38

Mastopexy and Breast

Reduction
ELIZABETH J. HALL-FINDLAY

For videos accompanying this chapter see ExpertConsult.com. This involves an understanding of the inferior wedge
See inside cover for access details. principle.3,4 The inferior ptotic gland needs to be “removed”
in a breast reduction. It is best “moved” in a masto-
pexy using Liacyr Ribeiro’s method5,6 where it can be
Introduction separated and moved up to the center of the breast (not
the upper pole). Filling the upper pole usually requires
The best way to approach esthetic breast surgery is to work either an implant or the addition of tissue (e.g., fat graft-
with gravity – not against it. Remove tissue where it is in ing). The inferior wedge is that tissue below the Wise
excess and add tissue where it is deficient. Although this pattern.
sounds simplistic, it forms the basis of the principles of When Robert Wise7 deconstructed a brassiere and devel-
esthetic breast surgery.1 Although in some cases the skin oped the “Wise pattern,” it was designed to be used for the
brassiere can be used to shape the breast, it is better to rely skin to shape and hold up the breast (Fig. 38.2). Unfor-
on parenchymal reshaping for a consistent, long-lasting tunately, skin is often not a good brassiere and it stretches
result. The parenchyma can be reshaped most easily by fol- with tension (as it does with skin expansion procedures).
lowing this “excess/deficiency” principle. If the surgeon, on the other hand, uses the Wise pattern
The surgeon needs to understand what various surgical for the parenchyma – and leaves behind a Wise pattern
maneuvers can achieve and what our limitations are as sur- (with no tension on either the parenchyma or the skin),
geons. With that knowledge, we can then manage surgical the result will be predictable and long-lasting. The Wise
results (and therefore patient expectations) more appropriately. pattern shown below starts flat but then develops a nice
Because the upper breast border will not change with conical shape when put together with the inferior wedge
either a breast reduction or mastopexy, the result can be removed.
predictable (but not always what either the surgeon or the Because the upper breast border is the more stable (and
patient desires).2 Some patients are high-breasted and some predictable) landmark, the inframammary fold (IMF)
are low-breasted. The breast is lifted – not at the upper becomes less important. In the past, I marked the new nip-
breast border – but by controlling the glandular ptosis. ple position at the level of the IMF until I realized how vari-
Once the patient (and the surgeon) understands this con- able the fold can be. Some patients not only have a variable
cept, it becomes clear what can be “removed” in a breast footprint location on the chest wall, the distance between
reduction or “moved” in a mastopexy. the upper breast border and the lower breast border (infra-
Patients and surgeons often think that the breast can be mammary fold) can vary from a few centimeters to well over
pushed up the chest wall, but the upper breast border will 15 cm.
only be elevated if something is added (an implant raises the Because of the variability of the IMF, the Regnault clas-
upper breast border on average 2 cm and fat grafting far less). sification of ptosis can be misleading. Paule Regnault8 clas-
The surgeon can transpose drawings onto the patient’s sified breast ptosis based on the relationship of the nipple to
photographs (Fig. 38.1) and the decision-making process the IMF. If the nipple was well below the level of the fold,
becomes simplified. Remove (or move) any ptotic gland then a mastopexy would be required. Unfortunately, some-
below the ideal breast shape. Determining the ideal nipple times the nipple is in a good position on the breast mound,
position then becomes simple once the shape is outlined. but the fold is abnormally high (especially in tuberous

574
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 CHAPTER 38 Mastopexy and Breast Reduction 575

Desired breast meridian

Upper breast border

10 cm
10 cm
* Desired breast mound shape
Desired nipple position

A B
• Fig. 38.1 Principles. (A) The upper breast border does not change in a breast reduction or mastopexy.
The key to a good result is for the surgeon to understand that the excess in the lower pole needs to be
“removed” in a breast reduction or “moved” in a mastopexy. (B) The surgeon can visualize the shape of
the final result by marking what is desired. The excess beyond that shape needs to be removed in a breast
reduction. The ideal nipple position should be determined at about 10 cm below the upper breast border
(since this remains unchanged) in an average “C” cup breast. The new breast meridian should be drawn
where it “should” be, not where it exists and the ideal breast meridian is about 10 cm from the chest
midline (straight, not around the curve of the breast) in the “average” patient. (© Elizabeth J. Hall-Findlay.)

breasts) and the approach should instead be to fill the lower Macromastia
pole of the breast and give a better breast shape by central-
izing an implant behind the existing nipple position. If the Assessment
breast is large and the nipple is high then the best approach History
would be to remove some of the ptotic gland. The nipple It is important for the surgeon to first assess patient desires
should be moved only if it is too low on what will be the in terms of size. Any previous biopsies, mammogram results,
final breast mound. and personal and family breast history should be outlined.
We should instead look at the amount of glandular ptosis The patient should be asked about past experience and
or nipple ptosis in relation to the upper breast border and wishes related to pregnancy and breastfeeding.
upper pole of the breast. Once the inferior wedge of glandu- Then details of other patient requests, such as shape and
lar ptosis is removed, the new nipple position can be easily upper pole fullness, should be determined.
determined. The ideal nipple position on an average “C”
cup breast is about 10 cm down from the upper breast bor- Examination and Photographs
der and about 10 cm from the chest midline (drawn straight The consultation is far easier if photographs are taken and
– not around the breast). used for the discussion. The surgeon can then mark on the
The upper breast border remains at the preopera- photos to illustrate what kind of result can be achieved (Fig.
tive level with a breast reduction or mastopexy but it can 38.3). The upper breast border is marked (here with a dot-
be elevated on average 2 cm with an augmentation or ted line). The distance of “flat” chest wall is marked with
mastopexy-augmentation.2 the vertical arrow on both the frontal and the lateral views.
It is easier to plan surgery if the surgeon first assesses Note that the drawing shows removal of the glandular ptosis
glandular ptosis and then nipple ptosis. The level of the IMF – removal of both inferior and lateral breast tissue where it
is the least important landmark. Sometimes it is better to is in excess. Once the desired inferior border of the breast
fill the lower pole of the breast (and lower the IMF) with an is determined, the new nipple is placed about one-third up
implant to centralize the breast mound behind the existing the breast mound. Note that the IMF is not marked – and
nipple position than it is to move the nipple. not needed.

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576 PA RT V Breast

There is still a bit of overhang in the final result because it

is difficult to lift the breast completely up onto the footprint
without some overhang. Having the breast shape completely
confined to the breast footprint is difficult unless the foot-
print is long vertically or without lowering the IMF (as often
happens with an inverted T inferior pedicle breast reduction).
Patients need to be warned that they will not achieve the
“double push up brassiere effect” without clothes. There is
normally a vertical distance of flat chest wall (this can vary
from about 9 cm to 16 cm in an average height patient)
between the clavicles and the upper breast border. The
breasts do not normally come up close to the clavicle and
the upper breast border should never be higher than the
preaxillary crease. This has become an important part of
managing patient expectations over the past few years with
A the new fashions in brassieres.
If a patient has very poor upper pole fullness, some of the
inferior wedge can be moved up5,6 (separated from all sur-
rounding breast tissue but left attached as a chest wall-based
flap) to provide better projection, but any attempt to try to
fill the upper pole is usually doomed to failure. The tissue
that is mistakenly pushed up will inevitably fall down result-
ing in unattractive glandular ptosis.
Patients often see more in the photographs than they do
in the mirror and by showing patients their photographs,
they can better understand the limitations of the procedure.
Patients need to understand that they cannot achieve either
a higher footprint or more upper pole fullness. They can,
however, achieve better projection.

Management Principles and Operative Options

B Reduction/Mastopexy
There are numerous designs and labels for various breast
reduction and mastopexy techniques. The design should be
divided into two categories:
1. pedicle design, and
2. skin resection pattern.

Pedicle Design
The breast is a superficial structure attached to the skin at
the nipple. Most of the blood supply to the breast is superfi-
cial. It starts out in a deep location around the periphery of
the breast and then both the arteries and veins travel around
the breast in the subcutaneous tissue.
Most of the blood supply to the breast comes from the
internal mammary system (Fig. 38.4). The inferior or cen-
C tral pedicle is supplied by the deep artery and vein that pen-
• Fig. 38.2 The “Wise” pattern. The Wise pattern was adapted from etrates through the intercostal muscles and the pectoralis
a deconstructed brassiere by Dr Robert Wise5 and it forms the basis muscle from the fourth interspace. That this artery (and
of an ideal breast shape. Once the flat pattern is coned (by removing venae comitantes) comes from the fourth interspace makes
or moving the inferior wedge) a good shape with good projection is sense because the breast is a fourth interspace structure.1
achieved. (A) The Wise pattern. (B) The Wise pattern coned. (C) The
There is also some blood supply from the superficial
Wise pattern is an excellent design for what should be left behind to
achieve a good breast shape rather than using it as a skin brassiere branch of the lateral thoracic system and this artery supplies
pattern. (© Elizabeth J. Hall-Findlay.) a lateral pedicle.

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 CHAPTER 38 Mastopexy and Breast Reduction 577

A B

C D
• Fig. 38.3 Managing patient expectations through consultation photographs. Patient photographs taken
at consultation can be used to manage patient expectations. Once the surgeon understands that the
upper breast border will not change, the expected result can be drawn on the preoperative photograph.
More projection can be achieved by coning the breast tissue after the inferior wedge is removed. The
breast cannot be elevated on the chest wall and the upper pole cannot be filled, but the angle (projec-
tion) can be increased. The surgeon will also know if tissue needs to be removed in the upper pole in the
occasional patient where reduced projection is desired. (A) Preoperative frontal breast reduction candidate
showing the desired final breast shape with inferior and lateral tissue removed. (B) Preoperative lateral of
same breast reduction candidate showing the patient that the upper breast does not change but the lower
pole is removed. (C) Postoperative view of same patient showing the postoperative result. The frontal
view matches the preoperative drawing. (D) Postoperative view of same patient showing the postopera-
tive result. The lateral view matches the preoperative drawing. The breast footprint remains unchanged
but the glandular ptosis is corrected and the nipple repositioned to the most projecting part of the breast.
(© Elizabeth J. Hall-Findlay.)

Most of the arteries are within the first centimeter deep and medial pedicles is in the subcutaneous tissue the ped-
to the skin surface at the level of the areola. The veins travel icles can be created as dermal-subcutaneous pedicles. The
separately from the arteries and they are more superficial – pedicle should be thick where the vessels are deep at the
just under the dermis. They can often be seen through the breast periphery and then can be thinned out closer to the
skin when examining the patient and they can be seen to areola where the vessels are found usually within the first
drain mainly superomedially. centimeter of tissue depth beneath the skin.
Because the blood supply to an inferior or central pedicle Pedicle design is based on blood supply. If the surgeon
comes up through the chest wall, the pedicle must be full does not believe that there is a safe pedicle available, then a
thickness. Because the blood supply to the superior, lateral, free nipple graft may be an option. Usually, however, there

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578 PA RT V Breast

Internal mammary artery

(Internal thoracic artery)

Thoracoacromial axis
Lateral thoracic artery

Second intercostal
artery and perforating
branches
Thoracoacromial
axis
Thoracoacromial
perforating branches

Anteriorlateral
perforators from
intercostal artery

Internal mammary
artery
Intercostal artery
B
Lateral thoracic artery

Fourth intercostal artery

and perforating branches

• Fig. 38.4 Blood supply. The major blood supply to the breast comes from the internal mammary (tho-
racic) system. There is also some contribution from the superficial branch of the lateral thoracic artery.
(A,B) The arteries penetrate up from the chest wall around the periphery of the breast and then they pass
around the breast parenchyma itself, up in the subcutaneous tissue. The arteries are superficial as they
course toward the areola. The veins are even more superficial as they course just under the dermis (and
are often visible through pale skin) with the majority draining superomedially. The branch of the internal
mammary artery from the fourth interspace actually penetrates directly up into the breast parenchyma just
medial to the breast meridian just above the fifth rib. This artery has accompanying venae comitantes. This
makes sense because the breast is a fourth interspace structure attached to the skin at the nipple and
sliding loosely over the pectoralis fascia. The breast is held in place by skin–fascial structures at the IMF
and over the sternum. The superior and lateral aspects of the breast slide freely over the underlying tis-
sues. (From Harmann EC, Spring MA, Stevens WG. One- and two-stage considerations for augmentation
mastopexy. In: Nahabedian MY, Neligan PC, eds. Plastic Surgery. Vol. 5: Breast. London: Elsevier; 2018.)

are good pedicle designs that can be used. The main choices up in the subcutaneous tissue and a deep branch that trav-
are inferior (and central), superior, medial, lateral, or a com- els along the pectoralis fascia. The deep nerve branch then
bination (Fig. 38.5).9,10 turns upward at the breast meridian and can be included
The superior pedicle is supplied by the internal mammary in a full-thickness pedicle. Evaluation of my patients has
system by the descending branch of the artery from the second shown that the medial pedicle actually has better return of
interspace and the medial pedicle is supplied by the third inter- sensation than either the lateral or superior pedicles.1 Other
space. There is clearly some variability but a true superomedial studies have shown that there is not much difference in sen-
pedicle can be designed to include these two axial arteries. sation recovery among the various pedicles.
Fig. 38.6 shows the artery and vein to the inferior wedge
that is about to be removed in a vertical breast reduction Skin Resection Pattern
using a true superomedial pedicle. The pedicle design determines the design of the parenchy-
Innervation to the nipple comes from various sources.11 mal resection pattern, but the skin pattern can vary. The
There are nerves that come from all directions but they are classic inverted T (Wise pattern) skin resection pattern12,13
mainly medial and lateral. There are several medial branches was designed to use the skin brassiere to hold up the remain-
but also a major nerve from the lateral fourth intercostal ing breast parenchyma. In those cases where the skin has
nerve. This nerve splits with a superficial branch that courses good elasticity, it can be used to shape the breast.

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 CHAPTER 38 Mastopexy and Breast Reduction 579

Internal mammary artery

2 Rib

3
Second superficial branch of
the internal mammary artery
4

Internal mammary artery

2

3 Rib
Third superficial branch of
4 the internal mammary artery

B
• Fig. 38.5 The various pedicle designs for the nipple and areolar complex. The four classic pedicle
designs. (A) Superior pedicle: The blood supply comes from the descending branch of the internal mam-
mary (thoracic) system at the second interspace. (B) Medial pedicle: The blood supply comes from the
third interspace branch of the internal mammary system.
Continued
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580 PA RT V Breast

Internal mammary artery

4 Rib
Fourth deep intercostal artery
5

6
Fifth superficial branch of the
internal mammary artery

Internal mammary artery

4 Rib
Fourth deep intercostal artery
5

Branches of fifth superficial branch of

the internal mammary artery (cut)

D
Fig. 38.5 cont’d (C) Inferior pedicle: The blood supply comes from the perforator that comes up at the fourth
interspace, along with its venae comitantes. This deep branch also comes from the internal mammary system.
There are also blood vessels that come up through the IMF. (D) Central pedicle: The central pedicle has a more
restricted blood supply than an inferior pedicle because it does not have the vessels coming through the IMF.
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 CHAPTER 38 Mastopexy and Breast Reduction 581

Lateral thoracic artey

Superficial branch
4

3
Second superficial branch of
the internal mammary artery 4
Third superficial branch of
the internal mammary artery 5

F
Fig. 38.5 cont’d (E) Lateral pedicle: The blood supply comes from the superficial branch of the lateral
thoracic artery. (F) A true superomedial pedicle combines both superior and medial pedicles to include two
axial arteries. The majority of the venous drainage is superomedial. (From Mackinnon S. Nerve Surgery.
New York: Thieme. 2015.)

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582 PA RT V Breast

it includes two axial arteries. I have pencil-Dopplered more

than 85 patients1 and the descending artery from the second
interspace is usually just medial and occasionally just lateral
to the breast meridian.
When the breast enlarges, the blood vessels also enlarge
and travel down with the nipple. The risk in a longer pedicle
is not that the blood vessels do not travel to the nipple but
that creation of the pedicle might not actually include those
particular vessels.
An inferior pedicle (using the inverted T skin resection
technique) is the easiest to inset but the weight of the breast
is left inferiorly. The medial and lateral pedicles are easy to
inset because they rotate into position. The superior pedicle
can be harder to inset because it needs to be folded or forced
up. Superior pedicles often need to be thinned in order to
• Fig. 38.6 This photo shows the artery and vein to the inferior wedge
allow an easier inset without compression and this leaves an
that is about to be removed in a vertical breast reduction using a super- empty concave lower pole.
omedial pedicle. (© Copyright Elizabeth J. Hall-Findlay.) The true superomedial pedicle (with the main base
medial but extending upward and across just lateral to the
Unfortunately, skin tends to stretch under tension and breast meridian) can be harder to inset than a true medial
many surgeons are now using the inferior wedge resection pedicle. But if the surgeon understands that the blood sup-
principle to remove the heavy inferior breast tissue, then ply is superficial, debulking deep tissue which is causing the
closing the pillars together following the Wise pattern7 for restriction can be performed safely. This not only provides
the parenchymal resection and closure instead of using the a good reliable blood supply but it also gives a nice elegant
Wise pattern for the skin resection pattern. The skin resec- curve to the lower pole of the breast on the table because
tion pattern will then depend on how much skin redun- the inferior border of the medial pedicle becomes the medial
dancy there is because it is used to redrape around the breast pillar.
parenchyma instead of being used as a handle or support. The lateral pedicle can be used, but it is often difficult
Not all “vertical” (or “inverted T”) breast reductions to remove some of the lateral bulk in a breast reduction
are the same. They can be designed with various pedicles. because the tissue that is in excess (laterally) forms the base
Usually, however, the term “vertical” is associated with the of the lateral pedicle. Although there are some veins that
superiorly (superior, medial or lateral)-based pedicles and drain superolaterally, the majority of the venous drainage is
the term “inverted T” is associated with inferior or central superomedial.
pedicles.14–26 The excess breast tissue is removed inferiorly With a mastopexy, breast tissue needs to be rearranged
(and laterally) with the superiorly-based pedicles and the because tightening the skin brassiere alone is not very effec-
excess breast tissue is removed superiorly (and laterally and tive. Patients who have developed ptosis have already dem-
medially) with the inferiorly-based pedicles. onstrated that their skin envelope cannot hold up the breast
It makes more sense to work with gravity rather than parenchyma. A small breast reduction is the easiest masto-
against it. The inferior pedicle tends to bottom out with pexy, especially when an inferior wedge of breast tissue is
time, pushing the IMF down. Over time, the IMF can end removed. When the patient wants to maintain their volume,
up several centimeters below the horizontal scar.27 then an inferior flap (described by Liacyr Ribeiro) can be
Periareolar skin resection patterns (where the outer created, moved up, and the pillars closed around caudal
doughnut skin edge is sutured to the inner doughnut hole to the flap.5,6 When this method of a mastopexy is used,
skin edge) are used only rarely because not much skin the pedicle is therefore based superiorly (superior, supero-
can be resected. If the patient has a significant amount of medial or superolateral). This method of “moving” breast
redundant skin, then more skin needs to be resected, using tissue (that is “removed” in a breast reduction) is a good
either a vertical or inverted T pattern. The breast is not well way of reshaping the breast when the skin brassiere has lost
reshaped when the skin alone is tightened – surgeons need elasticity.
to be aware that Benelli’s description28 of a periareolar mas-
topexy did not just tighten the skin; he reshaped the under- Operative Technique for Superomedial
lying breast parenchyma as well. Failure to follow this advice
has resulted in unsatisfactory results. Vertical Breast Reduction
Indications Assessment
Some surgeons believe that the inferior pedicle is a safer The surgeon needs to assess the footprint – whether the
pedicle for the very large breast reduction. I believe that the patient is high- or low-breasted. Then he or she needs to
true superomedial pedicle has the best blood supply because visualize what needs to be removed – usually inferiorly and

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 CHAPTER 38 Mastopexy and Breast Reduction 583

laterally. The patient needs to be consulted on her preferred freehand to be about 14–16 cm in length. A 14 cm cir-
breast size (and of course warned that an exact size and cumference matches a 4.5-cm diameter areola and a 16-cm
shape cannot be achieved). It is always a balance between circumference matches a 5-cm diameter areola. A large
size and shape to achieve a good result. paperclip is 16 cm long and can serve as a good template
The superomedial pedicle can be used with either the when unfolded. There is no need to draw out the opening
vertical or inverted T skin resection pattern29 – this will laterally in a mosque-type shape. It is in fact better to take
depend on the desired final size of the breast and the elastic- out length vertically rather than horizontally.
ity and amount of excess skin. The vertical distance from It is important to mark the medial part of the areolar
the lower border of the areola to the IMF is usually about 7 opening where desired and allow the lateral part to be vari-
cm in a “B” cup breast, 9 cm in a “C” cup breast and 11 cm able. The medial marking should fit the desired Wise pat-
in a “D” cup breast. Surgeons are often warned to keep the tern. The lateral side is more mobile and can be moved
vertical scar length at 5–7 cm in an inferior pedicle inverted medially to fit the desired shape and positioning.
T breast reduction because the weight of the breast stretches In order to mark the skin resection pattern, the breast can
out the skin. In a vertical type of breast reduction, however, then be rotated laterally and the vertical meridian marked
the extra vertical length is needed to accommodate projec- to match the breast and chest wall meridians. The breast is
tion and weight is not an issue. then rotated medially and the lateral meridian marked. The
breast can be held up with the surgeon’s thumb of the oppo-
Markings site hand and the two lines can be joined in a “U” or “V”
First the surgeon should mark the upper breast border shape but the bottom of the design should remain at least
because this is a landmark that does not change. This is 2–4 cm above the IMF. The surgeon can then test the skin
best determined by finding the pre-axillary indentation lat- resection pattern by pinching the skin.
erally and marking the upper breast border medial to that A vertical breast reduction using the superomedial ped-
indentation. The breast can be folded (not pushed up) to see icle does not rely on the skin brassiere so there is no need
where the fold between the breast and the chest wall occurs. to design a wide skin resection pattern. There should be no
Next, the surgeon should draw the chest midline and tension on the vertical skin closure. If an inverted T design
breast meridian. The “ideal” breast meridian should be is needed, the medial and lateral extensions are drawn about
marked and not the “existing” breast meridian. The surgeon 7 cm down the vertical limbs because the ideal vertical
can then draw what the resultant breast shape would be (Fig. parenchymal distance is about 7 cm. These extensions are
38.7A, B). This can help to mark the new nipple position. then drawn to meet the IMF both medially and laterally.
The ideal nipple position on an average “C” cup breast The skin resection pattern should not result in a tight clo-
on an average patient should be about 10 cm below the sure in any direction – it is used only to allow the skin to
upper breast border and 10 cm from the chest midline (not redrape loosely.
drawn around the curve of the breast but with a straight A pure medial pedicle is designed with the base about 4
ruler on a line parallel to the chest wall). If a surgeon places cm below the areolar opening along the vertical skin resec-
the new nipple (for example) at 24 cm from the supraster- tion pattern and 4 cm above into the areolar opening. A
nal notch, that distance will not change postoperatively. true superomedial pedicle takes the medial pedicle base and
It will remain at 24 cm. An arbitrary SSN-N distance can extends it up and across the breast meridian. This allows it
be misleading, leading to a nipple placement which is too to include two axial arteries (as opposed to one artery in
high. The surgeon needs to understand that the footprint a medial pedicle) but it does make it a bit harder to inset
cannot be changed; a low-breasted patient will remain occasionally. If it does prove to be too stiff to inset easily
low-breasted. then excess tissue can be safely debulked deep to the pedicle
Because the vertical approach leads to increased breast because the blood supply is superficial.
projection, it is important for the surgeon to place the new Finally, the areas that may need to be liposuctioned
nipple lower than they are used to doing with an inverted (preaxillary fullness and lateral chest wall areas) are marked
T, inferior pedicle, because, although the SSN-N distance (Fig. 38.7C, D).
will stay where marked, the nipple will be elevated vertically
with the increased projection that results. Positioning
It is always better to err on the side of leaving a nip- The patient is supine on the operating table with the arms
ple slightly lower because it is almost impossible to lower outstretched to the sides.
a nipple that is too high. I believe that the idea that the
nipple should be 45% down and 55% from the bottom of Infiltration
the breast30 will lead to many patients who have nipples that It is not a good idea to infiltrate along the incisions because
slip up over the edge of clothing. I believe that the ideal nip- the veins can be damaged. Lidocaine with epinephrine is
ple is slightly lower than the horizontal midline and slightly used in the areas to be suctioned. If the patient has a higher
lateral to the breast meridian. body mass index, then tumescent type of infiltration may be
The new areolar opening should be marked about 2 cm indicated for the lateral chest wall in particular – in the areas
above the new nipple position. The opening can be drawn where liposuction will be performed.

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584 PA RT V Breast

A B

C D
• Fig. 38.7 Markings for a vertical breast reduction using a superomedial pedicle. (A) The upper breast
border and desired breast meridian are marked. The new nipple position is marked about 10 cm below the
upper breast border. The IMF is marked at the chest midline (it is often different from one side to the other)
but it is not used to determine the new nipple position because it is often too high or too low. Because the
upper breast border remains unchanged from the preoperative position to the postoperative result, it is the
better landmark to use to determine the new nipple position. (B) The areolar opening is drawn freehand
about 2 cm above the new nipple position. The drawing should be performed so that the final result is a
circle. A large paperclip is 16 cm long and it can be folded out and used as a template if desired. The skin
opening will determine the new areolar diameter because the areolar skin is so elastic that it will stretch to
fit the skin pattern. A 16-cm circumference matches a 5-cm diameter areola and a 14-cm circumference
matches a 4.5-cm diameter areola. (C) A true superomedial pedicle is drawn. A pure medial pedicle has a
base that is about 4 cm up into the areolar opening and about 4 cm below along the vertical limb. A true
superomedial pedicle has an extension of the base up and slightly across the breast meridian to capture
the descending artery from the second interspace. A true superomedial pedicle contains the arteries from
both the second and third interspaces and still allows the lower border of the pedicle to become the medial
pillar (giving an elegant shape to the lower pole) while avoiding some of the difficulties inherent in insetting
a superior pedicle. (D) The lower skin resection pattern is drawn while rotating the breast medially and then
laterally to match the desired breast meridian drawn on the breast and continued down onto the chest
wall. The pattern should be joined usually about 4 cm above the IMF to take into account the fact that the
fold often rises but also to avoid the scar extending onto the chest wall. Closure of an ellipse ends up with
a longer scar at each end. The pattern should be designed only to remove the excess, not to use the skin
as a handle or brassiere. The key is to reshape the parenchyma (by removing the inferior wedge) and then
allowing the skin to redrape. (© Elizabeth J. Hall-Findlay.)

Technique (Fig. 38.831) around the base of the breast and held with a Kocher clamp
to tighten the breast skin and facilitate de-epithelialization.
De-epithelialization The veins are just deep to the dermis, so whatever method
The incision lines are incised around the areola and verti- is used, the surgeon should keep the dermis intact during
cally making sure that the vertical skin resection pattern de-epithelialization. The skin is easier to remove in a supero-
remains about 4 cm above the IMF. A lap pad is then placed medial pedicle than in an inferior pedicle.

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 A B

C D

E F
• Fig. 38.8 Operative technique for superomedial vertical breast reduction. (A) De-epithelialization of a superomedial pedicle. Note that the base of the
pedicle extends along the vertical limb but that the upper base extends across to just lateral to the breast meridian. This allows the pedicle to include
two axial arteries (from the second and third interspaces). (B) The superomedial pedicle is created as a full-thickness pedicle to include the ascend-
ing branch of the fourth intercostal nerve that travels above the pectoralis fascia and then turns upward toward the areola at the breast meridian.11
(C) Resection of the parenchyma is performed initially around the pedicle but mainly as an inferior wedge resection. An initial inferior vertical wedge
resection is performed while leaving a 2-cm thick lateral pillar (about 7 cm long). The medial pillar will be formed by the inferior border of the medial
pedicle. Extra parenchyma is removed from under the lateral flap – where there is excess. (D) Extra breast tissue is removed inferiorly above the IMF
and below the Wise pattern (which is marked in blue on the skin). This is performed to prevent bottoming out and to prevent an inferior pucker (which
is usually a problem of lack of subcutaneous tissue excision rather than a skin redundancy problem). Aggressively removing this tissue will result
in a higher IMF level. The blue forceps are pointing to the excess parenchyma that needs to be removed under the lateral flap. In a very glandular
breast (young women) this tissue needs to be carved out under the flap but also to remove any tissue lateral to the desired Wise pattern. In older
patients, this excess can be liposuctioned but it must be completely removed or else the breast will end up too wide and full laterally. Tissue needs to
be removed where it is in excess. (E) The lower border of the areola is closed first to allow the surgeon to assess the extent of resection. No dermal
undermining is needed for this closure. (F) The superomedial pedicle is easily rotated up into position. This maneuvre of pulling the areola cephalad
allows the medial and lateral pillars to fall together. The arrows marked on the skin show the lower edges of the pillars. This is usually about half-way
up the vertical skin resection with tissue removed inferiorly. The pillars do not extend as far down as the skin opening or as far down as the IMF. The
pillars are closed with a few relatively superficial sutures with no tension. The pillars should be sutured only enough to allow them to stay together
during the postoperative period so that they can heal together. Deep bites are not necessary and may lead to tissue necrosis. Tension should not be
relied upon to shape the breast because it will inevitably fail over time. The key is to remove all tissue where it is in excess.
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586 PA RT V Breast

7 cm

10 cm

I H

J K
Fig. 38.8 cont’d (G) The dermis is closed loosely both vertically and around the areola. Note the shape of the right breast. Good projection is achieved
along with narrowing of the breast base as compared with the unoperated left breast. (H) Although the pillars are often about 7 cm long, the skin can
be much longer because it tucks up under and behind the pillars. (I) The photograph shows that the breast does not settle by dropping as shown.
In order to determine whether a horizontal scar needs to be added, it is better to lift up the breast and then push down. Pushing it down like this will
make the surgeon think that a horizontal scar is needed. (J) The final breast shape and extent of excess skin can be shown by using this maneuver
where the breast is elevated and pushed down so that it slides down the chest wall to its original position. This allows the surgeon to determine if
any more subcutaneous tissue or parenchyma needs to be removed but also to assess whether a horizontal skin excision needs to be added. The
excess inferior skin in this example will just curve up under the parenchyma around the pillars and does not need to be modified. (K) Final closure.
The cross-hatched area shows where the liposuction has been performed (usually after deep dermal closure before subcuticular closure). Liposuction
is also performed along the lateral chest wall and (not to excess) in the preaxillary areas.

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 CHAPTER 38 Mastopexy and Breast Reduction 587

L M

N O
Fig. 38.8 cont’d (L–O) Postoperative photographs at 5 months. The patient was 41 years old, 5’11” tall, weighed 82 kg and wore a 34G brassiere.
She had 346 g removed from the right breast and 325 g from the left breast. She had 400 ml of fat suctioned from the inferior breast along the IMF
as well as along the lateral chest wall and in the preaxillary areas. (© Elizabeth J. Hall-Findlay.)

Pedicle Creation course through the parenchyma to supply the nipple. All
The pedicle is created initially as a full-thickness pedicle the other pedicles are supplied by superficial vessels in
cutting straight down toward the chest wall. Most of the the subcutaneous tissue.
bleeding occurs in the first few centimeters as initially No alteration is made at this stage for insetting the ped-
the veins are encountered just under the dermis and icle. If the pedicle is stiff then deep tissue can be debulked
then the arteries are severed in the subcutaneous tissue. later to allow for an easier inset.
There is not much bleeding from the breast parenchyma
itself. The only artery and vein (and lateral branches) that Parenchymal Resection
course through the parenchyma to the nipple penetrate The inferior wedge of parenchyma is then removed cutting
through the intercostals (and pectoralis muscle) at the straight down to the chest wall. A 2-cm thick lateral pil-
fourth interspace. This is the artery and vein that supply lar should be created before undermining the lateral flap.
an inferior and central pedicle. Of course there are ves- It is important to remove tissue down toward the pectoralis
sels that supply the parenchyma, but no other vessels that fasbia but there will be less bleeding if the fascia itself is left

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588 PA RT V Breast

undisturbed. The surgeon will encounter the deep perfora- Skin Closure
tors coming just up above the fifth rib (fourth interspace) The deep dermis is then closed with interrupted 3-0
just medial to breast meridian. There are some branches Monocryl sutures, again with the goal of achieving only
that perforate more laterally as well but all from the internal dermis-to-dermis contact so that the circulation to the skin
mammary system. edges is not compromised. The vertical skin is then closed
The excess parenchyma in a breast reduction is infe- with a subcuticular 3-0 or 4-0 Monocryl but it is important
rior and lateral. Once the inferior wedge of breast tissue not to “cinch” or “gather” the vertical incision. It was ini-
is removed, then more tissue can be beveled out under tially thought that it was important to shorten the vertical
the lateral flap. The lateral parenchymal pillar should be incision because of the fear of bottoming-out that occurred
about 2 cm thick and about 7 cm in length. If the tissue is when the skin stretched with the inferior pedicle, inverted
thick glandular tissue (as in a teenager) the surgeon needs T breast reduction.
to carefully carve out all tissue until a good Wise pattern Not only does the gathering compromise blood supply to
of parenchyma is left behind. If the lateral excess tissue the skin edges, but it is ineffective in shortening the vertical
is comprised mainly of fat, it can be removed later with skin length.32 It is important for surgeons to change their
liposuction, but any “white” glandular tissue needs to be thinking and realize that a longer vertical length is actually
directly excised. needed to accommodate the increased projection that occurs
Rarely does any parenchyma need to be removed medi- with the vertical approach. Bottoming out occurs with the
ally except just above the IMF. It is good to leave behind inferior pedicle procedures because the weight of the tis-
some parenchyma in the lateral aspect of the areolar open- sue is left in the lower pole and the skin brassiere stretches;
ing to serve as a platform so that the areola does not retract bottoming-out occurs with vertical procedures with inad-
once it is inset. Even a full-thickness pedicle will appear to equate resection of the lower pole (inferior wedge). The skin
be undermined once it is created. is allowed to redrape with a vertical approach as it is not
The surgeon should consciously leave behind a Wise pat- used as a handle to hold the breast up. Any procedures that
tern of parenchyma. This will mean not only removing the use skin (or dermis) as slings tend to fail over time because
inferior wedge of tissue and tissue under the lateral flap but skin (and dermis) stretches.
also tissue caudal to the Wise pattern above the IMF. This There is some tissue overhang in a vertical breast reduc-
will result in some elevation of the IMF – another reason to tion and the vertical length from the lower border of the
keep the lower border of the vertical skin resection pattern areola to the IMF is usually about 7 cm in a “B” cup breast,
about 4 cm above the original IMF. about 9 cm in a “C” cup breast and about 11 cm in a “D”
The surgeon who is less familiar with the vertical approach cup breast. It is important to warn patients that they will
will initially remove less parenchyma than required – the still be able to “hold a pencil” underneath their breasts.
breast looks smaller on the table than it is when sitting. Although the pillars are about 7 cm, the skin is longer and
it tucks up underneath the breast.
Pillar Closure The decision to add a “T”, a “J” or an “L” can be a diffi-
It is best to close the areolar opening first to best assess the cult one. It will depend on the quality and amount of excess
shape and to effectively close the pillars. The dermis does skin. As a guideline, a vertical incision length of up to 12 cm
not need to be undermined or released for this suture (usu- can be tolerated in patients with poor quality skin and up to
ally a 3-0 Monocryl). Once the areola is closed, the pedicle 15 cm with good quality skin for an average “C” to “D” cup
can be easily rotated up into the opening. If there is any breast. The way to test to see if the inferior end of the inci-
resistance, the deep tissue of the pedicle can be debulked sion will tuck up underneath the breast is to hold the breast
because the blood supply is superficial. up and push it down by lifting and sliding (see Fig. 3.8J),
If the pedicle is pulled up in a cephalad direction using and if the end of the incision tucks up under the pillars, no
forceps, the pillars will automatically fall together. The infe- further correction is necessary.
rior border of the medial pedicle becomes the medial pillar
and the first suture should be placed at the caudal end of the Areolar Closure
lateral pillar (about 7 cm down from the areolar opening The pedicle is allowed to sit comfortably in the areolar open-
as shown by the arrows on the photograph) and where the ing and it is usually rotated slightly to fit. Debulking of deep
inferior border of the medial pedicle meets the skin (i.e., at tissue in the superomedial pedicle to allow unrestricted inset
the caudal end of what is now the medial pillar). can be performed at any time during the procedure.
Deep bites are not necessary (and can actually lead to Four deep 3-0 Monocryl sutures are used to close the
tissue necrosis). It is only necessary to make sure that paren- dermis and the skin is closed with a subcuticular 3-0 or 4-0
chyma (not fat) is apposed on each side so that healing can Monocryl. If the skin opening is not completely circular, the
occur. I usually use only 3–4 sutures of 3-0 Monocryl to skin can be trimmed prior to closure.
hold the pillars in contact with each other. Any tension on The areola will eventually stretch out to match the skin
parenchyma (which I mistakenly tried with lateral pedicles opening circumference. A 16-cm circumference (of the
in a vain attempt to pull lateral tissue inward) will eventually skin opening, not the areola) will match a 5-cm diameter
release and the tissue will return toward its original position. areola. A 14-cm circumference matches a 4.5-cm diameter

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 CHAPTER 38 Mastopexy and Breast Reduction 589

areola. Areolar skin is quite elastic and will stretch to fit the Drains
skin opening. A permanent Gore-Tex type of suture can Drains can be used if desired. If a patient has a large lateral
be used in a circumvertical type of breast reduction (which dead space or had an unusual amount of bleeding during
is used to shorten the vertical length) but at the expense surgery then drains might be indicated. Seromas do occur
of some stretching that can occur beyond the Gore-Tex and drains would need to be left in for a long time to treat
pursestring. seroma formation. The advantage of the vertical approach is
that seroma fluid can easily work its way through the tissues
Liposuction for Tailoring with gravity without being blocked by an inframammary
After the deep dermis is closed, liposuction is easier to incision.
perform because there is some resistance to the tissues
and because it is easier to visualize the final Wise pat- Antibiotics
tern. Liposuction is performed beyond the Wise pattern The breast is often considered “clean” surgery, but it is well
to remove any excess tissue (this must be carved out and known that breast ducts contain bacteria and it may be best to
excised directly in young patients who have more paren- give a prophylactic dose of antibiotics before surgery (usually
chyma and less fat) (Fig. 38.9). Liposuction can also be a cephalosporin). In my experience, when patients are given a
used to reduce fat in the lateral chest wall and preaxillary full week of postoperative antibiotics, almost all problems with
areas. suture spitting disappear. Some of those problems recurred

A B

C D
• Fig. 38.9
Vertical breast reduction. (A–D) A 16-year-old patient who was 5’7” tall, weighed 61 kg and
wore a 32FF brassiere.
Continued

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590 PA RT V Breast

E F

G H
Fig. 38.9 cont’d (E) She had a true superomedial pedicle vertical breast reduction with 398 g removed from
the right breast and 388 g removed from the left breast. She only had a minimal amount of fat removed
with liposuction. (F–H) Postoperative photographs at just over one year. (© Elizabeth J. Hall-Findlay.)

when only a single prophylactic dose was given, but the use Patients are allowed to shower the next day. The paper
of triclosan (an antibacterial, not an antibiotic) impregnated tape will stay in place (without being changed) for 3–4
sutures helped reduce the incidence of suture spitting. weeks.
The pucker at the lower end of the vertical incision may
Taping and Garments swell and protrude for a few weeks and then it will tuck in
The incisions are best managed by covering them with paper under the pillars. Some patients may need a revision but this
tape. Steristrips can be used, but if they are placed across should not be performed for at least 6 months. Because the
the incision, blisters can occur from the shear forces as the parenchyma (and skin) is removed as a vertical ellipse, there
breast swells. Tape should be placed along the incision and is a dog-ear that disappears into the areola and one that can
glue is not necessary. The incisions are then covered with be a nuisance inferiorly. The inverted T, inferior pedicle type
gauze and the patient is placed in a non-compressive surgi- of breast reduction results in a horizontal type of excision of
cal brassiere. It is unnecessary (and ineffective) to tape all skin and parenchyma with a medial and lateral dog-ear –
the breast skin in an attempt to shape the breast. both of which can be a nuisance.

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 CHAPTER 38 Mastopexy and Breast Reduction 591

but to serve as something somewhat substantial to help

suture the flap upwards. Either a superior or superomedial
pedicle can be used with this inferior flap.
A superior pedicle is often used because a concave infe-
rior aspect to the breast will not occur because the central
aspect of the breast is filled with the flap. A superomedial
pedicle can be used if the nipple and areola have a long dis-
tance to travel – where rotation is better than folding.
Ruth Graf33 has described a similar mastopexy but using
a strip of pectoralis muscle to act as a handle to hold the flap
up higher on the chest wall. This does attach the flap to the
chest wall but the remaining breast will still tend to drop
down around the flap, back into its original position. This
flap can improve upper pole fullness to some degree but it
can cause a problem in weight loss patients when the flap
stays up and the breast drops down below the flap. Some
• Fig. 38.10 The inferior wedge that is normally removed in a breast surgeons complain that this procedure puts breast tissue
reduction is shown as an inferior flap left attached to its chest wall-
based blood supply but separated from breast and skin on all four
behind the pectoralis muscle, but in reality all that happens
sides to allow good mobilization. is that a strip of muscle acts as a handle over the breast tissue.

Operative Technique for Vertical Operative Technique for Vertical

Mastopexy Augmentation-Mastopexy
It is important to understand that the skin will not act as a The problem with the inferior flap in a mastopexy-augmen-
good brassiere in a patient who has already developed breast tation is that the blood supply to the inferior flap is dam-
ptosis. An inferior wedge of breast needs to be removed in aged when the implant is placed in either a subglandular or
a breast reduction or small mastopexy. If a patient likes her subpectoral location. The artery and vein to this flap come
breast size, then the inferior wedge of breast tissue needs to up through the intercostal muscles just above the fifth rib
“moved” rather than “removed”. Any attempt to push and and they are cauterized with insertion of the implant. The
hold up the parenchyma with the skin will be doomed to procedure can be performed while preserving the flap but it
failure. is difficult and skin closure can be a problem.
Liacyr Ribeiro6,7,8 describes an inferior flap along with a It is best to perform a “reduction-augmentation” or “plus-
superior pedicle. The flap needs to be separated on all four minus” procedure34,35 when both a mastopexy and an aug-
sides and left as a chest wall-based flap (Fig. 38.10). The mentation are desired (Fig. 38.12). Some surgeons believe
flap can be easily mobilized and moved up the chest wall that the mastopexy and the augmentation involve oppos-
and the medial and lateral pillars can then be closed caudal ing forces, but that is not really the best way to approach
to the flap to hold it up. The flap is sutured up to the chest the problem.36–38 The implant is used to add volume to the
wall long enough that breast tissue will heal to breast tis- upper and central poles of the breast and the inferior wedge
sue. The flap does not heal to pectoralis fascia even when resection is used to take care of the glandular ptosis.
sutured up but it will heal to the overlying breast tissue. The A superior pedicle is often used because a concave infe-
arrows in Fig. 38.10 outline the dermis: it can be seen how rior aspect to the breast will not occur because the central
much mobility this flap has because the dermis originated aspect of the breast is filled with the implant. A superome-
just above the IMF. dial pedicle can be used if the nipple and areola have a long
Any attempt to suture breast tissue to pectoralis fascia distance to travel – where rotation is better than folding.
will either fail or result in scar contracture that will cause Closing the skin under tension is not only unnecessary
the breast to move unnaturally every time the muscle is con- but can lead to wound healing problems. The skin will not
tracted. In normal circumstances, this flap can provide extra act as a good brassiere and skin tension should not be relied
breast projection and can prevent recurrent glandular ptosis upon to hold the implant up. Even a subfascial inferior sling
but it will not result in increased upper pole fullness (Fig. fails to hold up the implant in the long term.1 The ptotic
38.11).1 gland needs to be removed and patients need to understand
The blood supply to this inferior flap is the deep artery that a large implant will be subject to gravity.
and vein from the internal mammary system at the fourth Some surgeons will insert an implant into the subpec-
interspace. It is important to create the flap while being toral pocket, first keeping inferior muscle and fascia intact
careful to preserve the attachments to the chest wall just to close up the pocket completely. They then perform the
above the fifth rib and just medial to the breast meridian. mastopexy so that there is no contact between the implant
The flap is de-epithelialized not to maintain blood supply and the bacteria present in the breast ducts.

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592 PA RT V Breast

A B

C D
• Fig. 38.11 Vertical mastopexy. (A–D) Patient who had a mastopexy using an inferior flap and a superior
pedicle to rearrange (rather than remove) the inferior glandular ptosis.

Complications antibacterial impregnated sutures such as Monocryl Plus.

It appears that larger breast reductions and a higher BMI
The potential complications are basically the same for all may lead to a higher infection rate.
breast procedures: blood loss, infection, necrosis, hematoma, Necrosis: Nipple necrosis is a definite risk inherent in all
seroma, dehiscence, and unsatisfactory esthetic results. breast procedures that involve a transposition of the
Blood loss: It is unusual to need a transfusion or even an nipple and areola complex (Fig. 38.13). The rate is usu-
autologous transfusion for most esthetic breast surgery. ally less than 1%. A good understanding of the blood
Blood loss is higher for the inverted T inferior pedicle supply to the breast will help minimize the risk but the
breast reductions (about 300–400 ml) than a vertical occurrence of nipple necrosis is probably inevitable in
reduction (about 100–200 ml). A vertical mastopexy as any large volume practice. Although there are many rec-
described here has a blood loss of about 100 ml and a ommendations on what to do with incipient necrosis,
vertical mastopexy-augmentation rarely exceeds 100 ml. it is probably best only to intervene if it is possible that
Infection: The breast ducts contain bacteria and breast sur- there is compression causing obstruction on either ar-
gery should not be considered completely “clean”. A sin- terial inflow or venous outflow. The latter may develop
gle dose of prophylactic antibiotics is indicated but post- obvious venous congestion. Once it is clear that some
operative antibiotics should probably only be considered necrosis is likely, it is best to leave things alone and let
when an implant is used. Even this is controversial. In the extent of necrosis declare itself. The nipple areolar
my experience, suture spitting (festering) is a low-grade complex seems to be a “privileged” construct and it often
infection and it can be prevented to some degree by using recovers far better than expected with no intervention.1

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 CHAPTER 38 Mastopexy and Breast Reduction 593

E F

G H
Fig. 38.11 cont’d (E–H) She is shown just over a year after her surgery with better projection and a long-
lasting shape. (© Elizabeth J. Hall-Findlay.)

There are recommendations to remove the nipple–areola enters the breast laterally and courses up into the breast
and apply it as a free nipple graft but this is probably not initially deep peripherally and then in the subcutaneous
indicated in most cases. Removing sutures or taking the tissue. The veins are even more superficial and usually lie
patient back to the operating room to inspect the pedicle just beneath the dermis. Drains do not prevent or treat
for compression may be indicated but the surgeon needs hematomas but they may be indicated if there is an un-
to weigh the potential consequences of action versus in- usual amount of “ooze” that is evident during surgery.
action. Inaction is often a good choice. Seroma: Seromas occur where there is a lot of dead space
Hematoma: All plastic surgery procedures have a risk of he- and where there is some friction between the overlying
matoma. The rate is probably close to 1% of cases. The flap and underlying chest wall. Drains are needed for as
best way to prevent a hematoma is to understand the main long as shearing movement allows friction to occur. This
arterial supply and to check those areas for secure hemo- can range from several days to weeks. Quilting sutures
stasis before closure. There is an artery that comes up at are very effective in the abdomen but somewhat harder
the fourth interspace just medial to the breast meridian to use along the lateral chest wall.
along with some branches appearing laterally as well at Dehiscence: This can occur when sutures fail to hold. More
the fourth interspace. There are some vessels coming up in frequently the problem is excess tension on the closure
the subcutaneous tissue at the level of the IMF and there which leads to constriction of blood supply to the skin
is the superficial branch of the lateral thoracic artery that edges (Fig. 38.14).

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594 PA RT V Breast

A B

C D
• Fig. 38.12 Vertical mastopexy-augmentation. (A–D) Patient shown with a superior pedicle vertical mas-
topexy-augmentation with the implant (Allergan Style 15, each 339 ml) placed in a subglandular pocket.
She did not have much glandular ptosis and only 15 g was removed from the right breast and 25 g from
the left breast.

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 CHAPTER 38 Mastopexy and Breast Reduction 595

E F

G H
Fig. 38.12 cont’d (E–H) 3 years after her surgery. (© Elizabeth J. Hall-Findlay.)

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596 PA RT V Breast

A B

C D
• Fig. 38.13 Nipple necrosis. (A–D) Once established, sometimes nipple and areolar necrosis heals surpris-
ingly well without intervention. The photos were taken at 2 weeks, 6 weeks, and 3 months postoperatively.
(© Elizabeth J. Hall-Findlay.)

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 CHAPTER 38 Mastopexy and Breast Reduction 597

A B

C D

E
• Fig. 38.14 Dehiscence. Sometimes a dehiscence is best left alone for healing by secondary intention. (©
Elizabeth J. Hall-Findlay.)

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598 PA RT V Breast

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Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.