Superomedial Pedicle Technique of Reduction Mammaplasty Ronald E. Finger, M-D., Bernabe Vasquez, M.D., G. Stephenson Drew, M.D., and Kenna S. iven, M.D. Sevannah ond Augusta, Ca [A series of 148 patients who underwent reduction mammaplasty utilizing the superomedial pedicle tech- nique is presented. Resections as large as 4100 gm per breast with nipple-areola transpositions up to 30 cm were done with reliable nipple-areola survival, including pres- cervation of sensation. ‘The superior pedicle technique of breast reduction is recognized by many as technically easier and capable of producing a longer-lasting aesthetic effect. Classically, however, it has been limited to smaller resections. By incorporating the medial quadrant in the superior pedi- cle, more aggressive reductions can be safely undertaken with the same excellent results. Details of the procedure, the anatomic basis for its success, and complications are discussed, The controversy regarding the ideal proce- dure for hypermastia continues despite extensive work in this area by innumerable groups. A review of the literature for the first part of this century alone revealed 55 procedures designed to handle the problem of hypertrophic breasts. This proliferation suggests a failure of any one technique to be completely acceptable. ‘The objective of the reduction mammaplasty procedure is primarily to reduce the size of the hypertrophic breast with appropriate redraping of the skin envelope while maintaining a viable nipple-areola complex. Secondary objectives are to provide lasting conical projection, preserva- tion of nipple-areola sensation, and minimal scar- ring. Finally, the procedure should be quick, relatively bloodless, and reproducible with re- gard to different types and sizes of enlarged breasts. Reductions have been attempted by multiple approaches from amputation with nipple-areola grafting to a host of nipple-areola transpositions (Table I). The trend during the last 25 years has been toward a variety of combination dermal and glandular pedicles for nipple-areola trans- position. Bipedicle procedures have been pro- posed horizontally and vertically, while single pedicles have been based laterally, inferiorly, su- periorly, and superomedially. Weiner et al.' showed in 1973 that a single superiorly based dermal pedicle could sustain nipple-areola viability solely on its cutaneous vas- cular supply. Others, however, have reported problems with tension on the pedicle if it is too long with a resultant decrease in viability and nipple-areola sensation.”* Th 1975, Orlando. and Guthrie* reported a TABLE 1 Classification of Reduction Mammaplasty Techniques T, Amputation with nipple-areola graft IL Nippleareols transposition ‘A. Based on glandular pedicle with ereation of skin Maps B. Based on glandular dermal pedicle: Horizontal bipedicle Strombeck (1960) Pianguy (1967) Vertical bipedicle MeKissock (1972) Lateral pedicle ‘Skoog (1968) Inferior pedicle Robbins (1977) Superior pedicle Weiner (1973) Arufe (197) Hugo (1979) Superomedial pedicle ‘Orlanda (1975) Hrauben (1985) From the Division of Plastic Surgery at the Medical College of Georgia. Received for publication October 16, 1987; revised March 29, 1988. Presented atthe 38th Annual Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, at Point Clear, Alabama on June 1, 1987,472 PLASTIC AND RECONSTRUCTIVE SURGERY, March 1989 series of 12 patients using a superomedial pedicle with complete nipple-areola viability and re- tained sensation. They attributed the increased sensation over the superior pedicle to its added medial component, which carries fibers from the anterior cutaneous branches of the fourth and fifth intercostal nerves. Ten years later, Hauben® published a series of 78 patients operated on by the same technique. Nipple-areola transpositions of up to 15 cm were performed without vascular compromise or significant sensory deficit ‘This report represents our experience with the superomedial technique and its extended appli- cations. MATERIALS AND METHODS The superomedial pedicle technique was uti- lized to reduce 291 breasts on 148 patients be- tween 1975 and 1986. The ages of the patents varied from 14 to 67 years, with a mean of 36 years. The amount resected per breast varied from 105 to 4100 gm, with a mean of 692 gm. Fic. 2. Variations in pedicle design.Vol. 83, No. 3 / SUPEROMEDIAL PEDICLE REDUCTION Nipple-areola transpositions of 3.5 to 80 cm were performed, with a mean of 11.6 cm. All patients were followed for a minimum of 6 months, with the longest 116 months. The mean follow-up time was 19 months TABLE It Complications Perea Comptiaions Breas Early ‘Skin necrosis 20 Fat necrosts 12 Nipple-reolar necrosis os Dehiscence 12 Cellulitis oa Late Sensory changes has Not enough reduced 16 “Too much reduced os Recurrent prosis 12. Sear hypert 12. Nipple retsction 08 Dogars 08 Fic. 3. A 17-year-old patient wi 473 TrcHNIQUE Preoperatively, the patient is kept upright while the new nipple position is marked 20 to 22 cm from the suprasternal notch on the midbreast line, depending on the patient’s height and ha- bitus. The nipple can be arbitrarily moved me- ially or laterally to fit the patient's general shape. A modified Wise pattern is used to mark the new nipple site and incisions. The inframam- mary line is marked, and straight lines are drawn from the medial and lateral legs of the pattern to the respective ends of the inframammary in- cision. At surgery, infiltration with marcaine or lido- caine with 1:200,000 epinephrine is done in the prepectoral and incisional areas, except for the nipple-pedicle region. The actual procedure is technically simple, and the details are illustrated in Figure 1. Deepithe- lialization is performed. The nipple-areola com- plex is held with double hooks under tension and aN mild hypertrophy and asymmetry; 875 gm was removed from left breast and 875 gm from the right. Nipple transposition of 4.0 and 3.5 cm, respectively. (Abvve, left) Preoperative AP view. (Above, right) Preoperative lateral view. (Below, left) Postoperative AP view, 8-month follow-up. (Below, right) Postoperative lateral view, 8+ month follow-up.474 PLASTIC AND RECONSTRUCTIVE SURGERY, March 1989 undermined at 2 cm thickness and is made pro- gressively thicker at the base. Only 60 to 70 percent of the deepithelialized flap needs to be clevated, since this allows for ample rotational capacity. The nipple-areola complex is then ro- tated laterally and sutured into its new position with a temporary suture so that the remaining breast tissue can be easily excised. Alternatively, one can excise the excess breast tissue before elevation, rotation, and insetting ofthe nipple- areola complex. When excising the breast tissue, it is important to slightly bevel the flaps inferiorly along the inframammary line at C and D, but not along the medial and lateral vertical edges marked A and B. This provides for better con- tour at the inframammary line while retaining enough tissue to ensure adequate projection. Ad- ditional sculpturing of the medial and lateral flaps can be done as necessary. The incisions are closed in layers with 3-0 and 4-0 absorbable suture and reinforced with Steri-Strips. Drains are used if needed. With increasing pedicle lengths, the base is widened to ensure adequate vascularization (Fig. 2). Notice, however, that the lateral aspect does not change and begins approximately at the 10 o'clock position (right breast). This allows for a full-thickness wedge of lateral tissue to be excised to facilitate rotation. As in other methods of breast reduction, care must be taken to prevent tension on the pedicle during insetting of the nipple-areola complex. ‘The rotation required by this procedure actually causes less tension with increased pedicle lengths. With shorter pedicles, rotation is enhanced by making a small (1 to 2 cm) relaxing incision medially (arrow in Fig. 2, A) Resucts Two-hundred and ninety-one reductions up to 4100 gm per breast (mean of 692 gm) and nipple- areola transpositions up to 30 cm (mean 11.6 cm) were performed on 148 patients without major complications. There were no deaths in Fig. 4. A 30-year-old patient with moderate hypertrophy and ptosis; 425 gm was removed from each breast and nipple im were done bilaterally. (Abo transpositions oF left) Preoperative AP view. (Above, right) Preoperative lateral view. (Below, left) Postoperative AP view, 8smonth follow-up. (Below, right) Postoperative lateral view, S-month follow-up,Vol. 83, No, 3 / SUPEROMEDIAL PEDICLE REDUCTION 475 Fic. 5. A 58-year-old patient with marked hypertrophy and ptosis; 650-gm reductions were done bilaterally and nipple transpositions of 1.0 cm were also done bilaterally. (Above, let) preoperative AP view. (Above, right) Preoperative lateral view (Below, left) Postoperative AP view, 18-month follow-up. (Below, right) Postoperative lateral view, 18-month follow-up, the series or significant morbidity requiring pro- longed hospitalization or major surgical or med- ical intervention. The average blood loss was often less than 200 ec. Complications were grouped as either early or late (Table II). The early complications totaled 5.6 percent, which compares favorably with those reported in other series." Most compli- cations involved small areas of necrosis or dehis- cence, usually at the T portion of the incision, ‘There were two cases of partial nipple-areola loss involving less than 25 per cent of the areola. Both healed satisfactorily by secondary intention without need of revision. Late complications consisted mostly of nipple- areola sensory loss, found in approximately 15 percent of the reduced breasts. This also com- pares favorably with previous reports utilizing the superomedial pedicle, as well as with other techniques, including the bipedicle (McKissock), inferior pedicle, and superior pedicle tech- niques."**" Hypertrophic scars, nipple retraction, and dog-ears occurred in a small number of patients. Representative cases of varying sizes and shapes of ptosis are shown in Figures 3 to 7 Discussion As mentioned earlier, breast reductions have been performed in what appears to be every conceivable manner. Initially, significant prob- lems existed with the ability to reliably reduce the breast while maintaining nipple-areola viabil- ity and preventing major breast and skin necro- sis.!° A better understanding of anatomic prin- ciples has reduced these earlier complications Recent concerns deal with obtaining conical pro- jection, preservation of nipple-areola sensation, ‘and minimizing scarring. These, along with the need to find a procedure that is quick, technically simple, and adaptable to all types and sizes of breasts, have provided the impetus for the con- tinuing evolution of reduction mammaplasty. ‘The trend over the last two decades has been476 PLASTIC AND RECONSTRUCTIVE SURGERY, March 1989 Fie. 6. A. old patient with severe hypertrophy who underwent a i0-gm reduction on the right and a 2260-gm reduction on the let. Nipple transpositions of 16 cm were performed bilaterally. (Above, let) Preoperative AP view, suprasternal notch to nipple distance 39 cm and nipple to inframammary fold distance of 20 em bilaterally. (Above, right) Preoperative Jateral view, (Below, et) Postoperative AP view, |I-month follow-up. (Below, right) Postoperative lateral view, 1I-month follow- toward combination dermal-glandular pedicle operations'“*"*""""® rather than pure glandular pedicles. The bipedicle procedure of McKissock” and the inferior pedicle technique of Robbins!® have become the mainstay of modern reduction mammaplasty. Both these procedures have re- ceived wide acceptance, probably because of their reliability regarding nipple-areola survival on different types of breasts. Acceptable preser- vation of nipple-areola sensation also has been reported with both these techniques. A major criticism of these operations has centered on the loss of projection that occurs over time with the “bottoming out” of breast tissue from gravity.” Both operations are time-consuming and involve significant technical and artistic energy. ‘The superior pedicle technique was designed to avoid late loss of projection while allowing easy transposition of the nipple-areola complex. The procedure was found to be simple and quick to perform. Limitations of the pedicle lengths which could be fashioned using the superior ped- icle technique have been cited, however.*** Other complaints include vascular and sensory compromise that can occur with larger pedicles as well as difficulty with infolding of the dermal pedicles. ‘The superomedial pedicle technique as origi- nally described by Orlando and Guthrie* and reported here is a logical extension of the supe- rior pedicle operation. A review of the anatomy lends support to this concept. The principal blood supply to the breast is provided by the internal mammary perforators and the lateral thoracic artery." The intercostals and thora- coacromial perforators, while present, play a lesser role'® (Fig. 8). In extensive cadaver studies by Marcus," the internal mammary vessels were present in 100 percent of specimens while the lateral thoracic branches were absent in 30 per- cent of specimens Nipple areola circulation is provided by inter=Vol. 83, No. 3 / SUPEROMEDIAL PEDICLE REDUCTION > 477 Fic. 7. A 41-year-old patient who underwent massive weight loss with resultant generalized Maccidity and marked pros. Patient underwent reduction with nipple transpositions of 80 cm bilaterally. jent had significant loss of sensation of right nipple but retained excellent sensation on left. (Left) Preoperative AP view. (Right) Postoperative AP view, 8-month follow up. Fig. 8, Vascular supply of the breast nal mammary perforators and lateral thoracic branches, both of which run in the subcutaneous tissue ata depth of 1.0 to 2.0 cm at the periphery of the breast and become more superficial as they approach the nipple-areola complex. Here, branches from both vessels anastomose into a circular pattern in the majority of the cases."” By incorporating a medial component to the supe- rior pedicle, additional vascular supply by means of the internal mammary system is obtained. Innervation of the nipple-areola complex is generally felt to be due to the fourth lateral intercostal nerve branch. Craig and Sykes"? in their dissections found, however, that the nipple and areola are regularly supplied by the third, fourth, and fifth anterior cutaneous nerves as well as the fourth and fifth lateral cutaneous nerves. This would explain the preservation of sensation despite probable severance of the fourth lateral cutaneous branch or so-called nerve to the nipple Additionally, the pedicle based superomedially and the nipple-arcola complex rotated laterally avoid the kinking which can occur with the su- perior pedicle technique, particularly in larger478 reductions. This allows the procedure to be per- formed on all types of breasts regardless of size or degree of ptosis with complete security and relative ease Kenna S. Given, M.D. Division of Plastic Surgery, BD-LI5 Medical College of Georgia August, Ga. 30912-0415 ACKNOWLEDGMENTS “Theauthor woud ike to express ther gratitude to Pegg Bailey for her help in collcang these dsta and to aes Mill Kathy Pilcher, and Chris Murphy for Lele assistance inthe preparation of this manuscrip REFERENCES: 1. Weiner, D. L., Aiache, A. E., Silver, L., and Tittira ronda, T. "A single dermal pedicle for nipple crans- position in subcutaneous mastectomy, reduction ammaplasty, or mastopexy. Plast Reconstr. Surg. 51: 115, 1973. 2. Georgiude, N. G., Serafin, D., Riefkohl, R., and Geor- giade, G. STs there a reduction mammaplasty for “all seasons"? Plast. Reconstr, Surg, 68: 765, 1979. 3. Bostwick, J., II]. Breast Reduction. In Aesthetic and Reconstructive Breast Surgery. St. Louis: Mosby, 1988. 4, Orlando, J.C., and Guthrie, R.H. The superomedial dermal pedicle for nipple wansposition. Br. J. Plast Surg. 28:42, 1975. 5. Hauben, D. J." Experience and refinements with the superomedial dermal pedicle for nipple-arcola trans- position in reduction mammoplasty. Aesthetic Plast. Surg. 8: 189, 1984. 6. Strombeck, JO. Mammaplasty: Report of a new tech: nique based on the two-pedicle procedure. Br. J Plast. Surg. 19: 79, 1961 7. MeKissock, PK. Reduction mammaplasty with a ver- 10, 15 16, W 18, 19, 20. PLASTIC AND RECONSTRUCTIVE SURGERY, March 1989 tical dermal flap. 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Reconstr. Surg. 89: 64, 1977 Conroy, W. G. Reduction mammaplasty with maxi- ‘mum superior subdermal vascular pedicle. Ann. Plast. Surg. 2: 189, 1979. Marcus, G. H. Untersuchungen uber die arterielle Dlutversorgung der marl, Arch, Klin. Chir. 179: 361, 1934, Maliniac, J. W. Arterial blood supply of the breast ‘Arch Surg. 47: 329, 1943. Edholm, P., and Strombeck, J. 0. Influence of mam- maplasty on the arterial supply to the hypertrophic breast: Angiographic studies before and after opera- tion. Acta Chir. Scand. [Suppl] 341, p. 71, 1965. Craig, R. D.P., and Sykes, PA. Nipple sensitivity following reduction mammaplasty. Br. J. Plast. Surg. 23: 165, 1970,