Plastic & Reconstructive Surgery

362 Pages·2007·22.32 MB·English

Plastic & Reconstructive
Surgery

October 2007, Volume 120, Issue 5,Pg(1095-1441)
BREAST
ORIGINAL ARTICLES
Breast Reduction: Modified "Lejour Technique" in 500 Large Breasts.

Albert K. Hofmann, M.D.; Margot C. Wuestner-Hofmann, M.D.; Franco Bassetto, M.D.;
1095
Carlotta Scarpa, M.D.; Francesco Mazzoleni, M.D.
BREAST
ORIGINAL ARTICLES: Discussion
Discussion.

Elizabeth J. Hall-Findlay, M.D.
1105
BREAST
ORIGINAL ARTICLES
Validation of a Questionnaire for Measuring Morbidity in Breast
Hypertrophy.
1108
Leif Sigurdson, M.D., M.Sc., M.B.A.; Susan A. Kirkland, Ph.D.; Eric Mykhalovskiy, Ph.D.
Supplemental Digital Content is available in the text.
Immediate Nipple Reconstruction on a Free TRAM Flap Breast
Reconstruction.
1115
Eric H. Williams, M.D.; Lawrence Z. Rosenberg, M.D.; Paul Kolm, Ph.D.; Jorge I. de la
Torre, M.D.; R Jobe Fix, M.D.
Surveillance Mammography following the Treatment of Primary
Breast Cancer with Breast Reconstruction: A Systematic Review.
1125
G Philip Barnsley, M.D.; Eva Grunfeld, M.D., D.Phil.; Douglas Coyle, Ph.D.; Lawrence
Paszat, M.D., M.Sc.
BREAST
IDEAS AND INNOVATIONS
Skin Banking Closure Technique in Immediate Autologous Breast

Reconstruction.
1133
Eric C. Liao, M.D., Ph.D.; Brian I. Labow, M.D.; James W. May Jr, M.D.
EXPERIMENTAL
ORIGINAL ARTICLES
Dihydrotestosterone Stimulates Proliferation and Differentiation of
Fetal Calvarial Osteoblasts and Dural Cells and Induces Cranial
1137
Suture Fusion.
Ines C. Lin, M.D.; Alison E. Slemp, M.D.; Catherine Hwang, B.S.; Miguel Sena-Esteves,
Ph.D.; Hyun-Duck Nah, D.D.S., Ph.D.; Richard E. Kirschner, M.D.
The Effect of Fibrin on the Survival of Ischemic Skin Flaps in Rats.
Zhi Qi, M.D.; Yuanjun Gu, M.D., Ph.D.; Dohoon Kim, Ph.D.; Akihito Hiura, M.D., Ph.D.;
1148
Shoichiro Sumi, M.D., Ph.D.; Kazutomo Inoue, M.D., Ph.D.
Submucosal Injection of Micronized Acellular Dermal Matrix: Analysis
of Biocompatibility and Durability.
1156
Jeffrey B. Wise, M.D.; David Cabiling, B.S.; David Yan, M.D.; Natasha Mirza, M.D.; Richard
E. Kirschner, M.D.
Biocompatibility of Agarose Gel as a Dermal Filler: Histologic
Evaluation of Subcutaneous Implants.
1161
Sergio Fernández-Cossío, M.D.; Alvaro León-Mateos, M.D.; Francisco Gude Sampedro,
M.D., Ph.D.; María Teresa Castaño Oreja, M.D., Ph.D.
RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES
Optimal Use of Microvascular Free Flaps, Cartilage Grafts, and a
Paramedian Forehead Flap for Aesthetic Reconstruction of the Nose
1171
and Adjacent Facial Units.
Gary C. Burget, M.D.; Robert L. Walton, M.D.
RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES: Discussion
Discussion.

Frederick J. Menick, M.D.
1208
RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES
Aesthetic and Functional Outcome following Nasal Reconstruction.

Marc A. M. Mureau, M.D., Ph.D.; Sanne E. Moolenburgh, M.D.; Peter C. Levendag, M.D.,
1217
Ph.D.; Stefan O. P. Hofer, M.D., Ph.D.
RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES: Discussion
Discussion.

Fredrick J. Menick, M.D.
1228
RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES
Reconstruction of the Lower Lip: Rationale to Preserve the Aesthetic
Units of the Face.
1231
J Camilo Roldán, M.D., D.M.D.; Marcus Teschke, M.D., D.M.D.; Elfriede Fritzer, M.Sc.;
Anton Dunsche, M.D., D.M.D., Ph.D.; Franz Härle, M.D., D.M.D., Ph.D.; Jörg Wiltfang,
M.D., D.M.D., Ph.D.; Hendrik Terheyden, M.D., D.M.D., Ph.D.
Incomplete Excision of Basal Cell Carcinoma: A Prospective Trial.
Shirley Y. Su, M.B.B.S.; Francesco Giorlando, M.B.B.S., B.Med.Sci.; Edmund W. Ek,
1240
M.B.B.S.; Tam Dieu, F.R.A.C.S.
Immediate, Optimal Reconstruction of Facial Lentigo Maligna and
Melanoma following Total Peripheral Margin Control.
1249
Sameer S. Jejurikar, M.D.; Gregory H. Borschel, M.D.; Timothy M. Johnson, M.D.; Lori
Lowe, M.D.; David L. Brown, M.D.
RECONSTRUCTIVE
HEAD AND NECK: CASE REPORT
Romberg's Disease Associated with Horner's Syndrome: Contour
67e Restoration by a Free Anterolateral Thigh Perforator Flap and

Ancillary Procedures.
Dogan Tuncali, M.D.; Nesrin Tan Baser, M.D.; Ahmet Terzioglu, M.D.; Gurcan Aslan, M.D.
RECONSTRUCTIVE
TRUNK: ORIGINAL ARTICLE
New Continuous Negative-Pressure and Irrigation Treatment for
Infected Wounds and Intractable Ulcers.
1257
Kensuke Kiyokawa, M.D., Ph.D.; Nagahiro Takahashi, M.D.; Hideaki Rikimaru, M.D., Ph.D.;
Toshihiko Yamauchi, M.D., Ph.D.; Yojiro Inoue, M.D., Ph.D.
RECONSTRUCTIVE
TRUNK: SPECIAL TOPIC
Mechanisms Governing the Effects of Vacuum-Assisted Closure in
Cardiac Surgery.
1266
Malin Malmsjö, M.D., Ph.D.; Richard Ingemansson, M.D., Ph.D.; Johan Sjögren, M.D.,
Ph.D.
RECONSTRUCTIVE
TRUNK: IDEAS AND INNOVATIONS
Does AlloDerm Stretch?

Maurice Y. Nahabedian, M.D.
1276
RECONSTRUCTIVE
LOWER EXTREMITY: ORIGINAL ARTICLES
Prevention of Microsurgical Anastomotic Thrombosis Using Aspirin,
Heparin, and the Glycoprotein IIb/IIIa Inhibitor Tirofiban.
1281
Thomas L. Chung, D.O.; David W. Pumplin, Ph.D.; Luther H. Holton III, M.D.; Jesse A.
Taylor, M.D.; Eduardo D. Rodriguez, D.D.S., M.D.; Ronald P. Silverman, M.D.
The Effects of Systemic Phenylephrine and Epinephrine on Pedicle
Artery and Microvascular Perfusion in a Pig Model of
1289
Myoadipocutaneous Rotational Flaps.
Marga F. Massey, M.D.; Dhanesh K. Gupta, M.D.
RECONSTRUCTIVE
LOWER EXTREMITY: IDEAS AND INNOVATIONS
Does Fascia Lata Repair Facilitate Closure and Does It Affect
Compartment Pressures of the Anterolateral Thigh Flap Donor Site?
1300
Eduardo D. Rodriguez, M.D., D.D.S.; Rachel Bluebond-Langner, M.D.; Julie Park, M.D.;
Xiaojun You, B.S.; Gedge Rosson, M.D.; Navin Singh, M.D.
HAND/PERIPHERAL NERVE
ORIGINAL ARTICLES
Preoperative Soft-Tissue Distraction for Radial Longitudinal

Deficiency: An Analysis of Indications and Outcomes.
1305
Amir H. Taghinia, M.D.; Ayman A. Al-Sheikh, M.D.; Joseph Upton, M.D.
HAND/PERIPHERAL NERVE
ORIGINAL ARTICLES: Discussion
Discussion.

Kevin C. Chung, M.D., M.S.
1313
HAND/PERIPHERAL NERVE
ORIGINAL ARTICLES
Functional Assessment of the Reconstructed Fingertips after Free
Toe Pulp Transfer.
1315
Cheng-Hung Lin, M.D.; Yu-Te Lin, M.D.; Paolo Sassu, M.D.; Chih-Hung Lin, M.D.; Fu-Chan
Wei, M.D.
HAND/PERIPHERAL NERVE
IDEAS AND INNOVATIONS
A Prefabricated, Tissue-Engineered Integra Free Flap.

John M. Houle, M.D.; Michael W. Neumeister, M.D.
1322
PEDIATRIC/CRANIOFACIAL
ORIGINAL ARTICLES
The Diagnosis and Treatment of Single-Sutural Synostoses: Are
Computed Tomographic Scans Necessary?
1327
Jeffrey A. Fearon, M.D.; Davinder J. Singh, M.D.; Stephen P. Beals, M.D.; Jack C. Yu,
D.M.D., M.D.
Use of Calcium-Based Bone Cements in the Repair of Large, Full-
Thickness Cranial Defects: A Caution.
1332
James E. Zins, M.D.; Andrea Moreira-Gonzalez, M.D.; Frank A. Papay, M.D.
Location of the Infraorbital and Mental Foramen with Reference to the
Soft-Tissue Landmarks.
1343
Wu-Chul Song, M.D.; Sun-Heum Kim, M.D., Ph.D.; Doo-Jin Paik, M.D., Ph.D.; Seung-Ho
Han, M.D., Ph.D.; Kyung-Seok Hu, D.D.S.; Hee-Jin Kim, D.D.S., Ph.D.; Ki-Seok Koh, Ph.D.
PEDIATRIC/CRANIOFACIAL
SPECIAL TOPIC
Definitive Repair of the Unilateral Cleft Lip Nasal Deformity.

H Steve Byrd, M.D.; Kusai A. El-Musa, M.D.; Arjang Yazdani, M.D.
1348
Supplemental Digital Content is available in the text.
PEDIATRIC/CRANIOFACIAL
IDEAS AND INNOVATIONS
Correction of the Unilateral Cleft Lip Nasal Deformity with a
Composite Cartilage-Vestibular Lining Flap.
1357
Michael B. Lewis, M.D.; Andrew A. Winkler, M.D.; Ronald P. Silverman, M.D.
Microdialysis: Use in the Assessment of a Buried Bone-Only Fibular
Free Flap.
1363
Constantinos Mourouzis, Ph.D., M.D., D.D.S.; Rajiv Anand, F.D.S.R.C.S., F.R.C.S.; John R.
Bowden, M.Sc., F.D.S.R.C.S., F.R.C.S.; Peter A. Brennan, F.R.C.S., F.R.C.S.I., F.D.S.
COSMETIC
ORIGINAL ARTICLES
Observations on Periorbital and Midface Aging.

Val Lambros, M.D.
1367
Supplemental Digital Content is available in the text.
COSMETIC
ORIGINAL ARTICLES: Discussion
Discussion.

Joel E. Pessa, M.D.
1377
COSMETIC
ORIGINAL ARTICLES
Chin Surgery VII: The Textured Secured Implant-A Recipe for
Success.
1378
Stephen M. Warren, M.D.; Jason A. Spector, M.D.; Barry M. Zide, D.M.D., M.D.
Patient-Reported Benefit and Satisfaction with Botulinum Toxin Type
1386
A Treatment of Moderate to Severe Glabellar Rhytides: Results from a
Prospective Open-Label Study.
Mitchell A. Stotland, M.D.; Jonathan W. Kowalski, Pharm.D., M.S.; Belinda B. Ray, M.A.

COSMETIC
ORIGINAL ARTICLES: Discussion
Discussion.

Jean Carruthers, M.D.
1394
COSMETIC
ORIGINAL ARTICLES
A Primary Protocol for the Management of Ear Keloids: Results of
Excision Combined with Intraoperative and Postoperative Steroid
1395
Injections.
Daniel J. Rosen, M.D.; Mitesh K. Patel, M.D.; Katherine Freeman, Dr.P.H.; Paul R. Weiss,
M.D.
Magnetic Resonance Imaging and Explantation Investigation of Long-
Term Silicone Gel Implant Integrity.
1401
Nick Collis, M.Phil., B.Sc., F.R.C.S.Plast.(Ed.); Janet Litherland, M.R.C.P., F.R.C.R.; David
Enion, F.R.C.S.(G.), F.R.C.R.; David T. Sharpe, M.A., F.R.C.S.
Interest in Cosmetic Surgery and Body Image: Views of Men and
Women across the Lifespan.
1407
David A. Frederick, M.A.; Janet Lever, Ph.D.; Letitia Anne Peplau, Ph.D.
CME
CME Management of Wrist Injuries.
73e Kenji Kawamura, M.D., Ph.D.; Kevin C. Chung, M.D., M.S.
SPECIAL TOPIC
Objective Interpretation of Surgical Outcomes: Is There a Need for
Standardizing Digital Images in the Plastic Surgery Literature?
1419
Wendy L. Parker, M.D., Ph.D.; Marcin Czerwinski, M.D.; Hani Sinno, B.Sc.; Photis Loizides,
M.D.; Chen Lee, M.D.
EDITORIAL
It's Okay to Say "I'm Sorry".
Rod J. Rohrich, M.D.
1425
Our Complication, Your Problem.
Steven P. Davison, D.D.S., M.D.; Wajhma Massoumi, M.D.
1428
REVIEWS
Local Flap Reconstruction: A Practical Approach.
James Thornton, M.D.
1430
Surgical Management of Vitiligo.
Gervaise L. Gerstner, M.D.; Alan Matarasso, M.D.
1430
LETTERS
The Zygomatic-Orbital Artery.
Egidio Riggio, M.D.
1432
The Zygomatic-Orbital Artery: Reply.
Eman Elazab Beheiry, M.B.Ch.B., M.Sc., Ph.D.
1432
Surgical Treatment of Ear Defects.
Isaac J. Peled, M.D.
1433
Surgical Treatment of Ear Defects: Reply.
Fabio M. Abenavoli, M.D.
1433
An Alternative Approach to Brow Lift Fixation: Temporoparietal
Fascia, Galeal, and Periosteal Imbrication.
1433
Colin Morrison, M.Sc., F.R.C.S.(Plast.); James Zins, M.D.
An Alternative Approach to Brow Lift Fixation: Temporoparietal
Fascia, Galeal, and Periosteal Imbrication: Reply.
1434
Fernando O. Tuccillo, M.D.; Oscar Zimman, M.D., Ph.D.; Patricio Jacovella, M.D., Ph.D.;
Gabriel Repetti, M.D.
Did Hitler Have a Rhinoplasty?
Anne G. Warren, B.A.; Robert M. Goldwyn, M.D.
1435
Breast Cancer in the Previously Augmented Breast and Sentinel
Lymph Node Mapping: Theoretical and Clinical Considerations.
1435
Alexandre Mendonça Munhoz, M.D.; Cláudia Maria Aldrighi, M.D.
Epinephrine Use in the Fingers.
Apostolos D. Mandrekas, M.D.; George J. Zambacos, M.D.
1436
Epinephrine Use in the Fingers: Reply.
Donald H. Lalonde, M.D., M.Sc.; Christopher James Thomson, M.D.; Keith Denkler, M.D.;
1437
Anton Feicht, Ph.D.
The Evidence for and against the Effectiveness of Pressure Garment
Therapy for Scar Management.
1437
Alexander Anzarut, M.D., M.Sc.
The Evidence for and against the Effectiveness of Pressure Garment
Therapy for Scar Management: Reply.
1438
Gregory R. D. Evans, M.D.
BREAST
Breast Reduction: Modified “Lejour Technique”
in 500 Large Breasts
Albert K. Hofmann, M.D.
Background: The“minimalscartechnique”forbreastreduction,developedby
Margot C. Wuestner-
Marchac,Lassus,andLejour,hasbecomeanincreasinglypracticedalternative
Hofmann, M.D.
to standard operative procedures.
Franco Bassetto, M.D.
Methods: The authors introduced the modified “Lejour technique” in nearly
Carlotta Scarpa, M.D.
500 breast reductions in 250 overweight patients (adipose breasts) with a re-
Francesco Mazzoleni, M.D. sectionweightofmorethan700g.Theirtechniqueisastep-wisemodification
Ulm,Germany;andPadova,Italy ofthefollowingprocedures,resultingfromtheirexperiencewithcomplications
and outcomes. Planning of the nipple-areola complex is carried out for each
patient,andtheglandularbodyisunderminedonlycentrallyandatraumatically,
without liposuction. The superior mastopexy suture is waived in favor of the
submammary fold being fixed using three H points. The three H points serve
as a pivot by which later sagging is avoided. The skin closure does not have a
shapingfunctionwithouttension.Theverticalpleatedsutureisnotforcedbut
adjustedtotheretractionabilityofthepatient’sskin.Useoftheverticalpleated
suture is limited; in cases of longer incisions, it is combined with a horizontal
submammary transverse pleated suture.
Results: In 250 patients with an average follow-up of 4.2 years, the average
resection weight was 985 g for the right breast and 923 g for the left. The
operation lasted from 120 to 180 minutes. The results were evaluated as very
good in 75 percent, good in 19 percent, satisfactory in 5 percent, and unsatis-
factory in 1 percent. The complication rate was 14 percent.
Conclusions: Theauthors’experiencehasshownthatthistechniquecanbeap-
pliedasastandardtechnique.Itisparticularlysuitableforlargerbreasts,because
it reduces aesthetic deficiencies and simplifies the reduction technique. (Plast.
Reconstr.Surg.120:1095,2007.)
I
n the early 1990s, Marchac and de Olarte,1 tientswithmultiplestriae.Thescarminimalization
Lassus,2 and Lejour3 introduced the “mini- technique frequently leads to problems with scar
mal scar technique” for breast reduction. healing,duetoexcessivepleatingandconsequent
This approach has become an increasingly prac- compromisedbloodsupplytothewoundedgesor
ticed alternative to standard operative proce- to overlong vertical scars that protrude caudally
dures.4–7 In the last few years, there has been a below the submammary fold and are aesthetically
trend in plastic surgery toward reducing overall unsatisfactory, as they cannot be hidden by a bra.
scar length by confining the scar to one vertical Residualfoldsoruglypuckeringatthecaudalscar
incision.8–11 Results from patients with younger or polerequiresecondarysurgicalcorrection.14Many
more retractable skin, minimal breast hypertro- patientsareunconvincedbythebenefitsofshorter
phy,andaresectionweightoflessthan500ghave scars when the advantages are in conflict with a
confirmed that a long transverse scar in the sub- better aesthetic appearance. In our experience,
mammary fold can be avoided with no adverse tension-freescarsinthesubmammaryfold,when
effect on the aesthetic shape of the breast.12,13 theydonotvisiblyextendbeyondthebreastbase
Thisisnotthecaseforpatientswithvoluminous medially or laterally, nearly always produce un-
breasts, older patients with less elastic skin, or pa- obtrusive, dash-like scarring and are preferable
to an unattractive, forced, vertical scar.
From Ulm Klinik Rosengasse and the Plastic Surgery Insti- OneofthemainbenefitsofthemodifiedLejour
tute, University of Padova. technique is that all phases of the operative plan-
ReceivedforpublicationJanuary29,2005;acceptedJuly8, ning (detailed down to the skin suture) can be
2005. adapted to the individual patient. As a standard
Copyright©2007bytheAmericanSocietyofPlasticSurgeons procedure, therefore, it can be used on all breast
DOI: 10.1097/01.prs.0000279150.85155.1e types.15–18
www.PRSJournal.com 1095
Plastic and Reconstructive Surgery • October 2007
PATIENTS AND METHODS Lejour technique” in approximately 25 percent of
Between 1996 and 2003, we performed 1968 thepatients;thesepatientswereoverweightandhad
mammary reductions in approximately 1000 pa- a breast resection weight of more than 700 g.
tientsintwocenters,theUlmClinicRosengasseand By using this technique in these 250 patients
thePadovaPlasticSurgeryInstitute.Insmallreduc- with 500 breast reductions, we avoided the aes-
tions((cid:1)500g),wepreferredthepureverticaltech- thetic deficiencies and simplified the reduction
nique. From our early experience with the vertical technique for large breasts. We found no contra-
technique, we knew about the problems with the indications, even in cases of large resection
persistentverticaldog-eardeformityatthenadirof weights of 1000 g or more.
theincisionandaboutthelateralaxillaryfullnessin All250patientswithlargebreastreductionsof
larger breasts. Therefore, we used our “modified more than 700 g who were operated on with the
Fig.1. (Above)Individualplanningofthedisplacementaxisandtheheightofthenewnipple.(Center)Planningofthe
lateralandmedialresectionmargins.(Below)Markingofthecaudalincisionlineandsuperiornippledefinition.
1096
•
Volume 120, Number 5 Breast Reduction
modified technique were examined postopera- markedbylayingthebreastfirstlaterallyandthen
tively,andtheirprogressduringthistimewasdoc- medially,drawingtwoconnectinglinestothepre-
umented. The data gathered were used to deter- viously marked middle breast axis (Fig. 1, above
mine whether this procedure is suitable for high and center).
resection weights in adiposity. Nearly all patients The breast must be pushed up into a conical
hadahistoryofeitherfutileattemptsatdietingor shape during marking. The two vertical lines are
weight loss of a maximum 20 kg. then joined together by an arched line running
about two fingerwidths above the submammary
fold. Another curved line is then drawn around
Technique
the future position of the nipple, which vary in
Theoperativetreatmentbeginswithpreoper-
accordance with the plastic surgeon’s preferred
ativeplanningandsitemarking.Theaxisonwhich
method (Fig. 1, below).
the nipple is going to be superiorly relocated is
First, infiltrate up to tumescence subglandu-
then chosen. This is ascertained by laying a mea-
larly and epifascially with 250 ml of solution (500
suringtapearoundthepatient’sneckandmoving
ml of sodium chloride plus 1.5 mg of epineph-
it from nipple to nipple. In contrast to using a
rine). In this way, the prepared tissue is loosened
fixed template, this method allows the optimum
and bleeding is simultaneously arrested. After a
nipplerelocationtobeplannedfortheindividual
tourniquet is applied, the diameter of the nipple
patient.Theexactpositioningofthenippleonthe
is determined using a template; it may vary be-
markedaxisisfeltbypalpationofthetissuestart-
tween 4 and 5 cm, depending on the size of the
ingfromthemiddleofthesubmammaryfold.The
breast.19 The de-epithelialization area is then
bilateralverticalmarginsfortheskinresectionare
marked,withagapofatleasttwofingerwidthsleft
Fig.2. (Above)Thenipple-supportingflapisplanneddistally
upto2fingerwidthsfromthenipple.(Below)Themamillaiscut Fig. 3. (Above) Subcutaneous skin mobilization with scissors.
around in the size planned, cutting through the epidermis (Below)Bluntunderminingofthebreastglandonthepectoralis
only. fascia.
1097
Plastic and Reconstructive Surgery • October 2007
below the nipple so that blood flow is not com- Mobilization continues to the upper margin of the
promised after flap preparation. gland at the height of about the third intercostal
Next is the excision of the nipple and the space, to create a vertical tunnel about 8 to 10 cm
markedflap,wherebythecutisisonlysuperficially wide (Fig. 4, above, left and center).
transected (Fig. 2).20 The entire excised flap is Theoutcomeofbilateraldivisionofthebreast
de-epithelialized.Theskiniscompletelycutthrough gland is a medial and lateral mammary gland pil-
in the area of the preoperative markings using an lar. The surgeon then cuts around the de-epithe-
electriccauterizer.Theskinislaterallyandmedially lialized skin flap, and the actual resection of the
undermined atraumatically (i.e., mobilized) using tissuethatisgoingtobereducedtakesplace.The
scissors.Itisveryimportanttofindthecorrecttissue tissue can be resected with scissors or a scalpel
layer,whichisrecognizablebyitsminimalresistance. (Fig.4,above,rightandcenter).Itisimportantthat
Thinningoftheskinisrequiredforoptimalretrac- anipple-supportingflapwithathicknessofatleast
tion(Fig.3),buttheremustbenorisktotheblood one to two fingerwidths remains.21 This is obliga-
supplyfromoverskeletizationoftheskin.Next,the tory in the central or nipple-supporting area; the
breast glandular tissue is mobilized; this has to be layermaytaperattheedges.Theflapisthentested
carriedoutstrictlyepifascially.Mobilizationisbegun for deformability.
sharplyandcaudallyusingscissors,butsuperiormo- The nipple is superiorly positioned and se-
bilizationcanbecontinuedbluntly.Inthisway,dam- cured with sutures. Both side pillars of the mam-
agetothepectoralisfasciacanbelargelyexcluded. mary gland, which are connected to the pectoral
Fig.4. (Above,leftandcenter)Bilateraldivisionofthemammaryglandandcuttingaroundtheglandflap.(Above,right,andcenter,
leftandcenter)Glandresectioncreatinganipple-supportingsuperiorpedicleflap.(Center,right)Theresectedtissue.(Below)The
nipple-supportingsuperiorpedicleflapandconnectionofthelateralandmedialglandpillarbysuturetoformthenewbreast.
1098