Breast Reduction with Total Superior Pedicle : Plastic and Reconstructive Surgery – Global Open

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Breast: Original Article

Breast Reduction with Total Superior Pedicle

Escobar Jaramillo, Rodrigo MD*; Merelo Arias, Carlos A. MD

Author Information
Plastic and Reconstructive Surgery - Global Open 11(1):p e4735, January 2023. | DOI: 10.1097/GOX.0000000000004735
  • Open
  • SDC
  • Associated Video
  • DOMINICAN REPUBLIC

Abstract

Takeaways

Question: Reduce the risk of necrosis in the NAC by providing greater circulation through multiple pathways.

Findings: From a single-center study of 16-year duration, in the number of cases studied, 0% necrosis has been achieved with these techniques of large ascents of the NAC (up to 23 cm) to the new position.

Meaning: The total superior pedicle is a reproducible technique option for breast reduction that respects the greater blood supply to the NAC.

INTRODUCTION

The excessive growth of the breasts (currently known as macromastia) proposes a health problem in women. Symptoms, such as chronic upper/lower back pain, neck pain, intertrigo, paresthesias, grooves in bra slots, and inability to do sports, are predominant.1 Multiple causes have been proposed for breast hypertrophy, such as abnormal estrogen levels, overweight, eating habits, and genetic load, among others.2

Since 1930, when Schwartzmann introduced the deepithelialization of the nipple-areola complex (NAC), several techniques have been developed for breast reduction, where the inferior pedicle, superomedial pedicle, superior pedicle, central periareolar, and free nipple graft stand out.3 The inferior pedicle and free nipple graft have been favored as the first option in cases of displacement of the NAC from the sternal notch (SN) of 40 cm or more, along with the need for large volume resection. Considering the pedicle’s length was standardized as the most important criterion for technique selection.4

Subsequently, the inclusion of the vertical breast reduction technique was introduced by Lassus, extended by Marchac and Olarte, and popularized by Lejour. Even today, most surgeons prefer the traditional inferior pedicle.4 This is due to the apparent risk of partial or total necrosis, venous congestion, conical shape, and the impossibility of ascending the NAC. Similarly, according to Lassus, for a long rise of more than 9 cm (distance taken by us to consider a long ascending distance from notch to NAC), a supermedial technique is preferred.5,6

This study’s objective is to present a different technique for long NAC ascending in patients with macromastia using a total superior pedicle lifting approach from a vertical marking with horizontal modification, without injuring the dermis around the NAC. We propose this surgical approach to ensure a greater blood supply to the breast and promote the integrity of its vascular anatomy with the preservation of the NAC.

PATIENTS AND METHODS

Study Design

A single-center descriptive study was performed in Santiago de los Caballeros, Dominican Republic, highlighting the possibility of performing a breast reduction with a total superior pedicle with large NAC lengths. The study was carried out over 16 years (from 2006 to 2022). All study participants were managed according to the Declaration of Helsinki, through informed consent and patient disposition.

Macromastia is defined as a resection weight of 500 grams per breast regardless of body habitus or aesthetic proportions,7 whereas gigantomastia is considered when 1500 grams or more are removed from both breast tissues8; according to Chopping’s studies, breast volume could be classified as small (250 ml), medium (500 ml), and large (1000 ml).9 Hence, inclusion criteria were limited to macromastia with chronic pain, or inability to perform daily tasks, leisure activities, and sports. Exclusion criteria were cancer, unwillingness for surgery, and/or lack of emotional preparation for the procedure. Participants of this study were recruited from a nonprobabilistic convenience sampling. All minors attended with their parents or guardians who were in charge of signing the informed consent, and afterward sent to be assessed by the endocrinology department; factors, such as menarche, weight, and symptoms, were taken as surgical decision parameters.10 Patients were informed of the surgical procedure’s risks before signing the preoperative consent. Participants’ age, family history, and radiologist’s recommendation were taken as criteria for breast ultrasound, mammography, or tomosynthesis; in some cases, CT angiography was conducted.

During the mentioned period, approximately 232 procedures with breast tissue (≥500 grams) reductions were performed. After the procedure, all patients remained for observation for at least 24 hours in the hospital. Postsurgical management consisted of analgesics, antibiotics, soft bandages, fluid therapy, and a tight bra for up to 3 months. Likewise, follow-up was up to 12 months after surgery via face-to-face or telephone consultation.

Technique Description

Marking

Marking is making a vertical line at the midclavicular point separating the breast into two hemispheres (between 7 and 9 cm from the SN), with another line from the SN to the NAC. Thereafter, performing the Pintanguy maneuver, we marked the new NAC point; making an arc where the minimum distance allowed for the arc’s radius to achieve a circumference of 5 cm (areolar template size 4.5 cm) must be the length of the radius multiplied by π (3.14). Thus, it leaves us a margin of 0.5 cm for modification of the NAC (Figs. 1, 2).

F1
Fig. 1.:
Minimum diameter calculation.
F2
Fig. 2.:
Marking technique. An observed discrepancy in the proportion of skin resection/breast tissue resection was minor skin resection but increased breast tissue reduction when the skin had greater tension and dermis thickness. On the other hand, a challenge in this proportion is the combination of tough skin with abundant glandular tissue.1 , 2 Therefore, a vertical marking with compensatory horizontal correction was considered. That is due to its versatility, ease of marking, and simple modification after tissue resection. The laxity of the tissues when closing is essential to avoid skin suffering, opening of the T junction, or the need for over-resection due to excess skin tens.

A distance (cranial-caudal) was drawn from the highest point of the new NAC position downward (>10 cm), being the minimum space required to accommodate the rise and overlap of the NAC in its new stance. Originating at the two distal points of the arch’s openings, breast tissue is clamped to assess the percentage of skin resection necessary and delimited with a circle, creating two semicircles that converge. A centimeter from the opening should prevail to avoid tension at the skin level, then mark another semicircle at the lowest point of the upper ones, placed at 1 cm from the real breast fold. (See Video 1 [online], which shows the steps of marking in a patient undergoing a breast reduction.)

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Surgical Technique

Deepithelialization of the marked area was performed up to 4 cm caudal to the nipple (no other cuts were made to this area); an areolar template should be used to deepithelialize the areola (Figs. 3–10). After marking, patients were placed in a supine position, continuing the draw at the 4th intercostal space level (where the NAC should originally be), whereby the distribution of the breast tissue was assessed, finding three types of distribution: type A (redundant tissue at the caudal level), type B (equal distribution in both parts of the meridian), and type C (predominant at the cranial level, but with glandular breasts found mostly in young patients) (Fig. 11). Based on this distribution, resections were required in the upper areas of the breast through tunneling and resection of the excess tissue. The percentage of total resection depended on two factors: the volume that the patient wanted to reduce and the distribution of the gland in the breast. (See Video 2 [online], which shows the steps for a block lift approach in a patient undergoing a breast reduction, including marking and ascending.) In cases of NAC’s lateral deviations, while marking the vertical line (starting from the midclavicular point with lateral displacement of the NAC due to breast tissue excess toward the medial), more medial tissue should be removed during the resection; maintaining the 5–7 cm from the external line to the medial, allowing easy rotation of the NAC without resorting to other techniques.

F3
Fig. 3.:
Vertical measure for ascent. Deepithelialization of the marked area is performed, respecting a minimum of 10 cm vertically and 10 cm horizontally. We use a 4.5-cm areolotome in all cases.
F4
Fig. 4.:
Horizontal measurement of the calculation for ascent.
F5
Fig. 5.:
Medial limit of 5 cm from the sternal line of no cut or detachment. We make a tunnel of approximately 4–8 cm over the pectoral fascia, respecting a minimum of 5 cm from the sternal midline toward the outside (to respect Wuringer’s septum).
F6
Fig. 6.:
Central resected area and pedicle depth. We left 3 or more cm of thickness, and we proceed to the resection of the dome, which should never be less than 3 cm.
F7
Fig. 7.:
Deepithelialized area around NAC.
F8
Fig. 8.:
First stitch at 12 o’clock. The first NAC stitch is set to the new superior position at 12 o’clock with Vicryl 4-0.
F9
Fig. 9.:
Stitches in the cone dome. The second stitch closes the upper circle with Vicryl 3-0 at 6 o’clock and continues placing a stitch at 3 and 9 o’clock with Vicryl 4-0. Dome stitches are placed to achieve conization with prolene 2-0, and pillars are stitched with 3-0 Vicryl to close the gap up to 5–7 cm vertically.
F10
Fig. 10.:
Almost finished right breast comparison with left breast even without resecting tissue.
F11
Fig. 11.:
Breast tissue distribution. Type A: redundant tissue at the caudal level. Type B: equal distribution in both parts of the meridian. Type C: predominant at the cranial level, but with glandular breasts found mostly in young patients.

With the patient in a decubitus position and deepithelialized, a 5–7 cm in diameter area was marked from the sternal line toward the middle of the breast, representing Wuringer’s septum.11 Medial vessels are born in this septum, which protects the intercostal branch circulation that initially ascends horizontally and becomes more superficial up to approximately 3 cm. Then, it anastomoses with other arteries (internal mammary artery’s branches and lateral thoracic) or directly reaches the NAC. This cross-circulation creates a vascular bundle with a subdermal plexus (see figure, Supplemental Digital Content 1, which shows breast tissue blood flow structure, https://links.lww.com/PRSGO/C327; see figure, Supplemental Digital Content 2, which shows variations of the internal mammary artery’s supply to NAC, https://links.lww.com/PRSGO/C328; see figure, Supplemental Digital Content 3, which demonstrates breast tissue irrigation features, https://links.lww.com/PRSGO/C32912–17) that was performed without deepithelializing, leaving a 2 cm deep lateral skin thickness. At the level of the 4 cm marking, a deep cut was done without beveling until reaching the pectoralis major fascia and resecting the middle, lateral, and central caudal part block. Afterward, a proportional weight of the resected tissue is compared with the contralateral breast. The pedicle depth must be more than 2.5 cm, both laterally and superiorly to preserve the vessel circulation of the internal mammary artery’s branches, which reaches a depth of 1.5–1.7 cm, as well as the lateral thoracic circulation with an approximated depth of 2.5 cm (lateral thoracic artery and anterior intercostal branches enter the NAC between de 4 o’clock and 8 o’clock).14–18 (See figure, Supplemental Digital Content 3, which demonstrates breast tissue irrigation features, https://links.lww.com/PRSGO/C329.) If more resection is required, a tunnel should be made at the breast’s base toward the upper portion, respecting the medial 5–7 cm mentioned before. The scope of the tunnel for resection, which ranges between 4 and 8 cm in diameter, will depend on the width of the thorax to resect the excess segment of breast tissue.19

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NAC Ascension

After the resection, the distance from the highest point of the NAC to the free edge length was measured beside the width of the lateral edge to the middle of the skin opening. A 1:1 to 1:1.2 ratio is calculated from the measurements (Fig. 12). While following this, all NACs shall rise regardless of length. The first stitch with 4-0 Monocryl is placed at the highest point of the NAC, followed by stitches at 3 and 9 o’clock, closing the arch. Another stitch goes at 6 hours with Vicryl 3-0. Stitches (no more than two stitches) are placed in the dome, with prolene 2-0 in the central portion to promote breast projection. The pillars are faced with Vicryl 3-0 up to a measurement between 5 and 7 cm from the area of the breast fold, closing the T; in the case of mixed breasts or fatty breasts, the measurement must reach 5 cm between the NAC and the mammary groove; in case of glandular breasts, it should be 7 cm since they pendulate less than the previous ones. The lateral and medial skin tissue of the sulcus must be folded on itself, indicating the real amount of tissue to be resected, which is removed with a horizontal resection.

F12
Fig. 12.:
Length/width ratio. The ratio between length and width should always be greater than or equal to 1:1. If the index must be greater, it will be from the amplitude. In this way, a simpler ascent without any tension will be achieved, attaining an overlay of the NAC on its new bed without twisting.

A simple drawstring of 4 cm in diameter using nylon 2-0 is made in the tensionless NAC area, placing Jackson Prats- or Blake-type drains. The lower lateral incision should not go beyond the anterior axillary line; although in case of lateral excess of skin and fat, it usually reaches the middle and posterior axillary line. In cases of excess lateral fat, lateral liposuction was performed between the anterior axillary line and the posterior axillary line.

RESULTS

Two hundred thirty-two patients had one or both breasts weighing greater than or equal to 500 grams, meeting the inclusion criteria for this study. Considering that the procedure was conducted on both breasts, we might state that there were a total of 464 reductions. All SN-NAC distances were around 30–42 cm. Considering that the new NAC height was about 18–21 cm, generally speaking, the lifting range was approximately 12–23 cm. The average patient’s age was 34.5, and surgery time was approximately 3 hours. Of these participants, type A distribution was observed in 85%, while type B distribution was 10%, and type C was 5%. The mammary reductions with total superior pedicle lifting reached distances from the SN to the NAC of 30 to 42 cm in length. Considering both breasts, the average tissue extracted was 1253.3 ± 794.0 grams (SD, 95%). When evaluating the work performed on the right breast, the mean reduction observed was 783.2 ± 291.5 grams (SD, 95%), with a maximum and minimum extraction being 1786.0 and 501.0 grams, respectively, and the 50th percentile of 670.0 grams. On the other hand, the left breasts averaged a reduction of 820.9 ± 292.6 grams (SD, 95%). The maximum observed was 1782.0 grams, but the minimum was 508.0 grams, for the 50th percentile of 701.0 grams. NAC lifting length was between 30 and 42 cm, with elevations up to 23 cm in some cases (see Table 1; Figs. 13–18). All cases were resolved without consequences. Neither cases of tissue damage nor NAC necrosis were found in the entire series (Table 2).

Table 1. - Breast Reduction Data Tendencies
Parameters Age Right Breast Reduction Left Breast Reduction Total Tissue Reduction
Mean ± SD 95% 34.5 ± 11.5 722.6 ± 295.3 718.9 ± 308.3 1441.4 ± 589.6
Minimum extracted tissue 17.0 343.0 180.0 830.0
Maximum extracted tissue 65.0 1786.0 1782.0 3568.0
Percentile 25% 24.5 516.3 494.5 1020.8
Percentile 50% 34.0 603.5 635.0 1211.5
Percentile 75% 44.0 882.3 888.8 1772.3

Table 2. - Complications
Complication Quantity
Seroma 2
Hematoma 4
Infections 3
Partial lateral dehiscence 2
Widening of the scar around areola 4
Partial necrosis 0
Total necrosis 0

F13
Fig. 13.:
Bilateral reduction mammaplasty case no. 1. Patient who underwent bilateral reduction mammaplasty for macromastia. Preoperative frontal view.
F14
Fig. 14.:
Bilateral reduction mammaplasty case no. 1. Frontal view 11 months postoperatively.
F15
Fig. 15.:
Bilateral reduction mammaplasty case no. 2. Patient who underwent bilateral reduction mammaplasty for macromastia. Preoperative frontal view.
F16
Fig. 16.:
Bilateral reduction mammaplasty case no. 2. Frontal view 11 months postoperatively.
F17
Fig. 17.:
Bilateral reduction mammaplasty case no. 3. Patient who underwent bilateral reduction mammaplasty for macromastia. Preoperative frontal view.
F18
Fig. 18.:
Bilateral reduction mammaplasty case no. 3. Frontal view 6 months postoperatively.

DISCUSSION

The techniques established in breast reduction are diverse. When referring to macromastia, we limit the techniques to traditional options, such as inferior pedicle, free nipple graft, and superomedial pedicle. The degree of undermining or tunneling that we must perform in the breast and opening of the central detachment zone (tunnel) depends on the distribution of breast tissue and the width diameter of the rib cage.

The arterial flow of the breast from any of its origins (internal mammary artery’s branches, intercostal branches, lateral thoracic, acromioclavicular, and Manchón artery) goes to the NAC and is mainly found in the upper poles, going to the nipple as the central axis. The techniques described in the literature focus on one of these pedicles to ensure NAC preservation. However, the dominant blood supply of the NAC is not always symmetrical.20 In current superior pedicle techniques for NAC ascent, two things are done: disruption of a proportion of the venous return (which is superficial and transverse, but the most important is the superficial) and significant thinning of the pedicle, planning without taking into account the integrity of the greater proportion of arteries. However, techniques, including two pedicles, such as the superomedial, the Strombeck technique, the Findlay technique, and the Mckissock technique, have already been reported.6,21,22 Nonetheless, evidence from other studies has shown nipple necrosis rates of 0.8%–2.3% in the inferior pedicle, 2.1% in the superomedial pedicle, and 2.3% in the superolateral pedicle technique (Figs. 19, 20).12,23,24

F19
Fig. 19.:
Block approach and vascular flow. Mammary arterial flow, where the predominance of the internal mammary artery occupies between 48% and 60% of total circulation, whereas intercostal arteries occupy 24.4%, and lateral thoracic artery, 23.2%.
F20
Fig. 20.:
Breast arterial anatomy. Publications describing breast anatomy have emphasized different arterial and venous circulation trajectories, which predominate at the superior pole of the breast.

Based on the literature, after a certain volume is resected (1500 grams), in lengths greater than 9 cm of NAC rise and lengths from the SN to the NAC greater than 30–40 cm, doing a superior pedicle would not be an option because it could rotate or become congested. So an inferior pedicle, free nipple graft, or superomedial pedicle is advised in that situation.5,23,25 Likewise, it has been established that a long ascent pedicle with a superior technique can cause venous congestion, increased tissue tension, and difficulty in flap ascent. However, this technique can be performed safely with respect for multiple vascularity, maintenance of adequate venous drainage, and respect for nonresection areas, added to marking that prevents distortion of vascular structures.

We prefer to perform the reduction in a way that the entire upper circulation is included, preserving vascular structures (internal mammary artery’s branches, lateral thoracic, and intercostal branches) and obtaining an abundant blood supply for the NAC. On the other hand, the venous circulation of the breast is 90% transverse and superficial. Thus, we respect the integrity of the entire dermis (superomedial, lateral, and caudal up to 4 cm) to ensure the venous return to avoid NAC damage and loss. (See figure, Supplemental Digital Content 4, which shows breast tissue deep venous drainage distribution, https://links.lww.com/PRSGO/C330; see figure, Supplemental Digital Content 5, which shows superficial venous plexus features, https://links.lww.com/PRSGO/C331; see figure, Supplemental Digital Content 6, which describes the areolar venous drainage system, https://links.lww.com/PRSGO/C332.18,27,28) Inadequate drainage, torsion of the pedicle, hematoma, and elevations of more than 15 cm of the NAC are known causes of venous congestion.4

Vertical marking is versatile and allows us to mark in a horizontal position again if necessary. We prefer this instead of the Wise and McKissock patterns since the percentage of skin resection will not always be proportional to the wanted removal of breast tissue, which may produce tension in the closure. The horizontal correction allows the breast tissue to indicate the real percentage of resection and avoids subsequent retouching, which occurs recurrently. Preservation of the medial and lateral areas without detachment or resection in an established diameter protects the entire upper circulation, giving us more security in the absence of any traditional blood supply vessel to the breast. The fibrous horizontal septum, which originates from the medial to the lateral area, is thinner in the center. This septum rises to the skin area housing the mammary nutrient vessels. The septum behaves like a mammary mesentery, so respecting this area ensures the integrity of the existing pedicles.11

We performed random thoracic angiotomography in patients, which confirmed the variant of pedicles up to both breasts in the same patient. As described by Van Deventer et al and Kierath et al, the number of patients in whom the internal mammary artery’s branches predominated was 19 cases, external mammary was 5 cases, and external and internal mammary artery’s branches was 3 cases; however, more studies are required in the future with a larger population.16,18,20 Although we do not consider it to be a routine study for primary reductions, it can provide valuable information in secondary breast reductions where we do not know the viable pedicles or the technique that was previously performed. In these cases, as in this study, breast tomosynthesis28 and Doppler ultrasonography20,27 might be considered.

We have observed that a lateral displacement of the NAC is not necessarily the origin of true lateral implantation in cases of macromastia, but rather the product of overgrowth or asymmetric development toward the medial or lateral portion. To correct this in a breast marking, an asymmetric resection of the tissue will be performed at the time of tunneling, managing to medialize the NAC without making lateral cuts to the dermis.29 On the other hand, in cases of larger volumes, we have achieved a large resection only by removing the lower pole of the breast. In other cases, we have achieved a central tunnel over the pectoral fascia of variable width depending on the thorax, with a diameter of up to 8 cm, performing an upper resection of the tissue.

CONCLUSIONS

All surgical techniques for reduction mammoplasty are based on the care of the NAC, choosing pedicles that ensure a good circulatory supply. The understanding of these rules and anatomical knowledge is essential to prevent necrosis, especially if venous drainage is respected, both in its superficial and deep system. Applying this technique for more than 16 years, we have seen that it is safe, easy to reproduce, and respects the upper circulation of the breast. In the case of lateral displacement of the NAC, it allows their medialization. The percentage of complications is low, and in no case has there been damage or necrosis of the NAC. There is no evidence of limitation with the resection volumes, and the approach respects the vascular anatomy of the region.

COMMENTS

To our knowledge, there is no such thing as an innocuous technique for breast reduction, but as much regard, there is for vascularization, less likely the risk of creating a lesion in our patients.

ACKNOWLEDGMENT

We wish to thank Elly Pichardo, MD, and Luis Ariel López-Zabala, MD, for their contribution and support.

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Supplemental Digital Content

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