Medial pedicle reduction mammaplasty for severe mammary hypertrophy

Current options in reduction mammaplasty for severe mammary hypertrophy include amputation with free-nipple graft as well as the inferior pedicle and bipedicle techniques. Complications of these procedures include nipple-areola necrosis, insensitivity, and hypopigmentation. The purpose of this study was to determine whether medial pedicle reduction mammaplasty can minimize these complications. Twenty-three patients with severe mammary hypertrophy were studied. The medial pedicle successfully transposed the nipple-areola complex in 44 of 45 breasts (98 percent). Mean change in nipple position was 17.1 cm, and mean weight of tissue removed was 1604 g per breast. Nipple-areola sensation was retained in 43 of 44 breasts (98 percent) using a medial pedicle. Hypopigmentation was not observed, and central breast projection was restored in all patients. This study has demonstrated that medial pedicle reduction mammaplasty is a safe and reliable technique and should be given primary consideration in cases of severe mammary hypertrophy.     

Repeat reduction mammaplasty

Repeat reduction mammaplasty is an uncommonly performed procedure. Currently, no clear operative guidelines of management exist. Sixteen patients (28 breasts) with a mean age of 29 years (range, 13 to 52 years) underwent repeat breast reduction over an 11-year period. Before the first reduction, the mean notch to nipple distance was 29.6 cm (range, 24 to 38 cm) and mean nipple to inframammary crease distance was 15.5 cm (range, 12 to 18 cm). The mean mass of tissue excised was 615 g per breast. A number of different pedicles were used (six inferior, five superior, four superomedial, one unknown). All patients subsequently developed pseudoptosis. The nipple to inframammary crease distance was a mean of 11.4 cm (having initially been set at 7 cm) before the second procedure. At the second operation, two patients (three breasts) had their initial pedicles transected and the nipple-areola complex moved, and both patients developed vascular compromise of the nipple-areola complex (two breasts). Where the same pedicle was used in the second operation (five patients, 10 breasts), one patient developed unilateral nipple-areola complex necrosis. In eight patients, because of the development of pseudoptosis, the nipple was in a satisfactory position, and therefore only an inferior wedge of tissue required excision. This was performed without nipple-areola complex compromise, irrespective of the initial pedicle. The mean mass of tissue excised in the second operation was 325 g per breast (range, 120 to 620 g). Fourteen patients were available for follow-up after a mean of 5.1 years (range, 3 months to 11.7 years) following the repeat reduction mammaplasty. In the repeat breast reduction, where nipple-areola complex transposition is planned, the initial pedicle should be reused to maintain nipple-areola complex perfusion. Where the initial pedicle is not known, a free nipple graft may be the safest option. In patients with pseudoptosis, in whom the nipple does not require transposition, an inferior wedge of tissue can be safely excised, irrespective of the initial pedicle.     

Breast sensitivity after vertical mammaplasty

Breast sensation after reduction mammaplasty is a major concern for surgeons and patients. The sensitivity of 80 breasts that were reduced using Lejour's technique (a superior dermoglandular pedicle with resection at the lower quadrants) was assessed in a prospective study. Ten points were selected on each breast for this study, including the nipple, four points on the areola, and five points on the breast skin. The measurements were performed preoperatively and at 3, 6, and 12 months postoperatively. Pressure thresholds were measured with 20 Semmes-Weinstein monofilaments, temperature sensitivity with hot and cold metal probes, vibratory thresholds with the Biotesiometer, and static and moving two-point discrimination tests with a Disk-Criminator. To assess the influence of breast ptosis and hypertrophy on sensitivity, the population was divided into two groups. In group I (19 patients), the sternal notch-to-nipple distance was less than 29 cm, and less than 500 g of tissue per breast was removed. In group II (21 patients), the sternal notch-to-nipple distance was more than 29 cm, and more than 500 g of tissue was resected. The sensitivity on the nipple and areola was significantly decreased at 3 and 6 months postoperatively for all modalities. At 1 year, sensitivity recovered, and no breast or nipple-areola complex was insensitive. Pressure sensitivity was not significantly different from the preoperative measurement in any area of the breast or in either group of patients, except for superior breast skin, for which sensitivity was improved in group II (p = 0.0004). Temperature sensitivity in group I was not different preoperatively and postoperatively, but in group II, a significant decrease was observed in sensitivity for the nipple and areola (p = 0.01 and 0.004, respectively). Vibratory sensitivity was significantly decreased on the nipple, the areola, and the inferior breast skin (p = 0.01, 0.01, and 0.001, respectively) in group II but not in group I.In conclusion, ptotic or moderately hypertrophied breasts that were reduced using Lejour's technique recovered their preoperative level of sensitivity after an initial postoperative decline. However, in large breasts, although pressure sensitivity recovered after 1 year, temperature and vibration sensitivity remained diminished on the nipple-areola complex.     

Preservation of projection after reduction mammaplasty: long-term follow-up of the inferior pedicle technique

In reduction mammaplasty by the inferior pedicle technique, the dermal-breast pedicle can be manipulated to form a central breast mound and enhance breast projection. When this technique is applied both to macromastia and breast asymmetry, excellent early results are reported. To study the effects of time on breast reduction, 22 patients were followed for an average of 4.7 years. Contour of the breast mound and projection are well preserved. However, evaluation of long-term results reveals a gradual increase in the inframammary fold to inferior areola distance. Since no increase in the midclavicle to nipple distance is observed, inferior migration of the breast parenchyma and superior displacement of the nipple-areola with respect to the breast mound occur after reduction mammaplasty with the inferior pedicle technique.     

The prediction of breast reduction weight

Reimbursement for reduction mammaplasty has become more stringent because many insurers require specific documentation of patient symptoms and estimated weight of planned breast resection. The purpose of this study was to develop a simple, clinically useful method for predicting weight of breast tissue to be removed, using routine, easily obtained predictors (i.e., height, weight, age, measurements from sternal notch to nipple, and measurements from sternal notch to inframammary crease). Data were available from a retrospective review of 263 women undergoing reduction mammaplasty. Analyses were performed to predict resected weights obtained both in the operating room and by a pathologist for left and right breasts separately. Regression analyses showed that the sternal notch-to-nipple measurement accounted for nearly all of the explained variance in the resected weights, with correlations around 0.80 between sternal notch to nipple and resected weight. For sternal notch-to-nipple measurements > or 28.5 cm, predicted resected weights were approximately 600 g or more, and in general, 80 percent or more patients had specimen weights >500 grams. From 25.5 to 28 cm, the predicted weights ranged from about 400 to 600 g and the prediction rate of weights >500 g was 50 percent. The senior author predicted the resected breast weight to be >500 g 94 percent of the time. The equation alone did not produce an accurate prediction in the critical range, 400 to 600 g. The experienced surgeon more accurately predicted resected weights with use of practiced spatial relationship skills.     

Maximizing breast projection after free-nipple-graft reduction mammaplasty

In 1922, Thorek described standard free-nipple reduction mammaplasty for gigantomastia. This technique provided a simple and effective way to perform reduction mammaplasty. However, the technique is frequently criticized for producing a breast and nipple with poor projection. Even with the standard modification of the original technique, the resultant breast and nipple may be wide and flat, with unpredictable nipple-areola pigmentation. To create a breast mound and nipple with projection and even pigmentation, the free-nipple-graft breast reduction technique is presented. The Wise pattern skin reduction markings and the superiorly based parenchymal reduction technique are used. After the nipple-areola complex is removed, as a free graft, the inferior pole of the breast is then amputated along the Wise pattern skin markings, leaving lateral and medial pillars of breast tissue, with the apex of the resection corresponding to the new nipple location. The lateral and medial pillars of the superiorly based breast mound are then sutured together. Key interrupted sutures are placed, beginning at the most inferior and posterior point of the pillars, while recruiting tissue centrally to increase the projection. The intersecting point of the inverted T, at 7 cm from the new nipple position, is then sutured to the fasciae of the pectoralis major muscle. If more central projection is desired, the vertical limb design can be lengthened. The tissue inferior to the 7-cm mark is de-epithelialized and tucked under the central breast, if needed, contributing further to the final breast parenchyma projection. The skin of the vertical limb of the Wise pattern is then closed with a dog-ear at the apex to further contribute to nipple projection. The nipple is replaced as a free, thick, split-thickness skin graft. The breast is temporarily closed, and the medial and lateral breast tissue excess is liposuctioned to create a more conical breast. Excessive medial and lateral skin is then resected, keeping the inframammary crease incision under the breast mound. Twenty-five patients underwent free-nipple-graft reduction mammaplasty using this technique between 1992 and 2000. An average of 1600 g of breast tissue per breast was removed. The average follow-up period was 36 months. Patient satisfaction has been very high.     

Appropriate location of the nipple-areola complex in males

Gynecomastia is a common deformity encountered by plastic surgeons. The appropriate location of the nipple-areola complex is a major determinant of the aesthetic success of the procedure.To study the natural location of the nipple-areola complex in the normally built male, 50 nonobese men with no evidence of gynecomastia and an average age of 27.9 years were examined.Three ratios were calculated and found to be relatively constant; they were the ratio between the height of the nipple and the height of the patient, the ratio between the distance between the nipples and chest circumference, and the ratio between the suprasternal notch-to-nipple distance and the height of the patient.Using these three parameters, a method of locating the nipple-areola complex on the male chest wall was devised. The method is advocated as a reliable, simple, and useful technique.     

Precision in breast reduction

Precision in the design and performance of a breast reduction can be enhanced by careful formulation of the criteria. The breast cone should incline about 15 degrees medialward. The intersection of the midshoulder (anterior iliac) spine line with the inframammary fold offers a reference point for horizontal localization of the nipple. The nipple-suprasternal notch length, the diameter of the areola, and the nipple-inframammary fold length are determined by the height of the patient and the size of the brassiere cup. On this basis, a table for breast reduction can be drawn up that gives these dimensions for a given height and size of brassiere cup. Other important factors include the stretch direction of the skin and the course of the nerve to the nipple. A distinction is made between radial segment conization and anterior tangential conization. Criteria and measurements were incorporated into a technique comprising anterior tangential excision of glandular tissue and limited inferior radial segment excision of skin.     

Reliability of inferior pedicle reduction mammaplasty in burned oversized breasts

Heavy pendulous breasts cause physical and psychological trauma. Postburn deformity of breasts results in significant asymmetry, displacement of nipple-areola complex, due to burn scar contracture, and significant scarring; these factors add more psychological discomfort and subsequent behavioral changes. The use of the inferior pedicle procedure in burned breasts can solve many problems. The technique reduces the size of the large breast, eliminates the scar tissue by excising both medial and lateral flaps, and brings the mal-located nipple and areola to a normal position. This study stresses the possibility of harvesting the inferior dermal pedicle flap from within the postburn scar tissue without necrosis of the nipple and areola, because of the excellent flap circulation. Acceptable aesthetic appearance and retainment of nipple viability and sensitivity can be achieved with the inferior pedicle technique even with postburn deformity of the breast. The study was conducted on 11 women, all of whom had sustained deep thermal burns to the breasts and anterior torso and whose breasts were hypertrophied and pendulous.     

The pure posterior pedicle procedure for breast reduction

The inferior pedicle technique, which has already become classic, employs a glandular areola-bearing pedicle whose source of vascularization is primarily posterior. In fact, the inferior pedicle is a posterior pedicle with an inferior border. After systematically and progressively reducing this inferior border, I have completely eliminated it. The pure posterior pedicle that results is independent of the inframammary fold. It is vascularized by means of the pectoral muscle and fascia, as has been demonstrated by injection studies of the thoracoacromial artery in fresh cadavers. The resulting mammary reduction technique retains the advantages of the inferior pedicle technique while avoiding its major inconveniences: dependence on the inframammary fold, bulging at the inferior base of the pedicle, and the necessity of low positioning for the breast.     

Reduction mammaplasty with a circular folded pedicle technique.

A personal technique for breast reduction utilizing a circular dermal-breast pedicle is presented. After a cutaneous glandular excision in the inferior pole and glandular excision in a discoid shape under the central area, the pedicle is folded on itself to produce a direct elevation of the nipple-areola complex into its new position, to enhance projection, and to act as a central support. A rational economy of scars is obtained by a central convergence of the breast tissue that stretches the breast periphery and by sutures finishing in the inferoareolar area. There the skin excess is removed to avoid scar lengthening in both the caudal and cranial directions. Evaluation of long-term results reveals maintenance of breast projection, preservation of the inframammary fold to inferior areola distance, and minimal residual scarring.     

Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty

A method of breast reduction is presented that maintains the blood supply and innervation to the nipple and areola complex by means of an inferior pedicle, reduces the breast volume by removing tissue from the periphery of the breast, maintains breast shape with internal plication sutures, and limits the scar using a periareolar technique with a short inferior vertical-to-oblique extension. There were 167 breasts in 98 patients reduced in this fashion. The average resection volume was 632 g per breast, with an average follow-up of 7.6 months. The complication rate was similar to that observed using traditional inferior pedicle techniques with the inverted-T cutaneous scar. This technique has proven to be versatile, technically straightforward, and applicable to breasts of all sizes for both breast reduction and mastopexy. By combining the aesthetic advantage of less cutaneous scarring with the safety and familiarity of the inferiorly based pedicle, superior results in breast reduction can be obtained that are consistent, long-lasting, and satisfying for both patient and surgeon alike.     

Immediate breast reconstruction using biodimensional anatomical permanent expander implants: a prospective analysis of outcome and patient satisfaction

Immediate breast reconstruction is offered to the majority of women requiring a mastectomy for cancer treatment. Improvements in implant technology have seen the evolution of shaped, fixed-volume implants and permanent expanders. The theoretical benefits of biodimensional anatomical expander implants include better reconstructed breast form, the potential for achieving this at a single procedure, and the avoidance of a contralateral procedure as a result of improved ipsilateral cosmesis. The aim of the present study was to assess outcome after immediate breast reconstruction using the McGhan 150 permanent expander implant. A total of 107 consecutive patients (129 breast reconstructions) were studied over a 30-month period; 49 patients (68 reconstructions) had submuscular implant placement alone, and 58 patients (61 reconstructions) had an implant in conjunction with a latissimus dorsi flap. The mean patient age was 47 years (range, 22 to 72 years) and the mean follow-up was 18 months (range, 6 to 40 months). Outcome was assessed in the following four ways: geometric measurements, evaluation of photographs by four independent observers, linear numerical analogue scale, and a quality-of-life questionnaire. Geometric measurements after surgery showed median differences that were highly consistent with good symmetry. Transverse breast width difference between breasts was 0.35 cm, vertical breast height difference was 0.8 cm, sternal notch-to-nipple distance difference was 0.6 cm, midclavicular line-to-nipple distance difference was 0.5 cm, nipple-to-inframammary crease distance difference was 0.5 cm, midline-to-nipple distance difference was 0 cm, and projection difference was 0 cm. Photographic assessment by four observers who evaluated shape, cleavage, symmetry, and overall outcome produced correlation values of 0.73 to 0.81. More than 75 percent of each of these parameters was scored as good or excellent. A numerical analogue scale (from 1 to 10) assessing overall result by the surgeon and patient revealed good (7 to 8) or excellent (9 to 10) scores in 83 and 82 percent of respondents, respectively. Quality-of-life data showed that 81 and 88 percent of women felt "a little" or "not at all" less feminine, respectively, and 88 percent were satisfied with the appearance of their breasts. A total of 88 percent of women would also choose the same reconstructive procedure if faced with the same cancer diagnosis. Complication rates were low; infections occurred in 6.2 percent of reconstructions, hematoma occurred in 1.6 percent, and implant loss occurred in 3.9 percent. Only 24 of 107 patients (22 percent) elected to have a synchronous contralateral breast adjustment, and four of 107 (4 percent) chose to have a subsequent procedure for symmetry. Biodimensional expander implants used in immediate breast reconstruction are associated with high levels of patient and surgeon satisfaction. Optimum breast form can be achieved during a single operation with a low incidence of complications.     

"I" becomes "L": modification of vertical mammaplasty

The problems of the vertical mammaplasty by Lejour (i.e., gathering the skin envelope in one vertical suture, frequent secondary healing problems, and later sagging of the inferior glandular part in the case of large and very large breasts) are well known. A simple modification of the Lejour technique, that is, adding a lateral inframammary scar to shorten the vertical scar length, is presented. The modified L technique was used in 45 patients (90 breasts) between October of 1999 and August of 2001. With an average follow-up of 13 months, the jugular notch-to-nipple distance was 21 cm, the vertical scar length was 8.4 cm, the lateral inframammary scar length was 11 cm, and the average resection weight was 625 g per breast (range, 200 g to 2080 g). Even among patients who had very large glandular bases and resection weights it was possible to achieve a breast base reduction, modeling the glandular corpus to a harmonic, well-projecting, and youthful shape. Slight wound-healing problems with spontaneous cicatrization within 2 weeks occurred in six patients. In two patients who exhibited gigantomastia up to 2080 g per breast, partial mamilla necrosis occurred on one side. Ninety-one percent of the patients reported being "very satisfied" with the outcome, and 9 percent reporting being "satisfied." The authors' modification of the vertical mammaplasty to an L-shaped scar technique enables the surgeon to apply the principles of the Lejour technique for higher resection weights and diminishes wound-healing problems, and it is still a scar-minimizing technique that results in a scar-free cleavage. It is easy to learn and an ideal standard technique for a teaching hospital.     

SUPRASTERNAL NOTCH ECHOCARDIOGRAPHY AND ATRIAL ARRHYTHMIAS

Anterior-posterior single-crystal echocardiography has been used in atrial flutter and in sinus rhythm after cardioversion to demonstrate anterior movement of the posterior left atrial wall, representing the effects of atrial flutter and sinus contractions.(1) This is thought to be the first report of characteristic superior movement of the inferior left atrial wall during atrial flutter, atrial tachycardia, and sinus rhythm by single-crystal suprasternal notch echocardiography.     

The pseudodeltidium in Triplesia and Placotriplesia

Amsden, T. W: The pseudodeltidium in Triplesia and Placotriplesia .
North American species representing Triplesia range from the Middle Ordovician into the Lower Silurian, and possess a distinctive pseudodeltidial apparatus. The pseudodeltidium begins as a solid ridge of shell material just in front of the pedicle foramen and extends forward, opening into a hoodlike structure which partly covers a delthyrial notch; the cardinal process shaft bears a well-developed collar which fits into the delthyrial notch. In contrast, North American representatives of Placotriplesia , which are at present known only from early Late Silurian (Wenlockian) strata, have no delthyrial notch, and the pseudodeltidial ridge or fold is absent at all stages of growth; the cardinal process collar is vestigial or absent. Wright's observation that the type species of Placotriplesia, P. praecipta (Ulrich & Cooper) has a pseudodeltidial fold is incorrect, and his implication that Triptesia and Placotriplesia are connected by gradational forms is not supported by the evidence.     

Quantitation of breast sensibility following reduction mammaplasty: a comparison of inferior and medial pedicle techniques

The preservation of sensitivity within the nipple-areola complex is of paramount importance to patients presenting for reconstructive and aesthetic breast procedures. Previous attempts to measure sensation in the breast before and after surgery have relied primarily on the Semmes-Weinstein monofilament test, which is an imprecise study that measures the logarithm of force necessary to bend a series of six to 20 filaments. Within the last 10 years, various authors have published normative pressure threshold data for the breast that have varied by a magnitude of greater than 10-fold. Recently, precise anatomic studies have been performed that have elucidated the innervation of the nipple-areola complex medially and laterally from cutaneous branches of the intercostal nerves. Despite this knowledge, no quantitative sensibility studies have yet been performed that compare postoperative sensation when medially versus laterally innervated pedicles have been used in reduction mammaplasty. The present study is the first to use computer-assisted neurosensory testing to generate normal breast sensation data and to compare sensory outcomes between the inferior and the medial pedicle techniques of reduction mammaplasty.A total of 34 patients were divided into four groups and underwent breast sensory testing (67 breasts total) using the Pressure-Specified Sensory Device, a computer-assisted force transducer that measures static and moving one and two-point discrimination. Sensation in the nipple and in the four quadrants of the areola was measured. Groups I and II were composed of 17 unoperated controls with breast sizes ranging from 34A to 36C (group I; 18 breasts) and 36DD to 46EE (group II; 16 breasts) who presented to a general plastic surgery clinic. Groups III and IV were composed of 17 patients who underwent either medial or inferior pedicle reduction mammaplasty between July of 1997 and March of 1999. Pressure thresholds in the most sensitive breasts were as low as 0.3 g/mm2, a marked contrast to data from previous studies using Semmes-Weinstein monofilaments documenting the lowest recordable pressure threshold as greater than 2 g/mm2. Several findings from previous studies using Semmes-Weinstein monofilament testing were confirmed in unoperated controls, including an inverse relationship between sensitivity and breast size, superior nipple sensitivity when compared with the areola, and significant interpatient variability with respect to static and moving two-point discrimination among women matched according to age and breast size. When comparing medial with inferior pedicle reduction mammaplasty patients, it was found that despite significantly greater reductions using the medial pedicle technique (mean of 1.7 kg versus 1.1 kg of breast tissue removed), there were no significant differences in postoperative sensory outcomes in the sample size of 17 patients. Furthermore, within each group of patients undergoing either the medial or inferior pedicle technique, the amount of breast tissue removed did not correlate with postoperative sensory outcomes.Computer-assisted quantitative neurosensory testing is a highly accurate technique for measuring sensibility. The use of this technology demonstrates a 10-fold difference in measurable sensory thresholds in normal patients from preexisting data using Semmes-Weinstein monofilaments. Advances in measurement methods have allowed the authors to compare postoperative sensory outcomes reliably using two popular techniques of reduction mammaplasty.     

Breast volume and anthropomorphic measurements: normal values

Fifty-five consecutive female volunteers were evaluated. Linear measurements of the breast and nipple position were determined to fixed points on the chest wall. Volume determination was done by a standard chest-wall casting technique. A highly significant difference was found between left and right breasts in the axilla-to-nipple distance and nipple-to-midline measurements. A significant difference was also found in the distance from the lowest point of the breast (patient upright) to the nipple. Analysis of the volumetric difference between right and left breasts did not achieve statistical significance.     

A comparison of complication rates in large and small inferior pedicle reduction mammaplasty

The main objective of this retrospective study was to determine whether the rates of complications are higher in large reductions (> or =1000 g per breast) as compared with smaller reductions (< or =999 g per breast) using the inferior pedicle technique. A retrospective chart review of 133 consecutive patients operated on between October of 2000 and March of 2002 was undertaken. Complication data were recorded and analyzed on a per-breast basis. Two hundred sixteen breasts had reductions of 999 g or less, whereas 50 breasts had reductions of 1000 g or more. The overall mean follow-up period was 152 days (range, 20 to 522 days). There were no statistically significant differences in the rates of nipple necrosis, hematoma formation, seroma, delayed healing, culture-positive wound infection, fat necrosis, cyst formation, nipple sensation, or hypertrophic scarring between the large and small reductions. However, the rate of wound dehiscence was significantly lower in the smaller reduction group. The rates of wound dehiscence and hypertrophic scarring were also significantly lower in patients who had received at least 5 days of postoperative antibiotics. A statistically significant difference was also reported for clinical wound infection (p < 0.0005). Body mass index had no statistically significant effect on the rate of nipple necrosis, hematoma formation, fat necrosis, cyst formation, nipple sensation, or hypertrophic scarring. However, body mass index had a statistically significant effect on delayed healing, wound dehiscence, and culture-positive wound infection. A higher mean body mass index predicted a delayed healing, wound dehiscence, and infection. The inferior pedicle technique is a safe method of breast reduction regardless of degree of parenchymal resection. However, the use of postoperative antibiotics for at least 5 days is recommended to reduce rates of wound dehiscence and improve postoperative scarring.     

The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.