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Moufarrege Total Posterior Pedicle Breast Reduction

  • Author: Richard J Moufarrège, MD, FRCSC; Chief Editor: James Neal Long, MD, FACS  more...
 
Updated: Oct 28, 2014
 

Background

Mammaplasty has improved so much over time that this operation currently boasts one of the greatest numbers of surgical techniques. Authors have introduced certain modifications for surgical improvements, leading to a gradual development of techniques reminiscent of the evolution of species. However, this evolution introduced some avant-garde techniques that were eventually abandoned and condemned. Because they were used without an associated safety procedure, the techniques were deemed dangerous and had the potential for various complications.

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History of the Procedure

The purpose of mammary reduction is to decrease breast volume. With it, in the past, came the aesthetic need to add a grafted nipple in a trompe l'oeil fashion. That technique remains in use in some surgical centers, but it has fortunately been replaced in most of them by reductions with transposition of the nipple, with consequent conservation of the nipple as a flap based on a vascular pedicle. The quality of a transposed nipple is clearly superior to that of a grafted one.

A large pedicle was not required to keep the nipple alive; often, but not always, a thin strip of subcutaneous fat was sufficient. If the nipple survived the ischemia of fragile transposition, it remained inert, congestive for a long while, and insensitive, with its neighboring position being the only relation to underlying tissues. Innovators, attempting to increase the safety of the nipple by thickening its pedicle, recommended increasingly thicker fatty flaps. Survival of the nipple increased, yet the torsion of the pedicle, necessary for the new positioning of this important complex, often produced surprises.

These pedicles were always of superior origin (at the 12-, 10-, or 2-o'clock position), lateral origin (at the 3- or 9-o'clock position), or bifid but they were never of inferior origin. Resections were performed in the inferior quadrant of the breast, automatically cutting all bridges for a glandular pedicle of that quadrant. Because the transposition was always made toward the top, these glandular pedicles could not be very thick; if they were, displacement and torsion would be more damaging (see image below).

Before inferior and posterior pedicles, the upper Before inferior and posterior pedicles, the upper pedicle mammaplasties.

The advantage of creating a nipple of superior quality by adding a glandular bridge to the fatty pedicle was clear. Surgeons who were convinced of that principle also quickly understood that a thick pedicle cannot be soft enough to allow displacement of the nipple in all directions and without any constraint at will if that pedicle was superior, oblique, or lateral. They also understood that such a mobile pedicle cannot originate from close surrounding tissues to avoid mechanical constraints with mobilization of the nipple. Thus, it now appears obvious that such a pedicle should originate somewhere in the mass of breast tissue, allowing its displacement in all directions. This eliminates all limitations to the mobilization of the nipple-areola complex.

Evolution

In 1971, McKissock improved the pedicle of the nipple-areola complex by choosing 2 bridges. Between them, the inferior is quite large and connects the nipple to deep glandular tissue to allow vascularity of the nipple by perforating vessels emanating from the pectoralis major. Contrary to the previous techniques, McKissock's technique based the nipple on a mass of the breast gland that could represent 10-15% of the total mass of the remaining breast after reduction (see section A of the image below).

Amount of gland kept in the 3 techniques within th Amount of gland kept in the 3 techniques within the pedicle of the nipple-areola complex: A is the McKissock double-vertical pedicle at 10-15%. B is the Robbins inferior pedicle at 15-25%. C is the Moufarrège total pedicle at 100%.

Only a Biesenberger reduction based the nipple on a larger mass of the remaining breast; unfortunately, the Biesenberger method had too many problems inherent in the detachment of the breast from the pectoralis major, consequently causing interruption of the perforating vessels and a high rate of breast tissue necrosis. Thus, this type of reduction was abandoned.

In 1976, Robbins, carrying on McKissock's work, based the nipple on a simple inferior pedicle, probably a little larger than McKissock's.[1] Mammary mass in connection with the nipple had to represent 15-25% of the remaining mammary volume (see section B of the image above).

Since 1979, the author (Richard Moufarrege) has used 100% of the remaining gland as vascular support for the nipple-areola complex.[2] This pedicle initially was in a posterior and inferior position, but eventually it occupied the entire height of the gland. Care is always taken to include 100% of the remaining breast. This is the total dermoglandular posterior pedicle mammoplasty (see section C of the image above).

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Problem

Breast surgery, either lifting or reduction, consists of more than displacing an inert mass or simply reducing as in other resection surgery on undesirable tissue. Indeed, one must also be greatly concerned with how the breast will appear afterward and with the other functions of the remaining breast tissue. Reducing the breast tissue and not taking care of the nipple, its position, and its relationship with the remaining volume of the breast has already been suggested by some authors, but, in the author's opinion, these are inelegant gestures that discount the talent of plastic surgeons and their potential to achieve artful results.

The surgeon must preserve the most important functions of a woman's breast, such as the quality of sensation of the nipple, contractility, and breastfeeding ability. Plastic surgeons also must be very demanding in terms of shape, proportion, volume, and scarring. Obtaining a nicely shaped breast on a normally built woman with minimal scars; harmonious features; and a well-placed, sensitive, contractile nipple is now the standard in mammaplasty.

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Etiology

The origin of hypertrophies is multiple. Most breast hypertrophies do not have a precise etiology but seem to occur more frequently in some families. Hypomastia also seems to occur more frequently in some families. Apart from this majority of unexplained hypertrophies, a large number of hormones act on breast development, either by enlarging them or by reducing them. Among these are estrogen, progesterone, testosterone, glucocorticoids, insulin, prolactin, growth hormone, thyroid hormone, and oxytocin.

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Pathophysiology

Removed breast tissue is always examined in pathology in order to recognize the presence of any cancerous cells. If cancerous cells are present, the anatomical position of such tissues can be more easily evaluated in this one-block resection, which allows the oncological surgeon to determine the appropriate treatment in each individual case.

Some fibroadenomas are discovered without any clinical consequences on the future of the breast.

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Presentation

Characteristics

This technique is performed openly on a breast completely stripped on its anterior aspect. Resection is performed at the periphery, and the entire remaining gland is in direct contact with the nipple and acts as the pedicle. Thus, the pedicle of the nipple-areola complex is composed of the entire remaining breast that extends from the lowest to the highest limit of the breast, hence the term total pedicle. This characteristic lends the technique of the total pedicle all its other peculiarities and advantages, described below.

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Indications

Breast reduction is meant to treat the problem of very large breasts causing physical and physiological discomfort and pain. These problems can be so important and significant that, in some medical systems, their treatment is covered by medical insurance when the removed breast is larger than a certain average volume and weight.

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Relevant Anatomy

The breast extends from the second to the seventh rib. Its horizontal limits are the sternal bone medially and the frontal axillary line laterally. The breast glandular tissue is primarily vascularized by the perforating vessels arising from the internal mammary artery and intercostal arteries. According to different authors, this posterior vascularization provides 70-80% of the breast blood supply. This has been the very determinant factor in the choice of using a total posterior pedicle mammaplasty.

In the author’s point of view, innervation of the nipple is both the first and the most important issue. It originates from the intercostal nerves, mainly the fourth, fifth, and sixth, which run along the aponeurosis of the chest muscles and, once in the central area of the breast, proceed ventrally through the breast tissue to the nipple-areola complex. The conservation of these nerves allows the total posterior pedicle to preserve the erogenic sensation of the nipple-areola complex (see image below).

The lateral and medial skin flaps are elevated and The lateral and medial skin flaps are elevated and held with hooks. Even the upper quadrant has been entirely denuded. No parcels of gland are kept with the skin. The entire gland is fully exposed up to the pectoralis major and is ready for the resection on an open-sky basis.

The second nervous system is the one running in the subcutaneous tissue in the surrounding areas of the nipple-areola complex and gives the nipple the tactile sensation but not the erogenic one. This last one is responsible of the recuperation of the tactile sensation of the nipple but has no effect on the recovery of the erogenic sensitivity.

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

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Contraindications

In the author's opinion, severe obesity is a contraindication for the realization of a nice breast.

Patients should have completely stopped smoking 3 months before surgery and should not smoke during the 3 months after mammaplasty.

The author recommends that patients lose excess of weight for many reasons, among which are to be healthier for the perioperative period, to have less scarring owing to shorter incisions, and to have an acceptable ratio between the new breast volume and the abdomen volume.

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Contributor Information and Disclosures
Author

Richard J Moufarrège, MD, FRCSC Professor, Department of Plastic Surgery, Hôtel-Dieu, University of Montreal, Canada

Richard J Moufarrège, MD, FRCSC is a member of the following medical societies: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, Royal College of Physicians and Surgeons of Canada, Canadian Medical Association, Quebec Medical Association

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

Geoffrey L Robb, MD, FACS Chair, Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center

Geoffrey L Robb, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Society of Plastic Surgeons, American College of Surgeons, American Society of Maxillofacial Surgeons, American Society for Reconstructive Microsurgery, Texas Society of Plastic Surgeons

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. Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg. 1977 Jan. 59(1):64-7. [Medline].

  2. Moufarrège R, Beauregard G, Bosse JP, et al. Reduction mammoplasty by the total dermoglandular pedicle. Aesthetic Plast Surg. 1985. 9(3):227-32. [Medline].

  3. Aufricht G. Mammoplasty for pendulous breasts: Empiric and geometric planning. Plast Reconstr Surg. 1949. 4:13.

  4. Sinno H, Botros E, Moufarrège R. The effects of Moufarrege total posterior pedicle reduction mammaplasty on breastfeeding: a review of 931 cases. Aesthet Surg J. 2013 Sep 1. 33(7):1002-7. [Medline].

  5. Biesenberger H. Eine neue Methode der Mammoplastik. Zentralbl Chir. 1928. 55:2382.

  6. Drzewiecki A. Breast reduction by central pedicle technique [letter]. Plast Reconstr Surg. 1986 Dec. 78(6):830. [Medline].

  7. Dufourmentel C, Mouly R. [Mammaplasty by the oblique method.]. Ann Chir Plast. 1961 Apr. 6:45-58. [Medline].

  8. Lalardrie JP, Mitz V. Reduction mammoplasty using the technic of demol vault. J Chir (Paris). 1974 Jul-Aug. 108(1-2):57-68. [Medline].

  9. McKissock PK. Reduction mammaplasty by the vertical bipedicle flap technique. Rationale and results. Clin Plast Surg. 1976 Apr. 3(2):309-20. [Medline].

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

  11. Moufarrège R, Muller GH, Beauregard G, et al. Mammaplasty with a lower dermo-glandular pedicle. Ann Chir Plast. 1982. 27(3):249-54. [Medline].

  12. Moufarrège R. A new reduction mammaplasty with a vertical posterior pedicle. Quebec Society of Plastic Surgery Convention,. 1979.

  13. Peixoto G. Reduction mammaplasty: a personal technique. Plast Reconstr Surg. 1980 Feb. 65(2):217-26. [Medline].

  14. Pitanguy I. Une nouvelle technique de plastie mammaire: etude de 245 cas consecutifs et presentation d'une technique personnelle. Ann Chir Plast. 1972. 7:199.

  15. Skoog T. A technique of breast reduction; transposition of the nipple on a cutaneous vascular pedicle. Acta Chir Scand. 1963 Nov. 126:453-65. [Medline].

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

  17. Thorek M. Plastic surgery of the breast and abdominal wall. Charles C Thomas: Springfield, Ill; 1942.

 
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Before inferior and posterior pedicles, the upper pedicle mammaplasties.
Amount of gland kept in the 3 techniques within the pedicle of the nipple-areola complex: A is the McKissock double-vertical pedicle at 10-15%. B is the Robbins inferior pedicle at 15-25%. C is the Moufarrège total pedicle at 100%.
Three categories of classification of ptosis and hypertrophy in the Moufarrège total posterior pedicle: category I, no ptosis, keyhole angle 90°; category II, nipple below inframammary fold, presence of breast volume at the level of the inframammary fold, keyhole angle 140°; category III, extreme ptosis, emptiness of the breast at the level of the inframammary fold, keyhole angle 180°.
Keyhole positioning on the axis of the breast at the level of the inframammary fold.
Drawing of the key hole on the patient in a sitting position. In this case (Moufarrege category II), opening of the key hole arms is 140°.
Aperture of the keyhole arms and the first 5 cm of the arms before curving.
Continuation of the keyhole arms after the first 5 cm until they connect on the inframammary line.
Designing the dermal inferior pedicle and its dis-epidermization. A full-thickness incision is made around that pedicle and along the drawings of the modified keyhole.
Desepidermisation of the dermal inferior pedicle is made easier by the strip shaving technique.
This photograph shows the inferior dermal pedicle after desepidermisation.
The lateral and medial skin flaps are elevated and held with hooks. Even the upper quadrant has been entirely denuded. No parcels of gland are kept with the skin. The entire gland is fully exposed up to the pectoralis major and is ready for the resection on an open-sky basis.
The full thickness incision is performed first around the dermal pedicle and then along the external drawings.
The gland is entirely denuded on its anterior aspect by elevating the medial, upper, and lateral cutaneous flaps. The cleavage plane separates the flap subcutaneous tissue from the gland tissue.
The hand of the surgeon holds the entire gland before the resection procedure.
Resection is performed in the medial and mainly in the external quadrant. No resection in the lower or upper quadrants.
The surgeon's hand holds the entire denuded breast tissue while showing the pectoralis major muscle at the end of the elevation of the upper flap. For a better upper breast contour, the muscle fascia is divided, allowing the conserved upper quadrant of the breast to move upward, printing a convex effect on the upper part of the breast.
Left: The surgical piece is removed from the left breast. It consists of a very small resection in the medial quadrant and a very consistent resection in the lateral quadrant. This demonstrates the outstanding facility to remove the subaxillary gland in patients presenting very wide hypertrophy going as far as the medial axillary line. Right: The surgeon's hand holds the remaining breast tissue pulled downward in order to show the integrity of the upper quadrant after resection.
Lateral view after the resection. Hooks are holding the lateral and medial skin flaps, showing the complete exposition of the remaining gland entirely fixed on the pectoralis major from the top to the bottom of the gland.
The pathway taken by the intercostal nerve in the total posterior pedicle shows its preservation in the procedure.
Reconstitution begins by positioning the nipple-areola complex in its new location.
Reconstitution starts with the positioning of the nipple-areola complex in its new location, first with a stitch in the 12-o'clock position. The hooks maintain the extremities of the elliptical segment of the keyhole before suturing them.
The keyhole is closed around the areola while the surgeon's hand holds the total pedicle through the still open inferior vertical line.
Reconstitution after positioning the areola in its new location and joining together the edges of the medial and lateral flaps on the vertical line.
Closure is completed in an inverted 'T' fashion.
Shortening of the vertical incision when longer than 6 cm.
The inferior vertical incision is shortened into an inverted 'T' as soon as it is longer than 6 cm.
For the deerfoot closing, a small amount of skin is left at the corners of the flaps. They adapt spontaneously within 4 weeks and prevent classic superficial necrosis at the corners of the flaps.
Always avoid the classic ship anchor.
Lateral view showing the disposition of tissues after closing. Note the extension of the upper quadrant very high toward the clavicle, giving a very unique gablelike volume and appearance to the upper quadrant. The gablelike effect describes the well-filled surface curve of the upper quadrant of the breast, compared with very empty and concave upper quadrants achieved using other techniques. Also note the puckering of the longer inferior dermal pedicle reduced to a shorter inferior line, thus thickening the vertical infra-areolar incision. This constitutes a strong inferior dermal vault and acts as a natural bra, avoiding long-term stretching and pseudoptosis.
The diminution of the implementation base is easily obtained because the resection is mainly performed on the medial and lateral quadrants.
The resection of the outer quadrants allows an important diminution of the implementation base.
The 3 types of accepted incisions in the Moufarrège total pedicle are (1) the periareolar incision, which is used for very mild ptosis and liftings; (2) the simple vertical incision, which is used when the incision is shorter than 6 cm; and (3) the inverted-T incision with a short horizontal arm, which is used when the vertical incision is longer than 6 cm.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photos depict lateral and frontal aspects before surgery. Bottom photos depict lateral and frontal aspects after surgery.
Top photo depicts lateral aspect before surgery (tuberous breast). Bottom photo depicts lateral aspect after surgery.
 
 
 
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