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Fig. 14.13 Surgical
specimen weighing 7kg
and measuring 70×50cm
I. N. Stocchero et al.
Complications
The most frequent complication is epidermolysis. Some small wound dehiscence
may occur. Rarely, supercial ecchymosis in minimal areas may appear (Fig.14.14).
Discussion
This hybrid manner of operating was conceived to save surgical time and to reduce
bleeding. These are the prerequisites for its indication.
It is also fundamental to not expect rened remodeling in breast surgeries, nor
use the technique with great undermining of tissues, since both these situations call
for traditional, more complex techniques.
14 The Excision-Suture Tactic: AQuick andLow Bleeding Option forTissue Resection
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Fig. 14.14 Fleur-de-lis
suture, 30days PO
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However, with correct training and engagement of the surgical team, excellent
results may be achieved, which will expand the job market with these procedures as
part of the range of options.
Key Points oftheChapter
Adequate indication for the surgery. Knowing that the patient has had the necessary
level of understanding and clarication, especially when the primary objective of
the procedure is aesthetic
In cases where indication for the surgery was based on health needs, it is always
easier for the patient to accept a revision surgery at a later stage.
Tips forBetter Results
Make the patient a partner in the quest for the best possible result.
Whenever possible, wait for the best time to perform the surgery, for example,
until an additional weight loss may be achieved.
Be safe and honest when proposing the procedure. Make sure that all information was claried and understood by the patient.
Reference
Stocchero IN (2003) The Ex-suture: a nonbleeding excision for hair transplantation, Plast Reconstr
Surg; 111(5):1176.
Part III
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Behavior of Breast Surgery Improving
Body Contouring
Chapter 15
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Reduction Mammoplasty withLower
Pedicle
RicardoCavalcantiRibeiro, AlineGuimarãesGomesde Sousa,
andLuisFernandezde Córdova
Abstract Reducing mammoplasty with the use of an areolate lower pedicle is
among the current techniques of breast reduction and, when well indicated, offers
incalculable benets for both the patient and the surgeon, due to the reduction of
complications. The technique basically consists in the preparation of a dermo-adipose inferior pedicle ap containing the areola-papillary complex (CAP) to maintain its vascularization, therefore being considered a technique of choice in the
treatment of large gigantomastias or mammary hypertrophy. Postoperative care is
not very different from the guidelines given to patients submitted to other reduction
mammoplasty techniques. Different studies have shown that there are no signicant
differences between reducing mammoplasty by other techniques and mammoplasty
with lower pedicle elaboration, in terms of complications such as hematoma,
seroma, necrosis, and infections. The authors indicate the technique mainly in
young patients with reproductive expectations after surgery, due to the conservation
of the glandular anatomy and the preservation of its continuity with the CAP.
Keywords Breast reduction · Lower pedicle · Breast hypertrophy · Gigantomastia
R. C. Ribeiro (*)
Plastic and Reconstructive Surgery, Federal University of the State of Rio de Janeiro,
Rio de Janeiro, Brazil
e-mail: rribeiro@centroin.net.br
A. G. G. de Sousa
Division of Plastic and Reconstructive Surgery, Casa de Portugal,
Rio de Janeiro, Brazil
L. F. de Córdova
Carlos Chagas Institute, Rio de Janeiro, Brazil
Division of Plastic and Reconstructive, Surgery Global Plastic Surgery
State of México, México
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_15
265© The Author(s), under exclusive license to Springer Nature
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R. C. Ribeiro et al.
Synopsis
Reducing mammoplasty with the use of an areolate lower pedicle is among the current techniques of breast reduction and, when well indicated, offers incalculable
benets for both the patient and the surgeon, due to the reduction of complications.
The technique basically consists in the preparation of a dermo-adipose inferior pedicle ap containing the nipple-areola complex (NAC) to maintain its vascularization, therefore being considered a technique of choice in the treatment of large
gigantomastias or mammary hypertrophy. Postoperative care is not very different
from the guidelines given to patients submitted to other reduction mammoplasty
techniques. Different studies [1–33] have shown that there are no signicant differences between reducing mammoplasty by other techniques and mammoplasty with
lower pedicle elaboration, in terms of complications such as hematoma, seroma,
necrosis, and infections. The authors indicate the technique mainly in young patients
with reproductive expectations after surgery, due to the conservation of the glandular anatomy and the preservation of its continuity with the CAP.
Surgical Indication
The areolate ap is usually indicated in hypertrophy and gigantomastia, being very
useful in these patients when they present a distance between point A and the areola
of 8cm or more, sometimes reaching 20cm. In addition, due to the consistency of
the breasts, present most often, more glandular component should be suspected than
fat. In this situation, the risk of vascular complications increases when superior
pedicle techniques are used, mainly due to the reduction of venous return. It is notorious that some authors in the mentioned situation prefer to opt for the autograft of
the CAP, which may be dispensable with the lower dermo-adipose pedicle. Thus,
the viability of the complex is protected, presenting low rates of vascular impairment.
Surgical Technique
After a thorough preoperative evaluation, the patient is marked standing and
explained that the resulting scar will usually be shaped like an inverted T.Later,
within the demarcation, the design of the lower pedicle is made with width ranging
from 7 to 10cm, which ensures the conservation of the vessels that feed it.
The authors prefer to perform the marking with the patient awake, rather than
anesthetized, due to the ease of observation of breast dynamics in various positions
(Fig.15.1).
Under general anesthesia, the patient is positioned with open arms and may
remain semised or not during surgery. The procedure begins with peri-areolar
15 Reduction Mammoplasty withLower Pedicle
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Fig. 15.1 Preoperative markings. Points A, B, and C are established and the ap is designed
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decortication, as well as the entire lower cutaneous extension of the pedicle territory. A triangle-shaped upper segment formed by the AB, AC, and CB points is
dissected to the muscular plane, ne-tuning the rest in the upper and lateral sectors
(Fig.15.2). This maneuver will result in exposure of the pectoralis major muscle.
Once the muscle is exposed, excision of excess glandular and fatty tissue from the
lower pole is performed and design of the neo-breast follows with a personalized
pattern depending on each case (Fig.15.3). Breast modeling is done through the
union of the tissue that remains in the lower pedicle, partially dissected at its base in
the proportion of 1:1 with equal or slightly greater width at its base. These points
can be anchored to the muscle tissue of the pectoralis major, which confers stability
to the ap and avoids repeated assemblies that cause more trauma to the tissues.
Finally, points A, B, and C are sutured, and the CAP is positioned with modeling
and displacement of possible excess skin (Fig.15.4). Strict control of hemostasis
should be maintained to avoid hematomas or collections that may modify morphology or produce vascular compression with consequent suffering from the ap as
well as from the CAP (Fig.15.5).
The authors emphasize the use of suction drains and their maintenance until the
drainage volume is less than 15mL/day. The scar that will result in this surgery will
be an inverted T, differentiating from other techniques by maintaining the late
results, observing little movement of the ballast in the postoperative period.
The main disadvantage of this technique is the scar’s length. Due to the width at
the base of the breasts that most patients with breast hypertrophy, often
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Fig. 15.2 After periareolar decortication, the
breast is ready for excess
glandular and fat tissue
resection
R. C. Ribeiro et al.
Fig. 15.3 Transoperative
vision of the breast after
xation of dermal aps in
the pectoral fascia.
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Fig. 15.4 After suturing
points A, B, and C, the
position of the CAP is
decided and designed
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Fig. 15.5 Before and after pictures (21days pot op)
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gigantomastia, present, a reduced scar may not be an option and the aspect of the
resulting scar should be taken into consideration and duiring consultation perform a
cost-benet analysis. There are renements in this technique, as Hülya and
Turmedem explain, which propose a modication consisting of the resection of a
lower pedicle in pyramidal format by means of a dermal suspension technique to
improve the long-term projection of the operated breast. During this renement, the
lateral dermal aps are decorticated in the form of a triangle, as extension of the
lower pedicle, and xed on the fascia of the pectoralis major with important suspension of the pedicle, forming an internal support (inner bra), avoiding lateral displacement of the breast and a better projection, also improving the quality of the
vertical scar, due to the lower tension required at the time of closure, and therefore,
techniques that seek to achieve more limited scars could be justied. The authors
made a modication to improve the contour of the breasts by developing a dermoadipose ap with higher wings and removal of a dermo-adipose triangle at the junction of these with the lower pedicle (without compromising the base of the pedicle)
to round the shape of the inner bra, giving more projection and stability to the dermal suspension.
This type of renement does not increase the risks and/or complications trans- or
postoperatively and has shown enormous acceptance and satisfaction on the part of
patients, who seek not only to have a smaller breast but also to renew it.
Although the suspension by means of this new technique in the lower pedicle
seems an ideal condition, the authors of the same state that there is no guarantee
regarding the long-term suspension of the breasts, so they do not recommend it in
the simple correction of ptosis, without breast reduction.
Other authors, such as Azad and Col., proposed block resection of excess breast
tissue to avoid changes in the elaboration of the pedicle and ensure greater symmetry.
R. C. Ribeiro et al.
Postoperative Care
The authors recommend a series of postoperative care not very different from the
guidelines given to patients undergoing reduction mammoplasty. In most cases,
patients require hospitalization for 24–48 h. Drains are removed when the volume
drained is less than 15 mL in 24 h.
Discharge is performed with specic instructions in writing and medicines for
oral administration, such as an analgesic, an antibiotic for 7 days, and an antiinammatory for 4days.
In general, the operated patient should not perform abduction movements with a
rotational angle greater than 90° for an approximate period of 45days, which will
provide security until the scar xation of the ap and avoid detachment of hemostatic clots that can cause late bruising. Stitches are usually removed in 12–15days
and we routinely apply micropore tape for 3–4weeks.
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Complications
Among the most frequent complications, the same as in all mammoplasty procedures, such as hematomas, seromas, fatty necrosis, partial necrosis of the CAP (usually due to technical error with section of vascularization or deep decortication of
the skin), and hypertrophic or enlarged scars (in the case of excessive tension in the
sutures or very heavy breasts in which the exaggerated reduction would compromise the vascularization of the aps).
Different studies have shown that there are no signicant differences between
reducing mammoplasty by other techniques and mammoplasty with lower pedicle
elaboration, in terms of complications such as hematoma, seroma, necrosis, and
infections.
There is also no relationship between complications and the volume of the
resected. However, there seems to be a direct relationship between suture dehiscence and resections greater than 1000g in each breast, which may occur in the
presence of undiagnosed subclinical infection; therefore, the incidence of this type
of complication is highly limited when prophylactic antibiotic therapy is installed
and maintained appropriately after surgery. Infections usually arise as a result of
inadequate prophylaxis and, when they do occur, present as a severe condition with
very unsatisfactory results from an aesthetic point of view. Therefore, prophylactic
use of a rst- or second-generation cephalosporin and its maintenance until the
seventh postoperative day is recommended.
Another complication that occurs almost in a little with this type of technique
and that has become the goal of several studies are the problems associated with
breastfeeding after reducing mammoplasties, especially in young patients with
severe hypertrophy or gigantomastia. Thus, it is currently considered in some countries as the surgical technique of choice for this type of patient.
Key points for reducing mammoplasty surgery with lower pedicle safe and successful
Adequate preoperative evaluation of the patient
Surgical indication with criteria for mammary hypertrophy or gigantomastia associated with
pain or aesthetic complaints
Pre- and post-operative photographic record of the patient ALWAYS
Beware of section of vascularization or deep decortication of the skin
Care in the preparation of the lower pedicle
Prophylactic antibiotic therapy ALWAYS
Identify and treat complications early
Guidance and postoperative care
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