Vertical Bipedicle Breast Reduction 

Updated: Nov 16, 2015
Author: Bhupesh Vasisht, MD, FACS; Chief Editor: James Neal Long, MD, FACS 

Overview

Background

The purpose of bilateral breast reduction surgery is to reduce the size of hypertrophic breasts. Occasionally, unilateral breast reduction is performed to create symmetry with a smaller or reconstructed contralateral breast. The vertical, bipedicle, reduction mammaplasty is one of various techniques employed by some surgeons to reduce breast volume. Any breast reduction technique should prioritize patient safety, demonstrate reproducibility, and maintain breast aesthetics.

History of the Procedure

The bipedicle (full thickness vertical dermal flap) breast reduction, or McKissock reduction mammaplasty, has long been a standard to which other operative methods of breast reduction have been compared. Paul Kendrick McKissock, a California plastic surgeon, published his procedure in the March 1972 issue of Plastic and Reconstructive Surgery.[1] He initially developed the procedure as a modification of the Strombeck procedure[2] and refined it during the decade preceding publication. He is credited with making it a safe and reproducible operation. Since that time, his original technique has been modified by many surgeons, but the original principles have remained.

Problem

Women with macromastia can develop back and neck pain. The shoulders can become progressively notched from the pressure of the bra straps. The area under the breast can often develop intertrigo, which is characterized by frequent rash and skin breakdown. Frequent headaches may occur. Physical activity can be cumbersome and positioning for sleep may be difficult. Presently, only operative treatment can correct female breast hypertrophy. Breast reduction surgery alleviates the symptoms produced by mammary hypertrophy. The vertical bipedicle reduction mammaplasty can be adapted to the entire range of size and volume encountered in breast hypertrophy.

For information on other breast reduction techniques, see the Breast section of Medscape Reference’s Plastic Surgery journal.

Epidemiology

Frequency

The number of breast reduction procedures performed each year has increased. According to a recent publication by the American Society for Aesthetic Plastic Surgery, breast reduction was the fifth most frequent cosmetic procedure performed in the United States in 2006.[3] A total of 145,822 patients that underwent this procedure, although no specific information is available as to the specific techniques used in each surgery.[3]

In a study published in 2004, Rohrich et al reported that the McKissock technique is used by 4.8 percent of US plastic surgeons.[4] The most common technique is the inferior pedicle technique, used by 44.1 percent of the plastic surgeons surveyed.[4] The McKissock technique represents the fifth most commonly preferred technique in the United States.

Presentation

History

Bilateral breast hypertrophy presents at puberty or soon thereafter. Teenage females with large breasts frequently report that they are subjected to ridicule from their peers. This can represent the psychosocial component of the problem. Some women develop breast hypertrophy during pregnancy that persists even beyond. In extremely rare instances, rapidly progressive unremitting breast enlargement known as virginal breast hypertrophy may occur.

The symptoms of female breast hypertrophy relate to muscular discomfort. Patients report back pain, neck pain, shoulder discomfort, and even headache. Patients report poor posture due to the excessive weight of the breasts. Occasionally, ulnar nerve paresthesia can occur. Poor hygiene in the submammary crease leads to irritations, rashes, and even cutaneous infections.

Shoulder grooves develop over time from the pressure exerted by bra straps. If a bra is not worn, activities and even sleep may be difficult. Women with large breasts frequently report that they cannot participate in sports. Once this affects the patient's activities of daily living, the patient seeks medical attention.

Physical examination

Physical examination confirms the diagnosis of breast hypertrophy and attempts to rule out the possibility of breast cancer. Breast examination is typically performed with the patient in the seated and then recumbent positions. The breasts are assessed for any lumps, masses, scars, skin dimpling, or nipple discharge. The distance from the sternal notch to the nipple is often greater than 21 cm. The position of the nipple-areola complex (NAC) is noted in relation to the rest of the glandular tissue and the inframammary fold (IMF). Body surface area and excess breast tissue weight are estimated.

Secondary skeletal effects are examined by asking the patient to lean forward and examining vertical spinal alignment. Bra strap grooves are assessed for depth and skin breakdown. Intertrigo is assessed by lifting each breast and closely examining the skin for breakdown and rashes. Preoperative photographs to document mammary hypertrophy complete the physical examination.

Consultations

The treating plastic surgeon may seek the help of a general surgeon for evaluation of breast nodularity or an abnormal mammogram. Consultation with a spine surgeon is recommended to assess the back pain. Orthopedic surgeons may need to assess the patient for shoulder or other musculoskeletal pain.

Indications

See the list below:

  • Muscular pain in the neck, shoulder, and back as a result of mammary hypertrophy

  • Shoulder grooving from bra straps

  • Intermittent intertrigo in the submammary region or cleavage area

  • Alteration of activities of daily living as a result of enlarged breasts

Relevant Anatomy

The female breast is a glandular structure that varies in volume and shape. It occupies the area overlying the second to sixth ribs extending from the sternum to the anterior axillary line (see the image below). The center of each nipple-areola complex lies approximately 21 cm from the sternal notch. In women with mammary hypertrophy, that distance is longer and can sometimes reach more than 40 cm.

Anatomy of the breast. Anatomy of the breast.

The arterial supply of the breasts is from the lateral branches of the intercostal arteries, the lateral thoracic artery, and the perforating branches of the internal mammary artery. The nipple receives most of its blood supply from musculocutaneous perforating vessels from the pectoralis major muscle. These vessels travel through the breast tissue and supply the nipple-areola complex. An additional and substantial dermal plexus of arteries also supplies the nipple-areola complex and forms the basis of the vertical bipedicle technique.

The anterior cutaneous branches of the first to seventh intercostal nerves innervate the skin of the medial breast and the lateral cutaneous branches of the second to seventh intercostal nerves the lateral breast. The anterior and lateral cutaneous branches of the fourth intercostal nerve innervate the nipple-areola complex. Additional innervation to this complex is by the cutaneous branches of the third and fifth intercostal nerves.

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

Contraindications

The main contraindication for breast reduction surgery is the patient's preoperative medical condition. Patients with history of coronary arterial disease, thromboembolic disease, chronic lung disease, and chronic kidney disease are often not good candidates for surgery in general. An evaluation by the patient's primary physician is important in determining whether she is a good candidate. Patients who smoke are encouraged to stop smoking at least 4 weeks before surgery and not smoke for at least 4 weeks after the surgery.

 

Workup

Laboratory Studies

Routine blood work is not necessary in most patients. Patients who require large volume breast reduction may need routine laboratory tests in the rare event that a blood transfusion is needed. Mammogram is indicated in patients aged 35 years or older. A younger patient may require a mammogram if she has a history of breast cancer in the family.

 

Treatment

Medical Therapy

Medical treatment is often dictated by insurance companies, although no effective nonsurgical treatment for enlarged breasts exists. A special supportive brassiere may offer some relief but often increases the pressure on the shoulders.

Surgical Therapy

Bilateral reduction mammaplasty is the treatment of choice to alleviate the symptoms from mammary hypertrophy. The choice of reduction mammaplasty technique varies, but the expected outcomes are similar. The vertical bipedicle reduction mammaplasty is a reliable, reproducible, and aesthetically pleasing procedure.

Preoperative Details

In addition to a history and physical examination, the initial consultation involves a discussion of the risks and benefits of the vertical bipedicle reduction mammaplasty procedure. These risks are not unique to this technique and can occur with any of the reduction techniques.

Some of these risks include infection, hematoma, and delayed wound healing with possible dehiscence of the incisions. Impaired vascularity of tissues can result in the loss of skin or nipple-areola complex. This can lead to fatty necrosis of the breast tissue and may result in lumpiness of the breast tissue.

Scar formation is thoroughly discussed with the patient. The inverted T scar is often schematically demonstrated to the patient during this meeting. African American patients are told about the possibility of hypertrophic scars and even keloid formation.

Preauthorization from the insurance company is usually required. This may involve submission of preoperative photographs that demonstrate the symptoms such as shoulder grooving and intertrigo. Mammograms and blood work are ordered as appropriately indicated.

Before coming to the operating room, the appropriate surgical markings are drawn with a marking pen with the patient in the sitting or standing position. These markings are essentially the same for the inferior pedicle Wise pattern reduction. The sternal notch is marked in the midline. From this point, the midclavicular point is marked. This usually is about 7 to 7.5 cm from the midline. A straight line is drawn from this point to the nipple on each side. This line represents the breast meridian or the axis on which the breast reduction will be based. A midline vertical line is made from the sternal notch to the umbilicus as a reference point.

The inframammary fold (IMF) is then also marked. This point is transposed to the anterior breast on the previously drawn meridian. This is the site of the advancement of the nipple and is approximately 21 cm from the sternal notch. In tall or mature women, this measurement can be longer.

The vertical extent of the medial and lateral flaps is then marked. This determines the amount of skin that will be excised. The length is typically 7 cm (5 cm from the IMF to the lower extent of the nipple-areola complex) and is drawn inferiorly from the planned areolar margin on either side of the meridian. This should encompass the entire nipple-areola complex. The new nipple-areola complex is marked and is 42 mm in diameter. A line is then drawn laterally and medially from the end of the vertical lines and is usually perpendicular to this line. It extends to involve all the breast tissue medially and laterally. A horizontal line joins the end of these lines at the inframammary crease. Careful planning is important for correct nipple placement and bilateral symmetry.[5]

Intraoperative Details

Once the markings are in place, the patient is brought to the operating room. Prophylactic antibiotics may be given at this point. The patient is then scrubbed, draped, and prepared for surgery.

Once the patient is supine on the operating room table, the pedicle is measured and marked. The typical width of the pedicle is 8-10 cm. The pedicle is thicker and wider inferiorly and tends to be narrower superiorly. The nipple-areola complex is circumscribed with a 42-mm template. The skin superior and inferior to the nipple-areola complex is de-epithelialized. This marks the extent of the vertical bipedicle, which will be the basis of the blood supply to the nipple-areola complex.

The breast tissue lateral and medial to the pedicle is incised with a cautery unit. The lateral segment of tissue is removed through the skin, subcutaneous tissue, and breast tissue down to the pectoralis fascia. In a similar manner, the medial segment is removed down to the pectoralis fascia. At this point, the breast tissue above the nipple-areola complex can be removed, leaving a bridge of dermal tissue for the blood supply. Some surgeons leave the entire full thickness of breast tissue in the superior pole, and this portion is tucked and folded. All of the excised breast tissue is weighed. The wound is irrigated with saline and hemostasis is obtained. The flaps are then prepared for wound closure.

The medial and lateral flaps are approximated to each other in the meridian at the inframammary crease line. The nipple-areola complex is brought out through the previously marked keyhole, and a 5-0 Monocryl suture is used to approximate the 12-o'clock position of the nipple to the 12-o'clock position of the keyhole. The breast tissue above the Monocryl suture is typically folded in for the closure. Skin staples are then temporarily used to line up the wound edges. Interrupted 3-0 Monocryl sutures are then used for the subdermal closure. This is followed by a running subcuticular 4-0 Prolene suture to complete the closure.

The nipple-areola complex is closed with interrupted 5-0 Monocryl sutures followed by a running subcuticular 4-0 Prolene suture. The contralateral breast is addressed in a similar manner. At the end of the procedure, symmetry and good capillary refill of the nipple-areola complexes are achieved. Maintaining the patient's normal temperature and adequate fluids and using care in handling the pedicle during the procedure prevents undue risk to the viability of the nipple.

Once the procedure is complete, Steri-strips and light dressings are applied. The chest wall is then wrapped with elastic bandages (eg, Ace bandage).

Postoperative Details

Postoperative care after breast reduction surgery has evolved over the last few years. The wound is dressed with a bulky gauze dressing and then the chest is wrapped with an elastic bandage. Some surgeons place the patient directly into a bra.

Postoperative pain management can be achieved with either oral analgesics or with pain pumps. Small catheters are placed in each breast through a small puncture site. The pain pump delivers small constant doses of local anesthetics directly into the wound for a period of about 48-72 hours. These pumps are becoming more and more popular because they limit the amount of narcotics that patients need in the immediate postoperative period. In general, patients are instructed to rest and not lift anything heavy for a few weeks.

Follow-up

The patient is instructed to return to the office on day 2 after the surgery. At this visit, the original dressing is removed and the wound is inspected. The dressings are changed, and the patient typically can get the wound wet at this stage. After the wound has been wet, it is dried and topical antibiotic ointment is applied to the incisions. The patient returns at day 7 postsurgery and then at day 10. Sutures are removed at day 10.

Once the incisions appear to be healing, long-term visits are planned. The patient is asked to return at 6 weeks, 3 months, 6 months, and 1 year postsurgery. During this period, postoperative photographs are taken and outcomes recorded. Outcomes include documentation of the aesthetic result, long-term effects of gravity, scar maturation, nipple sensation, relief of preoperative symptoms, and patient satisfaction. Mammography, to establish a baseline for future breast cancer screening, can be repeated several months after surgery.

Complications

See the list below:

  • Hematoma

  • Seroma

  • Infection

  • Wound dehiscence

  • Fat necrosis

  • Nipple and/or pedicle necrosis

  • Loss of sensitivity of the nipple

  • Hypopigmentation of the nipple

  • Inability to breastfeed

  • Hypertrophic scars

  • Keloid scars

  • Marked lower breast fullness

Outcome and Prognosis

Outcome studies for breast reduction most often are not procedure-specific. The goal of breast reduction surgery should take into account patient safety; it should be reproducible, restore preoperative functional loss, and maintain the aesthetics of the breasts.[6]

Slezak and Dellon studied patients with gigantomastia.[7] They found that postoperative sensory outcome depends on a combination of factors, but most patients with gigantomastia have improved nipple sensation after a McKissock breast reduction.[7]

An outcome study from the Mayo Clinic in Scottsdale, Arizona, was published in 1997.[8] Of the respondents in the study, 94.2% believed the procedure was successful. Patients saw an improvement in body image, the ability to find clothes that fit, and the capacity to participate in sports. They experienced a decrease in notching of the shoulders from bra straps and decreases in shoulder pain, upper back pain, neck pain, and intertrigo. Pain or numbness in the hands, headaches, arm pain, and breast pain also decreased. Symptoms were either relieved or partially relieved in 88% of respondents. Of the respondents, 97.3% reported that they definitely or probably would undergo the procedure again. This outcome study supported the hypothesis that reduction mammaplasty is an effective procedure and the treatment of choice for symptomatic mammary hyperplasia.

A more recent study analyzing breast reduction complications was derived from the Breast Reduction Assessment: Value and Outcomes (BRAVO) study.[9] The resection weight correlated with increased risk and absolute number of complications. Delayed wound healing also correlated with resection weight and was inversely related to increasing age.[10] A British study assessed the aesthetic outcome of reduction mammaplasty.[11] Most patients rated the aesthetic outcomes of their surgery significantly higher than the consultants did. For both surgeons and patients, scarring was the most frequent cause of reported dissatisfaction. Silicone gel sheeting in the postoperative period may help mitigate these scars.

Symptomatic relief and improved body image has been shown in many studies that assess breast reduction.[12, 11] Among women who are obese and those who are not obese, no significant difference was reported concerning the resolution of physical symptoms or improvement in body image.[11]

Future and Controversies

Several variations in surgical technique may offer an opportunity to reduce the extent of scarring in the small-to-moderate volume breast. No current medical treatment for female breast hypertrophy exists.