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Short Scar Periareolar Inferior Pedicle Reduction (SPAIR) Mammaplasty 6 Dennis C

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Short Scar Periareolar Inferior Pedicle Reduction (SPAIR) Mammaplasty 6 Dennis C Short Scar Periareolar Inferior Pedicle Reduction (SPAIR) Mammaplasty 6 Dennis C. Hammond pattern technique have been thrown into sharper fo- reast reduction offers an opportunity rarely cus. Specifically, the inframammary scar can be prob- B seen in plastic surgery, for not only is there lematic in some patients, with the medial and lateral too much volume, there is too much skin. portions of the scar being prone to hypertrophy.Addi- tionally, the postoperative shape change associated With a sound operative strategy, excellent with the Wise pattern technique can occasionally spill technique, and a discerning artistic eye, over from simple postoperative settling into a shape distortion known as “bottoming out.”Taken together, the sculpting of an artistic and stable breast these two complications can adversely affect the over- shape can occur every time, and now we all result after breast reduction. Recent advances in breast reduction technique can do it with half the scar! What an exciting have attempted to address these problems by reducing time to be a plastic surgeon. the amount of cutaneous scar while preserving aes- thetic breast shape.The focus of this chapter will be to Dennis Hammond describe a reduced scar technique based on an inferi- „ or pedicle called the short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Introduction Operative Strategy Any operative procedure designed to reduce the en- The SPAIR mammaplasty bases the blood supply to the larged breast can be described as having four interre- nipple and areola on an inferior pedicle with parenchy- lated components. First, the volume of the breast must ma being removed from around the periphery of the be reduced, leaving behind strategically located tissue pedicle in the shape of a horseshoe. Skin is resected in a that will create an aesthetic breast shape. Second, the circumvertical pattern that limits the scar to the central excessively large skin envelope must be reduced, leav- portion of the breast and avoids the more traditional ing behind enough skin to cover the reduced breast. long inframammary scar. By reducing the circumfer- Third, a pedicle of tissue must be created that will reli- ence of the periareolar incision with the vertical skin ably maintain blood supply to the nipple and areola. component, large periareolar patterns can be managed Fourth, an aesthetic shape must be created, either pas- without excessive pleating or distortion of the periareo- sively or with some sort of shaping maneuver. The lar closure. In addition, the vertical component tends to most common procedure for breast reduction satisfies produce a coning effect, which enhances the overall these requirements by basing the blood supply to the shape of the breast. Shaping is accomplished with inter- nipple and areola on an inferior pedicle, resecting nal suturing of both the flaps and the pedicle. By com- parenchyma peripherally around the pedicle, using an bining these surgical maneuvers,a wide variety of breast inverted T-type of skin pattern to manage the excess problems ranging from simple ptosis to severe macro- skin envelope, and passively shaping the breast by mastia can be effectively and reliably managed [12–15]. closing the flaps around the inferior pedicle and allow- ing postoperative settling to “shape” the breast. This procedure,also referred to as the “Wise”pattern inferi- Marking or pedicle breast reduction, has stood the test of time as a reliable and versatile method of breast reduction. The goal of the marking procedure is to accurately However, with the description of various reduced identify the appropriate amount of skin to leave be- scar techniques of breast reduction [1–11], the well- hind that will effectively wrap around the inferior documented complications associated with the Wise pedicle and assist in shaping the breast. To organize 50 Chapter 6 SPAIR Mammaplasty Fig. 6.1. The inframammary fold location is identified with a Fig. 6.2. An 8-cm pedicle is centered on the breast meridian. line connecting the folds across the midline.Measuring up 4 cm On either side of the pedicle, a distance of 8 to 10 cm is meas- from this mark, a horizontal line is drawn and, where this line ured up from the fold, and these two points are communicated intersects the breast meridian, identifies the top of the periare- in a line that parallels the inframammary fold. This creates a olar pattern rectangular-shaped segment of skin that defines the limits of the inferior skin envelope Figs. 6.3, 6.4. By drawing the breast first up and out, and then up and in, the breast meridian can be transposed onto the breast at the level of the nipple to identify the medial and lateral points of the pattern this process, the breast is divided into four sections. by using the familiar maneuver of placing the fingers With the patient upright, the sternal midline, the in- of the left hand under the breast and palpating with framammary fold,and the lateral margin of the breast the fingers of the right hand anteriorly on the breast are marked. The inframammary fold mark is commu- to estimate the location of the fold. Alternatively, a di- nicated across the midline so that with the breasts in rect measurement from the midpoint of the clavicle repose the exact location of the fold can be seen with- down to this uppermost mark can be made, with this out any distortion caused by lifting or otherwise ma- distance measuring 21–24 cm in most patients. nipulating the breast. The breast meridian is visual- The inferior skin envelope is determined by direct ized and marked as it defines the longitudinal axis of measurement. An 8-cm pedicle width is diagrammed the breast. This line extends from the clavicle down to centered on the breast meridian. On either side of the and below the inframammary fold. The top of the pe- pedicle and extending from the inframammary fold riareolar pattern is marked by measuring up from the upward, a measurement of 8 to 10 cm is made. These inframammary fold 4 cm in the midline. A horizontal two marks are then smoothly communicated in a line line is drawn across the chest at this point and, where that parallels the inframammary fold (Fig. 6.2). This this line intersects the breast meridian, identifies the identifies the skin envelope that will be maintained in- top of the pattern (Fig. 6.1). This point can be checked feriorly,with the 8-cm longitudinal measurement being Dennis C. Hammond 51 Operative Technique Generally speaking, most cases of breast reduction in my practice are still performed under general anes- thesia and include an overnight stay in the hospital. However, cases of mastopexy and smaller reductions of 500 g or less are often performed in an outpatient setting. In preparing for the SPAIR procedure, several details are best managed ahead of time. Inherent in the SPAIR procedure is assessment of the shape of the breast during the procedure, as one of the operative goals is to create an aesthetically appealing breast im- mediately. This must be done with the patient upright Fig. 6.5. The final marking pattern with the skin to be resected at least 80°. Therefore, an operative table that will sit (crosshatched) and the skin of the inferior pedicle to be deep- ithelialized (dotted) up to this degree is mandatory. Preoperative communication with the anesthesiol- ogist will facilitate fluid management of the patient to allow the sitting position without creating significant used in cases of mastopexy and small reductions of less hypotension. A long ventilatory circuit will also allow than 400 g and the 10-cm measurement being used in the upright positioning of the patient to be accom- reductions of 800 g or more. plished without excessive manipulation by the anes- The medial and lateral portions of the periareolar thesiologist.The arms of the patient are extended out- pattern are determined by gently lifting the breast with ward 90° on padded arm boards and are gently the left hand up and out, and then up and in, thus al- secured with towels and gauze wraps.The head is sup- lowing the breast meridian to be transposed onto the ported on a foam headrest,and the knees are support- medial and lateral breast skin level with the nipple ed by a pillow to ease strain on the back. During the (Figs. 6.3, 6.4). This maneuver is designed to mimic draping of the chest, care is taken to ensure that the what the breast will look like once it is reduced, so tops of the shoulders can be seen to make certain that when lifting the breast slight pressure is applied to cre- malposition of the shoulders does not adversely influ- ate a rounded contour laterally and medially before ence the correct assessment of nipple-areola complex marking the lateral and medial portions of the periare- position or the location of the inframammary fold. olar pattern. Marking these points in this fashion en- The procedure is begun by injecting the margins of sures that enough skin will be preserved medially and the proposed incisions and the areas to be initially laterally to comfortably wrap around the inferior pedi- deepithelialized with a diluted solution of lidocaine cle after reduction without creating undue tension. A with epinephrine. This dramatically reduces oozing, measurement can be made from the midsternal line to particularly in the area of the inferior pedicle.A breast the medial mark at the level of the nipple, and this dis- tourniquet is applied and the center of the nipple tance should measure at least 12 cm in most cases. marked. Using a multidiameter areola marker, a circle Once these four landmarks are identified, they are measuring 52 mm in diameter is marked on the exist- smoothly joined together to create an elongated oval.
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