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Vertical Bipedicle Breast Reduction Treatment & Management

  • Author: Bhupesh Vasisht, MD, FACS; Chief Editor: James Neal Long, MD, FACS  more...
 
Updated: Nov 16, 2015
 

Medical Therapy

Medical treatment is often dictated by insurance companies, although no effective nonsurgical treatment for enlarged breasts exists. A special supportive brassiere may offer some relief but often increases the pressure on the shoulders.

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Surgical Therapy

Bilateral reduction mammaplasty is the treatment of choice to alleviate the symptoms from mammary hypertrophy. The choice of reduction mammaplasty technique varies, but the expected outcomes are similar. The vertical bipedicle reduction mammaplasty is a reliable, reproducible, and aesthetically pleasing procedure.

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Preoperative Details

In addition to a history and physical examination, the initial consultation involves a discussion of the risks and benefits of the vertical bipedicle reduction mammaplasty procedure. These risks are not unique to this technique and can occur with any of the reduction techniques.

Some of these risks include infection, hematoma, and delayed wound healing with possible dehiscence of the incisions. Impaired vascularity of tissues can result in the loss of skin or nipple-areola complex. This can lead to fatty necrosis of the breast tissue and may result in lumpiness of the breast tissue.

Scar formation is thoroughly discussed with the patient. The inverted T scar is often schematically demonstrated to the patient during this meeting. African American patients are told about the possibility of hypertrophic scars and even keloid formation.

Preauthorization from the insurance company is usually required. This may involve submission of preoperative photographs that demonstrate the symptoms such as shoulder grooving and intertrigo. Mammograms and blood work are ordered as appropriately indicated.

Before coming to the operating room, the appropriate surgical markings are drawn with a marking pen with the patient in the sitting or standing position. These markings are essentially the same for the inferior pedicle Wise pattern reduction. The sternal notch is marked in the midline. From this point, the midclavicular point is marked. This usually is about 7 to 7.5 cm from the midline. A straight line is drawn from this point to the nipple on each side. This line represents the breast meridian or the axis on which the breast reduction will be based. A midline vertical line is made from the sternal notch to the umbilicus as a reference point.

The inframammary fold (IMF) is then also marked. This point is transposed to the anterior breast on the previously drawn meridian. This is the site of the advancement of the nipple and is approximately 21 cm from the sternal notch. In tall or mature women, this measurement can be longer.

The vertical extent of the medial and lateral flaps is then marked. This determines the amount of skin that will be excised. The length is typically 7 cm (5 cm from the IMF to the lower extent of the nipple-areola complex) and is drawn inferiorly from the planned areolar margin on either side of the meridian. This should encompass the entire nipple-areola complex. The new nipple-areola complex is marked and is 42 mm in diameter. A line is then drawn laterally and medially from the end of the vertical lines and is usually perpendicular to this line. It extends to involve all the breast tissue medially and laterally. A horizontal line joins the end of these lines at the inframammary crease. Careful planning is important for correct nipple placement and bilateral symmetry.[5]

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Intraoperative Details

Once the markings are in place, the patient is brought to the operating room. Prophylactic antibiotics may be given at this point. The patient is then scrubbed, draped, and prepared for surgery.

Once the patient is supine on the operating room table, the pedicle is measured and marked. The typical width of the pedicle is 8-10 cm. The pedicle is thicker and wider inferiorly and tends to be narrower superiorly. The nipple-areola complex is circumscribed with a 42-mm template. The skin superior and inferior to the nipple-areola complex is de-epithelialized. This marks the extent of the vertical bipedicle, which will be the basis of the blood supply to the nipple-areola complex.

The breast tissue lateral and medial to the pedicle is incised with a cautery unit. The lateral segment of tissue is removed through the skin, subcutaneous tissue, and breast tissue down to the pectoralis fascia. In a similar manner, the medial segment is removed down to the pectoralis fascia. At this point, the breast tissue above the nipple-areola complex can be removed, leaving a bridge of dermal tissue for the blood supply. Some surgeons leave the entire full thickness of breast tissue in the superior pole, and this portion is tucked and folded. All of the excised breast tissue is weighed. The wound is irrigated with saline and hemostasis is obtained. The flaps are then prepared for wound closure.

The medial and lateral flaps are approximated to each other in the meridian at the inframammary crease line. The nipple-areola complex is brought out through the previously marked keyhole, and a 5-0 Monocryl suture is used to approximate the 12-o'clock position of the nipple to the 12-o'clock position of the keyhole. The breast tissue above the Monocryl suture is typically folded in for the closure. Skin staples are then temporarily used to line up the wound edges. Interrupted 3-0 Monocryl sutures are then used for the subdermal closure. This is followed by a running subcuticular 4-0 Prolene suture to complete the closure.

The nipple-areola complex is closed with interrupted 5-0 Monocryl sutures followed by a running subcuticular 4-0 Prolene suture. The contralateral breast is addressed in a similar manner. At the end of the procedure, symmetry and good capillary refill of the nipple-areola complexes are achieved. Maintaining the patient's normal temperature and adequate fluids and using care in handling the pedicle during the procedure prevents undue risk to the viability of the nipple.

Once the procedure is complete, Steri-strips and light dressings are applied. The chest wall is then wrapped with elastic bandages (eg, Ace bandage).

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Postoperative Details

Postoperative care after breast reduction surgery has evolved over the last few years. The wound is dressed with a bulky gauze dressing and then the chest is wrapped with an elastic bandage. Some surgeons place the patient directly into a bra.

Postoperative pain management can be achieved with either oral analgesics or with pain pumps. Small catheters are placed in each breast through a small puncture site. The pain pump delivers small constant doses of local anesthetics directly into the wound for a period of about 48-72 hours. These pumps are becoming more and more popular because they limit the amount of narcotics that patients need in the immediate postoperative period. In general, patients are instructed to rest and not lift anything heavy for a few weeks.

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Follow-up

The patient is instructed to return to the office on day 2 after the surgery. At this visit, the original dressing is removed and the wound is inspected. The dressings are changed, and the patient typically can get the wound wet at this stage. After the wound has been wet, it is dried and topical antibiotic ointment is applied to the incisions. The patient returns at day 7 postsurgery and then at day 10. Sutures are removed at day 10.

Once the incisions appear to be healing, long-term visits are planned. The patient is asked to return at 6 weeks, 3 months, 6 months, and 1 year postsurgery. During this period, postoperative photographs are taken and outcomes recorded. Outcomes include documentation of the aesthetic result, long-term effects of gravity, scar maturation, nipple sensation, relief of preoperative symptoms, and patient satisfaction. Mammography, to establish a baseline for future breast cancer screening, can be repeated several months after surgery.

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Complications

See the list below:

  • Hematoma
  • Seroma
  • Infection
  • Wound dehiscence
  • Fat necrosis
  • Nipple and/or pedicle necrosis
  • Loss of sensitivity of the nipple
  • Hypopigmentation of the nipple
  • Inability to breastfeed
  • Hypertrophic scars
  • Keloid scars
  • Marked lower breast fullness
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Outcome and Prognosis

Outcome studies for breast reduction most often are not procedure-specific. The goal of breast reduction surgery should take into account patient safety; it should be reproducible, restore preoperative functional loss, and maintain the aesthetics of the breasts.[6]

Slezak and Dellon studied patients with gigantomastia.[7] They found that postoperative sensory outcome depends on a combination of factors, but most patients with gigantomastia have improved nipple sensation after a McKissock breast reduction.[7]

An outcome study from the Mayo Clinic in Scottsdale, Arizona, was published in 1997.[8] Of the respondents in the study, 94.2% believed the procedure was successful. Patients saw an improvement in body image, the ability to find clothes that fit, and the capacity to participate in sports. They experienced a decrease in notching of the shoulders from bra straps and decreases in shoulder pain, upper back pain, neck pain, and intertrigo. Pain or numbness in the hands, headaches, arm pain, and breast pain also decreased. Symptoms were either relieved or partially relieved in 88% of respondents. Of the respondents, 97.3% reported that they definitely or probably would undergo the procedure again. This outcome study supported the hypothesis that reduction mammaplasty is an effective procedure and the treatment of choice for symptomatic mammary hyperplasia.

A more recent study analyzing breast reduction complications was derived from the Breast Reduction Assessment: Value and Outcomes (BRAVO) study.[9] The resection weight correlated with increased risk and absolute number of complications. Delayed wound healing also correlated with resection weight and was inversely related to increasing age.[10] A British study assessed the aesthetic outcome of reduction mammaplasty.[11] Most patients rated the aesthetic outcomes of their surgery significantly higher than the consultants did. For both surgeons and patients, scarring was the most frequent cause of reported dissatisfaction. Silicone gel sheeting in the postoperative period may help mitigate these scars.

Symptomatic relief and improved body image has been shown in many studies that assess breast reduction.[12, 11] Among women who are obese and those who are not obese, no significant difference was reported concerning the resolution of physical symptoms or improvement in body image.[11]

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Future and Controversies

Several variations in surgical technique may offer an opportunity to reduce the extent of scarring in the small-to-moderate volume breast. No current medical treatment for female breast hypertrophy exists.

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Contributor Information and Disclosures
Author

Bhupesh Vasisht, MD, FACS Voluntary Clinical Instructor, Department of Plastic Surgery, Cosmetic and Reconstructive Surgery, Rutgers New Jersey Medical School; Private Practice, South Shore Plastic Surgery

Bhupesh Vasisht, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons, New Jersey Society of Plastic 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

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.

Additional Contributors

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

Disclosure: Nothing to disclose.

Acknowledgements

Patricia K Gomuwka, MD, FACS Consulting Staff, Department of Plastic Surgery, Riverside Regional Medical Center

Patricia K Gomuwka, MD, FACS is a member of the following medical societies: American Cleft Palate/Craniofacial Association, American College of Physician Executives, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, Medical Society of Virginia, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References
  1. McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg. 1972 Mar. 49(3):245-52. [Medline].

  2. STROMBECK JO. Mammaplasty: report of a new technique based on the two-pedicle procedure. Br J Plast Surg. 1960 Apr. 13:79-90. [Medline].

  3. Cosmetic Surgery National Data Bank Statistics. American Society for Aesthetic Plastic Surgery. 2007. [Full Text].

  4. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B. Current Preferences for Breast Reduction Techniques: A Survey of Board-Certified Plastic Surgeons 2002. Plastic & Reconstructive Surgery. 2004. 114(7):1724-1733. [Full Text].

  5. Abramo AC. A Superior Vertical Dermal Pedicle for the Nipple-Areola: An Alternative for Severe Breast Hypertrophy and Ptosis. Aesthetic Plast Surg. 2011 Jul 7. [Medline].

  6. 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].

  7. Slezak S, Dellon AL. Quantitation of sensibility in gigantomastia and alteration following reduction mammaplasty. Plast Reconstr Surg. 1993 Jun. 91(7):1265-9. [Medline].

  8. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg. 1997 Sep. 100(4):875-83. [Medline].

  9. Cunningham BL, Gear AJ, Kerrigan CL, et al. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg. 2005 May. 115(6):1597-604. [Medline].

  10. Shermak MA, Chang D, Buretta K, Mithani S, Mallalieu J, Manahan M. Increasing age impairs outcomes in breast reduction surgery. Plast Reconstr Surg. 2011 Dec. 128(6):1182-7. [Medline].

  11. Godwin Y, Wood SH, O'Neill TJ. A comparison of the patient and surgeon opinion on the long-term aesthetic outcome of reduction mammaplasty. Br J Plast Surg. 1998 Sep. 51(6):444-9. [Medline].

  12. Chao JD, Memmel HC, Redding JF, et al. Reduction mammaplasty is a functional operation, improving quality of life in symptomatic women: a prospective, single-center breast reduction outcome study. Plast Reconstr Surg. 2002 Dec. 110(7):1644-52; discussion 1653-4. [Medline].

  13. Scott GR, Carson CL, Borah GL. Maximizing outcomes in breast reduction surgery: a review of 518 consecutive patients. Plast Reconstr Surg. 2005 Nov. 116(6):1633-9; discussion 1640-1. [Medline].

 
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Macromastia with marked notching of the shoulders from bra straps and striking intertrigo of the medial aspect of the breasts.
Preoperative surgical diagram of the classic Wise pattern or inferior pedicle reduction technique. The typical measurements are shown.
The markings for the vertical bipedicle reduction is essentially the same as for the inferior pedicle reduction. The shaded area depicts the tissue that will be preserved. This will be the vascular supply to the new nipple areolar complex once it is transposed to its new location.
Intraoperative schematic demonstrating the bipedicle flap. The medial and lateral flaps are brought into the midline and sutured at the inframammary fold. The letter M represents the meridian or the axis for the breast on which the reduction is maintained.
Preoperative and postoperative images. Preoperative measurement of nipple to sternal notch was 32 cm bilaterally. Over 1300 g of tissue were removed from each breast during the vertical bipedicle reduction mammaplasty procedure on this patient.
Preoperative and postoperative images. Preoperative measurement of nipple to sternal notch was 44 cm bilaterally. Over 3000 g of tissue were removed from each breast during the vertical bipedicle reduction mammaplasty procedure on this patient.
Anatomy of the breast.
 
 
 
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