Antony, Anuja K. M.D., M.P.H.; Yegiyants, S. Sara M.D., M.S.; Danielson, Kirstie K. Ph.D.; Wisel, Steven M.D.; Morris, David M.D.; Dolezal, Rudolph F. M.D.; Cohen, Mimis N. M.D.
Since the early twentieth century, attempts to optimize aesthetic and surgical outcomes in reduction mammaplasty have prompted constant development and revision of surgical techniques.1 The primary goals of reduction mammaplasty—substantial decrease in breast volume and preservation of the nipple-areola complex—have been consistently achieved through various combinations of pedicles and skin excision patterns.2,3 However, it is the ability to accomplish these primary aims while increasing attention to the aesthetic result, maintaining nipple-areola complex sensation, and minimizing scarring that has driven the evolution of reduction mammaplasty techniques—and the controversy over the ideal technique.2
The inferior pedicle technique with inverted-T skin excision, as described by Robbins in 1977, is the most commonly used procedure, gaining widespread acceptance for its consistency in nipple-areola complex viability, ease in teaching, and successful outcomes across reductions of all sizes. However, its critics recognize some aesthetic drawbacks to the technique, including a hypertrophic scar along the inframammary fold, squaring of the breast contours, and a tendency to produce pseudoptosis over time.3–6
To reduce these aesthetic complications, adaptations of the Hall-Findlay vertical reduction with medial or superomedial pedicles have recently gained acceptance. Although recent articles cite use of the superomedial pedicle with high satisfaction,7–9 this pedicle is often combined with a Wise pattern method of skin excision, contributing to higher scar burden. The superomedial pedicle with vertical scar reduction allows for a shorter scar with decreased scar hypertrophy and the benefits of retained upper pole fullness and more extensive lateral parenchymal reduction, producing a desirable surgical result with greater projection.1,5,6 Although the superomedial pedicle with vertical scar reduction technique has proven effective for small- and medium-volume reductions, some surgeons have expressed hesitancy in applying superomedial pedicle with vertical scar reduction techniques for large-volume reduction mammaplasties, citing increased complications rates with higher resection volumes.7,10,11 Furthermore, despite several studies indicating the reliability of superomedial pedicle reductions in gigantomastia,2,3,6–8 concern over compromise of the blood supply to the nipple-areola complex during pedicle rotation has prompted some surgeons to limit application of the vertical reduction with superomedial pedicle to breast reductions less than 1000 g.2,10
Although many studies have published successful results of superomedial pedicle and vertical scar reduction techniques in reduction mammaplasty of various sizes (typically <1000 g),1–3,6,7,10,12 a PubMed literature survey reveals that no studies have directly compared complication rates between matched cohorts for superomedial pedicle vertical scar reduction mammaplasty versus the traditional, criterion standard Wise-pattern with inferior pedicle technique. This study seeks to compare outcomes between cohorts matched by patient demographics and breast weight reduction for superomedial pedicle with vertical scar reduction mammaplasty versus inferior pedicle inverted-T reductions. Primary measures include rates of complication, postsurgical preservation of nipple-areola complex viability and sensation, and patient symptomatic relief. As a secondary outcome, this study will explore whether superomedial pedicle with vertical scar reduction techniques are suitable for larger reduction mammaplasty, and whether any patient selection criteria produce more favorable outcomes.
PATIENTS AND METHODS
This study is a retrospective review of all bilateral breast reductions performed by four surgeons at a single institution over a 3-year period between January of 2009 and June of 2012. Unilateral and oncoplastic bilateral breast reductions were excluded from the study. One hundred superomedial pedicle breast reduction breasts (50 patients) were matched to 100 inferior pedicle breast reduction breasts (50 patients). Matching was implemented based on age (±3 years) and size of reduction (±200 g). Patient demographics, including age, body mass index, ethnicity, smoking status, size of reduction, nipple-areola complex sensation, minor and major postoperative complications, and symptomatic relief were assessed.
The weight of reduction specimen from each breast was calculated intraoperatively. Mean weight of reduction per individual was used for matching purposes (pathologic weights were used for confirmation). Patients returning for follow-up were evaluated for complications for the duration of the study period of 3 years (3- to 6-month minimum follow-up for study inclusion), including minor complications (i.e., loss of nipple sensation, seroma, and wound breakdown) and major complications (i.e., return to the operating room, nipple necrosis, hematoma, and infection). Patients were generally seen at 6 weeks, 3 and 6 months, and annually for 5 years. Timing of assessment of patient symptomatic relief coincided with follow-up at 3 to 6 months and 1 year in the outpatient setting. An ad hoc assessment of aesthetic outcomes was made at these intervals; use of a standardized instrument to gauge aesthetic outcome is currently being considered for future work.
Statistical analyses were performed using SAS Version 9.2 (SAS Institute, Inc., Cary, N.C.). Patients in the superomedial pedicle and inferior pedicle groups were compared using t tests for continuous data and chi-square tests for categorical data, with Fisher’s exact test as appropriate. Whether the prevalence of complications differed between breasts in the superomedial pedicle and inferior pedicle groups was determined using generalized linear mixed models for a binary outcome accounting for the within-individual correlation between breasts. All generalized linear models are unadjusted because our statistical approach incorporated matching, controlling for age and size of reduction. Summary demographics between the two groups demonstrated that no significant difference between groups in terms of age (matched), body mass index, race, smoking, and reduction size (matched) was seen. True confounders to be included in the modeling would have had to differ between the superomedial pedicle and inferior pedicle groups. To assess whether the prevalence of complications differed between larger and smaller volume breast reductions in the superomedial pedicle and inferior pedicle cohorts, a median split was performed. Chi-square analysis using the median split was carried out to determine significance.
Superomedial Pedicle with Vertical Scar Reduction
Preoperative markings for a superomedial dermoglandular pedicle with vertical skin reduction technique are applied in the surgical holding area (Fig. 1, above, left). Skin quality (elasticity and stretch marks) and volume of reduction are assessed to determine new nipple position, typically at the inframammary fold or 1 to 2 cm below. The skin resection is drawn in the dome-mosque configuration, with the vertical limbs marked with displacement of the breast medially and laterally along the breast meridian. The lower extent of the vertical limbs is typically 3 to 6 cm above the inframammary fold, depending on the size of reduction (Fig. 1, above, right).
In the operating room, the nipple-areola complex diameters are measured at 38 to 42 mm, and a superomedial pedicle of 6 to 10 cm is deepithelialized while leaving an intact nipple-areola complex (Fig. 1, center, left). Dermoglandular resections proceed next, beginning with the inferior portion of the breast, with direct defatting of the inframammary fold in the mastectomy plane (Fig. 1, center, right). Dissection continues laterally to form the lateral pillar. The lateral pillar is approximated at 2- to 3-cm thickness as it approaches the chest wall, with care taken to preserve the pectoral fascia and neurovascular structures. C-shaped resection of the medial, inferior, lateral, and superior aspects of the breast allows for adequate reduction, coning of the breast, and rotational freedom of the superomedial pedicle (Fig. 1, below, left). Care is maintained to ensure that no undue tension or kinking is placed on the pedicle. Following additional breast contouring to achieve proper symmetry and extent of reduction, the nipple-areola complex is temporarily stapled into position. 2-0 Polydioxanone sutures are used to join lateral and medial pillars both in deep and superficial depths to adequately cone the breast. A drain is placed before skin closure. The nipple-areola complex is inset with 4-0 Vicryl (Ethicon, Inc., Somerville, N.J.) deep dermal and 4-0 running subcuticular Monocryl (Ethicon) sutures; 3-0 sutures are used along the vertical limb with mild cinching along the inferior limb and anchoring to the chest wall, keeping the vertical incision within the confines of the inferior pole of the breast (Fig. 1, below, right). [The authors recognize that a small T or L scar (<5 cm) can be used in lieu of cinching but is not routinely used in our practice or in this cohort.]
Inferior Pedicle with Inverted-T/Wise Pattern Reduction
Preoperative markings for an inferior pedicle with Wise-pattern skin excision are applied in the surgical holding area. With the patient standing, breast meridians are marked bilaterally along with new nipple location and proposed inframammary folds. In the operating room, nipple diameter markings are made at 38 to 42 mm, and an inferior pedicle is designed. The inferior pedicle and new nipple location are deepithelialized, care taken to leave the nipple-areola complex intact. The inferior pedicle is developed by incising to the depth of the chest wall. Resection proceeds according to preoperative markings, with additional “fanning-out” of the pedicle base inferiorly to maximize blood supply. Dermoglandular wedge resection of medial, superior, and lateral sections is performed to reduce breast volume, with careful attention to medial resection to maintain proper medial contours. Skin flaps are trimmed to 1.5-cm thickness, and a superior pocket is created for placement of the nipple-areola complex. Temporary staples are placed along the vertical limb of the incision, and the patient is evaluated for symmetry and adequacy of resection with temporary closure in the seated position. Additional reduction and contouring are accomplished as needed, and drains are placed bilaterally. Nipple-areola complexes are sutured to their new positions with 4-0 interrupted nonresorbable suture before closure of the inverted-T incision.
Four hundred twenty-four bilateral breast reductions were performed in 212 patients between January of 2009 and February of 2012 at a single institution, with three surgeons (R.F.D., D.M., and M.N.C.) exclusively using the inferior pedicle, inverted-T pattern and one surgeon (A.K.A.) preferentially using the superomedial pedicle with vertical scar technique. Inferior pedicle breast reduction was used in 76 percent of cases: 322 breasts were reduced in 161 patients using the inferior pedicle, inverted-T/Wise-pattern reduction, and 102 breasts in 51 patients were reduced using the superomedial pedicle, vertical scar reduction technique. After matching for age and weight of breast reduction, matched cohorts were identified with 50 patients (100 breasts) in the superomedial pedicle cohort and 50 patients (100 breasts) in the inferior pedicle cohort.
Mean age and body mass index was 31.4 ± 9.9 years and 30.8 ± 3.4 kg/m2, respectively, in the superomedial pedicle breast reconstruction cohort and 31.6 ± 9.9 years and 31.8 ± 3.6 kg/m2, respectively, in the inferior pedicle breast reduction cohort (p = 0.94 and p = 0.16, respectively). Ethnic distribution was equivalent between cohorts. Smoking was similar between cohorts, 10.2 percent and 12.5 percent, respectively (p = 0.73) (Table 1.) Mean volume of tissue reduced was 815 g per breast (range, 200 to 2068 g) and 840 g per breast (range, 250 to 2014 g), respectively. Mean volume of tissue reduced by side for superomedial pedicle and inferior pedicle was (right) 809.9 and 835.4 g and (left) 820.4 and 844.2 g (p = 0.74 and p = 0.76, respectively). All patients achieved symptomatic relief. No statistical difference in major or minor complications was seen between two cohorts. In the superomedial pedicle cohort, major complications occurred in 4 percent (i.e., return to operating room, 2 percent; wound infection, 2 percent) and minor complications occurred in 25 percent (i.e., decreased nipple sensation, 11 percent; seroma, 6 percent; minor skin breakdown, 8 percent). In the inferior pedicle cohort, major complications occurred in 3 percent (i.e., nipple-areola complex necrosis, 1 percent; hematoma, 1 percent; would infection, 1 percent) and minor complications occurred in 24 percent (i.e., decreased nipple sensation, 13.5 percent; seroma, 1 percent; minor skin breakdown, 10 percent). For the outcome of one or more complications, no significant difference was observed between the two cohorts (Table 2).
One case of nipple-areola complex loss occurred in the inferior pedicle cohort, with preservation of the nipple-areola complex in all superomedial pedicle reductions. The most common complication was decreased nipple sensation, which occurred in 11 of 100 reductions in the superomedial pedicle cohort and 13 of 100 reductions in the inferior pedicle cohort, and minor skin breakdown in eight of 100 and 10 of 100, respectively. There was no statistically significant difference in outcomes or complication rates between the superomedial pedicle and inferior pedicle cohorts. Patient satisfaction was high in both cohorts, with symptomatic relief. As a secondary outcome, data were analyzed with respect to size of reduction within the superomedial pedicle cohort. No statistical differences were found in complication rates in large-volume reduction compared with smaller reductions when using the superomedial pedicle technique or inferior pedicle technique (Tables 3 and 4). The superomedial pedicle vertical scar breast reduction offers excellent aesthetic results with long-term maintenance of shape and projection (Figs. 2 and 3). The superomedial pedicle vertical scar breast reduction technique can be used safely for larger reductions (>1000 g) (Fig. 4).
Superomedial pedicle techniques with vertical scar reductions and inferior pedicle reductions with traditional Wise patterns have the ability to produce consistently viable breast reductions with a high degree of patient satisfaction in the hands of an experienced surgeon. As pedicle selection and skin excision pattern may be considered independently,3 the many studies published in the past half-century exploring unique combinations of reduction mammaplasty generally report satisfactory results. In fact, this has led some authors1,5 to suggest that no single reduction mammaplasty technique may be universally applicable; rather, the use of certain surgical techniques may be more optimal for certain patient populations.13 But what patient characteristics predict a high rate of success with certain reduction techniques?
In our experience, superomedial pedicle reduction with a vertical scar is a safe and reliable choice for breast reductions of all sizes. Despite a theoretical concern that larger reductions may compromise vascular supply to the nipple-areola complex and a recent article that demonstrated higher complications with higher resection volumes,11 numerous series,2,7,14 including our own, have found that this technique does not create complications at an increased rate. Our study is the first matched cohort study to date comparing superomedial pedicle breast reduction with inferior pedicle breast reduction. We did not identify a statistical difference in minor or major complications. In addition, we did not observe a statistically significant difference in complications with smaller and larger volume reductions. However, we have found in our hands that certain patient selection criteria tend to produce the most optimal outcomes with the superomedial pedicle technique, including good skin elasticity with minimal striae, dense breast parenchyma, and patients desiring reduction with maintenance of a significant portion of prereduction breast volume (e.g., not requesting excessive reduction).
Patients with good skin elasticity and minimal striae may have more aesthetically pleasing results, as the skin rebounds more adequately to assume the shape of the postreduction breast. Good skin quality will obviate the need for return to the operating room for secondary revisions because of excess skin at the inferior border of the breast. Although good skin elasticity may be of importance to the overall aesthetic result in superomedial pedicle reductions, this method of parenchymal reduction is not dependent on skin for maintenance of ptosis or long-term contour. As such, high skin elasticity may be an overall independent predictor of successful reduction mammaplasty independent of technique selection.
In our experience, dense parenchyma in superomedial pedicle reductions may allow for greater control of breast contouring in achieving a final aesthetic result. A firmer breast parenchyma will allow for secure suture attachments between medial and lateral pillars, creating a stable base for the postsurgical breast. Parenchyma may be of greater importance in this type of procedure, which relies on glandular tissue for construction of the reduced breast.
Further technical modifications that allow for superior results include downward shifting of the preoperative markings to account for elastic recoil of the skin envelope, thus limiting the nipple-to–inframammary fold distance and the potential for a “ski-slope” nipple deformity. In addition, although some surgeons have indicated improved results with tightening of the lower pole,15 we have found that our method of plication in the deep fascia of the lateral pillar corresponding with the lateral breast border to the deep medial pillar (pedicle), with a second layer of 2-0 polydioxanone for reinforcement, cones the breast with high fidelity and reduces potential dead space. The number of sutures placed will depend on the glandular-to-fat ratio of the breast contents. Younger patients with more dense, glandular-type breasts will require fewer sutures because of the structural integrity of the breast (as discussed earlier). Finally, although liposuction can be used as an adjunctive measure to address the lower pole,16 we have found that direct defatting of the inferior pole and release of the inframammary fold in the mastectomy plane affords a simple and reliable method of addressing the inframammary fold without increasing complication rates. Drain use is essential for preventing fluid collection in the inframammary fold space.
The superomedial pedicle produces high levels of patient satisfaction, particularly in those who wish to maintain a significant postsurgical breast volume. The superomedial pedicle reduction may be more applicable to patients requesting a change in breast size of a large C cup to a small D cup, as the pedicle itself occupied the volume of approximately a B cup. In addition, Hall-Findlay1 suggests that patients seeking smaller reductions may have cosmetic expectations beyond what is feasible in small-volume reduction mammaplasty. We have found that maintenance of a significant portion of presurgical breast volume after resection fills the breast envelope and avoids excessive skin reduction and related scarring, decreases potential dead space with parenchymal-skin envelope proximity, and may afford additional leeway in contouring to achieve a desirable aesthetic outcome, with maintenance of adequate pedicle width to support the blood supply to the nipple-areola complex in larger reductions.
The superomedial pedicle with vertical scar reduction mammaplasty is an alternative technique for breast reduction with the advantage of a shorter incision and increased breast projection. This is the first large-volume, matched cohort study to date demonstrating that superomedial pedicle complication rates are consistent with those of the inferior pedicle Wise-pattern reduction across a wide range of breast sizes. Patient selection criteria are outlined that may allow for improved outcomes when using this technique.
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