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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Eser Yuksel, MD, Anthony Echo, MD, Gerardo Guerra, MD, Melvin Spira, MD, Maria Martinez, MD.
Baylor College of Medicine, Division of Plastic Surgery, Houston, TX, USA.

Background: Common complaints following reduction mammoplasty using the inferior pedicle for large ptotic breasts include the migration of the deep tissue, a lack of medial fullness, poor projection, and bottoming-out. These are attributed to the lack of deep tissue suspension and skin envelope relaxation. We address these issues through horizontal suspension and placation of the inferior pedicle, which now allows the skin flap to be the passive element in reduction mammoplasty.
Methods: The superior skin flap is designed based on the breast size. A vertical scarless technique is used if there was at least a distance of 9cm from the superior border of the existing areola to the planned nipple center on the superior flap. If the length was less than 9cm, the inverted-T design was used. The inferior pedicle is de-epithelialized, then dissected directly to the pectoral fascia. Medial and lateral dermal flaps are created on each inferior pedicle by incising along the inframammary fold approximately 5cm. These are then debulked and anchored superiorly to the chest wall above the remaining pedicle. The breast mound is further contoured by horizontally plicating the dermis below the nipple-areolar complex (NAC), which creates projection.
Results: Fifty-four women have undergone reduction mammaplasty using the horizontal approach. Breast projection and shape were sustained during follow-up, of which the median interval was 15 months.
Conclusion: Dermal suspension and horizontal dermal plication provides a structural foundation to the inferior pedicle. The sling-like effect from the dermal suspension maintains a defined inframammary crease, as well as medial and lateral borders, which prevents pedicle migration. Horizontal dermal plication, the critical step, shortens the length of the inferior pedicle while generating improved breast projection and contours by rotating the NAC anteriorly. The firmly shaped inferior pedicle breast mound allows the skin flap to now drape over the breast mound with minimal tension.

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