Anterior Intercostal Artery Perforator Flap Autologous ...

COSMETIC

Anterior Intercostal Artery Perforator Flap
Autologous Augmentation in Bariatric Mastopexy

Paolo Persichetti, M.D., Ph.D. Background: Breast reshaping after massive weight loss represents a challeng-
Stefania Tenna, M.D., Ph.D. ing procedure because of severe hypoplasia and tissue ptosis. Standard mas-
Beniamino Brunetti, M.D. topexy techniques are often inadequate to restore a pleasant profile and volume.
Achille Aveta, M.D. The authors present their experience with the anterior intercostal artery per-
Francesco Segreto, M.D. forator flap in breast autologous augmentation and remodeling.
Giovanni Francesco Marangi, Methods: Fifteen bariatric patients (30 breasts) affected by severe breast ptosis
M.D. and tissue laxity in the upper abdominal wall underwent superior pedicle
mastopexy with anterior intercostal artery perforator flap autologous augmen-
Rome, Italy tation. The flap was harvested including soft tissues above and below the in-
framammary fold, extending cranially 5 to 6 cm above the fold and inferiorly
over the costal cage and hypochondrium. The flap was completely islanded on
intercostal perforators originating from the fifth to seventh intercostal spaces.
It was cranially advanced and sutured to the pectoralis major fascia. The medial
and lateral borders were sutured together to shape an “autologous implant.”
Results: All of the flaps were transferred successfully. The donor site was always
closed primarily and upper abdominal laxity corrected. All of the breasts presented
soft at palpation, with no clinical signs of flap necrosis early or late postoperatively.
At 1-year follow-up, the breasts maintained good shape and projection.
Conclusions: The anterior intercostal artery perforator flap proved to be a
reliable option in bariatric mastopexy. The technique can be performed easily
and allows the harvesting of a large amount of tissue with a wide range of motion,
providing adequate breast volume and projection without the need for implant
placement. (Plast. Reconstr. Surg. 130: 917, 2012.)

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The number of bariatric surgery procedures colleagues2 already described the use of cadaveric
has increased constantly over the past dermis (AlloDerm; LifeCell Corp., Branchburg,
decade.1 Although they may solve the excess N.J.) to supplement suspension of the breast and
weight and many of its associated comorbidities, the implant in an anatomical position, but the
the patient is left with excess skin and soft tissue, ideal volume restoration in this scenario is repre-
often leading to referral to the plastic surgeon.
The breast profile may be severely distorted as a Disclosure: The authors have no financial interest
consequence of massive weight loss, with upper or commercial association with the subject matter or
pole deficiency, high-grade ptosis, and lowered products mentioned in this article. No funding was
inframammary fold. In these patients, mastopexy received for this work.
is challenging, traditional techniques are often
inadequate because of poor quality of tissues, and Supplemental digital content is available for
restoration of breast volume is a main issue for a this article. Direct URL citations appear in the
pleasant morphology. The thin overstretched der- text; simply type the URL address into any
mis and the poor subcutaneous tissue make im- Web browser to access this content. Clickable
plant placement alone unadvisable. Colwell and links to the material are provided in the
HTML text of this article on the Journal’s Web
From the Plastic and Reconstructive Surgery Unit, Campus site (www.PRSJournal.com).
Bio-Medico di Roma University.
Received for publication January 25, 2012; accepted April
19, 2012.
Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318262f38a

www.PRSJournal.com 917

Plastic and Reconstructive Surgery • October 2012

sented by the use of autologous tissues. Some flaps
such as the rotation-advancement of the supero-
medial pedicle described by Losken and Holtz3 or
the use of composite tissues nourished by inter-
costal perforators have been proposed. Starting
from Kerrigan and Daniel,4 several studies inves-
tigated the anatomy of perforators originating
from intercostal arteries.5,6 Pedicled and free flaps
nourished by these vessels have been described for
hand,5 breast, and trunk reconstruction.7 In par-
ticular, the use of intercostal artery perforator
flaps nourished by lateral branches of the inter-
costal system (lateral intercostal artery perforator
flap) has been previously reported in postbariatric
patients. The authors report their experience with
the anterior intercostal artery perforator flap,
based on anterior intercostal perforator branches
originating from the fifth to seventh intercostal
spaces, in the field of postbariatric autologous aug-
mentation mastopexy.

MATERIALS AND METHODS Fig. 1. Cadaveric study. (Above) Two or three perforators for

Cadaveric Study each intercostal space have been isolated. (Below) Perforators

In our preclinical phase, cadaveric studies emerging from the pectoralis major muscle fascia.
were performed to evaluate the viability of the
technique, focusing on localization of the perfo- costal artery perforator flap is drawn (Fig. 2). Flap
rators and range of motion of the flap. A large skin dimensions usually extend cranially until the
paddle above and below the inframammary fold lower margin of the areola (at least 5 to 6 cm above
was dissected to identify the number and course of the fold), and inferiorly 5 to 10 cm below the
the main perforators emerging from the pectora- inframammary fold, according to upper abdomi-
lis major, serratus anterior, and rectus abdominis nal skin laxity that needs to be corrected and al-
muscle fascia. On average, two or three musculo- ways checking manually for feasibility of primary
cutaneous perforators for each intercostal space closure. Flap harvesting is performed in supine
were found (Fig. 1). Flap dimensions ranged from position using 2.5ϫ loupe magnification: the su-
6 to 12 cm in width and 6 to 20 cm in length, perior portion of the flap is first dissected cranio-
depending on upper abdomen laxity. Range of caudally along and pectoralis major fascia; then,
motion of the flap was also assessed and was 3 to inferiorly, the flap is undermined following a
5 cm. The greatest advancement has been plane superficial to the serratus anterior and rec-
achieved by sacrificing the most caudal perfora- tus abdominis muscles fasciae. Major intercostal
tors. [See Figure, Supplemental Digital Content 1, perforators emerging through the pectoralis ma-
which shows a cadaveric study, http://links.lww. jor, serratus anterior, and rectus abdominis mus-
com/PRS/A539. (Left) Mobility of the flap. (Right) cles are isolated. The anterior intercostal artery
Increased range of motion after sacrifice of the perforator flap is islanded on perforator vessels
most caudal perforators.]

Flap Design and Operative Technique

Preoperative marking of inverted-T superior
pedicle mastopexy8 is planned. A pinch test of the
upper abdominal wall, in supine and orthostatic
positions, has to be performed to quantify the
amount of skin laxity. The position and number of
cutaneous intercostal perforators is identified by a
hand-held Doppler probe above and below the
inframammary fold, and then the anterior inter-

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Volume 130, Number 4 • Remodeling after Bariatric Mastopexy

Fig. 2. Preoperative markings after Doppler mapping. Fig. 3. Anterior intercostal perforators. Adequate mobility of the

from the fifth to seventh intercostal spaces, and all flap is achieved without skeletonizing perforators through the
of the perforators are initially spared without skel-
etonizing them through the muscle (Fig. 3). Mo- muscle.
bility of the flap is then evaluated. Perforators
from the seventh space can be sacrificed to en- Patient Population
hance cranial advancement and avoid their com-
pression by primary closure of the donor site. Mi- Fifteen bariatric patients (30 breasts) under-
nor lateral vessels may also be cut to obtain a better went anterior intercostal artery perforator flap au-
breast reshaping (Fig. 4). After careful evaluation tologous augmentation combined with inverted
of vascularity, the flap is decorticated. The supe- T-mastopexy at the Department of Plastic, Recon-
rior border is anchored to the pectoralis major structive, and Aesthetic Surgery of “Campus Bio-
fascia (Fig. 5, left), and the medial and lateral Medico di Rome” University from March of 2010
borders are flipped and sutured to each other in to April of 2011 (Table 1). In eight patients, the
a round shape fashion. The “autoimplant” is sta- severe breast ptosis was associated with significant
bilized to the pectoralis major fascia with absorb- skin laxity in the upper abdominal wall. The mean
able sutures to prevent shearing forces on the age of the patients was 40.3 years and the average
perforators (Fig. 5, right). (See Figure, Supple- body mass index was 32.7. Sleeve gastrectomy had
mental Digital Content 2, which shows the surgical been performed in four patients, biliopancreatic
technique, http://links.lww.com/PRS/A540. Medial diversion had been performed in nine patients,
and lateral borders of the anterior intercostal ar- transoral gastroplasty had been performed in one
tery perforator flap are sutured to model an au- patient, and gastric bypass had been performed in
toprosthesis.) Breast shape and projection are one patient. The average weight loss was 45 kg, and
checked and abdominal subcutaneous tissue is un- the average suprasternal notch–to–nipple dis-
dermined to achieve primary closure of the donor tance was 28.9 cm. All of the patients had stable
site, as in a reverse abdominoplasty. The superfi- weight control within the previous 6 months. No
cialis fascia must be fixed to rib periosteum with other surgical procedure was performed at the
nonabsorbable stitches to redefine the inframam- same time. Follow-up ranged from 6 to 12 months.
mary fold in the position planned during the pre-
operative drawing. Mastopexy is then completed RESULTS
with the patient sitting: the breast is sutured All of the flaps were transferred successfully.
around the “autologous implant” as in a standard The mean size of the flaps was approximately 8.8
inverted-T superior pedicle technique. (See Fig- ϫ 12.9 cm. Usually the flap was harvested on at
ure, Supplemental Digital Content 3, which shows least three perforators, mainly arising from the
an intraoperative view of the breast sutured over fifth space.
the anterior intercostal artery perforator flap in a Mean harvesting time for a single flap was 40
standard inverted-T technique, http://links.lww. minutes, and all of the procedures were per-
com/PRS/A541.) Suction drains are placed for formed bilaterally with a double team to reduce
each side and kept for at least 48 hours. operative time. Mean operative time was 3 hours,
and the use of anterior intercostal artery perfora-

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Plastic and Reconstructive Surgery • October 2012

Fig. 4. (Left) Anterior intercostal artery perforator flap completely islanded and decorticated. (Right) In-
creased mobility of the flap after sacrifice of the minor caudal perforators.

Fig. 5. (Left) “Key stitches” to the pectoralis major fascia. (Right) An “autoprosthesis” is shaped and sta-
bilized to the pectoralis major fascia to prevent shearing forces on the perforators.

tor flaps did not add a significant amount of extra tient 7, http://links.lww.com/PRS/A542. (Left) In-
time to the classic mastopexy procedure. All donor traoperative view: the “autologous implant” has
sites were closed primarily. Patients were all dis- been shaped and sutured. (Center) Preoperative
charged on the first postoperative day. Physical view. (Right) Photograph obtained 6 months post-
examination was performed 1, 3, 6, and 12 months operatively.] Upper abdominal skin laxity was al-
after surgery. Within the first month, one patient ways improved.
needed vertical scar revision of a single breast
and another presented inframammary fold caudal DISCUSSION
dislocation that had to be corrected with resus-
pension under local anesthesia. No other compli- The use of the intercostal vascular pedicle to
cations were registered. In all follow-up examina- supply a skin flap was first described by Esser in
tions, breasts were soft at palpation, with no 1931.9 Since then, several anatomical studies have
clinical signs of flap necrosis. At 12-month post- investigated the anatomy of these vessels.5,6 The
operative follow-up, a stable result with good nip- anterior intercostal arteries originate from the in-
ple position, breast shape, and projection was reg- ternal mammary artery from the first to the sixth
istered (Figs. 6 through 8). [See Figure, intercostal spaces and from its terminal branch,
Supplemental Digital Content 4, which shows pa- the musculophrenic artery, from the seventh to
the ninth spaces. These arteries communicate

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Table 1. Patients Who Underwent Anterior Intercostal Artery Perforator Flap Autologous Augmentation
Combined with Inverted-T Mastopexy

Age Suprasternal Upper Abdominal Flap No. of Perforators
Patient (yr) Notch–to–Nipple
Bariatric Procedure Laxity Dimension (cm) Supplying the Flap
Distance (cm)

1 55 Biliopancreatic diversion 34.5 ϩϩ 10 ϫ 18 4
ϩϩ 8ϫ7 3
2 50 Gastric bypass Left, 30; right, 28.5 ϩ 5
ϩ 10 ϫ 15 4
3 43 Sleeve gastrectomy Left, 26; right, 27 ϩϩ 10 ϫ 16 4
ϩ 3
4 33 Biliopancreatic diversion Left, 28; right, 27.5 ϩϩ 9 ϫ 18 3
ϩ 6 ϫ 10 4
5 28 Transoral gastroplasty 31 8ϫ8 4
8 ϫ 15 4
6 42 Biliopancreatic diversion Left, 27; right, 27.5 9 ϫ 16 3
8 ϫ 15 3
7 32 Sleeve gastrectomy 28 10 ϫ 8 5
10 ϫ 9 3
8 51 Sleeve gastrectomy Left, 26.5; right, 27.5 10 ϫ 14 4
8 ϫ 10
9 37 Biliopancreatic diversion 29 10 ϫ 15

10 48 Biliopancreatic diversion Left, 30.5; right, 30

11 35 Sleeve gastrectomy 30

12 40 Biliopancreatic diversion Left, 30; right, 31.5

13 46 Biliopancreatic diversion Left, 32; right, 31

14 34 Biliopancreatic diversion 28.5

15 31 Biliopancreatic diversion Left, 27; right, 25.5

with the posterior intercostal arteries at approxi- ments; these vessels extend horizontally along the
mately the medial third of the ribs, constituting a rib cage and anastomose vertically with each other.
vascular arcade from which multiple perforators Moreover, the vascular system deriving from these
arise.7 The course of intercostal vessels can be arteries shows anastomoses with the system belong-
divided horizontally into four segments: vertebral, ing to the superior epigastric artery.5 The anterior
intercostal, intermuscular, and rectal.4 Flaps are intercostal artery perforator flap is supplied by
named by the segment from which their vascular vessels originating from the muscular or rectal
supply arises. The pedicle of the dorsal intercostal segment of intercostal arteries7 and presents sev-
artery perforator flap derives from the vertebral eral advantages compared with the lateral inter-
segment. The dorsal intercostal artery perforator costal artery perforator flap, such as the larger
flap has been used mainly as a pedicled flap for the amount of harvestable tissue because of the
closure of midline back defects.10–12 The lateral greater number of perforators and superior mo-
intercostal perforator flap is based on vessels de- bility. The use of the anterior intercostal artery
riving from the costal segment. It was first de- perforator flap has been described for coverage
scribed by Badran et al. in 198413 and has been of epigastric abdominal wounds,23 for hand
used for correction of facial contour14 and for reconstruction,5 for correction of sequelae from
breast reconstruction.15–18 The use of this flap for augmentation mammaplasty24 and for reconstruc-
autologous breast augmentation was first reported tion of sternal defects.7 Anterior intercostal per-
by Hurwitz and Agha-Mohammadi, who per- forators are also the vessels that nourish the infe-
formed a “spiral flap.”19 Kwei et al.20 described its rior dermolipoglandular flap used in mastopexy
anatomical basis and, in addition to Hamdi and procedures and first presented by Dr. Ribeiro at
colleagues,21 reported their experience with the the Congress of the Brazilian Society of Plastic
lateral intercostal artery perforator flap. In 2011, Surgery in 1971. This flap is vascularized by arter-
Akyurek published an article about the use of a ies that arise from the fourth to sixth intercostal
pectoralis muscle sling to prevent the descent of spaces. In Dr. Ribeiro’s technique,25,26 it is har-
the flap when used for autologous breast augmen- vested from the lower pole of the breast, then
tation in bariatric patients.22 The lateral intercos- advanced cranially as a pedicled flap and sutured
tal artery perforator flap has the advantages of to the pectoralis major fascia to provide breast
improving breast fullness and correcting the ax- firmness and projection. Modifications of the clas-
illary roll at the same time, but a long scar in the sic Ribeiro technique to address massive weight
lateral chest wall results from the surgical proce- loss patients have already been described in the
dure. Moreover, this flap has limited mobility be- literature. Daniel suggested the passage of the flap
cause of its small arc of rotation and is nourished under a loop of pectoral muscle to improve long-
by few perforator vessels. In contrast, in the ante- term projection,27 whereas Ritz et al. reported
rior chest, several perforating branches can be their experience in passing the flap only under the
found from the fifth to eighth intercostal seg- pectoralis fascia.28 However, these procedures im-

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Plastic and Reconstructive Surgery • October 2012

Fig. 6. Photographs of patient 3 obtained (left) preoperatively and (right) 6 months postopera-
tively. Notice the improvement in abdominal skin laxity, with transition from convexity to con-
cavity (lateral view).

ply increased morbidity and could harm oncologic amount of tissue by islanding the flap on only
diagnosis and treatment. Perforator flaps in the two or three perforators arising from the fifth or
past decade have enhanced tissue recruitment and sixth intercostal space is possible. However, the
flap mobility, and in this sense, our anterior in- fifth intercostal space perforators should be pre-
tercostal artery perforator flap can be considered ferred, as the more caudal ones are more diffi-
an evolution of Ribeiro’s flap without many cult to spare when the flap is advanced cranially
tradeoffs. Vessel dissection in fact provides supe- and the inframammary fold redefined. In this
rior mobility compared with the classic Ribeiro case, distal flap vascularization is maintained by
flap, without the need to perform skeletonization the vertical network of linking vessels connecting
through the muscle. Even if the anterior intercos- adjacent intercostal spaces.5 Furthermore, minor
tal artery perforator flap may be nourished by the lateral branches may be cut either to increase the
fifth to eighth intercostal space perforators, our flap’s mobility or to improve its reshaping in a sort
experience proved that safely harvesting a large of round autologous implant. Finally, the advan-

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Volume 130, Number 4 • Remodeling after Bariatric Mastopexy

Fig. 7. Photographs of patient 1 obtained (left) preoperatively and (right) 12 months postoperatively.

Fig. 8. Lateral preoperative (right) and postoperative (left) views of patient 1.

tage of correcting at the same time upper abdom- dominoplasty. The viability of the flap has never
inal lipodystrophy and ptosis must also be empha- been compromised because of many perforators
sized. Currently, upper abdominal tissue laxity nourishing this flap, and no major complications
may be addressed with several surgical strategies, have been recorded. In some cases, a temporary
such as anchor-line, reverse, or circumferential distortion of the inframammary fold profile may
abdominoplasties.29,30 In our technique, the har- be experienced, especially in cases of large tissue
vesting of abdominal tissue has two main advan- recruitment from the abdomen.
tages: first, it adds further projection to the re-
constructed breast; and second, it induces an We never performed abdominoplasty and
abdominal tissue lift, solving superior abdominal mastopexy with anterior intercostal artery perfo-
ptosis, which is often refractory to standard ab- rator flap surgery at the same time because of the
increased risk of complications and the additional

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Plastic and Reconstructive Surgery • October 2012

tension that would be placed on the inframam- the vascular anatomy and perfusion of perforator flaps. Plast
mary fold. In planning the two procedures, we Reconstr Surg. 2008;121:772–780.
would perform abdominoplasty first and then, af- 7. Hamdi M, Van Landuyt K, de Frene B, Roche N, Blondeel P,
ter 6 months, when the result was stable and the Monstrey S. The versatility of the inter-costal artery perfora-
tension had been redistributed, breast reshaping. tor (ICAP) flaps. J Plast Reconstr Aesthet Surg. 2006;59:644–652.
In our experience, the anterior intercostal artery 8. Pitanguy I. Principles of reduction mammaplasty. In: Geor-
perforator flap proved to be a safe and reliable giade NG, Georgiade GS, Riefkohi R, eds. Aesthetic Surgery of
option in bariatric mastopexy: it requires easy dis- the Breast. Philadelphia: Saunders; 1990:191.
section and allows the harvesting of a large 9. Esser J. Biological or Artery Flaps of the Face. Monaco: Institut
amount of tissue with a wide arc of rotation, thus Esser de Chirurgie Structive; 1931.
overcoming the need for implant placement. Pos- 10. Minabe T, Harii K. Dorsal intercostal artery perforator flap:
sible contraindications to this technique are large Anatomical study and clinical applications. Plast Reconstr
scars in the area of flap harvesting, such as from Surg. 2007;120:681–689.
open cholecystectomy, or prior inferior pedicle 11. de Weerd L, Weum S. The sensate medial dorsal intercostal
breast reduction. artery perforator flap for closure of cervicothoracic midline
defects after spinal surgery: An anatomic study and case
CONCLUSIONS reports. Ann Plast Surg. 2009;63:418–421.
Autologous augmentation with the anterior 12. Isik D, Tekes L, Eseoglu M, Isik Y, Bilici S, Atik B. Closure of
intercostal artery perforator flap represents a valid large myelomeningocele defects using dorsal intercostal ar-
option for breast reshaping in the massive weight tery perforator flap. Ann Plast Surg. 2011;67:159–163.
loss population. The procedure can be easily stan- 13. Badran HA, El-Helaly MS, Safe I. The lateral intercostal
dardized and is easy to perform, increases breast neurovascular free flap. Plast Reconstr Surg. 1984;73:17–26.
volume and projection, and corrects upper abdom- 14. Badran HA, Youssef MK, Shaker AA. Management of facial
inal skin laxity usually not responsive to classic ab- contour deformities with deepithelialized lateral intercostal
dominoplasty procedures. Inverted-T mastopexy free flap. Ann Plast Surg. 1996;37:94–101; discussion 101–105.
with the anterior intercostal artery perforator flap 15. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled
proved to be a very good technique for restoring perforator flaps in breast reconstruction: A new concept. Br J
breast shape and projection in postbariatric patients. Plast Surg. 2004;57:531–539.
16. Holmstro¨m H, Lossing C. Lateral thoracodorsal flap: An
Stefania Tenna, M.D., Ph.D. intercostal perforator flap for breast reconstruction. Semin
Plastic and Reconstructive Surgery Unit Plast Surg. 2002;16:53–59.
Campus Bio-Medico di Roma University 17. Hamdi M, Spano A, Van Landuyt K, D’Herde K, Blondeel P,
Monstrey S. The lateral intercostal artery perforators: Ana-
Via Alvaro del Portillo tomical study and clinical application in breast surgery. Plast
200-00128 Rome, Italy Reconstr Surg. 2008;121:389–396.
[email protected] 18. Rubin JP. Mastopexy after massive weight loss: Dermal sus-
pension and total parenchymal reshaping. Aesthet Surg J.
REFERENCES 2006;26:214–222.
19. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast
1. Matarasso A, Roslin MS, Kurian M; Plastic Surgery Educa- reshaping: The spiral flap. Ann Plast Surg. 2006;56:481–486;
tional Foundation Technology Assessment Committee. Bari- discussion 486.
atric surgery: An overview of obesity surgery. Plast Reconstr 20. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous aug-
Surg. 2007;119:1357–1362. mentation after massive weight loss: The intercostal artery
perforator (ICAP) flap. Ann Plast Surg. 2006;57:361–365.
2. Colwell AS, Driscoll D, Breuing KH. Mastopexy techniques 21. Hamdi M, Van Landuyt K, Blondeel P, Hijjawi JB, Roche N,
after massive weight loss: An algorithmic approach and re- Monstrey S. Autologous breast augmentation with the lateral
view of the literature. Ann Plast Surg. 2009;63:28–33. intercostal artery perforator flap in massive weight loss pa-
tients. J Plast Reconstr Aesthet Surg. 2009;62:65–70.
3. Losken A, Holtz DJ. Versatility of the superomedial pedicle 22. Akyurek M. Vertical mastopexy and lateral intercostal artery
in managing the massive weight loss breast: The rotation- perforator (LICAP) flap with pectoralis muscle sling for au-
advancement technique. Plast Reconstr Surg. 2007;120:1060– tologous tissue breast augmentation in the bariatric patient.
1068. Ann Plast Surg. 2011;66:29–35.
23. Hallock GG. The island anterior intercostal artery perforator
4. Kerrigan CL, Daniel RK. The intercostal flap: An anatomical flap as another option for the difficult epigastric abdominal
and hemodynamic approach. Ann Plast Surg. 1979;2:411– wound. Ann Plast Surg. 2009;63:414–417.
421. 24. Juri J, Valotta F, Le´tiz MS. Submammary flap for correction
of severe sequelae from augmentation mammaplasty. Plast
5. Oki K, Murakami M, Tanuma K, Ogawa R, Ozawa H, Hyaku- Reconstr Surg. 2004;114:567–574.
soku H. Anatomical study of pectoral intercostal perforators 25. Ribeiro L. A new technique for reduction mammaplasty.
and clinical study of the pectoral intercostal perforator flap Plast Reconstr Surg. 1975;55:330–334.
for hand reconstruction. Plast Reconstr Surg. 2009;123:1789– 26. Ribeiro L, Accorsi A Jr, Buss A, Marcal-Pessoa M. Creation
1800. and evolution of 30 years of the inferior pedicle in reduction
mammaplasties. Plast Reconstr Surg. 2002;110:960–970.
6. Saint-Cyr M, Schaverien M, Arbique G, Hatef D, Brown SA, 27. Daniel M. Mammaplasty with pectoral muscle flap. Paper
Rohrich RJ. Three- and four-dimensional computed tomo- presented at: 64th Annual Scientific Meeting of the Ameri-
graphic angiography and venography for the investigation of

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can Society of Plastic and Reconstructive Surgeons; October plasty and inframammary fold reconstruction. Aesthetic Plast
7–11, 1995; Montreal, Quebec, Canada. Surg. 2010;34:226–231.
28. Ritz M, Silfen R, Southwick G. Fascial suspension mastopexy. 30. Persichetti P, Simone P, Scuderi N. Anchor-line abdomino-
Plast Reconstr Surg. 2006;117:86–94. plasty: A comprehensive approach to abdominal wall recon-
29. Agha-Mohammadi S, Hurwitz DJ. Management of upper ab- struction and body contouring. Plast Reconstr Surg. 2005;116:
dominal laxity after massive weight loss: Reverse abdomino- 289–294.

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