Inferior pedicle breast reduction: A retrospective review of technical modifications influencing patient safety, operative efficiency, and postoperative outcomes
The inferior pedicle technique remains the most popular approach to breast reduction in the United States. Modifications to this procedure have enhanced versatility, patient safety, and outcome satisfaction in patients with all degrees of macromastia. A 6-year retrospective review of 241 patients who underwent bilateral inferior pedicle breast reduction was conducted at our institution. Modifications analyzed included methylene blue tattooing to provide preoperative landmarks, preoperative hydrodissection to reduce intraoperative blood loss, incorporation of inframammary darting to reduce tension at the "T-junction," preservation of superomedial volume for enhanced medial fullness, and dermatome blade-guided tissue resection. Inframammary darting reduced the incidence of wound dehiscence. Preoperative hydrodissection reduced intraoperative blood loss by a factor of 2. Dermatome blade use reduced operative times at no increased incidence of postoperative seromas or hematomas. Outcomes resulting from these modifications appear to be at least comparable to, and perhaps better than, those previously reported.
Association of VA Surgeons
Inferior pedicle breast reduction: a retrospective review
of technical modiﬁcations inﬂuencing patient safety,
operative efﬁciency, and postoperative outcomes
Michael V. DeFazio, M.D., Kenneth L. Fan, M.D., Yash J. Avashia, B.S.,
Jun Tashiro, M.D., M.P.H., Steven Ovadia, B.S., Tarik Husain, M.D.,
Liliana Camison, M.D., Zubin J. Panthaki, M.D., Christopher J. Salgado, M.D.,
Seth R. Thaller, M.D., D.M.D., F.A.C.S.*
Department of Surgery, Division of Plastic, Aesthetic, Reconstructive Surgery, the DeWitt Daughtry Family, Department
of Surgery, University of Miami Health System, 1120 NW 14th St, Miami, FL 33136, USA
BACKGROUND: The inferior pedicle technique remains the most popular approach to breast reduc-
tion in the United States. Modiﬁcations to this procedure have enhanced versatility, patient safety, and
outcome satisfaction in patients with all degrees of macromastia.
METHODS: A 6-year retrospective review of 241 patients who underwent bilateral inferior pedicle
breast reduction was conducted at our institution. Modiﬁcations analyzed included methylene blue
tattooing to provide preoperative landmarks, preoperative hydrodissection to reduce intraoperative
blood loss, incorporation of inframammary darting to reduce tension at the “T-junction,” preservation
of superomedial volume for enhanced medial fullness, and dermatome blade– guided tissue resection.
RESULTS: Inframammary darting reduced the incidence of wound dehiscence. Preoperative hydro-
dissection reduced intraoperative blood loss by a factor of 2. Dermatome blade use reduced operative
times at no increased incidence of postoperative seromas or hematomas.
CONCLUSIONS: Outcomes resulting from these modiﬁcations appear to be at least comparable to,
and perhaps better than, those previously reported.
© 2012 Published by Elsevier Inc.
Inferior pedicle breast
Macromastia is a pathological condition that imposes
both physical and psychologic stress on a woman’s health-
related quality of life. In addition to psychosocial consider-
ations regarding poor perception of body image and sense of
self-esteem, macromastia has been implicated in a number
of musculoskeletal complaints including neck pain, back
pain, headache, peripheral neuralgias, and shoulder pain.
Given the substantial burden of breast hypertrophy on mul-
tiple domains of generalized well-being, it is not surprising
that the surgical relief of these symptoms has been the focus
of efforts by plastic and reconstructive surgeons since the
late 19th century.
Originally described between 1975 and 1977 by Ri-
, and Courtiss and Goldwyn
, the inferiorly
based dermal pedicle technique remains the most popular
approach to breast reduction in the United States
and is the
benchmark by which newer methodologies are mea-
* Corresponding author. Tel: ⫹1-305-243-4500; fax: ⫹1-305-243-
E-mail address: SThaller@med.miami.edu
Manuscript received April 5, 2012; revised manuscript July 8, 2012
0002-9610/$ - see front matter © 2012 Published by Elsevier Inc.
The American Journal of Surgery (2012) 204, e7– e14
The inverted T scar skin design, which includes
a variety of glandular pedicle types, is an attractive alterna-
tive among reduction mammaplasty protocols because of its
predictability, versatility, and level of control that it offers
over both the extent of reduction as well as the breast-
Common criticisms of this approach in-
clude breast shape abnormalities (pseudoptosis), areolar
malposition, hypertrophic scarring, increased operative
times, and poor long-term projection.
eral outcomes studies have shown high patient satisfaction
after reduction mammaplasty (86%–97%), particularly with
the inferior pedicle design.
In this retrospective review, modiﬁcations to the standard
inferior pedicle approach, used at our institution, were an-
alyzed along with the frequencies of various postoperative
complications and the rates of surgical revision. The overall
purpose of this study is to describe those modiﬁcations,
acquired by experience, that the authors believe to be crit-
ically important for optimizing patient safety, operative
efﬁciency, and aesthetic outcomes after breast reduction.
Patients and Methods
Approval for the study was granted by the University of
Miami/Jackson Memorial Hospital Institutional Review
Boards prior to study commencement. A retrospective anal-
ysis of medical and operative records was conducted on all
patients who underwent bilateral reduction mammaplasty
for either aesthetic or reconstructive purposes in a single
institution between 2005 and 2011.
All breast reductions were performed by 1 of 4 primary
plastic surgeons using a standardized approach to the infe-
rior pedicle technique with speciﬁc modiﬁcations used by
individuals at the University of Miami/Jackson Memorial
Hospitals, Miami, FL. Three hundred eighty-ﬁve consecu-
tive patients with a total of 770 breast reductions were
reviewed. Data were uniformly available for 241 patients in
this series. The remaining 144 patients were excluded from
further analysis because of incomplete or inaccessible med-
ical records. Patient-related factors analyzed in this study
include age, race, body mass index (BMI), medical comor-
bidities (diabetes and tobacco use), weight of resected breast
tissue, preoperative measurements, and postoperative com-
plications. Perioperative data related to operative times and
estimated intraoperative blood loss were also examined.
Modiﬁed operative technique
Technical modiﬁcations emphasized in this review focus
on concepts aimed at improving patient safety, reducing
postoperative complications, and enhancing aesthetic out-
come. These modiﬁcations are as follows:
1. Methylene blue tattooing, in selected locations, to pro-
vide precise surgical landmarks that do not fade during
preoperative preparation of the patient: injections of 1%
methylene blue solution are made using a small 29-G
needle to minimize the risk for permanent or residual
tattooing postoperatively. These landmarks provide a
basis to accurately guide closure of the ﬁnal reduced
breast mound, thereby enhancing the ﬁnal aesthetic re-
sult (Fig. 1A).
2. Use of preoperative hydrodissection to reduce intraoper-
ative blood loss: after the induction of general anesthe-
sia, 60 mL of a solution containing 25 mL of 1% lido-
caine with 1:100,000 epinephrine is inﬁltrated into the
skin and subcutaneous tissues along the marked sites of
incision as well as the surrounding breast tissue itself.
The inclusion of lidocaine in the solution provides more
superﬁcial anesthesia, and the use of a vasoconstrictor,
such as epinephrine, aids in the minimization of intra-
operative blood loss.
3. Incorporation of inframammary darting, in which a small
triangular section of excess tissue is left projecting along
the midinframammary line to reduce tension at the future
site “T-junction” closure: the height of the triangle is
approximately .5 cm and has an angle of 120°. Each side
limb is approximately 1 cm in length, and the base of the
triangle is situated along the inframammary line. It is
important to minimize upward projection of the triangle
wedge to prevent superior displacement of the nipple
4. Preservation of superomedial breast tissue volume dur-
ing glandular tissue resection: this technique serves to
accomplish 2 important purposes: (1) blood ﬂow to the
gland preserved from the prominent second intercostal
space perforator of the internal mammary artery and (2)
tissue overresection in this region is prevented, thereby
serving to enhance medial fullness as well as ﬁnal aes-
thetic result (Fig. 1C).
5. Use of the dermatome blade to improve operative efﬁ-
ciency during breast tissue resection: this technique is
combined using electrocautery to maintain meticulous
hemostasis. During glandular tissue resection, a thin
layer (.5 cm–1 cm) of prepectoral fascia and fat is pre-
served along the entire length of the pectoralis muscle.
This serves to protect nerve supply to the nipple, which
courses along the muscle surface before entering the
gland. Maintenance of this layer has become a standard-
ized part of the protocol at our institution regardless of
the method of breast tissue resection (Fig. 1D).
Given that the incorporation of a particular modiﬁcation
is often dependent on surgeon preference, not every patient
in this study was subject to all modiﬁcations while under-
going reduction mammaplasty.
Endpoints evaluated in this analysis include wound de-
hiscence, the development of seromas or hematomas, intra-
operative hemorrhage, infection, the development of venous
thromboembolism, and the effect of dermatome blade use
e8 The American Journal of Surgery, Vol 204, No 5, November 2012
on operative time. Additional postoperative complications
such as loss or decrease in nipple sensation, nipple necrosis,
symptomatic scar formation, and permanent or residual
methylene blue tattooing as well as rates of surgical revision
were also evaluated. Intraoperative hemorrhage was deﬁned
as bleeding necessitating transfusion. Infection was deﬁned
as cellulitis requiring systemic antibiotic therapy, if possible
guided by wound culture. Seroma was reported only when
clinically evident and was generally treated with aspiration
by the surgeon in the clinic. Patient satisfaction was as-
sessed at a 6- to 12-month follow-up through a voluntary
patient survey related to satisfaction in aesthetic outcome,
reduction or resolution of preoperative symptomatology,
and subjective improvement in the level of conﬁdence and
sense of self-esteem.
Univariate analyses were performed using Pearson chi-
square tests and t tests for categoric and independent vari-
ables, respectively. To evaluate the association between
scale-independent variables for outcomes and the speciﬁc
dependent predictors described previously, a linear regres-
sion analysis was performed. Two models were built using
the following surgical endpoints: operative time and esti-
mated blood loss. Independent predictors included age,
BMI, diabetes, tobacco use, and technical modiﬁcations
used. A backward, stepwise method of independent predic-
tor selection was used with signiﬁcance deﬁned as a value
of P ⱕ .05.
Associations between select patient factors, including tech-
nical modiﬁcations used, and speciﬁc outcome variables were
examined by multiple logistic regression analysis. Dependent
variables included the surgical complications described. Again,
a backward, stepwise method of independent predictor selec-
tion was used with signiﬁcance deﬁned as a P value ⱕ .05.
Statistical analyses were performed using SPSS, version 19
(SPSS Inc, Chicago, IL).
A retrospective analysis was performed on 241 patients
who underwent bilateral inferior pedicle breast reduction
during the period from 2005 to 2011 by 1 of 4 primary
plastic surgeons at our institution. The average age of the
study population was 43 years (range 17–79 years), and the
mean BMI was 32 kg/m
(24 –41 kg/m
). One hundred
nineteen patients were black (49%), 74 were white (31%),
37 were Hispanic (15%), and 11 patients were Asian (5%).
Seventeen patients (7%) were known diabetics, and a total
of 28 patients (12%) reported regular or occasional tobacco
use. The average sternal notch to nipple distance, which
indicates the degree of ptosis, was 32 cm (range 24 – 46 cm).
The mean weight of excised breast tissue in our sample was
982 g (range 185–1,930 g), with a large proportion of
Figure 1 (A) The use of methylene blue tattooing to provide precise surgical landmarks in selected locations, preoperatively. (B)
The incorporation of inframammary darting along the midinframammary line to minimize tension at the future site of closure. (C) The
de-epithelialized inferior pedicle with preservation of superomedial breast tissue volume (box). (D) Breast tissue resection using the
e9M.V. DeFazio et al. Inferior pedicle breast reduction
patients manifesting resection weights greater than or equal
to 1 kg per breast (46%) (Table 1).
Of the modiﬁcations analyzed, the use of methylene blue
tattooing was reported in 142 cases (59%). Preoperative
hydrodissection was used in 178 cases (74%). The incorpo-
ration of inframammary darting was noted in 136 cases
(56%), and the preservation of superomedial breast tissue
volume to maximize regional fullness was documented in
128 cases (53%). Furthermore, the use of the dermatome
blade to aid in breast tissue resection was reported in a total
of 51 cases (21%) (Table 2). No signiﬁcant difference in
age, BMI, comorbidities, or resection weights was identiﬁed
between the different modiﬁcation cohorts.
Linear regression analysis revealed a signiﬁcant reduc-
tion in the estimated intraoperative blood loss by approxi-
mately 109.1 mL (95% conﬁdence interval, 98.3–119.9) in
patients who underwent preoperative hydrodissection be-
fore incision (P ⬍ .001). This ﬁnding conﬁrms the trend
found using t test analysis. The average estimated blood loss
in patients without this technique was approximately 226
mL (range 100 – 400 mL) over the operative period. In
contrast, patients who received this modiﬁcation lost on
average 112 mL (50 mL–250 mL) intraoperatively (P ⬍
.001). This represents an average reduction in intraoperative
blood loss by a factor of approximately 2 associated using
hydrodissection in this study, a ﬁnding conﬁrmed using 2
analytic methods. No cases of intraoperative hemorrhage
requiring blood transfusion were reported.
The linear model for operative times (from incision to
close) showed a signiﬁcant reduction in mean operative
time associated using the dermatome blade during breast
tissue resection (P ⬍ .001). Through t test analysis, we
found that in cases in which electrocautery served as the
sole resection device, operative length averaged approxi-
mately 203 minutes (range 125–279 minutes). This is com-
pared with an average operative duration of 131 minutes
(range 114 –165 minutes) in situations in which the der-
matome blade was used to accomplish glandular tissue
Table 1 Descriptive characteristics of the sample population
Patients included in
analysis (n ⫽ 241)
Patients excluded from
analysis (n ⫽ 144)
Age (y) .211
Mean 43 42
Range 17–79 18–74
Mean 32 32
Range 24–41 23–40
Black 119 (49%) 82 (57%) .15
White 74 (31%) 35 (24%) .178
Hispanic 37 (15%) 22 (15%) .984
Asian 11 (5%) 5 (4%) .604
Tobacco use 28 (12%) 12 (8%) .308
Diabetes 17 (7%) 13 (9%) .944
SN:N (cm) .231
Mean 32 32
Range 24–46 24–44
Resected tissue weight .315
Left breast (g)
Mean 1,003 1,000
Range 190–1,930 180–1,920
Right breast (g)
Mean 960 970
Range 185–1,810 190–1,790
SN: N ⫽ sternal notch to nipple.
Table 2 Proportion of patients who underwent each
Absolute number Percentage
Methylene blue tattoo 142 59
hydrodissection 178 74
Inframammary darting 136 56
superomedial fullness 128 53
tissue resection 51 21
e10 The American Journal of Surgery, Vol 204, No 5, November 2012
resection (P ⬍ .001). Again, the signiﬁcance of this ﬁnding
was conﬁrmed using 2 analytic methods.
Complications noted in this series included minor wound
dehiscence requiring local wound care and dressing changes
in 24 cases (5%), infection requiring oral antibiotic therapy
in 6 cases (1.2%), fat necrosis in 3 cases (.6%), and symp-
tomatic scar formation in 28 cases (6%). Postoperative se-
romas developed in 5 cases (1.0%), each requiring drainage
with needle aspiration in the ofﬁce. Additionally, 3 (.6%)
unilateral hematomas requiring operative evacuation were
reported as well. There was no signiﬁcant difference in the
rate of infection, scar formation, or seroma/hematoma de-
velopment between the different modiﬁcation cohorts. Ad-
ditionally, no speciﬁc complication was associated more
frequently with any particular surgeon in the study sample.
Univariate analysis showed the absence of inframam-
mary darting to be the most signiﬁcant predictor of postop-
erative wound dehiscence. All cases of dehiscence in this
series occurred at the site of the “T-junction” closure. The
incorporation of inframammary darting along the inframam-
mary line reduced the odds of postoperative dehiscence by
a factor of 5.8 (P ⬍ .001). Multiple logistic regression
analysis controlling for demographic and modiﬁer variables
was used to conﬁrm the statistical signiﬁcance of this ﬁnd-
ing (P ⬍ .001). Additionally, when controlling for other
factors, a trend between tobacco use and wound dehiscence
was observed; however, this ﬁnding did not reach statistical
signiﬁcance (P ⫽ .089). No association between wound
dehiscence and age, BMI, or diabetes was noted.
Two patients reported unilateral loss of nipple sensation
(.4%), and 5 patients reported unilateral decreased nipple
sensation (1%). There was only 1 patient, a documented
cigarette smoker, who developed complete bilateral nipple
necrosis in the entire series (.4%). No cases of venous
thromboembolism or permanent postoperative methylene
blue tattooing were reported (Table 3).
Surgical revision was performed in 24 cases (5%), in-
cluding operative evacuation of the 3 hematomas, 4 cases
(17%) of operative scar revision secondary to hypertrophic
scarring, removal of fat necrosis in 3 cases (13%), and
reoperation for asymmetry in 2 other cases (8%). The re-
maining 12 revisions (50%) were performed for the correc-
tion of residual axillary fullness not directly related to the
After review, 96% of the 241 patients expressed overall
satisfaction with their postoperative results. This included a
reduction or resolution of preoperative symptomatology
such as neck pain (91%), back pain (96%), shoulder pain,
and grooving (100%) as well as subjective improvement in
perception of self-image (92%) and satisfaction with the
ﬁnal aesthetic outcome (95%). Eighty-six percent of these
patients also reported acceptable scar appearance, with a
minority of patients reporting thickened or pruritic scars and
only 4 patients requiring hypertrophic scar revision.
Success of the inferior pedicle technique in the reduction
of breast volume and subsequent relief of symptoms has
been well recognized by the plastic and reconstructive com-
Recent systematic review, focusing on the qual-
itative effects of surgical breast reduction, conﬁrmed both
physical and psychologic beneﬁts, including substantial im-
provements in exercise practices, weight loss, eating behav-
iors, and psychosexual function.
Pressures placed on qual-
ity outcomes in today’s health care environment have
challenged surgeons to identify and institute practices that
ultimately serve to minimize risks, improve efﬁciency, and
optimize patient outcomes. We aimed to identify those
factors that we believe serve to accomplish 1 or more of
The selection of appropriate candidates is essential for
optimizing safety and outcomes in patients who undergo
reduction mammaplasty. Among factors known to impair
outcomes after breast reduction are obesity and tobacco
Obese patients are at increased risk of postoperative
complications such as infection, dehiscence, venous throm-
boembolism, and delayed wound healing as well as fat and
Chen et al
reported a nearly 12-fold
increase in postoperative complications in obese patients
who underwent elective breast procedures including reduc-
tion. Although the impact of obesity was not the focus of
this investigation, it should be noted that over 70% of
complications were reported in patients with a BMI greater
than 35. Therefore, appropriate discussion and recommen-
dations for weight loss before surgery must be considered.
Additionally, smoking is considered a contraindication to
reduction mammaplasty. A recent review regarding the im-
pact of nicotine on postoperative complication rates re-
vealed double the risk of complications in active smokers
Table 3 Postoperative complication rates
Gross number (%)
“T-junction” wound dehiscience 24 (5.0)
Infection 6 (1.2)
Fat necrosis 3 (.6)
Symptomatic scar formation 28 (6.0)
Unilateral loss of nipple sensation 2 (.4)
Unilateral decreased nipple sensation 5 (1.0)
NAC necrosis 2 (.4)
Permanent postoperative methylene
blue tattooing 0
Unilateral seroma 5 (1.0)
Unilateral hematoma 3 (.6)
Hemorrhage (requiring transfusion) 0
Surgical revision 24 (5.0)
NAC ⫽ nipple areola complex; VTE ⫽ venous thromboembolism.
e11M.V. DeFazio et al. Inferior pedicle breast reduction
with signiﬁcant elevations in T-scar necrosis and postoper-
ative infection rates.
In our study, only 12% of patients
admitted to being active smokers. Of these, complications
were reported in approximately 75%, including the only
case of complete bilateral nipple necrosis. The most fre-
quently reported complication in this cohort of patients was
wound dehiscence at the site of “T-junction” closure. Be-
cause of the deleterious effects of nicotine on wound-heal-
ing capacity, we strongly encourage at least 4 weeks of
abstinence from smoking before surgery to reduce the risk
of smoking-related complications.
With the inferior pedicle technique, the provision of
consistent preoperative markings is essential to the design
of both boundaries that guide breast tissue resection as well
as skin ﬂaps that accurately guide closure of the ﬁnal re-
duced breast mound. The use of methylene blue tattooing to
reinforce selected landmarks offers 2 distinct advantages
during this process. First, it provides consistent preoperative
markings that do not fade during the preoperative prepara-
tion of the patient in the operating room. Second, it directs
the precise placement of critical sutures during closure that
ultimately inﬂuence the ﬁnal aesthetic contour of the re-
duced breast. In our series, no cases of permanent or resid-
ual tattooing were noted. This is likely because of our use of
small-caliber 29-G syringes to inject the dye preoperatively.
The use of this technique in reduction mammaplasty was
derived from its role in cleft lip repair at our institution.
The reduction of intraoperative blood loss is of signiﬁ-
cant priority in optimizing patient safety during elective
procedures. An average blood loss exceeding half a liter
during breast reduction is not uncommon.
lead to delayed postoperative recovery, prolonged hospital-
ization, and blood transfusion, which is often accompanied
by more serious risks. In this study, we found that the
preoperative inﬁltration of skin, subcutaneous, and glandu-
lar breast tissue with a solution containing dilute epineph-
rine was the most important factor predicting signiﬁcant
reductions in mean intraoperative blood loss compared with
procedures without hydrodissection (P ⬍ .001). Further-
more, the lack of need for blood transfusion in this series
conﬁrms the value of this technique and is consistent with
previously published studies.
Although concern exists over the potential for associated
complications using preoperative hydrodissection, such as
skin ﬂap necrosis, rebound bleeding, and postoperative he-
we found no signiﬁcant difference in
the frequencies of these complications postoperatively. Ad-
ditionally, other studies have reported briefer hospital stays,
more rapid recovery, and a reduction in hospital costs as
well as patient discomfort associated using this tech-
However, a limitation of this study was the esti-
mation of blood loss through subjective visual assessment
by the anesthesiologist. Previous reports have shown that
despite this commonly accepted practice, the visual estimate
is often imprecise and underestimated.
Compared with other methods of breast reduction, the
inferior pedicle technique is associated with increased op-
In this study, we found a signiﬁcant re-
duction in operative times associated with dermatome bla-
de– guided breast tissue resection. To our knowledge, this is
the ﬁrst reported use of this instrument in breast reduction
surgery. The shorter operative times that result have impor-
tant implications for patient safety, including decreased
exposure to anesthesia and a decreased risk of deep vein
thrombosis. Additionally, economic burden is reduced
through the more efﬁcient use of operating room resources.
Concern over the use of this technique is related to poten-
tially less hemostatic control. Interestingly, there was no
signiﬁcant difference in the rate of postoperative seroma or
hematoma development associated with dermatome blade
use. We found that adequate hemostasis could be main-
tained with controlled hypotension throughout breast tissue
resection as well as electrocauterization of actively bleeding
Wound dehiscence, most commonly at the “T-junction”
site of closure, is one of the most frequently reported com-
plications associated with this technique.
this complication in 24 patients (5%), which is consistent
with or lower than other reported series.
bute this ﬁnding to the incorporation of inframammary
darting to reduce tension at the site of “T-junction” closure,
which was associated with a signiﬁcant reduction in wound
dehiscence in our study (P ⬍ .001).
Of particular concern for women who undergo reduction
mammaplasty is loss of nipple-areola sensitivity and erec-
tility, which has been attributed to injured perforators of the
third through ﬁfth intercostal nerves.
nipple sensitivity have been reported to range from 1.3% to
as high as 25%, with a greater frequency of reduced sensa-
tion after larger-volume reductions (⬎1,000 g).
reported only 2 cases of unilateral loss of nipple sensation
(.4%) and only 5 cases of unilateral decreased nipple sen-
sation (1%). We attribute this low rate to the maintenance of
a thin layer of prepectoral fascia along the entire length of
the pectoralis muscle to protect the underlying nerve supply
before it projects superﬁcially toward the nipple. Our ap-
proach has been supported by numerous other studies.
Achieving high patient satisfaction is critical to the suc-
cess of any breast reduction protocol. Traditionally, satis-
faction rates are exceptionally high after reduction mamma-
plasty, which is not surprising given the substantial impact
of this procedure on multiple domains of patient well-being.
In our study, the overall satisfaction was noted to be 96%,
with over 90% of patients reporting a signiﬁcant improve-
ment in either preoperative symptomatology, baseline level
of comfort, or satisfaction in aesthetic outcome. Although
we achieved a 100% response rate from patients at the 6- to
12-month follow-up, satisfaction was assessed through a
voluntary patient survey, rather than a validated question-
naire, and is a limitation of this study.
e12 The American Journal of Surgery, Vol 204, No 5, November 2012
Interestingly, we documented 28 cases (6%) of symp-
tomatic or hypertrophic scarring, including 4 cases that
required scar revision. Despite this observation, the overall
satisfaction rates remained high. This result has been con-
ﬁrmed by other studies in which stronger correlations be-
tween satisfaction and breast volume as well as contour
have been noted.
Therefore, we speculate that the preser-
vation of superomedial breast tissue volume during the
operative design contributes more signiﬁcantly to satisfac-
tion in the aesthetic outcome than inframammary scarring,
which is often hidden under the breast while the patient is
upright (Fig. 2). Aslam et al
reported a signiﬁcantly higher
rate of patient dissatisfaction with postoperative scarring in
patients who were not well informed preoperatively about
surgical scarring. This observation emphasizes the impor-
tance of patient education in assuring realistic expectations
and satisfaction in clinical outcome.
In addition to the limitations mentioned previously, this
study is further limited by its retrospective nature. Although
the overall complication rate was not associated with any
speciﬁc surgeon in our study, the variability in technical
skill among surgeons invariably plays a role in operative
efﬁciency, complication rates, and clinical outcomes. Future
prospective studies evaluating the use of these modiﬁcations
would allow more deﬁnitive analysis from which sound
recommendations and guidelines for their use might be
The inferior pedicle technique is a highly effective ap-
proach to the management of breast hypertrophy with dem-
onstrated effects on both the physical and psychologic well-
being of patients. We have found that the incorporation of
minor technical modiﬁcations to the standard inferior pedi-
cle technique generates results that are at least comparable
to, and perhaps more favorable, than those previously re-
ported in the literature. Ultimately, improvements in patient
safety and operative efﬁciency will lead to signiﬁcant re-
ductions in postoperative complications as well as optimize
aesthetic outcomes after breast reduction. A continuous and
meticulous review of surgical protocol combined with an
awareness of potential risks and complications will allow
further improvements in these measures to be achieved.
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Figure 2 (A) A healthy 36-year-old woman with bilateral gigantomastia and asymmetrical breasts (left ⬎right) presented for breast
reduction surgery. (B) Approximately 900 g and 1,250 g of tissue was removed from the right and left breasts, respectively, using the inferior
pedicle technique with preservation of superomedial breast tissue volume resulting in enhanced medial fullness. Wise pattern postoperative
scarring was minimal. The postoperative view shows the patient at 6 months after surgery.
e13M.V. DeFazio et al. Inferior pedicle breast reduction
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e14 The American Journal of Surgery, Vol 204, No 5, November 2012