Inferior Pedicle

Paul A. Ghareeb

Albert Losken

DEFINITION

Reduction mammaplasty remains one of the most commonly performed operations by plastic surgeons.
Inferior pedicle reduction mammaplasty is one of the most widely used reduction techniques because it is easy to learn, is safe, and has reproducible outcomes.¹
This technique was described and refined in the 1970s by Ribiero, Robbins, Georgiade, and Courtiss and Goldwyn.²^,³
Is most commonly utilized with a Wise pattern (inverted T) skin excision.
The inferior pedicle reduction technique is extremely versatile and can be used in almost any reduction procedure. We have found it to be useful in patients with long nipple to notch distances and those with large anticipated reduction specimens.
The complication rates for inferior pedicle reductions have been shown to be equivalent for small and large (greater than 1000 g) reductions, making this technique particularly useful when treating gigantomastia.⁴

ANATOMY

Borders of the breast
- Superiorly: clavicle
- Medially: sternum
- Inferiorly: superior border of rectus fascia
- Laterally: anterior border of latissimus
Blood supply
- Intercostal perforators
  - Primary blood supply to the inferior pedicle
- Internal mammary perforators
- Lateral thoracic artery
- Thoracoacromial artery
Innervation
- Intercostal sensory branches
  - The fourth intercostal sensory nerve provides the majority of sensation to the nipple-areolar complex (NAC).
  - The sensory branches course just above pectoralis fascia before piercing the breast parenchyma to supply the overlying skin and nipple. It is important to maintain a layer of breast tissue over the pectoralis when performing reduction mammaplasty to prevent damage to these nerves.

PATIENT HISTORY AND PHYSICAL FINDINGS

Focused history
- Current brassiere size and desired size after mammaplasty is important to determine with the patient preoperatively in order to guide goals and expectations.
- Symptoms of macromastia and any interventions attempted must be elucidated and recorded preoperatively.
- History of childbirth, breast-feeding, and desire to have further children are important to discuss. With the inferior pedicle technique, most women maintain the ability to breast-feed postoperatively but should be counseled on this during the consultation.
- Mammographic history if applicable, as well as family history of breast disease or cancer.
- A history of smoking should be discussed prior to any reduction, and patients should be counseled to stop smoking at least 1 month prior to reduction mammaplasty due to the significantly increased risk of wound healing complications.
Physical exam
- Examine the overall breast shape, asymmetries, previous scars, and estimate breast size in grams. Always examine for breast masses and nipple sensation. Record breast measurements including sternal-notch-to-nipple and nipple-to-inframammary fold distances.
  - Patients considered to be good candidates for an inferior pedicle reduction often times have long nipple to notch and nipple to IMF distances, which can both be easily addressed with this technique. Furthermore, patients with boxy-appearing breasts can be shaped effectively with the skin excision.
- Evaluate existing ptosis utilizing the Regnault classification.
- Note any additional axillary tissue laterally that would not be resected with standard reduction mammaplasty. This is often an area that the patient assumes will be treated with standard reduction procedures but must be counseled that this is an additional area that must be treated.

IMAGING

Mammography is recommended for women who meet screening criteria.
No other routine imaging is required preoperatively.

SURGICAL MANAGEMENT

Preoperative Planning

Preoperative markings are critical to the success of any breast reduction.
The patient is examined in the standing position, with her arms resting to either side.
The midline is marked first from sternal notch to the umbilicus.
The true breast meridian is then marked on each side from the midclavicular line down onto the abdominal wall. Note that this may not always align with the position of the NAC.
Pitanguy point is then identified and marked by placing one’s fingers underneath the breast at the inframammary fold and curling them forward to be palpated by the opposite hand. This allows the surgeon to determine the final resting position of the NAC. This is approximately 21 cm from the sternal notch but can vary depending on the body and breast shape.
- It is important to mark this point correctly at the IMF. By marking too high, one may produce a “sunny side up” nipple, which points upward, or a “snoopy deformity” by placing the nipple too far inferiorly.
The vertical limbs of the Wise pattern are then created approximately 7 cm in length on each side, starting at Pitanguy point and coursing inferiorly. A McKissock keyhole tool may be used for the purpose of creating the vertical limbs, but we prefer to use the medial and lateral distraction technique. In this fashion, the breast is distracted medially and laterally, and the vertical limb is drawn in continuity with the superior and inferior breast meridian markings.
- The distance between the base of the vertical limbs correlates with the final change in breast base diameter.
The horizontal markings are then drawn to connect the vertical limbs to the inframammary fold marking at the medial and lateral most aspects of the breast.
- The horizontal takeout can be tailored as short or long as necessary to achieve the desired outcome. The markings are typically carried out further for larger resections or boxy-appearing breasts, whereas in smaller reductions, can be achieved with a shorter horizontal scar.
- The IMF marking is made just above the level of the existing IMF. It can be preserved at the inverted T-junction if viability of the upper flaps is a concern.
After the markings have been completed, they should be compared to the contralateral side to ensure symmetry. In asymmetric reductions, this may be difficult to assess.
FIG 1 demonstrates the standard preoperative markings for an inferior pedicle reduction.

FIG 1 • A,B. Preoperative markings for the inferior pedicle Wise pattern reduction in a patient undergoing bilateral oncoplastic reduction for a left breast cancer.

Positioning

The patient is placed supine on the operating room table and is positioned to be able to sit up if necessary.
The arms are extended on arm boards, taking care not to over extend and distort the breast. They are secured with standard straps and soft padded wraps to facilitate placing the patient in the upright position.
The breasts are prepped and draped to include the sternal notch, clavicles, and lateral most aspects of the breast and axilla. For unilateral procedures, the contralateral breast is exposed to be examined during the procedure.

Approach

At the start of the procedure, the planned inferior pedicle is designed from the inframammary fold incision along the breast meridian to include a 1-cm cuff of tissue surrounding the NAC. The base of the pedicle should be 8 to 10 cm in width to ensure proper vascularity of the NAC. This is kept wider in bigger reductions with longer pedicles.
The NAC is then marked by sight or with a cookie cutter at 40 to 44 mm, and the final nipple position is planned and marked at the apex of the vertical limbs. No tension is applied to the NAC while marking to reduce the likelihood of creating an unnatural final appearance.
A line approximately 1 cm above the inframammary fold is marked for the inferior aspect of the Wise pattern. This is performed to avoid disrupting the dense attachments of the fold.

TECHNIQUES

▪ Incision