Commentary on: Vertical Reduction Mammaplasty Utilizing the Superomedial Pedicle: Is It Really for Everyone?

In “Vertical Reduction Mammaplasty Utilizing the Supero-medial Pedicle: Is It Really for Everyone?,” Dr Neaman and his coauthors review a cohort of 290 patients (558 breasts) who underwent a vertical-style superomedial pedicle reduction mammaplasty and try to show that it is safe and effective for a wide range of patients with symptomatic macromastia. I appreciate the opportunity to comment on this article to give my perspective, gained after almost 30 years in practice. For the first 10 years of my practice, I used mainly an inferior pedicle, inverted-T-type breast reduction and, although the results were acceptable, I agreed with Madeleine Lejour1 that we could be striving for improvement. I have learned a lot by analyzing my experience since then, with over 2000 “vertical” breast reductions performed using superior, lateral, and medial pedicles. The word “vertical” is often used to describe a particular procedure, but I believe we should instead be separating out how we design the pedicle, the nature of the parenchymal resection, and the skin resection pattern. The “Wise pattern” is a term often used to describe an inverted-T, inferior pedicle breast reduction, but Robert Wise2 originally described only a skin resection design adapted from a brassiere pattern. I still occasionally apply a Wise pattern for the skin redraping when I use a superomedial pedicle in large breast reductions or in massive weight-loss patients. I always, on the other hand, apply a Wise pattern for the parenchymal design—not for what is removed, but for what is left behind (Figure 1). (A) The pattern as originally described by Robert Wise was not just the keyhole opening but was a skin pattern design adapted from a brassiere pattern. (B) The use of the Wise pattern for the parenchyma instead of the skin is an excellent way to remove the excess breast tissue inferiorly and allow the skin to be closed without tension (thereby leading to a reduction in wound healing problems). The superomedial pedicle not only has an excellent blood supply (both arterial and venous) but also allows the surgeon to more easily resect the excess lateral breast tissue as well as the heavy inferior breast tissue. We need to define what we mean by a “medial” pedicle versus a “superomedial” pedicle. I followed the original description of a pure medially based pedicle as described by both Skoog3 and Strombeck.4 This was often labeled “superomedial” because it appeared to have a superomedial orientation with the patient standing.5 The base of the pedicle, and therefore the blood supply, was medial—from the third interspace branch of the internal mammary artery. The pure medial orientation of the pedicle was more obvious when the patient was lying down. I believe that it is this pedicle that was used by the authors of the article being discussed here. Over the years, however, I have actually adapted the design to use a true “superomedial” pedicle, where the base (and therefore the blood supply) are superomedially oriented rather than purely medial. The true superomedial pedicle actually includes 2 arteries (from both the second and third interspaces) and is therefore more robust. The artery for a superior pedicle is the descending branch of the artery (which continues out to a deltopectoral flap) from the internal mammary artery at the second interspace. A true superomedial pedicle therefore has an excellent blood supply (most of the veins also drain superomedially), and it is easier to inset than a superior pedicle. The act of rotating the pedicle into position not only is easier but also allows the inferior border of the medial pedicle to become the medial pillar. This leaves an elegant curve to the lower pole of the breast and avoids the “snoopy” shape that is often associated with a pure superior pedicle. Although a true superomedial pedicle has a better blood supply than either a pure medial or superior pedicle, it can be somewhat more difficult to inset than a pure medial pedicle (and somewhat easier than a superior pedicle). Because the veins are just under the dermis and the arteries enter the areolar opening in the subcutaneous tissue, the pedicle can be made more supple by removing some of the deep tissue (that is void of important blood vessels). I am old enough to remember the huge advance in breast reduction surgery afforded by McKissock’s description of the vertical bipedicle.6 Suddenly, breast reduction became safer and more predictable. When it became clear that both pedicles were not necessary, the inferior pedicle became the favored approach in many countries.7,8 The superior pedicle could be more difficult to inset and was used mainly for some of the smaller breast reductions.9 The authors state that “the nipple-areola complex can be safely transposed even in patients with larger degrees of macromastia with no episodes of nipple necrosis.” They do, however, admit that superficial epidermolysis involving the NAC occurred in 4 breasts (0.7%). I would argue that this is part of the spectrum of poor blood supply to the nipple and areola, and a lack of circulation is a problem inherent in all breast reductions. My first episode of nipple necrosis occurred in a superior pedicle, and I believe in retrospect that my error was not thinning it enough to prevent compression. In my experience, nipple and areolar necrosis occurred in 1 of 300 to 400 patients,10 and the authors may just have not reached the threshold of enough patients in their series to make the claim that this particular approach is safe. So far, I have been able to reduce the risk of blood supply problems by using a true superomedial pedicle that has 2 arterial supplies rather than the single artery that supplies either a pure medial or a pure superior pedicle. The inferior pedicle, inverted-T breast reduction has become the standard over the past 40 years, but it involves leaving behind the heavy inferior breast tissue and removing the superior parenchyma. The skin brassiere is then used to shape the breast. The authors use their experience to show that the vertical-style breast reduction using a “superomedial” pedicle is safe and effective for a wide range of breast sizes. I believe that more surgeons would appreciate the versatility of a true superomedial pedicle—it has excellent sensation!—if they realized that they could still add an inverted-T skin resection pattern when needed. The advantage of leaving behind the superior breast tissue and removing the part of the breast that is more likely to respond over time to gravitational forces cannot be overestimated. Avoiding an inferior pedicle also allows the resection pattern of the parenchyma to be designed as more of a vertical ellipse rather than a horizontal ellipse allowing for better breast projection. The dog-ears of the ellipse end up superior at the areola and inferior rather than medial and lateral. If the inferior dog-ear ends up excessively large, an inverted-T can be added to deal with any redundant skin. The authors report complication rates that are consistent with other breast reduction techniques. They state that “complication rates are low with wound healing issues comprising a majority.” Complications and revisions occur with all types of surgery and we need to understand the causes to better understand how to prevent them. The majority of breast reduction complications are related to wound healing problems,11,13 and most of these can be blamed on tension. Revision rates may be high or low based not only on the initial learning curve, but also on the individual surgeon’s threshold for revision. The inverted-T inferior pedicle breast reduction has an equivalent problem with dog-ears, but revising them is more difficult than adding a T to the vertical scar. The vertical type of breast reduction using a superomedial pedicle allows the surgeon to use the parenchyma to shape the breast and then redrape the skin over the new shape. Most surgeons who try the vertical techniques tend initially to use too much tension on the skin because they are accustomed to using the skin as a brassiere to hold the remaining parenchyma. When they realize that the skin does not need to be tight, their problems with wound healing issues almost disappear. I believe that suture spitting is caused by a low-grade infection and wound healing problems are caused by tension. The ability to avoid tension on both the skin and the parenchyma is one of the advantages of a superomedial vertical breast reduction. The medial pedicle allows the surgeon to resect the breast tissue where it is in excess—especially laterally and inferiorly. The pillars can then be brought together without tension. When I initially tried using a lateral pedicle, I thought that the excess lateral tissue (which could not be resected because it was at the base of the pedicle) could be pulled medially with a tight pillar repair. Unfortunately, it became evident over time that the lateral fullness recurred. Following patient results long-term is humbling. The key to a good final result is to avoid tension—both on the skin and the parenchyma. A superomedially based pedicle enables us to use a breast reduction approach that avoids tension on the skin because it does not use skin as a brassiere. It also enables us to perform a breast reduction that avoids tension on the parenchyma because we can remove the excess tissue inferiorly and laterally. The authors have studied their results and have provided us with more evidence that a superomedial pedicle combined with a vertical type of breast reduction is safe and effective. It is fortunate now that there are several different safe approaches available for breast reduction. As surgeons, we need to continually evaluate our personal results and we need to have several designs available to adapt for different patients. One method is not necessarily “for everyone,” but the vertical-style superomedial pedicle has a wider application than is generally appreciated. The author receives royalties from QMP, Elsevier, and Lippincott.

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