The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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73.20 New Implant Selection in
Revision Surgery
Many complications are caused by poor initial implant selection.
Rippling and wrinkling are exacerbated by saline implants and
softer, underfilled silicone implants. Oversized implants, particu-
larly in patients with weak tissues, are prone to traction rippling,
malpositions, and stretch deformities. Smooth implants in patients
with laterally or medially sloping rib cages are also at higher risk
for malposition. The specific problems must be assessed, so that
the choices that caused these original issues can be understood
and changed during the revision surgery. New implants should
accurately match the patient’s ideal base width and be of a size
that the tissues can support. Patients with rippling issues should
be changed from saline to silicone, and higher degrees of cohe-
siveness can also be helpful in reducing this problem. Patients
with excessive implant movement can be switched from smooth
to textured implants if needed, after creation of a fresh pocket, or
reinforcement materials can be added in combination with a new
smooth implant to stabilize the repair (Fig. 73.28).
Fig. 73.24 (a–c) Patient before and (d–f) after photos from mastopexy with upper-pole fat grafting only (no implants were used).
Fig. 73.25 (a) Pre- and (b) postoperative photos demonstrating a
nipple reduction for elongated, ptotic nipples.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
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73.21 Pocket Control in Revision
Surgery
The breast pocket determines the relationship between the
implant and the patient. Many complications are due to loss of
control over the pocket due to suboptimal implant selection,
imprecise pocket dissection, or poor-quality tissues. The first
assessment, performed both visually and by manipulating the
implants, is whether the pocket is too large or too small, and
in what areas these problems exist (e.g., a pocket can be both
excessively large inferolaterally while simultaneously being
excessively tight superomedially).
Fig. 73.27 (a) Preoperative view of a fit, primary augmentation patient with bothersome axillary fullness. (b) Postoperative view demonstrating
improvement after primary augmentation and power-assisted liposuction of the axillary areas bilaterally.
Fig. 73.26 (a) Preoperative views of an inverted nipple. (b) Postoperative view of nipple after surgical correction.

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Excessively small pockets cause tightness, malposition, and
an unnatural appearance of the breasts, with the most common
cause being capsular contracture. Biofilm should be assumed in
most cases of capsular contracture unless a known triggering
event (such as trauma or an untreated hematoma) has occurred.
To minimize biofilm, the implants are replaced, and the capsule
should be removed entirely unless a neosubpectoral pocket is
needed for control. Further steps to minimize recontamination
include using an inframammary approach, antibiotic irrigation
with full bacterial spectrum coverage, minimal implant handling,
and the use of nipple shields and funnel devices. In cases of recur-
rent capsular contracture, ADM can be another option to reduce
the likelihood of recurrence (Fig. 73.29).
Excessively large pockets, which lead to malpositions and stretch
deformities, are another common issue. There are many described
ways to manage oversized pockets, including capsulorrhaphies,
capsular flaps, capsule cauterization, use of reinforcement mate-
rials, plane conversions, and creation of neosubpectoral pockets.
When smooth implants are used in conjunction with pocket
tightening, the author generally applies the “popcorn capsulor-
rhaphyµ as first described by Dr. Charles Randquist of Stockholm,
Sweden. This technique, named after the popping sound it often
makes, involves internally tenting the capsule away from the
chest wall with insulated forceps and applying energy to the
forceps via electrocautery. The capsule will shrink dramatically
as a “controlled capsular contracture,” and a series of these spot
cauterizations can be applied to the capsule anywhere the pocket
needs to be reduced, most commonly in the inferior and lateral
gutters. Adding ADM or mesh as reinforcement is an option for
additional stability (Fig. 73.30).
As an alternative option, particularly when textured implants
are used, a neosubpectoral pocket is often the best option to
expose fresh tissue, redefine the space, and regain pocket control.
73.22 Soft Tissue Coverage in
Revision Surgery
Tissue thickness is an extremely important variable in revision
surgery. Patients with very thin tissues will be prone to rippling,
implant palpability, and stretch deformities. Patients with very
thick, bulky tissues resting on top of an implant can be prone
to waterfall deformities as the parenchyma rotates off of the
implants.
Regarding patients with problems related to thin tissue, if
a patient has subglandular implants, a good option is a plane
exchange from the subglandular to the submuscular position.
This will add significant superomedial soft tissue coverage and
can be helpful to redefine the boundaries of the implant pockets.
Reinforcement material (ADM, mesh, etc.) can be placed as a pec-
toralis extension to stabilize the muscle and implant (Fig. 73.31).
For patients who are already dual plane, fat grafting of the
breast can add enough padding to hide many irregularities, even
in patients who have a relatively low body mass index. Fat grafting
can also be used to narrow the cleavage in patients with naturally
wide intermammary spacing (Fig. 73.32).
Fig. 73.28 (a,b) Lateral rippling was improved by switching from saline to more cohesive silicone gel implants in addition to pocket tightening and a
circumareolar mastopexy to minimize traction rippling.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
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Fig. 73.29 (a,b) Correction of capsular contracture, malposition, and rippling by changing from saline to silicone, increasing base width and reducing
projection of implants, changing from a subglandular plane to a dual plane, and performing inverted-T scar mastopexy.
Fig. 73.30 (a,b) Lateral malposition and an unnatural appearance corrected by exchange from saline to silicone implants, inferolateral popcorn
capsulorrhaphy of the internal pockets, proper release of underreleased inferior pectoralis origins, and circumareolar mastopexies to tighten the skin
and reposition the nipple–areola complexes.

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Fig. 73.31 (a,b) Implant visibility due to poor soft tissue coverage from subglandular placement of textured saline implants. The repair was achieved
by exchanging saline for appropriately shaped silicone implants, conversion from the subglandular plane to a dual plane, reinforcement with acellular
dermal matrix as bilateral pectoralis extensions, and vertical mastopexies.
Fig. 73.32 (a,b) Correction of excessively wide intermammary distance with lateral pocket tightening and medial capsulectomies, exchange to wider
silicone implants and fat grafting of the medial breasts and sternal area. This narrow intermammary distance with reasonably sized implants was not
achievable without fat grafting.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
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Patients with excessively thick tissues tend to have more issues
with ptosis and waterfall deformities due to gravity rotating the
tissues off the implants. Options for this problem include reducing
the implant size and projection, internally debulking the breast
tissue, and tightening the skin envelope with a mastopexy in
order to reposition the parenchyma back onto the implants.
73.23 Tissue Reinforcement in
Revision Surgery
For many patients requiring revision, a root issue is poor tissue
elasticity or thin tissues. Although smaller implant selection
can be helpful to reduce the load on the tissues, in some cases
reinforcement material can be important in order to stabilize
the implant position. Many types of materials such as acellular
dermal matrices and resorbable meshes are available. The tech-
nical application of these materials is similar regardless of the
material itself.
For cases where simple pocket reinforcement is needed, a strip
of material can be applied to the capsulorrhaphy line to take ten-
sion off the underlying repair. In cases where pectoralis muscle
stabilization is needed as well (e.g., exchanges from subglandular
to submuscular planes, or cases with significant animation defor-
mities), the reinforcement material can be added as a pectoralis
extension bridging the space from the pectoralis edge to the IMF
(Fig. 73.33).
73.24 Skin Envelope Adjustment
Once the implants are selected and placed, the pockets adjusted,
and any reinforcement material placed, the patient should
be examined in the seated position to assess for final skin
adjustment via mastopexy. Another way of thinking about this
is that the internal “framework” is now corrected, and the skin
envelope needs to be tightened and adjusted to fit the new
underlying frame. The mastopexy is used not just to tighten the
skin envelope but to ensure that the NACs are centered on the
breast mounds and have an aesthetic diameter (usually 38–42
mm). The mastopexy pattern selection discussed in the primary
augmentation mastopexy part of this chapter can be applied to
revision surgery in the same way.
73.25 Results—Case Example—
Revision Augmentation
Mastopexy
The patient shown in Fig. 73.34 was a healthy woman in her
30s who presented to the author’s practice with a past history
of oversized, smooth, round, high-profile saline implants placed
via inframammary incisions in the subglandular plane. She now
presented with stretch deformities, pain, rippling, capsular con-
tractures, and unnatural-appearing and disproportionate breasts.
The first part of the plan was to assess what went wrong with
her prior surgery, reverse these issues, and move forward in a
way that was unlikely to create the same complications again. To
understand the issues and solutions further, the case got broken
down into manageable segments as follows.
From an implant standpoint, the oversized, overfilled, smooth
saline implants contributed to an unnatural and unstable result
with malposition, tissue thinning, excess upper implant visibility,
and discomfort. The implant plan was to change from saline to
silicone to reduce the ´water hammerµ effect and to improve
rippling. The implant plan also included decreasing the implant
size and changing from high-profile to moderate-profile implants
to reduce mechanical tissue trauma over time. Finally, implants
were changed from smooth round to textured anatomic shells
in order to gain increased implant positional stability as well
as to improve the upper-pole aesthetics despite having a more
form-stable gel.
Since the patient had saline implants, a preoperative in-office
deflation was performed 6 weeks prior to surgery in order to
remove tension from the skin and allow it to contract and thicken.
The patient was warned that the immediate postdeflation appear-
ance could be disconcerting, but that the appearance would
improve dramatically up to the time of the definitive surgical
repair (Fig. 73.35).
From a pocket standpoint, the patient needed complete
capsulectomies to eliminate a presumed biofilm that had led to
capsular contracture. Additionally, an exchange from the sub-
glandular plane to a dual plane was planned in order to regain
pocket control, increase soft tissue coverage, and reduce the risk
Fig. 73.33 (a–d) This case involved severe soft tissue thinning,
malposition, rippling, ptosis, and capsular contracture. The surgical
correction was achieved with a single-stage procedure including
bilateral complete capsulectomies, implant exchange with proper
pectoralis elevation and stabilization with acellular dermal matrix
as a pectoralis extension, and inverted-T scar mastopexies. Without
reinforcement material this patient would be at high risk for partial
recurrence of her previous complications.

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Fig. 73.34 (a,b) Preoperative photos of a patient seen for revision of unnatural smooth, round, saline subglandular implants.
Fig. 73.35 (a) Photo taken the day of implant deflation and (b) 5 weeks later. Please note that no intervention was performed between these photos
except allowing time for skin retraction.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations
1131
of capsular contracture. Intraoperative washout with multiple
antibiotics as well as the use of a funnel device were also planned
to minimize biofilm.
With a history of subglandular pockets and a plan of creating
a new dual-plane space, the use of reinforcement material as
pectoralis extensions was planned in order to stabilize the
pectoralis major muscles and minimize window shading. Use of
reinforcement material was also planned to stabilize the implant
positions and minimize the risk of inferior or lateral malposition
(Fig. 73.36).
Finally, the patient was prepared for whatever mastopexy
pattern was needed for the best result, although it was felt that
a vertical mastopexy would be the most likely option needed
(Fig. 73.37).
73.26 Concluding Thoughts
Although there is an infinite range of anatomic variations and
challenges facing the surgeon performing primary and revision
augmentation mastopexy surgery, the problems can be broken
down into manageable parts in order to assess and properly
plan surgery. By keeping basic principles in mind, such as man-
agement of patient expectations, precise implant selection and
pocket dissection, proper tissue handling, and tailor tacking to
determine appropriate skin resection patterns, the complications
from this surgery are minimized and favorable patient outcomes
are maximized. As more experience is gained, increasingly chal-
lenging cases can be handled and corrected.
Clinical Caveats
• Realistic management of expectations preoperatively is
critical to success with augmentation mastopexy.
• A detailed physical examination is critical in order to identify
factors that will affect the surgical outcome, such as asymme-
tries, bony irregularities, and poor tissue elasticity.
• Implant size, style, and profile should be selected based
on biodimensional planning in order to minimize future
complications.
• Mastopexy patterns can be preselected, but in cases with
uncertainty, leaving options open (with proper discussion
and consent) will allow greater intraoperative flexibility and
will lead to the highest chance of surgical success.
• Implant or sizer placement should precede the mastopexy for
maximum accuracy. The mastopexy pattern should be tested
with a skin pinch (circumareolar) or tailor tacking with staples
(vertical or inverted-T scar) prior to skin resection, and the
patient must be evaluated in both the supine and fully seated
position to ensure proper correction.
• Circumareolar mastopexy patterns should be 0.5 to 1 cm
higher than they are wide (vertically oriented ovals) and
generally should not attempt to elevate the areolas more
than 2 to 3 cm. This pattern should not be applied to breasts
with significant grade 2 or 3 ptosis or significant glandular
ptosis, because the pattern has a flattening effect. The size
of the circumareolar pattern should be more conservative in
patients with thicker or tighter skin.
• Minimal tissue undermining and maintenance of the superior
subdermal plexus via a superior dermoglandular pedicle
is important to minimize the risk of nipple–areola loss.
De-epithelialization rather than full-thickness skin removal
should be performed.
• Mastopexy with fat grafting to the upper poles can be a
good substitute for implant augmentation mastopexy in
patients with preoperatively larger breasts who prefer a
lower-maintenance lifestyle.
Fig. 73.36 (a) The implant shells and capsules that were removed from the subglandular space. (b) Right breast has a new silicone implant in the
dual-plane space with reinforcement material as a pectoralis extension bridging from the muscle edge to the internal inframammary fold. The
mastopexy pattern has been temporarily tailor-tacked to ensure an appropriate skin resection.

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• Revision augmentation mastopexy can be vastly more dif-
ficult than primary surgery, and surgeons should start with
simpler cases and increase complexity over time. Familiarity
with the full array of mastopexy techniques, including the
use of reinforcement materials and fat grafting, is critical for
success in some cases.
Acknowledgments
I would like to thank Margaret Zheng for her assistance in for-
matting this chapter for submission.
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74 Clinical Decision Making in Breast Reduction and
Mastopexy
Foad Nahai
Abstract
The goals of breast reduction and mastopexy are to adjust the
volume and shape of the breast while minimizing scars and
assuring safety and viability of the nipple and areola. A variety
of vascular pedicles and patterns of skin excision are available.
Selection of pedicle and length of incisions is based on the mor-
phology and tissue characteristics of the breast, including shape,
volume, and skin quality. Incisions are made to access the deep
tissues and to remove excess skin. The breast is shaped through
rearrangement of the parenchyma, not through skin excision. Fat
grafting is a valuable addition for filling the upper pole of the
breast. Mesh support of the breast in mastopexy can be of value.
Keywords
short-scar breast reduction, mastopexy, mastopexy augmen-
tation superior pedicle, inferior pedicle, central pedicle lateral
pedicle, fat grafting.
74.1 Introduction
Although breast reduction actually treats or improves any
symptoms, I consider any operation on the female breast to be
an aesthetic procedure—not only augmentation and mastopexy
but also reduction and reconstruction. Whether we are restoring
body image and self-confidence in a woman who has lost a
breast, or enhancing the appearance of a “normal” breast in an
effort to boost a woman’s self-confidence, our goals are the same
as for any aesthetic procedure.
74.2 Principles of Breast Aesthetics
Breast aesthetics consist of the “four S’s”:
• Shape
• Size
• Symmetry
• Scars
74.2.1 Shape and Size
Breasts come in all shapes and sizes, some more aesthetic than
others. Although the ideal size will vary according to personal and
cultural preferences, there is more consensus on what constitutes
the ideal shape. I believe shape to be of the utmost importance.
The ideal aesthetic breast is projecting, with adequate volume
above and below the nipple–areola complex (NAC), more below
than above. The NAC should be located at the point of maximal
breast projection. Although breast size is subject to individual
taste and societal preference and is too often influenced by media
images, it is also true that disproportionately large or small
breasts do not complement a woman’s figure. They may also have
physical ramifications. Careful counseling is required when a thin,
5-foot 4-inch (163 cm), 100-pound (45-kg) woman requests a D
cup breast size. Conversely, a well-proportioned teenager whose
body development is advanced beyond that of her peers may seek
breast reduction to avoid what she feels is unwanted attention.
74.2.2 Symmetry
Ideally, a woman’s breasts are uniform in color and symmetrical
in size, shape, and nipple-areolar position. Although minor
asymmetry is the rule rather than the exception, gross asym-
metry is not only distracting but of practical importance to
a woman in terms of bra cup size and appearance in clothing.
When a surgeon is counseling a woman seeking breast surgery,
minor asymmetries of her breasts must be pointed out. Most
women are very accepting of these asymmetries preoperatively,
but this is not the case after aesthetic breast surgery.
74.2.3 Scars
Although many patients’ perception is that plastic surgery means
no visible scars, in reality that is not possible. Rather, our goals
should be to keep the scars minimal in length and as inconspic-
uous as possible as we enhance the breasts’ shape. There is no
question that shape is far more important than scars. I believe
that shortening of scars and maintenance of optimal shape are
mutually attainable goals.
How do we control shape, symmetry, size, and scars? Symmetry
and size are related more to the surgeon’s judgment, artistic
sense, and surgical skill than to operative technique. When breast
implants are placed, the shape of the breasts is largely dependent
on the dimensions, volume, and shape of the implant. Shape and
scars, on the other hand, are very much dependent on operative
technique. Optimal breast shape and minimal scars are possible
through a variety of techniques.
74.2.4 Safety: The Fifth S
Breast aesthetics also consist of safety—not only of the patient, but
also of the NAC. Knowledge of the arterial blood supply and venous
drainage of the breast, and specifically of the 1AC, is essential.
74.3 Breast Reduction
The goals of breast reduction are twofold: aesthetic and func-
tional. Most women seeking breast reduction have symptoms

74 Clinical Decision Making in Breast Reduction and Mastopexy
1135
related to the large size of the breast and the impact that breast
weight has on their lifestyle and on their ability to work and
exercise. Symptoms include pain and discomfort in the neck,
back, and shoulders; shoulder grooving; excessive sweating; or
frank intertrigo in the inframammary fold. The ideal procedure
should not only enhance the form of the breast but also relieve
the patient of these symptoms. A sufficient volume of breast
tissue must be resected to achieve these ends. Postoperative
dissatisfaction with breast reduction is not limited to scars
and shape—far too often the patient complains that her breasts
were not sufficiently reduced in weight or volume to relieve the
symptoms. Although our priority is the aesthetic result of the
reduction, surgeons must not lose sight of the patient’s goal:
relief of symptoms as well as aesthetic improvement.
Aesthetic goals are to reduce and reshape the breast with the
NAC in the appropriate position through minimal scars and with
minimal risk of nipple-areolar loss, delayed healing, or wound
disruption. By far the most common cause of dissatisfaction and
even litigation after breast reduction is scarring. For years breast
reduction procedures, although resulting in volume reduction,
resulted in poor breast shape, nonprojecting square or wide
breasts, and extensive scarring. Since the 1990s greater emphasis
has been placed on improvement and maintenance of shape with
minimization of scars.
The young woman shown in Fig. 74.1, who underwent an
inferior-pedicle Wise pattern breast reduction elsewhere, was
seen for evaluation of scars and shape improvement. She demon-
strates wide, nonprojecting breasts that have bottomed out, and
extensive inframammary scarring that extends beyond the breast,
across the midline, and past the anterior axillary fold.
Fig. 74.2 shows the typical long-term result of a central-pedicle
Wise pattern breast reduction. Despite the pleasing appearance
of the breasts, projection is moderate and bottoming out is noted,
especially on the left side.
The typical result after breast reduction with the superior pedi-
cle vertical technique demonstrates projecting breasts (Fig. 74.3).
Side-by-side comparison (Fig. 74.4) emphasizes the difference in
shape and projection.
A number of operative procedures are available for breast
reduction with a variety of pedicles to maintain the nipple and
areola, a variety of techniques to shape the breast, and varying
lengths of incisions. There is a tendency to refer to breast opera-
tions by the resulting scar, with terms such as periareolar, vertical,
and inverted-T. These terms should refer only to the scar and
reflect the pattern of skin excision. Different pedicles and shaping
techniques can be performed through each of these incisions.
The appropriate way to refer to a particular technique for breast
reduction should include the pedicle, the breast-shaping method,
and the resultant scar.
All breast reductions—regardless of pedicle selection, scar
placement, or scar length— entail four steps:
1. Incisions for access
2. Parenchymal resection
3. Breast reshaping
4. Management of excess skin
Fig. 74.1 Breast reduction with unsatisfactory aesthetic result (inferior
pedicle, Wise pattern). This patient’s breasts demonstrate bottoming
out; a wide, flat appearance; and prominent scars. Scars extend well
beyond the breast.
Fig. 74.2 Breast reduction, typical result (central pedicle, Wise pattern). (a) Frontal view. (b) Lateral view. (c) Oblique view.
a
b
c

1136
XI Breast Surgery
With the Wise pattern, all steps are performed through the pre-
operative markings, affording the best exposure and the option
for limitless skin excision. On the other hand, the periareolar
approach offers very limited exposure and skin excision. The
other short-scar options fall in between.
The short-scar superior pedicle or medial pedicle options
narrow the base of the breast, increase projection, and push
the nipple upward, whereas the Wise pattern central- or
inferior-pedicle procedures widen the base, flatten the breast, and
displace the nipple downward. It is not the scar or the pedicle that
defines the procedure or the result. It is the tissues resected, the
location in the breast where they are resected, and how the breast
is reshaped that define the result.
74.3.1 Liposuction-Only Breast
Reduction
The ultimate short-scar technique, liposuction-only breast
reduction, has a role in breast reduction. It is far more effective
in breasts where the large size is primarily related to fat rather
than parenchyma. Both ultrasound-assisted liposuction and
suction-assisted liposuction have been successfully applied
to reduce the volume of the breast. Liposuction has also been
advocated for correction of ptosis through skin contracture.
Although there is no question that liposuction will significantly
alter the volume of the breast, it has minimal effects in terms
of reshaping and enhancing projection or the appearance of the
breast. However, it is relatively simple, fast, and safe with little,
if any, risk of nipple-areolar sensory changes or loss. It is best
for individuals who may not be able to tolerate a 3-hour breast
reduction procedure and are not concerned about improving
breast shape. A small number of younger women with large,
nonptotic breasts and normal skin elasticity are also good candi-
dates for this technique.
Liposuction perhaps enjoys a wider role as an adjunct to breast
reduction, especially in recontouring the lateral part of the breast
and the anterior axillary fold area. Suction-assisted liposuction
has proved safe and efficacious for breast reduction, and fears of
tumor dissemination have proved to be unfounded when preop-
erative mammography has been performed. However, concern
regarding the safety of ultrasound-assisted liposuction within the
female breast is as yet unresolved.
74.3.2 Pedicles
A variety of pedicles have been described for breast reduction.
Although all are essentially safe and based on sound ana-
tomic knowledge, some are more popular than others. Each
pedicle has its own advantages, disadvantages, and special
indications. Each surgeon has his or her preferred pedicle
based on training and experience. Pedicle selection is based
on the technique and size of the breast. The most devastating
local complication of breast reduction is nipple-areolar loss.
Familiarity with a pedicle and its limitations will minimize
such risks. Compromised circulation, as in a heavy smoker,
increases the risk of nipple-areolar loss, regardless of the
pedicle chosen.
The NAC has an extensive blood supply radiating centrally
from the periphery (Fig. 74.5). The blood supply is based on the
perforators of the internal mammary artery through the pec-
toralis major muscle, the perforators based on the intercostal
Fig. 74.4 Side-by-side comparison of two different breast reduction
techniques. (a) Central pedicle/Wise pattern. (b) Superior pedicle/
vertical pattern demonstrates increased projection.
a
b
Fig. 74.3 Breast reduction, superior aesthetic result (superior pedicle, vertical pattern). (a) Frontal view. (b) Lateral view. (c) Oblique view.
a
b
c

74 Clinical Decision Making in Breast Reduction and Mastopexy
1137
vessels, laterally and medially, and the external mammary
artery (Fig. 74.6). A variety of pedicles are based on these
vessels.
Sensory innervation of the nipple–areola complex after breast
reduction depends not only on the pedicle selected but more so
on the degree of nipple displacement and the volume of resection.
With very large breasts, the incidence of postreduction changes in
nipple-areolar sensitivity is high regardless of the pedicle chosen.
Breastfeeding after breast reduction is more dependent on pedicle
selection.
Pedicle Options
Pedicle options include the following:
• Inferior
• Central
• Medial
• Superior
• Lateral, including septum-based
• Combinations
• Free nipple graft
The central and inferior pedicles have been the most popular,
especially in North America (Fig. 74.7). These pedicles are safe
and can be applied equally to minimally, moderately, and mas-
sively enlarged breasts. The vascular basis of these pedicles is the
musculocutaneous perforating branches of the internal mammary
artery through the pectoralis major muscle and intercostal perfo-
rating branches through the muscle. These pedicles are reliable;
however, the need to preserve and maintain central and lower
breast tissue may lead to postoperative bottoming out. Breast-
feeding after reduction with the central and inferior pedicles is
usually possible, and preservation of nipple-areolar sensitivity
with small to moderate reductions is possible.
The medial pedicle (Fig. 74.8) has gained favor as a safe alter-
native to the superior pedicle for short-scar vertical reductions.
The pedicle is based on medial perforating branches of the
internal mammary artery through the pectoralis major muscle
and intercostal perforating branches. It is a reliable pedicle for
minimally, moderately, and even massively enlarged breasts,
allowing easier elevation and inset of the NAC than the superior
pedicle. The medial pedicle allows resection of central and lower
breast tissue, which contributes to the minimization of bottom-
ing out. Breastfeeding is possible after reduction with the medial
pedicle, and preservation of nipple-areolar sensitivity is also
possible.
The superior pedicle, popularized with the Lassus and Lejour
vertical techniques, is based on superior perforating branches of
the internal mammary artery (most notably the second perfo-
rating branch) through the pectoralis major muscle, perforating
branches of the intercostal arteries, and branches of the external
mammary artery (Fig. 74.9). It is a safe and reliable pedicle best
Fig. 74.5 Blood supply to nipple–areola complex: a view.
Fig. 74.6 Blood supply to nipple–areola complex: coronal view.

1138
XI Breast Surgery
suited for minimally and moderately enlarged breasts where
nipple-areolar elevation and inset are relatively straightforward.
For a massively enlarged breast, the nipple and areola are carried
on a long dermal extension. Nipple-areolar elevation and inset are
not always easy and may require careful liposuction of the pedicle
base to inset the NAC. The superior pedicle allows resection of the
central and lower breast tissue, eliminating lower breast volume,
which contributes to bottoming out. It is less likely that the patient
will be able to breastfeed after the superior pedicle technique,
especially with a dermal extension, than with other techniques.
Nipple-areolar sensory preservation is possible.
The lateral pedicle (Fig. 74.10) based on the external mam-
mary artery enjoys the same advantages as the medial pedicle,
but not equal popularity. Occasionally, in an extremely ptotic
breast, I will combine a superior central and even inferior ped-
icle to ensure nipple-areolar safety. For truly gigantic breasts,
extremely ptotic breasts, and in women who are heavy smokers,
the free nipple graft is a safe alternative. Although hypopig-
mentation is a common problem, it would be preferable to total
nipple–areolar loss. Breastfeeding is possible after the lateral
pedicle technique, and nipple–areolar sensation is preserved.
Obviously, with the free nipple graft there is little, if any, chance
Fig. 74.7 Inferior pedicle design. (a) The design of an inferior pedicle in relation to the nipple-areolar blood supply. (b) Skin incision around the
superior border of the nipple–areola complex preserves the anteromedial intercostal perforator blood supply.
Fig. 74.8 Medial pedicle design. (a) The design of a medial pedicle in relation to the nipple-areolar blood supply. (b) Skin incision around the lateral
border of the nipple–areola complex preserves the internal mammary perforator blood supply.

74 Clinical Decision Making in Breast Reduction and Mastopexy
1139
of the ability to breastfeed or preservation of nipple-areolar
sensation. The septum-based pedicle is basically a modification
of this lateral pedicle.
74.3.3 %reDVW-SKDSing 7eFKniTueV
The original Wise pattern technique, which was the mainstay
of breast reduction for many years, especially in North America,
relied on the skin brassiere to maintain shape. This inevitably
led to the all too familiar wide, nonprojecting, bottomed-out
appearance. We no longer rely on a skin brassiere to shape or
maintain the shape of the breast. Our priority now is to reduce
the breast parenchyma, shape the new breast tissue, and then
manage the excess skin. I refer to this as shape and drape—that
is, shape the breast, drape the skin, and then manage the skin
excess. Not only have these recent advances improved breast
shape, they have also yielded longer-lasting results.
Breast-shaping techniques range from the internal mesh
application advocated by Sampaio Góes (Fig. 74.11) to a variety
of parenchymal incision and suturing techniques (Fig. 74.12), and
to the pectoral sling technique of Daniel, as popularized by Graf
and Biggs (Fig. 74.13). Since Sampaio Góes’s original description
Fig. 74.9 Superior pedicle design. (a) The design of a superior pedicle in relation to the nipple-areolar blood supply. (b) Skin incision around the
inferior border of the nipple–areola complex preserves the second internal mammary perforator and external mammary blood supply.
Fig. 74.10 Lateral pedicle design. (a) The design of a lateral pedicle in relation to the nipple-areolar blood supply. (b) Skin incision around the medial
border of the nipple–areola complex preserves the external mammary blood supply.

1140
XI Breast Surgery
of placing a “mixed mesh” to maintain shape, many “internal
support” mesh materials have been introduced.
My personal preference is the vertical scar superior pedicle
technique described by Lassus. Resection of the central and lower
breast tissue removes the breast mass, and the breast shaping is
performed through suturing of the medial and lateral pillars (Fig.
74.12). This, in fact, is the basis of the breast shaping with the
medial and lateral pedicle short-scar techniques. The Daniel tech-
nique involves isolation of an inferiorly based dermal-glandular
flap of breast tissue, which is mobilized, passed through a pecto-
ralis muscle loop, and sutured onto the chest wall. The loop pro-
vides stability for this flap, which improves breast projection (Fig.
74.13) The breast is further shaped through suturing of medial
and lateral pillars. The illustrations show the Daniel method, as
popularized by Graf and Biggs.
Fig. 74.11 Parenchymal shaping techniques. Mesh application as
advocated by Góes.
Fig. 74.12 Superior pedicle vertical scar technique. (a) Parenchymal pillar
plication. (b) Suturing of medial to lateral pillar to reshape parenchyma.
Fig. 74.13 Parenchymal shaping techniques. (a) Development of inferior dermal-glandular pedicle as in pectoralis sling technique of Graf and Biggs.
(b) Creation of a 3-cm pectoralis muscle sling. (c) The inferior pedicle is passed under the muscle and sutured to the chest wall, which improves
projection.

74 Clinical Decision Making in Breast Reduction and Mastopexy
1141
74.3.4 Skin
The most important factor in limiting incision length and scars in
breast reduction is not size or even nipple position; I believe it is
skin quality and quantity. Short scars and optimal breast shape
are compatible and limited only by skin quality, skin quantity,
pedicle safety, and surgical experience. The inverted-T is still
the standard in the United States, and without question it allows
maximal skin removal and maximum exposure to the breast
parenchyma for shaping procedures. I believe its role should be
limited to skin excision only, and not used for breast shaping. The
length and placement of the scar in reduction and mastopexy
should reflect the surgeon’s choice for management of the excess
skin. A number of the short-scar techniques, especially those
leaving only a periareolar scar, rely heavily on skin contraction
as a way of dealing with skin excess.
The ideal approach to breast reduction is to resect the excess
volume, then shape the breast, drape the skin, and finally deal
with the redundant or excess skin. This concept of shape and
drape is best demonstrated in a woman who underwent a 700-g
reduction through a vertical incision with a superior pedicle.
The redundant or excess breast skin is clearly shown. Options for
dealing with this include excision and closure with a purse-string
suture, a short horizontal T, or a J or L excision. Even in such a
large reduction, there is no need for a long horizontal component
(Fig. 74.14).
As stated previously, size is not the issue; skin redundancy and
skin elasticity, mandating skin resection, are the ultimate arbiters
of scar length. Although the three women shown in Fig. 74.15 have
breasts of differing sizes, they all have normal skin elasticity, a full
breast envelope, and skin that is firmly adherent to the underlying
breast. It is not possible to pinch the skin away from the breast
parenchyma of any of the three women shown. Therefore they
are all good candidates for breast reduction through limited scars.
They do not have skin laxity or an excessive amount of skin that
cannot be managed through limited scars.
In contrast, the three women shown in Fig. 74.16, who also
have different-sized breasts, are not the best candidates for short-
scar techniques because they demonstrate poor skin elasticity,
partially filled breast envelopes, and skin that is loosely adherent
or nonadherent to the underlying breast tissue. The breast skin
of any of these women can easily be pulled away from the paren-
chyma by gentle pinching. In these women longer scars will be
needed, because they have poor-quality skin that will not redrape
or contract and must be resected.
The incision options for dealing with excess skin include the
following:
• Periareolar
• Vertical
• Small T
• J or L
• Full-length inverted-T
As we progress down this list, we are able to remove increas-
ingly larger amounts of skin. The higher we remain on the list, the
more we rely on skin redraping and contraction, two options not
available with stretched, inelastic skin.
My concept of breast skin excision is three-dimensional:
unidimensional refers to periareolar skin removal; bidimensional
includes a periareolar and a vertical component; and tridimen-
sional includes a periareolar, vertical, and horizontal component.
The horizontal component may include a short T, a J or L, or the
long horizontal T (Fig. 74.17, Fig. 74.18, Fig. 74.19, Fig. 74.20,
Fig. 74.21).
74.3.5 Conclusion
There has been considerable progress in breast reduction over
the past few decades. Through the efforts of our colleagues in
Europe and South America, short-scar techniques have now
been accepted and adopted in North America. The concept of
Fig. 74.14 Management of redundant skin following breast reduction. (a) Excess horizontal skin following vertical scar breast reduction with paren-
chymal reshaping. (b) Following reduction and reshaping, excess skin may be managed by excision and conversion to a T- or J-shaped incision.
a
b

1142
XI Breast Surgery
Fig. 74.17 Periareolar skin excision. (a) After de-epithelialization. (b) After closure with periareolar scar.
Fig. 74.15 Various degrees of macromastia in patients with normal
skin elasticity. (a) Minimal macromastia, frontal and (b) lateral view.
(c) Moderate macromastia, frontal and (d) lateral view. (e) Severe
macromastia, frontal and (f) lateral view.
a
c
e
b
d
f
Fig. 74.16 Various degrees of macromastia in patients with poor skin
elasticity and parenchymal deflation. (a) Minimal macromastia, frontal
and (b) lateral view. (c) Moderate macromastia, frontal and (d) lateral
view. (e) Severe macromastia, frontal and (f) lateral view.
a
c
e
b
d
f

74 Clinical Decision Making in Breast Reduction and Mastopexy
1143
reducing and reshaping the breast through minimal scars is
sound and here to stay. A variety of reliable pedicles are available
to ensure nipple-areolar survival, and a variety of suturing and
shaping techniques are available to produce the desired breast
shape and projection. Although it is not essential, desirable, or
even possible for a surgeon to be intimately familiar with all of
these options, it is important that the surgeon be familiar with
two or three approaches. In the final analysis, we will each pick
the pedicle-shaping technique and incisions with which we are
familiar and that in our hands produce consistently good results,
with minimal morbidity and minimal scarring acceptable to our
patients while meeting their expectations.
The role of the quality and amount of excess skin in defining
the length and placement of scars in reduction and mastopexy
has been discussed. Not only skin quality and skin excess, but the
relationship of the skin envelope to the breast, together with the
quality and type of breast tissue (fat vs. fibrous tissue), should
be taken into account when choosing the procedure. These same
parameters also determine the quality and longevity of the result.
Fig. 74.18 Periareolar and vertical skin excision. (a) After de-epithelialization; (b) after closure with periareolar and vertical scar.
Fig. 74.19 J- or L-horizontal component added to the vertical and periareolar skin excision; tridimensional skin removal provides the option of
horizontal skin excision along the lateral inframammary fold. (a) After de-epithelialization. (b) After closure.
a
b

1144
XI Breast Surgery
The three women shown in Fig. 74.22, 74.23, and 74.24 had
breast reductions of varying amounts: 300 g, 500 g, and 1,000 g
per breast, respectively. A superior pedicle technique with a ver-
tical scar was the technique for all three. All demonstrate size
reduction, shape enhancement, and minimal scars (Table 74.1).
74.4 Mastopexy
Mastopexy is one of the most difficult breast procedures and is
perhaps one of the more challenging of all aesthetic procedures.
Patients have high expectations, yet the quality of their tissues,
gravity, and aging all conspire against the patient and surgeon
alike. A variety of procedures are available, with or without
implants or support mesh, with or without addition of fat grafts,
to lift, reshape, and resize the droopy breast. It is essential to
thoroughly evaluate the patient and her breasts before selecting
the appropriate technique.
In my practice the quality of the tissues not only guides me
in selecting the appropriate procedure for each patient, it also
enables me to predict the quality of the result so that I can better
Fig. 74.20 The short T-horizontal tridimensional skin incision provides a third component of skin excision for a short distance on either side of the
breast meridian. (a) After de-epithelialization. (b) After closure.
a
b
Fig. 74.21 The longer horizontal incision allows maximum skin resection. (a) After de-epithelialization. (b) After closure.
a
b

74 Clinical Decision Making in Breast Reduction and Mastopexy
1145
explain and demonstrate to the patient the anticipated result and
how long it may last.
Most patients seeking mastopexy desire fuller, perkier, lifted
breasts. Before examining the breasts, I try to establish whether
the patient is happy with her present breast volume and simply
looking for a breast lift or whether she is seeking both volume
enhancement and a lift. If possible, it is best to undertake a
mastopexy after the woman has completed her family rather than
between children.
Evaluation of the breasts includes grading of the ptosis.
Currently the two classifications available are those of Lalardie
and Regnault, glandular or cutaneous. The Lalardie classification
includes grades I through IV, based on nipple-areolar position.
Regnault’s classification, described in 1976, is more complicated
but takes more into account. Regnault’s classification defines the
different degrees of breast ptosis and facilitates evaluating the
problem and planning the operation.
Although such classifications are useful, not all women can be
classified into one of these categories. In addition, these classifica-
tions do not take into account the quality and quantity of excess
skin or the relationship of the skin to the underlying gland. My
preference is to evaluate the skin envelope and contents, the rela-
tionship of the skin to the gland, and finally the nipple position
(Fig. 74.25, Fig. 74.26, Fig. 74.27, Fig. 74.28, Fig. 74.29).
74.4.1 Evaluation of the Ptotic Breast
To fully evaluate a patient’s ptotic breasts, the surgeon must
consider the following:
• Skin
• Gland
• Skin–gland relationship
• Nipple position
In the skin I look for loss of elasticity, as evidenced by striae,
dermal thickness, and skin recoil. I also make a mental note of
the excess skin to be resected. The breast tissue is evaluated for
shape, volume, and consistency: Is the breast mostly fibrous, fatty,
or a combination of the two? In terms of the skin–gland relation-
ship, I assess whether the envelope is full or empty. Is the skin
adherent to the underlying tissues, or hanging loosely around it?
Skin quality and the skin–gland relationship are the key factors
in determining the appropriate procedure and the quality and
Fig. 74.22 Superior pedicle, vertical scar breast reduction: 300 g
resection. (a) Frontal views, preoperative and (b) postoperative. (c)
Lateral views, preoperative and (d) postoperative.
a
c
b
d
Fig. 74.23 Superior pedicle, vertical scar breast reduction: 500 g
resection. (a) Frontal views, preoperative and (b) postoperative. (c)
Lateral views, preoperative and (d) postoperative.
a
c
b
d
Fig. 74.24 Superior pedicle, vertical scar breast reduction: 1,000 g
resection. (a) Frontal views, preoperative and (b) postoperative. (c)
Lateral views, preoperative and (d) postoperative.
a
c
b
d

1146
XI Breast Surgery
longevity of the result. Finally, I assess the displacement of the
nipples and the degree of nipple elevation that will be required.
74.4.2 3DWienW 3rRÀOeV
The young woman shown in Fig. 74.30 has full, large breasts.
The skin has normal elasticity and recoil, the gland is firm and
fibrous, and the envelope is full, tight, and firmly adherent to the
parenchyma. The skin cannot be pinched away from the breast
tissue. Her nipples are displaced moderately. A good result is
anticipated in this woman regardless of technique, because all
of her tissue characteristics are favorable, and she has more than
adequate breast volume.
The young woman shown in Fig. 74.31 has partially atrophic
breasts; her skin has maintained some elasticity and recoil. Her
gland is soft and fibrofatty. Her skin envelope is half-full, loose,
and lightly adherent to the parenchyma, and the skin can be
pinched away from the breast tissue. Her nipples are moderately
displaced. A good result is anticipated, but the degree of projec-
tion will depend on the technique. I would certainly consider an
implant for this patient.
The middle-aged woman shown in Fig. 74.32 has deflated
breasts. The skin has lost most of its elasticity and recoil, the
gland is loose and fibrous, and the skin is barely adherent to the
parenchyma. The skin can be pinched away for 2 or 3 cm from the
breast tissue. Her nipples are moderately displaced. A reasonably
good result can be anticipated, but given the quality of her skin,
it will not be a long-lasting result, and the patient should be
warned about the possible need for early secondary procedures.
An implant should also be considered.
The middle-aged woman shown in Fig. 74.33 has deflated,
atrophic, and asymmetrical breasts. Skin elasticity and recoil are
minimal. The gland is soft and fibrous, and the skin envelope is
empty and barely adherent to the underlying parenchyma. The
skin can easily be pinched away several centimeters from the
breast tissue. An average result may be anticipated; however, the
patient should be warned that it will not be a long-lasting result
and that a revision may be required sooner rather than later.
74.4.3 Goals of Mastopexy
The goals of mastopexy include the following:
• Restoration of shape
• Restoration of volume
• Restoration of nipple–areolar position
Restoration of Shape
The ideal result after mastopexy is a projecting breast with the
nipple and areola at the point of maximal breast projection. There
should be breast volume above and below the NAC, more below
Fig. 74.25 Minor breast ptosis, nipple at level of inframammary fold.
(a) Frontal view. (b) Lateral view.
a
b
Table 74.1 Options for breast reduction
Breast characteristics
SNin e[FiViRn SDWWern Dnd ÀnDO VFDr
Periareolar
Vertical
Short horizontal T
J or L
Longer horizontal T
Traditional full-length
horizontal T
Size of reduction
< 500 g
X
X
X
X
500–1000 g
X
X
X
X
> 1,000 g
X
X
X
X
X
Skin elasticity
Normal
X
X
X
X
X
X
Inelastic
X
X
X
X
Skin excess
Minimal
X
X
X
X
X
Moderate
X
X
X
X
X
Massive
X
X
Parenchyma
Firm and fibrous
X
X
X
X
X
X
Soft and fatty
X
X
X
X
X
Skin–parenchyma
relationship
Firmly adherent
X
X
X
X
X
X
Loosely adherent
X
X
X
X

74 Clinical Decision Making in Breast Reduction and Mastopexy
1147
Fig. 74.26 Major breast ptosis, nipple at lower breast contour; breast
below inframammary fold. (a) Frontal view. (b) Lateral view.
a
b
Fig. 74.27 Moderate breast ptosis, nipple below inframammary fold
but above lower breast contour. (a) Frontal view. (b) Lateral view.
a
b
Fig. 74.28 Glandular ptosis. Nipple above inframammary fold but
gland descended below fold. (a) Frontal view. (b) Lateral view.
a
b
Fig. 74.29 Pseudoptosis. Nipple higher above fold, gland hypoplastic
but some gland below fold. (a) Frontal view. (b) Lateral view.
a
b
Fig. 74.30 Patient profile: ideal mastopexy candidate. The patient has
proportioned shape, volume, and skin elasticity. (a) Frontal view. (b)
Lateral view.
a
b
Fig. 74.32 Patient profile: suboptimal mastopexy candidate. The
patient has deflated breasts and significantly decreased skin elasticity.
(a) Frontal view. (b) Lateral view.
a
b
Fig. 74.31 Patient profile: good mastopexy candidate. The patient has
glandular atrophy and decreased skin elasticity. (a) Frontal view. (b)
Lateral view.
a
b
Fig. 74.33 Patient profile: poor candidate. The patient has deflated
breasts and minimal skin elasticity. (a) Frontal view. (b) Lateral view.
a
b

1148
XI Breast Surgery
than above. The breast should also be appropriately positioned
on the chest wall.
Restoration of Volume
Many women seeking mastopexy have postpartum involution
and a deflated appearance. Although they are candidates for
volume replacement with an implant, they are surprised when
the recommendation is made, because they feel that they have
adequate breast volume. During the initial evaluation, I tighten
the breast skin with my fingers to bring the 1AC to the appro-
priate position; this demonstrates to the patient the anticipated
postoperative breast volume without an implant. While holding
her skin, I ask her to look down at her breast and into a mirror to
preview this breast volume. Most patients who thought that they
had adequate breast volume in the ptotic stage are surprised that
the breasts will look smaller once the ptosis has been corrected. I
also explain to patients who require an implant that their results
will be better in terms of projection and in all likelihood will
last longer with an implant. There is a small group of women
whose minor degree of ptosis may be corrected with an implant
without any skin envelope adjustment.
The application of fat grafts has added another excellent
option for volume replacement or addition for all aesthetic and
reconstructive breast procedures. Fat grafting has been a welcome
addition in breast augmentation and mastopexy with or without
implants. Fat grafting of the upper pole in mastopexy with or
without implants enhances the results and is an excellent option
for adding volume to the upper pole.
Restoration of Nipple–Areolar Position
Restoration of nipple–areolar position is an integral part of the
mastopexy, and care should be taken to preserve the blood
supply to and venous drainage from the NAC, especially if the
mastopexy is combined with an implant and for all secondary
procedures.
74.4.4 Skin Removal and Mastopexy
As with a breast reduction, skin excision is planned according to
the tridimensional approach: periareolar, vertical, and horizon-
tal planes. The skin incision is designed to allow sufficient access
to the breast tissue for reshaping, placement of an implant, and
removal of excess skin. It should be noted that inelastic, stretched
skin with striae, or a skin envelope that is poorly adherent to the
underlying breast parenchyma, will not redistribute or contract
and must be excised. If an implant is being added, the implant is
placed first; then the skin excision is planned .
Establishing Surgical Priorities
During the patient evaluation, I identify the predominating
needs of the breast. If volume deficiency is predominant, volume
replacement is performed first and then skin excision. If the
predominant factor is skin excess rather than volume, the breast
is shaped and the excess skin resected. If volume deficiency and
skin excess are equal determining factors, volume adjustment is
performed first, followed by skin removal.
Skin Removal and Incision Placement
Similar to excisions for reduction mammaplasty, skin removal
for mastopexy is planned to permit circumareolar, vertical,
and, when necessary, horizontal excisions and remolding of
the breast to a more natural, uplifted, conical shape. This skin
removal should also allow repositioning of the nipple and areola
and, if ptosis recurs, additional corrections through the initial
incisions. The incisions and skin excisions are planned on a con-
tinuum from periareolar to circumareolar to vertical scars and
then to horizontal scars. With this approach, additional breast
tissue can be excised later.
When the NAC is low, requiring only a small degree of elevation
of 1 to 2 cm, an upper periareolar crescentic ellipse can be excised
to elevate it. An augmentation mammaplasty may be done through
this incision, if needed, to enhance breast volume to produce an
elevated nipple-areolar appearance (Fig. 74.34).
This upper periareolar ellipse can be rotated when specific
lateral or medial positioning of the nipple–areola complex is
necessary to move it to a more aesthetic position on the breast
(Fig. 74.35).
A circumareolar skin excision with periareolar purse-string
closure tightens the skin minimally without elevating the
areola. It is effective for patients with tubular breasts with pro-
tuberant areolae and for patients with very large areolae and
pseudoptosis who are to have augmentation mammaplasty.
Removal of breast skin leaves only a central circular scar. The
scar, however, tends to widen, and the nipple position is min-
imally elevated. It can also result in unnatural central breast
flatness and loss of attractive central projection; however, an
implant can minimize this flatness. Alternatively, breast shap-
ing and internal mesh support, as advocated by Sampaio Góes,
can enhance shape and projection. A permanent circular suture
in the skin periphery, the round block technique, reduces final
skin tension and produces a finer scar; this approach extends
the application of this technique to some patients with moder-
ate ptosis (Fig. 74.36).
In patients with glandular and minor ptosis, the circumare-
olar excision with a short vertical ellipse tightens the skin
and elevates the NAC. Care must be taken to avoid excessive
tightness below the areola. This incision can be shortened,
because the vertical component contributes primarily to close
the defect from the transposed NAC. The vertical scar tends
to shorten in the postoperative period with scar contraction
(Fig. 74.37).
For moderate ptosis the circumareolar excision with a vertical
and occasionally a short horizontal ellipse, J or L excision, pro-
duces a short inframammary scar and tightens the breast while
shortening the inframammary distance. This approach is best
only when there is excess skin after vertical mammaplasty that
will not redrape and contract and must be excised. Rather than
the short horizontal, J or L excision, I prefer to take up the skin
excess through a purse-string suture (Fig. 74.38).
For patients with major ptosis and excessive amounts of inelas-
tic skin, who need maximal breast elevation, a vertical and hor-
izontal excision provides effective breast elevation, even though
this approach produces a longer inframammary scar. However, I
make every effort to avoid the horizontal component if possible
(Fig. 74.39).

74 Clinical Decision Making in Breast Reduction and Mastopexy
1149
Fig. 74.34 Mastopexy techniques: minor inferior nipple malposition may be addressed with a small crescentic excision superior to the nipple.
(a) Following excision. (b) Following closure.
Fig. 74.35 Mastopexy techniques: crescentic excision may be rotated medially or laterally to correct malposition in specific directions. (a) Following
excision. (b) Following closure.
Fig. 74.36 Mastopexy techniques: periareolar mastopexy. (a) Following excision. (b) Following closure.

1150
XI Breast Surgery
Fig. 74.38 Mastopexy techniques: circum-vertical mastopexy with short T-horizontal component. (a) Following excision. (b) Following closure.
Fig. 74.39 Mastopexy techniques: circum-vertical mastopexy with full-length horizontal component. (a) Following excision. (b) Following closure.
Fig. 74.37 Mastopexy techniques: circum-vertical mastopexy. (a) Following excision. (b) Following closure.

74 Clinical Decision Making in Breast Reduction and Mastopexy
1151
74.4.5 Mastopexy Augmentation
Combining mastopexy with augmentation is even more chal-
lenging than mastopexy alone. The goals of the two procedures
are diametrically opposed. Mastopexy tightens and lifts the
breast, whereas an implant stretches and expands the tissues
and often displaces the breast downward. Though opinions have
differed as to whether this operation should be staged, there are
now several large studies supporting the efficacy and safety of
a one-stage procedure. My preference has always been a one-
stage procedure in which the implant is placed first, and then
the patient is marked for the mastopexy on the table during the
operation. I believe that is now also the preferred approach for
the majority of plastic surgeons. As with reduction and mas-
topexy, the quality of the tissues, including the skin, will guide
me in selection of technique and the anticipated result.
74.4.6 Conclusion
Mastopexy is a challenging procedure; the results are not
permanent, and early reoperation may be required to produce
the optimal result. A compromise must be struck between the
patient’s expectations and the realities of her tissue charac-
teristics. Careful evaluation of the breast volume, skin, and
tissue characteristics is an essential prerequisite for operative
planning. The patient should be counseled about the limitations
and longevity of these procedures. Technique selection and skin
excision patterns reflect the same principles as those discussed
for breast reduction. If an augmentation is planned, the breast
volume should be adjusted first and then the skin envelope. The
availability of a variety of supportive mesh and more significantly
the option of fat grafting has significantly improved the results
and longevity of these procedures (Table 74.2).
Table 74.2 Options for mastopexy
Breast characteristics
SNin e[FiViRn SDWWern Dnd ÀnDO VFDr
Periareolar
Vertical
Short horizontal T
J or L
Longer horizontal T
Traditional full-length
horizontal T
Nipple displacement
Minimal
X
X
X
X
Moderate
X
X
X
X
X
X
Maximum
X
X
X
X
X
Skin elasticity
Normal
X
X
X
X
X
X
Inelastic
X
X
X
X
X
Skin excess
Minimal
X
X
X
X
X
X
Moderate
X
X
X
X
X
Massive
X
X
Parenchyma
Firm and fibrous
X
X
X
X
X
X
Soft and fatty
X
X
X
X
X
Skin–parenchyma
relationship
Firmly adherent
X
X
X
X
X
X
Loosely adherent
X
X
X
X

1152
XI Breast Surgery
75 Medial Pedicle Vertical Breast Reduction
Elizabeth J. Hall-Findlay
Abstract
The medial pedicle vertical breast reduction technique is less
about scarring than it is about concepts. Most inverted-T type
approaches remove a horizontal ellipse of skin and breast tissue,
which, when closed, leave a medial and a lateral dog-ear. Most
vertical-type approaches remove an inferior vertical ellipse of
skin and breast tissue and, when closed, leave a superior and
an inferior dog-ear. The removal of an inferior vertical wedge of
breast tissue allows the surgeon to narrow and cone the breast,
and it also removes the heavy inferior breast tissue and leaves
behind the superior breast tissue.
There are numerous vertical approaches and numerous pedicle
choices. I prefer the (true) superomedial pedicle because it has
a dual axial blood supply, it rotates easily into position without
kinking or compression, and it has sensation, which is equivalent
to the other pedicles available. The inferior border of the medial
pedicle becomes the medial pillar so that as it rotates into posi-
tion, it leaves an elegant curve to the lower pole of the breast.
Keywords
breast reduction, medial pedicle, superomedial pedicle, dual
axial blood supply, inferior vertical wedge resection, vertical
elliptical excision, pillar closure, projection
75.1 Introduction
The medial pedicle vertical breast reduction technique is less
about scarring than it is about concepts. Most inverted-T type
approaches remove a horizontal ellipse of skin and breast tissue,
which, when closed, leave a medial and a lateral dog-ear. Most
vertical-type approaches remove an inferior vertical ellipse of
skin and breast tissue and, when closed, leave a superior and
an inferior dog-ear. The removal of an inferior vertical wedge of
breast tissue allows the surgeon to narrow and cone the breast,
and it also removes the heavy inferior breast tissue and leaves
behind the superior breast tissue.
There are numerous vertical approaches and numerous pedicle
choices. I prefer the (true) superomedial pedicle because it has
a dual axial blood supply, it rotates easily into position without
kinking or compression, and it has sensation, which is equivalent
to the other pedicles available. The inferior border of the medial
pedicle becomes the medial pillar so that as it rotates into posi-
tion, it leaves an elegant curve to the lower pole of the breast.
An important concept to understand is that the superomedial
pedicle vertical breast reduction uses the Wise pattern as a good
breast (brassiere) design for the pattern of the parenchyma, which
should be left behind, rather than for the skin resection pattern
(Fig. 75.1). Once the inferior vertical wedge of skin and breast
tissue and the breast tissue under the lateral flap are removed and
the breast is coned, all breast tissue inferior to the Wise pattern
is removed both directly and with liposuction. The skin is then
allowed to redrape over the newly shaped breast mound.
The idea that surgeons need to choose between scars and shape
is not true. The superomedial pedicle vertical breast reduction not
only results in reduced scars but also maintains a good, long-lasting
shape. The surgery takes less time, there is less blood loss, and
the recovery is faster. In my experience the complications are also
significantly less frequent with my vertical breast reductions than
with my previous inverted-T inferior pedicle breast reductions.
There are more pucker revisions with the vertical approach, but
that is partly a function of being easily able to perform a revision
and the surgeon’s threshold for revision. Many patients with the
inverted-T procedures are told that the lateral and medial dog-
ears cannot be corrected; this then makes the revision rate low.
:hen I first tried vertical breast reduction techniques in 1993,
I could see that there was a definite improvement in shape, but
I had problems with the superior pedicle. It could be difficult
to inset, and I did not understand the blood supply. I thought it
would be better as a full-thickness pedicle, but in fact it is safer
and less likely to be compressed when it is thinned. The problem
with thinning the superior pedicle is that it leaves an empty space
underneath, which tends to leave a concave inferior pole for a few
Fig. 75.1 (a,b) An important concept to understand is that the
superomedial pedicle vertical breast reduction uses the Wise pattern
as a good breast (brassiere) design for the pattern of the parenchyma,
which should be left behind, rather than for the skin resection pattern.
Once the inferior vertical wedge of skin and breast tissue and breast
tissue under the lateral flap is removed, and the breast coned, all
breast tissue inferior to the Wise pattern is removed both directly and
with liposuction. The skin is then allowed to redrape over the newly
shaped breast mound. (Reproduced with permission from Hall-Findlay
EJ. Aesthetic Breast Surgery: Concepts and Techniques. New York, NY:
Thieme Medical Publishers; 2010.)

75 Medial Pedicle Vertical Breast Reduction
1153
weeks after surgery. The medial pedicle is easy to inset, and the
shape of the breast “on the table” is quite good. A true superome-
dial pedicle has a better blood supply than a medial pedicle, but
it is a bit more difficult to inset. Both pedicles, however, can be
safely debulked of deep parenchyma because the blood supply is
superficial.
After some unsatisfactory experience with the superior pedicle,
I tried a lateral pedicle because I thought it would have the best
chance of good sensation, but again, I did not really understand
the anatomy. The problem with the lateral pedicle is that the
tissue that forms the base of the pedicle is exactly the same tissue
that needs to be removed to give a good reduction and a good
shape to the breast. I could see that the medial pedicle gave a
better shape, and I was also surprised that the medial pedicle had
excellent recovery of sensation.
The patient shown in Fig. 75.2 had a lateral pedicle on her right
side and a medial pedicle on her left side. She had good return of
sensation on both breasts. The problem with the lateral pedicle
is that the base of the pedicle prevents good resection of the
excess lateral breast tissue. The return of sensation in my practice
(patient reported on a Likert scale) is 85% in medial pedicles, 75.%
in lateral pedicles, and 67% in superior pedicles (Table 75.1).
Nipple necrosis is the complication that surgeons fear the most.
I believe that there are four main arterial supplies to the breast,
and sometimes only three of the four are dominant. We cannot
make a preoperative determination of which pedicle will be safe.
I believe that nipple necrosis is inevitable in a large-volume prac-
tice, and it is more likely to be a statistical occurrence rather than
bad surgery. A true superomedial pedicle is the safest because it
has a dual axial blood supply (Fig. 75.3).
The advantages are in the reduced scarring and the better shape,
but when surgeons realize that they do not need any tension on
the skin closure, the wound healing problems and complications
are dramatically reduced.
The other advantage is that the concept of the superomedial
pedicle and the vertical and lateral parenchymal resection can be
used in much larger breast reductions, even when an inverted-T
skin resection pattern is needed to reduce the redundant skin.
Skin does not need to be removed as often as surgeons think, but
some patients have far too much skin or too much skin of poor
quality. The advantages of the superomedial pedicle with the infe-
rior resection can still be preserved even when the final closure
has increased scarring with a T, a J, or an L pattern.
75.2 Indications and
Contraindications
The best candidates for a medial pedicle vertical breast reduction
are young, healthy patients who need a small to moderate-sized
breast reduction (usually up to 600 g or more). There is more of
a learning curve for the larger reductions, but the method is still
excellent. There is a point, however, when an inverted-T skin
Table 75.1 Recovery of sensation with different pedicles
Pedicle
Breasts
% return
Superior
58
67%
Lateral
147
75%
Medial
1206
85%
Fig. 75.2 This patient had a lateral pedicle on her right breast and a
medial pedicle on her left breast. She had good return of sensation on
both breasts. The problem with the lateral pedicle is that the base of
the pedicle prevents good resection of the excess lateral breast tissue.
Fig. 75.3 A true superomedial pedicle is the safest because it has a
dual axial blood supply. (Copyright Jennifer Gentry). Reproduced with
permission from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts and
Techniques. New York, NY: Thieme Medical Publishers; 2010.)

1154
XI Breast Surgery
resection pattern will be needed, but this point is not nearly
as early as some surgeons envision. The principles of a supero-
medial pedicle still apply in a very large breast reduction that
requires more than just vertical skin removal.
The best results in all breast reductions are achieved in young,
healthy women who are not overweight. The cosmetic result is
not as good in heavy or obese patients.
In some women with very large breasts, any of the pedicles
chosen will be long. Theoretically the blood supply stretches with
the breast as it grows and becomes ptotic, but the reality is that
nipple necrosis is more likely with the longer pedicles. The other
problem with excessively long pedicles is the sheer volume of the
pedicle itself, which limits the size of the reduction and increases
the weight of the breast in the lower pole. This extra weight can
be sutured up onto the chest wall, but it will tend to bottom out
with time.
Some patients who have large breasts, good nipple position,
good skin elasticity, and a large proportion of fat to gland may
be better candidates for liposuction-only. Some young patients
(rarely) may have such a good shape that the reduction can be
performed through an inframammary incision only.
The patient shown in Fig. 75.4 is young, healthy, and close to
her ideal body weight and needs a moderate-sized breast reduc-
tion. She was 20 years old, weighed 125 lb, and was 5 feet, 5 inches
tall. She was a good candidate for a medial pedicle vertical breast
reduction and had 495 g removed from her right breast and 455
g from her left breast. She had another 150 mL of fat removed
with liposuction (Fig. 75.4f). She is shown at 18 months after her
surgery (Fig. 75.4d,e).
The 58-year-old woman shown in Fig. 75.5 is a less ideal can-
didate because she has very large breasts and is not close to her
ideal weight; thus her cosmetic result will not be as good (Fig.
75.5a,b). She had 1,275 g removed from the right breast and 1,200
g from the left breast, and 400 mL of fat was also removed with
liposuction. She is shown at 4 years after surgery (Fig. 75.5c,d). An
inverted-T was not added; her resection was vertical only.
She then had breast re-reduction, which was performed 10
years after her initial reduction. Another 295 g was removed
from her right breast and 260 g from her left breast along with
another 600 mL of liposuction. She is shown a full year after the
re-reduction, and in this case an inverted-T skin resection was still
not needed (Fig. 75.5e–g).
75.3 Pertinent Anatomy
There is considerable variability in the breast footprint. Some
patients are high-breasted and some are low-breasted. This is
a very important fact to point out to patients to manage their
expectations better. There are only minimal changes that a
Fig. 75.4 This patient is young, healthy and close to her ideal body weight and needs a moderate sized breast reduction. (a–c) She was 20 years old,
weighed 125 lb and was 5 feet, 5 inches tall. (d,e) She is shown at 18 months after her surgery. (f ) She was a good candidate for a medial pedicle
vertical breast reduction and had 495 g removed from her right breast and 455 g from her left breast. She had another 150 mL of fat removed with
liposuction

75 Medial Pedicle Vertical Breast Reduction
1155
surgeon can make to the footprint. The upper breast border of the
footprint may start quite low on the chest wall, and this cannot
be changed with a breast reduction. The vertical dimension of
the footprint can be quite short, even in large, heavy breasts.
The variation in the vertical dimension can be from 3 to 15 cm.
The inframammary fold (IMF; the lower breast border) can be
quite different from one breast to the other in the same patient.
The horizontal dimensions of the footprint can also vary con-
siderably, with the medial breast border determining whether a
woman has a wide or narrow breast cleavage. The lateral breast
border usually extends to or just past the anterior axillary line,
with most patients having an ideal horizontal breast base diam-
eter of 11–14 cm.
The breast is an ectodermally derived subcutaneous structure
that is attached loosely to the skin (and firmly at the nipple). It is
only very loosely “attached” to the chest wall. Those attachments
are easily swept away with a finger during a subglandular breast
augmentation. The breast is held in place by fascial condensations
inferiorly (the IMF fold) and medially (over the sternum). These
act much like the gluteal fold and the sacrum (Fig. 75.6). The
breast moves easily over the chest wall and is quite mobile and
not held in place either superiorly or laterally.
When a woman lies on her side, the upper breast folds over the
sternum medially and the lower breast slides out. Only the lower
breast border (IMF) and the medial breast border are relatively
fixed structures (zones of adherence) holding the breast in place.
The only artery (and venae comitantes) that travels through
the breast parenchyma to the nipple enters the breast directly
from the chest wall at the fourth interspace and travels to the
nipple–areola complex (NAC; Fig. 75.7). Although there are lateral
branches (which are enclosed in a loose layer that is described
as a breast septum by Würinger), there are no other arteries that
course through the parenchyma to the nipple. There are, of course,
vessels that supply the breast parenchyma itself, but they do not
course through the parenchyma to the nipple. This chest wall–
based artery and vein supply an inferior (and central) pedicle.
The blood supply to the breast is therefore mainly superfi-
cial—the arteries and veins are in the subcutaneous tissue that
was pushed outward as the breast developed. Most of the blood
supply comes from the internal thoracic (internal mammary)
system via the second to sixth perforators. There is some supply
from the superficial branch of the lateral thoracic artery, but the
thoracoacromial system provides only minimal additional blood
supply (and none to the NAC).
The artery to a superior pedicle (Fig. 75.8a) comes from the
second (usually) intercostal space, and it descends and enters the
nipple area just medial to breast meridian and is always about 1
cm deep to the skin. It bleeds with significant force when it is cut
during creation of a pure medial pedicle (it can be traced with a
pencil Doppler preoperatively). The artery to the medial pedicle
also comes from the internal mammary system (usually from the
third intercostal space) and curves around the sternum, penetrates
Fig. 75.5 This 58-year-old woman is a less ideal candidate because she has very large breasts and is not close to her ideal weight; thus her cosmetic
result will not be as good. (a,b) She had 1,275 g removed from the right breast and 1,200 g from the left breast. Also, 400 mL of fat was removed
with liposuction. (c,d) She is shown at 4 years after surgery. An inverted-T was not added; her resection was vertical only. (e–g) She then had breast
re-reduction, which was performed 10 years after her initial reduction. Another 295 g was removed from her right breast and 260 g from her left
breast along with another 600 mL of liposuction. She is shown a full year after the re-reduction, and in this case an inverted-T skin resection was still
not needed.

1156
XI Breast Surgery
the pectoralis, and is pushed outward in the subcutaneous tissue
as the breast develops.
A true superomedial pedicle (Fig. 75.8b) includes both arteries
from the second and third interspaces. It became apparent when
creating a purely medial pedicle that the strong descending artery
from the second interspace was being sacrificed. :hy not keep
it? The true superomedial pedicle then incorporates the blood
supply to both a superior and a medial pedicle, making it very
safe. The only problem is that a true superomedial pedicle (the
base of which then extends lateral to the breast meridian) is more
difficult to inset. But when the surgeon understands that there is
no blood supply to the nipple coming through the parenchyma (it
is all superficial), then the surgeon can safely debulk as much deep
parenchyma as needed to facilitate an easier pedicle inset.
The fifth and sixth intercostals from the internal mammary
system also enter the breast just above the IMF and add extra
security to an inferior pedicle (Fig. 75.8c). This is typical for other
zones of adherence in the body. Many of these lower vessels are
cut during creation of a central pedicle.
The only other blood supply is the superficial branch of the
lateral thoracic artery, which can be seen curling around the
pectoralis and entering the lateral aspect of the breast. It supplies
a lateral pedicle (Fig. 75.8d), but it may enter the breast at a more
inferior level than the standard lateral pedicle.
It is interesting that the veins do not accompany the arteries
except for the deep perforator—they can be seen just under the
dermis, and they drain mainly superomedially. That is why I no
longer infiltrate my incision lines³I kept hitting veins and causing
small subcutaneous hematomas.
Although the main innervation to the nipple may come from
the lateral branch of the fourth intercostal nerve, there is no ques-
tion that good innervation comes from all four quadrants of the
breast. It appears that all the pedicles—lateral, medial, superior,
inferior, and central—have acceptable sensation. With the medial
pedicle, about 85% of patients will recover normal to near-normal
sensation, but that is reduced to about 75% with a lateral pedicle
and only 67% with a superior pedicle (see Table 75.1). The medial
and inferior pedicles appear to have similar recovery of sensation.
Most of the glandular breast tissue is concentrated deep to the
NAC and laterally in the upper-outer quadrant. The medial aspect
of the breast has some glandular tissue but a higher proportion
of fat.
Note that in the patient shown in Fig. 75.9, the base of the
medial pedicle only barely includes the descending artery.
Doppler examination in 85 patients in my practice showed that
this artery usually enters the pedicle just medial to the breast
meridian, but it would be safer to extend the pedicle base a bit
more laterally. In this patient the superficial branch of the lateral
thoracic artery enters the breast somewhat lower than a normally
designed lateral pedicle.
75.4 Preoperative Assessment
The key ingredient to a successful breast reduction is patient
education. It is important that patients understand the limits of
what can and what cannot be achieved. I make sure that patients
understand the concept of high- and low-breasted and that I
Fig. 75.6 (a) The breast is an ectodermally derived subcutaneous structure that is attached loosely to the skin (and firmly at the nipple). It is only very
loosely “attached” to the chest wall. Those attachments are easily swept away with a finger during a subglandular breast augmentation. The breast
is held in place by fascial condensations inferiorly (the inframammary fold) and medially (over the sternum). (b) These act much like the gluteal fold
and the sacrum. (Reproduced with permission from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts and Techniques. New York, NY: Thieme Medical
Publishers; 2010.)

75 Medial Pedicle Vertical Breast Reduction
1157
cannot change the breast footprint—that is, where the breast sits
on the chest wall.
I find that to take photographs during the consultation and
mark them for the patient is very helpful. I can show the patient
where her upper breast border is and emphasize that I cannot
change it with a breast reduction. I will also draw on the lateral
view to show her that she will still have some ptosis with some
breast overhang over the IMF. I warn all patients that they will
still be able to hold at least one pencil underneath the breast. I can
only change the lateral and inferior excess along with narrowing
the base diameter. Patients often think that they have no upper-
pole fullness because they see their breasts as ´flat,µ but then I
can show them with the pinch test and the drawing that they can
get more projection (or perkiness) with a superomedial pedicle
vertical breast reduction.
The patient shown in Fig. 75.10a is high-breasted with good
upper-pole fullness, and the patient shown in Fig. 75.10b is low-
breasted with poor upper-pole fullness. Both patients need to be
approached differently surgically, and they also need to have very
different expectations. The patient in Fig. 75.10a has a high upper
breast border but a low IMF level. She has a high breast footprint
that is long vertically. The patient in Fig. 75.10b has a low upper
breast border but a high IMF level. She has a low breast footprint
that is short vertically.
The patient shown in Fig. 75.10c has a low footprint and a low
IMF level. She has a long vertical footprint. The patient shown in
Fig. 75.10d has a low footprint with an average vertical distance.
My examination consists of assessing the breast footprint—the
upper, lateral, medial, and inferior breast borders—and then the
third dimension of how the breast sits on that footprint. Does the
patient have good upper-pole fullness? If so, she can achieve a
better cosmetic result. If a patient has a great deal of ptosis and a
poor upper pole, it will be futile to try to push the excess inferior
breast tissue into the upper pole, because it will just drop down
again. I can visualize how long the pedicle might be and whether
I need to warn the patient about a possible free nipple graft (very
Fig. 75.7 The only artery (and venae comitantes) that travels through the breast parenchyma to the nipple enters the breast directly from the chest
wall at the fourth interspace and travels to the nipple–areola complex. Although there are lateral branches (which are enclosed in a loose layer that
is described as a breast septum by Würinger), there are no other arteries that course through the parenchyma to the nipple. The blood supply to the
breast is therefore mainly superficial—the arteries and veins are in the subcutaneous tissue that was pushed outward as the breast developed. Most
of the blood supply comes from the internal thoracic (internal mammary) system via the second to sixth perforators. There is some supply from
the superficial branch of the lateral thoracic artery, but the thoracoacromial system provides only minimal additional blood supply (and none to the
nipple–areola complex). (Reproduced with permission from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts and Techniques. New York, NY: Thieme
Medical Publishers; 2010.)

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Fig. 75.8 Blood supply to various pedicles. (a) Superior pedicle. The artery to a superior pedicle comes from the second (usually) intercostal space
and descends and enters the nipple area just medial to the breast meridian and is always about 1 cm deep to the skin. It bleeds with significant force
when it is cut during creation of a pure medial pedicle (it can be traced with a pencil Doppler preoperatively). The artery to the medial pedicle also
comes from the internal mammary system (usually from the third intercostal space); it curves around the sternum, penetrates the pectoralis, and
is pushed outward in the subcutaneous tissue as the breast develops. (b) Superomedial pedicle. A true superomedial pedicle includes both arteries
from the second and third interspaces. In creating a purely medial pedicle, the strong descending artery from the second interspace is sacrificed;
why not keep it? The true superomedial pedicle then incorporates the blood supply to both a superior and a medial pedicle, making it very safe. The
only problem is that a true superomedial pedicle (the base of which then extends lateral to the breast meridian) is more difficult to inset. But because
there is no blood supply to the nipple coming through the parenchyma (it is all superficial), the surgeon can safely debulk as much deep parenchyma
as needed to facilitate an easier pedicle inset. (c) Inferior pedicle. The fifth and sixth intercostals from the internal mammary system also enter the
breast just above the inframammary fold and add extra security to an inferior pedicle. This is typical for other zones of adherence in the body. Many
of these lower vessels are cut during creation of a central pedicle. (d) Lateral pedicle. The only other blood supply is the superficial branch of the
lateral thoracic artery, which can be seen curling around the pectoralis and entering the lateral aspect of the breast. It supplies a lateral pedicle, but
it may enter the breast at a more inferior level than the standard lateral pedicle. (Reproduced with permission from Hall-Findlay EJ. Aesthetic Breast
Surgery: Concepts and Techniques. New York, NY: Thieme Medical Publishers; 2010.)

75 Medial Pedicle Vertical Breast Reduction
1159
rare). I will assess the skin quality and skin excess and again deter-
mine whether I need to warn the patient that I might need to add
a “hockey stick” or inverted-T to the vertical scar.
The two patients shown in Fig. 75.11a and Fig. 75.11b will
get very different results with any type of breast reduction. The
patient shown in Fig. 75.11a has a high breast footprint excellent
upper-pole fullness. The patient shown in Fig. 75.11b has a low
breast footprint and very poor upper-pole fullness. Any attempt
to push tissue into the upper pole is doomed to failure over time
(Fig. 75.11c).
It is important to decide preoperatively how much tissue will
need to be removed. Referring to Fig. 75.12, any attempt to push
“ab” out to “c” will inevitably result in the loss of “bc” and will
cause bottoming out.
The problem of bottoming out is illustrated in the patient shown
in Fig. 75.13a. Although the nipple was clearly placed too high
on this patient with a low footprint, there is still too much tissue
in the lower pole (Fig. 75.13b). This problem of bottoming out is
the fault of the surgeon (me)—not the procedure. A patient like
this provides the surgeon with a very difficult challenge, and help
filing the upper pole³not raising the upper breast border³can be
obtained by using an inferior (Ribeiro) type of flap (Fig. 75.13c).
Although it is tempting to elevate the upper pole of the breast
and suture the breast tissue up to the chest wall in order to
achieve an elevation of the upper breast border or to achieve more
upper-pole fullness, results are disappointing.
Fig. 75.9 In this patient, the base of the medial pedicle only barely
includes the descending artery (red arrow). Doppler examination in
85 patients in my practice showed that this artery usually enters the
pedicle just medial to the breast meridian, but it would be safer to
extend the pedicle base a bit more laterally. Note that the superficial
branch of the lateral thoracic artery (second red arrow) enters the
breast somewhat lower than a normally designed lateral pedicle.
Fig. 75.10 Breast footprint. (a) High-breasted patient with good upper-pole fullness, a high upper breast border but a low inframammary fold (IMF)
level. She has a high breast footprint that is long vertically. (b) Low-breasted patient with poor upper-pole fullness, a low upper breast border but
a high IMF level. She has a low breast footprint that is short vertically. (c) Patient with a low footprint and a low IMF level. She has a long vertical
footprint. (d) Patient with a low footprint and an average vertical distance.

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Fig. 75.11 These two patients will get very different results with any type of breast reduction. (a) This patient has a high breast footprint and excel-
lent upper-pole fullness (arrow). (b) This patient has a low breast footprint and very poor upper-pole fullness (arrow). (c) Any attempt to push tissue
into the upper pole is doomed to failure over time.
Fig. 75.12 It is important to decide preoperatively how much tissue will need to be removed. Any attempt to push “ab” out to “c” will inevitably
result in the loss of “bc” and will cause bottoming out.
Fig. 75.13 The problem of bottoming out is illustrated in this patient. (a) She underwent a medial pedicle vertical breast reduction. (b) Although
the nipple was clearly placed too high on this patient with a low footprint, there is still too much tissue in the lower pole. This problem of bottoming
out is the fault of the surgeon (me)—not the procedure. (c) A patient like this provides the surgeon with a very difficult challenge, and help filling the
upper pole—not raising the upper breast border—can be obtained by using an inferior (Ribeiro) type of flap.

75 Medial Pedicle Vertical Breast Reduction
1161
It is important to understand some definitions. The upper
breast border is at the junction of the chest wall and the breast
(Fig. 75.14, blue arrow). Sometimes this is well demarcated, and
sometimes it is a gentle slope. Projection is the measurement from
the chest wall to the most anteriorly projecting part of the breast.
This is where the nipple is ideally situated. Upper-pole fullness
can be increased in a breast reduction when increased projection
is achieved. The upper breast border cannot, however, be elevated
without the addition of either fat or an implant.
The upper breast border is clearly demarcated in the patient
shown in Fig. 75.15. Although projection is definitely improved,
there is minimal improvement in upper-pole fullness and no
elevation of the upper breast border.
The patient shown in Fig. 75.16 shows that initial improve-
ment in upper-pole fullness that is achieved by suturing breast
tissue up to the chest wall is lost over time. I tried elevating the
upper breast tissue and suturing it higher on the chest wall in 77
patients. I used absorbable 3–0 polydioxanone suture (PDS) in 43
patients and nonabsorbable 3–0 braided polyester suture (TiCron,
Medtronic, Minneapolis, MN) in 34 patients. In the 72 patients
who returned for follow-up, none of the initial improvement seen
postoperatively lasted for more than 5 months. The upper breast
border remained unchanged, and the upper pole dropped back to
its original position. Projection, on the other hand, was definitely
improved (which results in slightly more breast in the upper pole).
Improvement in upper-pole fullness can occasionally be
obtained by using the method popularized by Ruth Graf. This
takes the inferior wedge of breast tissue that is normally removed
in a breast reduction and uses it as a chest wall–based flap, which
is held up in place by a strip of pectoralis muscle. Using this ver-
tical wedge as a flap was originally described by Liacyr Ribeiro,
and it is a good method for rearranging the breast tissue in a
mastopexy. The pectoralis loop is effective at holding the wedge
of breast tissue higher on the chest wall, and it definitely improves
projection and can help fill the upper pole to some degree.
Fig. 75.14 It is important to understand some definitions. The upper
breast border (blue arrow) is at the junction of the chest wall and the
breast. Sometimes this is well demarcated, and sometimes it is a
gentle slope. Projection is the measurement from the chest wall to the
most anteriorly projecting part of the breast. This is where the nipple
is ideally situated. Upper-pole fullness can be increased in a breast
reduction when increased projection is achieved. The upper breast
border cannot, however, be elevated without the addition of either fat
or an implant.
Fig. 75.15 (a) The upper breast border is clearly demarcated in this patient (arrow). (b) Although projection is definitely improved, there is minimal
improvement in upper-pole fullness and no elevation of the upper breast border (arrow).

1162
XI Breast Surgery
I also warn patients that I often cannot make their breasts as
small as either of us would like. I cannot achieve as significant a
reduction with the vertical approaches as I could when I performed
inverted-T inferior pedicle reductions. The photographs taken
during the consultation are also useful for pointing out any asym-
metries and warning patients that symmetry is a goal but impos-
sible to achieve. Patients are also warned that breasts will change
with time, gravity, pregnancy, and weight gain and weight loss.
Teenagers are well aware that their breasts may grow as they
continue to develop and that a re-reduction might be indicated.
I believe that this is far better for many teenagers than having
them suffer until they are older, because they tend to withdraw
and stop participating in sports and other activities. As long as
the teenager understands the procedure and its limitations, then
I am fully prepared to perform the surgery when it is physically
indicated. The same applies to older patients. It is not age that
matters; it is health and psychological maturity of the patient.
75.5 Preoperative Planning
Much of preoperative planning consists of patient education. A
preoperatively informed patient is a surgeon’s best ally.
75.5.1 Markings
Upper Breast Border and Inframammary Fold
I start by marking the upper breast border (the junction of the
chest wall and the breast). This is sometimes a very clear demar-
cation, and sometimes it is less well defined. The upper breast
border is at the junction of the preaxillary fold and the breast—
where the lateral indentation occurs. I will then mark the IMF.
The patient shown in Fig. 75.17a has her upper breast border
marked with a dotted line. She is high-breasted with good upper-
pole fullness. The lowest points of her IMFs are marked on the
midline of the chest wall, with her right fold being slightly lower
than her left. Note that her new nipple position is not placed at
the level of the IMF, which is too low. The upper breast border will
not change from its preoperative position, and the nipple should
be about 8–10 cm down from the upper breast border. The patient
shown in Fig. 75.17b has a low footprint, and again the new nipple
position is not placed at the existing IMF, which is too high.
Ideal Breast Meridian
The breast meridian should be marked at its ideal or desired
position—not at its existing position. Sometimes the nipples
are too medial and sometimes they are too lateral. It is best to
err on the side of placing the meridian slightly lateral to a line
that would bisect the resulting breast after the reduction is per-
formed. More of the lateral breast tissue can be removed with
the medial pedicle vertical breast reduction, so the line can be
placed slightly more medially than it would be in an inverted-T
breast reduction. It does not matter where the line starts at the
clavicle, but it should be at the midline of the breast at the level of
the new nipple position. This will usually be about 8–10 cm from
the midline of the chest wall (not drawn around the breast but
straight from the midline).
In the patient shown in Fig. 75.18a the new meridian does
coincide with the existing meridian. In the patient shown in Fig.
75.18b, the existing meridian would be too medial. In the patient
shown in Fig. 75.18c the existing meridian would be too lateral
(this is more common than a nipple position that is too medial).
The ideal meridian is usually about 8–10 cm from the midline
of the chest. The surgeon should place the new meridian just lat-
eral of the line bisecting the resulting breast, because nipples that
are placed too medially look odd. On the other hand, the medial
pedicle vertical breast reduction removes more of the lateral
breast and narrows the breast cone better than the inverted-T
procedures, and the meridian can be drawn a bit more medially
than in an inverted-T procedure.
Fig. 75.16 (a–c) This patient shows that initial improvement in upper-pole fullness that is achieved by suturing breast tissue up to the chest wall is
lost over time.

75 Medial Pedicle Vertical Breast Reduction
1163
New Nipple Position
The new nipple position should be on the new breast meridian
about 8–10 cm below the upper breast border depending on
the height of the patient (Fig. 75.19). The surgeon should make
the nipple “too low” rather than “too high” because it is almost
impossible to lower a nipple postoperatively that has been
placed too high. I disagree with Patrick Mallucci’s ideal nipple
position being 45% down and 55% up the breast mound. That
might be the ideal when the patient arches her back and has her
arms elevated, but time tends to bottom out breasts, whether
in a breast reduction, a mastopexy, or with the addition of an
implant. Patients complain when the nipple is too high because
it slides up out of the brassiere or bathing suit (patients call it
nip-slip). I believe that the nipple should be placed just below the
horizontal meridian of the resultant breast.
The nipple does rise (as measured from the floor) from
where it is marked because of the increased projection that is
achieved. It is important to mark the new nipple position lower
in a vertical breast reduction than where one would place it in
an inverted-T breast reduction because the nipple rises more
with the increased projection that is achieved with the vertical
approaches. Measurements have shown that the suprasternal
notch to new nipple position does not change from its preopera-
tive marked level (as measured along the skin surface), but it does
Fig. 75.17 The arrows mark the upper breast border and the inframammary fold (IMF). (a) This patient has her upper breast border marked with a
dotted line. She is high-breasted with good upper-pole fullness. The lowest point of her IMF is marked on the midline of the chest wall, with her right
fold being slightly lower than her left. Note that her new nipple position is not placed at the level of the IMF, which is too low. The upper breast border
will not change from its preoperative position, and the nipple should be about 8–10 cm down from the upper breast border. (b) This patient has a low
footprint, and again the new nipple position is not placed at the existing IMF, which is too high.
Fig. 75.18 The new breast meridian should not be marked through the existing nipple position but through the desired nipple position. (a) In this
patient the new meridian does coincide with the existing meridian. (b) In this patient, the existing meridian would be too medial. (c) In this patient
the existing meridian would be too lateral (this is more common than a nipple position that is too medial).

1164
XI Breast Surgery
rise (as measured from the floor) because of the pendulum effect
(much as a child on a swing). It is better to mark the new nipple
position in relation to the upper breast border rather than the IMF.
The fold itself is a good landmark in many patients, but it can be
misleading in about 15% of patients.
Marking the new nipple at an arbitrary distance from the IMF
or the clavicle is also going to result in problems, especially in
low-breasted patients. The surgeon should be careful to lower the
nipple position in a patient with very poor upper-pole fullness. It
is difficult to lower a nipple that has been placed too high, but it is
easy to elevate a nipple that has been placed too low.
Areolar Opening
The top of the areolar opening should then be marked about 2
cm above the new nipple position. Most areolas are designed to
end up about 4–5 cm in diameter. The areolar opening can easily
be drawn freehand and then pinched at the bottom to make sure
that it forms a circle when closed.
Care should be taken to make sure that the medial aspect of
the areolar opening markings match from one side to the other.
Note that in the patient shown in Fig. 75.20, the pencil Doppler
marked the descending artery just lateral to the breast meridian,
and a pure medial pedicle would not incorporate this artery. A
true superomedial pedicle has a base that extends lateral to the
breast meridian so that it has a dual axial blood supply. Note that
the Doppler was used in this case for study purposes—it is not
necessary on routine breast reduction procedures. Note also that
a large paper clip can be opened up and used as a template for
the areola. A large paper clip is 15–16 cm long, which matches an
areola that is 5 cm in diameter.
Skin Resection Pattern
The skin resection pattern follows the vertical lines that would
be used in an inverted-T Wise pattern breast reduction. Instead
of carrying the vertical limbs laterally and medially once 5 cm is
reached, they are joined together well above the inframammary
fold.
These lines will match up with the breast and chest wall merid-
ians when the breast is rotated medially and laterally. The surgeon
can pinch the vertical limbs together to make sure that too much
skin is not being removed. Since a superomedial pedicle vertical
breast reduction does not use the skin as a brassiere and since
tension on the skin closure only causes wound healing problems,
it is better to be conservative with the skin resection pattern and
not take too much skin.
The lines need to be joined at least 2–4 cm above the IMF. This
is not only because closure of an ellipse lengthens the scar but
also because the IMF often rises. If the lines are brought down
to the fold, the scar will inevitably end up on the chest wall. The
skin resection may be drawn as a V, but the parenchymal resection
should be shaped more as a U. A postoperative pucker is more
likely to be due to excess subcutaneous tissue rather than skin.
All tissue beyond what would be a Wise pattern of parenchyma
should be removed (Fig. 75.21).
Superomedially Based Pedicle
The medially based pedicle is drawn with half of the base (4 cm)
in the areolar opening and half of the base (4 cm) on the vertical
limb, but a true superomedial pedicle is drawn in the areolar
opening just lateral to the breast meridian while keeping the
Fig. 75.19 The new nipple position should be on the new breast
meridian about 8–10 cm below the upper breast border, depending
on the height of the patient. The surgeon should make the nipple
“too low” rather than “too high” because it is almost impossible to
lower a nipple postoperatively that has been placed too high. Time
tends to bottom out breasts. Patients complain when the nipple is too
high because it slides up out of the brassiere or bathing suit (nip-slip).
(Image © Jennifer Gentry)
Fig. 75.20 Care should be taken to make sure that the medial aspect
of the areolar opening markings match from one side to the other.
Note that in this patient, the pencil Doppler marked the descending
artery just lateral to the breast meridian, and a pure medial pedicle
would not incorporate this artery. A true superomedial pedicle has
a base that extends lateral to the breast meridian so that it has a
dual axial blood supply. Note that the Doppler was used in this case
for study purposes—it is not necessary on routine breast reduction
procedures. Note also that a large paper clip can be opened up and
used as a template for the areola. A large paper clip is 15–16 cm long,
which matches an areola that is 5 cm in diameter.

75 Medial Pedicle Vertical Breast Reduction
1165
lower half based on the medial vertical limb. This then includes
the strong descending artery from the second interspace, which
then gives a true superomedial pedicle a dual axial blood supply.
The inferior border of the medial pedicle will become the medial
pillar.
It is wise to try to incorporate one of the veins that is visible
through the skin in the base of the pedicle, especially when the
pedicle is long. The veins can be seen just deep to the dermis. It
is safe to release the dermis inferiorly to allow for an easier inset
because both the veins and the arteries are more cephalad.
A true “superomedial” pedicle can be designed to take advan-
tage of the descending artery from the second interspace. It usually
enters the areolar opening just medial to the breast meridian, but
it will be missed in the patient shown in Fig. 75.21. This patient
has a very short pedicle so a pure medial pedicle can be used. A
pure medial pedicle is often erroneously called a superomedial
pedicle because it looks that way when a patient stands up.
Note that in the patient shown in Fig. 75.21a the red arrow was
determined by a pencil Doppler, and the medial pedicle marked
would miss including this artery. Although the artery usually
enters the areolar opening medial to the breast meridian, it is
safer to carry the base of the pedicle slightly lateral to the breast
meridian.
However, a true superomedial pedicle has a base that crosses
and extends slightly lateral to the breast meridian. This will make
the pedicle more difficult to inset, but because we know the
blood supply is superficial, we are free to debulk the area deep
to the breast meridian if the pedicle is stiff or difficult to inset.
This maneuver can preserve the descending artery that normally
supplies a superior pedicle.
Fig. 75.22a shows the difference between the vertical markings
in blue (which resemble a snowman) and the Wise pattern invert-
ed-T red markings. Although the nipple should actually be placed
lower in a vertical approach (to accommodate the increased
projection), the markings are clearly fairly similar. I will remove
all parenchyma (except the medial pedicle) below the red lines
but I will remove the skin only within the blue lines (Fig. 75.22b).
The idea is to leave parenchyma attached to the skin above the red
lines, leaving behind the Wise pattern.
The Wise pattern is a good design for the breast tissue that
should be left behind (Fig. 75.22c). The skin does not usually
need to be removed in the same pattern, but it can be allowed
to redrape over the new breast shape. The skin is not used as a
brassiere, so closure does not need to be tight.
Robert :ise took apart a brassiere and laid it out flat. The :ise
pattern, once brought together (Fig. 75.22d,e), nicely cones the
remaining breast tissue. The surgeon will need to keep this shape
in mind when performing the resection. It is a good design for
what should be left behind.
Fig. 75.22a–e shows how the surgeon can visualize what will
be left behind and how the shape is coned with an inferior vertical
wedge resection when the medial and lateral pillars are brought
together (Fig. 75.22f,g). Everything beyond the Wise pattern is
removed either directly or with liposuction.
Areas to Be Liposuctioned
Any areas past the breast borders that are to be liposuctioned are
then marked. In Fig. 75.23, a different patient is shown with the
lateral chest wall areas and preaxillary areas marked for liposuc-
tion. The cross-hatched areas are shown where the liposuction
is performed.
75.5.2 2SerDWiYe 7eFKniTue
Positioning
The patient is supine on the operating table with the arms angled
outward. For surgeons who wish to sit the patient up at the end
of the procedure, the arms should be carefully wrapped and the
Fig. 75.21 The skin resection pattern follows the vertical lines that
would be used in an inverted-T Wise pattern breast reduction. (a)
Instead of carrying the vertical limbs laterally and medially once 5 cm
is reached, they are joined together well above the inframammary fold
(IMF). (b) The lines need to be joined at least 2–4 cm above the IMF.
This is not only because closure of an ellipse lengthens the scar but also
because the IMF often rises. If the lines are brought down to the fold,
the scar will inevitably end up on the chest wall. The skin resection
may be drawn as a V. but the parenchymal resection should be shaped
more as a U. A postoperative pucker is more likely to be due to excess
subcutaneous tissue rather than skin. All tissue beyond what would be
a Wise pattern of parenchyma should be removed. The cross-hatched
area shows where parenchyma is removed but not the skin.

1166
XI Breast Surgery
Fig. 75.22 The Wise pattern is a good design for the breast tissue that should be left behind. (a,b) Note the difference between the vertical markings
in blue (which resemble a snowman) and the Wise pattern inverted-T red markings. Although the nipple should actually be placed lower in a vertical
approach (to accommodate the increased projection) the markings are clearly fairly similar. I will remove all parenchyma (except the medial pedicle)
below the red lines, but I will only remove the skin within the blue lines. The idea is to leave parenchyma attached to the skin above the red lines,
leaving behind the Wise pattern. (c–e) Robert Wise took apart a brassiere and laid it out flat. The Wise pattern, once brought together, nicely cones
the remaining breast tissue. The surgeon will need to keep this shape in mind when performing the resection. It is a good design for what should be
left behind. (f,g) The skin does not usually need to be removed in the same pattern, but it can be allowed to redrape over the new breast shape. The
skin is not used as a brassiere, so closure does not need to be tight. The photographs show how the surgeon can visualize what will be left behind and
how the shape is coned with an inferior vertical wedge resection when the medial and lateral pillars are brought together. Everything beyond the
Wise pattern is either removed directly or with liposuction.

75 Medial Pedicle Vertical Breast Reduction
1167
patient positioned on the table so that the back can go up in the
right position.
,nÀOWrDWiRn
I no longer infiltrate the incision lines, because I want to preserve
any veins that are found just below the dermis. I will infiltrate
the areas to be suctioned with either a tumescent type of fluid
(Ringer’s lactate 1 L with 1 mL of 1:1,000 epinephrine and 20 mL
of 2% plain lidocaine) or lidocaine with epinephrine (20 mL of 1%
with 1:200,000 epinephrine diluted with 60 mL of saline). I use
about 300–500 mL of tumescent fluid per side or about 40 mL of
the lidocaine with epinephrine per side. Most of the infiltration
is placed in the lateral chest wall in the preaxillary areas, and just
above the inframammary fold. These are the areas where most of
the liposuction is performed.
The markings are shown in Fig. 75.24a. The medial markings
are adjusted to match, and the lateral markings are carried later-
ally around the areola to avoid leaving any pigmented skin behind.
The new nipple position is marked lower on the larger breast
because closure of the vertical ellipse will push the nipple higher.
The base of the medial pedicle is extended across and lateral to
the breast meridian (cross-hatched area) in order to include the
descending artery from the second interspace (Fig. 75.24b). The
true superomedial pedicle is de-epithelialized. The arrows mark
where the dual axial arteries enter the pedicle (Fig. 75.24c).
Pedicle Creation
The pedicle is de-epithelialized in the usual fashion by placing
a lap pad around the base of the breast and holding it with a
Kocher clamp. This puts the skin under tension and allows it
to be removed more easily. The superomedial pedicle is much
easier to de-epithelialize than an inferior pedicle. A cuff of tissue
is left around the new areola using the Schwartzman maneuver.
Even when the nipple is high and contained within the areo-
lar opening, I still prefer a medially based pedicle rather than
a superior pedicle. This not only allows me better access to the
excess lateral breast tissue but it also maintains the elegant curve
to the lower pole of the breast because the inferior border of the
medial pedicle becomes the medial pillar. The pedicle is then cut
straight down to the chest wall to create a full-thickness pedicle.
The blood supply is superficial, but keeping it full thickness allows
preservation of sensation and ductal tissue.
Parenchymal Resection
The pedicle creation and parenchymal resection are performed
together, with the pedicle remaining relatively full thickness
(Fig. 75.24d). It can be thinned as needed to allow an easier inset.
The parenchyma is removed initially as an inferior vertical wedge
excision (Fig. 75.24e). The parenchyma is removed where it is in
excess—inferior and lateral. The bulk of the parenchyma under
the lateral flap needs to be removed (Fig. 75.24f). It is important
to leave a lateral pillar about 2 cm thick (see purple marked
areas) and then resect all excess parenchyma underneath the
lateral flap (Fig. 75.25a).
Any parenchyma that extends beyond the Wise pattern borders
needs to be removed. This is especially important laterally in
teenagers. In older women the excess can be removed with lipo-
suction. The breast tissue is removed laterally by beveling out the
resection after leaving behind a 2 cm lateral pillar that is about 7
cm long. The parenchyma beyond that is then removed by beveling
out under the lateral flap and removing tissue parallel to the chest
wall. When the patient has very thick glandular breast tissue (e.g.,
teenagers), this tissue will actually need to be carefully carved
out, making sure not to leave any ridges behind. Breasts that have
a higher fat content will be more forgiving. It is often difficult to
make breasts small enough when using a medial pedicle vertical
breast reduction, and it is this lateral breast tissue that needs to be
more extensively resected (Fig. 75.25b).
It is important to remove all breast tissue below the Wise pat-
tern, and this includes removing tissue by undermining down to
the inframammary fold. I find it easiest to grasp this extra tissue
with a Kocher clamp and then resect it. It is important to leave
enough fat on the dermis so that postoperative scar contracture
does not occur. Tissue is removed all along the inframammary fold,
both medially and laterally. Some of this tissue is quite fibrous and
will need to be directly excised. It can be finally complemented
with liposuction. Liposuction is usually performed after closure of
the pillars and the deep dermis.
Exposure of the pectoralis muscle can cause more bleeding, and
it can also damage some of the nerves that supply innervation to
the nipple. It is, however, important to make sure that the perfo-
rator (and its lateral branches) are carefully cauterized to prevent
a postoperative hematoma. The deep branch of the lateral fourth
intercostal nerve travels just above the pectoralis fascia and then
turns up toward the nipple at the breast meridian. Taking care
not to damage the pectoralis fascia and keeping the pedicle full
thickness might help in preservation of this nerve.
The lower limits of the pillars match what would be the lateral
and medial extensions in a Wise pattern skin resection (markings
on the skin). The inferior border of the medial pedicle which, when
rotated up, becomes the medial pillar. Both pillars will be about
Fig. 75.23 Patient with the lateral chest wall areas and preaxillary
areas marked for liposuction. The cross-hatched areas are shown
where the liposuction is performed.

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7 cm long in an ideal C-cup breast. The parenchyma below the
Wise pattern in the area marked by the inverted-T skin resection
pattern was called the “ghost” areas by Dr. Carolyn Kerrigan, and
this is the tissue that needs to be removed (Fig. 75.25c).
The ghost areas under the skin marking the inverted-T areas
needs to be cleared out, but a layer of fat needs to be left on the
dermis so that scar contracture to the chest wall does not occur.
The criss-cross inframammary fibers can be seen in this view (Fig.
75.25d).
Because the pedicle will tend to be thin at the distal end (not
because it is actually thinned, but it will appear to be thinned
much like an inferior pedicle), it is important to leave a small
platform of tissue superiorly and laterally to help prevent areolar
retraction postoperatively. The edge is marked in purple. This
tissue cannot, however, be pushed up into the upper pole to try
to increase upper-pole fullness because it will drop back down
again (Fig. 75.25e).
The first suture is placed at the base of the areola, and the
shape can then be assessed. The pedicle is then pulled up with
the forceps, which causes the pillars to fall together. This is a key
maneuver in making sure that the pillars are sutured together
properly (Fig. 75.25f).
The pillar sutures start about halfway up the skin opening—at
the same level as the inverted-T markings. The pillar closure is
about 5–7 cm long. The lower border of the pillars does not extend
as far down as the skin opening and definitely not down as far
as the original inframammary fold. This is a mistake that many
surgeons make when moving over to a vertical approach (Fig.
75.26a).
The upper Wise pattern markings show the inferior aspect of
both pillars. It can be seen that the inferior border of the medial
pedicle becomes the medial pillar. The pillar sutures start at the
level of markings about 1 or 2 cm deep to the skin. I use 3–0 poli-
glecaprone (Monocryl, Johnson & Johnson, New Brunswick, NJ) to
close the pillars, and only about three to four sutures are used. It
is not necessary, and in fact is contraindicated, to try to mobilize
lateral tissue and close it under tension. The pillar closure should
have very little tension. The pedicle can be pulled up during clo-
sure to make sure that the pillar can be better visualized. It might
be advisable to suture extra long pedicles up to breast tissue to
Fig. 75.24 Operative technique. (a) The markings are shown. The medial markings are adjusted to match, and the lateral markings are carried later-
ally around the areola to avoid leaving any pigmented skin behind. The new nipple position is marked lower on the larger breast because closure of
the vertical ellipse will push the nipple higher. (b) The base of the medial pedicle is extended across and lateral to the breast meridian (cross-hatched
area) in order to include the descending artery from the second interspace. (c) The true superomedial pedicle is de-epithelialized. The arrows
mark where the dual axial arteries enter the pedicle. (d) The pedicle creation and parenchymal resection are performed together with the pedicle
remaining relatively full thickness. It can be thinned as needed to allow an easier inset. (e) The parenchyma is removed initially as an inferior vertical
wedge excision. (f) The parenchyma is removed where it is in excess—inferior and lateral. The bulk of the parenchyma under the lateral flap needs to
be removed.

75 Medial Pedicle Vertical Breast Reduction
1169
help hold them there while healing occurs. Large, deep bites are
not necessary³pedicle sutures are needed only so that fibrous-
type tissue can heal to fibrous-type tissue.
The tissue (parenchyma and fat) between the upper and lower
limbs of the Wise pattern needs to be removed (Fig. 75.26c,d).
The deep dermis is closed, and then liposuction is performed
in the areas marked. It is easier to close the deep dermis first to
provide some resistance when performing the liposuction. Note
that the breast that remains behind has a Wise pattern shape. The
way to decide whether a T skin resection is needed is to lift the
breast off the chest wall and push it caudally. If the skin tucks in
then a T is not needed (Fig. 75.26d). It is important not to just
push the breast caudally or it will look as if there will be extra
skin (Fig. 75.26e).
Fig. 75.26f shows how the extra skin will tuck up behind the
pillars. Although the pillars may measure only about 7 cm, the
skin can be over 10 cm. The extra skin is actually needed to
accommodate the extra projection that results with this vertical
type of breast reduction.
The inferior vertical wedge excision results in good control of
the horizontal base diameter of the breast (Fig. 75.27a).
The areola is then closed with four interrupted deep dermal
sutures. The areola is sutured into place in the position where it
seems to sit the most easily without any kinking. Both the deep
dermis and the subcuticular closure are completed using 3–0
Monocryl. The vertical incision is not gathered. Initially when
vertical breast reduction was introduced it was thought that the
vertical incision could and should be kept short by cinching up the
closure. It actually did not work because the incisions stretch back
out (and if they didn’t they required a revision). Not only did it not
work, but the extra length is actually necessary to accommodate
the extra projection that is achieved with a vertical approach.
A B-cup breast will have a vertical length (from the lower edge
of the areola to the inframammary fold) of about 7 cm, a C-cup
Fig. 75.25 Operative technique. (a) It is important to leave a lateral pillar about 2 cm thick (see purple marked areas) and then resect all excess
parenchyma underneath the lateral flap. (b) Any parenchyma that extends beyond the Wise pattern borders needs to be removed. This is especially
important laterally in teenagers. (c) The lower limits of the pillars match what would be the lateral and medial extensions in a Wise pattern skin
resection (markings on the skin). The inferior border of the medial pedicle, which, when rotated up, becomes the medial pillar. Both pillars will be
about 7 cm long in an ideal C-cup breast. (d) The ghost areas under the skin marking the inverted-T areas needs to be cleared out, but a layer of fat
needs to be left on the dermis so that scar contracture to the chest wall does not occur. The criss-cross inframammary fibers can be seen in this view.
(e) Because the pedicle will tend to be thin at the distal end (not because it is actually thinned, but it will appear to be thinned much like an inferior
pedicle), it is important to leave a small platform of tissue superiorly and laterally to help prevent areolar retraction postoperatively. The edge is
marked in purple. This tissue cannot, however, be pushed up into the upper pole to try to increase upper-pole fullness, because it will drop back down
again. (f) The first suture is placed at the base of the areola, and the shape can then be assessed. The pedicle is then pulled up with the forceps, which
causes the pillars to fall together. This is a key maneuver in making sure that the pillars are sutured together properly.

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breast will have a length of about 9 cm, and a D-cup breast about
11 cm (Fig. 75.27b).
The skin is not sutured to breast tissue, and the skin pucker is
not sutured down to the chest wall. This just delays resolution of
the shape. Paper tape is used to cover the incisions (Fig. 75.27c).
No attempt is made to control the breast shape with tape. It is the
resection that controls the shape, leaving behind a Wise pattern of
parenchyma. The skin then redrapes over the new shape.
The 62-year-old patient shown in Fig. 75.24, Fig. 75.25, Fig.
75.26, and Fig. 75.27 had 312 g removed from the right breast
and 394 g from the left breast. Another 350 mL of fat was removed
with liposuction. She was 5 feet, 4 inches tall and weighed 150 lb.
She is shown at 3 weeks after surgery, both standing (Fig. 75.27d)
and lying down (Fig. 75.27e). It can be seen how quickly the infe-
rior puckers tuck in and settle.
Fig. 75.28 illustrates how a longer vertical length from the
bottom of the areola to the inframammary fold is actually desir-
able. A 5 cm vertical length results in a flattened breast with very
little projection.
The vertical length is longer with larger breasts and this is
needed to accommodate projection. The distance from the bottom
of the areola to the IMF is 7 cm on the patient in Fig. 75.28d, and
it is 9 cm on the patient in Fig. 75.28e.
75.6 Postoperative Care
The patients are placed in a noncompressing brassiere just to
provide support for about 2 weeks. They are not required to wear
the brassiere, but most patients will wear some form of support
for 2 to 3 weeks night and day.
Patients are encouraged to shower the next day, and the paper
tape forms a good cover and bandage. The tape is actually difficult
to remove before 3 to 4 weeks, and it is easier to remove dry than
in the shower.
Most patients understand that it takes about 1 to 2 weeks to get
back to normal activities and 3 to 4 weeks to get back to sporting
activities. They can walk during the first week or so to maintain
Fig. 75.26 Operative technique. (a) The pillar sutures start about halfway up the skin opening—at the same level as the inverted-T markings. The
pillar closure is about 5–7 cm long. The lower border of the pillars does not extend as far down as the skin opening and definitely not down as far as
the original inframammary fold. This is a mistake that many surgeons make when moving over to a vertical approach. (b,c) The tissue (parenchyma
and fat) between the upper and lower limbs of the Wise pattern needs to be removed. (d) The deep dermis is closed, and then liposuction is
performed in the areas marked. It is easier to close the deep dermis first to provide some resistance when performing the liposuction. Note that the
breast that remains behind has a Wise pattern shape. The way to decide whether a T skin resection is needed is to lift the breast off the chest wall and
push it caudally. If the skin tucks in, then a T is not needed. (e) It is important not to just push the breast caudally or it will look as if there will be extra
skin. (f) This illustration shows how the extra skin will tuck up behind the pillars. Although the pillars may only measure about 7 cm, the skin can be
over 10 cm. The extra skin is actually needed to accommodate the extra projection that results with this vertical type of breast reduction.

75 Medial Pedicle Vertical Breast Reduction
1171
fitness, and they can walk uphill if they want to maintain an aer-
obic training level. They are advised to start with the stationary
bicycle and then with time to progress to jogging. They can use
lower-body weights initially, but they should hold off on upper-
body weights for a few weeks. Patients are not restricted in their
arm movement or in driving.
The 18-year-old woman shown in Fig. 75.29 had 371 g removed
from her right breast and 263 g removed from her left breast (Fig.
75.29a–e). She had another 150 mL of fat removed using liposuc-
tion. She was 5 feet, 8 inches tall and weighed 150 lb. She is shown
over 2 years after her breast reduction (Fig. 75.29f–g). Note from
the mole under her left breast that the IMF has risen. The mole was
right in the IMF preoperatively. She had a long vertical footprint,
and her new nipple position was marked well above the IMF level.
The 53-year-old woman shown in Fig. 75.30 had a superomedial
pedicle vertical breast reduction with removal of 230 g from her
right breast and 190 g from her left breast. She had another 150
mL of fat removed using liposuction (Fig. 75.30a,b). She was 5 feet,
9 inches tall and weighed 140 lb. She is shown at 18 months after
her surgery (Fig. 75.30c,d). Her new nipple position was marked
at the IMF level, but note that it was marked at the desired—not
the existing—meridian. The overlay photos (Fig. 75.30e,f) show
that the upper breast border has not changed. The reduction does
not raise the footprint, but it removes the glandular ptosis.
The 43-year-old woman shown in Fig. 75.31 has a low footprint.
She had 160 g removed from her right breast and 110 g from her
left breast (Fig. 75.31a,b). She was 5 feet, 7 inches (170 cm) tall
and weighed 140 lb. She is shown only 7 weeks after her surgery,
but it can be seen that she still has a low footprint (Fig. 75.31c,d).
The 50-year-old woman shown in Fig. 75.32 underwent a
superomedial pedicle breast reduction with an added inverted-T
to remove the redundant skin (Fig. 75.32a,b). She had 1,080 g
removed from the right breast and 915 g from the left breast (Fig.
75.32c). She had another 800 mL of fat removed using liposuction.
She was 5 feet, 2 inches tall and weighed 180 lb. She is shown at 1
year after her surgery (Fig. 75.32d,e).
75.7 Problems and Complications
It is important to avoid any tension on either the breast tissue or
the skin. Tension on the skin causes wound healing problems, and
tension on the breast parenchyma causes eventual loss of shape.
The most significant problem with a medial pedicle vertical
breast reduction is the inability to make breasts as small as we
Fig. 75.27 Operative technique. (a) The inferior vertical wedge excision results in good control of the horizontal base diameter of the breast. (b) The
areola is then closed with four interrupted deep dermal sutures. The areola is sutured into place in the position where it seems to sit the most easily
without any kinking. Both the deep dermis and the subcuticular closure are completed using 3–0 Monocryl. The vertical incision is not gathered or
cinched. The skin is not sutured to breast tissue, and the skin pucker is not sutured down to the chest wall. This just delays resolution of the shape.
(c) Paper tape is used to cover the incisions. No attempt is made to control the breast shape with tape. It is the resection that controls the shape,
leaving behind a Wise pattern of parenchyma. The skin then redrapes over the new shape. (d,e) The 62-year-old patient shown in this series had 312
g removed from the right breast and 394 g from the left breast. Another 350 mL of fat was removed with liposuction. She was 5 feet, 4 inches tall and
weighed 150lb. She is shown at 3 weeks after surgery, both standing and lying down. It can be seen how quickly the inferior puckers tuck in and settle.

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would like. None of the breast reduction techniques can elevate
the breast footprint, and none of them can elevate the upper
breast border. It can be difficult to achieve symmetry.
The following are the most common reasons for revision :
1. Correction of an inferior breast pucker
2. Re-reduction
3. Correction of asymmetry
The most common potential complications include the
following:
1. Hematoma
2. Seroma
3. Infection
4. Wound healing problems
5. Dehiscence
Fig. 75.28 The vertical length is needed to accommodate the increased projection that results from a superomedial vertical breast reduction. (a–c)
These drawings illustrate how a longer vertical length from the bottom of the areola to the inframammary fold is actually desirable. A 5 cm vertical
length results in a flattened breast with very little projection. (d,e) Note in the photographs that the vertical length is longer with larger breasts and
that the vertical length is needed to accommodate projection. The distance from the bottom of the areola to the inframammary fold is 7 cm on the
patient in (d) and 9 cm on the patient in (e).