Maliniac ¹ in 1943 performed cadaver injections in 103 female breasts followed by roentgenographic studies. Mathes² used latex and barium injections and dissections to further define the blood supply. His studies showed the main sources of blood supply to the breast (Fig. 13.1A, B) to be from:

1. Medial perforating branches of the internal mammary artery (IM). (Major source of blood supply to medial-based flaps.)

2. Lateral thoracic artery (LT). (Major source of blood supply to laterally based flaps.)

3. Thoracoacromial artery (TA). (Major source of blood supply to superior-based flaps, and also contributes to lateral and inferior flaps.)

Fig. 13.1 An anatomic dissection performed by Dr. Stephen Mathes showing the vascular anatomy of the breast.

A The medial portion of the breast is reflected off the pectoralis muscle towards the midline and the black dots show the segmental branches of the internal mammary artery in the medial breast. The purple dots which are harder to see are on the reflected lateral portion of the breast and represent branches of the lateral thoracic artery as they enter the lateral breast. B A selective barium latex injection into the three arteries, internal mammary (IM), lateral thoracic (LT), and thoracoacromial (TA). These demonstrate the individual contributions of these arteries to the breast circulation.

These studies, in addition, identify direct communications of the vascular network between the terminal branches of the lateral thoracic artery, the internal mammary artery, and the musculocutaneous branches of the thoracoacromial arteries and associated veins (Fig. 13.2).

Fig. 13.2 The Gross specimen is represented radiographically. This demonstrates the vascular connections between the internal mammary (IM), the musculocutaneous perforators from the thoracoacromial (TA), and the lateral thoracic (LT) arteries. Note the interconnections of the three vascular systems at the nipple areola.

These findings allow the surgeon versatility in determining of the orientation of the dermoglandular flap for the vascular support of the NAC.

Functional anatomy (lactation and innervation)

Before describing the various flaps we need to consider the pertinent anatomy of the breast parenchyma and the innervation of the nipple. The simplified version of breast parenchyma is that 10–100 alveoli comprise a breast lobule. Multiple lobules form a single lobe. Each lobe is drained by 15–20 lactiferous ducts. The end of a duct dilates becoming the lactiferous sinus which empties into the nipple. The nipple is composed of two layers of circular and longitudinal smooth muscle the contraction of which makes the nipple firm, erect and allows milk to be emptied from the lactiferous sinuses.⁴ The lobules are attached to the skin by dense fibrous bands termed Cooper’s ligaments. The breast is firmly fixed to the skin in the area of the areola.

Common sense tells us that there must be adequate parenchyma in the nipple bearing flap for sufficient milk production, and that the milk must have an intact pathway to the nipple which must be innervated so that it can become erect and empty on demand. It stands to reason that broader, thicker flaps will produce and transport more milk than narrower thin flaps. This is not to say that all or even most of the women undergoing reduction mammaplasty will want to be able to lactate postoperatively. It is however, the reason that surgeons whose primary technique greatly reduces or eliminates the possibility of breast feeding, should have the versatility required to employ a technique that retains normal breast function.⁶

Innervation

Nipple

Most authors agree that nipple sensibility is primarily derived from the lateral cutaneous branch of the fourth intercostal nerve ³ (Fig. 13.3). Lesser contributions are made by the anterior cutaneous branches of the third, fourth, and fifth intercostal nerves and the third and fifth lateral cutaneous branches.

Fig. 13.3 Lateral cutaneous branch of the fourth intercostal nerve going directly to supply the nipple.

Reproduced from Cooper A. The anatomy of the breast. London: Longman; 1840.

Skin

Innervation of the skin is not really a matter of practical concern in reduction mammaplasty because it comes superficially from all directions. The nerves are: (1) the supraclavicular branch of the cervical plexus from C3 and C4, (2) the lateral cutaneous branches of the anterior thoracic intercostal nerves, and (3) the anterior perforating cutaneous branches of the intercostal nerves.^4,^5,⁷

Fascia

The body’s superficial fascia system invests the breast parenchyma with a superficial and deep layer.⁷ The superficial layer has the same important role in reconstituting the breasts during reduction mammaplasty as does the superficial muscular aponeurotic system (SMAS) in the face and neck and Scarpa’s fascia in the abdomen during the rhytidectomy and abdominoplasty respectively. This superficial layer of fascia is immediately deep to the subcutaneous fat and needs to be incorporated in the medial and lateral limbs as it is the repair of this fascia that takes the tension off the skin closure, presumably resulting in a more favorable scar. Superficial fascia repair should be performed on all incisions except the periareolar which is repaired with deep dermal sutures.

The posterior layer of the superficial fascia is on the deep surface of the gland. Between it and the fascia of the pectoralis major muscle is the well defined retromammary space, which contains loose areolar tissue and allows the breast to glide freely over the chest wall.⁷

As breast parenchyma increases in volume it acts as an internal expander. The skin stretches in response to the parenchymal expansion. The hypertrophy is usually greatest in the lower portion of the breast where the force of gravity is maximum. The most dependent area of the breast is the broadest and heaviest and the skin expansion the greatest.

Skin marking patterns and scars

The skin envelope needs to be reduced in both the vertical and horizontal directions. Incision planning to accomplish this skin reduction varies greatly. It can be accurately planned requiring little or no intraoperative adjustment; it can be done more or less freehand by intraoperative maneuvering, or a combination of both. With minor variations the vast majority of incisions will result in scars that fall broadly into three configurations.

These basic configurations with multiple variations resulting in one or more of the following scars (Fig. 13.4A, B, C):

Configuration #1 – Circumareolar.

Configuration #2 – Circumareolar plus descending from the areola vertically to the level of the IMF.

Configuration #3 – Circumareolar plus descending vertically to the IMF plus a horizontal scar in or above the original IMF.

Fig. 13.4 A Configuration #1, or the circumareolar suture line following periareolar reduction mammaplasty. B Configuration #2 demonstrating the circumareolar plus vertical skin closure following vertical reduction mammaplasty. C Demonstrates circumareolar, vertical and inframammary incision closure in Configuration #3 or the ‘Wise pattern’ reduction mammaplasty.

Analysis of the three configurations

Configuration #1 requires excision of excess periareolar skin in a circular, oval or elliptical manner. The resultant defect has to be reduced with a running gathering or pursestring suture so that the skin opening nearly matches the circumference of the reduced NAC.

Configuration #2 employs more limited (as compared to Configuration #1) periareolar de-epithelialization, excision of skin and parenchyma from between the medial and lateral limbs in the lower portion of the breast, and subcutaneous parenchyma excision, and/or suctioning, below the medial and lateral limbs to the IMF. Excess vertical skin is dealt with by either: gathering sutures to shorten the length of the vertical scar or leaving a ‘dog ear’ or pucker which is either allowed to improve spontaneously or is excised resulting in a limited horizontal scar.

Configuration #3 incorporates the periareolar de-epithelialization similar to Configuration #2, excision of skin and parenchyma between the medial and lateral limbs, and excision of skin and parenchyma in the horizontal direction in the lower portion of the breast resulting in a scar in the IMF.

Analysis of Surgery Resulting in Configurations 1, 2, and 3

Configuration #1 ⁸

These diagrams demonstrate the oval skin and outer areola de-epithelialization pattern; the creation of a superior based flap with a crescent of parenchyma excised (Fig. 13.5A), the extent of which may be expanded to include tissue from the inferior, medial and lateral aspects of the breast (Fig. 13.5B). The medial and lateral glandular flaps are developed and crisscrossed under the superior based NAC flap (Fig. 13.5C, D). The superior (12 o’clock) aspect of the areola is then sutured in a subdermal window to the skin (gently folding the flap pedicle) and thus preventing enlargement of the scar (Fig. 13.5E) Lacing sutures traversing the entire thickness of the breast diameter support the conical shape of the breast and allows control of the NAC projection (Fig. 13.5F).

Fig. 13.5 Circumareolar approach.

A Subcutaneous dissection freeing the skin from the parenchyma after de-epithelialization of a superior based flap and crescent excision of parenchyma. The extensive subcutaneous dissection is necessary to facilitate the pursestring closure. B Medial and lateral flaps developed below the superior flap as well as the areas of resection in the circumareolar reduction.C Medial flap being sutured to the pectoralis under the superiorly based nipple–areolar flap prior to D the crisscrossing of the lateral flap. E Suturing of the superior aspect of the nipple–areolar complex to strong fixation to the deep dermis of the pocket to stabilize the nipple–areolar complex in that position prior to the pursestring suture. F Lacing sutures that are accomplished with the use of a long slightly curved needle supporting the conical breast. These are large inverting sutures of 2-0 Mersilene. The sutures traverse the entire thickness of the breast diameter.

Advantage of Configuration #1: the sole advantage, in the author’s opinion, of the periareolar reduction mammaplasty is that it limits the postoperative scar to the periareolar area.

Disadvantages of the periareolar reduction mammaplasty are:

1. There is a very steep learning curve in creating a circumareolar scar trying to match a larger circular or oval skin defect to the smaller diameter of the areola. The large defect occurs because in this technique all of the excess skin and areola have to be excised in the periareolar area.

2. Gathering pursestring closure of the defect leads to a flattening of the breast secondary to the tension created by the skin on the breast tissue.

3. To overcome or prevent the flattening, creative work must be performed on the parenchyma in the form of crisscrossing glandular flaps sutured as an inverted T to produce a conical shape. The separated skin must be redraped over the cone in a tension free manner after having been dissected uniformly.

4. After the crisscross of glandular flaps it is often necessary to reinforce the conical shape by traversing the entire thickness of the breast diameter with lacing sutures, avoiding strangulating tension.

The proponents of this procedure have gained a degree of skill in this technique that the average plastic surgeon has found difficult to achieve. After an initial flurry of enthusiasm to utilize the periareolar procedure many have abandoned it. I am reluctant to criticize any technique that I have not tried to master. My initial bias against the technique was caused by the severe flattening created by the tension that the pursestring periareolar closure exerted on the breast mound. Benelli ⁸ and Goes⁹ have overcome this by manipulating the breast mound with maneuvers such as crisscross flaps, lacing sutures, encompassing mesh, and extensive subcutaneous dissection to achieve aesthetically pleasing breasts. They appear to have succeeded by converting a compressible breast into a fixed, firm breast which resists the pressure of tight skin.

Configuration #2

Advocates of vertical mammaplasty use primarily the mosque shape or the open circle for the neonipple–areola site (Fig. 13.6D) The nipple site is centered to correspond to the meridian of the breast with the superior border of the areola located at the level of the IMF. The markings from the lower edge of the nipple–areola site make use of the meridian line as it projects on the upper abdominal wall and the breast is maneuvered medially and laterally to determine the edges of the medial and lateral limbs (Fig. 13.6A, B

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