The deep per orator comes up directly rom the ourth interspace just above
the f th rib. A subglandular augmentation is shown on the le t, and a subpec-
toral augmentation is shown on the right. The deep artery per orates the pec-
toralis muscle and is accompanied by venae comitantes.
79
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
The artery is clearly shown in the le t
breast o this patient. It branches as it
enters the deep aspect o the breast
parenchyma, a ter it per orates the
pectoralis muscle.
The artery directly enters the breast
parenchyma and passes up to the are-
ola. The breast is a ourth interspace
structure; it makes sense that the deep
per orators come rom the ourth in-
terspace and pass directly to the cen-
ter o the breast.
80
Part I • Concepts and Principles
Descending Branch From the Second Interspace
The other arterial branches o the internal mammary system do not have such
specif c structures to supply, compared with the ourth branch. They travel up
into the subcutaneous tissue and spread out to supply the skin. The branch rom
the second interspace is actually quite strong and extends laterally to supply a
deltopectoral ap. It also has a descending branch that travels down toward the
breast; this is probably the second most dominant arterial input to the breast.
It extends into the subcutaneous tissue above the breast parenchyma and trav-
els toward and past the nipple. This artery reliably supplies a superior pedicle.
The red arrows marked on this patient’s skin indicate the results o a pencil
Doppler examination, showing where the descending branch o the artery rom
the second interspace reliably enters the breast at the level o the new areolar
opening. The artery almost always enters the areolar opening just medial to the
breast meridian and about 1 centimeter deep to the skin. It is a very strong ar-
tery that can supply a very long (and thinned) superior pedicle.
Branches From the Third and Fifth Interspaces
The other branches o the internal mammary system travel up into the subcu-
taneous tissue o the breast a ter they emerge rom around the sternum. Their
origin is deep, but they extend up over the breast tissue toward the nipple. These
branches rom the third interspace supply a medial pedicle. The branches rom
the f th interspace usually extend along the in ramammary old and supply the
breast in eriorly.
81
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
This patient’s right breast is shown, with the in ramammary old marked in blue.
On the le t, the hemostat is pointing to the f th branch o the internal mam-
mary system as it enters the medial aspect o the breast. On the right, the he-
mostat indicates the third branch rom the internal mammary system. This
branch generally supplies a medial pedicle. These vessels can be damaged with
a subglandular augmentation, making a subsequent mastopexy using a medial
pedicle inadvisable (a superior pedicle is likely to be more reliable). The black
marks on the pectoralis muscle show where the per orator and its branches rom
the ourth interspace have been cauterized.
The intercostal arteries supply branches at the level o the in ramammary old
just above the sixth rib. These enter through the in ramammary old area and
penetrate the subcutaneous tissue overlying the in erior pole o the breast.
This patient’s right breast is shown, with a short medial pedicle. The arrows
point to an artery that extends upward to the skin through the attachment at
the in ramammary old. These intercostal per orators need to be severed in a
central pedicle, making its blood supply somewhat less reliable than that o an
in erior pedicle, in which these vessels are preserved.
82
Part I • Concepts and Principles
Lateral Thoracic Artery
The lateral thoracic artery courses under the lateral border o the pectoralis mus-
cle. It sends a superf cial branch up around the pectoralis muscle toward the
breast. There are deep and superf cial branches. These branches supply a lateral
pedicle.
A subglandular breast augmentation dissection is being per ormed on this pa-
tient’s right breast through an in ramammary incision. The lateral edge o the
pectoralis f bers are clearly visible, and the superf cial branch o the lateral tho-
racic artery (arrows) can be seen winding its way around the lateral border o the
pectoralis muscle and into the breast tissue, which is elevated by the retractor.
The Doppler examination per ormed on this patient shows that the lateral tho-
racic artery (arrow) becomes superf cial just be ore the areolar opening and would
easily supply a lateral pedicle. Sometimes the Doppler examination reveals a
much lower artery that would all below a normally designed lateral pedicle.
Thoracoacromial Artery
The thoracoacromial artery sends some branches to the breast, both superf -
cial and deep. These are not particularly strong vessels, but the deep system
can o ten be seen anning out along with the other vessels on the undersur-
ace o the gland. This is best seen when creating a subglandular pocket or
breast augmentation.
83
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
The artery (arrow) shown on this patient’s right breast may be one o the per-
orators rom the thoracoacromial system. The breast tissue is being pulled up
in a cephalad direction.
Thus the breast has our main arterial blood supply patterns:
1. Deep per orator at the ourth interspace rom the internal mammary
system
2. Superf cial descending branch rom the second interspace rom the in-
ternal mammary system
3. Superf cial branch rom the third interspace rom the internal mammary
system
4. Lateral thoracic system
O the our blood supply systems, it is to be expected that sometimes only three
o the our will be dominant. It is my observation that nipple necrosis will be
inevitable in a certain number o cases when the least dominant system supplies
the chosen pedicle. Nipple necrosis is most likely the result o an un ortunate
(but unpredictable) choice o pedicle rather than surgical error.
84
Part I • Concepts and Principles
VENOU S DRAINAGE
Although some veins accompany the deep system, most o the venous drainage
rom the breast is superf cial and does not accompany the arteries. The veins
can easily be seen through the skin. They drain superomedially.
The veins in this patient are easily seen, because they are superf cial and lie just
below the dermis. When a pedicle is deepithelialized, it is important not to dam-
age the dermis to preserve these veins. It is clear rom the photo that most o
the veins drain superomedially.
Innervation
It is o ten stated that the main innervation o the nipple-areola complex is rom
the lateral ourth intercostal nerve. Although this is probably the main nerve,
there are also nerves coming rom the medial intercostals as well as the supra-
clavicular or thoracoacromial nerves. Superior, lateral, and medial pedicles o -
ten have surprisingly good sensation, even though it is requently said that the
in erior pedicle has the best sensation.
The lateral ourth intercostal nerve has a deep and a superf cial branch. The deep
branch passes over the pectoralis muscle and veers superf cially at the breast
meridian to supply the nipple-areola complex. The superf cial branch will be cut
when creating superior, medial, and in erior pedicles, but the deep branch can
be preserved with the creation o ull-thickness pedicles. O the our pedicles,
the lateral pedicle is most likely to include the superf cial branch o the ourth
intercostal system, but in my experience the lateral, superior, and medial pedi-
cles have equally good postoperative sensation.
Anatomy and Pedicle Design
ARTERIAL SU PPLY AND PEDICLE DESIGN
To design predictable, reliable pedicles and aps, the surgeon must be thor-
oughly amiliar with the deep and superf cial arterial input and venous drainage
systems.
The designs become more obvious i the surgeon observes bleeding patterns
while per orming breast surgery o all types. The deep input can be seen on the
undersur ace o the breast during a subglandular breast augmentation. When
per orming a subpectoral augmentation, the surgeon can see the same arterial in-
put. It is also important to note that the origin o the pectoralis muscle is much
broader over the chest wall than is usually described in textbooks.
During a medial pedicle vertical breast reduction, the per orator to an in erior
pedicle is usually transected as it per orates the pectoralis muscle with its venae
comitantes. The superf cial branch o the lateral thoracic artery curves around
the border o the pectoralis major muscle on its way up into the subcutaneous
tissue layer over the breast parenchyma; it is also transected as the parenchyma
is removed in a reduction. This artery is usually 1 or 2 cm deep to the skin sur-
ace when it is transected. The artery supplying the superior pedicle is also tran-
sected when a medial pedicle is used. It is o ten a very strong artery that is only
1 cm deep to the skin and is usually ound just medial to the breast meridian.
The veins are seen just under the skin, and it is wise or the surgeon to attempt
to include one o the veins in the base o the pedicle.
The main arterial supply comes rom the branches o the internal thoracic (mam-
mary) arteries. It is supplemented by branches o the lateral thoracic artery and
thoracoacromial artery.
85
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
86
Part I • Concepts and Principles
Fourth deep intercostal artery
Fifth superficial branch of the
internal mammary artery
5
4
6
Rib
Internal mammary artery
The in erior and central pedicles are supplied by the deep system, whereas the su-
perior, lateral, and medial pedicles are supplied by the superf cial system. The
in erior pedicle is supplied by branches o the internal mammary system rom
the ourth interspace. The artery that supplies an in erior pedicle does not run
in the subcutaneous tissue over the breast, but actually runs deep to the inter-
costals and the pectoralis muscle and per orates the muscle to enter the breast,
usually just medial to the breast meridian and above the f th rib (a ew cen-
timeters above the level o the in ramammary old). This artery has accompa-
nying venae comitantes. The central pedicle relies completely on these vessels,
whereas the in erior pedicle also has branches rom the intercostal arteries at
the level o the in ramammary old.
Inferior Pedicle
87
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
Fourth deep intercostal artery
Branches of fifth superficial branch of
the internal mammary artery (cut)
5
4
6
Rib
Internal mammary artery
The central pedicle is also supplied by the deep system and accompanying ve-
nae comitantes. It is less reliable than the in erior pedicle, because it does not
have the accessory input rom the intercostal branches, which enter the in erior
pedicle at the level o the in ramammary old.
When a central (Ribeiro) f ap is created to rearrange breast parenchyma (with-
out the nipple-areola complex), it is necessary to rely on the per orator rom
the internal mammary system at the ourth interspace. All the attachments and
some blood vessels need to be released rom the in ramammary old level to
mobilize the f ap completely.
Central Pedicle
88
Part I • Concepts and Principles
Second superficial branch of
the internal mammary artery
5
4
3
2
6
Rib
Internal mammary artery
Superior Pedicle
The superior pedicle is supplied by the superf cial system. The arterial input
originates rom the internal mammary branch rom the second interspace. This
vessel is deep as it comes around rom under the sternum, but it quickly trav-
els toward the sur ace and enters the subcutaneous tissue over the breast
parenchyma. It is usually only a centimeter below the sur ace o the skin, just
medial to the breast meridian, as it approaches the areola. It can be easily ound
with a handheld Doppler device. This artery is the descending branch o the
vessel that runs laterally and supplies a deltopectoral (Bakamjian) ap.
In this patient’s right breast, the artery that supplies a superior pedicle is held
in the orceps. The meridian is marked in blue superiorly. The deepithelialized
medially based pedicle can be seen in the lower right corner just underlying the
body o the hemostat.
89
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
This patient is shown intubated on the operating table. A Doppler unit can be
used to map out the artery that supplies a superior pedicle. It is di f cult to use
Doppler ultrasound or determining the location o anything but the superior ar-
tery and the superf cial branch o the lateral thoracic artery. H owever, in a se-
ries o patients, it has been demonstrated that the artery enters the superior
pedicle close to the breast meridian (see p. 90). There ore surgeons can sa ely
backcut a superior pedicle on either side so that it can be inset more easily.
Second superficial
branch of the
internal mammary
artery
Breast
meridian
Doppler Examination of Superior Artery
Doppler examination o the descending branch o internal mammary artery
rom second interspace was per ormed in 83 patients. Thirty o these patients
had some (usually minor) di erences between sides.
90
Part I • Concepts and Principles
Doppler Results in 83 Patients
Location of Artery Relative to New Breast Meridian
No. of Breasts
Medial
Central
Lateral
160
95 (59%)
27 (17%)
38 (24%)
Most o the arteries (59%) were ound just medial to the new breast meridian,
as seen in the patient’s right breast in the photograph below. Twenty- our per-
cent were ound just lateral to the breast meridian, as seen in the le t breast be-
low, with only two patients showing a signal signif cantly urther laterally. A
Doppler signal could not be ound in only two breasts. This study shows that
most breasts have a strong superior artery, which is quite superf cial and can be
ound close to the breast meridian.
The medial pedicle artery could not be ound in these Doppler examinations.
It is presumed that the artery rom the third interspace is deeper than the su-
perior artery ( rom the second interspace) as it proceeds up in the subcutaneous
tissue toward the areola. When per orming either a subglandular or subpectoral
breast augmentation pocket dissection, this medial pedicle artery is o ten seen pe-
ripherally as it comes around the sternum.
This patient shows that a true superomedial pedicle (rather than a pure medial
pedicle) can be used to incorporate this strong superior artery. The pedicle can
be sa ely thinned until the periphery, where the artery comes up through the pec-
toralis muscle. In larger breasts, a superomedial pedicle may be the best choice.
The more superior the pedicle, the more di f cult it can be to inset. Some o the
deeper parenchyma can be sa ely removed to allow easier inset i needed, because
this artery is quite superf cial (usually about 1 cm deep to the skin sur ace).
Doppler examination was also per ormed in the lateral aspect o the breast in
21 patients, and there was considerable variability in the location o the artery.
It was o ten quite low.
Medial Pedicle
91
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
Third superficial
branch of the internal
mammary artery
5
4
3
2
6
Rib
Internal mammary artery
The medial pedicle is supplied by the superf cial system. The arterial input de-
rives mainly rom the third interspace as it curves out rom under the sternum.
These arteries are deep initially and then travel in the subcutaneous tissue over
the breast. As the breast develops during puberty, the subcutaneous tissue and
the blood vessels that are contained within it are pushed outward.
The arterial supply to a medial pedicle is di f cult to determine with Doppler
ultrasonography. It is at a somewhat deeper level in the subcutaneous tissue
than the artery or the superior pedicle. The artery supplying a medial pedicle
can be seen just medial to the sternal border in both a subglandular and a sub-
pectoral breast augmentation. It is sometimes damaged during an augmenta-
tion procedure i the surgeon tries to narrow the cleavage. This then renders
the medial pedicle a poor choice i a subsequent mastopexy is per ormed. The
blood supply to an in erior and lateral pedicle can also be damaged during a
breast augmentation. A superior pedicle is probably the best choice or a
mastopexy a ter a previous augmentation.
Superficial branch
5
4
6
Lateral thoracic artery
92
Part I • Concepts and Principles
The superf cial branch o the lateral thoracic artery supplies a lateral pedicle;
however, it enters the breast at an in erior level that may be lower than many
lateral pedicle designs. The superf cial branch curves around rom under the lat-
eral edge o the pectoralis muscle and sends a superf cial branch toward the
breast. The main branch is superf cial and passes over the breast tissue and to-
ward the nipple. When the parenchyma is resected in a breast reduction, the ar-
tery is severed in the subcutaneous tissue as it curves around the lateral border
o the breast tissue. It travels toward the nipple-areola complex, but it enters
the breast at a airly low (caudal) level.
The deep vascular system supplies the in erior and central pedicles;
however, intercostal arteries at the level o the in ramammary old
provide additional blood to the in erior pedicle. The superf cial vas-
cular system supplies the superior, lateral, and medial pedicles.
Lateral Pedicle
93
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
VENOU S DRAINAGE AND PEDICLE DESIGN
The veins do not accompany the arteries, except in the case o the per orator
that supplies an in erior pedicle. There are venae comitantes that run along with
the per orator, but the other veins are separate rom the arteries. As shown in
the patient above, the veins are quite superf cial and can o ten be seen just be-
low the dermis. It is not a good idea to inf ltrate the incisions when per orm-
ing a breast reduction or mastopexy, because the needle may damage some o
these veins. In act, it is help ul to mark the visible veins and try to include one
in the base o the chosen pedicle. The veins are directly under the dermis and
should not be damaged during deepithelialization. Damage to the veins may be
as serious as damage to the arteries.
It is clear that the superior, medial, and lateral pedicles do not need to be ull
thickness or either arterial or venous circulation, but they must be ull thick-
ness toward the periphery to ensure that the vessels are included where they are
deeper. Keeping the pedicles ull thickness might preserve breast- eeding po-
tential, but more studies are required.
The breast is a superf cial structure, and most o the blood supply
to the breast is superf cial. The veins and the arteries travel sepa-
rately. There is only one main deep blood supply rom the ourth
branch o the internal mammary system that per orates the pec-
toralis muscle and has venae comitantes. The rest o the arterial sup-
ply is mainly rom the internal mammary branches, with some sup-
ply rom the superf cial branch o the lateral thoracic artery.
INNERVATION AND PEDICLE DESIGN
94
Part I • Concepts and Principles
Anterolateral
intercostal
nerves
Anteromedial intercostal
nerves
Supraclavicular nerves
3
3
4
5
4
5
6
Anterolateral intercostal nerve
Superficial branch of the fourth
lateral intercostal nerve
Deep branch of the fourth
lateral intercostal nerve
Anteromedial
intercostal nerve
Intercostal nerve
Innervation comes rom the lateral branch o the ourth intercostal nerve as well
as rom branches o the medial intercostal nerves and superior branches. There
is a deep and a superf cial branch o the lateral intercostal nerve, and although
the superf cial branch will be severed with all but a lateral pedicle, the deep
branch can be preserved with in erior and medial pedicles by keeping tissue in-
tact over the pectoralis muscle. The superior pedicle o ten needs to be thinned
to allow easier insetting o the pedicle; these nerves will be transected but the
superior branches will be le t intact.
95
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
I am o ten asked i the medial pedicle has good innervation, because we have
all been taught that the lateral ourth intercostal nerve is essential or nipple sen-
sation. I have studied sensation a ter breast reduction in superior, medial, and lat-
eral pedicles and ound that there was no real di erence, regardless o the pedi-
cle chosen. Eighty-f ve percent o patients recover normal to near-normal
sensation a ter breast reduction.
H ow can this be? Schlenz et al showed that the lateral ourth intercostal nerve
has a deep and a superf cial branch. The deep branch extends along the pec-
toralis ascia and turns vertically toward the nipple at the breast meridian. I tis-
sue over the pectoralis is preserved and i the medially based pedicle is kept ull
thickness, then theoretically the deep branch should be preserved.
There are multiple sources o innervation to the nipples. Schlenz and colleagues
and Würinger have also shown that there are distinct nerves coming rom the
medial intercostals. A superior pedicle is innervated by the supraclavicular nerves.
The nipple is supplied by several different nerves. This explains why
all the pedicles can recover good sensation in most cases.
BREAST-FEEDING POTENTIAL
It makes sense that a ull-thickness pedicle is more likely to preserve some duc-
tal tissue than a thinned or purely dermal pedicle. Norma Cruz-Korchin com-
pared patients who consulted or breast reduction but did not have the surgery
and then had a pregnancy with patients who had the surgery and then had a
pregnancy. H er study showed the same results in each group—about 60% o
each group were able to breast- eed success ully, and about 25% o each group
had to provide supplementary eedings. Although I still tell my patients that
there is a 50/ 50 chance that they will be able to breast- eed success ully, the re-
ality may be that large-breasted women have trouble breast- eeding, and the
surgery may make less o a di erence than we thought in the past.
REFLECTIONS
The breast is a subcutaneous structure that originates embryologically rom the
ourth interspace. It is attached to the skin and not to the deep tissues on the
chest wall. The breast has our borders: superior, lateral, medial, and in erior.
The skin zones o adherence hold the breast in place. The in ramammary old
(the in erior border) is a skin structure that is attached to the chest wall through
crisscrossing f bers. The medial breast border has looser skin attachments that
keep the breast rom sliding over the sternum. The breast does slide airly easily
superiorly and laterally, because there are no skin attachments in those areas. The
zones o adherence are rom the skin, not rom the breast. The in ramammary
old is much like the gluteal old, and the medial breast border attachments to
the sternum are much like the attachments o the skin to the sacrum.
An understanding o the anatomy o the breast is essential or modern breast
surgery procedures. Surgeons need to not only understand what can and can-
not be changed regarding the breast borders, but must also have a thorough
knowledge o the blood supply so that they may design and create reliable pedi-
cles and aps.
Arterial input is both deep, through the internal mammary per orator o the
ourth intercostal system, and superf cial in the subcutaneous layer, mainly rom
the internal mammary system but also rom the lateral thoracic artery. The ve-
nous drainage is separate rom the arterial system, except or the venae comi-
tantes that accompany the deep per orator. The veins lie just below the dermis
and are visible through the skin. They mainly drain superomedially. The nerves
come rom several directions, and pedicles can be designed ull thickness to in-
corporate the deep branch o the lateral ourth intercostal nerve as it passes over
the pectoralis muscle.
Concepts to Recall
• The breast is a subcutaneous structure that originates rom the ourth
interspace.
• The breast is held in place by skin attachments at the in ramammary old
and medial breast border (zones o adherence).
• The upper breast border and lateral breast border are more mobile, be-
cause they are not held in place by skin zones o adherence.
• The blood supply to the breast has a deep and a superf cial component.
• The deep artery enters the breast rom the ourth interspace as it per o-
rates the pectoralis muscle and is accompanied by venae comitantes.
• The superf cial blood supply is pushed outward into the subcutaneous
tissue as the breast develops.
• The main arterial input comes rom branches o the internal mammary
system.
• There is some arterial input rom the lateral thoracic system, with some
minor input rom the thoracoacromial system.
• The venous drainage is superf cial and drains primarily superomedially.
• Innervation is primarily rom the lateral and medial intercostal nerves.
• Knowledge o arterial input and venous drainage is important or the de-
sign and creation o pedicles and aps.
96
Part I • Concepts and Principles
97
Chapter 2 • Applied Anatomy: Key Concepts or Modern Breast Surgery
BIBLIOGRAPH Y
Inframammary Fold
Babuccu O, Zeyrek T, Comert A, et al. In ragluteal sulcus: a histologic and anatomic reap-
praisal. Aesthetic Plast Surg 32:496-502, 2008.
Bayati S, Seckel BR. In ramammary crease ligament. Plast Reconstr Surg 95:501-508,
1995.
Boutros S, Kattash M, Wien eld A, et al. The internal anatomy o the in ramammary old.
Plast Reconstr Surg 102:1030-1033, 1998.
Carlson GW, Grossl N, Lewis MM, et al. Preservation o the in ramammary old: what are
we leaving behind? Plast Reconstr Surg 98:447-450, 1996.
Lockwood TE. Superf cial ascial system (SFS) o the trunk and extremities: a new concept.
Plast Reconstr Surg 87:1009-1018, 1991.
Muntan CD, Sundine MJ, Rink RD, et al. In ramammary old: a histologic reappraisal.
Plast Reconstr Surg 105:549-556, 2000.
Nanigan BR, Wong GB, Khatri VP. In ramammary crease: positional relationship to the
pectoralis major muscle origin. Aesthet Surg J 27:509-512, 2007.
Nava M, Quattrone P, Riggio E. Focus on the breast ascial system: a new approach or
in ramammary old reconstruction. Plast Reconstr Surg 102:1034-1045, 1998.
Pennisi VR. Making a def nite in ramammary old under a reconstructed breast. Plast Re-
constr Surg 60:523-525, 1977.
Ryan JJ. A lower thoracic advancement ap in breast reconstruction a ter mastectomy. Plast
Reconstr Surg 70:153-158, 1982.
Ryan JJ. Discussion o Muntan CD, Sundine MJ, Rink RD, et al. In ramammary old: a
histologic reappraisal. Plast Reconstr Surg 105:549-556; discussion 557, 2000.
Blood and N erve Supply
Cooper AP. On the Anatomy o the Breast and Atlas. London: Longman, Orme, Green,
Brown, and Longmans, 1840.
Cordu N, Rozen WM, Taylor GI. The superf cial venous drainage o the breast: a clinical
study and implications or breast reduction surgery. J Plast Reconstr Aesthet Surg 10:
1-5, 2009.
Cordu N, Taylor GI. Subglandular breast reduction: the evolution o a minimal scar
approach to breast reduction. Plast Reconstr Surg 113:175-184, 2004.
Hamdi M, Spano A, Van Landuyt K, et al. The lateral intercostal artery per orators: anatom-
ical study and clinical application in breast surgery. Plast Reconstr Surg 121:389-396,
2008.
Manchot C. Die hautarterien des menschlichen körpers. Leipzig: Verlag von FCW Vogel,
1889.
Myers B, Donovan W. The location o the blood supply in random aps. Plast Reconstr
Surg 58:314-316, 1976.
Nakajima H , Imanishi N, Aiso S. Arterial anatomy o the nipple-areola complex. Plast Re-
constr Surg 96:843-845, 1995.
O’Dey D, Prescher A, Pallua N. Vascular reliability o nipple-areola complex-bearing pedi-
cles: an anatomical microdissection study. Plast Reconstr Surg 119:1167-1177, 2007.
Palmer JH , Taylor GI. The vascular territories o the anterior chest wall. Br J Plast Surg
39:287-299, 1986.
Reid CR, Taylor GI. The vascular territory o the acromiothoracic axis. Br J Plast Surg
37:194-212, 1984.
98
Part I • Concepts and Principles
Saint-Cyr M, Chang DW, Robb GL, et al. Internal mammary per orator recipient vessels or
breast reconstruction using ree TRAM, DIEP, and SIEA aps. Plast Reconstr Surg
120:1769-1773, 2007.
Salmon M. Artères de la peau. Travail du laboratoire d’anatomie de la aculté de Marseille,
Paris: Masson et Cie, 1936.
Schlenz I, Kuzbari R, Gruber H , et al. The sensitivity o the nipple-areola complex: an
anatomic study. Plast Reconstr Surg 105:905-909, 2000.
Schwabegger AH , Bodner G, Rieger M, et al. Internal mammary vessels as a model or
power Doppler imaging o recipient vessels in microsurgery. Plast Reconstr Surg
104:1656-1661, 1999.
van Deventer PV. The blood supply to the nipple-areolar complex o the human mammary
gland. Aesthetic Plast Surg 27:393-398, 2004.
van Deventer PV, Page BJ, Graewe FR. The sa ety o pedicles in breast reduction and
mastopexy. Aesthetic Plast Surg 32:307-312, 2008.
Würinger E. Ref nement o the central pedicle breast reduction by application o the liga-
mentous suspension. Plast Reconstr Surg 103:1400-1410, 1999.
Würinger E, Mader N, Posch E, et al. Nerve and vessel supplying ligamentous suspension
o the mammary gland. Plast Reconstr Surg 101:1486-1493, 1998.
Surgical
Principles
Chapter3
99
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e
r
s
p
e
c
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i
v
e
,
E
l
i
s
e
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i
n
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a
y
P
lastic surgery is a unique combination of art and science. Consequently, I do
not believe in slavishly adhering to prescribed measurements and ormulas to
dictate decision making. These ormulas may simpli y the planning process, but
they o ten neglect the reality o individual anatomic variants. What I do f rmly
believe in is the power o observation and measurement to help me better un-
derstand and appreciate what can and cannot be achieved or each patient.
It is critically important to be able to assess what we are seeing and to under-
stand—by measuring—what can be altered. For example, I have documented
a ter breast reduction procedures that the nipple position measured rom the
suprasternal notch does not change. Similarly, with a simple mastopexy, the nip-
ple position does not change. H owever, when an implant is placed, the nipple
position measured rom the suprasternal notch drops an average o 2 cm. When
an implant is added or a mastopexy-augmentation, the nipple position drops an
average o 2 cm, and the breast projection increases. These changes need to be
considered when the nipple position is marked or a mastopexy-augmentation.
In my experience, it is best to mark it at the same level as that used or a pure
mastopexy. (See the Appendices on pp. 121 through 127 or measurement data).
U PPER BREAST BORDER
My studies and measurements have shown that the upper breast border does
not change with a breast reduction or a mastopexy. Undermining and suturing
the breast tissue up to the chest wall does not provide a lasting result. Alterna-
tively, both an implant and the addition o at (either with injections or weight
strip) can raise the upper breast border.
The upper breast border can be lowered with parenchymal resection or with
weight loss. Some o the breast reduction procedures that involve removal o
superior pole tissue actually result in lowering o the upper breast border.
Rearranging the breast tissue by moving it out o the lower pole and bringing
the pillars underneath can improve projection but will not raise the upper breast
border. However, this lower pole breast tissue may be sutured under a pectoralis
sling to improve both projection and upper pole ullness to some degree.
TH E LOWER BREAST BORDER
The in ramammary old is o ten lowered, intentionally or inadvertently, with an
implant, and it can be elevated with procedures that permanently remove some
o the lower pole parenchyma. The old sometimes alls with an in erior pedicle
inverted-T breast reduction, and it sometimes rises with a superior or medial
pedicle vertical breast reduction. It will not be elevated unless the “ghost” areas
under the Wise brassiere pattern are removed.
100
Part I • Concepts and Principles
Breast surgery can be conceptually divided into approaches that move the nip-
ple and those that do not. With a breast augmentation the implant and pocket
creation are designed so that the mound is adapted to the existing nipple posi-
tion. When liposuction-only breast reduction is per ormed, the removal o vol-
ume can be adapted to some degree to the existing nipple position. This is also
true o at injections.
The surgeon has more parameters to take into account when moving the nipple-
areola complex, because the nipple location can now be adapted to the poten-
tial new mound position and shape. To best determine the new nipple position,
the surgeon needs to understand what he or she can do with all our breast
quadrants.
Breast surgery requires a clear assessment o all o the breast’s ootprint and
shape parameters be ore the best surgical procedures can be determined to
achieve the desired goals. Decision making will depend on understanding the
surgical management o the ollowing structures:
• Nipple-areola complex
• Parenchyma
• Skin
MOU ND ADAPTED TO TH E EXISTING
NIPPLE POSITION
Breast Augmentation
When breast augmentation with an implant is contemplated, the surgeon needs
to understand how to use the implant to shape the mound to f t the existing nip-
ple position. Each border needs to be analyzed, and a breast implant should be
chosen that will f t the desired breast base diameter, both vertically and horizon-
tally. The nipple should be centralized, not centered, on the f nal breast mound.
This means that the ideal nipple position is about a third to hal way up the
mound rom the in ramammary old and slightly lateral to the breast meridian.
Patients almost always want the upper breast border elevated, and some hope
that we can elevate it more than we are able. I the nipple is low and/ or there
is very little tissue in the lower quadrant, the in ramammary old may need to
be lowered and reconstituted.
When the nipple is positioned laterally, it may be best to use an implant with a
wide base diameter, with much o the implant base situated as lateral as possible
to better centralize the nipple on the mound. In these cases, it may not be a
good idea to try to decrease the cleavage, because it would exaggerate the ap-
pearance o a lateralized nipple.
101
Chapter 3 • Surgical Principles
An implant that is larger than the breast base diameter is needed to correct
tuberous breast de ormities; however, in many other patients the lateral border
o the breast does not extend to the lateral chest wall, and a larger implant will
be needed. The risk o visibility may be increased by extending the implant base
diameter beyond the actual breast ootprint, but the benef ts may well outweigh
the risks. The implant prof le can then be used to allow some exibility in size
choices.
Fat Injections
Fat injections are becoming more acceptable in breast surgery and can be used
to alter the breast mound to the existing nipple position. Fat can be added to
increase any o the our borders o the breast ootprint. It can also be used to
increase the volume o any o the our quadrants.
Previously, it was thought that at injections would inter ere with mammogra-
phy, but it is clear now that this is not a problem when the at injections are prop-
erly per ormed. Large volumes o at placed in one bolus will ail and likely cause
a large oil cyst. Smaller at injections placed in small aliquots can act as any gra t
would and receive blood rom the surrounding tissues. It has been shown that
all surgical breast procedures may leave calcif cations and questionable lumps,
but this risk can be minimized i at injections are care ully per ormed.
Liposuction
Fat removal can be used to alter the breast mound. Liposuction is used to con-
tour the in ramammary old and lateral chest wall in many breast reductions. It
can also be used in breast augmentation patients with excess at, especially
around the lateral breast border.
When liposuction is per ormed or breast reduction, the surgeon needs to eval-
uate all our quadrants with respect to the existing nipple position. The nipple
is o ten elevated to some degree with liposuction-only breast reduction.
MOVEMENT OF TH E NIPPLE ALONG WITH
MOU ND MODIFICATION
Movement of the Nipple-Areola Complex
I f nd the medial pedicle the easiest to use when per orming a vertical breast re-
duction. The superior pedicle is e ective or mastopexies, but a long superior
pedicle can be a challenge to inset. A true superomedial pedicle can incorporate
two blood supplies but can also be more di f cult to inset. The lateral pedicle
may be used in a mastopexy but prevents removal o the excess lateral breast tis-
102
Part I • Concepts and Principles
103
Chapter 3 • Surgical Principles
Medial pedicle deepithelialized
Third superficial branch of
the internal mammary artery
The medial pedicle is medially based and ull thickness down to the chest wall (to
the breast and chest wall meridian). It may appear to be superomedial when the
patient is standing; however, when the patient is lying down, the pedicle is clearly
based medially, and the blood supply comes rom the medial branches o the
internal mammary system. The veins are superf cial and may be seen just under
the dermis. It is important to preserve these veins, which travel separately rom
the arteries, especially in the longer pedicles. The innervation arises rom the
medial intercostal nerves and the deep branch o the lateral intercostal nerve i
the pectoralis ascia is le t undisturbed.
The medial pedicle has the advantages o a good blood supply and good inner-
vation, and it rotates easily into position without kinking or compression. The
entire base o the pedicle rotates. The in erior border o the medial pedicle be-
comes the medial pillar. This rotation provides a nice, elegant curve to the lower
portion o the breast, and the shape looks good while the patient is on the table.
sue during a breast reduction. The in erior pedicle prevents excision o excess
tissue whose weight can ultimately lead to bottoming out. Free nipple gra ts can
always be used, especially as a backup, when the blood supply is compromised.
Medial Pedicle
104
Part I • Concepts and Principles
This patient shows how the medially based pedicle appears to be superomedial
when she is standing (left), even though the blood supply is actually medial.
The orientation o the pedicle becomes more obvious when the patient is lying
down (right).
The medially based pedicle shown in this right breast is ull thickness. The ar-
terial supply is deep medially and comes rom the internal mammary system.
The arteries curve around the sternum and proceed into the subcutaneous tis-
sue toward the nipple. The distal end o the pedicle can be thinned, because at
that level most o the arteries are superf cial. The veins are superf cial except or
the venae comitantes that accompany the ourth branch o the internal mam-
mary system. A ull-thickness pedicle is more likely to include the deep branch
o the lateral intercostal nerve, which runs above the pectoralis ascia and turns
toward the nipple at the breast meridian. A ull-thickness pedicle is more likely
to include ducts or possible uture breast- eeding. However, most o the breast
parenchyma is located in the upper outer breast quadrant, and the medial pedi-
cle tends to contain more at than parenchyma.
Superficial
branch of
the lateral
thoracic artery
2nd
3rd
4th
(deep)
5th
Superficial
branches
of the internal
mammary
artery
105
Chapter 3 • Surgical Principles
Superior pedicle deepithelialized
Second superficial branch of
the internal mammary artery
A superior pedicle has an excellent blood supply rom the second branch o the
internal mammary system. The artery rom the second interspace sends a branch
in eriorly, and it is quite superf cial when it reaches the areola. This artery is usu-
ally ound just medial to the breast meridian and about 1 cm deep to the skin.
The artery is o ten o large caliber and quite strong, which explains why the su-
perior pedicle can be both long and thinned. In act, the pedicle is more likely
to survive when thinned, because it is less susceptible to kinking or compression.
When a superior pedicle is long, it can be di f cult to inset, because it needs to
be olded into position. In contrast, a medial pedicle is easier to inset when the
nipple needs to move a long distance, because it can be rotated into position.
Because a superior pedicle needs to be thinned, the area in erior to the pedicle
is empty, o ten resulting in a Snoopy-type shape in which the in erior pole is
initially concave.
Superior Pedicle
106
Part I • Concepts and Principles
Superomedial pedicle
deepithelialized
Third superficial branch of
the internal mammary artery
Second superficial branch of
the internal mammary artery
A short superior pedicle can be very use ul, especially in a mastopexy patient.
The superior pedicle is shown in this patient. The in erior pole breast parenchyma
is being mobilized to pass up and under the pedicle. The medial and lateral pil-
lars will then be closed underneath the in erior f ap.
Superomedial Pedicle
A true superomedial pedicle is a combination o a medial and a superior pedi-
cle. This may be a good choice when the nipple needs to move a greater dis-
tance than usual, because it can incorporate the internal mammary branches
rom both the second and third interspaces. Doppler ultrasonography can be
used to map out the artery, and the superomedial pedicle can then be designed.
I the artery tends to be more lateral than expected, which makes it more di f -
cult to inset the pedicle, the surgeon can apply his or her knowledge o anatomy
and preserve the f rst ew centimeters o breast tissue below the dermis (in-
cluding both the artery and the vein). Deep tissue can then be thinned sa ely
to allow the pedicle to inset more easily. The pedicle can still be kept ull thick-
ness in the more central portion o the breast to help preserve innervation.
107
Chapter 3 • Surgical Principles
On this patient’s right breast, crosshatching indicates the area where the der-
mis and superf cial parenchyma will be kept intact to preserve either the venous
drainage or the arterial input. In this area, there are no signif cant vessels deeper
than the f rst ew centimeters. The deep tissue under the crosshatched area can
be sa ely removed to more easily inset the pedicle.
This anesthetized patient is shown a ter a Doppler examination or the supe-
rior artery (red arrows). A handheld Doppler unit can be used to quickly locate
the artery i there is some concern (clearly not in this case) about a long pedicle.
108
Part I • Concepts and Principles
Lateral pedicle
deepithelialized
Superficial branch of
the lateral thoracic artery
To achieve an optimal breast shape, the lateral pedicle is designed with half of
the base of the pedicle placed in the areolar opening and half below it, as with
a medial pedicle.
Lateral Pedicle
I initially tried to use a lateral pedicle for breast reductions after I encountered
problems insetting a long superior pedicle. We have all been taught that sensa-
tion to the nipple comes from the lateral branch of the fourth intercostal nerve.
Therefore it made sense to use a lateral pedicle, which is easy to create and is
thought to have a good blood supply. H owever, it was interesting to note that
the superior and medial pedicles had equally good sensation because of the mul-
tiple sources of innervation to the nipple.
A Doppler examination can sometimes be per ormed to determine where the su-
perf cial branch o the lateral thoracic artery (red arrow) enters the breast. It may
be harder to f nd than the superior artery and tends to enter the breast more cau-
dally than many lateral pedicles designed as previously described. Surgeons who
use other pedicles will notice when they attempt to cauterize this artery that it o -
ten enters the breast well below a standard lateral pedicle design. This may ex-
plain why the lateral pedicle can have a higher incidence o nipple necrosis than
other pedicles.
A lateral pedicle can be e ective or a mastopexy, especially i the deep branch
o the lateral branch o the ourth intercostal nerve is to be sacrif ced. The prob-
lem with using a lateral pedicle in a breast reduction is that it prevents resec-
tion o the excess breast tissue laterally. I operated on a series o patients who
had one lateral and one medial pedicle; the medial pedicle proved to have a
much better shape, because I was able to resect the excess lateral breast tissue.
109
Chapter 3 • Surgical Principles
A lateral pedicle was used on this patient’s right breast, and a medial pedicle
was used on her le t. The nipple looks too high on the right, because not
enough breast tissue was removed in eriorly, which resulted in some bottom-
ing out with excess tissue in the lower pole. The problem in per orming an ad-
equate resection is that the lateral pedicle prevents removal o the redundant
lateral breast tissue.
110
Part I • Concepts and Principles
Inferior pedicle deepithelialized
Fifth superficial branch of
the internal mammary artery
Fourth deep branch of the internal
mammary artery
Many surgeons are reluctant to discontinue us-
ing an inferior pedicle inverted-T procedure, be-
cause it works so well. They believe that it is not
“broken,” and therefore there is no need to
change. Many surgeons achieve excellent results
with this approach. Unfortunately, in some pa-
tients, the results deteriorate with time, and the
inframammary fold drops out, making the nip-
ples look too high (pseudoptosis).
Inferior Pedicle
The inferior pedicle is an excellent, robust pedicle. When McKissock designed
the vertical bipedicle procedure, he revolutionized breast reduction surgery.
H is procedure was reproducible and reliable. Soon surgeons realized that the
superior pedicle was not necessary, and much of the world adopted the inferior
pedicle as the standard. This was combined with an inverted-T skin resection
pattern. McKissock originally described the vertical bipedicle technique with a
full-thickness inferior pedicle, thereby preserving the blood supply that enters
the deep surface of the breast.
This bottoming out o the in ramammary old is probably caused by the pressure
exerted during closure o the skin brassiere, which attens the breast and pushes
tissue in eriorly. Un ortunately, pushing tissue upward only works temporarily;
the breast will eventually drop out.
The in erior pedicle can be used with a vertical skin resection pattern, but a cir-
cumvertical design is necessary to accommodate the base o the pedicle. H am-
mond has per ected this procedure and has achieved excellent results.
The use o the in erior pedicle prevents the surgeon rom adjusting the in ra-
mammary old. Hammond has shown that the old does not drop a ter his pro-
cedures. However, in my experience, having used the in erior pedicle inverted-T
technique in the f rst 10 years o my practice, the old sometimes drops out well
below the original in ramammary scar.
111
Chapter 3 • Surgical Principles
The design o the in erior pedicle inverted-T breast reduction is shown in this
patient. To achieve a good result, most surgeons measure the medial and lat-
eral extensions o the skin aps and make them match the length o the scar
along the in ramammary old. Some surgeons have extended the in erior pedi-
cle as a complete side-to-side ap or use with extremely large breasts, where
the tissue is removed superiorly and the skin is brought down as a ap over the
pedicle, thereby avoiding the use o a vertical scar.
MOU ND SH APING
When a surgeon can reposition the nipple-areola complex, he or she needs to
know what can be done to the mound to best shape the parenchyma. Con-
versely, he or she needs to understand the limitations o mound creation to
know the best position or the new nipple.
Resection of Parenchyma
When breast tissue needs to be removed, many surgeons design the pedicle f rst
and then adapt the tissue removal to f t that pedicle. The vertical bipedicle
method o McKissock was later supplanted by the in erior pedicle when sur-
geons realized that they could rely on the blood supply o either the superior
or the in erior pedicle rather than both. The problem with a superior pedicle
was that it was more di f cult to inset, and most surgeons resorted to the relia-
bility and pliability o the in erior pedicle. Un ortunately, this required the re-
moval o most o the parenchyma superiorly and sometimes resulted in the loss
o upper pole ullness and bottoming out with time.
It makes more sense to f ght gravity by removing in erior breast tissue and leav-
ing superior breast tissue behind. When a patient is young and has good qual-
ity skin, the skin envelope may be able to de eat the orces o gravity. Many pa-
tients, however, develop signif cant ptosis with age. Much o the volume o the
breast is already in the lower pole, and the skin envelope has stretched—and
will likely do so again.
With the medial pedicle vertical breast reduction technique, a vertical wedge o
in erior breast tissue is excised, and then the pillars are brought together, thereby
narrowing the base and coning the breast tissue. There are two dog-ears: one
up into the areola, which is not a problem, and one in eriorly, which can some-
times become a problem. The inverted-T techniques also involve removal o a
wedge o breast tissue (and skin), but in a more horizontal direction, resulting
in two dog-ears: one medial and one lateral under the axilla. Both o these dog-
ears are quite di f cult and sometimes impossible to correct.
The removal o all the parenchyma beyond the Wise pattern is the key concept
when per orming a medial pedicle vertical breast reduction. The tissue that is
le t behind resembles the original Wise pattern, which was adapted rom a
brassiere design. By leaving the remaining breast tissue attached to the supe-
rior, medial, and lateral skin in a Wise pattern, there is less tendency or the
breast tissue to drop. By leaving the superior breast tissue and removing the in-
erior breast tissue, gravity is less likely to cause parenchyma to drop into the
lower pole (glandular ptosis) or the in ramammary old to drop (pseudoptosis).
112
Part I • Concepts and Principles
The rest o the tissue is removed using a combination o direct resection and
liposuction or tailoring. In my experience, it is best to remove the parenchyma
rom the in erior and heavy part o the breast. With a breast reduction, it is re-
moved as a vertical ellipse to allow the breast to be coned with increased pro-
jection and the base to be narrowed.
The surgeon needs to analyze all our borders o the breast and all our quad-
rants when per orming a breast reduction. Although surgeons would o ten like
to increase volume in the upper quadrant, this cannot be achieved with most
methods. The upper breast border and upper pole ullness are not changed with
sutures or undermining, but increased projection can be achieved with the ver-
tical techniques in which the in erior wedge is removed and the breast is coned.
The lower breast border (in ramammary old) can be elevated to some degree by
removing in erior tissue with direct excision and additional tailoring with lipo-
suction. In many breast reductions, there is no need to elevate the in ramam-
mary old, but it o ten rises, attesting to the power o the in erior parenchymal
resection.
The lateral breast border is narrowed with coning, and the lateral chest wall at
is suctioned. The medial breast border is better def ned with the coning process
and urther ref ned with some liposuction along the in ramammary old. It is
important not to place tension on either the remaining parenchyma or the skin.
In my experience, the best, long-lasting result can be achieved when the paren-
chyma is removed in eriorly and the remaining tissue is le t attached to the skin
superiorly, superomedially, and superolaterally. A vertical wedge o in erior
breast tissue is removed, along with the medial and lateral extensions o tissue
below the Wise pattern. This leaves the parenchyma behind in a Wise pattern,
which is then coned. The remaining skin adapts to the breast shape with a ver-
tical scar unless there is too much excess skin, which is removed in an anchor
pattern.
Rearrangement of Parenchyma
When a mastopexy is per ormed, it is tempting to tighten the skin brassiere and
push the extra breast tissue upward. I have been unsuccess ul in pushing breast
tissue upward into the upper pole with either sutures to pectoralis ascia or skin
tightening and the use o dermal aps. I strongly believe that tissue removed
in a breast reduction (an in erior vertical wedge) must be physically moved and
rearranged in a mastopexy and not simply pushed upward.
113
Chapter 3 • Surgical Principles
There are numerous ways o rearranging breast parenchyma, including various
extensions o the pedicles described previously or a central ap, as described by
Ribeiro and modif ed by Daniel and Gra .
Liacyr Ribeiro described an in erior ap without the nipple attached that is com-
pletely released rom its in erior attachments. This tissue is moved upward, un-
der the nipple-areola complex, and then the medial and lateral pillars are brought
around and sutured underneath the ap, holding it up into a higher position.
Because Ribeiro called it an “in erior pedicle,” it was misleading to North Amer-
ican surgeons and has not received proper attention.
Milton Daniel described suspending the ap under a strip o pectoralis muscle;
this approach was subsequently popularized by Ruth Gra . The in erior ap is
an e ective way o elevating the in erior parenchyma into a more superior po-
sition, and the use o the pectoralis strip can hold the ap (not the breast tissue
itsel ) up, where it can slightly increase upper pole ullness.
114
Part I • Concepts and Principles
The Ribeiro type l ap shown above has been completely released rom its in-
erior attachments. The ap is suspended with orceps at the upper border o
the dermis. The lower border o the dermis o the ap is now several centime-
ters rom the lower skin border (as shown by the arrows). It has the same vas-
cular supply as an in erior or central pedicle, with the artery entering the ap
just medial to the breast meridian and usually just above the f th rib ( rom the
internal mammary artery at the ourth interspace). This artery has venae comi-
tantes, whereas most o the breast has arterial input that is separate rom the
venous drainage.
The in erior ap has been completely separated rom all its surrounding at-
tachments. Care has been taken to preserve the deep blood supply to the ap,
which per orates the pectoralis muscle just above the f th rib and just medial
to the breast meridian. In this patient, the skin has been temporarily le t at-
tached to better demonstrate the ap design and dissection.
The vertical wedge of tissue that is removed in a breast reduction
must be moved in a mastopexy.
Resection or Rearrangement of Parenchyma
When an Implant Is Used
An implant is used in combination with a mastopexy when the patient either
desires a larger size or when the surgeon is trying to f ll the upper quadrant o
the breast. Patients o ten do not understand that f lling the upper pole cannot
usually be achieved by rearranging the ptotic in erior parenchyma. Usually an
implant is needed, although at injections can also provide some improvement.
Excess breast tissue in the lower quadrant (glandular ptosis) needs to be either
removed as in a reduction or moved as in a mastopexy.
115
Chapter 3 • Surgical Principles
When a mastopexy-augmentation is being planned, it is di f cult to envision how
the breast tissue can be rearranged at the same time an implant is placed. The
insertion o the implant destroys the blood supply to an in erior or central ap,
so some other means is needed. I have tried superior and medial pedicle exten-
sion aps, and they are only partially success ul. The problem is that the breast
tissue tends to all back to its original position, independent o where the im-
plant is sitting. In my experience, much o the ptotic tissue that can be moved in
a mastopexy alone cannot easily be moved in a mastopexy-augmentation. That
tissue needs to be removed and the concept o the reduction-augmentation may
not be as much o an oxymoron as it sounds.
U nfortunately the tissue that is moved in a mastopexy cannot easily
be moved in a mastopexy-augmentation. The principle of a reduction-
augmentation should be reconsidered.
In my experience with all f ve pedicles (superior, lateral, medial, in erior, and
central), the medial pedicle is the most elegant to inset and creates the best
shape while the patient is still on the operating table or a breast reduction. The
superior pedicle is o ten used or a mastopexy and is probably the best choice
or this procedure a ter a previous augmentation. The central ap (central pedi-
cle without the nipple) held under a strip o pectoralis muscle is an excellent
ap or a mastopexy when combined with a superior or lateral pedicle or
the nipple-areola complex. This ap usually cannot be used with a mastopexy-
augmentation, because the blood supply to the ap would be damaged with
the pocket dissection.
SKIN RESECTION
Surgeons o ten associate particular skin resection patterns with certain parenchy-
mal resection or reshaping techniques, but the surgical principles revolve more
around parenchymal concepts than f nal skin scar patterns. Skin is removed when
the nipple-areola complex needs to be moved and when there is excess skin.
The skin resection pattern contributes very little to breast reshaping unless it
has good tone and elasticity.
Skin is usually resected in a vertical pattern along with the parenchymal resec-
tion. However, the vertical breast reduction is less about the skin scars and more
about parenchymal shaping and long-lasting results. The skin and parenchyma
116
Part I • Concepts and Principles
are removed as a vertical ellipse, leaving two dog-ears. The upper dog-ear can
be chased up into the nipple, where it disappears. The in erior dog-ear extends
toward the in ramammary old and will disappear in patients with good skin
elasticity. Alternatively, i there is signif cant excess skin, especially the poor qual-
ity skin seen a ter massive weight loss, then consideration must be given to ex-
cising the excess as a J, L, or T shape.
Skin stretches and should not be used as a handle. With the vertical ap-
proach described here, the skin is not used as a brassiere to shape
the breast—instead, the parenchyma is shaped and the skin redrapes
over the newly formed mound.
Although a vertical skin resection pattern is pre erred when possible, it is clear
that the surgeon needs to treat excess skin as a separate issue. The medial pedi-
cle or the nipple-areola complex and in erior parenchymal resection can still be
used even i signif cant excess skin or poor quality skin needs to be removed,
leaving more extensive scars. Although there is nothing wrong with adding a
horizontal skin resection scar, surgeons need to raise their threshold or con-
version and not be quick to all back on this solution. It is not as easy as it seems
to add a horizontal scar. Sometimes, by doing so, we are simply adding two
more dog-ears that need to be chased.
Sometimes in large reductions or in patients with poor skin qual-
ity, a medial pedicle approach with inferior parenchymal resection
needs to be combined with an inverted-T skin resection pattern.
REFLECTIONS
Skoog recognized that the in erior wedge resection principle was a key to good
breast surgery. My experience has shown that maneuvers such as pushing tis-
sue into the upper pole, suturing gland to pectoralis ascia, or using dermal aps
as a brassiere are all doomed to ailure over time. The in erior wedge should be
removed in a breast reduction and moved in a mastopexy. The breast mound
is thereby shaped without tension, and the skin then redrapes over that new
shape (also without tension). When an implant is placed, it can be di f cult to
reshape the gland; it may be better to remove the in erior wedge and use a larger
implant to compensate (minus-plus).
117
Chapter 3 • Surgical Principles
Concepts to Recall
• An understanding o the various principles o breast surgery helps sur-
geons comprehend what they can and cannot do or patients and, equally
important, how to best manage patient expectations.
• A thorough knowledge o breast anatomy helps to ensure that surgery
can be sa ely per ormed. Measurements and analysis are the key elements
or making various procedures reliable and predictable.
• For breast augmentation, it is important to consider how to best match
the implant to the existing breast ootprint and how to position the
mound in relation to the existing nipple location. Because the nipple
is not moved, the implant is used to centralize the mound behind the
nipple.
• For breast reduction, three actors must be considered: the nipple-areola
complex, parenchymal resection, and the skin resection pattern. Several
choices and combinations are available. It makes intuitive sense that the
breast is most likely to hold its shape over the long term i the lower quad-
rant o the breast is excised and the medial and lateral pillars are brought
together, with the base coned.
• For a mastopexy, the best way to rearrange the breast tissue must be de-
termined. Trying to use the skin alone as a brassiere or trying to use der-
mal aps to suspend the breast will only result in ailure, because both
skin and dermis stretch. The skin brassiere can be more e ective in breast
reductions when skin quality is good; however, the skin is rarely o good
quality in a mastopexy patient. It is important with a mastopexy to move
the parenchyma that is removed in a breast reduction.
• For mastopexy-augmentation, all o these actors, as well as their interac-
tions, must be evaluated. Unquestionably, the actors that a ect the f nal
result are multiplied when mastopexy is combined with augmentation,
because more variables are involved and the resultant orces oppose
each other. The breast parenchyma and the implant are independent o
each other. Skin tightening procedures are even less likely to work when
an implant is added. I the lower pole parenchyma cannot be moved,
which is o ten the case once an implant is placed because it damages the
blood supply, it may be better to remove the lower pole and use a larger
implant.
118
Part I • Concepts and Principles
119
Chapter 3 • Surgical Principles
BIBLIOGRAPH Y
Au richt G. Mammaplasty or pendulous breasts: empiric and geometric planning. Plast
Reconstr Surg 4:13-29, 1949.
Blondeel PN, Hamdi M, Van de Sijpe, et al. The latero-central glandular pedicle technique
or breast reduction. Br J Plast Surg 56:348-359, 2003.
Brink RR. Evaluating breast parenchymal maldistribution with regard to mastopexy and
augmentation mammaplasty. Plast Reconstr Surg 86:715-719, 1990.
Brink RR. Evaluating breast parenchymal maldistribution with regard to mastopexy and
augmentation mammaplasty. Plast Reconstr Surg 106:491-496, 2000.
Daniel MJ. Mammoplasty with pectoral muscle ap. Presented at the Sixty- ourth Scientif c
Meeting o the American Society o Plastic and Reconstructive Surgeons, Montreal,
Oct 1995.
Davison SP, Mesbahi AN, Ducic I, et al. The versatility o the superomedial pedicle with
various skin patterns. Plast Reconstr Surg 120:1466-1476, 2007.
Gra R, Auersvald A, Bernardes A, et al. Reduction mammaplasty and mastopexy with
shorter scar and better shape. Aesthet Surg J 20:99-106, 2000.
Gra R, Biggs TM. In search o better shape in mastopexy and reduction mammaplasty.
Plast Reconstr Surg 110:309-317, 2002.
Gra R, Biggs TM, Steely RL. Breast shape: a technique or better upper pole ullness. Aes-
thetic Plast Surg 24:348-352, 2000.
Hall-Findlay EJ. Pedicles in vertical reduction and mastopexy. Clin Plast Surg 20:379-391,
2002.
H amdi M, H all-Findlay EJ. Pedicle choices in breast reduction. In H amdi M, H ammond
D, Nahai F, eds. Vertical Scar Mammaplasty. Berlin: Springer Verlag, 2005.
H ammond DC. Short scar periareolar in erior pedicle reduction (SPAIR) mammaplasty.
Plast Reconstr Surg 103:890-891, 1999.
H o man S. Recurrent de ormities ollowing reduction mammaplasty and correction o
breast asymmetry. Plast Reconstr Surg 78:55-62, 1986.
H o man S. Reduction mammaplasty: a medicolegal hazard? Aesthetic Plast Surg 11:113-
116, 1987.
Lalonde DH , Lalonde J, French R. The no vertical scar breast reduction: a minor varia-
tion that allows to remove vertical scar portion o the in erior pedicle Wise pattern T
scar. 27:335-344, 2003.
Lejour M. Evaluation o at in breast tissue removed by vertical mammaplasty. Plast Re-
constr Surg 99:386-393, 1997.
Losken A, Holtz DJ. Versatility o the superomedial pedicle in managing the massive weight
loss breast: the rotation-advancement technique. Plast Reconstr Surg 120:1060-1068,
2007.
McKissock PK. Discussion o Mathes SJ, Nahai F, Hester TR. Avoiding the at breast in re-
duction mammaplasty. Plast Reconstr Surg 66:63-70, 1980
Movassaghi K, Liao EC, Ting V, et al. Eliminating the vertical scar in breast reduction:
Boston modif cation o the Robertson technique. Aesthet Surg J 26:687-696, 2006.
Nagy MW, McCraw JB, Lalonde DH , et al. The no vertical scar mammaplasty: a durable
approach to a complex problem. Plast Reconstr Surg 116:216, 2005.
Ribeiro L. A new technique or reduction mammaplasty. Plast Reconstr Surg 55:330-334,
1975.
Ribeiro L, Accorsi A, Buss A, et al. Creation and evolution o 30 years o the in erior pedi-
cle in reduction mammaplasties. Plast Reconstr Surg 110:960-970, 2002.
120
Part I • Concepts and Principles
Skoog T. Breast hypertrophy. In Skoog T, ed. Plastic Surgery: New Methods and Ref ne-
ments. Breast H ypertrophy. Philadelphia: WB Saunders, 1974.
Tepper OM, Choi M, Small K, et al. An innovative three-dimensional approach to def n-
ing the anatomical changes occurring a ter short scar medial pedicle reduction mam-
maplasty. Plast Reconstr Surg 121:1875-1884, 2008.
Wise RJ. A preliminary report on a method o planning the mammaplasty. Plast Reconstr
Surg 17:367-375, 1956.
Fat Injections
Coleman SR. Structural at gra ting: more than just a permanent f ller. Plast Reconstr Surg
118(3 Suppl):S108-S120, 2006.
Coleman SR, Saboeiro AP. Fat gra ting to the breast revisited: sa ety and e f cacy. Plast Re-
constr Surg 119:775-785, 2007.
H yakusoku H, Ogawa R, Ono S, et al. Complications a ter autologous at injection to the
breast. Plast Reconstr Surg 123:360-370, 2009.
Pu LL, Coleman SR, Cui X, et al. Autologous at gra ts harvested and ref ned by the Coleman
technique: a comparative study. Plast Reconstr Surg 122:932-937, 2008.
Spear SL. Fat or breast: where are we? Plast Reconstr Surg 122:983-984, 2008.
Appendix A
Measurements in breast augmentation patients have shown that the supraster-
nal notch-to-nipple distance increases an average o 2 cm rom its preoperative
position. These results represent a sampling o 50 patients who underwent var-
ious types and sizes o breast augmentation. The average increase was 2.3 cm.
Breast Augmentation Measurements:
Suprasternal Notch-to-Nipple Change
Follow-up
Right Implant
Right Change (cm)
Left Implant
Left Change (cm)
4 yr
CMH -310
2.5
CMH -310
2.
32 mo
CMH -410
1.5
CMH -410
1.
29 mo
CMH -365
3.
CMH -365
2.
6 mo
CMH -280
2.5
CMH -280
2.5
18 mo
CMH -310
2.
CMH -310
2.5
24 mo
115-222
0.
115-222
0.5
25 mo
CML-335
2.5
CML-335
2.5
21 mo
120-300
3.
120-300
2.
16 mo
15-304
1.
15-304
1.5
21 mo
MPP-275
2.
MPP-275
2.
12 mo
15-397
2.
15-397
2.
12 mo
15-397
2.
15-397
2.
9 mo
15-286
3.
15-286
3.
8 mo
15-265
1.5
15-304
2.
7 mo
MPP-250
3.
MPP-250
2.
12 mo
15-286
4.5
15-304
5.
4 mo
15-265
2.
15-265
3.
7 mo
15-339
2.
15-339
2.
2 mo
15-397
3.
15-339
2.5
2 mo
115-272
2.
115-272
2.
7 mo
115-322
2.5
115-322
3.
1 mo
MPP-375
2
MPP-375
3.
1 mo
15-286
1.5
15-286
2.
9 mo
115-354
3.
115-354
2.5
2 mo
115-290
2
115-290
2
6 mo
115-354
2.5
115-354
2.5
115, 120—Biocell textured responsive silicone gel implants.
15, 20—Smooth-walled responsive silicone gel implants.
CML, CMH —Microcell textured highly cohesive silicone gel implants.
MPP—Moderate Plus Prof le MemoryGel silicone gel implants.
410—Biocell textured cohesive gel shaped implant.
121
Chapter 3 • Surgical Principles
Continued
Breast Augmentation Measurements:
Suprasternal Notch-to-Nipple Change—cont’d
Follow-up
Right Implant
Right Change (cm)
Left Implant
Left Change (cm)
2 mo
MPP-275
1.
MPP-275
1.
2 mo
120-440
3.
120-400
3.5
4 mo
CMH -280
1.5
CMH -280
1.5
8 mo
15-339
1.5
15-371
1.5
4 mo
115-272
3.
115-272
2.5
7 mo
115-354
3.
115-378
3.
7 mo
115-322
4.5
115-354
3.5
6 mo
115-272
0.5
115-253
1.5
1 mo
115-378
2.5
115-378
1.5
2 mo
115-354
0.
115-354
0.5
3 mo
MPP-300
1.
MPP-300
1.5
5 mo
15-371
3.5
15-371
3.
1 mo
120-500
2.5
120-550
2.5
1 mo
15-378
2.
15-378
2.
2 mo
120-440
2.5
120-440
2.5
4 mo
120-500
3.
120-500
3.
2 mo
15-371
3.5
15-339
3.5
3 wk
15-304
2.
15-304
2.
1 mo
15-371
2.5
15-371
3.
1 mo
MPP-375
2.5
MPP-375
3.
1 mo
15-339
1.5
15-339
1.5
1 mo
15-371
3.5
15-339
3.
1 mo
120-500
3.5
120-500
3.
1 mo
15-286
2.
15-286
2.
AVERAGE
2.29
2.29
CH ANGE
115, 120—Biocell textured responsive silicone gel implants.
15, 20—Smooth-walled responsive silicone gel implants.
CML, CMH —Microcell textured highly cohesive silicone gel implants.
MPP—Moderate Plus Prof le MemoryGel silicone gel implants.
410—Biocell textured cohesive gel shaped implant.
122
Part I • Concepts and Principles
Appendix B
The suprasternal notch-to-nipple distance remained close to the position where
it was marked for a breast reduction. This was independent of volume removed,
and in most patients in whom multiple measurements were made, this number
did not vary with longer-term follow-up.
Breast Reduction Measurements:
Suprasternal Notch-to-Nipple Distance
Follow-up
Right Excision (g)
Change (cm)
Left Excision (g)
Change (cm)
9 yr
410
2.
490
2.5
7 yr
1200
1.
1050
2.
6 yr
125
1.
150
1.
8 mo
205
2.
200
1.5
7 mo
270
1.
300
1.
30 mo
1165
2.5
950
1.5
2 mo
140
1.
270
1.5
15 mo
290
1.
325
1.
3 mo
730
1.
745
1.
24 mo
245
0.
285
0.5
18 mo
110
0.5
110
0.5
18 mo
175
0.5
175
0.5
22 mo
200
1.
300
0.5
22 mo
145
2.
145
2.
12 mo
440
2.
445
2.
5 mo
150
1.
175
1.
15 mo
460
3
435
3.
12 mo
220
0.
263
0.5
15 mo
685
0.5
800
1.5
1 mo
500
0.
450
0.5
7 mo
330
0.5
325
1.
7 mo
250
0.
310
0.5
4 mo
450
1.
385
1.
4 mo
480
1.
505
0.5
6 mo
315
0.
370
1.
4 mo
590
0.5
535
0.
123
Chapter 3 • Surgical Principles
Continued
Breast Reduction Measurements:
Suprasternal Notch-to-Nipple Distance—cont’d
Follow-up
Right Excision (g)
Change (cm)
Left Excision (g)
Change (cm)
1 mo
550
0.5
420
1.
1 mo
230
1.5
340
0.5
2 mo
310
0.5
315
1.
4 mo
445
0.5
430
1.
1 mo
205
0.
235
0.5
1 mo
340
1.
400
1.
1 mo
275
0.
305
0.
4 mo
470
2.
495
1.5
3 mo
165
2.
173
1.5
1 mo
150
0.5
120
1.5
1 mo
310
1.
300
1.
1 mo
985
0.5
675
1.5
1 mo
535
0.
460
0.
1 mo
520
1.
600
0.
1 mo
525
0.
560
1.5
1 mo
325
1.
300
0.5
1 mo
325
0.5
310
0.5
1 mo
425
0.
400
0.
5 mo
255
0.5
255
0.5
11 mo
410
1.
560
1.
4 mo
240
0.5
250
0.5
3 mo
320
0.5
350
1.
6 mo
350
1.
350
1.5
6 mo
635
0.
725
1.
AVERAGE
0.3
0.5
124
Part I • Concepts and Principles
Appendix C
Fifty patients were examined after mastopexy to determine whether there was
any change in the suprasternal notch-to-nipple distance, compared with the pre-
operative markings. There was a minimal change. In patients who were measured
on several postoperative visits, there was very little change over time.
Mastopexy Measurements:
Suprasternal Notch-to-Nipple Change
Right Change
Left Change
Follow-up
(cm)
(cm)
11 mo
1.5
1.
5 mo
1.
1.
6 mo
0.5
0.5
12 mo
1.5
1.5
28 mo
2.
1.
12 mo
1.5
2.
2 mo
0.
0.
1 mo
0.
0.
5 mo
0.
1
1 mo
1.
1.
12 mo
0.5
0.5
11 mo
1.5
1.
6 mo
0.5
1.
10 mo
1.
1.5
3 mo
0.5
0.5
6 mo
0.
1.
2 mo
1.
1.
1 mo
0.5
0.5
2 mo
0.5
0.5
2 mo
1.
1.
1 mo
1.5
1.5
6 wk
0.5
0.5
6 mo
1.
0.5
1 mo
1.
1.
6 mo
1.5
2.
125
Chapter 3 • Surgical Principles
Right Change
Left Change
Follow-up
(cm)
(cm)
12 mo
1.
1.
4 yr
0.
0.
6 mo
0.5
0.
12 mo
1.
1.5
1 mo
1.
1.5
2 mo
1.
2.5
2 mo
1.
1.5
4 mo
2.
1.5
4 mo
1.
1.
2 mo
0.5
0.5
2 mo
0.
1.
2 mo
1.5
1.5
1 mo
2.
2.
1 yr
1.5
1.5
2 mo
0.5
0.5
18 mo
0.
1.
1 mo
2.
2.5
4 mo
0.
0.
1 mo
0.5
0.
5 mo
0.
1.
1 mo
1.
1.
12 mo
0.5
0.5
2 mo
0.
0.
2 mo
0.
0.
12 mo
0.
1.
AVERAGE
0.6
0.7
Appendix D
Fi ty patients were examined a ter mastopexy-augmentation to determine
whether there was any change in the suprasternal notch-to-nipple distance, com-
pared with the preoperative markings. The distance lengthened, on average over
2 cm, independent o the pocket location and implant size. Patients who had
multiple ollow-up measurements had very little change with time, although
the distance in the lower pole did lengthen.
Mastopexy-Augmentation Measurements:
Suprasternal Notch-to-Nipple Change
Right
Right
Left
Left
Follow-up
Pocket
Implant
Change (cm)
Implant
Change (cm)
8 mo
Sub ascial
CML-335
4.5
CML-335
4.5
7 mo
Sub ascial
CML-335
3.0
CML-335
3.0
26 mo
Sub ascial
CML-230
1.5
CML-230
1.5
27 mo
Sub ascial
CML-335
3.0
CML-335
3.0
20 mo
Sub ascial
115-378
2.5
115-378
3.0
11 mo
Sub ascial
CMH -410
2.0
CMH -410
2.0
26 mo
Sub ascial
115-354
3.0
115-354
3.0
12 mo
Sub ascial
15-265
3.0
15-265
3.5
16 mo
Subglandular
115-203
1.5
115-203
1.5
18 mo
Subpectoral
15-286
1.5
15-286
2.0
5 mo
Sub ascial
115-253
4.5
115-253
4.5
1 mo
Sub ascial
115-354
2.0
115-354
2.0
10 mo
Subglandular
115-185
2.0
115-185
1.0
5 mo
Sub ascial
115-322
2.0
115-322
2.0
8 mo
Subglandular
MPP-325
1.5
MPP-300
1.5
18 mo
Subglandular
115-322
3.0
115-322
3.0
12 mo
Subglandular
15-213
2.5
15-213
3.0
6 mo
Subglandular
MPP-350
3.5
MPP-350
3.0
11 mo
Sub ascial
115-354
4.5
115-354
4.5
18 mo
Subglandular
115-378
6.0
115-378
5.0
115, 120—Biocell textured responsive silicone gel implants.
15, 20—Smooth-walled responsive silicone gel implants.
CML, CMH —Microcell textured highly cohesive silicone gel implants.
MPP—Moderate Plus Prof le MemoryGel silicone gel implants.
410—Biocell textured cohesive gel shaped implant.
126
Part I • Concepts and Principles
127
Chapter 3 • Surgical Principles
Right
Right
Left
Left
Follow-up
Pocket
Implant
Change (cm)
Implant
Change (cm)
3 mo
Subglandular
115-322
1.5
115-322
0.5
2 mo
Subpectoral
115-290
0.5
115-290
0.5
8 mo
Subglandular
15-339
3.
15-339
2.5
1 mo
Subglandular
15-234
0.5
15-234
0.5
8 mo
Subpectoral
MPP-350
3.
MPP-350
3.
12 mo
Subglandular
115-354
1.
115-354
1.
13 mo
Subglandular
15-339
3.
15-339
3.
12 mo
Subglandular
15-272
2.
15-272
2.
13 mo
Subglandular
410MM-320
2.5
410MM-320
2.
6 mo
Subglandular
15-194
1.
15-194
1.5
1 mo
Subglandular
15-265
2.5
15-265
2.5
3 mo
Subglandular
15-339
2.
15-339
2.
5 mo
Subglandular
15-213
3.
15-213
3.
4 mo
Subglandular
15-339
2.5
15-339
2.5
5 mo
Subglandular
120-600
4.
120-600
4.
1 mo
Subglandular
15-339
2.
15-339
2.5
3 mo
Subglandular
MPP-350
2.
MPP-350
2.5
3 mo
Subglandular
MPP-350
2.
MPP-350
2.
1 mo
Subglandular
15-371
2.
15-371
1.5
1 mo
Subglandular
15-339
1.
15-339
0.
1 mo
Subpectoral
15-371
1.5
15-371
1.5
4 mo
Subpectoral
15-265
2.5
15-265
2.5
1 mo
Subglandular
15-194
2.
15-194
2.
1 mo
Subglandular
15-397
3.
15-397
3.
1 mo
Subglandular
15-286
1.
15-286
0.5
2 mo
Subglandular
15-265
1.
15-265
1.
1 mo
Subglandular
15-339
3.
15-339
2.5
1 mo
Subglandular
10-210
2.
10-210
2.
1 mo
Subpectoral
15-213
2.
15-213
1.
1 mo
Subpectoral
15-286
2.
15-286
2.
AVERAGE
2.3
2.2
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