Phẫu Thuật Thẩm Mỹ Vòng 1: Các Khái Niệm Và Kỹ Thuật (Aesthetic Breast Surgery)

Van der Lei B. Pedicle modif cation in the Lejour vertical scar reduction mammaplasty [let-
ter]. Plast Reconstr Surg 99:2118-2120, 1997.
Würinger E, Mader N, Posch E, et al. Nerve and vessel supplying ligamentous suspension
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Outcomes
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Davis GM, Ringler SL, Short K, et al. Reduction mammaplasty: long-term e f cacy, mor-
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Davison SP, Mesbahi AN, Ducic I, et al. The versatility o the superomedial pedicle with
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Goin MK, Goin JM, Gianini MH. The psychic consequences o a reduction mammaplasty.
Plast Reconstr Surg 59:530-534, 1977.
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.
Letterman G, Schurter M. The e ects o mammary hypertrophy on the skeletal system.
Ann Plast Surg 5:425-431, 1980.
Mello AA, Domingos NAM, Miyasaki MC. Improvement in quality o li e and sel -esteem
a ter breast reduction surgery. Aesth Plast Surg 34:59-64, 2010.
Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plast
Reconstr Surg 100:875-883, 1997.
Spector JA, Kleinerman R, Culli ord AT IV, et al. The vertical reduction mammaplasty: a
prospective analysis o patient outcomes. Plast Reconstr Surg 117:374-381, 2006.
Sensation
Courtiss EH , Goldwyn RM. Breast sensation be ore and a ter plastic surgery. Plast Re-
constr Surg 58:1-13, 1976.
Craig RDP, Sykes PA. Nipple sensitivity ollowing reduction mammaplasty. Br J Plast Surg
23:165-172, 1970.
Farina MA, Newby BG, Alani H M. Innovation o the nipple areola complex. Plast Re-
constr Surg 66:497-501, 1980.
Fish JS, Bain JR, Levine R. Breast sensation ollowing reduction mammaplasty. Can J Plast
Surg 2:28-31, 1994.
Godwin Y, Valassiadou K, Lewis S, et al. Investigation into the possible cause o subjec-
tive decreased sensory perception in the nipple-areola complex o women with macro-
mastia. Plast Reconstr Surg 113:1598-1606, 2004.
Hamdi M, Greuse M, DeMey A, et al. A prospective quantitative comparison o breast sen-
sation a ter superior and in erior pedicle mammaplasty. Br J Plast Surg 54:39-42, 2001.
Mof d MM, Dellon AL, Elias JJ, et al. Quantitation o breast sensibility ollowing reduc-
tion mammaplasty: a comparison o in erior and medial pedicle techniques. Plast Re-
constr Surg 109:2283-2288, 2002.
380
Part II • Technique

381
Chapter 6 • Vertical Breast Reduction
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.
Schlenz I, Rigel S, Schemper M, et al. Alteration o nipple and areola sensitivity by reduc-
tion mammaplasty: a prospective comparison o f ve techniques. Plast Reconstr Surg
115:743-754, 2005.
Schreiber JE, Girotto JA, Mof d MM, et al. Comparison study o nipple-areolar sensation
a ter reduction mammaplasty. Aesthet Surg J 24:320-323, 2004.
Tairych GV, Kuzbari R, Rigel S, et al. Normal cutaneous sensibility o the breast. Plast
Reconstr Surg 102:701-704, 1998.
Temple CL, H urst LN. Reduction mammaplasty improves breast sensibility. Plast Re-
constr Surg 104:72-76, 1999.
Breast Cancer
Ambaye AB, MacLennon SE, Goodwin AJ, et al. Carcinoma and atypical hyperplasia in
reduction mammaplasty: increased sampling leads to increased detection. A prospec-
tive study. Plast Reconstr Surg 124:1386-1392, 2009.
Boice JD, Persson I, Brinton LA, et al. Breast cancer ollowing breast reduction surgery in
Sweden. Plast Reconstr Surg 106:755-762, 2000.
Brown MH , Weinberg M, Chong N, et al. A cohort study o breast cancer risk in breast
reduction patients. Plast Reconstr Surg 103:1674-1681, 1999.
H age JJ, Karim RB. Risk o breast cancer among reduction mammaplasty patients and the
strategies used by plastic surgeons to detect such cancer. Plast Reconstr Surg 117:727-
735, 2006.
Jansen DA, Murphy M, Kind GM, et al. Breast cancer in reduction mammaplasty: case re-
ports and a survey o plastic surgeons. Plast Reconstr Surg 101:361-364, 1998.
Pitanguy I, Torres E, Salgado F, et al. Breast pathology and reduction mammaplasty. Plast
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Books
Goldwyn RM, ed. Breast Reduction. Boston: Little Brown, 1990.
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Williams & Wilkins, 2001.

Appendix A
VERTICAL LENGTH MEASU REMENTS
In 40 consecutive patients or whom preoperative and postoperative measure-
ments were available, gathering or cinching up the vertical incision to shorten
the scar was not success ul. These results are independent o the amount o tis-
sue removed.
The patients were measured on the operating table be ore suturing, a ter su-
turing, and at each postoperative visit. The vertical length began to stretch out
within the f rst ew weeks, and many o these results were documented within
382
Part II • Technique
Measurements o Vertical Incision Length Showing Ine ectiveness o
Shortening Maneuvers
Right Breast
Preoperative
Operating Postoperative
Left Breast
Preoperative Operating Postoperative
Tissue

Length

Room

Length

Tissue

Length

Room

Length
Removed (g)

(cm)

(cm)

(cm)

Removed (g)

(cm)

(cm)

(cm)
880

18

7

13

650

17

6

13
250

15

4

12

250

15

4

12
550

15

7

12

475

14

6

10
725

11

7

10

650

11

7

12
475

12

6

10

475

13

6

10
375

12

7

12

200

12

5

11
450

13

6

9

550

14

7

10
600

14

7

12

800

16

8

13
725

15

7

12

625

14

7

12
800

13

7

11

700

13

7

11
375

11

6

10

450

11

6

8
300

10

5

8

350

10

6

7
170

8

5

7

200

8

4

7
300

10

6

8

300

10

5

8
930

14

7

13

830

13

6

12
780

13

8

13

720

13

6

13
910

13

7

10

660

11

6

11
360

8

4

8

335

8

5

8
410

12

7

12

500

13

7

12
535

11

5

9

440

10

4

9

the f rst ew months a ter surgery. The vertical scar was measured rom the lower
border o the areola to the in erior edge o the incision.
Gathering the incision is not only ine ective in shortening the skin, but it can
lead to constriction o the blood supply to the wound edges. I no longer gather
the incision; in act, I make sure to stretch it out so that no puckers or pleats
are le t in eriorly. In the past, I gathered only the lower portion o the incision
to prevent a teardrop areola, but the scar o ten contracted. I now leave the ver-
tical incision without any gathering or cinching. A long vertical length is needed
to accommodate the increased projection that results with the medial pedicle
vertical breast reduction.
383
Chapter 6 • Vertical Breast Reduction
Right Breast
Preoperative Operating Postoperative
Left Breast
Preoperative Operating Postoperative
Tissue

Length

Room

Length

Tissue

Length

Room

Length
Removed (g)

(cm)

(cm)

(cm)

Removed (g)

(cm)

(cm)

(cm)
1140

15

7

14

1140

15

6

14
430

9

4

8

440

9

4

8
480

9

5

9

425

8

4

8
380

10

6

9

455

10

5

9
495

11

5

8

475

11

5

9
680

10

5

9

680

10

5

9
1120

16

8

14

1080

16

8

13
1220

13

7

13

1130

13

6

13
340

11

5

11

300

10

5

8
550

13

6

13

655

13

6

13
510

10

8

10

510

10

6

7
650

14

7

10

725

14

7

9
680

10

6

9

680

10

6

9
430

10

5

11

495

10

5

11
370

11

5

12

435

11

7

11
410

11

6

9

475

11

6

10
970

13

7

12

770

12

6

12
700

11

5

11

750

11

6

10
570

9

5

9

600

9

5

9
410

12

6

11

485

12

6

11

Appendix B
COMPARISON OF RESU LTS IN NIPPLE SENSATION
Patients were asked at their follow-up visits to evaluate their preoperative and
postoperative sensation (using a Likert scale). Only patients who had either a
full year follow-up or who had already achieved full sensation were included in
the following table. Contrary to the concerns of many surgeons, the medial
pedicle actually performed better than either the superior or lateral pedicle. This
is a subjective assessment only. Patients were asked at the preoperative marking
session to touch their nipples and to remember the sensation so that they could
compare it with postoperative sensation.
384
Part II • Technique
Postoperative Sensation: Comparison of Pedicles
Return of Sensation
Pedicle

No. of Breasts

0%

25%

50%

75%

100%

75% 100%
Superior

58

10 (17%)
0 (0%)

9 (15.5%)

4 (7%)

35 (60%)

39 (67%)
Lateral

147

3 (2%)
14 (9.5%)
17 (11.5%)
20 (13.5%)
93 (63%)
113 (76.5%)
Medial

1206

38 (3%)
32 (2.5%)
116 (10%)

154 (13%)

866 (70%)
1020 (85%)
I now perform almost exclusively a medial or superomedial pedicle for all my
breast reductions and these results show that about 85% of patients will recover
normal to near-normal sensation postoperatively.
This table was prepared using the number of breasts rather than the number of
patients, because the results were often different from one side to the other.

Liposuction-Only
Breast Reduction
Chapter7
385
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L iposuction, which was introduced in the 1980s, has become very use ul or
reducing excess at in many areas o the body. Because the breasts are composed
o both at and f broglandular breast tissue, it makes sense that liposuction could
be used or volume reduction in breasts that have a large proportion o at. The
di f culty is that standard liposuction procedures can only remove so t at, not
glandular tissue. Other methods o liposuction that use ultrasound or other
technology may help to reduce some glandular tissue, but in this chapter I will
only review breast reduction using standard liposuction techniques with blunt
cannulas and without any other energy source involved, such as ultrasound.
The disadvantage o liposuction-only breast reduction is that excess skin is not
removed. There is some shrinkage o the skin with the removal o at, but this
is limited by the elasticity o the remaining skin. It would be ideal to be able to
use a liposuction-only technique to reduce the breasts, but o ten breasts with
a larger proportion o at (such as in perimenopausal patients) are ptotic, with
poorer quality skin. We would all like to o er teenagers a procedure with min-
imal scars; un ortunately, most teenagers who are close to their ideal body
weight have very little at in their breasts.
The main advantage of liposuction-only breast reduction is that it
results in minimal scarring; however, the breasts have reduced up-
per pole fullness and reduced projection.
The potential or nipple necrosis and other complications is less than with other
breast-reduction procedures. Because very little actual breast tissue is removed,
the ducts are likely to remain intact, so breast- eeding potential should be rela-
tively una ected. The nerves are also le t mainly intact, and the risk o sensory
loss is less. H owever, the idea that the procedure is less invasive and can be a
better choice or patients in poor health is incorrect. Liposuction-only reduc-
tion is still an invasive procedure, whether it is per ormed with a local or gen-
eral anesthetic.
It is di f cult to selectively reduce breasts so that they can maintain some pro-
jection. Un ortunately, it is necessary to remove some upper pole tissue to pro-
duce nipple elevation. Breast reduction using liposuction tends to atten the
breasts, and the amount o reduction is limited.
386
Part II • Technique

It is tempting to try liposuction-only or this
teenager to prevent extensive scarring. The
surgeon needs to be aware, however, that
such young women who are close to their
ideal body weight have very little at in the
breasts. The attempt to per orm liposuction-
only in this patient and her intraoperative
anatomy are shown below.
387
Chapter 7 • Liposuction-Only Breast Reduction
The lipoaspirate shows that very little at was removed in this teenager. Most
o the uid in the container is the tumescent inf ltration uid. The patient was
prepared or an open surgical procedure. The intraoperative photo shows that
much o the breast tissue was solid glandular tissue that needed to be carved
out surgically, much like so t soapstone. Even the portion o the breast that had
some at shows how di f cult it would be to remove that at by liposuction.
INDICATIONS AND CONTRAINDICATIONS
The best candidates or liposuction-only breast reduction have ull breasts with
nipples already in a relatively high position. These patients must eel that the
trade-o o losing some projection and a limited reduction is better than un-
dergoing a breast-reduction procedure that entails increased scarring and a
higher potential or loss o nipple and breast skin sensation.
The best candidates for liposuction-only breast reduction are peri-
menopausal women with good upper pole fullness and relatively
little nipple ptosis. They should also have good quality skin.

The patient must have breasts with a large proportion o at or liposuction-
only breast reduction to be success ul. The intraoperative photograph on
p. 387 shows that most o the at in these patients is in the subcutaneous tis-
sue. The breast is a skin-derived subcutaneous structure, and it has expanded
and pushed the subcutaneous tissue outward. It is in this subcutaneous tissue
that the majority o the arteries and veins can be ound.
As a woman ages (and o ten gains some weight), breasts contain a larger pro-
portion o atty tissue, and this at can be aspirated in a liposuction-only breast
reduction. The breast (and nipple) are innervated rom all our quadrants, which
is why all the di erent pedicles chosen or standard breast-reduction procedures
will recover good sensation. A liposuction-only breast reduction is less likely to
damage any o the nerves. Some o the nerves may be bruised and develop a tem-
porary neurapraxia, but most o these nerves should recover unevent ully. I did
see a patient recently who had undergone an attempt at liposuction-only breast
reduction 5 years previously, and she lost more than 50% o her nipple sensation.
PREOPERATIVE ASSESSMENT
It is important to determine preoperatively whether a breast has a signif cant
proportion o atty tissue to make liposuction-only breast reduction possible.
This can be done mainly by history and less by physical examination. The age
and weight o the patient are the primary considerations.
A young woman or a teenager at her ideal body weight will not be
a good candidate. These patients have very little fat interspersed in
the parenchyma.
An older woman is more likely to have enough atty tissue, but her cosmetic
result will not be optimal i she has already developed ptosis. Women who have
lost breast tissue over time and with pregnancies and who have lost volume rel-
ative to the skin envelope will also not be good candidates.
It is actually very di f cult to determine at content by physical examination.
Some very dense breasts are quite so t, and some very f rm breasts are mainly
atty. This di f culty in assessing breasts or at content was pointed out by
Lejour. I have tried to assess at content preoperatively and have been unsuc-
cess ul. Age and patient body weight are the best indicators.
388
Part II • Technique

389
Chapter 7 • Liposuction-Only Breast Reduction
If the surgeon orders a mammogram preoperatively, the radiologist can pro-
vide an idea of how dense the breast tissue is and if there is a large proportion of
fat or not, but even this has been somewhat unpredictable.
It is important to make certain that patients are prepared for the potential for
conversion to an open procedure, as needed. I mark all patients as if I am go-
ing to potentially proceed with my standard vertical approach. There might be
some patients who refuse conversion, but they then must be prepared for a dis-
appointing result with minimal reduction.
PLANNING
Liposuction-only breast reduction is best performed through two separate stab
incisions in (actually, above) the inframammary fold. Most liposuction results
are best when the tunnels can be crisscrossed, because this helps avoid irregu-
larities and depressions.
I perform the standard vertical markings preoperatively; if liposuction is un-
successful, I can then convert to an open procedure using a medial pedicle ver-
tical approach. It is important to mark the preaxillary fullness and areas on the
lateral chest wall that also need to be suctioned. The breast should be at least
visually divided into quadrants so that the volume in each area can be estimated
and symmetry between sides can be approached. The patient shown below has
the markings for a standard vertical breast reduction in case the liposuction is
unsuccessful.

390
Part II • Technique
Although breast volume was reduced in this patient, the results are not dramatic.
She was 49 years old, 5 feet 5 inches tall, and weighed 68 kg (150 pounds).
H er breasts were not excessively large preoperatively, and she just wanted
a slight reduction. A comparison of the breasts to the elbow crease position
(arrows) in the preoperative and postoperative views shows some elevation of
both the breasts and nipples. The total aspirate measured 1775 cc, and once it
settled, the fat measured 400 cc on the right breast and 425 cc on the left breast.
A comparable result with an open procedure would have probably been closer
to 300 g on each side.
Markings
The inframammary fold should be marked so that the small stab incisions can
be placed above it. This is especially important if much liposuction will be per-
formed just above the inframammary fold, because the fold itself will rise and
the stab incisions will end up on the chest wall instead of on the lower portion
of the breast. It is best to err on the side of placing the scars too high above the
fold instead of too low.

391
Chapter 7 • Liposuction-Only Breast Reduction
OPERATIVE TECH NIQU E
Tumescent inf ltration (1 L o Ringer’s lactate, 1 ml o 1:1000 epinephrine,
and 20 ml o 2% lidocaine) is essential to the procedure, whether or not the sur-
gery is per ormed with a general anesthetic. I pre er general anesthesia, and I
will then inf ltrate about 500 to 1000 ml o the tumescent solution per breast,
aiming or a 1:1 volume-to-aspirate ratio. Local anesthesia with sedation should
not be seen as less invasive. More tumescent uid needs to be inf ltrated when
a general anesthetic is not used, and usually a 2:1 ratio is needed.
Area of deep
liposuction
Superior area of
superficial liposuction
Inferior area of
superficial
liposuction
The surgery is best per ormed with the
patient in the supine position with the
arms angled outward.
Be ore the operation, the surgeon needs to visualize where the at should be
removed. The our quadrants o the breast should be evaluated—superior, me-
dial, lateral, and in erior—and the areas o excess determined. Sometimes more
at needs to be removed laterally than medially.

Many patients would like to retain any upper pole ullness, but liposuction needs
to be per ormed in the upper pole i nipple elevation is desired. Liposuction is
per ormed in all our quadrants and in both the superf cial and deep layers. To
take advantage o the skin shrinkage that can occur with superf cial liposuction,
some liposuction should be per ormed in the atty layer between the breast
parenchyma and the skin. The surgeon needs to be cautious in the superf cial
layer to prevent irregularities and scar de ormities.
Superf cial liposuction in the upper pole will help nipple elevation to some de-
gree, but volume reduction alone will also help to reduce drag on the nipple.
Most o the liposuction will be per ormed in the deep layers. In most patients,
the majority o the excess volume is in the lower pole, so most o the liposuc-
tion will be per ormed in that area.
The preaxillary ullness and the lateral chest wall also need to be marked sepa-
rately and suctioned appropriately. Some surgeons try to elevate the in ra-
mammary old i there is breast asymmetry or in cases o bottoming out below
the in ramammary scar in a re-reduction rom a previous inverted-T procedure.
I use standard liposuction techniques with blunt cannulas, usually about 3 to
4 mm in diameter. I have not used any external energy sources except my own.
392
Part II • Technique
To assess the volume removed, it is important to let the uid settle in the aspi-
rate container. There is still uid in the at layer once it settles, and it always
measures more than what would be removed in an open procedure. These pho-
tographs show the aspirate be ore and a ter settling (in di erent patients). The
at removed should not be measured until settling has occurred to obtain an
accurate estimate.

There is controversy about the e ectiveness o pathologic examination o the
tissue that has been removed by liposuction and whether there is much, i any,
actual glandular tissue included in the aspirate. Even when the pathologist has
a gross specimen to examine, the decision as to what areas to sample can be di -
f cult. The actual areas sampled are a very small portion o the whole, and many
areas o cancerous or precancerous cells may be missed. The problem acing a
pathologist with lipoaspirate is even more random, with only samples o tissue
being visualized. The likelihood o f nding any existing cancerous cells will be
minimal, even i cancer is present.
POSTOPERATIVE CARE
Patients are placed in a standard postoperative brassiere that will supply some
compression. Excessive compression is not necessary, and patients are told to
wear the brassiere day and night or about 2 weeks. They can remove the
brassiere and shower or bathe as they wish.
393
Chapter 7 • Liposuction-Only Breast Reduction
There can be extensive bruising associated with liposuction-only breast reduc-
tion. This may take weeks to resolve and will be ound extending beyond the
areas that were suctioned.
Patients are given progressive increases in activities, with walking only or the
f rst week or so, gradually moving to a stationary bicycle (where there is minimal
upper body movement), then stair-steppers, and f nally treadmills and elliptical
machines with arm movements. Lower-body weights can be started any time,
with a gradual increase in upper-body weights. Patients who want to maintain
an aerobic f tness level are encouraged to walk uphill, and a ter 3 or 4 weeks
they can try jogging, but they may want to wear a special brassiere or elastic wrap.

PROBLEMS AND COMPLICATIONS
There are ew problems and complications with liposuction-only breast reduc-
tion, which is part o the reason some patients pre er this technique. Some pa-
tients opt or a less-satis actory cosmetic result i they will be more likely to pre-
serve nipple sensation. I tell all patients that one choice is not necessarily better
than another; it o ten comes down to personal pre erence.
Complications such as skin or nipple necrosis are much less likely to occur, but
skin loss can occur with any orm o liposuction. Much o the at is in the su-
perf cial layers, and excessive liposuction can cause irregularities and potential
skin complications.
It is di f cult with all breast-reduction techniques to achieve symmetry. This is es-
pecially so with liposuction-only breast reduction. It is di f cult to measure how
much is removed in each quadrant, even when the aspirate is allowed to settle.
The main problem with liposuction-only breast reduction is that the breasts
may end up losing projection and taking on the appearance o a relative increase
in ptosis. O ten the breast is actually less ptotic than it was preoperatively, and
the nipples are in act elevated, but the shape o the breast looks atter because
o the loss o ullness and projection.
There is a limit to how much at can be removed, and this cannot always be de-
termined preoperatively. Some women wish to have smaller breasts than can be
achieved with a liposuction-only breast reduction.
Some patients are disappointed with the results and later request a mastopexy.
Good patient education is essential to avoid this problem, but occasionally pa-
tients wish to go ahead with an open procedure a ter the liposuction settles.
There is controversy as to whether liposuction makes postoperative imaging
more di f cult. All breast surgery can result in distortion and calcif cations, but
most radiologists are conf dent that they can distinguish benign rom malig-
nant changes. Alternatively, current mammography can miss up to 15% o can-
cers in breasts with no history o surgical intervention. Liposuction-only breast
reduction may make the breasts somewhat more dense on mammography,
which could potentially make diagnosis more di f cult. But when compared with
other surgical techniques o breast reduction, and breast augmentation, with
respect to imaging techniques, the changes induced by liposuction-only breast
reduction are likely to be insignif cant.
394
Part II • Technique

395
Chapter 7 • Liposuction-Only Breast Reduction
OU TCOMES
The outcomes o liposuction-only breast reduction are good i patients
are well selected and well educated. The breasts o ten lose some projec-
tion but are actually less ptotic. Measurements show that nipple and breast
elevation do occur. Nipple sensation is less likely to be lost than with other
breast-reduction techniques, and complications such as nipple necrosis
are almost nonexistent.
RESU LTS
This woman had liposuction-only breast reduction. Comparison o her preop-
erative nipple position to the elbow crease (arrows) shows that signif cant ele-
vation o both nipple and breast has been achieved. The breasts are somewhat
more symmetrical, but they are more ptotic appearing, with loss o ullness in
the upper pole. The nipple remains well centralized on the breast mound.

Good volume was achieved for this patient through liposuction-only breast re-
duction. H er breasts are ptotic postoperatively, but both the breasts and the
nipples have been elevated. This is best seen in the frontal views by comparing
the level of the elbow crease (arrows).
396
Part II • Technique

This woman underwent liposuction-only breast reduction with some improve-
ment in asymmetry and an overall slight reduction. She has lost upper pole full-
ness but has achieved some nipple elevation on both sides, with more elevation
seen in the left breast. Note the level of the elbow crease (arrows) preopera-
tively and postoperatively.
397
Chapter 7 • Liposuction-Only Breast Reduction

This patient underwent liposuction-only breast reduction, but her asymmetry
remains. She has smaller breasts postoperatively, and it is clear that both the
breasts and the nipples have been elevated when the preoperative and postop-
erative elbow crease positions (arrows) are compared.
398
Part II • Technique

Liposuction-only breast reduction was performed on this patient after a previ-
ous inverted-T breast reduction. Her breasts are still low, but there has been el-
evation of both the breasts and the nipples. Comparison of the elbow crease (ar-
rows) on the frontal view shows the change. The breasts have less volume but
appear to be more ptotic. Liposuction was performed between the inframam-
mary fold and the inframammary scar, and, as shown, the inframammary fold
has risen up, allowing it to tuck in at the level of the inframammary scar. Patients
are pleased when a brassiere underwire can sit at a more elevated position.
399
Chapter 7 • Liposuction-Only Breast Reduction

This young woman’s liposuction-only breast reduction produced very little
elevation of the nipple or the breast. Early in the recovery, as shown in the pho-
tographs with the bruising, there appeared to be a small amount of improve-
ment, but later photographs show that the result was disappointing. There was
volume reduction in all four quadrants of the breast. Despite liposuction in the
upper pole of the breast, nipple elevation did not occur, shown by comparing
the level of the elbow crease (arrows) with the nipple.
400
Part II • Technique
Preoperative
Early result

401
Chapter 7 • Liposuction-Only Breast Reduction
Late result
After medial pedicle vertical mastopexy
As seen in the later photographs, the patient eventually underwent a medial
pedicle vertical mastopexy with good results.
REFLECTIONS
Liposuction-only breast reduction is an excellent procedure to achieve reduc-
tion in breast size, but good patient selection is essential for an optimal result.
Good skin quality is required so that some retraction can occur. Patients should
not have much nipple ptosis, because only a small amount of nipple elevation
can be achieved. Although it would be ideal to be able to perform liposuction-
only breast reduction on teenagers, their breast tissue is usually too glandular
(with very little fat), especially if the patient is close to her ideal body weight.
Patients may have very different ideas of what a satisfactory result might be.
Good patient communication is essential for choosing the best surgical approach
for each patient.

Concepts to Recall
• The best candidates or liposuction-only breast reduction are older women
with good nipple position.
• This procedure is not a good choice or teenagers with normal body
weight.
• Surgery should not be seen as less invasive or medically compromised
patients.
• Trade-o s include ewer complications, but a less cosmetically pleasing
result.
• Advantages include ewer scars, less potential sensory loss, and ewer po-
tential complications.
• Disadvantages include less projection, more ptosis, and unpredictability
o outcome.
• The breast’s at content needs to be determined preoperatively.
• It is best to plan or an open procedure i liposuction ails to achieve the
desired result.
BIBLIOGRAPH Y
Abboud M, Vadoud-Seyedi J, De Mey A, et al. Incidence o calcif cations in the breast a -
ter surgical reduction and liposuction. Plast Reconstr Surg 96:620-626, 1995.
Brauman D. Liposuction breast reduction. Comment on Moskovitz MJ, Muskin E, Baxt
SA. Outcome study in liposuction breast reduction. Plast Reconstr Surg 116:1558-
1559; author reply 1559-1561, 2005.
Courtiss EH . Reduction mammaplasty by suction alone. Plast Reconstr Surg 92:1276-
1284, 1993.
Gray LN. Liposuction breast reduction. Aesthetic Plast Surg 22:159-162, 1998.
Gray LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg
108:1006-1010; discussion 1011-1013, 2001.
Di Giuseppe A. Breast reduction with ultrasound-assisted lipoplasty. Plast Reconstr Surg
112:71-82, 2003.
Lejour M. Evaluation o at in breast tissue removed by vertical mammaplasty. Plast Re-
constr Surg 99:386-393, 1997.
Matarasso A, Courtiss EH . Suction mammaplasty: the use o suction lipectomy to reduce
large breasts. Plast Reconstr Surg 87:709-717, 1991.
Moskovitz M. Constructive skepticism—case in point: liposuction breast reduction. Plast
Reconstr Surg 111:513-514; discussion 514, 2003.
Moskovitz MJ, Baxt SA, Jain AK, et al. Liposuction breast reduction: a prospective trial in
A rican American women. Plast Reconstr Surg 119:718-726, 2007.
Moskovitz MJ, Muskin E, Baxt SA. Outcome study in liposuction breast reduction. Plast
Reconstr Surg 114:55-60; discussion 61, 2004.
Rohrich TR Jr, Gosman AA, Brown SA, et al. Current pre erences or breast reduction
techniques: a survey o board-certif ed plastic surgeons 2002. Plast Reconstr Surg
114:1724-1733, 2004.
402
Part II • Technique

Breast
Re-reduction
Chapter8
403
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404
Part II • Technique
M

any surgeons have patients who have had an earlier breast reduction and
are now requesting a revision. Some patients want only a better shape, but many
ask or another reduction. The breast reduction may have been quite satis ac-
tory initially, but now—with aging, weight gain, or other hormonal changes—
the patient’s breasts have changed, and she requests a re-reduction.
As patients age, their breasts become less dense, and the proportion o atty tis-
sue increases. Breasts that did not respond much to weight gain and loss when
women were younger become heavier as they gain weight. Time and the in u-
ence o gravity can cause bottoming out. Pregnancy can also change a woman’s
breast size and shape, and we regularly see women who request revision o their
postpartum breast shape—with or without another reduction. With a previous
in erior pedicle inverted-T breast reduction, the in ramammary old may drop
below the original scar. Additionally, the shape o the breast may not be ideal
a ter the previous reduction. Patients o ten have too much residual lateral ull-
ness a ter a lateral pedicle vertical breast reduction. I per orm a re-reduction to
remove this excess lateral ullness.
This chapter ocuses on common problems requiring re-reduction. It empha-
sizes the e ectiveness o continuing to ollow the Wise pattern principle in these
cases, leaving behind the superior breast tissue and removing an in erior wedge
o breast tissue. This removal will o ten require excision o a previous in erior
pedicle; the nipple and areola will then rely on a random pattern blood supply.
Because all the remaining pedicle arteries were sacrif ced during the creation o
the in erior pedicle, it is impossible to sa ely design a new pedicle. The surgeon
must either determine the specif c pedicle used at the f rst operation—and use
it again—or realize that the nipple must be able to survive on a random pattern
blood supply. Since the nipple rarely needs to be urther elevated, the previous
in erior pedicle can be removed.
Nipples o ten appear to be too high when patients present or re-reduction. It
would be ideal to raise the breast ootprint on the chest wall to address this
problem; however, surgical maneuvers to elevate the upper breast border (apart
rom inserting an implant) have ailed. Reducing the lower pole ullness makes
the nipple appear to be better centralized on the breast mound. The best ap-
proach is to reduce the lower pole excess by adhering to the in erior wedge re-
section principle: by removing an in erior wedge o breast tissue and bringing
2
8A Re-reduction of
previous vertical
breast reduction
8B Re-reduction of
previous inverted-T
breast reduction

the pillars together, the breast can be reduced, the remainder o the breast
coned, and the mound better adjusted to the nipple position. Liposuction above
the in ramammary old will convert in erior breast skin back to chest wall skin as
the in ramammary old is elevated.
Many surgeons have noted that the in ramammary old has dropped a ter a pre-
vious in erior pedicle inverted-T breast reduction, and they are tempted to ex-
cise tissue along the in ramammary old in an attempt to push the tissue up-
ward. Un ortunately, this maneuver usually ails, even when the in ramammary
old is sutured down to either chest wall ascia or periosteum. The excess in e-
rior tissue needs to be removed—not pushed upward.
ANALYSIS OF TH E PROBLEM
It is essential to understand each patient’s problem be ore attempting a breast
re-reduction. Both the nipple position and the breast mound shape must be
evaluated. Nipple position should not be determined in relation to the existing
mound, but should be assessed relative to the upper breast border. The key to
achieving a good, long-lasting result is to understand that the lower pole needs
to be excised.
Nipple Position Too H igh Relative to the Upper Breast Border
I the nipple has been placed too high, correction will be extremely di f cult (i
not impossible). An ideal nipple is positioned about a third to hal way up the
breast mound. O ten with patients who present or breast re-reduction, the nip-
ple appears to be too high, because o the lower pole excess. This cannot be
pushed up into the upper pole, but it can be excised. Surgeons are o ten a raid
to excise a previous in erior pedicle to achieve lower pole reduction; however, as
long as the nipple does not need to be moved signif cantly, and as long as the
surgeon does not try to create a di erent pedicle (it will have only a random
pattern blood supply), the in erior pedicle can be easily and sa ely removed.
Excessive lower pole tissue causes the nipple to be too high on the
breast mound. Correction involves removing the excess tissue, with-
out creating a new pedicle.
405
Chapter 8 • Breast Re-reduction

This patient had a breast re-reduction without movement of the nipple-areola
complex. She had previously undergone an inferior pedicle inverted-T reduc-
tion. H er nipples appear to be too high, because there is too much lower pole
fullness. They are actually in a good position relative to the upper breast bor-
der (arrow). An inferior wedge of breast tissue was excised, with no concern
about blood supply to the nipple. Although the nipple-areola complex now relies
on a random pattern blood supply, it has not been moved, and no new pedicle
has been (mistakenly) created. She had 175 g of tissue removed from the right
breast and 195 g of tissue removed from the left breast. An additional 200 cc
of fat was removed with liposuction, just above the inframammary fold to ele-
vate it. The key to this correction is to adapt the breast mound to an already
good nipple position. The problem was not that the nipples were too high;
rather, the lower pole tissue was excessive.
406
Part II • Technique

Bottoming Out of the Inframammary Fold
The position of the inframammary fold should be assessed to determine whether
it needs to be elevated. Sometimes with an inferior pedicle inverted-T breast
reduction the inframammary fold will drop out below the inframammary scar.
Many surgeons place the inframammary scar slightly above the inframammary
fold; however, in the patient examples below, it is unlikely that the surgeons in-
tentionally placed the scars as high as they are in these photographs. Either the
scar was pulled up onto the breast mound, or the mound was pushed down-
ward, below the fold. Both situations could have happened, but in many pa-
tients the fold itself is too low.
407
All of these patients had previous inferior pedicle inverted-T breast reductions.
Their inframammary folds have bottomed out, and some chest wall skin has
now become incorporated into breast mound skin, exaggerating the volume in
the lower pole and making the nipples appear higher.
Chapter 8 • Breast Re-reduction

TREATMENT OPTIONS
Wedge Resection Principle
The best re-reduction strategy is to remove an inferior wedge of breast
tissue and then bring the breast pillars together. These are the same prin-
ciples as those followed for a primary breast reduction, but the surgeon
needs to be aware that the blood supply pattern to the nipple will be ran-
dom if an inferior pedicle was used for the primary reduction.
408
Part II • Technique
These photos show how the vertical wedge resection helps narrow and cone
the remaining breast tissue. This technique removes tissue below the Wise pat-
tern and retains tissue in the upper pole. The lower pole excision can then be
complemented with liposuction to tailor the shape.
Raising the Inframammary Fold
Patients who desire breast re-reduction usually have excess tissue in the lower
pole. Often the nipple appears to be positioned too high, usually because
the lower pole excess has altered the breast proportions. The lower pole tissue
needs to be excised. Although surgeons will often push the inframammary fold
upward with their hands to determine the desired position, this maneuver can-

This patient had an in erior pedicle inverted-T breast reduction. I placed the
nipples ar too high (too close to the upper breast border) (arrow). She had
2215 g o tissue removed rom the right breast and 2155 g removed rom the
le t breast. She is shown 7 months postoperatively, just be ore I removed skin
and breast tissue parallel to the in ramammary old, and I attempted to push
tissue up into the upper pole. The in ramammary old was sutured up to chest
wall ascia.
409
H er early result at 4 weeks looked promising, but her breasts bottomed out
again 4 months a ter the revision. This case convinced me that removal o skin
along the in ramammary old, along with “tucking up” o the breast tissue was
doomed to ailure. I have not been able to push tissue upward into the upper
pole and maintain it in that position. The only way that I know to f ll the up-
per pole and raise the upper breast border is with an implant (and possibly at
injections).
not be easily replicated with surgery. Excision o the in ramammary scar will
only result in loss o upper pole ullness and recurrent dropping o the old.
Chapter 8 • Breast Re-reduction

410
Part II • Technique
This patient’s nipples were too high. They were placed too close to the upper
breast border (red arrow). Because the nipples cannot be moved, an attempt
was made to change the mound—the upper pole was f lled with an implant,
and the in ramammary old was tucked up to reduce the lower pole. This is
quite a pain ul procedure, and there is usually some dropping out o the old.
H owever, there are not many other choices or this type o problem, because
it is not one o lower pole excess. Neither maneuver worked well. The patient is
shown 3 weeks and 61⁄2 years postoperatively. She has some improvement in the
right in ramammary old. (The black arrows compare the level o the in ra-
mammary old with that o the elbow crease.) This type o result can only be
achieved with extensive suturing to the deep tissues. Skin excision alone will
cause the in ramammary old to descend to its original level.
The best way to raise the inframammary fold is to remove weight.
This can be achieved by removing the inferior wedge of breast tis-
sue, but also by performing liposuction between the current infra-
mammary fold and the desired inframammary fold.
PROBLEMS AND COMPLICATIONS
Nipple-Areolar Necrosis
The most eared complication a ter re-reduction is nipple and areolar necrosis
(see Chapter 11). The most important concept to understand is that either the
original pedicle needs to be re-created, or the nipple should not be moved much
more than can be achieved with deepithelialization. Free nipple gra ts could
be a solution i the surgeon does not know the type o original pedicle, and i
Preoperative

3 weeks postoperatively
61⁄2 years postoperatively

Care must be taken, even with deepithelialization, not to undermine the areola.
This patient underwent a re-reduction 3 years a ter a lateral pedicle vertical
breast reduction. She originally had 475 g removed rom the right breast and
500 g removed rom the le t breast. Liposuction was also per ormed. In an at-
tempt to remove the excess lateral breast tissue, some o the areola was under-
mined, and not enough o the dermis around the areola was maintained. A par-
tial necrosis ensued, and it was allowed to demarcate and heal by secondary
intention. The f rst photo is shown 2 months a ter the re-reduction. She is also
shown 3 months and again 7 months a ter the re-reduction. Care must be taken
when the previous pedicle is removed.
411
Preoperative

2 months postoperatively
3 months postoperatively

7 months postoperatively
the nipples need to be elevated several centimeters. The surgeon can as-
sume (most likely) that an in erior pedicle was used and then re-create
the pedicle. I circulation is not good, the surgeon can convert to ree
nipple gra ts. Obviously, this option needs to be discussed with the pa-
tient preoperatively, because ree nipple gra ts can develop patchy depig-
mentation, will be insensate, and can lack nipple projection.
Chapter 8 • Breast Re-reduction

412
Part II • Technique
Because the in erior pedicle blood supply comes mainly rom the vessels
at the ourth interspace just above the f th rib, the blood supply could
theoretically be maintained by keeping a central pedicle intact and then
relying mainly on liposuction o the extra tissue or the reduction. This
would be a compromise, because it would be di f cult to remove enough
o an in erior wedge to achieve a good re-reduction.
To prevent nipple-areolar necrosis a ter re-reduction, it may be best
to use the original pedicle, because supplying vessels to the other
pedicles were sacrif ced in the f rst surgery. The supply to the nipple-
areola complex is maintained with a random vascular pattern.
Excess Skin Removal
The key to all breast surgery is to recognize that skin stretches under tension.
Good quality skin will stretch less than poor quality skin.
This patient shows how a “skin brassiere” will stretch. (She is also presented on
p. 417.) Fortunately, the skin relaxed and stretched back out again, showing
that it cannot be relied on as a brassiere to hold tissue up.
Preoperative

The patient is shown 2 weeks and 9 months postoperatively. The skin has
stretched back out without any further treatment. No improvement in upper
pole fullness was achieved.
Other Complications
Other potential complications are described in Chapter 6. These include
hematoma, seroma, infection, and hypertrophic scarring. Revisions address the
same problems as those presented in this chapter—inadequate resection, asym-
metry, and puckers.
413
Immediately after surgery the skin was too tight. The tightness placed pressure
on the nipple-areola complex. (Some surgeons would advise removal of the nip-
ple and areola, and conversion to a graft if suture removal did not work. In this
case nothing was done, and the areola regained color.) Excess skin was excised
to support breast tissue. This series of photos shows that a tight closure places
nipple circulation at risk and is not effective as a brassiere.
Immediate postoperative result
2 weeks postoperatively

9 months postoperatively
Chapter 8 • Breast Re-reduction

RESU LTS
414
Part II • Technique
This patient underwent a re-reduction using the inferior wedge resection prin-
ciple, followed by tailored tissue resection inferiorly and peripherally with lipo-
suction. She had 90 g of tissue removed from the right breast and 120 g re-
moved from the left breast. Another 450 cc of fat was removed with liposuction.
The skin below the previous scar has been returned to the chest wall. The breast
has been reduced, and the inframammary fold has been raised.
Preoperative
Immediate postoperative result
Preoperative

She is shown 10 days and 2 years postoperatively. The inframammary fold scar
has been tucked up without any skin excision, and the inframammary fold has
been elevated by removing weight (with both a wedge excision and liposuction
tailoring).
415
10 days postoperatively

2 years postoperatively
Chapter 8 • Breast Re-reduction

416
Part II • Technique
This patient presented for a re-reduction. An inferior pedicle was likely used for
the original surgery. The arrow in the photo on the left indicates the upper
breast border. The nipples needed to be elevated. The arrow in the photo on
the right indicates the inframammary scar, which is well above the inframam-
mary fold. It is unlikely that the surgeon placed it that high; it is more likely
that the inframammary fold dropped out below its original level.
A new pedicle was not used, but the skin around the areolas was deepithelialized
to elevate the nipple-areola complex to a better position. The patient is shown
11 days postoperatively with Micropore paper tape (3M, St. Paul, MN) in place.
She had 385 g of tissue removed from the right breast and 395 g removed from
her left breast. An additional 475 cc of fat was removed with liposuction.
Preoperative
11 days postoperatively
Preoperative

She is shown 7 years after surgery. H er inframammary fold is elevated into the
scar, and breast skin has now become chest wall skin. (See pp. 412 and 413 for
more postoperative photos of this patient.)
417
One year postoperatively the inframammary fold is elevated to the inframam-
mary scar level, and what was previously inferior breast skin has been converted
back to chest wall skin.
This patient had a re-reduction with removal of 235 g from her right breast and
280 g from her left breast. Liposuction was also performed between the infra-
mammary fold (red arrow) and the inframammary scar (blue arrow).
1 year postoperatively
Preoperative
7 years postoperatively
Chapter 8 • Breast Re-reduction

418
Part II • Technique
This patient wanted a re-reduction. Her nipples were not too high (the arrow in
the left photo indicates the upper breast border), but were slightly asymmetrical.
Note the height of the inframammary scar (blue arrow) above the inframammary
fold (red arrow).
The skin around the areolas was deepithelialized to correct the asymmetry. An
inferior wedge of breast tissue was excised, with 180 g removed from the right
breast and 160 g removed from the left breast. Another 350 cc of fat was re-
moved with liposuction. Note how the inferior wedge resection cones the breast.
The liposuction removed tissue between the inframammary fold and the infra-
mammary scar, both inferiorly and laterally.

419
This patient had a re-reduction through an inferior wedge resection, with de-
epithelialization around the areolas. The inframammary scar (arrow) was left
untreated. Liposuction alone was able to raise the inframammary fold into the
previous scar.
The patient is shown 8 months later with good correction of the size and asym-
metry, as well as elevation of the inframammary fold.
Chapter 8 • Breast Re-reduction

420
Part II • Technique
A breast re-reduction was performed through an inferior wedge resection com-
plemented by liposuction between the inframammary fold and the inframam-
mary scar. I removed 245 g of tissue from the right breast and 275 g from the
left breast. Another 275 cc of fat was removed with liposuction. The infra-
mammary fold was elevated.
This woman’s original surgery was 20 years previously, and the operative report
was unavailable. She wanted her areolas to be smaller and more symmetrical.
The nipples were well placed in relation to the upper breast border (black ar-
row). The inframammary fold (red arrow) was below the inframammary scar
(blue arrow).

These photographs show the patient at the end o surgery and on the day a ter
surgery, with the f esh-colored tape in place. Some surgeons would be tempted
to convert the pucker to a small T, but this is o ten unnecessary. In the photo
on the right, the in ramammary old has already tucked up into the previous
scar, and the pucker has tucked in on the le t breast.
421
Removal o the lower pole tissue improved the breast mound size and position.
Deepithelialization around the areolas did not involve creating a new pedicle,
but the nipples are now better centralized on the breast mound, because the
mound itsel has been reshaped.
Chapter 8 • Breast Re-reduction

422
Part II • Technique
This was one o my earlier vertical breast reduction patients. I used a lateral
pedicle or the nipple-areola complex. The arrow points to the upper breast bor-
der. I placed the nipples too high in the original procedure. The problem with
the lateral pedicle is that it o ten prevents adequate resection o the lateral ull-
ness, because the tissue that needs to be removed is at the base o the pedicle.
Attempts to pull the base o the pedicle medially result in it later alling back,
leaving too much lateral ullness. The patient is shown 10 years a ter the orig-
inal lateral pedicle reduction in which 450 g was removed rom the right breast,
and 510 g was removed rom the le t breast. Liposuction was also per ormed.
The in erior wedge resection principle can be applied to all cases o breast re-
reduction. I the patient’s nipples do not need to be elevated to any signif cant
degree, the skin around them can be deepithelialized without creating a new
pedicle. The previous pedicle can be ignored.

423
A re-reduction was performed, and the lateral pedicle was ignored. Tissue was
primarily removed laterally and inferiorly, with 205 g removed from the right
breast and 200 g removed from the left breast.
A J- and L-shaped skin resection was added to correct the excess skin inferiorly.
The intraoperative photo shows how the inferior wedge resection principle can
be applied to excise the excess tissue laterally and inferiorly, resulting in coning
of the breast. In the photo on the left, the re-reduction has been performed on
the right breast. The markings for the procedure are shown on the left breast.
The L on the left breast should have been placed higher and curved upward
more, because the scar in the postoperative photo extends below the infra-
mammary fold.
Chapter 8 • Breast Re-reduction

424
Part II • Technique
A lateral pedicle vertical breast reduction was originally performed on this pa-
tient, with 710 g removed from the right breast and 695 g removed from the
left breast. No liposuction was performed. I placed the nipples too high on the
breast mound. The arrows indicate the upper breast border. This position was
exaggerated, because I left too much lateral and inferior breast tissue. She un-
derwent a re-reduction with removal of 280 g from the right breast and 225 g
from the left breast. An additional 300 cc of fat was removed with liposuction.
Only a vertical incision was used, and the nipple scars were not corrected. The
result is good. The nipple does not appear to be as high, because the inferior
tissue was removed, and the mound shape and excess were corrected. This al-
lowed the nipple to look more centralized on the mound.
RE-CREATION OF TH E INFERIOR PEDICLE
I tried preserving the inferior pedicle to see if I could achieve the same results
as those presented previously in this chapter. I could have used the inferior
wedge resection procedure in the patient below, because only minimal eleva-

425
The inferior pedicle was re-created; 260 g was removed from the right breast,
and 285 g was removed from the left breast. Another 950 cc of tissue was re-
moved with liposuction. The patient is shown at her 7-month follow-up.
The inferior pedicle was maintained,
and the extra tissue was removed
from the lateral and medial aspects of
the breast. Only a minimal amount
was removed superiorly.
tion of the nipples was required. The nipple position was good in relation
to the upper breast border (arrow). The result was good, but the infra-
mammary fold was only slightly elevated.
Chapter 8 • Breast Re-reduction

426
Part II • Technique
The in ramammary old is elevated only minimally. I believe that the key to in-
ramammary old elevation is to remove the weight in the lower pole.
Although some weight is removed while maintaining the in erior pedicle, the
improvement is not as dramatic as when the in erior wedge resection principle
is ollowed.
REFLECTIONS
When a breast re-reduction is required, it is critical to f rst analyze the nipple
position and the location o the excess. Common problems include nipples that
are too high or too low, in ramammary olds that are too low, and bottoming
out o the in ramammary old.
Nipple-Areola Complex
I the nipples are too high, the correction can be per ormed by removing lower
pole tissue. This may not correct the problem completely, but it can make the
nipple appear to be better centralized on the breast mound. I the nipples are
too low, then it may be sa er to re-create the original pedicle to maintain the
blood supply to the nipple-areola complex. I the type o previous pedicle is un-
known, the surgeon might assume that it is a certain pedicle, but should warn
the patient that conversion to ree nipple gra ts may be needed.
I the nipples do not need to be moved signif cantly, then they can be deep-
ithelialized and maintained on a random pattern blood supply. This allows the
surgeon to remove the original pedicle without concern. It is unwise to try to

use a new pedicle. The blood vessels to the original pedicle were damaged when
it was created. I the original pedicle is removed, the nipple-areola complex will
rely on a random pattern blood supply.
Parenchymal Resection
The in erior wedge resection principle applies to breast re-reduction. By removing
an in erior wedge o breast tissue, the breast can be reduced, the remainder o
the breast coned, and the mound better adjusted to the nipple position. Be-
cause the upper breast border cannot be elevated (without an implant or at in-
jections), the surgeon must understand that to achieve a good re-reduction, the
parenchyma in the lower pole needs to be removed.
Raising the Inframammary Fold
The in ramammary olds drop out signif cantly below the in ramammary scar
in many patients who have undergone a previous in erior pedicle inverted-T
breast reduction. The key to reelevating the old to a better position is to re-
move the weight o the tissue pressing down on the old. This can be accom-
plished by removing the parenchyma directly and tailoring removal o the ex-
cess between the in ramammary old and the scar with liposuction. When an
in erior pedicle is re-created during the re-reduction, this elevation is not par-
ticularly success ul. This conf rms my belie that it is important to remove the
in erior heavy breast tissue and leave behind a Wise pattern o parenchyma in
the superior, superolateral, and superomedial aspects o the breast. When the
pillars are closed, the breast is narrowed and good projection is achieved. With
removal o the in erior weight, the shape can last longer. Skin that became in-
erior breast skin when the in ramammary old dropped can be converted back
to chest wall skin.
Concepts to Recall
• The upper breast border will remain unchanged without an implant or
at injections.
• The excess tissue is usually in the lower pole o the breast.
• The in ramammary old has o ten dropped to a lower position.
• An in erior wedge resection o excess lower pole is the ideal way to treat
lower pole excess.
• An excision along the in ramammary old will not push tissue up into the
upper pole.
• Breast tissue sutured up to the chest wall ascia will eventually drop.
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Chapter 8 • Breast Re-reduction

• Leaving behind tissue in the Wise pattern and removing in erior tissue is
the ideal approach to maintain the upper pole, cone the breast, and re-
move excess lower pole tissue.
• In ramammary olds o ten drop over time a ter an in erior pedicle
inverted-T breast reduction.
• The best way to elevate the in ramammary old is to remove in erior tissue.
• Suturing the in ramammary old up to the chest wall and rib periosteum
is pain ul and unpredictable.
• The nipple may appear to be too high, because there is excess tissue in
the lower pole.
• The nipple may appear to be too high, because the in ramammary old
has dropped.
• The nipple may appear to be too high, because it was placed too high.
• It is important to understand the blood supply to the nipple and areola.
• Removal o a previous pedicle causes the nipple to rely on a random pat-
tern blood supply.
• It is important not to create a new pedicle, because the original supply-
ing vessels were damaged with the f rst breast reduction.
• A pedicle can only be used when the surgeon re-creates the original pedi-
cle.
• The nipple rarely needs to be elevated, but some deepithelialization
around the areola is sa e.
• When the nipple needs to be signif cantly elevated, it is important to either
re-create the original pedicle or consider ree nipple gra ts.
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Losee JE, Caldwell EH , Serletti JM. Secondary reduction mammaplasty: is using a di er-
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Pandeya NK. In erior pedicle technique or reduction mammaplasty a ter a Strombeck re-
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Part II • Technique