Pedicle Choices in Breast Reduction

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Moustapha Hamdi, Elizabeth J. Hall-Findlay

y failing to prepare, you are preparing to fail.

Benjamin Franklin

Surgeons should choose the right technique for the right patient. We plastic surgeons may be artists, but even artists still need to plan and to trace lines to create beautiful works.

M. Hamdi

Introduction

Breast reduction surgery usually combines a skin and parenchymal resection with a pedicle to maintain blood supply to the nipple-areola complex. This pedicle should allow adequate movement of the nipple to its new, more elevated position [1-3].

The design of the pedicle depends on sound knowledge of the blood supply to the breast (Fig. 2.1). As pointed out by Reid and Taylor [3], Corduff and Taylor [4], the main arterial supply to the breast enters superficially and descends into the parenchyma at the level of the nipple and areola [1]. There is also a major perforator that comes up through the pectoral muscle just medial to the breast meridian at approximately the level of the fifth/sixth intercostal space. Taylor also makes it clear that the veins are superficial and do not accompany the arteries [2].

It is key to preserve blood supply to the nipple areola complex; however, it is also important to preserve sensation and breastfeeding potential. A dermal pedicle alone may have adequate circulation,but it is less likely to provide sensation (Fig. 2.2) and is unlikely to have any breastfeeding potential. It may appear that a full-thickness dermoglandular pedicle would be the ideal option; however, there can occasionally be difficulties with inset, resulting in compression and torsion of the pedicle such that the blood supply is compromised. The classification that follows is necessarily arbitrary, and variations thereof can and will be used; it does, however, provide a basis for pedicle planning and design (Fig. 2.3).

Fig. 2.1 a-c. Arterial anatomy of the breast. a Anterior view. b Lateral view. c Coronal view

Fig. 2.1 a-c. Arterial anatomy of the breast. a Anterior view. b Lateral view. c Coronal view

Breast Innervation
Fig. 2.2 a,b. Innervation of the breast. a Anterior view. b Coronal view
Wedge Biopsy Nipple Areolar Complex
Fig. 2.3. Various pedicles for the nipple-areola complex
Inferior Central Breast

Inferior Pedicle/Central Pedicle

The inferior pedicle has become the mainstay of breast reduction surgery in North America. It relies on the perforator from the fifth or sixth intercostal space that comes through the pectoral muscle into the breast parenchyma just medial to the breast meridian. This perforator does have an accompanying vein. Both the inferior [5, 6] and central pedicles [7] can survive on the perforator alone, but one needs to be aware that occasionally this perforator is absent. In addition, the inferior pedicle has both venous drainage and arterial input through the inferior dermal bridge, which imbues it with some extra reliability.

Sensation to the nipple-areola complex is usually well preserved as long as there is some preservation of the tissue over the pectoralis fascia lateral to the pedicle. Austrian researchers [8] have shown that a major branch of the fourth intercostal nerve travels just above the pectoralis fascia until the breast meridian, where it turns and passes upward toward the nipple-areola complex (Chap. 1). Sensation can therefore be preserved using both the inferior and central pedicles. Some surgeons rotate the base of the pedicle more laterally in an effort to incorporate more sensory innervation. Breastfeeding potential is preserved with both pedicles because there is little to no interference with the ductal system.

Superior Pedicle

The superior pedicle may be either dermal or full thickness dermoglandular [9,10]. The full-thickness pedicle is more difficult to inset but is more likely to preserve breastfeeding potential. Innervation is superficial and comes down from the clavicular area. Sensation is therefore preserved with both types of superior pedicle.

The arterial blood supply is relatively constant with a major vessel from the internal thoracic (mammary) system. Taylor has demonstrated that this vessel originates from the second or third interspace [4] and runs obliquely downward toward the nipple. The angle taken by this vessel will depend on the degree of breast ptosis. It enters the breast at the level of the breast meridian but will be located more medially the greater the distance cephaled to the nipple. It is because this vessel is very superficial and can always be found about 1 cm deep to the skin surface that the superior pedicle can be quite radically thinned. In fact, trying to inset a full-thickness superior pedicle can compromise nipple-areola circulation secondary to compression.

Lateral Pedicle

The lateral thoracic vessels descend at an oblique angle and enter the breast superficially. This means that both dermal [11] and dermoglandular pedicles [12,13] will have adequate arterial input; and venous drainage is likewise superficial. Since the fourth lateral intercostal nerve has both a deep and a superficial branch, sensation is well preserved with either a thick or a thin pedicle [14,15].A full-thickness laterally based pedicle is more likely than a dermal pedicle to preserve ductal tissue.

The lateral pedicle is relatively easy to rotate into position. The main drawback of the lateral pedicle is the resultant lateral fullness of the breast if the pedicle is left too full. This may require later resection or lipo-suction, which in turn may compromise the pedicle itself.

Medial Pedicle

The medial pedicle is sometimes described as a "su-peromedial" pedicle because it will often appear to be quite superior, especially with the more ptotic breast [13]. Keeping some superior tissue does preserve vas-cularity, but retaining too much superior tissue will interfere with the ease of inset.

The blood supply to the medial pedicle is provided by several smaller branches from the internal thoracic (mammary) system (third to sixth intercostal spaces). Since these vessels enter the breast at a superficial level, the pedicle can be either dermal or full thickness dermoglandular. The large artery that provides circulation to the superior pedicle will usually be cut as it descends obliquely toward the nipple; however, some side branches may be preserved.

A full-thickness dermoglandular pedicle (taken directly down to the breast meridian) is more likely to preserve sensation since the deep branch of the fourth intercostal nerve, which travels just above the pec-toralis major muscle, can be preserved. It is therefore important to leave some tissue over the muscle during parenchymal resection.

As with the other pedicles, a full-thickness pedicle is more likely to preserve ductal tissue and allow the possibility of breastfeeding in the future.

Discussion

The aim of all mammaplasty techniques is to reduce breast volume while improving breast shape and position. However the techniques also endeavor to maintain circulation, sensation, and ductal integrity to the nipple-areola complex. A dermoglandular or central pedicle is most likely to achieve the ultimate goal. Basing the pedicle on one of the four major orientations outlined above may confer advantages to one pedicle over another depending on the degree of breast hypertrophy and nipple ptosis as well as on patient expectations and the surgeon's experience [16]. Advantages and disadvantages of each pedicle are summarized in Table 2.1.

The superior pedicle, which is widely used in continental Europe, is more suited to mastopexy and reduction of less than 1000 g per breast [9,10]. More challenging cases require more experienced surgeons to handle the remaining tissue and be able to mold it into an aesthetically pleasing shape. The shape of the breast often looks unsightly in the early stages because of the folded pedicle and the exaggerated narrowing and projection of the reduced breast. Once the breast settles, the final shape is excellent and,most importantly, long-lasting results can be achieved. The

Table 2.1. Advantages and disadvantages of the various breast reduction pedicles. Some drawbacks can be overcome with adequate experience. NAC, nipple-areola complex

Amount of gland resection

Breast projection

NAC sensitivity

Ability to breastfeed

Superior pedicle

++

+++

+

+

Inferior pedicle

+++

+

++

++

Lateral pedicle

++

+++

+++

++

Medial pedicle

+++

++

++

++

pedicle should be thinned enough to avoid kinking and/or venous congestion,which may result in nipple-areola complications. Sensitivity of the nipple-areola complex is significantly decreased with techniques that use a superior pedicle, particularly during the early (up to 6 months) postoperative period [17,18]. Patients who have highly sensitive nipple-areola complexes or who are very anxious about nipple-areola complex sensitivity loss are better served by an alternative pedicle.

The inferior pedicle is widely used in North America, the U.K., and Australia [5,6]. The pedicle has a robust blood supply and a relatively reproducible outcome, which is why it has been used for so long. Sagging of the pedicle is unavoidable at long-term follow-up and likely to occur more frequently than with other pedicles; thus favorable aesthetic results that are long lasting are more difficult to achieve with the inferior-pedicle-based mammaplasty. Modifications in the design of the inferior pedicle such as using anchoring to the thorax or tightening the closure of the vertical pillar can provide more reliable results [19]. The inferior pedicle can be ideally used for very large breasts with considerable ptosis in which the nipple actually points to the ground. The length of the inferior pedicle may be shorter than that of any other pedicle. Nipple-areola sensitivity is better preserved if the pedicle is shifted more laterally to include the deep branch of the fourth intercostal nerve.

The lateral pedicle can be used in large breasts instead of the superior pedicle to avoid pedicle kinking. This pedicle has major advantages in terms of arterial input and breast sensation; branches from the lateral thoracic artery contribute to the blood supply, and the deep branches of the fourth intercostal nerve are incorporated. The main problem with the lateral pedicle is occasional persistent lateral fullness in cases of insufficient resection of the pedicle due to anxiety concerning vascularity of the pedicle [13]. Designing a superolateral pedicle [12] may reduce this problem, but then preservation of the deep branch of the fourth intercostal nerve would not be possible. Basing the lateral pedicle on the horizontal septum described by Wuringer et al. [20] (Fig. 2.4) would allow inclusion of this branch. Septum-based lateral mammaplasty gives

Breast Innervation
Fig. 2.4. A cephalic view of the right breast, which shows the blood and nerve supply to the septum-based lateral pedicle
Fig. 2.5. A cephalic view of the right breast, which shows the blood and nerve supply to the septum-based medial pedicle

excellent results in terms of preservation of nipple-areola complex sensitivity [14] (Chap. 9), and it is recommended for young patients who have exacting demands on preservation of nipple sensitivity. Good aesthetic results are obtained using this technique for moderate breast hypertrophy or for mastopexy.

The medial pedicle seems to be the most logical design for breast reduction [13]. It is shorter than the superior one and has a rotation inset rather than a folding inset. It contains branches from the internal mammary perforators and sensory innervation from the anterior rami of the intercostal nerves. Nipple-are-ola complex sensitivity is well preserved using the medial pedicle compared to the inferior pedicle [21, 22]. Moreover, if the medial pedicle is based on the horizontal septum, one can preserve the deep branch of the fourth intercostal nerve (Fig. 2.5), and in that way better preservation of the nipple-areola sensation can be obtained (Chap. 9). Due to its orientation, the medial pedicle has good potential for maintaining its shape. The pedicle is directed perpendicular to the pull of gravity, which causes breast sagging in an in-ferolateral direction. Techniques based on the medial pedicle (Chaps. 7 and 9) allow for significant gland resection, especially on the lateral side. On the other hand, nipple-areola projection is less than that for the lateral pedicle technique; this can be avoided by anchoring the medial pillar on the pectoralis major fascia at the level of the nipple.

Summary

There is no "best" way to perform breast reduction. As with any other procedure in plastic surgery, the best technique may be that one which the surgeon has mastered and with which he or she is most confident. In the following chapters, the reader will be exposed to different techniques using different or modified pedicles in breast reduction. The authors present the fruits of their experience and errors over many years of breast surgery. All of them have performed a variety of techniques before settling on their preferred way, again using the accumulated wisdom and experience of the surgeons before them. All the above-described pedicles or their modifications are reliable, and they may work in experienced hands for every breast reduction. However, some pedicles are preferred to others in different circumstances, and it is imperative that young surgeons be aware of the pros and cons of each pedicle in order to generate a good outcome.

References

1. Brash JC, Jamieson EB (eds) (1943) Cunningham's Textbook of Anatomy, 8th edn. Oxford University Press, London

2. Maliniac JW (1943) Arterial blood supply of the breast.Arch Surg 47:329

3. Reid CR, Taylor GI (1984) The vascular territory of the acromiothoracic axis. Br J Plast Surg 37:194

4. Corduff N, Taylor GI (2004) Subglandular breast reduction: the evolution of a minimal scar approach to breast reduction. Plast Reconstr Surg 113:175

5. Robbins TH (1977) A reduction mammaplasty with the are-ola-nipple based on an inferior pedicle. Plast Reconstr Surg 59:64

6. Georgiade NG, Serafin D, Riefkohl R, Georgiade GS (1979) Is there a reduction mammaplasty for "all seasons"? Plast Re-constr Surg 63(6):765

7. Hester TR, Bostwick J, Miller L, Cunningham SJ (1985) Breast reduction utilizing the maximally vascularized central breast pedicle. Plast Reconstr Surg 76:890

8. Schlenz I, Kuzbari R, Gruber H, Holle J (2000) The sensitivity of the nipple-areola complex: an anatomic study. Plast Reconstr Surg 105:905

9. Lassus C (1996) A 30-year experience with vertical mammaplasty. Plast Reconstr Surg 97:373

10. Lejour M (1999) Vertical mammaplasty: update and appraisal of late results. Plast Reconstr Surg 104:771

11. Skoog T (1974) Plastic Surgery: New Methods and Refine-ments.Almquist and Wiksell, Stockholm

12. Cardenas-Camerena L, Vergara R (2001) Reduction mammaplasry with superolateral dermoglandular pedicle: another alternative. Plast Reconstr Surg 107:693

13. Hall- Findlay EJ (1999) A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 104:748

14. Hamdi M, Van de Sijpe K, Van Landuyt K, Blondeel PN, Monstrey S (2003) Evaluation of nipple-areola complex sensitivity after the latero-central glandular pedicle technique in breast reduction. Br J Plast Surg 56:360

15. Hefter W, Elvenes OP, Lindholm P (2003) A retrospective quantitative assessment of breast sensation after lateral pedicle mammaplasty. Br J Plast Surg 56(7^667

16. Davis GM, Ringler SL, Short K, Serrick D, Bengston BP (1995) Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg 96:1106

17. Hamdi M, Greuse M, DeMey A, Webster MHC (1999) Breast sensation after superior pedicle versus inferior pedicle mammaplasty: prospective clinical evaluation. Br J Plast Surg 54:39

18. Greuse M, Hamdi M, DeMey A (2001) Breast sensitivity after vertical mammaplasty. Plast Reconstr Surg 107:970-974

19. Hammond DC (1999) Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast Reconstr Surg 103:890

20. W├╝ringer E,Mader N,Posch E,Holle J (1998) Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 101:1486

21. Mofid MM, Dellon AL, Elias JJ, Nahabedian MY (2002) Quantitation of breast sensibility following reduction mammaplasty: a comparison of inferior and medial pedicle techniques. Plast Reconstr Surg 109(7^2283

22. Ferreira MC, Costa MP, Cunha MS, Sakae E, Fels KW (2003) Sensibility of the breast after reduction mammaplasty.Ann Plast Surg 51(1):1

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  • GAETANA MANFRIN
    Are nipples removed in pedical breast reduction?
    12 days ago

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