Reduction mammoplasty is one of the most frequently performed procedures in plastic surgery. The goals of reduction mammoplasty are to reduce the volume of a breast, to create an aesthetic shape that is stable over time, to maintain blood supply and innervation to the areolar complex, and to make fine limited scars. The different types of methods and modification were all concerning in achieving aesthetically acceptable scar and utmost long term shape and satisfaction with minimal complications.
There are different types of techniques have been used to achieve the above aims with the basis and the knowledge of the blood supply and innervation to the breasts (1-3); to avoid distortion and ischaemia of the nipple areolar complex (NAC) and alteration of nipple sensation apart from the good aesthetic outcome and maintaining ability for breastfeeding function (4,5). Among all the techniques using different pedicle such as superior, inferior, medial, lateral central/posterior, or combinations of pedicles were suitable for different types of patient according to degree of hypertrophy, ptosis and particular surgeon’s preference or expertise (6-10).
Central pedicle technique
Central pedicle or posterior pedicle reduction mammoplasty was first described by Balch in 1981 (11) and later popularized by Hester, 1985 (12). It was described by Hester (12) that the central pedicle is designed to incorporate vascular contributions from the lateral thoracic artery, intercostal perforators, internal mammary perforators, and thoracoacromial artery by means of the pectoralis major muscle. The basis of this procedure was found by Würinger, 1998 (2) in his study on the blood and nerve supply on female cadaver breasts. Würinger et al., 1998, have shown a thin horizontal fibrous septum, a guiding structure for the main supplying nerve of the nipple, originating from the pectoral fascia along the level of the fifth rib, heading toward the nipple which lies in between a cranial and a caudal vascular network, responsible for the supply of the nipple areola complex. The cranial vascular sheet is supplied by the thoracoacromial artery and a branch of the lateral thoracic artery, whereas the caudal sheet is supplied by perforating branches from anastomoses of intercostal arteries.
With the basis of the anatomical importance of blood and nerve supply to the NAC and breast parenchymal, central pedicle with/without combination was used by various authors in breast reduction with good cosmetic result and low complication rate.
Technique and modification
The original technique from Hester et al. (12): preoperative markings were made with the patient in the standing position. Wide undermining of thick (1.5 cm) skin and subcutaneous tissue flaps was carried out around the areolar. This plane of undermining is deep to the subdermal vascular plexus of the skin, thereby preserving skin flap viability. The central breast mound is reduced by tangential excision. Laterally, the dissection leaves 1 cm of adipose tissue on the chest wall to preserve the nerve supply from the fourth intercostal nerve. The breasts were shaped “free hand” with the patient in a sitting position. The excess skin and dog ears were trimmed and NAC was repositioned by sitting up the patient and new NAC are marked and sutured. Layered closure trimmed the inverted T skin design by using buried dermal and intracuticular sutures to complete the operation.
In 2001, Grant and colleagues, modified the technique by not elevating the medial and lateral skin flaps from the inframammary crease. Instead, begin the flap elevation approximately 3 cm below the predicted final flap length. The technique differs from operations that use the standard Wise pattern, in that more skin is left in the medial and lateral flaps than is needed for closure. The advantage of this technique is that shaping is still “free hand” and therefore allows the surgeon to individualize the result, fitting it to the particular patient’s body habitus. Because there is flexibility in the skin envelope, excellent projection is possible. Time is saved, because flap elevation is abbreviated (5).
In 2009, Datta et al. modified the technique by fixing the double pedicle cranially to the chest wall: three heavy nonabsorbable stitches are passed through the deep aspect of the gland, approximately 3 cm below the areola, and fixed to the pectoralis fascia at the level of the second or third rib. The central pedicle was plicated and fixed to the chest wall functions as an endoprosthesis and provides filling to the upper pole (13).
The technique was used by different authors such as Balch (1981), Moufarrege (1985), Levet (1990), Würinger (1998), White (1996), Grant (2001), Byung (2008) and Yang et al. (2012), and Bayramiçli M. (2012) which had shown satisfactory result in their series (2,11,14-19).
Central pedicle technique which acquires the maximally vascular supply mainly from the pectoralis major muscle is a very good pedicle to avoid all the inadequate remaining tissue perfusion. Due to this reason it obtained a good result with low complications. There are few recognized postoperative complications noted when utilize this technique mainly due to the degree of hypertrophy such as slight wound dehiscence, haematoma or seroma. There was no NAC necrosis reported. However, some degree of reduce nipple sensation which was temporary (Table 1).
In Byung series, the technique of periareolar skin incision and the noticed complications are areolar widening in 24 breasts (29%), persistent periareolar wrinkles in eight breasts (10%) and poor sensation to the NAC in 12 breasts (15%), in which more than 500 g of breast tissue was removed per breast in his series of 41 patients (20).
Datta et al. documented no NAC necrosis in his 91-patient series. However, there were fat necrosis, some degree of nipple sensory loss nipple sensation (three patients complained of some degree of nipple sensory loss when amount of parenchymal removal >1,200 gm in 4 patients). Apart from this wound dehiscence, haematoma and seroma complication in few patients within removal of parenchymal from 800-1,400 gm patients which was low in complication rate (15).
Yang series showed no hematoma and NAC necrosis. Minimal wound dehiscence occurred in one case and healed by dressing change. Satisfactory breast shape was achieved with good NAC sensibility in his 2-year followup (16).
Long term complication was unremarkable as the technique does not affect breastfeeding (20). As we know the projection and the contour of the breast is important in long term aesthetic outcomes, this technique gives the forward projection needed for good contour and good aesthetic result (3,11-14,16-19,21).
Central pedicle reduction mammaplasty technique is one of the good and reliable options to correct breast hypertrophy and ptosis. It may not suitable for massive reduction or severe ptosis breasts. However, the choice of technique should be individualized to patient and preference by the surgeon. None of the techniques is superior to others. Various modifications were introduced by different authors to improve the technique and reduce scar formation which will give more satisfaction to patients. With the current trend of using the principle of the technique in breast oncoplastic surgery for breast cancer treatment, this will gain better outcome for breast conserving surgery with good oncology resection without affecting the aesthetic outcome of the breast with radiotherapy.
I gratefully acknowledge the support and guidance from my supervisor, Dr. Visnu Lohsiriwat, Consultant Plastic, Head Neck and Breast in Siriraj Hospital, Mahidol University, Thailand for his helpful input and contribution in this article. I also would like to thank my Oncoplastic Breast Consultant Dr. Char-Hong, Ng and team in Breast Surgery Unit, Department of Surgery, University Malaya Medical Center, University of Malaya, Malaysia for his endless support.
Disclosure: The author declares no conflict of interest.
- Ricbourg B. Applied anatomy of the breast: blood supply and innervation. Ann Chir Plast Esthet 1992;37:603-20. [PubMed]
- Würinger E, Mader N, Posch E, et al. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 1998;101:1486-93. [PubMed]
- Würinger E. Refinement of the central pedicle breast reduction by application of the ligamentous suspension. Plast Reconstr Surg 1999;103:1400-10. [PubMed]
- Schlenz I, Rigel S, Schemper M, et al. Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques. Plast Reconstr Surg 2005;115:743-51; discussion 752-4. [PubMed]
- Cho BC, Yang JD, Baik BS. Periareolar reduction mammoplasty using an inferior dermal pedicle or a central pedicle. J Plast Reconstr Aesthet Surg 2008;61:275-81. [PubMed]
- Lista F, Ahmad J. Vertical scar reduction mammaplasty: a 15-year experience including a review of 250 consecutive cases. Plast Reconstr Surg 2006;117:2152-65; discussion 2166-9.. [PubMed]
- Courtiss EH, Goldwym RM. Reduction mammaplasty by the inferior pedicle technique. An alternative to free nipple and areola grafting for severe macromastia or extreme ptosis. Plast Reconstr Surg 1977;59:500-7. [PubMed]
- Georgiade NG, Serafin D, Morris R, et al. Reduction mammaplasty utilizing an inferior pedicle nipple-areolar flap. Ann Plast Surg 1979;3:211-8. [PubMed]
- Ribeiro L, Accorsi A Jr, Buss A, et al. Creation and evolution of 30 years of the inferior pedicle in reduction mammaplasties. Plast Reconstr Surg 2002;110:960-70. [PubMed]
- Nahabedian MY, McGibbon BM, Manson PN. Medial pedicle reduction mammaplasty for severe mammary hypertrophy. Plast Reconstr Surg 2000;105:896-904. [PubMed]
- Balch CR. The central mound technique for reduction mammaplasty. Plast Reconstr Surg 1981;67:305-11. [PubMed]
- Hester TR Jr, Bostwick J 3rd, Miller L, et al. Breast reduction utilizing the maximally vascularized central breast pedicle. Plast Reconstr Surg 1985;76:890-900. [PubMed]
- Datta G, Carlucci S. Selective breast reduction: a personal approach with a central-superior pedicle. Plast Reconst Surg 2009;123:433-42. [PubMed]
- Moufarrege R, Beauregard G, Bosse JP, et al. Reduction mammoplasty by the total dermoglandular pedicle. Aesthetic Plast Surg 1985;9:227-32. [PubMed]
- White DJ, Baack BR, Loutfy W, et al. Clinical applications of the central pedicle technique of breast reduction. Operat Tech Plast Reconstr Surg 1996;3:176-83.
- Yang YQ, Sun JM, Xiong LY, et al. Reduction mammaplasty with central gland pedicle based on Würinger’s horizontal septum. Zhonghua Zheng Xing Wai Ke Za Zhi 2012;28:245-7. [PubMed]
- Bayramiçli M. The central pillar technique: a new septum-based pedicle design for reduction mammaplasty. Aesthet Surg J 2012;32:578-90. [PubMed]
- Levet Y. The pure posterior pedicle procedure for breast reduction. Plast Reconstr Surg 1990;86:67-75. [PubMed]
- Grant JH 3rd, Rand RP. The maximally vascularized central pedicle breast reduction: evolution of a technique. Ann Plast Surg 2001;46:584-9. [PubMed]
- Sinno H, Botros E, Moufarrege R. The effects of oufarrege total posterior pedicle reduction mammaplasty on breastfeeding: a review of 931 cases. Aesthet Surg J 2013;33:1002-7. [PubMed]
- Savaci N. Reduction mammoplasty by the central pedicle, avoiding a vertical scar. Aesthetic Plast Surg 1996;20:171-5. [PubMed]