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Fig. 14.11 Figure shows the close proximity of the intercostal
branches of the Internal mammary artery to the anchor points of
Cooper’s ligament (marked in blue)
ceps by the assistant, while an intersection suture monocryl
3-0 is placed between the lower border of the medial and
lateral pillars and the breast meridian intersection at the IMF.
The Santareno inner bra ap is located deep to the lateral
pillar, helping to reinforce the thin ap and contour the lateral breast (Fig.14.12a–d). Pillars are closed using 2 layers
of monocryl 3-0. Special care must be taken considering the
direction and depth of the needle over the medial pillar, since
its upper two-thirds is in fact the pedicle base; the surgeon
should remember that the pedicle vessels are at about 1cm
S. Santareno
depth from the surface. The assistant’s hand (not forceps)
should help in the approximation of the pillars. In cases
where an extra support is need or implants are combined, the
transposition of the Santareno ap may be performed with
PDS 3/0 transcutaneously, another type of inner brasserie
described by the auth.
14.3.7 Horizontal Skin Excision at theIMF
andClosure
The IMF is then marked again and a horizontal skin excision
is planned (Fig. 14.13a–f). Care must be taken in deepithelizing so as not to cut the skin at the base of the
Santareno inner bra ap. A minimum distance of about 3cm
from the medial edge of the horizontal scar until the medial
line should be kept scarless. This is a safe working distance
which may be used to perform nal medial scar adjustments, always saving a minimum 1.5cm distance from the
medial line. Final closure is performed (starting from the
edges toward the tripod point) in 2 layers of monocryl 3–0
and an intradermic suture with monocryl 4-0, under active
drainage (1 Blake drain per breast in an independent lateral
opening).
Op-Site copolymer acrylic spray dressing
(Smith + Nephew, Hull, United Kingdom), Omnistrips
12×101mm (Hartmann, Heidenheim, Germany), and a surgical bra are applied. If no major blood loss and no major
comorbidities, the patient is discharged on the same day
under antibiotic prophylaxis (amoxicillin-clavulanate;
clindamycin if allergic to penicillin), analgesics, gastric protection, elastic socks, and subcutaneous 40mg enoxaparin
sodium for 1week (Pannucci etal. 2012).
cd
14 The Superomedial Pedicle Breast Reduction Technique: ASimple andEective Approach toanEsthetic Breast Reduction
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a b
207
Fig. 14.12 (a) De-epithelized inferior ap. (b) Flap has been incised, it is thinned if associated breast reduction, whereas it is kept as full thickness
if it is a mastopexy. (c, d) Illustration showing the inferior ap being used for augmentation of the lower pole
208
ab
cd
ef
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S. Santareno
Fig. 14.13 (a) The triangular suture between the medial and lateral
aps and the inferior ap is placed along the breast meridian. (b) The
excess skin creating the dog ear is assessed. (c) The vertical incision is
closed. (d) Markings are made at 1.5cm from midline where the incision should end. (e) Inframammary crease is remarked and excess skin
removed along the line. (f) Closure is completed
14 The Superomedial Pedicle Breast Reduction Technique: ASimple andEective Approach toanEsthetic Breast Reduction
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209
14.4 Part 3: Follow-Up
Manual lymphatic drainage (Vodder method) (Kasseroller
1998) is started at the rst postoperative day and repeated
daily until the end of the rst week. Drains are maintained
until below 30cc/24 hours drainage (usually at day 3–4).
When removed, the patients may shower. If the Omnistrips
remain wet, a hairdryer on the cold air mode may be used.
In case the Omnistrips fall, a copper-zinc moisturizer
(Bariederm Cica-cream with copper-zinc, Uriage, Paris,
France) may be used over the scars until the third week.
Usually driving, exercise, movements of the arms above the
shoulders, and bending the torso at the hips are advised to
be avoided until the same period. However under the RUR
or UFR (Ultra-fast recovery) protocol designed by the
authors, which also included special physiotherapy conditioning that strongly diminishes the inammatory phase,
the arms may be raised, weight lifting up to 15kg and driving are allow after the draw removal. Lifting of over 15kg
weights may only be performed after the sixth week.
Patients must use a special surgical bra day and night until
the third week; from then the bra is changed to a special
model up to the sixth week. A silicone dressing, exchanged
daily (Cica-care silicone gel sheet, Smith+Nephew, Hull,
United Kingdom) should be used over the scars from the
rst until the end of third month. From the third until the
18th month, massage the scars with a greasy oil (Bariederm
Dermatological Cica-oil, Uriage, Paris, France, or grape
seed oil) and sunscreen protection is advised; patients
should also sleep with a sports bra for long-term stable
results (Ogawa etal. 2021).
Clinical evaluation of the patients is performed at day 1,
week 1, week 3, week 6, 6months, and 12months.
14.5 Results
The majority of the patients operated by this technique
reported no major complications. Among my 82 cases, 2
complications occurred. One 65-year-old gigantomastia
patient suffered a partial NAC necrosis of the right breast,
managed with conservative debridement with Flaminal®
Hydro (Flen Health, Belgium) (Vandenbulcke et al. 2006)
each 3days (during 21days), followed by a PICO™ singleuse negative-pressure wound therapy device (Smith+Nephew,
Hull, United Kingdom) (Saunders et al. 2021) for 3 more
weeks. Another 47-year-old patient had a major hematoma of
the left breast in the rst 4 postoperative hours, which had to
be managed with prompt surgical drainage; this patient was
under oral omega 3 supplementations and did not follow our
instructions regarding a preoperative 7 day withdrawal of
supplements. The patient recovered uneventfully.
The postoperative frontal, oblique and prole views at the
preoperative and 6-month follow-up of the patient in the
video are shown along with in Figs.14.14 and 14.15. In this
particular case, the weight of resected breast was 590g on
the right breast, 525g on the left side. The patient fullled
the follow-up plan with no complications.
ab
Fig. 14.14 (a) Preoperative frontal view. (b) Preoperative oblique view. (c) Preoperative prole view
c
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Fig. 14.15 (a) The postoperative frontal view at 6-month follow-up of the patient. (b) The postoperative oblique view at 6-month follow-up of
the patient. (c) The postoperative prole view at 6-month follow-up of the patient
S. Santareno
14.6 Complications
observed in patients with diabetes, history of tobacco use,
or increased nipple to inframammary fold (N-IMF) dis-
When the reduction mammaplasty is with a lower pedicle
tance (Bauermeister etal. 2019).
combined with a “wise pattern” it is safe and applicable to a
wide range of breast sizes, with low complication rates and
good vascularization of the NAC.However, the “bottomingout” and loss of projection over time—what I call the pancake effect—are major drawbacks (Meshulam- Derazon etal.
2009). This effect occurs because the shape and weight of the
breast are maintained exclusively by the skin envelope
(Fahmy etal. 2019). Also, the design of the pedicle does not
allow any extra space to obtain an inner brasserie with a dermal ap to overcame this situation.
The nipple sensation gradually improves in the majority
of patients (83.3%) over a period of 3–8months postoperatively (Hauben 1984). This happens because the sensory
supply of the NAC comes equally from anterior and lateral
cutaneous branch of the fourth intercostal nerve, plus anterior cutaneous branches of the second to fth intercostal
nerves and the lateral cutaneous branches of the third to
fth intercostal nerve. In one study more than 75% of
patients who experienced altered sensation stated that this
was of no concern to them (Hauben 1984). However, in a
recent literature review, the complication rates with the use
of the superomedial pedicle were lower than with the use
of the inferior pedicle (16% vs. 29.7%); risk factors
included a SN-N distance >35.5 cm, ptosis grade of 3,
breast reduction weight >831g, and BMI >30; there was
no statistically signicant increase in complication rate
Pearls
1. The superomedial pedicle breast reduction offers a substantial fullness of the medial quadrant of the breast, with
a more natural and pleasing cleavage and no glandular
bottoming-out phenomenon as with the inferior pedicle.
2. This technique shortens the length of the pedicle while
broadening the pedicle as a means to enhance blood ow
and maintain innervation of the NAC.
3. This ap is obliquely designed, so it becomes more robust
with a great vascularization and venous drainage (second
and third interspaces arteries and veins), allowing a better
arc of rotation to position the NAC.
4. It allows the inferior border of the medial pedicle to
become the medial pillar, which leaves an elegant curve
to the lower pole of the breast.
5. The magic behind it is the correct placement of the scars,
the correct manipulation of the dermal aps, the smart
aplication of the Santareno inner bra ap with or with
volume, the meticulous suture technique (starting from
the edges to the center for a tension free tripod closure),
the RUR or UFR (Ultra-fast recovery) protocol designed
by the authors and a good scar treatment protocol.
6. It is indicated to resections up to 1000g per breast. The
only risk factor associated with complication is the
BMI>28.
14 The Superomedial Pedicle Breast Reduction Technique: ASimple andEective Approach toanEsthetic Breast Reduction
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211
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Breast Reduction Inferior Dermal
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Pedicle Technique: Modified
KulwantS.Bhangoo
15
15.1 Introduction
Breast reduction is one of the most commonly performed
plastic surgery procedures (Annual Statistics American
Society of Plastic Surgery 2020). It also happens to be one of
the most gratifying procedures for both the patient and the
surgeon because it results in improvement of both form and
function. It is also a technically complex and difcult surgical procedure which is fraught with possible complications.
Patients with hyperplasia of the breasts suffer from back
pain, neck pain, shoulder grooving under the bra straps, skin
rashes, headaches, poor posture, and they also have impaired
exercise tolerance (Figs.15.1 and 15.2). Some patients also
experience numbness and tingling in their upper extremities
due to traction on the nerves in the neck from the weight of
the large breasts. Excessively large breasts also restrict recreational activities, such as swimming. It also imposes restrictions with regard to costumes and garments. The patients
have poor self-esteem and impaired psychological
well-being.
For patients with excessively large breasts, surgery is the
only option (Fig.15.3). The goal of surgery is to excise the
excess skin, reduce volume, obtain a pleasing shape, and
maintain function. The nipple areolar complex is moved to a
more desirable position with preservation of sensation, erectability, and lactation (Fig.15.4).
Supplementary Information The online version contains supplementary
material available at
K. S. Bhangoo (*)
Plastic Surgery, Mercy Hospital of Buffalo, Buffalo, NY, USA
Plastic Surgery, State University of New York at Buffalo,
Buffalo, NY, USA
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_15
https://doi.org/10.1007/978- 981- 99- 3726- 4_15.
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K. S. Bhangoo
Fig. 15.1 Surgery is the only option for treating excessively large breasts
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
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Fig. 15.2 Crease dermatitis in the inframammary fold
215
Fig. 15.3 Shoulder grooves from bra straps
Fig. 15.4 Shoulder grooves from bra straps
15.2 Historical Prospective andEvolution
ofTechnique
Earlier techniques entailed excessive undermining and
removal of a wedge of breast tissue. This was a timeconsuming and lengthy procedure which resulted in excessive blood loss and also frequently impaired wound healing.
In the 1960s Skoog advocated lateral or medial pedicle but
this resulted in problems with nipple transposition (Skoog
1963). Strombeck’s technique of horizontal bipedicle also
suffered from the same problem (Strombeck 1960). In the
1970s McKissock technique was popular (McKissock 1972).
This was a vertical bipedicle technique but this also had
restrictions with regard to nipple areolar transposition and
had other drawbacks, such as attening of the upper pole and
bottoming out of the breast post-operatively. Resection of the
breast tissue under the verticle pedicle was the cause of lack
of projection and decreased vascularity due to resection of
the deep pectoral perpendicular perforator vessels.
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Fig. 15.5 Vascular anatomy of the breast
K. S. Bhangoo
metries which should be noted. Nipples should be checked to
ensure sensation and projection.
Physical examination by palpation should be done to
detect any lumps. If present, needle localization should be
done to ensure their removal during surgery. Patients over
the age of 30 should have a pre-operative mammogram in
view of the fact that breast cancers have an earlier age onset
these days.
Measurements are also made as follows as these are helpful in detecting asymmetries:
1. Midclavicular point to nipple
2. Suprasternal notch to nipple
3. Nipple to midline
4. Nipple to inframammary fold
5. Areola diameter
6. Internipple distance
15.4 Inferior Dermal Pedicle: Pertinent
Anatomy
Fig. 15.6 Vascular anatomy of the breast
Over the ensuing years, many types of pedicles were
used, including horizontal, vertical, inferior, superior, central, lateral, and medial pedicles. (Hirshowitz and Moscona
1982; Orlando and Guthrie 1975; Hugo and McClellan 1979;
Arufe et al. 1977; Hall-Findlay 2005; Nahabedian et al.
2000) It became clear that the inferior pedicle technique,
combined with an inverted “T” closure proved the most
effective and resulted in accomplishing many of the desired
objectives (Robbins 1977; Georgiade et al. 1979). It was
noted that the inferior pedicle was sufcient to maintain sensation and circulation to the transposed nipple areolar complex (Figs.15.5 and 15.6). In many cases, it also resulted in
preservation of lactation. This method was easily reproducible, safe, and easy to teach and learn. The inferior pedicle
technique is currently the most popular technique.
15.3 Patient Assessment
Pre-operative patient assessment includes obtaining a
detailed medical history. If a patient has any medical conditions, such as thyroid disorder, hypertension, or diabetes,
then these should be controlled. Physical examination should
involve usual assessment to detect any pre-operative asym-
Inferior pedicle technique has become the workhorse of
breast reduction surgery in recent years and is most commonly used. This technique is based on the premise that the
superior segment of the breast is not necessary for circulation and sensation of the nipple areolar complex. It was noted
that the inferior pedicle satised many of the goals of breast
reduction, such as preservation of sensation to nipple areola
complex and breast feeding potential in addition to obtaining
volume reduction. The glandular core and the nipple areola
complex are nourished by the perforators from the underlying pectoral muscles. The skin aps are nourished and sensate due to the medial intercostal and lateral pectoral vessels
and nerves. This allows for safe excision of the medial and
lateral breast segments without compromising circulation or
sensation.
15.5 Surgical Steps oftheClassical Inferior
Pedicle
The surgical steps of the classical inferior dermal pedicle are
illustrated below:
Figures 15.5, 15.6, 15.7, and 15.8 illustrate the pertinent
vascular anatomy.
Figure 15.9 illustrates the concept of the technique
schematically.
Figure 15.10 shows the three areas of glandular resection
in the classical inferior pedicle technique.
Figure 15.11 illustrates the markings.
Figure 15.12 shows de-epithelialization of the inferior
dermal pedicle.
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