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

2520
Part XI  Breast Surgery
After reduction of excess breast tissue, and with the hook still holding the breast
straight up, one interrupted stitch of 2-0 nylon is placed from the superior part of
the breast parenchyma to the pectoralis muscle, just superior to the chest wall–based
flap, at the level of the second intercostal space to aid in upper pole definition.
The pillars are then closed with 2-0 nylon in several layers. It is preferable to place
the needle deeper laterally than medially to preserve more fullness medially. Closure
of mammary pillars and the deep dermis union of points B and C are shown.

Deep dermis of the vertical wound is sutured, starting with subareolar points B and
C. To reduce the outer circumference and wound tension, and to compensate the
peri areolar skin around the areola, a round block suture is made all the way around
the periareolar skin with 3-0 colorless nylon. Eight cardinal points are marked in
the outer and inner circumferences to spread the periareolar skin uniformly around
the areola. The running suture passes through the deep dermis of the outer skin and
the areolar deep tissue. In the external skin the suture follows the markings, taking
a large bite of tissue; in the areola the suture is passed between the markings, tak-
ing a small amount of tissue. Tensioning the suture reduces the outer circumference
down to the desired diameter for the nipple-areola complex (about 4.5 cm).
Starting from point D, the skin is closed with a subdermal interrupted suture of 3-0
Monocryl, anchoring the vertical wound on the deep pillars of tissue, so the verti-
cal scar is kept at the same level as the new inframammary crease.
2521
Chapter 70  Short-Scar Mammaplasty With a Pectoralis Loop

In patients with significant skin redundancy, it is possible to excise a small horizon-
tal ellipse of skin in the new inframammary fold, ending with a short inverted-T scar.
This can better adjust the skin envelope without jeopardizing the youthful breast
shape achieved with vertical principles associated with chest wall–based flap. A run-
ning intradermic suture with 4-0 Monocryl finally closes the skin. No drains are
used. An excision of a horizontal ellipse of skin is shown above, which ends with a
short inverted-T scar in selected cases.
Postoperative Care
A compressive, molding brassiere is recommended for 1 to 2 months to reduce post-
operative swelling and tension on scars. It also helps to support the breasts while in-
ternal tissues are healing and until the final shape is more stable.
Massage and ultrasound therapy for lymphatic drainage are indicated from the sec-
ond postoperative day, three sessions per week for the first postoperative month or
two. Significant reduction in swelling and pain and increased comfort have been re-
ported by patients who received these treatments.
Special care of scars is necessary to improve healing. A topical antibiotic ointment
maintains local moisture and helps with cell migration to accelerate wound healing.
After the first week, when all the wounds are healed, and for 2 to 3 months postop-
eratively, Micropore tapes are used over the scars to prevent stretching and widen-
ing them. Silicone gel or sheets can also be used to help prevent hypertrophic scars.
2522
Part XI  Breast Surgery

The patient is encouraged to walk the first day after surgery; driving and other phys-
ical activities can be resumed after 3 weeks.
Patients are closely followed in the postoperative period and are clinically evaluated
at 5 to 7 days, 2 weeks, 1, 3, 6, and 12 months, and yearly thereafter. The patient’s
results are documented photographically at each follow-up visit.
Problems and Complications
The major drawback to this procedure is the length of time before the final result
can be appreciated. The surgeon and patient must be patient while the skin retracts,
wrinkles flatten, and the overcorrected breast, with its superior bulge and inferior
flatness, evolves to an aesthetically pleasing contour.
Wound-healing problems such as dehiscence, widening, and irregularities are some-
times seen as a result of the vertical and periareolar skin-gathering suture. Eventu-
ally some skin redundancy remains in the new inframammary fold, which necessi-
tates excision by a horizontal approach. Although this horizontal incision is small, it
does add a horizontal component to the resulting scar. It is important not to elongate
the scar out of medial and lateral limits of the breast to avoid hypertrophic scars.
Outcomes
Better and long-term upper pole fullness (second, third, and fourth costal rib) has
been observed with the patient in the erect position. Breast shape and projection
have been stable when the patient is lying supine. The areola maintains its upward
projection, with little lateral tilting. Vertical and periareolar scars are usually of good
quality, because there is less tension in the closure. Approximating the pillars and
the round block suture reduces wound tension and improves the final scar. Narrow-
ing the base of the breast is observed in all cases.
2523
Chapter 70  Short-Scar Mammaplasty With a Pectoralis Loop

Results
2524
Part XI  Breast Surgery
The patient is seen preoperatively and 2 years postoperatively.

2525
Chapter 70  Short-Scar Mammaplasty With a Pectoralis Loop
The patient is seen preoperatively and 1 year postoperatively.
The patient is seen preoperatively and 2 years postoperatively.
The patient is seen preoperatively and 3 years postoperatively.

The patient is seen preoperatively and 10 years postoperatively.
Concluding Thoughts
Long-term breast projection and upper pole fullness remain goals of mammaplasty.
The chest wall–based mammary flap held by the pectoralis loop helps to achieve
these goals and results in a youthful-looking breast. The flap can be performed in
any kind of reduction mammaplasty or mastopexy. Short scars, such as those in the
periareolar vertical technique, are good for mild and moderate breast hypertrophy
and ptosis.
2526
Part XI  Breast Surgery

Clinical Caveats
 The vertical principles associated with a chest wall–based flap held by a pectoralis
strip promote better and long-lasting breast upper pole fullness with the patient
in both upright and supine position. The areola remains in a good location and
very little breast descent occurs, with no bottoming out.
 The absence of a scar in the inframammary fold is a major advantage. The cir-
cumvertical scar does not cross the new inframammary crease and has a better
quality because of the reduced skin tension, achieved through the round block su-
ture and internal sutures of breast tissue.
 A youthful appearance of the breast is achieved as a result of better projection
and a narrower base.
2527
Chapter 70  Short-Scar Mammaplasty With a Pectoralis Loop
Suggested Readings
Arié G. Una nueva técnica de mastoplastia. Rev Lat Am Cir Plast III:23-28, 1957.
Benelli L. A new periareolar mammaplasty: round block technique. Aesthetic Plast Surg
14:99-100, 1990.
Biesenberg H. Deformitäten und Kosmetische Operationen der Weiblichen Brust. Vienna:
W Mandrich, 1931.
Bozola AR, Oliveira MD, Sanchez VM. Mamoplastia em L. Rev AMRIGS 26:207-214, 1982.
de Araujo Cerqueira A. Mammoplasty: breast fixation with dermoglandular mono upper
pedicle under the pectoralis muscle. Aesthetic Plast Surg 22:276-283, 1998.
Chiari AJ. The L short-scar mammaplasty: a new approach. Plast Reconstr Surg 90:233-
246, 1992.
Daniel M. Mammaplasty with pectoral muscle flap. Presented at the Sixty-fourth ASPRS/
PSEF/ASMS Annual Scientific Meeting, Montreal, Oct 1995.
Dufourmentel C, Mouly R. [Mammaplasty by the oblique method] Ann Chir Plast 6:45-58,
1961.
Elbaz JS, Verheecke G. [The L-form cicatrix in breast plastic surgery] Ann Chir Plast 17:283-
288, 1972.
Ely JF. Guidelines for reduction mammaplasty. Ann Plast Surg 6:424-429, 1981.
Góes JC. Periareolar mammaplasty: double skin technique with application of polyglactine
or mixed mesh. Plast Reconstr Surg 97:959-968, 1996.
Góes JC. Periareolar mammaplasty with mixed mesh support: the double skin technique.
Plast Reconstr Surg 2:575-576, 1992.

Graf R, Auersvald A, Bernardes A, Biggs TM. Reduction mammaplasty and mastopexy with
shorter scar and better shape. Aesthetic Surg J 20:99-106, 2000.
Graf R, Biggs TM. In search of better shape in mastopexy and reduction mammoplasty. Plast
Reconstr Surg 110:309-317, 2002.
Graf R, Biggs TM, Steely RL. Breast shape: a technique for better upper pole fullness. Aes-
thetic Plast Surg 24:348-352, 2000.
Graf R, Reis de Araujo LR, Rippel R, et al. Reduction mammaplasty using the vertical scar
and thoracic wall flap technique. Aesthetic Plast Surg 27:6-12, 2003.
Hall-Findlay E. A simplified vertical reduction mammaplasty: shortening the learning curve.
Plast Reconst Surg 104:748-759, 1999.
Hall-Findlay E. Vertical breast reduction with a medially-based pedicle. Aesthetic Plast Surg
22:185-194, 2002.
Holländer E. Die operation der mamahypertrophie und der hangebrust. Deutsche Med
Wochenschr 50:1400, 1924.
Horibe K, Spina V, Lodovici O. Mamaplastia redutora: nuovo abordaje del método lateral
oblícuo. Cir Plast Ib Latinoamer 11:7-15, 1976.
Lassus C. Breast reduction: evolution of a technique. A single scar. Aesthetic Plast Surg
11:107, 1989.
Lassus C. A technique for breast reduction. Int Surg 53:69-72, 1970.
Lassus C. Update on vertical surgery. Plast Reconstr Surg 104:2289-2298, 1999.
Lejour M. Vertical mammaplasty: early complications after 250 personal consecutive cases.
Plast Reconst Surg 104:746-770, 1999.
Lejour M. Vertical Mammaplasty and Liposuction of the Breast. St Louis: Quality Medical
Publishing, 1993.
Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 94:100-
114, 1994.
Lejour M, Abboud M, Declety A, et al. [Reduction of mammaplasty scars: from a short in-
framammary scar to a vertical scar] Ann Chir Plast Esthet 35:369-379, 1990.
Levet Y. The pure posterior pedicle procedure for breast reduction. Plast Reconstr Surg 86:67-
75, 1990.
Lexer E. Ptosis operation. Clin Monatsbl Augenh 1923, 70:464, 1923.
Lotsch GM, Gorhbandt E. Operationen an der weibliche brustdrüse. Chir Oper Leipzig
1955.
Marchac D, Olarte G. Reduction mammaplasty and correction of ptosis with a short scar.
Plast Reconst Surg 69:45-55, 1982.
Meyer R, Kesselring UK. Reduction mammaplasty with an L-shaped suture line. Plast Re-
constr Surg 55:139-148, 1975.
Mottura AA. Circumvertical reduction mastoplasty: new considerations. Aesthetic Plast Surg
27:85-93, 2003
Peixoto G. Reduction mammaplasty: a personal technique. Plast Reconstr Surg 65:217-225,
1980.
Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg 20:78-85, 1967.
2528
Part XI  Breast Surgery

Regnault P. Reduction mammaplasty by the “B” technique. Plast Reconstr Surg 53:19-24,
1974.
Ribeiro L. A new technique for reduction mammaplasty. Plast Reconst Surg 55:330-334,
1975.
Ribeiro L, Backer E. Mastoplastia com pediculo de seguridad. Rev Espan Cir Plast 16:223-
234, 1973.
Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr
Surg 17:367-375, 1956.
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.
2529
Chapter 70  Short-Scar Mammaplasty With a Pectoralis Loop

This page intentionally left blank
This page intentionally left blank

Alternative Approaches to
Breast Reduction

ELIZABETH J. HALL-FINDLAY, FOAD NAHAI
CHAPTER 71

B
reast reduction can be immensely satisfying for both the patient and the sur-
geon. This is the only procedure that we perform on the female breast that
treats symptoms. Outcome studies have repeatedly shown high patient satisfaction,
along with significant improvement in back pain, neck pain, shoulder grooving, skin
rashes, and even headaches. It is equally important to document the real improve-
ment in self-esteem with improvement in posture, exercise tolerance, and psycho-
logical well-being.
Surgery is the only real option available for breast reduction. Medical treatment,
such as hormone therapy, is not effective. Supportive brassieres can help to a rela-
tively minor degree, because they transfer the discomfort to other areas, such as the
shoulders.
The goals of breast reduction surgery are to reduce volume while achieving an aes-
thetically pleasing shape and maintaining breast function. For improved shape, the
nipple-areola complex must be moved superiorly. Surgical approaches should pre-
serve blood supply not only to the nipple and areola, but also to the remaining
parenchyma and skin. Sensation and breast-feeding potential are also considered.
As famously stated by Sir Harold Gillies, much that we do in plastic surgery involves
a battle between beauty and blood supply. Breast reduction is no different. Patients re-
quest improvement in symptoms and they are rarely disappointed. On the other hand,
the rate of lawsuits for breast reduction is high, proving that aesthetics are just as
important. Patients request the surgery for medical reasons, but they seek legal ad-
vice for the cosmetic result (see Chapter 8).
Evolution of Technique
Before 1900, attempts to reduce breast size were limited to volume reduction with-
out much regard to nipple position or viability. In the first part of the twentieth cen-
tury, multiple techniques were described to move the nipple-areola complex and to
reduce bulk. To maintain viability, two-stage procedures were often recommended.
As time progressed, surgeons focused on better preservation of nipple and skin flap
circulation and shape. Various pedicles and resection techniques were described, each
with advantages and disadvantages.
2532
Part XI  Breast Surgery

2533
Chapter 71  Alternative Approaches to Breast Reduction
The following principles of breast reduction became clearer with experience:
1. The dermoglandular pedicle is considered preferable for the nipple-areola
complex to maintain blood supply, preserve sensation, and increase the po-
tential for lactation. (At least, this is true in North America.)
2. Extensive skin undermining should be avoided to reduce problems of skin
necrosis that were common in the Biesenberger type of procedure (which was
the most popular mammaplasty procedure between 1930 and the 1980s).
In North America the inferior pedicle technique combined with an inverted-T clo-
sure proved most effective for accomplishing these principles. This method proved
safe, reproducible, and relatively easy to teach. Minor wound-healing problems oc-
curred at the T junction, but the technique provided relative safety for the nipple-
areola complex. Sensation was good, and lactation was certainly possible in many
patients. The trade-off of extensive scarring was undesirable but certainly thought
to be justified. The boxy shape, along with lateral and medial dog-ears, was an issue
that could not always be solved. The development of pseudoptosis or bottoming out
with time was thought to be an inevitable consequence of gravity acting on skin with
poor elasticity.
The inferior pedicle eventually became the workhorse of the inverted-T approach.
McKissock’s initial description of a vertical bipedicle was revolutionary at the time,
but it was soon realized that either the superior or inferior pedicle alone was suffi-
cient. One pedicle made inset of the nipple easier and thereby avoided some of the
tension on the nipple-areola complex. Strombeck’s horizontal bipedicle had similar
problems. Skoog advocated a lateral or medial pedicle instead.
Many of the pedicles for the inverted-T procedure suffered because they had to be
thinned and converted to a dermal pedicle to allow ease of inset. This approach was
unfortunate because it reduced blood supply, innervation, and breast-feeding po-
tential. Only the inferior and central pedicles were full thickness and stood the test of
time. Some surgeons adopted the central mound technique, despite the skin under-
mining, because it had a good blood supply and was thought to provide better po-
tential for lactation. Gradinger became a champion of either free nipple grafts or a
superior pedicle combined with an inverted-T skin pattern.
On the other hand, Europeans and South Americans obtained good results with var-
ious types of vertical skin closure and circumareolar techniques. The circumareolar
techniques proved difficult to reproduce and tended to flatten the breast, resulting in
widening of the areolar scar and the areola itself. These procedures have been re-
stricted to small reductions and mastopexies.

The vertical reduction mammaplasty techniques were slow to gain popularity in
North America. The superior pedicle (as described by Lassus, Marchac and de Olarte,
Lejour, Berthe, Nahai, and Hidalgo) can be difficult to inset and often requires ag-
gressive thinning. Otherwise, the pedicle could be compressed by the excessive fold-
ing required.
Various other pedicles for the vertical approach have been described in an attempt
to make the procedure easier and more applicable to larger breast reductions. Amer-
ican surgeons were initially intimidated by the odd shape at the end of the proce-
dure and were nervous about leaving an inferior pucker that could take months to
settle.
In U.S. surgical practices, patients with smaller breast reductions tend to be more
critical of their results. Most surgeons continue to use the technique with which they
are comfortable (inferior pedicle with inverted-T closure), especially to avoid po-
tential lawsuits in a country that has become increasingly litigious. However, sur-
geons keep circling back to previously described techniques to combine the best as-
pects of the older methods with newer approaches that incorporate shorter scars.
Indications for and Advantages and Disadvantages
of Various Techniques
Breast reduction techniques are sometimes divided arbitrarily into long- and short-
scar techniques. Often the term Wise pattern is used to describe the inverted-T infe-
rior pedicle technique, but care must be taken to separate the skin resection pattern
from the pedicle design. Wise described only a skin resection pattern. It is not rea-
sonable to compare one skin pattern using one pedicle with another skin pattern us-
ing a different pedicle.
Many surgeons who have now adopted the vertical skin resection pattern approach
have stayed with it because of the improvement in the scarring, breast shape, and
longevity of shape. However, it is not the skin pattern that makes the difference; it
is the nature of the parenchymal resection and the pedicle design that resists gravity.
Some surgeons add a short horizontal scar to remove redundant skin, but this ap-
proach is still different from most procedures that use an inverted-T skin pattern. It
can be confusing, because people are often comparing apples with oranges.
Although the skin and dermis help shape the breast with the inverted-T designs, there
is likely to be more bottoming out or pseudoptosis with time if the weight of the
pedicle and the remaining breast are left inferiorly. Advantages of the so-called ver-
2534
Part XI  Breast Surgery

2535
Chapter 71  Alternative Approaches to Breast Reduction
tical techniques should not be attributed to the skin pattern; rather, they result from
the fact that the breast parenchyma is resected inferiorly and the pedicle weight is
carried superiorly. Skin and dermis are elastic structures that adapt to stress; they
are not particularly good at resisting deforming forces.
To properly evaluate the advantages and disadvantages of the different approaches
to breast reduction, we must separate the approach to the nipple-areola complex
from the skin and parenchymal resection patterns.
Skin Resection Patterns
Historically, one skin resection pattern is often associated with a particular pedicle,
but the two should be considered separately. Most of the skin and parenchymal re-
section patterns can be combined with most of the pedicles. The final scar should re-
flect the pattern of skin resection chosen to deal with the excess skin once the breast
shape has been established. The skin brassiere can no longer be relied on to shape
or support the breast. How much breast tissue is removed, where it is removed from,
and how the remaining tissue is brought together shapes the breast, not the skin.
Inverted-T Skin Resection Pattern
The inverted-T skin resection pattern has become the mainstay of breast reduction
and usually is associated with the inferior pedicle. This approach relies on the skin
brassiere to shape and hold the remaining breast parenchyma. With the advent of
vertical techniques, it has become evident that it is not always necessary to remove
all the skin above the inframammary fold. The inverted-T skin resection is best for
patients with very large breasts or for massive-weight-loss patients who have a large
amount of loose, inelastic skin.

2536
Part XI  Breast Surgery
Because vertical patterns are often associated with superiorly based pedicles and be-
cause the inverted-T usually is associated with an inferior pedicle, the vertical method
may retain its shape longer, because it avoids the deleterious effects of gravity. The
reduced incidence of bottoming out, or pseudoptosis, may be attributed to the na-
ture of the parenchymal resection rather than the skin pattern. Several authors noted
that the weight of the inferior pedicle stretches the skin and causes bottoming out
with time. It is probably a combination of removing breast parenchyma inferiorly
and not relying on the skin to hold the shape that has given the vertical pattern a
better reputation for longevity. The illustration above compares the inverted-T and
vertical skin resection patterns.
Vertical Skin Resection Pattern
The vertical skin resection procedure has taken some time to gain wide acceptance.
It is not for all patients, but it can be applied to a wide variety of breast sizes. Whereas
inverted-T patterns rely on the skin to shape the breast, vertical patterns rely on the
breast to shape the skin.
Initially the vertical skin resection was limited to smaller breast reductions, but now
surgeons are using it for reductions up to 2000 g and above. Some surgeons prefer
to use the vertical approach for the parenchymal resection because it cones the breast
better than the inverted-T. For the larger reductions, they will add a short T or an
L to remove the excess skin, but retain the shape advantages of the vertical approach.
Berthe and colleagues showed that adding a T during the initial surgery did not
change their revision rate. It can be difficult to know exactly where to place the T.
The problem then becomes one of chasing lateral and medial dog-ears again.

Lateral Skin Resection Pattern
Lateral skin and parenchymal resection patterns alone, as described by Dufourmentel
and Mouly, result in medial displacement of the nipple-areola complex. This shape is
unacceptable in larger reductions. When designed separately from the skin, parenchy-
mal resection can achieve an acceptable result. The tissue is resected using various
pedicles, and the skin excision is tapered laterally. Lateral skin resection avoids the
unsightly medial inframammary scar that can occur with the inverted-T resection
but still sometimes results in medial displacement of the breasts and an unattractive
shape.
The B technique (Regnault) was a variation on the lateral resection. It used a superior
pedicle and tapered the skin resection laterally, leaving a B-shaped scar. This method
did not achieve general acceptance, because the design is somewhat complicated.
Circumareolar Skin Resection Pattern
2537
Chapter 71  Alternative Approaches to Breast Reduction
Small breast reductions can be performed through a circumareolar skin excision
where the “donut” is sutured to the “hole” during closure. Benelli has described a
“round block” technique, but it has not achieved wide acceptance. With this tech-
nique the skin must be separated from the gland first so that there is minimal tension
on the skin closure. A permanent suture is still required to prevent scar widening. This
method can be applied to small reductions and mastopexies with minimal ptosis.
Sampaio Goés has used absorbable and permanent mesh to help hold the shape of
the rearranged gland, but this mesh is not available in North America. Surgeons also
have used dermis as a sling or support mechanism, but skin and dermis are well
known for their elastic properties; they both stretch when placed under tension.

Pattern With No Vertical Scar
2538
Part XI  Breast Surgery
For a skin resection pattern that avoids the vertical scar, most surgeons use a form
of broad-based inferior pedicle. This works well for very large breast reductions, but
even with parenchymal rearrangement, the breasts tend to be flattened and lack up-
per pole fullness. Many surgeons believe that the vertical scar is less of a problem
aesthetically than the long scar in the inframammary fold. The vertical incision may
be more visible in frontal view, but it is less prone to develop hypertrophic wide scars
than the inframammary fold incision.
Liposuction-Only
Liposuction alone can be an effective technique, but it relies on skin elasticity and
retraction. The nipple can rise to a higher position if liposuction is performed above
the areola, but this can lead to loss of upper pole fullness. The breasts tend to be flat-
ter and have residual ptosis.
Liposuction has a lower risk of complications. Nipple necrosis is less likely, and sen-
sation and breast-feeding potential are more likely to be preserved. The procedure is
more easily performed in a fatty breast, such as the already ptotic perimeno pausal
breast. This procedure does not work well in the most ideal indication: a teenager
who is of normal body weight. Teens can have thick, fibrous, glandular breasts with
minimal fat. This approach has been advocated for medically compromised patients,
because it is a relatively fast procedure and some consider it less invasive.

Blood Supply to the Nipple-Areola Complex
Pedicles can have many different variations, but they are generally classified as hor-
izontal, vertical, inferior, superior, central, lateral, and medial.
Horizontal Bipedicle
The horizontal bipedicle (Strombeck) combined a laterally based circulation to the
areola with a medially based circulation. A dermal pedicle was usually sufficient but
often caused nipple retraction. The more robust dermoglandular pedicle was also
more difficult to mobilize and inset. This approach fell out of favor because of these
difficulties.
Vertical Bipedicle
The vertical bipedicle (McKissock) offered a significant improvement because it pro-
vided sufficient circulation to the nipple and was not as difficult to inset. It remained
the mainstay of breast-reduction surgery in North America in the 1970s but has since
been abandoned by most surgeons.
Inferior Pedicle
2539
Chapter 71  Alternative Approaches to Breast Reduction
The inferior pedicle was embraced by many surgeons when it was discovered that
the superior portion (which was difficult to inset) of the vertical bipedicle was not
necessary for circulation to the nipple-areola complex and that the inferior pedicle
alone satisfied many of the goals of breast reduction: adequate circulation, good sen-
sation, and breast-feeding potential.

Superior Pedicle
2540
Part XI  Breast Surgery
Although many surgeons embraced the inferior pedicle, the superior pedicle was still
being used, especially in Europe and South America. Some surgeons strongly believed
that the superior pedicle caused less ptosis, because it involved removing the heavy in-
ferior tissue. The superior pedicle alone also had good circulation but was not as
easy to inset. This pedicle often had to be thinned to allow for insetting, causing con-
cerns about the blood supply, sensation, and breast-feeding potential. When the
anatomy is clearly understood, however, the only drawback is in breast-feeding po-
tential, as it would be with any dermal (rather than dermoglandular) pedicle.
Central Pedicle
Some surgeons modified the inferior pedicle and instead removed the dermal com-
ponent and based the nipple-areola complex on a central or posterior pedicle. This
pedicle is based on the same blood supply as the inferior pedicle—the perforating
artery through the pectoralis muscle that enters the breast usually just medial to the
breast meridian a few centimeters above the inframammary fold. The perforating ar-

tery has accompanying venous drainage, which meant that surgeons did not need to
rely as much on the dermal bridge for venous drainage as was needed with other
pedicle designs.
Lateral Pedicle
2541
Chapter 71  Alternative Approaches to Breast Reduction
Just as it became evident that the dual circulation through the vertical bipedicle was
unnecessary, it also became evident that the dual circulation through the horizontal
bipedicle was unnecessary. These bipedicles were not easy to inset without depress-
ing the nipple-areola complex. The lateral pedicle was used, but it was overshadowed
by the successful application of the inferior pedicle.
Medial Pedicle
The medially based pedicle was also discovered to have a good blood supply, but
again, it was relatively ignored. Because surgeons mistakenly thought that the only
innervation to the nipple came superficially through the lateral fourth intercostal
nerve, they believed the medially based pedicle would interfere with sensation.

Liposuction-Only
2542
Part XI  Breast Surgery
Liposuction alone for breast reduction does not require a pedicle for the blood sup-
ply to the nipple. The nature of liposuction is that it leaves major vessels and nerves
intact and thus revolutionized our approach to body contouring surgery in the 1980s
and beyond. Liposuction does not work well when the breast tissue is mainly glan-
dular. Because no skin is removed, the shape is limited by the ability of the skin to
retract.
Free Nipple Grafts
Removing the nipple-areola complex completely and replacing it as a graft has not
gained the popularity it probably deserves. It is a good method, especially in large
breasts where neither sensation nor breast-feeding potential is an issue. Although
free nipple grafts will lose some projection of the nipple and can result in some patchy
depigmentation, the cosmetic result is usually good. The use of free nipple grafts al-
lows unparalleled parenchymal resection. They are a good option in the very large
breast or in a breast where the pedicle to the nipple-areola complex is particularly
long.
5
71-1 Free nipple
graft technique

Patient Profiles
The following patient examples demonstrate a range of problems, with indications for
different breast reduction techniques.
2543
Chapter 71  Alternative Approaches to Breast Reduction
This 49-year-old patient was quite pleased with the results of her liposuction-only
breast reduction. She was 4 feet 11 inches tall, weighed 52 kg (115 pounds), and
wore a 34 D brassiere. Preoperative preparation included marking her for a vertical
reduction in case the liposuction did not succeed. From the right breast 600 cc of
fat was aspirated and from the left breast 575 cc was aspirated. Postoperatively, her
nipple position was elevated by 1.5 cm on each side.

Although it would be ideal to perform liposuction-only breast reduction in young
patients of normal weight, the breast tissue in these young women is often too thick
and fibrous for liposuction. For example, liposuction alone in this 24-year-old pa-
tient would not be applicable. She was 5 feet 2 inches tall, weighed 54 kg (118
pounds), and wore a 34 DD brassiere. A vertical approach was used with 475 g re-
moved on the left and 350 g on the right. The postoperative photos were taken at
6 months, when the scars were still hypertrophic.
2544
Part XI  Breast Surgery

This 37-year-old patient, who requested a liposuction-only breast reduction, was a
better candidate than the previous patient shown, because she was older and slightly
overweight. She was 5 feet 8 inches tall, weighed 77 kg (170 pounds), and wore a
38 DD brassiere. Because she had a relatively high nipple position, she underwent
liposuction alone. Volumes removed were 625 cc from the right side and 675 cc from
the left side. The patient lost upper pole fullness and was not happy with the shape.
She returned at 1 year requesting a mastopexy.
2545
Chapter 71  Alternative Approaches to Breast Reduction
This 22-year-old patient had breast reduction with an inverted-T skin resection pat-
tern with an inferior pedicle for the nipple-areola complex. Unfortunately, because
she was prone to hypertrophic scar formation, this was not the best approach for
her. All the scars were noticeable, but the scar along the inframammary fold was par-
ticularly thick. Perhaps a vertical skin resection pattern would have been more ap-
propriate for her.

This 37-year-old patient might have had too long a pedicle (18 cm [7 inches]) for
the vertical approach with a medial pedicle. An inverted-T inferior pedicle would
have been a good choice, but I decided to use free nipple grafts with a vertical skin
resection pattern. A T was added because the length of the vertical scar exceeded
18 cm. She had 1355 g removed from the right breast and 1325 g from the left breast.
She was 5 feet 5 inches tall, weighed 104 kg (230 pounds), and wore a 42 F/G bras -
siere. A further reduction, especially of the lower pole, would improve the result.
2546
Part XI  Breast Surgery

This 15-year-old patient is also a poor scar-former. She had surgery with the verti-
cal pattern and a medially based pedicle for the nipple-areola complex. She was
pleased with the result of the breast reduction and, fortunately, did not need an in-
framammary scar.
2547
Chapter 71  Alternative Approaches to Breast Reduction
These images show how little fat was present in her breasts. Liposuction alone would
not have been successful.

2548
Part XI  Breast Surgery
Most patients are appropriate candidates for the vertical approach. This 34-year-old
patient had 625 g removed from the right breast and 720 g removed from the left
breast. She was 5 feet 7 inches tall, weighed 84 kg (185 pounds), and wore a 36 F
brassiere.
A vertical approach was successful for this 24-year-old patient. She was 5 feet
4 inches tall, weighed 56 kg (123 pounds), and wore a 34 D brassiere. She had 295 g
removed from the right breast and 315 g from the left breast.

Most surgeons have the impression that the vertical approach does not work well
for large breast reductions, but this patient shows the vertical technique’s versatility.
This 56-year-old woman was 5 feet 2 inches tall, weighed 82 kg (180 pounds), and
wore a 38 H brassiere. From the right breast 1475 g was removed and 1400 g from
the left breast. Photos taken 3 years postoperatively show maintenance of projection
and shape.
Physical Examination and Preoperative Planning
Much of preoperative planning depends on a thorough understanding of breast aes-
thetics and the patient’s goals. Photographs and digital imaging can be helpful to the
patient when determining the desired size and shape.
The breasts are examined for masses or unusual shapes, asymmetries, or problems.
Scoliosis, pectus deformities, and rib prominence need to be assessed. The chest cir-
cumference is measured at a level under the axilla. This measurement is the closest
to bra size. If the chest measures 38 inches, then the patient is told to try a 38 size
bra first. (Patients have often been wearing too tight a bra. Otherwise the breasts fall
under the band or the back rides up too much.) The size along the inframammary
fold is also measured. The inframammary fold is marked while the measuring tape is
held along the fold. Next the distance between the suprasternal notch and the in-
framammary fold in the midline is measured. These measurements are for postop-
erative analysis. We also document that we discussed nipple sensation levels.
2549
Chapter 71  Alternative Approaches to Breast Reduction

2550
Part XI  Breast Surgery
A good way to determine the new nipple position is to use the method described by
Gradinger. He places a measuring tape along the fold under one breast and over the
top of the other breast. He also uses a weighted tape measure around the neck to de-
termine the true breast meridian. It is helpful to put the tape under both breasts and
mark the position at the inframammary fold at the midline.
Inverted-T Technique
It is important to mark the breast preoperatively and determine the new nipple po-
sition. The key landmarks are the breast meridian, the inframammary fold, and the
upper breast border. The surgeon should make the following determinations:
 Position of the inframammary fold (using the tape measure)
 Transposition of the inframammary fold to the front of the breast to deter-
mine the new vertical nipple position while being aware that the upper breast
border will not change postoperatively
 Breast (chest wall) meridian to determine the new horizontal nipple position
 Breast meridian markings using the Wise pattern
 Distance of the vertical limbs
 Design of the areolar opening (either preoperatively or using a triangle if done
intraoperatively)
 Pedicle design (usually superior, inferior, or central)
 Areas to be suctioned
The following measurements are also taken:
 Distance from the suprasternal notch to the nipple on both sides
 Distance from the inframammary fold to the nipple on both sides
 Suprasternal notch to the new nipple position on both sides (should be lower
on a larger breast)
The following photographs demonstrate how the markings are made. These are the
same initial markings as made for the inverted-T inferior pedicle.
Position of the Inframammary Fold: Using the Tape Measure

Determining the New Vertical Nipple Position
2551
Chapter 71  Alternative Approaches to Breast Reduction
The fold level can vary from one patient to another. It can be marked with the tape
measure, as shown above, or with the transposition of the marking anteriorly from
the finger placed under the breast in the inframammary fold (left). Descriptions ex-
ist in which an arbitrary distance is marked from the suprasternal notch, or a point
is marked in reference to the midpoint of the humerus. Unfortunately, these can be
misleading, and reliance on anything but the level of the inframammary fold preop-
eratively can be disastrous. Sometimes the fold is abnormally high or low; in this
case, the upper breast border is a better landmark because it does not change post-
operatively. This patient’s fold was almost at her elbow crease.
Determining the New Horizontal Nipple Position
The vertical breast meridian is marked by dropping a line from the midclavicle
to the midbreast or midchest position. The line does not necessarily go through the
nipple, but should be drawn for an ideal nipple position on the chest wall. If exces-
sive lateral tissue will be removed, the true meridian would fall on the chest midline
rather than the midline of the existing breast.

Breast Meridian Markings Using the Wise Pattern
2552
Part XI  Breast Surgery
This is the Wise pattern and is taken from his article and transferred onto x-ray film.
The areola circumference measured 14 cm. The dotted lines show how the vertical
limbs can be positioned differently, depending on how much skin is to be removed.
The distance of the vertical limbs measured 5 cm.
Distance of the Vertical Limbs
In this patient, a superior pedicle was designed, and the distance of the vertical limbs
was 6 cm. The vertical limbs of the resection are limited to 5 to 6 cm to prevent bot-
toming out of the breast postoperatively. The angle of separation between the verti-
cal limbs depends on the amount of tissue to be resected, while trying to match the
distance of the resulting skin length between the upper flaps and the lower incision
along the inframammary fold.

Design of the Areolar Opening
2553
Chapter 71  Alternative Approaches to Breast Reduction
The design of the areolar opening is determined either preoperatively or by using a
triangle if done intraoperatively. The design in this patient was drawn as an inferior
pedicle (a superior pedicle would be a better choice because of the short distance).
Here the areolar opening has been drawn according to the Wise pattern and as a tri-
angle in which the design will be determined intraoperatively after the resection.
The skin resection follows the Wise pattern with a keyhole opening for the nipple-
areola complex and an excision that gives an anchor-shaped skin closure. Some sur-
geons design the keyhole preoperatively, whereas others prefer to incorporate an are-
olar opening once the resection has been performed. The areola itself is reduced and
the new areola diameter is designed usually between 3.5 cm and 4.5 cm. This means
that the skin opening should measure about 14 cm in circumference to avoid scar
widening.
Pedicle Design
The pedicle design (usually superior, inferior, or central) is separate from the skin
resection pattern. The patient above would be best served with a superior pedicle (as
shown on the left) because the inset would be relatively easy. An inferior pedicle is
also marked for comparison. The areas to be suctioned are the preaxillary fullness
and the lateral chest wall fat.

2554
Part XI  Breast Surgery
This photograph shows placement of the tape measure beneath the breasts and mark-
ing of the inframammary fold position. The level of the inframammary fold can vary
considerably from patient to patient.
Vertical Technique
The surgeon should make the following determinations and then mark the breasts
accordingly:
 Position of the inframammary fold (using a tape measure) while being cogni -
zant of the level of the upper breast border
 Breast (chest wall) meridian to determine a new horizontal nipple position
 Transposition of the inframammary fold to the front of the breast to deter-
mine the new vertical nipple position
 Breast meridian by rotating the breast laterally and medially (as shown by
Lejour)
 Inferior extent of skin resection: 2, 4, and 6 cm above the inframammary fold
 Design of the areolar opening
 Design of the pedicle (usually superior or medial, sometimes inferior)
 Areas to be liposuctioned
These additional measurements are also made:
 The distance from the suprasternal notch to the nipple on both sides
 The distance from the inframammary fold to the nipple on both sides
 The suprasternal notch to the new nipple position on both sides (should be
lower on the larger breast)
 The distance from the suprasternal notch to the inframammary fold in the
midline
 The circumference of the new areolar opening (16 to 20 cm)
 The circumference around the skin resection pattern (divided in half, it should
be the vertical scar length while standing)
The photographs that follow show how the markings are developed (these are the
same initial markings as made for the inverted-T inferior pedicle).
Position of the Inframammary Fold: Using the Tape Measure

Determining the New Horizontal Nipple Position
2555
Chapter 71  Alternative Approaches to Breast Reduction
Note that the meridian marking is independent of the current nipple position. The
marking should be at the chest wall and breast meridian. If there is a significant
amount of lateral breast tissue, select the chest wall meridian rather than the breast
meridian. It is easy to be misled into marking the meridian through the nipple, but the
surgeon should be careful to ignore the actual nipple position and mark where the
nipple should be.
Determining the New Vertical Nipple Position
Transposition of the inframammary fold to the front of the breast will assist the sur-
geon in determining the new vertical position for the nipple. Placing the finger in the
inframammary fold can be used alone, but marking the inframammary fold first with
the tape measure helps considerably. With the finger maneuver, the tendency is to
place the nipple position much higher than the true inframammary fold level. When
the patient has a good deal of upper pole fullness, the surgeon can make the mark
higher—the nipple should be at the most projecting part of the breast. But if the pa-
tient has little upper pole fullness, care must be taken to keep the new nipple posi-
tion low. It is important to be aware that the upper breast border is an important
landmark.

2556
Part XI  Breast Surgery
The new nipple position must be placed about 2 cm lower than what the surgeon is
used to when performing an inverted-T procedure. This lowering is important to ac-
commodate the increased projection that results with this procedure. It is also nec-
essary because closure of a vertical ellipse tends to push the nipple even higher. (It
is for this latter reason that the new nipple position needs to be lowered in the larger
breast to achieve a symmetrical result.) If the patient does not have much upper pole
fullness, this lowered nipple position is essential.
Marking the Breast Meridian by Rotating the Breast
Laterally and Medially
Lejour marked the breast meridian resection pattern by rotating the breast upward
and outward and then upward and inward to join the meridian marked on the up-
per breast to the meridian marked on the chest wall below the inframammary fold.
The design does not remove much skin. The closure should not be under tension. In
fact, the skin can be quite loose at closure because the skin is not being used to hold
the shape. We are so accustomed to using the skin brassiere to hold the shape with
the inverted-T that many surgeons put lateral tension on the vertical closure. Not
only is this unnecessary, but it can lead to wound-healing problems.

Inferior Extent of the Skin Resection
2557
Chapter 71  Alternative Approaches to Breast Reduction
The vertical lines are then joined well above the inframammary fold. In a small re-
duction (less than 300 g) the lower portion of the U should be at least 2 cm above
the inframammary fold. In a larger reduction (300 to 600 g), at least 4 cm of a skin
bridge should remain. For a larger resection 6 cm and more should be left. This ex-
tra skin is important; otherwise the scar will go below the fold as the ellipse is closed.
Some surgeons believe that a V closure is less likely to cause the scar to extend be-
low the fold onto the chest wall, but the U is essential to encourage adequate removal
of the excess subcutaneous tissue that causes a postoperative pucker.
Design of the Areolar Opening
Some surgeons prefer to design the areolar opening at the end of the resection. In
this case the new nipple position was initially marked at the level of the inframam-
mary fold, which was 27 cm from the suprasternal notch. Because the inframam-
mary fold was low, it was decided to elevate the fold during the surgery (above right)
and the new nipple position was elevated to 25 cm from the suprasternal notch. The
vertical incisions were then joined as a triangle for a later areolar opening design.

2558
Part XI  Breast Surgery
For surgeons who prefer to mark the areolar opening before surgery, an opening is de-
signed that will close as a circle. Lejour drew a mosque-shaped design, but I prefer
a design that does not extend horizontally. The important aspect of the areolar open-
ing is that it is a circle when closed. I usually make the areola about 5 cm in diame-
ter. The ideal circumference of the areolar opening would be 16 cm but can be ex-
tended to 18 to 20 cm without significant areolar or scar widening.
The symmetry of the areolar design and skin resection pattern is checked.
Design of the Pedicle
The medial and laterally based pedicles have already been discussed in previous chap-
ters (see Chapters 68 and 69).
With the superior pedicle, the areolar opening becomes
the base. For most moderate-sized breasts this is a
purely glandular pedicle. For larger breasts or for the
nipple-areola that is significantly displaced inferiorly,
a dermal component extending beyond the areolar
opening is necessary. Insetting of these long glandular
dermal pedicles can be challenging as the pedicle has
to be folded in order for the nipple to be inset in the
appropriate position. This is perhaps the major short-
coming of the superior pedicle and has led many to
choose the medial pedicle over the superior for these
patients.

Liposuction-Only
Preoperative planning for liposuction depends only on whether the patient wishes
to undergo a definitive procedure if the liposuction alone does not produce much as-
pirate. The breast is marked preoperatively to indicate the areas of increased fullness
and to determine which areas will need the most concentration.
The patient is usually marked for a vertical approach and then the areas to be suc-
tioned are also marked. If the patient does not have much upper pole fullness, this
area is avoided. On the other hand, if this area is not suctioned, there will be little
upward movement of the nipple-areola complex. Some superficial liposuction above
the areola is needed for upward migration.
2559
Chapter 71  Alternative Approaches to Breast Reduction
This patient had a high nipple position and lots of upper pole fullness. She wanted to
try liposuction-only breast reduction, but she was 18 years old and not overweight at
55 kg (122 pounds). She was 5 feet 2 inches tall and wore a 38 C brassiere. She agreed
to have the vertical approach if liposuction failed. Unfortunately, only a minimal
amount of fat was removed with liposuction-only.
She then underwent a vertical breast reduction with a medial pedicle; 620 g was re-
moved from the right breast and 570 g from the left breast. The photograph on the
left shows how little of the breast tissue was fat.

Operative Technique
Inverted-T Breast Reduction
Inferior Pedicle
2560
Part XI  Breast Surgery
Care must be taken not to undermine the full-thickness pedicle when incising it down
to the chest wall. The pedicle is “floppy,” so care must be taken not to disturb the
perforating artery branch from the internal mammary system through the pectoralis
muscle. This perforating artery is not visualized during the dissection. Although ves-
sels from the dermal bridge inferiorly are not as robust, they still can contribute sig-
nificant arterial inflow and venous drainage to the inferior pedicle. This can be im-
portant when the perforating artery is negligible, especially because there is no way
to determine this preoperatively. The inferior pedicle is therefore probably more re-
liable than a purely central pedicle.
The parenchymal resection follows the skin resection pattern. With the inferior ped -
icle, the flaps are drawn together over the pedicle after resecting breast tissue supe-
riorly, inferiorly laterally, and inferiorly medially. An inferior pedicle has a relatively
broad base of at least 6 to 10 cm and is a full-thickness pedicle. Care must be taken
because it is not difficult to inadvertently undermine the pedicle.
A skin-length discrepancy often occurs horizontally. An attempt is made to bring the
tissue toward the meridian to try to avoid a boxy shape, while trying to flatten the
resultant dog-ears as they are chased medially and laterally. The result is a breast
shape held together by the skin brassiere. The use of drains and antibiotics varies
from surgeon to surgeon.

Central Pedicle
2561
Chapter 71  Alternative Approaches to Breast Reduction
The illustrations below and on p. 2562 are derived
from John Bostwick’s description of the central pedi-
cle. His concept of the arterial blood supply is clearly
outlined, showing how arterial input is preserved with
the central pedicle incisions.
Medial and lateral resections narrow the breast. Central pedicle vascularity is pre-
served by the central and peripheral vessels. Superior and inferior resections permit
lifting the breast and removing ptotic tissue while shifting the breast parenchyma up-
ward. The central pedicle is nourished by musculofascial perforating arteries and by
flow coming from the periphery via the medial and lateral intercostal perforating
and external mammary arteries. The central mound must not be resected to such a
degree that the underlying perforating vessels coursing into it and into the areola are
compromised.

2562
Part XI  Breast Surgery
The central pedicle surmounted by the nipple-areola complex is moved to its new
position, and the incisions are closed in a lateral to medial direction. The excellent
mobility of the pedicle and the nipple-areola make this technique especially good
for large ptotic breasts.
Free Nipple Grafts
Free nipple grafts may be used independently of the skin resection pattern chosen.
Some form of pedicle must be retained as a bed for the graft; this usually involves
leaving some tissue attached to the areolar opening. Since no significant length is in-
volved, maintaining blood supply to this tissue is not an issue. It is usually superi-
orly based with a triangle of tissue removed inferiorly to create a circle.
This resection will permit some narrowing of the breasts during closure. The infe-
rior and lateral resected portions of the breast parenchyma are shown.
Vertical Breast Reduction
This technique is described in Chapters 68 and 69.

Liposuction-Only Breast Reduction
Since no pedicle is needed for the nipple-areola complex and there is no skin un-
dermining, liposuction poses fewer risks to blood supply. Nor does it typically im-
pair sensation and breast-feeding potential.
Some claim that liposuction-only is good for patients with medical problems because
it is less invasive. Liposuction should be treated as a major surgical procedure, how-
ever, and the recovery is not necessarily easier.
The breast is infiltrated with tumescent-type fluid. Liposuction is performed through
one or two small incisions. If the surgeon wants to achieve some skin retraction and
nipple elevation, then some form of superficial liposuction must be performed above
the areola. Care must be taken not to suction too much so as to avoid reducing up-
per pole fullness to any significant degree. Unfortunately, it is difficult to achieve
much reduction in the upper outer quadrant because this tissue tends to be fibrous
rather than fat.
Perimenopausal women have more fat tissue in the breasts than do teenagers. If a
young woman is thin, it is unlikely that much tissue can be removed with liposuc-
tion. It is important to mark her for an open reduction if the liposuction does not
remove much fat. As with other liposuction procedures, it can take about 6 weeks
for the swelling to decrease and about 6 months for the breast to soften and for the
lumpiness to settle.
2563
Chapter 71  Alternative Approaches to Breast Reduction
This patient successfully underwent liposuction-only breast reduction. She had pre-
operative markings for a vertical breast reduction in case liposuction alone was un-
successful. Once the fluid settled, approximately 600 cc of fat was removed from
each breast.

Postoperative Management
Inverted-T Skin Resection
Complications with inverted-T techniques usually consist of minor wound-healing
problems, especially at the T junction. Nipple-areola necrosis can occur, and patients
must realize that all breast reductions involve some reduction of blood supply to the
nipple-areola complex. Patients rarely complain about the scars and shape because
they are so pleased with the reduction in volume. On the other hand, it is difficult
to prevent and treat the boxy shape and dog-ears that are early problems or the
pseudoptosis and bottoming out that occur with time.
Free Nipple Grafts
With any skin resection pattern, free nipple grafts are covered with a bolus tie-over
type of dressing that is left in place for approximately 1 week. Once the dressing is re-
moved, the areola will look dusky, and portions of the nipple may look dark and
desiccated. This is allowed to declare itself; over time the outer surface of the skin
separates. Some depigmentation may occur, especially in dark-skinned individuals.
Depigmentation may take more than 6 months to settle and repigment.
2564
Part XI  Breast Surgery
This 37-year-old patient had a vertical reduction designed, but the pedicle would
have been excessively long (18 cm [7 inches]). It was therefore decided to convert to
free nipple grafts.
In this patient a vertical skin resection (with a T to remove redundant skin) and free
nipple grafts were used. The photograph shows the bolus dressings at the end of the
procedure. Although 1355 g was removed from the right breast and 1325 g from the
left breast, that was probably not enough and more should have been removed.

Six days after surgery, the nipple-areola complex looked a bit frightening. This is ac-
tually typical for free nipple grafts in the initial postoperative period.
Patients need to be informed preoperatively so that they can accept this stage. These
photographs can help to reassure patients in the postoperative period.
2565
Chapter 71  Alternative Approaches to Breast Reduction
This photograph of the same patient 3 weeks later shows a bit of blistering, but good
color and nipple projection.
Four months after surgery the breasts appear underresected, but the free nipple grafts
healed well.

This 27-year-old woman had problems with depigmentation. She had 2025 g re-
moved from the right breast and 1770 g from the left breast. The result was less than
satisfactory. The photographs were taken 7 days, 3 months, and finally 14 months
postoperatively. She is scheduled for a revision.
Vertical Skin Resection
Vertical skin resection has a higher revision rate, possibly because the problems (most
often puckers) can be more easily treated with the vertical approach than the prob-
lems (dog-ears and bottoming out) with the inverted-T techniques.
The vertical approach has a definite learning curve; it is best for surgeons to start
with the opposite breast in a reconstruction patient or with relatively small reduc-
tions. Patients requiring larger reductions may be more accepting of irregularities.
Patients who are well informed preoperatively understand that it may take weeks or
even months for the shape to settle. The inverted-T technique has a learning curve
as well, but practicing these techniques in residency reduces anxiety.
Puckers often can be revised under local anesthesia in the office. It is important to
advise patients that a revision will not be considered until a full year has elapsed.
Large puckers, correction of asymmetry, or further volume reduction may require
general anesthesia.
Nipple necrosis is a serious complication. When it occurs, little can be done. Breast
reduction is a blood supply–reducing operation. Although new nipples can be made
(as in breast reconstruction), they do not look as good as the original.
2566
Part XI  Breast Surgery

Wound-healing problems still occur, especially at the lower end of the vertical inci-
sion, with larger breast reductions, and in the more obese patients. Again, patients
are asked to leave these areas open to heal and to return for removal of any exposed
deep sutures.
As nipple and areola sensation returns, patients may experience hypersensitivity,
along with tingling and discomfort. Sensation may not return completely.
2567
Chapter 71  Alternative Approaches to Breast Reduction
This 24-year-old patient is shown preoperatively, as well as at 10 days and 18 months
postoperatively. She had a vertical approach with a medial pedicle; 295 g were re-
moved from the right breast and 315 g from the left breast. Puckers that are evident
initially usually settle and disappear. Patients are informed before surgery that they
must wait at least 1 year before any kind of revision is considered. Preoperative coun-
seling advises that 95% of patients worry about puckers, swelling, and asymmetry
and that only 5% actually need a revision.
Preoperative
18 months postoperatively
10 days postoperatively

2568
Part XI  Breast Surgery
Liposuction-Only
Liposuction-only breast reduction does not require much in the way of postopera-
tive care. Compression dressings are indicated, but it takes weeks for the swelling to
settle and months for the induration to soften. Too much compression has been shown
to cause skin necrosis.
Outcomes and Complications
Multiple studies have shown that breast reduction is outstanding in terms of out-
comes research (something insurance providers seem to ignore). Back pain, neck pain,
shoulder grooving, rashes under the breasts, and even headaches are significantly re-
lieved. Patients feel much more comfortable, and they can more easily participate in
sports and other physical activities. They sit, stand, and walk with better posture and
have better exercise tolerance.
Many patients comment on how much better they feel immediately after surgery—
the evening of the same day. Patients have the surgery as day procedures, or they may
stay over one night in the hospital. The vertical approach has reduced operating time
in half. It now takes us about 90 minutes to complete a breast reduction, whereas it
used to take about 3 hours for an inverted-T inferior pedicle approach. Both pain
levels and recovery time are also significantly reduced.
Immediate Complications
Immediate complications may include hematoma, seroma, circulation problems, and
infection.
Hematoma
Hematoma had not been a problem until I (E.H.-F.) started using tumescent-type in-
filtration. It is clear that some of the vessels (the perforating artery from the pec-
toralis muscle) were in spasm from the infiltration in at least two of my cases. One
must actively find these vessels and cauterize them.