Superior vertical dermal pedicle for the nipple-areola

Abstract

The goal in reduction mammaplasty and mastopexy is to achieve a pleasing balance among size, shape, and projection of the breast with optimal sensation and appropriate blood supply for the nipple-areola and breast, accompanied by breastfeeding after the surgery. Anthropomorphic measurements of the female breast and thorax are useful as guidelines in planning reduction mammaplasty [1]. Size, shape, and projection of the breast and its landmarks are distorted in massive breast hypertrophy and severe breast ptosis. Measurements are employed in an attempt to achieve symmetry between the breasts and its correlation with the torso shape, also to establish its position on the thorax. The traditional treatment for massive breast hypertrophy or severe breast ptosis is amputation of the inferior portion of the breast with free graft ing of the nipple-areola [2]. The usual complications of free nipple-areola graftechnique include temporary or permanent loss of sensation, necrosis, hypopigmentation, and flatness of the nipple-areola. The relatively high number of complications and the disadvantage of the free nipple-areola graft led to the development of numerous pedicle techniques to avoid nipple-areola deformities. Age, smoke, body mass index, and amount of mammary tissue resected must be taken into account to choose the appropriate pedicle technique for the nipple-areola in reduction mammaplasty. However, the main criteria in deciding the suitable pedicle technique for nipple-areola are the surgical parameters. The length and the thickness of the pedicle rather than the amount of mammary tissue resected are the most important limiting factors for the transposition of the nipple-areola [3]. Several pedicle techniques were proposed to avoid vascular compromise and loss of sensation of the nipple- areola in reduction mammaplasty for massive breast hypertrophy and severe ptosis. Inferior pedicle techniques are usually reported as the main support pedicle for nipple-areola in heavy hypertrophy and ptosis of the breast [4]. Superior pedicle techniques have also provided a safety transposition of the nipple-areola in reduction mammaplasty for moderate and large breast hypertrophy and ptosis [5]. A variation of the superior pedicle techniques is the vertical orientation of the pedicle. It addresses a straight transposition for the nipple-areola avoiding a winding course of the pedicle to lead the nipple-areola to the new location without distortion [6]. Although the medial pedicle technique originates from the superomedial pedicle technique it was developed for all breast hypertrophy, especially management of severe mammary hypertrophy [7]. Another alternative for transposition of the nipple-areola is a dermoglandular latero-central pedicle that was proposed to reduction mammaplasty for moderate breast hypertrophy [8]. No matter what pedicle technique is used, the excessive length and thickness of pedicle can cause torsion, twisting, and compression over the pedicle during the transposition of the nipple-areola with damage of the vascularity and sensibility of the nipple-areola. To appraise nipple-areola viability aft er transposition, an intraoperative evaluation of the blood supply can be carried out independent of the pedicle technique used for the nipple-areola. It is performed by applying an intravenous injection of fluorescein sodium 10% and watching the coloring of the nipple-areola exposed to ultraviolet light in a darkish operating room [9]. Otherwise, temporary loss of sensation of the nipple- areola is a common occurrence in reduction mammaplasty with extensive resection of the breast tissue or excessive raise of the nipple-areola. Recovery of sensation of the nipple and areola can result from the regeneration of the cutaneous branches of the intercostal nerves or from the remaining cutaneous innervation of the breast rather than the preserved adjacent cutaneous branches [10]. Quantitative tests using Semmes- Weinstein monofilaments or computer-assisted neurosensory testing are employed to quantify the sensibility of the breast and nipple-areola aft er reduction mammaplasty [11, 12]. Subjective tests as crude touch with to identify, not quantify, sensation on the breast skin and nipple-areola aft er reduction mammaplasty [13]. Prospective studies have demonstrated that nipple-areola sensation at month 6 was statistically similar compared to reduction mammaplasty with superior and inferior pedicle techniques for the nipple-areola [14]. No statistically significant difference was found on breast and nipple-areola sensation regarding the amount of breast tissue removed [15]. No diff erence was found in the aesthetic outcome and complications between superior and inferior pedicle techniques in reduction mammaplasty [16]. © 2009 Springer-Verlag Berlin Heidelberg.