**1. Introduction**

The various techniques of reduction mammaplasty and mastopexy include free nipple [1], wise pattern [2], bipedicle [3–5], inferior pedicle [6, 7], vertical pedicle [8–11], superomedial [12–14], superolateral [15, 16], and septal-based pedicle [17, 18]. There are specific advantages to each technique. However, the majority of those surgeries encounter the identical challenges of recreating upper-pole fullness, conserving the sensation of the nipple areola complex (NAC), and maintaining adequate blood supply with massive breast ptosis. Current reduction mammaplasty techniques identify parenchymal reshaping and resection as critical for maintaining shape. Liposuction of the breast [19–27] by itself or combined with resection of the parenchyma has been utilized safely and reliably since the early 1980s for reduction mammaplasty. One suitable technique for breasts of varying sizes is reduction mammaplasty with liposuction, with aspirate volumes greater than 2000 cc. Liposuction-assisted reduction mammaplasty has had positive results and is associated with very low morbidity rates. Over a 10-year postoperative monitoring period, the safety and reliability of liposuction-assisted vertical reduction mammaplasty has been verified [8, 9, 26, 28].

Liposuction-assisted vertical reduction mammaplasty has a few complications, such as kinking of the pedicle in the markedly glandular breasts, reduction in NAC sensitivity, an ill-defined inframammary fold, and delayed wound healing [28–33]. More recently, the senior author introduced a scarless breast reduction procedure for fatty breasts, associating an extensive breast liposuction to the use of internal threads [34]. We managed to treat fatty breasts mini-invasively by emptying the breast from its volume and molding it accordingly to its desired form and position utilizing loops [34]. The use of internal threads has proven its effectiveness in other breast and body contouring procedures [35–40]. Nevertheless, in breast reduction, this approach is limited to more massive glandular breasts necessitating glandular resection [34].

The power-assisted liposuction mammaplasty (PALM) technique was created to address the complications of liposuction-assisted vertical reduction mammaplasty and the limitations of existing breast reduction techniques [41].

The main procedural steps of PALM include the following:

