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15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
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Fig. 15.49 Pre and post 600g resected
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K. S. Bhangoo
Fig. 15.50 Pre and post 650g resected
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
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Fig. 15.51 Pre and post 700g resected
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K. S. Bhangoo
Fig. 15.52 Pre and 3years post op 800g resected
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
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Fig. 15.53 Pre and post 900g resected
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K. S. Bhangoo
Fig. 15.54 Pre and post 1000g resected
15.20 Caveats
1. Ensure accurate markings.
2. Pedicle width should be like a pyramid with a wider base.
3. Keep the dissection supercial to the muscle.
4. Keep the aps at least 1cm or more thick.
5. During closure, take a bite 0.5 cm away from the skin
edge through the dermis. This will result in a better scar.
6. Ensure adequate resection of the breast tissue to prevent
the most common complication which is under resection.
References
Annual Statistics American Society of Plastic Surgery 2020.
Arufe HN, Erenfryd A, Saubidet M.Mammaplasty with a single, ver-
tical, superiorly-based pedicle to support the nipple-areola. Plast
Reconstr Surg. 1977;60:221–7.
Georgiade NG, etal. Reduction mammaplasty utilizing an inferior ped-
icle nipple-areolar ap. Ann Plast Surg. 1979;3:211.
Hall-Findlay EJ.Reduction mammaplasty. The art of aesthetic surgery,
principles and techniques. Foad Nahai Quality Medical Publishing;
2005. p.1951–2043.
Hirshowitz B, Moscona AR. Modication of the bipedicled vertical
dermal ap technique in reduction mammaplasty. Ann Plast Surg.
1982;8:3663–369.
Hugo NE, McClellan RM. Reduction mammaplasty with a single
superiorly- based pedicle. Plast Reconstr Surg. 1979;63:230–4.
McKissock PK.Reduction mammaplasty with a vertical dermal ap.
Plast Reconstr Surg. 1972;49:245–52.
Nahabedian MY, McGibbon BM, Manson PN.Medial pedicle reduc-
tion mammaplasty for severe mammary hypertrophy. Plast Reconstr
Surg. 2000;105:896–904.
Orlando JC, Guthrie RH Jr. The superomedial dermal pedicle for nipple
transposition. Br J Plast Surg. 1975;28:42–5.
Robbins TH.A reduction mammaplasty with the areola-nipple based
on an inferior dermal pedicle. Plast Reconstr Surg. 1977;59:64–7.
Skoog T.A technique of breast reduction—transposition of the nipple
on a cutaneous vascular pedicle. Acta Chir Scand. 1963;126:453–65.
Strombeck JO.Mammaplasty: report of a new technique based on the
two-pedicle procedure. Br J Plast Surg. 1960;13:79–90.
Wise RJ.A preliminary report on a method of planning the mammo-
plasty. Plast Reconstr Surg. 1956;17:367–75.
Breast Reduction withFree Nipple Graft
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Transfer
MubarizMammadli, MohanThomas, andJamesD’silva
16
The female breast is one of those rare organs that anatomically has no bony or cartilaginous support to keep it in place
while gravity is continuously acting on it and trying to bring
it down. Soft brous suspensions attach it to the chest wall to
maintain its projection, while its adult shape is inuenced by
the genetic predisposition and the bone, cartilage, and muscle elements that are present at the base of the breast. A ‘perfect breast’ for a woman involves having the right proportion
of fat, glandular tissue, and connective tissue in a skin envelope that hold everything in place at a right projection on a
chest which is proportionate to her height, weight, and lower
body making it look conical and perky (Kotti 2018).
Breast reduction procedures are of different types based
on the breast volume, extent of droop, prociency of the surgeon in a particular technique, etc. The principal aim of these
procedures is to reposition the droopy, large breast having a
low nipple position and a large areola into a well-positioned,
uplifted, and perky breast with nipple pointing forward and
outward. A breast reduction usually involves moving the
nipple on its vascular pedicle which includes the residual
breast tissue left behind after adequate excision of the breast
tissue has been undertaken.
Excess breast tissue, fat deposits, and skin either naturally
or due to pathologies can lead to breast enlargement and
drooping, also called ‘breast ptosis’. Breast tissue is further
affected by ageing, gravity, and smoking which causes glandular and skin stretching primarily in the lower pole and the
peri-areolar area which bears the brunt of the excess weight.
Supplementary Information The online version contains supplementary material available at
M. Mammadli (*)
Aesthetic Plastic Surgeon, Plastic Surgery Clinic, Baku, Azerbaijan
M. Thomas · J. D’silva
Aesthetic Surgeon, The Cosmetic Surgery Institute
and D.Y. Patil University, Mumbai, India
https://doi.org/10.1007/978- 981- 99- 3726- 4_16.
Usually most breast reduction procedures include using a
parenchymal pedicle to preserve nipple sensation and viability as the most major step for breast reduction surgery. For
very large breasts with Grade III glandular ptosis an inferior
pedicle technique of pedicle creation is usually chosen, but a
bipedicle or superior pedicle technique may also be used,
depending on the clinical situation. In severe macromastia,
however, when the reduction is large and the nipple-areolar
complex requires signicant elevation, a free nipple graft
technique offers several advantages. The signicantly lowered NAC usually requires a very long pedicle if it has to be
repositioned at a higher level with its intact vascularity. Such
long pedicles are usually wide-based to preserve nipple viability which in turn compromises an adequate breast reduction and achievement of a desirable contour. For these
patients, a free nipple graft technique provides exibility and
ease in shaping the breasts to give adequate reduction and
superior shape (Stephen and Colen 2001) (Fig.16.1a, b).
The rst breast tissue amputation/free nipple graft reduction mammaplasty is ascribed to Thorek (Thorek 1989), who
in 1922 performed breast reduction with a free nipple graft in
a patient with virginal hypertrophy. Many surgeons at the
time considered it unacceptable, and this form of mammoplasty is still not accepted by some contemporary surgeons.
However, in selected individuals, this method offers an
exceptionally safe alternative to pedicled breast reduction
techniques.
Some techniques incorporate a de-epithelialized inferior
pedicle that is buried as an autologous implant. This tongue
of tissue is sutured to the chest wall to maximize contour,
projection, and superior pole fullness; the results are permanent and long lasting. In certain situations, this technique
enables the surgeon to begin the procedure as a pedicle technique and then decide intraoperatively, if indicated, to convert to a free nipple graft by simply shortening the pedicle
and transferring the nipple-areolar complex as a free graft.
The ability to convert easily to a free nipple graft technique
is an advantage when the preoperative choice of technique is
unclear.
© 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_16
243
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M. Mammadli et al.
ab
Fig. 16.1 (a, b) Tissue excision in a breast reduction with free NAC graft technique
The free nipple graft technique of breast reduction is
avoided by most surgeons because it is regarded as an amputation, precludes future breast feeding, and reduces erotic
nipple sensibility.
Ahmed etal. (Ahmed and Kolhe 2000) undertook retro-
Free nipple graft
B
A
C
Lateral resection
this technique tends to require a very signicant reduction as
in gigantomastia or tends to be older or have greater anaesthetic risk.
Some indications for amputation/free nipple grafting
include (Oneal etal. 1991)
spective studies on 17 of their patients who had undertaken
free nipple grafts and compared them with those undergoing
inferior pedicle breast reduction and they found sensation
and erotic function in almost all of their patients 1year after
breast reduction. They postulate that the nipple-areolar graft
is placed onto a dermal bed which is richly innervated by the
supraclavicular and upper intercostal nerves and it therefore
recovers good sensations. They have also demonstrated erectile function in the majority of free nipple-areolar grafts
patients and conclude that even a small amount of muscle
remaining in the graft can allow it to retain an erotic
function.
1. Women with extreme macromastia (gigantomastia),
Fig.16.2. Please rule out hormonal issues such as raised
level of prolactin.
2. Ladies with systemic diseases with poor microcirculation
or poor wound-healing potential (e.g., diabetes, chronic
steroids, collagen vascular disease, rheumatoid arthritis,
and so forth).
3. Prior breast incisions due to surgical procedures that may
limit pedicle or skin ap viability.
4. Very old women who only want alleviation of symptoms
due to heavy breast and are not worried about nippleareola sensation.
Lower resection
16.1 Indications
The decision to perform an amputation/free nipple graft
reduction mammaplasty in lieu of the more common pedicled techniques is typically based on a concern for the safety
of the patient and/or the safety of the nipple-areolar complex.
The procedure can be done rapidly with minimal skin undermining, minimal blood loss, and without concern for the distance that the nipple-areola will be transposed or the amount
of glandular resection required. The obvious drawback to
free nipple grafting is loss of nipple function in terms of
breast feeding or erotic stimulation. Thus, a candidate for
16.1.1 Relative Indications
1. Patient with a primarily fatty breast in whom pedicle
techniques frequently do not maintain good long term
contour.
2. This technique can also result in improved nipple projection in patients who have severely inverted nipples.
3. In the patient with large breasts who is undergoing
lumpectomy for a centrally located breast cancer, free
nipple graft facilitates aggressive lumpectomy while preserving breast contour.
16 Breast Reduction withFree Nipple Graft Transfer
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abc
Fig. 16.2 Gigantomastia as seen from frontal view (a), Three quarter view (b) and Left lateral view (c) which shows the degree of Ptosis
245
16.2 Marking oftheExcision
Preoperative markings are undertaken with the patient standing (Fig. 16.3a–d). The most important markings are the
position of nipple-areola complex, the breast meridian, and
the inframammary crease. The new nipple location is marked
by transposing the inframammary crease onto the breast
through a bimanual palpation taking care that the distance of
the nipple from the sternal notch is 21–25cm. It is kept at
21cm in short statured individuals, while the distance is kept
longer in taller ladies. A modied Wise pattern is then
marked without the central dome with the vertical limbs (AB
and AC in the gure) measuring 7–8 cm. The dome is not
marked so that there is an option of moving the new NAC
position based on the overall shape of the breast achieved
during surgery as it is more important to centre the NAC on
the breast mound. The angle between the two limbs depends
on the preoperative size of the breast, the desired breast volume, and the lateral skin laxity (amount of skin to be rotated
inwards). If more breast tissue is to be resected, the angle
BAC (Fig.16.3c) is made wide but to increase the breast vol-
ume, the angle is made narrow. Projection can also be
increased by leaving longer medial and lateral pillars with
the distal tissue (>7cm) being de-epithelized and tucked in
(Casas etal. 2001).
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M. Mammadli et al.
a
b
c
d
Fig. 16.3 (a, b) Bimanual palpation to transpose the inframammary
crease to the breast. The neo nipple position ‘A’ is marked on the breast
meridian. (c) AC and AB are lines drawn based on the wise pattern
16.3 Technique
Patient is placed in a supine position under general anaesthesia, arms extended and exed at the elbow with good padding and support at the shoulder. This is done to prevent any
traction on the brachial plexus caused due to the abnormal
position of the arm for a long period of time (Fig.16.4).
1. Harvest of nipple-areola complex
The rst step of this technique of breast reduction
involves harvesting the nipple-areola complex. A cookie
which are usually 7 cm in length. The angle between the two lines
depends on the lateral skin laxity. (d) The markings completed on the
patient
cutter of 42mm diameter is used to mark the outline of
the incision. This is centred on the nipple and the marking
is done with the breast skin fully stretched so that there
are no discrepancies on either sides (Fig.16.5a). The projection of the nipple when the breast skin is fully stretched
has to be assessed. If the nipple papule has a projection of
more than 5mm, then the distal part of the nipple should
be amputated and closed primarily just like a nipple
reduction surgery (Oneal etal. 1991).
(a) Marking of the outline of NAC harvest (Fig.16.5b).
The cookie cutter is used to mark the depression on
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