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Breast Reduction, Moufarrege Total Posterior Pedicle
Updated: Nov 25, 2008
Introduction
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.
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 1).
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 glandular 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 Image 2A).
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 Image 2B).
Since 1979, the author 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 (see Image 2C).
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.
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.
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.
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 60-70% of the breast blood supply. This has been the very determinant factor in the choice of using a total posterior pedicle mammaplasty.
Innervation of the nipple 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. This allows the total posterior pedicle to preserve the continuity of these very important nerves in order to conserve nipple sensitivity (see Image 11).
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References
Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg. Jan 1977;59(1):64-7. [Medline].
Moufarrège R, Beauregard G, Bosse JP, et al. Reduction mammoplasty by the total dermoglandular pedicle. Aesthetic Plast Surg. 1985;9(3):227-32. [Medline].
Aufricht G. Mammoplasty for pendulous breasts: Empiric and geometric planning. Plast Reconstr Surg. 1949;4:13.
Biesenberger H. Eine neue Methode der Mammoplastik. Zentralbl Chir. 1928;55:2382.
Drzewiecki A. Breast reduction by central pedicle technique [letter]. Plast Reconstr Surg. Dec 1986;78(6):830. [Medline].
Dufourmentel C, Mouly R. [Mammaplasty by the oblique method.]. Ann Chir Plast. Apr 1961;6:45-58. [Medline].
Lalardrie JP, Mitz V. Reduction mammoplasty using the technic of demol vault. J Chir (Paris). Jul-Aug 1974;108(1-2):57-68. [Medline].
McKissock PK. Reduction mammaplasty by the vertical bipedicle flap technique. Rationale and results. Clin Plast Surg. Apr 1976;3(2):309-20. [Medline].
McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg. Mar 1972;49(3):245-52. [Medline].
Moufarrège R, Muller GH, Beauregard G, et al. Mammaplasty with a lower dermo-glandular pedicle. Ann Chir Plast. 1982;27(3):249-54. [Medline].
Moufarrège R. A new reduction mammaplasty with a vertical posterior pedicle. Quebec Society of Plastic Surgery Convention,. 1979.
Peixoto G. Reduction mammaplasty: a personal technique. Plast Reconstr Surg. Feb 1980;65(2):217-26. [Medline].
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.
Skoog T. A technique of breast reduction; transposition of the nipple on a cutaneous vascular pedicle. Acta Chir Scand. Nov 1963;126:453-65. [Medline].
Strombeck JO. Mammaplasty: report of a new technique based on the two-pedicle procedure. Br J Plast Surg. Apr 1960;13:79-90. [Medline].
Thorek M. Plastic surgery of the breast and abdominal wall. Charles C Thomas: Springfield, Ill; 1942.
Further Reading
Keywords
breast reduction, breast surgery, Moufarrège total posterior pedicle, Moufarrège mammaplasty, total pedicle reduction mammaplasty, total pedicle, total pedicle mammaplasty, mammaplasty with the total pedicle, total pedicle mastopexy, Moufarrège posterior pedicle, Moufarrège mastopexy, hypomastia, mammaplasty, tuberous breast correction, immediate reconstruction, immediate breast reconstruction, immediate post mastectomy reconstruction by the Moufarrege mammaplasty design
