Pedicle Viability As the Determinant Factor for Conversion to Free Nipple Graft

Abstract

INTRODUCTION Women with extremely large breasts have many complaints. Reduction mammaplasty improves shape and relieves physical symptoms and alleviates psychological complaints. Mammaplasty is a an evolving technique; no single method is ideal or suitable for all breasts. Many techniques are advocated for reduction mammaplasty, including the superior, vertical, horizontal, lateral and inferior (the most popular) pedicle techniques. Even after 60 years of development in breast reduction techniques, there are still reported incidences of nipple-areola complex (NAC) necrosis. Objective To assess the perioperative conversion to free nipple graft to prevent the complication of nipple necrosis when pedicle viability is grossly compromised. Methods Between January 2002 and March 2006, 66 patients (132 breasts) underwent reduction mammaplasty using the inferior pedicle technique. The patients presented with breast gigantism and required excision of more than 1000 g of breast tissue per side. The mean patient age was 34.81 years. Patients had neck, shoulder and back pain as well as psychological complaints. Data regarding sternal notch-to-nipple distances and inframammary fold-to-nipple distances were recorded preoperatively and postoperatively. The weights of the excised breast tissue from either side were recorded. Viability of the pedicle flap was carefully monitored through perioperative clinical observation of skin colour, temperature, capillary refill and bleeding characteristics, and reassessed after pedicle folding and placement inside the newly tailored skin envelope. Nonvital NAC, as evaluated by the surgeon during surgery, necessitated conversion to the free nipple graft technique. Results During the course of the study, two patients (four breasts; 3.03%) exhibited impending gangrene to the NAC, and perioperative conversion to the free nipple graft was performed. In these two patients, the pedicle length ranged from 23 cm to 25 cm, and breast mass reduction ranged from 1950 g to 2250 g. Conclusion Perioperative conversion to a free nipple-areola graft is always a good and safe option when impending gangrene to the NAC is evident during mammaplasty by inferior pedicle technique.

Mammoplasty Using Modified Superomedial Pedicle Technique in Severely Macromastia and Ptotic Breasts

“…Many plastic surgeons do not recommend pedicled mammoplasty methods in breasts where more than 1,000 gr breast tissue excisions are planned due to the high risk of serious complications [ 2 ]. For this reason, the main indication of the free nipple-areola technique is patients planned for a breast tissue excision of over 1,000 gr.…”

“…Many pedicle techniques have been defined over the years, and some have been modified as a result of research. However, there is no single technique ideal for shaping breasts of all sizes, and no technique is superior to another [ 2 , 22 ].…”

“…Al-Shaham studied pedicle viability to determine whether to switch to a free breast graft. In mammoplasty operations planned with an inferior pedicle, upon observing circulatory failure in the nipple-areola, they switched to this technique at the expense of extending the operation by 1 or 1.5 hours [ 2 ]. In none of our cases, a switch to a free nipple graft technique was considered or required during or after surgery.…”

“…On the other hand, breasts in this condition in adolescence constitute gigantomastia. Besides cosmetic problems, severe macromastia and ptotic breasts may cause intense back, neck, and shoulder pain by disrupting body posture [ 2 ]. Hygiene problems and dermatitis, bad smells, and fungal infections under the breasts in women frequently accompany chronic and severe pain.…”

“…The incidence of partial or total necrosis of the NAC varies in large series; however, it is reported to be between 0.4 and 6% [ 2 ]. Despite the complication rates mentioned so far, surgery is still the gold standard.…”