History of development of different techniques

In the 1970s McKissock¹ introduced the vertical bipedicle breast reduction technique, which was the first procedure for breast reduction surgery that was both reliable and reproducible. Before then:

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 Europeans^14–18 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.

Principles behind the techniques

The three main problems with breast reduction are:

Maintaining the blood supply

The breast is a superficial ectodermal structure that develops from the fourth interspace and its blood supply is superficial,²⁰ except for the perforator through the pectoralis muscle. The perforator:

• comes from the fourth or fifth interspace from the internal mammary artery;

• is accompanied by venae comitantes;

• can have several branches as it passes through the pectoralis muscle.

The superficial arteries comprise:

• one from the second or third interspace from the internal mammary system (which is a robust artery supplying a superior pedicle);

• the medial branches of the internal mammary system;

• the superficial thoracic vessel (a branch of the lateral thoracic system).

The veins do not accompany the arteries and are found separately (and seen) just beneath the dermis.

Types of pedicle

The blood supply of the different pedicles (Fig. 17.1A-E) is as follows:

• the inferior pedicle relies on the perforator and its venae comitantes;

• a superior pedicle is well supplied by the long branch of the internal mammary system from the second or third interspace;

• medial vessels supply a medial pedicle;

• the superficial thoracic artery supplies a lateral pedicle.

Fig. 17.1 Skin resection patterns and pedicles for breast reduction. A, Inverted T with inferior pedicle. B, Vertical with medial pedicle. C, Vertical with superior pedicle. D, Circumvertical with superior pedicle. E, Circumvertical with inferior pedicle (short scar periareolar inferior pedicle reduction [SPAIR] technique). F, Periareolar with central pedicle. G, Horizontal with wide-based inferior pedicle.

The inferior pedicle must therefore be a full thickness dermoglandular pedicle to survive. In contrast, the superior, medial and lateral pedicles can all be dermal because both their venous and arterial blood supply is superficial. The innervation and the ductal system, however, will only be preserved with a full thickness pedicle.

The choice of pedicle is often a personal preference for the surgeon. All seem to have comparable postoperative sensibility. Although the lateral fourth intercostal nerve provides the main sensation to the nipple and areola, several other nerves (medial, supraclavicular) are also important. Many of the pedicles preserve the deep branch of the lateral fourth intercostal as it runs just above the pectoralis fascia. It is important to leave tissue on the fascia to preserve this nerve and protect sensation.

Inferior pedicle

The inferior pedicle is safe and reliable, maintaining blood supply, sensation and breastfeeding potential for the nipple-areolar complex; this mandates that the skin is then used as a brassiere. Long scars and bottoming out over time are accepted as minor problems compared with the ease and safety of creating an inferior pedicle.

The inferior pedicle is supplied by an arterial perforator through the pectoralis muscle that usually comes from the internal mammary system at the level of the fourth intercostal space and is accompanied by venae comitantes. There can be several branches, but it enters the breast usually just medial to the breast meridian about 4–6 cm above the IMF.

Central pedicle

The central pedicle may not be quite as reliable as an inferior pedicle because there are many small but powerful blood vessels that enter the breast superficially from the level of the IMF. These are cut when a central pedicle is created. Creation of a central pedicle also severs the superficial veins, which supply most of the breast.

A central pedicle relies on the same arterial perforator and its venae comitantes as supply an inferior pedicle, and is therefore, by definition, full thickness.^21,22

Superior pedicle

The superior pedicle has a very robust artery supplying it from the internal mammary system at the level of the second or third interspace. This strong artery usually enters the pedicle very superficially just medial to the breast meridian. If there is some concern about the vessel it can be easily picked up by Doppler preoperatively. The veins are separate from the artery, lie just beneath the dermis, and can usually be seen through the skin when performing the preoperative markings. The superior pedicle may need to be thinned to inset it without compression or kinking. Thinning will not damage its (superficial) blood supply.

Although the superior pedicle remains a good choice for a mastopexy, it often needs to be significantly thinned to inset correctly. This thinning leaves an empty space inferiorly and can leave an odd shape at the end of the procedure.

Lateral pedicle

The lateral pedicle is supplied via the superficial thoracic artery (a branch of the lateral thoracic artery, which runs just deep to the edge of the pectoralis muscle). The lateral pedicle is reliable, but can be a problem in breast reduction surgery because the base of the pedicle is the tissue that needs to be removed to achieve a good reduction.

Medial pedicle

The medial pedicle has surprisingly good sensation, especially when created as a full thickness pedicle where the deep branch of the fourth intercostal nerve is preserved by leaving tissue over the pectoralis fascia.

The vascular supply of the medial pedicle is from the medial branches of the internal mammary system (probably the third and fourth interspaces) and the orientation of the pedicle is best viewed when the patient is lying down. The surgeon can then visualize where the breast began before it grew large and ptotic.

Some surgeons prefer to call this pedicle ‘superomedial’ because of its orientation when the patient is standing. But pedicles are usually named according to their blood supply and the arteries and veins are both ‘medial’.

Because the base of the medial pedicle rotates and the inferior border of the medial pedicle becomes the medial pillar, the use of the medial pedicle gives an elegant curve to the lower pole of the breast.

To allow the medial pedicle to rotate easily into position, the vessel that supplies a superior pedicle is usually transected when creating it.

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 Passot²⁵ 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:

Choice of breast reduction operation

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