Severe gestational gigantomastia: management challenges

Gestational gigantomastia is rare and characterised by rapid and disproportionate enlargement of the breast during pregnancy. It often requires surgical removal of more than 1500 g of breast tissue. Of the 50 case reports published worldwide, not one was in South African literature. This unusual case report is of a female presenting with gigantomastia at five weeks gestational age. The patient was multiparous and decided to terminate the pregnancy due to the physical and emotional effects of the large, pendulous breasts. Management included breast reduction and free nipple grafting in a staged approach. The complications are briefly outlined. Despite rare presentation, patient satisfaction was achieved.

Simultaneous correction of a pectus excavatum with tubular breast deformity using a custom-made silicone implant

Pectus excavatum (PE) is one of the most common congenital deformities of the thorax and is characterized by a depressed sternum with reduction of the antero-posterior thoracic diameter. Although the majority of patients with PE have no physiologic limitations, it is often associated with psychological problems influencing the patients' quality of life. Surgical treatment options show particular variation with regard to invasiveness and morbidity of the respective procedures. Surgical treatment using a custom-made silicone implant represents a less invasive alternative for patients without further accompanying physical symptoms. This article describes the simultaneous correction of a PE combined with tubular breast deformity using this minimally invasive technique.

Breast Device Surgery in Australia: Early Results from the Australian Breast Device Registry

BACKGROUND

The Australian Breast Device Registry (ABDR) is a clinical quality registry designed to monitor the performance of breast devices; and the quality and safety of breast device surgery.

OBJECTIVE

To report on breast device surgery characteristics across Australia.

METHODS

Participants were registered patients in the ABDR from 2012 to 2018. Results are described using percentages, mean and median. Revision rates were calculated using survival analysis methods.

RESULTS

A total of 37,603 patients were registered and had undergone reconstruction (post-cancer 15.1%, risk-reducing mastectomy 3.4% and developmental deformity 2.4%) or cosmetic augmentation (74.7%) procedures. The majority of breast implant devices were silicone filled with textured surface (reconstruction 74.0% and augmentation 64.0%). Sub-pectoral plane was the most common for both reconstruction (60.1%) and augmentation (76.6%) procedures. For reconstruction surgery, the most common surgical incision was previous mastectomy scar (44.0%) and inframammary (31.8%), and for augmentation, it was inframammary (83.4%). Intraoperative/postoperative antibiotic usage for reconstruction was 85.8% and augmentation was 89.4%. Revision incidence due to complication at 12 months post-cancer reconstruction was 5.1%, risk-reducing reconstruction 5.7% and developmental deformity implants 4.5%. Revision incidence due to complication at 12 months after augmentation procedure was 1.1%. Patient-reported outcome measures (PROMs) indicate high levels of satisfaction at 1 year for augmentation and reconstruction procedures.

CONCLUSION

We report on early data from the ABDR and reflect on the uptake of the registry by surgeons and patients. The registry also benefits from international collaborative approaches to addressing challenges and is committed to facilitate international post-market surveillance.

Breast pathology in adolescence

OBJECTIVE

Description of breast pathology in adolescents.

METHODS

A retrospective descriptive study of adolescents who were referred to the Gynecology consultation of a tertiary pediatric hospital for suspected breast pathology, in the period from the 1st June 2011 to the 30th December 2018.

RESULTS

One hundred and two female adolescents (11 to 18 years old) with suspected breast pathology were referred (6% of the motives for consultation), with confirmation in 58 (56.9%), who were included in the study. The reasons for referral were breast masses (66%), anomalies in breast size or symmetry (29%) and infection (5%). Of breast masses, the most frequent diagnosis was fibroadenoma (76%), followed by fibro-cystic pathology (18%). In most cases, a conservative approach was chosen, with clinical and imaging surveillance. Surgery was required in 29% of these cases. Anomalies in breast size and symmetry were observed in 17 adolescents. Two adolescents were submitted to symmetrization, after 18 years of age. Infectious and inflammatory pathology occurred in three cases: two mastitis and one retroareolar cyst. The approach consisted mainly of antibiotherapy. There were no cases of malignant breast disease.

CONCLUSION

Lumps or breast masses are the most frequent breast pathology in adolescence, and in the majority of cases surveillance was recommended, as they are a mere sign of hormonal oscillations at this age. Objective examination and/or breast ultrasound are usually enough to make the diagnosis. The approach must be mainly conservative, since malignancy is extremely rare in this age group.

The Pedicled Robertson Mammaplasty: Minimization of Complications in Obese Patients With Extreme Macromastia

BACKGROUND

Breast reduction for extreme macromastia in obese patients is a potentially high-risk endeavor. Free nipple grafting as well as a variety of pedicled techniques have been advocated for large reductions in obese patients, but the number of different approaches suggests that no single method is ideal. This paper suggests the Robertson Mammaplasty, an inferior pedicle technique characterized by a curvilinear skin extension onto the pedicle, as a potentially favorable approach to this clinical situation.

OBJECTIVES

The author sought to determine the safety of the Pedicled Robertson Mammaplasty for extreme macromastia in obese patients.

METHODS

The records of a single surgeon's practice over a 15-year period were retrospectively reviewed. Inclusion criteria were a Robertson Mammaplasty performed with a >3000-g total resection and a patient weight at least 20% above ideal body weight. Records were reviewed for patient characteristics, operative times, and complications.

RESULTS

The review yielded 34 bilateral reduction patients that met inclusion criteria. The mean resection weight was 1859.2 g per breast, the mean body mass index was 36.4 kg/m2, and the mean sternal notch-to-nipple distance was 41.4 cm. Mean operative time was 122 minutes. There were no cases of nipple necrosis and no major complications that required reoperation under general anesthesia. A total 26.4% of patients had minor complications that required either local wound care or small office procedures, and 4.4% received small revisions under local anesthesia.

CONCLUSIONS

The Pedicled Robertson Mammaplasty is a fast and safe operation that yields good aesthetic results and a relative minimum of complications in the high-risk group of obese patients with extreme macromastia.

LEVEL OF EVIDENCE: 4

Tuberous Breast

N/a.

EEC-LM-ADULT syndrome caused by R319H mutation in TP63 with ectrodactyly, syndactyly, and teeth anomaly: A case report

RATIONALE

Ectrodactyly ectodermal dysplasia-cleft lip/palate (EEC) syndrome, limb-mammary syndrome (LMS), and acro-dermato-ungual-lacrimal-tooth (ADULT) syndrome are caused by a TP63 gene disorder and have similar features. In the present article, a R319H mutation in TP63 is reported, and the correlation between genotype and phenotype is discussed based on the current case and previous literature.

PATIENT CONCERNS

A 13-year-old Japanese boy had ectrodactyly in the right hand and left foot and syndactyly in the left and right foot, and tooth shape abnormalities.

DIAGNOSES

Peripheral blood samples were obtained, and mutation analysis was performed. A heterozygous G>A transition at cDNA position 956 of the TP63 gene was found. The patient was diagnosed with ELA (EEC/LM/ADULT) syndrome based on his clinical features and mutation analysis results.

INTERVENTIONS

The patient underwent surgery to correct the left foot malformation at 1 year of age and the right foot syndactyly at 11 years of age.

OUTCOMES

No complications were observed after the first and second operations. He can walk comfortably after them, and no additional interventions will be planned in him. We continued to follow up with him up to the present.

LESSONS

The concept of ELA syndrome, which is the original concept of combining 3 syndromes (EEC syndrome/LMS/ADULT syndrome) into a unique clinical entity, can help clinicians to better understand TP63-related syndromes and improve the differential diagnosis of these syndromes.

Inferior pedicle breast reduction and long nipple-to-inframammary fold distance: How long is safe?

BACKGROUND

Free nipple grafting indications in breast reduction surgery are outdated. Safety of inferior pedicle technique for large resections and long pedicles has not been clearly defined. We evaluated patients who underwent inferior pedicle reduction mammoplasty to define the safety constraints of the inferior pedicle.

METHODS

A retrospective review of patients who underwent inferior pedicle reduction mammoplasty due to symptomatic macromastia at Mayo Clinic over a six-year period was conducted. Patients with prior breast surgeries were excluded. Demographics, breast measurements, and surgical outcomes were collected. Univariate and multivariate analyses were performed to assess for predictors of necrosis.

RESULTS

Overall, 288 patients (576 breasts) underwent inferior pedicle breast reduction from 2014 to 2019. The mean sternal notch-to-nipple (SNN) distance was 31.5 cm (standard deviation[SD]:4.2; range[r]:16-48), and the mean nipple-to-inframammary fold (N-IMF) distance was 14.8 cm (SD:4.0; r:7.5-27). The mean resection weight was 699.6 g (SD:310.4; r:125-2,385). The median follow-up was 3.9 months (interquartile range[IQR]:2.8-9.0). The overall skin or nipple areolar complex necrosis rate was 2.1%; the overall complication rate was 14.8%. On multivariate analysis, overall necrosis was not found to be associated with the N-IMF distance (adjusted odds ratio[aOR]:1.05, 95%-CI 0.88-1.16). Resection weight was statistically associated with an increased risk of overall necrosis (aOR:1.003, 95%-CI 1.001-1.005), adjusting for N-IMF and SNN distances.

CONCLUSION

Inferior pedicle breast reduction offers low risk of necrosis and can be safely performed in patients regardless of the N-IMF distance. No association was found between N-IMF distance and overall necrosis in our cohort, including lengths >15 cm. However, large resections could increase the risk of necrosis.

Idiopathic gigantomastia: newer mechanistic insights implicating the paracrine milieu

PURPOSE

Gigantomastia refers to pathological breast enlargement usually occurring in the peripubertal or peripartum period. Idiopathic gigantomastia, however, is a rare entity with hypotheses citing local expression of hormones and growth factors in causing this disease, none of which have been systemically analysed. The purpose of this study was to delve deeper into the mechanistic pathways causing this condition.

METHODS

Herein, we describe three patients of idiopathic gigantomastia, all of whom had had normal puberty and uneventful pregnancies. Further, one of the patients had postmenopausal gigantomastia which is extremely rare, with only four cases described in the literature. Serum markers of autoimmunity, incriminated hormones and growth factors analysed, were normal in all the cases. Breast tissue specimens were subjected to histopathological examination and immunohistochemistry for ER, PR and Her-2-Neu. Quantitative immunofluorescence for aromatase, IGF2, EGFR, TGF-β, PDGFR-α, β, IGF1 and PTHrP was also performed.

RESULTS

Of these, the tissue expression of aromatase, IGF2, EGFR, TGF-β, PDGFR-α and β were found to be upregulated, whereas IGF1 and PTHrP were comparable to normal breast.

CONCLUSION

This observation that paracrine overexpression of these factors is responsible for the pathogenesis of apparently idiopathic gigantomastia may have therapeutic ramifications in the future for patients with this debilitating condition.

[Oncoplasty by the Thorek technique for lower quadrant cancers in a condition of gigantomastia]

OBJECTIVE

Describe our experience of Oncoplasty according to Thorek in gigantomastia with hard and less plastic breasts and a major ptosis.

METHODOLOGY

Thirteen cases of breast carcinoma on gigantomastia operated using the Thorek technique between 2014 and 2019 in Burkina Faso were analyzed retrospectively. The operative indications, technique and results were considered. Breast Q was used to assess patient satisfaction.

RESULTS

The indication of oncoplasty by the Thorek's technique was breast lower quadrants carcinoma, associated with a major ptosis, gigantomastia. There was a consequence on the spine in 9 over 13 cases. The breasts were hard and less plastic, making the other breast reduction techniques difficult. This technique helped remove the carcinoma, reduce the volume of the breast and address the ptosis. The patients were satisfied with the volume of the remaining breasts and their aesthetic look. The resection margins were safe. Two cases of aerolar dyschromia were noticed.

CONCLUSION

The Thorek technique remains an alternative concerning tumours on gigantomastia, with hard and less plastic breasts and a major ptosis. The results combine carcinological and aesthetic requirements.

Breast Asymmetry in Women Requesting Plastic Surgery of the Breast

OBJECTIVE

Breast asymmetries have a high prevalence among women requesting breast augmentation. However, the prevalence of breast asymmetries in women undergoing other types of breast surgeries is not known.

METHODS

The breast measurements of consecutively women evaluated for plastic surgery of the breast, but without prior breast surgery, were prospectively recorded in a plastic surgery database. They were classified into three groups according to the presenting breast problem: hypoplastic breasts, macromastia, and ptotic breasts. Comparisons were made between the right and left side of each patient regarding the symmetry of the nipple-areola complex (size and position), breast mound, and chest wall.

RESULTS

The breast measurements of 304 women were analyzed. The mean age was 35 ± 12 years. The study population was distributed in the following manner: 126 hypoplastic breast cases, 100 macromastia cases, and 78 ptotic breast cases. Asymmetry of the position of the nipple-areola complex was found in 54%, 59%, and 56% of the groups, respectively. Asymmetry of the breast mound volume was found in 41%, 47%, and 44% of the groups. Asymmetry of the chest wall was present in 12%, 11%, and 10% of the groups, respectively. Overall, we found that 91% of the cases had at least one type of breast asymmetry. Prevalence of asymmetry was not different (p>0.05) among the groups, but the magnitude was larger in macromastia.

CONCLUSION

Breast asymmetries were detected in the majority of women and the prevalence was similar across the different groups, however the magnitude was greater in hypertrophic breasts.

Why Choose the Septum-Supero-Medial (SSM)-Based Mammaplasty in Patients with Severe Breast Ptosis: An Anatomical Point of View

Nipple-areola complex (NAC) loss is one of the most devastating complications of mastopexy or breast reduction, and it requires revisional procedures with poor aesthetic outcome. In high-risk patients, a free nipple graft could be a choice, but it is associated with the same aesthetic concerns for both patients and surgeons. We report our experience with the septum-supero-medial-based mammaplasty to treat 22 patients with severe breast ptosis (nipple-to-sternal-notch distance > 40 cm). No NAC loss was observed. The study highlights surgical technical details and discusses anatomical considerations to justify the successful result. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Gestational Gigantomastia Complicated by PTHrP-Mediated Hypercalcemia

CONTEXT

Gestational gigantomastia is an uncommon condition characterized by abnormal and excessive growth of breast tissue during an otherwise uncomplicated pregnancy. Gestational gigantomastia may be accompanied by hypercalcemia, which in some cases has been associated with elevated serum levels of PTHrP. The source of the PTHrP in these cases has been suggested to be the enlarged breasts.

OBJECTIVE

To describe the rapid resolution of hypercalcemia and normalization of serum PTHrP after elective termination of pregnancy, indicating that the placenta was the source of the PTHrP.

DESIGN

A retrospective analysis of clinical and biochemical data over a 2-year interval and review of literature.

SETTING

An academic medical center.

PATIENT

A 33-year-old G8P4 female who presented at week 8 of pregnancy with gestational gigantomastia and subsequently developed marked hypercalcemia at week 13. Serum levels of PTH were suppressed but circulating PTHrP was elevated. There was no history of hypercalcemia or significant breast growth during previous pregnancies.

INTERVENTION

Hypercalcemia was poorly responsive to IV saline, prednisone, calcitonin, and cinacalcet. She requested termination of pregnancy at week 20.

RESULTS

Serum levels of calcium, PTH, and PTHrP normalized within 48 hours of termination of pregnancy.

CONCLUSION

The rapid resolution of hypercalcemia after termination of pregnancy, despite persistent gigantomastia, provides evidence for a pathologic role of the placenta in the excess production of PTHrP, possibly through an as yet uncharacterized placenta-breast hormonal axis.

[Fat grafting of the breast]

An increasing amount of evidence supports the benefits of fat grafting for breast augmentation, correction following breast-conserving surgery, breast reconstructions as well as correction of tuberous, hypoplastic and asymmetrical breasts. The aim of fat grafting is to create a breast with an aesthetic, natural appearance. In this review, we describe the most common indications for fat grafting of the breast and give an overview of the techniques in use as well as their associated risks and future perspectives.

Superomedial Pedicle Vertical Scar Breast Reduction: Objective and Subjective Assessment of Breast Symmetry and Aesthetics

BACKGROUND

The superomedial vertical scar breast reduction (SVBR) described by Hall-Findlay is gaining popularity among surgeons worldwide. The aim of this study was to evaluate its long-term aesthetic outcome, the extent of quality of life improvement and the factors that influence patient satisfaction and reviewers' evaluation of aesthetic/surgical outcome.

METHODS

In this historical prospective study, we included women who underwent SVBR at least one year prior to enrollment and responded to a quality of life questionnaire. Their breasts were photographed, measured and evaluated by the plastic surgery staff.

RESULTS

A total of 40 patients responded to the questionnaire, and the breasts of 31 of them were measured and photographed. All 31 patients had good breast symmetry according to objective breast measurements. There was a clear correlation between the patients' and the reviewers' scores of breast symmetry, scar appearance and breast shape (r = 0.4-0.65, r = 0.432-0.495 and r = 0.335-0.403, respectively). The factor that most influenced reviewers' and patients' satisfaction with the overall aesthetic outcome was the breast-to-body proportion.

CONCLUSIONS

The proportions between the breast size and the patient's body habitus are pivotal to patient satisfaction and should be taken into consideration when planning a reduction mammaplasty. The SVBR technique for breast reduction provided good cosmetic outcome and symmetry over a long-term follow-up.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Evolution of Breast Reduction Publications: A Bibliometric Analysis

OBJECTIVE

This study aims to make a bibliometric analysis of the studies on breast reduction (BR) between the years 1980 and 2016 and identify important studies through trend topics as well as active authors, countries, universities, scientific journals, and citation and co-citation analyses about BR.

BACKGROUND

Although BR looks like one of the cosmetic surgeries performed in order to restore the woman's appearance, in fact it is a reconstructive surgery that eliminates back pain, stance disorder, headache, shoulder pain, back and cervical disk hernia, difficulty in breathing, hollowness caused by bra straps, hygiene problems under breasts (e.g., rash or fungal infections), and limitations in some daily activities. However, the related literature has little information about the publications on this issue.

METHODS

Bibliometric analysis was performed by downloading all the documents published between 1980 and 2016 from Thomson Reuters Web of Science (WoS; Thomson Reuters, New York, NY, USA), using the keywords including "breast reduction", "gigantomastia", "reduction mammaplasty", and "reduction mammoplasty".

RESULTS

There was a total of 1427 publications in the WoS database. Of these publications, 869 (60.90%) were research articles. The top three research areas of these publications were surgery with 1178 (82.55%) publications, oncology with 78 (5.47%) publications, and obstetrics gynecology with 67 (4.70%) publications. The top three countries that contributed to the literature most were the USA (515), England (147), and Turkey (83), respectively; the top university that contributed most was Harvard University, and the top two authors who contributed most were Drew PJ and Iwuagwu OC (13; 0.91%). The top-cited publication was "A Simplified Vertical Reduction Mammaplasty: Shortening the Learning Curve" written by Hall-Findlay, EJ in 1999. The journals with top numbers of publications were Plastic and Reconstructive Surgery (483; 33.85%), Annals of Plastic Surgery (164; 11.50%) and Aesthetic Plastic Surgery (147; 10.30%) respectively.

CONCLUSION

Despite the fact that the BR literature is contributed by developed countries, developing countries, particularly Turkey and Brazil, also had significant contributions to the literature.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reductive Augmentation of the Breast

AIM

Although breast reduction surgery plays an invaluable role in the correction of macromastia, it almost always results in a breast lacking in upper pole fullness and/or roundness. We present a technique of breast reduction combined with augmentation termed "reductive augmentation" to solve this problem. The technique is also extremely useful for correcting breast asymmetry, as well as revising significant pseudoptosis in the patient who has previously undergone breast augmentation with or without mastopexy.

METHODS

An evolution of techniques has been used to create a breast with more upper pole fullness and anterior projection in those patients desiring a more round, higher-profile appearance. Reductive augmentation is a one-stage procedure in which a breast augmentation is immediately followed by a modified superomedial pedicle breast reduction. Often, the excision of breast tissue is greater than would normally be performed with breast reduction alone.

RESULTS

Thirty-five patients underwent reductive augmentation, of which 12 were primary surgeries and 23 were revisions. There was an average tissue removal of 255 and 227 g, respectively, per breast for the primary and revision groups. Six of the reductive augmentations were performed for gross asymmetry. Fourteen patients had a previous mastopexy, and 3 patients had a previous breast reduction. The average follow-up was 26 months.

CONCLUSIONS

Reductive augmentation is an effective one-stage method for achieving a more round-appearing breast with upper pole fullness both in primary breast reduction candidates and in revisionary breast surgery. This technique can also be applied to those patients with significant asymmetry.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Resolution Of Gestational Gigantomastia With Termination Of Pregnancy

Less than 100 cases of gestational gigantomastia have been described in literature. The aetiology and risk factors are not well-established. Various treatments have been used with some consensus. We present the case of a 47-year-old female who presented to us with bilateral gigantomastia in her 16th week of gestation. She had massively enlarged breasts which were very painful. Relevant laboratory investigations were normal. An incisional biopsy done prior to, and two trucut samples at presentation to us, showed normal breast tissue proliferation. In the absence of adequate pain control, it was decided to electively terminate the pregnancy and give a trial of tamoxifen. She made a rapid recovery following termination without requiring the use of tamoxifen.

Use of the BREAST-Q™ Survey in the Prospective Evaluation of Reduction Mammaplasty Outcomes

INTRODUCTION

BREAST-Q™ is a patient-reported outcomes survey instrument with a specific module that evaluates breast reduction surgery. It allows assessment of patient's satisfaction with received treatment and evaluates the impact of surgery on different aspects of the patient's quality of life. This article aims to assess the satisfaction and quality of life of patients who underwent reduction mammaplasty.

MATERIALS AND METHODS

Women aged between 18 and 60 years, with a body mass index ranging from 19 to 30 kg/m², who were already scheduled for reduction mammaplasty, were included in the study. The Brazilian version of the BREAST-Q™ Reduction/Mastopexy Module (preoperative 1.0 and postoperative 1.0 versions) was self-applied preoperatively and 1 and 6 months after the operation.

RESULTS

One hundred and seven patients were included in the study and completed the 6-month follow-up. The median age was 33 years, and the median preoperative body mass index was 25 kg/m². The superomedial pedicle was used in 96.3% of the cases, and the total median weight of the resected breast was 1115 g. There was a significant improvement in the scores of the scales: Psychosocial well-being, Sexual well-being, Physical well-being, and Satisfaction with the breasts compared to the preoperative assessment (p < 0.0001). The scales Satisfaction with the NAC and Satisfaction with the outcome, available only in the postoperative version, demonstrated high satisfaction rates at the two postoperative periods evaluated.

CONCLUSION

Reduction mammaplasty improved the quality of life and provided high levels of patient satisfaction with outcomes 1 and 6 months postoperatively.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Gestational gigantomastia with spontaneous resolution in an Indian woman

We present the case of a 20-year-old woman, primigravida with 24 weeks of amenorrhoea due to pregnancy. She came with symptoms of rapidly increasing size of both the breasts since 8 weeks. On examination, both breasts were grossly enlarged, right more than left, with the level of the nipples reaching beyond the level of the umbilicus. Breast circumference was measured to be 72 cm on the right, and left breast was 66 cm. No palpable lumps in both breasts. No axillary lymphadenopathy noted. Hormonal studies were found to be within the normal range. The pregnancy was terminated due to pre-eclampsia. The patient opted for regular follow-up and observation. While regularly following up, the size of both breasts was observed to gradually reduce to a circumference of 40 cm on the right and 30 cm on the left.

Treatment of Gigantomastia Using a Medial-Lateral Bipedicle Reduction Mammoplasty: The Role of Doppler-Assisted Preoperative Perforator Identification

The purpose of this study is to introduce a breast reduction technique designed to reduce the incidence of postoperative nipple-areola complex ischemia and necrosis following reduction mammoplasty, while at the same time allowing all the other goals of breast reduction to be realized. This is achieved through preoperative detection of perforating vessels supplying the nipple-areola complex using a hand-held Doppler. The horizontally based parenchymal pedicle is designed to include these perforators whether originating from the internal mammary artery, lateral thoracic artery or both. This technique provides freedom in pedicle shaping and fixation to the pectoral fascia to achieve the best breast contour. The study included 50 patients equally divided into two groups: the study group (using preoperative Doppler for detection of perforators) and control group (without preoperative Doppler). The average body mass index of our patients was 32.4 and 29.8 for study and control groups, respectively. The average suprasternal notch to nipple distance was 40.8 cm in the study group and 38.9 cm in the control group. In all cases of the study group, both medial and lateral pedicles were used each of them containing one perforator. The average resection weight per side was 1433.6 g for the study group and 1173.2 g for the control group. None of the study group cases experienced NAC necrosis, while four cases of the control group experienced NAC necrosis (3 partial and 1 total). The horizontally based parenchymal pedicle constructed with the aid of preoperative perforator identification with a Doppler is an effective technique for breast reduction that results in a very low rate of postoperative ischemia and necrosis of the nipple-areola complex. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .