Breast Reduction: Superomedial Pedicle Wise-Pattern Approach

The Clinical Problem

Breast hypertrophy is a frequent condition in women. It may occur due to excessive development of glandular tissue during puberty, secondary to weight gain or as a result of naturally occurring fat deposition of breast tissue that takes place with aging.

In this chapter, based on a case report, we will discuss clinical findings, expectations, surgical techniques, postoperative evolution, and possible complications.

During puberty, RB saw her breasts develop rapidly. Her clothes wouldn’t fit right—she would often have to buy larger garments for her upper body—her brassiere would hurt her shoulders, and she could not adequately cushion her breasts during sports activities.

Secondary to the increase in volume and weight of her breasts, the skin of her breasts stretched, along with all of their support system (Cooper’s ligaments), which led to breast ptosis that resulted in both caudal and lateral placement of the nipple-areola complex. She started to frequently feel pain in her back and cervical region, which led her to seek medical help.

At physical examination, the patient presented with large-based breasts that were bulkier in their lower pole, with a loss in cleavage volume (at the projection of upper quadrants; Fig. 26.1 ). Her inframammary folds showed signs of dermatitis caused by the folding of the breasts over the abdomen, and her shoulders had visible sites of skin depression caused by the brassiere straps. Undoubtedly, there was an indication for surgical treatment of her breasts.

Surgical Preparation and Technique

Management and Treatment Options

Treatment for breast hypertrophy is surgical, through breast reduction. Surgery has three main objectives:

1.

Reducing the amount of breast tissue (glandular or fatty)
2.

Correcting the shape of breasts
3.

Cranially repositioning the nipple-areola complex (NAC), thus bringing a more aesthetic shape for breasts

During the preoperative evaluation, it is important to do the following:

•

Evaluate the patient’s weight.
•

Get adequate imaging (ultrasound [US], mammography, magnetic resonance imaging [MRI]) under the guidance of a breast disease specialist.
•

Inform the patient about placement and size of surgery scars.
•

Inform the patient about the possible impact on breastfeeding, and discuss all other possible complications.

Many techniques have been developed, with modifications performed mainly on the incisions and pedicles used.

Techniques using periareolar incisions, with a vertical extension, lateral extension (L), and Wise pattern (anchor) have been developed and are used according to the preferences of the patient and surgeon. The Wise pattern is drawn with the junction of two ellipses, one horizontal and another one vertical, which allow for skin redraping over the breasts in a tridimensional fashion, thus helping the reshaping and aesthetic projection of the breasts.

Although surgery for reduction of large breasts will frequently result in extensive scars, patients will usually accept them in exchange for the reduction in their weight and volume and the more adequate reshaping and replacement of the breasts. Improvements in self-esteem and well-being have already been proven by scientific studies.

Among the most frequently used pedicles in breast reduction, the inferior and the superomedial pedicles stand out due to their versatility and possibility of being used even for gigantomastia patients. The superomedial pedicle is our preferred choice.

The choice of the superomedial pedicle presents some advantages, among them the ability of safely lifting the NAC for many centimeters because of the presence of branches from the perforator vessels of the second intercostal space (ICS). Another advantage is the possibility of shaping the pedicle with a smaller thickness (2 cm), thus allowing for greater mobility of the NAC and allowing for resection of breast tissue in all quadrants. It is also important to note that the superomedial pedicle preserves the cleavage (projection of the upper medial quadrants) better than the inferior pedicle.

Even so, in situations in which the distance between the NAC and suprasternal notch is much greater than the distance between the NAC and inframammary fold (IMF), use of the inferior pedicle should be considered.