Reduction mammaplasty with inverted-T techniques

Introduction

Reduction mammaplasty remains one of the most sought-fafter operations among women with mammary hypertrophy. Since its inception over 100 years ago, techniques for reduction mammaplasty have expanded and there are now dozens that have been described. Techniques can vary, based on the orientation of the pedicle for transposition of the nipple–areolar complex, as well as for cutaneous incisional patterns. Skin patterns have varied from short scar to long scar techniques and nipple transposition techniques have ranged from free graft to dermal pedicles to dermoparenchymal pedicles with orientations that can be anywhere along a 360-degree circle. The important principle with reduction mammaplasty is to recognize that patients will vary based on symptoms and anatomy and that it is important to individualize all patients and to provide the best options and techniques to optimize outcomes.

When considering patients for reduction mammaplasty it is important to differentiate between “cosmetic” and “functional” reduction mammaplasty. Although all reduction mammaplasty procedures are aesthetic in nature, the principles governing the two are important to differentiate for a variety of reasons that include patient expectations, surgical technique, and desired outcome. Cosmetic patients are typically interested in minimizing scars and improving appearance, whereas the functional patient is less concerned about scar location and more interested in reducing symptoms such as neck, pain, back pain and postural changes. For the past several decades, debates have focused on short scar versus inverted-T skin incision patterns and whether or not one should be preferred over the other. It is this author’s opinion, that both are useful and indicated for certain patient and breast types. This chapter will focus on inverted-T techniques for reduction mammaplasty ( Video Lecture 9.1 ).

Breast anatomy

Reduction mammaplasty requires a specific understanding of breast anatomy with an emphasis on the parenchymal architecture, vascularity and innervation. Although breast anatomy is covered in a previous chapter, the salient aspects will be reviewed. The vascularity to the breast is diverse and includes the perforating branches of the internal mammary and the lateral thoracic artery and vein. Other sources include the intercostal and thoracoacromial vessels. All pedicles are designed as a means of repositioning the NAC and to capture one or several sources of blood supply to minimize the risk of partial or total necrosis.

The vascularity to the NAC is derived from several sources and primarily from the subdermal plexus of vessels that are supplied by the internal mammary and lateral thoracic perforators ( Fig. 9.1 ). The anterior intercostal arteries and veins are also significant contributors with the 4th anterior intercostal being the most important ( Fig. 9.2 ). Within the breast, along the 4th intercostal space, is a horizontal structure known as Würinger’s septum. This contains the 4th intercostal artery and vein that can maintain vascularity to the nipple–areolar complex. This becomes especially important in the event that the peripheral subdermal plexus is violated resulting in reduced blood supply to the NAC.

The innervation to the breast and the NAC is through the 2–6 intercostal nerves. Preservation of sensation to the NAC is best achieved by understanding the neural pathways within the breast that lead to the nipple–areolar complex. In a cadaveric study, Schlenz demonstrated that the 3–5 lateral and anterior intercostal nerves innervated the NAC. The course of the anterior nerve was more superficial in the majority of cases whereas the lateral intercostal traversed more deeply within the pectoral fascia in the majority of cadavers. The implication is that sensation is more likely preserved by minimizing the amount of medial dissection and by preserving the deep central mound along the 4th intercostal segment.

Historical Perspective

Inverted-T techniques for reduction mammaplasty were first described by Robert Wise in 1956. Prior to this, many short scar techniques were commonly used that included the inframammary incision only by Guinard in 1903, Morestin in 1905, and Passot in 1921. The vertical incision with a short horizontal component was first described by Lexer in 1923. This was converted into a vertical-only incision as described by Lotsch in 1923 and Dartigues in 1925.

One of the principal reasons for the inverted-T pattern was to overcome some of the shortcomings in the shaping of the breast that was encountered with some short scar methods. The inverted-T incision allowed for 3D control of the breast and improved the predictability and reproducibility of the final outcome. The original inverted-T operation has undergone numerous modifications over the years, but the basic pattern has been retained and has been adopted by many plastic surgeons around the world because of its reliability and ability to deliver predictable and reproducible outcomes.

Since the original description of the inverted-T incision pattern, various pedicles for transposition of the NAC have been described and include the medial, superomedial, central mound, inferior, lateral, superior as well as the vertical and horizontal bipedicle techniques. Each of these techniques is capable of delivering a good to excellent outcome and these are reasons to consider one over the other. Advocates for medial pedicle techniques cite improved vascularity, innervation and less bottoming out of the breast over time. Inferior pedicle techniques provide improved versatility because the pedicle is not rotated; however, limitations include a tendency to bottom out over time. The central mound provides excellent vascularity and mobility as well as facilitating glandular resection along the lower and lateral aspects of the breast.

The benefits of reduction mammaplasty are now well accepted and understood. In a recent study of 206 women of whom 103 had mammary hypertrophy (operative cohort) and 103 had normal size breast (non-operative cohort), it was demonstrated that mammary hypertrophy cohort had a significant improvement in body dysmorphic disorder examination, body investment scale, and breast evaluation questionnaire scores 6 months postoperatively ( P ≤ 0.001) when compared with the normal size breast cohort that had no change in the three variables over the same time frame ( P = 0.876; P = 0.442; and P = 0.184). Mundy et al . have also demonstrated that Breast-Q scores will improve following reduction mammaplasty compared with normative controls that did not have reduction mammaplasty. Related to this, Oliveira de Sa et al . demonstrated that following reduction mammaplasty, there was a statistically significant improvement in postural patterns related to the horizontal alignment of the anterosuperior iliac spines and the angle of the acromion and anterior superior iliac spines at 3-months’ follow-up. Long-term evaluation is necessary. In another study of 348 consecutive patients having reduction mammaplasty using an inverted-T technique, quality of life issues were examined using the Breast-Q, Short-Form 36, Breast-Related Symptoms Questionnaire, and Modified Breast Evaluation Questionnaire, demonstrating significant improvement in satisfaction with breasts, psychosocial well-being, sexual well-being, and physical well-being ( P < 0.0001).

The inverted-T skin pattern

The inverted-T pattern has undergone several modifications over the years. The original pattern described by Robert Wise was based on the manufacturing process for a woman’s brassiere, taking into account the conical shape of the breast. A skin pattern was delineated that had relationships to the chest circumference, angulation of the chest wall, and the breast size. The classic inverted-T pattern had vertical and horizontal limbs with a keyhole pattern at the upper apex for insetting of the NAC.

The primary reasons for using the inverted-T technique are numerous. The resections are accurate because the incisions permit wide exposure of the parenchyma with precise resection of glandular tissue. The technique has proven useful for breast of all sizes; however, it is especially useful for breasts that will require a resection of 300 g. The naturally ptotic breast almost always conceals the horizontal scar and the complication profile with the inverted-T technique is similar to short scar techniques. Finally, the breast appearance upon completion of the operation is usually excellent and is not as dependent upon breast remodeling and scar contracture compared with the short scar techniques.

Patient Selection

Patient selection begins with a thorough history and physical examination. Common complaints include back pain, neck pain, postural changes, bra strap indentations, and/or intertrigo. Comorbidities such as diabetes mellitus, hypertension, and cardiac disease are noted. Other important considerations include restricted activities of daily living and whether dieting and prior weight loss has been effective in reducing breast volume. Women over the age of 35 are encouraged to obtain a mammogram. On examination, an assessment of volume and symmetry is made. Important measurements include the sternal notch-to-nipple, inframammary fold, base width, and nipple-to-sternum distances.

A thorough discussion of the risks and benefits are reviewed. Patients are told that their symptoms may improve but not guaranteed. Risks include but are not limited to bleeding, infection, scar, fat necrosis, inability to adequately nurse following childbirth, altered sensation of the NAC, delayed healing, skin necrosis, incisional dehiscence, poor cosmetic result, partial or total nipple–areolar necrosis, and further surgery. Incisional patterns and pedicle techniques are reviewed with each patient. In general, the authors’ preference is to select the inverted-T for resections that are estimated to be greater than 300 g. Short scar techniques are usually performed for reduction weight that is estimated to be less than 300 g. Pedicle techniques are usually based on the distance that the NAC will be elevated from the natural position of the NAC on the breast.

The following algorithm is the authors preferred approach for pedicle selection and is based on nipple elevation in centimeters ( Box 9.1 ). The central mound or superomedial pedicle is considered when nipple elevation is <6 cm, a medial pedicle is considered when nipple elevation is >6 cm, and the inferior pedicle is selected when the length of the proposed inferior pedicle is less than the medial pedicle. Free nipple graft is considered when the pedicle length exceeds the perfusion capacity to the NAC. This is usually the case for severe mammary hypertrophy with resection volumes that exceed 2000 g/breast.

Box 9.1

Skin pattern and pedicle selection

• <6 cm of nipple elevation – central mound or superomedial pedicle

• >6 cm of nipple elevation – medial or inferior pedicle

• <300 g resection – short scar technique

• >300 g resection – inverted-T technique

Markings

The typical markings for the inverted-T incision are as follows ( Fig. 9.3 ): the sternal midline is delineated; the breast meridian is delineated bilaterally, bisecting the midline of the breast. Any preexisting asymmetry of the NAC will be corrected during the operation in order to center the nipple along the breast meridian and to ensure that the distance from the sternal midline to the nipple will be equal on both sides. The inframammary fold is delineated bilaterally. The ideal nipple position is marked and based on the level of the inframammary fold. This may be done with calipers or free hand. The vertical limbs of the inverted-T pattern are delineated with a length that ranges from 8 cm to 9 cm. This will vary based on the volume of the breast. The angle of the apex is usually 60 degrees by can be narrowed or widened based on the base width of the breast. For breasts with a wide base width the angle can be increased to 70 degrees that will facilitate narrowing of the breast. For breasts with a normal to narrow base width, the angle is reduced to 50 degrees. Although the keyhole pattern is described with the original description, the authors preference is not to delineate and commit to the keyhole at the time of the original markings but rather to perform it as the final step of the reduction mammaplasty. The reason is to accurately place the NAC on the breast mound such that the upper pole to lower pole ratio approximates 50%. The horizontal component of the inverted-T pattern is then marked and extends from the inferior point of both vertical limbs to the lateral and medial limits of the inframammary fold. The horizontal incision should never cross the sternal midline and should be tailored laterally to eliminate any dog-ear and to follow the desired lateral mammary fold to optimize contouring and appearance.

Treatment/surgical technique

The Bipedicle Techniques

There are two bipedicle techniques for reduction mammaplasty that incorporate the inverted-T incision pattern. These include the horizontal bipedicle, also known as the Strömbeck, and the vertical bipedicle, also known as the McKissock, named after the surgeons that described them. The horizontal bipedicle technique was initially described in 1960 with the intent of improving the vascularity to the NAC. A schematic illustration of this technique is illustrated in Fig. 9.4 . Prior to the description, upper pole resections of the breast were common that tended to disrupt the vascularity of the nipple–areolar complex. The benefit of the bipedicle technique was that it included perforators from the medial and lateral segments of the breast, thus preserving the vascularity. In a review of 100 patients following the Strömbeck repair, late complications included wide scars in 51%, loss of nipple sensation in 27%, and nipple inversion in 18%. Patient satisfaction was achieved in 96%.

Paul McKissock initially described the vertical bipedicle technique for reduction mammaplasty in 1972 ( Fig. 9.5 ). The impetus for this technique was that many of the previous techniques were plagued by skin or nipple–areolar necrosis, loss of sensation, and irregular contour. The vertically oriented bipedicle flap was thought to minimize some of these shortcomings. Simplification of this vertical bipedicle ultimately led to the development of the inferior pedicle technique that was later described by Robbins in 1977. For a while thereafter there was controversy as to whether vertical bipedicle was superior, equivalent, or inferior to the inferior pedicle technique. Two groups of patients were later studied to discern any differences. Ramón’s study evaluating 27 patients following the McKissock repair and 24 patients following the inferior pedicle repair demonstrated good to excellent aesthetic outcomes in both. The subjective evaluations of the patients and the surgeons were also found to correlate without any significant differences.

Thus, with our improved understanding of the vascularity and innervation of the breast, these bipedicle techniques have been replaced by the unipedicle techniques in the majority of cases and will be described throughout the remainder of the chapter.

Inferior Pedicle Technique

The inferior pedicle technique for nipple–areolar transposition with the inverted-T skin pattern was one of the first techniques described in the modern era of reduction mammoplasty. The vascularity to the NAC is derived from the subdermal plexus from the intercostal and internal mammary perforators that are included with inferior pedicle ( Fig. 9.6 ). An important consideration with the inferior pedicle technique is the length to width ratio of the pedicle. This may range from as low as 1.5:1 and as high as 4:1. Although no optimal ratio has been established, it is generally agreed that ratios exceeding 2:1 may be associated with increased morbidity. It is always important to assess the arterial and venous bleeding from the distal edge of the flap. When absent, conversion to a free nipple graft is considered. Fluorescent angiography can assist with this decision. Figs. 9.7 & 9.8 illustrate the technique in a schematic format.

Markings

The patient is marked in the upright position. Important breast measurements include the sternal notch-to-nipple distance, nipple to inframammary (IMF) distance, and the base diameter of the breast. The sternal midline, breast meridian and the inframammary fold are marked bilaterally. The new position of the NAC is marked and correlates to the level of the inframammary fold along the breast meridian. The distance from the sternal notch to the desired NAC will vary but typically ranges from 22 cm to 27 cm. An inverted-T pattern is delineated and based on the location of the desired NAC. The inferior pedicle is delineated in the operating room with the patient in the supine position. The base of the inferior pedicle typically ranges from 6 cm to 10 cm and is dependent upon the base diameter of the breast. The inferior pedicle is usually centered along the inferior breast meridian and always includes a cuff of tissue measuring 1 cm around the areola to preserve the vascular plexus supplying the nipple–areolar plexus.

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