Moufarrege Total Posterior Pedicle Breast Reduction Treatment & Management
- Author: Richard J Moufarrège, MD, FRCSC; Chief Editor: James Neal Long, MD, FACS more...
The total pedicle is by no means limited to a drawing and can adapt to all sorts of incisions of preestablished drawings, yet the author favors a manner of drawing for reasons of simplicity, standardization, and, most importantly, conservation of reasonable scar length.
The author divides the breast into 3 categories (see image below).
See the list below:
Category I: The hypertrophy is not accompanied by ptosis. The nipple stays approximately at the level of the inframammary fold.
Category II: The nipple is lower than the inframammary fold, but the breast at the level of this fold has a certain consistency and a true glandular projection.
Category III: Hypertrophy is accompanied by extreme ptosis, the nipple is very low, and the breast at the level of the fold is practically empty.
Begin with the drawing of the keyhole described by Aufricht, with certain modifications. Draw with the patient in a sitting position; the axis of each breast passes through the marked nipple, which is not necessarily the midclavicular line. Then, choose the keyhole position at the level of the inframammary fold (see image below).
This position appears lower than that recommended in previous literature. This is because the position is measured on skin already stretched down by the weight of hypertrophy. Once the hypertrophy is treated, the new nipple site spontaneously rises 1-2 cm.
The upper curved part of the keyhole is not a circle, but an oval with a longer horizontal axis, for 2 reasons. First, upon closing (A joins C), it has a tendency to look circular, whereas a circle would lead to a vertical oval figure when closed. Second, the natural tendency of tissues, caused by weight and trimming, is a vertically elongating effect on the nipple-areola complex. The opening of the keyhole arms (angle AB/CD) is 90° for category I, 140° for category II, and 180° for category III (see image below).
See Advantages in Postoperative Details for a description of why this technique allows such wide-angle openings of the keyhole. After 5 cm, keyhole arms curve toward each other to join on the inframammary fold (see images below).
With the patient positioned supine, make the circular periareolar incision 5 cm in diameter to definitively fit a 4-cm space. This imparts a particular conical projection on the nipple-areola complex.
Perform an inverted-U incision to delimit the dermal pedicle. With a width of 6 cm, it extends from the superior part of the nipple-areola complex to the inframammary line. The interior area of that inverted U is deepithelialized. Then, perform full-thickness incisions of the skin based on preestablished drawings (see image below).
Undermining flaps and exposure of gland
Detach skin and subcutaneous fat flaps from the breast gland up to the aponeurosis of the pectoralis major muscle. Upon completion of the undermining, the breast is fully exposed on the frontal aspect, while the posterior aspect remains entirely attached to the pectoralis major aponeurosis (see image below).
Technically, undermining is performed quite easily by holding the internal, then superior, and then external flaps separately with skin hooks, successively placed in 2 positions at the same time in points A and B, A and C, and, finally, C and D. The assistant raises these points. The surgeon then can easily, by putting some pressure with a sponge on the gland with one hand, define with the other hand with a No. 10 scalpel blade the cleavage plane that is established between glandular tissue and subcutaneous fatty tissue. This allows for a practically bloodless dissection (see image above).
Pay special attention to detachment of the exterior flap in the subaxillary region. Avoid cutting the areolar tissue at the extremity of the external quadrant of the breast to preserve intercostal nerves. Note the fifth in particular; these nerves run along the aponeurosis of the pectoralis, through that areolar tissue, medially toward the center of the breast, and then ascend through the mammary gland anteriorly to join the nipple-areola complex (see image below).
The advantages of working openly on a breast are immediately recognizable. Resection is performed easily in areas most in need. Large hypertrophies typically are characterized by a particular excess of glandular tissue spreading quite far in the subaxillary region for which resection in the external quadrant is the most important. Save that areolar tissue for the same reason one safeguards the intercostal nerves. No resection is performed in the inferior or superior quadrants. These 2 quadrants are the protected zones of the total dermoglandular pedicle. Resection in the internal quadrant is quite small (see images below).
The nipple is set in its new position in the circle obtained by the closing of the curved line through the junction of A and C corners. Technically, begin by joining the upper limit of the areola to the center of curved line AC with a stitch (see image below).
The second stitch in 1 stage brings the lower limit of the areola against points A and C.
The third cardinal stitch of the reconstitution brings points B and D together to close the vertical line (see image below).
If the vertical line is too long (>6 cm), reduce it by retaining an elliptical horizontal area in the lower part of the line to create an inverted T with a very short horizontal arm (2-5 cm) (see image below).
Pay special attention at the closure of the 2 corners at the junction of the vertical line, with the circular one around the areola and the horizontal one in the inframammary fold. To avoid a small loss of skin at these corners, keep a small excess of skin in a deerfoot fashion (see image below).
Because of skin undermining and centralization of all remaining glandular mass, this technique avoids the classic anchor scar that traditionally results from most techniques using preestablished sketches (see image below).
The 6-cm-wide dermal pedicle, which, according to the case, is originally from 2-5 times the length of the AB/CD vertical line, must now occupy a 4-5 cm length at the end of the operation and, consequently, must intensively pucker. This creates a dermal inferior vault all the more resistant to traction and elongation; thus it is thicker and doubled-up by the dermis of the cutaneous flaps that cover it. This provides the total pedicle a certain capacity to resist stretching and, consequently, classic pseudoptosis, by lengthening of the vertical line, slipping of the gland in a subnipple position, and upper orientation of the nipples (see image below).
See the list below:
Absolute nipple security: As a result of pediculation of the nipple-areola complex on the entire remaining gland, viability of the nipple-areola complex is ensured. The author has never experienced nipple loss in more than 5000 bilateral mammaplasties from 1979-2005.
Relative security of cutaneous flaps: Undermining of the lateral cutaneous flaps, entirely free of glandular tissue, allows use of the skin to its maximum elasticity, thus allowing important cutaneous trimming and a secure width-to-length ratio (1:1), in comparison with the ratios of 1:2 and 1:3 associated with classic techniques. In addition to superior viability of cutaneous flaps, this makes breast reshaping and lifting much more efficient and homogeneous.
Mammary projection: Because the remaining gland is entirely in a central position, an exceptional projection of the breast and nipple is achieved that is consistent from patient to patient (see image below).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.
Unique superior profile: Undermining of superior skin flaps up to the aponeurosis, with complete preservation of the superior quadrant of the breast, creates an esthetically pleasing projection over the nipple area (see image above).
Reduction of pseudoptosis: Pseudoptosis by stretching of the inferior vertical line is reduced because of the presence of a strong dermal inferior vault, explained previously (see image above).
Breastfeeding ability: Postreduction breastfeeding is entirely possible and normal because galactophorous channels are preserved. Consequently, the remaining mammary gland, capable of galactogenous activity, is in direct communication with the nipple.
Preservation of nipple sensation: Preservation of intercostal nerves responsible for nipple-areola sensibility ensures, without doubt, a conservation of nipple sensation (see image below).
Open-sky approach: Surgery is performed openly, thus visualization is better. Perform resection in 1 or 2 sections. One is not compelled, after an attempt to suture, to reoperate and resect glandular fragments in search of a certain form or symmetry (see images below).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.
Teaching: Standardization of technique, its method, and its execution under direct vision make the procedure easy to teach to residents.
Execution time: Time of execution with this technique is relatively short because supplementary resection is unnecessary.
Realization of equal breasts: Direct visualization of the completely exposed glandular tissue makes realization of equal breasts easy because the amount of the gland that needs resection in the second breast is not based on the amount taken from the first, but, rather, by the tissue left after resection.
Reduction of breast width: This technique is particularly applicable to wide breasts in which the gland extends behind the midaxillary line. Undermining of pure cutaneous and subcutaneous flaps, the important resection in the external quadrant, and trimming, much more extensive than in classic techniques, allows the external wall to adhere properly on the lateral wall of the chest and allows a diminution of the implementation base of the breast (see image below).
Form and surface: The absence of parcels of mammary gland sequestered randomly under the skin gives a much more homogeneous texture; the patient has a breast with a more regular, natural look and pure lines. The skin acts like a rubber sack in which a gel (the mammary tissue) is placed and automatically takes the most regular and harmonious shape.
Realization of an immediately attractive form: The total pedicle yields, in the immediate postsurgical stage, an attractive shape because of the disposition of the central pedicle and the potential of reshaping by cutaneous flaps, which have become elastic.
Shortening of scar length: The classic anchor-shaped scar is avoided. Scarring can range from a periareolar incision in mild ptosis, to a vertical incision, to an inverted T with a short horizontal arm (see image below).
The patient is usually seen the second day after surgery. The static drain (Penrose), which drains the outer dead space secondary to the external quadrant resection, is removed, and the bandage is exchanged for the patient's bra over some sponges. Follow-up visits occur 1 week, 1 month, 3 months, and 6 months after surgery. The patient is seen once a year thereafter.
The deerfoot closure adapts within a month as the excess skin heals and overlapping at the flap corners disappears.
First sketches can be considered difficult. This difficulty eases and eventually disappears with repetition.
General prejudice against cutaneous flaps can be considered a disadvantage. Surgeons are famously apprehensive about completely undermining real cutaneous fatty flaps as far as the aponeurosis because of the fear of skin loss in the flaps. However, this is completely unfounded. Skin has its own vascular network, and circulation does not depend on vessels coming from the gland.
Outcome and Prognosis
Twenty-five years of experience
From 1979-2005, the author performed 5000 bilateral reduction mammaplasties using the total dermoglandular pedicle technique. Patient ages ranged from 14-72 years, and the average age was 30 years. Resection ranged from 100-1600 g per breast; transposition ranged from 3-32 cm. The author experienced no nipple loss in 5000 patients (see images below).
In 2% of patients, the author encountered skin healing problems, chiefly at the junction of horizontal and vertical incisions and mainly in the first 7 years. Wounds, which resulted in a certain amount of skin loss, eventually healed spontaneously without skin grafting. In the last 18 years, this problem has diminished, as the deerfoot closing technique at the junction of these incisions was adopted (see image below).
Curiously, a great number of these patients were surprisingly amenable to having ameliorated nipple sensation, either because of diminution of traction on the nerves or possibly because of psychological factors.
After mammaplasty, 500 patients became pregnant. All carried their pregnancy to term normally and had normal lactation. The psychological impact on these patients is estimated as positive in 99% of cases.
Using a retrospective chart review and a patient questionnaire answered by close to 580 women who underwent the Moufarrège procedure, a study by Sinno et al indicated that the operation does not negatively affect lactation and breastfeeding. The study found no statistically significant difference in the preoperative and postoperative percentages of women who could lactate (100% and 98%, respectively). There was also no statistically significant variation before and after surgery in the percentage of women who were capable of breastfeeding for 4 months (44% and 33%, respectively) or 6 months (28% and 29%, respectively).
Future and Controversies
When the total posterior pedicle was presented in the early 1990s, criticisms from traditional surgeons were experienced because of their fear of losing the undermined skin. The evolution of the technique over time has proved the safety of such skin flaps divided from the gland tissue.
The inclusion of the entire remaining gland in the pedicle of the nipple-areola complex and the preservation of the intercostal innervation of the nipple make this technique superior in terms of functionality. Conservation of a whole and unique block of gland enveloped by a gland-free bag of elastic skin without any constraint due to the presence of sequestrated parcels of breast tissue under the skin allows the realization of achieving very attractive and natural-looking breasts.
A retrospective study based on a cohort of nearly 900 patients with a minimal postoperative follow up of 15 years revealed a diminution of breast cancer incidence by 52% compared with the general population.
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].
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.
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].
Biesenberger H. Eine neue Methode der Mammoplastik. Zentralbl Chir. 1928. 55:2382.
Drzewiecki A. Breast reduction by central pedicle technique [letter]. Plast Reconstr Surg. 1986 Dec. 78(6):830. [Medline].
Dufourmentel C, Mouly R. [Mammaplasty by the oblique method.]. Ann Chir Plast. 1961 Apr. 6:45-58. [Medline].
Lalardrie JP, Mitz V. Reduction mammoplasty using the technic of demol vault. J Chir (Paris). 1974 Jul-Aug. 108(1-2):57-68. [Medline].
McKissock PK. Reduction mammaplasty by the vertical bipedicle flap technique. Rationale and results. Clin Plast Surg. 1976 Apr. 3(2):309-20. [Medline].
McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg. 1972 Mar. 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. 1980 Feb. 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. 1963 Nov. 126:453-65. [Medline].
Strombeck JO. Mammaplasty: report of a new technique based on the two-pedicle procedure. Br J Plast Surg. 1960 Apr. 13:79-90. [Medline].
Thorek M. Plastic surgery of the breast and abdominal wall. Charles C Thomas: Springfield, Ill; 1942.