## Superior pedicle with inverted-T skin resection - Markings (First Method): 1. Place patient in an upright position 2. Mark the midline 3. Mark the breast meridian to determine a new horizontal nipple position 4. Mark the vertical nipple location (Pitanguy's point) by transposition of IMF to front of breast 5. Mark the IMF position, elevating mark a few millimeters onto the breast (keeps the IMF scar on the breast and not on the chest because the base of the breast is narrowed during reduction) 6. Measure bilaterally from notch to nipple and from midline to ensure symmetry 7. Mark the vertical limbs, measuring approximately 7-8 cm under tension - Long limbs can always be shortened on the operating table - Short limbs may result in closure under tension, which may compromise shape and skin viability - The angle of divergence determines amount of skin resection 8. Connect vertical limbs to the medial and lateral aspects of the IMF marking following a lazy-S pattern 9. Mark the pedicle approximately 10-12 cm from the midline 10. Mark the areola at 42 mm; replace at 38 mm to minimize traction and distortion 11. Mark any areas to be liposuctioned > Important Tip: Large pendulous breasts demonstrate recoil of superior skin flap after elevation of the flap; plan for this when marking the new nipple location - Technical Notes: - Develop the pedicle before raising skin flaps. To avoid undercutting, bevel away from pedicle - Sit the patient up and tailor-tack, as needed, to achieve desired shape - Hidalgo reviewed the inverted-T pattern markings with modifications to improve aesthetic outcome - Markings (Alternative Method): 1. Place patient in an upright position 2. Mark the midline 3. Mark the upper breast border 4. Mark the position of the IMF 5. Transpose the level of the IMF to the breast and mark at the junction of the transposed IMF and breast meridian for new nipple position 6. Confirm new nipple position is 8-10 cm below upper breast border at intersection of breast meridian 7. Mark top of areolar opening 2 cm above new nipple position 8. Extend areolar markings to create 4-cm diameter opening upon closure 9. Mark vertical limbs by rotating breast medially and laterally 10. Join vertical limbs at meridian 2-4 cm above IMF 11. Design pedicle with 6-10 cm base; carry base slightly lateral to meridian if superomedial pedicle desired 12. Mark areas to be liposuctioned > Additional Technical Tips: - Create a V pattern rather than U when joining vertical limbs above IMF to prevent skin pucker on closure - After parenchyma excision, approximate breast pillars, inset the NAC, and close vertical incision in gathering fashion as needed - Refer to Hall-Findlay for detailed technique review