Improving Long-Term Breast Shape with the Medial Pedicle Wise Pattern Breast Reduction

David L. Abramson, M.D., Stephen Pap, M.D., Suzan Shifteh, P.A., and Scot B. Glasberg, M.D.

Background: Reduction mammaplasty has both a reconstructive and an aesthetic component. Relief of neck, back, and shoulder pain, as well as psychosocial improvement, is the main indication for intervention. Patient satisfaction is high, with early improvement in most cases. Preoperative planning confirms the anatomical variations as well as the best technique to achieve optimal cosmetic and functional results. Techniques for breast reduction have evolved in response to the great variety of challenges. The surgeon must tailor the surgical approach by considering a wide range of anatomic deformities, from gigantomastia to mild ptosis. Medial pedicle techniques have been shown to be reliable in severe breast hypertrophy.

Methods: The authors present a series of 88 consecutive patients who underwent reduction mammaplasty using a medial pedicle technique with a Wise pattern skin resection. The purpose of the study was to evaluate the complication rate, operative time, and long-term effects on pseudoptosis.

Results: The average weight reduction was 1814 g (both breasts combined), and the average operative time was 104.5 minutes. Patients were followed up for a minimum of 1 year, and the complication rate was 6.8 percent. The distance from the inframammary fold to the nipple was measured in patients widi more than 1 year of follow-up. The results exhibited an average increase in this length of only 11 percent for reductions between 500 and 1200 g per side and of 34percent for reductions greater than 1200 g per side.

Conclusions: The authors conclude that this technique is an effective and reliable approach to a wide range of breast hypertrophy, with reproducible breast weight reduction and less long-term pseudoptosis or "bottoming out." In addition, the operative time is short and the complication rate is acceptably low. (Plast. Reconstr. Surg. 115: 1937, 2005.)

Reduction mammaplasty operations have both a reconstructive and an aesthetic component. Among the many indications, the relief of neck, back, and shoulder pain and the associated psychosocial improvements are the main justifications for operative intervention. In most cases, patient satisfaction is high, with early improvement in symptoms such as skin rash, shoulder and back pain, and shoulder grooving.¹

Careful preoperative planning determines the anatomical abnormality and the best technique to achieve optimal cosmetic and functional results. Parameters to be assessed include the amount of ptosis, symmetry, size and shape of each breast, skin changes, elasticity, and tone and position of the nipples. The usual preoperative workup should also include a past medical and family history and assess the need for baseline mammography. A detailed physical examination of the breast includes measurements of breast size, degree of ptosis, masses, superior pole fullness, nipple-sternal distance, nipple—inframammary fold distance, and distance of the nipple from the medial limb of the Wise pattern. In addition, patients need to be counseled regarding the position of the surgical scars, possible nipple loss, skin necrosis, and changes in nipple sensibility. Lactation, an issue of concern for women of childbearing age, may also be affected in these patients.

As summarized by Spear and Mijidian,1 the surgical techniques for breast reduction have evolved in response to the great variety of challenges encountered in this patient population. The surgeon must tailor technique and surgical approach to each patient and consider a wide range of anatomic deformities, from gigantomastia to mild ptosis, and the preoperative status of the patient, from healthy and young to more frail and elderly. This has resulted in a large repertoire of surgical techniques, including periareolar mastopexy, vertical scar mastopexy, inferior pedicle reduction, McKissock reduction, superior pedicle reduction, central mound reduction, and free nipple graft reduction, among others.

We present a series of 88 patients who underwent reduction mammaplasty using a unique medial pedicle technique. The purpose of the study was to evaluate the complication rate, the effects on operative time, and the long-term effects of pseudoptosis ("bottoming out").

Patients and Methods
From June of 2001 through April of 2002, 88 patients underwent medial pedicle breast reduction at the Lenox Hill Hospital in New York. The operations were performed by the two attending surgeon authors.
All patients who were assessed to be candidates for medial pedicle breast reduction underwent that procedure. Exclusion criteria included a pedicle length of less than 6 cm or greater than 16 cm. Short pedicles were excluded because of the inability to rotate the pedicle into the keyhole portion of the Wise pattern. Medial pedicle length was measured from the medial vertical limb of the Wise pattern to the nipple. In addition, patients with a lack of superior and medial fullness could be excluded because of concern over the substance vascularity of the parenchymal pedicle. A periareolar incision from a previous biopsy that violated the pedicle would also exclude the patient from a medial pedicle reduction mammaplasty.  The  preoperative workup included a mammogram if the patient was 35 years of age or older, hematocrit analysis, and a urine pregnancy test when indicated.

Preoperative marking was performed with the use of a Wise pattern (Fig. 1). The distance between the sternal notch and the new nipple position ranged from 21 to 24.5 cm, depending on patient height, estimated volume of reduction, and location of the inframammary fold. The new nipple position was marked 0.5 to 1.5 cm below the level of the inframammary fold. This number increased as the volume of the reduction increased.

Postoperatively, the patients were followed up for a minimum of 1 year, and the distance from the nipple to the inframammary fold was measured in patients with more than 1 year of follow-up. All 88 patients were followed up for more than 6 months, and 63 patients had nipple-to-inframammary fold distances measured at more than 1 year postoperatively. This allowed for assessment of any pseudoptosis or "bottoming out" that might have developed.

Results
Eighty-eight patients underwent reduction mammaplasty from June of 2001 to April of 2002 using a medial pedicle technique with a Wise pattern skin resection. The average age of the patients was 30 years. The average amount of breast tissue removed was 1814 g per patient, and the average operative time was 104.5 minutes (for patients who underwent breast reduction only). The surgical procedure lasted from 55 to 145 minutes. All operations were performed as an ambulatory procedure unless a concomitant surgical procedure required an overnight stay (Figs. 2 through 5). The average length of the procedure did decrease as the study period progressed. This was likely because of the surgeons' increasing comfort with the operative technique. The complication rate was 6.8 percent (six of 88 patients) and included a small hematoma, a stable postoperative ventricular tachycardia, a partial nipple loss (2000-g reduction of that breast), two cases of significant wound dehiscence of the vertical limb, and one needle biopsy to confirm an area of fat necrosis. Both significant cases of wound dehiscence occurred in patients who used tobacco during both the preoperative and postoperative periods.
The nipple-to-inframammary fold distance increased 11 percent in patients whose reductions were between 500 and 1200 g per side and 34 percent in patients whose reduction was greater than 1200 g per breast (Table I).

Discussion
Different techniques have demonstrated certain improvements in the postoperative results in breast reduction patients. Patient satisfaction after breast reduction surgery is as high as 94 percent, with variables such as breast size and shape, sensation, and scars, as well as improvement of neck pain, back pain, rashes, and shoulder grooving.² Techniques are constantly improving in attempts to make it easier for surgeons to adopt them and to offer patients a wider choice of options.
To maintain lactation ability, the integrity of the mammary gland must be carefully preserved during the operation. Reduction mammaplasty with a superior-lateral dermoglandular pedicle was developed from an original technique by Skoog to minimize damage to the galactophorous ducts and to reduce innervation injury. In a series of 112 patients over a 7-year period, only a small number of complications were observed, with a high level of long-term patient satisfaction.³ The correction of postoperative pseudoptosis as the inferior skin envelope stretches over time has also been attempted. However, the long-term outcome of these changes resulted in a much less optimal cosmetic result. The modified Robertson reduction mammaplasty can be used for both small and large reductions and seems to avoid postoperative pseudoptosis.4 With an average reduction weight of 910 g and a follow-up of 4.7 years, the authors demonstrated significant improvement in back and shoulder pain and shoulder grooving, as well as significant increases in activity levels. Pseudoptosis evaluated by the attending surgeons was good or excellent in 95 percent of patients.

The use of the superficial fascial system to aid in tissue suspension with nonabsorbable sutures has resulted in more predictable scarring with a reduced risk of scar widening and hypertrophy. A series of 109 patients with a 6-month follow-up showed a reduced incidence of hypertrophic scarring at 3 percent; this allegedly should ensure a more reliable and stable long-term breast contour.³
Loss of a natural inframammary fold and noticeable medial and lateral scars in the inverted-T techniques have prompted some surgeons to consider using the central pedicle technique. It has been argued that this approach provides a better vascular and nerve supply to the nipple-areola complex and causes no damage to the lactiferous ducts.⁶ Others have espoused the use of ultrasound-assisted liposuction to further minimize surgical scarring and to enhance the ability to shape the breast in  a three-dimensional way.7 Liposuction as an aid to conventional breast reduction has proven to be particularly useful for treatment of the axillary "fat roll" without additional morbidity.⁸

Computer-assisted neurosensory testing measured nipple-areola complex sensitivity in patients undergoing medial and inferior pedicle reduction mammaplasty. Although the medial pedicle technique allowed for greater mean weight reduction than the inferior pedicle technique (1700 g versus 1100 g), no significant changes were seen in postoperative nipple-areola complex sensitivity in a series of 17 patients.9
The use of medial pedicle techniques has been shown to be reliable in severe breast hypertrophy. A series of 23 patients showed no hypopigmentation; 98 percent retained sensibility of the nipple-areola complex, with a mean weight of removed tissue of 1604 g per patient and a mean follow-up of 25 months.10

Postoperative lengthening of the nipple-to-inframammary fold distance in patients undergoing our technique was considerably less than that of recent studies involving inferior pedicle techniques. Currently, the most common form of reduction mammaplasty performed is the inferior pedicle technique. This technique has been proven to be reliable, providing good nipple viability, good sensation, and reasonable shape. However, as the size of breast reduction increases, there is an increasing trend toward more postoperative pseudoptosis. This is related to the source of the remaining breast tissue (the inferior pedicle) causing pressure on the gradually lengthening vertical limb, resulting in "bottoming out." Reus and Mathes11 showed that there was a 48 percent increase in the length of the vertical limb after inferior pedicle reduction mammaplasty when the resected volume was between 500 and 1200 g. When   the  amount  of resected   tissue  was greater than 1200 g, the average vertical limb lengthening was 72 percent. Erdogan et al.12 reported similar findings in 2002 when they showed that the vertical limb increased in length by approximately 49 percent when the amount resected was between 500 and 1200 g. The overall series had an increase in the areo-la-to-inframammary fold distance of 52 percent.

Conclusions
The use of a medial pedicle breast reduction in combination with a Wise pattern or inverted-T skin excision provides excellent long-term results, with decreased "bottoming out," good breast shape, shortened operative time, and an acceptably low complication rate. In addition, the medial pedical technique maintains medial and superior pole fullness and blood flow to the nipple based on intercostal  perforators  providing  excellent vascularity. We believe that because of the decrease in "bottoming out," this techniques should be the method of choice for reduction mammaplasty with resections ranging from 500 to 1500 g per side.

REFERENCES
1.  Spear, S. L., and Mijidian, A.    Reduction mammaplasty
and mastopexy: General considerations. In S. L. Spear (Ed.), Surgery of the Breast: Principles and Art. Philadelphia: Lippincott-Raven, 1998. Pp. 673-684.
2.  Brown, A. P., Hill, C, and Khan, K.    Outcome of reduc-
tion mammaplasty: A patient's perspective. Br.J. Plast. Surg. 53: 584, 2000.
3.  Cardenas-Camarena,  L.,  and Vergara,  R.    Reduction
mammaplasty with superior-lateral dermoglandular pedicle: Another alternative. Plast. Reconslr. Surg. 107: 693, 2001.
4.  Chalekson, C. P., Neumeister, M. W., Zook, E. G., and
Russell, R. C. Outcome analysis of reduction mammaplasty using the modified Robertson technique. Plast. Reconstr. Surg. 110: 71; discussion 80, 2002.
5.  Lockwood, T.    Reduction mammaplasty and mastopexy
with superficial fascial system suspension. Plast. Recon-str. Surg. 103: 1411, 1999.
6.  Frey, M.    A new technique of reduction mammaplasty:
Dennis suspension and elimination of medial scars. lit.]. Plast. Surg. 52: 45, 1999.
7.  Goes, J. C, and Landecker, A.    Ultrasound-assisted li-
poplasty (UAL) in breast surgery. Aesthetic Plast. Surg. 26: 1, 2002.
8.  Price, M. F., Massey, B., Rumbolo, P. M, and Paletta, C. E.
Liposuction as an adjunct procedure in reduction mammaplasty. Ann. Plast. Surg. 47: 115, 2001.
9.  Mofid, M. M., Dellon, A. L., Elias, J. J., and Nahabedian,
M. Y.    Quantitation of breast sensibility following reduction mammaplasty: A comparison of inferior and medial pedicle techniques. Plast. Reconslr. Surg. 109: 2283, 2002.
10.  Nahabedian, M. Y., McGibbon, B. M., and Manson, P. N.
Medial pedicle reduction mammaplasty for severe mammary hypertrophy. PlasL Reconstr. Surg. 105: 896, 2000.
11.  Reus, W. F., and Mathes, S.J.    Preservation of projection after
reduction mammaplasty: Long-term follow-up of the inferior pedicle technique. PlasL Reconstr. Surg. 82: 644, 1998.
12.  Erdogan, B., Ayhan, M., Deren, O., et al.    Importance of
pedicle length in inferior pedicle technique and long-term outcome of areola to fold distance. Aesthetic Plast. Surg. 26: 436, 2002.