Modified Superomedial Pedicle Breast Reduction or Mastopexy for Patients With Medially Positioned Nipple Areola Complex

The goal of any breast reduction or mastopexy procedure is to reduce breast ptosis by mobilizing or excising soft tissue while transposing the nipple areolar complex (NAC) into a more aesthetically pleasing cranial position on the breast mound. Achieving successful NAC transposition relies on successfully designing a breast pedicle that allows sufficient mobility while preserving vascularity. The superomedial pedicle (SMP) design for breast reduction and mastopexy procedures is thought to result in enhanced long-term aesthetic results and, in most scenarios, can preserve sufficient NAC vascularity.^1-4

A medially positioned NAC is an anatomic configuration that is especially common in women who have undergone significant weight loss. When attempting a SMP procedure in a patient with a medially positioned NAC, it can be challenging to achieve sufficient arc of rotation of the NAC without unacceptably narrowing the base of the pedicle and thereby threatening the vascularity of the NAC. Therefore, the experienced surgeon is often left to resort to less desirable pedicle designs, such as the inferior pedicle, which are thought to result in poorer shape and longevity compared with the SMP.⁵ A suite of modifications to the traditional SMP technique, modified superomedial pedicle (M-SMP), has been developed to manage a medially positioned NAC that allows for successful NAC repositioning while preserving pedicle vascularity.

M-SMP Technique

The 2 SMP modifications that allow for safe performance of a breast reduction or mastopexy in a patient with a medially positioned NAC are medial canting of both vertical limbs and broadening the base of the pedicle by shifting the lateral border further laterally (Figure 1). Shifting the vertical limbs medially increases the distance between the medial edge of the areola and the medial vertical limb, functionally lengthening the pedicle and increasing the freedom of rotation. Widening the base of the pedicle by extending its origin further laterally allows for a greater degree of back cutting up the medial vertical limb (Figure 2). Additionally, the wider pedicle base can improve NAC projection. Lastly, the pedicle base can provide a well-vascularized de-epithelialized recipient tissue site if free nipple grafting were to become necessary during the operation.

Preoperative Markings

The surgeon should mark and measure the sternal notch, midline, breast meridians, and inframammary folds (IMF). The surgeon should then identify the ideal cosmetic position for the new NAC (usually 1 to 2 cm above the current IMF). Next, the surgeon should design preoperative markings for a Wise pattern skin excision. Importantly, while designing the Wise pattern skin excision, the medial and lateral vertical limbs should each be canted medially an equal distance. This will result in the NAC being further away from the medial vertical limb, but the 2 vertical limbs are no further apart from each other. Of note, the M-SMP modifications can be used in vertical skin excision designs but often are not sufficient in patients who have undergone significant weight loss and therefore have a significant amount of excess skin, which very much benefits from the horizontal excision used in the Wise pattern skin excision.

The surgeon should next design the broad-based dermoglandular pedicle. To achieve satisfactory markings, the surgeon should mark a routine superomedial pedicle pattern (base of 6 to 8 cm starting at the breast meridian and extending medially) but should also mark an additional 3 to 4 cm lateral to the breast meridian to encompass most of the additional tissue routinely included in a superior pedicle.

De-epithelialization of Dermoglandular Pedicle

After carefully marking the patient, the surgeon should de-epithelialize the M-SMP dermoglandular pedicle, taking care to preserve the NAC.

Excision of Breast Parenchyma and Isolation of Breast Pedicle

Next the surgeon can begin the excision of the excess breast parenchyma down to the chest wall fascia, taking care to preserve and isolate the anticipated M-SMP pedicle. The pedicle should not be undermined and should remain full thickness, ideally remaining fixed to the pectoralis fascia.

Transposition and Inset of Pedicle With Medial Pedicle Back Cut as Needed

Following excision of the excess breast parenchyma, the NAC should be rotated (clockwise in the right breast and counterclockwise in the left breast), and a tacking stitch should fix the superior-most portion of the NAC to the keyhole apex. While transposing the NAC to the keyhole position, a medialized nipple may be unable to successfully rotate with a hindered arc of rotation secondary to the superomedial pedicle’s medial base. A back cut is often necessary to allow the NAC to rotate into position and can be made along the pedicle’s medial base. In a standard superomedial pedicle pattern, such a back cut would reduce a superomedial pedicle’s base width by a significant proportion and potentially compromise the NAC perfusion. However, when the M-SMP design is utilized, such a back cut is perfectly acceptable because the NAC vascularity is maintained by the wider pedicle base. A “cut-as-you-go” approach can be employed while deciding how large of a back cut is required, erring on a more conservative approach to ensure the greatest amount of vascular perfusion to the distal end of flap pedicle.

Closure

After insetting the NAC, the medial and lateral pillars can be joined along the breast meridian securing the NAC and remaining breast parenchyma in place. To complete the procedure, a closed suction drain is recommended to be placed through the lateral aspect of the horizontal incision to prevent seroma, and the deep dermal and subcutaneous layers are sequentially closed on both breasts.

An IRB-approved retrospective review was completed to assess the surgical outcomes of those patients with medially positioned NACs who underwent either breast reduction or mastopexy utilizing the M-SMP technique. Demographics (age, body mass index), operative details (weight of tissue excised from each breast), and outcomes (perioperative complications, incidence of partial or total NAC loss, and aesthetics) were recorded for each patient and statistically compared. Patient satisfaction reporting was ascertained during routine postoperative visits.

A modified superomedial pedicle breast procedure was performed on 8 women with medially positioned NAC (16 breasts); 6 underwent breast reduction, and 2 underwent mastopexy. Mean age was 38.0 years (range 21-50 years), and mean BMI was 28.1 (range 23-35). The mean weight of tissue removed was 509 grams (range 245-889 grams) in patients undergoing a reduction and 105 grams (range 83-131 grams) in those patients undergoing mastopexies. There was 1 perioperative complication (hematoma), and there were no instances of partial or complete NAC loss. All patients had satisfactory breast shape and NAC position, and all were pleased with results (Figure 3).

The inferior and superomedial pedicles are 2 common pedicle designs used for either breast reduction or mastopexy procedures. The inferior pedicle can successfully transpose a medially positioned NAC but results in the long-term “bottoming out” phenomenon, whereby the breast parenchyma migrates inferiorly and manifests in breast pseudoptosis.⁵ In the seminal superomedial technique article, Orlando and Guthrie described a wide pedicle base without highlighting the flexibility or utility of the original design.³ Modern superomedial technique papers have suggested a narrowing base, which elicits its own potential pitfalls and complications.¹ In particular, the modern superomedial pedicle design can be challenging to design in women with medially positioned NAC due to the hindered arc of rotation. In addition, in a superomedial pedicle design, an excessively medially positioned NAC can result in shortened vertical limbs causing undue tension on the final closure.⁴ This increased tension with excessive medial strain can also result in poor breast projection with a retracted NAC, wound breakdown/dehiscence, and diminished perfusion.⁴

One solution to a medialized NAC in crafting a superomedial breast pedicle was described in 2013.⁴ In this technique, Iorio et al proposed incorporating a back cut to the medial aspect of the horizontal limb to allow for enhanced mobility while transposing the NAC with a lengthened arc of rotation. The challenge with this back-cut method involves the possibility of sacrificing too much of the pedicle’s base, resulting in inadequate vascular perfusion to the pedicle’s tip and subsequent NAC necrosis. Back cutting a pedicle’s base is a risky endeavor and can unpredictably jeopardize the NAC. An aggressive back cut can ruin a breast reduction with no suitable backup strategy available to the surgeon. Additionally, attempts to thin the SMP pedicle to enhance ease of transposition could incidentally sacrifice the vascular pedicle. Once the pedicle’s vascularity has been compromised, the only available remaining option involves a free nipple graft, which is difficult to perform in the designed location after excision of breast parenchyma.

The modifications described herein offer a novel technique to address a medially positioned NAC by increasing the width of the base pedicle and changing the angles of the vertical limbs. The pedicle design avoids the long-term pseudoptosis outcome associated with the use of the inferior pedicle approach. Additionally, the design allows for increased arc of NAC rotation, diminished tension on the pedicle’s medial base, allowance of back cuts when necessary, and enhanced final NAC projection. It is important to note that the NAC should be inset prior to closure of the breast pillars, as transposition of the NAC after pillar closure may result in excess tension and an inability to further rotate the pedicle.

It is important to acknowledge limitations concerning of this examination of the M-SMP technique. At this time, the study includes a limited number of patients with a subjective means of measuring patient satisfaction. Further studies could address these limitations by including a larger patient study population and the addition of an objective patient satisfaction survey.

Ultimately, the M-SMP breast reduction or mastopexy provides a surgeon with the freedom to improvise during a given procedure, with a “cut-as-you-go” approach. This technique allows the freedom to pivot to either a superior or superomedial pedicle, depending on what is most suitable for each individual patient. The pedicle can serve as the “ultimate backup” design for breast reductions and mastopexies, as the pedicle is planned to be noncommittal and allows for freedom for modifications throughout the procedure, with the final objective of maximizing the cosmetic outcome.

The M-SMP technique for breast reduction and mastopexy is a novel modification to the standard superomedial pedicle technique that can be used to address a medially positioned NAC. The design allows for back cutting of the pedicle to create a sufficient arc of rotation for the NAC. The design is recommended in patients with medially positioned NAC; however, the design can be used in any breast reduction or mastopexy surgeries because it allows the surgeon the freedom to improvise intraoperatively and has no disadvantage that cannot be undone as needed.

Affiliations: Icahn School of Medicine at Mount Sinai, New York, NY

Correspondence: Peter William Henderson, MD; peter.henderson@mountsinai.org

Ethics: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Disclosures: The authors have no relevant financial or nonfinancial interests to disclose.