75 Medial Pedicle Vertical Breast Reduction
1173
6. Fat necrosis
7. Nipple necrosis
75.7.1 Revisions
Correction of an Inferior Breast Pucker
Puckers are not necessarily more common with the vertical
approach, but they are easier to correct than the medial and
lateral puckers that occur with an inverted-T procedure. Puckers
can be prevented by adding a T, a J, or an L at the time of the
initial surgery, but it was pointed out by de Mey that adding a T
did not necessarily lower the revision rate. It is not always easy
to design a T or to know exactly where to put it.
Puckers are present in many patients, but they tend to disap-
pear over time as the pucker tucks in. Initially I thought it was
best to correct puckers through adding a T incision, but that often
just adds two new dog-ears to chase. It is often better to correct a
pucker through a vertical skin incision and a horizontal fat exci-
sion. Most puckers are actually caused by excess subcutaneous
tissue rather than excess skin.
The patient shown in Fig. 75.33 had 300 g removed from the
right breast and 290 g from the left breast. Her small puckers
were corrected through small vertical elliptical skin excisions
(Fig. 75.33b–d) and larger horizontal fat excisions with good
results (Fig. 75.33e).
Re-reduction
Re-reduction is not always straightforward. It is important not to
remove too much skin. Wider tissue excision can be performed,
especially laterally, as in the following patient. Liposuction is an
important adjunct to a re-reduction. But often the vertical scar
ends up too long and a J and an L or a T may need to be added.
Unfortunately, sometimes increased problems with dog-ears can
be a nuisance.
The patient shown in Fig. 75.34a initially had a vertical breast
reduction, and she underwent a re-reduction. At the time of the
re-reduction she had 403 g and 290 g removed along with another
375 mL of liposuction (Fig. 75.34b). The vertical incision was too
long and a J and an L were added. It can be seen that this does not
always solve the problem because it adds a new lateral dog-ear to
be chased (Fig. 75.34c).
Correction of Asymmetry
It is important to lower the new nipple position on the larger side
when performing a vertical breast reduction. This lower nipple
position will be needed only partly because of the tension on the
skin with the increased weight. But this is more of a problem
Fig. 75.29 This 18-year-old woman was a good candidate for a superomedial pedicle vertical breast reduction. The markings show that she had a low
breast footprint and that her inframammary fold was already lower than her existing nipple position. The new nipple position was instead marked in
relation to the upper breast border. (a–e) She had 371 g removed from her right breast and 263 g removed from her left breast. She had another 150
mL of fat removed using liposuction. She was 5 feet, 8 inches tall and weighed 150 lb. (f,g) She is shown over 2 years after her breast reduction Note
from the mole under her left breast that the inframammary fold has risen. The mole was right in the inframammary fold preoperatively. She had a
long vertical footprint, and her new nipple position was marked well above the inframammary fold level.
1174
XI Breast Surgery
Fig. 75.30 This 53-year-old woman had very laterally displaced nipples. She was 5 feet, 9 inches tall and weighed 140 lb. (a,b) Her new nipple
position was marked at the inframammary fold level, but note that it was marked at the desired, not the existing, meridian. She 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. (c,d) She is shown at 18 months after her surgery. (e,f) The overlay photos show that the upper breast border has not changed. The
reduction does not raise the footprint but it removes the glandular ptosis.
Fig. 75.31 This 43-year-old woman has a low footprint. She was 5 feet,
7 inches tall and weighed 140 lb. (a,b) She had 160 g removed from her
right breast and 110 g from her left breast. (c,d) She is shown only 7 weeks
after her surgery, but it can be seen that she still has a low footprint.
Fig. 75.32 This 50-year-old woman underwent a superomedial pedicle
breast reduction. She was 5 feet, 2 inches tall and weighed 180 lb. (a,b)
She had 1,080 g removed from the right breast and 915 g from the left
breast. (c) She had an added inverted-T to remove the redundant skin.
She had another 800 cc of fat removed using liposuction. (d,e) She is
shown at one year after her surgery.
75 Medial Pedicle Vertical Breast Reduction
1175
with the vertical approach because closure of a wider inferior
ellipse will push the ends farther.
The patient shown in Fig. 75.35 shows that the new nipple
should have been positioned lower on the larger breast. Part of
the problem is that the nipple has been pushed up, and part of the
problem is that not enough inferior breast tissue was resected on
the right side.
75.8 Complications
75.8.1 Hematoma
The patient shown in Fig. 75.36 came in 2 weeks after surgery
with a hematoma. At that stage it was allowed to resolve on its
own. This patient had had drains in place, and she was fine the
following morning when the drains were removed. It is assumed
that the actual removal of the drain stirred up some bleeding,
which caused the hematoma. I have not used drains routinely
since.
It is important to know the vascular anatomy to the breast and
to seek out any potential bleeders before closing. This is especially
important in those patients where a tumescent type of infiltration
has been used. The vessels may be in spasm, only to release later
when the epinephrine effect has worn off.
The incidence of hematoma has been only about 1 in 400
patients.
75.8.2 Seroma
Seroma is probably fairly common. I have not aspirated or drained
seromas on a routine basis, and they seem to resolve uneventfully.
We keep close contact with patients postoperatively, and rarely
has any patient reported any spontaneous drainage. In contrast
to an abdominoplasty, where the seroma does not have a path to
drain, the breast seroma seems to be absorbed quite well.
75.8.3 Infection
There is no question that infection will occasionally occur
(Fig. 75.37). I was able to reduce not only my incidence of
infection but also my incidence of suture spitting when I put all
patients on a week of antibiotics. The suture-spitting problem
disappeared almost completely. Breasts have multiple ducts con-
nected to the environment, and it is incorrect to classify breast
surgery as “clean.” The presence of bacteria in ducts means that
whenever ducts are transected, the surgery should be classified
as “clean-contaminated.” Now the recommendation is only one
intraoperative dose of antibiotics, and unfortunately when I did
Fig. 75.33 Pucker correction. (a) This patient had 300 g removed from the right breast and 290 g from the left breast. (b–d) Her small puckers were
corrected through small vertical elliptical skin excisions and larger horizontal fat excisions.(e) She is shown after the pucker correction with good results.
1176
XI Breast Surgery
that, some suture spitting and low-grade infection as seen in Fig.
75.37 occurred. The problem seems to be improved with the use
of one preoperative dose of antibiotics and the use of an antibac-
terial (triclosan-impregnated) suture (Monocryl Plus, Johnson
& Johnson, New Brunswick, NJ). I do believe that many cases of
suture spitting were caused by a low-grade infection.
75.8.4 Wound Healing Problems
Although infection is one cause of wound healing problems,
I believe that many areas of delayed healing are actually areas
of too much tension (Fig. 75.38). Wound healing problems are
common in inverted-T procedures at the T junction, and open
sores and delayed healing are the most commonly reported
problems with inverted-T breast reductions.
Now that I make sure that I avoid any constriction on the skin
closure the incidence of healing problems is extremely low. It is
important to close the breast tissue pillars (to avoid fat necrosis)
under very little tension, and it is important to close the skin (to
avoid wound healing problems) under very little tension.
75.8.5 Dehiscence
The type of wound dehiscence seen in Fig. 75.39a is uncommon
and can result from either a low-grade infection or, more likely, a
suture failure. It is best not to resuture the area but to let it heal
by secondary intention as shown.
75.8.6 Fat Necrosis
Fat necrosis tends to occur in the upper pole of the breast just
above the areola. This is most likely due to some parasitic fat
at the end of the pedicle that did not have an adequate blood
supply. Although I have encountered a few patients with a firm
Fig. 75.34 Re-reduction. (a) This patient initially had a vertical breast reduction, and she underwent a re-reduction as marked. (b) At the time of the
re-reduction she had 403 g and 290 g removed along with another 375 mL of liposuction. The vertical incision was too long, and a J and an L were
added. (c) It can be seen that this does not always solve the problem because it adds a new lateral dog-ear to be chased.
Fig. 75.35 (a,b) This patient shows that the new nipple should have been positioned lower on the larger breast. Part of the problem is that the nipple
has been pushed up, and part of the problem is that not enough inferior breast tissue was resected on the right side.
75 Medial Pedicle Vertical Breast Reduction
1177
mass in this area in the first few weeks to months after surgery,
they have all resolved on their own without requiring any surgi-
cal intervention.
Fat necrosis can occur if large, constricting bites of tissue are
taken in order to close the pillars. This is more likely to be a prob-
lem if the pillars are closed under tension.
More commonly, fat necrosis occurs in association with nipple
necrosis when the blood supply to the pedicle fails.
75.8.7 Nipple Necrosis
Nipple necrosis unfortunately can and does occur. Fig. 75.40
shows a patient with a partial nipple and areolar necrosis, which
healed very well without any intervention. It is better to wait and
see what results rather than debriding the tissue too early.
75.9 Outcomes
There is no question that all forms of breast reduction have
a significant improvement in back pain, neck pain, shoulder
grooving, and even headaches. The rashes under the breasts can
be improved, and patients often report better exercise tolerance
and psychological well-being. Patients often concentrate preop-
eratively on the symptoms, but they concentrate postoperatively
on the cosmetic appearance.
Fig. 75.36 This patient came in 2 weeks after surgery with a hema-
toma. At that stage it was allowed to resolve on its own. This patient
had had drains in place, and she was fine the following morning when
the drains were removed. It is assumed that the actual removal of the
drain stirred up some bleeding, which caused the hematoma. I have
not used drains routinely since.
Fig. 75.37 There is no question that infection will occasionally occur
as it did in this patient at the junction of the areola and the vertical
incision. Suture spitting is often a low-grade infection.
Fig. 75.38 (a,b) Although infection is one cause of wound healing problems, It is important to close the skin (to avoid wound healing problems such
as this) under very little tension.
1178
XI Breast Surgery
Fig. 75.40 (a–d) Nipple necrosis unfortunately can and does occur. The example provided here shows a patient with a partial nipple and areolar
necrosis that healed very well without any intervention. It is better to wait and see what results rather than debriding the tissue too early. She is
shown before surgery and at 2 weeks, 6 weeks, and 3 months after surgery.
Fig. 75.39 (a,b) This type of wound dehiscence is uncommon and can result from either a low-grade infection or, more likely, a suture failure. It is
best not to resuture the area but to let it heal by secondary intention as shown.
75 Medial Pedicle Vertical Breast Reduction
1179
75.10 Results
The 19-year-old woman shown in Fig. 75.41 had a superomedial
pedicle vertical breast reduction. She had 310 g removed from
the right breast and 200 g removed from the left breast. She had
another 40 mL of fat removed with liposuction. She is shown
at 13 months postoperatively. She was 5 feet, 8 inches tall and
weighed 150 lb. The overlay shows that the breast reduction does
not elevate the breast footprint but removes the breast tissue
where it is in excess (inferior and lateral).
The 54-year-old woman shown in Fig. 75.42 had a superomedial
pedicle vertical breast reduction. There was no added inverted-T
scar. She had 640 g removed from her right breast and 610 g from
her left breast. She had another 1,050 mL of fat removed with
liposuction. She is shown at 2 years after her breast reduction. She
was 5 feet, 4 inches tall and weighed 175 lb.
75.11 Concluding Thoughts
The best breast reduction is the breast reduction that that par-
ticular surgeon does the best. I have tried all the various pedicles
and many of the skin resection patterns. I have found that I
can achieve the best results cosmetically and with the fewest
complications when I use the (true) superomedial vertical breast
reduction.
Because the breast tissue is removed where it is “in excess”
(inferiorly) and leaves the remaining breast tissue attached to the
superior skin flaps, I have been able to achieve better, long-lasting
results with this technique. It makes sense from a gravity stand-
point. The vertical elliptical excision (rather than a horizontal type
of elliptical excision) allows better control of the horizontal base
diameter of the breast, and it gives a result with better projection.
Although I originally moved to a vertical pattern breast reduc-
tion from the standard inferior pedicle inverted-T breast reduc-
tion in order to avoid the IMF scar, it is clear that the improved
results are not as much about the reduced scarring as they are
about the improved shape. That shape can be maintained for
longer because the superomedial pedicle vertical breast reduc-
tion works with gravity rather than against it. Whenever there
is too much excess, redundant skin, then it can be removed in
an inverted-T pattern while maintaining the shape advantages.
There is nothing wrong with adding an inverted-T when there is
too much excess skin. :hen a patient has had significant weight
loss, for example, the skin will not retract well, and any excess
will need to be removed. This excess removal is best performed
by removing skin above and along the IMF. The Wise pattern is
Fig. 75.41 This 19-year-old woman had a superomedial pedicle vertical breast reduction. She was 5 feet, 8 inches tall and weighed 150 lb. (a,b) She
is shown preoperatively with her markings. (c,d) She had 310 g removed from the right breast and 200 g removed from the left breast. She had
another 40 mL of fat removed with liposuction. (e,f) She is shown at 13 months postoperatively. The overlay shows that the breast reduction does
not elevate the breast footprint but removes the breast tissue where it is in excess (inferior and lateral).
1180
XI Breast Surgery
a good design for the parenchyma that is left behind, but it also
remains a good design when excess skin needs to be removed. It
takes time and experience, however, for surgeons to realize that
the superomedial pedicle vertical approach does not use the skin
as a brassiere and that the skin does not need to be tightened to
give the breast shape. The skin will redrape over the newly shaped
breast mound, and obviously this is best achieved when the skin
has good elasticity.
The vertical concept takes a readjustment in thinking for
surgeons to accept that the extra vertical distance is needed to
accommodate the increased projection that results with the
superomedial pedicle vertical breast reduction. When the skin is
being used as a brassiere, surgeons will keep it short vertically
because they know that it will stretch; however, if there is a
significant amount of redundant skin of poor quality, it must be
removed. The Wise pattern is the best way to achieve good results
in these cases.
The true superomedial pedicle appears to be the safest pedicle
because it has a dual axial blood supply. The true superomedial
pedicle takes into account the fact that the majority of the arterial
supply to the breast comes in a segmental pattern from the inter-
nal thoracic (internal mammary) system. The venous drainage
tends to be mainly superomedial.
Clinical Caveats
• Surgeons should understand the concept of low- and
high-breasted.
• The (true) superomedial pedicle vertical breast reduction is
not about the scars.
• A vertical or inverted-T skin resection pattern can be used.
• The advantages are a long-lasting shape with good projection.
• The surgeon should leave behind parenchyma in a Wise
pattern and excise or suction all tissue beyond that pattern.
• A key maneuver for a good result includes pulling up on the
pedicle so that the pillars fall together where they should be
sutured.
• A second key maneuver for a good result is to lift the breast
up off the chest wall. If the redundant inferior skin tucks in,
then an inverted-T skin resection is not needed.
• The concept of the vertical wedge resection is key: it narrows
the breast base, uses parenchymal excision and shaping to
maintain the result, and removes the heavy inferior pole, and
it does not rely on skin as a brassiere.
• What is “removed” in a breast reduction should be “moved”
in a mastopexy.
• Patient education is the key to a good result.
Fig. 75.42 This 54-year-old woman had a superomedial pedicle vertical breast reduction. She was 5 feet, 4 inches tall and weighed 175 lb. (a–c) She
is shown preoperatively. There was no added inverted-T scar. She had 640 g removed from her right breast and 610 g from her left breast. She had
another 1,050 mL of fat removed with liposuction. (d–f) She is shown at 2 years after her breast reduction.
75 Medial Pedicle Vertical Breast Reduction
1181
Suggested Reading
[1] Arie G. Una nueva tecnica de mastoplastia. Rev Latino Cir Plast 1957;3:28
[2] Asplund OA, Davies DM. Vertical scar breast reduction with medial flap or glan-
dular transposition of the nipple-areola. Br J Plast Surg 1996;49(8):507–514
[3] Benelli L. A new periareolar mammaplasty: the “round block” technique. Aes-
thetic Plast Surg 1990;14(2):93–100
[4] Berthe J-V, Massaut J, Greuse M, Coessens B, De Mey A. The vertical mamma-
plasty: a reappraisal of the technique and its complications. Plast Reconstr Surg
2003;111(7):2192–2199, discussion 2200–2202
[5] Chiari Júnior A. The L short-scar mammaplasty: a new approach. Plast Reconstr
Surg 1992;90(2):233–246
[6] Lejour M. Vertical Mammaplasty and Liposuction of the Breast. St Louis: Quality
Medical Publishing; 1993
[7] Courtiss EH, Goldwyn RM. Reduction mammaplasty by the inferior pedicle tech-
nique. An alternative to free nipple and areola grafting for severe macromastia or
extreme ptosis. Plast Reconstr Surg 1977;59(4):500–507
[8] Georgiade 1G, Serafin D, Morris R, Georgiade G. Reduction mammaplasty utiliz-
ing an inferior pedicle nipple-areolar flap. Ann Plast Surg 1979;3(3):211–218
[9] Gradinger GP. Reduction mammoplasty utilizing nipple-areola transplantation.
Clin Plast Surg 1988;15(4):641–654
[10] Graf R, Auersvald A, Bernardes A, Biggs TM. Reduction mammaplasty and mas-
topexy with shorter scar and better shape. Aesthetic Surg J 2000;20:99–106
[11] Hall-Findlay EJ. Vertical breast reduction with a medially-based pedicle. Aesthet
Surg J 2002;22(2):185–194
[12] Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast
Surg 2002;29(3):379–391
[13] Hall-Findlay E-. A simplified vertical reduction mammaplasty: shortening the
learning curve. Plast Reconstr Surg 1999;104(3):748–759, discussion 760–763
[14] Hall-Findlay EJ. Invited discussion, simplifying the vertical reduction mammma-
plasty. Plast Reconstr Surg 2004;113(1):173–174
[15] Strauch B, Elkowitz M, Baum T, Herman C. Superolateral pedicle for breast
surgery: an operation for all reasons. PRS 2005;115(5):1269–1277 discussion
1278–1279
[16] Hall-Findlay E-. The three breast dimensions: analysis and effecting change. Plast
Reconstr Surg 2010;125(6):1632–1642
[17] Hall-Findlay EJ, Shestak KC. Breast reduction. Plast Reconstr Surg
2015;136(4):531e–544e
[18] Hall-Findlay EJ. Discussion: The blood supply of the breast revisited. Plast Recon-
str Surg 2016;137(5):1398–1400
[19] Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mamma-
plasty. Plast Reconstr Surg 1999;103(3):890–901, discussion 902
[20] Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr Surg
1996;97(2):373–380
[21] Mallucci P, Branford OA. Concepts in aesthetic breast dimensions: analysis of the
ideal breast. J Plast Reconstr Aesthet Surg 2012;65(1):8–16
[22] Marchac D, de Olarte G. Reduction mammaplasty and correction of ptosis with a
short inframammary scar. Plast Reconstr Surg 1982;69(1):45–55
[23] Matthews JLK, Oddone-Paolucci E, Lawson DM, Hall-Findlay EJ. Vertical
Scar Breast Reduction: Does Gathering the Incision Matter? Ann Plast Surg
2016;77(1):25–31
[24] Mc.issock P.. Reduction mammaplasty with a vertical dermal flap. Plast Recon-
str Surg 1972;49(3):245–252
[25] Mistry RM, MacLennan SE, Hall-Findlay EJ. Principles of breast re-reduction: a
reappraisal. Plast Reconstr Surg 2017;139(6):1313–1322
[26] Palmer JH, Taylor GI. The vascular territories of the anterior chest wall. Br J Plast
Surg 1986;39(3):287–299
[27] Peixoto G. Reduction mammaplasty: a personal technique. Plast Reconstr Surg
1980;65(2):217–226
[28] Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg
1967;20(1):78–85
[29] Psillakis JM, Cardoso de Oliveira M. History of reduction mammaplasty. In
Reduction Mammaplasty. Boston: Little, Brown; 1990:1–15
[30] Regnault P. Reduction mammaplasty by the “B” technique. Plast Reconstr Surg
1974;53(1):19–24
[31] Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg
1975;55(3):330–334
[32] Robbins TH. A reduction mammaplasty with the areola-nipple based on an
inferior dermal pedicle. Plast Reconstr Surg 1977;59(1):64–67
[33] Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola com-
plex: an anatomic study. Plast Reconstr Surg 2000;105(3):905–909
[34] Skoog T. A technique of breast reduction—transposition of the nipple on a cuta-
neous vascular pedicle. Acta Chir Scand 1963;126:453–465
[35] Spear SL, Howard MA. Evolution of the vertical reduction mammaplasty. Plast
Reconstr Surg 2003;112(3):855–868, quiz 869
[36] Spector JA, Kleinerman R, Culliford AT IV, Karp NS. The vertical reduction
mammaplasty: a prospective analysis of patient outcomes. Plast Reconstr Surg
2006;117(2):374–381, discussion 382–383
[37] Strong B, Hall-Findlay EJ. How does volume of resection relate to symptom relief
for reduction mammaplasty patients? Ann Plast Surg 2015;75(4):376–382
[38] Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast
Reconstr Surg (1946) 1956;17(5):367–375
[39] Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous
suspension of the mammary gland. Plast Reconstr Surg 1998;101(6):1486–1493
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76 %reDVW 5eduFWiRn 7Ke /DWerDO 3ediFOe 7eFKniTue
Moustapha Hamdi
Abstract
During the past 18 years, the author has been performing
septum-based mammaplasty. This technique uses a lateral or
medial pedicle based on Würinger’s horizontal septum:
• A lateral pedicle with dual blood supply from the lateral tho-
racic artery and the septum intercostal arteries is used.
• A two-part gland resection is performed as a limited crescent-
shaped resection caudal to the septum and a larger C-shaped
resection cranial to the septum, around the pedicle.
• The lateral pillar is sutured onto the pectoralis fascia, thereby
ensuring that there is no tension on the pedicle and providing
more breast projection.
• The breast closure is done in a pure vertical, J-shape or limited
T-scar, or standard T-scar following an algorithm based on patient
age, nipple distance from the sternal notch, and skin quality.
Breasts with up to 55 cm nipple-to–sternum notch distance were
operated successfully using the septum-based pedicle technique.
Mean gland resection was 620 g (40–2,800 g) per breast. Partial areola
necrosis occurred in four cases (0.4%). Total areola necrosis occurred
in one breast (0.1%) as a result of an infection in a diabetic patient.
This chapter reports on the safety and ease of breast shaping
by using the septum-based lateral mammaplasty and provides an
update on the technique, results, and complications during the
last decade.
Keywords
breast reduction, mammaplasty, lateral pedicle, Würinger’s
septum, safety
76.1 Introduction
The multitude of techniques described for reduction mamma-
plasty pays testament to the lack of consistent results across
all patient groups. Good and bad results are often attributed to
each specific pedicle, and, as with all surgical procedures, it is
this dissatisfaction that drives the ongoing pursuit of new and
improved techniques. However, it is difficult to assign primary
responsibility for complications or unsatisfactory results solely
to a certain pedicle type. The global outcome in breast reduc-
tion is attributed to many factors, including skin quality, the
patient’s age and expectations, the degree of ptosis, and, last but
not least, the surgeon’s experience. While a variety of technical
refinements have been described over the decades, each breast
reduction procedure addresses the following essential elements:
1. Preservation of nipple–areola complex (NAC) blood and nerve
supply
2. Removal of excess parenchyma
3. Excision of redundant skin
4. Reshaping of the breast parenchyma
5. Redraping of the skin
In 1963, Skoog was attributed with being the first to
describe the use of a lateral dermal pedicle breast reduction.
Subsequently, in 1999, Hall-Findlay reported using a lateral
or medial dermoglandular pedicle combined with a vertical
scar. This allows minimization of scarring, while the concept
of pedicle rotation avoids kinking of the pedicle and venous
congestion sometimes encountered with the superior pedicle.
Hall-Findlay highlighted that there should be no undermining
of the pedicle, to ensure continuity with the chest wall and
maximization of perfusion. This technique has been further
published by Cárdenas-Camarena. Many surgeons still detach
the lateral dermal pedicle from the chest wall and maintain a
thickness of approximately 2 to 3 cm. Thus resection of glan-
dular tissue occurs in a plane dorsal to the pedicle itself, as well
as in the remaining quadrants of the breast. This considerably
limits perfusion of the pedicle.
Würinger has recently described a horizontal septum trans-
versing the breast, which carries an identifiable neurovascular
supply to the NAC (Fig. 76.1). With this constantly evolving
knowledge of functional three-dimensional breast anatomy, we
have further modified the foregoing techniques to optimize the
vascularity of the breast and innervation of the NAC. We have
termed this a septum-based lateral mammaplasty (SLM) and
consider it to be an evolution of the centrolateral glandular
pedicle. This improved vascularization of the NAC is responsible
for a significant decrease in early and late postoperative compli-
cations in our hands. Our lateral glandular technique maintains
a column of parenchyma between the pectoralis major muscle
and the NAC at the level of Würinger’s septum. Thus continuity
is maintained not only with the lateral breast pillar but also the
chest wall itself, resulting in maximum preservation of perforat-
ing vessels (Fig. 76.2).
Preservation of the ability to lactate is often a fundamental
prerequisite for women of fertile age who intend to undergo
a reduction mammaplasty procedure. It is known that the
sculpture of the pedicle during mammaplasty can influence the
breastfeeding potential; therefore, it is important to maintain as
much continuity as possible between the remaining glandular
tissue and the 1AC. Although to date we have no definitive data
on postoperative breastfeeding, we intuitively feel that the SLM
retains maximum glandular continuity to maximize the chances
of lactating.
76 Breast Reduction: The Lateral Pedicle Technique
1183
Fig. 76.1 Sagittal section in the breast shows Würinger’s horizontal septum.
1184
XI Breast Surgery
76.2 Indications and
Contraindications
The SLM reduces the inferolateral and central parts of the
breast, while the NAC is centered on the horizontal septum
via a lateral pedicle. The choice of pedicle inevitably depends
on different factors, such as the degree of hypertrophy, the
position of the NAC, the lateral fullness, and the age of the
patient. The key concept to achieving an acceptable result in
reduction mammaplasty is flexibility in the choice of pedicle
and skin resection. No procedure can be prescriptive, and the
surgeon must be able to choose the most appropriate proce-
dure for each patient. In our experience, small reductions or
mastopexies are often more suited to the superior pedicle
technique.
We feel that the SLM is best suited to younger patients,
where it is paramount to achieve maximum NAC sensitivity,
continuity of the NAC and glandular tissue for breastfeeding, and
good projection of the breast mound. By definition, any lateral
pedicle technique limits resection from the lateral pillar and
axillary areas. This persistent lateral fullness can be a drawback,
particularly in obese patients with excess axillary fat in addition
to the macromastia. Basing the lateral pedicle over Würinger’s
septum ensures optimum vascularization of the NAC and enables
more tissue to be removed laterally than would be possible with
standard lateral pedicle techniques. However, even with this
additional perfusion, we would recommend a septum-based
medial pedicle mammaplasty (SMM) in cases of extreme lateral
fullness.
Having a dual blood supply, lateral pedicle (lateral thoracic
artery), and the septum (intercostal arteries) makes nipple–areola
vascularization more robust. Therefore, the SLM technique is
widely indicated for patients who have macromastia or major
breast ptosis. The transverse circumference of the breast does
not increase dramatically with macromastia, in contrast to the
vertical circumference. Thus a laterally based technique is likely
to have a shorter pedicle length than its superior or inferior
counterpart. To date, the author has performed resections of up
to 2,800 g per side with no compromise of nipple perfusion. Thus
there is no specific upper resection weight limit, although in cases
of extreme gigantomastia, consideration may need to be given to
a free nipple graft procedure.
The choice of skin closure pattern is based on the patient’s per-
sonal characteristics (Fig. 76.3). It can also be better determined
perioperatively rather than at the time of preoperative marking.
In general the vertical scar mammaplasty is selected for young
patients (< 30 years old) or for patients who have nipple-to-
Fig. 76.2 The septum-based lateral mammaplasty is a technique of breast reduction in which the nipple–areola complex is based on a lateral pedicle
with a central component that contains Würinger’s septum.
76 Breast Reduction: The Lateral Pedicle Technique
1185
sternal notch (N-SN) distances of less than 30 cm and good skin
quality. These patients would be expected to have adequate
skin retraction and a good cosmetic result from a vertical scar.
For older patients, or those with a N-SN distance of > 30 cm an
L- or J-shaped scar or limited inverted T is used. However, in
patients at high risk of hypertrophic scarring, a vertical scar
is advocated and the patient advised as to the likely require-
ment for a secondary revision. Patients who have poor skin
quality with associated striae are best suited to an inverted-T
procedure.
Although the excellent vascularity of the NAC allows us to
perform this technique in smokers, we would favor techniques
that limited skin undermining with direct excision of excess skin.
We have found that leeches are not a good option for congested
areola, and an extensive infection can occur, especially in patients
with risk factors. In inexperienced hands, we recommend possibly
converting any technique of pedicle-based mammaplasty to a
free-NAC technique in high-risk situations, such as a combination
of a very long pedicle (> 15 cm) in a smoker with other vascular or
metabolic pathologies.
76.3 Pertinent Anatomy
Würinger et al described a ligamentous suspension of the breast
containing a horizontal septum that attaches the NAC to the
thoracic wall at the level of the fifth rib. The septum includes
branches and perforators from the intercostal, thoracoacro-
mial, and lateral thoracic vessels, as well as the lateral branch
of the fourth intercostal nerve (Fig. 76.1). This horizontal
fibrous septum is a thin lamina of dense connective tissue that
transverses the breast from medial to lateral and extends to the
center of the nipple. It therefore divides the gland, including
the lactiferous ducts, into a cranial and caudal segment. This
separation of the glandular tissue is proportionally consistent
in all patients, in that hypertrophy of breast tissue appears to
occur mainly in the cranial segment. A laterally based pedicle
technique that has its foundation on Würinger’s septum will
therefore allow resection of the cranial parenchymal excess,
thus permitting maximum reduction of the parenchyma while
preserving sensation and vascularity. Würinger’s description
has confirmed the findings of other anatomic studies to further
our knowledge of the nerve supply to the NAC. The anterior
ramus of the lateral branches of the fourth intercostal nerve
can take a superficial or deep course toward the 1AC. In the
deeper variation, the nerve runs on the serratus and pectoralis
major fascia before penetrating the breast parenchyma after 3
to 5 cm to run obliquely toward the 1AC. These findings were in
accordance with a more recent study by Schlenz et al, who also
found that the lateral cutaneous branch of the fourth intercos-
tal nerve supplied the nipple in 93% of breasts by following a
deep retromammary course. In the remaining 7%, the anterior
cutaneous branches of the third, fourth, and fifth intercostal
nerves took a superficial course in the subcutaneous tissue.
Thus, to ensure that sensation is maintained, it is necessary
to include the entirety of the parenchyma surrounding the
nerve. In the pedicle described in traditional lateral pedicle
techniques (i.e., 2–3 cm thick), sensation will be preserved in
only the superficial nerve variant, leaving a large percentage of
patients with a sensory deficit.
76.4 Preoperative Assessment
76.4.1 History
The symptoms of female breast hypertrophy are often related
to muscular discomfort. Patients frequently report back pain,
neck pain, shoulder discomfort, and occasionally headaches.
They often develop poor posture to compensate for the excessive
breast weight. Poor hygiene in the submammary crease leads to
irritations, rashes, and even skin infections. Shoulder grooves
develop over time from the pressure exerted by bra straps.
However, if a bra is not worn, activities and even sleep may be
difficult. The excessive breast weight often prevents the patient
from participating in sports and wearing any form of revealing
attire. Once this affects the patient’s activities of daily living, the
patient seeks medical attention.
As well as obtaining details pertinent to the presenting com-
plaint, it is important to obtain a detailed medical history in the
standard fashion. This specifically includes baseline information
about breast cancer risk factors, menstrual history, and family
Fig. 76.3 Choice of skin closure pattern.
1186
XI Breast Surgery
plans. At this stage it is useful to ask the patient what size breasts
are desired prior to the examination.
76.4.2 Physical Examination
The physical examination confirms the diagnosis of breast
hypertrophy and attempts to rule out the possibility of breast
cancer. It is essential to note the patient’s skin type, striae, and
any evidence of keloid or hypertrophic scarring from previous
surgery or injury. This will affect the decisions made regarding
the skin closure pattern. A record should be made of the patient’s
height, weight, and body mass index.
An aesthetic examination of the breasts is typically performed
when the patient is in the seated position with the arms by the
sides. Bra strap grooves are assessed for depth and skin break-
down. Intertrigo is assessed by lifting each breast and closely
examining the skin for breakdown and rashes. A circumferential
evaluation of the muscular and bony thorax is essential in all
cases. The vertical alignment of the thorax, any asymmetry, and
any differences in shoulder position or muscle mass are noted. A
comparison of the two breasts and their relationship to the chest
wall is made to define any breast asymmetry at an early stage.
Particular note is made of excess lateral breast tissue with a
poorly defined lateral breast border, as this may not be suitable
for SLM. The relative volume and shape of the breasts is compared
and recorded. Measurements of the N-SN and nipple-to-midline
distances are noted. The degree of ptosis is assessed from the
position of the NAC in relation to the rest of the glandular tissue
and the inframammary fold (IMF).
The breast examination is then repeated in the recumbent posi-
tion with the arms both by the sides and then elevated over the
head. The breasts are assessed for any lumps, masses, scars, skin
dimpling, or nipple discharge. Preoperative photographs to docu-
ment mammary hypertrophy complete the physical examination.
76.4.3 Recommendations
The consultation is competed with a discussion regarding breast
size, a review of expectations, and reinforcement of the realistic
goals of surgical treatment.
76.5 Preoperative Planning
A precise marking is the main key to obtain the desired aesthetic
result with maximal breast symmetry. The patient is marked
on the day of surgery and in the standing position (Fig. 76.4).
The midline, IMF, and meridian of the breast are outlined. The
meridian is best marked by hanging a tape measure around
the patient’s neck and letting it drop toward the nipples. The
nipple distance from the suprasternal notch is then measured
and marked on the patient. The proposed new nipple position
is marked by placing two fingers (two-finger maneuver) in the
IMF and projecting this onto the skin (Fig. 76.5a). However,
the nipple is lower 1 to 2 cm than its position localized by the
two-finger maneuver. Actually, this results in a new position
at a horizontal line drawn from the lateral fold of the breast at
the anterior line of the axilla (Fig. 76.5b). This insures that the
nipple position is not too high, as it will be expected to rise by a
certain degree when the pillars are approximated. The vertical
pillars are marked by rotating the breast superomedially and
superolaterally to extrapolate the lines, as described by Lejour
(Fig. 76.5c,d). The mosque-shaped pattern of the areola, which
varies between 14 and 20 cm in length, is adjustable to suit the
size of the breast, the N-SN distance, and the new nipple position
(Fig. 76.5e). The width of the mosque-shaped periareolar design,
which is between 4 and 10 cm, should be larger for greater
resection and should also leave enough space for the pedicle to
settle without compression. The vertical lateral and medial lines
are then connected by a curve to the periareolar line (Fig. 76.5f).
The medial line is marked first and can be transferred to the
contralateral breast by pushing both breasts to each other
(mirror effect) (Fig. 76.5g). The medial limb has to be identical
on both breasts to achieve a good symmetry. The lateral limb
position outlines the central segment of parenchyma and skin to
be excised, which will decide the size of the reduced breast. The
position of the lateral limb allows adjustment for any asymmetry
between the two breasts. The vertical pillars are joined centrally
at a level approximately 2 to 4 cm above the IMF. The lateral
pedicle is then marked with a 6- to 8-cm base. The base of the
pedicle is left as ¾ and ¼ in the vertical limb and the opening
of the areola, respectively (Fig. 76.5h). It should be remembered
that the final skin closure decision will be taken on the table with
the aid of a tailor-tacking technique.
The procedure is performed under general anesthesia, with the
patient supine. The operating table should have a break to permit
flexion of the patient to the sitting position, and the patient’s arms
are held securely adducted by her sides. The incision lines and
Fig. 76.4 Schema represents the septum-based lateral mammaplasty
markings with the landmarks: point B is the future position of the
nipple. Distance from A to B = 2 cm, C to G and D to G’ = 6 cm, H to I =
2–4 cm.
76 Breast Reduction: The Lateral Pedicle Technique
1187
Fig. 76.5 Step-by-step skin markings. (a) The two-fingers maneuver to locate the new position of the nipple at the breast axis. (b) The new position
is lowered onto a horizontal line that is drawn from the junction of the lateral fold of the breast with the anterior line of the axilla. (c) Lateral vertical
(incision) line. (d) Medial vertical (incision) line. (e) The areolar mosque-shape dome. (f) Connecting the vertical lines to the new areolar line. (g)
The medial vertical line transferred to the right breast (mirror effect). (h) The markings are completed with the designed lateral pedicle. The medial
vertical lines are symmetrical.
1188
XI Breast Surgery
base of the breast are infiltrated with 40 mL of 1 lidocaine and
1:200,000 adrenaline, diluted with 40 mL of normal saline. The
pedicle itself should not be infiltrated, to ensure no compromise
of perfusion.
The technique can be summarized as follows (Fig. 76.6):
1. A laterally based pedicle located over Würinger’s septum
2. A two-part gland resection, which is divided into a crescentic
resection caudal to the septum and a larger C-shaped resection
cranial to the septum, around the pedicle
3. Suturing of the breast pillars in the midline and to the pectoralis
fascia
4. Skin closure with minimal undermining in a fashion determined
perioperatively (tailor-tack technique)
76.6 2SerDWiYe 7eFKniTue
The operative sequence is described as follows:
76.6.1 Pedicle De-Epithelialization and
Skin Incision
All preoperative markings are checked to ensure that important
landmarks have not been erased with the patient prepping. The
NAC is marked with a 45-mm-diameter areolar ring without ten-
sion. De-epithelialization is performed on top of the glandular
pedicle to the lateral vertical incision, leaving a 1.5-cm cuff of
dermis around the areola. Skin incisions are completed with a
scalpel.
76.6.2
Pedicle Dissection and
Glandular Resection
In preparation for the inferior horizontal resection, the inferior
pole of the breast skin is undermined, starting from the inferior
limit of each vertical line (6 cm length) until 1 to 2 cm above the
IMF. The thickness of the skin flap is similar to that of a postmas-
tectomy skin flap. The superficial fascia is incised and dissected
over the gland 2 cm above the IMF. This fascia is kept attached to
the IMF and can be used to suspend the IMF in a higher position
at the end of the procedure, if needed. The gland is incised along
the medial pillar (between points D and Gɼ) to the level of the
pectoralis fascia. This line is then extended cranially along the
new areolar marking toward point E on Fig. 76.7, which lies
at the upper edge of the base of the pedicle. Digital dissection
superiorly, medially, and inferiorly permits good visualization
of Würinger’s septum. Care is taken to ensure that no dissec-
tion is performed laterally and centrally in order to prevent
inadvertent undermining of the pedicle. Würinger’s septum can
be held and palpated to allow resection of breast parenchyma
under direct vision from around the pedicle. It is important to
ensure that the dissection inferior to the pedicle is minimal
to avoid damaging the neurovascular bundles in Würinger’s
septum. Once the appropriate amount of parenchyma has been
excised, the weight is noted to aid with symmetrization, and
the specimen is sent for histopathology. Meticulous hemostasis
is performed.
The dermis of the pedicle is carefully incised at the base to
allow better upward rotation. The base of the lateral pillar is
rotated superomedially and secured with 1–0 polyglactin suture
(Vicryl, Johnson & Johnson, New Brunswick, NJ) to the pectoralis
fascia. This maneuver transposes the pedicle to the midline of the
breast without tension. In the majority of cases no further fixation
is required, but it can be performed superiorly to the pectoralis
fascia if additional support is required. If needed, the IMF is sus-
pended and fixed onto the pectoralis fascia with heavy stitches
using the superficial fascia, which was dissected at the beginning
of the procedure.
76.6.3
Skin Closure
Points C and D on Fig. 76.8, at the new 6 o’clock position on the
periareolar incision, are closed with a 3–0 absorbable suture, and
the lateral and medial pillars are approximated with 1–0 Vicryl
sutures. The periareolar incision is closed in three layers—a
2–0 polydioxanone (PDS) interlocking suture as described by
Hammond, at the level of the deep dermis commencing at the
12 o’clock position with a well-buried knot; minimal interrupted
4–0 Vicryl stitches to approximate the dermis in a tension-free
manner and ensure appropriate skin eversion; subcuticular 4–0
poliglecaprone (Monocryl, Johnson & Johnson, New Brunswick,
NJ). Attention is now turned to closure of the vertical incisions
with one of the following modifications:
Vertical Scar
If a vertical closure is advocated, then the skin is undermined
to a very limited degree to permit closure with a small amount
of wrinkling. The deep dermis is approximated with interrupted
figure-of-8 sutures using a 3–0 Vicryl, and a 3–0 Monocryl sub-
cuticular purse-string suture is placed at the inferior edge of the
scar. These sutures serve to shorten the length of the scar and
avoid migration over the IMF. In the event of inadequate wound
edge apposition, some interrupted 6–0 nylon can be used to
achieve satisfactory approximation.
L or J Scar
The skin excess is moved laterally at the inferior edge of the
vertical scar to avoid crossing the IMF or extending the scar
medially.
Inverted-T Scar
If an inverted-T closure is required, then this is designed at the
end of the surgery. The vertical scar is tailor-tacked with staples
and a horizontal ellipse designed to excise the dog-ear. Thus
the horizontal component is as short as possible. Skin closure is
performed in two layers using subcuticular 3–0 PDS in the deep
dermis and a subcuticular 4–0 Monocryl.
Liposuction
Liposuction is undertaken in selected cases once the skin has
been closed. Indications include persistent asymmetry, lateral
fullness, and to give improved definition of the IMF.
76 Breast Reduction: The Lateral Pedicle Technique
1189
Fig. 76.6 The surgical technique. (a) The lateral pedicle is de-epithelialized and the inferior breast skin is undermined. (b) Crescent gland resection
caudal to the septum. (c) Medial and cranial incision of the skin-gland and septum dissection. (d) Crescent gland resection around the lateral
septum-based pedicle. (e) The septum-based lateral pedicle is rotated upward. (f) The areola is closed using an interlocking suture. (g) The lateral
pedicle is fixed onto the pectoral fascia. (h) The skin is closed following the algorithm described in the text.
1190
XI Breast Surgery
76.7 Postoperative Care
A suction drain is placed bilaterally, and attention is given to
ensuring the drain is in the retroareolar area prior to closure,
in order to prevent a hematoma that could compromise pedicle
perfusion. Dermabond (Johnson & Johnson, New Brunswick,
NJ) tissue glue is placed over the sutured incision lines as a
waterproof dressing. This enables the wounds to be left dressing
free for monitoring, sterility, and patient comfort. The drains
are removed after 24–48 hours, and the patient is discharged.
Patients are instructed to wear a nonwired sports bra day
and night for a month to ensure optimum breast shaping and
support.
76.8 Problems and Complications
Since January 2000, more than 500 patients have undergone
breast reduction using a septum-based mammaplasty. The
pedicle for the NAC is based on a horizontal septum and is
designed to incorporate the lateral branch of the fourth intercos-
tal vessels and nerve. Although this chapter describes only the
septum-based lateral pedicle, the septum-based medial pedicle
has also been used for these patients.
Breasts with up to 55 cm N-SN distance were operated suc-
cessfully using the septum-based pedicle technique. Mean gland
resection was 620 g (40–2,800 g) per breast. Septum-based
lateral mammaplasty was the used (57%). I currently use the
septum-based medial mammaplasty more frequently in cases of
major breast hypertrophy.
The postoperative complications we experienced in a con-
secutive series of 500 patients (1,000 breasts) who underwent
bilateral septum-based lateral and medial breast reduction are
shown in Table 76.1. The differences between complications after
lateral and medial pedicles were not significant.
Scar-related problems, namely wound dehiscence, were the
most common complication and occurred with an incidence of
approximately 7%. Other complications included hematoma,
skin necrosis, and infection and occurred with a frequency of
less than 1%. In 2002, I had an unfortunate experience with
one case of unilateral areola congestion that was immediately
managed with leeches. A few days after the procedure, the
patient developed an extensive breast infection, most probably
Fig. 76.7 Pedicle dissection and glandular resection.
Fig. 76.8 Skin closure.
Table 76.1 Postoperative complications in 500 patients
Complications (N = 1,000 breasts)
Number (%)
Wound dehiscence
70 (7.0)
Wound infection
< 10 (1.0)
Unilateral retroareolar hematoma
< 10 (1.0)
Unilateral partial areolar necrosis
< 10 (1.0)
Unilateral total areolar necrosis
< 10 (1.0)
76 Breast Reduction: The Lateral Pedicle Technique
1191
secondary to therapy with leeches. This resulted in major
necrosis of the NAC and of the central part of the breast. She
was a high-risk patient with diabetes type 2, obesity, an active
smoking habit, and breast ptosis type III, with a sternal notch-
to-NAC distance of 38 cm. I strongly believe that this kind of
complication could occur with almost any technique of breast
reduction. However, preoperative consultation and medical
optimization of the patient are necessary to minimize the
complication rate.
76.9 Outcomes
We have shown in a prospective study that septum-based
lateral mammaplasty maintains sensitivity of the NAC from
the immediate postoperative period and that all patients
had normal sensation at a 6-month review. We have also
observed excellent stability of shape with an improved con-
ical profile of the breast mound and projection of the nipple.
By ensuring the glandular pedicle remains attached to the
pectoralis muscle, we preserve the original strength of the
connective tissue support, which includes the attachments of
the superficial fascia and Cooper’s ligaments. The resection
of glandular tissue superior to the pedicle and repositioning
of the pedicle in a more cranial position results in improved
nipple projection.
The key to preserving breastfeeding potential after reduc-
tion mammaplasty is preparation of the pedicle, sparing as
many lobules and connected lactiferous ducts as possible, in
addition to maintaining adequate NAC sensitivity. We have
no firm data on the possibility of breast lactation using our
technique. However, several previous studies have shown the
lateral dermal pedicle to be superior to many other reduction
techniques in terms of successful breastfeeding. We feel that
our technique is superior to many of the lateral dermal pedicle
methods, as it preserves an intact column of glandular tissue,
thereby leaving the functional unit of the breast undisturbed.
Intuitively, this, combined with the total preservation of
sensation of the NAC, we have demonstrated, should lead to
successful breastfeeding.
76.10 Results
Clinical cases are summarized in Fig. 76.9, Fig. 76.10, Fig. 76.11,
and Fig. 76.12.
76.11 Concluding Thoughts
We feel that the septum-based lateral mammaplasty technique
is safe and valuable for breast reduction. This procedure provides
resection of large amounts of breast tissue without compromis-
ing the viability of the nipple–areolar sensitivity, good aesthetic
outcome, and successful breastfeeding.
The technique is strongly recommended for young patients
with large breasts.
Fig. 76.9 A 29-year-old patient presented for breast reduction. She had cup F with a 31 cm nipple-to–sternal notch (N-SN) distance. The nipple was
elevated to 32 cm N-SN distance. Following our algorithm, a vertical scar is indicated in this case. The breast was reduced using a septum-based
lateral mammaplasty technique to cup D as requested by the patient. At the same time, a fibroadenoma was included within the gland resection of
the left breast. (a–c) Preoperative views. (d) Preoperative markings. (e–g) Postoperative views. (h) The vertical scar at 6 months postoperatively.
a
g
d
b
e
f
c
h
1192
XI Breast Surgery
Fig. 76.10 A 46-year-old patient requested moderate breast reduction (from cup DD to B-C). A vertical scar closure is still indicated (preoperative
nipple-to-sternal notch distance was 30 cm). Gland resection was 376 g at right and 266 at left. (a–c) Preoperative views. (d) Preoperative markings.
(e–g) Postoperative views at 1 year. (h) A hand-up view shows the vertical scar.
a
d
g
b
e
f
c
h
Fig. 76.11 A 55-year-old patient with a body mass index of 35 presented with major breast hypertrophy. The nipples were located at 42 (right) and 40
cm (left) from the sternal notch. A septum-based lateral mammaplasty with an extended inverted-T scar was performed. The scar was extended over the
midline in order to correct immediately the dog-ears due to the asymmetry of the inframammary folds and to the midline abdominal previous scar. The
amount of gland resection was 1,400 g and 950 g at the right and left breast, respectively. (a–c) Preoperative views. (d–f) Results at 5 years follow-up.
a
b
c
d
e
f
76 Breast Reduction: The Lateral Pedicle Technique
1193
Fig. 76.12 A 44-year-old patient, who underwent bypass-surgery with 60 kg weight loss, presented for a breast reduction/mastopexy procedure. In
this challenging case, the nipples were located at 35 (right) and 38 cm (left) from the sternal notch. The skin quality was extremely poor; therefore,
the septum-based lateral mammaplasty was done with a conventional inverted-T scar. The amount of gland resection was 850 g and 1,130 g at the
right and left breast, respectively. (a–c) Preoperative views. (d) Surgical markings. The septum became extremely thin due to the long-term large-
breast hypertrophy and ptosis. The perforator vessels and nerves could still be seen through the septum, which was transilluminated with the surgical
light. (e–h) Early results at 4 months postoperatively
1194
XI Breast Surgery
Clinical Caveats
• The lateral pedicle technique is best suited to younger
patients with a well-defined lateral breast border and no
excessive lateral fullness. Consider an alternative pedicle in
patients not meeting these criteria.
• The technique offers increased viability of the nipple–areola
complex (NAC), preservation of sensation of the NAC,
reduced rate of wound complications, and increased poten-
tial for lactating. In addition, the support of the glandular
tissue behind the NAC improves the conical projection of the
breast and prevents flattening of the NAC.
• Preoperative marking should be made on the day of surgery
and is the key to achieving the desired result. The medial
vertical incisions should be symmetrical, and any necessary
adjustments can be made with the lateral incisions. The nipple
should be sited at 1 to 2 cm below the inframammary fold.
• The dissection of the pedicle centers around Würinger’s hori-
zontal septum, which includes branches and perforators from
the intercostal, thoracoacromial, and lateral thoracic vessels,
as well as the lateral branch of the fourth intercostal nerve.
• A two-part gland resection is performed as a limited crescen-
teric resection caudal to the septum, and a larger C-shaped
resection cranial to the septum, around the pedicle.
• The lateral pillar is sutured onto the pectoralis fascia, thereby
ensuring that there is no tension on the pedicle.
• The final decision regarding skin closure is made on the table:
̑ Vertical scar is best suited to patients who have nipple-to-
sternal notch (N-SN) distances of less than 30 cm, with
good skin quality. However, it may also be appropriate in
patients at high risk of hypertrophic scarring, albeit with a
high incidence of secondary revisions.
̑ L or J scar is suitable for older patients, or those with a
nipple to sternal notch distance of > 30 cm.
̑ Inverted-T scar is used in patients who have poor skin
quality with associated striae.
• Liposuction can be undertaken to give better symmetry,
reduce lateral fullness, and give better definition of the
inframammary fold.
Suggested Reading
[1] Arie G. Una nueva tecnica de mastoplastia. Rev Latino Cir Plast 1957;3:28
[2] Asplund OA, Davies DM. Vertical scar breast reduction with medial flap or glan-
dular transposition of the nipple-areola. Br J Plast Surg 1996;49(8):507–514
[3] Beer GM, Morgenthaler :, Spicher I, Meyer VE. Modifications in vertical scar
breast reduction. Br J Plast Surg 2001;54(4):341–347
[4] Cárdenas-Camarena L, Vergara R. Reduction mammaplasty with superi-
or-lateral dermoglandular pedicle: another alternative. Plast Reconstr Surg
2001;107(3):693–699
[5] Chiummariello S, Cigna E, Buccheri EM, Dessy LA, Alfano C, Scuderi N. Breast-
feeding after reduction mammaplasty using different techniques. Aesthetic Plast
Surg 2008;32(2):294–297
[6] Greuse M, Hamdi M, DeMey A. Breast sensitivity after vertical mammaplasty.
Plast Reconstr Surg 2001;107(4):970–976
[7] Hall-Findlay E-. A simplified vertical reduction mammaplasty: shortening the
learning curve. Plast Reconstr Surg 1999;104(3):748–759, discussion 760–763
[8] Hamdi M, Greuse M, De Mey A, Webster MH. A prospective quantitative com-
parison of breast sensation after superior and inferior pedicle mammaplasty. Br J
Plast Surg 2001;54(1):39–42
[9] Hamdi M, Blondeel P, Van de Sijpe K, Van Landuyt K, Monstrey S. Evaluation
of nipple-areola complex sensitivity after the latero-central glandular pedicle
technique in breast reduction. Br J Plast Surg 2003;56(4):360–364
[10] Hamdi M, Van Landuyt K, Tonnard P, Verpaele A, Monstrey S. Septum-based
mammaplasty: a surgical technique based on Würinger’s septum for breast
reduction. Plast Reconstr Surg 2009;123(2):443–44
[11] Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mamma-
plasty. Plast Reconstr Surg 1999;103(3):890–901, discussion 902
[12] Hefter W, Elvenes OP, Lindholm P. A retrospective quantitative assess-
ment of breast sensation after lateral pedicle mammaplasty. Br J Plast Surg
2003;56(7):667–673
[13] Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr Surg
1996;97(2):373–380
[14] Lejour M. Vertical mammaplasty: update and appraisal of late results. Plast
Reconstr Surg 1999;104(3):771–781, discussion 782–784
[15] Lockwood T. Reduction mammaplasty and mastopexy with superficial fascial
system suspension. Plast Reconstr Surg 1999;103(5):1411–1420
[16] Ramirez OM. Reduction mammaplasty with the “owl” incision and no under-
mining. Plast Reconstr Surg 2002;109(2):512–522, discussion 523–524
[17] Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensi-
tivity by reduction mammaplasty: a prospective comparison of five techniques.
Plast Reconstr Surg 2005;115(3):743–751, discussion 752–754
[18] Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola com-
plex: an anatomic study. Plast Reconstr Surg 2000;105(3):905–909
[19] Skoog T. 3ODVWLF 6XUJHU\ 1HZ 0HWKRGV DQG 5HfiQHPHQWV Stockholm: Almquist &
Wiksell; 1974
[20] Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous
suspension of the mammary gland. Plast Reconstr Surg 1998;101(6):1486–1493
77 Short-Scar Mammaplasty with a Pectoralis Loop
1195
77 Short-Scar Mammaplasty with a Pectoralis Loop
Ruth Graf, Maria Cecília Closs Ono, and Thomas M. Biggs
Abstract
Breast reduction and mastopexy are among the most challeng-
ing operations, mainly because the difficulty of ensuring long-
lasting results. This chapter focuses on reshaping the breast with
internal tissues to achieve better outcomes that are more stable
in the long term. The description of the chest wall–based flap and
pectoralis loop can be used in vertical and short inverted-T scar
helping to achieve these goals.
The vertical technique is ideally indicated for mild and mod-
erate cases of breast ptosis and hypertrophy, where less skin
compensation is necessary. In great hypertrophies and severe
ptosis, vertical mammaplasty is contraindicated because more
skin excess has to be removed. The authors prefer to use a short
inverted-T scar incision in these cases, in order to remove more
skin and reduce skin compensation.
A youthful appearance of the breast can be achieved due to
better projection and a narrower base because the chest wall–
based flap fills the upper and medial part of the breast, and the
sutures to close the breast tissue pillars reduce the base breast
width.
Keywords
breast surgery, mammaplasty, breast reduction, mastopexy,
chest wall–based flap, pectoral sling, pectoral loop
77.1 Introduction
As the evolution of every surgical procedure is persistent and
ongoing, so it is with breast surgery. The great advances by Wise,
Pitanguy, Lassus, Lejour, Benelli, and others brought us to the
close of the twentieth century. These techniques have not only
simplified the operative plan but have contributed to a shorter
scar and a more aesthetic breast.
This chapter describes a maneuver designed to provide a better
and longer-lasting shape to the breast. This maneuver involves
the use of a chest wall–based flap of breast tissue that is moved
into the upper pole of the breast and held in place by a loop of
pectoral muscle under which it is passed. The technique can be
used with standard inverted-T incisions, vertical incisions with
short transverse components, L-shaped incisions, or pure vertical
incisions. Our choice, and the maneuver described in this chapter,
is a vertical incision with whatever redundant skin, which is
removed from around the areola after excising the vertical ellipse
and closed with a round block suture. If reduction is necessary, it
can easily be carried out by removing the desired amount from
the base and central part of the breast. There is no limit to the
amount of breast tissue that can be removed.
This technique has stood the test for nearly 30 years and over
2,000 cases. Nipple necrosis and skin necrosis have been avoided,
the vertical and periareolar scars fade well, fullness in the upper
pole has remained, and the flap’s existence in the area where it
was placed has been verified by many X-rays.
77.2 Indications and
Contraindications
It is possible to use this combination of techniques for mastopexy
only, when there is no breast tissue in excess to be removed, or
for breast reduction when the resection of excessive breast tissue
is done in the columns or base of the breast, after the thoracic
wall flap is fixed. :ith this technique we have observed that
we remove less breast tissue compared with other techniques
that do not use the chest wall–based flap, and the breasts have
a narrower base. In our experience the average amount of breast
tissue resected was 250 to 500 g, less than in other techniques
we have used without the thoracic flap. The breast becomes
more compact and less likely to bottom out.
This technique is ideally indicated for mild and moderate cases
of breast ptosis and hypertrophy, where less skin compensation is
necessary. In our experience, great hypertrophies and severe ptosis
constitute relative contraindications to vertical mammaplasty. We
have preferred to use a short inverted-T incision in these cases, in
order to remove more skin and reduce skin compensation.
77.3 Pertinent Anatomy
The mammary gland is anchored to the pectoralis major fascia
by the suspensory ligaments (Cooper’s ligaments), and it is the
main structure responsible for maintaining the shape of a non-
operated breast.
The second to sixth intercostal nerves supply breast innervation.
Lateral innervation is predominantly from the anterior rami of the
lateral cutaneous branches of the third through sixth intercostal
nerves. Medial innervation arises from the anterior cutaneous
branches of the second through sixth intercostal nerves. Nerve
supply to the nipple is from the third, fourth, and fifth anterior
and lateral cutaneous nerves. The lateral cutaneous branch of
the fourth intercostal nerve innervates the nipple by way of two
branches. The superficial branch passes up through the superficial
parenchyma; the deep branch passes inferolaterally on the pec-
toralis major fascia before coursing up into the areola. This fact
might give one pause in considering techniques that rely heavily
on inferolateral resection of the gland.
Blood supply to the mammary gland is from multiple sources,
including the internal mammary perforators (most notably the
second to fifth perforators), the thoracoacromial vessels, the
vessels to the serratus anterior, the lateral thoracic vessels, and
the terminal branches of the third to eighth intercostal vessels.
One important aspect, first described in 1998 by :ringer, is the
concept of a mesentery-like fibrous septum that runs through
the level of the fifth rib, responsible for the blood supply of the
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XI Breast Surgery
nipple–areola complex (NAC). We apply this concept when think-
ing about the dissection of a chest wall–based flap, important for
achieving an ideal breast shape (Fig. 77.1).
77.4 Preoperative Assessment
Each patient must be evaluated in terms of the amount of breast
parenchyma, the amount and quality of skin excess, and the
scars she would accept. Local breast examination is performed
to exclude masses, and any suspicious lesion should be fully
evaluated with appropriate investigations before surgery. It is
advisable to obtain preoperative mammograms in all patients
older than 30 years and breast ultrasound in younger patients.
77.5 Preoperative Planning
Markings are done with the patient in the upright position.
Midline is drawn from the suprasternal notch to the xiphoid
process, and breast meridians are marked from a point 5 cm
lateral to the suprasternal notch over the clavicle to the NAC. On
the breast meridian line, point A is marked about 17 to 20 cm
from the clavicle, which will be the top of the areola, and point D
about 2 to 4 cm above the inframammary fold (IMF), depending
on breast size (Fig. 77.2). In great hypertrophies or severe ptosis,
point D should be marked higher, up to 4 cm above the IMF. This
maneuver is done to leave skin and subcutaneous tissue of the
lower breast pole as part of the thoracic wall, with a new, higher
inframammary crease.
The breast is then gently displaced laterally (a technique
described by Lejour) and a medial line is drawn connecting point
A to D. Similarly, a lateral line is drawn with the breast displaced
medially. It should be pointed out that the tension resulting from
these displacements should be firm enough to allow adequate
skin resection but not so tense as to create difficulty with closure.
This distance varies also in accordance with the size of the breast.
Over the medial and lateral lines, points B and C, respectively,
are marked about 5 to 8 cm above point D. A gently curved line
is drawn from point A to point B, and again from point A to point
C. Line A–B should never be closer than 9 cm to the midline,
and line A–C never less than 10 cm to the anterior axillary fold
(Fig. 77.2).
The variation in distances from point D to the IMF and vertical
lines B–D and C–D allow the surgeon the latitude of adjustments
depending on the size of the breast. The larger the breast, the
greater will be these distances, but never exceeding 4 cm and 6
cm, respectively. It is better to compensate the skin around the
areola with the round block suture. One additional item in the
markings is to move points B and C slightly closer to each other,
so they will be closed with less tension, avoiding skin dehiscence.
Fig. 77.1 Würinger’s concept of a mesentery-like fibrous septum
responsible for the blood supply of the nipple–areola complex.
Figs. 77.2 (a) Skin marks for vertical breast reduction. (b) Preoperative markings.
77 Short-Scar Mammaplasty with a Pectoralis Loop
1197
77.6 2SerDWiYe 7eFKniTue
The patient is placed supine on the operating table and, after
induction of general or epidural anesthesia (local is also possible),
prepped and draped. The markings are infiltrated subdermally
(except superior to the areola) with normal saline-epinephrine
solution (1:100.000). The area of skin demarcated by A–B,
A–C, B–D, and C–D is de-epithelialized by the Schwartzman
maneuver, leaving the NAC (4.5–5 cm in diameter) in place.
To start creating the chest wall–based flap (Fig. 77.3), dermis
is incised along the lines B–D, C–D, and also B–C, passing 1 cm
below the NAC. Along the vertical lines the incision is beveled
inward for 1 to 2 cm so as to preserve tissue on the medial and
lateral pillars for closure later. After preserving this tissue, the
incisions continue inward and away from the flap so that the
base is broad. This dissection is carried to the chest wall, with a
minimal amount of subcutaneous tissue being left on the skin as
dissection is carried to the IMF, and continues superiorly to the
second intercostal space.
After this dissection has been completed laterally and medially,
a large hook is placed in the NAC to lift the breast straight up
and help with the dissection of the breast tissue from point B to
C down to the pectoral fascia. Great care must be taken at this
point not to undercut the flap (Fig. 77.4). The flap is now freely
mobile and based on vessels from the fifth and sixth intercostal
spaces, as a perforator flap. It is very important that the flap not be
restrained; otherwise, continuous dissection should be extended
to the pectoral fascia to better release it. This freely mobile, totally
chest wall–based flap is made up of the tissue that in other proce-
dures “bottoms out,” but in this procedure it is transposed into the
upper pole, where it will be permanently fixed.
The breast tissue is retracted upward and cephalad and dis-
sected off the pectoral fascia up to the second intercostal space
(Fig. 77.5), creating a space in the upper pole of the breast into
which the flap will be fixed. Before this, a strip of pectoral muscle
approximately 8 to 10 cm long and 1.5 to 2 cm wide is marked
with methylene blue (Fig. 77.6, left). The caudal or inferior line is
marked at the cephalad end of the flap base. This muscle strip is
elevated, incorporating no more than half of the muscle thickness
(the posterior fascia of the muscle is not violated), and the donor
site is closed with 2–0 nylon (Fig. 77.6, right). This loop will be
used to help hold the flap in the upper pole of the breast.
The mammary flap is then passed under the pectoral loop into
the space created in the upper pole of the breast. It is very import-
ant that all dermal elements on the flap be completely passed
under this loop (Fig. 77.7).
A running suture of 2–0 nylon, starting laterally and finishing
medially, is placed to fix the breast tissue of the flap to the pec-
toral fascia. The dermis of the flap is then sutured to the pectoral
flap only superiorly. If after passing the flap under the loop there
seems to be excessive tension on the loop causing pressure on the
flap, the loop can be better released laterally once medial dissec-
tion disrupts the origin of the muscle.
:ith the flap in the correct position, breast tissue excess can be
resected (Fig. 77.8, Fig. 77.9). Breast reduction is made in accordance
with the breast size and the desire of the patient. Most of the tissue
is removed as a central inverted kill to narrow the base of the breast,
and, if necessary, from the base to reduce breast projection. One
should avoid overreducing the medial part of the breast, that is, the
tissue under the NAC, to retain more projection of the complex. Great
reductions with this technique (vertical incision and circumvertical
closure) remove about 800 to 1,000 g, including the liposuction in
Fig. 77.3 Initial dissection of the chest wall–based flap.
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XI Breast Surgery
the lateral aspect of the breast, which is on average 300 mL of fat. The
chest wall–based flap can be used for any breast size.
After reduction of breast tissue excess, and with the hook still
holding the breast straight up, one interrupted stitch of 2–0 nylon
is placed from the superior part of the breast parenchyma to the
pectoralis muscle, just superior to the chest wall–based flap, at
the level of the second intercostal space.
The pillars are then closed with 2–0 nylon in several layers. It is
preferable to place the needle laterally deeper than medially, so as
to preserve more fullness medially (Fig. 77.10).
Deep dermis of the vertical wound is sutured starting with
subareolar points B and C. To reduce the outer circumference and
wound tension, and to compensate the periareolar skin around
the areola, a round block suture is made all the way around the
periareolar skin with 3–0 colorless nylon (Fig. 77.11). Eight car-
dinal points are marked in the outer and inner circumferences to
regularly spread the periareolar skin around the areola. The run-
ning suture passes through the deep dermis of the outer skin and
the areolar deep tissue. In the external skin the suture is passed
on the markings, taking large amounts of tissue; in the areola the
suture is passed between the markings, taking small amounts of
tissue. Tensioning the suture reduces the outer circumference
down to the desired diameter for the NAC (about 4.5 cm).
Starting from point D, skin is closed with subdermal interrupted
suture of 3–0 poliglecaprone (Monocryl, Johnson & Johnson, New
Brunswick, NJ), anchoring the vertical wound on the deep pillar
tissue, so the vertical scar is kept at the same level as the new
inframammary crease.
Fig. 77.4 Chest wall–based flap.
Fig. 77.6 Pectoralis major muscle strip (a) demarcation, (b) dissection, and (c) closure of the donor site.
Fig. 77.5 Mammary base dissection.
a
b
c
77 Short-Scar Mammaplasty with a Pectoralis Loop
1199
It is important to mention that in patients with larger breasts, it
is possible to excise a small horizontal ellipse of skin in the new IMF,
ending with a short inverted-T scar. This can better adjust the skin
envelope, without jeopardizing the youthful breast shape achieved
with vertical principles associated with a chest wall–based flap (Fig.
77.12). The distances of 5 cm between points A and B and A and C,
and 5 cm between B and D and 5 cm between C and E, have to be
maintained, and the horizontal line finishes before the end of the fold
medially and laterally with a slightly superior to the inframamm-
ary fold to avoid elongating the horizontal scar; a round block
suture is not needed. A running intradermic suture with 4–0
Monocryl finally closes the skin. 1o drains are used.
77.7 Postoperative Care
Use of a molding compressive brassiere is recommended for 1 to
2 months to reduce postoperative swelling and tension on scars.
It also helps to support the breasts while internal tissues are
healing and the final shape is becoming more stable.
Lymphatic drainage massages and ultrasound are indicated
from the second postoperative day, three sessions per week for
1 to 2 months. Significant improvements in swelling, pain, and
discomfort have been reported by patients.
Special care with the scars is necessary to improve wound
healing. Topical antibiotic ointment maintains the local humidity
and helps with cell migration to accelerate wound closure. After
the first week, when all the wounds are healed, and during 2 to 3
months, sterile strips (micropore tapes) are used over the scars to
avoid stretching and widening. Silicone gel or sheets can also be
used to avoid hypertrophic scars.
:alking is encouraged on the first day after surgery. Driving
and physical activities can be resumed after 3 weeks.
Fig. 77.7 Chest wall–based flap under the pectoralis muscle strip flap.
Fig. 77.8 Equalization of breast tissue pillars.
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XI Breast Surgery
Fig. 77.9 Upper pole definition.
Fig. 77.10 Closure of mammary pillars and the deep dermis union of points B and C.
77 Short-Scar Mammaplasty with a Pectoralis Loop
1201
Fig. 77.11 Round block.
1202
XI Breast Surgery
Patients are closely followed in the postoperative period, being
clinically evaluated within 5 to 7 days; 2 weeks; 1, 3, 6, and 12
months; and yearly later on. Photographic documentation is also
made when the patient returns.
77.8 Problems and Complications
The major drawback is the time taken before the final result can
be appreciated. It is important that both the surgeon and the
patient must have patience while the skin retracts, the wrinkles
flatten, and the overcorrected breast with its superior bulge and
inferior flatness evolves to an aesthetically pleasing breast.
Wound-healing problems, such as dehiscence, widening, and
irregularities, are sometimes seen due to vertical and periareolar
skin-gathering suture. Eventually some skin redundancy remains
in the new IMF, which necessitates excision by a horizontal
approach. Although this horizontal incision is small, it does add a
horizontal component to the resulting scar. It is important not to
elongate the scar out of the medial and lateral limits of the breast
to avoid hypertrophic scars.
77.9 Outcomes
• Better and long-term upper-pole fullness (second, third, and
fourth costal rib) has been observed with the patient in an
erect position.
• Breast shape and projection have been stable when the patient
is lying in the supine position. The areola has maintained its
upward projection, with little lateral tilting.
• Vertical and periareolar scars have usually been of good qual-
ity because there is less tension in the closure. Approximating
the pillars and the round block suture reduce wound tension
and improve final scar aspect.
• Narrowing the base of the breast is observed in all cases.
Fig. 77.13 shows the results of this procedure on a mammogram.
Fig. 77.12 (a–d) Excision of a horizontal ellipse of skin, ending with a short inverted-T scar in patients with larger breasts.
77 Short-Scar Mammaplasty with a Pectoralis Loop
1203
77.10 Results
Results in several patients are demonstrated in Fig. 77.14, Fig.
77.15, Fig. 77.16, Fig. 77.17, Fig. 77.18, and Fig. 77.19.
77.11 Concluding Thoughts
• Long-lasting improvements are achieved with the chest wall–
based flap associated to the muscle loop.
• Upper-pole fullness is maintained.
• The vertical technique is used for mild hypertrophy and mild
breast ptosis, whereas the short horizontal scar is used for
large hypertrophy and breast ptosis.
Fig. 77.14 (a,b) Pre- and (c,d) 2 years postoperative views, with a vertical technique.
Fig. 77.13 Chest wall–based flap with the muscle loop in a short
inverted-T scar technique in mammogram.
a
c
b
d
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XI Breast Surgery
Clinical Caveats
• Some advantages of this technique include the following:
̑ The vertical principles associated with a chest wall–
based flap held by a pectoralis strip promote better and
long-lasting breast upper-pole fullness with the patient in
both upright and supine positions. The areola remains in
a good location, and very little breast descent occurs (no
bottoming out).
̑ Absence of scar in the inframammary fold is a major
advantage. The circumvertical scar does not cross the new
inframammary crease and has better quality due to less
skin tension, achieved through the round-block suture and
internal sutures of breast tissue.
̑ A youthful appearance of the breast has been achieved
due to better projection and a narrower base.
̑ In cases where the vertical technique is not possible, the
better choice is to perform a short horizontal scar.
Fig. 77.15 (a,b) Pre- and (c,d) 1 year postoperative views, with a vertical technique.
a
c
b
d
77 Short-Scar Mammaplasty with a Pectoralis Loop
1205
Fig. 77.16 (a) Pre- and (b) 2 years postoperative views, with a vertical technique.
a
c
b
d
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XI Breast Surgery
Fig. 77.17 (a) Pre- and (b) 3 years postoperative views, with a vertical technique.
a
c
b
d
77 Short-Scar Mammaplasty with a Pectoralis Loop
1207
Fig. 77.19 (a,b) Pre- and (c,d) 2 years postoperative views, with a short horizontal scar technique.
Fig. 77.18 (a,b) Pre- and (c,d) 3 years postoperative views, with a short horizontal scar technique.
a
c
b
d
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XI Breast Surgery
Suggested Reading
[1] Arié G. Una nueva técnica de mastoplastia. Rev Lat Cir Plast 1957;3:23–28
[2] Biesenberg H. Deformitäten und Kosmetische Operationen der Weiblichen Brust.
Wien: Mandrich; 1931
[3] Benelli L. A new periareolar mammaplasty: the “round block” technique. Aes-
thetic Plast Surg 1990;14(2):93–100
[4] Bozola AR, et cols. Mamoplastia em “L”- contribuição pessoal. Rev AMRIGS, Porto
Alegre 1982;26(3):207–214
[5] de Araujo Cerqueira A. Mammoplasty: breast fixation with dermoglandular
mono upper pedicle flap under the pectoralis muscle. Aesthetic Plast Surg
1998;22(4):276–283
[6] Chiari A Jr. The L short-scar mammaplasty: a new approach. Plast Reconstr Surg
1992;90(2):233–246
[7] Daniel M. Mammaplasty with pectoral muscle flap. Paper presented at the 64th
American Annual Scientific Meeting; Montreal; 1995: 293–295
[8] Dufourmentel C, Mouly R. Mammaplasty by the oblique method [in French]. Ann
Chir Plast 1961;6:45
[9] Elbaz JS, Verheecke G. The L-form scar in breast plastic surgery [in French]. Ann
Chir Plast 1972;17(4):283–288
[10] Ely JF. Guidelines for reduction mammaplasty. Ann Plast Surg 1981;6(6):424–429
[11] Góes JCS. Periareolar mammaplasty: double skin technique with application of
polyglactine or mixed mesh. Plast Reconstr Surg 1996;97(5):959–968
[12] Góes JCS. Periareolar mammaplasty with mixed mesh support: the double skin
technique. Plast Reconstr Surg 1992;2:575–576
[13] Graf R, Biggs TM, Steely RL. Breast shape: a technique for better upper pole
fullness. Aesthetic Plast Surg 2000;24(5):348–352
[14] Graf R, Auersvald A, Bernardes A, Biggs TM. Reduction mammaplasty and mas-
topexy with shorter scar and better shape. Aesthet Surg J 2000;20:99–106
[15] Graf R, Biggs TM. In search of better shape in mastopexy and reduction mammo-
plasty. Plast Reconstr Surg 2002;110(1):309–317, discussion 318–322
[16] Graf R, Reis de Araujo LR, Rippel R, Neto LG, Pace DT, Biggs T. Reduction mamm-
aplasty and mastopexy using the vertical scar and thoracic wall flap technique.
Aesthetic Plast Surg 2003;27(1):6–12
[17] Hall-Findlay E-. A simplified vertical reduction mammaplasty: shortening the
learning curve. Plast Reconstr Surg 1999;104(3):748–759, discussion 760–763
[18] Hall-Findlay EJ. Vertical breast reduction with a medially-based pedicle. Aesthet
Surg J 2002;22(2):185–194
[19] Holländer E. Die operation der mamahypertrophie und der hangebrust. Dtsch
Med Wochenschr 1924;50:1400
[20] Horibe K, Spina V, Lodovici O. Mamaplastia redutora: nuovo abordaje del método
lateral oblícuo. Cir Plast Ib Latinoamer 1976;11(1):7–15
[21] Lassus C. Breast reduction: evolution of a technique—a single vertical scar.
Aesthetic Plast Surg 1987;11(2):107–112
[22] Lassus C. A technique for breast reduction. Int Surg 1970;53(1):69–72
[23] Lassus C. Update on vertical mammaplasty. Plast Reconstr Surg
1999;104(7):2289–2298, discussion 2299–2304
[24] Lejour M, Abboud M, Declety A, Kertesz P. Reduction of mammaplasty scars:
from a short inframammary scar to a vertical scar [in French]. Ann Chir Plast
Esthet 1990;35(5):369–379
[25] Lejour M. Vertical Mammaplasty and Liposuction of the Breast. St. Louis, MO:
Quality Medical Publishing; 1993
[26] Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr
Surg 1994;94(1):100–114
[27] Lejour M. Vertical mammaplasty: early complications after 250 personal consec-
utive cases. Plast Reconstr Surg 1999;104(3):764–770
[28] Levet Y. The pure posterior pedicle procedure for breast reduction. Plast Reconstr
Surg 1990;86(1):67–75
[29] Lexer E. Ptosis operation. Clin Monatsbl Augenh 1923;70:464
[30] Lotsch GM, Gorhbandt E. Operationen an der weibliche Brustdrüse. Leipzig, GDR:
Chir. Oper.; 1955
[31] Marchac D, de Olarte G. Reduction mammaplasty and correction of ptosis with a
short inframammary scar. Plast Reconstr Surg 1982;69(1):45–55
[32] Meyer R, Kesselring UR. Reduction mammaplasty with an L-shaped suture line.
Development of different techniques. Plast Reconstr Surg 1975;55(2):139–148
[33] Mottura AA. Circumvertical reduction mastoplasty: new considerations. Aesthet-
ic Plast Surg 2003;27(2):85–93
[34] Peixoto G. Reduction mammaplasty: a personal technique. Plast Reconstr Surg
1980;65(2):217–226
[35] Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg
1967;20(1):78–85
[36] Regnault P. Reduction mammaplasty by the “B” technique. Plast Reconstr Surg
1974;53(1):19–24
[37] Ribeiro L, Backer E. Mastoplastia com pediculo de seguridad. Rev Espan Cir Plast
1973;6:223
[38] Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg
1975;55(3):330–334
[39] Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast
Reconstr Surg (1946) 1956;17(5):367–375
[40] Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous
suspension of the mammary gland. Plast Reconstr Surg 1998;101(6):1486–1493
78 Alternative Approaches to Breast Reduction
1209
78 Alternative Approaches to Breast Reduction
Elizabeth J. Hall-Findlay, Niamh Corduff, Genevieve F. Caron, and Don Lalonde
Abstract
There are many alternative procedures for performing a satisfac-
tory breast reduction. Much depends on the patient’s wishes, her
anatomy, and the skill and expertise of the surgeon. There is no
right answer for everyone. This chapter presents different alter-
natives to the superomedial pedicle vertical breast reduction. In a
young woman (with more gland than fat) with a good breast shape
and good skin elasticity, a good result can be achieved through a
parenchyma-only resection through an inframammary fold inci-
sion. The nipple and the breast can both be elevated by removal
of parenchyma only. Liposuction-only can achieve a good result,
usually in an older woman (with more fat than gland) with a good
breast shape and good skin elasticity. The nipple and the breast can
be elevated in a similar manner by removal of the weight only. An
inverted-T, inferior pedicle breast reduction still remains the “work-
horse” for many breast reduction surgeons. Although a free nipple
graft amputation-reduction can be used, there are problems with
depigmentation and less than satisfactory results. A no-vertical-scar
procedure also has significant limitations. Many surgeons are
surprised at how long a thin superior pedicle can be and still give
acceptable results without resorting to a free nipple graft.
Keywords
breast reduction, alternative breast reduction techniques, paren-
chyma-only breast reduction, liposuction-only breast reduction,
inverted-T inferior pedicle breast reduction, superomedial ped-
icle vertical breast reduction, free nipple graft breast reduction,
amputation breast reduction, no vertical scar breast reduction,
long thin superior pedicle breast reduction
78.1 Introduction
The best breast reduction is the breast reduction that the surgeon
does the best. That said, there are alternative approaches to breast
reduction, and each surgeon should understand the advantages
and disadvantages of each technique. Plastic surgeons need to be
creative when assessing each individual problem.
Breast reduction involves removing the excess breast tissue
while moving the nipple to a good position and reshaping the
breast mound to give an aesthetically pleasing result. As is fre-
quently repeated in plastic surgery, it is a balance between beauty
and blood supply.
78.2 Indications and
Contraindications
There are certain principles in breast surgery that have become
evident over the years. First, it is important to use a technique
that gives good, consistent, predictable results. That is why the
inferior pedicle, inverted-T technique became the standard
method of breast reduction in the 1970s and 1980s. To achieve
good, long-lasting results, however, it is important to respect
the effects of gravity. The inferior pedicle technique removed
superior breast tissue and left behind the inferior breast tissue,
which was more susceptible to the effects of gravity over time.
It is also important to respect the effects of tension on the
skin. The inferior pedicle technique relies on the skin brassiere
to hold the breast shape, but skin can stretch. Tissue expansion
works because it relies on applying tension to stretch the skin.
Unfortunately, the skin brassiere would stretch to varying degrees
because of the weight of the breast tissue inferiorly. This stretch-
ing would occur just with using the skin brassiere to hold up the
inferior breast tissue, but it would also occur over time, especially
with the changes that occurred with pregnancy and weight gain.
The patient shown in Fig. 78.1 had an inverted-T, inferior pedicle
breast reduction with a good initial result This type of shape deteri-
oration after pregnancy is only rarely seen with a superomedial ped-
icle vertical breast reduction where the inferolateral breast tissue
is removed. As the pregnancy progresses, the inferolateral breast
tissue that has been left behind expands and stretches the skin with
it (Fig. 78.1). Of course this does not happen with all inferior pedicle
breast reductions, but it is less likely to occur when this breast tissue
is removed in a superomedial type of breast reduction.
It is also important to respect the effects of tension on wound
healing. Plastic surgeons are well aware that wound healing prob-
lems often occur at the T junction. This is partly due to reduced
blood supply to the corners of the skin, but it is also due to the fact
that there is tension on the skin in order to use the skin brassiere
to hold up the breast. Surgeons often design the vertical limbs of
an inverted-T, inferior breast reduction at 5 to 7 cm because they
know that this skin will stretch out postoperatively. Gravity wins.
Just as tension on the incision edges was inevitable when using
the skin brassiere to hold up the breast parenchyma, tension on
the incision edges also caused wound healing problems when
the vertical incision was cinched or gathered in a vertical breast
reduction in order to shorten the vertical length. Once surgeons
realized that cinching the vertical incision did not result in short-
ening, wound healing problems could be avoided by suturing the
skin edges without the inevitable tension caused by gathering. This
cinching of the vertical limbs ended with wound healing problems
because the blood supply to the skin edges was strangled.
Tension on the parenchyma should also be avoided. This became
evident initially during attempts to use a lateral pedicle. It was
thought that pulling and rotating the pedicle medially would take
care of the lateral excess, but the body inevitably adapts to ten-
sion, and the pedicle slid back out until the tension was relieved.
This resulted in a less than desirable shape.
The patient shown in Fig. 78.2 had a breast reduction that used
a lateral pedicle on her right breast and a medial pedicle on her
left breast. The lateral pedicle shifted back, causing too much lat-
eral and inferior fullness. It soon became evident that the medial
pedicle actually had better sensation (85% recovery of normal to
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near-normal sensation) than either the lateral pedicle (76%) or the
superior pedicle (67%).
The principles of working with gravity and avoiding skin ten-
sion can be applied to numerous skin resection patterns. There
are times when an inverted-T skin resection pattern needs to
be added to a superiorly (superior, superolateral, superomedial)
based pedicle when there is just too much redundant skin.
Occasionally a patient has very large breasts but has an excellent
breast shape with a good nipple position and good skin quality.
These patients can be treated with a parenchyma-reducing proce-
dure only. The most common method is liposuction-only, but this
approach can be used only when the breast contains a lot of fat. A
teenager who is not overweight usually has breasts with minimal
fat. In those younger patients with an excellent breast shape,
excision of the posterior gland alone can give a good reduction
through an inframammary incision only. The important caveat
here is that the skin must have enough good elasticity to contract
around the smaller breast mound that results from this excision.
78.3 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. 78.2 This patient had a breast reduction that used a lateral pedicle
on her right breast and a medial pedicle on her left breast. The lateral
pedicle shifted back, causing too much lateral and inferior fullness. It
soon became evident that the medial pedicle actually had better sensa-
tion (85% recovery of normal to near-normal sensation) than either the
lateral pedicle (76%) or the superior pedicle (67%). (Reproduced with
permission from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts and
Techniques. New York, NY: Thieme Medical Publishers; 2010.)
Fig. 78.1 Inferior pedicle breast reduction. (Reproduced with permission from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts and Techniques.
New York, NY: Thieme Medical Publishers; 2010.) (a) This patient had an inverted-T, inferior pedicle breast reduction. (b) Her initial result was good.
(c) She is shown after two pregnancies. This type of shape deterioration after pregnancy is only rarely seen with a superomedial pedicle vertical breast
reduction where the inferolateral breast tissue is removed. (d) This drawing shows a possible explanation for why with pregnancy the lateral breast
tissue enlarges and drags down the lateral and inferior breast. Because the lateral and inferior breast tissue is removed with a superomedial pedicle,
vertical breast reduction, this type of deterioration has not been seen in the author’s practice since moving away from the inferior pedicle reduction.
78 Alternative Approaches to Breast Reduction
1211
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 consid-
erably, 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 to 14 cm.
The patient shown in Fig. 78.3 has a low footprint with a
distance of 14 cm from her clavicle to her upper breast border.
Some high-breasted patients will have a distance of only 8 cm.
Her footprint is 10 cm vertically. Some patients, even with very
large breasts, will have a vertical footprint of only 3 to 4 cm.
Although the upper breast border cannot be changed in a breast
reduction, the IMF can be elevated if desired. Some patients
Fig. 78.3 (a–d) This patient has a low footprint, with a distance of 14 cm from her clavicle to her upper breast border. Some high-breasted patients
will have a distance of only 8 cm. Her footprint is 10 cm vertically. Some patients, even with very large breasts, will have a vertical footprint of only
3 to 4 cm. Although the upper breast border (dotted line) cannot be changed in a breast reduction, the inframammary fold can be elevated if desired.
Some patients would happily tolerate more breast overhang if they did not need to wear their brassiere or bathing suit band low down on the chest wall.
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XI Breast Surgery
would happily tolerate more breast overhang if they did not
need to wear their brassiere or bathing suit band low down on
the chest wall.
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) through the septum described by
Würinger.
The blood supply to the breast (Fig. 78.4) is therefore mainly
superficial³the 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 mam-
mary) 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 not to the nipple itself).
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. It is held in
place by fascial condensations inferiorly (the IMF) and medially
(over the sternum), much like the gluteal fold and the sacrum
(Fig. 78.5). 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 rel-
atively fixed structures (zones of adherence) holding the breast
in place.
There are numerous variations in pedicles and skin resection
patterns that can be used for a breast reduction (Fig. 78.6).
The artery to a superior pedicle (Fig. 78.7a) comes from the
second (usually) intercostal space, and it descends and enters the
nipple area just medial to the breast meridian. It is always about
1 cm deep to the skin³it bleeds with significant force when it is
cut during creation of a purely 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,
Fig. 78.4 The only artery that travels (with its venae comitantes) 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 (enclosed in a loose layer that is described
as Würinger’s breast septum), 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. 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 to the upper breast skin, not to the nipple itself. (Reproduced
with permission from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts and Techniques. New York, NY: Thieme Medical Publishers; 2010.)
78 Alternative Approaches to Breast Reduction
1213
penetrates the pectoralis, and is pushed outward with the subcu-
taneous tissue.
A true superomedial pedicle (Fig. 78.7b) 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 paren-
chyma (it is all superficial), then the surgeon can safely debulk as
much deep parenchyma as needed to facilitate an easier pedicle
inset.
The deep system then comes from the fourth intercostal space
and enters the posterior aspect of the breast as it perforates
the intercostal muscles and the pectoralis muscle. It enters the
breast just medial to the breast meridian. It has accompanying
venae comitantes—and these vessels are all cut when a medial
pedicle vertical breast reduction is performed. This artery (and
branches) and veins are enclosed in Würinger’s septum. This
is the (deep) blood supply to an inferior (Fig. 78.7c) or central
pedicle.
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. 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. 78.7d) but it may enter the breast at a lower
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. Thus it is not a
good idea to infiltrate the incision lines³the needles can damage
the small veins and cause small subcutaneous hematomas.
Although the main innervation to the nipple may come from
the lateral branch of the fourth intercostal nerve, there is no
question that good innervation comes from all four quadrants
of the breast. It appears that all the pedicles—lateral, medial,
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 76%
with a lateral pedicle and only 67% with a superior pedicle. 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.
Fig. 78.5 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). These act much like the gluteal fold and
the sacrum. 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 (inframammary fold) and the
medial breast border are relatively fixed structures (zones of adherence) holding the breast in place. (Reproduced with permission from Hall-Findlay
EJ. Aesthetic Breast Surgery: Concepts and Techniques. New York, NY: Thieme Medical Publishers; 2010.)
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XI Breast Surgery
78.4 Preoperative Assessment
The key ingredient to a successful breast reduction is patient edu-
cation. Patients must understand the limits of what can and what
cannot be achieved. It is also important that patients understand
the concept of high- and low-breasted and that we cannot change
the breast footprint—that is, where the breast sits on the chest wall.
It is very helpful to take photographs during the consultation
and mark them for the patient. We can show the patient where
her upper breast border is and emphasize that we cannot change
it with a breast reduction. We can also draw on the lateral view
to show the patient that she will still have some ptosis with some
breast hanging over the IMF. We warn all patients that they will
still be able to hold at least one pencil underneath the breast. We
can change the lateral and inferior excess along with narrowing
the base diameter. If a patient has poor upper-pole fullness,
liposuction-only would not be ideal and a vertical approach is
indicated to give them more projection.
The 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. If the patient
has good upper-pole fullness, we can achieve a better cosmetic
result. If a patient has a great deal of ptosis and poor upper-pole
fullness, it will be futile to try to push the excess inferior breast
tissue into the upper pole because it will just drop down again. We
can visualize how long the pedicle might be and determine if we
Fig. 78.6 There are numerous variations in pedicles and skin resection patterns that can be used for a breast reduction. The blood supply to the
inferior and central pedicles comes from the deep artery and vena comitans. The blood supply to the other pedicles is superficial, with the arteries
about 1 cm deep in the subcutaneous tissue and the veins running just beneath the dermis. (Reproduced with permission from Hall-Findlay EJ.
Aesthetic Breast Surgery: Concepts and Techniques. New York, NY: Thieme Medical Publishers; 2010.)
78 Alternative Approaches to Breast Reduction
1215
Fig. 78.7 Blood supply to various pedicles. (a) Superior pedicle. The artery to a superior pedicle comes from the second (usually) intercostal space
and it descends and enters the nipple area just medial to the breast meridian. It is always about 1 cm deep to the skin—it bleeds with significant force
when it is cut during creation of a medial pedicle (it can be traced with a pencil Doppler preoperatively). The artery to the medial pedicle also comes
from the internal mammary system (usually from the third intercostal space), and it curves around the sternum, penetrates the pectoralis, and is
pushed outward with the subcutaneous tissue. (b) Superomedial pedicle. A true superomedial pedicle 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. 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 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. (c) Inferior pedicle. The deep system then comes from the
fourth intercostal space and enters the posterior aspect of the breast as it perforates the intercostal muscles and the pectoralis muscle. It enters the
breast just medial to the breast meridian. It has accompanying venae comitantes—and these vessels are all cut when a medial pedicle vertical breast
reduction is performed. This artery (and branches) and veins are enclosed in the septum described by Würinger. This is the (deep) blood supply to
an inferior or central 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. 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 lower 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.)
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need to warn the patient about a possible free nipple graft (very
rare). It is important to assess the skin quality and skin excess and
again determine whether we need to warn the patient that we
might need to add a “hockey stick” to their vertical scar.
We also warn patients that we often cannot make their breasts
as small as we or they would like. We cannot achieve as signif-
icant a reduction with the vertical approaches as we can with
some inverted-T inferior pedicle reductions. The photographs
taken during the consultation are also useful for pointing out
any asymmetries and warning patients that symmetry is a goal
but impossible to achieve. Patients are also warned that breasts
will change with time, gravity, pregnancy, and weight gain and
weight loss.
Teenagers are well aware that their breasts might grow as they
continue to develop and that a re-reduction might be indicated.
We believe that it can be far better for many teenagers to undergo
a breast reduction early rather than having them suffer until they
are older. Teenagers with large breasts tend to withdraw and stop
participating in sports and other activities. As long as the teenager
understands the procedure and its limitations then we are 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.
78.5 Preoperative Planning
Much of preoperative planning consists of patient education.
A preoperatively informed patient is a surgeon’s best ally. The
various alternative approaches to breast reduction are described
below in more detail but some markings are applicable to
all breasts.
78.5.1 Markings
Upper Breast Border and Inframammary Fold
It is best to start by marking the upper breast border (the junc-
tion of the chest wall and the breast). This is sometimes a very
clear demarcation 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. The IMF is then
marked. It can be very different from one side to the other.
The patient shown in Fig. 78.8 has her upper breast border
marked with a dotted line. She is high breasted with good upper-
pole fullness. The distance between her clavicle and her upper
breast border is only 8 cm. The new nipple position is marked at
9 cm, but in this case the patient only had breast tissue removed
through an inframammary incision, and the nipples were not
moved. See below, however, to show how much the nipples were
elevated with removal of the parenchyma only, and not the skin.
The lowest point of her inframammary fold is marked on the
midline of the chest wall, with her right fold being slightly lower
than her left. Her inframammary folds were also raised only with
removal of weight, not with any skin removal. The breast meridian
is marked where it is expected to be once the reduction is finished.
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 performed.
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 in an inverted-T breast reduction. It doesn’t
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 to 10 cm from the midline of the chest wall.
New Nipple Position
The new nipple position should be on the new breast meridian,
about 8 to 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 if it has been placed too high.
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 preoperatively marked
Fig. 78.8 This patient has her upper breast border marked with a
dotted line. She is high-breasted with good upper-pole fullness. The
distance between her clavicle and her upper breast border is only 8 cm.
The new nipple position is marked at 9 cm down from the upper breast
border, but in this case the patient only had breast tissue removed
through an inframammary incision, and the nipples were not moved.
78 Alternative Approaches to Breast Reduction
1217
level (as measured along the skin surface), but it does rise (as
measured from the floor) because of the pendulum effect. It is
better to mark the new nipple position in relation to the upper
breast border rather than the inframammary fold. The fold itself
is a good landmark in many patients, but it can be misleading in
about 15% of patients.
Marking the new nipple at an arbitrary distance from the IMF
or the clavicle is also going to result in problems, especially in
low-breasted patients because the breast cannot be pushed up
the chest wall. 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 to 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 areolar opening
markings medially match from one side to the other. The lateral
extent may vary; it is only important laterally to make sure that
what is left behind is symmetrical.
Skin Resection Pattern
The skin resection pattern follows the vertical lines that would
be used in an inverted-T Wise pattern breast reduction (Fig. 78.9).
Instead of carrying the vertical limbs laterally and medially once
5 to 7 cm is reached, they are joined together well above the
inframammary fold in the vertical approaches. When an inverted-T
skin resection is necessary because of too much redundant skin, the
design can be drawn before surgery or adapted during surgery.
These vertical lines will match up with the breast and chest wall
meridians when the breast is rotated medially and laterally in a
vertical reduction, in an inverted-T reduction, or in an amputa-
tion-free nipple graft reduction. The surgeon can pinch the lines
together to make sure that too much skin is not being removed.
Since a medial 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. With the
inverted-T inferior pedicle breast reductions, more skin is removed
because the shape is being held by the skin acting as a brassiere.
There is nothing wrong with adding an inverted-T when there
is too much excess skin. :hen a patient has had significant weight
loss, for example, the skin will not retract well and any excess
will need to be removed. This excess removal is best performed
by removing skin above and along the IMF. The Wise pattern is
a good design for the parenchyma that is left behind, but it also
remains a good design when excess skin needs to be removed. It
takes time and experience, however, for surgeons to realize that
the superomedial pedicle vertical approach does not use the skin
as a brassiere and that the skin does not need to be tightened to
give the breast shape. The skin will redrape over the newly shaped
breast mound, and obviously this is best achieved when the skin
has good elasticity. It takes a readjustment in thinking for surgeons
to accept that the extra vertical distance is needed to accommodate
the increased projection that results with the superomedial pedicle
vertical breast reduction. When the skin is being used as a brassiere,
surgeons will keep it short vertically because they know that it will
stretch. But when there is a significant amount of redundant skin of
poor quality, it must be removed. The Wise pattern is the best way
to achieve good results in these cases.
Fig. 78.9 (a) The difference between the inverted-T (red lines) and the vertical (blue line) show that the design is fairly similar. It is best to design a
vertical pattern lower than what would normally be drawn for an inverted-T, inferior pedicle breast reduction because the increased projection that is
achieved with the vertical reduction will result in a higher nipple postoperatively. (b) The vertical skin resection pattern can be designed more as a V,
but it is important for the surgeon to understand that the parenchyma needs to be removed more as a U. A postoperative pucker is more the result of
excess subcutaneous tissue rather than excess skin. Note that the vertical skin resection pattern should stay about 4 cm above the inframammary fold.
1218
XI Breast Surgery
78.6 2SerDWiYe 7eFKniTue
78.6.1 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
patient positioned on the table so that the back can go up in the
right position.
78.6.2 ,nÀOWrDWiRn
It is not a good idea to infiltrate the incision lines because we
want to preserve any veins that are found just below the dermis.
It is best to 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). We use about 300 to 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,
preaxillary areas, and just above the inframammary fold. These
are the areas where most of the liposuction is performed.
78.6.3 Parenchymal Resection Only
(Inframammary Fold Scar)
Breast Reduction
The excess breast parenchyma can be removed from the poste-
rior aspect of the breast through an inframammary incision. This
procedure is indicated only in young patients with an excellent
breast shape and excellent nipple position on the mound. It is also
imperative that they have good quality skin with good elasticity.
The 17-year-old patient shown in Fig. 78.10 had no skin
removed. She had 265 g removed from the right breast and 260 g
from the left breast. She is shown at 5 years after her breast reduc-
tion. Note how much her nipple has been elevated. The arrows
mark the upper breast border, the nipple, and the elbow crease.
The upper breast border has not changed much, but the whole
breast (including the nipple) and the inframammary fold IMF have
been elevated without any skin resection.
A 5- to 8-cm incision is made in the IMF. A fiberoptic retractor is
used, and a subglandular pocket is created. The excess breast tissue
is removed in pieces (this is not a particularly easy procedure) in the
shape of a ring. If the surgeon imagines a child’s stacking toy with
the nipple at the top (Fig. 78.10h,i), the goal is to remove one or two
of the bottom rings. It is easier to remove a complete disk of breast
tissue, but it is important to leave some breast tissue under the nipple
to avoid nipple inversion. Some parenchyma will probably need to
be removed in the upper pole, but it is important to assess the breast
preoperatively and only remove breast tissue where it is in excess.
It is tempting to remove the bottom disc of the breast, but it is
best to remove a ring as described by Corduff and Taylor. If excess
parenchyma is not left directly behind the areola, then nipple
retraction or collapse will occur.
The 13-year-old girl shown in Fig. 78.11 had a similar paren-
chymal resection-only procedure through an IMF incision. She
had 102 g removed from her right breast and 156 g from her left
breast. Another 180 mL of fat was removed using liposuction.
She was 5 feet, 4 inches (163 cm) tall and weighed 145 lb (66 kg).
She is shown at 5 months after her surgery with elevation of the
nipple and breast. The upper breast border has remained much
the same, but the nipple and the breast (and the IMF) have risen.
Postoperative support is indicated, but compression is not nec-
essary. There can be significant elevation of the nipple, the breast,
and the IMF—all by removing weight.
78.6.4 Liposuction-Only Breast Reduction
It would be ideal if a young patient needing a breast reduction
would be a candidate for a liposuction-only breast reduction,
but liposuction will only remove soft fat. If a young woman is
not overweight, her breasts are usually very glandular and the
parenchyma needs to be carefully carved out.
The young woman shown in Fig. 78.12 has a breast that
would not be amenable to liposuction-only. The breast is mainly
glandular with only a small amount of fat. As women approach
menopause, their breasts tend to be more fatty and less glandu-
lar—especially if they have gained weight. These patients are good
candidates for liposuction-only breast reduction but only if they
have a good breast shape with good upper pole fullness and good
quality skin. The nipple can be elevated and the skin can retract
nicely, but if the patient does not have an ideal breast shape, the
result is just empty.
It is a good idea to prepare the patient for a possible skin/
parenchymal resection, and markings are therefore made for both
approaches in case there is very little fat that can be removed. It
is actually difficult to assess the amount of fat preoperatively by
physical examination. Age and body weight are better indicators.
The patient shown in Fig. 78.13 underwent a liposuction-only
breast reduction. She had a good breast shape and good skin
quality, which allowed for a satisfactory postoperative shape.
The arrows mark the upper breast border, the nipple position,
and the elbow crease. Note how much the nipple and the breast
were elevated with only minimal change in the upper breast
border.
The patient shown in Fig. 78.14a–f underwent a liposuc-
tion-only breast reduction. Note the elevation of the nipple and
the breast after just removing the weight with liposuction. The
arrows mark the upper breast border, the nipple, and the elbow
crease. She did not have as good fullness or as good skin quality
as the first patient. The problem with liposuction-only is that
the breast can appear somewhat empty. This patient did decide
later to undergo a vertical reduction. The vertical procedure gives
more elevation and more projection but with more scarring and
potentially more loss of sensation.
Depending on the size of the breasts, approximately 500 to
1,000 mL of a tumescent type of fluid is infiltrated into each
breast. Liposuction is best performed by targeting those areas of
the breast where there is excess. It is important not to remove
too much fat in the upper pole if the patient wants to keep some
upper-pole fullness.
78 Alternative Approaches to Breast Reduction
1219
Fig. 78.10 (a–c) This 17-year-old patient had a breast reduction where no skin was removed. (d) She had 265 g removed from the right breast and
260 g from the left breast. The only incision is about 8 cm long in the inframammary fold. (e–g) She is shown at 5 years after her breast reduction.
Note how much her nipple has been elevated. The arrows mark the upper breast border, the nipple, and the elbow crease. The upper breast border
has not changed much, but the whole breast (including the nipple) and the inframammary fold have been elevated without any skin resection. (h,i)
A 5 to 8 cm incision is made in the inframammary fold. A fiberoptic retractor is used and a subglandular pocket is created. The excess breast tissue
is removed in pieces (this is not a particularly easy procedure) in the shape of a ring. If the surgeon imagines a child’s stacking toy with the nipple
at the top, the goal is to remove one or two of the bottom rings. It is easier to remove a complete disk of breast tissue, but it is important to leave
some extra breast tissue under the nipple to avoid nipple inversion. Some parenchyma will probably need to be removed in the upper pole, but it is
important to assess the breast preoperatively and only remove breast tissue where it is in excess.
1220
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Fig. 78.11 (a,b) This 13-year-old girl had a parenchymal resection-only procedure through an inframammary fold incision. She had 102 g removed
from her right breast and 156 g from her left breast. Another 180 mL of fat was removed using liposuction. She was 5 feet, 4 inches tall (163 cm)
and weighed 145 lb (63 kg). (c,d) She is shown at 5 months after her surgery with elevation of the nipple and breast. The upper breast border has
remained much the same, but the nipple and the breast (and the inframammary fold) have risen.
Once the fluid has settled out in the fat aspirate, the volume of
the fat is about double what would be expected with direct exci-
sion (Fig. 78.14g). Liposuction-only breast reduction is not less
invasive than excisional surgery. The recovery from liposuction
can actually be more painful than those areas of the breast where
direct excision was performed. Patients can still lose sensation,
but their ability to breastfeed should be preserved.
Liposuction-only is a good way to correct some asymmetries.
The patient shown in Fig. 78.15 had liposuction performed on her
left breast only. She is shown at 1 year after surgery.
Some form of support postoperatively is indicated. Actual
compression might help to some degree, but it is not absolutely
essential. It is important not to apply too much compression to
avoid damage to the skin.
78 Alternative Approaches to Breast Reduction
1221
78.6.5 Inferior Pedicle, Inverted-T Breast
Reduction
It is difficult to perform a breast reduction using an inferior pedicle
without using an inverted-T or L skin resection pattern. The skin
is used as a brassiere to hold up the parenchyma because much of
the parenchyma is removed from the upper pole, and the skin is
used to hold up the inferior pedicle. The Wise pattern is used for
the skin pattern in an inferior pedicle, inverted-T breast reduction,
whereas the Wise pattern is instead used for the parenchyma that
is left behind in a superomedial pedicle vertical breast reduction.
The blood supply to an inferior pedicle (Fig. 78.16) comes from
the chest wall via the artery and vein that penetrate through the
breast parenchyma to supply the nipple. This system is enclosed in
Würinger’s septum, which separates the upper-pole breast tissue
from the lower pole. Thin membranes enclose the artery and
venae comitantes at the level of the fourth interspace. The main
artery and vein enter the breast just medial to the breast meridian,
but there are some lateral branches that lie above the fifth rib. The
inferior pedicle also has blood supply through the inframammary
fold, which is one of the “zones of adherence” in the body.
The markings (Fig. 78.17) are performed using the Wise pattern
to determine the shape of the skin brassiere. The inferior pedicle
is designed as a chest wall–based pedicle with a base of usually 8
cm. The vertical limbs of the Wise pattern are kept at 5 to 7 cm
(depending on the size of the reduction) with the realization that
these limbs will stretch over time. The horizontal excision follows
the Wise pattern and curves up along the inframammary fold,
much as the underwire of a brassiere does.
After the pedicle is de-epithelialized, the inferior pedicle is created
being careful not to undermine it because it is a chest wall–based
pedicle. The breast resection is then performed between the Wise
pattern and the inframammary fold, and it is extended superiorly
to keep the inferior pedicle intact. Once the resection is complete,
the closure is performed to advance the lower skin toward the
breast meridian to avoid postoperative puckers (dog-ears).
An inverted-T, inferior pedicle breast reduction can give a good
result, especially when the breasts are not too large (Figs. 78.18).
Unfortunately, when a breast is excessively large, a boxy type of
shape can result (Fig. 78.19). This boxy shape is far less frequently
seen when a superomedial pedicle vertical approach is used.
The patient shown in Fig. 78.20 achieved a good shape with
her inverted-T, inferior pedicle breast reduction, but she started
developing thick scars. She is shown at a full year after her surgery
with even thicker scars. The scars are bad around the areola and
vertically, but they are worse along the inframammary fold.
78.6.6 No-Vertical-Scar Breast Reduction
The no-vertical-scar breast reduction leaves the breast tissue and
NAC attached inferiorly. The excess breast is resected superiorly,
and the skin is brought down to the inframammary fold. A new
opening is created for the areola. This method results in a signifi-
cant discrepancy between the upper skin flap and the lower skin
margin. When the skin is closed, this often leads to pleating and
wrinkling of the skin closure that does not settle over time.
Some surgeons will use this “Passot” type technique in
extremely large breast reductions, but many surgeons who
have tried it have since abandoned it because of the difficulty in
achieving a nice inframammary closure. The downside of the skin
closure far outweighs the disadvantage of a vertical scar.
The advantage is that a smaller opening can be made for
the areola, and this can result in a better scar than with other
techniques.
The patient shown in Fig. 78.21 underwent a no-vertical-scar
breast reduction. The result is good, but the breasts are a bit wide
postoperatively.
Lalonde has abandoned the no-vertical-scar technique in spite of
advocating it for several years. He has adopted the medial pedicle
vertical scar technique for most of his cases in the last 5 years. He
says that “the reason is that even though the no vertical scar has a
hidden scar advantage, that positive feature is clearly outweighed
by negative problems with the no vertical scar technique. Those
problems are: (1) long term shape flattening and bottoming out of
the breast (2) lateral and medial dog ears of the no vertical scar are
harder to avoid and manage than the single medial dog ear of the
vertical reduction, and (3) the vertical reduction has much better
long term shape and projection than the no vertical scar reduc-
tion. The Wise pattern T scar reduction is even worse than the no
vertical scar reduction and has no place in my practice anymore.”
The patient shown in Fig. 78.22 shows a more typical result
from a no-vertical-scar breast reduction with a wide boxy shape
and puckered, irregular skin in the IMF.
78.6.7 Free Nipple Graft Breast Reduction
This technique involves amputating the inferior breast tissue
and skin and placing the nipple and areola on de-epithelialized
Fig. 78.12 This young woman has a breast that would not be amenable
to liposuction-only. The breast is mainly glandular with only a small
amount of fat. As women approach menopause, their breasts tend to
be more fatty and less glandular—especially if they have gained weight.
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XI Breast Surgery
Fig. 78.13 (a–d) This patient underwent a liposuction-only breast reduction. She had a good breast shape and good skin quality, which allowed for a
satisfactory postoperative shape. The arrows mark the upper breast border, the nipple position, and the elbow crease. Note how much the nipple and
the breast were elevated with only minimal change in the upper breast border. (Reproduced with permission from Hall-Findlay EJ. Aesthetic Breast
Surgery: Concepts and Techniques. New York, NY: Thieme Medical Publishers; 2010.)
skin as a free nipple graft. The excess skin is removed, leaving an
inverted-T scar.
When surgeons are worried about the length of the pedicle,
they can convert to a free nipple graft. Unfortunately, the free
graft often results in problems with permanent depigmentation,
especially in dark-skinned patients. The nipple can end up flat-
tened, and patients are unlikely to regain much if any sensation.
Patients definitely will not be able to breastfeed.
The patient shown in Fig. 78.23 underwent a free nipple graft
breast reduction with a relatively short IMF scar. She had 1,355 g
removed from the right breast and 1,325 g removed from the left
breast. She is shown at 6 days after surgery when the bolus dress-
ing was removed and then at 4 months. She actually obtained a
fairly good result except that the nipples were placed too close to
the upper breast border, and there was not enough inferior breast
tissue removed. She retained more nipple projection than is usual
with this technique.