Central Pedicle Breast Reduction 

  • Author: Jorge I de la Torre, MD, FACS; Chief Editor: James Neal Long, MD, FACS   more...
 
Updated: Mar 29, 2012
 

History of the Procedure

Balch first described the central pedicle reduction technique in 1981, although it was also described by many, including Hester et al.[1, 2] The principle of this technique is to preserve the breast volume where maximum projection is desired. Evolution of the technique has resulted in the current technique described here.[3, 4]

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Problem

Macromastia or mammary hyperplasia is the condition of large breast size out of proportion to a woman's body habitus that is associated with symptoms including back, neck, and shoulder pain. Macromastia is a common condition treated by plastic surgeons.

Reduction mammaplasty is one of the 5 most frequently performed reconstructive operations. According to the American Society of Aesthetic Plastic Surgeons (ASPS), more than 153,087 breast reduction procedures were performed in 2007 up from 47,874 in 1997.[5] The ASPS/Plastic Surgery Educational Foundation (PSEF) procedural data from 2007 lists 105,706 cases of reduction mammaplasty, up from 39,639 cases in 1992.[6]

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Etiology

Etiology is unknown.

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Pathophysiology

The precise pathophysiology of macromastia is unclear.[7] End-organ hypersensitivity to hormonal stimulation appears to play a role. With the onset of menarche and hormonal production, breast growth and, in some cases, hypertrophy can be seen. Some patients present with macromastia following pregnancy; others see exacerbation of macromastia related to weight gain or obesity.[8, 9]

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Presentation

Preoperative assessment includes a 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.

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Indications

Macromastia is a common condition treated by plastic surgeons. Because women have various body shapes and sizes, and rules regarding insurance coverage vary from region to region, no universally accepted definition of macromastia that requires surgery exists. However, definite symptoms exist, which have been documented by numerous authors including Hagerty, Shewmake, and Gonzalez among many others.[10, 11, 12] 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 using various pedicles and skin resections.[13, 14, 15, 16, 17, 18, 19, 20] 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.

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Relevant Anatomy

Breast shape varies among patients, but knowing and understanding the anatomy of the breast (see the image below) ensures safe surgical planning. When the breasts are carefully examined, significant asymmetries are revealed in most patients. Any preexisting asymmetries, spinal curvature, or chest wall deformities must be recognized and demonstrated to the patient, as these may be difficult to correct and can become noticeable in the postoperative period. Preoperative photographs with multiple views are obtained on all patients and maintained as part of the office record.

Anatomy of the breast. Anatomy of the breast.

The female breast 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.

For more information about the relevant anatomy, see Breast Anatomy.

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Contraindications

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 often 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. Smoking, diabetes, and obesity have been associated with increased complication rates, including nipple necrosis.

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Contributor Information and Disclosures
Author

Jorge I de la Torre, MD, FACS  Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS 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

Disclosure: Nothing to disclose.

Coauthor(s)

James Neal Long, MD, FACS  Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS 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, Southeastern Society of Plastic and Reconstructive Surgeons, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Specialty Editor Board

Pankaj Tiwari, MD  Assistant Professor, Division of Plastic Surgery, Ohio State University College of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Nicolas (Nick) G Slenkovich, MD  Director, Colorado Plastic Surgery Center

Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

James Neal Long, MD, FACS  Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS 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, Southeastern Society of Plastic and Reconstructive Surgeons, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author John H. Grant III, MD, to the development and writing of this article.

References

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  2. 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].

  3. 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].

  4. Cho BC, Yang JD, Baik BS. Periareolar reduction mammoplasty using an inferior dermal pedicle or a central pedicle. J Plast Reconstr Aesthet Surg. 2008;61(3):275-81. [Medline].

  5. Surgical and Nonsurgical Procedures: 11-year Comparison, 1997-2007 [database online]. http://www.surgery.org: American Society of Aesthetic Plastic Surgeons; 6/23/08. Updated 6/23/08.

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  12. Gonzalez F, Walton RL, Shafer B, et al. Reduction mammaplasty improves symptoms of macromastia. Plast Reconstr Surg. Jun 1993;91(7):1270-6. [Medline].

  13. 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].

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  24. Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques. Plast Reconstr Surg. Mar 2005;115(3):743-51; discussion 752-4. [Medline].

  25. 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].

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  27. Gamboa-Bobadilla GM, Killingsworth C. Large-volume reduction mammaplasty: the effect of body mass index on postoperative complications. Ann Plast Surg. Mar 2007;58(3):246-9. [Medline].

  28. Setälä L, Papp A, Joukainen S, Martikainen R, Berg L, Mustonen P, et al. Obesity and complications in breast reduction surgery: are restrictions justified?. J Plast Reconstr Aesthet Surg [serial online]. Nov 24 2007;[Medline]. Available at http://www.sciencedirect.com/science/journal/17486815.

  29. Chan LK, Withey S, Butler PE. Smoking and wound healing problems in reduction mammaplasty: is the introduction of urine nicotine testing justified?. Ann Plast Surg. Feb 2006;56(2):111-5. [Medline].

  30. Spector JA, Singh SP, Karp NS. Outcomes after breast reduction: does size really matter?. Ann Plast Surg. May 2008;60(5):505-9. [Medline].

  31. Iwuagwu OC. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Plast Reconstr Surg. Dec 2003;112(7):1969-70; author reply 1970. [Medline].

  32. O'Blenes CA, Delbridge CL, Miller BJ, Pantelis A, Morris SF. Prospective study of outcomes after reduction mammaplasty: long-term follow-up. Plast Reconstr Surg. Feb 2006;117(2):351-8. [Medline].

  33. Balch CR. The central mound technique for reduction mammaplasty. Plast Reconstr Surg. Mar 1981;67(3):305-11. [Medline].

  34. Georgiade NG, Serafin D, Morris R, Georgiade G. Reduction mammaplasty utilizing an inferior pedicle nipple-areolar flap. Ann Plast Surg. Sep 1979;3(3):211-8. [Medline].

  35. Ribeiro L, Accorsi A Jr, Buss A, Marcal-Pessoa M. Creation and evolution of 30 years of the inferior pedicle in reduction mammaplasties. Plast Reconstr Surg. Sep 1 2002;110(3):960-70. [Medline].

 
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Central pedicle breast reduction. Left: Preoperative anteroposterior view 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.
Central pedicle breast reduction. Expected degree of change using the central pedicle reduction using the technique of Hester.
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.
Central pedicle breast reduction. The image demonstrates the deepithelialized central pedicle, preserving the subdermal plexus.
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.
Central pedicle breast reduction. The central pedicle is isolated just prior to tangential excision.
Central pedicle breast reduction. The inferior pedicle is divided, allowing increased mobility of the breast mound on the chest wall.
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.
Patient with macromastia, preoperative view.
Postoperative view following central mound reduction mammaplasty.
Anatomy of the breast.
 
 
 
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