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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.