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Breast: Original Articles

The Central Mound Pedicle: A Safe and Effective Technique for Reduction Mammaplasty

DeLong, Michael R. M.D.; Chang, Irene B.A.; Farajzadeh, Matt B.S.; Nahabet, Edward H. M.D.; Roostaeian, Jason M.D.; Festekjian, Jaco M.D.; Rough, James M.D.; Da Lio, Andrew L. M.D.

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Plastic and Reconstructive Surgery: October 2020 - Volume 146 - Issue 4 - p 725-733
doi: 10.1097/PRS.0000000000007173
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Abstract

Reduction mammaplasty is a common procedure used by plastic surgeons to improve quality of life in patients with symptomatic macromastia, or to restore symmetry in patients with congenital discrepancies or after unilateral reconstruction.1–3 Although this is a common procedure, adherence to fundamental plastic surgery principles is required to remove the excess skin and breast parenchyma and to reposition the nipple while maintaining adequate perfusion to all tissues.4 Improper technique or overly aggressive resection can result in necrosis of the nipple, skin, or fat, and can lead to a poor cosmetic result.5,6 In addition, the extent of skin excision must be balanced with the ultimate scar burden on the breast mound and inframammary fold.7

These considerations have resulted in the development and description of numerous techniques for performing reduction mammaplasty, categorized by differing skin pattern reductions and pedicle designs.8–12 The most commonly used technique is the inferior pedicle with a Wise incision pattern, preferred by an estimated 70 percent of surgeons.13 The inferior/Wise approach offers the safe excision of large tissue volumes with predictability and reproducibility.14,15 However, some surgeons have criticized this approach for perceived shortcomings, including squaring of the breast borders and late pseudoptosis.16

Many critics of the inferior/Wise approach have adopted the superomedial pedicle reduction, using either a Wise or vertical incision pattern. Advocates of this technique believe that the superiorly based pedicle affords longevity to the final breast mound shape and position by primarily resecting tissue inferiorly. In addition, limiting the skin incision to only a vertical ellipse can reduce the eventual scar burden for patients. However, although studies have suggested that the superomedial pedicle can be used safely for larger reductions, some surgeons are hesitant to use the superomedial technique in gigantomastia patients with ptosis because of the reliance on a superiorly based blood supply and potential for nipple ischemia.17,18 The superomedial and inferior pedicle techniques also may be of limited utility in re-reduction patients where the original pedicle is unknown.19

The central mound pedicle technique, introduced by Balch in 1981,20 offers many advantages. The central mound relies on a highly vascular glandular pedicle directly from the chest wall and can be safely used in re-reductions regardless of the pedicle design used in the prior reduction. In addition, the central mound technique allows the surgeon to precisely predict and modify the base width of the breast mound by shaping the underlying coned pedicle and draping the skin over the final desired shape. By centering the pedicle under the nipple and point of maximal projection, an aesthetic and anatomical breast contour can be constructed. The preservation of the directly underlying tissue also may limit the likelihood of damage to the sensory cutaneous nerves destined for the nipple-areola complex.

Multiple senior surgeons at our institution exclusively perform their reduction mammaplasty procedures with the central mound technique. We evaluate multiple decades of patients having undergone this relatively less common technique to report on our experience with respect to expected safety and efficacy outcomes for the central mound procedure.

PATIENTS AND METHODS

Operative Technique

The central mound pedicle reduction mammaplasty is a highly reproducible technique (Figs. 1 and 2). [See Video (online), which demonstrates the steps of the central mound breast reduction technique, including excision patterns and internal mastopexy sutures.] Preoperative markings are made with the patient in the sitting position, with a typical Wise-pattern skin reduction design drawn on the patient. The expected new nipple-areola complex position is marked at or just slightly above the Pitanguy point. The limbs of the Wise pattern are then marked based on surgeon preference estimating the final breast size and extent of expected resection.

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Fig. 1.
Fig. 1.:
Schematic depicting the central mound reduction technique. (Above, left) A standard Wise-pattern incision is marked on the patient. (Above, center) The superior skin flaps are elevated in the plane between the breast capsule and subcutaneous tissue. (Above, right) The desired base width is marked, and the breast parenchyma is resected to preserve the central mound cone. (Below, left and below, center) The central mound pedicle is secured to the upper parenchymal ridge as an internal mastopexy. (Below, right) Closure.
Fig. 2.
Fig. 2.:
Central mound surgical technique. (Above, left) Skin incision with desired pattern. (Above, second from left) Skin flaps raised in plane between breast parenchyma and subcutaneous fat. (Above, second from right) Full-thickness skin excision on tissue inside the Wise pattern. (Above, right) Circular template used to mark central mound pedicle with desired base width. (Center, left) Parenchyma resection leaving the previously marked conical central mound. (Center, second from left) Marking the superior wedge of the central mound and (center, second from right) excision of this superior wedge. (Center, right) Internal mastopexy performed by elevating central mound pedicle where wedge was excised and (below, left) Sutured into place. CM, central mound. (Below, center) Demonstration of internal mastopexy sutures. (Below, right) Closure.

Once in the operating room, an areolar template is used to mark the new preferred size of the areola. Incisions are made through skin based on the preoperative Wise-pattern markings. The skin around the areola and the inferior pole is completely removed down to the breast capsule. Superiorly, medial and lateral skin flaps are created at the junction between the subcutaneous fat and the breast capsule. This plane will vary based on the patient’s body habitus and body fat percentage. Dissecting in this plane maintains the entire subcutaneous layer on the skin flap and is usually adequate to maintain adequate vascular perfusion to the skin flaps. In extremely thin patients, if the surgeon feels that insufficient subcutaneous tissue is present, or if the capsule is not clearly defined, a rim of breast tissue measuring a few millimeters can be included on the skin flaps in a more conservative elevation. The desired base width for the patient’s body habitus is determined and the breast parenchyma is marked with a circle of this diameter centered on the nipple. Parenchymal reduction is conducted circumferentially to create a cone-shaped breast central mound pedicle, with the apex and resulting point of maximal projection being the nipple-areola complex. The amount of tissue to resect can be reliably determined without needing anatomical landmarks by using a circular template based on the final anticipated base width and resecting tissue outside of this construct as demonstrated (See Video). The usual diameter of the neo–breast mound will vary, again depending on the patient’s body habitus, breast shape, and desired final breast volume; however,, in general, as with implant-based breast reconstructions, this diameter will range anywhere from 11 to 15 cm as a rough estimate. For surgeons less familiar with the central mound technique, a more conservative resection can be used with the knowledge that additional tissue can be resected after a tailor-tacking assessment, as discussed below.

In large ptotic breasts, the surgeon will find that, in the supine position, the notch-to-nipple distance will not be as lengthy as in the sitting position. The central breast mound can easily be performed on these cases simply because the vessels will still be present from the central mound originating off of the chest wall. Alternatively, in extremely severe cases, or if the breast is overprojecting in the supine position, the central mound can be trimmed appropriately, removing the nipple-areola complex, in addition to the circumferential resection. The nipple-areola complex is then grafted in these cases.

A ridge of breast parenchyma is intentionally left at the superior portion of the dissection cavity in the intrinsic breast mound. This ridge is approximately 2 to 3 cm in width, spanning the entire width of the upper quadrants. At this time, absorbable sutures are placed, securing the newly shaped and reduced central breast mound to this superior parenchymal ridge, creating an internal mastopexy of the entire neo–breast mound. With this maneuver, the breast mound is supported not only by the skin envelope, but by the internal parenchymal mastopexy.

The skin flaps are then redraped and tailor-tacked with staples. The patient’s back is then elevated on the operating room table to assess symmetry, shape, and nipple position. Adjustments can be made as necessary. If the initial resection based on the desired base width template is felt to be insufficient, more tissue can be resected from the central mound pedicle in the areas that still appear inappropriately full or convex. This step can be repeated with tailor-tacking to ensure that the final appearance of the breast is the desired size and shape and that satisfactory symmetry is achieved. Once the result appears acceptable, the patient is returned to the supine position and the incisions are closed after hemostasis is ensured. A closed-suction drain may be used if desired. Finally, a new areolar defect is created at a desired distance from the inframammary fold and the underlying nipple-areola complex is delivered and the skin is closed with absorbable sutures.

Study Design

Institutional review board approval for the study was granted through the University of California, Los Angeles (no. 18-001222). All patients undergoing reduction mammaplasty between June of 1999 and November of 2018 were identified by using CPT code 19318. This period was selected because it represents all available years in our facility’s archives. We further restricted the study population to only patients of surgeons at our institution who solely use the central mound reduction technique. The remaining surgeons at our institution do not use the central mound technique, so none of their patients were included. Both macromastia patients and patients undergoing unilateral symmetrizing reduction for asymmetry or after reconstruction were included but were evaluated separately for some outcomes.

Patient demographics, medical comorbidities, smoking status, operative details, follow-up, and postoperative adverse events were extracted by chart review. Patients who had undergone bilateral reduction mammaplasty for symptoms were then contacted by phone and were asked to complete the BREAST-Q reduction module questions on a Likert scale ranging from 1 to 5 for both their preoperative and their postoperative scores. Although a baseline response before surgery would have been preferable to eliminate recall biases, this information is not routinely obtained at our institution and so the preoperative scores had to be obtained postoperatively. The use of the individual questions on a Likert scale was performed to isolate the different satisfaction endpoints. Associations between preoperative variables and outcomes were assessed with chi-square tests, Wilcoxon tests, and Kendall tau-b correlations.

RESULTS

A total of 325 patients were identified for inclusion (227 bilateral and 98 unilateral; 552 breasts). The average patient age was 46 years, and the average body mass index was 27.4 kg/m2. Thirteen patients reported actively smoking, and 54 patients were former smokers. Among the bilateral macromastia patients, the average operative time was 3 hours 34 minutes, and average breast tissue removed was 533 g from the right and 560 g from the left. Among all patients, average follow-up was 169 days. Complete demographics data are listed in Table 1.

Table 1. - Patient Demographics
Characteristic Value (%)
Mean patient age ± SD, yr 46 ± 15.1
Mean BMI ± SD, kg/m2 27.3 ± 4.5
Bilateral 227 (69.8)
Ethnicity
 Asian 7 (2.2)
 Black 35 (10.8)
 Hispanic 19 (5.8)
 Indian 1 (0.3)
 White 220 (67.7)
 Other 12 (3.7)
 Unknown 31 (9.5)
Diabetes 6 (1.8)
Hypertension 29 (8.9)
Smoking status
 Current 13 (4)
 Former 54 (16.6)
 Never 258 (79.4)
Mean follow-up ± SD, days 169 ± 293
Mean operation time ± SD, min 183.3 ± 62.4
Mean amount of tissue removed ± SD, g
 Right 532 ± 331
 Left 560 ± 351

On a per-breast basis for all patients, the following complication rates were observed: seroma, 0.2 percent; hematoma, 1.1 percent; dehiscence, 2.9 percent; infection, 1.5 percent; hypertrophic scar, 4.6 percent; nipple necrosis, 0.4 percent; fat necrosis, 0.9 percent; and skin flap necrosis, 1.7 percent. Unsurprisingly, nipple necrosis was associated with diabetes (p < 0.001), amount of tissue removed (p = 0.04), and hypertension (p = 0.01), and dehiscence was also associated with amount of tissue removed (p = 0.03).

Ninety-six bilateral macromastia patients (42.3 percent) completed the BREAST-Q Reduction/Mastopexy questions on a Likert scale ranging from 1 to 5 (Figs. 3 and 4). The following changes in average symptom frequency were observed postoperatively: shoulder pain, 3.40 to 1.41 (of 5) (p < 0.001); neck pain, 2.94 to 1.63 (p < 0.001); painful shoulder grooving, 3.78 to 1.57 (p < 0.001); rashes under breasts, 2.08 to 1.09 (p < 0.001); and back pain, 3.27 to 1.64 (p < 0.001). Nipple sensation was also reduced from 3.53 to 3.05 (p < 0.001). Patients were also satisfied with breast appearance in clothes, 1.48 to 3.70 (of 4) (p < 0.001); breast size match to their body habitus, 1.46 to 3.70 (p < 0.001); breast size, 1.39 to 3.61; (p < 0.001); breast shape in a bra, 1.91 to 3.64 (p < 0.001); comfort of bra fit, 1.53 to 3.59; (p < 0.001); how breasts hang, 1.38 to 3.70 (p < 0.001); and how normal breasts appeared postoperatively, 1.57 to 3.60 (p < 0.001).

Fig. 3.
Fig. 3.:
BREAST-Q symptom results among bilateral macromastia patients.
Fig. 4.
Fig. 4.:
BREAST-Q satisfaction results among bilateral macromastia patients.

In addition, the revision rates from our series were very low. Sixteen of 325 patients (4.9 percent) underwent revision for dissatisfaction with the appearance of their scar, and only three patients (0.9 percent) requested re-reduction for inadequate volume removal.

DISCUSSION

Reduction mammaplasty is an important and common procedure available to breast plastic and reconstructive surgeons.21 However, safe and effective implementation of this procedure requires the maintenance of a robust blood supply to the nipple while strategically removing excess tissues to reduce and shape the final breast mound. The breast parenchyma and skin receive blood supply from the thoracoacromial artery, internal mammary perforators (second through fifth), lateral thoracic artery, thoracodorsal artery, and terminal branches of the intercostal perforators (third through eighth), with roughly 60 percent of the perfusion supplied by the internal mammary perforators. Multiple surgical variations for performing a reduction mammaplasty have been reported and popularized among the plastic surgery community, each relying on differing vascular pedicles.7,9,10,18

The most common technique is the inferior pedicle with Wise-pattern skin incision.13 The basic steps for an inferior/Wise reduction involve the creation of a (usually) deepithelialized inferior pedicle based on perforators from the fourth through sixth intercostals.22 The superior and lateral tissues are removed based on surgeon judgment, and then the nipple is repositioned to the apex of the skin incision. Although this technique remains the most popular, critics have suggested that the inferior/Wise approach may result in boxy breast borders and a less appealing final cosmetic result. In addition, some surgeons believe that preferential removal of superior tissues with preservation of inferior tissues can lead to late pseudoptosis and bottoming-out of the breast with time.

The second most popular option for reduction mammaplasty is the superomedial pedicle, often combined with a limited vertical incision, as popularized by Hall-Findlay. Perceived benefits of this approach include preferential removal of inferior tissues, reproducible and reliable pedicle, and reduction in scar burden.7,16

Reports have presented evidence that a superior pedicle design may provide a longer lasting lift and better cosmetic match to a prosthetic reconstruction compared to inferior pedicle techniques.23 Some comparisons between the superomedial and inferior/Wise techniques suggest that complication rates are comparable between these two techniques.24,25 However, in a literature review and retrospective analysis of 938 procedures by Bauermeister et al., the superomedial reduction technique was associated with lower complication rates than the inferior/Wise technique based on comparisons to historical controls.26

The central breast mound reduction technique has the advantage of being supplied from multiple sources. Because the base of the mound is never violated, some have called this technique the “maximally vascular central breast mound reduction,” as perforators from the internal mammary, intercostal, thoracoacromial, and perhaps some branches from the lateral thoracic arteries can contribute to the central mound vascular supply. The maximally vascularized pedicle enables the central mound technique to be used for all appropriate breast reduction candidates. There are no specific contraindications for this approach other than general contraindications for reduction mammaplasty.27 Conceptually, the central breast mound reduction technique has the following significant advantages:

  1. Wide skin undermining, which allows redraping of the overlying skin envelope in a much more controlled and tension-free fashion.
  2. Circumferential resection of the large and ptotic breast parenchyma in a dome-shaped fashion.
  3. Creation of an internal parenchymal mastopexy by securing the upper pole of the new breast mound to the upper glandular ridge or pectoralis major fascia.
  4. Tension-free closure of skin flaps. Because the skin flaps do not bear the primary burden of supporting the new breast mound, the scars should in theory be less prone to hypertrophic scar formation.

In our retrospective evaluation, we review the largest number of breasts undergoing a central mound reduction that we are aware of.28 Although a robust analysis is not possible because of differences in patient populations, resected tissue amounts, and follow-up duration, we observed a lower complication rate in our series than previously described in other studies that used inferior/Wise or superomedial patterns.24–26,29 We also observed correlation between the amount of tissue removed and complication rates, which is consistent with prior studies.4,6 These data do not allow a definitive comparison, but provide evidence that the central mound technique offers a safe alternative for reduction mammaplasty.

Regarding the effectiveness of the central mound technique, we observed substantial and statistically significant improvements in all symptom and appearance questions from the BREAST-Q Reduction/Mastopexy module, asked on a Likert scale ranging from 1 to 5, among macromastia patients. On average, patients reported reduced or relieved symptoms along with an enhanced and harmonized appearance. Unfortunately, these data are limited by susceptibility to recall bias because preoperative values were acquired postoperatively during the retrospective review. They are also not directly comparable to other studies, which reported aggregate scores of a total of 100. Again, these data provide a reassuring benchmark for the success of the central mound technique. Patient satisfaction was similarly reflected in the very low revision rates of 4.9 percent for scar revision and 0.9 percent for revision of the reduction itself, although we acknowledge that these rates may be underestimates because patients may undergo revisions at a different center if they are truly unhappy with their results. Figures 5 and 6 demonstrate typical results in a patient undergoing central mound reduction for macromastia.

Fig. 5.
Fig. 5.:
Frontal views of a patient who underwent bilateral reduction mammaplasty for macromastia with removal of 833 g from the right and 814 g from the left shown (left) preoperatively, (center) 6 weeks postoperatively, and (right) 1 year postoperatively. Of note, the patient lost weight between 6 weeks and 1 year postoperatively.
Fig. 6.
Fig. 6.:
Lateral views of the patient who underwent bilateral reduction mammaplasty for macromastia with removal of 833 g from the right and 814 g from the left shown (left) preoperatively, (center) 6 weeks postoperatively, and (right) 1 year postoperatively. Of note, the patient lost weight between 6 weeks and 1 year postoperatively.

In addition, although we observed a statistical reduction in nipple sensation in our cohort, the degree was relatively minor based on the BREAST-Q questionnaire, decreasing only from 3.53 to 3.05 (p < 0.05) and unlikely to be clinically meaningful. Although there are not comparable data on nipple sensation in relation to the BREAST-Q from other studies, the decrease observed in our series was likely relatively minimal. We believe that the central mound technique may have particular utility in preserving sensation to the nipple because of the centrally preserved tissues underlying the nipple-areola complex. For example, superiorly based pedicles have been associated with the greatest reduction in nipple sensation because of resection of underlying tissues.30 Prior sensitivity comparisons between the superomedial and inferior/Wise techniques have concluded no difference in postoperative nipple sensations.31,32 However, these studies used objective sensation measurements, and the results cannot be compared to the subjective results in our cohort based on BREAST-Q questions.

The centralization of the pedicle underneath the final nipple position has additional theoretical advantages that are more difficult to measure. By minimally disrupting the underlying breast parenchyma, lactation is likely to be less impaired compared to other techniques. The preservation of a cone of breast tissue directly underneath the nipple also allows the placement of the nipple-areola complex at the point of maximal projection, which may be partially responsible for the high satisfaction scores observed in our patient population. The reliance on a central, maximally vascularized pedicle also allows the central mound technique to be used safely in patients undergoing re-reduction with unknown prior pedicle, or patients with a history of radiation therapy.

Ultimately, our evaluation of the central mound technique in 552 breasts demonstrates reassuring safety and effectiveness outcomes. Our data provide a benchmark in a large series of patients to establish the expected complication rates and efficacy results. Further rigorous evaluation will be required to understand the relative benefits or disadvantages compared to other techniques.

CONCLUSIONS

The central mound reduction mammaplasty technique offers a relatively safe and effective method for treating patients with symptomatic macromastia or breast asymmetry. Theoretical benefits for this technique include versatile reduction, preservation of nipple sensation, reliable nipple perfusion in re-reduction patients, and sustained results with internal mastopexy. Further research is needed to robustly assess the relative performance compared to alternative reduction techniques.

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