Inferior Pedicle Breast Reduction Treatment & Management

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 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.

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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.

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 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.

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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]

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 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.

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.

A single-surgeon study by Friedman et al indicated that in inferior pedicle breast reduction, the risk of fat necrosis is greater in patients with a BMI of over 35 or a nipple-to–inframammary fold distance of over 20 cm as well as in those in whom greater than 1000 g of breast tissue has been resected. However, these factors led to only a minimal increase in the risk for a major wound complication. In this study, outcomes of the inferior pedicle procedure were not found to be affected by nicotine use or by the presence of diabetes or hypertension. ^[8]

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 ^[9] :

• 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

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. ^[10]

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. ^[11]

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. ^[12]

In general, the changes made in the techniques of reduction mammoplasty have been to shorten the lateral extension of the scar. ^[13] 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. ^{[14, 15]}