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Moufarrege Total Posterior Pedicle Breast Reduction Workup

  • Author: Richard J Moufarrège, MD, FRCSC; Chief Editor: James Neal Long, MD, FACS  more...
 
Updated: Oct 28, 2014
 

Laboratory Studies

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  • In preparation for a breast reduction, blood analysis, including a complete blood cell count, is recommended. Coagulation studies are useful to assess for bleeding disorders.
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Imaging Studies

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  • A mammogram is recommended in patients older than 35 years.
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Contributor Information and Disclosures
Author

Richard J Moufarrège, MD, FRCSC Professor, Department of Plastic Surgery, Hôtel-Dieu, University of Montreal, Canada

Richard J Moufarrège, MD, FRCSC is a member of the following medical societies: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, Royal College of Physicians and Surgeons of Canada, Canadian Medical Association, Quebec Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

James Neal Long, MD, FACS Founder of Magnolia Plastic Surgery; Former Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Section Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Additional Contributors

Geoffrey L Robb, MD, FACS Chair, Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center

Geoffrey L Robb, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Society of Plastic Surgeons, American College of Surgeons, American Society of Maxillofacial Surgeons, American Society for Reconstructive Microsurgery, Texas Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous editor Saleh M Shenaq, MD†, to the development and writing of this article.

References
  1. Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg. 1977 Jan. 59(1):64-7. [Medline].

  2. Moufarrège R, Beauregard G, Bosse JP, et al. Reduction mammoplasty by the total dermoglandular pedicle. Aesthetic Plast Surg. 1985. 9(3):227-32. [Medline].

  3. Aufricht G. Mammoplasty for pendulous breasts: Empiric and geometric planning. Plast Reconstr Surg. 1949. 4:13.

  4. Sinno H, Botros E, Moufarrège R. The effects of Moufarrege total posterior pedicle reduction mammaplasty on breastfeeding: a review of 931 cases. Aesthet Surg J. 2013 Sep 1. 33(7):1002-7. [Medline].

  5. Biesenberger H. Eine neue Methode der Mammoplastik. Zentralbl Chir. 1928. 55:2382.

  6. Drzewiecki A. Breast reduction by central pedicle technique [letter]. Plast Reconstr Surg. 1986 Dec. 78(6):830. [Medline].

  7. Dufourmentel C, Mouly R. [Mammaplasty by the oblique method.]. Ann Chir Plast. 1961 Apr. 6:45-58. [Medline].

  8. Lalardrie JP, Mitz V. Reduction mammoplasty using the technic of demol vault. J Chir (Paris). 1974 Jul-Aug. 108(1-2):57-68. [Medline].

  9. McKissock PK. Reduction mammaplasty by the vertical bipedicle flap technique. Rationale and results. Clin Plast Surg. 1976 Apr. 3(2):309-20. [Medline].

  10. McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg. 1972 Mar. 49(3):245-52. [Medline].

  11. Moufarrège R, Muller GH, Beauregard G, et al. Mammaplasty with a lower dermo-glandular pedicle. Ann Chir Plast. 1982. 27(3):249-54. [Medline].

  12. Moufarrège R. A new reduction mammaplasty with a vertical posterior pedicle. Quebec Society of Plastic Surgery Convention,. 1979.

  13. Peixoto G. Reduction mammaplasty: a personal technique. Plast Reconstr Surg. 1980 Feb. 65(2):217-26. [Medline].

  14. Pitanguy I. Une nouvelle technique de plastie mammaire: etude de 245 cas consecutifs et presentation d'une technique personnelle. Ann Chir Plast. 1972. 7:199.

  15. Skoog T. A technique of breast reduction; transposition of the nipple on a cutaneous vascular pedicle. Acta Chir Scand. 1963 Nov. 126:453-65. [Medline].

  16. Strombeck JO. Mammaplasty: report of a new technique based on the two-pedicle procedure. Br J Plast Surg. 1960 Apr. 13:79-90. [Medline].

  17. Thorek M. Plastic surgery of the breast and abdominal wall. Charles C Thomas: Springfield, Ill; 1942.

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Before inferior and posterior pedicles, the upper pedicle mammaplasties.
Amount of gland kept in the 3 techniques within the pedicle of the nipple-areola complex: A is the McKissock double-vertical pedicle at 10-15%. B is the Robbins inferior pedicle at 15-25%. C is the Moufarrège total pedicle at 100%.
Three categories of classification of ptosis and hypertrophy in the Moufarrège total posterior pedicle: category I, no ptosis, keyhole angle 90°; category II, nipple below inframammary fold, presence of breast volume at the level of the inframammary fold, keyhole angle 140°; category III, extreme ptosis, emptiness of the breast at the level of the inframammary fold, keyhole angle 180°.
Keyhole positioning on the axis of the breast at the level of the inframammary fold.
Drawing of the key hole on the patient in a sitting position. In this case (Moufarrege category II), opening of the key hole arms is 140°.
Aperture of the keyhole arms and the first 5 cm of the arms before curving.
Continuation of the keyhole arms after the first 5 cm until they connect on the inframammary line.
Designing the dermal inferior pedicle and its dis-epidermization. A full-thickness incision is made around that pedicle and along the drawings of the modified keyhole.
Desepidermisation of the dermal inferior pedicle is made easier by the strip shaving technique.
This photograph shows the inferior dermal pedicle after desepidermisation.
The lateral and medial skin flaps are elevated and held with hooks. Even the upper quadrant has been entirely denuded. No parcels of gland are kept with the skin. The entire gland is fully exposed up to the pectoralis major and is ready for the resection on an open-sky basis.
The full thickness incision is performed first around the dermal pedicle and then along the external drawings.
The gland is entirely denuded on its anterior aspect by elevating the medial, upper, and lateral cutaneous flaps. The cleavage plane separates the flap subcutaneous tissue from the gland tissue.
The hand of the surgeon holds the entire gland before the resection procedure.
Resection is performed in the medial and mainly in the external quadrant. No resection in the lower or upper quadrants.
The surgeon's hand holds the entire denuded breast tissue while showing the pectoralis major muscle at the end of the elevation of the upper flap. For a better upper breast contour, the muscle fascia is divided, allowing the conserved upper quadrant of the breast to move upward, printing a convex effect on the upper part of the breast.
Left: The surgical piece is removed from the left breast. It consists of a very small resection in the medial quadrant and a very consistent resection in the lateral quadrant. This demonstrates the outstanding facility to remove the subaxillary gland in patients presenting very wide hypertrophy going as far as the medial axillary line. Right: The surgeon's hand holds the remaining breast tissue pulled downward in order to show the integrity of the upper quadrant after resection.
Lateral view after the resection. Hooks are holding the lateral and medial skin flaps, showing the complete exposition of the remaining gland entirely fixed on the pectoralis major from the top to the bottom of the gland.
The pathway taken by the intercostal nerve in the total posterior pedicle shows its preservation in the procedure.
Reconstitution begins by positioning the nipple-areola complex in its new location.
Reconstitution starts with the positioning of the nipple-areola complex in its new location, first with a stitch in the 12-o'clock position. The hooks maintain the extremities of the elliptical segment of the keyhole before suturing them.
The keyhole is closed around the areola while the surgeon's hand holds the total pedicle through the still open inferior vertical line.
Reconstitution after positioning the areola in its new location and joining together the edges of the medial and lateral flaps on the vertical line.
Closure is completed in an inverted 'T' fashion.
Shortening of the vertical incision when longer than 6 cm.
The inferior vertical incision is shortened into an inverted 'T' as soon as it is longer than 6 cm.
For the deerfoot closing, a small amount of skin is left at the corners of the flaps. They adapt spontaneously within 4 weeks and prevent classic superficial necrosis at the corners of the flaps.
Always avoid the classic ship anchor.
Lateral view showing the disposition of tissues after closing. Note the extension of the upper quadrant very high toward the clavicle, giving a very unique gablelike volume and appearance to the upper quadrant. The gablelike effect describes the well-filled surface curve of the upper quadrant of the breast, compared with very empty and concave upper quadrants achieved using other techniques. Also note the puckering of the longer inferior dermal pedicle reduced to a shorter inferior line, thus thickening the vertical infra-areolar incision. This constitutes a strong inferior dermal vault and acts as a natural bra, avoiding long-term stretching and pseudoptosis.
The diminution of the implementation base is easily obtained because the resection is mainly performed on the medial and lateral quadrants.
The resection of the outer quadrants allows an important diminution of the implementation base.
The 3 types of accepted incisions in the Moufarrège total pedicle are (1) the periareolar incision, which is used for very mild ptosis and liftings; (2) the simple vertical incision, which is used when the incision is shorter than 6 cm; and (3) the inverted-T incision with a short horizontal arm, which is used when the vertical incision is longer than 6 cm.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photo depicts lateral aspect before surgery (tuberous breast). Bottom photo depicts lateral aspect after surgery.
 
 
 
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