Breast Reduction—Inferior Pedicle Technique

Introduction

Breast reduction can be performed for either functional or cosmetic reasons. Optimal size, shape, and symmetry and minimal scarring, as four primary goals, should be applied to any type of breast reduction; for example, the breasts after reduction should be as the patient desired and in proportion to the patient’s body habitus. The shape after breast reduction should be cosmetically pleasing and hopefully long-lasting. Symmetry may be also important for most women after breast reduction.

Inverted-T inferior pedicle breast reduction was popularized in the 1970s in the United States. It is still the most commonly performed breast reduction procedure in the United States. The procedure itself can be suitable for almost all patients and in various breast sizes and shapes. Its design and surgical technique are reasonably consistent, and it can be performed in a standardized fashion. It is considered the most versatile but safe technique for breast reduction, with lower rates of complication or revision, ^, although prominent scarring or “bottoming-out” can be a concern over the long term.

This chapter describes the author’s preferred technique for inverted-T inferior pedicle breast reduction. Several technical refinements of the surgical technique are described in detail. In addition, pearls to achieve an optimal outcome and management of complications after inferior pedicle breast reduction are discussed.

Indications and Contraindications

It is a common thought that classic inferior pedicle breast reduction is indicated for almost all patients regardless of breast size and shape ( Fig. 19.1 ). For patients who are relatively older and have an elongated breast shape because of poor breast skin condition, the inverted-T inferior pedicle breast reduction can be selected for more predictable results ( Fig. 19.2 ). The overall amount of breast tissue reduction may not be critical, although the average weight of this type of breast reduction is usually less than 1000 g from each breast. However, the distance from the suprasternal notch to the nipple should be less than 15 cm so that adequate blood supply to the nipple can be ensured based on the inferiorly based pedicle. If the distance is more than 15 cm, a free nipple graft procedure should be considered based on common standard practice. In general, the inverted-T pattern will remove excess breast skin from both vertical and horizontal orientations. Younger women with good breast skin condition (no stretch marks) may have a better long-term outcome, although the inverted-T inferior pedicle breast reduction has been criticized as resulting in a bottoming-out breast shape and an unsightly scar.

Preoperative Evaluation and Special Considerations

Unlike the medial pedicle breast reduction technique, the classic inverted-T inferior pedicle breast reduction has fewer special considerations and intraoperative adjustments. Each step of the procedure can be performed in a standardized fashion based on the preoperative and intraoperative markings ( Fig. 19.3 ). However, several important points should be considered to achieve an optimal outcome after the inferior pedicle breast reduction. The new nipple position should be placed 1 cm lower than the level of the inframammary fold (IMF) to avoid a possible high-riding nipple. The inferior pedicle should be made sufficiently thick and may include the perforators from the central part of the breast to ensure robust blood supply to the nipple. The plication of the inferior pedicle can ensure upper pole fullness and easy in-set of the nipple–areola complex. The lateral horizontal incision should not be extended beyond the anterior axillary line for most cases.

The distance between the nipple and the IMF should be controlled to 5–6 cm for the classic inverted-T inferior pedicle breast reduction so future bottoming-out may be avoided. However, this also depends on patient breast skin quality.

In management of the inverted-T closure in the lower pole of the breast, it is important to ensure primary healing because of the tension in this area after the closure. The surgeon should pay attention to this important issue and develop a strategy to reduce tension on the closure ( Box 19.1 ).

Surgical Techniques