BREAST

Septum-Based Mammaplasty: A SurgicalTechnique Based on Wuringer’s Septum forBreast Reduction

Moustapha Hamdi, M.D.,Ph.D.

Koenraad Van Landuyt,M.D., Ph.D.

Patrick Tonnard, M.D.Alex Verpaele, M.D.

Stan Monstrey, M.D., Ph.D.

Gent, Belgium

Background: During the past 7 years, the senior author (M.H.) has been per-forming septum-based mammaplasty. The aim of this article is to report thesafety and ease of breast shaping by using this technique.Methods: A series of 110 consecutive patients underwent septum-based breastreduction performed by a single surgeon. This technique uses a lateral or medialpedicle based on Wuringer’s horizontal septum, which carries the main nervesupply to the nipple in addition to intercostal perforators.Results: Mean nipple-to-sternal notch distance was 33 cm (range, 22 to 45 cm).Mean resection was 658 g (range, 160 to 1980 g). Nipple elevation was 9 cm onaverage (range, 3 to 17 cm). A retroareolar hematoma occurred in three breasts.Total areola necrosis occurred in one breast (0.5 percent) as a result of aninfection in a diabetic patient. Limited wound dehiscence occurred in 15 breasts(7.7 percent). A secondary scar revision was needed in 10 patients (9 percent).One patient required a revision.Conclusions: Based on a well-vascularized and constant anatomical septum, aseptum-based pedicle is safe, even in large breasts. This technique is safe anddemonstrates ease of pedicle shaping and breast remodeling in patients un-dergoing reduction mammaplasty. (Plast. Reconstr. Surg. 123: 443, 2009.)

Lejour’s technique with a superior pedicle,wide skin undermining, and a vertical scarclosure has been widely used.1 Many patients

have obtained very good results with this tech-nique when it was performed by experiencedsurgeons.2,3 However, a number of complicationshave been identified in the literature. These in-clude kinking of the pedicle in the very fibrousbreast, an ill-defined inframammary fold, andpoor nipple-areola sensitivity.4–8 Indeed, breastsensation following use of the superior pedicletechnique was significantly compromised up to 6months after surgery, as we have previouslyreported.7,8 Our first aim was to maintain nipple-areola sensation with acceptable aesthetic results.We believe it is wise to modify one’s existing tech-

nique to achieve better results in one’s own patientgroup.9–12

Based on reported anatomical and clinicalstudies,13–15 the first author (M.H.) developed aseptum-based mammaplasty.16 The technique isbased on the following:

1. The use of a lateral or medial pedicle, de-pending on the indication.

2. A pedicle based on the horizontal septum,

From the Plastic Surgery Department, Ghent University Hos-pital, and the Coupure Centrum for Plastic Surgery.Received for publication January 9, 2008; accepted August18, 2008.Presented at the Annual Meeting of the American Society forAesthetic Plastic Surgery, in New York, New York, April 19through 24, 2007.Copyright ©2009 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318196b852

Disclosure: None of the authors has a financialinterest to declare in relation to the content of thisarticle.

Supplemental digital content is available forthis article. A direct URL citation appears inthe printed text; simply type the URL addressinto any web browser to access this content. Aclickable link to the material is provided in theHTML text and PDF of this article on theJournal’s Web site (www.PRSJournal.com).

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which was described by Wuringer et al.14

This carries an identifiable neurovascularsupply to the nipple-areola complex (Fig. 1).

3. A two-part gland resection with a crescenticresection caudal to the horizontal septum inthe inferior part of the breast, followed by aC-shaped resection cranial to the horizontalseptum around the pedicle.

4. The suturing of the lateral pillar to the pec-toralis fascia.

5. Closure of the skin with minimal undermin-ing.

The aim of this article is to describe the surgicaltechnique and to report the 7-year clinical expe-rience of using the septum-based mammaplasty.

PATIENTS AND METHODSSince January of 2000, the first author has

performed various techniques for breast reduc-tion in a total of 148 patients. In 110 of thesepatients, the pedicle for the nipple-areola com-plex was based on the horizontal septum to in-corporate the lateral branch of the fourth inter-costal nerve and perforator vessels (Fig. 1). Thisseptum was originally described by Wuringer etal.14 Eighty-four patients underwent a bilateralbreast reduction and a unilateral procedure wasperformed in 26 patients after contralateral breastreconstruction. The 38 patients who were not in-cluded in this series underwent mastopexy andsmall reduction procedures, generally with use ofa superior pedicle. The preoperative breast mea-

surements were collected prospectively and theperioperative and postoperative data were lookedat retrospectively.

IndicationsThe key point of this technique is reduction of

the inferolateral and central parts of the breastand preservation of the nipple-areola complex onthe horizontal septum using a lateral (septum-based lateral mammaplasty) or medial pedicle(septum-based medial mammaplasty). The choiceof pedicle depends on a number of factors, suchas degree of hypertrophy, position of the nipple-areola complex, lateral fullness, and age of thepatient (Fig. 2, above). In our experience, a lateralpedicle offers good projection and maintains nip-ple-areola complex sensitivity. It is therefore ourfavored technique in younger patients. A medialpedicle is chosen in cases of extreme breast hy-pertrophy with significant lateral fullness.

The choice of skin closure pattern is based onour personal experience and is related directly tothe patient’s characteristics (Fig. 2, below). It is alsodetermined perioperatively rather than at thetime of preoperative marking. In general, the ver-tical scar mammaplasty is selected in patientsyounger than 30 years or in patients with a nipple-to-sternal notch distance less than 30 cm. Thesepatients usually have good skin quality and ade-quate skin retraction is expected. In very largebreast reductions (�1500 g), secondary revision

Fig. 1. Sagittal section of the breast shows Wuringer’s horizontal septum.

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of a vertical scar is more likely to be required. Forolder patients or those with a nipple-to-sternalnotch distance greater than 30 cm, an L- or J-shaped scar or a short inverted-T scar can be usedif the skin quality is still good. However, a verticalscar can still be performed for these patients inspecific cases, such as patients who have dark skinor a history of hypertrophic scarring. An invert-ed-T scar is more suitable for patients who havepoor skin elasticity associated with striae. Insmokers, we generally favor techniques with lim-ited skin undermining and direct excision of theexcess skin.

Operative Technique

MarkingThe patient is marked in the standing position

preoperatively (Figs. 3 and 4). The midline, in-framammary fold, and axis of the breast are drawn.We used to put the new position of the nipple atthe level of the inframammary fold or not morethan 1 cm above, taking into account the fact thatthe nipple will rise more than previously planned

as the pillars are closed. The periareolar markingis drawn as a mosque or a circular pattern. The

Fig. 2. Indications for mammaplasty techniques (dotted line, optional). (Above) Choice of pedicle in breast reduction. (Below) Choiceof scar closure in breast reduction techniques.

Fig. 3. Diagram showing the septum-based lateral mamma-plasty markings. Point b is the future position of the nipple; a-b �

2 cm; c-g � d-g= � 6 cm; h-i � 2 to 4 cm.

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circumference varies between 14 and 20 cm, de-pending on the amount of gland resection. Thevertical incision lines are marked by rotating thebreast superolaterally and then superomedially.This maneuver will determine the central resec-tion of the gland. The vertical lines are joined toeach other 2 to 4 cm above the inframammary fold(Fig. 4, left). A lateral or medial pedicle is de-signed, depending on the indications, with a basewidth of 6 to 8 cm (Fig. 4, center).

Surgical ProcedureThe operation is performed under general an-

esthesia with the patient in the supine positionand the arms adducted.

Infiltration and Pedicle DeepithelializationThe first step is local infiltration along the

incision lines and the base of the breast with 40 ccof 1% lidocaine with 1:200,000 adrenaline dilutedwith 40 cc of saline. The pedicle itself is not in-

Fig. 4. A 39-year-old patient presented with moderate bilateral breast hypertrophy. She was reduced from a D cup to a C cup. Thenipple was elevated from 31 cm to 22 cm (nipple-to–sternal notch distance). (Left) Preoperative markings of septum-based lateralmammaplasty. The lateral and medial vertical incision lines join each other 2 to 4 cm (distance h-i) above the inframammary fold.(Center) Seventy-five percent of the lateral pedicle is based on the lateral pillar (inferior to point c). The area of skin undermining isshown by the dotted line that starts from line g-g= and goes to the lateral and medial ends of the inframammary fold. (Right)Postoperative views show the results 1 year postoperatively.

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filtrated. The nipple-areola complex is markedwith a 45-mm-diameter areola ring. The pedicle isfirst deepithelialized using a scalpel.

Resection of the Inferior Part of the GlandThe inferior pole breast skin is undermined,

starting below line g-g= to 1 to 2 cm above theinframammary fold. The ideal thickness of theskin flap is similar to a mastectomy skin flap. Acrescentic resection of the inferior pole is per-formed with an incision following a line connect-ing point g to point g=. The distance betweenpoints c and g is 6 to 8 cm (Fig. 5). The gland willeasily peel off the inferior surface of the horizontalseptum through an almost avascular plane withthe help of a scalpel. Perforators and nerves canbe seen and palpated as small cords within theseptum.

Pedicle Dissection and C-Shaped Resectionof the Gland

Depending on the indication, either a lateralor a medial pedicle is dissected and a C-shapedresection of the gland is performed around thepedicle, which maintains its attachment to thechest wall by means of the septum at approxi-mately the level of the fifth rib.

Septum-Based Lateral PedicleThe surgical technique that is performed on

the marked patient in Figure 4, left and center, isshown in the video, and the results are shown inFigure 4, right. (See Video, Supplemental DigitalContent 1, which demonstrates the surgical tech-nique, http://links.lww.com/A654.)

The breast gland is incised along the medialvertical line between points d and g= straight downto the level of the pectoralis fascia and then ex-tended superiorly toward the upper edge of thebase of the pedicle (point e). The gland is sepa-rated from the rest of the breast by digital dissec-tion, except for the lateral and central attach-ments. The resection is then performed aroundthe pedicle under direct vision and palpation ofthe horizontal septum. The gland excision shouldbe very limited inferior to the pedicle to avoiddamaging the nerves and vessels within the sep-tum. The septum, which connects the nipple-are-ola complex with the thoracic wall, is thereby pre-served. The base of the lateral pillar is rotatedsuperomedially and secured with 1-0 polydiox-anone to the pectoral fascia. This moves the pedi-cle centrally to its new position without any ten-sion. Fixation of the pedicle to the remainingsuperior breast is unnecessary in most of the cases.

Septum-Based Medial PedicleIn the septum-based medial mammaplasty

technique (Figs. 6 through 8), the initial surgical

steps are identical up to and including the cres-centic excision of the gland inferior to the hori-zontal septum. Superior to the septum, the skin isincised from the superomedial base of the pediclelaterally and inferiorly. The lateral pillar is thendefined bevelling laterally, depending on the de-sired amount of resection before cutting downthrough the septum at the lateral pillar (Fig. 7,above, left). The C-shaped resection of the gland isthen completed by continuing the incisionaround the pedicle back to the starting point (Fig.7, above, right). The pedicle is still attached cen-trally to the thoracic wall through the septum,which contains the intercostal perforators andnerves (Fig. 7, center, left). Similar to the lateralpedicle technique, minimum excision is per-formed inferior to pedicle. The lateral pillar is alsofixed to the pectoral fascia.

Closure of the SkinAfter closure of the periareolar incision

(points c and d) with a 3-0 absorbable suture, thelateral pillar is fixed to the pectoralis fascia and thelateral and medial pillars are brought togetherwith a few 1-0 polydioxanone stitches. The peri-areolar incision is closed in three layers. A 2-0polydioxanone purse-string stitch at the level ofdeep dermis is used first. The knot is placed at the12-o’clock position and buried under the breastskin, similar to the technique described by Ham-mond et al.17,18 A few 4-0 Vicryl (Ethicon, Inc.,Somerville, N.J.) stitches are then used to close thedermis, followed by a subcuticular 4-0 Monocryl(Ethicon) suture. At this point, the decision ismade regarding skin closure pattern.

Vertical ClosureIf a vertical closure pattern is chosen (Figs. 9

through 12), the skin is undermined to a limited

Fig. 5. Crescentic gland resection inferior to the horizontal sep-tum as identified by line g-g=.

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extent (1 to 2 cm) to permit closure with smallwrinkles. The deep dermis is sutured with inter-rupted figure-of-eight stitches using 3-0 Vicryl toshorten the length of the vertical incision. A 3-0Monocryl purse-string subcuticular suture isplaced only at the inferior end of the verticalwound (2 to 4 cm length). This permits shorteningof the vertical scar and avoids crossing the infra-mammary fold with additional vertical skin exci-sion; 6-0 nylon stitches may be added to smoothout the skin wrinkles (Fig. 10).

L or J ClosureThe skin excess is shifted laterally at the end

of the vertical scar. The final scar tends to be in aJ shape rather than an L shape. In either case, thereis no extension to the medial side of the breast,where hypertrophic scars occur more frequently.

Inverted-T ClosureIf an inverted-T closure is indicated, it will be

designed at the end of surgery, and any redundantskin in the inferior pole of the breast is excised(Figs. 6 through 8). Skin closure is performed withtwo layers using interrupted 3-0 polydioxanone inthe deep dermis and a running subcuticular 4-0Monocryl suture (Fig. 7, below).

LiposuctionLiposuction is undertaken after skin closure, if

necessary. Indications include persistent breastasymmetry, lateral fullness, and axillary tail prom-inence. Better definition of the inframammaryfold can also be obtained by performing superfi-

cial liposuction to the skin flaps along the infra-mammary fold and at the inferior end of the ver-tical scar (Fig. 10).

Postoperative CareOne suction drain is left in place in each

breast. Attention must be paid to place the drainbehind the areola to avoid a retroareolar hema-toma. A gauze dressing is used to cover the inci-sions, and Micropore adhesive tape (3M, St. Paul,Minn.) is placed. The drains are removed 1 to 2days later and the patients are then dischargedfrom the hospital. They are instructed to wear asports bra night and day for 1 month.

RESULTSPatient characteristics and surgical data are

summarized in Table 1. A vertical scar procedurewas used in 60.8 percent of the patients (Figs. 4and 9 through 12) and an inverted-T scar wasneeded in 18.6 percent of the breasts (Figs. 6through 8 and 13). Patients with a nipple-to–sternal notch distance up to 45 cm were operatedon, and gland resection up to almost 2 kg perside was excised using the septum-based mamma-plasty. Complications are listed in Table 2. Ret-roareolar hematoma occurred in three breasts.Drainage was required in one patient, but shewent on to develop superficial sloughing in part ofthe areola (0.5 percent). One patient who under-went a septum-based lateral mammaplasty devel-oped an atypical infection of the right areola after

Fig. 6. Preoperative views of a 49-year-old patient with a 60-kg weight loss after gastric bypass surgerypresented for breast reduction. She underwent a septum-based lateral mammaplasty technique with atotal resection of 1630 g on the right and 1140 g on the left with an additional 100-cc liposuction.

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application of medicinal leeches to relieve venouscongestion. Total necrosis of the central mound ofthe breast developed after 1 week, and the patientwill require further surgery to correct the defect.This patient had risk factors of diabetes mellitus

and was a heavy smoker. Limited wound dehis-cence occurred in 15 breasts, with the followingdistribution regarding scar closure type: 10 of 118breasts (8.5 percent) had a vertical scar, one of 36(3 percent) had a J-scar, and four of 40 (10 per-

Fig. 7. (Above, left) Deepithelialized pedicle and undermining the skin of the lower pole of the breast. (Above, right) C-shapedresection of the gland around the pedicle. (Center, left) The medial pedicle, which is still attached to the thoracic wall by meansof the septum, is rotated upward. (Center, right) This view shows the light through the septum, which contains perforatorvessels and nerves. (Below) The skin was closed with an inverted-T pattern.

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cent) had an inverted-T scar. Secondary closurewas not required in any of these patients.

One reoperation was required (a septum-based lateral mammaplasty in patient 9) becauseof inadequate gland excision on the lateral side. Asecondary scar correction was performed underlocal anesthesia in 10 patients (9 percent). Thesescars were corrected at the inferior end of thevertical scar in five patients [one bilateral and fourunilateral, six breasts (5 percent)]. Three patientswith an inverted-T closure required correction ofdog-ears [three bilateral (15 percent)]. In two pa-tients, the J scar was corrected unilaterally (5.6percent). However, five of these 10 patients wereat the beginning of the series.

DISCUSSIONCurrent techniques of breast reduction are

numerous. The literature is replete with advocatesand opponents of each technique. Good and badresults are attributed to each specific pedicle. It isdifficult, however, to assign primary responsibilityfor complications or unsatisfactory results to pedi-cle type only. The global outcome in breast re-duction is attributed to many factors, such as skinquality, the patient’s age and expectations, thedegree of ptosis, and the surgeon’s experienceand understanding of breast anatomy. Dependingon the fundamental principles of plastic surgeryand recent anatomical findings of blood and nervesupply to the breast, we customized our techniquein breast reduction and adopted an algorithm forchoosing pedicles and scars to improve results andto increase patient satisfaction.

Vertical scar mammaplasty with a superiorpedicle has become very popular with many sur-geons because it provides longstanding good aes-thetic results with minimal scars.1–3,19–21 However,difficulty in folding the superior pedicle has oftenbeen encountered in patients who have glandularor fibrous breast tissue. Thinning of the superiorpedicle can help to avoid this problem but com-promises the sensitivity of the nipple-areolacomplex.7,8 Breast reduction with an inferior pedi-cle solves this problem, but bottoming-out and aboxy shape of the reduced breast are the majordrawbacks of this technique. Modifications havebeen reported by Hammond et al.18 to overcomethe disadvantages of the inferior pedicle. The con-cept of pedicle rotation laterally or medially inbreast reduction has been reported by many au-thors to avoid kinking of the pedicle and venouscongestion.9–11,22–25 Skoog22 was the first to de-scribe the lateral dermoglandular pedicle, andmany other authors23–25 have modified his tech-nique to a superolateral pedicle with a more glan-dular component. Hall-Findlay11 and others9,10 re-ported a simplified vertical mammaplasty in whichthe superior pedicle was designed superomediallyin most of the cases. However, none of these tech-niques relies on specific anatomical structures oron well-established neurovascular bundles.

Wuringer et al.14 reported a new description ofbreast anatomy. The authors described a ligamen-tous suspension of the breast consisting of a hor-izontal septum attaching the nipple-areola com-plex to the thoracic wall at the level of the fifth riband connected by a medial ligament to the ster-num and a lateral ligament to the lateral edge of

Fig. 8. Results at 2 years postoperatively.

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the pectoralis minor muscle.14 This horizontal sep-tum includes branches and perforators from theintercostal, thoracoacromial, and lateral thoracicvessels and also the lateral branch of the fourthintercostal nerve. These findings confirmed theanatomical description of the lateral branch of

the fourth intercostal nerve reported by otherauthors.13,15 The horizontal fibrous septum is athin lamina of dense connective tissue that arisesfrom the pectoral fascia at the level of the fifth riband, traversing the breast from medial to lateral,extends to the middle of the nipple. It therebydivides the gland into a cranial part and a caudalpart. While heading to the nipple, it also dividesthe lactiferous ducts, emptying into the lactiferoussinuses, horizontally into two even planes of ductopenings into the nipple. Thus, the horizontalseptum separates two anatomical units of glandu-lar tissue. The separation of the glandular tissuefollows certain proportions insofar as the variousvolumes in different-sized breasts seem to becaused mainly by the parenchymal layer cranial tothe horizontal septum. Using these findings, weadopted a technique based on the horizontal sep-tum. In the septum-based mammaplasty tech-nique, the pedicle may be lateral or medial. Theseptum-based mammaplasty, which is an evolutionof the centrolateral or centromedial glandularpedicle techniques, preserves the sensitivity of thenipple-areola complex after breast reduction andalso enhances the blood supply to the pedicle byincluding the intercostal perforators in the pedi-cle. We previously showed in a prospective study26

that the sensitivity of the nipple-areola complexwas maintained in the immediate postoperativeperiod after a reduction mammaplasty based onthe horizontal septum.

Fig. 9. Preoperative views of a 28-year-old patient who had a large breast hypertrophy. The nipple-to-sternal notch distance was 42 cm. A septum-based medial mammaplasty technique was performedwith a 1335-g resection on the right and a 1305-g resection on the left.

Fig. 10. The vertical scar at the end of surgery. A 3-0 polydiox-anone purse-string suture (white dotted line) is placed at the bot-tom of the vertical incision. Liposuction was also performed toimprove the definition of the inferior pole of the breast (blackdotted line).

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In contrast, persistent lateral fullness withlateral pedicle techniques is a drawback.11 Thiscan be avoided by basing the lateral pedicle onthe septum (septum-based lateral mammaplastytechnique), which provides a dual blood supplyto the pedicle (lateral thoracic artery and inter-costal perforators) so more breast tissue can beremoved laterally with less risk of compromisingthe pedicle. However, if the patient initially hasextreme lateral fullness, we would rather choosethe medial pedicle (septum-based medial mam-maplasty technique), which allows a larger andeasier resection of the gland laterally. However,the medial pedicle gives, at least in our septum-

based lateral mammaplasty, less breast projection.Therefore, septum-based medial mammaplasty ismore suitable for older patients. The septum-based lateral mammaplasty technique is more of-ten used in younger patients, which gives a betteroutcome in terms of nipple-areola complex sen-sitivity and breast projection. The senior author(M.H.) has not had to convert to a free nipplegraft despite pedicles in excess of 15 cm. Ourone major complication in this series occurredin a diabetic smoker who developed venous con-gestion of the nipple-areola complex postopera-tively and was treated with medicinal leeches.This resulted in a severe soft-tissue infection that

Fig. 11. Result at 6 months postoperatively.

Fig. 12. The patient with arms above her head toshow the vertical scar.

Table 1. Patient Characteristics and Operative Data

Value (%)

No. of patients 110No. of breasts

Unilateral 26Bilateral 84

Age, yearsMean 37Range 18–66

N-SN distance, cmMean 33Range 22–45

Nipple elevation, cmMean 9Range 3–17

Weight of gland resected per breast, gMean 658Range 160–1980

Type of scar (n � 194 breasts)Vertical 118 (60.8)Short inverted-T, J, or L 36 (18.6)Inverted-T 40 (20.6)

N-SN, nipple-to-sternal notch.

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caused necrosis of the gland. It might have beenwiser to choose an alternative operative procedurefor this patient, such as a free nipple graft.

Scar-related problems have been our secondconcern. Systematic skin closure with only a ver-tical scar in every patient has resulted in manycomplications, such as wound dehiscence, se-roma, hematoma, and a high rate of secondaryrevision.27 There have been attempts to decreasethese complications by using limited skin under-mining and adding short horizontal scars.27

Vertical excision techniques involve more than avertical pattern skin closure. The underlying re-modeling of the breast is key to this concept.1,11,19,28

Despite the fact that we are very keen on using

Fig. 13. A 50-year-old, mildly overweight patient presented with heavy breasts associated withasymmetry. The nipple-to-sternal notch distance was 41 cm preoperatively and was elevated to 27cm using the septum-based lateral mammaplasty technique. Gland resection was 763 g and 932 gfrom the right and left breasts, respectively. The closure was performed with an inverted-T scar.(Above) Preoperative views. (Below) Results at 9 months postoperatively.

Table 2. Postoperative Complications

Complications (n � 194 breasts) No. of Breasts (%)

Wound dehiscence 15 (7.7)Wound infection 2 (1)Unilateral retroareolar hematoma 3 (1.5)Unilateral partial areola necrosis 1 (0.5)Unilateral total areola necrosis 1 (0.5)

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vertical and any other short-scar techniques inbreast reduction, breast shaping and modelingare most important to patients. We believe inthe scar-reducing concept, but it should not be atthe cost of a high rate of wound dehiscence andscar revision.

Adopting an algorithm for choosing the pedi-cle and the scar will yield higher patient satisfac-tion because it allows the right technique to beselected for the right patient. We still prefer avertical scar to close the breast in young patientsor those with dark skin, even with the potential forsecondary scar correction, because this will resultin more a limited scar, rather than ending up withan inverted-T scar performed immediately at theend of surgery. Based on a well-vascularized andconstant anatomical structure, the pedicle is safer,especially in the event of major breast hypertro-phy. In our experience, the septum-based mam-maplasty technique shows advantages over con-ventional techniques of breast reduction in termsof pedicle shaping, breast remodeling, and main-taining nipple-areola complex sensation.

Moustapha Hamdi, M.D., Ph.D.Gent University Hospital

De Pintelaan 1859000 Gent, Belgium

moustapha.hamdi@ugent.be

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