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Nicholson et al. Plast Aesthet Res 2018;5:34 I http://dx.doi.org/10.20517/2347-9264.2018.30 Page 5 of 11

Figure 3. Undermining of the skin at the medial end of the inframammary fold (IMF), to allow tension-free re-draping of the skin at
closure and prevent standing cone deformity

Figure 4. Elevation of the medial flap of the skin envelope, with assistant retracting away from the chest using skin hooks

The lateral flap is raised in the same way and at the same thickness, again not completely. The superior part
of the skin envelope is elevated beyond the existing superior border of the breast base to create a pocket
almost close to the clavicle, as planned preoperatively, to widen the base and to create fullness of upper pole.
Adequacy of undermining is checked by placing a hand in the pocket formed by the skin envelope. The
superior part is then connected to the medial and lateral parts of the skin envelope flap.

The reduction is then performed. Tissue that is not part of the skin flaps or the central mound, as defined
by the dermal strip and lateral wings, is excised. This usually corresponds to the tissue beneath the small
triangles of skin remaining around the already dissected parts. Tissue is preserved on the chest wall at the
lower medial and lateral quadrants and at the superior pole to ensure good contour. Meticulous attention is
paid to haemostasis with the patient at normotension.