The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

2420
Part XI  Breast Surgery
Liposuction
Liposuction has been used to reduce breast size and with concomitant skin retrac-
tion, raising the level of the nipple-areola complex. The most obvious benefit is pro-
vision of a breast lift with minimal scarring. The preservation of neurovascular struc-
tures is another advantage. The limitations of this procedure lie in the fact that the
majority of the substance removed from the breast is fat, not breast parenchyma. In
addition, the patient must have supple, elastic skin to achieve the greatest benefit.
With the advent of ultrasound-assisted lipectomy (UAL), more-aggressive cases have
been tried, because UAL can assist in skin retraction and hence greater nipple ele-
vation than could be accomplished with standard suction-assisted lipectomy (SAL).
The ideal patient for this procedure has mild breast hypertrophy resulting from an
overabundance of fat, minimal ptosis, and good skin quality. The indications for this
procedure are also expanded to women who have already had a breast reduction
procedure and want a small adjustment. The benefits are that further manipulation
of the pedicle is avoided, and there is a decreased risk of devascularization and/or
nerve injury.
The breast is usually accessed through two small stab incisions above the infra-
mammary fold at the medial and lateral aspects of the breast, and another one at
the areola. The placement of these incisions facilitates a more uniform removal of
fat by allowing overlap. When this technique is employed correctly, there is minimal
risk of damage to the neurovascular supply of the nipple and hence a decreased risk
of nipple necrosis and/or loss of sensation.
The main disadvantage of this treatment is its limited application. Only a small sub-
set of women fits the strict criteria for this procedure. On the wrong patient, this
technique will produce suboptimal results that may be very difficult to correct.

Technique
The breast should be marked with the patient standing. Contour circles to delineate
the areas of greatest protrusion should be used. Standard wetting solution is used (1 L
lactated Ringer’s solution, 1 ml of 1:1000 epinephrine, and 25 ml 1% lidocaine)
when general anesthesia is employed. If the plan is to use local anesthesia alone, the
breast may be blocked using up to 100 ml of 0.25% bupivacaine (Marcaine) with
1:400,000 fresh epinephrine and 300 units of hyaluronidase.
Cannula selection usually depends on the experience of the surgeon. Inexperienced
surgeons should use a smaller cannula at first to “get a feel” for the patient’s tissues
and then switch to a larger cannula for major tissue removal. Pretunneling is not re-
quired. Care should be taken to avoid inadvertently entering the chest cavity.
2421
Chapter 67  Control and Precision in Mastopexy
The breasts are marked before liposuction. The strategy should promote even resec-
tion of fat in areas of excess as well as suctioning of the base of the breast to reduce
the breast mound so that the skin can retract more against the chest wall. The goals
of suctioning are correction of the hypertrophy and a decrease in the overall weight
of the breast. Accurate recording of suction volume is essential to prevent overresec-
tion and asymmetry. It is much easier to remove excess tissue later—but virtually im-
possible to replace overaggressively suctioned breast fat.
Postoperatively, no drains or sutures are used. Absorbent pads are used to catch the
drainage. Paper tape is applied horizontally from the bottom of the breast toward
the nipple-areola complex, forming a sling under the lower portion of the breast.
Then horizontal pieces of paper tape are applied from the superior portion of the
breast downward toward the nipple-areola complex. A Reston sponge is applied in
half-moon shapes, followed by a snug brassiere. Firm, supportive pressure on the
breast is the goal of these dressings. The dressings are removed at 1 week and the pa-
tient’s bra is placed in a more contoured bra. To help combat any persistent edema,
the patient is instructed to wear the bra day and night for up to 6 months.

Mastopexy to Correct the Overaugmented Breast
One of the increasingly common operations that we perform is to revise patients
who underwent augmentation years earlier with large saline implants and now have
breasts that are too large and too low. Many other presentations can occur, includ-
ing ptosis with capsular contracture, which can produce bizarre asymmetrical con-
figurations for which a treatment plan is difficult to develop. Some of these patients
had large implants placed inappropriately in an attempt to treat breast ptosis by “fill-
ing up” the deflated skin envelope because the patient would not accept additional
scars. Others have simply gained breast size from a weight increase over the decades.
Our approach to these patients, especially when they have saline implants in place,
is to perform a preliminary in-office deflation of their implants to set up the breast for
definitive correction. This simple procedure is done with a local anesthetic; an 18-
gauge needle is inserted into the implant through the lower pole while compressing
the device with the opposite hand until it is completely deflated. The patient then has
an opportunity to live with her natural breast shape and size for 3 or 4 weeks while the
ligaments shorten and the skin recovers from the overstretched condition. This has
the advantage of giving the patient the opportunity to decide whether she even needs
or wants additional implants as well as shape correction with a mastopexy. Some
patients have a satisfactory shape and can simply undergo reaugmentation, usually
in a new plane, and their implants are often replaced with silicone gel devices.
Many of these reoperative patients have the idea that they must have implants to
give them the shape they want, but the two-stage approach allows them to see that
they have adequate parenchyma to produce breasts of suitable size if a mastopexy
alone can be performed. It is much easier to plan the definitive correction after im-
plant deflation than to try to accomplish everything in a single stage. This approach
decreases the chances of the patient’s needing yet another revision.
Postoperative Care
Postoperative care following a mastopexy starts in the operating room. Because of
our preference for parenchymal reshaping to maintain a more permanent result, the
breast should be held in its exaggerated shape for the first several weeks after sur-
gery; that is, the fullness of the upper pole, with a flattened lower pole shape, must
be splinted to assist in solid internal healing to keep the breast shape high and round.
2422
Part XI  Breast Surgery

The use of Tegaderm has been exceedingly helpful in this regard. We use large sheets
cut longitudinally so that two long, narrow sheets can be used as a clear, support-
ive dressing. Care must be taken not to pull the Tegaderm over the skin, because this
will create shear forces that can cause blistering. Rather, the breast is held in the de-
sired position and the Tegaderm is simply laid down flat against the skin to hold it
in place. The first sheet goes from lateral to medial, from the nipple down to the in-
framammary fold. This material can also be used to support the drain and maintain
its position. The second sheet goes across the upper pole, overlapping the lower sheet
at approximately the level of the nipple. We usually cut out a small segment to avoid
flattening the nipple. A rolled-up ABD sponge taped into a large “hotdog” shape is
used to accentuate the pressure curving along the new inframammary fold. This
sponge is held in place with a half-sheet of Tegaderm. Next, we place the patient in
a support bra, which helps maintain the final shape. An advantage of using Tega-
derm is that when the patient takes off the bra, she can shower normally without
losing support.
The drain is ordinarily removed on the first postoperative day. With a smaller
mastopexy, we may choose not to use a drain at all. Typically, a mastopexy proce-
dure is not associated with anything more than minor pain. Oral analgesics are suf-
ficient, and ketorolac tromethamine (Toradol) has also been helpful in patients who
are sensitive to narcotics.
The patient is seen 1 week after drain removal. At this time a small amount of the
Tegaderm is removed around the edge of the areola, and the interrupted nylon su-
tures are removed. At 2 weeks postoperatively the patient returns after removing all
of the remainder of the Tegaderm in the shower in the morning. The breasts are sim-
ply gently washed, patted dry, or dried with a hairdryer, and the patient puts the
support bra back on.
We recommend that the patient wear a support bra day and night for 8 weeks fol-
lowing mastopexy. “Push-up” bras that accentuate the upper pole are helpful dur-
ing this period to encourage the breast to heal in a high, round position.
Scar treatment begins 3 weeks postoperatively with such over-the-counter prepara-
tions as Mederma or Scarguard. An underwire bra often helps define the new infra-
mammary fold shape and position. Typically, we do not consider scar revisions for
1 year after surgery, although if a small amount of redundant tissue exists at the in-
feriormost portion of the vertical scar at 6 months postoperatively, we may consider
a small revision in the office if the patient is unable to wear a swimsuit or is un-
comfortable with it.
2423
Chapter 67  Control and Precision in Mastopexy

2424
Part XI  Breast Surgery
Outcomes and Complications
Although patients who undergo mastopexy always look better than they might have
looked had they not had the operation, the result must be considered semiperma-
nent. Invariably, a little shape is lost over time, and the nipple descends. If bottom-
ing out occurs, the nipple position may be disproportionately high. These shape issues
are ordinarily addressed at 1 to 2 years postoperatively to let the shape settle before
any revision is offered.
This 37-year-old woman underwent vertical mastopexy to treat pseudoptosis. No-
tice the error on the right in placing the nipple too high on the breast mound. She is
shown before and 1 year after surgery. The lateral views show the considerable breast
elevation that has been achieved, clearly demonstrating that the nipple position is
too high.

Bleeding and infection are rarely seen after a mastopexy. Nipple and areolar defor-
mities can usually be prevented by avoiding tension on the closure. We do not excise
too much skin and make certain that the pedicle moves freely to the new nipple po-
sition. If the scar is wide or the shape of the areola is irregular, these problems can be
corrected rather easily by reexcision and closure in the proper shape.
As in the case of reduction mammaplasty, breast-feeding following mastopexy may
or may not be successful. In patients who do become pregnant after mastopexy, we
encourage them to try breast-feeding, but to be aware that they may have to sup-
plement the nutritional needs of the baby. It is important to advise patients that ad-
ditional corrections may be desirable when pregnancies occur after mastopexy.
It is not uncommon to encounter some problems with implant malposition when a
mastopexy is done concomitantly. As opposed to breast augmentation alone, where
malposition problems may be addressed as early as 3 months postoperatively, we are
reluctant to correct the augmentation-mastopexy patient for at least 6 months, be-
cause we have seen many cases in which the deformity either improves on its own
or is not fully stabilized during this time frame. Of course, correction of these prob-
lems is aimed at either changing the level of the implant by capsulotomy or capsu-
lorrhaphy or revising the mastopexy if the implant is in the proper location. Typi-
cally, mastopexy revisions are possible by skin-only techniques.
Chronic pain following mastopexy can be enigmatic. Occasionally this is caused by
ongoing fibrocystic breast disease, condrochondritis, or sutures that have inadver-
tently encircled sensory nerve fibers. The latter is usually diagnosed by pinpoint ten-
derness laterally with shooting pain and can be attributed to the neuroma. A small
amount of lidocaine or bupivacaine in the area is usually diagnostic. Fortunately,
this usually resolves without treatment.
Most patients remain pleased with mastopexy results, particularly as the years go
by and the scars fade. We have seen patients in whom the scars become virtually in-
visible. Late tanning (more than 9 months postoperatively) appears to help fade the
scars. If the shape remains satisfactory, the scars are well accepted by most patients.
2425
Chapter 67  Control and Precision in Mastopexy

2426
Part XI  Breast Surgery
Results
This 44-year-old patient had tissues that were very fatty without much glandular
substance. An implant was obviously necessary to lend adequate volume and shape.
Additional factors included lack of support from any type of glandular flap. There-
fore the plan included placing an implant with an appropriate base diameter. This
patient chose saline; however, our preference is a round or shaped silicone gel device
in most cases. She is shown 1 year after placement of a saline-filled implant with a
final volume of 360 cc in the subpectoral position and a skin-tightening vertical
mastopexy.

In this 40-year-old patient, we considered adding an implant, but because she could
create her desired shape and size in a bra, we decided a mastopexy alone was all that
was needed. She underwent a vertical mastopexy in which the superiorly based
parenchymal flap from the lower pole was folded underneath the upper pole to cre-
ate some additional upper pole convexity. She is shown 7 months postoperatively. If
this patient desires additional fullness, an implant can be added later after the masto -
pexy is healed and stable.
2427
Chapter 67  Control and Precision in Mastopexy

This 38-year-old woman had an unusual asymmetry condition in which the larger
breast had a higher, smaller nipple-areola complex. Both breasts required a mastopexy
to reshape the parenchyma; the plan included reducing the volume on the left so that
the parenchymal volumes could be equalized. This approach allowed equal sized and
shaped implants to be placed. When the ratio of breast parenchymal volume to im-
plant volume and dimensions is equal, the evolution of shape over time is much more
likely to result in a long-lasting, symmetrical correction.
The correction included an autoaugmentation with a superiorly based parenchymal
flap on the right with a 150 cc smooth silicone gel implant. On the left breast, a 154 g
reduction was done in the inferior pole, and a 150 cc silicone implant placed.
Although her result was satisfactory at 9 months postoperatively, by 2 years there
was a worsening of the shape on the right. This was associated with a 5-pound weight
loss that was significant in this very petite patient.
2428
Part XI  Breast Surgery
Preoperative
2 years postoperatively
9 months postoperatively

This 37-year-old woman underwent a vertical mastopexy with a small, 200 g re-
duction. The patient is shown before and 1 year after surgery.
2429
Chapter 67  Control and Precision in Mastopexy

This 36-year-old woman presented with asymmetry. She is shown preoperatively and
3 months after vertical mastopexy in which 30 g of tissue was resected from the right
and 200 g from the left breast.
2430
Part XI  Breast Surgery

This 42-year-old woman underwent explantation of 360 cc saline implants and sub-
sequent vertical mastopexy. She is shown preoperatively and 9 months postopera-
tively.
2431
Chapter 67  Control and Precision in Mastopexy

This 47-year-old woman had severe ptosis and glandular excess. An inverted-T re-
duction with superomedial pedicle was performed. She is shown before and 4 years
after surgery.
2432
Part XI  Breast Surgery

This 43-year-old patient who had a previous augmentation mastopexy underwent
explantation of 200 cc implants and then mastopexy with an inverted-T pattern. She
is shown before and 9 months after surgery.
2433
Chapter 67  Control and Precision in Mastopexy

This 24-year-old woman had macromastia as well as breast asymmetry, with the
right side larger than the left; 100 cc of tissue was aspirated from the left breast and
350 cc from the right. She is shown before and 1 month after liposuction.
2434
Part XI  Breast Surgery

2435
Chapter 67  Control and Precision in Mastopexy

This 37-year-old woman was treated for severe ptosis. A Wise pattern mastopexy with a
superior pedicle was done. No reduction was performed on the left breast, and 100 g
of tissue was resected from the right. She is shown before and 3 months after surgery.
2436
Part XI  Breast Surgery

This 57-year-old woman had moderate ptosis and breast atrophy. Augmentation with
275 cc implants was performed, followed by vertical mastopexy. She is shown pre-
operatively and 1 year postoperatively.
2437
Chapter 67  Control and Precision in Mastopexy

Concluding Thoughts
At present, all mastopexy techniques are imperfect. Although surgeons are doing a
better job of reducing overall scar length, we still struggle to obtain a beautiful, sta-
ble, long-term shape that will justify the scarring. Most women will accept the scars
if the shape is attractive. The periareolar techniques work best if the breast tissue is
relatively fibrous and the skin is good. We await the development of a suitable in-
ternal mesh to use in the Góes technique. In the meantime, we have found that the
vertical techniques provide the best, most predictable results, with or without the
use of implants.
Clinical Caveats
Periareolar Mastopexy Without Parenchymal Reshaping
 This technique is suitable only in mild to moderate ptosis cases in which a mini-
mal amount of elevation is required.
 The amount of nonpigmented skin excision should be less than the amount of pig-
mented skin.
Benelli Periareolar Mastopexy Technique
 The surgeon should start with mild to moderate ptosis cases until he or she is more
familiar with this technique.
 Although this technique can be applied to more advanced degrees of ptosis, it has
its limitations in treating patients with severe ptosis and/or poor-quality skin.
 The best results are with patients without striae and with dense fibroglandular
parenchyma.
 The amount of skin removed should be limited to decrease the resultant periare-
olar scalloping.
 Tension on the parenchymal sutures should be avoided to preserve maximal glan-
dular and nipple areolar circulation.
Góes Periareolar Technique With Mesh Support
 The surgeon should accept a slightly larger areolar size in relation to the base width
of the breast.
 The amount of skin removed lateral to the nipple-areola complex should be lim-
ited.
2438
Part XI  Breast Surgery

 Flap dissection should be performed very carefully so that the skin flaps drape
smoothly over the mesh.
 The space between the mesh and skin should be drained for at least 1 week.
 The original mesh used (Vicryl/Dacron) is no longer available. The current preferred
mesh is Vipro, manufactured by Ethicon.
Vertical Mastopexy Without Implants
 The nipple position is set approximately 2 cm below the usual A-point. (The A-
point in breast surgery refers to the anterior projection of the inframammary fold
onto the breast. With inverted-T techniques, this represents the position of the new
nipple. With vertical mastopexy, it represents the top of the areola.)
 The surgeon should be cautious in marking the medial and lateral pillars, keep-
ing in mind that minimal if any breast tissue will be excised.
 Parenchymal shaping sutures are used in the superior pole and in the lateral pil-
lars to assist in shaping the breast.
 The new nipple-areolar position is marked with an areolar template with the pa-
tient in the upright position before final suturing.
 Securing the breast with either Tegaderm or Micropore paper tape for 2 to 3 weeks
helps to mold the final breast shape.
Liposuction Only
 The key to success with liposuction is correct patient selection.
 The ideal patient is one in whom the nipple-areola complex is already in a good
position.
 Liposuction-only candidates should have a majority of fat rather than fibroglan-
dular tissue.
Wise Pattern
 The surgeon should attempt to tailor the horizontal component of the scar within
the new inframammary crease to help camouflage it.
 The pattern is useful for reoperative cases when the breasts have been overaugmented.
 A two-stage approach is planned with in-office deflation at least 4 weeks before
the definitive correction.
 The surgeon meets with the patient 1 week before the final correction to determine
whether an implant is needed, and if so, what type and size.
2439
Chapter 67  Control and Precision in Mastopexy
Continued

Clinical Caveats—cont’d
Biologic Meshes
 Biologic meshes are useful adjuncts in primary cases in which the breast paren chyma
and skin are very stretched out.
 Mesh is invaluable in revisional cases of augmentation mastopexy where the breast
parenchyma is lacking.
 The correction must be good while the patient is still on the operating table, be-
cause there will be very little settling over time.
 Ideally, a “lamellar” structure will be created to coapt acellular dermal matrix to
vascularized tissue, such as a skin flap and/or breast parenchyma.
 These matrices must be drained to avoid seroma and to enhance the revascular-
ization and incorporation of the matrix.
 The greatest drawback is the cost of acellular dermal matrix.
2440
Part XI  Breast Surgery
Annotated Bibliography
Brink RR. Management of true ptosis of the breast. Plast Reconstr Surg 91:657-662, 1993.
This is one of two classic articles defining breast ptosis and should be familiar to all sur-
geons who operate on the breast.
Colwell AS, Breuing KH. Improving shape and symmetry in mastopexy with autologous or
cadaveric dermal slings. Ann Plast Surg 61:138-142, 2008.
This article is a good starting point of reference for the use of acellular dermal matrices
in both mastopexy and revisional augmentation mastopexy.
de Bruijn HP, Johannes S. Mastopexy with 3D preshaped mesh for long-term results: devel-
opment of the internal bra system. Aesthetic Plast Surg 32:757-765, 2008.
de Bruijn HP, ten Thije RH, Johannes S. Mastopexy with mesh reinforcement: the mechan-
ical characteristics of polyester mesh in the female breast. Plast Reconstr Surg 124:364-
371, 2009.
Theses articles demonstrate Goés’s technique with a different type of mesh and discusses
the clinical, mammographic, and histologic fate of the implanted meshes.
Gray LN. Re-evaluating lipoplasty-only breast reduction. Aesthet Surg J 26:72-75, 2006.
The author presents his new algorithm for breast reductions in which he still performs
85% lipoplasty-only but now performs vertical mastopexy in 10% and conventional
breast reductions in 5% of patients.

Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg 29:379-
391, 2002.
The author reviews the different pedicles used for the vertical technique for reductions
and mastopexies. She stresses how skin resection patterns and pedicles are separate pro-
cedures and should not be considered the same.
Lassus C. Breast reduction: evolution of a technique—a single vertical scar. Aesthetic Plast
Surg 11:107-112, 1987.
Lassus C. Update on vertical mammaplasty. Plast Reconstr Surg 104:2289-2298, 1999.
One of the pioneers in vertical mastopexy and reduction techniques, the author demon-
strates long-term results and the evolution of his technique.
Matarasso A, Courtiss EH. Suction mammaplasty. The use of suction lipectomy to reduce
large breasts. Plast Reconstr Surg 87:709-717, 1991.
One of the preliminary papers dealing with suction-only techniques for the breast. The
authors define the types of patients for which this technique is suitable and show clini-
cal results.
Maxwell GP, Gabriel A. Use of the acellular dermal matrix in revisionary aesthetic breast
surgery. Aesthet Surg J 29:485-493, 2009.
This article is a good reference on the use of acellular dermal matrices in both mastopexy
and revisional augmentation mastopexy.
Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg 3:193-203, 1976.
This is a classic article defining breast ptosis; it should be required reading for all sur-
geons who operate on the breast.
Spear SL, Dayan JH, Clemens MW. Augmentation mastopexy. Clin Plast Surg 36:105-115,
vii; discussion 117, 2009.
Excellent review of techniques for augmentation mastopexy for moderate to more se-
vere cases. Very good guidelines for patient selection and subsequent technique for aug-
mentation mastopexy.
Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy. Plast Reconstr Surg
85:961-966, 1990.
The authors demonstrate the technique and give long-term results. Technical maneu-
vers and planning are demonstrated.
Suggested Readings
Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthetic Plast Surg
14:93-100, 1990.
Brink RR. Evaluating breast parenchymal maldistribution with regard to mastopexy and
augmentation mammaplasty. Plast Reconstr Surg 86:715-719; discussion 719-721, 1990.
Chiari A Jr. The L short-scar mammaplasty: a new approach. Plast Reconstr Surg 90:233-
246, 1992.
Courtiss EH. Reduction mammaplasty by suction alone. Plast Reconstr Surg 92:1276-1284;
discussion 1285-1289, 1993.
2441
Chapter 67  Control and Precision in Mastopexy

Góes JCS. Periareolar mammaplasty: double skin technique. In Hinderer UT, ed. Plastic Sur-
gery, vol II. New York: Elsevier, 1992.
Gruber RP, Jones HW Jr. The “donut” mastopexy: indications and complications. Plast Re-
constr Surg 65:34-38, 1980.
Lassus C. An “all-season” mammaplasty. Aesthetic Plast Surg 10:9-15, 1986.
Lejour M. Vertical mammaplasty for breast hypertrophy and ptosis. Oper Tech Plast Surg
3:189-198, 1996.
Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 94:100-
114, 1994.
Lejour M. Vertical mammaplasty: update and appraisal of late results. Plast Reconstr Surg
104:771-781, 1999.
Marchac D, de Olarte G. Reduction mammaplasty and correction of ptosis with a short in-
framammary scar. Plast Reconstr Surg 69:45-55, 1982.
Persoff MM. Vertical mastopexy with expansion augmentation. Aesthetic Plast Surg 27:13-
19, 2003.
Pitanguy I. Surgical correction of breast hypertrophy. Br J Plast Surg 20:78-85, 1967.
Regnault P. The hypoplastic and ptotic breast: a combined operation with prosthetic aug-
mentation. Plast Reconstr Surg 37:31-37, 1996.
Rohrich RJ, Parker TH III. Aesthetic management of the breast after explantation: evalua-
tion and mastopexy options. Plast Reconstr Surg 120:312-315, 2007.
Spicer TE. Reduction mammaplasty and mastopexy. In Selected Readings in Plastic Surgery.
Dallas: Baylor University Medical Center, 1994.
Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr
Surg 17:367-375, 1956.
2442
Part XI  Breast Surgery

Breast Reduction:
The Medial Pedicle Technique

ELIZABETH J. HALL-FINDLAY
CHAPTER 68

2444
Part XI  Breast Surgery
Inferior tissue removed
below Wise pattern
Medial pedicle area
of deepithelialized
tissue
Pedicle rotation
Area of initial
tissue excision
T
he key to the medial pedicle vertical breast reduction technique is less about
creating shorter scars than it is about understanding its fundamental concepts.
Most inverted-T breast reduction approaches remove a horizontal ellipse of skin and
breast tissue that when closed leaves medial and lateral dog-ears. Most vertical ap-
proaches remove a vertical ellipse of skin and breast tissue and when closed leave
superior and inferior dog-ears. Removal of an inferior vertical wedge of breast tis-
sue allows the surgeon to not only narrow and cone the breast but also to remove
the heavy inferior breast tissue, leaving behind the superior breast tissue.
There are multiple vertical approaches and numerous pedicle choices. I prefer the
medial pedicle because it has a good blood supply, the pedicle rotates easily into po-
sition without kinking or compression, and the retained sensation is equivalent to
that of the other available pedicle approaches. The inferior border of the medial pedi-
cle becomes the medial pillar so that, as it rotates into position, it leaves an elegant
curve to the lower pole of the breast.
It is essential to understand that the medial pedicle vertical breast reduction uses the
Wise pattern as a good breast (brassiere) design for the pattern of the parenchyma
that should be left behind rather than for what should be removed. Once the vertical
wedge is removed and the breast is coned, all breast tissue inferior to the Wise pat-
tern is removed either directly or with liposuction. The skin is then allowed to re-
drape over the newly shaped breast mound.
The belief that surgeons must choose between scars and shape is not true. The medial
pedicle vertical breast reduction not only results in reduced scars but also maintains
a good, long-lasting breast shape. The surgery takes less time, blood loss is less, and

2445
Chapter 68  Breast Reduction: The Medial Pedicle Technique
the recovery is faster. In my experience, the incidence of complications is also sig-
nificantly lower with vertical breast reductions than with inverted-T inferior pedi-
cle breast reductions. There are more pucker revisions with the vertical approach,
but that is partly a function of being easily able to perform a revision and the sur-
geon’s threshold for revision. Many patients who undergo inverted-T procedures are
told that the lateral and medial dog-ears cannot be corrected, and this makes the re-
vision rate low.
Evolution of Technique
When I first tried vertical breast reduction techniques in 1993, I could see that there
was a definite improvement in shape, but I had problems with the superior pedicle;
it could be difficult to inset, and I did not understand the blood supply. I thought it
would be better as a full-thickness pedicle, but in fact, it is safer and less likely to be
compressed when it is thinned. The problem with thinning the superior pedicle is
that it leaves an empty space underneath, which tends to leave a concave inferior
pole for a few weeks after surgery. The medial pedicle is easy to inset, and the shape
of the breast while the patient is still on the operating table is quite good.
I then tried a lateral pedicle, because I thought it would have the best chance of re-
taining good sensation, but again, I did not really understand the anatomy. The prob-
lem with the lateral pedicle is that the tissue that forms the base of the pedicle is ex-
actly the same tissue that needs to be removed to produce a good reduction and an
aesthetic breast contour. I could see that the medial pedicle gave a better shape, but
I was also surprised that the medial pedicle produced excellent recovery of sensation.
In this patient a lateral pedicle was used on her right side and a medial pedicle on
the left. She had good return of sensation in both breasts. The problem with the lat-
eral pedicle is that the base of the pedicle prevents good resection of the excess lateral
breast tissue.

2446
Part XI  Breast Surgery
Advantages and Disadvantages
The advantages are in the reduced scarring and better shape, and when surgeons re-
alize that they do not need any tension on the skin closure, the wound-healing prob-
lems and complications are dramatically reduced.
Another advantage is that the concept of the medial pedicle and vertical parenchymal
resection can be used in much larger breast reductions, even when an inverted-T skin
resection pattern is needed to reduce the redundant skin. Skin does not need to be
removed as often as surgeons think, but some patients have far too much skin, or
too much skin of poor quality. The advantages of the medial pedicle with the infe-
rior resection can still be preserved, even when the final closure has increased scarring
with a T, J, or an L.
The disadvantage of the medial pedicle vertical breast reduction is that inevitably
nipple necrosis will occur in some cases. I believe that there are four main arterial
supplies to the breast, and sometimes only three of the four are dominant. We cannot
determine preoperatively which pedicle will be safe. I believe that nipple necrosis is
inevitable in a large-volume practice, and it is more likely to be a statistical occur-
rence rather than a result of bad surgery.
Indications and Contraindications
The best candidates for a medial pedicle vertical breast reduction are young, healthy
women who need a small- to moderate-sized breast reduction. There is more of a
learning curve for the larger reductions, but the method is still excellent. However,
there is a point at which an inverted-T skin resection pattern will be needed, but this
point is not nearly as early as some surgeons envision.
The best results in all breast reductions are achieved in women who are not over-
weight; the cosmetic result is not as good in heavy or obese patients. In some very
large–breasted women, any of the pedicles chosen will be long. Theoretically, the
blood supply stretches with the breast as it grows and becomes ptotic, but the real-
ity is that nipple necrosis is more likely with the longer pedicles. The other problem

2447
Chapter 68  Breast Reduction: The Medial Pedicle Technique
with excessively long pedicles is their sheer volume, which limits the size of the re-
duction and increases the weight of the breast in the lower pole. This extra weight
can be sutured up onto the chest wall, but it will tend to bottom out with time.
Some patients who have large breasts, good nipple position, and a large proportion
of fat to gland may be better candidates for liposuction-only breast reduction (see
Chapter 71).
Patient Profiles
This patient is young and healthy, and close to her ideal body weight. She needed a
moderate-sized breast reduction and was a good candidate for a medial pedicle ver-
tical breast reduction, which was especially fortunate, because she turned out to be
a bad scar former.

2448
Part XI  Breast Surgery
This older woman is a less than an ideal candidate because she has very large breasts,
and her cosmetic result will not be ideal, because she is not close to her ideal weight.
A further reduction might be indicated to reduce some of the volume that still ex-
ists in the lower pole.
Pertinent Anatomy
Blood Supply
The blood supply to the breast is mainly superficial; the arteries and veins are in the
subcutaneous tissue that was pushed outward as the breast developed. The breast is
a skin-derived subcutaneous structure that is attached loosely to the skin (and firmly
at the nipple). It is only very loosely “attached” to the chest wall. These attachments
are easily swept away with a finger during a subglandular breast augmentation. The
breast is held in place by fascial condensations inferiorly (the inframammary fold)
and medially (over the sternum). These act much like the gluteal fold and the sacrum.
The breast moves easily over the chest wall, is quite mobile, and is not held in place
either superiorly or laterally.

2449
Chapter 68  Breast Reduction: The Medial Pedicle Technique
When a woman lies on her side, the upper breast folds over the sternum medially and
the lower breast slides out. Only the lower breast border (inframammary fold) and
the medial breast border are relatively fixed structures holding the breast in place.
Internal
mammary
artery
Medial pedicle
Internal mammary
perforators
2
3
4
The artery to a superior pedicle comes (usually) from the second intercostal space;
it descends and enters the nipple area just medial to breast meridian and is always
about 1 cm deep to the skin. It bleeds with significant force when cut during creation
of a medial pedicle; it can be traced with a pencil Doppler preoperatively. The artery
to the medial pedicle also comes from the internal mammary system (usually from
the third intercostal space); it curves around the sternum, penetrates the pectoralis,
and is pushed outward with the subcutaneous tissue.
The deep system then comes from the fourth intercostal space and enters the poste-
rior aspect of the breast as it perforates the intercostal muscles and the pectoralis.
It enters the breast just medial to the breast meridian. It has accompanying venae
comitantes, and these vessels are all cut when a medial pedicle vertical breast re-
duction is performed. It is this artery (and branches) and veins that are enclosed in the
septum described by Würinger et al. This is the blood supply to an inferior or cen-
tral pedicle.

2450
Part XI  Breast Surgery
The fifth and sixth intercostal arteries from the internal mammary system also enter
the breast just above the inframammary fold and add extra security to an inferior
pedicle. Many of these lower vessels are cut during creation of a central pedicle.
The only other blood supply is the superficial branch of the lateral thoracic artery;
it can be seen curling around the pectoralis and entering the lateral aspect of the
breast. It supplies a lateral pedicle.
It is interesting that the veins do not accompany the arteries except for the deep per-
forator; they can be seen just under the dermis and drain mainly superomedially.
That is why I no longer infiltrate my incision lines—I kept hitting veins and causing
small subcutaneous hematomas.
Innervation
Although the main innervation to the nipple may come from the lateral branch of
the fourth intercostal nerve, there is no question that good innervation comes from
all four quadrants of the breast. It appears that all the pedicles—lateral, medial, su-
perior, inferior, and central—all have fairly equivalent sensation. I tell my patients
that about 85% of patients will recover normal to near-normal nipple sensation.
However, they are all warned that they may lose feeling completely in the nipples.
Most of the glandular breast tissue is concentrated deep to the nipple-areola com-
plex and laterally in the upper-outer quadrant. The medial aspect of the breast has
some glandular tissue but a higher proportion of fat.
Preoperative Assessment
A key ingredient to a successful breast reduction operation is patient education. I
have a detailed handout to give to patients; the contents are reinforced with a DVD
and a group PowerPoint session. It is essential to make patients understand what can
and cannot be achieved. I make certain that patients comprehend the concept of
high-breasted and low-breasted and that I cannot surgically change the breast foot-
print, or where the breast sits on the chest wall.
I find that taking photographs during the consultation and marking them for the pa-
tient is very helpful. I can show the patient where her upper breast border is and re-
inforce that I cannot change it. I also draw on the lateral view to show her that she
will still have some ptosis; I warn all patients that they will still be able to hold at

2451
Chapter 68  Breast Reduction: The Medial Pedicle Technique
The patient on the left is high-breasted, with good upper pole fullness; the patient
on the right is low-breasted, with poor upper pole fullness. Not only do both pa-
tients require different surgical approaches, but also they need to have very different
expectations.
The patient on the left has a high upper breast border but a low inframammary fold
level. She has a high breast footprint, but it is long vertically. The patient on the right
has a high upper breast border and a high inframammary fold level. She has a high
breast footprint, but the footprint is relatively short vertically.
least one pencil underneath the breast. I can only change the lateral and inferior ex-
cess along with narrowing the base diameter. Patients often think that they have no
upper pole fullness because they see their breasts as “flat,” but then I can show them
with the pinch test and the drawing that they can get more projection (or perkiness)
with a medial pedicle vertical breast reduction.

2452
Part XI  Breast Surgery
The patient on the left has a very low upper breast border and an inframammary fold
level that is actually below her elbow crease. She has a low breast footprint that is long
vertically. The patient on the right has a very low upper breast border but a very high in-
framammary fold level. She has a low breast footprint that is actually very short verti-
cally. (Not all numbers shown on these patients are necessary for surgical marking; some
are done for preoperative and postoperative measurement for later assessment purposes.)
My examination consists of assessing the breast footprint—the upper, lateral, me-
dial, and inferior breast borders—and then the third dimension—how the breast sits
on that footprint. Does the patient have good upper pole fullness? If so, a better cos-
metic result can be achieved. If a patient has a great deal of ptosis and a poor upper
pole, it will be futile to try to push the excess inferior breast tissue into the upper
pole, because it will just drop down again. I can visualize how long the pedicle might
be and whether I need to warn the patient about a possible free nipple graft (very
rare). I assess the skin quality and skin excess and again determine whether I need
to warn the patient that I might need to add a “hockey stick” to their vertical scar.
The results in these two patients will be very different with any type of breast re-
duction. The patient on the left not only has a high breast footprint, but she also has
excellent upper pole fullness. The patient on the right has a low breast footprint and
very poor upper pole fullness. Any attempt to push tissue into the upper pole is
doomed to failure over time.

2453
Chapter 68  Breast Reduction: The Medial Pedicle Technique
A
B
A
B C
A
B
It is important to decide preoperatively how much tissue will need to be removed.
Any attempt to push AB out to C will inevitably result in the loss of BC and will
cause bottoming out.
The problem of bottoming out is illustrated in this patient. Although the nipple was
clearly placed too high, there is still too much tissue in the lower pole. This example
of bottoming out is the fault of the surgeon (me)—not the procedure. A patient like
this provides the surgeon with a very difficult challenge.
Although it is tempting to elevate the upper pole of the breast and suture the breast
tissue up to the chest wall to elevate the upper breast border or to achieve more up-
per pole fullness, results will be disappointing.

2454
Part XI  Breast Surgery
Upper breast border
Upper pole fullness
Projection
The upper breast border is clearly demarcated in this patient. Although projection
is definitely improved, there is no improvement in upper pole fullness or elevation
of the upper breast border.
It is important to understand some definitions. The
upper breast border is at the junction of the chest
wall and the breast. Sometimes this is well demar-
cated, and sometimes it is a gentle slope. Projection
is the measurement from the chest wall to the ante-
riormost projecting part of the breast. This is where
the nipple is ideally situated.
This patient shows that the initial improvement in upper pole fullness achieved by
suturing breast tissue up to the chest wall is lost over time.

2455
Chapter 68  Breast Reduction: The Medial Pedicle Technique
I tried elevating the upper breast tissue and suturing it higher on the chest wall in
77 patients. I used absorbable 3-0 PDS in 43 patients and nonabsorbable 3-0 Ticron
in 34 patients. In the 72 patients who returned for follow-up, none of the initial im-
provement lasted for more than 5 months. The upper breast border remained un-
changed, and the upper pole dropped back to its original position. Projection, on the
other hand, was definitely improved.
Improvement in upper pole fullness can occasionally be obtained by using the method
popularized by Ruth Graf (see Chapter 72). This takes the inferior wedge of breast tis-
sue that is normally removed in a breast reduction and uses it as a chest wall–based
flap that is held in place by a strip of pectoralis muscle. Using this vertical wedge as
a flap was originally described by Liacyr Ribeiro, and it is a good method for rear-
ranging the breast tissue in a mastopexy. The pectoralis loop is effective at holding
the wedge of breast tissue higher on the chest wall, and it definitely improves pro-
jection and can help fill the upper pole to some degree.
I also warn patients that I often cannot make their breast as small as either of us
would like. I cannot achieve as significant a reduction with the vertical approaches
as I could when I performed inverted-T inferior pedicle reductions. The photographs
taken during the consultation are also useful for pointing out any asymmetries and
warning patients that symmetry is a goal but impossible to achieve. Patients are also
warned that breasts will change with time, gravity, pregnancy, weight gain, and
weight loss.
Teenagers are well aware that their breasts might grow as they continue to develop
and that a re-reduction might be indicated. I think that this is far better for many
teenagers than having them suffer until they are older, because they tend to with-
draw and stop participating in sports and other activities if their breasts are large.
As long as the teenager understands the procedure and its limitations, I am fully pre-
pared to perform the surgery when it is physically indicated. The same applies to
older patients. It is not age that matters; it is the health and the psychological matu-
rity of the patient.

2456
Part XI  Breast Surgery
Preoperative Planning
Much of preoperative planning consists of patient education. A preoperatively in-
formed patient is a surgeon’s best ally.
Markings
Upper Breast Border and Inframammary Fold
I start by marking the upper breast border (the junction of the chest wall and the
breast). This is sometimes a very clear demarcation, and sometimes it is less well de-
fined. The upper breast border is often at the top of any striae that may be present.
I then mark the inframammary fold.
I have marked the upper breast border of this patient with a dashed line. She is high-
breasted, with good upper pole fullness. The lowest point of her inframammary fold
is marked on the midline of the chest wall, with the right fold being slightly higher
than the left. The breast meridian is marked where it is expected to be once the re-
duction is completed.
Ideal Breast Meridian
The breast meridian should be marked at its ideal or desired position, not at its ex-
isting position. Sometimes the nipples are too medial, and sometimes they are too lat-
eral. It is best to err on the side of placing the meridian slightly lateral to a line that
would bisect the resulting breast after the reduction is performed. More of the lat-
eral breast tissue can be removed with the medial pedicle vertical breast reduction,
so the line can be placed slightly more medially than one would in an inverted-T
breast reduction. It does not matter where the line starts at the clavicle, but it should
be at the midline of the breast at the level of the new nipple position. This will usu-
ally be about 8 to 10 cm from the midline of the chest wall.

2457
Chapter 68  Breast Reduction: The Medial Pedicle Technique
Upper breast
border
Areolar opening
New nipple-areolar
location
8-10 cm
2 cm
In the patient on the left, the new meridian does coincide with the existing merid-
ian. In the patient in the middle, the existing meridian would be too medial. In the
patient on the right, the existing meridian would be too lateral.
The surgeon should place the new meridian just lateral to the line bisecting the re-
sulting breast, because nipples placed too medially look odd. On the other hand, the
medial pedicle vertical breast reduction removes more of the lateral breast and nar-
rows the breast cone better than the inverted-T procedures, and the meridian can be
drawn a bit more medially than in an inverted-T reduction.
New Nipple Position
The new nipple position should be on the new breast meridian, about 8 to 10 cm
below the upper breast border. The surgeon should position the nipple too low rather
than too high, because a nipple placed too high is almost impossible to lower post-
operatively, but it is easy to elevate a nipple that has been placed too low. It is better

2458
Part XI  Breast Surgery
to mark the new nipple position in relation to the upper breast border rather than
to the inframammary fold. The fold itself is a good landmark in many patients, but
it can be misleading in about 15% of patients.
Marking the new nipple at an arbitrary distance from the inframammary fold or the
clavicle will also result in problems, especially in low-breasted patients. In the illus-
tration on p. 2457, the new nipple position has been marked higher than the infra-
mammary fold because the woman is high-breasted and has good upper pole full-
ness. The surgeon should be careful to lower the nipple position in a patient with
very poor upper pole fullness. It is difficult to lower a nipple that has been placed
too high.
Areolar Opening
The top of the areolar opening should then be marked about 2 cm above the new
nipple position. Most areolae are designed to result in a diameter of about 4 to 5 cm.
The areolar opening can easily be drawn freehand and then pinched at the bottom
to make certain that it forms a circle when closed.
Care should be taken to ensure that the areolar-opening markings match from one
side to the other.
Skin Resection Pattern
The skin resection pattern follows the vertical lines that would be used in an inverted-
T Wise pattern breast reduction. Instead of carrying the vertical limbs laterally and
medially, once 5 cm is reached, they are joined together well above the inframam-
mary fold.

2459
Chapter 68  Breast Reduction: The Medial Pedicle Technique
These lines will match up with the breast and chest wall meridians when the breast
is rotated medially and laterally. The surgeon can pinch the lines together to make
certain that not too much skin is being removed. Since a medial pedicle vertical breast
reduction does not use the skin as a brassiere and tension on the skin closure only
causes wound healing problems, it is better to be conservative with the skin resec-
tion pattern and not take too much skin.
The lines need to be joined at least 2 to 4 cm above the inframammary fold. This is
not only because closure of an ellipse lengthens the scar but also because the infra-
mammary fold often rises. If the lines are brought down to the fold, the scar will in-
evitably end up on the chest wall. It is also important to make the skin resection pat-
tern as a U rather than a V. It may be tempting to create a V, because it may seem to
avoid a pucker more easily, but in fact the opposite can occur—a postoperative pucker
is more likely to be the result of excess subcutaneous tissue rather than skin. It is
more difficult to remove enough of the inferior subcutaneous tissue when a V is de-
signed.
Medially Based Pedicle
The medially based pedicle is best drawn with half of the base in the areolar opening
and half on the vertical limb. The inferior border of the medial pedicle will become
the medial pillar. The base of the medial pedicle is usually about 6 to 10 cm.
It is wise to try to incorporate one of the veins that are
visible through the skin in the base of the pedicle, es-
pecially when the pedicle is long. A true “superomedial”
pedicle can be designed to take advantage of the de-
scending artery from the second interspace. It usually
enters the areolar opening just medial to the breast
meridian, but it will be missed in this patient. This pa-
tient has a very short pedicle so a pure medial pedicle
can be used. A pure medial pedicle is often called a su-
peromedial pedicle, because it looks that way when a
patient stands up.

2460
Part XI  Breast Surgery
A true superomedial pedicle has a base that crosses and extends slightly lateral to
the breast meridian. This will make the pedicle more difficult to inset, but because
the blood supply is superficial, the surgeon is free to debulk the area deep to the
breast meridian if the pedicle is stiff or difficult to inset. This maneuver can preserve
the descending artery that normally supplies a superior pedicle.
Areas to Be Liposuctioned
Any areas past the breast borders that are to be liposuctioned are then marked. A
different patient is shown above with the lateral chest wall areas and preaxillary ar-
eas marked for liposuction. The indented area just below the preaxillary fullness is
marked with X’s as an area to avoid resection either directly or with liposuction.
This shows difference between the vertical markings in blue (which resemble a snow-
man) and the Wise pattern inverted-T red markings. Although the nipple should ac-
tually be placed lower in a vertical approach (to accommodate the increased pro-
jection), the markings are clearly fairly similar. I will remove all parenchyma (except
the medial pedicle) below the red lines, but I will only remove the skin within the
blue lines. The idea is to leave parenchyma attached to the skin above the red lines,
leaving behind the Wise pattern.

2461
Chapter 68  Breast Reduction: The Medial Pedicle Technique
The Wise pattern is a good design for what should be left behind. The skin does not
usually need to be removed in the same pattern, but it can be allowed to redrape over
the new breast shape. The skin is not used as a brassiere, so closure does not need
to be tight.
The Wise pattern, once brought together, nicely cones the remaining breast tissue.
The surgeon should keep this shape in mind when performing the resection. It is a
good design for what should be left behind.
These images show how the surgeon can visualize what will be left behind and how
the shape is coned with an inferior vertical wedge resection when the medial and
lateral pillars are brought together. Everything beyond the Wise pattern is removed ei-
ther directly or with liposuction.
The crosshatched areas shown are where
liposuction is to be performed.

2462
Part XI  Breast Surgery
Operative Technique
Positioning
The patient is placed supine on the operating table with the arms angled outward.
For surgeons who wish to position the patient upright at the end of the procedure, the
arms should be carefully wrapped and the patient positioned on the table so that
her back can go up in the right position.
Infiltration
I no longer infiltrate the incision lines, because I want to preserve any veins that are
found just below the dermis. I infiltrate the areas to be suctioned with either a tumes-
cent type of fluid (1 L Ringer’s lactate with 1 ml of 1:1000 epinephrine and 20 ml
of 2% plain lidocaine) or lidocaine with epinephrine (20 ml of 1% lidocaine with
1:200,000 epinephrine diluted with 60 ml of saline solution). I use approximately
300 to 500 ml of tumescent fluid per side, or about 40 ml of the lidocaine with ep-
inephrine per side. Most of the infiltrate is placed in the lateral chest wall, preaxil-
lary areas, and just above the inframammary fold. These are the areas where most
of the liposuction is performed.
Pedicle Creation
The pedicle is deepithelialized in the usual fashion by placing a lap pad around the
base of the breast and holding it with a Kocher clamp. This puts the skin under ten-
sion and allows it to be removed more easily. The medial pedicle is much easier to
deepithelialize than an inferior pedicle. A cuff of tissue is left around the new areola
using the Schwartzman maneuver.
Even when the nipple is high and contained within the areolar opening, I still pre-
fer a medially based pedicle. This not only allows me better access to the excess lat-
eral breast tissue but it also maintains the elegant curve to the lower pole of the
breast because the inferior border of the medial pedicle becomes the medial pillar.

2463
Chapter 68  Breast Reduction: The Medial Pedicle Technique
The pedicle is then cut straight down to chest wall to create a full thickness pedicle.
The blood supply is superficial but keeping it full thickness allows preservation of
sensation and ductal tissue.
Parenchymal Resection
The pedicle creation and parenchymal resection are performed together, with the
pedicle remaining full thickness and the resection being performed en bloc. The ar-
rows above show the lower limits of the pillars. The left arrow shows the inferior
border of the medial pedicle, which, when rotated up, becomes the medial pillar.
Both pillars will be about 7 cm long in an ideal C cup breast.
Because the pedicle will tend to be thin at the distal end (not because it is actually
thinned, but it will appear to be thinned much like an inferior pedicle), it is impor-
tant to leave a small platform of tissue superiorly and laterally to help prevent post-
operative areolar retraction. However, this tissue cannot be pushed up into the up-
per pole to try to increase upper pole fullness, because it will drop back down again.

2464
Part XI  Breast Surgery
The breast tissue is removed laterally by beveling out the resection after leaving be-
hind a 2 cm lateral pillar that is about 7 cm long. The parenchyma beyond that is
then removed by beveling out under the lateral flap and removing tissue parallel to
the chest wall. If the patient has very thick glandular breast tissue (many teenagers,
for example), this tissue must actually be carefully carved out, making certain not
to leave any ridges behind. Breasts that have a higher fat content will be more for-
giving. It is often difficult to make breasts small enough when using a medial pedi-
cle vertical breast reduction, and it is this lateral breast tissue that needs to be more
extensively resected.
It is important to remove all breast tissue below the Wise pattern and this includes
removing tissue by undermining down to the inframammary fold. I find it easiest to
grasp this extra tissue with a Kocher clamp and then resect it. It is important to leave
enough fat on the dermis so that postoperative scar contracture does not occur. Tis-
sue is removed all along the inframammary fold both medially and laterally. Some
of this tissue is quite fibrous and will need to be directly excised. It can be comple-
mented with liposuction, which is usually performed after closure of the pillars and
the deep dermis.

2465
Chapter 68  Breast Reduction: The Medial Pedicle Technique
With the resection complete, it can be seen that the pectoralis fascia is not exposed.
The pedicle is being held up by a skin hook. Exposure of the pectoralis muscle can
not only cause more bleeding but it can also damage some of the nerves that supply
the nipple. The deep branch of the lateral fourth intercostal nerve travels just above
the pectoralis fascia and then turns up toward the nipple at the breast meridian. The
surgeon should exercise care not to damage the pectoralis fascia and keep the pedi-
cle full thickness to preserve this nerve.
The arrows in these photos show the inferior aspect of both pillars. It can be seen
that the inferior border of the medial pedicle becomes the medial pillar. The pillar
sutures start at the level of the arrows about 1 or 2 cm deep to the skin. I use 3-0
Monocryl to close the pillars; only about three or four sutures are used. It is not nec-
essary, and in fact is contraindicated, to try to mobilize lateral tissue and close it un-
der tension. The pillar closure should have very little tension. The pedicle can be
pulled up during closure to make certain that the pillar can be better visualized. It
might be advisable to suture extra long pedicles to breast tissue to help hold them
there while healing occurs. Large, deep bites are not necessary; pedicle sutures are
only needed so that fibrous-type tissue can heal to fibrous-type tissue.

2466
Part XI  Breast Surgery
Good projection
Little projection
More projection
The deep dermis is closed and then liposuction is performed in the areas marked. It
is easier to close the deep dermis first to provide some resistance when performing
the liposuction. The breast that remains behind has a Wise-pattern shape.
The areola is closed with four interrupted deep dermal sutures. The areola is sutured
into place in the position in which it seems to sit the most easily without any kink-
ing. Both the deep dermis and the subcuticular closure are completed using 3-0
Monocryl. The vertical incision is not gathered. When vertical breast reduction was
initially introduced, it was thought that the vertical incision could and should be
kept short by cinching up the closure. This did not work, however, because the in-
cisions stretched back out (and if they didn’t, they required revision). Not only did
it not work, but the extra length is actually necessary to accommodate the extra pro-
jection that is achieved with a vertical approach. A B cup breast will have a vertical
length (from the lower edge of the areola to the inframammary fold) of about 7 cm,
a C cup breast will have a length of about 9 cm, and a D cup breast about 11 cm.
This illustration demonstrates how a longer vertical length from the bottom of the
areola to the inframammary fold is actually desirable. A 5 cm vertical length results
in a flattened breast with very little projection.

2467
Chapter 68  Breast Reduction: The Medial Pedicle Technique
In these photographs it is evident that the vertical length is longer with larger breasts
and that vertical length is needed to accommodate projection. The skin is not su-
tured to breast tissue, and the skin pucker is not sutured down to the chest wall; this
would just delay resolution of the shape.
This patient had 255 g removed from her right breast and 195 g from her left breast.
Liposuction volume was 400 cc. The vertical incisions measured 9 cm before closure
and 9 cm after closure. The incisions were not cinched or gathered and the skin is
not tacked down to either chest wall or breast parenchyma. The incisions were then
covered with Micropore paper tape. Drains are rarely used. Patients are allowed to
shower the next day, and the tape remains in place for 3 to 4 weeks.
Postoperative Care
Patients are placed in a noncompressing brassiere to provide support for about 2 weeks.
They are not required to wear the brassiere, but most patients will wear some form of
support for 2 to 3 weeks night and day. Patients are encouraged to shower the next
day, and the paper tape forms a good cover and bandage. The tape is actually difficult
to remove before 3 to 4 weeks, and it is easier to remove dry than in the shower.

2468
Part XI  Breast Surgery
Most patients understand that it takes about 1 to 2 weeks to get back to normal ac-
tivities and 3 to 4 weeks to resume sporting activities. They can walk during the first
week or so to remain fit, and they can walk uphill if they want to maintain an aer-
obic training level. They are advised to start with the stationary bicycle and then with
time to progress to jogging. They can use lower-body weights initially, but they should
hold off on upper-body weights for a few weeks. Patients are not restricted in their
arm movement or in driving.
Problems
It is important to avoid any tension on the breast tissue or on the skin. Tension on
the skin causes wound-healing problems, and tension on the breast parenchyma
causes eventual loss of contour.
The most significant problem with a medial pedicle vertical breast reduction is the
inability to make breasts as small as we would like. None of the breast reduction
techniques can elevate the breast footprint and none of them can elevate the upper
breast border. It can be difficult to achieve symmetry.
The most common reasons for revision are for correction of an inferior breast pucker,
re-reduction, and correction of asymmetry. The most common complications are
hematoma, seroma, infection, wound-healing problems, dehiscence, fat necrosis, and
nipple necrosis.
Revisions
Correction of an Inferior Breast Pucker
It is not necessarily the case that puckers are more common with the vertical ap-
proach but they are easier to correct than the medial and lateral puckers that occur
with an inverted-T procedure. Puckers can be prevented by adding a T, a J, or an L
at the time of the initial surgery, but de Mey and colleagues noted that adding a T
did not necessarily lower the revision rate. It is not always easy to design a T or to
know exactly where to put it.
Puckers occur in many patients’ breasts, but the pucker tends to disappear over time
as it tucks in. Initially I thought it was best to correct puckers by adding a T incision,
but that often adds two new dog-ears to chase. It is usually better to correct a pucker
through a vertical skin incision and a horizontal fat excision. Most puckers are ac-
tually caused by excess subcutaneous tissue rather than by excess skin.