Medial Pedicle and Mastopexy Breast Reduction 

Updated: Nov 23, 2021
Author: John M Anastasatos, MD; Chief Editor: James Neal Long, MD, FACS 



Mastopexy is a compound word derived from the Greek mastos (breast) and pexy (to fix or secure). It refers to the correction of ptotic and pendulous breasts. The term mammaplasty refers to shaping of the breast, as the Greek derivative plasty means to mold.

The principles and techniques used to correct pendulous ptotic breasts (see the image below) are similar to those used to perform a breast reduction. In all techniques used, the most critical consideration is the viability of the nipple-areola complex (NAC). This article focuses on the medial pedicle as the one that provides blood supply to the NAC. The medial pedicle technique can be used to safely perform a large breast reduction, a mastopexy, or a mastopexy with simultaneous augmentation.[1] For information on other techniques for breast reduction, augmentation, and reconstruction, see the Breast section of Medscape Drugs and Disease's Plastic Surgery journal.[2]

This patient had obvious and significant breast pt This patient had obvious and significant breast ptosis. Medial pedicle mastopexy was performed, in addition to a subpectoral breast augmentation with saline-filled breast implants. The breast implants were filled to a volume capacity of 450 mL bilaterally. This image shows the preoperative front view.

History of the Procedure

The history and evolution of breast reduction spans many centuries. Paul from the Greek island of Aegina was the first to describe details of reduction mammoplasty in the 6th century AD.[3] Multiple techniques of breast reduction and mastopexy have been described over the past century. In the last 3 decades, the main evolution and progress in the field of reduction mammaplasty and mastopexy has been in better molding of the breast parenchyma (limiting the resultant scars) and not relying on the skin envelope for long-term parenchymal support and breast shape.


The true etiology of breast hypertrophy is not clearly understood. The breasts are hormonally sensitive organs that change with hormonal and, especially, estrogen variations. Breast enlargement usually begins with changes associated with puberty and pregnancy. In some women, estrogen receptors that are hypersensitive to estrogen may be a cause of mammary hyperplasia.[4, 5, 6, 7]

The problem of breast ptosis is also not clearly understood. The ideal youthful-looking breast should have a natural tear drop shape, adequate projection (perkiness), and no ptosis. The entire breast parenchyma should be above the inframammary fold (IMF), and the NAC should be centered at the breast or be slightly lower than the center.

The most established classification to describe ptosis according to the relative positions of the NAC, breast parenchyma, and IMF is by Regnault.[8]

  • First-degree ptosis - Mild ptosis in which the NAC lies at or slightly above the IMF

  • Second-degree ptosis - Moderate ptosis in which the NAC is below the IMF but above the highest projecting part of the breast

  • Pseudoptosis - Condition in which the NAC is above the IMF, but the lower pole of the breast is below the IMF

  • Third-degree ptosis - Severe ptosis in which the NAC is below the IMF and at the lowest projecting part of the breast



The true frequency of ptosis and macromastia is not known. Most plastic surgeons in the United States typically work with patients who have these problems following pregnancy.


The true etiology of ptosis and macromastia is not known. They are generally assumed to be results of hormonal changes on the breasts and, especially, the actions of estrogen on the estrogen parenchymal receptors.


The pathophysiology of ptosis and macromastia is felt to be strongly associated with estrogen hormonal levels or estrogen receptor hypersensitivity to circulating levels of estrogen. The pathophysiology is not thoroughly understood. In a great majority of cases, ptotic breasts are associated with asymmetry in terms of parenchymal volume, NAC diameter and position, and shape. These morphologic differences may represent true anatomic variations or may be due to variations in physiologic actions of the breasts.


A complete patient history and physical examination should be performed. The physical examination should entail a thorough examination of the breasts and nipple-areola complexes (NACs), the axillae and supraclavicular areas for any lymphadenopathy and accessory breast tissue, and the rest of the abdomen and pelvis for any accessory breasts.

Clinically, hypertrophic breasts may present with ptosis, an enlarged NAC, decreased sensitivity of the NAC (which may improve following reduction mammaplasty), prominent and visible veins, stretch marks of the skin, and hypersensitivity and irritation of the inframammary skin.


Indications to perform a mastopexy are primarily aesthetic; that is, to position the nipple-areola complex (NAC) in a more aesthetically pleasing location relative to the rest of the breast and to give the breast youthful shape and projection. The indications can also be psychological, as saggy or asymmetric breasts can be detrimental to the self-esteem of an individual.

The indications for a reduction mammoplasty may be aesthetic, but they are chiefly functional. Macromastia may cause neck pain, back pain, shoulder strap indentations and shoulder pain, chest heaviness, labored breathing, headaches, poor posture, and skin irritation and infections. In addition, the psychological burden can be significant. Women with macromastia may find it difficult to exercise, participate in activities of daily living, and find proper clothing. This condition affects their self-esteem and self image.

Relevant Anatomy

Breast shape varies among patients, but knowing and understanding the anatomy of the breast (see the image below) ensures safe surgical planning. When the breasts are carefully examined, significant asymmetries are revealed in most patients. Any preexisting asymmetries, spinal curvature, or chest wall deformities must be recognized and demonstrated to the patient, as these may be difficult to correct and can become noticeable in the postoperative period. Preoperative photographs with multiple views are obtained on all patients and maintained as part of the office record.

Anatomy of the breast. Anatomy of the breast.

The blood supply to the breast comes primarily from branches of the internal mammary artery. The thoracoacromial, thoracodorsal, lateral thoracic, and intercostal arteries also contribute. Those arteries create rich anastomotic plexuses.[9]

The innervation of the breast comes from the anterior rami of the second to the sixth intercostals nerves. The skin of the upper part of the breast is innervated by the supraclavicular nerves. The nipple-areola complex (NAC) gets rich innervation from the anterior branches of the second to sixth intercostal nerves and from the lateral branches of the fourth and fifth intercostal nerves. The nerve supply from the fourth intercostal nerve is believed to play a unique role in the NAC innervations.[10, 11]

For more information about the relevant anatomy, see Breast Anatomy.


Overall poor health is a contraindication for this procedure. Prior breast reduction or mastopexy with another technique is not a contraindication to performing this operation.



Laboratory Studies

The following basic laboratory studies are routinely ordered as part of the preoperative workup:

  • A CBC with a platelet count

  • Activated partial thromboplastin time (aPTT) and international normalized ratio (INR)

  • Basic metabolic profile

  • Serum pregnancy tests (These tests should be ordered even if the patient states she is not pregnant.)

Additional laboratory studies may be ordered depending on the history, physical examination, associated comorbidities, and overall health status of the patient.

Imaging Studies

Imaging studies are not usually required. If any suspicious masses are found during the physical examination, the patient should be evaluated before surgery with ultrasonography and mammography, if needed. Women who have a strong family history of breast cancer or who are aged 35 years or older might undergo a preoperative mammogram to serve as a baseline.

Histologic Findings

All dermoglandular tissue resected during the operation should be sent for histological evaluation.


The Regnault classification is commonly used to describe the degree of ptosis.



Medical Therapy

No effective medical therapy exists to relieve the pathology and correct the breast shape. The therapy is purely surgical.

Surgical Therapy

The goals of surgery are to reduce the breast volume, relieve symptoms related to macromastia and ptosis, raise the nipple-areola complex (NAC), and, from an aesthetic standpoint, to create beautiful and youthful-looking breasts.

A retrospective study by Swanson indicated that vertical breast reduction using a medial pedicle can be safely combined with the insertion of breast implants in order to provide upper-pole fullness. In the study, complication and reoperation rates did not significantly differ between women undergoing just medial pedicle breast reduction (56 patients) and those undergoing the reduction procedure plus implant insertion (24 patients).[12]

Preoperative Details

Accurate preoperative markings are critical to the outcome of the surgery.

First, mark the breast meridian. Following that, design an ellipse or pineapple shape, which is centered on the breast meridian (the breast meridian bisects it).

Next, mark the medial pedicle and its dimensions. The base of the medial pedicle is at the superomedial aspect of the elliptical/pineapple design for the breast reduction or mastopexy. A medial pedicle base length of 6 cm provides abundant blood supply for the viability of the NAC. For larger breast reductions using the medial pedicle, make the pedicle base length 8-10 cm. The precise length of the medial pedicle is not critical; it just needs to be long enough to comfortably carry the NAC superiorly.

At the superior aspect of the elliptical/pineapple design, draw a half circle or 3/4 of a circle; this is the location of the new NAC. The top of that circular design is typically marked at 21 cm from the superior margin of the sternal notch.

Intraoperative Details

The operation begins after the patient has been prepared and draped. Two 2-0 silk sutures are used. One is sutured to the umbilicus, and the other is sutured at the midline of the superior portion of the sternum. These sutures serve to create a reliable central axis of the anterior torso. The author confirms the accuracy of the preoperative breast markings by using the 2 silk sutures and the technique of triangulation. The markings are modified, if necessary, before the breast cuts are made.

Infiltrate the markings on the breasts with local anesthetic. A mixture of 1% lidocaine with epinephrine (1:100000) is adequate to provide vasoconstriction during the operation and expedite it. For more information, see Infiltrative Administration of Local Anesthetic Agents.

Use a “cookie cutter” to mark the new NAC. To properly select the new diameter of the NAC, consider the patient’s wishes and also the eventual cup size of the new breast mound.

After that step, proceed to deepithelialize the medial pedicle, which will provide blood supply to the NAC. Then, make the first cuts through the breast parenchyma, separating the medial pedicle. Bevel the scalpel out (away from the pedicle) when making these cuts so as not to undercut the pedicle; the goal is to maintain all possible blood supply to the NAC. Appropriate pedicle volume is also essential to contribute to adequate upper breast pole projection.

Then, proceed to cut the breast tissue inferior to the medial pedicle. An almost triangular segment of breast tissue is removed inferiorly. Finally, complete the breast cuts by cutting the superior marked circumference (the area in which the new NAC will be placed) and the tissue lateral to the medial pedicle.

If the breast cuts are satisfactory, attain complete homeostasis at this point.

Evaluate the medial pedicle for its thickness and ability to rotate in a superomedial direction without any inferior tension. At this point, the pedicle thickness can be reduced, if appropriate. When the pedicle is positioned superiorly, examine its thickness to make sure that it sits comfortably in its new position without undue pressure or constriction. These measures ensure good viability of the pedicle and, hence, the NAC.

The next critical step of this operation is to bring together the medial and lateral pillars of the inferior pole of the breast. This is done with 3-0 nylon suture. Three sutures are adequate. This step is critical because it gives support, round shape, and prominent projection to the new breast mound.

At this point, position the patient upright. With the patient in the upright position, mark the excess skin on the inferomedial and inferolateral aspects of the new breast. Lower the patient again to excise the excess skin. In some select cases, the excess skin in the lower aspect of the breast may be gathered (bunched up), extending the incision slightly onto the upper abdominal skin. This avoids an inframammary fold (IMF) scar. The series of patient images below illustrate this gathered (purse-string) approach to medial pedicle mastopexy.

Medial pedicle mastopexy without inframammary scar Medial pedicle mastopexy without inframammary scars. With the purse-string technique pictured below, the skin is gathered below the new inframammary fold (IMF). This gathered-up skin eventually will settle down and become part of the new IMF. This is illustrated in the series of images below, starting with this image of the preoperative front view.
Preoperative side view. Preoperative side view.
Preoperative side view. Preoperative side view.
Intraoperative view. The most inferior curvilinear Intraoperative view. The most inferior curvilinear line indicates the position of the original inframammary fold. The curvilinear line located more superiorly indicates the new position of the inframammary fold.
A Prolene suture is used to gather up the tissue e A Prolene suture is used to gather up the tissue excess between the new inframammary fold and the old one.
Tightening of the purse-string suture. Tightening of the purse-string suture.
Full tightening of the purse-string suture. Knot i Full tightening of the purse-string suture. Knot is under the skin.
Postoperative side view. Postoperative side view.
Postoperative side view. Postoperative side view.
Postoperative front view. Postoperative front view.

Bring the patient to the upright position again and check the shape and symmetry of the breasts. If satisfied, lay the patient down and proceed to close the wounds.

Drains are usually not needed. If necessary, the decision to use a drain is made in the operating room.

Postoperative Details

The patient is seen the day after surgery to evaluate the viability of the breast flaps, the viability of the NAC, and the presence of any hematomas. In the case of intraoperative drain placement, the drains are also removed at this time.


For the first 3 weeks, see the patient every week. After that, follow-up visits can be sparser.


As with any type of reduction or mastopexy procedure, the most worrisome complication of this operation is partial or complete nipple-areolar necrosis. To prevent this complication, the viability of the nipple-areola complex (NAC) is evaluated closely following its inset at its new position and also at the end of the surgery. The viability is best evaluated by the presence of good quality bleeding (ie, slow bright red ooze).

Temporary loss of sensation to the NAC is a more common complication. Patients commonly experience dysesthesias after the surgery, but sensation returns to normal after a few days or months. Permanent loss of NAC sensation is extremely rare.

Partial or complete flap necrosis is a potential but rare complication with this operation.

Hematomas may occur. Small hematomas that do not add extra tension on the incisions and do not threaten the pedicle can be treated with observation. Larger hematomas should be drained in the operating room.

Wound dehiscence or small wound breakdown may occur at different parts of the incisions. Unless such breakdowns compromise the aesthetic outcome, they are generally treated conservatively.

Contour irregularities may occur, particularly when the inferior part of the incision is gathered to avoid an inframammary fold (IMF) scar. Such irregularities may eventually require revision if they do not flatten out or assume a smooth appearance.

Bilateral breast asymmetry can be listed as a complication if it is significant. Asymmetry may be related to the volume, shape, or position of the NAC, or a combination of these factors. Maximal accuracy can be achieved by spending a considerable amount of time making the preoperative markings and confirming them during surgery with the patient in both the supine and upright positions.

Outcome and Prognosis

Women who undergo breast reduction for symptomatic macromastia experience an immediate relief of the weight-related symptoms. This operation has a high rate of satisfaction. The main advantages of the medial pedicle technique are the long-lasting breast shape and projection and, frequently, the ability to perform the operation without creating a scar in the inframammary fold (IMF).[13]

A study of more than 100 vertical mammaplasties using a medial pedicle technique found that physical symptoms significantly decreased postoperatively in patients who underwent mastopexy (resection weight < 300 g per breast) or breast reduction. Together, the three procedures investigated, which also included augmentation/mastopexy, had a 94.3% patient satisfaction rate, while rates of improvement in self-esteem and quality of life were reported as 89.3% and 69.5%, respectively. The procedures also had a reported 15.1% complication rate; persistent nipple numbness was reported by 10.6% of patients.[14]

A study by Sapino et al indicated that in breast reduction mammoplasty using the Wise pattern, the superomedial pedicle (SMP) technique provides better aesthetic results than does the inferior pedicle (IFP) procedure. Using a 24-month follow-up period, the investigators reported that the SMP patients had a significantly shorter sternal notch–to-nipple distance than did those who underwent the IFP procedure. In addition, the length of the lower pole (the distance between the inframammary fold and the inferior border of the nipple-areola complex [NAC]) increased 29.5% in the SMP group, versus 40.9% in the IFP patients. In judging aesthetic results, patients and surgeons each gave a significantly higher visual analogue scale (VAS) score to the SMP technique’s outcomes.[15]

The series of patient images below depict a patient who underwent medial pedicle mastopexy in conjunction with breast augmentation and nipple-areola complex reduction. The operation resulted in no IMF scars.

This patient had obvious and significant breast pt This patient had obvious and significant breast ptosis. Medial pedicle mastopexy was performed, in addition to a subpectoral breast augmentation with saline-filled breast implants. The breast implants were filled to a volume capacity of 450 mL bilaterally. This image shows the preoperative front view.
Preoperative side view. Preoperative side view.
Postoperative side view. Postoperative side view.
Postoperative side view. Postoperative side view.
Postoperative front view. Postoperative front view.

The series of patient images below depict a patient who underwent mastopexy on each breast. Periareolar and vertical incisions were used; no incision was made under the breast. The postoperative photos were taken 3 months after the operation; these incisions fade even more over time.

This patient wanted to maintain her plentiful brea This patient wanted to maintain her plentiful breast volume but wanted her breasts to be "perky, beautiful, and youthful" like they used to be before she had children. This is a common surgery requested by women after they have had children and have breastfed. This image shows the preoperative front view.
Preoperative side view. Preoperative side view.
Preoperative side view. Preoperative side view.
Postoperative front view. Postoperative front view.
Postoperative side view. Postoperative side view.
Postoperative side view. Postoperative side view.

Further outcomes of the medial pedicle surgery are demonstrated in the images below.

A breast lift and a breast augmentation were perfo A breast lift and a breast augmentation were performed at the same operative time in this patient. The breast lift technique utilized was the medial pedicle method described in the text. The round, smooth 300 cc breast implants placed contained cohesive silicone gel.
This patient had a breast lift utilizing the media This patient had a breast lift utilizing the medial pedicle technique described. The photos of her postoperative results were taken a year following the procedure.

Future and Controversies

The ability to perform this operation with limited scarring represents an obvious advantage. Because the inframammary fold (IMF) scar tends to heal most prominently, avoidance of a scar there is preferred. The cut-off points for pedicle length and safe reduction volumes have not been established. The author has used this operation in performing very large (1110-1200 g) breast reductions without any problems or the need to use a nipple-areolar free graft. Based on personal experience and supported by published literature, the author notes that this is a safe operation in properly selected patients who need very large volume breast reductions.

The author uses this operation in combination with a bilateral augmentation mammoplasty (BAM). Whether performing a mastopexy and a BAM at the same time is best is controversial. The 2 operations can oppose each other in many ways. For example, a BAM serves to lower the IMF, while a mastopexy or reduction technique raises the IMF. A mastopexy reduces breast volume, while a BAM increases volume. A BAM adds extra tension on the breast and additional pressure to all parenchymal and external suture lines, while the opposite is needed for optimal healing. Because the variables are in opposition, many surgeons feel that the 2 operations are best performed at different times. Performing the breast lift first and augmentation later may lead to superior outcome and more accurate results.

However, some advantages to performing these 2 operations synchronously are also apparent. Surgeons who perform these operations together usually perform a skin-only mastopexy in association with a BAM. The author finds that the predictability of the medial pedicle technique and the long-lasting correction of the breast projection may complement the features of a BAM and may allow for longer-lasting results.