Abstract
Looking to improve the esthetic and functional results of the central pedicle technique, we add the dermis mesh shaping and support forming a “central cone” to manage the mammary tissue. The periareolar skin agglomeration searches for a reduction in horizontal submammary scars’ size. The purpose of this chapter is to describe this surgical technique (combination of techniques).
Keywords
- reduction mammoplasty (RM)
- central pedicle (CP)
- dermis mesh (DM)
- periareolar
- nipple-areolar complex (NAC)
1. Introduction
There are multiple techniques of Breast Reduction (BR) [1, 2, 3] that look to, alongside reducing the size, achieve a symmetric pleasant looking shape, stable through time with minimal ptosis, minimal scarring, and frequency of complications.
Techniques based on structural support from skin and suture usually end up with ptosis and ample scars, because of the weight of the mammary tissue and the expansion of the skin and scars. Besides that, the mammary cone loses firmness and projection.
The BR technique based on the Central Pedicle (CP) was initially described by Balch in 1981 [4] and popularized by Hester in 1985 [5]. It is a trusted technique since the CP has good irrigation and innervation from the perforating branches of the fourth and fifth intercostal spaces [6], and if a wide base is kept, it will also receive irrigation from the perforating branches of the internal mammarian artery and branches from the lateral thoracic artery [5], allowing to reduce great volumes, achieve better mastopexies, and preserve lactation [7, 8, 9].
In this chapter, we will show the combination of two techniques: CP + Mesh of Dermis that produces a stable and well-projected central cone, described by Sampaio Goes in 1996 [10, 11] and Circumferential Periareolar Suture described by Benelli in 1990 [12], which allows reducing the submammary scar. Both of these techniques have been proposed in the literature and used separately. By combining them, we pretend to obtain better long-term results in shape, reducing ptosis, and achieving minimal submamarian scarring.
This association of techniques has been applied in patients with mamarian hypertrophy and great ptosis, looking to reach the ever-increasing expectations of the patients [13].
We present here a description of this systematized
This technique, as well as all the images shown here, and the results of a series of 300 patients who were intervened with this technique, followed and analyzed before, during, and after the procedure; were first published in the “Cirugía Plástica Ibero Latinoamericana” magazine in March 2021, volume 47, N 1, pages 35–48. Used with permission of the editor.
2. Surgical technique
The inframammary fold is marked 1 cm over the original, sculpting the skin triangle of 1 cm in point D (Figure 11). The caudal pole’s skin flaps are trimmed near the future inframammary fold (Figure 12A and B), and the superficial fascia of the chest wall is anchored to the dermis of the cone’s inferior pole with nylon 4.0, 3.5−4 cm from the bottom edge of the areola, to strengthen the inferior pole (Figure 13A and B); then, the inferior pole’s flaps are pulled towards the lower middle line (Figure 14A); they are marked and trimmed leaving 4−5 cm in the middle edge (vertical scar) (Figure 14B and C).
Two plane sutures of the skin flaps just like the periareolar wound (Figure 15A–C). Suction drainage is left in the lateral zone and armpit, which comes out under the inferior pole and is removed 1−2 days before medical discharge. All sutures used are non-resorbable.
For wound care and bandaging, paper tissue is applied as support for the breast for 1 week, until the first wound dressing. The symmetry of the NAC is confirmed with the strings anchored in the middle line (Figure 16) during the structuring of the mammaries.
At the end of this work, clinical cases are attached with the aim of demonstrating the results of the described technique (Figures 17–19).
3. Discussion
When analyzing the traditional techniques of breast reduction, in which the assembling of the reduced pedicles and positioning of the tissues depend on the skin flaps sutured to each other [1, 2, 3] and it is them which support the shape and weight of the breast, we tend to see how, in many cases, the weight causes the skin to stretch, the scar to widen, and in the medium and long term we end up seeing breast ptosis, both of the ANP and the inferior pole, causing the breasts to lose shape and firmness.
The combined technique presented here is based on the CP technique (described by Bach [4]) that is safe for removing great volumes and pexies [4, 5, 6, 7, 8, 9, 10]. It allows us to: with the dermis mesh (technique described by Góes [11, 12]) that surrounds the CP, one anchored to the aponeurosis creates a stable central cone or mound [10], as a nucleus for the future breast, that in its vertex including the projected and positioned NAC. The reinforcement of the inferior pole of the dermis cone, with the Scarpa fascia suture in its lower third (author’s contribution), would reduce the ptosis of the inferior pole. After that, this dermis cone is covered by the skin flaps (double layer), which, with a small tension, help in the firmness of the reduced breast. Suturing around the areola in “Raund Block” described by Benelli [13], accumulating skin around the areola, allows to reduce the inferior horizontal scar, in order to keep it inside the margins of the breast, achieving an average of 13,4 cm in the right breast and 13,2 cm in the left (6,5 to 18 cm), although it is not enough to talk about reduced scarring in all the cases, particularly in big reductions [15]. By cutting the skin 1 cm above the original submammary fold (Figure 10), the scar is left in the inferior pole, the compression with silicone becomes easier, and its trauma by the breast holder in the postoperative is prevented. A breast that is firm, pleasant-looking, well projected, round, and stable with minimal ptosis is achieved; just like it was confirmed in the follow-up of the patients and the measurements taken of the nipple to the collarbone and to the submammary fold.
Another difficulty is obtaining adequate breast symmetry at the end of the surgery. This technique allows us to confirm breast symmetry in three stages by comparing the volume of the tissues:
When finishing reduces the central pedicles (pulled) and the skin flaps (Figure 6).
Once the central cone is formed (Figure 7). The symmetric position of the NAC is also verified.
When the central cone is covered with the skin flaps (Figure 8), verify the thickness of the fat-skin flaps, suturing them around the NAC and presenting them when covering the cone.
This achieves an adequate symmetry in 97% of the cases according to questionnaire done to the patients during the postoperative period [14]. Of these patients, 57.7% evaluated the results as “very satisfactory” and 37.9% as “satisfactory.”
In all these stages, tissue can be removed if it is necessary for the final symmetry.
In the published series of 300 patients [14], a low frequency of complications is reported (11.3%): re-intervened hematomas (1%), localized hematomas treated by deferred punction (1.3%), total necrosis of the NAC (0.3%), partial necrosis of the NAC (1.3%), necrosis of the skin flap ends greater than 1 cm (2%), fat necrosis greater than 2 cms (2%), hypoesthesia of the NAC (3.3%). All of these are among average or below average frequency of complications described in other techniques [16, 17, 18, 19, 20, 21].
In the same series [14], 14.3% of the patients required a surgical touch-up: lateral breast liposuction (7.7%), lipoinjection (1%), scar correction (3%), escharotomies and re-sutures of the skin flaps (1.3%), removal of fat necrosis (1%). Only one patient in the entire series (0.3%) required a major surgical corrective reintervention in order to remove some extensive calcified necrosis and reconstruction with bilateral implants.
Complications were primarily present in patients with obesity and a smoking habit [14].
4. Conclusions
Based on a published series of patients who intervened with this technique [14], it can be concluded that it is possible to combine the techniques of CP, autologous dermis mesh, and circumferential periareolar, all of them described in Medical Literature for reduction and/or breast pexias. The combined technique here utilized is versatile in the management of the breasts’ volume and symmetry, also for mobilizing the NAC and stabilizing it with dermis mesh anchored to the pectoralis major fascia and the chest wall fascia. Also, it produces a stable, well-projected central cone, which, by being covered with skin (double layer), can achieve a breast with greater firmness.
The accumulation of periareolar skin with “Raund Block”, allows to reduce the submammary scar, in order to not exceed the breast limits.
In our experience, it is a safe procedure, with few complications [14]. Because of the good irrigation and sensitivity of the CP, we can reduce major breast volumes and preserve lactation, since all the mammarian tissues of the CP are connected to the NAC. The obtained breast shape is stable in time, with minimal ptosis of the NAC and the inferior pole, achieving high satisfaction with the patients [14].
Conflict of interests
The authors declare having no financial interest related to the contents of this article. Neither have they received help or payments for the realization of this study.
References
- 1.
Pitanguy I. Surgical treatment of breast hypertrophy. British Journal of Plastic Surgery. 1967; 20 (1):78-85 - 2.
Georgiade N. Reduction mammaplasty utilizing the inferior pedicle nipple-areolar flap. Annals of Plastic Surgery. 1979; 3 (3):211-212 - 3.
McKissock P. Reduction mammaplasty by the vertical bipedicle flap technique: Rationale and results. Clinicals of Plastic Surgery. 1976; 3 (2):309-320 - 4.
Balch C. The central mound technique for reduction mammaplasty. Plastic Reconstruction Surgery. 1981; 67 (3):305-311 - 5.
Hester T et al. Breast reduction utilizing the maximally vascularized central breast pedicle. Plastic Reconstruction Surgery. 1985; 76 (6):890-900 - 6.
Calderon W et al. Mamoplastía de Reducción con incisión periareolar: anatomía y clínica del pedículo central. Cir. Plást. Iberolatinoam. 2016; 42 (1):21-28 - 7.
White D et al. Clinical applications of the central pedicle technique of the breast reduction. Operative Techniques in Plastic and Reconstructive Surgery. 1996; 3 (3):176-183 - 8.
Grant J et al. The maximally vascularized central pedicle breast reduction: Evolution of a technique. Annals of Plastic Surgery. 2001; 46 :584-589 - 9.
See M-H. Central pedicle reduction mammaplasty: A reliable technique. Gland Surgery. 2014; 3 (1):51-54 - 10.
Delong M et al. The Central Mound Pedicle: A safe and effective technique for reduction mammaplasty. Plastic Reconstruction Surgery. 2020; 146 (4):725-733 - 11.
Góes JC. Periareolar mammaplasty: Doble skin technique with application of Polyglactine or mixed mesh. Plastic and Reconstructive Surgery. 1996; 97 (5):959-968 - 12.
Góes JC. Periareolar mastopexy: Doble skin technique with mesh support. Surgical Journal. 2003; 23 :129-135 - 13.
Benelli L. A new periareolar mammaplasty: The “Round Block” technique. Surgical Journal. 1990; 14 (2):93-100 - 14.
Rudolph A. Mamoplastía de reducción con Pedículo Central y Malla de Dermis. Cir. Plást. Iberolatinoam. 2021; 47 (1):35-48 - 15.
Yépez I. Mamoplastía de reducción con cicatrices pequeñas para grandes hipertrofias mamarias o gigantomastias. Cir. Plást. Iberolatinoam. 2013; 39 (1):1-8 - 16.
Souto G. The impact of breast reduction surgery on breastfeeding performance. Journal of Human Lactation. 2003; 19 (1):43-49 - 17.
Wirthmann A et al. Reduction mammaplasty in adolescents and elderly: A ten year case series analyzing age related outcome with focus on safety and complications. Journal of Plastic, Reconstructive & Esthetic Surgery. 2018; 71 (3):377-383 - 18.
Gulcelik M et al. Early complications of a reduction mammaplasty technique in the treatment of macromastia with or without breast cancer. Clinical Breast Cancer. 2011; 11 (6):395-399 - 19.
Fischer J et al. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Esthetic Surgery Journal. 2014; 34 (1):66-73 - 20.
Srinivasaiah N et al. Risk factors for complications following breast reduction: Results from a randomized control trial. The Breast Journal. 2014; 20 (3):274-278 - 21.
Zhang M et al. Risk factors for complications after reduction mammaplasty: A meta-analysis. PLoS One. 2016; 11 (12):e0167746