The purpose of the examination is to identify those anatomic relationships that are potentially likely to influence the final result and develop a surgical plan designed to deal with them. To that end, the exam begins with a notation regarding the height and weight of the patient. In particular, the weight is best documented on an in-office scale that remains constant over time. It is best to weigh each patient the same way every time to provide the most consistent result. It is my practice to weigh each patient in her undergarments and changing gown to remove clothing as a confounding variable. In this fashion, there can be no question as to how the weight of the patient has changed over time. This can be an issue for patients who gain or lose significant amounts of weight postoperatively and note a change in the size or shape of their breast. Having this information for review can help the patient understand how her change in body habitus may have affected the breast. Also, documentation of the patient’s weight over time can protect the surgeon should any medicolegal issues develop postoperatively.

Many patients, particularly those with significant macromastia associated with varying levels of obesity, present with a very wide breast base diameter that extends in a diffuse fashion onto the lateral chest wall. In many cases, the base diameter of the breast is not only wide but asymmetric as well (Figure 7.4). Making note of this aspect of breast shape can direct appropriate attention to managing each breast in a slightly different fashion using a preoperative plan that narrows the wider breast to a greater degree than the opposite narrower breast. Also, liposuction recontouring of the lateral chest wall fullness can be used to recreate proportion between this area and the reduced breast. It is advisable to discuss the need for lateral liposuction ahead of time with the patient as this aspect of the procedure can lead to additional swelling and ecchymosis over and above that seen with a standard breast reduction procedure.

Figure 7.4 (A,B) Significant asymmetry in breast base width, as demonstrated in each of these patients, can profoundly affect the eventual result after breast reduction, particularly if the same pattern is used on each side. To obtain the best symmetry, a more aggressive skin resection will be required on the wider side to narrow the breast to the desired degree.

The contour of the upper pole of the breast is assessed for any degree of concavity. Should there be a lack of fullness in the upper pole, direct surgical recontouring with internal suture suspension will be required to provide the optimal result and this must be factored into the overall surgical plan (Figure 7.5).

Figure 7.5 (A,B) In patients with excessive ptosis, a lack of fullness in the upper pole of the breast can often be noted. In these patients, restoration of an aesthetic upper pole contour is best accomplished with internal suture plication to reposition the breast superiorly to recreate upper pole fullness.

In patients with severe macromastia, the weight of the breast along with the expansion of the skin envelope can be so severe that ischemic changes can be noted in the most dependent portion of the breast. Often these changes can be seen as a dull rubor present in the skin along with the presence of a dilated capillary network (Figure 7.6). Such changes are indicative of a reduced capacity for these tissues to tolerate surgical manipulation and serve as a marker for increased risk of wound healing difficulties and possible NAC ischemia. Making note of these changes can allow the surgeon to alter the technique of reduction as needed and also allow adequate preoperative counseling to be done to appraise the patient of her risk for complications.

Figure 7.6 In patients with profound macromastia, the weight of the breast can be of sufficient magnitude so as to create a relative ischemia in the most dependent portion of the breast. This often manifests as a dependent rubor with a dilated capillary network being visible through an atrophic and thin cutaneous cover. Such patients are at risk for postoperative complications including ischemia and possible necrosis of the skin, fat and NAC.

It is possible to gauge the consistency of the breast via palpation and use this information as a guide to the amount of fat that is present. Fibrous parenchyma can easily be distinguished from the softer and more compliant superficial fat as the fibrous tissue has a lobulated or ‘cobblestone’ texture that can be detected through the skin. Distinguishing between a breast that has been largely replaced by fat versus a fibrous breast can help predict how easy it will be surgically to reshape the reduced breast. Typically, a breast with a higher percentage of fibrous tissue is more difficult to dissect accurately and is less forgiving during shaping than a fatty breast. Anticipating these factors ahead of time can help the surgeon prepare for the challenges each particular patient may present at the time of surgery.

Finally, any asymmetry in the size and shape of the breasts, the level of the inframammary fold (IMF) and the position of the NAC are noted. To assess these relationships it is helpful to stand several feet away from the patient as she stands comfortably upright and observe the overall appearance of the breasts. At times it requires a careful and considered side to side comparison, but often subtle differences in the volume or shape of the breasts can be identified. When asymmetries are noted, they often come as a complete surprise to the patient and it can sometimes be helpful to have the patient stand in front of a mirror to confirm these asymmetries. Once identified, each asymmetry can then be discussed as to how it will be treated. It is at this point that a very important part of the preoperative consult takes place. Generally, patients will seek reassurance that any difference in the size or shape of the breasts will be corrected. It is helpful to communicate to the patient that every effort will be made to create the most symmetrical result possible and the overwhelming likelihood is that whatever asymmetries are present will be improved. However, it is very common for small asymmetries in size, shape or position to persist even after the breast reduction has fully healed. By proactively discussing the issue of breast asymmetry, patients become better educated as to the challenges that breast reduction can pose with regard to the quality of the final result and are better able to accept and understand any small asymmetries that may persist postoperatively. Using this approach can be a tremendous aid in helping to head off any patient misconceptions about breast reduction and can help to maintain a very high level of patient satisfaction.

After the overall breast evaluation has been made and the breast measurements have been performed, it is important to assess what the goals of the patient are for breast reduction. It is here that specific issues such as size, shape, areolar diameter and symmetry are optimally discussed. Although most patients will have reasonable expectations, at times it can be surprising to discover what preconceived notions some women can have regarding the results of breast reduction. For instance, one fairly common example is the overweight woman who requests ‘A’ cup breasts. By sorting out these unrealistic expectations ahead of time, the chances for a misunderstanding between the patient and the surgeon are greatly diminished and the potential for patient dissatisfaction is reduced.

While recent developments in breast reduction technique have focused on reducing the extent of cutaneous scarring, perhaps no other strategy is more effective at accomplishing this than liposuction breast reduction (LBR). Although some have referred to LBR as ‘no scar’ breast reduction, it is perhaps more accurate simply to recognize that whatever small scars are created are generally so inconsequential as to be of no significance at all. In this method, standard liposuction technique is applied to the breast through strategically placed stab incisions to allow sufficient reduction in breast volume to be performed. These scars can be hidden in the inframammary fold, around the areolar junction with the breast and in the axilla. Using two entry portals allows for crosshatching to be performed and more effectively allows for the removal of greater amounts of breast volume than one portal alone. Several reports have documented the utility of this technique in safely reducing the breast in a fashion that does not interfere with the subsequent ability of the breast to be appropriately screened with mammography. In difficult cases, magnetic resonance imaging (MRI) evaluation can be used to visualize dense areas. What becomes an issue in LBR is the ability to remove appropriate amounts of tissue in dense breasts as well as managing the redundant skin envelope once the volume is reduced. Certainly, in the aged breast, when the bulk of the breast volume is made up of fat, a significant volume reduction can be accomplished with relative ease. In the more youthful fibrous breast, volume reduction can be somewhat limited using standard liposuction technique. In these cases, it may be more helpful to use alternative techniques such as ultrasound assisted liposuction (UAL) or power assisted liposuction (PAL) to extract the fat from within the interstices of the breast parenchyma more effectively. Once the desired volume reduction is performed, a relative excess of skin is created. In young patients with a more elastic skin quality, a mild rebound contraction takes place with modest amounts of fat removal and acceptable results can be obtained without the need for any type of skin tightening procedure (Figure 7.10). In older patients, this effect is less dramatic and an excessive and ptotic skin envelope can result after volume reduction that exacerbates the ptotic appearance of the breast. While some surgeons have simply accepted this unavoidable and variably unaesthetic ptotic breast shape, others have applied skin envelope reduction techniques in an attempt to improve the aesthetic result. In all instances, however, the simplicity and speed with which the procedure can be performed makes it an attractive technique in appropriately selected patients. Using the technique analysis described previously, LBR involves basically the use of a central mound to maintain the vascularity of the NAC, removes tissue in a diffuse fashion from each segment of the breast, either accepts skin redundancy or uses a standard skin excism pattern to take up the excess skin and shape the breast.

Figure 7.10 (A,B) Preoperative appearance of a 19-year-old woman who presents with mild macromastia. In addition to strain on her neck and back, she notes difficulty wearing clothes and participating in sports-related activities. As a result of the relatively modest amount of volume that will need to be removed to relieve her symptoms, as well as the likelihood that her skin will rebound and not create any redundancy after volume reduction, she presents as an excellent candidate for liposuction breast reduction. (C) Preoperative marks in preparation for liposuction breast reduction. (D,E) Intraoperative appearance of the right breast after the addition of 500 cc of tumescent fluid through an inframammary fold stab incision (D). After the fat and fluid have been removed via power assisted liposuction technique using a 4 mm five-hole mercedes tip cannula, the size and contour of the breast is visibly reduced (E). (F) Appearance of the liposuction aspirate from each breast. (G–I) Ten-week postoperative appearance after the removal of 200 cc of fat from each breast. The breasts are smaller, more comfortable and better proportioned relative to the remainder of her body habitus, all accomplished without the need for any skin incisions on the breast. The scar resulting from the small stab incision hides easily within the inframammary fold (I).

In younger patients who will not require tightening of the skin envelope after volume reduction, strategic placement of the incision portals can result in well-hidden and almost imperceptible scars. Also, placing incision portals in different quadrants of the breast can allow for passage of the liposuction cannula in a crisscrossing manner, resulting in smoother fat removal, which minimizes the potential for the creation of inadvertent divots or other contour irregularities. One strategy combines the use of a stab incision in the medial and lateral portions of the inframammary fold. This can be combined with an incision at the areolar border or high in the axilla to provide a different axis of approach for passage of the liposuction cannula. Using different approaches maximizes the ability of the surgeon to remove appropriate amounts of fat evenly and thoroughly from each quadrant of the breast. Touch up spot removal is also facilitated.

In patients who will have an excessively redundant skin envelope after volume reduction, a decision must be made as to the management of this excess skin. In selected cases, it may be reasonable simply to accept the redundant and underfilled skin envelope as a consequence of the volume reduction. The breast will have a decidedly unaesthetic appearance; however, the procedure is simple and can be performed quickly. Recovery is relatively easy and relief of symptoms is fairly predictable. Patients who are candidates for LBR alone with no skin excision include the elderly as well as patients who are considered to be at increased risk for complications resulting from a prolonged operative procedure. Also, certain patients may simply elect to decline skin envelope reduction secondary to concerns over the scar, or lack of concern over the less than ideal resulting shape of the breast. Conversely, if the shape of the breast is a concern, a standard skin envelope reduction pattern can be diagrammed and the access portals for liposuction incorporated into this pattern. Everything from a periareolar approach to a full inverted T skin pattern can be used, depending on the degree of skin redundancy as well as the comfort level of the surgeon. It is important to mark the patient preoperatively exactly as they would be marked for a standard breast reduction using the technique of choice for a given surgeon. Strategically then, once the volume of the breast has been reduced, the skin pattern can be excised removing skin only without the need for any internal dissection of the breast. Placing these marks preoperatively can ease the intraoperative decision making that occurs when the time comes to reduce the skin envelope.

Although the procedure could potentially be performed with IV sedation used in conjunction with tumescent local anesthesia, the use of a general anesthetic is also an excellent option. Using a solution consisting of 1 liter of normal saline combined with 30 cc of 1% lidocaine with epinephrine, tumescence of the breast is performed. Fluid is added to the breast until the consistency of the breast is quite firm. Typically, 1 liter of fluid is used in each breast. After appropriate tumescence has been applied, volume reduction is performed using standard liposuction technique. The utilization of smaller three-hole mercedes tip cannulas in the range of 3–4 mm in diameter can help prevent inadvertent over-resection of fat with the creation of contour irregularities as can potentially occur when larger, more aggressive cannula diameters are used. Fat removal is concentrated evenly around the more superficial and peripheral contours of the breast, as well as deeply under the breast. Finally, the cannula is passed directly through the substance of the breast in an attempt to remove fat from within the more dense fibroglandular stroma. This maneuver will be more successful in older patients or more obese patients where much of the breast has been replaced by fat. In younger patients or patients with a more dense character to the breast, it will be much more difficult to remove this interstitial fat. In these types of patients, power assisted liposuction or the use of ultrasonic liposuction is more effective in removing this interstitial fat. Volume removal proceeds until the desired effect is noted. As the liposuction aspirate collects in the catch container, the fat will be noted to float on top of the tumescent fluid, which allows direct measurement of the amount of fat removed. Although small amounts of actual breast parenchyma can be sheared off and removed with the fat, the contribution of this tissue to the overall volume of aspirate is negligible.

After appropriate volume reduction has been performed, the redundant skin envelope is addressed. There is no need to perform any deep dissection within the breast to remove additional volume, therefore removal of the redundant skin envelope is simply a superficial procedure. The redundant skin is removed according to the previously made marks, limiting the resection to no deeper than the dermis. Additional tailoring can be performed as needed to recontour the breast into the most aesthetic shape possible. The incisions are then simply closed without the need for any drains (Figures 7.11, 7.12).

Figure 7.11 (A,B) Preoperative appearance of a 70-year-old woman who presents with an invasive lobular carcinoma of the right breast in association with left macromastia. (C) Preoperative marks in preparation for a right modified radical mastectomy with immediate latissimus dorsi flap with tissue expander breast reconstruction and left breast reduction using liposuction followed by skin envelope recontouring using a circumvertical technique. (D) Immediate postoperative appearance of the left breast after reduction using power assisted liposuction technique. The skin envelope is redundant and ptotic. (E) After circumvertical plication, the base diameter of the breast is narrowed, the NAC lifted and the overall shape of the breast is improved. (F) Appearance of the inferior pole of the breast after removal of the plication staples showing the vertical segment that will need to be de-epithelialized. (G,H) The redundant skin envelope identified by the plication maneuver is de-epithelialized. Note the access portal at the base of the vertical segment that was used to perform the liposuction. (I,J) The margins of the de-epithelialized segment are scored through the dermis, but no deeper, to allow easier closure without creating tissue crowding. (K,L) After closure of the vertical segment (K), a purse string suture is used to cinch down the periareolar defect (L).

Figure 7.12 (A,B) Preoperative appearance of a 42-year-old woman in preparation for liposuction breast reduction followed by skin envelope recontouring. (C) Preoperative marks demonstrating the planned circumvertical recontouring strategy. (D) Immediate appearance of the right breast after power assisted liposuction reduction. (E) Appearance after skin envelope recontouring using a circumvertical pattern. (F) Appearance of the liposuction aspirate after removing 1200 cc of fat from each breast. (G,H) One-year postoperative appearance demonstrating a reduction in breast volume, a lifting of the position of the NAC and an aesthetic recontouring of the skin envelope. It is important to note, however, that the upper pole contour remains underfilled as a result of the lack of direct internal tissue rearrangement that is afforded by more invasive approaches.

Postoperatively, a support garment is worn simply for comfort for a period of 4–6 weeks or until the swelling has largely resolved. Wound care proceeds as for any surgical incision. Any exposed suture ends are clipped at 7–10 days and the incision is treated with a vitamin E-based scar cream for a period of 6 weeks. Decisions regarding return to work are made individually depending on the nature of the patient’s occupation. Many patients can return to light duty in as little as 3–5 days; however, I allow up to 6 weeks off for occupations involving heavier manual labor. Recreational aerobic or weight lifting activities are restricted for 4 weeks from the time of surgery.

It must be recognized that, while this operative strategy is simple and can be considered to be relatively less invasive than standard reduction techniques, several disadvantages are associated with this technique. Perhaps the most significant technical disadvantage is that no internal breast rearrangement or direct breast re-shaping can be performed. Where this effect is most dramatically noted is in the upper pole of the reduced breast. Very typically, a hollowing out of the upper pole is created after volume reduction via liposuction and, while the skin tightening may initially seem partially to correct this contour, the effect is short lived. Once the swelling in the breast recedes, the skin envelope inevitably relaxes and a hollowing out of the upper pole of the breast is the result. If patients have not been advised of this beforehand, it can potentially be a source of patient dissatisfaction postoperatively. In addition, since very little actual breast parenchyma is removed in the aspirate, any opportunity to screen the tissue via histologic examination is essentially lost. Therefore, in patients who have any marker for potential breast pathology including a previous family history of breast cancer, or previous biopsies documenting histologic changes associated with increased risk for breast cancer, LBR may not be the ideal choice as a breast reduction technique as the opportunity to screen the breast specimen for pathology is lost. Despite these limitations, it is advisable to send the liposuction aspirate to pathology for analysis. By doing so, the volume of tissue removed is documented and at least a general and non-specific histologic evaluation of a portion of the aspirate can be performed. Should an occult breast cancer be identified in the aspirate, appropriate treatment options could be considered, with the most likely treatment option being mastectomy since the exact location of the tumor would be unknown.

It is highly recommended that the patient obtain a baseline postoperative mammogram once the breast has fully healed to document the postoperative mammographic appearance of the breast. This is done anywhere from 6 to 12 months after the procedure. In this fashion, any future mammograms can be compared to the baseline study to allow better interpretation of any questionable findings which may develop.

Up until the mid-1990s, the most commonly used method for breast reduction by far was the inverted T inferior pedicle technique. Although effective, this technique resulted in an inframammary scar that extended from the parasternal area to the axilla in many patients. While it was recognized that this scar was unavoidable, it was still seen as a significant disadvantage, particularly when it healed in anything less than a fine line fashion. Therefore, when the ‘vertical’ mammaplasty was introduced to plastic surgery, a great deal of interest resulted. This technique allowed a breast reduction to be performed with only a periareolar and a vertical scar with the majority of the inframammary scar being eliminated. In general terms, the technique is based on a superior or superomedial pedicle with the excess parenchyma being removed from the inferior pole of the breast. A combined periareolar and vertical skin resection pattern is used and simple skin redraping is relied upon to shape the breast. Although this surgical strategy seems relatively straightforward, many nuances have been incorporated into the individual applications of the technique by surgeons around the world and in depth considerations of these nuances are beyond the intent of this book. What will be described here is a vertical technique that incorporates the basics of the procedure with modifications designed to minimize the disadvantages.

The original descriptions of the vertical mammaplasty based the blood supply to the NAC on a superior pedicle. While this pedicle was familiar to plastic surgeons around the world, most American plastic surgeons had no experience with it. This is likely why the procedure was relatively slow to catch on in the USA. At times, the pedicle construction in the hands of some surgeons created a flap of tissue that appeared alarmingly thin with the possibility of compromise of the vascularity to the NAC being a real concern. And, in fact, as the technique became more commonly practiced in the USA, anecdotal reports of NAC necrosis raised concerns about the reliability of the superior pedicle. To address these concerns, a slight reorientation of the pedicle into more of a superomedial direction was described. This essentially increases the chances that the flap of tissue carrying the NAC will include the robust second intercostal perforator off the internal mammary system. Also, when the NAC is rotated up into the periareolar defect, less tension is placed on the NAC than with the standard vertical pedicle. As a result there is potentially less compromise to the blood supply to the NAC. This superomedial pedicle modification is now utilized by many surgeons who use the vertical mammaplasty technique.

With the creation of a superior or superomedial pedicle, the tissue in the inferior pole of the breast becomes expendable and it is this tissue that is removed to accomplish the breast reduction. Typically, removal of tissue can be feathered around the pedicle to allow additional amounts of parenchyma to be removed as needed. This is a technical maneuver that must be performed with great care as over-resection of tissue in this area can create a divot-like deformity in the inferior pole of the breast. At times, this resulting cleft is seen only when the patient raises her arms and puts the lower pole of the breast under a relative stretch and, occasionally, it can be seen even as a static deformity with the arms at the sides (Figure 7.13). This potential complication is made even more troublesome by the fact that it is very hard to predict when this complication will occur as traditional vertical technique has advocated that the inferior pole of the breast be made to appear markedly flattened and even distorted to a certain extent at the end of the procedure. Therefore, the shape that will result in the inferior pole of the breast once full settling has taken place can be a source of uncertainty. This aspect of the vertical mammaplasty creates a significant conceptual problem. Vertical mammaplasty enthusiasts believe that removing this inferior pole tissue will prevent the breast from developing the well-known complication of ‘bottoming out’ with loss of an aesthetic lower pole contour. What remains underemphasized is that the surrounding breast parenchyma that is expected to fall into the lower pole void also stretches and, in a sense, bottoms out. If the attachments of Scarpa’s fascia in the lower pole of the breast are likewise resected with the parenchyma, the propensity of the remaining lower pole tissues to ‘bottom out’ into the subscarpal space is further aggravated. This phenomenon was recognized early on thus leading to the realization that if the lower pole contour was not overcorrected initially, an overly ptotic and elongated lower pole with an inordinately high NAC position could result. In effect, the eventual shape of the breast that results after vertical mammaplasty actually depends on a certain and undefined component of bottoming out. Therefore, the technical challenge of removing just enough tissue from the lower pole of the breast to allow the surrounding parenchyma to fall into the void and, at the same time, predicting how much the breast would settle seems to be a relatively unpredictable task, leaving the quality of the final result perhaps more to chance than might be optimal. Also, these uncertainties become more significant as the amount of breast tissue removed increases.

Figure 7.13 (A,B) Appearance of a patient who has undergone a vertical mammaplasty on the left. When she raises her arms, the tension along the inferior pole of the breast highlights the notch that is very commonly left over after the tissues in the inferior pole have been resected.

The original description of the vertical mammaplasty advocated creating a periareolar opening that had the exact circumference as the incision in the areola. In this way, the two incisions would match perfectly, creating a well-healed and inconspicuous scar. This strategy, however, created an incision length from the bottom of the periareolar pattern down to the inframammary fold that could reach alarming lengths in larger reductions. The length of this ‘vertical’ incision could be reduced somewhat by stopping the inferior extent of the incision short of the IMF by several centimeters and then adding an additional component of plication after the breast had been reduced. This maneuver tended to prevent the vertical scar from extending down onto the abdomen. Also, the placement of an accordion type suture pulled up to gather the incision was advocated as a means of shortening the distance between the IMF and the bottom of the areola. Despite these maneuvers, one of the hallmark complications of a less than ideal result after a vertical mammaplasty is a bottomed out, ptotic appearing breast where the distance from the IMF to the bottom of the areola is far too long and out of proportion to the overall shape of the breast. In essence, since the length of the periareolar and areolar incisions are nearly equal, any redundancy in the skin pattern must be taken up by the vertical segment alone. In larger breast reductions, this can result in a pronounced excess of bunched skin at the bottom of the vertical segment near the IMF. Several strategies for managing this bunched skin have been advocated, including the use of purse string sutures, debulking with liposuction, as well as just simply allowing the area to heal and contract in over time. Despite these surgical maneuvers, the end result of this skin excess problem is often a contracted, irregular and atrophic scar that distorts the lower pole of the breast. It is most often visible when the arms are raised over the head but, in severe instances, can be seen as a static deformity with the arms at the sides. With this in mind, it is telling that secondary revision of this lower pole deformity accounts for many of the revisionary procedures that have been reported after traditional vertical mammaplasty. To avoid these types of complications, it is far better to distribute the stress of managing the redundant skin envelope over the entire incision length. This is accomplished by diagramming a periareolar lift type pattern drawn in a manner very similar to a patient undergoing a circumvertical mastopexy where the outer periareolar incision has a larger diameter than the inner areolar incision. By using a purse string suture to control the larger periareolar opening, the dimensions of the vertical incision can be diminished, which places less overall stress on the vertical component. Secondly, there is no significant drawback to curving the inferior portion of the incision out laterally near the IMF to help take up the remaining vertical component of excess skin. This curvilinear skin takeout allows skin to be removed along two vectors both horizontally and vertically, a maneuver that affords great latitude in taking out any redundant skin and negates any potential for the vertical scar to extend down onto the chest wall as can happen with a straight vertical skin takeout. For vertical mammaplasty ‘purists’, these modifications run against the traditional teaching of precisely equal periareolar closures and a vertical component that runs straight down to the IMF without medial or lateral deviation. However, once these modifications become part of the overall plan, the advantages of the vertical, or more precisely the circumvertical mammaplasty, become evident.

Because the initial shape of a standard vertical mammaplasty can be so distorted, it is difficult to reliably perform any additional and separate shaping maneuvers other than simply to close the vertical incision and allow the postoperative settling process to run its course. In traditional vertical technique, when the immediate postoperative result is created, the remaining breast parenchyma is forcibly pushed into the upper pole of the breast to such an extent that the upper pole actually bulges. When this is combined with the flattened lower pole contour created by the aggressive vertical closure along with the bunched skin closure just above the IMF, the result can be decidedly unaesthetic. This is, however, how the initial result must appear as significant settling of the breast does occur. As the skin envelope relaxes, the forces shifting the breast parenchyma superiorly are overcome by gravity and, more often than not, an acceptable breast shape ultimately results. However, there is no direct control, particularly in the upper pole. This can be problematic for patients who present with an upper concavity as it is very likely this concavity will persist after the final shape has settled into place. When the modifications described previously are employed, these early shape issues are avoided as the breast demonstrates an aesthetic appearance immediately and maintains a pleasing shape during the healing process. As a result, the need for shaping maneuvers can be assessed and performed as needed with confidence. Therefore, in selected patients, it is possible to undermine the breast in a subglandular plane and use the suture suspension technique described previously for augmentation mastopexy to autoaugment the upper pole of the breast. Since the shape of the breast can be assessed immediately, these sutures can be used to good effect to fill in any preoperative upper pole concavity that may be present.

Taking these considerations into account, the following modified vertical mammaplasty technique is recommended in appropriately selected cases. Patients who are candidates for this procedure are those who need only a modest reduction of approximately 400 grams or less, although it is possible to push this limit to roughly 500 grams as needed. Typically, the breast preoperatively has a full appearance without an overly ptotic or excessively redundant skin envelope. Also, the technique works best in patients who do not have an excessive upper pole concavity as this contour is better corrected using the SPAIR technique.

The marks for this modified vertical mammaplasty are straightforward and easy to apply. With the patient standing upright and the shoulders held in a tension free posture, a line joining the two inframammary fold locations is marked across the torso so that it can be seen in the midline area between the breasts (Figure 7.14 C). If the inframammary folds are asymmetric, the higher fold line is used as the reference line. The breast meridian is then diagrammed on each side in such a way so as to divide the breast vertically into two equal halves (Figure 7.14 D). Measuring up from the inframammary fold reference line in the midline, an additional line is marked extending superiorly in 1 cm increments. At the 4 cm mark, a second line is drawn parallel to the inframammary fold reference line and this line extends across the tops of the breasts such that it intersects the breast meridian on each side. This then becomes the superior extent of the proposed periareolar incision (Figure 7.14 E). By then transposing the breast superomedially and superolaterally, the breast meridian can be ‘ghosted’ onto the breast to identify the medial and lateral extent of the periareolar pattern (Figure 7.14 F,G). The margins of the proposed vertical extension of the pattern are then marked. By lifting the top of the areola up to the desired level on the breast, the inferior pole of the breast can be pinched together until a pleasing shape has been created. The approximate location of this vertical takeout is then estimated and marked with the line extending down to the inframammary fold (Figure 7.14 H,I). When the distance from the IMF to the nipple exceeds 10 cm, it is best to begin to draw the inferior vertical segment with a slight lateral curve as it extends inferiorly toward the IMF. This will prevent the vertical incision from becoming too long and will help shape the breast appropriately. A smooth line is then drawn just below the inferior margin of the areola and the medial, superior and lateral points are joined into a smooth and slightly elongated oval (Figure 7.14 J,K). Since the management of the periareolar opening is similar to that which occurs in an augmentation mastopexy, it is possible to use the interlocking Gore-Tex technique to assist in managing the periareolar closure. These marks are applied as desired by marking the eight cardinal points around the areola as well as around the periareolar incision (Figure 7.14 L). Symmetrically applying the marks from side to side completes the marking pattern (Figure 7.14 M,N).

Figure 7.14 (D) A breast meridian is then drawn in such a way so as to divide the breast into two equal halves. It is important to ignore the position of the nipple as this line is drawn as many nipple positions are translocated either medially or laterally and using an off center nipple position could skew the location of the breast meridian. (E) A line is drawn in the midline marked off in centimeter increments. For most patients, by measuring up 4 cm from the inframammary fold line and then marking a line parallel across the chest until it meets the breast meridian, the proper location for the top of the periareolar pattern will be identified. This point can be raised or lowered as needed according to the judgment and experience of the surgeon to meet the needs of an individual patient. (F,G) By transposing the breast superomedially and superolaterally and ‘ghosting’ the position of the meridian onto the breast, the medial and lateral extent of the periareolar pattern can be determined. (H,I) By plicating the lower pole skin envelope with a pinching maneuver applied by fingers, a pleasing breast shape can be created. This maneuver identifies the approximate margins of the vertical takeout that will be required to create an aesthetic breast shape. (J,K) By drawing a line just under the inferior border of the areola and smoothly communicating this line around to the medial, superior and lateral marks, an elongated oval will result that then identifies the dimensions of the periareolar component. (L) The eight cardinal points used to identify the fixation points for the interlocking Gore-Tex suture are applied and the proposed locations for the subglandular suspension sutures are drawn. (M,N) Symmetrically applying the marks completes the marking process.

At the time of surgery, the areola is placed under maximal tension with the aid of a breast tourniquet and an areolar diameter of 40–44 mm is marked with the aid of a multidiameter areolar marker (Figure 7.15 A,B). The areolar and periareolar incisions are then made and the intervening tissue de-epithelialized (Figure 7.15 C). The dermis is divided around the periphery of the periareolar opening leaving a small 5 mm dermal cuff that will ultimately hold the Gore-Tex purse string suture. This dermal cuff is undermined directly at the level of the dermis for a distance of 1–2 cm back from the incisional edge. This eventually will allow the periareolar opening to be closed without inordinate bunching or tissue crowding (Figure 7.15 D). The proposed vertical skin incisions are then made and the intervening segment of breast tissue removed (Figure 7.15 E–G). Trimming either medially or laterally can be performed as needed to reduce the breast further. If needed, the parenchymal removal can extend medially and laterally around the inferior half of the areola. Every effort should be made to keep the attachments of Scarpa’s fascia to the underside of the breast intact. At no time should the amount of tissue that is removed be so extensive that a void is created in the inferior pole of the breast. If desired, the breast can now be undermined in the subglandular plane to allow the underside of the breast to be advanced superiorly. This undermining is limited to the central breast area and every effort is made to keep the internal mammary perforators intact (Figure 7.15 H,I). By advancing the deep surface of the breast superiorly and suturing it to the pectoralis major fascia with a 3-0 absorbable monofilament, any preoperative concavity that may have been present in the upper pole of the breast can be corrected. One to three such sutures can be used as needed to shape the upper pole (Figure 7.15 J). Once the desired amount of tissue has been removed, the vertical pillars are closed again with a 3-0 absorbable monofilament suture (Figure 7.15 K,L) and the skin incision is closed in a tailor tack fashion with staples until a pleasing shape is created (Figure 7.15 M,N). If necessary, the inferior extent of the plication can curve outward along the IMF as needed to create a pleasing aesthetic shape to the lower pole. By insetting the NAC into the periareolar defect again with staples and sitting the patient up, the shape of the breast can be assessed. Further plication, tissue removal or elevation of the NAC can be performed as needed to create the desired result. Once the optimal size and shape have been created, the stapled edges are marked with a surgical marker and the staples removed (Figure 7.15 O,P). The redundant skin is de-epithelialized (Figure 7.15 Q) and the vertical segment closed. A drain may be placed as desired. The NAC is then inset using the interlocking Gore-Tex technique (Figure 7.15 R–T). At this point the breast should have a pleasing shape. Slight fullness in the upper pole and a mild flattening along the vertical segment are acceptable but should not be so excessive as to detract from the aesthetic appearance of the breast (Figure 7.15 U–X). Dressings consist of Dermabond tissue glue to the incision which is then covered with Opsite dressings. A surgical bra is applied. Postoperatively, suture ends are clipped at 7–10 days and a vitamin E-based scar cream is applied for 6 weeks. Non-strenuous activities are allowed almost immediately; however, vigorous exertion is delayed for 4 weeks. Full healing has generally taken place by 6 months, at which time the final shape of the breast can be reliably assessed (Figures 7.16 A,B, 7.17 A–H).

Figure 7.15 (A,B) With the NAC under maximal tension, a 40–44 mm areola is marked with the aid of a multidiameter areolar marker. (C) The areolar and periareolar incisions are made extending partially into the dermis and the intervening segment of skin is de-epithelialized. (D) The dermis is divided leaving a 5 mm dermal cuff that will eventually hold the purse string suture and the periareolar skin edges are then undermined just at the level of the dermis for a distance of 2–3 cm to allow a tension-free purse string closure. (E–G) The margins of the proposed vertical segment are incised (E) and the redundant skin and parenchyma are removed (F,G). Care is taken not to undermine below the inferior attachments of Scarpa’s fascia as they insert into the breast. (H–J) The underside of the superior margin of the breast is undermined in a subglandular plane (H,I) and the leading edge of the superior flap is pulled up and under itself and sutured to the pectoralis major fascia in an attempt to ‘autoaugment’ the upper pole of the breast and correct a preoperative upper pole concavity (J). (K,L) The vertical pillars are closed to create an aesthetic breast shape. This maneuver also prevents a ‘dead space’ from forming in the inferior pole of the breast that can lead to notching and shape distortion in the lower pole.

Figure 7.16 (A,B) Four-month postoperative result demonstrating an aesthetic breast shape and excellent symmetry. Note that on the lateral view, the overcorrected upper pole shape has settled into a pleasing contour.

Figure 7.17 (A) Preoperative appearance of a 49-year-old woman in preparation for a left unilateral vertical breast reduction to correct her preoperative asymmetry. (B,C) Preoperative marks. (D–F) The vertical segment is resected from the inferior pole of the breast. (G) Immediate results after the removal of 168 grams of tissue from the left breast. (H) Final result at 15 months demonstrating better symmetry and an overall aesthetic result.

While the vertical mammaplasty paved the way for a better understanding of how to reduce the breast with fewer scars, there are several disadvantages associated with the procedure including the potential for postoperative shape distortion with a high-riding NAC and wound breakdown at the inferior margin of the vertical incision. Also, these complications become more likely with larger reductions. However, it is the necessity to significantly over-correct the shape of the breast with an attendant settling period where the shape of the breast matures over time that is problematic for many surgeons as most patients have a desire to achieve a more or less aesthetic result immediately. In an attempt to address these concerns, a new limited scar procedure called the short scar periareolar inferior pedicle reduction or SPAIR mammaplasty has been described that is designed to allow an effective reduction in breast volume to be performed while, at the same time, providing an excellent shape with a limited cutaneous scar burden. The procedure bases the blood supply to the NAC on an inferior pedicle, resects tissue peripherally from around the superior hemisphere of the pedicle, uses a circumvertical skin management strategy and controls shape with internal suturing. This procedure has proven to be an excellent option for a wide range of patients ranging from those seeking simple mastopexy to those needing reductions of 2000 grams or more.

The marking pattern for the SPAIR procedure is best applied with the patient standing upright, weight evenly distributed on both feet and the shoulders and arms held in a tension free and loose posture at the sides (Figure 7.18 A,B). The goal of the marking pattern is to identify the dimensions of the skin envelope that will need to be preserved to easily wrap around the inferior pedicle that will be used to carry the NAC. To this end, this operation typifies exactly the old axiom that it is not what is taken that is important, but rather it is what is left behind that will most directly affect the final result. Initially, the midline over the sternum is marked along with the location of the inframammary fold on each side. The most inferior extent of the inframammary fold for each breast is identified and a line connecting these two points is carried across the midline. If the two folds are at different levels, these two lines will not intersect and further marks are based on the higher of the two folds. This line drawn across the torso allows the location of the fold to be identified visually without the need to manipulate the breast in any way (Figure 7.18 C,D). Laterally, the inframammary fold line is extended over and around the lateral margin of the breast to mark the limits of the dissection of the lateral flap (Figure 7.18 E). In the midline, a distance of 4 cm is measured up from the inframammary fold line (Figure 7.18 F) and a second line parallel to the inframammary fold line is drawn across the top of each breast (Figure 7.18 G). This line marks the top of the periareolar pattern. The breast meridian is then marked on each side by visually dividing the breast in half and drawing a line that bisects the breast extending from the upper chest down and around the breast and onto the chest wall (Figure 7.18 H,I). When drawing the breast meridian it is best to ignore the position of the nipple as many patients present with a nipple position that is either laterally or more commonly medially translocated and basing the location of the breast meridian on such a translocated nipple would cause the remainder of the marking pattern to be applied asymmetrically. Once the top of the pattern is identified, the inferior portion is then marked. By lifting the inferior pole of the breast away from the abdomen, an 8 cm wide pedicle can be measured centered on the breast meridian (Figure 7.18 J). This measurement is repeated along the breast meridian as it extends up onto the breast and in this fashion a perfectly oriented 8 cm wide inferior pedicle is drawn directly in the midline of the breast (Figure 7.18 K,L). On either side of the pedicle, a distance of 8–10 cm is measured up from the inframammary fold (Figure 7.18 M,N) and these two points are joined in a line that parallels the line of the inframammary fold (Figure 7.18 O). As an approximation, in smaller breast reductions of 500 grams or less per side, the 8 cm measurement is used and in larger reductions of more than 1000 grams per side, this length measures 10 cm. For reductions between 500 and 1000 grams per side this length measures 9 cm. The goal of these marks is to identify a skin envelope in the lower pole of the breast of sufficient surface area easily to cover the lower portion of the breast after it is reassembled. To this end, there is no advantage to shortening this measurement to 7 cm and only in cases of gigantomastia where 1500 grams per side or more are planned to be removed can the measurement be lengthened up to 12 cm. Finally then, the amount of skin that will be preserved medially and laterally is determined. By gently rotating the breast up and out until a smooth and rounded contour is created in the medial portion of the breast, the breast meridian can be translocated onto the medial breast skin at the level of the nipple (Figure 7.18 P). This mark then determines how much skin must be left medially to wrap easily around the reduced breast. The process is then reversed as the breast is rotated up and in and a mark is made on the lateral portion of the breast that will similarly identify how much lateral skin to preserve (Figure 7.18 Q). In this fashion, four cardinal landmarks are identified that define the dimensions of the periareolar portion of the pattern (Figure 7.18 R). The lateral, superior and medial marks are then smoothly joined to the inferior pedicle marks to determine the limits of the periareolar pattern (Figure 7.18 S). After the periareolar pattern is finalized, the proposed limits of the inferior pedicle are outlined by carrying the 8 cm pedicle marks up and around the NAC, skirting the proposed areolar incision by a distance of 2–3 cm (Figure 7.18 T). As a final check to the marking pattern, the distance from the midsternal line to the most medial edge of the periareolar mark should measure at least 12 cm (Figure 7.18 U). If this is not the case, the markings should be rechecked to be certain the breast was not unintentionally pulled too far laterally as the medial mark was made. Lastly, the dimensions of the periareolar pattern are measured at their widest horizontal and vertical extent. This measurement is helpful in that it is an indication of how challenging the procedure will be, particularly as it relates to managing the skin envelope. In an approximate fashion, any measurement less than 15 cm indicates that the procedure should proceed easily and skin redraping will not be a challenge. For measurements of between 15 and 20 cm, it can be anticipated that intraoperative adjustment of the proposed vertical segment may well be required to obtain the best result. And for measurements greater than 20 cm, experience with the technique will be required to manage the redundant skin envelope effectively. It is highly recommended that the marking pattern be photographed and photos of the marks be made available in the operating room at the time of surgery. This visual information can be of help in confirming intraoperative observations that are sometimes made during the procedure relative to asymmetries in breast volume or, in particular, differences in breast width. Also, these photos can be referenced later after full healing has taken place and the final result has stabilized. Going back and assessing how the marking pattern impacted upon the final result can be an enlightening educational tool (Figure 7.18 V,W).

Figure 7.18 (A,B) Preoperative appearance of a woman in preparation for bilateral breast reduction using the SPAIR technique. (C) A line is drawn along the inframammary fold on each side and the two folds are joined with a line that extends across the midline. In this case, there is an asymmetry in the fold level with the left fold being slightly higher than the right. (D) As a result of drawing the fold line across the midline, it is possible to identify the location of each fold directly without moving or distorting the breasts in any way. As a result, the remainder of the marking pattern can be applied with greater accuracy. (E) The inframammary fold line is extended laterally around the breast to define the limits of the lateral flap dissection. (F) In the midline between the breasts, a distance of 4 cm is measured up from the inframammary fold line. In this case, the higher of the two folds is chosen to set the remainder of the pattern. (G) This 4 cm measurement sets the top of the periareolar pattern and a line parallel to the inframammary fold line is drawn across the top of the breasts at this level. (H,I) The breast meridian is diagrammed in such a way so as to divide the breast volumetrically into two equal halves. To this end, the position of the nipple is ignored to prevent an asymmetrically located nipple from skewing the location of the meridian line. (J) An 8 cm wide inferior pedicle is diagrammed centered on the breast meridian. This pedicle width is used for all reductions regardless of size. (K,L) The 8 cm width is confirmed further up onto the breast (K) allowing a perfectly centered pedicle to be constructed on the breast (L).

The procedure is performed under general anesthesia and, while most patients are able to be discharged home the same day, occasionally a patient will elect to stay overnight in the hospital either for pain control issues or to help manage postoperative nausea and vomiting. At surgery, the patient is placed in a mild beach chair position to help bring the base of the breast up level with the plane of the floor. This helps the surgeon better judge how the tissue planes fit together during the dissection. The periareolar tissues as well as the proposed vertical segment are infiltrated with a diluted solution of 1% lidocaine with epinephrine to assist with hemostasis (Figure 7.19 A). A breast tourniquet is applied and the areola is placed under maximal stretch while an areolar diameter of 40–44 mm is marked with the aid of a multidiameter areolar marker. The areolar and periareolar incisions are made and the skin over the inferior pedicle is de-epithelialized as is a small segment of skin immediately adjacent to the periareolar incision (Figure 7.19 B). The dermis is then divided around the entire periphery of the periareolar defect leaving a cuff of dermis attached to the periareolar skin incision that measures 5 mm in width (Figure 7.19 C,D). This dermal cuff will serve as the architectural scaffold into which the Gore-Tex purse string suture will eventually be placed. The dermis of the inferior pedicle is left intact to preserve whatever potential dermal contribution is present to the vascularity of the NAC. Once the dermal shelf has been created along the margins of the periareolar incision, the dermal edges are undermined and the flaps are dissected away from the main substance of the breast mound. Flap dissection proceeds in an exacting fashion by initially dissecting the flaps directly at the level of the dermis and then progressively increasing the thickness of the medial (Figure 7.19 E,F) and superior (Figure 7.19 G,H) flaps until the chest wall is reached. At this point the thickness of the medial and superior breast flaps approaches 4–6 cm. Every effort must be made to make these dissection planes as smooth and evenly contoured as possible. Laterally, the flap is dissected down to the lateral mark directly at the junction of the superficial fat with the breast capsule (Figure 7.19 I). This creates a lateral flap that is only 1–2 cm thick in most patients; however, experience has shown that the lateral flap must be this thin or the breast will demonstrate too much lateral fullness and a ‘boxy’ appearance to the breast will result. At the junction of the relatively thinner lateral flap with the thicker superior flap in the upper outer quadrant of the breast, every effort must be made to make this transition smooth and without an abrupt step off. This will help ensure a smooth rounded contour to the breast in this area. The reasoning behind this flap dissection strategy is that the initial flap dissection must be thin to allow the skin edges to be eventually pulled in by the purse string suture without creating tissue crowding as the flap edges are drawn around the inferior pedicle. Deeply, however, the medial and superior flaps are left thicker to provide substance and a smooth and contoured shape to the reduced breast. It is important to emphasize that the dissection along the medial and lateral aspects of the pedicle along the inframammary fold must stop slightly above the fold to avoid opening the loose subscarpal space. In this manner, the position of the inframammary fold will remain unchanged as a result of the procedure and a stable breast shape will be better maintained over time.

Figure 7.19 (A) At the beginning of the procedure, the patient is placed slightly upright to allow the surgeon better to visualize how the dissection planes will fit together during the operation. To assist in hemostasis, a dilute solution of lidocaine with epinephrine is injected into the dermis across the entire proposed periareolar and vertical skin pattern. The vasoconstrictive effect of the epinephrine greatly aids in maintaining hemostasis particularly during de-epithelialization. (B) After placement of a breast tourniquet to maximally stretch the areola, an areolar diameter of 40–44 mm is diagrammed and the areolar and periareolar are incisions scored. The skin about the limits of the inferior pedicle is de-epithelialized as is a rim around the periareolar incision. (C,D) The dermis around the periphery of the periareolar incision is divided leaving a 5 mm dermal cuff (C). This small rim of dermal collagen will serve as a firm and reliable architectural scaffold to ultimately hold the purse string suture. The dermis around the limits of the inferior pedicle is then likewise divided (D). (E,F) Medially, the flap dissection proceeds directly under the dermis to create a very thin flap (E) that then becomes progressively thicker until the dissection reaches the pectoralis major muscle. At this point the flap is commonly 4–6 cm thick (F). (G,H) The same strategy is used to create the superior flap. In this fashion, the leading edges of the flaps will easily fit around the inferior pedicle without creating a tissue crowding effect and the thicker deep portions of the flaps will create a smooth and contoured base to the breast. (I) The lateral flap dissection proceeds at the level of the breast capsule. (J,K) Once the flaps have been dissected, the main substance of the breast mound can be delivered from within the confines of flaps. (L) By dissecting along the internal breast septum, the redundant tissue in the superior aspect of the breast mound can be better delineated, allowing the pedicle to be safely skeletonized without risking injury to the underlying septum and the associated vascular arcade supplying the tissues in the inferior pedicle and the NAC.

Once the flaps have been developed, the main substance of the breast mound can be delivered from within the confines of the flaps (see Figure 7.19 J,K). The redundant parenchyma is then dissected free from around the pedicle, working from medial to lateral. During this dissection, the internal breast septum is protected by, working from deep to superficial, to better isolate the redundant tissue in the superior aspect of the breast mound (see Figure 7.19 L). This allows the pedicle to be skeletonized with little risk of inadvertent injury to the septum and the associated vascular arcade supplying the NAC. Every effort is made not to undermine the pedicle and a full and evenly contoured pedicle of parenchyma is retained to provide vascularity to the NAC as well as provide the basis for the eventual shape of the breast (see Figure 7.19 M–P). Once the pedicle has been completely skeletonized, it should fit evenly into the space created by the flap dissection without any excess fullness or, conversely, any areas that are in any way underfilled. The shape of the excised segment of parenchyma is that of a horseshoe with the lateral limb being slightly longer than the medial limb (see Figure 7.19 Q). Trimming can be done in any area where the dissection planes seem uneven or excessively full. Once the breast has been completely reduced, the weight of the resected specimen is recorded for comparison to the preoperative estimates as well as for comparison to the amount eventually resected from the opposite breast. Such comparisons can be particularly helpful in cases of breast asymmetry.

After the major portion of the breast reduction has been accomplished, the breast must then be reassembled into a pleasing aesthetic shape. In many patients, simply as a result of the preoperative planning of the procedure and the manner in which the surrounding flaps and pedicle have been sculpted, all that is required at this point is a tailor tack recontouring of the lower pole skin envelope to create an aesthetic shape. However, in patients who present with any degree of concavity in the upper pole of the breast, internal breast shaping maneuvers can be used to good effect to improve the overall quality of the final result. To prepare the breast flaps for internal suture plication, first the medial and superior flaps are undermined to release them from their attachments to the pectoralis major muscle and allow repositioning. The medial flap is undermined for a distance of 1–3 cm with care being taken not to inadvertently injure the very important internal mammary perforators. The superior flap is undermined up to and beyond the superior border of the breast (Figure 7.20 A,B). The deep leading edge of the undermined superior flap is then advanced upward to shift the position of the entire flap superiorly, where it is sutured to the pectoralis major fascia to hold it in position. One to three evenly spaced sutures are used to secure the flap in the desired location. In essence this amounts to an ‘autoaugmentation’ of the superior pole of the breast. The degree to which the flap is advanced superiorly is determined individually for each patient. Mildly ptotic patients will require only a modest flap advancement while extremely ptotic patients will require a more aggressive degree of undermining and a more significant flap advancement to correct the upper pole concavity (Figure 7.20 C–F). Medially, the undermined leading edge of the flap is imbricated upon itself to gather the deep flap tissues together and create a more rounded and full medial contour to the breast (Figure 7.20 G–J). Finally, the base of the inferior pedicle is sutured down to the pectoralis fascia to hold the pedicle in position and keep it from falling off laterally in the breast (Figure 7.20 K). The net effect of these shaping maneuvers is to improve the three-dimensional relationship between the flaps and the pedicle with the goal being a full and rounded breast contour that is properly positioned on the chest wall.

Figure 7.20 (A,B) To begin breast shaping, the medial and superior flaps are undermined. (C–F) The undermined edge of the superior flap is identified (C) and advanced superiorly (D) and sutured to the fascia of the pectoralis major muscle (E) to shift the superior flap tissues into the upper pole of the breast. This accomplishes an ‘autoaugmentation’ of the upper pole and can correct any element of upper pole concavity that may be present preoperatively. In this case, approximately 5 cm of flap advancement was accomplished using this technique (F). (G,H) Medially, the undermined edge of the dissected flap is imbricated upon itself to gather this tissue together to create a fuller, more rounded medial contour. (I,J) Before medial flap plication, the medial contour of the breast appears flattened (I) and after plication a fuller and more rounded contour is created (J). (K) The underside of the inferior pedicle is sutured to the pectoralis major fascia as needed to secure it in the center of the breast and keep these tissues from falling off laterally.

After the breast has been reduced and the shaping maneuvers applied as needed, the redundant skin envelope in the inferior pole of the breast must be managed. The exact dimensions of the skin resection are determined using a ‘tailor tack’ approach with skin staples. By securing a hemostat to the pedicle and applying upward traction, the redundant skin flaps on either side of the pedicle will buckle. These two buckle points are stapled together to begin the plication of the inferior pole. This staple point is called the key staple as it sets the rest of the plication pattern (Figure 7.21 A–C). The remainder of the redundant skin envelope is then folded in on itself and progressively stapled into position until a smooth and contoured shape has been created (Figure 7.21 D,E). As the staple line is developed from superior to inferior, the pattern curves inferolaterally along the inframammary fold as much as needed to create an aesthetic shape. At no time should the staple line extend down onto the upper abdomen. It is this lateral curving of the plication line that prevents many of the wound healing problems seen at the base of the vertical incision in the more classic vertical mammaplasty techniques. Alternatively, a small ‘T’ can be added at this point to take up the redundant tissue. The critical goal of this plication maneuver is to take up the redundant skin envelope and create an aesthetic breast shape immediately. This represents one of the great advantages of the SPAIR technique, namely that the breast must have an aesthetic appearance at the time of the procedure. Not only is this an advantage for the patient, but the surgeon can now make much more accurate and technically correct judgments about breast size and shape due to the fact that the breast has an aesthetic shape immediately as compared to the classic vertical mammaplasty where the distorted early breast appearance can hinder such efforts. To this end then, after the vertical segment has been plicated, the NAC is inset into the periareolar defect with staples and the patient is placed upright to assess the shape of the breast. Adjustment of the staple line can be performed as needed by either tightening a bit more the line of plication or, alternatively, loosening some of the staples to create the desired shape. Once the desired breast shape has been achieved, the patient is returned to the supine position and the plication line is marked with a surgical marker. Cross-hatched orientation marks are placed across the plication line to aid in accurately putting the vertical incision back together once the appropriate skin segments have been either de-epithelialized or resected (Figure 7.21 F). After the staples have been removed, the dimensions of the plicated inferior skin envelope can be visualized. The shape of the resection area typically assumes that of a canted ‘V’ with the inferior point of the ‘V’ angled laterally along the inframammary fold (Figure 7.21 G). The inferior pedicle is then de-epithelialized to preserve any potential contribution the subdermal vascular plexus may be providing to the blood supply to the NAC (Figure 7.21 H) and the redundant medial and lateral wedges of tissue on either side of the pedicle are removed (Figure 7.21 I). It is helpful in particular to remove the lateral wedge of tissue in a full thickness fashion as this then allows the lateral flap to pass over on top of the de-epithelialized inferior pedicle to meet the medial incision without creating any tissue crowding or bunching (Figure 7.21 J). A drain is placed as desired and the vertical incision is closed using 4-0 absorbable monofilament sutures placed in an inverted interrupted fashion followed by a subcuticular skin closure with the same material (Figure 7.21 K).

Figure 7.21 (A–C) By placing upward traction on the inferior pedicle, two buckle points will be created on either side of the pedicle (A). By grasping these points and bringing them together with a ‘key’ staple, the top of the vertical pattern is set (B). By grasping the dermal edges at this key staple point and applying upward traction, the general location and shape of the remainder of the vertical plication line can be visualized (C). (D,E) By folding the redundant inferior pole skin in on itself (D), the vertical plication line can be set by progressively tailor tacking the skin edges together until a pleasing shape is created (E). Near the inframammary fold, the plication line curves out laterally as the redundant skin envelope is gradually taken up. (F) After the shape of the inferior pole is set, the plication line is marked and cross-hatches applied to aid in accurately reclosing the vertical incision once the redundant skin is removed. (G) The appearance of the inferior skin segment is that of a canted ‘V’ with the point of the ‘V’ variably angled off laterally. (H,I) The inferior pedicle is de-epithelialized (H) and medial and lateral wedges of tissue are removed from either side of the pedicle (I). (J) The lateral flap is passed over the top of the de-epithelialized inferior pedicle and joined to the medial incision. (K) Appearance after closure of the vertical segment using the cross-hatch marks as a guide to accurate closure.

The final step in completing the procedure is management of the periareolar defect. Here all the technical details described previously for either the simple purse string or the interlocking Gore-Tex closure are utilized. If the dimensions of the periareolar defect are greater than 10 cm, the tendency is to use the simple purse string technique as use of the interlocking Gore-Tex technique can become cumbersome with periareolar defects larger than this. When the interlocking Gore-Tex technique is used, it is helpful to re-resect the periareolar opening to create a circular defect. Commonly, this will require resecting a small additional wedge of skin along the medial margin of the periareolar defect (Figure 7.22 A). Once the defect is re-excised, the eight cardinal points utilized in the interlocking Gore-Tex technique are applied (Figure 7.22 B) and the suture is placed in the dermal shelf developed at the beginning of the procedure, creating the characteristic pinwheel appearance (Figure 7.22 C). The purse string is then cinched down and the areola inset with a running 4-0 absorbable monofilament suture to complete the procedure (Figure 7.22 D–F). Postoperatively, suture ends are clipped at 7–10 days and a support garment is worn for comfort for 6 weeks. Full return to vigorous activity is allowed at 4 weeks (Figures 7.23–7.27).

Figure 7.22 (A,B) The periareolar defect is re-excised to create a circular opening (A) and the eight cardinal points are applied in preparation for placement of the interlocking Gore-Tex suture (B). (C,D) The Gore-Tex suture is passed in an interlocking fashion around the periphery of the periareolar defect using the dermal shelf created at the beginning of the procedure as an architectural strut to hold the suture (C). The suture is then cinched down to create a periareolar opening of the desired dimension (D). (E) Appearance of the right breast after the resection of 1004 grams. Note that, as compared to the left breast, the base diameter is reduced, the NAC diameter reduced, the breast is lifted, the upper pole has been filled in and the shape is aesthetic. (F) Final appearance at the conclusion of the case demonstrating an aesthetic and symmetric result.

Figure 7.23 (A,B) Two-month postoperative result after the removal of 1004 grams of tissue from the right breast and 961 grams of tissue from the left.

Figure 7.24 (A,B) Preoperative appearance of an 18-year-old woman in preparation for bilateral breast reduction using the SPAIR technique. (C) Preoperative marks. (D,E) One-year postoperative result after the removal of 292 grams of tissue from the right breast and 199 grams of tissue from the left. (F,G) The periareolar and vertical scars have healed in a fine line fashion.

Figure 7.25 (A,B) Preoperative appearance of a 50-year-old woman in preparation for bilateral breast reduction using the SPAIR technique. (C) Preoperative marks. (D,E) Nine-year postoperative result after the removal of 580 grams of tissue from the right breast and 500 grams of tissue from the left. This case demonstrates the stability afforded by the SPAIR technique as, despite the passage of many years, the shape of the breast, and in particular the upper pole, remains aesthetic.

Figure 7.26 (A,B) Preoperative appearance of a 51-year-old woman in preparation for bilateral breast reduction using the SPAIR technique. (C,D) One-year postoperative result after the removal of 212 grams of tissue from the right breast and 213 grams of tissue from the left.

Figure 7.27 (A,B) Preoperative appearance of a 30-year-old woman in preparation for bilateral breast reduction using the SPAIR technique. (C) Preoperative marks. (D,E) Seven-month postoperative result after the removal of 1082 grams of tissue from the right breast and 895 grams of tissue from the left.

For many surgeons, the gold standard technique for performing breast reduction remains the inverted T inferior pedicle technique. This technique bases the blood supply to the NAC on an inferior pedicle, resects tissue from around the periphery of the pedicle and uses a tapered wedge pattern to resect skin from around the inferior pole of the breast with a central superior extension that results in a scar along the inframammary fold with a central extension up to and around the NAC, hence the name the inverted T.

The patient is marked in the upright position. A line is drawn in the midline of the chest and a breast meridian is then drawn on each breast designed to separate the breast visually in half (Figure 7.28 A). The location of the inframammary fold is transposed onto the anterior surface of the breast by placing the fingers of the examining hand under the breast at the level of the fold and curling them forward so they can be palpated with the opposite hand (Figure 7.28 B). The distance from the clavicle to this point is then measured as an aid to applying the marks symmetrically (Figure 7.28 C). A 7 cm limb is then angled down medially and laterally from this point (Figure 7.28 D), creating a distance of between 7 and 10 cm between the bottom of these limbs. This distance determines how much the base diameter of the breast will be narrowed. A line is diagrammed in the inframammary fold and it is carried far enough medially and laterally to ensure that a dog ear will not form at the end of the incision after closure. The inferior ends of the vertical limbs are then joined to the inframammary line with an arcing sweep that preserves a small amount of skin centrally and resects more skin laterally. This minor adjustment can assist in maximizing breast projection and help in narrowing the breast base diameter (Figure 7.28 E, F).

Figure 7.28 (A) The markings for an inferior pedicle inverted T breast reduction begin by first marking the midline and then diagramming the breast meridian on each side. (B) By placing the fingers of the hand under the breast at the level of the inframammary fold, the level of the fold is transposed anteriorly onto the breast. (C) The length of the breast meridian is measured from the clavicle down to the fold mark. Depending on the height and weight of the patient and the size of the breast, this distance typically measures anywhere from 18 to 23 cm. (D) Using the fold mark as the top of the pattern, medial and lateral limbs are drawn extending inferiorly. These limbs measure 7 cm in length. (E) The distance between the inferior extent of the limbs ranges from 7 to 10 cm with the 10 cm measurement being used for a larger wide breast and the 7 cm measurement used for a smaller narrower breast. (F) A line is drawn in the inframammary fold and the inferior extent of the medial and lateral limbs are connected in an arcing fashion to the most medial and lateral extent of the inframammary fold line. The length of the inframammary fold incision is made long enough be certain a dog ear will not result once the inframammary fold incision is closed medially and laterally.

As with the other breast reduction techniques, an incision measuring 40–44 mm is made around the areola with the areola under maximal tension. The incisions are then made through the dermis and into the subcutaneous tissue around the entire periphery of the pattern. However, the base of the inferior pedicle is left undisturbed and the skin about the pedicle is simply de-epithelialized (Figure 7.29 A–C). The superiorly based flaps are then dissected free from the remainder of the breast mound using a similar dissection strategy to the SPAIR procedure. The goal is to sculpt the flaps such that they are somewhat thin to begin with and then become progressively thicker as dissection proceeds down to the chest wall. This will ensure that smooth rounded contours will be created once the flaps are closed around the inferior pedicle. The inferior pedicle is then skeletonized with care being taken not to undermine the pedicle and potentially interrupt the vessels in the breast septum. Also, dissection proceeds carefully in the region of the inframammary fold on either side of the pedicle to avoid opening up the loose subscarpal space, which could potentially lead to inferior migration of the breast parenchyma and the classic complication of ‘bottoming out’ (Figure 7.29 D,E). The flaps are then approximated along the inframammary fold and up along the vertical incision with interrupted and running 4-0 absorbable monofilament sutures. The patient is then placed in the upright position and a circular defect is created in the midline at the apex of the breast. The areola is then sutured into position to complete the procedure (Figure 7.29 F–H).

Figure 7.29 (A,B) Preoperative appearance of a 40-year-old woman in preparation for inverted T inferior pedicle breast reduction. (C) The inferior pedicle is de-epithelialized and the incisions around the periphery of the pattern are extended through the dermis. (D,E) After development of the flaps, the inferior pedicle is skeletonized with care being taken not to undermine the pedicle or violate the inframammary fold of the breast. (F) Final appearance of the breasts after closure of the flaps and insetting of the areolas on each side; 1669 grams of tissue was removed from the right breast and 1657 grams of tissue from the left. (G,H) Three-year postoperative result. Despite the large amount of tissue that was removed, the breasts are soft with no evidence of fat necrosis.

The advantages of the classic inferior pedicle inverted T breast reduction are that it is a very technically straightforward procedure, it is widely applicable to many patients and even very large breast reductions can be performed with relative ease (Figures 7.30–7.32). One nuance to this classic technique relates to the shaping of the breast. After the flaps and pedicle have been dissected free, it is possible to suture the pedicle to the pectoralis major fascia using absorbable shaping sutures to stabilize the shape of the breast during the early healing process. Utilization of such internal shaping sutures is just one of many maneuvers that have been reported over the years in an attempt to improve the results of breast reduction (Figure 7.33 A–I).

Figure 7.30 (A,B) Preoperative appearance of a 53-year-old woman in preparation for bilateral breast reduction using the inverted T inferior pedicle technique. (C) Preoperative marks. The distance between the vertical limbs was measured at 10 cm to narrow the breast maximally. (D) Intraoperative appearance after the removal of 1110 grams of tissue from the right breast and 1140 grams of tissue from the left. (E,F) The nine-year postoperative result demonstrates an aesthetic result with well-healed scars.

Figure 7.31 (A,B) Preoperative appearance of a 32-year-old woman in preparation for bilateral inverted T inferior pedicle breast reduction. (C) After preliminary closure of the breast flaps around the inferior pedicle, the breasts demonstrate a symmetric appearance. (D) Final appearance after insetting of the areolas; 1320 grams of tissue was removed from the right breast and 1090 grams of tissue from the left. (E,F) Nine-year postoperative appearance demonstrating a symmetrically aesthetic result that has remained stable over time.

Figure 7.32 (A,B) Preoperative appearance of a 35-year-old woman who presents with gigantomastia. (C) Preoperative marks in preparation for bilateral inverted T inferior pedicle breast reduction. (D,E) One-year postoperative result after the removal of 4437 grams of tissue from the right breast and 4381 grams of tissue from the left. Despite the massive size of the breasts, there was complete viability of the flaps and pedicles thus demonstrating the utility of the inverted T inferior pedicle approach.

Figure 7.33 (A,B) Preoperative appearance of a 38-year-old woman in preparation for bilateral breast reduction using the inferior pedicle inverted T technique. (C) Preoperative marks. (D) After skeletonization the pedicle can be seen to easily fall away laterally, potentially creating a hollow in the medial and superior portions of the breast. (E) In an attempt to improve the shape of the breast, the pedicle is repositioned and sutured in a contoured fashion to the pectoralis major fascia. (F,G) Using this internal suture suspension strategy re-distributes the volume of the pedicle to ensure that a rounded and full breast shape is created. (H,I) Five-year postoperative result demonstrating a stable and symmetrically aesthetic result.

Another nuance to the classic inverted T inferior pedicle procedure involves the use of a free nipple graft. In selected cases, the length of the pedicle may be so excessive that it is deemed by the surgeon an unreasonable risk to attempt a pedicled procedure. In these cases, the NAC is removed as a full thickness graft, thinned slightly and temporarily placed in a saline moistened sponge. Then, after the breast is reassembled and the inframammary and vertical skin incisions are closed, the location for the NAC is determined with the patient upright and this area is de-epithelialized and the graft applied and secured with a bolus tie-over dressing. An alternative method is to attempt a pedicled procedure initially with conversion over to a full thickness graft technique only after it becomes clear that the pedicled NAC is ischemic. In this instance, the NAC is removed as a full thickness graft and the ischemic portion of the pedicle is debrided back to viable tissue. The flaps are closed and the NAC applied as a graft as before. The disadvantage of the full thickness graft technique relates to the certain loss of sensation that results as well as the potential for variable take of the NAC as a graft with loss of nipple projection. Also, in patients with darkly pigmented areolas, variable take of the graft can result in depigmentation of the areola. However, in properly selected patients, the technique can provide consistent and reliable results while obviating the possibility of NAC necrosis. It remains up to each individual surgeon to assess the risks versus the benefits when deciding when to use the free NAC graft technique.