Increasing Projection in Patients Undergoing Free Nipple Graft Reduction Mammoplasty

David L. Abramson, M.D. Brooklyn, New York, USA

Abstract. Reduction mammoplasty in patients with giganto-mastia has traditionally been performed by a technique involv­ing free nipple grafting. These patients usually have only a small amount of breast tissue above the inframammary fold and therefore this type of procedure has often left patients with an insufficient amount of superior pole projection. I have per­formed free nipple grafting in three patients with gigantomastia using a technique that utilizes two deepithelialized pedicles to increase projection. This technique is simple to perform, does not significantly lengthen the operative time, and results in a breast that provides significant projection.

Key words: Reduction mammoplasty—Free nipple graft— Deepithelialized

Patients with gigantomastia and extreme ptosis frequently have minimal, if any, breast tissue above the level of the inframammary fold. Because of this, obtain­ing adequate breast volume and projection in patients undergoing reduction mammoplasty by the free nipple graft technique will frequently result in a flat, boxy breast with poor projection. This is particularly trouble­some because these women are accustomed to the large volume of breast tissue that was present prior to surgery, making the difference in breast shape even more pro­nounced. Mathes et al. reported using an inferior dermal pedicle as a method for augmenting projection in patients undergoing reduction mammoplasty [1]. The need for increasing projection is even more pronounced in pa­tients having reduction mammoplasty by the free nipple graft technique. To correct this problem Romano et al. described using a superiorly based dermal pedicle extending from the keyhole to the superior aspect of the areola [2]. This superiorly based flap is folded and secured beneath the medial and lateral flaps. Although this technique aids in increasing projection, the amount of parenchyma that can be folded is limited and sometimes additional projection is required to match the breast size and shape with the individual's body habitus. Thus I have begun to use two deepithelialized flaps to augment projection in patients undergoing free nipple grafting.

Surgical Technique

Preoperative markings are performed with the patient standing. A Wise pattern is used to mark the new location for the nipple-areola complex and the vertical limbs. A curvilinear incision is marked between the inferior aspect of the vertical limbs and a point 3 cm above the areola complex. The entire area above this line and be­tween the vertical limbs will be deepithelialized (Fig. 1A). Additionally an inferior dermal pedicle is designed that is approximately 9 cm wide at the base and extends superiorly to a point halfway between the inframammary and the nipple (Fig. IB). The remainder of the markings are made in the standard fashion. The nipple-areola com­plex is harvested and then the two previously marked areas are deepithelialized. The incisions are then made, creating two dermal parenchymal flaps, and the excess breast tissue is removed. The medial and lateral flaps are brought to the inframammary fold while simultaneously placing the inferior pedicle against the pectoralis and folding the superior pedicle under the flaps. The breast is then closed in a manner of the surgeon's choice.
The inferior dermal parenchymal pedicle can be adjusted in width and length to suit the requirements of the particular patient.

Results

This technique has been used on three patients and all have been satisfied with the amount of projection in the postoperative breast. The patients treated in this manner were all above ideal body weight and therefore needed a significant amount of volume left behind to match their body type (Figs. 2A and B). Additionally, the nipple sternal distance on both breasts was more than 40 cm. The use of the two deepithelatized pedicles did not hinder closure or place undue tension on the wound edges. All patients' incisions healed without complica­tions (Figs. 3A and B). All three patients were African American and therefore had pigmentary changes in the nipple areolar graft.

Discussion

Large-volume breast reduction represents a unique reconstruction problem. The body habitus of the patient as well as the distribution of the existing breast tissue re­quires significant changes in technique in order for the surgeon to create a well-formed breast with reasonable projection. These patients may have more than 90% of the preoperative breast tissue located below the inframammary fold, therefore parenchymal flaps must be de­signed that can easily be moved cephalad as well as fit inside the predetermined skin envelope. Additionally, any attempt to augment the projection of the breast must not come at the expense of the uniformly high success rate of the nipple graft itself. One of the main advantages of the free nipple graft procedure is the ease of perform­ing the surgical technique, since it is essentially an am-putative procedure between the preoperative markings. Despite adding these dermalparertchymal flaps the pro­cedure is still technically straightforward and can uni­formly produce good results. This technique provides a simple solution to the problem of inadequate projection in patients undergoing free nipple graft breast reduction.

References

1. Mathes SJ, Nahai F, Hester TR: Avoiding the flat breast in reduction mammoplasty. Plast Reconstr Surg 66:63, 1980
2. Romano JJ, Francel TJ, Hoopes JE: Free nipple graft reduction mammoplasty. Ann Plast Surg 28:271, 1992