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Medial Pedicle and Mastopexy Breast Reduction

  • Author: John M Anastasatos, MD; Chief Editor: James Neal Long, MD, FACS  more...
 
Updated: Mar 03, 2016
 

Background

Mastopexy is a compound word derived from the Greek mastos (breast) and pexy (to fix or secure). It refers to the correction of ptotic and pendulous breasts. The term mammaplasty refers to shaping of the breast, as the Greek derivative plasty means to mold.

The principles and techniques used to correct pendulous ptotic breasts (see the image below) are similar to those used to perform a breast reduction. In all techniques used, the most critical consideration is the viability of the nipple-areola complex (NAC). This article focuses on the medial pedicle as the one that provides blood supply to the NAC. The medial pedicle technique can be used to safely perform a large breast reduction, a mastopexy, or a mastopexy with simultaneous augmentation. For information on other techniques for breast reduction, augmentation, and reconstruction, see the Breast section of Medscape Reference's Plastic Surgery journal.[1]

This patient had obvious and significant breast ptThis patient had obvious and significant breast ptosis. Medial pedicle mastopexy was performed, in addition to a subpectoral breast augmentation with saline-filled breast implants. The breast implants were filled to a volume capacity of 450 mL bilaterally. This image shows the preoperative front view.
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History of the Procedure

The history and evolution of breast reduction spans many centuries. Paul from the Greek island of Aegina was the first to describe details of reduction mammoplasty in the 6th century AD.[2] Multiple techniques of breast reduction and mastopexy have been described over the past century. In the last 3 decades, the main evolution and progress in the field of reduction mammaplasty and mastopexy has been in better molding of the breast parenchyma (limiting the resultant scars) and not relying on the skin envelope for long-term parenchymal support and breast shape.

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Problem

The true etiology of breast hypertrophy is not clearly understood. The breasts are hormonally sensitive organs that change with hormonal and, especially, estrogen variations. Breast enlargement usually begins with changes associated with puberty and pregnancy. In some women, estrogen receptors that are hypersensitive to estrogen may be a cause of mammary hyperplasia.[3, 4, 5, 6]

The problem of breast ptosis is also not clearly understood. The ideal youthful-looking breast should have a natural tear drop shape, adequate projection (perkiness), and no ptosis. The entire breast parenchyma should be above the inframammary fold (IMF), and the NAC should be centered at the breast or be slightly lower than the center.

The most established classification to describe ptosis according to the relative positions of the NAC, breast parenchyma, and IMF is by Regnault.[7]

  • First-degree ptosis - Mild ptosis in which the NAC lies at or slightly above the IMF
  • Second-degree ptosis - Moderate ptosis in which the NAC is below the IMF but above the highest projecting part of the breast
  • Pseudoptosis - Condition in which the NAC is above the IMF, but the lower pole of the breast is below the IMF
  • Third-degree ptosis - Severe ptosis in which the NAC is below the IMF and at the lowest projecting part of the breast
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Epidemiology

Frequency

The true frequency of ptosis and macromastia is not known. Most plastic surgeons in the United States typically work with patients who have these problems following pregnancy.

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Etiology

The true etiology of ptosis and macromastia is not known. They are generally assumed to be results of hormonal changes on the breasts and, especially, the actions of estrogen on the estrogen parenchymal receptors.

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Pathophysiology

The pathophysiology of ptosis and macromastia is felt to be strongly associated with estrogen hormonal levels or estrogen receptor hypersensitivity to circulating levels of estrogen. The pathophysiology is not thoroughly understood. In a great majority of cases, ptotic breasts are associated with asymmetry in terms of parenchymal volume, NAC diameter and position, and shape. These morphologic differences may represent true anatomic variations or may be due to variations in physiologic actions of the breasts.

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Presentation

A complete patient history and physical examination should be performed. The physical examination should entail a thorough examination of the breasts and nipple-areola complexes (NACs), the axillae and supraclavicular areas for any lymphadenopathy and accessory breast tissue, and the rest of the abdomen and pelvis for any accessory breasts.

Clinically, hypertrophic breasts may present with ptosis, an enlarged NAC, decreased sensitivity of the NAC (which may improve following reduction mammaplasty), prominent and visible veins, stretch marks of the skin, and hypersensitivity and irritation of the inframammary skin.

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Indications

Indications to perform a mastopexy are primarily aesthetic; that is, to position the nipple-areola complex (NAC) in a more aesthetically pleasing location relative to the rest of the breast and to give the breast youthful shape and projection. The indications can also be psychological, as saggy or asymmetric breasts can be detrimental to the self-esteem of an individual.

The indications for a reduction mammoplasty may be aesthetic, but they are chiefly functional. Macromastia may cause neck pain, back pain, shoulder strap indentations and shoulder pain, chest heaviness, labored breathing, headaches, poor posture, and skin irritation and infections. In addition, the psychological burden can be significant. Women with macromastia may find it difficult to exercise, participate in activities of daily living, and find proper clothing. This condition affects their self-esteem and self image.

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Relevant Anatomy

Breast shape varies among patients, but knowing and understanding the anatomy of the breast (see the image below) ensures safe surgical planning. When the breasts are carefully examined, significant asymmetries are revealed in most patients. Any preexisting asymmetries, spinal curvature, or chest wall deformities must be recognized and demonstrated to the patient, as these may be difficult to correct and can become noticeable in the postoperative period. Preoperative photographs with multiple views are obtained on all patients and maintained as part of the office record.

Anatomy of the breast. Anatomy of the breast.

The blood supply to the breast comes primarily from branches of the internal mammary artery. The thoracoacromial, thoracodorsal, lateral thoracic, and intercostal arteries also contribute. Those arteries create rich anastomotic plexuses.[8]

The innervation of the breast comes from the anterior rami of the second to the sixth intercostals nerves. The skin of the upper part of the breast is innervated by the supraclavicular nerves. The nipple-areola complex (NAC) gets rich innervation from the anterior branches of the second to sixth intercostal nerves and from the lateral branches of the fourth and fifth intercostal nerves. The nerve supply from the fourth intercostal nerve is believed to play a unique role in the NAC innervations.[9, 10]

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

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Contraindications

Overall poor health is a contraindication for this procedure. Prior breast reduction or mastopexy with another technique (eg, Weiss pattern) is not a contraindication to performing this operation.

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Contributor Information and Disclosures
Author

John M Anastasatos, MD Private Practice

John M Anastasatos, MD is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, Southeastern Society of Plastic and Reconstructive 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

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 Drugs & Diseases gratefully acknowledge the medical review of this article by Abigail E Chaffin, MD.

References
  1. 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].

  2. Shewmake K. Selected Readings in Plastic Surgery. 1994. 7:30:

  3. Pang S. Premature thelarche and premature adrenarche. Pediatric Annals. 1981. 10:29.

  4. Ilicki A, Prager Lewin R, et al. Premature thelarche--natural history and sex hormone secretion in 68 girls. Acta Paediatr Scand. 1984 Nov. 73(6):756-62. [Medline].

  5. Root AW, Shulman DI. Isosexual precocity: current concepts and recent advances. Fertil Steril. 1986 Jun. 45(6):749-66. [Medline].

  6. Jabs AD, Frantz AG, Smith-Vaniz A, et al. Mammary hypertrophy is not associated with increased estrogen receptors. Plast Reconstr Surg. 1990 Jul. 86(1):64-6. [Medline].

  7. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg. 1976 Apr. 3(2):193-203. [Medline].

  8. Maliniac JW. Arterial blood supply of the breast. Arch Surg. 1943. 47:329.

  9. Craig RD, Sykes PA. Nipple sensitivity following reduction mammaplasty. Br J Plast Surg. 1970 Apr. 23(2):165-72. [Medline].

  10. Courtiss EH, Goldwyn RM. Breast sensation before and after plastic surgery. Plast Reconstr Surg. 1976 Jul. 58(1):1-13. [Medline].

  11. Swanson E. Breast Reduction versus Breast Reduction Plus Implants: A Comparative Study with Measurements and Outcomes. Plast Reconstr Surg Glob Open. 2014 Dec. 2 (12):e281. [Medline]. [Full Text].

  12. Swanson E. Prospective outcome study of 106 cases of vertical mastopexy, augmentation/mastopexy, and breast reduction. J Plast Reconstr Aesthet Surg. 2013 Jul. 66(7):937-49. [Medline].

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Medial pedicle mastopexy without inframammary scars. With the purse-string technique pictured below, the skin is gathered below the new inframammary fold (IMF). This gathered-up skin eventually will settle down and become part of the new IMF. This is illustrated in the series of images below, starting with this image of the preoperative front view.
Preoperative side view.
Preoperative side view.
Intraoperative view. The most inferior curvilinear line indicates the position of the original inframammary fold. The curvilinear line located more superiorly indicates the new position of the inframammary fold.
A Prolene suture is used to gather up the tissue excess between the new inframammary fold and the old one.
Tightening of the purse-string suture.
Full tightening of the purse-string suture. Knot is under the skin.
Postoperative side view.
Postoperative side view.
Postoperative front view.
This patient had obvious and significant breast ptosis. Medial pedicle mastopexy was performed, in addition to a subpectoral breast augmentation with saline-filled breast implants. The breast implants were filled to a volume capacity of 450 mL bilaterally. This image shows the preoperative front view.
Preoperative side view.
Preoperative side view.
Postoperative side view.
Postoperative side view.
Postoperative front view.
This patient wanted to maintain her plentiful breast volume but wanted her breasts to be "perky, beautiful, and youthful" like they used to be before she had children. This is a common surgery requested by women after they have had children and have breastfed. This image shows the preoperative front view.
Preoperative side view.
Preoperative side view.
Postoperative front view.
Postoperative side view.
Postoperative side view.
Anatomy of the breast.
 
 
 
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