And having made those incisions now, we'll go ahead and deepithelialize our inferior pedicle. So now, there's our inferior pedicle. And now to prepare for the purse string suture, what we'll do is we'll just gently peel back a small bit of dermis, like this, all the way around the periurelar defect. And this will allow us to create a small dermal shelf that will be quite helpful when it comes to placing our purse string suture. And so this is carried all the way around the opening with just a little scraping maneuver here. It's very easy to peel back that epidermis and a part of the dermis, leaving behind a dermal shelf that we'll use to help hold the suture. Once that's all done, now we're ready to start to create our flaps. And so now, we'll begin the dissection by making our incision here, right through the dermal shelf like this, leaving behind a small little shelf of dermis. And this is what's going to hold our Gore-Tex stitch, or our Teflon suture, polytetrafluoroethylene. Gore-Tex doesn't really make that anymore for plastic surgeons, but it is available by a company called Surgiform. And I'll show you the package when we get to that point. But the bottom line is it's a polytetrafluoroethylene, or a Teflon suture. And it really is the best suture to perform this maneuver with because, as you'll see, there'll be a fairly vigorous shelf of tissue that this suture has to slide through. And normal sutures like proline or nylon just don't do it well. But the Teflon, because of its unique handling features, being very smooth, very supple, slides through the opening really without much trouble. So there's our dermal shelf right there. We just carry this down to the limits of our inferior pedicle, and now we just bring this around the top like this. And this actually will define, then, the size of our pedicle and start to determine how much tissue we're actually going to remove as part of our breast reduction. So once that's done, the tourniquet's taken off, and now we're ready to start to create our flaps. Now, the flap creation is really a key part of this operation, and it's begun by first making a small incision just under the dermis. And the strategy behind this relates to the end of the operation, because we're going to want to be able to pull this edge in. And so this can't be very bulky at all. It's got to be quite thin so that it can wrap around our inferior pedicle. So the flap dissection initially is fairly thin. And then, as we dissect more deeply into the breast, the dissection will become thicker so that we can actually begin to shape the breast with the way that we create our flaps. So there's our initial incision, which I think has worked out very well. And now we'll begin the dissection of our flaps proper. So this is done by just dissecting through the fat of the breast, with the idea being that as we get down into the breast, this will become thicker as we go. There's a fairly large second intercostal perforator right in this area that's nice to get control of ahead of time. I'm just getting the sense it's right in there. So as we dissect down here, I typically will go medially first, and then we'll work our way all the way around. So the strategy here is to try to do this as smoothly as possible. You'd like to have smooth flaps without any angular edges or areas of over-dissection. So we want to have a smooth receptacle, as it were, for our inferior pedicle to fit into. So this has begun all the way around like this. And basically, we just carry this idea right down to the chest wall. Now, one of the strategies that I typically use as I'm dissecting is notice that my assistant is not helping me in any way. And that's by design, because as your assistants pull and retract, they distort the breast. So you can see I can visualize what these flaps look like just by letting go and seeing how the tissue stands up. And that's a real advantage when it comes to shaping the breast, because it does have a less-than-firm substance to it, and it's very easy to create a divot or a scallop when you didn't really intend to heavy clamp. So it's best to do this by yourself so that you can see how the tissues lay as a result of your dissection. So now here, just a little bit of help like this will allow me to see this lateral flap. So we use the same strategy dissecting medially and superiorly. In other words, we go fairly thin at first, and then we get thicker as we get down to the chest wall. You can see I'm communicating here this superior dissection. With our medial dissection, like this. And now we've got that carried right down to the chest wall, right there, like that. So there's our medial flap. Thin at first, and then thicker near the chest wall. Superiorly, thin at first, thicker near the chest wall. Laterally, we need to carry this pretty much right at the level of the breast fascia. And this has been a dissection plane which has been demonstrated by experience, because if you keep your lateral flap too thick, you'll end up with a boxy, square breast. So basically, we want to try to find the fascia of the breast here laterally, and then use that as our dissection plane down to our preoperative mark, which is right here. And then, with this being a little bit thinner than the rest of the flaps, we want to make a smooth transition between the superior flap here and our thinner lateral flap. And you can see how that releases very nicely. And so we're basically down to the chest wall there. So now we've got our medial flap, our superior flap, and now we just want to develop our lateral flap. And where we're heading now is all the way down into the corner of our pocket, like this. So we want to get all the way down into there. And that's fairly easily done by working from above down, meaning above down, to get that properly dissected. Now, as I dissect this, I'm using visual cues to identify the breast fascia, but I'm also assessing it with my fingers as I go, to be certain that it's proper thickness. And as I'm working my way down into that corner, we'd like to fall short of the chest wall as we dissect this down, so that we preserve the innervation, any nerve branches which are coming up into the pedicle. But we're almost down to our corner there, like this. Like so. And the idea is that we're going to get this released, but not violate the inframammary fold. See, so we're above the fold there. So we're pretty much down into that corner right there. And so that is basically our pedicle development, from medial to superior to lateral. And so what this basically accomplishes now is a delivery of the breast from within the confines of the flaps. And having done that, we're ready to skeletonize our pedicle. And the idea behind skeletonizing the pedicle is just to basically come all the way around the pedicle like this to remove this redundant tissue. As we do this, one of the structures that we'll want to preserve is the internal breast septum. And we'll identify the septum as we dissect down into the breast. So we want to smoothly skeletonize this tissue away from the inferior pedicle, all the way around like this, heading down into the corner a little bit to be certain that the breast is properly reduced. No matter what technique you're using, no matter what technique you're utilizing, I think that novice surgeons, when they first begin to utilize short scar techniques, tend to under-reduce the breast just a bit out of concern for the blood supply to the pedicle and basic concerns over the skin pattern. So we're going to make an effort to be certain that we get all the way through this redundant tissue. And again, make an effort to get down into the corner here. And here's where your assistant can help you. So that you can accurately see what you're debriding away. Let's just kind of take a peek and see what we've got going there. Now here, notice that I angled superiorly just a little bit. We'd like to avoid inadvertently undermining the pedicle, if at all possible. And that's how we'll preserve the breast septum. The other thing to note, again, as we discussed when we started, not a tremendous amount of bleeding associated with this. We're making every effort to be as fastidious with our hemostasis as we can be. Okay, so now there's our specimen. Okay, so now there's our specimen. And very typically, it's a little bit longer laterally than it is medially. It tends to come out as a wedge, like this. So now the idea is that we've created a space for our inferior pedicle to sit in, like so. And that's how we'll elevate the breast. And now we'll just apply our vertical segment, like so. And that should accomplish our breast reduction for us.

breast reduction

inferior pedicle

purse string suture

flap creation

Teflon sutures