Fig. 1

What is the best pedicle for breast lifting or breast reduction?

It seems that every pedicle type imaginable has been tried and everyone tends to have their favorite (Fig. 1). In general, this does imply an overall robust blood supply to the breast. However, it would be nice to know without a doubt which technique offers the best blood supply to the nipple areolar complex (NAC), best nerve supply and gives the most aesthetic breast shape and long-term stability. The problem is that there are hundreds of general articles on this topic but few are well done on specific blood supply volumes and how it relates to final breast lifting or breast reduction results.

For years, many believed that a sternal notch to nipple distance of greater than 30cm was an indication for a free nipple graft. A careful inferior pedicle proved that it could be used for SN-N distances of greater than 40cm with very low ischemic issues, but this technique has problems with ‘bottoming out’ of the inferior pole of the breast over time.

Because the inferior pedicle has been used by the majority of plastic surgeons for so many years, it has a reputation as the technique with the best blood supply.

But is that really true?

A wonderfully written article in April 2007 in the PRS Journal analyzed the major arterial supply to the NAC and found that the inferior pedicle actually ranked very low with regard to vascular reliability. Overall, the superolateral and superomedial pedicles ranked highest with regard to vascular reliability in the study which used dye injected into cadaver’s arterial supply to the NAC. The standard inferior or superior pedicles ranked lowest. Another arterial cadaver study in the APS Journal in 2004 demonstrated slightly better medial blood supply and also showed excellent blood supply to the NAC from both medial and lateral sources.

Whichever pedicle is selected should be treated with extra care to avoid damage to the nerves, vessels and lymphatics. The pyramidal-shaped pedicle realistically should always be as large as possible and with as limited of undermining as feasible to maintain integrity to the NAC (Fig. #2). Conceivably, the NAC could remain connected to a combination of two or more pedicle subtypes if it can still be rotated and lifted without restrictions.

The technique specific for a medial or superomedial pedicle is much like any other where de-epithelialization of the marked pedicle is performed first. The extent of the top of the pedicle typically begins halfway between the top (12 o’clock position) of the keyhole for a medial pedicle or near the top position for a superomedial pedicle (Fig. #3). Release must be made opposite the pedicle to allow the NAC to rotate easily into the slot created superiorly. Care must be taken to leave the base as wide as possible for maximum perfusion.

Four Major Arterial Sources Supplying the Nipple Areolar Complex

(Fig. 2)
(In descending order of reproducibility)

1. Lateral Thoracic Artery (LTA)
2. Internal Mammary Artery (IMA)
3. Anterior Branches of the Intercostal Arteries (ABIA)
4. Branches from the Highest Thoracic Arteries (HTA)

Based on experience along with studies mentioned, the medial or superomedial pedicle breast lift or reduction can be an invaluable technique and can be performed with simultaneous augmentation. Why not use the superolateral pedicle since it possibly has the best blood supply?

My answer is liposuction.

The lateral breast and anterior axilla are routinely liposuctioned during cosmetic mastopexy or breast reduction to improve aesthetics and shorten lateral inframammary scars. The trauma of liposuction to this area would likely damage the pedicle.

If the blood supply from medial and lateral is best, why does the inferior pedicle technique remain most popular? See multiple answers below:

1. The inferior technique is still taught most often in plastic surgery residency programs
2. It requires no rotation that could ‘kink’ a pedicle like a lateral or medial pedicle
3. It has a proven track record from multiple doctors over time
4. It has no tension on the areolas on closure for nice periareolar scars
5. Most using this are not placing simultaneous implants

Why use a medial or superomedial pedicle?

1. One of the most robust and consistent arterial supplies to the breast from the IMA
2. Can be a shorter procedure compared to an inferior pedicle technique
3. Allows breast implant placement inferior to the pedicle for easy access
4. Not reliant on anterior perforators that are severed with simultaneous augmentation
5. Does not require ‘accordion-like’ bunching compared to superior pedicle technique
6. Bottoming out is not an issue as compared to an inferior pedicle technique
7. It allows safe and vigorous liposuction laterally if required

Regardless of which pedicle type is selected, the goal of the surgeon should be to use the technique that works best in their own hands. Although many may disagree, the medial or superomedial pedicle has some distinct advantages over other options.
More prospective studies are needed to justify one technique over another for basic breast reduction or mastopexy.

Key Points to Avoid Problems During Breast Lift or Breast Reduction

• Pedicle type is not as critical as the care in creating an ideal shaped pedicle (a wide-based pyramid is ideal for any pedicle type)
• Staging a mastopexy or breast reduction 3 months prior to implant placement is ideal (simultaneous augmentation cuts the mid pectoral perforators & increases tension)
• Avoid the procedure in patients who smoke (no tobacco for 3 weeks before & after. Urine Cotinine testing confirm cessation)
• Realize limitations of nipple repositioning in SN-N distances ≥ 35cm (prepare patient for the possibility of conversion to a free nipple graft if needed)

* This article by Dr. Cuzalina appeared in the December 2009 issue of Surge.

• Read more about breast lift surgery in Tulsa
• Read more about breast reduction in Tulsa
  

Tags: Breast Lift, breast reduction surgery

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