Superior Pedicle Breast Reduction

  • Author: James Neal Long, MD, FACS; Chief Editor: Jorge I de la Torre, MD, FACS  more...
 
Updated: Dec 21, 2015
 

Background

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.[1] Each particular technique during this time period differed primarily on the origin of the parenchymal pedicle, which provided the neurovascular contributions to the nipple-areola complex (NAC).

Though the inferiorly based pedicle technique remains one of the most popular techniques in the United States today, because of their advantages over other procedures, the Superiorly based techniques continue their increasing popularity among both surgeons and patients. See the image below.

Breast reduction, superomedial pedicle. 2 months p Breast reduction, superomedial pedicle. 2 months postoperative lateral view.

Vertical reductions, as espoused by Lassus and then refined 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 Lejour Breast Reduction, Simplified Vertical Breast Reduction, and Vertical Bipedicle Breast Reduction).

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History of the Procedure

In 1957, Arie first described the superior pedicle mammoplasty.[2] This description was followed by refinements given to us by Ivo Pitanguy in 1967,[3] eventhough 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 type reductions.[4] Soon thereafter, Orlando and Guthrie demonstrated the superomedial pedicle technique, which varied only in the more medially-directed superior pedicle.[5] 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.[6] Arufe et al confirmed adequate vascularity of the superior pedicle with preoperative arteriograms on several patients.[7]

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 small vessel 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 inherent to these methods. 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.[8]

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Indications

The indications for superior pedicle reduction are the general indications for breast reduction, which are well-described as the 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.

The selection of a straight vertical pedicle technique is best reserved for those patients with less ptosis. Transposing the nipple more than 5 cm with a pure vertical technique can be difficult, particularly in patients with dense breast tissue. The superior-medial pedicle is indicated for patients who require lengthier nipple transpositions.

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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.

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-areola 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.[9] 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.

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

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Contraindications

Superior and superomedial pedicled breast reductions are probably contraindicated if breast scars completely cross the proposed pedicle and are known or presumed to have transected the pedicle blood supply. These techniques should be given very careful consideration in patients who have had previous breast reduction by a pedicle of a differing orientation as they may develop fatty necrosis or nipple slough.

Relative contraindications for the superior medial pedicle include NAC transpositions of less than 5 cm or greater than 20 cm and, in the superior pedicle, transposition of greater than 5 cm. Since superior-medial 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 appropriately confined.

Resection volume greater than 2000 g is a relative contraindication, although the Author has experience using this technique in properly selected patients with resections exceeding 4000 g per side. Others have supported this, demonstrating acceptable morbidity rates.[10]

Because of the limited undermining required to transpose tissues, the authors have found fewer complications with the superomedial pedicle in patients who smoke (compared to other techniques in patients who smoke). Limited undermining maintains vascular beds connecting parenchyma 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 far less common.

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Contributor Information and Disclosures
Author

James Neal Long, MD, FACS Founder of Magnolia Plastic Surgery; Former 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; Section 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, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Coauthor(s)

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 Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Dean R Cerio, MD Managing Partner, Plastic and Reconstructive Surgeon, East Coast Advanced Plastic Surgery

Dean R Cerio, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Southeastern Society of Plastic and Reconstructive Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

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 Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous editor Saleh M Shenaq, MD†, to the development and writing of this article.

References
  1. Lassus C. Breast reduction: evolution of a technique--a single vertical scar. Aesthetic Plast Surg. 1987. 11(2):107-12. [Medline].

  2. Arie G. Una nueva tecnica de mastoplastia. Rev Iber Latino Am Cir Plast. 1957. 3:28.

  3. Pitanguy I. Surgical correction of breast hypertrophy. British Journal of Plastic Surgery. 1967. 20:78.

  4. Weiner DL, Aiache AE, Silver L, Tittiranonda T. A single dermal pedicle for nipple transposition in subcutaneous mastectomy, reduction mammaplasty, or mastopexy. Plast Reconstr Surg. 1973 Feb. 51(2):115-20. [Medline].

  5. Orlando JC, Guthrie RH Jr. The superomedial dermal pedicle for nipple transposition. Br J Plast Surg. 1975 Jan. 28(1):42-5. [Medline].

  6. Hugo NE, McClellan RM. Reduction mammaplasty with a single superiorly-based pedicle. Plast Reconstr Surg. 1979 Feb. 63(2):230-4. [Medline].

  7. Arufe HN, Erenfryd A, Saubidet M. Mammaplasty with a single, vertical, superiorly-based pedicle to support the nipple-areola. Plast Reconstr Surg. 1977 Aug. 60(2):221-7. [Medline].

  8. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg. 1999 Sep. 104(3):748-59; discussion 760-3. [Medline].

  9. Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola complex: an anatomic study. Plast Reconstr Surg. 2000 Mar. 105(3):905-9. [Medline].

  10. Landau AG, Hudson DA. Choosing the superomedial pedicle for reduction mammaplasty in gigantomastia. Plast Reconstr Surg. 2008 Mar. 121(3):735-9. [Medline].

  11. Altuntas ZK, Kamburoglu HO, Yavuz N, Dadacı M, Ince B. Long-term changes in nipple-areolar complex position and inferior pole length in superomedial pedicle inverted 't' scar reduction mammaplasty. Aesthetic Plast Surg. 2015 Jun. 39 (3):325-30. [Medline].

  12. Hauben DJ. Experience and refinements with the supero-medial dermal pedicle for nipple-areola transposition in reduction mammoplasty. Aesthetic Plast Surg. 1984. 8(3):189-94. [Medline].

  13. Finger RE, Vasquez B, Drew GS, Given KS. Superomedial pedicle technique of reduction mammaplasty. Plast Reconstr Surg. 1989 Mar. 83(3):471-80. [Medline].

  14. Kim P, Kim KK, Casas LA. Superior pedicle autoaugmentation mastopexy: a review of 34 consecutive patients. Aesthet Surg J. 2010 Mar. 30(2):201-10. [Medline].

  15. Davison SP, Mesbahi AN, Ducic I, Sarcia M, Dayan J, Spear SL. The versatility of the superomedial pedicle with various skin reduction patterns. Plast Reconstr Surg. 2007 Nov. 120(6):1466-76. [Medline].

  16. Manahan MA, Buretta KJ, Chang D, Mithani SK, Mallalieu J, Shermak MA. An outcomes analysis of 2142 breast reduction procedures. Ann Plast Surg. 2015 Mar. 74 (3):289-92. [Medline].

  17. Choi M, Unger J, Small K, Tepper O, Kumar N, Feldman D, et al. Defining the kinetics of breast pseudoptosis after reduction mammaplasty. Ann Plast Surg. 2009 May. 62(5):518-22. [Medline].

  18. Cruz-Korchin N, Korchin L. Breast-feeding after vertical mammaplasty with medial pedicle. Plast Reconstr Surg. 2004 Sep 15. 114(4):890-4. [Medline].

  19. Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg. 2002 Jul. 29(3):379-91. [Medline].

  20. Thorek M. Possibilities in the reconstruction of the human form. N Y Med J. 1922. 116:572.

 
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Preoperative markings of a superomedial pedicle reduction. Notice that the base of the pedicle is made wider for longer nipple transpositions.
Preoperative markings of a superior pedicle technique breast reduction.
Breast reduction, superior pedicle. The pedicle, now developed, is imbricated superiorly into the new NAC inset position.
Breast reduction, superior pedicle. The NAC is into the new position. Vertical closure, no inframammary incision line. The lateral dimpling is from intraparenchymal pillar suturing and typically settles out completely within 6 weeks.
Breast reduction, superomedial pedicle. Preoperative view of a 55-year-old woman with macromastia.
Breast reduction, superomedial pedicle. Preoperative lateral view of a 55-year-old woman with macromastia.
Breast reduction, superomedial pedicle. 2 months postoperative view. Nipple-areolar complexes are sensate and viable. Note eliminated symmastia.
Breast reduction, superomedial pedicle. 2 months postoperative lateral view.
Anatomy of the breast.
 
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