Key Points

Summary

The evolution of procedures for reduction of breast volume and improvement of breast shape has been ongoing, based on the rich blood supply that has allowed a plethora of pedicle types. With particular consideration of the primary pattern of sensory innervation to the nipple–areola complex previously described, the authors have utilized the superolateral dermoparenchymal pedicle as a basis for surgery on a variety of presenting breast shapes.

This has been proven to be a versatile and effective technique for a wide array of breast morphologies and with differing patterns of skin excision. The operative technique involves superior rotation of a superolaterally based dermoparenchymal pedicle, resulting in a ‘periwinkle’ effect that provides desirable superior pole fullness and increased projection to the breast.

Over 1500 breast procedures have been performed by the authors during the past 15 years using the superolateral pedicle. Experience has demonstrated that the operation is safe, with total nipple–areola loss observed in only four cases. Long-term follow-up to 15 years has shown that the results are maintained well with time.

Patient Selection

The superolateral dermoparenchymal pedicle has been adapted for surgery on a myriad of breast types using differing skin excisions. A simple classification system that reflects the versatility of the superolateral pedicle operation has been developed and is used to select appropriate patients for this technique.¹

Type I: Superolateral dermoparenchymal pedicle using the modified Wise pattern:²

Type II: Superolateral dermoparenchymal pedicle using the vertical pattern:

Indications

The evolution of procedures designed to reduce breast volume and improve breast shape has been an ongoing process since the first reports by the Greek physician, Paulus Aegineta, probably during the seventh century ce (sixth book of the Synopsis of Medicine in Seven Books). Since that time, almost every conceivable pedicle type, both dermal and parenchymal, has been successfully employed. This flexibility in pedicle selection is afforded by the rich blood supply network to the breast, which includes the internal mammary artery, lateral thoracic artery, multiple intercostal perforators, thoracoacromial artery, and thoracodorsal artery. As Aufricht stated: ‘There is sufficient blood supply from any direction of the breast hemisphere to nourish the corresponding tissue.³

The anatomic innervation to the breast has been described by several authors. A detailed description of the anatomy was provided by Sir Astley Cooper in 1840.⁴ Craig and Sykes⁵ have elucidated the importance of the third, fourth, and fifth anterior cutaneous nerves, and the fourth and fifth lateral cutaneous nerves, in supplying sensation to the nipple–areola complex. Courtiss and Goldwyn⁶ identified the lateral cutaneous branch of the fourth intercostal nerve as the major source of innervation to the nipple–areola complex. Attempts at preserving maximal nipple–areola sensation during breast surgery must take these anatomic features into account.

In searching for a technique that could be tailored for use in almost any breast surgery, including both reduction and mastopexy, the following goals have been used as guidelines: (1) an adequate and safe reduction of breast volume or modification of breast shape; (2) correction of ptosis; (3) a lasting and aesthetically pleasing shape with superior pole fullness; and (4) a nipple–areola complex with retained sensibility and vascularity. In an attempt to satisfy these criteria and especially in consideration of the anatomy of the sensory nerve supply to the nipple–areola complex, the authors have utilized the superolateral dermoparenchymal pedicle.

The superolateral dermoparenchymal pedicle technique integrates elements from several other operations. Strombeck⁷ developed a horizontal bipedicled dermoparenchymal flap for breast reduction in 1960. Skoog⁸ is credited with describing the first lateral pedicle, modifying the Strombeck procedure by elevating the nipple–areola complex on a lateral dermal pedicle alone. In 1982, Nicolle⁹ presented his experience with the lateral dermoparenchymal pedicle for breast reduction. Cardenas-Camerana and Vergara¹⁰ described their successful use of the superolateral dermoglandular pedicle.

The superolateral dermoparenchymal pedicle has been successfully employed by the authors in over 1500 breast operations, including reduction mammaplasty and mastopexy procedures, using differing patterns of skin excisions. For many years the procedure was performed using a modified Wise pattern only, for skin excision. During the past 7 years, following the presentations of Lassus,¹¹ Lejour and Abboud,¹² and especially Hall-Findlay,¹³ a vertical pattern of skin and breast excision has been offered to patients. Follow-up for some patients has been for 15 years (Figs 21.13 and 21.14). Routinely, patients are followed for a minimum of 5 years.

Operative Techniques

Wise pattern procedure (types Ia (Fig. 21.1), Ib (Fig. 21.2), Ic (Fig. 21.3))

Markings

The preoperative skin markings are drawn with the patient in the standing position. A modified Wise pattern is utilized. The breast meridian is determined as follows. The distance from the sternal notch to the acromion is measured along the clavicle. From the midpoint, a vertical line is drawn, separating the breast mass equally. This line is generally toward the nipple–areola complex, unless the complex is severely displaced. The inframammary fold is then marked, extending medially from a point 2 cm from the midline of the chest and extending laterally to the mid-axillary line. By grasping the medial points of the lower edge of the vertical skin marking, each in turn, the excess breast is folded and the edge of the fold is marked to determine the excision sites. The midpoint of the closure is also marked on the inframammary fold. In this manner, potential dog ears are eliminated with this initial marking and folding maneuver.

Fig. 21.1 Wise-type pattern variation (Ia).

Superolateral dermoparenchymal (SLDP) resection reserved for larger reductions. Pedicle is well vascularized and contains the main innervation to the nipple–areola complex. It provides superior pole fullness and projection.

With permission from Strauch B, Elkowitz M, Baum T, Herman C. Superolateral pedicle for breast surgery: an operation for all reasons. Plast Reconstr Surg 2005;115(5):1269–77; discussion 1278–9.

Fig. 21.2 Wise-type variation (Ib).

Wise-type pattern resection with SLDP for mastopexy for correction of ptosis.

With permission from Strauch B, Elkowitz M, Baum T, Herman C. Superolateral pedicle for breast surgery: an operation for all reasons. Plast Reconstr Surg 2005;115(5):1269–77; discussion 1278–9.

Fig. 21.3 Wise-type variation (Ic).

Wise-type pattern resection with SLDP procedure tailored for very large-breasted women with nipple–areola complexes longer than 40 cm from the sternal notch. A free nipple–areola graft is placed on a dermal bed of the SLDP pedicle.

With permission from Strauch B, Elkowitz M, Baum T, Herman C. Superolateral pedicle for breast surgery: an operation for all reasons. Plast Reconstr Surg 2005;115(5):1269–77; discussion 1278–9.

Markings for nipple placement are made along the breast meridian at a level that accounts for the patient’s breast size and shape, height, and degree of nipple ptosis. Nipple placement is generally located between 21 and 25 cm from the sternal notch. In a small subset of patients presenting with very large breasts (1200 g or more) and initial nipple–areola ptosis of 40 cm or more, who desire retention of nipple sensibility, the new nipple–areola site may be located at 29 to 31 cm. The pattern is traced using 7-cm vertical limbs and a 42-mm areolar diameter.

Pedicle creation

Buy Membership for Plastic Reconstructive Surgery Category to continue reading. Learn more here