Critical view of safety (CVS) was introduced among general surgeons in response to a sudden surge in biliary injuries associated with the increased use of laparoscopy.1 CVS was identified as a safe method for dissection and protection of the cystic duct and artery. A large case series after the implementation of CVS reported no bile duct injuries, suggesting a successful reduction of complications with the introduction of CVS.2 The authors introduce a similar concept regarding identification and protection of the superomedial pedicle during breast reductions for trainee education to avoid pedicle transection.
Orlando and Guthrie3 introduced the superomedial pedicle as an alternative to superior pedicle breast reduction in 1975. This technique included incorporation of additional medial parenchyma for improved vascularity of the nipple–areola complex. The superomedial pedicle is widely used by plastic surgeons and has similar complication rates to both the superior and inferior pedicle technique.4 A retrospective review of 938 superomedial reduction mammaplasties reports low complication rates overall, but a 3% partial nipple necrosis complication rate exists.5 Prevention of nipple loss is multifaceted, and protection of the pedicle is of foremost importance. The proposed CVS in superomedial breast reduction can be used by both the novice and experienced plastic surgeon to ensure safe, efficient, and reproducible protection of the pedicle.
To obtain the CVS, superomedial breast reduction is carried out in a standard fashion with Wise skin pattern. The pedicle is deepithelized and the breast skin and parenchyma are resected in an en bloc fashion. The superomedial pedicle must then be divided from the lateral breast pillar to facilitate rotation of the pedicle for final inset. During this step, CVS is used to prevent surgical errors. CVS is defined by three anatomic landmarks: superomedial pedicle, lateral pillar, and breast meridian (Fig. 1, left).
;)
Fig. 1.: (Left) Standard Wise pattern superomedial breast reduction with resection of skin and parenchyma before division of the superomedial pedicle and lateral pillar. (Right) The critical view of safety as defined by the superomedial pedicle, breast meridian, and lateral pillar. Dissection is carried out along the trajectory of the breast meridian. Illustration by Scott Holmes, CMI. Copyright Baylor College of Medicine.
To define the CVS clearly, the surgeon uses an allis clamp to pull the pedicle upward and medially while the assistant uses an allis clamp to pull the lateral pillar in an upward and lateral direction to create tension over the breast meridian (Fig. 1, right). Division of the superomedial pedicle from the lateral pillar may then be carried out following the course of the breast meridian. [See Video (online), which demonstrates division of the superomedial pedicle from the lateral breast pillar using the critical view of safety. The surgeon uses an allis clamp to pull the pedicle upward and medially while the assistant uses an allis clamp to pull the lateral pillar in an upward and lateral direction to create tension over the breast meridian. Division of the superomedial pedicle from the lateral pillar may then be carried out following the course of the breast meridian.] Before division, the CVS should be agreed on in a time-out fashion. Use of CVS avoids dissection medially, which would threaten the pedicle, or laterally, which could result in unintentional violation of the skin or hollowing of the lateral breast. The surgeon should take care to reassess the trajectory over the breast meridian continuously.
{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video demonstrates division of the superomedial pedicle from the lateral breast pillar using the critical view of safety. The surgeon uses an allis clamp to pull the pedicle upward and medially while the assistant uses an allis clamp to pull the lateral pillar in an upward and lateral direction to create tension over the breast meridian. Division of the superomedial pedicle from the lateral pillar may then be carried out following the course of the breast meridian.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_of1uf4uv"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}
Implementation of CVS is a simple and reproducible way to protect the superomedial pedicle in breast reduction. CVS should be implemented by plastic surgeons to aid in trainee education, decrease preventable technical errors, and increase efficiency in the operating room.
ACKNOWLEDGMENT
The authors thank Scott Holmes, CMI, a member of the Michael E. DeBakey Department of Surgery at Baylor College of Medicine, for assistance with the figure.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Strasberg SM. A perspective on the critical view of safety in laparoscopic cholecystectomy. Ann Laparosc Endosc Surg. 2017;2.
2. Singh R, Brunt LM. Critical view of safety: its feasibility and efficacy in preventing bile duct injuries. Ann Laparosc Endosc Surg. 2018;3.
3. Orlando JC, Guthrie RH Jr. The superomedial dermal pedicle for nipple transposition. Br J Plast Surg. 1975;28:42–45.
4. Toplu G, Altinel D, Serin M. Evaluation of factors related to postoperative complications in patients who underwent reduction mammoplasty. Eur J Breast Heal. 2021;17:157.
5. Bauermeister AJ, Gill K, Zuriarrain A, Earle SA, Newman MI. Reduction mammaplasty with superomedial pedicle technique: a literature review and retrospective analysis of 938 consecutive breast reductions. J Plast Reconstr Aesthet Surg. 2019;72:410–418.
GUIDELINES
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:
- Text—maximum of 500 words (not including references)
- References—maximum of five
- Authors—no more than five
- Figures/Tables—no more than two figures and/or one table
Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.
We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
