Evolution of technique

The short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty was developed in an attempt to eliminate the major complications related to the use of the inverted T pattern inferior pedicle technique for breast reduction. As experience was gained using the inverted T or “Wise pattern” approach, it soon became clear that the extensive scar burden was a significant drawback for many patients and in particular for younger women undergoing this procedure. In addition, every patient who undergoes this procedure experiences a progressive change in the shape of the breast over time with expansion of the lower pole breast contour and a gradual shift of the breast volume progressively into the lower pole. When this change occurs to excess, the aesthetic result is variably compromised leading to the well recognized phenomenon of “bottoming out”. In these patients, the upper pole of the breast appears hollowed out and the inframammary fold scar actually becomes positioned up onto the breast as the breast itself migrates down the chest wall incorporating upper abdominal skin into the formation of the skin envelope of the lower pole of the breast. One frequent admonition for young surgeons is to plan for this occurrence and at the time of placement of the nipple and areola complex (NAC), it is very common to artificially place the NAC in a low position in preparation for the “bottoming out” phenomenon to occur. It is likely that division of Scarpa’s fascia at the level of the fold during dissection of the breast along with disruption of the internal fascial scaffold of the breast predisposes to “bottoming out”. Therefore, despite the fact that the inverted T inferior pedicle technique for breast reduction has been the standard method used around the globe for many years, the scar burden and the shape change over time are disadvantages that certainly justify the search for alternative techniques of breast reduction.

In evaluating other techniques designed to reduce the scar burden associated with breast reduction, two contrasting methods stand out. First, based on the work of Benelli,¹ attempts to limit the scar to just the periareolar area have been described. Here the inherent “dog-ear” that is created by the use of a large periareolar incision and a smaller areolar incision places great stress on the subsequent skin closure. Therefore, while the scar can be limited to just the periareolar incision when this technique is used, severe drawbacks include compromise of the size, shape, and position of the areola, stippling and irregularity in the periareolar scar, and shape distortion with flattening of the breast itself. As a result, this technique can be reliably utilized only in small reductions of 200 g at most and where the skin envelope is only minimally redundant. In contrast to strictly periareolar techniques stands the classical vertical mammaplasty of Lassus and Lejour.²^–¹⁰ Here, the defect created for the NAC is designed to more or less match the dimensions of the incision made around the areola. As a result, the inherent “dog-ear” that is created with the application of the vertical segment is entirely limited to the area between the inferior portion of the areola and the inframammary fold. For a breast of any size, the stress placed on this portion of the breast both in scar quality and healing can be significant. As well, because the parenchymal removal is performed in the inferior pole of the breast, not only is the internal scaffold of the breast disrupted but the entire inframammary fold is released. As a result, and as with the inverted T approach, the breast will “bottom out” or change shape over time. In fact, it is commonly recommended that the shape of the breast appears significantly distorted at the end of the procedure such that the upper pole is overfilled and the lower pole appear flattened in preparation for this shape change to take place. Therefore, rather than eliminating bottoming out as has been claimed by some, the final result actually depends on bottoming out to create the final breast shape. Another significant drawback related to limiting the skin removal to the vertical segment involves the final shape of the breast. For larger breast reductions, plicating the lower pole of the breast in a vertical fashion from the areola down to the fold simply results in a vertical scar that is too long. The distance from the areola to the fold becomes excessive and the breast appears “bottomed out” with a nipple position that is too high. As well, due to irregular tissue approximation at the level of the inframammary fold (IMF), wound breakdown, unsightly scars, and shape distortion can also occur. Often times, these complications become manifest only when the patient raises her arms over shoulder level. In an attempt to manage this aspect of the pattern, various strategies for creating scar contracture at the level of the fold have been described including the use of purse-string sutures and aggressive liposuction however these issues continue to be responsible for many revisions in patients undergoing vertical mammaplasty. For these reasons, the vertical mammaplasty is best applied to smaller breast reductions of ≤400 g. Using the technique in larger patients may risk unfavorable results with an unacceptably high revision rate.

Despite the disadvantages associated with these various procedures, there are very effective strategic design elements of each that can be combined to provide a versatile and widely applicable technique of breast reduction. From the inverted T experience comes the reliability noted with the use of the inferior pedicle to maintain the vascularity of the NAC even in extreme circumstances. Also, by keeping this centrally located mound of tissue directly under the NAC, the shape of the breast can be better controlled and very importantly, the dissection can be modified to allow the structure of the IMF to remain intact. From the periareolar experience comes the realization that the size of the periareolar incision can exceed that of the areolar incision up to point and still provide a controlled and aesthetic periareolar shape and scar. From the vertical experience comes the observation that the addition of a vertical segment to the skin pattern is a powerful and effective shaping maneuver that can offset the disadvantages associated with purely periareolar techniques. Therefore by using an inferior pedicle technique for management of the vascularity to the NAC with a combined and slightly modified vertical and periareolar or circumvertical skin pattern, the dog-ear inherent in the skin envelope management strategy is distributed over the entire incision as opposed to just around the areola (i.e., Benelli) or just to the vertical segment (i.e., vertical mammaplasty). The result is a very effective, reliable, and widely applicable technique for breast reduction. This is the basis for the SPAIR procedure.¹¹^–¹⁴