And so now we'll de-epithelialize the remainder of our inferior pedicle and typically I'll start this down at the level of the fold as this is where the dermis tends to be the thinnest and where it's the easiest to buttonhole all the way through into the fat. And the reason that I prefer not to do that if possible is that the blood supply to this pedicle is coming from two major sources in my view. One is the subdermal plexus that we're trying to preserve here and then the second comes from the perforators which we identified in the breast septum. Go ahead and set that aside. So now you can see that dermis, nicely vascularized. And so what we'd like to do at this point is now deal with the redundancy on either side. So immediately, we'll go ahead and remove this small little wedge of tissue, like this. And this is where you can begin to do some trimming if you care to try to make the breast just a bit smaller. You can easily get another 50 to 100 grams of tissue with what we're about to do as far as trimming this redundant tissue away. And it can help you avoid that situation where, particularly when you're first using short scar techniques, there can be a reluctance to adequately debride the breast. And now we'll come and we'll deal with this lateral aspect, like this. And this is where we'll tend to really make an impact upon the extra tissue that needs to be removed. We'll take that right through there like that. And just carry that right through the dermis, right through the corner of our pedicle. And we'll just debride this away. Now this is going to be the lateral aspect of our inferior pedicle. And again, down here in the inframammary fold area, don't go straight down. Try to preserve that scarpia fascia attachment to the breast right in that area. And now as we come up laterally here, we'll try to be certain that we debride this adequately. Like that. And now here's this corner that we were talking about right here. And it sometimes can be very useful to clean this corner out here and just sculpt in this shape along the corner of the breast. And so now as that lays in there, we won't have quite so much bulk like so. And so now as we assess our flaps, it feels the proper thickness. Now as we finally get ready to put the breast together, there's our inferior pedicle with our attachments here to the septum and the septal perforators coming up. Here's our pectoralis major, and here's the extent of our dissection. So now as this comes together, we should be able to create a very pleasing shape to our breast. Now the decision with regards to a drain. I have that bovie. For a minimal dissection like this, I think today we'll avoid the use of a drain. For the larger reductions, 800-gram reductions or 1,000-gram reductions, the space can be a little bit more significant, and it certainly makes sense to drain someone like that. But I think routinely we tend to try to avoid drains if at all possible. So with that in mind, we'll go ahead and we'll put this back together now. And we'll do that by bringing together our pattern. And now we'll put the orientation marks together. So this is where you can see the numbering system helps bring all this together. Now as we come down to the apex of the vertical, we want to try to put that together one-to-one right there. And then where we take up the dog ear is basically right there. So now as we put this together, we're starting to see the final shape of the breast like this. And so now what we'll do is we'll close this, and we'll deal with our periureal defect here like this. In my practice, the spare mammoplasty is probably one of the happiest procedures that I perform because the patients present with a problem, we fix the problem, they heal, and they continue on with their life better off than when they started. Having said that, there are certain complications that do develop. Perhaps the most common one is a minor type of complication where the wound simply separates. and has to heal secondarily over time. That's easily managed. As well, a certain number of patients will present with small areas of dead fat afterwards which are buried under the flaps. This will present as a lump which, of course, needs to be removed so that it doesn't hinder screening for a subject with cancer as a patient ages. Perhaps the most troubling complications relate to internal skin damage. Perhaps the most troubling complications relate to internal scarring of the breast. When the breast flaps are sutured superiorly, sometimes a space can be created inside the breast which can fill with fluid, and as that fluid absorbs, it can create almost a puckered-like appearance to the breast, which can require a reoperation to release the scar to restore a normal shape. That appears to be a complication unique to the spare mammoplasty, and while it's easily managed, it does require another trip to the OR to address.

breast reduction

de-epithelializing

blood supply

surgical techniques

complications