The Safety of Long Inframammary Fold to Nipple Lengths in Inferior Pedicle Breast Reductions: A Decade of Experience

Breast reduction is one of the most common procedures performed by plastic surgeons.¹ During this procedure, both breast tissue and skin are excised in order to reshape the breast to a smaller volume, correct ptosis, and treat the symptoms of back and neck pain, intertrigo, and shoulder grooving associated with macromastia.² During the excision of breast tissue, maintaining the viability of the nipple areolar complex (NAC) is of utmost importance.¹ This is achieved through methods of isolating various blood supply to the NAC. The inferior pedicle, which includes the third and fourth intercostal space internal mammary perforators, is one of the most commonly used for breast reduction.³ Indications for its use include long sternal notch-to-nipple distance, large ptotic breasts, young patients who desire to maintain the ability to breast feed, and patient desire to preserve nipple sensation.^4,5

Previous authors have warned against the use of the inferior pedicle technique in patients with long nipple-to–inferior mammary fold (IMF) distances⁶ for several reasons, including a risk of kinking and decreased reliability of blood supply.⁷ Well-known textbooks have alternatively recommended free nipple grafting for nipple-to-IMF distances of 8 to 15 cm or greater and resection weights of 2000 g or greater; however, this recommendation remains largely unsupported.⁸ Furthermore, no study has demonstrated a critical length for inferior pedicles.⁶

In the authors’ practice, inferior pedicle mammoplasties have been successfully performed for over 10 years on almost all patients. Here, outcomes with NAC viability for breast reduction are reported for the inferior pedicle technique in patients with nipple-to-IMF distances of up to 28 cm. The authors also describe their safe surgical technique for successful breast reduction in patients with long nipple-to-IMF distances.

Study Method

A retrospective chart review was performed that included procedures performed from October 2009 to April 2021 by 2 different surgeons in New Orleans, Louisiana. Institutional review board approval was obtained. Patient age, preoperative breast measurements, medical and social history, and intraoperative notes were collected. Patients included were those who underwent breast reduction with inferior pedicle technique. Patients were excluded from the study if breast reduction was performed for oncologic purposes, if prior breast procedures had been performed, and if sufficient follow-up data were unavailable. For statistical analysis, univariate and multivariate analyses were performed. Spearman correlation was then used to assess relationships between all the variables collected.

Surgical Technique

Each patient was seen preoperatively in the holding area. At this time, the breasts were marked for an inferior pedicle, Wise pattern reduction. The width of the pedicle ranged from 8 to 12 cm, and the NAC was marked with a 38- to 43-mm cookie cutter. Standard techniques were used by both surgeons with the exception that one surgeon preferred use of a Harmonic scalpel for the dissection of the pedicle.

Several methods were used to ensure the safety of the procedure. First, the pedicle was curved medially rather than folding it to fit into the breast during closure to prevent kinking. Also, a wide pedicle width (10-12 cm) was maintained in patients with larger breasts to theoretically capture more perforators that supply the breast pedicle. Finally, to accommodate the larger pedicle, the Wise pattern skin resections were altered: the angle of the central skin resection was narrowed, and the vertical length of the superior breast flaps was increased.

The study population consisted of 221 patients and 436 breasts. The average patient age was 38 years, and average body mass index (BMI) was 32.35 kg/m². A small percentage of patients reported history of tobacco use, current tobacco use, and history of diabetes (9%, 9%, and 8%, respectively). Average follow-up time was 135 days. Demographic data for the patient population is reported in Table 1.

The average nipple-to-IMF distance for this patient population was 16.03 cm. The majority of patients had grade 3 ptosis (89%). The average sternal notch–to-nipple distance was 33.57 cm, the average base width among patients was 18.44 cm, and the average pedicle width of the inferior pedicles used for breast reductions was 10 cm. Preoperative measurements and resection measurements are detailed in Table 2.

There was no incidence of total nipple necrosis. The most common complication was a superficial wound at the T junction of the breast reduction incision (23%), and the second-most common complication was small seroma formation (7.6%), which were serially aspirated in the office. A subset of patients also had superficial wounds surrounding the NAC, IMF, or vertical incision. Three patients presented with partial nipple necrosis postoperatively. The nipple-to-IMF distances for these patients were 11.5, 19, and 16 cm, and medical risk factors included obesity (BMI 29.14, 32.06, and 37.11 kg/m²). Notably, pedicles for breast reduction were at least 10 cm wide. All complications resolved with local wound care and did not require surgical interventions. One patient did have a 4 × 4-mm area that had permanent pigment loss. Postoperative complications are reported in Table 3.

Correlation analysis (Table 4) demonstrated that diabetes was associated with surgical site infections requiring intravenous antibiotics and debridement in the operating room. Age and BMI were positively correlated with the incidence of seroma that required drainage. Breast base width was positively correlated with seroma necessitating drainage and negatively correlated with surgical site infections necessitating operative debridement. There was no correlation between adverse outcomes and patient characteristics, such as degree of ptosis, base width, nipple-to-IMF distance, nipple-to–sternal notch distance, NAC size, and resection weight. Univariate and multivariate analyses did not reveal statistically significant relationships.

The current study demonstrates that successful breast reduction may be performed with inferior pedicles up to 28 cm. Figure 1A and Figure 2A show 2 patients with above-average pedicle length (20 and 22 cm, respectively), both of whom achieved satisfactory results (Figure 1B, Figure 2B). Within this patient population and through years of experience, the authors found that the inferior pedicle has an extremely reliable blood supply. This is interesting, since anatomic variation to the NAC has been described in the literature.⁹ The arterial supplies to the inferior pedicle originate from the internal thoracic artery, traveling within the deep tissue, coursing within the fourth and fifth intercostal space^9,10 and from the anterior intercostal arteries, which send perforators radiating from the IMF.¹¹ According to previous authors, these sources supply the NAC in a fraction of breasts.⁹ The internal thoracic artery is the most constant and reliable source of arterial supply to the NAC; the NAC received perforating arteries from this source in 100% of dissected cadaver breasts.¹² The most common perforator to supply the NAC was a branch from the internal thoracic artery traveling within the second or third intercostal space.¹² If the NAC was not vascularized by the internal thoracic artery, it was likely supplied by the anterior intercostal arteries (24.4%) or the lateral thoracic arteries (23.2%).

Interestingly, the current case series has proven that there is sufficient vasculature supplying the inferior pedicle of the NAC for all patients as long as the pedicle width was maintained at 10 to 12 cm. An advantage of the inferior pedicle technique is the flexibility to widen the base of the pedicle to include more vascular supply to the flap. Notably, the blood supply to the nipple was never interrogated with a Doppler preoperatively,¹³ and a “blind resection” in all patients proved to be sufficient as long as the pedicle width was large.

Previous authors have reported that reliability of the vascular supply of the inferior pedicle may increase with the inclusion of Wuringer’s septum within the pedicle. Wuringer’s septum, which originates at the level of the fifth rib and heads towards the nipple, contains the lateral cutaneous branch of the fourth intercostal nerve, thoracoacromial artery, a branch of the lateral thoracic artery, and perforating branches of the fourth and fifth intercostal arteries.¹⁴ There are several other advantages to including the septum within the pedicle, including added resistance to NAC necrosis via pedicle kinking⁶ and increased NAC sensation due to inclusion of the lateral branch of the fourth intercostal nerve.¹⁵ Inclusion of the septum within  breast reductions may have allowed for smaller inferior pedicle widths; Portincasa et al and Kelahmetoglu et al have both reported successful breast reductions with preservation of Wuringer’s septum and inferior pedicle base widths of 8 cm; average resection weights ranged from 560 to 1406 g, and average pedicle length was 15.71 to 14.91 cm.^6,16

Previously published reports have also demonstrated the safety of inferior pedicle breast reduction with long nipple-to-IMF distances. Bustos et al reported a case series of 576 breasts with mean nipple-to-IMF distance of 14.8 cm (range, 7.5-27 cm). In their study, only 2 patients presented with partial NAC necrosis; pedicle lengths were 18 and 15 cm, and no issues were observed intraoperatively.⁸ The authors did report a correlation between mean breast resection weight and NAC or skin necrosis on multivariate analysis. No relationship between complications and nipple-to-IMF distance was reported on multivariate analysis. Spears et al also demonstrated safe inferior pedicle technique in 15 patients with gigantomastia and pedicle lengths of up to 38 cm. There were also no incidences of nipple necrosis reported in this study.⁵

Comparison of the current study’s postoperative complications rates with those reported in the National Surgical Quality Improvement Program database (2006-2015) demonstrated similar rates of superficial infection (2%-2.7%) and deep wound infection (0.4%-0.6%). Simpson et al reported a total wound complication rate (eg, “superficial infection, deep wound infection, dehiscence, organ space infection”) in 3.8% of patients. Another study of 2142 breast reductions in 1148 patients reported a wound complication rate of 14.9%, infection rate of 7.3%, and seroma rate of 1.2%.¹⁷ Nipple necrosis rates in these 2 studies were not reported, but this complication is known to occur approximately once in every 200 to 400 patients.¹³ The current study’s rate of partial nipple necrosis matches the expected outcomes described in the literature. The authors found no reported complications of dehiscence; however, there was a high rate of superficial wounds at the T junction, NAC and IMF, or vertical incision that resolved with local wound care (as seen in Figure 1B and Figure 2B) and had satisfactory results. With the exception of these superficial wounds, complication rates matched those observed in the literature.

Spearman’s correlation test was used to assess the relationships between variables within the patient population. In this sample, a correlation was found between certain patient baseline characteristics (age, BMI, base width, and diabetes) and adverse outcomes. However, as seen in Table 4, these relationships were significant (P < .05) but the correlation coefficient was low, with all being less than 0.3, indicating a weak relationship. Therefore, no definitive statement could be made regarding the relationship between these patient characteristics and adverse outcomes in patients receiving inferior pedicle reductions.

While the safety of breast reduction with long inferior pedicles has been demonstrated with this study, there are limitations due to the retrospective nature of the research. Outcomes data, such as rates of fat necrosis and patient satisfaction scores, were not collected and therefore could not be analyzed. Furthermore, comments on long-term aesthetic outcomes were not standardized and therefore could not be included in the study.

Breast reductions with an inferior pedicle are safe to perform, without the risk of nipple necrosis, for all patients with inferior pedicle length up to 33 cm.

Dr Kumar and Dr Yoo served as co-first authors in preparation of this manuscript. The authors extend special recognition to Denise Danos, PhD, for assistance with data statistical analysis.

Affiliations: ¹Tulane University School of Medicine, New Orleans, LA; ²Department of Surgery, Section of Plastic & Reconstructive Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA

Correspondence: Jonathan C Boraski, DMD, MD; jboras@lsuhsc.edu

Funding: There were no outside funding sources for this manuscript.

Ethics: Institutional review board approval was obtained.

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