Plastic surgery

PART VI

BREAST

CHAPTER 55  BREAST REDUCTION: INVERTED-T TECHNIQUE

SCOTT L. SPEAR

Reduction mammoplasty is a clear example of the interface between reconstructive and aesthetic plastic surgery. The goals of the procedure are weight and volume reduction of the breast, but aesthetic enhancement is also an important goal, particularly in some women. Excellent procedures have been described and emphasis has shifted to technical refinements for improved safety and predictable aesthetic results. At the same time, greater importance has been placed on preservation of both sensation and physiologic function. Although there is a fundamental difference between reduction mammoplasty and mastopexy, both operations can follow the design of the techniques to be described for reduction mammoplasty alone (Chapter 56).

ANATOMY AND PHYSIOLOGY

Sensory innervation to the superior portion of the breast is supplied by the supraclavicular nerves formed from the third and fourth branches of the cervical plexus. The medial breast skin is supplied by the anterior cutaneous divisions of the second through seventh intercostal nerves. The dominant innervation to the nipple is derived from the lateral cutaneous branch of the fourth intercostal nerve, whereas lateral cutaneous branches of other intercostal nerves travel subcutaneously to and beyond the midclavicular line. Independent confirmation of the importance of the lateral cutaneous branch of the fourth intercostal nerve has led to greater acceptance of techniques that include it in the vascular pedicle to the nipple.

There are three chief sources of blood supply to the breast. The internal mammary artery supplies the medial portion through medial perforators near the sternal border. The variable lateral thoracic artery supplies the lateral portion. The anterior and lateral branches of the intercostal vessels supply the remainder. Although there is a substantial degree of collateralization among these vessels in the breast parenchyma, it has been estimated that the internal mammary artery provides approximately 60% of the total. The lateral thoracic artery is thought to supply an additional 30%, primarily to the upper, outer, and lateral portions. The anterior and lateral branches of the third, fourth, and fifth posterior intercostal arteries supply the remaining lower outer breast quadrant. The variability and overlap between these vascular networks account for the remarkable safety of nipple-bearing pedicles of diverse design based on different vascular supplies.

The breast has two major venous drainage systems: one superficial and the other deep. The superficial drainage system is divided into two types: transverse and longitudinal. The transverse veins run medially in the subcutaneous space and empty into the internal mammary veins by multiple perforating vessels. The longitudinal drainage ascends to the suprasternal area to connect with the superficial veins of the lower neck. There are anastomotic connections across the midline, but only between the superficial systems. The major portion of the deep drainage is through perforating branches of the internal mammary vein. Additional venous drainage is in the direction of the axillary vein. A remaining route of drainage is posteriorly through perforators into the intercostal veins, which carry blood posteriorly to the vertebral veins.

The lymphatic pathways draining the breast parallel closely the venous pathways and include cutaneous, internal mammary, posterior intercostal, and axillary routes. Although most lymph flow is through the axillary region, the internal thoracic channels may carry 3% to 20% of the total.

Despite an extensive search for underlying metabolic causes of breast hypertrophy and gigantomastia, these conditions remain poorly understood phenomena, the products of end-organ hormonal sensitivity, genetic background, and overall body weight.

REDUCTION MAMMOPLASTY

Indications

Women seek to reduce the size of their breasts for both physical and psychological reasons. Heavy, pendulous breasts cause neck and back pain as well as grooves from the pressure of brassiere straps. The breasts themselves may be chronically painful, and the skin in the inframammary region is subject to maceration, irritation, and rashes. From a psychological point of view, excessively large breasts can be a troublesome focus of embarrassment for the teenager as well as the woman in her senior years. Unilateral hypertrophy with asymmetry heightens embarrassment. At a minimum, excessively large breasts can ultimately pose a liability for some women in terms of comfort, wearing clothes, and daily functioning, including many forms of exercise.

Inverted-T Techniques

Two decisions confront the surgeon: (a) choice of incision (scar) pattern and (b) choice of pedicle type. The inverted-T scar pattern can be applied to virtually any pedicle, including a superior pedicle, an inferior pedicle, a vertical bipedicle, a central mound pedicle, and a superomedial pedicle. The scar pattern and the pedicle type used in breast reduction are, for the most part, independent variables. Furthermore, there is no absolute cutoff regarding when an inverted-T scar pattern approach is appropriate instead of a vertical technique that avoids or attempts to avoid a transverse inframammary scar. At Georgetown University Hospital, we use both vertical techniques and inverted-T techniques, depending on the (a) size of the breast, (b) degree of ptosis, and (c) patient’s goals. Even when performing an inverted-T technique, we can virtually always shorten the transverse scar component because of our increasing experience with vertical scar techniques. The distinction, therefore, between vertical and inverted-T techniques has become less clear as surgeons add a short transverse scar to vertical techniques or shorten the transverse scar in inverted-T techniques.

The majority of American plastic surgeons still use an inverted-T scar pattern, most commonly with an inferior pedicle. Informal polls at recent breast meetings suggest that this preference is evolving with more surgeons opting for superomedial or central pedicles. There are several major advantages to the inferior pedicle with inverted-T scar technique. It is reproducible, straightforward, and easily taught. To a large extent, the skin incisions correspond to the underlying incisions that are made in the breast parenchyma itself. In this way, once the lines are drawn on the skin preoperatively, the cutting of the tissues and the closure of the wound proceed along the preoperatively planned lines. This has great advantage in terms of predictability and reliability. In contrast, vertical scar techniques often involve a significant disparity between the skin incisions and underlying glandular incisions. A significant amount of intraoperative judgment and adjustment is required in vertical scar procedures in terms of both removing tissue and reshaping tissue to obtain an acceptable result. Finally, the closure of the skin may require adjustment to deal with the excess skin at the caudal end of the vertical incision (Chapter 56).

Once the decision has been made to perform a breast reduction, the surgeon must choose the orientation of the pedicle. This chapter describes the vertical bipedicle technique, the inferior pedicle technique, a central mound technique, and my preferred technique, the superomedial pedicle technique.

Vertical Pedicle Technique

McKissock first described his vertical bipedicle technique for nipple transposition during reduction mammoplasty in 1972. With this technique, the central breast is reduced to a vertically oriented bipedicle flap based superiorly on the upper margin of the new areolar window and inferiorly on the inframammary fold (IMF) and chest wall musculature. The flap carries the nipple–areola and, although de-epithelialized, depends primarily on the parenchyma for blood supply.

FIGURE 55.1. Preoperative markings. A. Drawing the basic landmarks, including the midline and breast meridian, for most breast procedures. B. A tangent is drawn from the lower most portion of the IMF across the midline. C. This tangent is then superimposed onto the surface of the breast. D. The length of the fold is then measured. It is often between 20 and 24 cm long. E. An arc that is just over one-half the length of the fold is transposed onto the surface of the breast medially. F. A wire keyhole pattern (which is centered around the nipple site) can then be superimposed on the breast such that it crosses the arc line drawn in Figure 55.4. G. The keyhole pattern is completed by making the limbs the desired length, anywhere from 5 to 8 cm long, depending on the size of the breast. It is important to double-check that the length of these proposed superiorly based lateral and medial flaps along their cut, free, inferior edges matches the length of the fold to which they are to be approximated.

With the patient erect, the markings are made in a fashion similar to all breast reductions (Figure 55.1). The midline is drawn and the breast meridian is established by dropping a line from the midclavicle through the nipple and continuing inferiorly across the IMF. The IMF is marked, and a tangent to the fold is drawn across the lower thorax and transposed to the anterior breast and marked on the breast meridian. Whereas the initial descriptions set the nipple some 2 cm higher, the best location for the new nipple position may be at the IMF level depending on where the patient’s breast parenchyma is situated. In patients with an empty upper breast, it is important to keep the new nipple location centered or near where the breast volume lies or is expected to lie at the end of the procedure. The entire length of the IMF is measured with a tape measure. In most cases, it is between 20 and 24 cm long. Using a tape, a mark is made in the shape of a short arc on the surface of the breast that measures just over one-half the length of the fold (e.g., for a 22-cm fold, the distance would be 12 to 13 cm). Diverging lines are then drawn from the new nipple point; they pass as tangents to either side of the existing areola and meet the arc line drawn from the ends of the IMF. A wire keyhole pattern is then adjusted to a similar angle of divergence and superimposed on the lines, indicating the proper size and location of the new areolar window. The length of the limbs of the pattern is 5 to 8 cm. From these extremities, lines are directed medially and laterally to intersect the IMF.

The new areola is circumscribed using a 42- to 48-mm cookie cutter within the existing areola. The vertical pedicle is outlined by extending the lines of the vertical limbs inferiorly to the IMF as two parallel lines straddling the breast meridian. The entire pedicle, except the reduced nipple–areola, is de-epithelialized. The vertical pedicle is then incised along its medial and lateral margins to the fascia of the underlying musculature, and medial and lateral dermoglandular wedges are resected (Figure 55.2). A thin layer of breast over the lateral musculature is retained to favor preservation of sensation to the nipple–areola complex. Additional breast tissue is resected from the remaining medial and lateral elements: little to none medially, but a considerable amount, including the axillary tail, laterally. A window of breast tissue is removed from the upper portion of the bipedicle flap, from the level of the nipple to the height of the keyhole pattern, creating a bucket-handle (Figure 55.3). This resection must not extend above the upper limit of the areolar window to avoid the loss of superior breast volume. The upper portion of this bipedicle flap should be kept at least 2 cm if not 3 cm thick. The flap from the upper edge of the now-reduced areola all the way to the IMF is left full thickness. The flap is folded superiorly on itself, bringing the areola into position within the keyhole pattern. The medial and lateral flaps are brought together over the pedicle, and closure is begun, working from the extremities toward the center (Figure 55.4). Any central excess of skin is either excised at the vertical closure, or “worked-in” to the closure. Specific strategies for fine-tuning the planned incisions and closure techniques apply to all the various pedicles and are addressed in detail when describing the author’s preferred technique later in this chapter.

FIGURE 55.2. McKissock technique. Medial and lateral dermoglandular resections.

FIGURE 55.3. McKissock technique. Central glandular resection produces bucket-handle flap for infolding.

Inferior Pedicle Technique

The inferior pedicle technique remains the most popular technique among U.S. plastic surgeons today. The planning of the inferior pedicle technique is essentially the same as for the McKissock bipedicle procedure, with the desired nipple location determined in the same manner. An inferiorly based dermoglandular pedicle is planned with a base of 4 to 9 cm at the IMF that gradually tapers as it ascends to encompass the nipple–areola complex. De-epithelialization with this technique is limited to the zone immediately about and inferior to the nipple–areola (Figure 55.5). Skin and parenchymal resections are performed not only medial and lateral to the pedicle, as described above, but also superior to the nipple–areola, up to the level of the keyhole pattern. These excisions are performed leaving a beveled carpet of breast tissue over the muscular fascia, especially laterally. Immediately superior to the 1-cm de-epithelialized cuff about the nipple–areola, the pedicle is terminated and incised down to muscle fascia, taking care not to undercut (Figure 55.6). A pyramidal pedicle of dermis and parenchyma is thus left deep to and inferior to the nipple–areola, based on the chest wall musculature and IMF. In the vicinity of the areola, it measures 2 to 4 cm in thickness, and near the base it is 4 to 10 cm. After completion of the breast resection, the nipple–areola is brought to the desired position in the keyhole pattern, and the medial and lateral flaps are brought together as with the McKissock technique (Figure 55.7).

FIGURE 55.4. McKissock technique. A. Vertical bipedicle flap folded on itself as key sutures tied. B. Closure.

FIGURE 55.5. Inferior pedicle technique. A. Preoperative markings with inferior pedicle de-epithelialized. B. Medial dermoglandular resection.

Central Mound Technique

The central mound technique is a further evolution of the prior two designs. The pedicle is based on central chest wall musculature alone and is not contiguous with any skin boundary. Hence, it has no directional base in the sense of traditional skin pedicles that may be classified as superior, inferior, or transverse.

Preoperative marking is again performed as for the McKissock technique. The skin is de-epithelialized within the entire keyhole pattern, a process continued inferiorly to include the skin around the reduced nipple–areola complex (Figure 55.8). An incision is placed in the inframammary crease and is carried down perpendicularly to the pectoralis fascia. Incisions are now made and beveled around the margins of the keyhole pattern at its medial and lateral limbs. This incision is continued below the level of the limbs to circumscribe the de-epithelialized pattern, including the nipple–areola, and is beveled in a caudal direction toward the IMF. The limb incisions, both medial and lateral, are made in the standard fashion, developing flaps of thickness similar to those in other techniques. Now the medial and lateral inferior quadrants of skin and breast, as well as the central inferior tissue intervening between the nipple–areola and the IMF, are excised as a single curvilinear, ellipsoid unit that includes the axillary tail (Figure 55.9). A skin incision at the superior aspect of the keyhole is deepened only enough to allow comfortable transposition of the central mound pedicle with its nipple–areola into the keyhole position. The skin flaps are brought about the pedicle as in other techniques, and closure is performed (Figure 55.10).

FIGURE 55.6. Inferior pedicle technique. Pedicle developed.

FIGURE 55.7. Inferior pedicle technique. A. Nipple–areola positioned. B. Closure.

FIGURE 55.8. Central mound technique. A. Preoperative markings. B. Limited central de-epithelialization.

AUTHOR’S TECHNIQUE

The patient is marked in the standing position in the exam room or in the office the day prior to surgery. Over the years, I have become increasingly fond of marking these procedures the day before surgery and photographing the plan. This is especially helpful when the breast reduction is the first case of the day or is scheduled on a particularly busy day where it may be more difficult to plan the surgery in an appropriately supportive setting. The markings are made as described above. I often mark the upper border of the existing breast parenchyma to give some perspective as to where the breast will lie at the end of the breast reduction procedure. This allows a better appreciation of where the nipple might sit after the breast reduction. While the IMF can be one useful landmark as to where to site the nipple, it is also becoming increasingly clear that there needs to be left some critical length of tissue/breast skin between the upper border of the breast and the upper border of the areola. Depending on the overall breast size after breast reduction, this can be anywhere from 7 to 9 cm or even more.

FIGURE 55.9. Central mound technique. Dermoglandular resection.

FIGURE 55.10. Central mound technique. A. Nipple–areola advanced superiorly. B. Closure.

The ideal length of the limbs of the keyhole pattern varies between 5 and 8 cm, depending on the size of the breast currently and the size of the planned breast after reduction. The larger the breast and the larger the breast that is to remain after the procedure, the longer these limbs should be. Five centimeters is the minimum length of the vertical limb of the keyhole, and I will often go to 6, 7, or even 8 cm, depending on how big the breasts will be left postoperatively. I am well aware that when the breast is made too large for the skin flaps, the skin flaps will often stretch, and that when the skin flaps are larger than the breast, the skin flaps will often shrink postoperatively. A fairly straight line is then initially drawn from the lowest most point of the vertical limb of the keyhole to the medial most extent of the IMF mark. The same is done laterally to the lateral most extent of the IMF.

FIGURE 55.11. Superomedial pedicle. The base of superomedial pedicle should be drawn so that it connects to the keyhole pattern somewhere along the areola window superiorly and along the vertical limb inferiorly. The precise attachment is not critical, but it should be drawn so as to facilitate rotation.

At this point, the lengths of the transverse incisions are reviewed to shorten the overall incision lengths and to equalize the lengths of the medial and lateral fold incisions to the upper transverse incisions that come off the vertical limbs of the keyhole pattern. In the vast majority of cases, this results in shortening the medial incisions by 2 to 4 cm and takes both the medial and lateral IMF incisions out of the fold as they move away from the breast meridian such that they join the upper incisions 2 or 3 cm above the old fold. After drawing the keyhole and the planned incisions, the pedicle is designed.

I am particularly impressed with the versatility and speed of the superomedial pedicle and now use this approach in a large majority of my breast reduction procedures, regardless of whether they are inverted-T scar patterns or vertical scar patterns. The design for the superomedial pedicle is drawn so that it starts superiorly, along the arch of the previously drawn keyhole, and ends either at or near the bottom of the vertical limb of the keyhole (Figure 55.11). The planned areola is circumscribed, leaving several centimeters around the areolar margins as the pedicle is drawn. Some surgeons prefer to use an inverted-V pattern rather than a keyhole pattern and this procedure is conceptually compatible with that. The limbs of the inverted-V need to be drawn at least 11 or 12 cm long and the areola window is created after the resection and preliminary closure have been performed

At this point, the plan is evaluated for symmetry. The upper border of the planned areola, the location and length of the vertical limb of the keyhole pattern, and the length and location of the line joining the bottom of the keyhole pattern to the medial IMF incision are key points to evaluate for symmetry. As mentioned earlier, because of preexisting asymmetry that is virtually always present, it is typical to place a larger resection on the larger breast. My preference is to try to decrease the magnitude of the volume asymmetry without tipping the scales so much that the larger breast becomes the smaller one.

I like to photograph the markings on the patient for later reference both intraoperatively and postoperatively. With the advent of digital photography, it is relatively simple to print these photographs for use during the actual surgical procedure.

I often have the patient lie down at this point and shorten the incisions both medially and laterally by at least 2 cm or double-check where I have already marked them to be shortened (Figure 55.12). This shortening is done in such a way that the medial most extent of the incision is brought lateral by 2 cm and this new end point is drawn midway between the upper and lower previously planned incisions. The same is done laterally, so that the scars or incisions that will be made will curve somewhat off the IMF as compared with the original plan. Thus, even preoperatively, the planned length of the incision will be 4 cm or more shorter than the preoperative length of the IMF.

To be certain that the lines that I have drawn are not lost during the preparation of the patient, I lightly score these lines just prior to surgery using an 18G or 21G needle.

One of the most remarkable advantages over the inferior pedicle technique is the reduced time required for de-epithelializing. Because the pedicle is almost always quite small and substantially smaller than with other techniques, de-epithelialization is brief and is all within the keyhole pattern itself. The incisions are then scored around the margins of the keyhole and from the keyhole to the IMF and along the IMF. I prefer to dissect the lateral flap first. The skin incision is deepened to a depth of 1 to 2 cm of breast tissue. A laterally based flap is created that extends to the axillary tail, leaving sufficient soft tissue to ensure viability of the lateral skin flap (Figure 55.13). In recent years, I have focused more on parenchymal remodeling and support when performing this operation. Medial and lateral glandular pillars are created and are approximated inferior to the nipple, thus coning and supporting the breast. In order to develop a lateral pillar, the lateral flap must be left extra thick (3 to 5 cm) along the lateral keyhole limb and must taper as it extends superiorly and laterally. The medial and inferior incisions are made through the dermis down to or near the muscle fascia. Once all these incisions have been made, the pedicle is held using hooks or atraumatic clamps, and incisions are made straight down along the margins of the pedicle superiorly, laterally, and inferiorly, taking care not to undermine the pedicle (Figure 55.14). In particular, as the dissection is carried laterally away from the pedicle, some beveling is performed to leave soft tissue along the chest wall in the anticipated path of the neurovascular supply to the nipple–areolar complex. The breast tissue itself is removed in a C, or inverted-C pattern from either breast (Figure 55.15). The key elements of this resection are to leave adequate blood supply to the nipple–areola pedicle by not undermining the pedicle and leaving it fully attached to the chest wall. The breast tissue is aggressively removed in the medial wedge area, as well as inferiorly and laterally. The area of greatest risk in this operation is the circulation to the lateral skin flap and, therefore, that flap must not be made too thin or be traumatized in the dissection.

FIGURE 55.12. Even when performing an inverted-T–type reduction, the planned incisions can be several centimeters shorter than the preexisting inframammary fold, so long as care is taken to resect the breast tissue that would otherwise remain in that area. The dashed lines at the bottom of the breast represent a shortened inframammary incision.

FIGURE 55.13. Lateral flap dissection. A laterally based flap of some safe thickness is dissected to allow access to the lateral breast tissue.

FIGURE 55.14. Pedicle dissection. The superomedial pedicle is developed by cutting around the previously marked pedicle straight down toward the chest wall, without undermining and with some feathering laterally to protect the neurovascular supply.

I may then incise just the dermis of some of the pedicle itself, where it joins the keyhole medially, to allow for easier rotation of the dermoglandular pedicle. After rotation of the nipple–areola, the areola is attached at the meridian of the keyhole aperture. The keyhole pattern is then closed around the pedicle at the 6 o’clock location of the areolar window, and the reduced breast is held up vertically at the top of the keyhole with a strong hook. It is at this moment when parenchymal sutures are placed between the recently created lateral pillar and the medial pillar and pedicle. This is typically a 2-0 suture on a sturdy large needle. This usually includes three or four sutures including one placed on the backside of the medial and lateral pillars as they are flipped over, taking care not to tie any of these sutures too tight (Figure 55.16). Once satisfied with the glandular reshaping and coning of the breast, the remaining skin can be stapled or sutured, including the 6 o’clock position on the most inferior aspect of the vertical limbs of the keyhole. Because the upper flap lengths have been measured preoperatively to approximate one-half of the IMF length, there are rarely any significant dog-ears to deal with. A small 10-French suction drain is often placed along the IMF and brought out through the lateral extreme of the incision or through a stab incision laterally to help facilitate drainage. The final closure is accomplished and the staples are removed.

The technique is easy to perform and teach. The same pedicle can also be used as part of a vertical scar pattern reduction technique. The creation of the pedicle is virtually the same. The only difference is that the skin is tailored to the breast at the end of the operation and excess skin can be removed as necessary either in a vertical or a combined vertical and short T pattern (Figure 55.17).

FIGURE 55.15. The resulting specimen is an inverted-C or C shape, depending on which breast.

BREAST AMPUTATION WITH FREE NIPPLE GRAFT: AUTHOR’S TECHNIQUE

An excellent, if often maligned, alternative to reduction mammoplasty with a nipple-bearing pedicle is breast amputation with free nipple graft. This technique consistently produces well-shaped breasts.In large women, in particular, an attractive breast contour is more easily accomplished with this technique than with conventional approaches. The disadvantage is the relatively unnatural appearance and function of the nipple–areola complex: Specialized sensation is lost, as well as some degree of nipple projection, especially erectile nipple projection; lactation is similarly sacrificed; and occasional spotty survival of the grafted areola produces areas of depigmentation that can be troublesome in dark-skinned individuals.

This rapid technique is especially indicated for women with gigantomastia, who require a resection of 2,500 g or more of breast tissue per side, as well as for patients with other complicating factors, such as increased age or systemic disease where significant reduction in blood loss and operating time is desired. It remains the preferred alternative for many elderly patients who present for reduction mammoplasty because of increasing symptoms involving a demineralized skeletal system. With respect to the patient with extremely large breasts, I consider this alternative whenever the nipple–areola complex is to be elevated more than 15 cm. This guideline is modified by other factors, especially the age of the patient. I am reluctant to use this alternative in young or unmarried patients, for example. Although concern for ischemic injury to the retained nipple–areola complex in such greatly enlarged breasts remains a major indication for this alternative, it may not be the sole reason to recommend it. Rather, the technical reality of breast reduction for such large breasts may prove unwieldy when a pedicle is maintained.

FIGURE 55.16. Pillars. To provide a better breast shape with more projection, the breast gland is closed by approximating medial and lateral pillars of tissue which have been purposely left during the resection. A. The first suture is placed just below the inferior edge of the areola. B. The second and third sutures are placed successively inferior toward the inframammary fold. C. A suture is often added on the back side of the pillars as well.

FIGURE 55.17. Inverted-T, superomedial pedicle. A. Frontal view of plan for breast reduction using superomedial pedicle and inverted-T scar pattern. B. Lateral view of plan. C and D. Before and 3 months after 575-g reduction using the author’s technique.

Preoperative Marking

The breast markings remain similar to those for the previously described inverted-T techniques (Figure 55.18). The wire keyhole pattern is not used for this technique, however. Instead, two diverging arms are drawn from the selected nipple point at an angle approximating 90°. Limb length is measured at 10 to 12 cm. The inframammary line is marked, and the medial and lateral extensions from the limbs are drawn as has already been described for the other pedicle techniques. The areola is marked for reduction to 42 to 50 mm with the help of an areolar marker.

FIGURE 55.18. Free nipple graft. Author’s breast amputation with free nipple–areola graft, technique. A. Breast meridian marked. B. Preoperative markings completed. C. Amputation completed. D. Central tissue coned and rotated into retromammary space. E. Free nipple–areolar graft added at closure.

Technique

The procedure is begun by rapidly removing the nipple–areola complex as a full-thickness skin graft with attached subjacent ductal tissue at the site of the nipple papilla and setting it aside in a moist saline sponge, clearly indicating the side of origin, right or left. I do not follow the skin markings as some have suggested when performing the glandular resection, because I find it too often results in inadequate central projection of the breast. Far better is Rubin’s alternative of retaining an inferior parenchyma pedicle at the inframammary line to be covered by the superior skin flaps. I prefer, however, to retain superiorly based parenchyma between the diverging limbs of the pattern, as well as an additional amount dropping below this area if needed. This retained tissue is designated with a single curvilinear line placed below the diverging arms, and the enclosed area is rapidly deskinned. Clearly, the greatest pitfall in this otherwise straightforward procedure is the amputation of excessive breast tissue, leaving only superior flaps with subcutaneous tissue and little breast. It is important therefore to leave sufficient breast tissue across the extent of the superior retained breast flap as one amputates the excess tissue inferiorly.

The amputating incision is carried perpendicularly to the chest wall musculature. The inframammary incision is similarly carried perpendicularly to the musculature. The large intervening wedge of gland is then dissected progressively from medial to lateral away from the muscle fascia, maintaining exact hemostasis as the resection progresses. The central portion of the remaining superior gland, including the deskinned portion between and below the diverging limbs, is now dissected from the underlying muscle fascia superiorly to the apex of the inverted-V pattern. The dermal edges of the inverted-V are incised and undermined just as much as needed to allow infolding of the superiorly based dermal flap. The most inferior points of the inverted-V are then approximated, thus effectively coning and infolding the breast. Closure is completed in the standard fashion working both vertically and from the extremities centrally.

Finally, the site for the nipple–areola complex is determined and measured upward from the IMF on either side. It may or may not fall precisely at the superior extent of the vertical closure. The area is marked with the areolar marker and is de-epithelialized. The defatted nipple–areola complex is sutured in place and secured with a tie-over dressing. It is important to thin the areola graft sufficiently but not so thin that the areola has an unnatural appearance. Similarly, a small amount of ductal tissue, a gram or so, is left within the papilla, to favor nipple projection. A greasy dressing with wet cotton bolus is then tied in place over the complex and is removed at 4 to 7 days.

CONCLUSION

Despite the many recent advances in breast reduction surgery, the inverted-T scar technique remains a comfortable and predictable technique for the surgeon who performs breast surgery. Although there is appropriate increasing interest in short scar or vertical scar techniques, the inverted-T option has proven reliable and safe, which may be as important to the patient as the length of the scar in the IMF. As our personal techniques of breast reduction surgery continue to evolve and improve, certain concepts and principles have become increasingly clear. One’s preferred technique needs to be reliable, consistent, and reproducible. Because of the increasing pressures of cost and time, it needs to be efficient and relatively quick.

It needs to result in the bare minimum of serious complications such as ischemic loss of the nipple and over-elevation of the nipple. It needs to fulfill the reconstructive goal of sufficient weight reduction while doing a reasonable job of creating an attractive breast, particularly for the younger and more slender patient. And, finally it needs to reduce the breast successfully in one operation with a minimal risk of revision which insurance carriers often view as cosmetic and will not cover.

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