Aesthetic Plastic Surgery

, Volume 35, Issue 4, pp 608–616

The Dermal Suspension Sling: Shaping the Inferior Pedicle during Breast Reduction


    • Plastic Surgery DivisionBaylor College of Medicine
  • Gerardo Guerra
    • Plastic Surgery DivisionBaylor College of Medicine
  • Eser Yuksel
    • Plastic Surgery DivisionBaylor College of Medicine
Innovative Techniques

DOI: 10.1007/s00266-010-9632-5

Cite this article as:
Echo, A., Guerra, G. & Yuksel, E. Aesth Plast Surg (2011) 35: 608. doi:10.1007/s00266-010-9632-5



Complaints following reduction mammaplasty using the inferior pedicle include the migration of the deep tissue, a lack of medial fullness, poor projection, and bottoming-out. These are attributed to the lack of deep tissue suspension and skin envelope relaxation. We address these issues through horizontal dermal suspension and plication of the inferior pedicle.


The inferior pedicle is designed with medial and lateral triangular flaps in the areas, which would normally be excised. These triangular flaps are deepithelialized and defatted. The flaps are attached to the chest wall above the inferior pedicle to create a dermal sling. The breast mound is further contoured by horizontally plicating the dermis below the nipple–areola complex (NAC), which creates projection and rotates the NAC into the desired position in relation to the chest wall.


Sixty-six women have undergone breast reduction using the horizontal dermal suspension sling modification to the inferior pedicle breast reduction technique. Breast projection and shape were sustained during follow-up, of which the median interval was 16 months.


Dermal suspension and horizontal dermal plication provides a structural foundation to the inferior pedicle. The sling-like effect from the dermal suspension maintains a defined inframammary fold and maintains medial and lateral borders of the breast. Horizontal dermal plication shortens the length of the inferior pedicle while generating improved breast projection by rotating the NAC anteriorly. The firmly shaped inferior pedicle breast mound allows the skin flap to drape over the breast mound with minimal tension.


Inferior pedicle breast reductionDermal suspensionDermal slingBreast reductionReduction mammoplastyInferior pedicle reduction mammoplastyDermal plication dermal flaps

In 2008, the American Society of Plastic Surgeons reported that over 79,400 women underwent breast reduction surgery. Breast reduction surgery is life-changing for many women who suffer from macromastia by resolving such physical problems as lower back pain, shoulder pain from bra strap grooves, and intertrigo below the breasts. There is also a social improvement, with better-fitting clothes, the ability to exercise easier, less public attention from grossly enlarged breasts, and more confidence at work and in the social setting.

Youthful breasts rely on the Cooper’s ligaments to provide suspension to the adipose and glandular tissues of the breast. However, with aging and excessive hypertrophy, these ligaments become less effective in maintaining projection and shape, resulting in ptotic breasts.

Traditionally, with the inferior pedicle breast reduction technique, the inferior pedicle predominantly provides the breast volume. Meanwhile, the conical design of the skin envelope shapes the inferior pedicle, thus creating the final breast appearance. As the underlying pedicle shifts and settles, there is a loss of medial fullness and loss of projection. These postoperative sequelae can also be attributed to the superior skin envelope, which may fail to retain the shape of the breast as it stretches and relaxes.

While inferior pedicle techniques remain a popular surgical option in reduction mammaplasty, the necessity for both suspension and shaping of the inferior pedicle has not been entirely addressed. Multiple methods of inferior pedicle suspension without firm breast mound shaping have been described in the literature. These include the use of synthetic mesh [1, 2] suspending the superior margin of the pedicle [3, 4] and a superficial fascial system mode of suspension [5], all with attempts of maintaining long-term lift of the breast. Recently, the use of dermal appendages for suspension has gained some popularity. The fixation of dermal flaps arising off the lower [69], lateral [10], and upper [10] edges of the inferior pedicle to the pectoralis major fascia has been described and appears to be the most promising. However, these approaches to dermal suspension fall short of addressing the excessive length of the inferior pedicle commonly seen in severe ptosis, which will permit the breast tissue to bottom-out and ultimately fail to recreate any significant projection.

Horizontal dermal suspension and plication are the critical maneuvers that give the inferior pedicle structure and form, thus becoming less reliant upon the skin envelope for breast shape. The technique can help maintain more medial fullness and better nipple–areola complex (NAC) projection by transferring the weight of the inferior pedicle to the chest wall through the sling-like effect from the medial/lateral triangular dermal suspension flaps. Also, through horizontal dermal plication, nipple-to-inframammary fold (N-IMF) distance is reduced on the inferior pedicle, creating better NAC projection.

Patients and Methods


Physical examinations of 66 women confirmed the diagnosis of breast hypertrophy. The age of the patients varied from 16 to 67 years (mean = 35 years), and the mean body mass index was 32.87 kg/m2. Macromastia ranged from mild to severe, and ptosis was Grades II and III. Patient bra cup sizes ranged from D to J. The mean preoperative sternal notch-to-nipple distance was 35.2 cm. The mean preoperative N-IMF distance was 17 cm (Table 1).
Table 1

Preoperative breast measurements and body mass index (BMI) in our patient sample (n = 66) who underwent an inferior pedicle breast reduction with the dermal suspension sling


Shortest (length)/lowest (BMI)

Longest (length)/highest (BMI)

Average ± SD

Sternal notch to nipple [SN-N] (cm)



35.2 ± 4.8

Nipple to inframammary fold [N-IMF] (cm)



17.0 ± 4.2

BMI (k/m2)



32.87 ± 6.2


All markings and measurements are made while the patient is standing upright. The sternal notch, breast meridian, and the sternal midline are marked. A mark is placed 18–21 cm away from the sternal notch along the breast meridian to represent the tentative nipple location. The definitive nipple location is finalized intraoperatively for symmetry and proper projection, taking into consideration the initial markings, the midpoint of the humerus between the olecranon and the acromion, the height of the torso, and the distance to the inframammary crease. The inframammary fold is marked from its most medial portion to the lateral portion, not extending beyond the anterior axillary line. A mark is placed on this line immediately below the nipple to outline the center of the base of the inferior pedicle. The inframammary lines are measured for symmetry and adjustments are made as necessary. The areola is reduced to a diameter of 42–45 mm.

The superior flap is marked as an inverted V, with the apex at the tentative new nipple location and each limb extending downward 7–9 cm on each side of the areola. A line extending from the medial and lateral ends of the inframammary folds to the limb of the inverted V is then marked. A 10–18-cm inferior pedicle is marked. It is important to remember that the triangular wedges of tissue on either side of the inferior pedicle will be deepithelialized and left attached to the inferior pedicle. These dermal flaps will be used for the inferior pedicle suspension later in the procedure (Fig. 1).
Fig. 1

Preoperative markings, with the patient in the standing position. The medial and lateral lines that approach the planned nipple–areola complex must be no more than 9 cm. The streak pattern shows the skin area planned to be deepithelialzed (inferior pedicle and dermal flaps). The base of the inferior central pedicle must measure 8–10 cm (blue) and at least 5 cm for the dermal flaps (red)

Surgical Technique

Everything below the superior skin flap, with the exception of the NAC, is completely deepithelialized (inferior pedicle, medial/lateral dermal flaps). Then, along the superior margin of the inferior pedicle, dissection is performed at an angle perpendicular to the chest wall to the pectoralis fascia.

The superior flap is elevated and thinned to a thickness of 7–10 mm using sharp scissors up to approximately 2 cm superior to the planned areola location. Bipolar cautery, which is essential to prevent thermal damage to the thin flap, is used for hemostasis. From just above the planned areola location, the thickness of the flap is now increased to greater than 2 cm for the next 4–6 cm of dissection. Dissection is performed cranially toward the clavicle above the pectoralis major fascia (Fig. 2).
Fig. 2

Dissection is carried out over the superior border of the inferior pedicle and is extended to the pectoral fascia. Breast tissue is excised in different proportions according to the level of the flap. Left superior and inferior flaps of a right breast are shown in a frontal view. Right a cross section of the superior flap is shown to better understand the different flap thicknesses

The medial and lateral aspects of the inframammary fold are incised to the borders of the inferior pedicle base, leaving a 10–18-cm central pedicle base that was previously marked. The adipose tissue is removed from immediately below these medial/lateral triangular dermal flaps to a thickness of 1 cm, which will eventually allow them to be rotated superiorly to the chest wall while keeping the subdermal plexus intact. Excess adipose tissue is debulked from the lateral and medial chest wall to provide a gradual transition to the breasts. Additional tissue is removed from the central portion of each inferior pedicle to adjust for volume and asymmetry.

The medial triangular dermal flap is lifted cranially and anchored to the pectoralis major fascia approximately 3 cm from the sternal midline at the level of the second or third rib. The lateral triangular dermal flap is rotated cranially and medially, encompassing the remaining tissue of the inferior pedicle, and attached to the pectoralis major fascia with 0 PDS suture approximately 2–3 cm away from the medial flap attachment (Fig. 3). This is then repeated on the contralateral breast. Adjustments to the recently positioned triangular dermal flaps, along with subsequent minor resections to the breast mound are made to correct for any asymmetries. The incisions that previously released the dermal wings are now extended to release any deformity that occurred to the inframammary fold following the dermal suspension.
Fig. 3

Top, left intraoperative view of the inferior pedicle with its dermal flaps. Top, right dermal wings encompass the inferior pedicle and the corners are sutured to the pectoralis major fascia. Bottom the dermal wing is rotated and secured to the pectoralis fascia

Inadequate projection of the breast mound is addressed by decreasing the distance between the lateral flaps on the chest wall, which tightens the breast mound. If horizontal deviation of a breast is present, simple resuspension of the dermal flaps will correct the deviation. With proper suspension, the breast mound should be fairly firm and centered along the midclavicular line. The breast mounds are secured in place using 0 PDS sutures to reinforce the dermal flaps to the pectoralis fascia.

At this point, the NAC will often appear to be sitting high with superior projection (“star gazing”). An ellipse is drawn on the inferior pedicle, with the superior border approximately 3 cm below the NAC and the inferior border 3 cm above the inframammary crease. Plicating this ellipse using a continuous 3-0 PDS suture reduces the length of the infra-areolar dermis, thereby producing a cone-shaped mound with the NAC centered on it (Fig. 4).
Fig. 4

The excessive projection is corrected by dermal plication. An ellipse is drawn on the inferior pedicle, then the ellipse is plicated using a continuous suture

The superior cutaneous flap is pulled into place and temporarily secured with staples. Symmetry is ensured by evaluating the breast shape with the patient in an upright position. Then, a Blake suction drain is placed in each breast through a separate stab incision.

The opening for each areola is determined. Once the center is determined, a 30-mm-diameter circle is drawn and excised. The excess adipose tissue surrounding the aperture is debulked, then the areola is pulled through and sutured into place (Fig. 5).
Fig. 5

The planned new position of the nipple–areola complex is used as a reference. The final position of the nipple is decided on once the cutaneous flap is secured in place, then a keyhole is marked and excised. The areola is pulled through and sutured in place

Routine preoperative administration of clindamycin 600 mg IV was used. All patients were given postoperative antibiotics consisting of 5 days of oral clindamycin. The drains were removed on the first postoperative visit, usually in 5–7 days.

Patients wore a surgical bra as directed until the first post-operative appointment, then they were instructed to wear a well-fitting, full-coverage wireless bra that provided good support for at least 4–6 weeks. Patients were advised to sleep with the bra on for at least 3 weeks.


The primary author has used the horizontal dermal suspension and plication technique for reduction mammaplasty surgeries utilizing the inverted-T pattern since 1998 on 66 patients with mild to severe cases of macromastia. The mean weight of total amount of tissue removed per breast was 1,131 g (standard deviation = 661 g). Free nipple grafts were used on only two women, both of whom had a nipple-to-inframammary fold distance of 26 cm bilaterally. In these patients, the inferior pedicle was designed with the dermal wings on each side; however, the length of the pedicle was limited to 20 cm to ensure viability. The nipples were beyond this point; therefore, they were harvested as a free nipple graft and placed on the skin envelope at the end of the case instead of bring the NAC through the skin flap (Figs. 68).
Fig. 6

A 26-year-old female. Top preoperative pictures. Bottom seventeen months after inverted-T reduction mammaplasty with dermal suspension and plication. Total amount of tissue removed: left breast, 407 g; right breast, 416 g
Fig. 7

A 38-year-old female. Top preoperative pictures; note extent of areola pigmentation.Bottom fifteen months after inferior pedicle reduction mammaplasty with dermal suspension and plication. Total amount of tissue removed: left breast, 1,247 g; right breast, 1,283 g
Fig. 8

A 54-year-old female. Top preoperative pictures; note convergence of right nipple. Bottom twelve months after inferior pedicle reduction mammaplasty with dermal suspension and plication. Total amount of tissue removed: left breast, 1,932 g; right breast, 1,898 g

The median follow-up was 17 months. There was no nipple loss in any of the patients. Favorable results regarding nipple and areola sensation were observed during the postoperative follow-up evaluations. Excluding the patients in whom free nipple grafts were used, none of the patients had a significant loss of nipple sensation from their preoperative state.

A minor postoperative infection occurred in one patient, requiring incision and drainage and eventual scar revision. A case of mild keloid scar formation was treated with triamcinolone injections with favorable results. One patient reported feeling a hard lump on her right breast and presented with slight asymmetry; fat necrosis was confirmed by mammogram and fine needle biopsy and a minor revision by direct excision of the fat necrosis resolved the issue. There were no other reported complications from the patients.


Numerous breast reduction techniques have been described over the years. In North America, as well as in some parts of Europe, the use of the inferior pedicle and inverted-T scar method is predominant [11]. Inferior pedicle breast reduction techniques have been criticized for having inadequate projection, upward NAC rotation, “star-gazing,” and “bottoming-out” or pseudoptosis.

Although other breast reduction techniques such as the superior and medial pedicle have minimal development of pseudoptosis [12, 13], these methods are usually indicated only in mild to moderate cases of ptosis and are contraindicated in cases where there is greater resection volumes or long-distance NAC transposition. The vertical bipedicle of McKissock [14] provides good circulation to the nipple, but also results in flat breasts with inadequate projection [1517]. The increasingly popular superior pedicle vertical scar mammaplasty, first described by Passot [18] and popularized by Lejour [19, 20], is also not commonly used for treating large breasts because of wound-healing problems [21, 22].

Early results following the inverted-T/Wise pattern reduction are often satisfactory because the conical shape of the superior flap provides the structural support for the deep tissues of the inferior pedicle. However, loss of shape and projection is a possible consequence as the cutaneous tissue becomes relaxed, thereby allowing the inferior pedicle to migrate laterally or inferiorly, causing a lateral fullness or pseudoptosis (bottoming-out), respectively [2325].

To deal with this inferior pole excess, suturing the inferior pedicle to the chest wall has been proposed [610]. Fixation of the deep tissues is a maneuver not commonly employed by many surgeons but it may allow for better long-term results [26, 27],

Other surgeons have been more aggressive and have resorted to the use of internal suspension techniques with the use of a mesh or allogenous materials to support the pedicle, trying to create an internal brassiere or sling [1, 2]. Although this approach seems to avoid the inferior migration of breast parenchyma, there is potential risk for infection or tissue reaction. We think that the deepithelialized triangular dermal flaps provide optimal material for breast suspension because it is autologous and readily available. It also does not add any additional cost to the surgery as would using a piece of any of the readily available dermal matrix products.

Horizontal Dermal Suspension

Using internal breast-shaping sutures has been proposed to address the lack of projection [28]. While this is better than relying solely on the skin for shaping the pedicle, the proposed use of slings for horizontal dermal suspension provides additional support and facilitates the shaping of the breast. From our experience, the triangular dermal flaps that arise off the lower edges of the inferior pedicle allow the greatest manipulation of the remaining deep breast tissue. This suspension method is advantageous in many ways. First, each flap encircles the central core of breast tissue, preventing lateral bulging while creating a medial fullness that is often difficult to produce. Second, each flap provides countertraction to the other, thereby securing the tissue in its desired location on the chest wall, which allows for better positioning of the breast mound and prevents migration. Third, the flap attachments are easily placed on the chest wall, which allows intraoperative adjustments of the breast mound to change the projection, position, and shape. Fourth, securing the inferior pedicle dermis to the pectoral fascia transfers the weight of the inferior pedicle to the musculoskeletal system, thereby allowing the skin of the superior flap to drape over the inferior pedicle. Fifth, the dermal flaps suspend the inferior portion of the breast mound through a sling-like effect, which preserves the inframammary fold and decreases the potential of bottoming-out.

Horizontal Dermal Plication

The integral step in achieving the desire breast projection and reducing pseudoptosis is reducing the nipple–inframammary fold (N-IMF) distance of the inferior pedicle. With long, ptotic breasts, the N-IMF distance is often greater than the standard 5–7 cm created on the superior skin flap. With this discrepancy in length, it is easy to see how the inferior pedicle can drift freely once the NAC is secured to the superior skin flap. Horizontal dermal plication reduces this distance, which stabilizes and limits the movement of the inferior pedicle. It also produces better breast projection by positioning the NAC in its ideal position in relation to its anatomic landmarks without relying on the skin flap.

Nipple–Areola Complex Aperture

Initial markings for nipple placement should serve as a reference point because the stretch of the skin may unevenly move the preoperative markings [29]. For this reason we have routinely been creating the NAC aperture once the superior flap is secured into place and the patient is in the sitting position. The aperture diameter (30 mm) is intentionally made smaller than the NAC diameter (42–45 mm) to provide added breast contours by creating a pseudoherniation of the NAC. This avoids a wide, flat NAC that occurs when the aperture and the NAC are the same diameter.

Superior Flap

By removing the tension from the superior skin flap closure, a more predictable result is obtained. It was interesting that none of the patients in our review suffered from skin necrosis at the inverted-T junction following the reduction, demonstrating the minimal tension on the closure.


Horizontal dermal suspension and plication is an effective adjunct to the inferior pedicle breast reduction technique for producing medial breast fullness and breast projection. Through the sling-like effect on the inferior pedicle from the medial/lateral triangular dermal flaps, a central breast mound is stabilized, thereby providing structural support to the inferior pedicle. The horizontal dermal plication shortens the N-IMF distance, further stabilizing the inferior pedicle by decreasing the discrepancy between the N-IMF distance on the inferior pedicle and the superior skin flap. By creating a structured breast mound, the superior skin flap is able to simply drape over the already formed deep tissue, taking tension off of the skin.


A. Echo, G. Guerra, and E. Yuksel have no conflicts of interest of financial ties to disclose.

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© Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2010