Superior Pedicle Breast Reduction 

Updated: Feb 24, 2020
Author: James Neal Long, MD, FACS; Chief Editor: Jorge I de la Torre, MD, FACS 

Overview

Background

Until the early 1990s, when Lejour began to popularize Lassus' concept of vertical scar mammoplasty, the vast majority of breast reductions used some variation of the Wise pattern for skin resection.[1] Each particular technique during this time period differed primarily on the origin of the parenchymal pedicle, which provided the neurovascular contributions to the nipple-areola complex (NAC).

Though the inferiorly based pedicle technique remains one of the most popular techniques in the United States today, because of their advantages over other procedures, the Superiorly based techniques continue their increasing popularity among both surgeons and patients. See the image below.

Breast reduction, superomedial pedicle. 2 months p Breast reduction, superomedial pedicle. 2 months postoperative lateral view.

Vertical reductions, as espoused by Lassus and then refined by Lejour, are, essentially, founded on superiorly based pedicles with inferiorly based parenchymal resections and pure vertical closures. These are more fully discussed in other articles (see Lejour Breast Reduction, Simplified Vertical Breast Reduction, and Vertical Bipedicle Breast Reduction).

History of the Procedure

In 1957, Arie first described the superior pedicle mammoplasty.[2] This description was followed by refinements given to us by Ivo Pitanguy in 1967,[3] eventhough Weiner is credited for bringing this technique to the fore in the United States with his 1973 publication describing the superiorly based dermal pedicle for reductions and mastopexy, which claimed avoidance of the distortions problematic with Skoog type reductions.[4] Soon thereafter, Orlando and Guthrie demonstrated the superomedial pedicle technique, which varied only in the more medially-directed superior pedicle.[5] Seeking a safer pedicle to ensure nipple viability, Hugo and McClellan, as well as Hauben, later incorporated more parenchyma beneath the de-epithelized dermal pedicle.[6] Arufe et al confirmed adequate vascularity of the superior pedicle with preoperative arteriograms on several patients.[7]

Author-noted advantages of the superiorly based pedicle technique include less skin undermining and simplified resections, which result in significant reductions in operative time. Importantly, these techniques foster preservation of dermoparenchymal relationships with maintained small vessel connectivity which, in turn, minimizes the risk of skin and fat necrosis. Shaping the breast mound, which can be difficult with techniques that disrupt the dermoparenchymal relationship, becomes more easily achievable with intraparenchymal pillar suturing techniques, which are inherent to these methods. Durability of results with the superomedial variant has been shown by advocates such as Elizabeth Hall-Findlay. In her series of cases, she has demonstrated good long-term shape with minimal development of pseudoptosis (bottoming out) over time.[8]

Indications

The indications for superior pedicle reduction are the general indications for breast reduction, which are well-described as the stigmata of macromastia. These typically include upper back pain, brassiere strap pain, grooving or hyperpigmentation, inframammary intertrigo, and difficulty engaging in the activities of daily living.

The selection of a straight vertical pedicle technique is best reserved for those patients with less ptosis. Transposing the nipple more than 5 cm with a pure vertical technique can be difficult, particularly in patients with dense breast tissue. The superior-medial pedicle is indicated for patients who require lengthier nipple transpositions.

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.

Blood supply to the breast comes from the internal thoracic artery via the anterior perforators, lateral thoracic artery, thoracoacromial artery, and lateral perforators of the intercostal arteries. The nipple-areola complex (NAC) rests on a vascular "watershed" zone, receiving contributions from all of these vessels. The internal thoracic is the dominant axis among these contributing vascular supplies; it provides as much as 60% of overall inflow.

Nerve supply to the NAC is from the anterior and lateral perforating branches of the third, fourth, and fifth intercostal nerves, with the fourth being the primary sensory contributor. In a recent report, Schlenz et al demonstrated that the lateral contributors frequently reach the NAC in direct ascent from the chest wall in 90% of dissections.[9] Nonviolation of the pectoralis fascia along the deep lateral resection margin usually results in maintenance of NAC sensibility and, in some cases in which nerve traction is reduced by the procedure, even yields increased sensitivity. Medial branches are, conversely, found in a more superficial plane. Maintenance of the dermoparenchymal relationship in this anteromedial region, as is done with the superomedial technique, helps decrease the potential for injury to these nerves during pedicle development.

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

Contraindications

Superior and superomedial pedicled breast reductions are probably contraindicated if breast scars completely cross the proposed pedicle and are known or presumed to have transected the pedicled blood supply. These techniques should be given very careful consideration in patients who have had previous breast reduction by a pedicle of a differing orientation as they may develop fatty necrosis or nipple slough.

Relative contraindications for the superior medial pedicle include NAC transpositions of less than 5 cm or greater than 20 cm and, in the superior pedicle, transposition of greater than 5 cm. Since superior-medial transposition of the nipple requires a significant arc of rotation, patients with tight firm breasts that have poor pliability are less ideal candidates for the superomedial procedure and better candidates for the straight superior pedicled approach, as long as NAC pedicle lengths are kept appropriately confined.

Resection volume greater than 2000 g is a relative contraindication, although the Author has experience using this technique in properly selected patients with resections exceeding 4000 g per side. Others have supported this, demonstrating acceptable morbidity rates.[10]

Because of the limited undermining required to transpose tissues, the authors have found fewer complications with the superomedial pedicle in patients who smoke (compared to other techniques in patients who smoke). Limited undermining maintains vascular beds connecting parenchyma to skin with the pedicle axial on the very robust blood supply of internal thoracic artery perforators. More, the parenchyma targeted for resection falls in the "watershed" area between lateral and medial vascular zones, making fat necrosis far less common.

 

Workup

Laboratory Studies

See the list below:

  • Preoperative CBC and PT/aPTT are screening exams routinely used by the authors to establish preoperative adequacy of hematocrit and coagulation.

Imaging Studies

See the list below:

  • Mammograms should be ordered according to guidelines established by the National Cancer Institute, the American Cancer Society, and the American College of Radiology. Each of these organizations recommends annual mammograms for women over 40.

Other Tests

See the list below:

  • In women who have undergone gastric bypass surgery, investigations should be directed towards malnutritive states, which can impact protein synthetic function and, therefore, healing. In addition to CBC and PT/aPTT, prealbumin and albumin levels can be helpful (though not definitive) in establishing the absence of these problems. Other useful lab data include serum B12 and folate levels.

 

Treatment

Medical Therapy

In patients with macromastia who are obese, physician-directed weight loss programs that include diet and exercise may help reduce symptoms but are unlikely to lead to complete resolution alone. Often, patients find it difficult to exercise due to the physically limiting effects of macromastia.

Surgical Therapy

Breast reduction surgery directs its intentions toward 2 primary alterations in breast habitus. The first goal is a reduction in weight, with a consequent reduction in size.[11] Second, by placing most retained breast tissue at or above the inframammary fold, a favorable change in weight vectors on the upper thorax and spine is produced. While the surgeon always strives to provide good shape, aesthetic contour, and bilateral symmetry, reduction mammaplasty should be considered an operation to improve function. Aside from the aesthetic improvement, which is always sought and often realized, resultant patient-noted benefits, such as relief from upper back and shoulder pain and the increased ability to engage in the activities of daily living, remain essential to patient satisfaction.

Preoperative Details

Marking may differ significantly from the familiar Wise pattern. The surgeon may choose to use markings which permit a pure vertical closure. The author has found that pure vertical closure can be more difficult to achieve in cases where patients have a greater excess of skin than of volume. In such cases, tailoring an inframammary skin excision can improve cosmetic appearances by reducing inferior bunching and eliminating dog-ear redundancies. Often, this tailor tacking approach will yield inframammary scars that are significantly shorter than would be possible with inferior-pedicled, Wise pattern reductions. These shorter incisions are the byproduct of dermoparenchymal shaping by means of intraparenchymal pillar suturing rather than relying on the traditional skin resections to achieve desired shape. Another direct benefit from this phenomenon is a reduced-tension skin closure.

Proposed nipple location is set with the "A" point (top of the keyhole) approximately 2 cm below the anteriorly transposed inframammary fold. Medial and lateral skin excision limits are identified by lateral and medial displacement of breast tissue using the native breast meridian as the reference line. The breast meridian should be delineated by marks at the clavicle and below the inframammary fold (IMF), each of which is relatively immobile during displacement. The ultimate result of this process should be a vertically oriented oval topped by a mosque-shaped dome with its apex approximately 2 cm below the anteriorly transposed IMF and its lower limit 2-4 cm above the native IMF.

Anticipating resection volume helps direct marking of skin. The use of a McKissock-type keyhole can be helpful but is not required, since opportunity for custom siting is available after resection. If developing the nipple-areola complex (NAC) inset position (keyhole) is deferred, do not over-resect skin cephaladly, since this will force unfavorably high NAC positioning in order to avoid scar extension above the NAC.

The author prefers to develop a mosque-shaped keyhole for NAC insetting during de-epithelialization and development of the pedicle, as this method saves time. Skin markings are conservative, with the lower limit of the resection between 2 cm and 4 cm above the native IMF; this location depends on the anticipated resection volume (greater-volume resections warrant higher placement). If necessary, additional skin can be removed postresection. Since this technique employs intraparenchymal pillar suturing to achieve breast shaping, significant, if any, additional skin resection to improve contour is usually not required. Small skin redundancies tend to retract in short order because of inferior resectional or liposuction thinning coupled with an absence of skin loading in the context of natural skin elasticity. Be aware that skin of poor quality is unlikely to recoil with time and should be considered for resection.

  • Pedicle markings differ based on choice of either superior or superomedial pedicles. The upper border of the superomedial pedicle should obliquely divide the intended NAC inset position between its inferomedial one third and the superolateral two thirds. The lower border is an oblique line, drawn within the planned skin resection margins, that respects and reflects the oblique traverse of the parasternal perforators into the pedicle.

  • Draw the lateral limb by dropping a vertical line straight down from the starting point of the lateral limb of the inverted "V" where the circular component of the new areolar defect comes together; the width of the pedicle varies according to its length. See the image below.

    Preoperative markings of a superomedial pedicle re Preoperative markings of a superomedial pedicle reduction. Notice that the base of the pedicle is made wider for longer nipple transpositions.
  • The superior pedicle reduction has a pattern of de-epithelization that comes down caudally from the intended NAC inset position, encompassing the new nipple areolar complex and extending approximately 1 cm around it and approximately 2 cm below its caudal border. See the image below.

    Preoperative markings of a superior pedicle techni Preoperative markings of a superior pedicle technique breast reduction.

A retrospective study by Altuntaş et al indicated that owing to greater postoperative sagging of the lower pole of the breast than of the NAC, during inverted T-scar superomedial pedicle breast mammaplasty, the nipple position should be marked 1.5-1.75 cm lower than the portion of the breast with the greatest projection. This, according to the study, will allow the NAC to eventually occupy the correct position.[12]

Intraoperative Details

The superomedial pedicled mammoplasty begins by de-epithelization of the pedicle and circumscription of the NAC with the breasts placed in mammostats to provide skin stretch and hemostasis. The pedicle is developed by incision along markings straight down to but not through the loose areolar connective tissue plane directly above the superficial pectoralis major muscle fascia.

Excess breast tissue is removed in a dermoglandular en-bloc resection with minimal undermining. Areas of redundancy addressed are superior, lateral, and inferior. Conservative resection superiorly is advised in order to prevent inadequate deep support of the transposed NAC at its inset site, which can result in nipple retraction. During resection, dermoglandular lateral flaps 2-3 cm thick are preserved, as they have the benefit of improved vascularity and retained structural integrity. This thick subdermal tissue retained on the lateral flap is helpful in preventing skin dimpling when lateral pillar sutures are placed.

Thin-skin undermining in a mastectomy plane at the inferomedial (caudal to the pedicle) and inferolateral (caudal to the thicker lateral dermoglandular flap) aspects of resection allows for a straight vertical closure without unsightly inferior bulging in all but the largest of reductions. The lateral flap transition from its superior thicker region to the inferior thinner zone is roughly determined as the area where the lateral Wise pattern skin resection would have been performed. Subcutaneous contour irregularities after transposition can be addressed by SAL, which may also be used for fine contouring after final closure.

After resection, the approximate 4-o'clock position of the NAC is affixed to the apex of the mosque-shaped keyhole inset site. A dermal back cut at the most inferior portion of the de-epithelialized pedicle may be required to achieve an adequate arc of rotation. This is particularly true in pedicles that are relatively short and wide. Because of the benefit of greater perforator capture, wider pedicle bases are advised when tenable. The pedicle soft tissue bulk is transposed superomedially and secured in position by intraparenchymal suturing to unify the medial (the now transposed lower pedicle border) and lateral (the thicker portion of the lateral breast flap) pillars. The positional interrelation of the pillars can be manipulated by the surgeon to achieve the desired breast shape. The pillar positioning that is selected should reflect a tension-free NAC inset. See the images below.

Breast reduction, superior pedicle. The pedicle, n Breast reduction, superior pedicle. The pedicle, now developed, is imbricated superiorly into the new NAC inset position.
Breast reduction, superior pedicle. The NAC is int Breast reduction, superior pedicle. The NAC is into the new position. Vertical closure, no inframammary incision line. The lateral dimpling is from intraparenchymal pillar suturing and typically settles out completely within 6 weeks.

The superior pedicle technique varies in that the pedicle is developed along lines directly inferior to the NAC inset position and that resection is inferiorly based. Once resection is complete, the pedicle is folded superiorly to be inset without rotation of the NAC.

Drains are optional.

Postoperative Details

Evaluate the surgical site for presence of hematoma and for sensitivity and viability of the NAC.

Follow-up

Postoperatively, the patient should wear a soft support brassiere without under wire for 3-6 weeks, dependent on observed patient healing.

Complications

Incidence of complications is similar to other techniques of reduction mammoplasty. Hauben reported on 212 patients; in 1 patient total loss of the NAC occurred (the first time he used this technique, the pedicle length was 26 cm, and the patient was a heavy smoker). In addition, he had another partial loss of the NAC. Decreased sensation of the NAC was present, but no incidence was quoted; nipple retraction was present in 2% of patients and hematoma in 2.26%. No transfusion was necessary.[13]

Finger et al reported only 2 partial losses of the NAC (< 25%) and decreased sensation in 15% in 148 patients (291 breasts). Other complications were hypertrophic scars, nipple retraction, and dog-ears. Average blood loss was 200 mL.[14]

Hugo and McClellan reported on 34 patients (68 breasts) with an average of 760 g resected and 12 cm of nipple transposition. One patient (1.4%) had a partial loss of the NAC, and 2 (3%) had infections.[6]

Outcome and Prognosis

Results of breast reduction are satisfactory and among the most well accepted by patients regardless of the technique used.[15] The advantages of the superior pedicle techniques are many for both surgeon and patient. See the images below.

Breast reduction, superomedial pedicle. Preoperati Breast reduction, superomedial pedicle. Preoperative view of a 55-year-old woman with macromastia.
Breast reduction, superomedial pedicle. Preoperati Breast reduction, superomedial pedicle. Preoperative lateral view of a 55-year-old woman with macromastia.
Breast reduction, superomedial pedicle. 2 months p Breast reduction, superomedial pedicle. 2 months postoperative view. Nipple-areolar complexes are sensate and viable. Note eliminated symmastia.
Breast reduction, superomedial pedicle. 2 months p Breast reduction, superomedial pedicle. 2 months postoperative lateral view.

Reduction of the width of the breast is achieved easily without compromising the viability or sensitivity of the nipple-areola complex (NAC), which receives its blood supply from internal mammary and lateral thoracic arteries; nerve supply is from the anterior and lateral intercostal contributions. Symmastia, which cannot be corrected using other techniques without creating scars across the midline, is corrected with the superomedial technique.

The achievable breast projection is superior over other techniques (a cosmetic advantage that is appreciated by surgeons and patients).

Distance from the inframammary fold (IMF) to the NAC does not increase significantly postoperatively with use of the superiorly based techniques. More, they resist change over time and do not develop pseudoptosis, which is a common late finding with the inferior pedicle technique.

Operation times are shorter. These techniques do not employ skin undermining or tailored skin excisions for shaping. Further, dermoglandular resection is completed en-bloc, which is simple and fast.

The superior pedicle technique tends to preserve projection but is limited by pedicle length. This technique is suggested for resections of no more than 1200 g and NAC transpositions of no more than 9 cm.

The superomedial pedicle technique may better preserve sensation to the NAC than the superior pedicle technique.[16, 17] The author has found the superomedial pedicle technique useful for all breast types, not restricted to use on nonsmokers or patients with soft and mobile breasts. The superomedial pedicle technique can be safely used for resections of up to 2000 g and cephalic NAC transpositions of 5-15 cm with reliable preservation of viability and sensibility. Attainable pedicle lengths likely exceed the author's limit of 27 cm.

Recently published articles corroborate the above assertions. Davison et al reported a statistically significant reduction in operation time of 41 min (P = 0.0001) in a matched consecutive cohort of 25 patients.[18] Furthermore, out of 279 patients, all nipples were found to be viable, NAC hypesthesia was reported in only 2 patients, and the overall complication rate was 18% (74% of the patients with complications had BMIs >30).[18] Landau and Hudson looked at the superomedial pedicle technique in 61 patients (122 breasts) over a 10-y period. Mean resection weight was >1300 g per breast. They found a partial areola necrosis rate of 6.5%. All nipples were viable. Minor complications (eg, wound breakdown) were reported in 18% of patients (Landau, Hudson, 2008).[10] These figures attest to the safety and versatility of the superomedial pedicle technique for reduction mammaplasty regardless of breast size or patient BMI.

A retrospective study by Manahan et al of 2152 breast reductions (1148 patients), including with inferior and superior pedicle procedures, indicated that surgical outcomes are negatively impacted by morbid obesity, tobacco use, cardiac disease, and secondary surgery. For example, patients with cardiac disease were more likely to undergo reoperation for scars and fat necrosis, while a body mass index of 35 kg/m or more was associated with an increased risk of infection, seromas, fat necrosis, and minor wounds.[19]

Future and Controversies

Elizabeth Hall-Findlay has shown good results using her combination of superomedial pedicle combined with vertical closure. The long-term results she has presented suggest that the late development of pseudoptosis is less problematic than with other techniques. The learning curve for this technique can be steep. Nevertheless, no other technique appears to have the distinct advantages of this particular approach, with benefits that include faster operative times, greater control over breast shaping, reduced risk of peri-incisional skin necrosis, reduced risk of NAC insensitivity and nonviability, and reduced incidence of fat necrosis, as well as greater durability of the aesthetic result. Although some have cited the steep learning curve as a barrier to wide acceptance of the technique, with proper application, durable, satisfying results are within easy reach.