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Plastic Surgery > BREAST
Breast Reduction, Central Pedicle
Article Last Updated: Jul 26, 2005
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Editors: Geoffrey L Robb, MD, Chair, Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Michael J Miller, MD, FACS, Professor, Department of Surgery, Chief, Division of Plastic Surgery, Ohio State University College of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
macromastia, central pedicle breast reduction, reduction mammaplasty, central mound technique
History of the Procedure
Hester et al first described the central pedicle reduction technique in 1985. Since then, its similarity to other reduction mammaplasty techniques has been shown.
Problem
Macromastia is a common condition treated by plastic surgeons. The American Society of Plastic Surgeons(ASPS)/Plastic Surgery Educational Foundation (PSEF) Web site lists 84,780 cases, placing it among the top 5 reconstructive operations performed. Because women have a variety of body shapes and sizes, no simple definition for macromastia exists.
Frequency
According to the American Society of Aesthetic Plastic Surgeons, more than 144,000 breast reduction procedures were performed in 2004.
Etiology
Etiology is unknown.
Clinical
See Indications for presenting symptoms and complaints. Preoperative analysis consists of the standard history and physical examination, with special attention directed to breast history and health, including family history of breast cancer. Preoperative photos should be taken and reviewed with the patient to point out conditions such as preexisting asymmetry. Representative before and after photos also should be reviewed if available to ensure that the patient understands the scars and has realistic expectations.
Macromastia is a common condition treated by plastic surgeons. The ASPS/PSEF Web site lists 84,780 cases, placing it among the top 5 reconstructive operations performed. Because women have a variety of body shapes and sizes, no simple definition for macromastia exists. However, definite symptoms exist, which have been documented by numerous authors (Hagerty, 1989; Shewmake, 1994; Gonzalez, 1993). Most commonly, these symptoms consist of upper back and neck pain, breast pain, shoulder grooving from bra straps, and inframammary intertrigo.
In an effort to relieve these symptoms of pain, a number of surgical techniques for reduction mammaplasty have been described (Courtiss, 1977; McKissock, 1976; Parenteau, 1989; Yousif, 1992; Reus, 1988; Moufarrege, 1985; Wise, 1956). The ideal breast reduction results in complete relief of symptoms while maintaining normal sensation and the ability to lactate. Additionally, the operation should result in an aesthetically pleasing breast shape with minimal scarring and a low complication rate. Lastly, most or all of these objectives should be achieved in a time-efficient and cost-efficient manner.
The relevant anatomy is that of the female breast. This consists of the glandular breast mound and the axillary tail of Spence. The nipple-areola complex (NAC) is the most prominent anatomic feature on the breast. It has important relations to the underlying glandular tissue.
The first of these relations consists of the blood supply to the NAC, which enters through the glandular breast tissue but also receives contributions from the subdermal plexus of the breast skin.
The second important anatomic relationship between the glandular breast tissue and the NAC is that of innervation. The nipple lies in the dermatome of the fourth intercostal nerve. Additional innervation is contributed by adjacent dermatomes. No clear anatomic distinction has been identified for innervation contributing erogenous versus tactile sensation.
Lastly, one must consider the communication between the lactiferous ducts of the glandular breast tissue and the nipple. Clearly the importance of this depends upon the patient's childbearing status and any prior demonstration of the ability (or inability) to lactate.
Contraindications to breast reduction surgery are similar to contraindications to any elective surgical procedure, including cardiac and pulmonary considerations. Fortunately, most women seeking breast reduction surgery are young and in otherwise good health. Since the operation is performed to relieve symptoms and not to treat a life- or limb-threatening disease, use common sense regarding general anesthetic risks.
Lab Studies
- Order routine lab work according to the criteria for elective surgery under general anesthesia in the practicing physician's hospital. Age, medical history, social habits, and family history influence the need for these tests. If the surgeon has concerns, seek consultation from the patient's primary care provider.
Imaging Studies
- Consider mammography in patients presenting for breast reduction surgery. Current practice suggests that mammograms should be obtained for patients aged 40 years and older. Some surgeons also advocate mammography in patients aged 35-40 years with a family history of breast cancer.
Other Tests
- Determine the need for chest radiographs and ECG according to the criteria for elective surgery under general anesthesia in the practicing physician's hospital. Age, medical history, social habits, and family history influence the need for these tests. If the surgeon has concerns, seek consultation from the patient's primary care provider.
Preoperative details
- The operative technique begins with the preoperative markings, which are made with the patient in a standing position.
- First, mark the patient's midline from the manubrium to the umbilicus. Next, mark the mid axis of each breast from approximately the mid point of the clavicle to the areola.
- Make a mark corresponding to the inframammary crease on the mid line and a second mark approximately 2.5 cm superior to the first. The second mark indicates the ideal level of the NAC. Transfer this new mark to the lines marking the mid axis of each breast.
- The final lines to be drawn radiate out from these points and lie tangent to the medial and lateral borders of the NAC (see Image 3).
- Position the patient on the operating table in a supine position, with the arms well padded and outstretched on arm boards. Cast padding is useful for wrapping the arms since such wraps provide firm support, yet conveniently may be torn by hand to provide access to intravenous (IV) sites and other areas.
- The patient also must be positioned so that she can be raised to a sitting position during the operation. A sitting position is helpful for ascertaining symmetry and for shaping.
- Deep venous thrombosis (DVT) prophylaxis with sequential compression devices or similar therapy is indicated.
Intraoperative details
- Begin the operation by marking the size of the new NAC. This marking should not be performed with the skin under stretch, since the areola is then too small.
- Scribe a partial thickness incision around the new areola and along each of the tangent lines. Then deepithelialize the skin encompassed by the tangents and outside the newly sized areola (see Image 4).
- The operation continues using electrocautery to elevate the medial and lateral skin flaps from the inframammary crease. The technique differs from operations that use the standard Wise pattern because more skin is left in the medial and lateral flaps than is needed for closure.
- Elevate the skin flaps with a uniform thickness of approximately 1.5 cm. Flap elevation at this thickness preserves the subdermal plexus, thus ensuring skin flap viability. Elevate flaps medially until the perforators from the internal mammary arteries are identified. Preserve these vessels.
- Elevate the lateral flap, taking care to stay approximately 1.5 cm from the chest wall. Dissection is carried out at this level to preserve the blood and nerve contributions from the fourth intercostal neurovascular bundle.
- Then undermine the area between the medial and lateral flaps (see Images 5-6). Flap elevation in this region may extend as far superiorly as the clavicle.
- Once the entire central pedicle breast mound has been exposed (see Image 7), it should be reduced through a series of tangential excisions maintaining a conical breast shape. Remove approximately one half of the volume planned for resection from each breast in this fashion. Take care not to place traction on the tissue being excised from the breast mound because the blood supply to the nipple can be compromised inadvertently.
- After completion of reduction of the central breast mound, redrape the skin flaps and tailor them to fit (see Image 8). Accomplish approximation of the vertical incision first. The total length of this vertical limb should be 8 cm (3 cm for the NAC and 5 cm for the vertical incision extending from the inferior border of the areola to the inframammary crease).
- Then pull the medial and lateral skin flaps toward the vertical incision and resect redundant tissue. The projection of the reduced breast is accurately controlled by this maneuver. The surgeon must be cognizant of the 3D geometry involved in reducing the breast. If one reduces the volume of a cone without reducing the diameter of the base of the cone, the cone has decreased projection.
- In the final shaping, drawing the skin flaps toward the vertical skin incision allows reduction of the length of the inframammary incision. In taking out dog ears at the medial and lateral ends of the inframammary incision, the incision should be curved superiorly to reflect the narrowed base of the breast. Failure to do this may result in incisions that deviate from the inframammary crease, thus are more visible.
- Lastly, the position for the NAC is determined with the patient in an upright position. Mark the skin for excision and check the NACs for viability prior to resection of the skin. In this way they still can be salvaged as free nipple grafts placed on deepithelialized skin flaps if necessary.
- Once viability is ensured, make the keyhole incision and deliver the nipple areola.
- Close the skin incisions in a layered fashion with resorbable sutures placed in the deep dermis and either skin staples or a running intracuticular closure. If staples are used, remove them in 5 days.
- In summary, the greatest advantage of this technique is that shaping is still "freehand," allowing the surgeon to individualize the result, fitting it to the particular patient's body habitus. Because flexibility is present in the skin envelope, excellent projection is possible.
- A layered closure with interrupted buried deep dermal sutures followed by a running subcuticular closure completes the operation.
Postoperative details
- The operation may be performed as an outpatient procedure or with an overnight stay, depending upon insurance and comorbid factors.
- If drains are placed, they may be removed on the first postoperative day.
- Observe the patient at a follow-up visit 1-2 weeks after surgery and then again approximately 3 months postoperatively.
- Most patients are able to resume normal activity 2-3 weeks postoperatively and are able to resume more vigorous activity 4-6 weeks postoperatively.
- Edema resolution and tissue settling may be expected to last 3-6 months until complete.
Follow-up
- With uncomplicated healing, no follow-up care is required.
- If complications such as seroma or wound dehiscence occur, appropriate medical and surgical care are required until complete resolution is achieved. This occasionally may involve additional surgery.
- Resolution of symptoms usually is recognized early in the postoperative course.
Complications are usually minimal and may consist of seroma and small areas of wound separation (especially at the 3-way junction of the inverted T incision). Nipple areola loss should be approximately 1% and is frequently associated with loss of underlying glandular breast tissue (L Vasconez, MD, oral communication). Loss of sensation is an uncommon problem with use of a central glandular technique, as it safely preserves the nerve distribution to the nipple. All of these problems should be treated conservatively with frequent office visits for reassurance. In the case of nipple loss, corrective surgery is usually required but should be deferred for several months until edema has resolved and any compromised tissue has been débrided.
In a recently reported series of 153 patients, presenting symptoms were back and neck pain, shoulder grooving, and intertrigo (Grant, 2001). An average of 794 g was reduced per side. One case of nipple areola loss occurred in 306 breasts. Wound healing complications (usually a small dehiscence at the inverted T incision) were observed in 24 patients, and all but one of these complications were managed by local wound care alone. Minor revisions under local anesthesia were required in 13 patients. Patient satisfaction and relief of symptoms were high. A typical result is shown in Image 2.
A multitude of breast reduction techniques has been described over the years. Variations of the inferior pedicle technique are the most common procedures in use today (Georgiade, 1989; Balch, 1981). Certainly, no single best operative technique exists for reduction mammaplasty. The authors' intention in this article is to illustrate one technique and to present results from a representative series of patients.
| Media file 1:
Central pedicle breast reduction. Left: Preoperative anteroposterior of a representative patient with markings for planned incisions. Note ptosis of nipple areola complex below inframammary fold. Right: Oblique view, demonstrating the same findings. |
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| Media file 2:
Central pedicle breast reduction. Expected degree of change using the central pedicle reduction using the technique of Hester (same patient as Image 1). |
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| Media file 3:
Central pedicle breast reduction. Preoperative anteroposterior image in a representative patient with the shaded area of the right breast demonstrating the flap undermining in the operation as described by Hester. |
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| Media file 4:
Central pedicle breast reduction. The image demonstrates the de-epithelialized central pedicle, preserving the subdermal plexus. |
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| Media file 5:
Central pedicle breast reduction. The skin flaps have been widely undermined. The surgeon's hand must support the pedicle to avoid injury to the blood supply. Note that positioning of the central pedicle is not limited by any skin bridges. |
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| Media file 6:
Central pedicle breast reduction. The central pedicle is isolated just prior to tangential excision. |
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| Media file 7:
Central pedicle breast reduction. The inferior pedicle is divided, allowing increased mobility of the breast mound on the chest wall. |
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| Media file 8:
Central pedicle breast reduction. The right breast has been shaped temporarily using skin staples. After reduction of the second side, the nipple-areola complexes will be delivered and inset. |
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- Balch CR. The central mound technique for reduction mammaplasty. Plast Reconstr Surg. Mar 1981;67(3):305-11. [Medline].
- Courtiss EH, Goldwym RM. Reduction mammaplasty by the inferior pedicle technique. An alternative to free nipple and areola grafting for severe macromastia or extreme ptosis. Plast Reconstr Surg. Apr 1977;59(4):500-7. [Medline].
- Georgiade GS, Riefkohl RE, Georgiade NG. The inferior dermal-pyramidal type breast reduction: long-term evaluation. Ann Plast Surg. Sep 1989;23(3):203-11. [Medline].
- Gonzalez F, Walton RL, Shafer B, et al. Reduction mammaplasty improves symptoms of macromastia. Plast Reconstr Surg. Jun 1993;91(7):1270-6. [Medline].
- Grant JH 3rd, Rand RP. The maximally vascularized central pedicle breast reduction: evolution of a technique. Ann Plast Surg. Jun 2001;46(6):584-9. [Medline].
- Hagerty RC, Hagerty RF. Reduction mammaplasty: central cone technique for maximal preservation of vascular and nerve supply. South Med J. Feb 1989;82(2):183-5. [Medline].
- Hamdi M, Blondeel P, Van de Sijpe K, et al. Evaluation of nipple-areola complex sensitivity after the latero-central glandular pedicle technique in breast reduction. Br J Plast Surg. Jun 2003;56(4):360-4. [Medline].
- Hester TR Jr, Bostwick J 3rd, Miller L, Cunningham SJ. Breast reduction utilizing the maximally vascularized central breast pedicle. Plast Reconstr Surg. Dec 1985;76(6):890-900. [Medline].
- McKissock PK. Reduction mammaplasty by the vertical bipedicle flap technique. Rationale and results. Clin Plast Surg. Apr 1976;3(2):309-20. [Medline].
- McKissock PK. Invited discussion: Breast reduction utilizing the maximally vascularized central breast pedicle. Plast Reconstr Surg. 1985;76:899-900.
- Moufarrege R, Beauregard G, Bosse JP, et al. Reduction mammoplasty by the total dermoglandular pedicle. Aesthetic Plast Surg. 1985;9(3):227-32. [Medline].
- Parenteau JM, Regnault P. The Regnault "B" technique in mastopexy and breast reduction: a 12-year review. Aesthetic Plast Surg. Spring 1989;13(2):75-9. [Medline].
- Poell JG. Vertical reduction mammaplasty. Aesthetic Plast Surg. Mar-Apr 2004;28(2):59-69. [Medline].
- Reus WF, Mathes SJ. Preservation of projection after reduction mammaplasty: long-term follow-up of the inferior pedicle technique. Plast Reconstr Surg. Oct 1988;82(4):644-52. [Medline].
- Shewmake KB. Reduction mammaplasty and mastopexy. Selected Readings in Plast Surg. 1994;7:30:1-27.
- Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr Surg. May 1956;17(5):367-75. [Medline].
- Yousif NJ, Larson DL, Sanger JR, Matloub HS. Elimination of the vertical scar in reduction mammaplasty. Plast Reconstr Surg. Mar 1992;89(3):459-67; discussion 468. [Medline].
Breast Reduction, Central Pedicle excerpt Article Last Updated: Jul 26, 2005
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