Central Pedicle Breast Reduction Treatment & Management
- Author: Jorge I de la Torre, MD, FACS; Chief Editor: James Neal Long, MD, FACS more...
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. See the image below.
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.
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 the image below.
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. See the images below.
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. See the image below.
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). See the image below.
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. A vertical-only incision is possible; however, unacceptable puckering of the vertical incision is a common complication. 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.
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.
See the list below:
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 Medscape Reference article Wound Healing and Repair.
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.[24, 25, 26] 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.[27, 28] Loss of the capacity to lactate postoperatively has been demonstrated to be unusual with various pedicles.
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.[30, 31, 32]
Outcome and Prognosis
In a reported series of 153 patients, presenting symptoms were back and neck pain, shoulder grooving, and intertrigo. 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.[33, 34, 35] In addition, satisfactory aesthetic outcomes can be achieved with this technique. See the images below.
Future and Controversies
Routine screening mammography guidelines ought to be followed in the preoperative workup for breast reduction; however, controversy exists regarding the use of mammography. The American Cancer Society and the American Congress of Obstetricians and Gynecologists recommends yearly mammography for women older than 40 years.[37, 38] However, according to the the US Preventive Services Task Force, routine screening mammography in women aged 40-49 years is not indicated and biennial screening mammography for women aged 50-74 years is recommended. Evidence-based guidelines aimed specifically at reduction mammoplasty evaluation have not been clearly developed. Additional preoperative mammography must be analyzed for its potential adverse effects, including unneeded additional imaging or biopsy procedures.
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.[40, 41, 42] 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 Medscape Reference Plastic Surgery articles:
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