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

With the patient anesthetized in the supine position, a tourniquet is placed at the base of the breast. The areola is traced with a 42-mm diameter washer, centering the nipple in the hole of the washer. The superolateral dermoparenchymal pedicle is then drawn with a 10- to 12-cm width, starting 2 cm lateral to the meridian and ending 2 to 3 cm lateral to the lower edge of the lateral point of the vertical marking. Depending on the length of the nipple–areola complex and extending 1 to 2 cm beyond the new 42-mm areolar border, determines the length of the pedicle. A 1 : 1 ratio of length : width is the result.

In type Ia patients (reduction and nipple–areola transposition), the breast resection is accomplished with incisions perpendicular to the chest wall, following the Wise pattern, excising excess skin, breast, and fat to the level of the pectoralis major fascia. Patients with exceedingly large breasts are considered as candidates for the superolateral pedicle with a free nipple graft (type Ic). As a general rule, this procedure is used in cases in which the distance from the nipple to the sternal notch exceeds 40 cm preoperatively. In these cases, the superolateral pedicle is drawn, ignoring the significantly lower nipple–areola complex. The entire pedicle is de-epithelialized. Creation of the pedicle is then performed as in a standard reduction, by incising at the borders of the pedicle to the level of the pectoralis major fascia. The nipple–areola complex, having been removed initially, is thinned and then suture-bolstered to the rotated de-epithelialized pedicle. In the pure mastopexy cases (type Ib), the breast tissue that otherwise would have been resected during a reduction mammaplasty is maintained in continuity with the superolateral dermoglandular pedicle, after removal of the full thickness of the overlying skin.

Pedicle insertion and closure

The pedicle is rotated superiorly and the Wise pattern is approximated with a single 3-0 nylon suture from the two lower corners of the vertical portion of the closure to the previously marked midpoint of the inframammary line. A second 3-0 nylon suture secures the upper end of the vertical limb. Closure of the skin flaps maintains the position of the new superiorly rotated pedicle. It is not necessary to support the pedicle with sutures to the pectoralis major fascia or surrounding breast parenchyma. In the free nipple graft patients, the dermal pedicle showing through the circle is flattened and secured to the edges with 4-0 chromic sutures. The rotation of the pedicle superiorly facilitates approximation of the medial and lateral flaps, allowing for closure of the inframammary fold, with no tension exerted across the pedicle. Vertical closure is achieved with 5-0 interrupted nylon for the nipple–areola complex and the vertical portion of the wound. Transverse closure is achieved in three layers: (1) 2-0 chromic for the superficial fascial system; (2) running 4-0 wire for the deep dermal layer; and (3) a 4-0 nylon loose running suture for the skin. A Penrose drain is brought through the lateral corner of the wound. At this point, a decision is made as to whether to return an autologously donated unit of blood. In type Ic cases, the nipple grafts are placed on the dermal bed showing through the keyhole, secured with a running 5-0 nylon suture, and bolstered with 5-0 nylon sutures. Mastopexy patients have the excess breast tissue rotated superiorly with the pedicle, to further provide augmentation and upper pole fullness.

Vertical pattern procedure (types IIa (Fig. 21.4), IIb.i (Fig. 21.5), IIb.ii (Fig. 21.6))

Indications

The vertical approach, although a relatively recent addition in our armamentarium, is now commonly used for those patients requiring reductions of a total of 1200 g or less and a nipple–sternal notch distance of 35 cm or less. Almost all mastopexy and mastopexy with augmentation cases are now done with the vertical pattern as well, although some post bariatric breast mastopexy surgery is still done with the Wise-type pattern, to take advantage of the lateral inframammary scar, allowing for reduction of the excess lateral fold.

Fig. 21.4 Vertical pattern variation (IIa).

Vertical reduction using an SLDP pedicle for moderate-to-small reductions.

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. 21.5 Vertical pattern variation (IIb.i).

Vertical mastopexy. All tissue is utilized except for the skin covering of the tissue between the vertical pillars. The SLDP pedicle and all the attached de-skinned tissue are rotated superiorly.

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. 21.6 Vertical pattern variation (IIb.ii).

Vertical mastopexy with simultaneous augmentation. The vertical pillars are redrawn after the placement of the inflated prosthesis.

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 Apr 15;115(5):1269–77; discussion 1278–9.

Markings

The preoperative markings are drawn with the patient in the standing position, using the same markings as described by Lejour and Abboud.¹³ Nipple height placement is determined as previously described for the Wise pattern patient and is generally between 21 and 25 cm, depending on the height of the patient. The standard mosque pattern is marked with vertical limbs traced free-hand, based on the surgeon’s assessment of the patient’s skin envelope. The vertical limbs curve to automatically meet at a point 2 to 3 cm superior to the inframammary fold.

Pedicle creation

Creation of the superolateral dermoparenchymal pedicle ensues in a manner similar to that described for the Wise pattern technique. A tourniquet is applied to the base of the breast and kept in place for most of the resection, reducing the overall blood loss. The base of the superolateral pedicle starts about 2 cm lateral to the apex of the mosque, but measures no more than 8 to 10 cm as the nipple distance is shorter, so that the length of the flap is therefore shorter. Again, a 1 : 1 flap dimension is planned.

In reduction mammaplasty cases, the breast resection is accomplished with incisions perpendicular to the chest wall to the level of the pectoralis major fascia. The de-epithelialization of the pedicle, all the incisions down through the dermis, and the two long lower pole incisions incised to the pectoralis muscle, are all accomplished under tourniquet control with a knife. This is unlike the Wise pattern cases in which the tourniquet is released after the de-epithelialization. When the tourniquet is released, the tip of the inferior flap is elevated with a Bovie until the fascia is visualized. Finger dissection is then done at the level of the fascia, completely undermining the superior portion of the breast, much as one does in developing a suprapectoral augmentation pocket. The balance of the resection is then completed, leaving only the superolateral pedicle. No undermining or further resection of the vertical pillars is done.

In mastopexy cases, the breast tissue that otherwise would have been resected is maintained in continuity with the superolateral dermoparenchymal pedicle. This deskinned tissue is then rotated into the upper pole of the breast, to provide further superior pole fullness.

In those patients undergoing simultaneous augmentation and mastopexy (type IIb.ii), the inflated prosthesis is placed either in a subglandular or subpectoral pocket, and then the final skin markings are readjusted and redrawn. In these patients, the markings for a routine mastopexy are used; however, exposure for a subglandular or subpectoral pocket is entered through a midline or through the medial vertical line. Following prosthetic placement, a decision is made about the extent of the vertical excess, and the vertical skin markings are adjusted accordingly. The vertical excess is either removed or de-epithelialized and swung superiorly with the pedicle as with a mastopexy alone.

The pedicle, in all types, is rotated superiorly and the base of the areola mosque incision is approximated. Closure of the vertical incision in layers maintains the superiorly rotated position of the pedicle. Care is taken not to compromise the pedicle base in the deep vertical closure. The pedicle is not sutured to the pectoralis major fascia or surrounding parenchyma. The nipple–areola complex is closed in one layer of 5-0 nylon. The last layer of the vertical closure is in the deep dermis. The vertical breast pedicle is closed with four layers of 3-0 Vicryl. Superficial dermal closure is achieved with 3-0 Monocryl as a running shirring suture. A running 5-0 nylon suture completes the vertical skin closure. Closure of the superficial dermal layer with a continuous running suture allows for shortening of the vertical dimension to a final length between 7 and 10 cm. Neither the skin nor the vertical parenchymal pillars are undermined. Drains are not placed.

Postoperative Care

Pitfalls and How to Correct

The superolateral pedicle has been used in 1500 breast surgeries. Patients have been followed up to 15 years (see Figs 21.7–21.14 for examples). Total nipple–areola necrosis was observed in four patients. Two had bilateral loss and two had unilateral loss, a total nipple–areola loss of six, or a loss of 0.2% of all nipple–areola complexes. Epidermolysis associated with partial areolar loss was seen in three cases (0.2%). In type I cases, delayed wound healing at the ‘T’ closure was observed in 126 cases (8%), but all healed without the need for operative intervention. Some loss of pigmentation with partial or complete repigmentation was seen in all patients with free nipple grafts. Twelve cases involving free nipple grafts required color tattooing (0.8%). Palpable fat necrosis occurred in 26 patients (1.7%); one patient with fat necrosis underwent excision of the area of fat necrosis by a general surgeon, because it was misinterpreted by the surgeon as being a suspicious breast mass. Three patients who had undergone type II (vertical pattern) reductions using the superolateral pedicle required reoperation for contour revision (0.4%); the revision involved adding a transverse incision at the inframammary fold. Clinically detectable postoperative infections occurred in two patients (0.1%), but did not require surgical intervention. Scar revision was required in seven patients with type I procedures (0.9%), all resulting from unfavorable scars in the lateral or medial segments of the transverse incision line. Nipple–areola sensibility was evaluated as normal or slightly reduced at 1-year follow-up in 1440 patients (96%), with only 60 patients (4%) reporting significantly decreased or absent sensibility. There were no clinically detectable cases of hematoma or seroma. No operative or perioperative mortalities have been experienced.

Fig. 21.7 A Preoperative photograph of a 1600-g reduction per side, using a type Ia procedure. B Postoperative. Correction of ptosis, upper pole fullness, and projection, as well as a significant size reduction, have been achieved.

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. 21.8 A Preoperative photograph of a Wise-type pattern, pure mastopexy, type Ib. B Postoperative photograph demonstrates correction of ptosis, projection, and fullness of the breast.

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. 21.9 A Preoperative photograph of an extremely large-breasted patient with a type Ic reduction with free nipple–areola graft. B Postoperative view of patient in A shows well-reduced and nicely shaped breast. Grafts in African-American patients usually re-pigment in 9 months; however, some require additional color. Nipples are flatter.

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. 21.10 A Preoperative photograph of a vertical pattern reduction, type IIa. B Postoperative photograph of patient in A. Six hundred grams per side were removed. Even greater projection achieved with this technique.

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. 21.11 A Preoperative view of vertical pattern mastopexy, type IIb.i. B Postoperative oblique views showing projection and superior pole fullness.

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. 21.12 A Preoperative view of vertical pattern mastopexy with augmentation, type IIb.ii. B Status post (130 kg) 300-pound weight loss requiring both mastopexy and augmentation.

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. 21.13 A, B Preoperative photographs before Wise-type pattern reduction, type Ia. C, D 1 year postoperatively.

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. 21.14 A Same patient as in Figure 21.13, now 10 years postoperative. Shows continued excellent contour of the reduced breast in frontal view. B Same patient showing oblique view 10 years postoperatively.

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.

Complications of decreased sensibility or survival of the nipple–areola complex, although extremely low, have been seen in both types I and II reduction procedures. Obviously, losses at the T intersection have been seen only in type I procedures.

The incidence of complications using the superolateral dermoparenchymal pedicle compares favorably with those documented in studies using the inferior pedicle technique.^14,15 A total of six complete nipple–areola necroses occurred in four patients out of the entire series of 1500 (0.2%). Satisfactory nipple sensation was maintained in 96% of cases, which may be attributable to preservation of the lateral cutaneous fourth intercostal nerve supply to the nipple–areolar complex. There was a very low incidence of contour deformities requiring further operation (0.4%).

Complications can be minimized and outcomes optimized by tailoring the technique to the patient’s anatomy. The Wise type pattern reduction is currently reserved for larger reductions with a nipple–areola–sternal notch distance up to 40 cm. Wise type pattern reductions with free nipple grafts are used in larger-breasted patients with nipple–areola distances of 40 cm or more. Vertical reductions are currently performed more commonly in reductions of 1200 g or less and nipple–areola distances of 35 cm or less. Almost all mastopexies and mastopexies with augmentation are currently performed with a vertical approach. Using the superolateral dermoparenchymal pedicle in free nipple graft patients, although sacrificing nipple–areola sensibility and nipple projection, allows for significant reductions and, at the same time, the resultant appearance of the breast is full and youthful because of the usual benefits of this pedicle procedure. In larger breasted women presenting with a significant axillary fold, use of the Wise-type pattern allows for incorporation and resection of this fold with a lateral extension of the inframammary line. The technique also can be employed in cases where excessive breast size and nipple–areolar ptosis necessitate use of a free nipple–areola graft.