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BREAST
Breast Reduction in Gigantomastia Using thePosterosuperior
Pedicle: An AlternativeTechnique, Based on Preservation of
theAnterior Intercostal Artery Perforators
Ali Mojallal, M.D.Michel Moutran, M.D.Christo Shipkov,
M.D.Michel Saint-Cyr, M.D.
Rod J. Rohrich, M.D.Fabienne Braye, M.D.
Lyon, France; and Dallas, Texas
Background: The purpose of this study was to describe and
evaluate the out-comes of breast reduction in cases of
gigantomastia using a posterosuperiorpedicle.Methods: Four hundred
thirty-one breast reductions were performed between2004 and 2007.
Fifty patients of 431 (11.6 percent) responded to the
inclusioncriteria (�1000 g of tissue removed per breast (100
breasts). The mean age was 33.2years (range, 17 to 58 years). The
average notch-to-nipple distance was 37.9 cm(range, 35 to 46 cm).
The mean body mass index was 27 (range, 22 to 35 cm). Thetechnique
of the posterosuperior pedicle was used, in which the perforators
fromfourth anterior intercostal arteries are preserved (posterior
pedicle). Results wereevaluated by means of self-evaluation at 1
year postoperatively.Results: The average weight resected was 1231
g (range, 1000 to 2500 g). Thelength of hospital stay was 2.3 days
(range 2 to 4 days). Thirty seven patientsevaluated their results
as “very good” (74 percent), nine as “good” (18 percent), andfour
as “acceptable” (8 percent). There were no “poor” results. The
chief complaintwas insufficient breast reduction (four patients),
despite the considerable improve-ment in their daily life (8
percent). Back pain totally resolved in 46 percent andpartially
(with significant improvement) in 54 percent of cases. One major
and sevenminor complications were recorded.Conclusions: The
posterosuperior pedicle for breast reduction is a reproducibleand
versatile technique. The preservation of the anterior intercostal
artery perfo-rators enhances the reliability of the vascular supply
to the superior pedicle. (Plast.Reconstr. Surg. 125: 32, 2010.)
Gigantomastia is defined as excessive breasthypertrophy, with
breast weight greaterthan 1500 g, as opposed to a mean
breastweight, in France, of 300 g. It is often seen in
obesepatients. Gigantomastia can be idiopathic with
normal body mass index, idiopathic with highbody mass index, or
associated with some hor-monal disturbances, as in puberty
gigantomastiaand pregnancy gigantomastia.2 Rare cases of
druginduced gigantomastia have been reported in-criminating
penicillamine,3 neothetazone,4 andciclosporine.5 In cases of
gigantomastia, severeptosis is usually present (a sternal
notch-to-nippledistance superior to 32 cm as defined in
ourpractice),6 with occasionally compromised vascu-lar supply to
the nipple-areola complex. The rec-ommended surgical procedure for
gigantomastia,until recently, was the Thorek procedure, in whichthe
nipple-areola complex is harvested and trans-
From the Department of Plastic, Reconstructive and
AestheticSurgery, Edouard Herriot Hospital, University of
Lyon-France, and the Department of Plastic Surgery, University
ofTexas Southwestern Medical Center.Received for publication
February 27, 2009; accepted July28, 2009.Presented at the
International Society of Aesthetic PlasticSurgery Meeting 2006, in
Rio de Janeiro, Brazil; the Inter-national Plastic, Reconstructive
and Aesthetic Surgery Meet-ing 2007, in Berlin, Germany; and the
French Society ofPlastic Reconstructive and Aesthetic Surgery
Meeting 2007,in Paris, France.Copyright ©2009 by the American
Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181c49561
Disclosure: The authors have no financial interestto declare in
relation to the content of this article.
www.PRSJournal.com32
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ferred to its new position.7–9 The main disadvan-tages of this
technique are the risks of total orpartial necrosis of the
nipple-areola complexgraft, loss of any future breast feeding,
nipple-areola complex discoloration and loss of sensitiv-ity, and
finally, possible loss of nipple-areola com-plex projection.2
Although successful refinementsof the technique were reported, no
complete res-olution of all problems was achieved.10–13
The indications of free nipple-areola complexgraft significantly
decreased with the spread of the“conservative” techniques, based on
the nipple-areola complex transposition on a reliable vascu-larized
pedicle, with improved results. However,few authors used the
superior pedicle techniques forbreast reduction in cases of
gigantomastia.14 Previ-ously published reports focus on the
inferior pedicletechniques15 or the McKissock’s bipedicled
nipple-areola complex transposition16 or the superomedialpedicle
breast reduction.17 The goal of this studywas to describe the
posterosuperior pedicle tech-nique of breast reduction in
gigantomastia, basedon the perforators of the anterior intercostal
ar-teries, and to present the prospective results of 50consecutive
patients.
PATIENTS AND METHODSThis study was conducted after obtaining
ap-
proval by the Institutional Review Board of theUniversity of
Lyon. Four hundred thirty-onebreast reductions were performed at
our institu-tion between January of 2004 and January of 2007.All
overweight patients were advised to reduce andstabilize their body
weight before surgery. Patientswere also advised to stop smoking at
least 1 monthbefore surgery. Fifty of 431 patients (11.6
percent)responded to the inclusion criteria (�1000 g oftissue
removed per breast; 100 breasts). The meanage was 33.2 years
(range, 17 to 58 years). Theaverage notch-to-nipple distance was
37.9 cm(range, 35 to 46 cm). Twenty-eight patients (56percent) had
a body mass index superior to 25.The mean body mass index was 27
(range, 22 to35). Thirteen patients (26 percent) previously
hadundergone a bariatric procedure for weight re-duction and 12 (24
percent) had undergone anabdominoplasty. Eight patients presented
with di-abetes mellitus, without the need for insulin
admin-istration (16 percent), and five smoked regularly
(10percent). Patient data are listed in Table 1.
None of the patients had any previous breastsurgery. All
patients reported dorsal and cervicalpain. A written consent form
was signed by all
patients. In cases with language barrier the visualdocumentation
of oral consent, as described byDanino et al., was used.18
The lower age limit for reduction mamma-plasty was 17 years.
Under this age, patients werereferred to pediatric endocrinologists
for follow-up. Patients with juvenile and postgravid giganto-mastia
were also referred to specialists in order torule out metabolic
disorders.
The breast tissue removed was weighed anddocumented at the time
of surgery. The breastswere not infiltrated before weighing.
The evaluation criteria were as follows: dura-tion of surgery,
length of hospital stay, complica-tion rate, duration of dressing
care, and patientsatisfaction. Medical records were reviewed
atpostoperative days 15 and 30, and at 3 months, 6months, and 1
year.
Subjective and objective methods were used toevaluate the
results. Patient satisfaction was eval-uated at 1 year and was
rated as “very good,”“good,” “acceptable,” or “poor” by the
patient.The same scale was used by an unbiased third-party
jury.
The subjective method included a self-evalu-ation anonymous
questionnaire, sent to all pa-tients, accompanied by an explanatory
letter. Thequestionnaire with the corresponding responseswas then
mailed back to the surgeon and then theinformation recorded and
analyzed.
We have used the method of closed-endedquestion scale for
collecting and evaluating theresults. The objective method was
based on eval-uation of preoperative and postoperative pho-tographs
by five adults (three women and twomen), not doctors, nurses, or
other medical
Table 1. Patients’ Data before Surgery*
Characteristic Value (%)*
No. of patients 50Mean age (yr) 33.2Sternal notch-to-nipple
distance (cm)
Mean 37.9Range 35–46
BMIMean 27Range 22–35
No. of patients with idiopathicgigantomastia with high BMI 28
(56)
No. of patients with idiopathicgigantomastia with normal BMI 15
(30)
No. of patients with juvenile gigantomastia 5 (10)No. of
patients with post-gravid gigantomastia 2 (4)No. of patients with
diabetes mellitus 8 (16)No. of smokers 5 (10)BMI, body mass
index.*Percentage of all patients.
Volume 125, Number 1 • Breast Reduction in Gigantomastia
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staff. Photographs of each patient (frontal,oblique, and
profile) were presented to the juryon a computer screen: on the
left, a preoperativephotograph; and on the right, a
postoperativephotograph. The photographs were of the
samedimensions, brightness, and contrast. The pre-sentation was
performed using Power Point, Mi-crosoft Office software (Microsoft
Corp., Red-mond, Wash.). The duration of each casepresentation was
20 seconds. The raters wereasked to evaluate the result as “very
good,”“good,” “acceptable,” or “poor.”
Surgical Key Points
Vascular Supply to the BreastIn gigantomastia, the vascular
anatomy of the
breast remains the same but the breast is more ptoticwith an
increased sternal notch-to-nipple distanceand broad base (Fig. 1).
Various reports19–21 haveemphasized the fact that the vascular
supply to thenipple-areola complex relied mainly on
perforatingarterial branches from (1) the internal mammaryartery,
(2) the lateral thoracic artery at the level ofthe fourth
intercostal artery, and (3) the anteriorintercostal artery at the
level of the mid fourth and
Fig. 1. Anterior intercostal perforators from the fourth and
fifth intercostal spaces. Schematic pre-sentation after Würinger
et al. (Nerve and vessel supplying ligamentous suspension of the
mammarygland. Plast Reconstr Surg. 1998;101:1486 –1493). (Left)
Illustration of gigantomastia with breast ptosisbelow the
inframammary fold and hollowness of the superior quadrants. (
Right) The zone of resectioncaudal to the horizontal septum is
shown in gray.
Fig. 2. Computed tomographic angiography scan of a
cadavericspecimen and anterior intercostal perforators at the
fourth andfifth intercostal space (blue arrows).
Plastic and Reconstructive Surgery • January 2010
34
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mid fifth intercostal space (Figs. 2 and 3). Thislatter artery
is crucial in our technique, as we in-clude it in the pedicle.
Würinger et al.22 describeda horizontal septum, which divides the
breast intosuperior and inferior portions. This septum con-tains
the vascular and nerve supply to the nipple-areola complex in a
mesenteric-like manner. Thefibrous horizontal septum is a key point
in ourtechnique because the perforators from the an-terior
intercostal artery emerge from the pec-toralis major muscle at the
level of the fourthand fifth intercostal space, and run in this
hor-izontal septum.22 Our technique combines thesuperior dermal
pedicle and the posterior vas-cular pedicle to the nipple-areola
complex (cen-tral mound technique).
Posterosuperior Technique
Preoperative MarkingsThe preoperative markings are performed
with
the patient in the standing position (Figs. 4 and 5).First, the
midthoracic vertical axis is drawn fol-lowed by both inframammary
folds. From a fixedpoint, 5 cm lateral to the sternal notch, a line
tothe nipple, representing the axis of each breast, isdrawn. The
axis is continued below the inframam-mary fold on the
thoracoabdominal skin. This lineis usually at 10 to 12 cm from the
midthoracic line.Then, point A (upper pole of the future areola)
onthe breast axis (corresponding approximatelyto the level of the
inframammary fold) is marked.The medial and lateral arms of the
“keyhole” are
Fig. 3. Schematic presentation of the fourth and fifth
intercostal arteries perforators and nerves forthe nipple-areola
complex and the horizontal septum in cases of gigantomastia. The
zone of resec-tion and the vascular supply from the anterior
intercostal perforators are presented on the left
smallillustration.
Volume 125, Number 1 • Breast Reduction in Gigantomastia
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marked, moving the breast laterally and medially(maneuver
described by Bisenberger,23 as twostraight vertical lines from
point A down across theinframammary fold following the breast
axis.Points B and B= are marked at 7 to 8 cm from point
A. BB= is the width of the nipple-areola complexbearing pedicle.
A 1:2 width-to-length ratio of thepedicle is respected. This
renders the dermal vas-cular supply to the nipple-areola complex
morereliable. AB and AB� are the diameters of twosemicircles that
will form the future areola. PointsC and C� are marked on the
straight lines of thekeyhole 6 cm from B and B=. BC and BC� are
thefuture distance from the nipple-areola complex tothe
inframammary fold. This distance is limited to6 cm (overcorrection)
to anticipate future second-ary breast ptosis. Drawings are
completed by join-ing vertically points C and C= to the
inframammaryfold (Fig. 4). The width of the horizontal
inferiorincision should not exceed the mammary projec-tion
area.
Operative ProcedureThe patient is operated on in a
semisitting
position. The future areola complex is markedwith a “cookie
cutter” (45 mm in diameter) Thenipple-areola complex bearing
pedicle is deepi-thelialized. The incisions are made following
thepreoperative drawings. Glandular resection isstarted in the
lower central portion of the breast,beginning from the inframammary
fold incision.The resection is stopped when the inferior borderof
the pectoralis major muscle is reached. Resec-tion is then
continued to the lateral extension andinferomedial portion of the
breast. Two glandulartriangles are resected in the inferior lateral
andmedial breast regions, to allow better shaping ofthe breast
(Fig. 4). The dermoglandular superiorpedicle is then incised and
suspended verticallywith hooks. The glandular resection joins the
dis-tal part of the nipple-areola complex bearing pedi-cle and is
limited to a plane joining caudally theinferior border of the
nipple-areola complex bear-ing pedicle and the pectoralis major
muscle, ce-phalically. The result is a pedicle thinner towardits
tip and thicker toward its pectoralis major or-igin. Its anatomical
design is justified by the im-portance of the vascular supply to
the nipple-are-ola complex from the dermoglandular flap, whichis
enhanced by the direct perforator of the ante-rior intercostal
artery at the level of the fourth andfifth intercostal space. At
this point, the range ofmotion of the nipple-areola complex pedicle
islimited by the nipple-areola complex tractionfrom the fibrous
horizontal septum, described byWüringer.22 The posterior sheath of
the horizon-tal septum may be carefully incised to render
thepedicle more pliable. Perforators from the ante-rior intercostal
artery emerge from the pectoralismajor muscle, at the level of the
fourth and fifth
Fig. 4. Schematic presentation of the preoperative drawings;the
filled area represents the zone of undermining. IMF, infra-mammary
fold.
Fig. 5. Preoperative markings of a patient in the upright
posi-tion. A diameter of 7 to 8 cm of the areolar circle, drawn
preop-eratively, allows a length-to-width ratio of approximately
2:1.
Plastic and Reconstructive Surgery • January 2010
36
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intercostal space, and are cranial to this posteriorsheath of
the horizontal septum (Figs. 3 and 6).
The glandular resection involves the inferiorpole of the breast
with its medial and lateral ex-tensions.
Pedicle plication can be facilitated by means ofdigital
softening (digitoclasia) of the dermoglan-
dular pedicle without injuring the blood vessels. Insome cases,
gentle lipoaspiration of the pediclewith a 3.6-mm cannula can
reduce its density andfacilitate its plication.
To also preserve the blood supply to the breastparenchyma and
nipple-areola complex from theperforating branches of the internal
mammaryartery, a limited tunnel 4 to 5 cm wide is dissectedabove
the pectoralis major fascia (Fig. 7). The roleof this tunnel is to
reach the superior pole of thebreast and to facilitate the
plication and suspen-sion of the reduced breast by gliding over
thepectoralis fascia. We make the tunnel between theanterior
intercostals artery perforators and inter-nal mammary artery
perforators to preserve bothvascular supply to the breast.
The lateral pillar of the breast is anchored tothe fascia of the
pectoralis major muscle in theretroglandular tunnel with three
resorbable su-tures of 1.0 size. The role of these sutures is (1)
tomodify the distribution of the mammary glandwithin the new
reduced breast, (2) to control thelateral extension of the breast
and define the lat-eral mammary fold, while reducing the base
di-ameter of the breast, and (3) to decrease the ten-sion on the
anchoring sutures. In cases of axillaryadipose extension,
complementary lipoaspirationin the lateral thoracic area can be
used. A singledrain is used for each breast and incisions are
Fig. 6. Intraoperative view after careful opening of the
inferiorsheath of the horizontal septum. The fourth and fifth
anteriorintercostal perforators, directed to the nipple-areola
complex,can be visualized as a darker, vertical line in the center
of thepedicle (arrow). This pedicle must be respected to enhance
thevascular supply and preserve the sensibility of the
nipple-areolacomplex.
Fig. 7. (Left) Intraoperative view of the right breast after
resection. The vascular supply is preserved. Amedial subglandular
tunnel was meticulously undermined between the internal mammary
perforatorsand anterior intercostal perforators for anchoring the
lateral breast pillar and lateral pexy. (Right) Finalclosure of the
right breast.
Volume 125, Number 1 • Breast Reduction in Gigantomastia
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closed with resorbable 3-0 and 4-0 monofilamentsutures (Fig. 7).
Drains are usually removed 48hours following surgery.
RESULTSThe mean follow-up period was 16 months
(range, 13 to 23 months). The average weightresected was 1231 g
(range, 1000 g to 2500 g). Theaverage duration of surgery was 2h
(range, 1.50 to2.30 hours). The average length of hospital staywas
2.3 days (range, 2 to 4 days). The durationof the outpatient
postoperative care until com-plete wound healing was 15.2 days
(range, 13 to20 days). Results are listed in Table 2.
One major complication was observed. It con-sisted of bilateral
infection, treated with incisionand drainage as well as intravenous
antibiotics.Seven minor complications were recorded, includ-ing one
desquamation of the nipple-areola com-plex without necrosis (2
percent) and healing bysecondary intention. In six cases, delayed
healing(12 percent) occurred at the junction site of theinverted T
incision. The postoperative sequelaeincluded a hypochromic areola
at 1 year after theprocedure, corrected with tattooing. Three
hyper-trophic scars in the lateral part of the horizontalscar were
observed.
Patients were asked about their overall satis-faction 1 year
following surgery. Thirty-seven pa-tients evaluated their results
as “very good” (74percent), nine as “good” (18 percent), and four
as“acceptable” (8 percent). There were no resultsassessed as
“poor.” When asked about their chiefcomplaint, four patients
reported insufficientbreast reduction, despite a functional
improve-ment in their daily life (8 percent). Forty-six
percent of the patients found that their backpain had totally
resolved versus 54 percent whohad partial resolution but
significantly improve-ment. Figures 8 through 10 illustrate the
possi-ble results accomplished with the technique de-scribed
above.
DISCUSSIONWith the introduction of deepithelialization of
the nipple-areola complex bearing pedicle, de-scribed by
Schwartzmann in 1930, and the con-servative breast reduction
techniques, the indica-tions for free nipple graft mammaplasty
havedecreased significantly. The main indication forfree
nipple-areola complex graft remains severegigantomastia. Inferior
pedicle and McKissocktechniques remain widely used not only in
gi-gantomastia, but also in classic reductionmammaplasty.15,16
The breast reduction with a posterosuperiorpedicle, as described
above, seems to be a reli-able and versatile alternative in breast
reduc-tion, especially in gigantomastia, eliminatingthe need for
free nipple graft, regardless of theweight and ptosis of the
breast. Nevertheless,some key elements should be analyzed
preciselybefore surgery: age, previous medical history,cause of
gigantomastia, smoking habits, qualityof the breast skin,
histological component of themammary gland (glandular or adipose),
degreeof ptosis, and width of the chest wall. The pres-ence of
symmastia, position of the inframam-mary fold, and presence of
lateral thoracic ex-tension of the breast should also be taken
intoconsideration. These elements do not changethe choice of the
surgical technique but allow anadjustment of the preoperative
markings withspecial attention to the vascular supply of
thenipple-areola complex.
With the development of the reduction mam-maplasty techniques,
based on the deepithelial-ized dermoglandular nipple-areola
complex–bearing pedicle, three important componentshave been
identified: (1) the vascular supply of thenipple-areola complex,
(2) the breast shape, and(3) scars left on the breast. Reduction
mamma-plasty can be considered a safe procedure from avascular
standpoint. The most important criterionis the shape of the breast,
which is determined bythe way that the glandular resection is
performed.With the introduction of the key-hole model (withor
without a predefined areolar incision) andwedge glandular
resection, satisfactory aestheticshape of the breast was
achieved.24,25 More re-cently, the focus has placed on reducing
the
Table 2. Postoperative Results and Details about theSurgical
Procedure
Characteristic Value (%)
Follow-up period (mo)Mean 16Range 13–23
Duration of surgery (hr)Mean 2Range 1.50–2.30
Length of hospital stay (days)Mean 2.3Range 2–4
Average amount of breast tissue removed (g)Mean 1231Range
1000–2500
Major complicationsBilateral infection 1 (2)
Minor complicationsDelayed healing 6 (12)Areola desquamation 1
(2)
Plastic and Reconstructive Surgery • January 2010
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length of the scars—the concept of the large in-verted T pattern
was followed by J or L scars,26,27passing through the short
inverted T,28 and end-ing with the vertical scar mammaplasty.29,30
In ouropinion, the inframammary scar is not an issue aslong as it
is located within the inframammary foldand maximal breast
projection area. Furthermore,the shape of the reduced breast should
not becompromised to shorten the scars.
In gigantomastia, large volumes are usuallyassociated with
ptosis, axillary extensions, and hol-lowness of the upper breast
pole. However, thevascular supply to the breast remains
principallyunmodified, although the blood vessels arestretched
down, following the hypertrophic and
ptotic breast. Because of the increased sternalnotch-to-nipple
distance, the vascular safety of thenipple-areola complex remains a
primary con-cern. Reduction mammaplasties following the in-ferior,
superior, superomedial or lateral pediclemodels provide adequate
blood supply to the nip-ple-areola complex in cases of reduction
mamma-plasty in “normal-sized” breasts, but might not in-clude
sufficient arterial flow to the nipple-areolacomplex in cases of
gigantomastia. To render thistechnique applicable to gigantomastia,
we de-cided to combine the superior pedicle techniquewith the
central mound technique (posteriorpedicle).31 When the breast is
largely ptotic underthe inframammary fold, all vascular branches
have
Fig. 8. Photographs of a 58-year-old woman with gigantomastia
and breast asymmetry obtained (above)preoperatively (frontal and
oblique views) before resection of 1650 g from the right and 1100 g
from the leftbreast. (Below) Result at 2 years (frontal and oblique
views).
Volume 125, Number 1 • Breast Reduction in Gigantomastia
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a vertical direction and there is no need to use asuperomedial
or superolateral pedicle. In thesecases, the wide superior pedicle
receives bloodsupply from perforators of the internal
mammaryartery,32 the lateral thoracic artery, and branchesof the
thoracoacromial artery. However, the pres-ervation of the
perforating branches of the fourthand fifth anterior intercostal
artery enhances thevascularization to the breast parenchyma and
nip-ple-areola complex.22 There is no need to dissectthe fourth and
fifth intercostal perforators. Theirpreservation can be obtained by
simply avoidingany dissection over the pectoralis major muscle
orcarefully undermining over the inferior part of thepectoralis
major muscle and digital underminingin its upper part, so that
Würinger’s septum is
preserved. Thus, the perforating branches of theanterior
intercostal artery can be safely respected,and will additionally
augment the vascularizationto the breast parenchyma and
nipple-areola com-plex through the posterior pedicle. The
mammarygland maintains its posterior attachments, includ-ing
Würinger’s septum. The posterior pedicle canalso be designed in
combination with either aninferior or superior pedicle. Thus, the
techniquecan be regarded as a combination of the centralmound and
the superior pedicle techniques.These different issues make the
procedure simpleand relatively fast (can be performed over 2 to
2.5hours’ operating time).
The original technique, based on the horizon-tal septum, was
proposed by Würinger in 1999.33
Fig. 9. Photographs of a 42-year-old woman obtained (above)
preoperatively (frontal and lateral) before re-section of 1600 g
from the right and 1720 g from the left breast. Note the hollowness
of the upper pole of thebreast and descent of the whole breast
parenchyma below the inframammary fold. (Below) Result at 2
years(frontal and lateral views).
Plastic and Reconstructive Surgery • January 2010
40
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This central pedicle technique is entirely based onthe
perforators within the horizontal septum.22 Inher series of 42
patients the average amount ofresected breast tissue was 712 g
(range, 250 to2100 g). The good results and low complicationsrate
in her series showed the reliability of thistechnique, which seems
safe even in very largeresections. However, the few cases of large
resec-tions in this series (disparity of cases) seem notsufficient
to conclude if this technique could beregularly used in
gigantomastia cases and we donot have any experience with it.
In a recent study Hamdi et al. described atechnique for
reduction mammaplasty on a su-peromedial or superolateral pedicle,
based on
Würinger’s septum.34 The results of Hamdi et al.confirm the
important role of the horizontal sep-tum for the vascularization of
the nipple and are-ola. However, they design the pedicle either on
alateral or medial base. In this way blood supplyfrom the lateral
thoracic (superolateral pedicle)and internal mammary artery
(superomedial pedi-cle) is included in the pedicle in addition to
theblood supply from Würinger’s septum (intercostalperforators).34
In our technique a superior pediclealong with the preservation of
the horizontal sep-tum is used. In this way, as the pedicle is wide
andlong and descends below the inframammary fold,blood supply to
the nipple-areola complex comesfrom the thoracoacromial, lateral
thoracic, and
Fig. 10. Photographs of a 39-year-old woman obtained (above)
preoperatively (frontal and oblique views)before resection of 1480
g from the right and 1530 g from the left breast. Note the
hollowness of the upperpole of the breast and descent of the whole
breast parenchyma below the inframammary fold. (Below) Resultat 1
year (frontal and oblique views).
Volume 125, Number 1 • Breast Reduction in Gigantomastia
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internal mammary arteries. This blood supply isenhanced by the
inclusion of the intercostal per-forators (horizontal septum). In
addition, we pre-serve the 2:1 length-to-width pedicle ratio,
whichalso enhances the blood supply to the areola.Hamdi et al. also
seem to respect this 2:1 ratio. Incases of excessive ptosis this
ratio might not bepreserved, but this would not alter significantly
thedesign of the pedicle. However, in their study theaverage amount
of breast tissue resected is 658 gper breast which is 1231 g per
breast in the studypresented herein.
In our experience, the superior pedicle couldbe plicated without
difficulties. This was attribut-able to the thinness of the pedicle
distally and thecareful digitoclasy to soften the breast
paren-chyma along the pedicle and to dissect enoughspace at the
superior pole, to which the breast willglide. In medially or
laterally based pedicles, thepedicle is rather rotated than
plicated, which canbe an additional advantage but may cause
torsionof the nipple-areola complex–bearing pedicle.
The limited undermining between gland andskin decreases the risk
of vascular compromise ofthe breast tissue and possible
cytosteatonecrosis.Furthermore, the sutures, placed to fix the
glandmedially (glandulopexy), are used to decrease ten-sion on the
scars, rather than to determine a long-term breast shape.
All patients reported good recovery of nipple-areola complex
sensitivity at 1 year even thoughthis was not among the studied
criteria. The in-nervation of the nipple-areola complex is
pro-vided by the fourth intercostal nerve, which runsclose to the
anterior intercostal arterial supply.35As a result, the
preservation of the perforatorsfrom the anterior intercostal
arteries would sparethe corresponding sensitive nerves in all types
ofbreast reduction, thus respecting the sensitivity ofthe
nipple-areola complex. This was reported alsoby Würinger22 and
Hamdi.34
The final scars in cases with gigantomastia areinverted T scars.
The inframammary scar neverexceeded the width of the reduced breast
and thusremain “hidden” in the inframammary fold. Thelength of this
scar was reduced whenever possible.
The complication rate in this series remainslow, with no total
nipple-areola loss and one caseof superficial epidermolysis. We
noted delayedhealing in 12 percent of the cases at the junctionof
the inverted T, which is less than other reportedresults, but not
significantly different.17,30,36 Themain patient complaint in this
study was the in-sufficient reduction, which was observed in
casesof juvenile gigantomastia and was not attributable
to a recurrence of the gigantomastia.37,38 Finally, inaddition
to the free nipple graft, inferior pedicle,or McKissock techniques,
the posterosuperiorpedicle technique represents another useful
andsafe option in gigantomastia breast reduction.32,39
CONCLUSIONSThe posterosuperior pedicle for breast reduc-
tion is a reproducible and versatile technique. Thepreservation
of the anterior intercostal artery per-forators enhances the
reliability of the vascularsupply to the superior pedicle. This
minimally in-vasive subglandular dissection renders the proce-dure
safe and reliable in cases with gigantomastia.
Ali Mojallal, M.D.Department of Plastic, Reconstructive and
Aesthetic
SurgeryEdouard Herriot HospitalUniversity of Lyon-France
5 Place d’Arsonval 69437 Lyon, Cedex 03,
[email protected]
ACKNOWLEDGMENTSThe authors thank Alexandra Hernandez, M.A.,
from Gory Details Illustration for help in preparing theartwork
for this article.
REFERENCES1. Bricout N. Hypertrophie et ptose. In: Chirurgie du
Sein. 1st ed.
Paris: Springer-Verlag; 1996:73–84.2. Dancey A, Khan M, Dawson
J, Peart F. Gigantomastia: A
classification and review of the literature. J Plast
ReconstrAesthet Surg. 2008;61:493–502.
3. Sakai Y, Wakamatsu S, Ono K, Kumagai N. Gigantomastiainduced
by bucillamine. Ann Plast Surg. 2002;49:193–195.
4. Scott EHM. Hypertrophy of the breast, possibly related
tomedication: A case report. S Afr Med J. 1970;44:449–450.
5. Cerveli V, Orlando G, Giudiceandre F, et al. Gigantomastiaand
breast lumps in a kidney transplant recipient. TransplantProc.
1999;31:3224–3225.
6. Jackson IT, Bayramicli M, Gupta M, Yavuzer R. Importanceof
the pedicle length measurement in reduction mamma-plasty. Plast
Reconstr Surg. 1999;104:398–400.
7. Thorek M. Possibilities in the reconstruction of the
humanform 1922. Aesthetic Plast Surg. 1989;13:55–58.
8. Oneal RM, Goldstein JA, Rohrich R, Izenberg PH, PollockRA.
Reduction mammoplasty with free-nipple transplanta-tion:
Indications and technical refinements. Ann Plast
Surg.1991;26:117–121.
9. Bardot J, Samson P, Aubert JP, Magalon G. Reduction
mam-maplasty with free nipple: Apropos of 5 cases (in French).Ann
Chir Plast Esthet. 1995;40:77–82.
10. Robertson DC. The technique of inferior flap
mammaplasty.Plast Reconstr Surg. 1967;40:372–377.
11. Arons MS. Reduction of very large breasts: The inferior
flaptechnique of Robertson. Br J Plast Surg. 1976;29:137–141.
12. Koger KE, Sunde D, Press BH, Hovey LM. Reduction
mam-maplasty for gigantomastia using inferiorly based pedicleand
free nipple transplantation. Ann Plast Surg. 1994;33:561–564.
Plastic and Reconstructive Surgery • January 2010
42
-
13. Neuprez A, Haykal S, Calteux N. The use of an
inferiordermo-glandular flap in Thorek’s technique, based on
aseries of 21 cases (in French). Ann Chir Plast Esthet.
1999;44:231–237.
14. Mojallal A, Comparin JP, Voulliaume D, Chichery A, PapaliaI,
Foyatier JL. Reduction mammaplasty using superior pedi-cle in
macromastia (in French). Ann Chir Plast Esthet.
2005;50:118–126.
15. Robbins TH. A reduction mammaplasty with the areola-nip-ple
based on an inferior dermal pedicle. Plast Reconstr
Surg.1977;59:64–67.
16. McKissock PK. Reduction mammaplasty with a vertical der-mal
flap. Plast Reconstr Surg. 1972;49:245–252.
17. Landau AG, Hudson DA. Choosing the superomedial pedi-cle for
reduction mammaplasty in gigantomastia. Plast Re-constr Surg.
2008;121:735–739.
18. Danino AM, Lile A, Moutel G, Herve C, Malka G.
Visualdocumentation of oral consent: A new method of
informedconsent before major gigantomastia reduction for an
illit-erate population. Plast Reconstr Surg.
2006;117:1370–1371.
19. Nakajima H, Imanishi N, Aiso S. Arterial anatomy of
thenipple-areola complex. Plast Reconstr Surg. 1995;96:843–845.
20. van Deventer PV. The blood supply to the
nipple-areolacomplex of the human mammary gland. Aesthetic Plast
Surg.2004;27:393–398.
21. O’Dey D, Prescher A, Pallua N. Vascular reliability of
nipple-areola complex-bearing pedicles: An anatomical
microdis-section study. Plast Reconstr Surg.
2007;119:1167–1177.
22. Würinger E, Mader N, Posch E, Holle J. Nerve and
vesselsupplying ligamentous suspension of the mammary gland.Plast
Reconstr Surg. 1998;101:1486–1493.
23. Biesenberger H. Eine neue Methode der Mammaplastik.Zentralbl
Chir. 1928;55:2382–2387.
24. Pitanguy I. A new technic of plastic surgery of the
breast:Study of 245 consecutive cases and presentation of a
personaltechnic (in French). Ann Chir Plast. 1962;7:199–208.
25. Weiner DL, Aiache AE, Silver L, Tittiranonda T. A
singledermal pedicle for nipple transposition in
subcutaneousmastectomy, reduction mammaplasty, or mastopexy.
PlastReconstr Surg. 1973;51:115–120.
26. Baux S, Mimoun M, Zumer L, Nivesse D. Reduction mam-moplasty
with a J-shaped scar (the Jean-Sauveur Elbaz tech-
nic): Review of 125 cases (in French). Ann Chir Plast
Esthet.1990;35:123–127.
27. Bozola AR. Breast reduction with short L scar. Plast
ReconstrSurg. 1990;85:728–738.
28. Ramirez OM. Reduction mammaplasty with the “owl” inci-sion
and no undermining. Plast Reconstr Surg. 2002;109:512–522;
discussion 523–524.
29. Lejour M. Vertical mammaplasty. Plast Reconstr Surg.
1993;92:985–986.
30. Azzam C, De Mey A. Vertical scar mammaplasty in
giganto-mastia: Retrospective study of 115 patients treated using
themodified lejour technique. Aesthetic Plast Surg.
2007;31:294–298.
31. Rodier-Bruant C, Wilk A, Rosenstiel M, Nisand G, Meyer
C.Does the choice of mammoplasty pedicle influence the shapeof the
reduced-sized breast? (in French). Ann Chir Plast
Esthet.1995;40:404–411.
32. Ricbourg B. Applied anatomy of the breast: Blood supply
andinnervation (in French). Ann Chir Plast Esthet.
1992;37:603–620.
33. Würinger E. Refinement of the central pedicle breast
reduc-tion by application of the ligamentous suspension. Plast
Re-constr Surg. 1999;103:1400–1410.
34. Hamdi M, Van Landuyt K, Tonnard P, Verpaele A, MonstreyS.
Septum-based mammaplasty: A surgical technique basedon Würinger’s
septum for breast reduction. Plast ReconstrSurg.
2009;123:443–454.
35. Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of
thenipple-areola complex: An anatomic study. Plast ReconstrSurg.
2000;105:905–909.
36. Lacerna M, Spears J, Mitra A, et al. Avoiding free nipple
graftsduring reduction mammaplasty in patients with gigantomas-tia.
Ann Plast Surg. 2005;55:21–24; discussion 24.
37. Kulkarni D, Beechey-Newman N, Hamed H, Fentiman
IS.Gigantomastia: A problem of local recurrence. Breast
2006;15:100–102.
38. Boyce SW, Hoffman PG Jr, Mathes SJ. Recurrent macromas-tia
after subcutaneous mastectomy. Ann Plast Surg. 1984;13:511–518.
39. Datta G, Carlucci S. Selective breast reduction: A
personalapproach with a central-superior pedicle. Plast Reconstr
Surg.2009;123:433–442.
Volume 125, Number 1 • Breast Reduction in Gigantomastia
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