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); and also to determine how much tissue (skin and parenchyma) will be excised between the limbs. The incision pattern is rounded off 2–5 cm above the IMF (Fig. 13.6C) to protect against the lower end of the final scar projecting below the IMF and also to raise the level of the IMF.

Fig. 13.6 Vertical approach.

A, B Medial and lateral markings made in continuity with the markings of the meridian of the breast and are accomplished by mobilizing the breast medially and laterally. C Lower curved marking above the inframammary fold. D Mosque shaped marking designating the new NAC complex site.

(Adapted from Lejour.¹¹)

Vertical mammaplasty surgeons with one notable exception ¹⁰ use either superior¹¹, medial,¹² or lateral¹³ flaps. It is suggested that the length of a superior based flap should not exceed 10 cm as folding it can lead to vascular impairment. Indeed, if a superior based flap is going to be greater than 10 cm in length, Lassus will use a lateral based flap.¹³

Advantages of the vertical mammaplasty are:

1. Elimination of the horizontal scar in the IMF.

2. It gains breast projection as a result of suturing medial and lateral parenchymal limbs (pillars) from the lower edge of the NAC to the inferior parenchymal border. This is facilitated by creating a parenchymal defect in the central lower portion of the breast inferior to the lower edge of the pillars.

3. The vertical mammaplasty pattern is ideally suited for superior, medial, and lateral pedicles and nipple transplantation. Hammond ¹⁰ has modified the inferior pedicle technique to accommodate the vertical mammaplasty pattern.

4. It raises the IMF. Authors extolling the virtues of the vertical mammaplasty technique cite this as one of the main advantages. I am not sure that the elevation of the IMF is necessary or even desirable in all cases. Some breasts appear short and the NAC higher than normal. It has never been clear to me how the IMF is raised uniformly along its entire length unless the parenchyma beneath the lower border of the medial and lateral limbs is excised the full extent of the IMF and skin contracts uniformly along that entire fold. I believe this accounts for the reason that some of the vertical mammaplasties that I see have a rather straight IMF rather than the natural curvilinear one.

Disadvantages of configuration #2

1. Some skin gathering technique is necessary: either in the vertical limb portion of the skin closure; or the periareolar portion; or by creating a purposeful dog ear or pucker at the lower end of the vertical scar which is allowed to settle.

2. Most marking techniques that result in Configuration 2 create nearly parallel or moderately diverging vertical medial and lateral limbs. It seems to be more natural to have diverging limbs because the lower portion of the breast is wider and more tissue needs to be removed to correct this increased breadth.

Configuration #3

Patterns to fit different sized breasts were described by Wise in 1956 ¹⁴ (Fig. 13.7). His concept has been simplified by the adjustable McKissock keyhole breast marker (Fig. 13.8). The marker can be opened more widely for broader bigger breasts and can be adjusted to compensate for asymmetry (Fig. 13.9). The retained tissue is equal on both sides. The top of the new NAC site should be at the level of the IMF and should bisect the breast rather than be on a direct line with the existing NAC if it is displaced, as it is in the right breast of this patient (Fig. 13.9). The most common error is for the nipple to be placed too high on the chest wall. This error can occur in all three configurations. It can be due to: (1) retraction of skin that was stretched preoperatively secondary to the heavy weight of the breast; (2) the medial and lateral vertical parenchymal limb closure pushing the nipple upward; (3) postoperative settling of parenchyma; (4) restretching of the vertically gathered skin in vertical mammaplasty; and/or (5) simply marking it too high on the chest wall. One way to ensure that the top of the areola is at the IMF is shown in Fig. 13.10.

Fig. 13.7 Inverted ‘T’ approach. Use of the Wise pattern marking on the right breast.

The pattern is reversed when used on the left breast. Note that the divergence and separation of the medial and lateral vertical limbs is determined by the pattern. This necessitated having several patterns for different sized breasts.

Fig. 13.8 The metal McKissock keyhole pattern marker opening can be spread or narrowed, as necessary, to accommodate to different sized breasts without changing the angle that the medial and lateral vertical limbs make with the lower edge of the partially opened circle.

Fig. 13.9 The application of the marker adjusted to asymmetric breasts is demonstrated.

Note the symmetrical preservation of skin and parenchyma above the markings.

Fig. 13.10 The best way to determine the new level of a nipple–areolar complex.

By placing a tape measure in the inframammary fold under one breast and then bringing it directly across the anterior surface of the opposite breast and securing it over the arms, automatically transfers the level of the inframammary fold to the opposite breast. This then becomes the superior point of the new nipple–areolar complex site. A second tape measure draped around the neck and allowed to hang down bisecting the breast in its true meridian allows the location of the nipple–areolar complex in the proper meridian access. Point 1 diagrammed on the right breast represents the transfer of the lowest point of the inframammary fold from the opposite breast. The inframammary fold is not a straight line, it is a curvilinear line and the top of the NAC site should be at the lowest point of the inframammary fold. Point 2 on the right breast is a line connecting the two poles of the breast in the meridian as it divides the breast to establish the line on which the nipple–areolar complex is to be located.

The breadth of the breast determines the spread of the vertical limbs in the McKissock breast marker pattern. The broader the breast the greater the spread (whereas in Configuration 2 the vertical lines are parallel or moderately divergent throughout).

Determination of the length of the scar in the IMF. It is necessary to excise skin between the diverging medial and lateral limbs as well as below the limbs to the IMF (see Fig. 13.20A) The broader the breast the longer will be the scar in the IMF. It should be short enough to avoid it being seen medially in the cleavage area or laterally in the anterior axillary line. It is always shorter than the full length of the IMF.

The McKissock adjustable keyhole skin marking device provides versatility in application of a Wise like pattern by being able to spread the medial and lateral arms more widely as the breadth of breast increases. The adjustable skin marker can be used for any flap design the surgeon prefers.

Advantages of Configuration #3:

1. The McKissock keyhole pattern provides an open circle for the new nipple site. It is easiest to fit a round NAC into a circular new nipple site than one that is oval, elliptical, or mosque shaped.

2. The ease of spreading the medial and lateral limbs allows for resection in the transverse direction of the skin and breast tissue where the breast is widest.

3. This configuration allows for excision of skin and breast tissue along the entire lower aspect of the breast as well as any other portion of the breast that a particular flap pattern calls for. Precise planning without intraoperative adjustment is made easier by virtue of having the length of the lower border of the medial and lateral limbs exactly the length of the predetermined incision in the IMF.

Disadvantages of Configuration #3:

1. The obvious disadvantage is the horizontal scar in the IMF. Of the three scar components, (periareolar, vertical, and horizontal) the scar in the IMF is the most likely to hypertrophy. Every effort should be made to eliminate tension on the skin closure by strong subcutaneous (superficial fascia) closure.

2. Critics claim that Wise pattern relies on the skin closure to shape the breast. I believe this criticism to be unjustified if the surgeon properly approximates superficial fascia of the medial and lateral limbs.

3. Hall-Findlay ²³ states that using the Wise pattern technique (Configuration #3) ‘the IMF drops with time.’ I find this conclusion tenuous and believe that breast tissue, particularly in the inferior pedicle technique, can settle and become more dependent even as it was preoperatively but the IMF which was not altered at the time of the previous surgery remains in its original position.

Hybrids of Configurations #2 and #3 (Table 13.1)

Marchac ²⁴ (Figs 13.16, 13.17, 13.18) in a widely referenced publication has modified the traditional Configuration #2 or vertical mammaplasty markings to include a short (up to 7–8 cm) horizontal scar above the inframammary fold. In all other aspects he is a strict adherent to the superior based vertical mammaplasty technique.

Table 13.1 Comparison of Configuration 3 (Wise pattern) to Configuration 2 (vertical): different described techniques

	Configuration 3	Configuration 2
A. Horizontal bipedicle	Strombeck¹⁵
B. Vertical bipedicle	McKissock¹⁶
C. Superior pedicle	Weiner¹⁹	Lassus¹³ Lejour¹¹
	Marchac¹⁹ Nahai³⁰
D. Inferior pedicle	Courtiss²²	Hammond¹⁰
E. Lateral pedicle	Skoog³¹	Lassus¹³
F. Medial pedicle		Hall-Findlay¹²
G. Nipple transplantation	Gradinger¹⁷ and Cassis²⁰
H. Superior medial	Hauben²¹

Fig. 13.16 Lateral based flap utilizing the vertical mammaplasty marking technique or Configuration #2 as advocated by Lassus.¹³

Fig. 13.17 Lateral based dermoglandular flap in combination with the Wise pattern reduction markings as advocated by Skoog.³¹

Fig. 13.18 The markings are made on the operating table, the patient being in the semisitting position.

A The axis of the breast corresponds to the vertical of the desired nipple position and is located 8–10 cm from the midline. B The upper limit of the breast is self-evident when the breast is lifted up. C The inner side of the vertical resection is determined by pushing the breast laterally, keeping some fullness medially, and drawing a line in continuity with the axis of the breast. D The same maneuver is done laterally. E The horizontal inferior line d–e is usually located 5 cm above the inframammary fold. The hatched area located below represents the skin that will be resected at the final adjustment. There is, therefore, only about 2 cm of skin not resected above the inframammary fold. Point a is located at the summit of a curve joining b to c slightly above the areola. Note an indent of 0.6 to 0.8 cm made at the level of b and c to diminish the tension of the suture below the areola.

Redrawn from Marchac D, DeObest G. Reduction mammaplasty and correction of ptosis with a short inframammary scar. Plast Reconstr Surg 1982;59:45.

Hall-Findlay ¹² uses the advantages of the diverging limbs provided by the Wise pattern (Fig. 13.19), but rather than extending the incision medially and laterally at the base of the limbs she rounds it off at the bottom to end above the IMF and uses a gathering suture for closure which results in somewhat of a pucker at the level of the new IMF and relies on nature to flatten this with time. Both of these authors present their work with great clarity and I feel have incorporated the advantages of Configuration #2 and Configuration #3.

Fig. 13.19 Medial based dermoglandular flap in combination with a vertical pattern. Skin marking utilizing vertical mammaplasty but adopting the diverging medial and lateral limbs as part of the Wise pattern.

A Skin markings for vertical reduction mammaplasty with a medially based pedicle. The markings for a standard Wise pattern are included for comparison. This demonstrates what the marking would be if the Wise pattern were completed rather than the elongation of the medial and lateral limbs rounded out above the inframammary fold. B The extent of inferior glandular resection corresponds with the skin resection with the Wise pattern. C De-epithelialization of the superomedial pedicle is illustrated along with excision of skin and parenchyma above and below the pedicle. The area where breast tissue is excised and liposuctioned is indicated above the IMF.

Redrawn from Hall-Findlay EJ Vertical breast reduction with medially based pedicle. Aesth Surg J 2002;March/April:185.

Other marking configurations

Variations of ‘lateral’ approach,²⁵^,²⁶ the B technique,²⁷ and the L-shaped suture line²⁸ have been published by highly respected surgeons. A review of these articles show excellent results. It is beyond the scope of this chapter.

Nipple-bearing flaps

As already discussed under Anatomy, Mathes showed that the surgeon can orient the base of the nipple-bearing flap in practically any direction on the breast if sound flap principles are followed and a well nourished NAC will result. The base of the nipple-bearing flap, regardless of its orientation, can be adapted to either the vertical mammaplasty technique (Configuration #2) or the Wise/McKissock (Configuration #3) skin marking technique. The sole exception to that is a broad based inferior pedicle nipple bearing flap is very difficult, if not impossible, to use in the vertical mammaplasty marking technique. What follows is a review of the orientation of various nipple-bearing flaps that have been popularized.

A The horizontal bipedicle flap as described by Strombeck,¹⁵ (Fig. 13.11) was the first technique that allowed for safe reproducible one stage reduction mammaplasty procedures. The circulation to the NAC resulting from the horizontally oriented bipedicle flap was reliable, the skin flaps were not in jeopardy. The reason this procedure lost favor was that if the pedicle was long the parenchyma would ‘bottom out’ or drop and assume an inferior position as time passed. If the pedicle was too short, it was difficult to maneuver the NAC into position in the keyhole. There was also a tendency for loss of nipple projection.

B The vertical bipedicle flap: McKissock,¹⁶ (Fig. 13.12) adapted the bipedicle principle expounded by Strombeck and rotated the orientation of the pedicle 90°, to the superior/inferior direction. This procedure has remained popular and has stood the test of time. Its major advantages are that it has a safe blood supply to the NAC, and that it retains tissue in the most needed portion of the breast superiorly and allows for removal of a large portion of the tissue in the heavier part of the breast inferiorly. The pedicle is independent of the medial and lateral limbs which can be left to the desired thickness and the superficial fascia can be sutured on top of the inferior pedicle to take tension off the skin closure. Most surgeons who use this technique use the Configuration #3 skin markings (Wise pattern markings).

C The superior pedicle flap: This seems to be the favorite pedicle orientation of European and South American plastic surgeons. Its major advantages are that it allows the surgeon to resect parenchyma from the heaviest portions of the breast inferolaterally. The medial and lateral limbs can be left as thick as the surgeon wishes and provide bulk to the breast by suturing them together in a vertical fashion bringing the skin of the medial and lateral limbs together for a closure without tension. The superior flap is equally adaptable to either skin marking be it the vertical mammaplasty marking ¹¹ (Fig. 13.13), or the Wise pattern marking¹⁷ (Fig. 13.14). If the NAC has to elevate more than 9–10 cm there is the risk of interference with circulation when the flap is folded. Because of this, Lassus recommends switching from the superior based flap to the lateral based flap if the flap is over 9 cm in length.

D The inferior pedicle flap: North American plastic surgeons who are more inclined to use the Wise pattern skin marking technique or its modification, also tend to favor the inferior pedicle ²² (Fig. 13.15). The inferior pedicle has a robust blood supply. In my opinion it provides the best pedicle for retaining nipple innervation and adequate parenchyma in continuity with the nipple to preserve functional lactation. Its major disadvantages are: (1) a tendency to ‘bottom out’ resulting in the breast appearing bottom heavy; (2) this increases the distance from the NAC to the IMF which causes the nipple to appear to be too high; and (3) a horizontal scar in the IMF at least as long, and usually longer, as the width at the base of the pedicle (approximately 8 cm). Suturing the pedicle to the pectoralis fascia² seems to minimize the bottoming out and the stretching of the vertical scar.

E The lateral pedicle flap: This flap can have primarily a dermal pedicle as advocated by Skoog³¹ who uses it in conjunction with a Wise pattern (Fig. 13.17) or a dermal glandual pedicle as advocated by Lassus¹³ and Blondeel.³² Lassus uses it in conjuction with a vertical mammaplasty pattern (Fig. 13.16) whereas Blondeel uses a hybrid (vertical plus horizontal IMF scar). If one uses a robust lateral flap, innervation to the nipple is preserved. The disadvantage of the lateral flap is that most patients want to get rid of the heaviness in the lateral aspect of the breast, a feat more easily accomplished with other flap orientations.

F Vertical mammaplasty with a short horizontal scar (Fig. 13.18): This procedure has appeal because it is a sensible way of eliminating skin in the vertical direction. It uses a superior pedicle, it creates medial and lateral pillars which are approximated in layers and it raises the inframammary fold in all cases. I do not understand the need to, or the virtue of, raising the IMF in every patient. The footprint of the breast does not change with hypertrophy so why alter it?

G Vertical mammaplasty with a medial pedicle (Fig. 13.19): Hall-Findlay¹² has rationally combined the concepts and applications of the vertical pattern and the Wise pattern while modifying both. She plans as if she would use the Wise pattern (Configuration #3) but then eliminates the tapered vertical skin excision to avoid a scar in the IMF. The medial based flap allows unlimited resection of parenchyma in the heavy lateral aspect of the breast. (I suspect that it does so with sacrifice of some nipple sensation, projection and erectility.) It preserves parenchyma medially, which is good. The net result is, few women complain of too much cleavage or too little fullness in the centre part of the breast.

Fig. 13.11 Horizontal bipedicle flap as designed by Strombeck.¹⁵

Fig. 13.12 Vertical bipedicle flap as designed by McKissock.¹⁶

Fig. 13.13 Superior based pedicle flap as utilized in vertical mammaplasty or Configuration #2. After Lejour.¹¹

Fig. 13.14 Superior based flap as used by Weiner ¹⁹ in combination with Configuration #3 or Wise pattern type of skin marking.

Fig. 13.15 Inferior pedicle flap as utilized in the Wise pattern ¹⁴ reduction markings.

Note that the flap itself contributes the main portion of the bulk of the breast to the thinned, particularly lateral flaps.

Free Nipple Graft

Advantages of the free nipple graft ^17,^18,²⁰ (Fig. 13.20)

1. Offers an opportunity to achieve excellent breast shape without having to consider the elevation or rotation of a nipple-bearing flap.

2. Allows for precise excision of breast tissue where it is heaviest without concern for preservation or innervation of, or circulation to, the NAC.

3. Does not result in distortion of breast tissue.

4. Requires no skin undermining.

5. Removes the tissue most prone to developing breast cancer (that breast tissue immediately deep to the NAC and adjacent to it. This is an especially important consideration in doing unilateral reduction mammaplasty on a woman who has been treated for cancer of the opposite breast.).

6. Gives long-lasting predictable results with minimal concern for distortion or settling.

Fig. 13.20 Free nipple graft.

A View of the markings from underneath. Note that B + B′ = A, which is approximately 10 cm in length. Points 1, 2 and 3 as shown are now seen from the undersurface of the breast. Note that the length of B and B′ was determined by how widely it was necessary to open the Wise pattern so that when added together they would be the same length as A. The other point to note on this series of markings is the proposed inferior mound which will act as a buttress. B Resection of the breast tissue in a perpendicular fashion with relation to the flaps and their medial margins and retention of the de-epithelialized breast mound. C The initial sutures are shown, and the inferior closure is started at the medial and lateral ends rather than in the middle so that any differences can be adjusted without extending the incision. D, E Closure before and after suturing of the graft.

Redrawn from Gradinger GP. Breast reduction with the free nipple graft technique. In: Spear SL, editor. Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven; 1988, p. 807–21.

Disadvantages of the free nipple graft technique

1. Elimination of pleasurable sensation.

2. Elimination of the ability to breast feed.

3. Hypopigmentation of the nipple, particularly in people of color (Fig. 13.21). Superficial nipple necrosis is anticipated in every free nipple graft because of the thickness of the graft (Fig. 13.22). The nipple usually regains erectility because the smooth muscle layers of the areola and the nipple are included in this composite graft.

4. Flat appearance of the lower portion of the breast. If the medial and lateral limbs are substantial flattening can be avoided. Other techniques can be utilized, such as retention of breast tissue between the medial and lateral limbs in cases of very ptotic atrophic breasts or retention of a mound of tissue just above the inframammary fold that is de-epithelialized and used as a batten behind the medial and lateral limb closure. Free nipple grafting should be reserved for those women who do not have pleasurable nipple sensation preoperatively and have no wish to breast feed a baby in the future.

Fig. 13.21 Postoperative free nipple graft procedure in an African-American woman with hypopigmentation not only of the nipple but of a portion of the areola bilaterally. This can be treated either with areolar punch grafts from the dark areas of the areola or with tattooing. It does represent a major drawback in free nipple grafting in people of color. A The risk of hypopigmentation can be lessened by thinning the areola and, most importantly, removing all of the smooth muscle fibers by ‘coring’ out the nipple to enhance the ‘take’ and decrease (eliminate) superficial necrosis. The trade-off of these maneuvers is a loss of nipple projection and erectility. B Punch grafts from areola to hypopigmented nipple. C Final result of grafting

(Courtesy of Dr. Roger Friedenthal).

Fig. 13.22 A 43 year old women sought reduction mammaplasty because of neck and shoulder pain secondary to breast hypertrophy. A Preoperative frontal view. B Demonstrates the superficial necrosis of the nipple at three weeks following free nipple transplantation. Every patient is advised that this will happen and that it will take six to eight weeks for the nipple to heal. C Preoperative lateral view. D Three years postoperative. E Three year postoperative lateral view.

Conclusion

In this chapter I have attempted to present those techniques which appear most widely in the literature and seem to be most popular among plastic surgeons. As Goldwyn ²⁹ stated in his classic textbook on reduction mammaplasty ‘if, indeed reduction mammaplasty was simple and an excellent result were automatic, the need for this book detailing various concepts and techniques would not have been necessary… while not flitting from one technique to another like a butterfly the surgeon would be wise to have in his or her repertoire two or three procedures along with their variations in their execution.’ Quoting Goldwyn further ‘a surgeon may believe that one method fits every patient, the reality is that the surgeon may be trying to fit every patient to a single procedure.’

The flip side of making a case for versatility is that a surgeon should first learn to do one technique well. I saw an advertisement of a father struggling to change an infant’s diaper. The caption was: REPETITION first instills COMPETENCE, then CONFIDENCE. This is certainly true of surgical training. It is the confidence that comes with learning one technique well that influences surgeons to stick with that technique. It is only with expanded experience that we broaden our approach and adopt other established techniques and begin to think ‘outside of the box’ ourselves.

In reviewing many, many articles while writing this chapter, I was struck by the similarity of appearance of postoperative results where authors had used widely varying techniques. I experimented with randomly opening books, looking at postoperative results and trying to guess which procedure had been used to achieve this result. Often I was incorrect. My conclusion was that surgeons with great experience reporting on their experience achieve very similar results. This reinforces the notion that there are certainly many ways of performing reduction mammaplasty well.

I have purposely limited the bibliography to those authors that I have referenced in the text. I found reading each of them educational.

References

1 Maliniac JW. Arterial blood supply to the breast. Arch Surg. 1943;47:329.

2 Mathes ST, Schooler W. Inferior pedicle reduction techniques. In: Mathes ST, editor. Plastic surgery, Vol 6. Saunders-Elsevier; 2006:601. chapter 137

3 Cooper A. The anatomy of the breast. Longman, London, 1840, in The breast, principles and art edited by Spear, SL. Pertinent anatomy of the breast reduction mammaplasty, Golden edition. Philadelphia: Little Brown; 1990. p. 17

4 Haagensen CD. Anatomy of the mammary gland. In Diseases of the breast, 2nd ed, Philadelphia: Saunders; 1971:4-20.

5 Moore KL. The developing human. In Clinically oriented embryology, 2nd ed, Philadelphia: Saunders; 1977:379-380.

6 Gradinger G. Is there virtue in versatility in reduction mammaplasty? Aesth Surg J. 1997;17(5):308-315.

7 Rehman I. Embryology and anatomy of the breast. In: Spear SL, editor. The breast. St. Louis: Mosby; 1978:3-21.

8 Benelli LC. Periareolar Benelli mastopexy and reduction. In: Spear SL, editor. The breast, principles and art. Philadelphia: Lippincott-Raven; 1998:685.