Smoll et al. report an increased risk of nipple numbness after a Hall-Findlay breast reduction compared with an inferior pedicle Wise pattern technique.1 The authors summarize the results of patient surveys, stating that they audited their subjective and objective outcomes. They refer the reader to their original article.2 However, the referenced article includes no such subjective outcomes assessment and in fact cites a lack of subjective outcome measurements as a limitation of the study.
The authors offer no anatomical explanation for their finding, which conflicts with previously published data. My prospective outcome study of Hall-Findlay mammaplasties revealed a 21.5 percent incidence of persistent nipple numbness after breast reduction.3 Hall-Findlay reported a 15 percent risk.4 By contrast, Courtiss and Goldwyn reported a 35 percent rate of nipple numbness 2 years after an inverted-T, inferior pedicle breast reduction.5
Anatomical studies reveal that the lateral cutaneous branch of the fourth intercostal nerve and the medially based anterior cutaneous sensory branches provide the dominant nipple innervation in most women.6 The Hall-Findlay technique preserves a medial pedicle and its deep parenchymal attachment.4 The inferior pedicle Wise pattern technique preserves a posterior base on the chest wall but includes a parenchymal dissection lateral to the pedicle. The lateral cutaneous branch, which usually takes a deep course,6 is at risk in either operation, depending on the extent of the posterolateral dissection. A disadvantage of the inferior pedicle Wise pattern procedure is the division of the superficial medially based sensory branches to the nipple. An inferior pedicle contains no superficial sensory branches (ironically, it represents the one orientation that reliably excludes any superficial sensory nerve branches or axial blood supply to the nipple). Therefore, from an anatomical perspective, one might expect better preservation of nipple sensation (and blood supply) after a medial pedicle vertical mammaplasty.
So how might one explain the authors’ finding? The authors indicate that they used a “modified superior medial pedicle technique based on that described by Elizabeth Hall-Findlay.”2 The Hall-Findlay technique, however, incorporates a medial pedicle.4 A difference of just a few centimeters in pedicle orientation might determine whether all of the anterior cutaneous sensory branches, which reach the right areolar edge between the 1-o’clock and 4-o’clock positions,6 are included in the pedicle. Even more important, a superior pedicle is separated from its deep innervation, accounting for its poor performance on objective nipple sensory testing.7 In support of their contention that existing data comparing inferior and medial pedicle reductions are inconclusive,2 the authors inaccurately reference a study by Kreithen et al.; in fact, the referenced article compares the inferior pedicle Wise pattern and Lejour superior pedicle techniques.8
Smoll et al. rely on data obtained from 40 percent of their patients who responded to mailed surveys, well below the 80 percent benchmark for evidence-based medicine.9 The surveys were all mailed at the same time in March of 2010.1 Women treated with the inferior pedicle Wise pattern (1999 through 2005) were surveyed at a longer follow-up interval than patients treated using the Hall-Findlay technique (2005 through 2009). A low response rate for mailed surveys, sent to some patients over a decade after their surgery, is expected (the sample sizes for the individual treatment groups are not provided). Moreover, the rate of reported nipple numbness is known to decrease with time.3 Chronology bias is relevant to any study that compares a historic group of patients with a more recently treated group.10 The authors recognize that dissimilar follow-up times can introduce bias.2 By asking plastic surgeons to “keep an eye out” for nipple numbness after a Hall-Findlay mammaplasty (or rather a superomedial pedicle vertical mammaplasty), the authors invite recall bias. Such bias may be avoided by using a prospective study design.10
The authors suggest that an anticipated randomized controlled trial using surveys will offer the final word on the relative merits of the techniques.1 Certainly, patient-derived data are an essential part of procedure evaluation. However, there is no substitute for measurements of the aesthetic result.11,12 A modest boost in breast projection and upper pole projection, avoidance of a wide (“boxy”) lower pole and nipple overelevation, and elimination of a long horizontal scar are all advantages of the vertical technique.11 The only published prospective, randomized study reveals that patients prefer the overall aesthetic result and scarring of the vertical mammaplasty compared with the inverted-T mammaplasty.13 In view of the preponderance of evidence favoring the vertical technique,3,4,11–13 it is becoming increasingly difficult to ethically justify a randomized study. Properly informed patients are likely to choose the vertical technique.
The author has no financial interest to declare in relation to the content of this communication. There was no outside funding for this study.
Eric Swanson, M.D.
11413 Ash Street, Office 913
Leawood, Kan. 66211
1. Smoll NR, Marne B, Maung H, Findlay MW, Hunter-Smith DJ. Nipple sensation losses in Hall-Findlay breast reduction technique. Plast Reconstr Surg. 2013;131:461e–462e
2. Hunter-Smith DJ, Smoll NR, Marne B, Maung H, Findlay MW. Comparing breast-reduction techniques: Time-to-event analysis and recommendations. Aesthetic Plast Surg. 2012;36:600–606
3. Swanson E. Prospective outcome study of 106 cases of vertical mastopexy, augmentation/mastopexy, and breast reduction. J Plast Reconstr Aesthet Surg. 2013;66:937–949
4. Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg. 2002;29:379–391
5. Courtiss EH, Goldwyn RM. Breast sensation before and after plastic surgery. Plast Reconstr Surg. 1976;58:1–13
6. Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola complex: An anatomic study. Plast Reconstr Surg. 2000;105:905–909
7. Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensitivity by reduction mammaplasty: A prospective comparison of five techniques. Plast Reconstr Surg. 2005;115:743–751 discussion 752.
8. Kreithen J, Caffee H, Rosenberg J, et al. A comparison of the Lejour and Wise pattern methods of breast reduction (comparative study). Ann Plast Surg. 2005;54:236–241 discussion 241–242.
9. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Therapy. Evidence-based Medicine: How to Practice and Teach EBM. 20002nd ed New York Churchill Livingstone:105–154
10. Pannucci CJ, Wilkins EG. Identifying and avoiding bias in research. Plast Reconstr Surg. 2010;126:619–625
11. Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg. 2013;131:802e–819e
12. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301
13. Cruz-Korchin N, Korchin L. Vertical versus Wise pattern breast reduction: Patient satisfaction, revision rates, and complications. Plast Reconstr Surg. 2003;112:1573–1578 discussion 1579.
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