**7. Outcome**

A total of 426 consecutive women (852 breasts) underwent breast reduction with the PALM technique from January 2008 to January 2019. The NAC was based on the central, lateral, and superior pedicles. The parameters of interest included BMI, age, previous breast surgery, smoking, N-SN distance, weight of the resected specimen, preoperative breast size, extent of NAC elevation, total volume of fat aspirated per breast, and the type of final wound closure.

The patient comorbidities noted included diabetes mellitus, obesity, hypertension, coronary artery disease, smoking, and breast cancer. Patients presenting after implant removal, in addition to those presenting for unilateral or breast reduction after any type of breast oncologic surgery were excluded from the study. Complications such as hematoma, partial areolar necrosis, seroma, wound dehiscence and/or wound infection were also recorded. Data was integrated and analyzed in a computerized database. All patients are followed up for 2 years following surgery.

The mean age of the patients was 39 years (range, 20–69 years), the mean BMI was 31 kg/ m<sup>2</sup> (range, 24–43 kg/m<sup>2</sup> ), the mean NAC elevation was 17 cm (range, 10–30 cm), and the mean N-SN distance was 37 cm (range, 29–49 cm). Thirty-seven of the 426 patients (9%) were smokers. The mean glandular resection mass was 245 g (range, 40–630 g), and the mean lipoaspirate volume was 750 mL per breast (range, 270–3200 mL). Twenty-nine patients (7%) presented with gigantomastia. The mean glandular resection mass per breast was 3.1 kg (range, 2.9–3.5 kg), and the mean body weight of these 11 patients was 91 kg (range, 82–99 kg) (**Tables 1** and **2**).

A short T wound-closure pattern was applied for 596 of the 856 breasts (71%), whereas the vertical and J wound-closure patterns were applied for 204 breasts


#### **Table 1.**

*Patients demographics.*


**Table 2.** *Operative data.*


#### **Table 3.**

*Complications following PALM.*

(24%) and 42 breasts (5%), respectively. The patients were monitored for an average of 26 months (range, 12–48 months) (**Table 2**). At ≥12 months postoperatively, all patients presented with maintenance of the upper-pole fullness (**Figures 6**–**9**).

Postoperative complications included seroma detection in 26 breasts (3%), the development of wound infections in 17 breasts (2%), and wound dehiscence in eight breasts (0.9%). No patients developed hematoma nor total areolar necrosis, but four patients, both of whom were current smokers had partial areolar necrosis (1%). The revision surgery rate was 5%. Each case with postoperative complications was successfully treated conservatively (**Table 3**).

### **8. Discussion**

The goals of reduction mammaplasty and mastopexy include safety and predictability, fast recovery, long-lasting results, and minimal complications, as well as the achievement of an appropriate size, shape, and projection of the breast [49]. Successful results are ascribed to the surgeon's experience and understanding of breast anatomy, patient age and expectations, skin quality, and the degree of ptosis [17]. The PALM surgical technique provides a customizable approach to reduction mammaplasty and mastopexy that also accommodates patients with gigantomastia and massive breast ptosis, averting the challenges of conventional vertical mammaplasty such as reduced NAC sensitivity postoperatively, kinking of the pedicle, and venous congestion of the NAC.

Breast liposuction as a sole procedure or in conjunction with parenchymal resection has proven to be a safe and reliable [19–28] approach to decrease breast weight and volume. Our personal experience shows that liposuction is appropriate for breasts with lateral fullness and inferior excess. Liposuction facilitates longevity of a desired breast shape and delays ptosis when excess tissue is taken out, pulling forces are reduced, a natural contour is reestablished, and superior rotation of the breast is promoted. If there is asymmetry after bilateral breast reduction, liposuction is a sufficient and dependable option to restore breast symmetry and improve the breast shape. The PALM technique includes liposuction for breast shaping and volume reduction, restricting parenchymal resection to the inferior pole of the breast and ensuring tension-free folding of the NAC during its superior transposition. This procedure is even indicated for cases of severe ptosis in which massive folding and substantial NAC elevations are expected and when the superior pedicle does not supply adequate blood supply to the NAC. A better definition of the breast contour and enhancement of skin retraction can be obtained through liposuction

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

and tunnelization below the inframammary fold using a Lipomatic system. This will further redrape the vertical wound closure to reduce puckering, wrinkling, and the need for scar revision.

By reducing the degree of tissue dissection and resection, the PALM technique aims to preserve an optimal blood supply to the breast. In this technique, liposuction is considered as a key step for volume and weight reduction. Dissection is restricted to a section of the inferior pole and the medial aspect of the breast, and minimal tissue resection is limited to a part of the lower outer quadrant.

To ensure a maximal vascularization to the breast parenchyma and NAC, it is essential to preserve the central, lateral, and superior pedicles. NAC sensitivity is also maintained in the PALM technique through a lateral pedicle containing Wuringer's horizontal septum [50], which carries a neurovascular supply to the NAC and can be combined into septum-based mammaplasty via the methods developed by Hamdi et al. [17]. Greater NAC elevations can be attained with a continuous blood supply to the NAC. Protection of the periareolar vein polygon is achieved through deepithelialization of a wide surface area of skin around the NAC [51], which also maintains the venous networks supplying the NAC. Breast tissue resection is reduced to a minimum with PALM to promote sufficient venous drainage of the NAC through large transposition distances that are necessary for patients with gigantomastia and noticeable breast ptosis. NAC elevations as big as 28 cm were accomplished with PALM.

The preservation of blood supply to the breast reduces the rate of wound healing complications with PALM. A 3-mm dermal rim is preserved around the edge of the breast wound; therefore, PALM facilitates wound closure and ensures apposition and eversion of the wound edges under minimal tension, enhancing wound healing and decreasing excessive scaring. Adequate preservation of a large area of deepithelialized tissue around the gland carrying the NAC also develops a firm anchoring structure at the deepithelialized edges for sutures from the dermis to the chest wall during glandular transposition. In addition, PALM enables the development of a superior pocket, supplying a comfortable fit of the transposed parenchymal tissue that reduces tension on the NAC upon final wound closure. PALM can be completed with just two V-Loc sutures. The V-Loc sutures are encouraged for glandular suspension and skin closure because they reduce operating times, wound complications, and foreign-body interaction because they require less suture material and fewer knots.

Additionally, V-Loc sutures decrease compression of the glandular and fatty tissue during suspension of the gland in its new position because fewer knots are needed. In our opinion, when approximating the two pillars in superior pedicle breast reduction, the application of V-Loc sutures can minimize fat necrosis from compression of the parenchyma and gland. There are various benefits associated with glandular suspension sutures from the dermis to the chest wall sutures. To affix the breast parenchyma in its new position, V-Loc sutures are placed from the second rib at the upper pole to the sixth rib inferiorly. Upper-pole fulness and parenchymal support is ensured through the use of strong V-Loc sutures, attaching the dermal edges of the breast glandular flap to the rib perichondrium in the presence of a superior pocket accommodating the flap. The new IMF is redefined utilizing 2 cm to 4 cm cephalad to its original location according to the extent of ptosis. This step is achieved utilizing V-Loc sutures.

After glandular suspension in the desired position, a single 3–0 V-Loc suture is applied for vertical and periareolar wound closure under minimal tension. Various patterns of skin closure are compatible with PALM. When the NAC elevation is less than 10 cm, a vertical wound closure is chosen preoperatively. However, when the NAC elevation is greater than 10 cm, the decision for a short T or J wound closure is decided intraoperatively after the NAC is elevated to the desired position and redraping of the parenchymal tissues.

In this study, most patients presented with ptotic breasts that required NAC elevations greater than 10 cm. Therefore, a short T wound-closure pattern was most common. Postoperatively, 24 patients (12%) became pregnant, specifically nine primary and 15 secondary or tertiary pregnancies. After PALM, all 24 patients were able to breastfeed, with the preservation of breastfeeding capacity attributed to reduced glandular resection and maintenance of the maximal amount of breast parenchyma.

Although liposuction is a frequently performed procedure in plastic surgery, few surgeons have much experience with breast liposuction and especially powerassisted breast liposuction. As a result, a limitation of PALM is the learning curve for surgeons to learn the skills necessary to undertake power-assisted breast liposuction. Due to the diligence, attention to detail, and precision required for surgeons to perform breast liposuction, the senior author recommends that liposuction be performed in small volumes and that cases of massive ptosis and gigantomastia be avoided entirely until the adequate skills are developed.

Fatty breasts are easily treatable using the PALM technique, whereas glandular breasts are considered as more difficult cases since liposuction is limited. Nevertheless, those glandular tissues are not contraindicated for the PALM technique. Various measures can assist is achieving satisfactory results and overcome the challenges associated with glandular breasts, such as precisely and delicately performing liposuction of the breast, expanding the amount of glandular resection from the lower pole while preserving the lateral septum, and dissecting a larger upper-pole pocket to accommodate the transposed glands.

Tips for making precise preoperative markings for PALM are fundamental for obtaining an esthetically pleasing and symmetrical breast shape. The main tips include:

