Medial Pedicle and Mastopexy Breast Reduction Treatment & Management

Updated: Mar 03, 2016
  • Author: John M Anastasatos, MD; Chief Editor: James Neal Long, MD, FACS  more...
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Treatment

Medical Therapy

No effective medical therapy exists to relieve the pathology and correct the breast shape. The therapy is purely surgical.

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Surgical Therapy

The goals of surgery are to reduce the breast volume, relieve symptoms related to macromastia and ptosis, raise the nipple-areola complex (NAC), and, from an aesthetic standpoint, to create beautiful and youthful-looking breasts.

A retrospective study by Swanson indicated that vertical breast reduction using a medial pedicle can be safely combined with the insertion of breast implants in order to provide upper-pole fullness. In the study, complication and reoperation rates did not significantly differ between women undergoing just medial pedicle breast reduction (56 patients) and those undergoing the reduction procedure plus implant insertion (24 patients). [11]

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Preoperative Details

Accurate preoperative markings are critical to the outcome of the surgery.

First, mark the breast meridian. Following that, design an ellipse or pineapple shape, which is centered on the breast meridian (the breast meridian bisects it).

Next, mark the medial pedicle and its dimensions. The base of the medial pedicle is at the superomedial aspect of the elliptical/pineapple design for the breast reduction or mastopexy. A medial pedicle base length of 6 cm provides abundant blood supply for the viability of the NAC. For larger breast reductions using the medial pedicle, make the pedicle base length 8-10 cm. The precise length of the medial pedicle is not critical; it just needs to be long enough to comfortably carry the NAC superiorly.

At the superior aspect of the elliptical/pineapple design, draw a half circle or 3/4 of a circle; this is the location of the new NAC. The top of that circular design is typically marked at 21 cm from the superior margin of the sternal notch.

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Intraoperative Details

The operation begins after the patient has been prepared and draped. Two 2-0 silk sutures are used. One is sutured to the umbilicus, and the other is sutured at the midline of the superior portion of the sternum. These sutures serve to create a reliable central axis of the anterior torso. The author confirms the accuracy of the preoperative breast markings by using the 2 silk sutures and the technique of triangulation. The markings are modified, if necessary, before the breast cuts are made.

Infiltrate the markings on the breasts with local anesthetic. A mixture of 1% lidocaine with epinephrine (1:100000) is adequate to provide vasoconstriction during the operation and expedite it. For more information, see Infiltrative Administration of Local Anesthetic Agents.

Use a “cookie cutter” to mark the new NAC. To properly select the new diameter of the NAC, consider the patient’s wishes and also the eventual cup size of the new breast mound.

After that step, proceed to de-epithelialize the medial pedicle, which will provide blood supply to the NAC. Then, make the first cuts through the breast parenchyma, separating the medial pedicle. Bevel the scalpel out (away from the pedicle) when making these cuts so as not to undercut the pedicle; the goal is to maintain all possible blood supply to the NAC. Appropriate pedicle volume is also essential to contribute to adequate upper breast pole projection.

Then, proceed to cut the breast tissue inferior to the medial pedicle. An almost triangular segment of breast tissue is removed inferiorly. Finally, complete the breast cuts by cutting the superior marked circumference (the area in which the new NAC will be placed) and the tissue lateral to the medial pedicle.

If the breast cuts are satisfactory, attain complete homeostasis at this point.

Evaluate the medial pedicle for its thickness and ability to rotate in a superomedial direction without any inferior tension. At this point, the pedicle thickness can be reduced, if appropriate. When the pedicle is positioned superiorly, examine its thickness to make sure that it sits comfortably in its new position without undue pressure or constriction. These measures ensure good viability of the pedicle and, hence, the NAC.

The next critical step of this operation is to bring together the medial and lateral pillars of the inferior pole of the breast. This is done with 3-0 nylon suture. Three sutures are adequate. This step is critical because it gives support, round shape, and prominent projection to the new breast mound.

At this point, position the patient upright. With the patient in the upright position, mark the excess skin on the inferomedial and inferolateral aspects of the new breast. Lower the patient again to excise the excess skin. In some select cases, the excess skin in the lower aspect of the breast may be gathered (bunched up), extending the incision slightly onto the upper abdominal skin. This avoids an inframammary fold (IMF) scar. The series of patient images below illustrate this gathered (purse-string) approach to medial pedicle mastopexy.

Medial pedicle mastopexy without inframammary scar Medial pedicle mastopexy without inframammary scars. With the purse-string technique pictured below, the skin is gathered below the new inframammary fold (IMF). This gathered-up skin eventually will settle down and become part of the new IMF. This is illustrated in the series of images below, starting with this image of the preoperative front view.
Preoperative side view. Preoperative side view.
Preoperative side view. Preoperative side view.
Intraoperative view. The most inferior curvilinear Intraoperative view. The most inferior curvilinear line indicates the position of the original inframammary fold. The curvilinear line located more superiorly indicates the new position of the inframammary fold.
A Prolene suture is used to gather up the tissue e A Prolene suture is used to gather up the tissue excess between the new inframammary fold and the old one.
Tightening of the purse-string suture. Tightening of the purse-string suture.
Full tightening of the purse-string suture. Knot i Full tightening of the purse-string suture. Knot is under the skin.
Postoperative side view. Postoperative side view.
Postoperative side view. Postoperative side view.
Postoperative front view. Postoperative front view.

Bring the patient to the upright position again and check the shape and symmetry of the breasts. If satisfied, lay the patient down and proceed to close the wounds.

Drains are usually not needed. If necessary, the decision to use a drain is made in the operating room.

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Postoperative Details

The patient is seen the day after surgery to evaluate the viability of the breast flaps, the viability of the NAC, and the presence of any hematomas. In the case of intraoperative drain placement, the drains are also removed at this time.

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Follow-up

For the first 3 weeks, see the patient every week. After that, follow-up visits can be sparser.

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Complications

As with any type of reduction or mastopexy procedure, the most worrisome complication of this operation is partial or complete nipple-areolar necrosis. To prevent this complication, the viability of the nipple-areola complex (NAC) is evaluated closely following its inset at its new position and also at the end of the surgery. The viability is best evaluated by the presence of good quality bleeding (ie, slow bright red ooze).

Temporary loss of sensation to the NAC is a more common complication. Patients commonly experience dysesthesias after the surgery, but sensation returns to normal after a few days or months. Permanent loss of NAC sensation is extremely rare.

Partial or complete flap necrosis is a potential but rare complication with this operation.

Hematomas may occur. Small hematomas that do not add extra tension on the incisions and do not threaten the pedicle can be treated with observation. Larger hematomas should be drained in the operating room.

Wound dehiscence or small wound breakdown may occur at different parts of the incisions. Unless such breakdowns compromise the aesthetic outcome, they are generally treated conservatively.

Contour irregularities may occur, particularly when the inferior part of the incision is gathered to avoid an inframammary fold (IMF) scar. Such irregularities may eventually require revision if they do not flatten out or assume a smooth appearance.

Bilateral breast asymmetry can be listed as a complication if it is significant. Asymmetry may be related to the volume, shape, or position of the NAC, or a combination of these factors. Maximal accuracy can be achieved by spending a considerable amount of time making the preoperative markings and confirming them during surgery with the patient in both the supine and upright positions.

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Outcome and Prognosis

Women who undergo breast reduction for symptomatic macromastia experience an immediate relief of the weight-related symptoms. This operation has a high rate of satisfaction. The main advantages of the medial pedicle technique are the long-lasting breast shape and projection and, frequently, the ability to perform the operation without creating a scar in the inframammary fold (IMF).

A study of more than 100 vertical mammaplasties using a medial pedicle technique found that physical symptoms significantly decreased postoperatively in patients who underwent mastopexy (resection weight < 300 g per breast) or breast reduction. Together, the three procedures investigated, which also included augmentation/mastopexy, had a 94.3% patient satisfaction rate, while rates of improvement in self-esteem and quality of life were reported as 89.3% and 69.5%, respectively. The procedures also had a reported 15.1% complication rate; persistent nipple numbness was reported by 10.6% of patients. [12]

The series of patient images below depict a patient who underwent medial pedicle mastopexy in conjunction with breast augmentation and nipple-areola complex reduction. The operation resulted in no IMF scars.

This patient had obvious and significant breast pt 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.
Preoperative side view. Preoperative side view.
Postoperative side view. Postoperative side view.
Postoperative side view. Postoperative side view.
Postoperative front view. Postoperative front view.

The series of patient images below depict a patient who underwent mastopexy on each breast. Periareolar and vertical incisions were used; no incision was made under the breast. The postoperative photos were taken 3 months after the operation; these incisions fade even more over time.

This patient wanted to maintain her plentiful brea This patient wanted to maintain her plentiful breast volume but wanted her breasts to be "perky, beautiful, and youthful" like they used to be before she had children. This is a common surgery requested by women after they have had children and have breastfed. This image shows the preoperative front view.
Preoperative side view. Preoperative side view.
Preoperative side view. Preoperative side view.
Postoperative front view. Postoperative front view.
Postoperative side view. Postoperative side view.
Postoperative side view. Postoperative side view.
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Future and Controversies

The ability to perform this operation with limited scarring represents an obvious advantage. Because the inframammary fold (IMF) scar tends to heal most prominently, avoidance of a scar there is preferred. The cut-off points for pedicle length and safe reduction volumes have not been established. The author has used this operation in performing very large (1110-1200 g) breast reductions without any problems or the need to use a nipple-areolar free graft. Based on personal experience and supported by published literature, the author notes that this is a safe operation in properly selected patients who need very large volume breast reductions.

The author uses this operation in combination with a bilateral augmentation mammoplasty (BAM). Whether performing a mastopexy and a BAM at the same time is best is controversial. The 2 operations can oppose each other in many ways. For example, a BAM serves to lower the IMF, while a mastopexy or reduction technique raises the IMF. A mastopexy reduces breast volume, while a BAM increases volume. A BAM adds extra tension on the breast and additional pressure to all parenchymal and external suture lines, while the opposite is needed for optimal healing. Because the variables are in opposition, many surgeons feel that the 2 operations are best performed at different times. Performing the breast lift first and augmentation later may lead to superior outcome and more accurate results.

However, some advantages to performing these 2 operations synchronously are also apparent. Surgeons who perform these operations together usually perform a skin-only mastopexy in association with a BAM. The author finds that the predictability of the medial pedicle technique and the long-lasting correction of the breast projection may complement the features of a BAM and may allow for longer-lasting results.

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