The Short Scar Periareolar Inferior Pedicle

Reduction (SPAIR) Mammaplasty

Dennis C. Hammond, M.D.1

ABSTRACT

Although generally effective, the inverted T inferior pedicle breast reduction

technique is associated with continuing concerns over cutaneous scar as well as shape
distortion, which can to worsen over time. This article will outline a technique of breast
reduction that is also based on an inferior pedicle but manages the skin envelope with a
combined periareolar and vertical skin excision. By combining these elements, an effective
method of breast reduction is created that reduces the amount of cutaneous scar by half and
yet results in an improved and long-lasting breast shape that is stable over time. This
method, called the ‘‘short scar periareolar inferior pedicle reduction’’ (or ‘‘SPAIR’’
mammaplasty) is applicable to a wide variety of breast problems ranging from simple
ptosis to extremes of macromastia. Aesthetically pleasing results are consistently and
reliably obtained with few complications. It is offered as an effective method of reduced scar
breast reduction.

KEYWORDS: Breast, reduction, SPAIR, scar

R ecent techniques of breast reduction have fo- maneuvers can be seen immediately, precise control
cused on reducing the amount of cutaneous scar asso- over the final result is achieved. As well, the final shape
ciated with the procedure. To this end, several different that is created is maintained over time and is resistant
surgical strategies have been described with nearly all of to postoperative change in shape or ‘‘bottoming out.’’
them basing the blood supply to the nipple and areola on Taken together, these factors combine to create a reliable
some variant of a superior pedicle.1–11 The focus of this and consistent technique for managing in an aesthetic
article is to describe a short scar technique based on an fashion the patient with a ptotic or enlarged breast.
inferior pedicle. The excess skin envelope is managed
using a combined periareolar and vertical excision pat-
tern, and shape is enhanced with a pattern of internal PREOPERATIVE MARKING
parenchymal sutures. The technique, called a ‘‘short scar The goal of the marking pattern is to identify that part of
periareolar inferior pedicle reduction’’ (or ‘‘SPAIR’’ the skin envelope that must be retained to easily wrap
mammaplasty)12–14 is applicable to all types of macro- around the inferior pedicle in a tension-free manner.
mastia as well as cases of moderate to severe ptosis. The With the patient standing, the midsternal line, infra-
advantages afforded by the procedure include the crea- mammary fold, and lateral breast contour are marked
tion of an aesthetic breast shape immediately without the (Fig. 1). Four points are then identified around the
need for a period of postoperative settling to define the periphery of the breast, which will eventually define an
ultimate result. Because the effect of direct shaping elongated oval. The top point is identified by placing a

New Trends in Reduction and Mastopexy; Editor in Chief, Saleh M. Shenaq, M.D.; Guest Editors, Scott L. Spear, M.D., F.A.C.S. and Steven
P. Davison, M.D., D.D.S., F.A.C.S. Seminars in Plastic Surgery, Volume 18, Number 3, 2004. Address for correspondence and reprint requests:
Dennis C. Hammond, M.D., Center for Breast and Body Contouring, 4070 Lake Drive, Suite 202, Grand Rapids, MI 49546. 1Center for Breast
and Body Contouring, Grand Rapids, MI. Copyright # 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001
USA. Tel: +1(212) 584-4662. 1535-2188,p;2004,18,03,231,243,ftx,en;sps00130x.
231
232 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER 3 2004

Figure 1 With the patient standing, (A) the midsternal line, (B)
the lateral breast fold, and (C) the inframammary fold are marked.

mark 4 cm up from the inframammary fold. One Next, the breast meridian is drawn, extending
repeatable way to identify the fold is to draw a line the line down the center of the breast and onto the chest
connecting the inframammary fold across the midline wall (Fig. 4). An 8-cm inferior pedicle is drawn, placing
(Fig. 2). With the breasts in repose, accurate identifica- the base of the pedicle at the inframammary fold
tion of the fold can then be made without manipulating and centering the width of the pedicle on the breast
or possibly distorting the breast. A distance of 4 cm is
measured up from this point over the sternum. Drawing
a line across the breasts parallel to this identifies the top
mark of the pattern (Fig. 3).

Figure 3 With the breasts in repose, the exact location of the

fold can be seen in the midline. A point is measured 4 cm up from
the fold in the midline and a line parallel to this is drawn across
Figure 2 The inframammary folds are joined by a parallel line the breasts. This identifies the superior part of the periareolar
that extends across the midline. pattern.
 SPAIR MAMMAPLASTY/HAMMOND 233

Figure 4 The breast meridian is drawn, dividing the breast into Figure 5 An 8-cm wide pedicle is drawn, centering the pedicle
two equal volumetric halves. The location of the nipple and areola on the breast meridian. On either side of the pedicle, a distance
is ignored when drawing this line as it is often displaced medially of 8 to 10 cm is measured up from the fold (here 9 cm was used).
or laterally in relation to the volume of the breast. The meridian These two points are then joined in a smooth line that parallels
line is carried down onto the chest wall. the inframammary fold. This marking sequence identifies the
inferior skin envelope to be preserved.

meridian. A distance of 8 to 10 cm is then measured up the top of the areola by 2 cm. The same pattern is dia-
on either side of the pedicle, and these two points are grammed on each breast, with care being taken to ensure
joined in a line that parallels the curve of the inframam- symmetry in the skin left behind on each breast (Fig. 8).
mary fold (Fig. 5). This identifies the inferior portion of The dimensions of the oval are measured and noted.
the oval and delineates the inferior skin envelope that Experience has shown that dimensions of 15 cm or less
will be preserved. The shorter measurement is used for are easily handled without difficulty. Oval measurements
smaller breasts and in cases of mastopexy, and the longer of 15 to 20 cm require some experience with the
measurement is used in cases of more significant macro- technique to obtain aesthetic results with consistency,
mastia. The medial and lateral portions of the pattern are and measurements of greater than 20 cm often require
identified by lifting the breast up and out and then up extra care to obtain acceptable breast shapes. This com-
and in with just enough tension to create a rounded pletes the marking process.
medial and lateral breast contour. The breast meridian is
then transposed onto the medial and lateral portion of
the breast to identify the medial and lateral points of the OPERATIVE TECHNIQUE
oval (Fig. 6). A 52-mm areolar mark is made in the existing areola
In this fashion, four landmarks are identified that with the skin under stretch (Fig. 9). The areolar and
outline the skin envelope to be preserved. Typically this periareolar incisions are made, and the inferior pedicle is
outline has the shape of an elongated oval (Fig. 7). The de-epithelialized as is a rim of skin around the periar-
inferior pedicle is diagrammed inside the oval, skirting eolar pattern (Fig. 10). The incisions are deepened, and a

Figure 6 (A, B) By drawing the breast up and out in a way that creates the rounded medial contour desired at the end of the case, the
precise amount of medial skin envelope required to wrap around the inferior pedicle can be seen. A mark is made medially transposing
the location of the breast meridian onto the medial breast skin at the level of the nipple. The same maneuver is performed laterally,
drawing the breast up and in and transposing the breast meridian onto the breast skin at the level of the nipple.
234 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER 3 2004

rim of dermis around the periareolar pattern is preserved

by incising through the dermis 5 mm away from the skin
edge (Fig. 11). This creates a ledge into which the
periareolar purse-string suture is ultimately placed. Flaps
are then developed around the periphery of the breast,
which are initially elevated just under the dermis and
become gradually thicker as dissection proceeds down to
the chest wall (Fig. 12). Medially and superiorly the flaps
are 4- to 6-cm thick near the chest wall. Laterally the
flap is kept somewhat thin with dissection proceeding at
the level of the breast capsule, making the flap 2- to 3-cm
thick (Fig. 13).
Once the flaps are developed, the inferior pedicle
is skeletonized, removing excess tissue from around the
periphery of the pedicle. Care is taken not to undermine
Figure 7 In this fashion, four points are identified, which
typically form an elongated oval. This outlines the skin envelope
the pedicle (Fig. 14). The superior and medial flaps
to be preserved to wrap around the inferior pedicle without are then undermined, with care being taken not to divide
tension. the internal mammary perforators. The upper flap is
then sutured under itself, drawing the internal leading

Figure 8 (A, B) The four points are joined and the inferior pedicle is outlined. The skin to be resected is cross-hatched; the skin to be de-
epithelialized is dotted. The dimensions of the periareolar pattern are measured and noted.

Figure 10 The inferior pedicle within the periareolar pattern is

Figure 9 A 52-mm areolar diameter is diagrammed on the de-epithelialized along with a rim of dermis at the periphery of the
existing areola. pattern.
 SPAIR MAMMAPLASTY/HAMMOND 235

The medial flap is plicated upon itself by grasping the

deep leading edge of the flap in two locations separated
by several centimeters and suturing them together
(Fig. 16). This again uses the patient’s own tissues to
fill in the medial portion of the breast, creating a full,
rounded contour. Finally the inferior pedicle is sutured
to the pectoralis major fascia to prevent the pedicle from
falling off laterally into the axilla (Fig. 17). This cen-
tralizes the pedicle and enhances the shape and projec-
tion of the breast and prevents undue lateral fullness.
The redundant inferior skin envelope is plicated together
with staples until a rounded contour is created.
In larger reductions, the vertical plication curves
out laterally but never extends below the inframammary
Figure 11 Once de-epithelialized, the dermis is divided around fold. The areola is inset with staples and the shape of the
the pedicle and around the periareolar pattern, leaving a 5-mm breast is assessed with the patient upright (Fig. 18).
dermal shelf, which will ultimately hold the purse-string suture. Revision of the skin plication via additional skin tight-
ening is performed as needed to create an aesthetic breast
shape. Once the desired shape has been created, the skin
edge of the flap superiorly and fixing it to the pectoralis is marked with a surgical marker (Fig. 19A) and the
major fascia (Fig. 15). In this fashion the patient’s own staples removed. At this point a slightly canted V-shaped
tissues are used to autoaugment the upper pole of the pattern is seen with the inferior pedicle centered in the
breast, thereby correcting any preoperative concavity. middle (Fig. 19B). The skin over the inferior pedicle is

Figure 12 (A) Initial dissection of the medial flap occurs just under the dermis and gradually becomes thicker until (B) the chest wall is
reached, where the flap is 4 to 6 cm thick. (C) The same strategy is used to dissect the superior flap, keeping it thin initially and (D)
gradually making the flap thicker until the chest wall is reached.
236 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER 3 2004

Figure 13 (A) Laterally the flap is kept somewhat thin, dissecting the breast at the level of the breast capsule. (B) Dissection continues
down to the lateral breast fold.

Figure 14 After the flaps are developed, (A) the inferior pedicle is skeletonized and (B) a C-shaped segment of tissue is removed from
around the pedicle.

de-epithelialized, and the medial and lateral wedges of closure of the vertical segment. This eases the vertical
skin and parenchyma on either side of the pedicle are closure and prevents distortion due to tissue crowding,
removed (Fig. 20). which can occur if the lateral flap is not fully released.
Incising the full thickness of the lateral flap allows The vertical incision is closed with interrupted inverted
it to pass over the top of the inferior pedicle during 4–0 absorbable monofilament sutures followed by a

Figure 15 After the breast has been reduced, the remaining tissue must be reshaped. (A) The superior flap is undermined and (B) the
leading deep edge of the upper flap is pushed up under itself and sutured to the pectoralis major fascia.
 SPAIR MAMMAPLASTY/HAMMOND 237

Figure 16 (A) The medial flap is undermined and (B) the deep leading edge is plicated to itself to create a rounded medial contour.

running subcuticular suture of the same material. With defect that measures 3.5 to 4 cm in diameter is created
closure of the vertical segment, the dimensions of the (Fig. 22). The suture is passed initially from deep to
periareolar defect are significantly reduced. superficial and ends by passing the needle from super-
However, there is still a variable discrepancy be- ficial to deep. In this fashion, the knot is buried deeply
tween the circumference of the areolar incision and the under the dermal ledge and potential erosion with
circumference of the periareolar defect. This is managed exposure of the knot is avoided. It is necessary to use 8
by placing a purse-string suture in the dermal ledge to 10 throws of the knot to ensure that it will resist
created during the initial de-epithelialization. For the slipping.
purse-string suture to pass easily, it must have several At this point, with the patient upright, the
attributes. The suture must be strong, long-lasting or periareolar defect often has an elongated ovoid shape.
permanent, and smooth or monofilament so as to pass This is corrected by de-epithelializing additional skin as
easily through the dermal framework of the ledge. I have needed to create a perfect circle, and the areola is inset as
found Goretex (W. L. Gore, Phoenix, AZ) suture to before with 4–0 absorbable monofilament suture
best satisfy these requirements. I use the CV3 size on a (Fig. 23). The incisions are supported with tape and
straight needle (Fig. 21), which allows passage of the dressed with a clear occlusive adhesive sheeting. Drains
suture within the dermal ledge with a minimum of are placed only in reductions of larger than 800 to 1000 g.
passes. The purse-string suture is drawn closed until a A support garment is placed to complete the procedure.

Figure 18 The redundant inferior skin envelope is plicated upon

Figure 17 The base of the inferior pedicle is sutured centrally to itself with staples until a smooth contour is created and the areola
the pectoralis major fascia to keep the pedicle from falling off is temporarily inset. With the patient upright, a pleasing contour
laterally. should be evident.
238 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER 3 2004

Figure 19 (A) The vertical staple line is marked and cross-hatched. (B) Once the staples are removed, the inferior pedicle can be seen
lying centrally within the skin pattern that needs to be removed.

POSTOPERATIVE CARE
Patients are typically kept overnight in the hospital,
although some cases of mastopexy and reductions of
less than 500 g are performed on an outpatient basis.
Dressings are changed at 7 to 10 days and tape support of
the wound is continued for 6 weeks, changing the tape as
needed. A support garment is worn for the first 6 weeks.
There is no need for tight or conforming dressings to be
applied. The initial swelling is largely gone by 6 weeks,
and the full result is mature at 6 months to 1 year.

RESULTS
The results of the SPAIR mammaplasty have been very
satisfying to both patient and surgeon alike. The shapes
Figure 20 The inferior pedicle is de-epithelialized and a small that result are more rounded in appearance than with my
medial wedge and a larger full-thickness lateral wedge of skin and previous Wise pattern inferior pedicle reductions and,
parenchyma are removed. generally speaking, are more aesthetic. In particular,
excellent projection of the breast is created and main-
tained over time. In cases of mastopexy, parenchymal

Figure 21 (A) CV3 Goretex suture on a straight needle is used to create a purse-string around the periareolar defect. (B) The needle is
passed directly into the substance of the de-epithelialized dermal shelf created at the beginning of the procedure.
 SPAIR MAMMAPLASTY/HAMMOND 239

Figure 22 (A) Once the purse-string suture is in place, (B) tension on the suture is applied until the periareolar defect is  3.5 to 4 cm in
diameter.

repositioning combined with vertical skin tightening is The technique is easily applied to reductions of
quite effective in coning the breast and improving the 500 g or less (Fig. 24). The resection of parenchyma and
overall shape. Accomplishing these goals with a mini- the plication of the inferior skin envelope proceed in a
mum of scar is particularly attractive to this subgroup of straightforward fashion, and aesthetic results are rela-
patients who generally have high aesthetic expectations. tively easy to obtain. For reductions of 500 to 1000 g, it is

Figure 23 (A) With the patient upright, the periareolar defect created after placement of the purse-string suture is often irregular. (B, C)
Using an areolar template, a 44-mm circular pattern is centered over the areolar opening. (D) The additional skin is de-epithelialized to
create a circular areolar defect into which (E) the areola is inset. (F) At the conclusion of the reduction on the first side, the breast should
have an aesthetic appearance. (G) After reduction of both sides, reasonable symmetry should be evident.
240 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER 3 2004

Figure 23 (continued)

helpful to have some experience using vertical incisions, the periareolar scar. It is not uncommon to note persis-
as plication of the redundant skin can require some tent pleating in the skin around the areola, and the areola
finesse. Generally speaking, however, good to excellent itself may have an elongated or irregular appearance. As
results are also obtained in this group of patients well, in these patients, who tend to be over their ideal
(Fig. 25). For reductions of more than 1000 g, there body weight, stretch of the skin in the inferior pole of the
may be some compromise in the aesthetic appearance of breast can result in some loss of breast projection.

Figure 24 (A, B) The preoperative appearance of a 17-year-old woman in preparation for a SPAIR mammaplasty.
Figure 24 (continued) (C, D) Appearance 6 months after removal of 420 g of tissue from the right breast and 452 g from the left.

Figure 25 (A, B) The preoperative appearance of a 34-year-old woman in preparation for a SPAIR mammaplasty. (C, D) The
preoperative marks were placed as described in the text, showing a periareolar dimension of 16 by 20 cm on the right and 18 by
21 cm on the left. (E, F) Appearance 6 months after removal of 806 g of tissue from the right breast and 704 g from the left.
242 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER 3 2004

Figure 26 The preoperative appearance of a 42-year-old woman

in preparation for a SPAIR mammaplasty. (C) The preoperative
marks outline a periareolar dimension of 17 by 23 cm on the right
and 22 by 28 cm on the left. (D, E) Appearance 8 months after
removal of 1336 g from the right breast and 1589 g from the left.

However, the overall aesthetic results still tend to be removed after complete resolution of swelling has oc-
better than with the Wise pattern inferior pedicle curred, usually around 1 year postoperatively. Unattrac-
technique (Fig. 26). tive scars can develop in the vertical segment or around
the areola, and these are easily revised. Shape distortion
typically involves stretch of the skin of the inferior pole
COMPLICATIONS of the breast, a problem easily addressed by simply
Significant complications are unusual with this tech- tightening the vertical skin closure. Overall, however,
nique and tend to be isolated to large reductions or complications are few and tend to be easily managed
patients with an excessively redundant skin envelope. often with simple office procedures.
The most common issue requiring attention postopera-
tively is usually a small wound dehiscence in the vertical
skin closure. In every instance, these small wounds heal SUMMARY
secondarily with only local wound care. Occasionally fat The SPAIR mammaplasty has proven to be an effective,
necrosis will be identified as a small mass near the apex of consistent, and reliable method of breast reduction and
the inferior pedicle, and the firm mass of necrotic fat is ptosis management; it is straightforward, easily learned,
 SPAIR MAMMAPLASTY/HAMMOND 243

and generally applicable to a wide variety of patients. It is 6. Lejour M. Vertical mammaplasty and liposuction of the
recommended as a useful tool that can assume a promi- breast. Plast Reconstr Surg 1994;94:100–114
nent place in the armamentarium of the plastic surgeon 7. Peixoto G. Reduction mammaplasty. Aesthetic Plast Surg
1984;8:231–236
who deals with macromastia and ptosis.
8. Arie G. Una nueva tecnica de mastoplastia. Rev Latinoam Cir
Plast 1957;3:23–38
9. Regnault P. Reduction mammaplasty by the B technique.
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1986;10:9–15 12. Hammond DC. Short scar periareolar inferior pedicle reduc-
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vertical scar. Aesthetic Plast Surg 1987;11:107–112 890–901
4. Lassus C. A 30-year experience with vertical mammaplasty. 13. Hammond DC. Short scar periareolar inferior pedicle reduc-
Plast Reconstr Surg 1996;97:373–380 tion (SPAIR) mammaplasty/mastopexy: how I do it step by
5. Lejour M, Abbound M. Vertical mammaplasty without step. Perspectives Plast Surg 2001;15:61–70
inframammary scar with breast liposuction. Perspectives Plast 14. Hammond DC. The SPAIR mammaplasty. Clin Plast Surg
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