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Although generally effective, the inverted T inferior pedicle breast reduction technique is associated with continuing concerns over cutaneous scar as well as shape distortion, which can to worsen over time. This article will outline a technique of breast reduction that is also based on an inferior pedicle but manages the skin envelope with a combined periareolar and vertical skin excision. By combining these elements, an effective method of breast reduction is created that reduces the amount of cutaneous scar by half and yet results in an improved and long-lasting breast shape that is stable over time. This method, called the “short scar periareolar inferior pedicle reduction” (or “SPAIR” mammaplasty) is applicable to a wide variety of breast problems ranging from simple ptosis to extremes of macromastia. Aesthetically pleasing results are consistently and reliably obtained with few complications. It is offered as an effective method of reduced scar breast reduction.
Recent techniques of breast reduction have focused on reducing the amount of cutaneous scar associated with the procedure. To this end, several different surgical strategies have been described with nearly all of them basing the blood supply to the nipple and areola on some variant of a superior pedicle.1,2,3,4,5,6,7,8,9,10,11 The focus of this article is to describe a short scar technique based on an inferior pedicle. The excess skin envelope is managed using a combined periareolar and vertical excision pattern, and shape is enhanced with a pattern of internal parenchymal sutures. The technique, called a “short scar periareolar inferior pedicle reduction” (or “SPAIR” mammaplasty)12,13,14 is applicable to all types of macromastia as well as cases of moderate to severe ptosis. The advantages afforded by the procedure include the creation of an aesthetic breast shape immediately without the need for a period of postoperative settling to define the ultimate result. Because the effect of direct shaping maneuvers can be seen immediately, precise control over the final result is achieved. As well, the final shape that is created is maintained over time and is resistant to postoperative change in shape or “bottoming out.” Taken together, these factors combine to create a reliable and consistent technique for managing in an aesthetic fashion the patient with a ptotic or enlarged breast.
The goal of the marking pattern is to identify that part of the skin envelope that must be retained to easily wrap around the inferior pedicle in a tension-free manner. With the patient standing, the midsternal line, inframammary fold, and lateral breast contour are marked (Fig. 1). Four points are then identified around the periphery of the breast, which will eventually define an elongated oval. The top point is identified by placing a mark 4 cm up from the inframammary fold. One repeatable way to identify the fold is to draw a line connecting the inframammary fold across the midline (Fig. 2). With the breasts in repose, accurate identification of the fold can then be made without manipulating or possibly distorting the breast. A distance of 4 cm is measured up from this point over the sternum. Drawing a line across the breasts parallel to this identifies the top mark of the pattern (Fig. 3).
Next, the breast meridian is drawn, extending the line down the center of the breast and onto the chest wall (Fig. 4). An 8-cm inferior pedicle is drawn, placing the base of the pedicle at the inframammary fold and centering the width of the pedicle on the breast meridian. A distance of 8 to 10 cm is then measured up on either side of the pedicle, and these two points are joined in a line that parallels the curve of the inframammary fold (Fig. 5). This identifies the inferior portion of the oval and delineates the inferior skin envelope that will be preserved. The shorter measurement is used for smaller breasts and in cases of mastopexy, and the longer measurement is used in cases of more significant macromastia. The medial and lateral portions of the pattern are identified by lifting the breast up and out and then up and in with just enough tension to create a rounded medial and lateral breast contour. The breast meridian is then transposed onto the medial and lateral portion of the breast to identify the medial and lateral points of the oval (Fig. 6).
In this fashion, four landmarks are identified that outline the skin envelope to be preserved. Typically this outline has the shape of an elongated oval (Fig. 7). The inferior pedicle is diagrammed inside the oval, skirting the top of the areola by 2 cm. The same pattern is diagrammed on each breast, with care being taken to ensure symmetry in the skin left behind on each breast (Fig. 8). The dimensions of the oval are measured and noted. Experience has shown that dimensions of 15 cm or less are easily handled without difficulty. Oval measurements of 15 to 20 cm require some experience with the technique to obtain aesthetic results with consistency, and measurements of greater than 20 cm often require extra care to obtain acceptable breast shapes. This completes the marking process.
A 52-mm areolar mark is made in the existing areola with the skin under stretch (Fig. 9). The areolar and periareolar incisions are made, and the inferior pedicle is de-epithelialized as is a rim of skin around the periareolar pattern (Fig. 10). The incisions are deepened, and a rim of dermis around the periareolar pattern is preserved by incising through the dermis 5 mm away from the skin edge (Fig. 11). This creates a ledge into which the periareolar purse-string suture is ultimately placed. Flaps are then developed around the periphery of the breast, which are initially elevated just under the dermis and become gradually thicker as dissection proceeds down to the chest wall (Fig. 12). Medially and superiorly the flaps are 4- to 6-cm thick near the chest wall. Laterally the flap is kept somewhat thin with dissection proceeding at the level of the breast capsule, making the flap 2- to 3-cm thick (Fig. 13).
Once the flaps are developed, the inferior pedicle is skeletonized, removing excess tissue from around the periphery of the pedicle. Care is taken not to undermine the pedicle (Fig. 14). The superior and medial flaps are then undermined, with care being taken not to divide the internal mammary perforators. The upper flap is then sutured under itself, drawing the internal leading edge of the flap superiorly and fixing it to the pectoralis major fascia (Fig. 15). In this fashion the patient's own tissues are used to autoaugment the upper pole of the breast, thereby correcting any preoperative concavity. The medial flap is plicated upon itself by grasping the deep leading edge of the flap in two locations separated by several centimeters and suturing them together (Fig. 16). This again uses the patient's own tissues to fill in the medial portion of the breast, creating a full, rounded contour. Finally the inferior pedicle is sutured to the pectoralis major fascia to prevent the pedicle from falling off laterally into the axilla (Fig. 17). This centralizes the pedicle and enhances the shape and projection of the breast and prevents undue lateral fullness. The redundant inferior skin envelope is plicated together with staples until a rounded contour is created.
In larger reductions, the vertical plication curves out laterally but never extends below the inframammary fold. The areola is inset with staples and the shape of the breast is assessed with the patient upright (Fig. 18). Revision of the skin plication via additional skin tightening is performed as needed to create an aesthetic breast shape. Once the desired shape has been created, the skin is marked with a surgical marker (Fig. 19A) and the staples removed. At this point a slightly canted V-shaped pattern is seen with the inferior pedicle centered in the middle (Fig. 19B). The skin over the inferior pedicle is de-epithelialized, and the medial and lateral wedges of skin and parenchyma on either side of the pedicle are removed (Fig. 20).
Incising the full thickness of the lateral flap allows it to pass over the top of the inferior pedicle during closure of the vertical segment. This eases the vertical closure and prevents distortion due to tissue crowding, which can occur if the lateral flap is not fully released. The vertical incision is closed with interrupted inverted 4–0 absorbable monofilament sutures followed by a running subcuticular suture of the same material. With closure of the vertical segment, the dimensions of the periareolar defect are significantly reduced.
However, there is still a variable discrepancy between the circumference of the areolar incision and the circumference of the periareolar defect. This is managed by placing a purse-string suture in the dermal ledge created during the initial de-epithelialization. For the purse-string suture to pass easily, it must have several attributes. The suture must be strong, long-lasting or permanent, and smooth or monofilament so as to pass easily through the dermal framework of the ledge. I have found Goretex (W. L. Gore, Phoenix, AZ) suture to best satisfy these requirements. I use the CV3 size on a straight needle (Fig. 21), which allows passage of the suture within the dermal ledge with a minimum of passes. The purse-string suture is drawn closed until a defect that measures 3.5 to 4 cm in diameter is created (Fig. 22). The suture is passed initially from deep to superficial and ends by passing the needle from superficial to deep. In this fashion, the knot is buried deeply under the dermal ledge and potential erosion with exposure of the knot is avoided. It is necessary to use 8 to 10 throws of the knot to ensure that it will resist slipping.
At this point, with the patient upright, the periareolar defect often has an elongated ovoid shape. This is corrected by de-epithelializing additional skin as needed to create a perfect circle, and the areola is inset as before with 4–0 absorbable monofilament suture (Fig. 23). The incisions are supported with tape and dressed with a clear occlusive adhesive sheeting. Drains are placed only in reductions of larger than 800 to 1000 g. A support garment is placed to complete the procedure.
Patients are typically kept overnight in the hospital, although some cases of mastopexy and reductions of less than 500 g are performed on an outpatient basis. Dressings are changed at 7 to 10 days and tape support of the wound is continued for 6 weeks, changing the tape as needed. A support garment is worn for the first 6 weeks. There is no need for tight or conforming dressings to be applied. The initial swelling is largely gone by 6 weeks, and the full result is mature at 6 months to 1 year.
The results of the SPAIR mammaplasty have been very satisfying to both patient and surgeon alike. The shapes that result are more rounded in appearance than with my previous Wise pattern inferior pedicle reductions and, generally speaking, are more aesthetic. In particular, excellent projection of the breast is created and maintained over time. In cases of mastopexy, parenchymal repositioning combined with vertical skin tightening is quite effective in coning the breast and improving the overall shape. Accomplishing these goals with a minimum of scar is particularly attractive to this subgroup of patients who generally have high aesthetic expectations.
The technique is easily applied to reductions of 500 g or less (Fig. 24). The resection of parenchyma and the plication of the inferior skin envelope proceed in a straightforward fashion, and aesthetic results are relatively easy to obtain. For reductions of 500 to 1000 g, it is helpful to have some experience using vertical incisions, as plication of the redundant skin can require some finesse. Generally speaking, however, good to excellent results are also obtained in this group of patients (Fig. 25). For reductions of more than 1000 g, there may be some compromise in the aesthetic appearance of the periareolar scar. It is not uncommon to note persistent pleating in the skin around the areola, and the areola itself may have an elongated or irregular appearance. As well, in these patients, who tend to be over their ideal body weight, stretch of the skin in the inferior pole of the breast can result in some loss of breast projection. However, the overall aesthetic results still tend to be better than with the Wise pattern inferior pedicle technique (Fig. 26).
Significant complications are unusual with this technique and tend to be isolated to large reductions or patients with an excessively redundant skin envelope. The most common issue requiring attention postoperatively is usually a small wound dehiscence in the vertical skin closure. In every instance, these small wounds heal secondarily with only local wound care. Occasionally fat necrosis will be identified as a small mass near the apex of the inferior pedicle, and the firm mass of necrotic fat is removed after complete resolution of swelling has occurred, usually around 1 year postoperatively. Unattractive scars can develop in the vertical segment or around the areola, and these are easily revised. Shape distortion typically involves stretch of the skin of the inferior pole of the breast, a problem easily addressed by simply tightening the vertical skin closure. Overall, however, complications are few and tend to be easily managed often with simple office procedures.
The SPAIR mammaplasty has proven to be an effective, consistent, and reliable method of breast reduction and ptosis management; it is straightforward, easily learned, and generally applicable to a wide variety of patients. It is recommended as a useful tool that can assume a prominent place in the armamentarium of the plastic surgeon who deals with macromastia and ptosis.