Surgical Science, 2011, 2, 80-88
doi:10.4236/ss.2011.22018 Published Online April 2011 (
Copyright © 2011 SciRes. SS
Modification of Moufarrege Total Posterior Pedicle
Mammaplasty: COnical Plicated Central U shaped
(COPCU’s) Mammaplasty
Eray Copcu
Adnan Menderes University, Medical Faculty, Department of Plastic,
Reconstruti ve a n d Aes t het ic Surgery, Aydin, Turkey,
Received February 4, 2011; revised March 8, 2011; accepted March 18, 2011
Reduction mammaplasty and mastopexy is one of the biggest operation groups which have many techniques
and their modifications. Generally accepted that, new modifications are the results of improvements of ex-
isting techniques. In this study we present a new modification of Moufarrege total posterior pedicle mamma-
plasty. We performed central plication to achieve a juvenile look in the superior pole of the breast and to
prevent postoperative pseudoptosis and used central U shaped flap to achieve maximum NAC safety and to
preserve lactation and nipple sensation. Sixty-nine patients were operated with the above mentioned tech-
nique. Out of 69 patients, 52 underwent reduction mammaplasty (11 had gigantomastia), eleven mastopexy,
and six oncoplastic. All of the patients were satisfied with functional and aesthetic results and none of them
had major complications such as total NAC loss. Only six patients had wound healing problems on the suture
line and two patients had minimal hematoma. Since we performed conical plication we would like to evalu-
ate long term effects of the plication in the breast parenchyma. Breast parenchyma was visualized with USG
in younger patients and mammography in older patient in postoperative 6 months and 1 year. We never ob-
served any problem related with our sutures and retroareolar part of the areola examination for ductal
patency was performed and interestingly all the patients had very clear ductal patency. Our modification is a
safe, reliable technique which creates the least scar, avoids previously described disadvantages, provides
maximum preservation of functions, can be employed in all breasts regardless of their sizes and is appropri-
ate for oncoplastic surgery and revision surgery.
Keywords: Breast Reduction, Mammaplasty, Pedicle
1. Introduction
There is no other procedure in breast surgery where the
surgeon has a greater opportunity to demonstrate his or
her aesthetic abilities than with a breast reduction [1].
There have been numerous studies on reduction mam-
maplasty and its modifications in the literature. The ear-
liest reports of breast reduction surgery date back hun-
dreds of years. Durston recognized the disability of large
female breast in 1670 [2]. The multitude of modifications
of reduction mammaplasty indicates that the ideal tech-
nique has not yet to be found. There are three reasons for
seeking the ideal techniqu e :
One reason is to preserve functional features of the
breast: breastfeeding and arousal. Another reason is to
achieve the real geometric and aesthetic shape of the
breast with the least scar. The last one is to minimize
complications of prior surgical techniques without caus-
ing an additio nal complication [3].
In 1970s McKissock introduced the vertical bipedicle
breast reduction technique, which was the first procedure
for breast reduction surgery that was both reliable and
reproducible [4]. Total posterior pedicle was described
by Moufarrege [5]. It was called total posterior pedicle
since the pedicle was just behind the NAC and the whole
posterior pedicle was made of the gland. Total posterior
pedicle achieved maximum gland and nipple security and
Moufarrege reported low rates of complications in more
than 10000 patients undergoing reduction mammaplasty
[6]. Moreover, none of them were major complications.
However, Moufarrege did not recommend total posterior
pedicle for very large breasts. It has been recommended
that the techniques described so far could be used for
reduction of breasts moderate in size. The management
of gigantomastia is still deba table. Many authors propo se
that nipple areola graft can be utilized for the manage-
ment of gigantomastia. In this study we present a new
modification of Moufarrege total posterior pedicle
We use total posterior pedicle as like in Moufarrege
technique; but we create a central located U shaped pedi-
cle for two reasons:
First, we try to prevent post-operative bottoming-out
deformity secondary to the bulky tissue of lower part of
the breast and, second we create only one space which
can be drained only one drain instead of two spaces. We
also perform conical plication in the superior part of the
breast for juvenile look.
In fact, conical plication creates fullness in the supe-
rior pole which in turn leads to an attractive and younger
look, the technique does not cause postoperative pseu-
doptosis which frequently occurs in mammaplasty tech-
niques, central U shaped pedicle allows maximum pres-
ervation of functions and the technique is applicable in
all breasts irrespective of their sizes. In short, maximum
preservation of functions and an aesthetic breast with
minimum scar are achieved by Conical Plicated Central
U shaped (COPCU’s) mammaplasty.
2. Material and Methods
This technique was a modification of the total posterior
pedicled mammaplasty described by Moufarrege [6]. The
most important feature of the technique was that the cen-
tral U shaped pedicle was a total posterior pedicle. The
“open sky” approach was used and all tissues were easily
accessible. Thus, the desirable shape was given and
maximum preservation of all anatomical structures was
achieved. While central U shaped pedicle was being cre-
ated, peripheral tissues were resected and posterior and
superior connections of the pedicle were preserved com-
pletely. The pedicle directly carried the NAC and all
vascular and neural connections of the pedicle were pre-
The first stage of the procedure was marking. A pre-
operative marking which was quite simple and easy to
apply in all patients was developed. As Moufarrege de-
scribed, the marking was performed when the patient
was seated. In order to preserve the axis of each breast
crossing the nipple, the vertical axis crossing the nipple
and paralleling the margins of the breast was identified
and this axis did not have to cross the midclavicular line
(Figure 1).
After the axis of the breast was detected, the in-
framammarian fold was marked. and the upper point of
the keyhole pattern was determined. This point was the
place where the inframammarian fold was located (Fig-
ure 3).
Next, the standard keyhole pattern was marked. Ex-
tending arms of the pattern had an angle of 90 degrees
and each was 5 cm in length (Figure 4).
Figure 1. Axis of the breast.
Figure 2. Marking of the i n f r a -mammarian fold.
Copyright © 2011 SciRes. SS
Figure 3. Determining of the upper point of the keyhole
Figure 4. Drawing of the keyhole pattern.
Moufarrege classified breasts into three based on their
size when marking the standard keyhole pattern. We in-
creased the angle between the arms of the keyh ole to 135
degrees only in cases of gigantomastia. A larger angle is
not more advantageous. In fact, creating a larger angle
requires harvesting more skin and causes tension on the
suture line, which may lead to difficulties in healing.
Arms of the keyhole 5 cm in length formed a curve 3 cm
above the inframammarian fold (Figure 4). Then, a ver-
tical pedicle 6 cm in length running the midline of the
breast was marked (Figu r e 5 ).
It extended to 2 cm above the NAC in the superior part
and till the end of the marked area in the inferior part.
Last, the periareolar area 5 cm in diameter was marked.
The second stage was surgery. Patients were in the su-
pine position with a slight flexion in the waist. The tu-
mescent technique was used in all patients. After inci-
sions appropriate for the markings were made, the skin
on the pedicle wa s d e -epitheli z e d ( Figure 6).
Subsequently, skin flaps were undermined, starting in
the medial. The breast including dermal fat was under-
mined from the gland to aponeurosis of the pectoralis
Figure 5. Dr awing of the pedicle 6 cm in length running the
midline of the breast.
Figure 6. De-epithelisation of the breast.
Copyright © 2011 SciRes. SS
major. At the end of undermining, the breast was com-
pletely exposed in the front view. Resection of the pe-
ripheral tissue started at the medial and continued at the
lateral and at the inferior part minimally so as to create a
6 cm-U shaped pedicle in the middle. Resection margins
in the inferior did not extend beyond the inframam-
marian fold and no resection was made in the superior.
Unlike the posterior pedicle mammaplasty described by
Moufarrege, the technique described here involved mini-
mal resection in the inferior, which prevented excess in
the horizontal part, and only one hole was created for
drainage. Resection of the external quadrant extending to
the subaxiallary region was performed gently and the
areolar tissue in this area was preserved especially in
cases of gigantomastia and extreme hypertrophy (Figure
After the resection was completed, a U shaped total
posterior pedicle 6cm in width remained in the middle.
Following resection, conical plication was carried out to
achieve posterior fullness.
Plication was performed in such a way to create a cone
at the two o’clock and ten o’clock positions of the NAC
with oblique continuous suture with 2/0 PDS (Figure 8 ).
After conical plication was created, the breast was se-
cured in its new position with temporary sutures ru nning
Figure 7. U shaped total posterior pedicle 6 cm in width.
Figure 8. Conical plication of the pedicle.
through inf erior and su perior parts of the NAC. One v er-
tical suture was put 6 cm below the NAC and the area
below this point was closed with pursing sutures. The
subdermis was closed with 3/0 PDS, the vertical incision
with 4/0 PDS and the periareolar region with 5/0 PDS
without tension. One drainage tube (Hemovac®) was
placed and temporary sutures were removed at the end of
the operation. Only a short vertical scar appeared in all
cases and reverse T incision was avoided. Pressure
dressing was done at the end of the operation and the
drain tubes were removed within two days of the opera-
A detailed physical examinatio n of the breast include s
measurements of breast size, degree of ptosis, masses,
superior pole fullness, nipple sternal distance, nipple-
inframmammary fold distance were recorded. Semmes-
Weinstein monofilaments were used to test the sensitiv-
ity of the nipple and cardinal points of the areola before
surgery and 3, 6, and 12 months after surgery (Figure 9).
3. Results
COPCU’s mammaplasty was performed in 69 patients.
The median age of the patients was 24,2 years, ranging
from 17 years to 66 years. Data of the patients are pre-
sented in Table:
Copyright © 2011 SciRes. SS
Range Average
Age 17-66 24.2
Jugular notch to nipple di st an c e
Pre-operative 21-43 cm. 27 cm.
Post-operative 18-24 cm. 21 cm.
Nipple to inframammarian crease
Pre-operative 8-18 cm. 14.5 cm.
Post-operative 7-12 cm. 9 cm.
Resection weight(per breast) 110-1880 gr 480 gr
Follow up 6-36 months 12 months
Figure 9. Evaluation of the sensitivity of the breast with
Semmes-Weinstein monofilaments and control of the erec-
tion of nipple with “cotton test”.
The mean distance between the xiphoid process and
the areola was 27 cm, ranging between 21 cm and 43 cm.
The mean resected tissue weight per breast was 480 gr,
ranging from 110 gr to 1880gr. Out of 69 patients in-
cluded in the study, 52 underwent reduction mamma-
plasty (11 had gigantomastia), eleven mastopexy, and six
oncoplastic surgery.
Out of six patients undergoing oncoplastic surgery,
two underwent COPCU’s mammaplasty and th e superior
part where the tumors were located was resected. Both
patients underwent breast reduction. In the remaining
four patients undergoing oncoplastic surgery, partial
mastectomy was performed based on the markings de-
scribed in COPCU’s mammaplasty, breast prostheses
were placed under pectoralis muscle and the opposite
breast was reduced.
The patients were followed for six months minimum.
Lateral photographs were taken to compare preoperative
and postoperative superior fullness in all patien ts (Figure
None of the patients had such total NAC necrosis. Par-
tial NAC loss (approximately 10% of the NAC) was seen
in one patient who was heavy smoker and she did not
stop smoking even our advice. Necrotic areas were
healed spontaneously with routine dressings without any
surgical approach. Two days after removal of the drain-
age tubes, two patients had minimal hematoma, which
was treated conventionally. Two patients had about 3 cm
opening on the NAC and suture line, but they healed
Figure 10. Pre and post-operative view of the patient oper-
ated with COPCU’s mammaplasty for reduction of the
Figure 11. Pre and post-operative views of the patient oper-
ated with COPCU’s mammaplasty for reduction of the
Copyright © 2011 SciRes. SS
Figure 12. Pre and post-operative view of the patient oper-
ated with COPCU’s mammaplasty for reduction of the
Figure 13. Pre and post-operative view of the patient with
breast Ca. 350 ml. Baker prosthesis was applied for the left
spontaneously. Four patients were operated for scar revi-
sion surgery under the local anesthesia. All patients were
satisfied with aesthetic results. None of the patients re-
ported decreased sensual or sex ual sensibility in th e short
term and long term. Six patients gave birth within six
months of the operations and none of them had decreased
lactation. Since we performed conical plication we
would like to evaluate long term effects of the plication
in the breast parenchyma. Breast parenchyma was visu-
alized with USG in younger patients and mammography
in older patient in postoperative 6 months and 1 year. We
never observed any problem related with our sutures and
retroareolar part of the areola examination for ductal
patency was performed and interestingly all the patients
had very clear duc t a l p at e nc y (Figure 14).
4. Discussion
The goal of aesthetic surgery is generally accepted to be
to re-shape normal structures of the body to improve
patient’s appearance and self esteem [7]. The surgeons
who perform breast reduction surgery or mastopexy have
great responsibility because of the breast is exceptional
organ. The breast is one of the most important organs of
women. It plays a role not in sexuality due to its visual
Figure 14. Ultrasonography of the patient operated with
COPCU’s mammaplasty.
and sensual importance but also in reproduction due to
its capability of milk production. None of the plastic
surgery operations put as much a heavy burden on plastic
surgeons as reduction mammaplasty [3].
Reduction mammaplasty techniques described so far
are named after locations of pedicles. Among them are
inferior, lateral, medial, central, total posterior pedicle
and mixed [8-11].
The leading cause of ongoing attempts to seek an ideal
technique is complications such as failure to achieve the
desirable aesthetic result, decreased or lack of lactation,
decreased or loss of sensual and erogenous feeling of the
nipple, insufficient projection and postoperative pseu-
doptosis and wound healing problems. Ultimate goal of
any pedicle is to provide sufficient blood supply to the
nipple areola complex [12]. It has been reported that su-
perior pedicled mammaplasty causes considerable changes
in blood circulation due to the transposition of the pedi-
cle and that there is decreased NAC sensation in the su-
perior pedicle in the short term. The nerves innervate the
NAC can be easily injured with inferior pole resections
with superior pedicle techniques [13,14]. Bottoming out,
inferior pole excess or pseudo ptosis is more frequent in
inferior based pedicles [14]. Attempts to seek reduction
mammaplasty techniques preserving the NAC emerged
from the results of the studies by Bisenberger [15]. How-
ever, they revealed considerably high rates of complica-
tions. Moufarrege published his own technique in 1985
as “Total Dermoglandular Pedicle” and also he presented
his largest series in 2006 with more than 5000 patients
[5,6]. Moufarrege has used 100% of the remaining gland
for the nipple-areola complex. The pedicle initially was
in posterior and inferior position, but eventually it occu-
pied the entire height of the gland. This was the total
posterior pedi cle [6].
Nipple necrosis is the most frightening complication
of reduction mammaplasty. The rates of nipple necrosis
have been reported to be 2.1% in the superodermal pedi-
Copyright © 2011 SciRes. SS
cle [16], 2.3% in the superolateral [17] and 0.8% in infe-
rior pedicle [18]. The leading cause of nipple necrosis is
insufficient arterial blood supply or long-lasting venous
congestion; this can be attributed to inadequate knowl-
edge about the vascular anatomy of the NAC and use of
long peripheral pedicle and the resultant distortion of the
pedicle. However, total posterior pedicle described by
Moufarrege and its modification COPCU’s mamma-
plasty have theoretically avoided such complications.
Functional results of breast reduction are as important
as its aesthetic results. The Surgeon General’s health
goals for 2010 are that 75% of women initiate breast-
feeding and that 50% continue it through 6 months post-
partum [19]. Maximum preservation of breast functions
depends on exact knowledge of anatomical features of
the breast. At present, vascularization and innervations of
the nipple areola complex (NAC) has been clearly de-
scribed and the vessels and the nerves have been shown
to reach vertically the NAC at the fourth and fifth ribs
through a separate fibrous septum [20,21]. It should be
noted that vascularization and innervation of the NAC is
through the cen tral breast parenchyma which can be seen
as inferior to the breast shape in standing position. If the
glandular tissue is not removed with the central pedicle,
then the patient keeps her lactation potential with good
nipple sensation [22]. The principle underlying the tech-
nique described here is complete preservation of these
tissues. Any technique which avoids resection of the
central parenchyma does not detach the central part of
the breast from thoracic wall and does not violate the
lateral pectoral fascia carries a low risk of injuring the
dominant nerve supply to th e nipple and areola [23].
A larger pedicle does not necessarily achieve better
breast functions. The thing is that vessels and nerves of
the NAC should be completely preserv ed. As a matter of
fact, a large pedicle may cause such complications as
displacement and folding of the flaps [24]. So that the
breast looks natural after reduction mammaplasty, it can
move to all directions and has a soft texture. This can
only be achieved with a total posterior pedicle since it is
not possible for a flap from the neighboring areas to
achieve natural mobility of the breast.
It has been emphasized that a gland connected to the
ducts and the nipple should be preserved for a successful
breastfeeding following breast reduction [25]. However,
to our knowledge, ther e have not been any studies show-
ing how much breast tissue should be preserved for suf-
ficient milk production. Maintenance of lactation should
never be disregarded. Therefore, a maximum amount of
the gland should be preserved. Only a pedicle located on
the gland allows preservation of a maximum amount of
the gland, which was only achieved by Moufarrege total
posterior pedicle mammaplasty and its modifications.
In our technique we perform three important modifi-
cations to the origin al technique of the Moufarrege. First,
we create central located U shaped total posterior pedicle.
The philosophy of the pedicle is as same as Moufarrege
technique and pedicle is 100% of remaining gland. But
we excise some breast tissue from the lower part of the
breast. This allows using only one drain since we create
single space instead of two and more importantly we
prevent the possibility of the bottoming-out deformity in
post-operative period especially in gigantomastia.
Secondly, we describe the term of conical plication in
the breast. As far as we know, conical plication has not
been described in the literature before. The conical plica-
tion which we developed is directed to w ar ds preservation
of the juvenile breast look and superior fullness in the
long term.
In 1985, Pennington performed plication and pedicle
suspension in the pectoral fascia to prevent bottoming
out, a frequently encountered complication of inferior
pedicle, and reported his 20-year experience [26]. Pen-
nington made plication, both superficial and deep, in the
inferior pole. Unlike the plication by Pennington, plica-
tion in COPCU’s mammaplasty is performed in the su-
perior only to create a conical appearance. The suture
technique used in COPCU’s mammaplasty is similar to
that described by Tonnard for MACS lift [27]. However,
the technique presented here does not damage the tissue
since it only involves plication and no problems due to
plication were shown in postoperative mammography in
the long term. The size of the breast was not associated
with complications in the present series. This can be as-
cribed to safety of the pedicle.
There is no limitation of the breast size for COPCU’s
mammoplasty; even it can be used for the correction of
the gigantomastia with success (Figure 15)
Finally, we use vertical skin closure instead of in-
verted T scar and prevent the possibility of hypertrophic
scars or keloid on horizontal part of the scar.
According to the results of this study and the studies
of Moufarrege, advantages of total posterior pedicle
mammaplasty and its modification can be listed as in the
following [6] :
1) Since it is a total posterior pedicle, it provides co m-
plete safety of the NAC. The nipple is located on the
pedicle and the vessels and nerves extending the nipple
are completely protected. In fact, we did not observe any
complications concerning the nipple.
2) The pedicle is in the midline and involves the whole
gland. Therefore, it is one of the best to create the most
natural breast in terms of tissue consistency and mobility.
3) A young breast has fullness in the superior. Conical
plication does not only create a juvenile look of the
breast but also prevents such complications of classic
Copyright © 2011 SciRes. SS
Figure 15. Patient with gigantomastia and excised materials
from breasts.
mammaplasty as loosening of the suture put on the pec-
toral muscle, flattening in the superior pole and pseu-
4) Moufarrege total posterior pedicle mammaplasty
offers excellent projection of the breast. In fact, the
whole pedicle is made of the gland and located in the
central, which h e lp s to achiev e a near normal projection.
5) The technique provides maximum protection of the
sensual and sexual innervation of the NAC.
6) It is one of safest techniques for lactation since the
pedicle is situated on the gland.
7) It is easy to perform and teach since open sky ap-
proach is used. It does not increase operation time and
does not requir e li posuction.
8) External quadr an ts of the br east, most susceptible to
cancer, were resected. This is a kind of prophylaxis
against cancer.
9) Reverse T scar is avoided and a very small vertical
scar, which can be tolerated by patients, is created.
There are not any marked disadvantages of the tech-
nique. However, thinning likely to occur in elevation of
dermal pedicles may cause skin problems. Although the
patients included in this study were heavy smokers, they
did not have skin loss. This indicates that dermal flaps
have a rich blood supply.
It can be concluded that Moufarrege total posterior
pedicle and it’s modification COPCU’s mammaplasty
cannot only be used safely for breast reduction and
mastopexy, in which a young projectile breast is created
and maximum protection of breast functions is provided,
but also is appropriate for oncoplastic surgery.
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