Superomedial pedicle extension flaps essentially involve the rotation of lower pole dermatoglandular tissue attached to the superomedial nipple–areola complex (NAC) pedicle and moved to remote areas in the breast where additional volume is required (Fig. 31.1). All breast reduction and mastopexy techniques rely on repositioning the NAC on a vascularized pedicle, resecting tissue as needed, and reshaping the breast mound with the pedicle and residual breast tissue. Extension flaps and autoaugmentation techniques are relatively new and are slightly more involved. In addition to relying on residual breast tissue for shape and size, they rotate local or distant flaps from one region of the body to fill an area of volume void within the breast. Although distant flaps have been reported, the majority of autoaugmentation techniques are local from the thoracic or abdominal region, or from within the breast. Local ‘non-breast’ options for autoaugmentation techniques typically use fasciocutaneous flaps or perforator flaps from the lateral chest wall or upper abdominal region.¹^–⁴ Local breast flaps are dermatoglandular flaps or glandular flaps based off the chest wall or as extension flaps from various NAC pedicles.⁵^–⁷ Although these autoaugmentation techniques were initially used to improve shape and volume in mastopexy cases, they have become more popular recently out of necessity in the management of the massive weight loss breast, and partial mastectomy defects.

Fig. 31.1 A, B The superomedial pedicle is de-epithelialized and extended down to the IMF and chest wall. C, D Medial and lateral pillars are dissected, creating the extended pedicle. Note the lower pole parenchymal defect once the pedicle has been rotated superiorly. The parenchyma is transected from the lateral pillar to above the proposed nipple position and a pocket is created for the pedicle.D, E The extended pedicle has been rotated superiorly and suspended for autoaugmentation. F The lateral breast is advanced medially to allow for parenchymal plication and closure of the vertical pillars. G, H Skin is redraped over the shaped breast mound.

A, C, E, G redrawn from Losken A, Holtz DJ. Versatility of the superomedial pedicle in managing the massive weight loss breast: the rotation-advancement technique. Plast Reconstr Surg 2007;120:1060.

Patient Selection

Numerous options exist for extending pedicles to autoaugment certain locations within the breast. Surgeons will often rely on a technique that they are familiar with and modify their approach to best address the deformity. Various authors have employed central or inferior pedicle techniques, and designed vascularized attachments to provide suspension of the breast mound, and autoaugmentation mainly in the upper pole where volume is often desired.⁶^,⁷ Although the majority of surgeons still use the inferior pedicle breast reduction technique,⁸ there is a growing trend toward the more superiorly based pedicle designs. It is felt that the superomedial pedicle technique can afford more reliable cosmetic outcomes, shorter operating times, and less pseudoptosis.⁹^,¹⁰ The superomedial pedicle is a relatively short, well-vascularized pedicle that can easily rotate into position.

Breast reduction techniques using superiorly based pedicles, whether superior or superomedial, both have the excess dermatoglandular tissue resected in an ‘en bloc’ wedge type fashion from the lower pole. This tissue is subsequently very amenable to being used as a vascularized extension of the NAC pedicle design for rotation to fill the upper or outer breast quadrant. Graf initially described the use of this lower pole breast tissue as a weaving technique through the pectoralis muscles to autoaugment the breast mound in mastopexy techniques.¹¹ Although it can also be used as an extended superior pedicle flap, this chapter is going to focus on it being rotated as an extended superomedial pedicle. Many of the advantages of the superomedial technique as described by Hall-Findlay can also be applied to the extended superomedial technique.¹⁰^,¹² The extended pedicle is easily rotated laterally and superiorly with the NAC to provide elevation of the nipple and autoaugmentation of the upper or lateral breast. This is a more natural arc of rotation than the extended superior pedicle where the nipple needs to move superiorly, and the pedicle extends below the nipple and is then tucked superiorly. Dermal release below the nipple is often required when using the extended superior pedicle, which could potentially compromise viability of the extension. The extended superomedial pedicle takes tissue from the lower pole where volume is often less desirable, and rotating it to the upper pole where there is often a volume void. This also leaves a lower pole defect, amenable to parenchymal plication with the added benefits of glandular reshaping, narrowing the breast mounds, tightening the IMF and minimizing recurrent ptosis (Fig. 31.1). This extended superomedial technique can be used with a vertical or a standard Wise mastopexy skin pattern.

Indications

Since the extended superomedial pedicle can be rotated into the lateral or upper breast region it is used to autoaugment a volume void in that location. The indications for this technique fall into four general categories.

1. Women with breast ptosis and sufficient breast volume who desire a mastopexy with upper pole fullness and don’t wish to have an implant will benefit from the extended superomedial technique (Fig. 31.2). There needs to be sufficient breast tissue within the breast mound that can be rotated superiorly for this technique to work in these patients.

2. Women with long atrophic breasts following massive weight loss (MWL) are often more challenging and are amenable to the extended superomedial technique (Figs 31.3 and 31.4). The two main issues following MWL are that the breast has an unstable envelope with significant skin laxity, and an unstable mound with loss of volume and form. The breast is often very ptotic, laterally displaced, with a flat upper pole. The chest can be wide, with ill-defined landmarks and a loose infra-mammary fold. These are some of the reasons why management of the breast following MWL is challenging, and often requires additional steps in order to maintain shape and size expectations, and minimize recurrence of the deformity. The extended superomedial pedicle can be used in a rotation-advancement fashion to fill the upper pole volume deficiency, narrow the base of the breast, tighten the IMF, and autoaugment the upper pole.¹⁰ Parenchymal reshaping will also allow redraping of the skin over the mound. This will minimize the risk of recurrent ptosis, especially in the MWL patient where any reliance on the skin envelope for reshaping will invariably cause recurrent ptosis.

3. Symmetry procedures on patients with breast cancer who have relatively small breasts and who underwent implant based reconstructions can be performed using the extended superomedial pedicle (Fig. 31.5). This provides the desired upper pole fullness to match the implant reconstruction when the size difference is not enough to warrant contralateral implant augmentation.

4. Reconstruction of the partial mastectomy defect in the upper or outer quadrant has also been described using reduction techniques with the extended superomedial technique.¹³ In order to support the ever expanding indications for breast conservation therapy in women with breast cancer and minimize the incidence of poor cosmetic results, there has been a recent surge in the popularity of oncoplastic techniques. These techniques essentially involve reconstruction of the partial mastectomy defect using local breast tissue (volume displacement techniques) or using local or distant flaps (volume replacement techniques). Reduction or mastopexy techniques essentially use local breast tissue (volume displacement) to reconstruct the partial mastectomy defect and reshape the breast (Fig. 31.6). This approach relies on there being sufficient breast tissue following resection to keep the NAC alive and reshape the mound. Occasionally the defect is such that breast tissue in that location is not enough to fill the defect. The nipple pedicle is often limited by how it can be rotated since the nipple needs to be in a particular location on the breast mound. This is where autoaugmentation techniques can be used to fill the defect. The extended superomedial pedicle will allow rotation of the NAC into the desired location, as well as repositioning lower pole breast tissue into the defect. Upper quadrant defects are often adequately reconstructed with this technique, since the dead space is filled with the extended vascularized pedicle (Fig. 31.7). A similar volume reducing procedure is performed on the opposite side for symmetry.

Fig. 31.2 This 45-year-old woman with post pregnancy breast ptosis desired as much upper pole fullness as possible without the need for implant augmentation. She had an extended superomedial pedicle transferred from the lower-pole to autoaugment the superior aspect of her breast.

Fig. 31.3 This 29-year-old woman lost over 55 kg (125 pounds) and had significant breast deflation with relatively long, ptotic breasts. The extended superomedial approach was used to augment the volume void in her outer quadrant without the need for implants. Breast projection and definition was restored. A, B Preoperative. C, D Nine months postoperative.

Fig. 31.4 A 39-year-old woman who lost 65 kg (148 pounds) through diet and exercise. She had significant ptosis with volume loss and lack of definition to her breast. She underwent a superomedial mastopexy with the rotation advancement technique and a Wise skin take out pattern. A, B Preoperative. C, D 4 weeks postoperatively with good shape, size and symmetry. E F Longitudinal evaluation of her results at 1 year postoperatively demonstrated some volume loss with resolution of swelling with, however, maintenance of her breast shape and nipple position over time.

Fig. 31.5 A–D Preoperative markings. 48-year-old patient with left implant reconstruction and right breast ptosis. The extended superomedial approach was used to achieve sufficient upper pole fullness in the right breast to prevent the need for an implant augmentation on that side. E De-epithelialization of extended superomedial pedicle. F–I Distal end of extended medial pedicle is rotated up to fill the upper pole as the nipple–areola complex settles into its elevated position. J Closure in vertical fashion.K, L Postoperative results.

Fig. 31.6 A–B This is a 42-year-old woman with moderate sized breasts, minimal ptosis and some asymmetry. She desired breast preservation and had a left lateral quadrant tumor (ductal carcinoma is situ). C She is shown preoperatively with guide wire in place and standard verticel markings.D–E The tumor is removed through the periareolar markings specimen weighing 92 g. This left an outer quadrant volume void. F–G The superomedial pedicle is created and extended down to the level of the IMF. The medial and lateral pillars are created and the pedicle is released. H–I The extended pedicle is then rotated laterally to fill in the defect and the pillars are plicated in the usual manner. J–K A contralateral reduction is performed using the same technique removing a total of 120 g. L–M Her result is shown 1 year following completion of radiation therapy with good lateral contour and reasonable symmetry.

From Losken A, Styblo TM, Carlson GW et al. Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques. Ann Plast Surg 2007;3:235.

Fig. 31.7 A This 44-year-old patient with a history of lateral DCIS, underwent a 110 g partial mastectomy leaving a lateral defect down to chest wall. She had moderate breast volume with minimal ptosis. B, C The defect in relation to her breast mound was such that the volume void was lateral. D The nipple was in a decent position requiring only minimal elevation, and the remaining breast required a lower pole reduction in order to reshape the mound. There was no lateral tissue available to fill the defect without compromising shape. E We elected to use an extended superomedial pedicle and rotate the pedicle to fill the lateral defect and reshape the breast mound. This approach was determined after evaluation of the defect, the residual breast tissue and both of these factors in relation to the nipple position and the proposed nipple position. A 118 g superomedial mastopexy was performed on the contralateral side. F Her results are shown a year following radiation therapy to the left breast.

Benefits

The benefits of using an extended superomedial pedicle include the ability to use local breast parenchyma, without the morbidity of a donor site, and provide vascularized tissue to areas in the breast where there is a volume void. The arc of rotation is ideal for transfer to the lateral or upper breast region. Volume is taken from the lower pole where it is often excessive, and transferred to the upper pole where it is often deficient. The rotation advancement technique allows lower pole glandular plication, upper pole autoaugmentation, as well as suspension of the breast if necessary (Fig. 31.1). This autoaugmentation technique will often give the appearance of an augmented breast without the need for implant placement in women who desire upper pole fullness. Since this technique does not bring in tissue from outside the breast, patients who have insufficient breast volume and still desire upper pole fullness will require implant augmentation or alternative techniques. Since this technique is based on a well-vascularized dermatoglandular pedicle, placement of a submuscular or even subglandular implant is still an option if necessary. The theoretical, although unproven, advantages of using the lower pole as a donor site along with glandular plication with the superomedial technique is to reduce the incidence of pseudoptosis.

Operative Technique

Marking

The patient is marked preoperatively in the standing position.

The midaxial line of the breast and the existing inframammary fold (IMF) is marked. The proposed new nipple location is determined typically 1–2 cm above the IMF. This typically results in a suprasternal notch to nipple distance of 20–23 cm, depending on the height of the patient, level of the IMF, and desired size after the mastopexy. If the IMF is loose or low, the desired level of the IMF is also marked and taken into consideration when deciding on the nipple position. A mosque-shaped areolar pattern is then drawn, as described previously,¹²^,¹⁴ with a diameter of about 5 cm, and length of the periareolar scar of less than 16 cm. Relatively conservative glandular displacement techniques are then performed off the breast meridian to decide on the medial and lateral pillar positions and width of the extended pedicle (Fig. 31.5). Horizontal Wise pattern markings are typically included about 10 cm beneath the top of the proposed NAC location. The superomedial pedicle is drawn and extended down to within the vertical markings stopping about 2–3 cm above the IMF in a ‘U’ shaped pattern.

Surgical technique

The NAC is incised and the superomedial pedicle as well as the extended pedicle is de-epithelialized down to just above the IMF. The dermis is then released creating the outline of the pedicle. The pedicle is back-cut medially only as much as is necessary to minimize restriction of rotation while keeping the pedicle base as wide as possible (Fig. 31.1). Parenchyma is then incised almost down to the level of the chest wall with no undermining inferiorly. The lateral parenchymal extension is then transected from the lateral pillar up to the superior markings and minimal undermining is performed superiorly above the proposed nipple position to create a pocket for the autoaugmentation. Elevation of the pedicle off the chest wall is required inferiorly for rotation into the upper pole; however, central attachments are left intact to maximize pedicle viability. This allows for safe pedicle back-cut for nipple inset when necessary. Once the dermatoglandular pedicle has been created, the excess skin and parenchyma is resected depending on size and shape desired. The pedicle is then rotated superiorly and suspended as needed to fill the upper pole (Fig. 31.1D, E). It is important to minimize excessive tension or torsion on the pedicle which could impair perfusion of the extension. Parenchymal plication is performed by bringing the medial and lateral pillar together with 2-0 polydioxanone suture to reshape, and narrow the lower pole of the breast. This can also redefine and tighten the IMF at a higher elevation if necessary. Lateral parenchymal plication is performed in a horizontal orientation as needed. Once the breast mound has been shaped, the skin envelope is redraped and any excess skin removed (Fig. 31.1F, G). Lateral breast skin is advanced medially to redefine the lateral breast and eliminate the lateral breast roll. Although this is often performed through a vertical only skin take out pattern, the horizontal component is usually required in the massive weight loss breast to redefine the lateral mound and remove the excess skin.

When implant augmentation is performed at the time of mastopexy, the subglandular pocket is created by undermining the superomedial pedicle. The width of the extended superomedial pedicle drawn preoperatively is more conservative to minimize the risk of over-resection of lower pole skin. Autoaugmentation techniques are still employed, and parenchymal reshaping is performed prior to implant placement. Once the desired breast size has been determined, the skin is redraped over the mound and the amount to be resected is determined.

Oncoplastic reduction techniques

When the extended superomedial technique is used to reconstruct the partial mastectomy defect, the preoperative markings are similar to described above. Communication with the resective surgeon is important, and the plan is discussed preoperatively. Resection is performed through the Wise pattern markings if necessary. Once the partial mastectomy is performed the defect is evaluated. The extended superomedial pedicle is useful for lateral defects where tissue can be transferred from the lower pole.

On examination of the partial mastectomy defect, the goals are to:

1. Keep the nipple alive and position it appropriately on the mound.

2. Fill the dead space.

3. Resect excess breast tissue when necessary.

4. Reshape the breast mound using the pedicles and remaining breast tissue.

Numerous options exist for defects in the lateral part of the breast mound. When the defect is below the level of the nipple or if the defect is relatively small, it can be filled with residual breast tissue using almost any pedicle or reduction technique. If the breasts are small to moderate sized, an extended superomedial dermatoglandular pedicle can be rotated into the defect, closing the remaining breast in a vertical mastopexy fashion. The nipple is incised and the lower pole is de-epithelialized. If it appears as though additional tissue is required from the lower pole to fill a relatively high outer quadrant defect, then the extended superomedial pedicle is created. The size is determined by the amount of tissue available, and the size of the defect. The pedicle is then rotated into the defect and secured with suture fixation (Fig. 31.6). Excess breast tissue is not resected until a decision has been made how to fill the dead space, rotate the nipple and reshape the breast mound. Parenchymal plication and skin redraping are then performed as previously described.

Management of the contralateral breast is typically performed using a similar technique to that used on the ipsilateral side to maximize symmetry; however, the lower pole tissue is resected. Since the ipsilateral side involves a volume loss procedure (partial mastectomy), glandular resection is always required on the opposite breast, even if a mastopexy technique was used for partial breast reconstruction. The contralateral side is purposely kept about 10% smaller than the ipsilateral breasts to allow for anticipated radiation fibrosis.

Pitfalls and How to Correct

The extended superomedial technique has been used at our institution on 53 patients for all the above mentioned indications. We reported favorable results with mastopexy techniques in the massive weight loss patients,¹⁰ as well as for the reconstruction of partial mastectomy defects.¹³ Fat necrosis remains a concern, especially when length is required for the extended pedicle. This is minimized by keeping the superomedial pedicle as wide as possible, and preserving central perforating vessels if the arc of rotation allows. We have experienced some early edema and fat necrosis in four patients at the most distal portion of the flap; however, this did resolve with time. Recurrent ptosis is another issue which is minimized using this technique, however, not prevented. Despite overcorrection and extensive glandular manipulation, revision rate is up to 10% especially in the MWL breast when implants are also used.¹⁰