In 1975, Ribeiro described a new technique for reduction mammaplasty in which the nipple is based on an inferior dermal flap (1). Two years later, Robbins (2) and then Courtiss and Goldwyn (3) reported a similar procedure. Soon thereafter, Reich (4), then Georgiade and et al. (5), published their experience with the same method. Since then, the inferior pedicle technique has become one of the most common methods of breast reduction in use today. In 1987 a survey of the members of the American Society of Plastic and Reconstructive Surgery found that 36% preferred this method (6). This may have changed with the introduction of newer techniques, such as the short-scar technique of Marchac (7), the Lejour vertical mammaplasty (8), and the round block operation of Benelli (9).

The operation is versatile and safe and can be used for most cases of breast hypertrophy. There are virtually no contraindications, except perhaps in cases of gigantomastia. The pedicle in these cases will be large, and adequate reduction may not be possible. Free nipple grafting for this group of patients is preferred. An inferior flap consisting of dermis and glandular tissue with free nipple grafting will prevent overresection and maintain an aesthetic contour.

The term “inferior pedicle” is descriptive but misleading because it implies that the blood supply comes through an inferiorly based pedicle. A more accurate description, as given by Labanter et al. (10), is the inferior segment technique. The main blood supply of the breast is from the lateral thoracic, internal mammary, and intercostal vessels. It is therefore possible to resect the inferior segment without compromising the blood supply (Fig. 95.1). A procedure using this principle was described by Hester et al. (11) in an operation using a central breast pedicle. An understanding of the anatomy is essential if one is to maintain circulation and sensation to the nipple. A layer of tissue over the fascia must be preserved to protect the vessels as they enter the pedicle. The pedicle can be sculpted to the appropriate size and the flaps thinned when further reduction is required. (Patients often complain of lateral fullness after a reduction mammaplasty if adequate resection has not been performed in this area.) On the other hand, care must be taken to preserve enough tissue medially for adequate cleavage. Before closure, the pedicles and the thickness of the flaps should be compared in order to obtain the best possible symmetry. Suction-assisted lipectomy can be added for further refinement.