them forward to be
palpated by the opposite hand. This allows the surgeon to determine the final
resting position of the NAC. This is approximately 21 cm from the sternal
notch but can vary depending on the body and breast shape.
■ It is important to mark this point correctly at the IMF. By marking too high,
one may produce a “sunny side up” nipple, which points upward, or a
“snoopy deformity” by placing the nipple too far inferiorly.
■ The vertical limbs of the Wise pattern are then created approximately 7 cm in
length on each side, starting at Pitanguy point and coursing inferiorly. A
McKissock keyhole tool may be used for the purpose of creating the vertical
limbs, but we prefer to use the medial and lateral distraction technique. In this
fashion, the breast is distracted medially and laterally, and the vertical limb is
drawn in continuity with the superior and inferior breast meridian markings.

■ The distance between the base of the vertical limbs correlates with the final
change in breast base diameter.
■ The horizontal markings are then drawn to connect the vertical limbs to the
inframammary fold marking at the medial and lateral most aspects of the
breast.
■ The horizontal takeout can be tailored as short or long as necessary to
achieve the desired outcome. The markings are typically carried out further
for larger resections or boxy-appearing breasts, whereas in smaller reductions,
can be achieved with a shorter horizontal scar.
■ The IMF marking is made just above the level of the existing IMF. It can be
preserved at the inverted T–junction if viability of the upper flaps is a
concern.
■ After the markings have been completed, they should be compared to the
contralateral side to ensure symmetry. In asymmetric reductions, this may be
difficult to assess.
■ FIG 1 demonstrates the standard preoperative markings for an inferior pedicle
reduction.
FIG 1 • A,B. Preoperative markings for the inferior
pedicle Wise pattern reduction in a patient undergoing
bilateral oncoplastic reduction for a left breast cancer.
Positioning
■ The patient is placed supine on the operating room table and is positioned to
be able to sit up if necessary.

■ The arms are extended on arm boards, taking care not to over extend and
distort the breast. They are secured with standard straps and soft padded wraps
to facilitate placing the patient in the upright position.
■ The breasts are prepped and draped to include the sternal notch, clavicles, and
lateral most aspects of the breast and axilla. For unilateral procedures, the
contralateral breast is exposed to be examined during the procedure.
Approach
■ At the start of the procedure, the planned inferior pedicle is designed from the
inframammary fold incision along the breast meridian to include a 1-cm cuff of
tissue surrounding the NAC. The base of the pedicle should be 8 to 10 cm in
width to ensure proper vascularity of the NAC. This is kept wider in bigger
reductions with longer pedicles.
■ The NAC is then marked by sight or with a cookie cutter at 40 to 44 mm, and
the final nipple position is planned and marked at the apex of the vertical
limbs. No tension is applied to the NAC while marking to reduce the likelihood
of creating an unnatural final appearance.
■ A line approximately 1 cm above the inframammary fold is marked for the
inferior aspect of the Wise pattern. This is performed to avoid disrupting the
dense attachments of the fold.
T E C H N I Q U E S
■ Incision
■ The nipple is incised sharply with a knife through the epidermis only.
■ The remainder of the Wise pattern markings and the planned inferior pedicle
are then incised sharply, and the pedicle is de-epithelialized with a large
curved Mayo scissors or a no. 10 blade (TECH FIG 1).
■ It is helpful to place a towel around the base of the breast and secure tightly
with a clamp to maintain appropriate tension for de-epithelialization.
■ Linear partial-thickness incisions through the epidermis with a scalpel can
further assist with de-epithelialization with scissors.

TECH FIG 1 • The Wise pattern has been incised and
the inferior pedicle de-epithelialized.
■ Dissection
■ The superior flaps are then developed up toward the breast base. The extent
of dissection depends on the size of the breasts and the pedicle and is limited
if possible. These are generally created approximately 1 in. thick to maintain
upper pole fullness and to ensure vascularity to the overlying skin (TECH
FIG 2B).
■ The nondominant hand is typically placed under the breast, and the
parenchyma is grasped and rolled inferiorly over the hand to provide
tension for dissection when an assistant is unavailable to retract.
■ Once the superior flaps have been created, the dermoglandular pedicle is
developed straight down to the chest wall. The pedicle should not be
undermined in order to prevent nipple necrosis.
■ The “two finger” dissection technique is useful when developing the
pedicle to provide tension. The nondominant index and long fingers are
used to spread the parenchyma, and the tissue is divided with cautery. This
allows the surgeon to retract for him or herself, which is the best way to
ensure that the pedicle is not being undermined.

TECH FIG 2 • A,B. The superior flaps are elevated
first. These are kept relatively thick to ensure enough
superior pole fullness and to help prevent bottoming-
out.
■ The pedicle is kept wider at the base to ensure optimal vascularity.
■ Resection
■ The medial resection is then carried out. Care is taken initially to leave some
breast tissue at the medial aspect of the excision to maintain medial fullness.
This is examined after tailor tacking, and further resection can be carried out
if required.
■ The superior and lateral areas are then resected, and the entire specimen is
handed off en bloc to be weighed (TECH FIG 3). The breast parenchyma is
kept superiorly if possible to maintain upper pole fullness. However, we will
typically over-resect the lateral aspect of the reduction due to the common
presence of additional axillary tissue. This can be further treated with
liposuction if necessary.
■ The inferior corners of the vertical limbs are then brought down and secured
at the breast meridian marking to form the inverted T, and the rest of the
breast is tailor-tacked with staples to evaluate shape and symmetry.
Additional resection can be performed at this time to achieve a satisfactory
result.
■ Often times, there remains excess skin that can be removed. This is often
found at the vertical component but can also occur at the medial or lateral

horizontal incision. Appropriate tailor tacking at this point in the procedure
is important to identify these areas for further resection.
TECH FIG 3 • A. The inferior pedicle is demonstrated
after medial and lateral resection has been carried
out. B. The resected specimen is demonstrated. Note
that the majority of resected tissue is from the lateral
aspect of the breast.
■ Suturing
■ Internal shaping sutures are not generally used in our practice but can be
considered based upon surgeon preference.
■ If the final NAC position was not previously marked and incised, this may
now be done so. It is often helpful to sit the patient up to ensure that the NAC
is symmetrically placed at the point of maximal projection on the breast
mound. This is often measured at 4 to 5 cm from the inframammary fold to
the inferior aspect of the NAC.
■ A suture can be used in a pendulum fashion to ensure symmetric
positioning of the nipple.
■ Drains are not typically used in our reduction procedures but may be
considered based on surgeon preference.
■ The inverted T junction is closed first with an external 3-0 monofilament
suture in half-buried horizontal mattress fashion. The T junction at the NAC
base is next closed in similar fashion, followed by the rest of the incisions.
The incisions are closed with 3-0 monofilament suture in interrupted deep
dermal fashion, followed by a running subcuticular stitch with 3-0 or 4-0

monofilament suture (TECH FIG 4). Mastisol and Steri-Strips are then
placed over the incisions, and padding is placed over the breasts. A
supportive surgical brassiere is placed in the operating room at the
completion of the case.
TECH FIG 4 • The final on-table result after closure
and inset of the NAC. The inferior T junction is closed
with an external half-buried horizontal mattress suture.
In this case, the left side (oncologic side) was kept
bigger in anticipation for radiation therapy.
PEARLS AND PITFALLS
Markings
and
incision
■ The preoperative markings are key to achieving a successful outcome in
reduction mammaplasty.
■ Mark and incise the inframammary fold incision approximately 1 cm
above the true IMF to avoid disrupting the fold.
■ The horizontal incision can be made as long or short as necessary to
properly shape the breast.
Flaps
and
pedicle
■ One can choose whether to develop the superior flaps or pedicle first,
but in our experience, it is easier to develop the flaps first and then to
use the “two finger” technique to develop the pedicle. This technique for
pedicle development can be utilized for other pedicle types as well.
■ The surgeon must be aware of the pedicle at all times when performing
the resection. Avoiding undermining of the pedicle is critical to a safe

procedure.
■ Developing thicker superior flaps will prevent flattening of the upper
pole and further protect against bottoming out.
NAC
■ Leave a layer of breast parenchyma over the pectoralis fascia to avoid
damaging the sensory nerves to the nipple.
■ The NAC should never be placed too high or too medial, because this
creates an unnatural look and may be difficult to conceal in a bathing
suit or brassiere.
■ The NAC should be observed for signs of ischemia or congestion prior
to completion of the procedure. In rare circumstances, conversion to a
free nipple graft can be performed for salvage if the NAC is felt to be
nonviable.
POSTOPERATIVE CARE
■ The vast majority of reduction mammoplasties in our practice are performed
on an outpatient basis and are seen back in the office within 2 weeks for a
routine postoperative appointment.
■ The patient is kept in a supportive surgical bra or wireless sports bra at all
times except when showering for the first 4 to 6 weeks. Once all of their
incisions have healed, they are cleared to begin wearing a bra with
underwiring.
OUTCOMES
■ Satisfaction rates with reduction mammaplasty are among the highest in any
area of plastic surgery, with approximately 95% of patients stating they would
do it again if given the choice.5,6 Several reports using validated questionnaires
have determined reproducible improvement in both physical and psychosocial
symptoms postoperatively.5,7 Furthermore, reduction surgery has been found to
be a stimulus for further weight loss and blood glucose control in motivated
patients.8
■ The reoperation rates for reduction mammaplasty are approximately 8% to
9%.9 Most of these cases are for scar revision, although some patients require
revision for fat necrosis or other causes.
■ Postoperative results are demonstrated in FIGS 2 and 3.
COMPLICATIONS
■ The overall complication rate for reduction mammaplasty ranges widely from
5.1% to 45% in the literature.6,9–11 Most complications are mild in nature and

can be treated conservatively.
■ Wound healing problems are the most common complication of Wise pattern
reduction mammaplasty. This most commonly occurs at the inferior T junction,
and in almost all cases may be treated conservatively with Silvadene or moist
wet to dry dressings with resolution.
FIG 2 • (A) Preoperative and (B) postoperative result of
a 27-year-old female who underwent inferior pedicle
reduction mammaplasty. An inferior pedicle was chosen
for easier inset. A superior or superomedial pedicle
would have been fairly long and harder to appropriately
reduce. Her nipple to notch measurements were 34.5
cm on the right and 34 cm on the left, while her nipple
to IMF measurements were 16 on the right and 17 on
the left. Final resection volumes were 1088 g on the
right and 959 g on the left.
■ To avoid necrosis at the T junction, one must take care to avoid shearing the
skin edges from the underlying breast tissue and excessive tension on the
closure at this area.
■ Bottoming out, which refers to the development of excess lower pole tissue
and stretching over time, is a phenomena that can occur with inferior pedicle
reductions. There have been several techniques presented to prevent this, but at
the current time, we do not routinely perform any additional maneuvers to
avoid this.
■ Hematomas, fat necrosis, and infectious complications are relatively common
following reduction mammaplasty. Most can be treated conservatively, but

some patients will require surgical intervention.
FIG 3 • (A) Preoperative and (B) postoperative result of
a 54-year-old female who underwent inferior pedicle
reduction mammaplasty. In this case, most of the breast
volume was carried superiorly, and therefore, an inferior
pedicle was chosen. Her nipple-to-notch measurements
were 33 cm on the right and 32 cm on the left, while her
nipple-to-IMF measurements were 16 cm bilaterally.
Her final resection volumes were 801 g on the right and
706 g on the left.
■ Nipple-areola complex sensation is often affected following reduction
mammaplasty. The greatest degree of sensitivity change persists in the early
preoperative period, but most patient have improved or normal sensation at 6
months postoperatively.12 Theoretically, the inferior pedicle technique leaves
more branches of the fourth intercostal nerve to the NAC intact, possibly
providing some benefit when compared to other pedicle types.
■ Nipple ischemia and necrosis is a rare but unfortunate complication of any
reduction mammaplasty procedure. The overall risk of either partial or full
necrosis is approximately 3.6%.11 Partial-thickness loss can be treated
conservatively with Silvadene and dressing changes, whereas full-thickness
defects must often be debrided and primarily closed for optimal results.
Depigmentation can occur after partial-thickness loss, especially in darker
colored areolas.
REFERENCES
1. Rohrich RJ, Gosman AA, Brown SA, et al. Current preferences for breast

reduction techniques: a survey of board-certified plastic surgeons 2002. Plast
Reconstr Surg. 2004;114:1724-1733.
2. Courtiss EH, Goldwyn RM. Reduction mammaplasty by the inferior pedicle
technique. An alternative to free nipple and areola grafting for severe
macromastia or extreme ptosis. Plast Reconstr Surg. 1977;59:500-507.
3. Georgiade NG, Serafin D, Morris R, et al. Reduction mammaplasty utilizing
an inferior pedicle nipple areolar flap. Ann Plast Surg. 1979;3:211-218.
4. Hunter J, Ceydeli A. Correlation between complication rate and tissue
resection volume in inferior pedicle reduction mammaplasty: a retrospective
study. Aesthetic Surg J. 2006;26:153-156.
5. Gonzalez M, Glickman L, Aladegbami B, Simpson R. Quality of life after
breast reduction surgery: a 10-year retrospective analysis using the Breast Q
Questionnaire: does breast size matter? Ann Plast Surg. 2012;69:361.
6. Dabbah A, Lehman JA, Parker MG, et al. Reduction mammaplasty: an
outcome analysis. Ann Plast Surg. 1995;35:337-341.
7. Coriddi M, Nadeau M, Taghizadeh M, Taylor A. Analysis of satisfaction and
well-being following breast reduction using a validated survey instrument: the
BREAST-Q. Plast Reconstr Surg. 2013;132:285.
8. Singh K, Pinell X, Losken A. Is reduction mammaplasty a stimulus for weight
loss and improved quality of life? Ann Plast Surg. 2010;64(5):585-587.
9. Manahan M, et al. An outcomes analysis of 2142 breast reduction procedures.
Ann Plast Surg. 2015;74:289.
10. Fischer J, Cleveland E, Shang E, et al. Complications following reduction
mammaplasty. Aesthet Surg J. 2014;34:66-73.
11. Cunningham B, Gear A, Kerrigan C, Collins E. Analysis of breast reduction
complications derived from the BRAVO study. Plast Reconstr Surg.
2005;115:1597.
12. Hamdi M, Greuse M, Mey A, Webster M. A prospective quantitative
comparison of breast sensation after superior and inferior pedicle
mammaplasty. Br J Plast Surg. 2001;54:39-42.

9
CHAPTER
Breast Reduction with Free
Nipple Graft
Paul A. Ghareeb and Albert Losken
DEFINITION
■ Reduction mammaplasty is one of the most commonly performed operations
in plastic surgery.
■ Free nipple graft reduction was first reported by Thorek in 1922.1
■ This technique is typically reserved for patients at high risk for nipple loss, in
patients who wish to be smaller than what can be achieved by preserving the
nipple on a pedicle, and in those who are at increased anesthetic risk.
■ The nipple may be preserved with the areola as a composite graft or may be
harvested by itself with subsequent tattooing of the areola.
ANATOMY
■ Borders of the breast:
■ Superiorly: Clavicle
■ Medially: Sternum
■ Inferiorly: Superior border of rectus fascia
■ Laterally: Anterior border of latissimus
■ Blood supply:
■ Intercostal perforators
■ Internal mammary perforators
■ Lateral thoracic artery
■ Thoracoacromial artery
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Focused history:
■ Current brassiere size and desired size after mammaplasty is important to

determine with the patient preoperatively.
• Free nipple graft reduction is a good option in patients who wish to be
smaller than what can be achieved with a pedicled reduction.
■ Symptoms of macromastia and any interventions should be documented.
■ History of breast-feeding and the desire to have further children are important
to discuss.
• Patients undergoing free nipple graft reduction should be counseled about
the inability to breast-feed postoperatively, as this may affect their decision
to undergo this procedure until childbearing is complete.
■ Mammographic history if applicable, as well as family history of breast
disease or cancer.
■ A history of smoking should be discussed prior to any reduction, and patients
should be counseled to stop smoking at least 1 month prior to reduction
mammaplasty due to the significantly increased risk of wound healing
complications.
■ Physical exam:
■ Examine the overall breast shape, asymmetries, previous scars, and estimate
breast size in grams. Examine for breast masses and nipple sensation. Record
breast measurements including sternal notch to nipple and nipple to
inframammary fold distances.
■ Evaluate existing ptosis utilizing the Regnault classification.
■ Note any additional axillary tissue laterally that would not be resected with
standard reduction mammaplasty. This area must be pointed out
preoperatively so that patients understand where the limit of resection will be.
IMAGING
■ Mammography is recommended for women who meet screening criteria.
SURGICAL MANAGEMENT
Preoperative Planning
■ Patients who are good candidates for free nipple graft reduction include the
following:
■ Patients who are at increased risk for nipple necrosis, including patients with
gigantomastia (where greater than 2000 g of tissue per breast is expected to be
resected)
■ Patients who would like to be smaller than what a pedicled reduction can

provide
■ Patients with medical comorbidities who would not tolerate a longer
operation, as the free graft technique is significantly shorter
■ Patients who are smokers or who have other comorbidities whereby breast
amputation is safer than having undermined Wise pattern flaps
■ Furthermore, any breast reduction where the NAC is felt to be nonviable may
be converted to a free nipple graft.
■ The surgical markings are performed in the preoperative holding area, with the
patient standing and arms resting on each side.
■ We typically utilize a Wise pattern skin excision pattern when performing a
free nipple graft procedure for optimal shaping of the skin envelope (FIG 1).
Our technique for marking is described in detail in the Inferior Pedicle chapter.
Positioning
■ The patient is placed supine on the operating room table, with arms extended
on arm boards and secured with soft roll. It is important not to extend the arms
too far, as this may distort the breast shape.
■ The patient is positioned at the break of the bed, so that she may be placed in
the upright position if necessary.

FIG 1 • Wise pattern skin excision markings.
Approach
■ The method of nipple graft to be performed is determined by the patient’s skin
color and quality, scarring, and desires.
■ We feel that tattooing of the areola oftentimes produces superior results as
compared with the free nipple-areolar graft, especially in patients with darker
skin who are at risk for depigmentation. However, in patients who do not wish
to undergo future tattooing, the areola should be grafted.
■ If the entire nipple-areolar complex is to be grafted, the nipple is marked with
a cookie cutter at approximately 40 to 44 mm.
■ If the nipple is to be harvested with subsequent tattooing of the areola, then the
nipple base is marked.
■ The standard Wise pattern markings are re-marked, with the inframammary
fold incision marked at 1 cm above the actual fold. This is to preserve the

dense attachments present in this area.
■ The resection pattern is based on breast amputation techniques, with the
majority of the reduction specimen taken out as a wedge at the inferior pole of
the breast.
■ Many other techniques have been described for resection of breast tissue,
including the creation of dermoglandular flaps to provide improved
projection. However, we feel that with a conservative resection and
preservation of superior and central breast tissue with minimal undermining,
adequate shape can be created.
T E C H N I Q U E S
■ If the initial surgical plan is to perform a free nipple graft, then the nipple is
harvested first (TECH FIG 1A).
■ After the nipple is harvested, the inferior breast tissue is resected in a wedge-
shaped pattern, making sure to preserve enough tissue superiorly to maintain
adequate breast projection.
■ The Wise pattern markings are incised sharply.
■ The resection is typically started at the superior aspect of the breast.
■ At first, minimal tissue is resected from the vertical component of the Wise
pattern. This is maintained to ensure adequate projection and can always be
resected later if necessary.
■ Once the horizontal component of the Wise pattern is reached, the
dissection is aimed inferiorly toward the fold and carried down to the chest
wall (TECH FIG 1B).
• It is easy to over-resect with this technique. It is important to aim caudally
when performing the initial resection and not to undermine the superior
breast flaps. More tissue can always be resected if necessary after the
initial specimen is removed.
■ After the resection has been carried out, the remaining inferior breast tissue
is tucked superiorly and the breast is tailor-tacked and examined for shape
and symmetry.
■ If required, additional tissue may be resected prior to closure. Oftentimes,
excess fullness remains laterally and should be excised.
■ If the skin envelope is felt to be too loose, additional skin can be resected
from the vertical components. By excising more lateral vertical skin, the

lateral aspect of the breast can be advanced medially to provide a more
defined lateral breast border.
■ Once adequate shape has been obtained, the incisions are closed with a 3-0
monofilament absorbable suture in deep dermal fashion, followed by a
running subcuticular stitch.
■ Drains are not typically used in our practice.
■ Another option is to attempt an inferior or central mound and if it seems as
though the pedicle is too long or the nipple appears congested or poorly
perfused, it can be converted to a shorter glandular mound and free nipple or
nipple areolar graft.
■ It is important not to commit to a keyhole reduction pattern if a graft is
anticipated.
■ Free nipple and areolar grafting
■ The NAC is incised sharply with a knife and harvested as a full-thickness
graft.
■ Once the breast has been reduced and all incisions have been closed, the
point of maximal projection is marked with the cookie cutter at 40 to 44
mm. This area is then de-epithelialized.
■ After adequate thinning with a scissor on the back table, the graft is then
secured to the recipient bed with a 4-0 or 5-0 absorbable suture (TECH
FIG 1C).
■ A xeroform and cotton-ball tie-over bolster is then used to secure the graft.
■ Free nipple grafting
■ The nipple is transected at the base sharply with a knife.
■ After the reduction is complete, the point of maximal projection is marked.
■ Two small rectangular flaps are lifted in a horizontal fashion to provide for
increased contact between the nipple and recipient bed (TECH FIG D–F).
■ The nipple graft is then placed between the flaps and is secured at the base.
■ The edges of the nipple are trimmed, and the flaps are sutured to the nipple
edges with a 5-0 absorbable suture to allow for maximal graft survival.
■ A Telfa nonstick dressing is applied to the nipple and secured with Steri-
Strips to act as a bolster.

TECH FIG 1 • A. The nipple-areola complex is sharply
removed with a no. 10 blade. It is then thinned on the
back table to an appropriate depth for grafting. B.
(Left) The proposed area of breast tissue to be
excised is marked. (Right) The tissue is removed,
making sure to leave enough tissue superiorly and
centrally with minimal undermining. C. The nipple is
inset with a 5-0 absorbable suture after final closure is
achieved. A Xeroform tie-over bolster is utilized to
maintain graft position for 1 to 2 weeks. D. After
closure of the reduction incisions, two small
rectangular flaps are designed to allow placement of
the nipple graft. E. Elevation of the rectangular flaps.

F. Insetting of the nipple graft within the rectangular
flaps to allow for maximal nipple graft
revascularization and take.
PEARLS AND PITFALLS
Skin excision
■ Wise pattern skin excision pattern is well suited for free nipple
graft reduction.
Nipple graft
technique
■ The nipple can be grafted alone, or the nipple-areolar complex can
be grafted as a unit.
■ Often grafting the nipple alone with subsequent tattooing is
optimal but involves an additional step and cost.
Do not over-
resect
■ It is easy to over-resect tissue. Be sure to leave enough tissue
behind to adequately shape the breast.
Bolstering
■ The bolster should be left in place for 1 to 2 weeks to maximize
graft take.
Improving
projection
■ An inferior dermoglandular flap can be created if needed to
augment projection.
FIG 2 • A,B. Preoperative photos of a 54-year-old
female presenting with gigantomastia. Her nipple-to-
notch measurements were 51 cm on the right and 50
cm on the left. Her nipple-to-fold measurement was 20
cm bilaterally. C,D. Postoperative results after free
nipple-only reduction with a Wise pattern skin excision,
before ultimate tattooing of the areola. The resection

specimens weighed 2102 g on the left and 2126 g on
the right.
POSTOPERATIVE CARE
■ The vast majority of reduction mammoplasties in our practice are performed
on an outpatient basis. Patients undergoing free nipple graft reduction are
instructed to maintain the bolster dressing until their follow-up appointment.
This is removed in the office approximately 10 to 14 days postoperatively, and
the graft is assessed. A protective dressing is then kept on for an additional 2
weeks.
■ The patient is kept in a supportive surgical brassiere or wireless sports
brassiere at all times except when showering for the first 4 to 6 weeks. Once
the incisions have healed, she is cleared to begin wearing a brassiere with
underwiring.
OUTCOMES
■ Pre- and postoperative photos of free nipple graft reductions are shown in
FIGS 2 and 3.
■ Reduction mammaplasty is one of the most satisfying procedures performed
by plastic surgeons, with approximately 95% of patients willing to undergo the
procedure again when surveyed.2,3
■ Reoperation rates for reduction mammaplasty are around 8% to 9%. Most of
these are for scar revisions, although rarely they may include other causes.4
■ Nipple sensitivity and erectile function may be preserved to some degree, but
in certain situations may be lost completely.5
■ With the free nipple graft technique, the ability to breast-feed is lost. Patients
must be counseled on this prior to the operation.
COMPLICATIONS
■ Overall complication rates following breast reduction vary widely in the
literature, from 5.1% to 45%.6–8 Most of these complications are minor and
may be treated conservatively.
■ Complications following free nipple breast reduction are likely less common
than other techniques, because the length of the procedure is often shorter and
there is minimal undermining and repositioning of breast tissue.
■ Wound healing complications are often lower in free nipple reductions, owing

to decreased undermining.9 This is most often treated with local wound care,
but in some cases debridement and closure or skin grafting may be necessary.
■ Partial or full graft loss is extremely uncommon in our practice but can occur.
Severe cases may be treated with debridement and delayed nipple
reconstruction.
■ Hypopigmentation may occur and is more troublesome in patients with darker
skin (FIG 4). Patients should be counseled on this prior to surgery, and free
nipple-only grafts with subsequent tattooing should be considered in these
patients.
■ When free nipple-areolar grafts undergo hypopigmentation, it is difficult to
correct this with tattooing.
FIG 3 • A,B. Pre- and postoperative photos of a 61-
year-old female with gigantomastia. She wished to be
much smaller and did not have a preference for nipple
sensibility or function. Her nipple-to-notch
measurements were 42 cm on the right and 41 cm on
the left. Her nipple-to-fold measurements were 23 cm
on the right and 20 cm on the left. She underwent a free
nipple-only reduction with a Wise pattern skin excision.
The total amount of tissue excised was 2300 g on the
right and 1900 g on the left.

FIG 4 • A,B. Preoperative photos of a 29-year-old
female with a right breast scar. Her nipple-to-notch
measurements were 47 cm on the right and 50 cm on
the right. Her nipple-to-IMF distances were 26 cm on
the right and 20 cm on the left. C,D. Postoperative
photos after bilateral free nipple reduction using a Wise
pattern skin excision, before areolar tattooing. The
amount of tissue resected was 2350 g on the right and
2250 g on the left. She developed some
hypopigmentation of the grafts bilaterally.
REFERENCES
1. Thorek M. Possibilities in the reconstruction of the human. NY Med J.
1922;116:572-575.
2. Gonzalez M, Glickman L, Aladegbami B, Simpson R. Quality of life after

breast reduction surgery: a 10-year retrospective analysis using the breast Q
questionnaire: does breast size matter? Ann Plast Surg. 2012;69:361.
3. Dabbah A, Lehman JA, Parker MG, et al. Reduction mammaplasty: an
outcome analysis. Ann Plast Surg. 1995;35:337-341
4. Manahan M, et al. An outcomes analysis of 2142 breast reduction procedures.
Ann Plast Surg. 2015;74:289.
5. Ahmed O, Kolhe P. Comparison of nipple and areolar sensation after breast
reduction by free nipple graft and inferior pedicle techniques. Br J Plast Surg.
2000;53:126-129.
6. Fischer J, Cleveland E, Shang E, et al. Complications following reduction
mammaplasty. Aesthet Surg J. 2014;34:66-73.
7. Manahan M. et al. An outcomes analysis of 2142 breast reduction procedures.
Ann Plast Surg. 2015;74:289.
8. Cunningham B, Gear A, Kerrigan C, Collins E. Analysis of breast reduction
complications derived from the BRAVO study. Plast Reconstr Surg.
2005;115:1597.
9. Hawtof DB, Levine M, Kapetansky DI, Peiper D. Complications of reduction
mammaplasty: comparison of nipple-areolar graft and pedicle. Ann Plast Surg.
1989;23:3-10.

10
CHAPTERGynecomastia
John T. Stranix and Alexes Hazen
DEFINITION
■ Gynecomastia refers to benign, excessive enlargement of parenchymal tissue
in the male breast. The etiology of gynecomastia is multifactorial, often
idiopathic, and affects up to 40% to 50% of men.1
ANATOMY
■ In gynecomastia, the excess glandular tissue is typically centered under the
nipple-areola complex (NAC), with a predominantly fibrous component (FIG
1).
■ Pseudogynecomastia refers to diffuse fatty enlargement of the male breast
related to obesity and demonstrates a predominance of adipose vs fibrous
tissue.
■ Normal male breasts are flat in appearance with mild fullness around the
NAC.
■ The male NAC diameter is normally 2 to 4 cm (mean 2.8 cm) and centered on
the midclavicular line over the fourth intercostal space. Mean sternal notch to
nipple distance is 20 cm.
■ The pectoralis muscle provides superior fullness to the anterior male chest that
transitions inferiorly to flat tissue over the lower chest at the level of the
inframammary fold (IMF).
■ A well-defined IMF results in a more feminine breast appearance.
PATHOGENESIS
■ Benign proliferation of male breast parenchyma occurs due to a relative
increase in the ratio of free estrogen to androgen locally in the breast.2

■ Physiologic gynecomastia occurs in newborns (circulating maternal
estrogens), adolescents (excess plasma estradiol during early stages of
puberty), and men after age 65 (decreased testosterone production).
■ Neonatal and pubertal gynecomastia are typically self-limiting and usually
resolve over several months to years.
■ Pathologic gynecomastia can result from various metabolic (cirrhosis, renal
failure), endocrine (hypogonadal state, hyperthyroidism), oncologic (adrenal or
testicular tumors), or congenital (Klinefelter syndrome) disorders.
■ Pharmacologic gynecomastia has been linked to a number of medications and
occurs by several known mechanisms; however, direct mechanisms have not
been identified for all associated medications.3
■ Gynecomastia does not increase the risk of male breast cancer development
compared to the normal male population.
■ Patients with Klinefelter syndrome, however, have up to a 50 times increased
risk of developing breast cancer.4 Due to the elevated oncologic risk in this
population, an excisional technique should be used to provide a specimen for
pathology analysis.
FIG 1 • Cross-sectional depiction of normal male chest

anatomy compared to gynecomastia.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Clinical evaluation of enlarged male breasts begins with a detailed history and
review of symptoms, focusing on elucidating known causes of gynecomastia
and differentiation from pseudogynecomastia and tumor.
■ History should include age, onset and duration of enlargement, breast
symptoms (pain, tenderness, discharge), medications, alcohol or recreational
drug use, and social/psychological effects of breast enlargement. Past medical,
surgical, family, and reproductive history should also be obtained.
■ Signs/symptoms of liver disease, malnutrition, kidney failure, hyper- or
hypothyroidism, weight changes, adrenal disease, and malignancy.
■ Physical examination
■ Breasts should be assessed for symmetry, nipple abnormalities, glandular or
fat predominance, skin excess, degree of ptosis, and nodules or masses.
Approximately 50% of gynecomastia is bilateral.1 Axillary and
supraclavicular lymph node basins should be examined in the setting of a
suspicious mass.
■ Glandular tissue in gynecomastia is characterized by mobile, rubbery
subareolar breast tissue.
■ Masses or nodules with abnormal firmness, overlying skin changes, eccentric
location, or associated nipple discharge should raise concern for breast
carcinoma.
■ Secondary sexual characteristics should be examined: body hair distribution,
muscle mass, penile development, and testicular size, consistency, and
symmetry.
■ Signs of systemic disease should also be evaluated: thyromegaly,
exophthalmos, hepato- or splenomegaly, abdominal masses, ascites or
cirrhotic stigmata, visual fields, cranial nerves, and fundoscopy.
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ Laboratory or radiographic studies are not necessary in most cases of
gynecomastia.
■ Mammography, and possibly biopsy, is indicated if findings on physical
examination are consistent with a breast neoplasm.
■ Testicular ultrasound should be obtained in the setting of prepubertal bilateral

gynecomastia, evidence of undervirilization, and/or a testicular mass.5
Endocrine labs are also appropriate in this situation; consider karyotype if
Klinefelter syndrome is possible.
■ Laboratory testing should be directed by abnormalities identified on history
and physical exam.
DIFFERENTIAL DIAGNOSIS
■ Physiologic
■ Drug-induced
■ Hypogonadism
■ Tumors
■ Systemic
■ Congenital
■ Familial
■ Miscellaneous
■ Idiopathic
NONOPERATIVE MANAGEMENT
■ The majority of patients with new-onset gynecomastia are best managed with
reassurance and observation for 12 to 18 months.1,6
■ No detectable abnormality is found in up to 60% of patients on initial
evaluation.5
■ Correction of underlying causes should be performed: discontinue offending
medications, correct hormonal imbalances, address metabolic or endocrine
disorders.
■ Medical therapy with testosterone and aromatase inhibitors has had limited
success. Treatment with tamoxifen, however, has been shown to result in
gynecomastia regression in recent randomized trials.1
SURGICAL MANAGEMENT
■ Surgical intervention should be considered for patients with a diagnosis of
symptomatic gynecomastia of duration greater than 12 months.
■ Due to irreversible fibrosis of hypertrophic breast tissue that develops 6 to 12
months after the onset of gynecomastia, medical treatments beyond that stage
are unlikely to result in significant regression.1,7
■ Surgical treatment of gynecomastia has evolved to become increasingly less
invasive through the use of liposuction and endoscopy; however, more severe

cases often require open techniques with a higher scar burden.
■ Multiple classification systems have been developed to guide surgical
management. The system devised by Rohrich et al.7 classified gynecomastia
based on breast size and degree of ptosis.
Preoperative Planning
■ In addition to standard components of informed consent, the preoperative
consultation must include a discussion of scar burden/location, possible need
for direct excision of residual subareolar fibrous tissue, as well as the potential
for undercorrection requiring a second-stage procedure.
■ Even patients with only mild gynecomastia may have a residual fibrous
component that is not amenable to liposuction and requires excision.
■ Preoperative markings are performed with the patients in the upright sitting or
standing position.
■ Prophylactic antibiotics covering skin flora are administered prior to skin
incision.
Positioning
■ Surgery is performed under general anesthesia as an outpatient procedure.
■ Patients are positioned supine with arms abducted and secured to padded,
adjustable arm boards. The hips are centered over the bed break, and the
patient is secured with a safety strap.
■ Intraoperative assessment of adequate/symmetric resection requires sitting
the patients fully upright in the operating room and they should be secured in
a manner that enables this to be safely accomplished.
■ Sequential compression devices are applied to the lower extremities.
■ The entire anterior chest is prepped into the field to allow intraoperative
symmetry assessment. Chest hair is removed with electric clippers as needed.
Approach
■ Patients with mild to moderate glandular hypertrophy (grades I and II) rarely
have significant skin excess. Definitive treatment with suction-assisted
lipectomy, power-assisted liposuction (PAL), and/or ultrasound-assisted
liposuction (UAL) is frequently possible; direct excision of residual subareolar
fibrous tissue may be required.7,8
■ UAL is often associated with improved skin retraction, making it a more

effective treatment modality for gynecomastia than conventional liposuction
alone.9
■ PAL has been shown to reduce operative fatigue and improve control in chest
wall contouring.10
■ Patients with more severe gynecomastia and/or ptosis (grades III and IV)
typically require resection of excess skin and possibly NAC repositioning.
■ Our preference is to perform redundant skin excision along the IMF.
■ In extreme cases, breast amputation with free nipple grafting may be
necessary.
T E C H N I Q U E S
■ Ultrasound-Assisted Liposuction
Markings
■ With the patient standing, the IMF, breast boundaries, and planned incision
sites along the lateral IMF are marked.
■ Concentric topographic marks centered over the most prominent area of the
breast may also be drawn to assist with liposuction.
■ An inferior semicircular periareolar incision may be included if direct
excision is anticipated.
Liposuction
■ Use a no. 11 blade to make bilateral breast stab incisions along the lateral
IMF.
■ Additional stab incisions (periareolar, upper anterior axilla) may improve
cross-hatching and undermining/disruption of the IMF.
■ Systematically infiltrate all treatment areas in multiple layers with wetting
solution using a 3.0-mm cannula with a 1:1 ratio of infiltrate to estimated
aspirate (superwet technique).
■ Wetting solution consists of 1 L of lactated Ringer solution containing 1 cc
of 1:1000 epinephrine and 30 cc of 1% lidocaine.
■ Perform UAL on a high energy level using a 3.0- to 5.0-mm cannula
connected to a standard surgical aspirator. Unlike traditional liposuction, the
intermediate and immediate subdermal adipose layers are targeted to achieve