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Bonomi F, Harder Y, Treglia G, Limido E, De Monti M, Parodi C. Sensory preservation in reduction mammoplasty using the nipple-areola complex-carrying pedicle technique for gigantomastia: A systematic review and meta-analysis. JPRAS Open 2025; 43:153-163. [PMID: 39735203 PMCID: PMC11681826 DOI: 10.1016/j.jpra.2024.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Accepted: 11/10/2024] [Indexed: 12/31/2024] Open
Abstract
Background Gigantomastia is a disabling condition characterized by excess breast tissue. Historically, free nipple graft (FNG) has been preferred, prioritizing the nipple-areola complex (NAC) vascularity. The NAC-carrying pedicle technique, which is most commonly used in case of hypertrophy of the breast, has been suggested as a viable alternative for gigantomastia according to recent evidence, with reduced rates of NAC necrosis and improved outcomes. Nevertheless, a detailed outcome evaluation of the technique in terms of sensory preservation is currently lacking. Therefore, this systematic review and meta-analysis aimed to assess the risk of sensory loss associated with the NAC-carrying pedicle technique in cases of gigantomastia. Methods Following the PRISMA guidelines, a literature search identified studies reporting postoperative sensitivity with the NAC-carrying pedicle technique in resections exceeding 1000 g of adipo-glandular tissue. Then, a proportion meta-analysis was conducted to assess the pooled rate of sensation loss through the NAC-carrying pedicle technique. Results Seventeen studies (843 patients, 1685 breasts) met the inclusion criteria. The meta-analysis revealed an exceptionally low risk of sensory loss with the NAC-carrying pedicle technique (1.3%; 95% confidence interval: 0.7-2.0), without significant statistical heterogeneity. Conclusion This study provides the first comprehensive evaluation of sensory preservation with the NAC-carrying pedicle technique in gigantomastia. The NAC-carrying pedicle technique emerges as the first choice, offering safety and favorable functional outcomes. Surgical caution remains crucial with the option to switch to FNG as required, ensuring patient safety and procedure success. Further research on the impact of different NAC-carrying pedicle techniques on sensory preservation is warranted.
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Affiliation(s)
- F. Bonomi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Y. Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - G. Treglia
- Division of Medical Education and Research, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - E. Limido
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
- Department of Surgery, Ospedale Beata Vergine di Mendrisio, Ente Ospedaliero Cantonale (EOC), Mendrisio, Switzerland
| | - M. De Monti
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Department of Surgery, Ospedale Beata Vergine di Mendrisio, Ente Ospedaliero Cantonale (EOC), Mendrisio, Switzerland
| | - C. Parodi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
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Kanjoor JR, Jain A, Pakkiri S. Gigantic Macromastia: Modified Superomedial Pedicle is a Good Solution. Indian J Plast Surg 2024; 57:440-446. [PMID: 39734382 PMCID: PMC11679172 DOI: 10.1055/s-0044-1787721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2024] Open
Abstract
Background Reduction of very huge breast-gigantic macromastia-is a challenge to breast surgeons in choosing the right procedure to obtain an optimal outcome. The feasibility of a superomedial pedicle (SMP) with some modifications proves to be a good option to achieve a viable nipple areolar complex (NAC) with good size and shape after good resection above 800 g. Materials and Methods Out of the 35 patients with 70 breast reductions, 15 can be considered gigantic macromastia with reductions above 800 g. A retrospective analysis of 30 breast reductions in these 15 patients from 2010 to 2023 was done. All cases were done using SMP with some modifications. The sternal notch to the nipple, the new NAC site, pedicle length, resection weight, and complications were analyzed. The modifications followed were lowering the new NAC, narrowing the distance between medial and lateral pillar width, medializing the pedicle, and lengthening the vertical limb. Results There was no total necrosis of the NAC. Partial necrosis occurred in three patients that were managed conservatively and one case of fat necrosis needed debridement. All of them had a good size, shape, and form. Conclusion SMP is a versatile technique with flexibility to modify the dimensions to get a robust blood supply to the NAC, after obtaining an adequate resection.
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Affiliation(s)
| | - Aakansh Jain
- Roys Cosmetic Surgery Centre, Coimbatore, Tamil Nadu, India
| | - Sathya Pakkiri
- Roys Cosmetic Surgery Centre, Coimbatore, Tamil Nadu, India
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Qiang S, Wang JY, Wang N, Wei SM, Zhang ZX. Vertical Scar Reduction Mammaplasty Using the Superomedial-Based Pedicle Technique in Gigantomastia. Ann Plast Surg 2024; 93:290-296. [PMID: 38980950 DOI: 10.1097/sap.0000000000004009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
BACKGROUND Breast reduction surgery has witnessed significant advancements in recent years; however, it continues to pose challenges for both surgeons and patients when dealing with cases involving excessive breast volume and severe breast ptosis. This study aimed to assess the aesthetic outcomes and the impact on the quality of life, as measured by the BREAST-Q questionnaire, in patients with gigantomastia and severe breast ptosis who underwent reduction mammaplasty using the superomedial-based pedicle technique. METHODS We present a retrospective series comprising 84 patients who underwent reduction mammoplasty utilizing the superomedial pedicle technique. The surgical resections exceeded 1 kg per breast, with a mean resection weight of 1506.58 g (right breast) and 1500.32 g (left breast). The preoperative mean suprasternal notch to nipple distance measured 40.50 cm (right breast) and 40.38 cm (left breast). Postoperatively, the patients were followed up for a minimum of 6 months. Both preoperative and postoperative BREAST-Q surveys were administered to the participants, and scores were analyzed using descriptive statistics. RESULTS Complications were observed in 3 patients (3.57%), characterized by partial loss of the areola, which resolved spontaneously over time. Additionally, 2 cases of hematoma and 2 instances of minor delayed wound healing were reported. All patients expressed satisfaction with their aesthetic outcomes, as they achieved a natural breast shape and minimal scarring, along with symptomatic relief. CONCLUSIONS The superomedial pedicle reduction mammaplasty technique has demonstrated its ability to produce satisfactory aesthetic outcomes and long-term benefits in patients with excessively large breasts. Careful patient selection and postoperative management are vital for achieving optimal results. Further investigations involving larger sample sizes and longer follow-up periods are warranted to validate our findings. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Shuai Qiang
- From the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University
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Kaplan HY, Rysin R, Shachar Y. The Infero-Central Mound Reduction Mammoplasty: A Single Surgeon, 20-year Experience. Aesthetic Plast Surg 2024; 48:914-924. [PMID: 37380748 DOI: 10.1007/s00266-023-03442-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/27/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Reduction mammoplasty (RM) remains one of the most common plastic surgeries worldwide. Many different techniques have been described in the literature, each with its advantages and limitations. Nipple-areolar complex necrosis remains a daunting complication, regardless of the chosen surgical approach. OBJECTIVE We describe the senior author's (HYK) unique reduction mammoplasty technique, employing the infero-central (IC) pedicle throughout the last two decades. PATIENTS AND METHODS A retrospective chart review of 520 patients undergoing breast reduction was performed. After exclusion criteria, 360 were included in the study. These patients underwent RM with the IC technique, with stabilization of the breast mound and plication of the inferior pole dermis to prevent bottoming out. Demographics, operative data, and complications were recorded. Pre- and postoperative photographs were evaluated by a specialists' panel. The BREAST-Q questionnaire was utilized to assess satisfaction rates. RESULTS BREAST-Q questionnaire-satisfaction with breast score was 84.19, and outcome score was 91.67. Aesthetic outcome evaluation, reviewed by four plastic surgeons, yielded a high score in all parameters (1.64-2; range 0-2). On a per-breast basis for all patients, the following complications were analyzed: dehiscence (3.61%), infection (2.22%), hematoma (1.66%), superficial wound healing problems (1.38%), seroma (0.83%), skin flap ischemia (1.52%), hypertrophic scar (1.38%), fat necrosis (0.97%), and partial nipple ischemia (0.27%). CONCLUSION Infero-central mound technique can be applied to breast reductions of nearly all sizes, allowing for consistently satisfactory aesthetic outcomes for most patients. Due to robust vascularity of the pedicle, complication rates are kept at a minimum. IC mound technique is an essential tool in the plastic surgeon's armamentarium. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Haim Yoel Kaplan
- Department of Plastic Surgery, Yitzhak Shamir Medical Center, 70300, Tzrifin, Israel.
- Private clinic, 10 Dubnov street, 6473209, Tel Aviv, Israel.
| | - Roman Rysin
- Private clinic, 10 Dubnov street, 6473209, Tel Aviv, Israel
| | - Yair Shachar
- Private clinic, 10 Dubnov street, 6473209, Tel Aviv, Israel
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Cunning JR, Mookerjee VG, Alper DP, Rios-Diaz AJ, Bauder AR, Kimia R, Broach RB, Barrette LX, Fischer JP, Butler PD. How Does Reduction Mammaplasty Surgical Technique Impact Clinical, Aesthetic, and Patient-Reported Outcomes?: A Comparison of the Superomedial and Inferior Pedicle Techniques. Ann Plast Surg 2023; 91:28-35. [PMID: 37450858 DOI: 10.1097/sap.0000000000003610] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes. METHODS Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed. RESULTS Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03). CONCLUSIONS The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.
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Affiliation(s)
| | - Vikram G Mookerjee
- Division of Plastic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - David P Alper
- Division of Plastic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Arturo J Rios-Diaz
- From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia
| | - Andrew R Bauder
- From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia
| | | | - Robyn B Broach
- From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia
| | | | - John P Fischer
- From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia
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Talwar AA, Copeland-Halperin LR, Walsh LR, Christopher AN, Cunning J, Broach RB, Baratta MD, Copeland M, Shankaran V, Butler PD. Outcomes of Extended Pedicle Technique vs Free Nipple Graft Reduction Mammoplasty for Patients With Gigantomastia. Aesthet Surg J 2023; 43:NP91-NP99. [PMID: 36161307 DOI: 10.1093/asj/sjac258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG). OBJECTIVES The authors compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty employing EP vs FNG. METHODS A multi-institutional, retrospective study of adult patients with gigantomastia who underwent reduction mammoplasty at 2 tertiary care centers from 2017 to 2020 was performed. Gigantomastia was defined as reduction weight >1500 g per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at 1 institution employed the EP technique, whereas those at the other utilized FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes. RESULTS Fifty-two patients met the inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, P < 0.05) but no other differences in surgical or medical complications. Baseline BREAST-Q scores did not differ between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (P < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (P < 0.05), independent of institution or surgical experience. CONCLUSIONS This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Ankoor A Talwar
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Libby R Copeland-Halperin
- Division of Plastic Surgery, Department of Surgery, The Brigham and Women's Hospital, Boston, MA, USA
| | - Landis R Walsh
- Division of Plastic Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica Cunning
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael D Baratta
- Division of Plastic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Michelle Copeland
- Division of Plastic Surgery, Department of Surgery, Mount Sinai Health System, New York, NY, USA
| | - Vidya Shankaran
- Division of Plastic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Paris D Butler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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7
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Eren S, Öreroğlu AR. Modified Central Pedicle in Breast Reduction and Mastopexy: The Dermal Suspension Technique. Aesthetic Plast Surg 2022; 46:2753-2765. [PMID: 35794243 DOI: 10.1007/s00266-022-02980-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Breast reduction and mastopexy surgery are among the most performed plastic surgery operations throughout the world. Despite development of a variety of surgical techniques for mastopexy surgeries, problems associated with this operation are not yet fully eliminated. OBJECTIVES The aim of this paper is to show the favorable reliability of the central pedicle surgery and introduce the modification with dermal suspension flaps for glandular repositioning and skin envelope reinforcement. METHODS The modified central pedicle reduction mastopexy with dermal suspension surgical technique is explained with details on flap planning, skin dissection, parenchyma resection, breast shaping and nipple-areola repositioning and skin re-drape and closure. RESULTS The breast contour is formed by shaping of the central gland and wrapping of the central gland by the deepithelized dermal flaps like a brassiere after peripheric resection. This results in an aesthetically pleasant glandular shaping, better longevity of the breast shape and tensionless skin closure, followed by high quality scars. Results from over 1850 cases are discussed. CONCLUSIONS Even though the central pedicle reduction mammoplasty technique requires more experience and has a steeper learning curve in comparison with other popular techniques used today, the long run advantages such as better projection, upper pole fullness and less breast sagging are far more satisfying. In this method, the envelope formed by the skin does not define the breast contour. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Serdar Eren
- Acıbadem Maslak Hastanesi, Büyükdere Caddesi No: 40, Sarıyer, 34457, Istanbul, Türkiye
| | - Ali Rıza Öreroğlu
- Dr. Öreroğlu Aesthetic Clinic, Maçka Cd. No: 24/28 Narmanlı Apt. Teşvikiye Nişantaşı, Şişli, 34367, Istanbul, Türkiye.
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Hunt SC, Sun Y, Azad S. A Simplified Approach to Breast Reduction Using the Medial Pedicle. Aesthet Surg J Open Forum 2022; 4:ojac019. [PMID: 35662909 PMCID: PMC9153379 DOI: 10.1093/asjof/ojac019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Breast reduction is a common procedure for plastic surgery. We have adopted a modified technique using the medial pedicle, with markings using a 15-9-9 framework and a methodical step wise approach.
Objectives
This study introduces the 15-9-9 framework as a design for medial pedicle breast reductions that is easy to perform and teach, with favourable outcomes.
Methods
Markings using the 15-9-9 framework was used, describing the mosque dome and medial pedicle length and width. The technique was performed in day surgery under general anesthesia. Patients were followed up to 1 year, with photographs taken at each visit and complications recorded. A retrospective review of 80 patients between November 2013 and July 2019 was completed in a single surgeon’s practice.
Results
Patients were an average of 49 years (18-72 years) with a BMI of 28 (23-32). The average postoperative sternal notch to areola distance was 22 cm (19-26 cm) and sternal notch to nipple distance was 24 cm (21-28). The average duration of the surgical procedure was 3.4 hours. An average of 464 g (90-1210 g) was removed from each breast. Complication rates were low with minor fat necrosis (14%), T junction breakdown (10%), hematoma (3.8%), dog ear formation (3.8%), junctional necrosis (2.5%), and partial nipple loss (1.3%). One patient had a cerebrovascular accident in the late postoperative period. Aesthetically pleasing results were achieved postoperatively.
Conclusions
This technique using the 15-9-9 framework is simple to learn, perform and teach with overall aesthetically pleasing outcomes.
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Affiliation(s)
- Sarah C Hunt
- Northern Ontario School of Medicine in Thunder Bay, Ontario, Canada
| | - Yue Sun
- Northern Ontario School of Medicine in Thunder Bay, Ontario, Canada
| | - Sanjay Azad
- Northern Ontario School of Medicine in Thunder Bay, Ontario, Canada
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9
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Double-Unit Superomedio-Central (DUS) Pedicle Inverted-T Reduction Mammaplasty in Gigantomastia: A 7-year Single-Center Retrospective Study. Aesthetic Plast Surg 2021; 45:2061-2074. [PMID: 34145475 PMCID: PMC8481221 DOI: 10.1007/s00266-021-02351-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/09/2021] [Indexed: 11/15/2022]
Abstract
Introduction Reduction mammaplasty in patients with gigantomastia is challenging. The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is the standard technique for reduction mammaplasty in our clinic. The aim of this study was to review our approach in cases with gigantomastia in comparison with the current literature. Patients and Methods From 01/2011 to 12/2017, we performed 831 reduction mammaplasties in 630 patients. The Double-Unit Superomedio-Central (DUS) pedicle and inverted-T incision was implemented as a standard procedure for gigantomastia. Patient demographics and the outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility, and surgical revision rate were obtained and retrospectively analyzed. Results In 37 patients, 55 reduction mammaplasties were performed with more than 1000 g per breast. Mean resection weight was 1311 g on right side and 1289 g on left side. Mean age was 52.5 years, mean body mass index was 32.8 kg/m2, mean sternal-notch-to-nipple distance was 38.3 cm. A free NAC graft was necessary in four breasts. Overall complication rate was 14.5%; secondary surgical revision rate was 12.7%. 91% of the patients were “very satisfied” and “satisfied” with the aesthetic result. Nipple sensibility was rated “high” and “medium” in 83%. Conclusion The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is very effective to achieve volume reduction and aesthetically pleasing reproducible results with a low complication rate in cases with gigantomastia. Level of Evidence Level of Evidence This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Supplementary Information The online version contains supplementary material available at 10.1007/s00266-021-02351-y.
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Singolda R, Bracha G, Zoabi T, Zaretski A, Inbal A, Gur E, Barnea Y, Arad E. Superiomedial Pedicle Breast Reduction for Gigantic Breast Hypertrophy: Experience in 341 Breasts and Suggested Safety Modifications. Aesthetic Plast Surg 2021; 45:375-385. [PMID: 32964280 DOI: 10.1007/s00266-020-01973-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Reduction mammoplasty in patients with gigantic breast hypertrophy runs a high risk of complication. Traditionally, inferior pedicle reductions or free nipple grafting techniques have been recommended for gigantic breasts on the basis of measurements and expected resection weights. The superiomedial pedicle (SMP) technique has been less commonly used, due to concerns of vascular inadequacy. This study examines the outcomes of SMP in large reductions and outlines suggested modifications for enhanced safety. METHODS This is a retrospective review of all patients who underwent SMP breast reduction in our institution between 2005 and 2016. Included are cases with resection weights greater than 800 g. RESULTS A total of 173 patients with 341 breasts were included. Mean sternal notch to nipple (SNN) distance was mean 35.0 ± 6.6 cm (range 23-44.5) on the left and 34.9 ± 6.6 cm (range 18-46) on the right. Mean resection weight was 1152.2 ± 368.6 g (range 810-2926) on the left and 1159.4 ± 326.6 g (range 800-2528) on the right. The total complication rate was 22.7%. Minor complications occurred in 63 (18.6%) breasts. Major complications occurred in 12 (4.1%) breasts. NAC congestion and partial necrosis occurred in 1.8% and total NAC necrosis in 0.9%. CONCLUSION The SMP reduction technique is a safe option for gigantic breast reduction with comparable complication rates to other techniques. Preoperative measurements or resection weights are not reliable risk factors alone. High tissue density may be a significant risk factor. High-risk breasts mandate surgical planning and should be tailored to include technical modifications as described. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Affiliation(s)
- Roei Singolda
- Department of Plastic and Reconstructive Surgery, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel.
- Department of Plastic Surgery, Tel-Aviv Sourasky Medical Center, 6 Weizmann St., 6423906, Tel-Aviv, Israel.
| | - Gal Bracha
- Department of Plastic and Reconstructive Surgery, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Tariq Zoabi
- Department of Plastic and Reconstructive Surgery, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Arik Zaretski
- Department of Plastic and Reconstructive Surgery, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Amir Inbal
- Department of Plastic and Reconstructive Surgery, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal Gur
- Department of Plastic and Reconstructive Surgery, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yoav Barnea
- Department of Plastic and Reconstructive Surgery, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Ehud Arad
- Department of Plastic and Reconstructive Surgery, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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11
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Toplu G, Altınel D, Serin M. Evaluation of Factors Related to Postoperative Complications in Patients Who Underwent Reduction Mammoplasty. Eur J Breast Health 2021; 17:157-164. [PMID: 33870116 DOI: 10.4274/ejbh.galenos.2021.6336] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/26/2021] [Indexed: 12/01/2022]
Abstract
Objective This study aimed to investigate whether there was an increase in the number of postoperative complications in patients undergoing reduction mammoplasty depending on the technique used (i.e., pedicle type, skin incision pattern), existence of concomitant diseases, and presence of other risk factors. Materials and Methods A total of 186 patients who underwent breast reduction between 2013 and 2018 (bilateral, n = 170; unilateral, n = 16) were included in the study. A retrospective review of the data of patients who underwent reduction mammoplasty, which was performed by the same surgical team in a single institution over a 6-year period, was carried out. Superomedial, superior, and inferior pedicles were used in 99, 55, and 32 patients, respectively. The median follow-up period was 4 years. Results The median patient age was 45 (range: 16-75) years. The median total reduction weight was 2,194 (range: 80-4,800) grams. The median distance between the sternal notch and nipple was 31 cm (range: 24-45 cm) for the right breast and 30 cm (range: 22-45 cm) for the left breast. The overall complication rate was 6.9%. The complication rates in patients with and without any concomitant diseases were 10.2% and 4.6%, respectively. The overall complication rate was significantly higher in patients with smoking habit, accessory breasts, progesterone use, cerebrovascular disease, morbid obesity (Body Mass Index ≥40 kg/m2), and thalassemia. Conclusion Our analysis shows that the presence of concomitant diseases increases the risk for postoperative complications in patients who underwent reduction mammoplasty. Our findings do not suggest that any of the techniques have significant superiority to each other in terms of pedicle safety and overall complication rate.
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Affiliation(s)
- Gaye Toplu
- Department of Plastic Surgery, University of Health Sciences Turkey, İstanbul Training and Research Hospital, İstanbul, Turkey
| | - Dinçer Altınel
- Department of Plastic Surgery, University of Health Sciences Turkey, İstanbul Training and Research Hospital, İstanbul, Turkey
| | - Merdan Serin
- Department of Plastic Surgery, University of Health Sciences Turkey, İstanbul Training and Research Hospital, İstanbul, Turkey
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Restifo RJ. The Pedicled Robertson Mammaplasty: Minimization of Complications in Obese Patients With Extreme Macromastia. Aesthet Surg J 2020; 40:NP666-NP675. [PMID: 32173731 DOI: 10.1093/asj/sjaa073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Breast reduction for extreme macromastia in obese patients is a potentially high-risk endeavor. Free nipple grafting as well as a variety of pedicled techniques have been advocated for large reductions in obese patients, but the number of different approaches suggests that no single method is ideal. This paper suggests the Robertson Mammaplasty, an inferior pedicle technique characterized by a curvilinear skin extension onto the pedicle, as a potentially favorable approach to this clinical situation. OBJECTIVES The author sought to determine the safety of the Pedicled Robertson Mammaplasty for extreme macromastia in obese patients. METHODS The records of a single surgeon's practice over a 15-year period were retrospectively reviewed. Inclusion criteria were a Robertson Mammaplasty performed with a >3000-g total resection and a patient weight at least 20% above ideal body weight. Records were reviewed for patient characteristics, operative times, and complications. RESULTS The review yielded 34 bilateral reduction patients that met inclusion criteria. The mean resection weight was 1859.2 g per breast, the mean body mass index was 36.4 kg/m2, and the mean sternal notch-to-nipple distance was 41.4 cm. Mean operative time was 122 minutes. There were no cases of nipple necrosis and no major complications that required reoperation under general anesthesia. A total 26.4% of patients had minor complications that required either local wound care or small office procedures, and 4.4% received small revisions under local anesthesia. CONCLUSIONS The Pedicled Robertson Mammaplasty is a fast and safe operation that yields good aesthetic results and a relative minimum of complications in the high-risk group of obese patients with extreme macromastia. LEVEL OF EVIDENCE: 4
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Reliability and versatility of the Wise pattern, medial pedicle for breast reduction in South Africa. Surg Open Sci 2020; 2:85-91. [PMID: 32754711 PMCID: PMC7391885 DOI: 10.1016/j.sopen.2019.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 11/23/2022] Open
Abstract
Background Breast hypertrophy is a condition of abnormal enlargement of the breast which may continue until each breast weighs more than 1.5 kg (macromastia) or even more than 2 kg (gigantomastia). Supporting such heavy weights leads to cervical and upper thoracic back pain, costochondritis, and fungal infections in the mammary folds, making reduction mammoplasty essential. However, there is a lack of consensus among plastic surgeons as to the best technique. This study reports the results of reduction mammoplasties in South African women using the Wise pattern, minimally undermined with a medial pedicle. Methods A retrospective record review of the reduction mammoplasties was conducted over a 1-year period. Patient records were assessed for early complications related to vascular reliability. Results One hundred and fourteen Wise pattern minimally undermined, medial pedicle techniques were performed on 57 consecutive patients in the 1-year period at the NetCare Rand Clinic in Berea, Johannesburg, South Africa (EN). The patients' sternal notch to nipple distances ranged from 28 to 52 cm. The volume of breast reduction ranged from 345 g to 3300 g per breast. The overall complication rate was 9.7%, consisting of fat necrosis (3.5%), infection (1.7%), dehiscence (3.5%), and nipple epidermolysis (0.9%). Conclusion The minimally undermined Wise pattern medial pedicle breast reduction technique proved to be a reliable technique for breast reduction in the South African population. Safety in pedicle breast reduction with sternal notch to nipple distances of up to 50 cm, as well as reliability and versatility in a wide range of breast sizes, was demonstrated.
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The Central Mound Pedicle: A Safe and Effective Technique for Reduction Mammaplasty. Plast Reconstr Surg 2020; 146:725-733. [DOI: 10.1097/prs.0000000000007173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Guridi R, Rodriguez JR. A Step-by-Step Approach to a Successful Cosmetic Breast Reduction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2117. [PMID: 31321163 PMCID: PMC6554151 DOI: 10.1097/gox.0000000000002117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/29/2018] [Indexed: 11/25/2022]
Abstract
Evolution of breast reduction techniques has been a result of combining different skin marking patterns with a wide variety of pedicles. Despite the many differences that may exist among these procedures, they all rely on a few key principles. To make surgery more expeditious and minimize technical challenges, these principles can be incorporated into simple surgical strategies. The authors present a step-by-step approach to help to achieve a successful cosmetic breast reduction for patients with small to moderate breast hypertrophy. Special emphasis is given to intraoperative clues that make this procedure more reproducible and straightforward.
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Affiliation(s)
- Rodrigo Guridi
- Department of Plastic and Reconstructive Surgery, Clínica Las Condes, Santiago, Chile
| | - José Ramón Rodriguez
- Department of Plastic and Reconstructive Surgery, Clínica Las Condes, Santiago, Chile
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Pereira Filho O, BIns Ely J, Lee KH, Paulo EM, Granemann AS. Multiplanar Assembly Mammaplasty Based on the Divine Proportion. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e1979. [PMID: 30881817 PMCID: PMC6416132 DOI: 10.1097/gox.0000000000001979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 08/22/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The study sought to plan mastopexy and breast reduction according to the principle of the divine proportion, represented by the letter phi, via the convergent assembly of multiple layers to create the new breast. This strategy is based on the constancy of the submammary fold and the orientation of the vertex of a V-shaped triangle opening at approximately 60° at the umbilicus, with each branch opening in the direction of the acromioclavicular joint. METHODS The strategy was prospectively investigated in 265 patients (n = 530 breasts). The mean patient age was 36 years. The follow-up ranged from 6 months to 3 years. RESULTS A total of 220 patients (83%) received a good score (1-4) according to Strasser grading. Complications were few, but included delayed healing with minimal scar ulceration in 19 patients (7%), asymmetry in 16 (6%), and partial nipple necrosis in 4 (1.5%). CONCLUSIONS This approach adds precision to mammaplasty, reduces the laxity in the axillary region, promotes bulk in the upper pole, and eases nipple-areola complex elevation.
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Affiliation(s)
- Osvaldo Pereira Filho
- Plastic Surgery Department, Clinica Jane - Hospital Ilha - UFSC, Florianópolis, Santa Catarina, Brazil
| | - Jorge BIns Ely
- Universidade Federal de Santa Catarina - UFSC, Florianópolis, Santa Catarina, Brazil
| | - Kuang Hee Lee
- Clinica Jane - Hospital Ilha, Florianópolis, Santa Catarina, Brazil
| | | | - Alfredo Spautz Granemann
- Clinica Jane, Plastic Surgery Department, Cirurgia Plástica, Florianópolis, Santa Catarina, Brazil
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Breast Reduction Using the Superomedial Pedicle- and Septal Perforator-Based Technique: Our Clinical Experience. Aesthetic Plast Surg 2019; 43:27-35. [PMID: 29948104 DOI: 10.1007/s00266-018-1177-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/03/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Adequate tissue removal must be performed for symptom relief following reduction mammoplasty. However, this is not always possible in patients with gigantomastia because the pedicle is planned wider and the breast cannot be sufficiently reduced to prevent compromising the blood supply to the pedicle. To maximize blood circulation to the nipple-areola complex in our patients, the pedicle was planned to include the internal thoracic artery branches coming from both the second and third interspaces and the intercostal artery branches coming from the fourth and fifth intercostal spaces. METHODS A total of 185 patients underwent reduction mammoplasty with the superomedial pedicle- and septal perforator-based technique. The mean weight of excised tissue was 928.77 g from the right breast and 899.92 g from the left, whereas the mean distance of nipple-areola transfer was 11.52 cm on the right breast and 11.27 cm on the left. RESULTS Complications developed in 11 patients (5.94%): hematoma occurred in three patients, partial loss of areola and fat necrosis in five patients, and wound dehiscence in three patients. CONCLUSIONS The pedicle included vessels of both superomedial and septum origin without any disruption in circulation. Consequently, the blood supply of the nipple-areola complex was preserved. Furthermore, in cases where the pedicle was long, intercostal perforators were identified and the pedicle was narrowed thoroughly; thus, the breast was reduced to the desired volume while minimizing the risk of complications. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Grieco MP, Bertozzi N, Grignaffini E, Raposio E. A three-year experience with medial-pedicle-based breast reduction for different mammary hypertrophy. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:389-396. [PMID: 30333464 PMCID: PMC6502123 DOI: 10.23750/abm.v89i3.5776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/15/2016] [Indexed: 11/23/2022]
Abstract
Background and aim:The aim of breast reduction is to reduce excessive breast volume, ensuring an adequate vascular supply and sensitivity of the nipple-areola complex, as well as to produce an aesthetically pleasing final shape. The authors report on their experience with medial-pedicle-based breast reduction combined with both vertical and inverted-T skin resection patterns for different types of breast hypertrophy. Methods:From January 2012 to June 2015, 27 female patients (mean age: 49 years) underwent reduction mammoplasty with the medial pedicle technique. The choices of medial pedicle base widths were: 6 cm for low-grade mammary hypertrophy (350-500 gr per breast), 6-8 cm for medium-grade hypertrophy (500-1000 gr per breast), or 8-10 cm for severe mammary hypertrophy (>1000 gr per breast). The authors chose the model of vertical skin resection for low-grade breast hypertrophy. The vertical model was used for medium-grade breast hypertrophy, and Wise skin resection was chosen on a case-by-case basis; only the Wise model was applied to severe breast hypertrophy. Results: The mean weight of breast excised was 540 g on the left (range, 207 to 1160 g) and 564.8 g on the right (range, 215 to 1150 g). The complications were minor and self-limiting. All patients reported relief of neck pain, back pain, and bra strap indentations after 6 months of follow-up. Conclusions: Breast reduction surgery must address both functional and aesthetic issue by restoring an aesthetically pleasing shape to ptotic or hypertrophic breasts, repositioning the NAC in a physiological position. Various breast reduction techniques have been attempted to combine the safety of the pedicle with aesthetic and functional results. Surgeons should tailor the best technique to each patient. We found that medial-pedicle-based reduction mammoplasty is effective and reliable because it can be applied to a wide range of breast hypertrophy, with reproducible breast weight reduction and results that are aesthetically satisfactory for both patients and surgeons. (www.actabiomedica.it)
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Affiliation(s)
- Michele Pio Grieco
- Department of Surgical Sciences, Plastic Surgery Division, University of Parma, Parma, Italy Cutaneous, Regenerative, Mininvasive and Plastic Surgery Unit, Parma University Hospital, Italy.
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McKissock's Reduction Mammaplasty Revisited: A Case Series Study with 12-months Follow-up. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1791. [PMID: 30276040 PMCID: PMC6157950 DOI: 10.1097/gox.0000000000001791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 04/03/2018] [Indexed: 11/26/2022]
Abstract
Background Reduction mammaplasty is 1 of the highly challenging yet demanded plastic surgeries worldwide. Different techniques have been described, and their modifications are always evolving to achieve better aesthetic results. The objective of the current study was to explore the efficiency and safety of bipedicled McKissock's technique with 3 newly added modifications as a reliable procedure for reduction mammaplasty. Methods The study was conducted in Royal Hospital, Cairo, Egypt, during the period from January 2015 to October 2016. It included 25 female patients undergoing reduction mammaplasty. All patients were evaluated by detailed history, careful physical examination, and photographed pre- and postoperatively. The new modifications included surgical undermining and thinning of the bipedicle for volume reduction and contour enhancement. The second modification was a dermal suspension of the lower pole for parenchymal support and longer breast shape stability. The third change was an S-shaped folding of the upper pole of the pedicle during nipple-areolar complex (NAC) transposition. After the operation, all subjects were followed up for 12 months to assess the outcomes of the procedure. Results Twenty-five female patients were included in the analysis of this study. The age of the patients ranged from 22 to 49 years with a mean age of 36.2 (7.3) years. The mean body mass index was 30.5 ± 4.3 kg/m2 with a minimum of 24 and a maximum of 38. The average time of operation was 4 hours. The resected tissue was 630-980 g. The optimal aesthetic appearance of the breasts was achieved at 6-9 months postoperatively and marinated to 12 months. The maintenance of improvement was measured by the distance between the mid-clavicular point and 12 O'clock point of the NAC (12'NAC). It varied between 28 and 43 cm preoperatively (mean ± SD, 34.12 ± 4.19 cm), and between 19 and 22 cm postoperatively (mean ± SD, 20.70 ± 1.03 cm; P < 0.001). The average percentage reduction in mid-clavicular point-NAC distance was 38.7% ± 6.2% with a minimum reduction of 27.6% and a maximum 48.8%. Moreover, the nipple to inframammary crease distance varied between 16 and 20 cm preoperatively (mean ± SD, 16.08 ± 1.66 cm), and between 8 and 10 cm postoperatively (mean ± SD, 8.04 ± 0.79 cm; P < 0.001). The patients were very satisfied in most of the cases (20 cases), satisfied in 3 cases, and 2 cases were unsatisfied as they wanted slightly smaller breasts. No complications detected in 18 cases (72%), superficial wound dehiscence at the T-junction in 3 (12%), and seroma in 1 (4%). Two cases (8%) demanded smaller breasts and 1 case (4%) needed a surgical revision of widened scars after 11 months. The major drawbacks were NAC sensitivity alteration and the inability to lactate. Conclusion We can conclude that our modifications for the McKissock's technique with its maintained aesthetic shape in those patients are a reliable option that can be considered, as it is a simple, efficient, and satisfactory method that can improve the results of reduction mammaplasty operations.
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Computed Tomographic Angiography-Based Characterization of Source Blood Vessels for Nipple-Areola Complex Perfusion in Hypertrophic Breasts. Aesthetic Plast Surg 2017; 41:524-530. [PMID: 28233132 DOI: 10.1007/s00266-017-0791-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/05/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Current knowledge about the blood supply of the nipple-areola complex (NAC) has largely been derived from studies on cadavers or persons with breasts of normal size. The aim of this study was to identify and classify the NAC blood supply by computed tomographic angiography (CTA) examination in female volunteers with breast hypertrophy. METHODS CTA examination was performed on hypertrophic breasts of 23 female subjects. The main blood supplies were revealed through image data analyses. The dominant blood supply of the NAC and its vascular sources were identified and sorted. The detectable diameter threshold of blood vessels was set beyond 1.0 mm. RESULTS A total of 61 dominant blood vessels were identified. The source arteries were traced as the internal thoracic artery (ITA, 50.8%), lateral thoracic artery (LTA, 27.8%), thoracoacromial artery (TA, 14.8%), brachial artery (BA, 3.3%), and axillary artery (AA, 3.3%), and the corresponding reproducibility of these source vessels was 31, 37, 9, 4.3, and 4.3%, in all breasts. The intercostal artery (IA) was not identified as a dominant NAC supplying vessel in any CTA scan image. Twenty-six breasts had only one dominant artery, whereas 17 breasts showed multiple dominant blood supplies. Three breasts showed no dominant blood vessels of the NAC, with diameters greater than the detectable threshold of 1.0 mm, and 52.2% of the breasts demonstrated anatomically symmetrical patterns of blood supply for the NAC. CONCLUSIONS The ITA, LTA, and TA are likely to be the main vessel sources, whereas the IA is unlikely to be the dominant vessel for NAC perfusion, on the basis of the studied breasts. An asymmetrical pattern of bilateral breast blood supply was demonstrated in a considerable portion of the females with breast hypertrophy in this study. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Stirling AD, Murray CP, Lee MA. The arterial supply of the nipple areola complex (NAC) and its relations: an analysis of angiographic CT imaging for breast pedicle design. Surg Radiol Anat 2017; 39:1127-1134. [PMID: 28432407 DOI: 10.1007/s00276-017-1858-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 04/13/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE To investigate the blood supply to the nipple areola complex (NAC) on thoracic CT angiograms (CTA) to improve breast pedicle design in reduction mammoplasty. METHODS In a single centre, CT scans of the thorax were retrospectively reviewed for suitability by a cardiothoracic radiologist. Suitable scans had one or both breasts visible in extended fields, with contrast enhancement of breast vasculature in a female patient. The arterial sources, intercostal space perforated, glandular/subcutaneous course, vessel entry point, and the presence of periareolar anastomoses were recorded for the NAC of each breast. RESULTS From 69 patients, 132 breasts were suitable for inclusion. The most reproducible arterial contribution to the NAC was perforating branches arising from the internal thoracic artery (ITA) (n = 108, 81.8%), followed by the long thoracic artery (LTA) (n = 31, 23.5%) and anterior intercostal arteries (AI) (n = 21, 15.9%). Blood supply was superficial versus deep in (n = 86, 79.6%) of ITA sources, (n = 28, 90.3%) of LTA sources, and 10 (47.6%) of AI sources. The most vascularly reliable breast pedicle would be asymmetrical in 7.9% as a conservative estimate. CONCLUSION We suggest that breast CT angiography can provide valuable information about NAC blood supply to aid customised pedicle design, especially in high-risk, large-volume breast reductions where the risk of vascular-dependent complications is the greatest and asymmetrical dominant vasculature may be present. Superficial ITA perforator supplies are predominant in a majority of women, followed by LTA- and AIA-based sources, respectively.
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Affiliation(s)
- Aaron D Stirling
- Mark Lee Plastic Surgeon, St John of God Hospital, Subiaco, Perth, WA, 6008, Australia. .,Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Dublin, Ireland.
| | - Conor P Murray
- Mark Lee Plastic Surgeon, St John of God Hospital, Subiaco, Perth, WA, 6008, Australia.,Envision Medical Imaging, Cambridge St, Subiaco, Perth, WA, 6008, Australia
| | - Mark A Lee
- Mark Lee Plastic Surgeon, St John of God Hospital, Subiaco, Perth, WA, 6008, Australia
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Makboul M, Abdelhamid MS, Al-Attar GS. Long-term follow-up and patient satisfaction after reduction mammoplasty: Superomedial versus inferior pedicle. Indian J Plast Surg 2016; 49:214-219. [PMID: 27833284 PMCID: PMC5052994 DOI: 10.4103/0970-0358.191299] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Surgery for hypertrophied breasts represents a challenge for plastic surgeons. The search for a good post-surgical cosmetic breast has led to the development of many techniques. Objectives for reduction mammoplasty are to achieve elevated, symmetrical breasts, a round shape, good projection, small cicatrices that are not very perceptible, and a lasting result. Patients and Methods: This study was carried out on sixty cases who had done reduction mammoplasty from January 2009 to December 2014. All patients were examined and were asked for late post-operative results and overall patients' satisfaction. Results: Long-term projection and contour of the breast were more satisfactory among patients who had superomedial pedicle with a statistically significant difference. No statistically significant difference was observed between patients underwent either superomedial or inferior pedicle reduction mammoplasty with regard to breast shape symmetry, nipple symmetry and sensation. The mean score for satisfaction was higher among patients who underwent superomedial pedicle rather than the inferior pedicle method. Conclusion: The superomedial pedicle shows better long-term cosmetic results.
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Affiliation(s)
- Mohamed Makboul
- Department of Plastic Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mahmoud S Abdelhamid
- Department of Plastic Surgery, Faculty of Medicine, Aswan University, Aswan, Egypt
| | - Ghada S Al-Attar
- Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
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Abstract
Numerous combinations of pedicle design and incision patterns have been described for mastopexy, but upper pole volume deficiency, suboptimal shape, or recurrent ptosis are still undesired postoperative findings. The challenges of preventing such outcomes are amplified in the massive weight loss (MWL) patient population, where both the extent of morphologic deformation and alterations in tissue characteristics (ie, a materials failure) can be severe. To correct this problem, we propose a technique that combines breast circumference-reduction with maximal glandular rotation and superomedial repositioning: the circumrotational technique. The technique reduces the circumference of the breast base, enhances anterior projection, and defines the lateral breast border by maximal glandular rotation and elevation, reorienting and engaging lax structural elements within the parenchyma. It also recruits ptotic lateral breast tissue into the upper pole, maximizing volume. This technique proposes an initial glandular hyperelevation, upper pole tissue "stacking," and broad peripheral fixation of the breast-to-chest wall to support the breast during the healing period and combat the propensity for recurrence. The circumrotational technique has been mostly used for mastopexy after MWL, but can also be used for typical mastopexies in non-MWL patients with grade 2 or 3 breast ptosis.
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Affiliation(s)
- Gabriele Cáceres Miotto
- Dr Miotto is a Post-Doctoral Fellow, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia. Dr Eaves is a Professor of Surgery, Division of Plastic Surgery, Emory University; Medical Director of the Emory Aesthetic Center and Emory Ambulatory Surgery Center, Atlanta, Georgia, USA; and Evidence-Based Medicine Section Co-editor for Aesthetic Surgery Journal
| | - Felmont F Eaves
- Dr Miotto is a Post-Doctoral Fellow, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia. Dr Eaves is a Professor of Surgery, Division of Plastic Surgery, Emory University; Medical Director of the Emory Aesthetic Center and Emory Ambulatory Surgery Center, Atlanta, Georgia, USA; and Evidence-Based Medicine Section Co-editor for Aesthetic Surgery Journal
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The short-scar periareolar inferior pedicle reduction technique in severe mammary hypertrophy. Plast Reconstr Surg 2014; 135:34-40. [PMID: 25539294 DOI: 10.1097/prs.0000000000000802] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reduction mammaplasty in severe mammary hypertrophy is challenging to even the very experienced plastic surgeon. Extremely long pedicles threaten blood supply, and the severely stretched skin envelope is difficult to effectively shape and reduce. In this setting, free-nipple techniques and inverted-T pattern skin resections are often used. METHODS A retrospective review of 88 consecutive patients undergoing breast reduction with the removal of at least 1000 g of tissue in at least one breast over a 17-year period was performed. Patient demographics, comorbidities, and complications were noted during routine postoperative care. RESULTS One hundred forty breasts in 88 patients were noted to meet the study criteria. The mean body mass index of the patients was 37 kg/m (range, 24 to 57 kg/m), and 89 percent of the patients were categorized as obese. The mean volume of resection was 1336 g (range, 1000 to 3144 g). Mean follow-up was 10 months (range, 1 to 96 months). There was a 16.4 percent incidence of minor delayed healing along with a 2.9 percent incidence of partial areolar necrosis, which was treated conservatively and allowed to heal by secondary intention. There was a 5.7 percent reoperation rate related to excisional biopsy of fat necrosis in 4.3 percent and revision of periareolar scar in 1.4 percent. CONCLUSION Combining an inferior pedicle approach with a circumvertical skin pattern in the setting of severe mammary hypertrophy is a safe and effective technique for breast reduction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Mastopexy and reduction mammoplasty pedicles and skin resection patterns. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2014; 2:e202. [PMID: 25426385 PMCID: PMC4236363 DOI: 10.1097/gox.0000000000000125] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 05/01/2014] [Indexed: 11/27/2022]
Abstract
SUMMARY Mastopexy and reduction mammoplasty share techniques of pedicle formation and skin excision patterns, with the main difference being the amount of breast tissue resected. Various types of excision patterns and orientation of pedicles were developed throughout the years, each with flares of popularity at different times. This article reviews the multiple techniques of pedicle orientation and skin excision patterns separately and gives the advantages and disadvantages of each.
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See MH. Central pedicle reduction mammoplasty: a reliable technique. Gland Surg 2014; 3:51-4. [PMID: 25083495 DOI: 10.3978/j.issn.2227-684x.2014.02.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 02/27/2014] [Indexed: 11/14/2022]
Abstract
Reduction mammoplasty is one of the most frequently performed procedures in plastic surgery for macromastia or gigantomastia. Recently it is also evolved for oncoplastic breast cancer surgery due to equivalent in terms of outcome for breast conserving surgery with radiotherapy versus mastectomy. Various techniques and modification has been made to achieve long lasting and aesthetically good result with minimal morbidity. Central (posterior) reduction mammoplasty is known for its versatile pedicle due to its good blood supply and innervation for maintaining of nipple sensation with unremarkably long term complication and proven in preservation of breastfeeding function. It is one of the good and reliable options to correct breast hypertrophy and ptosis. Various modifications were introduced by different authors to improve the technique and reduce scar formation which will give more satisfaction to patients.
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Affiliation(s)
- Mee-Hoong See
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine Building, University of Malaya, 50603 Kuala Lumpur, Malaysia
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The free-nipple breast-reduction technique performed with transfer of the nipple-areola complex over the superior or superomedial pedicles. Aesthetic Plast Surg 2014; 38:718-26. [PMID: 24902916 DOI: 10.1007/s00266-014-0343-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 04/24/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although the free-nipple breast-reduction technique is essentially an amputation, achieving aesthetic results still is important. The authors present their technique for free nipple-areola complex (NAC) transfer over the superomedial or superior pedicle full-thickness flaps in patients for whom a free-nipple technique is inevitable due to certain risk factors. METHODS The study included 25 patients who underwent surgery with the aforementioned method for addressing severe gigantomastia. The patients had a mean age of 43 years (range 34-59 years) and a mean body mass index (BMI) of 35.8 kg/m(2) (range 28-42 kg/m(2)). During the operation, the NAC was elevated as a full-thickness skin graft, then transposed to the superior or superomedial pedicles, which had been planned previously. The subsequent stages of the operation thus became a Wise-pattern breast reduction. RESULTS The mean resection per breast was 1,815 g (range 1,620-2,410 g). Breast projection, shape, and areolar pigmentation were assessed during the follow-up visit. One patient experienced a partial loss of the NAC graft, which healed secondarily, and three patients experienced a patchy hypopigmentation of the NAC. Breast projection and conical structure were observed to be preserved during the follow-up period. CONCLUSIONS The modified free-nipple technique aimed to convert the reduction procedure to a technique similar to pedicle methods, yielding successful results during the early phases. The full-thickness flap constructed in this way provides more fullness and a maximum contribution to projection in patients who will inevitably undergo breast reduction with the free-nipple method. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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A simple method to choose a pedicle for reduction mammoplasty. EUROPEAN JOURNAL OF PLASTIC SURGERY 2014. [DOI: 10.1007/s00238-013-0906-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Munhoz AM, Montag E, Gemperli R. Current aspects of therapeutic reduction mammaplasty for immediate early breast cancer management: An update. World J Clin Oncol 2014; 5:1-18. [PMID: 24527398 PMCID: PMC3920176 DOI: 10.5306/wjco.v5.i1.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 11/02/2013] [Accepted: 11/16/2013] [Indexed: 02/06/2023] Open
Abstract
Breast-conservation surgery (BCS) is established as a safe surgical treatment for most patients with early breast cancer. Recently, advances in oncoplastic techniques are capable of preserving the breast form and quality of life. Although most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Among technical options, therapeutic reduction mammaplasty (TRM) remains a useful procedure since the BCS defect can be repaired and the preoperative appearance can be improved, resulting in more proportional breasts. As a consequence of rich breast tissue vascularization, the greater part of reduction techniques have based their planning on preserving the pedicle of the nipple-areola complex after tumor removal. Reliable circulation and improvement of a conical shape to the breast are commonly described in TRM reconstructions. With an immediate approach, the surgical process is smooth since both procedures can be carried out in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reduces the incidence of margin involvement. Regardless of the fact that there is no consensus concerning the best TRM technique, the criteria is determined by the surgeon’s experience, the extent/location of glandular tissue resection and the size of the defect in relation to the size of the remaining breast. The main advantages of the technique utilized should include reproducibility, low interference with the oncological treatment and long-term results. The success of the procedure depends on patient selection, coordinated planning and careful intra-operative management.
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A matched cohort study of superomedial pedicle vertical scar breast reduction (100 breasts) and traditional inferior pedicle Wise-pattern reduction (100 breasts): an outcomes study over 3 years. Plast Reconstr Surg 2014; 132:1068-1076. [PMID: 24165588 DOI: 10.1097/prs.0b013e3182a48b2d] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The superomedial pedicle vertical scar breast reduction is gaining popularity for its round, projecting breast and shorter incision when compared with the traditional Wise-pattern reduction using an inferior pedicle. However, there is a paucity of large-volume institutional outcomes studies identifying how this technique fares against more traditional methods of reduction. METHODS A retrospective review of a prospectively maintained database of bilateral breast reductions over a 3-year period was performed. One hundred superomedial breast reductions (50 patients) were matched to 100 inferior pedicle breast reductions (50 patients). Matching was implemented based on age (±3 years) and size of reduction (±200 g). Patient demographics, size of reduction, nipple-areola complex sensitivity, minor and major postoperative complications, and symptomatic relief were assessed. Statistical analysis was performed with SAS Version 9.2. RESULTS Two hundred twelve patients underwent 424 bilateral breast reductions between January of 2009 and June of 2012 at a single institution. Mean volume of tissue reduced was 815 g per breast (range, 200 to 2068 g) and 840 g per breast (range, 250 to 2014 g), respectively. All patients achieved symptomatic relief. No statistical difference in major or minor complications was seen between the two cohorts. No statistical difference in major or minor complications was seen between the two cohorts. No significant difference in complications was seen between small- and large-volume reductions. CONCLUSION Superomedial pedicle vertical scar breast reduction is a novel, alternative mammaplasty technique with excellent functional and aesthetic outcomes which can be used for a wide range of macromastia without a significant difference in complication rates when compared with traditional Wise pattern inferior pedicle reduction mammaplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Karsidag S, Akcal A, Karsidag T, Yesiloglu N, Yesilada AK, Ugurlu K. Reduction mammaplasty using the free-nipple-graft vertical technique for severe breast hypertrophy: improved outcomes with the superior dermaglandular flap. Aesthetic Plast Surg 2011; 35:254-61. [PMID: 20931192 DOI: 10.1007/s00266-010-9592-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 08/19/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Management of severe mammary hypertrophy is a challenge. The limitations of most dermal pedicle techniques include insufficient breast projection with severe hypertrophy. The authors have designed a free-nipple-graft vertical technique with a superior demaglandular flap to provide acceptable breast projection and an attractive, smooth breast contour for patients with severe hypertrophy and gigantomastia who are not suitable for pedicle breast reduction techniques. METHODS Reduction was performed for 24 patients with severe mammary hypertrophy between 2003 and 2009. This study evaluated patient age, cup size, mean distances from sternal notch to nipple and from nipple to inframammary fold, amount of resection, complications, and postoperative breast shape. RESULTS All 24 patients were followed regularly to 1 year postoperatively. The inclusion criteria for the reported technique specified gigantomastia larger than 1,000 g per side, grade 4 breast ptosis, and increased sternal notch-to-nipple distance. The mean distance from the sternal notch to the nipple was 48.5 cm, and the mean distance from the nipple to the inframammary fold was 19.5 cm. The new nipple was positioned at a mean of 23.5 cm. The tissue excised per breast was 1,670 g. All the patients had long-lasting, pronounced nipple and adequate breast mound projection with attractive, smooth breast contours. CONCLUSION A free-nipple graft with a superior dermaglandular flap yields a conical breast with adequate projection and fullness. Parenchyma sutures to the pectoral fascia provide long lasting results. Plastic surgeons experienced in superior pedicle breast reduction can adopt this technique easily.
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Affiliation(s)
- Semra Karsidag
- Plastic and Reconstructive Surgery Clinic, Sisli Etfal Training and Research Hospital, Istanbul, Turkey
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Wettstein R, Christofides E, Pittet B, Psaras G, Harder Y. Superior pedicle breast reduction for hypertrophy with massive ptosis. J Plast Reconstr Aesthet Surg 2011; 64:500-7. [DOI: 10.1016/j.bjps.2010.05.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 05/17/2010] [Accepted: 05/19/2010] [Indexed: 11/29/2022]
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The Superior Pedicle-Nipple Graft Technique Trumps Medial Pedicle Breast Reduction with Nipple Preservation for Management of Gigantomastia. Plast Reconstr Surg 2010. [DOI: 10.1097/01.prs.0000388783.29715.c6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vertical Reduction Mammaplasty Combined With a Superomedial Pedicle in Gigantomastia. Ann Plast Surg 2010; 64:279-85. [DOI: 10.1097/sap.0b013e3181b0a5d8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Superior and superomedial pedicle wise-pattern reduction mammaplasty: maximizing cosmesis and minimizing complications. Ann Plast Surg 2009; 63:128-34. [PMID: 19542877 DOI: 10.1097/sap.0b013e318188d0be] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Our center has refined a wise-pattern superior and superomedial pedicle breast reduction technique with predictable quality outcomes giving high patient satisfaction and a very low complication or revision rate. Fifty patients who underwent bilateral superior or superomedial pedicle wise-pattern breast reduction were included in the study. Demographic and perioperative data were collected, as were details of complications. A 21-item postal questionnaire was used to evaluate satisfaction with outcome parameters. The superomedial pedicle technique was used in 86% reductions, and the superior pedicle in 14%, and the mean weight removed from the breasts was 778 g (range, 244-1766 g). Mean patient satisfaction with outcome parameters, as well as maintenance of shape was excellent, as were mean improvements in symptoms of macromastia. No patient required a revision procedure. Superior and superomedial pedicle wise-pattern scar reduction mammaplasty with the technique presented predictably gives excellent results and patient satisfaction, with long-term preservation of shape.
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Copcu E. A versatile breast reduction technique: conical plicated central U shaped (COPCUs) mammaplasty. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2009; 3:7. [PMID: 19575809 PMCID: PMC2714313 DOI: 10.1186/1750-1164-3-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 07/03/2009] [Indexed: 11/27/2022]
Abstract
Background There have been numerous studies on reduction mammaplasty and its modifications in the literature. The multitude of modifications of reduction mammaplasty indicates that the ideal technique has yet to be found. There are four reasons for seeking the ideal technique. One reason is to preserve functional features of the breast: breastfeeding and arousal. Other reasons are to achieve the real geometric and aesthetic shape of the breast with the least scar and are to minimize complications of prior surgical techniques without causing an additional complication. Last reason is the limitation of the techniques described before. To these aims, we developed a new versatile reduction mammaplasty technique, which we called conical plicated central U shaped (COPCUs) mammaplasty. Methods We performed central plication to achieve a juvenile look in the superior pole of the breast and to prevent postoperative pseudoptosis and used central U shaped flap to achieve maximum NAC safety and to preserve lactation and nipple sensation. The central U flap was 6 cm in width and the superior conical plication was performed with 2/0 PDS. Preoperative and postoperative standard measures of the breast including the superior pole fullness were compared. Results Forty six patients were operated with the above mentioned technique. All of the patients were satisfied with functional and aesthetic results and none of them had major complications. There were no changes in the nipple innervation. Six patients becoming pregnant after surgery did not experience any problems with lactation. None of the patients required scar revision. Conclusion Our technique is a versatile, safe, reliable technique which creates the least scar, avoids previously described disadvantages, provides maximum preservation of functions, can be employed in all breasts regardless of their sizes.
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Affiliation(s)
- Eray Copcu
- Department of Plastic Reconstructive and Aesthetic Surgery, Medical Faculty, Adnan Menderes University, 09100, Aydin, Turkey.
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Abstract
BACKGROUND The optimal reduction technique for the treatment of macromastia greater than 1 kg remains controversial. Conventionally, breast amputation and free nipple grafting has been used, but this leaves a flat and insensate nipple. Anatomical studies have suggested the superomedial technique to be a safe choice in these patients. METHODS A retrospective study analyzing the outcome of reduction mammaplasty for macromastia greater than 1 kg using the superomedial pedicle technique was performed. Data were collected over a 10-year period from 1995 to 2005. All reduction mammaplasty patients with resection weights greater than 1 kg per breast were included in the study. RESULTS Sixty-one patients were included (122 breasts). The mean age was 29 years. The mean suprasternal notch to nipple distance was 35 cm on the left and 35 cm on the right, and the mean nipple to inframammary crease distance was 19 cm on the left and 20 cm on the right. The Wise keyhole reduction pattern technique was used for all patients. Mean follow-up was 12 months. The mean resection weight per breast was 1360 g for the left breast and 1398 g for the right breast. Fifteen different surgeons performed the operations over this period. All patients had viable nipples postoperatively; there was partial areola necrosis in eight breasts (6.5 percent), with only minor other complications, including T-junction breakdown in 22 breasts (18 percent) and dog-ear excisions. CONCLUSIONS This study has confirmed the superomedial pedicle technique to be safe and reliable for resections greater than 1 kg.
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O'Dey DM, Prescher A, Pallua N. Vascular Reliability of Nipple-Areola Complex???Bearing Pedicles: An Anatomical Microdissection Study. Plast Reconstr Surg 2007; 119:1167-1177. [PMID: 17496587 DOI: 10.1097/01.prs.0000254360.98241.dc] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Vascular-dependent necrosis of the nipple-areola complex following reduction mammaplasty is still present. Concerning anatomy, there is a lack of literature comparing the vasculature of different nipple-areola complex-bearing pedicles in detail. Including six arterial sources supplying the breast, this anatomical work intends to clarify arterial impact and vascular reliability of different nipple-areola complex-bearing pedicles. METHODS Microdissections of anterior chest walls following vessel filling with dye were performed to examine the architecture of the arteries supplying the breast and their contribution to the blood supply of the nipple-areola complex on seven female corpses (14 breasts). RESULTS Four of six arterial sources supporting the breast were found to be mainly responsible for the blood supply of the nipple-areola complex. These are, in descending order of reproducibility, branches originating from the lateral thoracic artery, the internal mammary artery, the anterior branches of the intercostal arteries, and those deriving from the highest thoracic arteries. Despite vessel variability, both arrangements and subcutaneous courses of arteries advancing to the nipple-areola complex showed characteristic relationships. CONCLUSIONS Vascular variability and overlap may account for the remarkable safety of diverse nipple-areola complex-bearing pedicles, even though pedicle thickness influences vascular reliability. Lateral and medial approaches, however, clearly show vascular advantages over that which can be observed in inferior and superior pedicles. The former may therefore be regarded as more reliable. Especially the full-thickness glandular dermal superolaterally based pedicle should regularly enclose dominant branches originating from the lateral thoracic artery and supplementary arteries deriving from minor important sources in this region.
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Affiliation(s)
- Dan Mon O'Dey
- Aachen, Germany From the Department of Plastic Surgery, Reconstructive, and Hand Surgery, Burn Center, and the Institute of Anatomy, RWTH Aachen University
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Ricci MD, Munhoz AM, Pinotti M, Geribela AH, Teixeira LC, Aldrighi C, Ferreira MC, Filassi JR, Pinotti JA. The influence of reduction mammaplasty techniques in synchronous breast cancer diagnosis and metachronous breast cancer prevention. Ann Plast Surg 2007; 57:125-32; discussion 133. [PMID: 16861988 DOI: 10.1097/01.sap.0000216245.16475.b9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although reduction mammaplasty (RM) is a well-described technique for cosmetic objectives, there are few reports regarding its bilateral application combined with oncologic breast surgery in patients with breast cancer. The purpose of this study is to analyze the role of RM in the contralateral breast (CB) synchronous cancer (SBC) incidence, the impact in risk reduction for metachronous breast cancer (MBC), the disease-free period, and overall survival METHODS Patients were divided into 2 groups; group I: 114 pts submitted to oncologic surgery associated with immediate CB RM. Group II: 135 pts without CB RM. Mean time of follow-up was 51.5 months for both groups. Data regarding age, tumor size, histologic type and grade, clinical stage, and adjuvant therapy were collected RESULTS Except for the CB RM, no differences were observed between the groups. In group I, the diagnosis of an occult, synchronic, and invasive carcinoma was noted in 1.8%, in situ in 2.6%, and MBC in 1.8%. In group II, MBC was observed in 6.7%. No difference was observed between the 2 groups (P = 0.062). The initiation of adjuvant therapy, the disease-free period, and overall survival were not influenced by the CB RM. CONCLUSION CB RM is a reliable technique providing an opportunity for diagnosis of an occult SBC. There is evidence of reduction of MBC; however, a larger number of patients are necessary for significant conclusions. The technique should be considered in combination with immediate breast reconstruction. Success depends on patient selection and careful intraoperative management.
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Affiliation(s)
- Marcos Desidério Ricci
- Department of Gynecology and Division of Plastic Surgery, University of São Paulo School of Medicine, São Paulo, Brazil
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Munhoz AM, Montag E, Arruda EG, Aldrighi C, Gemperli R, Aldrighi JM, Ferreira MC. Superior-medial dermoglandular pedicle reduction mammaplasty for immediate conservative breast surgery reconstruction: technical aspects and outcome. Ann Plast Surg 2007; 57:502-8. [PMID: 17060729 DOI: 10.1097/01.sap.0000233969.25031.cb] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Reduction mammaplasty procedures and especially the superior-medial dermoglandular pedicle (SMDP) technique are frequently used for esthetic objectives; however, few reports have been available regarding its application following conservative breast surgery reconstruction. The purpose of this study is to analyze the feasibility of the technique and describe the surgical planning and its outcome following oncologic surgery. METHODS Thirty-nine patients underwent immediate bilateral SMDP breast reconstructions. Mean time of follow-up was 20 months. SMDP was indicated to reconstruct inferior breast defects in patients with enough remaining breast tissue. Reconstructed (RB) and opposite (OB) breast complications were evaluated and information on esthetic result and patient satisfaction was collected. RESULTS Tumors (51.2%) measured 2 cm or less (T1) and 66.6% were located in the lower outer quadrants. Mean change in nipple position was 12.5 cm. Immediate RB complications occurred in 8 patients (20.5%), with skin necrosis in 3 (7.6%), infection in 2 (5.1%), dehiscence in 2 (5.1%), and partial areola necrosis in 1 (2.5%) patient. Late complications were observed in 7.6%. All late complications were observed after adjuvant radiotherapy. The cosmetic result was considered to be good or very good in 84.6%, and the majority of patients were either very satisfied or satisfied. All complications were treated by conservative approach. CONCLUSION SMDP is a reliable technique and should be given primary consideration in cases of lower quadrant reconstruction. The success of the procedure depends on patient selection, coordinated planning, and careful intraoperative management.
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Munhoz AM, Montag E, Arruda EG, Aldrighi C, Gemperli R, Aldrighi JM, Ferreira MC. Critical analysis of reduction mammaplasty techniques in combination with conservative breast surgery for early breast cancer treatment. Plast Reconstr Surg 2006; 117:1091-103; discussion 1104-7. [PMID: 16582770 DOI: 10.1097/01.prs.0000202121.84583.0d] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although reduction mammaplasty is a well-described technique for aesthetic purposes, there are few previous reports regarding its application and clinical outcome following conservative breast surgery reconstruction. The purpose of this study was to analyze the feasibility of the technique and its outcome following conservative breast surgery. METHODS Oncologic data and information on age, body mass index, smoking history, and comorbid conditions were collected. Reconstructed and opposite breast complications were evaluated. Reduction mammaplasty was indicated to reconstruct moderate breast defects in patients with enough remaining breast tissue. Mean follow-up was 22 months. RESULTS Seventy-four patients underwent immediate reduction mammaplasty following breast-conserving surgery. In 55.4 percent of patients, tumors measured 2 cm or less (T1) and in 47.2 percent they were located in the upper outer quadrants. Breast complications occurred in 13 patients (17.6 percent), with skin necrosis in six (8.1 percent), infection in two (2.7 percent), partial areola necrosis in two (2.7 percent), dehiscence in two, and total areola necrosis in one (1.35 percent). Late complications represented by skin lesions and fat necrosis were observed in five patients (6.8 percent). Obese patients and smokers had a significantly higher rate of reconstructed breast complications compared with the normal/overweight patients (p = 0.002) and nonsmokers (p = 0.043). No significant association between complications and age, hypertension, diabetes, axillary lymph node dissection, or chemotherapy was found. CONCLUSIONS Reduction mammaplasty is a consistent technique for reconstruction following breast-conserving surgery. Complications are more often observed in the reconstructed breast, and obese patients and smokers are higher risk patients.
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Lacerna M, Spears J, Mitra A, Medina C, McCampbell E, Kiran R, Mitra A. Avoiding Free Nipple Grafts During Reduction Mammaplasty in Patients With Gigantomastia. Ann Plast Surg 2005; 55:21-4; discussion 24. [PMID: 15985786 DOI: 10.1097/01.sap.0000168249.09491.21] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Excessive breast hypertrophy or gigantomastia (>2000 g excision of tissue per breast) has traditionally been approached with breast amputation and free nipple grafting during reduction mammaplasty procedures. Disadvantages of free nipple grafts include loss of sensation, poor projection, uneven nipple-areolar complex pigmentation, and loss of lactation. We report our experiences utilizing the inferior pedicle technique of reduction mammaplasty with successful preservation of the nipple-areola complex for patients with gigantomastia. Between 2001 and 2003, 15 patients (ages 19--45) were identified with gigantomastia through review of pathology and operative reports. The inferior pedicle technique was performed in all cases by the attending staff assisted by plastic surgery residents. Patients were followed regularly from 1 week up to 1 year postoperatively. All patients reported relief from the physical sequelae of breast hypertrophy. One patient experienced bilateral partial nipple desquamation; she maintained sensation throughout and healed well with moist dressings. Otherwise, there were no complications and all patients achieved satisfactory esthetic outcomes. Our results suggest that inferior pedicle technique can be successfully performed in patients with gigantomastia. Breast amputation with free nipple grafting need not be considered standard practice for this patient population. Maintaining a wider pedicle base and meticulous intraoperative handling of the pedicle may contribute to the increased viability of the nipple-areolar complex during these cases.
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Affiliation(s)
- M Lacerna
- Division of Plastic and Reconstructive Surgery, Hand Center, Temple University School of Medicine, Philadelphia, PA, USA
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Abramson DL, Pap S, Shifteh S, Glasberg SB. Improving Long-Term Breast Shape with the Medial Pedicle Wise Pattern Breast Reduction. Plast Reconstr Surg 2005; 115:1937-43. [PMID: 15923840 DOI: 10.1097/01.prs.0000165085.23537.a7] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reduction mammaplasty has both a reconstructive and an aesthetic component. Relief of neck, back, and shoulder pain, as well as psychosocial improvement, is the main indication for intervention. Patient satisfaction is high, with early improvement in most cases. Preoperative planning confirms the anatomical variations as well as the best technique to achieve optimal cosmetic and functional results. Techniques for breast reduction have evolved in response to the great variety of challenges. The surgeon must tailor the surgical approach by considering a wide range of anatomic deformities, from gigantomastia to mild ptosis. Medial pedicle techniques have been shown to be reliable in severe breast hypertrophy. METHODS The authors present a series of 88 consecutive patients who underwent reduction mammaplasty using a medial pedicle technique with a Wise pattern skin resection. The purpose of the study was to evaluate the complication rate, operative time, and long-term effects on pseudoptosis. RESULTS The average weight reduction was 1814 g (both breasts combined), and the average operative time was 104.5 minutes. Patients were followed up for a minimum of 1 year, and the complication rate was 6.8 percent. The distance from the inframammary fold to the nipple was measured in patients with more than 1 year of follow-up. The results exhibited an average increase in this length of only 11 percent for reductions between 500 and 1200 g per side and of 34 percent for reductions greater than 1200 g per side. CONCLUSIONS The authors conclude that this technique is an effective and reliable approach to a wide range of breast hypertrophy, with reproducible breast weight reduction and less long-term pseudoptosis or "bottoming out." In addition, the operative time is short and the complication rate is acceptably low.
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Affiliation(s)
- David L Abramson
- Department of Plastic Surgery, Manhattan Eye Ear and Throat Hospital, USA
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Abstract
The main sources of blood supply to the breast are described in textbooks as the internal thoracic, lateral thoracic, and posterior intercostal arteries. Textbooks, however, do not describe the contribution of each to the nippie-areoia complex (NAC), nor do they describe the pattern of supply. To investigate this issue, 15 female cadavers were injected intraarterially with latex, and dissections were performed on 27 breasts. The results were as follows: In all the dissected breasts (27/27), the NAC received at least one or more vessels from the internal thoracic artery. In 20 of 27 dissected breasts, the NAC received vessels from the anterior intercostal arteries, In 19 of the 27 dissected breasts, the NAC received vessels from the lateral thoracic artery. Direct branches from the axillary artery supplied the NAC in 2 of the 27 breasts. The posterior intercostal arteries supplied the NAC in only 1 of the 27 dissected breasts. An underlying segmental pattern could be detected that can be explained by the embryological development. According to this study, the internal thoracic arteries are to be considered the main and constantly reliable source of blood supply to the NAC.
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Free Nipple Reduction Mammaplasty with a Horizontal Scar in High-Risk Patients. Aesthetic Plast Surg 2002. [DOI: 10.1007/s00266-001-0008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ozerdem OR, Anlatici R, Maral T, Demiralay A. Modified free nipple graft reduction mammaplasty to increase breast projection with superior and inferior dermoglandular flaps. Ann Plast Surg 2002; 49:506-10. [PMID: 12439019 DOI: 10.1097/00000637-200211000-00011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Classic free nipple graft reduction mammaplasty often yields flat, boxy breasts with poor projection. The authors modified this technique using superior and inferior pyramidal dermoglandular flaps to increase the fullness and projection of the breast. Six patients (12 breasts) with gigantomastia underwent breast reduction by this method. The results were aesthetically pleasing, with conically shaped breasts and good projection. The technique is easy to perform and it is possible to switch from pedicled nipple-areolar transposition to this method intraoperatively in patients in whom perfusion of the nipple is questionable.
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Affiliation(s)
- Omer Refik Ozerdem
- Başkent University, *Adana, dagger Ankara, and double dagger Alanya Research and Teaching Centers, Turkey
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