Inferior Pedicle Breast Reduction Using a Circumvertical Pattern

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CHAPTER 18 Inferior Pedicle Breast Reduction Using a Circumvertical Pattern

Dennis C. Hammond

Introduction

The goals of breast reduction are to reduce the volume of the breast so that the stress on the neck and shoulders is reduced resulting in relief of the upper torso complaints. At the same time, the reduction must be performed in such a manner so as to create the most aesthetically pleasing and long-lasting result possible. To accomplish these goals, any breast reduction operation can be subdivided into four specific elements. First, a versatile and reliable method for preserving blood supply and innervation to the nipple–areola complex (NAC) must be designed. Typically this requirement is satisfied by creating a pedicle of breast parenchyma and dermis that is variably based from some quadrant of the base of the breast. Second, a variable volume of breast parenchyma and fat must be removed in such a way that the blood supply to the pedicle is respected and left intact. Third, the redundant skin envelope must be reduced such that it wraps around the reduced breast in a complimentary fashion, and fourth, the shape of the breast must be controlled.

For many years, the preferred method for performing breast reduction has combined the use of an inferiorly based pedicle with an inverted T or ‘Wise’ skin pattern and many reports have documented the success of this technique in reducing the symptomatically enlarged breast.¹^–⁶ However, it is possible to combine the inferior pedicle approach with a short scar circumvertical skin pattern to accomplish the same reduction in volume with a much less significant scar burden. This procedure, called the short scar periareolar inferior pedicle reduction or SPAIR mammaplasty⁷^–⁹ is applicable to breasts of all sizes and provides aesthetic, long-lasting results in a consistent fashion. This chapter will outline the markings, operative technique, and results of this versatile method of breast reduction.

Patient Selection

Virtually any patient who presents for breast reduction is a candidate for an inferior pedicle technique. Barring the presence of a previously placed scar across the base of the breast along the inframammary fold, the only limiting factor is the length of the pedicle. This length can be measured preoperatively by extending a tape measure with the breast in repose from the inframammary fold to the nipple. It is advisable to measure this distance in every patient who presents for breast reduction using an inferior pedicle technique. In general terms, a pedicle length of 10 cm or less will in only rare circumstances exhibit any degree of NAC ischemia. For pedicle lengths of 10 to 20 cm, ischemia to the distal end of the pedicle may be seen particularly when other risk factors such as a smoking history, or the presence of systemic diseases such as diabetes are co-existent. For pedicle lengths of 20 cm or more, particular attention to operative technique is required to ensure optimal vascularization of the NAC.

While pedicle length is an important variable that can influence the subsequent development of ischemia to the NAC, another anatomic feature of the breast that directly affects the vascularization of the inferior pedicle relates to the identification and preservation of the internal breast septum.¹⁰^–¹² This septum, which has a cranial and caudal leaf, runs transversely within the breast at the junction of the lower third with the upper two-thirds and most likely represents a traction imbrication as the enlarging breast folds over itself as it hypertrophies (Fig. 18.1). Within this septum run several sizable intercostal perforators that provide direct axial blood flow to the inferior pedicle. As such, the septum functions as a neurovascular mesentery. The septum is easily identified in most patients during skeletonization of the inferior pedicle (Fig. 18.2). Once the redundant tissue is removed from the apex of the pedicle near the base of the breast, the mesenteric space can be seen to present a mobile interface as the cranial and caudal layers slide past one another. Preserving this vascular mesentery becomes a critical technical maneuver when attempting to ensure adequate vascularization of the inferior pedicle.

Fig. 18.1 A The preadolescent breast remains flattened with small neurovascular perforators preferentially entering the underside of the breast bud at the level of the fourth interspace. B As the breast begins to develop and enlarge, the upper and lower poles of the breast fold over each other ‘dragging’ the neurovascular pedicles along with the developing breast. Along the deep margins of this folded construct a, ‘septum’ forms that contains the developing neurovascular network emanating from the deep perforators. C In the fully formed breast, this septum becomes easily identified and contains a cranial and caudal leaf, each with its own perforator network.

Fig. 18.2 A Appearance of the internal breast septum after the redundant upper pole tissue of an enlarged breast has been dissected away from the surrounding flaps based on an inferior pedicle and reflected inferiorly. The contained perforators can be seen coursing through the septal leafs. B Appearance of the septum after the medial aspect has been opened and the space between the inferior leaf of the septum and the inferior pole of the breast bluntly separated. With a finger inserted into this space, the architecture of the septum and the contained perforators can be more clearly seen.

With permission from Hammond DC. Atlas of aesthetic breast surgery. Elsevier; 2008, Figs 16.1–16.8C.

While development of a well-vascularized pedicle is an important element of the overall strategy behind the SPAIR mammaplasty, it is the management of the redundant skin envelope that demands the most technical skill. In smaller breast reductions, the pattern becomes a simple combination of a modest periareolar component that then extends down to the inframammary fold in a tapered ‘V’ shape. As the amount of breast parenchyma that is removed becomes greater, and the skin envelope becomes more redundant, it becomes necessary to curve the lower portion of the ‘V’ laterally in the shape of a ‘J’ to avoid having the vertical incision extend down onto the chest wall. In particularly large reductions of 1000 g or more, this lateral extension can run for some distance along the lateral inframammary fold. One alternative to curving the skin take-out laterally is to add a small ‘T’ takeout along the central inframammary fold. In either instance, the inframammary fold scar is shorter than in the classic Wise pattern procedure and hides well in the inframammary fold.

Indications

It is possible to use an inferior pedicle for virtually any patient undergoing either a mastopexy or a breast reduction. However, the circumvertical pattern becomes more difficult to apply as the surface area of the breast becomes excessive. Therefore, in patients with extreme ptosis with a very redundant and lax skin envelope or in patients with massive breast hypertrophy, a point is reached where a more traditional inverted T pattern will more efficiently reduce the skin envelope with better approximation of the skin edges and fewer wound healing complications. As a general rule, for breast reductions of over 1500 g per side, an inverted T skin pattern used in conjunction with an inferior pedicle will be easier to use than a circumvertical pattern. As well, for small reductions of less than approximately 200 g, the traditional vertical mammaplasty with either the superior or superomedial pedicle will be a quicker and less labor-intensive option. For all other cases, depending upon the experience and technical skill of the surgeon, the inferior pedicle circumvertical skin pattern strategy can provide outstanding and long-lasting results.

Operative Technique

Marking

When marking the patient for an inferior pedicle circumvertical procedure, the basic goal is to determine that portion of the redundant skin envelope that will need to be preserved so as to easily wrap around the inferior pedicle in a contoured fashion to create the most aesthetic result. To accomplish this task, four cardinal points are identified that will define that portion of the skin envelope that will be preserved. Initially, basic orientation marks are applied to identify the inframammary fold on each side, the midsternal line and the breast meridian (Fig. 18.3A–D). It should be noted that the breast meridian does not necessarily run through the nipple as often the NAC is malpositioned either medially or laterally. As well, it is a very useful maneuver to draw a line across the midline connecting the two inframammary folds. This allows the location of the fold to be visualized without manipulating and possibly distorting the position of the breast. The first cardinal mark is located by drawing a line that parallels the inframammary fold line 4 cm above the inframammary fold. Where this line intersects the breast meridian on each side represents the top of the periareolar pattern (Fig. 18.3E). The inferior cardinal point is identified by drawing an 8 cm wide pedicle that extends up to the NAC centered on the breast meridian (Fig. 18.3F). The length of this pedicle mark varies slightly with a pedicle length of 8 cm being used for mastopexies and small breast reductions of less than 400 g, and 10 cm being used for larger breast reductions of more than approximately 800 g (Fig. 18.3G). Medially and laterally, the standard breast displacement maneuver used in traditional vertical mammaplasty procedures is used to estimate how much medial and lateral skin will need to be preserved to easily wrap around the breast. By gently rotating the breast first up and out, and then up and in, the breast meridian can be ghosted onto the periareolar pattern to identify the medial and lateral cardinal points (Fig. 18.3H, I). Communicating these four cardinal points into an elongated oval identifies the limits of skin resection that will be required to properly reduce the dimensions of the skin envelope (Fig. 18.3J). The inferior pedicle is drawn in skirting the top of the existing areola by 1–2 cm to complete the pattern (Fig. 18.3K).

Fig. 18.3 A Initial marks highlighting the midsternal line and the inframammary fold. B A line connecting the inframammary fold on each side allows the location of the fold to be accurately and consistently determined without manipulating the breast. C The breast meridian is diagrammed to bisect the breast in half. When drawing this line, the location of the nipple is ignored. D This line is carried down onto the chest wall. E A distance of 4 cm is measured up from the inframammary fold along the midsternal line. A line is then drawn across the breast at this point that parallels the inframammary fold. Where this line intersects the breast meridian marks the first cardinal point of the periareolar pattern.F, G An 8 cm pedicle width is then drawn centered on the breast meridian with a length of 8 to 10 cm. This marks the second cardinal point. H, I By transposing the breast medially and laterally and ghosting the breast meridian onto the transposed breast, the medial and lateral cardinal points can be identified. J The four cardinal points are joined into an oval to complete the periareolar pattern. K The top of the inferior pedicle is drawn around the areola to complete the pattern.

Surgical technique

At surgery, a breast tourniquet is applied to place the areola under maximum stretch and a 40–44 mm areolar diameter is marked with the aid of a circular template (Fig. 18.4A). The inferior pedicle is de-epithelialized as is a rim of dermis around the periareolar pattern (Fig. 18.4B). The dermis is divided around the periareolar opening taking care to leave a 5 mm dermal shelf that will eventually hold the purse-string suture (Fig. 18.4C). Medial, and superior flaps are then developed by initially dissecting just under the dermis and then curving smoothly downward creating a progressively thicker flap until the pectoralis major muscle is reached (Fig. 18.4D, E). In this fashion, the flaps are developed in such a way that the thinner leading edges of the flaps will smoothly redrape around the periareolar opening once the purse-string suture is cinched down without creating any tissue crowding; however, enough tissue is left behind at the base of the breast to create smooth even contours around the periphery of the reduced breast. Laterally the flap must be thinner and dissection is performed at the junction of the lateral skin flap with the breast fascia. If the lateral breast flap is made thicker than this, the breast will appear overly wide. It is important to note that the inframammary fold is not disrupted during this dissection and all the normal attachments of the fold are preserved to prevent postoperative bottoming out. Once the flaps have been developed, the inferior pedicle is skeletonized being careful not to undermine the pedicle in any way and potentially divide the breast septum. The specimen that is then removed is in the shape of a horseshoe with lateral limb being slightly longer than the medial limb (Fig. 18.4F, G).

Fig. 18.4 A With the areola under maximal stretch, a 40 mm diameter is diagrammed. B The inferior pedicle is de-epithelialized along with a peripheral rim of tissue. C The dermis is divided leaving a 5 mm dermal shelf around the periphery of the periareolar pattern. This dermal shelf will eventually hold the PTFE purse-string suture. D The initial flap dissection is performed just under the dermis to prevent tissue crowding once the purse-string suture is cinched down. E As dissection nears the chest wall, the flap becomes decidedly thicker to help contour the peripheral margins of the reduced breast. F Appearance of the resected specimen.G After the inferior pedicle has been skeletonized, volume of the pedicle should rest comfortably within the confines of the breast flaps. H, I With traction placed on the tip of the inferior pedicle, the margins of the periareolar opening will buckle on either side of the pedicle. These two points are temporarily stapled together to begin the vertical plication. This point is called the ‘key’ staple. J By placing upward traction at the point of the key staple, the entire vertical segment will infold making for an easy determination as to the extent of vertical plication necessary to create a smooth and contoured inferior pole of the breast. K Appearance of the vertical segment after full staple plication. Note that the plication line curves laterally near the inframammary fold rather than running down onto the abdominal wall. L After the areola has been temporarily stapled into position, the breast can be seen to demonstrate an aesthetic shape. M The vertical plication line is marked and crosshatched to allow accurate re-approximation once the redundant skin has been removed. N After removal of the staples, the vertical segment typically assumes the shape of a contoured and canted ‘V.’ The area over the pedicle will be de-epithelialized and the redundant tissue medial and lateral to the pedicle will be resected. O Appearance of the inferior pedicle after de-epithelialization and resection of the redundant tissue. P With temporary staple closure of the vertical segment, a rounded inferior breast contour is noted.Q After layered closure of the vertical incision, the NAC rests comfortably within the confines of the surrounding breast flaps. This complementary relationship between the pedicle and the flaps is what is responsible for the outstanding breast shape created by combining the inferior pedicle with the circumvertical skin pattern. R Appearance of the periareolar opening after placement of the interlocking PTFE suture. S Appearance of the areola after the PTFE suture is cinched down. T Final result after removing 435 g of tissue from the right breast and 440 g from the left.

To apply the circumvertical pattern, traction is applied to the tip of the inferior pedicle by grasping the dermis above the areola and pulling upward. As a result, the periareolar opening will then be seen to buckle on either side of the pedicle and these two points are grasped and temporarily stapled together to form the key staple point (Fig. 18.4H, I). Hemostats are then applied to the dermis at this point and upward traction is applied to the inferior skin envelope. As a result of this maneuver, the skin of the lower pole will be seen to fold inward (Fig. 18.4J). This imbrication line is then likewise stapled together until a rounded and pleasing lower pole contour is created (Fig. 18.4K). The areola is temporarily stapled into the remaining periareolar defect and the shape of the breast is assessed with the patient upright (Fig. 18.4L). Further tightening or even loosening of the vertical plication pattern can be performed as needed to create the desired breast shape. Once the extent of the vertical component has been finalized, the edges are marked with a surgical pen and the staples removed (Fig. 18.4M, N). The inferior pedicle is de-epithelialized and the redundant medial and lateral wedges of tissue on either side of the pedicle are removed (Fig. 18.4O) and the vertical incision is closed in layers with 4-0 absorbable monofilament suture (Fig. 18.4P). Once again the patient is placed upright and the shape of the remaining periareolar defect is assessed. If it is not perfectly circular, a surgical marker is used to mark a perfect circle and the redundant skin is removed, keeping in mind the need to leave behind a small dermal shelf. The areola is then inset into the periareolar defect using a CV-3 polytetrafluoroethylene (PTFE) suture placed in an interlocking fashion.¹³ In this technique, eight evenly spaced bites of dermis are incorporated into a standard periareolar purse string suture to join the dermal edges of the areola to the like edges of the periareolar incision (Fig. 18.4Q–S). In doing so, the tendency for the areola to spread postoperatively is minimized. The PTFE suture is used preferentially for this purpose due to the handling qualities of the material and the fact that it slides so easily through the dermal framework, thus allowing the diameter of the areolar opening to be easily controlled. The areola is then inset using a single subcuticular 4-0 absorbable monofilament. No deep intradermal sutures are used to avoid inadvertent cutting of the interlocking PTFE suture. At the conclusion of the case, the shape of the breast should be reasonably aesthetic (Fig. 18.4T). Certainly the breast should not have an intentionally distorted appearance as noted with some vertical techniques. In the ideal situation, the lower pole of the breast should appear mildly flattened to allow for postoperative resolution of swelling and mild stretching of the skin envelope. Most importantly, however, is the fact that the position of the inframammary fold does not change postoperatively, a fact that contributes greatly to the long term stability of the result.