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The relatively high number of complications and disadvantages of the conventional techniques in breast reduction combined with our expertise in restoring sensation in breast reconstructive procedures, led to the development of a new technique that was crystallised from the traditional techniques and is able to overcome most of their disadvantages.
The key issue of the technique is that the nipple is vascularised and innervated on a column of glandular tissue that remains in contact in its posterior part with the pectoralis muscle and its perforators and in its lateral aspect to the lateral pillar of breast tissue. Due to the ptosis that develops during the process of hypertrophy, this column will gain sufficient length to be turned upwards into the new position of the nipple. Resection of glandular tissue is performed cranially, medial and inferior to this column. Undermining of the skin is reduced to an absolute minimum and glandular resections are always performed in the shape of a wedge. In this way, undermining of the breast gland over the pectoralis muscle is avoided. The glandular pedicles are sutured together after loosely fitting the glandular cone with the nipple into its new position.
The long term results of the first 68 cases were reviewed and compared to our experience with the superior dermal pedicle technique combined with the vertical scar as described by Lassus and later by Lejour. Due to increased vascularisation of the nipple–areolar complex (NAC), wound complications were markedly reduced with the new technique. Sensation in the NAC was preserved in almost all cases. There was a high satisfaction about the obtained aesthetical results in regard to shape and volume.
Increased viability of the NAC, a reduced rate of wound complications and preservation of sensation in NAC are the main advantages of this technique. Additionally, flattening of the NAC is avoided by the support by glandular tissue behind the NAC that improves projection and hereby the aesthetic conic appearance of both breast and nipple.
The availability of numerous different techniques for breast reduction and the abundance of reports of modifications over the last decennia, are clear indications that none of these techniques have proven to be ideal. Nevertheless, there has been a continuous evolution and major improvements have been made over the years. A popular technique over the last decennium has been the vertical scar technique developed by Lassus
Generally, new inventions or techniques are the result of an improvement of an existing technique. Dissatisfaction with the established techniques is the most important motivator to develop a new technique. After experiencing bilateral nipple necrosis with the superior dermal pedicle technique, we felt the need to change the technique that we were using in an attempt to improve the vascularisation and the innervation of the nipple–areola complex (NAC).
The risk of inadequate blood supply to the NAC is just one of the disadvantages and problems that have been reported about the superior dermal pedicle technique with vertical scar. Other problems include a difficult inset of the superior pedicle, an increased incidence of wound healing problems, loss of nipple sensation and projection, flattening and late bottoming-out of the breast and an increased reoperation rate.
helped significantly to get new insights as how to modify the existing techniques in order to obtain better results. Additionally, we had the advantage to apply our skills, know how and experiences in autologous breast reconstruction into the field of breast reduction.
reported her modification of the vertical scar technique and the use of a medial or lateral dermoglandular pedicle. A similar technique was also described by Cardenas-Camarena.
The lateral dermoglandular pedicle that they described had a thickness of 2–3 cm and resection of glandular tissue was performed dorsal, cranial, caudal and medial to this pedicle.
In the technique we describe, the NAC is vascularised by a glandular pedicle. A column of breast gland tissue between the nipple areola and the pectoralis muscle is kept intact and remains connected with the pectoralis perforators and with the lateral breast pillar by a lateral glandular pedicle.
The aim of this article is to report this new technique in breast reduction and to compare the short-term complications and the long-term aesthetic results to our own experience with the superior dermal pedicle technique. Advantages and disadvantages of the technique will be discussed.
1. Materials and methods
1.1 Pre-operative markings
The pre-operative drawing is almost identical to the one described for the vertical scar technique
(Fig. 1(A)) . On top of this drawing two additional markings are made:
Fig. 1(A) Pre-operative markings similar to the superior dermal pedicle with vertical scar technique; (B) marking of the level of the main vascular and nervous structures to the NAC (red line) and positioning of the laterocentral glandular pedicle (shaded area); (C) marking of the level of the horizontal resection.
1. Location of the lateral glandular pedicle: a line is drawn from the origin of the anterior ramus of the lateral branch of the fourth intercostal nerve at the midaxillary line to the nipple following the convexity of the lateral part of the breast (Fig. 1(B)). This indicates the level where the main sensory nerves to the NAC can be expected in addition to the larger side branches of the lateral thoracic artery to the breast gland and the NAC. Once the new circumference of the areola is marked (diameter between 38 and 45 mm) two lines are drawn from the outer borders of the new areola parallel to line A. These two lines form the width of the glandular pedicle can vary between 4 and 5 cm (Fig. 1(B)). One has to take into account when drawing these lines that sufficient length is available to be able to rotate the glandular pedicle into the new nipple-areolar position.
2. Determination of the horizontal resection: the amount of tissue resection in the lower poles can vary significantly and therefore the distance between the inframammary fold and nipple should be measured. If this is more than 8 cm, a resection in the inferior pole should be performed. To determine the amount of resection, a horizontal line is drawn parallel to the inframammary crease at 6–8 cm below the new lower border of the NAC (Fig. 1(C)). This horizontal line gradually joins the inframammary crease in its lateral and medial portions. Finally a dotted line indicates the amount of undermining in the lower portions of the breast.
1.2 Surgical technique
The operation started with the de-epithelialisation of the area on top of the glandular pedicle between the new NAC and the lateral vertical incision. Furthermore, a full thickness incision is performed at the border of the new areolar position and the medial and lateral incision lines that converge at the inframammary crease. In preparation of the inferior horizontal resection, a subcutaneous undermining is performed between the dotted lines and the inframammary crease (Fig. 2(a)) . In very large breasts (>600 cm3 resection), pre-pectoral undermining of the breast gland is performed in the lower 2–3 cm. This is to allow easy removal of the lower excess of breast tissue.
Fig. 2Schematic representation of the technique (see text for more details): (a) incisions and skin undermining; (b) creation of the glandular column; (c) the horizontal resection; (d) the vertical resection; (e) and (f) cranial repositioning of the glandular column with the NAC; (g) suturing of the medial and lateral pillar; (h) skin closure.
In the next step a latero-central glandular pedicle is created. In order to preserve the lateral vascularisation and innervation of the NAC, a column of glandular tissue between the NAC and the pectoralis muscle will be created in continuity with the lateral pillar of the breast (Fig. 2(b)). It is important that the base of this column is situated on top of the pectoralis muscle to include the pectoralis muscle perforators and is obviously not detached from the muscle in the process of gland resection. To avoid this, the breast gland, shifted laterally as the patient lay down, should be relocated and held by the surgical assistant in a more medial and cranial position. To achieve a sufficiently wide base for the glandular pedicle, the breast is pushed so far medially that the NAC is at the level of—or somewhat more medial to—the midclavicular line and at the level of the fourth rib. Along the lines of the lateral glandular pedicle, drawn pre-operatively, and around the medial edge of the NAC, a straight incision is made down to the pectoralis muscle. Just before reaching the pectoralis muscle, the incision can be bevelled outwards to increase the number of perforators included into the pedicle.
The horizontal resection in the lower poles of the breast should be performed after the creation of the columnar lateral glandular pedicle in order to avoid deformation of the glandular pedicle during incision. The horizontal resection is performed by making a straight cut down to the pectoralis fascia along the horizontal line drawn pre-operatively (Fig. 2(c)).
Next, the lateral and medial pillars will be created. As in the superior dermal pedicle technique the breast gland is incised following the midclavicular line after pulling the breast gland over that line, respectively, medially and laterally. The lateral incision down to the pectoralis muscle will be in continuity with the inferior incision of the glandular pedicle. The medial incision down to the pectoralis continues into the area cranial to the lateral glandular pedicle (Fig. 2(d)). The area between the superior border of the lateral glandular pedicle and the new NAC will be removed following the lines of the pre-operative drawings. All glandular tissue between the skin and the pectoralis muscle will be resected in a conical fashion to create a cylindrical cavity that will accommodate the columnar shape of the lateral glandular pedicle.
Before suturing the medial and lateral pedicle together, the lateral glandular pedicle with the areolar complex is repositioned (Fig. 2(e) and (f)). The entire column pivots on the perforators of the pectoralis muscle and the NAC rotates cranially to fit in its new position. The glandular pedicle is only kept in place by subdermal suturing to avoid kinking or compression of the pedicle. Both pillars are sutured together with separate deep and superficial resorbable stitches to provide a nice conical shape of the breast (Fig. 2(g)). One should avoid closing the pillars too tight to avoid compression of the glandular pedicle. Because no undermining of the breast gland took place, fixation of the breast gland to the pectoralis muscle is not necessary. In some cases where the breast gland shifts too much laterally, a medial anchoring stitch can be placed at the level of the inframammary crease.
After checking and performing eventual minor corrections in order to achieve maximal symmetry, the skin is sutured (Fig. 2(h)). Following the preference of each surgeon the incision can be limited to a vertical incision only or converted into an inverted T. Skin closure is mostly performed by subdermal resorbable suturing in addition to Dermabond (Ethicon), a skin adhesive. Aseptic dressings and a supportive bra are put on.
1.3 Patient population
In order to evaluate our short term and long-term result, we retrospectively reviewed the charts of 68 patients undergoing a primary bilateral breast reduction between April 1999 and December 2001 and compared them to the data of 48 other patients who had undergone a superior dermal pedicle reduction mammoplasty in the same period. The demographic data are shown in Table 1. The higher number of smokers in the vertical scar group was not statistically significant. Mean age and body mass index (BMI) were comparable. The charts of both groups were reviewed for early and late post-operative complications.
The Mann–Whitney U-test was used for the analysis of age, height, weight, BMI, operating time, resected weight and hospital stay. The Pearson Chi-Square and Fisher's exact test were used to analyse the incidence of haematomas, seromas, infections, smokers, NAC necrosis, delayed wound healing and wound dehiscence.
2. Results
Table 2 shows the peroperative data. Operating time, resected weight and hospital stay were comparable for both groups. No other statistically significant differences were found. Table 3 shows the incidence of early post-operative complications per breast. The incidence of early post-operative complications was lower for the lateral glandular technique for any type of complication. The decrease in the early post-operative complications was nevertheless only significant for delayed wound healing and partial NAC necrosis.
The incidence of late post-operative complications and reoperation rate was also lower in the lateral glandular group. Nine patients (13%) showed a late post-operative complication (one fat necrosis, two widening of the scar and six medial or lateral dog ears). Six patients (9%) were reoperated, four for a dog-ear correction and two for a scar revision. In the vertical scar group 23 patients (48%) showed late post-operative complications ranging from scar widening (n=4), adherence of the scar in the inframammary fold (n=2), fat necrosis (n=1), scarring of the NAC due to partial nipple necrosis (n=4), a low vertical scar or dog ear at the inframammary fold (n=7), discoloration of the scar (n=1), volume asymmetry (n=1) and finally a need for a secondary reduction (n=2). Twenty of these patients (42%) underwent a reoperation for correction of one of these complications.
3. Discussion
The introduction and the popularisation of the vertical scar technique by Lassus and later by Lejour
brought important refinements to the existing techniques in the 1970s and the 1980s. Major progresses were mainly the principal of internal shaping of the breast gland and reduction of the scar length into a single vertical scar. Even after using this technique in our department for several years we never felt completely comfortable with the unpredictable and inadequate blood supply to the NAC, the frequent post-operative wound healing problems and the loss of nipple sensation and projection. The often-disappointing late results with flattening of the NAC and late bottoming-out of the breast created a certain amount of dissatisfaction with both patients and surgeons. In an attempt to overcome these problems, we used our experience in autologous breast reconstruction and the recent literature on breast anatomy to find a way to overcome these complications and develop a new and better technique.
The technique itself is a further evolution of the technique of Skoog in 1963
By leaving the glandular breast tissue intact lateral and posterior to the NAC over its full thickness from the nipple to the pectoralis fascia, chances are much higher that the innervation from the fourth intercostal nerve and the vascularisation from the branches of the lateral thoracic vessels, are left intact. As described in the anatomical studies,
the anterior ramus of the lateral branches of the fourth intercostal nerve can run very superficial in the breast to reach the NAC. On the other hand, it can also have a very deep course, running on top of the serratus and pectoralis muscle fascia to penetrate the breast gland from the lower surface and run obliquely through the breast gland to the NAC (Fig. 3(a)) . As there is no way to predict the course of the nerve through the gland, one has to include the breast gland tissue around these nerves and vascular structures to achieve the highest success rate in preserving nipple sensation and vascularisation. Even though 2–3 cm glandular tissue is included in the pedicle that Hall-Findley had described, there is still a possibility to interrupt the innervation and vascularisation in the case of a very deep course of the nerve (Fig. 3(b)).
Fig. 3Schematic drawings illustrating the course of nerves and vessels in the breast (a) and comparing the technique of Hall-Findlay (b) and the latero-central glandular technique (c).
The lateral glandular technique improves the vascularisation of the NAC by preserving the pectoralis perforators to the posterior part of the breast gland. By tilting and partially rotating the central glandular column carrying the NAC, with the pectoralis perforators as a pivot point, a triple vascularisation is guaranteed: first by a short dermal (lateral) pedicle containing the dermal plexus, by a thick and wide glandular pedicle including the branches of the lateral thoracic vessels and finally by the deep vascularisation from the pectoralis perforators (Fig. 3(c)). Additionally, we were able to prove in a concurrent study by our group that sensation returns to a normal level in almost all cases 3 months post-operatively.
Hamdi M, Blondeel PN, Van de Sijpe KA, Van Landuyt KH, Monstrey SJ. Evaluation of nipple–areola complex sensitivity after laterocentral glandular pedicle technique in breast reduction. Br J Plast Surg 2003;56(4):360–4.
The improved vascularisation of the NAC was mainly responsible for a significant decrease in early and late post-operative complications. The most important decrease was seen in the reduced number of post-operative infections and delayed wound healing. No or very limited undermining of the skin and the breast gland explains this observation.
We were very critical in our definition of partial necrosis of the NAC. All cases demonstrating cyanosis and the slightest epidermolysis at more than 2 mm from the wound edge were classified as a partial NAC necrosis. Cyanosis and epidermolysis are clear signs of impaired blood supply to the NAC. They can give rise to minor problems as discoloration or delayed wound healing or more severe complications as partial full thickness necrosis eventually combined with partial necrosis of the glandular tissue and/or fat necrosis. This critical approach was applied to both groups. Only one patient was observed with a partial necrosis of the NAC in the lateral glandular group. As this was one of the first patients that we treated with this technique and this problem did not repeat itself later on, we believe that a technical error is the basis of this complication. In both groups, one patient had to be converted from its original technique into a free nipple technique. Both patients had a large resection weight, 1500 and 1800 g, respectively, and immediate peroperative cyanosis was apparent.
The longest follow-up of patients in the lateral glandular group is 3 years to date. We have observed an excellent stability of the shape and aesthetic result of the reduction (Fig. 4, Fig. 5) . Additionally, we have observed an improved conical shape of the breast and improved projection of the nipple. This is explained by two important inherent parts of the technique. First, in contrast to the superior dermal pedicle technique, none of the glandular tissue is detached from the pectoralis fascia. With the laterocentral glandular technique, the base of the breast over the pectoralis muscle is left untouched. In that way, we are relying on the original strength of the connective tissue skeleton of the superficial fascia surrounding the breast gland and the collagen fibres within the breast gland (Cooper's ligaments). Although one cannot prevent further post-operative stretching of the collagen fibres by aging, continuous gravity will eventually stretch the pre-pectoral scar tissue, developed after undermining of the gland with the superior dermal pedicle technique, to a larger extend than the original connective tissue skeleton maintained by the laterocentral glandular technique. We also do not believe there is a need to modify the dimensions of the base of the breast as they hardly change in the course of the development of breast hypertrophy.
Fig. 4Three years post-op result in a 20-year-old patient.
The resection of glandular tissue cranial to the NAC and the repositioning/tilting of the glandular pedicle in a more cranial position are responsible for the improved nipple projection. During the process of the development of breast hypertrophy, the nipple shifts downwards and the amount of tissue between the pectoralis fascia and the NAC increases (Fig. 6(a)) . Also the vessels and nerves increase in length. By surgically creating a columnar glandular pedicle that uses its attachment to the pectoralis fascia as a pivot point, a higher volume of glandular tissue is repositioned in the new central area of the breast. As its glandular pedicle is actually too long, the pressure behind the NAC increases and will push the NAC forward (Fig. 6(b)). Repositioning of glandular tissue in the central part of the breast and closure of both breast pillars below it will create a conic shape of the breast. We regard it as extremely important to reconstruct the normal conic shape of the breast and the nipple. The NAC often has a conical shape, which is a continuation of the contour lines of the breast gland. With the superior dermal pedicle technique and also other techniques, flattening of the nipple is often observed because glandular resection takes place behind the new position of the NAC.
Fig. 6Illustrative drawing demonstrating the use of the increase in the length of the vascular-nervous pedicle to facilitate the rotational movement of the NAC and to increase the projection of the nipple.
At this moment we do not have any data on the possibility of later lactation. It seems logical, however, that as the ductuli are left in continuation with the lateral part of the gland that lactation should be somehow possible. Further long-term results and a larger patient group are necessary to confirm this assumption.
Over the last 3 years the technique has been shown to be easy to perform and to be easily taught to junior residents. The only delicate point in the dissection is the perpendicular incision of the glandular tissue during the creation of the lateral glandular pedicle. Care has to be taken to avoid accidental damage to the pectoralis muscle or perforation of the intercostal space and/or pleura. After performing the resection of the glandular tissue and before suturing, elective additional resection can take place in all four quadrants of the breast to obtain perfect symmetry on both sides. The central excision exposes the entire gland and by removing slices of breast gland tissue, the shape of the breast can easily be adapted to achieve the desired shape and volume. A 12-gauge drain is positioned between both pillars and within the cavity of the glandular pedicle. This is to avoid any possible haematoma and pressure on the pedicle itself. Except for a few smaller reductions, we have always used an additional horizontal scar to close the skin. We believe that by using the short inverted-T scar, many wound healing problems can be avoided and better long-term results can be obtained. We have noted that the absence of a wrinkled vertical scar decreases the anxiety, worries and even disappointment of patients, even if it was explained to the patient pre-operatively that the aspect of the scar would improve in the first 6 months. Additionally, by reducing the skin in one direction only (horizontally) an excess of skin is left in a vertical direction. This is kept together in the beginning by the retraction of the vertical scar. After a few years, the pull of gravity puts more pressure on the vertical scar that finally will elongate. This finally results in flattening of the NAC and bottoming-out of the gland and an upward rotation of the NAC. The horizontal scar with the lateral glandular technique is often short and does not show in the medial or lateral portions of the breast. Patients do not complain about this part of the scar as it is often well hidden in the inframammary crease. As we tried to limit the length of the horizontal scar a dog-ear was observed in six patients in the medial or lateral aspect of the horizontal scar. Four patients requested a surgical correction of this problem.
Despite the learning curve in the first 3 years of our experience, we have not seen an increase in operating time. A smaller area of de-epithelialisation, the absence of skin and gland undermining, the easy resection, the open exposure of the gland and the facility to perform additional volume and shape changes, are probably responsible for a comparable operating time.
In conclusion, the lateral glandular technique is a further refinement of pre-existing techniques that has shown to simplify breast reduction surgery and make the procedure clearly safer. Better long-term results can be achieved as sensation is preserved in NAC and there is an improved shape of the breast and nipple. Despite the success that we have encountered with this technique, we do not think the technique is indicated for gigantomastia. For this disorder the free nipple technique probably still remains the preferred surgical procedure.
Hamdi M, Blondeel PN, Van de Sijpe KA, Van Landuyt KH, Monstrey SJ. Evaluation of nipple–areola complex sensitivity after laterocentral glandular pedicle technique in breast reduction. Br J Plast Surg 2003;56(4):360–4.
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