eMedicine Specialties > Plastic Surgery > Breast

Breast Reduction, Central Pedicle

Updated: Apr 20, 2009

Introduction

History of the Procedure

Hester et al first described the central pedicle reduction technique in 1985.¹ 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.^2,3

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 1997.⁴ The ASPS/Plastic Surgery Educational Foundation (PSEF) procedural data from 2007 lists 105,706 cases of reduction mammaplasty, up from 39,639 cases in 1992.⁵

Etiology

Etiology is unknown.

Pathophysiology

The precise pathophysiology of macromastia is unclear.⁶ 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.^7,8

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.

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.^9,10,11 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.^{12,13,14,15,16,17,18,19} 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.

Relevant Anatomy

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.

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.

Workup

Laboratory 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.

Treatment

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 nipple-areola complex (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 adjacent to the medial and lateral borders of the NAC.

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.
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.

Central pedicle breast reduction. The image demonstrates the deepithelialized central pedicle, preserving the subdermal plexus.
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. Flap elevation in this region may extend as far superiorly as the clavicle.

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.
Once the entire central pedicle breast mound has been exposed, 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.

Central pedicle breast reduction. The inferior pedicle is divided, allowing increased mobility of the breast mound on the chest wall.
After completion of reduction of the of the central breast mound, redrape the skin flaps and tailor them to fit. 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; redrape the skin flaps and tailor from the inferior border of the areola to the inframammary crease).

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.
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. For more information, see eMedicine article Wound Healing, Healing and Repair.
Resolution of symptoms usually is recognized early in the postoperative course.

Complications

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.^20,21,22 Loss of sensation is an uncommon problem with the use of a central glandular technique, as it safely preserves the nerve distribution to the nipple.^23,24 Loss of the capacity to lactate postoperatively has been demonstrated to be unusual with various pedicles.²⁵

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 debrided. Obesity and smoking have been identified as increasing the risks for complications following reduction mammaplasty and should be avoided, if possible, to reduce complications.^26,27,28

Outcome and Prognosis

In a reported series of 153 patients, presenting symptoms were back and neck pain, shoulder grooving, and intertrigo.² 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. Other authors have also shown the efficacy of symptomatic relief.^29,30,31 In addition, satisfactory aesthetic outcomes can be achieved with this technique.

Patient with macromastia, preoperative view.

Postoperative view of patient in image 9, following central mound reduction mammaplasty.

Future and Controversies

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.^32,33,34 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. For information on other breast reduction techniques, see the following eMedicine Plastic Surgery articles:

Breast Reduction, Inferior Pedicle
Breast Reduction, Lejour
Breast Reduction, Liposuction Only
Breast Reduction, Moufarrège Total Posterior Pedicle
Breast Reduction, Simplified Vertical
Breast Reduction, Superior Pedicle
Breast Reduction, Vertical Bipedicle

Multimedia

Media file 1: 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.

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).

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.

Media file 4: Central pedicle breast reduction. The image demonstrates the deepithelialized central pedicle, preserving the subdermal plexus.

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.

Media file 6: Central pedicle breast reduction. The central pedicle is isolated just prior to tangential excision.

Media file 7: Central pedicle breast reduction. The inferior pedicle is divided, allowing increased mobility of the breast mound on the chest wall.

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.

Media file 9: Patient with macromastia, preoperative view.

Media file 10: Postoperative view of patient in image 9, following central mound reduction mammaplasty.

References

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

Keywords

breast reduction, central pedicle, macromastia, central pedicle breast reduction, reduction mammaplasty, central mound technique, large breasts, mammaplasty, mammoplasty, nipple reconstruction, nipple-areola complex, NAC, inframammary crease, IFM crease, breast reduction technique, reduction surgery, breast reduction pictures, large breast treatment, large breast reduction, large breast surgery, before breast reduction, after breast reduction, deep vein thrombosis, obesity, smoking, complications breast reduction, breast surgery complications, macromastia symptoms, large breast symptoms, breast reduction complications, breast reduction before, breast reduction after

Contributor Information and Disclosures

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, 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, Assistant Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, University of Alabama at Birmingham and Kirklin Clinics
James Neal Long, MD 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.

Medical Editor

Pankaj Tiwari, MD, Assistant Professor, Division of Plastic Surgery, Ohio State University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

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

Steven F Morris, MD, MSc, FRCSC, Professor, Department of Surgery, Professor, Department of Anatomy and Neurobiology, Cross Appointment (Professor), Division of Otolaryngology, Member, Faculty of Graduate Studies, Dalhousie University; Attending Plastic Surgeon, Queen Elizabeth II Health Sciences Center and Izaak Walton Killam Grace Health Centre, Nova Scotia
Disclosure: Nothing to disclose.

Acknowledgments

The author would like to acknowledge Dr. John H. Grant III for his work on the original edition of the topic.

Further Reading