Medial Pedicle and Mastopexy Breast Reduction

Mastopexy is a compound word derived from the Greek mastos (breast) and pexy (to fix or secure). It refers to the correction of ptotic and pendulous breasts. The term mammaplasty refers to shaping of the breast, as the Greek derivative plasty means to mold.

The principles and techniques used to correct pendulous ptotic breasts (see the image below) are similar to those used to perform a breast reduction. In all techniques used, the most critical consideration is the viability of the nipple-areola complex (NAC). This article focuses on the medial pedicle as the one that provides blood supply to the NAC. The medial pedicle technique can be used to safely perform a large breast reduction, a mastopexy, or a mastopexy with simultaneous augmentation. ^[1] For information on other techniques for breast reduction, augmentation, and reconstruction, see the Breast section of Medscape Drugs and Disease's Plastic Surgery journal. ^[2]

This patient had obvious and significant breast ptosis. Medial pedicle mastopexy was performed, in addition to a subpectoral breast augmentation with saline-filled breast implants. The breast implants were filled to a volume capacity of 450 mL bilaterally. This image shows the preoperative front view.

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The history and evolution of breast reduction spans many centuries. Paul from the Greek island of Aegina was the first to describe details of reduction mammoplasty in the 6th century AD. ^[3] Multiple techniques of breast reduction and mastopexy have been described over the past century. In the last 3 decades, the main evolution and progress in the field of reduction mammaplasty and mastopexy has been in better molding of the breast parenchyma (limiting the resultant scars) and not relying on the skin envelope for long-term parenchymal support and breast shape.

The true etiology of breast hypertrophy is not clearly understood. The breasts are hormonally sensitive organs that change with hormonal and, especially, estrogen variations. Breast enlargement usually begins with changes associated with puberty and pregnancy. In some women, estrogen receptors that are hypersensitive to estrogen may be a cause of mammary hyperplasia. ^{[4, 5, 6, 7]}

The problem of breast ptosis is also not clearly understood. The ideal youthful-looking breast should have a natural tear drop shape, adequate projection (perkiness), and no ptosis. The entire breast parenchyma should be above the inframammary fold (IMF), and the NAC should be centered at the breast or be slightly lower than the center.

The most established classification to describe ptosis according to the relative positions of the NAC, breast parenchyma, and IMF is by Regnault. ^[8]

• First-degree ptosis - Mild ptosis in which the NAC lies at or slightly above the IMF

• Second-degree ptosis - Moderate ptosis in which the NAC is below the IMF but above the highest projecting part of the breast

• Pseudoptosis - Condition in which the NAC is above the IMF, but the lower pole of the breast is below the IMF

• Third-degree ptosis - Severe ptosis in which the NAC is below the IMF and at the lowest projecting part of the breast

Frequency

The true frequency of ptosis and macromastia is not known. Most plastic surgeons in the United States typically work with patients who have these problems following pregnancy.

The true etiology of ptosis and macromastia is not known. They are generally assumed to be results of hormonal changes on the breasts and, especially, the actions of estrogen on the estrogen parenchymal receptors.

The pathophysiology of ptosis and macromastia is felt to be strongly associated with estrogen hormonal levels or estrogen receptor hypersensitivity to circulating levels of estrogen. The pathophysiology is not thoroughly understood. In a great majority of cases, ptotic breasts are associated with asymmetry in terms of parenchymal volume, NAC diameter and position, and shape. These morphologic differences may represent true anatomic variations or may be due to variations in physiologic actions of the breasts.

A complete patient history and physical examination should be performed. The physical examination should entail a thorough examination of the breasts and nipple-areola complexes (NACs), the axillae and supraclavicular areas for any lymphadenopathy and accessory breast tissue, and the rest of the abdomen and pelvis for any accessory breasts.

Clinically, hypertrophic breasts may present with ptosis, an enlarged NAC, decreased sensitivity of the NAC (which may improve following reduction mammaplasty), prominent and visible veins, stretch marks of the skin, and hypersensitivity and irritation of the inframammary skin.

Indications to perform a mastopexy are primarily aesthetic; that is, to position the nipple-areola complex (NAC) in a more aesthetically pleasing location relative to the rest of the breast and to give the breast youthful shape and projection. The indications can also be psychological, as saggy or asymmetric breasts can be detrimental to the self-esteem of an individual.

The indications for a reduction mammoplasty may be aesthetic, but they are chiefly functional. Macromastia may cause neck pain, back pain, shoulder strap indentations and shoulder pain, chest heaviness, labored breathing, headaches, poor posture, and skin irritation and infections. In addition, the psychological burden can be significant. Women with macromastia may find it difficult to exercise, participate in activities of daily living, and find proper clothing. This condition affects their self-esteem and self image.

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.

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The blood supply to the breast comes primarily from branches of the internal mammary artery. The thoracoacromial, thoracodorsal, lateral thoracic, and intercostal arteries also contribute. Those arteries create rich anastomotic plexuses. ^[9]

The innervation of the breast comes from the anterior rami of the second to the sixth intercostals nerves. The skin of the upper part of the breast is innervated by the supraclavicular nerves. The nipple-areola complex (NAC) gets rich innervation from the anterior branches of the second to sixth intercostal nerves and from the lateral branches of the fourth and fifth intercostal nerves. The nerve supply from the fourth intercostal nerve is believed to play a unique role in the NAC innervations. ^{[10, 11]}

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

Overall poor health is a contraindication for this procedure. Prior breast reduction or mastopexy with another technique is not a contraindication to performing this operation.