Chapter 72

Free Nipple Areolar Graft Reduction Mammaplasty

Anthony Erian, Amal Dass

72.1
Introduction
Free nipple graft reduction mammaplasty describes a
breast reduction technique in which the nippleareolar
complex (NAC) is transposed as a free graft to ensure its
viability and to minimize complications. With advances
in surgical techniques coupled with a better understanding of the vascular anatomy of the breast and the
NAC, the limits at which free nipple grafting is preferred
over transposition on a pedicle have been pushed further and further. However, it is still an operation that
many surgeons turn to when faced with uncertainty
over the viability of the NAC.

72.2
History
Breast reduction techniques had been described as early
as the late nineteenth century, and Morestins [1] report
on transposing the nipple at the turn of the century. The
concept of maintaining the nipple on a dermoglandular
pedicle, as suggested by Strombeck in 1960 [2], revolutionized breast reduction surgery and still forms the
basis of all subsequent improvements and modications of the technique to this day. It was Thorek [3],
however, who popularized free nipple grafting in 1922.
Thorek combined the free nipple graft with lower pole
amputation and his technique continues to this day
albeit with a Wise pattern modication.

72.3
Indications
Size and Haste would aptly describe the most common indications for the free nipple graft reduction
mammaplasty. Gigantomastia, described as a breast that
requires resections in excess of 1,800 g per side, and the
high risk in surgical patients [4], e.g., the elderly and
those with medical comorbidities which limit the time
that can be spent safely under general anesthesia, are the

most common reasons for considering a free nipple

graft reduction mammaplasty.
There are other indications for nipple areolar transplant in breast reduction (Table 72.1). Free nipple grafts
are indicated if the NAC looks underperfused on a pedicle. This can be conrmed intraoperatively by intravenous (IV) administration of 2 g of uorescein followed
by examination under a Woods lamp 15 min later. A
yellowgreen uorescence of the NAC conrms an adequate blood supply, whereas a dark blue appearance
indicates inadequate perfusion [4].
However, most surgeons would simply assess the
nipple viability clinically. If there is no tension due to
closure or constriction at the base of the pedicle and no
hematoma or hypotension, the NAC should be removed
from the pedicle and sited as a free nipple graft.
Avascular scar tissue from prior breast surgery may
compromise the formation of a vascular pedicle. If this
is the case, it may be prudent to consider free nipple
grafting at the outset.
Male patients with severe gynecomastia may require
a subtotal mastectomy which precludes keeping the NAC
on an adequate dermoglandular pedicle, while the
significant skin excision required in male patients
following massive weight loss may mandate free nipple
grafting for the best results [5]. Gender reassignment
surgery to the breast involves breast amputation with
free nipple grafting. The areola also has to be harvested
and reduced to approximate the smaller male areola.

72.4
Vascular Anatomy of the Breast
The blood supply to the breast comes from six main
sources: the internal thoracic artery, the highest thoracic
artery, the anterior and posterior branches of the intercostal arteries, the thoracoacromial artery, the supercial
thoracic artery, and the lateral thoracic artery. Of these,
the internal thoracic vessels provide approximately 60%
of the blood supply, with the lateral thoracic vessels providing approximately 30%. The tributaries of these two
vessels form a rich anastomotic network around the
NAC [4]. The arterial anatomy of the NAC is complex as

M.A. Shiman (ed.), Mastopexy and Breast Reduction: Principles and Practice,
Springer-Verlag Berlin Heidelberg 2009

72

556

72 Free Nipple Areolar Graft Reduction Mammaplasty

Table 72.1 Indications for nipple areolar transplant in breast
reduction

1. Gigantomastia
2. High-risk surgical candidates
3. Threatened NAC viability intraoperatively
4. Patients with previous operative scars
5. Patients with severe gynecomastia
6. Male patients after massive weight loss, resulting in
severely redundant and inelastic skin

pedicle reduction techniques as well as the fact that the

most reliable pedicles are thicker and fashioned with a
wider base without releasing their attachment to the
pectoralis fascia.
Cadaveric anatomic studies do not take into account,
however, the ow rate within these vessels in vivo and
cannot be relied on solely for formulating an operative
approach. However, an intimate knowledge of the vascular anatomy of the breast and its NAC can aid in
ensuring nipple viability and a better aesthetic result
whether it be a nipple transposition on a pedicle or a
free nipple graft.

7. Female to male gender reassignment

72.5
Preoperative Markings
a result of the contributions from six dierent sources.
Various sources have identied the internal thoracic and
the lateral thoracic arteries as the main blood supply
routes to the NAC [6]. The reliability of the internal thoracic artery [7] as the sole blood supply route to the NAC
has also been reported, as has the reliability of a lateral
thoracic arterybearing pedicle [8, 9].
The arterial supply around the NAC has recently
been described as split into a supercial and deep anastomotic network [10]. The supercial system comprises
tributaries of the internal thoracic, the highest thoracic
and the supercial thoracic arteries, whereas the deep
system is formed by the anastomoses of the lateral thoracic artery, the anterior and posterior branches of the
intercostals arteries, and the thoracoacromial artery.
This may seem to suggest that the medial and lateral
pedicles are the most reliable. However, the blood supply of the NAC described above fails to describe the
importance of the perforators of the anterior branches
of the intercostals arteries and the highest thoracic
artery from the rst to the fth intercostals spaces [10].
Indeed, the perforators of the fourth and fth intercostals vessels inferior to the NAC are remarkably consistent and of similar caliber to the internal thoracic and
lateral thoracic vessels [11, 12].
Pedicle thickness and adherence to the pectoralis
major muscle are also clearly important to the viability
of the NAC. This may reect on contributions from the
perforators of the pectoralis major, which has been
implicated in blood supply to the NAC. A thicker pedicle ensures that the vessels are enclosed safely within,
thereby ensuring their viability while enhancing the
reliability of the pedicle. An inferior pedicle with a base
width of 810 cm is thought to ensure adequate perfusion for a pedicle of up to 21 cm in length [4].
While it has not been conrmed, as has been suggested, that the integrity of the NAC rests solely with the
perforators rather than the subdermal plexi, there is little doubt that the perforators play an important role in
NAC viability as evidenced by the success of the inferior

The inferior pedicle reduction technique is most often

used with free nipple grafts followed by the superior
pedicle technique [13]. Other pedicles such as the superolateral and medial pedicles have also been employed.
All these reductions employ standard Wise pattern
markings to fashion the skin envelope over the underlying reduced breast parenchyma.
The placement of the nipple is the most vital step in
preoperative planning. A superiorly displaced nipple is
aesthetically unpleasant and may even peek out over the
bra, causing distress to the patient. Moreover, correction
of a high nipple is virtually impossible.
The breast meridian lines are drawn and the inframammary fold is transposed to the front of the breast
either using calipers or the surgeons nger within the
fold. The sternal notch-to-nipple distance varies between
21 and 25 cm and should be tailored to the patients size
and reduction. This should roughly correspond to the
inframammary fold. The nipple position is placed
12 cm below the measured nipple position along the
meridian. This is to accommodate the spring back or
McKissock eect when the weight of the breast tissue is
removed and to prevent the nipple from pointing
upwards secondary to lower pole fullness.
The position of the nipple can also be checked against
the mid-point of the humerus 23 cm as well as the
internipple distance which should approximate the
sternal notch-to-nipple distance.
Gradinger [14] has suggested another method of
identifying the transposed nipple position (Fig. 72.1). A
line is drawn from the superior point of the anterior
axillary fold to the xyphoid sternum. This is to approximate the superior rim of a normal tting brassiere. The
superior rim of the areola should be 3 cm below this line
along the meridian.
Gradinger also drapes a weighted tailors tape measure around the neck and over the patients chest, disregarding whether it falls medial or lateral to the nipple. A
second tape is placed horizontally across the breast at

72.7 Complications

measure is to describe the true meridian to locate the

nipple and to plan the operation around it rather than
use the nipples of a massively hypertrophied breast to
ascertain this.
The Wise pattern keyhole is then placed over the new
nipple position and the template traced dening the
vertical limbs. The vertical limbs vary between 5 and
9 cm with 77.5 cm being the most commonly used
lengths. This describes the nipple-to-inframammary
fold distance, which denes the lower pole of the new
breast. A lazy S shaped incision is drawn from the lateral vertical limb to where the breast mound seems to
end laterally. The process is repeated medially.
Women with gigantomastia frequently have excessively large areolas. The NAC is marked with a template
prior to harvesting the free nipple graft. This usually
varies from 4.2 to 4.7 cm in diameter and is chosen
according to the planned reduction size.

Fig. 72.1 Identifying the transposed nipple position. Adapted

from [33]

72.6
Operative Technique: Free Nipple Grafting
The NAC is removed as a full thickness unit and thinned
with a pair of scissors taking care to preserve the smooth
muscle of the nipple and the dermis of the nipple and
areola, as this is thought to more likely provide good
postoperative projection and perhaps even erectility. It
is then stored in a sponge moistened with saline.
The new nippleareolar site is de-epithelialized. The
breast reduction is then carried out according to the preoperative markings to fashion the skin envelope and the
breast parenchyma reduced around the pedicle chosen.
The graft is positioned onto the recipient site with
interrupted sutures and sutured into place with a running suture peripherally. A tie-over bolster dressing made
up of Xerofoam gauze and mineral oilmoistened cotton
is secured over the graft and left in place for 710 days.

72.7
Complications

Fig. 72.2 The intersection of the two tapes is transposed onto the
breast and describes the superior margin of the areola

the level of the inframammary fold. The intersection of

the two tapes is transposed onto the breast and describes
the superior margin of the areola (Fig. 72.2). This should
correspond to a point within 12 cm of that described
by the prior technique. The point of the weighted tape

Any form of breast reduction involves signicant scarring which the patient must be made fully aware of. Any
hesitation on the part of the patient regarding this or
any of the other complication must result in postponement or cancellation of surgery until reassessment at a
later date.
Criticism of the free nipple graft technique has frequently been directed at the seemingly greater postoperative loss of sensation in the NAC when compared to
maintaining the NAC on a pedicle. While this may seem
a reasonable conclusion, given that the NAC is severed
from its vascular and nerve attachments as a free graft,
recent reports contradict these earlier ndings [1517].

557

558

72 Free Nipple Areolar Graft Reduction Mammaplasty

Studies have shown that even patients with free nipple

grafts have a reasonable recovery in sensation, with
erectile function persisting in most patients [1820].
The recovery of sensation in the free nipple graft is
likely multifactorial. Breast surgery by necessity divides
some intercostal nerve bers decreasing the sensation.
Postoperative nipple sensibility has been shown to be
inversely proportional to the amount of breast tissue
resected [21]. Patients requiring free nipple graft reduction mammaplasty also tend to be older, which would
also likely impair recovery in sensation [18].
Reinnervation from the intercostals and supraclavicular nerves probably explains why a large proportion of
individuals regain some form of sensation after a free
nipple graft [22, 23]. It has also been suggested that
patients with gigantomastia have a chronic traction
injury to the fourth intercostal nerve, relief of which
contributes to improvement in sensation [24]. It is also
noteworthy that the lack of sensation seems to bother
the surgeon more than the patient.
Good recovery rates in erectile function of the nipple
have also been demonstrated, which contradicts earlier
conclusions by some authors that it was impossible to
maintain erectile function in a free nipple graft. This
could well be due to retaining a good amount of areolar
smooth muscle when fashioning the graft [18, 20].
Nipple necrosis can occur with a free nipple graft,
although partial loss is more common. This can be due
to lack of vascularity of the parenchymal pedicle or
improper harvesting and fashioning of the graft, or due
to medical illnesses that limit vascularity as a whole.
Partial nipple loss should be allowed to heal secondarily,
with the patient warned about depigmentation. Nipple
reconstruction should be planned for full nipple loss
after allowing it to heal.
Hypopigmentation of the nipple is an unsightly complication which can occur even with good graft uptake.
It has been well described in the literature [25] and
seems more common in the darker areolas of patients
of African origin. Tattooing of the hypopigmented
patches is frequently unsatisfactory because of the dullgray appearance it often takes despite the best eorts.
The patient must be made aware of this and be accepting of the possibility of this complication.
Lactation is obviously compromised in a free nipple
graft, as the lactiferous ducts are severed. The younger
patient in whom the free nipple graft is indicated must
accept this or have her surgery delayed till after
childbearing.
All the other complications of breast surgery can also
be encountered with a free nipple graft. These include
hematomas, seromas, infections, skin necrosis, fat
necrosis, and other wound complications. Complications
seen in any other type of breast reduction can obviously
also occur, such as breast asymmetry, over- or underresection, a high-riding nipple or bottoming out,

hypertrophic scarring, widening of scars at the

T-junction, nipple numbness, and skin or nipple loss.

72.8
Aesthetic Considerations
The best breast reductions are performed with three
main considerations:
1. Pedicle design and position
2. Area of resection
3. Redraping or skin envelope design [26]
Creating an aesthetically shaped breast in a patient with
a signicant reduction has been one of the great surgical
challenges in breast reduction surgery. Poor long-term
projection is a very common complaint encountered by
the surgeon [13].
Suction lipectomy has also been employed around
the breast mound to enhance the appearance of the
breast. Candidates for large reductions frequently tend
to be overweight, and reducing the fat folds in the axilla
and medial and lateral ends of the chest wall enhances
the results of the surgery.
Inferior pedicle reduction mammaplasty with free
nipple graft remains the technique most used by
surgeons today. However, detractors of the technique
cite the problem of bottoming out, in which the lower
pole of the reduced breast descends gradually stretching the skin of the lower pole, causing the nipple to ride
up and point upwards. Bottoming out is thought to
occur at a rate of 0.44 mm a year on average and needs
to be considered in the preoperative planning and when
fashioning and xing the inferior pedicle. Some surgeons prefer to amputate the lower pole and fashion the
breast mound over superior or medial pedicle aps to
avoid this phenomenon. Others cite [27] vascular insufciency of the lower pole to justify its amputation and
the use of an alternative pedicle to the inferior one.
However, the sheer number of surgeons who still
prefer and employ this method, some 74% of surgeons
in one survey [13], suggests that the inferior pedicle
technique oers consistent results which are reproducible with acceptable risks.
There have been many suggestions, most of which
are based on modications of the inferior pedicle technique, to improve the shape and projection of the breast.
Most solutions to this problem have centered around
retaining a dermoparenchymal ap, which can be
shaped to approximate the breast mound. Traction on
the lateral ap provides most of the coverage of the
resultant defect. This allows attening of the lateral pole
and diminishes the need for the medial ap to be pulled
excessively. Pulling the medial ap laterally in excess
results in a breast that lacks the medial fullness of an
unoperated breast.

72.8 Aesthetic Considerations

Koger et al. [28] suggested preserving an inferior

dermoparenchymal ap with a tapering, oblique excision of the glandular tissue to the muscle fascia to
enhance the breast mound. In fashioning the ap, it is
important to realize that in very large breasts frequently
more than 90% of breast parenchyma is below the inframammary fold. Therefore aps must be designed that
can move cephalad and t under skin envelope [29].
Other surgeons have suggested staircasing the incision and retaining glandular tissue along the excision
line to help provide breast tissue for projection [30], as
well as a keel-shaped excision of the keyhole to prevent
excess attening [31].
Vertical pedicle aps are being increasingly used to
shape the breast and to increase projection. A superolateral dermoparenchymal ap has been employed by
Strauch et al. [25], in which the ap is rotated upwards
after fashioning it to create a periwinkle eect by circular rotation [25] to increase projection from chest
wall and create a more rounded contour (Fig. 72.3).
Hidalgo et al. [13] have suggested leaving de-epithelialized breast tissue below the 7-cm vertical limb to
fold inwards to increase projection and then to bring in
lateral and medial pillars to do the same.
Abramson [29] de-epithelializes the superior pedicle
between the two vertical limbs of the Wise template while
also maintaining an inferior dermal pedicle extending
halfway between the inframammary fold and nipple. The
lower ap is sutured to the pectoralis fascia and the superior ap is the folded over it while bringing in the lateral
and medial aps together (Fig. 72.4).
Ozerdem et al. [32] have also used a similar technique and suggested preserving the area between the
vertical limbs of the Wise pattern even in a nonfree
nipple graft reduction so that both superior and inferior

dermoparenchymal aps can be fashioned if the viability of the NAC is called into question.
Casas et al. [33] have suggested suturing the lateral
and medial pillars of a superior parenchymal ap
together to increase projection in a throwback to the
Lejour technique of vertical mammaplasty where the
medial and lateral pillars are sewn together. They also
suggest intentionally creating a dog ear under the nipple to increase projection. However, projection and
erectility are more likely a function of maintaining the
areolar smooth muscle in the grafted NAC.
Breast amputation with the horizontal scar modied
to include a backfolded dermoglandular superior pedicle
ap with a free nipple graft after amputation of the lower
pole has also been described [34]. Despite the added
burden of de-epithelialization of the ap, the authors specically cite the ease and speed of the operation (average
81 min operating time) in advocating this method.
The medial pedicle has also been used albeit less
commonly, citing preservation of blood supply from the
internal thoracic vessels and innervation to NAC as the
advantages of this ap [35].
However, the choice of operative technique is ultimately dependent on the training and familiarity of the
surgeon with it. No one technique has been shown to be
markedly superior to another. As surgeons are attempting
larger and larger reductions without a free nipple graft, it
must always be remembered that a good number of candidates for a free nipple graft reduction mammaplasty are
chosen to reduce the time spent intraoperatively. It is
important not to compromise this by increasing the
operative time spent by harvesting and de-epithelializing
aps. Aesthetics, while very important, should come only
secondary to safety and symptom relief which are
paramount.

Fig. 72.3 (a-c) The ap is rotated upwards

after fashioning it to create a periwinkle
eect by circular rotation [25] to increase
projection from chest wall and create a
more rounded contour. Adapted from [25]

559

560

72 Free Nipple Areolar Graft Reduction Mammaplasty

Fig. 72.4 (a,b) The superior pedicle between the two vertical
limbs of the Wise template is de-epithelialized while also
maintaining an inferior dermal pedicle extending halfway
between the inframammary fold and nipple. The lower ap is
sutured to the pectoralis fascia, and the superior ap is the
folded over it while bringing in the lateral and medial aps
together. Adapted from [29]

72.9
Current Controversies with Free Nipple
Graft Reduction Mammaplasty
The decision to perform a free nipple graft rests not on
a set of rules but rather on arbitrary guidelines based on
experience and largely anectodal evidence. Limits for
inferior pedicle reductions have been based both on
reduction weights and other measurements.
The issue, of course, has been the viability of the
pedicle; however, advances in the understanding of the
vascular anatomy of the NAC and technical advances
have challenged the limits set by the earlier experiences
of surgeons.
Wise et al. [36] in a report detailing their experience
with reduction mammaplasties in 1963 have recommended free nipple grafting in all reductions of more
than three bra sizes. This then increased from 1,000 g
(Gradinger [14]) to 1,500 g (Robbins [37], Jackson et al.
[38]) to 2,500 g (Georgiade [39]). Georgiade has subsequently reported success without free nipple grafting in
reductions of up to 3,300 g, while Chang et al. [40] have
successfully transposed reductions of up to 5,100 g with
a very low NAC necrosis rate of 1.2% over a 7-year
period.
Pedicle length is a very common consideration in
considering grafting over transposition of the nipple.

Common concerns are viability of the blood supply to

the NAC and pedicle, folding and kinking of the pedicle,
as well as excess tissue beneath and over the pedicle
which can compromise it.
As with decisions based on the weight of the reduction, the recommended inferior pedicle length over
which free nipple grafting should be considered has also
increased over time from 15 to 25 cm [26]. This has been
attributed to better handling of the pedicle, creating a
pedicle with a wider base, and retaining the attachment
of the base of the pedicle to the chest wall so as not to
interrupt blood supply from the perforators.
Other authors cite the importance of the suprasternal notch (SSN)-to-nipple distance as most important
in recommending free nipple grafting for distances
exceeding 40 cm [25]. There has even been a suggestion
that since the inframammary fold-to-nipple distance,
which determines pedicle length, remains relatively
constant when compared to the increasing SSN-tonipple distance in progressively larger breasts, the inferior pedicle technique with transposition of the NAC
on the pedicle should be applicable to all breast reductions regardless of size, rendering free nipple grafting
obsolete [38].

72.10
Conclusions
There is little doubt that free nipple grafting maintains
its place as a therapeutic option especially when patient
tness limits the operating time and when the NAC
viability is called into question.

References
1.
2.

3.
4.

5.

6.

Morestin H: Hypertorphie mammaire. Bull Mem Soc Anat

Paris 1905;80:682
Strombeck JO: Mammaplasty: report of a new technique
based on the two pedicle procedure. Br J Plast Surg
1960;13:7990
Thorek M: Possibilities in the reconstruction of the human
form. N Y Med J 1922;116:572
Jones GE: Breast Reduction. In: Mathes SJ (ed), Plastic
Surgery, 2nd edn. Philadelphia, Saunders Elsevier 2005, pp
539584
Tashkandi M, Al-Qattan MM, Hassanain JM, Hawary MB,
Sultan M: The surgical management of high-grade gynecomastia. Ann Plast Surg 2004;53(1):1720; discussion 21
Nakajima H, Imanishi N, Aiso S: Arterial anatomy of the
nipple-areola complex. Plast Reconstr Surg 1995;96(4):
843845

References
7.

8.

9.
10.

11.
12.

13.

14.
15.

16.
17.
18.

19.
20.

21.

22.

23.
24.

van Deventer PV: The blood supply to the nipple-areola

complex of the human mammary gland. Aesthetic Plast
Surg 2004;28(6):393390
Blondeel PN, Hamdi M, Van de Sijpe KA, Van Landuyt
KH, Thiessen FE, Monstrey SJ: The latero-central glandular pedicle technique for breast reduction. Br J Plast Surg
2003;56(4):348359
Marcus GH: Untersuchung uber die arterielle Blutversorgung
der Mamilla. Arch F Klin Chir 1934;179:361
ODey D, Prescher A, Pallua N: Vascular reliability of nipple-areola complex-bearing pedicles: an anatomical
microdissection study. Plast Reconstr Surg 2007;119(4):
11671177
Manchot C: The Cutaneous Arteries of the Human Body.
Berlin, Springer 1983
Cordu N, Taylor GI: Subglandular breast reduction: The
evolution of a minimal scar approach to breast reduction.
Plast Reconstr Surg 2004;113(1):175184
Hidalgo DA, Elliot LF, Palumbo S, Casas L, Hammond D:
Current trends in breast reduction. Plast Reconstr Surg
1999;104(3):806815
Gradinger GP: Reduction mammoplasty utilizing nippleareola transplantation. Clin Plast Surg 1988;15(4):641654
Hoopes JE, Jabaley ME: Reduction mammaplasty: amputation and augmentation. Plast Reconstr Surg 1969;44(5):
441446
Craig RD, Sykes PA: Nipple sensitivity following reduction
mammaplasty. Br J Plast Surg 1970;23(2):165172
Courtiss EH, Goldwyn RM: Breast sensation before and
after plastic surgery. Plast Reconstr Surg 1976;58(1):113
Townsend PL: Nipple sensation following breast reduction and free nipple transplantation. Br J Plast Surg
1974;27(4):308310
OConor CM: Glandular excision with immediate mammary reconstruction. Plast Reconstr Surg 1964;33:5760
Ahmed OA, Kolhe PS: Comparison of nipple and areolar
sensation after breast reduction by free nipple graft and
inferior pedicle techniques. Br J Plast Surg 2000;53(2):
126129
Gonzalez F, Brown FE, Gold ME, Walton RL, Shafer B:
Preoperative and postoperative nipple-areola sensibility in
patients undergoing reduction mammaplasty, Plast
Reconstr Surg 1993;92(5):809814
Sarhadi NS, Shaw Dunn J, Lee FD, Soutar DS: An anatomical study of the nerve supply of the breast, including the
nipple and areola. Br J Plast Surg 1996;49(3):156164
Farina MA, Newby BG, Alani HM: Innervation of the nippleareola complex. Plast Reconstr Surg 1980;66(4):497501
Slezak S, Lee DA: Quantitation of sensibility in gigantomastia and alteration following reduction mammaplasty.
Plast Reconstr Surg 1993;91(7):12651269

25.

26.

27.

28.

29.

30.
31.

32.

33.

34.

35.

36.

37.
38.

39.

40.

Strauch B, Elkowitz M, Baum T, Herman C: Superolateral

pedicle for breast surgery: an operation for all reasons.
Plast Reconstr Surg 2005;115(5):12691277; discussion
12781279
Gerzenshtein J, Oswald T, McCluskey P, Caplan J, Angel
MF: Avoiding free nipple grafting with the inferior pedicle
technique. Ann Plast Surg. 2005;55(3):245249
Aydin H, Bilgin-Karabulut A, Tumerdem B: Reduction
mammaplasty using inferior pedicle technique combined
with dermal suspension. Plast Reconstr Surg 2003;111(3):
13621363
Koger KE, Sunde D, Press BH, Hovey LM: Reduction
mammaplasty for gigantomastia using inferiorly based
pedicle and free nipple transplantation. Ann Plast Surg
1994;33(5):561564
Abramson DL: Increasing projection in patients undergoing free nipple graft reduction mammoplasty. Aesthetic
Plast Surg 1999;23(4):282284
McKissock P: Color Atlas of Mammaplasty. New York,
Thieme 1991, pp 4778
Fredricks S: Reduction mammaplasty for gigantomastia
using inferiorly based pedicle and free nipple transplantation. Ann Plast Surg 1995;34(5):559
Ozerdem OR, Anlatici R, Maral T, Demiralay A: Modied
free nipple graft reduction mammaplasty to increase
breast projection with superior and inferior dermoglandular aps. Ann Plast Surg 2002;49(5):506510
Casas LA, Byun MY, Depoli PA: Maximizing breast projection after free-nipple-graft reduction mammaplasty.
Plast Reconstr Surg 2001;107(4):955960
Aydin H, Bilgin-Karabulut A, Tmerdem B: Free nipple
reduction mammaplasty with a horizontal scar in highrisk patients. Aesthetic Plast Surg 2002;26(6):457460
Nahabedian MY, McGibbon BM, Manson PN: Medial
pedicle reduction mammaplasty for severe mammary
hypertrophy. Plast Reconstr Surg 2000;105(3):896904
Wise RJ, Gannon JP, Hill JR: Further experience with
reduction mammaplasty. Plast Reconstr Surg 1963;32:
1220
Robbins TH: Reduction mammaplasty by the Robbins
technique. Plast Reconstr Surg 1987;79(2):308309
Jackson IT, Bayramicli M, Gupta M, Yavuzer R: Importance
of the pedicle length measurement in reduction mammaplasty. Plast Reconstr Surg 1999;104(2):398400
Georgiade GS, Riefkohl RE, Georgiade NG: The inferior
dermal-pyramidal type breast reduction: Long-term evaluation. Ann Plast Surg 1989;23(3):203211
Chang P, Shaaban AF, Canady JW, Ricciardelli EJ, Cram
AE: Reduction mammaplasty: The results of avoiding nipple-areolar amputation in cases of extreme hypertrophy.
Ann Plast Surg 1996;37(6):585591

561