Key points
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The pedicle, the skin resection pattern and the parenchymal resection pattern should all be treated as separate entities.
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The Wise pattern (not just the keyhole opening) is an excellent pattern for what parenchyma should be left behind.
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The resection is in the shape of a vertical ellipse rather than the horizontal ellipse that is common with an inferior pedicle inverted T pattern. The vertical wedge excision results in coning of the breast with good projection and an absence of medial and lateral dog-ears. There are, however, two vertical dog-ears, one into the areola and one inferiorly.
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The excess parenchyma should be excised by direct excision and then tailored out by liposuction.
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Neither the pillars nor the skin should be closed under tension.
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Under-resection will result in bottoming out over time.
Introduction
Vertical breast reduction is not just one procedure. There are many breast reduction techniques which fit into the category of ‘short scar’ or ‘vertical’ approaches. The word ‘vertical’ applies only to the fact that there is a vertical scar (as well as a scar around the areola) but little or no inframammary scar. It is important to separate the concepts of the skin resection pattern (which results in a vertical scar), the pedicle design, and the parenchymal resection. Different pedicles can be adapted to different skin resection patterns. The pedicle will dictate the parenchymal resection to some degree but there are still multiple possible variations.
This chapter will describe the medial pedicle design with a vertical skin resection pattern and an inferior parenchymal resection pattern. An inferior pedicle will dictate a superior resection and a more difficult skin closure. The technique described here can easily incorporate a superior, a lateral or a medial pedicle. The medial pedicle is chosen because it has a reliable blood supply, it has good sensation and it is easy to inset. The fact that the inferior border of the medial pedicle becomes the medial pillar allows the surgeon to give the patient an immediate good shape with an elegant lower pole.
Patient selection
The best patients for a vertical type approach using a medial pedicle are those with good skin quality and who require a small to medium breast reduction (up to 1000 g). The same technique can be used with larger breast reductions but the skin resection pattern may need to be altered to include a ‘J’, and ‘L’ or a ‘T’ extension along the inframammary fold. The surgeon’s threshold for conversion will occur earlier in patients (such as massive weight loss) with poor skin quality.
There are very few patients where a superomedial or medial pedicle cannot be used. A truly superomedial pedicle is more likely to include the strong descending artery from the second interspace, but it may be more difficult to inset than a purely medial pedicle. The advantage to persisting with a medially or superomedially based pedicle even in very large breast reductions is that the heavy inferior breast tissue is removed (thereby defying gravity) and the superior breast tissue remains still attached to the chest wall and the superior skin. Extremely large patients could be warned that the surgeon may need to convert to free nipple grafts intraoperatively but this would only rarely happen.
Patients and surgeons need to understand that the breast cannot be elevated on the chest wall. Some patients are ‘high-breasted’ and some are ‘low-breasted’. Some patients will have a narrow vertical breast footprint and some will have a very long vertical breast footprint. The upper breast border cannot be changed with sutures but the inframammary fold can be elevated slightly. Much of plastic surgery is about managing patient expectations and a patient who understands that her brassiere band or underwire will remain at the same level will be more appreciative of the final result.
There are very few flaps that have been able to increase upper pole fullness long-term. Only implants and fat injections seem successful at elevating the upper breast border and increasing upper pole fullness and unfortunately many of the procedures that remove tissue in the upper pole create an actual loss in upper pole fullness. I tried suturing breast tissue up higher onto the chest wall in 77 patients (43 with PDS and 34 with braided polyester) and in not one of the patients who returned for follow-up did the improvement in upper pole fullness last for more than a few months. The medial pedicle vertical breast reduction, however, does maintain upper pole fullness. It is important for surgeons to realize that pushing tissue into the upper pole will only end up with bottoming-out and a poor result.
Indications
Surgeons and patients (and only some insurance carriers) are well aware that breast reduction surgery of any type will improve upper back and neck pain, shoulder grooving, skin rashes, posture, exercise tolerance and self-esteem. The medial pedicle vertical breast reduction is a good choice for patients who want to preserve sensation and the possible ability to breastfeed. The statistics for breastfeeding after medial pedicle reduction are about the same as for other full thickness pedicles such as the inferior pedicle (about 60%). About 85% of patients recover normal to near-normal sensation with this technique. This is comparable to most of the other pedicle techniques.
There is no question that patients who are overweight will not get as good a cosmetic improvement as those patients who are closer to their ideal body weight. The obese patient is more prone to complications. These patients tend to believe that they will lose weight after the surgery but it has been my experience that if they have not changed their lifestyle prior to surgery they are unlikely to change it after surgery.
Operative technique
Pre-operative preparation
It is important to note and explain to the patient about the breast footprint and whether they are ‘high-breasted’ or ‘low-breasted’ ( Figure 14.1 ). They also need to be aware of how much upper pole fullness they have (or not) and that this upper slope will not change. They also need to be aware that there will still be some breast skin resting on the chest wall after surgery. They often bring in photos of women where the nipple sits well above the inframammary fold but they need to realize that the nipple will be lower with an inferior curve to the lower pole of the breast. The nipple will still sit about one-third to one-half up the breast mound, but the breast mound shape will be slightly lower than that achieved in many breast augmentation patients.
Markings
Upper breast border
The upper breast border sits just above the pre-axillary indentation and it is usually just above any striae that may be present ( Figure 14.2 ). This border is marked to give the surgeon an idea of where the nipple should be – usually about 9–11 cm below this border.
Inframammary fold
The inframammary fold is often a good guide for the new nipple position but it can be misleading in patients with either a very long or very short vertical breast footprint. The upper breast border is actually a better guide.
Breast meridian
The breast meridian should be drawn where it is desired, not where it is. The surgeon should ignore the current nipple position and draw the breast meridian where it should be. This will usually be about 10 cm from the midline at the medial extent of the inframammary fold. The medial pedicle vertical breast reduction is more effective than an inverted T inferior pedicle technique at reducing the lateral breast fullness so the meridian can be drawn a bit more medially. It is, however, better to have the new nipple position marked too far laterally than too far medially (the same rule applies to making it lower rather than higher).
New nipple position
The new nipple position should be at the intersection of the mark made on the breast meridian which will be about 10 cm below the upper breast border ( Figure 14.3 ). This will often be (except in about 15% of patients) about the level of the inframammary fold. The nipple is best placed lower in patients who have poor upper pole fullness and the surgeon needs to be aware that the nipple will appear to be higher because of the increased projection that is achieved with this technique. In asymmetry cases the new nipple position should be placed slightly lower on the larger breast to accommodate for the skin stretch in the larger breast and the fact that closure of a wider ellipse will push the superior end of the ellipse higher.
Upper areolar border
The upper border of the areola is then marked about 2 cm above the new nipple position ( Figures 14.4, 14.5 ). The areola is designed to be about 4–5 cm in diameter and 2 cm works well as a standard measurement.
Areolar design
The areola is designed so that it ends up as a circle when it is closed ( Figure 14.6 ). It does not need to be ‘mosque’ shaped. A good template is a large paper clip made into a circle and then opened out. A large paper clip is 16 cm in length and 16 cm is the circumference around a 5 cm diameter areola. The original Wise pattern had a 14 cm diameter areola which matches a 4.5 cm diameter areola.
