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
  

The theory behind this procedure posits that Botox injections can relax muscles and affect a woman’s posture in such a way that simulates lifting of the breasts.  Although the breast lift is popular and effective, and Botox offers a relatively easy fix for wrinkles, the so-called Botox Breast Lift is not a cost effective cosmetic treatment people should consider.

Reporter Liz Bonis asks Dr. Mark Mandell-Brown about the procedure and he says the basic sales pitch is, “rather than spending four or five or ten thousand dollars on a breast lift, lets do $200-$300 of botox.”

Are we just throwing away the 300 dollars then? Boniz Asks.

“Yes.”

Is there any research to support that this would be even remotely effective?

“No. In reality, the tissue’s too heavy for that to happen.”

A ‘short scar lift’ avoids the use of a long incision within the inframammary fold (where the breast and chest meet).  The question is a commonly debated topic among cosmetic surgeons who perform breast lift surgery, and this article includes a discussion of the various short-scar techniques performed today.

The truth of the matter is that as long as patients present different anatomical considerations, and hold different aesthetic preferences, no ‘best’ technique exists.  Choosing the best technique means aiming for the most satisfying result with the least amount of risk.

You can read the article here. Please be aware: toward the end of the article, there are some images of real surgery taking place.

Challenging Cosmetic Surgery
‘Simultaneous Mastopexy and Augmentation’

Angelo Cuzalina, MD, DDS

Cosmetic surgery of the breast often involves treatment of both breast hypoplasia as well as ptosis. Many women have a combination of breast problems and desire simultaneous breast lift and augmentation. An isolated mastopexy or basic augmentation with implants can be relatively straight forward in select patients; however, combining mastopexy with implants during the same surgery can be a daunting and risky task for even the most experienced surgeon.

Regnault Classification of Breast Ptosis

• Pseudoptosis: Nipple is above the fold & loose breast parenchyma hangs below the IMF
• Grade 1 Ptosis: Nipple is at the fold
• Grade2 Ptosis: Nipple is 1-3 cm below the fold, but above the lowest contour of the breast
• Grade 3 Ptosis: Nipple is located at the lowest contour of the breast >3 cm below the fold

The Regnault breast ptosis classification system was developed in 1976 to demonstrate various breast shapes that help guide a surgeons’ decision making process with regard to augmentation and mastopexy. Unfortunately, the grade of ptosis is only one small aspect for determining the ideal procedure for each patient.

Other Parameters as Important as Ptosis Grade for Treatment Planning

• Current breast volume: The current cup size the patient believes she has
• Firmness of breast tissue: Chiefly at the inframammary fold to avoid a ‘double bubble’ deformity
• The patient’s vision of the ideal breast: especially related to roundness or natural contours
• The amount of size change required: Ideal cup size
• Areolar diameter: desired areolar width
• Breast dimensions: especially nipple to fold distance and base width

No easy or dogmatic method for simultaneous mastopexy and augmentation exists. This is why cosmetic surgery is artistic. Yet, a few rules (or suggestions) can help one avoid problems. First rule, significant ptosis with a nipple to fold distance greater than 10 cm will be difficult to treat without a horizontal incision such as with an inverted T mastopexy unless the surgeon is extremely experienced in a Lejour mastopexy or using a very large implant. Personally, adding a short horizontal incision or lateral curve at the base of a borderline vertical mastopexy case can make the result turn out better with only a small extra scar in the crease. Second rule, a periareolar mastopexy cannot produce major lifting particularly on heavy, dense breast, must less a smaller areolar diameter when simultaneously placing an implant (eventually the smaller circle created will stretch). If the patient has large areolas and wants a smaller diameter at the same time as augmentation, adding a vertical component (scar) will actually improve the areolar scar and can lend to smaller areolas by placing suture tension inferiorly and not around the areolas.

The tendency early in one’s cosmetic breast surgery career is at times to be too conservation with the incision choice and the amount of breast parenchyma and fat excision during simultaneous mastopexy and augmentation. This can be especially true for the type 2 or 3 ptosis patient who is already a C or D cup and desires to be a ‘full C’ with more ‘rounded or upper pole fullness. These are particularly difficult because often a reduction of significant breast tissue and placement of a larger implant is needed to increase the ratio of implant volume to breast volume to achieve the look the patient hopes for. Basically, the more percentage of natural breast tissue, the more natural the breast. And, often more ptotic relapse will occur in women with naturally large, dense breast than one with large breasts due to implants (i.e. reducing natural breast tissue weight in exchange for implant volume will improve long term results).

Another surgical pearl to remember is that you can always remove more skin if needed during the procedure but it is hard to put it back if you remove too much. Having said this, a more conservation incision such as a periareolar or ‘donut only’ type incision for the heavy breast or type 2 or 3 ptosis very often leads to less than ideal results. An inverted T or vertical (Lejour type) mastopexy may be a much better choice for this breast type particularly if the patient wants significant parenchymal elevation. These larger incisions do have the potential for minor wound dehiscence at the trifurcations. So, another nice technique that two of our past presidents (Dr. Bob Jackson and Dr. Claude Crockett) have employed routinely for years is to place the implants in a ‘total submuscular’ position (diagram). The coverage of the lower half of the implant gives added protection particularly if the incision breaks down at little or a lot. Ultimately, the simultaneous mastopexy and breast augmentation can be very rewarding to the patient and surgeon, but will always remain a challenge.