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Title: Why Did We Change our Technique From A Superior Pedicle Into A Laterocentral
Glandular Pedicle For Breast Reduction?
Authors: Moustapha Hamdi, M.D., Phillip Blondeel, MD, PhD,
Karlien Vandesijpe, MD, Koenraad Van Landuyt, MD, Stan Monstrey, MD, PhD,
Introduction: We have been using Lejour’ technique for breast reduction(1) for years.
However, some specific problems were associated with this technique such as bad
definition of the inframammary fold, kinking of the pedicle in very fibrous breast and
very bad nipple-areola sensitivity postoperatively. We have been using a new technique
of breast reduction with a laterocentral glandular pedicle in our institute since 1999.
Using this technique, we conduct a prospective study in order to quantitatively assess the
nipple-areola sensitivity.
Material and Methods: The pedicle is based on a horizontal septum and it is designed to
incorporate the lateral branch of the fourth intercostal vessels and of the nerve. The
operative technique will be illustrated. The sensitivity of the nipple-areola complex was
evaluated by one independent examiner in 20 consecutive patients preoperatively, 2
weeks and three months postoperatively. The nipple and four cardinal points of the areola
were tested. Pressure thresholds were measured with Semmes-Weinstein monofilaments,
temperature sensitivity with hot 40°c and cold 4°c metal probes and vibratory thresholds
with the Biothesiometer. Average sensation of the areola was calculated by means of the
four areas tested.
Results: A series of 50 patients underwent breast reduction by the same surgeon with a
mean follow-up of 15 months. The patient’s characteristics were reported in table I. One
partial areola necrosis was reported. The pressure and the vibration sensitivity decreased
at 2 weeks postoperatively. At three months postoperatively, the thresholds were quite
similar to the preoperative values of both areola and nipple. Concerning the ability to
recognize temperature, 40 % and 80% of the patients could distinguish between cold and
hot at 2 weeks and 3 months respectively after surgery (Table II).
Discussion: Breast sensation after Lejour’ technique was compromised significantly as
was reported by our studies ( 2,3). Our first concern was to obtain better nipple-areola
sensitivity in our patients with adequate aesthetic results but without complicating the
technique. Based on the reported anatomical and clinical studies (4,5), we described a
latero-central glandular pedicle technique that based on the horizontal septum. In this
technique, we modified the superior dermal pedicle in the following points: (1) use of a
lateral pedicle, (2) dissection the pedicle on a horizontal septum to include the main
source of innervation to the nipple, (3) pedicle suturing into the pectoralis fascia, (4)
preservation the inframammary fold and suspend it higher by means of the superficial
fascial system, (5) closure the skin with minimal undermining vertically or in short
inverted-T if the skin quality is not appropriate for vertical way closure.
Conclusion: Although satisfactory aesthetic results can be achieved with the superior
pedicle reduction mammaplasty, we found it necessary to modify our techniques in breast
reduction to achieve a better outcome regarding breast sensation. Moreover, laterally
designing the pedicle prevents pedicle kinking and consequently reducing venous
congestion, which are often observed with superior pedicle mammaplasty. Based on a
good vascularized and constant anatomical septum, this technique is safe even in
important breast hypertrophy. The septum-based lateral mammaplasty technique shows
clear advantages over the conventional techniques of breast reduction in terms of breast
sensation and ease of pedicle shaping and modeling.
50
No of patients:
Unilateral
8
Bilateral
42
37 years (19-66 yrs)
Mean age
Mean nipple distance from SSM
Mean nipple elevation
Mean weight of gland resected per breast
32 cm (19-43 cm)
8 cm (1-16 cm)
648 g (40-1680 g)
Type of Scar (no of patients):
With only vertical
25
With short horizontal
9
With Inverted-T
16
Table 1 shows Patient’s characteristics and preoperative findings:
Sensation test
Site
Pressure (g/mm2)
Vibration (µ)
Preop.
2 -week
value
value
Nipple
34.6 ± 2.2
134.2±23*
0.001
46.2±3.8
NS
Areola
49.2±6.8
152.3± 24.5*
0.001
57.4±5.7
NS
Nipple
3.7±1
10.3±1.5*
0.003
6.4±1.2
NS
3.1±0.6
9.7±1.5*
0.001
6.7±1.2
NS
95%
30%*
<0.001
72.5%
0.006
37%*
<0.001
80%
0.04
Areola
Hot
&
cold Nipple
discrimination %
Areola
95%
P
3- month
P
value
Table II shows the sensitivity of nipple-areola complex preoperatively, 2-week and 3-month
postoperatively:
Values are mean ±SEM or percent.
* p<0.05
NS = non-significant
References:
(1) Lejour, M. Vertical mammaplasty and liposuction of the breast. Plast. Reconstr. Surg,
94: 100-114, 1994
(2) Hamdi, M., Greuse, M., De Mey, A, Webster MHC. Breast sensation after superior
pedicle versus inferior pedicle mammaplasty: Prospective clinical evaluation. Br. J. Plast.
Surg, 54:39-42,1999.
(3) Greuse, M., Hamdi, M., DeMey, A. Breast sensitivity after vertical mammaplasty.
Plast. Reconstr. Surg, 107:970-976, 2001.
(4) Wuringer, E., Mader, N., Posch, E., and Holle, J. Nerve and vessel supplying
ligamentous suspension of the mammary gland. Plast Reconstr Surg,101: 1486-1493,
1998.
(5) Schlenz, I., Kuzbari, R., Gruber, H., Holle, J. The sensitivity of the nipple-areola
complex: an anatomic study. Plast. Reconstr. Surg., 105:905-9, 2000.