Vertical Breast Reduction Using the Superomedial Pedicle

Elizabeth J. Hall-Findlay

History

Vertical breast reduction has been slow to achieve widespread popularity. Many surgeons are concerned about the learning curve and having to revise the pucker that can occur at the lower end of the vertical incision.

Surgeons realize that patients who are preoperatively informed are willing to accept that some time is necessary for the results to settle in most plastic surgery procedures. This is no different in breast reduction surgery than it is in rhinoplasty, facelift, or liposuction surgery.

Although most surgeons can accept that there is a certain revision rate inherent in most plastic surgery procedures, they find it more difficult to accept in breast reduction. Perhaps this is because the problems (lateral and medial dog-ears, boxy shape, and bottoming out) with the inverted-T, inferior pedicle (1,2) procedures were so difficult to correct that the revision rate remained low.

Despite the development of the vertical approach by Daniel Marchac (3) and also by Claude Lassus (4,5,6), not many surgeons were willing to try to reduce scarring when they had a method (inverted T, inferior pedicle) that they believed to be safe and reliable. Madeleine Lejour (7,8,9,10) popularized vertical breast reduction, but surgeons found the technique difficult and the complication rate too high.

The most common comment that I get from surgeons who try the medial pedicle vertical breast reduction is that they find it so easy and predictable. I initially had problems insetting the superior pedicle, so I tried the lateral pedicle. I assumed that the lateral pedicle would have better sensation, but I found that the medial pedicle actually gave better shape and surprisingly equal sensation. The problem with the lateral pedicle is that the base of the pedicle is the same tissue that we want to remove, and it results in a shape that has excess lateral fullness. I now almost exclusively use a medially based pedicle (11,12,13). The medial pedicle is easy to inset, is full thickness, has reliable circulation, and has good sensation. My results are best when I keep the pedicle full thickness, when the inferior border of the medial pedicle becomes the medial pillar, when I remove the inferior and lateral breast tissue, and when I minimize gathering of the vertical incision.

Since the mid-1990s, many of the problems with the vertical approach have been addressed, and consistency of results can be achieved. Surgeons who have adopted this approach are often surprised at how fast the learning curve can be. Those who resist the vertical approach can still be heard saying that it becomes a choice of scars over shape. However, once surgeons incorporate the vertical approach for the breast reduction and mastopexy patients, they realize that both the scars and the shape—both short and long term—are significantly improved.

Surgeons who have used the inverted-T techniques have learned to use the skin to reshape the breast. Unfortunately, over time, the skin will stretch, and some bottoming out or pseudoptosis will occur. The concepts used for “vertical” breast surgery are quite different. Instead of using the remaining skin to shape the breast, the nature of the resection and the reshaping of the breast parenchyma are used to shape the skin.

Indications

Although vertical breast reductions are best used for small to medium-sized breast reductions, the medial pedicle can be used for larger breast reductions even when an inverted T is needed to reduce the skin envelope. Very large reductions or reductions in massive-weight-loss patients are often best performed with a medial pedicle because it allows the surgeon to remove the heavy inferior breast tissue. There are times when a vertical skin excision will not be enough, and the remaining excess will need to be removed with a J, an L, or a T. Surgeons initially do not realize how well the skin redrapes to the new breast shape, and they will convert to a T far more often than is necessary.

Adding a T excision to the skin is rarely needed unless the vertical incision is longer than about 13 to 15 cm. It has been shown that adding a horizontal skin excision does not alter the revision rate (14). It may, in fact, be surprising to learn that it is difficult to know where to actually place the horizontal scar. One of the hardest things for surgeons new to this technique to accept is that a vertical incision of more than 5 cm is far from negative. A longer vertical scar is both necessary and desirable to accommodate the extra projection that occurs with the vertical techniques.

It would be ideal for a surgeon to start getting comfortable with the technique by reducing the opposite side in a breast reconstruction patient. Because reconstruction patients often require revision, there is ample opportunity to correct the inevitable problems that result over the learning curve.

Contraindications

The medial pedicle vertical breast reduction is far more than just a vertical scar and a pedicle that is easy to inset. The nature of the excision (removing the inferior breast tissue) and the reshaping of the breast are what provide a good, long-lasting shape. Because of this, I will still use the same approach in very large reductions or in postbariatric patients, but I will excise the excess (poor-quality) skin that will not retract.

There are very few contraindications to performing a vertical breast reduction. The real limitations are the length of the pedicle and the amount and quality of the remaining skin.

Blood supply to the nipple may be compromised in a very long pedicle. It is impossible to give a numerical value to this. With growth, puberty, and pregnancy, the breasts become larger and more ptotic. However, as the skin and breast tissue stretch, so do the blood vessels and nerves. When the patient is lying in the supine position, it is clear that the pedicle is not as long as it appears when the patient is standing. The risk of losing blood supply results from the fact that we remove more than 75% of the tissue (and blood supply) from around the pedicle when we perform the resection.

Is the pedicle “superomedial” or “medial”? The pedicle may look as if it is “superomedial” when the patient is standing and the markings performed. However, the blood supply is actually medial, coming mainly from the internal mammary artery at the third interspace. When the pedicle appears to be excessively long, a true “superomedial” pedicle can be designed by incorporating the descending branch of the internal mammary branch that comes from the second interspace. I have “Dopplered” this vessel and transected it in most of my purely medial pedicles, and it almost always enters the areolar opening just medial to the breast meridian usually less than 1 cm deep to the surface. If the base of a long pedicle is carried up into and lateral to the 12 o’clock position of the areolar opening, the arteries from both the second and third interspaces will be included. The pedicle will now be more difficult to inset, but the artery can be preserved by resecting tissue in the deeper aspect of the pedicle, where there is a paucity of blood vessels.

An overly large pedicle may contribute to bottoming out. It may be advisable to suture the bulk of the pedicle up onto the chest wall, but it is questionable whether these sutures are actually as effective as desired. A good alternative in a very large breast is to consider free nipple grafts (15).

Operative Technique

Preoperative Planning

Determination of New Nipple Position

The new nipple position is often best placed at the level of the inframammary fold. I have analyzed my results over the years and have found that there are several patients in whom the level of the inframammary fold is actually misleading, with nipples ultimately being placed too high or too low. What I have found is that the upper breast border (the junction of the top of the breast with the chest wall) is the most static and reliable landmark. The upper breast border does not change in patients in any of the postoperative photos from the preoperative photos. The surgeon can then use this landmark to visualize the result and accurately determine the new nipple position.

It is important for surgeons (and patients) to understand that some patients are “high breasted” and some are “low breasted.” The actual attachment or “footprint” of the breast on the chest wall is quite variable from one patient to another. The distance from the clavicle to the upper breast border can be quite short or can be quite long. There are no surgical maneuvers of which I am aware (except implants and fat injections) that can actually raise the level of the upper breast border.

Since the upper breast border is static, it is a good landmark to determine new nipple position. The nipple is usually best located about one-third to one-half the distance up the final breast mound. This point is usually 8 to 11 cm below the upper breast border in an average C cup breast.

It is interesting to note how different both the upper breast border and inframammary fold levels can be from one patient to another. Not only are the levels very different, but also the breasts in some patients have a long vertical attachment to the chest wall (footprint), and some have a very short vertical attachment.

The new nipple position should be determined in relationship to the existing breast upper breast border and not at some arbitrary distance from the suprasternal notch (Fig. 91.1).

Marking the Upper Breast Border

The upper breast border is at the junction of the chest wall and the breast. This is very clear in some patients, with a definite demarcation line, and it is blurred in other patients, where the breast slopes gently away from the chest wall. The upper breast border is usually at the level of the upper edge of the stretch marks. The upper breast border is always below the preaxillary fullness, but in some very low-breasted patients it can be well below that level. These patients need to understand that the breast cannot be lifted on the chest wall, and if their breasts are attached at a low level, they will remain at that level.

Marking the Level of the Inframammary Fold

This level is becoming less important in determining the new nipple position, but it is important in deciding how aggressive the surgeon can be in resecting tissue at the fold in order to elevate the fold itself. Sometimes the inframammary fold can be at quite different levels on the same patient. The surgeon can thus be more aggressive with the resection of the lower fold.

Marking the Breast Meridian

The breast should be divided into halves at the level of the new nipple position. Although it does not matter where the line starts, it is easier to draw it beginning at the clavicle and then making the mark down the breast bisecting it. The nipple looks best slightly lateral to the midline and it is therefore better to err on the side of marking the meridian slightly more lateral. For surgeons who are comfortable with the inverted-T, inferior pedicle type of breast reduction, the meridian can be marked more medially because the medial pedicle vertical breast reduction is usually more effective at removing the excess lateral tissue. It is important not to draw the meridian through the existing nipple position but to draw it at the level of the desired new nipple position.

Marking the New Nipple Position

The new nipple can then be marked at the intersection of the vertical mark (8 to 11 cm from the upper breast border) and the new breast meridian (8 to 11 cm from the midline of the sternum). This position will often be at the level of the inframammary fold but not always. It is important at this stage for the surgeon to stand back and visualize the result to make sure that the nipple is designed at a good level both horizontally and vertically.

The surgeon has more flexibility with nipple position in patients with a very full upper pole, but he or she should place the nipple lower in a patient who has a ski-jump type of slope to the upper half of the breast. Nipples can always be raised if a revision is needed, but they cannot be lowered.

If there is significant asymmetry, the new nipple position should be placed up to 1 cm or so lower on the larger breast. The larger breast can be heavier, and closure of a wider vertical ellipse in the larger breast will push the nipple further up than it will on the smaller breast.

Figure 91.1. Markings. A: The upper breast border is marked with a dotted line at the junction of the chest wall and the breast. This patient is “high breasted,” with a short distance between her clavicle and the top of her breast. Her inframammary fold level is marked between her breasts, and it is relatively low, showing that this patient has a fairly long vertical breast footprint. B: The breast meridian is marked. The meridian should not be drawn through the existing nipple position but through the desired nipple position. In this patient the meridian is marked at 8 cm from the chest midline (through the “air,” not around the skin). The new nipple position is marked at the intersection of the breast meridian and at 9 cm from the upper breast border. C: The new areola is marked at 2 cm above the new nipple position. It is drawn freehand so that when closed it will complete a circle. It is drawn with a circumference of 14 to 16 cm to match a 4.5- to 5-cm-diameter areola. D: Then new nipple position is marked at 20 cm. This is measured from the suprasternal notch but is not determined at some arbitrary distance but as measured from the top of the upper breast border. This patient was 5′2″ tall. The vertical limbs are designed much as one would with an inverted-T approach. E: Instead of carrying the vertical limbs of the Wise pattern medially and laterally, they are curved around and joined about 2 to 4 cm above the inframammary fold. The surgeon can pinch the skin to make sure that not too much skin is being removed. The skin closure is not used to hold the breast, so this should be designed for a loose, tension-free closure. F: The patient is shown lying down with the areolar opening, the skin resection pattern, and the medial pedicle drawn. The breast slides up the chest wall when the patient is supine. G: The final marking with the patient standing. H: The final markings shown with the breasts pulled up. The skin resection pattern should be designed as a U rather than a V and it should stay well above the inframammary fold. If a V is used, the surgeon may not remove enough subcutaneous tissue just above the fold, and if the skin pattern is carried down to the fold, the scar will extend down onto the chest wall.

Design of the Skin Resection Pattern

Areolar Opening

The top of the areola is then marked 2 cm above the new nipple position. This accommodates most areolar diameters of 4 to 5 cm. The areola is then drawn so that it will close as a circle. It does not actually need to be mosque shaped since it is probably better to take out more distance vertically than horizontally. The original Wise pattern design (16) was 14 cm in circumference, and this matches a 4.5-cm-diameter areola. A large paperclip can be used as a template because it is 16 cm in length and this matches a 5-cm-diameter areola. If the areola is not a “perfect” circle at the end of the procedure, it is quite simple to make the appropriate adjustments. It is important to make sure that there is symmetry in the design from one breast to the other.

Skin Resection Opening

The lateral and medial breast limbs are much the same as with the Wise pattern. The breast can be rotated laterally and medially to match up the breast limbs with the breast and chest wall meridians. Instead of extending these limbs at 5 cm laterally and medially, the limbs are curved down as a U and joined about 2 to 4 cm above the inframammary fold.

It is important to recognize that the medial pedicle vertical breast reduction does not rely on the skin as a brassiere, and the skin flaps can (and should) be loose enough so that there is no tension on the closure. The surgeon can pinch the skin both with the patient standing and again supine in the operating room to gauge the closure and tension.

It is tempting to bring the skin resection pattern down as a V instead of a U in order to avoid a pucker, but the surgeon will inevitably not remove enough subcutaneous tissue. Postoperative puckers are more a problem of excess subcutaneous tissue than they are a problem of excess skin. The final skin resection pattern with the areolar opening and the vertical limbs should actually resemble a snowman.

It is important to stay well above the inframammary fold because the fold itself will rise and because closure of a vertical ellipse will push down and easily cross the inframammary fold. Again it is important to match the markings on both sides to achieve symmetry.

Surgeons will initially have trouble with the idea of a vertical limb that exceeds 5 to 7 cm, but if ideal breasts are analyzed, an ideal B cup breast will have a distance of 7 cm from the bottom of the areola to the inframammary fold, an ideal C cup breast will have a distance of 9 cm from the bottom of the areola to the inframammary fold, and an ideal D cup breast will have a distance of 11 cm from the bottom of the areola to the inframammary fold.

Patients often ask for breasts that sit completely within the confines of the breast footprint, but it is important for both surgeons and patients to understand that the breast will hang like an awning off the footprint with some breast skin touching chest wall skin. An excellent shape can still be achieved, but a longer vertical distance is needed with this curved lower pole and a longer distance is needed to accommodate the increased projection that results from the vertical approach. A vertical distance of 5 cm would flatten the breast. The parenchymal pillars are best designed at approximately 7 cm, but the skin distance will be longer as it curves down over the inferior pole of a well-projecting breast.

Design of A Medially and Superomedially Based Pedicle

Design of A Medially Based Pedicle

The medially based pedicle will often appear to be “superomedially” based when a patient is standing up, but when a patient is lying down the true medial nature of the base can be seen. The blood supply is medial, whereas a true superomedial pedicle has
both a medial and a superior blood supply. The best way to design a medially based pedicle that is easy to inset is to place half of the base of the pedicle in the areolar opening and half of the base in the vertical limb of the skin resection pattern. A base of about 8 cm is ideal, but it may extend up to 10 to 11 cm in a larger pedicle.

The veins can usually be seen just below the skin, and it would be ideal to try to include one of the visible veins within the base design. The artery to the medial pedicle comes from the internal mammary system at the level of the third interspace. It is deep as it comes around the sternum and then proceeds up in the subcutaneous tissue toward the areola. It travels separately from the veins.

The inferior border of the medial pedicle becomes the medial pillar as the pedicle is rotated up into position.

Design of A Superomedially Based Pedicle

A true superomedially based pedicle may be a good choice for the longer pedicles since it will include both the medial and superior arteries. It will, however, be more difficult to inset. Because we know that the descending branch of the artery from the second interspace almost always enters the areolar opening just medial to the breast meridian and almost always within 1 cm below the skin surface, we can create a wider base superiorly and then remove deeper tissue (that has minimal blood vessels) in order to make it easier to inset the pedicle.

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