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

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Part XI  Breast Surgery
know now is that clear venous congestion would probably benefit from surgery. But
this is rare. For the same reason, applying leeches would only treat venous conges-
tion; most of us believe that nipple necrosis develops from lack of arterial inflow.
This inflow restriction is caused by the surgery, and intervention has little to offer.
This patient developed necrosis that healed without intervention. The first postop-
erative photograph shows the patient 4 weeks after surgery. The second postoperative
photograph is at 6 weeks, and the final photograph is at 4 months. Intervention
would probably result in a less satisfactory outcome.
These photos show an example of complete necrosis. The right areola is slightly dusky
at the 1 and 2 o’clock positions, but this is quite common in the immediate postop-
erative period. It is difficult to decide whether to observe or intervene.

The first photograph was taken at 10 days postoperatively, and the final photograph
was taken at 3 months postoperatively. The necrotic tissue was removed in the of-
fice. The patient declined any form of reconstruction.
Flap Necrosis
Flap necrosis occurs more often with the inverted-T techniques, especially at the
T junction itself.
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Chapter 71  Alternative Approaches to Breast Reduction
Postoperatively this patient had an unusual pattern of necrosis accompanied by an
infection in the right breast. Necrosis at the T on the left breast is fairly typical of
the inverted-T techniques (although it is not usually associated with this degree of
redness).

2572
Part XI  Breast Surgery
She healed well after debridement and healing by secondary intention. The final pho-
tographs are shown at 15 years postoperatively.
Infection
Infection can occur with any operation. It remains controversial as to whether to
treat breast surgery patients prophylactically with antibiotics and, if so, for how long.
Late Complications
Late complications are related more to shape. Problems with the inverted-T tech-
niques are related to the inframammary scar and the problem of medial and lateral
dog-ears. The shape can be somewhat boxy and projection compromised.
Scars
This patient was a bad scar-former, but she convinced me to accept Lejour’s chal-
lenge to try to improve scarring in my procedures.
With the vertical approach, the scar may fall below the inframammary fold if the
markings are carried down to the fold initially. The lower end of the vertical skin ex-
cision should end about 2, 4, or 6 cm above the inframammary fold. This is impor-
tant not only because the inframammary fold tends to rise with the vertical approach,
but also because of the ellipse effect: the scar becomes longer in a vertical direction
when the ellipse is closed.

Even 2 cm above the fold was not enough in this patient. Her inframammary fold
was raised more than I expected.
Shape
Until the vertical approach became a routine technique in our practices, we were not
aware that the results with the inverted-T were somewhat unsatisfactory. We had be-
come accustomed to the boxy shape resulting after the inverted-T and had accepted
it as inevitable. Fortunately, the coning of the breast tissue that occurs with the ver-
tical approach has eliminated this problem. The problem of chasing lateral and me-
dial dog-ears has also disappeared because the vector of pull is horizontal.
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Chapter 71  Alternative Approaches to Breast Reduction
Although many patients have satisfactory scars
with the inverted-T approach, it is not uncom -
mon for patients to request correction of the
medial and lateral puckers. However, there is
really no good solution for these dog-ears.
Initially, when using the vertical approach, I (E.H.-F.) had a higher revision rate,
about 5%, for persistent puckers at the inferior end of the vertical scar. Once I real-
ized that the pucker resulted from excess subcutaneous tissue rather than excess skin,
the revision rate decreased.
With the vertical approach the shape is better, with narrowing of the breast base and
more projection, and lasts longer. The result at 1 year is the same as the result at 2,
3, and 10 years. With the inverted-T approach, the shape deteriorates to some de-
gree each year, particularly when a patient became pregnant after surgery.

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Part XI  Breast Surgery
This patient initially had a good result with the inverted-T technique using an infe-
rior pedicle. After having two children, her breast skin stretched and the shape bot-
tomed out (right).
Much depends on skin elasticity and genetics. This patient had one pregnancy and
the shape held.
It is unfair to attribute results to one skin resection pattern versus another, and it is
probably even more unreasonable to compare techniques with different pedicles. The
first patient had an inferior pedicle and the second patient had a medial pedicle. Was
it the patient, the skin resection pattern, or the pedicle weight that made the differ-
ence? Probably a combination of the three influences the result, but the pedicle weight
is a significant factor. With the medial or superior pedicle, the heavy inferior breast
tissue is removed, leaving the desired superior breast tissue. With the inferior ped -
icle, we are leaving what we want to remove and removing what we want to leave.
The skin resection pattern is partly to blame. Skin and dermis are notoriously unre-

liable at holding anything when stress is applied. In fact, both skin and dermis will
adapt and deform with stress. The vertical approaches use the breast to shape the
breast, and the inverted-T approaches use the skin to shape the breast. Shaping works
best when it relies on inelastic tissues to take the stress.
Underresection
Recurrent ptosis is the result of leaving too much inferior breast tissue. Underresec-
tion is a particular problem in vertical breast reductions because it is difficult to
gauge how much breast tissue should be removed. Surgeons who are comfortable
preoperatively evaluating the amount of breast tissue to be excised should make cer-
tain they actually remove that amount and are not fooled into thinking that the
breasts are smaller than they are at the end of surgery.
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Chapter 71  Alternative Approaches to Breast Reduction
This patient did not have enough tissue removed in the lower pole (and her nipples
were placed too high). She was marked for further excision, both by direct excision
and liposuction.
This patient needed removal of lateral breast
tissue and chest wall fat. The problem here
was not one of underresection; rather, it was
the result of not recognizing that the infra-
mammary fold rises—especially laterally—
and that the fat between the old and new in-
framammary fold should be removed.

Asymmetry
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Part XI  Breast Surgery
Asymmetry usually occurs in patients whose breasts are asymmetrical to start with.
This series of images shows how the asymmetry was corrected. The solution did not
rely on skin resection but on adjustment of the parenchyma with removal (both di-
rectly and with liposuction) of the areas of excess.

Puckers
Puckers are more common in the vertical techniques, whereas medial and lateral dog-
ears are more common in the inverted-T skin resection patterns.
It is tempting to try to remove the puckers with a T incision, but a vertical (small)
skin excision is better. The key is to recognize that the problem is caused by excess
subcutaneous tissue rather than excess skin.
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Chapter 71  Alternative Approaches to Breast Reduction
In this patient, puckers were removed through a short transverse or T excision. The
initial result was acceptable. This example shows that a surgeon’s revision rate will
depend on his or her threshold for revision.

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Part XI  Breast Surgery
This patient’s pucker (mostly subcutaneous tissue) was excised through a vertical in-
cision. It is important to mark the inframammary fold first to make sure that the
scar does not go below the fold. With a horizontal excision it can be difficult to know
exactly where to put the transverse scar. The problem also then becomes one of chas-
ing dog-ears horizontally.
This patient had more extensive problems with puckers. Cross-hatching shows the
area of excess subcutaneous tissue. The skin excess is marked vertically. Puckers are
less a problem of excess skin than an excess subcutaneous tissue.
It appears that this patient would require a T closure to correct puckers. In fact, a
small vertical excision, not extending past the marked inframammary fold, with hor-
izontal excision of underlying subcutaneous tissue is the procedure of choice.

Results
Liposuction-Only
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Chapter 71  Alternative Approaches to Breast Reduction
This 45-year-old patient was 5 feet 7 inches tall, weighed 73 kg (160 pounds), and
wore a 38 DD brassiere. She had 1000 cc of fat aspirated from the right breast and
900 cc of fat aspirated from the left breast. She is shown here at 2 months postop-
eratively. The right nipple rose 2.5 cm and the left nipple rose 2 cm. Note the eleva-
tion of both the breast and the nipple in relation to the patient’s elbow crease. The
result will be acceptable to some patients and not acceptable to others; the loss of
upper pole fullness makes the shape appear to be more ptotic, even though there is a
measurable elevation.

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Part XI  Breast Surgery
Inverted-T Techniques
This 26-year-old patient underwent a breast reduction using the inverted-T tech-
nique and an inferior pedicle. She was 5 feet 1 inch tall, weighed 88 kg (193 pounds),
and wore a 42 DD brassiere. She had 910 g removed from the right breast and 1050 g
from the left breast. The patient is shown 2 months after the procedure. The result
is somewhat boxy and the cleavage is narrowed, because the breast cannot be coned
as easily as it can with the vertical approach. The inverted-T techniques tend to re-
sult in a wider breast base than the vertical techniques, because the skin and
parenchyma are closed using a horizontal elliptical excision of skin and breast tis-
sue, whereas the vertical approach uses a vertical elliptical excision of skin and breast
tissue.

This 26-year-old patient had a breast reduction with an inverted-T skin resection
pattern and an inferior pedicle for the nipple. She was 5 feet 8 inches tall, weighed
77 kg (170 pounds), and wore a 38 D brassiere. She had 640 g removed from the
right breast and 525 g from the left breast. Note the wide breast base.
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Chapter 71  Alternative Approaches to Breast Reduction
This 20-year-old patient had an inverted-T skin resection with an inferior pedicle for
the nipple. She was 5 feet 5 inches tall, weighed 73 kg (160 pounds), and wore a 40 DD
brassiere. She had 600 g removed from the right breast and 540 g from the left breast.

This 19-year-old patient underwent an inverted-T skin resection with an inferior
pedicle for the nipple. She was 5 feet 1 inch tall, weighed 59 kg (130 pounds), and
wore a 36 D brassiere. She had 255 g of tissue removed from the right breast and
285 g from the left breast.
She had gained weight in the photographs shown at 3 years after surgery. The final
postoperative photographs show her, with some weight loss, 20 years later. These
images show evidence of recurrent ptosis, or bottoming out that can occur with time.
Note that both the weight gain and weight loss tend to occur mainly in the upper pole.
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Part XI  Breast Surgery
Preoperative
3 years postoperatively
20 years postoperatively

Inverted-T Techniques With Free Nipple Grafts
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Chapter 71  Alternative Approaches to Breast Reduction
These images show a 62-year-old woman 2 years after breast reduction. Because her
history of smoking and desire for a significant reduction could cause problems, a
breast reduction with an inverted-T skin resection and free nipple grafts was done.
She was pleased with her reduced breast size and even regained some nipple sensation.
Case from John Bostwick III, MD

In this patient, 1700 g were removed from each breast. She is shown at 1 month post-
operatively. The nipple-areola grafts healed well, but superficial desquamation of the
areolar skin is still evident. The pigmentation is expected to diminish with time.
2584
Part XI  Breast Surgery
Case from John Bostwick III, MD

Vertical Techniques
2585
Chapter 71  Alternative Approaches to Breast Reduction
This 21-year-old patient was 5 feet 3 inches tall, weighed 91 kg (200 pounds), and
wore a 38 DD brassiere. She had 525 g removed from the right breast and 480 g re-
moved from the left breast. She is shown 1 month and 1 year after surgery. Note that
the breast tissue is narrowed as the breast is coned.
Preoperative
1 month postoperatively
1 year postoperatively

This 49-year-old woman was 5 feet 1 inch tall, weighed 69 kg (153 pounds), and
wore a 38 D brassiere. She had 260 g removed from each breast. She is shown
10 days and 1 year postoperatively.
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Part XI  Breast Surgery
Preoperative
10 days postoperatively
1 year postoperatively

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Chapter 71  Alternative Approaches to Breast Reduction
Preoperative
2 weeks postoperatively
2 years postoperatively
This 56-year-old woman was 5 feet 7 inches tall, weighed 64 kg (140 pounds), and
wore a 36 DD brassiere. She had some asymmetry, and the new nipple position
should have been lowered on the larger side. She had 260 g removed from the right
breast and 225 g from the left breast. The first postoperative views were taken
2 weeks after surgery; the final views were taken 2 years after surgery. Note that the
nipple position is higher on the larger side. Closure of the vertical ellipse tends to
push the nipple higher on the larger breast.

This 64-year-old patient had 700 g removed from her right breast and 800 g from
her left breast using the vertical approach and a medial pedicle. She was 5 feet
6 inches tall, weighed 82 kg (180 pounds), and wore a 40 DD brassiere. She is shown
6 weeks and 31⁄2 years postoperatively.
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Part XI  Breast Surgery
Preoperative
6 weeks postoperatively
31⁄2 years postoperatively

This 51-year-old patient was 5 feet 2 inches tall, weighed 81 kg (178 pounds), and
wore a 38 DD brassiere. She had a vertical breast reduction with a medial pedicle
and had 570 g removed from the right breast and 690 g from the left breast. An ad-
ditional 475 cc of fat was removed from the preaxillary area and lateral chest wall
area. She is shown 2 weeks and 4 years after surgery.
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Chapter 71  Alternative Approaches to Breast Reduction
Preoperative
2 weeks postoperatively
4 years postoperatively

Concluding Thoughts
The best breast reduction is the breast reduction that the surgeon does the best. There
is no “right” way to approach breast reduction, but surgeons must have the ability to
use several different approaches, depending on the circumstances (see the table be-
low). It is important to understand that the pedicle, the skin resection pattern, and the
parenchymal resection pattern can be used in various combinations. Many of us who
perform vertical approaches like the fact that we remove the heavier inferior breast
tissue, reshape the parenchyma, and then allow the skin to redrape. We believe that
this not only results in fewer scars, but also provides a better shape with good pro-
jection. We have also found that this shape tends to last longer than procedures that
rely on the skin as a brassiere or support.
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Part XI  Breast Surgery
Skin Excision Pattern and Final Scar
Choosing the Best Option*
Traditional
Short
Longer
Full-Length
Liposuction-
Horizontal
Horizontal
Horizontal
Breast Characteristic
Only
Periareolar
Vertical
T, J, or L
L
T
Size of Reduction
500 g




500-1000 g




1000 g





Skin Elasticity
Normal






Inelastic




Skin Excess
Minimal






Moderate




Massive


Parenchyma
Firm and fibrous





Soft and fatty





Skin-Parenchyma
Relationship
Firmly adherent






Loosely adherent



*General recommendations for choosing skin excision patterns in breast reduction are based on the characteristics of the breast. Taking into account
the size of the reduction, skin elasticity, skin excess, quality of the parenchyma, and the skin-parenchyma relationship, the appropriate skin excision
patterns are indicated. A given skin excision pattern can usually accommodate a number of parenchymal resection techniques.

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Chapter 71  Alternative Approaches to Breast Reduction
Clinical Caveats
 The procedure must be adapted to the needs and desires of the patient, but within
the experience and expertise of the surgeon. No one procedure fits all patients, but
many surgeons now think that the vertical approach (with whichever pedicle is
most comfortable for the surgeon) has wide applicability.
 The shape of the breast is determined by the resection, specifically which parts of
the breast are resected, and how the rest of the breast is reshaped. The skin plays
little role in shaping or maintaining breast shape.
 The longevity of the result depends not only on the technique but perhaps even
more on the patient’s tissues; specifically, the quality and elasticity of the skin.
 Liposuction is best for those patients for whom breast shape and projection is not
a priority. The appeal of this technique is that it is less likely to cause problems
with scarring, circulation, sensation, or breast-feeding.
 Liposuction alone has limited usefulness in those patients for whom it would be
the most desirable: teenagers. In teens who are close to ideal body weight, it is un-
likely that much of the breast is composed of fat. Perimenopausal women have the
highest volume of breast fat, especially if they are overweight. These patients of-
ten have more ptosis, and shape can be an issue.
 The inverted-T skin resection pattern may still be the best choice for patients with
large breasts or in massive-weight-loss patients who have a considerable amount
of excess skin.
 Inverted-T techniques use the skin to shape the breast. It takes a different mind-
set to change from exact measurements and short vertical limbs in the inverted-T
procedures to looser skin and long vertical limbs which are needed to accommo-
date projection in the vertical procedures.
 It is critical in both inverted-T and vertical approaches to properly mark the new
nipple position. A nipple that is too high is difficult or impossible to correct. Ar-
bitrary measurements from the suprasternal notch should be avoided. The nipple
should be designed at the level of the inframammary fold and in relation to the
upper breast border. With the vertical approach, this position should be somewhat
lower to accommodate the increased projection.
 The inframammary fold can rise with some of the vertical techniques and tends
to drop beneath the horizontal scar with the inverted-T technique.
 Each method of breast reduction has advantages and disadvantages. The surgeon
should evaluate each patient’s desires in light of her physical presentation. No one
technique satisfies all. Each surgeon should be comfortable with several techniques,
even if he or she prefers one technique for most patients.

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 state im-
proves the shape and projection of the breast and leaves no horizontal scars. Lassus and
Lejour described superiorly based nipple flaps; Asplund and Davies describe a medially
based flap or glandular transposition of the nipple in small reductions. After a short
learning curve, the complications have been few and minor.
Courtiss EH. Reduction mammaplasty by suction alone. Plast Reconstr Surg 92:1276-1284,
1993.
This was the first in a series of articles documenting the use of liposuction alone for
breast reduction.
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.
The Courtiss articles led to the acceptance in North America and beyond of the inferior
pedicle inverted-T breast reduction as the procedure of choice for the majority of pa-
tients.
Daane SP, Rockwell B. Breast reduction techniques and outcomes: a meta-analysis. Aesthet
Surg J 19:293-302, 1999.
This and the preceding three articles present outcomes research that document signifi-
cant improvement in patients undergoing reduction mammaplasty surgery.
Goldwyn RM. Reduction Mammaplasty. Boston: Little Brown, 1990.
This classic textbook, edited by one of the most respected plastic surgeons, offers an ex-
cellent historical review of the various approaches to breast-reduction surgery. Practic-
ing plastic surgeons can learn a great deal by reading and rereading what has been writ-
ten here.
Gradinger GP. Reduction mammaplasty utilizing nipple-areola transplantation. Plast Re-
constr Surg Clin Plast Surg 15:641-654, 1988.
Gradinger reviews free nipple grafts using an inverted-T skin resection pattern. This
technique has fallen out of favor, but probably should be considered more often.
Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr Surg 97:373-380,
1996.
The author discusses the evolution of his vertical mammaplasty breast reduction tech-
nique. In a 30-year period there were few complications, indicating that it is a safe pro-
cedure producing long-lasting results.
Lejour M. Vertical Mammaplasty and Liposuction of the Breast. St Louis: Quality Medical
Publishing, 1993.
The many publications of Lassus and Lejour increased acceptance of the vertical skin
resection pattern.
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Part XI  Breast Surgery

Nahai FR, Nahai F. MOC-PSSM CME article: breast reduction. Plast Reconstr Surg 121
(1 Suppl):S1-S13, 2008.
The goal of this continuing medical education module was to present the preoperative as-
sessment, formation of a surgical treatment plan and its execution, postoperative pa-
tient management, and identification and treatment of early and late postoperative com-
plications in breast reduction surgery.
Pitanguy I. Surgical correction of breast hypertrophy. Br J Plast Surg 20:78-85, 1967.
Pitanguy detailed the different pedicles used for breast reduction using the inverted-T
skin resection pattern.
Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior pedicle.
Plast Reconstr Surg 59:64-67, 1977.
This article first described the inferior pedicle with an inverted-T skin resection pattern
and led to an almost uniform acceptance of the procedure as the standard of care in
breast-reduction surgery.
Sampaio Góes JC. Periareolar mammaplasty double skin technique. Breast Dis 4:111-127,
1991.
Many articles in this list are important landmarks in the attempt to reduce scars and
limit them to the periareolar location only.
Spear SL, Howard MA. Evolution of the vertical reduction mammaplasty. Plast Reconstr
Surg 112:855-868, 2003.
The authors present a good review of the main variations of the vertical skin resection
pattern. This article highlights the differences between the techniques of Lassus, Lejour,
Hammond, and Hall-Findlay and then details Spear’s preferred approach.
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Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthetic Plast Surg
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Biesenberger H. Eine neue methode der mammaplastik. Zentralbl Chir 55:2382, 1928.
Casas LA, Byun MY, Depoli PA, Gradinger GP. Maximizing breast projection after free-
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Chiari AJ. The L short scar mammaplasty: a new approach. Plast Reconstr Surg 90:233-246,
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Corduff N, Taylor GI. Subglandular breast reduction: the evolution of a minimal scar ap-
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Chapter 71  Alternative Approaches to Breast Reduction

Cruz NI, Korchin L. Lactational performance after breast reduction with different pedicles.
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Davison SP, Mesbahi AN, Ducic I, Sarcia M, Dayan J, Spear SL. The versatility of the su-
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Dufourmentel C, Mouly R. Plastie mammaire par la methode oblique. Ann Chir Plast 6:45-
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Georgiade NG, Serafin D, Morris R, et al. Reduction mammaplasty utilizing an inferior ped -
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Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts & Techniques. St Louis: Quality Med-
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Part XI  Breast Surgery

Hidalgo DA. Improving safety and aesthetic results in inverted T scar breast reduction. Plast
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Chapter 71  Alternative Approaches to Breast Reduction

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Skoog T. A technique of breast reduction—transposition of the nipple on a cutaneous vas-
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Sterodimas A, Pineda EF, Meirelles V, Pitanguy I. Maximizing nipple graft survival after per-
forming free nipple-areola complex reduction mammaplasty. J Plast Reconstr Aesthet
Surg 61:971-972, 2008.
Stevens WG, Gear AJ, Stoker DA, et al. Outpatient reduction mammaplasty: an eleven-year
experience. Aesthet Surg J 28:171-179, 2008.
Strombeck JO. Mammaplasty: report of a new technique based on the two-pedicle proce-
dure. Br J Plast Surg 13:79-90, 1960.
Van der Lei B. Pedicle modification in the Lejour vertical scar reduction mammaplasty. Plast
Reconstr Surg 99:2118-2120, 1997.
Wiener DL, Aiache AE, Silver L, et al. A single dermal pedicle for nipple transposition in
subcutaneous mastectomy, reduction mammaplasty or mastopexy. Plast Reconstr Surg
51:115, 1973.
Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr
Surg 17:367-375, 1956.
Zoumaras J, Lawrence J. Inverted-T versus vertical scar breast reduction: one surgeon’s
5-year experience with consecutive patients. Aesthet Surg J 28:521-526; discussion 526-
527, 2008.
2596
Part XI  Breast Surgery

Mastopexy and Breast Reduction
in Massive-Weight-Loss Patients

J. PETER RUBIN, JONATHAN TOY
CHAPTER 72

2598
Part XI  Breast Surgery
T
he rate of obesity continues to rise in the United States at an alarming rate,
with more than 35% of the population considered obese. To lower their risk
of obesity-related medical conditions, many people have sought to lose weight ei-
ther through bariatric surgical procedures or lifestyle modification—diet and exercise.
After massive weight loss, defined as the loss of more than 23 kg (50 pounds), the
individual is often left with redundant skin and excess subcutaneous tissue. For this
reason, an increasing number of patients are seeking plastic surgery consultation for
correction of these deformities.
After the abdomen, the next body area with which many women are most concerned
is their breasts and their appearance after massive weight loss. Many of these women
had full breasts before their weight loss and have severe deformities after reaching
their goal weight. Extensive and asymmetrical volume deflation, descent and medi-
alization of the nipple-areola complex, distortion of shape, including breast flatten-
ing, coupled with an excess of inelastic skin relative to the breast parenchyma makes
the breast deformities difficult to treat. During the evolution of breast reduction and
mastopexy procedures after massive weight loss, plastic surgeons have focused on
key aesthetic goals: repositioning of the nipple-areola complex, minimization of scar
and proper scar placement, achieving adequate projection and medial fullness of the
breast, and long-term stability of the results.
The technique of dermal suspension, parenchymal reshaping, and selective autolo-
gous tissue volume augmentation (autoaugmentation) in massive-weight-loss pa-
tients was developed with the principles of prior breast reshaping procedures in
mind. Earlier techniques in breast reduction and mastopexy relied on dermal sup-
port to maintain shape and were dependent on skin resection patterns. Bottoming
out of parenchyma with recurrent breast ptosis were negative features of the tech-
niques relying on these principles. The introduction of the vertical mammaplasty by
Lassus and expanded on by Lejour heralded more long-lasting and reliable meth-
ods of parenchymal reshaping, with less reliance on the dermal envelope for shape.
Others developed methods of dermal suspension to elevate breast tissues as well as
techniques to increase upper pole fullness with sutures to affix the parenchyma to
surrounding structures. Graf and Biggs devised a dermoglandular pedicle that is
passed under a partial-thickness loop of pectoralis muscle and fixed to the pectoralis
fascia under the breast. Closure of medial and lateral pillars behind the flap helps
to secure elevation.

2599
Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
The approach to the breasts of massive-weight-loss patients differs from techniques
used for non–weight loss patients. Short-scar techniques in general have a limited
role because of the need for more extensive skin resection. In our technique of der-
mal suspension, parenchymal reshaping, and selective autoaugmentation, the vas-
cularity of the nipple-areola complex is ensured with a central dermoglandular ped -
icle. A modification of the traditional Wise pattern allows control of the skin envelope
and nipple position.
In this chapter we highlight the anatomic changes observed in the breast after weight
loss and present details of a versatile technique to achieve an aesthetically pleasing
result.
Goals of Breast-Reshaping Surgery
 To use all available breast tissue while maintaining the ability to recruit additional
autologous tissue
 To address nipple position
 To restore superior pole projection
 To reshape the skin envelope without relying on it for support
 To eliminate the lateral skin roll
 To create a discrete “lateral sweep” or defined lateral curvature to the breast shape
Advantages and Disadvantages of Mastopexy and Breast Reduction
in Massive-Weight-Loss Patients
Advantages
 A lateral axillary roll deformity can be eliminated.
 Autoaugmentation of the breast may be achieved with the use of tissue in the lateral
axillary roll.
 The skin envelope can be easily controlled.
 Parenchymal reshaping is facilitated.
 Long-lasting elevation of the parenchyma is achieved.
Disadvantages
 Scars are long.
 Operative time is increased because of the large areas to be deepithelialized.
 A high degree of intraoperative tailoring is required.

2600
Part XI  Breast Surgery
Indications and Contraindications
Indications for dermal suspension and parenchymal reshaping with selective au-
toaugmentation include severe ptosis with deflated breast shape and adequate
parenchymal volume to build a breast mound. Although not required to perform
this procedure, a lateral skin roll allows recruitment of chest wall tissue into the
breast mound.
There are relatively few contraindications to the procedures mentioned. Patients
who are current users of tobacco products are instructed to stop for 1 month before
and after surgery. We routinely screen patients with a positive history of tobacco use
with a cotinine urine test before surgery. Patients who have had previous breast sur-
gery must be carefully evaluated to ensure that their old scars will not compromise
any planned procedure. Patients with active intertrigo or diffuse fibrocystic disease
may also not be ideal candidates. Also, inadequate parenchymal volume to build a
breast mound is a relative contraindication, although lateral roll volume needs to
be considered and may add sufficient volume. Finally, patients with a BMI higher
than 35 may not be ideal candidates.
Patient Profiles
Good candidates for dermal suspension and parenchymal reshaping with selective
autoaugmentation include those with parenchymal deficiency relative to skin with
breast deflation and lateral skin roll. Poor candidates include those with no lateral
skin roll, a short nipple-to-inframammary fold distance, and minimal breast ptosis.
This 40-year-old massive-weight-loss patient had lost 61 kg (135 pounds) before
breast surgery and presented with a BMI of 33.8. She was a good candidate for the
dermal suspension/parenchymal reshaping technique. These images demonstrate ex-
tensive breast ptosis and parenchymal deflation with a significant increase in the dis-
tance from the nipple to the inframammary fold; she had a sizable lateral skin roll.
(Results are discussed on p. 2614.)

This 44-year-old massive-weight-loss patient was not an ideal candidate for the der-
mal suspension/parenchymal reshaping technique. Although she had lost more than
45 kg (100 pounds) after gastric bypass surgery (a BMI change from 41.8 to 25.4),
her breasts were not extensively deflated and she had moderate ptosis. There was
only modest parenchymal volume and minimal lateral skin roll for autoaugmentation.
Postoperative images 3 months after a combined mastopexy-augmentation with
saline implants and Wise pattern skin resection demonstrate excellent nipple repo-
sitioning and improvement in breast shape and projection. The use of the Wise pat-
tern skin resection was necessary to adequately control the breast envelope and deal
with the skin excess.
2601
Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients

2602
Part XI  Breast Surgery
Pertinent Anatomy
Women who have undergone massive weight loss have characteristic breast defor-
mities that distinguish them from other women seeking correction of volume loss
and breast ptosis. The Pittsburgh Rating Scale describes the spectrum of deformities
seen after massive weight loss, with most patients exhibiting the more severe grades.
This scale was designed to classify postbariatric deformities, in recognition that the
standard ptosis grading scale was not descriptive enough to characterize the unique
changes in breast shape that occur in this population. The least severe deformities
involve grade I or II ptosis or macromastia. The midrange deformities (Pittsburgh
Scale severity of 2 out of 3) demonstrate grade III ptosis and can still be treated with
traditional breast-reshaping techniques. The most severe deformities (Pittsburgh
Scale severity of 3 out of 3) have one or both of the findings unique to the massive-
weight-loss patient: severe volume depletion with a flattened breast shape and/or a
prominent lateral roll of skin and fat that merges the breast mound with the upper
back tissues. Additionally, in any patient who has undergone massive weight loss,
the nipples may be medialized. Failure to recognize this finding and move the nip-
ples laterally along a true breast meridian is a pitfall of breast reshaping in massive-
weight-loss patients.
Grading Scale for Severity of Breast Deformities After Weight Loss
Severity
Grade
Deformities Noted
Recommended Treatment
0
Normal
Normal
1
Ptosis grade I or II or severe
Traditional mastopexy (with preference for vertical
macromastia
technique), standard breast reduction techniques,
or implant augmentation  elevation of nipple
through limited mastopexy scars
2
Ptosis grade III, moderate
Traditional mastopexy (often requiring Wise pattern)
volume loss, or constricted
Consider implant augmentation to accompany
breast
mastopexy
3
Severe lateral roll and/or
Parenchymal reshaping techniques with dermal
severe volume loss with
suspension
loose skin
Consider autoaugmentation
Avoid implant augmentation if existing volume will
create a reasonable result

The changes in breast shape after weight loss, in the most severe form, are charac-
terized by two findings that pose significant technical challenges. The first finding is
volume loss with a stretched skin envelope and flattening of the breast against the
chest wall.
2603
Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
The second finding is a roll of skin and fat on the lateral border of the breast ex-
tending onto the chest wall. This roll of skin and fat obscures the lateral curve of
the breast, an important aesthetic unit. The technique of dermal suspension and se-
lective autoaugmentation described in this chapter can correct these deformities and
restore breast shape by using available parenchyma to build projection and recruit-
ing the lateral chest wall tissue into the breast mound. In any massive-weight-loss
patient, the surgeon must also be aware that the nipple position may be abnormally
medial and should be repositioned along a true breast meridian.

2604
Part XI  Breast Surgery
Preoperative Assessment
In evaluating any massive-weight-loss patient, the surgeon should take a detailed
history, including the type of weight-loss surgery, time since the surgery, and the pa-
tient’s starting and current BMIs. The patient should be as close to goal weight as
possible and at a stable weight, no more than a 2 kg (5-pound) change per month, for
3 months. This weight stabilization often occurs 12 to 18 months after gastric by-
pass. For a patient with a BMI over 35, the surgeon should consider referring the
patient back to the weight-loss specialists to optimize her diet and exercise programs
and optimize the BMI.
Physical examination of the breast should include a careful search for masses.
Parenchymal volume should be assessed, along with the presence and size of a lat-
eral roll of skin and fat. The surgeon should determine whether the native breast
parenchyma and lateral roll together would provide adequate volume for a breast
reshaping procedure. Prior scars should be noted and considered in terms of their
impact on blood supply in the selected procedure. Mammography is performed in
accordance with the American Cancer Society guidelines.
Preoperative Planning
Choice of Technique
Many procedures have been described for correction of the breast deformities seen
in massive-weight-loss patients. The severity of each of the above-mentioned defor-
mities, the preferred breast size of the patient, and the surgeon’s experience will all
influence the type of procedure offered. Each patient is unique and the chosen pro-
cedure must not only address each aspect of the breast deformity, but it must be able
to deliver the size and shape that the patient desires.
Excessive Breast Volume (Pittsburgh Grade 1)
Some patients, despite massive weight loss, maintain significant breast volume de-
spite varying degrees of ptosis. Patients who desire to be smaller than their current
size will require a breast reduction. Although short-scar techniques have increased
in popularity, the skin redundancy and poor skin elasticity will result in a large infe-
rior dog-ear that will require horizontal excision. The pitfall of the short-scar tech-
nique in these patients would be to chase the dog-ear inferiorly. This would leave an
unsightly scar below the inframammary fold. A predictable shape and size can be

achieved using a Wise pattern skin excision. This excision will often need to be car-
ried out laterally onto the breast to excise redundancy in this area. A medial or infe-
rior pedicle can be used depending on the nipple to fold distance and the experience
of the surgeon. Due to the medial positioning of the nipple in many patients who
have undergone massive weight loss, it may be difficult to get adequate nipple rota-
tion if a medial pedicle is chosen. This must be given consideration in the preopera-
tive planning. Liposuction of the lateral fold can also be a useful adjunctive procedure
to assist in contouring the lateral fold of the breast.
Inadequate Breast Volume (Pittsburgh Grades 1 or 2)
Patients who have experienced significant breast involution as a result of massive
weight loss will require breast implants if larger breasts are desired and a prominent
lateral chest roll is not available to recruit into the breast mound (see next section).
This autologous augmentation is almost always a better choice than implant aug-
mentation. Young patients who have good skin tone can be considered for an iso-
lated breast augmentation. In patients where there is excessive skin redundancy or
an enlarged nipple-areola complex, a concomitant mastopexy may be necessary. In
complicated cases where there is significant asymmetry or a loose inframammary
fold, a staged mastopexy-augmentation may be necessary to achieve the best aes-
thetic outcome.
Adequate Breast Volume and Severe Changes
(Pittsburgh Grade 3)
The majority of patients who have undergone massive weight loss present with sig-
nificant breast ptosis and skin redundancy but maintain adequate breast volume.
Even if the native parenchyma appears to have reduced volume, the lateral skin and
fat roll adjacent to the breast mound, when added to the existing parenchyma, can
create adequate size. During the consultation these patients often state that they
want a breast reduction because of the significant skin redundancy and ptosis, when
in reality they require a mastopexy. The parenchymal volume is often sufficient to
achieve a good size and shape, but there is rarely much to spare. During the physical
examination, the surgeon must determine whether there is adequate breast volume
and whether there is a lateral skin roll with sufficient volume. For patients with suf-
ficient parenchymal volume, severe ptosis, and a lateral skin fold, we recommend
dermal suspension of the breast tissue to the chest wall with parenchymal reshap-
ing and autoaugmentation from the lateral skin roll. In difficult cases, where there
is significant asymmetry, the smaller breast can be augmented using autologous tis-
sue to match the larger breast. If the autoaugmentation is not sufficient, the larger
breast may need to be reduced to match the smaller breast.
2605
Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients

2606
Part XI  Breast Surgery
The surgical plan is as follows:
 Mark with a Wise pattern, encompassing the lateral roll of tissue.
 Deepithelialize the entire Wise pattern area.
 Deglove the breast parenchyma.
 Elevate the medial and lateral parenchymal flaps.
 Suspend the dermal edge of flaps to rib periosteum.
 Plicate the dermis to shape the breast.
 Place sutures along the lateral edge of the breast to define its curvature.
 Redrape the skin.
 Release any dermis that is tethering the nipple.
 Close the skin.
Markings
The incision design is based on an extended Wise pattern that preserves both the in-
ferior and central pedicle. The midline, inframammary fold, and sternal notch are
marked as in traditional mastopexy. A point 4 to 5 cm from the sternal notch is
marked along the clavicle, and a new breast meridian in marked in the position at
which the nipple will be placed. This line often lies lateral to the current nipple po-
sition as a result of the medialized position of the nipple in a massive-weight-loss
patient. The new nipple position is gauged in relation to the inframammary fold and
raised 2 cm along the new breast meridian. A keyhole pattern is then drawn, with
vertical limbs of 5 cm. The lateral extent of the Wise pattern extends onto the lat-
eral skin roll and is used for breast autoaugmentation. The robust lateral thoracic
Lateral Wise extensions depend
on amount of skin roll and/or
size of lateral flap desired
Extent of deepithelialization depends on
size of lateral flap used for volume
augmentation and need not
include entire Wise pattern
4-5 cm
Deepithelialized areas

perforators allow mobilization of a significant amount of tissue to the breast. Al-
though other authors have advocated the use of tissue that extends onto the back,
we often discard the tissue beyond the posterior axillary line because of concerns
about vascularity and potential fat necrosis.
Operative Technique
2607
Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
A 42 mm cookie-cutter is used to mark the circumference of the new nipple-areola
complex. The entire dermis lying within the Wise pattern is deepithelialized. A pedi-
cle base of approximately 10 cm is then marked. The medial and lateral extents of
this pedicle are determined by the desired pivot points for the arc of rotation of the
medial and lateral flaps. The dermis is scored in all areas except the pedicle base.
Flaps 1 to 1.5 cm thick are then raised and the breast is completely degloved down
to the pectoralis major fascia. During this dissection, the flaps are constantly moni-
tored to ensure uniform thickness. Dissection continues along the fascia to the level
of the clavicles.
Care must be exercised not to release the attachments medially over the sternum, or
synmastia may result. Medially, it is important to preserve perforators, including the
perforator from the second intercostal artery. The lateral and medial flaps are then el-
evated down to the chest wall and mobilized. These flaps remain attached to the pre-
viously delineated 10 cm central pedicle, which is not undermined. Dissection of
these flaps is limited to the minimal amount of tissue necessary to rotate the flaps to
preserve the blood supply. These flaps are normally discarded in a traditional infe-
rior pedicle breast reduction.
1-1.5 cm thick flap
Undermined area
Central dermal extension
Pectoralis major fascia
Medial dermal flap
elevated and mobilized
Lateral dermal flap
elevated and mobilized
5
72-1 Dermal
suspension
mastopexy

Once the breast parenchyma is degloved and the medial
and lateral flaps are elevated, dermal suspension is per-
formed in a specific sequence, with the patient in a sitting
position. The central dermal extension is suspended to the
periosteum of the second rib along the new breast merid-
ian with two permanent 0 braided sutures to ensure sta-
bility. This is performed by placing the fingers of the non-
dominant hand in the intercostal spaces, ensuring safe
fixation to the rib periosteum. If the inframammary fold
is low or the central dermal extension is short, the central
pedicle may need to be suspended to the third rib. The
suspension should bring the pedicle and the nipple-areola
complex to the desired nipple position. The final decision
as to which rib to fixate the parenchyma to is made while
the patient is on the operating table.
2608
Part XI  Breast Surgery
Second rib
Central dermal extension
suspended to rib periosteum
2
Central dermal extension
suspended to rib periosteum
Lateral flap fixated to rib periosteum
and plication initiated
Fourth rib
Medial flap fixated
to rib periosteum
Dashed lines indicate
areas to be plicated
3
The lateral breast flap is mobilized and rotated superiorly and medially to shape the
lateral border of the breast parenchyma. This flap is commonly fixated to the rib
peri osteum of the third rib just inferior to where the central pedicle was suspended
with two permanent sutures. The size and length of the lateral flap can be reduced
to selectively adjust the amount of autoaugmentation to achieve the desired size.
The medial flap is then rotated superiorly and laterally to the level of the fourth rib
periosteum and fixated in a similar manner. This flap is suspended medial to the new
breast meridian to restore superomedial fullness to the breast. It is helpful to redrape
the breast skin flaps after each fixation step to confirm that the correct level of der-
mal suspension has been achieved.

Once the dermal flaps have been suspended to the desired position, the breast paren -
chyma is shaped using 2-0 braided absorbable sutures. The lateral dermal flap is pli-
cated to the central dermal pedicle first with interrupted sutures, followed by a run-
ning overlay suture. This is repeated for the medial flap. In some patients, suturing the
dermis of the medial flap to the central pedicle dermis will distort the medial con-
tour. In these cases, the breast parenchyma of the medial flap is sutured to the paren -
chyma of the central pedicle. Once the desired shape of the lateral and medial breast
parenchyma has been achieved, the inferior plication is performed to increase nipple
projection. The distance from the inframammary fold to the nipple-areola complex
is measured and an inferior plication is performed to set this distance at 5 cm.
Dermal suspension and parenchymal reshaping are both performed with the patient
in the sitting position. To minimize asymmetry, each of the previously outlined steps
is performed sequentially on both breasts. The patterns of plication cannot be pre-
dicted preoperatively; adjustments must be made intraoperatively to achieve the de-
sired shape. Additional rows of plication may be required. The surgeon should be
satisfied with the shape of the parenchyma while the patient is on the operating table
and should not leave the operating room if he or she is not happy with the dermal
plication and the breast shape and projection after skin flaps are redraped. If the
shape is not optimal, removal of previous plication sutures or further plication is
necessary.
2609
Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
Central dermal extension
suspended to rib periosteum
Lateral flap plicated
Medial flap plicated
5 cm

To further define the lateral sweep of the breast, the dermis of the lateral flap is se-
cured to the serratus fascia. In addition to defining the lateral border of the breast,
these sutures help increase nipple projection and minimize the risk of lateral herni-
ation of the breast parenchyma. The lateral flap is not fixated to the rib periosteum
to avoid potential injury to the long thoracic nerve and the thoracodorsal vessels
and nerve.
The breast flaps are redraped, and the final breast shape and projection are assessed.
Closure begins with a half-buried 2-0 polypropylene suture that secures both breast
flaps in an inverted-T fashion to the inframammary fold. This is tied over an iodine-
impregnated petrolatum gauze bolster to protect the skin and is left in place for
1 week. The remainder of the skin is temporarily reapproximated with staples. The
vertical limb is closed in two layers with absorbable sutures, and the horizontal in-
cision is closed with a running deep dermal suture. One drain is draped around the
pedicle before closure and is brought out laterally through the incision.
2610
Part XI  Breast Surgery
Central dermal extension
suspended to rib periosteum
Lateral flap plicated
Medial flap plicated
5 cm
Dermis of lateral flap
sutured to serratus fascia

The nipple-areola complex is occasionally tethered by the dermis and requires re-
lease to bring the nipple to the proper position. If this is not performed, the nipple
may have a retracted appearance postoperatively. Because of the robust blood sup-
ply from the pedicle, the dermis around the areola may be safely scored halfway
around its circumference. The nipple-areola complex is secured to the skin flaps with
an absorbable suture in one layer. Cyanoacrylate glue is used along all suture lines
to seal the incisions.
Postoperative Care
Gauze fluffs are placed over all incisions, and the chest is wrapped with an elastic
(Ace) wrap until the first postoperative visit. The drains are removed when the out-
put is less than 30 ml per day. The bolster stitch is also removed during this visit.
Patients are instructed to wear a sports bra for 6 weeks to allow complete healing
of all incision lines. We recommend the use of a sports bra that has a zipper in the
front for patient comfort. The patient is instructed to minimize strenuous activity
and not to lift anything greater than 4.5 kg (10 pounds) for the first 3 weeks, after
which activity can slowly increase. Patients can begin wearing an underwire bra at
6 weeks postoperatively.
2611
Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
Dermis scored
around areola

This procedure can be performed on an outpatient basis if no other procedure is
performed at that time. If it is combined with other body-contouring procedures,
we often keep the patient overnight in the hospital.
Combined Procedures
Patients who present for body contouring after massive weight loss often have mul-
tiple anatomic areas that they want corrected. The technique of mastopexy with der-
mal suspension and autoaugmentation can be combined with other body-contouring
procedures in selected patients. Many patients request combined mastopexy with
abdominal recontouring. For these women, the abdominal recontouring procedure
should be performed first. Because the abdominal recontouring procedure will lower
the inframammary fold, intraoperative adjustments may need to be made to the in-
ferior line of deepithelialization before the mastopexy is performed. Similarly, if a
fleur-de-lis abdominoplasty is to be performed, the inframammary fold may also be
rotated medially, and the markings may require adjustment. In patients with loose
inframammary folds, we consider deferring the mastopexy to a second stage to
achieve the best aesthetic outcome.
This technique can easily be combined with either an upper body lift or with bra-
chioplasty. When it is performed in combination with an upper body lift, the mark-
ings from the upper back lift will blend into the lateral skin roll excision for the
mastopexy, leaving a single incision line. The lateral flap for the mastopexy is marked
as usual and extends no farther than the posterior axillary line. The patient is posi-
tioned prone, and the upper back lift is performed first. The patient is then turned
to the supine position for the mastopexy. The lateral incision of the mastopexy is
then closed with no dog-ears by blending it into the upper back incision. When com-
bining a mastopexy with brachioplasty, we attempt to merge the caudally directed
axillary incision of the brachioplasty with the lateral incision of the mastopexy. We
try to avoid an inverted-T point in the axilla if possible. The patient should be in-
formed that there may be redundancy at the posterior axillary line that can be cor-
rected with an upper body lift at a later time.
2612
Part XI  Breast Surgery

2613
Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
Fat grafting has recently become a popular technique for soft tissue augmentation.
However, fat grafting has little role in the primary correction of breast ptosis result-
ing from massive weight loss. Once a patient has completely recovered from masto -
pexy with dermal suspension and parenchymal reshaping, fat grafting may be useful
to correct any contour deformities or areas in which more fullness is desired. It could
be a useful ancillary procedure in patients with significant skin redundancy and in-
sufficient breast volume who desire a larger breast size without using implants. In
these select cases, the patient may benefit from a two-stage procedure in which she
undergoes a dermal suspension mastopexy in the first stage, followed by fat injec-
tions in a second stage to augment breast size.
Problems and Complications
This technique has proved very safe and reliable. Complications include hematoma
(less than 1%), seroma (less than 3%), and minor wound dehiscence at the T point
(5%). The generous central pedicle blood supply, combined with the increased vas-
cular network within the pedicle that is so commonly observed in weight-loss pa-
tients, helps prevent nipple loss. In fact, we have had no nipple necrosis in more than
120 dermal suspension mastopexy cases.
Wound dehiscence at the vertical incision and/or triple point is managed with de-
bridement and gauze dressings in an office visit. These have all healed well with con-
servative measures. We routinely place a half-buried 2-0 polypropylene suture at the
T point and remove this in the office 5 to 7 days postoperatively. This helps rein-
force the closure at that juncture.
Seromas have been observed in the lateral region of the breast after drain removal
and have all been treated with needle aspiration in the office. None has required
reoperation.
One must always be wary of fat necrosis at the distal end of any transposed flap.
We have not observed this in the lateral chest wall flap used for autologous augmen-
tation, but we take several measures to avoid this complication. First, the lateral ex-
tent of the flap is limited to the region of the posterior axillary line. We do not ex-
tend this flap onto the midback. Second, the edge of the flap is checked for signs of
arterial bleeding. Third, we exclude active smokers.

Results
2614
Part XI  Breast Surgery
This 40-year-old woman with a BMI of 33.8 lost 61 kg (135 pounds) before sur-
gery. The lateral view of the surgical markings demonstrates an important point in the
preoperative planning of this operation. The resection required to capture the lat-
eral skin fold can extend beyond the tissue within the Wise pattern used for autol-
ogous augmentation. This flexibility allows the skin lateral skin envelope to be ade-
quately contoured, with adjustment of the amount tissue mobilized to the breast.
The results are seen 7 months postoperatively.

This 49-year-old woman lost 74 kg (163 pounds) after a laparoscopic gastric by-
pass procedure. Her BMI at the time of surgery was 27. She had significant preoper-
ative asymmetry. By selectively resecting the breast parenchyma and by using lateral
fold flaps of different volumes, postoperative symmetry can be dramatically im-
proved. She is shown 1 year postoperatively.
2615
Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients

This 37-year-old patient with a BMI of 22.6 had lost a total of 62 kg (136 pounds).
She had a small breast volume with no true lateral skin fold. Despite these findings,
the procedure allowed very good control of the skin envelope and parenchymal re-
shaping. She is shown 18 months postoperatively.
2616
Part XI  Breast Surgery

This 42-year-old woman with a BMI of 25 underwent a combined fleur-de-lis ab-
dominoplasty and mastopexy. To prevent running the incision onto the chest, we
stopped the incision at the xyphoid process. Four months after her initial procedure,
the patient was left with a small dog-ear at the cephalad aspect of the fleur-de-lis in-
cision. If a dog-ear remains 3 months postoperatively, we excise it in the office with
the patient under local anesthesia. By waiting, we can minimize the cephalad exten-
sion of the scar. The patient is shown 4 months postoperatively (before the dog-ear
excision) and at 7 months from her initial procedure.
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Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients

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Part XI  Breast Surgery
Medial pedicle
Medial pedicle
rotated
Dermal release to increase
pedicle mobility
Pedicle placement
under skin
Wise incision
Breast Reduction in Massive-Weight-Loss Patients
In a massive-weight-loss patient with ptosis and adequate or excessive parenchymal
volume, a good option is breast reduction with a Wise pattern skin resection in con-
junction with a traditional or extended medial pedicle. The Wise pattern allows re-
section of excess skin and precise control of the dermal envelope. The vascularly ro-
bust medial pedicle provides a pleasing medial curve to the breast shape and allows
excellent repositioning of the nipple-areola complex. Upper pole fullness may be
achieved by parenchymal elevation with suturing to the rib periosteum or pectoralis
fascia. A decrease in the amount of pseudoptosis or bottoming out is an added ben-
efit. Small to large parenchymal resections are possible, and the added benefit of fa-
miliarity of technique with most surgeons makes this an appealing alternative in
massive-weight-loss patients.