In the 1970s McKissock ¹ introduced the vertical bipedicle breast reduction technique, which was the first procedure for breast reduction surgery that was both reliable and reproducible. Before then:

• a popular breast reduction procedure was the Biesenberger ² method, but this often ended up with problems with skin flap necrosis;

• Strombeck’s ³ horizontal bipedicle was not easy and it was difficult to close the skin flaps over the pedicles without compression;

• the lateral wedge of Dufourmentel ⁴ was relatively easy to perform, but left the breasts with a ‘snoopy’ shape and medialized nipples;

• Skoog’s ⁵ lateral and medial pedicles were not widely known.

When it was discovered that either of McKissock’s pedicles could be severed, the inferior pedicle with an inverted T skin resection pattern became the favored method.⁶^–⁸ It has a reliable blood supply to the nipple and areolar complex and the skin flaps close easily over the pedicle. The skin brassiere was tightened to control the breast shape. Although most surgeons around the world now use an inferior pedicle alone for the nipple and the Wise skin resection pattern⁹ for the skin, some still prefer the vertical bipedicle of McKissock, especially for larger reductions.

Meanwhile, the South Americans ¹⁰^–¹³ and the Europeans¹⁴^–¹⁸ developed expertise with a vertical skin resection pattern and a vertical wedge resection of parenchyma. These techniques were used mainly for small reductions, with an inverted T skin resection pattern used for the larger reductions. Many of these surgeons used the superior pedicle¹⁹ for the nipple-areolar complex rather than the inferior pedicle, even when they chose an inverted T skin resection pattern. Many European and South American surgeons continue to use a superior pedicle, but often combine it with a Wise skin resection pattern.

Free nipple grafts

Free nipple grafts are an important consideration especially if any of the other pedicles have an unpredictable blood supply,^23,²⁴ especially for the larger reductions. There is a loss of sensation, a loss of projection to the nipple, and a loss of breastfeeding potential. There is also a chance of irregular pigmentation.

Minimizing the risk of nipple necrosis

Although breast reduction is predictable and safe, there is a risk of complete nipple necrosis in around 1 in 300 patients. Some surgeons routinely use free nipple grafts, whereas many reserve these for the large reductions. The nipple is preserved with the Passot ²⁵ technique (or when a similar pedicle is used in a variation of the Robertson²⁶ technique) where the complete inferior breast is used as a broad pedicle, and this is occasionally selected for extremely large reductions.

Skin resection pattern

The skin resection pattern (Fig. 17.2A-G) is determined mainly by the amount and quality of the excess skin.

• A full inverted T pattern is needed if there is a significant amount of excess skin, especially when it is poor quality (as in patients who have undergone massive weight loss). There is too much skin and the redundant skin cannot adapt to the new breast shape without further resection. It is the most commonly used breast reduction resection pattern, especially for the larger breast.

• The horizontal (often called no-vertical scar technique) usually involves a very widely based inferior pedicle with a horizontal skin resection pattern. A cutout is made for the nipple and areola, and the longer superior flap is gathered to fit the skin along the IMF. There is no vertical resection of breast tissue or skin.

• The vertical approaches are best used for small and medium-sized breast reductions. Pedicle choice depends mainly on surgeon preference.

• The periareolar approach should be confined to small breast reductions and may be indicated if there is little excess skin or a constricted lower pole.

Fig. 17.2 Pedicle designs for nipple-areola complex. A, Inferior. B, Central. C, Superior. D, Lateral. E, Medial.

Approaches to minimize scarring and maximize breast shape

Surgeons around the world are becoming more interested in the vertical approach, which involves the use of different pedicles with a vertical wedge resection of breast tissue. Proponents of this technique note:

• shorter scars;

• an improved shape with more projection;²⁷^–³⁴

• shape that lasts longer and does not bottom out as easily as with the inferior pedicle, inverted T techniques.

The aim of further reducing scars is evident in the techniques that attempt to confine the scar to the area around the areola. The periareolar method is best suited for small breast reductions and some mastopexies.^35,³⁶ These are difficult procedures with a long learning curve. Separation of the skin flaps from the parenchyma is an essential component to achieve a good outcome.

The controversy continues between using the skin brassiere to shape the breast versus reshaping the breast and allowing the skin to redrape. Many methods rely on the skin brassiere to shape the breast and hold it in position:

• inverted T techniques tend to resect tissue around an inferior pedicle and then rely on the skin pattern to hold the breast up;

• the vertical component of the Wise skin pattern is kept short to accommodate for expected stretching in the healing period, but this shortening tends to flatten the breast and prevent projection;

• vertical approaches rely on the vertical wedge resection and subsequent coning of the breast tissue to shape the skin and do not rely on the skin to hold the shape.

Unanswered questions

Many questions are still debated by surgeons and include:

• How important is the skin brassiere in shaping the breast? Does it depend on the quality of the patient’s skin?

• How important is the nature of the breast resection in shaping the breast?

• How important are breast parenchymal sutures?

• Does the pedicle have any influence over the resultant shape or is it just a means of maintaining blood supply to the nipple?

• The inferior pedicle mandates that the tissue resection is superior and the tissue left behind is inferior. Does gravity have more of an effect on inferior tissue left behind than superior tissue left behind?

• Does leaving the breast tissue attached to the upper skin flaps help prevent bottoming-out (as in the superior type pedicles) or does separating the breast tissue away from the upper skin flaps (as with an inferior pedicle) have any effect on bottoming-out?

• Can breast tissue be secured up to the chest wall so that it does not drop out?

• Can the upper pole of the breast be improved by suturing breast tissue up to the pectoralis fascia?

• Can the level of the inframammary fold (IMF) be changed? Does it drop over time with certain procedures and does it rise with others?

• Is there one pedicle with a more reliable blood supply?

• Is there one pedicle with better final results as far as nipple and areola sensation are concerned? What about breast skin sensation?

• Is there one pedicle or approach that is more likely to preserve the ability to breastfeed?

• How important is the length of the pedicle in preserving circulation to the nipple and areola? Did the vessels stretch during development as much as the skin and parenchyma?

Indications

The volume of resection is not as important as suspected in improving symptoms associated with large breasts. Postoperative improvement may be as much dependent on other comorbidities such as osteo-arthritis of the cervical spine. The breast reduction will not correct any underlying disease, but can remove the weight that can aggravate the resultant symptoms. The actual elevation of the breast tissue may be as important as the amount of weight resected.

Choice of breast reduction operation

The most common skin resection patterns are the inverted T and the vertical techniques.

Inverted T resection

The inverted T resection is used for larger reductions and for patients with a large excess of skin, especially when there is poor skin elasticity (e.g. in patients who have had a massive weight loss).⁴⁰

The choice of pedicle can vary. There is no consensus on which pedicle may have a more robust blood supply or which pedicle will likely preserve better sensation. The most common pedicle choice is the inferior pedicle because it is easy to create and has a reliable blood supply. All other pedicles (central, superior, lateral and medial) can be used with the inverted T skin resection patterns.

Many surgeons try to confine the inframammary scar to the breast width itself, but in the larger reductions it is difficult not to extend the lateral and medial incisions further to avoid dog-ear formation.

Vertical approach

The second most common skin resection pattern is the vertical approach. The most common pedicles are the superior and the medially based pedicles. Both the lateral and the inferior (short scar peri-areolar inferior pedicle reduction [SPAIR]³⁰) pedicles are also used. Some surgeons take up more skin into the areola and call the procedure the ‘circumvertical’ approach.^41,⁴² This is done to shorten the vertical scar, but does require more finesse in closing the areola without puckering and stretching.

Other techniques

Periareolar technique

For very small breast reductions, the periareolar technique can be used. This is a commonly misunderstood technique because it does not just involve suturing the skin under tension to the areola, but also involves separation of the skin from the breast tissue. The breast tissue is reduced and reformed ³⁵ with sutures or it is wrapped in various forms of mesh.³⁶

For very large breast reductions, variations of the Passot ²⁵ technique can be used. In these cases, the pedicle is a complete inferior pedicle from medial to lateral. The upper skin flap is brought down over the inferior tissue and a cutout is then created for the areola. The upper skin flap is much longer than the incision along the IMF and a considerable amount of gathering is needed. This procedure is some-times called the ‘no vertical scar technique’ because the scar is confined to the IMF and the periareolar areas. Pribaz⁴³ has modified the Robertson technique as a variation for the extremely large reductions. Rubin⁴⁰ has developed a variation that can restore some shape for patients who have had massive weight loss.

Liposuction-only breast reduction

Liposuction-only breast reduction ^44,⁴⁵ is useful in women with fatty breasts, fairly high nipples and good upper pole fullness. Breasts tend to contain more fatty tissue than glandular tissue around meno-pause and these patients may be good candidates for liposuction only. Volume can be reduced, but a good shape can be best achieved in patients with high nipples and good upper pole fullness. Unfortunately many older women have developed ptosis and loss of upper pole volume. Large breasts in teenagers tend to be very glandular if they are normal body weight, and liposuction-only is not likely to be effective.

Medial pedicle vertical breast reduction vs inferior pedicle, inverted T reduction

Dog-ears

I prefer the medial pedicle vertical approach for most breast reductions. The resection pattern is a vertical ellipse or wedge resection (Fig. 17.3), which results in two dog-ears – one superiorly and one inferiorly:

• the superior one disappears into the areola;

• the inferior one (usually) disappears with time.

Fig. 17.3 Comparison of inverted T and vertical markings.

In contrast, the inferior pedicle, inverted T reduction involves a horizontal elliptical excision of breast tissue and skin – also with two dog-ears – one medially and one laterally. The advantage of a vertical reduction is that the dog-ear can be easily corrected if it persists (about 5% of cases). The dog-ears with an inverted T approach are often more difficult to correct.

Other differences

The vertical elliptical excision cones the breast, narrows the base, and gives it more projection, whereas the inverted T inferior pedicle compresses the breast by keeping the vertical limb short to prevent bottoming-out.

The medial pedicle vertical breast reduction is my preferred technique. I used an inferior pedicle, inverted T breast reduction for the first 10 years of my practice, but then in 1993 started using the vertical approach, initially with a superior pedicle. Because of problems insetting the superior pedicle, I switched to a lateral pedicle with the assumption that it would provide good sensation, but finally settled on a medial pedicle because it not only provides good sensation but also allows complete access to the excess breast tissue laterally.

The other difference is that in the medial pedicle vertical technique, the breast tissue is left attached to the skin and the heavy inferior breast tissue is removed. I believe that because an inverted T inferior pedicle removes the breast tissue superiorly and leaves behind the heavy inferior breast tissue the resultant breast is more likely to bottom out with time.

Preoperative Considerations

Patients who recover best from surgery appear to be those who are closest to their ideal body weight. Obese patients take longer to recover from the anesthetic, and are more likely to have wound healing complications. The size of the breasts and amount of resection also play important roles in the immediate healing phase.

The surgeon needs to look for previous biopsy scars and avoid any pedicle where the scar crosses the base of the pedicle. Even a superficial biopsy will likely have damaged the blood supply.

Smokers are more likely to have problems with blood supply and healing. Although many patients are unable to quit smoking, it is best to advise them to stop smoking before and after their surgery.

A history of medication use, needs to include alternative and herbal therapies. Many medications and herbal preparations can increase bleeding (e.g. acetylsalicylic acid, ibuprofen, gingko).

It is unclear whether diabetes mellitus plays a role in reducing blood supply. The surgeon needs to take all the factors into consideration when weighing the risks and potential benefits of breast reduction surgery.

Medial Pedicle Vertical Breast Reduction

Operative Approach

Preoperative markings

The markings are all made preoperatively with the patient in the standing position. It is important to make sure that the markings are symmetrical for what is left behind (not for what is removed). The sequence below should be followed.

1 Inframammary fold level

The first marking is the level of IMF. Some patients have high folds and some have very low folds.

2 Breast meridian

The next marking should be the breast meridian (i.e. where it is expected to be after the reduction). The current nipple position is ignored and the breast meridian is marked in its desired position. Because a medial pedicle vertical breast reduction allows extensive lateral resection, it can be placed more medially than for an inverted T, inferior pedicle breast reduction.

3 New nipple position

The ideal nipple position in a breast reduction is at the most projecting part of the breast. This should be about 2 cm lower than for an inferior pedicle, inverted T reduction. If a patient has a great deal of upper pole fullness, the new nipple position can be moved up slightly. But if a patient has a concave upper pole then it is important to ensure that the new nipple position is no higher than the IMF.

Nipple position is determined preoperatively. Trying to decide where to place the nipple during surgery is more likely to cause misplacement, with the nipples being placed too high.

There is no point waiting to determine the new nipple position intraoperatively because it can be more accurately determined with the patient standing. The level of the IMF can change slightly, but the amount of upper pole fullness will not.

4 Areolar opening

The areolar opening should end up as a circle when closed. A 16 cm circumference matches a 5 cm diameter and 14 cm matches a diameter of 4.5 cm.

5 Skin resection pattern

The skin closure does not need to be tight. The shape of the breast is determined by the nature of the resection and the closure of the breast pillars, therefore the skin does not need to act as a tight brassiere. The skin resection pattern can be designed so that the skin is loose (but not redundant) at the end of the procedure. The areolar opening and the skin resection pattern together take on the shape of a snowman. The vertical limbs of the inverted T pattern will approximate the vertical limbs of the vertical pattern. But instead of taking the vertical limbs horizontally and medially to meet the IMF, the limbs are circled around to meet each other about 2–4 cm above the IMF. It is important not to bring the pattern down to the fold or the scar will end up below the fold (because of the nature of closing an ellipse and because the IMF does rise to some degree). It is also important to make the skin resection inferiorly more of a ‘U’ than a ‘V.’ The ‘V’ may seem to leave less of a pucker but it will, in fact, leave redundant skin.

6 Pedicle design

The medial pedicle is best designed keeping one half of the base in the areolar opening and one half of the base below the areolar opening (Fig. 17.4A). This design allows the pedicle to rotate easily into position and allows the inferior border of the medial pedicle to become the medial pillar. Too much tissue left below the areolar opening may contribute to the appearance of pseudoptosis. The base is usually 68 cm in length.

Fig. 17.4 Vertical breast reduction using a medial pedicle. A, Area to be resected. B, De-epithelialized medial pedicle. C, Resection specimen. D, The medial pedicle rotated superiorly. E&F, The first pillar suture is closed. Usually only three to four sutures are used. Only superficial bites of fibrous tissue are taken – not deep bites of fat. G, Final closure. A good breast shape is left on the table at the end of the procedure.

It is important to try to keep a vein in the design – these can be easily seen through the skin lying just beneath the dermis.

Although the pedicle may appear to be superomedial when the patient is standing it will look medial when the patient is lying down.

The blood supply comes from the medial branches of the internal mammary system.

A long pedicle looks much shorter when the patient is lying down and may have a more risky blood supply, but the vessels must stretch with the breast tissue and nipple as ptosis develops. Theoretically, at least, a long pedicle should still have good blood supply.

Operative technique

Infiltration

• The patient is completely supine and under a full general anesthetic.

• The breast is infiltrated with either a solution of lidocaine with epinephrine or with a tumescent type of fluid. The infiltration can be used in the whole breast, but is mainly used for the areas marked for liposuction tailoring.

Pedicle creation

• The pedicle is de-epithelialized leaving a 1 cm ring of tissue around the new areolar circumference (Schwartzmann maneuver⁴⁶) (Fig. 17.4B).

• The pedicle is then created (either by knife or by cutting cautery) full thickness down to breast meridian. It is important to leave tissue over the pectoralis muscle to preserve innervation.⁴⁷ The medial pedicle will be mobile and appear to be undermined – much as occurs with the creation of a full thickness inferior pedicle.

Tissue resection

• Breast tissue is removed en bloc. The skin is not undermined, but the tissue resection is beveled medially and laterally (Fig. 17.4C).

• The inferior border of the medial pedicle will become the medial pillar.

• Leave 1–2 cm of lateral pillar attached to the skin resection margin laterally for about 7 cm in length. The rest of the tissue inferiorly can be resected more aggressively. It is difficult not to under-resect with this technique and it is important to remove as much breast tissue as was estimated preoperatively. The extra tissue can be removed laterally parallel to the chest wall while still maintaining a lateral pillar.

• Do not remove too much tissue superiorly – just enough for the medial pedicle to inset easily (Fig. 17.4D). Leave some tissue as a platform for the medial pedicle because it can often be thin distally (even though full thickness) and this will prevent areolar retraction postoperatively.

• Ensure an adequate resection by visualizing the Wise pattern leave a Wise pattern behind of breast tissue (not skin). This tissue is left attached to the superior, medial and lateral skin flaps and the rest of the parenchyma is resected. Although this leaves redundant skin, most of the skin will redrape over the new breast shape.

• The extra tissue below the Wise pattern can be excised directly or removed via liposuction. (This is often similar to the procedure used in gynecomastia where the central breast tissue is resected and then liposuction is used for peripheral contouring and refinement. One benefit to completing the peripheral shaping with liposuction is that the skin is likely to retract better than with direct excision alone). Liposuction is performed to shape the remaining breast into a Wise pattern and to reduce the excess in the preaxillary and lateral chest wall regions. This is usually performed after pillar and dermal closure to get a more accurate idea of the remaining shape.

• Although the resection is beveled laterally and medially it is impor tant to actually undermine the tissue down to the IMF. Often the pucker that can result is more a problem of excess subcutaneous tissue than excess skin. It is also important not to denude the underlying dermis of all fat or else scar contracture is likely to develop. A 1-cm thickness to maintain some fat is essential, but this undermining should extend laterally and medially because the IMF will often rise to some degree with this technique. This ‘undermining’ is often best achieved with a combination of direct excision and liposuction.

Pillar closure

• As the medial pedicle rotates into position, the inferior border becomes the medial pillar.

• Pillar closure is made easier by placing the first suture in the base of the areola. The dermis does not need to be undermined in this maneuver. The lateral pillar should be about 7 cm in length and the inferior edge of the pillars starts about half way up the skin resection opening – not at the IMF.

• The pillars are closed (Fig. 17.4E&F) to achieve a Wise pattern of breast tissue left behind on the table. All tissue below is ignored during pillar closure and later tailored with liposuction and/or direct excision.

• Pillar closure is achieved without undue tension. Only enough sutures are needed to bring the breast edges together to allow healing to occur over the ensuing weeks. The author starts the pillar closure inferiorly and then completes the closure toward the areola. Only three to four sutures are needed. Large bites of breast tissue are not only unnecessary but can potentially cause fat necrosis. Sutures should be placed in the fibrous tissue to allow fibrous tissue to heal to fibrous tissue rather than asking fat to heal to fat (which is unlikely to hold long term).

Skin closure

• The dermis is closed with deep interrupted sutures. It is important not to use too many sutures and to place only enough so that dermis approximates dermis.

• Liposuction for tailoring is then performed at this stage and the skin is finally closed with a loose subcuticular suture. The skin is not gathered. Although gathering was initially advocated by Lejour, I found that the vertical limb either lengthened with time or remained contracted with skin pleats that required revision. It is a little more uncomfortable for the surgeon to leave a pucker that protrudes at the lower end of the incision, but wound healing problems virtually disappeared once gathering was abandoned.

• If the areola is not a complete circle on the table, then extra skin can be de-epithelialized so that the final result is a circle. Because the vertical limb is not gathered, there is no issue with the areola being pulled down into a tear-drop shape. The areola is closed with four interrupted deep dermal sutures and then a subcuticular suture to complete the closure.

• I use 3–0 Monocryl for all sutures in the breast reduction – pillars, dermis, areola and subcuticular. Sutures are not used to control tension, but are used only to hold edges together until healing occurs.

Any tension on the pillars or skin is to be avoided. It can be difficult for the surgeon who is converting from an inverted T method to realize that the skin can be closed loosely and that tension is detrimental to healing. The inverted T methods tend to rely on skin tension to hold the shape whereas the vertical methods use the vertical wedge excision and breast closure to shape the skin.

• The skin is not sutured up to the breast tissue and the pucker is not sutured down to chest wall. Resolution occurs faster if the skin and tissue can settle without interference. Suturing the skin down results in indentations, which require time to resolve.

• Drains are only rarely used. They do not prevent hematomas and would need to be left in for weeks to prevent a seroma. If tumescent infiltration is used in the breast, seek out the known blood vessels and make sure that they are secured because the tumescent fluid will cause constriction during surgery, which will be released over time postoperatively. Seromas do develop but tend to disappear without treatment.

Antibiotic cover

All patients are treated with perioperative antibiotics. Cephalosporins are given intraoperatively and for about 5 days postoperatively. I have noticed that antibiotic use is associated with not only fewer wound infections, but also a dramatic reduction in suture splitting and wound healing problems.

Procedure completion

• All the incisions are covered with paper tape (Fig. 17.4G). The paper tape is not applied across the incision, but directly over the incision in the same direction. Steristrips often cause blistering because of tension across the wound. The paper tape covers any gaps in the skin that result from loose closure and is left in place for 3 weeks. The patient showers directly over the tape and pats it dry. When the tape eventually separates a nicely healed incision is left behind. Some surgeons reapply the paper tape to try to reduce long-term hypertrophic scarring.

Postoperative Care

The patient is placed in a loose brassiere to hold dressings in place. Although it would be ideal to be able to compress the lateral chest wall where liposuction was performed it is not recommended so that the breast itself is not compressed.

Patients are allowed to shower the day after surgery and are told to use the brassiere for about 2 weeks day and night. After the initial bandages are removed, patients often find that pantiliners (with the adhesive strip attached to the brassiere) function well if there is any more oozing from the incisions).

Patients are restricted to light activities for the first couple of weeks, with return to full activities in 3–4 weeks. They are not told to restrict arm movement.

Pre and postoperative views for one patient are shown in Fig. 17.5A-L.

Fig. 17.5 Before and after medial pedicle vertical breast reduction. This 22-year-old patient was 5′5″ tall, wore a 36G brassiere and weighed 160 pounds. She had 635 g removed from the right breast and 620 g from the left breast. Another 125 mL of fat was removed by liposuction from the lateral chest wall and inferior breast. A, Preoperative frontal view. B, Preoperative lateral view. C, Preoperative frontal markings. D, Intraoperative view. E&F, Frontal and later views 13 months’ postoperatively. She had full recovery of sensation on the right side and only slightly decreased sensation on the left nipple. The distance from the inferior border of her areola to the IMF was 10 cm on the right side and 9 cm on the left side. G&H She had small puckers 13 months’ postoperatively, which were revised under local anesthesia through a small vertical incision where a minimal amount of skin was removed, but the excess subcutaneous tissue was removed horizontally through the vertical incision. I&J, Correction of right pucker at 13 months through vertical skin excision and horizontal subcutaneous excision. K&L Correction of right pucker at 13 months through vertical skin excision and horizontal subcutaneous excision.

I have found that recovery time from a medial pedicle verticle breast reduction is about 2–4 weeks, which is about half that required for inverted T inferior pedicle reductions. Operating time is only about 2 hours and intraoperative blood loss is minimal.

Inverted T, Inferior Pedicle Breast Reduction

Operative Approach

Preoperative markings

The markings (Fig. 17.6A-E) are all made preoperatively with the patient in the standing position. Some surgeons prefer to decide where to place the nipple during surgery, but I believe that a more accurate determination can be achieved preoperatively to avoid placing the nipple too high or on the concave upper surface of the breast. It is important to make sure that the markings are symmetrical for what is left behind, not for what is removed and to make them in the following sequence.

Fig. 17.6 Inverted T breast reduction procedure. A, Preoperative markings for inverted T, inferior pedicle breast reduction. B, Preoperative markings shown with left breast lifted. It is important to try to match the final horizontal distance of the upper flaps to the distance along the inframammary fold. C, Lateral appearance preoperatively. D, Frontal appearance 3 weeks’ postoperatively. E, Lateral appearance 3 weeks’ postoperatively.

1 IMF level

The first marking is the level of the IMF. Some patients have high folds and some patients have very low folds.

2 Breast meridian

The next marking should be the breast meridian (i.e. where it is expected to be after the reduction). The current nipple position is ignored and the breast meridian is marked in its expected position postoperatively. Because an inverted T, inferior pedicle breast reduction tends to leave a wider breast than a vertical procedure it is important not to place the nipples too medially.

3 New nipple position

The ideal nipple position in a breast reduction is at the most projecting part of the breast. If a patient has a concave upper pole then keep the new nipple position no higher than the IMF. It is also important to realize that the IMF may drop out to some degree with the inverted T, inferior pedicle procedure, so making the nipple appear too high. I believe that the new nipple position can be more accurately determined with the patient standing preoperatively rather than intraoperatively.

4 Areolar opening

The areolar opening should end up as a circle when closed. A 16 cm circumference matches a 5 cm diameter. The Wise pattern has a 14 cm circumference, which matches a diameter of 4.5 cm. The areolar opening may be designed intraoperatively to ensure that the final opening is a complete circle. The upper border of the areola should be placed about 2 cm above the position determined for the new nipple itself.

5 Skin resection pattern

The skin closure needs to be fairly accurate because the skin is used as a brassiere to hold the final breast shape. The Wise pattern is followed with the vertical limbs extending laterally and medially to achieve a good closure. Some surgeons design the divergence of the vertical limbs at a specific angle, but many measure the upper skin flap margins and attempt to match the resultant distance to the lower skin flap margins. The vertical limbs are designed at 5–6 cm to take into account the fact that the vertical limbs will lengthen postoperatively. The medial and lateral extensions are usually curved up medially and laterally to help shape the breast and avoid dog-ear formation.

6 Pedicle design

The inferior pedicle is designed to be about 8–10 cm wide at the base. It is important to keep some of the pedicle medially to ensure that the perforator from the internal mammary system is preserved. The artery and its venae comitantes enter the pedicle just medial to the breast meridian about 4–6 cm above the IMF. There are often several branches, which supply the pedicle more laterally as well.

Several surgeons believe that it may be important to try to cant the pedicle base laterally to some degree to include the deep branch of the lateral fourth intercostal nerve to preserve nipple sensation. It is probably more important, however, to leave tissue over the pectoralis muscle to preserve this nerve around the level of the fourth interspace.

Operative technique

Infiltration

• The patient is completely supine and under a full general anesthetic.

Pedicle creation

• The new areolar diameter is determined and the pedicle de epithelialized. A cuff of de-epithelialized skin is left around the areola following the Schwartzmann maneuver.⁴⁶ The pedicle is completely de-epithelialized and then carried down directly to the chest wall with either a scalpel or a cutting cautery. Care must be taken to make sure that the pedicle is full thickness. It will tend to be quite mobile and will appear to have been thinned.

The inferior pedicle must be full thickness to preserve its blood supply.

• Some surgeons will suture the pedicle to the chest wall after the tissue is resected to try to hold it up and prevent later bottoming out. This maneuver is controversial because no one is certain how effective the suturing is long term.

Tissue resection

• The breast tissue is removed along with the skin along the previously marked lines in the keyhole pattern. The tissue can be removed either with a scalpel or with cutting cautery. If a significant amount of tumescent type infiltration was used, the surgeon will find it easier to use a scalpel. There is a considerable amount of bleeding laterally during direct excision.

• Liposuction can be used to tailor out the resection peripherally, much as would be performed with a gynecomastia procedure. Many patients have excess fat in the preaxillary areas and the lateral chest wall. Avoid removing too much tissue under the superior flap to avoid losing upper pole fullness.

Flap closure

• The lateral and medial skin flaps are brought together over the inferior pedicle and closed. Occasionally sutures are placed in the breast tissue itself, but most surgeons just close the deep dermis. It is difficult to close the flaps with enough tension to support the breast, but without causing so much tension that wound healing problems result.

Skin closure

• The skin is closed first laterally and medially to prevent dog-ears and to move as much of the lateral and medial flaps toward the center of the breast to try to give as much projection as possible.

• The deep dermis is closed and then the skin is closed with a subcuticular suture.

Postoperative Care

Drains are usually brought out through a separate stab wound laterally, secured into place as needed and usually removed the following day. Patients are placed in a compression type brassiere or an elasticized wrap. Care must be taken not to compress the areola area too much.

Patients are restricted from moving their arms above their head to any significant degree and asked to limit their activities for the first few weeks. Full return to activities usually takes 4–6 weeks.

Pre and postoperative views for one patient are shown in Figs 17.7A-D.

Fig. 17.7 Before and after inferior pedicle inverted T breast reduction. This 25-year-old woman was 5′6″ tall, wore a 42DD brassiere, and weighed 185 pounds. A, Preoperative frontal view. Her markings show measurements of 7 cm medially and 11 cm laterally designed to match the length of the inferior incision along the inframammary fold. B, Preoperative lateral view. C, Postoperative frontal view at 4-month follow-up after having had 1025 g removed from the right breast and 1300 g removed from the left breast. D, Postoperative lateral view at 4-month follow-up.

Optimizing outcomes

• Expertise at more than one operation:

• a medial pedicle vertical breast reduction may not be possible if a breast biopsy has been performed across the base of the pedicle

• there may be too much redundant skin at the end of a vertical procedure necessitating the conversion from a vertical skin resection pattern to an inverted T skin resection pattern

• a patient who has had massive weight loss may have little breast tissue above the IMF and many of the standard approaches will result in failure to achieve a good size and shape

• Understand the anatomy, especially when deciding which pedicle to use:

• a good knowledge of the arterial input is essential to safe pedicle creation

• visualizing and maintaining venous circulation is equally important

• preserving nipple and areolar sensation is not always predictable, but a good understanding of innervation will help

Complications and Side Effects

Scarring, loss of sensation and potential inability to breastfeed are expected side effects:

• scarring depends on the length of the scars and the patient’s genetic make-up;

• recovery of nipple sensation can be unpredictable, but results have shown that approximately 85% of patients recover normal to nearnormal sensation;

• chances of breastfeeding are probably somewhat better than 50/50.⁴⁸

Serious complications are rare and less serious complications tend to be more common. As with any procedure, severe untoward events can occur. Deep venous thrombosis and pulmonary emboli cannot always be prevented, but intermittent compression devices, postoperative mobilization and prophylaxis as indicated all help prevent their occurrence.

Wound healing and infection

Wound healing problems (Figs 17.8A&B, 17.9A-F and 17.10A-D) are more likely in obese patients. Smoking also appears to have an adverse effect on wound healing. Perioperative antibiotics not only reduce the infection rate (which is more common in the larger patients), but also reduce wound healing problems. The breast ducts are contaminated with Staphylococcus epidermidis and proprionibacteria. It makes sense that some form of antibacterial pro-phylaxis may be indicated in breast surgery. It is not completely ‘clean’ surgery.

Fig. 17.8 Dehiscence of the areola. A, Dehiscence of the areola at 3 weeks. It healed in a few months by secondary intention. B, View at 18 months.

Fig. 17.9 Infection with tissue necrosis. This woman underwent an inverted T inferior pedicle breast reduction at age 55 years. She was 5′6″ tall and weighed 172 pounds. She had 770 g removed from each side. A, Preoperative frontal view. B, Preoperative lateral view. C&D, She developed an infection with tissue necrosis, which was treated by debridement and healing by secondary intention. E&F, Postoperative views at 15-year follow-up with no further surgery.

Fig. 17.10 Infection. This 56-year-old woman had a vertical breast reduction using a medial pedicle. She was 5′4″ tall, wore a 40DD brassiere and weighed 155 pounds. A, Preoperative frontal view. B, Intraoperative view. She had 715 g removed from the right breast and 550 g from the left breast and was placed on perioperative cephalosporins, but developed an infection in the right breast at 3 weeks. C, Postoperative view at 1 month. The infection was successfully treated with ciprofloxacin and healed well without any further treatment. She had full recovery of sensation in her nipples and areolas. D, Postoperative view at 1-year follow-up.

Skin flap necrosis

Whenever skin flaps are mobilized or undermined, the risk of necrosis increases. Techniques that minimize both undermining and tension on the skin are more likely to heal uneventfully. I have noted a significantly reduced problem with skin flap necrosis using the vertical approach. This is probably because the breast tissue is left attached to the skin flaps and the skin is closed loosely under little or no tension.

Nipple-areolar necrosis

Creation of a pedicle also involves a reduction of blood supply. The four main arterial inputs to the breast may not all be equally dominant. Nipple necrosis (Fig. 17.11A-D and see Fig. 17.10) can occur when one of these vessels is weak or there is constriction, kinking or compression of the pedicle obstructing venous return. External compression is unlikely to be strong enough to cause necrosis, but a hematoma could be a problem.

Fig. 17.11 Nipple necrosis healing by secondary intention. Nipple necrosis can result from a lack of arterial input or venous congestion. It is often unpredictable and difficult to assess and treat. A, Preoperative view. B, Postoperative view at 2 weeks. C, Postoperative view at 6 weeks. D, Postoperative view at 3 months. These photographs show that it can be best to leave the areola to declare itself and heal by secondary intention.

If a nipple and areola look congested, removal of sutures and release of compression are indicated.

Duskiness alone is hard to interpret. If all dusky nipples were removed and replaced as grafts there would be more problems than leaving them alone. Often a dusky areola has excellent circulation. Sometimes some blistering can occur with complete recovery, though sometimes with some irregular pigmentation. Sometimes only a partial loss occurs and it is often best to leave this to heal by secondary intention because the outcome can be excellent. Rarely does full necrosis occur and this may require debridement and reconstruction.

Hematomas and seromas

Meticulous hemostasis can prevent the development of a hematoma (Fig. 17.12A-D), but drains cannot. If infiltration is used, the vessels may be constricted and the surgeon may not notice them. A careful search for known vessels is important before closure.

Fig. 17.12 Hematoma formation.

A, Preoperative markings for vertical breast reduction using a medial pedicle.

B, Intraoperative photograph after 740 g was removed from the right breast and 700 g removed from the left breast. C, Hematoma developed postoperatively. Tumescent infiltration had been used and the perforator that would normally supply an inferior pedicle was bleeding. It had probably been in a constricted state because of the tumescent infiltration and had not been properly cauterized. D. Patient seen at 2 months’ postoperatively.

Leaving a drain in for a couple of days is unlikely to prevent a seroma. Seromas do occur, but do not behave in the same way as abdominal seromas. They can drain on their own and tend to disappear. Only rarely will a patient complain of a sudden ‘gush’ during the postoperative period.

Asymmetry

Asymmetry can occur with any breast procedure. If it persists postoperatively it can often be treated with liposuction to the larger side. It is interesting that patients will tolerate asymmetry on the same side better than if the asymmetry is reversed postoperatively.

Under-resection

It is more common to under-resect the breasts when a vertical approach is used. It is important for the surgeon to estimate how much should be removed preoperatively and to keep close to this estimate when performing a reduction. Under-resection of lateral fat is also more of a problem with the vertical approach because the IMF often rises. Remove the excess fat between the old fold and the new fold or a bulge of tissue will result.

Puckers

Puckers (see Fig. 17.5G-L) occur with both the vertical and the inverted T procedures. The horizontal excision of skin and breast tissue with the inverted T results in a lateral dog-ear and a medial dog-ear. The lateral dog-ear is often difficult to correct without chasing it around the back. The medial dog-ear presents a particular problem because it is important not to let the scar cross the midline of the chest. It is often better to accept a small dog-ear medially rather than a hypertrophic scar across the midline.

The vertical approach also results in two dog-ears, but at right angles to those that develop with an inverted T. The one dog-ear superiorly disappears into the areola. The lower dog-ear creates a pucker inferiorly. This can require correction in about 5% of patients. This is often easily performed through a small vertical incision under local anesthesia in the office.