Maximizing breast projection after free-nipple-graft reduction mammaplasty

In 1922, Thorek described standard free-nipple reduction mammaplasty for gi gantomastia. This technique provided a simple and effective way to perform reduction mammaplasty. However, the technique is frequently criticized for producing a breast and nipple with poor projection. Even with the standard modification of the original technique, the resultant breast and nipple may be wide and flat, with unpredictable nipple-areola pigmentation. To create a breast mound and nipple with projection and even pigmentation, the free- nipple-graft breast reduction technique is presented. The Wise pattern skin reduction markings and the superiorly based parenchym al reduction technique are used. After the nipple-areola complex is removed , as a free graft, the inferior pole of the breast is then amputated along the Wise pattern skin markings, leaving lateral and medial pillars of breas t tissue, with the apex of the resection corresponding to the new nipple lo cation. The lateral and medial pillars of the superiorly based breast mound are then sutured together. Key interrupted sutures are placed, beginning a t the most inferior and posterior point of the pillars, while recruiting ti ssue centrally to increase the projection. The intersecting point of the in verted T, at 7 cm from the new nipple position, is then sutured to the fasc iae of the pectoralis major muscle. If more central projection is desired, the vertical limb design can be lengthened. The tissue inferior to the 7-cm mark is deepithelialized and tucked under the central breast, if needed, c ontributing further to the final breast parenchyma projection. The skin of the vertical limb of the Wise pattern is then closed with a dog-ear at the apex to further contribute to nipple projection. The nipple is replaced as a free, thick, split-thickness skin graft. The breast is temporarily closed , and the medial and lateral breast tissue excess is liposuctioned to creat e a more conical breast. Excessive medial and lateral skin is then resected , keeping the inframammary crease incision under the breast mound. Twenty-five patients underwent free-nipple-graft reduction mammaplasty usin g this technique between 1992 and 2000. An average of 1600 g of breast tiss ue per breast was removed. The average follow-up period was 36 months. Pati ent satisfaction has been very high.