Superomedial Pedicle Research Articles

Reductive Augmentation of the Breast

AimAlthough breast reduction surgery plays an invaluable role in the correction of macromastia, it almost always results in a breast lacking in upper pole fullness and/or roundness. We present a technique of breast reduction combined with augmentation termed “reductive augmentation” to solve this problem. The technique is also extremely useful for correcting breast asymmetry, as well as revising significant pseudoptosis in the patient who has previously undergone breast augmentation with or without mastopexy.MethodsAn evolution of techniques has been used to create a breast with more upper pole fullness and anterior projection in those patients desiring a more round, higher-profile appearance. Reductive augmentation is a one-stage procedure in which a breast augmentation is immediately followed by a modified superomedial pedicle breast reduction. Often, the excision of breast tissue is greater than would normally be performed with breast reduction alone.ResultsThirty-five patients underwent reductive augmentation, of which 12 were primary surgeries and 23 were revisions. There was an average tissue removal of 255 and 227 g, respectively, per breast for the primary and revision groups. Six of the reductive augmentations were performed for gross asymmetry. Fourteen patients had a previous mastopexy, and 3 patients had a previous breast reduction. The average follow-up was 26 months.ConclusionsReductive augmentation is an effective one-stage method for achieving a more round-appearing breast with upper pole fullness both in primary breast reduction candidates and in revisionary breast surgery. This technique can also be applied to those patients with significant asymmetry.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Comparison of Sensory Changes Following Superomedial and Inferior Pedicle Breast Reduction.

Comparison of Sensory Changes Following Superomedial and Inferior Pedicle Breast Reduction.

Die Ribeiro-Technik bei Gigantomastie – Review von 294 Reduktionsplastiken in 8 Jahren

Reduction mammaplasty in patients with gigantomastia is challenging even to very experienced plastic surgeons. Extremely elongated pedicles impair the vascular supply of the nipple-areola complex. Breast shaping and effective reduction are difficult due to the severely stretched skin envelope. The Ribeiro technique is the standard technique for reduction mammaplasty in our clinic. The aim of this study is to review our approach in patients with gigantomastia in comparison to the current literature. From 01/2009 to 12/2016, we performed 1247 reduction mammaplasties in 760 patients. In 294 reduction mammoplasties (23.6 %), resection weight was more than 1000 g per breast corresponding to the definition of gigantomastia. The Ribeiro technique with a superomedial pedicle and inferior dermoglandular flap for autologous augmentation of the upper pole was implemented as standard procedure. In cases with a sternal notch-nipple distance > 40 cm, free nipple grafting was performed. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and surgical revision rate were obtained and retrospectively analysed. In 174 patients, 294 reduction mammaplasties were performed with a resection weight of more than 1000 g per breast. Average resection weight was 1389.6 g (range, 1000-4580 g). Average age was 43.5 years (range, 18-76 years), average body mass index (BMI) was 29.2 kg/m2 (range, 19-40 kg/m2), average sternal notch-nipple distance was 34.8 cm (range, 27-52 cm), average operation time was 117 minutes (range, 72-213 minutes). A free nipple graft was necessary in 30 breasts. Overall complication rate was 7.8 %; secondary surgical revision rate was 16 %. 93 % of the patients were "very satisfied" and "satisfied" with the aesthetic result. Nipple sensitivity was rated "very good" and "good" in 88 %. The Ribeiro technique is a well established, versatile standard technique for reduction mammaplasty, which helps to create high-quality reproducible results with longterm formstable shape. In gigantomastia, this procedure is also very effective to achieve volume reduction and aesthetically pleasing results with a low complication rate.

Mastopexie nach massivem Gewichtsverlust – Erweiterte Ribeiro-Technik und Einsatz der lateralen Interkostalarterien-Perforatorlappenplastik (LICAP-Flap) zur Autoaugmentation

Mastopexy in massive weight loss patients is challenging. The breast mound is often unstable and deflated, with a loose inelastic skin envelope. It has become apparent that mammaplasty techniques in these cases should rely more on glandular recontouring rather than on the skin envelope for shaping. Published methods include plication, suspension and autoaugmentation. The residual local tissue (glandular breast tissue, fat tissue, dermoglandular fat flap) is utilised to its full extent in order to reshape a form-stable breast with full upper pole projection. The evolution of a technique is presented. In this study we retrospectively analysed 68 massive weight loss patients who underwent an extended Ribeiro technique with a superomedial pedicle mastopexy and suspension by an inferior dermoglandular flap. The current procedure involves incorporating the lateral intercostal artery perforator flap (LICAP flap) and medial breast pillar additionally to the inferior dermoglandular Ribeiro flap. This essentially autoaugments the upper pole by creating an "autoprosthesis", narrows the widened breast, and redefines the inframammary fold. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility and surgical revision rate were obtained. From 01/2011 to 12/2016, we performed 136 autoaugmentation mastopexies. The average age was 41.2 years, average body mass index (BMI) was 27,1 kg/m2, average weight loss was 54.3 kg, average sternal notch-NAC distance was 32.3 cm, average operation time was 109 minutes. In 12 breasts, a free-nipple graft was necessary. The complication rate was 5.1 %, surgical revision rate was 17.6 %. 95 % of the patients were "very satisfied" or "satisfied" with the aesthetic result. Nipple sensibility was rated as "very good" or "good" by 85 % of patients. Modification of the Ribeiro technique by using the medial and lateral breast pillar (LICAP flap) allows autoaugmentation of the upper pole. Parenchymal shaping through plication and suspension of the breast mound should improve breast shape over time, with the aim of reducing the incidence of recurrent ptosis. The presented technique is a reproducible and reliable method with a low complication rate.

Superomedial pedicle reduction mammaplasty: increased resection weight does not increase nipple necrosis

BackgroundThe superomedial pedicle (SMP) reduction mammaplasty offers several advantages over more traditional operative techniques, such as retained sensation to the nipple areola complex (NAC) and improved preservation of long-term breast shape. However, many surgeons believe that using the SMP can cause an increase in NAC necrosis rates up to 13.1%, especially in large volume reductions. The aims of this paper are to determine the rate of nipple necrosis when performing an SMP reduction mammaplasty at our institution and establish if there is a difference in those rates based on the weight of tissue removed. We then compared our overall rate of nipple necrosis to those found using a systematic review of literature involving other pedicles to determine if this technique is equivalent to more commonly used methods. MethodsWe performed a retrospective chart review of patients who underwent breast reduction surgery using SMP at a single institution between May 1, 2013, and May 1, 2015. Each breast was counted separately, and the weight of the tissue removed was recorded. Six-mo follow-up data were analyzed using the chi-square analysis to compare rates of NAC necrosis among our patients and historical cohorts. ResultsOne hundred thirty-five breasts (70 patients) met inclusion criteria. Patients had a mean resection weight per breast of 1016.7 g (±478.3). There was an NAC necrosis rate of 0% in the groups where 1200 g or less of tissue were removed and 2.3% (n = 1) in the group where greater than 1200 g of tissue were removed. We found no statistically significant difference in the rate of NAC necrosis with increased resection weights, (P = 0.32). The overall rate of NAC necrosis for this study was 0.7% per breast, which is equivalent to the rates found during the systematic review of literature. ConclusionsIn this study, the SMP breast reduction technique shows a low rate of NAC. We found no statistically significant increase in NAC necrosis rates as the volume of tissue removed increases, and the SMP appears to have an overall rate of NAC necrosis similar to more commonly used pedicles. Although the results of this study may be related to patient selection or surgical technique, we believe that this pedicle preserves the breast's main blood supply so that less tissue ischemia occurs.

Oncoplastic Breast Surgery after Neoadjuvant Chemotherapy Replacing Mastectomy in Locally Advanced Breast Cancer (LABC): Single Institute Experience

Background: Integration of neoadjuvant chemotherapy (NCT) in early 70s resulted that many LABC tumors become resectable but with total mastectomy especially those with partial response, oncoplastic techniques give better oncological outcome with better cosmetic results. Objective: We evaluate the oncological safety of oncoplastic breast surgery (OS) in LABC showing partial response to NCT. Methods: We prospectively analyzed the data of 32 out of 58 patients with LABC who showed partial response to NCT and could have conservative surgery with advanced oncoplastic techniques rather than total mastectomy. Results: Out of 58 patients with LABC, received neoadjuvant chemotherapy, complete response was observed in 8 patients (13%), partial response reported in 32 (55.1%) cases, 12 patients (20%) had stable disease and 6 patients (10%) showed progressive disease. Data of 32 cases were studied (mean age 44.84 ± 9.10 years; range 26 - 59 years). Inferior pedicle was performed in 9 cases, mini LD flap in 3 patients, 5 had Grissotti technique, 6 with superomedial pedicle, 4 had V mammoplasty and 3 with J mammoplasty and 2 had vertical mammoplasty. Margins were positive in 5 cases (15.6%) with mean margin width 9.63 ± 5.72 (range 0 - 22 mm), and the local recurrence was reported in 2 cases (6.2%). Complications were reported in 3 cases (9.3%). The follow up was 1.67 ± 1.03 (range 0 - 3.3 years). Conclusions: Integration of neoadjuvant chemotherapy together with advanced oncoplastic techniques opens a new way for management of LABC especially those showing partial response with avoidance of total mastectomy, and comparable oncological safety in addition to better aesthetic and psychological outcome.

Short-Scar Mammaplasty in Severe Macromastia.

It is generally claimed that short-scar mammaplasty is limited to small-to-medium reductions. Its use in patients with severe macromastia has been associated with a high rate of complications. This report presents our experience of reduction mammaplasty greater than 1000 g per breast using a short-scar technique. The procedure is based on the following: a) modified breast marking method with conservative placement of the nipple-areola complex, determined not only by the level of the inframammary fold but also degree of upper pole volume loss; b) use of liposuction for contouring the inferior pole; c) vertical design dermoglandular resection; d) superomedial pedicle; and e) skin closure without undermining or gathering. A total of 69 patients were identified (n = 138 breasts). Mean age was 38.0 years with average BMI of 36.4 kg/m. Mean weight of breast removed was 1333.8 g (range, 1002-3275). New nipple position was determined to be inferior to the inframammary fold at a mean distance of 4.6 cm, as predicted by the degree of flatness of upper pole. Complications included delayed healing (7.2%), fat necrosis (10.1%), infection (5.8%), hematoma (2.9%), and seroma (1.5%). There were no instances of nipple-areola complex necrosis. Revision of dog-ears was necessary in 7 patients (10.1%). The authors conclude that in using a modified short-scar mammaplasty approach in cases of severe macromastia, the outcomes can be improved with reduced scar burden, pleasing breast shape, and a low complication rate.

Antibiotic prophylaxis in reduction mammaplasty: study protocol for a randomized controlled trial.

BackgroundThe role of antibiotics in surgical procedures where the risk of surgical site infection (SSI) is low remains uncertain. There is, to date, no evidence to justify the routine use of antibiotics in postoperative reduction mammaplasty. The aim of this study is to evaluate the effect of postoperative antibiotic treatment on the occurrence of SSI after breast reduction surgery.MethodsThis is a double-blind randomized clinical trial with 124 breast hypertrophy patients allocated to two treatment groups: antibiotic (n = 62) and placebo (n = 62). All patients will undergo reduction mammoplasty, performed by the same surgical team. The surgeons will raise the nipple-areola complex by the superomedial pedicle technique. The patients will receive antibiotics intravenously during anesthetic induction and every 6 hours thereafter during their 24-hour hospital stay. During discharge from the hospital, each patient will receive a numbered package containing either cephalexin or placebo capsules and will be directed to take one capsule every 6 hours for 7 days. Neither the surgery team nor the patients will know the contents of the capsules. Patients will be monitored for the occurrence of SSI once weekly during the first 30 days following hospital discharge by a single surgeon who is blinded to their treatment group. SSI will be evaluated based on the definition adopted by the Centers for Disease Control and Prevention.DiscussionDue to the variety of risk factors for SSI and limited case studies, conclusions regarding the effect of antibiotics on the occurrence of SSIs following reduction mammaplasty are potentially biased. In recent studies, perioperative antibiotic prophylaxis was effective in preventing infection and is therefore recommended in clinical practice. However, antibiotic use in the postoperative period still remains controversial.Trial registrationClinicaltrials.gov Identifier: NCT02569866. Registered on 4 October 2015.

The "Superior Ledge": a Modification of the Standard Superomedial Pedicle Reduction Mammoplasty to Accentuate Nipple-Areola Complex Projection.

The superomedial pedicle parenchymal excision pattern for reduction mammaplasty has the benefits of a reproducible breast shape and improved superomedial fullness, but is limited by a susceptibility to nipple retraction. The senior author of this paper has formalized the "superior ledge" modification of the superomedial pedicle technique (SL-SMP) to address these limitations. To describe the technical details of the SL-SMP breast reduction technique and to analyze patient outcomes. The technique involves only partial-thickness parenchymal excision superolateral to the pedicle, thereby leaving a "superior ledge" of parenchyma on top of which the nipple-areola complex (NAC) rests in a tension-free manner. Postoperative photographs were recorded; and patient demographics, intraoperative details, complications, and outcomes were recorded and analyzed. One hundred seven patients underwent SL-SMP reduction mammaplasty between 2007 and 2013. Complications included wound-healing complications (9.3%), infection (2.8%), seroma (1.9%), and hematoma (1.9%). Mean follow-up was 44.6months (Range: 17-72), and during that period no incidence of clinically relevant NAC retraction was noted by either the patient or surgical team. Maintenance of a distinct superior ledge underlying the final position of the NAC is an important modification to stress, to prevent nipple retraction. Importantly, the height of the ledge can be personalized for each patient. We feel it is a valuable addition to the plastic surgeon's armamentarium to optimize outcomes for patients seeking relief from excessive breast tissue. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Triangular lipodermal flaps in Wise pattern reduction mammoplasty (superomedial pedicle): A novel technique to reduce T-junction necrosis

Background Although Wise pattern reduction mammoplasty is one of the most prevalent procedures providing satisfactory cutaneous reduction, it is at the expense of inevitable lengthier scars and wound complications, especially at the inverted T junction. Objective To describe a novel technique providing tension-free closure at the T junction through performing triangular lipodermal flaps. The aim is to alleviate skin tension, thus reducing skin necrosis, dehiscence and excessive scarring at the T junction. Methods One hundred seventy-three consecutive procedures were performed on 137 patients between 2009 and 2013. Data collected included demographics, perioperative morbidity and resected breast tissue weight. The follow-up period ranged from three to 30 months; early and late postoperative complications and patient satisfaction were recorded. Results Superficial epidermolysis without T-junction dehiscence was experienced in eight (4.6%) procedures while five (2.9%) procedures developed full-thickness wound dehiscence. Ninety-four percent of patients were highly satisfied with the outcome. Conclusions The technique is safe, versatile and easy to execute, providing a tension-free zone and acting as internal dermal sling, thus providing better wound healing with more favourable aesthetic outcome and maintaining breast projection.

Long-term follow-up and patient satisfaction after reduction mammoplasty: Superomedial versus inferior pedicle.

Background:Surgery for hypertrophied breasts represents a challenge for plastic surgeons. The search for a good post-surgical cosmetic breast has led to the development of many techniques. Objectives for reduction mammoplasty are to achieve elevated, symmetrical breasts, a round shape, good projection, small cicatrices that are not very perceptible, and a lasting result.Patients and Methods:This study was carried out on sixty cases who had done reduction mammoplasty from January 2009 to December 2014. All patients were examined and were asked for late post-operative results and overall patients' satisfaction.Results:Long-term projection and contour of the breast were more satisfactory among patients who had superomedial pedicle with a statistically significant difference. No statistically significant difference was observed between patients underwent either superomedial or inferior pedicle reduction mammoplasty with regard to breast shape symmetry, nipple symmetry and sensation. The mean score for satisfaction was higher among patients who underwent superomedial pedicle rather than the inferior pedicle method.Conclusion:The superomedial pedicle shows better long-term cosmetic results.

Clinical efficacy of superomedial pedicled mammaplasty based on Würinger's horizontal septum

Objective To study the method and effect of superomedial pedicled mammaplasty based on Wuringer's horizontal septum. Methods During August 2014 to August 2015, 25 cases of cromastia were treated with septum-based mammaplasties with a superomedial pedicled and vertical incision. Based on the preoperation design, the superomedial pedicle was deepithelialized with preservation of the dermis and the subdermal plexus. The pedicle was dissected as described, the excess tissue was removed with the prepectoral fascia preserved. After remodeling the shape of mammary gland, the incision was sutured. Results There was no hematoma, no fat liquefaction and no partial or complete NAC necrosis. The pre and postoperative NAC sensibilities were comparable in all the patients. The patients were followed up for 6 to 12 months, and all the patients were satisfied with the therapeutic effect and expressed acceptance to the scar. Conclusions The breast reduction based on well-vascularized septum and superomedial pedicle is safe with minor scar, even in large breasts. This technique demonstrates ease of pedicle shaping and breast remodeling. The satisfied effect could be obtained for patients with severe ptosis of breasts just after operations and in future. Key words: Cromastia; Reductive mammoplasty

Triangular lipodermal flaps in Wise pattern reduction mammoplasty (superomedial pedicle): A novel technique to reduce T-junction necrosis.

Although Wise pattern reduction mammoplasty is one of the most prevalent procedures providing satisfactory cutaneous reduction, it is at the expense of inevitable lengthier scars and wound complications, especially at the inverted T junction. To describe a novel technique providing tension-free closure at the T junction through performing triangular lipodermal flaps. The aim is to alleviate skin tension, thus reducing skin necrosis, dehiscence and excessive scarring at the T junction. One hundred seventy-three consecutive procedures were performed on 137 patients between 2009 and 2013. Data collected included demographics, perioperative morbidity and resected breast tissue weight. The follow-up period ranged from three to 30 months; early and late postoperative complications and patient satisfaction were recorded. Superficial epidermolysis without T-junction dehiscence was experienced in eight (4.6%) procedures while five (2.9%) procedures developed full-thickness wound dehiscence. Ninety-four percent of patients were highly satisfied with the outcome. The technique is safe, versatile and easy to execute, providing a tension-free zone and acting as internal dermal sling, thus providing better wound healing with more favourable aesthetic outcome and maintaining breast projection.

Beware of pyoderma gangrenosum complicating mastopexy: the importance of early detection and treatment.

Beware of pyoderma gangrenosum complicating mastopexy: the importance of early detection and treatment.

The Superomedial Pedicle Wise-Pattern Breast Reduction: Reproducible, Reliable, and Resilient.

The combination of the superomedial pedicle with the traditional Wise-pattern skin resection has gained increasing popularity for its versatility and ability to achieve significant reduction of breast parenchyma and skin envelope with improved contour and lasting results. Here the authors review the pertinent anatomy and discuss their surgical technique and its benefits. In addition, a retrospective chart review of 80 patients (151 breasts) who underwent superomedial pedicle Wise-pattern breast reduction between 2010 and 2014 was performed. Mean specimen weights and complication rates, including seroma, delayed wound healing, nipple loss, infection, and reoperation were calculated for the cohort.

Effect of Dermal Thickness on Scars in Women with Type III-IV Fitzpatrick Skin.

Both patients and physicians desire minimal scarring after surgical procedures. The removal of foreign bodies from around the wound, prevention of infection, and wound closure without tension is recommended for reducing scarring. The reasons underlying the differing appearance of scars between different anatomical regions of the same individual are not fully understood. Moreover, to our knowledge, the relationship between incision width and dermal thickness in different anatomical regions has yet to be investigated. Hence, in the present study, we aimed to determine the effect of dermal thickness on scar formation. Fifty patients who were treated and followed up for breast hypertrophy between 2010 and 2013 were retrospectively investigated. In all patients, a 2 × 2-cm skin biopsy specimen was obtained from the medial right breast at the horizontal line of the T scar. A routine superomedial pedicle breast reduction was subsequently performed. The extracted excision materials and skin biopsy specimens were examined pathologically. Dermal thickness was measured from the starting point of the subcutaneous tissue to the end point of the epidermis, at four different sites. The average dermal thickness was then calculated for each patient. The skin color of all patients was determined according to the Fitzpatrick classification. Scar width was measured in three different regions, including a combination of the vertical and horizontal portions of the T scar and the flap confluence. After the measurements, the scars were evaluated for vascularity, pigmentation, elasticity, thickness, and height by two plastic surgeons and a clinical nurse, who were blinded to patient data. The mean age of the 50 female patients was 40.8 years (range 18-65 years). The average follow-up period was 16 months (range 12-18 months). An average of 987.5 g (range 505-1621 g) of breast and fatty tissue was removed. The average dermal thickness was 4.99 mm (range 3.5-6.8 mm). The most common skin type was Fitzpatrick type IV (33 patients). The average total scar score was 14 (range 8-25). The total scar score was not significantly associated with dermal thickness. The scar width in patients with a dermal thickness of <0.5 cm was narrower than that in patients with a dermal thickness of ≥0.5 cm. Scar vascularity and noticeability were observed less often in patients with Fitzpatrick skin type III, regardless of scar width. The study findings show that increased dermal thickness is a risk factor for wide scar formation. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long-term changes in nipple-areolar complex position and inferior pole length in superomedial pedicle inverted 't' scar reduction mammaplasty.

Proper nipple-areolar complex position in reduction mammoplasty patients is a challenging problem regardless of the preferred technique. Postoperatively, the nipple-areolar complex is often not located at the most projected area of the breast. This retrospective observational study aimed to find the long-term measurements of the nipple-areolar complex position and inferior pole length after inverted T scar-superomedial pedicle reduction mammoplasty. Forty-eight female patients (96 breasts) were included in this study. The inclusion criteria were that no previous operation should have been done on any of the breasts and both NAC complexes should be at least 30 cm from the midclavicular point. Preoperatively, the distance from the midclavicular point to the new nipple was recorded. All patients were operated on with the inverted T pattern and superomedial pedicle technique. The resection weights, the distance from the midclavicular point to the nipple distance, and the distance from the NAC lower border to the inframammary fold were evaluated postoperatively with an average of 15-month follow-up. The mean preoperative distance from the midclavicular point to the nipple was 34.21 cm for the right breast and 34.26 cm for the left breast. The mean resection weight per breast was 1035 g for the right breast and 1081 g for the left breast. The descent of the NAC was 1.61 cm for the right breast and 1.79 cm for left breast (mean: 1.7 cm) at the end of the follow-up. Additionally, the inframammary length increased 3.31 cm for the right breast and 3.59 cm for the left breast (mean: 3.45 cm). In this study, we found that the new nipple-areolar complex does not go upward but goes downward. However, it was not located at the most projected area of the breast as it was set intra-operatively. This was because the lower pole of the breast sagged more than the nipple: clinically, we observed a nipple superior displacement of 1.75 cm (3.45 - 1.7 = 1.75). According to this calculation, we believe that the new nipple position should be marked at 1.5-1.75 cm below the most projected area of the breast after final shaping so that in the long term, the nipple-areolar complex would be at the proper position. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The free-nipple breast-reduction technique performed with transfer of the nipple-areola complex over the superior or superomedial pedicles.

Although the free-nipple breast-reduction technique is essentially an amputation, achieving aesthetic results still is important. The authors present their technique for free nipple-areola complex (NAC) transfer over the superomedial or superior pedicle full-thickness flaps in patients for whom a free-nipple technique is inevitable due to certain risk factors. The study included 25 patients who underwent surgery with the aforementioned method for addressing severe gigantomastia. The patients had a mean age of 43 years (range 34-59 years) and a mean body mass index (BMI) of 35.8 kg/m(2) (range 28-42 kg/m(2)). During the operation, the NAC was elevated as a full-thickness skin graft, then transposed to the superior or superomedial pedicles, which had been planned previously. The subsequent stages of the operation thus became a Wise-pattern breast reduction. The mean resection per breast was 1,815 g (range 1,620-2,410 g). Breast projection, shape, and areolar pigmentation were assessed during the follow-up visit. One patient experienced a partial loss of the NAC graft, which healed secondarily, and three patients experienced a patchy hypopigmentation of the NAC. Breast projection and conical structure were observed to be preserved during the follow-up period. The modified free-nipple technique aimed to convert the reduction procedure to a technique similar to pedicle methods, yielding successful results during the early phases. The full-thickness flap constructed in this way provides more fullness and a maximum contribution to projection in patients who will inevitably undergo breast reduction with the free-nipple method. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Combination of Three Techniques for Breast Reduction: A Series of Ten Consecutive Cases

There is continuing controversy regarding the most effective and safest technique for breast reduction surgery. This case series describes our experience with a breast reduction approach that combines three techniques aimed at addressing three different aspects of breast reduction: skin reduction, shaping, and nipple areolar complex shaping. We assessed the perioperative course and postoperative outcomes (for a mean of 19 months) of 10 consecutive women who underwent breast reduction surgery involving a combination of three techniques: “inverted T” skin reduction, modified Hall-Findley supero-medial pedicle for glandular reduction, and inferior de-epithelialized flap (modified “Foustanos” flap) for molding and improved shaping of the breast. The final bra cup size was C or D in all patients. The overall results were graded as excellent in four patients and very good in six patients. Each patient was completely satisfied with her surgery. Six patients developed venous congestion of the nipple areolar complex, which resolved within 24 - 48 hours after surgery. Two patients had uneventful delayed wound healing in the vertical scar of the inverted T pattern. There was a 100% nipple areolar complex survival rate. No patient had a major adverse event, permanently altered nipple areolar complex sensitivity, or bottoming out of the lower pole. None required revision surgery. This case series confirms our expectations that the solution to questions about breast reduction methods may depend on melding different techniques into a single procedure. The combination of techniques herein described was both effective and safe. Level of Evidence: Level IV, therapeutic study.

Superomedial pedicle mammaplasty in the treatment of a variety of breast deformity

Objective To investigate the effect of superomedial pedicle mammaplasty in the treatment of the deformity of hypermastia,and secondary deformity after implants or polyacryamide hydrogel removal.Methods Thirty-six patients underwent a new technique for mammaplasty.This technique involved a superomedial pedicle with or without Wuringer's horizontal septum which was used to repair the deformity of hypermastia,and secondary deformity after implants or polyacryamide hydrogel removed.Results In our series,the new nipple-to-sternal-notch distance was (20.10±1.94) cm postoperatively.Mean nipple elevation was 7.5 cm (range 4 13 cm),and there were no he matoma and partial or complete nipple-areolar complex (NAC) necrosis occurred.Minimal wound dehiscence occurred in two cases (5.56 ％),the rest cases were healed in stage Ⅰ.Twenty eight patients were followed up for 6 to 18 months.NAC sensibilities were comparable before and after operation,and good breast shapes were produced with unconspicuous incision scar in all cases.Conclusions Superomedial pedicle mammaplasty could achieve satisfactory results with respect to breast contouring and scar,meanwhile maintain the NAC viability and sensibility. Key words: Superomedial pedicle; Mammaplasty; Breast implant; Polyacrylamide hydrogel