eMedicine Specialties > Plastic Surgery > Breast

Breast Reduction, Simplified Vertical

Author: Elizabeth J Hall-Findlay, MD, FRCS(C), Private Practice, Banff Plastic Surgery Centre
Contributor Information and Disclosures

Updated: Oct 21, 2009

Introduction

Vertical reduction mammaplasty techniques have only recently achieved a measure of acceptance in North America.^{1,2,3,4,5,6,7,8,9,10,11} Although the desire to eliminate some of the extensive scarring of the anchor-shaped techniques is certainly strong, most surgeons are still not willing to compromise their comfort with the safety of the inferior pedicle technique.

History of the Procedure

Use of the superior pedicle in the initial vertical techniques that Lassus^1,2,3 and Lejour or Lejour et al^5,6,7,8 describe prevented wide acceptance of the vertical approach. The superior pedicle can be difficult to inset; either the pedicle needs to be thinned to allow it to be folded into place, or the blood supply is at risk because of vascular kinking or compression. Thinning may improve circulation by avoiding compression, but the ability to retain sensation or allow for breastfeeding is reduced.

Different pedicles have been described over the years, including the lateral pedicle,^12,13 the horizontal bipedicle and the lateral pedicle,^14,15,16 the vertical bipedicle,^17,18 the inferior pedicle,^19,20,21 and the superior pedicle.²² All these pedicles were used with the anchor-shaped reduction techniques while surgeons in Europe^{12,1,2,3,4,6,5,7,8} and in South America^23,24,25,26 tried techniques that reduced scarring. However, the inferior-pedicle and central-mound techniques^27,28 had proven so reliable and safe that surgeons in North America were reluctant to switch to a method that they thought was riskier, even though scarring could be reduced. Hammond has combined the vertical approach (circumvertical) with an inferior pedicle,⁹ but surgeons are still reluctant to switch away from the inverted-T inferior pedicle technique.

Problem

Various approaches to breast reduction have been attempted to combine the safety of the pedicle with the appeal of the short-scar techniques. No one method is best, but the ability to use different approaches in different situations can expand the breast reduction and mastopexy repertoire of the plastic surgeon. The key is to realize that the pedicle, the skin-resection pattern, and the parenchymal-resection pattern must all be viewed separately. The phrases vertical and inverted-T apply to the skin resection pattern. Both approaches can use different pedicles and different parenchymal resection patterns.

Surgeons initially believed that they had to choose between an improved shape and an improved scar.²⁹ However, many practitioners started to realize that both the shape and the scars could be improved and that some vertical techniques improved the longevity of the shape.

Although many surgeons started using the vertical approach because of the reduced scarring, it has become clear that the key is about concepts not scars. Reduced scarring is only a small part of the appeal. Improvement occurs because the parenchymal (and skin) resection is performed through a vertical ellipse. The breast is coned rather than being pushed up and flattened by a horizontal ellipse. This coning improves projection. The vertical elliptical excision also means that the lateral and medial parenchymal pillars are brought together; the resultant healing process holds the shape in the long term.

The inverted-T techniques usually rely on the skin brassiere to shape the breast, whereas the vertical techniques usually use the breast to shape the skin. Medial-pedicle vertical breast reduction also leaves the tissue attached to the skin superiorly, and the heavy inferior breast tissue is removed. The skin is then allowed to conform to the new shape.

With many of the inverted-T inferior-pedicle techniques, the surgeon undermines the skin to remove the superior tissue, leaving the heavy inferior breast tissue behind. This tissue is then pushed up by tightly closing the skin horizontally. Skin (dermis) is an elastic structure that stretches. Therefore, the fact that the vertical incision stretches with inverted-T techniques and that the tissue bottoms out is not surprising. By comparison, medial-pedicle vertical reduction uses the healing of the relatively inelastic medial and lateral pillars to hold the shape. No tension is applied to the skin. The best results are also achieved when very little tension is applied to the parenchymal closure.

Indications

Medial-pedicle vertical reduction mammaplasty is simple and reliable.^{30,31,32,33,34,35} The procedure is fast and involves few adjustments. The pedicle is full thickness, and the resection is beveled out as the tissue is removed en bloc. The desirable breast tissue (superior portion) is left in place, and the undesirable breast tissue (inferior and lateral portion) is removed. The durability of the shape of the breast appears to be due to the removal of the heavy inferior breast tissue and the lack of reliance on skin for shaping.

The often quoted rule of the Wise-pattern inferior-pedicle technique is to keep the vertical incision shorter than 5 cm.³⁶ Although this rule was designed to prevent bottoming-out with time, it prevents good projection. The coning of the breast with the medial-pedicle vertical technique improves projection, and the lengthened vertical scar is far from undesirable. Vertical techniques are based on vertical wedge resection of the tissue (and skin) instead of horizontal excision of the tissue (and skin). This vertical ellipse allows the breast tissue to be coned and improves the projection.

Relevant Anatomy

The breast is a superficial ectodermal structure, and most of its blood supply is superficial. The breast is a skin structure that is relatively mobile on the chest wall. It is attached to the skin at the nipple level. The breast is held in place on the chest wall not by deep attachments but by the skin structures of the inframammary fold and the sternum. The upper and lateral breast borders are not held in place in the same way.

The superior pedicle is supplied from a strong medial vessel from the second or third interspace. It is superficial by the time it reaches the center of the breast. For this reason, a superior pedicle can be easily and safely thinned. The medial pedicle is supplied from medial vessels from the third to fifth interspaces. The pedicle may appear to be superomedial when the patient is standing, but the blood supply is medial. The medial pedicle can be thinned.³⁰ The author likes to use a full-thickness medial pedicle for both innervation and breastfeeding potential.

The breast can be visualized as a cylinder, especially when the patient leans forward and the breast hangs. Regardless of the level on the cylinder at which breast tissue is removed, the distance around the circumference of the cylinder should be the same. This means that the vertical limb of the breast reduction should be manageable at any size. On the converse, if the pedicle is to be retained, the large (ie, long-cylinder) breast has a long pedicle, which makes reducing lower-pole fullness more difficult. As with most breast reductions, small reductions often give the best cosmetic results.

Sensation in the nipple-areola complex is an important consideration. Inferior- and central-pedicle reductions often maintain good sensation, and free nipple grafts result in permanent loss of sensation. Surgeons are taught that the main sensation comes laterally from the fourth intercostal nerve. Therefore, a lateral-pedicle technique should result in sensation better than is present after a superior- or medial-pedicle technique is used. However, sensation comes from several directions.

Surgeons in Austria³⁸ demonstrated that the deep branch of the lateral fourth intercostal nerve runs across the breast just above the level of the pectoralis fascia until the mid portion of the breast, where it then runs superiorly toward the nipple. Because the pectoralis fascia is not exposed and because the pedicle is full thickness, this anatomy explains why the medial-pedicle technique maintains sensation as good as that associated with the lateral-pedicle technique.

Thinning of a pedicle likely reduces breastfeeding potential. The medial pedicle used in this technique is full thickness. About 60% of patients can breastfeed, with 25% needing to supplement.³⁹ Of interest, the same statistics also apply to large-breasted women whether or not they undergo breast-reduction surgery.

Contraindications

Large breast reductions (>1500-2000 g) can be performed using this technique, but the size of the pedicle causes heaviness and increases the potential for bottoming-out with time. As with most breast reductions, small reductions often result in the best cosmetic results. For massive breast reductions, the medial pedicle can be used, and the heavy inferior breast tissue can be removed. At the end of the resection, the excess skin must be treated separately. It may need to be removed as a J, L, or inverted-T shape. Good-quality skin retracts better than poor-quality skin.

The limit of pedicle length has not been established, but the author considers using a free nipple graft when the pedicle approaches 15 cm (from the edge of the de-epithelialized area to the nipple). The patient is preoperatively warned that, if the circulation is not good with the medially based pedicle, free nipple grafts will be used. If sensation or breastfeeding is more important than shape, an inferior pedicle may be the best choice.

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