Inferior Pedicle Breast Reduction Research Articles

Commentary on: Vertical Reduction Mammaplasty Utilizing the Superomedial Pedicle: Is It Really for Everyone?

In “Vertical Reduction Mammaplasty Utilizing the Supero-medial Pedicle: Is It Really for Everyone?,” Dr Neaman and his coauthors review a cohort of 290 patients (558 breasts) who underwent a vertical-style superomedial pedicle reduction mammaplasty and try to show that it is safe and effective for a wide range of patients with symptomatic macromastia. I appreciate the opportunity to comment on this article to give my perspective, gained after almost 30 years in practice. For the first 10 years of my practice, I used mainly an inferior pedicle, inverted-T-type breast reduction and, although the results were acceptable, I agreed with Madeleine Lejour1 that we could be striving for improvement. I have learned a lot by analyzing my experience since then, with over 2000 “vertical” breast reductions performed using superior, lateral, and medial pedicles. The word “vertical” is often used to describe a particular procedure, but I believe we should instead be separating out how we design the pedicle, the nature of the parenchymal resection, and the skin resection pattern. The “Wise pattern” is a term often used to describe an inverted-T, inferior pedicle breast reduction, but Robert Wise2 originally described only a skin resection design adapted from a brassiere pattern. I still occasionally apply a Wise pattern for the skin redraping when I use a superomedial pedicle in large breast reductions or in massive weight-loss patients. I always, on the other hand, apply a Wise pattern for the parenchymal design—not for what is removed, but for what is left behind (Figure 1). Figure 1. (A) The pattern as originally described by Robert Wise was not just the keyhole opening but was a skin pattern design adapted from a brassiere pattern. (B) The use of the Wise pattern for the parenchyma instead of the skin is an excellent way to remove …

Étude rétrospective de 184 réductions mammaires bilatérales à pédicule supérieur et sans drainage postopératoire

The safety of non-drainage has already been proven on inferior pedicle breast reduction techniques while other authors said that the superior pedicle breast reduction techniques increase the risk of postoperative drainage. We want to prove that non-drainage of superior pedicle breast reduction techniques is as safe as the non-drainage of inferior pedicle breast reduction techniques. We made a retrospective study of 184 superior pedicle breast reductions in the last 5 years at the hospital of Lille. The complications were compared with the review of inferior pedicle breast reduction on the previous studies. We observed: 1.35% of hematomas, 0.54% of fat necrosis, 0.27% of infections, 4.1% of wounds dehisences, 0.81% of nipple loss and no seroma. No significant statistical difference between the complication rate of these two breast reductions techniques was found. Non-drainage in superior pedicle breast reduction techniques is as safe as the non-drainage in inferior pedicle breast reduction techniques and can be considered as reliable.

The Dermal Suspension Sling: Shaping the Inferior Pedicle during Breast Reduction

Complaints following reduction mammaplasty using the inferior pedicle include the migration of the deep tissue, a lack of medial fullness, poor projection, and bottoming-out. These are attributed to the lack of deep tissue suspension and skin envelope relaxation. We address these issues through horizontal dermal suspension and plication of the inferior pedicle. The inferior pedicle is designed with medial and lateral triangular flaps in the areas, which would normally be excised. These triangular flaps are deepithelialized and defatted. The flaps are attached to the chest wall above the inferior pedicle to create a dermal sling. The breast mound is further contoured by horizontally plicating the dermis below the nipple-areola complex (NAC), which creates projection and rotates the NAC into the desired position in relation to the chest wall. Sixty-six women have undergone breast reduction using the horizontal dermal suspension sling modification to the inferior pedicle breast reduction technique. Breast projection and shape were sustained during follow-up, of which the median interval was 16months. Dermal suspension and horizontal dermal plication provides a structural foundation to the inferior pedicle. The sling-like effect from the dermal suspension maintains a defined inframammary fold and maintains medial and lateral borders of the breast. Horizontal dermal plication shortens the length of the inferior pedicle while generating improved breast projection by rotating the NAC anteriorly. The firmly shaped inferior pedicle breast mound allows the skin flap to drape over the breast mound with minimal tension.

Preventing the “Bottoming Out” and “Star-gazing” Phenomena in Inferior Pedicle Breast Reduction with an Acellular Dermal Matrix Internal Brassiere

The phenomena of "bottoming out" (pseudoptosis) and "star-gazing" (the upward rotation of the nipple-areola complex) is a common postoperative problem when using the inferior pedicle breast reduction technique. Multiple techniques have been described to help prevent this problem, including internal suspension techniques and the use of mesh to support the pedicle. We describe our technique and present a case series in which acellular dermal matrix (AlloDerm(®)) is used as an internal brassiere or sling to support the inferior pedicle and prevent postoperative "bottoming out" and "star-gazing." Twenty-seven patients underwent inferior pedicle reduction mammaplasty through a Wise pattern performed by a single surgeon. In each case, acellular dermal matrix (0.79-2.03 mm thick) was sutured to the chest wall as a sling or internal brassiere to support the inferior pedicle. The pedicle was also plicated in a horizontal fashion to increase the projection of the breast and to improve the position of the nipple-areola complex. The mean weight of reduction per breast was 850 g. The mean distance from the nipple to the inframammary fold was 16.4 cm. The mean distance from the sternal notch to the nipple was 32.2 cm. Only one patient developed cellulitis and one patient had partial skin flap necrosis. There was no nipple loss. At routine follow-up it was found that the aesthetic breast shape has been retained and pseudoptosis or "bottoming out" was not significant in any patient. The longest follow-up is 29 months. The use of an acellular dermal matrix internal brassiere is a safe and effective technique for preventing the "bottoming out" and "star-gazing" phenomena that occurs after inferior pedicle breast reduction. Longer-term follow-up will be required to assess the longevity of these results.

Preventing the “Bottoming out and Star-gazing” Phenomenon in Inferior Pedicle Breast Reduction with an Acellular Dermal Matrix Internal Brassiere

In the last 22 years we have studied the subject presented by the authors. It is believed that the ptotic breast loses its ability to sustain its shape because the skin and its connective framework become flabby and inefficient causing a high frequency of early recurrence of breast ptosis after

The Bivectorial Full-Thickness Superiorly Based NAC Flap: A New Option to Increase Plasticity and Decrease Tension in the Superior Pedicle Vertical Mammaplasty Technique

Being an anatomist as well as a plastic surgeon, I would like to comment on the blood supply of the flaps described by O’Dey et al. [1]. I congratulate the authors on a wellwritten and good article. However, the statement that the authors created the term ‘‘highest thoracic artery,’’ which does not appear in anatomy text books, is incorrect. It appears in the 6th edition of Nomina Anatomica [2] and described as arteria thoracica superior, the internationally accepted nomenclature. It is a branch of the first part of the axillary artery and well described and illustrated in anatomy textbooks. The blood vessel named the ‘‘supreme anterior intercostal artery’’ by the authors could be an aberrant highest intercostal artery (arteria intercostalis suprema), usually originating from the costocervical trunk (a branch of the subclavian artery) or a nipple-areola branch of the internal thoracic artery [3]. The highest intercostal artery must not be confused with the highest thoracic artery they are two different arteries of different origin. The former artery supplies the thoracic wall from the internal aspect and the latter from the external. The author described in his operative technique complete detachment of the pedicle from the pectoral fascia and undermining of the flap to the level of the second rib in order to preserve branches originating from the thoracoacromial artery. The safety of this pedicle relies on his research done on seven cadaver dissections [4]. I would recommend that the authors read the article by Reid and Taylor [5]. They have done extensive research on the vascular territory of the acromiothoracic axis in 110 cadaver studies and their research revealed that the dominant supply to the skin is from the pectoral artery, one of the branches of the acromiothoracic trunk (thoracoacromial artery) by means of its fasciocutaneous branches, along the free lower border of the pectoralis major muscle. They have also shown that the dominant supply to the rib cage is from branches of the pectoral artery to ribs 3–5 in the midclavicular line. Dissecting the pedicle as the authors described, superiorly, to the level of the second rib will sacrifice these vessels with the risk of tissue necrosis. A better way to obtain upper-pole fullness would be to keep the posterior component of the flap attached to the chest wall to preserve the blood supply and to anchor this mass to the pectoral fascia at the level of the second rib. I have utilized this principle in inferior pedicle breast reduction and mastopexy procedures with good results.

The triplicated inferior pedicle – a new method for breast reduction and mastopexy

Robbins described the inferior pedicle breast reduction in 1977. Since this time it has proved to be a safe and reliable technique. Favourable results have been reported with regard to breast feeding and nipple sensation. A common criticism of the technique is its tendency to inferior descent (pseudoptosis or bottoming out). This can leave a significantly empty upper pole. By a series of evolutionary modifications over the last 20 years, a technique has developed that overcomes the shortfalls of the inferior pedicle technique. We describe a series of 50 cases using this definitive technique.

Breast Reduction Trend among Plastic Surgeons: A National Survey

A number of breast reduction techniques have been developed over the years, but debate over which technique is better for patients continues to grow. The authors' goal was to survey members of the American Society of Plastic Surgeons to identify their preferences and practices and report their opinion regarding issues related to the various breast reduction techniques. In the fall of 2006, a one-page anonymous survey was sent to 5112 plastic surgeons who were members of the American Society of Plastic Surgeons. A follow-up survey was sent 2 weeks after the first mailing as a friendly reminder. The questionnaires were then collected over a 6-week period. Of the 5112 plastic surgeons surveyed, 2665 (52 percent) responded to the survey. The majority of the respondents (69 percent) use the inferior pedicle breast reduction technique. Ninety-two percent of the respondents use intraoperative deep venous thrombosis prophylaxis. Sixty-one percent of respondents performed over 75 percent of their cases on an outpatient basis and 97 percent of respondents use general anesthesia. Ninety-three percent of the respondents use preoperative antibiotics. Over 70 percent of the respondents do not think breast reduction should be a cosmetic procedure. In conclusion, the inferior pedicle technique has traditionally been the procedure of choice and remains so today. However, there has been an increase in the use of the newer techniques. Plastic surgeons are becoming more cognizant of the risk of deep venous thrombosis among their patients. The majority of breast reductions are now performed as outpatient procedures.

Use of the VersaJet for Pedicle Deepithelialization During Breast Reduction Surgery

Many modern techniques of breast reduction require that a pedicle of breast tissue be deepithelialized. The process of deepithelialization is both tedious and time consuming. Many techniques have been described to facilitate the process of deepithelialization in breast reduction, but none have replaced the gold standard of using the scalpel. This series details the authors' results using the VersaJet Hydrosurgery System for pedicle deepithelialization in breast reduction surgery. In this study, 20 patients underwent inferior pedicle breast reduction using the VersaJet for pedicle deepithelialization between September 2006 and June 2007. The overall time required for pedicle deepithelialization using the VersaJet was compared with the average overall time required for deepithelialization using the scalpel. Intraoperative and postoperative complications were recorded. An overall time-savings of 10 to 25 min per case was noted using the VersaJet for pedicle deepithelialization rather than the scalpel. No intraoperative or postoperative complications were encountered due to use of the VersaJet for pedicle deepithelialization. The VersaJet is a safe and effective tool for pedicle deepithelialization in breast reduction surgery. The VersaJet significantly facilitates the process of pedicle deepithelialization and requires less time than use of the scalpel for the procedure.

Secondary shaping of the free TRAM: an inferior pedicle reduction mammaplasty

Secondary shaping of the transverse rectus abdominis myocutaneous (TRAM) flap is a routine treatment, and includes liposuction, skin excision, inframammary fold replacement, dermal fat grafts or lipofilling. Major flap revision may include an augmentation procedure with implants or expanders. We present an inferior pedicle breast reduction in a woman who underwent breast reconstruction using a free TRAM flap. To our knowledge, there are no reports about reduction mammaplasty or mastopexy in Free TRAM flap breast reconstruction. Reduction mammaplasty should be regarded as a valuable option in free TRAM or deep inferior epigastric perforator secondary reshaping.

Improving the Results of Inferior Pedicle Breast Reduction Using Pedicle Suspension and Plication

The inferior pedicle technique of breast reduction is a widely-used safe technique. It has been criticised as prone to producing inferior quadrant fullness, called variously "pseudoptosis" or "bottoming out." Described are the results of a technique of inferior pedicle suspension and plication which overcome these problems.

Total Nipple-Areola Complex Necrosis in Inferior Pedicle Breast Reduction

Total Nipple-Areola Complex Necrosis in Inferior Pedicle Breast Reduction

Breast Reduction as an Alternative Treatment Option for Early Breast Cancer in Women With Macromastia

Macromastia has been considered a relative contraindication to breast conservation therapy because of difficulties with postoperative radiation therapy and cosmesis. This study evaluates the feasibility of the inferior pedicle reduction mammaplasty as a component of breast conservation therapy for patients with early breast cancer. A retrospective review identified 6 patients with macromastia receiving oncologic treatment of breast cancer and simultaneous breast reduction. Mean age was 43.5 +/- 8.7 (mean +/- SD) years, and all breast cancers were stage I or II, averaging 2.3 +/- 1.5 cm in size. All patients underwent a Wise-pattern inferior pedicle breast reduction after cancer extirpation and received postoperative radiation as part of their treatment. They were evaluated for postoperative complications, esthetic outcome of the breasts, and local recurrence. Patients in this series were followed for an average of 30.3 months, with no significant postoperative complications and recurrences. Breast reduction incisions healed primarily and adjuvant radiation was completed without a delay. All patients were pleased with the esthetic result and had improvement of their symptoms related to macromastia. Thus, we believe that breast reduction is a reasonable and safe option for early breast cancer patients with macromastia who desire breast conservation therapy. Our combined oncologic and reconstructive approach may improve the outcome of this group of patients with early breast cancers.

Patients??? and Surgeons??? Perspectives on the Scar Components after Inferior Pedicle Breast Reduction Surgery

Scarring is the most frequent cause of dissatisfaction both for the surgeons and for the patients in breast reduction surgery. Some of the techniques used today use the classic inverted T scar. An inverted T scar is a combination of three separate scars (periareolar, vertical, and inframammary). To the authors' knowledge, no study has investigated the cosmetic outcome of these three scar components separately. The aim of this study was to determine the surgeons' and patients' perspectives on the cosmetic outcome of these three scar components. A total of 19 patients who had inferior pedicle reduction mammaplasties were included in the study. The patients' perspectives on their reduction mammaplasty scars and the surgeons' evaluations of scar hypertrophy, widening, and color match were assessed by Likert scales. Patient evaluations revealed that periareolar scars were the most pleasing, whereas the inframammary scars were the least pleasing. Surgeon evaluations revealed no significant difference in scar hypertrophy, color match, or widening for the three scar components. However, the vertical scar had a tendency to widen and the inframammary scar color tended to match poorly. In this study, patients were most pleased with the periareolar scars and least pleased with the inframammary scars. Surgeons need to find ways of getting rid of the inframammary scar and should also deal with vertical scar widening. Scar hypertrophy was not a problem in this patient population.

Pyoderma gangrenosum complicating bilateral breast reduction

Pyoderma gangrenosum complicating bilateral breast reduction

The Short Scar Periareolar Inferior Pedicle Reduction (SPAIR) Mammaplasty

Although generally effective, the inverted T inferior pedicle breast reduction technique is associated with continuing concerns over cutaneous scar as well as shape distortion, which can to worsen over time. This article will outline a technique of breast reduction that is also based on an inferior pedicle but manages the skin envelope with a combined periareolar and vertical skin excision. By combining these elements, an effective method of breast reduction is created that reduces the amount of cutaneous scar by half and yet results in an improved and long-lasting breast shape that is stable over time. This method, called the "short scar periareolar inferior pedicle reduction" (or "SPAIR" mammaplasty) is applicable to a wide variety of breast problems ranging from simple ptosis to extremes of macromastia. Aesthetically pleasing results are consistently and reliably obtained with few complications. It is offered as an effective method of reduced scar breast reduction.

No Vertical Scar Breast Reduction: A Good Alternative to the T-SCAR Inferior Pedicle Breast Reduction

Techniques of the no vertical scar breast reduction, as used in more than 65 patients for over three years, are detailed. This technique is basically the same as the standard inferior pedical T-scar technique, except that the verticle scar is eliminated. Refinements of the technique include avoiding the ‘armpit’ breast; creating tension-free periareolar suturing with a small areolar hole; knowing how to perform the technique when there is only 3 cm of skin between the areola and the new areola position; and applying the same technique to mastopexy.

No vertical scar breast reduction: A good alternative to the T-scar inferior pedicle breast reduction

No vertical scar breast reduction: A good alternative to the T-scar inferior pedicle breast reduction

The purse-string reduction mammaplasty: a variation of the marconi technique to minimize inframammary scars

Fourteen patients underwent an inferior pedicle breast reduction modified to significantly reduce the transverse inframammary scar. The technique is described and its results and limitations are discussed. We believe this technique provides the benefits inherent in an inferior pedicle procedure while avoiding the sometimes objectionable inframammary scar, especially for breasts in which the resection is less than 600 g.