Summary/Key Points

Introduction

The goals of breast reduction are to reduce the volume of the breast so that the stress on the neck and shoulders is reduced resulting in relief of the upper torso complaints. At the same time, the reduction must be performed in such a manner so as to create the most aesthetically pleasing and long-lasting result possible. To accomplish these goals, any breast reduction operation can be subdivided into four specific elements. First, a versatile and reliable method for preserving blood supply and innervation to the nipple–areola complex (NAC) must be designed. Typically this requirement is satisfied by creating a pedicle of breast parenchyma and dermis that is variably based from some quadrant of the base of the breast. Second, a variable volume of breast parenchyma and fat must be removed in such a way that the blood supply to the pedicle is respected and left intact. Third, the redundant skin envelope must be reduced such that it wraps around the reduced breast in a complimentary fashion, and fourth, the shape of the breast must be controlled.

For many years, the preferred method for performing breast reduction has combined the use of an inferiorly based pedicle with an inverted T or ‘Wise’ skin pattern and many reports have documented the success of this technique in reducing the symptomatically enlarged breast.^1–6 However, it is possible to combine the inferior pedicle approach with a short scar circumvertical skin pattern to accomplish the same reduction in volume with a much less significant scar burden. This procedure, called the short scar periareolar inferior pedicle reduction or SPAIR mammaplasty^7–9 is applicable to breasts of all sizes and provides aesthetic, long-lasting results in a consistent fashion. This chapter will outline the markings, operative technique, and results of this versatile method of breast reduction.

Patient Selection

Virtually any patient who presents for breast reduction is a candidate for an inferior pedicle technique. Barring the presence of a previously placed scar across the base of the breast along the inframammary fold, the only limiting factor is the length of the pedicle. This length can be measured preoperatively by extending a tape measure with the breast in repose from the inframammary fold to the nipple. It is advisable to measure this distance in every patient who presents for breast reduction using an inferior pedicle technique. In general terms, a pedicle length of 10 cm or less will in only rare circumstances exhibit any degree of NAC ischemia. For pedicle lengths of 10 to 20 cm, ischemia to the distal end of the pedicle may be seen particularly when other risk factors such as a smoking history, or the presence of systemic diseases such as diabetes are co-existent. For pedicle lengths of 20 cm or more, particular attention to operative technique is required to ensure optimal vascularization of the NAC.

While pedicle length is an important variable that can influence the subsequent development of ischemia to the NAC, another anatomic feature of the breast that directly affects the vascularization of the inferior pedicle relates to the identification and preservation of the internal breast septum.^10–12 This septum, which has a cranial and caudal leaf, runs transversely within the breast at the junction of the lower third with the upper two-thirds and most likely represents a traction imbrication as the enlarging breast folds over itself as it hypertrophies (Fig. 18.1). Within this septum run several sizable intercostal perforators that provide direct axial blood flow to the inferior pedicle. As such, the septum functions as a neurovascular mesentery. The septum is easily identified in most patients during skeletonization of the inferior pedicle (Fig. 18.2). Once the redundant tissue is removed from the apex of the pedicle near the base of the breast, the mesenteric space can be seen to present a mobile interface as the cranial and caudal layers slide past one another. Preserving this vascular mesentery becomes a critical technical maneuver when attempting to ensure adequate vascularization of the inferior pedicle.

Fig. 18.1 A The preadolescent breast remains flattened with small neurovascular perforators preferentially entering the underside of the breast bud at the level of the fourth interspace. B As the breast begins to develop and enlarge, the upper and lower poles of the breast fold over each other ‘dragging’ the neurovascular pedicles along with the developing breast. Along the deep margins of this folded construct a, ‘septum’ forms that contains the developing neurovascular network emanating from the deep perforators. C In the fully formed breast, this septum becomes easily identified and contains a cranial and caudal leaf, each with its own perforator network.

Fig. 18.2 A Appearance of the internal breast septum after the redundant upper pole tissue of an enlarged breast has been dissected away from the surrounding flaps based on an inferior pedicle and reflected inferiorly. The contained perforators can be seen coursing through the septal leafs. B Appearance of the septum after the medial aspect has been opened and the space between the inferior leaf of the septum and the inferior pole of the breast bluntly separated. With a finger inserted into this space, the architecture of the septum and the contained perforators can be more clearly seen.

With permission from Hammond DC. Atlas of aesthetic breast surgery. Elsevier; 2008, Figs 16.1–16.8C.

While development of a well-vascularized pedicle is an important element of the overall strategy behind the SPAIR mammaplasty, it is the management of the redundant skin envelope that demands the most technical skill. In smaller breast reductions, the pattern becomes a simple combination of a modest periareolar component that then extends down to the inframammary fold in a tapered ‘V’ shape. As the amount of breast parenchyma that is removed becomes greater, and the skin envelope becomes more redundant, it becomes necessary to curve the lower portion of the ‘V’ laterally in the shape of a ‘J’ to avoid having the vertical incision extend down onto the chest wall. In particularly large reductions of 1000 g or more, this lateral extension can run for some distance along the lateral inframammary fold. One alternative to curving the skin take-out laterally is to add a small ‘T’ takeout along the central inframammary fold. In either instance, the inframammary fold scar is shorter than in the classic Wise pattern procedure and hides well in the inframammary fold.

Indications

It is possible to use an inferior pedicle for virtually any patient undergoing either a mastopexy or a breast reduction. However, the circumvertical pattern becomes more difficult to apply as the surface area of the breast becomes excessive. Therefore, in patients with extreme ptosis with a very redundant and lax skin envelope or in patients with massive breast hypertrophy, a point is reached where a more traditional inverted T pattern will more efficiently reduce the skin envelope with better approximation of the skin edges and fewer wound healing complications. As a general rule, for breast reductions of over 1500 g per side, an inverted T skin pattern used in conjunction with an inferior pedicle will be easier to use than a circumvertical pattern. As well, for small reductions of less than approximately 200 g, the traditional vertical mammaplasty with either the superior or superomedial pedicle will be a quicker and less labor-intensive option. For all other cases, depending upon the experience and technical skill of the surgeon, the inferior pedicle circumvertical skin pattern strategy can provide outstanding and long-lasting results.

Operative Technique

Marking

When marking the patient for an inferior pedicle circumvertical procedure, the basic goal is to determine that portion of the redundant skin envelope that will need to be preserved so as to easily wrap around the inferior pedicle in a contoured fashion to create the most aesthetic result. To accomplish this task, four cardinal points are identified that will define that portion of the skin envelope that will be preserved. Initially, basic orientation marks are applied to identify the inframammary fold on each side, the midsternal line and the breast meridian (Fig. 18.3A–D). It should be noted that the breast meridian does not necessarily run through the nipple as often the NAC is malpositioned either medially or laterally. As well, it is a very useful maneuver to draw a line across the midline connecting the two inframammary folds. This allows the location of the fold to be visualized without manipulating and possibly distorting the position of the breast. The first cardinal mark is located by drawing a line that parallels the inframammary fold line 4 cm above the inframammary fold. Where this line intersects the breast meridian on each side represents the top of the periareolar pattern (Fig. 18.3E). The inferior cardinal point is identified by drawing an 8 cm wide pedicle that extends up to the NAC centered on the breast meridian (Fig. 18.3F

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