Techniques in

Cosmetic Surgery
Creation and Evolution of 30 Years of the
Inferior Pedicle in Reduction Mammaplasties
Liacyr Ribeiro, M.D., Affonso Accorsi, Jr., M.D., Afonso Buss, M.D., and Marcelo Marcal-Pessoa, M.D.
Rio de Janeiro, Brazil

The article describes the experience of the senior author over the past 30 years using the glandular dermo-lipo
flap. The flap primarily provides an effective enhancement of the shape of the breast that varies according to the
age of the patient, skin elasticity, and mammary gland
firmness. More than 2000 patients have had this procedure, including those with asymmetric breasts who had
the procedure done on only one breast. (Plast. Reconstr.
Surg. 110: 960, 2002.)

tening of the breasts and large horizontal scars

were unacceptable. Jurado,6 Courtiss and Goldwyn,7 Goldwyn,8 and Reich,9 among others,
also developed procedures described as inferior pedicle techniques that are unrelated to
our procedure. Our flap works as a natural
prosthesis and maintains the conical shape of
breasts for a long time, lessening the chances
of basculae movement.
Over the past 30 years, the technique was
adapted to allow the development of five different kinds of flaps for different indications.10
Currently, the flap technique is performed in
most cases of reduction mammaplasty and reconstructive surgery and in the treatment of
tuberous breasts, in which it is combined with
Peixotos11 technique and the periareolar and
vertical approaches.
The indications for the flap procedure are
(1) techniques that result in an inverted-T, (2)
techniques that result in a vertical and an areolar scar (lozenge technique), and (3) periareolar techniques, in cases of tuberous
breasts, which result in an areolar scar only
(circumferential technique). This article describes the anatomy of the inferiorly based flap
and the applications and complications of the
techniquea worthy option in plastic surgery
of the breast.

The dermo-lipo glandular flap was first described in Brazil at the congress of the Brazilian Society of Plastic Surgery in 1971 and at the
congress of the International Society of Plastic
and Reconstructive Surgery held in Rio de Janeiro in 1972. The flap has been mistakenly
referred to as a pedicle in the Spanish plastic
surgery literature.1,2 It is shaped at the central
part of the lower pole of the breast, precisely in
the portion to be resected in reduction techniques with the inverted-T,3 to provide breast
firmness after a large removal of mammary
tissue.
In the senior authors first years of experience, this flap proved to be effective not only in
keeping good breast shape but also in supplying vascularization of the lower portion. The
author was then encouraged to develop a new
approach, described in Plastic and Reconstructive
Surgery in 1975,4 which should be considered
the first technique to use a vascular flap because it held the areola complex at its edge.
The results of the technique were similar to
those Passot5 achieved with his technique of
areolar and horizontal scars; however, the flat-

ANATOMY

OF THE INFERIORLY

BASED FLAP

The inferiorly based flap originates from a

dermo-lipo glandular flap and is located on the
lower pole of the breast. The flap receives a

From the Pathology and Breast Reconstruction Institute and Clnica Fluminense de Cirurgia Plstica. Received for publication July 2, 2001;
revised December 7, 2001.
DOI: 10.1097/01.PRS.0000019879.75710.7C

960

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INFERIOR PEDICLE IN REDUCTION MAMMAPLASTY

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FIG. 1. Inferior flap technique. (a) With the patient in a semisitting position, the new areolae are marked with diameters of
4 cm. (b, c) Point A, which corresponds to the inframammary fold at the upper pole of the breas, is marked, and points B and
C are marked with a bidigital maneuver. (d) Final view of the markings, as in Pitanguys technique. (e, f) The inferior flap is drawn
4 to 5 cm from the middle point of the inframammary fold, with a length 2 cm below the areolae-papillae complex and a thickness
of 2 to 3 cm. (g through i) The exceeding breast gland is resected, and the inferior pedicle is attached over the pectoral fascia.
(j) The breast is mounted by joining points B and C to the middle point of the inframammary fold. (k) Final view with the sutures
completed.

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PLASTIC AND RECONSTRUCTIVE SURGERY,

September 1, 2002

FIG. 2. Inferior flap technique case. (Left) Preoperative views of a patient with mild breast hypertrophy and severe ptosisa
good indication for the inferior flap technique. (Center) One-year postoperative views. (Right) Ten-year postoperative views. Note
that the inferior pedicle gives a very stable result.

normal and reliable vascular supply from the

fourth, fifth, and sixth intercostal perforating
vessels of the internal mammary arteries. Venous and lymphatic drainage flows into the
internal mammary vein and into the lymphonodi12 in the opposite direction of the arterial
stream.8,10,13 The decorticated skin helps sustain the flap so it can be attached to the pectoralis fascia; the fat tissue accounts for the
volume of the breasts; and the glandular tissue
allows recanalization of the milk ducts with no

damage to the properties of the mammary

gland.
SURGICAL TECHNIQUES
Inferior Flap Technique

With the patient in a half-sitting position, the

new areolae are drawn 4 cm in diameter with a
demarcator. A vertical line is drawn from the
hemiclavicular line to the upper edge of the
areolae (Fig. 1, a), and point A is marked cor-

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INFERIOR PEDICLE IN REDUCTION MAMMAPLASTY

963

FIG. 3. Lozenge technique. (a through d) After marking point A, the point is re-marked 2 cm higher than the first mark. Points
B and C are then drawn by a bidigital maneuver, and point D is marked 3 cm above the midpoint of the inframammary fold. (e,
f) Decortication of the lozenge area previously marked. (g) By a transversal incision perpendicular to the pectoral fascia, the
breast is divided, resulting in the upper and inferior breast poles. (h) The inferior flap is detached from the skin by a sharp
undermining. (i) The lateral and medial prolongations of the inferior flap are dissected carefully to preserve the perforating
vessels that support the flap. (j) Anterior view of the inferior pedicle ready to be attached to pectoral fascia. (k) Lateral view of
the inferior flap attached to the pectoral fascia after all breast gland resection is complete. Suture begins at point D with a maximum
length of 7 cm. (l) Separated stitches from point D, 4 cm long, will form the future vertical scar. (m) The areola is sutured by
compensatory separated stitches, and any eventual dog-ear is corrected. (n, o) The vertical incision is ready to be sutured. Using
the Gillies hook, the breast is pulled up to be immobilized with Micropore tape. (p) Final areola sutures are made in U-shaped,
separated stitches, and the vertical suture is made with separated stitches.

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PLASTIC AND RECONSTRUCTIVE SURGERY,

September 1, 2002

FIG. 4. Lozenge technique case. (Left) Preoperative views of a young patient with mild breast hypertrophy and ptosis. (Center,
first three rows) Fifteen-day postoperative views. (Right) One-year postoperative views. (Center, below) One-year postoperative view
demonstrating the position of the vertical scar.

responding to the projection of the inframammary fold on the upper pole of the breast. By
means of a pinching maneuver and the surgeons judgment, points B and C are determined (Fig. 1, b and c). The points are linked
to the inframammary fold with curving lines, as
in Pitanguys technique3 (Fig. 1, d).
With the breast lifted so that the lower pole
can be seen, the drawing of the flap is started at
the central portion and is extended to 1 to 2
cm below the inferior edge of the areola. The

outlined flap is decorticated, and an incision is

made on its edges downward to the muscular
level to allow the shaping of a dermo-lipo glandular flap, supplied by the fourth, fifth, and
sixth intercostal perforating vessels. It is important that the flap be 2 to 3 cm thick (Fig. 1, e,
f, and g).
When the resection of the remaining tissue
of the breast is completed, the flap is attached
to the pectoralis fascia with nylon 3-0 separate
stitches. The distal edge of the flap is bent over

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INFERIOR PEDICLE IN REDUCTION MAMMAPLASTY

965

FIG. 5. Periareolar (tuberous breast) technique. (a) The A, B, and C points are drawn, as in the lozenge technique; however,
the D point is located 6 to 8 cm above the inframammary fold. (b through h) The surgical sequence is the same as in the lozenge
technique except that the inferior pedicle is folded under itself to support the new upper pole of the breast. In cases of tuberous
breasts with severe hypomastia, silicone breast implants can be used to achieve good symmetry and, if required, increase breast
volume. (i, j) The periareolar technique is concluded by a round block maneuver, as recognized by Benelli.

itself to give the upper pole tissue more projection and to bring the remaining mammary
tissue close to the retroglandular area (Fig. 1, h
and i). This procedure ensures the recanalization of the glandular tissue and will allow normal breast-feeding.
Points B and C are joined at the middle point of
the flap base, and the breast is finished (Fig. 1, j).
Suturing is done with separate nylon 4-0 stitches.
Skin suturing is continuous using nylon 5-0. The
areola is placed at the new position and is sutured with nylon 5-0 U stitches (Gillies/Perseu
techniques)10 (Fig. l, k, and Fig. 2).
Evolution of scars. After Peixotos14 16 technique was published, in 1989 we followed the
principles of dermal and epidermal retraction
in an attempt to reduce scarring.11 Unlike

Peixoto our results were flattened and flabby

breasts, so we used the inferiorly based flap as
a corrective procedure. The best results were
obtained in cases of mild-to-moderate hypertrophy and ptosis. The vertical scars were no
longer than 5 cm, and the breasts had a desirable conical shape. The drawing was made according to Aries procedure, in which the inferior vertex of the ellipsis ends at the
inframammary fold.17 Starting at the fold, a flap
3 cm wide and 6 cm long was outlined. The
surgical sequence was similar to that described
above.10
Lozenge Technique

Based on Peixotos concepts11 and the techniques by Lotsch, Joseph, and Arie, we devel-

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September 1, 2002

FIG. 6. Circumferential technique case. (Left) Preoperative views of a patient with

medium-sized breasts and ptosis who required a mastopexy. (Right and center, below)
Postoperative result 1 year after circumferential technique reduction and mastopexy.

oped a procedure that resulted in periareolar

and vertical scars.17 The shape of a lozenge,
which gave the name to the technique, was
slightly changed: the upper edge gained a
round shape to allow removal of more periareolar skin. The technique is advised only for
young patients with stretchable skin and moderate hypertrophy,18 even though we have
made resections of up to 900 g on each side.

The new areola is marked, and point A is

determined by the projection of the inframammary fold on the upper pole of the breast (Fig.
3, a). Points B and C are marked by means of a
pinching maneuver and the surgeons judgment to determine the amount of skin to be
resected (Fig. 3, b and c). Point D is marked 3
cm above the inframammary fold and 10 to 11
cm from the middle line. A curved line is

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INFERIOR PEDICLE IN REDUCTION MAMMAPLASTY

967

FIG. 7. Tuberous breast case. (Left) Preoperative views. Note the typical case of tuberous breast with marked herniation of the breast gland through the areolae-papillae
complex. In this case, there was symmetry, but hypomastia was also present. (Right and
center, below) Postoperative result after the periareolar approach for tuberous breast without
the use of silicone breast implants.

drawn to join points A, B, and C, and points B

and C are linked to point D by straight lines
(Fig. 3, d).
After decortication of the outlined area, a
transversal incision is made below the areola

downward to the muscular section, dividing

the breast into equal halves (Fig. 3, e, f, and g).
The shaping of the flap starts by undermining
the lower pole of the breast and resetting both
its lateral and medial edges, with care taken

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PLASTIC AND RECONSTRUCTIVE SURGERY,

September 1, 2002

FIG. 8. (Left) Preoperative views of a patient with tuberous breasts and asymmetry, pseudoherniation of the breast gland through the areolae-papillae complex, snoopy nose breasts, and
mild-grade hypomastia. (Right) Postoperative results after periareolar approach combined with
silicone breast implants to increase breast volume.

not to jeopardize the perforating vessels that

will provide the blood supply to the inferiorly
based flap (Fig. 3, h). The tissue behind the
nipple-areola complex is resected, leaving
enough to maintain the safety of the vascular
complex (Fig. 3, i and j). The new upper pole
is made from the flap attached to the pectoralis
fascia (Fig. 3, k) and is sutured with separate
stitches up to 4 to 6 cm from point D (Fig. 3, l).
As the Gillies hook is positioned to help push
the breast upward, a dog-ear might be noted at
the inferior portion, in which case excision is
required (Fig. 3, m and n). The areola is sutured
with separate stitches (Gillies/Perseu) (Fig. 3, p).
Drainage by suction is the standard procedure
for 24 hours, and the skin is sutured with sepa-

rate stitches. With the hook pulling the breasts

upward, immobilization is accomplished with Micropore tape (3M, So Paulo, Brazil) for about 15
days to retain the shape of the flap during the
necessary retraction of the skin (Fig. 4).
Circumferential Technique

The search for smaller scars led to the

development of new procedures, such as the
circumferential technique, that resulted in a
periareolar scar only. Combined with the
inferiorly based flap, the technique has
given us satisfactory aesthetic results. This
procedure is used only for young patients
with hypertrophy or tuberous breasts19 and

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INFERIOR PEDICLE IN REDUCTION MAMMAPLASTY

with resections no greater than 500 g per

breast.20
Demarcation of points A, B, and C follows the
same steps as in the lozenge technique outline.
However, point D is now marked 6 to 8 cm
above the inframammary fold, depending on
the size of the breast (Fig. 5, a). The operative
steps are also very similar to the lozenge technique, even though the final suture is made
around the areola by means of subdermal
stitches (Benellis round block21) (Fig. 5, b
through j, and Fig. 6).
Technique for Tuberous Breasts

Tuberous breasts are rarely found, and their

main characteristics19 are (1) hypertrophy of
the nipple-areola complex, (2) pseudoherniation, (3) hypoplasia with breast asymmetry, and
(4) constriction of the lower pole and reduction of supero-inferior diameter.
The hypertrophied areola is treated by
means of a circumareolar resection and according to the circumferential procedure,20
with the shaping of an inferiorly based flap
bent over itself19 (Fig. 5, a through j). For cases
of severe hypomastia and asymmetry, the circumferential technique can be combined with
breast augmentation procedures to achieve the
best aesthetic results (Figs. 7 and 8).
COMPLICATIONS

It is always important to consider complications, even though only 0.5 percent of our
approximately 4000 breast procedures resulted
in total or partial necrosis caused by inadequate handling of the flap, damage of the perforating vessels, or vascular complications observed more than 3 weeks postoperatively.
The inverted-T procedure with flaps (inferior flap technique) (n 3000) resulted in two
cases of total necrosis of the areola and 11 cases
of partial necrosis of the areola. Hypertrophic
scars/keloids occurred in 251 cases.
In the vertical scar (lozenge technique) with
flaps (n 800), no cases of total or partial
necrosis of the areola were reported. Hypertrophic scars/keloids occurred in 82 cases, and
there were 68 cases of asymmetry.
In the periareolar scar (circumferential technique) (n 200, tuberous breasts included),
no cases of total or partial necrosis of the areola were reported. Enlargement of scars17 was
seen in 100 cases, and flattening of the breasts
occurred in 50 cases.

We cannot provide exact data for all of the

results because some of the procedures were
performed during other operations or in surgical demonstrations.
CONCLUSIONS

Over the past 30 years, the flap has been

widely used because it provides a conical shape
to the breasts and gives good long-term results.
Once the flap is sutured to the muscle wall, the
weight of the remaining breast is reduced and
the basculae movement is decreased. The procedure has proved to be very effective when
combined with other techniques (such as the
inverted-T, vertical, and periareolar), depending on the desired final results.
Liacyr Ribeiro, M.D.
Av. Sete de Setembro, 301
24230-251 Niteroi
Rio de Janeiro, Brazil
ribeiroliac@alternex.com.br
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de seguridad. Rev. Esp. Cir. Plast. 16: 223, 1973.
2. Ribeiro, L. Cirurgia Plstica da Mama. Rio de Janeiro:
Medsi Ed. Mdica e Cientfica Ltda., 1989.
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N. G. Georgiade, G. S. Georgiade, and R. Riefkohi
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5. Passot, R. La correcion esthetique du prolapsus mammaire par la proced de la transposicion du mamelon.
Presse Med. 33: 317, 1925.
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18. Ribeiro, L. The lozenge technique. In R. M. Goldwyn

(Ed.), Reduction Mammaplasty. Boston: Little, Brown,
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