You are in: eMedicine Specialties > Plastic Surgery > BREAST Breast Reduction, Superior PedicleArticle Last Updated: Jun 26, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: James N Long, MD, Assistant Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, University of Alabama at Birmingham and Kirklin Clinics James N Long is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, and Southeastern Surgical Congress Coauthor(s): Peter D Ray, MD, Assistant Professor of Surgery, Staff Physician, Division of Plastic Surgery, University of Alabama Hospital; 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 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; Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; 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 Author and Editor Disclosure Synonyms and related keywords: reduction mammoplasty superomedial pedicle, reduction mammoplasty superior pedicle, breast reduction, nipple-areolar complex, NAC INTRODUCTIONSection 2 of 12
  Until the early 1990s, when Lejour began to popularize Lassus' concept of vertical scar mammoplasty, the vast majority of breast reductions used some variation of the Wise pattern for skin resection. Each particular technique during this time differed primarily on the origin of the parenchymal pedicle, which provides the neurovascular contributions to the nipple-areolar complex (NAC). The inferiorly based pedicle is the most popular technique in the United States today. Because of the advantages over other procedures, the superiorly based techniques are becoming increasingly popular among surgeons and patients. Vertical reduction, as espoused by Lassus and modified by Lejour, are, essentially, founded on superiorly based pedicles with inferiorly based parenchymal resections and pure vertical closures. These are more fully discussed in other articles (see Breast Reduction, Lejour; Breast Reduction, Simplified Vertical; Breast Reduction, Vertical Bipedicle). History of the ProcedureIn 1957, Arie first described the superior pedicle mammoplasty. This description was followed with refinements by Ivo Pitanguy in 1967. Weiner is credited for bringing this technique to the fore in the United States with his 1973 publication describing the superiorly based dermal pedicle for reductions and mastopexy, which claimed avoidance of the distortions problematic with Skoog reductions. Soon thereafter, Orlando and Guthrie demonstrated the superomedial pedicle technique, which varied only in the more medial-directed superior pedicle. Seeking a safer pedicle to ensure nipple viability, Hugo and McClellan, as well as Hauben, later incorporated more parenchyma beneath the de-epithelized dermal pedicle. Arufe et al confirmed adequate vascularity of the superior pedicle with preoperative arteriograms on several patients. Author-noted advantages of the superiorly based pedicle technique include less skin undermining and simplified resections, which result in significant reductions in operative time. Importantly, these techniques foster preservation of dermoparenchymal relationships with maintained microvascular connectivity which, in turn, minimizes the risk of skin and fat necrosis. Shaping the breast mound, which can be difficult with techniques that disrupt the dermoparenchymal relationship, becomes more easily achievable with intraparenchymal pillar suturing techniques, which are part of these techniques. Durability of results with the superomedial variant has been shown by advocates such as Elizabeth Hall-Findlay. In her series of cases, she has demonstrated good long-term shape with minimal development of pseudoptosis (bottoming out) over time. INDICATIONSSection 3 of 12
The indications for superior pedicle reduction are the general indications for breast reduction, which are well-described as stigmata of macromastia. These typically include upper back pain, brassiere strap pain, grooving or hyperpigmentation, inframammary intertrigo, and difficulty engaging in the activities of daily living. RELEVANT ANATOMYSection 4 of 12
Blood supply to the breast comes from the internal thoracic artery via the anterior perforators, lateral thoracic artery, thoracoacromial artery, and lateral perforators of the intercostal arteries. The nipple areolar complex (NAC) rests on a vascular 'watershed' zone, receiving contributions from all of these vessels. The internal thoracic is the dominant axis among these contributing vascular supplies; it provides as much as 60% of overall inflow. Nerve supply to the NAC is from the anterior and lateral perforating branches of the third, fourth, and fifth intercostal nerves, with the fourth being the primary sensory contributor. In a recent report, Schlenz et al demonstrated that the lateral contributors frequently reach the NAC in direct ascent from the chest wall in 90% of dissections. Nonviolation of the pectoralis fascia along the deep lateral resection margin usually results in maintenance of NAC sensibility and, in some cases in which nerve traction is reduced by the procedure, even yields increased sensitivity. Medial branches are, conversely, found in a more superficial plane. Maintenance of the dermoparenchymal relationship in this anteromedial region, as is done with the superomedial technique, helps decrease the potential for injury to these nerves during pedicle development. CONTRAINDICATIONSSection 5 of 12
Superior and superomedial pedicled breast reductions are contraindicated if breast scars completely cross the proposed pedicle and are known or presumed to have transected the pedicle blood supply. These techniques are ill-advised in patients who have had previous breast reduction by a pedicle of other orientation. Relative contraindications include planned resection in excess of 2000 g per side or NAC transpositions of less than 5 cm or greater than 15 cm. Since transposition of the nipple requires a significant arc of rotation, patients with tight, firm breasts that have poor pliability are less ideal candidates for the superomedial procedure and better candidates for the straight superior pedicled approach, as long as NAC pedicle lengths are kept appropriate. The authors have found fewer complications with the superomedial pedicle in patients who are smokers due to the limited undermining required to transpose tissues. Limited undermining maintains vascular beds connectingparenchyma to skin with the pedicle axial on the very robust blood supply of internal thoracic artery perforators. More, the parenchyma targeted for resection falls in the 'watershed' area between lateral and medial vascular zones, making fat necrosis rare. WORKUPSection 6 of 12
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Other Tests
TREATMENTSection 7 of 12
Medical TherapyIn patients with macromastia who are obese, physician-directed weight loss programs that include diet and exercise may help reduce symptoms but are unlikely to lead to complete resolution alone. Often, patients find it difficult to exercise due the physically limiting effects of macromastia. Surgical TherapyBreast reduction surgery directs its intentions toward 2 primary alterations in breast habitus. The first goal is a reduction in weight, with a consequent reduction in size. Second, by placing most retained breast tissue at or above the inframammary fold, a favorable change in weight vectors on the upper thorax and spine is produced. While the surgeon always strives to provide good shape, aesthetic contour, and bilateral symmetry, reduction mammaplasty should be considered an operation to improve function. Aside from the aesthetic improvement, which is always sought and often realized, resultant patient-noted benefits, such as relief from upper back and shoulder pain and the increased ability to engage in the activities of daily living, remain essential to patient satisfaction. Preoperative DetailsMarking may differ significantly from the familiar Wise pattern. The surgeon may choose to use markings which permit a pure vertical closure. The author has found that pure vertical closure can be more difficult to achieve in cases where patients have a greater excess of skin than of volume. In such cases, tailoring an inframammary skin excision can improve cosmetic appearances by reducing inferior bunching and eliminating dog-ear redundancies. Often, this tailor tacking approach will yield inframammary scars that are significantly shorter than would be possible with inferior-pedicled, Wise pattern reductions. These shorter incisions are the byproduct of dermoparenchymal shaping by means of intraparenchymal pillar suturing rather than relying on the traditional skin resections to achieve desired shape. Another direct benefit from this phenomenon is a tension-free skin closure. Proposed nipple location is set with the "A" point (top of the keyhole) approximately 2 cm below the anteriorly transposed inframammary fold. Medial and lateral skin excision limits are identified by lateral and medial displacement of breast tissue using the native breast meridian as the reference line. The breast meridian should be delineated by marks at the clavicle and below the inframammary fold (IMF), each of which is relatively immobile during displacement. The ultimate result of this process should be a vertically oriented oval topped by a mosque-shaped dome with its apex approximately 2 cm below the anteriorly transposed IMF and its lower limit 2-4 cm above the native IMF. The author prefers to develop a mosque-shaped keyhole for NAC insetting during de-epithelialization and development of the pedicle, as this method saves time. Skin markings are conservative, with the lower limit of the resection between 2 cm and 4 cm above the native IMF; this location depends on the anticipated resection volume. If necessary, additional skin can be removed postresection. Since this technique employs intraparenchymal pillar suturing to achieve breast shaping, significant, if any, additional skin resection to improve contour is usually not required. Small skin redundancies tend to retract in short order because of inferior resectional or liposuction thinning coupled with an absence of skin loading. Be aware that skin of poor quality is unlikely to retract and should be resected.
Intraoperative Details
Postoperative DetailsEvaluate the surgical site for presence of hematoma and for sensitivity and viability of the NAC. Follow-upPostoperatively, the patient should wear a soft support brassiere without under wire for 3-6 weeks, dependent on observed patient healing. COMPLICATIONSSection 8 of 12
Incidence of complications is similar to other techniques of reduction mammoplasty. Hauben reported on 212 patients; in 1 patient total loss of the NAC occurred (the first time he used this technique, the pedicle length was 26 cm, and the patient was a heavy smoker). In addition, he had another partial loss of the NAC. Decreased sensation of the NAC was present, but no incidence was quoted; nipple retraction was present in 2% of patients and hematoma in 2.26%. No transfusion was necessary. Finger et al reported only 2 partial losses of the NAC (<25%) and decreased sensation in 15% in 148 patients (291 breasts). Other complications were hypertrophic scars, nipple retraction, and dog-ears. Average blood loss was 200 mL. Hugo and McClellan reported on 34 patients (68 breasts) with an average of 760 g resected and 12 cm of nipple transposition. One patient (1.4%) had a partial loss of the NAC, and 2 (3%) had infections. OUTCOME AND PROGNOSISSection 9 of 12
Results of breast reduction are satisfactory and among the most well accepted by patients regardless of the technique used. The advantages of the superior pedicle techniques are many for both surgeon and patient.
FUTURE AND CONTROVERSIESSection 10 of 12
Elizabeth Hall-Findlay has shown good results using her combination of superomedial pedicle combined with vertical closure. The long-term results she has presented suggest that the late development of pseudoptosis is less problematic than with other techniques. The learning curve for this technique can be steep. No other technique appears to have the distinct advantages of this particular approach with benefits that include faster operative times, greater control over breast shaping, reduced risk of peri-incisional skin necrosis, reduced risk of NAC insensitivity or nonviability, reduced risk of fat necrosis, and durability of results. Some have cited the steep learning curve as a barrier to wide acceptance of the technique. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Breast Reduction, Superior Pedicle excerpt Article Last Updated: Jun 26, 2006 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
