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

2470
Part XI  Breast Surgery
Re-reduction
Re-reduction is not always straightforward. It is important not to remove too much
skin. Wider tissue excision can be performed, especially laterally, as in the following
patient. Liposuction is an important adjunct to a re-reduction. But often the vertical
scar ends up too long, and the surgeon may need to add a J and an L or a T. Unfor-
tunately, sometimes increased problems with dog-ears can be a nuisance.
This patient initially had a vertical breast reduction. She underwent re-reduction sur-
gery, in which 403 g and 290 g were removed, and another 375 cc of liposuction.
The vertical incision was too long, and a J and an L were added. It can be seen that
this does not always solve the problem, because it adds a new lateral dog-ear to be
chased.
Correction of Asymmetry
It is important to lower the new nipple position on the larger side when performing a
breast reduction. This lower nipple position will be needed only partly because of the
tension on the skin with the increased weight. But this is more of a problem with the
vertical approach because closure of a wider inferior ellipse will push the ends further.

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Chapter 68  Breast Reduction: The Medial Pedicle Technique
For this patient, the new nipple position should have been placed lower on the larger
breast. Part of the problem is that the nipple has been pushed up; in addition, not
enough inferior breast tissue was resected on the right side.
Complications
Hematoma
This patient came in 2 weeks after surgery with a hematoma. At that stage it was al-
lowed to resolve on its own. This patient had had drains in place, and she was fine
the morning after surgery, when the drains were removed. It is assumed that the ac-
tual removal of the drain led to some bleeding, which caused the hematoma. Since
this instance, I have not used drains routinely.
It is important to know the vascular anatomy of the breast and to seek out any po-
tential bleeders before closure. This is especially important in patients in whom tumes-
cent infiltration has been used. The vessels may be in spasm, only to release later
when the epinephrine effect has worn off.
The incidence of hematoma has only been about 1 in 400 patients.

2472
Part XI  Breast Surgery
Seroma
Seroma is probably fairly common. I have not aspirated or drained seromas routinely,
and they seem to resolve uneventfully. We keep close contact with patients postop-
eratively, and rarely has a patient reported any spontaneous drainage. Unlike an ab-
dominoplasty, in which a seroma does not have a path to drain, a breast seroma
seems to resorb quite well.
Infection
Inevitably, infection will occasionally occur. I was
able to reduce not only the incidence of infection in
my patients but also the incidence of suture-spitting
when I began to order 1 week of antibiotic therapy
for all patients. The suture-spitting problem disap-
peared almost completely. Breasts have multiple
ducts exposed to the environment, and I believe that
they are not completely “clean.”
As reported by Bratzler and Houck, the National Surgical Infection Project now rec-
ommends giving only one intraoperative dose of antibiotics; unfortunately, when I
did that, some suture-spitting and low-grade infection occurred, as seen above. The
incidence of this problem seems to be reduced by using an antibacterial (triclosan-
impregnated) suture (Monocryl Plus) and giving one intraoperative dose of an an-
tibiotic agent. I think that many cases of suture-spitting were caused by low-grade
infection.
Wound-Healing Problems
Although infection is one cause of wound-healing problems, I think that many areas
of delayed healing are actually areas of too much tension. Wound-healing problems
are common in inverted-T procedures at the T junction, and open sores and delayed
healing are the most commonly reported problems with inverted-T breast reductions.

2473
Chapter 68  Breast Reduction: The Medial Pedicle Technique
Now that I make certain that I avoid any constriction on the skin closure, the inci-
dence of healing problems is extremely low. It is important to close the breast tissue
pillars (to avoid fat necrosis) under very little tension and to close the skin (to avoid
wound-healing problems) under very little tension.
Dehiscence
This type of wound dehiscence is uncommon and can result from either a low grade
infection or more likely a suture failure. It is best not to resuture the area but to let
it heal by secondary intention, as shown here.
Fat Necrosis
Fat necrosis tends to occur in the upper pole of the breast, just above the areola. This
is most likely caused by some parasitic fat at the end of the pedicle that did not have
an adequate blood supply. Although I have encountered a few patients with a firm
mass in this area in the first few weeks to months after surgery, these masses have all
resolved on their own without requiring any surgical intervention.
Fat necrosis can occur if large, constricting bites of tissue are taken to close the pil-
lars. This is more likely to be a problem if the pillars are closed under tension.
More commonly, fat necrosis occurs in association with nipple necrosis when the
blood supply to the pedicle fails.

2474
Part XI  Breast Surgery
Nipple Necrosis
Unfortunately, nipple necrosis can and does occur. This patient had partial nipple
and areolar necrosis that healed very well without intervention. The first postoper-
ative photograph shows the patient 4 weeks after surgery, the second at 6 weeks,
and the third at 4 months. It is better to wait and see what results rather than de-
briding the tissue too early.
Outcomes
There is no question that all forms of breast reduction result in a significant im-
provement in back pain, neck pain, shoulder grooving, and even headaches. The
rashes under the breasts can be reduced, and patients often report better exercise tol-
erance and psychological well-being. Patients often concentrate preoperatively on the
symptoms, but postoperatively they concentrate on the cosmetic appearance.

2475
Chapter 68  Breast Reduction: The Medial Pedicle Technique
Results
This 59-year-old patient was 5 feet 4 inches tall, weighed 82 kg (180 pounds), and
wore a 40 D brassiere. She had a medial pedicle vertical breast reduction in which
430 g was removed from her right breast and 530 g from her left breast. Another
525 cc of liposuction was performed mainly in the lateral chest wall, preaxillary ar-
eas, and just above the inframammary fold. She is shown at her 1-year follow-up.
The extra preoperative markings were done only for study purposes, and these mea -
surements showed at 1 year postoperatively that the nipple position stayed at the
same distance from the suprasternal notch as it was measured to be preoperatively
(23 cm). The vertical scars measured 8 and 7 cm, respectively, and the inframam-
mary fold was raised slightly.

2476
Part XI  Breast Surgery
This 38-year-old patient was 5 feet 9 inches tall, weighed 79 kg (175 pounds), and
wore a 38 D brassiere. She had a medial pedicle vertical breast reduction in which
300 g was removed from the right breast and 320 g from the left breast. Another
300 cc of liposuction was performed in the lateral chest wall, preaxillary areas, and
above the inframammary fold. She is shown at her 1-year follow-up.

2477
Chapter 68  Breast Reduction: The Medial Pedicle Technique
This patient had a medial pedicle vertical breast reduction in which 800 g was re-
moved from her right breast and 645 g from her left breast. She had an additional
325 cc of liposuction performed in the lateral chest wall and above the inframam-
mary fold. She is shown 9 months after surgery.

2478
Part XI  Breast Surgery
This woman had a medial pedicle vertical breast reduction in which 350 g was re-
moved from the right breast and 325 g from the left breast. Another 200 cc of lipo-
suction was performed in the lateral chest wall and above the inframammary fold.
Clinical Caveats
 Surgeons should understand the concept of low-breasted and high-breasted.
 The medial pedicle vertical breast reduction is not about the scars; it is about the
concepts.
 A vertical or inverted-T skin resection pattern can be used.
 The advantages are a long-lasting shape with good projection.
 The surgeon should leave behind parenchyma in a Wise pattern and excise or li-
posuction all tissue beyond that pattern.
 The vertical wedge resection is a key concept: it narrows the breast base, uses
parenchymal excision and shaping to maintain the result, removes the heavy infe-
rior pole, and does not rely on the skin as a brassiere.
 What is removed in a breast reduction should be moved in a mastopexy.
 Patient education is essential to a good result.

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Chapter 68  Breast Reduction: The Medial Pedicle Technique
Annotated Bibliography
Asplund O, Davies DM. Vertical scar breast reduction with medial flap or glandular trans-
position of the nipple-areola. Br J Plast Surg 49:507-514, 1996.
Vertical scar breast reduction is a well-accepted technique that the authors believe im-
proves the shape and projection of the breast and leaves no horizontal scars. Lassus and
Lejour described superiorly based nipple flaps; the authors describe a medially based
flap or glandular transposition of the nipple in small reductions.
Berthe JV, Massaut J, Greuse M, et al. The vertical mammaplasty: a reappraisal of the tech-
nique and its complications. Plast Reconstr Surg 111:2192-2199, 2003.
The authors modified their previous Lejour superior pedicle vertical scar mammaplasty
technique by decreasing the skin undermining and avoiding liposuction in the breast.
Primary skin excision was performed in the submammary fold at the end of the opera-
tion if the skin could not be puckered adequately. However, the technical modifications
did not significantly change the rate of secondary scar and volume corrections, which
were still necessary in 22% of the operated breasts. In large breasts, the addition of a
horizontal scar at the end of the operation did not change the rate of secondary revi-
sion, which does compare favorably with the figures obtained with inverted-T superior
pedicle mammaplasty.
Corduff N, Taylor GI. Subglandular breast reduction: the evolution of a minimal scar ap-
proach to breast reduction. Plast Reconstr Surg 113:175-184, 2004.
The authors describe a modification of the breast reduction procedure. By means of an
inframammary incision, the breast is mobilized from the chest wall, and a “doughnut”
anulus of breast tissue is removed from the undersurface of the gland. No skin is ex-
cised. The nipple-areola complex is left attached to a central core of breast tissue that
receives its blood supply from the subdermal plexus of vessels. When the resulting de-
fect is closed within the breast by strategically placed sutures, the base of the gland is
narrowed, the breast is projected forward, and the circumareolar and vertical scars of
other techniques are eliminated.
Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts & Techniques. St Louis: Quality Med-
ical Publishing, 2011.
A comprehensive text based on the author’s extensive experience in breast surgery, cov-
ering her approach to analysis and technique, which is simple and provides consistent
results.
Hall-Findlay EJ. Pedicles in vertical reduction and mastopexy. Clin Plast Surg 20:379-391,
2002.
The author, who performed a standard inferior pedicle Wise pattern technique for the
first 11 years of her practice and has now used variations of the vertical technique, found
that the medial pedicle gives the best breast reduction results in her hands. A lateral
pedicle is used for mastopexies so that the inferior and lateral tissue can be rotated up
under the areola. When faced with a re-reduction of a previous inferior pedicle, the ver-
tical technique can still be used, and an adaptation of the inferior pedicle can be very
acceptable.

2480
Part XI  Breast Surgery
Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve.
Plast Reconstr Surg 104:748-759; discussion 760-763, 1999.
The author describes modifications to the standard Lejour vertical reduction mam ma -
plasty that simplify the technique and make it more reliable and easier to perform. These
modifications include using a medial (or lateral) dermoglandular pedicle, not under-
mining the skin, using liposuction only rarely to reduce breast volume, and not using
pectoralis fascia sutures; the modified technique has been used in a series of 400 verti-
cal breast reductions. In this series, scarring was reduced and the technique was easily
learned and applied.
Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast
Reconstr Surg 103:890-901; discussion 902, 1999.
A method of breast reduction is presented that maintains the blood supply and inner-
vation to the nipple-areola complex by means of an inferior pedicle, reduces the breast
volume by removing tissue from the periphery of the breast, maintains breast shape with
internal plication sutures, and limits the scar using a periareolar technique with a short
inferior vertical-to-oblique extension.
Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr Surg 97:373-380,
1996.
The author had previously used a vertical mammaplasty without a submammary scar
for all breast reductions with a central wedge resection, an upper pedicle for the areola,
no undermining, and a vertical scar. However, in large breasts, the inferior portion of
the vertical scar showed below the submammary fold. Therefore he added a short hor-
izontal scar, following the dogma of the time that the length of a vertical scar should
not exceed 5.5 cm. However, he found that the horizontal scar moved upward. Con-
vinced that it was possible to finish every mammaplasty with a vertical scar, he again
modified the procedure to make the vertical scar stay above the inframammary fold in
almost all patients. This has proved to be a safe, effective, and long-lasting procedure.
Marchac D, de Olarte G. Reduction mammaplasty and correction of ptosis with a short in-
framammary scar. Plast Reconstr Surg 69:45-55, 1982.
The main sequelae of mammaplasties are scars, particularly visible when they trespass the
breast limits. If the new inframammary fold is located higher than the original, the hor-
izontal limb of the T suture can be kept short and hidden beneath the breast. The glan-
dular tissue is split vertically and overlapped for ptosis. For reduction, an inferior re-
section with medial or lateral remodeling is performed. The results are very satisfactory
for ptosis and mild to moderate hypertrophy. High conical breasts with minimal scars are
produced.
Palmer JH, Taylor GI. The vascular territories of the anterior chest wall. Br J Plast Surg
39:287-299, 1986.
Through a series of fresh cadaver injection, dissection, and radiographic studies, the au-
thors defined the vascular architecture of the anterior chest wall and correlated it to the
findings of previous writers in this area. Their findings confirmed that the dominant sup-
ply to this region is from the internal thoracic artery, which interconnects in all layers
with the posterior intercostals, the lateral thoracic, acromiothoracic, and transverse cer-
vical arteries.

2481
Chapter 68  Breast Reduction: The Medial Pedicle Technique
Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola complex: an
anatomic study. Plast Reconstr Surg 105:905-909, 2000.
Although preservation of the sensitivity of the nipple and areola is an important goal in
breast surgery, only scant and contradictory information about the course and distri-
bution of the supplying nerves has been found in the literature. The authors dissected
28 female cadaver breasts and found that the nipple and areola were always innervated
by the lateral and anterior cutaneous branches of the third, fourth, and fifth intercostal
nerves. Their findings suggest that the nerves innervating the nipple and areola are best
protected if resections at the base of the breast and skin incisions at the medial areolar
border are avoided.
Spector JA, Kleinerman R, Culliford AT IV, et al. The vertical reduction mammaplasty: a
prospective analysis of patient outcomes. Plast Reconstr Surg 117:374-381; discussion
382-383, 2006.
Although breast reductions based on a Wise pattern incision remain common, patient
and surgeon dissatisfaction with this procedure because of unsightly scars and long-term
bottoming out of the breast prompted a search for alternative methods of breast re-
duction. The authors studied patient outcomes after vertical reduction mammaplasty
using prospectively collected data from questionaires. The authors found that vertical
reduction mammaplasty resulted in significant improvement in all quality-of-life factors
analyzed, including problems in buying clothes and brassieres, and difficulty in playing
sports and running.
Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension
of the mammary gland. Plast Reconstr Surg 101:1486-1493, 1998.
The authors first described anatomic findings (from 28 breast specimens of female ca-
davers) showing a thin, horizontal, fibrous septum originating from the pectoral fascia
along the level of the fifth rib, heading toward the nipple. This fibrous septum lies be-
tween a cranial and a caudal vascular network, and being mesentery-like, is responsi-
ble for the supply of the nipple areola complex. The cranial vascular sheet is supplied
by the thoracoacromial artery and a branch of the lateral thoracic artery, whereas the
caudal sheet is supplied by perforating branches from anastomoses of intercostal arter-
ies. The fibrous septum is also a guiding structure for the main supplying nerve of the
nipple. Knowledge of this structure is of value and relevance in clinical applications.
Suggested Readings
Arie G. Una nueva técnica de mastoplastia. Rev Iber Latino Am Cir Plast 3:28, 1957.
Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthetic Plast Surg
14:93-100, 1990.
Biesenberger H. Eine neue Methode der Mammaplastik. Zentralbl Chir 55:2382, 1928.
Bratzler DW, Houck PM, et al. Antimicrobial prophylaxis for surgery: an advisory statement
from the National Surgical Infection Prevention Project. Clin Infect Dis 38:1706-1715,
2004.

2482
Part XI  Breast Surgery
Chiari Júnior A. The L short scar mammaplasty: a new approach. Plast Reconstr Surg 90:233-
246, 1992.
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 59:500-507, 1977.
Dufourmentel C, Mouly R. [Mammaplasty by the oblique method] Ann Chir Plast 6:45-58,
1961.
Georgiade NG, Serafin D, Morris R, Georgiade G. Reduction mammaplasty utilizing an in-
ferior pedicle nipple-areolar flap. Ann Plast Surg 3:211-218, 1979.
Gradinger GP. Reduction mammaplasty utilizing nipple-areola transplantation. Clin Plast
Surg 15:641-654, 1988.
Graf R, Auersvald A, Bernardes A, Biggs TM. Reduction mammaplasty and mastopexy with
shorter scar and better shape. Aesthet Surg J 20:99-106, 2000.
Hall-Findlay EJ. Vertical breast reduction with a medially based pedicle. Operative strate-
gies. Aesthet Surg J 22:185-195, 2002.
Lejour M. Vertical Mammaplasty and Liposuction of the Breast. St Louis: Quality Medical
Publishing, 1994.
McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg
49:245-252, 1972.
Peixoto G. Reduction mammaplasty: a personal technique. Plast Reconstr Surg 65:217-226,
1980.
Pitanguy I. Surgical correction of breast hypertrophy. Br J Plast Surg 20:78-85, 1967.
Psillakis JM, Cardoso de Oliveira M. History of reduction mammaplasty. In Goldwyn RM,
ed. Reduction Mammaplasty. Boston: Little Brown, 1990.
Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg 55:330-334,
1975.
Regnault P. Reduction mammaplasty by the B technique. Plast Reconstr Surg 53:19-25, 1974.
Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior pedicle.
Plast Reconstr Surg 59:64-67, 1977.
Rohrich RJ. Minimally invasive, limited incision breast surgery: passing fad or emerging
trend? Plast Reconstr Surg 110:1315-1317, 2002.
Rohrich RJ, Gosman AA, Brown SA, et al. current preferences for breast reduction tech-
niques: a survey of board-certified plastic surgeons 2002. Plast Reconstr Surg 114:1724-
1733, 2004.
Schwartzman E. [Avoidance of nipple necrosis by preservation of corium in one-stage plas-
tic surgery of the breast] Rev Chir Struct 7:206-209, 1937.
Skoog T. A technique of breast reduction; transposition of the nipple on a cutaneous vascu-
lar pedicle. Acta Chir Scand 126:453-465, 1963.
Spear SL, Howard MA. Evolution of the vertical reduction mammaplasty. Plast Reconstr
Surg 112:855-868, 2003.
Strombeck JO. Mammaplasty: report of a new technique based on the two-pedicle proce-
dure. Br J Plast Surg 13:79-90, 1960.
Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr
Surg 17:367-375, 1956.

Breast Reduction:
The Lateral Pedicle Technique

MOUSTAPHA HAMDI, ANNE DANCEY
CHAPTER 69

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Part XI  Breast Surgery
T
he multitude of techniques described for reduction mammaplasty pays testa-
ment to the lack of consistent results across all patient groups. Good and bad re-
sults are often attributed to each specific pedicle, and, as with all surgical procedures,
it is this dissatisfaction that drives the pursuit of new and improved techniques. How-
ever, it is difficult to assign primary responsibility for complications or unsatisfac-
tory results solely to a certain pedicle type. The global outcome in breast reduction
can be attributed to many factors, including skin quality, the patient’s age and ex-
pectations, the degree of ptosis, and the surgeon’s experience. Although a variety of
technical refinements have been described over the decades, each breast reduction
procedure addresses the following essential elements:
 Preservation of nipple-areola complex blood and nerve supply
 Removal of excess parenchyma
 Excision of redundant skin
 Reshaping of the breast parenchyma
 Redraping of the skin
The vogue has been to create a vertical scar, the superior pedicle technique popular-
ized by Lejour. However, despite good results in the hands of many experienced
surgeons, there have been numerous problems with this technique, mainly related
to the steep learning curve associated with the method. Nevertheless, the vertical
scar mammaplasty remains popular with many surgeons because it provides long-
standing aesthetic results with minimal scars. We feel that it is important to consider
the vertical technique as a concept rather than as a scar with a specific pedicle. Breast
shaping and remodeling are the most important elements of this technique, and they
can be modified according to an individual patient’s needs.
Skoog is credited with being the first to describe the use of a lateral dermal pedicle
breast reduction in 1963. In 1999 Hall-Findlay reported using a lateral or medial
dermoglandular pedicle combined with a vertical scar. This produces minimal scar-
ring, and the concept of pedicle rotation avoids kinking of the pedicle and the
venous congestion sometimes encountered with the superior pedicle. Hall-Findlay
pointed out that there should be no undermining of the pedicle to ensure continuity
with the chest wall and maximization of perfusion. This technique was further de-
scribed by Cárdenas-Camarena and Vergara. Many surgeons still detach the lateral
dermal pedicle from the chest wall and maintain a thickness of approximately 2 to
3 cm. Thus resection of glandular tissue occurs in a plane dorsal to the pedicle itself,
as well as in the remaining quadrants of the breast. This considerably limits perfu-
sion of the pedicle.

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Chapter 69  Breast Reduction: The Lateral Pedicle Technique
Anterolateral
intercostal perforators
and anterolateral
intercostal nerves
Internal
mammary artery
Internal mammary
perforators and
anteromedial
intercostal nerves
Fibrous septum
Inframammary
crease ligament
Lateral thoracic artery
External
mammary artery
Lateral
thoracic artery
Deep cranial
ligament
Cervical plexus
2
3
4
5
3
4
5
Anterolateral
intercostal perforators
and anterolateral
intercostal nerves
Internal
mammary artery
Internal mammary
perforators and
anteromedial
intercostal nerves
Fibrous septum
Inframammary
crease ligament
Lateral thoracic artery
External
mammary artery
Lateral
thoracic artery
Deep cranial
ligament
Cervical plexus
2
3
4
5
3
4
5
ammary
Internal m
s and
perforators
dial
anteromed
l nerves
intercostal
2
3
4
5
Pectoralis major
muscle
Fibrous septum
Retromammary
space
Clavicle
Intercostal
arteries
4
5
Deep branches
of intercostal
nerves
4
5
6
Thoracoacromial
artery
Inframammary
crease ligament
Pectoral
fascia
Würinger described a horizontal septum traversing the breast that carries an iden-
tifiable neurovascular supply to the nipple-areola complex. The sagittal section of
the breast above shows the horizontal septum described by Würinger. With knowl-
edge of functional three-dimensional breast anatomy constantly evolving, we have
further modified the previously described techniques to optimize the vascularity of the
breast and innervation of the nipple-areola complex. We have called this a septum-
based lateral mammaplasty (SLM) and consider it to be an evolution of the centro-
lateral glandular pedicle. It is this improved vascularization of the nipple-areola com-
plex that is responsible for a significant decrease in early and late postoperative
complications in our hands.

Our lateral glandular technique maintains a column of parenchyma between the
pectoralis major muscle and the nipple-areola complex at the level of Würinger’s
septum. Thus continuity is maintained not only with the lateral breast pillar, but also
with the chest wall itself, resulting in maximum preservation of perforating vessels.
Preserving the ability to lactate is often a fundamental prerequisite for women of
reproductive age who intend to undergo a reduction mammaplasty procedure. It
is known that sculpture of the pedicle during mammaplasty can influence breast-
feeding potential, and therefore it is important to maintain as much continuity as
possible between the remaining glandular tissue and the nipple-areola complex.
Although to date we have no definitive data on postoperative breast-feeding, we in-
tuitively feel that the SLM procedure retains maximum glandular continuity to max-
imize the chances of lactating.
2486
Part XI  Breast Surgery
Parenchyma
undisturbed
between
nipple and
pectoralis major
muscle

Indications and Contraindications
The SLM reduces the infralateral and central parts of the breast, while the nipple-
areola complex is centered on the horizontal septum via a lateral pedicle. The choice
of pedicle depends on different factors, such as the degree of hypertrophy, the posi-
tion of the nipple-areola complex, lateral fullness, and the age of the patient. The
key to achieving an acceptable result in reduction mammaplasty is flexibility in the
choice of pedicle and skin resection. No single procedure can be prescriptive; the
surgeon must be able to choose the most appropriate procedure for each patient. In
our experience, small reductions or mastopexies are often more suited to the supe-
rior pedicle technique.
We think that the SLM is best suited to younger patients, in whom it is paramount to
achieve maximum nipple-areola complex sensitivity, continuity of the nipple-areola
complex and glandular tissue for breast-feeding, and good projection of the breast
mound. By definition, any lateral pedicle technique limits resection from the lateral
pillar and axillary areas. This persistent lateral fullness can be a drawback, particu-
larly in obese patients with excess axillary fat in addition to the macromastia. Bas-
ing the lateral pedicle over Würinger’s septum ensures optimal vascularization of the
nipple-areola complex and enables the surgeon to remove more tissue laterally than
would be possible with standard lateral pedicle techniques. However, even with this
additional perfusion, we recommend a septum-based medial pedicle mammaplasty
(SMM) in patients with extreme lateral fullness.
Having a dual blood supply, the lateral pedicle (lateral thoracic artery) and the sep-
tum (intercostal arteries), makes nipple-areola vascularization more robust. Therefore
the SLM technique is widely indicated for patients with macromastia or major breast
ptosis. The transverse circumference of the breast does not increase dramatically
with macromastia, in contrast to the vertical circumference. Thus a laterally based
technique is likely to have a shorter pedicle length than its superior or inferior coun-
terpart. To date, the senior author (M.H.) has performed resections of up to 2100 g
per side with no compromise of nipple perfusion. Thus we have no specific upper
resection weight limit, although in cases of extreme gigantomastia, a free nipple graft
procedure may need to be considered.
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Chapter 69  Breast Reduction: The Lateral Pedicle Technique

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Part XI  Breast Surgery
The choice of skin closure pattern is based on the patient’s individual characteris-
tics. This can be better determined perioperatively than during preoperative mark-
ing. In general, the vertical scar mammaplasty is selected for young patients (less
than 30 years of age), for those with dark skin, or for patients who have nipple-to-
sternal notch distances of less than 30 cm with good skin quality. These patients
would be expected to have adequate skin retraction and a good cosmetic result from
a vertical scar. For older patients, or those with a nipple-to-sternal notch distance of
more than 30 cm, an L- or J-shaped scar or a limited inverted-T is used. However,
in patients at high risk for hypertrophic scarring, a vertical scar is advised, and the pa-
tient is told that a secondary revision procedure will be necessary. Patients who have
poor skin quality with associated striae are best suited to an inverted-T procedure.
Although the excellent vascularity of the nipple-areola complex allows this tech-
nique to be performed in patients who smoke, we favor techniques that limit skin
undermining with direct excision of excess skin. We have found that leeches are not
a good option for a congested areola, and an extensive infection can occur, espe-
cially in patients with known risk factors. For inexperienced surgeons, we recom-
mend converting any pedicle-based mammaplasty technique to a free nipple-areola
complex procedure in high-risk situations, such as a combination of a very long pedi-
cle (more than 15 cm) in patients who smoke or have other vascular or metabolic
pathologic conditions.
SKIN CLOSURE PATTERN
Age 30 years or dark skin
or
Nipple–sternal notch 30 cm
Age 30 years
or
Nipple–sternal notch 30 cm
Quality of skin
Quality of skin
Good
Good
Bad
Short T or L scar
Vertical scar mammaplasty
Inverted-T or J scar

Pertinent Anatomy
2489
Chapter 69  Breast Reduction: The Lateral Pedicle Technique
Würinger et al described a ligamentous suspension of the breast containing a horizon-
tal septum that attaches the nipple-areola complex to the thoracic wall at the level of
the fifth rib. The septum includes branches and perforators from the intercostal, tho-
racoacromial and lateral thoracic vessels, as well as the lateral branch of the fourth
intercostal nerve. This horizontal fibrous septum is a thin lamina of dense connec-
tive tissue that traverses the breast from medial to lateral and extends to the center
of the nipple. Thus it divides the gland, including the lactiferous ducts, into cranial
and caudal segments. This separation of the glandular tissue is proportionally con-
sistent in all patients, in that hypertrophy of breast tissue appears to occur mainly
ctoralis
muscle
romammary
space
y
Axillary
artery
l
Lateral
c
thoraci
artery
s
Fibrous
m
septum
ostal
Interco
s
arterie
4
5
branches
Deep b
rcostal
of inter
s
nerves
4
5
6
Clavicle
Thoracoacromial
artery
Inframammary
crease ligament
Pec
major m
Retr
Pectoral
fascia
Internal
mammary artery
Fibrous septum
Lateral thoracic artery
Deep branch of
fourth intercostal nerve
Anterolateral
intercostal perforators
and anterolateral
intercostal nerves
4
5
6
Lateral
thoracic artery
Deep cranial
ligament

in the cranial segment. A laterally based pedicle technique that has its foundation
on Würinger’s septum will therefore allow resection of the cranial parenchymal ex-
cess, thus permitting maximum reduction of the parenchyma while preserving sen-
sation and vascularity. Würinger’s description has confirmed the findings of other
anatomic studies to further our knowledge of the nerve supply to the nipple-areola
complex. The anterior ramus of the lateral branches of the fourth intercostal nerve
can take a superficial or deep course toward the nipple-areola complex. In the deeper
variation, the nerve runs on the serratus and pectoralis major fascia before penetrat-
ing the breast parenchyma after 3 to 5 cm to run obliquely toward the nipple-areola
complex. These findings were in accordance with a more recent study by Schlenz
and colleagues, who also found that the lateral cutaneous branch of the fourth in-
tercostal nerve supplied the nipple in 93% of breasts by following a deep retromam-
mary course. In the remaining 7%, the anterior cutaneous branches of the third,
fourth, and fifth intercostal nerves took a superficial course in the subcutaneous tis-
sue. Thus to ensure that sensation is maintained, it is necessary to include the entire
parenchyma surrounding the nerve. In the 2 to 3 cm thick pedicle described in tra-
ditional lateral pedicle techniques, sensation will only be preserved in the superficial
nerve variant, leaving a percentage of patients with a sensory deficit.
Preoperative Assessment
History
The symptoms of female breast hypertrophy are often related to muscular discom-
fort. Patients frequently report back pain, neck pain, shoulder discomfort, and oc-
casionally headaches. They often develop poor posture to compensate for the exces-
sive breast weight. Poor hygiene in the submammary crease leads to irritation, rashes,
and even skin infections. Shoulder grooves develop over time from the pressure ex-
erted by brassiere straps. However, if the patient does not wear a brassiere, activi-
ties and even sleep may be difficult. The excessive breast weight often prevents a
woman from participating comfortably in sports and wearing any form of reveal-
ing clothing. Typically, once this affects the patient’s activities of daily living, she will
seek medical attention.
2490
Part XI  Breast Surgery

In addition to gathering details on the presenting complaint, it is important to ob-
tain a thorough medical history that specifically includes baseline information about
breast cancer risk factors, the patient’s menstrual history, and reproductive plans.
At this stage it is useful to ask what size breasts she is hoping to achieve.
Physical Examination
Physical examination confirms the diagnosis of breast hypertrophy and attempts to
rule out the possibility of breast cancer. It is essential to note the patient’s skin type,
striae, and any evidence of keloids or hypertrophic scarring from previous surgery
or injury. This will affect decisions on the skin closure pattern. A record should be
made of the patient’s height, weight, and BMI.
An aesthetic examination of the breasts is typically performed with the patient sit-
ting up or standing with her arms at her sides. Brassiere-strap grooves are assessed
for depth and skin breakdown. Intertrigo is assessed by lifting each breast and closely
examining the skin for breakdown and rashes. A circumferential evaluation of the
muscular and bony thorax is essential. The vertical alignment of the thorax, asym-
metry, or differences in shoulder position or muscle mass are noted. The two breasts
and their relationship to the chest wall are compared to define any breast asymme-
try at an early stage. Excess lateral breast tissue with a poorly defined lateral breast
border is particularly noted, because this may disqualify the patient for an SLM.
The relative volume and shape of the breasts are compared and recorded. Nipple-
to-sternal notch and nipple-to-midline are measured and recorded. The degree of
ptosis is assessed from the position of the nipple-areola complex in relation to the
rest of the glandular tissue and the inframammary fold.
The breast examination is then repeated with the patient in the recumbent position
with her arms by her sides and then elevated over her head. The breasts are assessed
for any lumps, masses, scars, skin dimpling, or nipple discharge. Preoperative pho-
tographs are taken to document mammary hypertrophy to complete the physical
examination.
Recommendations
The consultation includes a discussion of breast size, a review of the patient’s expec-
tations, and reinforcement of realistic goals for surgical treatment.
2491
Chapter 69  Breast Reduction: The Lateral Pedicle Technique

2492
Part XI  Breast Surgery
Preoperative Planning
Precise marking is the key to obtaining the desired aesthetic result with optimal
breast symmetry. The breasts are marked on the day of surgery with the patient
standing. The midline, inframammary fold, and meridian of the breast are outlined.
The meridian is best marked by hanging a tape measure around the patient’s neck
and letting it drop toward the nipples. The nipple distance from the suprasternal
notch is then measured and marked. Point B is the future position of the nipple. The
distance between the points are as follows: A to B  2 cm; C to G  D to G  6 cm;
and H to I  2 to 4 cm.
Meridian line
New nipple
location
Inframammary
crease
A
B
D
E
C
F
G
H
I
2 cm
2-4 cm
6 cm
6 cm
G

The proposed new nipple position is marked with the two-finger maneuver—placing
two fingers in the inframammary fold and projecting this onto the skin (left, arrow).
In the second photo (right), one finger is in the inframammary fold and the second
finger would be where the tip of the marker is shown. However, the nipple is lowered
1 to 2 cm more than its position, as determined by the two-finger maneuver. This
results in a new position at a horizontal line drawn from the lateral fold of the breast
at the anterior line of the axilla toward the breast meridian (left, arrow). This en-
sures that the nipple position will not be too high, since it will be expected to rise
by a certain degree when the pillars are approximated.
2493
Chapter 69  Breast Reduction: The Lateral Pedicle Technique
The vertical pillars are marked by rotating the breast superomedially and supero-
laterally to extrapolate the lines, as described by Lejour.
New
nipple
position

The mosque-shaped pattern of the areola, which varies from 14 to 20 cm in length,
is adjustable to suit the size of the breast, the nipple distance from the sternal notch,
and the new nipple position. The width of the mosque-shaped periareolar design,
which is between 4 and 10 cm, should be larger for a greater resection and should
also leave enough space for the pedicle to settle without compression.
The vertical, lateral, and medial lines are then connected in a curve to the periareo-
lar line.
2494
Part XI  Breast Surgery
The medial line is marked first and can be transferred to the contralateral breast by
pushing both breasts to each other (mirror effect), as shown. The medial limb has
to be identical on both breasts to achieve good symmetry. The lateral limb position
outlines the central segment of parenchyma and skin to be excised, which will de-
termine the size of the reduced breast. The position of the lateral limb allows adjust-
ment for any asymmetry between the two breasts. The vertical pillars are joined cen-
trally at a level approximately 2 to 4 cm above the inframammary fold. The lateral
pedicle is then marked with a 6 to 8 cm base.

The base of the pedicle is marked to be three quarters in the lateral vertical limb and
one quarter as the opening of the areola, respectively. The final skin closure decision
will be made while the patient is on the operating table, with the aid of a tailor-tacking
technique.
The procedure is performed with the patient supine and under general anesthesia.
The operating table should have a break to permit flexion to the sitting position; the
patient’s arms are held securely adducted to the side. The incision lines and base of
the breast are infiltrated with 40 ml of 1% lidocaine and 1:200,000 epinephrine, di-
luted with 40 ml of normal saline solution. The pedicle itself should not be infiltrated
to ensure that perfusion is not compromised.
Operative Sequence
The operative sequence can be summarized as follows:
1. A laterally based pedicle is developed located over Würinger’s septum.
2. A two-part gland resection is divided into a crescentoid resection caudal to
the septum, and a larger C-shaped resection is done cranial to the septum,
around the pedicle.
3. Breast pillars are sutured in the midline and to the pectoralis fascia.
4. The skin is closed with minimal undermining in a fashion determined peri-
operatively (tailor-tacking technique).
2495
Chapter 69  Breast Reduction: The Lateral Pedicle Technique

5. The lateral pedicle is deepithelialized and the inferior breast skin is undermined.
2496
Part XI  Breast Surgery
6. A C-shaped resection of the gland is done caudal to the septum.
Skin undermined
Pedicle
deepithelialized
A
D
E
C
F
G
H
G
Area of
gland
resection

7. The medial and cranial skin and gland are incised and the septum is dissected.
The arrow (left) indicates an intercostal perforator vessel within the septum.
2497
Chapter 69  Breast Reduction: The Lateral Pedicle Technique
Inferior
wedge
excision
Cranial
incision
Medial
incision
A
D
E
C
F
G
H
G
C-shaped gland
resection
D
E
C
F
G
H
G
E
8. A C-shaped gland resection is done around the lateral septum-based pedicle.

9. The septum-based lateral pedicle is rotated upward.
2498
Part XI  Breast Surgery
Fifth
intercostal
artery
and vein
Fibrous
septum
Pedicle
rotation
Sixth
intercostal
nerve
A
D
E
C
F
G
G
Interlocking
sutures
D
C
10. The areola is closed using an interlocking suture technique.

11. The lateral pillar is fixed onto the pectoral fascia.
2499
Chapter 69  Breast Reduction: The Lateral Pedicle Technique
Lateral pillar
sutured to
pectoral fascia
12. The skin is closed according to the technique described in number 3, p. 2501.

Operative Technique
The operative technique is as follows:
1. Pedicle deepithelialization and skin incision: All preoperative markings are
checked to ensure that important landmarks have not been erased during pa-
tient preparation. The nipple-areola complex is marked with a 45 mm diam-
eter areolar ring with no tension. Deepithelialization is performed on top of
the glandular pedicle to the lateral vertical incision, leaving a 1.5 cm cuff of
dermis around the areola. Skin incisions are completed with a scalpel.
2. Pedicle dissection and glandular resection: In preparing the inferior horizon-
tal resection, the inferior pole of the breast skin is undermined, starting from
the inferior limit of each vertical line (6 cm long) to 1 to 2 cm above the infra-
mammary fold. The skin flap thickness is similar to that of the skin after a
mastectomy. The superficial fascia is incised and dissected over the gland 2 cm
above the inframammary fold.
2500
Part XI  Breast Surgery
This fascia remains attached to the inframammary fold and can be used to
suspend the fold in a higher position at the end of the procedure, if needed.
The gland is incised along the medial pillar (between points D and G) to the
level of the pectoralis fascia. This line is then extended cranially along the
new areolar marking toward point E, which lies at the upper edge of the base
of the pedicle. Digital dissection superiorly, medially, and inferiorly permits
good visualisation of Würinger’s septum. The surgeon is careful not to dis-
Inferior
wedge
excision
Cranial
incision
Medial
incision
A
D
E
C
F
G
H
G
5
69-1 Septum-based
lateral mammaplasty

sect laterally and centrally to prevent inadvertent undermining of the pedi-
cle. Würinger’s septum can be held and palpated to allow resection of the
breast parenchyma under direct vision from around the pedicle. It is impor-
tant to ensure that dissection inferior to the pedicle is minimal to avoid dam-
aging the neurovascular bundles in Würinger’s septum. Having excised the
appropriate amount of parenchyma, the weight is noted to aid in symmetriza-
tion, and the specimen is sent for histopathologic evaluation. Meticulous he-
mostasis is maintained.
The dermis of the pedicle is carefully incised at the base to allow better
upward rotation. The base of the lateral pillar is rotated superomedially and
secured with 1-0 Vicryl to the pectoralis facia. This maneuver transposes the
pedicle to the midline of the breast without tension. In the majority of cases
no further fixation is required, but fixation can be performed superiorly to
the pectoralis fascia if additional support is needed. The inframammary fold
is suspended if necessary and fixed onto the pectoralis fascia with heavy
stitches using the superficial fascia that was dissected at the beginning of the
procedure.
2501
Chapter 69  Breast Reduction: The Lateral Pedicle Technique
Interlocking
sutures
D
C
3. Skin closure: Points C and D at the new 6 o’clock position on the periareo-
lar incision are closed with a 3-0 absorbable suture, and the lateral and me-
dial pillars are approximated with 1-0 Vicryl sutures. The periareolar inci-
sion is closed in three layers: (1) a 2-0 PDS interlocking suture as described
by Hammond, at the level of the deep dermis, beginning at the 12 o’clock po-
sition with a well-buried knot, (2) minimal interrupted 4-0 Vicryl suture to

approximate the dermis in a tension-free manner and ensure appropriate skin
eversion, and (3) subcuticular 4-0 Monocryl. Attention is now turned to clo-
sure of the vertical incisions with one of the following modifications:
 Vertical scar: If a vertical closure is advocated, then the skin is undermined
to a very limited degree to permit closure with a small amount of wrin-
kling. The deep dermis is approximated with interrupted figure-of-eight
sutures using 3-0 Vicryl, and a 3-0 Monocryl subcuticular purse-string su-
ture is placed at the inferior edge of the scar. These sutures shorten the
length of the scar and avoid migration over the inframammary fold. In the
event of inadequate wound edge apposition, some interrupted 6-0 nylon
can be used to achieve satisfactory approximation.
 L or J scar: The skin excess is moved laterally at the inferior edge of the
vertical scar to avoid crossing the inframammary fold or extending the scar
medially.
 Inverted-T scar: If an inverted-T closure is required, this is designed at the
end of the operation. The vertical scar is tailor-tacked with staples and a
horizontal ellipse is designed to excise the dog-ear. Thus the horizontal
component is as short as possible. The skin is closed in two layers with sub-
cuticular 3-0 PDS in the deep dermis and a subcuticular 4-0 Monocryl.
4. Liposuction: Liposuction is performed in selected cases once the skin has been
closed. Indications include persistent asymmetry, lateral fullness, and the need
for improved definition of the inframammary fold.
Postoperative Care
Suction drains are placed bilaterally, ensuring that the drains are in the retroareolar
area before closure to prevent a hematoma that could compromise pedicle perfu-
sion. Dermabond tissue glue is placed over the sutured incision lines as a waterproof
dressing. This enables the wounds to be left free of dressings for monitoring, steril-
ity, and patient comfort. The drains are removed after 24 to 48 hours and the pa-
tient is discharged. Patients are instructed to wear a nonwire sports bra day and
night for a month to ensure optimal breast shaping and support.
Problems and Complications
The postoperative complications we experienced in a consecutive series of 110 pa-
tients are shown in the table. Scar-related problems, namely wound dehiscence, were
the most common complication, occurring in approximately 8% of patients. Other
complications included hematoma, skin necrosis and infection and occurred with a
2502
Part XI  Breast Surgery

Outcomes
We have shown in a prospective study that the septum-based lateral mammaplasty
maintains the sensitivity of the nipple-areola complex from the immediate postop-
erative period and that all patients had normal sensation at a 6-month follow-up.
We have also observed excellent stability of breast shape, with an improved conical
profile of the breast mound and projection of the nipple. By ensuring that the glan-
dular pedicle remains attached to the pectoralis muscle, we preserve the original
strength of the connective tissue support, which includes the attachments of the su-
perficial fascia and Cooper’s ligaments. Resection of glandular tissue superior to the
pedicle and repositioning of the pedicle in a more cranial position result in improved
nipple projection.
The key to preserving breast-feeding potential after reduction mammaplasty is prepa-
ration of the pedicle, sparing as many lobules and connected lactiferous ducts as
possible; we also strive to maintain adequate nipple-areola complex sensitivity. We
have no firm data on the possibility of breast lactation using our technique. How-
ever, several previous studies have shown the lateral dermal pedicle to be superior
to many other reduction techniques in terms of successful breast-feeding. We feel
that our technique is superior to many of the lateral dermal pedicle methods, be-
cause it preserves an intact column of glandular tissue, thereby leaving the functional
unit of the breast undisturbed. Intuitively, this, combined with the total preservation
of sensation to the nipple-areola complex we have demonstrated, should lead to suc-
cessful breast-feeding.
2503
Chapter 69  Breast Reduction: The Lateral Pedicle Technique
Postoperative Complications in 110 Patients
Complications (N  194 breasts)
Number (%)
Wound dehiscence
15 (7.7)
Wound infection
2 (1.0)
Unilateral retroareolar hematoma
3 (1.5)
Unilateral partial areolar necrosis
1 (0.5)
Unilateral total areolar necrosis
1 (0.5)
frequency of less than 1%.Despite the fact that we wanted to use vertical and any
other short-scar techniques to minimize scarring, we feel strongly that this should
not be at the expense of a high rate of wound dehiscence and scar revision. Thus we
have developed an algorithmic approach to skin closure.

2504
Part XI  Breast Surgery
Results
This 29-year-old patient presented for breast reduction. She had F cup breasts with
a 31 cm nipple-to-sternal notch distance. The nipple was elevated to a 32 cm nipple-
to-sternal notch distance. Following our algorithm, a vertical scar was indicated in
this case. The breast was reduced using the SLM technique to create D cup breasts,
as requested by the patient. At the same time, a fibroadenoma was included within
the gland resection of the left breast. The vertical scar is shown at 6 months post-
operatively.

This 46-year-old woman requested moderate breast reduction (from a DD cup to a
B or C). A vertical scar closure was indicated by her preoperative nipple-to-sternal
notch distance of 30 cm. Gland resection was 376 g on the right and 266 on the left.
She is shown 1 year postoperatively.
2505
Chapter 69  Breast Reduction: The Lateral Pedicle Technique

This 55-year-old woman with a BMI of 35 had major breast hypertrophy. The nip-
ples were located 42 cm (right breast) and 40 cm (left breast) from the sternal notch.
An SLM procedure with an extended inverted-T scar was done. The scar was ex-
tended over the midline to immediately correct the dog-ears caused by the asymme-
try of the inframammary folds and to the previous midline abdominal scar. The
amount of gland resection was 1400 g on the right breast and 950 g on the left breast.
The results are shown 5 years postoperatively.
2506
Part XI  Breast Surgery

This 44-year-old woman had undergone a gastric bypass procedure and had lost 60 kg
(132 pounds) when she presented for a breast reduction/mastopexy procedure. In
this challenging case, the nipples were located at 35 cm (right breast) and 38 cm (left
breast) from the sternal notch. The skin quality was extremely poor; therefore the
SLM procedure was done with a conventional inverted-T scar. The amount of gland
resection was 850 g (right breast) and 1130 g (left breast). Preoperative views show
the septum of the right breast. The septum became extremely thin as a result of the
long-term breast hypertrophy and ptosis. The perforator vessels and nerves could
still be seen through the septum that was transilluminated with the surgical light.
Early results are shown at 4 months postoperatively.
2507
Chapter 69  Breast Reduction: The Lateral Pedicle Technique

Concluding Thoughts
We feel that the septum-based lateral mammaplasty technique is safe and valuable
for breast reduction. This procedure provides resection of a large amount of breast
tissue without compromising the viability of the nipple-areola complex. The main
advantages are maintaining nipple-areola sensitivity and a good aesthetic outcome.
The technique is strongly recommended for young patients with large breasts.
Clinical Caveats
 The lateral pedicle technique is best suited to younger patients with a well-defined
lateral breast border and no excessive lateral fullness. An alternative pedicle should
be considered for patients who do not meet these criteria.
 The technique offers increased viability of the nipple-areola complex, preserva-
tion of sensation to the nipple-areola complex, reduced rate of wound complica-
tions, and increased potential for breast-feeding. In addition, the support of the
glandular tissue behind the nipple-areola complex improves the conical projec-
tion of the breast and prevents flattening of the nipple-areola complex.
 Preoperative marking should be done on the day of surgery and is the key to
achieving the desired result. The medial vertical incisions should be symmetrical,
and any necessary adjustments can be made with the lateral incisions. The nipple
should be sited 1 to 2 cm below the inframammary fold.
 The dissection of the pedicle centers around Würinger’s horizontal septum, which
includes branches and perforators from the intercostal, thoracoacromial, and lat-
eral thoracic vessels, as well as the lateral branch of the fourth intercostal nerve.
 A two-part gland resection is performed as a limited crescentoid resection caudal
to the septum and a larger C-shaped resection cranial to the septum, around the
pedicle.
 The lateral pillar is sutured onto the pectoralis fascia, thereby ensuring that there
is no tension on the pedicle.
2508
Part XI  Breast Surgery

 The final decision regarding skin closure is made while the patient is on the op-
erating table:
– A vertical scar is best suited to patients with nipple-to-sternal notch distances
of less than 30 cm and good skin quality. However, the vertical scar may also
be appropriate in patients at high risk of hypertrophic scarring, although there
is a high incidence of secondary revisions.
– An L- or J-shaped scar is suitable for older patients or those with a nipple-to-
sternal notch distance greater than 30 cm.
– The inverted-T scar is used in patients who have poor skin quality with asso-
ciated striae.
 Liposuction can be undertaken to give better symmetry, reduce lateral fullness,
and create better definition of the inframammary fold.
2509
Chapter 69  Breast Reduction: The Lateral Pedicle Technique
Annotated Bibliography
Chiummariello S, Cigna E, Buccheri EM, et al. Breastfeeding after reduction mammaplasty
using different techniques. Aesthetic Plast Surg 32:294-297, 2008.
The authors review breast-feeding ability after four different pedicle techniques of breast
reduction used in their unit. Breast-feeding was defined as more than 3 weeks of lacta-
tion not requiring nutritional supplementation. Breast-feeding was successful in 60.7%
of patients with a superior pedicle, 55.1% with a lateral pedicle, 48% with a medial
pedicle, and 43.5% with an inferior pedicle. No description was given of the technique
used or statistical analysis of results. The authors conclude that the ability to breast-feed
is adequately preserved in techniques that spare the connections between the lobules and
milk ducts and vital nipple-areola complex.
Hamdi M, Van Landuyt K, Tonnard P, Verpaele A, Monstrey S. Septum-based mammaplasty:
a surgical technique based on Würinger’s septum for breast reduction. Plast Reconstr
Surg 123:443-454, 2009.
This paper describes the septum-based mammaplasty with use of a medial or lateral
pedicle technique, as indicated. An algorithmic approach is used for decision-making,
particularly in relation to the pattern of skin closure. The authors’ experience with a se-
ries of 110 consecutive patients over a period of 7 years is outlined. Resections ranged
from 160 g to 1980 g, and the postoperative complication rate included 0.5% areolar
necrosis, 7.7% limited wound dehiscence, 9% secondary scar revision. The technique is
considered to be safe and demonstrates ease of pedicle shaping and breast remodelling
in patients undergoing reduction mammaplasty.

Hamdi M, Vande Sijpe K, Van Landuyt K, Blondeel PN, Monstrey S. Evaluation of nipple-
areola complex sensitivity after the latero-central glandular pedicle technique in breast
reduction. Br J Plast Surg 56:360-364, 2003.
The authors record the sensitivity of the nipple-areola complex in 20 consecutive pa-
tients undergoing a septum based lateral pedicle technique. Measurements are made pre-
operatively, at 2 weeks and 3 months post surgery using a variety of validated sensory
measurements. Results show that at 2 weeks all patients had reduced sensitivity, but by
3 months pressure and vibration perception were the same as the preoperative measure-
ments. Temperature recognition on the nipple remains impaired in 27.5% of patients at
3 months. They conclude that the latero-central pedicle preserves sensitivity of the
nipple-areola complex in all patients.
Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the nipple-areola complex: an
anatomic study. Plast Reconstr Surg 105:905-909, 2000.
The authors dissected 28 female cadavers to record the nipple and areola innervation.
The most constant innervation pattern was by the 4th lateral cutaneous branch (79%)
and by the 3rd and 4th anterior cutaneous branches (57%). The anterior cutaneous
branches took a superficial course within the subcutaneous tissue. The lateral cutaneous
branches took a deep course within the pectoral fascia and reached the nipple from its
posterior surface in 93 percent of the dissected breasts. In 7% of the dissected breasts, the
lateral cutaneous branches took a superficial course within the subcutaneous fat and
reached the nipple from the lateral side. The authors suggest that resections at the base
of the breast and skin incisions at the medial areolar border are best avoided.
Würinger E, Mader N, Posch E, et al. Nerve and vessel supplying ligamentous suspension
of the mammary gland. Plast Reconstr Surg 101:1486-1493, 1998.
This paper gives an anatomic description of a thin horizontal septum of dense connec-
tive tissue in the breast, based on the authors’ findings for 28 breast specimens. This sep-
tum is the basis for the neurovascular supply to the nipple and contains branches of the
lateral thoracic artery, the thoracoacromial artery and intercostal arteries. The nerve sup-
ply runs along the septum, either following a deep course from the lateral cutaneous
branch of the 4th and 5th intercostal nerves, or a more superficial course from the an-
terior and lateral branches of the 2nd to 4th intercostal nerves.
Suggested Readings
Arie G. Una nueva tecnica de mastoplastia. Rev Iber Latino Am Cir Plast 3:28, 1957.
Asplund OA, Davies DM. Vertical scar breast reduction with medial flap or glandular trans-
position of the nipple-areola. Br J Plast Surg 49:507-514, 1996.
Beer GM, Morgenthaler W, Spicher I, et al. Modifications in vertical scar breast reduction. Br
J Plast Surg 54:341-347, 2001.
Cárdenas-Camarena L, Vergara R. Reduction mammaplasty with superolateral dermoglan-
dular pedicle: another alternative. Plast Reconstr Surg 107:693-699, 2001.
Greuse M, Hamdi M, DeMey A. Breast sensitivity after vertical mammaplasty Plast Recon-
str Surg 107:970-974, 2001.
2510
Part XI  Breast Surgery

Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve.
Plast Reconstr Surg 104:748-759, 1999.
Hamdi M, Greuse M, DeMey A, et al. Breast sensation after superior pedicle versus inferior
pedicle mammaplasty: prospective clinical evaluation. Br J Plast Surg 54:39-42, 1999.
Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast
Reconstr Surg 103:890-901, 1999.
Hefter W, Elvenes OP, Lindholm P. A retrospective quantitative assessment of breast sensa-
tion after lateral pedicle mammaplasty. Br J Plast Surg 56:667-673, 2003.
Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr Surg 97:373-380,
1996.
Lejour M. Vertical mammaplasty: update and appraisal of late results. Plast Reconstr Surg
104:771-781, 1999.
Lockwood T. Reduction mammaplasty and mastopexy with superficial fascial system sus-
pension. Plast Reconstr Surg 103:1411-1420, 1999.
Ramirez OM. Reduction mammaplasty with the “owl” incision and no undermining. Plast
Reconstr Surg 109:512-522; discussion 523-524, 2002.
Schlenz I, Rigel S, Schemper M, et al. Alteration of nipple and areolar sensitivity by reduction
mammaplasty: a prospective comparison of five techniques. Plast Reconstr Surg 115:743-
751, 2005.
Skoog T. A technique of breast reduction; transposition of the nipple on a cutaneous vascu-
lar pedicle. Acta Chir Scand 126:453-465, 1963.
Skoog T. Plastic Surgery: New Methods and Refinements. Stockholm: Almquist & Wiksell,
1974.
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Chapter 69  Breast Reduction: The Lateral Pedicle Technique

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Short-Scar Mammaplasty
With a Pectoralis Loop

RUTH MARIA GRAF,
ANDRÉ RICARDO DALL’OGLIO TOLAZZI,
MARIA CECÍLIA CLOSS ONO, THOMAS M. BIGGS
CHAPTER 70

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Part XI  Breast Surgery
B
reast surgery is ever evolving; the great advances of Wise, Pitanguy, Lassus,
Lejour, Benelli, and others have given us techniques that not only simplify the
operative plan for mammaplasty but also produce a shorter scar and a more aes-
thetic breast. In this chapter we will describe the short-scar mammaplasty with a
pectoralis loop, a maneuver designed to give a pleasing and long-lasting contour to
the breast. This maneuver involves the use of a chest wall–based flap of breast tis-
sue that is moved into the upper pole of the breast and held in place by a loop of
pectoral muscle, under which it is passed. The technique can be used with standard
inverted-T incisions, vertical incisions with short transverse components, L-shaped
incisions, or pure vertical incisions. Our choice, and the maneuver described in this
chapter, is a vertical incision, with redundant skin removed from around the areola
after excision of a vertical ellipse, and closure with a round block suture. If breast
reduction is necessary, it can easily be carried out by removing the desired amount
of tissue from the base and central part of the breast. A wide range of parenchymal
reduction procedures can be performed.
Indications and Contraindications
It is possible to use this combination of techniques for mastopexy only, when there
is no excess breast tissue to be removed, or for breast reduction, when resection of ex-
cess breast tissue is done in the columns or base of the breast, after the thoracic wall
flap is fixed. With this technique we found that we removed less breast tissue than
with other techniques that do not use the chest wall–based flap, and the breasts have
a narrower base. In our experience, the average amount of breast tissue resected was
250 to 500 g, less than in other techniques we have used without the thoracic flap.
This technique is ideally indicated for mild and
moderate cases of breast ptosis and hypertro-
phy, where less skin compensation is neces-
sary. Significant hypertrophy and severe pto-
sis constitute relative contraindications to
vertical mamma plasty. We prefer to use a short
inverted-T incision in these cases to excise
more skin and reduce skin compensation. This
patient has significant breast ptosis, and the
breast has been marked for the inverted-T pat-
tern of skin resection.

Pertinent Anatomy
The mammary gland is anchored to the pectoralis major fascia by the suspensory
ligaments (Cooper’s ligaments), which help to maintain the shape of the nonoper-
ated breast.
The breast is innervated by the second to sixth intercostal nerves. Lateral innerva-
tion is predominantly from the anterior rami of the lateral cutaneous branches of
the third through sixth intercostal nerves. Medial innervation arises from the ante-
rior cutaneous branches of the second through sixth intercostal nerves. The nerve
supply to the nipple is from the third, fourth, and fifth anterior and lateral cutaneous
nerves. The lateral cutaneous branch of the fourth intercostal nerve, which is con-
sidered to be the most important, innervates the nipple with two branches. The su-
perficial branch passes up through the superficial paren chyma; the deep branch passes
inferolaterally on the pectoralis major fascia before coursing up into the areola. This
fact might give one pause in considering techniques that rely heavily on inferolat-
eral resection of the gland.
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Chapter 70  Short-Scar Mammaplasty With a Pectoralis Loop
The blood supply to the mammary gland is from multiple sources, including the in-
ternal mammary perforators (most notably the second to fifth perforators), the tho-
racoacromial artery, the artery to the serratus anterior, the lateral thoracic artery,
and the terminal branches of the third to eighth intercostal arteries. One important
aspect, first described in 1998 by Würinger et al, is the concept of a mesentery-like
fibrous septum that runs through the breast at the level of the fifth rib and contains
perforator vessels responsible for the blood supply of the nipple-areola complex. We
apply this concept when thinking about the dissection of a chest wall–based flap,
which is important for achieving an ideal breast shape.
Thoracoacromial artery
Fourth intercostal artery
Pectoralis major muscle
Fibrous septum
Deep branches of
intercostal nerves
4
5
6
Inframammary
crease ligament
Pectoral fascia
Retromammary space
Clavicle
Fifth intercostal artery

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Part XI  Breast Surgery
Preoperative Assessment
Each patient must be evaluated for the amount of breast parenchyma, the amount
and quality of excess skin, and the scars that are acceptable to the patient. Local
breast examination is performed to exclude masses, and any suspicious lesion should
be fully investigated before surgery. It is advisable to obtain preoperative mammo-
grams in all patients older than 30 years of age, and breast ultrasonography in
younger patients.
Preoperative Planning
Markings are done with the patient in the upright position. The midline (M) is drawn
from the suprasternal notch to the xyphoid process, breast meridians are marked
from a point 5 cm lateral to the suprasternal notch over the clavicle to the nipple-
areola complex. On the breast meridian line, point A is marked about 17 to 20 cm
from the clavicle, at the top of the areola, and point D about 2 to 4 cm above the
inframammary fold, depending on breast size. If the patient has significant hyper-
trophy or severe ptosis, point D should be marked higher, up to 4 cm above the in-
framammary fold. This leaves skin and subcutaneous tissue of the lower breast pole
as part of the thoracic wall, with a higher new inframammary fold.
The breast is then gently displaced laterally (the technique described by Lejour) and
a medial line is drawn connecting point A to point D. Similarly, a lateral line is drawn
with the breast displaced medially. The tension resulting from these displacements
should be firm enough to allow adequate skin resection, but not so tense as to create
difficulty with closure. This distance varies, depending on the size of the breast. The
A
M
12 cm
9 cm
20 cm
2 cm
5 cm
B
C
D

medial and lateral lines, points B and C, respectively, are marked about 5 to 8 cm
above point D. A gently curved line is drawn from point A to point B, and again
from point A to point C. Line AB should never be closer than 9 cm to the midline,
and line AC never less than 10 cm to the anterior axillary fold.
The variation in distances of point D to the inframammary fold and vertical lines
BD and CD allows the surgeon the latitude to make adjustments, depending on the
size of the breast. The larger the breast, the greater these distances, but never exceed-
ing 4 and 8 cm, respectively. Points B and C are marked slightly closer to each other
so they can be closed with less tension.
Operative Technique
The patient is placed supine on the operating table and is prepared and draped. Gen-
eral or epidural anesthesia is induced (in some cases local anesthesia may be used),
and the marked areas are infiltrated subdermally (except superior to the areola) with
normal saline–epinephrine solution (1:100,000). The area of skin demarcated by
AB, AC, BD, and CD is deepithelialized by a Schwartzman maneuver, leaving the
nipple-areola complex (4.5 to 5.0 cm in diameter) in place. To start creating the chest
wall–based flap, the dermis is incised along the lines BD and CD, as well as BC,
passing 1 cm below the nipple-areola complex.
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Chapter 70  Short-Scar Mammaplasty With a Pectoralis Loop
Along the vertical lines, the incision is beveled inward for 1 to 2 cm to preserve tis-
sue on the medial and lateral pillars for later closure. The incisions continue inward
and away from the flap so that the base is broad. This dissection is carried to the
chest wall, with a minimal amount of subcutaneous tissue being left on the skin as dis-
section is carried to the inframammary fold.
5
70-1 Vertical
mammaplasty

After this dissection has been completed laterally and medially, a large hook is placed
in the nipple-areola complex to lift the breast straight up and help with the dissection
of the breast tissue from point B to C down to the pectoral fascia. Great care must
be taken at this point not to undercut the flap. The flap is now mobile and based on
vessels from the fifth and sixth intercostal spaces as a perforator flap. It is very im-
portant that the flap is unrestrained; otherwise, continuous dissection should be ex-
tended to the pectoral fascia to better release it. This freely mobile, totally chest
wall–based flap is made up of the tissue that in other procedures bottoms out, but
in this procedure it is being transposed into the upper pole, where it will be perma-
nently fixed.
The breast tissue is retracted upward and cephalad and dissected off the pectoral
fascia up to the second intercostal space, creating a space in the upper pole of the
breast into which the flap will be fixed.
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Part XI  Breast Surgery
A strip of pectoral muscle approximately 8 to 10 cm long and 1.5 to 2.0 cm wide is
marked with methylene blue. The caudal or inferior line is marked at the cephalad
end of the flap base. This muscle strip is elevated, incorporating no more than half of
Markings
Dissection
Closure