Inferior Pedicle Breast Reduction 

Updated: Jun 16, 2020
Author: Susan E Downey, MD; Chief Editor: James Neal Long, MD, FACS 

Overview

Background

Patients with large breasts experience a significant range of symptoms, some severe enough to interfere with activities of daily living. Patients with large heavy breasts commonly report significant neck and shoulder pain. They may develop grooves in their shoulders from the weight of their bra straps, experience difficulty wearing clothes, and find that the heaviness of their breasts interferes with sports activities. Some patients have even had to eliminate some activities from their lives because their large breasts get in their way.[1, 2]

Patients may present to plastic surgeons for reduction mammoplasty starting at puberty. If reduction mammoplasty is performed at an early age, such as age 14 years, the patient should be advised that she may require an additional procedure at a later time. If breasts are significantly large, surgery should be considered in the teenage years so the teenager's activities are not restricted, nor is she harassed.

The true genetics of breast development are not known. Even within the same family, one sister may have small breasts while the other has large breasts.

This article addresses the inferior pedicle technique (see image below) for breast reduction, which is an alternative to free nipple and areola grafting.[3]

Breast reduction, inferior pedicle. Closure of inc Breast reduction, inferior pedicle. Closure of incisions (top). Final position of incisions (bottom). Used with permission from Downey SE. Plastic Surgery for Common Breast Problems. In: Hindle WH, ed. Breast Care: A Clinical Guidebook for Women's Primary Health Care Providers. New York: Springer-Verlag New York Inc; 1999.

For details on other techniques, visit the Breast section of Medscape’s Plastic Surgery journal.

Indications

In general, a patient is considered a candidate for breast reduction if the size and weight of her breasts cause her significant neck and shoulder pain. Criteria have been established by some insurance companies as to the amount to be removed from each breast according to a patient's height and weight. More recently, however, insurance companies have relied more heavily on symptomatology, such as neck and shoulder pain, to approve the surgery. Small reductions in which the breasts are not reduced by at least 2 cup sizes are not usually covered by insurance and would likely be considered a breast lift or mastopexy.

Relevant Anatomy

Breast shape varies among patients, but knowing and understanding the anatomy of the breast (see 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.

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

Contraindications

The only real contraindication to breast reduction surgery is if the patient is not medically able to undergo the surgery.

Scars are the main risk that should be discussed with the patient. The scars from this procedure extend around the nipple-areolar complex (NAC), vertically between the NAC and the inframammary fold (IMF), and under the IMF. The scars are placed such that the scar around the NAC blends in when the color change occurs. The wound under the breast is placed under the fold to be hidden by the natural overhang of the breast. Fortunately, the vertical component of the scar tends to heal very well, even in patients who may form hypertrophic or very noticeable scars elsewhere.

Keloids are a risk in some patients. The most common place for keloid formation is in the IMF, principally in the medial portion. Patients who have a history of keloids should be warned of the risk for keloid formation. However, in general, the scars respond to steroid injection and pressure.

Patients with extremely large breasts have a higher risk of problems, principally loss of the NAC. This risk is almost negligible in women with smaller breasts; if these women smoke cigarettes, the risk is increased. In women with extremely large breasts, the possibility of a conversion to a free nipple graft should be discussed with the patient.

However, a retrospective study of a single surgeon’s experience indicated that the pedicled Robertson mammoplasty, an inferior pedicle technique involving a curvilinear skin extension onto the pedicle, is a safe and effective means of breast reduction in patients who are obese and have extreme macromastia. Patients in the report had a mean body mass index (BMI) of 36.45 kg/m2, with the mean resection weight being 1859.2 grams per breast and the sternal notch to nipple distance extending a mean 41.4 cm. No nipple necrosis occurred in association with the Robertson surgery, and no major complications leading to reoperation under general anesthesia arose. Minor complications requiring either local wound care or small office procedures occurred in 26.4% of patients, with 4.4% of patients undergoing small revisions under local anesthesia.[4]

The possibility of loss of nipple sensation exists in reduction mammaplasty, as does possible loss of the ability to breastfeed. Women have successfully breastfed following reduction mammoplasty, but patients should be warned that this may not be possible. In general, if loss of nipple sensation does occur, it usually improves over the course of the year or so following surgery.

A prospective, nonrandomized study by Muslu et al indicated that inferior pedicle breast reduction is a safe technique with regard to sensory changes. Although reduced skin sensation was found in the upper medial and lower lateral portions of the breast in women who underwent the procedure, a reduction that did not occur with superomedial pedicle breast reduction, the investigators found that neither the inferior nor the superomedial pedicle surgeries led to changes in the two-point discrimination test on the areola.[5]

 

Workup

Laboratory Studies

See the list below:

  • The patient should undergo a preoperative mammogram if she is older than 35 years. Blood is not usually required for this surgery; unless the patient is extremely large, transfusions are very rarely required.

 

Treatment

Preoperative Details

The breast reduction reduces the skin envelope and the volume of breast tissue. The markings are critical for the procedure and need to be made preoperatively (see image below), before the patient has received narcotic medication. At the time of the markings for the patient's reduction, adjustments are made for correction of asymmetry problems. The most important marking is for the new position of the nipple-areolar complex (NAC). This should be marked at a position commensurate with the inframammary fold (IMF), which is also 21-25 cm from the sternal notch. This should be at a position approximating one third of the way up the upper arm. The NAC can be reduced in size if large. A 4.5-cm NAC is appropriate for a reduced breast.

Breast reduction. Markings and preoperative assess Breast reduction. Markings and preoperative assessment. Used with permission from Downey SE. Plastic Surgery for Common Breast Problems. In: Hindle WH, ed. Breast Care: A Clinical Guidebook for Women's Primary Health Care Providers. New York: Springer-Verlag New York Inc; 1999.

The vertical limb is then marked. In general, this should be short (4.5 cm) to minimize the chance of eventual bottoming out of the breast. A longer vertical limb leads to premature bottoming out. The horizontal limb should then be marked. The total length of the upper portion of the horizontal limb should be equal to or greater than the inferior limb to allow for closure around the volume of the breast tissue.

Intraoperative Details

Once the markings are complete, the patient is taken to the operating room, both breasts are prepared and draped, and surgery is begun. The inferior pedicle of breast technique (see image below) involves leaving a pedicle of tissue with the nipple in the superior portion of the pedicle, creating a wedge-shaped pedicle down to the chest wall. The pedicle should be an 8-cm base in smaller reductions and a 10-cm base in larger reductions. The pedicle is de-epithelialized. Originally, this was thought to preserve blood flow and nipple sensation. This is probably not absolutely critical but remains standard for the reduction process.

Breast reduction, inferior pedicle. Closure of inc Breast reduction, inferior pedicle. Closure of incisions (top). Final position of incisions (bottom). Used with permission from Downey SE. Plastic Surgery for Common Breast Problems. In: Hindle WH, ed. Breast Care: A Clinical Guidebook for Women's Primary Health Care Providers. New York: Springer-Verlag New York Inc; 1999.

In extremely large reductions, the intended position of the nipple can be de-epithelialized. In case the nipple should become cyanotic during the procedure, the surgery could be converted to a free nipple graft. However, in general, reductions using the inferior pedicle technique can be performed in all patients except those with the most extremely large breasts. The excess breast tissue medially, laterally, and superiorly is then excised, and the upper breast flap is then elevated off the pectoralis fascia. The upper breast flap is then thinned to create the desired volume in the breasts.

The breasts should not be reduced down to a standard size but to one that is compatible with the remainder of the patient's body habitus. This may range from a B to a D cup or even bigger in larger women. Breast tissue should be carefully preserved, marked, and protected so that each specimen sent separately from each breast can be evaluated by a pathologist. Rarely, an occult malignancy has been found in a breast reduction specimen. In such cases, knowing in which breast the cancer has arisen is critical. When excess breast tissue is being excised, do not to let the pedicle fall to one side, as this causes undue cyanosis of the pedicle and may increase the chance of nipple loss.

After irrigating the wounds and obtaining hemostasis, the wounds are temporarily closed and the patient is placed in a sitting position to ensure that symmetry exists between the two breasts. The volume of breast tissue resected is weighed to provide data to the insurance companies. Knowing the volume of resected tissue is also helpful for determining that symmetry has been achieved during the reduction process.

The wounds are closed with buried sutures and then either a subcuticular suture or Dermabond on the skin.

Ding et al described a breast reduction technique combining the use of an inferior pedicle with a dermal suspension sling, as a means of helping to ensure good breast projection and shape. During the surgery, deepithelialized and defatted medial and lateral triangular flaps were created from the inferior pedicle where excision normally would occur and were attached to the chest wall above the pedicle. At median 12-month follow-up, breast projection and shape were retained, as was sensation in the nipple-areolar complex (NAC).[6]

Postoperative Details

The patient is placed in a surgical bra immediately following the procedure, as this helps minimize postoperative pain. The patient is generally kept in the hospital for one night following the surgery, during which the viability of the NAC is monitored.

Follow-up

Follow up with the patient as needed postoperatively to ascertain healing of the wounds. In general, the scars do very well around the NAC. Vertically but in the inframammary incision, some thickening of the scar may occur, particularly in the medial portion. This may require a Kenalog injection. The patient should be reminded to establish a new baseline mammogram approximately 6 months after the reduction mammoplasty.

Complications

The most devastating complication following a reduction mammoplasty is total loss of the nipple-areolar complex (NAC). This is extremely rare. Of course, the incidence of this complication is higher in patients who smoke or who have extremely large breasts. In patients with extremely large breasts, consider the possibility of a free nipple graft, and, as mentioned earlier, consider de-epithelialization of the upper portion from where the nipple is to be removed, which would allow the nipple to be placed as a graft.[7]

Smokers should be advised to quit smoking prior to the procedure and informed of the increased risk of problems if they continue to smoke.

In the case of impending loss of the NAC, convert the procedure to a free nipple graft. Otherwise, hematoma formation is the main complication that could arise. Some surgeons opt for drain placement, though the risk of hematoma or seroma is small. Infection is also unusual in a reduction mammoplasty.

In a retrospective study of 241 patients who underwent bilateral inferior pedicle breast reduction, DeFazio et al reported improved results through the use of inframammary darting, preoperative hydrodissection, and dermatome blades. Outcomes of these techniques were listed as follows[8] :

  • Inframammary darting: T-junction tension was reduced, along with the incidence of wound dehiscence

  • Preoperative hydrodissection: Intraoperative blood loss was decreased by a factor of 2

  • Dermatome blade use: Surgery time was shortened without increasing the incidence of postoperative seromas or hematomas

Outcome and Prognosis

Patients who undergo reduction mammoplasty are, in general, the most satisfied patients treated by plastic surgeons. They tend to experience immediate relief of their neck and shoulder pains. Even older patients, who have had heavy breasts for an extensive period of time, experience relief from their neck and shoulder pain.[9]

Complaints include migration of tissue, a lack of fullness, and poor projection. Echo et al studied 66 women who had breast reduction surgery with the dermal suspension sling modification. They concluded that the sling provides a structural foundation to the inferior pedicle that helped sustain breast projection and shape during follow-up of a median of 16 months.[10]

A study published in 1999 found that the risk of breast cancer was not increased after breast reduction; in fact, the risk of developing breast cancer was significantly decreased after breast reduction.[11]

Future and Controversies

In general, the changes made in the techniques of reduction mammoplasty have been to shorten the lateral extension of the scar.[12] Some surgeons now propose using just a vertical component, but this may leave a scar that descends onto the upper abdominal wall.

In general, the scars that result from this procedure heal very well. Care should be taken that the inferior scar is as short as possible to prevent it from extending either into the axillary area or medially, where it may be visible when wearing certain clothing or be more prone to keloid formation. Occasionally, some redundancy is present laterally to the breast area; this may require liposuction.[13, 14]