Summary/Key Points

1. An inferior flap can be used to create a central mound in either a breast reduction or a mastopexy to elevate the breast and increase projection.

2. An inferior flap can also be used with the nipple–areola complex attached to create an inferior pedicle.

3. An inferior flap without the nipple–areola complex can be used to shape the breast and prevent postoperative ptosis by suturing the flap to the pectoralis fascia.

4. An inferior flap can be used with either an inverted T skin resection pattern (Pitanguy) or a vertical (lozenge) pattern.

The use of an inferiorly based dermolipoglandular flap in reduction mammaplasty was first described in Brazil at the congress of the Brazilian Society of Plastic Surgery in 1971, and was first published in 1973.¹ The flap has been mistakenly referred to as an ‘inferior pedicle.’

Created in 1969, it was first used as a ‘security flap’ to ease shaping of the breast in cases of over-resection of breast tissue and difficulty in getting good projection with the techniques used at that time. It was observed, over the years, that the breasts operated upon with this technique had better projection and were more stable over time regarding shape and fullness of the superior quadrants of the breast, with long lasting results. The inferior flap is de-epithelialized. The dermis, when fixed to the pectoralis muscle, acts like an internal ligament reducing the weight applied over the entire breast and skin. The tendency to develop ptosis in the postoperative period is thereby lessened.

This inferior flap can also be used for the transposition of the nipple–areola complex in reduction mammaplasties and this possibility was introduced by the senior author in 1975,² based on the follow-up of the patients operated upon this technique and analysis of the vascularization of this flap. This was later confirmed by the works of Robbins,³ and Courtiss and Goldwin,⁴ in 1977, who demonstrated that the principal sources of blood flow to the inferior pedicle are the perforating and intercostal branches of the internal mammary artery.

At present, the inferior flap is used in almost all mammaplasties performed in our practice, alone or in combination with another technique. We often use Peixoto’s principles,⁵ which result in reduction of the scars as in the lozenge technique.⁶^–⁸

The objective of this chapter is to describe the anatomy, application, indication and surgical technique of the inferior flap as an important option in plastic surgery of the breast.

Anatomy

The inferiorly based flap is built from the inferior quadrants of the breast and has dermis, fat and mammary gland as its components. Its vascular supply is reliable and is made by branches of the internal mammary artery. It has an axial pattern with perforators of the intercostal vessels in greater number in the fourth, fifth and sixth intercostal spaces with an average diameter of approximately 1 mm (Fig. 15.1). These perforators are the main source of blood supply to the central and inferior segments of the breast. The venous drainage occurs in the opposite direction toward the internal mammary vein. The lymphatics drain to the internal mammary chain.

Fig. 15.1 Perforating vessel from the fifth intercostal artery giving branches to the inferior quadrants of the breast and reaching the nipple–areola complex.

Indications and Patient Selection

The inferior flap technique with an inverted T skin resection pattern is indicated in cases of large breasts where the resection of tissue is expected to be over 500 g on each side, or in ptotic breasts where the skin is too flaccid. It is also indicated for less experienced surgeons in minor resections (see Figs 15.32 and 15.33). The lozenge technique cannot be used for every patient. The best results are attained in young patients with elastic skin and mild to moderate hypertrophy, even though we have made resections of up to 900 g on each side (see Fig. 15.34). Mild to moderate ptosis and as an adjunct in breast augmentation with correction of ptosis are also good indications.

I Inferior flap technique with inverted T skin resection pattern

Also called pedicle I (there are four more variants from the original flap numbered from II to V),⁷ it is used routinely in mammaplasties where the resection of tissue is expected to be over 500 g on each side, or in ptotic breasts were the skin is too flaccid. It is used with the skin markings of the Pitanguy technique,⁹ resulting in a breast with an ‘inverted T’ scar. The great advantage is the achievement of a conical and firm breast with long lasting result.

Operative technique (inverted T)

With the patient in a half-sitting position, the new areolae are drawn 4 cm in diameter with an areolar marker (Figs 15.2A and 15.3). A vertical line is drawn from the midclavicular line to the upper edge of the areolae, and point A is marked corresponding to the projection of the inframammary fold on the upper pole of the breast (Figs 15.2B and 15.4). By means of a pinching maneuver and the surgeon’s judgment, points B and C are marked, determining the amount of skin to be resected horizontally (Figs 15.2C and 15.5). The points are linked to the inframammary fold with curving lines, as in Pitanguy’s technique (Figs 15.2D, E, 15.6 and 15.7).