Improving the Results of Inferior Pedicle Breast Reduction Using Pedicle Suspension and Plication

The inferior pedicle technique of breast reduction is a widely-used safe technique. It has been criticised as prone to producing inferior quadrant fullness, called variously “pseudoptosis” or “bottoming out.” Described are the results of a technique of inferior pedicle suspension and plication which overcome these problems.     

Breast Reduction with Inferior Pedicle Fascial Suspension

The ultimate aim of breast reduction surgery is to reduce breast tissue with long-term maintenance of good breast shape. A technique using interwoven fascial flap suspension of the inferior pedicle through the pectoralis muscle and fascia is described. For this study, 25 patients were followed for 1 year after surgery. The vertical length of the breast between the lower midline of the areola and the new inframammary fold was measured 10 days after surgery and compared with a follow-up measurement 1 year later. These measurements were expressed as a ratio and compared with visual impressions. A ratio of more than 1.3 or a 2-cm difference in length or more was considered representative of breast “bottoming out.” This was the case with two patients, both of whom had put on substantial weight after the procedure. The author contends that a consistently reliable technique that maintains good breast shape with more extensive scarring is preferable to a technique that occasionally “gets it right” with less scarring. Good scar management and variations in technique such as the fascial flap suspension described in this report have been of considerable benefit to the author’s patients undergoing breast reduction surgery.     

A Modified Excision for Combined Reduction Mammoplasty and Breast Conservation Therapy in the Treatment of Breast Cancer

Wide local excision combined with postoperative radiotherapy is a useful technique for patients with breast cancer. For patients with macromastia whose tumor is situated in the lower pole of the breast, a breast reduction (keyhole\inverted T pattern ) can be used to achieve wide local excision. However, for patients whose tumor is not in the inferior portion of the breast, and in whom this cancer also is situated close to the skin (requiring excision of skin with a 1-cm margin for oncologic safety), the traditional keyhole pattern cannot be used. A modification of the keyhole pattern\inverted T is described. The pedicle used depends on the site of the tumor. Although the breast scars are in different positions, a similar breast shape as well as symmetry still can be achieved. This is a useful technique for a select subgroup of patients. The outcomes for three patients are presented.     

Breast Sculpturing: Overcoming the Limits of Traditional Approaches in Breast Reduction

Background  A technique based on original refinements of the vertical breast reduction was developed in our department. The aim of the technique was the safe and aggressive sculpture of an attractive breast mound with minimal scarring and long-lasting results that is easy to perform and suitable for teaching purposes in a surgical training unit. Methods  Fifty consecutive patients who were to undergo bilateral breast reduction were prospectively enrolled in the study. Accurate standard anthropometric measurements and photographs were taken preoperatively and postoperatively at 2, 6, 12, 24, and 36 months. A selective breast liposuction plus a superior pedicle breast reduction with a vertical scar skin pattern was performed in all cases. Results  Nipple lifting ranged from 5 to 14 cm; reduction of the distance between the inframammary fold and the nipple ranged from 0.5 to 7 cm; breast base width reduction ranged from 0 to 7 cm. Conclusion  This technique further contributes to vertical mammaplasty refinements, enhancing the key role of selective liposuction prior to surgical dissection of the breast. The basic principle is to convert a large breast into a middle-sized one, making vertical scar breast reduction the most appropriate technique for all cases. A thorough and selective liposuction of the breast mound reduces the breast cone base width safely and with virtually no limitations, thus breaking a taboo of traditional breast reduction techniques.     

A New Personal Surgical Procedure for Breast Reduction and Lifting

A series of 40 patients operated from 1995 through 1997 is reviewed. The women ranged in age from 18 to 40 and were seen in either a university- or a private-hospital setting. Thirty-eight of the patients underwent reduction mammaplasty, which was performed using an inferior pedicle technique with a straight-line incision; two patients underwent mastopexy only. The reduction procedure depends on the formation of a cap from medial, lateral, and superior flaps. Following resection of breast tissue the cap is joined to a cone—the nipple–areola complex carried on a subcutaneous inferior pedicle. The cone is fixed to the chest wall with simple vertical stitches, minimizing the recurrence of ptosis. This technique is safe and versatile, avoids a submammary scar, and offers an aesthetic and long-lasting result.     

Avoiding free nipple grafts during reduction mammaplasty in patients with gigantomastia

Excessive breast hypertrophy or gigantomastia (>2000 g excision of tissue per breast) has traditionally been approached with breast amputation and free nipple grafting during reduction mammaplasty procedures. Disadvantages of free nipple grafts include loss of sensation, poor projection, uneven nipple-areolar complex pigmentation, and loss of lactation. We report our experiences utilizing the inferior pedicle technique of reduction mammaplasty with successful preservation of the nipple-areola complex for patients with gigantomastia. Between 2001 and 2003, 15 patients (ages 19--45) were identified with gigantomastia through review of pathology and operative reports. The inferior pedicle technique was performed in all cases by the attending staff assisted by plastic surgery residents. Patients were followed regularly from 1 week up to 1 year postoperatively. All patients reported relief from the physical sequelae of breast hypertrophy. One patient experienced bilateral partial nipple desquamation; she maintained sensation throughout and healed well with moist dressings. Otherwise, there were no complications and all patients achieved satisfactory esthetic outcomes. Our results suggest that inferior pedicle technique can be successfully performed in patients with gigantomastia. Breast amputation with free nipple grafting need not be considered standard practice for this patient population. Maintaining a wider pedicle base and meticulous intraoperative handling of the pedicle may contribute to the increased viability of the nipple-areolar complex during these cases.     

Breastfeeding After Reduction Mammaplasty Using Different Techniques

Background This study reviewed mammary glandular function and breastfeeding after reduction mammaplasty performed via four different surgical techniques. Patients who underwent this procedure were asked to answer questions concerning the birth of a child, natural breastfeeding, and the reasons why natural breastfeeding was not performed or was interrupted. Methods Between 1992 and 2001, 368 reduction mammaplasties were performed in the Department of Plastic Surgery at the “La Sapienza” University of Rome. After reduction mammaplasty, 105 patients had a child and were enrolled in the study. Breastfeeding data were compared with data from hospital records at the time of surgery in terms of patient age, reduction mammaplasty technique, sensitivity of the nipple–areola complex after the operation, and proportion of the gland removed. Results Maternal breastfeeding was considered to have occurred if it lasted more than 3 weeks and was not accompanied by any nutritional supplements. Babies were breastfed by 60.7% of the patients who underwent a superior pedicle reduction mammaplasty, by 43.5% of those who underwent an inferior pedicle reduction mammaplasty, by 48% of those who underwent a medial pedicle reduction mammaplasty, and by 55.1% of those who underwent a lateral pedicle reduction mammaplasty. Conclusions The findings demonstrate that conservative reduction mammaplasty techniques supported by medical and paramedical staff permit subsequent breastfeeding. In particular, the best outcomes resulted from superior pedicle reduction mammaplasty. Skilled execution of the surgical technique is mandatory to guarantee adequate vascularization and sensitivity of the nipple–areola complex and to spare as many of the glandular ducts and lobules as possible.     

No-vertical-scar inferior pedicle breast reduction using the dermal suspension sling

Background

The authors previously presented favorable outcomes with the use of the horizontal dermal suspension sling and plication of the inferior pedicle in reduction mammaplasty surgical cases. We propose a modification to this technique tailored to patients with moderate to severe ptosis. The modification avoids the vertical scar inherent to the inverted T pattern.

Methods

The surgical technique utilizes portions of the dermal suspension and plication technique previously described by the authors. Minor modifications were made to take advantage of the vertical excess of skin found in patients with moderate to severe macromastia and ptotic breasts. The modification leads to a superior skin flap that drapes the inferior pedicle and newly constructed breast mound, resulting in a single inframammary scar.

Results

Thirty-eight women have undergone breast reduction using the vertical scarless inferior pedicle with horizontal dermal suspension and plication surgical technique. Breast projection and shape were sustained during follow-up with positive aesthetic results; the median follow–up time was 7 months.

Conclusions

The modifications to our surgical technique allowed for an improved appearance in the postoperative breast scar and in the overall cosmetic outcome in patients who underwent large-volume breast reductions. Level of Evidence: IV, therapeutic study     

Reduction Mammaplasty Using the Free-Nipple-Graft Vertical Technique for Severe Breast Hypertrophy: Improved Outcomes with the Superior Dermaglandular Flap

Background  

Management of severe mammary hypertrophy is a challenge. The limitations of most dermal pedicle techniques include insufficient breast projection with severe hypertrophy. The authors have designed a free-nipple-graft vertical technique with a superior demaglandular flap to provide acceptable breast projection and an attractive, smooth breast contour for patients with severe hypertrophy and gigantomastia who are not suitable for pedicle breast reduction techniques.     

Use of the VersaJet for pedicle deepithelialization during breast reduction surgery

Background  Many modern techniques of breast reduction require that a pedicle of breast tissue be deepithelialized. The process of deepithelialization is both tedious and time consuming. Many techniques have been described to facilitate the process of deepithelialization in breast reduction, but none have replaced the gold standard of using the scalpel. This series details the authors’ results using the VersaJet Hydrosurgery System for pedicle deepithelialization in breast reduction surgery. Methods  In this study, 20 patients underwent inferior pedicle breast reduction using the VersaJet for pedicle deepithelialization between September 2006 and June 2007. The overall time required for pedicle deepithelialization using the VersaJet was compared with the average overall time required for deepithelialization using the scalpel. Intraoperative and postoperative complications were recorded. Results  An overall time-savings of 10 to 25 min per case was noted using the VersaJet for pedicle deepithelialization rather than the scalpel. No intraoperative or postoperative complications were encountered due to use of the VersaJet for pedicle deepithelialization. Conclusions  The VersaJet is a safe and effective tool for pedicle deepithelialization in breast reduction surgery. The VersaJet significantly facilitates the process of pedicle deepithelialization and requires less time than use of the scalpel for the procedure.     

Breast Sensitivity Before and After the L Short-Scar Mammaplasty

Background  

Breast sensitivity preservation is among the aims of modern breast surgery. Large-volume resection, extensive undermining, and resections at the breast base have been associated with breast sensitivity alterations. The L short-scar mammaplasty technique is designed to preserve breast sensitivity by resection of tissue in the middle and inferior portions of the breast, but specifically dissection and preservation of the breast lateral neurovascular pedicle. Using this technique, a prospective study was designed for measurement of breast sensitivity quantitatively and subjectively to determine whether different resection volumes of the breast correlate with alteration of sensitivity postoperatively.     

Breast sensation after superior pedicle versus inferior pedicle mammaplasty: anatomical and histological evaluation.

Despite contradictory information about the course and distribution of the nerves supplying the breast, surgical techniques using an inferior pedicle have been recommended over those using a superior pedicle for preserving the nipple-areolar sensation after surgery. This anatomical study was designed to quantify the nerve branches preserved in inferior and superior pedicles after reduction mammaplasty performed on cadavers. Reduction mammaplasty was done on four fresh cadavers (within 48h of death) using a superior pedicle on the right and an inferior pedicle on the left in a standard way. The pedicle was cut at its base and then fixed in formalin. The base was divided in biopsy specimens and embedded in paraffin. The nerves were quantified and located in each pedicle with haematoxylin-eosin stain and light-microscopic evaluation. Histological evaluation of the pedicles showed the presence of a variable number of nerves (between one and seven) within two superior pedicles and three inferior pedicles. The nerves were located in fibrous tissue and accompanied by vessels in most cases. The nerves were always found superficially and were most likely to be located in the central part of the pedicle. Our results showed that including the nerves within the pedicle is technically uncertain regardless of the mammaplasty technique used. The final recovery of sensation in the breast after mammaplasty seems to result from the regeneration of severed cutaneous nerve branches or the remaining cutaneous innervation rather than the preserved adjacent cutaneous branches.     

Long-Lasting Evolution of Ptosis Control After Reduction Mammaplasty Using the Hammock Technique

Background The hammock technique combines inferior pedicle mammaplasty with retropectoral and inferior suspensions to prevent displacement of breast tissue toward the inferior mammarian pole. This study aimed to assess the long-lasting internal suspension with the author’s mammary reduction technique. Methods From 1987 to 2005, the hammock technique was performed for 623 breast reduction patients (1,201 breasts), including 318 women (636 breasts) who underwent the technique between 1994 and 2005. From the latter group, the author retrospectively reviewed the case histories of 281 patients who had come for long-term follow-up evaluation. All had significant ptosis associated with breast hypertrophy. Preoperative and postoperative examinations included evaluation of postoperative bottoming out by monitoring of three measurements: the sternal notch-to-nipple length, the inferior areolar border-to-inframammary fold length, and the distance between the inframmary fold and the projection of the lowest breast contour on the chest wall. Results The evaluation data on postoperative ptosis are derived from a control study at 30 months, 5 years, and 7 years or more for 281 women (562 breasts) of the 318 who underwent surgery using this technique over the 11-year period. Review after 2.5 to 7 years or more shows that inferior areolar border-inframammary fold distance increases no more than 10 mm. Conclusions The hammock technique suspension achieves true permanent breast lifting through dermis strips from the inferior pedicle itself. This procedure also gives predictable results, a low morbidity rate, and good breast shape.     

Central Pedicled Breast Reduction Technique in Male Patients After Massive Weight Loss

Male patients after massive weight loss often suffer from redundant skin and soft tissue in the anterior and lateral chest region, causing various deformities of pseudogynecomastia. Techniques with free or pedicled nipple–areola complex (NAC) transposition are widely accepted. The authors present their approach to male breast reduction with preservation of the NAC on a central dermoglandular pedicle and a wide elliptical tissue excision of breast and lateral thorax tissue in combination with liposuction. Male breast reduction was performed on patients after moderate to massive weight loss due to diet or bariatric procedures. Former procedures included free nipple–areola grafts or inferior pedicled techniques for NAC preservation. As a modification, we performed a central pedicled breast reduction on nine male patients with excessive liposuction of the pedicle and a horizontal elliptical skin removal, allowing for sufficient tissue removal at the lateral thorax. From October 2010 until June 2011, nine male patients had central pedicled breast reconstructions after massive weight loss. Mean age was 29.1 years, mean preoperative body mass index was 29.2, and mean preoperative weight loss was 63.9 kg. The chest wall improvement was rated “very good” by eight patients. No major complications occurred in all nine patients. Male chest deformities after massive weight loss can be dealt by several approaches. The optimal scar positioning and the preservation of NAC may be the most challenging aspects of these procedures. Therefore, the preservation of the NAC on a central dermoglandular pedicle with a horizontal submammary scar course may optimize the esthetic outcome.     

A prospective quantitative comparison of breast sensation after superior and inferior pedicle mammaplasty.

Reduction mammaplasty techniques using the inferior pedicle have been recommended to preserve the nipple and areolar sensation after surgery. The vertical scar mammaplasty with a superior pedicle has often been criticised because of the potential for damage to the sensory supply of the nipple-areola complex. The aim of this study was to assess the breast sensation in two prospective series of patients operated upon using superior pedicle and inferior pedicle mammaplasties. Between November 1996 and February 1997, 20 consecutive patients (39 breasts) underwent breast reduction using the inferior pedicle technique with inverted T scar (Robbin's technique). This series of patients was matched with another series of 18 patients (36 breasts) who had breast reduction using a vertical scar mammaplasty with superior pedicle (Lejour's technique) in another centre. Cutaneous pressure thresholds were recorded using Semmes-Weinstein monofilaments. The values were obtained on the quadrants of the skin of the breast, the areola and the nipple. The sensitivity test was performed preoperatively, then at 3 and 6 months postoperatively. Patients' characteristics (age, weight, breast ptosis, breast mass resected and risk factors) were statistically similar between the two groups. The preoperative values of pressure sensation on the different areas tested were statistically similar between the two groups. The sensitivity decreased on almost all the tested areas of the breast at 3 months postoperatively. No patient had an insensitive area on the breast at 6 months after surgery. Some areas of the breast showed a significant difference in pressure sensitivity after one technique compared to the other: better sensation on the skin of the superior and lateral quadrants after the superior pedicle technique at 3 months (P< 0.001), poorer areolar sensation on the inferior quadrant after the superior pedicle technique at 3 and 6 months (P< 0.05) and on the superior quadrant after the inferior pedicle technique at 3 months only (P< 0.05). However, the mean value of the areolar quadrants was statistically similar after both techniques. The nipple sensation was significantly decreased in both groups at 3 months but remained comparable between the two groups. Breast innervation was damaged by breast reduction using both the inferior and the superior pedicle techniques. The breast skin had better sensation after the superior pedicle technique while the areola had slightly better sensation after the inferior pedicle technique. At 6 months, the mean value of nipple-areola complex pressure sensation was comparable in the two series of patients.     

The effect of superior pedicle breast reductions on breast sensation

The aim of this study was to assess nipple, areola and breast skin sensation after breast reductions with two different superior pedicle techniques: a short, vertical scar technique compared to a long, inverted-T scar technique. Thirty-six women with a vertical technique (group I) and ten women with an inverted-T technique (group II) with a resection weight of ≤500 g per breast completed their 1-year follow-up. The four modalities used to evaluate sensation were pressure with Semmes–Weinstein filaments, vibration with a vibrometer, and temperature and pain perception on a qualitative basis. The evaluation revealed that 1-year after breast reduction, the sensation was either reduced, unaltered, or improved in both groups. In the nipple, the mean sensation was markedly reduced throughout all qualities in both groups with the exception of pain, which was enhanced. In the areola, the mean sensation was also reduced in all qualities in both groups. In the quadrants of the skin, mean sensation was improved in terms of pressure and vibration in group I (8.3% normal pressure values preoperatively vs. 70% normal pressure values postoperatively) but reduced in the lower quadrant of the skin in group II with the inverted-T scar. This reduction of pressure was also significant (p = 0.04) in comparison with group I. Apart from this difference between the two groups, this study showed that in breast reductions with a superior pedicle technique, the long-scar technique did not lead to a greater reduction of sensation in the nipple and areola than the short-scar technique.     

Aesthetic Remodeling of the Healthy Breast in Breast Reconstruction Using Expanders and Implants

Background  Breast reconstruction using expanders and implants still is the most common surgical procedure in many hospitals. The most important factor in obtaining a satisfactory aesthetic result for both the patient and the surgeon is to achieve the greatest symmetry possible between the healthy breast and the reconstructed breast. To get a good result, it is necessary to make an exhaustive preoperative examination that facilitates selection of the most suitable technique for remodeling the healthy breast and to choose the most suitable expander for placement on the side to be reconstructed. Methods  A retrospective study investigated 60 patients submitted to breast reconstruction between October 2005 and January 2008. The study analyzed the characteristics of the healthy breast (e.g., volume, ptosis), which is treated in the first part of the first operation. These characteristics are used later as a model for reconstructing the mastectomy side. The most adequate technique for remodeling the healthy breast based on its characteristics is indicated, as well as techniques not recommended for obtaining the desired symmetry. Results  This study aimed to determine the basis for selecting the most appropriate technique to use in managing the healthy breast and obtaining the most aesthetic result in breast reconstruction. The healthy breast analysis allows an algorithm of indications to be elaborated based on the volume and degree of ptosis exhibited by the healthy breast. The healthy breast should resemble the reconstructed breast with its anatomic implant. In this study, the technique used most often to remodel the healthy breast was reduction surgery with a superomedial pedicle, and glandular flap (autoimplant) (30%). The results were highly satisfactory for both the patient and the surgeon. Conclusions  Aesthetic remodeling of the healthy breast is the first surgical treatment in breast reconstruction in two stages using expanders and implants. The expander for reconstruction of the other breast then is selected according to the measurements of the healthy modified breast. This reproducible and simple model of breast reconstruction, with its detailed preoperative plan, allows clinicians to obtain a good aesthetic result for breast reconstruction patients.     

Practice profiles in breast reduction: A survey among Canadian plastic surgeons

BACKGROUND:

Breast reduction is an increasingly common procedure performed by Canadian plastic surgeons. Recent studies in the United States show that use of the inferior/central pedicle inverted T scar method is predominant. However, it is unknown what the practice preferences are among Canadian plastic surgeons.

OBJECTIVE:

The goal of the present study was to assess trends in breast reduction surgery among Canadian surgeons, including patient selection criteria, surgical techniques and outcomes.

METHOD:

Surveys were distributed to plastic surgeons at the Canadian Society for Plastic Surgery meetings in 2005 and 2006. Completed surveys were obtained from 140 respondents, and results were analyzed with Excel and SAS software.

RESULTS:

There was a 40% response rate. The majority of surgeons (66%) used more than one technique for breast reduction. Most commonly, surgeons use the inverted T scar technique (66%) followed by vertical scar techniques (26%). The most popular vertical scar techniques included the Hall-Findlay (14%) and Lejour (13%) methods. Most surgeons (55%) reported complication rates of less than 5% and the most common complication reported was wound dehiscence. There was no difference in overall complication rates between inverted T scar and vertical scar surgeries. The majority of surgeons (98%) carried out breast reduction either exclusively as day surgery or in combination with same-day admission. Breast reduction performed as day surgery resulted in cost savings of $873 per patient.

CONCLUSIONS:

Canadian plastic surgeons are performing more vertical scar breast reductions than American surgeons. However, both groups rely predominantly on inverted T scar techniques.     

Central pedicle reduction mammaplasty with a vertical scar: a technical modification

Background: This study introduces a central pedicle reduction mammaplasty with a vertical scar technique.

Objectives: This study is aimed to create a more conical breast shape and long-lasting better projection by modifying reduction mammaplasty by central pedicle flap.

Method: Preoperative markings were made including the meridian line of breast and the new location of the nipple-areola complex (NAC). The new location of the inframammary fold was marked ～2?～?4?cm above the original inframammary fold. An incision was made around the areola, the area between the resection margins and NAC was excised en bloc. The breast parenchyma was excised circumferentially, so that a cone shaped central mound was formed. An inferior and inferolateral glandular resection was performed to reduce the area of the breast base by elevating the position of the inframammary fold. After completion of dissection, the central pedicle surmounted by the NAC was transposed to its new location.

Result: Fifty-six patients were operated with our modified central pedicle technique. The mean amount of resection was 475?g (range?=?130–1080?g). The mean length of follow-up was 18?months (range?=?12–53?months). The mean postoperative satisfaction score was 4.23 (SD?=?0.81). The breast parenchymal ratio significantly increased from 1.2 preoperatively to 3.9 postoperatively.

Conclusion: The modified central pedicle reduction mammaplasty with a vertical scar technique is a versatile breast reduction technique for all shapes and tissue conditions, by providing an attractive conical shape of the breast with minimum scar burden and maximum preservation of breast function.