Fig. 8.8. Anterior view: the lateral ligaments can be shortened by plication and fixed to the thoracic wall. After , with permission of Plastic Reconstructive Surgery
Fig. 8.7. Lateral view: after total isolation of the pedicle, the pedicle is translocated upward by fixation sutures. After , with permission of Plastic Reconstructive Surgery
After resection, shaping of the breast cone follows. When the pedicle is totally isolated, fixation to the thoracic wall is necessary to raise the pedicle (Figs. 8.7, 8.8). Its fibrous elements provide sturdy structures for fixation, unlike the residual breast parenchyme,where sutures cut through easily. The rims of the horizontal septum or the vertical ligaments can be shortened by plication sutures, and the plicated part can be sus-
Fig. 8.8. Anterior view: the lateral ligaments can be shortened by plication and fixed to the thoracic wall. After , with permission of Plastic Reconstructive Surgery pended at the pectoralis fascia. This allows excellent modeling of the breast, which can be further supported by a dermal brassiere built by the periareolar skin excess, which in turn can be fixed to the thoracic wall. But all those sutures may irritate the neurovascular supply running along the ligamentous suspension and thus should be placed cautiously so as not to cause congestion.
This made me keep intact a medial dermal bridge of about 2 to 3 cm that holds the pedicle in a higher position. The medial dermal connection between the pedicle and the skin envelope, as well as the medial part of the horizontal septum, acts as a pivot point that allows the lateral edge of the pedicle comprising the horizontal septum to rotate upward, according to the principle of the Hall-Findlay technique . Thus, far fewer or even no fixation sutures are necessary. In this way the advantage of a technique keeping the upper parts of the breast intact, which acts against the force of gravity, can be combined with the advantage of having an intact horizontal septum, which implicates an optimized neurovascular supply. In this way also a double source of neurovascular supply is provided both by the horizontal septum and the medial ligament.
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