Breast Reduction—Medial Pedicle Technique

Introduction

Breast reduction can be performed for either functional or cosmetic reasons. Optimal size, shape, symmetry, and scarring, as four primary goals, should be applied to each type of breast reduction; for example, breast size after breast 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 long-lasting. Although the exact symmetry may be hard to achieve, most women desire a more symmetric result after breast reduction. It is also quite desirable to have minimal scarring after any type of breast reduction.

Medial pedicle breast reduction was promoted by Lejour from Belgium, but the procedure has been popularized by Hall-Findlay. ^, However, the medial pedicle breast reduction has been criticized by many plastic surgeons, especially in North America, for its inconsistent cosmetic outcome and higher revision rate. In addition, the learning curve for medial pedicle vertical breast reduction appears to be longer because many intraoperative adjustments should be done by the surgeon to produce a cosmetically acceptable final result.

In this chapter, the author describes his preferred technique for medial pedicle breast reduction, emphasizing patient selection and several technical refinements of the surgical technique.

Indications and Contraindications

It is the author’s opinion that medial pedicle breast reduction is not indicated for all patients. ^, In general, younger women with good breast skin condition (no stretch marks) and reasonably well-maintained round shape of the breast are good candidates for this type of breast reduction. ( Fig. 18.1 ). The overall amount of breast tissue reduction may not be a critical issue, although the average weight of this type of breast reduction is usually between 300 and 500 g for each breast. However, the distance from nipple to inframammary fold (IMF) should be less than 10 cm. For patients who are relatively older and have poor breast skin condition and elongated breast shape, the classic inverted- T inferior pedicle breast reduction, not the medial pedicle breast reduction, should be performed for more predictable results ( Fig. 18.2 ). Box 18.1 summarizes the indications for the medial pedicle breast reduction in the author’s practice.

Preoperative Evaluation and Special Considerations

Unlike the classic inverted- T inferior pedicle technique, the medial pedicle breast reduction does require some special considerations and more intraoperative adjustments. For example, the new nipple position should be placed “lower” during the preoperative marking because the vertical technique in general has a tendency to place the nipple too high and to create more upper pole fullness after such a breast reduction. Therefore, the surgeon should pay particular attention to avoiding a high-riding nipple and inform the patient about the temporary appearance of the breast postoperatively.

The new IMF should be placed higher than the actual IMF, so the distance between the nipple and the IMF can be shortened. This distance can be shortened further by a running subcuticular closure. However, the distance between the nipple and the new IMF will never be 5–6 centimeters as after the classic inverted-T inferior pedicle breast reduction. Frequently it will be about 7–8 centimeters, so an optimal breast shape after reduction can be maintained.

The management of the excess tissue in the lower pole of the breast can be critical to the success of the medial pedicle breast reduction. The surgeon should pay attention to this important issue and develop a strategy or technique to properly remove the extra tissue in this part of the breast ( Box 18.2 ).

Surgical Techniques