BREAST

Enhancing Pedicle Safety in Mastopexy and

Breast Reduction Procedures: The
Posteroinferomedial Pedicle, Retaining the
Medial Vertical Ligament of Würinger
Petrus V. van Deventer,
M.B.Ch.B.,
M.Med.Sc.(Anat.), M.Med.
Frank R. Graewe,
M.B.Ch.B., M.Med.,
Dr.med.
Bellville, South Africa
Background: Nipple necrosis, a potential postoperative complication of breast
surgery procedures, should be avoided. Because of the great variation in the
blood supply to the nipple, it is advisable to include as many arteries in the
pedicle as possible. According to the literature, the perforators of the internal
thoracic artery are the most constant and reliable sources of blood to the
nipple-areola complex. It is also supplied by the lateral thoracic artery and the
anterior intercostal arteries. If two of the above-mentioned main vessel branches
are included in the pedicle, the vascular supply to the breast will be more
reliable. According to the anatomical studies of Würinger and van Deventer, we
can safely include the dual blood supply to the nipple-areola complex.
Methods: In the authors’ technique, a pedicle is raised that includes the hor-
izontal septum and the medial vertical ligament of the breast (i.e., inferior and
superomedial pedicles), but with the breast tissue remaining attached to the
pectoral fascia. The second, third, and fourth perforators of the internal tho-
racic artery are found in the medial vertical ligament, and the inferior mammary
branches of the anterior intercostal arteries are in the horizontal septum. The
authors have performed this technique in 106 consecutive patients (211 breasts)
between 2001 and 2009.
Results: Good results regarding breast shape, nipple projection, and upper
breast fullness were obtained.
Conclusions: The posteroinferomedial pedicle technique is safe and versatile
and can be used with a periareolar, vertical scar, or inverted-T skin approach.
The technique is easy to perform and has a short learning curve. (Plast.
Reconstr. Surg. 126: 786, 2010.)

F
unctionally and aesthetically, the nipple is
the most important part of the breast. It is
therefore important to attempt preservation
of the neurovascular anatomy of the nipple-areola
complex during mastopexy and breast reduction
surgery. It has been shown that the blood supply
to the nipple-areola complex is not constant.1–5
According to the literature,4,5 the perforators of
the internal thoracic artery are the most constant
and reliable source of blood supply to the nipple-
areola complex. It is also supplied by the lateral
mammary branches of the lateral thoracic artery
From the Division of Plastic and Reconstructive Surgery,
Faculty of Health Sciences, University of Stellenbosch.
Received for publication November 5, 2009; revised March
3, 2010.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181e5f7da
and the inferior mammary branches of the ante-
rior intercostal arteries (Fig. 1).
If two of the above-mentioned main vessel
branches are included in the pedicle, the vascular
supply to the breast will be more reliable. Accord-
ing to the anatomical studies of Würinger et al.6,7
and van Deventer,4,5 we can safely include the dual
blood supply to the nipple-areola complex.
In our technique, we raise a pedicle that in-
cludes the horizontal septum and the medial ver-
tical ligament of the breast (i.e., inferior and su-
peromedial pedicles) but with the breast tissue
remaining attached to the pectoral fascia. The
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

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Volume 126, Number 3 • Enhancing Pedicle Safety

Fig. 1. Illustration of the main sources of the blood supply to the breast (i.e., internal thoracic, lateral thoracic, and
anterior intercostal arteries).

second, third, and fourth perforators of the inter-

nal thoracic artery are found in the medial vertical
ligament, and the inferior mammary branches of
the anterior intercostal arteries are in the hori-
zontal septum.
Considering the anatomical descriptions,1–5
the most reliable source of blood supply to the
nipple-areola complex is the internal thoracic ar-
tery by means of the first to fourth intercostal
perforators, and therefore a superomedial pedicle
would be safe to use. However, there is still a risk
of inadequate blood supply to the nipple-areola
complex if the pedicle does not include at least
one of the four upper perforators5 (Fig. 2).
O’Dey et al. studied anatomical dissections
and determined the dimensions of the arteries
from the main sources supplying the nipple-areola Fig. 2. Cadaver dissection revealing absent second and third
complex.8 The diameter of the medial mammary perforators of the right breast. A superomedial pedicle as illus-
arteries (perforators from the internal thoracic trated would be a random flap.
artery) measured 1.8 ⫾ 0.3 mm, the diameter of
the lateral mammary arteries (branches of the lat-
eral thoracic artery) measured 1.5 ⫾ 0.3 mm, and flow through a tube with a diameter of 1.2 mm is
the diameter of the inferior mammary arteries slightly greater than twice the rate of flow through
(branches of the anterior intercostal arteries) a tube with a diameter of 1 mm. Therefore, the
measured 1.2 ⫾ 0.2 mm. blood flow to the nipple-areola complex from the
perforating branches of the internal thoracic ar-

冉 冊
According to the equation of Poiseuille
tery (medial mammary arteries) is much greater
␲共␳1⫺␳2兲r4
V⫽ , the volume of a liquid flow- than that of the branches of the lateral thoracic
8l␩ artery (lateral mammary arteries) and the least in
ing through a tube per second is proportional to the branches from the anterior intercostal arteries
the fourth power of the radius. For instance, the (inferior mammary arteries).

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 Plastic and Reconstructive Surgery • September 2010

The vascularity of an inferior pedicle can be

enhanced by including perforators from the internal
thoracic artery. This can be performed by retaining
the medial vertical ligament of Würinger,4,5 at-
tached to the inferior pedicle, creating an internal
thoracic-anterior intercostal dual blood supply to
the nipple-areola complex. By so doing, the most
reliable source of blood supply to the pedicle is
ensured5 (Fig. 3). The venous drainage of the
pedicle will also be enhanced because the above-
mentioned arteries are accompanied by relatively
large veins.

PATIENTS AND METHODS

In the period from 2001 to 2009, 211 breasts
in 106 consecutive female patients had breast re-
ductions or mastopexy procedures. Breast reduc-
tions were performed on 78 patients, one of which
had a unilateral reduction after mastectomy, and
28 patients had a mastopexy.
All operations were performed under general
anesthesia in the Louis Leipoldt Medi Clinic and
the Monte Vista Clinic in the Western Cape, South
Africa. The age of the patients varied from 16 to
68 years, with a mean of 40 years, and all were in
good general health.
Surgical Procedure
Preoperative Markings
All of the preoperative skin markings were
performed in the upright position (Fig. 4). The
inferior areola border was determined by project-
Fig. 4. Skin markings of the posteroinferomedial pedicle for a
modified Wise pattern.
ing the submammary fold onto the anterior breast
skin just lateral to the midclavicular line. The su-
perior areola border is marked 4 cm above this
point (the nipple therefore is at a point 2 cm above
the submammary level).
A variety of surgical approaches were used in
this study. In the cases involving small breasts, a
periareolar approach was used. In the larger and
ptotic breasts, a vertical “lollipop” approach was
indicated, but in very large breasts it was necessary
to use a modified Wise pattern approach. By dis-
placing the breast tissue medially and laterally, the

Fig. 3. Schematic presentation of the posteroinferomedial pedicle with its dual blood supply.

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Volume 126, Number 3 • Enhancing Pedicle Safety

vertical arms of the “keyhole” are determined and
the marks continued inferiorly from the future
nipple position to a point 2 cm above the sub-
mammary fold.
Surgical Technique
Under general anesthesia with local infiltration
to each breast with 10 ml of 0.5% Marcaine and
1:200,000 adrenalin diluted with 30 ml of normal
saline, the breast is deepithelialized as in an inferior
pedicle approach. A medial flap is developed ap-
proximately 1 cm thick, preserving the second, third,
and fourth perforators of the internal thoracic artery
in the pedicle (in the medial, vertical ligament of the
ligamentous suspension attached to the pedicle).
This incision is carried deep onto the anterior chest
wall (Fig. 5, above, left).
The lateral flap is mobilized, transecting the
branches of the lateral thoracic artery in the lateral
vertical ligament of Würinger. The dissection is
carried deeper to reach the lateral chest wall (Fig.
5, above, right). The deep fascia containing the
lateral cutaneous branches of the fourth poste-
rior intercostal nerve is preserved. The medial
and lateral dissection planes are then connected
to each other superior to the areola and carried
onto the anterior chest wall in the subclavicular
area, bevelling it to create a thick superior flap
(Fig. 5, below). This procedure enhances upper
breast fullness.
In patients with breast hypertrophy, the ex-
cessive breast parenchyma is then removed, excis-
ing the axillary tail and the required amount from
the central mound. The transected lateral vertical
ligament of Würinger is a useful guide for pre-

Fig. 5. (Above, left) Developing the medial flap, preserving the perforators of the internal thoracic artery in the medial vertical
ligament attached to the pedicle. (Above, right) Developing the lateral flap, sacrificing the lateral mammary branches of the
lateral thoracic artery if necessary. (Below, left) Superior aspect of medial and lateral dissection planes with a breast mass
between two planes preserved to obtain upper breast fullness. (Below, right) Medial and lateral dissection planes joined to
each other, preserving the medial vertical ligament, medially, and breast tissue attached to the superior flap for upper breast
fullness.

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 Plastic and Reconstructive Surgery • September 2010
Fig. 6. Intraoperative photograph of the ligamentous suspen-
sion of Würinger. The lateral vertical ligament is sacrificed.
serving the horizontal septum when breast tissue
is removed. The medial vertical ligament of
Würinger is kept intact (Fig. 6).
After adequate parenchyma has been re-
moved, the lower aspect of the pedicle is anchored
with an absorbable 3-0 suture to the thoracic fascia
to place the nipple in its normal anatomical po-
sition. This also prevents the pedicle from displac-
ing laterally because of gravity. If necessary, better
mobilization of the pedicle can be obtained by
transecting the dermis of the pedicle just above the
submammary crease, taking care not to injure the in-
ferior mammary arteries. This step converts the breast
into an island flap attached to the pectoral fascia that
enables the surgeon to place the breast mound in
exactly the position required.
Skin closure is performed by approximating
the medial and lateral flaps with 3-0 interrupted
absorbable subcutaneous sutures. By lengthening
the vertical infraareola suture line, the horizontal
scar can be limited to the inframammary crease
(Fig. 7). The nipple-areola complex is anchored
with similar sutures, superiorly, laterally, medially,
and inferiorly, to ensure normal shape and even
tension.
The suture lines are closed with a continuous
subcuticular 3-0 absorbable suture. Drains are
used routinely and removed the following day.
The procedures are performed on an ambulatory
basis or patients are kept in the hospital for one
night. Follow-up is after 1 week, after 3 months,
and annually.
RESULTS
In the breast reduction patients, the mean
mass removed from the right breast was 423 g and
that from the left breast was 503 g. If less than 150
790
Fig. 7. Lengthening the vertical incision line will shorten the in-
framammary scar to hide it completely in the submammary
crease.
g breast tissue was removed, the procedure was
considered a mastopexy.
Satisfactory breast shape, nipple projection,
and upper breast fullness can be obtained (Figs. 8
and 9). All of the patients were satisfied with the
postoperative results.
Complications
One patient developed a postoperative hema-
toma (0.47 percent), three patients developed fat
necrosis in one breast (1.4 percent), and six
breasts had a decrease or absence of nipple sen-
sation postoperatively (2.8 percent) (Table 1). In-
fection developed in two breasts (0.94 percent).
Infection in one cleared on antibiotic treatment,
and the other needed surgical intervention. There
were no instances of nipple necrosis, epidermol-
ysis, wound dehiscence, or scar-related complica-
tions, and no reoperations were necessary.
DISCUSSION
The complication of nipple necrosis in breast
reduction and mastopexy procedures has been
reported in the literature to range up to 7.3
percent.9 The reason for this complication can be
attributed to the lack of knowledge and under-
standing of the blood supply to the nipple. Con-
sidering previous research on the blood supply of
the breast, namely that of Manchot,1 Marcus,2
Palmer and Taylor,3 Reid and Taylor,10 O’Dey et
al.,8 Würinger et al.,6,7 and van Deventer,8,9 our
described procedure constitutes a safe technique
with all the benefits of the inferior pedicle. The
safety of the nipple-areola complex is greatly en-
hanced by adding the blood supply of the perfo-
Volume 126, Number 3 • Enhancing Pedicle Safety

Fig. 8. Preoperative and 18-month postoperative views of a patient who had a mastopexy using the
posteroinferomedial pedicle with retained medial vertical ligament.

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 Plastic and Reconstructive Surgery • September 2010

Fig. 9. Preoperative and 7-month postoperative views of a patient who had a breast reduction using a
posteroinferomedial pedicle with retained medial vertical ligament. A mass of 690 g was removed from the
right breast and 500 g was removed from the left.

Table 1. Patient Data and Complications septum to enhance the blood supply of a lateral
Patient Data Value (%) or medial pedicle. This technique relies on the
No. of patients 106 branches of the anterior intercostal arteries to
Age, years enhance the blood supply to the pedicle. In a study
Average 40
Range 16–68 by the first author,4 it was found that the nipple-
Operated breasts 211 areola complex received blood vessels from the an-
Unilateral procedures 1
Loss of or decreased nipple sensation 6 (2.8) terior intercostal arteries in only 20 of 27 dissected
Fat necrosis 3 (1.4) breasts. A further finding4 was that the nipple-areola
Infection 2 (0.93)
Hematoma 1 (0.47) complex received vessels from the lateral thoracic
Nipple necrosis or epidermolysis 0 (0)
Wound dehiscence 0 (0) artery in only 19 of 27 dissected breasts. This could
Scar-related complications 0 (0) well be the reason for the occurrence of total nipple
necrosis of 2.1 percent and partial necrosis of 7.3
rating branches of the internal thoracic artery to percent in the laterocentral glandular pedicle tech-
the inferior pedicle (Fig. 3). nique as reported by Blondeel et al.9 in 2003.
Hamdi et al.11 reported on a septum-based mam- It is our opinion that it is of crucial importance
maplasty for breast reduction using the horizontal to include the perforating arteries of the internal

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Volume 126, Number 3 • Enhancing Pedicle Safety

thoracic artery (medial mammary arteries) in the
pedicle to ensure adequate blood supply to the
nipple. A previous study has shown that the nipple
always receives one or more perforating vessels
from the internal thoracic artery.4 It is therefore
important to keep the medial vertical ligament
intact, which includes these vessels.
CONCLUSION
We conclude that the posteroinferomedial
pedicle with retained medial vertical ligament is a
safer technique for breast reduction and mas-
topexy procedures.
Petrus V. van Deventer, M.B.Ch.B., M.Med.Sc.(Anat.),
M.Med.
P.O. Box 6115
Welgemoed 7538, South Africa
peetvandeventer@telkomsa.net
REFERENCES
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Vogel; 1889.
2. Marcus GH. Untersuchungen uber die arterielle Blutversor-
gung der Mammila. Arch Klin Chir. 1934;179:361–369.
3. Palmer JH, Taylor GI. The vascular territories of the anterior
chest wall. Br J Plast Surg. 1986;39:287–299.
4. van Deventer PV. The blood supply to the nipple-areola
complex of the human mammary gland. Aesthetic Plast Surg.
2004;27:393–398.
5. van Deventer PV, Page J, Graewe FR. The safety of pedicles
in mastopexy and breast reduction procedures. Aesthetic Plast
Surg. 2008;32:307–312.
6. Würinger E, Mader N, Posch E, Holle J. Nerve and vessel
supplying ligamentous suspension of the mammary gland.
Plast Reconstr Surg. 1988;101:1486–1493.
7. Wueringer E, Tschabitscher M. New aspects of the topo-
graphical anatomy of the mammary gland regarding its neu-
rovascular supply along a regular ligamentous suspension.
Eur J Morphol. 2004:40:181–189.
8. O’Dey DM, Pallua N, Perscher A. Vascular reliability of nip-
ple-areola complex-bearing pedicles: An anatomical micro-
dissection study. Plast Reconstr Surg. 2007;119:1167–1177.
9. Blondeel PN, Hamdi M, Van de Sijpe KA, Van Landuyt K,
Thiessen FE, Monstrey S. The latero-central glandular pedi-
cle technique for breast reduction. Br J Plast Surg. 2003;56:
348–359.
10. Reid CD, Taylor GI. The vascular territory of the acromio-
thoracic axis. Br J Plast Surg. 1984;37:194–212.
11. Hamdi M, Van Landuyt K, Tonnard P, Verpaele A, Monstrey
S. Septum-based mammaplasty: A surgical technique based
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Online CME Collections

This partial list of titles in the developing archive of CME article collections is available online at www.
PRSJournal.com. These articles are suitable to use as study guides for board certification, to help readers refamiliarize
themselves on a particular topic, or to serve as useful reference articles. Articles less than 3 years old can be taken for CME
credit.
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Breast Cancer: Advances in Surgical Management —Alan R. Shons and Charles E. Cox
Breast Reconstruction with Free Tissue Transfer—Michael S. Beckenstein and James C. Grotting
Recurrent Mammary Hyperplasia: Current Concepts—Rod J. Rohrich et al.
Evolution of the Vertical Reduction Mammaplasty—Scott L. Spear and Michael A. Howard
Breast Augmentation—Cancer Concerns and Mammography: A Literature Review—Michael G. Jakubietz et al.
Breast Augmentation—Scott L. Spear et al.

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