**4.4 Pedicle dissection and inferior resection of the gland**

An incision is performed on the gland along the preoperative drawings. Dissection of the dermis is then performed 5 mm from the edge of the wound with a rim of dermis extending beyond the epidermis along the wound edge. During NAC dissection, a large zone of deepithelialized skin is preserved circumferentially. Both inferior and lower lateral dissection of the gland is then performed to the pectoralis fascia. Lateral dissection, which is enabled by the liposuction and tunnelization performed earlier in the procedure, is started 6 cm from the base of the mosque pattern. The thickness of the inferior pole flap is similar to that of the postmastectomy skin flap because skin undermining is limited. Medial dissection is performed in a beveled manner 2 cm to 3 cm from the edge of the medial.

To maintain fullness of the medial flap, a vertical line is made to the pectoralis fascia. A wide upper-inner supra-aponevrotic pocket is created and dissected on the pectoralis fascia. This pocket extends inferiorly to the third rib space, laterally from the axis of the breast, medially 2 cm to 3 cm from the midline, and superiorly to the first rib. If a subcutaneous tension is judged too important in the upper pole of the breast, a vertical dissection through the gland can be performed to release the tethering fibers.

The upper-inner pocket is extended to minimize tension on the NAC and to ensure upper-pole fullness, because the upper-inner pocket will ultimately contain the upper bulk of the transposed gland. The dissection approach preserves the rich periareolar venous network of the NAC as well as the superior, central, and lateral pedicles (**Figure 4A**).

The excess fatty-glandular tissue in the lower pole of the breast is estimated and resected (**Figure 4B**).

The NAC and breast parenchyma are rotated superomedially by 180° to fill the upper-inner pocket and lift the breast (**Figure 4B**). The NAC is then affixed to its predetermined position. To suspend the breast tissue inside the subcutaneous pocket, barbed running sutures (V-Loc 180, 2–0, Covidien, Mansfield, MA) are placed from the dermis to the chest wall.

Needle bites at the caudal edge of the dermo-glandular flap are utilized to prevent medial tension on the NAC and a medially pointing nipple. The sutures extend medially in a horizontal manner from the middle aspect of the pocket at the level of the second edge to the medial edge of the pocket 2 cm to 3 cm from the midline. Suspension then continues caudally with V-Loc sutures placed in a vertical manner from the second, third, fourth, and sixth rib cartilages (**Figure 4C**).

To suspend the breast tissue inside the subcutaneous pocket, glandular to chest wall sutures are used to avoid tension on the transposed gland and to maintain adequate shaping of the breast mound. After transposition of the gland, the excess tissue localized in the lower part of the breast is originating from the inferior and lateral zone of the breast in the inverted T technique. An horizontal and lateral suture is performed using V-Loc sutures, facing the sixth rib space to the breast axis line and then continued in a superficial plane (**Figure 4C**).

#### **Figure 5.**

*(A-B) with the same barbed thread, suturing is continued superficially to close the wound. (A) Closure with a short T scar: The reported a and b lengths are equal to the previously measured a and b mid-distances located between the IMF and both points a and B in Figure 2C. (B) Closure with a vertical scar.*

*Power-Assisted Liposuction Mammaplasty (PALM): A Short Scar Mammaplasty… DOI: http://dx.doi.org/10.5772/intechopen.98816*

Redraping of the periareolar and vertical wounds is performed using skin staples, which are removed when the final skin closure takes place. In cases where vertical wound closure are not adequate, a peroperative decision regarding pattern of skin closure (either short T or J closure) is made (**Figure 5A**). Closure of the vertical and periareolar wounds is achieved under minimal tension using a 2–0 V-Loc running sutures (**Figure 5**). At the lower part of the wound closure, a subcutaneous drain is placed and secured to the skin. The same procedure is then performed contralaterally.

When necessary, subsequent liposuction is performed. The indications for additional liposuction include treatment of breast asymmetry or fullness at the lower lateral quadrant requiring correction, excess fat necessitating additional volume reduction, and the need for subcutaneous undermining of the lateral breast to relieve persistent tension after the transposition of the breast to its new position.
