A new technique of reduction mammaplasty: dermis suspension and elimination of medial scars.

In the last decades new techniques of reduction mammaplasty significantly improved the results obtained and led to a reduced incidence of complications. However, some important problems like the loss of a natural submammary fold and alteration in the shape of the breast with time still remained mostly unsolved and the medial scars in the inverted T techniques are aesthetically unsatisfying. A new strategy for reduction mammaplasty has been developed based on a combination of advantages of other techniques. The principle of using de-epithelialized infra-areolar skin for dermis suspension prevents sagging of the remaining breast tissue behind the inframammary fold to create a long-lasting, natural shape of the reduced breast with an accentuated submammary fold. The central pedicle is favoured because of good modelling even in big reductions. Better vascular and nerve supply of the nipple-areola complex and the continuity of the lactiferous ducts are further advantages of the central pedicle. Secondary operations after reduction mammaplasty or augmentation usually dictate the use of a superior pedicle together with the dermis suspension technique. B-shaped skin incisions prevent medial submammary scars and can be used up to a 10 cm transposition distance of the nipple without disadvantage. The operative technique is described in detail. Examples are given for the primary procedure and the technique as a secondary correction. The principle of dermis suspension in combination with the prevention of a medial scar is applicable to reduction mammaplasty as well as mastopexy.     

Long-Lasting Evolution of Ptosis Control After Reduction Mammaplasty Using the Hammock Technique

Background The hammock technique combines inferior pedicle mammaplasty with retropectoral and inferior suspensions to prevent displacement of breast tissue toward the inferior mammarian pole. This study aimed to assess the long-lasting internal suspension with the author’s mammary reduction technique. Methods From 1987 to 2005, the hammock technique was performed for 623 breast reduction patients (1,201 breasts), including 318 women (636 breasts) who underwent the technique between 1994 and 2005. From the latter group, the author retrospectively reviewed the case histories of 281 patients who had come for long-term follow-up evaluation. All had significant ptosis associated with breast hypertrophy. Preoperative and postoperative examinations included evaluation of postoperative bottoming out by monitoring of three measurements: the sternal notch-to-nipple length, the inferior areolar border-to-inframammary fold length, and the distance between the inframmary fold and the projection of the lowest breast contour on the chest wall. Results The evaluation data on postoperative ptosis are derived from a control study at 30 months, 5 years, and 7 years or more for 281 women (562 breasts) of the 318 who underwent surgery using this technique over the 11-year period. Review after 2.5 to 7 years or more shows that inferior areolar border-inframammary fold distance increases no more than 10 mm. Conclusions The hammock technique suspension achieves true permanent breast lifting through dermis strips from the inferior pedicle itself. This procedure also gives predictable results, a low morbidity rate, and good breast shape.     

Mammoplasty with an L-shaped limited scar and retropectoral dermopexy

In mammoplasty the goal of the surgeon is giving the breast new form and volume and good, durable shape with minimal scarring. This article presents a simple technique of reduction mammoplasty that avoids incisions in the so-called hypertrophic areas of the chest, the medial and the lateral extremities of the submammary fold. The technique is based on nipple transposition on a superior semicircular flap in the new predetermined side, supra-areolar dermopexy. The skin of the inferior pole of the breast is internally de-epithelized to two curvilinear incisions that end near the projection of the anterior axillary line to form an inferior dermal flap for retropectoral dermopexy. The limited residual scar is L-shaped. Ptotic and hypertrophic breasts can be treated with this method.     

Short scar reduction mammaplasty in the bariatric patient

Reduction mammaplasty may be necessary even after massive weight loss. Patients typically present with unfavorable breast features such as significant loss of upper pole volume, inelastic skin, and severe ptosis. The most common approach in the United States has been the Wise-pattern inferior pedicle technique, emphasizing skin excision. This report presents the short scar vertical reduction mammaplasty approach for the bariatric patient population. It aims to demonstrate improved outcomes with less scar burden. The study included 15 women (n = 29 breast reductions) with mean age of 41.8 years. All the patients had undergone gastric bypass surgery, with mean weight loss of 109 pounds and mean body mass index of 33.3 kg/m(2). A modified superomedial pedicle vertical mammaplasty technique was used. New nipple position was placed lower than the inframammary fold in accordance with vertical lack of upper pole fullness. Suction-assisted lipectomy was used to contour the inferior pole of the breast before glandular resection. A full-thickness superomedial pedicle and median incision of the upper pole maximized pedicle safety. The mean breast resection was 605 g on the right side (range, 352-945) and 592 g on the left side (range, 360-908). Patient satisfaction was high, with pleasing and stable breast shape at long-term, and a mean patient-related aesthetic ranking of 4.3 of 5.0. No major complications were noted. It is shown that superomedial pedicle vertical reduction mammaplasty can be an alternative approach in bariatric patients, achieving long-term pleasing and stable results with significantly decreased scar burden.     

改良真皮帽双环法行乳房缩小整形术

目的：灵活应用真皮帽双环法行乳房缩小成形。方法：采用传统的双环法设计切口，外下象限辅助S形切口线，保留乳晕周围较大面积完整的真皮帽，切除乳房外下象限腺体组织，设计外上及内下两个腺体组织瓣交错连接固定成形，乳晕周围内外环真皮荷包缝合，修整乳晕周围及外象限多余皮肤，切口呈环形，辅助切口瘢痕较小。结果：术后三月随访，新乳房的大小和形态．乳头乳晕的位置和形态均满意，除具有良好的感觉及勃起功能外，还保留了泌乳功能。结论：用组织瓣旋转固定的改良真皮帽双环法行乳房缩小成形，手术操作简单，组织瓣及乳头乳晕供血丰富，组织损伤小，值得推广。     

Mammoplasty with an L-shaped limited scar and retropectoral dermopexy

In mammoplasty the goal of the surgeon is giving the breast new form and volume and good, durable shape with minimal scarring. This article presents a simple technique of reduction mammoplasty that avoids incisions in the so-called hypertrophic areas of the chest, the medial and the lateral extremities of the submammary fold. The technique is based on nipple transposition on a superior semicircular flap in the new predetermined side, supra-areolar dermopexy. The skin of the inferior pole of the breast is internally de-epithelized to two curvilinear incisions that end near the projection of the anterior axillary line to form an inferior dermal flap for retropectoral dermopexy. The limited residual scar is L-shaped. Ptotic and hypertrophic breasts can be treated with this method.Presented at the XXXIVth National Congress of Italian Society of Plastic Surgery, Bari, 2–5 October 1985     

内上腺体蒂乳房缩小成形术

目的 探讨一种能够保持乳房功能和形成良好外观的乳房缩小成形术。方法 根据乳房肥大的程度设计不同类型的皮肤切口，采用内上腺体蒂技术，切除外上方和下方过多的乳腺组织，将保留的乳腺组织重新塑形，切除多余的皮肤后缝合切口。结果 本组36例72侧乳房术后形态良好，无并发症，乳头乳晕感觉良好，效果满意。结论 内上腺体蒂技术是一种安全、有效的手术方法，能获得持久的塑形效果，通过选择不同类型的皮肤切口可以适用于各种程度乳房肥大的矫治。     

A New Personal Surgical Procedure for Breast Reduction and Lifting

A series of 40 patients operated from 1995 through 1997 is reviewed. The women ranged in age from 18 to 40 and were seen in either a university- or a private-hospital setting. Thirty-eight of the patients underwent reduction mammaplasty, which was performed using an inferior pedicle technique with a straight-line incision; two patients underwent mastopexy only. The reduction procedure depends on the formation of a cap from medial, lateral, and superior flaps. Following resection of breast tissue the cap is joined to a cone—the nipple–areola complex carried on a subcutaneous inferior pedicle. The cone is fixed to the chest wall with simple vertical stitches, minimizing the recurrence of ptosis. This technique is safe and versatile, avoids a submammary scar, and offers an aesthetic and long-lasting result.     

乳房重度下垂的直线切口法乳房成形术

目的 介绍应用直线切口法乳房成形术(Lejour法)治疗重度乳房下垂方法及效果.方法 按Lejour法设计手术切口.该类患者新乳头位置较正常人群可适当下移1～2 cm,新乳房下皱襞上移5～10 cm,通过适当下移新乳头位置及上移新乳房下皱襞达到缩短垂直切口距离.剥离乳腺组织,将下垂乳腺组织从乳腺深层固定于胸大肌第2、3肋水平.皮肤无张力缝合.结果 36例中乳房肥大者30例、体积基本正常者6例,经术后3个月至2年随访,无明显并发症,新乳房外形挺拔自然,患者满意.结论 本术式简便易行,远期效果好,可作为重度乳房下垂的术式之一.     

Dermafascial Fixation Suture: A Technique for a More Durable Projection with Short-Scar (Vertical) Reduction Mammaplasty

Background Short-scar reduction mammaplasty has several advantages over the traditional technique, mainly reduced scarring and superior long-term breast shape. Multiple modifications of the short scar reduction mammaplasty technique have been made in an effort to decrease the learning curve while improving the results. The authors present another modification of the short-scar technique for a more durable projection without reliance on a skin envelope. Methods The perimeters of the medial pedicle and the nipple–areola complex are marked, and the medial pedicle is deepithelialized. A 2 × 5-cm skin area at the inferior border of the pedicle is further deepithelialized, then pexied to the pectoralis fascia in a superomedial direction using a nonabsorbable monofilamanet suture with a horizontal mattress suturing technique. Results Taking the suture bites from the dermis rather than the breast parenchyma for the pexy aims to spare the pedicle’s circulation. This durable internal rearrangement of the breast parenchyma with dermafascial pexy further decreases the tension at the nipple–areola complex because the final breast shape no longer relies on the skin closure. Suture spitting at the nipple–areola complex also is prevented with elimination of the purse-string suture because there is no need for a further decrease in the tension with the purse-string suture after the dermafascial pexy. Conclusions The authors believe that the dermafascial pexy is a concept more than a technique. It incorporates the two strongest structures, the dermis and the fascia, to achieve more durable results not only with reduction mammaplasty, but also with any aesthetic breast surgery that uses the pedicles.     

复合组织下蒂法乳房缩小整形术25例

目的：回顾性总结复合组织下蒂法乳房缩小整形术25例病例资料,探讨复合组织下蒂法乳房缩小整形术手术注意事项及其并发症防治。方法：从2003～2008年5年间,对25例女性乳房肥大患者分别进行手术治疗,方法采用复合组织下蒂法。通过对术中复合组织下蒂的修整及术后乳房外形、乳头乳晕复合体血运、术后瘢痕及乳房感觉等方面观察,分析复合组织下蒂法乳房缩小整形术的术中注意事项及术后并发症的防治策略。结果：25例患者均取得了较好的效果,无乳头乳晕复合体血运障碍发生。结论：复合组织下蒂法乳房缩小整形术是较好的乳房缩小术式,良好的术前设计及术中调整是确保手术成功的关键。     

Viability and sensation of the nipple-areolar complex after reduction mammaplasty

Reduction mammaplasty with nipple-areolar transposition on a medial pedicle was designed as an alternative to amputation and free nipple graft for women with severe mammary hypertrophy. The purpose of this study was to review the viability and sensory outcome of the nipple-areolar complex (NAC) in 72 women (133 breasts) after medial pedicle and inferior pedicle reduction mammaplasty between 1996 and 2000. The medial pedicle was used for 41 women (79 breasts) with moderate to severe mammary hypertrophy. An inferior pedicle was used for 31 women (54 breasts) with mild to moderate mammary hypertrophy. Mean follow-up for all patients was 25 months. Total sensation of the NAC was obtained in 68 of 79 breasts (86%) after medial pedicle reduction mammaplasty and in 50 of 54 breasts (92%) after inferior pedicle reduction mammaplasty. Total viability of the NAC occurred in 74 of 79 breasts (94%) after medial pedicle reduction mammaplasty and in 53 of 54 breasts (98%) after inferior pedicle reduction mammaplasty. Quantitative sensory testing of the NAC using the pressure-specified sensory device demonstrated that static and moving sensory thresholds of the NAC are lowest in the inferior pedicle group followed by the control group and the medial pedicle group. It can be concluded from this study that the medial and inferior pedicle techniques are capable of supporting vascularity and innervation to the NAC. The medial pedicle technique for severe mammary hypertrophy is a good alternative to free nipple grafting. The amount of breast tissue removed does not correlate with sensory outcome for both inferior and medial pedicle techniques. The pressure-specified sensory device is an excellent means of assessing sensory outcome.     

隆乳术切口和假体置放层次及手术剥离范围探讨

目的：探讨隆乳术的切口选择、假体置放层次和腔穴剥离范围。方法：于1996例9月至2001年9月间行隆乳术537例，选择三种手术切口；乳房下皱襞切口、乳晕切口、腋窝切口；假体置放于乳腺后间隙或胸大肌后间隙；胸大肌后间隙的剥离范围以第6肋间隙为下界。术后随访半年-5年。结果：术后乳房位置、形态、手感均满意511例（占95.2%）。结论：乳房下皱襞切口适于站立时乳房下皱襞明显或者乳房轻度下垂者；对于乳晕直径≥4cm的受术者，可采用乳晕缘内上或者内下弧形切口；腋下切口最为隐蔽，适于所有的受术者。假体置放于胸大肌后间隙具有手感更真实、不易形成纤维囊性硬变、不影响哺乳等优势。在胸大肌后间隙进行剥离，顺应乳房下皱襞韧带的解剖结构，将下界定于第6肋间隙。     

Central pedicle reduction mammaplasty with a vertical scar: a technical modification

Background: This study introduces a central pedicle reduction mammaplasty with a vertical scar technique.

Objectives: This study is aimed to create a more conical breast shape and long-lasting better projection by modifying reduction mammaplasty by central pedicle flap.

Method: Preoperative markings were made including the meridian line of breast and the new location of the nipple-areola complex (NAC). The new location of the inframammary fold was marked ～2?～?4?cm above the original inframammary fold. An incision was made around the areola, the area between the resection margins and NAC was excised en bloc. The breast parenchyma was excised circumferentially, so that a cone shaped central mound was formed. An inferior and inferolateral glandular resection was performed to reduce the area of the breast base by elevating the position of the inframammary fold. After completion of dissection, the central pedicle surmounted by the NAC was transposed to its new location.

Result: Fifty-six patients were operated with our modified central pedicle technique. The mean amount of resection was 475?g (range?=?130–1080?g). The mean length of follow-up was 18?months (range?=?12–53?months). The mean postoperative satisfaction score was 4.23 (SD?=?0.81). The breast parenchymal ratio significantly increased from 1.2 preoperatively to 3.9 postoperatively.

Conclusion: The modified central pedicle reduction mammaplasty with a vertical scar technique is a versatile breast reduction technique for all shapes and tissue conditions, by providing an attractive conical shape of the breast with minimum scar burden and maximum preservation of breast function.     

容量提升理论指导下的鼻唇沟填充技术

目的探讨一种能够同时解决皮肤松垂和容量流失问题的鼻唇沟填充技术，力求恢复年轻时中面部软组织的分布特征，达到自然流畅的年轻化效果。方法采用点状注射法进行深内侧脂肪室的填充，形成深部支撑提升；以扇状注射法进行白唇真皮深层的填充，补充鼻唇沟内下方的缺失。在美学颧突点到鼻唇沟的垂线上进行多层次的连续线状注射，补充中面部的容量流失，重塑中面部年轻化曲线，拉升鼻唇沟外上方的皮肤松垂。结果本组共418例患者，其中412例患者的老化鼻唇沟得到明显改善，使面部呈现年轻化效果；6例患者的老化鼻唇沟得到一定程度改善，效果基本满意。37例患者在治疗后出现局部皮下淤血、青紫，于10d内消失。最佳效果维持时间6—12个月。结论恢复年轻时面部软组织分布特征的填充术，是一种针对面部老化后解剖学改变特点的注射填充技术，能够有效地恢复自然年轻态的鼻唇沟，并在一定程度上可达到面中部提升的效果。     

Revisiting breast masses with the plastic surgeon: suggestions for biopsy and resection

Between 250,000 and 500,000 breast mass biopsies are performed each year. This is a common procedure of the breast that should be planned such that maximum treatment is achieved with minimal disfigurement and scarring. Plastic surgery techniques must be used in the choice of biopsy site and planned excision and can result in an improved cosmetic result for the patient. Subareolar masses are resected using a radial elliptical incision. Lateral and medial masses are resected using the Wise pattern reduction mammaplasty whereas the vertical mammaplasty is used for lesions of the central inferior breast and inframammary fold. Awareness of these basic reconstructive principles by the general surgeon can minimize disfigurement and facilitate future reconstruction by the plastic surgeon so that both cure and cosmesis can be achieved.     

Innovations to the vertical reduction mammaplasty: making the transition

The vertical reduction mammaplasty can be challenging to learn. In addition, first attempts to perform the vertical reduction mammaplasty can lead to inconsistent aesthetic results. The authors describe their transition from a traditional inverted-T reduction mammaplasty to a modified vertical reduction mammaplasty based on a technique described by Elizabeth Hall-Findlay. In their early cases using the Hall-Findlay technique, they noted several aesthetic complications. These problems included a persistent vertical dog-ear deformity at the nadir of the incision, a teardrop deformity of the nipple-areola complex, lateral deviation of the nipple, and lateral axillary fullness. They developed several modifications to the Hall-Findlay technique to correct the aesthetic deficiencies and to simplify further the vertical reduction method. The authors think their innovations facilitate the transition from a traditional inverted-T breast reduction to a successful vertical reduction mammaplasty technique.     

Secondary shaping of the free TRAM: an inferior pedicle reduction mammaplasty.

Secondary shaping of the transverse rectus abdominis myocutaneous (TRAM) flap is a routine treatment, and includes liposuction, skin excision, inframammary fold replacement, dermal fat grafts or lipofilling. Major flap revision may include an augmentation procedure with implants or expanders. We present an inferior pedicle breast reduction in a woman who underwent breast reconstruction using a free TRAM flap. To our knowledge, there are no reports about reduction mammaplasty or mastopexy in Free TRAM flap breast reconstruction. Reduction mammaplasty should be regarded as a valuable option in free TRAM or deep inferior epigastric perforator secondary reshaping.     

A retrospective quantitative assessment of breast sensation after lateral pedicle mammaplasty.

Preservation of sensitivity is one of the important objectives in reduction mammaplasty. The lateral or medial pedicle reduction mammaplasty technique aims to maintain superficial innervation of the breast. These superficial nerves are smaller and more variable compared with deep and larger nerve structures, which are excised during this procedure. An assessment of recovery of tactile sensitivity after lateral pedicle mammaplasty was performed retrospectively. One hundred and one women, operated on between the year 1985 and 2000, with a lateral pedicle mammaplasty, were reviewed. Using a standardised questionnaire, women reported on subjective changes in sensation after surgery, including time of recovery and the influence which surgery had on sensual function. Fifty-nine of these women were tested 3-7 years after surgery. Touch sensitivity was measured using a set of 20 Semmes-Weinstein monofilaments. Erectile function was also tested. The mean pressure threshold for the areola region was 19.12 g/mm(2) and for the nipple 16.75 g/mm(2), which is better that in studies on inferior pedicle mammaplasty. In previous studies patients were tested earlier, which may explain this difference.No correlation was found between sensitivity and resected tissue (for the areola p=0.88 and for the nipple p=0.82) or between sensitivity and age of patients (for the areola p=0.73 and for the nipple p=0.80). There were individual differences in the results. It is speculated that variability in anatomy of superficial nerves might explain these differences. Nearly all patients tested regained their erectile function. The majority of patients did not notice any change in their erogenous function. Twelve (12%) reported a post-surgical improvement of sensation. Nipples with partial loss of sensation persisted in 2% of the patients.     

Periareolar reduction mammaplasty utilizing the inferior dermal pedicle

The critical points which should not be overlooked when performing reduction mammaplasty are to minimize scar on the breast and to ensure a sufficient blood supply for the viability of the nipple–areolar complex. Periareolar reduction mammaplasty has been widely used because it left only one scar around the areola. However, with the typical periareolar reduction mammaplasty technique, it is difficult to remove a large amount of breast tissue and mobilize the remaining breast tissue. It may result in necrosis of the nipple–areolar complex in some cases. To overcome these limitations we combined the periareolar incision with the inferior dermal pedicle, which has a relatively good blood supply. This new technique was employed in 22 consecutive women (44 breasts) with hypertrophy and a varying degree of ptosis. Infiltration of a tumescent solution and liposuction were performed in all cases. After periareolar incision, dissection of the skin was performed, and the breast was elevated from the fascia of the pectoralis major muscle, leaving the inferior dermal pyramidal pedicle. An adequate amount of tissue was resected in the superior, medial, and lateral areas. After mastopexy, closure was done with a purse-string suture. The amount of tissue resected ranged from 180 to 1510 g per breast, and the mean was 466.1 g. The mean length of elevation of the nipple was 10.6 cm along the meridian of the breast. There were a few complications which needed revision operation: hematoma collection in one breast (2.3%), wound dehiscence in one breast (2.3%), and fat necrosis in one breast (2.3%). There was no necrosis of the nipple–areolar complex. With this new technique of periareolar reduction mammaplasty utilizing the inferior dermal pedicle, we were able to minimize the scar, preserve the nipple–areolar complex, and improve the motility of the breast tissue. But we also observed a flat or square appearance in the case of a large amount of resection in the patients with poor skin elasticity. This technique is safe and versatile and produces aesthetically acceptable results in selected patients.