Breast ( anatomy, reduction,

tuberous breast deformity,

gynecomastia)
Anatomy for plastic surgery of the breast
Parenchymal borders:

• Superior border: clavicle

• Medial border: sternum
• Inferior border: inframammary
fold
• Lateral border: anterior border
of the latissimus dorsi
Parenchyma
• The functioning parenchyma produces milk in the post-partum
period. Adipose tissue comprises a significant amount of the
breast volume, representing 50–70% of the breast volume.
• With age and the hormonal changes of menopause, the
glandular tissue of the breast involutes, increasing the adipose
to parenchymal tissue ratio.
• The Cooper’s ligaments provide
numerous interconnections between
the deep and superficial fascial layers.
These ligaments pass through ad
invest in the breast parenchyma
securing to the pectoralis fascia. With
attenuation of these support structures,
breast ptosis will develop.
 Nipple areola complex
• The nipple areola complex is the primary
landmark of the breast.
• The nipple itself may project as much as
≥1 cm, with a diameter of approximately
4–7 mm.
• The areola consists of pigmented skin
surrounding the nipple proper and is on
average approximately 4.2–4.5 cm in
diameter.
• The areola consists of keratinized,
stratified epithelium and contains not only
the lactiferous sinus openings, but also
sebaceous glands and the Montgomery
glands.
• Deep to the nipple and areolar there are
smooth muscle fibers which are arranged
circumferentially and radially. These
fibers are attached to the thick
connective tissue of the areola and are
responsible for nipple erection.
 Vascularity
• The breast has a rich vascular supply
from multiple arterial sources.
• The primary arterial supply includes
three main sources: the internal
mammary perforators, lateral thoracic
artery and the anterolateral intercostal
perforators.
• Additional arterial supply includes the
thoracoacromial artery and its perforators
and the vessels of the serratus anterior.
• The internal mammary perforators enter
the superior medial portion of the breast
via the second through sixth intercostal
spaces. The second and third perforators
are the predominant of these perforating
vessels. Because of their larger caliber
the second or third perforators are the
preferred recipient vessels for free tissue
reconstruction using the internal
mammary perforators.
• Supplying the superolateral aspect
of the breast is the lateral thoracic
or external mammary artery. This
vessel is a primary branch of the
axillary artery and enters the
breast after passing around the
lateral border of the pectoralis
major muscle at the inferior aspect
of the axilla. It distributes its
branches in the upper outer
quadrant of the breast.
• The lateral intercostal vessels
represent an additional important
blood supply of the breast. The
lateral breast receives anterior
intercostal arteries from the third
through sixth interspaces. These
vessels perforate the serratus
anterior just lateral to the pectoral
border. Lateral intercostal vessels
enter the breast at the anterior
margin of the latissimus dorsi to
supply the lateral breast and
overlying skin.
• Medial intercostal perforators are
responsible for direct supply of the
inferior central portion of the breast
inferior to the nipple areolar
complex.
• Venous drainage of the breast is via
two systems. The subdermal venous
plexus above the superficial fascia is
quite variable and represents the
superficial system. The veins arise
from the periareolar venous plexus
within the parenchyma, the
superficial systems anastomose with
the deep system. The deep system
parallels the arterial supply with the
veins paired to their respective
arteries. Venous perforators following
the internal mammary perforators
drain via the internal mammary vein
to the innominate vein. The lateral
thoracic veins drain via the azygos
vein into the superior vena cava.
• Vascular anatomy is also of importance with regard to the recipient site for microvascular
anastomosis when free tissue transfer is used for breast reconstruction.
• The thoracodorsal vessels have been used, particularly when the reconstruction is immediately
postmastectomy. The thoracodorsal artery is often small (<2 mm) and may have insufficient flow.
The axillary vessels can be technically difficult for the assistant, since they must operate across
the chest. In addition, the axillary system may limit flap movement and shaping the breast.
• The use of the internal mammary vessels as a recipient site facilitates shaping the medial portion
of the breast. However, the technique requires partial rib resection and eliminates the opportunity
for a potential coronary artery bypass graft.
• The internal mammary vessel may be preferred in delayed cases, especially in patients who
have had adjuvant radiation, as dissection of axillary vessels can be very difficult.
 Lymphatics
• The predominance of lymph
drainage of the breast is via the
interlobular lymphatic vessels to the
subareolar plexus. Lymph is
directed toward the axillary lymph
nodes.
• This drainage is parallel to the
venous drainage of the breast.
Lateral lymphatics course around
the edge of the pectoralis major
toward the pectoral lymph nodes.
Additional lymphatics course
through the pectoral muscles to the
apical lymph nodes. From the
axillary lymph nodes, lymph drains
into the subclavian and
supraclavicular lymph nodes.
 Innervation
• Sensory innervation has three
major nerve distributions which
include the anterior lateral
intercostals, the medial intercostals,
and the cervical plexus.
• The anterior rami of the lateral
cutaneous nerves of the
intercostals provide sensation to
the lateral portion of the breast
extending to and including the
nipple areolar complex. The breast
demonstrates a dermatomal pattern
derived from the anterolateral and
anteromedial branches of the
intercostal nerves (T3–T5).
• Branches of the cervical plexus
provide the superior medial sensory
innervation.
• Intercostal segmental nerves
contribute the remainder of the
breast sensation and can be
considered the primary sensory
nerves. The third through sixth
anterolateral intercostal nerves pass
through the interdigitations of the
serratus muscles to enter the lateral
aspect of the breast.
• Along the medial border of the
breast, the second through sixth
anteromedial intercostal nerves
enter the breast parenchyma
alongside the internal mammary
perforating vessels. These sensory
nerves provide innervation to the
medial breast and nipple areolar
complex.1
 Musculature

• The muscles directly

associated with the breast
include the pectoralis major,
serratus anterior, external
oblique and the superior
portion of the rectus
abdominis
 Pectoralis major
• Origin- medial clavicle and lateral
sternum
• Insertion- on the humerus
• Blood suplly: toracoacromial artery;
intercostal perforators from the internal
mammary artery
• Inervation: medial and lateral anterior
thoracic nerves
• Action: flex; adduct and rotate the arm
medially.
• The pectoralis major is extremely
important in both aesthetic and
reconstructive breast surgery, since
it provides muscle coverage for the
breast implant
 Serratus anterior
• Origin is the outer surface of the upper borders of
the first through eighth ribs
• Insertion is on the deep surface of the scapula
• Vascular supply is derived equally from the
lateral thoracic artery and branches from the
thoracodorsal artery
• The long thoracic nerve serves to innervate the
serratus anterior, which acts to rotate the
scapula, raising the point of the shoulder and
drawingthe scapula forward toward the body.
• Because the serratus anterior underlies the
lateral aspect of the breast, in aesthetic surgery,
blunt elevation of the pectoralis major laterally
inadvertently elevates a small portion of the
serratus muscle. To completely cover the implant
with muscle in reconstructive surgery, often the
serratus anterior must be elevated sharply to
obtain a sufficient muscle layer to provide
coverage.
 Rectus abdominis
• Origin at the crest of the pubis
and interpubic ligament to its
insertion at the xiphoid process
and cartilages of the fifth through
seventh ribs.
• It acts to compress the abdomen
and flex the spine
• When placing an implant for
breast reconstruction, in
attempting to achieve complete
coverage with muscle, the rectus
fascia must often be elevated to
place the implant sufficiently
caudal.
 External oblique
• Its origin is from the lower eight ribs, and its insertion
is along the anterior half of the iliac crest and the
aponeurosis of the linea alba from the xiphoid to the
pubis
• It acts to compress the abdomen, flex and laterally
rotate the spine, and depress the ribs.
• Elevated along with the rectusabdominis fascia to
provide inferior coverage of the breast implant during
reconstructive surgery
• In aesthetic surgery, placement of the implant
inferiorly is usually not below these fascial
attachments. If the implant is placed behind the
fascia, the implant often “rides too high” and may
result in a “double bubble” effect, wherein the breast
parenchyma slides over and off the implant
Gynecomastia
 Gynecomastia
• Gynecomastia is enlargement of the male breast
and is caused by an increase in ductal tissue,.
stroma, and/or fat. Most frequently, the changes
occur at the time of hormonal change: infancy,
adolescence, and old age.
• The most common cause of gynecomastia is
unknown (idiopathic).

• In all three age groups (neonatal, adolescent,

and older men), gynecomastia appears to be
related to either an increase in estrogens, a
decrease in androgens, or a deficit in androgen
receptors.
• The incidence of gynecomastia rises again in
older men (age > 65 years).

COMMON CAUSES OF GYNECOMASTIA


PATHOLOGY
• Three types of gynecomastia
have been described: florid,
fibrous, and intermediate. The
6
florid type is characterized by an
increase in ductal tissue and
vascularity.
• The fibrous type has more
stromal fibrosis with few ducts.
• The intermediate type is a
mixture of the two.
DIAGNOSIS
• A careful history and physical examination
is the most important part of any workup
for gynecomastia.
• The history notes the time of onset of the
gynecomastia, symptoms associated with
the gynecomastia, drug use.
• Physical examination includes assessment
of the breast gland and includes the nature
of the tissue, isolated masses, and
tenderness. The thyroid is evaluated for
enlargement. The testes are examined for
asymmetry, masses, enlargement, or
atrophy.
• Laboratory evaluation is based on the
findings of the history and physical
examination
 CLASSIFICATION
Simon, Hoffman, and Kahn divided gynecomastia into four grades:
1

grade 1: small enlargement, no skin excess

grade 2 a: moderate enlargement, no skin excess
b: moderate enlargement with extra skin
grade 3: marked enlargement with extra skm
Letterman and Schuster' created a classification system based on the
type of correction:
1: intra-areolar incision with no excess skin
2: intra-areolar incision with mild redundancy corrected with
excision of skin
through a superior periareolar scar
3: excision of chest skin with or without shifting the nipple.
Rohrich et al.,in a paper discussing the utility of ultrasound-assisted liposuction
in the treatment of gynecomastia, developed the following classification
grade I: minimal hypertrophy (<250 g of breast tissue) without ptosis
grade II: moderate hypertrophy (250 to 500 g of breast tissue) without ptosis
grade III: severe hypertrophy (>500 g breast tissue) with grade I ptosis

grade IV: severe hypertrophy with grade II or III ptosis

TREATMENT OF GYNECOMASTIA
• The goal of surgery is:
- to remove the excess breast tissue and skin,
- ensure adequate positioning of the nipple-areola complex,
- ensure symmetry between the breasts and chest wall,
- to avoid significant scarring
• Most fibrous or solid Simon stage 1 or 2a lesions are treated
with surgical excision or more recently, in selected cases, with
ultrasonic liposuction:with sharp tip cannulas, power-assisted
liposuction, or ultrasound-assisted liposuction.
• If surgical excision is chosen, a periareolar incision is
performed.
• The skin incision is placed at the junction of the areola and skin.
• After the incision is made, a cuf of tissue 1 to 1.5 an in
thickness is preserved directly deep to the nipple/areola
complex. This maneuver prevents postoperative nipple/areola
depression or adherence of the nipple/areola to the chest wall.
• When liposuction is unsuccessful at
removing all of the tissue required to
achieve a good result, the pull-through
technique is added.
• In this technique, either the lateral or
periareolar incision is opened slightly
(about 1.5 em) and the residual tissue is
grasped. The tissue is pulled out through
the wound and removed with scissors or
electrocautery. The pull-through
resection is performed until the desired
contour is achieved.
• All patients are treated with compression
garments for at least 1 month
 COMPLICATIONS

• Complications include inadequate resection, overresection, excess

skin, complex scars, hematoma, seroma, partial nipple necrosis, suture
line dehiscence, pain, loss of nipple sensation, and infection.
• Potential risks of ultrasonic liposuction include thermal burns and skin
necrosis, because one of the byproducts of ultrasonic energy is heat.
• This is avoided by using cool towels over the skin and avoiding
superficial planes near the skin surface.
TUBEROUS BREAST
DEFORMITY
• Tuberous breast deformity describes a spectrum of aberrant breast
morphology first reported by Rees and Aston
• There are several features of the tuberous breast that are important to
identify before management. These include a constricted base,
contraction of the skin envelope, relative micromastia, enlarged
diameter of the nipple-areola complex and herniation of breast
parenchyma through the nipple-areola complex.
• Although the exact etiology has not
been elucidated, it is generally
accepted that this disorder has an
embryologic origin.Most reports have
speculated that the superficial
investing fascia of the breast is
abnormal and constricted at the base
of the breast. This constriction at the
base and deficiency at the areola is
responsible for the reduced base
diameter and areolar herniation
 Classification
Von Heimburg:
Type 1: hypoplasia of the lower
medial quadrant
Type II: hypoplasia of the lower
medial and lateral quadrants
with sufficient skin in the
subareolar area
Type III: hypoplasia of the lower
medial and lateral quadrants
with a deficiency of the
subareolar skin
Type IV: severe breast constriction
with minimal breast base
 Grolleau Classification
Type 1: lower medial quadrant deficiency

• Type II: lower medial and lateral quadrant deficiency

Type Ill: deficiency of all four quadrants

 Treatment
• The goals of surgery are to restore volume to the hypoplastic breast(s),
expand the lower pole by releasing the tethering fibrous attachments or
bands between the breast parenchyma and deep fascial and pectoralis
muscle and also between the breast parenchyma and skin, and where
necessary reduce the areola size and recess the herniated breast tissue.
• The Mandrekas technique is
illustrated. (Above, left) A
periareolar approach is
advocated. (Above, center)
The dissection proceeds in
the subcutaneous plane to
the pectoral fascia. (Above,
right) The dissection
continues to the desired
inframammary fold. (Below,
left) The inferior pole of the
breast is exteriorized, and the
constrictive band is divided
vertically. (Below, right)
Finally, the areola is reduced,
and the breast is recontoured
BREAST REDUCTION
• Reduction mammoplasty is a dear example of the interface between
reconstructive and aesthetic plastic surgery. The goals of the procedure
are weight and volume reduction of the breast, but aesthetic enhancement
is also an important goal, particularly in some women.

• Women seek to reduce the size of their breasts for both physical and
psychological reasons. Heavy, pendulous breasts cause neck and back
pain as well as grooves from the pressure of brassiere straps. The
breasts themselves may be chronically painful, and the skin in the
inframammary region is subject to maceration, irritation, and rashes.
From a psychological paint of view, excessively large breasts can be a
troublesome focus of embarrassment for the teenager as well as the
woman in her senior years.
• Excessively large breasts can ultimately pose a liability for some
women in terms of comfort, wearing clothes, and daily functioning,
including many forms of exercise.
 PREOPERATIVE ASSESSMENT
1. Hystory
A breast history must be obtained, with special emphasis placed on the
results of any previous open or percutaneous biopsies, whether any
masses have been or are currently present, and when the last
mammogram was obtained.
Other important information relates to the reproductive history of the
patient and whether she was able to successfully breast-feed.
Basic information regarding general health status and medications can
identify the need for preoperative physiologic optimization with the help
of the patient’s primary care provider.
Perhaps most importantly, whether or not the patient is a current or
previous smoker must be documented
Finally, the patient should provide some guidance as to what size
breast she was hoping to have after the procedure.
 2.Physical Examination
• The patient is best examined in the standing position, with the arms
comfortably at the sides.
• Any asymmetries in the size of the breasts, the position of the
nipple-areola complex, and the level of the inframammary fold are
noted. Measurements from the mid clavicle or the sternal notch
down to the nipple are obtained, and the distance from the
inframammary fold up to the nipple is noted.
• The breast is palpated to assess for any potential masses, and the
density of the parenchyma is noted.
• Finally, an assessment is made as to the estimated amount of
breast tissue that will be removed from each side.
• Photographic documentation of the patient’s preoperative
appearance is a vital part of the preoperative consultation.
 OPERATIVE STRATEGY
• Any procedure designed to reduce the breast must include four
cardinal elements.
1. First, a pedicle must be incorporated into the design that preserves
the vascularity and innervation to the nipple-areola complex;
2. Second, and closely related to pedicle choice, selected quadrants of
the breast must be removed to accomplish the desired volume
reduction;
3. Third, the excessive skin envelope must be managed in such a way
as to minimize scarring as much as possible and yet allow a
proportional relationship to be created between the remaining skin
and the reduced breast volume;
4. Fourth, an overall aesthetic breast shape must be created either as a
function of the overall operative strategy or secondary to defined
maneuvers designed to create a specific contour.
• Two decisions confront the surgeon:
(a) choice of incision (scar) pattern and
(b) choice of pedicle type
• The inverted-T scar pattern am be applied to virtually any pedicle,
including a superior pedicle, an inferior pedicle, a vertical bipedicle, a
central mound pedicle, and a superomedial pedide
• The inverted-T inferior pedicle has been the preferred method of
breast reduction around the world over the past 40 years.
 Inferior pedicle breast reduction
• As will be demonstrated, in patients who have very long or large,
pendulous breasts, one of the benefits of the inverted T procedure is
reducing the amount of skin between the bottom of the areola and the
inframammary fold.
• Another group of patients that may benefit from this operation are those
with a wide, boxy breast where the upper pole and lower pole of the breast
are of similar width.
 Details of planning
• With the patient in the upright position,
the initial marking consists of creating a
line along the midclavicular plane starting
from the clavicle down to a projection
point through the inframammary fold
where the new nipple-areolar complex will
be located.
• Since in many patients, the nipple-
areolar complex does not sit in the
midclavicular plane, it is important to
create this line, ignoring the actual
nipple location if it is too lateral or too
medial
• After creating the midclavicular lines on
both sides, another mark is made in the
midline to make sure that these lines
are symmetrically placed an
equidistance from the midline
• Beginning at the lower extension of
the midclavicular line at the point
where the nipple projection was
created based upon the
inframammary fold, an equilateral
triangle is created. In smaller
patients, it may be in the 7 cm range,
while in relatively large patients,
frequently it can be anywhere from
8–9 cm in length.
• Once these equilateral triangles have
been created the next step will be
creating the transverse incision lines
extending from the lower limbs of
the triangle
 Detailed description of technical
procedure
• With the patient in the operating
room, there are several important
aspects in patient positioning.
• The arms are on arm boards but
should not be at an extreme right
angle, since this can distort the
breast shape at the time of closure
• A dilute solution of
saline/epinephrine is injected,
avoiding injection into the site of
the inferior pedicle.
• The first step consists of marking
the nipple-areolar complex
• Next, the areola is incised, followed by an
incision marking out the limits of the inferior
pedicle. The inferior pedicle is de-
epithelialized by the appropriate method. This
author makes superficial cuts with the knife
and completes the de-epithelialization with
scissors
• Initially the medial segments of skin and breast
tissue are resected, making sure to leave some
breast tissue present on the pectoralis fascia
• The other important aspect is to not apply
excessive traction, pulling laterally on the
pedicle as it is being dissected, since this can
cause extensive undermining of the medial
portion of the inferior pedicle
• The medial triangle is held gently as it is
resected. Also, the superior edge of the medial
segment undergoes slight undermining in order
to start thinning out the residual medial skin
flap. In a similar manner, the lateral segments
are resected.
• Once the lateral segments are
resected, they are compared for
symmetry, evaluating the amount
of tissue that has been removed
from each side. The remaining
volumes of the inferior pedicles
are now compared
• The third phase consists of
elevating the superior flap
• Once it is ensured that the residual
tissues are now symmetrical,
closure over a drain is now
performed. Initially, an apical
suture is used to bring the medial
and lateral flaps down to the
appropriate point in the
midclavicular line
• The patient is placed in the upright
position and symmetry and shape
is confirmed. Once this has been
confirmed, a few 3-0 and mostly 4-
0 Vicryls are placed in the
appropriate deep layer
• Once the sutures are in, followed by a
4-0 Monocryl subcuticular, the
patient is placed in the upright
position and, using the original
either 38–42 mm cookie cutter, the
nipple-areolar complex location is
identified. In most patients, this is
4 cm at the most above the
inframammary fold.
• Originally, many authors described
at least 5 cm from the bottom of
the areola to the inframammary
fold.
• Upon completion of the procedure,
the nipple should be slightly low
and slightly lateral
 Complications
• Probably the most common complication associated with the
inferior pedicle technique is necrosis at the apical closure.
• One of the benefits of this technique is that in very large patients,
if at the end of the procedure it appears that the nipple-areolar
complex may have some vascular compromise, it is still possible
to do free nipple areolar grafts
• Other complications that can be seen with any breast surgery
such as infection or hematoma need to be treated in the
traditional manner
 Superior or medial pedicle
• Vertical scar reduction mammaplasty using a superior or medial
pedicle has the advantage of improved longterm projection of
the breasts, along with less scarring than inverted-T
scar/inferior pedicle breast reduction techniques.
 Skin marking
• In the sitting position, the midline of the
chest and the inframammary creases are
marked.
• The central axis of the breast is drawn by
extending a straight line from the midpoint
of the clavicle through the nipple to
intersect with the inframammary crease.
One hand is inserted behind the breast to
the level of the inframammary crease, and
this point is projected anteriorly onto the
breast and marked (A).
• The inferior limit of the skin excision is
marked B, 2–4 cm above the
inframammary crease, depending on the
size of the reduction.
• The roof of the mosque dome pattern is
drawn by extending curved lines from point
A to points C and D to form the border of
the new nipple-areola complex
• The roof is drawn so that when
points C and D are brought
together, the roof will form a
circle. The vertical limbs of the
mosque dome pattern are
constructed by extending curved
lines from point B to points C and
D to form the margins of the skin
to be excised.
• Blocking triangles are drawn from
point C and point D, toward the
central axis of the breast, to
prevent the formation of the
teardrop deformity of the areola.
• After the patient has been anesthetized and
placed in the supine position, a tourniquet is
applied to the breast to keep the skin taut. The
nipple-areola complex is outlined using a
metal washer, 4.5 cm in diameter, centered
over the nipple.
• At this point in the operation, we select the
type of pedicle to be used to transpose the
nippleareola complex.
• The superior pedicle is drawn from the
blocking triangles inferiorly, leaving a 2.5 cm
border around the nipple-areola complex.
• The medial pedicle can be drawn with a base
that is partially in the roof and in the vertical
limb or completely in the vertical limb of the
mosque dome, depending on the location of
the nipple-areola complex.
• A small incision is made superior to point B
through the skin that will later be excised.
• Each breast is infiltrated with 500 ml of
asolution composed of 1000 ml of Ringer’s
lactate solution, 40 ml of 2% lidocaine and
1 ml of 1 : 1000 epinephrine.
• To facilitate de-epithelialization of the
pedicle, a tourniquet is applied to the
base of the breast to increase tension
of the skin overlying the breast. Before
de-epithelialization, the nipple-areola
complex and the pedicle are marked,
as explained previously. To prevent
damage to the blood vessels travelling
superficial through the pedicle, it is
important to leave the deep dermis
intact when deepithelializing as
opposed to removing the skin full
thickness.
• The excision is extended down to
the chest wall, leaving a layer of
breast tissue over the pectoralis
fascia to prevent bleeding and
postoperative pain.
• When excising tissue deep to the
pedicle, it is important to leave the
pedicle at least 2.5 cm thick to
preserve its blood and nerve
supply.
• When excising breast tissue
laterally and superiorly, the flaps
should be maintained 2.5 cm thick
throughout their length
• The tissue between the end of the
vertical wound and the
inframammary crease is thinned to
prevent a dog-ear from forming
• Liposuction is performed after
excision because it is very difficult to
accurately assess the composition of
the breast preoperatively by clinical
examination.
• Access to these areas is through the
medial and lateral pillars created by
the surgical excision
• Wound closure is performed in two
planes, including parenchymal pillar
sutures and gathering of the skin of
the vertical wound using box
stitches. Inverted 1-0 Vicryl sutures
(Ethicon Inc, Somerville, NJ) placed
through the superficial fascial system
are used to reapproximate the
medial and lateral pillars of the
breast parenchyma
• Each breast is injected with 10 ml of 0.5% 1 : 200 000
bupivacaine for postoperative pain relief. The wounds are dressed
with paraffin gauze, followed by dry gauze, and finally by
abdominal pads. These are held in place by the patient’s bra.
• Patients should wear a bra at all times for 3 weeks following
surgery. On postoperative day 1, they are instructed to shower
and wash their wounds with soap and water and dress them with
dry gauze
 Short scar periareolar inferior pedicle
reduction (SPAIR) mammaplasty
• The short scar periareolar inferior pedicle reduction (SPAIR)
mammaplasty was developed in an attempt to eliminate the
major complications related to the use of the inverted T pattern
inferior pedicle technique for breast reduction.
• After utilizing the SPAIR mammaplasty for the past 14 years, it
is clear that the pattern can be applied to a breast of basically
any shape, size, or volume.
• The patient is marked in the
upright position. Basic
landmarks, including the
location of the inframammary
fold, the breast meridian, and
the midsternal line are drawn
in.
• Areola marked; Division of dermis around periareolar incision;
Incision of superior aspect of pedicle; C-shaped segment
removed around top and sides of pedicle; tailor tacking and
marking of orientation lines
• De-epithelialization and removal of redundant tissue medial to
pedicle; periareolar opening re-drawn to approximate perfect
circle; 8 points drawn to mark and then place interlocking
purse-string Teflon suture.
Pre and post SPAIR

425 g L 300 g R

961 g L 1004 g R
L short-scar
• Technique principle “what is most important is what remains,
no what is removed”
• Uses superomedial transposition pedicle with resection of
middle and inferior portions of breast
• Important to preserve 3rd, 4th and 5th intercostal nerves
• Important to avoid resection of a large amount of skin at the
top of the mammary cone because this leads to areolar
enlargement and scarring with early relapse of ptosis
• According to author one of most important indications for this
technique is asymmetry as they feel it is “better to mark and
resect directly to preserve similar portions of the breast, than
to mark and resect different breast portions and only as a
consequence, reach similar portions that will result in
symmetry”
• Technique is more concerned with focusing on what skin will remain than
the skin that will be removed
• Standing - Point A –projection of submammary sulcus on mid-mammary
line, A’ marked 2 cm above A
• Dorsal decubitus with skin on stretch – C- 8 cm from midsternal line and 2
cm from submammary sulcus; B 10 cm from midsternal line and 8 cm from
point A; Point B ′ is marked between the nipple and point A. The larger and
more ptosed the breast is, the closer point B′ should be from point A . Point
C ′ is marked 7 cm from point B ′ , forming line B ′ C ′ C, with breast skin
stretched medially and upwards; D 3 cm from submammary sulcus at end
of skin fold formed by union of BC and B’C’
• From lines BC and B ′ C ′ , the incisions in mammary tissue
converge at 60° towards the chest; An incision or a
resection of the necessary mammary tissue is made in the
superior pole, between the areola and point B ′
• The bases of the pillars formed are resected at the
horizontal blue lines, making them 7 cm high
• The lateral line B ′ C ′ was sutured to the medial line BC originating the upright stem
of the L scar. A temporary skin compensation pouch is made using more medial
skin, in order to achieve a well-projected mammary cone top. The new areola
position is marked within 3.6 cm and de-epithelialized with A ′ as the vertex
1248 R 1252 L 565 R 552 L 450 R 405 L
Periareolar with mesh support
• Technique based on reshaping breast parenchyma and treating
glandular mound separately from skin
• Skin is redraped over new breast architecture through a periareolar
approach with new breast assembled through glandular flap rotation
and fixation to ant. pec fascia
• Addition of mixed mesh applied as a sandwich between two layers of
cutaneous lining to attempt to obtain a longer-lasting result
Evolution of technique
• Periareolar mammoplasty initially intended to reposition the glandular mound and
provide new positioning with relation to the thorax in a new aesthetic format; skin cover
was detached from the gland and only cover repositioned gland with limitation of scar to
periareolar region
• Excessive periareolar skin – de-epithelialized and used as an internal flap (“internal bra
support”)
• Early post operatively – observed tissue structure was insufficient to maintain ideal conic
format
• Goes started using support mesh sandwiched between the external layer of skin and de-
epithelialized layer to add support
• Initially polyglactin 910 mesh used but is absorbable and resulted in loss of aesthetic
result after ~ 2 yrs
• 910 polyester used subsequently with better long term results
• Currently use Ultrapro made of polypropylene and monocryl
Patient selection
• No ideal for all pts
• Ideally pt has thicker, more elastic skin and pts that have breasts with
greater proportions of glandular tissue (younger)
• Resection of up to 1/3 of breast volume
• Glandular reassembly may be technically difficult in patients with
exaggerated breast ptosis and a narrow breast base
• 4 cardinal pts marked in
order to bring the NAC to
new position
• A – superior point 2 cm
above projection of IMF on
breast surface and 16-18
cm from sternal notch
• B – 7 cm from IMF (if <7 cm
available more skin by be
harvested by advance
dissection inferiorly to the
IMF
• C – at least 9 cm from
midline and up to 10.5 cm
in pt with large breasts
• D – 12-13 cm from lateral
border of breast
• De-epithelialization around areola and marked borders
• Dissection of upper skin flap – beveled so that thickness of adipose tissue attached to skin
increases progressively to enhance upper pole fulness
• Carried down to anterior pec fascia and then carried superiorly for 4 cm
• Medial flap kept uniformly thin and dissection stopped 2 cm before reaching fascia to
preserve perforating vessels
• Inferior flap kept thin and stopped once reaching IMF
• Lateral flap dissected to lateral border of breast and then carried upward to lateral border
of pec major
• Dermal flap disconnected from gland with some adipose attached and inturrupted 1-1.5
cm from boarder of NAC
• Reassembly of gland performed by lifting the superior pole
after detachment from thoracic wall and performing the
inferior mastopexy to project the mammary cone.
• Mesh is then placed between the internal and external skin
layers in a sandwich
Sculpted Pillar Vertical Reduction
Mammaplasty
• Authors claim this technique gives the most consistently good results
with a minimum number of complications
• Claim it is very easy to learn
• Advantages are that is narrows the breast base, leaves fullness in the
superior pole and reduces the height of the column of breast tissue
left behind
Evolution of this technique
Higdon and Grotting
• From constellation of maneuvers aimed at creating a stable breast
cone built from tow pyramids of carefully shaped breast tissue – again
using what is left behind is most important concept
• Similar approach as superior pedicle with vertical pillar popularized by
Lassus
• If NAC cannot be physically manipulated to it’s new position then
convert to superomedial pedicle similar to Hall-Findlay
• Use shaping sutures described by Marchac, De Souza and shape
pillars as described by Chiari without glandular rotation.
Patient Selection
• Pts with moderate breast hypertrophy and smaller (~1000 g)
• Ideal pts are young with more fibrous parenchyma and normal skin
without striae
• If breast is very large a superomedial pedicle is chosen instead of
superior pedicle
• Often use an inverted T skin resection for larger breasts
• Will not perform on smokers unless they stop 4 weeks prior
• Markings are just as described for the Grotting
Sculpted Vertical Mastopexy - Slide 23
• De-epithelialization of pedicle; Dissection in the mastectomy plane the
lower pole skin from the anterior bases of the pillars; Subglandular
dissection; Sharp dissection of lateral and medial vertical
Sharp dissection of a 2 cm thick pedicle for the nipple areolar complex; Marking the pillars’ bases for
resection, typically 5–7 cm from the top of the pillars; Simulated position of the nipple areola after base
resection; Closure of the cephalic and caudal extents of the pillars after placing a superior shaping
suture; Placement of a lateral shaping suture; Closure and inset of NAC
 273 g R
225 g L

552 g R
789 g L