Superior-medial pedicle technique for large breast reduction

Abstract

The surgical techniques of reduction mammoplasty combine both the reconstructive and aesthetic aspects of plastic surgery [1]. While the primary goal of reduction mammoplasty is to decrease the weight and size of the breast, aesthetic improvement is a high priority. Current refinements in breast reduction techniques strive to provide relief of physical discomfort while preserving breast function and maximizing aesthetic results. Reduction mammoplasty has been described for more than 100 years; early techniques involved mastectomy or simple amputation of the breast. The procedure has evolved significantly from the lower pole amputation and free nipple graft described by Th orek in 1931 [2]. Schwarzmann [3] proposed preserving the subdermal arterial and venous supply of the nipple/areola complex. This approach increased nipple survival and led to the practice of deepithelializing the pedicles of the breast flaps, which is still practiced today. In 1956, Wise expanded this concept, resulting in the inverted T scar still commonly used [4]. To increase nipple viability, various approaches were developed to maintain the nipple areolar complex on a pedicle of both dermis and subcutaneous tissue. Breast resection was performed above and below the level of the nipple areolar complex (NAC). Variation in parenchymal resection included Strömbeck s horizontal bipedicle, Skoog s lateral pedicle, McKissock s vertically oriented, bipedicle flap, Ribeiro s inferiorly based dermoglandular flap, Weiner s superiorly based pedicle and the central-mound technique described by Balch [5-10]. Each of these techniques attempted to preserve vascularity, innervation and lactation of the nipple areolar complex. While the inferior pedicle remains the most popular technique in the United States today, the superomedial based techniques are becoming increasingly popular. Lejour s and Lassus utilization of the vertical scar mammoplasty emphasized resection of breast tissue rather than skin and advocated the use of suction assisted lipectomy to shape the breast [11-14]. These techniques preserve the dermoparenchymal microvasculature which in turn minimizes the risk of skin and fat necrosis. The superiorly based pedicle techniques include less skin undermining and simplified resections resulting in reduced operative time. Shaping the breast mound, which can be difficult with techniques that disrupt the dermoparenchymal relationship, becomes more easily achievable with intraparenchymal pillar suturing which are part of these techniques. Subsequent variations of the vertical reduction mammoplasty include utilization of the superomedial pedicle and durability of the superomedial variant has been demonstrated by advocates such as Hall-Findlay [15, 16]. Her results show this approach provides an elegant synthesis of the superomedial pedicle and vertical closure, maintaining the dermoparenchymal unit yielding excellent long term results. The experiences of the author have also demonstrated the superomedial reduction to be a simple method of vertical reduction mammoplasty with excellent long term aesthetic results having low complication rates and safety even in larger volume reductions. The safety profile is maintained in larger volume reductions up to 2,750 g and in patients otherwise considered to be high risk. © 2009 Springer-Verlag Berlin Heidelberg.