Surgical anatomy of reduction mammaplasty: a historical perspective and current concepts.

Reduction mammaplasty is the volumetric reduction in the bulk of the breast. Techniques have evolved from primarily reducing the breast bulk to reducing with emphasis on functional and aesthetic outcome. The deeper understanding of the surgical anatomy of the breast has guided this development. While Paulus Aegina (sixth century AD), Dieffenbach (1848) and Gaillard-Thomas (1882) set the pace in glandular reduction; Pousson (1897) and Dehner (1908) focused on breast ptosis. It took quite some time before the enigma of the vascularization to the nipple areolar complex could be solved. Progress over a decade saw Thorek's (1922) free nipple grafting replaced by the periareolar de-epithelialization introduced by Schwarzmann (1930); which subsequently gave way to the Gillies and McIndoe (1939) skin-gland undermining technique. The era of breast remodeling while preserving the nipple areolar complex was soon ushered forward. This was driven by Arie (1957), Strombeck (1960) and Pitanguy (1961). The preservation of the subdermal plexus became crucial whilst retaining sensory supply to the breast as the pectoral fascia was spared. Skoog's (1963) nipple transposition without skin-gland undermining formed the basis for modern day reduction mammaplasty. Aesthetics was in mind throughout this period as different skin incisions were developed and advanced following Dieffenbach's small submammary incision in 1848. Surgical landmarks that ensured reproducible aesthetic outcomes were described by Penn (1955) and Wise (1956). Liposuction-assisted reduction was introduced by Teimourian in 1985 and is best utilised in patients with predominantly fatty breast tissue.

VRAM flap for an above knee amputation stump.

Although routinely utilized in reconstruction of groin, perineal and thigh defects, the pedicled vertical rectus abdominis myocutaneous (VRAM) flap has only once been previously reported for coverage of above knee amputation (AKA) stumps. A 36 year old man sustained a traumatic above knee amputation after stepping on an improvised explosive device (IED). Following several sessions of debridement, an ipsilateral pedicled VRAM flap was utilized to provide padded soft tissue coverage and maintain bone length (6 cm below the greater trochanter), avoiding both a debilitating hip disarticulation and a need for a free flap. We describe this procedure, report the outcomes and discuss considerations for utilizing this flap.