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R. C. Ribeiro et al.
Conclusions
After more than 30 years of evolution of mammary reconstruction techniques, the
use of a lower pedicle, became the technique of choice for the treatment of large
gigantomastias or mammary hypertrophy. The authors indicate this technique
mainly in young patients with reproductive expectations after surgery, due to the
conservation of the glandular anatomy , thus avoiding the late complications associated with areola grafts used in the past and preserving lactation. These advances,
together with the fact that they guarantee a lasting suspension, demonstrate the
interest of current plastic surgeons in achieving a balance between the reality of
the patient with this breast pathology and her aesthetic expectations, as well as
maintaining their longings for personal fulllment as having a victorious
motherhood.
References
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reduction techniques: a survey of board-certied plastic surgeons 2002. Plast Reconstr Surg.
2004;114(7):1724–36.
Georgiade GS, Riefkohl RE, Georgiade NG.The inferior dermal-pyramidal type breast reduction:
long-term evaluation. Ann Plast Surg. 1989;23(3):203–11.
Scott GR, Carson CL, Borah GL.Maximizing outcomes in breast reduction surgery: a review of
518 consecutive patients. Plast Reconstr Surg. 2005;116(6):1633–41.
Pérez-Macias JM.Long-lasting evolution of ptosis control after reduction mammaplasty using the
hammock technique. Aesthetic Plast Surg. 2007;31(3):266–74.
Ribeiro L, Accorsi A Jr, Buss A, Marcal-Pessoa M.Creation and evolution of 30 years of the infe-
rior pedicle in reduction mammaplasties. Plast Reconstr Surg. 2002;110(3):960–70.
Jurado J.Plásticas mamárias de redução baseadas em retalho dérmico vertical monopediculado.
Anais XII Congresso Brasileiro de Cirurgia Plástica 1976;29.
Robbins TH.A reduction mammaplasty with the areola-nipple based on an inferior dermal pedi-
cle. Plast Reconstr Surg. 1977;59(1):64–7.
Courtiss EH, Goldwyn RM.Reduction mammaplasty by the inferior pedicle technique. An alterna-
tive to free nipple and areola grafting for severe macromastia or extreme ptosis. Plast Reconstr
Surg. 1977;59(4):500–7.
Calderon Ortega W, Arriagada Stuven J, Godoy Silanes M, Gomes SL.Anatomia y clinica de las
mamoplastias de reducción según técnica del pedículo inferior. Rev Chil Cir. 1992;44(4):437–41.
Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas DA. Reduction mammaplasty with
the inferior pedicle technique: early and late complications in 371 patients. Br J Plast Surg.
1996;49(7):442–6.
Wallace WH, Thompson WO, Smith RA, Barraza KR, Davidson SF, Thompson JT 2nd. Reduction
mammaplasty using the inferior pedicle technique. Ann Plast Surg. 1998;40(3):235–40.
O’Grady KF, Thoma A, Dal Cin A.A comparison of complication rates in large and small inferior
pedicle reduction mammaplasty. Plast Reconstr Surg. 2005;115(3):736–42.
Zambacos GJ, Mandrekas AD.Complication rates in inferior pedicle reduction mammaplasty.
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Hunter JG, Ceydeli A.Correlation between complication rate and tissue resection volume in infe-
rior pedicle reduction mammaplasty: A retrospective study. Aesthetic Surg J. 2006;26(2):153–6.
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Nahabedian MY, Mod MM.Viability and sensation of the nipple-areolar complex after reduction
mammaplasty. Ann Plast Surg. 2002;49(1):24–32.
Pitanguy I, Salgado F, Radwansky HN.Reduções mamárias: técnicas pessoais sem descolamento
cutâneo. In: Mélega JM, ed. Cirurgia plástica: fundamentos e arte. Cirurgia Estética. Rio de
Janeiro: Médica e Cientíca; 2003. p.477–84.
Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensitivity by
reduction mammaplasty: a prospective comparison of ve techniques. Plast Reconstr Surg.
2005;115(3):743–51.
Ribeiro L.A new technique for reduction mammaplasty. Plast Reconstr Surg. 1975;55(3):330–4.
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pedicle nipple-areolar ap. Ann Plast Surg. 1979;3(3):211–8.
Saldanha OR, Maloof RG, Dutra RT, Luz OAL, Saldanha Filho O, Saldanha CB. Mamaplastia
redutora com implante de silicone. Rev Bras Cir Plást. 2010;25(2):317–24.
Bezerra FJF, Moura RMG, Silva Júnior VV. Mamoplastia redutora e simetrização de mama
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2007;22(1):52–9.
Anger M, Schneider EJ, Souza CE, Nakayama LI. Mamoplastia redutora de pedículo inferior:
sensibilidade aréolo-mamilar, indicações e resultados. Arq Catarin Med. 2001;30(3/4):32–7.
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de mamoplastia quanto a sua inuência tardia na distância do complexo areolopapilar ao sulco
inframamário. Rev Bras Cir Plást. 2011;26(4):664–9.
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na técnica de Skoog. Rev Bras Cir Plást. 2009;24(3):321–7.
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relief of symptoms and patient satisfaction. Aesthetic Plast Surg. 2005;29(2):83–7.
Arié G.Una nueva técnica de mastoplastia. Rev Latinoam Cir Plast. 1957;3(1):23–31.
Ariyan S. Reduction mammaplasty with the nipple-areola carried on a single, narrow inferior
pedicle. Ann Plast Surg. 1980;5(3):167–77.
Castro CC, Salema RF, Ferreira VB, Gazola LA.Mamaplastia redutora pela técnica de pedículo
dermogorduroso da base inferior. Rev Bras Cir. 1983;73(1):47–52.
Migliori MR, Muldowney JB.Breast reduction: the inferior pedicle as an axial pattern ap. Aesthet
Surg J. 1997;17(1):55–7.
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Cir. 2002;41(1):11–5.
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quistos? Rev Bras Cir Plást. 2006;21(2):73–6.
Plastic and Reconstructive Surgery, March 2003- 111 (3), page 1363.
Plastic and Reconstructive Surgery 107 (7) June 2002 page 2605
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Chapter 16
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Importance ofGlandular
andDermoglandular Flaps forBreast
Surgery
CarlosOscarUebel
Abstract We have many techniques for breast reduction and for mastopexies.
Since Pitanguy presented his technique at the Second World Congress of IPRAS
(International Plastic Reconstructive Aesthetic Surgery) in 1959 in London
(Pitanguy 1959) and published his paper in 1967in a peer-reviewed journal—the
British Journal of Plastic Surgery (Pitanguy 1967)—many other papers appear in
the literature, especially using dermoglandular aps to enhance the volume and to
ll out the upper pole of the breast. Skoog (Skoog 1971), Ribeiro (Ribeiro 1975),
and Silveira Neto (Silveira Netto 1976) can be referred as introducers of this new
approach. We have also started with two similar procedures that we want to discuss
in this chapter—the superior glandular ap and the lateral dermoglandular rotation ap.
Introduction
We have many techniques for breast reduction and for mastopexies. Since Pitanguy
presented his technique at the Second World Congress of IPRAS (International Plastic
Reconstructive Aesthetic Surgery) in 1959in London (Pitanguy 1962), and published
his paper in 1967in a peer-reviewed journal—the British Journal of Plastic Surgery
(Pitanguy 1967)—many other papers appear in the literature, especially using dermoglandular aps to enhance the volume and to ll out the upper pole of the breast.
Skoog (Skoog 1971), Ribeiro (Ribeiro 1975), and Silveira Neto (Silveira Netto 1976)
C. O. Uebel (*)
Division Plastic Surgery, PUCRS University, Porto Alegre, Brazil
e-mail: carlos@uebel.com.br
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_16
275© The Author(s), under exclusive license to Springer Nature
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can be referred as introducers of this new approach. We have also started with two
similar procedures that we want to discuss in this chapter—the superior glandular ap
and the lateral dermoglandular rotation ap.
C. O. Uebel
Method andTechnique
Superior Pedicle Flap
This is a very simple procedure combined with the Pitanguy-Ariê technique (Ariê
1957) indicated for ptotic and medium breast hypertrophy. An ellipse of the skin is
removed vertically reaching 2cm above the inframammary sulcus or extended laterally as shown in Fig.16.1a–c. A superior pedicle glandular ap is erased from below
and rotated by itself into a tunnel undermined into the upper pole of the breast. This
is a maneuver to ll out and to enhance the volume of the breast giving a good support as shown at postoperative 18months (Figs.16.2a–d and 16.3a–c). An intradermal suture is placed, and sterile strips are applied to protect the suture and are kept
in place for 15days. We can use the “L” technique published by Bozola (1990).
Very often, in around 30%, we combine the procedure with abdominoplasty and
other body contouring surgeries (Fig.16.4a–c).
c
Fig. 16.1 (a, b, c) A superior pedicle glandular ap is erased and rotated by itself to ll out the
upper breast pole
cd
16 Importance ofGlandular andDermoglandular Flaps forBreast Surgery
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ab
277
Fig. 16.2 (a, b, c, d) Postoperative 18months with a fullling upper pole
Supralateral Dermoglandular Flap
The most common breast reduction technique still used in Brazil is the one described
by Pitanguy in 1967. It consists of removing a keel-shaped portion of the breast tissue, which results in two lateral pillars that provide the necessary structure to raise
the nipple-areola complex (NAC) in a very natural shape while maintaining good
physiologic function. This technique is especially useful for patients with mild to
moderate hypertrophic breasts (Fig.16.5a–c).
However, for patients with larger breast hypertrophy, with or without asymmetry,
it is signicantly more challenging to raise the NAC, and the procedure may create
some skin tension. For such patients, the techniques described by Skoog in 1971
(Skoog 1971) and Silveira Neto in 1976 (Silveira Netto 1976) and modied by the
author in 1978 (Uebel and Uebel 1978; Uebel 2011; Uebel 2012) are very useful to
be applied.
Technique
Points A, B, and C are marked with the patient in an upstanding position in the same
fashion as in the Pitanguy technique. The supralateral ap is outlined (Fig.16.6).
The patient is given general anesthesia and sometimes epidural anesthesia through
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ab
c
C. O. Uebel
Fig. 16.3 (a, b, c) Ptotic breast with the Pitanguy-Ariê technique and superior pedicle ap to
enhance the upper pole
c
Fig. 16.4 (a, b, c) This technique can be combined frequently with abdominoplasty
16 Importance ofGlandular andDermoglandular Flaps forBreast Surgery
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279
a continuous-infusion catheter. To reduce intraoperative bleeding, a local inltration
of saline and epinephrine 1:200,000 is done. The dermoglandular ap is deepithelialized and prepared, together with the NAC; the ap is then ready to be relocated to
its new site without excessive tension and with a good blood supply.
ab
c
Fig. 16.5 (a, b, c) Medium breast hypertrophy treated with the Pitanguy technique
Fig. 16.6 The supralateral
ap is outlined
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C. O. Uebel
In 1971, Skoog published his nipple-areola-dermis ap rotation technique for
severe hypertrophic breasts. However, this technique sometimes results in problems
with vascular support and lactation. In 1976, and with the use of the same principles
described by Skoog, Silveira Neto modied the technique by rotating an inner glandular ap which improved irrigation and lactation ability. In 1978, we published another
variation of the technique outlining the supralateral dermoglandular ap. In addition to achieving good vascular support and function, this maneuver offers a better
contouring to the upper pole of the breast and axillary regions (Figs. 16.7 and 16.8).
abc
def
gh
i
Fig. 16.7 (a–m) A 52-year-old patient with severe hypertrophy was treated with the supralateral
dermoglandular rotation ap technique. She is shown 3months postoperatively with improved
breast contour, axillary reduction, and nipple-areola projection
de
16 Importance ofGlandular andDermoglandular Flaps forBreast Surgery
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abc
281
fg
Fig. 16.8 (a–j) Very common association in a 42-year-old patient with breast hypertrophy and
abdomen accidity. She underwent breast reduction with the supralateral dermoglandular ap
and abdominoplasty. Two days postoperatively with sterile strips and 6months postoperatively in
sitting and standing positions
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C. O. Uebel
jih
Fig. 16.8 (continued)
For patients with severe breast hypertrophy, with or without asymmetry, there is
a bigger challenge to address when raising the NAC.In such cases, the technique of
the supralateral dermoglandular ap is indicated to bring the NAC upward with-
out any tension, thereby preserving the neurovascular supply and physiologic lactation function. Good sensitivity and a natural contour of the breast and axillary region
can be achieved with this technique (Fig.16.7).
The external supralateral dermoglandular ap is designed and deepithelialized, preserving the NAC.Resection is done en bloc, removing a complete piece of
the mammary tissue reaching the pectoralis major fascia. The ap is rotated from
the external site to upward to anchor the areola in the new position. Sutures of 4-0
nylon and 3-0 Monocryl are placed in all levels to close the glandular parenchyma.
Intradermal sutures are placed, and sterile strips are applied. Sterile strips are maintained for more than 3months (Fig.16.8).
Conclusion
The denitive breast reduction technique continues to elude plastic surgeons. We
have revisited the superior pedicle ap and the supralateral dermoglandular
ap, both of which are important techniques to enhance breast contour and preserve
the neurophysiologic function for breastfeeding. They are simple to execute and
improve the axillary extension and the upper pole contour giving an excellent NAC
projection and an outstanding patient satisfaction, as evidenced by a low revision
rate. The operations should be an option when treating patients with medium-tolarge breast hypertrophy.
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