Key Points

1. The superomedial extension flap can relocate lower pole tissue into the upper pole of the breast.

2. The superomedial extension flap can be used for breast reductions, mastopexies, and massive weight loss patients.

3. Various modifications of the superomedial extension flap can be used in oncoplastic surgery to close and fill the defects created by the surgical resection.

4. The superomedial extension flap can be combined with either vertical or inverted T skin resection patterns.

5. Fat necrosis at the distal end of the flap can occur but usually resolves spontaneously.

6. The superomedial extension flap can prevent postoperative ptosis because it removes and relocates the lower pole breast tissue.

Summary

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

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