Anatomical investigations showed that this septum is part of a suspension apparatus, which is attached to the thoracic wall, mainly following the borders of pectoralis major.²^–⁴ This ligamentous suspension carries the whole weight of the breast like a sling. The horizontal septum takes its origin from the periosteum of the fifth rib and merges medially into a vertical medial ligament, which attaches to the sternum. Laterally, the septum merges into a lateral vertical ligament, which originates from the pectoral fascia at the lateral edge of pectoralis minor (Fig. 14.1). These vertical ligaments continue into the capsule of the breast in an anterior direction (Fig. 14.1). A ligamentous structure also arises from the origin of this deep part of the ligamentous suspension, which inserts into the overlying skin, thereby determining the shape of the breast. This structure can be seen as a densification of Cooper’s ligaments and builds the intermammary sulcus and the cleavage medially as well as the inframammary fold inferiorly. Laterally, it forms a strong ligament heading into the skin of the axilla, the suspensory ligament of the axilla, which shapes the axillary hollow.

Fig. 14.1 Diagram of left breast, anteromedial view.

The deep part of the ligamentous suspension emerging from the thoracic wall is coloured gray, the superficial part inserting into the overlying skin is yellow.

Redrawn from Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 1998;101:1486–500.

The ligamentous suspension is not only important because of its shaping potential. Its main importance lies in the fact that it is the guiding structure of the main nerves and vessels to the nipple. Rising from the thoracic wall, the neurovascular structures attach to the ligamentous sling, while travelling to the nipple, where they build a subdermal plexus. From there the breast tissue is mainly supplied in a retrograde direction. This retrograde supply may be the reason for the possible occurrence of fat necrosis after breast operations.

The neurovascular supply runs along two main pathways, a central source along the horizontal septum, as well as a superficial source along the vertical ligaments merging into the capsule of the breast. The horizontal septum guides a cranial vascular layer, which comprises branches of the thoracoacromial artery as well as a branch of the lateral thoracic artery. The caudal vascular layer consists of cutaneous perforating branches from anastomoses of the intercostal arteries.

Most importantly, the deep branch of the lateral cutaneous branch of the fourth or fifth intercostal nerve (also the main nerve to the nipple), attaches to the caudal vascular layer (Fig. 14.2).

Fig. 14.2 Diagram of left breast, anteromedial view, cranial and caudal vascular layer guided by horizontal septum.

Redrawn from Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 1998;101:1486–500.

The second main path comprises perforating branches from anastomoses of the internal thoracic artery and the anterior cutaneous branches of the second to fourth intercostal nerves along the medial ligament as well as branches of the lateral thoracic artery and the corresponding lateral cutaneous nerve branches along the lateral ligament (Fig. 14.3).

Fig. 14.3 Diagram of left breast, anteromedial view, neurovascular supply guided by vertical ligaments.

Redrawn from Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 1998;101:1486–500.

The ligamentous suspension can be developed easily by blunt dissection along the retromammary space in a caudal direction. At the level of the fourth intercostal space the retromammary space changes its direction to continue as a horizontal plane of loose areolar tissue heading toward the nipple. This areolar tissue provides a pre-existing bipartition of the breast, as it divides the breast and its system of milk ducts into a cranial and a caudal glandular layer. Below this areolar tissue is the horizontal septum (Fig. 14.4).

Fig. 14.4 Vertical sectional view.

The horizontal septum can be found by opening up the retromammary space in a caudal direction.

Redrawn from Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 1998;101:1486–500.

The ability to localize the course of the neurovascular supply of the breast is important for any surgical treatment of this organ; it has allowed maintenance of the neurovascular supply in breast reduction procedures to be more precise.⁵^–⁷

Among the many different techniques of breast reduction and mastopexy, two principal groups can be differentiated concerning the neurovascular supply of the nipple-carrying pedicle.

The nipple can be supplied by the vessels running along either of the vertical ligaments, merging into the subdermal plexus along the capsule of the breast, which affords a dermal pedicle to elevate the nipple. These pedicles can be cranial, medial, or lateral pedicles.⁸^–¹⁰

The second big group of pedicles derives its neurovascular supply via the horizontal septum by a central parenchymal pedicle. These are the central and inferior pedicle techniques such as the techniques of Georgiade,¹ Levet,¹¹ Hester,¹² or McKissock.¹³ Combining those two main neurovascular sources is possible.

Patient Selection

The technique could be offered to patients with large and ptotic breasts, to elderly patients, to smokers and obese patients, to pre-irradiated breasts, and to patients with weak connective tissue. Because of its safe neurovascular supply it can be applied to all these difficult cases. In secondary reduction the technique can be applied, when the horizontal septum was maintained previously.⁶

Of course the patients must be informed about increased risks in special situations. In case of very weak connective tissue, a certain ptosis may recur. A severe smoker must be informed that she might be at increased risk for skin necrosis. An obese patient is always at increased surgical risk and should be motivated to lose weight.

In any case the method is preferable in patients who are anxious to preserve the sensitivity of their nipples and to preserve their breastfeeding ability. As it ends up with a short scar, it is also a good choice in patients, especially young women, who are anxious to have inconspicuous scars.

In a severely ptotic breast the method might be preferable to techniques supplied by dermal pedicles, as a dermal pedicle may be a limiting factor to raise the nipple.

Indications

Women suffering from carrying the weight of their breasts often get diseases of their cervical spine, have eczema, refrain from sport and social contacts, and often have problems in finding clothing that fits. A reduction and lifting of the breast for cosmetic reasons is also a good indication. A beautiful breast can be a big help in raising the patient’s self-esteem.

Mastopexy only should be limited to normal-sized breasts. Women with rather large, ptotic breasts, just coming in for mastopexy are not usually a good indication. I recommend them to have a certain reduction also, because their weak tissue is very likely to let the ptosis reoccur, because too much weight pulls it down.

Breast asymmetries can be congenital or after treatment of breast cancer. They are a good indication to be corrected by reduction or mastopexy.

Juvenile breast hypertrophy often is a big physical and psychological problem for the affected patient. As the anatomical structures are respected in my technique it is very likely to maintain viability, sensitivity and breastfeeding capacity; it can be recommended also in young patients. They must be informed that the breast may go on growing after the reduction.

Operative Technique (Box 14.1)

Markings

After sterile draping in a semi-upright position the preoperative marking is drawn freehand (Fig. 14.5). As the resection of the gland is handled independent of the resection of the skin envelope, most patterns of scar reducing resections can be applied. The midsternal line, the inframammary fold, the suprasternal notch and the xiphoid are marked as fixed reference points.

Box 14.1 Summary of operative technique

• Position the new nipple site rather low.

• Determine the periareolar skin excess, keeping well above the inframammary fold.

• Mark a medial pedicle with a dermal base narrow enough to allow its full mobility.

• Mark the areolar opening, distributing the skin excess within the circumareolar scar and the vertical scar in a proportion of roughly 1 : 1 in smaller breasts, up to 1 : 2 in large ones.

• Infiltrate the subcutaneous plane only, keeping laterally and caudally.

• De-epithelialize the pedicle and incise remaining periareolar skin excess.

• Separate gland in its lateral and caudal area in the subcutaneous plane from skin.

• Reach the retromammary space with a horizontal incision through the gland at about the level of the third rib.

• Open up the areolar tissue in a caudal direction bluntly, at the level of the fourth intercostal space move anteriorly to the nipple.

• Remove the cranial glandular layer between the horizontal incision and the horizontal septum including the tail of Spence.

• According to the desired size of the breast, resect the lateral ligament and the lateral third of the horizontal septum.

• Maintain at least the medial two-thirds of the horizontal septum and the medial ligament in the pedicle.

• In case of mastopexy no resection is performed.

• Shape the breast by upward rotation of the medial pedicle.

• Trim the residual skin excess, in particular caudally.

• Do not extend the skin excision to the inframammary fold, rather extend it laterally.

• Insert suction drains laterally.

• Close periareolar and vertical wound edges in two layers, gathering skin if necessary.

Fig. 14.5 Marking of the medial pedicle (stippled) with narrow dermal bridge.

The residual skin excess (hatched) will be excised.

From Würinger E, Vertical scar mammaplasty with the inferocentral pedicle. In: Hamdi M, Hammond DC, Nahai F, editors. Vertical scar mammaplasty, Springer; 2005. With kind permission from Springer Science + Business Media.

First the new nipple site is determined. This point is kept rather low, in big breasts it can even be below the inframammary fold. Much skin will be needed to cover a nicely projecting breast. The distended skin shrinks as soon as the heavy weight of the hypertrophic gland no longer pulls it down. The skin in the upper part of the breast should not be tightened under tension to stabilize the shape. This is very likely to be the reason for the breast becoming too flat and the nipple becoming too high. This leaves a very unaesthetic appearance, which is difficult to correct.

Next the skin excess is determined by pulling the breast medially and laterally, similar to the method of Lejour, and by inverting the abundant skin.

These vertical lines are joined cranially just below the marking of the new nipple position. Caudally they are joined about 4–5 cm (in bigger breasts 6–8 cm) above the submammary fold. The bigger the breast, the more the submammary fold will be elevated. The lines finally build a periareolar circle or oval shape (Fig. 14.5).

The areolar opening can be determined now in a mosque pattern or a circular pattern according to the surgeon’s preference. The skin excess will be distributed roughly in a proportion of 1 : 1 in smaller breasts, or 1 : 2 in large ones within the future circumareolar and vertical scar. I usually determine the definite extent of periareolar skin excision later, namely after resection and after distributing the skin. Sometimes all skin is needed for sufficient projection of the breast and only very little or no additional skin will have to be removed around the new nipple site.

A medial pedicle with a dermal base narrow enough to allow its full mobility is outlined. It is helpful to do this from a static viewpoint as it will keep the central pedicle in a higher position, preventing its sagging through. The remaining skin excess cranial and caudal to the pedicle will be excised in full thickness. The size of the areola is determined with an areola marker and incised intracutaneously. In most cases my preferred size is 42 mm.

With help of a mammary circle, all drawings are transferred symmetrically from one breast side to the other side.

Infiltration

The skin envelope is infiltrated with 0.5% xylocaine with epinephrine within the subcutaneous layer only. The lateral and inferior parts of the breast are infiltrated superficially, whilst the cranial part, the future medial pedicle, as well as the gland itself, are not infiltrated.

Preparation

The medial pedicle is de-epithelialized to keep the subdermal plexus. The remaining periareolar skin excess is incised circularly, thereby keeping the medial dermal bridge.

In the lateral and caudal region the skin envelope is separated from the gland in a subcutaneous plane to the thoracic wall. This subcutaneous plane can usually be found easily by gently pushing the opened scissors forward parallel and about 2 cm below the skin. In the region of the submammary fold care is taken not to injure the horizontal septum.

Resection

Whereas the determination of skin excess and the marking is performed similar to most vertical scar patterns, the resection differs distinctly and I think that this is the main point in my technique. Knowing the location of the main neurovascular supply within a clearly defined, regular structure makes it easier to predict which areas can be safely resected. The easy clinical accessibility of the horizontal septum allows for maintenance of optimal supply for the nipple.²^,³

The level of resection is found bluntly taking advantage of the pre-existing bipartition of the gland (Fig. 14.6). The retromammary space is reached by a horizontal incision through the gland at the cranial border of the pedicle, approximately at the level of the third rib. The part of the breast cranial of this horizontal incision is left intact, thereby maintaining superior fullness (Fig. 14.7). The part of the breast caudal to the incision is peeled off bluntly following the retromammary space down to the level of the fourth intercostal space. Here the retromammary space merges into areolar tissue, which can be progressively opened up with the fingers in an anterior direction to the nipple (Fig. 14.8). The horizontal septum is situated caudal to this areolar tissue. With blunt dissection the medial and lateral vertical ligaments are encountered. This tissue between the horizontal incision through the breast and the horizontal septum corresponds to the cranial glandular layer; it is resected and builds the main part of the resection. The amount of resected tissue varies as the thickness of the cranial layer varies with different breast sizes. In small breasts the cranial glandular layer amounts to less than 2 cm, in large breasts it can be more than 6 cm thick, whereas the caudal glandular layer usually has a thickness of about 2 cm in all breast sizes.

Fig. 14.6 Schematic view of resection of cranial glandular layer (gray); the cranial part is left intact for upper fullness (CR).

Redrawn from Würinger E. Refinement of the central pedicle breast reduction by application of the ligamentous suspension. Plast Reconstr Surg 1999;103:1400–10.

Fig. 14.7 The retromammary space is reached via a horizontal cut through the gland.

Redrawn from Würinger E. Refinement of the central pedicle breast reduction by application of the ligamentous suspension. Plast Reconstr Surg 1999;103:1400–10.

Fig. 14.8 Left breast, anterior view after de-epithelialization of medial pedicle; the cranial glandular layer is mobilized bluntly along the areolar tissue.

The horizontal septum can thus be used as a guide to achieve symmetry and this can also be done in preoperatively asymmetric breasts. The cranial glandular layer, which comprises the difference in volume, is mostly removed in this technique. This allows removing the very region where the actual hypertrophy and the accumulation of fat seems to take place. The thickness of the pedicle, comprising the caudal glandular layer, will be more or less equal on both sides.⁵

According to the desired size of the breast, at least the medial two-thirds of the horizontal septum and the medial ligament are maintained. Resection usually affects the lateral ligament including the tail of Spence and the lateral third of the horizontal septum, which allows for resection of lateral fullness. The deep branch of the lateral cutaneous branch of the fourth intercostal nerve can thereby be preserved, which runs within the retromammary space from lateral to medial and changes its direction after 3 to 5 cm to rise toward the nipple along the level of the fibrous septum.² The pedicle consists finally of the horizontal fibrous septum and its attached neurovascular layers, of both the caudal glandular layer and of the medial ligament (Fig. 14.9).

Fig. 14.9 Left breast, submammary fold (right, hatched); the pedicle after resection of cranial glandular layer seen laterally.

From Würinger E. Vertical scar mammaplasty with the inferocentral pedicle. In: Hamdi M, Hammond DC, Nahai F, editors. Vertical scar mammaplasty, Springer; 2005. With kind permission from Springer Science + Business Media.

In case of mastopexy only, a similar preparation along the retromammary space is performed, but it is not continued forward to the nipple. No glandular resection is done in this case.

Shaping

After resection of the cranial glandular layer, the pedicle mainly consists of parts of the ligamentous suspension. Its fibrous elements provide sturdy structures, which are more suitable for shaping than the residual breast tissue, where sutures cut through easily. The new breast shape is mainly gained by upward rotation of the pedicle similar to the technique described by Hall-Findlay.¹⁴ This allows combining the advantage of a technique that keeps the upper parts of the breast intact, and that acts against the force of gravity, with the advantage of keeping the horizontal septum intact, which means an optimized neurovascular supply. Upward rotation of the pedicle reduces the diameter of the base of the breast and increases projection of the nipple. The pedicle can be held in an elevated position with some fixation sutures. Also the periareolar dermis can be used for shaping to accentuate projection of the nipple. Usually no fixation sutures are necessary.

Final adjustment

The skin envelope is rearranged after shaping the gland. The areolar opening is closed. The skin excess is distributed more or less equally, half around the nipple, half caudal to the nipple into the vertical scar. In bigger breasts, up to two-thirds of the skin excess will be gathered in the vertical scar. Eventual periareolar skin excess can be removed now cautiously, providing sufficient projection. Contrary to the cranial part of the breast, where I leave skin generously, I remove any residual skin excess caudal of the nipple, which I estimate freehand. It can also be inverted and the plicated skin excess can be stapled temporarily together. The vertical resection should not reach the inframammary fold. In the case of greater excess skin the resection line is directed slightly laterally, always staying well above the inframammary fold. A drain is placed subcutaneously to the lateral side. The skin around the nipple is distributed equally with Vicryl stitches and closed with a Monocryl purse-string suture. Initially, some fine wrinkles may be seen along the suture lines, which will settle in a few weeks. The vertical skin is closed in two layers. A Mepore dressing and a bandage are applied.

Pitfalls and How to Correct

Breast is too large

When the skin envelope is rearranged, the breast can remain too large. Further resection is necessary and the points where resection can be performed without danger to the neurovascular supply are checked. First, the lateral aspect of the breast is inspected and any residual tissue, comprising the lateral ligament up to the axilla and the tail of Spence are removed. Next the horizontal septum is checked and its lateral parts including the corresponding part of the caudal glandular layer are removed, until about 1 cm lateral to the level of the nipple to save the main nerve. Next the cranial part of the gland above the horizontal incision to the retromammary space is inspected. Further resection can be performed there, always keeping in mind the maintenance of sufficient upper fullness. Finally also the inferior glandular layer is inspected for eventual bulky glandular tissue, which can be removed cautiously within the distal two-thirds.

Breast is asymmetric

Both pedicles are checked for symmetry. Similar to the procedure described above, all eventual glandular excess is removed from the larger side. It must be kept in mind that in primarily asymmetric breasts, the pedicle of the larger or ptotic side comprising the horizontal septum will be longer than the pedicle of the smaller breast. Therefore less lateral resection of the horizontal septum is performed in the smaller breast initially to compensate for its shorter pedicle.

Also a different thickness of the skin envelope can be the reason for asymmetry; it should also be equalized.

Unequal position of nipples

First the size of both breasts is checked and an eventual asymmetry corrected as mentioned above. Then the skin envelope is measured from the midsternal line to the vertical scar as well as from the suprasternal notch and the xiphoid to the nipple. Any inequality of the flaps is corrected.

Postoperative Care

The patient stays at the hospital overnight. The drains and the bandage are removed the next day. Then a sports bra is worn day and night, and then after 2 weeks only during the day. The patient is allowed to move her arms freely. Non-resorbable stitches are removed after 2 weeks; the scars are then treated with ointment, with massage of the scar starting 2 weeks later. Examples of two patients are shown preoperatively and with their postoperative result in Figs 14.10 and 14.11.

Fig. 14.10 Elderly, overweight patient A, B before and C, D 4 years after resection of 980 g from the right breast and 1200 g from the left breast.

Fig. 14.11 Middle-aged patient with breast hypertrophy and ptosis. A, C Anterior and B, D lateral view before and 9 years after resection of 360 g left breast and 440 g right breast.

Redrawn from Würinger E. Refinement of the central pedicle breast reduction by application of the ligamentous suspension. Plast Reconstr Surg 1999;103:1400–10.

References

1 Georgiade NG, Serafin D, Riefkohl R, Georgiade GS. Is there a reduction mammaplasty for ‘all seasons’? Plast Reconstr Surg. 1979;63:765-773.

2 Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg. 1998;101:1486-1500.

3 Würinger E, Tschabitscher M. New aspects of the topography of the mammary gland regarding its neurovascular supply along a regular ligamentous suspension. Eur J Morphol. 2003;40(3):181-189.

4 Würinger E. Vertical scar mammaplasty with the inferocentral pedicle. In: Hamdi M, Hammond DC, Nahai F, editors. Vertical scar mammaplasty. Berlin: Springer, 2005.

5 Würinger E. Refinement of the central pedicle breast reduction by application of the ligamentous suspension. Plast Reconstr Surg. 1999;103:1400-1410.

6 Würinger E. Secondary reduction mammaplasty. Plast Reconstr Surg. 2002;109:812-814.

7 van Deventer PV, Page BJ, Graewe FR. The safety of pedicles in breast reduction and mastopexy procedures. Aesth Plast Surg. 2008;32:307-312.

8 Strömbeck JO. Mammaplasty: Reports on a new technique based on the two pedicle procedure. Br J Plast Surg. 1961;13:79.

9 Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg. 1967;20:78.

10 Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg. 1994;94:100-114.

11 Levet Y. The pure posterior pedicle procedure for breast reduction. Plast Reconstr Surg. 1990;86:67.