Central Pedicle Breast Reduction 

Updated: Aug 23, 2018
Author: Jorge I de la Torre, MD, FACS; Chief Editor: James Neal Long, MD, FACS 

Overview

History of the Procedure

Balch first described the central pedicle reduction technique in 1981, although it was also described by many, including Hester et al.[1, 2, 3] The principle of this technique is to preserve the breast volume where maximum projection is desired, in the central portion of the breast. Evolution of the technique has resulted in the current technique described here.[4, 5]

Problem

Macromastia, or mammary hyperplasia, is the condition of large breast size out of proportion to a woman's body habitus that is associated with symptoms including back, neck, and shoulder pain. Macromastia is a common condition treated by plastic surgeons.

Reduction mammaplasty is one of the 5 most frequently performed reconstructive operations. According to the American Society of Aesthetic Plastic Surgeons (ASPS), more than 153,087 breast reduction procedures were performed in 2007 up from 47,874 in 1997.[6] The ASPS/Plastic Surgery Educational Foundation (PSEF) procedural data from 2007 lists 105,706 cases of reduction mammaplasty, up from 39,639 cases in 1992.[7]

Etiology

Etiology is unknown.

Pathophysiology

The precise pathophysiology of macromastia is unclear.[8] End-organ hypersensitivity to hormonal stimulation appears to play a role. With the onset of menarche and hormonal production, breast growth and, in some cases, hypertrophy can be seen. Some patients present with macromastia following pregnancy; others see exacerbation of macromastia related to weight gain or obesity.[9, 10]

Presentation

Preoperative assessment includes a standard history and physical examination, with special attention directed to breast history and health, including family history of breast cancer. Preoperative photos should be taken and reviewed with the patient to point out conditions such as preexisting asymmetry. Representative before and after photos also should be reviewed if available to ensure that the patient understands the scars and has realistic expectations.

Indications

Macromastia is a common condition treated by plastic surgeons. Because women have various body shapes and sizes, and rules regarding insurance coverage vary from region to region, no universally accepted definition of macromastia that requires surgery exists. However, definite symptoms exist, which have been documented by numerous authors including Hagerty, Shewmake, and Gonzalez among many others.[11, 12, 13] Most commonly, these symptoms consist of upper back and neck pain, breast pain, shoulder grooving from bra straps, and inframammary intertrigo.

In an effort to relieve these symptoms of pain, a number of surgical techniques for reduction mammaplasty have been described using various pedicles and skin resections.[14, 15, 16, 17, 18, 19, 20, 21] The ideal breast reduction results in complete relief of symptoms while maintaining normal sensation and the ability to lactate. Additionally, the operation should result in an aesthetically pleasing breast shape with minimal scarring and a low complication rate. Lastly, most or all of these objectives should be achieved in a time-efficient and cost-efficient manner.

Successful breast reduction involves remodeling the breast parenchyma and creating a pedicle to maintain blood supply to the nipple-areola complex (NAC). Although vascular compromise is generally venous in breast reduction surgery, clear anatomical descriptions of the breast veins are lacking in textbooks.

A study by Karacor-Altuntas indicated that central pedicle horizontal scar breast reduction can be safely and effectively used in cases of gigantomastia without free nipple graft. The study included 53 patients (106 breasts) in whom the distance from the midclavicular point to the nipple ranged from 38-52 cm, with no patients experiencing postoperative nipple loss.[22]

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 female breast consists of the glandular breast mound and the axillary tail of Spence. The nipple-areola complex (NAC) is the most prominent anatomic feature on the breast. It has important relations to the underlying glandular tissue.

The first of these relations consists of the blood supply to the NAC, which enters through the glandular breast tissue but also receives contributions from the subdermal plexus of the breast skin.

The second important anatomic relationship between the glandular breast tissue and the NAC is that of innervation. The nipple lies in the dermatome of the fourth intercostal nerve. Additional innervation is contributed by adjacent dermatomes. No clear anatomic distinction has been identified for innervation contributing erogenous versus tactile sensation.

Lastly, one must consider the communication between the lactiferous ducts of the glandular breast tissue and the nipple. Clearly, the importance of this depends upon the patient's childbearing status and any prior demonstration of the ability (or inability) to lactate.

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

Contraindications

Contraindications to breast reduction surgery are similar to contraindications to any elective surgical procedure, including cardiac and pulmonary considerations. Fortunately, most women seeking breast reduction surgery are often young and in otherwise good health. Since the operation is performed to relieve symptoms and not to treat a life- or limb-threatening disease, use common sense regarding general anesthetic risks. Smoking, diabetes, and obesity have been associated with increased complication rates, including nipple necrosis.

 

Workup

Laboratory Studies

Order routine lab work according to the criteria for elective surgery under general anesthesia in the practicing physician's hospital. Age, medical history, social habits, and family history influence the need for these tests. If the surgeon has concerns, seek consultation from the patient's primary care provider.

Imaging Studies

Consider mammography in patients presenting for breast reduction surgery. Current practice suggests that mammograms should be obtained for patients aged 40 years and older. Some surgeons also advocate mammography in patients aged 35-40 years with a family history of breast cancer.

Other Tests

Determine the need for chest radiographs and ECG according to the criteria for elective surgery under general anesthesia in the practicing physician's hospital. Age, medical history, social habits, and family history influence the need for these tests. If the surgeon has concerns, seek consultation from the patient's primary care provider.

 

Treatment

Preoperative Details

The operative technique begins with the preoperative markings, which are made with the patient in a standing position.

First, mark the patient's midline from the manubrium to the umbilicus. Next, mark the mid axis of each breast from approximately the mid point of the clavicle to the areola.

Make a mark corresponding to the inframammary crease on the mid line and a second mark approximately 2.5 cm superior to the first. The second mark indicates the ideal level of the nipple-areola complex (NAC). Transfer this new mark to the lines marking the mid axis of each breast.

The final lines to be drawn radiate out from these points and lie adjacent to the medial and lateral borders of the NAC. See the image below.

Central pedicle breast reduction. Preoperative ant Central pedicle breast reduction. Preoperative anteroposterior image in a representative patient with the shaded area of the right breast demonstrating the flap undermining in the operation as described by Hester.

Position the patient on the operating table in a supine position, with the arms well padded and outstretched on arm boards. Cast padding is useful for wrapping the arms since such wraps provide firm support, yet conveniently may be torn by hand to provide access to intravenous (IV) sites and other areas.

The patient also must be positioned so that she can be raised to a sitting position during the operation. A sitting position is helpful for ascertaining symmetry and for shaping.

Deep venous thrombosis (DVT) prophylaxis with sequential compression devices or similar therapy is indicated.

Intraoperative Details

Begin the operation by marking the size of the new NAC. This marking should not be performed with the skin under stretch, since the areola is then too small.

Scribe a partial thickness incision around the new areola and along each of the tangent lines. Then deepithelialize the skin encompassed by the tangents and outside the newly sized areola. See the image below.

Central pedicle breast reduction. The image demons Central pedicle breast reduction. The image demonstrates the deepithelialized central pedicle, preserving the subdermal plexus.

The operation continues using electrocautery to elevate the medial and lateral skin flaps from the inframammary crease. The technique differs from operations that use the standard Wise pattern because more skin is left in the medial and lateral flaps than is needed for closure.

Elevate the skin flaps with a uniform thickness of approximately 1.5 cm. Flap elevation at this thickness preserves the subdermal plexus, thus ensuring skin flap viability. Elevate flaps medially until the perforators from the internal mammary arteries are identified. Preserve these vessels.

Elevate the lateral flap, taking care to stay approximately 1.5 cm from the chest wall. Dissection is carried out at this level to preserve the blood and nerve contributions from the fourth intercostal neurovascular bundle.

Then undermine the area between the medial and lateral flaps. Flap elevation in this region may extend as far superiorly as the clavicle. See the images below.

Central pedicle breast reduction. The skin flaps h Central pedicle breast reduction. The skin flaps have been widely undermined. The surgeon's hand must support the pedicle to avoid injury to the blood supply. Note that positioning of the central pedicle is not limited by any skin bridges.
Central pedicle breast reduction. The central pedi Central pedicle breast reduction. The central pedicle is isolated just prior to tangential excision.

Once the entire central pedicle breast mound has been exposed, it should be reduced through a series of tangential excisions maintaining a conical breast shape. Remove approximately one half of the volume planned for resection from each breast in this fashion. Take care not to place traction on the tissue being excised from the breast mound because the blood supply to the nipple can be compromised inadvertently. See the image below.

Central pedicle breast reduction. The inferior ped Central pedicle breast reduction. The inferior pedicle is divided, allowing increased mobility of the breast mound on the chest wall.

After completion of reduction of the of the central breast mound, redrape the skin flaps and tailor them to fit. Accomplish approximation of the vertical incision first. The total length of this vertical limb should be 8 cm (3 cm for the NAC and 5 cm for the vertical incision extending from the inferior border of the areola to the inframammary crease; redrape the skin flaps and tailor from the inferior border of the areola to the inframammary crease). See the image below.

Central pedicle breast reduction. The right breast Central pedicle breast reduction. The right breast has been shaped temporarily using skin staples. After reduction of the second side, the nipple-areola complexes will be delivered and inset.

Then pull the medial and lateral skin flaps toward the vertical incision and resect redundant tissue. The projection of the reduced breast is accurately controlled by this maneuver. The surgeon must be cognizant of the 3D geometry involved in reducing the breast. If one reduces the volume of a cone without reducing the diameter of the base of the cone, the cone has decreased projection.

In the final shaping, drawing the skin flaps toward the vertical skin incision allows reduction of the length of the inframammary incision. A vertical-only incision is possible; however, unacceptable puckering of the vertical incision is a common complication.[23] In taking out dog ears at the medial and lateral ends of the inframammary incision, the incision should be curved superiorly to reflect the narrowed base of the breast. Failure to do this may result in incisions that deviate from the inframammary crease, thus are more visible.

Lastly, the position for the NAC is determined with the patient in an upright position. Mark the skin for excision and check the NACs for viability prior to resection of the skin. In this way, they still can be salvaged as free nipple grafts placed on deepithelialized skin flaps if necessary.

Once viability is ensured, make the keyhole incision and deliver the nipple areola.

Close the skin incisions in a layered fashion with resorbable sutures placed in the deep dermis and either skin staples or a running intracuticular closure. If staples are used, remove them in 5 days.

In summary, the greatest advantage of this technique is that shaping is still "freehand," allowing the surgeon to individualize the result, fitting it to the particular patient's body habitus. Because flexibility is present in the skin envelope, excellent projection is possible.

A layered closure with interrupted buried deep dermal sutures followed by a running subcuticular closure completes the operation.

Postoperative Details

The operation may be performed as an outpatient procedure or with an overnight stay, depending upon insurance and comorbid factors.

If drains are placed, they may be removed on the first postoperative day.

Observe the patient at a follow-up visit 1-2 weeks after surgery and then again approximately 3 months postoperatively.

Most patients are able to resume normal activity 2-3 weeks postoperatively and are able to resume more vigorous activity 4-6 weeks postoperatively.

Edema resolution and tissue settling may be expected to last 3-6 months until complete.

Follow-up

See the list below:

  • With uncomplicated healing, no follow-up care is required.

  • If complications such as seroma or wound dehiscence occur, appropriate medical and surgical care are required until complete resolution is achieved. This occasionally may involve additional surgery. For more information, see Medscape Reference article Wound Healing and Repair.

  • Resolution of symptoms usually is recognized early in the postoperative course.

Complications

Complications are usually minimal and may consist of seroma and small areas of wound separation (especially at the 3-way junction of the inverted T incision). Nipple areola loss should be approximately 1% and is frequently associated with loss of underlying glandular breast tissue.[24, 25, 26] Loss of sensation is an uncommon problem with the use of a central glandular technique, as it safely preserves the nerve distribution to the nipple.[27, 28] Loss of the capacity to lactate postoperatively has been demonstrated to be unusual with various pedicles.[29]

All of these problems should be treated conservatively with frequent office visits for reassurance. In the case of nipple loss, corrective surgery is usually required but should be deferred for several months until edema has resolved and any compromised tissue has been debrided. Obesity and smoking have been identified as increasing the risks for complications following reduction mammaplasty and should be avoided, if possible, to reduce complications.[30, 31, 32]

Outcome and Prognosis

In a reported series of 153 patients, presenting symptoms were back and neck pain, shoulder grooving, and intertrigo.[4] An average of 794 g was reduced per side. One case of nipple areola loss occurred in 306 breasts. Wound healing complications (usually a small dehiscence at the inverted T incision) were observed in 24 patients, and all but one of these complications were managed by local wound care alone. Minor revisions under local anesthesia were required in 13 patients. Patient satisfaction and relief of symptoms were high. Other authors have also shown the efficacy of symptomatic relief.[33, 34, 35] In addition, satisfactory aesthetic outcomes can be achieved with this technique. See the images below.

Patient with macromastia, preoperative view. Patient with macromastia, preoperative view.
Postoperative view following central mound reducti Postoperative view following central mound reduction mammaplasty.

Future and Controversies

Routine screening mammography guidelines ought to be followed in the preoperative workup for breast reduction; however, controversy exists regarding the use of mammography.[36] The American Cancer Society and the American Congress of Obstetricians and Gynecologists recommends yearly mammography for women older than 40 years.[37, 38] However, according to the the US Preventive Services Task Force, routine screening mammography in women aged 40-49 years is not indicated and biennial screening mammography for women aged 50-74 years is recommended.[39] Evidence-based guidelines aimed specifically at reduction mammoplasty evaluation have not been clearly developed. Additional preoperative mammography must be analyzed for its potential adverse effects, including unneeded additional imaging or biopsy procedures.

Technique modifications

Bayramiçli presented a modification of the technique referred to as the central pillar technique.[23] His series described an average reduction in tissue per breast of 910.7 g (range, 440-1935 g), and transposition of the nipple was 9.6 cm (range, 6-17 cm). This technique is applicable for young patients with glandular breasts that require significant reduction and transposition of the NAC, as opposed to the "free nipple graft" technique.

A study by Kim et al reported that all breast shapes and tissue conditions can be addressed using a modified central pedicle breast reduction operation employing a vertical scar technique. According to the report, in which 56 patients underwent the modified surgery, the procedure minimizes scar burden, maximizes breast function preservation, and produces an attractive conical breast shape.[40]

Other techniques

A number of breast reduction techniques have been described over the years. Variations of the inferior pedicle technique are the most common procedures in use today.[41, 42, 43] Certainly, no single best operative technique exists for reduction mammaplasty. The authors' intention in this article is to illustrate one technique and to present results from a representative series of patients. For information on other breast reduction techniques, see the following Medscape Reference Plastic Surgery articles:

  • Inferior Pedicle Breast Reduction

  • Lejour Breast Reduction

  • Liposuction Only Breast Reduction

  • Moufarrège Total Posterior Pedicle Breast Reduction

  • Simplified Vertical Breast Reduction

  • Superior Pedicle Breast Reduction

  • Vertical Bipedicle Breast Reduction