Evolution of the technique

Breast reduction remains one of the most common procedures related to breast surgery, second only to augmentation mammoplasty. Numerous procedures have been developed specifically for breast reduction surgery, and the inferior pedicle technique has been performed for over three decades.^1–4 Many procedures have been developed to reduce scar length and enhance breast shape. With the development of several short scar breast reduction techniques, some surgeons either no longer employ or limit the patients in whom they perform inferior pedicle procedures.

The inferior pedicle procedure is associated with an inverted T incision and still remains one of the most common techniques employed for breast reduction surgery.^5–8 The length of the horizontal incision can frequently be kept short, and, in the past, this was considered one of the primary negative aspects of this procedure. Key to a successful outcome with the inferior pedicle procedure is proper shaping of the pedicle to minimize recurrent ptosis and bottoming out. With proper patient selection and proper design, the length of that horizontal incision frequently can be kept short. This technique is particularly suited for very large breasts when there is a large discrepancy between skin envelope volume and breast tissue.

This section discusses those factors associated with a successful outcome, including proper patient selection and proper design of both the pedicle and the skin envelope. Specific areas that will be addressed in the evolution of this technique relate to the application of the inverted T inferior pedicle to very large and pendulous breasts. It will be demonstrated that scars, particularly in the horizontal plane along the inframammary fold, frequently can be kept short, avoiding any visible medial or lateral scarring.

One important aspect is modifying the shape of the pedicle itself, so that the bulk of the tissue is centrally located under the nipple-areolar complex with minimal tissue along the lower border of the inferior pedicle. Hester was one of the first to suggest this concept.⁹ By keeping the bulk of the tissue centrally and minimizing the tissue along the inferior aspect, secondary problems of bottoming out can be reduced.^10,11

Also important in the design of this technique has been the realization that the superior flap needs to be kept relatively thick in order to maintain as much superior fullness as possible. If a significant amount of the remaining breast tissue is left attached to the superior flap, then it is less likely to migrate inferiorly over time. This is another maneuver to reduce the effects of gravity in an attempt to minimize the major problem of bottoming out. Also, by leaving the superior flap thick, this helps reduce the common problem of superior flattening after the surgery which is an issue with many patterns in reduction mammoplasty.

Although many variations are popular today, the inferior pedicle with an inverted T has now been utilized for over 30 years and remains a mainstay procedure for many surgeons. Certainly minimizing scar length is a major goal; however, creating a breast with proper contour and shape is the most important component of the surgery, and in selected patients with very large, long breasts, the inverted T with a modified inferior pedicle can give excellent results.

Patient selection

As will be demonstrated, in patients who have very long or large, pendulous breasts, one of the benefits of the inverted T procedure is reducing the amount of skin between the bottom of the areola and the inframammary fold. Some patients can have an exaggerated distance between the inframammary fold and the areola and yet the areola is not in a markedly ptotic location. When trying to reduce this amount of lower pole skin, a transverse incision can enhance the shape and contour of the breast.

Another group of patients that may benefit from this operation are those with a wide, boxy breast where the upper pole and lower pole of the breast are of similar width. In these patients, taking out transverse skin again can often enhance the result. The key to the procedure is not carrying the transverse scar close to the midline or laterally beyond the anterior axillary fold. This maneuver minimizes not only a very visible scar but a potential hypertrophic scar. Patients with transverse incisions that develop thickened or hypertrophic scars usually have the majority of their problems at the most medial and lateral extent, while the central portion under the breast frequently has the best appearance. This fact is probably due to the pressure of the overlying breast tissue compressing and flattening the scar.

Details of planning and marking

Details of planning

As with any surgical procedure, the two most important components are proper patient selection and proper planning of the procedure. With this technique, although modifications are performed intraoperatively, the majority of the procedure is based on the preoperative patient’s markings. With the patient in the upright position, the initial marking consists of creating a line along the midclavicular plane starting from the clavicle down to a projection point through the inframammary fold where the new nipple-areolar complex will be located. Since in many patients, the nipple-areolar complex does not sit in the midclavicular plane, it is important to create this line, ignoring the actual nipple location if it is too lateral or too medial. After creating the midclavicular lines on both sides, another mark is made in the midline to make sure that these lines are symmetrically placed an equidistance from the midline (Fig. 8.2.1A).

Fig. 8.2.1 (A,B) Patient preoperative marking. With the patient in an upright position, the midclavicular line is drawn. The nipple location is determined by a projection through the breast from the inframammary fold. This is marked at the bottom of the midclavicular line. Symmetry is confirmed by using a ruler to compare the distance of each midclavicular line from the midline.

Creating an equilateral triangle

Beginning at the lower extension of the midclavicular line at the point where the nipple projection was created based upon the inframammary fold, an equilateral triangle is created. In smaller patients, it may be in the 7 cm range, while in relatively large patients, frequently it can be anywhere from 8–9 cm in length (Fig. 8.2.1B). In patients with a very wide, boxy breast the base of the triangle should be made slightly longer than either side to help narrow and cone the breast and reduce the boxy appearance. Once these equilateral triangles have been created the next step will be creating the transverse incision lines extending from the lower limbs of the triangle (Fig. 8.2.2).

Fig. 8.2.2 Equilateral triangles are drawn extending from the proposed nipple location. These typically vary anywhere from 7 to 8 cm per side. In a wide breast, the base of the triangle may need to be slightly wider than the sides in order to narrow the breast.

Visualizing or examining the asymmetric patient

One trick is to take a tape measure and have the patient hold it under their arms against their chest wall and place it transversely along the base of each triangle. As demonstrated in Figure 8.2.3, it is obvious that the patient’s left breast is not only larger but the nipple-areolar complex is lower. Having a transverse tape measure helps one visualize any asymmetry (Fig. 8.2.3).

Fig. 8.2.3 With the patient in the upright position, a tape measure is placed marking the bottom of the equilateral triangles. This assists in identifying any breast asymmetry which may not be immediately apparent. In this case, there is significantly more breast tissue below the markings on the left breast with also a lower location of the nipple-areolar complex.

This completes the basic markings and in this technique the areolar will be brought out secondarily based upon the shape of the breast, therefore, no marking of the areola is made at this time.

Detailed description of technical procedure

With the patient in the operating room, there are several important aspects in patient positioning. The arms are on arm boards but should not be at an extreme right angle, since this can distort the breast shape at the time of closure. The arms are well-secured with slight elevation. The patient is prepped and draped in a manner where all the markings are readily visible. A dilute solution of saline/epinephrine is injected, avoiding injection into the site of the inferior pedicle. The first step consists of marking the nipple-areolar complex (Fig. 8.2.4). With this technique, no traction is applied to the nipple-areolar complex as the cookie cutter is applied to the skin. One problem with applying to much tension at the time of marking is that it could lead to a very tight closure with potential healing problems. Also, having the areola being tight and smooth can result in an artificial appearance. After the marking is made, with the areolar tissue at rest, symmetry is compared and proper location of the cookie cutter incision is evaluated.

Fig. 8.2.4 With the patient asleep and with the markings in location, a nipple marker is placed to outline the incision for the nipple-areolar complex. This varies anywhere from 38–42 mm in diameter.

Next, the areola is incised, followed by an incision marking out the limits of the inferior pedicle. The inferior pedicle is de-epithelialized by the appropriate method. This author makes superficial cuts with the knife and completes the de-epithelialization with scissors (

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