Superior Pedicle Breast Reduction
- Author: James Neal Long, MD, FACS; Chief Editor: Jorge I de la Torre, MD, FACS more...
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. 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.
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).
History of the Procedure
In 1957, Arie first described the superior pedicle mammoplasty. This description was followed by refinements given to us by Ivo Pitanguy in 1967, 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. Soon thereafter, Orlando and Guthrie demonstrated the superomedial pedicle technique, which varied only in the more medially-directed superior pedicle. 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. Arufe et al confirmed adequate vascularity of the superior pedicle with preoperative arteriograms on several patients.
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.
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.
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.
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. 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.
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.
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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