الفهرس 
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Abstract
Breast enlargement is a normal physiological process that occurs in females; however, it becomes a disorder when the breast enlargement becomes pronounced causing discomfort and hardship to persons and thus affecting their normal daily life and activities (Agbenorku, 2013).
Women with breast hypertrophy may experience physical symptoms such as pain from back of the neck, back and shoulder region, shoulder strap grooving, headaches, and intertrigo. Many women also describe difficulties in finding clothes that fit without looking fat and difficulties in exercising because of the breast movement. There are also psychosocial problems associated with breast hypertrophy and have a feeling of low social self-esteem. Several studies have shown that breast reduction gives a better quality-of-life with less back, neck, and shoulder problems as well as better self-esteem (Lewin et al., 2014).
Breast reduction is a common cosmetic surgical procedure. It aims not only at bringing down the size of the breast proportionate to the build of the individual, but also to overcome the discomfort caused by massive, ill‑shaped and hanging breasts (Saleem and John, 2013).
The rapid evolution of breast reduction techniques is now directed towards surgical precision and ultimate patient satisfaction. The state of the art concept is shifted from obtaining excellent aesthetic results to the maintenance and longevity of these results and address minor details that were overlooked earlier (Magdy, 2008).
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Although there is no universal technique applied for all breast reductions, many options are available to the surgeon. It is critically important to realize that in breast reduction surgery, the pedicles and the skin excision patterns are independent variables, so any pedicle can be used with any skin resection pattern (Aboulwafa et al., 2013).
The most popular two skin patterns are the wise “Inverted-T” and “vertical” patterns were both can be combined with several different nipple pedicles. The “Inverted-T” tends to be associated more with an inferior or central pedicle whereas the “vertical” pattern is often associated with superior or superomedial pedicles (Aboulwafa et al., 2013).
The inferior pedicle reduction mammoplasty is still very popular because of its well-recognized advantages. First, this technique can be utilized with almost all breast sizes, and even in cases of gigantomastia it is possible to avoid free nipple grafts. Second, it retains superior vascularity and sensibility in the NAC when compared to other techniques. Finally, because of the relative ease with which the technique can be learned and performed successfully, it is suitable for junior trainees. (Zic; et al., 2013).
The main drawback of the inferior pedicle technique is pseudo ptosis or ‘‘bottoming out’’ caused by descent of the breast tissue over time. Other technical disadvantages include time-consuming de-epithelialization, poor projection, and tension at the inverted T-junction point, which is known for all Wise pattern techniques and even the short T conversion of the vertical mammoplasty. In trying to resolve the main problem of the inferior pedicle technique, namely, pseudo ptosis, Robbins added pedicle plication and suspension, later modified by Pennington. This modification fixed only the
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lower and central parts of the breast with the plicated pedicle at the inframammary level, but it did not address the medial and lateral parts of the breast. Furthermore, the technique lacked real ‘‘high’’ suspension. Further modifications of internal dermal suspension have been published by Frey for mastopexy after massive weight loss (Zic; et al., 2013).
Bottoming out is one of the most annoying late sequel after breast reduction operations. Many modifications of the known techniques as well as the development of new modalities with modifications of pedicle sites, dimensions and vector addressed this problem with variable success (MAGDY,2008).
Over the years many techniques have been developed to combat this problem, including internal suspension of the pedicle with sutures, dermal flaps, fascia, and muscle flaps. The use of mesh as an internal brassiere to support the pedicle has been pioneered by Go´es (Brown et al., 2010).
Other modification of inferior pedicle to overcome the bottoming out is triplicated inferior pedicle which divide the inferior pedicle flap into three parts to its half and plicate the two lateral parts above the central part to overcome the bottoming out and give better breast projection and upper pole fullness (Katsaros et al., 2010).
In our thesis 20 patients suffered from breast hypertrophy, ten patients were operated with triplicated inferior pedicle group (I) and ten patients were operated with ordinary inferior pedicle without modification group (II).
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Pre & postoperative measurements had been measured for all patients including Sternal notch to nipple distances (SN-N), Inframammary fold to nipple distances (IMF-N) to assess occurrence of bottoming out.
There is no significant difference in complications between group (I) and group (II). There is less bottoming out after 6 months in group (I) (one case) than group (II) (five cases) with P value 0.006. Better upper pole fullness after 6 months in group (I) than group (II) with P value 0.020. better breast projection after 6 months in group (I) with P value 0.001.
So, triplicated inferior pedicle gave better esthetic results without increase in complications.