eMedicine Specialties > Plastic Surgery > Breast

Breast Reduction, Inferior Pedicle: Treatment

Author: Susan E Downey, MD, Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Southern California
Contributor Information and Disclosures

Updated: Aug 5, 2008

Treatment

Preoperative Details

The breast reduction reduces the skin envelope and the volume of breast tissue. The markings are critical for the procedure and need to be made preoperatively, before the patient has received narcotic medication. At the time of the markings for the patient's reduction, adjustments are made for correction of asymmetry problems. The most important marking is for the new position of the nipple-areolar complex (NAC). This should be marked at a position commensurate with the inframammary fold (IMF), which is also 21-25 cm from the sternal notch. This should be at a position approximating one third of the way up the upper arm. The NAC can be reduced in size if large. A 4.5-cm NAC is appropriate for a reduced breast.

The vertical limb is then marked. In general, this should be short (4.5 cm) to minimize the chance of eventual bottoming out of the breast. A longer vertical limb leads to premature bottoming out. The horizontal limb should then be marked. The total length of the upper portion of the horizontal limb should be equal to or greater than the inferior limb to allow for closure around the volume of the breast tissue.

Intraoperative Details

Once the markings are complete, the patient is taken to the operating room, both breasts are prepared and draped, and surgery is begun. The inferior pedicle of breast technique involves leaving a pedicle of tissue with the nipple in the superior portion of the pedicle, creating a wedge-shaped pedicle down to the chest wall. The pedicle should be an 8-cm base in smaller reductions and a 10-cm base in larger reductions. The pedicle is de-epithelialized. Originally, this was thought to preserve blood flow and nipple sensation. This is probably not absolutely critical but remains standard for the reduction process.

In extremely large reductions, the intended position of the nipple can be de-epithelialized. In case the nipple should become cyanotic during the procedure, the surgery could be converted to a free nipple graft. However, in general, reductions using the inferior pedicle technique can be performed in all patients except those with the most extremely large breasts. The excess breast tissue medially, laterally, and superiorly is then excised, and the upper breast flap is then elevated off the pectoralis fascia. The upper breast flap is then thinned to create the desired volume in the breasts.

The breasts should not be reduced down to a standard size but to one that is compatible with the remainder of the patient's body habitus. This may range from a B to a D cup or even bigger in larger women. Breast tissue should be carefully preserved, marked, and protected so that each specimen sent separately from each breast can be evaluated by a pathologist. Rarely, an occult malignancy has been found in a breast reduction specimen. In such cases, knowing in which breast the cancer has arisen is critical. When excess breast tissue is being excised, do not to let the pedicle fall to one side, as this causes undue cyanosis of the pedicle and may increase the chance of nipple loss.

After irrigating the wounds and obtaining hemostasis, the wounds are temporarily closed and the patient is placed in a sitting position to ensure that symmetry exists between the two breasts. The volume of breast tissue resected is weighed to provide data to the insurance companies. Knowing the volume of resected tissue is also helpful for determining that symmetry has been achieved during the reduction process.

The wounds are closed with buried sutures and then either a subcuticular suture or Dermabond on the skin.

Postoperative Details

The patient is placed in a surgical bra immediately following the procedure, as this helps minimize postoperative pain. The patient is generally kept in the hospital for one night following the surgery, during which the viability of the NAC is monitored.

Follow-up

Follow up with the patient as needed postoperatively to ascertain healing of the wounds. In general, the scars do very well around the NAC. Vertically but in the inframammary incision, some thickening of the scar may occur, particularly in the medial portion. This may require a Kenalog injection. The patient should be reminded to establish a new baseline mammogram approximately 6 months after the reduction mammoplasty.

Complications

The most devastating complication following a reduction mammoplasty is total loss of the nipple-areolar complex (NAC). This is extremely rare. Of course, the incidence of this complication is higher in patients who smoke or who have extremely large breasts. In patients with extremely large breasts, consider the possibility of a free nipple graft, and, as mentioned earlier, consider de-epithelialization of the upper portion from where the nipple is to be removed, which would allow the nipple to be placed as a graft. 

Smokers should be advised to quit smoking prior to the procedure and informed of the increased risk of problems if they continue to smoke.

In the case of impending loss of the NAC, convert the procedure to a free nipple graft. Otherwise, hematoma formation is the main complication that could arise. Some surgeons opt for drain placement, though the risk of hematoma or seroma is small. Infection is also unusual in a reduction mammoplasty.

More on Breast Reduction, Inferior Pedicle

Overview: Breast Reduction, Inferior Pedicle
Workup: Breast Reduction, Inferior Pedicle
Treatment: Breast Reduction, Inferior Pedicle
Follow-up: Breast Reduction, Inferior Pedicle
Multimedia: Breast Reduction, Inferior Pedicle
References
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References

  1. Blomqvist L, Eriksson A, Brandberg Y. Reduction mammaplasty provides long-term improvement in health status and quality of life. Plast Reconstr Surg. Oct 2000;106(5):991-7. [Medline].

  2. Courtiss EH, Goldwyn 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].

  3. Brown MH, Weinberg M, Chong N, et al. A cohort study of breast cancer risk in breast reduction patients. Plast Reconstr Surg. May 1999;103(6):1674-81. [Medline].

  4. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. Sep 1999;104(3):806-15; quiz 816; discussion 817-8. [Medline].

  5. Bostwick J. Breast reduction. In: Bostwick J, ed. Aesthetic and Reconstructive Surgery. St. Louis, Mo: CV Mosby; 1983.

  6. Downey SE. Plastic surgery for common breast problems. In: Hindle WH, ed. Breast Care: A Clinical Guidebook for Women's Primary Health Care Providers. New York: Springer-Verlag; 1999.

  7. Goldwyn RM. Reduction mammoplasty in the unfavorable result. In: Goldwyn R, Cohen M, eds. Plastic Surgery Avoidance and Treatment. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001.

  8. Hoffman S. Inferior pedicle technique. In: Spear S, ed. Breast Reduction in Surgery of the Breast: Principles and Art. Philadelphia, Pa: Lippincott-Raven; 1998.

  9. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg. Mar 1975;55(3):330-4. [Medline].

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Further Reading

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Keywords

breast reduction, reduction mammoplasty, inferior pedicle, heavy breasts, large breasts, nipple-areolar complex, NAC, nipple scar tissue, keloids, inframammary fold, IMF

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Contributor Information and Disclosures

Author

Susan E Downey, MD, Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Southern California
Susan E Downey, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society for Aesthetic Plastic Surgery, and American Society of Plastic Surgeons
Disclosure: Ethicon, Inc. Honoraria Consulting

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.

Managing Editor

Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston
Saleh M Shenaq, MD† is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Pediatrics, American Association for Hand Surgery, American Association for the Advancement of Science, American Association of Plastic Surgeons, American Burn Association, American College of Physician Executives, American College of Surgeons, American Congress of Rehabilitation Medicine, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Gene Therapy, American Society of Law Medicine and Ethics, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Trauma Society, Association for Academic Surgery, International College of Surgeons, Lipoplasty Society of North America, Plastic Surgery Research Council, Society for Neuroscience, Society of Surgical Oncology, Southern Medical Association, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Frederick J Menick, MD, Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona College of Medicine; Private Practice in Tucson, Arizona
Frederick J Menick, MD is a member of the following medical societies: American Association of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic and Reconstructive Surgery, American Society of Plastic Surgeons, and Canadian Society of Plastic Surgeons
Disclosure: none None None

 
 
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